hospital_name,last_updated_on,version,location_name,hospital_address,type_2_npi,license_number|NC,attester_name,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula."
"Rex Hospital, Inc.",2026-06-05,3.0.0,"Rex Hospital, Inc.|Rex Holly Spring Hospital","4420 Lake Boone Trail, Raleigh, NC 27607|850 S Main St, Holly Springs, NC 27540",1497797088,H0065,Chad Setliff,true
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,billing_class,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,modifiers,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|min,standard_charge|max,standard_charge|methodology,additional_generic_notes
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,199000.36,360919.81,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,80975.46,145942.25,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,150928.76,397739.02,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,98790.80,259561.38,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,39415.99,102204.38,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,30661.75,79003.62,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,21228.00,54002.05,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,,86.00,,,,,0,71254.67,186584.22,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,96060.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,70022.93,183319.89,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,96060.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,47343.65,123214.55,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,96060.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,47343.65,123214.55,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,82994.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,55142.64,143883.66,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,82994.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,38558.31,99931.34,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,82994.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,36489.42,94448.31,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,96845.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,60456.99,157967.90,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,96845.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,43718.51,113607.06,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,73758.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,54908.59,143263.40,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,73758.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,39476.79,102365.54,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,53071.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,42346.80,109971.70,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,53071.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,30469.42,78493.92,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,44147.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,23426.99,59829.88,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,44147.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,15743.09,44147.00,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,28648.00,,"$5,440 per diem paid for each additional day above the threshold.",32627.7,32627.7,32627.7,1 through 10,13353.81,33870.74,case rate,"$5,440 per diem paid for each additional day above the threshold."
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,44147.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,33111.02,85494.81,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,22147.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,16124.31,40897.87,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,22147.00,,"$5,440 per diem paid for each additional day above the threshold.",20905.0,20905.0,20905.0,1 through 10,11041.37,28005.44,case rate,"$5,440 per diem paid for each additional day above the threshold."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,23741.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,23068.51,58879.81,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,23741.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,14939.27,37892.13,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,22172.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,22172.00,60954.22,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,22172.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,13967.01,35426.08,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,22172.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,12041.70,30542.70,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,41296.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,30021.84,77307.74,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,35617.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,24126.28,61683.17,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,110692.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,51268.60,133616.57,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,76643.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,43322.54,112557.68,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,85198.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,33507.69,86546.07,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,22878.00,,"$5,440 per diem paid for each additional day above the threshold.",21595.0,21595.0,21595.0,1 through 10,16348.17,41465.66,case rate,"$5,440 per diem paid for each additional day above the threshold."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,17851.00,,"$5,440 per diem paid for each additional day above the threshold.",16850.0,16850.0,16850.0,1 through 10,7905.90,20052.60,case rate,"$5,440 per diem paid for each additional day above the threshold."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,38974.00,,"$5,440 per diem paid for each additional day above the threshold.",38797.53,36789.0,39987.94,1 through 10,20089.63,50985.07,case rate,"$5,440 per diem paid for each additional day above the threshold."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,32650.00,,"$5,440 per diem paid for each additional day above the threshold.",30819.0,30819.0,32676.25,1 through 10,13025.04,33036.86,case rate,"$5,440 per diem paid for each additional day above the threshold."
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,32841.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,32841.00,97543.99,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,32841.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,25787.19,66084.96,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,32841.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,20281.95,51494.77,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,32841.00,,"$5,440 per diem paid for each additional day above the threshold.",,,,0,22298.52,56839.13,case rate,"$5,440 per diem paid for each additional day above the threshold.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,32841.00,,"$5,440 per diem paid for each additional day above the threshold.",49088.73,49088.73,49088.73,1 through 10,14490.34,36145.66,case rate,"$5,440 per diem paid for each additional day above the threshold."
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,30449.00,,,,,,,16490.00,54106.99,case rate,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,30449.00,,,,,,,11823.02,35030.00,case rate,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,30449.00,,,,,,,11144.06,35030.00,case rate,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,4210.00,,,,,,,4210.00,9518.00,per diem,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,5414.00,,,,,,,5414.00,31619.23,per diem,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,5414.00,,,,,,,5414.00,15908.00,per diem,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,5414.00,,,,,,,5414.00,15908.00,per diem,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,5414.00,,,,,,,5414.00,21243.91,per diem,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,5414.00,,,,,,,5414.00,15908.00,per diem,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,5414.00,,,,,,,5414.00,15908.00,per diem,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,4210.00,,,,,,,4210.00,9947.78,per diem,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,4210.00,,,,,,,4210.00,9518.00,per diem,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,4210.00,,,,,,,4210.00,9518.00,per diem,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,4210.00,,,,,,,4210.00,9518.00,per diem,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,4210.00,,,,,,,4210.00,9518.00,per diem,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Commercial,,4210.00,,,,,,,4210.00,9518.00,per diem,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2194.26,12686.00,case rate,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,902.01,5152.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3684.09,6735.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,5754.00,case rate,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,38900,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,17457.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,4890.88,17457.00,case rate,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,877.14,5152.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",361,RC,31627,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,8045.00,case rate,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2025.00,4311.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5152.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,17457.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,666.26,4121.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15777,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3870.33,12408.00,case rate,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,13852.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,10087.00,24600.00,case rate,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3870.33,12408.00,case rate,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,12247.00,case rate,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,18291.76,case rate,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)",360,RC,43775,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,8612.00,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2194.26,12686.00,case rate,
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64488,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,17457.00,case rate,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3684.09,6735.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,902.01,5152.00,case rate,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,10087.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1825.06,6735.00,case rate,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,10016.47,24600.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,8442.00,case rate,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3870.33,17457.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5613.15,13852.00,case rate,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,10087.00,case rate,
PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,60512,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20930,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22853,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,8045.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",361,RC,31654,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,5152.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5613.15,10022.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,4890.88,10022.00,case rate,
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22845,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13852.00,case rate,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3684.09,6735.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,10087.00,case rate,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5200.74,13852.00,case rate,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3870.33,17457.00,case rate,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4964.08,17457.00,case rate,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6274.19,10022.00,case rate,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1825.06,17457.00,case rate,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,52940.00,case rate,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,877.14,5152.00,case rate,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3788.00,5754.00,case rate,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,877.14,5152.00,case rate,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6274.19,10087.00,case rate,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
INSERTION OF INTRAUTERINE DEVICE (IUD),360,RC,58300,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20936,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,8045.00,case rate,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5200.74,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,902.01,5152.00,case rate,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3870.33,17457.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,5613.15,17457.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,8213.00,case rate,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22552,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,10022.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31633,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,6735.00,case rate,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,9503.00,,,,,,,9503.00,27871.00,case rate,
"ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20931,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,10087.00,case rate,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3870.33,10022.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3660.29,5754.00,case rate,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,8442.00,case rate,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4964.08,10087.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,15260.00,,,,,,,8612.00,17457.00,case rate,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4890.88,17457.00,case rate,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,39682.00,case rate,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1494.54,4311.00,case rate,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,52940.00,case rate,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,17457.00,case rate,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6314.07,13852.00,case rate,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,9423.00,39682.00,case rate,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,4749.28,8045.00,case rate,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,17457.00,case rate,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3870.33,10087.00,case rate,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,29826,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64468,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,13527.54,case rate,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,642.16,4311.00,case rate,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,1759.87,10087.00,case rate,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63048,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,173.00,13652.00,case rate,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)",360,RC,43845,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6314.07,24600.00,case rate,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3120.11,8442.00,case rate,
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93655,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3318.21,5754.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,10022.00,case rate,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,4964.08,12686.00,case rate,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3660.29,17457.00,case rate,
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93623,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1878.73,5754.00,case rate,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,13852.00,case rate,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,5613.15,17457.00,case rate,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,12247.00,case rate,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)",360,RC,43644,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,8612.00,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2244.50,10087.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,17457.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,902.01,5152.00,case rate,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,19334.39,case rate,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,17457.00,case rate,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5613.15,13852.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,17457.00,case rate,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3120.11,5754.00,case rate,
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,20937,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,8045.00,case rate,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,39682.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,10022.00,case rate,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,17457.00,case rate,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3522.17,17457.00,case rate,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3318.21,8442.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20985,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,2194.26,11124.00,case rate,
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64466,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1425.11,6735.00,case rate,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3788.00,13652.00,case rate,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,8612.00,17457.00,case rate,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1539.73,4311.00,case rate,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5152.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,902.01,5152.00,case rate,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31632,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,6872.88,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1825.06,6735.00,case rate,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,17457.00,case rate,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,52940.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,8612.00,13852.00,case rate,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3628.02,8442.00,case rate,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,13852.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1558.81,17457.00,case rate,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,13852.00,case rate,
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT",360,RC,27487,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,13852.00,case rate,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,4890.88,10022.00,case rate,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,34125.00,52940.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,10087.00,24600.00,case rate,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3684.09,8442.00,case rate,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15772,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5691.37,10022.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3028.17,8045.00,case rate,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,4376.00,case rate,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,8045.00,case rate,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3660.29,24600.00,case rate,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3684.09,8442.00,case rate,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,10087.00,24600.00,case rate,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,10087.00,case rate,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,17457.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3660.29,5754.00,case rate,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22840,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,17457.00,case rate,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,5754.00,case rate,
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63052,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,6872.88,17457.00,case rate,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2244.50,10087.00,case rate,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1759.87,4311.00,case rate,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3395.25,17457.00,case rate,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3870.33,10087.00,case rate,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5152.00,case rate,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3308.62,8045.00,case rate,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,6274.19,12408.00,case rate,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,9350.00,case rate,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64486,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3395.25,8045.00,case rate,
"OMENTAL FLAP, INTRA-ABDOMINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49905,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,6636.00,10022.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,13852.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3121.59,13852.00,case rate,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,8442.00,case rate,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,5754.00,case rate,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,1970.84,8442.00,case rate,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3522.17,17457.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,6735.00,case rate,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2638.41,5754.00,case rate,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5200.74,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL",360,RC,60650,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2638.41,9350.00,case rate,
"EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; PERINEAL APPROACH",360,RC,45130,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93657,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3308.62,8045.00,case rate,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,24600.00,case rate,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,17457.00,case rate,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,10087.00,case rate,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61782,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,17457.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49616,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,19334.39,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,9423.00,39682.00,case rate,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3870.33,12408.00,case rate,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4121.00,39682.00,case rate,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,10087.00,case rate,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,8045.00,case rate,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,19334.39,case rate,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1539.73,4311.00,case rate,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,6735.00,case rate,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,6735.00,case rate,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,2194.26,11124.00,case rate,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3028.17,8045.00,case rate,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3120.11,8442.00,case rate,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1558.81,17457.00,case rate,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,13852.00,case rate,
"INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC/DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93662,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49596,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,13852.00,case rate,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3308.62,8045.00,case rate,
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,61783,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,14302,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,7277.94,case rate,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,19334.39,case rate,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1878.73,5754.00,case rate,
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT",360,RC,27486,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,837.72,4311.00,case rate,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,4749.28,8045.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,10022.00,case rate,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3870.33,10022.00,case rate,
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22842,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3684.09,8045.00,case rate,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3660.29,5754.00,case rate,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5152.00,case rate,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3684.09,8045.00,case rate,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1970.84,6735.00,case rate,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,13852.00,case rate,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5691.37,10022.00,case rate,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,17457.00,case rate,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,9350.00,case rate,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,5613.15,17457.00,case rate,
"CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27132,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5754.00,case rate,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1134.38,6735.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,17457.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63035,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,173.00,13652.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,17457.00,case rate,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,15260.00,,,,,,,8612.00,17457.00,case rate,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G, ABDOMINAL APPROACH",360,RC,58146,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5219.00,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION),360,RC,38724,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2194.26,8442.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,12408.00,case rate,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6274.19,10022.00,case rate,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,5754.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,4376.00,case rate,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,17457.00,case rate,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3121.59,12408.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5485.35,13852.00,case rate,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT",360,RC,23474,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22634,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2244.50,5754.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4890.88,17457.00,case rate,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,8612.00,13852.00,case rate,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3547.15,6735.00,case rate,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,6649.00,case rate,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5691.37,10022.00,case rate,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22614,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3120.11,10087.00,case rate,
"REMOVAL OF TOTAL OR NEAR TOTAL NON-INFECTED MESH OR OTHER PROSTHESIS AT THE TIME OF INITIAL OR RECURRENT ANTERIOR ABDOMINAL HERNIA REPAIR OR PARASTOMAL HERNIA REPAIR, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49623,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,4749.28,12408.00,case rate,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);",360,RC,58150,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5219.00,12247.00,case rate,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3870.33,17457.00,case rate,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,15260.00,,,,,,,8612.00,17457.00,case rate,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,9423.00,39682.00,case rate,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2638.41,8442.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3308.62,12408.00,case rate,
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63053,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,10006,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,3028.17,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,931.82,4311.00,case rate,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,24600.00,case rate,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3870.33,12408.00,case rate,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5200.74,17457.00,case rate,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3120.11,8442.00,case rate,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,6636.00,12408.00,case rate,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,5754.00,case rate,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,8442.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5754.00,case rate,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2194.26,8045.00,case rate,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,4376.00,case rate,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,6649.00,case rate,
"VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL;",360,RC,57110,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64473,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2194.26,12408.00,case rate,
"SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S)",360,RC,58180,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5219.00,12247.00,case rate,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,12408.00,case rate,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3120.11,5754.00,case rate,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19126,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6274.19,17457.00,case rate,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,5754.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3028.17,8045.00,case rate,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3660.29,5754.00,case rate,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,5754.00,case rate,
"LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL OF GEROTA'S FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES, AND ADRENALECTOMY)",360,RC,50545,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,4376.00,case rate,
ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22846,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13852.00,case rate,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2194.26,8442.00,case rate,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5219.00,10087.00,case rate,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,17457.00,case rate,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,82346.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,877.14,5152.00,case rate,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1878.73,6735.00,case rate,
"REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27134,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,39682.00,case rate,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,5754.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE RESECTION AND ANASTOMOSIS",360,RC,44202,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"LAPAROSCOPY, SURGICAL, TOTAL HYSTERECTOMY FOR RESECTION OF MALIGNANCY (TUMOR DEBULKING), WITH OMENTECTOMY INCLUDING SALPINGO-OOPHORECTOMY, UNILATERAL OR BILATERAL, WHEN PERFORMED",360,RC,58575,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5219.00,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,4749.28,8045.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5152.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,8442.00,case rate,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2638.41,8442.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,9503.00,,,,,,,9503.00,27871.00,case rate,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,13852.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,990.00,8442.00,case rate,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5691.37,10022.00,case rate,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,990.00,5152.00,case rate,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,10022.00,case rate,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3628.02,8442.00,case rate,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR",360,RC,22558,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,837.72,4311.00,case rate,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3318.21,10087.00,case rate,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,17457.00,case rate,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49618,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5754.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3522.17,8045.00,case rate,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,82346.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,24600.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,10087.00,case rate,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2194.26,8442.00,case rate,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1494.54,4311.00,case rate,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5219.00,10087.00,case rate,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3522.17,17457.00,case rate,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1759.87,4311.00,case rate,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,52940.00,case rate,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3395.25,10087.00,case rate,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,527.80,4311.00,case rate,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2194.26,5754.00,case rate,
"REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITHOUT VAGOTOMY",360,RC,43860,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,S2900,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,,,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1878.73,5754.00,case rate,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1878.73,9350.00,case rate,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3120.11,8442.00,case rate,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3120.11,6735.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES)",360,RC,21147,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,4376.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,6258.49,case rate,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,13527.54,case rate,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22632,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11045,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,57.15,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5691.37,10022.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; CERVICAL BELOW C2 SEGMENT",360,RC,22600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,13527.54,case rate,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5200.74,13852.00,case rate,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8700.96,case rate,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,8045.00,case rate,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,8045.00,case rate,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,931.82,4311.00,case rate,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1878.73,5754.00,case rate,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,9503.00,,,,,,,9503.00,27871.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, WITH PERINEAL BODY RECONSTRUCTION, WITH OR WITHOUT LEVATOR PLICATION",360,RC,57308,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,3788.00,5754.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3547.15,8442.00,case rate,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,642.16,4311.00,case rate,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,17457.00,case rate,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,837.72,4311.00,case rate,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5200.74,13852.00,case rate,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,17457.00,case rate,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,24600.00,case rate,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2638.41,5754.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,990.00,5152.00,case rate,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,10022.00,case rate,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,17457.00,case rate,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,902.01,5152.00,case rate,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,13852.00,case rate,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1970.84,5754.00,case rate,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,124.01,4311.00,case rate,
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; SINGLE IMPLANT",360,RC,52441,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,8045.00,case rate,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,57.15,4311.00,case rate,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,17457.00,case rate,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,4376.00,case rate,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM (SEPARATE PROCEDURE)",360,RC,49255,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1825.06,9350.00,case rate,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,13852.00,case rate,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3121.59,10087.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,5152.00,case rate,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2194.26,5754.00,case rate,
PYLOROPLASTY,360,RC,43800,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,990.00,5152.00,case rate,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,24600.00,case rate,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,17457.00,case rate,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1425.11,4311.00,case rate,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,12247.00,24600.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,7510.57,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5152.00,case rate,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5200.74,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64467,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37252,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,10910.59,24600.00,case rate,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5200.74,13852.00,case rate,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,13852.00,case rate,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4121.00,39682.00,case rate,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2025.00,8213.00,case rate,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3522.17,8045.00,case rate,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36247,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36907,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36245,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,594.81,4376.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,10087.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5200.74,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,82346.00,case rate,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2025.00,4311.00,case rate,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,13852.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,5754.00,case rate,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,13852.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5219.00,17457.00,case rate,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),750,RC,43273,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,17457.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5691.37,10022.00,case rate,
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27535,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1970.84,5754.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,17457.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS",360,RC,44204,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,6636.00,10022.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,676.91,2912.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,990.00,4376.00,case rate,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,6636.00,12408.00,case rate,
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE)",360,RC,45400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,1539.73,8442.00,case rate,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,17457.00,case rate,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3318.21,8442.00,case rate,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,6258.49,case rate,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1825.06,4311.00,case rate,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG-ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9601,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,27871.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,7300.39,13852.00,case rate,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,4376.00,case rate,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3547.15,6735.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,17457.00,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5200.74,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5200.74,13852.00,case rate,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY LYMPH NODES",360,RC,19305,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3120.11,8442.00,case rate,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)",360,RC,21145,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,902.01,5152.00,case rate,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2025.00,12408.00,case rate,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION",360,RC,43645,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,8612.00,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ARTHROSCOPY, KNEE, SURGICAL FOR HARVESTING OF CARTILAGE (CHONDROCYTE CELLS)",360,RC,S2112,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,,,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22515,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,13852.00,case rate,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,527.80,4311.00,case rate,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,66990,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3628.02,8045.00,case rate,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,6636.00,12408.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,8612.00,13852.00,case rate,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13852.00,case rate,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13852.00,case rate,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1878.73,12408.00,case rate,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,17457.00,case rate,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63044,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13652.00,case rate,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,10087.00,24600.00,case rate,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,6872.88,13852.00,case rate,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3121.59,10087.00,case rate,
"REPAIR OF PARASTOMAL HERNIA, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL OR RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS, WHEN PERFORMED; REDUCIBLE",360,RC,49621,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,13852.00,case rate,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3121.59,5754.00,case rate,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH RADICAL NECK DISSECTION",360,RC,60254,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3788.00,12247.00,case rate,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL;",360,RC,58940,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5219.00,10087.00,case rate,
"SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,58720,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3121.59,12408.00,case rate,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITH FIXATION",360,RC,27450,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5691.37,10022.00,case rate,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,12408.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,5754.00,case rate,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5691.37,10022.00,case rate,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13527.54,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,9350.00,case rate,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,8045.00,case rate,
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BICORTICAL OR TRICORTICAL (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20938,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,8045.00,case rate,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,26125,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,173.00,8442.00,case rate,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; EACH ADDITIONAL SEGMENT, THORACIC OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63057,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,6735.00,case rate,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,17457.00,case rate,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,4749.28,17457.00,case rate,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5485.35,13852.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL CAROTID ARTERY, OPEN OR PERCUTANEOUS, INCLUDING ANGIOPLASTY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION; WITH DISTAL EMBOLIC PROTECTION",360,RC,37215,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,54.52,92.57,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,4376.00,case rate,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"FASCIOTOMY, HIP OR THIGH, ANY TYPE",360,RC,27025,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3522.17,8045.00,case rate,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,56606,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5200.74,13852.00,case rate,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,17457.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,8213.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,642.16,6649.00,case rate,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3547.15,8442.00,case rate,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; EACH ADDITIONAL PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,52442,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13102,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5219.00,17457.00,case rate,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,3058.98,5754.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,15260.00,,,,,,,3318.21,17457.00,case rate,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"BALLOON DILATION, URETERAL STRICTURE, INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,50706,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5754.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2753.54,5754.00,case rate,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,17457.00,case rate,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; ABDOMINAL APPROACH",360,RC,58140,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5219.00,12247.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1539.73,4311.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,931.82,4311.00,case rate,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
BACKBENCH PREPARATION OF CORNEAL ENDOTHELIAL ALLOGRAFT PRIOR TO TRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,65757,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2638.41,5754.00,case rate,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,931.82,8442.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,4964.08,12686.00,case rate,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,7510.57,case rate,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,64636,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SECOND LEVEL, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22858,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
REMOVAL OF ANTERIOR INSTRUMENTATION,360,RC,22855,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,13852.00,case rate,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,10087.00,24600.00,case rate,
"PLACEMENT OF ADJUSTABLE SUTURE(S) DURING STRABISMUS SURGERY, INCLUDING POSTOPERATIVE ADJUSTMENT(S) OF SUTURE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR SPECIFIC STRABISMUS SURGERY)",360,RC,67335,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,173.00,8442.00,case rate,
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS)",360,RC,44207,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE",360,RC,44187,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2753.54,5754.00,case rate,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,13852.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5219.00,17457.00,case rate,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,990.00,4376.00,case rate,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"THORACOSCOPY, SURGICAL; WITH THORACIC SYMPATHECTOMY",360,RC,32664,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; COMMON FEMORAL",360,RC,35371,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36215,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5485.35,13852.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,13852.00,case rate,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,4507.53,17457.00,case rate,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3660.29,5754.00,case rate,
"GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY",360,RC,43846,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4121.00,8045.00,case rate,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,17457.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,8213.00,case rate,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2025.00,4311.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5754.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2638.41,8442.00,case rate,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,8213.00,case rate,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,5754.00,case rate,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,4376.00,case rate,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27245,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (OMENTAL TACKING PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49326,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,17457.00,case rate,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1970.84,5754.00,case rate,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,12408.00,case rate,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY",360,RC,50546,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2025.00,10087.00,case rate,
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY",360,RC,50548,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2025.00,10087.00,case rate,
"URETEROLYSIS, WITH OR WITHOUT REPOSITIONING OF URETER FOR RETROPERITONEAL FIBROSIS",360,RC,50715,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,9721.99,case rate,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,12408.00,case rate,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3318.21,5754.00,case rate,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3318.21,8442.00,case rate,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,1539.73,8442.00,case rate,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,990.00,6735.00,case rate,
"INSERTION OF MESH OR OTHER PROSTHESIS FOR REPAIR OF PELVIC FLOOR DEFECT, EACH SITE (ANTERIOR, POSTERIOR COMPARTMENT), VAGINAL APPROACH (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,57267,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,173.00,12247.00,case rate,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,4749.28,8045.00,case rate,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3121.59,10087.00,case rate,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3121.59,10087.00,case rate,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,17457.00,case rate,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5754.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,8612.00,13852.00,case rate,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGECTOMY AND/OR OOPHORECTOMY, ABDOMINAL OR VAGINAL APPROACH",360,RC,59120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4121.00,13110.66,case rate,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,6872.88,13852.00,case rate,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,17457.00,case rate,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1878.73,5754.00,case rate,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1878.73,5754.00,case rate,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1878.73,5754.00,case rate,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,1878.73,8442.00,case rate,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3628.02,8045.00,case rate,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2194.26,5754.00,case rate,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,527.80,5152.00,case rate,
"INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH, METHYLMETHACRYLATE) TO INTERVERTEBRAL DISC SPACE OR VERTEBRAL BODY DEFECT WITHOUT INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22859,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2194.26,8442.00,case rate,
REINSERTION OF SPINAL FIXATION DEVICE,360,RC,22849,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3628.02,8045.00,case rate,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22585,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,8612.00,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS",360,RC,22548,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,6649.00,case rate,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3120.11,8045.00,case rate,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,17457.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"POSTERIOR VERTEBRAL JOINT(S) ARTHROPLASTY (EG, FACET JOINT[S] REPLACEMENT), INCLUDING FACETECTOMY, LAMINECTOMY, FORAMINOTOMY, AND VERTEBRAL COLUMN FIXATION, INJECTION OF BONE CEMENT, WHEN PERFORMED, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE",360,RC,0202T,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,13852.00,case rate,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3684.09,8442.00,case rate,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3522.17,8045.00,case rate,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,24600.00,case rate,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15272,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,4376.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,4376.00,case rate,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,7300.39,13852.00,case rate,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,7300.39,13852.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,4376.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3660.29,17457.00,case rate,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,5152.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,8213.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,856.54,5152.00,case rate,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3058.98,10087.00,case rate,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,17457.00,case rate,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,17457.00,case rate,
"VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; WITH REPAIR OF ENTEROCELE",360,RC,58280,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5219.00,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4749.28,10087.00,case rate,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,4749.28,12408.00,case rate,
"HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS (NONOBSTETRICAL)",360,RC,58520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2025.00,10087.00,case rate,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,17457.00,case rate,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH RADICAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY), WITH REMOVAL OF TUBE(S) AND OVARY(S), IF PERFORMED",360,RC,58548,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,6636.00,10022.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5754.00,case rate,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,13852.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1558.81,17457.00,case rate,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,360,RC,51600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID BLADDER, INCLUDING INTESTINE ANASTOMOSIS;",360,RC,51590,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,3318.21,5754.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,17457.00,case rate,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,17457.00,case rate,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,12247.00,24600.00,case rate,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1970.84,9350.00,case rate,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE);",360,RC,60540,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2025.00,12247.00,case rate,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF SKULL,360,RC,61500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,9503.00,,,,,,,8612.00,13852.00,case rate,
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, INTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61781,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; RE-AMPUTATION",360,RC,27886,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,8612.00,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"ACETABULOPLASTY; RESECTION, FEMORAL HEAD (EG, GIRDLESTONE PROCEDURE)",360,RC,27122,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,8442.00,case rate,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,17457.00,case rate,
"REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27137,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE",360,RC,63077,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,990.00,4121.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL (IE, PERITONEAL, MESENTERIC, RETROPERITONEAL), PRIMARY OR SECONDARY TUMOR(S) OR CYST(S), SUM OF THE MAXIMUM LENGTH OF TUMOR(S) OR CYST(S); 5 CM OR LESS",360,RC,49186,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,3788.00,5754.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR WITHOUT BIOPSY(S) (SEPARATE PROCEDURE)",360,RC,49000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2638.41,5754.00,case rate,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2753.54,5754.00,case rate,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64474,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,19334.39,case rate,
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY CONTINUOUS INFUSION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64487,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1878.73,5754.00,case rate,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,6735.00,case rate,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1878.73,5754.00,case rate,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2638.41,8442.00,case rate,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3870.33,12408.00,case rate,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11046,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2194.26,12408.00,case rate,
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE), WITH SIGMOID RESECTION",360,RC,45402,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2194.26,6735.00,case rate,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,9350.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,12408.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2753.54,8442.00,case rate,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3870.33,17457.00,case rate,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,527.80,10087.00,case rate,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND ANASTOMOSIS OTHER THAN COLORECTAL",360,RC,44625,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,902.01,4121.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE PROCEDURE),360,RC,44346,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; THORACIC (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22610,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,931.82,4376.00,case rate,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,17457.00,case rate,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2244.50,10087.00,case rate,
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44206,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44143,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE),360,RC,44139,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2244.50,5754.00,case rate,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ENTEROENTEROSTOMY, ANASTOMOSIS OF INTESTINE, WITH OR WITHOUT CUTANEOUS ENTEROSTOMY (SEPARATE PROCEDURE)",360,RC,44130,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3628.02,8442.00,case rate,
"CORRECTION OF MALROTATION BY LYSIS OF DUODENAL BANDS AND/OR REDUCTION OF MIDGUT VOLVULUS (EG, LADD PROCEDURE)",360,RC,44055,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2025.00,12247.00,case rate,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,12408.00,case rate,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
"PERSONALIZED, ANTERIOR AND LATERAL INTERBODY CAGE (IMPLANTABLE)",360,RC,C1831,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,,,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,C5276,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,17457.00,case rate,
ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE),360,RC,44005,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2025.00,12247.00,case rate,
"REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITH VAGOTOMY",360,RC,43865,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"OSTECTOMY OF STERNUM, PARTIAL",360,RC,21620,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
EXCISION FIRST AND/OR CERVICAL RIB;,360,RC,21615,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3121.59,12408.00,case rate,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2753.54,10087.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,7277.94,case rate,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR OSTEOTOMY (INCLUDES CORRECTION OF GENU VARUS [BOWLEG] OR GENU VALGUS [KNOCK-KNEE]); BEFORE EPIPHYSEAL CLOSURE",360,RC,27455,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3660.29,5754.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1825.06,6735.00,case rate,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1825.06,4311.00,case rate,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1825.06,4311.00,case rate,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"OPEN TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27514,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,5152.00,case rate,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,12408.00,case rate,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5691.37,10022.00,case rate,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3788.00,10087.00,case rate,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1425.11,4311.00,case rate,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2025.00,4311.00,case rate,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3522.17,8045.00,case rate,
"PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE PROCEDURE)",360,RC,38770,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,6649.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,5152.00,case rate,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3684.09,6735.00,case rate,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,990.00,6735.00,case rate,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19084,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37232,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13852.00,case rate,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15847,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36909,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,10910.59,24600.00,case rate,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3121.59,5754.00,case rate,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5200.74,13852.00,case rate,
"ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS",360,RC,36620,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5754.00,case rate,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3522.17,17457.00,case rate,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36217,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"EXPLORATION NOT FOLLOWED BY SURGICAL REPAIR, ARTERY; LOWER EXTREMITY (EG, COMMON FEMORAL, DEEP FEMORAL, SUPERFICIAL FEMORAL, POPLITEAL, TIBIAL, PERONEAL)",360,RC,35703,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,4681.00,case rate,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,5200.74,13852.00,case rate,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,676.91,8442.00,case rate,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3028.17,8442.00,case rate,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3501.31,8442.00,case rate,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,8045.00,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"THORACOSCOPY, SURGICAL; WITH MEDIASTINAL AND REGIONAL LYMPHADENECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,32674,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,594.81,4311.00,case rate,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13122,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE",360,RC,27703,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,13852.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5691.37,10022.00,case rate,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,124.01,4311.00,case rate,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1425.11,4311.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5691.37,10022.00,case rate,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,124.01,4311.00,case rate,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,17457.00,case rate,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,9503.00,,,,,,,9503.00,27871.00,case rate,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,990.00,4376.00,case rate,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,5754.00,case rate,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,8045.00,case rate,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1970.84,5754.00,case rate,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,7510.57,case rate,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
"VULVECTOMY, RADICAL, PARTIAL;",360,RC,56630,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5219.00,12247.00,case rate,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4121.00,13852.00,case rate,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,4376.00,case rate,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,9350.00,case rate,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,837.72,4311.00,case rate,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,4376.00,case rate,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"COLECTOMY, PARTIAL; WITH ANASTOMOSIS",360,RC,44140,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,17457.00,case rate,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3318.21,5754.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,17457.00,case rate,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,9350.00,case rate,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,24600.00,case rate,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,7962.20,13852.00,case rate,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"THORACOSCOPY, SURGICAL; WITH REMOVAL OF A SINGLE LUNG SEGMENT (SEGMENTECTOMY)",360,RC,32669,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND ANASTOMOSIS",360,RC,44120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,13852.00,case rate,
"THORACOSCOPY, SURGICAL; WITH THERAPEUTIC WEDGE RESECTION (EG, MASS, NODULE), INITIAL UNILATERAL",360,RC,32666,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMBAR, SACRAL, OR LUMBOSACRAL",360,RC,22015,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; CERVICAL, THORACIC, OR CERVICOTHORACIC",360,RC,22010,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,594.81,4311.00,case rate,
"REDUCTION OF VOLVULUS, INTUSSUSCEPTION, INTERNAL HERNIA, BY LAPAROTOMY",360,RC,44050,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,2025.00,11124.00,case rate,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL",360,RC,44020,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,2025.00,11124.00,case rate,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,17457.00,case rate,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,15260.00,,,,,,,12378.98,24600.00,case rate,
"MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,69990,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,629.57,2912.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,88.31,96.50,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,191.17,208.90,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,384.38,420.05,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1825.06,4311.00,case rate,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4121.00,9721.99,case rate,
"THYROIDECTOMY, TOTAL OR COMPLETE WITH PARATHYROID AUTOTRANSPLANTATION",360,RC,C7555,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2025.00,12247.00,case rate,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3522.17,8045.00,case rate,
"INTRAOPERATIVE NEAR-INFRARED FLUORESCENCE IMAGING OF MAJOR EXTRA-HEPATIC BILE DUCT(S) (E.G., CYSTIC DUCT, COMMON BILE DUCT AND COMMON HEPATIC DUCT) WITH INTRAVENOUS ADMINISTRATION OF INDOCYANINE GREEN (ICG) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,C9776,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,,,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,877.14,5152.00,case rate,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,877.14,5152.00,case rate,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3660.29,5754.00,case rate,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER THAN ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE)",360,RC,43848,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3660.29,8045.00,case rate,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3547.15,6735.00,case rate,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,13852.00,case rate,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5613.15,13852.00,case rate,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,13527.54,case rate,
"GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL POUCH",360,RC,43634,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1425.11,5152.00,case rate,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR, PARAESOPHAGEAL HIATAL HERNIA (INCLUDING FUNDOPLICATION), VIA LAPAROTOMY, EXCEPT NEONATAL; WITHOUT IMPLANTATION OF MESH OR OTHER PROSTHESIS",360,RC,43332,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,17457.00,case rate,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1659.09,6735.00,case rate,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3547.15,8442.00,case rate,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5219.00,10087.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,17457.00,case rate,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,12408.00,case rate,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3660.29,5754.00,case rate,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1825.06,6735.00,case rate,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,5754.00,case rate,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1970.84,5754.00,case rate,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3058.98,5754.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,8045.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3547.15,8045.00,case rate,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING, OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, FEMUR",360,RC,27495,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"OPEN TREATMENT OF FEMORAL SHAFT FRACTURE, WITH OR WITHOUT EXTERNAL FIXATION, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,27506,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10087.00,case rate,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,3120.11,12408.00,case rate,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1825.06,4311.00,case rate,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,5152.00,case rate,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,594.81,4311.00,case rate,
"OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE WITHOUT INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27511,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6636.00,10022.00,case rate,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,4376.00,case rate,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,5754.00,case rate,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5691.37,10022.00,case rate,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,5691.37,12247.00,case rate,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2025.00,4311.00,case rate,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,5152.00,case rate,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5691.37,10087.00,case rate,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3120.11,6735.00,case rate,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,1878.73,8442.00,case rate,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1425.11,6735.00,case rate,
"BONE MARROW ASPIRATION FOR BONE GRAFTING, SPINE SURGERY ONLY, THROUGH SEPARATE SKIN OR FASCIAL INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20939,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1425.11,4311.00,case rate,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,124.01,4311.00,case rate,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1425.11,4311.00,case rate,
"EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)/EXTRACORPOREAL LIFE SUPPORT (ECLS) PROVIDED BY PHYSICIAN; INITIATION, VENO-ARTERIAL",361,RC,33947,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3120.11,5754.00,case rate,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,10022.00,case rate,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3120.11,5754.00,case rate,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,4890.88,17457.00,case rate,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3522.17,8045.00,case rate,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,17457.00,case rate,
"ALLOGRAFT, INCLUDES TEMPLATING, CUTTING, PLACEMENT AND INTERNAL FIXATION, WHEN PERFORMED; OSTEOARTICULAR, INCLUDING ARTICULAR SURFACE AND CONTIGUOUS BONE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20932,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"MANUAL PREPARATION AND INSERTION OF DRUG-DELIVERY DEVICE(S), INTRAMEDULLARY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20702,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"SELECTIVE CATHETER PLACEMENT, EACH INTRACRANIAL BRANCH OF THE INTERNAL CAROTID OR VERTEBRAL ARTERIES, UNILATERAL, WITH ANGIOGRAPHY OF THE SELECTED VESSEL CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (EG, MIDDLE CEREBRAL ARTERY, POSTERIOR INFERIOR CEREBELLAR ARTERY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,36228,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3121.59,5754.00,case rate,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,6735.00,case rate,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5754.00,case rate,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,17457.00,case rate,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3121.59,5754.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,17457.00,case rate,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,6735.00,case rate,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,13852.00,case rate,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANTATION OR REPLACEMENT; WITH TESTING OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR",481,RC,93641,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,173.00,12247.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,13852.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,17457.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,5152.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,8045.00,case rate,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,1759.87,3142.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,5754.00,case rate,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3684.09,5754.00,case rate,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,5754.00,case rate,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,13852.00,case rate,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; EACH ADDITIONAL BRANCH SUBTENDED BY THE BYPASS GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3058.98,5754.00,case rate,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3684.09,5754.00,case rate,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2025.00,12408.00,case rate,
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37253,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37247,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,24600.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,52940.00,case rate,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3318.21,8442.00,case rate,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY;",360,RC,58275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,5219.00,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,24600.00,case rate,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37223,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,13852.00,case rate,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,360,RC,58340,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5485.35,13852.00,case rate,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3318.21,8442.00,case rate,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,4890.88,10022.00,case rate,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,15260.00,,,,,,,8612.00,17457.00,case rate,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,17457.00,case rate,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2025.00,8442.00,case rate,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5219.00,8045.00,case rate,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,8612.00,13852.00,case rate,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,3318.21,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE",360,RC,11005,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,990.00,4376.00,case rate,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3318.21,8442.00,case rate,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,1539.73,8442.00,case rate,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,642.16,4311.00,case rate,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE STENTING, AND ALL ANGIOPLASTY IN THE CENTRAL DIALYSIS SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36908,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,173.00,6735.00,case rate,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2753.54,5754.00,case rate,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,150.52,4311.00,case rate,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,990.00,8442.00,case rate,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5152.00,case rate,
"LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS)",360,RC,58740,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3788.00,10087.00,case rate,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3058.98,6735.00,case rate,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3788.00,8442.00,case rate,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3318.21,6735.00,case rate,
"COLPOPEXY, ABDOMINAL APPROACH",360,RC,57280,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3788.00,10087.00,case rate,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,4890.88,10022.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CESAREAN DELIVERY ONLY;,360,RC,59514,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,24600.00,case rate,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY",360,RC,59830,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,4681.00,case rate,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,676.91,2912.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6636.00,10945.84,case rate,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,642.16,6649.00,case rate,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5152.00,case rate,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5485.35,13852.00,case rate,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,4311.00,case rate,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5613.15,13852.00,case rate,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,13852.00,case rate,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5200.74,13852.00,case rate,
EXCISION OF CAROTID BODY TUMOR; WITHOUT EXCISION OF CAROTID ARTERY,360,RC,60600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"TWIST DRILL HOLE(S) FOR SUBDURAL, INTRACEREBRAL, OR VENTRICULAR PUNCTURE; FOR EVACUATION AND/OR DRAINAGE OF SUBDURAL HEMATOMA",360,RC,61108,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,64466,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,12247.00,24600.00,case rate,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3318.21,8045.00,case rate,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8213.00,19334.39,case rate,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, BIPOLAR ARTHROPLASTY)",360,RC,27125,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,8612.00,13852.00,case rate,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,6872.88,13852.00,case rate,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64491,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3395.25,17457.00,case rate,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,6872.88,13852.00,case rate,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3395.25,10087.00,case rate,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,4376.00,8045.00,case rate,
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64492,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,17457.00,case rate,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3028.17,17457.00,case rate,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1825.06,4311.00,case rate,
"REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT",360,RC,27138,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3395.25,17457.00,case rate,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,856.54,5152.00,case rate,
"LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE POSTERIOR BONY ELEMENTS (INCLUDING THE APPLICATION OF BRIDGING BONE GRAFT AND NON-SEGMENTAL FIXATION DEVICES [EG, WIRE, SUTURE, MINI-PLATES], WHEN PERFORMED)",360,RC,63051,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3395.25,8045.00,case rate,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11107,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, FEMORAL NECK AND PROXIMAL FEMUR",360,RC,27187,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,8442.00,13852.00,case rate,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63078,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT",360,RC,63081,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,8612.00,13852.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1659.09,5152.00,case rate,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT",360,RC,27236,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3318.21,10022.00,case rate,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,13852.00,case rate,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,5613.15,10022.00,case rate,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK OR PSEUDOMENINGOCELE, WITH LAMINECTOMY",360,RC,63709,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"DURAL GRAFT, SPINAL",360,RC,63710,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,8045.00,case rate,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5152.00,case rate,
"HEPATECTOMY, RESECTION OF LIVER; PARTIAL LOBECTOMY",360,RC,47120,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
"BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,47001,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,990.00,9350.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,856.54,4121.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1759.87,4311.00,case rate,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,5152.00,case rate,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,8045.00,case rate,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,676.91,4376.00,case rate,
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64469,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)",360,RC,36248,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,92978,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5754.00,case rate,
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY CONTINUOUS INFUSIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64489,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
"REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND URETHROPLASTY, SACROPERINEAL APPROACH",360,RC,46744,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR VAGINAL), POUCH ADVANCEMENT; COMBINED TRANSPERINEAL AND TRANSABDOMINAL APPROACH",360,RC,46712,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1134.38,4311.00,case rate,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,6872.88,13852.00,case rate,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2638.41,5754.00,case rate,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,1759.87,8442.00,case rate,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3028.17,8045.00,case rate,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1759.87,6735.00,case rate,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3318.21,8442.00,case rate,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,588.93,4311.00,case rate,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3788.00,7510.57,case rate,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,6872.88,13852.00,case rate,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,124.01,4311.00,case rate,
"INTRODUCTION OF CATHETER, AORTA",360,RC,36200,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; ABDOMEN",360,RC,35840,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,5152.00,case rate,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1878.73,5754.00,case rate,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2638.41,6735.00,case rate,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3628.02,8442.00,case rate,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3628.02,8045.00,case rate,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,124.01,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2244.50,5754.00,case rate,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1759.87,4376.00,case rate,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15276,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,4964.08,12408.00,case rate,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,877.14,2912.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11047,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3628.02,10087.00,case rate,
"BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-FEMORAL",360,RC,35661,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
ANGIOSCOPY (NONCORONARY VESSELS OR GRAFTS) DURING THERAPEUTIC INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,35400,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"PROCTOPEXY (EG, FOR PROLAPSE); ABDOMINAL APPROACH",360,RC,45540,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2194.26,5754.00,case rate,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; DEEP (PROFUNDA) FEMORAL",360,RC,35372,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,13852.00,case rate,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2194.26,8442.00,case rate,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,8045.00,case rate,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2753.54,5754.00,case rate,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2638.41,8045.00,case rate,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2194.26,17457.00,case rate,
"PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE SPARING; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES",360,RC,55845,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,12247.00,,,,,,,2025.00,12247.00,case rate,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6649.00,13852.00,case rate,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,5200.74,13852.00,case rate,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2194.26,5754.00,case rate,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1539.73,5152.00,case rate,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,527.80,4311.00,case rate,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3121.59,6735.00,case rate,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; CAROTID, VERTEBRAL, SUBCLAVIAN, BY NECK INCISION",360,RC,35301,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMPLETE, COMBINED ABDOMINOPERINEAL, WITH COLOSTOMY",360,RC,45395,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2753.54,17457.00,case rate,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,2025.00,12408.00,case rate,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1558.81,4311.00,case rate,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1134.38,5152.00,case rate,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,4311.00,17457.00,case rate,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,877.14,4311.00,case rate,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,8612.00,19334.39,case rate,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2194.26,5754.00,case rate,
"EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; ABDOMINAL AND PERINEAL APPROACH",360,RC,45135,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SINGLE INTERSPACE, LUMBAR",360,RC,22857,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,11124.00,,,,,,,11124.00,24600.00,case rate,
"UNLISTED PROCEDURE, MECKEL'S DIVERTICULUM AND THE MESENTERY",360,RC,44899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA AND PERINEUM",360,RC,11004,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,1316.38,4311.00,case rate,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
EXCISION OF LESION OF MESENTERY (SEPARATE PROCEDURE),360,RC,44820,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 7 TO 12 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22843,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, POPLITEAL ARTERY",360,RC,35151,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CLOSURE OF INTESTINAL CUTANEOUS FISTULA,360,RC,44640,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)/EXTRACORPOREAL LIFE SUPPORT (ECLS) PROVIDED BY PHYSICIAN; INITIATION, VENO-ARTERIAL",360,RC,33947,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); 4 OR MORE CORONARY ARTERIAL GRAFTS",360,RC,33536,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3501.31,8045.00,case rate,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3501.31,8442.00,case rate,
REVISION OF COLOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) (SEPARATE PROCEDURE),360,RC,44345,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,5219.00,8442.00,case rate,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,3522.17,8045.00,case rate,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1558.81,4376.00,case rate,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,3121.59,8442.00,case rate,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,2244.50,10087.00,case rate,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3628.02,10087.00,case rate,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,1539.73,6735.00,case rate,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3628.02,8045.00,case rate,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,2244.50,5754.00,case rate,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,931.82,4311.00,case rate,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,3522.17,8045.00,case rate,
"ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE",360,RC,44310,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,2025.00,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,150.52,4311.00,case rate,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2244.50,6735.00,case rate,
"LAPAROSCOPY, SURGICAL, CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE, WITH RESECTION AND ANASTOMOSIS",360,RC,44227,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6735.00,24600.00,case rate,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,10087.00,,,,,,,3628.02,10087.00,case rate,
"LAPAROSCOPY, SURGICAL, MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)",360,RC,44213,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,1825.06,5152.00,case rate,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,7962.20,13852.00,case rate,
"LAPAROSCOPY, SURGICAL; EACH ADDITIONAL SMALL INTESTINE RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,44203,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,,75.00,,,,,0,6636.00,10022.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN LEVEL CECOSTOMY",360,RC,44188,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,2025.00,6735.00,case rate,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,8442.00,,,,,,,2244.50,8442.00,case rate,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,6735.00,,,,,,,6636.00,10022.00,case rate,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3788.00,5754.00,case rate,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Aetna,Commercial,,4376.00,,,,,,,3121.59,5754.00,case rate,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,inpatient,,,0.14000,0.08000,Aetna,Commercial,,0.06160,,,,,,,0.04214,0.11382,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,130.00000,78.00000,Aetna,Commercial,,57.20,,,,,,,39.13,105.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Aetna,Commercial,,63.70,,,,,,,26.03,96.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,25.00000,15.00000,Aetna,Commercial,,11.00,,,,,,,7.53,20.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Aetna,Commercial,,12.25,,,,,,,5.00,31.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,Aetna,Commercial,,41.80,,,,,,,28.59,77.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,46.55,,,,,,,19.02,138.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,54.00000,32.40000,Aetna,Commercial,,23.76,,,,,,,16.25,43.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,26.46,,,,,,,5.99,40.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Aetna,Commercial,,92.25,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,Aetna,Commercial,,54.12,,,,,,,37.02,100.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Aetna,Commercial,,60.27,,,,,,,24.62,132.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,22.07000,13.24000,Aetna,Commercial,,9.71,,,,,,,6.64,17.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,142.00000,85.20000,Aetna,Commercial,,62.48,,,,,,,42.74,115.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Aetna,Commercial,,69.58,,,,,,,28.43,371.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,inpatient,,,39570.00000,23742.00000,Aetna,Commercial,,17410.80,,,,,,,11910.57,32170.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Aetna,Commercial,,19389.30,,,,,,,7921.91,29368.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,17004.00000,10202.40000,Aetna,Commercial,,7481.76,,,,,,,5118.20,13824.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Aetna,Commercial,,8331.96,,,,,,,162.39,12620.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,1919.00000,1151.40000,Aetna,Commercial,,844.36,,,,,,,577.62,1560.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Aetna,Commercial,,940.31,,,,,,,384.18,1424.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,7252.00000,4351.20000,Aetna,Commercial,,3190.88,,,,,,,2182.85,5895.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Aetna,Commercial,,3553.48,,,,,,,1451.85,5382.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,1734.00000,1040.40000,Aetna,Commercial,,762.96,,,,,,,521.93,1409.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Aetna,Commercial,,849.66,,,,,,,347.15,1286.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,3295.00000,1977.00000,Aetna,Commercial,,1449.80,,,,,,,991.79,2678.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Aetna,Commercial,,1614.55,,,,,,,659.66,2445.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,40220.00000,24132.00000,Aetna,Commercial,,17696.80,,,,,,,12106.22,32698.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Aetna,Commercial,,19707.80,,,,,,,8052.04,29851.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,12517.00000,7510.20000,Aetna,Commercial,,5507.48,,,,,,,3767.62,10176.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Aetna,Commercial,,6133.33,,,,,,,2505.90,9290.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,11120.00000,6672.00000,Aetna,Commercial,,4892.80,,,,,,,3347.12,9040.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Aetna,Commercial,,5448.80,,,,,,,2226.22,8253.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,15665.00000,9399.00000,Aetna,Commercial,,6892.60,,,,,,,4715.16,12735.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Aetna,Commercial,,7675.85,,,,,,,3136.13,11626.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,31578.00000,18946.80000,Aetna,Commercial,,13894.32,,,,,,,9504.98,25672.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Aetna,Commercial,,15473.22,,,,,,,6321.92,23437.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,2639.00000,1583.40000,Aetna,Commercial,,1161.16,,,,,,,794.34,2145.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Aetna,Commercial,,1293.11,,,,,,,528.33,1958.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,11117.00000,6670.20000,Aetna,Commercial,,4891.48,,,,,,,3346.22,9038.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Aetna,Commercial,,5447.33,,,,,,,2225.62,8251.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,16042.00000,9625.20000,Aetna,Commercial,,7058.48,,,,,,,4828.64,13042.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Aetna,Commercial,,7860.58,,,,,,,3211.61,11906.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,2696.00000,1617.60000,Aetna,Commercial,,1186.24,,,,,,,811.50,2191.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Aetna,Commercial,,1321.04,,,,,,,539.74,2000.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,8366.00000,5019.60000,Aetna,Commercial,,3681.04,,,,,,,2518.17,6801.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Aetna,Commercial,,4099.34,,,,,,,1674.87,6209.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,8920.00000,5352.00000,Aetna,Commercial,,3924.80,,,,,,,2684.92,7251.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Aetna,Commercial,,4370.80,,,,,,,1785.78,6620.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,11277.00000,6766.20000,Aetna,Commercial,,4961.88,,,,,,,3394.38,9168.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Aetna,Commercial,,5525.73,,,,,,,2257.66,8369.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Aetna,Commercial,,99.00,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,Aetna,Commercial,,200.20,,,,,,,136.96,369.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Aetna,Commercial,,222.95,,,,,,,5.88,337.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,Aetna,Commercial,,400.84,,,,,,,274.21,740.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Aetna,Commercial,,446.39,,,,,,,5.88,676.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,inpatient,,,31.28000,18.77000,Aetna,Commercial,,13.76,,,,,,,9.42,25.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Aetna,Commercial,,15.33,,,,,,,6.26,79.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,inpatient,,,20.34000,12.20000,Aetna,Commercial,,8.95,,,,,,,6.12,16.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Aetna,Commercial,,9.97,,,,,,,4.07,16.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,inpatient,,,278.96000,167.38000,Aetna,Commercial,,122.74,,,,,,,83.97,226.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Aetna,Commercial,,136.69,,,,,,,55.85,1004.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,inpatient,,,21.64000,12.98000,Aetna,Commercial,,9.52,,,,,,,6.51,17.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Aetna,Commercial,,10.60,,,,,,,4.33,50.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,inpatient,,,0.03000,0.02000,Aetna,Commercial,,0.01320,,,,,,,0.00903,0.02439,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,inpatient,,,21.42000,12.85000,Aetna,Commercial,,9.42,,,,,,,6.45,17.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Aetna,Commercial,,10.50,,,,,,,4.29,52.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,inpatient,,,40.61000,24.37000,Aetna,Commercial,,17.87,,,,,,,12.22,33.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Aetna,Commercial,,19.90,,,,,,,8.13,232.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,inpatient,,,20.37000,12.22000,Aetna,Commercial,,8.96,,,,,,,6.13,16.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Aetna,Commercial,,9.98,,,,,,,4.08,24.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,inpatient,,,19.90000,11.94000,Aetna,Commercial,,8.76,,,,,,,5.99,16.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Aetna,Commercial,,9.75,,,,,,,3.98,48.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Aetna,Commercial,,741.00,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Aetna,Commercial,,204.75,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,inpatient,,,65.26000,39.16000,Aetna,Commercial,,28.71,,,,,,,19.64,53.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Aetna,Commercial,,31.98,,,,,,,13.07,170.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Aetna,Commercial,,133.66,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,inpatient,,,15495.00000,9297.00000,Aetna,Commercial,,6817.80,,,,,,,4663.99,12597.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Aetna,Commercial,,7592.55,,,,,,,3102.10,11500.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,inpatient,,,6.33000,3.80000,Aetna,Commercial,,2.79,,,,,,,1.91,5.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,Aetna,Commercial,,88.00,,,,,,,60.20,162.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Aetna,Commercial,,98.00,,,,,,,40.04,186.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Aetna,Commercial,,150.00,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,inpatient,,,29.65000,17.79000,Aetna,Commercial,,13.05,,,,,,,8.92,24.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Aetna,Commercial,,14.53,,,,,,,5.94,75.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,Aetna,Commercial,,543.40,,,,,,,371.74,1004.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Commercial,,605.15,,,,,,,247.25,916.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,Aetna,Commercial,,461.12,,,,,,,315.45,852.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Commercial,,513.52,,,,,,,209.81,777.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,Aetna,Commercial,,311.08,,,,,,,212.81,574.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Aetna,Commercial,,346.43,,,,,,,141.54,524.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,Aetna,Commercial,,242.00,,,,,,,165.55,447.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Aetna,Commercial,,269.50,,,,,,,110.11,408.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,Aetna,Commercial,,194.48,,,,,,,133.04,359.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Aetna,Commercial,,216.58,,,,,,,88.49,343.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,Aetna,Commercial,,205.04,,,,,,,140.27,378.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Aetna,Commercial,,228.34,,,,,,,93.29,345.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Commercial,,926.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Commercial,,786.00,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Aetna,Commercial,,530.25,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Aetna,Commercial,,412.50,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Aetna,Commercial,,331.50,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Aetna,Commercial,,349.50,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,inpatient,,,27.47000,16.48000,Aetna,Commercial,,12.09,,,,,,,8.27,22.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,Aetna,Commercial,,251.24,,,,,,,171.87,464.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Aetna,Commercial,,279.79,,,,,,,114.31,423.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,Aetna,Commercial,,115.28,,,,,,,78.86,213.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Aetna,Commercial,,128.38,,,,,,,52.45,194.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,2469.00000,1481.40000,Aetna,Commercial,,1086.36,,,,,,,743.17,2007.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Aetna,Commercial,,1209.81,,,,,,,494.29,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,Aetna,Commercial,,307.12,,,,,,,210.10,567.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Aetna,Commercial,,342.02,,,,,,,139.74,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Aetna,Commercial,,523.50,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,Aetna,Commercial,,275.44,,,,,,,188.43,508.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,306.74,,,,,,,125.33,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,469.50,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,Aetna,Commercial,,270.60,,,,,,,185.12,500.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Aetna,Commercial,,301.35,,,,,,,123.12,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Aetna,Commercial,,461.25,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,Aetna,Commercial,,193.16,,,,,,,132.14,356.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,215.11,,,,,,,87.89,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,329.25,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,Aetna,Commercial,,175.56,,,,,,,120.10,324.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Aetna,Commercial,,195.51,,,,,,,79.88,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Aetna,Commercial,,299.25,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Aetna,Commercial,,1772.25,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Aetna,Commercial,,428.25,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Aetna,Commercial,,196.50,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,Aetna,Commercial,,137.72,,,,,,,94.21,254.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Aetna,Commercial,,153.37,,,,,,,62.66,232.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Aetna,Commercial,,234.75,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,Aetna,Commercial,,693.00,,,,,,,474.07,1280.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Commercial,,771.75,,,,,,,240.06,1168.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Commercial,,1181.25,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,Aetna,Commercial,,550.88,,,,,,,376.85,1017.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Commercial,,613.48,,,,,,,240.06,929.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Commercial,,939.00,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,Aetna,Commercial,,282.04,,,,,,,192.94,521.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Aetna,Commercial,,314.09,,,,,,,128.33,475.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Aetna,Commercial,,480.75,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,Aetna,Commercial,,149.60,,,,,,,102.34,276.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Aetna,Commercial,,166.60,,,,,,,68.07,274.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Aetna,Commercial,,255.00,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,Aetna,Commercial,,119.68,,,,,,,81.87,221.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Aetna,Commercial,,133.28,,,,,,,54.45,274.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Aetna,Commercial,,204.00,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,inpatient,,,216.17000,129.70000,Aetna,Commercial,,95.11,,,,,,,65.07,175.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Aetna,Commercial,,105.92,,,,,,,43.28,774.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Aetna,Commercial,,683.25,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Aetna,Commercial,,341.25,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,5187.00000,3112.20000,Aetna,Commercial,,2282.28,,,,,,,1561.29,4217.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Aetna,Commercial,,2541.63,,,,,,,120.36,3849.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,inpatient,,,153.80000,92.28000,Aetna,Commercial,,67.67,,,,,,,46.29,125.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Aetna,Commercial,,75.36,,,,,,,30.79,509.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2562.00000,1537.20000,Aetna,Commercial,,1127.28,,,,,,,771.16,2082.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Aetna,Commercial,,1255.38,,,,,,,240.06,1901.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,Aetna,Commercial,,434.72,,,,,,,297.39,803.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Aetna,Commercial,,484.12,,,,,,,197.80,733.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,626.00000,375.60000,Aetna,Commercial,,275.44,,,,,,,188.43,508.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,306.74,,,,,,,125.33,464.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,Aetna,Commercial,,120.12,,,,,,,82.17,221.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Aetna,Commercial,,133.77,,,,,,,54.65,268.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,inpatient,,,872.14000,523.28000,Aetna,Commercial,,383.74,,,,,,,262.51,709.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,inpatient,,,1070.23000,642.14000,Aetna,Commercial,,470.90,,,,,,,322.14,870.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,inpatient,,,2.18000,1.31000,Aetna,Commercial,,0.95920,,,,,,,0.65618,1.77,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,2078.00000,1246.80000,Aetna,Commercial,,914.32,,,,,,,625.48,1689.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Aetna,Commercial,,1018.22,,,,,,,162.39,1542.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,Aetna,Commercial,,1211.76,,,,,,,828.95,2239.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Commercial,,1349.46,,,,,,,240.06,2044.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,Aetna,Commercial,,535.04,,,,,,,366.02,988.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Commercial,,595.84,,,,,,,240.06,902.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,Aetna,Commercial,,271.04,,,,,,,185.42,500.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Aetna,Commercial,,301.84,,,,,,,123.32,457.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Commercial,,2065.50,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Commercial,,912.00,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Aetna,Commercial,,462.00,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,2813.00000,1687.80000,Aetna,Commercial,,1237.72,,,,,,,846.71,2286.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Aetna,Commercial,,1378.37,,,,,,,238.43,2087.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,inpatient,,,3.10000,1.86000,Aetna,Commercial,,1.36,,,,,,,0.93310,2.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,9.84000,5.90000,Aetna,Commercial,,4.33,,,,,,,2.96,8.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Aetna,Commercial,,144.46,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,inpatient,,,66.43000,39.86000,Aetna,Commercial,,29.23,,,,,,,20.00,54.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Aetna,Commercial,,32.55,,,,,,,13.30,179.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,Aetna,Commercial,,54.12,,,,,,,37.02,100.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Aetna,Commercial,,60.27,,,,,,,24.62,132.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00490,,,,,,,0.00200,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00490,,,,,,,0.00200,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00490,,,,,,,0.00200,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00490,,,,,,,0.00200,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00490,,,,,,,0.00200,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,inpatient,,,237.69000,142.61000,Aetna,Commercial,,104.58,,,,,,,71.54,193.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Aetna,Commercial,,116.47,,,,,,,47.59,728.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,inpatient,,,273.90000,164.34000,Aetna,Commercial,,120.52,,,,,,,82.44,222.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Aetna,Commercial,,134.21,,,,,,,54.83,872.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,inpatient,,,158.70000,95.22000,Aetna,Commercial,,69.83,,,,,,,47.77,129.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Aetna,Commercial,,77.76,,,,,,,31.77,450.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,Aetna,Commercial,,150.48,,,,,,,102.94,278.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Aetna,Commercial,,167.58,,,,,,,68.47,253.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Aetna,Commercial,,256.50,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00490,,,,,,,0.00200,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00490,,,,,,,0.00200,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,Aetna,Commercial,,680.24,,,,,,,465.35,1256.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Commercial,,757.54,,,,,,,309.51,1147.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,3094.00000,1856.40000,Aetna,Commercial,,1361.36,,,,,,,931.29,2515.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Aetna,Commercial,,1516.06,,,,,,,327.43,2296.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Commercial,,1159.50,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,inpatient,,,330.40000,198.24000,Aetna,Commercial,,145.38,,,,,,,99.45,268.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Aetna,Commercial,,161.90,,,,,,,66.15,1002.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,inpatient,,,329.28000,197.57000,Aetna,Commercial,,144.88,,,,,,,99.11,267.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Aetna,Commercial,,161.35,,,,,,,65.92,1000.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,inpatient,,,153.16000,91.90000,Aetna,Commercial,,67.39,,,,,,,46.10,124.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Aetna,Commercial,,75.05,,,,,,,30.66,434.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,inpatient,,,158.82000,95.29000,Aetna,Commercial,,69.88,,,,,,,47.80,129.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Aetna,Commercial,,77.82,,,,,,,31.80,450.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,Aetna,Commercial,,188.32,,,,,,,128.83,347.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Aetna,Commercial,,209.72,,,,,,,70.59,317.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Aetna,Commercial,,321.00,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,Aetna,Commercial,,212.52,,,,,,,145.38,392.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Aetna,Commercial,,236.67,,,,,,,70.59,358.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Aetna,Commercial,,362.25,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,10.00000,6.00000,Aetna,Commercial,,4.40,,,,,,,3.01,8.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Aetna,Commercial,,4.90,,,,,,,2.00,7.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,Aetna,Commercial,,1099.12,,,,,,,751.90,2030.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Commercial,,1224.02,,,,,,,500.10,1854.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Commercial,,1873.50,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,Aetna,Commercial,,891.00,,,,,,,609.52,1646.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Commercial,,992.25,,,,,,,405.40,1502.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Commercial,,1518.75,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,Aetna,Commercial,,751.52,,,,,,,514.11,1388.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Commercial,,836.92,,,,,,,341.94,1267.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Commercial,,1281.00,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00440,,,,,,,0.00301,0.00813,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,inpatient,,,322.28000,193.37000,Aetna,Commercial,,141.80,,,,,,,97.01,262.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Aetna,Commercial,,157.92,,,,,,,64.52,914.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,Aetna,Commercial,,28.60,,,,,,,19.57,52.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,31.85,,,,,,,13.01,48.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,inpatient,,,81.13000,48.68000,Aetna,Commercial,,35.70,,,,,,,24.42,65.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Aetna,Commercial,,39.75,,,,,,,16.24,221.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,inpatient,,,53.52000,32.11000,Aetna,Commercial,,23.55,,,,,,,16.11,43.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Aetna,Commercial,,26.22,,,,,,,10.71,115.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,inpatient,,,126.03000,75.62000,Aetna,Commercial,,55.45,,,,,,,37.94,102.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Aetna,Commercial,,61.75,,,,,,,25.23,431.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,inpatient,,,30.86000,18.52000,Aetna,Commercial,,13.58,,,,,,,9.29,25.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Aetna,Commercial,,15.12,,,,,,,6.18,99.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,inpatient,,,16.63000,9.98000,Aetna,Commercial,,7.32,,,,,,,5.01,13.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Aetna,Commercial,,8.15,,,,,,,3.33,42.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,inpatient,,,116.79000,70.07000,Aetna,Commercial,,51.39,,,,,,,35.15,94.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Aetna,Commercial,,57.23,,,,,,,23.38,367.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,inpatient,,,33.65000,20.19000,Aetna,Commercial,,14.81,,,,,,,10.13,27.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Aetna,Commercial,,16.49,,,,,,,6.74,97.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,inpatient,,,96.04000,57.62000,Aetna,Commercial,,42.26,,,,,,,28.91,78.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Aetna,Commercial,,47.06,,,,,,,19.23,309.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,inpatient,,,275.02000,165.01000,Aetna,Commercial,,121.01,,,,,,,82.78,223.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Aetna,Commercial,,134.76,,,,,,,55.06,907.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,inpatient,,,42.62000,25.57000,Aetna,Commercial,,18.75,,,,,,,12.83,34.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Aetna,Commercial,,20.88,,,,,,,8.53,145.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,inpatient,,,51.42000,30.85000,Aetna,Commercial,,22.62,,,,,,,15.48,41.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Aetna,Commercial,,25.20,,,,,,,10.29,128.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,inpatient,,,166.08000,99.65000,Aetna,Commercial,,73.08,,,,,,,49.99,135.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Aetna,Commercial,,81.38,,,,,,,33.25,597.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,inpatient,,,128.79000,77.27000,Aetna,Commercial,,56.67,,,,,,,38.77,104.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Aetna,Commercial,,63.11,,,,,,,25.78,372.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,inpatient,,,154.18000,92.51000,Aetna,Commercial,,67.84,,,,,,,46.41,125.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Aetna,Commercial,,75.55,,,,,,,30.87,544.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,inpatient,,,146.33000,87.80000,Aetna,Commercial,,64.39,,,,,,,44.05,118.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Aetna,Commercial,,71.70,,,,,,,29.30,518.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,inpatient,,,26.14000,15.68000,Aetna,Commercial,,11.50,,,,,,,7.87,21.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Aetna,Commercial,,12.81,,,,,,,5.23,209.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,inpatient,,,28.56000,17.14000,Aetna,Commercial,,12.57,,,,,,,8.60,23.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Aetna,Commercial,,13.99,,,,,,,5.72,88.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,inpatient,,,68.05000,40.83000,Aetna,Commercial,,29.94,,,,,,,20.48,55.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Aetna,Commercial,,33.34,,,,,,,13.62,196.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,inpatient,,,140.75000,84.45000,Aetna,Commercial,,61.93,,,,,,,42.37,114.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Aetna,Commercial,,68.97,,,,,,,28.18,392.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,0.51000,0.31000,Aetna,Commercial,,0.22440,,,,,,,0.15351,0.41463,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,inpatient,,,26.23000,15.74000,Aetna,Commercial,,11.54,,,,,,,7.90,21.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,inpatient,,,5.92000,3.55000,Aetna,Commercial,,2.60,,,,,,,1.78,4.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,inpatient,,,0.11000,0.07000,Aetna,Commercial,,0.04840,,,,,,,0.03311,0.08943,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,inpatient,,,0.80000,0.48000,Aetna,Commercial,,0.35200,,,,,,,0.24080,0.65040,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,inpatient,,,7.76000,4.66000,Aetna,Commercial,,3.41,,,,,,,2.34,6.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,inpatient,,,0.79000,0.47000,Aetna,Commercial,,0.34760,,,,,,,0.23779,0.64227,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,0.47000,0.28000,Aetna,Commercial,,0.20680,,,,,,,0.14147,0.38211,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,inpatient,,,0.64000,0.38000,Aetna,Commercial,,0.28160,,,,,,,0.19264,0.52032,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,inpatient,,,1666.78000,1000.07000,Aetna,Commercial,,733.38,,,,,,,501.70,1355.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,inpatient,,,0.02000,0.01000,Aetna,Commercial,,0.00880,,,,,,,0.00602,0.01626,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,inpatient,,,25.77000,15.46000,Aetna,Commercial,,11.34,,,,,,,7.76,20.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,inpatient,,,81.46000,48.88000,Aetna,Commercial,,35.84,,,,,,,24.52,66.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,0.07000,0.04000,Aetna,Commercial,,0.03080,,,,,,,0.02107,0.05691,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,inpatient,,,4.25000,2.55000,Aetna,Commercial,,1.87,,,,,,,1.28,3.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,inpatient,,,6.12000,3.67000,Aetna,Commercial,,2.69,,,,,,,1.84,4.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,inpatient,,,1.12000,0.67000,Aetna,Commercial,,0.49280,,,,,,,0.33712,0.91056,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,inpatient,,,1.61000,0.97000,Aetna,Commercial,,0.70840,,,,,,,0.48461,1.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,inpatient,,,2.56000,1.54000,Aetna,Commercial,,1.13,,,,,,,0.77056,2.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,inpatient,,,1.79000,1.07000,Aetna,Commercial,,0.78760,,,,,,,0.53879,1.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,inpatient,,,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,inpatient,,,0.02000,0.01000,Aetna,Commercial,,0.00880,,,,,,,0.00602,0.01626,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,inpatient,,,22.10000,13.26000,Aetna,Commercial,,9.72,,,,,,,6.65,17.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Aetna,Commercial,,10.83,,,,,,,4.42,62.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,inpatient,,,1100.73000,660.44000,Aetna,Commercial,,484.32,,,,,,,331.32,894.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,inpatient,,,77.03000,46.22000,Aetna,Commercial,,33.89,,,,,,,23.19,62.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,inpatient,,,134.92000,80.95000,Aetna,Commercial,,59.36,,,,,,,40.61,109.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,inpatient,,,166.43000,99.86000,Aetna,Commercial,,73.23,,,,,,,50.10,135.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,inpatient,,,17.28000,10.37000,Aetna,Commercial,,7.60,,,,,,,5.20,14.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,inpatient,,,0.13000,0.08000,Aetna,Commercial,,0.05720,,,,,,,0.03913,0.10569,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,inpatient,,,36.34000,21.80000,Aetna,Commercial,,15.99,,,,,,,10.94,29.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Aetna,Commercial,,17.81,,,,,,,7.28,115.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,inpatient,,,65.26000,39.16000,Aetna,Commercial,,28.71,,,,,,,19.64,53.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Aetna,Commercial,,31.98,,,,,,,13.07,232.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,inpatient,,,143.90000,86.34000,Aetna,Commercial,,63.32,,,,,,,43.31,116.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Aetna,Commercial,,70.51,,,,,,,28.81,479.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,inpatient,,,63.57000,38.14000,Aetna,Commercial,,27.97,,,,,,,19.13,51.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Aetna,Commercial,,31.15,,,,,,,12.73,208.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,inpatient,,,249.07000,149.44000,Aetna,Commercial,,109.59,,,,,,,74.97,202.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Aetna,Commercial,,122.04,,,,,,,49.86,719.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,inpatient,,,11.23000,6.74000,Aetna,Commercial,,4.94,,,,,,,3.38,9.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,inpatient,,,25.48000,15.29000,Aetna,Commercial,,11.21,,,,,,,7.67,20.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,inpatient,,,0.75000,0.45000,Aetna,Commercial,,0.33000,,,,,,,0.22575,0.60975,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,inpatient,,,0.04000,0.02000,Aetna,Commercial,,0.01760,,,,,,,0.01204,0.03252,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,inpatient,,,13.35000,8.01000,Aetna,Commercial,,5.87,,,,,,,4.02,10.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,inpatient,,,11.89000,7.13000,Aetna,Commercial,,5.23,,,,,,,3.58,9.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Aetna,Commercial,,5.83,,,,,,,2.38,71.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,inpatient,,,17.69000,10.61000,Aetna,Commercial,,7.78,,,,,,,5.32,14.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Aetna,Commercial,,8.67,,,,,,,3.54,41.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,inpatient,,,33.35000,20.01000,Aetna,Commercial,,14.67,,,,,,,10.04,27.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Aetna,Commercial,,16.34,,,,,,,6.68,111.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,inpatient,,,54.96000,32.98000,Aetna,Commercial,,24.18,,,,,,,16.54,44.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Aetna,Commercial,,26.93,,,,,,,11.00,232.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,inpatient,,,139.15000,83.49000,Aetna,Commercial,,61.23,,,,,,,41.88,113.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Aetna,Commercial,,68.18,,,,,,,27.86,495.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,inpatient,25,ML,548.70000,329.22000,Aetna,Commercial,,241.43,,,,,,,165.16,446.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,inpatient,5,ML,316.25000,189.75000,Aetna,Commercial,,139.15,,,,,,,95.19,257.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,inpatient,1,UN,371.25000,222.75000,Aetna,Commercial,,163.35,,,,,,,111.75,301.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,inpatient,1,UN,82.95000,49.77000,Aetna,Commercial,,36.50,,,,,,,24.97,67.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,inpatient,1,ML,64.90000,38.94000,Aetna,Commercial,,28.56,,,,,,,19.53,52.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,inpatient,1,ML,64.90000,38.94000,Aetna,Commercial,,28.56,,,,,,,19.53,52.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,Aetna,Commercial,,1289.09,,,,,,,881.85,2381.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,Aetna,Commercial,,8558.81,,,,,,,5855.01,15814.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,inpatient,100,ML,128.45000,77.07000,Aetna,Commercial,,56.52,,,,,,,38.66,104.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,inpatient,1,ML,84.10000,50.46000,Aetna,Commercial,,37.00,,,,,,,25.31,68.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,inpatient,1,UN,3544.00000,2126.40000,Aetna,Commercial,,1559.36,,,,,,,1066.74,2881.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,inpatient,5,ML,304.25000,182.55000,Aetna,Commercial,,133.87,,,,,,,91.58,247.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Aetna,Commercial,,228.19,,,,,,,0.89680,247.36,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,inpatient,10,ML,2414.30000,1448.58000,Aetna,Commercial,,1062.29,,,,,,,726.70,1962.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,inpatient,1,UN,471.55000,282.93000,Aetna,Commercial,,207.48,,,,,,,141.94,383.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,inpatient,1,UN,5220.40000,3132.24000,Aetna,Commercial,,2296.98,,,,,,,1571.34,4244.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,inpatient,0.5,ML,79.90000,47.94000,Aetna,Commercial,,35.16,,,,,,,24.05,64.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,inpatient,1,ML,33.65000,20.19000,Aetna,Commercial,,14.81,,,,,,,10.13,27.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,inpatient,10,ML,34.85000,20.91000,Aetna,Commercial,,15.33,,,,,,,10.49,28.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,inpatient,30,ML,47.00000,28.20000,Aetna,Commercial,,20.68,,,,,,,14.15,38.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,inpatient,1,ML,19.85000,11.91000,Aetna,Commercial,,8.73,,,,,,,5.97,16.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,inpatient,1,ML,25.20000,15.12000,Aetna,Commercial,,11.09,,,,,,,7.59,20.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,inpatient,1,UN,436.70000,262.02000,Aetna,Commercial,,192.15,,,,,,,131.45,355.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,inpatient,1,UN,748.20000,448.92000,Aetna,Commercial,,329.21,,,,,,,225.21,608.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,inpatient,10,ML,219.00000,131.40000,Aetna,Commercial,,96.36,,,,,,,65.92,178.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,inpatient,10,ML,219.00000,131.40000,Aetna,Commercial,,96.36,,,,,,,65.92,178.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,Aetna,Commercial,,96.36,,,,,,,65.92,178.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Aetna,Commercial,,37.09,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Aetna,Commercial,,43.16,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,inpatient,0.5,ML,568.50000,341.10000,Aetna,Commercial,,250.14,,,,,,,171.12,462.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Aetna,Commercial,,278.56,,,,,,,6.49,421.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,inpatient,2,ML,26.75000,16.05000,Aetna,Commercial,,11.77,,,,,,,8.05,21.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,inpatient,30,ML,30.90000,18.54000,Aetna,Commercial,,13.60,,,,,,,9.30,25.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,inpatient,5,ML,23.80000,14.28000,Aetna,Commercial,,10.47,,,,,,,7.16,19.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,inpatient,10,ML,47.55000,28.53000,Aetna,Commercial,,20.92,,,,,,,14.31,38.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,inpatient,2,ML,29.35000,17.61000,Aetna,Commercial,,12.91,,,,,,,8.83,23.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,Aetna,Commercial,,14.23,,,,,,,9.74,26.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,inpatient,1,UN,2741.35000,1644.81000,Aetna,Commercial,,1206.19,,,,,,,825.15,2228.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,inpatient,1,ML,17.75000,10.65000,Aetna,Commercial,,7.81,,,,,,,5.34,14.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,inpatient,1,ML,16.75000,10.05000,Aetna,Commercial,,7.37,,,,,,,5.04,13.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,inpatient,1,ML,17.00000,10.20000,Aetna,Commercial,,7.48,,,,,,,5.12,13.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,inpatient,1,ML,21.35000,12.81000,Aetna,Commercial,,9.39,,,,,,,6.43,17.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,Aetna,Commercial,,10.21,,,,,,,6.98,18.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,inpatient,0.25,ML,22.75000,13.65000,Aetna,Commercial,,10.01,,,,,,,6.85,18.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,inpatient,5,ML,20322.25000,12193.35000,Aetna,Commercial,,8941.79,,,,,,,6117.00,16521.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,inpatient,1,UN,300.90000,180.54000,Aetna,Commercial,,132.40,,,,,,,90.57,244.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Aetna,Commercial,,147.44,,,,,,,60.24,309.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,Aetna,Commercial,,1089.00,,,,,,,744.98,2012.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,inpatient,1,UN,70.30000,42.18000,Aetna,Commercial,,30.93,,,,,,,21.16,57.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,inpatient,30,ML,84.80000,50.88000,Aetna,Commercial,,37.31,,,,,,,25.52,68.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,inpatient,10,ML,385.00000,231.00000,Aetna,Commercial,,169.40,,,,,,,115.89,313.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,inpatient,1,UN,774.35000,464.61000,Aetna,Commercial,,340.71,,,,,,,233.08,629.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,inpatient,30,ML,66.65000,39.99000,Aetna,Commercial,,29.33,,,,,,,20.06,54.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,inpatient,20,ML,72.25000,43.35000,Aetna,Commercial,,31.79,,,,,,,21.75,58.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,inpatient,10,ML,39.65000,23.79000,Aetna,Commercial,,17.45,,,,,,,11.93,32.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,inpatient,30,ML,28.15000,16.89000,Aetna,Commercial,,12.39,,,,,,,8.47,22.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,inpatient,6,ML,60837.10000,36502.26000,Aetna,Commercial,,26768.32,,,,,,,18311.97,49460.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,inpatient,1,ML,158.35000,95.01000,Aetna,Commercial,,69.67,,,,,,,47.66,128.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,inpatient,1,UN,520.25000,312.15000,Aetna,Commercial,,228.91,,,,,,,156.60,422.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,inpatient,0.3,ML,49.90000,29.94000,Aetna,Commercial,,21.96,,,,,,,15.02,40.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,inpatient,0.4,ML,61.20000,36.72000,Aetna,Commercial,,26.93,,,,,,,18.42,49.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,inpatient,0.6,ML,83.85000,50.31000,Aetna,Commercial,,36.89,,,,,,,25.24,68.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,inpatient,0.8,ML,106.45000,63.87000,Aetna,Commercial,,46.84,,,,,,,32.04,86.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,inpatient,1,ML,129.05000,77.43000,Aetna,Commercial,,56.78,,,,,,,38.84,104.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,inpatient,0.8,ML,70.85000,42.51000,Aetna,Commercial,,31.17,,,,,,,21.33,57.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,inpatient,1,UN,1235.40000,741.24000,Aetna,Commercial,,543.58,,,,,,,371.86,1004.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,inpatient,1,UN,2341.05000,1404.63000,Aetna,Commercial,,1030.06,,,,,,,704.66,1903.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,Aetna,Commercial,,18.79,,,,,,,12.85,34.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,inpatient,2,ML,123.00000,73.80000,Aetna,Commercial,,54.12,,,,,,,37.02,100.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,inpatient,1,UN,3055.75000,1833.45000,Aetna,Commercial,,1344.53,,,,,,,919.78,2484.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,Aetna,Commercial,,2568.04,,,,,,,1756.77,4745.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,inpatient,1,UN,1345.40000,807.24000,Aetna,Commercial,,591.98,,,,,,,404.97,1093.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,inpatient,2,ML,21.50000,12.90000,Aetna,Commercial,,9.46,,,,,,,6.47,17.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,inpatient,1,ML,64.55000,38.73000,Aetna,Commercial,,28.40,,,,,,,19.43,52.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,inpatient,50,ML,35.60000,21.36000,Aetna,Commercial,,15.66,,,,,,,10.72,28.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,inpatient,1,UN,2420.70000,1452.42000,Aetna,Commercial,,1065.11,,,,,,,728.63,1968.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,inpatient,2,ML,6479.00000,3887.40000,Aetna,Commercial,,2850.76,,,,,,,1950.18,5267.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,inpatient,1,UN,168.00000,100.80000,Aetna,Commercial,,73.92,,,,,,,50.57,136.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,Aetna,Commercial,,503.51,,,,,,,344.45,930.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,inpatient,100,ML,101.15000,60.69000,Aetna,Commercial,,44.51,,,,,,,30.45,82.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,inpatient,0.6,ML,263.20000,157.92000,Aetna,Commercial,,115.81,,,,,,,79.22,213.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,inpatient,0.8,ML,263.20000,157.92000,Aetna,Commercial,,115.81,,,,,,,79.22,213.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,inpatient,0.6,ML,881.50000,528.90000,Aetna,Commercial,,387.86,,,,,,,265.33,716.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,inpatient,0.42,ML,896.45000,537.87000,Aetna,Commercial,,394.44,,,,,,,269.83,728.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,inpatient,0.4,ML,1424.70000,854.82000,Aetna,Commercial,,626.87,,,,,,,428.83,1158.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,inpatient,0.3,ML,2129.05000,1277.43000,Aetna,Commercial,,936.78,,,,,,,640.84,1730.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,inpatient,0.5,ML,3537.70000,2122.62000,Aetna,Commercial,,1556.59,,,,,,,1064.85,2876.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,inpatient,0.4,ML,7059.40000,4235.64000,Aetna,Commercial,,3106.14,,,,,,,2124.88,5739.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,inpatient,0.6,ML,10581.10000,6348.66000,Aetna,Commercial,,4655.68,,,,,,,3184.91,8602.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,inpatient,2,ML,1695.15000,1017.09000,Aetna,Commercial,,745.87,,,,,,,510.24,1378.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,inpatient,5,ML,8246.30000,4947.78000,Aetna,Commercial,,3628.37,,,,,,,2482.14,6704.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,inpatient,20,ML,32160.05000,19296.03000,Aetna,Commercial,,14150.42,,,,,,,9680.18,26146.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,Aetna,Commercial,,2481.71,,,,,,,1697.72,4585.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,Aetna,Commercial,,4935.68,,,,,,,3376.45,9119.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,Aetna,Commercial,,140.29,,,,,,,95.97,259.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,Aetna,Commercial,,140.29,,,,,,,95.97,259.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,inpatient,10,ML,8806.85000,5284.11000,Aetna,Commercial,,3875.01,,,,,,,2650.86,7159.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,inpatient,100,ML,83.30000,49.98000,Aetna,Commercial,,36.65,,,,,,,25.07,67.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,inpatient,150,ML,101.35000,60.81000,Aetna,Commercial,,44.59,,,,,,,30.51,82.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,inpatient,0.5,ML,153.95000,92.37000,Aetna,Commercial,,67.74,,,,,,,46.34,125.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Aetna,Commercial,,75.44,,,,,,,30.82,145.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,inpatient,0.05,ML,18.70000,11.22000,Aetna,Commercial,,8.23,,,,,,,5.63,15.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,inpatient,1,UN,141.95000,85.17000,Aetna,Commercial,,62.46,,,,,,,42.73,115.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,inpatient,4,ML,884.70000,530.82000,Aetna,Commercial,,389.27,,,,,,,266.29,719.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,Aetna,Commercial,,17651.00,,,,,,,12074.89,32614.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,Aetna,Commercial,,70240.76,,,,,,,48051.07,129785.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,inpatient,1,ML,985.50000,591.30000,Aetna,Commercial,,433.62,,,,,,,296.64,801.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,inpatient,50,ML,100.65000,60.39000,Aetna,Commercial,,44.29,,,,,,,30.30,81.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,193.80000,116.28000,Aetna,Commercial,,85.27,,,,,,,58.33,157.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,inpatient,1,UN,13260.65000,7956.39000,Aetna,Commercial,,5834.69,,,,,,,3991.46,10780.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,inpatient,1,UN,2245.35000,1347.21000,Aetna,Commercial,,987.95,,,,,,,675.85,1825.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,inpatient,60,ML,709.90000,425.94000,Aetna,Commercial,,312.36,,,,,,,213.68,577.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,inpatient,0.2,ML,60.60000,36.36000,Aetna,Commercial,,26.66,,,,,,,18.24,49.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,inpatient,100,ML,184.45000,110.67000,Aetna,Commercial,,81.16,,,,,,,55.52,149.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,inpatient,200,ML,224.70000,134.82000,Aetna,Commercial,,98.87,,,,,,,67.63,182.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,inpatient,100,ML,77.35000,46.41000,Aetna,Commercial,,34.03,,,,,,,23.28,62.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,inpatient,50,ML,76.30000,45.78000,Aetna,Commercial,,33.57,,,,,,,22.97,62.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,inpatient,100,ML,77.35000,46.41000,Aetna,Commercial,,34.03,,,,,,,23.28,62.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,Aetna,Commercial,,44.66,,,,,,,30.55,82.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,inpatient,1000,ML,105.00000,63.00000,Aetna,Commercial,,46.20,,,,,,,31.61,85.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,inpatient,1,UN,56048.55000,33629.13000,Aetna,Commercial,,24661.36,,,,,,,16870.61,45567.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,inpatient,1,UN,4464.60000,2678.76000,Aetna,Commercial,,1964.42,,,,,,,1343.84,3629.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,inpatient,100,ML,70.60000,42.36000,Aetna,Commercial,,31.06,,,,,,,21.25,57.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,inpatient,20,ML,26.95000,16.17000,Aetna,Commercial,,11.86,,,,,,,8.11,21.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,inpatient,10,ML,1113.90000,668.34000,Aetna,Commercial,,490.12,,,,,,,335.28,905.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,inpatient,20,ML,1830.00000,1098.00000,Aetna,Commercial,,805.20,,,,,,,550.83,1487.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,inpatient,5.26,ML,316.10000,189.66000,Aetna,Commercial,,139.08,,,,,,,95.15,256.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,inpatient,26.3,ML,474.30000,284.58000,Aetna,Commercial,,208.69,,,,,,,142.76,385.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,inpatient,1,UN,710.25000,426.15000,Aetna,Commercial,,312.51,,,,,,,213.79,577.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,inpatient,1,UN,568.80000,341.28000,Aetna,Commercial,,250.27,,,,,,,171.21,462.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Aetna,Commercial,,278.71,,,,,,,113.87,597.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,inpatient,100,ML,112.00000,67.20000,Aetna,Commercial,,49.28,,,,,,,33.71,91.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,inpatient,100,ML,168.00000,100.80000,Aetna,Commercial,,73.92,,,,,,,50.57,136.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,inpatient,1,UN,609.65000,365.79000,Aetna,Commercial,,268.25,,,,,,,183.50,495.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,Aetna,Commercial,,28.16,,,,,,,19.26,52.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,inpatient,1,UN,159.35000,95.61000,Aetna,Commercial,,70.11,,,,,,,47.96,129.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,inpatient,1,ML,34.20000,20.52000,Aetna,Commercial,,15.05,,,,,,,10.29,27.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,inpatient,1,UN,380.00000,228.00000,Aetna,Commercial,,167.20,,,,,,,114.38,308.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,25404.55000,15242.73000,Aetna,Commercial,,11178.00,,,,,,,7646.77,20653.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,inpatient,1,UN,1854.60000,1112.76000,Aetna,Commercial,,816.02,,,,,,,558.23,1507.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,inpatient,1,UN,961.85000,577.11000,Aetna,Commercial,,423.21,,,,,,,289.52,781.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,inpatient,1,ML,36.05000,21.63000,Aetna,Commercial,,15.86,,,,,,,10.85,29.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,14,ML,30285.20000,18171.12000,Aetna,Commercial,,13325.49,,,,,,,9115.85,24621.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,inpatient,5,ML,72.05000,43.23000,Aetna,Commercial,,31.70,,,,,,,21.69,58.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,inpatient,20,ML,185.65000,111.39000,Aetna,Commercial,,81.69,,,,,,,55.88,150.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,inpatient,2,ML,320.55000,192.33000,Aetna,Commercial,,141.04,,,,,,,96.49,260.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,inpatient,40,ML,438.00000,262.80000,Aetna,Commercial,,192.72,,,,,,,131.84,356.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,Aetna,Commercial,,6969.01,,,,,,,4767.43,12876.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,Aetna,Commercial,,11.59,,,,,,,7.93,21.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,inpatient,1,UN,60.00000,36.00000,Aetna,Commercial,,26.40,,,,,,,18.06,48.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Aetna,Commercial,,29.40,,,,,,,12.01,44.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,inpatient,50,ML,32.20000,19.32000,Aetna,Commercial,,14.17,,,,,,,9.69,26.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,inpatient,0.5,ML,22.30000,13.38000,Aetna,Commercial,,9.81,,,,,,,6.71,18.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,inpatient,30,ML,87.55000,52.53000,Aetna,Commercial,,38.52,,,,,,,26.35,71.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,inpatient,10,ML,147.95000,88.77000,Aetna,Commercial,,65.10,,,,,,,44.53,120.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,inpatient,1,ML,32.10000,19.26000,Aetna,Commercial,,14.12,,,,,,,9.66,26.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,inpatient,10,ML,26.80000,16.08000,Aetna,Commercial,,11.79,,,,,,,8.07,21.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,inpatient,30,ML,23.95000,14.37000,Aetna,Commercial,,10.54,,,,,,,7.21,19.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,inpatient,50,ML,29.45000,17.67000,Aetna,Commercial,,12.96,,,,,,,8.86,23.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,inpatient,10,ML,43.10000,25.86000,Aetna,Commercial,,18.96,,,,,,,12.97,35.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,inpatient,30,ML,53.45000,32.07000,Aetna,Commercial,,23.52,,,,,,,16.09,43.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,inpatient,300,ML,178.50000,107.10000,Aetna,Commercial,,78.54,,,,,,,53.73,145.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,inpatient,2,ML,53.10000,31.86000,Aetna,Commercial,,23.36,,,,,,,15.98,43.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,inpatient,0.25,ML,24.70000,14.82000,Aetna,Commercial,,10.87,,,,,,,7.43,20.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,Aetna,Commercial,,13.11,,,,,,,8.97,24.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,inpatient,10,ML,170.20000,102.12000,Aetna,Commercial,,74.89,,,,,,,51.23,138.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,Aetna,Commercial,,157.19,,,,,,,107.53,290.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,Aetna,Commercial,,508.66,,,,,,,347.97,939.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,inpatient,5,ML,118261.70000,70957.02000,Aetna,Commercial,,52035.15,,,,,,,35596.77,96146.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,inpatient,100,ML,76.65000,45.99000,Aetna,Commercial,,33.73,,,,,,,23.07,62.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,inpatient,1,ML,40.15000,24.09000,Aetna,Commercial,,17.67,,,,,,,12.09,32.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,inpatient,1,ML,44.70000,26.82000,Aetna,Commercial,,19.67,,,,,,,13.45,36.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,inpatient,0.75,ML,36.40000,21.84000,Aetna,Commercial,,16.02,,,,,,,10.96,29.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,inpatient,1,UN,1052.35000,631.41000,Aetna,Commercial,,463.03,,,,,,,316.76,855.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,inpatient,5,ML,3636.80000,2182.08000,Aetna,Commercial,,1600.19,,,,,,,1094.68,2956.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,inpatient,5,ML,33.10000,19.86000,Aetna,Commercial,,14.56,,,,,,,9.96,26.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,inpatient,1,UN,15765.00000,9459.00000,Aetna,Commercial,,6936.60,,,,,,,4745.27,12816.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,inpatient,0.1,ML,21.05000,12.63000,Aetna,Commercial,,9.26,,,,,,,6.34,17.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,inpatient,0.5,ML,430.80000,258.48000,Aetna,Commercial,,189.55,,,,,,,129.67,350.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Aetna,Commercial,,211.09,,,,,,,86.25,417.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,inpatient,1,ML,236.50000,141.90000,Aetna,Commercial,,104.06,,,,,,,71.19,192.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Aetna,Commercial,,115.89,,,,,,,47.35,196.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,inpatient,1,ML,64.90000,38.94000,Aetna,Commercial,,28.56,,,,,,,19.53,52.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,inpatient,50,ML,108.00000,64.80000,Aetna,Commercial,,47.52,,,,,,,32.51,87.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,inpatient,0.5,ML,144.25000,86.55000,Aetna,Commercial,,63.47,,,,,,,43.42,117.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Aetna,Commercial,,70.68,,,,,,,28.88,111.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,inpatient,1,ML,2673.70000,1604.22000,Aetna,Commercial,,1176.43,,,,,,,804.78,2173.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,inpatient,1000,ML,87.50000,52.50000,Aetna,Commercial,,38.50,,,,,,,26.34,71.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,inpatient,50,ML,3336.40000,2001.84000,Aetna,Commercial,,1468.02,,,,,,,1004.26,2712.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,Aetna,Commercial,,150.83,,,,,,,103.18,278.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,inpatient,100,ML,818.20000,490.92000,Aetna,Commercial,,360.01,,,,,,,246.28,665.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,inpatient,5,ML,319.70000,191.82000,Aetna,Commercial,,140.67,,,,,,,96.23,259.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Aetna,Commercial,,738.67,,,,,,,137.63,800.72,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,inpatient,1,UN,1360.75000,816.45000,Aetna,Commercial,,598.73,,,,,,,409.59,1106.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,inpatient,10,ML,87.50000,52.50000,Aetna,Commercial,,38.50,,,,,,,26.34,71.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,inpatient,5,ML,38.40000,23.04000,Aetna,Commercial,,16.90,,,,,,,11.56,31.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,inpatient,6,ML,6247.80000,3748.68000,Aetna,Commercial,,2749.03,,,,,,,1880.59,5079.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,Aetna,Commercial,,20.00,,,,,,,13.68,36.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,Aetna,Commercial,,27.92,,,,,,,19.10,51.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,inpatient,1,UN,262.00000,157.20000,Aetna,Commercial,,115.28,,,,,,,78.86,213.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,inpatient,1,UN,352.50000,211.50000,Aetna,Commercial,,155.10,,,,,,,106.10,286.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,inpatient,30,ML,46.30000,27.78000,Aetna,Commercial,,20.37,,,,,,,13.94,37.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,inpatient,1,UN,218.65000,131.19000,Aetna,Commercial,,96.21,,,,,,,65.81,177.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,99.80000,59.88000,Aetna,Commercial,,43.91,,,,,,,30.04,81.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,inpatient,50,ML,155.95000,93.57000,Aetna,Commercial,,68.62,,,,,,,46.94,126.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,inpatient,1,UN,22.00000,13.20000,Aetna,Commercial,,9.68,,,,,,,6.62,17.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,inpatient,1,ML,64.75000,38.85000,Aetna,Commercial,,28.49,,,,,,,19.49,52.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,inpatient,200,ML,11976.20000,7185.72000,Aetna,Commercial,,5269.53,,,,,,,3604.84,9736.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,inpatient,0.5,ML,34.20000,20.52000,Aetna,Commercial,,15.05,,,,,,,10.29,27.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,inpatient,250,ML,80.50000,48.30000,Aetna,Commercial,,35.42,,,,,,,24.23,65.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,inpatient,0.25,ML,23.65000,14.19000,Aetna,Commercial,,10.41,,,,,,,7.12,19.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,inpatient,1,UN,9718.80000,5831.28000,Aetna,Commercial,,4276.27,,,,,,,2925.36,7901.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,inpatient,1,UN,249.90000,149.94000,Aetna,Commercial,,109.96,,,,,,,75.22,203.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,inpatient,250,ML,137.85000,82.71000,Aetna,Commercial,,60.65,,,,,,,41.49,112.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,Aetna,Commercial,,8558.81,,,,,,,5855.01,15814.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,inpatient,10,ML,93.85000,56.31000,Aetna,Commercial,,41.29,,,,,,,28.25,76.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,inpatient,0.25,ML,70.45000,42.27000,Aetna,Commercial,,31.00,,,,,,,21.21,57.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,5,ML,74.35000,44.61000,Aetna,Commercial,,32.71,,,,,,,22.38,60.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,inpatient,5,ML,74.35000,44.61000,Aetna,Commercial,,32.71,,,,,,,22.38,60.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,inpatient,5,ML,84.05000,50.43000,Aetna,Commercial,,36.98,,,,,,,25.30,68.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,inpatient,1,UN,8199.90000,4919.94000,Aetna,Commercial,,3607.96,,,,,,,2468.17,6666.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,inpatient,1,ML,385.00000,231.00000,Aetna,Commercial,,169.40,,,,,,,115.89,313.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,inpatient,1,UN,70.35000,42.21000,Aetna,Commercial,,30.95,,,,,,,21.18,57.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,inpatient,1,UN,66.30000,39.78000,Aetna,Commercial,,29.17,,,,,,,19.96,53.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,inpatient,1,UN,29.30000,17.58000,Aetna,Commercial,,12.89,,,,,,,8.82,23.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,inpatient,250,ML,112.90000,67.74000,Aetna,Commercial,,49.68,,,,,,,33.98,91.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,inpatient,250,ML,132.15000,79.29000,Aetna,Commercial,,58.15,,,,,,,39.78,107.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,inpatient,250,ML,90.15000,54.09000,Aetna,Commercial,,39.67,,,,,,,27.14,73.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,inpatient,1,UN,17.85000,10.71000,Aetna,Commercial,,7.85,,,,,,,5.37,14.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,inpatient,1,UN,1263.90000,758.34000,Aetna,Commercial,,556.12,,,,,,,380.43,1027.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,inpatient,20,ML,452.80000,271.68000,Aetna,Commercial,,199.23,,,,,,,136.29,368.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,inpatient,30,ML,907.80000,544.68000,Aetna,Commercial,,399.43,,,,,,,273.25,738.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,inpatient,1,ML,28.30000,16.98000,Aetna,Commercial,,12.45,,,,,,,8.52,23.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,inpatient,250,ML,134.75000,80.85000,Aetna,Commercial,,59.29,,,,,,,40.56,109.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,250,ML,141.75000,85.05000,Aetna,Commercial,,62.37,,,,,,,42.67,115.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,inpatient,1,ML,20.95000,12.57000,Aetna,Commercial,,9.22,,,,,,,6.31,17.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,inpatient,1,ML,18.75000,11.25000,Aetna,Commercial,,8.25,,,,,,,5.64,15.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,inpatient,250,ML,141.75000,85.05000,Aetna,Commercial,,62.37,,,,,,,42.67,115.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,inpatient,250,ML,164.50000,98.70000,Aetna,Commercial,,72.38,,,,,,,49.51,133.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,Aetna,Commercial,,44.66,,,,,,,30.55,82.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,inpatient,100,ML,91.70000,55.02000,Aetna,Commercial,,40.35,,,,,,,27.60,74.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,inpatient,1,UN,13881.15000,8328.69000,Aetna,Commercial,,6107.71,,,,,,,4178.23,11285.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,inpatient,1,UN,4065.55000,2439.33000,Aetna,Commercial,,1788.84,,,,,,,1223.73,3305.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,inpatient,20,ML,113.05000,67.83000,Aetna,Commercial,,49.74,,,,,,,34.03,91.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,inpatient,20,ML,117.85000,70.71000,Aetna,Commercial,,51.85,,,,,,,35.47,95.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,inpatient,1,UN,17829.40000,10697.64000,Aetna,Commercial,,7844.94,,,,,,,5366.65,14495.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,inpatient,1,UN,28362.00000,17017.20000,Aetna,Commercial,,12479.28,,,,,,,8536.96,23058.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,Aetna,Commercial,,28.75,,,,,,,19.67,53.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,inpatient,1,ML,147.45000,88.47000,Aetna,Commercial,,64.88,,,,,,,44.38,119.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,inpatient,0.5,ML,161.50000,96.90000,Aetna,Commercial,,71.06,,,,,,,48.61,131.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Aetna,Commercial,,79.14,,,,,,,32.33,128.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,Aetna,Commercial,,120.12,,,,,,,82.17,221.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,inpatient,10,ML,97.90000,58.74000,Aetna,Commercial,,43.08,,,,,,,29.47,79.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,inpatient,1,UN,4576.00000,2745.60000,Aetna,Commercial,,2013.44,,,,,,,1377.38,3720.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,inpatient,1,UN,549.95000,329.97000,Aetna,Commercial,,241.98,,,,,,,165.53,447.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,Aetna,Commercial,,11.48,,,,,,,7.86,21.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,inpatient,0.5,ML,22.35000,13.41000,Aetna,Commercial,,9.83,,,,,,,6.73,18.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,inpatient,1,UN,324.35000,194.61000,Aetna,Commercial,,142.71,,,,,,,97.63,263.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,inpatient,1,UN,493.50000,296.10000,Aetna,Commercial,,217.14,,,,,,,148.54,401.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,inpatient,5,ML,6392.40000,3835.44000,Aetna,Commercial,,2812.66,,,,,,,1924.11,5197.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,inpatient,1,ML,28.40000,17.04000,Aetna,Commercial,,12.50,,,,,,,8.55,23.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,inpatient,10,ML,6878.50000,4127.10000,Aetna,Commercial,,3026.54,,,,,,,2070.43,5592.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,inpatient,50,ML,33292.40000,19975.44000,Aetna,Commercial,,14648.66,,,,,,,10021.01,27066.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,inpatient,1,UN,55.00000,33.00000,Aetna,Commercial,,24.20,,,,,,,16.55,44.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,inpatient,1,UN,80.00000,48.00000,Aetna,Commercial,,35.20,,,,,,,24.08,65.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,Aetna,Commercial,,39.14,,,,,,,26.77,72.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,inpatient,1,UN,39374.65000,23624.79000,Aetna,Commercial,,17324.85,,,,,,,11851.77,32011.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,inpatient,1,UN,8111.05000,4866.63000,Aetna,Commercial,,3568.86,,,,,,,2441.43,6594.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,inpatient,1,UN,88.95000,53.37000,Aetna,Commercial,,39.14,,,,,,,26.77,72.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,inpatient,1,UN,75.60000,45.36000,Aetna,Commercial,,33.26,,,,,,,22.76,61.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,Aetna,Commercial,,38.63,,,,,,,26.43,71.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,inpatient,2,ML,2093.30000,1255.98000,Aetna,Commercial,,921.05,,,,,,,630.08,1701.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,inpatient,10,ML,462.25000,277.35000,Aetna,Commercial,,203.39,,,,,,,139.14,375.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,inpatient,1,ML,1095.00000,657.00000,Aetna,Commercial,,481.80,,,,,,,329.60,890.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,Aetna,Commercial,,17.05,,,,,,,11.66,31.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,Aetna,Commercial,,17.05,,,,,,,11.66,31.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,Aetna,Commercial,,10878.91,,,,,,,7442.16,20101.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,inpatient,1,UN,809.35000,485.61000,Aetna,Commercial,,356.11,,,,,,,243.61,658.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,inpatient,4,ML,6099.95000,3659.97000,Aetna,Commercial,,2683.98,,,,,,,1836.08,4959.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,inpatient,10,ML,14837.25000,8902.35000,Aetna,Commercial,,6528.39,,,,,,,4466.01,12062.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,inpatient,0.5,ML,731.15000,438.69000,Aetna,Commercial,,321.71,,,,,,,220.08,594.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Aetna,Commercial,,358.26,,,,,,,146.38,774.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,Aetna,Commercial,,12855.88,,,,,,,8794.59,23754.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,4,ML,26225.00000,15735.00000,Aetna,Commercial,,11539.00,,,,,,,7893.73,21320.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,inpatient,1,UN,21020.20000,12612.12000,Aetna,Commercial,,9248.89,,,,,,,6327.08,17089.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,inpatient,1,UN,31468.15000,18880.89000,Aetna,Commercial,,13845.99,,,,,,,9471.91,25583.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,inpatient,1,UN,16047.65000,9628.59000,Aetna,Commercial,,7060.97,,,,,,,4830.34,13046.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,inpatient,1,UN,1807.55000,1084.53000,Aetna,Commercial,,795.32,,,,,,,544.07,1469.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,inpatient,1,UN,3746.95000,2248.17000,Aetna,Commercial,,1648.66,,,,,,,1127.83,3046.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,inpatient,100,ML,94.50000,56.70000,Aetna,Commercial,,41.58,,,,,,,28.44,76.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,inpatient,50,ML,3914.20000,2348.52000,Aetna,Commercial,,1722.25,,,,,,,1178.17,3182.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,inpatient,5,ML,84083.00000,50449.80000,Aetna,Commercial,,36996.52,,,,,,,25308.98,68359.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,inpatient,10,ML,1978.60000,1187.16000,Aetna,Commercial,,870.58,,,,,,,595.56,1608.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,inpatient,2,ML,493.20000,295.92000,Aetna,Commercial,,217.01,,,,,,,148.45,400.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,inpatient,1,UN,4629.40000,2777.64000,Aetna,Commercial,,2036.94,,,,,,,1393.45,3763.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,inpatient,1,UN,9181.80000,5509.08000,Aetna,Commercial,,4039.99,,,,,,,2763.72,7464.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,inpatient,1,UN,4571.50000,2742.90000,Aetna,Commercial,,2011.46,,,,,,,1376.02,3716.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,inpatient,0.8,ML,2013.40000,1208.04000,Aetna,Commercial,,885.90,,,,,,,606.03,1636.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,inpatient,0.5,ML,1264.35000,758.61000,Aetna,Commercial,,556.31,,,,,,,380.57,1027.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,inpatient,1,UN,44.30000,26.58000,Aetna,Commercial,,19.49,,,,,,,13.33,36.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,inpatient,1,UN,129.20000,77.52000,Aetna,Commercial,,56.85,,,,,,,38.89,105.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,Aetna,Commercial,,33.44,,,,,,,22.88,61.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,inpatient,50,ML,88.00000,52.80000,Aetna,Commercial,,38.72,,,,,,,26.49,71.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,inpatient,50,ML,10778.05000,6466.83000,Aetna,Commercial,,4742.34,,,,,,,3244.19,8762.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,inpatient,10,ML,13382.60000,8029.56000,Aetna,Commercial,,5888.34,,,,,,,4028.16,10880.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,inpatient,1,UN,16408.85000,9845.31000,Aetna,Commercial,,7219.89,,,,,,,4939.06,13340.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,inpatient,4,ML,11159.75000,6695.85000,Aetna,Commercial,,4910.29,,,,,,,3359.08,9072.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,inpatient,3,ML,877.30000,526.38000,Aetna,Commercial,,386.01,,,,,,,264.07,713.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,inpatient,1,UN,4037.40000,2422.44000,Aetna,Commercial,,1776.46,,,,,,,1215.26,3282.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,inpatient,2,ML,1656.85000,994.11000,Aetna,Commercial,,729.01,,,,,,,498.71,1347.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,inpatient,1,UN,309.65000,185.79000,Aetna,Commercial,,136.25,,,,,,,93.20,251.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,inpatient,1,UN,4647.20000,2788.32000,Aetna,Commercial,,2044.77,,,,,,,1398.81,3778.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,Aetna,Commercial,,22558.01,,,,,,,15431.73,41681.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,inpatient,1000,ML,122.50000,73.50000,Aetna,Commercial,,53.90,,,,,,,36.87,99.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,inpatient,0.05,ML,61.35000,36.81000,Aetna,Commercial,,26.99,,,,,,,18.47,49.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Aetna,Commercial,,30.06,,,,,,,1.78,45.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,inpatient,10,ML,1082.50000,649.50000,Aetna,Commercial,,476.30,,,,,,,325.83,880.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Aetna,Commercial,,530.42,,,,,,,6.49,803.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,inpatient,40,ML,16023.00000,9613.80000,Aetna,Commercial,,7050.12,,,,,,,4822.92,13026.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,inpatient,10,ML,41.15000,24.69000,Aetna,Commercial,,18.11,,,,,,,12.39,33.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,inpatient,100,ML,191.65000,114.99000,Aetna,Commercial,,84.33,,,,,,,57.69,155.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,Aetna,Commercial,,29.15,,,,,,,19.94,53.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,inpatient,200,ML,367.30000,220.38000,Aetna,Commercial,,161.61,,,,,,,110.56,298.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,inpatient,15,ML,57.50000,34.50000,Aetna,Commercial,,25.30,,,,,,,17.31,46.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,inpatient,15,ML,34.25000,20.55000,Aetna,Commercial,,15.07,,,,,,,10.31,27.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,inpatient,15,ML,39.90000,23.94000,Aetna,Commercial,,17.56,,,,,,,12.01,32.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,inpatient,1,ML,89877.30000,53926.38000,Aetna,Commercial,,39546.01,,,,,,,27053.07,73070.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,inpatient,10,ML,9488.70000,5693.22000,Aetna,Commercial,,4175.03,,,,,,,2856.10,7714.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,10,ML,86755.05000,52053.03000,Aetna,Commercial,,38172.22,,,,,,,26113.27,70531.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,inpatient,1,UN,7132.10000,4279.26000,Aetna,Commercial,,3138.12,,,,,,,2146.76,5798.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,10,ML,19171.55000,11502.93000,Aetna,Commercial,,8435.48,,,,,,,5770.64,15586.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,inpatient,2.4,ML,4810.20000,2886.12000,Aetna,Commercial,,2116.49,,,,,,,1447.87,3910.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,inpatient,11.7,ML,29212.00000,17527.20000,Aetna,Commercial,,12853.28,,,,,,,8792.81,23749.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,inpatient,13.4,ML,33345.80000,20007.48000,Aetna,Commercial,,14672.15,,,,,,,10037.09,27110.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,inpatient,1,UN,48587.00000,29152.20000,Aetna,Commercial,,21378.28,,,,,,,14624.69,39501.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,inpatient,1,UN,105505.20000,63303.12000,Aetna,Commercial,,46422.29,,,,,,,31757.07,85775.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,Aetna,Commercial,,39.73,,,,,,,27.18,73.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,inpatient,250,ML,199.50000,119.70000,Aetna,Commercial,,87.78,,,,,,,60.05,162.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,inpatient,1,UN,997.50000,598.50000,Aetna,Commercial,,438.90,,,,,,,300.25,810.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,inpatient,1,UN,668.55000,401.13000,Aetna,Commercial,,294.16,,,,,,,201.23,543.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Aetna,Commercial,,327.59,,,,,,,133.84,569.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,inpatient,1,ML,18.40000,11.04000,Aetna,Commercial,,8.10,,,,,,,5.54,14.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,inpatient,18,ML,1972.25000,1183.35000,Aetna,Commercial,,867.79,,,,,,,593.65,1603.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,inpatient,1,ML,26620.10000,15972.06000,Aetna,Commercial,,11712.84,,,,,,,8012.65,21642.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,inpatient,6,ML,5890.65000,3534.39000,Aetna,Commercial,,2591.89,,,,,,,1773.09,4789.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,inpatient,24,ML,35224.60000,21134.76000,Aetna,Commercial,,15498.82,,,,,,,10602.60,28637.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,inpatient,50,ML,80.05000,48.03000,Aetna,Commercial,,35.22,,,,,,,24.10,65.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,Aetna,Commercial,,11.59,,,,,,,7.93,21.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,inpatient,0.5,ML,58.45000,35.07000,Aetna,Commercial,,25.72,,,,,,,17.59,47.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,inpatient,0.6,ML,9514.15000,5708.49000,Aetna,Commercial,,4186.23,,,,,,,2863.76,7735.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,inpatient,0.5,ML,489.25000,293.55000,Aetna,Commercial,,215.27,,,,,,,147.26,397.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Aetna,Commercial,,239.73,,,,,,,97.95,495.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,inpatient,5,ML,21317.55000,12790.53000,Aetna,Commercial,,9379.72,,,,,,,6416.58,17331.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,inpatient,0.5,ML,1012.45000,607.47000,Aetna,Commercial,,445.48,,,,,,,304.75,823.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,inpatient,0.8,ML,1610.35000,966.21000,Aetna,Commercial,,708.55,,,,,,,484.72,1309.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,inpatient,1,UN,344.75000,206.85000,Aetna,Commercial,,151.69,,,,,,,103.77,280.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,inpatient,7,ML,48344.85000,29006.91000,Aetna,Commercial,,21271.73,,,,,,,14551.80,39304.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,Aetna,Commercial,,8365.39,,,,,,,5722.69,15456.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,Aetna,Commercial,,4433.88,,,,,,,3033.18,8192.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,Aetna,Commercial,,445.48,,,,,,,304.75,823.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,inpatient,1,UN,36064.10000,21638.46000,Aetna,Commercial,,15868.20,,,,,,,10855.29,29320.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,inpatient,1,UN,2928.00000,1756.80000,Aetna,Commercial,,1288.32,,,,,,,881.33,2380.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,Aetna,Commercial,,15826.93,,,,,,,10827.06,29243.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,inpatient,5,ML,20846.10000,12507.66000,Aetna,Commercial,,9172.28,,,,,,,6274.68,16947.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,inpatient,5,ML,419.55000,251.73000,Aetna,Commercial,,184.60,,,,,,,126.28,341.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,inpatient,1,UN,82165.25000,49299.15000,Aetna,Commercial,,36152.71,,,,,,,24731.74,66800.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,inpatient,16,ML,12554.95000,7532.97000,Aetna,Commercial,,5524.18,,,,,,,3779.04,10207.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,inpatient,4,ML,3345.05000,2007.03000,Aetna,Commercial,,1471.82,,,,,,,1006.86,2719.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,inpatient,100,ML,201.25000,120.75000,Aetna,Commercial,,88.55,,,,,,,60.58,163.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,inpatient,10,ML,3995.45000,2397.27000,Aetna,Commercial,,1758.00,,,,,,,1202.63,3248.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,inpatient,50,ML,18877.10000,11326.26000,Aetna,Commercial,,8305.92,,,,,,,5682.01,15347.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,inpatient,1,UN,17338.20000,10402.92000,Aetna,Commercial,,7628.81,,,,,,,5218.80,14095.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,inpatient,1,UN,51888.40000,31133.04000,Aetna,Commercial,,22830.90,,,,,,,15618.41,42185.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,inpatient,10,ML,10365.35000,6219.21000,Aetna,Commercial,,4560.75,,,,,,,3119.97,8427.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,inpatient,1,UN,6279.25000,3767.55000,Aetna,Commercial,,2762.87,,,,,,,1890.05,5105.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,inpatient,1,UN,12634.60000,7580.76000,Aetna,Commercial,,5559.22,,,,,,,3803.01,10271.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,Aetna,Commercial,,8278.34,,,,,,,5663.13,15296.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,inpatient,1,UN,13855.50000,8313.30000,Aetna,Commercial,,6096.42,,,,,,,4170.51,11264.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,inpatient,16,ML,11070.85000,6642.51000,Aetna,Commercial,,4871.17,,,,,,,3332.33,9000.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,inpatient,4,ML,2974.00000,1784.40000,Aetna,Commercial,,1308.56,,,,,,,895.17,2417.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,10,ML,3428.95000,2057.37000,Aetna,Commercial,,1508.74,,,,,,,1032.11,2787.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,50,ML,16044.60000,9626.76000,Aetna,Commercial,,7059.62,,,,,,,4829.42,13044.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,inpatient,1,UN,75742.60000,45445.56000,Aetna,Commercial,,33326.74,,,,,,,22798.52,61578.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,inpatient,1,UN,15195.80000,9117.48000,Aetna,Commercial,,6686.15,,,,,,,4573.94,12354.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,inpatient,1,ML,8211.30000,4926.78000,Aetna,Commercial,,3612.97,,,,,,,2471.60,6675.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,inpatient,25,ML,19413.25000,11647.95000,Aetna,Commercial,,8541.83,,,,,,,5843.39,15782.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,inpatient,5,ML,4102.65000,2461.59000,Aetna,Commercial,,1805.17,,,,,,,1234.90,3335.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,inpatient,1,UN,11554.40000,6932.64000,Aetna,Commercial,,5083.94,,,,,,,3477.87,9393.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,inpatient,1,UN,110033.00000,66019.80000,Aetna,Commercial,,48414.52,,,,,,,33119.93,89456.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,inpatient,1,UN,2163.00000,1297.80000,Aetna,Commercial,,951.72,,,,,,,651.06,1758.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,inpatient,15,ML,61507.80000,36904.68000,Aetna,Commercial,,27063.43,,,,,,,18513.85,50005.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,inpatient,10,ML,41095.25000,24657.15000,Aetna,Commercial,,18081.91,,,,,,,12369.67,33410.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,inpatient,0.25,ML,65.65000,39.39000,Aetna,Commercial,,28.89,,,,,,,19.76,53.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,inpatient,100,ML,88.00000,52.80000,Aetna,Commercial,,38.72,,,,,,,26.49,71.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,inpatient,1,UN,6416.85000,3850.11000,Aetna,Commercial,,2823.41,,,,,,,1931.47,5216.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,inpatient,1,UN,17822.95000,10693.77000,Aetna,Commercial,,7842.10,,,,,,,5364.71,14490.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,inpatient,11,ML,100657.05000,60394.23000,Aetna,Commercial,,44289.10,,,,,,,30297.77,81834.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,inpatient,3,ML,27497.75000,16498.65000,Aetna,Commercial,,12099.01,,,,,,,8276.82,22355.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,inpatient,1,UN,6743.50000,4046.10000,Aetna,Commercial,,2967.14,,,,,,,2029.79,5482.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,inpatient,1,UN,5603.90000,3362.34000,Aetna,Commercial,,2465.72,,,,,,,1686.77,4555.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,inpatient,1,UN,9216.70000,5530.02000,Aetna,Commercial,,4055.35,,,,,,,2774.23,7493.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,inpatient,1,UN,124890.65000,74934.39000,Aetna,Commercial,,54951.89,,,,,,,37592.09,101536.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,inpatient,10,ML,53208.20000,31924.92000,Aetna,Commercial,,23411.61,,,,,,,16015.67,43258.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,inpatient,20,ML,20471.00000,12282.60000,Aetna,Commercial,,9007.24,,,,,,,6161.77,16642.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,inpatient,7,ML,17024.40000,10214.64000,Aetna,Commercial,,7490.74,,,,,,,5124.34,13840.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,inpatient,0.5,ML,869.40000,521.64000,Aetna,Commercial,,382.54,,,,,,,261.69,706.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Aetna,Commercial,,426.01,,,,,,,174.05,872.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,inpatient,1,UN,32838.55000,19703.13000,Aetna,Commercial,,14448.96,,,,,,,9884.40,26697.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,inpatient,100,ML,107.45000,64.47000,Aetna,Commercial,,47.28,,,,,,,32.34,87.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,inpatient,1.5,ML,16340.20000,9804.12000,Aetna,Commercial,,7189.69,,,,,,,4918.40,13284.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,inpatient,1,UN,36433.75000,21860.25000,Aetna,Commercial,,16030.85,,,,,,,10966.56,29620.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,inpatient,100,ML,273.00000,163.80000,Aetna,Commercial,,120.12,,,,,,,82.17,221.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,inpatient,1,UN,87.60000,52.56000,Aetna,Commercial,,38.54,,,,,,,26.37,71.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,Aetna,Commercial,,36.41,,,,,,,24.91,67.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,Aetna,Commercial,,36.41,,,,,,,24.91,67.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,inpatient,0.5,ML,739.45000,443.67000,Aetna,Commercial,,325.36,,,,,,,222.57,601.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,inpatient,0.8,ML,1173.55000,704.13000,Aetna,Commercial,,516.36,,,,,,,353.24,954.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,inpatient,20,ML,68131.75000,40879.05000,Aetna,Commercial,,29977.97,,,,,,,20507.66,55391.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Aetna,Commercial,,1969.72,,,,,,,525.79,2135.18,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,inpatient,0.5,ML,104.05000,62.43000,Aetna,Commercial,,45.78,,,,,,,31.32,84.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Aetna,Commercial,,50.98,,,,,,,20.83,97.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,inpatient,1.7,ML,46244.25000,27746.55000,Aetna,Commercial,,20347.47,,,,,,,13919.52,37596.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,inpatient,3,ML,9288.55000,5573.13000,Aetna,Commercial,,4086.96,,,,,,,2795.85,7551.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,inpatient,0.5,ML,520.00000,312.00000,Aetna,Commercial,,228.80,,,,,,,156.52,422.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Aetna,Commercial,,254.80,,,,,,,104.10,544.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,inpatient,20,ML,30117.40000,18070.44000,Aetna,Commercial,,13251.66,,,,,,,9065.34,24485.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,inpatient,1,ML,3021.70000,1813.02000,Aetna,Commercial,,1329.55,,,,,,,909.53,2456.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,inpatient,30,ML,82676.70000,49606.02000,Aetna,Commercial,,36377.75,,,,,,,24885.69,67216.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,inpatient,20,ML,65144.20000,39086.52000,Aetna,Commercial,,28663.45,,,,,,,19608.40,52962.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,inpatient,0.28,ML,11967.50000,7180.50000,Aetna,Commercial,,5265.70,,,,,,,3602.22,9729.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,inpatient,0.56,ML,23918.10000,14350.86000,Aetna,Commercial,,10523.96,,,,,,,7199.35,19445.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,inpatient,0.7,ML,29894.05000,17936.43000,Aetna,Commercial,,13153.38,,,,,,,8998.11,24303.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,inpatient,1,UN,68158.20000,40894.92000,Aetna,Commercial,,29989.61,,,,,,,20515.62,55412.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,inpatient,1,UN,942.40000,565.44000,Aetna,Commercial,,414.66,,,,,,,283.66,766.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Aetna,Commercial,,461.78,,,,,,,188.67,1002.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,inpatient,0.5,ML,2546.40000,1527.84000,Aetna,Commercial,,1120.42,,,,,,,766.47,2070.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Aetna,Commercial,,1247.74,,,,,,,509.79,1889.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,inpatient,1,ML,2546.45000,1527.87000,Aetna,Commercial,,1120.44,,,,,,,766.48,2070.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Aetna,Commercial,,1247.76,,,,,,,509.80,1889.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,Aetna,Commercial,,22487.67,,,,,,,15383.61,41551.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,inpatient,1.5,ML,4087.55000,2452.53000,Aetna,Commercial,,1798.52,,,,,,,1230.35,3323.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,inpatient,1,ML,255.50000,153.30000,Aetna,Commercial,,112.42,,,,,,,76.91,207.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,inpatient,1,UN,63488.50000,38093.10000,Aetna,Commercial,,27934.94,,,,,,,19110.04,51616.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,inpatient,2,ML,234.40000,140.64000,Aetna,Commercial,,103.14,,,,,,,70.55,190.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Aetna,Commercial,,114.86,,,,,,,6.49,173.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,Aetna,Commercial,,8365.39,,,,,,,5722.69,15456.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,inpatient,0.11,ML,352.45000,211.47000,Aetna,Commercial,,155.08,,,,,,,106.09,286.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Aetna,Commercial,,172.70,,,,,,,1.78,261.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,inpatient,36,ML,26733.05000,16039.83000,Aetna,Commercial,,11762.54,,,,,,,8046.65,21733.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,inpatient,1,UN,10993.10000,6595.86000,Aetna,Commercial,,4836.96,,,,,,,3308.92,8937.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,inpatient,1,UN,43783.25000,26269.95000,Aetna,Commercial,,19264.63,,,,,,,13178.76,35595.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,inpatient,0.5,ML,883.00000,529.80000,Aetna,Commercial,,388.52,,,,,,,265.78,717.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Aetna,Commercial,,432.67,,,,,,,176.78,914.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,inpatient,20,ML,61242.05000,36745.23000,Aetna,Commercial,,26946.50,,,,,,,18433.86,49789.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,inpatient,1,UN,7315.00000,4389.00000,Aetna,Commercial,,3218.60,,,,,,,2201.82,5947.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,inpatient,0.5,ML,257.30000,154.38000,Aetna,Commercial,,113.21,,,,,,,77.45,209.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Aetna,Commercial,,126.08,,,,,,,51.51,232.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,inpatient,0.5,ML,81.25000,48.75000,Aetna,Commercial,,35.75,,,,,,,24.46,66.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Aetna,Commercial,,39.81,,,,,,,16.27,62.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,inpatient,0.1,ML,17.05000,10.23000,Aetna,Commercial,,7.50,,,,,,,5.13,13.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,inpatient,0.1,ML,16.90000,10.14000,Aetna,Commercial,,7.44,,,,,,,5.09,13.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,inpatient,0.1,ML,16.75000,10.05000,Aetna,Commercial,,7.37,,,,,,,5.04,13.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,inpatient,5,ML,35224.60000,21134.76000,Aetna,Commercial,,15498.82,,,,,,,10602.60,28637.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,inpatient,1,UN,21795.75000,13077.45000,Aetna,Commercial,,9590.13,,,,,,,6560.52,17719.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,inpatient,20,ML,364.45000,218.67000,Aetna,Commercial,,160.36,,,,,,,109.70,296.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,Aetna,Commercial,,16618.16,,,,,,,11368.33,30705.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,inpatient,0.3,ML,465.10000,279.06000,Aetna,Commercial,,204.64,,,,,,,140.00,378.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Aetna,Commercial,,227.90,,,,,,,93.11,434.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,inpatient,1,UN,327.80000,196.68000,Aetna,Commercial,,144.23,,,,,,,98.67,266.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,inpatient,5,ML,192.90000,115.74000,Aetna,Commercial,,84.88,,,,,,,58.06,156.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,inpatient,1,UN,94.25000,56.55000,Aetna,Commercial,,41.47,,,,,,,28.37,76.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,inpatient,0.5,ML,91.05000,54.63000,Aetna,Commercial,,40.06,,,,,,,27.41,74.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,inpatient,1,UN,1399.95000,839.97000,Aetna,Commercial,,615.98,,,,,,,421.38,1138.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,inpatient,10,ML,4408.90000,2645.34000,Aetna,Commercial,,1939.92,,,,,,,1327.08,3584.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,50,ML,20944.45000,12566.67000,Aetna,Commercial,,9215.56,,,,,,,6304.28,17027.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,inpatient,1.5,ML,6363.00000,3817.80000,Aetna,Commercial,,2799.72,,,,,,,1915.26,5173.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,Aetna,Commercial,,20.13,,,,,,,13.77,37.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,inpatient,0.5,ML,4182.45000,2509.47000,Aetna,Commercial,,1840.28,,,,,,,1258.92,3400.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,inpatient,1,ML,126.65000,75.99000,Aetna,Commercial,,55.73,,,,,,,38.12,102.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,inpatient,100,ML,1113.00000,667.80000,Aetna,Commercial,,489.72,,,,,,,335.01,904.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,inpatient,500,ML,64.00000,38.40000,Aetna,Commercial,,28.16,,,,,,,19.26,52.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,inpatient,1,UN,16.70000,10.02000,Aetna,Commercial,,7.35,,,,,,,5.03,13.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,inpatient,1,UN,17.60000,10.56000,Aetna,Commercial,,7.74,,,,,,,5.30,14.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,inpatient,1,UN,20.05000,12.03000,Aetna,Commercial,,8.82,,,,,,,6.04,16.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,inpatient,5,ML,24.90000,14.94000,Aetna,Commercial,,10.96,,,,,,,7.49,20.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,inpatient,1,UN,654.25000,392.55000,Aetna,Commercial,,287.87,,,,,,,196.93,531.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,inpatient,1,UN,2058.00000,1234.80000,Aetna,Commercial,,905.52,,,,,,,619.46,1673.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,inpatient,1,UN,516.55000,309.93000,Aetna,Commercial,,227.28,,,,,,,155.48,419.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,inpatient,1,UN,23.95000,14.37000,Aetna,Commercial,,10.54,,,,,,,7.21,19.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,inpatient,5,ML,196.60000,117.96000,Aetna,Commercial,,86.50,,,,,,,59.18,159.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,inpatient,1.25,ML,48.40000,29.04000,Aetna,Commercial,,21.30,,,,,,,14.57,39.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,inpatient,1,ML,29.70000,17.82000,Aetna,Commercial,,13.07,,,,,,,8.94,24.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,inpatient,50,ML,81.40000,48.84000,Aetna,Commercial,,35.82,,,,,,,24.50,66.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,inpatient,5,ML,79.85000,47.91000,Aetna,Commercial,,35.13,,,,,,,24.03,64.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,inpatient,1,UN,164.50000,98.70000,Aetna,Commercial,,72.38,,,,,,,49.51,133.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,inpatient,1,UN,84.35000,50.61000,Aetna,Commercial,,37.11,,,,,,,25.39,68.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,inpatient,1,UN,7346.35000,4407.81000,Aetna,Commercial,,3232.39,,,,,,,2211.25,5972.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,inpatient,0.5,ML,28.10000,16.86000,Aetna,Commercial,,12.36,,,,,,,8.46,22.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,inpatient,0.3,ML,39.90000,23.94000,Aetna,Commercial,,17.56,,,,,,,12.01,32.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,inpatient,10,ML,97.15000,58.29000,Aetna,Commercial,,42.75,,,,,,,29.24,78.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,inpatient,20,ML,101.60000,60.96000,Aetna,Commercial,,44.70,,,,,,,30.58,82.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,inpatient,50,ML,147.00000,88.20000,Aetna,Commercial,,64.68,,,,,,,44.25,119.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,inpatient,0.5,ML,25.85000,15.51000,Aetna,Commercial,,11.37,,,,,,,7.78,21.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,inpatient,20,ML,1179.50000,707.70000,Aetna,Commercial,,518.98,,,,,,,355.03,958.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,inpatient,10,ML,2255.00000,1353.00000,Aetna,Commercial,,992.20,,,,,,,678.75,1833.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,inpatient,25,ML,5775.00000,3465.00000,Aetna,Commercial,,2541.00,,,,,,,1738.28,4695.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,inpatient,2000,ML,180.85000,108.51000,Aetna,Commercial,,79.57,,,,,,,54.44,147.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,inpatient,2000,ML,180.85000,108.51000,Aetna,Commercial,,79.57,,,,,,,54.44,147.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,inpatient,2000,ML,194.50000,116.70000,Aetna,Commercial,,85.58,,,,,,,58.54,158.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,inpatient,2000,ML,195.65000,117.39000,Aetna,Commercial,,86.09,,,,,,,58.89,159.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,inpatient,10,ML,308.40000,185.04000,Aetna,Commercial,,135.70,,,,,,,92.83,250.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,0.1,ML,22.85000,13.71000,Aetna,Commercial,,10.05,,,,,,,6.88,18.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,inpatient,1,UN,27.90000,16.74000,Aetna,Commercial,,12.28,,,,,,,8.40,22.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,inpatient,1,UN,63.15000,37.89000,Aetna,Commercial,,27.79,,,,,,,19.01,51.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,inpatient,1,UN,3520.00000,2112.00000,Aetna,Commercial,,1548.80,,,,,,,1059.52,2861.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,inpatient,2.5,ML,1204.10000,722.46000,Aetna,Commercial,,529.80,,,,,,,362.43,978.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,inpatient,1,UN,523.95000,314.37000,Aetna,Commercial,,230.54,,,,,,,157.71,425.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,inpatient,1,UN,698.50000,419.10000,Aetna,Commercial,,307.34,,,,,,,210.25,567.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,inpatient,10,ML,1199.00000,719.40000,Aetna,Commercial,,527.56,,,,,,,360.90,974.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,inpatient,5,ML,335.80000,201.48000,Aetna,Commercial,,147.75,,,,,,,101.08,273.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,inpatient,5,ML,19.30000,11.58000,Aetna,Commercial,,8.49,,,,,,,5.81,15.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,inpatient,1,UN,12869.00000,7721.40000,Aetna,Commercial,,5662.36,,,,,,,3873.57,10462.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,inpatient,1,ML,52.40000,31.44000,Aetna,Commercial,,23.06,,,,,,,15.77,42.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,inpatient,1,UN,357.25000,214.35000,Aetna,Commercial,,157.19,,,,,,,107.53,290.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,inpatient,250,ML,693.00000,415.80000,Aetna,Commercial,,304.92,,,,,,,208.59,563.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,inpatient,1,UN,83.10000,49.86000,Aetna,Commercial,,36.56,,,,,,,25.01,67.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,inpatient,1,ML,28.65000,17.19000,Aetna,Commercial,,12.61,,,,,,,8.62,23.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,inpatient,10,ML,42.40000,25.44000,Aetna,Commercial,,18.66,,,,,,,12.76,34.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,inpatient,2,ML,28.40000,17.04000,Aetna,Commercial,,12.50,,,,,,,8.55,23.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,inpatient,20,ML,53.45000,32.07000,Aetna,Commercial,,23.52,,,,,,,16.09,43.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,inpatient,5,ML,31.00000,18.60000,Aetna,Commercial,,13.64,,,,,,,9.33,25.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,inpatient,150,ML,94.00000,56.40000,Aetna,Commercial,,41.36,,,,,,,28.29,76.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,inpatient,16.7,ML,465.05000,279.03000,Aetna,Commercial,,204.62,,,,,,,139.98,378.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,inpatient,5,ML,319.00000,191.40000,Aetna,Commercial,,140.36,,,,,,,96.02,259.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,inpatient,50,ML,843.95000,506.37000,Aetna,Commercial,,371.34,,,,,,,254.03,686.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,inpatient,1,UN,858.55000,515.13000,Aetna,Commercial,,377.76,,,,,,,258.42,698.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,inpatient,1,UN,19973.00000,11983.80000,Aetna,Commercial,,8788.12,,,,,,,6011.87,16238.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,inpatient,1,ML,84.55000,50.73000,Aetna,Commercial,,37.20,,,,,,,25.45,68.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,inpatient,0.5,ML,59.70000,35.82000,Aetna,Commercial,,26.27,,,,,,,17.97,48.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,inpatient,0.5,ML,121.05000,72.63000,Aetna,Commercial,,53.26,,,,,,,36.44,98.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,Aetna,Commercial,,12855.88,,,,,,,8794.59,23754.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,inpatient,0.2,ML,18.45000,11.07000,Aetna,Commercial,,8.12,,,,,,,5.55,15.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,inpatient,5,ML,93.35000,56.01000,Aetna,Commercial,,41.07,,,,,,,28.10,75.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,inpatient,1,UN,2978.05000,1786.83000,Aetna,Commercial,,1310.34,,,,,,,896.39,2421.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,inpatient,1.6666666666666665,ML,128.65000,77.19000,Aetna,Commercial,,56.61,,,,,,,38.72,104.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,inpatient,1,UN,2262.45000,1357.47000,Aetna,Commercial,,995.48,,,,,,,681.00,1839.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,inpatient,10,ML,42.60000,25.56000,Aetna,Commercial,,18.74,,,,,,,12.82,34.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,inpatient,2,ML,35.05000,21.03000,Aetna,Commercial,,15.42,,,,,,,10.55,28.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,inpatient,4,ML,29.35000,17.61000,Aetna,Commercial,,12.91,,,,,,,8.83,23.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,inpatient,20,ML,5230.30000,3138.18000,Aetna,Commercial,,2301.33,,,,,,,1574.32,4252.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,inpatient,20,ML,13051.70000,7831.02000,Aetna,Commercial,,5742.75,,,,,,,3928.56,10611.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,inpatient,20,ML,26087.25000,15652.35000,Aetna,Commercial,,11478.39,,,,,,,7852.26,21208.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,inpatient,20,ML,52158.50000,31295.10000,Aetna,Commercial,,22949.74,,,,,,,15699.71,42404.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,inpatient,100,ML,180.95000,108.57000,Aetna,Commercial,,79.62,,,,,,,54.47,147.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,inpatient,1,UN,316.30000,189.78000,Aetna,Commercial,,139.17,,,,,,,95.21,257.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,inpatient,1,UN,4712.40000,2827.44000,Aetna,Commercial,,2073.46,,,,,,,1418.43,3831.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,inpatient,2,ML,37.15000,22.29000,Aetna,Commercial,,16.35,,,,,,,11.18,30.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,Aetna,Commercial,,73.77,,,,,,,50.46,136.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,inpatient,0.5,ML,321.65000,192.99000,Aetna,Commercial,,141.53,,,,,,,96.82,261.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Aetna,Commercial,,157.61,,,,,,,64.39,336.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,inpatient,1,UN,37.10000,22.26000,Aetna,Commercial,,16.32,,,,,,,11.17,30.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,inpatient,1,ML,27.85000,16.71000,Aetna,Commercial,,12.25,,,,,,,8.38,22.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,inpatient,1,UN,1034.85000,620.91000,Aetna,Commercial,,455.33,,,,,,,311.49,841.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,inpatient,5,ML,252.00000,151.20000,Aetna,Commercial,,110.88,,,,,,,75.85,204.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,Aetna,Commercial,,3224.41,,,,,,,2205.79,5957.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.4,ML,17.65000,10.59000,Aetna,Commercial,,7.77,,,,,,,5.31,14.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,inpatient,1000,ML,87.50000,52.50000,Aetna,Commercial,,38.50,,,,,,,26.34,71.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,inpatient,1,UN,6248.60000,3749.16000,Aetna,Commercial,,2749.38,,,,,,,1880.83,5080.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,inpatient,1,ML,70.60000,42.36000,Aetna,Commercial,,31.06,,,,,,,21.25,57.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,inpatient,1,UN,483.00000,289.80000,Aetna,Commercial,,212.52,,,,,,,145.38,392.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,inpatient,0.1,ML,23.30000,13.98000,Aetna,Commercial,,10.25,,,,,,,7.01,18.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,inpatient,1,ML,169.40000,101.64000,Aetna,Commercial,,74.54,,,,,,,50.99,137.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,inpatient,1,UN,18064.20000,10838.52000,Aetna,Commercial,,7948.25,,,,,,,5437.32,14686.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,Aetna,Commercial,,1740.46,,,,,,,1190.64,3215.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,inpatient,1,UN,30.90000,18.54000,Aetna,Commercial,,13.60,,,,,,,9.30,25.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,inpatient,2,ML,757.60000,454.56000,Aetna,Commercial,,333.34,,,,,,,228.04,615.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,inpatient,1,UN,143.75000,86.25000,Aetna,Commercial,,63.25,,,,,,,43.27,116.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,Aetna,Commercial,,1205.86,,,,,,,824.92,2228.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,inpatient,1,UN,1507.85000,904.71000,Aetna,Commercial,,663.45,,,,,,,453.86,1225.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,inpatient,3,ML,109.25000,65.55000,Aetna,Commercial,,48.07,,,,,,,32.88,88.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,inpatient,1,ML,40.95000,24.57000,Aetna,Commercial,,18.02,,,,,,,12.33,33.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,inpatient,1,UN,23.80000,14.28000,Aetna,Commercial,,10.47,,,,,,,7.16,19.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,inpatient,15,ML,377.25000,226.35000,Aetna,Commercial,,165.99,,,,,,,113.55,306.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,inpatient,45,ML,482.55000,289.53000,Aetna,Commercial,,212.32,,,,,,,145.25,392.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,inpatient,5,ML,334.00000,200.40000,Aetna,Commercial,,146.96,,,,,,,100.53,271.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,inpatient,60,ML,535.35000,321.21000,Aetna,Commercial,,235.55,,,,,,,161.14,435.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,inpatient,2,ML,25.05000,15.03000,Aetna,Commercial,,11.02,,,,,,,7.54,20.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,inpatient,30,ML,116.10000,69.66000,Aetna,Commercial,,51.08,,,,,,,34.95,94.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,inpatient,4,ML,22.65000,13.59000,Aetna,Commercial,,9.97,,,,,,,6.82,18.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,inpatient,1,UN,7227.30000,4336.38000,Aetna,Commercial,,3180.01,,,,,,,2175.42,5875.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,inpatient,20,ML,26468.35000,15881.01000,Aetna,Commercial,,11646.07,,,,,,,7966.97,21518.77,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,inpatient,1,ML,5590.45000,3354.27000,Aetna,Commercial,,2459.80,,,,,,,1682.73,4545.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,inpatient,5,ML,26468.35000,15881.01000,Aetna,Commercial,,11646.07,,,,,,,7966.97,21518.77,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,inpatient,10,ML,107.00000,64.20000,Aetna,Commercial,,47.08,,,,,,,32.21,86.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,Aetna,Commercial,,3224.41,,,,,,,2205.79,5957.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,inpatient,1,ML,350.20000,210.12000,Aetna,Commercial,,154.09,,,,,,,105.41,284.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,inpatient,1,UN,1243.00000,745.80000,Aetna,Commercial,,546.92,,,,,,,374.14,1010.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,inpatient,1,ML,7030.60000,4218.36000,Aetna,Commercial,,3093.46,,,,,,,2116.21,5715.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,inpatient,26.3,ML,332.30000,199.38000,Aetna,Commercial,,146.21,,,,,,,100.02,270.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,inpatient,5.26,ML,308.30000,184.98000,Aetna,Commercial,,135.65,,,,,,,92.80,250.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,inpatient,52.6,ML,673.55000,404.13000,Aetna,Commercial,,296.36,,,,,,,202.74,547.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,Aetna,Commercial,,17651.00,,,,,,,12074.89,32614.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,Aetna,Commercial,,70240.76,,,,,,,48051.07,129785.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,Aetna,Commercial,,647.37,,,,,,,442.86,1196.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,Aetna,Commercial,,1289.09,,,,,,,881.85,2381.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,26823.30000,16093.98000,Aetna,Commercial,,11802.25,,,,,,,8073.81,21807.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,inpatient,1,ML,320.15000,192.09000,Aetna,Commercial,,140.87,,,,,,,96.37,260.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,Aetna,Commercial,,127.62,,,,,,,87.31,235.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,Aetna,Commercial,,138.49,,,,,,,94.74,255.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,Aetna,Commercial,,127.51,,,,,,,87.23,235.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,Aetna,Commercial,,185.37,,,,,,,126.81,342.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,inpatient,16,ML,2035.00000,1221.00000,Aetna,Commercial,,895.40,,,,,,,612.53,1654.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,inpatient,2,ML,495.00000,297.00000,Aetna,Commercial,,217.80,,,,,,,149.00,402.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,inpatient,8,ML,996.60000,597.96000,Aetna,Commercial,,438.50,,,,,,,299.98,810.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,inpatient,0.5,ML,77.55000,46.53000,Aetna,Commercial,,34.12,,,,,,,23.34,63.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,inpatient,26.3,ML,337.40000,202.44000,Aetna,Commercial,,148.46,,,,,,,101.56,274.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,Aetna,Commercial,,2481.71,,,,,,,1697.72,4585.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,Aetna,Commercial,,4935.68,,,,,,,3376.45,9119.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,Aetna,Commercial,,20.00,,,,,,,13.68,36.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,Aetna,Commercial,,27.92,,,,,,,19.10,51.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,1,ML,19.05000,11.43000,Aetna,Commercial,,8.38,,,,,,,5.73,15.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,inpatient,1000,ML,84.00000,50.40000,Aetna,Commercial,,36.96,,,,,,,25.28,68.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,Aetna,Commercial,,150.83,,,,,,,103.18,278.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,inpatient,100,ML,61.00000,36.60000,Aetna,Commercial,,26.84,,,,,,,18.36,49.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,Aetna,Commercial,,33.44,,,,,,,22.88,61.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,inpatient,5,ML,292.85000,175.71000,Aetna,Commercial,,128.85,,,,,,,88.15,238.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,inpatient,1,UN,20.80000,12.48000,Aetna,Commercial,,9.15,,,,,,,6.26,16.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,Aetna,Commercial,,19.05,,,,,,,13.03,35.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,inpatient,1,UN,25.10000,15.06000,Aetna,Commercial,,11.04,,,,,,,7.56,20.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,Aetna,Commercial,,12.85,,,,,,,8.79,23.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,inpatient,1,UN,19.50000,11.70000,Aetna,Commercial,,8.58,,,,,,,5.87,15.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,inpatient,1,UN,19.25000,11.55000,Aetna,Commercial,,8.47,,,,,,,5.79,15.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,inpatient,250,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,inpatient,100,ML,103.35000,62.01000,Aetna,Commercial,,45.47,,,,,,,31.11,84.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,inpatient,12,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,inpatient,1,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,inpatient,5,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,Aetna,Commercial,,126.06,,,,,,,86.24,232.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,inpatient,1,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,inpatient,0.09999,ML,63.05000,37.83000,Aetna,Commercial,,27.74,,,,,,,18.98,51.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.14844,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,inpatient,50,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.14844,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,Aetna,Commercial,,96.36,,,,,,,65.92,178.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,Aetna,Commercial,,503.51,,,,,,,344.45,930.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,10,ML,46.50000,27.90000,Aetna,Commercial,,20.46,,,,,,,14.00,37.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,inpatient,0.5,ML,31.55000,18.93000,Aetna,Commercial,,13.88,,,,,,,9.50,25.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,inpatient,1,UN,36575.00000,21945.00000,Aetna,Commercial,,16093.00,,,,,,,11009.08,29735.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,inpatient,10,ML,318.15000,190.89000,Aetna,Commercial,,139.99,,,,,,,95.76,258.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,Aetna,Commercial,,96.36,,,,,,,65.92,178.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,inpatient,8,ML,63.85000,38.31000,Aetna,Commercial,,28.09,,,,,,,19.22,51.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,inpatient,500,ML,115.50000,69.30000,Aetna,Commercial,,50.82,,,,,,,34.77,93.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,inpatient,1,ML,27.75000,16.65000,Aetna,Commercial,,12.21,,,,,,,8.35,22.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,75.10000,45.06000,Aetna,Commercial,,33.04,,,,,,,22.61,61.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,inpatient,20,ML,108.15000,64.89000,Aetna,Commercial,,47.59,,,,,,,32.55,87.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,inpatient,40,ML,153.25000,91.95000,Aetna,Commercial,,67.43,,,,,,,46.13,124.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,inpatient,2,ML,21.85000,13.11000,Aetna,Commercial,,9.61,,,,,,,6.58,17.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,inpatient,2,ML,19.60000,11.76000,Aetna,Commercial,,8.62,,,,,,,5.90,15.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,inpatient,5,ML,13686.90000,8212.14000,Aetna,Commercial,,6022.24,,,,,,,4119.76,11127.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Aetna,Commercial,,6706.58,,,,,,,271.45,10158.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,inpatient,1,ML,2799.00000,1679.40000,Aetna,Commercial,,1231.56,,,,,,,842.50,2275.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Aetna,Commercial,,1371.51,,,,,,,271.45,2077.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,inpatient,20,ML,79.65000,47.79000,Aetna,Commercial,,35.05,,,,,,,23.97,64.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,inpatient,1,UN,48.35000,29.01000,Aetna,Commercial,,21.27,,,,,,,14.55,39.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,inpatient,1,UN,28.20000,16.92000,Aetna,Commercial,,12.41,,,,,,,8.49,22.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,Aetna,Commercial,,20.13,,,,,,,13.77,37.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,inpatient,1,UN,63.60000,38.16000,Aetna,Commercial,,27.98,,,,,,,19.14,51.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,Aetna,Commercial,,13.11,,,,,,,8.97,24.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,inpatient,5,ML,28.50000,17.10000,Aetna,Commercial,,12.54,,,,,,,8.58,23.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,inpatient,2,ML,20.65000,12.39000,Aetna,Commercial,,9.09,,,,,,,6.22,16.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,inpatient,2,ML,20.15000,12.09000,Aetna,Commercial,,8.87,,,,,,,6.07,16.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,inpatient,2,ML,20.25000,12.15000,Aetna,Commercial,,8.91,,,,,,,6.10,16.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,Aetna,Commercial,,11.59,,,,,,,7.93,21.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,inpatient,100,ML,153.75000,92.25000,Aetna,Commercial,,67.65,,,,,,,46.28,125.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,inpatient,100,ML,405.05000,243.03000,Aetna,Commercial,,178.22,,,,,,,121.92,329.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,inpatient,4,ML,66.20000,39.72000,Aetna,Commercial,,29.13,,,,,,,19.93,53.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,inpatient,1,ML,114.75000,68.85000,Aetna,Commercial,,50.49,,,,,,,34.54,93.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,inpatient,1,UN,17.40000,10.44000,Aetna,Commercial,,7.66,,,,,,,5.24,14.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,inpatient,0.4,ML,64.00000,38.40000,Aetna,Commercial,,28.16,,,,,,,19.26,52.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,inpatient,0.25,ML,17.35000,10.41000,Aetna,Commercial,,7.63,,,,,,,5.22,14.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,inpatient,500,ML,94.50000,56.70000,Aetna,Commercial,,41.58,,,,,,,28.44,76.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,inpatient,50,ML,215.60000,129.36000,Aetna,Commercial,,94.86,,,,,,,64.90,175.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,inpatient,10,ML,835.00000,501.00000,Aetna,Commercial,,367.40,,,,,,,251.34,678.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,inpatient,0.5,UN,65.25000,39.15000,Aetna,Commercial,,28.71,,,,,,,19.64,53.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,81.95000,49.17000,Aetna,Commercial,,36.06,,,,,,,24.67,66.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,inpatient,300,ML,222.60000,133.56000,Aetna,Commercial,,97.94,,,,,,,67.00,180.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,Aetna,Commercial,,38.74,,,,,,,26.50,71.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,Aetna,Commercial,,22.48,,,,,,,15.38,41.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,inpatient,2,ML,28.40000,17.04000,Aetna,Commercial,,12.50,,,,,,,8.55,23.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,Aetna,Commercial,,16618.16,,,,,,,11368.33,30705.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,inpatient,1,UN,319.00000,191.40000,Aetna,Commercial,,140.36,,,,,,,96.02,259.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,inpatient,8,ML,64.55000,38.73000,Aetna,Commercial,,28.40,,,,,,,19.43,52.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,inpatient,50,ML,72.70000,43.62000,Aetna,Commercial,,31.99,,,,,,,21.88,59.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,inpatient,50,ML,64.90000,38.94000,Aetna,Commercial,,28.56,,,,,,,19.53,52.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,inpatient,50,ML,75.00000,45.00000,Aetna,Commercial,,33.00,,,,,,,22.57,60.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,inpatient,1,ML,19.25000,11.55000,Aetna,Commercial,,8.47,,,,,,,5.79,15.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,inpatient,8,ML,68.40000,41.04000,Aetna,Commercial,,30.10,,,,,,,20.59,55.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,inpatient,50,ML,96.60000,57.96000,Aetna,Commercial,,42.50,,,,,,,29.08,78.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,inpatient,1,ML,30.70000,18.42000,Aetna,Commercial,,13.51,,,,,,,9.24,24.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,inpatient,50,ML,103.95000,62.37000,Aetna,Commercial,,45.74,,,,,,,31.29,84.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,250.40000,150.24000,Aetna,Commercial,,110.18,,,,,,,75.37,203.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,inpatient,10,ML,170.95000,102.57000,Aetna,Commercial,,75.22,,,,,,,51.46,138.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,inpatient,50,ML,80.65000,48.39000,Aetna,Commercial,,35.49,,,,,,,24.28,65.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,inpatient,100,ML,70.35000,42.21000,Aetna,Commercial,,30.95,,,,,,,21.18,57.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,inpatient,1,GR,103.95000,62.37000,Aetna,Commercial,,45.74,,,,,,,31.29,84.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,inpatient,20,ML,81.90000,49.14000,Aetna,Commercial,,36.04,,,,,,,24.65,66.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,inpatient,1,UN,96.60000,57.96000,Aetna,Commercial,,42.50,,,,,,,29.08,78.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,109.20000,65.52000,Aetna,Commercial,,48.05,,,,,,,32.87,88.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,inpatient,500,ML,478.80000,287.28000,Aetna,Commercial,,210.67,,,,,,,144.12,389.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,inpatient,50,ML,117.85000,70.71000,Aetna,Commercial,,51.85,,,,,,,35.47,95.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,300,ML,567.00000,340.20000,Aetna,Commercial,,249.48,,,,,,,170.67,460.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,inpatient,1,UN,1165.70000,699.42000,Aetna,Commercial,,512.91,,,,,,,350.88,947.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,inpatient,1,UN,1242.40000,745.44000,Aetna,Commercial,,546.66,,,,,,,373.96,1010.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,Aetna,Commercial,,16.06,,,,,,,10.99,29.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,inpatient,100,ML,74.35000,44.61000,Aetna,Commercial,,32.71,,,,,,,22.38,60.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,inpatient,100,ML,153.30000,91.98000,Aetna,Commercial,,67.45,,,,,,,46.14,124.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,250,ML,218.50000,131.10000,Aetna,Commercial,,96.14,,,,,,,65.77,177.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,1000,ML,512.40000,307.44000,Aetna,Commercial,,225.46,,,,,,,154.23,416.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,inpatient,1000,ML,961.80000,577.08000,Aetna,Commercial,,423.19,,,,,,,289.50,781.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,Aetna,Commercial,,39.73,,,,,,,27.18,73.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,inpatient,1,UN,103.15000,61.89000,Aetna,Commercial,,45.39,,,,,,,31.05,83.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,inpatient,1,UN,247.75000,148.65000,Aetna,Commercial,,109.01,,,,,,,74.57,201.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,inpatient,10,ML,66.80000,40.08000,Aetna,Commercial,,29.39,,,,,,,20.11,54.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,inpatient,40,ML,78.15000,46.89000,Aetna,Commercial,,34.39,,,,,,,23.52,63.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,inpatient,1,UN,735.15000,441.09000,Aetna,Commercial,,323.47,,,,,,,221.28,597.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,inpatient,1,UN,17.55000,10.53000,Aetna,Commercial,,7.72,,,,,,,5.28,14.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,0.1,ML,275.20000,165.12000,Aetna,Commercial,,121.09,,,,,,,82.84,223.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,inpatient,0.2,ML,63.45000,38.07000,Aetna,Commercial,,27.92,,,,,,,19.10,51.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,inpatient,10,ML,105.10000,63.06000,Aetna,Commercial,,46.24,,,,,,,31.64,85.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,inpatient,100,ML,289.80000,173.88000,Aetna,Commercial,,127.51,,,,,,,87.23,235.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,50,ML,176.40000,105.84000,Aetna,Commercial,,77.62,,,,,,,53.10,143.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,inpatient,5,ML,120.55000,72.33000,Aetna,Commercial,,53.04,,,,,,,36.29,98.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,inpatient,50,ML,71.40000,42.84000,Aetna,Commercial,,31.42,,,,,,,21.49,58.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,inpatient,50,ML,171.80000,103.08000,Aetna,Commercial,,75.59,,,,,,,51.71,139.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,inpatient,5,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,inpatient,5,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,inpatient,5,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,inpatient,5,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,inpatient,50,ML,75.60000,45.36000,Aetna,Commercial,,33.26,,,,,,,22.76,61.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,inpatient,2,ML,34.75000,20.85000,Aetna,Commercial,,15.29,,,,,,,10.46,28.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,inpatient,100,ML,71.40000,42.84000,Aetna,Commercial,,31.42,,,,,,,21.49,58.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,inpatient,250,ML,1785.00000,1071.00000,Aetna,Commercial,,785.40,,,,,,,537.28,1451.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,inpatient,10,ML,99.55000,59.73000,Aetna,Commercial,,43.80,,,,,,,29.96,80.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,inpatient,0.5,ML,25.15000,15.09000,Aetna,Commercial,,11.07,,,,,,,7.57,20.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,inpatient,0.5,ML,34.85000,20.91000,Aetna,Commercial,,15.33,,,,,,,10.49,28.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,inpatient,1,ML,27.75000,16.65000,Aetna,Commercial,,12.21,,,,,,,8.35,22.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,Aetna,Commercial,,27.76,,,,,,,18.99,51.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,0.5,ML,22.45000,13.47000,Aetna,Commercial,,9.88,,,,,,,6.76,18.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,0.5,ML,22.50000,13.50000,Aetna,Commercial,,9.90,,,,,,,6.77,18.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,inpatient,1,ML,25.60000,15.36000,Aetna,Commercial,,11.26,,,,,,,7.71,20.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,Aetna,Commercial,,18.79,,,,,,,12.85,34.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,Aetna,Commercial,,11.48,,,,,,,7.86,21.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,Aetna,Commercial,,120.12,,,,,,,82.17,221.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,inpatient,50,ML,131.05000,78.63000,Aetna,Commercial,,57.66,,,,,,,39.45,106.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,inpatient,100,ML,94.50000,56.70000,Aetna,Commercial,,41.58,,,,,,,28.44,76.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,inpatient,50,ML,81.90000,49.14000,Aetna,Commercial,,36.04,,,,,,,24.65,66.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,inpatient,3,ML,17.75000,10.65000,Aetna,Commercial,,7.81,,,,,,,5.34,14.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,inpatient,10,ML,68.30000,40.98000,Aetna,Commercial,,30.05,,,,,,,20.56,55.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,55.90000,33.54000,Aetna,Commercial,,24.60,,,,,,,16.83,45.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,inpatient,500,ML,82.25000,49.35000,Aetna,Commercial,,36.19,,,,,,,24.76,66.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,333.3,ML,310.80000,186.48000,Aetna,Commercial,,136.75,,,,,,,93.55,252.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,inpatient,10,ML,79.75000,47.85000,Aetna,Commercial,,35.09,,,,,,,24.00,64.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,inpatient,20,ML,319.25000,191.55000,Aetna,Commercial,,140.47,,,,,,,96.09,259.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,inpatient,500,ML,75.00000,45.00000,Aetna,Commercial,,33.00,,,,,,,22.57,60.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,inpatient,4,ML,64.15000,38.49000,Aetna,Commercial,,28.23,,,,,,,19.31,52.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,inpatient,100,ML,105.00000,63.00000,Aetna,Commercial,,46.20,,,,,,,31.61,85.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,inpatient,50,ML,52.00000,31.20000,Aetna,Commercial,,22.88,,,,,,,15.65,42.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Aetna,Commercial,,25.48,,,,,,,10.41,42.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,inpatient,400,ML,161.60000,96.96000,Aetna,Commercial,,71.10,,,,,,,48.64,131.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,inpatient,15,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,Aetna,Commercial,,27.76,,,,,,,18.99,51.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,inpatient,1,ML,451.85000,271.11000,Aetna,Commercial,,198.81,,,,,,,136.01,367.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,Aetna,Commercial,,73.77,,,,,,,50.46,136.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,inpatient,50,ML,276.60000,165.96000,Aetna,Commercial,,121.70,,,,,,,83.26,224.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,inpatient,8,ML,65.70000,39.42000,Aetna,Commercial,,28.91,,,,,,,19.78,53.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,inpatient,50,ML,79.60000,47.76000,Aetna,Commercial,,35.02,,,,,,,23.96,64.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,inpatient,36,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,inpatient,6,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,inpatient,100,ML,247.60000,148.56000,Aetna,Commercial,,108.94,,,,,,,74.53,201.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,Aetna,Commercial,,4433.88,,,,,,,3033.18,8192.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,inpatient,1,UN,87.60000,52.56000,Aetna,Commercial,,38.54,,,,,,,26.37,71.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,inpatient,200,ML,150.40000,90.24000,Aetna,Commercial,,66.18,,,,,,,45.27,122.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,inpatient,1,ML,364.25000,218.55000,Aetna,Commercial,,160.27,,,,,,,109.64,296.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,inpatient,20,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,inpatient,1,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,inpatient,1,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,inpatient,180,ME,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,Aetna,Commercial,,6969.01,,,,,,,4767.43,12876.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,inpatient,15,ML,394.60000,236.76000,Aetna,Commercial,,173.62,,,,,,,118.77,320.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,Aetna,Commercial,,246.82,,,,,,,168.85,456.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,Aetna,Commercial,,136.97,,,,,,,93.70,253.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,Aetna,Commercial,,213.00,,,,,,,145.71,393.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,Aetna,Commercial,,199.03,,,,,,,136.16,367.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,Aetna,Commercial,,179.08,,,,,,,122.51,330.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,inpatient,15,ML,367.40000,220.44000,Aetna,Commercial,,161.66,,,,,,,110.59,298.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,Aetna,Commercial,,246.82,,,,,,,168.85,456.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,Aetna,Commercial,,136.97,,,,,,,93.70,253.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,Aetna,Commercial,,213.00,,,,,,,145.71,393.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,Aetna,Commercial,,1205.86,,,,,,,824.92,2228.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,inpatient,4,ML,101.20000,60.72000,Aetna,Commercial,,44.53,,,,,,,30.46,82.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,Aetna,Commercial,,11.04,,,,,,,7.56,20.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,Aetna,Commercial,,13.05,,,,,,,8.92,24.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,inpatient,1,UN,195.30000,117.18000,Aetna,Commercial,,85.93,,,,,,,58.79,158.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,Aetna,Commercial,,503.51,,,,,,,344.45,930.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,Aetna,Commercial,,503.51,,,,,,,344.45,930.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,inpatient,50,ML,73.60000,44.16000,Aetna,Commercial,,32.38,,,,,,,22.15,59.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,inpatient,8,ML,64.45000,38.67000,Aetna,Commercial,,28.36,,,,,,,19.40,52.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,inpatient,80,ML,173.25000,103.95000,Aetna,Commercial,,76.23,,,,,,,52.15,140.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,0.5,ML,63.20000,37.92000,Aetna,Commercial,,27.81,,,,,,,19.02,51.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,inpatient,10,ML,38.75000,23.25000,Aetna,Commercial,,17.05,,,,,,,11.66,31.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,inpatient,50,ML,88.00000,52.80000,Aetna,Commercial,,38.72,,,,,,,26.49,71.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,Aetna,Commercial,,1135.40,,,,,,,776.72,2097.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,inpatient,1,ML,17.20000,10.32000,Aetna,Commercial,,7.57,,,,,,,5.18,13.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,inpatient,50,ML,73.80000,44.28000,Aetna,Commercial,,32.47,,,,,,,22.21,60.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,inpatient,100,ML,597.25000,358.35000,Aetna,Commercial,,262.79,,,,,,,179.77,485.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,inpatient,1,UN,109.20000,65.52000,Aetna,Commercial,,48.05,,,,,,,32.87,88.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,inpatient,1,UN,115.50000,69.30000,Aetna,Commercial,,50.82,,,,,,,34.77,93.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,Aetna,Commercial,,19.05,,,,,,,13.03,35.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,Aetna,Commercial,,28.75,,,,,,,19.67,53.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,inpatient,1,UN,47.45000,28.47000,Aetna,Commercial,,20.88,,,,,,,14.28,38.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,inpatient,1,UN,66.05000,39.63000,Aetna,Commercial,,29.06,,,,,,,19.88,53.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,inpatient,1,UN,36.50000,21.90000,Aetna,Commercial,,16.06,,,,,,,10.99,29.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,66.05000,39.63000,Aetna,Commercial,,29.06,,,,,,,19.88,53.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,inpatient,50,ML,48.45000,29.07000,Aetna,Commercial,,21.32,,,,,,,14.58,39.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,inpatient,4,ML,88.80000,53.28000,Aetna,Commercial,,39.07,,,,,,,26.73,72.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,inpatient,250,ML,260.40000,156.24000,Aetna,Commercial,,114.58,,,,,,,78.38,211.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,inpatient,1,ML,118.25000,70.95000,Aetna,Commercial,,52.03,,,,,,,35.59,96.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,Aetna,Commercial,,2988.92,,,,,,,2044.69,5522.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,inpatient,12,ML,30.95000,18.57000,Aetna,Commercial,,13.62,,,,,,,9.32,25.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,inpatient,1,UN,83.25000,49.95000,Aetna,Commercial,,36.63,,,,,,,25.06,67.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,inpatient,40,ML,178.35000,107.01000,Aetna,Commercial,,78.47,,,,,,,53.68,145.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,inpatient,40,ML,50.60000,30.36000,Aetna,Commercial,,22.26,,,,,,,15.23,41.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,inpatient,400,ML,237.75000,142.65000,Aetna,Commercial,,104.61,,,,,,,71.56,193.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,inpatient,200,ML,150.40000,90.24000,Aetna,Commercial,,66.18,,,,,,,45.27,122.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,Aetna,Commercial,,212.52,,,,,,,145.38,392.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,inpatient,0.5,ML,68.25000,40.95000,Aetna,Commercial,,30.03,,,,,,,20.54,55.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,inpatient,1,UN,22.10000,13.26000,Aetna,Commercial,,9.72,,,,,,,6.65,17.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,inpatient,1,UN,22.80000,13.68000,Aetna,Commercial,,10.03,,,,,,,6.86,18.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,inpatient,50,ML,26.05000,15.63000,Aetna,Commercial,,11.46,,,,,,,7.84,21.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,Aetna,Commercial,,2568.04,,,,,,,1756.77,4745.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,inpatient,5,ML,63.15000,37.89000,Aetna,Commercial,,27.79,,,,,,,19.01,51.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,inpatient,0.5,ML,63.30000,37.98000,Aetna,Commercial,,27.85,,,,,,,19.05,51.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,inpatient,1,UN,144.90000,86.94000,Aetna,Commercial,,63.76,,,,,,,43.61,117.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,inpatient,0.1,ML,19.35000,11.61000,Aetna,Commercial,,8.51,,,,,,,5.82,15.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,Aetna,Commercial,,7.06,,,,,,,4.83,13.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,inpatient,0.08,ML,66.20000,39.72000,Aetna,Commercial,,29.13,,,,,,,19.93,53.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,10,ML,456.15000,273.69000,Aetna,Commercial,,200.71,,,,,,,137.30,370.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,inpatient,10,ML,462.10000,277.26000,Aetna,Commercial,,203.32,,,,,,,139.09,375.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,inpatient,10,ML,361.05000,216.63000,Aetna,Commercial,,158.86,,,,,,,108.68,293.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,Aetna,Commercial,,38.83,,,,,,,26.56,71.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,Aetna,Commercial,,7.06,,,,,,,4.83,13.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,inpatient,5,ML,24.85000,14.91000,Aetna,Commercial,,10.93,,,,,,,7.48,20.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,inpatient,2,ML,158.65000,95.19000,Aetna,Commercial,,69.81,,,,,,,47.75,128.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,Aetna,Commercial,,39.14,,,,,,,26.77,72.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,inpatient,1,UN,125.55000,75.33000,Aetna,Commercial,,55.24,,,,,,,37.79,102.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,1,ML,84.10000,50.46000,Aetna,Commercial,,37.00,,,,,,,25.31,68.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,Aetna,Commercial,,157.19,,,,,,,107.53,290.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,Aetna,Commercial,,508.66,,,,,,,347.97,939.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,Aetna,Commercial,,11.59,,,,,,,7.93,21.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,inpatient,0.5,ML,24.95000,14.97000,Aetna,Commercial,,10.98,,,,,,,7.51,20.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,inpatient,1,UN,730.25000,438.15000,Aetna,Commercial,,321.31,,,,,,,219.81,593.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,Aetna,Commercial,,28.16,,,,,,,19.26,52.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,inpatient,0.5,ML,103.50000,62.10000,Aetna,Commercial,,45.54,,,,,,,31.15,84.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Aetna,Commercial,,50.72,,,,,,,20.72,88.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,Aetna,Commercial,,66.55,,,,,,,45.53,122.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,Aetna,Commercial,,126.06,,,,,,,86.24,232.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,inpatient,1,UN,39.00000,23.40000,Aetna,Commercial,,17.16,,,,,,,11.74,31.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,inpatient,1,UN,61.50000,36.90000,Aetna,Commercial,,27.06,,,,,,,18.51,50.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,inpatient,1,UN,26.40000,15.84000,Aetna,Commercial,,11.62,,,,,,,7.95,21.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,Aetna,Commercial,,16.06,,,,,,,10.99,29.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,inpatient,1,UN,210.00000,126.00000,Aetna,Commercial,,92.40,,,,,,,63.21,170.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,inpatient,1,UN,75.60000,45.36000,Aetna,Commercial,,33.26,,,,,,,22.76,61.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,Aetna,Commercial,,38.63,,,,,,,26.43,71.38,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,inpatient,1,UN,82.30000,49.38000,Aetna,Commercial,,36.21,,,,,,,24.77,66.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,Aetna,Commercial,,11.04,,,,,,,7.56,20.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,Aetna,Commercial,,13.05,,,,,,,8.92,24.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,inpatient,8,ML,66.95000,40.17000,Aetna,Commercial,,29.46,,,,,,,20.15,54.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,inpatient,50,ML,84.00000,50.40000,Aetna,Commercial,,36.96,,,,,,,25.28,68.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,Aetna,Commercial,,10.21,,,,,,,6.98,18.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,Aetna,Commercial,,18.79,,,,,,,12.85,34.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,2,ML,23.95000,14.37000,Aetna,Commercial,,10.54,,,,,,,7.21,19.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,5,ML,26.20000,15.72000,Aetna,Commercial,,11.53,,,,,,,7.89,21.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,inpatient,500,ML,531.30000,318.78000,Aetna,Commercial,,233.77,,,,,,,159.92,431.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,inpatient,4,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,Aetna,Commercial,,1135.40,,,,,,,776.72,2097.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,Aetna,Commercial,,10878.91,,,,,,,7442.16,20101.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,Aetna,Commercial,,10878.91,,,,,,,7442.16,20101.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,Aetna,Commercial,,10878.91,,,,,,,7442.16,20101.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,Aetna,Commercial,,10878.91,,,,,,,7442.16,20101.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,Aetna,Commercial,,10878.91,,,,,,,7442.16,20101.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,Aetna,Commercial,,16618.16,,,,,,,11368.33,30705.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,inpatient,14,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,inpatient,150,ME,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,inpatient,5,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,inpatient,15,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,inpatient,10,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,inpatient,100,ML,403.95000,242.37000,Aetna,Commercial,,177.74,,,,,,,121.59,328.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,inpatient,60,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,inpatient,100,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,inpatient,500,ME,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,inpatient,4,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,inpatient,4,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,inpatient,500,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,inpatient,16,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,inpatient,8,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,inpatient,100,ML,106.70000,64.02000,Aetna,Commercial,,46.95,,,,,,,32.12,86.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,Aetna,Commercial,,13.05,,,,,,,8.92,24.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,inpatient,0.1,ML,23.05000,13.83000,Aetna,Commercial,,10.14,,,,,,,6.94,18.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,Aetna,Commercial,,13.18,,,,,,,9.01,24.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,Aetna,Commercial,,212.52,,,,,,,145.38,392.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,inpatient,4,ML,757.00000,454.20000,Aetna,Commercial,,333.08,,,,,,,227.86,615.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,Aetna,Commercial,,21.52,,,,,,,14.72,39.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,Aetna,Commercial,,11.33,,,,,,,7.75,20.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,inpatient,5,ML,26.10000,15.66000,Aetna,Commercial,,11.48,,,,,,,7.86,21.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,inpatient,1,ML,278.25000,166.95000,Aetna,Commercial,,122.43,,,,,,,83.75,226.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Aetna,Commercial,,136.34,,,,,,,55.71,221.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.2,ML,16.85000,10.11000,Aetna,Commercial,,7.41,,,,,,,5.07,13.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,Aetna,Commercial,,237.51,,,,,,,162.48,438.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,Aetna,Commercial,,135.70,,,,,,,92.83,250.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,inpatient,287.5,ML,276.75000,166.05000,Aetna,Commercial,,121.77,,,,,,,83.30,225.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,inpatient,555,ML,298.45000,179.07000,Aetna,Commercial,,131.32,,,,,,,89.83,242.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,inpatient,557.5,ML,238.65000,143.19000,Aetna,Commercial,,105.01,,,,,,,71.83,194.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,inpatient,560,ML,260.60000,156.36000,Aetna,Commercial,,114.66,,,,,,,78.44,211.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,inpatient,0.09,ML,291.30000,174.78000,Aetna,Commercial,,128.17,,,,,,,87.68,236.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Aetna,Commercial,,142.74,,,,,,,1.78,216.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,Aetna,Commercial,,10.12,,,,,,,6.92,18.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,Aetna,Commercial,,10.12,,,,,,,6.92,18.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,inpatient,10,ML,41.15000,24.69000,Aetna,Commercial,,18.11,,,,,,,12.39,33.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,Aetna,Commercial,,29.15,,,,,,,19.94,53.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,Aetna,Commercial,,16.37,,,,,,,11.20,30.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,inpatient,1,UN,45136.00000,27081.60000,Aetna,Commercial,,19859.84,,,,,,,13585.94,36695.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,Aetna,Commercial,,15826.93,,,,,,,10827.06,29243.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,Aetna,Commercial,,22558.01,,,,,,,15431.73,41681.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,Aetna,Commercial,,138.49,,,,,,,94.74,255.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,Aetna,Commercial,,127.51,,,,,,,87.23,235.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,Aetna,Commercial,,185.37,,,,,,,126.81,342.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,15,ML,46791.25000,28074.75000,Aetna,Commercial,,20588.15,,,,,,,14084.17,38041.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,Aetna,Commercial,,3359.93,,,,,,,2298.50,6208.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,Aetna,Commercial,,1740.46,,,,,,,1190.64,3215.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,Aetna,Commercial,,3359.93,,,,,,,2298.50,6208.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,Aetna,Commercial,,1740.46,,,,,,,1190.64,3215.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,Aetna,Commercial,,3359.93,,,,,,,2298.50,6208.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,Aetna,Commercial,,1740.46,,,,,,,1190.64,3215.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,Aetna,Commercial,,445.48,,,,,,,304.75,823.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,Aetna,Commercial,,8278.34,,,,,,,5663.13,15296.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,Aetna,Commercial,,8278.34,,,,,,,5663.13,15296.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,Aetna,Commercial,,8278.34,,,,,,,5663.13,15296.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,Aetna,Commercial,,22487.67,,,,,,,15383.61,41551.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,Aetna,Commercial,,1089.00,,,,,,,744.98,2012.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,Aetna,Commercial,,1837.29,,,,,,,1256.87,3394.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,Aetna,Commercial,,3646.85,,,,,,,2494.78,6738.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,Aetna,Commercial,,751.56,,,,,,,514.14,1388.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,Aetna,Commercial,,1837.29,,,,,,,1256.87,3394.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,Aetna,Commercial,,3646.85,,,,,,,2494.78,6738.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,Aetna,Commercial,,751.56,,,,,,,514.14,1388.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,inpatient,67,ML,278.85000,167.31000,Aetna,Commercial,,122.69,,,,,,,83.93,226.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,inpatient,2,ML,44.10000,26.46000,Aetna,Commercial,,19.40,,,,,,,13.27,35.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,inpatient,4,ML,29.75000,17.85000,Aetna,Commercial,,13.09,,,,,,,8.95,24.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,Aetna,Commercial,,647.37,,,,,,,442.86,1196.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,inpatient,5,ML,671.00000,402.60000,Aetna,Commercial,,295.24,,,,,,,201.97,545.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,inpatient,1,UN,107.00000,64.20000,Aetna,Commercial,,47.08,,,,,,,32.21,86.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,inpatient,1,UN,583.00000,349.80000,Aetna,Commercial,,256.52,,,,,,,175.48,473.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,inpatient,1,UN,313.75000,188.25000,Aetna,Commercial,,138.05,,,,,,,94.44,255.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,inpatient,20,ML,30.50000,18.30000,Aetna,Commercial,,13.42,,,,,,,9.18,24.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,inpatient,50,ML,30.60000,18.36000,Aetna,Commercial,,13.46,,,,,,,9.21,24.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,inpatient,20,ML,34.15000,20.49000,Aetna,Commercial,,15.03,,,,,,,10.28,27.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,inpatient,5,ML,38.00000,22.80000,Aetna,Commercial,,16.72,,,,,,,11.44,30.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,inpatient,5,ML,115.10000,69.06000,Aetna,Commercial,,50.64,,,,,,,34.65,93.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,inpatient,5,ML,49.10000,29.46000,Aetna,Commercial,,21.60,,,,,,,14.78,39.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,inpatient,1,UN,234.40000,140.64000,Aetna,Commercial,,103.14,,,,,,,70.55,190.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,inpatient,1,UN,47.45000,28.47000,Aetna,Commercial,,20.88,,,,,,,14.28,38.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,inpatient,100,ML,91.00000,54.60000,Aetna,Commercial,,40.04,,,,,,,27.39,73.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,inpatient,1,UN,48.35000,29.01000,Aetna,Commercial,,21.27,,,,,,,14.55,39.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,Aetna,Commercial,,11.59,,,,,,,7.93,21.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,inpatient,1,UN,31.25000,18.75000,Aetna,Commercial,,13.75,,,,,,,9.41,25.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,inpatient,1,UN,29.65000,17.79000,Aetna,Commercial,,13.05,,,,,,,8.92,24.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,Aetna,Commercial,,13.05,,,,,,,8.92,24.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,Aetna,Commercial,,13.18,,,,,,,9.01,24.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,inpatient,50,ML,87.25000,52.35000,Aetna,Commercial,,38.39,,,,,,,26.26,70.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,inpatient,50,ML,89.05000,53.43000,Aetna,Commercial,,39.18,,,,,,,26.80,72.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,inpatient,5,ML,53.55000,32.13000,Aetna,Commercial,,23.56,,,,,,,16.12,43.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,Aetna,Commercial,,16.37,,,,,,,11.20,30.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,inpatient,2,ML,307.00000,184.20000,Aetna,Commercial,,135.08,,,,,,,92.41,249.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,inpatient,1,UN,473.00000,283.80000,Aetna,Commercial,,208.12,,,,,,,142.37,384.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,inpatient,0.25,ML,28.95000,17.37000,Aetna,Commercial,,12.74,,,,,,,8.71,23.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,inpatient,1,ML,105.75000,63.45000,Aetna,Commercial,,46.53,,,,,,,31.83,85.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,inpatient,5,ML,20.55000,12.33000,Aetna,Commercial,,9.04,,,,,,,6.19,16.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,inpatient,100,ML,74.20000,44.52000,Aetna,Commercial,,32.65,,,,,,,22.33,60.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,inpatient,0.5,ML,26.60000,15.96000,Aetna,Commercial,,11.70,,,,,,,8.01,21.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,inpatient,1,ML,30.65000,18.39000,Aetna,Commercial,,13.49,,,,,,,9.23,24.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,Aetna,Commercial,,11.59,,,,,,,7.93,21.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,inpatient,1,ML,32.30000,19.38000,Aetna,Commercial,,14.21,,,,,,,9.72,26.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,Aetna,Commercial,,38.74,,,,,,,26.50,71.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,inpatient,2,ML,166.15000,99.69000,Aetna,Commercial,,73.11,,,,,,,50.01,135.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,inpatient,10,ML,128.35000,77.01000,Aetna,Commercial,,56.47,,,,,,,38.63,104.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,inpatient,0.3,ML,20.95000,12.57000,Aetna,Commercial,,9.22,,,,,,,6.31,17.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,inpatient,0.3,ML,17.95000,10.77000,Aetna,Commercial,,7.90,,,,,,,5.40,14.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,inpatient,2,ML,204.45000,122.67000,Aetna,Commercial,,89.96,,,,,,,61.54,166.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,inpatient,1,UN,247.55000,148.53000,Aetna,Commercial,,108.92,,,,,,,74.51,201.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,inpatient,1,UN,73.90000,44.34000,Aetna,Commercial,,32.52,,,,,,,22.24,60.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,Aetna,Commercial,,2988.92,,,,,,,2044.69,5522.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,inpatient,1,ML,227.20000,136.32000,Aetna,Commercial,,99.97,,,,,,,68.39,184.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,inpatient,1,ML,101.10000,60.66000,Aetna,Commercial,,44.48,,,,,,,30.43,82.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,inpatient,1,ML,34.20000,20.52000,Aetna,Commercial,,15.05,,,,,,,10.29,27.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,inpatient,10,ML,212.70000,127.62000,Aetna,Commercial,,93.59,,,,,,,64.02,172.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,inpatient,5,ML,107.00000,64.20000,Aetna,Commercial,,47.08,,,,,,,32.21,86.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,inpatient,2,ML,22.35000,13.41000,Aetna,Commercial,,9.83,,,,,,,6.73,18.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.25,ML,72.30000,43.38000,Aetna,Commercial,,31.81,,,,,,,21.76,58.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,inpatient,10,ML,72.65000,43.59000,Aetna,Commercial,,31.97,,,,,,,21.87,59.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,inpatient,1,UN,410.50000,246.30000,Aetna,Commercial,,180.62,,,,,,,123.56,333.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,inpatient,500,ML,1256.00000,753.60000,Aetna,Commercial,,552.64,,,,,,,378.06,1021.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,inpatient,1,UN,16.90000,10.14000,Aetna,Commercial,,7.44,,,,,,,5.09,13.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,inpatient,1,UN,16.90000,10.14000,Aetna,Commercial,,7.44,,,,,,,5.09,13.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,inpatient,1,UN,16.95000,10.17000,Aetna,Commercial,,7.46,,,,,,,5.10,13.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,inpatient,1,UN,16.80000,10.08000,Aetna,Commercial,,7.39,,,,,,,5.06,13.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,inpatient,1,ML,202.50000,121.50000,Aetna,Commercial,,89.10,,,,,,,60.95,164.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,inpatient,0.5,ML,22.20000,13.32000,Aetna,Commercial,,9.77,,,,,,,6.68,18.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,inpatient,0.1,ML,17.55000,10.53000,Aetna,Commercial,,7.72,,,,,,,5.28,14.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,inpatient,1,ML,24.45000,14.67000,Aetna,Commercial,,10.76,,,,,,,7.36,19.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,inpatient,25,ML,256.70000,154.02000,Aetna,Commercial,,112.95,,,,,,,77.27,208.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,inpatient,5,ML,86.45000,51.87000,Aetna,Commercial,,38.04,,,,,,,26.02,70.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,inpatient,0.5,ML,65.45000,39.27000,Aetna,Commercial,,28.80,,,,,,,19.70,53.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,inpatient,1,UN,83.60000,50.16000,Aetna,Commercial,,36.78,,,,,,,25.16,67.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,inpatient,1,UN,83.60000,50.16000,Aetna,Commercial,,36.78,,,,,,,25.16,67.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,inpatient,1,UN,83.60000,50.16000,Aetna,Commercial,,36.78,,,,,,,25.16,67.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,inpatient,10,ML,404.65000,242.79000,Aetna,Commercial,,178.05,,,,,,,121.80,328.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,inpatient,10,ML,100.00000,60.00000,Aetna,Commercial,,44.00,,,,,,,30.10,81.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,inpatient,5,ML,104.75000,62.85000,Aetna,Commercial,,46.09,,,,,,,31.53,85.16,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,500,ML,82.50000,49.50000,Aetna,Commercial,,36.30,,,,,,,24.83,67.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,inpatient,30,ML,82.45000,49.47000,Aetna,Commercial,,36.28,,,,,,,24.82,67.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,inpatient,30,ML,95.15000,57.09000,Aetna,Commercial,,41.87,,,,,,,28.64,77.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,inpatient,50,ML,394.80000,236.88000,Aetna,Commercial,,173.71,,,,,,,118.83,320.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,inpatient,10,ML,115.70000,69.42000,Aetna,Commercial,,50.91,,,,,,,34.83,94.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,inpatient,0.3,ML,5298.55000,3179.13000,Aetna,Commercial,,2331.36,,,,,,,1594.86,4307.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,inpatient,1,ML,269.90000,161.94000,Aetna,Commercial,,118.76,,,,,,,81.24,219.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,inpatient,1,UN,715.00000,429.00000,Aetna,Commercial,,314.60,,,,,,,215.22,581.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,inpatient,1,UN,85.10000,51.06000,Aetna,Commercial,,37.44,,,,,,,25.62,69.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,inpatient,1,UN,367.80000,220.68000,Aetna,Commercial,,161.83,,,,,,,110.71,299.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,inpatient,20,ML,646.00000,387.60000,Aetna,Commercial,,284.24,,,,,,,194.45,525.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,inpatient,5,ML,79.80000,47.88000,Aetna,Commercial,,35.11,,,,,,,24.02,64.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,inpatient,1,UN,848.40000,509.04000,Aetna,Commercial,,373.30,,,,,,,255.37,689.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,inpatient,0.25,ML,27.95000,16.77000,Aetna,Commercial,,12.30,,,,,,,8.41,22.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,inpatient,0.25,ML,28.70000,17.22000,Aetna,Commercial,,12.63,,,,,,,8.64,23.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,inpatient,1,UN,2850.10000,1710.06000,Aetna,Commercial,,1254.04,,,,,,,857.88,2317.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,inpatient,0.25,ML,22.80000,13.68000,Aetna,Commercial,,10.03,,,,,,,6.86,18.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,1,ML,58.60000,35.16000,Aetna,Commercial,,25.78,,,,,,,17.64,47.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,inpatient,1,ML,55.45000,33.27000,Aetna,Commercial,,24.40,,,,,,,16.69,45.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,inpatient,1,ML,45.50000,27.30000,Aetna,Commercial,,20.02,,,,,,,13.70,36.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,inpatient,30,ML,27459.60000,16475.76000,Aetna,Commercial,,12082.22,,,,,,,8265.34,22324.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,inpatient,10,ML,92.40000,55.44000,Aetna,Commercial,,40.66,,,,,,,27.81,75.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,Aetna,Commercial,,127.62,,,,,,,87.31,235.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,inpatient,20,ML,305.10000,183.06000,Aetna,Commercial,,134.24,,,,,,,91.84,248.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,inpatient,1,UN,9076.45000,5445.87000,Aetna,Commercial,,3993.64,,,,,,,2732.01,7379.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,inpatient,2,ML,27.35000,16.41000,Aetna,Commercial,,12.03,,,,,,,8.23,22.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,inpatient,60,ML,120.60000,72.36000,Aetna,Commercial,,53.06,,,,,,,36.30,98.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,inpatient,1,UN,131.40000,78.84000,Aetna,Commercial,,57.82,,,,,,,39.55,106.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,inpatient,1,UN,97.30000,58.38000,Aetna,Commercial,,42.81,,,,,,,29.29,79.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,inpatient,1,UN,442.10000,265.26000,Aetna,Commercial,,194.52,,,,,,,133.07,359.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,inpatient,10,ML,511.55000,306.93000,Aetna,Commercial,,225.08,,,,,,,153.98,415.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,inpatient,1,ML,353.10000,211.86000,Aetna,Commercial,,155.36,,,,,,,106.28,287.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,inpatient,0.5,ML,40477.65000,24286.59000,Aetna,Commercial,,17810.17,,,,,,,12183.77,32908.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,inpatient,10,ML,567.95000,340.77000,Aetna,Commercial,,249.90,,,,,,,170.95,461.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,inpatient,2,ML,40.90000,24.54000,Aetna,Commercial,,18.00,,,,,,,12.31,33.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,Aetna,Commercial,,199.03,,,,,,,136.16,367.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,Aetna,Commercial,,179.08,,,,,,,122.51,330.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,inpatient,1,UN,26867.20000,16120.32000,Aetna,Commercial,,11821.57,,,,,,,8087.03,21843.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,inpatient,1,UN,3832.85000,2299.71000,Aetna,Commercial,,1686.45,,,,,,,1153.69,3116.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,Aetna,Commercial,,237.51,,,,,,,162.48,438.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,Aetna,Commercial,,135.70,,,,,,,92.83,250.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,inpatient,250,ML,437.00000,262.20000,Aetna,Commercial,,192.28,,,,,,,131.54,355.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,inpatient,250,ML,437.00000,262.20000,Aetna,Commercial,,192.28,,,,,,,131.54,355.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,inpatient,1,ML,786.55000,471.93000,Aetna,Commercial,,346.08,,,,,,,236.75,639.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,inpatient,1,UN,40057.65000,24034.59000,Aetna,Commercial,,17625.37,,,,,,,12057.35,32566.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,inpatient,1,UN,20036.85000,12022.11000,Aetna,Commercial,,8816.21,,,,,,,6031.09,16289.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,Aetna,Commercial,,22.48,,,,,,,15.38,41.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,inpatient,1,UN,34.00000,20.40000,Aetna,Commercial,,14.96,,,,,,,10.23,27.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,inpatient,1,UN,129.05000,77.43000,Aetna,Commercial,,56.78,,,,,,,38.84,104.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,inpatient,5,ML,371.70000,223.02000,Aetna,Commercial,,163.55,,,,,,,111.88,302.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,inpatient,1,UN,94.85000,56.91000,Aetna,Commercial,,41.73,,,,,,,28.55,77.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,inpatient,0.5,ML,26.25000,15.75000,Aetna,Commercial,,11.55,,,,,,,7.90,21.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,inpatient,0.75,ML,49.95000,29.97000,Aetna,Commercial,,21.98,,,,,,,15.03,40.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,inpatient,1,ML,175.25000,105.15000,Aetna,Commercial,,77.11,,,,,,,52.75,142.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,inpatient,2,ML,30.90000,18.54000,Aetna,Commercial,,13.60,,,,,,,9.30,25.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,inpatient,5,ML,813.05000,487.83000,Aetna,Commercial,,357.74,,,,,,,244.73,661.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,inpatient,0.4,ML,531.50000,318.90000,Aetna,Commercial,,233.86,,,,,,,159.98,432.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,inpatient,1,UN,18.75000,11.25000,Aetna,Commercial,,8.25,,,,,,,5.64,15.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,Aetna,Commercial,,66.55,,,,,,,45.53,122.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,inpatient,1,UN,276.30000,165.78000,Aetna,Commercial,,121.57,,,,,,,83.17,224.63,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,inpatient,5,ML,266.40000,159.84000,Aetna,Commercial,,117.22,,,,,,,80.19,216.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,Aetna,Commercial,,38.83,,,,,,,26.56,71.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,inpatient,1,UN,88.25000,52.95000,Aetna,Commercial,,38.83,,,,,,,26.56,71.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,inpatient,1,UN,88.25000,52.95000,Aetna,Commercial,,38.83,,,,,,,26.56,71.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,inpatient,1,UN,526.70000,316.02000,Aetna,Commercial,,231.75,,,,,,,158.54,428.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,inpatient,1,UN,84.65000,50.79000,Aetna,Commercial,,37.25,,,,,,,25.48,68.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,inpatient,1,UN,84.65000,50.79000,Aetna,Commercial,,37.25,,,,,,,25.48,68.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,inpatient,4,ML,29.75000,17.85000,Aetna,Commercial,,13.09,,,,,,,8.95,24.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,inpatient,3,ML,75.05000,45.03000,Aetna,Commercial,,33.02,,,,,,,22.59,61.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,inpatient,3,ML,75.45000,45.27000,Aetna,Commercial,,33.20,,,,,,,22.71,61.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,inpatient,3,ML,71.45000,42.87000,Aetna,Commercial,,31.44,,,,,,,21.51,58.09,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,inpatient,2,ML,29.00000,17.40000,Aetna,Commercial,,12.76,,,,,,,8.73,23.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,inpatient,0.5,ML,39.05000,23.43000,Aetna,Commercial,,17.18,,,,,,,11.75,31.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,inpatient,2,ML,3656.00000,2193.60000,Aetna,Commercial,,1608.64,,,,,,,1100.46,2972.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,inpatient,1,UN,12542.25000,7525.35000,Aetna,Commercial,,5518.59,,,,,,,3775.22,10196.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,inpatient,1,UN,25068.40000,15041.04000,Aetna,Commercial,,11030.10,,,,,,,7545.59,20380.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,inpatient,10,ML,2068.75000,1241.25000,Aetna,Commercial,,910.25,,,,,,,622.69,1681.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,inpatient,12.5,ML,2753.30000,1651.98000,Aetna,Commercial,,1211.45,,,,,,,828.74,2238.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,inpatient,15,ML,3080.00000,1848.00000,Aetna,Commercial,,1355.20,,,,,,,927.08,2504.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,inpatient,50,ML,433.25000,259.95000,Aetna,Commercial,,190.63,,,,,,,130.41,352.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,inpatient,1,UN,17.05000,10.23000,Aetna,Commercial,,7.50,,,,,,,5.13,13.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,inpatient,1,UN,17.50000,10.50000,Aetna,Commercial,,7.70,,,,,,,5.27,14.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,inpatient,1,ML,653.00000,391.80000,Aetna,Commercial,,287.32,,,,,,,196.55,530.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,inpatient,1,UN,60.60000,36.36000,Aetna,Commercial,,26.66,,,,,,,18.24,49.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,inpatient,200,ML,745.95000,447.57000,Aetna,Commercial,,328.22,,,,,,,224.53,606.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,inpatient,1,UN,105.00000,63.00000,Aetna,Commercial,,46.20,,,,,,,31.61,85.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,inpatient,1,UN,39.70000,23.82000,Aetna,Commercial,,17.47,,,,,,,11.95,32.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,inpatient,1,UN,61.50000,36.90000,Aetna,Commercial,,27.06,,,,,,,18.51,50.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,Aetna,Commercial,,12.85,,,,,,,8.79,23.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,inpatient,1,UN,21.70000,13.02000,Aetna,Commercial,,9.55,,,,,,,6.53,17.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,inpatient,1,UN,315.00000,189.00000,Aetna,Commercial,,138.60,,,,,,,94.81,256.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,inpatient,1,UN,1663.10000,997.86000,Aetna,Commercial,,731.76,,,,,,,500.59,1352.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,inpatient,10,ML,2189.00000,1313.40000,Aetna,Commercial,,963.16,,,,,,,658.89,1779.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,inpatient,50,ML,104.50000,62.70000,Aetna,Commercial,,45.98,,,,,,,31.45,84.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,inpatient,50,ML,113.75000,68.25000,Aetna,Commercial,,50.05,,,,,,,34.24,92.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,inpatient,1,UN,417.20000,250.32000,Aetna,Commercial,,183.57,,,,,,,125.58,339.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,inpatient,5,ML,96.35000,57.81000,Aetna,Commercial,,42.39,,,,,,,29.00,78.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,inpatient,5,ML,302.95000,181.77000,Aetna,Commercial,,133.30,,,,,,,91.19,246.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,inpatient,1,UN,3628.20000,2176.92000,Aetna,Commercial,,1596.41,,,,,,,1092.09,2949.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,inpatient,1,UN,89.05000,53.43000,Aetna,Commercial,,39.18,,,,,,,26.80,72.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,inpatient,1,UN,34.30000,20.58000,Aetna,Commercial,,15.09,,,,,,,10.32,27.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,inpatient,1,UN,201.30000,120.78000,Aetna,Commercial,,88.57,,,,,,,60.59,163.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,inpatient,1,UN,174.05000,104.43000,Aetna,Commercial,,76.58,,,,,,,52.39,141.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,inpatient,1,ML,64.55000,38.73000,Aetna,Commercial,,28.40,,,,,,,19.43,52.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,inpatient,1,ML,64.85000,38.91000,Aetna,Commercial,,28.53,,,,,,,19.52,52.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,inpatient,1,ML,64.70000,38.82000,Aetna,Commercial,,28.47,,,,,,,19.47,52.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,inpatient,0.5,ML,238.95000,143.37000,Aetna,Commercial,,105.14,,,,,,,71.92,194.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,inpatient,1,UN,91.10000,54.66000,Aetna,Commercial,,40.08,,,,,,,27.42,74.06,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,inpatient,1,ML,385.20000,231.12000,Aetna,Commercial,,169.49,,,,,,,115.95,313.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,inpatient,10,ML,1813.25000,1087.95000,Aetna,Commercial,,797.83,,,,,,,545.79,1474.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,inpatient,1,UN,82.95000,49.77000,Aetna,Commercial,,36.50,,,,,,,24.97,67.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,inpatient,1000,ML,101.50000,60.90000,Aetna,Commercial,,44.66,,,,,,,30.55,82.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,inpatient,1000,ML,98.00000,58.80000,Aetna,Commercial,,43.12,,,,,,,29.50,79.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,inpatient,1000,ML,94.50000,56.70000,Aetna,Commercial,,41.58,,,,,,,28.44,76.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,inpatient,1000,ML,84.00000,50.40000,Aetna,Commercial,,36.96,,,,,,,25.28,68.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,inpatient,1000,ML,98.00000,58.80000,Aetna,Commercial,,43.12,,,,,,,29.50,79.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,inpatient,1000,ML,98.00000,58.80000,Aetna,Commercial,,43.12,,,,,,,29.50,79.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,inpatient,100,ML,356.00000,213.60000,Aetna,Commercial,,156.64,,,,,,,107.16,289.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,inpatient,17,ML,5076.25000,3045.75000,Aetna,Commercial,,2233.55,,,,,,,1527.95,4126.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Aetna,Commercial,,2487.36,,,,,,,0.31040,3767.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,inpatient,1,ML,642.70000,385.62000,Aetna,Commercial,,282.79,,,,,,,193.45,522.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,inpatient,0.5,ML,254.90000,152.94000,Aetna,Commercial,,112.16,,,,,,,76.72,207.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,inpatient,20,ML,95.55000,57.33000,Aetna,Commercial,,42.04,,,,,,,28.76,77.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,inpatient,1,UN,4022.30000,2413.38000,Aetna,Commercial,,1769.81,,,,,,,1210.71,3270.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,inpatient,10,ML,486.20000,291.72000,Aetna,Commercial,,213.93,,,,,,,146.35,395.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,inpatient,20,ML,715.00000,429.00000,Aetna,Commercial,,314.60,,,,,,,215.22,581.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,inpatient,1,UN,1730.85000,1038.51000,Aetna,Commercial,,761.57,,,,,,,520.99,1407.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,inpatient,1.5,ML,1650.30000,990.18000,Aetna,Commercial,,726.13,,,,,,,496.74,1341.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,45414.56000,27248.74000,Aetna,Commercial,,19982.41,,,,,,,13669.78,36922.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Aetna,Commercial,,22253.13,,,,,,,162.39,33706.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,156212.38000,93727.43000,Aetna,Commercial,,68733.45,,,,,,,47019.93,127000.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,257500.00000,154500.00000,Aetna,Commercial,,113300.00,,,,,,,77507.50,209347.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,11159.74000,6695.84000,Aetna,Commercial,,4910.29,,,,,,,3359.08,9072.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Aetna,Commercial,,5468.27,,,,,,,327.43,8282.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,7390.20000,4434.12000,Aetna,Commercial,,3251.69,,,,,,,2224.45,6008.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Aetna,Commercial,,3621.20,,,,,,,327.43,5485.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Aetna,Commercial,,194.25,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Aetna,Commercial,,10.24,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Aetna,Commercial,,0.90000,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Aetna,Commercial,,6.86,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,inpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Commercial,,0.15000,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,inpatient,1,UN,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,inpatient,1000,ML,42.00000,25.20000,Aetna,Commercial,,18.48,,,,,,,12.64,34.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Aetna,Commercial,,20.58,,,,,,,8.41,34.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Aetna,Commercial,,0.15000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Aetna,Commercial,,0.15000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Aetna,Commercial,,0.15000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,inpatient,20,ML,0.20000,0.12000,Aetna,Commercial,,0.08800,,,,,,,0.06020,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Aetna,Commercial,,0.09800,,,,,,,0.04004,0.16260,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Aetna,Commercial,,0.15000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Aetna,Commercial,,0.15000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Aetna,Commercial,,0.15000,,,,,,,0.04004,0.15000,percent of total billed charges,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 1,11100016,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,Aetna,Commercial,,5693.00,,,,,,,384.00,5693.00,per diem,
HC LTC LONG TERM PRIVATE ROOM LEVEL 1,11100017,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,Aetna,Commercial,,5693.00,,,,,,,256.00,5693.00,per diem,
HC LTC BED HOLD  SHORT TERM PRIVATE ROOM,11100020,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,Aetna,Commercial,,5693.00,,,,,,,384.00,5693.00,per diem,
HC LTC BED HOLD LONG TERM CARE PRIVATE ROOM,11100021,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,Aetna,Commercial,,5693.00,,,,,,,256.00,5693.00,per diem,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 2,11100022,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,Aetna,Commercial,,5693.00,,,,,,,384.00,5693.00,per diem,
HC LTC LONG TERM PRIVATE ROOM LEVEL 2,11100023,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,Aetna,Commercial,,5693.00,,,,,,,256.00,5693.00,per diem,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 3,11100024,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,Aetna,Commercial,,5693.00,,,,,,,384.00,5693.00,per diem,
HC LTC LONG TERM PRIVATE ROOM LEVEL 3,11100025,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,Aetna,Commercial,,5693.00,,,,,,,256.00,5693.00,per diem,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 4,11100026,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,Aetna,Commercial,,5693.00,,,,,,,384.00,5693.00,per diem,
HC LTC LONG TERM PRIVATE ROOM LEVEL 4,11100027,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,Aetna,Commercial,,5693.00,,,,,,,256.00,5693.00,per diem,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 1,11200004,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,Aetna,Commercial,,5693.00,,,,,,,371.20,5693.00,per diem,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 1,11200005,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,Aetna,Commercial,,5693.00,,,,,,,243.20,5693.00,per diem,
HC LTC BED HOLD SHORT TERM SEMI PRIVATE ROOM,11200008,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,Aetna,Commercial,,5693.00,,,,,,,371.20,5693.00,per diem,
HC LTC BED HOLD LONG TERM CARE SEMI PRIVATE,11200009,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,Aetna,Commercial,,5693.00,,,,,,,243.20,5693.00,per diem,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 2,11200010,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,Aetna,Commercial,,5693.00,,,,,,,371.20,5693.00,per diem,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 2,11200011,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,Aetna,Commercial,,5693.00,,,,,,,243.20,5693.00,per diem,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 3,11200012,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,Aetna,Commercial,,5693.00,,,,,,,371.20,5693.00,per diem,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 3,11200013,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,Aetna,Commercial,,5693.00,,,,,,,243.20,5693.00,per diem,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 4,11200014,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,Aetna,Commercial,,5693.00,,,,,,,371.20,5693.00,per diem,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 4,11200015,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,Aetna,Commercial,,5693.00,,,,,,,243.20,5693.00,per diem,
HC REX PRIVATE ROOM,11100002,CDM,110,RC,,,,,facility,inpatient,,,1328.00000,796.80000,Aetna,Commercial,,5693.00,,,,,,,849.92,5693.00,per diem,
HC REX OB PRIVATE ROOM,11120001,CDM,112,RC,,,,,facility,inpatient,,,1328.00000,796.80000,Aetna,Commercial,,5693.00,,,,,,,849.92,5693.00,per diem,
HC REX HOSPICE PRIVATE ROOM,11150001,CDM,115,RC,,,,,facility,inpatient,,,1328.00000,796.80000,Aetna,Commercial,,2085.00,,,,,,,849.92,2085.00,per diem,
HC REX CONTINUED NEONATAL CARE PRIVATE ROOM,11710001,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,Aetna,Commercial,,1064.00,,,,,,,974.00,1558.44,per diem,
HC REX LEVEL 1 NURSERY ROOM,11710002,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,Aetna,Commercial,,1064.00,,,,,,,974.00,1558.44,per diem,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Aetna,Commercial,,389.25,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Aetna,Commercial,,965.25,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Aetna,Commercial,,1443.75,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Aetna,Commercial,,2168.25,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Aetna,Commercial,,2601.75,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Aetna,Commercial,,3121.50,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Aetna,Commercial,,3747.00,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX LEVEL 3 INTERMEDIATE NURSERY ROOM,11733001,CDM,173,RC,,,,,facility,inpatient,,,4517.00000,2710.20000,Aetna,Commercial,,3569.00,,,,,,,2890.88,5493.00,per diem,
HC REX ICU ROOM,12000002,CDM,202,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,Aetna,Commercial,,6258.00,,,,,,,1228.00,6258.00,per diem,
HC REX ICU ROOM,12000002,CDM,210,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,Aetna,Commercial,,6258.00,,,,,,,1228.00,6258.00,per diem,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Aetna,Commercial,,1548.75,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Aetna,Commercial,,2274.75,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Aetna,Commercial,,4137.00,,,,,,,615.00,4137.00,percent of total billed charges,
HC REX INTERMEDIATE CARE ROOM,12090002,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,Aetna,Commercial,,5197.00,,,,,,,1228.00,5197.00,per diem,
HC REX INTERMEDIATE CARE SEMI PRIVATE ROOM,12090004,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,Aetna,Commercial,,5197.00,,,,,,,1228.00,5197.00,per diem,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Aetna,Commercial,,120.00,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Aetna,Commercial,,474.75,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Aetna,Commercial,,129.75,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,,87.75,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Aetna,Commercial,,19.50,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Aetna,Commercial,,107.25,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Aetna,Commercial,,118.50,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Aetna,Commercial,,393.00,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Aetna,Commercial,,447.75,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Aetna,Commercial,,381.00,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Aetna,Commercial,,69.00,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Aetna,Commercial,,54.75,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Aetna,Commercial,,172.50,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Aetna,Commercial,,158.25,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Aetna,Commercial,,3924.75,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Aetna,Commercial,,3924.75,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Aetna,Commercial,,3736.50,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Aetna,Commercial,,1339.50,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,43.50,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Aetna,Commercial,,2253.75,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Aetna,Commercial,,1144.50,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Aetna,Commercial,,234.75,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Aetna,Commercial,,819.75,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Aetna,Commercial,,256.50,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Aetna,Commercial,,927.00,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Aetna,Commercial,,681.75,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Aetna,Commercial,,227.25,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Aetna,Commercial,,375.00,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Aetna,Commercial,,703.50,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Aetna,Commercial,,199.50,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Aetna,Commercial,,153.00,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Aetna,Commercial,,819.00,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Aetna,Commercial,,711.00,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Aetna,Commercial,,214.50,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Aetna,Commercial,,32.25,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Aetna,Commercial,,26.25,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Aetna,Commercial,,105.00,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Aetna,Commercial,,355.50,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Aetna,Commercial,,94.50,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Aetna,Commercial,,214.50,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Aetna,Commercial,,100.50,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Aetna,Commercial,,8.25,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,inpatient,,,4985.00000,2991.00000,Aetna,Commercial,,1694.90,,,,,,,857.42,4137.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Aetna,Commercial,,1894.30,,,,,,,633.10,3669.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,inpatient,,,20100.00000,12060.00000,Aetna,Commercial,,6834.00,,,,,,,3457.20,16683.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Aetna,Commercial,,7638.00,,,,,,,2552.70,14797.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,inpatient,,,5074.00000,3044.40000,Aetna,Commercial,,1725.16,,,,,,,872.73,4211.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Aetna,Commercial,,1928.12,,,,,,,644.40,3735.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,inpatient,,,4240.00000,2544.00000,Aetna,Commercial,,1441.60,,,,,,,729.28,3519.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Aetna,Commercial,,1611.20,,,,,,,538.48,3121.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,inpatient,,,3478.00000,2086.80000,Aetna,Commercial,,1182.52,,,,,,,598.22,2886.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Aetna,Commercial,,1321.64,,,,,,,441.71,2560.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Aetna,Commercial,,347.25,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,Aetna,Commercial,,7039.00,,,,,,,2530.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,inpatient,,,4530.00000,2718.00000,Aetna,Commercial,,7039.00,,,,,,,2899.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,inpatient,,,4461.00000,2676.60000,Aetna,Commercial,,7039.00,,,,,,,2855.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,inpatient,,,3531.00000,2118.60000,Aetna,Commercial,,7039.00,,,,,,,2259.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,inpatient,,,5835.00000,3501.00000,Aetna,Commercial,,7039.00,,,,,,,3734.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,inpatient,,,4143.00000,2485.80000,Aetna,Commercial,,7039.00,,,,,,,2651.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,inpatient,,,4143.00000,2485.80000,Aetna,Commercial,,7039.00,,,,,,,2651.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,inpatient,,,4821.00000,2892.60000,Aetna,Commercial,,7039.00,,,,,,,3085.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,inpatient,,,4821.00000,2892.60000,Aetna,Commercial,,7039.00,,,,,,,3085.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,inpatient,,,5866.00000,3519.60000,Aetna,Commercial,,7039.00,,,,,,,3754.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,Aetna,Commercial,,7039.00,,,,,,,2530.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,Aetna,Commercial,,7039.00,,,,,,,2530.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,inpatient,,,3531.00000,2118.60000,Aetna,Commercial,,7039.00,,,,,,,2259.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,Aetna,Commercial,,7039.00,,,,,,,2530.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,inpatient,,,1745.00000,1047.00000,Aetna,Commercial,,7039.00,,,,,,,1116.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,inpatient,,,4110.00000,2466.00000,Aetna,Commercial,,7039.00,,,,,,,2630.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,inpatient,,,1691.00000,1014.60000,Aetna,Commercial,,7039.00,,,,,,,1082.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,inpatient,,,6499.00000,3899.40000,Aetna,Commercial,,7039.00,,,,,,,4159.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Aetna,Commercial,,888.00,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Aetna,Commercial,,1824.00,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Aetna,Commercial,,2763.00,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Aetna,Commercial,,3222.75,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Aetna,Commercial,,90.75,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Aetna,Commercial,,1279.50,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Aetna,Commercial,,2569.50,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Aetna,Commercial,,62.25,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Aetna,Commercial,,350.25,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Aetna,Commercial,,516.75,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Aetna,Commercial,,1167.75,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Aetna,Commercial,,884.25,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Aetna,Commercial,,59.25,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Aetna,Commercial,,66.00,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Aetna,Commercial,GP,15.75,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,inpatient,,,333.00000,199.80000,Aetna,Commercial,,7039.00,,,,,,,213.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Aetna,Commercial,,1126.50,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Aetna,Commercial,,1066.50,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Aetna,Commercial,,855.00,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Aetna,Commercial,,643.50,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Aetna,Commercial,,432.00,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Aetna,Commercial,,220.50,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,inpatient,,,1638.00000,982.80000,Aetna,Commercial,,7039.00,,,,,,,1048.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,inpatient,,,4895.00000,2937.00000,Aetna,Commercial,,7039.00,,,,,,,3132.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,inpatient,,,6492.00000,3895.20000,Aetna,Commercial,,7039.00,,,,,,,4154.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,inpatient,,,3430.00000,2058.00000,Aetna,Commercial,,7039.00,,,,,,,2195.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,inpatient,,,2604.00000,1562.40000,Aetna,Commercial,,7039.00,,,,,,,1666.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,inpatient,,,26158.00000,15694.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,21187.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,inpatient,,,27399.00000,16439.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,22193.19,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,inpatient,,,28837.00000,17302.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,23357.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,inpatient,,,30074.00000,18044.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,24359.94,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,inpatient,,,31316.00000,18789.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,25365.96,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,inpatient,,,32554.00000,19532.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,26368.74,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,inpatient,,,33591.00000,20154.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,27208.71,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,inpatient,,,35029.00000,21017.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,28373.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,inpatient,,,36268.00000,21760.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,29377.08,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,inpatient,,,37507.00000,22504.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,30380.67,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,inpatient,,,38747.00000,23248.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,31385.07,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,inpatient,,,388.00000,232.80000,Aetna,Commercial,,7039.00,,,,,,,248.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,inpatient,,,534.00000,320.40000,Aetna,Commercial,,7039.00,,,,,,,341.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,inpatient,,,829.00000,497.40000,Aetna,Commercial,,7039.00,,,,,,,530.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,inpatient,,,836.00000,501.60000,Aetna,Commercial,,7039.00,,,,,,,535.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,inpatient,,,4035.00000,2421.00000,Aetna,Commercial,,7039.00,,,,,,,2582.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,inpatient,,,9685.00000,5811.00000,Aetna,Commercial,,7039.00,,,,,,,6198.40,7844.85,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,inpatient,,,10407.00000,6244.20000,Aetna,Commercial,,7039.00,,,,,,,6660.48,8429.67,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,inpatient,,,11179.00000,6707.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9054.99,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,inpatient,,,6094.00000,3656.40000,Aetna,Commercial,,7039.00,,,,,,,3900.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,inpatient,,,7873.00000,4723.80000,Aetna,Commercial,,7039.00,,,,,,,5038.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,inpatient,,,8955.00000,5373.00000,Aetna,Commercial,,7039.00,,,,,,,5731.20,7253.55,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,inpatient,,,11530.00000,6918.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9339.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,inpatient,,,11836.00000,7101.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9587.16,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,inpatient,,,12124.00000,7274.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9820.44,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,inpatient,,,12413.00000,7447.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10054.53,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,inpatient,,,12701.00000,7620.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10287.81,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,inpatient,,,4946.00000,2967.60000,Aetna,Commercial,,7039.00,,,,,,,3165.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,inpatient,,,668.00000,400.80000,Aetna,Commercial,,7039.00,,,,,,,427.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,inpatient,,,4406.00000,2643.60000,Aetna,Commercial,,7039.00,,,,,,,2819.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,inpatient,,,5949.00000,3569.40000,Aetna,Commercial,,7039.00,,,,,,,3807.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,inpatient,,,8146.00000,4887.60000,Aetna,Commercial,,7039.00,,,,,,,5213.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,inpatient,,,10324.00000,6194.40000,Aetna,Commercial,,7039.00,,,,,,,6607.36,8362.44,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,inpatient,,,11787.00000,7072.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9547.47,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,inpatient,,,13350.00000,8010.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10813.50,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,inpatient,,,15229.00000,9137.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12335.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,inpatient,,,16324.00000,9794.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,13222.44,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,inpatient,,,17940.00000,10764.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,14531.40,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,inpatient,,,18819.00000,11291.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,15243.39,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,inpatient,,,19970.00000,11982.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16175.70,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,inpatient,,,20711.00000,12426.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16775.91,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,inpatient,,,20897.00000,12538.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16926.57,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,inpatient,,,21207.00000,12724.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,17177.67,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,inpatient,,,21825.00000,13095.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,17678.25,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,inpatient,,,22444.00000,13466.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18179.64,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,inpatient,,,23062.00000,13837.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18680.22,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,inpatient,,,23685.00000,14211.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19184.85,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,inpatient,,,24302.00000,14581.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19684.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,inpatient,,,24922.00000,14953.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,20186.82,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,inpatient,,,13406.00000,8043.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10858.86,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,inpatient,,,11362.00000,6817.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9203.22,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,Aetna,Commercial,,7039.00,,,,,,,4507.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,Aetna,Commercial,,7039.00,,,,,,,4507.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,Aetna,Commercial,,7039.00,,,,,,,4507.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,inpatient,,,6480.00000,3888.00000,Aetna,Commercial,,7039.00,,,,,,,4147.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,inpatient,,,13406.00000,8043.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10858.86,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,inpatient,,,7562.00000,4537.20000,Aetna,Commercial,,7039.00,,,,,,,4839.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,inpatient,,,8521.00000,5112.60000,Aetna,Commercial,,7039.00,,,,,,,5453.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,inpatient,,,303.00000,181.80000,Aetna,Commercial,,7039.00,,,,,,,193.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,inpatient,,,1271.00000,762.60000,Aetna,Commercial,,7039.00,,,,,,,813.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,inpatient,,,508.00000,304.80000,Aetna,Commercial,,7039.00,,,,,,,325.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,inpatient,,,508.00000,304.80000,Aetna,Commercial,,7039.00,,,,,,,325.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,inpatient,,,808.00000,484.80000,Aetna,Commercial,,7039.00,,,,,,,517.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,inpatient,,,10794.00000,6476.40000,Aetna,Commercial,,7039.00,,,,,,,6908.16,8743.14,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,inpatient,,,1890.00000,1134.00000,Aetna,Commercial,,7039.00,,,,,,,1209.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,inpatient,,,1225.00000,735.00000,Aetna,Commercial,,7039.00,,,,,,,784.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Aetna,Commercial,,5380.50,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,inpatient,,,296.00000,177.60000,Aetna,Commercial,,7039.00,,,,,,,189.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Aetna,Commercial,,567.00,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Aetna,Commercial,,2.25,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Aetna,Commercial,,1236.75,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Aetna,Commercial,,1595.25,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Aetna,Commercial,,1955.25,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Aetna,Commercial,,2313.75,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Aetna,Commercial,,2673.00,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Aetna,Commercial,,3032.25,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Aetna,Commercial,,3390.75,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Aetna,Commercial,,495.75,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Aetna,Commercial,,2460.00,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Aetna,Commercial,,3241.50,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Aetna,Commercial,,970.50,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Aetna,Commercial,,1322.25,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Aetna,Commercial,,1474.50,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Aetna,Commercial,,1632.75,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Aetna,Commercial,,1790.25,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Aetna,Commercial,,1947.00,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Aetna,Commercial,,2105.25,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Aetna,Commercial,,1236.75,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Aetna,Commercial,,718.50,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Aetna,Commercial,,1790.25,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Aetna,Commercial,,970.50,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Aetna,Commercial,,1322.25,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Aetna,Commercial,,1474.50,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Aetna,Commercial,,1632.75,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Aetna,Commercial,,1947.00,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Aetna,Commercial,,2105.25,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Aetna,Commercial,,2460.00,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Aetna,Commercial,,3241.50,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Aetna,Commercial,,374.25,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,inpatient,,,3430.00000,2058.00000,Aetna,Commercial,,7039.00,,,,,,,2195.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,inpatient,,,285.00000,171.00000,Aetna,Commercial,,7039.00,,,,,,,182.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,inpatient,,,1357.00000,814.20000,Aetna,Commercial,,7039.00,,,,,,,868.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,inpatient,,,1537.00000,922.20000,Aetna,Commercial,,7039.00,,,,,,,983.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,inpatient,,,1719.00000,1031.40000,Aetna,Commercial,,7039.00,,,,,,,1100.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,inpatient,,,1901.00000,1140.60000,Aetna,Commercial,,7039.00,,,,,,,1216.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,inpatient,,,2085.00000,1251.00000,Aetna,Commercial,,7039.00,,,,,,,1334.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,inpatient,,,2268.00000,1360.80000,Aetna,Commercial,,7039.00,,,,,,,1451.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,inpatient,,,2450.00000,1470.00000,Aetna,Commercial,,7039.00,,,,,,,1568.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,inpatient,,,2631.00000,1578.60000,Aetna,Commercial,,7039.00,,,,,,,1683.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,inpatient,,,2812.00000,1687.20000,Aetna,Commercial,,7039.00,,,,,,,1799.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,inpatient,,,2996.00000,1797.60000,Aetna,Commercial,,7039.00,,,,,,,1917.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,inpatient,,,3177.00000,1906.20000,Aetna,Commercial,,7039.00,,,,,,,2033.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,inpatient,,,3414.00000,2048.40000,Aetna,Commercial,,7039.00,,,,,,,2184.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,inpatient,,,3598.00000,2158.80000,Aetna,Commercial,,7039.00,,,,,,,2302.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,inpatient,,,4293.00000,2575.80000,Aetna,Commercial,,7039.00,,,,,,,2747.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,inpatient,,,4574.00000,2744.40000,Aetna,Commercial,,7039.00,,,,,,,2927.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,inpatient,,,4787.00000,2872.20000,Aetna,Commercial,,7039.00,,,,,,,3063.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,inpatient,,,4969.00000,2981.40000,Aetna,Commercial,,7039.00,,,,,,,3180.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,inpatient,,,5150.00000,3090.00000,Aetna,Commercial,,7039.00,,,,,,,3296.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,Aetna,Commercial,,7039.00,,,,,,,2796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,inpatient,,,4636.00000,2781.60000,Aetna,Commercial,,7039.00,,,,,,,2967.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,inpatient,,,4123.00000,2473.80000,Aetna,Commercial,,7039.00,,,,,,,2638.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,inpatient,,,2613.00000,1567.80000,Aetna,Commercial,,7039.00,,,,,,,1672.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,inpatient,,,2825.00000,1695.00000,Aetna,Commercial,,7039.00,,,,,,,1808.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,inpatient,,,2486.00000,1491.60000,Aetna,Commercial,,7039.00,,,,,,,1591.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,inpatient,,,3342.00000,2005.20000,Aetna,Commercial,,7039.00,,,,,,,2138.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Aetna,Commercial,,,75.00,,4148.0,3705.0,6222.0,346,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,inpatient,,,337.00000,202.20000,Aetna,Commercial,,7039.00,,,,,,,215.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,Aetna,Commercial,,7039.00,,,,,,,6452.48,8166.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,Aetna,Commercial,,7039.00,,,,,,,6452.48,8166.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,Aetna,Commercial,,7039.00,,,,,,,6452.48,8166.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,inpatient,,,1275.00000,765.00000,Aetna,Commercial,,7039.00,,,,,,,816.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,inpatient,,,2096.00000,1257.60000,Aetna,Commercial,,7039.00,,,,,,,1341.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,inpatient,,,2329.00000,1397.40000,Aetna,Commercial,,7039.00,,,,,,,1490.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,inpatient,,,1264.00000,758.40000,Aetna,Commercial,,7039.00,,,,,,,808.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,inpatient,,,483.00000,289.80000,Aetna,Commercial,,7039.00,,,,,,,309.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,inpatient,,,483.00000,289.80000,Aetna,Commercial,,7039.00,,,,,,,309.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Aetna,Commercial,,,75.00,,6919.0,6919.0,8529.22,119,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,inpatient,,,7494.00000,4496.40000,Aetna,Commercial,,7039.00,,,,,,,4796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,inpatient,,,1016.00000,609.60000,Aetna,Commercial,,7039.00,,,,,,,650.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,inpatient,,,404.00000,242.40000,Aetna,Commercial,,7039.00,,,,,,,258.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,inpatient,,,4574.00000,2744.40000,Aetna,Commercial,,7039.00,,,,,,,2927.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,inpatient,,,10837.00000,6502.20000,Aetna,Commercial,,7039.00,,,,,,,6935.68,8777.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,inpatient,,,5274.00000,3164.40000,Aetna,Commercial,,7039.00,,,,,,,3375.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Aetna,Commercial,,230.25,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00750,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,inpatient,,,39984.00000,23990.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,32387.04,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,inpatient,,,41222.00000,24733.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,33389.82,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,inpatient,,,1885.00000,1131.00000,Aetna,Commercial,,7039.00,,,,,,,1206.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,inpatient,,,557.00000,334.20000,Aetna,Commercial,,7039.00,,,,,,,356.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,inpatient,,,2915.00000,1749.00000,Aetna,Commercial,,7039.00,,,,,,,1865.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Aetna,Commercial,,,75.00,,3222.95,674.0,6223.12,247,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,6843.00,,,,,,,10.56,7281.00,case rate,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Aetna,Commercial,,6843.00,,,,,,,16.21,7281.00,case rate,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Aetna,Commercial,,6843.00,,,,,,,34.50,7281.00,case rate,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Commercial,,6843.00,,,,,,,18.85,7281.00,case rate,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Commercial,,6843.00,,,,,,,18.66,7281.00,case rate,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Aetna,Commercial,Q0,0.75750,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Aetna,Commercial,Q0,0.75750,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,Aetna,Commercial,,204.00,,,,,,,103.20,498.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Aetna,Commercial,,228.00,,,,,,,76.20,441.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,Aetna,Commercial,,253.64,,,,,,,128.31,619.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Aetna,Commercial,,283.48,,,,,,,94.74,549.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,1375.00000,825.00000,Aetna,Commercial,,467.50,,,,,,,236.50,1141.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Aetna,Commercial,,522.50,,,,,,,174.62,1012.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,19569.00000,11741.40000,Aetna,Commercial,,6653.46,,,,,,,3365.87,16242.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Aetna,Commercial,,7436.22,,,,,,,2485.26,14406.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,9120.00000,5472.00000,Aetna,Commercial,,3100.80,,,,,,,1568.64,7569.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Aetna,Commercial,,3465.60,,,,,,,1158.24,6714.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,Aetna,Commercial,,1740.80,,,,,,,880.64,4249.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Commercial,,1945.60,,,,,,,650.24,3769.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,4954.00000,2972.40000,Aetna,Commercial,,1684.36,,,,,,,852.09,4111.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Aetna,Commercial,,1882.52,,,,,,,629.16,3647.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,7438.00000,4462.80000,Aetna,Commercial,,2528.92,,,,,,,1279.34,6173.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Aetna,Commercial,,2826.44,,,,,,,944.63,5475.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,8418.00000,5050.80000,Aetna,Commercial,,2862.12,,,,,,,1447.90,6986.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Aetna,Commercial,,3198.84,,,,,,,1069.09,6197.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5120.00000,3072.00000,Aetna,Commercial,,1740.80,,,,,,,880.64,4249.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Commercial,,1945.60,,,,,,,650.24,3769.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,6348.00000,3808.80000,Aetna,Commercial,,2158.32,,,,,,,1091.86,5268.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Aetna,Commercial,,2412.24,,,,,,,806.20,4673.40,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,Aetna,Commercial,,108.12,,,,,,,54.70,263.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Commercial,,120.84,,,,,,,40.39,234.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,Aetna,Commercial,,35.02,,,,,,,17.72,85.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Aetna,Commercial,,39.14,,,,,,,13.08,75.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,209.00000,125.40000,Aetna,Commercial,,71.06,,,,,,,35.95,173.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Aetna,Commercial,,79.42,,,,,,,26.54,153.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,145.00000,87.00000,Aetna,Commercial,,49.30,,,,,,,24.94,120.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Commercial,,55.10,,,,,,,18.41,106.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,Aetna,Commercial,,108.12,,,,,,,54.70,263.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Commercial,,120.84,,,,,,,40.39,234.11,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,126.00000,75.60000,Aetna,Commercial,,42.84,,,,,,,21.67,104.58,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Aetna,Commercial,,47.88,,,,,,,16.00,92.76,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,151.00000,90.60000,Aetna,Commercial,,51.34,,,,,,,25.97,125.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Aetna,Commercial,,57.38,,,,,,,19.18,111.17,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,184.00000,110.40000,Aetna,Commercial,,62.56,,,,,,,31.65,152.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Aetna,Commercial,,69.92,,,,,,,23.37,135.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,295.00000,177.00000,Aetna,Commercial,,100.30,,,,,,,50.74,244.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Aetna,Commercial,,112.10,,,,,,,37.47,217.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,355.00000,213.00000,Aetna,Commercial,,120.70,,,,,,,61.06,294.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Aetna,Commercial,,134.90,,,,,,,45.09,261.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1048.00000,628.80000,Aetna,Commercial,,356.32,,,,,,,180.26,869.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Commercial,,398.24,,,,,,,133.10,771.54,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,Aetna,Commercial,,35.02,,,,,,,17.72,85.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Aetna,Commercial,,39.14,,,,,,,13.08,75.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,425.00000,255.00000,Aetna,Commercial,,144.50,,,,,,,73.10,352.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Aetna,Commercial,,161.50,,,,,,,53.98,312.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,Aetna,Commercial,,204.00,,,,,,,103.20,498.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Aetna,Commercial,,228.00,,,,,,,76.20,441.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1073.00000,643.80000,Aetna,Commercial,,364.82,,,,,,,184.56,890.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Aetna,Commercial,,407.74,,,,,,,136.27,789.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,948.00000,568.80000,Aetna,Commercial,,322.32,,,,,,,163.06,786.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Aetna,Commercial,,360.24,,,,,,,120.40,697.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,Aetna,Commercial,,253.64,,,,,,,128.31,619.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Aetna,Commercial,,283.48,,,,,,,94.74,549.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,Aetna,Commercial,,253.64,,,,,,,128.31,619.18,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Aetna,Commercial,,283.48,,,,,,,94.74,549.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,273.00000,163.80000,Aetna,Commercial,,92.82,,,,,,,46.96,226.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Commercial,,103.74,,,,,,,34.67,200.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,774.00000,464.40000,Aetna,Commercial,,263.16,,,,,,,133.13,642.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Aetna,Commercial,,294.12,,,,,,,98.30,569.82,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Commercial,,3840.00,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,503.00000,301.80000,Aetna,Commercial,,171.02,,,,,,,86.52,417.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Aetna,Commercial,,191.14,,,,,,,63.88,370.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Aetna,Commercial,,339.00,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,1349.00000,809.40000,Aetna,Commercial,,458.66,,,,,,,232.03,1119.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Aetna,Commercial,,512.62,,,,,,,171.32,993.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,Aetna,Commercial,,1740.80,,,,,,,880.64,4249.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Commercial,,1945.60,,,,,,,650.24,3769.34,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1484.00000,890.40000,Aetna,Commercial,,504.56,,,,,,,255.25,1231.72,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Aetna,Commercial,,563.92,,,,,,,188.47,1092.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1379.00000,827.40000,Aetna,Commercial,,468.86,,,,,,,237.19,1144.57,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Aetna,Commercial,,524.02,,,,,,,175.13,1015.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,Aetna,Commercial,,19.72,,,,,,,9.98,48.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,22.04,,,,,,,7.37,42.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,Aetna,Commercial,,19.72,,,,,,,9.98,48.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,22.04,,,,,,,7.37,42.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,Aetna,Commercial,,19.72,,,,,,,9.98,48.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,22.04,,,,,,,7.37,42.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,Aetna,Commercial,,19.72,,,,,,,9.98,48.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,22.04,,,,,,,7.37,42.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,Aetna,Commercial,,181.90,,,,,,,92.02,444.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Commercial,,203.30,,,,,,,67.94,393.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,Aetna,Commercial,,181.90,,,,,,,92.02,444.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Commercial,,203.30,,,,,,,67.94,393.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,Aetna,Commercial,,181.90,,,,,,,92.02,444.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Commercial,,203.30,,,,,,,67.94,393.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00750,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Aetna,Commercial,,5040.00,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,Aetna,Commercial,,313.48,,,,,,,158.58,765.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Aetna,Commercial,,350.36,,,,,,,117.09,678.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,Aetna,Commercial,,313.48,,,,,,,158.58,765.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Aetna,Commercial,,350.36,,,,,,,117.09,678.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,Aetna,Commercial,,313.48,,,,,,,158.58,765.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Aetna,Commercial,,350.36,,,,,,,117.09,678.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1215.00000,729.00000,Aetna,Commercial,,413.10,,,,,,,208.98,1008.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Aetna,Commercial,,461.70,,,,,,,154.31,894.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1631.00000,978.60000,Aetna,Commercial,,554.54,,,,,,,280.53,1353.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Aetna,Commercial,,619.78,,,,,,,207.14,1200.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Aetna,Commercial,,2174.25,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,inpatient,,,350.00000,210.00000,Aetna,Commercial,,119.00,,,,,,,60.20,290.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Commercial,,133.00,,,,,,,44.45,257.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,inpatient,,,463.00000,277.80000,Aetna,Commercial,,157.42,,,,,,,79.64,384.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Commercial,,175.94,,,,,,,58.80,340.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,inpatient,,,140.00000,84.00000,Aetna,Commercial,,47.60,,,,,,,24.08,116.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Commercial,,53.20,,,,,,,17.78,103.07,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,inpatient,,,95.00000,57.00000,Aetna,Commercial,,32.30,,,,,,,16.34,78.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,36.10,,,,,,,12.06,69.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,inpatient,,,166.00000,99.60000,Aetna,Commercial,,56.44,,,,,,,28.55,137.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Aetna,Commercial,,63.08,,,,,,,21.08,122.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,inpatient,,,350.00000,210.00000,Aetna,Commercial,,119.00,,,,,,,60.20,290.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Commercial,,133.00,,,,,,,44.45,257.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,inpatient,,,91.00000,54.60000,Aetna,Commercial,,30.94,,,,,,,15.65,75.53,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,34.58,,,,,,,11.56,66.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,inpatient,,,101.00000,60.60000,Aetna,Commercial,,34.34,,,,,,,17.37,83.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,38.38,,,,,,,12.83,74.36,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5270.00000,3162.00000,Aetna,Commercial,,1791.80,,,,,,,906.44,4374.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Aetna,Commercial,,2002.60,,,,,,,669.29,3879.77,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,1024.00000,614.40000,Aetna,Commercial,,348.16,,,,,,,176.13,849.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Aetna,Commercial,,389.12,,,,,,,130.05,753.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,inpatient,,,637.00000,382.20000,Aetna,Commercial,,216.58,,,,,,,109.56,528.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Commercial,,242.06,,,,,,,80.90,468.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,inpatient,,,39570.00000,23742.00000,Aetna,Commercial,,17410.80,,,,,,,11910.57,32170.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Aetna,Commercial,,19389.30,,,,,,,7921.91,29368.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,17004.00000,10202.40000,Aetna,Commercial,,7481.76,,,,,,,5118.20,13824.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Aetna,Commercial,,8331.96,,,,,,,162.39,12620.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,297.00000,178.20000,Aetna,Commercial,,100.98,,,,,,,51.08,246.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Aetna,Commercial,,112.86,,,,,,,33.78,218.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,308.00000,184.80000,Aetna,Commercial,,104.72,,,,,,,52.98,255.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Aetna,Commercial,,117.04,,,,,,,33.78,226.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,1919.00000,1151.40000,Aetna,Commercial,,844.36,,,,,,,577.62,1560.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Aetna,Commercial,,940.31,,,,,,,384.18,1424.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,7252.00000,4351.20000,Aetna,Commercial,,3190.88,,,,,,,2182.85,5895.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Aetna,Commercial,,3553.48,,,,,,,1451.85,5382.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,1734.00000,1040.40000,Aetna,Commercial,,762.96,,,,,,,521.93,1409.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Aetna,Commercial,,849.66,,,,,,,347.15,1286.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,3295.00000,1977.00000,Aetna,Commercial,,1449.80,,,,,,,991.79,2678.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Aetna,Commercial,,1614.55,,,,,,,659.66,2445.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,40220.00000,24132.00000,Aetna,Commercial,,17696.80,,,,,,,12106.22,32698.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Aetna,Commercial,,19707.80,,,,,,,8052.04,29851.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,12517.00000,7510.20000,Aetna,Commercial,,5507.48,,,,,,,3767.62,10176.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Aetna,Commercial,,6133.33,,,,,,,2505.90,9290.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,11120.00000,6672.00000,Aetna,Commercial,,4892.80,,,,,,,3347.12,9040.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Aetna,Commercial,,5448.80,,,,,,,2226.22,8253.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,15665.00000,9399.00000,Aetna,Commercial,,6892.60,,,,,,,4715.16,12735.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Aetna,Commercial,,7675.85,,,,,,,3136.13,11626.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,31578.00000,18946.80000,Aetna,Commercial,,13894.32,,,,,,,9504.98,25672.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Aetna,Commercial,,15473.22,,,,,,,6321.92,23437.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,2639.00000,1583.40000,Aetna,Commercial,,1161.16,,,,,,,794.34,2145.51,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Aetna,Commercial,,1293.11,,,,,,,528.33,1958.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,11117.00000,6670.20000,Aetna,Commercial,,4891.48,,,,,,,3346.22,9038.12,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Aetna,Commercial,,5447.33,,,,,,,2225.62,8251.04,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,16042.00000,9625.20000,Aetna,Commercial,,7058.48,,,,,,,4828.64,13042.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Aetna,Commercial,,7860.58,,,,,,,3211.61,11906.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,9476.00000,5685.60000,Aetna,Commercial,,3221.84,,,,,,,1629.87,7865.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Aetna,Commercial,,3600.88,,,,,,,1203.45,6976.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,Aetna,Commercial,,1186.24,,,,,,,811.50,2191.85,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Aetna,Commercial,,1321.04,,,,,,,539.74,2000.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,Aetna,Commercial,,916.64,,,,,,,463.71,2237.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Aetna,Commercial,,1024.48,,,,,,,342.39,1984.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,8366.00000,5019.60000,Aetna,Commercial,,3681.04,,,,,,,2518.17,6801.56,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Aetna,Commercial,,4099.34,,,,,,,1674.87,6209.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Aetna,Commercial,,0.75750,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,8920.00000,5352.00000,Aetna,Commercial,,3924.80,,,,,,,2684.92,7251.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Aetna,Commercial,,4370.80,,,,,,,1785.78,6620.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,11277.00000,6766.20000,Aetna,Commercial,,4961.88,,,,,,,3394.38,9168.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Aetna,Commercial,,5525.73,,,,,,,2257.66,8369.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6131.00000,3678.60000,Aetna,Commercial,,2084.54,,,,,,,1054.53,5088.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Aetna,Commercial,,2329.78,,,,,,,778.64,4513.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,inpatient,,,15495.00000,9297.00000,Aetna,Commercial,,6817.80,,,,,,,4663.99,12597.43,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Aetna,Commercial,,7592.55,,,,,,,3102.10,11500.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,inpatient,,,1255.00000,753.00000,Aetna,Commercial,,426.70,,,,,,,215.86,1041.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Aetna,Commercial,,476.90,,,,,,,35.64,923.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,inpatient,,,537.00000,322.20000,Aetna,Commercial,,182.58,,,,,,,92.36,445.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6720.00000,4032.00000,Aetna,Commercial,,2284.80,,,,,,,1155.84,5577.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Aetna,Commercial,,2553.60,,,,,,,853.44,4947.26,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5270.00000,3162.00000,Aetna,Commercial,,1791.80,,,,,,,906.44,4374.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Aetna,Commercial,,2002.60,,,,,,,669.29,3879.77,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,940.00000,564.00000,Aetna,Commercial,,319.60,,,,,,,161.68,780.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Aetna,Commercial,,357.20,,,,,,,119.38,692.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,inpatient,,,220.00000,132.00000,Aetna,Commercial,,74.80,,,,,,,37.84,182.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Aetna,Commercial,,83.60,,,,,,,27.94,161.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,555.00000,333.00000,Aetna,Commercial,,188.70,,,,,,,95.46,460.65,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Aetna,Commercial,,210.90,,,,,,,70.48,408.59,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5436.00000,3261.60000,Aetna,Commercial,,1848.24,,,,,,,934.99,4511.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Aetna,Commercial,,2065.68,,,,,,,690.37,4001.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,19845.00000,11907.00000,Aetna,Commercial,,6747.30,,,,,,,3413.34,16471.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Aetna,Commercial,,7541.10,,,,,,,2520.32,14609.89,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,27390.00000,16434.00000,Aetna,Commercial,,9312.60,,,,,,,4711.08,22733.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Aetna,Commercial,,10408.20,,,,,,,3478.53,20164.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,Aetna,Commercial,,95.54,,,,,,,48.33,233.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Aetna,Commercial,,106.78,,,,,,,35.69,206.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,Aetna,Commercial,,95.54,,,,,,,48.33,233.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Aetna,Commercial,,106.78,,,,,,,35.69,206.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,Aetna,Commercial,,89.42,,,,,,,45.24,218.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Aetna,Commercial,,99.94,,,,,,,33.40,193.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,Aetna,Commercial,,89.42,,,,,,,45.24,218.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Aetna,Commercial,,99.94,,,,,,,33.40,193.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,Aetna,Commercial,,89.42,,,,,,,45.24,218.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Aetna,Commercial,,99.94,,,,,,,33.40,193.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,inpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00340,,,,,,,0.00172,0.00830,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00380,,,,,,,0.00127,0.00736,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,3125.00000,1875.00000,Aetna,Commercial,,1062.50,,,,,,,537.50,2593.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Aetna,Commercial,,1187.50,,,,,,,396.88,2300.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Aetna,Commercial,,879.00,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Aetna,Commercial,,1130.25,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Aetna,Commercial,,1061.25,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Aetna,Commercial,,1027.50,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Aetna,Commercial,,7473.00,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Aetna,Commercial,Q1,4751.25,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Aetna,Commercial,Q0,2846.25,,,,,,,759.76,2846.25,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Aetna,Commercial,,317.25,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Commercial,,411.75,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Commercial,,282.75,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Aetna,Commercial,,438.75,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Commercial,,282.75,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Commercial,,282.75,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Commercial,,69.00,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Commercial,,216.00,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Commercial,,327.75,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Aetna,Commercial,,196.50,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Aetna,Commercial,,175.50,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Aetna,Commercial,,489.00,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,inpatient,,,110.00000,66.00000,Aetna,Commercial,,37.40,,,,,,,18.92,91.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,41.80,,,,,,,13.97,80.98,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Aetna,Commercial,,24.75,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Aetna,Commercial,,1424.25,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,,,75.00,,27344.48,857.74,36372.0,272,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,,,75.00,,5637.049999999999,1339.06,15727.73,358,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Aetna,Commercial,,,75.00,,,,,0,48.05,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Aetna,Commercial,,,75.00,,,,,0,72.07,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Commercial,,,75.00,,12346.54,2834.3199999999997,16431.75,43,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Aetna,Commercial,,,75.00,,6180.97,3893.46,44887.1,19,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Aetna,Commercial,,,75.00,,,,,0,319.11,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Aetna,Commercial,,,75.00,,,,,0,319.11,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Aetna,Commercial,,699.00,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Aetna,Commercial,,1055.25,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Aetna,Commercial,,1095.00,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Aetna,Commercial,,1293.00,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Aetna,Commercial,,1573.50,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Aetna,Commercial,,2639.25,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Aetna,Commercial,,4681.50,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Aetna,Commercial,,5048.25,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Aetna,Commercial,,476.25,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Aetna,Commercial,,638.25,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Aetna,Commercial,,4764.00,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Aetna,Commercial,,5351.25,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Aetna,Commercial,,5351.25,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Aetna,Commercial,,1273.50,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Aetna,Commercial,,2076.75,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Aetna,Commercial,,550.50,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Aetna,Commercial,,822.00,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Aetna,Commercial,,351.75,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Aetna,Commercial,,726.00,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Aetna,Commercial,,515.25,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Aetna,Commercial,,1158.75,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Aetna,Commercial,,803.25,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Aetna,Commercial,,1396.50,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Aetna,Commercial,,337.50,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Aetna,Commercial,,903.00,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Aetna,Commercial,,5619.00,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Aetna,Commercial,,5590.50,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Aetna,Commercial,,1798.50,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Aetna,Commercial,,1309.50,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Aetna,Commercial,,2325.00,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Aetna,Commercial,,6317.25,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Aetna,Commercial,,318.75,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Aetna,Commercial,,425.25,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Aetna,Commercial,,1633.50,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Aetna,Commercial,,1569.00,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Aetna,Commercial,,3476.25,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Aetna,Commercial,,1843.50,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Aetna,Commercial,,2249.25,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Commercial,,237.00,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Aetna,Commercial,,240.75,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Aetna,Commercial,,,75.00,,10621.16,1211.7200000000003,46863.94,610,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Commercial,,,75.00,,3321.23,2179.31,43219.399999999994,50,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Aetna,Commercial,,,75.00,,,,,0,120.72,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Commercial,,,75.00,,16777.77,2345.6900000000005,55862.76,40,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Aetna,Commercial,,,75.00,,,,,0,307.71,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Commercial,,,75.00,,,,,0,44.39,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Aetna,Commercial,,,75.00,,,,,0,146.95,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Aetna,Commercial,,,75.00,,,,,0,91.49,767.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Aetna,Commercial,,,75.00,,,,,0,104.70,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Aetna,Commercial,,5351.25,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Aetna,Commercial,,774.00,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Aetna,Commercial,,666.75,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Aetna,Commercial,,872.25,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Aetna,Commercial,,788.25,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Aetna,Commercial,,1054.50,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Aetna,Commercial,76,1054.50,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,,1398.75,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Aetna,Commercial,,2811.00,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Aetna,Commercial,76,2811.00,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Aetna,Commercial,,2958.75,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Aetna,Commercial,76,2958.75,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Aetna,Commercial,,1525.50,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Aetna,Commercial,,1695.75,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Aetna,Commercial,,1787.25,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Aetna,Commercial,,1971.75,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Aetna,Commercial,,1374.75,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Aetna,Commercial,,1966.50,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Commercial,,257.25,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Commercial,,309.75,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Commercial,,309.75,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Commercial,,,75.00,,,,,0,58.46,3466.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Aetna,Commercial,,2131.50,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Aetna,Commercial,,20474.25,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Aetna,Commercial,,2814.75,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Aetna,Commercial,,3237.00,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Aetna,Commercial,,3237.00,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Aetna,Commercial,,486.00,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Aetna,Commercial,,531.00,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Aetna,Commercial,,918.75,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Aetna,Commercial,,645.00,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Aetna,Commercial,,685.50,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Aetna,Commercial,,703.50,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Aetna,Commercial,,480.75,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,,1398.75,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,76,1398.75,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,,1398.75,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,76,1398.75,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Commercial,,257.25,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Aetna,Commercial,,487.50,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Aetna,Commercial,,272.25,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,,1398.75,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,76,1398.75,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Commercial,,341.25,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Aetna,Commercial,76,645.00,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Aetna,Commercial,76,685.50,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Aetna,Commercial,,374.25,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Aetna,Commercial,,783.00,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Aetna,Commercial,,1221.75,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Aetna,Commercial,,1757.25,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Aetna,Commercial,,5185.50,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Aetna,Commercial,,549.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Aetna,Commercial,,4550.25,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Aetna,Commercial,,1690.50,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Aetna,Commercial,,2127.75,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Aetna,Commercial,,1386.00,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Aetna,Commercial,,653.25,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Commercial,,411.75,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Aetna,Commercial,,603.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Commercial,,939.00,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Aetna,Commercial,,6123.00,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Aetna,Commercial,,1807.50,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Aetna,Commercial,,303.75,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Aetna,Commercial,,420.00,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Aetna,Commercial,,1246.50,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Aetna,Commercial,,1442.25,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Aetna,Commercial,,955.50,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Commercial,,237.00,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Aetna,Commercial,,487.50,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Aetna,Commercial,,1633.50,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,inpatient,,,3123.00000,1873.80000,Aetna,Commercial,,7039.00,,,,,,,1998.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Commercial,,4376.00,,,,,,,625.22,4376.00,case rate,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Aetna,Commercial,,263.25,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,inpatient,,,1054.00000,632.40000,Aetna,Commercial,,7039.00,,,,,,,674.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Aetna,Commercial,,,75.00,,4407.51,4407.51,4407.51,1 through 10,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Aetna,Commercial,,4311.00,,,,,,,6.41,4311.00,case rate,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,inpatient,,,465.00000,279.00000,Aetna,Commercial,,7039.00,,,,,,,297.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Aetna,Commercial,,4311.00,,,,,,,93.09,4311.00,case rate,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Aetna,Commercial,,4376.00,,,,,,,186.78,4376.00,case rate,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Aetna,Commercial,,4376.00,,,,,,,186.78,4376.00,case rate,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,inpatient,,,322.00000,193.20000,Aetna,Commercial,,7039.00,,,,,,,206.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Aetna,Commercial,,4376.00,,,,,,,64.46,5189.94,case rate,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,inpatient,,,757.00000,454.20000,Aetna,Commercial,,7039.00,,,,,,,484.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Aetna,Commercial,,4376.00,,,,,,,151.55,4376.00,case rate,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,inpatient,,,162.00000,97.20000,Aetna,Commercial,,7039.00,,,,,,,103.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Commercial,,4311.00,,,,,,,32.43,4311.00,case rate,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Aetna,Commercial,,4311.00,,,,,,,203.70,4311.00,case rate,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Aetna,Commercial,,224.25,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Aetna,Commercial,,4311.00,,,,,,,103.59,4311.00,case rate,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Commercial,,84.75,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Aetna,Commercial,,226.50,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Commercial,,27.75,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Commercial,,27.75,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Aetna,Commercial,,17.25,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,43.50,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,42.00,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Aetna,Commercial,,81.75,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Commercial,,150.00,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Commercial,,120.75,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Commercial,,84.75,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Commercial,,99.75,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Commercial,,84.75,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Aetna,Commercial,,328.50,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Commercial,,37.50,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Commercial,,309.75,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Commercial,,216.00,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Commercial,,27.75,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Aetna,Commercial,,143.25,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Commercial,,201.75,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Aetna,Commercial,GP,50.25,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Commercial,GP,56.25,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Commercial,GP,,75.00,,,,,0,1.87,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Aetna,Commercial,GP,,75.00,,,,,0,18.85,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,GP,,75.00,,1265.22,1074.23,2399.8,1 through 10,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Aetna,Commercial,GP,,75.00,,,,,0,2.49,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Aetna,Commercial,GP,,75.00,,1362.75,1362.75,1362.75,1 through 10,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Commercial,GP,,75.00,,828.57,348.61,1770.75,301,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Commercial,GP,,75.00,,442.5,325.5,1143.0,57,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,GP,,75.00,,955.0,944.0,85160.04999999999,1 through 10,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,GP,,75.00,,,,,0,9.19,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Commercial,GP,,75.00,,697.22,348.61,1822.5,71,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Aetna,Commercial,GP,,75.00,,537.75,424.5,955.0,1 through 10,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Aetna,Commercial,GP,,75.00,,,,,0,22.44,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,GP,123.75,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Commercial,GP,104.25,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Commercial,GP,,75.00,,,,,0,31.47,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,GP,,75.00,,,,,0,18.23,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,GP,,75.00,,1107.0,441.75,2000.25,1 through 10,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Aetna,Commercial,GP,,75.00,,432.0,432.0,729.1700000000001,1 through 10,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Commercial,GP,,75.00,,,,,0,7.32,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,GP,,75.00,,,,,0,18.38,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Commercial,GP,,75.00,,,,,0,13.24,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,GP,,75.00,,393.0,296.07,906.0,41,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Commercial,GP,,75.00,,,,,0,15.42,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Commercial,GP,4311.00,,,,,,,28.04,4311.00,case rate,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Commercial,GP,4311.00,,,,,,,28.04,4311.00,case rate,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,GP,,75.00,,,,,0,14.18,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,GP,,75.00,,,,,0,14.18,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,GP,,75.00,,,,,0,13.87,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Commercial,GP,,75.00,,,,,0,19.79,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Commercial,GP,97.50,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Commercial,GP,52.50,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Commercial,GP,22.50,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Aetna,Commercial,GP,,75.00,,446.0,218.25,2092.0,13,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Aetna,Commercial,GP,,75.00,,300.33,300.33,685.5,1 through 10,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Aetna,Commercial,GP,,75.00,,309.75,308.14,1870.5,1 through 10,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Commercial,GP,,75.00,,205.5,205.5,1327.0,1 through 10,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,GO,,75.00,,1222.5,1222.5,1222.5,1 through 10,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,GO,,75.00,,,,,0,18.23,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,GO,,75.00,,,,,0,20.10,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,GO,,75.00,,,,,0,18.38,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Commercial,GO,,75.00,,,,,0,10.91,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,GO,,75.00,,432.0,366.35999999999996,1091.98,24,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Commercial,GO,,75.00,,,,,0,15.42,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Commercial,GO,,75.00,,,,,0,1.87,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Commercial,GO,,75.00,,1035.75,390.5,1970.96,24,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Commercial,GO,,75.00,,1038.0,1009.5,3303.75,1 through 10,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,GO,,75.00,,,,,0,9.66,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Commercial,GO,,75.00,,,,,0,25.55,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Aetna,Commercial,GO,,75.00,,1870.14,582.0,4059.0699999999997,1 through 10,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Aetna,Commercial,GO,,75.00,,,,,0,22.44,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,GO,123.75,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,GO,,75.00,,,,,0,7.63,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Aetna,Commercial,GO,,75.00,,,,,0,34.90,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Commercial,GO,,75.00,,751.5,751.5,751.5,1 through 10,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Commercial,GO,,75.00,,751.5,751.5,751.5,1 through 10,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Commercial,GO,,75.00,,,,,0,11.69,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Commercial,GO,,75.00,,4649.08,4649.08,4649.08,1 through 10,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Aetna,Commercial,GO,,75.00,,4059.0699999999997,4059.0699999999997,4059.0699999999997,1 through 10,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Aetna,Commercial,GO,,75.00,,1038.0,1038.0,1038.0,1 through 10,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Commercial,GO,,75.00,,,,,0,31.47,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Aetna,Commercial,GN,,75.00,,505.52,252.76,1017.0,58,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Aetna,Commercial,GN,252.00,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Aetna,Commercial,GN,140.25,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Commercial,GN,201.75,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Commercial,GN,150.00,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Commercial,GN,236.25,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Commercial,GN,,75.00,,,,,0,19.94,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Commercial,GN,,75.00,,,,,0,10.91,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Commercial,GN,,75.00,,,,,0,13.24,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Commercial,GN,,75.00,,,,,0,15.42,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Aetna,Commercial,GN,,75.00,,,,,0,35.68,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,GN,,75.00,,,,,0,21.19,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Aetna,Commercial,GN,,75.00,,960.0,468.0,10904.59,1 through 10,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Aetna,Commercial,GN,,75.00,,,,,0,40.35,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Aetna,Commercial,GN,,75.00,,,,,0,10.59,276.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Commercial,GN,97.50,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Commercial,GN,52.50,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Commercial,GN,22.50,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Aetna,Commercial,GN,160.50,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Aetna,Commercial,GN,171.75,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Commercial,GN,80.25,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Aetna,Commercial,GN,264.75,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Commercial,GN,411.75,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Aetna,Commercial,GN,443.25,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Aetna,Commercial,,648.00,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Commercial,,411.75,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Aetna,Commercial,,663.75,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Aetna,Commercial,,378.00,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Aetna,Commercial,,558.75,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Aetna,Commercial,,2817.00,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Commercial,,32.25,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Aetna,Commercial,,111.00,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Aetna,Commercial,,393.75,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Aetna,Commercial,,392.25,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Aetna,Commercial,,422.25,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Commercial,,282.75,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Commercial,,282.75,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Aetna,Commercial,,1017.75,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Aetna,Commercial,,313.50,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Aetna,Commercial,,609.00,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Commercial,,80.25,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Aetna,Commercial,,425.25,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Aetna,Commercial,,357.00,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Aetna,Commercial,,489.00,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Commercial,,343.50,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Commercial,,117.00,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Commercial,,135.00,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Aetna,Commercial,,4311.00,,,,,,,203.70,4311.00,case rate,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Aetna,Commercial,,98.25,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Aetna,Commercial,,1156.50,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Aetna,Commercial,,1156.50,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Aetna,Commercial,,198.00,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Aetna,Commercial,,198.00,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Aetna,Commercial,,4376.00,,,,,,,186.78,4376.00,case rate,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Commercial,,4376.00,,,,,,,494.00,4376.00,case rate,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Aetna,Commercial,,525.00,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,inpatient,,,2272.00000,1363.20000,Aetna,Commercial,,7039.00,,,,,,,1454.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Aetna,Commercial,,12247.00,,,,,,,303.99,12247.00,case rate,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Aetna,Commercial,,623.25,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Aetna,Commercial,,378.75,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Aetna,Commercial,,166.50,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Aetna,Commercial,,249.75,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Aetna,Commercial,,253.50,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Aetna,Commercial,,138.75,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Aetna,Commercial,,4532.25,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Aetna,Commercial,,4532.25,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Aetna,Commercial,,762.75,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Aetna,Commercial,,3150.00,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Aetna,Commercial,,3150.00,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Aetna,Commercial,,3199.50,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Aetna,Commercial,,865.50,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Aetna,Commercial,,414.00,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Aetna,Commercial,,423.75,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Aetna,Commercial,,1012.50,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Aetna,Commercial,,722.25,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Commercial,,412.50,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Aetna,Commercial,,722.25,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Aetna,Commercial,,788.25,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Aetna,Commercial,,339.75,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Commercial,,953.25,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Aetna,Commercial,,869.25,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Aetna,Commercial,,546.00,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Commercial,,360.75,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Aetna,Commercial,,844.50,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Commercial,,237.00,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Aetna,Commercial,,568.50,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Aetna,Commercial,,93.00,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Aetna,Commercial,,718.50,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Commercial,,428.25,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Aetna,Commercial,,348.00,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Commercial,,404.25,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Aetna,Commercial,,377.25,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Aetna,Commercial,,1179.00,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Aetna,Commercial,,303.75,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Aetna,Commercial,,1179.00,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Aetna,Commercial,,303.75,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Commercial,,279.75,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Aetna,Commercial,,505.50,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Aetna,Commercial,,616.50,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Aetna,Commercial,,641.25,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Aetna,Commercial,,666.00,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Commercial,,404.25,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Aetna,Commercial,,321.75,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Aetna,Commercial,,221.25,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Commercial,,327.75,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Commercial,,189.75,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Aetna,Commercial,,460.50,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Aetna,Commercial,,460.50,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Aetna,Commercial,,410.25,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Commercial,,159.00,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Commercial,,159.00,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Commercial,,159.00,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Commercial,,159.00,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Aetna,Commercial,,300.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Aetna,Commercial,,300.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Aetna,Commercial,,300.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Aetna,Commercial,,200.25,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Aetna,Commercial,,274.50,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Aetna,Commercial,,274.50,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Aetna,Commercial,,1226.25,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Aetna,Commercial,,1226.25,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Aetna,Commercial,,342.75,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Commercial,,341.25,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Aetna,Commercial,,1118.25,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Aetna,Commercial,,1144.50,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Aetna,Commercial,,636.00,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Aetna,Commercial,,924.75,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Aetna,Commercial,,317.25,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Aetna,Commercial,,747.75,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Commercial,,347.25,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Aetna,Commercial,,408.00,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Aetna,Commercial,,986.25,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Aetna,Commercial,,1191.00,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Aetna,Commercial,,1462.50,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Aetna,Commercial,,2075.25,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Aetna,Commercial,,2279.25,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Aetna,Commercial,,2892.00,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Aetna,Commercial,,1701.00,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Aetna,Commercial,,1905.00,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Aetna,Commercial,,2143.50,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Aetna,Commercial,,3402.00,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Aetna,Commercial,,3810.00,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Aetna,Commercial,,4252.50,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Aetna,Commercial,,781.50,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,141.00,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,141.00,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Aetna,Commercial,,4311.00,,,,,,,44.39,4311.00,case rate,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Commercial,,219.00,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Commercial,,220.50,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Commercial,,36.00,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Commercial,,36.00,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Commercial,,79.50,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Commercial,,581.25,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Commercial,,581.25,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Commercial,,581.25,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Commercial,,581.25,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Commercial,,581.25,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Commercial,,581.25,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Commercial,,56.25,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Aetna,Commercial,GP,4311.00,,,,,,,10.39,4311.00,case rate,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Aetna,Commercial,,4311.00,,,,,,,90.29,4311.00,case rate,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,inpatient,,,2744.00000,1646.40000,Aetna,Commercial,,7039.00,,,,,,,1756.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Aetna,Commercial,,4311.00,,,,,,,549.35,4311.00,case rate,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Aetna,Commercial,,4311.00,,,,,,,517.24,4311.00,case rate,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Aetna,Commercial,,4376.00,,,,,,,730.44,4376.00,case rate,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,inpatient,,,1085.00000,651.00000,Aetna,Commercial,,7039.00,,,,,,,694.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Aetna,Commercial,,4376.00,,,,,,,204.52,4376.00,case rate,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Aetna,Commercial,,4376.00,,,,,,,464.46,4376.00,case rate,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Aetna,Commercial,,4311.00,,,,,,,195.85,4311.00,case rate,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Aetna,Commercial,,4311.00,,,,,,,195.85,4311.00,case rate,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Aetna,Commercial,,4311.00,,,,,,,601.32,4311.00,case rate,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Aetna,Commercial,,4311.00,,,,,,,81.06,4311.00,case rate,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Aetna,Commercial,,4311.00,,,,,,,90.48,4311.00,case rate,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Aetna,Commercial,,4311.00,,,,,,,101.04,4311.00,case rate,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Commercial,,4311.00,,,,,,,86.33,4311.00,case rate,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Aetna,Commercial,,89.25,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,,4311.00,,,,,,,24.32,4311.00,case rate,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,,4311.00,,,,,,,24.32,4311.00,case rate,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Aetna,Commercial,,4311.00,,,,,,,39.21,4311.00,case rate,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Commercial,,4311.00,,,,,,,30.73,4311.00,case rate,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Aetna,Commercial,,4311.00,,,,,,,57.87,4311.00,case rate,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Aetna,Commercial,,4311.00,,,,,,,98.02,4311.00,case rate,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Aetna,Commercial,,4311.00,,,,,,,95.00,4311.00,case rate,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Aetna,Commercial,,4311.00,,,,,,,116.49,4311.00,case rate,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Aetna,Commercial,,4311.00,,,,,,,77.10,4311.00,case rate,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,inpatient,,,770.00000,462.00000,Aetna,Commercial,,7039.00,,,,,,,492.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Aetna,Commercial,,4311.00,,,,,,,154.15,4311.00,case rate,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Aetna,Commercial,,4311.00,,,,,,,145.15,4311.00,case rate,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,inpatient,,,638.00000,382.80000,Aetna,Commercial,,7039.00,,,,,,,408.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Aetna,Commercial,,4311.00,,,,,,,127.73,4311.00,case rate,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Aetna,Commercial,,452.25,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Aetna,Commercial,,4311.00,,,,,,,170.03,4311.00,case rate,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,inpatient,,,182.00000,109.20000,Aetna,Commercial,,7039.00,,,,,,,116.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Aetna,Commercial,,4311.00,,,,,,,36.44,4311.00,case rate,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,inpatient,,,152.00000,91.20000,Aetna,Commercial,,7039.00,,,,,,,97.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Commercial,,4311.00,,,,,,,30.43,4311.00,case rate,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,inpatient,,,280.00000,168.00000,Aetna,Commercial,,7039.00,,,,,,,179.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Aetna,Commercial,,4311.00,,,,,,,56.06,4311.00,case rate,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Aetna,Commercial,,291.00,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,Aetna,Commercial,,7039.00,,,,,,,485.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Aetna,Commercial,,4311.00,,,,,,,151.95,4311.00,case rate,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Aetna,Commercial,,4311.00,,,,,,,143.07,4311.00,case rate,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,inpatient,,,2295.00000,1377.00000,Aetna,Commercial,,7039.00,,,,,,,1468.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Aetna,Commercial,,4311.00,,,,,,,459.46,4311.00,case rate,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Aetna,Commercial,,4311.00,,,,,,,114.42,4311.00,case rate,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,inpatient,,,1863.00000,1117.80000,Aetna,Commercial,,7039.00,,,,,,,1192.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Aetna,Commercial,,4311.00,,,,,,,372.97,4311.00,case rate,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Aetna,Commercial,,4311.00,,,,,,,351.18,4311.00,case rate,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,inpatient,,,2132.00000,1279.20000,Aetna,Commercial,,7039.00,,,,,,,1364.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Aetna,Commercial,,4376.00,,,,,,,101.04,4376.00,case rate,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Commercial,,777.75,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Aetna,Commercial,,4376.00,,,,,,,2357.57,10168.19,case rate,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Aetna,Commercial,,4311.00,,,,,,,284.00,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Aetna,Commercial,,4311.00,,,,,,,364.37,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Aetna,Commercial,,4311.00,,,,,,,157.21,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Aetna,Commercial,,4311.00,,,,,,,163.81,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Aetna,Commercial,,4311.00,,,,,,,174.36,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Aetna,Commercial,,4311.00,,,,,,,289.91,4311.00,case rate,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Aetna,Commercial,,4311.00,,,,,,,361.54,4311.00,case rate,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Aetna,Commercial,,4311.00,,,,,,,1842.40,7946.26,case rate,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,inpatient,,,660.00000,396.00000,Aetna,Commercial,,7039.00,,,,,,,422.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Commercial,,4311.00,,,,,,,132.13,4311.00,case rate,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Commercial,,4311.00,,,,,,,124.41,4311.00,case rate,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,inpatient,,,3189.00000,1913.40000,Aetna,Commercial,,7039.00,,,,,,,2040.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Aetna,Commercial,,4311.00,,,,,,,638.44,5754.00,case rate,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Aetna,Commercial,,4311.00,,,,,,,601.13,4311.00,case rate,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,inpatient,,,1528.00000,916.80000,Aetna,Commercial,,7039.00,,,,,,,977.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Aetna,Commercial,,4311.00,,,,,,,288.03,4311.00,case rate,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Aetna,Commercial,,4311.00,,,,,,,325.54,4311.00,case rate,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,inpatient,,,2142.00000,1285.20000,Aetna,Commercial,,7039.00,,,,,,,1370.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Aetna,Commercial,,4376.00,,,,,,,428.83,5152.00,case rate,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Aetna,Commercial,,4376.00,,,,,,,403.77,4376.00,case rate,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,inpatient,,,1397.00000,838.20000,Aetna,Commercial,,7039.00,,,,,,,894.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Aetna,Commercial,,4311.00,,,,,,,263.33,4311.00,case rate,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,inpatient,,,621.00000,372.60000,Aetna,Commercial,,7039.00,,,,,,,397.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Aetna,Commercial,,4311.00,,,,,,,124.32,4311.00,case rate,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Aetna,Commercial,,4311.00,,,,,,,117.06,4311.00,case rate,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,inpatient,,,720.00000,432.00000,Aetna,Commercial,,7039.00,,,,,,,460.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Aetna,Commercial,,4311.00,,,,,,,144.14,4311.00,case rate,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Aetna,Commercial,,4311.00,,,,,,,135.72,4311.00,case rate,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,Aetna,Commercial,,7039.00,,,,,,,39.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,,75.00,,,,,0,12.21,208.90,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,inpatient,,,373.00000,223.80000,Aetna,Commercial,,7039.00,,,,,,,238.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Commercial,,4311.00,,,,,,,74.67,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Aetna,Commercial,,4376.00,,,,,,,422.24,4376.00,case rate,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Commercial,JW,99.00,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Aetna,Commercial,,4311.00,,,,,,,110.46,4311.00,case rate,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,inpatient,,,499.00000,299.40000,Aetna,Commercial,,7039.00,,,,,,,319.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Aetna,Commercial,,4311.00,,,,,,,99.90,4311.00,case rate,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,inpatient,,,604.00000,362.40000,Aetna,Commercial,,7039.00,,,,,,,386.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Aetna,Commercial,,4311.00,,,,,,,120.92,4311.00,case rate,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Aetna,Commercial,,4311.00,,,,,,,94.06,4311.00,case rate,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,inpatient,,,586.00000,351.60000,Aetna,Commercial,,7039.00,,,,,,,375.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Aetna,Commercial,,4311.00,,,,,,,117.32,4311.00,case rate,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Aetna,Commercial,,4311.00,,,,,,,154.95,4311.00,case rate,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Aetna,Commercial,,4376.00,,,,,,,257.11,4376.00,case rate,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Aetna,Commercial,,4311.00,,,,,,,66.35,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,inpatient,,,3941.00000,2364.60000,Aetna,Commercial,,7039.00,,,,,,,2522.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,inpatient,,,3941.00000,2364.60000,Aetna,Commercial,,7039.00,,,,,,,2522.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Commercial,,4311.00,,,,,,,666.26,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,inpatient,,,1950.00000,1170.00000,Aetna,Commercial,,7039.00,,,,,,,1248.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Aetna,Commercial,,4311.00,,,,,,,390.39,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Aetna,Commercial,,4311.00,,,,,,,367.57,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,inpatient,,,3103.00000,1861.80000,Aetna,Commercial,,7039.00,,,,,,,1985.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Aetna,Commercial,,4311.00,,,,,,,621.22,4311.00,case rate,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Aetna,Commercial,,4311.00,,,,,,,584.92,4311.00,case rate,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Aetna,Commercial,,4311.00,,,,,,,324.79,4311.00,case rate,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Aetna,Commercial,,4311.00,,,,,,,401.88,4311.00,case rate,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Aetna,Commercial,,4311.00,,,,,,,527.80,4311.00,case rate,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,inpatient,,,543.00000,325.80000,Aetna,Commercial,,7039.00,,,,,,,347.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Aetna,Commercial,,4376.00,,,,,,,108.71,4376.00,case rate,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,inpatient,,,4385.00000,2631.00000,Aetna,Commercial,,7039.00,,,,,,,2806.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,inpatient,,,4850.00000,2910.00000,Aetna,Commercial,,7039.00,,,,,,,3104.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,inpatient,,,5734.00000,3440.40000,Aetna,Commercial,,7039.00,,,,,,,3669.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Aetna,Commercial,,4311.00,,,,,,,856.54,4311.00,case rate,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,inpatient,,,804.00000,482.40000,Aetna,Commercial,,7039.00,,,,,,,514.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Commercial,,4376.00,,,,,,,160.96,4376.00,case rate,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Aetna,Commercial,,4311.00,,,,,,,295.00,4311.00,case rate,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Aetna,Commercial,,4311.00,,,,,,,295.00,4311.00,case rate,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Aetna,Commercial,,4311.00,,,,,,,284.00,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Aetna,Commercial,,4311.00,,,,,,,284.00,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Commercial,,4311.00,,,,,,,109.71,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Aetna,Commercial,,4311.00,,,,,,,427.52,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Aetna,Commercial,,4311.00,,,,,,,238.45,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,inpatient,,,2333.00000,1399.80000,Aetna,Commercial,,7039.00,,,,,,,1493.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Aetna,Commercial,,4311.00,,,,,,,467.07,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Aetna,Commercial,,4311.00,,,,,,,439.77,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Aetna,Commercial,,4311.00,,,,,,,385.86,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Aetna,Commercial,,4311.00,,,,,,,251.65,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Aetna,Commercial,,4311.00,,,,,,,159.66,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,inpatient,,,1781.00000,1068.60000,Aetna,Commercial,,7039.00,,,,,,,1139.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Aetna,Commercial,,,75.00,,,,,0,356.56,4121.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Aetna,Commercial,,1335.75,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Aetna,Commercial,,4311.00,,,,,,,320.07,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Aetna,Commercial,,4311.00,,,,,,,260.32,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Aetna,Commercial,,4311.00,,,,,,,260.32,4311.00,case rate,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Commercial,,4311.00,,,,,,,338.17,4311.00,case rate,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,inpatient,,,1794.00000,1076.40000,Aetna,Commercial,,7039.00,,,,,,,1148.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Commercial,,4311.00,,,,,,,359.16,5754.00,case rate,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Aetna,Commercial,,8442.00,,,,,,,776.43,8442.00,case rate,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,inpatient,,,4119.00000,2471.40000,Aetna,Commercial,,7039.00,,,,,,,2636.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Aetna,Commercial,,8442.00,,,,,,,824.62,12408.00,case rate,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,inpatient,,,3475.00000,2085.00000,Aetna,Commercial,,7039.00,,,,,,,2224.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Aetna,Commercial,,4376.00,,,,,,,695.70,17457.00,case rate,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,inpatient,,,3475.00000,2085.00000,Aetna,Commercial,,7039.00,,,,,,,2224.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Aetna,Commercial,,4376.00,,,,,,,695.70,17457.00,case rate,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,inpatient,,,512.00000,307.20000,Aetna,Commercial,,7039.00,,,,,,,327.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Aetna,Commercial,,4311.00,,,,,,,102.50,4311.00,case rate,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,inpatient,,,594.00000,356.40000,Aetna,Commercial,,7039.00,,,,,,,380.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Aetna,Commercial,,4311.00,,,,,,,118.92,4311.00,case rate,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,Aetna,Commercial,,7039.00,,,,,,,39.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,,75.00,,,,,0,12.21,208.90,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,inpatient,,,1100.00000,660.00000,Aetna,Commercial,52,7039.00,,,,,,,704.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Aetna,Commercial,52,4376.00,,,,,,,220.22,5754.00,case rate,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,Aetna,Commercial,,7039.00,,,,,,,485.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Aetna,Commercial,,4311.00,,,,,,,151.95,4311.00,case rate,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Aetna,Commercial,,533.25,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Aetna,Commercial,,1095.75,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Commercial,,95.25,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,inpatient,,,919.00000,551.40000,Aetna,Commercial,,7039.00,,,,,,,588.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Aetna,Commercial,,4376.00,,,,,,,173.00,5152.00,case rate,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Aetna,Commercial,,4376.00,,,,,,,173.23,4376.00,case rate,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,inpatient,,,373.00000,223.80000,Aetna,Commercial,,7039.00,,,,,,,238.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Commercial,,4311.00,,,,,,,74.67,4311.00,case rate,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Commercial,,358.00,,,,,,,59.12,365.00,case rate,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Aetna,Commercial,,477.00,,,,,,,129.99,624.00,case rate,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Aetna,Commercial,,1073.00,,,,,,,259.79,1295.00,case rate,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Aetna,Commercial,,2266.00,,,,,,,409.68,3235.00,case rate,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Aetna,Commercial,,2624.00,,,,,,,589.86,3709.00,case rate,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Aetna,Commercial,,3008.25,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Aetna,Commercial,,993.00,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,inpatient,,,1207.00000,724.20000,Aetna,Commercial,,7039.00,,,,,,,772.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Aetna,Commercial,,,75.00,,,,,0,161.50,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Aetna,Commercial,,270.75,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Aetna,Commercial,,222.00,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Commercial,,141.75,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,inpatient,,,156.00000,93.60000,Aetna,Commercial,,7039.00,,,,,,,99.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Commercial,,,75.00,,,,,0,20.87,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,inpatient,,,156.00000,93.60000,Aetna,Commercial,,7039.00,,,,,,,99.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Commercial,,,75.00,,,,,0,20.87,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Aetna,Commercial,,2052.00,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Commercial,,106.53,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,99.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Aetna,Commercial,,131.97,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Aetna,Commercial,,127.20,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Commercial,,168.01,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Commercial,,211.47,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Commercial,,196.63,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Commercial,,251.75,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Aetna,Commercial,,95.93,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Commercial,,38.16,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Aetna,Commercial,,120.31,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Commercial,,53.00,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Aetna,Commercial,,141.51,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Aetna,Commercial,,132.50,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Aetna,Commercial,,215.18,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Aetna,Commercial,,230.55,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Commercial,,231.61,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Aetna,Commercial,,210.41,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Aetna,Commercial,,95.93,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Aetna,Commercial,,134.62,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Aetna,Commercial,,205.64,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Aetna,Commercial,,259.17,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Commercial,,34.98,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Commercial,,56.18,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Aetna,Commercial,,93.28,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Aetna,Commercial,,137.80,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Commercial,,181.79,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Aetna,Commercial,,122.43,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Commercial,,168.01,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Commercial,,251.75,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Aetna,Commercial,,305.28,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,25.97,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Commercial,,49.29,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Aetna,Commercial,,72.61,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Aetna,Commercial,,59.36,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Commercial,,25.44,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,inpatient,,,130.00000,78.00000,Aetna,Commercial,,57.20,,,,,,,39.13,105.69,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Commercial,,63.70,,,,,,,26.03,96.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,25.00000,15.00000,Aetna,Commercial,,11.00,,,,,,,7.53,20.32,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Aetna,Commercial,,12.25,,,,,,,5.00,31.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,Aetna,Commercial,,41.80,,,,,,,28.59,77.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,46.55,,,,,,,19.02,138.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,54.00000,32.40000,Aetna,Commercial,,23.76,,,,,,,16.25,43.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,26.46,,,,,,,5.99,40.08,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Commercial,JW,92.25,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,Aetna,Commercial,,54.12,,,,,,,37.02,100.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Commercial,,60.27,,,,,,,24.62,132.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,JW,71.25,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,inpatient,,,142.00000,85.20000,Aetna,Commercial,,62.48,,,,,,,42.74,115.45,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Aetna,Commercial,,69.58,,,,,,,28.43,371.55,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,inpatient,,,275.00000,165.00000,Aetna,Commercial,,93.50,,,,,,,47.30,228.25,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Commercial,,104.50,,,,,,,34.92,202.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,Aetna,Commercial,,88.00,,,,,,,60.20,162.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Commercial,,98.00,,,,,,,40.04,186.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Commercial,JW,150.00,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,Aetna,Commercial,,200.20,,,,,,,136.96,369.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Commercial,,222.95,,,,,,,5.88,337.70,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,Aetna,Commercial,,400.84,,,,,,,274.21,740.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Commercial,,446.39,,,,,,,5.88,676.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Commercial,JW,683.25,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Commercial,JW,341.25,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,Aetna,Commercial,,434.72,,,,,,,297.39,803.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Commercial,,484.12,,,,,,,197.80,733.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,626.00000,375.60000,Aetna,Commercial,,275.44,,,,,,,188.43,508.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,306.74,,,,,,,125.33,464.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,Aetna,Commercial,,120.12,,,,,,,82.17,221.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Commercial,,133.77,,,,,,,54.65,268.27,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Commercial,JW,741.00,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Commercial,JW,204.75,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,Aetna,Commercial,,251.24,,,,,,,171.87,464.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Commercial,,279.79,,,,,,,114.31,423.80,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,Aetna,Commercial,,115.28,,,,,,,78.86,213.01,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Aetna,Commercial,,128.38,,,,,,,52.45,194.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,Aetna,Commercial,,1211.76,,,,,,,828.95,2239.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Commercial,,1349.46,,,,,,,240.06,2044.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,Aetna,Commercial,,535.04,,,,,,,366.02,988.61,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Commercial,,595.84,,,,,,,240.06,902.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,Aetna,Commercial,,271.04,,,,,,,185.42,500.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Aetna,Commercial,,301.84,,,,,,,123.32,457.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Commercial,JW,2065.50,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Commercial,JW,912.00,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Aetna,Commercial,JW,462.00,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,2813.00000,1687.80000,Aetna,Commercial,,1237.72,,,,,,,846.71,2286.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Aetna,Commercial,,1378.37,,,,,,,238.43,2087.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,Aetna,Commercial,,54.12,,,,,,,37.02,100.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Commercial,,60.27,,,,,,,24.62,132.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,Aetna,Commercial,,150.48,,,,,,,102.94,278.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Aetna,Commercial,,167.58,,,,,,,68.47,253.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Aetna,Commercial,JW,256.50,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,Aetna,Commercial,,680.24,,,,,,,465.35,1256.90,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Commercial,,757.54,,,,,,,309.51,1147.44,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,3094.00000,1856.40000,Aetna,Commercial,,1361.36,,,,,,,931.29,2515.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Aetna,Commercial,,1516.06,,,,,,,327.43,2296.37,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Commercial,JW,1159.50,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,Aetna,Commercial,,188.32,,,,,,,128.83,347.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Aetna,Commercial,,209.72,,,,,,,70.59,317.66,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Aetna,Commercial,JW,321.00,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,Aetna,Commercial,,212.52,,,,,,,145.38,392.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Aetna,Commercial,,236.67,,,,,,,70.59,358.48,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Aetna,Commercial,JW,362.25,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,10.00000,6.00000,Aetna,Commercial,,4.40,,,,,,,3.01,8.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Aetna,Commercial,,4.90,,,,,,,2.00,7.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,Aetna,Commercial,,1099.12,,,,,,,751.90,2030.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Commercial,,1224.02,,,,,,,500.10,1854.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Commercial,JW,1873.50,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,Aetna,Commercial,,891.00,,,,,,,609.52,1646.33,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Commercial,,992.25,,,,,,,405.40,1502.95,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Commercial,JW,1518.75,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,Aetna,Commercial,,751.52,,,,,,,514.11,1388.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Commercial,,836.92,,,,,,,341.94,1267.68,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Commercial,JW,1281.00,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,Aetna,Commercial,,28.60,,,,,,,19.57,52.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,31.85,,,,,,,13.01,48.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,JW,48.75,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,2469.00000,1481.40000,Aetna,Commercial,,1086.36,,,,,,,743.17,2007.30,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Aetna,Commercial,,1209.81,,,,,,,494.29,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,Aetna,Commercial,,307.12,,,,,,,210.10,567.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Aetna,Commercial,,342.02,,,,,,,139.74,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Aetna,Commercial,,523.50,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,Aetna,Commercial,,275.44,,,,,,,188.43,508.94,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,306.74,,,,,,,125.33,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,469.50,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,Aetna,Commercial,,270.60,,,,,,,185.12,500.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Commercial,,301.35,,,,,,,123.12,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Commercial,,461.25,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,Aetna,Commercial,,193.16,,,,,,,132.14,356.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,215.11,,,,,,,87.89,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,329.25,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,Aetna,Commercial,,175.56,,,,,,,120.10,324.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Commercial,,195.51,,,,,,,79.88,6571.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Commercial,,299.25,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Aetna,Commercial,JW,1772.25,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Commercial,JW,428.25,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Aetna,Commercial,JW,196.50,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,Aetna,Commercial,,137.72,,,,,,,94.21,254.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Aetna,Commercial,,153.37,,,,,,,62.66,232.31,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Aetna,Commercial,JW,234.75,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,Aetna,Commercial,,693.00,,,,,,,474.07,1280.47,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Commercial,,771.75,,,,,,,240.06,1168.96,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Commercial,JW,1181.25,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,Aetna,Commercial,,550.88,,,,,,,376.85,1017.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Commercial,,613.48,,,,,,,240.06,929.23,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Commercial,JW,939.00,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,Aetna,Commercial,,282.04,,,,,,,192.94,521.13,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Aetna,Commercial,,314.09,,,,,,,128.33,475.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Aetna,Commercial,JW,480.75,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,Aetna,Commercial,,149.60,,,,,,,102.34,276.42,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Aetna,Commercial,,166.60,,,,,,,68.07,274.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Aetna,Commercial,JW,255.00,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,Aetna,Commercial,,119.68,,,,,,,81.87,221.14,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Aetna,Commercial,,133.28,,,,,,,54.45,274.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Aetna,Commercial,JW,204.00,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2562.00000,1537.20000,Aetna,Commercial,,1127.28,,,,,,,771.16,2082.91,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Aetna,Commercial,,1255.38,,,,,,,240.06,1901.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Aetna,Commercial,,221.25,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Commercial,,477.75,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Commercial,,477.75,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Commercial,,477.75,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Commercial,,477.75,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Aetna,Commercial,,4311.00,,,,,,,50.90,4311.00,case rate,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Aetna,Commercial,,4311.00,,,,,,,799.81,4311.00,case rate,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Aetna,Commercial,,95.93,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Aetna,Commercial,,4311.00,,,,,,,46.37,4311.00,case rate,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Aetna,Commercial,,4376.00,,,,,,,485.76,4376.00,case rate,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,inpatient,,,209.00000,125.40000,Aetna,Commercial,,91.96,,,,,,,62.91,169.92,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Aetna,Commercial,,227.25,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Aetna,Commercial,,4376.00,,,,,,,372.48,4376.00,case rate,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Aetna,Commercial,,4376.00,,,,,,,372.48,4376.00,case rate,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Aetna,Commercial,,4376.00,,,,,,,81.43,4376.00,case rate,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Aetna,Commercial,,4376.00,,,,,,,81.43,4376.00,case rate,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Aetna,Commercial,,252.75,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Aetna,Commercial,,210.00,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Commercial,,201.75,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,inpatient,,,9379.00000,5627.40000,Aetna,Commercial,,7039.00,,,,,,,6002.56,7596.99,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Aetna,Commercial,,6735.00,,,,,,,1877.68,9423.00,case rate,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Aetna,Commercial,,834.75,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Commercial,,4376.00,,,,,,,195.47,4376.00,case rate,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Aetna,Commercial,,4376.00,,,,,,,225.63,4376.00,case rate,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Aetna,Commercial,,4311.00,,,,,,,151.93,4311.00,case rate,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,inpatient,,,1985.00000,1191.00000,Aetna,Commercial,,7039.00,,,,,,,1270.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Aetna,Commercial,,4311.00,,,,,,,397.40,4311.00,case rate,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,inpatient,,,1985.00000,1191.00000,Aetna,Commercial,,7039.00,,,,,,,1270.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Aetna,Commercial,,4311.00,,,,,,,397.40,9423.00,case rate,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,inpatient,,,11676.00000,7005.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9457.56,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Aetna,Commercial,,12247.00,,,,,,,2337.54,13852.00,case rate,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,inpatient,,,11676.00000,7005.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9457.56,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Aetna,Commercial,,12247.00,,,,,,,2337.54,13852.00,case rate,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,inpatient,,,20316.00000,12189.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16455.96,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Aetna,Commercial,,12247.00,,,,,,,4067.26,24600.00,case rate,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,inpatient,,,20316.00000,12189.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16455.96,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Aetna,Commercial,,12247.00,,,,,,,4067.26,24600.00,case rate,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,inpatient,,,8640.00000,5184.00000,Aetna,Commercial,,7039.00,,,,,,,5529.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Aetna,Commercial,,10087.00,,,,,,,1729.73,13852.00,case rate,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,inpatient,,,8640.00000,5184.00000,Aetna,Commercial,,7039.00,,,,,,,5529.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Aetna,Commercial,,10087.00,,,,,,,1729.73,13852.00,case rate,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,inpatient,,,18331.00000,10998.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,14848.11,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Aetna,Commercial,,12247.00,,,,,,,3669.87,24600.00,case rate,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,inpatient,,,18331.00000,10998.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,14848.11,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Aetna,Commercial,,12247.00,,,,,,,3669.87,24600.00,case rate,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,inpatient,,,29657.00000,17794.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,24022.17,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Aetna,Commercial,,12247.00,,,,,,,5937.33,52940.00,case rate,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,inpatient,,,29657.00000,17794.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,24022.17,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Aetna,Commercial,,12247.00,,,,,,,5937.33,52940.00,case rate,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Commercial,,201.75,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Aetna,Commercial,,307.50,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Aetna,Commercial,,4311.00,,,,,,,111.97,4311.00,case rate,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Aetna,Commercial,,4311.00,,,,,,,96.51,4311.00,case rate,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Aetna,Commercial,,4311.00,,,,,,,145.33,4311.00,case rate,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Aetna,Commercial,,4376.00,,,,,,,128.37,4376.00,case rate,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Aetna,Commercial,,4376.00,,,,,,,730.44,4376.00,case rate,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Commercial,,107.25,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Commercial,,4311.00,,,,,,,59.38,4311.00,case rate,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Commercial,,4311.00,,,,,,,36.76,4311.00,case rate,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Commercial,,4311.00,,,,,,,59.38,4311.00,case rate,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Commercial,,4311.00,,,,,,,36.76,4311.00,case rate,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Commercial,,4311.00,,,,,,,59.38,4311.00,case rate,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Commercial,,4311.00,,,,,,,36.76,4311.00,case rate,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Commercial,,386.25,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,,123.75,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Aetna,Commercial,,711.75,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Aetna,Commercial,,363.00,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Commercial,,96.00,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Aetna,Commercial,,105.75,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Commercial,,118.50,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Commercial,,69.00,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Commercial,,69.00,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Commercial,,159.00,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Aetna,Commercial,,307.50,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Commercial,,386.25,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Aetna,Commercial,,48.00,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Aetna,Commercial,,48.00,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Commercial,,112.50,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Commercial,,63.75,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Commercial,,99.75,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Commercial,,386.25,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,40000.00000,24000.00000,Aetna,Commercial,,13600.00,,,,,,,6880.00,33200.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Aetna,Commercial,,15200.00,,,,,,,5080.00,29448.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,inpatient,,,777.00000,466.20000,Aetna,Commercial,,7039.00,,,,,,,497.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Aetna,Commercial,,,75.00,,,,,0,155.56,12408.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,inpatient,,,8778.00000,5266.80000,Aetna,Commercial,,7039.00,,,,,,,5617.92,7110.18,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Aetna,Commercial,,,75.00,,,,,0,1757.36,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,inpatient,,,8778.00000,5266.80000,Aetna,Commercial,,7039.00,,,,,,,5617.92,7110.18,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Aetna,Commercial,,,75.00,,,,,0,1757.36,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,inpatient,,,4941.00000,2964.60000,Aetna,Commercial,,7039.00,,,,,,,3162.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Aetna,Commercial,,,75.00,,,,,0,661.11,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,inpatient,,,292.00000,175.20000,Aetna,Commercial,,7039.00,,,,,,,186.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Commercial,,4311.00,,,,,,,58.46,4311.00,case rate,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,inpatient,,,884.00000,530.40000,Aetna,Commercial,,7039.00,,,,,,,565.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Aetna,Commercial,,4311.00,,,,,,,176.98,4311.00,case rate,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Aetna,Commercial,,153.75,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Aetna,Commercial,,153.75,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,inpatient,,,970.00000,582.00000,Aetna,Commercial,,7039.00,,,,,,,620.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Aetna,Commercial,,4311.00,,,,,,,194.19,4311.00,case rate,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,inpatient,,,1230.00000,738.00000,Aetna,Commercial,,7039.00,,,,,,,787.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Aetna,Commercial,,4376.00,,,,,,,246.25,4376.00,case rate,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,inpatient,,,324.00000,194.40000,Aetna,Commercial,,7039.00,,,,,,,207.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Commercial,,4311.00,,,,,,,64.86,4311.00,case rate,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,inpatient,,,6259.00000,3755.40000,Aetna,Commercial,,7039.00,,,,,,,4005.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Aetna,Commercial,,4376.00,,,,,,,1253.05,5152.00,case rate,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Commercial,,4376.00,,,,,,,420.60,4376.00,case rate,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,inpatient,,,486.00000,291.60000,Aetna,Commercial,,7039.00,,,,,,,311.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Aetna,Commercial,,4311.00,,,,,,,97.30,5754.00,case rate,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,inpatient,,,20624.00000,12374.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16705.44,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Aetna,Commercial,,15260.00,,,,,,,3318.21,17457.00,case rate,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Commercial,,4376.00,,,,,,,588.69,4376.00,case rate,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,inpatient,,,842.00000,505.20000,Aetna,Commercial,,7039.00,,,,,,,538.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Aetna,Commercial,,4376.00,,,,,,,168.57,4376.00,case rate,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,inpatient,,,2336.00000,1401.60000,Aetna,Commercial,,7039.00,,,,,,,1495.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Aetna,Commercial,,4376.00,,,,,,,467.67,17457.00,case rate,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,inpatient,,,2317.00000,1390.20000,Aetna,Commercial,,7039.00,,,,,,,1482.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Aetna,Commercial,,4376.00,,,,,,,463.86,17457.00,case rate,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,inpatient,,,2322.00000,1393.20000,Aetna,Commercial,,7039.00,,,,,,,1486.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Aetna,Commercial,,6735.00,,,,,,,464.86,6735.00,case rate,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,inpatient,,,11929.00000,7157.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9662.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Aetna,Commercial,,6735.00,,,,,,,2388.19,24600.00,case rate,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,inpatient,,,524.00000,314.40000,Aetna,Commercial,,7039.00,,,,,,,335.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Aetna,Commercial,,4311.00,,,,,,,104.90,4311.00,case rate,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Aetna,Commercial,,429.75,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,inpatient,,,1331.00000,798.60000,Aetna,Commercial,,7039.00,,,,,,,851.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,inpatient,,,2561.00000,1536.60000,Aetna,Commercial,,7039.00,,,,,,,1639.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Commercial,,4311.00,,,,,,,512.71,4311.00,case rate,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,inpatient,,,2561.00000,1536.60000,Aetna,Commercial,,7039.00,,,,,,,1639.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,inpatient,,,1895.00000,1137.00000,Aetna,Commercial,,7039.00,,,,,,,1212.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Aetna,Commercial,,4311.00,,,,,,,379.38,4311.00,case rate,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,inpatient,,,1895.00000,1137.00000,Aetna,Commercial,,7039.00,,,,,,,1212.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,inpatient,,,3456.00000,2073.60000,Aetna,Commercial,,7039.00,,,,,,,2211.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Aetna,Commercial,,4311.00,,,,,,,676.91,4311.00,case rate,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,inpatient,,,3456.00000,2073.60000,Aetna,Commercial,,7039.00,,,,,,,2211.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,inpatient,,,2561.00000,1536.60000,Aetna,Commercial,,7039.00,,,,,,,1639.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Commercial,,4311.00,,,,,,,512.71,4311.00,case rate,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,inpatient,,,2561.00000,1536.60000,Aetna,Commercial,,7039.00,,,,,,,1639.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,inpatient,,,5187.00000,3112.20000,Aetna,Commercial,,2282.28,,,,,,,1561.29,4217.03,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Aetna,Commercial,,2541.63,,,,,,,120.36,3849.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,Aetna,Commercial,,543.40,,,,,,,371.74,1004.05,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Commercial,,605.15,,,,,,,247.25,916.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,Aetna,Commercial,,461.12,,,,,,,315.45,852.02,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Commercial,,513.52,,,,,,,209.81,777.83,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,Aetna,Commercial,,311.08,,,,,,,212.81,574.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Aetna,Commercial,,346.43,,,,,,,141.54,524.74,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,Aetna,Commercial,,242.00,,,,,,,165.55,447.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Commercial,,269.50,,,,,,,110.11,408.21,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,Aetna,Commercial,,194.48,,,,,,,133.04,359.35,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Commercial,,216.58,,,,,,,88.49,343.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,Aetna,Commercial,,205.04,,,,,,,140.27,378.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Aetna,Commercial,,228.34,,,,,,,93.29,345.87,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Commercial,JW,926.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Commercial,JW,786.00,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Aetna,Commercial,JW,530.25,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Commercial,JW,412.50,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Commercial,JW,331.50,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Aetna,Commercial,JW,349.50,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,2078.00000,1246.80000,Aetna,Commercial,,914.32,,,,,,,625.48,1689.41,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Aetna,Commercial,,1018.22,,,,,,,162.39,1542.29,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Aetna,Commercial,,,75.00,,129.0,127.8,140.4,23,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,141.00,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,inpatient,,,797.00000,478.20000,Aetna,Commercial,,7039.00,,,,,,,510.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Aetna,Commercial,,4311.00,,,,,,,159.56,4311.00,case rate,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,inpatient,,,988.00000,592.80000,Aetna,Commercial,,7039.00,,,,,,,632.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Commercial,,,75.00,,1215.19,1215.19,1215.19,1 through 10,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,inpatient,,,1432.00000,859.20000,Aetna,Commercial,,7039.00,,,,,,,916.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Aetna,Commercial,,,75.00,,,,,0,173.00,1064.69,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,inpatient,,,886.00000,531.60000,Aetna,Commercial,,7039.00,,,,,,,567.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Aetna,Commercial,,,75.00,,1072.69,507.38,1201.26,23,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,inpatient,,,179.00000,107.40000,Aetna,Commercial,,7039.00,,,,,,,114.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Aetna,Commercial,,,75.00,,,,,0,35.84,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,inpatient,,,1828.00000,1096.80000,Aetna,Commercial,,7039.00,,,,,,,1169.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Aetna,Commercial,,,75.00,,,,,0,365.97,3142.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,inpatient,,,2594.00000,1556.40000,Aetna,Commercial,,7039.00,,,,,,,1660.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Aetna,Commercial,,,75.00,,,,,0,519.32,3142.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,inpatient,,,945.00000,567.00000,Aetna,Commercial,,7039.00,,,,,,,604.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Aetna,Commercial,,,75.00,,670.95,525.0,670.95,1 through 10,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,inpatient,,,2883.00000,1729.80000,Aetna,Commercial,,7039.00,,,,,,,1845.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Aetna,Commercial,,,75.00,,,,,0,577.18,3142.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,inpatient,,,956.00000,573.60000,Aetna,Commercial,,7039.00,,,,,,,611.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Aetna,Commercial,,,75.00,,1072.69,507.38,1201.26,23,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,inpatient,,,886.00000,531.60000,Aetna,Commercial,,7039.00,,,,,,,567.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Aetna,Commercial,,,75.00,,,,,0,173.00,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,inpatient,,,1402.00000,841.20000,Aetna,Commercial,,7039.00,,,,,,,897.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Aetna,Commercial,,1630.50,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Aetna,Commercial,,3174.00,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Aetna,Commercial,,14349.00,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Aetna,Commercial,,321.75,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Aetna,Commercial,,339.00,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Aetna,Commercial,,300.75,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Aetna,Commercial,,498.75,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Commercial,,238.50,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,Aetna,Commercial,,134.20,,,,,,,91.81,247.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Commercial,,243.00,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Aetna,Commercial,,408.75,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Aetna,Commercial,,264.00,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Commercial,,360.75,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Aetna,Commercial,,450.75,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Aetna,Commercial,,295.50,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Commercial,,331.50,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Aetna,Commercial,,375.00,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Commercial,,114.00,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Aetna,Commercial,,202.50,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Commercial,,90.00,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Aetna,Commercial,,375.75,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Aetna,Commercial,,503.25,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Aetna,Commercial,,134.25,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Aetna,Commercial,,226.50,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Aetna,Commercial,,271.50,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Aetna,Commercial,,362.25,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Aetna,Commercial,,438.00,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Aetna,Commercial,,809.25,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Aetna,Commercial,,438.75,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Commercial,,288.75,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Aetna,Commercial,,228.75,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Commercial,,331.50,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Commercial,,372.00,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Commercial,,495.00,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Aetna,Commercial,,696.75,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Commercial,,327.75,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Aetna,Commercial,,245.25,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Aetna,Commercial,,423.00,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Aetna,Commercial,,369.00,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Aetna,Commercial,,532.50,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Aetna,Commercial,,656.25,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Commercial,,436.50,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Aetna,Commercial,,255.75,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Aetna,Commercial,,405.75,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Aetna,Commercial,,276.75,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Aetna,Commercial,,276.00,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Aetna,Commercial,,908.25,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Aetna,Commercial,,564.00,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Aetna,Commercial,,1002.00,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Aetna,Commercial,,1419.00,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Aetna,Commercial,,1560.75,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Aetna,Commercial,,318.75,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Aetna,Commercial,,286.50,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Aetna,Commercial,,344.25,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Aetna,Commercial,,346.50,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Commercial,,953.25,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Aetna,Commercial,,391.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Aetna,Commercial,,330.00,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Aetna,Commercial,,304.50,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Commercial,,331.50,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Aetna,Commercial,,365.25,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Aetna,Commercial,,284.25,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Aetna,Commercial,,223.50,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Aetna,Commercial,,281.25,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Aetna,Commercial,,260.25,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Aetna,Commercial,,489.75,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Aetna,Commercial,,323.25,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Aetna,Commercial,,295.50,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Aetna,Commercial,,207.00,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Aetna,Commercial,,630.75,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Aetna,Commercial,,320.25,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Commercial,,278.25,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Aetna,Commercial,,361.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Commercial,,237.00,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Aetna,Commercial,,285.00,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Aetna,Commercial,,265.50,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Commercial,,163.50,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Aetna,Commercial,,333.75,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Commercial,,347.25,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Aetna,Commercial,,285.00,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Aetna,Commercial,,397.50,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Commercial,,347.25,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Aetna,Commercial,,300.75,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Commercial,,243.00,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Aetna,Commercial,,319.50,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,,371.25,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,,371.25,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,,371.25,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Aetna,Commercial,,586.50,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Aetna,Commercial,,241.50,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Aetna,Commercial,,185.25,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Aetna,Commercial,,791.25,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Aetna,Commercial,,546.00,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Aetna,Commercial,,666.00,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Aetna,Commercial,,373.50,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Aetna,Commercial,,396.75,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Commercial,,741.00,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Commercial,,780.75,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Aetna,Commercial,,805.50,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Aetna,Commercial,,402.75,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Aetna,Commercial,,73.50,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Aetna,Commercial,,435.00,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Aetna,Commercial,,482.25,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Aetna,Commercial,,613.50,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Aetna,Commercial,,499.50,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Aetna,Commercial,,607.50,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Aetna,Commercial,,1566.00,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Aetna,Commercial,,3483.75,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Aetna,Commercial,,2682.75,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Aetna,Commercial,,138.75,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Aetna,Commercial,,1026.00,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Aetna,Commercial,,1046.25,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Aetna,Commercial,,3035.25,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Aetna,Commercial,,4309.50,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Aetna,Commercial,,994.50,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Aetna,Commercial,,1929.00,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Aetna,Commercial,,773.25,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Aetna,Commercial,,901.50,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Aetna,Commercial,,1206.00,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Commercial,,603.00,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Aetna,Commercial,,1212.00,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Aetna,Commercial,,725.25,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Aetna,Commercial,,599.25,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Aetna,Commercial,,829.50,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Aetna,Commercial,,1749.75,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Aetna,Commercial,,1032.00,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Commercial,,153.00,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Aetna,Commercial,,131.25,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Aetna,Commercial,,903.00,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Aetna,Commercial,,578.25,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Aetna,Commercial,,792.75,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Aetna,Commercial,,268.50,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Aetna,Commercial,,714.75,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Aetna,Commercial,,126.75,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Aetna,Commercial,,702.00,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Aetna,Commercial,,229.50,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Aetna,Commercial,,255.75,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Commercial,,107.25,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Aetna,Commercial,,558.00,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Aetna,Commercial,,496.50,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Aetna,Commercial,,492.75,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Aetna,Commercial,,242.25,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Aetna,Commercial,,484.50,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Aetna,Commercial,,259.50,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Aetna,Commercial,,182.25,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Aetna,Commercial,,201.00,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Aetna,Commercial,,695.25,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Aetna,Commercial,,229.50,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Commercial,,683.25,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Aetna,Commercial,,218.25,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Aetna,Commercial,,591.00,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Aetna,Commercial,,1757.25,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Aetna,Commercial,,3029.25,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Aetna,Commercial,,2503.50,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Aetna,Commercial,,2698.50,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Aetna,Commercial,,1526.25,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Aetna,Commercial,,3385.50,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Aetna,Commercial,,3385.50,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Aetna,Commercial,,3385.50,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Aetna,Commercial,,2289.75,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Aetna,Commercial,,1339.50,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,inpatient,,,1404.00000,842.40000,Aetna,Commercial,,7039.00,,,,,,,898.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Aetna,Commercial,,,75.00,,,,,0,281.08,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Aetna,Commercial,,201.00,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Aetna,Commercial,,280.50,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Aetna,Commercial,,249.00,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Aetna,Commercial,,623.25,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,inpatient,,,163.00000,97.80000,Aetna,Commercial,,71.72,,,,,,,49.06,132.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Aetna,Commercial,,375.75,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Aetna,Commercial,,1560.75,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Aetna,Commercial,,462.75,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Aetna,Commercial,,609.00,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Aetna,Commercial,,645.75,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Aetna,Commercial,,350.25,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Aetna,Commercial,,370.50,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Aetna,Commercial,,392.25,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Aetna,Commercial,,568.50,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Aetna,Commercial,,552.00,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Aetna,Commercial,,809.25,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Aetna,Commercial,,171.75,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Aetna,Commercial,,324.00,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Aetna,Commercial,,797.25,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Commercial,,461.25,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Aetna,Commercial,,588.75,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,37500.00000,22500.00000,Aetna,Commercial,,12750.00,,,,,,,6450.00,31125.00,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Aetna,Commercial,,14250.00,,,,,,,4762.50,27607.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Aetna,Commercial,,162.75,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Aetna,Commercial,,1389.75,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,inpatient,,,2253.00000,1351.80000,Aetna,Commercial,,7039.00,,,,,,,1441.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Aetna,Commercial,,4311.00,,,,,,,451.05,8213.00,case rate,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Aetna,Commercial,,315.00,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Commercial,,412.50,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Aetna,Commercial,,405.00,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Aetna,Commercial,,300.75,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Aetna,Commercial,,447.00,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Aetna,Commercial,,372.75,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Aetna,Commercial,,564.00,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Aetna,Commercial,,435.75,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Aetna,Commercial,,696.00,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Aetna,Commercial,,1036.50,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Aetna,Commercial,,651.00,,,,,,,54.05,2905.00,per diem,Paid in addition when billed with ER services.
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Aetna,Commercial,,,75.00,,1633.3200000000002,1633.3200000000002,1633.3200000000002,1 through 10,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Commercial,,257.25,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Commercial,,309.75,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Aetna,Commercial,,1017.75,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Commercial,,507.75,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Aetna,Commercial,,513.75,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Aetna,Commercial,,828.00,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Aetna,Commercial,,437.25,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Aetna,Commercial,,2187.75,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Aetna,Commercial,,1120.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Aetna,Commercial,,819.75,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Aetna,Commercial,,732.00,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Aetna,Commercial,,537.75,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Aetna,Commercial,,1399.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Aetna,Commercial,,760.50,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Aetna,Commercial,,1559.25,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Aetna,Commercial,,1201.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Aetna,Commercial,,1717.50,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Aetna,Commercial,,1201.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Aetna,Commercial,,1783.50,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Aetna,Commercial,,2049.75,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Aetna,Commercial,,642.00,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Aetna,Commercial,,1175.25,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Aetna,Commercial,,922.50,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Aetna,Commercial,,1683.75,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Aetna,Commercial,,781.50,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Aetna,Commercial,,861.00,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Aetna,Commercial,,941.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Aetna,Commercial,,1338.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Aetna,Commercial,,1977.00,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Aetna,Commercial,,1977.00,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Aetna,Commercial,,1872.75,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Aetna,Commercial,,2907.00,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Aetna,Commercial,,3633.00,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Aetna,Commercial,,623.25,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Aetna,Commercial,,1079.25,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Aetna,Commercial,,970.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Aetna,Commercial,,1194.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Aetna,Commercial,,1864.50,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Aetna,Commercial,,583.50,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Aetna,Commercial,,1098.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Aetna,Commercial,,648.00,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Aetna,Commercial,,817.50,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Aetna,Commercial,,599.25,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Commercial,,870.00,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Aetna,Commercial,,990.75,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Commercial,,870.00,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Aetna,Commercial,,1208.25,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Commercial,,953.25,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Aetna,Commercial,,692.25,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Aetna,Commercial,,1755.75,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Aetna,Commercial,,2207.25,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,inpatient,,,277.00000,166.20000,Aetna,Commercial,,121.88,,,,,,,83.38,225.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,inpatient,,,51.00000,30.60000,Aetna,Commercial,,22.44,,,,,,,15.35,41.46,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,inpatient,,,99.00000,59.40000,Aetna,Commercial,,43.56,,,,,,,29.80,80.49,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,inpatient,,,2030.00000,1218.00000,Aetna,Commercial,,893.20,,,,,,,611.03,1650.39,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,inpatient,,,988.00000,592.80000,Aetna,Commercial,,434.72,,,,,,,297.39,803.24,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,inpatient,,,107.00000,64.20000,Aetna,Commercial,,47.08,,,,,,,32.21,86.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,inpatient,,,208.00000,124.80000,Aetna,Commercial,,91.52,,,,,,,62.61,169.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,inpatient,,,188.00000,112.80000,Aetna,Commercial,,82.72,,,,,,,56.59,152.84,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,inpatient,,,2794.00000,1676.40000,Aetna,Commercial,,1229.36,,,,,,,840.99,2271.52,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,inpatient,,,12493.00000,7495.80000,Aetna,Commercial,,5496.92,,,,,,,3760.39,10156.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Aetna,Commercial,,1232.25,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Commercial,,389.25,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Aetna,Commercial,,1524.75,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Aetna,Commercial,,352.50,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,inpatient,,,12371.00000,7422.60000,Aetna,Commercial,,5443.24,,,,,,,3723.67,10057.62,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Commercial,,507.75,,,,,,,135.54,1560.00,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,inpatient,,,87.00000,52.20000,Aetna,Commercial,,38.28,,,,,,,26.19,70.73,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,inpatient,,,878.00000,526.80000,Aetna,Commercial,,386.32,,,,,,,264.28,713.81,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,inpatient,,,119.00000,71.40000,Aetna,Commercial,,52.36,,,,,,,35.82,96.75,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Aetna,Commercial,,89.25,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,inpatient,,,584.00000,350.40000,Aetna,Commercial,,256.96,,,,,,,175.78,474.79,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,inpatient,,,323.00000,193.80000,Aetna,Commercial,,142.12,,,,,,,97.22,262.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,inpatient,,,44.00000,26.40000,Aetna,Commercial,,19.36,,,,,,,13.24,35.77,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,inpatient,,,5280.00000,3168.00000,Aetna,Commercial,,2323.20,,,,,,,1589.28,4292.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,inpatient,,,6.00000,3.60000,Aetna,Commercial,,2.64,,,,,,,1.81,4.88,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,inpatient,,,649.00000,389.40000,Aetna,Commercial,,285.56,,,,,,,195.35,527.64,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,inpatient,,,122.00000,73.20000,Aetna,Commercial,,53.68,,,,,,,36.72,99.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,inpatient,,,42.00000,25.20000,Aetna,Commercial,,18.48,,,,,,,12.64,34.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,inpatient,,,82.00000,49.20000,Aetna,Commercial,,36.08,,,,,,,24.68,66.67,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,inpatient,,,254.00000,152.40000,Aetna,Commercial,,111.76,,,,,,,76.45,206.50,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,inpatient,,,77.00000,46.20000,Aetna,Commercial,,33.88,,,,,,,23.18,62.60,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,inpatient,,,6058.00000,3634.80000,Aetna,Commercial,,2665.52,,,,,,,1823.46,4925.15,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,inpatient,,,183.00000,109.80000,Aetna,Commercial,,80.52,,,,,,,55.08,148.78,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Aetna,Commercial,,806.25,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,Aetna,Commercial,,134.20,,,,,,,91.81,247.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Aetna,Commercial,,1071.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,inpatient,,,305.00000,183.00000,Aetna,Commercial,,134.20,,,,,,,91.81,247.97,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Aetna,Commercial,,1512.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Aetna,Commercial,,1512.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,inpatient,,,1343.00000,805.80000,Aetna,Commercial,,590.92,,,,,,,404.24,1091.86,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,inpatient,,,487.00000,292.20000,Aetna,Commercial,,214.28,,,,,,,146.59,395.93,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Aetna,Commercial,,326.25,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Aetna,Commercial,,1680.00,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Aetna,Commercial,,1203.75,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Aetna,Commercial,,2508.00,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Aetna,Commercial,,2508.00,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Aetna,Commercial,,2508.00,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,inpatient,,,1309.00000,785.40000,Aetna,Commercial,,575.96,,,,,,,394.01,1064.22,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Aetna,Commercial,,981.75,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,inpatient,,,1929.00000,1157.40000,Aetna,Commercial,,848.76,,,,,,,580.63,1568.28,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Aetna,Commercial,,1446.75,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,inpatient,,,1069.00000,641.40000,Aetna,Commercial,,470.36,,,,,,,321.77,869.10,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Aetna,Commercial,,801.75,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,inpatient,,,1908.00000,1144.80000,Aetna,Commercial,,839.52,,,,,,,574.31,1551.20,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Aetna,Commercial,,1431.00,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,inpatient,,,1230.00000,738.00000,Aetna,Commercial,,541.20,,,,,,,370.23,999.99,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Aetna,Commercial,,922.50,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Aetna,Commercial,,651.00,,,,,,,84.71,2905.00,per diem,Paid in addition when billed with ER services.
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Aetna,Commercial,,651.00,,,,,,,343.59,2905.00,per diem,Paid in addition when billed with ER services.
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Aetna,Commercial,,651.00,,,,,,,343.59,2942.87,per diem,Paid in addition when billed with ER services.
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Aetna,Commercial,,651.00,,,,,,,343.59,2942.87,per diem,Paid in addition when billed with ER services.
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Aetna,Commercial,,651.00,,,,,,,171.27,3501.50,per diem,Paid in addition when billed with ER services.
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Aetna,Commercial,,651.00,,,,,,,206.81,2905.00,per diem,Paid in addition when billed with ER services.
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Aetna,Commercial,,651.00,,,,,,,225.43,2905.00,per diem,Paid in addition when billed with ER services.
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Commercial,,651.00,,,,,,,64.86,2905.00,per diem,Paid in addition when billed with ER services.
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Aetna,Commercial,,651.00,,,,,,,507.91,2905.00,per diem,Paid in addition when billed with ER services.
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Aetna,Commercial,,651.00,,,,,,,258.06,2905.00,per diem,Paid in addition when billed with ER services.
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Aetna,Commercial,,651.00,,,,,,,227.83,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Aetna,Commercial,,651.00,,,,,,,254.05,2905.00,per diem,Paid in addition when billed with ER services.
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Aetna,Commercial,,651.00,,,,,,,171.27,2908.74,per diem,Paid in addition when billed with ER services.
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Aetna,Commercial,,651.00,,,,,,,171.27,3211.99,per diem,Paid in addition when billed with ER services.
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Aetna,Commercial,,651.00,,,,,,,171.27,2942.40,per diem,Paid in addition when billed with ER services.
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Aetna,Commercial,,651.00,,,,,,,343.59,2905.00,per diem,Paid in addition when billed with ER services.
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Aetna,Commercial,,651.00,,,,,,,343.59,2905.00,per diem,Paid in addition when billed with ER services.
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Aetna,Commercial,,651.00,,,,,,,171.27,3037.26,per diem,Paid in addition when billed with ER services.
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Aetna,Commercial,,651.00,,,,,,,343.59,2905.00,per diem,Paid in addition when billed with ER services.
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Aetna,Commercial,,651.00,,,,,,,171.27,3356.74,per diem,Paid in addition when billed with ER services.
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Aetna,Commercial,,651.00,,,,,,,171.27,3008.52,per diem,Paid in addition when billed with ER services.
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Aetna,Commercial,,651.00,,,,,,,171.27,3500.13,per diem,Paid in addition when billed with ER services.
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Aetna,Commercial,,651.00,,,,,,,343.59,4490.21,per diem,Paid in addition when billed with ER services.
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,inpatient,,,34463.00000,20677.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,27915.03,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Aetna,Commercial,,,75.00,,,,,0,2025.00,21022.43,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Aetna,Commercial,,651.00,,,,,,,232.56,3266.55,per diem,Paid in addition when billed with ER services.
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Aetna,Commercial,,651.00,,,,,,,343.59,3891.19,per diem,Paid in addition when billed with ER services.
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Aetna,Commercial,,651.00,,,,,,,343.59,4523.15,per diem,Paid in addition when billed with ER services.
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Aetna,Commercial,,651.00,,,,,,,84.71,2905.00,per diem,Paid in addition when billed with ER services.
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Aetna,Commercial,,651.00,,,,,,,171.27,3052.31,per diem,Paid in addition when billed with ER services.
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Aetna,Commercial,,651.00,,,,,,,560.56,2905.00,per diem,Paid in addition when billed with ER services.
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Aetna,Commercial,,357.75,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Aetna,Commercial,,651.00,,,,,,,102.31,2905.00,per diem,Paid in addition when billed with ER services.
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Aetna,Commercial,,651.00,,,,,,,171.27,2905.00,per diem,Paid in addition when billed with ER services.
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Aetna,Commercial,,651.00,,,,,,,232.56,2905.00,per diem,Paid in addition when billed with ER services.
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Aetna,Commercial,,651.00,,,,,,,343.59,2905.00,per diem,Paid in addition when billed with ER services.
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Aetna,Commercial,,651.00,,,,,,,343.59,2905.00,per diem,Paid in addition when billed with ER services.
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Aetna,Commercial,,651.00,,,,,,,380.58,2905.00,per diem,Paid in addition when billed with ER services.
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Commercial,,651.00,,,,,,,95.09,2905.00,per diem,Paid in addition when billed with ER services.
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,inpatient,,,337.00000,202.20000,Aetna,Commercial,,7039.00,,,,,,,215.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Aetna,Commercial,,4376.00,,,,,,,67.47,4376.00,case rate,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,inpatient,,,34463.00000,20677.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,27915.03,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Aetna,Commercial,,,75.00,,,,,0,2025.00,21022.43,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,inpatient,,,34463.00000,20677.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,27915.03,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Aetna,Commercial,,,75.00,,,,,0,2025.00,21022.43,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,inpatient,,,31466.00000,18879.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,25487.46,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Aetna,Commercial,,,75.00,,,,,0,2025.00,19194.26,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,inpatient,,,269.00000,161.40000,Aetna,Commercial,,7039.00,,,,,,,172.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Commercial,,4376.00,,,,,,,53.85,5152.00,case rate,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,inpatient,,,728.00000,436.80000,Aetna,Commercial,,7039.00,,,,,,,465.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Aetna,Commercial,,4376.00,,,,,,,145.75,5152.00,case rate,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,inpatient,,,629.00000,377.40000,Aetna,Commercial,,7039.00,,,,,,,402.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Commercial,,4376.00,,,,,,,125.93,8045.00,case rate,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,inpatient,,,1993.00000,1195.80000,Aetna,Commercial,,7039.00,,,,,,,1275.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Aetna,Commercial,,4376.00,,,,,,,399.00,8045.00,case rate,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,inpatient,,,5105.00000,3063.00000,Aetna,Commercial,,7039.00,,,,,,,3267.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Aetna,Commercial,,10087.00,,,,,,,1022.02,17457.00,case rate,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,inpatient,,,543.00000,325.80000,Aetna,Commercial,,7039.00,,,,,,,347.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Aetna,Commercial,,,75.00,,,,,0,108.71,375.70,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,inpatient,,,1387.00000,832.20000,Aetna,Commercial,,7039.00,,,,,,,887.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Aetna,Commercial,,4311.00,,,,,,,277.68,4311.00,case rate,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,inpatient,,,880.00000,528.00000,Aetna,Commercial,,7039.00,,,,,,,563.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Aetna,Commercial,,4311.00,,,,,,,176.18,4311.00,case rate,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,inpatient,,,57551.00000,34530.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,46616.31,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Aetna,Commercial,,,75.00,,,,,0,2025.00,35106.11,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,inpatient,,,4857.00000,2914.20000,Aetna,Commercial,,7039.00,,,,,,,3108.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Aetna,Commercial,,8442.00,,,,,,,972.37,13852.00,case rate,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,inpatient,,,4857.00000,2914.20000,Aetna,Commercial,,7039.00,,,,,,,3108.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Aetna,Commercial,,8442.00,,,,,,,972.37,13852.00,case rate,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,inpatient,,,29535.00000,17721.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,23923.35,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Aetna,Commercial,,,75.00,,,,,0,2025.00,18016.35,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,inpatient,,,1110.00000,666.00000,Aetna,Commercial,,7039.00,,,,,,,710.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Aetna,Commercial,,4311.00,,,,,,,222.22,4311.00,case rate,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,inpatient,,,2999.00000,1799.40000,Aetna,Commercial,,7039.00,,,,,,,1919.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Aetna,Commercial,,4376.00,,,,,,,600.40,5754.00,case rate,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,inpatient,,,155.00000,93.00000,Aetna,Commercial,,7039.00,,,,,,,99.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Aetna,Commercial,,4311.00,,,,,,,31.03,4311.00,case rate,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Aetna,Commercial,,4311.00,,,,,,,29.22,4311.00,case rate,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,inpatient,,,421.00000,252.60000,Aetna,Commercial,,7039.00,,,,,,,269.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Aetna,Commercial,,4311.00,,,,,,,84.28,4311.00,case rate,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,inpatient,,,2921.00000,1752.60000,Aetna,Commercial,,7039.00,,,,,,,1869.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Aetna,Commercial,,8442.00,,,,,,,584.78,13852.00,case rate,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,inpatient,,,629.00000,377.40000,Aetna,Commercial,,7039.00,,,,,,,402.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Commercial,,6735.00,,,,,,,125.93,13852.00,case rate,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,inpatient,,,456.00000,273.60000,Aetna,Commercial,,7039.00,,,,,,,291.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Aetna,Commercial,,4311.00,,,,,,,91.29,4311.00,case rate,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,inpatient,,,232.00000,139.20000,Aetna,Commercial,,7039.00,,,,,,,148.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Aetna,Commercial,,4311.00,,,,,,,46.45,4311.00,case rate,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,inpatient,,,201.00000,120.60000,Aetna,Commercial,,7039.00,,,,,,,128.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Commercial,,4311.00,,,,,,,40.24,4311.00,case rate,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,inpatient,,,481.00000,288.60000,Aetna,Commercial,,7039.00,,,,,,,307.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Commercial,,4311.00,,,,,,,96.30,4311.00,case rate,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,inpatient,,,1109.00000,665.40000,Aetna,Commercial,,7039.00,,,,,,,709.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Aetna,Commercial,,4311.00,,,,,,,222.02,4311.00,case rate,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,inpatient,,,458.00000,274.80000,Aetna,Commercial,,7039.00,,,,,,,293.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Commercial,,4311.00,,,,,,,91.69,4311.00,case rate,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,inpatient,,,285.00000,171.00000,Aetna,Commercial,,7039.00,,,,,,,182.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Aetna,Commercial,,,75.00,,,,,0,57.06,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,inpatient,,,101.00000,60.60000,Aetna,Commercial,,7039.00,,,,,,,64.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,4311.00,,,,,,,20.22,4311.00,case rate,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,inpatient,,,1400.00000,840.00000,Aetna,Commercial,,7039.00,,,,,,,896.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Aetna,Commercial,,4311.00,,,,,,,280.28,4311.00,case rate,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,inpatient,,,1582.00000,949.20000,Aetna,Commercial,,7039.00,,,,,,,1012.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Aetna,Commercial,,4311.00,,,,,,,316.72,4311.00,case rate,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Aetna,Commercial,,4311.00,,,,,,,298.21,4311.00,case rate,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,inpatient,,,2330.00000,1398.00000,Aetna,Commercial,,7039.00,,,,,,,1491.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Aetna,Commercial,,4376.00,,,,,,,466.47,5152.00,case rate,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Aetna,Commercial,,4376.00,,,,,,,439.20,4376.00,case rate,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,inpatient,,,311.00000,186.60000,Aetna,Commercial,,7039.00,,,,,,,199.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Aetna,Commercial,,4311.00,,,,,,,62.26,4311.00,case rate,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,inpatient,,,311.00000,186.60000,Aetna,Commercial,,7039.00,,,,,,,199.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Aetna,Commercial,,4311.00,,,,,,,62.26,4311.00,case rate,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,inpatient,,,804.00000,482.40000,Aetna,Commercial,,7039.00,,,,,,,514.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Commercial,,4311.00,,,,,,,160.96,4311.00,case rate,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Commercial,,4311.00,,,,,,,151.55,4311.00,case rate,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Aetna,Commercial,,4311.00,,,,,,,136.10,4311.00,case rate,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,inpatient,,,577.00000,346.20000,Aetna,Commercial,,7039.00,,,,,,,369.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Aetna,Commercial,,4311.00,,,,,,,115.52,4311.00,case rate,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Aetna,Commercial,,4311.00,,,,,,,108.76,4311.00,case rate,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,inpatient,,,4720.00000,2832.00000,Aetna,Commercial,,7039.00,,,,,,,3020.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Aetna,Commercial,,4311.00,,,,,,,944.94,13527.54,case rate,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,inpatient,,,3377.00000,2026.20000,Aetna,Commercial,,7039.00,,,,,,,2161.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,inpatient,,,712.00000,427.20000,Aetna,Commercial,,7039.00,,,,,,,455.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Aetna,Commercial,,4311.00,,,,,,,142.54,4311.00,case rate,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,inpatient,,,565.00000,339.00000,Aetna,Commercial,,7039.00,,,,,,,361.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Aetna,Commercial,,4311.00,,,,,,,113.11,4311.00,case rate,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,inpatient,,,1414.00000,848.40000,Aetna,Commercial,,7039.00,,,,,,,904.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,inpatient,,,765.00000,459.00000,Aetna,Commercial,,7039.00,,,,,,,489.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Aetna,Commercial,,4311.00,,,,,,,153.15,4311.00,case rate,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,inpatient,,,1292.00000,775.20000,Aetna,Commercial,,7039.00,,,,,,,826.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,inpatient,,,581.00000,348.60000,Aetna,Commercial,,7039.00,,,,,,,371.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Aetna,Commercial,,4311.00,,,,,,,116.32,4311.00,case rate,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,inpatient,,,1275.00000,765.00000,Aetna,Commercial,,7039.00,,,,,,,816.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Aetna,Commercial,,4311.00,,,,,,,240.34,4311.00,case rate,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,inpatient,,,1168.00000,700.80000,Aetna,Commercial,,7039.00,,,,,,,747.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,inpatient,,,3019.00000,1811.40000,Aetna,Commercial,,7039.00,,,,,,,1932.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Aetna,Commercial,,4376.00,,,,,,,604.40,5754.00,case rate,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,inpatient,,,3019.00000,1811.40000,Aetna,Commercial,,7039.00,,,,,,,1932.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Aetna,Commercial,,4376.00,,,,,,,604.40,5754.00,case rate,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,inpatient,,,300.00000,180.00000,Aetna,Commercial,,7039.00,,,,,,,192.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Aetna,Commercial,,4311.00,,,,,,,60.06,4311.00,case rate,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,inpatient,,,1943.00000,1165.80000,Aetna,Commercial,,7039.00,,,,,,,1243.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Aetna,Commercial,,4376.00,,,,,,,388.99,17457.00,case rate,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,inpatient,,,1464.00000,878.40000,Aetna,Commercial,,7039.00,,,,,,,936.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Aetna,Commercial,,4311.00,,,,,,,293.09,4311.00,case rate,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,inpatient,,,834.00000,500.40000,Aetna,Commercial,,7039.00,,,,,,,533.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Aetna,Commercial,,4311.00,,,,,,,166.97,9350.00,case rate,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,inpatient,,,1623.00000,973.80000,Aetna,Commercial,,7039.00,,,,,,,1038.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Aetna,Commercial,,4311.00,,,,,,,324.92,4311.00,case rate,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,inpatient,,,1770.00000,1062.00000,Aetna,Commercial,,7039.00,,,,,,,1132.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Aetna,Commercial,,4376.00,,,,,,,354.35,4376.00,case rate,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,Aetna,Commercial,,7039.00,,,,,,,1157.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Aetna,Commercial,,,75.00,,,,,0,173.00,1251.65,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,Aetna,Commercial,,7039.00,,,,,,,1157.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,inpatient,,,2105.00000,1263.00000,Aetna,Commercial,,7039.00,,,,,,,1347.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,inpatient,,,2105.00000,1263.00000,Aetna,Commercial,,7039.00,,,,,,,1347.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,inpatient,,,677.00000,406.20000,Aetna,Commercial,,7039.00,,,,,,,433.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Commercial,,4311.00,,,,,,,135.54,4311.00,case rate,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,inpatient,,,677.00000,406.20000,Aetna,Commercial,,7039.00,,,,,,,433.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Commercial,,4311.00,,,,,,,135.54,9423.00,case rate,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,inpatient,,,519.00000,311.40000,Aetna,Commercial,,7039.00,,,,,,,332.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Commercial,,4311.00,,,,,,,103.90,9423.00,case rate,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,inpatient,,,684.00000,410.40000,Aetna,Commercial,,7039.00,,,,,,,437.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Aetna,Commercial,,4376.00,,,,,,,136.94,4376.00,case rate,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,inpatient,,,684.00000,410.40000,Aetna,Commercial,,7039.00,,,,,,,437.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Aetna,Commercial,,4376.00,,,,,,,136.94,9423.00,case rate,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,inpatient,,,2691.00000,1614.60000,Aetna,Commercial,,7039.00,,,,,,,1722.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,inpatient,,,2756.00000,1653.60000,Aetna,Commercial,,7039.00,,,,,,,1763.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,inpatient,,,2756.00000,1653.60000,Aetna,Commercial,,7039.00,,,,,,,1763.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,inpatient,,,1594.00000,956.40000,Aetna,Commercial,,7039.00,,,,,,,1020.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,inpatient,,,1594.00000,956.40000,Aetna,Commercial,,7039.00,,,,,,,1020.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,inpatient,,,916.00000,549.60000,Aetna,Commercial,,7039.00,,,,,,,586.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,inpatient,,,916.00000,549.60000,Aetna,Commercial,,7039.00,,,,,,,586.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,inpatient,,,1130.00000,678.00000,Aetna,Commercial,,7039.00,,,,,,,723.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,inpatient,,,1130.00000,678.00000,Aetna,Commercial,,7039.00,,,,,,,723.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,inpatient,,,1153.00000,691.80000,Aetna,Commercial,,7039.00,,,,,,,737.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,inpatient,,,1153.00000,691.80000,Aetna,Commercial,,7039.00,,,,,,,737.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,inpatient,,,5059.00000,3035.40000,Aetna,Commercial,,7039.00,,,,,,,3237.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Aetna,Commercial,,6735.00,,,,,,,1012.81,17457.00,case rate,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Aetna,Commercial,,4311.00,,,,,,,928.36,4311.00,case rate,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,inpatient,,,795.00000,477.00000,Aetna,Commercial,,7039.00,,,,,,,508.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Aetna,Commercial,,4311.00,,,,,,,159.16,4311.00,case rate,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,inpatient,,,725.00000,435.00000,Aetna,Commercial,,7039.00,,,,,,,464.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Aetna,Commercial,,4311.00,,,,,,,145.15,4311.00,case rate,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,inpatient,,,818.00000,490.80000,Aetna,Commercial,,7039.00,,,,,,,523.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Aetna,Commercial,,4311.00,,,,,,,163.76,4311.00,case rate,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,inpatient,,,742.00000,445.20000,Aetna,Commercial,,7039.00,,,,,,,474.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Aetna,Commercial,,4376.00,,,,,,,148.55,13852.00,case rate,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,inpatient,,,2247.00000,1348.20000,Aetna,Commercial,,7039.00,,,,,,,1438.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Aetna,Commercial,,4376.00,,,,,,,449.85,8045.00,case rate,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,inpatient,,,742.00000,445.20000,Aetna,Commercial,,7039.00,,,,,,,474.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Aetna,Commercial,,6735.00,,,,,,,148.55,8045.00,case rate,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,inpatient,,,3723.00000,2233.80000,Aetna,Commercial,,7039.00,,,,,,,2382.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Aetna,Commercial,,6735.00,,,,,,,745.34,8045.00,case rate,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,inpatient,,,886.00000,531.60000,Aetna,Commercial,,7039.00,,,,,,,567.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Aetna,Commercial,,4311.00,,,,,,,177.38,4311.00,case rate,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,inpatient,,,686.00000,411.60000,Aetna,Commercial,,7039.00,,,,,,,439.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Aetna,Commercial,,4311.00,,,,,,,137.34,4311.00,case rate,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,inpatient,,,195.00000,117.00000,Aetna,Commercial,,7039.00,,,,,,,124.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Commercial,,4376.00,,,,,,,39.04,5152.00,case rate,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,inpatient,,,533.00000,319.80000,Aetna,Commercial,,7039.00,,,,,,,341.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Aetna,Commercial,,4376.00,,,,,,,106.71,5152.00,case rate,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,inpatient,,,555.00000,333.00000,Aetna,Commercial,,7039.00,,,,,,,355.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Aetna,Commercial,,4376.00,,,,,,,111.11,8045.00,case rate,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,inpatient,,,590.00000,354.00000,Aetna,Commercial,,7039.00,,,,,,,377.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Aetna,Commercial,,4311.00,,,,,,,118.12,4311.00,case rate,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,inpatient,,,583.00000,349.80000,Aetna,Commercial,,7039.00,,,,,,,373.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Aetna,Commercial,,4376.00,,,,,,,116.72,8045.00,case rate,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,inpatient,,,665.00000,399.00000,Aetna,Commercial,,7039.00,,,,,,,425.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Aetna,Commercial,,6735.00,,,,,,,133.13,13852.00,case rate,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,inpatient,,,4163.00000,2497.80000,Aetna,Commercial,,7039.00,,,,,,,2664.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Aetna,Commercial,,6735.00,,,,,,,833.43,8045.00,case rate,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,inpatient,,,2128.00000,1276.80000,Aetna,Commercial,,7039.00,,,,,,,1361.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Aetna,Commercial,,4311.00,,,,,,,426.03,4311.00,case rate,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,inpatient,,,1343.00000,805.80000,Aetna,Commercial,,7039.00,,,,,,,859.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Aetna,Commercial,,4311.00,,,,,,,268.87,4311.00,case rate,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,inpatient,,,1464.00000,878.40000,Aetna,Commercial,,7039.00,,,,,,,936.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Aetna,Commercial,,4311.00,,,,,,,293.09,4311.00,case rate,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,inpatient,,,694.00000,416.40000,Aetna,Commercial,,7039.00,,,,,,,444.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Aetna,Commercial,,8442.00,,,,,,,138.94,8442.00,case rate,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,inpatient,,,587.00000,352.20000,Aetna,Commercial,,7039.00,,,,,,,375.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Aetna,Commercial,,4311.00,,,,,,,117.52,4311.00,case rate,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,inpatient,,,606.00000,363.60000,Aetna,Commercial,,7039.00,,,,,,,387.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Aetna,Commercial,,4311.00,,,,,,,121.32,4311.00,case rate,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,inpatient,,,884.00000,530.40000,Aetna,Commercial,,7039.00,,,,,,,565.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Aetna,Commercial,,4376.00,,,,,,,166.63,4376.00,case rate,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,inpatient,,,14058.00000,8434.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11386.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Aetna,Commercial,,15260.00,,,,,,,2814.41,18878.80,case rate,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,inpatient,,,14058.00000,8434.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11386.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Aetna,Commercial,,15260.00,,,,,,,2814.41,18878.80,case rate,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,inpatient,,,14058.00000,8434.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11386.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,inpatient,,,6186.00000,3711.60000,Aetna,Commercial,,7039.00,,,,,,,3959.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,inpatient,,,10514.00000,6308.40000,Aetna,Commercial,,7039.00,,,,,,,6728.96,8516.34,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Commercial,,15260.00,,,,,,,2104.90,17457.00,case rate,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,inpatient,,,10514.00000,6308.40000,Aetna,Commercial,,7039.00,,,,,,,6728.96,8516.34,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Commercial,,15260.00,,,,,,,2104.90,15260.00,case rate,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,inpatient,,,10514.00000,6308.40000,Aetna,Commercial,,7039.00,,,,,,,6728.96,8516.34,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Commercial,,15260.00,,,,,,,2104.90,17457.00,case rate,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,inpatient,,,10514.00000,6308.40000,Aetna,Commercial,,7039.00,,,,,,,6728.96,8516.34,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Commercial,,15260.00,,,,,,,2104.90,15260.00,case rate,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,inpatient,,,11452.00000,6871.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9276.12,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Aetna,Commercial,,6735.00,,,,,,,2292.69,13852.00,case rate,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,inpatient,,,11452.00000,6871.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9276.12,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Aetna,Commercial,,6735.00,,,,,,,2292.69,13852.00,case rate,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,inpatient,,,7673.00000,4603.80000,Aetna,Commercial,,7039.00,,,,,,,4910.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Aetna,Commercial,,6735.00,,,,,,,1536.13,8045.00,case rate,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,inpatient,,,7902.00000,4741.20000,Aetna,Commercial,,7039.00,,,,,,,5057.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Aetna,Commercial,,6735.00,,,,,,,1581.98,8045.00,case rate,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,inpatient,,,7902.00000,4741.20000,Aetna,Commercial,,7039.00,,,,,,,5057.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Aetna,Commercial,,6735.00,,,,,,,1581.98,9423.00,case rate,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,inpatient,,,4800.00000,2880.00000,Aetna,Commercial,,7039.00,,,,,,,3072.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Aetna,Commercial,,6735.00,,,,,,,960.96,9423.00,case rate,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,inpatient,,,4471.00000,2682.60000,Aetna,Commercial,,7039.00,,,,,,,2861.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Aetna,Commercial,,8442.00,,,,,,,895.09,13852.00,case rate,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,inpatient,,,6062.00000,3637.20000,Aetna,Commercial,,7039.00,,,,,,,3879.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Aetna,Commercial,,6735.00,,,,,,,1213.61,24600.00,case rate,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,inpatient,,,6062.00000,3637.20000,Aetna,Commercial,,7039.00,,,,,,,3879.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Aetna,Commercial,,4311.00,,,,,,,1213.61,13852.00,case rate,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,inpatient,,,6062.00000,3637.20000,Aetna,Commercial,,7039.00,,,,,,,3879.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Aetna,Commercial,,4311.00,,,,,,,1213.61,13852.00,case rate,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,inpatient,,,4394.00000,2636.40000,Aetna,Commercial,,7039.00,,,,,,,2812.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Aetna,Commercial,,4311.00,,,,,,,879.68,13852.00,case rate,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,inpatient,,,2417.00000,1450.20000,Aetna,Commercial,,7039.00,,,,,,,1546.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Aetna,Commercial,,4376.00,,,,,,,483.88,4376.00,case rate,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,inpatient,,,2475.00000,1485.00000,Aetna,Commercial,,7039.00,,,,,,,1584.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Aetna,Commercial,,4311.00,,,,,,,495.50,4311.00,case rate,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,inpatient,,,1613.00000,967.80000,Aetna,Commercial,,7039.00,,,,,,,1032.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Aetna,Commercial,,4311.00,,,,,,,322.92,4311.00,case rate,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,inpatient,,,792.00000,475.20000,Aetna,Commercial,,7039.00,,,,,,,506.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Aetna,Commercial,,4311.00,,,,,,,158.56,4311.00,case rate,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,inpatient,,,2474.00000,1484.40000,Aetna,Commercial,,7039.00,,,,,,,1583.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,inpatient,,,379.00000,227.40000,Aetna,Commercial,,7039.00,,,,,,,242.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Aetna,Commercial,,4311.00,,,,,,,75.88,4311.00,case rate,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,inpatient,,,482.00000,289.20000,Aetna,Commercial,,7039.00,,,,,,,308.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Aetna,Commercial,,4376.00,,,,,,,96.50,4376.00,case rate,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,inpatient,,,282.00000,169.20000,Aetna,Commercial,,7039.00,,,,,,,180.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Aetna,Commercial,,,75.00,,,,,0,56.46,4121.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,inpatient,,,542.00000,325.20000,Aetna,Commercial,,7039.00,,,,,,,346.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Aetna,Commercial,,4311.00,,,,,,,108.51,4311.00,case rate,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,inpatient,,,5294.00000,3176.40000,Aetna,Commercial,,7039.00,,,,,,,3388.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Aetna,Commercial,,15260.00,,,,,,,1059.86,17457.00,case rate,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,inpatient,,,1277.00000,766.20000,Aetna,Commercial,,7039.00,,,,,,,817.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Aetna,Commercial,,,75.00,,,,,0,255.66,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,inpatient,,,7494.00000,4496.40000,Aetna,Commercial,,7039.00,,,,,,,4796.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Aetna,Commercial,,6735.00,,,,,,,1500.30,17457.00,case rate,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,inpatient,,,395.00000,237.00000,Aetna,Commercial,,7039.00,,,,,,,252.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Aetna,Commercial,,4311.00,,,,,,,79.08,4311.00,case rate,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,inpatient,,,1640.00000,984.00000,Aetna,Commercial,,7039.00,,,,,,,1049.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Aetna,Commercial,,4376.00,,,,,,,328.33,4376.00,case rate,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Aetna,Commercial,,4376.00,,,,,,,309.14,4376.00,case rate,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,inpatient,,,2136.00000,1281.60000,Aetna,Commercial,,7039.00,,,,,,,1367.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Aetna,Commercial,,4311.00,,,,,,,427.63,4311.00,case rate,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Commercial,,4311.00,,,,,,,171.72,4311.00,case rate,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,inpatient,,,3077.00000,1846.20000,Aetna,Commercial,,7039.00,,,,,,,1969.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Aetna,Commercial,,4376.00,,,,,,,616.02,17457.00,case rate,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,inpatient,,,2239.00000,1343.40000,Aetna,Commercial,,7039.00,,,,,,,1432.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Aetna,Commercial,,4311.00,,,,,,,448.25,8045.00,case rate,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,inpatient,,,535.00000,321.00000,Aetna,Commercial,,7039.00,,,,,,,342.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Commercial,,4376.00,,,,,,,107.11,4376.00,case rate,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,inpatient,,,1016.00000,609.60000,Aetna,Commercial,,7039.00,,,,,,,650.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Aetna,Commercial,,4376.00,,,,,,,203.40,4376.00,case rate,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,inpatient,,,3854.00000,2312.40000,Aetna,Commercial,,7039.00,,,,,,,2466.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Aetna,Commercial,,4311.00,,,,,,,771.57,4311.00,case rate,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,inpatient,,,642.00000,385.20000,Aetna,Commercial,,7039.00,,,,,,,410.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Aetna,Commercial,,4311.00,,,,,,,128.53,4311.00,case rate,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,inpatient,,,802.00000,481.20000,Aetna,Commercial,,7039.00,,,,,,,513.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Aetna,Commercial,,4311.00,,,,,,,160.56,4311.00,case rate,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,inpatient,,,642.00000,385.20000,Aetna,Commercial,,7039.00,,,,,,,410.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Aetna,Commercial,,4311.00,,,,,,,128.53,4311.00,case rate,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,inpatient,,,695.00000,417.00000,Aetna,Commercial,,7039.00,,,,,,,444.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Aetna,Commercial,,4311.00,,,,,,,139.14,4311.00,case rate,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,inpatient,,,5294.00000,3176.40000,Aetna,Commercial,,7039.00,,,,,,,3388.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Aetna,Commercial,,4311.00,,,,,,,902.01,4311.00,case rate,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,inpatient,,,2378.00000,1426.80000,Aetna,Commercial,,7039.00,,,,,,,1521.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Aetna,Commercial,,4311.00,,,,,,,476.08,4311.00,case rate,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,inpatient,,,2502.00000,1501.20000,Aetna,Commercial,,7039.00,,,,,,,1601.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Aetna,Commercial,,4311.00,,,,,,,500.90,5754.00,case rate,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,inpatient,,,2478.00000,1486.80000,Aetna,Commercial,,7039.00,,,,,,,1585.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Aetna,Commercial,,4311.00,,,,,,,496.10,5754.00,case rate,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,inpatient,,,636.00000,381.60000,Aetna,Commercial,,7039.00,,,,,,,407.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Aetna,Commercial,,4311.00,,,,,,,127.33,5152.00,case rate,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,inpatient,,,1160.00000,696.00000,Aetna,Commercial,,7039.00,,,,,,,742.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Commercial,,4311.00,,,,,,,232.23,4311.00,case rate,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,inpatient,,,175.00000,105.00000,Aetna,Commercial,,7039.00,,,,,,,112.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Aetna,Commercial,,4311.00,,,,,,,35.03,4311.00,case rate,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,inpatient,,,6291.00000,3774.60000,Aetna,Commercial,,7039.00,,,,,,,4026.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Aetna,Commercial,,8442.00,,,,,,,1259.46,13852.00,case rate,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,inpatient,,,7767.00000,4660.20000,Aetna,Commercial,,7039.00,,,,,,,4970.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Aetna,Commercial,,15260.00,,,,,,,1554.95,17457.00,case rate,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,inpatient,,,90.00000,54.00000,Aetna,Commercial,,7039.00,,,,,,,57.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,4311.00,,,,,,,18.02,4311.00,case rate,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,inpatient,,,2491.00000,1494.60000,Aetna,Commercial,,7039.00,,,,,,,1594.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Aetna,Commercial,,4311.00,,,,,,,498.70,5754.00,case rate,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,inpatient,,,294.00000,176.40000,Aetna,Commercial,,7039.00,,,,,,,188.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Commercial,,,75.00,,327.05999999999995,327.05999999999995,327.05999999999995,1 through 10,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,inpatient,,,231.00000,138.60000,Aetna,Commercial,,7039.00,,,,,,,147.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Aetna,Commercial,,,75.00,,,,,0,46.25,832.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Aetna,Commercial,,4311.00,,,,,,,39.21,4311.00,case rate,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,inpatient,,,404.00000,242.40000,Aetna,Commercial,,7039.00,,,,,,,258.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Aetna,Commercial,,4311.00,,,,,,,80.88,4311.00,case rate,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,inpatient,,,408.00000,244.80000,Aetna,Commercial,,7039.00,,,,,,,261.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Aetna,Commercial,,4311.00,,,,,,,81.68,4311.00,case rate,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,inpatient,,,2474.00000,1484.40000,Aetna,Commercial,,7039.00,,,,,,,1583.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,inpatient,,,202.00000,121.20000,Aetna,Commercial,,7039.00,,,,,,,129.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Commercial,,4311.00,,,,,,,40.44,4311.00,case rate,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,inpatient,,,1592.00000,955.20000,Aetna,Commercial,,7039.00,,,,,,,1018.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,inpatient,,,4497.00000,2698.20000,Aetna,Commercial,,7039.00,,,,,,,2878.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Aetna,Commercial,,11124.00,,,,,,,900.30,24600.00,case rate,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,inpatient,,,4234.00000,2540.40000,Aetna,Commercial,,7039.00,,,,,,,2709.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Aetna,Commercial,,12247.00,,,,,,,847.65,24600.00,case rate,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,inpatient,,,2921.00000,1752.60000,Aetna,Commercial,,7039.00,,,,,,,1869.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Aetna,Commercial,,11124.00,,,,,,,584.78,24600.00,case rate,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,inpatient,,,4574.00000,2744.40000,Aetna,Commercial,,7039.00,,,,,,,2927.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Aetna,Commercial,,,75.00,,,,,0,915.71,6649.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,inpatient,,,1055.00000,633.00000,Aetna,Commercial,,7039.00,,,,,,,675.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Aetna,Commercial,,4311.00,,,,,,,211.21,4311.00,case rate,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Aetna,Commercial,,4311.00,,,,,,,198.87,4311.00,case rate,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,inpatient,,,1471.00000,882.60000,Aetna,Commercial,,7039.00,,,,,,,941.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Aetna,Commercial,,4311.00,,,,,,,294.49,4311.00,case rate,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,inpatient,,,288.00000,172.80000,Aetna,Commercial,,7039.00,,,,,,,184.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Commercial,,4311.00,,,,,,,57.66,4311.00,case rate,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Commercial,,4311.00,,,,,,,54.29,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,inpatient,,,1918.00000,1150.80000,Aetna,Commercial,,7039.00,,,,,,,1227.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Aetna,Commercial,,4311.00,,,,,,,383.98,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Aetna,Commercial,,4311.00,,,,,,,361.54,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Aetna,Commercial,,4311.00,,,,,,,221.11,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,inpatient,,,2511.00000,1506.60000,Aetna,Commercial,,7039.00,,,,,,,1607.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Aetna,Commercial,,4311.00,,,,,,,502.70,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Aetna,Commercial,,4311.00,,,,,,,473.32,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,inpatient,,,2034.00000,1220.40000,Aetna,Commercial,,7039.00,,,,,,,1301.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Aetna,Commercial,,4311.00,,,,,,,383.41,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,inpatient,,,1738.00000,1042.80000,Aetna,Commercial,,7039.00,,,,,,,1112.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Aetna,Commercial,,4311.00,,,,,,,347.95,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Aetna,Commercial,,4311.00,,,,,,,327.61,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,inpatient,,,1583.00000,949.80000,Aetna,Commercial,,7039.00,,,,,,,1013.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Aetna,Commercial,,4311.00,,,,,,,316.92,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Aetna,Commercial,,4311.00,,,,,,,298.40,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,inpatient,,,1646.00000,987.60000,Aetna,Commercial,,7039.00,,,,,,,1053.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Aetna,Commercial,,4311.00,,,,,,,310.27,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Aetna,Commercial,,4311.00,,,,,,,322.33,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,inpatient,,,1515.00000,909.00000,Aetna,Commercial,,7039.00,,,,,,,969.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Aetna,Commercial,,4311.00,,,,,,,303.30,4311.00,case rate,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Aetna,Commercial,,4311.00,,,,,,,285.58,4311.00,case rate,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,inpatient,,,1509.00000,905.40000,Aetna,Commercial,,7039.00,,,,,,,965.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Aetna,Commercial,,4311.00,,,,,,,302.10,4311.00,case rate,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Aetna,Commercial,,4311.00,,,,,,,284.45,4311.00,case rate,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,inpatient,,,3322.00000,1993.20000,Aetna,Commercial,,7039.00,,,,,,,2126.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Aetna,Commercial,,4311.00,,,,,,,665.06,9350.00,case rate,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Aetna,Commercial,,4311.00,,,,,,,626.20,4311.00,case rate,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,inpatient,,,1860.00000,1116.00000,Aetna,Commercial,,7039.00,,,,,,,1190.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Aetna,Commercial,,4311.00,,,,,,,350.61,4311.00,case rate,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,inpatient,,,1818.00000,1090.80000,Aetna,Commercial,,7039.00,,,,,,,1163.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Aetna,Commercial,,4376.00,,,,,,,363.96,5152.00,case rate,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Aetna,Commercial,,4376.00,,,,,,,342.69,4376.00,case rate,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,inpatient,,,2306.00000,1383.60000,Aetna,Commercial,,7039.00,,,,,,,1475.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,inpatient,,,368.00000,220.80000,Aetna,Commercial,,7039.00,,,,,,,235.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Aetna,Commercial,,4311.00,,,,,,,73.67,4311.00,case rate,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Aetna,Commercial,,6735.00,,,,,,,915.54,6735.00,case rate,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,inpatient,,,220.00000,132.00000,Aetna,Commercial,,7039.00,,,,,,,140.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Aetna,Commercial,,,75.00,,,,,0,44.04,152.22,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,inpatient,,,2841.00000,1704.60000,Aetna,Commercial,,7039.00,,,,,,,1818.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Aetna,Commercial,,,75.00,,,,,0,568.77,12408.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,inpatient,,,2990.00000,1794.00000,Aetna,Commercial,,7039.00,,,,,,,1913.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Aetna,Commercial,,,75.00,,,,,0,598.60,17457.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,inpatient,,,20137.00000,12082.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16310.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Aetna,Commercial,,6735.00,,,,,,,4031.43,24600.00,case rate,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,inpatient,,,10706.00000,6423.60000,Aetna,Commercial,,7039.00,,,,,,,6851.84,8671.86,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Aetna,Commercial,,6735.00,,,,,,,2143.34,24600.00,case rate,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,inpatient,,,519.00000,311.40000,Aetna,Commercial,,7039.00,,,,,,,332.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Commercial,,4311.00,,,,,,,103.90,9423.00,case rate,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,inpatient,,,1168.00000,700.80000,Aetna,Commercial,,7039.00,,,,,,,747.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,inpatient,,,1074.00000,644.40000,Aetna,Commercial,,7039.00,,,,,,,687.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Aetna,Commercial,,4376.00,,,,,,,215.01,5152.00,case rate,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,inpatient,,,693.00000,415.80000,Aetna,Commercial,,7039.00,,,,,,,443.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Aetna,Commercial,,4311.00,,,,,,,138.74,4311.00,case rate,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,inpatient,,,776.00000,465.60000,Aetna,Commercial,,7039.00,,,,,,,496.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Aetna,Commercial,,4311.00,,,,,,,155.36,4311.00,case rate,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,inpatient,,,5458.00000,3274.80000,Aetna,Commercial,,7039.00,,,,,,,3493.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Aetna,Commercial,,4376.00,,,,,,,1092.69,6649.00,case rate,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,inpatient,,,3712.00000,2227.20000,Aetna,Commercial,,7039.00,,,,,,,2375.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,inpatient,,,4719.00000,2831.40000,Aetna,Commercial,,7039.00,,,,,,,3020.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Aetna,Commercial,,4376.00,,,,,,,944.74,6649.00,case rate,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,inpatient,,,3869.00000,2321.40000,Aetna,Commercial,,7039.00,,,,,,,2476.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,inpatient,,,4864.00000,2918.40000,Aetna,Commercial,,7039.00,,,,,,,3112.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Aetna,Commercial,,6735.00,,,,,,,973.77,6735.00,case rate,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,inpatient,,,3988.00000,2392.80000,Aetna,Commercial,,7039.00,,,,,,,2552.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,inpatient,,,1688.00000,1012.80000,Aetna,Commercial,,7039.00,,,,,,,1080.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Aetna,Commercial,,4376.00,,,,,,,337.94,4376.00,case rate,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,inpatient,,,573.00000,343.80000,Aetna,Commercial,,7039.00,,,,,,,366.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Aetna,Commercial,,4311.00,,,,,,,114.71,4311.00,case rate,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,inpatient,,,7462.00000,4477.20000,Aetna,Commercial,,7039.00,,,,,,,4775.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Aetna,Commercial,,8442.00,,,,,,,1493.89,13852.00,case rate,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,inpatient,,,1990.00000,1194.00000,Aetna,Commercial,,7039.00,,,,,,,1273.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Aetna,Commercial,,4376.00,,,,,,,398.40,4376.00,case rate,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,inpatient,,,1492.00000,895.20000,Aetna,Commercial,,7039.00,,,,,,,954.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,inpatient,,,2653.00000,1591.80000,Aetna,Commercial,,7039.00,,,,,,,1697.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Aetna,Commercial,,6735.00,,,,,,,531.13,6735.00,case rate,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,inpatient,,,28766.00000,17259.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,23300.46,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Aetna,Commercial,,4311.00,,,,,,,4311.00,17547.26,case rate,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,inpatient,,,4187.00000,2512.20000,Aetna,Commercial,,7039.00,,,,,,,2679.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Aetna,Commercial,,6735.00,,,,,,,838.24,24600.00,case rate,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,inpatient,,,13279.00000,7967.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10755.99,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Aetna,Commercial,,6735.00,,,,,,,2658.46,24600.00,case rate,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,inpatient,,,8848.00000,5308.80000,Aetna,Commercial,,7039.00,,,,,,,5662.72,7166.88,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Aetna,Commercial,,6735.00,,,,,,,1771.37,24600.00,case rate,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,inpatient,,,3479.00000,2087.40000,Aetna,Commercial,,7039.00,,,,,,,2226.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Aetna,Commercial,,4376.00,,,,,,,676.91,4376.00,case rate,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,inpatient,,,1241.00000,744.60000,Aetna,Commercial,,7039.00,,,,,,,794.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Aetna,Commercial,,4376.00,,,,,,,248.45,8045.00,case rate,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,inpatient,,,1696.00000,1017.60000,Aetna,Commercial,,7039.00,,,,,,,1085.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Aetna,Commercial,,4311.00,,,,,,,284.00,4311.00,case rate,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,inpatient,,,1876.00000,1125.60000,Aetna,Commercial,,7039.00,,,,,,,1200.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Aetna,Commercial,,4311.00,,,,,,,375.58,4311.00,case rate,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Aetna,Commercial,,4311.00,,,,,,,353.63,4311.00,case rate,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,inpatient,,,1732.00000,1039.20000,Aetna,Commercial,,7039.00,,,,,,,1108.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Aetna,Commercial,,4311.00,,,,,,,284.00,4311.00,case rate,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,inpatient,,,1289.00000,773.40000,Aetna,Commercial,,7039.00,,,,,,,824.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Aetna,Commercial,,8442.00,,,,,,,258.06,17457.00,case rate,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,inpatient,,,733.00000,439.80000,Aetna,Commercial,,7039.00,,,,,,,469.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Aetna,Commercial,,8442.00,,,,,,,146.75,17457.00,case rate,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,inpatient,,,1229.00000,737.40000,Aetna,Commercial,,7039.00,,,,,,,786.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Aetna,Commercial,,4311.00,,,,,,,173.00,17457.00,case rate,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,inpatient,,,7165.00000,4299.00000,Aetna,Commercial,,7039.00,,,,,,,4585.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Aetna,Commercial,,10087.00,,,,,,,1434.43,13852.00,case rate,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,inpatient,,,1791.00000,1074.60000,Aetna,Commercial,,7039.00,,,,,,,1146.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Aetna,Commercial,,10087.00,,,,,,,358.56,13852.00,case rate,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,inpatient,,,1576.00000,945.60000,Aetna,Commercial,,7039.00,,,,,,,1008.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,inpatient,,,1854.00000,1112.40000,Aetna,Commercial,,7039.00,,,,,,,1186.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Aetna,Commercial,,4311.00,,,,,,,371.17,8213.00,case rate,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,inpatient,,,1046.00000,627.60000,Aetna,Commercial,,7039.00,,,,,,,669.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Aetna,Commercial,,4311.00,,,,,,,209.41,8213.00,case rate,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,inpatient,,,3586.00000,2151.60000,Aetna,Commercial,,7039.00,,,,,,,2295.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Aetna,Commercial,,6735.00,,,,,,,717.92,6735.00,case rate,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,inpatient,,,3586.00000,2151.60000,Aetna,Commercial,,7039.00,,,,,,,2295.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Aetna,Commercial,,6735.00,,,,,,,717.92,9423.00,case rate,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,inpatient,,,2602.00000,1561.20000,Aetna,Commercial,,7039.00,,,,,,,1665.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,inpatient,,,2602.00000,1561.20000,Aetna,Commercial,,7039.00,,,,,,,1665.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,inpatient,,,2602.00000,1561.20000,Aetna,Commercial,,7039.00,,,,,,,1665.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,inpatient,,,2602.00000,1561.20000,Aetna,Commercial,,7039.00,,,,,,,1665.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,inpatient,,,3465.00000,2079.00000,Aetna,Commercial,,7039.00,,,,,,,2217.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Aetna,Commercial,,4311.00,,,,,,,693.69,8045.00,case rate,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,inpatient,,,2980.00000,1788.00000,Aetna,Commercial,,7039.00,,,,,,,1907.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Aetna,Commercial,,4376.00,,,,,,,596.60,17457.00,case rate,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,inpatient,,,6144.00000,3686.40000,Aetna,Commercial,,7039.00,,,,,,,3932.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Aetna,Commercial,,4376.00,,,,,,,1230.03,17457.00,case rate,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,inpatient,,,7144.00000,4286.40000,Aetna,Commercial,,7039.00,,,,,,,4572.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Aetna,Commercial,,4376.00,,,,,,,1430.23,17457.00,case rate,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,inpatient,,,5291.00000,3174.60000,Aetna,Commercial,,7039.00,,,,,,,3386.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Aetna,Commercial,,4376.00,,,,,,,1059.26,17457.00,case rate,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,inpatient,,,4767.00000,2860.20000,Aetna,Commercial,,7039.00,,,,,,,3050.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Aetna,Commercial,,4376.00,,,,,,,954.35,17457.00,case rate,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,inpatient,,,1192.00000,715.20000,Aetna,Commercial,,7039.00,,,,,,,762.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Aetna,Commercial,,4311.00,,,,,,,238.64,4311.00,case rate,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,inpatient,,,8038.00000,4822.80000,Aetna,Commercial,,7039.00,,,,,,,5144.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Aetna,Commercial,,6735.00,,,,,,,1609.21,17457.00,case rate,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,inpatient,,,8296.00000,4977.60000,Aetna,Commercial,,7039.00,,,,,,,5309.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Aetna,Commercial,,6735.00,,,,,,,1660.86,17457.00,case rate,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,inpatient,,,12470.00000,7482.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10100.70,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Aetna,Commercial,,6735.00,,,,,,,2496.49,17457.00,case rate,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,inpatient,,,6955.00000,4173.00000,Aetna,Commercial,,7039.00,,,,,,,4451.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Aetna,Commercial,,4376.00,,,,,,,1392.39,17457.00,case rate,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,inpatient,,,2658.00000,1594.80000,Aetna,Commercial,,7039.00,,,,,,,1701.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,inpatient,,,1848.00000,1108.80000,Aetna,Commercial,,7039.00,,,,,,,1182.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,inpatient,,,891.00000,534.60000,Aetna,Commercial,,7039.00,,,,,,,570.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Aetna,Commercial,,4376.00,,,,,,,178.38,12408.00,case rate,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,inpatient,,,1611.00000,966.60000,Aetna,Commercial,,7039.00,,,,,,,1031.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Aetna,Commercial,,4311.00,,,,,,,322.52,6649.00,case rate,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,inpatient,,,1191.00000,714.60000,Aetna,Commercial,,7039.00,,,,,,,762.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Aetna,Commercial,,4311.00,,,,,,,238.44,6649.00,case rate,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,inpatient,,,3702.00000,2221.20000,Aetna,Commercial,,7039.00,,,,,,,2369.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Aetna,Commercial,,4376.00,,,,,,,741.14,12408.00,case rate,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,inpatient,,,3251.00000,1950.60000,Aetna,Commercial,,7039.00,,,,,,,2080.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Aetna,Commercial,,4376.00,,,,,,,650.85,12408.00,case rate,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,inpatient,,,3254.00000,1952.40000,Aetna,Commercial,,7039.00,,,,,,,2082.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Aetna,Commercial,,4311.00,,,,,,,651.45,6649.00,case rate,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,inpatient,,,2805.00000,1683.00000,Aetna,Commercial,,7039.00,,,,,,,1795.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Aetna,Commercial,,4311.00,,,,,,,561.56,6649.00,case rate,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,inpatient,,,2658.00000,1594.80000,Aetna,Commercial,,7039.00,,,,,,,1701.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,inpatient,,,4769.00000,2861.40000,Aetna,Commercial,,7039.00,,,,,,,3052.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Aetna,Commercial,,6735.00,,,,,,,954.75,17457.00,case rate,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,inpatient,,,5532.00000,3319.20000,Aetna,Commercial,,7039.00,,,,,,,3540.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Aetna,Commercial,,6735.00,,,,,,,1107.51,17457.00,case rate,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,inpatient,,,8107.00000,4864.20000,Aetna,Commercial,,7039.00,,,,,,,5188.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Aetna,Commercial,,6735.00,,,,,,,1623.02,17457.00,case rate,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,inpatient,,,751.00000,450.60000,Aetna,Commercial,,7039.00,,,,,,,480.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Aetna,Commercial,,4311.00,,,,,,,150.35,4311.00,case rate,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,inpatient,,,10877.00000,6526.20000,Aetna,Commercial,,7039.00,,,,,,,6961.28,8810.37,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Aetna,Commercial,,11124.00,,,,,,,2025.00,11124.00,case rate,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,inpatient,,,7831.00000,4698.60000,Aetna,Commercial,,7039.00,,,,,,,5011.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Aetna,Commercial,,,75.00,,,,,0,1567.77,5418.27,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,inpatient,,,3807.00000,2284.20000,Aetna,Commercial,,7039.00,,,,,,,2436.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Aetna,Commercial,,,75.00,,,,,0,762.16,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,inpatient,,,17121.00000,10272.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,13868.01,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Aetna,Commercial,,9503.00,,,,,,,3427.62,52940.00,case rate,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,inpatient,,,7327.00000,4396.20000,Aetna,Commercial,,7039.00,,,,,,,4689.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Aetna,Commercial,,12247.00,,,,,,,1466.87,13852.00,case rate,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,inpatient,,,902.00000,541.20000,Aetna,Commercial,,7039.00,,,,,,,577.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Aetna,Commercial,,4311.00,,,,,,,180.58,4311.00,case rate,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,inpatient,,,3481.00000,2088.60000,Aetna,Commercial,,7039.00,,,,,,,2227.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,inpatient,,,3481.00000,2088.60000,Aetna,Commercial,,7039.00,,,,,,,2227.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,inpatient,,,17238.00000,10342.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,13962.78,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Aetna,Commercial,,12247.00,,,,,,,3451.05,13852.00,case rate,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,inpatient,,,16182.00000,9709.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,13107.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,11196.33,case rate,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,inpatient,,,16182.00000,9709.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,13107.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,9871.02,case rate,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,inpatient,,,8795.00000,5277.00000,Aetna,Commercial,,7039.00,,,,,,,5628.80,7123.95,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Aetna,Commercial,,12247.00,,,,,,,1760.76,13852.00,case rate,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,inpatient,,,8795.00000,5277.00000,Aetna,Commercial,,7039.00,,,,,,,5628.80,7123.95,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Aetna,Commercial,,12247.00,,,,,,,1760.76,13852.00,case rate,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,inpatient,,,9322.00000,5593.20000,Aetna,Commercial,,7039.00,,,,,,,5966.08,7550.82,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,6449.89,case rate,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,inpatient,,,9322.00000,5593.20000,Aetna,Commercial,,7039.00,,,,,,,5966.08,7550.82,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,inpatient,,,12428.00000,7456.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10066.68,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,inpatient,,,9035.00000,5421.00000,Aetna,Commercial,,7039.00,,,,,,,5782.40,7318.35,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,inpatient,,,2910.00000,1746.00000,Aetna,Commercial,,7039.00,,,,,,,1862.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Aetna,Commercial,,4311.00,,,,,,,582.58,4311.00,case rate,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,inpatient,,,2368.00000,1420.80000,Aetna,Commercial,,7039.00,,,,,,,1515.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Aetna,Commercial,,4311.00,,,,,,,474.07,4681.00,case rate,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,inpatient,,,2368.00000,1420.80000,Aetna,Commercial,,7039.00,,,,,,,1515.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Aetna,Commercial,,8442.00,,,,,,,474.07,8442.00,case rate,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,inpatient,,,804.00000,482.40000,Aetna,Commercial,,7039.00,,,,,,,514.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Commercial,,4311.00,,,,,,,160.96,4681.00,case rate,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,inpatient,,,6560.00000,3936.00000,Aetna,Commercial,,7039.00,,,,,,,4198.40,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Aetna,Commercial,,4311.00,,,,,,,990.00,4538.86,case rate,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Aetna,Commercial,,4311.00,,,,,,,317.81,4311.00,case rate,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,inpatient,,,2021.00000,1212.60000,Aetna,Commercial,,7039.00,,,,,,,1293.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Aetna,Commercial,,4311.00,,,,,,,404.60,4311.00,case rate,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,inpatient,,,3211.00000,1926.60000,Aetna,Commercial,,7039.00,,,,,,,2055.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Aetna,Commercial,,4376.00,,,,,,,594.81,9423.00,case rate,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,inpatient,,,487.00000,292.20000,Aetna,Commercial,,7039.00,,,,,,,311.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Aetna,Commercial,,4311.00,,,,,,,97.50,4311.00,case rate,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,inpatient,,,2859.00000,1715.40000,Aetna,Commercial,,7039.00,,,,,,,1829.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Commercial,,4311.00,,,,,,,572.37,6649.00,case rate,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,inpatient,,,2859.00000,1715.40000,Aetna,Commercial,,7039.00,,,,,,,1829.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Commercial,,4311.00,,,,,,,572.37,10768.00,case rate,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,inpatient,,,218.00000,130.80000,Aetna,Commercial,,7039.00,,,,,,,139.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Commercial,,4311.00,,,,,,,43.64,4311.00,case rate,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,inpatient,,,218.00000,130.80000,Aetna,Commercial,,7039.00,,,,,,,139.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Commercial,,4311.00,,,,,,,43.64,4311.00,case rate,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,inpatient,,,9944.00000,5966.40000,Aetna,Commercial,,7039.00,,,,,,,6364.16,8054.64,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Aetna,Commercial,,4311.00,,,,,,,1990.79,17457.00,case rate,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,inpatient,,,9944.00000,5966.40000,Aetna,Commercial,,7039.00,,,,,,,6364.16,8054.64,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Aetna,Commercial,,4376.00,,,,,,,1990.79,8045.00,case rate,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,inpatient,,,4014.00000,2408.40000,Aetna,Commercial,,7039.00,,,,,,,2568.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Aetna,Commercial,,4311.00,,,,,,,803.60,12408.00,case rate,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,inpatient,,,6092.00000,3655.20000,Aetna,Commercial,,7039.00,,,,,,,3898.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Aetna,Commercial,,4376.00,,,,,,,1219.62,10022.00,case rate,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,inpatient,,,3452.00000,2071.20000,Aetna,Commercial,,7039.00,,,,,,,2209.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Aetna,Commercial,,4376.00,,,,,,,594.81,4376.00,case rate,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,Aetna,Commercial,,7039.00,,,,,,,1157.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Aetna,Commercial,,,75.00,,,,,0,173.00,1251.65,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,inpatient,,,629.00000,377.40000,Aetna,Commercial,,7039.00,,,,,,,402.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Commercial,,4311.00,,,,,,,125.93,4311.00,case rate,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,inpatient,,,2859.00000,1715.40000,Aetna,Commercial,,7039.00,,,,,,,1829.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Commercial,,4311.00,,,,,,,572.37,6649.00,case rate,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,inpatient,,,2859.00000,1715.40000,Aetna,Commercial,,7039.00,,,,,,,1829.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Commercial,,4311.00,,,,,,,572.37,10768.00,case rate,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Aetna,Commercial,,651.00,,,,,,,651.00,2905.00,per diem,Paid in addition when billed with ER services.
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,inpatient,,,1959.00000,1175.40000,Aetna,Commercial,,7039.00,,,,,,,1253.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Aetna,Commercial,,4376.00,,,,,,,392.19,8213.00,case rate,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Aetna,Commercial,,294.00,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Aetna,Commercial,,344.25,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Commercial,,279.75,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Commercial,,279.75,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Aetna,Commercial,,294.00,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Aetna,Commercial,,240.00,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Aetna,Commercial,,670.50,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Aetna,Commercial,,430.50,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Aetna,Commercial,,856.50,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Aetna,Commercial,,702.00,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Aetna,Commercial,,793.50,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Aetna,Commercial,,578.25,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Aetna,Commercial,,627.75,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Commercial,,236.25,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Aetna,Commercial,,568.50,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Aetna,Commercial,,232.50,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Aetna,Commercial,,618.75,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Aetna,Commercial,,720.75,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Commercial,,389.25,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Commercial,,477.75,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Aetna,Commercial,,320.25,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Aetna,Commercial,,626.25,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Aetna,Commercial,,501.00,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Commercial,,404.25,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Aetna,Commercial,,493.50,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Commercial,,777.75,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Aetna,Commercial,,617.25,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Aetna,Commercial,,689.25,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Aetna,Commercial,,225.75,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Aetna,Commercial,,883.50,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Aetna,Commercial,,573.00,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Aetna,Commercial,,187.50,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Aetna,Commercial,,173.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Commercial,,139.50,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Aetna,Commercial,,826.50,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Aetna,Commercial,,618.75,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Aetna,Commercial,,149.25,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Aetna,Commercial,,513.00,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Commercial,,316.50,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Aetna,Commercial,,725.25,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Aetna,Commercial,,543.00,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Commercial,,309.75,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Aetna,Commercial,,369.00,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Aetna,Commercial,,344.25,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,82.50,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Commercial,,104.25,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Aetna,Commercial,,50.25,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Aetna,Commercial,,81.75,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Aetna,Commercial,,5598.00,,,,,,,1113.08,5598.00,per diem,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Aetna,Commercial,,5598.00,,,,,,,811.19,5598.00,per diem,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Aetna,Commercial,,5598.00,,,,,,,728.92,5598.00,per diem,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Aetna,Commercial,,5598.00,,,,,,,1131.38,5598.00,per diem,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Aetna,Commercial,,5598.00,,,,,,,1071.94,5598.00,per diem,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Aetna,Commercial,,2016.00,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Aetna,Commercial,,5598.00,,,,,,,1071.94,5598.00,per diem,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Aetna,Commercial,,5598.00,,,,,,,1071.94,5598.00,per diem,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Aetna,Commercial,,5598.00,,,,,,,162.27,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Aetna,Commercial,,5598.00,,,,,,,266.85,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Aetna,Commercial,,5598.00,,,,,,,533.53,5598.00,per diem,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Aetna,Commercial,,5598.00,,,,,,,812.24,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Aetna,Commercial,,5598.00,,,,,,,727.88,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Aetna,Commercial,,5598.00,,,,,,,1054.86,5598.00,per diem,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Aetna,Commercial,,5598.00,,,,,,,1550.57,5598.00,per diem,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Aetna,Commercial,,395.25,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Aetna,Commercial,,674.25,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Commercial,,428.25,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Aetna,Commercial,,759.00,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Aetna,Commercial,,2052.00,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Aetna,Commercial,,1851.75,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Commercial,,360.75,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Aetna,Commercial,,1101.00,,,,,,,760.10,3601.53,per diem,Paid in addition when billed with ER services.
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Aetna,Commercial,,1101.00,,,,,,,343.59,4352.85,per diem,Paid in addition when billed with ER services.
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Aetna,Commercial,,1101.00,,,,,,,343.59,3155.53,per diem,Paid in addition when billed with ER services.
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Aetna,Commercial,,1101.00,,,,,,,343.59,3286.68,per diem,Paid in addition when billed with ER services.
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Aetna,Commercial,,1101.00,,,,,,,343.59,3127.52,per diem,Paid in addition when billed with ER services.
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Aetna,Commercial,,1101.00,,,,,,,343.59,3810.99,per diem,Paid in addition when billed with ER services.
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Aetna,Commercial,,1101.00,,,,,,,760.10,2893.96,per diem,Paid in addition when billed with ER services.
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Aetna,Commercial,,1101.00,,,,,,,343.59,3525.98,per diem,Paid in addition when billed with ER services.
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Aetna,Commercial,,1101.00,,,,,,,343.59,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Aetna,Commercial,,1101.00,,,,,,,343.59,3252.52,per diem,Paid in addition when billed with ER services.
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Aetna,Commercial,,1101.00,,,,,,,743.14,2917.94,per diem,Paid in addition when billed with ER services.
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Aetna,Commercial,,1101.00,,,,,,,343.59,3522.51,per diem,Paid in addition when billed with ER services.
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Aetna,Commercial,,1101.00,,,,,,,343.59,2876.72,per diem,Paid in addition when billed with ER services.
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Aetna,Commercial,,1101.00,,,,,,,343.59,3192.74,per diem,Paid in addition when billed with ER services.
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Aetna,Commercial,,1101.00,,,,,,,343.59,2972.99,per diem,Paid in addition when billed with ER services.
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Aetna,Commercial,,1101.00,,,,,,,84.71,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Commercial,,1101.00,,,,,,,50.65,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Aetna,Commercial,52,1101.00,,,,,,,791.19,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Aetna,Commercial,52,1101.00,,,,,,,787.39,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Aetna,Commercial,,1101.00,,,,,,,343.59,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Aetna,Commercial,,1101.00,,,,,,,343.59,3169.56,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Aetna,Commercial,,1101.00,,,,,,,343.59,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Aetna,Commercial,,1101.00,,,,,,,343.59,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Aetna,Commercial,,1101.00,,,,,,,343.59,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Aetna,Commercial,,1101.00,,,,,,,343.59,3113.44,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Aetna,Commercial,,1101.00,,,,,,,343.59,2996.32,per diem,Paid in addition when billed with ER services.
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Aetna,Commercial,,1101.00,,,,,,,343.59,3326.94,per diem,Paid in addition when billed with ER services.
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Aetna,Commercial,,1101.00,,,,,,,343.59,2828.57,per diem,Paid in addition when billed with ER services.
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Aetna,Commercial,,1101.00,,,,,,,343.59,3407.46,per diem,Paid in addition when billed with ER services.
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Aetna,Commercial,,1101.00,,,,,,,343.59,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Aetna,Commercial,,1101.00,,,,,,,343.59,3981.96,per diem,Paid in addition when billed with ER services.
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Aetna,Commercial,,1101.00,,,,,,,343.59,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Aetna,Commercial,,1101.00,,,,,,,343.59,4009.45,per diem,Paid in addition when billed with ER services.
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Aetna,Commercial,,1101.00,,,,,,,845.85,3021.02,per diem,Paid in addition when billed with ER services.
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Aetna,Commercial,,1101.00,,,,,,,647.85,3021.02,per diem,Paid in addition when billed with ER services.
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Aetna,Commercial,,1101.00,,,,,,,895.29,3021.02,per diem,Paid in addition when billed with ER services.
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Aetna,Commercial,,1101.00,,,,,,,848.45,3010.70,per diem,Paid in addition when billed with ER services.
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Aetna,Commercial,,1101.00,,,,,,,848.45,3010.70,per diem,Paid in addition when billed with ER services.
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Aetna,Commercial,,1101.00,,,,,,,848.45,3010.70,per diem,Paid in addition when billed with ER services.
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Aetna,Commercial,,1101.00,,,,,,,707.71,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Aetna,Commercial,,1101.00,,,,,,,814.41,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Aetna,Commercial,,1101.00,,,,,,,814.41,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Aetna,Commercial,,1101.00,,,,,,,899.50,3027.91,per diem,Paid in addition when billed with ER services.
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Aetna,Commercial,,1101.00,,,,,,,650.65,3027.91,per diem,Paid in addition when billed with ER services.
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Aetna,Commercial,,1101.00,,,,,,,919.72,3027.91,per diem,Paid in addition when billed with ER services.
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Aetna,Commercial,,1101.00,,,,,,,894.09,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Aetna,Commercial,,1101.00,,,,,,,845.44,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Aetna,Commercial,,1101.00,,,,,,,845.44,2825.00,per diem,Paid in addition when billed with ER services.
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Aetna,Commercial,,1101.00,,,,,,,908.91,3048.50,per diem,Paid in addition when billed with ER services.
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Aetna,Commercial,,1101.00,,,,,,,908.91,3048.50,per diem,Paid in addition when billed with ER services.
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Aetna,Commercial,,1101.00,,,,,,,908.91,3048.50,per diem,Paid in addition when billed with ER services.
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Aetna,Commercial,,1101.00,,,,,,,206.81,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Aetna,Commercial,,1101.00,,,,,,,232.56,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Aetna,Commercial,,1101.00,,,,,,,791.19,2825.00,per diem,Paid in addition when billed with ER services.
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Aetna,Commercial,,1101.00,,,,,,,375.38,2825.00,per diem,Paid in addition when billed with ER services.
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Aetna,Commercial,,319.50,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Commercial,,243.00,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Commercial,,299.25,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,inpatient,,,1745.00000,1047.00000,Aetna,Commercial,,7039.00,,,,,,,1116.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Aetna,Commercial,,4311.00,,,,,,,349.35,4311.00,case rate,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Aetna,Commercial,,4311.00,,,,,,,328.93,4311.00,case rate,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Commercial,,118.50,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,inpatient,,,1831.00000,1098.60000,Aetna,Commercial,,7039.00,,,,,,,1171.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Aetna,Commercial,,4311.00,,,,,,,366.57,4311.00,case rate,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Aetna,Commercial,,4311.00,,,,,,,345.14,4311.00,case rate,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Aetna,Commercial,,678.75,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Aetna,Commercial,,405.00,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Commercial,,356.25,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Commercial,,356.25,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Aetna,Commercial,,974.25,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Commercial,,777.75,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Aetna,Commercial,,635.25,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Aetna,Commercial,,462.00,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Aetna,Commercial,,449.25,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Commercial,,219.00,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Aetna,Commercial,,323.25,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Commercial,,237.75,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Commercial,,216.00,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Aetna,Commercial,,510.00,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Aetna,Commercial,,210.75,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Commercial,,436.50,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Commercial,,436.50,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Aetna,Commercial,,1077.00,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Aetna,Commercial,,564.00,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Aetna,Commercial,,1399.50,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Aetna,Commercial,,3262.50,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Aetna,Commercial,,189.00,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Aetna,Commercial,,132.75,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Aetna,Commercial,,276.75,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Aetna,Commercial,,137.25,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Aetna,Commercial,,320.25,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Aetna,Commercial,,246.75,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Commercial,,206.25,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Commercial,,299.25,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Aetna,Commercial,,473.25,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Commercial,,388.50,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Aetna,Commercial,,655.50,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Aetna,Commercial,,421.50,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Commercial,,42.75,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Aetna,Commercial,,271.50,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Aetna,Commercial,,567.00,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Aetna,Commercial,,228.75,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Aetna,Commercial,,498.75,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Commercial,,316.50,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Aetna,Commercial,,717.00,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Aetna,Commercial,,449.25,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Commercial,,316.50,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Commercial,,343.50,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Aetna,Commercial,,273.00,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Aetna,Commercial,,1893.00,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Aetna,Commercial,,1626.75,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Aetna,Commercial,,829.50,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Aetna,Commercial,,390.75,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Aetna,Commercial,,414.75,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Aetna,Commercial,,252.00,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Commercial,,96.00,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Aetna,Commercial,,384.00,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Aetna,Commercial,,303.00,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Aetna,Commercial,,303.00,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Aetna,Commercial,,1803.00,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Commercial,,35.25,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Aetna,Commercial,,10.50,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Aetna,Commercial,,84.00,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Commercial,,122.25,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Commercial,,99.00,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Commercial,,19.50,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Aetna,Commercial,,33.00,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Commercial,,141.75,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Aetna,Commercial,,198.75,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00750,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Aetna,Commercial,,66.00,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Commercial,,189.75,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Commercial,,141.75,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Aetna,Commercial,,297.75,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Aetna,Commercial,,116.25,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Commercial,,69.75,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Commercial,,401.25,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,68.25,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,68.25,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Commercial,,53.25,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Commercial,,99.75,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Commercial,,99.75,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Commercial,,99.75,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Commercial,,21.75,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Commercial,,54.00,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Aetna,Commercial,,132.75,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Aetna,Commercial,,93.00,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Commercial,,29.25,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Commercial,,108.75,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Commercial,,108.75,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Commercial,,108.75,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,67.50,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,67.50,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,67.50,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Aetna,Commercial,,115.50,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Commercial,,21.75,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Commercial,,32.25,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Commercial,,31.50,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,141.00,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Commercial,,36.00,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Commercial,,121.50,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Commercial,,86.25,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Commercial,,86.25,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Commercial,,86.25,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Commercial,,75.00,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Commercial,,31.50,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Commercial,,69.75,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Aetna,Commercial,,45.00,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Commercial,,30.00,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Commercial,,30.00,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Aetna,Commercial,,124.50,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,,66.75,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,,66.75,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Commercial,,49.50,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Aetna,Commercial,,39.75,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Aetna,Commercial,,193.50,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Commercial,,49.50,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Aetna,Commercial,,182.25,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,67.50,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,67.50,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Commercial,,135.00,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Commercial,,69.75,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Aetna,Commercial,,109.50,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Commercial,,59.25,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Commercial,,29.25,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Aetna,Commercial,,224.25,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Aetna,Commercial,,4.50,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Commercial,,69.75,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Commercial,,150.75,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Aetna,Commercial,,434.25,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Commercial,,117.75,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Commercial,,91.50,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Commercial,,91.50,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Commercial,,91.50,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Commercial,,91.50,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Commercial,,29.25,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,141.00,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Commercial,,152.25,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Commercial,,152.25,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Commercial,,152.25,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Commercial,,152.25,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Commercial,,22.50,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,82.50,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,82.50,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,82.50,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Commercial,,53.25,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Aetna,Commercial,,128.25,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Commercial,,121.50,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Aetna,Commercial,,58.50,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Aetna,Commercial,,178.50,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Commercial,,117.00,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Commercial,,69.75,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Aetna,Commercial,,165.75,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Commercial,,90.00,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Commercial,,114.00,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Commercial,,35.25,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Commercial,,35.25,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Aetna,Commercial,,17.25,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Aetna,Commercial,,147.75,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Commercial,,99.00,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Commercial,,30.00,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Commercial,,63.00,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Commercial,,28.50,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Commercial,,60.00,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Commercial,,60.00,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Commercial,,31.50,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Commercial,,118.50,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Commercial,,118.50,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Aetna,Commercial,,111.75,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Commercial,,54.00,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Commercial,,28.50,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Commercial,,75.00,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Commercial,,107.25,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Aetna,Commercial,,62.25,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Commercial,,107.25,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Aetna,Commercial,,132.75,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Commercial,,19.50,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Commercial,,19.50,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Commercial,,19.50,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,43.50,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Commercial,,80.25,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Aetna,Commercial,,1.50,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Aetna,Commercial,,246.75,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Commercial,,41.25,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Aetna,Commercial,,109.50,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Aetna,Commercial,,170.25,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Commercial,,161.25,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Commercial,,161.25,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Commercial,,33.75,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Aetna,Commercial,,39.75,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Commercial,,75.00,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Commercial,,37.50,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Commercial,,49.50,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Commercial,,33.75,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Commercial,,24.00,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Commercial,,24.00,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Commercial,,32.25,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Commercial,,11.25,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Aetna,Commercial,,125.25,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Commercial,,33.75,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Aetna,Commercial,,120.00,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Aetna,Commercial,,142.50,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Commercial,,54.00,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Commercial,,49.50,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Commercial,,100.50,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Commercial,,97.50,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Aetna,Commercial,,81.00,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Commercial,,28.50,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Commercial,,86.25,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Commercial,,86.25,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Commercial,,97.50,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Aetna,Commercial,,144.75,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Commercial,,59.25,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Commercial,,9.00,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Commercial,,278.25,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Commercial,,278.25,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Aetna,Commercial,,168.75,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Commercial,,24.00,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Commercial,,105.00,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Commercial,,84.75,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Commercial,,72.75,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Aetna,Commercial,,102.75,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Commercial,,90.00,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Aetna,Commercial,,6.00,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Aetna,Commercial,,16.50,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Commercial,,79.50,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Aetna,Commercial,,130.50,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Commercial,,27.75,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Commercial,,96.00,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Aetna,Commercial,,200.25,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Aetna,Commercial,,110.25,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Commercial,,204.75,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Aetna,Commercial,,155.25,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Commercial,,37.50,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Aetna,Commercial,,177.75,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,141.00,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Aetna,Commercial,,154.50,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Aetna,Commercial,,30.75,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Aetna,Commercial,,219.75,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Commercial,,150.75,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Commercial,,34.50,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Commercial,,84.75,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Commercial,,84.75,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Commercial,,37.50,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Commercial,,101.25,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Aetna,Commercial,,167.25,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Aetna,Commercial,,15.75,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,42.00,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Commercial,,42.75,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Commercial,,108.75,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Aetna,Commercial,,51.00,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,,87.75,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Aetna,Commercial,,129.75,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Commercial,,72.75,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Commercial,,87.00,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Commercial,,87.00,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Commercial,,11.25,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,,66.75,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,,66.75,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Commercial,,26.25,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Commercial,,33.75,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Aetna,Commercial,,51.75,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Aetna,Commercial,,345.75,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Commercial,,91.50,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Commercial,,54.00,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Commercial,,146.25,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Aetna,Commercial,,62.25,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Aetna,Commercial,,8.25,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Commercial,,26.25,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Commercial,,101.25,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Aetna,Commercial,,81.00,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,42.00,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Aetna,Commercial,,595.50,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Aetna,Commercial,,335.25,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Aetna,Commercial,,199.50,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Aetna,Commercial,,427.50,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Aetna,Commercial,,630.75,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,,123.75,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Aetna,Commercial,,222.00,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Aetna,Commercial,,270.75,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Commercial,,63.75,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Commercial,,63.75,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Commercial,,63.75,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Aetna,Commercial,,174.75,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Commercial,,108.75,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Commercial,,92.25,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Commercial,,100.50,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Aetna,Commercial,,147.00,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Aetna,Commercial,,129.75,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Aetna,Commercial,,375.75,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Aetna,Commercial,,552.75,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Aetna,Commercial,,94.50,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Commercial,,104.25,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Commercial,,27.75,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Commercial,,112.50,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Commercial,,69.75,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Commercial,,121.50,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Aetna,Commercial,,324.75,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Aetna,Commercial,,324.75,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Aetna,Commercial,,242.25,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Commercial,,206.25,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Aetna,Commercial,,218.25,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Aetna,Commercial,,198.00,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Aetna,Commercial,,459.00,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Commercial,,120.75,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Aetna,Commercial,,177.75,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Aetna,Commercial,,149.25,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Commercial,,74.25,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Aetna,Commercial,,243.75,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Aetna,Commercial,,203.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Aetna,Commercial,,242.25,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Aetna,Commercial,,188.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Aetna,Commercial,,136.50,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Commercial,,139.50,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Commercial,,139.50,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Aetna,Commercial,,185.25,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Commercial,,54.00,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Aetna,Commercial,,33.00,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Commercial,,112.50,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Aetna,Commercial,,147.00,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Aetna,Commercial,,351.00,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Aetna,Commercial,,212.25,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Commercial,,26.25,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,42.00,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Commercial,,54.00,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Commercial,,84.75,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Aetna,Commercial,,267.00,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Aetna,Commercial,,109.50,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Commercial,,151.50,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Commercial,,107.25,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,,87.75,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Commercial,,87.75,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Commercial,,59.25,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Aetna,Commercial,,76.50,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,42.00,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Commercial,,63.75,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Aetna,Commercial,,73.50,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,42.00,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Aetna,Commercial,,168.00,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Commercial,,60.00,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Commercial,,29.25,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Aetna,Commercial,,14.25,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Commercial,,35.25,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Commercial,,11.25,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Aetna,Commercial,,30.75,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Commercial,,141.00,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Commercial,,91.50,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Commercial,,97.50,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Commercial,,53.25,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Commercial,,117.75,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Aetna,Commercial,,20.25,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Aetna,Commercial,,39.75,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Aetna,Commercial,,140.25,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Aetna,Commercial,,140.25,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Commercial,,72.75,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Commercial,,159.75,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Commercial,,153.00,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Commercial,,24.00,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Commercial,,153.00,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Commercial,,23.25,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Commercial,,52.50,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Commercial,,108.75,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Commercial,,69.00,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Commercial,,29.25,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Commercial,,22.50,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Commercial,,22.50,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Commercial,,19.50,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,,96.75,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Commercial,,87.00,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Commercial,,59.25,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,82.50,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Aetna,Commercial,,13.50,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Aetna,Commercial,,254.25,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Aetna,Commercial,,51.00,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Commercial,,63.00,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,,66.75,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Aetna,Commercial,,12.00,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Aetna,Commercial,,183.75,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Commercial,,63.00,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Aetna,Commercial,,115.50,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Commercial,,27.75,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Commercial,,74.25,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Aetna,Commercial,,58.50,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Commercial,,30.00,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Commercial,,42.75,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Commercial,,28.50,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Commercial,,47.25,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Commercial,,135.00,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Aetna,Commercial,,24.75,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Commercial,,28.50,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Aetna,Commercial,,171.00,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Aetna,Commercial,,126.75,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Aetna,Commercial,,345.75,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Commercial,,159.75,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Commercial,,159.75,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Commercial,,471.75,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Aetna,Commercial,,435.75,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Aetna,Commercial,,130.50,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Commercial,,120.75,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Commercial,,262.50,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Commercial,,159.00,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Commercial,,123.00,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Commercial,,123.00,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Commercial,,206.25,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Aetna,Commercial,,192.75,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Aetna,Commercial,,577.50,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Aetna,Commercial,,65.25,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Aetna,Commercial,,62.25,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Commercial,,36.00,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Aetna,Commercial,,84.00,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Aetna,Commercial,,434.25,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Aetna,Commercial,,209.25,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Commercial,,41.25,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Aetna,Commercial,,115.50,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Aetna,Commercial,,72.00,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Aetna,Commercial,,72.00,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Aetna,Commercial,,72.00,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Commercial,,347.25,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Commercial,,220.50,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Aetna,Commercial,,66.00,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Aetna,Commercial,,66.00,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Commercial,,38.25,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Aetna,Commercial,,94.50,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Commercial,,9.00,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Commercial,,112.50,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Commercial,,90.00,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Aetna,Commercial,,411.00,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Aetna,Commercial,,231.75,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Commercial,,95.25,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Commercial,,27.00,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Aetna,Commercial,,16.50,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Aetna,Commercial,,172.50,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Commercial,,21.75,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Aetna,Commercial,,13.50,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Commercial,,79.50,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Commercial,,43.50,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Commercial,,26.25,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Commercial,,26.25,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Aetna,Commercial,,14.25,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Commercial,,45.75,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Aetna,Commercial,,48.00,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Commercial,,34.50,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Commercial,,42.00,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Commercial,,53.25,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Commercial,,11.25,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Commercial,,22.50,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Commercial,,189.75,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Commercial,,100.50,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Aetna,Commercial,,128.25,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Commercial,,19.50,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Commercial,,121.50,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Commercial,,59.25,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Commercial,,21.75,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00750,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Aetna,Commercial,,310.50,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Aetna,Commercial,,1.50,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Commercial,,388.50,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Commercial,,60.75,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Commercial,,21.75,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Commercial,,120.75,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Aetna,Commercial,,1470.00,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Aetna,Commercial,,105.75,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,,66.75,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Aetna,Commercial,,25.50,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Commercial,,28.50,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Commercial,,52.50,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Commercial,,52.50,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Commercial,,11.25,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Commercial,,26.25,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Commercial,,56.25,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Commercial,,36.75,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Aetna,Commercial,,396.75,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Aetna,Commercial,,575.25,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Commercial,,100.50,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Aetna,Commercial,,1353.75,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Aetna,Commercial,,943.50,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Aetna,Commercial,,219.75,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Commercial,,4311.00,,,,,,,4.18,4311.00,case rate,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Aetna,Commercial,,1448.25,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Aetna,Commercial,,17.25,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Aetna,Commercial,,194.25,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Commercial,,34.50,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Aetna,Commercial,,1356.00,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Aetna,Commercial,,530.25,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Commercial,,80.25,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Aetna,Commercial,,384.75,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Commercial,,141.75,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Aetna,Commercial,,1470.00,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Aetna,Commercial,,85.50,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Commercial,,243.00,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Aetna,Commercial,,145.50,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Aetna,Commercial,,714.75,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Aetna,Commercial,,479.25,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Commercial,,105.00,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Commercial,QW,105.00,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Commercial,,34.50,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Aetna,Commercial,,208.50,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Aetna,Commercial,,1191.75,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Aetna,Commercial,,890.25,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Aetna,Commercial,,208.50,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Aetna,Commercial,,456.75,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Aetna,Commercial,,358.50,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Commercial,,153.00,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Aetna,Commercial,,319.50,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Commercial,,37.50,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,82.50,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Commercial,QW,51.31,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Commercial,,75.00,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Commercial,,122.25,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Aetna,Commercial,,680.25,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Commercial,,206.25,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Commercial,,99.00,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,,123.75,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Commercial,,66.75,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Commercial,,32.25,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Aetna,Commercial,,210.00,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Commercial,,59.25,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Aetna,Commercial,,145.50,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,68.25,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Aetna,Commercial,,51.75,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Commercial,,49.50,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Commercial,,262.50,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Commercial,,101.25,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Commercial,,159.75,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Aetna,Commercial,,164.25,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Commercial,,101.25,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Commercial,,101.25,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Commercial,,206.25,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Commercial,,33.75,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Commercial,,33.75,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Aetna,Commercial,,57.00,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Commercial,,32.25,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Commercial,,63.00,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Commercial,,75.75,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Aetna,Commercial,,111.75,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Aetna,Commercial,,996.00,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Commercial,,41.25,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Aetna,Commercial,,81.00,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Commercial,,88.50,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Commercial,,48.75,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Commercial,,42.75,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Aetna,Commercial,,203.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Aetna,Commercial,,125.25,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Aetna,Commercial,,203.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Aetna,Commercial,,239.25,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,inpatient,,,515.00000,309.00000,Aetna,Commercial,,7039.00,,,,,,,329.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Commercial,,,75.00,,,,,0,8.36,356.33,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Aetna,Commercial,,394.50,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Aetna,Commercial,,157.50,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00750,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Aetna,Commercial,,20.25,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Commercial,,82.50,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Commercial,,139.50,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Aetna,Commercial,,110.25,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Aetna,Commercial,,110.25,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Commercial,,29.25,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Aetna,Commercial,,148.50,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Aetna,Commercial,,89.25,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Aetna,Commercial,,191.25,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Aetna,Commercial,,195.75,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Aetna,Commercial,,58.50,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Commercial,,102.00,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Aetna,Commercial,,156.75,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Aetna,Commercial,,155.25,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Commercial,,388.50,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Aetna,Commercial,,111.00,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Aetna,Commercial,,342.00,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Aetna,Commercial,,447.75,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Aetna,Commercial,,566.25,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Aetna,Commercial,,420.75,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Aetna,Commercial,,243.75,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Aetna,Commercial,,168.75,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Aetna,Commercial,,764.25,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Aetna,Commercial,,265.50,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Aetna,Commercial,,456.75,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Aetna,Commercial,,168.00,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Commercial,,60.00,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Commercial,,99.00,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Commercial,,101.25,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Aetna,Commercial,,411.00,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Aetna,Commercial,,76.50,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Aetna,Commercial,,131.25,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Aetna,Commercial,,275.25,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Commercial,,495.00,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Commercial,,0.00750,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Aetna,Commercial,,93.00,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Aetna,Commercial,,169.50,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Aetna,Commercial,,277.50,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Aetna,Commercial,,239.25,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Aetna,Commercial,,239.25,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Aetna,Commercial,,444.75,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Aetna,Commercial,,411.00,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Commercial,,72.75,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,,96.75,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Aetna,Commercial,,295.50,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Aetna,Commercial,,234.75,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Aetna,Commercial,,186.75,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Commercial,,57.75,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Aetna,Commercial,,288.00,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Commercial,,99.00,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Aetna,Commercial,,506.25,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Commercial,,141.75,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Aetna,Commercial,,310.50,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Aetna,Commercial,,192.00,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Aetna,Commercial,,195.75,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Commercial,,117.75,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Commercial,,117.75,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Commercial,,404.25,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Commercial,,104.25,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Commercial,,123.00,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Aetna,Commercial,,13.50,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Aetna,Commercial,,310.50,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,68.25,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Aetna,Commercial,,185.25,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Aetna,Commercial,,1643.25,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Aetna,Commercial,,264.75,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Aetna,Commercial,,144.00,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Aetna,Commercial,,531.00,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Commercial,,388.50,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Aetna,Commercial,,265.50,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Commercial,,288.75,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Aetna,Commercial,,275.25,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Commercial,,288.75,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Commercial,,389.25,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Aetna,Commercial,,963.75,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Commercial,,60.00,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Commercial,,288.75,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Aetna,Commercial,,275.25,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Aetna,Commercial,,234.00,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Commercial,,96.75,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Aetna,Commercial,,932.25,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Commercial,,18.00,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Aetna,Commercial,,144.00,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Commercial,,60.00,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Aetna,Commercial,,681.00,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Commercial,,495.00,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Aetna,Commercial,,355.50,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Aetna,Commercial,,267.00,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Aetna,Commercial,,93.75,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Commercial,,112.50,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Commercial,,71.25,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Aetna,Commercial,,124.50,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Commercial,,60.00,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Aetna,Commercial,,119.25,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Aetna,Commercial,,1191.75,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Aetna,Commercial,,598.50,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Aetna,Commercial,,244.50,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Commercial,,49.50,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Commercial,,31.50,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Aetna,Commercial,,78.75,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Aetna,Commercial,,186.00,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Aetna,Commercial,,225.00,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Aetna,Commercial,,225.00,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Aetna,Commercial,,207.75,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Aetna,Commercial,,424.50,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,68.25,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,68.25,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Commercial,,42.75,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Aetna,Commercial,,509.25,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Aetna,Commercial,,488.25,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Commercial,,780.75,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Aetna,Commercial,,802.50,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Commercial,,161.25,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Aetna,Commercial,,314.25,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Commercial,,220.50,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Aetna,Commercial,,711.75,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Aetna,Commercial,,930.00,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Aetna,Commercial,,450.00,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Commercial,,68.25,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Aetna,Commercial,,1146.00,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Commercial,,21.00,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,,123.75,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,,123.75,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Commercial,,123.75,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Commercial,,44.25,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Commercial,,780.75,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Commercial,,780.75,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Commercial,,870.00,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Commercial,,46.50,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,inpatient,,,2616.00000,1569.60000,Aetna,Commercial,,7039.00,,,,,,,1674.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Aetna,Commercial,,,75.00,,,,,0,523.72,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,inpatient,,,8570.00000,5142.00000,Aetna,Commercial,,7039.00,,,,,,,5484.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Commercial,,4376.00,,,,,,,1715.71,8045.00,case rate,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,inpatient,,,8570.00000,5142.00000,Aetna,Commercial,,7039.00,,,,,,,5484.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Commercial,,4376.00,,,,,,,1715.71,9423.00,case rate,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,inpatient,,,8570.00000,5142.00000,Aetna,Commercial,,7039.00,,,,,,,5484.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Commercial,,4376.00,,,,,,,1715.71,13852.00,case rate,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,inpatient,,,8570.00000,5142.00000,Aetna,Commercial,,7039.00,,,,,,,5484.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Commercial,,4376.00,,,,,,,1715.71,8045.00,case rate,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,inpatient,,,8570.00000,5142.00000,Aetna,Commercial,,7039.00,,,,,,,5484.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Commercial,,4376.00,,,,,,,1715.71,9423.00,case rate,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,inpatient,,,35477.00000,21286.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,28736.37,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Aetna,Commercial,,,75.00,,,,,0,150.52,21640.97,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,inpatient,,,6012.00000,3607.20000,Aetna,Commercial,,7039.00,,,,,,,3847.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Aetna,Commercial,,,75.00,,,,,0,150.52,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,inpatient,,,2474.00000,1484.40000,Aetna,Commercial,,7039.00,,,,,,,1583.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Commercial,,8442.00,,,,,,,495.29,13852.00,case rate,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,inpatient,,,2474.00000,1484.40000,Aetna,Commercial,,7039.00,,,,,,,1583.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Commercial,,8442.00,,,,,,,495.29,13852.00,case rate,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,inpatient,,,6715.00000,4029.00000,Aetna,Commercial,,7039.00,,,,,,,4297.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Aetna,Commercial,,,75.00,,,,,0,1344.34,52940.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,inpatient,,,2043.00000,1225.80000,Aetna,Commercial,,7039.00,,,,,,,1307.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Aetna,Commercial,,4311.00,,,,,,,409.01,52940.00,case rate,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,inpatient,,,3368.00000,2020.80000,Aetna,Commercial,,7039.00,,,,,,,2155.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Aetna,Commercial,,,75.00,,,,,0,674.27,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,inpatient,,,909.00000,545.40000,Aetna,Commercial,,7039.00,,,,,,,581.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Aetna,Commercial,,,75.00,,,,,0,181.98,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,inpatient,,,909.00000,545.40000,Aetna,Commercial,,7039.00,,,,,,,581.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Aetna,Commercial,,,75.00,,,,,0,181.98,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,inpatient,,,1981.00000,1188.60000,Aetna,Commercial,,7039.00,,,,,,,1267.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,inpatient,,,1981.00000,1188.60000,Aetna,Commercial,,7039.00,,,,,,,1267.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,inpatient,,,4166.00000,2499.60000,Aetna,Commercial,,7039.00,,,,,,,2666.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,inpatient,,,4166.00000,2499.60000,Aetna,Commercial,,7039.00,,,,,,,2666.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,inpatient,,,1896.00000,1137.60000,Aetna,Commercial,,7039.00,,,,,,,1213.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,4311.00,case rate,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,inpatient,,,1896.00000,1137.60000,Aetna,Commercial,,7039.00,,,,,,,1213.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,inpatient,,,447.00000,268.20000,Aetna,Commercial,,7039.00,,,,,,,286.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Aetna,Commercial,,4311.00,,,,,,,89.49,4311.00,case rate,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,inpatient,,,823.00000,493.80000,Aetna,Commercial,,7039.00,,,,,,,526.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Aetna,Commercial,,4311.00,,,,,,,164.76,9423.00,case rate,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,inpatient,,,1794.00000,1076.40000,Aetna,Commercial,,7039.00,,,,,,,1148.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,inpatient,,,1794.00000,1076.40000,Aetna,Commercial,,7039.00,,,,,,,1148.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,inpatient,,,1416.00000,849.60000,Aetna,Commercial,,7039.00,,,,,,,906.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,inpatient,,,1416.00000,849.60000,Aetna,Commercial,,7039.00,,,,,,,906.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,inpatient,,,1586.00000,951.60000,Aetna,Commercial,,7039.00,,,,,,,1015.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,inpatient,,,1586.00000,951.60000,Aetna,Commercial,,7039.00,,,,,,,1015.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,inpatient,,,1416.00000,849.60000,Aetna,Commercial,,7039.00,,,,,,,906.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,4376.00,case rate,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,inpatient,,,1416.00000,849.60000,Aetna,Commercial,,7039.00,,,,,,,906.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Commercial,,4376.00,,,,,,,173.00,9423.00,case rate,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,inpatient,,,7717.00000,4630.20000,Aetna,Commercial,,7039.00,,,,,,,4938.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Aetna,Commercial,,4376.00,,,,,,,1544.94,9423.00,case rate,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,inpatient,,,3858.00000,2314.80000,Aetna,Commercial,,7039.00,,,,,,,2469.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Aetna,Commercial,,4376.00,,,,,,,772.37,8045.00,case rate,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,inpatient,,,3858.00000,2314.80000,Aetna,Commercial,,7039.00,,,,,,,2469.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Aetna,Commercial,,4376.00,,,,,,,772.37,9423.00,case rate,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,inpatient,,,7166.00000,4299.60000,Aetna,Commercial,,7039.00,,,,,,,4586.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Aetna,Commercial,,4376.00,,,,,,,1434.63,13852.00,case rate,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,inpatient,,,7166.00000,4299.60000,Aetna,Commercial,,7039.00,,,,,,,4586.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Aetna,Commercial,,4376.00,,,,,,,1434.63,13852.00,case rate,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,inpatient,,,5512.00000,3307.20000,Aetna,Commercial,,7039.00,,,,,,,3527.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Commercial,,6735.00,,,,,,,1103.50,13852.00,case rate,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,inpatient,,,5512.00000,3307.20000,Aetna,Commercial,,7039.00,,,,,,,3527.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Commercial,,6735.00,,,,,,,1103.50,13852.00,case rate,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,inpatient,,,1378.00000,826.80000,Aetna,Commercial,,7039.00,,,,,,,881.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Aetna,Commercial,,4376.00,,,,,,,275.88,8045.00,case rate,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,inpatient,,,1378.00000,826.80000,Aetna,Commercial,,7039.00,,,,,,,881.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Aetna,Commercial,,4376.00,,,,,,,275.88,9423.00,case rate,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,inpatient,,,5512.00000,3307.20000,Aetna,Commercial,,7039.00,,,,,,,3527.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Commercial,,6735.00,,,,,,,1103.50,13852.00,case rate,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,inpatient,,,5512.00000,3307.20000,Aetna,Commercial,,7039.00,,,,,,,3527.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Commercial,,6735.00,,,,,,,1103.50,13852.00,case rate,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,inpatient,,,2659.00000,1595.40000,Aetna,Commercial,,7039.00,,,,,,,1701.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,inpatient,,,8570.00000,5142.00000,Aetna,Commercial,,7039.00,,,,,,,5484.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Commercial,,4376.00,,,,,,,1715.71,8045.00,case rate,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,inpatient,,,8570.00000,5142.00000,Aetna,Commercial,,7039.00,,,,,,,5484.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Commercial,,4376.00,,,,,,,1715.71,9423.00,case rate,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,inpatient,,,794.00000,476.40000,Aetna,Commercial,,7039.00,,,,,,,508.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Aetna,Commercial,,4311.00,,,,,,,158.96,4311.00,case rate,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,inpatient,,,29057.00000,17434.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,23536.17,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Aetna,Commercial,,6735.00,,,,,,,5817.21,24600.00,case rate,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,inpatient,,,4394.00000,2636.40000,Aetna,Commercial,,7039.00,,,,,,,2812.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Aetna,Commercial,,4311.00,,,,,,,879.68,8213.00,case rate,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,inpatient,,,4394.00000,2636.40000,Aetna,Commercial,,7039.00,,,,,,,2812.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Aetna,Commercial,,4311.00,,,,,,,879.68,9423.00,case rate,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,inpatient,,,439.00000,263.40000,Aetna,Commercial,,7039.00,,,,,,,280.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,6735.00,,,,,,,87.89,17457.00,case rate,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,inpatient,,,439.00000,263.40000,Aetna,Commercial,,7039.00,,,,,,,280.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,6735.00,,,,,,,87.89,9423.00,case rate,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,inpatient,,,439.00000,263.40000,Aetna,Commercial,,7039.00,,,,,,,280.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,6735.00,,,,,,,87.89,17457.00,case rate,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,inpatient,,,439.00000,263.40000,Aetna,Commercial,,7039.00,,,,,,,280.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Commercial,,6735.00,,,,,,,87.89,9423.00,case rate,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,inpatient,,,2257.00000,1354.20000,Aetna,Commercial,,7039.00,,,,,,,1444.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Commercial,,6735.00,,,,,,,451.85,6735.00,case rate,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,inpatient,,,2257.00000,1354.20000,Aetna,Commercial,,7039.00,,,,,,,1444.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Commercial,,6735.00,,,,,,,451.85,9423.00,case rate,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,inpatient,,,2257.00000,1354.20000,Aetna,Commercial,,7039.00,,,,,,,1444.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Commercial,,6735.00,,,,,,,451.85,6735.00,case rate,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,inpatient,,,2257.00000,1354.20000,Aetna,Commercial,,7039.00,,,,,,,1444.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Commercial,,6735.00,,,,,,,451.85,9423.00,case rate,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,inpatient,,,16729.00000,10037.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,13550.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Aetna,Commercial,,8442.00,,,,,,,3349.15,13852.00,case rate,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,inpatient,,,16729.00000,10037.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,13550.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Aetna,Commercial,,8442.00,,,,,,,3349.15,13852.00,case rate,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,inpatient,,,27882.00000,16729.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,22584.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Aetna,Commercial,,8442.00,,,,,,,5581.98,24600.00,case rate,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,inpatient,,,27882.00000,16729.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,22584.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Aetna,Commercial,,8442.00,,,,,,,5581.98,24600.00,case rate,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,inpatient,,,10037.00000,6022.20000,Aetna,Commercial,,7039.00,,,,,,,6423.68,8129.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Aetna,Commercial,,4311.00,,,,,,,2009.41,13852.00,case rate,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,inpatient,,,10037.00000,6022.20000,Aetna,Commercial,,7039.00,,,,,,,6423.68,8129.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Aetna,Commercial,,4311.00,,,,,,,2009.41,13852.00,case rate,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,inpatient,,,23142.00000,13885.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18745.02,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Aetna,Commercial,,4311.00,,,,,,,4311.00,16011.95,case rate,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,inpatient,,,23142.00000,13885.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18745.02,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Aetna,Commercial,,4311.00,,,,,,,4311.00,14116.62,case rate,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,inpatient,,,9307.00000,5584.20000,Aetna,Commercial,,7039.00,,,,,,,5956.48,7538.67,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Aetna,Commercial,,8442.00,,,,,,,1863.26,13852.00,case rate,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,inpatient,,,9307.00000,5584.20000,Aetna,Commercial,,7039.00,,,,,,,5956.48,7538.67,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Aetna,Commercial,,8442.00,,,,,,,1863.26,13852.00,case rate,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,inpatient,,,23479.00000,14087.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19017.99,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Aetna,Commercial,,8442.00,,,,,,,4700.50,24600.00,case rate,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,inpatient,,,23479.00000,14087.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19017.99,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Aetna,Commercial,,8442.00,,,,,,,4700.50,24600.00,case rate,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,inpatient,,,21152.00000,12691.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,17133.12,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Aetna,Commercial,,8442.00,,,,,,,4234.63,24600.00,case rate,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,inpatient,,,21152.00000,12691.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,17133.12,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Aetna,Commercial,,8442.00,,,,,,,4234.63,24600.00,case rate,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,inpatient,,,28133.00000,16879.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,22787.73,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Aetna,Commercial,,8442.00,,,,,,,5632.23,52940.00,case rate,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,inpatient,,,28133.00000,16879.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,22787.73,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Aetna,Commercial,,8442.00,,,,,,,5632.23,52940.00,case rate,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,inpatient,,,12328.00000,7396.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9985.68,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Aetna,Commercial,,8442.00,,,,,,,2468.07,13852.00,case rate,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,inpatient,,,23300.00000,13980.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18873.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Aetna,Commercial,,8442.00,,,,,,,4664.66,24600.00,case rate,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,inpatient,,,23300.00000,13980.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18873.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Aetna,Commercial,,8442.00,,,,,,,4664.66,24600.00,case rate,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,inpatient,,,21204.00000,12722.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,17175.24,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Aetna,Commercial,,8442.00,,,,,,,4245.04,24600.00,case rate,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,inpatient,,,21204.00000,12722.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,17175.24,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Aetna,Commercial,,8442.00,,,,,,,4245.04,24600.00,case rate,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,inpatient,,,24040.00000,14424.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19472.40,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Aetna,Commercial,,8442.00,,,,,,,4812.81,52940.00,case rate,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,inpatient,,,24040.00000,14424.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19472.40,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Aetna,Commercial,,8442.00,,,,,,,4812.81,52940.00,case rate,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,inpatient,,,9493.00000,5695.80000,Aetna,Commercial,,7039.00,,,,,,,6075.52,7689.33,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Aetna,Commercial,,4311.00,,,,,,,1900.50,13852.00,case rate,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,inpatient,,,9493.00000,5695.80000,Aetna,Commercial,,7039.00,,,,,,,6075.52,7689.33,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Aetna,Commercial,,4311.00,,,,,,,1900.50,13852.00,case rate,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,inpatient,,,20464.00000,12278.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16575.84,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Aetna,Commercial,,4311.00,,,,,,,4096.89,24600.00,case rate,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,inpatient,,,20464.00000,12278.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16575.84,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Aetna,Commercial,,4311.00,,,,,,,4096.89,24600.00,case rate,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,inpatient,,,17629.00000,10577.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,14279.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Aetna,Commercial,,4311.00,,,,,,,3529.33,13852.00,case rate,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,inpatient,,,17629.00000,10577.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,14279.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Aetna,Commercial,,4311.00,,,,,,,3529.33,13852.00,case rate,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,inpatient,,,20588.00000,12352.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16676.28,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Aetna,Commercial,,4311.00,,,,,,,4121.72,14244.84,case rate,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,13121.19,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Commercial,LM,12247.00,,,,,,,3243.04,27871.00,case rate,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,13121.19,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Commercial,RI,12247.00,,,,,,,3243.04,27871.00,case rate,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,13121.19,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Commercial,RC,12247.00,,,,,,,3243.04,27871.00,case rate,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,13121.19,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Commercial,LD,12247.00,,,,,,,3243.04,27871.00,case rate,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,13121.19,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Commercial,LC,12247.00,,,,,,,3243.04,27871.00,case rate,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,Aetna,Commercial,LC,7039.00,,,,,,,5348.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Commercial,LC,4311.00,,,,,,,1673.07,27871.00,case rate,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,Aetna,Commercial,RI,7039.00,,,,,,,5348.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Commercial,RI,4311.00,,,,,,,1673.07,27871.00,case rate,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,Aetna,Commercial,RC,7039.00,,,,,,,5348.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Commercial,RC,4311.00,,,,,,,1673.07,27871.00,case rate,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,Aetna,Commercial,LD,7039.00,,,,,,,5348.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Commercial,LD,4311.00,,,,,,,1673.07,27871.00,case rate,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,Aetna,Commercial,LC,7039.00,,,,,,,5348.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Commercial,LC,4311.00,,,,,,,1673.07,27871.00,case rate,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,LM,12247.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,RI,12247.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,RC,12247.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,LD,12247.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,LC,12247.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,LM,4311.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,RI,4311.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,RC,4311.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,LD,4311.00,,,,,,,2874.47,27871.00,case rate,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,11629.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Commercial,LC,4311.00,,,,,,,2874.47,27871.00,case rate,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,LM,9503.00,,,,,,,4290.29,27871.00,case rate,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,RI,9503.00,,,,,,,4290.29,27871.00,case rate,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,RC,9503.00,,,,,,,4290.29,27871.00,case rate,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,LD,9503.00,,,,,,,4290.29,27871.00,case rate,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,LC,9503.00,,,,,,,4290.29,27871.00,case rate,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,LM,9503.00,,,,,,,4290.29,27871.00,case rate,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,RI,9503.00,,,,,,,4290.29,27871.00,case rate,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,RC,9503.00,,,,,,,4290.29,27871.00,case rate,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,LD,9503.00,,,,,,,4290.29,27871.00,case rate,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,17358.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Commercial,LC,9503.00,,,,,,,4290.29,27871.00,case rate,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,LM,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,RI,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,RC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,LD,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,LC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,RC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,LD,4311.00,,,,,,,4311.00,27871.00,case rate,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,18399.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Commercial,LC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LM,9503.00,,,,,,,8108.50,27871.00,case rate,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,RI,9503.00,,,,,,,8108.50,27871.00,case rate,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,9503.00,,,,,,,8108.50,27871.00,case rate,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,9503.00,,,,,,,8108.50,27871.00,case rate,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,9503.00,,,,,,,8108.50,27871.00,case rate,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LM,9503.00,,,,,,,8108.50,27871.00,case rate,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,RI,9503.00,,,,,,,8108.50,27871.00,case rate,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,9503.00,,,,,,,8108.50,27871.00,case rate,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,9503.00,,,,,,,8108.50,27871.00,case rate,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,9503.00,,,,,,,8108.50,27871.00,case rate,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LM,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,RI,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,RC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LD,4311.00,,,,,,,4311.00,27871.00,case rate,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,32806.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Commercial,LC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,inpatient,,,23143.00000,13885.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18745.83,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Aetna,Commercial,,9503.00,,,,,,,4633.23,27871.00,case rate,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,inpatient,,,23143.00000,13885.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18745.83,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Aetna,Commercial,,9503.00,,,,,,,4633.23,27871.00,case rate,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,inpatient,,,23787.00000,14272.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19267.47,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Aetna,Commercial,,4311.00,,,,,,,4311.00,27871.00,case rate,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,inpatient,,,23787.00000,14272.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19267.47,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Aetna,Commercial,,4311.00,,,,,,,4311.00,27871.00,case rate,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,LM,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,RI,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,RC,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,LD,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,LC,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,LM,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,RI,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,RC,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,LD,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,20134.98,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Commercial,LC,,75.00,,,,,0,4976.57,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LM,9503.00,,,,,,,5191.19,27871.00,case rate,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,RI,9503.00,,,,,,,5191.19,27871.00,case rate,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,RC,9503.00,,,,,,,5191.19,27871.00,case rate,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LD,9503.00,,,,,,,5191.19,27871.00,case rate,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LC,9503.00,,,,,,,5191.19,27871.00,case rate,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LM,9503.00,,,,,,,5191.19,27871.00,case rate,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,RI,9503.00,,,,,,,5191.19,27871.00,case rate,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,RC,9503.00,,,,,,,5191.19,27871.00,case rate,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LD,9503.00,,,,,,,5191.19,27871.00,case rate,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LC,9503.00,,,,,,,5191.19,27871.00,case rate,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LM,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LM,4311.00,,,,,,,4311.00,27871.00,case rate,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,RI,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,RI,4311.00,,,,,,,4311.00,27871.00,case rate,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,RC,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,RC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LD,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LD,4311.00,,,,,,,4311.00,27871.00,case rate,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,Aetna,Commercial,LC,7039.00,,,,,,,7039.00,21003.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Commercial,LC,4311.00,,,,,,,4311.00,27871.00,case rate,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,inpatient,,,393.00000,235.80000,Aetna,Commercial,,7039.00,,,,,,,251.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Aetna,Commercial,,,75.00,,,,,0,78.68,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,inpatient,,,1664.00000,998.40000,Aetna,Commercial,,7039.00,,,,,,,1064.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Aetna,Commercial,,,75.00,,1247.33,1181.44,4156.05,38,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,inpatient,,,1865.00000,1119.00000,Aetna,Commercial,,7039.00,,,,,,,1193.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Commercial,,,75.00,,,,,0,373.37,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,inpatient,,,422.00000,253.20000,Aetna,Commercial,,7039.00,,,,,,,270.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Commercial,,,75.00,,,,,0,84.48,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,inpatient,,,2527.00000,1516.20000,Aetna,Commercial,,7039.00,,,,,,,1617.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Aetna,Commercial,,,75.00,,,,,0,505.91,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,inpatient,,,986.00000,591.60000,Aetna,Commercial,,7039.00,,,,,,,631.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,inpatient,,,11572.00000,6943.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9373.32,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Aetna,Commercial,,12247.00,,,,,,,2316.71,27871.00,case rate,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,inpatient,,,10706.00000,6423.60000,Aetna,Commercial,,7039.00,,,,,,,6851.84,8671.86,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Aetna,Commercial,,12247.00,,,,,,,2143.34,27871.00,case rate,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,inpatient,,,10706.00000,6423.60000,Aetna,Commercial,,7039.00,,,,,,,6851.84,8671.86,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Aetna,Commercial,,12247.00,,,,,,,2143.34,27871.00,case rate,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,inpatient,,,10210.00000,6126.00000,Aetna,Commercial,,7039.00,,,,,,,6534.40,8270.10,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Aetna,Commercial,,12247.00,,,,,,,2044.04,27871.00,case rate,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,inpatient,,,4250.00000,2550.00000,Aetna,Commercial,,7039.00,,,,,,,2720.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Aetna,Commercial,,,75.00,,,,,0,850.85,27871.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,inpatient,,,7367.00000,4420.20000,Aetna,Commercial,,7039.00,,,,,,,4714.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Aetna,Commercial,,4311.00,,,,,,,1474.87,10022.00,case rate,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,inpatient,,,10893.00000,6535.80000,Aetna,Commercial,,7039.00,,,,,,,6971.52,8823.33,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Aetna,Commercial,,12247.00,,,,,,,2180.78,12247.00,case rate,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,inpatient,,,9673.00000,5803.80000,Aetna,Commercial,,7039.00,,,,,,,6190.72,7835.13,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Aetna,Commercial,,12247.00,,,,,,,1936.53,12247.00,case rate,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,inpatient,,,10326.00000,6195.60000,Aetna,Commercial,,7039.00,,,,,,,6608.64,8364.06,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Aetna,Commercial,,12247.00,,,,,,,2067.27,12247.00,case rate,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,inpatient,,,4543.00000,2725.80000,Aetna,Commercial,,7039.00,,,,,,,2907.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Aetna,Commercial,,12247.00,,,,,,,909.51,12247.00,case rate,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,inpatient,,,10624.00000,6374.40000,Aetna,Commercial,,7039.00,,,,,,,6799.36,8605.44,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Aetna,Commercial,,12247.00,,,,,,,2126.92,12247.00,case rate,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,inpatient,,,13251.00000,7950.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10733.31,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Aetna,Commercial,,12247.00,,,,,,,2652.85,12247.00,case rate,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,inpatient,,,11937.00000,7162.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9668.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Aetna,Commercial,,12247.00,,,,,,,2389.79,12247.00,case rate,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,inpatient,,,12734.00000,7640.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10314.54,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Aetna,Commercial,,12247.00,,,,,,,2549.35,12247.00,case rate,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,inpatient,,,12950.00000,7770.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10489.50,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Aetna,Commercial,,12247.00,,,,,,,2592.59,12247.00,case rate,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,inpatient,,,15877.00000,9526.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12860.37,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Aetna,Commercial,,12247.00,,,,,,,3094.46,12247.00,case rate,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,inpatient,,,6778.00000,4066.80000,Aetna,Commercial,,7039.00,,,,,,,4337.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,inpatient,,,203.00000,121.80000,Aetna,Commercial,,7039.00,,,,,,,129.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Commercial,,,75.00,,,,,0,40.64,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,inpatient,,,97.00000,58.20000,Aetna,Commercial,,7039.00,,,,,,,62.08,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Commercial,,,75.00,,,,,0,19.42,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,inpatient,,,1503.00000,901.80000,Aetna,Commercial,,7039.00,,,,,,,961.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Aetna,Commercial,,4311.00,,,,,,,300.90,9423.00,case rate,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,inpatient,,,4128.00000,2476.80000,Aetna,Commercial,,7039.00,,,,,,,2641.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Aetna,Commercial,,4311.00,,,,,,,826.43,9423.00,case rate,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,inpatient,,,8064.00000,4838.40000,Aetna,Commercial,,7039.00,,,,,,,5160.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,inpatient,,,484.00000,290.40000,Aetna,Commercial,,7039.00,,,,,,,309.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Aetna,Commercial,,,75.00,,,,,0,96.90,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,inpatient,,,626.00000,375.60000,Aetna,Commercial,,7039.00,,,,,,,400.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,,75.00,,,,,0,125.33,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,inpatient,,,626.00000,375.60000,Aetna,Commercial,,7039.00,,,,,,,400.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Commercial,,,75.00,,,,,0,125.33,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,inpatient,,,215.00000,129.00000,Aetna,Commercial,,7039.00,,,,,,,137.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Commercial,,,75.00,,,,,0,43.04,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,inpatient,,,7671.00000,4602.60000,Aetna,Commercial,,7039.00,,,,,,,4909.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,inpatient,,,39133.00000,23479.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,31697.73,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Aetna,Commercial,,9503.00,,,,,,,7834.43,39682.00,case rate,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,inpatient,,,12282.00000,7369.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9948.42,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Aetna,Commercial,,12247.00,,,,,,,1411.00,12247.00,case rate,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,inpatient,,,2525.00000,1515.00000,Aetna,Commercial,,7039.00,,,,,,,1616.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Aetna,Commercial,,12247.00,,,,,,,337.85,12247.00,case rate,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,inpatient,,,2824.00000,1694.40000,Aetna,Commercial,,7039.00,,,,,,,1807.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Aetna,Commercial,,,75.00,,9418.0,9418.0,9418.0,1 through 10,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,inpatient,,,1266.00000,759.60000,Aetna,Commercial,,7039.00,,,,,,,810.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Aetna,Commercial,,9503.00,,,,,,,253.45,9503.00,case rate,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,inpatient,,,528.00000,316.80000,Aetna,Commercial,,7039.00,,,,,,,337.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Aetna,Commercial,,,75.00,,,,,0,105.71,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,inpatient,,,528.00000,316.80000,Aetna,Commercial,,7039.00,,,,,,,337.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Aetna,Commercial,,,75.00,,,,,0,105.71,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,inpatient,,,528.00000,316.80000,Aetna,Commercial,,7039.00,,,,,,,337.92,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Aetna,Commercial,,,75.00,,,,,0,105.71,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,inpatient,,,7882.00000,4729.20000,Aetna,Commercial,,7039.00,,,,,,,5044.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Aetna,Commercial,,12247.00,,,,,,,1577.98,24600.00,case rate,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,inpatient,,,7882.00000,4729.20000,Aetna,Commercial,,7039.00,,,,,,,5044.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Aetna,Commercial,,12247.00,,,,,,,1577.98,24600.00,case rate,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,inpatient,,,14979.00000,8987.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12132.99,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Aetna,Commercial,,12247.00,,,,,,,2998.80,24600.00,case rate,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,inpatient,,,14979.00000,8987.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12132.99,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Aetna,Commercial,,12247.00,,,,,,,2998.80,24600.00,case rate,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,inpatient,,,18267.00000,10960.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,14796.27,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Aetna,Commercial,,12247.00,,,,,,,3657.05,39682.00,case rate,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,inpatient,,,13268.00000,7960.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10747.08,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Aetna,Commercial,,6735.00,,,,,,,2656.25,24600.00,case rate,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,inpatient,,,15077.00000,9046.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12212.37,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Aetna,Commercial,,6735.00,,,,,,,3018.42,24600.00,case rate,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,inpatient,,,18194.00000,10916.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,14737.14,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Aetna,Commercial,,12247.00,,,,,,,3642.44,39682.00,case rate,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,inpatient,,,3193.00000,1915.80000,Aetna,Commercial,,7039.00,,,,,,,2043.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Aetna,Commercial,,6735.00,,,,,,,639.24,8045.00,case rate,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,inpatient,,,14089.00000,8453.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11412.09,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Aetna,Commercial,,8442.00,,,,,,,2820.62,13852.00,case rate,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,inpatient,,,14089.00000,8453.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11412.09,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Aetna,Commercial,,8442.00,,,,,,,2820.62,13852.00,case rate,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,inpatient,,,10215.00000,6129.00000,Aetna,Commercial,,7039.00,,,,,,,6537.60,8274.15,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Aetna,Commercial,,8442.00,,,,,,,2045.04,8442.00,case rate,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,inpatient,,,2944.00000,1766.40000,Aetna,Commercial,,7039.00,,,,,,,1884.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Aetna,Commercial,,8442.00,,,,,,,589.39,8442.00,case rate,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,inpatient,,,2902.00000,1741.20000,Aetna,Commercial,,7039.00,,,,,,,1857.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Aetna,Commercial,,4376.00,,,,,,,580.98,5152.00,case rate,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,inpatient,,,2902.00000,1741.20000,Aetna,Commercial,,7039.00,,,,,,,1857.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Aetna,Commercial,,4376.00,,,,,,,580.98,5152.00,case rate,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,inpatient,,,20392.00000,12235.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16517.52,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Aetna,Commercial,,6735.00,,,,,,,4082.48,39682.00,case rate,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,inpatient,,,14925.00000,8955.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12089.25,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Aetna,Commercial,,8442.00,,,,,,,2987.99,39682.00,case rate,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,inpatient,,,2367.00000,1420.20000,Aetna,Commercial,,7039.00,,,,,,,1514.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Aetna,Commercial,,6735.00,,,,,,,473.87,8045.00,case rate,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,inpatient,,,23786.00000,14271.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19266.66,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Aetna,Commercial,,6735.00,,,,,,,4761.96,24600.00,case rate,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,inpatient,,,24521.00000,14712.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,19862.01,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Aetna,Commercial,,6735.00,,,,,,,4909.10,24600.00,case rate,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,inpatient,,,26728.00000,16036.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,21649.68,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Aetna,Commercial,,6735.00,,,,,,,5350.95,24600.00,case rate,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,inpatient,,,8508.00000,5104.80000,Aetna,Commercial,,7039.00,,,,,,,5445.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Aetna,Commercial,,4376.00,,,,,,,1703.30,8700.96,case rate,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,inpatient,,,11401.00000,6840.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9234.81,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Aetna,Commercial,,8442.00,,,,,,,2282.48,8442.00,case rate,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,inpatient,,,11401.00000,6840.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9234.81,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Aetna,Commercial,,8442.00,,,,,,,2282.48,8442.00,case rate,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,inpatient,,,49887.00000,29932.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,40408.47,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Aetna,Commercial,,12247.00,,,,,,,9987.38,82346.00,case rate,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,inpatient,,,5750.00000,3450.00000,Aetna,Commercial,,7039.00,,,,,,,3680.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Aetna,Commercial,,8442.00,,,,,,,1151.15,8442.00,case rate,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,inpatient,,,3821.00000,2292.60000,Aetna,Commercial,,7039.00,,,,,,,2445.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Aetna,Commercial,,8442.00,,,,,,,764.96,8442.00,case rate,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,inpatient,,,57698.00000,34618.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,46735.38,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Aetna,Commercial,,12247.00,,,,,,,11551.14,82346.00,case rate,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,inpatient,,,2639.00000,1583.40000,Aetna,Commercial,,7039.00,,,,,,,1688.96,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Aetna,Commercial,,,75.00,,,,,0,528.33,4681.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Aetna,Commercial,,4311.00,,,,,,,2199.23,9485.27,case rate,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,inpatient,,,2086.00000,1251.60000,Aetna,Commercial,,7039.00,,,,,,,1335.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Aetna,Commercial,,4311.00,,,,,,,417.62,5152.00,case rate,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,inpatient,,,4188.00000,2512.80000,Aetna,Commercial,,7039.00,,,,,,,2680.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Aetna,Commercial,,,75.00,,,,,0,594.81,2912.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,inpatient,,,6480.00000,3888.00000,Aetna,Commercial,,7039.00,,,,,,,4147.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Aetna,Commercial,,12247.00,,,,,,,867.02,12247.00,case rate,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,inpatient,,,6480.00000,3888.00000,Aetna,Commercial,,7039.00,,,,,,,4147.20,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Aetna,Commercial,,,75.00,,8294.85,8294.85,8294.85,1 through 10,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,inpatient,,,3232.00000,1939.20000,Aetna,Commercial,,7039.00,,,,,,,2068.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Aetna,Commercial,,,75.00,,8294.85,8294.85,8294.85,1 through 10,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,inpatient,,,2295.00000,1377.00000,Aetna,Commercial,,7039.00,,,,,,,1468.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Aetna,Commercial,,12247.00,,,,,,,307.07,12247.00,case rate,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,inpatient,,,3232.00000,1939.20000,Aetna,Commercial,,7039.00,,,,,,,2068.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Aetna,Commercial,,,75.00,,,,,0,432.44,7977.75,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,inpatient,,,3232.00000,1939.20000,Aetna,Commercial,,7039.00,,,,,,,2068.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Aetna,Commercial,,,75.00,,,,,0,432.44,7977.75,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,inpatient,,,3043.00000,1825.80000,Aetna,Commercial,,7039.00,,,,,,,1947.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Aetna,Commercial,,,75.00,,,,,0,407.15,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,inpatient,,,2787.00000,1672.20000,Aetna,Commercial,,7039.00,,,,,,,1783.68,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Aetna,Commercial,,12247.00,,,,,,,372.90,12247.00,case rate,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,inpatient,,,9580.00000,5748.00000,Aetna,Commercial,,7039.00,,,,,,,6131.20,7759.80,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Aetna,Commercial,,12247.00,,,,,,,1281.80,12247.00,case rate,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,inpatient,,,15230.00000,9138.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12336.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Aetna,Commercial,,12247.00,,,,,,,1411.00,12247.00,case rate,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,inpatient,,,15230.00000,9138.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12336.30,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Aetna,Commercial,,12247.00,,,,,,,1411.00,12247.00,case rate,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,inpatient,,,1624.00000,974.40000,Aetna,Commercial,,7039.00,,,,,,,1039.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Aetna,Commercial,,,75.00,,,,,0,217.29,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,inpatient,,,8084.00000,4850.40000,Aetna,Commercial,,7039.00,,,,,,,5173.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Aetna,Commercial,,,75.00,,,,,0,1081.64,7977.75,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,inpatient,,,1658.00000,994.80000,Aetna,Commercial,,7039.00,,,,,,,1061.12,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Aetna,Commercial,,,75.00,,,,,0,221.84,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,inpatient,,,3156.00000,1893.60000,Aetna,Commercial,,7039.00,,,,,,,2019.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Aetna,Commercial,,12247.00,,,,,,,422.27,12247.00,case rate,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,inpatient,,,25442.00000,15265.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,20608.02,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Aetna,Commercial,,12247.00,,,,,,,1411.00,16639.07,case rate,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,inpatient,,,22534.00000,13520.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18252.54,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Aetna,Commercial,,4311.00,,,,,,,1411.00,14737.24,case rate,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,inpatient,,,22534.00000,13520.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18252.54,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Aetna,Commercial,,4311.00,,,,,,,1411.00,14737.24,case rate,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,inpatient,,,3025.00000,1815.00000,Aetna,Commercial,,7039.00,,,,,,,1936.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Aetna,Commercial,,,75.00,,2380.75,2147.75,3106.7300000000005,34,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,Aetna,Commercial,,7039.00,,,,,,,907.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Aetna,Commercial,,,75.00,,,,,0,150.52,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,inpatient,,,20137.00000,12082.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,16310.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Aetna,Commercial,,,75.00,,,,,0,2025.00,12283.57,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,inpatient,,,22381.00000,13428.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,18128.61,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Aetna,Commercial,,6735.00,,,,,,,4480.68,24600.00,case rate,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,inpatient,,,2482.00000,1489.20000,Aetna,Commercial,,7039.00,,,,,,,1588.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Aetna,Commercial,,6735.00,,,,,,,496.90,82346.00,case rate,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,inpatient,,,1931.00000,1158.60000,Aetna,Commercial,,7039.00,,,,,,,1235.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Aetna,Commercial,,9503.00,,,,,,,386.59,9503.00,case rate,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,inpatient,,,5548.00000,3328.80000,Aetna,Commercial,,7039.00,,,,,,,3550.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Aetna,Commercial,,6735.00,,,,,,,1110.71,82346.00,case rate,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,inpatient,,,5548.00000,3328.80000,Aetna,Commercial,,7039.00,,,,,,,3550.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Aetna,Commercial,,6735.00,,,,,,,1110.71,82346.00,case rate,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,inpatient,,,6377.00000,3826.20000,Aetna,Commercial,,7039.00,,,,,,,4081.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Aetna,Commercial,,6735.00,,,,,,,1276.68,82346.00,case rate,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,inpatient,,,2575.00000,1545.00000,Aetna,Commercial,,7039.00,,,,,,,1648.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Aetna,Commercial,,12247.00,,,,,,,515.51,82346.00,case rate,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,inpatient,,,13721.00000,8232.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11114.01,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Aetna,Commercial,,,75.00,,,,,0,2025.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,inpatient,,,4800.00000,2880.00000,Aetna,Commercial,,7039.00,,,,,,,3072.00,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Aetna,Commercial,,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,Aetna,Commercial,,7039.00,,,,,,,907.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Aetna,Commercial,,,75.00,,,,,0,150.52,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,inpatient,,,2127.00000,1276.20000,Aetna,Commercial,,7039.00,,,,,,,1361.28,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Aetna,Commercial,,,75.00,,,,,0,150.52,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,inpatient,,,2836.00000,1701.60000,Aetna,Commercial,,7039.00,,,,,,,1815.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Aetna,Commercial,,,75.00,,,,,0,150.52,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,inpatient,,,7965.00000,4779.00000,Aetna,Commercial,,7039.00,,,,,,,5097.60,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Aetna,Commercial,,,75.00,,,,,0,1594.59,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,inpatient,,,18522.00000,11113.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,15002.82,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Aetna,Commercial,,,75.00,,,,,0,2025.00,11298.42,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,inpatient,,,9224.00000,5534.40000,Aetna,Commercial,,7039.00,,,,,,,5903.36,7471.44,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Aetna,Commercial,,,75.00,,,,,0,1846.64,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,inpatient,,,6467.00000,3880.20000,Aetna,Commercial,,7039.00,,,,,,,4138.88,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Aetna,Commercial,,,75.00,,,,,0,1294.69,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,inpatient,,,7476.00000,4485.60000,Aetna,Commercial,,7039.00,,,,,,,4784.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Aetna,Commercial,,,75.00,,,,,0,1496.70,10022.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,inpatient,,,288.00000,172.80000,Aetna,Commercial,,7039.00,,,,,,,184.32,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Commercial,,,75.00,,,,,0,57.66,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,Aetna,Commercial,,7039.00,,,,,,,907.52,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Aetna,Commercial,,,75.00,,,,,0,150.52,981.11,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,inpatient,,,7970.00000,4782.00000,Aetna,Commercial,,7039.00,,,,,,,5100.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Aetna,Commercial,,,75.00,,,,,0,1595.59,8045.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,inpatient,,,3041.00000,1824.60000,Aetna,Commercial,,7039.00,,,,,,,1946.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Commercial,,4376.00,,,,,,,406.89,4376.00,case rate,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,inpatient,,,3041.00000,1824.60000,Aetna,Commercial,,7039.00,,,,,,,1946.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Commercial,,,75.00,,,,,0,406.89,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,inpatient,,,3041.00000,1824.60000,Aetna,Commercial,,7039.00,,,,,,,1946.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Commercial,,,75.00,,,,,0,406.89,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,inpatient,,,3041.00000,1824.60000,Aetna,Commercial,,7039.00,,,,,,,1946.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Commercial,,,75.00,,,,,0,406.89,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,inpatient,,,13301.00000,7980.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10773.81,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Aetna,Commercial,,8442.00,,,,,,,2662.86,13852.00,case rate,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,inpatient,,,26602.00000,15961.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,21547.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Aetna,Commercial,,8442.00,,,,,,,5325.72,24600.00,case rate,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,inpatient,,,26602.00000,15961.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,21547.62,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Aetna,Commercial,,10087.00,,,,,,,5325.72,24600.00,case rate,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,inpatient,,,42829.00000,25697.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,34691.49,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Aetna,Commercial,,10087.00,,,,,,,8574.37,26125.69,case rate,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,inpatient,,,34962.00000,20977.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,28319.22,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Aetna,Commercial,,,75.00,,,,,0,594.81,21326.82,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,inpatient,,,9476.00000,5685.60000,Aetna,Commercial,,7039.00,,,,,,,6064.64,7675.56,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Aetna,Commercial,,12247.00,,,,,,,1897.10,82346.00,case rate,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,inpatient,,,4345.00000,2607.00000,Aetna,Commercial,,7039.00,,,,,,,2780.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Aetna,Commercial,,,75.00,,,,,0,869.87,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,inpatient,,,21406.00000,12843.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,17338.86,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Aetna,Commercial,,8442.00,,,,,,,4285.48,24600.00,case rate,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,inpatient,,,34241.00000,20544.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,27735.21,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Aetna,Commercial,,8442.00,,,,,,,6855.05,24600.00,case rate,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,inpatient,,,34241.00000,20544.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,27735.21,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Aetna,Commercial,,8442.00,,,,,,,6855.05,24600.00,case rate,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,inpatient,,,34241.00000,20544.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,27735.21,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Aetna,Commercial,,8442.00,,,,,,,6855.05,24600.00,case rate,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,inpatient,,,32373.00000,19423.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,26222.13,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Aetna,Commercial,,,75.00,,,,,0,2025.00,22398.88,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,inpatient,,,6766.00000,4059.60000,Aetna,Commercial,,7039.00,,,,,,,4330.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Aetna,Commercial,,12247.00,,,,,,,1354.55,12247.00,case rate,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,inpatient,,,6766.00000,4059.60000,Aetna,Commercial,,7039.00,,,,,,,4330.24,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Aetna,Commercial,,12247.00,,,,,,,1354.55,12247.00,case rate,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,inpatient,,,107.00000,64.20000,Aetna,Commercial,,7039.00,,,,,,,68.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Commercial,,,75.00,,,,,0,21.42,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,inpatient,,,39142.00000,23485.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,31705.02,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Aetna,Commercial,,12247.00,,,,,,,1411.00,25792.05,case rate,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,inpatient,,,39142.00000,23485.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,31705.02,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Aetna,Commercial,,12247.00,,,,,,,1411.00,25792.05,case rate,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,inpatient,,,47944.00000,28766.40000,Aetna,Commercial,,7039.00,,,,,,,7039.00,38834.64,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Aetna,Commercial,,12247.00,,,,,,,1411.00,31355.38,case rate,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,inpatient,,,2399.00000,1439.40000,Aetna,Commercial,,7039.00,,,,,,,1535.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Aetna,Commercial,,,75.00,,,,,0,480.28,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,inpatient,,,6494.00000,3896.40000,Aetna,Commercial,,7039.00,,,,,,,4156.16,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Aetna,Commercial,,4311.00,,,,,,,1300.10,9423.00,case rate,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,inpatient,,,10837.00000,6502.20000,Aetna,Commercial,,7039.00,,,,,,,6935.68,8777.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Aetna,Commercial,,12247.00,,,,,,,2169.57,12247.00,case rate,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,Aetna,Commercial,LD,7039.00,,,,,,,2199.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Commercial,LD,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,Aetna,Commercial,RC,7039.00,,,,,,,2199.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Commercial,RC,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,Aetna,Commercial,RI,7039.00,,,,,,,2199.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Commercial,RI,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,Aetna,Commercial,LM,7039.00,,,,,,,2199.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Commercial,LM,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,Aetna,Commercial,LD,7039.00,,,,,,,1758.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Commercial,LD,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,Aetna,Commercial,RC,7039.00,,,,,,,1758.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Commercial,RC,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,Aetna,Commercial,RI,7039.00,,,,,,,1758.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Commercial,RI,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,Aetna,Commercial,LM,7039.00,,,,,,,1758.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Commercial,LM,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,Aetna,Commercial,LD,7039.00,,,,,,,1507.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Commercial,LD,,75.00,,10378.5,10378.5,10378.5,1 through 10,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,Aetna,Commercial,RC,7039.00,,,,,,,1507.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Commercial,RC,,75.00,,10378.5,10378.5,10378.5,1 through 10,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,Aetna,Commercial,RI,7039.00,,,,,,,1507.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Commercial,RI,,75.00,,10378.5,10378.5,10378.5,1 through 10,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,Aetna,Commercial,LM,7039.00,,,,,,,1507.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Commercial,LM,,75.00,,10378.5,10378.5,10378.5,1 through 10,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,Aetna,Commercial,LD,7039.00,,,,,,,316.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,LD,,75.00,,,,,0,99.10,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,Aetna,Commercial,RC,7039.00,,,,,,,316.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,RC,,75.00,,,,,0,99.10,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,Aetna,Commercial,RI,7039.00,,,,,,,316.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,RI,,75.00,,,,,0,99.10,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,Aetna,Commercial,LM,7039.00,,,,,,,316.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,LM,,75.00,,,,,0,99.10,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,Aetna,Commercial,LC,7039.00,,,,,,,2199.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Commercial,LC,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,Aetna,Commercial,LC,7039.00,,,,,,,1758.72,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Commercial,LC,,75.00,,,,,0,173.00,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,Aetna,Commercial,LC,7039.00,,,,,,,1507.84,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Commercial,LC,,75.00,,10378.5,10378.5,10378.5,1 through 10,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,Aetna,Commercial,LC,7039.00,,,,,,,316.80,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Commercial,LC,,75.00,,,,,0,99.10,9423.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,inpatient,,,32611.00000,19566.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,26414.91,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Aetna,Commercial,,,75.00,,,,,0,594.81,19892.71,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,inpatient,,,61737.00000,37042.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,50006.97,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Aetna,Commercial,,12247.00,,,,,,,9423.00,82346.00,case rate,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,inpatient,,,11403.00000,6841.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,9236.43,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Aetna,Commercial,,12247.00,,,,,,,2282.88,13852.00,case rate,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,inpatient,,,2851.00000,1710.60000,Aetna,Commercial,,7039.00,,,,,,,1824.64,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Aetna,Commercial,,4311.00,,,,,,,173.00,9423.00,case rate,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Aetna,Commercial,,431.25,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,inpatient,,,4021.00000,2412.60000,Aetna,Commercial,,7039.00,,,,,,,2573.44,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Aetna,Commercial,,8442.00,,,,,,,538.01,20050.47,case rate,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,inpatient,,,3304.00000,1982.40000,Aetna,Commercial,,7039.00,,,,,,,2114.56,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Aetna,Commercial,,,75.00,,,,,0,442.08,3641.00,percent of total billed charges,"There were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Aetna,Commercial,,967.50,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Aetna,Commercial,,1172.25,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Aetna,Commercial,,867.75,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Aetna,Commercial,,1671.75,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Aetna,Commercial,,1671.75,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Aetna,Commercial,,674.25,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Aetna,Commercial,,544.50,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Aetna,Commercial,,544.50,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Aetna,Commercial,,1918.50,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Aetna,Commercial,,1918.50,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Commercial,,372.00,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Commercial,,288.75,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Aetna,Commercial,,2052.00,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Commercial,,41.25,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Aetna,Commercial,,1026.00,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Aetna,Commercial,,182.25,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Aetna,Commercial,,656.25,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Aetna,Commercial,,466.50,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Commercial,,121.50,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Aetna,Commercial,,144.75,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Aetna,Commercial,,957.00,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Aetna,Commercial,,213.75,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Commercial,,163.50,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Aetna,Commercial,,222.75,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Aetna,Commercial,,81.75,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Aetna,Commercial,,105.75,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Commercial,,32.25,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,inpatient,,,6499.00000,3899.40000,Aetna,Commercial,,7039.00,,,,,,,4159.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Aetna,Commercial,,4376.00,,,,,,,1301.10,17457.00,case rate,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,inpatient,,,3624.00000,2174.40000,Aetna,Commercial,,7039.00,,,,,,,2319.36,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Aetna,Commercial,,6735.00,,,,,,,725.52,8045.00,case rate,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,inpatient,,,7984.00000,4790.40000,Aetna,Commercial,,7039.00,,,,,,,5109.76,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Aetna,Commercial,,4376.00,,,,,,,1598.40,13852.00,case rate,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,inpatient,,,2607.00000,1564.20000,Aetna,Commercial,,7039.00,,,,,,,1668.48,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Aetna,Commercial,,4376.00,,,,,,,521.92,5152.00,case rate,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,Aetna,Commercial,,7039.00,,,,,,,1351.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Aetna,Commercial,,6735.00,,,,,,,422.62,24600.00,case rate,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,Aetna,Commercial,,7039.00,,,,,,,1351.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Aetna,Commercial,,6735.00,,,,,,,422.62,8045.00,case rate,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,Aetna,Commercial,,7039.00,,,,,,,1351.04,7039.00,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Aetna,Commercial,,6735.00,,,,,,,422.62,17457.00,case rate,
HC REX MED SURG SEMI PRIVATE ROOM,11200003,CDM,120,RC,,,,,facility,inpatient,,,1328.00000,796.80000,Aetna,Commercial,,5693.00,,,,,,,849.92,5693.00,per diem,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Aetna,Commercial,,4781.25,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Aetna,Commercial,,6332.25,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Aetna,Commercial,,7107.75,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX LEVEL 2 NURSERY ROOM,11720015,CDM,172,RC,,,,,facility,inpatient,,,3166.00000,1899.60000,Aetna,Commercial,,3569.00,,,,,,,2026.24,3569.00,per diem,
HC REX LEVEL 4 INTENSIVE NURSERY ROOM,11740002,CDM,174,RC,,,,,facility,inpatient,,,6546.00000,3927.60000,Aetna,Commercial,,4223.00,,,,,,,4189.44,5695.00,per diem,
HC REX INTENSIVE CARE SEMI PRIVATE ROOM,12000008,CDM,210,RC,,,,,facility,inpatient,,,3522.00000,2113.20000,Aetna,Commercial,,6258.00,,,,,,,1228.00,6258.00,per diem,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Aetna,Commercial,,5873.25,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Aetna,Commercial,,7611.75,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Aetna,Commercial,,8481.00,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Aetna,Commercial,,360.00,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Aetna,Commercial,,225.00,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Aetna,Commercial,,360.00,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Aetna,Commercial,,225.00,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Aetna,Commercial,,25.50,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,67.50,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Aetna,Commercial,,180.00,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Aetna,Commercial,,280.50,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Aetna,Commercial,,990.00,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Aetna,Commercial,,1068.75,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Aetna,Commercial,,1674.00,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,inpatient,,,293.00000,175.80000,Aetna,Commercial,,99.62,,,,,,,50.40,243.19,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,350.80"
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Aetna,Commercial,,111.34,,,,,,,37.21,215.71,percent of total billed charges,"Paid In Addition to Other Negotiated Rates for all of the listed billing codes, when the sum of the listed billing codes on the claim is greater than $3,199.21"
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Aetna,Commercial,,504.00,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Aetna,Commercial,,78.00,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Aetna,Commercial,,762.00,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Aetna,Commercial,,131.25,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Aetna,Commercial,,193.50,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Aetna,Commercial,,144.00,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Aetna,Commercial,,2371.50,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Aetna,Commercial,,226.50,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Aetna,Commercial,,222.00,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Aetna,Commercial,,231.75,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Aetna,Commercial,,213.75,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Aetna,Commercial,,255.75,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Aetna,Commercial,,324.00,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Aetna,Commercial,,462.75,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Aetna,Commercial,,33.00,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Aetna,Commercial,,31.50,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Aetna,Commercial,,53.25,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Aetna,Commercial,,165.75,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Aetna,Commercial,,301.50,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Aetna,Commercial,,667.50,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Aetna,Commercial,,55.50,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Aetna,Commercial,,40.50,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Aetna,Commercial,,198.75,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Aetna,Commercial,,30.00,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Aetna,Commercial,,562.50,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Aetna,Commercial,,881.25,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Aetna,Commercial,,3007.50,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Aetna,Commercial,,918.00,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Commercial,,1345.50,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Aetna,Commercial,,1701.75,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Aetna,Commercial,,369.00,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Aetna,Commercial,,3007.50,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Aetna,Commercial,,525.00,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Aetna,Commercial,,585.00,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Aetna,Commercial,,67.50,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Aetna,Commercial,,1198.50,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Aetna,Commercial,,1926.75,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Aetna,Commercial,,375.00,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Aetna,Commercial,,3000.00,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Aetna,Commercial,,1818.75,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Aetna,Commercial,,1350.00,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Aetna,Commercial,,1818.75,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Aetna,Commercial,,1350.00,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Aetna,Commercial,,885.00,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Aetna,Commercial,,885.00,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Aetna,Commercial,,792.75,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Aetna,Commercial,GP,178.50,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,inpatient,,,30903.00000,18541.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,25031.43,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,inpatient,,,14943.00000,8965.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12103.83,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,inpatient,,,30903.00000,18541.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,25031.43,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,inpatient,,,14943.00000,8965.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12103.83,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,inpatient,,,12987.00000,7792.20000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10519.47,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,inpatient,,,13273.00000,7963.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10751.13,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,inpatient,,,13560.00000,8136.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,10983.60,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,inpatient,,,13848.00000,8308.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11216.88,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,inpatient,,,14135.00000,8481.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11449.35,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,inpatient,,,14421.00000,8652.60000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11681.01,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,inpatient,,,14708.00000,8824.80000,Aetna,Commercial,,7039.00,,,,,,,7039.00,11913.48,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,inpatient,,,14995.00000,8997.00000,Aetna,Commercial,,7039.00,,,,,,,7039.00,12145.95,per diem,Must be billed with surgical revenue code and inpatient room and board code.
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Aetna,Commercial,,,75.00,,6384.0,4148.0,9561.0,316,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Aetna,Commercial,,374.25,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Aetna,Commercial,,184.50,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Aetna,Commercial,,150.00,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,217464.31,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,88488.65,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,164932.46,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,107956.96,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,80597.33,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,36759.60,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,100993.62,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,44236.00,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,56375.49,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,43073.14,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33506.65,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23197.61,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,93789.97,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,46747.97,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,42904.68,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,334593.30,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,56057.93,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,61730.91,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,41834.53,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25481.65,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,45207.26,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,31156.94,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,36061.88,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24954.68,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20424.48,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,47355.29,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27291.24,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17892.43,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,35550.36,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17396.38,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13779.48,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,30838.61,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19401.47,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15942.20,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,26367.89,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13468.09,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10013.46,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,30765.20,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17919.47,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14280.17,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14926.14,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8496.69,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12728.65,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8808.86,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18880.68,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10941.45,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14139.54,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10518.78,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8037.74,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22234.10,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14508.11,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11777.48,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16469.17,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8737.01,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6218.86,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12278.94,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7609.68,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7102.80,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13794.15,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8858.31,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6773.63,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13326.69,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8895.40,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15746.70,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7306.79,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14916.10,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7850.74,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18590.93,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11715.67,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8315.91,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18485.08,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10996.30,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7998.34,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11375.70,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9419.28,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7291.34,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14500.40,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8835.12,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7083.47,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28124.19,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20859.52,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20859.52,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28838.15,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18662.81,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11457.58,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15895.84,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7904.83,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9591.58,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7392.55,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19097.02,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11384.96,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12790.47,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14901.40,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9313.41,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9919.20,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7002.35,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7101.25,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11153.93,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6863.27,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17697.71,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8775.63,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12468.25,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7778.12,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10478.61,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33887.57,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17783.49,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13265.66,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,29879.71,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14320.37,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10220.55,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17291.29,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10755.23,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7089.67,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6738.10,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11218.84,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6602.10,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10065.22,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6634.56,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13011.44,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8012.23,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6270.62,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14195.95,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7960.46,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6405.07,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,35560.42,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20432.98,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15721.23,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,29810.93,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14865.08,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11488.48,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23928.57,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11544.13,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7150.71,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13005.26,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8471.99,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6764.37,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14576.11,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9206.02,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6755.09,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12751.83,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9152.70,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7007.77,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12972.82,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8573.18,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6472.30,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10476.29,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9489.60,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7444.32,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5891.25,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11086.71,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7157.65,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5786.93,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15512.60,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8264.13,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6464.57,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14561.43,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9424.68,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6456.08,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8434.90,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6107.60,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7169.26,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15078.35,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8202.32,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,50649.98,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22169.17,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,88388.21,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,84952.11,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,45026.47,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,77865.93,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,76519.91,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,51736.36,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,51736.36,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,60258.96,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,42135.88,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,39875.04,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,39158.00,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25266.05,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,66066.40,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,47774.87,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,60003.20,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,43139.58,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,46275.88,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33296.48,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,38959.42,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22955.78,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11627.59,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25600.63,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17395.60,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14896.76,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,36183.17,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17794.28,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12478.29,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27883.89,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20986.22,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14697.42,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,21772.81,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14049.92,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9369.82,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25208.89,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16554.93,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,26064.23,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15538.08,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13524.50,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24554.42,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,26742.66,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28887.59,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,48283.30,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,37716.18,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,54074.48,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33562.27,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,41699.33,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28409.33,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20657.06,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,32807.37,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,26364.80,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,56025.48,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,47342.15,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,36616.65,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,43939.31,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28796.41,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13325.15,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8032.33,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6517.88,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16235.81,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6279.12,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5558.23,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18028.42,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9199.05,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,21840.81,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14119.47,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8114.23,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10850.27,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7490.69,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5304.01,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12999.09,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5829.43,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,4447.10,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13546.13,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9178.96,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6491.62,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10176.52,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6132.32,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10125.50,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6765.13,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13106.48,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7986.74,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10233.69,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6615.24,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5304.77,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6354.06,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7665.32,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6493.92,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17042.50,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8373.85,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6201.08,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,52595.58,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19646.40,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,35414.37,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19515.82,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,21953.62,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14552.92,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,34367.39,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25277.64,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25736.64,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,39467.06,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19816.37,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13311.25,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,36446.68,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19453.23,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13934.02,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28906.92,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19028.25,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13586.32,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28522.14,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17224.08,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12791.23,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20887.32,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12557.11,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10096.14,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18668.20,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11043.43,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7657.58,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20184.95,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12710.10,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9953.98,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23353.70,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13930.16,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11323.14,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,34872.74,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18899.24,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11731.88,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27499.88,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19585.37,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13230.89,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8658.96,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6345.57,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14630.98,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8819.68,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6551.10,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17455.87,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10276.94,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8072.50,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15055.16,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8508.29,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5801.60,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16092.08,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9302.60,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7116.71,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11599.00,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7535.49,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13156.72,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8474.31,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6194.92,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12341.52,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7033.25,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5134.03,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10730.50,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6954.45,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13288.05,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8160.59,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5945.34,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19435.45,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12625.86,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9775.48,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,31996.07,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,43199.85,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23339.79,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18080.96,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28481.16,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17754.13,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13198.42,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,26454.44,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17176.17,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13760.94,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28458.00,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16899.55,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11464.55,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19369.78,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14001.24,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11483.87,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27256.47,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14355.90,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11744.26,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33019.87,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17836.03,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12523.13,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,86088.73,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,56706.98,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,44370.46,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,70545.60,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,45491.60,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16138.46,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9091.65,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6435.99,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15122.38,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9670.39,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7523.90,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13526.81,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7430.41,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5732.08,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14797.88,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8389.30,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6337.07,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13841.28,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9386.82,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7323.01,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,52557.70,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33698.27,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,42111.14,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25891.16,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,65861.64,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,47006.05,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33171.30,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,43605.50,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,21483.83,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,44969.28,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24997.17,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15021.95,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,41151.49,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28179.81,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22163.78,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24367.45,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15834.81,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,38240.81,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23694.44,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19793.97,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,34100.83,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18514.45,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10049.78,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27623.49,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19932.29,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15293.92,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23433.29,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17114.34,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13533.01,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22348.45,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25865.66,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17088.08,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13032.31,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14598.51,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9559.91,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,29300.19,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20526.49,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16434.41,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28945.54,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14868.95,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10266.90,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24240.71,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16498.52,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25384.30,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14437.78,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11330.10,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22496.79,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15373.51,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14783.19,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11355.60,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14888.27,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12632.07,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24269.33,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16997.66,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13721.54,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13094.90,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8829.74,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25555.05,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16987.63,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12804.35,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,29807.84,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16385.70,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12473.67,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23107.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17293.60,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13043.88,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7159.20,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10836.36,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7170.79,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8304.32,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6496.25,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16150.05,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10946.84,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7014.71,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14579.97,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8873.77,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6761.27,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20106.14,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9842.70,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7391.77,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15850.25,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10258.39,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7684.62,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13881.48,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8358.40,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10946.84,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7344.64,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11143.89,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7348.50,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12419.56,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7832.19,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15340.31,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9631.76,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7142.20,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11939.74,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7849.97,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12857.68,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8459.61,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6720.33,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23655.82,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13985.01,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9787.85,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,51551.70,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27753.31,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14815.64,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,38801.02,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,21411.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13342.92,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25953.75,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14282.50,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12081.14,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15817.01,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14254.68,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17471.32,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15836.34,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15884.24,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10096.90,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7628.22,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17316.79,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9294.88,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13811.93,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9671.93,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6875.63,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8978.85,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5605.34,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11912.69,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7659.90,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12305.21,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8008.37,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12622.78,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7934.20,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17866.16,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11742.72,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27876.93,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15382.01,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11889.51,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23240.88,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13295.77,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12585.70,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28431.72,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14791.70,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10603.78,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24266.22,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12516.15,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11194.12,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,29726.72,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17765.71,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12207.85,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12031.70,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7855.38,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5730.53,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11250.52,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6943.61,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11918.88,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13649.67,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8850.58,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6867.11,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,37257.21,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,29564.45,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25884.20,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,41081.95,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22560.15,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17285.11,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25531.10,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15070.62,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12921.04,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20563.55,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11143.11,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8930.95,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,24586.11,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12676.88,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9019.81,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25047.41,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14447.06,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9477.99,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23492.78,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12922.59,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8482.01,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14800.19,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9271.70,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33395.40,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19000.45,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13613.36,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12373.98,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7697.75,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5569.04,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14867.41,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9026.76,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7037.12,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9896.02,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7185.49,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11319.29,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6970.67,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9768.51,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6254.39,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9258.56,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13713.81,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8773.32,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6261.35,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16386.50,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12785.05,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18911.60,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11757.40,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17031.68,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9427.77,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12547.07,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9100.93,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18217.73,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12296.71,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15538.08,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11308.46,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14913.77,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9760.01,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5997.10,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9972.51,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6509.40,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12388.68,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7198.60,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9110.98,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6123.05,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17388.65,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11327.01,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28549.93,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16852.41,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12277.40,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28614.07,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14913.00,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11949.79,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15107.70,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10517.26,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16763.57,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9719.85,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14352.80,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7573.36,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11649.99,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20769.87,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12333.81,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15161.03,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9335.83,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8352.21,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11994.60,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8495.15,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6058.14,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8715.36,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5338.79,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9210.65,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13987.33,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8678.27,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5989.38,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7431.18,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19900.61,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9121.80,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8331.35,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13675.94,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9559.91,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8339.08,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14855.83,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,46854.62,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,32293.55,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19855.02,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33148.13,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12334.58,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,2474.47,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9947.78,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8660.51,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8325.94,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,35924.35,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22638.20,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15680.26,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,31714.81,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15293.92,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11408.13,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9269.38,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6756.64,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6140.04,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17990.54,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10711.96,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9017.48,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11781.34,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8025.37,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12716.28,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17363.15,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8765.59,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5813.96,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18560.03,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9887.52,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7574.91,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,46246.52,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18227.76,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10233.69,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,36356.26,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18436.39,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11357.14,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,37074.85,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18788.74,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14095.51,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25347.19,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12559.44,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10222.09,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6506.29,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,4970.99,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,43349.76,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17047.11,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10353.43,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,38052.30,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17059.50,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12087.33,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25925.94,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13536.08,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8737.79,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16343.99,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10337.20,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7510.78,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,20962.26,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11038.81,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7493.78,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,21866.29,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,67840.46,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,39089.99,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16369.48,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12499.16,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,36077.32,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17477.50,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11693.25,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15021.95,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8641.20,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7789.71,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12507.66,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7649.85,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,17104.30,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8897.72,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6568.87,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,54336.43,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15939.88,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8837.46,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,30793.79,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8349.87,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8200.76,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9227.65,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16123.78,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13362.24,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11723.39,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16966.00,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9205.26,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5697.30,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11868.65,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14414.63,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7751.84,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33356.75,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15723.52,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9967.88,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,29311.79,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12392.53,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16108.32,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,30595.96,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16347.08,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,11073.59,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13560.83,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7772.70,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13923.97,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6079.02,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13049.31,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7553.25,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,15076.80,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8675.19,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,6249.76,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14447.84,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8794.18,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,165900.61,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,56352.32,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,25816.99,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,31020.18,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18011.41,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16847.77,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,28967.18,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,18987.31,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,16598.19,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12896.32,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,9791.72,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10739.01,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7115.94,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10123.17,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5780.74,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,5226.73,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,52940.21,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,30006.43,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,59807.72,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,33490.40,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23678.99,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,22054.06,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,12772.69,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,8197.66,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,48228.42,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,21309.20,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,23230.06,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10936.80,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,7905.62,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10957.67,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,37183.02,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,19926.89,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,14174.32,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,27421.06,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,13630.36,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Medicare Advantage,,10196.57,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18291.76,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6560.16,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5424.67,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,22545.56,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7774.54,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5424.67,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10060.43,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1633.21,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,32038.43,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6899.91,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,25792.05,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,22545.56,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7774.54,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,701.74,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,701.74,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6899.91,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5424.67,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6258.49,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,319.81,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6258.49,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,21162.17,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,32038.43,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,47311.30,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3615.61,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,244.15,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,557.85,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3615.61,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,422.46,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,25792.05,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,21162.17,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18878.80,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3615.61,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,915.45,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6560.16,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10060.43,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6258.49,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5994.30,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,535.40,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6258.49,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6560.16,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,25792.05,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3615.61,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1018.28,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6899.91,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,23598.81,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,21162.17,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18878.80,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,915.45,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,211.50,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,33707.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1633.21,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18581.69,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,576.77,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6258.49,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,62.46,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,8700.96,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1018.28,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,211.50,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,701.74,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,915.45,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,319.81,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,8700.96,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,204.11,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,419.53,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,135.52,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,62.46,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6856.33,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13659.58,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,21162.17,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,33707.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11002.73,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,419.53,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6258.49,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7977.75,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,576.77,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13110.66,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6899.91,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,244.15,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5994.30,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6732.92,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,319.81,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,92.57,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,211.50,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,701.74,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1018.28,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1018.28,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5424.67,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1633.21,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5994.30,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4925.76,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13110.66,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6732.92,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,576.77,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,8700.96,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7977.75,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7977.75,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18878.80,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6732.92,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6560.16,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4229.43,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,576.77,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1018.28,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,244.15,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,535.40,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,419.53,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3826.18,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,135.52,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,135.52,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18878.80,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13659.58,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,319.81,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,915.45,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11002.73,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,8700.96,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,244.15,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,687.98,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,96.50,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,9721.99,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7774.54,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,244.15,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7277.94,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6258.49,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,204.11,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3999.90,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,319.81,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3876.27,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,244.15,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,535.40,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6219.43,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,135.52,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1557.34,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3409.61,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,535.40,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,244.15,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,459.63,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5189.94,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,419.53,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,211.50,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,4025.91,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18878.80,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18878.80,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,419.53,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,18878.80,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5994.30,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,11922.91,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2153.70,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,701.74,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,211.50,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3342.81,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,211.50,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13659.58,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,10945.84,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,701.74,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5994.30,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,13527.54,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3710.28,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,319.81,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1813.02,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,6133.95,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3309.13,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,643.57,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,419.53,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,135.52,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3626.08,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2053.05,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,208.90,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,135.52,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1923.16,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,419.53,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5424.67,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2883.21,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5683.29,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,576.77,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3009.02,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1239.63,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,958.53,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,19334.39,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2397.85,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1438.52,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3826.18,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3826.18,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1703.44,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1682.59,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,314.28,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1018.28,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3848.97,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,8700.96,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3964.64,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,1994.40,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,8700.96,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,2452.76,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,7510.57,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,255.70,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,5344.67,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,,3411.22,,,,,,,3121.59,5754.00,fee schedule,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Aetna,Medicare Advantage,,0.03346,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Aetna,Medicare Advantage,,31.07,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Aetna,Medicare Advantage,,5.97,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,22.70,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,12.91,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Aetna,Medicare Advantage,,29.40,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Aetna,Medicare Advantage,,29.40,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Aetna,Medicare Advantage,,31.14,,,,,,,4.42,81.55,fee schedule,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,22.70,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Aetna,Medicare Advantage,,33.94,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Aetna,Medicare Advantage,,9457.23,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Aetna,Medicare Advantage,,4063.96,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Aetna,Medicare Advantage,,60234.02,,,,,,,0.20220,163224.30,fee schedule,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Aetna,Medicare Advantage,,458.64,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Aetna,Medicare Advantage,,1733.23,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Aetna,Medicare Advantage,,414.43,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Aetna,Medicare Advantage,,787.50,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Aetna,Medicare Advantage,,9612.58,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Aetna,Medicare Advantage,,2991.56,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Aetna,Medicare Advantage,,2657.68,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Aetna,Medicare Advantage,,3743.93,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Aetna,Medicare Advantage,,7547.14,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Aetna,Medicare Advantage,,630.72,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Aetna,Medicare Advantage,,2656.96,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Aetna,Medicare Advantage,,3834.04,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Aetna,Medicare Advantage,,644.34,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Aetna,Medicare Advantage,,1999.47,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Aetna,Medicare Advantage,,2131.88,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Aetna,Medicare Advantage,,2695.20,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Aetna,Medicare Advantage,,31.55,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Aetna,Medicare Advantage,,108.75,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Aetna,Medicare Advantage,,217.73,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Aetna,Medicare Advantage,,7.48,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Aetna,Medicare Advantage,,4.86,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Aetna,Medicare Advantage,,66.67,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Aetna,Medicare Advantage,,5.17,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Aetna,Medicare Advantage,,0.00717,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Aetna,Medicare Advantage,,5.12,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Aetna,Medicare Advantage,,9.71,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Aetna,Medicare Advantage,,4.87,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Aetna,Medicare Advantage,,4.76,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Aetna,Medicare Advantage,,236.13,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Aetna,Medicare Advantage,,15.60,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Aetna,Medicare Advantage,,42.59,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Aetna,Medicare Advantage,,3703.30,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Aetna,Medicare Advantage,,7.72,,,,,,,1.27,20.19,fee schedule,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Aetna,Medicare Advantage,,43.50,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Aetna,Medicare Advantage,,47.80,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Aetna,Medicare Advantage,,47.80,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Aetna,Medicare Advantage,,7.09,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Medicare Advantage,,295.17,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Medicare Advantage,,250.47,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Aetna,Medicare Advantage,,168.97,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Aetna,Medicare Advantage,,131.45,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Aetna,Medicare Advantage,,105.64,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Aetna,Medicare Advantage,,111.37,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Medicare Advantage,,295.17,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Medicare Advantage,,250.47,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Aetna,Medicare Advantage,,168.97,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Aetna,Medicare Advantage,,131.45,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Aetna,Medicare Advantage,,105.64,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Aetna,Medicare Advantage,,111.37,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Aetna,Medicare Advantage,,6.57,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Aetna,Medicare Advantage,,136.47,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Aetna,Medicare Advantage,,62.62,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Aetna,Medicare Advantage,,590.09,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Aetna,Medicare Advantage,,166.82,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Aetna,Medicare Advantage,,166.82,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Aetna,Medicare Advantage,,146.99,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Aetna,Medicare Advantage,,146.99,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,104.92,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,104.92,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Aetna,Medicare Advantage,,95.36,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Aetna,Medicare Advantage,,95.36,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Aetna,Medicare Advantage,,564.76,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Aetna,Medicare Advantage,,136.47,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Aetna,Medicare Advantage,,62.62,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Aetna,Medicare Advantage,,74.81,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Aetna,Medicare Advantage,,74.81,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Medicare Advantage,,376.43,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Medicare Advantage,,376.43,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Medicare Advantage,,299.23,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Medicare Advantage,,299.23,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Aetna,Medicare Advantage,,153.20,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Aetna,Medicare Advantage,,153.20,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Aetna,Medicare Advantage,,81.26,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Aetna,Medicare Advantage,,81.26,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Aetna,Medicare Advantage,,65.01,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Aetna,Medicare Advantage,,65.01,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Aetna,Medicare Advantage,,51.66,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Aetna,Medicare Advantage,,217.73,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Aetna,Medicare Advantage,,108.75,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Aetna,Medicare Advantage,,1239.69,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Aetna,Medicare Advantage,,36.76,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Aetna,Medicare Advantage,,612.32,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Aetna,Medicare Advantage,,236.13,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Aetna,Medicare Advantage,,208.44,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Aetna,Medicare Advantage,,255.78,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Aetna,Medicare Advantage,,0.52102,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Aetna,Medicare Advantage,,496.64,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Medicare Advantage,,658.21,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Medicare Advantage,,290.62,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Aetna,Medicare Advantage,,147.22,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Medicare Advantage,,658.21,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Medicare Advantage,,290.62,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Aetna,Medicare Advantage,,147.22,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Aetna,Medicare Advantage,,672.31,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Aetna,Medicare Advantage,,3.55,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Aetna,Medicare Advantage,,12.79,,,,,,,1.97,33.47,fee schedule,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Aetna,Medicare Advantage,,46.03,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Aetna,Medicare Advantage,,15.88,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Aetna,Medicare Advantage,,29.40,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Aetna,Medicare Advantage,,56.81,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Aetna,Medicare Advantage,,65.46,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Aetna,Medicare Advantage,,37.93,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Aetna,Medicare Advantage,,81.74,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Aetna,Medicare Advantage,,81.74,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Medicare Advantage,,369.49,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Aetna,Medicare Advantage,,739.47,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Medicare Advantage,,369.49,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Aetna,Medicare Advantage,,78.97,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Aetna,Medicare Advantage,,78.70,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Aetna,Medicare Advantage,,36.61,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Aetna,Medicare Advantage,,37.96,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Aetna,Medicare Advantage,,102.29,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Aetna,Medicare Advantage,,102.29,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Aetna,Medicare Advantage,,115.44,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Aetna,Medicare Advantage,,115.44,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Aetna,Medicare Advantage,,2.39,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Aetna,Medicare Advantage,,0.12720,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.05405,0.49560,fee schedule,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Medicare Advantage,,597.02,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Medicare Advantage,,597.02,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Medicare Advantage,,483.98,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Medicare Advantage,,483.98,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Medicare Advantage,,408.21,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Medicare Advantage,,408.21,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Aetna,Medicare Advantage,,77.02,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,15.54,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,15.54,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Aetna,Medicare Advantage,,19.39,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Aetna,Medicare Advantage,,12.79,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Aetna,Medicare Advantage,,30.12,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Aetna,Medicare Advantage,,7.38,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Aetna,Medicare Advantage,,3.97,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Aetna,Medicare Advantage,,27.91,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Aetna,Medicare Advantage,,8.04,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Aetna,Medicare Advantage,,22.95,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Aetna,Medicare Advantage,,65.73,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Aetna,Medicare Advantage,,10.19,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Aetna,Medicare Advantage,,12.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Aetna,Medicare Advantage,,39.69,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Aetna,Medicare Advantage,,30.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Aetna,Medicare Advantage,,36.85,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Aetna,Medicare Advantage,,34.97,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Aetna,Medicare Advantage,,6.25,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Aetna,Medicare Advantage,,6.83,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Aetna,Medicare Advantage,,16.26,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Aetna,Medicare Advantage,,33.64,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Aetna,Medicare Advantage,,0.12189,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Aetna,Medicare Advantage,,6.27,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Aetna,Medicare Advantage,,1.41,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Aetna,Medicare Advantage,,2.51,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Aetna,Medicare Advantage,,0.02629,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Aetna,Medicare Advantage,,0.19120,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Aetna,Medicare Advantage,,1.85,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Aetna,Medicare Advantage,,0.18881,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.09409,0.95700,fee schedule,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Aetna,Medicare Advantage,,0.15296,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Aetna,Medicare Advantage,,1834.14,,,,,,,333.69,4844.60,fee schedule,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Aetna,Medicare Advantage,,0.00478,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Aetna,Medicare Advantage,,0.02151,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Aetna,Medicare Advantage,,0.61423,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Aetna,Medicare Advantage,,6.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Aetna,Medicare Advantage,,19.47,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Aetna,Medicare Advantage,,0.01673,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Aetna,Medicare Advantage,,1.02,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Aetna,Medicare Advantage,,1.46,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Aetna,Medicare Advantage,,0.26768,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Aetna,Medicare Advantage,,0.38479,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Aetna,Medicare Advantage,,0.61184,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Aetna,Medicare Advantage,,0.42781,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Aetna,Medicare Advantage,,0.00478,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Aetna,Medicare Advantage,,5.28,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Aetna,Medicare Advantage,,263.07,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Aetna,Medicare Advantage,,18.41,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Aetna,Medicare Advantage,,119.20,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Aetna,Medicare Advantage,,121.41,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Aetna,Medicare Advantage,,7.18,,,,,,,3.46,18.64,fee schedule,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Aetna,Medicare Advantage,,0.03107,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Aetna,Medicare Advantage,,8.69,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Aetna,Medicare Advantage,,15.60,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Aetna,Medicare Advantage,,34.39,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Aetna,Medicare Advantage,,15.19,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Aetna,Medicare Advantage,,59.53,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Aetna,Medicare Advantage,,8.43,,,,,,,2.25,25.35,fee schedule,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Aetna,Medicare Advantage,,6.09,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Aetna,Medicare Advantage,,0.17925,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Aetna,Medicare Advantage,,0.00956,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Aetna,Medicare Advantage,,31.81,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Aetna,Medicare Advantage,,16.02,,,,,,,2.67,42.05,fee schedule,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Aetna,Medicare Advantage,,2.84,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Aetna,Medicare Advantage,,4.23,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Aetna,Medicare Advantage,,7.97,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Aetna,Medicare Advantage,,13.14,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Aetna,Medicare Advantage,,33.26,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Aetna,Medicare Advantage,,131.14,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Aetna,Medicare Advantage,,75.58,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Aetna,Medicare Advantage,,88.73,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Aetna,Medicare Advantage,,1.80,,,,,,,1.65,61.57,fee schedule,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Aetna,Medicare Advantage,,15.51,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Aetna,Medicare Advantage,,15.51,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Aetna,Medicare Advantage,,11.35,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Aetna,Medicare Advantage,,0.28680,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Aetna,Medicare Advantage,,65.96,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Aetna,Medicare Advantage,,80.41,,,,,,,73.58,14437.16,fee schedule,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Aetna,Medicare Advantage,,3.96,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Aetna,Medicare Advantage,,4.73,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Aetna,Medicare Advantage,,4.37,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Aetna,Medicare Advantage,,4.78,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Aetna,Medicare Advantage,,5.10,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Aetna,Medicare Advantage,,30.70,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Aetna,Medicare Advantage,,20.10,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Aetna,Medicare Advantage,,83.82,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Aetna,Medicare Advantage,,92.15,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Aetna,Medicare Advantage,,4.64,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Aetna,Medicare Advantage,,1.99,,,,,,,1.82,2630.36,fee schedule,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Aetna,Medicare Advantage,,72.72,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Aetna,Medicare Advantage,,10.38,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Aetna,Medicare Advantage,,3.88,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Aetna,Medicare Advantage,,3.87,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Aetna,Medicare Advantage,,182.65,,,,,,,167.14,1791.89,fee schedule,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Aetna,Medicare Advantage,,4.31,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Aetna,Medicare Advantage,,112.70,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Aetna,Medicare Advantage,,4.13,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Aetna,Medicare Advantage,,4.03,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Aetna,Medicare Advantage,,3.96,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Aetna,Medicare Advantage,,777.69,,,,,,,711.66,3874.58,fee schedule,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Aetna,Medicare Advantage,,4.03,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Aetna,Medicare Advantage,,19.10,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Aetna,Medicare Advantage,,8.04,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Aetna,Medicare Advantage,,8.33,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Aetna,Medicare Advantage,,11.23,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Aetna,Medicare Advantage,,4.74,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Aetna,Medicare Advantage,,6.02,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Aetna,Medicare Advantage,,19.19,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Aetna,Medicare Advantage,,7.74,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Aetna,Medicare Advantage,,5.69,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Aetna,Medicare Advantage,,6.86,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Aetna,Medicare Advantage,,0.53775,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Aetna,Medicare Advantage,,104.37,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Aetna,Medicare Advantage,,178.82,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Aetna,Medicare Advantage,,546.01,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Aetna,Medicare Advantage,,52.34,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Aetna,Medicare Advantage,,52.34,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Aetna,Medicare Advantage,,52.34,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Aetna,Medicare Advantage,,0.35850,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Aetna,Medicare Advantage,,11.82,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Aetna,Medicare Advantage,,13.75,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Aetna,Medicare Advantage,,9.25,,,,,,,6.49,421.94,fee schedule,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Aetna,Medicare Advantage,,5.21,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Aetna,Medicare Advantage,,6.69,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Aetna,Medicare Advantage,,5.89,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Aetna,Medicare Advantage,,1.67,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Aetna,Medicare Advantage,,4.37,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Aetna,Medicare Advantage,,0.62140,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Aetna,Medicare Advantage,,4.31,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Aetna,Medicare Advantage,,4.40,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Aetna,Medicare Advantage,,6.39,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Aetna,Medicare Advantage,,7.39,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Aetna,Medicare Advantage,,5.69,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Aetna,Medicare Advantage,,11.36,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Aetna,Medicare Advantage,,7.01,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Aetna,Medicare Advantage,,7.73,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Aetna,Medicare Advantage,,3.63,,,,,,,3.32,2034.63,fee schedule,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Aetna,Medicare Advantage,,4.24,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Aetna,Medicare Advantage,,4.00,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Aetna,Medicare Advantage,,4.06,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Aetna,Medicare Advantage,,5.10,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Aetna,Medicare Advantage,,9.75,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Aetna,Medicare Advantage,,439.66,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Aetna,Medicare Advantage,,3.86,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Aetna,Medicare Advantage,,4.15,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Aetna,Medicare Advantage,,4.24,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Aetna,Medicare Advantage,,7.83,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Aetna,Medicare Advantage,,59.01,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Aetna,Medicare Advantage,,0.39435,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Aetna,Medicare Advantage,,5.54,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Aetna,Medicare Advantage,,5.44,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Aetna,Medicare Advantage,,5443.20,,,,,,,4068.51,15083.17,fee schedule,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Aetna,Medicare Advantage,,7.65,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Aetna,Medicare Advantage,,0.34655,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Aetna,Medicare Advantage,,37.73,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Aetna,Medicare Advantage,,71.92,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Aetna,Medicare Advantage,,101.65,,,,,,,93.02,1836.94,fee schedule,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Aetna,Medicare Advantage,,16.80,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Aetna,Medicare Advantage,,20.27,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Aetna,Medicare Advantage,,9.01,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Aetna,Medicare Advantage,,11.02,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Aetna,Medicare Advantage,,92.02,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Aetna,Medicare Advantage,,185.07,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Aetna,Medicare Advantage,,3.87,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Aetna,Medicare Advantage,,12.15,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Aetna,Medicare Advantage,,16.46,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Aetna,Medicare Advantage,,15.93,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Aetna,Medicare Advantage,,17.27,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Aetna,Medicare Advantage,,9.48,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Aetna,Medicare Advantage,,6.73,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Aetna,Medicare Advantage,,240.92,,,,,,,220.46,45153.30,fee schedule,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Aetna,Medicare Advantage,,190.73,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Aetna,Medicare Advantage,,37.85,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Aetna,Medicare Advantage,,55.24,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,386.13,fee schedule,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Aetna,Medicare Advantage,,4.68,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Aetna,Medicare Advantage,,6.45,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Aetna,Medicare Advantage,,6.80,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Aetna,Medicare Advantage,,11.93,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Aetna,Medicare Advantage,,14.63,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Aetna,Medicare Advantage,,20.04,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Aetna,Medicare Advantage,,25.44,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Aetna,Medicare Advantage,,30.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Aetna,Medicare Advantage,,16.93,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Aetna,Medicare Advantage,,18.19,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Aetna,Medicare Advantage,,5.07,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Aetna,Medicare Advantage,,4.73,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Aetna,Medicare Advantage,,5.90,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Aetna,Medicare Advantage,,5.90,,,,,,,5.40,1737.53,fee schedule,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Aetna,Medicare Advantage,,2.03,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Aetna,Medicare Advantage,,40.87,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Aetna,Medicare Advantage,,10.21,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Aetna,Medicare Advantage,,4.06,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Aetna,Medicare Advantage,,4.92,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Aetna,Medicare Advantage,,8.85,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Aetna,Medicare Advantage,,8.90,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Aetna,Medicare Advantage,,16.74,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Aetna,Medicare Advantage,,29.40,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Aetna,Medicare Advantage,,21.57,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Aetna,Medicare Advantage,,21.57,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Aetna,Medicare Advantage,,21.57,,,,,,,19.74,998.56,fee schedule,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Aetna,Medicare Advantage,,5.14,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Aetna,Medicare Advantage,,15.43,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Aetna,Medicare Advantage,,8.51,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Aetna,Medicare Advantage,,7.97,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Aetna,Medicare Advantage,,8.14,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Aetna,Medicare Advantage,,6.99,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Aetna,Medicare Advantage,,6.99,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Aetna,Medicare Advantage,,9.28,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Aetna,Medicare Advantage,,94.70,,,,,,,86.66,4808.71,fee schedule,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Aetna,Medicare Advantage,,40.15,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Aetna,Medicare Advantage,,6.58,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Aetna,Medicare Advantage,,15.22,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Aetna,Medicare Advantage,,0.35850,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Aetna,Medicare Advantage,,0.34655,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Aetna,Medicare Advantage,,6.57,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Aetna,Medicare Advantage,,7.52,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Aetna,Medicare Advantage,,37.62,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Aetna,Medicare Advantage,,5.60,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Aetna,Medicare Advantage,,24.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Aetna,Medicare Advantage,,139.83,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Aetna,Medicare Advantage,,43.24,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Aetna,Medicare Advantage,,62.21,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Aetna,Medicare Advantage,,49.04,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Aetna,Medicare Advantage,,4.48,,,,,,,4.10,849.34,fee schedule,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Aetna,Medicare Advantage,,4.35,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Aetna,Medicare Advantage,,24.13,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Aetna,Medicare Advantage,,42.66,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Aetna,Medicare Advantage,,125.58,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Aetna,Medicare Advantage,,0.37045,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Aetna,Medicare Advantage,,24.17,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Aetna,Medicare Advantage,,62.90,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Aetna,Medicare Advantage,,62.90,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Aetna,Medicare Advantage,,210.68,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Aetna,Medicare Advantage,,13.98,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Aetna,Medicare Advantage,,3.11,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Aetna,Medicare Advantage,,3.11,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Aetna,Medicare Advantage,,3.11,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Aetna,Medicare Advantage,,3.11,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Aetna,Medicare Advantage,,3.11,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Aetna,Medicare Advantage,,3.11,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Aetna,Medicare Advantage,,31.81,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Aetna,Medicare Advantage,,183.41,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Aetna,Medicare Advantage,,183.41,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Aetna,Medicare Advantage,,6.05,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Aetna,Medicare Advantage,,6.05,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Aetna,Medicare Advantage,,77.59,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Aetna,Medicare Advantage,,77.59,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Aetna,Medicare Advantage,,7.13,,,,,,,6.53,6536.44,fee schedule,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Aetna,Medicare Advantage,,3.90,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Aetna,Medicare Advantage,,19.91,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Aetna,Medicare Advantage,,24.22,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Aetna,Medicare Advantage,,36.79,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Aetna,Medicare Advantage,,5.58,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Aetna,Medicare Advantage,,192.09,,,,,,,3.74,490.35,fee schedule,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Aetna,Medicare Advantage,,27.70,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Aetna,Medicare Advantage,,33.93,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Aetna,Medicare Advantage,,4.13,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Aetna,Medicare Advantage,,211.44,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Aetna,Medicare Advantage,,0.33460,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Aetna,Medicare Advantage,,194.49,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Aetna,Medicare Advantage,,194.49,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Aetna,Medicare Advantage,,31.81,,,,,,,29.11,731.44,fee schedule,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Aetna,Medicare Advantage,,0.47800,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Aetna,Medicare Advantage,,0.41825,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Aetna,Medicare Advantage,,0.40630,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Aetna,Medicare Advantage,,0.38240,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Aetna,Medicare Advantage,,24.06,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Aetna,Medicare Advantage,,46.32,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Aetna,Medicare Advantage,,2764.65,,,,,,,2529.92,9842.05,fee schedule,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Aetna,Medicare Advantage,,25.33,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Aetna,Medicare Advantage,,3.29,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Aetna,Medicare Advantage,,18.40,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Aetna,Medicare Advantage,,457.94,,,,,,,419.06,1666.50,fee schedule,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Aetna,Medicare Advantage,,20.57,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Aetna,Medicare Advantage,,2.36,,,,,,,2.16,526.89,fee schedule,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Aetna,Medicare Advantage,,51.10,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Aetna,Medicare Advantage,,14.48,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Aetna,Medicare Advantage,,22.88,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Aetna,Medicare Advantage,,44.08,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Aetna,Medicare Advantage,,53.70,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Aetna,Medicare Advantage,,14.40,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Aetna,Medicare Advantage,,252.62,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Aetna,Medicare Advantage,,0.34655,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Aetna,Medicare Advantage,,11.23,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Aetna,Medicare Advantage,,0.28680,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Aetna,Medicare Advantage,,0.74090,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Aetna,Medicare Advantage,,19.16,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Aetna,Medicare Advantage,,18.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Aetna,Medicare Advantage,,18.24,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Aetna,Medicare Advantage,,18.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Aetna,Medicare Advantage,,24.26,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Aetna,Medicare Advantage,,25.09,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Aetna,Medicare Advantage,,112.71,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Aetna,Medicare Advantage,,4.37,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Aetna,Medicare Advantage,,67.34,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Aetna,Medicare Advantage,,4.61,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Aetna,Medicare Advantage,,274.16,,,,,,,250.88,41599.23,fee schedule,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Aetna,Medicare Advantage,,13.14,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Aetna,Medicare Advantage,,5.50,,,,,,,5.03,3313.63,fee schedule,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Aetna,Medicare Advantage,,13.14,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Aetna,Medicare Advantage,,16.87,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Aetna,Medicare Advantage,,6.44,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Aetna,Medicare Advantage,,0.35850,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Aetna,Medicare Advantage,,7.50,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Aetna,Medicare Advantage,,4.61,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Aetna,Medicare Advantage,,16.19,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Aetna,Medicare Advantage,,7.12,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Aetna,Medicare Advantage,,1.55,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Aetna,Medicare Advantage,,1.55,,,,,,,1.42,1358.23,fee schedule,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Aetna,Medicare Advantage,,75.55,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Aetna,Medicare Advantage,,113.36,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Aetna,Medicare Advantage,,22.88,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Aetna,Medicare Advantage,,22.88,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Aetna,Medicare Advantage,,169.75,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Aetna,Medicare Advantage,,6.87,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Aetna,Medicare Advantage,,5.60,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Aetna,Medicare Advantage,,135.03,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Aetna,Medicare Advantage,,286.41,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Aetna,Medicare Advantage,,22.23,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Aetna,Medicare Advantage,,0.97990,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Aetna,Medicare Advantage,,135.94,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Aetna,Medicare Advantage,,26.77,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Aetna,Medicare Advantage,,40.15,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Aetna,Medicare Advantage,,4.05,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Aetna,Medicare Advantage,,4.22,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Aetna,Medicare Advantage,,49.04,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Aetna,Medicare Advantage,,145.71,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Aetna,Medicare Advantage,,15.30,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Aetna,Medicare Advantage,,38.08,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Aetna,Medicare Advantage,,20.79,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Aetna,Medicare Advantage,,1.03,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Aetna,Medicare Advantage,,5.04,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Aetna,Medicare Advantage,,4.03,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Aetna,Medicare Advantage,,6.87,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Aetna,Medicare Advantage,,6.87,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Aetna,Medicare Advantage,,4.13,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Aetna,Medicare Advantage,,7.17,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Aetna,Medicare Advantage,,8.17,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Aetna,Medicare Advantage,,29.52,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Aetna,Medicare Advantage,,29.85,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Aetna,Medicare Advantage,,11.68,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Aetna,Medicare Advantage,,14.81,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Aetna,Medicare Advantage,,7.54,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Aetna,Medicare Advantage,,18.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Aetna,Medicare Advantage,,90.82,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Aetna,Medicare Advantage,,217.56,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Aetna,Medicare Advantage,,40.09,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Aetna,Medicare Advantage,,76.53,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Aetna,Medicare Advantage,,21.08,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Aetna,Medicare Advantage,,144.37,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Aetna,Medicare Advantage,,65.96,,,,,,,60.36,18855.26,fee schedule,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Aetna,Medicare Advantage,,443.25,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Aetna,Medicare Advantage,,5.02,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Aetna,Medicare Advantage,,229.88,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Aetna,Medicare Advantage,,5.96,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Aetna,Medicare Advantage,,20.23,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Aetna,Medicare Advantage,,8.62,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Aetna,Medicare Advantage,,4.13,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Aetna,Medicare Advantage,,394.64,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Aetna,Medicare Advantage,,18.04,,,,,,,16.51,22477.68,fee schedule,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Aetna,Medicare Advantage,,4.18,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Aetna,Medicare Advantage,,7.56,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Aetna,Medicare Advantage,,12.75,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Aetna,Medicare Advantage,,9.09,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Aetna,Medicare Advantage,,11.50,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Aetna,Medicare Advantage,,17.22,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Aetna,Medicare Advantage,,18.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Aetna,Medicare Advantage,,44.37,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Aetna,Medicare Advantage,,4.90,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Aetna,Medicare Advantage,,5.34,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Aetna,Medicare Advantage,,5.33,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Aetna,Medicare Advantage,,76.61,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Aetna,Medicare Advantage,,104.68,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Aetna,Medicare Advantage,,58.99,,,,,,,53.98,11755.45,fee schedule,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Aetna,Medicare Advantage,,25.68,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Aetna,Medicare Advantage,,493.18,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Aetna,Medicare Advantage,,656.29,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Aetna,Medicare Advantage,,6.30,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Aetna,Medicare Advantage,,46.89,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Aetna,Medicare Advantage,,4.33,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Aetna,Medicare Advantage,,0.64530,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Aetna,Medicare Advantage,,14.34,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Aetna,Medicare Advantage,,7.70,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Aetna,Medicare Advantage,,5.33,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Aetna,Medicare Advantage,,20.92,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Aetna,Medicare Advantage,,27.53,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Aetna,Medicare Advantage,,0.31070,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Aetna,Medicare Advantage,,11.88,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Aetna,Medicare Advantage,,8.63,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Aetna,Medicare Advantage,,35.36,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Aetna,Medicare Advantage,,0.37045,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Aetna,Medicare Advantage,,0.41825,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Aetna,Medicare Advantage,,3.91,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Aetna,Medicare Advantage,,49.48,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Aetna,Medicare Advantage,,5.41,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Aetna,Medicare Advantage,,5.88,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Aetna,Medicare Advantage,,7.67,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Aetna,Medicare Advantage,,4.13,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Aetna,Medicare Advantage,,131.71,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Aetna,Medicare Advantage,,6.41,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Aetna,Medicare Advantage,,5.72,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Aetna,Medicare Advantage,,7.04,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Aetna,Medicare Advantage,,10.30,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Aetna,Medicare Advantage,,12.77,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Aetna,Medicare Advantage,,14.54,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Aetna,Medicare Advantage,,42.66,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Aetna,Medicare Advantage,,121.44,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Aetna,Medicare Advantage,,12.69,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Aetna,Medicare Advantage,,5.90,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Aetna,Medicare Advantage,,7.12,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Aetna,Medicare Advantage,,14.64,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Aetna,Medicare Advantage,,6.67,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Aetna,Medicare Advantage,,40.68,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Aetna,Medicare Advantage,,85.38,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Aetna,Medicare Advantage,,276.30,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Aetna,Medicare Advantage,,2.06,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Aetna,Medicare Advantage,,3.96,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Aetna,Medicare Advantage,,3.90,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Aetna,Medicare Advantage,,30129.50,,,,,,,23675.99,87773.83,fee schedule,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Aetna,Medicare Advantage,,29.98,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Aetna,Medicare Advantage,,179.45,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Aetna,Medicare Advantage,,2.39,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Aetna,Medicare Advantage,,3.57,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Aetna,Medicare Advantage,,18.32,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Aetna,Medicare Advantage,,20.08,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Aetna,Medicare Advantage,,1.28,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Aetna,Medicare Advantage,,4.11,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Aetna,Medicare Advantage,,9.60,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Aetna,Medicare Advantage,,10.68,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Aetna,Medicare Advantage,,8.70,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Aetna,Medicare Advantage,,20.29,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Aetna,Medicare Advantage,,20.26,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Aetna,Medicare Advantage,,20.29,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Aetna,Medicare Advantage,,19.83,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Aetna,Medicare Advantage,,251.51,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Aetna,Medicare Advantage,,1288.20,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Aetna,Medicare Advantage,,70.64,,,,,,,64.64,2699.23,fee schedule,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Aetna,Medicare Advantage,,7.91,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Aetna,Medicare Advantage,,97.23,,,,,,,88.98,11700.78,fee schedule,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Aetna,Medicare Advantage,,0.69310,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Aetna,Medicare Advantage,,5.03,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Aetna,Medicare Advantage,,142.24,,,,,,,86.25,417.81,fee schedule,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Aetna,Medicare Advantage,,56.52,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Aetna,Medicare Advantage,,15.51,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Aetna,Medicare Advantage,,25.81,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Aetna,Medicare Advantage,,2.96,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Aetna,Medicare Advantage,,34.48,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Aetna,Medicare Advantage,,69.26,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Aetna,Medicare Advantage,,628.58,,,,,,,535.27,1984.42,fee schedule,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Aetna,Medicare Advantage,,20.91,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Aetna,Medicare Advantage,,2.33,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Aetna,Medicare Advantage,,793.78,,,,,,,667.95,2476.28,fee schedule,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Aetna,Medicare Advantage,,5.65,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Aetna,Medicare Advantage,,7.39,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Aetna,Medicare Advantage,,81.93,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Aetna,Medicare Advantage,,3.02,,,,,,,2.76,665.20,fee schedule,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Aetna,Medicare Advantage,,76.41,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Aetna,Medicare Advantage,,150.40,,,,,,,137.63,800.72,fee schedule,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Aetna,Medicare Advantage,,6.00,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Aetna,Medicare Advantage,,325.22,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Aetna,Medicare Advantage,,20.91,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Aetna,Medicare Advantage,,51.95,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Aetna,Medicare Advantage,,9.18,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Aetna,Medicare Advantage,,9.37,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Aetna,Medicare Advantage,,8.43,,,,,,,7.71,4637.12,fee schedule,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Aetna,Medicare Advantage,,4.49,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Aetna,Medicare Advantage,,4.97,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Aetna,Medicare Advantage,,2271.55,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Aetna,Medicare Advantage,,0.92015,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Aetna,Medicare Advantage,,13.80,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,261.63,fee schedule,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Aetna,Medicare Advantage,,2.59,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Aetna,Medicare Advantage,,71.37,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Aetna,Medicare Advantage,,0.39435,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Aetna,Medicare Advantage,,0.33460,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Aetna,Medicare Advantage,,0.38240,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Aetna,Medicare Advantage,,11.07,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Aetna,Medicare Advantage,,52.26,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Aetna,Medicare Advantage,,42.88,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Aetna,Medicare Advantage,,23.85,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Aetna,Medicare Advantage,,0.31070,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Aetna,Medicare Advantage,,37.27,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Aetna,Medicare Advantage,,9.64,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Aetna,Medicare Advantage,,5.26,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Aetna,Medicare Advantage,,278.94,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Aetna,Medicare Advantage,,51.90,,,,,,,47.49,8888.74,fee schedule,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Aetna,Medicare Advantage,,13.78,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Aetna,Medicare Advantage,,8.17,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Aetna,Medicare Advantage,,19.24,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Aetna,Medicare Advantage,,5.65,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Aetna,Medicare Advantage,,187.04,,,,,,,171.16,7213.29,fee schedule,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Aetna,Medicare Advantage,,59.73,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Aetna,Medicare Advantage,,0.31070,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Aetna,Medicare Advantage,,1.76,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Aetna,Medicare Advantage,,32.95,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Aetna,Medicare Advantage,,4.42,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Aetna,Medicare Advantage,,19.30,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Aetna,Medicare Advantage,,20.55,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Aetna,Medicare Advantage,,43.02,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Aetna,Medicare Advantage,,23.22,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Aetna,Medicare Advantage,,80.41,,,,,,,73.58,14437.16,fee schedule,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Aetna,Medicare Advantage,,38.01,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Aetna,Medicare Advantage,,22.43,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Aetna,Medicare Advantage,,16.84,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Aetna,Medicare Advantage,,17.77,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Aetna,Medicare Advantage,,17.77,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Aetna,Medicare Advantage,,20.09,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Aetna,Medicare Advantage,,2.82,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Aetna,Medicare Advantage,,4.31,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Aetna,Medicare Advantage,,4.22,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Aetna,Medicare Advantage,,5.76,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Aetna,Medicare Advantage,,2.64,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Aetna,Medicare Advantage,,1834.14,,,,,,,1641.62,6085.97,fee schedule,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Aetna,Medicare Advantage,,4.82,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Aetna,Medicare Advantage,,4.00,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Aetna,Medicare Advantage,,14.75,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Aetna,Medicare Advantage,,89.27,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Aetna,Medicare Advantage,,92.02,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Aetna,Medicare Advantage,,46.02,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Aetna,Medicare Advantage,,16.81,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Aetna,Medicare Advantage,,15.85,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Aetna,Medicare Advantage,,21.75,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Aetna,Medicare Advantage,,4.00,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Aetna,Medicare Advantage,,4.00,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Aetna,Medicare Advantage,,5.32,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Aetna,Medicare Advantage,,7.00,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Aetna,Medicare Advantage,,4.34,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Aetna,Medicare Advantage,,3.91,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Aetna,Medicare Advantage,,26.98,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Aetna,Medicare Advantage,,31.58,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Aetna,Medicare Advantage,,0.33460,,,,,,,0.28028,1.14,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Aetna,Medicare Advantage,,35.53,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Aetna,Medicare Advantage,,10.65,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Aetna,Medicare Advantage,,24.93,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Aetna,Medicare Advantage,,4.84,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Aetna,Medicare Advantage,,82.69,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Aetna,Medicare Advantage,,66.84,,,,,,,61.17,938.07,fee schedule,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Aetna,Medicare Advantage,,5.51,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Aetna,Medicare Advantage,,108.22,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Aetna,Medicare Advantage,,216.96,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Aetna,Medicare Advantage,,0.41825,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Aetna,Medicare Advantage,,0.40630,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Aetna,Medicare Advantage,,2.13,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Aetna,Medicare Advantage,,4.45,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Aetna,Medicare Advantage,,57.52,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Aetna,Medicare Advantage,,3.88,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Aetna,Medicare Advantage,,3.96,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Aetna,Medicare Advantage,,22.60,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Aetna,Medicare Advantage,,6.76,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Aetna,Medicare Advantage,,32.21,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Aetna,Medicare Advantage,,33.88,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Aetna,Medicare Advantage,,10.46,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Aetna,Medicare Advantage,,83.33,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Aetna,Medicare Advantage,,5.01,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Aetna,Medicare Advantage,,4.48,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Aetna,Medicare Advantage,,33.88,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Aetna,Medicare Advantage,,39.32,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Aetna,Medicare Advantage,,41.83,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Aetna,Medicare Advantage,,0.76480,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Aetna,Medicare Advantage,,24.26,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Aetna,Medicare Advantage,,29.64,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Aetna,Medicare Advantage,,29.64,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Aetna,Medicare Advantage,,21.92,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Aetna,Medicare Advantage,,19.05,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Aetna,Medicare Advantage,,112.57,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Aetna,Medicare Advantage,,6.26,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Aetna,Medicare Advantage,,5.54,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Aetna,Medicare Advantage,,5.62,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Aetna,Medicare Advantage,,5.38,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Aetna,Medicare Advantage,,5.40,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Aetna,Medicare Advantage,,777.69,,,,,,,711.66,10302.59,fee schedule,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Aetna,Medicare Advantage,,72.61,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Aetna,Medicare Advantage,,1.02,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Aetna,Medicare Advantage,,13.49,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Aetna,Medicare Advantage,,13.49,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Aetna,Medicare Advantage,,971.67,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Aetna,Medicare Advantage,,27.02,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Aetna,Medicare Advantage,,28.17,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Aetna,Medicare Advantage,,44.69,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Aetna,Medicare Advantage,,44.69,,,,,,,40.90,21050.28,fee schedule,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Aetna,Medicare Advantage,,15.62,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Aetna,Medicare Advantage,,1.47,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Aetna,Medicare Advantage,,35.24,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Aetna,Medicare Advantage,,5.99,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Aetna,Medicare Advantage,,9.92,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Aetna,Medicare Advantage,,5.66,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Aetna,Medicare Advantage,,4.59,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Aetna,Medicare Advantage,,38.60,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Aetna,Medicare Advantage,,116.32,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Aetna,Medicare Advantage,,23.40,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Aetna,Medicare Advantage,,22.53,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Aetna,Medicare Advantage,,1093.66,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Aetna,Medicare Advantage,,36.57,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Aetna,Medicare Advantage,,5.75,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Aetna,Medicare Advantage,,1.15,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Aetna,Medicare Advantage,,77.93,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Aetna,Medicare Advantage,,20.22,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Aetna,Medicare Advantage,,20.22,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Aetna,Medicare Advantage,,153.71,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Aetna,Medicare Advantage,,153.71,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Aetna,Medicare Advantage,,4.11,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Aetna,Medicare Advantage,,131.44,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Aetna,Medicare Advantage,,6.24,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Aetna,Medicare Advantage,,5.34,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Aetna,Medicare Advantage,,0.44215,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Aetna,Medicare Advantage,,20.10,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Aetna,Medicare Advantage,,77.52,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Aetna,Medicare Advantage,,117.95,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Aetna,Medicare Advantage,,4.89,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Aetna,Medicare Advantage,,85.36,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Aetna,Medicare Advantage,,126.12,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Aetna,Medicare Advantage,,23.89,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Aetna,Medicare Advantage,,23.89,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Aetna,Medicare Advantage,,88.11,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Aetna,Medicare Advantage,,327.20,,,,,,,299.42,4744.44,fee schedule,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Aetna,Medicare Advantage,,6.79,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Aetna,Medicare Advantage,,78.82,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Aetna,Medicare Advantage,,78.82,,,,,,,72.13,24709.62,fee schedule,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Aetna,Medicare Advantage,,5.43,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Aetna,Medicare Advantage,,13.14,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Aetna,Medicare Advantage,,19.12,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Aetna,Medicare Advantage,,0.40630,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Aetna,Medicare Advantage,,2.27,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Aetna,Medicare Advantage,,22.59,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Aetna,Medicare Advantage,,16.55,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Aetna,Medicare Advantage,,2.27,,,,,,,2.08,66.02,fee schedule,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Aetna,Medicare Advantage,,91.14,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Aetna,Medicare Advantage,,18.07,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Aetna,Medicare Advantage,,20.98,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Aetna,Medicare Advantage,,8.43,,,,,,,7.71,1553.65,fee schedule,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Aetna,Medicare Advantage,,3342.02,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Aetna,Medicare Advantage,,4.25,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Aetna,Medicare Advantage,,110.48,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Aetna,Medicare Advantage,,177.35,,,,,,,150.45,812.71,fee schedule,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Aetna,Medicare Advantage,,59.15,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Aetna,Medicare Advantage,,3.92,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Aetna,Medicare Advantage,,9.26,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Aetna,Medicare Advantage,,9.26,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Aetna,Medicare Advantage,,57.63,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Aetna,Medicare Advantage,,73.59,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Aetna,Medicare Advantage,,97.23,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Aetna,Medicare Advantage,,174.10,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Aetna,Medicare Advantage,,9.61,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Aetna,Medicare Advantage,,34.94,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Aetna,Medicare Advantage,,34.94,,,,,,,31.97,11012.21,fee schedule,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Aetna,Medicare Advantage,,3.87,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Aetna,Medicare Advantage,,3.88,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Aetna,Medicare Advantage,,174.74,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Aetna,Medicare Advantage,,9.44,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Aetna,Medicare Advantage,,11.40,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Aetna,Medicare Advantage,,13.04,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Aetna,Medicare Advantage,,18.57,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Aetna,Medicare Advantage,,94.70,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Aetna,Medicare Advantage,,63.91,,,,,,,58.48,19464.19,fee schedule,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Aetna,Medicare Advantage,,5.97,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Aetna,Medicare Advantage,,17.73,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Aetna,Medicare Advantage,,17.73,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Aetna,Medicare Advantage,,26.12,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Aetna,Medicare Advantage,,425.42,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Aetna,Medicare Advantage,,13.80,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Aetna,Medicare Advantage,,13.80,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Aetna,Medicare Advantage,,215.79,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Aetna,Medicare Advantage,,215.79,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Aetna,Medicare Advantage,,215.79,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Aetna,Medicare Advantage,,111.01,,,,,,,101.59,1341.56,fee schedule,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Aetna,Medicare Advantage,,895.52,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Aetna,Medicare Advantage,,1.94,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Aetna,Medicare Advantage,,22.59,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Aetna,Medicare Advantage,,116.32,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Aetna,Medicare Advantage,,53.78,,,,,,,49.22,2905.12,fee schedule,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Aetna,Medicare Advantage,,20095.84,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Aetna,Medicare Advantage,,51.97,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Aetna,Medicare Advantage,,51.97,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Aetna,Medicare Advantage,,83.53,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Aetna,Medicare Advantage,,83.53,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Aetna,Medicare Advantage,,21.18,,,,,,,19.38,3392.97,fee schedule,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Aetna,Medicare Advantage,,15.07,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Aetna,Medicare Advantage,,15.07,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Aetna,Medicare Advantage,,15.07,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Aetna,Medicare Advantage,,0.48760,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Aetna,Medicare Advantage,,0.48760,,,,,,,0.44620,938.40,fee schedule,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Aetna,Medicare Advantage,,10.59,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Aetna,Medicare Advantage,,30.88,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Aetna,Medicare Advantage,,11.23,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Aetna,Medicare Advantage,,20.12,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Aetna,Medicare Advantage,,18.16,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Aetna,Medicare Advantage,,21.03,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Aetna,Medicare Advantage,,2575.95,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Aetna,Medicare Advantage,,69.96,,,,,,,64.02,9932.57,fee schedule,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Aetna,Medicare Advantage,,10.66,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Aetna,Medicare Advantage,,10.66,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Aetna,Medicare Advantage,,13.74,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Aetna,Medicare Advantage,,33.15,,,,,,,30.33,12178.65,fee schedule,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Aetna,Medicare Advantage,,138.18,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Aetna,Medicare Advantage,,23.36,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Aetna,Medicare Advantage,,35.20,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Aetna,Medicare Advantage,,14.22,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Aetna,Medicare Advantage,,14.30,,,,,,,13.09,8282.77,fee schedule,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Aetna,Medicare Advantage,,248.38,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Aetna,Medicare Advantage,,151.87,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Aetna,Medicare Advantage,,3.93,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Aetna,Medicare Advantage,,52.23,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Aetna,Medicare Advantage,,4.58,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Aetna,Medicare Advantage,,209.67,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Aetna,Medicare Advantage,,4.68,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Aetna,Medicare Advantage,,21.19,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Aetna,Medicare Advantage,,119.20,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Aetna,Medicare Advantage,,75.60,,,,,,,61.99,229.82,fee schedule,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Aetna,Medicare Advantage,,3229.11,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Aetna,Medicare Advantage,,18.41,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Aetna,Medicare Advantage,,68.21,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Aetna,Medicare Advantage,,130.40,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Aetna,Medicare Advantage,,1110.68,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Aetna,Medicare Advantage,,50.52,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Aetna,Medicare Advantage,,22.86,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Aetna,Medicare Advantage,,35.41,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Aetna,Medicare Advantage,,96.82,,,,,,,88.60,38051.26,fee schedule,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Aetna,Medicare Advantage,,5.26,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Aetna,Medicare Advantage,,322.69,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Aetna,Medicare Advantage,,29.28,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Aetna,Medicare Advantage,,656.58,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Aetna,Medicare Advantage,,1.94,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Aetna,Medicare Advantage,,9.25,,,,,,,6.49,803.43,fee schedule,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Aetna,Medicare Advantage,,14.65,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Aetna,Medicare Advantage,,42.22,,,,,,,38.64,11892.27,fee schedule,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Aetna,Medicare Advantage,,9.83,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Aetna,Medicare Advantage,,45.80,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Aetna,Medicare Advantage,,15.83,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Aetna,Medicare Advantage,,87.78,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Aetna,Medicare Advantage,,13.74,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Aetna,Medicare Advantage,,8.19,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Aetna,Medicare Advantage,,9.54,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Aetna,Medicare Advantage,,150.10,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Aetna,Medicare Advantage,,106.10,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Aetna,Medicare Advantage,,62.97,,,,,,,57.63,64389.60,fee schedule,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Aetna,Medicare Advantage,,10.71,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Aetna,Medicare Advantage,,79.53,,,,,,,72.78,5293.44,fee schedule,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Aetna,Medicare Advantage,,214.31,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Aetna,Medicare Advantage,,90.23,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Aetna,Medicare Advantage,,90.23,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Aetna,Medicare Advantage,,38.89,,,,,,,35.59,21681.15,fee schedule,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Aetna,Medicare Advantage,,1.59,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Aetna,Medicare Advantage,,17.15,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Aetna,Medicare Advantage,,38.89,,,,,,,35.59,24749.25,fee schedule,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Aetna,Medicare Advantage,,17.04,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Aetna,Medicare Advantage,,16.42,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Aetna,Medicare Advantage,,313.75,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Aetna,Medicare Advantage,,1078.22,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Aetna,Medicare Advantage,,11.42,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Aetna,Medicare Advantage,,271.46,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Aetna,Medicare Advantage,,2859.93,,,,,,,2617.11,78305.96,fee schedule,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Aetna,Medicare Advantage,,4.17,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Aetna,Medicare Advantage,,31.45,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Aetna,Medicare Advantage,,22.78,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Aetna,Medicare Advantage,,22.78,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Aetna,Medicare Advantage,,21.58,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Aetna,Medicare Advantage,,4.03,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Aetna,Medicare Advantage,,6.66,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Aetna,Medicare Advantage,,4.23,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Aetna,Medicare Advantage,,47.68,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Aetna,Medicare Advantage,,2.31,,,,,,,2.11,740.34,fee schedule,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Aetna,Medicare Advantage,,15.80,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Aetna,Medicare Advantage,,159.78,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Aetna,Medicare Advantage,,1.12,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Aetna,Medicare Advantage,,4.40,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Aetna,Medicare Advantage,,1.74,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Aetna,Medicare Advantage,,174.47,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Aetna,Medicare Advantage,,8.64,,,,,,,7.91,4372.04,fee schedule,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Aetna,Medicare Advantage,,4.56,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Aetna,Medicare Advantage,,34.94,,,,,,,31.97,26143.70,fee schedule,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Aetna,Medicare Advantage,,19.13,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Aetna,Medicare Advantage,,57.83,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Aetna,Medicare Advantage,,93.09,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Aetna,Medicare Advantage,,6.30,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Aetna,Medicare Advantage,,19.20,,,,,,,11.70,50.28,fee schedule,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Aetna,Medicare Advantage,,92.02,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Aetna,Medicare Advantage,,8.32,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Aetna,Medicare Advantage,,8.32,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Aetna,Medicare Advantage,,8.32,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Aetna,Medicare Advantage,,8.32,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Aetna,Medicare Advantage,,8.32,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Aetna,Medicare Advantage,,105.08,,,,,,,96.16,7061.40,fee schedule,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Aetna,Medicare Advantage,,125.47,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Aetna,Medicare Advantage,,31.29,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Aetna,Medicare Advantage,,31.29,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Aetna,Medicare Advantage,,116.93,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Aetna,Medicare Advantage,,263.41,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.29100,1195.20,fee schedule,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Aetna,Medicare Advantage,,82.40,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Aetna,Medicare Advantage,,3.96,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Aetna,Medicare Advantage,,13.36,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Aetna,Medicare Advantage,,1229.89,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Aetna,Medicare Advantage,,31.05,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Aetna,Medicare Advantage,,112.71,,,,,,,103.14,14110.89,fee schedule,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Aetna,Medicare Advantage,,11.50,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Aetna,Medicare Advantage,,1085.84,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Aetna,Medicare Advantage,,139.26,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.29100,751.44,fee schedule,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Aetna,Medicare Advantage,,8619.32,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Aetna,Medicare Advantage,,108.23,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Aetna,Medicare Advantage,,96.82,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Aetna,Medicare Advantage,,65.13,,,,,,,59.60,15471.98,fee schedule,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Aetna,Medicare Advantage,,48.52,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Aetna,Medicare Advantage,,68.59,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Aetna,Medicare Advantage,,7.24,,,,,,,6.63,311.39,fee schedule,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Aetna,Medicare Advantage,,425.66,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Aetna,Medicare Advantage,,144.87,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Aetna,Medicare Advantage,,29.53,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Aetna,Medicare Advantage,,29.53,,,,,,,27.02,2482.70,fee schedule,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Aetna,Medicare Advantage,,48.10,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Aetna,Medicare Advantage,,11.47,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Aetna,Medicare Advantage,,5.70,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Aetna,Medicare Advantage,,4.25,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Aetna,Medicare Advantage,,31.14,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Aetna,Medicare Advantage,,31.14,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Aetna,Medicare Advantage,,44.50,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Aetna,Medicare Advantage,,44.50,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Aetna,Medicare Advantage,,137.25,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Aetna,Medicare Advantage,,11.67,,,,,,,10.68,4660.46,fee schedule,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Aetna,Medicare Advantage,,25.61,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Aetna,Medicare Advantage,,38.94,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Aetna,Medicare Advantage,,38.94,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Aetna,Medicare Advantage,,31.78,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Aetna,Medicare Advantage,,27.32,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Aetna,Medicare Advantage,,27.32,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Aetna,Medicare Advantage,,29.52,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Aetna,Medicare Advantage,,29.52,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Aetna,Medicare Advantage,,380.74,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Aetna,Medicare Advantage,,29.67,,,,,,,27.15,11278.32,fee schedule,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Aetna,Medicare Advantage,,34.31,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Aetna,Medicare Advantage,,34.31,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Aetna,Medicare Advantage,,6.84,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Aetna,Medicare Advantage,,21.17,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Aetna,Medicare Advantage,,86.81,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Aetna,Medicare Advantage,,86.81,,,,,,,79.44,3044.99,fee schedule,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Aetna,Medicare Advantage,,35.63,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Aetna,Medicare Advantage,,38.46,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Aetna,Medicare Advantage,,337.64,,,,,,,308.97,81666.49,fee schedule,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Aetna,Medicare Advantage,,21.63,,,,,,,19.80,1605.38,fee schedule,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Aetna,Medicare Advantage,,4.06,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Aetna,Medicare Advantage,,10.22,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Aetna,Medicare Advantage,,42.12,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Aetna,Medicare Advantage,,4.28,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Aetna,Medicare Advantage,,65.83,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Aetna,Medicare Advantage,,65.83,,,,,,,60.24,30500.89,fee schedule,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Aetna,Medicare Advantage,,15.69,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Aetna,Medicare Advantage,,21.03,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Aetna,Medicare Advantage,,15.17,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Aetna,Medicare Advantage,,144.87,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Aetna,Medicare Advantage,,238.62,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Aetna,Medicare Advantage,,238.62,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Aetna,Medicare Advantage,,8.32,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Aetna,Medicare Advantage,,5.79,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Aetna,Medicare Advantage,,29.67,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Aetna,Medicare Advantage,,2243.30,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Aetna,Medicare Advantage,,229.91,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Aetna,Medicare Advantage,,258.33,,,,,,,236.40,39491.13,fee schedule,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Aetna,Medicare Advantage,,4892.57,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Aetna,Medicare Advantage,,23.89,,,,,,,21.86,12635.51,fee schedule,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Aetna,Medicare Advantage,,4.18,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Aetna,Medicare Advantage,,4.06,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Aetna,Medicare Advantage,,19.42,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Aetna,Medicare Advantage,,207.79,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Aetna,Medicare Advantage,,200.09,,,,,,,183.10,24372.77,fee schedule,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Aetna,Medicare Advantage,,25.68,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Aetna,Medicare Advantage,,98.79,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Aetna,Medicare Advantage,,13.06,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Aetna,Medicare Advantage,,89.64,,,,,,,82.03,27041.13,fee schedule,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Aetna,Medicare Advantage,,8.16,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Aetna,Medicare Advantage,,20.94,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Aetna,Medicare Advantage,,19.78,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Aetna,Medicare Advantage,,19.78,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Aetna,Medicare Advantage,,0.40280,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Aetna,Medicare Advantage,,0.40280,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Aetna,Medicare Advantage,,209.70,,,,,,,191.90,50567.38,fee schedule,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Aetna,Medicare Advantage,,18.16,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Aetna,Medicare Advantage,,627.69,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Aetna,Medicare Advantage,,271.50,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Aetna,Medicare Advantage,,271.50,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Aetna,Medicare Advantage,,627.69,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Aetna,Medicare Advantage,,24.87,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Aetna,Medicare Advantage,,35.59,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Aetna,Medicare Advantage,,35.59,,,,,,,32.57,6893.96,fee schedule,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Aetna,Medicare Advantage,,124.28,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Aetna,Medicare Advantage,,73.66,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Aetna,Medicare Advantage,,693.91,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Aetna,Medicare Advantage,,693.91,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Aetna,Medicare Advantage,,32.39,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Aetna,Medicare Advantage,,26.54,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Aetna,Medicare Advantage,,26.54,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Aetna,Medicare Advantage,,26.54,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Aetna,Medicare Advantage,,67142.82,,,,,,,13645.27,176902.85,fee schedule,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Aetna,Medicare Advantage,,225.23,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Aetna,Medicare Advantage,,608.59,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Aetna,Medicare Advantage,,608.60,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Aetna,Medicare Advantage,,14.94,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Aetna,Medicare Advantage,,76.98,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Aetna,Medicare Advantage,,76.98,,,,,,,70.44,3033.78,fee schedule,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Aetna,Medicare Advantage,,352.72,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Aetna,Medicare Advantage,,49.81,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Aetna,Medicare Advantage,,23.90,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Aetna,Medicare Advantage,,61.06,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Aetna,Medicare Advantage,,7.39,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Aetna,Medicare Advantage,,25.33,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Aetna,Medicare Advantage,,16.56,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Aetna,Medicare Advantage,,207.46,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Aetna,Medicare Advantage,,9.25,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Aetna,Medicare Advantage,,112.71,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Aetna,Medicare Advantage,,1.94,,,,,,,1.78,261.59,fee schedule,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Aetna,Medicare Advantage,,6389.20,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Aetna,Medicare Advantage,,3.92,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Aetna,Medicare Advantage,,60.45,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Aetna,Medicare Advantage,,60.45,,,,,,,55.32,32495.93,fee schedule,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Aetna,Medicare Advantage,,211.04,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Aetna,Medicare Advantage,,80.53,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Aetna,Medicare Advantage,,35.44,,,,,,,32.43,5429.19,fee schedule,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Aetna,Medicare Advantage,,61.49,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Aetna,Medicare Advantage,,19.42,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Aetna,Medicare Advantage,,4.07,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Aetna,Medicare Advantage,,4.00,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Aetna,Medicare Advantage,,29.00,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Aetna,Medicare Advantage,,54.65,,,,,,,50.01,17719.94,fee schedule,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Aetna,Medicare Advantage,,0.32265,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Aetna,Medicare Advantage,,0.31070,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Aetna,Medicare Advantage,,87.10,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Aetna,Medicare Advantage,,3.88,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Aetna,Medicare Advantage,,182.55,,,,,,,167.05,28031.82,fee schedule,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Aetna,Medicare Advantage,,111.16,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Aetna,Medicare Advantage,,3.88,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Aetna,Medicare Advantage,,11.73,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Aetna,Medicare Advantage,,21.31,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Aetna,Medicare Advantage,,3.87,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Aetna,Medicare Advantage,,17.54,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Aetna,Medicare Advantage,,78.34,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Aetna,Medicare Advantage,,9.19,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Aetna,Medicare Advantage,,5.60,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Aetna,Medicare Advantage,,6.51,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Aetna,Medicare Advantage,,7.70,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Aetna,Medicare Advantage,,0.70505,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Aetna,Medicare Advantage,,46.10,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Aetna,Medicare Advantage,,2.65,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Aetna,Medicare Advantage,,4.67,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Aetna,Medicare Advantage,,3.88,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Aetna,Medicare Advantage,,22.53,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Aetna,Medicare Advantage,,4.12,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Aetna,Medicare Advantage,,6.50,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Aetna,Medicare Advantage,,6.26,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Aetna,Medicare Advantage,,4.37,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Aetna,Medicare Advantage,,4.11,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Aetna,Medicare Advantage,,4.28,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Aetna,Medicare Advantage,,21.76,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Aetna,Medicare Advantage,,22.77,,,,,,,20.84,1039.04,fee schedule,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Aetna,Medicare Advantage,,4.07,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Aetna,Medicare Advantage,,4.45,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Aetna,Medicare Advantage,,79.73,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Aetna,Medicare Advantage,,79.73,,,,,,,72.96,15544.97,fee schedule,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Aetna,Medicare Advantage,,16.24,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Aetna,Medicare Advantage,,6.66,,,,,,,6.09,4722.62,fee schedule,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Aetna,Medicare Advantage,,20.05,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Aetna,Medicare Advantage,,4.47,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Aetna,Medicare Advantage,,47.27,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Aetna,Medicare Advantage,,11.02,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.29100,33.96,fee schedule,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Aetna,Medicare Advantage,,4.15,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Aetna,Medicare Advantage,,4.73,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Aetna,Medicare Advantage,,999.61,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Aetna,Medicare Advantage,,19.49,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Aetna,Medicare Advantage,,4.49,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Aetna,Medicare Advantage,,30.27,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Aetna,Medicare Advantage,,113.02,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Aetna,Medicare Advantage,,2.31,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Aetna,Medicare Advantage,,4.88,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Aetna,Medicare Advantage,,266.01,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Aetna,Medicare Advantage,,15.30,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Aetna,Medicare Advantage,,4.79,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Aetna,Medicare Advantage,,5.95,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Aetna,Medicare Advantage,,42.47,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Aetna,Medicare Advantage,,2.83,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Aetna,Medicare Advantage,,20.79,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Aetna,Medicare Advantage,,19.54,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Aetna,Medicare Advantage,,25.45,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Aetna,Medicare Advantage,,26.22,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Aetna,Medicare Advantage,,156.37,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Aetna,Medicare Advantage,,16.99,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Aetna,Medicare Advantage,,17.14,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Aetna,Medicare Advantage,,18.82,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Aetna,Medicare Advantage,,17.03,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Aetna,Medicare Advantage,,18.28,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Aetna,Medicare Advantage,,9.49,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Aetna,Medicare Advantage,,18.64,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Aetna,Medicare Advantage,,32.96,,,,,,,30.16,1527.45,fee schedule,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Aetna,Medicare Advantage,,4.88,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Aetna,Medicare Advantage,,4.88,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Aetna,Medicare Advantage,,123.46,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Aetna,Medicare Advantage,,5.32,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Aetna,Medicare Advantage,,5.32,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Aetna,Medicare Advantage,,12.88,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Aetna,Medicare Advantage,,2.06,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Aetna,Medicare Advantage,,4.48,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Aetna,Medicare Advantage,,33.96,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Aetna,Medicare Advantage,,3.98,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Aetna,Medicare Advantage,,100.95,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Aetna,Medicare Advantage,,12.12,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Aetna,Medicare Advantage,,21.19,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Aetna,Medicare Advantage,,5.11,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Aetna,Medicare Advantage,,4.18,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Aetna,Medicare Advantage,,4.19,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Aetna,Medicare Advantage,,21.74,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Aetna,Medicare Advantage,,5.08,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Aetna,Medicare Advantage,,4.18,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Aetna,Medicare Advantage,,0.45410,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Aetna,Medicare Advantage,,5.72,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Aetna,Medicare Advantage,,5.35,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Aetna,Medicare Advantage,,46.99,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Aetna,Medicare Advantage,,4.06,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Aetna,Medicare Advantage,,11.57,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Aetna,Medicare Advantage,,7.10,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Aetna,Medicare Advantage,,1.79,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Aetna,Medicare Advantage,,4.12,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Aetna,Medicare Advantage,,4.96,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Aetna,Medicare Advantage,,19.45,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Aetna,Medicare Advantage,,0.80065,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Aetna,Medicare Advantage,,3.44,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Aetna,Medicare Advantage,,3.90,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Aetna,Medicare Advantage,,4.05,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Aetna,Medicare Advantage,,5.38,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Aetna,Medicare Advantage,,0.31070,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Aetna,Medicare Advantage,,7.79,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Aetna,Medicare Advantage,,19.08,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Aetna,Medicare Advantage,,5.47,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Aetna,Medicare Advantage,,4.34,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Aetna,Medicare Advantage,,4.51,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Aetna,Medicare Advantage,,4.76,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Aetna,Medicare Advantage,,39.32,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Aetna,Medicare Advantage,,3.93,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Aetna,Medicare Advantage,,4.11,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Aetna,Medicare Advantage,,20.16,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Aetna,Medicare Advantage,,7.49,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Aetna,Medicare Advantage,,45.78,,,,,,,41.89,5452.46,fee schedule,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Aetna,Medicare Advantage,,6.72,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Aetna,Medicare Advantage,,18.36,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Aetna,Medicare Advantage,,7.58,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Aetna,Medicare Advantage,,4.06,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Aetna,Medicare Advantage,,4.03,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Aetna,Medicare Advantage,,655.17,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Aetna,Medicare Advantage,,21.08,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Aetna,Medicare Advantage,,9.54,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Aetna,Medicare Advantage,,6.30,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Aetna,Medicare Advantage,,23.22,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Aetna,Medicare Advantage,,24.28,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Aetna,Medicare Advantage,,35.13,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Aetna,Medicare Advantage,,6.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Aetna,Medicare Advantage,,281.90,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Aetna,Medicare Advantage,,114.98,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Aetna,Medicare Advantage,,114.98,,,,,,,105.22,4286.20,fee schedule,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Aetna,Medicare Advantage,,1.41,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Aetna,Medicare Advantage,,529.80,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Aetna,Medicare Advantage,,4.51,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Aetna,Medicare Advantage,,54.49,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Aetna,Medicare Advantage,,4.61,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Aetna,Medicare Advantage,,4.82,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Aetna,Medicare Advantage,,63.00,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Aetna,Medicare Advantage,,5.07,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Aetna,Medicare Advantage,,4.64,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Aetna,Medicare Advantage,,5.52,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Aetna,Medicare Advantage,,5.41,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Aetna,Medicare Advantage,,4.78,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Aetna,Medicare Advantage,,6.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Aetna,Medicare Advantage,,24.19,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Aetna,Medicare Advantage,,145.08,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Aetna,Medicare Advantage,,43.22,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Aetna,Medicare Advantage,,43.22,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Aetna,Medicare Advantage,,46.49,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Aetna,Medicare Advantage,,46.76,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Aetna,Medicare Advantage,,18.64,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Aetna,Medicare Advantage,,0.88430,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Aetna,Medicare Advantage,,0.88430,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Aetna,Medicare Advantage,,0.93210,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Aetna,Medicare Advantage,,8.52,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Aetna,Medicare Advantage,,10.37,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Aetna,Medicare Advantage,,14.34,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Aetna,Medicare Advantage,,19.62,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Aetna,Medicare Advantage,,25.02,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Aetna,Medicare Advantage,,52.76,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Aetna,Medicare Advantage,,3.20,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Aetna,Medicare Advantage,,0.34655,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Aetna,Medicare Advantage,,241.82,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Aetna,Medicare Advantage,,1.92,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Aetna,Medicare Advantage,,27.25,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Aetna,Medicare Advantage,,5.53,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Aetna,Medicare Advantage,,6.33,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Aetna,Medicare Advantage,,7.17,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Aetna,Medicare Advantage,,179.88,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Aetna,Medicare Advantage,,4.39,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Aetna,Medicare Advantage,,73.71,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Aetna,Medicare Advantage,,5.76,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Aetna,Medicare Advantage,,22.23,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Aetna,Medicare Advantage,,22.06,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Aetna,Medicare Advantage,,21.58,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Aetna,Medicare Advantage,,5.46,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Aetna,Medicare Advantage,,4.85,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Aetna,Medicare Advantage,,4.33,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Aetna,Medicare Advantage,,11.03,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Aetna,Medicare Advantage,,12.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Aetna,Medicare Advantage,,63.98,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Aetna,Medicare Advantage,,6.67,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Aetna,Medicare Advantage,,15.09,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Aetna,Medicare Advantage,,143.20,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Aetna,Medicare Advantage,,9.02,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Aetna,Medicare Advantage,,14.93,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Aetna,Medicare Advantage,,348.04,,,,,,,318.49,2612.54,fee schedule,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Aetna,Medicare Advantage,,370.93,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Aetna,Medicare Advantage,,0.84800,,,,,,,0.77600,893.68,fee schedule,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Aetna,Medicare Advantage,,4.25,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Aetna,Medicare Advantage,,51.62,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Aetna,Medicare Advantage,,27.54,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Aetna,Medicare Advantage,,125.22,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Aetna,Medicare Advantage,,166.94,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Aetna,Medicare Advantage,,8.64,,,,,,,7.91,889.90,fee schedule,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Aetna,Medicare Advantage,,80.26,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Aetna,Medicare Advantage,,83.53,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Aetna,Medicare Advantage,,4.56,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Aetna,Medicare Advantage,,4.60,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Aetna,Medicare Advantage,,5.10,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Aetna,Medicare Advantage,,6.80,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Aetna,Medicare Advantage,,4.61,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Aetna,Medicare Advantage,,1938.44,,,,,,,1773.86,9551.37,fee schedule,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Aetna,Medicare Advantage,,12.52,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Aetna,Medicare Advantage,,85.38,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Aetna,Medicare Advantage,,15.92,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Aetna,Medicare Advantage,,4.24,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Aetna,Medicare Advantage,,0.58555,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Aetna,Medicare Advantage,,1.06,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Aetna,Medicare Advantage,,5.10,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Aetna,Medicare Advantage,,6.48,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Aetna,Medicare Advantage,,165.63,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Aetna,Medicare Advantage,,4.66,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Aetna,Medicare Advantage,,4.07,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Aetna,Medicare Advantage,,4.66,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Aetna,Medicare Advantage,,5.16,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Aetna,Medicare Advantage,,1.80,,,,,,,1.65,61.68,fee schedule,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Aetna,Medicare Advantage,,88.35,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Aetna,Medicare Advantage,,100.38,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Aetna,Medicare Advantage,,6.85,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Aetna,Medicare Advantage,,10.13,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Aetna,Medicare Advantage,,6.79,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Aetna,Medicare Advantage,,12.77,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Aetna,Medicare Advantage,,7.41,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Aetna,Medicare Advantage,,6.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Aetna,Medicare Advantage,,0.41825,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Aetna,Medicare Advantage,,28.66,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Aetna,Medicare Advantage,,1.51,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Aetna,Medicare Advantage,,22.47,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Aetna,Medicare Advantage,,20.67,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Aetna,Medicare Advantage,,4.13,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Aetna,Medicare Advantage,,111.15,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Aetna,Medicare Advantage,,76.24,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Aetna,Medicare Advantage,,201.70,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Aetna,Medicare Advantage,,4.90,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Aetna,Medicare Advantage,,4.16,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Aetna,Medicare Advantage,,63.35,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Aetna,Medicare Advantage,,100.12,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Aetna,Medicare Advantage,,5478.32,,,,,,,3998.59,14823.96,fee schedule,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Aetna,Medicare Advantage,,8.08,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Aetna,Medicare Advantage,,5.10,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Aetna,Medicare Advantage,,5.10,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Aetna,Medicare Advantage,,43.77,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Aetna,Medicare Advantage,,27.80,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Aetna,Medicare Advantage,,7.15,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Aetna,Medicare Advantage,,29.96,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Aetna,Medicare Advantage,,17.09,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Aetna,Medicare Advantage,,45.43,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Aetna,Medicare Advantage,,20.21,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Aetna,Medicare Advantage,,124.59,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Aetna,Medicare Advantage,,7.78,,,,,,,7.12,44.31,fee schedule,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Aetna,Medicare Advantage,,5.26,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Aetna,Medicare Advantage,,6.84,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Aetna,Medicare Advantage,,28.93,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Aetna,Medicare Advantage,,94.70,,,,,,,86.66,21685.53,fee schedule,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Aetna,Medicare Advantage,,8.76,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Aetna,Medicare Advantage,,5.29,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Aetna,Medicare Advantage,,5.34,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Aetna,Medicare Advantage,,22.31,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Aetna,Medicare Advantage,,6.89,,,,,,,6.30,2210.31,fee schedule,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Aetna,Medicare Advantage,,8.56,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Aetna,Medicare Advantage,,30.75,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Aetna,Medicare Advantage,,187.04,,,,,,,171.16,1679.19,fee schedule,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Aetna,Medicare Advantage,,10.18,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Aetna,Medicare Advantage,,8.38,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Aetna,Medicare Advantage,,7.01,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Aetna,Medicare Advantage,,13.20,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Aetna,Medicare Advantage,,8.65,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Aetna,Medicare Advantage,,57.99,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Aetna,Medicare Advantage,,57.99,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Aetna,Medicare Advantage,,57.99,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Aetna,Medicare Advantage,,57.99,,,,,,,53.07,38712.04,fee schedule,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Aetna,Medicare Advantage,,43.25,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Aetna,Medicare Advantage,,95.50,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Aetna,Medicare Advantage,,6.09,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Aetna,Medicare Advantage,,11.99,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Aetna,Medicare Advantage,,35.32,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Aetna,Medicare Advantage,,75.60,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Aetna,Medicare Advantage,,4.40,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Aetna,Medicare Advantage,,4.25,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Aetna,Medicare Advantage,,11.57,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Aetna,Medicare Advantage,,12.06,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Aetna,Medicare Advantage,,4.06,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Aetna,Medicare Advantage,,4.29,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Aetna,Medicare Advantage,,400.17,,,,,,,366.19,3497.54,fee schedule,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Aetna,Medicare Advantage,,4.07,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Aetna,Medicare Advantage,,13.71,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Aetna,Medicare Advantage,,32.15,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Aetna,Medicare Advantage,,8.88,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Aetna,Medicare Advantage,,40.07,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Aetna,Medicare Advantage,,11.69,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Aetna,Medicare Advantage,,5.23,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Aetna,Medicare Advantage,,5.38,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Aetna,Medicare Advantage,,5.47,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Aetna,Medicare Advantage,,76.87,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Aetna,Medicare Advantage,,5.14,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Aetna,Medicare Advantage,,6.27,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Aetna,Medicare Advantage,,8.87,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Aetna,Medicare Advantage,,0.48760,,,,,,,0.44620,20.67,fee schedule,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Aetna,Medicare Advantage,,111.15,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Aetna,Medicare Advantage,,2.70,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Aetna,Medicare Advantage,,0.39435,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Aetna,Medicare Advantage,,247.33,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Aetna,Medicare Advantage,,5.94,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Aetna,Medicare Advantage,,5.93,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Aetna,Medicare Advantage,,60.23,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Aetna,Medicare Advantage,,7.17,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Aetna,Medicare Advantage,,7.73,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Aetna,Medicare Advantage,,4.23,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Aetna,Medicare Advantage,,4.22,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Aetna,Medicare Advantage,,4.36,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Aetna,Medicare Advantage,,4.70,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Aetna,Medicare Advantage,,1751.44,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Aetna,Medicare Advantage,,4.22,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Aetna,Medicare Advantage,,4.33,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Aetna,Medicare Advantage,,4.83,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Aetna,Medicare Advantage,,4.00,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Aetna,Medicare Advantage,,20.91,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Aetna,Medicare Advantage,,47.28,,,,,,,43.26,4637.71,fee schedule,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Aetna,Medicare Advantage,,20.92,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Aetna,Medicare Advantage,,11.69,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Aetna,Medicare Advantage,,23.16,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Aetna,Medicare Advantage,,25.19,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Aetna,Medicare Advantage,,5.08,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Aetna,Medicare Advantage,,0.35850,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Aetna,Medicare Advantage,,4.47,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Aetna,Medicare Advantage,,16.87,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Aetna,Medicare Advantage,,1.16,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Aetna,Medicare Advantage,,4.05,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Aetna,Medicare Advantage,,6.79,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Aetna,Medicare Advantage,,4.03,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Aetna,Medicare Advantage,,115.44,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Aetna,Medicare Advantage,,4.29,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Aetna,Medicare Advantage,,3.87,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Aetna,Medicare Advantage,,5.64,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Aetna,Medicare Advantage,,1.03,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Aetna,Medicare Advantage,,6.56,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Aetna,Medicare Advantage,,1.03,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Aetna,Medicare Advantage,,6.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Aetna,Medicare Advantage,,4.10,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Aetna,Medicare Advantage,,14.82,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Aetna,Medicare Advantage,,0.41825,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Aetna,Medicare Advantage,,5.39,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Aetna,Medicare Advantage,,5.57,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Aetna,Medicare Advantage,,5.39,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Aetna,Medicare Advantage,,2.00,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Aetna,Medicare Advantage,,5.43,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Aetna,Medicare Advantage,,3.85,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Aetna,Medicare Advantage,,27.13,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Aetna,Medicare Advantage,,40.49,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Aetna,Medicare Advantage,,6.66,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Aetna,Medicare Advantage,,7.49,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Aetna,Medicare Advantage,,4.62,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Aetna,Medicare Advantage,,83.07,,,,,,,76.02,2935.85,fee schedule,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Aetna,Medicare Advantage,,7.39,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Aetna,Medicare Advantage,,181.07,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Aetna,Medicare Advantage,,55.24,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Aetna,Medicare Advantage,,34.36,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Aetna,Medicare Advantage,,0.50880,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Aetna,Medicare Advantage,,0.50880,,,,,,,0.46560,1119.13,fee schedule,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Aetna,Medicare Advantage,,0.83650,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Aetna,Medicare Advantage,,26.11,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Aetna,Medicare Advantage,,0.38240,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Aetna,Medicare Advantage,,3.90,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Aetna,Medicare Advantage,,6.55,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Aetna,Medicare Advantage,,4.83,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Aetna,Medicare Advantage,,9.79,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Aetna,Medicare Advantage,,332.51,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Aetna,Medicare Advantage,,14.57,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Aetna,Medicare Advantage,,8.85,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Aetna,Medicare Advantage,,1.83,,,,,,,1.68,17.66,fee schedule,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Aetna,Medicare Advantage,,90.16,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Aetna,Medicare Advantage,,115.33,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Aetna,Medicare Advantage,,79.83,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Aetna,Medicare Advantage,,127.95,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Aetna,Medicare Advantage,,28.11,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Aetna,Medicare Advantage,,21.58,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Aetna,Medicare Advantage,,3.84,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Aetna,Medicare Advantage,,5.99,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Aetna,Medicare Advantage,,27.75,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Aetna,Medicare Advantage,,164.00,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Aetna,Medicare Advantage,,384.12,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Aetna,Medicare Advantage,,4.17,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Aetna,Medicare Advantage,,4.46,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Aetna,Medicare Advantage,,15.95,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Aetna,Medicare Advantage,,16.67,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Aetna,Medicare Advantage,,16.13,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Aetna,Medicare Advantage,,18.82,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Aetna,Medicare Advantage,,16.67,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Aetna,Medicare Advantage,,16.13,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Aetna,Medicare Advantage,,35.85,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Aetna,Medicare Advantage,,17.57,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Aetna,Medicare Advantage,,16.67,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Aetna,Medicare Advantage,,16.13,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Aetna,Medicare Advantage,,16.13,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Aetna,Medicare Advantage,,15.95,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Aetna,Medicare Advantage,,17.21,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Aetna,Medicare Advantage,,16.67,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Aetna,Medicare Advantage,,18.82,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Aetna,Medicare Advantage,,15.95,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Aetna,Medicare Advantage,,3.86,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Aetna,Medicare Advantage,,244.62,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Aetna,Medicare Advantage,,5.41,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Aetna,Medicare Advantage,,11.17,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Aetna,Medicare Advantage,,10.75,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Aetna,Medicare Advantage,,10.75,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Aetna,Medicare Advantage,,10.75,,,,,,,9.84,19644.81,fee schedule,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Aetna,Medicare Advantage,,4.52,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Aetna,Medicare Advantage,,2575.68,,,,,,,0.04004,6806.87,fee schedule,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Aetna,Medicare Advantage,,4.59,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Aetna,Medicare Advantage,,25.57,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Aetna,Medicare Advantage,,1751.44,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Aetna,Medicare Advantage,,83.70,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Aetna,Medicare Advantage,,21.57,,,,,,,19.74,922.55,fee schedule,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Aetna,Medicare Advantage,,5.45,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Aetna,Medicare Advantage,,11.04,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Aetna,Medicare Advantage,,1680.31,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Aetna,Medicare Advantage,,79.42,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Aetna,Medicare Advantage,,73.68,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Aetna,Medicare Advantage,,160.98,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Aetna,Medicare Advantage,,194.49,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Aetna,Medicare Advantage,,194.49,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Aetna,Medicare Advantage,,72.29,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Aetna,Medicare Advantage,,65.96,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Aetna,Medicare Advantage,,65.96,,,,,,,60.36,19908.25,fee schedule,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Aetna,Medicare Advantage,,76.52,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Aetna,Medicare Advantage,,69.32,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Aetna,Medicare Advantage,,75.23,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Aetna,Medicare Advantage,,69.26,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Aetna,Medicare Advantage,,100.69,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Aetna,Medicare Advantage,,486.37,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Aetna,Medicare Advantage,,118.31,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Aetna,Medicare Advantage,,238.19,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Aetna,Medicare Advantage,,5.47,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Aetna,Medicare Advantage,,18.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Aetna,Medicare Advantage,,80.64,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Aetna,Medicare Advantage,,6.05,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Aetna,Medicare Advantage,,6.05,,,,,,,5.54,8325.59,fee schedule,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Aetna,Medicare Advantage,,25.18,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,47.09,fee schedule,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Aetna,Medicare Advantage,,4.55,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Aetna,Medicare Advantage,,20.08,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Aetna,Medicare Advantage,,6.37,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Aetna,Medicare Advantage,,81.93,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Aetna,Medicare Advantage,,14.58,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Aetna,Medicare Advantage,,18.16,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Aetna,Medicare Advantage,,69.99,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Aetna,Medicare Advantage,,4.97,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Aetna,Medicare Advantage,,10.35,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Aetna,Medicare Advantage,,6.00,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Aetna,Medicare Advantage,,6.98,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Aetna,Medicare Advantage,,4.66,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Aetna,Medicare Advantage,,4.60,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Aetna,Medicare Advantage,,24.70,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Aetna,Medicare Advantage,,17.21,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Aetna,Medicare Advantage,,18.64,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Aetna,Medicare Advantage,,17.06,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Aetna,Medicare Advantage,,18.10,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Aetna,Medicare Advantage,,16.89,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Aetna,Medicare Advantage,,17.93,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Aetna,Medicare Advantage,,68.47,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.04004,0.71810,fee schedule,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Aetna,Medicare Advantage,,15.07,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Aetna,Medicare Advantage,,26.15,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,274.16,,,,,,,0.04004,720.99,fee schedule,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Aetna,Medicare Advantage,,1.14,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Aetna,Medicare Advantage,,52.34,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Aetna,Medicare Advantage,,4.48,,,,,,,4.10,849.34,fee schedule,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Aetna,Medicare Advantage,,259.60,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Aetna,Medicare Advantage,,10.64,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Aetna,Medicare Advantage,,11.11,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Aetna,Medicare Advantage,,7.54,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Aetna,Medicare Advantage,,0.66920,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Aetna,Medicare Advantage,,219.56,,,,,,,200.92,27145.97,fee schedule,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Aetna,Medicare Advantage,,76.04,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Aetna,Medicare Advantage,,52.34,,,,,,,0.54280,162.54,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Aetna,Medicare Advantage,,6.63,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Aetna,Medicare Advantage,,2.81,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Aetna,Medicare Advantage,,2.81,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Aetna,Medicare Advantage,,2.81,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Aetna,Medicare Advantage,,2.81,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Aetna,Medicare Advantage,,17.95,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Aetna,Medicare Advantage,,25.85,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Aetna,Medicare Advantage,,36.63,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Aetna,Medicare Advantage,,5.22,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Aetna,Medicare Advantage,,4.68,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Aetna,Medicare Advantage,,13.80,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Aetna,Medicare Advantage,,48.83,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Aetna,Medicare Advantage,,3.92,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Aetna,Medicare Advantage,,12.71,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Aetna,Medicare Advantage,,3.87,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Aetna,Medicare Advantage,,5.72,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Aetna,Medicare Advantage,,296.64,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Aetna,Medicare Advantage,,296.64,,,,,,,271.45,2077.42,fee schedule,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Aetna,Medicare Advantage,,19.04,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Aetna,Medicare Advantage,,11.56,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Aetna,Medicare Advantage,,6.74,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Aetna,Medicare Advantage,,18.21,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.29100,33.96,fee schedule,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Aetna,Medicare Advantage,,24.95,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Aetna,Medicare Advantage,,58.08,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Aetna,Medicare Advantage,,15.20,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Aetna,Medicare Advantage,,58.08,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Aetna,Medicare Advantage,,7.12,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Aetna,Medicare Advantage,,138.18,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Aetna,Medicare Advantage,,6.81,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Aetna,Medicare Advantage,,4.94,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Aetna,Medicare Advantage,,4.82,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Aetna,Medicare Advantage,,4.84,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Aetna,Medicare Advantage,,6.30,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Aetna,Medicare Advantage,,1.70,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Aetna,Medicare Advantage,,36.75,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Aetna,Medicare Advantage,,96.81,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Aetna,Medicare Advantage,,37.05,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Aetna,Medicare Advantage,,192.04,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Aetna,Medicare Advantage,,15.82,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Aetna,Medicare Advantage,,5.97,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Aetna,Medicare Advantage,,4.54,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Aetna,Medicare Advantage,,16.73,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Aetna,Medicare Advantage,,21.03,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Aetna,Medicare Advantage,,17.88,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Aetna,Medicare Advantage,,14.44,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Aetna,Medicare Advantage,,22.04,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Aetna,Medicare Advantage,,89.86,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Aetna,Medicare Advantage,,4.54,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Aetna,Medicare Advantage,,15.38,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Aetna,Medicare Advantage,,6.46,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Aetna,Medicare Advantage,,27.43,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Aetna,Medicare Advantage,,58.08,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Aetna,Medicare Advantage,,11.35,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Aetna,Medicare Advantage,,4.16,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Aetna,Medicare Advantage,,15.30,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Aetna,Medicare Advantage,,6.86,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Aetna,Medicare Advantage,,3.92,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Aetna,Medicare Advantage,,4.15,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Aetna,Medicare Advantage,,22.59,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Aetna,Medicare Advantage,,8.13,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Aetna,Medicare Advantage,,5.58,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Aetna,Medicare Advantage,,51.53,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Aetna,Medicare Advantage,,80.95,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Aetna,Medicare Advantage,,19.20,,,,,,,17.57,619.74,fee schedule,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Aetna,Medicare Advantage,,15.59,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Aetna,Medicare Advantage,,19.59,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Aetna,Medicare Advantage,,53.20,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Aetna,Medicare Advantage,,21.08,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Aetna,Medicare Advantage,,21.04,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Aetna,Medicare Advantage,,30.72,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Aetna,Medicare Advantage,,1.41,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Aetna,Medicare Advantage,,12.21,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Aetna,Medicare Advantage,,6.79,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Aetna,Medicare Advantage,,182.55,,,,,,,167.05,28031.82,fee schedule,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Aetna,Medicare Advantage,,76.24,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Aetna,Medicare Advantage,,40.25,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Aetna,Medicare Advantage,,15.43,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Aetna,Medicare Advantage,,17.38,,,,,,,1.80,53.96,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Aetna,Medicare Advantage,,17.93,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Aetna,Medicare Advantage,,14.44,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Aetna,Medicare Advantage,,21.02,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Aetna,Medicare Advantage,,88.93,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.29100,14.29,fee schedule,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Aetna,Medicare Advantage,,16.11,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Aetna,Medicare Advantage,,16.35,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Aetna,Medicare Advantage,,23.09,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Aetna,Medicare Advantage,,7.34,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Aetna,Medicare Advantage,,25.47,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Aetna,Medicare Advantage,,41.06,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Aetna,Medicare Advantage,,24.84,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Aetna,Medicare Advantage,,59.85,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Aetna,Medicare Advantage,,40.86,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Aetna,Medicare Advantage,,19.28,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Aetna,Medicare Advantage,,16.81,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Aetna,Medicare Advantage,,24.84,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Aetna,Medicare Advantage,,19.57,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Aetna,Medicare Advantage,,23.09,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Aetna,Medicare Advantage,,26.10,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Aetna,Medicare Advantage,,114.43,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Aetna,Medicare Advantage,,28.17,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Aetna,Medicare Advantage,,135.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Aetna,Medicare Advantage,,157.93,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Aetna,Medicare Advantage,,193.40,,,,,,,176.98,922.11,fee schedule,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Aetna,Medicare Advantage,,8.72,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Aetna,Medicare Advantage,,19.98,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Aetna,Medicare Advantage,,17.77,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Aetna,Medicare Advantage,,36.64,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Aetna,Medicare Advantage,,52.22,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Aetna,Medicare Advantage,,122.46,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Aetna,Medicare Advantage,,229.87,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Aetna,Medicare Advantage,,21.58,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Aetna,Medicare Advantage,,24.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,183.88,fee schedule,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Aetna,Medicare Advantage,,15.97,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Aetna,Medicare Advantage,,18.68,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Aetna,Medicare Advantage,,175.70,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Aetna,Medicare Advantage,,4.19,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Aetna,Medicare Advantage,,65.77,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Aetna,Medicare Advantage,,15.16,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Aetna,Medicare Advantage,,25.12,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Aetna,Medicare Advantage,,69.26,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Aetna,Medicare Advantage,,42.16,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Aetna,Medicare Advantage,,5.78,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Aetna,Medicare Advantage,,28.81,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Aetna,Medicare Advantage,,17.06,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Aetna,Medicare Advantage,,18.73,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Aetna,Medicare Advantage,,43.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Aetna,Medicare Advantage,,41.06,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Aetna,Medicare Advantage,,18.07,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Aetna,Medicare Advantage,,6.98,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Aetna,Medicare Advantage,,8.31,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Aetna,Medicare Advantage,,17.06,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Aetna,Medicare Advantage,,0.22260,,,,,,,0.20370,1324.83,fee schedule,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Aetna,Medicare Advantage,,23.79,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Aetna,Medicare Advantage,,6.01,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Aetna,Medicare Advantage,,8.33,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Aetna,Medicare Advantage,,17.15,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Aetna,Medicare Advantage,,6.63,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Aetna,Medicare Advantage,,15.08,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Aetna,Medicare Advantage,,41.59,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Aetna,Medicare Advantage,,15.30,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Aetna,Medicare Advantage,,21.08,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Aetna,Medicare Advantage,,5.37,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Aetna,Medicare Advantage,,5.38,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Aetna,Medicare Advantage,,6.12,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Aetna,Medicare Advantage,,10.21,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Aetna,Medicare Advantage,,6.24,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Aetna,Medicare Advantage,,31.32,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Aetna,Medicare Advantage,,22.59,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Aetna,Medicare Advantage,,33.38,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Aetna,Medicare Advantage,,6.97,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Aetna,Medicare Advantage,,24.93,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Aetna,Medicare Advantage,,25.57,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Aetna,Medicare Advantage,,19.57,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Aetna,Medicare Advantage,,4.24,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Aetna,Medicare Advantage,,16.32,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Aetna,Medicare Advantage,,4.12,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Aetna,Medicare Advantage,,13.36,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Aetna,Medicare Advantage,,19.66,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Aetna,Medicare Advantage,,25.42,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Aetna,Medicare Advantage,,74.28,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Aetna,Medicare Advantage,,19.06,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Aetna,Medicare Advantage,,76.30,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Aetna,Medicare Advantage,,17.93,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Aetna,Medicare Advantage,,15.33,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Aetna,Medicare Advantage,,9.49,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Aetna,Medicare Advantage,,25.09,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Aetna,Medicare Advantage,,17.87,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Aetna,Medicare Advantage,,12.43,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Aetna,Medicare Advantage,,38.62,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Aetna,Medicare Advantage,,5.29,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Aetna,Medicare Advantage,,75.00,,,,,,,0.04004,200.52,fee schedule,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Aetna,Medicare Advantage,,15.08,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Aetna,Medicare Advantage,,100.12,,,,,,,90.46,335.36,fee schedule,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Aetna,Medicare Advantage,,40.07,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Aetna,Medicare Advantage,,66.11,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Aetna,Medicare Advantage,,57.22,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Aetna,Medicare Advantage,,17.66,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Aetna,Medicare Advantage,,15.70,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Aetna,Medicare Advantage,,19.02,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Aetna,Medicare Advantage,,75.00,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Aetna,Medicare Advantage,,75.00,,,,,,,0.04004,200.52,fee schedule,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Aetna,Medicare Advantage,,14.29,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Aetna,Medicare Advantage,,3.84,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Aetna,Medicare Advantage,,59.18,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Aetna,Medicare Advantage,,139.26,,,,,,,127.44,7479.15,fee schedule,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Aetna,Medicare Advantage,,20.94,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Aetna,Medicare Advantage,,35.95,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Aetna,Medicare Advantage,,36.72,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Aetna,Medicare Advantage,,100.12,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Aetna,Medicare Advantage,,96.82,,,,,,,0.04004,215.56,fee schedule,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,1834.14,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,1834.14,,,,,,,0.04004,4844.60,fee schedule,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Aetna,Medicare Advantage,,38.46,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,90.23,,,,,,,0.04004,237.76,fee schedule,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Aetna,Medicare Advantage,,58.99,,,,,,,53.98,11755.45,fee schedule,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Aetna,Medicare Advantage,,94.31,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Aetna,Medicare Advantage,,134.07,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Aetna,Medicare Advantage,,74.40,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Aetna,Medicare Advantage,,115.70,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Aetna,Medicare Advantage,,108.11,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Aetna,Medicare Advantage,,97.27,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Aetna,Medicare Advantage,,87.81,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Aetna,Medicare Advantage,,134.07,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Aetna,Medicare Advantage,,74.40,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Aetna,Medicare Advantage,,115.70,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Aetna,Medicare Advantage,,0.50880,,,,,,,0.46560,2034.07,fee schedule,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Aetna,Medicare Advantage,,24.19,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Aetna,Medicare Advantage,,27.52,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Aetna,Medicare Advantage,,6.00,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Aetna,Medicare Advantage,,7.09,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Aetna,Medicare Advantage,,21.08,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Aetna,Medicare Advantage,,46.68,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Aetna,Medicare Advantage,,34.94,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Aetna,Medicare Advantage,,4.48,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Aetna,Medicare Advantage,,4.48,,,,,,,4.10,849.34,fee schedule,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Aetna,Medicare Advantage,,17.59,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Aetna,Medicare Advantage,,15.40,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Aetna,Medicare Advantage,,98.50,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Aetna,Medicare Advantage,,9.64,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Aetna,Medicare Advantage,,0.39220,,,,,,,0.35890,128.59,fee schedule,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Aetna,Medicare Advantage,,15.10,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Aetna,Medicare Advantage,,27.52,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Aetna,Medicare Advantage,,11.69,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Aetna,Medicare Advantage,,6.15,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Aetna,Medicare Advantage,,7.73,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Aetna,Medicare Advantage,,378.78,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Aetna,Medicare Advantage,,9.26,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Aetna,Medicare Advantage,,114.34,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Aetna,Medicare Advantage,,21.03,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Aetna,Medicare Advantage,,7.13,,,,,,,6.53,1915.21,fee schedule,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Aetna,Medicare Advantage,,4.11,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Aetna,Medicare Advantage,,34.49,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Aetna,Medicare Advantage,,329.86,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Aetna,Medicare Advantage,,17.64,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Aetna,Medicare Advantage,,51.38,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Aetna,Medicare Advantage,,142.74,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Aetna,Medicare Advantage,,26.10,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Aetna,Medicare Advantage,,27.60,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Aetna,Medicare Advantage,,10.35,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Aetna,Medicare Advantage,,15.62,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Aetna,Medicare Advantage,,11.34,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Aetna,Medicare Advantage,,15.79,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Aetna,Medicare Advantage,,8.72,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Aetna,Medicare Advantage,,15.79,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Aetna,Medicare Advantage,,11.58,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Aetna,Medicare Advantage,,21.22,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Aetna,Medicare Advantage,,62.24,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Aetna,Medicare Advantage,,28.61,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Aetna,Medicare Advantage,,28.26,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Aetna,Medicare Advantage,,3.84,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Aetna,Medicare Advantage,,1623.53,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Aetna,Medicare Advantage,,7.40,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Aetna,Medicare Advantage,,19.90,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Aetna,Medicare Advantage,,15.56,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Aetna,Medicare Advantage,,42.63,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Aetna,Medicare Advantage,,12.09,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Aetna,Medicare Advantage,,55.38,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Aetna,Medicare Advantage,,56.82,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Aetna,Medicare Advantage,,35.95,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Aetna,Medicare Advantage,,0.84800,,,,,,,0.77600,358.48,fee schedule,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Aetna,Medicare Advantage,,16.31,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Aetna,Medicare Advantage,,5.28,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Aetna,Medicare Advantage,,5.45,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Aetna,Medicare Advantage,,109.69,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Aetna,Medicare Advantage,,6.23,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Aetna,Medicare Advantage,,21.57,,,,,,,19.74,4331.81,fee schedule,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Aetna,Medicare Advantage,,15.07,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Aetna,Medicare Advantage,,15.09,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Aetna,Medicare Advantage,,15.12,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Aetna,Medicare Advantage,,15.13,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Aetna,Medicare Advantage,,15.07,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Aetna,Medicare Advantage,,34.63,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Aetna,Medicare Advantage,,100.12,,,,,,,3.87,262.57,fee schedule,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Aetna,Medicare Advantage,,3.84,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Aetna,Medicare Advantage,,15.82,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Aetna,Medicare Advantage,,11.96,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Aetna,Medicare Advantage,,109.02,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Aetna,Medicare Advantage,,110.44,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Aetna,Medicare Advantage,,86.29,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Aetna,Medicare Advantage,,19.07,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Aetna,Medicare Advantage,,2.82,,,,,,,2.58,65.50,fee schedule,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Aetna,Medicare Advantage,,8.84,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Aetna,Medicare Advantage,,18.07,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Aetna,Medicare Advantage,,18.82,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Aetna,Medicare Advantage,,17.93,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Aetna,Medicare Advantage,,3.84,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Aetna,Medicare Advantage,,5.41,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Aetna,Medicare Advantage,,5.94,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Aetna,Medicare Advantage,,37.92,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Aetna,Medicare Advantage,,2.27,,,,,,,2.08,66.02,fee schedule,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Aetna,Medicare Advantage,,30.01,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Aetna,Medicare Advantage,,20.10,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Aetna,Medicare Advantage,,85.38,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Aetna,Medicare Advantage,,276.30,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Aetna,Medicare Advantage,,6.30,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Aetna,Medicare Advantage,,5.96,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Aetna,Medicare Advantage,,174.53,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Aetna,Medicare Advantage,,24.31,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Aetna,Medicare Advantage,,15.30,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Aetna,Medicare Advantage,,24.74,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Aetna,Medicare Advantage,,14.83,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Aetna,Medicare Advantage,,36.15,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Aetna,Medicare Advantage,,68.47,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Aetna,Medicare Advantage,,9.32,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Aetna,Medicare Advantage,,14.70,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Aetna,Medicare Advantage,,6.31,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Aetna,Medicare Advantage,,8.72,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Aetna,Medicare Advantage,,50.19,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Aetna,Medicare Advantage,,18.07,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Aetna,Medicare Advantage,,20.98,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Aetna,Medicare Advantage,,19.67,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Aetna,Medicare Advantage,,6.00,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Aetna,Medicare Advantage,,7.09,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Aetna,Medicare Advantage,,16.00,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Aetna,Medicare Advantage,,20.08,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Aetna,Medicare Advantage,,5.54,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Aetna,Medicare Advantage,,8.22,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Aetna,Medicare Advantage,,4.94,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Aetna,Medicare Advantage,,10.21,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Aetna,Medicare Advantage,,5.72,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Aetna,Medicare Advantage,,6.26,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Aetna,Medicare Advantage,,4.22,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Aetna,Medicare Advantage,,3.91,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Aetna,Medicare Advantage,,126.98,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Aetna,Medicare Advantage,,8.13,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Aetna,Medicare Advantage,,21.03,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Aetna,Medicare Advantage,,63.91,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Aetna,Medicare Advantage,,7.13,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Aetna,Medicare Advantage,,174.10,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Aetna,Medicare Advantage,,174.10,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Aetna,Medicare Advantage,,174.10,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Aetna,Medicare Advantage,,174.10,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Aetna,Medicare Advantage,,174.10,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Aetna,Medicare Advantage,,182.55,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Aetna,Medicare Advantage,,79.53,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Aetna,Medicare Advantage,,65.13,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Aetna,Medicare Advantage,,65.83,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Aetna,Medicare Advantage,,65.83,,,,,,,0.04004,176.79,fee schedule,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Aetna,Medicare Advantage,,96.54,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Aetna,Medicare Advantage,,4.62,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Aetna,Medicare Advantage,,63.91,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Aetna,Medicare Advantage,,63.91,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Aetna,Medicare Advantage,,25.50,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Aetna,Medicare Advantage,,7.09,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Aetna,Medicare Advantage,,5.51,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Aetna,Medicare Advantage,,35.41,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Aetna,Medicare Advantage,,7.16,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Aetna,Medicare Advantage,,2.96,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Aetna,Medicare Advantage,,0.84800,,,,,,,0.77600,358.48,fee schedule,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Aetna,Medicare Advantage,,180.92,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Aetna,Medicare Advantage,,11.69,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Aetna,Medicare Advantage,,6.15,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Aetna,Medicare Advantage,,6.24,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Aetna,Medicare Advantage,,66.50,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Aetna,Medicare Advantage,,13.96,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Aetna,Medicare Advantage,,18.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Aetna,Medicare Advantage,,4.03,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Aetna,Medicare Advantage,,21.03,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Aetna,Medicare Advantage,,129.01,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Aetna,Medicare Advantage,,73.71,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Aetna,Medicare Advantage,,0.99185,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Aetna,Medicare Advantage,,0.66920,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Aetna,Medicare Advantage,,66.14,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Aetna,Medicare Advantage,,71.33,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Aetna,Medicare Advantage,,57.04,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Aetna,Medicare Advantage,,62.28,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Aetna,Medicare Advantage,,0.53775,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Aetna,Medicare Advantage,,1.94,,,,,,,1.78,216.20,fee schedule,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Aetna,Medicare Advantage,,9.83,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Aetna,Medicare Advantage,,15.83,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Aetna,Medicare Advantage,,18.59,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Aetna,Medicare Advantage,,6.86,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Aetna,Medicare Advantage,,9.01,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Aetna,Medicare Advantage,,8.89,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Aetna,Medicare Advantage,,250.82,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Aetna,Medicare Advantage,,96.82,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Aetna,Medicare Advantage,,96.82,,,,,,,88.60,38051.26,fee schedule,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Aetna,Medicare Advantage,,6.56,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Aetna,Medicare Advantage,,132.88,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Aetna,Medicare Advantage,,75.23,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Aetna,Medicare Advantage,,69.26,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Aetna,Medicare Advantage,,100.69,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Aetna,Medicare Advantage,,58.90,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Aetna,Medicare Advantage,,83.07,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Aetna,Medicare Advantage,,83.07,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Aetna,Medicare Advantage,,83.07,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Aetna,Medicare Advantage,,83.07,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Aetna,Medicare Advantage,,83.07,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Aetna,Medicare Advantage,,83.07,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Aetna,Medicare Advantage,,2575.68,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Aetna,Medicare Advantage,,0.29680,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Aetna,Medicare Advantage,,38.94,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Aetna,Medicare Advantage,,38.94,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Aetna,Medicare Advantage,,38.94,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Aetna,Medicare Advantage,,76.98,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Aetna,Medicare Advantage,,101.65,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Aetna,Medicare Advantage,,4.69,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Aetna,Medicare Advantage,,4.69,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Aetna,Medicare Advantage,,4.69,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Aetna,Medicare Advantage,,4.69,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Aetna,Medicare Advantage,,4.69,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Aetna,Medicare Advantage,,4.69,,,,,,,4.29,1267.75,fee schedule,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Aetna,Medicare Advantage,,66.65,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Aetna,Medicare Advantage,,10.54,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Aetna,Medicare Advantage,,0.39220,,,,,,,0.35890,22.08,fee schedule,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Aetna,Medicare Advantage,,45849.27,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Aetna,Medicare Advantage,,30.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Aetna,Medicare Advantage,,16.85,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Aetna,Medicare Advantage,,17.93,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Aetna,Medicare Advantage,,17.75,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Aetna,Medicare Advantage,,17.93,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Aetna,Medicare Advantage,,72.29,,,,,,,66.15,1092.00,fee schedule,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Aetna,Medicare Advantage,,16.91,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Aetna,Medicare Advantage,,4.85,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Aetna,Medicare Advantage,,5.14,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Aetna,Medicare Advantage,,4.60,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Aetna,Medicare Advantage,,160.37,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Aetna,Medicare Advantage,,34.67,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Aetna,Medicare Advantage,,175.90,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Aetna,Medicare Advantage,,62.96,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Aetna,Medicare Advantage,,13.24,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Aetna,Medicare Advantage,,13.24,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Aetna,Medicare Advantage,,1.22,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Aetna,Medicare Advantage,,3.10,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Aetna,Medicare Advantage,,19.10,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Aetna,Medicare Advantage,,14.40,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Aetna,Medicare Advantage,,110.12,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Aetna,Medicare Advantage,,18.64,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Aetna,Medicare Advantage,,4.10,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Aetna,Medicare Advantage,,14.15,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Aetna,Medicare Advantage,,9.14,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Aetna,Medicare Advantage,,104.19,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Aetna,Medicare Advantage,,4.37,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Aetna,Medicare Advantage,,25.48,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Aetna,Medicare Advantage,,25.57,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Aetna,Medicare Advantage,,139.34,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Aetna,Medicare Advantage,,74.99,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Aetna,Medicare Advantage,,12.38,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Aetna,Medicare Advantage,,4.88,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Aetna,Medicare Advantage,,4.25,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Aetna,Medicare Advantage,,4.35,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Aetna,Medicare Advantage,,4.23,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Aetna,Medicare Advantage,,4.30,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Aetna,Medicare Advantage,,5.41,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Aetna,Medicare Advantage,,8.13,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Aetna,Medicare Advantage,,7.29,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Aetna,Medicare Advantage,,7.31,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Aetna,Medicare Advantage,,8.16,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Aetna,Medicare Advantage,,9.08,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Aetna,Medicare Advantage,,27.51,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Aetna,Medicare Advantage,,11.73,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Aetna,Medicare Advantage,,3.88,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Aetna,Medicare Advantage,,4.34,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Aetna,Medicare Advantage,,3.92,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Aetna,Medicare Advantage,,4.09,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Aetna,Medicare Advantage,,3.93,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Aetna,Medicare Advantage,,0.51385,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Aetna,Medicare Advantage,,5.69,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Aetna,Medicare Advantage,,27.89,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Aetna,Medicare Advantage,,56.02,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Aetna,Medicare Advantage,,11.34,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Aetna,Medicare Advantage,,1.02,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Aetna,Medicare Advantage,,21.75,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Aetna,Medicare Advantage,,11.56,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Aetna,Medicare Advantage,,6.30,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Aetna,Medicare Advantage,,7.47,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Aetna,Medicare Advantage,,7.09,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Aetna,Medicare Advantage,,44.37,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Aetna,Medicare Advantage,,18.44,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Aetna,Medicare Advantage,,7.15,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Aetna,Medicare Advantage,,4.09,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Aetna,Medicare Advantage,,7.09,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Aetna,Medicare Advantage,,7.16,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Aetna,Medicare Advantage,,20.85,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Aetna,Medicare Advantage,,21.28,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Aetna,Medicare Advantage,,28.20,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Aetna,Medicare Advantage,,5.59,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Aetna,Medicare Advantage,,12.80,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Aetna,Medicare Advantage,,3.91,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Aetna,Medicare Advantage,,8.89,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Aetna,Medicare Advantage,,73.37,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Aetna,Medicare Advantage,,113.05,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Aetna,Medicare Advantage,,5.40,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Aetna,Medicare Advantage,,0.12720,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Aetna,Medicare Advantage,,0.12720,,,,,,,0.11640,78.49,fee schedule,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Aetna,Medicare Advantage,,4.59,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Aetna,Medicare Advantage,,4.55,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Aetna,Medicare Advantage,,4.91,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Aetna,Medicare Advantage,,3.93,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Aetna,Medicare Advantage,,4.22,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Aetna,Medicare Advantage,,4.46,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Aetna,Medicare Advantage,,17.73,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Aetna,Medicare Advantage,,3.23,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Aetna,Medicare Advantage,,4.09,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Aetna,Medicare Advantage,,4.45,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Aetna,Medicare Advantage,,4.33,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Aetna,Medicare Advantage,,6.36,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Aetna,Medicare Advantage,,7.33,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Aetna,Medicare Advantage,,6.30,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Aetna,Medicare Advantage,,5.28,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Aetna,Medicare Advantage,,6.24,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Aetna,Medicare Advantage,,21.75,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Aetna,Medicare Advantage,,5.57,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Aetna,Medicare Advantage,,8.84,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Aetna,Medicare Advantage,,7.72,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Aetna,Medicare Advantage,,21.04,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Aetna,Medicare Advantage,,39.71,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Aetna,Medicare Advantage,,4.07,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Aetna,Medicare Advantage,,30.68,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Aetna,Medicare Advantage,,12.83,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Aetna,Medicare Advantage,,6.14,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Aetna,Medicare Advantage,,4.09,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Aetna,Medicare Advantage,,4.40,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Aetna,Medicare Advantage,,5.56,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Aetna,Medicare Advantage,,2.51,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Aetna,Medicare Advantage,,5.01,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Aetna,Medicare Advantage,,4.29,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Aetna,Medicare Advantage,,48.86,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Aetna,Medicare Advantage,,59.16,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Aetna,Medicare Advantage,,17.66,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Aetna,Medicare Advantage,,10.21,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Aetna,Medicare Advantage,,1623.53,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Aetna,Medicare Advantage,,4.13,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Aetna,Medicare Advantage,,5.81,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Aetna,Medicare Advantage,,5.65,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Aetna,Medicare Advantage,,54.30,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Aetna,Medicare Advantage,,24.16,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Aetna,Medicare Advantage,,8.17,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Aetna,Medicare Advantage,,50.84,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Aetna,Medicare Advantage,,25.57,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Aetna,Medicare Advantage,,1.53,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Aetna,Medicare Advantage,,1.53,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Aetna,Medicare Advantage,,27.13,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Aetna,Medicare Advantage,,5.34,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Aetna,Medicare Advantage,,5.65,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Aetna,Medicare Advantage,,17.28,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Aetna,Medicare Advantage,,60.37,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Aetna,Medicare Advantage,,61.66,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Aetna,Medicare Advantage,,64.46,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Aetna,Medicare Advantage,,37.14,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Aetna,Medicare Advantage,,20.48,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Aetna,Medicare Advantage,,26.30,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Aetna,Medicare Advantage,,17.36,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Aetna,Medicare Advantage,,45.21,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Aetna,Medicare Advantage,,10.72,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Aetna,Medicare Advantage,,0.92015,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Aetna,Medicare Advantage,,0.72895,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Aetna,Medicare Advantage,,98.11,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Aetna,Medicare Advantage,,5.27,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Aetna,Medicare Advantage,,5.84,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Aetna,Medicare Advantage,,35.55,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Aetna,Medicare Advantage,,300.18,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Aetna,Medicare Advantage,,4.05,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Aetna,Medicare Advantage,,5.09,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Aetna,Medicare Advantage,,4.17,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Aetna,Medicare Advantage,,312.37,,,,,,,40.54,695.47,fee schedule,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Aetna,Medicare Advantage,,5.31,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Aetna,Medicare Advantage,,4.16,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Aetna,Medicare Advantage,,4.19,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Aetna,Medicare Advantage,,5.84,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Aetna,Medicare Advantage,,4.23,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Aetna,Medicare Advantage,,28.99,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Aetna,Medicare Advantage,,38.60,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Aetna,Medicare Advantage,,3.98,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Aetna,Medicare Advantage,,4.16,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Aetna,Medicare Advantage,,4.07,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Aetna,Medicare Advantage,,4.41,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Aetna,Medicare Advantage,,61.35,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Aetna,Medicare Advantage,,20.66,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Aetna,Medicare Advantage,,6.02,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Aetna,Medicare Advantage,,15.64,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Aetna,Medicare Advantage,,0.33460,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Aetna,Medicare Advantage,,0.33460,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Aetna,Medicare Advantage,,0.68115,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Aetna,Medicare Advantage,,1.83,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Aetna,Medicare Advantage,,22.43,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Aetna,Medicare Advantage,,4.11,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Aetna,Medicare Advantage,,1.58,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Aetna,Medicare Advantage,,1.58,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Aetna,Medicare Advantage,,1.58,,,,,,,1.45,62.05,fee schedule,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Aetna,Medicare Advantage,,226.42,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Aetna,Medicare Advantage,,5.31,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Aetna,Medicare Advantage,,85.23,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Aetna,Medicare Advantage,,96.71,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Aetna,Medicare Advantage,,0.28680,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Aetna,Medicare Advantage,,3.92,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Aetna,Medicare Advantage,,12.71,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Aetna,Medicare Advantage,,23.90,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Aetna,Medicare Advantage,,25.04,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Aetna,Medicare Advantage,,16.01,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Aetna,Medicare Advantage,,23.90,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Aetna,Medicare Advantage,,27.88,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Aetna,Medicare Advantage,,26.78,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Aetna,Medicare Advantage,,18.82,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Aetna,Medicare Advantage,,18.28,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Aetna,Medicare Advantage,,19.72,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Aetna,Medicare Advantage,,19.71,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Aetna,Medicare Advantage,,22.74,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Aetna,Medicare Advantage,,4.47,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Aetna,Medicare Advantage,,32.66,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Aetna,Medicare Advantage,,17.75,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Aetna,Medicare Advantage,,102.30,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Aetna,Medicare Advantage,,94.36,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Aetna,Medicare Advantage,,4.05,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Aetna,Medicare Advantage,,17.21,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Aetna,Medicare Advantage,,16.49,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Aetna,Medicare Advantage,,19.16,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Aetna,Medicare Advantage,,27.65,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Aetna,Medicare Advantage,,4.02,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Aetna,Medicare Advantage,,4.12,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Aetna,Medicare Advantage,,3.11,,,,,,,2.84,3932.58,fee schedule,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Aetna,Medicare Advantage,,64.51,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Aetna,Medicare Advantage,,170.88,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Aetna,Medicare Advantage,,1.71,,,,,,,1.56,63.16,fee schedule,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Aetna,Medicare Advantage,,10.92,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Aetna,Medicare Advantage,,11.84,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Aetna,Medicare Advantage,,0.37045,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Aetna,Medicare Advantage,,97.45,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Aetna,Medicare Advantage,,5.50,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Aetna,Medicare Advantage,,473.04,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Aetna,Medicare Advantage,,87.90,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Aetna,Medicare Advantage,,1.65,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Aetna,Medicare Advantage,,154.39,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Aetna,Medicare Advantage,,6.35,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Aetna,Medicare Advantage,,19.07,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Aetna,Medicare Advantage,,28.41,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Aetna,Medicare Advantage,,5.33,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Aetna,Medicare Advantage,,22.66,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Aetna,Medicare Advantage,,202.77,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Aetna,Medicare Advantage,,7.70,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Aetna,Medicare Advantage,,6.68,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Aetna,Medicare Advantage,,6.86,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Aetna,Medicare Advantage,,68.35,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Aetna,Medicare Advantage,,1.49,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Aetna,Medicare Advantage,,5.99,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Aetna,Medicare Advantage,,5.99,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Aetna,Medicare Advantage,,12.77,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Aetna,Medicare Advantage,,681.17,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Aetna,Medicare Advantage,,14.83,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Aetna,Medicare Advantage,,5.45,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Aetna,Medicare Advantage,,4.73,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Aetna,Medicare Advantage,,5.65,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Aetna,Medicare Advantage,,14.94,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Aetna,Medicare Advantage,,3.94,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Aetna,Medicare Advantage,,3.96,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Aetna,Medicare Advantage,,5.97,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Aetna,Medicare Advantage,,9.70,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Aetna,Medicare Advantage,,7.16,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Aetna,Medicare Advantage,,14.01,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Aetna,Medicare Advantage,,13.25,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Aetna,Medicare Advantage,,10.87,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Aetna,Medicare Advantage,,50.06,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Aetna,Medicare Advantage,,4.09,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Aetna,Medicare Advantage,,6.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Aetna,Medicare Advantage,,103.07,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Aetna,Medicare Advantage,,117.97,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Aetna,Medicare Advantage,,47.51,,,,,,,43.48,20380.52,fee schedule,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Aetna,Medicare Advantage,,22.08,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Aetna,Medicare Advantage,,4.47,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Aetna,Medicare Advantage,,69.32,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Aetna,Medicare Advantage,,72.92,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Aetna,Medicare Advantage,,28.31,,,,,,,25.91,6736.54,fee schedule,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Aetna,Medicare Advantage,,6.54,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Aetna,Medicare Advantage,,28.82,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Aetna,Medicare Advantage,,25.33,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Aetna,Medicare Advantage,,25.69,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Aetna,Medicare Advantage,,25.68,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Aetna,Medicare Advantage,,13.56,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Aetna,Medicare Advantage,,31.40,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Aetna,Medicare Advantage,,23.25,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Aetna,Medicare Advantage,,105.66,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Aetna,Medicare Advantage,,1.06,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Aetna,Medicare Advantage,,14.70,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Aetna,Medicare Advantage,,10.80,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Aetna,Medicare Advantage,,3.92,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Aetna,Medicare Advantage,,4.12,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Aetna,Medicare Advantage,,1.25,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Aetna,Medicare Advantage,,122.26,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Aetna,Medicare Advantage,,84.39,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Aetna,Medicare Advantage,,4.28,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Aetna,Medicare Advantage,,4.19,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Aetna,Medicare Advantage,,4.21,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Aetna,Medicare Advantage,,4.22,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Aetna,Medicare Advantage,,4.39,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Aetna,Medicare Advantage,,7.98,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Aetna,Medicare Advantage,,31.63,,,,,,,28.94,30042.51,fee schedule,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Aetna,Medicare Advantage,,135.74,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Aetna,Medicare Advantage,,9.78,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Aetna,Medicare Advantage,,23.45,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Aetna,Medicare Advantage,,108.11,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Aetna,Medicare Advantage,,97.27,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Aetna,Medicare Advantage,,37.02,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Aetna,Medicare Advantage,,14.14,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Aetna,Medicare Advantage,,147.56,,,,,,,135.03,19940.84,fee schedule,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Aetna,Medicare Advantage,,17.15,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Aetna,Medicare Advantage,,190.73,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Aetna,Medicare Advantage,,2.19,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Aetna,Medicare Advantage,,0.33460,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Aetna,Medicare Advantage,,23.68,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Aetna,Medicare Advantage,,4.62,,,,,,,4.23,2844.74,fee schedule,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Aetna,Medicare Advantage,,0.77675,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Aetna,Medicare Advantage,,0.58555,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Aetna,Medicare Advantage,,21.51,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Aetna,Medicare Advantage,,259.21,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Aetna,Medicare Advantage,,9.72,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Aetna,Medicare Advantage,,32.50,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Aetna,Medicare Advantage,,129.01,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Aetna,Medicare Advantage,,73.71,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Aetna,Medicare Advantage,,56.26,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Aetna,Medicare Advantage,,56.26,,,,,,,51.49,324.34,fee schedule,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Aetna,Medicare Advantage,,187.99,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Aetna,Medicare Advantage,,100.12,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Aetna,Medicare Advantage,,100.12,,,,,,,91.62,14871.35,fee schedule,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Aetna,Medicare Advantage,,0.94405,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Aetna,Medicare Advantage,,0.29875,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Aetna,Medicare Advantage,,0.47800,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Aetna,Medicare Advantage,,24.37,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Aetna,Medicare Advantage,,4.18,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Aetna,Medicare Advantage,,3.93,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Aetna,Medicare Advantage,,3.97,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Aetna,Medicare Advantage,,12.21,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Aetna,Medicare Advantage,,8.13,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Aetna,Medicare Advantage,,23.42,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Aetna,Medicare Advantage,,30.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Aetna,Medicare Advantage,,88.84,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Aetna,Medicare Advantage,,4.35,,,,,,,3.98,70.40,fee schedule,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Aetna,Medicare Advantage,,50.19,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Aetna,Medicare Advantage,,6.27,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Aetna,Medicare Advantage,,11.94,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Aetna,Medicare Advantage,,41.88,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Aetna,Medicare Advantage,,0.31800,,,,,,,0.29100,22.93,fee schedule,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Aetna,Medicare Advantage,,194.32,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Aetna,Medicare Advantage,,0.25095,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Aetna,Medicare Advantage,,4.78,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Aetna,Medicare Advantage,,127.03,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Aetna,Medicare Advantage,,19.13,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Aetna,Medicare Advantage,,8.97,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Aetna,Medicare Advantage,,4.48,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Aetna,Medicare Advantage,,36.15,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Aetna,Medicare Advantage,,66.04,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Aetna,Medicare Advantage,,11.56,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Aetna,Medicare Advantage,,63.67,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Aetna,Medicare Advantage,,0.96795,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Aetna,Medicare Advantage,,38.22,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Aetna,Medicare Advantage,,2.82,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Aetna,Medicare Advantage,,2.82,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Aetna,Medicare Advantage,,2.82,,,,,,,2.58,65.50,fee schedule,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Aetna,Medicare Advantage,,125.88,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Aetna,Medicare Advantage,,6.99,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Aetna,Medicare Advantage,,1.77,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Aetna,Medicare Advantage,,1.77,,,,,,,1.62,62.83,fee schedule,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Aetna,Medicare Advantage,,1.25,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Aetna,Medicare Advantage,,0.39220,,,,,,,0.35890,22.08,fee schedule,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Aetna,Medicare Advantage,,17.94,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Aetna,Medicare Advantage,,18.03,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Aetna,Medicare Advantage,,17.08,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Aetna,Medicare Advantage,,6.93,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Aetna,Medicare Advantage,,4.18,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Aetna,Medicare Advantage,,5.01,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Aetna,Medicare Advantage,,3.90,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Aetna,Medicare Advantage,,3.86,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Aetna,Medicare Advantage,,9.33,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Aetna,Medicare Advantage,,514.07,,,,,,,470.42,2713.48,fee schedule,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Aetna,Medicare Advantage,,4.73,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Aetna,Medicare Advantage,,11.67,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Aetna,Medicare Advantage,,11.67,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Aetna,Medicare Advantage,,25.31,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Aetna,Medicare Advantage,,25.31,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Aetna,Medicare Advantage,,25.31,,,,,,,23.16,2285.98,fee schedule,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Aetna,Medicare Advantage,,0.26290,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Aetna,Medicare Advantage,,4.31,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Aetna,Medicare Advantage,,3.02,,,,,,,2.76,352.23,fee schedule,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Aetna,Medicare Advantage,,5.19,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Aetna,Medicare Advantage,,5.31,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Aetna,Medicare Advantage,,4.07,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Aetna,Medicare Advantage,,4.18,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Aetna,Medicare Advantage,,54.11,,,,,,,49.52,530.89,fee schedule,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Aetna,Medicare Advantage,,0.27485,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Aetna,Medicare Advantage,,20.58,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Aetna,Medicare Advantage,,14.48,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Aetna,Medicare Advantage,,178.28,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Aetna,Medicare Advantage,,25.09,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Aetna,Medicare Advantage,,9.49,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Aetna,Medicare Advantage,,14.70,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Aetna,Medicare Advantage,,6.98,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Aetna,Medicare Advantage,,5.19,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Aetna,Medicare Advantage,,3.99,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Aetna,Medicare Advantage,,4.04,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Aetna,Medicare Advantage,,20.32,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Aetna,Medicare Advantage,,4.43,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Aetna,Medicare Advantage,,53.29,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Aetna,Medicare Advantage,,75.28,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Aetna,Medicare Advantage,,3.54,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Aetna,Medicare Advantage,,6.89,,,,,,,6.30,1234.35,fee schedule,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Aetna,Medicare Advantage,,18.80,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Aetna,Medicare Advantage,,5.78,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Aetna,Medicare Advantage,,19.60,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Aetna,Medicare Advantage,,11.35,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Aetna,Medicare Advantage,,11.32,,,,,,,10.36,1624.68,fee schedule,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Aetna,Medicare Advantage,,8.59,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Aetna,Medicare Advantage,,63.29,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Aetna,Medicare Advantage,,24.98,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Aetna,Medicare Advantage,,27.19,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Aetna,Medicare Advantage,,11.01,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Aetna,Medicare Advantage,,5.28,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Aetna,Medicare Advantage,,5.34,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Aetna,Medicare Advantage,,6.45,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Aetna,Medicare Advantage,,5.43,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Aetna,Medicare Advantage,,4.45,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Aetna,Medicare Advantage,,99.71,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Aetna,Medicare Advantage,,366.58,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Aetna,Medicare Advantage,,9.20,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Aetna,Medicare Advantage,,14.78,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Aetna,Medicare Advantage,,18.80,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Aetna,Medicare Advantage,,23.03,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Aetna,Medicare Advantage,,72.41,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Aetna,Medicare Advantage,,4.72,,,,,,,4.32,2692.85,fee schedule,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Aetna,Medicare Advantage,,30.38,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Aetna,Medicare Advantage,,50.46,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Aetna,Medicare Advantage,,21.28,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Aetna,Medicare Advantage,,8.20,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Aetna,Medicare Advantage,,14.35,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Aetna,Medicare Advantage,,7.47,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Aetna,Medicare Advantage,,48.11,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Aetna,Medicare Advantage,,41.60,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Aetna,Medicare Advantage,,15.43,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Aetna,Medicare Advantage,,15.50,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Aetna,Medicare Advantage,,15.46,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Aetna,Medicare Advantage,,57.11,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Aetna,Medicare Advantage,,21.77,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Aetna,Medicare Advantage,,0.34655,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Aetna,Medicare Advantage,,158.05,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Aetna,Medicare Advantage,,3.73,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Aetna,Medicare Advantage,,3.73,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Aetna,Medicare Advantage,,1.80,,,,,,,1.65,61.57,fee schedule,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Aetna,Medicare Advantage,,1.10,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Aetna,Medicare Advantage,,519.73,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Aetna,Medicare Advantage,,24.26,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Aetna,Medicare Advantage,,23.42,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Aetna,Medicare Advantage,,22.23,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Aetna,Medicare Advantage,,22.59,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Aetna,Medicare Advantage,,20.08,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Aetna,Medicare Advantage,,5.88,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Aetna,Medicare Advantage,,7.93,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Aetna,Medicare Advantage,,11.96,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Aetna,Medicare Advantage,,23.42,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Aetna,Medicare Advantage,,23.42,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Aetna,Medicare Advantage,,18.28,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Aetna,Medicare Advantage,,85.08,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Aetna,Medicare Advantage,,13.99,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Aetna,Medicare Advantage,,11.70,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Aetna,Medicare Advantage,,0.33920,,,,,,,0.31040,3767.59,fee schedule,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Aetna,Medicare Advantage,,16.73,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Aetna,Medicare Advantage,,4.78,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Aetna,Medicare Advantage,,4.61,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Aetna,Medicare Advantage,,153.61,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Aetna,Medicare Advantage,,60.92,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Aetna,Medicare Advantage,,4.11,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Aetna,Medicare Advantage,,22.84,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Aetna,Medicare Advantage,,6.01,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Aetna,Medicare Advantage,,39.73,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Aetna,Medicare Advantage,,20.39,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Aetna,Medicare Advantage,,24.58,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Aetna,Medicare Advantage,,6.08,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Aetna,Medicare Advantage,,0.33460,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Aetna,Medicare Advantage,,577.63,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Aetna,Medicare Advantage,,9.28,,,,,,,8.49,2985.35,fee schedule,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Aetna,Medicare Advantage,,116.20,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Aetna,Medicare Advantage,,170.88,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Aetna,Medicare Advantage,,4.12,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Aetna,Medicare Advantage,,251.02,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Aetna,Medicare Advantage,,12.87,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Aetna,Medicare Advantage,,415.58,,,,,,,346.52,1284.64,fee schedule,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Aetna,Medicare Advantage,,10.59,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Aetna,Medicare Advantage,,10.59,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Aetna,Medicare Advantage,,27.20,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Aetna,Medicare Advantage,,4.27,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Aetna,Medicare Advantage,,539.50,,,,,,,330.39,1448.89,fee schedule,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Aetna,Medicare Advantage,,10854.08,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Aetna,Medicare Advantage,,37334.76,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Aetna,Medicare Advantage,,61542.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Aetna,Medicare Advantage,,2667.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Aetna,Medicare Advantage,,1766.26,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Aetna,Medicare Advantage,,61.90,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Aetna,Medicare Advantage,,3.26,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Aetna,Medicare Advantage,,0.28680,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Aetna,Medicare Advantage,,2.19,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Aetna,Medicare Advantage,,10.04,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Aetna,Medicare Advantage,,0.04780,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Aetna,Medicare Advantage,,124.04,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Aetna,Medicare Advantage,,307.59,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Aetna,Medicare Advantage,,460.07,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Aetna,Medicare Advantage,,690.95,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Aetna,Medicare Advantage,,829.09,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Aetna,Medicare Advantage,,994.72,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Aetna,Medicare Advantage,,1194.04,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Aetna,Medicare Advantage,,493.54,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Aetna,Medicare Advantage,,724.89,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Aetna,Medicare Advantage,,1318.32,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Aetna,Medicare Advantage,,38.24,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Aetna,Medicare Advantage,,151.29,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Aetna,Medicare Advantage,,41.35,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,,27.96,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,14.82,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Aetna,Medicare Advantage,,6.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Aetna,Medicare Advantage,,34.18,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,15.06,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Aetna,Medicare Advantage,,37.76,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Aetna,Medicare Advantage,,125.24,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Aetna,Medicare Advantage,,142.68,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Aetna,Medicare Advantage,,121.41,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Aetna,Medicare Advantage,,21.99,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Aetna,Medicare Advantage,,17.45,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Aetna,Medicare Advantage,,54.97,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Aetna,Medicare Advantage,,50.43,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Aetna,Medicare Advantage,,1250.69,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Aetna,Medicare Advantage,,1250.69,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Aetna,Medicare Advantage,,1190.70,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Aetna,Medicare Advantage,,426.85,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Aetna,Medicare Advantage,,718.20,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Aetna,Medicare Advantage,,364.71,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Aetna,Medicare Advantage,,74.81,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,19.36,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,15.06,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Aetna,Medicare Advantage,,261.23,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Aetna,Medicare Advantage,,81.74,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Aetna,Medicare Advantage,,295.40,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Aetna,Medicare Advantage,,217.25,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Aetna,Medicare Advantage,,72.42,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Aetna,Medicare Advantage,,119.50,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Aetna,Medicare Advantage,,224.18,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Aetna,Medicare Advantage,,63.57,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Aetna,Medicare Advantage,,48.76,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Aetna,Medicare Advantage,,260.99,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Aetna,Medicare Advantage,,226.57,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Aetna,Medicare Advantage,,68.35,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Aetna,Medicare Advantage,,10.28,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Aetna,Medicare Advantage,,8.37,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Aetna,Medicare Advantage,,33.46,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Aetna,Medicare Advantage,,113.29,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Aetna,Medicare Advantage,,30.11,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Aetna,Medicare Advantage,,68.35,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Aetna,Medicare Advantage,,32.03,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Aetna,Medicare Advantage,,2.63,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Aetna,Medicare Advantage,,1191.41,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Aetna,Medicare Advantage,,4803.90,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Aetna,Medicare Advantage,,1212.69,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Aetna,Medicare Advantage,,1013.36,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Aetna,Medicare Advantage,,831.24,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Aetna,Medicare Advantage,,110.66,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Medicare Advantage,,945.01,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Aetna,Medicare Advantage,,1082.67,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Aetna,Medicare Advantage,,1066.18,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Aetna,Medicare Advantage,,843.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Aetna,Medicare Advantage,,1394.57,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Aetna,Medicare Advantage,,990.18,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Aetna,Medicare Advantage,,990.18,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Aetna,Medicare Advantage,,1152.22,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Aetna,Medicare Advantage,,1152.22,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Aetna,Medicare Advantage,,1401.97,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Medicare Advantage,,945.01,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Medicare Advantage,,945.01,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Aetna,Medicare Advantage,,843.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Aetna,Medicare Advantage,,945.01,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Aetna,Medicare Advantage,,417.06,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Aetna,Medicare Advantage,,982.29,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Aetna,Medicare Advantage,,404.15,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Aetna,Medicare Advantage,,1553.26,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Aetna,Medicare Advantage,,282.98,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Aetna,Medicare Advantage,,581.25,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Aetna,Medicare Advantage,,880.48,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Aetna,Medicare Advantage,,1026.98,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Aetna,Medicare Advantage,,28.92,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Aetna,Medicare Advantage,,407.73,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Aetna,Medicare Advantage,,818.81,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Aetna,Medicare Advantage,,19.84,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Aetna,Medicare Advantage,,111.61,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Aetna,Medicare Advantage,,164.67,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Aetna,Medicare Advantage,,372.12,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Aetna,Medicare Advantage,,281.78,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Aetna,Medicare Advantage,,18.88,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Aetna,Medicare Advantage,,21.03,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Aetna,Medicare Advantage,GP,5.02,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Aetna,Medicare Advantage,,79.59,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Aetna,Medicare Advantage,,358.98,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Aetna,Medicare Advantage,,339.86,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Aetna,Medicare Advantage,,272.46,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Aetna,Medicare Advantage,,205.06,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Aetna,Medicare Advantage,,137.66,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Aetna,Medicare Advantage,,70.27,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Aetna,Medicare Advantage,,391.48,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Aetna,Medicare Advantage,,1169.90,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Aetna,Medicare Advantage,,1551.59,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Aetna,Medicare Advantage,,819.77,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Aetna,Medicare Advantage,,622.36,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Aetna,Medicare Advantage,,6251.76,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Aetna,Medicare Advantage,,6548.36,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Aetna,Medicare Advantage,,6892.04,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Aetna,Medicare Advantage,,7187.69,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Aetna,Medicare Advantage,,7484.52,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Aetna,Medicare Advantage,,7780.41,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Aetna,Medicare Advantage,,8028.25,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Aetna,Medicare Advantage,,8371.93,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Aetna,Medicare Advantage,,8668.05,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Aetna,Medicare Advantage,,8964.17,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Aetna,Medicare Advantage,,9260.53,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Aetna,Medicare Advantage,,92.73,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Aetna,Medicare Advantage,,127.63,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Aetna,Medicare Advantage,,198.13,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Aetna,Medicare Advantage,,199.80,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Aetna,Medicare Advantage,,964.37,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Aetna,Medicare Advantage,,2314.72,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Aetna,Medicare Advantage,,2487.27,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Aetna,Medicare Advantage,,2671.78,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Aetna,Medicare Advantage,,1456.47,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Aetna,Medicare Advantage,,1881.65,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Aetna,Medicare Advantage,,2140.24,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Aetna,Medicare Advantage,,2755.67,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Aetna,Medicare Advantage,,2828.80,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Aetna,Medicare Advantage,,2897.64,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Aetna,Medicare Advantage,,2966.71,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Aetna,Medicare Advantage,,3035.54,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Aetna,Medicare Advantage,,1182.09,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Aetna,Medicare Advantage,,159.65,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Aetna,Medicare Advantage,,1053.03,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Aetna,Medicare Advantage,,1421.81,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Aetna,Medicare Advantage,,1946.89,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Aetna,Medicare Advantage,,2467.44,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Aetna,Medicare Advantage,,2817.09,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Aetna,Medicare Advantage,,3190.65,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Aetna,Medicare Advantage,,3639.73,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Aetna,Medicare Advantage,,3901.44,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Aetna,Medicare Advantage,,4287.66,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Aetna,Medicare Advantage,,4497.74,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Aetna,Medicare Advantage,,4772.83,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Aetna,Medicare Advantage,,4949.93,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Aetna,Medicare Advantage,,4994.38,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Aetna,Medicare Advantage,,5068.47,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Aetna,Medicare Advantage,,5216.18,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Aetna,Medicare Advantage,,5364.12,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Aetna,Medicare Advantage,,5511.82,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Aetna,Medicare Advantage,,5660.72,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Aetna,Medicare Advantage,,5808.18,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Aetna,Medicare Advantage,,5956.36,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Aetna,Medicare Advantage,,3204.03,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Aetna,Medicare Advantage,,2715.52,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Aetna,Medicare Advantage,,1683.28,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Aetna,Medicare Advantage,,1683.28,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Aetna,Medicare Advantage,,1683.28,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Aetna,Medicare Advantage,,1548.72,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Aetna,Medicare Advantage,,3204.03,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Aetna,Medicare Advantage,,1807.32,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Aetna,Medicare Advantage,,2036.52,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Aetna,Medicare Advantage,,72.42,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Medicare Advantage,,303.77,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Aetna,Medicare Advantage,,121.41,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Aetna,Medicare Advantage,,121.41,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Aetna,Medicare Advantage,,193.11,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Aetna,Medicare Advantage,,2579.77,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Aetna,Medicare Advantage,,451.71,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Aetna,Medicare Advantage,,292.77,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Aetna,Medicare Advantage,,1714.59,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Aetna,Medicare Advantage,,70.74,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Aetna,Medicare Advantage,,180.68,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Aetna,Medicare Advantage,,0.71700,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Aetna,Medicare Advantage,,394.11,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Aetna,Medicare Advantage,,508.35,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Aetna,Medicare Advantage,,623.07,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Aetna,Medicare Advantage,,737.32,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Aetna,Medicare Advantage,,851.80,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Aetna,Medicare Advantage,,966.28,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Aetna,Medicare Advantage,,1080.52,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Aetna,Medicare Advantage,,157.98,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Aetna,Medicare Advantage,,783.92,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Aetna,Medicare Advantage,,1032.96,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Aetna,Medicare Advantage,,309.27,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Aetna,Medicare Advantage,,421.36,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Aetna,Medicare Advantage,,469.87,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Aetna,Medicare Advantage,,520.30,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Aetna,Medicare Advantage,,570.49,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Aetna,Medicare Advantage,,620.44,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Aetna,Medicare Advantage,,670.87,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Aetna,Medicare Advantage,,394.11,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Aetna,Medicare Advantage,,228.96,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Aetna,Medicare Advantage,,570.49,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Aetna,Medicare Advantage,,309.27,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Aetna,Medicare Advantage,,421.36,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Aetna,Medicare Advantage,,469.87,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Aetna,Medicare Advantage,,520.30,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Aetna,Medicare Advantage,,620.44,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Aetna,Medicare Advantage,,670.87,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Aetna,Medicare Advantage,,783.92,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Aetna,Medicare Advantage,,1032.96,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Aetna,Medicare Advantage,,119.26,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Aetna,Medicare Advantage,,819.77,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Aetna,Medicare Advantage,,68.11,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Aetna,Medicare Advantage,,324.32,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Aetna,Medicare Advantage,,367.34,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Aetna,Medicare Advantage,,410.84,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Aetna,Medicare Advantage,,454.34,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Aetna,Medicare Advantage,,498.31,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Aetna,Medicare Advantage,,542.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Aetna,Medicare Advantage,,585.55,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Aetna,Medicare Advantage,,628.81,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Aetna,Medicare Advantage,,672.07,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Aetna,Medicare Advantage,,716.04,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Aetna,Medicare Advantage,,759.30,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Aetna,Medicare Advantage,,815.95,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Aetna,Medicare Advantage,,859.92,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Aetna,Medicare Advantage,,1026.03,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Aetna,Medicare Advantage,,1093.19,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Aetna,Medicare Advantage,,1144.09,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Aetna,Medicare Advantage,,1187.59,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Aetna,Medicare Advantage,,1230.85,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Aetna,Medicare Advantage,,1044.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Aetna,Medicare Advantage,,1108.00,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Aetna,Medicare Advantage,,985.40,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Aetna,Medicare Advantage,,624.51,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Aetna,Medicare Advantage,,675.17,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Aetna,Medicare Advantage,,594.15,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Aetna,Medicare Advantage,,798.74,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Aetna,Medicare Advantage,,80.54,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Aetna,Medicare Advantage,,2409.60,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Aetna,Medicare Advantage,,2409.60,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Aetna,Medicare Advantage,,2409.60,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Aetna,Medicare Advantage,,304.73,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Aetna,Medicare Advantage,,500.94,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Aetna,Medicare Advantage,,556.63,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Aetna,Medicare Advantage,,302.10,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Aetna,Medicare Advantage,,115.44,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Aetna,Medicare Advantage,,115.44,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Aetna,Medicare Advantage,,1791.07,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Aetna,Medicare Advantage,,242.82,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Aetna,Medicare Advantage,,96.56,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Aetna,Medicare Advantage,,1093.19,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Aetna,Medicare Advantage,,2590.04,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Aetna,Medicare Advantage,,1260.49,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Aetna,Medicare Advantage,,73.37,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Aetna,Medicare Advantage,,9556.18,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Aetna,Medicare Advantage,,9852.06,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Aetna,Medicare Advantage,,450.51,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Aetna,Medicare Advantage,,133.12,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Aetna,Medicare Advantage,,696.68,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,18.40,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,13.38,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Aetna,Medicare Advantage,,20.55,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Aetna,Medicare Advantage,,43.74,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Medicare Advantage,,23.90,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Medicare Advantage,,644.59,,,,,,,18.66,7281.00,fee schedule,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Aetna,Medicare Advantage,Q0,0.24139,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Aetna,Medicare Advantage,Q0,0.24139,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Aetna,Medicare Advantage,,143.40,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Aetna,Medicare Advantage,,178.29,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Aetna,Medicare Advantage,,328.62,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Aetna,Medicare Advantage,,4676.99,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Aetna,Medicare Advantage,,2179.68,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Medicare Advantage,,1223.68,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Aetna,Medicare Advantage,,1184.01,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Aetna,Medicare Advantage,,1777.68,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Aetna,Medicare Advantage,,2011.90,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Medicare Advantage,,1223.68,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Aetna,Medicare Advantage,,1517.17,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Medicare Advantage,,76.00,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Aetna,Medicare Advantage,,24.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Aetna,Medicare Advantage,,49.95,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,6.69,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Medicare Advantage,,34.66,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Medicare Advantage,,76.00,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Aetna,Medicare Advantage,,30.11,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Aetna,Medicare Advantage,,36.09,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Aetna,Medicare Advantage,,43.98,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Aetna,Medicare Advantage,,70.50,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Aetna,Medicare Advantage,,84.84,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Medicare Advantage,,250.47,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Aetna,Medicare Advantage,,24.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Aetna,Medicare Advantage,,101.58,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Aetna,Medicare Advantage,,143.40,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Aetna,Medicare Advantage,,256.45,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Aetna,Medicare Advantage,,226.57,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Aetna,Medicare Advantage,,178.29,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Aetna,Medicare Advantage,,178.29,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Aetna,Medicare Advantage,,184.99,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Medicare Advantage,,1223.68,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Aetna,Medicare Advantage,,120.22,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Aetna,Medicare Advantage,,108.03,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Aetna,Medicare Advantage,,322.41,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Aetna,Medicare Advantage,,1223.68,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Aetna,Medicare Advantage,,354.68,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Aetna,Medicare Advantage,,329.58,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,13.86,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Medicare Advantage,,127.86,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Medicare Advantage,,127.86,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Medicare Advantage,,127.86,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Aetna,Medicare Advantage,,1606.08,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Aetna,Medicare Advantage,,220.36,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Aetna,Medicare Advantage,,220.36,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Aetna,Medicare Advantage,,220.36,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Aetna,Medicare Advantage,,290.38,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Aetna,Medicare Advantage,,389.81,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Aetna,Medicare Advantage,,692.86,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Medicare Advantage,,83.65,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Medicare Advantage,,110.66,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Medicare Advantage,,33.46,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,22.70,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Aetna,Medicare Advantage,,39.67,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Medicare Advantage,,83.65,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,21.75,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,24.14,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Aetna,Medicare Advantage,,1259.53,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Aetna,Medicare Advantage,,244.74,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Medicare Advantage,,359.98,,,,,,,80.90,468.96,fee schedule,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Aetna,Medicare Advantage,,9457.23,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Aetna,Medicare Advantage,,4063.96,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Aetna,Medicare Advantage,,36.91,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Aetna,Medicare Advantage,,36.91,,,,,,,33.78,226.75,fee schedule,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Aetna,Medicare Advantage,,458.64,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Aetna,Medicare Advantage,,1733.23,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Aetna,Medicare Advantage,,414.43,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Aetna,Medicare Advantage,,787.50,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Aetna,Medicare Advantage,,9612.58,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Aetna,Medicare Advantage,,2991.56,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Aetna,Medicare Advantage,,2657.68,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Aetna,Medicare Advantage,,3743.93,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Aetna,Medicare Advantage,,7547.14,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Aetna,Medicare Advantage,,630.72,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Aetna,Medicare Advantage,,2656.96,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Aetna,Medicare Advantage,,3834.04,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Aetna,Medicare Advantage,,2264.76,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Aetna,Medicare Advantage,,644.34,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Aetna,Medicare Advantage,,644.34,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Aetna,Medicare Advantage,,1999.47,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Aetna,Medicare Advantage,,0.24139,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Aetna,Medicare Advantage,,2131.88,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Aetna,Medicare Advantage,,2695.20,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Aetna,Medicare Advantage,,1465.31,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Aetna,Medicare Advantage,,3703.30,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Aetna,Medicare Advantage,,38.94,,,,,,,35.64,923.93,fee schedule,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Aetna,Medicare Advantage,,128.34,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Aetna,Medicare Advantage,,1606.08,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Aetna,Medicare Advantage,,1259.53,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Aetna,Medicare Advantage,,224.66,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Aetna,Medicare Advantage,,52.58,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Aetna,Medicare Advantage,,132.65,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Aetna,Medicare Advantage,,1299.20,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Aetna,Medicare Advantage,,4742.95,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Aetna,Medicare Advantage,,6546.21,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Aetna,Medicare Advantage,,67.16,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Aetna,Medicare Advantage,,67.16,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Aetna,Medicare Advantage,,62.86,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Aetna,Medicare Advantage,,62.86,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Aetna,Medicare Advantage,,62.86,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Aetna,Medicare Advantage,,746.88,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Aetna,Medicare Advantage,,280.11,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Aetna,Medicare Advantage,,360.17,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Aetna,Medicare Advantage,,338.19,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Aetna,Medicare Advantage,,327.43,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Aetna,Medicare Advantage,,2381.40,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Aetna,Medicare Advantage,Q1,1514.07,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Aetna,Medicare Advantage,Q0,907.00,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Aetna,Medicare Advantage,,43.50,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Aetna,Medicare Advantage,,135.52,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Medicare Advantage,,221.51,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Medicare Advantage,,48.51,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Aetna,Medicare Advantage,,221.51,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Medicare Advantage,,48.51,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Medicare Advantage,,74.83,,,,,,,65.64,759.00,fee schedule,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Medicare Advantage,,21.99,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Medicare Advantage,,221.51,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Medicare Advantage,,221.51,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Aetna,Medicare Advantage,,48.51,,,,,,,44.39,759.00,fee schedule,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Aetna,Medicare Advantage,,55.93,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Aetna,Medicare Advantage,,348.72,,,,,,,113.51,759.00,fee schedule,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,26.29,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Aetna,Medicare Advantage,,9.64,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Aetna,Medicare Advantage,,348.72,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,,74.83,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,,74.83,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Aetna,Medicare Advantage,,74.83,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Aetna,Medicare Advantage,,221.51,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Medicare Advantage,,348.72,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Aetna,Medicare Advantage,,74.83,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Aetna,Medicare Advantage,,348.72,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Aetna,Medicare Advantage,,348.72,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Aetna,Medicare Advantage,,384.86,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Aetna,Medicare Advantage,,384.86,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Aetna,Medicare Advantage,,139.59,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Aetna,Medicare Advantage,,384.86,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Aetna,Medicare Advantage,,139.59,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Aetna,Medicare Advantage,,384.86,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Aetna,Medicare Advantage,,139.59,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Aetna,Medicare Advantage,,1846.07,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Aetna,Medicare Advantage,,1846.07,,,,,,,1686.28,6317.25,fee schedule,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Aetna,Medicare Advantage,,101.58,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Aetna,Medicare Advantage,,135.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Aetna,Medicare Advantage,,520.54,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Aetna,Medicare Advantage,,608.17,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Aetna,Medicare Advantage,,608.17,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Aetna,Medicare Advantage,,608.17,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Aetna,Medicare Advantage,,729.44,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Medicare Advantage,,115.13,,,,,,,63.26,1067.00,fee schedule,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Aetna,Medicare Advantage,,76.72,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Aetna,Medicare Advantage,,348.72,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Medicare Advantage,,74.83,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Aetna,Medicare Advantage,,348.72,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Medicare Advantage,,74.83,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Aetna,Medicare Advantage,,348.72,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Medicare Advantage,,48.51,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Aetna,Medicare Advantage,,348.72,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Aetna,Medicare Advantage,,221.51,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Aetna,Medicare Advantage,,221.51,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Aetna,Medicare Advantage,,348.72,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,5351.25,fee schedule,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Aetna,Medicare Advantage,,246.65,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Aetna,Medicare Advantage,,115.13,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Aetna,Medicare Advantage,,276.48,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Aetna,Medicare Advantage,,276.48,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Aetna,Medicare Advantage,,276.48,,,,,,,253.01,1067.00,fee schedule,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Aetna,Medicare Advantage,76,336.03,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,,608.17,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Aetna,Medicare Advantage,,608.17,,,,,,,556.54,2811.00,fee schedule,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Aetna,Medicare Advantage,76,895.77,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Aetna,Medicare Advantage,,608.17,,,,,,,556.54,2958.75,fee schedule,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Aetna,Medicare Advantage,76,942.86,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1966.50,fee schedule,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Medicare Advantage,,81.98,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Medicare Advantage,,98.71,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Medicare Advantage,,98.71,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Medicare Advantage,,348.72,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Aetna,Medicare Advantage,,8037.04,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Aetna,Medicare Advantage,,8037.04,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Aetna,Medicare Advantage,,729.44,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Aetna,Medicare Advantage,,729.44,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Aetna,Medicare Advantage,,729.44,,,,,,,667.51,3237.00,fee schedule,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Aetna,Medicare Advantage,,154.87,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Aetna,Medicare Advantage,,169.21,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Aetna,Medicare Advantage,,292.77,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Aetna,Medicare Advantage,,205.54,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Aetna,Medicare Advantage,,218.45,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Aetna,Medicare Advantage,,224.18,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Aetna,Medicare Advantage,,153.20,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,,445.74,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,76,445.74,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,,445.74,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,76,445.74,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Medicare Advantage,,81.98,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Aetna,Medicare Advantage,,155.35,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Aetna,Medicare Advantage,,86.76,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,,445.74,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,76,445.74,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Medicare Advantage,,348.72,,,,,,,91.09,3466.00,fee schedule,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Aetna,Medicare Advantage,76,205.54,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Aetna,Medicare Advantage,76,218.45,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Aetna,Medicare Advantage,,119.26,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Aetna,Medicare Advantage,,384.86,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Aetna,Medicare Advantage,,1438.52,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Medicare Advantage,,139.59,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Aetna,Medicare Advantage,,139.59,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Medicare Advantage,,384.86,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Aetna,Medicare Advantage,,384.86,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Aetna,Medicare Advantage,,608.17,,,,,,,482.48,1807.50,fee schedule,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Aetna,Medicare Advantage,,96.80,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Aetna,Medicare Advantage,,133.84,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Aetna,Medicare Advantage,,397.22,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Aetna,Medicare Advantage,,459.60,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Aetna,Medicare Advantage,,304.49,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Medicare Advantage,,75.52,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Aetna,Medicare Advantage,,155.35,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Aetna,Medicare Advantage,,520.54,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Medicare Advantage,,1723.45,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Aetna,Medicare Advantage,,211.50,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Aetna,Medicare Advantage,,3342.81,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Aetna,Medicare Advantage,,213.83,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Aetna,Medicare Advantage,,244.15,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Aetna,Medicare Advantage,,204.11,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Aetna,Medicare Advantage,,204.11,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Aetna,Medicare Advantage,,5189.94,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Aetna,Medicare Advantage,,319.81,,,,,,,151.55,4376.00,fee schedule,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Medicare Advantage,,38.72,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Aetna,Medicare Advantage,,459.63,,,,,,,203.70,4311.00,fee schedule,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Aetna,Medicare Advantage,,71.46,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Aetna,Medicare Advantage,,244.15,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,213.83,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Medicare Advantage,,213.83,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,135.52,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,135.52,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Aetna,Medicare Advantage,,213.83,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Medicare Advantage,,135.52,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Medicare Advantage,,135.52,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Aetna,Medicare Advantage,,213.83,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,25.75,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,25.75,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Aetna,Medicare Advantage,,41.27,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Medicare Advantage,,135.52,,,,,,,34.82,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Medicare Advantage,,38.48,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Medicare Advantage,,213.83,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Medicare Advantage,,213.83,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Medicare Advantage,,213.83,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Aetna,Medicare Advantage,,213.83,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Medicare Advantage,,213.83,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Medicare Advantage,,213.83,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Medicare Advantage,,213.83,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,213.83,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Medicare Advantage,,213.83,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Aetna,Medicare Advantage,,39.21,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Medicare Advantage,,39.21,,,,,,,35.88,440.00,fee schedule,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Aetna,Medicare Advantage,GP,16.01,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Medicare Advantage,GP,17.93,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Medicare Advantage,GP,2.87,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Aetna,Medicare Advantage,GP,28.92,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,GP,11.71,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Aetna,Medicare Advantage,GP,3.82,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Aetna,Medicare Advantage,GP,36.57,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Medicare Advantage,GP,38.96,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Medicare Advantage,GP,30.59,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,GP,26.29,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,GP,14.10,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Medicare Advantage,GP,39.20,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Aetna,Medicare Advantage,GP,38.24,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Aetna,Medicare Advantage,GP,34.42,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,GP,39.44,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Medicare Advantage,GP,33.22,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Medicare Advantage,GP,48.28,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,GP,27.96,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,GP,30.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Aetna,Medicare Advantage,GP,36.09,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Medicare Advantage,GP,11.23,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,GP,28.20,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Medicare Advantage,GP,20.32,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,GP,30.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Medicare Advantage,GP,23.66,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Medicare Advantage,GP,43.02,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Medicare Advantage,GP,43.02,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,GP,21.75,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,GP,21.75,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,GP,21.27,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Medicare Advantage,GP,30.35,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Medicare Advantage,GP,31.07,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Medicare Advantage,GP,16.73,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Medicare Advantage,GP,7.17,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Aetna,Medicare Advantage,GP,73.13,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Aetna,Medicare Advantage,GP,101.10,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Aetna,Medicare Advantage,GP,103.73,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Medicare Advantage,GP,68.83,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,GO,21.75,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,GO,27.96,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,GO,30.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,GO,28.20,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Medicare Advantage,GO,16.73,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,GO,30.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Medicare Advantage,GO,23.66,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Medicare Advantage,GO,2.87,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Medicare Advantage,GO,38.96,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Medicare Advantage,GO,30.59,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,GO,14.82,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Medicare Advantage,GO,39.20,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Aetna,Medicare Advantage,GO,38.24,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Aetna,Medicare Advantage,GO,34.42,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,GO,39.44,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,GO,11.71,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Aetna,Medicare Advantage,GO,53.54,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Medicare Advantage,GO,36.33,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Medicare Advantage,GO,30.35,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Medicare Advantage,GO,17.93,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Medicare Advantage,GO,76.00,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Aetna,Medicare Advantage,GO,96.32,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Aetna,Medicare Advantage,GO,99.19,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Medicare Advantage,GO,48.28,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Aetna,Medicare Advantage,GN,85.08,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Aetna,Medicare Advantage,GN,80.30,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Aetna,Medicare Advantage,GN,44.69,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Medicare Advantage,GN,64.29,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Medicare Advantage,GN,47.80,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Medicare Advantage,GN,75.28,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Medicare Advantage,GN,30.59,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Medicare Advantage,GN,16.73,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Medicare Advantage,GN,20.32,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Medicare Advantage,GN,23.66,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Aetna,Medicare Advantage,GN,54.73,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,GN,32.50,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Aetna,Medicare Advantage,GN,156.54,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Aetna,Medicare Advantage,GN,61.90,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Aetna,Medicare Advantage,GN,16.25,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Medicare Advantage,GN,31.07,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Medicare Advantage,GN,16.73,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Medicare Advantage,GN,7.17,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Aetna,Medicare Advantage,GN,51.15,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Aetna,Medicare Advantage,GN,54.73,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Medicare Advantage,GN,25.57,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Aetna,Medicare Advantage,GN,84.37,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Medicare Advantage,GN,131.21,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Aetna,Medicare Advantage,GN,141.25,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Aetna,Medicare Advantage,,164.49,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Aetna,Medicare Advantage,,164.49,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Aetna,Medicare Advantage,,327.39,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Aetna,Medicare Advantage,,557.85,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Aetna,Medicare Advantage,,327.39,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Aetna,Medicare Advantage,,327.39,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Medicare Advantage,,164.49,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Aetna,Medicare Advantage,,62.46,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Aetna,Medicare Advantage,,327.39,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Aetna,Medicare Advantage,,135.52,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Aetna,Medicare Advantage,,135.52,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Medicare Advantage,,135.52,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Aetna,Medicare Advantage,,135.52,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Aetna,Medicare Advantage,,327.39,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Aetna,Medicare Advantage,,164.49,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Aetna,Medicare Advantage,,327.39,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Medicare Advantage,,62.46,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Aetna,Medicare Advantage,,327.39,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Aetna,Medicare Advantage,,164.49,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Aetna,Medicare Advantage,,164.49,,,,,,,113.51,489.00,fee schedule,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Medicare Advantage,,109.46,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Medicare Advantage,,164.49,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Medicare Advantage,,327.39,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Aetna,Medicare Advantage,,459.63,,,,,,,203.70,4311.00,fee schedule,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Aetna,Medicare Advantage,,31.31,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Aetna,Medicare Advantage,,327.39,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Aetna,Medicare Advantage,,327.39,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Aetna,Medicare Advantage,,63.10,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Aetna,Medicare Advantage,,327.39,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Aetna,Medicare Advantage,,204.11,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Medicare Advantage,,1723.45,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Aetna,Medicare Advantage,,735.65,,,,,,,121.87,735.65,fee schedule,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Aetna,Medicare Advantage,,543.01,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Aetna,Medicare Advantage,,447.69,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Aetna,Medicare Advantage,,557.85,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Aetna,Medicare Advantage,,53.06,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Aetna,Medicare Advantage,,419.53,,,,,,,57.98,528.00,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Aetna,Medicare Advantage,,80.78,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Aetna,Medicare Advantage,,164.49,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Aetna,Medicare Advantage,,1069.64,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Aetna,Medicare Advantage,,1069.64,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Aetna,Medicare Advantage,,1069.64,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Aetna,Medicare Advantage,,254.13,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Aetna,Medicare Advantage,,327.39,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Aetna,Medicare Advantage,,111.80,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Aetna,Medicare Advantage,,254.13,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Aetna,Medicare Advantage,,327.39,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Medicare Advantage,,135.52,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Aetna,Medicare Advantage,,327.39,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Aetna,Medicare Advantage,,327.39,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Medicare Advantage,,254.13,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Aetna,Medicare Advantage,,557.85,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,546.00,fee schedule,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Medicare Advantage,,114.96,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Aetna,Medicare Advantage,,254.13,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Medicare Advantage,,327.39,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Aetna,Medicare Advantage,,62.46,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Medicare Advantage,,254.13,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Aetna,Medicare Advantage,,111.80,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Medicare Advantage,,111.80,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Aetna,Medicare Advantage,,111.80,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Aetna,Medicare Advantage,,1069.64,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Aetna,Medicare Advantage,,1069.64,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Aetna,Medicare Advantage,,1069.64,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Aetna,Medicare Advantage,,96.80,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Medicare Advantage,,164.49,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Aetna,Medicare Advantage,,135.52,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Aetna,Medicare Advantage,,135.52,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Aetna,Medicare Advantage,,164.49,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Medicare Advantage,,135.52,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Aetna,Medicare Advantage,,327.39,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Aetna,Medicare Advantage,,327.39,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Medicare Advantage,,135.52,,,,,,,76.08,1831.00,fee schedule,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Medicare Advantage,,60.47,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Aetna,Medicare Advantage,,146.75,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Aetna,Medicare Advantage,,146.75,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Aetna,Medicare Advantage,,130.73,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Medicare Advantage,,164.49,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Medicare Advantage,,327.39,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Medicare Advantage,,327.39,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Medicare Advantage,,327.39,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Aetna,Medicare Advantage,,557.85,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Aetna,Medicare Advantage,,557.85,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Aetna,Medicare Advantage,,557.85,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Aetna,Medicare Advantage,,164.49,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Aetna,Medicare Advantage,,135.52,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Aetna,Medicare Advantage,,135.52,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Aetna,Medicare Advantage,,327.39,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Aetna,Medicare Advantage,,327.39,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Aetna,Medicare Advantage,,1069.64,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Medicare Advantage,,557.85,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Aetna,Medicare Advantage,,327.39,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Aetna,Medicare Advantage,,557.85,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Aetna,Medicare Advantage,,1069.64,,,,,,,147.64,1831.00,fee schedule,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Aetna,Medicare Advantage,,294.69,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Aetna,Medicare Advantage,,327.39,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Aetna,Medicare Advantage,,557.85,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Medicare Advantage,,111.80,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Aetna,Medicare Advantage,,164.49,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Aetna,Medicare Advantage,,327.39,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Aetna,Medicare Advantage,,327.39,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Aetna,Medicare Advantage,,327.39,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Aetna,Medicare Advantage,,327.39,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Aetna,Medicare Advantage,,327.39,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Aetna,Medicare Advantage,,557.85,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Aetna,Medicare Advantage,,1069.64,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Aetna,Medicare Advantage,,327.39,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,74.83,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,74.83,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,31.32,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Aetna,Medicare Advantage,,48.51,,,,,,,44.39,4311.00,fee schedule,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Medicare Advantage,,69.79,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Medicare Advantage,,70.27,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Medicare Advantage,,11.47,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Medicare Advantage,,11.47,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,74.83,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,74.83,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,74.83,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,74.83,,,,,,,20.54,88.50,fee schedule,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Medicare Advantage,,25.33,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,74.83,,,,,,,20.54,88.50,fee schedule,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Medicare Advantage,,185.22,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Medicare Advantage,,185.22,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Medicare Advantage,,185.22,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Medicare Advantage,,185.22,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Medicare Advantage,,185.22,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Aetna,Medicare Advantage,,185.22,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Medicare Advantage,,43.65,,,,,,,13.06,56.25,fee schedule,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Aetna,Medicare Advantage,GP,15.93,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Aetna,Medicare Advantage,,208.90,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Aetna,Medicare Advantage,,3009.02,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Aetna,Medicare Advantage,,643.57,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Aetna,Medicare Advantage,,643.57,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,464.46,4376.00,fee schedule,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Aetna,Medicare Advantage,,248.32,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Aetna,Medicare Advantage,,248.32,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Aetna,Medicare Advantage,,762.41,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Aetna,Medicare Advantage,,208.90,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Aetna,Medicare Advantage,,208.90,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Aetna,Medicare Advantage,,208.90,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Medicare Advantage,,420.05,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Aetna,Medicare Advantage,,62.46,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,,62.46,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,,62.46,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Aetna,Medicare Advantage,,208.90,,,,,,,39.21,4311.00,fee schedule,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Medicare Advantage,,38.96,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Aetna,Medicare Advantage,,208.90,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Aetna,Medicare Advantage,,208.90,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Aetna,Medicare Advantage,,739.72,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Aetna,Medicare Advantage,,310.35,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Aetna,Medicare Advantage,,310.35,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Aetna,Medicare Advantage,,310.35,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Aetna,Medicare Advantage,,310.35,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Aetna,Medicare Advantage,,310.35,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Aetna,Medicare Advantage,,279.21,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Aetna,Medicare Advantage,,244.15,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Aetna,Medicare Advantage,,420.05,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Medicare Advantage,,420.05,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Aetna,Medicare Advantage,,420.05,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Aetna,Medicare Advantage,,135.52,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Aetna,Medicare Advantage,,348.72,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Aetna,Medicare Advantage,,348.72,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Aetna,Medicare Advantage,,728.08,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Aetna,Medicare Advantage,,728.08,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Aetna,Medicare Advantage,,728.08,,,,,,,351.18,4311.00,fee schedule,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Aetna,Medicare Advantage,,509.55,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Aetna,Medicare Advantage,,315.31,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Medicare Advantage,,315.31,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Aetna,Medicare Advantage,,6899.91,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Aetna,Medicare Advantage,,310.35,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Aetna,Medicare Advantage,,728.08,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Aetna,Medicare Advantage,,199.33,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Aetna,Medicare Advantage,,207.69,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Aetna,Medicare Advantage,,310.35,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Aetna,Medicare Advantage,,936.01,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Aetna,Medicare Advantage,,936.01,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Aetna,Medicare Advantage,,6899.91,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Medicare Advantage,,310.35,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Medicare Advantage,,310.35,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Aetna,Medicare Advantage,,2053.05,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Aetna,Medicare Advantage,,2053.05,,,,,,,601.13,4311.00,fee schedule,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Aetna,Medicare Advantage,,365.19,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Aetna,Medicare Advantage,,365.19,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Aetna,Medicare Advantage,,936.01,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Aetna,Medicare Advantage,,936.01,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Aetna,Medicare Advantage,,936.01,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Aetna,Medicare Advantage,,310.35,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Aetna,Medicare Advantage,,208.90,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Aetna,Medicare Advantage,,208.90,,,,,,,117.06,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Aetna,Medicare Advantage,,172.08,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Aetna,Medicare Advantage,,172.08,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,208.90,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,208.90,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Medicare Advantage,,739.72,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Aetna,Medicare Advantage,,936.01,,,,,,,422.24,4376.00,fee schedule,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Medicare Advantage,JW,31.55,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Aetna,Medicare Advantage,,728.08,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Aetna,Medicare Advantage,,728.08,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Aetna,Medicare Advantage,,144.36,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Aetna,Medicare Advantage,,119.26,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Aetna,Medicare Advantage,,728.08,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Aetna,Medicare Advantage,,310.35,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Aetna,Medicare Advantage,,936.01,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Aetna,Medicare Advantage,,420.05,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Aetna,Medicare Advantage,,728.08,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Aetna,Medicare Advantage,,936.01,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Aetna,Medicare Advantage,,936.01,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Aetna,Medicare Advantage,,728.08,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Aetna,Medicare Advantage,,728.08,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Aetna,Medicare Advantage,,936.01,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Aetna,Medicare Advantage,,936.01,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Aetna,Medicare Advantage,,936.01,,,,,,,527.80,4311.00,fee schedule,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Aetna,Medicare Advantage,,129.78,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Aetna,Medicare Advantage,,1048.02,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Aetna,Medicare Advantage,,1159.15,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Aetna,Medicare Advantage,,936.01,,,,,,,856.54,4311.00,fee schedule,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Medicare Advantage,,192.16,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Aetna,Medicare Advantage,,374.04,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Aetna,Medicare Advantage,,374.04,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Aetna,Medicare Advantage,,310.35,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Aetna,Medicare Advantage,,310.35,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Medicare Advantage,,310.35,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Aetna,Medicare Advantage,,936.01,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Aetna,Medicare Advantage,,728.08,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Aetna,Medicare Advantage,,728.08,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Aetna,Medicare Advantage,,728.08,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Aetna,Medicare Advantage,,936.01,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Aetna,Medicare Advantage,,728.08,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Aetna,Medicare Advantage,,936.01,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Aetna,Medicare Advantage,,728.08,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Aetna,Medicare Advantage,,728.08,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Aetna,Medicare Advantage,,728.08,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Aetna,Medicare Advantage,,728.08,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Aetna,Medicare Advantage,,728.08,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Medicare Advantage,,2053.05,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Medicare Advantage,,2053.05,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Aetna,Medicare Advantage,,2053.05,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Aetna,Medicare Advantage,,2053.05,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Aetna,Medicare Advantage,,1923.16,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Aetna,Medicare Advantage,,1923.16,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Aetna,Medicare Advantage,,208.90,,,,,,,102.50,4311.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Aetna,Medicare Advantage,,141.97,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,208.90,,,,,,,12.21,208.90,fee schedule,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Aetna,Medicare Advantage,52,262.90,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Aetna,Medicare Advantage,,348.72,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Aetna,Medicare Advantage,,144.98,,,,,,,123.79,1912.00,fee schedule,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Aetna,Medicare Advantage,,349.18,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Medicare Advantage,,135.52,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Aetna,Medicare Advantage,,420.05,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Aetna,Medicare Advantage,,420.05,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Medicare Advantage,,204.11,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Medicare Advantage,,92.57,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Aetna,Medicare Advantage,,166.49,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Aetna,Medicare Advantage,,291.11,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Aetna,Medicare Advantage,,447.69,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Aetna,Medicare Advantage,,644.59,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Aetna,Medicare Advantage,,885.87,,,,,,,748.05,5152.00,fee schedule,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Aetna,Medicare Advantage,,316.44,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Aetna,Medicare Advantage,,327.39,,,,,,,161.50,3641.00,fee schedule,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Aetna,Medicare Advantage,,86.28,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Aetna,Medicare Advantage,,70.74,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Medicare Advantage,,45.17,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Medicare Advantage,,135.52,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Medicare Advantage,,135.52,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,2052.00,fee schedule,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Medicare Advantage,,48.04,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,44.93,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Aetna,Medicare Advantage,,59.51,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Aetna,Medicare Advantage,,57.36,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Medicare Advantage,,75.76,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Medicare Advantage,,95.36,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Medicare Advantage,,88.67,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Medicare Advantage,,113.53,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Aetna,Medicare Advantage,,43.26,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Medicare Advantage,,17.21,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Aetna,Medicare Advantage,,54.25,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Medicare Advantage,,23.90,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Aetna,Medicare Advantage,,63.81,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Aetna,Medicare Advantage,,59.75,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Aetna,Medicare Advantage,,97.03,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Aetna,Medicare Advantage,,103.97,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Medicare Advantage,,104.44,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Aetna,Medicare Advantage,,94.88,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Aetna,Medicare Advantage,,43.26,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Aetna,Medicare Advantage,,60.71,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Aetna,Medicare Advantage,,92.73,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Aetna,Medicare Advantage,,116.87,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Medicare Advantage,,15.77,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Medicare Advantage,,25.33,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Aetna,Medicare Advantage,,42.06,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Aetna,Medicare Advantage,,62.14,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Medicare Advantage,,81.98,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Aetna,Medicare Advantage,,55.21,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Medicare Advantage,,75.76,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Medicare Advantage,,113.53,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Aetna,Medicare Advantage,,137.66,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,11.71,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Medicare Advantage,,22.23,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Aetna,Medicare Advantage,,32.74,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Aetna,Medicare Advantage,,26.77,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Medicare Advantage,,11.47,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Medicare Advantage,,31.07,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Aetna,Medicare Advantage,,5.97,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,22.70,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,12.91,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Medicare Advantage,JW,29.40,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Medicare Advantage,,29.40,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,JW,22.70,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Aetna,Medicare Advantage,,33.94,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Medicare Advantage,,65.72,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Medicare Advantage,,47.80,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Aetna,Medicare Advantage,JW,47.80,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Medicare Advantage,,108.75,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Medicare Advantage,,217.73,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Medicare Advantage,JW,217.73,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Aetna,Medicare Advantage,JW,108.75,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Medicare Advantage,,236.13,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Medicare Advantage,,65.25,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Medicare Advantage,JW,236.13,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Medicare Advantage,JW,65.25,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Medicare Advantage,,136.47,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Aetna,Medicare Advantage,,62.62,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Medicare Advantage,,658.21,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Medicare Advantage,,290.62,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Aetna,Medicare Advantage,,147.22,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Aetna,Medicare Advantage,JW,658.21,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Aetna,Medicare Advantage,JW,290.62,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Aetna,Medicare Advantage,JW,147.22,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Aetna,Medicare Advantage,,672.31,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Medicare Advantage,,29.40,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Aetna,Medicare Advantage,,81.74,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Aetna,Medicare Advantage,JW,81.74,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Medicare Advantage,,369.49,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Aetna,Medicare Advantage,,739.47,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Aetna,Medicare Advantage,JW,369.49,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Aetna,Medicare Advantage,,102.29,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Aetna,Medicare Advantage,JW,102.29,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Aetna,Medicare Advantage,,115.44,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Aetna,Medicare Advantage,JW,115.44,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Aetna,Medicare Advantage,,2.39,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Medicare Advantage,,597.02,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Aetna,Medicare Advantage,JW,597.02,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Medicare Advantage,,483.98,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Aetna,Medicare Advantage,JW,483.98,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Medicare Advantage,,408.21,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Aetna,Medicare Advantage,JW,408.21,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,15.54,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,JW,15.54,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Aetna,Medicare Advantage,,590.09,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Aetna,Medicare Advantage,,166.82,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Aetna,Medicare Advantage,,166.82,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Medicare Advantage,,146.99,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Medicare Advantage,,146.99,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,104.92,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,104.92,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Medicare Advantage,,95.36,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Medicare Advantage,,95.36,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Aetna,Medicare Advantage,JW,564.76,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Medicare Advantage,JW,136.47,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Aetna,Medicare Advantage,JW,62.62,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Aetna,Medicare Advantage,,74.81,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Aetna,Medicare Advantage,JW,74.81,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Medicare Advantage,,376.43,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Aetna,Medicare Advantage,JW,376.43,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Medicare Advantage,,299.23,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Aetna,Medicare Advantage,JW,299.23,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Aetna,Medicare Advantage,,153.20,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Aetna,Medicare Advantage,JW,153.20,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Aetna,Medicare Advantage,,81.26,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Aetna,Medicare Advantage,JW,81.26,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Aetna,Medicare Advantage,,65.01,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Aetna,Medicare Advantage,JW,65.01,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Aetna,Medicare Advantage,,612.32,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Aetna,Medicare Advantage,,62.46,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Medicare Advantage,,41.27,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Medicare Advantage,,41.27,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Medicare Advantage,,41.27,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Medicare Advantage,,41.27,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Aetna,Medicare Advantage,,208.90,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Aetna,Medicare Advantage,,1239.63,,,,,,,799.81,4311.00,fee schedule,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Aetna,Medicare Advantage,,43.26,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Aetna,Medicare Advantage,,420.05,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Aetna,Medicare Advantage,,1703.44,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Aetna,Medicare Advantage,,54.16,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Aetna,Medicare Advantage,,208.90,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Aetna,Medicare Advantage,,1923.16,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Aetna,Medicare Advantage,,1923.16,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Aetna,Medicare Advantage,,1923.16,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Aetna,Medicare Advantage,,1923.16,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Aetna,Medicare Advantage,,165.89,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Aetna,Medicare Advantage,,165.89,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Medicare Advantage,,165.89,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Aetna,Medicare Advantage,,3342.81,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Medicare Advantage,,315.31,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Aetna,Medicare Advantage,,643.57,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Aetna,Medicare Advantage,,728.08,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Aetna,Medicare Advantage,,1633.21,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Aetna,Medicare Advantage,,1633.21,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Aetna,Medicare Advantage,,5994.30,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Aetna,Medicare Advantage,,5994.30,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Aetna,Medicare Advantage,,5994.30,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Aetna,Medicare Advantage,,5994.30,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Aetna,Medicare Advantage,,18878.80,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Aetna,Medicare Advantage,,18878.80,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Medicare Advantage,,165.89,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Aetna,Medicare Advantage,,208.90,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Aetna,Medicare Advantage,,141.97,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Aetna,Medicare Advantage,,208.90,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Aetna,Medicare Advantage,,184.27,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Aetna,Medicare Advantage,,420.05,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Aetna,Medicare Advantage,,3009.02,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Medicare Advantage,,41.27,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Medicare Advantage,,208.90,,,,,,,59.38,4311.00,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Medicare Advantage,,46.60,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Medicare Advantage,,420.05,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Medicare Advantage,,46.60,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Medicare Advantage,,643.57,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Medicare Advantage,,46.60,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Medicare Advantage,,420.05,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,,135.52,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Aetna,Medicare Advantage,,96.50,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Aetna,Medicare Advantage,,96.50,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Medicare Advantage,,39.21,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Aetna,Medicare Advantage,,39.21,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Medicare Advantage,,39.21,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Medicare Advantage,,39.21,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Medicare Advantage,,39.21,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Medicare Advantage,,25.75,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Aetna,Medicare Advantage,,208.90,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Medicare Advantage,,420.05,,,,,,,97.08,420.05,fee schedule,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Aetna,Medicare Advantage,,15.30,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Aetna,Medicare Advantage,,15.30,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,6.69,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Medicare Advantage,,35.85,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Medicare Advantage,,20.32,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Medicare Advantage,,62.46,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Medicare Advantage,,420.05,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Aetna,Medicare Advantage,,18382.97,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Aetna,Medicare Advantage,,7510.57,,,,,,,155.56,12408.00,fee schedule,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Aetna,Medicare Advantage,,2097.94,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Aetna,Medicare Advantage,,2097.94,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Aetna,Medicare Advantage,,1180.90,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Medicare Advantage,,69.79,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Aetna,Medicare Advantage,,135.52,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Aetna,Medicare Advantage,,135.52,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Aetna,Medicare Advantage,,985.70,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Medicare Advantage,,255.70,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Aetna,Medicare Advantage,,2153.70,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Medicare Advantage,,459.63,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Aetna,Medicare Advantage,,2153.70,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Aetna,Medicare Advantage,,3626.08,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Aetna,Medicare Advantage,,1723.45,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Aetna,Medicare Advantage,,739.72,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Aetna,Medicare Advantage,,1703.44,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Aetna,Medicare Advantage,,1703.44,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Aetna,Medicare Advantage,,1703.44,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Aetna,Medicare Advantage,,11922.91,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Aetna,Medicare Advantage,,650.00,,,,,,,104.90,4311.00,fee schedule,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Aetna,Medicare Advantage,,136.95,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Aetna,Medicare Advantage,,318.11,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Medicare Advantage,,739.72,,,,,,,512.71,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Medicare Advantage,,612.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Aetna,Medicare Advantage,,739.72,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Aetna,Medicare Advantage,,452.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Aetna,Medicare Advantage,,825.98,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Medicare Advantage,,739.72,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Aetna,Medicare Advantage,,612.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Aetna,Medicare Advantage,,1239.69,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Medicare Advantage,,295.17,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Medicare Advantage,,250.47,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Aetna,Medicare Advantage,,168.97,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Medicare Advantage,,131.45,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Medicare Advantage,,105.64,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Aetna,Medicare Advantage,,111.37,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Aetna,Medicare Advantage,JW,295.17,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Aetna,Medicare Advantage,JW,250.47,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Aetna,Medicare Advantage,JW,168.97,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Medicare Advantage,JW,131.45,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Medicare Advantage,JW,105.64,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Aetna,Medicare Advantage,JW,111.37,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Aetna,Medicare Advantage,,496.64,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Aetna,Medicare Advantage,,62.46,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,74.83,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Aetna,Medicare Advantage,,557.85,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Medicare Advantage,,557.85,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Aetna,Medicare Advantage,,557.85,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Aetna,Medicare Advantage,,327.39,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Aetna,Medicare Advantage,,164.49,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Aetna,Medicare Advantage,,985.70,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Aetna,Medicare Advantage,,985.70,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Aetna,Medicare Advantage,,327.39,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Aetna,Medicare Advantage,,985.70,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Aetna,Medicare Advantage,,327.39,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Aetna,Medicare Advantage,,557.85,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Aetna,Medicare Advantage,,557.85,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Aetna,Medicare Advantage,,2452.76,,,,,,,409.80,2452.76,fee schedule,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Aetna,Medicare Advantage,,1011.45,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Aetna,Medicare Advantage,,4572.55,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Aetna,Medicare Advantage,,327.39,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Aetna,Medicare Advantage,,327.39,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Aetna,Medicare Advantage,,164.49,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Aetna,Medicare Advantage,,327.39,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Aetna,Medicare Advantage,,327.39,,,,,,,55.36,1831.00,fee schedule,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,12.91,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Aetna,Medicare Advantage,,72.89,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Medicare Advantage,,92.57,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Aetna,Medicare Advantage,,111.80,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Aetna,Medicare Advantage,,111.80,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Medicare Advantage,,92.57,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Aetna,Medicare Advantage,,111.80,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Aetna,Medicare Advantage,,92.57,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Medicare Advantage,,254.13,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Aetna,Medicare Advantage,,111.80,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Medicare Advantage,,92.57,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Aetna,Medicare Advantage,,92.57,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Medicare Advantage,,92.57,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Aetna,Medicare Advantage,,111.80,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Aetna,Medicare Advantage,,111.80,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Aetna,Medicare Advantage,,92.57,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Aetna,Medicare Advantage,,92.57,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Aetna,Medicare Advantage,,92.57,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Aetna,Medicare Advantage,,92.57,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Aetna,Medicare Advantage,,111.80,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Aetna,Medicare Advantage,,111.80,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Aetna,Medicare Advantage,,111.80,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Medicare Advantage,,92.57,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Aetna,Medicare Advantage,,92.57,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Medicare Advantage,,92.57,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Medicare Advantage,,92.57,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Medicare Advantage,,111.80,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Aetna,Medicare Advantage,,111.80,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Aetna,Medicare Advantage,,111.80,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Aetna,Medicare Advantage,,111.80,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Aetna,Medicare Advantage,,92.57,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Aetna,Medicare Advantage,,111.80,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Aetna,Medicare Advantage,,111.80,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Aetna,Medicare Advantage,,111.80,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Medicare Advantage,,111.80,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Aetna,Medicare Advantage,,111.80,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Aetna,Medicare Advantage,,111.80,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Aetna,Medicare Advantage,,111.80,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Aetna,Medicare Advantage,,92.57,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Aetna,Medicare Advantage,,830.63,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Aetna,Medicare Advantage,,830.63,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Aetna,Medicare Advantage,,830.63,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Aetna,Medicare Advantage,,830.63,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Aetna,Medicare Advantage,,2053.05,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Aetna,Medicare Advantage,,92.57,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Aetna,Medicare Advantage,,111.80,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Aetna,Medicare Advantage,,92.57,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Aetna,Medicare Advantage,,92.57,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Medicare Advantage,,375.47,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Aetna,Medicare Advantage,,92.57,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Aetna,Medicare Advantage,,92.57,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Aetna,Medicare Advantage,,92.57,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Aetna,Medicare Advantage,,92.57,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Aetna,Medicare Advantage,,375.47,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Aetna,Medicare Advantage,,92.57,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Aetna,Medicare Advantage,,111.80,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Aetna,Medicare Advantage,,92.57,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Aetna,Medicare Advantage,,92.57,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Aetna,Medicare Advantage,,375.47,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Aetna,Medicare Advantage,,111.80,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Aetna,Medicare Advantage,,92.57,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Aetna,Medicare Advantage,,92.57,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Aetna,Medicare Advantage,,375.47,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Aetna,Medicare Advantage,,92.57,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Medicare Advantage,,92.57,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Aetna,Medicare Advantage,,111.80,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Aetna,Medicare Advantage,,92.57,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Aetna,Medicare Advantage,,375.47,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Aetna,Medicare Advantage,,92.57,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Medicare Advantage,,92.57,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Aetna,Medicare Advantage,,92.57,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Medicare Advantage,,92.57,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Aetna,Medicare Advantage,,375.47,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Aetna,Medicare Advantage,,92.57,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Medicare Advantage,,92.57,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Aetna,Medicare Advantage,,92.57,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Medicare Advantage,,92.57,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Aetna,Medicare Advantage,,92.57,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,,576.46,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,,576.46,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,,576.46,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Aetna,Medicare Advantage,,187.16,,,,,,,138.66,586.50,fee schedule,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Aetna,Medicare Advantage,,76.96,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Aetna,Medicare Advantage,,187.16,,,,,,,49.45,311.44,fee schedule,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Aetna,Medicare Advantage,,252.15,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Aetna,Medicare Advantage,,173.99,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Aetna,Medicare Advantage,,212.23,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Aetna,Medicare Advantage,,119.02,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Aetna,Medicare Advantage,,126.43,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Aetna,Medicare Advantage,,375.47,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Aetna,Medicare Advantage,,375.47,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Aetna,Medicare Advantage,,375.47,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Aetna,Medicare Advantage,,254.13,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Aetna,Medicare Advantage,,254.13,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Aetna,Medicare Advantage,,254.13,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Aetna,Medicare Advantage,,2153.70,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Aetna,Medicare Advantage,,254.13,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Aetna,Medicare Advantage,,5683.29,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Aetna,Medicare Advantage,,111.80,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Aetna,Medicare Advantage,,1633.21,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Aetna,Medicare Advantage,,1633.21,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Aetna,Medicare Advantage,,1633.21,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Aetna,Medicare Advantage,,3309.13,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Aetna,Medicare Advantage,,3309.13,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Aetna,Medicare Advantage,,3309.13,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Aetna,Medicare Advantage,,5683.29,,,,,,,150.22,5683.29,fee schedule,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Aetna,Medicare Advantage,,557.59,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Aetna,Medicare Advantage,,3309.13,,,,,,,82.40,3309.13,fee schedule,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Medicare Advantage,,48.76,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Aetna,Medicare Advantage,,41.83,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Aetna,Medicare Advantage,,287.76,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Aetna,Medicare Advantage,,184.27,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Aetna,Medicare Advantage,,252.62,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Aetna,Medicare Advantage,,85.56,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Aetna,Medicare Advantage,,254.13,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Aetna,Medicare Advantage,,92.57,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Aetna,Medicare Advantage,,576.46,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Aetna,Medicare Advantage,,576.46,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Aetna,Medicare Advantage,,111.80,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Medicare Advantage,,92.57,,,,,,,28.63,268.00,fee schedule,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Aetna,Medicare Advantage,,177.82,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Aetna,Medicare Advantage,,158.22,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Aetna,Medicare Advantage,,157.02,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Aetna,Medicare Advantage,,254.13,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Aetna,Medicare Advantage,,254.13,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Aetna,Medicare Advantage,,111.80,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Aetna,Medicare Advantage,,111.80,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Aetna,Medicare Advantage,,111.80,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Aetna,Medicare Advantage,,111.80,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Medicare Advantage,,111.80,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Aetna,Medicare Advantage,,92.57,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Aetna,Medicare Advantage,,5683.29,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Aetna,Medicare Advantage,,5683.29,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Aetna,Medicare Advantage,,5683.29,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,198.96,3309.13,fee schedule,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Aetna,Medicare Advantage,,426.85,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Aetna,Medicare Advantage,,335.56,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Aetna,Medicare Advantage,,92.57,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Aetna,Medicare Advantage,,92.57,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Aetna,Medicare Advantage,,111.80,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Aetna,Medicare Advantage,,254.13,,,,,,,166.37,623.25,fee schedule,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Medicare Advantage,,38.96,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Aetna,Medicare Advantage,,111.80,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Aetna,Medicare Advantage,,2053.05,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Aetna,Medicare Advantage,,92.57,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Aetna,Medicare Advantage,,92.57,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Aetna,Medicare Advantage,,92.57,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Aetna,Medicare Advantage,,111.80,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Aetna,Medicare Advantage,,111.80,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Aetna,Medicare Advantage,,111.80,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Aetna,Medicare Advantage,,111.80,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Aetna,Medicare Advantage,,92.57,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Aetna,Medicare Advantage,,92.57,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Aetna,Medicare Advantage,,254.06,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Aetna,Medicare Advantage,,187.16,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Aetna,Medicare Advantage,,187.16,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Aetna,Medicare Advantage,,18382.97,,,,,,,4762.50,27607.50,fee schedule,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Aetna,Medicare Advantage,,51.86,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Aetna,Medicare Advantage,,5683.29,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Aetna,Medicare Advantage,,830.63,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Aetna,Medicare Advantage,,92.57,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Aetna,Medicare Advantage,,111.80,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Aetna,Medicare Advantage,,111.80,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Aetna,Medicare Advantage,,187.16,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Aetna,Medicare Advantage,,187.16,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Aetna,Medicare Advantage,,187.16,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Aetna,Medicare Advantage,,111.80,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Aetna,Medicare Advantage,,187.16,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Aetna,Medicare Advantage,,111.80,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Aetna,Medicare Advantage,,348.72,,,,,,,165.97,3466.00,fee schedule,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Aetna,Medicare Advantage,,81.98,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Medicare Advantage,,98.71,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Medicare Advantage,,422.46,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Aetna,Medicare Advantage,,422.46,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Aetna,Medicare Advantage,,422.46,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Aetna,Medicare Advantage,,422.46,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Aetna,Medicare Advantage,,422.46,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Aetna,Medicare Advantage,,565.91,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Aetna,Medicare Advantage,,422.46,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Aetna,Medicare Advantage,,422.46,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Aetna,Medicare Advantage,,422.46,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Aetna,Medicare Advantage,,422.46,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Aetna,Medicare Advantage,,422.46,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Aetna,Medicare Advantage,,422.46,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Aetna,Medicare Advantage,,422.46,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Aetna,Medicare Advantage,,1372.52,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Aetna,Medicare Advantage,,1372.52,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Aetna,Medicare Advantage,,422.46,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Aetna,Medicare Advantage,,422.46,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Aetna,Medicare Advantage,,565.91,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Aetna,Medicare Advantage,,565.91,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Aetna,Medicare Advantage,,1372.52,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Medicare Advantage,,422.46,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Medicare Advantage,,565.91,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Aetna,Medicare Advantage,,422.46,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Aetna,Medicare Advantage,,422.46,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Aetna,Medicare Advantage,,1372.52,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Aetna,Medicare Advantage,,1372.52,,,,,,,257.00,2207.25,fee schedule,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Aetna,Medicare Advantage,,66.20,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,24.52,,,,,,,10.21,208.95,fee schedule,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Medicare Advantage,,23.66,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Aetna,Medicare Advantage,,758.21,,,,,,,406.41,2131.58,fee schedule,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Aetna,Medicare Advantage,,236.13,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Medicare Advantage,,25.57,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Aetna,Medicare Advantage,,49.71,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,44.93,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Aetna,Medicare Advantage,,2029.49,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Aetna,Medicare Advantage,,2199.30,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Aetna,Medicare Advantage,,235.64,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Medicare Advantage,,235.64,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Aetna,Medicare Advantage,,235.64,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Aetna,Medicare Advantage,,235.64,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Aetna,Medicare Advantage,,4573.80,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Medicare Advantage,,422.46,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Aetna,Medicare Advantage,,60234.02,,,,,,,0.20220,163224.30,fee schedule,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Aetna,Medicare Advantage,,20.79,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Aetna,Medicare Advantage,,209.84,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Aetna,Medicare Advantage,,28.44,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Aetna,Medicare Advantage,,139.58,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Aetna,Medicare Advantage,,77.20,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Aetna,Medicare Advantage,,10.52,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Aetna,Medicare Advantage,,1093.27,,,,,,,1000.45,10134.22,fee schedule,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Aetna,Medicare Advantage,,1.43,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Aetna,Medicare Advantage,,155.11,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Medicare Advantage,,29.16,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Medicare Advantage,,10.04,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Aetna,Medicare Advantage,,19.60,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Aetna,Medicare Advantage,,60.71,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,18.40,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Aetna,Medicare Advantage,,2326.30,,,,,,,1212.81,6878.34,fee schedule,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Aetna,Medicare Advantage,,43.74,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Aetna,Medicare Advantage,,422.46,,,,,,,215.22,1560.00,fee schedule,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Aetna,Medicare Advantage,,72.89,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Aetna,Medicare Advantage,,182.55,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Aetna,Medicare Advantage,,565.91,,,,,,,257.00,1560.00,fee schedule,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Aetna,Medicare Advantage,,320.98,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Aetna,Medicare Advantage,,284.53,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Aetna,Medicare Advantage,,422.46,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Aetna,Medicare Advantage,,1372.52,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Aetna,Medicare Advantage,,1372.52,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Aetna,Medicare Advantage,,1372.52,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Aetna,Medicare Advantage,,1533.49,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Aetna,Medicare Advantage,,528.59,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Aetna,Medicare Advantage,,630.81,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Aetna,Medicare Advantage,,352.39,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Aetna,Medicare Advantage,,403.87,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Aetna,Medicare Advantage,,711.49,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Aetna,Medicare Advantage,,92.57,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,3501.50,fee schedule,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Aetna,Medicare Advantage,,246.89,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Aetna,Medicare Advantage,,269.11,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Medicare Advantage,,92.57,,,,,,,64.86,2905.00,fee schedule,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Aetna,Medicare Advantage,,606.34,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Aetna,Medicare Advantage,,308.07,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Aetna,Medicare Advantage,,271.98,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Aetna,Medicare Advantage,,303.29,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,4490.21,fee schedule,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Aetna,Medicare Advantage,,8236.66,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Aetna,Medicare Advantage,,92.57,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Aetna,Medicare Advantage,,669.20,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Aetna,Medicare Advantage,,114.00,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Aetna,Medicare Advantage,,187.16,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Aetna,Medicare Advantage,,454.34,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Medicare Advantage,,999.30,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Aetna,Medicare Advantage,,1633.21,,,,,,,67.47,4376.00,fee schedule,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Aetna,Medicare Advantage,,8236.66,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Aetna,Medicare Advantage,,8236.66,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Aetna,Medicare Advantage,,7520.37,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Aetna,Medicare Advantage,,1994.40,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Aetna,Medicare Advantage,,1994.40,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Medicare Advantage,,6560.16,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Aetna,Medicare Advantage,,3710.28,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Aetna,Medicare Advantage,,2053.05,,,,,,,1022.02,17457.00,fee schedule,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Aetna,Medicare Advantage,,129.78,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Aetna,Medicare Advantage,,915.45,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,176.18,4311.00,fee schedule,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Aetna,Medicare Advantage,,13754.69,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,972.37,13852.00,fee schedule,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Aetna,Medicare Advantage,,7058.86,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Aetna,Medicare Advantage,,420.05,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Aetna,Medicare Advantage,,420.05,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Aetna,Medicare Advantage,,650.00,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Aetna,Medicare Advantage,,6133.95,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Medicare Advantage,,6560.16,,,,,,,125.93,13852.00,fee schedule,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Aetna,Medicare Advantage,,108.98,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Aetna,Medicare Advantage,,1994.40,,,,,,,46.45,4311.00,fee schedule,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Medicare Advantage,,48.04,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Medicare Advantage,,985.70,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Aetna,Medicare Advantage,,2153.70,,,,,,,222.02,4311.00,fee schedule,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Medicare Advantage,,109.46,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Aetna,Medicare Advantage,,68.11,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,24.14,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Aetna,Medicare Advantage,,1703.44,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Aetna,Medicare Advantage,,1703.44,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Aetna,Medicare Advantage,,1557.34,,,,,,,62.26,4311.00,fee schedule,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Aetna,Medicare Advantage,,74.33,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Medicare Advantage,,310.35,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Medicare Advantage,,310.35,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Aetna,Medicare Advantage,,310.35,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Aetna,Medicare Advantage,,310.35,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Aetna,Medicare Advantage,,310.35,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Aetna,Medicare Advantage,,13527.54,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Aetna,Medicare Advantage,,252.20,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Aetna,Medicare Advantage,,1703.44,,,,,,,142.54,4311.00,fee schedule,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Aetna,Medicare Advantage,,135.03,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Aetna,Medicare Advantage,,337.95,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Aetna,Medicare Advantage,,182.84,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Aetna,Medicare Advantage,,308.79,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Aetna,Medicare Advantage,,138.86,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Aetna,Medicare Advantage,,304.73,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Aetna,Medicare Advantage,,304.73,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Aetna,Medicare Advantage,,279.15,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Aetna,Medicare Advantage,,3411.22,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Aetna,Medicare Advantage,,3411.22,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Aetna,Medicare Advantage,,3710.28,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Aetna,Medicare Advantage,,650.00,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Aetna,Medicare Advantage,,1438.52,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Aetna,Medicare Advantage,,650.00,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Aetna,Medicare Advantage,,1633.21,,,,,,,354.35,4376.00,fee schedule,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Aetna,Medicare Advantage,,432.35,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Aetna,Medicare Advantage,,432.35,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Aetna,Medicare Advantage,,503.10,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Aetna,Medicare Advantage,,503.10,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Medicare Advantage,,161.80,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Aetna,Medicare Advantage,,161.80,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Medicare Advantage,,124.04,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Aetna,Medicare Advantage,,163.48,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Aetna,Medicare Advantage,,163.48,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Aetna,Medicare Advantage,,643.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Aetna,Medicare Advantage,,658.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Aetna,Medicare Advantage,,658.68,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Aetna,Medicare Advantage,,380.97,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Aetna,Medicare Advantage,,380.97,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Aetna,Medicare Advantage,,218.92,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Aetna,Medicare Advantage,,218.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Aetna,Medicare Advantage,,270.07,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Aetna,Medicare Advantage,,270.07,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Aetna,Medicare Advantage,,275.57,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Aetna,Medicare Advantage,,275.57,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,1012.81,17457.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Aetna,Medicare Advantage,,1177.08,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Aetna,Medicare Advantage,,190.00,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Aetna,Medicare Advantage,,173.28,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Aetna,Medicare Advantage,,1633.21,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Aetna,Medicare Advantage,,1633.21,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Medicare Advantage,,650.00,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Aetna,Medicare Advantage,,1633.21,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Aetna,Medicare Advantage,,1633.21,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Aetna,Medicare Advantage,,5683.29,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Aetna,Medicare Advantage,,1633.21,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Aetna,Medicare Advantage,,650.00,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Aetna,Medicare Advantage,,1633.21,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Aetna,Medicare Advantage,,1633.21,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Aetna,Medicare Advantage,,1633.21,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Aetna,Medicare Advantage,,221.51,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Aetna,Medicare Advantage,,221.51,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Aetna,Medicare Advantage,,18878.80,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Aetna,Medicare Advantage,,18878.80,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Aetna,Medicare Advantage,,3359.86,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Aetna,Medicare Advantage,,1478.45,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Medicare Advantage,,11922.91,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Medicare Advantage,,11922.91,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Aetna,Medicare Advantage,,5683.29,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,1213.61,24600.00,fee schedule,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Aetna,Medicare Advantage,,1448.82,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Aetna,Medicare Advantage,,1448.82,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Aetna,Medicare Advantage,,5683.29,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Aetna,Medicare Advantage,,650.00,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Aetna,Medicare Advantage,,1703.44,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Aetna,Medicare Advantage,,422.46,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Medicare Advantage,,459.63,,,,,,,173.00,4311.00,fee schedule,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Aetna,Medicare Advantage,,90.58,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Aetna,Medicare Advantage,,419.53,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Aetna,Medicare Advantage,,985.70,,,,,,,56.46,4121.00,fee schedule,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Aetna,Medicare Advantage,,129.54,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Aetna,Medicare Advantage,,10945.84,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Aetna,Medicare Advantage,,3710.28,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Aetna,Medicare Advantage,,10945.84,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Aetna,Medicare Advantage,,1703.44,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Aetna,Medicare Advantage,,985.70,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Aetna,Medicare Advantage,,985.70,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Aetna,Medicare Advantage,,1703.44,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Aetna,Medicare Advantage,,1438.52,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Aetna,Medicare Advantage,,3710.28,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Medicare Advantage,,1994.40,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Aetna,Medicare Advantage,,1994.40,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Aetna,Medicare Advantage,,1994.40,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Aetna,Medicare Advantage,,985.70,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Aetna,Medicare Advantage,,985.70,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Aetna,Medicare Advantage,,985.70,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Aetna,Medicare Advantage,,254.13,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Aetna,Medicare Advantage,,985.70,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Aetna,Medicare Advantage,,1703.44,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Aetna,Medicare Advantage,,2153.70,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Aetna,Medicare Advantage,,2153.70,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Aetna,Medicare Advantage,,2153.70,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Medicare Advantage,,701.74,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Aetna,Medicare Advantage,,739.72,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Aetna,Medicare Advantage,,6133.95,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Aetna,Medicare Advantage,,10945.84,,,,,,,1554.95,17457.00,fee schedule,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,21.51,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Aetna,Medicare Advantage,,2153.70,,,,,,,498.70,5754.00,fee schedule,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Medicare Advantage,,70.27,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Aetna,Medicare Advantage,,55.21,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Aetna,Medicare Advantage,,135.52,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Aetna,Medicare Advantage,,255.70,,,,,,,80.88,4311.00,fee schedule,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Aetna,Medicare Advantage,,97.51,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Medicare Advantage,,211.50,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Medicare Advantage,,739.72,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Aetna,Medicare Advantage,,1011.93,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,584.78,24600.00,fee schedule,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Aetna,Medicare Advantage,,1093.19,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Aetna,Medicare Advantage,,739.72,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Aetna,Medicare Advantage,,739.72,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Aetna,Medicare Advantage,,728.08,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Medicare Advantage,,68.83,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Medicare Advantage,,68.83,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Aetna,Medicare Advantage,,936.01,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Aetna,Medicare Advantage,,936.01,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Aetna,Medicare Advantage,,280.35,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Aetna,Medicare Advantage,,936.01,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Aetna,Medicare Advantage,,936.01,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Aetna,Medicare Advantage,,486.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Aetna,Medicare Advantage,,486.13,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Aetna,Medicare Advantage,,936.01,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Aetna,Medicare Advantage,,936.01,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Aetna,Medicare Advantage,,936.01,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Aetna,Medicare Advantage,,936.01,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Aetna,Medicare Advantage,,393.39,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Aetna,Medicare Advantage,,393.39,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Aetna,Medicare Advantage,,408.69,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Aetna,Medicare Advantage,,936.01,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Aetna,Medicare Advantage,,936.01,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Aetna,Medicare Advantage,,936.01,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Aetna,Medicare Advantage,,936.01,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Aetna,Medicare Advantage,,2053.05,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Aetna,Medicare Advantage,,2053.05,,,,,,,626.20,4311.00,fee schedule,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Aetna,Medicare Advantage,,444.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Aetna,Medicare Advantage,,444.54,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Aetna,Medicare Advantage,,936.01,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Aetna,Medicare Advantage,,936.01,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Aetna,Medicare Advantage,,87.95,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Aetna,Medicare Advantage,,1239.63,,,,,,,915.54,6735.00,fee schedule,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Aetna,Medicare Advantage,,52.58,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Aetna,Medicare Advantage,,7510.57,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Aetna,Medicare Advantage,,7510.57,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,2143.34,24600.00,fee schedule,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Medicare Advantage,,124.04,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Aetna,Medicare Advantage,,279.15,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Aetna,Medicare Advantage,,739.72,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Aetna,Medicare Advantage,,459.63,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Aetna,Medicare Advantage,,739.72,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Aetna,Medicare Advantage,,1703.44,,,,,,,1092.69,6649.00,fee schedule,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Aetna,Medicare Advantage,,887.17,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,944.74,6649.00,fee schedule,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Aetna,Medicare Advantage,,924.69,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,973.77,6735.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Aetna,Medicare Advantage,,953.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Aetna,Medicare Advantage,,1703.44,,,,,,,337.94,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Aetna,Medicare Advantage,,136.95,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Aetna,Medicare Advantage,,10945.84,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Aetna,Medicare Advantage,,739.72,,,,,,,398.40,4376.00,fee schedule,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Aetna,Medicare Advantage,,356.59,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Aetna,Medicare Advantage,,739.72,,,,,,,531.13,6735.00,fee schedule,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Aetna,Medicare Advantage,,6875.07,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Aetna,Medicare Advantage,,18878.80,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Aetna,Medicare Advantage,,11922.91,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Aetna,Medicare Advantage,,739.72,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Aetna,Medicare Advantage,,3710.28,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Aetna,Medicare Advantage,,310.35,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Aetna,Medicare Advantage,,728.08,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Aetna,Medicare Advantage,,728.08,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Aetna,Medicare Advantage,,310.35,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Aetna,Medicare Advantage,,310.35,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Aetna,Medicare Advantage,,3411.22,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Aetna,Medicare Advantage,,3411.22,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Aetna,Medicare Advantage,,293.73,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Aetna,Medicare Advantage,,7510.57,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Aetna,Medicare Advantage,,7510.57,,,,,,,358.56,13852.00,fee schedule,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Aetna,Medicare Advantage,,376.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Aetna,Medicare Advantage,,830.63,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Aetna,Medicare Advantage,,830.63,,,,,,,209.41,8213.00,fee schedule,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Aetna,Medicare Advantage,,857.05,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Aetna,Medicare Advantage,,857.05,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Medicare Advantage,,621.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Medicare Advantage,,621.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Medicare Advantage,,621.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Aetna,Medicare Advantage,,621.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Aetna,Medicare Advantage,,3710.28,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Aetna,Medicare Advantage,,3710.28,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Aetna,Medicare Advantage,,3710.28,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Aetna,Medicare Advantage,,3710.28,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Aetna,Medicare Advantage,,3710.28,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Aetna,Medicare Advantage,,3710.28,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Aetna,Medicare Advantage,,985.70,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Aetna,Medicare Advantage,,6133.95,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Aetna,Medicare Advantage,,6133.95,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Aetna,Medicare Advantage,,6133.95,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Aetna,Medicare Advantage,,6560.16,,,,,,,1392.39,17457.00,fee schedule,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Aetna,Medicare Advantage,,635.26,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Aetna,Medicare Advantage,,441.67,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Aetna,Medicare Advantage,,1703.44,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Aetna,Medicare Advantage,,701.74,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Aetna,Medicare Advantage,,701.74,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Aetna,Medicare Advantage,,2153.70,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Aetna,Medicare Advantage,,3626.08,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Aetna,Medicare Advantage,,2153.70,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Aetna,Medicare Advantage,,2153.70,,,,,,,561.56,6649.00,fee schedule,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Aetna,Medicare Advantage,,635.26,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Aetna,Medicare Advantage,,3626.08,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Aetna,Medicare Advantage,,3626.08,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Aetna,Medicare Advantage,,3626.08,,,,,,,1623.02,17457.00,fee schedule,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Aetna,Medicare Advantage,,179.49,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Aetna,Medicare Advantage,,2599.60,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Aetna,Medicare Advantage,,1871.61,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Aetna,Medicare Advantage,,909.87,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Aetna,Medicare Advantage,,18878.80,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Aetna,Medicare Advantage,,739.72,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Aetna,Medicare Advantage,,831.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Aetna,Medicare Advantage,,831.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Aetna,Medicare Advantage,,5994.30,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Aetna,Medicare Advantage,,3867.50,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Aetna,Medicare Advantage,,3867.50,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Aetna,Medicare Advantage,,5994.30,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Aetna,Medicare Advantage,,5994.30,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Aetna,Medicare Advantage,,2227.96,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Aetna,Medicare Advantage,,2227.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Aetna,Medicare Advantage,,2970.29,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Aetna,Medicare Advantage,,2159.36,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Aetna,Medicare Advantage,,3009.02,,,,,,,582.58,4311.00,fee schedule,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Aetna,Medicare Advantage,,565.95,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Aetna,Medicare Advantage,,565.95,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Aetna,Medicare Advantage,,192.16,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Aetna,Medicare Advantage,,1633.21,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Aetna,Medicare Advantage,,1633.21,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Aetna,Medicare Advantage,,1633.21,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,9423.00,fee schedule,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Aetna,Medicare Advantage,,116.39,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Medicare Advantage,,650.00,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Medicare Advantage,,1633.21,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Medicare Advantage,,255.70,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Medicare Advantage,,255.70,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Aetna,Medicare Advantage,,3626.08,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Aetna,Medicare Advantage,,3626.08,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Aetna,Medicare Advantage,,1703.44,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Aetna,Medicare Advantage,,6732.92,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,4376.00,fee schedule,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Aetna,Medicare Advantage,,432.35,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Medicare Advantage,,1633.21,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Medicare Advantage,,650.00,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Aetna,Medicare Advantage,,1633.21,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Aetna,Medicare Advantage,,1069.64,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Aetna,Medicare Advantage,,830.63,,,,,,,392.19,8213.00,fee schedule,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Aetna,Medicare Advantage,,93.69,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Aetna,Medicare Advantage,,109.70,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Medicare Advantage,,89.15,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Aetna,Medicare Advantage,,89.15,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Aetna,Medicare Advantage,,93.69,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Aetna,Medicare Advantage,,111.80,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Aetna,Medicare Advantage,,111.80,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Aetna,Medicare Advantage,,111.80,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Aetna,Medicare Advantage,,111.80,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,568.50,fee schedule,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Aetna,Medicare Advantage,,74.09,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Aetna,Medicare Advantage,,254.13,,,,,,,160.28,720.75,fee schedule,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Medicare Advantage,,124.04,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Aetna,Medicare Advantage,,111.80,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Aetna,Medicare Advantage,,111.80,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Medicare Advantage,,111.80,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Aetna,Medicare Advantage,,254.13,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Aetna,Medicare Advantage,,111.80,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Aetna,Medicare Advantage,,111.80,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Aetna,Medicare Advantage,,111.80,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Aetna,Medicare Advantage,,111.80,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Aetna,Medicare Advantage,,92.57,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Aetna,Medicare Advantage,,92.57,,,,,,,46.25,467.00,fee schedule,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Medicare Advantage,,44.45,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Aetna,Medicare Advantage,,263.38,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Aetna,Medicare Advantage,,197.18,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Aetna,Medicare Advantage,,47.56,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,111.80,,,,,,,8.28,467.00,fee schedule,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Aetna,Medicare Advantage,,163.48,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Medicare Advantage,,92.57,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,725.25,fee schedule,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Aetna,Medicare Advantage,,173.04,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Aetna,Medicare Advantage,,98.71,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Aetna,Medicare Advantage,,92.57,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Aetna,Medicare Advantage,,111.80,,,,,,,91.89,467.00,fee schedule,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,26.29,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Medicare Advantage,,33.22,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Aetna,Medicare Advantage,,16.01,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Aetna,Medicare Advantage,,26.05,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Aetna,Medicare Advantage,,1372.52,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Aetna,Medicare Advantage,,1533.49,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Aetna,Medicare Advantage,,1533.49,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Aetna,Medicare Advantage,,1533.49,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Aetna,Medicare Advantage,,1533.49,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Aetna,Medicare Advantage,,422.46,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Aetna,Medicare Advantage,,1533.49,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Aetna,Medicare Advantage,,1533.49,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Aetna,Medicare Advantage,,1533.49,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Aetna,Medicare Advantage,,1533.49,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Aetna,Medicare Advantage,,1533.49,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Aetna,Medicare Advantage,,1533.49,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Aetna,Medicare Advantage,,1533.49,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Aetna,Medicare Advantage,,2366.07,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Aetna,Medicare Advantage,,2050.65,,,,,,,1550.57,5598.00,fee schedule,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Aetna,Medicare Advantage,,125.95,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Aetna,Medicare Advantage,,254.13,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Aetna,Medicare Advantage,,576.46,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Aetna,Medicare Advantage,,576.46,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,1851.75,fee schedule,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Aetna,Medicare Advantage,,114.96,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Aetna,Medicare Advantage,,830.63,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Aetna,Medicare Advantage,,830.63,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Aetna,Medicare Advantage,,830.63,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Aetna,Medicare Advantage,,92.57,,,,,,,84.71,2825.00,fee schedule,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Medicare Advantage,,60.47,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Aetna,Medicare Advantage,52,944.53,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Aetna,Medicare Advantage,52,939.99,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Aetna,Medicare Advantage,,375.47,,,,,,,343.59,4009.45,fee schedule,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Aetna,Medicare Advantage,,1009.77,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Aetna,Medicare Advantage,,773.40,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Aetna,Medicare Advantage,,1068.81,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Aetna,Medicare Advantage,,1012.88,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Aetna,Medicare Advantage,,1012.88,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Aetna,Medicare Advantage,,1012.88,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Aetna,Medicare Advantage,,844.87,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Aetna,Medicare Advantage,,972.25,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Aetna,Medicare Advantage,,972.25,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Aetna,Medicare Advantage,,1073.83,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Aetna,Medicare Advantage,,776.75,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Aetna,Medicare Advantage,,1097.97,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Aetna,Medicare Advantage,,1067.37,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Aetna,Medicare Advantage,,1009.30,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Aetna,Medicare Advantage,,1009.30,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Aetna,Medicare Advantage,,1085.06,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Aetna,Medicare Advantage,,1085.06,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Aetna,Medicare Advantage,,1085.06,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Aetna,Medicare Advantage,,246.89,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Aetna,Medicare Advantage,,254.13,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Aetna,Medicare Advantage,,944.53,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Aetna,Medicare Advantage,,448.12,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Aetna,Medicare Advantage,,92.57,,,,,,,41.04,319.50,fee schedule,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Medicare Advantage,,77.44,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Medicare Advantage,,62.46,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Aetna,Medicare Advantage,,728.08,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Aetna,Medicare Advantage,,728.08,,,,,,,328.93,4311.00,fee schedule,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Medicare Advantage,,37.76,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Aetna,Medicare Advantage,,728.08,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Aetna,Medicare Advantage,,728.08,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Aetna,Medicare Advantage,,129.06,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Medicare Advantage,,111.80,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Aetna,Medicare Advantage,,111.80,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Aetna,Medicare Advantage,,254.13,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Aetna,Medicare Advantage,,111.80,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Aetna,Medicare Advantage,,254.13,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Aetna,Medicare Advantage,,111.80,,,,,,,50.84,269.00,fee schedule,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,7.41,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Aetna,Medicare Advantage,,11.19,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Aetna,Medicare Advantage,,50.68,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Medicare Advantage,,9.20,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Aetna,Medicare Advantage,,50.49,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Aetna,Medicare Advantage,,8.66,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Medicare Advantage,,173.80,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Aetna,Medicare Advantage,,153.53,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Aetna,Medicare Advantage,,590.00,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Aetna,Medicare Advantage,,308.84,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Aetna,Medicare Advantage,,1229.60,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Aetna,Medicare Advantage,,1229.60,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Aetna,Medicare Advantage,,69.63,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Aetna,Medicare Advantage,,77.77,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Aetna,Medicare Advantage,,60.46,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Aetna,Medicare Advantage,,47.58,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Aetna,Medicare Advantage,,175.44,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Aetna,Medicare Advantage,,107.19,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Medicare Advantage,,37.10,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Aetna,Medicare Advantage,,69.28,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Aetna,Medicare Advantage,,209.87,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Medicare Advantage,,183.09,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Aetna,Medicare Advantage,,247.05,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Aetna,Medicare Advantage,,247.05,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Medicare Advantage,,2.38,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Aetna,Medicare Advantage,,369.47,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Aetna,Medicare Advantage,,54.13,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Aetna,Medicare Advantage,,46.27,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Aetna,Medicare Advantage,,213.59,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Medicare Advantage,,248.04,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Aetna,Medicare Advantage,,426.25,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Aetna,Medicare Advantage,,427.81,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Medicare Advantage,,135.08,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Aetna,Medicare Advantage,,78.79,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Aetna,Medicare Advantage,,100.42,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Aetna,Medicare Advantage,,366.30,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Aetna,Medicare Advantage,,355.50,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Aetna,Medicare Advantage,,187.88,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Aetna,Medicare Advantage,,180.09,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Aetna,Medicare Advantage,,131.10,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Aetna,Medicare Advantage,,261.31,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Medicare Advantage,,132.12,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Aetna,Medicare Advantage,,318.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Aetna,Medicare Advantage,,204.84,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Aetna,Medicare Advantage,,313.54,,,,,,,80.88,549.16,fee schedule,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Aetna,Medicare Advantage,,574.56,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Medicare Advantage,,17.78,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Aetna,Medicare Advantage,,5.34,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Aetna,Medicare Advantage,,9.26,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Medicare Advantage,,10.24,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Medicare Advantage,,7.97,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Medicare Advantage,,4.57,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Medicare Advantage,,65.87,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Aetna,Medicare Advantage,,8.97,,,,,,,8.21,198.75,fee schedule,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,0.00239,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Aetna,Medicare Advantage,,7.43,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Medicare Advantage,,14.19,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Medicare Advantage,,65.87,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Aetna,Medicare Advantage,,65.87,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Aetna,Medicare Advantage,,65.87,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Medicare Advantage,,65.87,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Aetna,Medicare Advantage,,65.87,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,15.98,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,15.98,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,15.98,,,,,,,14.63,60.75,fee schedule,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Medicare Advantage,,16.97,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,15.44,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,14.08,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,14.35,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Medicare Advantage,,17.36,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Medicare Advantage,,17.36,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Aetna,Medicare Advantage,,17.36,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,15.57,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,7.01,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Medicare Advantage,,16.22,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,14.04,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Medicare Advantage,,14.59,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Aetna,Medicare Advantage,,14.55,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Aetna,Medicare Advantage,,14.55,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Medicare Advantage,,14.99,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Medicare Advantage,,17.10,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Medicare Advantage,,17.10,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Medicare Advantage,,17.10,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,14.35,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,14.35,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,14.35,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Aetna,Medicare Advantage,,34.58,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Medicare Advantage,,4.79,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Medicare Advantage,,8.66,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,8.66,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,5.25,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Medicare Advantage,,8.25,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,6.13,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,6.13,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,18.31,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Medicare Advantage,,14.25,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Medicare Advantage,,17.78,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,15.44,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Medicare Advantage,,6.87,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Medicare Advantage,,6.87,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Medicare Advantage,,6.87,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Medicare Advantage,,17.15,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Medicare Advantage,,5.32,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Medicare Advantage,,5.32,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,5.32,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Aetna,Medicare Advantage,,4.64,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Medicare Advantage,,5.64,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Medicare Advantage,,4.48,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Aetna,Medicare Advantage,,31.38,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,,5.47,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,,5.47,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Medicare Advantage,,6.39,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Aetna,Medicare Advantage,,5.17,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,13.06,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,13.06,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Aetna,Medicare Advantage,,20.10,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,11.38,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,14.97,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,14.97,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,4.88,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,6.09,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,6.09,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.30,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Medicare Advantage,,4.61,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Aetna,Medicare Advantage,,40.88,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,28.74,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,28.74,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Medicare Advantage,,19.76,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Medicare Advantage,,17.28,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Aetna,Medicare Advantage,,14.55,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,6.90,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Medicare Advantage,,12.24,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Medicare Advantage,,5.43,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Aetna,Medicare Advantage,,29.62,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Aetna,Medicare Advantage,,15.79,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Medicare Advantage,,5.41,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Medicare Advantage,,14.45,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Aetna,Medicare Advantage,,68.27,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Medicare Advantage,,15.58,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Medicare Advantage,,9.86,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Medicare Advantage,,9.86,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Medicare Advantage,,9.86,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Medicare Advantage,,9.86,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Medicare Advantage,,11.66,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,27.63,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Medicare Advantage,,83.50,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Medicare Advantage,,83.50,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Medicare Advantage,,83.50,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Medicare Advantage,,83.50,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,10.36,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Medicare Advantage,,4.17,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,4.17,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,4.17,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,4.17,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Medicare Advantage,,4.17,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Aetna,Medicare Advantage,,5.04,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Medicare Advantage,,13.64,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,4.16,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,4.16,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Aetna,Medicare Advantage,,7.63,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Aetna,Medicare Advantage,,19.69,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Aetna,Medicare Advantage,,19.63,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Medicare Advantage,,13.33,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Aetna,Medicare Advantage,,13.64,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Medicare Advantage,,19.14,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Aetna,Medicare Advantage,,8.48,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,10.29,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Medicare Advantage,,8.69,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Medicare Advantage,,8.69,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Aetna,Medicare Advantage,,5.04,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Aetna,Medicare Advantage,,19.00,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Medicare Advantage,,26.98,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Medicare Advantage,,12.22,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Medicare Advantage,,12.22,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Medicare Advantage,,12.12,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,6.86,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,12.26,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Medicare Advantage,,6.40,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Medicare Advantage,,6.40,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,20.88,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Medicare Advantage,,20.48,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Medicare Advantage,,7.30,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Aetna,Medicare Advantage,,7.30,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Aetna,Medicare Advantage,,8.68,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Medicare Advantage,,11.13,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,7.10,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,7.10,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,7.10,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Medicare Advantage,,13.70,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Medicare Advantage,,41.62,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Medicare Advantage,,18.31,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,18.31,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Aetna,Medicare Advantage,,7.01,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,7.23,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Medicare Advantage,,43.76,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Aetna,Medicare Advantage,,43.76,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Medicare Advantage,,3.79,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Medicare Advantage,,3.79,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Medicare Advantage,,3.79,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,5.02,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Medicare Advantage,,6.13,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Aetna,Medicare Advantage,,6.13,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Aetna,Medicare Advantage,,104.00,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Medicare Advantage,,5.05,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,5.01,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,5.01,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,5.01,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,15.47,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Aetna,Medicare Advantage,,22.11,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Aetna,Medicare Advantage,,20.54,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Medicare Advantage,,19.49,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Medicare Advantage,,19.49,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Medicare Advantage,,3.89,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,3.89,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,3.89,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Aetna,Medicare Advantage,,4.24,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Medicare Advantage,,11.38,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Medicare Advantage,,18.90,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Medicare Advantage,,18.90,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Medicare Advantage,,5.10,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Medicare Advantage,,5.36,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Medicare Advantage,,5.36,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Medicare Advantage,,5.15,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Medicare Advantage,,3.48,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Aetna,Medicare Advantage,,27.36,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Medicare Advantage,,7.28,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Aetna,Medicare Advantage,,9.56,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Aetna,Medicare Advantage,,17.81,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Medicare Advantage,,5.62,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,13.53,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Medicare Advantage,,6.08,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Medicare Advantage,,15.03,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Medicare Advantage,,17.96,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Aetna,Medicare Advantage,,13.22,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,4.19,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Medicare Advantage,,5.89,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,4.79,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Medicare Advantage,,5.38,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Aetna,Medicare Advantage,,5.38,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Medicare Advantage,,65.87,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Aetna,Medicare Advantage,,65.87,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,15.95,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Medicare Advantage,,8.34,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Medicare Advantage,,5.53,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Medicare Advantage,,15.95,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Aetna,Medicare Advantage,,15.95,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Aetna,Medicare Advantage,,19.47,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Medicare Advantage,,11.83,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Medicare Advantage,,13.73,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Medicare Advantage,,26.98,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,26.98,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,26.98,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Aetna,Medicare Advantage,,12.72,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Medicare Advantage,,14.56,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Aetna,Medicare Advantage,,14.56,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Aetna,Medicare Advantage,,19.01,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Medicare Advantage,,19.01,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Aetna,Medicare Advantage,,12.77,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Medicare Advantage,,12.77,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Aetna,Medicare Advantage,,22.06,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Aetna,Medicare Advantage,,22.06,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Aetna,Medicare Advantage,,31.72,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Aetna,Medicare Advantage,,23.68,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Medicare Advantage,,31.11,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Aetna,Medicare Advantage,,39.99,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,28.39,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,28.39,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,378.19,,,,,,,16.22,381.82,fee schedule,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Aetna,Medicare Advantage,,39.99,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Aetna,Medicare Advantage,,39.99,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Aetna,Medicare Advantage,,49.80,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Aetna,Medicare Advantage,,82.45,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Medicare Advantage,,15.42,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Medicare Advantage,,12.23,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Medicare Advantage,,12.23,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Medicare Advantage,,11.28,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Medicare Advantage,,6.01,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Aetna,Medicare Advantage,,65.70,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Aetna,Medicare Advantage,,25.75,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Medicare Advantage,,4.66,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Medicare Advantage,,4.66,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Aetna,Medicare Advantage,,18.05,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,,15.25,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Aetna,Medicare Advantage,,17.86,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Medicare Advantage,,16.21,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Medicare Advantage,,19.23,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Medicare Advantage,,19.23,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,10.79,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Medicare Advantage,,10.79,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,,17.86,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,,17.86,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Medicare Advantage,,9.64,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Medicare Advantage,,13.98,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Aetna,Medicare Advantage,,20.51,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Aetna,Medicare Advantage,,9.42,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,14.53,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Medicare Advantage,,12.48,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Medicare Advantage,,11.38,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,13.13,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Aetna,Medicare Advantage,,11.94,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Aetna,Medicare Advantage,,13.13,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Aetna,Medicare Advantage,,20.51,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,20.51,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Medicare Advantage,,13.65,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Medicare Advantage,,15.25,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Aetna,Medicare Advantage,,15.27,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,14.03,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,13.65,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,15.13,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Aetna,Medicare Advantage,,116.06,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Aetna,Medicare Advantage,,68.04,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Aetna,Medicare Advantage,,68.04,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Aetna,Medicare Advantage,,343.18,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Aetna,Medicare Advantage,,345.35,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,,10.36,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Aetna,Medicare Advantage,,180.16,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Aetna,Medicare Advantage,,378.19,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Medicare Advantage,,5.71,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Medicare Advantage,,5.71,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Medicare Advantage,,5.71,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Medicare Advantage,,3.17,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,3.17,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Aetna,Medicare Advantage,,6.73,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Medicare Advantage,,6.73,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Aetna,Medicare Advantage,,4.06,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Aetna,Medicare Advantage,,180.16,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,180.16,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Aetna,Medicare Advantage,,62.46,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Aetna,Medicare Advantage,,62.46,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Aetna,Medicare Advantage,,25.75,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Medicare Advantage,,14.74,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Medicare Advantage,,4.03,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,2.51,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,2.51,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Medicare Advantage,,8.24,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,6.86,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,4.23,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Aetna,Medicare Advantage,,5.90,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Medicare Advantage,,2.69,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,4.75,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Aetna,Medicare Advantage,,858.84,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Aetna,Medicare Advantage,,858.84,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Aetna,Medicare Advantage,,13.76,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Medicare Advantage,,18.71,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Aetna,Medicare Advantage,,18.97,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Aetna,Medicare Advantage,,18.97,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Aetna,Medicare Advantage,,12.60,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Medicare Advantage,,24.32,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,24.32,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Aetna,Medicare Advantage,,24.32,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Aetna,Medicare Advantage,,32.71,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Medicare Advantage,,24.32,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Aetna,Medicare Advantage,,20.18,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Aetna,Medicare Advantage,,18.97,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Aetna,Medicare Advantage,,18.97,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Aetna,Medicare Advantage,,20.51,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Aetna,Medicare Advantage,,9.66,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Medicare Advantage,,20.07,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Medicare Advantage,,20.07,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Aetna,Medicare Advantage,,12.56,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Medicare Advantage,,14.67,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Aetna,Medicare Advantage,,16.24,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Medicare Advantage,,32.71,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Aetna,Medicare Advantage,,16.24,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Aetna,Medicare Advantage,,13.64,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Aetna,Medicare Advantage,,13.64,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,13.64,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Medicare Advantage,,4.54,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,7.30,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Aetna,Medicare Advantage,,10.79,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Aetna,Medicare Advantage,,10.30,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Aetna,Medicare Advantage,,18.22,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,9.92,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Aetna,Medicare Advantage,,13.88,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,13.88,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Aetna,Medicare Advantage,,26.40,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Aetna,Medicare Advantage,,26.40,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,,19.06,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Aetna,Medicare Advantage,,19.06,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Medicare Advantage,,4.55,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Aetna,Medicare Advantage,,4.18,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,10.15,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Aetna,Medicare Advantage,,10.15,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Aetna,Medicare Advantage,,19.06,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,10.44,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Aetna,Medicare Advantage,,19.76,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,5.84,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Medicare Advantage,,6.12,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Aetna,Medicare Advantage,,6.12,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,6.37,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,6.37,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Aetna,Medicare Advantage,,6.86,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Medicare Advantage,,6.86,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Aetna,Medicare Advantage,,12.37,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,7.08,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Aetna,Medicare Advantage,,10.94,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Aetna,Medicare Advantage,,10.94,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Aetna,Medicare Advantage,,10.01,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,10.01,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Medicare Advantage,,10.01,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Aetna,Medicare Advantage,,9.14,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Aetna,Medicare Advantage,,10.48,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Aetna,Medicare Advantage,,10.04,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Aetna,Medicare Advantage,,10.04,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Medicare Advantage,,10.04,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Medicare Advantage,,8.56,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Medicare Advantage,,8.56,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,8.56,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,8.56,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Aetna,Medicare Advantage,,7.03,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Medicare Advantage,,7.03,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Aetna,Medicare Advantage,,8.55,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Aetna,Medicare Advantage,,8.17,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,8.91,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Medicare Advantage,,10.94,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,10.94,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Medicare Advantage,,122.28,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,4.57,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,6.23,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Medicare Advantage,,9.43,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Medicare Advantage,,5.04,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,7.93,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Aetna,Medicare Advantage,,5.04,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,9.17,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,9.17,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,9.17,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,9.17,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Aetna,Medicare Advantage,,9.17,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,5.71,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Aetna,Medicare Advantage,,5.71,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,5.71,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Aetna,Medicare Advantage,,6.35,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Medicare Advantage,,19.06,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Aetna,Medicare Advantage,,6.17,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,6.17,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Aetna,Medicare Advantage,,12.70,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Aetna,Medicare Advantage,,12.70,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,12.70,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Aetna,Medicare Advantage,,12.70,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Aetna,Medicare Advantage,,14.65,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Medicare Advantage,,10.95,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Medicare Advantage,,10.95,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,25.52,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Aetna,Medicare Advantage,,25.52,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Aetna,Medicare Advantage,,12.70,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Aetna,Medicare Advantage,,12.70,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Medicare Advantage,,12.70,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Aetna,Medicare Advantage,,39.51,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Medicare Advantage,,45.41,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Aetna,Medicare Advantage,,45.41,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Aetna,Medicare Advantage,,45.41,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Medicare Advantage,,37.20,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Medicare Advantage,,90.21,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Medicare Advantage,,37.20,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Medicare Advantage,,37.20,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Medicare Advantage,,101.55,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Aetna,Medicare Advantage,,151.19,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Aetna,Medicare Advantage,,441.79,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Aetna,Medicare Advantage,,37.20,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Aetna,Medicare Advantage,,37.20,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Aetna,Medicare Advantage,,37.20,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,37.20,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Aetna,Medicare Advantage,,37.20,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Aetna,Medicare Advantage,,45.41,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Aetna,Medicare Advantage,,278.77,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Medicare Advantage,,16.21,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Aetna,Medicare Advantage,,17.52,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Aetna,Medicare Advantage,,17.03,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Aetna,Medicare Advantage,,17.03,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Aetna,Medicare Advantage,,17.03,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Aetna,Medicare Advantage,,272.90,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Medicare Advantage,,272.90,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Aetna,Medicare Advantage,,3.36,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Aetna,Medicare Advantage,,3.36,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,3.69,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,3.69,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Aetna,Medicare Advantage,,3.69,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Aetna,Medicare Advantage,,9.13,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Aetna,Medicare Advantage,,180.16,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Medicare Advantage,,5.94,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,7.77,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Aetna,Medicare Advantage,,6.14,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Aetna,Medicare Advantage,,97.16,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Aetna,Medicare Advantage,,19.13,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Aetna,Medicare Advantage,,25.63,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Aetna,Medicare Advantage,,13.13,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Aetna,Medicare Advantage,,5.00,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Aetna,Medicare Advantage,,14.04,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,17.45,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Medicare Advantage,,12.22,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Aetna,Medicare Advantage,,5.53,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Aetna,Medicare Advantage,,19.01,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Aetna,Medicare Advantage,,4.53,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Medicare Advantage,,13.83,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Medicare Advantage,,13.65,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Aetna,Medicare Advantage,,5.49,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Aetna,Medicare Advantage,,15.24,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Aetna,Medicare Advantage,,8.56,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Medicare Advantage,,8.56,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Aetna,Medicare Advantage,,14.43,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Aetna,Medicare Advantage,,9.13,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Medicare Advantage,,13.98,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,7.08,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Aetna,Medicare Advantage,,5.49,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Aetna,Medicare Advantage,,14.19,,,,,,,12.99,189.75,fee schedule,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Medicare Advantage,,32.03,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Aetna,Medicare Advantage,,5.04,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Aetna,Medicare Advantage,,5.04,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Medicare Advantage,,13.64,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Medicare Advantage,,4.55,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,6.51,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,14.03,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Medicare Advantage,,7.03,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,180.16,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Aetna,Medicare Advantage,,180.16,,,,,,,53.18,381.82,fee schedule,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Aetna,Medicare Advantage,,0.47800,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Medicare Advantage,,131.10,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Aetna,Medicare Advantage,,15.49,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,15.95,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Aetna,Medicare Advantage,,7.75,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Aetna,Medicare Advantage,,27.36,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Aetna,Medicare Advantage,,805.10,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,37.20,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,16.88,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Aetna,Medicare Advantage,,5.83,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,,28.85,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Aetna,Medicare Advantage,,2.86,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Aetna,Medicare Advantage,,12.70,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Medicare Advantage,,17.54,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Aetna,Medicare Advantage,,17.54,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Aetna,Medicare Advantage,,9.64,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Aetna,Medicare Advantage,,9.64,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Aetna,Medicare Advantage,,9.64,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Aetna,Medicare Advantage,,37.20,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Aetna,Medicare Advantage,,128.93,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Aetna,Medicare Advantage,,196.31,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Aetna,Medicare Advantage,,87.98,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Aetna,Medicare Advantage,,680.36,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Aetna,Medicare Advantage,,1934.37,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Aetna,Medicare Advantage,,397.76,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Aetna,Medicare Advantage,,9.64,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Aetna,Medicare Advantage,,11.82,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Aetna,Medicare Advantage,,6.86,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Aetna,Medicare Advantage,,5.84,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Medicare Advantage,,19.63,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,28.39,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,28.39,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,28.39,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,28.39,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,28.39,,,,,,,5.61,57.08,fee schedule,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Aetna,Medicare Advantage,,432.11,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Aetna,Medicare Advantage,,196.31,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,21.25,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Medicare Advantage,,37.20,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Aetna,Medicare Advantage,,145.22,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Aetna,Medicare Advantage,,805.10,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Aetna,Medicare Advantage,,231.14,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,37.20,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Aetna,Medicare Advantage,,74.41,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Aetna,Medicare Advantage,,128.93,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Aetna,Medicare Advantage,,196.31,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Medicare Advantage,,26.40,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Aetna,Medicare Advantage,QW,26.40,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Aetna,Medicare Advantage,,15.24,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Aetna,Medicare Advantage,,65.87,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Aetna,Medicare Advantage,,1229.60,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Aetna,Medicare Advantage,,441.79,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Aetna,Medicare Advantage,,97.16,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,22.06,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Aetna,Medicare Advantage,,247.05,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Aetna,Medicare Advantage,,44.27,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Aetna,Medicare Advantage,,45.41,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Aetna,Medicare Advantage,,17.03,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Aetna,Medicare Advantage,,5.53,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,30.96,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Medicare Advantage,QW,54.39,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Aetna,Medicare Advantage,,44.66,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Aetna,Medicare Advantage,,18.31,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Aetna,Medicare Advantage,,441.79,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Medicare Advantage,,151.19,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Medicare Advantage,,10.94,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,,19.76,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Aetna,Medicare Advantage,,19.76,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Medicare Advantage,,28.74,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Aetna,Medicare Advantage,,40.88,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Aetna,Medicare Advantage,,9.17,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Aetna,Medicare Advantage,,151.19,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,41.62,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Aetna,Medicare Advantage,,23.03,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Medicare Advantage,,22.06,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Aetna,Medicare Advantage,,145.22,,,,,,,70.07,262.50,fee schedule,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Medicare Advantage,,32.27,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Aetna,Medicare Advantage,,50.91,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Aetna,Medicare Advantage,,52.34,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Medicare Advantage,,32.27,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Medicare Advantage,,32.27,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Aetna,Medicare Advantage,,65.72,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Medicare Advantage,,12.72,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Aetna,Medicare Advantage,,12.72,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Aetna,Medicare Advantage,,21.54,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Medicare Advantage,,12.22,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,18.31,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Aetna,Medicare Advantage,,23.68,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Aetna,Medicare Advantage,,31.11,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Aetna,Medicare Advantage,,29.03,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Aetna,Medicare Advantage,,135.99,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Medicare Advantage,,12.22,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Aetna,Medicare Advantage,,54.39,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,37.20,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Aetna,Medicare Advantage,,37.20,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,10.29,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Aetna,Medicare Advantage,,12.26,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Medicare Advantage,,2.38,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Aetna,Medicare Advantage,,37.20,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Aetna,Medicare Advantage,,37.20,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Aetna,Medicare Advantage,,145.22,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Aetna,Medicare Advantage,,9.14,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Aetna,Medicare Advantage,,278.77,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Aetna,Medicare Advantage,,74.41,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,56.17,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Aetna,Medicare Advantage,,2.51,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Aetna,Medicare Advantage,,41.27,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Aetna,Medicare Advantage,,41.27,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Aetna,Medicare Advantage,,56.17,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Aetna,Medicare Advantage,,56.17,,,,,,,29.43,110.25,fee schedule,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Aetna,Medicare Advantage,,9.32,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Aetna,Medicare Advantage,,21.48,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Aetna,Medicare Advantage,,25.75,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Aetna,Medicare Advantage,,180.16,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Aetna,Medicare Advantage,,56.17,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,28.21,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Aetna,Medicare Advantage,,28.21,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Aetna,Medicare Advantage,,28.21,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Aetna,Medicare Advantage,,378.19,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Aetna,Medicare Advantage,,378.19,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Medicare Advantage,,123.48,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Aetna,Medicare Advantage,,123.48,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Aetna,Medicare Advantage,,149.17,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Aetna,Medicare Advantage,,159.32,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Aetna,Medicare Advantage,,159.32,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Aetna,Medicare Advantage,,152.38,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Aetna,Medicare Advantage,,13.85,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Aetna,Medicare Advantage,,280.20,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Aetna,Medicare Advantage,,133.02,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Aetna,Medicare Advantage,,153.29,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Aetna,Medicare Advantage,,199.88,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Aetna,Medicare Advantage,,22.71,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Medicare Advantage,,22.71,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Medicare Advantage,,36.90,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Aetna,Medicare Advantage,,44.92,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Aetna,Medicare Advantage,,54.26,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Aetna,Medicare Advantage,,35.48,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Aetna,Medicare Advantage,,72.72,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Aetna,Medicare Advantage,,28.52,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Medicare Advantage,,56.17,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Aetna,Medicare Advantage,,41.27,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Aetna,Medicare Advantage,,25.75,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Aetna,Medicare Advantage,,41.27,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Aetna,Medicare Advantage,,56.17,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Aetna,Medicare Advantage,,56.17,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Aetna,Medicare Advantage,,56.17,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Aetna,Medicare Advantage,,378.19,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Aetna,Medicare Advantage,,858.84,,,,,,,80.53,858.84,fee schedule,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Medicare Advantage,,23.18,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,,135.52,,,,,,,24.90,135.52,fee schedule,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Aetna,Medicare Advantage,,94.17,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Aetna,Medicare Advantage,,74.81,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Aetna,Medicare Advantage,,858.84,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Aetna,Medicare Advantage,,56.17,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Aetna,Medicare Advantage,,180.16,,,,,,,53.18,288.00,fee schedule,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Aetna,Medicare Advantage,,31.55,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Aetna,Medicare Advantage,,858.84,,,,,,,24.90,858.84,fee schedule,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Aetna,Medicare Advantage,,45.17,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Aetna,Medicare Advantage,,180.16,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Aetna,Medicare Advantage,,12.77,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Aetna,Medicare Advantage,,180.16,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Medicare Advantage,,180.16,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Aetna,Medicare Advantage,,180.16,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Aetna,Medicare Advantage,,180.16,,,,,,,80.53,404.25,fee schedule,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Aetna,Medicare Advantage,,33.22,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Aetna,Medicare Advantage,,108.40,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Aetna,Medicare Advantage,,5.32,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Aetna,Medicare Advantage,,180.16,,,,,,,53.18,310.50,fee schedule,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,21.75,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Aetna,Medicare Advantage,,152.38,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Aetna,Medicare Advantage,,149.17,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Aetna,Medicare Advantage,,152.38,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Aetna,Medicare Advantage,,54.26,,,,,,,38.44,144.00,fee schedule,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Aetna,Medicare Advantage,,169.21,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Aetna,Medicare Advantage,,123.80,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Aetna,Medicare Advantage,,153.29,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Medicare Advantage,,378.19,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Aetna,Medicare Advantage,,87.71,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Medicare Advantage,,180.16,,,,,,,53.18,288.75,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Aetna,Medicare Advantage,,124.04,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Aetna,Medicare Advantage,,54.26,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Medicare Advantage,,22.71,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Medicare Advantage,,180.16,,,,,,,53.18,288.75,fee schedule,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Aetna,Medicare Advantage,,87.71,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Aetna,Medicare Advantage,,56.17,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Aetna,Medicare Advantage,,135.52,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Aetna,Medicare Advantage,,378.19,,,,,,,24.90,932.25,fee schedule,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Aetna,Medicare Advantage,,5.74,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Aetna,Medicare Advantage,,54.26,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Medicare Advantage,,22.71,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Aetna,Medicare Advantage,,180.16,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Aetna,Medicare Advantage,,180.16,,,,,,,132.13,646.00,fee schedule,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Aetna,Medicare Advantage,,113.29,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Aetna,Medicare Advantage,,180.16,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Aetna,Medicare Advantage,,22.71,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Aetna,Medicare Advantage,,22.71,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Aetna,Medicare Advantage,,22.71,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Aetna,Medicare Advantage,,54.26,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Aetna,Medicare Advantage,,22.71,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Aetna,Medicare Advantage,,44.92,,,,,,,31.83,119.25,fee schedule,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Aetna,Medicare Advantage,,379.77,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Aetna,Medicare Advantage,,190.72,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Aetna,Medicare Advantage,,77.91,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Aetna,Medicare Advantage,,180.16,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Aetna,Medicare Advantage,,180.16,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,180.16,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Aetna,Medicare Advantage,,41.27,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Aetna,Medicare Advantage,,180.16,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,66.83,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Aetna,Medicare Advantage,,191.34,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Aetna,Medicare Advantage,,191.34,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Aetna,Medicare Advantage,,191.34,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Aetna,Medicare Advantage,,191.34,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,88.62,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,88.62,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Aetna,Medicare Advantage,,88.62,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Aetna,Medicare Advantage,,151.73,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Aetna,Medicare Advantage,,417.25,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Medicare Advantage,,512.12,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Aetna,Medicare Advantage,,710.36,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Medicare Advantage,,687.31,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Aetna,Medicare Advantage,,268.93,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Aetna,Medicare Advantage,,154.87,,,,,,,51.19,2907.00,fee schedule,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Aetna,Medicare Advantage,,226.81,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Aetna,Medicare Advantage,,817.42,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Aetna,Medicare Advantage,,254.89,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Aetna,Medicare Advantage,,74.74,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Aetna,Medicare Advantage,,617.44,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Aetna,Medicare Advantage,,3.17,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,,10.36,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,,10.36,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Aetna,Medicare Advantage,,10.36,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Aetna,Medicare Advantage,,6.06,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Medicare Advantage,,512.12,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Aetna,Medicare Advantage,,512.12,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Aetna,Medicare Advantage,,710.36,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,66.83,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,66.83,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,66.83,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,66.83,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Aetna,Medicare Advantage,,66.83,,,,,,,10.79,2907.00,fee schedule,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Aetna,Medicare Advantage,,625.22,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Medicare Advantage,,5683.29,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Medicare Advantage,,8700.96,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Aetna,Medicare Advantage,,8700.96,,,,,,,495.29,13852.00,fee schedule,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Aetna,Medicare Advantage,,1604.88,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Aetna,Medicare Advantage,,488.28,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Aetna,Medicare Advantage,,804.95,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Aetna,Medicare Advantage,,217.25,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Aetna,Medicare Advantage,,217.25,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Aetna,Medicare Advantage,,473.46,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Aetna,Medicare Advantage,,473.46,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Aetna,Medicare Advantage,,995.67,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Aetna,Medicare Advantage,,995.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Aetna,Medicare Advantage,,453.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Aetna,Medicare Advantage,,453.14,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Aetna,Medicare Advantage,,106.83,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Aetna,Medicare Advantage,,196.70,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Medicare Advantage,,428.77,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Medicare Advantage,,428.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Medicare Advantage,,338.42,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Medicare Advantage,,338.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Aetna,Medicare Advantage,,379.05,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Aetna,Medicare Advantage,,379.05,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Medicare Advantage,,338.42,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Aetna,Medicare Advantage,,338.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Aetna,Medicare Advantage,,5683.29,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Aetna,Medicare Advantage,,5683.29,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Aetna,Medicare Advantage,,5683.29,,,,,,,1103.50,13852.00,fee schedule,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Aetna,Medicare Advantage,,635.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,87.89,9423.00,fee schedule,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Medicare Advantage,,539.42,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Medicare Advantage,,539.42,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Medicare Advantage,,539.42,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Aetna,Medicare Advantage,,539.42,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Aetna,Medicare Advantage,,5994.30,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Aetna,Medicare Advantage,,5994.30,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Aetna,Medicare Advantage,,2398.84,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Aetna,Medicare Advantage,,2398.84,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Aetna,Medicare Advantage,,5530.94,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Aetna,Medicare Advantage,,5530.94,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Aetna,Medicare Advantage,,5994.30,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Aetna,Medicare Advantage,,5994.30,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Aetna,Medicare Advantage,,18878.80,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Aetna,Medicare Advantage,,18878.80,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Aetna,Medicare Advantage,,11922.91,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Aetna,Medicare Advantage,,18878.80,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Aetna,Medicare Advantage,,18878.80,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Aetna,Medicare Advantage,,11922.91,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Aetna,Medicare Advantage,,18878.80,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Aetna,Medicare Advantage,,18878.80,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Aetna,Medicare Advantage,,18878.80,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Aetna,Medicare Advantage,,18878.80,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Aetna,Medicare Advantage,,18878.80,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Aetna,Medicare Advantage,,18878.80,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Aetna,Medicare Advantage,,2268.83,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Aetna,Medicare Advantage,,2268.83,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Aetna,Medicare Advantage,,4890.90,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Aetna,Medicare Advantage,,4890.90,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Aetna,Medicare Advantage,,4213.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Aetna,Medicare Advantage,,4213.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Aetna,Medicare Advantage,,4920.53,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Medicare Advantage,LM,3871.56,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Medicare Advantage,RI,3871.56,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Medicare Advantage,RC,3871.56,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Medicare Advantage,LD,3871.56,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Aetna,Medicare Advantage,LC,3871.56,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Medicare Advantage,LC,1997.32,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Medicare Advantage,RI,1997.32,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Medicare Advantage,RC,1997.32,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Medicare Advantage,LD,1997.32,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Aetna,Medicare Advantage,LC,1997.32,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,LM,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,RI,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,RC,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,LD,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,LC,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,LM,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,RI,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,RC,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,LD,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Aetna,Medicare Advantage,LC,3431.56,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,LM,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,RI,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,RC,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,LD,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,LC,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,LM,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,RI,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,RC,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,LD,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Aetna,Medicare Advantage,LC,5121.77,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,LM,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,RI,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,RC,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,LD,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,LC,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,RC,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,LD,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Aetna,Medicare Advantage,LC,5428.89,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LM,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,RI,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,RC,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LD,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LC,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LM,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,RI,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,RC,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LD,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LC,9679.98,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LM,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,RI,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,RC,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LD,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LC,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,RC,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LD,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Aetna,Medicare Advantage,LC,9679.98,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Aetna,Medicare Advantage,,11922.91,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Aetna,Medicare Advantage,,11922.91,,,,,,,4633.23,27871.00,fee schedule,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Aetna,Medicare Advantage,,5685.09,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Aetna,Medicare Advantage,,5685.09,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,LM,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,RI,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,RC,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,LD,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,LC,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,LM,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,RI,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,RC,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,LD,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Aetna,Medicare Advantage,LC,5941.06,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LM,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,RI,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,RC,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LD,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LC,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LM,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,RI,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,RC,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LD,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LC,6197.27,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LM,6197.27,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,RI,6197.27,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,RC,6197.27,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LD,6197.27,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Aetna,Medicare Advantage,LC,6197.27,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Aetna,Medicare Advantage,,687.98,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Aetna,Medicare Advantage,,687.98,,,,,,,222.64,3641.00,fee schedule,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Aetna,Medicare Advantage,,445.74,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Aetna,Medicare Advantage,,100.86,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Aetna,Medicare Advantage,,603.95,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Aetna,Medicare Advantage,,348.72,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Aetna,Medicare Advantage,,5994.30,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Aetna,Medicare Advantage,,11922.91,,,,,,,2044.04,27871.00,fee schedule,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Aetna,Medicare Advantage,,1015.75,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Aetna,Medicare Advantage,,3381.57,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Aetna,Medicare Advantage,,3381.57,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Aetna,Medicare Advantage,,3381.57,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Aetna,Medicare Advantage,,3381.57,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Aetna,Medicare Advantage,,3381.57,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Aetna,Medicare Advantage,,3381.57,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Aetna,Medicare Advantage,,3381.57,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Aetna,Medicare Advantage,,3381.57,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Aetna,Medicare Advantage,,3381.57,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Aetna,Medicare Advantage,,3381.57,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Aetna,Medicare Advantage,,3381.57,,,,,,,3094.46,12247.00,fee schedule,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Aetna,Medicare Advantage,,1619.94,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Aetna,Medicare Advantage,,48.52,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Aetna,Medicare Advantage,,23.18,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Aetna,Medicare Advantage,,1633.21,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,826.43,9423.00,fee schedule,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Aetna,Medicare Advantage,,1927.30,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Aetna,Medicare Advantage,,115.68,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Aetna,Medicare Advantage,,149.61,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Aetna,Medicare Advantage,,51.38,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Aetna,Medicare Advantage,,1833.37,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Aetna,Medicare Advantage,,18878.80,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Aetna,Medicare Advantage,,7977.75,,,,,,,1411.00,12247.00,fee schedule,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Aetna,Medicare Advantage,,603.48,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Aetna,Medicare Advantage,,674.94,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Aetna,Medicare Advantage,,302.57,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Aetna,Medicare Advantage,,126.19,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Aetna,Medicare Advantage,,126.19,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Aetna,Medicare Advantage,,126.19,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Aetna,Medicare Advantage,,18878.80,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Aetna,Medicare Advantage,,18878.80,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Aetna,Medicare Advantage,,11002.73,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Aetna,Medicare Advantage,,11002.73,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Aetna,Medicare Advantage,,11002.73,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Aetna,Medicare Advantage,,8700.96,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Aetna,Medicare Advantage,,11002.73,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Aetna,Medicare Advantage,,11002.73,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Aetna,Medicare Advantage,,3309.13,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Aetna,Medicare Advantage,,8700.96,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Aetna,Medicare Advantage,,8700.96,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Aetna,Medicare Advantage,,3826.18,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Aetna,Medicare Advantage,,3826.18,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Aetna,Medicare Advantage,,1923.16,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Aetna,Medicare Advantage,,1923.16,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Aetna,Medicare Advantage,,11002.73,,,,,,,4082.48,39682.00,fee schedule,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Aetna,Medicare Advantage,,3567.07,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Aetna,Medicare Advantage,,3309.13,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Aetna,Medicare Advantage,,8700.96,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Aetna,Medicare Advantage,,11002.73,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Aetna,Medicare Advantage,,20050.47,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Aetna,Medicare Advantage,,8700.96,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Aetna,Medicare Advantage,,3826.18,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Aetna,Medicare Advantage,,3826.18,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Aetna,Medicare Advantage,,23598.81,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Aetna,Medicare Advantage,,3826.18,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Aetna,Medicare Advantage,,3826.18,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Aetna,Medicare Advantage,,33707.96,,,,,,,11551.14,82346.00,fee schedule,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Aetna,Medicare Advantage,,630.72,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Aetna,Medicare Advantage,,8700.96,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Aetna,Medicare Advantage,,739.72,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Aetna,Medicare Advantage,,7977.75,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Aetna,Medicare Advantage,,7977.75,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Aetna,Medicare Advantage,,1276.32,,,,,,,432.44,3641.00,fee schedule,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Aetna,Medicare Advantage,,548.50,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Aetna,Medicare Advantage,,7977.75,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Aetna,Medicare Advantage,,7977.75,,,,,,,432.44,7977.75,fee schedule,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Aetna,Medicare Advantage,,727.28,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Aetna,Medicare Advantage,,1276.32,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Aetna,Medicare Advantage,,7977.75,,,,,,,1281.80,12247.00,fee schedule,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Aetna,Medicare Advantage,,3639.97,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Aetna,Medicare Advantage,,3639.97,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Aetna,Medicare Advantage,,388.14,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Aetna,Medicare Advantage,,7977.75,,,,,,,1081.64,7977.75,fee schedule,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Aetna,Medicare Advantage,,396.26,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Aetna,Medicare Advantage,,1276.32,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Aetna,Medicare Advantage,,7977.75,,,,,,,1411.00,16639.07,fee schedule,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Aetna,Medicare Advantage,,5385.63,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Aetna,Medicare Advantage,,5385.63,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Aetna,Medicare Advantage,,557.85,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,3641.00,fee schedule,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Aetna,Medicare Advantage,,4812.74,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Aetna,Medicare Advantage,,20050.47,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Aetna,Medicare Advantage,,33707.96,,,,,,,496.90,82346.00,fee schedule,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Aetna,Medicare Advantage,,461.51,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Aetna,Medicare Advantage,,23598.81,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Aetna,Medicare Advantage,,23598.81,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Aetna,Medicare Advantage,,33707.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Aetna,Medicare Advantage,,29888.13,,,,,,,515.51,82346.00,fee schedule,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Aetna,Medicare Advantage,,3279.32,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Aetna,Medicare Advantage,,1147.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,9423.00,fee schedule,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Aetna,Medicare Advantage,,1903.63,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Aetna,Medicare Advantage,,4426.76,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Aetna,Medicare Advantage,,2204.54,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Aetna,Medicare Advantage,,1545.61,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Aetna,Medicare Advantage,,1786.76,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Aetna,Medicare Advantage,,419.53,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Aetna,Medicare Advantage,,164.49,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Aetna,Medicare Advantage,,3309.13,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Medicare Advantage,,1633.21,,,,,,,406.89,4376.00,fee schedule,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Medicare Advantage,,726.80,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Medicare Advantage,,726.80,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Aetna,Medicare Advantage,,726.80,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Aetna,Medicare Advantage,,18878.80,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Aetna,Medicare Advantage,,18878.80,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Aetna,Medicare Advantage,,18878.80,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Aetna,Medicare Advantage,,33707.96,,,,,,,1897.10,82346.00,fee schedule,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Aetna,Medicare Advantage,,1038.45,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Aetna,Medicare Advantage,,11922.91,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Aetna,Medicare Advantage,,18878.80,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Aetna,Medicare Advantage,,18878.80,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Aetna,Medicare Advantage,,18878.80,,,,,,,6855.05,24600.00,fee schedule,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Aetna,Medicare Advantage,,7737.15,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Aetna,Medicare Advantage,,3381.57,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Aetna,Medicare Advantage,,3381.57,,,,,,,1354.55,12247.00,fee schedule,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Aetna,Medicare Advantage,,25.57,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Aetna,Medicare Advantage,,25792.05,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Aetna,Medicare Advantage,,25792.05,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Aetna,Medicare Advantage,,25792.05,,,,,,,1411.00,31355.38,fee schedule,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Aetna,Medicare Advantage,,573.36,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Aetna,Medicare Advantage,,1552.07,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Aetna,Medicare Advantage,,5994.30,,,,,,,2169.57,12247.00,fee schedule,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Medicare Advantage,LD,821.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Medicare Advantage,RC,821.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Medicare Advantage,RI,821.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Medicare Advantage,LM,821.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Medicare Advantage,LD,656.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Medicare Advantage,RC,656.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Medicare Advantage,RI,656.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Medicare Advantage,LM,656.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Medicare Advantage,LD,563.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Medicare Advantage,RC,563.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Medicare Advantage,RI,563.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Medicare Advantage,LM,563.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,LD,118.31,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,RC,118.31,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,RI,118.31,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,LM,118.31,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Aetna,Medicare Advantage,LC,821.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Aetna,Medicare Advantage,LC,656.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Aetna,Medicare Advantage,LC,563.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Aetna,Medicare Advantage,LC,118.31,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Aetna,Medicare Advantage,,650.00,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Aetna,Medicare Advantage,,33707.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Aetna,Medicare Advantage,,5994.30,,,,,,,2282.88,13852.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Aetna,Medicare Advantage,,681.39,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Aetna,Medicare Advantage,,111.80,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Aetna,Medicare Advantage,,20050.47,,,,,,,538.01,20050.47,fee schedule,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Aetna,Medicare Advantage,,789.66,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Aetna,Medicare Advantage,,327.39,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Aetna,Medicare Advantage,,576.46,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Aetna,Medicare Advantage,,576.46,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Aetna,Medicare Advantage,,254.13,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Aetna,Medicare Advantage,,254.13,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Aetna,Medicare Advantage,,254.13,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,1918.50,fee schedule,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Aetna,Medicare Advantage,,118.54,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Aetna,Medicare Advantage,,92.02,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Aetna,Medicare Advantage,,576.46,,,,,,,266.00,2052.00,fee schedule,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Aetna,Medicare Advantage,,13.14,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Aetna,Medicare Advantage,,326.95,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Aetna,Medicare Advantage,,39.21,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Aetna,Medicare Advantage,,135.52,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Aetna,Medicare Advantage,,62.46,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Aetna,Medicare Advantage,,96.50,,,,,,,32.43,134.00,fee schedule,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Aetna,Medicare Advantage,,46.13,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Aetna,Medicare Advantage,,254.13,,,,,,,175.00,957.00,fee schedule,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Aetna,Medicare Advantage,,68.11,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Aetna,Medicare Advantage,,132.37,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Aetna,Medicare Advantage,,132.37,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Aetna,Medicare Advantage,,62.46,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Aetna,Medicare Advantage,,62.46,,,,,,,24.55,269.00,fee schedule,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Aetna,Medicare Advantage,,10.28,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Aetna,Medicare Advantage,,3876.27,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Aetna,Medicare Advantage,,3309.13,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Aetna,Medicare Advantage,,7510.57,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Aetna,Medicare Advantage,,739.72,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Aetna,Medicare Advantage,,8700.96,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Aetna,Medicare Advantage,,3826.18,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Aetna,Medicare Advantage,,3826.18,,,,,,,422.62,17457.00,fee schedule,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Aetna,Medicare Advantage,,1523.62,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Aetna,Medicare Advantage,,2017.88,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Aetna,Medicare Advantage,,2265.00,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Aetna,Medicare Advantage,,1871.61,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Aetna,Medicare Advantage,,2425.61,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Aetna,Medicare Advantage,,2702.61,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Aetna,Medicare Advantage,,114.72,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Aetna,Medicare Advantage,,71.70,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Aetna,Medicare Advantage,,114.72,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Aetna,Medicare Advantage,,71.70,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Aetna,Medicare Advantage,,8.13,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,21.51,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Aetna,Medicare Advantage,,57.36,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Aetna,Medicare Advantage,,89.39,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Aetna,Medicare Advantage,,315.48,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Aetna,Medicare Advantage,,340.57,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Aetna,Medicare Advantage,,533.45,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Aetna,Medicare Advantage,,70.03,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Aetna,Medicare Advantage,,160.61,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Aetna,Medicare Advantage,,24.86,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Aetna,Medicare Advantage,,242.82,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Aetna,Medicare Advantage,,41.83,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Aetna,Medicare Advantage,,61.66,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Aetna,Medicare Advantage,,45.89,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Aetna,Medicare Advantage,,755.72,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Aetna,Medicare Advantage,,72.18,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Aetna,Medicare Advantage,,70.74,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Aetna,Medicare Advantage,,73.85,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Aetna,Medicare Advantage,,68.11,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Aetna,Medicare Advantage,,81.50,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Aetna,Medicare Advantage,,103.25,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Aetna,Medicare Advantage,,147.46,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Aetna,Medicare Advantage,,10.52,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Aetna,Medicare Advantage,,10.04,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Aetna,Medicare Advantage,,16.97,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Aetna,Medicare Advantage,,52.82,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Aetna,Medicare Advantage,,96.08,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Aetna,Medicare Advantage,,212.71,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Aetna,Medicare Advantage,,17.69,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Aetna,Medicare Advantage,,12.91,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Aetna,Medicare Advantage,,63.34,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Aetna,Medicare Advantage,,9.56,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Aetna,Medicare Advantage,,179.25,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Aetna,Medicare Advantage,,280.82,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Aetna,Medicare Advantage,,958.39,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Aetna,Medicare Advantage,,292.54,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Aetna,Medicare Advantage,,428.77,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Aetna,Medicare Advantage,,542.29,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Aetna,Medicare Advantage,,117.59,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Aetna,Medicare Advantage,,958.39,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Aetna,Medicare Advantage,,167.30,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Aetna,Medicare Advantage,,186.42,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Aetna,Medicare Advantage,,21.51,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Aetna,Medicare Advantage,,381.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Aetna,Medicare Advantage,,613.99,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Aetna,Medicare Advantage,,119.50,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Aetna,Medicare Advantage,,956.00,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Aetna,Medicare Advantage,,579.58,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Aetna,Medicare Advantage,,430.20,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Aetna,Medicare Advantage,,579.58,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Aetna,Medicare Advantage,,430.20,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Aetna,Medicare Advantage,,282.02,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Aetna,Medicare Advantage,,282.02,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Aetna,Medicare Advantage,,252.62,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Aetna,Medicare Advantage,GP,56.88,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Aetna,Medicare Advantage,,7385.82,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Aetna,Medicare Advantage,,3571.38,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Aetna,Medicare Advantage,,7385.82,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Aetna,Medicare Advantage,,3571.38,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Aetna,Medicare Advantage,,3103.89,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Aetna,Medicare Advantage,,3172.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Aetna,Medicare Advantage,,3240.84,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Aetna,Medicare Advantage,,3309.67,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Aetna,Medicare Advantage,,3378.26,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Aetna,Medicare Advantage,,3446.62,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Aetna,Medicare Advantage,,3515.21,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Aetna,Medicare Advantage,,3583.80,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Aetna,Medicare Advantage,,119.26,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Aetna,Medicare Advantage,,58.79,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Aetna,Medicare Advantage,,47.80,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,205155.01,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,83479.86,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,155596.66,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,101846.19,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,76035.22,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34678.87,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,95277.00,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,41732.08,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,53184.42,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,40635.04,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31610.05,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21884.54,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,88481.10,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,44101.86,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,40476.11,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,315654.06,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,52884.84,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,58236.71,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,39466.54,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24039.29,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,42648.36,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,29393.34,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34020.64,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23542.15,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19268.38,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,44674.80,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,25746.45,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16879.65,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,33538.08,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16411.68,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12999.51,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,29093.03,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18303.27,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15039.81,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24875.37,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12705.75,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9446.66,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,29023.77,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16905.16,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13471.86,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14081.26,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8015.75,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12008.16,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8310.25,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17811.96,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10322.12,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13339.19,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9923.38,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7582.77,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20975.57,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13686.90,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11110.83,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15536.95,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8242.46,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5866.85,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11583.91,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7178.94,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6700.75,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13013.35,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8356.90,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6390.22,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12572.35,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8391.89,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14855.38,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6893.20,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14071.79,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7406.36,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17538.61,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11052.52,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7845.20,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17438.75,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10373.87,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7545.60,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10731.79,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8886.11,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6878.62,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13679.62,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8335.02,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6682.52,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26532.25,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19678.79,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19678.79,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27205.80,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17606.42,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10809.04,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14996.08,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7457.39,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9048.66,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6974.10,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18016.06,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10740.53,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12066.48,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14057.92,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8786.24,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9357.74,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6605.99,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6699.29,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10522.58,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6474.78,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16695.95,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8278.90,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11762.50,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7337.85,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9885.48,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31969.41,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16776.88,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12514.77,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,28188.41,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13509.78,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9642.03,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16312.54,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10146.44,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6688.37,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6356.70,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10583.81,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6228.40,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9495.49,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6259.02,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12274.94,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7558.71,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5915.68,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13392.41,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7509.87,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6042.52,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,33547.57,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19276.40,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14831.35,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,28123.52,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14023.66,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10838.19,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22574.12,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10890.69,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6745.95,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12269.11,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7992.44,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6381.48,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13751.05,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8684.92,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6372.73,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12030.03,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8634.62,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6611.10,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12238.51,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8087.91,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6105.94,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9883.29,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8952.45,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7022.94,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5557.78,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10459.16,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6752.50,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5459.37,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14634.53,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7796.35,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6098.65,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13737.20,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8891.21,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6090.64,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7957.45,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5761.89,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6763.45,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14224.86,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7738.04,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,47783.00,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20914.31,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,83385.10,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,80143.50,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,42477.80,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,73458.42,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,72188.59,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,48807.89,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,48807.89,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,56848.08,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,39750.83,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,37617.96,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,36941.51,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23835.90,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,62326.79,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,45070.63,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,56606.79,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,40697.72,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,43656.49,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31411.77,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,36754.17,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21656.40,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10969.42,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24151.54,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16410.94,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14053.55,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34135.07,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16787.06,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11771.97,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26305.56,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19798.32,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13865.49,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20540.39,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13254.64,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8839.45,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23781.97,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15617.86,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24588.90,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14658.57,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12758.96,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23164.55,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,25228.92,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27252.44,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,45550.28,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,35581.30,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,51013.66,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31662.52,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,39338.99,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26801.25,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19487.79,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,30950.35,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24872.45,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,52854.23,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,44662.41,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34544.01,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,41452.18,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27166.42,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12570.90,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7577.67,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6148.94,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15316.80,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5923.70,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5243.61,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17007.94,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8678.35,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20604.54,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13320.25,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7654.93,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10236.10,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7066.69,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5003.78,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12263.29,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5499.46,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,4195.38,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12779.37,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8659.40,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6124.17,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9600.49,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5785.21,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9552.36,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6382.20,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12364.60,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7534.66,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9654.42,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6240.79,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5004.50,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5994.40,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7231.43,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6126.34,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16077.83,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7899.86,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5850.08,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,49618.47,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18534.34,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,33409.78,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18411.15,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20710.96,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13729.17,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,32422.07,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23846.83,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24279.85,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,37233.08,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18694.69,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12557.78,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34383.66,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18352.10,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13145.30,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27270.68,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17951.18,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12817.28,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26907.68,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16249.13,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12067.20,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19705.02,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11846.33,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9524.66,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17611.51,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10418.33,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7224.13,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19042.41,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11990.66,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9390.55,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22031.79,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13141.66,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10682.21,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,32898.81,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17829.47,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11067.81,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,25943.28,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18476.76,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12481.97,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8168.83,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5986.39,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13802.81,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8320.45,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6180.28,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16467.80,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9695.23,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7615.57,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14202.98,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8026.69,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5473.21,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15181.21,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8776.04,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6713.88,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10942.45,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7108.95,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12412.00,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7994.63,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5844.26,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11642.94,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6635.14,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,4843.42,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10123.11,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6560.80,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12535.90,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7698.67,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5608.81,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18335.33,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11911.19,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9222.15,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,30184.97,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,40754.58,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22018.67,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17057.51,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26869.02,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16749.18,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12451.34,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24957.02,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16203.93,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12982.02,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26847.17,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15942.97,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10815.61,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18273.38,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13208.72,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10833.84,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,25713.65,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13543.30,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11079.49,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31150.82,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16826.44,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11814.27,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,81215.78,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,53497.15,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,41858.92,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,66552.45,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,42916.60,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15224.96,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8577.03,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6071.69,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14266.40,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9123.01,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7098.02,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12761.14,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7009.82,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5407.62,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13960.26,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7914.43,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5978.37,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13057.81,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8855.49,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6908.50,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,49582.74,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31790.82,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,39727.49,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24425.62,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,62133.62,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,44345.33,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31293.68,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,41137.26,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20267.76,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,42423.85,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23582.24,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14171.65,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,38822.16,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26584.73,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20909.23,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22988.16,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14938.50,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,36076.24,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22353.25,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18673.56,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,32170.59,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17466.46,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9480.92,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26059.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18804.05,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14428.23,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22106.88,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16145.60,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12766.99,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21083.44,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24401.57,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16120.83,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12294.63,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13772.18,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9018.78,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27641.69,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19364.61,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15504.16,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27307.11,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14027.31,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9685.75,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22868.59,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15564.64,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23947.45,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13620.55,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10688.77,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21223.39,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14503.31,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13946.41,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10712.83,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14045.54,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11917.05,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22895.59,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16035.53,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12944.85,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12353.68,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8329.94,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24108.54,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16026.07,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12079.58,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,28120.60,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15458.21,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11767.61,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21799.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16314.72,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12305.55,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6753.96,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10222.98,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6764.90,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7834.26,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6128.54,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15235.90,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10327.21,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6617.65,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13754.69,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8371.48,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6378.56,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18968.06,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9285.57,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6973.37,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14953.07,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9677.73,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7249.64,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13095.74,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7885.28,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10327.21,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6928.91,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10513.10,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6932.55,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11716.57,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7388.86,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14471.99,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9086.57,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6737.92,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11263.91,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7405.63,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12129.89,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7980.76,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6339.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22316.81,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13193.41,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9233.82,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,48633.68,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26182.37,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13977.02,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,36604.74,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20199.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12587.66,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24484.67,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13474.06,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11397.30,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14921.71,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13447.81,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16482.38,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14939.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14985.13,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9525.38,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7196.43,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16336.59,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8768.75,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13030.12,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9124.46,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6486.44,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8470.61,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5288.06,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11238.39,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7226.32,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11608.69,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7555.07,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11908.28,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7485.09,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16854.87,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11078.04,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26298.99,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14511.33,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11216.52,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21925.36,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12543.18,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11873.30,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26822.38,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13954.43,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10003.57,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22892.66,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11807.69,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10560.49,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,28044.08,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16760.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11516.84,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11350.66,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7410.74,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5406.16,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10613.70,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6550.58,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11244.23,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12877.05,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8349.60,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6478.41,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,35148.31,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27890.99,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24419.06,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,38756.56,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21283.16,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16306.71,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24085.94,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14217.57,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12189.66,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19399.58,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10512.37,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8425.42,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23194.44,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11959.32,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8509.25,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23629.63,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13629.30,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8941.50,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22163.00,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12191.12,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8001.90,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13962.44,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8746.89,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31505.09,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17924.95,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12842.79,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11673.57,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7262.03,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5253.81,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14025.86,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8515.81,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6638.79,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9335.87,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6778.76,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10678.58,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6576.10,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9215.58,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5900.37,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8734.49,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12937.56,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8276.72,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5906.93,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15458.96,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12061.37,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17841.13,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11091.89,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16067.62,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8894.12,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11836.86,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8585.78,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17186.54,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11600.67,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14658.57,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10668.36,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14069.59,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9207.56,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5657.64,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9408.03,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6140.94,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11687.43,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6791.13,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8595.26,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5776.46,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16404.39,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10685.86,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26933.90,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15898.50,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11582.45,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,26994.41,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14068.87,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11273.39,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14252.55,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9921.94,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15814.69,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9169.67,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13540.38,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7144.68,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10990.56,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19594.22,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11635.67,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14302.86,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8807.39,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7879.44,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11315.66,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8014.29,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5715.23,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8222.04,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5036.59,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8689.29,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13195.59,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8187.05,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5650.36,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7010.55,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18774.16,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8605.47,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7859.76,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12901.83,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9018.78,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7867.06,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14014.93,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,44202.47,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,30465.61,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18731.15,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31271.82,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11636.40,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,2334.41,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9384.70,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8170.29,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7854.66,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,33890.90,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21356.79,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14792.70,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,29919.63,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14428.23,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10762.39,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8744.70,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6374.19,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5792.49,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16972.21,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10105.62,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8507.06,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11114.47,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7571.10,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11996.49,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16380.33,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8269.42,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5484.87,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17509.46,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9327.85,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7146.14,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,43628.79,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17196.00,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9654.42,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34298.36,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17392.82,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10714.28,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34976.27,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17725.23,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13297.65,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,23912.44,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11848.53,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9643.48,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6138.01,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,4689.61,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,40896.00,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16082.18,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9767.39,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,35898.40,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16093.87,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11403.14,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24458.43,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12769.89,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8243.20,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15418.86,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9752.08,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7085.64,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,19775.72,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10413.97,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7069.60,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20628.58,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,64000.43,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,36877.35,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15442.91,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11791.66,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,34035.21,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16488.21,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11031.37,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14171.65,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8152.08,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7348.78,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11799.68,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7216.84,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16136.13,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8394.08,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6197.05,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,51260.78,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15037.62,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8337.23,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,29050.75,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7877.24,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7736.57,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8705.33,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15211.11,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12605.89,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11059.80,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16005.66,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8684.21,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5374.81,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11196.84,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13598.71,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7313.06,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31468.63,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14833.51,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9403.66,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27652.63,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,11691.07,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15196.53,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,28864.11,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15421.77,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10446.78,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12793.24,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7332.74,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13135.82,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5734.92,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12310.67,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7125.71,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,14223.40,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8184.14,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5896.00,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13630.04,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,8296.40,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,156510.01,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,53162.57,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,24355.65,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,29264.32,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,16991.90,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15894.12,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,27327.53,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,17912.56,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,15658.67,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12166.34,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9237.47,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10131.14,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,6713.15,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9550.16,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,5453.53,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,4930.88,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,49943.59,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,28307.95,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,56422.38,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,31594.72,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,22338.67,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20805.72,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12049.71,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7733.64,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,45498.51,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,20103.02,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,21915.15,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10317.74,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,7458.13,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,10337.42,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,35078.32,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,18798.95,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,13372.00,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,25868.92,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,12858.83,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Alignment,Medicare Advantage,,9619.41,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17256.38,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5117.61,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,21269.40,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7334.47,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5117.61,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9490.97,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1540.76,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,30224.93,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6509.35,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,21269.40,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7334.47,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,662.02,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,662.02,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6509.35,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5117.61,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5904.24,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,301.71,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5904.24,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,19964.31,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,30224.93,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,44633.30,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,230.33,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,526.27,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,398.55,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,19964.31,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17810.19,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,863.63,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9490.97,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5904.24,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,505.09,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5904.24,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3410.95,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,960.64,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6509.35,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,22263.03,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,19964.31,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17810.19,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,863.63,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,199.53,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,31799.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1540.76,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17529.90,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,544.12,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5904.24,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,58.92,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,8208.45,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,960.64,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,199.53,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,662.02,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,863.63,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,301.71,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,8208.45,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,192.56,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,395.78,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,127.85,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,58.92,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6468.24,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12886.40,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,19964.31,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,31799.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10379.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,395.78,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5904.24,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,544.12,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12368.55,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6509.35,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,230.33,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6351.81,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,301.71,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,87.33,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,199.53,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,662.02,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,960.64,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,960.64,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5117.61,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1540.76,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4646.94,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12368.55,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6351.81,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,544.12,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,8208.45,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17810.19,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6351.81,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6188.83,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,544.12,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,960.64,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,230.33,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,505.09,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,395.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3609.60,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,127.85,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,127.85,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17810.19,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12886.40,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,301.71,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,863.63,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10379.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,8208.45,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,230.33,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,649.04,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,91.04,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,9171.69,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7334.47,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,230.33,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5904.24,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,192.56,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,301.71,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,230.33,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,505.09,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,127.85,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,505.09,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,230.33,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,433.61,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,395.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,199.53,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17810.19,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17810.19,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,395.78,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,17810.19,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,11248.03,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2031.79,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,662.02,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,199.53,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,199.53,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12886.40,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,10326.26,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,662.02,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3500.26,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,301.71,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,607.14,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,395.78,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,127.85,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3420.83,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,197.08,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,127.85,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,395.78,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5117.61,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,544.12,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2838.70,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,904.27,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1357.09,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3609.60,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3609.60,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1607.02,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,296.49,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,960.64,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,8208.45,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,8208.45,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,241.23,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Alignment,Medicare Advantage,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Alignment,Medicare Advantage,,29.38,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Alignment,Medicare Advantage,,56824.55,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Alignment,Medicare Advantage,,7.28,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Alignment,Medicare Advantage,,3.35,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Alignment,Medicare Advantage,,12.07,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Alignment,Medicare Advantage,,0.12000,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Alignment,Medicare Advantage,,1730.32,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Alignment,Medicare Advantage,,112.45,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Alignment,Medicare Advantage,,114.54,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Alignment,Medicare Advantage,,6.77,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Alignment,Medicare Advantage,,7.95,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Alignment,Medicare Advantage,,30.01,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Alignment,Medicare Advantage,,15.11,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Alignment,Medicare Advantage,,1.70,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Alignment,Medicare Advantage,,62.23,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Alignment,Medicare Advantage,,75.86,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Alignment,Medicare Advantage,,1.88,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Alignment,Medicare Advantage,,172.31,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Alignment,Medicare Advantage,,733.67,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Alignment,Medicare Advantage,,8.73,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Alignment,Medicare Advantage,,3.42,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Alignment,Medicare Advantage,,5135.09,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Alignment,Medicare Advantage,,95.90,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Alignment,Medicare Advantage,,227.28,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Alignment,Medicare Advantage,,5.57,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Alignment,Medicare Advantage,,5.57,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Alignment,Medicare Advantage,,20.35,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Alignment,Medicare Advantage,,20.35,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Alignment,Medicare Advantage,,20.35,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Alignment,Medicare Advantage,,8.75,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Alignment,Medicare Advantage,,89.34,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alignment,Medicare Advantage,,4.23,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Alignment,Medicare Advantage,,2.93,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Alignment,Medicare Advantage,,2.93,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Alignment,Medicare Advantage,,2.93,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Alignment,Medicare Advantage,,2.93,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Alignment,Medicare Advantage,,2.93,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Alignment,Medicare Advantage,,2.93,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Alignment,Medicare Advantage,,30.01,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Alignment,Medicare Advantage,,173.03,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Alignment,Medicare Advantage,,173.03,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Alignment,Medicare Advantage,,5.71,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Alignment,Medicare Advantage,,5.71,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Alignment,Medicare Advantage,,73.20,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Alignment,Medicare Advantage,,73.20,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Alignment,Medicare Advantage,,6.73,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Alignment,Medicare Advantage,,181.22,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Alignment,Medicare Advantage,,183.48,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Alignment,Medicare Advantage,,183.48,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Alignment,Medicare Advantage,,30.01,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Alignment,Medicare Advantage,,2608.16,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Alignment,Medicare Advantage,,432.02,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Alignment,Medicare Advantage,,2.23,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Alignment,Medicare Advantage,,258.64,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Alignment,Medicare Advantage,,5.19,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Alignment,Medicare Advantage,,1.46,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Alignment,Medicare Advantage,,1.46,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Alignment,Medicare Advantage,,62.23,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Alignment,Medicare Advantage,,17.02,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Alignment,Medicare Advantage,,55.65,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Alignment,Medicare Advantage,,28424.06,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Alignment,Medicare Advantage,,66.64,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Alignment,Medicare Advantage,,91.73,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Alignment,Medicare Advantage,,134.19,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Alignment,Medicare Advantage,,593.00,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Alignment,Medicare Advantage,,748.85,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Alignment,Medicare Advantage,,2.85,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Alignment,Medicare Advantage,,141.89,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Alignment,Medicare Advantage,,7.95,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Alignment,Medicare Advantage,,263.15,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Alignment,Medicare Advantage,,48.96,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Alignment,Medicare Advantage,,176.45,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Alignment,Medicare Advantage,,75.86,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Alignment,Medicare Advantage,,1730.32,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Alignment,Medicare Advantage,,63.06,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Alignment,Medicare Advantage,,733.67,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Alignment,Medicare Advantage,,42.16,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Alignment,Medicare Advantage,,42.16,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Alignment,Medicare Advantage,,308.68,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Alignment,Medicare Advantage,,74.36,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Alignment,Medicare Advantage,,74.36,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Alignment,Medicare Advantage,,2.14,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Alignment,Medicare Advantage,,21.31,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Alignment,Medicare Advantage,,15.61,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Alignment,Medicare Advantage,,2.14,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Alignment,Medicare Advantage,,7.95,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Alignment,Medicare Advantage,,167.31,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alignment,Medicare Advantage,,164.25,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Alignment,Medicare Advantage,,9.07,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Alignment,Medicare Advantage,,32.96,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Alignment,Medicare Advantage,,32.96,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Alignment,Medicare Advantage,,89.34,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Alignment,Medicare Advantage,,60.29,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Alignment,Medicare Advantage,,203.58,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Alignment,Medicare Advantage,,203.58,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Alignment,Medicare Advantage,,203.58,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Alignment,Medicare Advantage,,104.73,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Alignment,Medicare Advantage,,50.74,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Alignment,Medicare Advantage,,49.03,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Alignment,Medicare Advantage,,49.03,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Alignment,Medicare Advantage,,78.80,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Alignment,Medicare Advantage,,78.80,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Alignment,Medicare Advantage,,19.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Alignment,Medicare Advantage,,0.46000,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Alignment,Medicare Advantage,,0.46000,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Alignment,Medicare Advantage,,66.00,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Alignment,Medicare Advantage,,31.27,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Alignment,Medicare Advantage,,13.49,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Alignment,Medicare Advantage,,19.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Alignment,Medicare Advantage,,112.45,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Alignment,Medicare Advantage,,71.32,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Alignment,Medicare Advantage,,91.34,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Alignment,Medicare Advantage,,1.83,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Alignment,Medicare Advantage,,8.73,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Alignment,Medicare Advantage,,39.83,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Alignment,Medicare Advantage,,141.60,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Alignment,Medicare Advantage,,100.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Alignment,Medicare Advantage,,59.41,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Alignment,Medicare Advantage,,75.03,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Alignment,Medicare Advantage,,85.12,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Alignment,Medicare Advantage,,85.12,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Alignment,Medicare Advantage,,36.69,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Alignment,Medicare Advantage,,36.69,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Alignment,Medicare Advantage,,256.09,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Alignment,Medicare Advantage,,2698.05,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Alignment,Medicare Advantage,,2.18,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Alignment,Medicare Advantage,,1.64,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Alignment,Medicare Advantage,,164.59,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Alignment,Medicare Advantage,,8.15,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Alignment,Medicare Advantage,,32.96,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Alignment,Medicare Advantage,,18.11,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Alignment,Medicare Advantage,,7.85,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Alignment,Medicare Advantage,,7.85,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Alignment,Medicare Advantage,,7.85,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Alignment,Medicare Advantage,,7.85,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Alignment,Medicare Advantage,,7.85,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Alignment,Medicare Advantage,,99.13,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Alignment,Medicare Advantage,,248.50,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Alignment,Medicare Advantage,,29.29,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Alignment,Medicare Advantage,,106.33,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Alignment,Medicare Advantage,,131.38,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Alignment,Medicare Advantage,,102.10,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Alignment,Medicare Advantage,,91.34,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Alignment,Medicare Advantage,,61.44,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Alignment,Medicare Advantage,,6.83,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Alignment,Medicare Advantage,,136.67,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Alignment,Medicare Advantage,,27.86,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Alignment,Medicare Advantage,,27.86,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Alignment,Medicare Advantage,,29.38,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Alignment,Medicare Advantage,,29.38,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Alignment,Medicare Advantage,,41.98,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Alignment,Medicare Advantage,,41.98,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Alignment,Medicare Advantage,,129.48,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Alignment,Medicare Advantage,,11.01,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Alignment,Medicare Advantage,,36.74,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alignment,Medicare Advantage,,36.74,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Alignment,Medicare Advantage,,29.98,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Alignment,Medicare Advantage,,25.77,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Alignment,Medicare Advantage,,25.77,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Alignment,Medicare Advantage,,27.85,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Alignment,Medicare Advantage,,27.85,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Alignment,Medicare Advantage,,359.19,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Alignment,Medicare Advantage,,27.99,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Alignment,Medicare Advantage,,19.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Alignment,Medicare Advantage,,81.90,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Alignment,Medicare Advantage,,81.90,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Alignment,Medicare Advantage,,36.28,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Alignment,Medicare Advantage,,318.53,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Alignment,Medicare Advantage,,20.41,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Alignment,Medicare Advantage,,62.10,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Alignment,Medicare Advantage,,62.10,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Alignment,Medicare Advantage,,14.31,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Alignment,Medicare Advantage,,136.67,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Alignment,Medicare Advantage,,225.11,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Alignment,Medicare Advantage,,225.11,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Alignment,Medicare Advantage,,7.85,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Alignment,Medicare Advantage,,5.46,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Alignment,Medicare Advantage,,27.99,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Alignment,Medicare Advantage,,2116.32,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Alignment,Medicare Advantage,,216.90,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Alignment,Medicare Advantage,,243.71,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Alignment,Medicare Advantage,,22.54,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Alignment,Medicare Advantage,,188.76,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Alignment,Medicare Advantage,,12.32,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Alignment,Medicare Advantage,,84.57,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Alignment,Medicare Advantage,,0.38000,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Alignment,Medicare Advantage,,0.38000,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Alignment,Medicare Advantage,,197.83,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Alignment,Medicare Advantage,,33.58,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Alignment,Medicare Advantage,,33.58,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Alignment,Medicare Advantage,,69.49,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Alignment,Medicare Advantage,,654.63,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Alignment,Medicare Advantage,,654.63,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Alignment,Medicare Advantage,,30.56,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Alignment,Medicare Advantage,,25.04,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Alignment,Medicare Advantage,,25.04,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Alignment,Medicare Advantage,,25.04,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Alignment,Medicare Advantage,,63342.28,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Alignment,Medicare Advantage,,72.62,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Alignment,Medicare Advantage,,72.62,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Alignment,Medicare Advantage,,195.72,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Alignment,Medicare Advantage,,8.73,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Alignment,Medicare Advantage,,106.33,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Alignment,Medicare Advantage,,1.83,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Alignment,Medicare Advantage,,57.03,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Alignment,Medicare Advantage,,57.03,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Alignment,Medicare Advantage,,75.97,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Alignment,Medicare Advantage,,33.43,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Alignment,Medicare Advantage,,27.36,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Alignment,Medicare Advantage,,51.56,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Alignment,Medicare Advantage,,172.22,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Alignment,Medicare Advantage,,21.48,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Alignment,Medicare Advantage,,75.22,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Alignment,Medicare Advantage,,75.22,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Alignment,Medicare Advantage,,6.28,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Alignment,Medicare Advantage,,31.09,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Alignment,Medicare Advantage,,43.19,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Alignment,Medicare Advantage,,108.47,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Alignment,Medicare Advantage,,108.47,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Alignment,Medicare Advantage,,328.34,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Alignment,Medicare Advantage,,0.80000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Alignment,Medicare Advantage,,8.15,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Alignment,Medicare Advantage,,1828.72,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Alignment,Medicare Advantage,,1.70,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Alignment,Medicare Advantage,,94.45,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Alignment,Medicare Advantage,,5168.23,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Alignment,Medicare Advantage,,7.34,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Alignment,Medicare Advantage,,89.34,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Alignment,Medicare Advantage,,6.50,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Alignment,Medicare Advantage,,176.45,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Alignment,Medicare Advantage,,54.71,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Alignment,Medicare Advantage,,54.71,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Alignment,Medicare Advantage,,54.71,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Alignment,Medicare Advantage,,54.71,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Alignment,Medicare Advantage,,377.52,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Alignment,Medicare Advantage,,0.46000,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Alignment,Medicare Advantage,,44.60,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Alignment,Medicare Advantage,,4.36,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alignment,Medicare Advantage,,78.37,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Alignment,Medicare Advantage,,0.48000,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Alignment,Medicare Advantage,,0.48000,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Alignment,Medicare Advantage,,1.73,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Alignment,Medicare Advantage,,10.54,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Alignment,Medicare Advantage,,10.14,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Alignment,Medicare Advantage,,10.14,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Alignment,Medicare Advantage,,10.14,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Alignment,Medicare Advantage,,2429.89,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Alignment,Medicare Advantage,,20.35,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Alignment,Medicare Advantage,,183.48,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Alignment,Medicare Advantage,,183.48,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Alignment,Medicare Advantage,,68.20,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Alignment,Medicare Advantage,,62.23,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Alignment,Medicare Advantage,,62.23,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Alignment,Medicare Advantage,,5.71,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Alignment,Medicare Advantage,,5.71,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alignment,Medicare Advantage,,258.64,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alignment,Medicare Advantage,,4.23,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Alignment,Medicare Advantage,,207.13,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Alignment,Medicare Advantage,,279.85,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Alignment,Medicare Advantage,,279.85,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Alignment,Medicare Advantage,,18.11,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Alignment,Medicare Advantage,,172.22,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Alignment,Medicare Advantage,,148.99,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Alignment,Medicare Advantage,,182.45,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Alignment,Medicare Advantage,,0.21000,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Alignment,Medicare Advantage,,70.75,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Alignment,Medicare Advantage,,94.45,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Alignment,Medicare Advantage,,70.75,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Alignment,Medicare Advantage,,70.75,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Alignment,Medicare Advantage,,131.38,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Alignment,Medicare Advantage,,94.45,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Alignment,Medicare Advantage,,91.34,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alignment,Medicare Advantage,,1730.32,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alignment,Medicare Advantage,,1730.32,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Alignment,Medicare Advantage,,36.28,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alignment,Medicare Advantage,,85.12,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Alignment,Medicare Advantage,,55.65,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Alignment,Medicare Advantage,,0.48000,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alignment,Medicare Advantage,,4.23,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alignment,Medicare Advantage,,4.23,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Alignment,Medicare Advantage,,0.37000,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Alignment,Medicare Advantage,,6.73,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Alignment,Medicare Advantage,,0.80000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Alignment,Medicare Advantage,,20.35,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Alignment,Medicare Advantage,,94.45,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alignment,Medicare Advantage,,2.66,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Alignment,Medicare Advantage,,2.14,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Alignment,Medicare Advantage,,60.29,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Alignment,Medicare Advantage,,6.73,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alignment,Medicare Advantage,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alignment,Medicare Advantage,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alignment,Medicare Advantage,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alignment,Medicare Advantage,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alignment,Medicare Advantage,,164.25,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Alignment,Medicare Advantage,,172.22,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Alignment,Medicare Advantage,,75.03,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alignment,Medicare Advantage,,61.44,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Alignment,Medicare Advantage,,62.10,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alignment,Medicare Advantage,,62.10,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Alignment,Medicare Advantage,,4.36,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Alignment,Medicare Advantage,,60.29,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Alignment,Medicare Advantage,,60.29,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Alignment,Medicare Advantage,,0.80000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Alignment,Medicare Advantage,,1.83,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Alignment,Medicare Advantage,,236.62,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Alignment,Medicare Advantage,,91.34,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Alignment,Medicare Advantage,,91.34,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Alignment,Medicare Advantage,,55.57,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Alignment,Medicare Advantage,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alignment,Medicare Advantage,,78.37,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Alignment,Medicare Advantage,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alignment,Medicare Advantage,,78.37,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Alignment,Medicare Advantage,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alignment,Medicare Advantage,,78.37,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Alignment,Medicare Advantage,,2429.89,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Alignment,Medicare Advantage,,0.28000,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alignment,Medicare Advantage,,36.74,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alignment,Medicare Advantage,,36.74,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alignment,Medicare Advantage,,36.74,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Alignment,Medicare Advantage,,72.62,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Alignment,Medicare Advantage,,95.90,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Alignment,Medicare Advantage,,4.42,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Alignment,Medicare Advantage,,4.42,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Alignment,Medicare Advantage,,4.42,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Alignment,Medicare Advantage,,4.42,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Alignment,Medicare Advantage,,4.42,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Alignment,Medicare Advantage,,4.42,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Alignment,Medicare Advantage,,0.37000,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Alignment,Medicare Advantage,,68.20,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Alignment,Medicare Advantage,,0.12000,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Alignment,Medicare Advantage,,0.12000,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Alignment,Medicare Advantage,,294.69,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Alignment,Medicare Advantage,,1.49,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Alignment,Medicare Advantage,,1.49,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Alignment,Medicare Advantage,,1.49,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Alignment,Medicare Advantage,,2.93,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Alignment,Medicare Advantage,,1.61,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Alignment,Medicare Advantage,,44.82,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Alignment,Medicare Advantage,,26.71,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Alignment,Medicare Advantage,,29.84,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Alignment,Medicare Advantage,,139.21,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Alignment,Medicare Advantage,,4.36,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Alignment,Medicare Advantage,,53.08,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Alignment,Medicare Advantage,,53.08,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Alignment,Medicare Advantage,,94.45,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Alignment,Medicare Advantage,,94.45,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Alignment,Medicare Advantage,,4.10,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Alignment,Medicare Advantage,,0.30000,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alignment,Medicare Advantage,,2.66,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alignment,Medicare Advantage,,2.66,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alignment,Medicare Advantage,,2.66,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Alignment,Medicare Advantage,,1.67,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Alignment,Medicare Advantage,,1.67,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Alignment,Medicare Advantage,,0.37000,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Alignment,Medicare Advantage,,484.97,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Alignment,Medicare Advantage,,11.01,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Alignment,Medicare Advantage,,11.01,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Alignment,Medicare Advantage,,23.88,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Alignment,Medicare Advantage,,23.88,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Alignment,Medicare Advantage,,23.88,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Alignment,Medicare Advantage,,2.85,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Alignment,Medicare Advantage,,51.05,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Alignment,Medicare Advantage,,6.50,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Alignment,Medicare Advantage,,10.68,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Alignment,Medicare Advantage,,4.45,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Alignment,Medicare Advantage,,3.52,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Alignment,Medicare Advantage,,3.52,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Alignment,Medicare Advantage,,1.70,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Alignment,Medicare Advantage,,0.32000,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Alignment,Medicare Advantage,,8.75,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Alignment,Medicare Advantage,,392.06,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Alignment,Medicare Advantage,,508.96,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Alignment,Medicare Advantage,,608.10,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Alignment,Medicare Advantage,,339.60,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Alignment,Medicare Advantage,,34.82,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Alignment,Medicare Advantage,,34.82,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Alignment,Medicare Advantage,,36.74,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Alignment,Medicare Advantage,,127.85,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Alignment,Medicare Advantage,,208.97,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Alignment,Medicare Advantage,,45.76,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Alignment,Medicare Advantage,,208.97,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Alignment,Medicare Advantage,,45.76,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Alignment,Medicare Advantage,,70.59,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Alignment,Medicare Advantage,,208.97,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Alignment,Medicare Advantage,,208.97,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Alignment,Medicare Advantage,,45.76,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Alignment,Medicare Advantage,,328.98,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Alignment,Medicare Advantage,,9.09,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Alignment,Medicare Advantage,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Alignment,Medicare Advantage,,70.59,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Alignment,Medicare Advantage,,70.59,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Alignment,Medicare Advantage,,70.59,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Alignment,Medicare Advantage,,208.97,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Alignment,Medicare Advantage,,328.98,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Alignment,Medicare Advantage,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Alignment,Medicare Advantage,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Alignment,Medicare Advantage,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Alignment,Medicare Advantage,,363.08,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Alignment,Medicare Advantage,,363.08,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Alignment,Medicare Advantage,,131.69,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Alignment,Medicare Advantage,,363.08,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Alignment,Medicare Advantage,,131.69,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Alignment,Medicare Advantage,,363.08,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Alignment,Medicare Advantage,,131.69,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Alignment,Medicare Advantage,,1741.58,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Alignment,Medicare Advantage,,1741.58,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Alignment,Medicare Advantage,,573.75,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Alignment,Medicare Advantage,,573.75,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Alignment,Medicare Advantage,,573.75,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Alignment,Medicare Advantage,,688.15,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Alignment,Medicare Advantage,,108.61,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Alignment,Medicare Advantage,,328.98,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Alignment,Medicare Advantage,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Alignment,Medicare Advantage,,328.98,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Alignment,Medicare Advantage,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Alignment,Medicare Advantage,,328.98,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Alignment,Medicare Advantage,,45.76,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Alignment,Medicare Advantage,,328.98,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Alignment,Medicare Advantage,,208.97,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Alignment,Medicare Advantage,,208.97,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Alignment,Medicare Advantage,,328.98,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Alignment,Medicare Advantage,,108.61,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Alignment,Medicare Advantage,,260.83,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Alignment,Medicare Advantage,,260.83,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Alignment,Medicare Advantage,,260.83,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alignment,Medicare Advantage,,573.75,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Alignment,Medicare Advantage,,573.75,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Alignment,Medicare Advantage,,573.75,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Alignment,Medicare Advantage,,328.98,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Alignment,Medicare Advantage,,7582.11,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Alignment,Medicare Advantage,,7582.11,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Alignment,Medicare Advantage,,688.15,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Alignment,Medicare Advantage,,688.15,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Alignment,Medicare Advantage,,688.15,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Alignment,Medicare Advantage,,328.98,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Alignment,Medicare Advantage,,363.08,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Alignment,Medicare Advantage,,1357.09,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Alignment,Medicare Advantage,,131.69,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Alignment,Medicare Advantage,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Alignment,Medicare Advantage,,363.08,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Alignment,Medicare Advantage,,363.08,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Alignment,Medicare Advantage,,573.75,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alignment,Medicare Advantage,,1625.90,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Alignment,Medicare Advantage,,199.53,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Alignment,Medicare Advantage,,3153.59,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Alignment,Medicare Advantage,,201.73,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Alignment,Medicare Advantage,,230.33,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Alignment,Medicare Advantage,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Alignment,Medicare Advantage,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Alignment,Medicare Advantage,,4896.17,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Alignment,Medicare Advantage,,301.71,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Alignment,Medicare Advantage,,433.61,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Alignment,Medicare Advantage,,230.33,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Alignment,Medicare Advantage,,201.73,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Alignment,Medicare Advantage,,201.73,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,127.85,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,127.85,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Alignment,Medicare Advantage,,201.73,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Alignment,Medicare Advantage,,127.85,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Alignment,Medicare Advantage,,127.85,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Alignment,Medicare Advantage,,201.73,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Alignment,Medicare Advantage,,24.29,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Alignment,Medicare Advantage,,24.29,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Alignment,Medicare Advantage,,38.93,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Alignment,Medicare Advantage,,127.85,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Alignment,Medicare Advantage,,201.73,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Alignment,Medicare Advantage,,201.73,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Alignment,Medicare Advantage,,201.73,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Alignment,Medicare Advantage,,201.73,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Alignment,Medicare Advantage,,201.73,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Alignment,Medicare Advantage,,201.73,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Alignment,Medicare Advantage,,201.73,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,201.73,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Alignment,Medicare Advantage,,201.73,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Alignment,Medicare Advantage,,36.99,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Alignment,Medicare Advantage,,36.99,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Alignment,Medicare Advantage,,155.18,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Alignment,Medicare Advantage,,155.18,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Alignment,Medicare Advantage,,308.86,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Alignment,Medicare Advantage,,526.27,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Alignment,Medicare Advantage,,308.86,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Alignment,Medicare Advantage,,308.86,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Alignment,Medicare Advantage,,155.18,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Alignment,Medicare Advantage,,58.92,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Alignment,Medicare Advantage,,308.86,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Alignment,Medicare Advantage,,127.85,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Alignment,Medicare Advantage,,127.85,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Alignment,Medicare Advantage,,127.85,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Alignment,Medicare Advantage,,127.85,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Alignment,Medicare Advantage,,308.86,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Alignment,Medicare Advantage,,155.18,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Alignment,Medicare Advantage,,308.86,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Alignment,Medicare Advantage,,58.92,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Alignment,Medicare Advantage,,308.86,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Alignment,Medicare Advantage,,155.18,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Alignment,Medicare Advantage,,155.18,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Alignment,Medicare Advantage,,155.18,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Alignment,Medicare Advantage,,308.86,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Alignment,Medicare Advantage,,433.61,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Alignment,Medicare Advantage,,308.86,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Alignment,Medicare Advantage,,308.86,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Alignment,Medicare Advantage,,308.86,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Alignment,Medicare Advantage,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alignment,Medicare Advantage,,1625.90,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Alignment,Medicare Advantage,,694.01,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Alignment,Medicare Advantage,,422.35,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Alignment,Medicare Advantage,,526.27,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Alignment,Medicare Advantage,,395.78,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Alignment,Medicare Advantage,,155.18,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Alignment,Medicare Advantage,,1009.09,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Alignment,Medicare Advantage,,1009.09,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Alignment,Medicare Advantage,,1009.09,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Alignment,Medicare Advantage,,239.75,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Alignment,Medicare Advantage,,308.86,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Alignment,Medicare Advantage,,105.47,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Alignment,Medicare Advantage,,239.75,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Alignment,Medicare Advantage,,308.86,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Alignment,Medicare Advantage,,127.85,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Alignment,Medicare Advantage,,308.86,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Alignment,Medicare Advantage,,308.86,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Alignment,Medicare Advantage,,239.75,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Alignment,Medicare Advantage,,526.27,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Alignment,Medicare Advantage,,239.75,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Alignment,Medicare Advantage,,308.86,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Alignment,Medicare Advantage,,58.92,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Alignment,Medicare Advantage,,239.75,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Alignment,Medicare Advantage,,105.47,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Alignment,Medicare Advantage,,105.47,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Alignment,Medicare Advantage,,105.47,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Alignment,Medicare Advantage,,1009.09,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Alignment,Medicare Advantage,,1009.09,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Alignment,Medicare Advantage,,1009.09,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Alignment,Medicare Advantage,,155.18,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Alignment,Medicare Advantage,,127.85,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Alignment,Medicare Advantage,,127.85,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Alignment,Medicare Advantage,,155.18,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Alignment,Medicare Advantage,,127.85,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Alignment,Medicare Advantage,,308.86,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Alignment,Medicare Advantage,,308.86,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Alignment,Medicare Advantage,,127.85,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Alignment,Medicare Advantage,,155.18,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Alignment,Medicare Advantage,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Alignment,Medicare Advantage,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Alignment,Medicare Advantage,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Alignment,Medicare Advantage,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Alignment,Medicare Advantage,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Alignment,Medicare Advantage,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Alignment,Medicare Advantage,,155.18,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Alignment,Medicare Advantage,,127.85,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Alignment,Medicare Advantage,,127.85,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Alignment,Medicare Advantage,,308.86,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Alignment,Medicare Advantage,,308.86,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Alignment,Medicare Advantage,,1009.09,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Alignment,Medicare Advantage,,526.27,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Alignment,Medicare Advantage,,308.86,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Alignment,Medicare Advantage,,526.27,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Alignment,Medicare Advantage,,1009.09,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Alignment,Medicare Advantage,,308.86,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Alignment,Medicare Advantage,,526.27,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Alignment,Medicare Advantage,,105.47,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Alignment,Medicare Advantage,,155.18,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Alignment,Medicare Advantage,,308.86,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Alignment,Medicare Advantage,,308.86,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Alignment,Medicare Advantage,,308.86,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Alignment,Medicare Advantage,,308.86,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Alignment,Medicare Advantage,,308.86,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Alignment,Medicare Advantage,,526.27,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Alignment,Medicare Advantage,,1009.09,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Alignment,Medicare Advantage,,308.86,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Alignment,Medicare Advantage,,70.59,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Alignment,Medicare Advantage,,70.59,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Alignment,Medicare Advantage,,29.55,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Alignment,Medicare Advantage,,45.76,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,70.59,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,70.59,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,70.59,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,70.59,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,70.59,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Alignment,Medicare Advantage,,41.18,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Alignment,Medicare Advantage,,197.08,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Alignment,Medicare Advantage,,2838.70,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Alignment,Medicare Advantage,,607.14,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Alignment,Medicare Advantage,,607.14,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Alignment,Medicare Advantage,,197.08,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Alignment,Medicare Advantage,,197.08,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Alignment,Medicare Advantage,,197.08,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Alignment,Medicare Advantage,,396.27,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Alignment,Medicare Advantage,,58.92,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Alignment,Medicare Advantage,,58.92,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Alignment,Medicare Advantage,,58.92,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Alignment,Medicare Advantage,,197.08,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Alignment,Medicare Advantage,,197.08,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Alignment,Medicare Advantage,,197.08,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Alignment,Medicare Advantage,,697.85,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Alignment,Medicare Advantage,,292.78,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Alignment,Medicare Advantage,,292.78,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Alignment,Medicare Advantage,,292.78,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Alignment,Medicare Advantage,,292.78,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Alignment,Medicare Advantage,,292.78,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Alignment,Medicare Advantage,,263.41,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Alignment,Medicare Advantage,,230.33,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Alignment,Medicare Advantage,,396.27,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Alignment,Medicare Advantage,,396.27,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Alignment,Medicare Advantage,,396.27,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Alignment,Medicare Advantage,,127.85,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Alignment,Medicare Advantage,,328.98,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Alignment,Medicare Advantage,,328.98,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Alignment,Medicare Advantage,,686.87,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Alignment,Medicare Advantage,,686.87,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Alignment,Medicare Advantage,,686.87,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Alignment,Medicare Advantage,,297.46,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alignment,Medicare Advantage,,297.46,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Alignment,Medicare Advantage,,6509.35,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Alignment,Medicare Advantage,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Alignment,Medicare Advantage,,686.87,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Alignment,Medicare Advantage,,292.78,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Alignment,Medicare Advantage,,883.03,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Alignment,Medicare Advantage,,883.03,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Alignment,Medicare Advantage,,6509.35,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Alignment,Medicare Advantage,,292.78,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Alignment,Medicare Advantage,,292.78,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Alignment,Medicare Advantage,,1936.84,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Alignment,Medicare Advantage,,1936.84,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Alignment,Medicare Advantage,,883.03,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Alignment,Medicare Advantage,,883.03,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Alignment,Medicare Advantage,,883.03,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Alignment,Medicare Advantage,,292.78,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Alignment,Medicare Advantage,,197.08,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Alignment,Medicare Advantage,,197.08,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,197.08,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,197.08,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Alignment,Medicare Advantage,,697.85,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Alignment,Medicare Advantage,,883.03,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Alignment,Medicare Advantage,,686.87,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Alignment,Medicare Advantage,,686.87,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Alignment,Medicare Advantage,,686.87,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Alignment,Medicare Advantage,,292.78,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Alignment,Medicare Advantage,,883.03,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Alignment,Medicare Advantage,,396.27,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alignment,Medicare Advantage,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Alignment,Medicare Advantage,,883.03,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Alignment,Medicare Advantage,,883.03,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Alignment,Medicare Advantage,,686.87,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Alignment,Medicare Advantage,,686.87,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Alignment,Medicare Advantage,,883.03,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Alignment,Medicare Advantage,,883.03,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Alignment,Medicare Advantage,,883.03,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Alignment,Medicare Advantage,,883.03,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Alignment,Medicare Advantage,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Alignment,Medicare Advantage,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Alignment,Medicare Advantage,,292.78,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Alignment,Medicare Advantage,,883.03,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Alignment,Medicare Advantage,,686.87,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Alignment,Medicare Advantage,,686.87,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Alignment,Medicare Advantage,,686.87,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Alignment,Medicare Advantage,,883.03,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Alignment,Medicare Advantage,,686.87,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Alignment,Medicare Advantage,,883.03,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Alignment,Medicare Advantage,,686.87,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Alignment,Medicare Advantage,,686.87,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Alignment,Medicare Advantage,,686.87,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Alignment,Medicare Advantage,,686.87,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Alignment,Medicare Advantage,,686.87,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Alignment,Medicare Advantage,,1936.84,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Alignment,Medicare Advantage,,1936.84,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Alignment,Medicare Advantage,,1936.84,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Alignment,Medicare Advantage,,1936.84,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Alignment,Medicare Advantage,,1814.30,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Alignment,Medicare Advantage,,1814.30,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Alignment,Medicare Advantage,,197.08,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,197.08,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Alignment,Medicare Advantage,,328.98,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Alignment,Medicare Advantage,,136.77,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Alignment,Medicare Advantage,,127.85,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Alignment,Medicare Advantage,,396.27,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Alignment,Medicare Advantage,,396.27,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Alignment,Medicare Advantage,,192.56,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Alignment,Medicare Advantage,,87.33,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Alignment,Medicare Advantage,,157.07,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Alignment,Medicare Advantage,,274.63,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Alignment,Medicare Advantage,,422.35,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Alignment,Medicare Advantage,,608.10,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Alignment,Medicare Advantage,,835.73,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Alignment,Medicare Advantage,,308.86,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Alignment,Medicare Advantage,,127.85,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Alignment,Medicare Advantage,,127.85,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Alignment,Medicare Advantage,,58.92,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Alignment,Medicare Advantage,,38.93,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Alignment,Medicare Advantage,,38.93,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Alignment,Medicare Advantage,,38.93,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Alignment,Medicare Advantage,,38.93,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Alignment,Medicare Advantage,,197.08,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Alignment,Medicare Advantage,,1169.46,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Alignment,Medicare Advantage,,396.27,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Alignment,Medicare Advantage,,1607.02,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Alignment,Medicare Advantage,,51.09,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Alignment,Medicare Advantage,,197.08,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Alignment,Medicare Advantage,,1814.30,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Alignment,Medicare Advantage,,1814.30,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Alignment,Medicare Advantage,,1814.30,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Alignment,Medicare Advantage,,1814.30,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Alignment,Medicare Advantage,,156.50,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Alignment,Medicare Advantage,,156.50,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Alignment,Medicare Advantage,,156.50,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Alignment,Medicare Advantage,,3153.59,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alignment,Medicare Advantage,,297.46,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Alignment,Medicare Advantage,,607.14,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Alignment,Medicare Advantage,,686.87,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Alignment,Medicare Advantage,,1540.76,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Alignment,Medicare Advantage,,1540.76,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Alignment,Medicare Advantage,,5655.00,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Alignment,Medicare Advantage,,5655.00,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Alignment,Medicare Advantage,,5655.00,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Alignment,Medicare Advantage,,5655.00,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Alignment,Medicare Advantage,,17810.19,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Alignment,Medicare Advantage,,17810.19,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Alignment,Medicare Advantage,,156.50,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Alignment,Medicare Advantage,,197.08,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Alignment,Medicare Advantage,,197.08,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Alignment,Medicare Advantage,,396.27,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Alignment,Medicare Advantage,,2838.70,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Alignment,Medicare Advantage,,38.93,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Alignment,Medicare Advantage,,197.08,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Alignment,Medicare Advantage,,396.27,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Alignment,Medicare Advantage,,607.14,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Alignment,Medicare Advantage,,396.27,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Alignment,Medicare Advantage,,127.85,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Alignment,Medicare Advantage,,91.04,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Alignment,Medicare Advantage,,91.04,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Alignment,Medicare Advantage,,36.99,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Alignment,Medicare Advantage,,36.99,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Alignment,Medicare Advantage,,36.99,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Alignment,Medicare Advantage,,36.99,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Alignment,Medicare Advantage,,36.99,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Alignment,Medicare Advantage,,24.29,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Alignment,Medicare Advantage,,197.08,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Alignment,Medicare Advantage,,396.27,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Alignment,Medicare Advantage,,58.92,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Alignment,Medicare Advantage,,396.27,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Alignment,Medicare Advantage,,17342.42,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Alignment,Medicare Advantage,,7085.44,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Alignment,Medicare Advantage,,127.85,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Alignment,Medicare Advantage,,127.85,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Alignment,Medicare Advantage,,929.91,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Alignment,Medicare Advantage,,241.23,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Alignment,Medicare Advantage,,2031.79,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alignment,Medicare Advantage,,433.61,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Alignment,Medicare Advantage,,2031.79,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Alignment,Medicare Advantage,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alignment,Medicare Advantage,,1625.90,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Alignment,Medicare Advantage,,697.85,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Alignment,Medicare Advantage,,1607.02,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Alignment,Medicare Advantage,,1607.02,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Alignment,Medicare Advantage,,1607.02,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Alignment,Medicare Advantage,,11248.03,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Alignment,Medicare Advantage,,613.21,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Alignment,Medicare Advantage,,697.85,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Alignment,Medicare Advantage,,697.85,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Alignment,Medicare Advantage,,697.85,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Alignment,Medicare Advantage,,58.92,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Alignment,Medicare Advantage,,70.59,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Alignment,Medicare Advantage,,526.27,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Alignment,Medicare Advantage,,526.27,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Alignment,Medicare Advantage,,526.27,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Alignment,Medicare Advantage,,308.86,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Alignment,Medicare Advantage,,155.18,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Alignment,Medicare Advantage,,929.91,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Alignment,Medicare Advantage,,929.91,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Alignment,Medicare Advantage,,308.86,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Alignment,Medicare Advantage,,929.91,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Alignment,Medicare Advantage,,308.86,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Alignment,Medicare Advantage,,526.27,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Alignment,Medicare Advantage,,526.27,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Alignment,Medicare Advantage,,2313.92,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Alignment,Medicare Advantage,,308.86,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Alignment,Medicare Advantage,,308.86,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Alignment,Medicare Advantage,,155.18,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Alignment,Medicare Advantage,,308.86,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Alignment,Medicare Advantage,,308.86,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Alignment,Medicare Advantage,,87.33,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Alignment,Medicare Advantage,,105.47,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Alignment,Medicare Advantage,,105.47,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Alignment,Medicare Advantage,,87.33,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Alignment,Medicare Advantage,,105.47,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Alignment,Medicare Advantage,,87.33,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Alignment,Medicare Advantage,,239.75,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Alignment,Medicare Advantage,,105.47,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Alignment,Medicare Advantage,,87.33,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Alignment,Medicare Advantage,,87.33,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Alignment,Medicare Advantage,,87.33,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Alignment,Medicare Advantage,,105.47,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Alignment,Medicare Advantage,,105.47,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Alignment,Medicare Advantage,,87.33,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Alignment,Medicare Advantage,,87.33,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Alignment,Medicare Advantage,,87.33,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Alignment,Medicare Advantage,,87.33,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Alignment,Medicare Advantage,,105.47,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Alignment,Medicare Advantage,,105.47,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Alignment,Medicare Advantage,,105.47,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Alignment,Medicare Advantage,,87.33,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Alignment,Medicare Advantage,,87.33,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Alignment,Medicare Advantage,,87.33,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Alignment,Medicare Advantage,,87.33,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Alignment,Medicare Advantage,,105.47,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Alignment,Medicare Advantage,,105.47,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Alignment,Medicare Advantage,,105.47,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Alignment,Medicare Advantage,,105.47,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Alignment,Medicare Advantage,,87.33,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Alignment,Medicare Advantage,,105.47,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Alignment,Medicare Advantage,,105.47,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Alignment,Medicare Advantage,,105.47,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Alignment,Medicare Advantage,,105.47,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Alignment,Medicare Advantage,,105.47,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Alignment,Medicare Advantage,,105.47,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Alignment,Medicare Advantage,,105.47,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Alignment,Medicare Advantage,,87.33,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Alignment,Medicare Advantage,,783.61,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Alignment,Medicare Advantage,,783.61,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Alignment,Medicare Advantage,,783.61,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Alignment,Medicare Advantage,,783.61,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Alignment,Medicare Advantage,,1936.84,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Alignment,Medicare Advantage,,87.33,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Alignment,Medicare Advantage,,105.47,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Alignment,Medicare Advantage,,87.33,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Alignment,Medicare Advantage,,87.33,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Alignment,Medicare Advantage,,354.22,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Alignment,Medicare Advantage,,87.33,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Alignment,Medicare Advantage,,87.33,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Alignment,Medicare Advantage,,87.33,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Alignment,Medicare Advantage,,87.33,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Alignment,Medicare Advantage,,354.22,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Alignment,Medicare Advantage,,87.33,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Alignment,Medicare Advantage,,105.47,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Alignment,Medicare Advantage,,87.33,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Alignment,Medicare Advantage,,87.33,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Alignment,Medicare Advantage,,354.22,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Alignment,Medicare Advantage,,105.47,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Alignment,Medicare Advantage,,87.33,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Alignment,Medicare Advantage,,87.33,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Alignment,Medicare Advantage,,354.22,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Alignment,Medicare Advantage,,87.33,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Alignment,Medicare Advantage,,87.33,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Alignment,Medicare Advantage,,105.47,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Alignment,Medicare Advantage,,87.33,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Alignment,Medicare Advantage,,354.22,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Alignment,Medicare Advantage,,87.33,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Alignment,Medicare Advantage,,87.33,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Alignment,Medicare Advantage,,87.33,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Alignment,Medicare Advantage,,87.33,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Alignment,Medicare Advantage,,354.22,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Alignment,Medicare Advantage,,87.33,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Alignment,Medicare Advantage,,87.33,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Alignment,Medicare Advantage,,87.33,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Alignment,Medicare Advantage,,87.33,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Alignment,Medicare Advantage,,87.33,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Alignment,Medicare Advantage,,543.83,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Alignment,Medicare Advantage,,543.83,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Alignment,Medicare Advantage,,543.83,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Alignment,Medicare Advantage,,176.57,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Alignment,Medicare Advantage,,176.57,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Alignment,Medicare Advantage,,354.22,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Alignment,Medicare Advantage,,354.22,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Alignment,Medicare Advantage,,354.22,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Alignment,Medicare Advantage,,239.75,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Alignment,Medicare Advantage,,239.75,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Alignment,Medicare Advantage,,239.75,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Alignment,Medicare Advantage,,2031.79,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Alignment,Medicare Advantage,,239.75,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Alignment,Medicare Advantage,,5361.59,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Alignment,Medicare Advantage,,105.47,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Alignment,Medicare Advantage,,1540.76,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Alignment,Medicare Advantage,,1540.76,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Alignment,Medicare Advantage,,1540.76,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Alignment,Medicare Advantage,,3121.82,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Alignment,Medicare Advantage,,3121.82,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Alignment,Medicare Advantage,,3121.82,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Alignment,Medicare Advantage,,5361.59,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Alignment,Medicare Advantage,,3121.82,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Alignment,Medicare Advantage,,239.75,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Alignment,Medicare Advantage,,87.33,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Alignment,Medicare Advantage,,543.83,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Alignment,Medicare Advantage,,543.83,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Alignment,Medicare Advantage,,105.47,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Alignment,Medicare Advantage,,87.33,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Alignment,Medicare Advantage,,239.75,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Alignment,Medicare Advantage,,239.75,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Alignment,Medicare Advantage,,105.47,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Alignment,Medicare Advantage,,105.47,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Alignment,Medicare Advantage,,105.47,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Alignment,Medicare Advantage,,105.47,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Alignment,Medicare Advantage,,105.47,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Alignment,Medicare Advantage,,87.33,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Alignment,Medicare Advantage,,5361.59,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Alignment,Medicare Advantage,,5361.59,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Alignment,Medicare Advantage,,5361.59,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Alignment,Medicare Advantage,,87.33,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Alignment,Medicare Advantage,,87.33,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Alignment,Medicare Advantage,,105.47,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Alignment,Medicare Advantage,,239.75,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Alignment,Medicare Advantage,,105.47,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Alignment,Medicare Advantage,,1936.84,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Alignment,Medicare Advantage,,87.33,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Alignment,Medicare Advantage,,87.33,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Alignment,Medicare Advantage,,87.33,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Alignment,Medicare Advantage,,105.47,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Alignment,Medicare Advantage,,105.47,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Alignment,Medicare Advantage,,105.47,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Alignment,Medicare Advantage,,105.47,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Alignment,Medicare Advantage,,87.33,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Alignment,Medicare Advantage,,87.33,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Alignment,Medicare Advantage,,176.57,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Alignment,Medicare Advantage,,176.57,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Alignment,Medicare Advantage,,17342.42,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Alignment,Medicare Advantage,,5361.59,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Alignment,Medicare Advantage,,783.61,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Alignment,Medicare Advantage,,87.33,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Alignment,Medicare Advantage,,105.47,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Alignment,Medicare Advantage,,105.47,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Alignment,Medicare Advantage,,176.57,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Alignment,Medicare Advantage,,176.57,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Alignment,Medicare Advantage,,176.57,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Alignment,Medicare Advantage,,105.47,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Alignment,Medicare Advantage,,176.57,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Alignment,Medicare Advantage,,105.47,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Alignment,Medicare Advantage,,328.98,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Alignment,Medicare Advantage,,398.55,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Alignment,Medicare Advantage,,398.55,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Alignment,Medicare Advantage,,398.55,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Alignment,Medicare Advantage,,398.55,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Alignment,Medicare Advantage,,398.55,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Alignment,Medicare Advantage,,533.88,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Alignment,Medicare Advantage,,398.55,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Alignment,Medicare Advantage,,398.55,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Alignment,Medicare Advantage,,398.55,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Alignment,Medicare Advantage,,398.55,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Alignment,Medicare Advantage,,398.55,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Alignment,Medicare Advantage,,398.55,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Alignment,Medicare Advantage,,398.55,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Alignment,Medicare Advantage,,1294.83,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Alignment,Medicare Advantage,,1294.83,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Alignment,Medicare Advantage,,398.55,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Alignment,Medicare Advantage,,398.55,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Alignment,Medicare Advantage,,533.88,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Alignment,Medicare Advantage,,533.88,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Alignment,Medicare Advantage,,1294.83,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alignment,Medicare Advantage,,398.55,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alignment,Medicare Advantage,,533.88,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Alignment,Medicare Advantage,,398.55,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Alignment,Medicare Advantage,,398.55,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Alignment,Medicare Advantage,,1294.83,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Alignment,Medicare Advantage,,1294.83,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,23.13,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Alignment,Medicare Advantage,,715.29,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Alignment,Medicare Advantage,,1914.61,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Alignment,Medicare Advantage,,2074.81,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Alignment,Medicare Advantage,,222.30,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Alignment,Medicare Advantage,,222.30,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Alignment,Medicare Advantage,,222.30,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Alignment,Medicare Advantage,,222.30,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Alignment,Medicare Advantage,,4314.91,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Alignment,Medicare Advantage,,398.55,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Alignment,Medicare Advantage,,56824.55,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Alignment,Medicare Advantage,,1031.39,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Alignment,Medicare Advantage,,2194.62,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Alignment,Medicare Advantage,,398.55,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Alignment,Medicare Advantage,,172.22,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Alignment,Medicare Advantage,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Alignment,Medicare Advantage,,268.42,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Alignment,Medicare Advantage,,398.55,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Alignment,Medicare Advantage,,1294.83,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Alignment,Medicare Advantage,,1294.83,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Alignment,Medicare Advantage,,1294.83,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Alignment,Medicare Advantage,,1446.69,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Alignment,Medicare Advantage,,498.67,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Alignment,Medicare Advantage,,595.10,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Alignment,Medicare Advantage,,332.44,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Alignment,Medicare Advantage,,381.01,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Alignment,Medicare Advantage,,671.22,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Alignment,Medicare Advantage,,87.33,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Alignment,Medicare Advantage,,87.33,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Alignment,Medicare Advantage,,87.33,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Alignment,Medicare Advantage,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Alignment,Medicare Advantage,,942.74,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Alignment,Medicare Advantage,,1540.76,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Alignment,Medicare Advantage,,1881.51,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Alignment,Medicare Advantage,,1881.51,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Alignment,Medicare Advantage,,6188.83,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Alignment,Medicare Advantage,,3500.26,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Alignment,Medicare Advantage,,1936.84,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Alignment,Medicare Advantage,,863.63,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Alignment,Medicare Advantage,,396.27,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Alignment,Medicare Advantage,,396.27,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Alignment,Medicare Advantage,,613.21,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Alignment,Medicare Advantage,,5786.75,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Alignment,Medicare Advantage,,6188.83,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Alignment,Medicare Advantage,,1881.51,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Alignment,Medicare Advantage,,929.91,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Alignment,Medicare Advantage,,2031.79,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Alignment,Medicare Advantage,,1607.02,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Alignment,Medicare Advantage,,1607.02,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Alignment,Medicare Advantage,,1469.19,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Alignment,Medicare Advantage,,292.78,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Alignment,Medicare Advantage,,292.78,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Alignment,Medicare Advantage,,292.78,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Alignment,Medicare Advantage,,292.78,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Alignment,Medicare Advantage,,292.78,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Alignment,Medicare Advantage,,12761.83,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Alignment,Medicare Advantage,,237.92,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Alignment,Medicare Advantage,,1607.02,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Alignment,Medicare Advantage,,3218.13,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Alignment,Medicare Advantage,,3218.13,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Alignment,Medicare Advantage,,3500.26,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Alignment,Medicare Advantage,,613.21,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Alignment,Medicare Advantage,,1357.09,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Alignment,Medicare Advantage,,613.21,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Alignment,Medicare Advantage,,1540.76,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Alignment,Medicare Advantage,,1540.76,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Alignment,Medicare Advantage,,1540.76,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Alignment,Medicare Advantage,,613.21,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Alignment,Medicare Advantage,,1540.76,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Alignment,Medicare Advantage,,1540.76,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Alignment,Medicare Advantage,,5361.59,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Alignment,Medicare Advantage,,1540.76,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Alignment,Medicare Advantage,,613.21,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Alignment,Medicare Advantage,,1540.76,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Alignment,Medicare Advantage,,1540.76,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Alignment,Medicare Advantage,,1540.76,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Alignment,Medicare Advantage,,208.97,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Alignment,Medicare Advantage,,208.97,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Alignment,Medicare Advantage,,17810.19,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Alignment,Medicare Advantage,,17810.19,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alignment,Medicare Advantage,,11248.03,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alignment,Medicare Advantage,,11248.03,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Alignment,Medicare Advantage,,5361.59,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Alignment,Medicare Advantage,,5361.59,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Alignment,Medicare Advantage,,613.21,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Alignment,Medicare Advantage,,1607.02,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Alignment,Medicare Advantage,,398.55,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alignment,Medicare Advantage,,433.61,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Alignment,Medicare Advantage,,395.78,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Alignment,Medicare Advantage,,929.91,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Alignment,Medicare Advantage,,10326.26,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Alignment,Medicare Advantage,,3500.26,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Alignment,Medicare Advantage,,10326.26,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Alignment,Medicare Advantage,,1607.02,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Alignment,Medicare Advantage,,929.91,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Alignment,Medicare Advantage,,929.91,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Alignment,Medicare Advantage,,1607.02,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Alignment,Medicare Advantage,,1357.09,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Alignment,Medicare Advantage,,3500.26,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Alignment,Medicare Advantage,,1881.51,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Alignment,Medicare Advantage,,1881.51,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Alignment,Medicare Advantage,,1881.51,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Alignment,Medicare Advantage,,929.91,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Alignment,Medicare Advantage,,929.91,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Alignment,Medicare Advantage,,929.91,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Alignment,Medicare Advantage,,239.75,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Alignment,Medicare Advantage,,929.91,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Alignment,Medicare Advantage,,1607.02,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Alignment,Medicare Advantage,,2031.79,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Alignment,Medicare Advantage,,2031.79,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Alignment,Medicare Advantage,,2031.79,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alignment,Medicare Advantage,,662.02,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Alignment,Medicare Advantage,,697.85,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Alignment,Medicare Advantage,,5786.75,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Alignment,Medicare Advantage,,10326.26,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Alignment,Medicare Advantage,,2031.79,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Alignment,Medicare Advantage,,127.85,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Alignment,Medicare Advantage,,241.23,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alignment,Medicare Advantage,,199.53,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Alignment,Medicare Advantage,,697.85,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Alignment,Medicare Advantage,,697.85,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Alignment,Medicare Advantage,,697.85,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Alignment,Medicare Advantage,,686.87,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Alignment,Medicare Advantage,,883.03,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Alignment,Medicare Advantage,,883.03,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Alignment,Medicare Advantage,,883.03,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Alignment,Medicare Advantage,,883.03,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Alignment,Medicare Advantage,,883.03,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Alignment,Medicare Advantage,,883.03,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Alignment,Medicare Advantage,,883.03,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Alignment,Medicare Advantage,,883.03,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Alignment,Medicare Advantage,,883.03,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Alignment,Medicare Advantage,,883.03,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Alignment,Medicare Advantage,,883.03,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Alignment,Medicare Advantage,,883.03,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Alignment,Medicare Advantage,,1936.84,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Alignment,Medicare Advantage,,1936.84,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Alignment,Medicare Advantage,,883.03,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Alignment,Medicare Advantage,,883.03,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Alignment,Medicare Advantage,,1169.46,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Alignment,Medicare Advantage,,7085.44,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Alignment,Medicare Advantage,,7085.44,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Alignment,Medicare Advantage,,697.85,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Alignment,Medicare Advantage,,433.61,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Alignment,Medicare Advantage,,697.85,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Alignment,Medicare Advantage,,1607.02,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Alignment,Medicare Advantage,,1607.02,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Alignment,Medicare Advantage,,10326.26,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Alignment,Medicare Advantage,,697.85,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Alignment,Medicare Advantage,,697.85,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Alignment,Medicare Advantage,,17810.19,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Alignment,Medicare Advantage,,11248.03,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Alignment,Medicare Advantage,,697.85,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Alignment,Medicare Advantage,,3500.26,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Alignment,Medicare Advantage,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Alignment,Medicare Advantage,,686.87,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Alignment,Medicare Advantage,,686.87,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Alignment,Medicare Advantage,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Alignment,Medicare Advantage,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Alignment,Medicare Advantage,,3218.13,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Alignment,Medicare Advantage,,3218.13,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Alignment,Medicare Advantage,,7085.44,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Alignment,Medicare Advantage,,7085.44,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Alignment,Medicare Advantage,,783.61,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Alignment,Medicare Advantage,,783.61,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Alignment,Medicare Advantage,,3500.26,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Alignment,Medicare Advantage,,3500.26,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Alignment,Medicare Advantage,,3500.26,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Alignment,Medicare Advantage,,3500.26,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Alignment,Medicare Advantage,,3500.26,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Alignment,Medicare Advantage,,3500.26,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Alignment,Medicare Advantage,,929.91,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Alignment,Medicare Advantage,,5786.75,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Alignment,Medicare Advantage,,5786.75,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Alignment,Medicare Advantage,,5786.75,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Alignment,Medicare Advantage,,6188.83,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Alignment,Medicare Advantage,,1607.02,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Alignment,Medicare Advantage,,662.02,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Alignment,Medicare Advantage,,662.02,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Alignment,Medicare Advantage,,2031.79,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Alignment,Medicare Advantage,,3420.83,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Alignment,Medicare Advantage,,2031.79,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Alignment,Medicare Advantage,,2031.79,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Alignment,Medicare Advantage,,3420.83,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Alignment,Medicare Advantage,,3420.83,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Alignment,Medicare Advantage,,3420.83,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Alignment,Medicare Advantage,,17810.19,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Alignment,Medicare Advantage,,697.85,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Alignment,Medicare Advantage,,5655.00,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Alignment,Medicare Advantage,,5655.00,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Alignment,Medicare Advantage,,5655.00,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Alignment,Medicare Advantage,,2838.70,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Alignment,Medicare Advantage,,1540.76,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Alignment,Medicare Advantage,,1540.76,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Alignment,Medicare Advantage,,1540.76,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alignment,Medicare Advantage,,613.21,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alignment,Medicare Advantage,,1540.76,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Alignment,Medicare Advantage,,241.23,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Alignment,Medicare Advantage,,241.23,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Alignment,Medicare Advantage,,3420.83,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Alignment,Medicare Advantage,,3420.83,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Alignment,Medicare Advantage,,1607.02,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Alignment,Medicare Advantage,,6351.81,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Alignment,Medicare Advantage,,1540.76,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alignment,Medicare Advantage,,613.21,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alignment,Medicare Advantage,,1540.76,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Alignment,Medicare Advantage,,1009.09,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Alignment,Medicare Advantage,,783.61,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Alignment,Medicare Advantage,,105.47,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Alignment,Medicare Advantage,,105.47,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Alignment,Medicare Advantage,,105.47,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Alignment,Medicare Advantage,,105.47,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Alignment,Medicare Advantage,,239.75,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Alignment,Medicare Advantage,,105.47,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Alignment,Medicare Advantage,,105.47,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Alignment,Medicare Advantage,,105.47,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Alignment,Medicare Advantage,,239.75,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Alignment,Medicare Advantage,,105.47,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Alignment,Medicare Advantage,,105.47,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Alignment,Medicare Advantage,,105.47,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Alignment,Medicare Advantage,,105.47,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Alignment,Medicare Advantage,,87.33,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Alignment,Medicare Advantage,,87.33,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,105.47,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Alignment,Medicare Advantage,,87.33,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Alignment,Medicare Advantage,,87.33,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Alignment,Medicare Advantage,,105.47,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Alignment,Medicare Advantage,,1294.83,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Alignment,Medicare Advantage,,1446.69,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Alignment,Medicare Advantage,,1446.69,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Alignment,Medicare Advantage,,1446.69,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Alignment,Medicare Advantage,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Alignment,Medicare Advantage,,398.55,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Alignment,Medicare Advantage,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Alignment,Medicare Advantage,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Alignment,Medicare Advantage,,1446.69,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Alignment,Medicare Advantage,,1446.69,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Alignment,Medicare Advantage,,1446.69,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Alignment,Medicare Advantage,,1446.69,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Alignment,Medicare Advantage,,1446.69,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Alignment,Medicare Advantage,,2232.14,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Alignment,Medicare Advantage,,1934.58,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Alignment,Medicare Advantage,,239.75,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Alignment,Medicare Advantage,,543.83,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Alignment,Medicare Advantage,,543.83,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Alignment,Medicare Advantage,,783.61,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Alignment,Medicare Advantage,,783.61,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Alignment,Medicare Advantage,,783.61,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Alignment,Medicare Advantage,,87.33,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Alignment,Medicare Advantage,,354.22,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Alignment,Medicare Advantage,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Alignment,Medicare Advantage,,87.33,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Alignment,Medicare Advantage,,58.92,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Alignment,Medicare Advantage,,686.87,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Alignment,Medicare Advantage,,686.87,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Alignment,Medicare Advantage,,686.87,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Alignment,Medicare Advantage,,686.87,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Alignment,Medicare Advantage,,105.47,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Alignment,Medicare Advantage,,105.47,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alignment,Medicare Advantage,,239.75,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Alignment,Medicare Advantage,,105.47,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Alignment,Medicare Advantage,,239.75,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Alignment,Medicare Advantage,,105.47,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Alignment,Medicare Advantage,,10.56,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Alignment,Medicare Advantage,,47.81,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Alignment,Medicare Advantage,,8.68,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Alignment,Medicare Advantage,,47.63,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Alignment,Medicare Advantage,,8.17,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Alignment,Medicare Advantage,,163.96,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Alignment,Medicare Advantage,,144.84,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Alignment,Medicare Advantage,,556.60,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Alignment,Medicare Advantage,,291.36,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Alignment,Medicare Advantage,,1160.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Alignment,Medicare Advantage,,1160.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Alignment,Medicare Advantage,,65.69,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Alignment,Medicare Advantage,,73.37,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Alignment,Medicare Advantage,,57.04,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Alignment,Medicare Advantage,,44.89,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Alignment,Medicare Advantage,,165.51,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Alignment,Medicare Advantage,,101.12,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Alignment,Medicare Advantage,,35.00,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Alignment,Medicare Advantage,,65.36,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Alignment,Medicare Advantage,,197.99,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Alignment,Medicare Advantage,,172.73,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Alignment,Medicare Advantage,,233.07,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Alignment,Medicare Advantage,,233.07,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Alignment,Medicare Advantage,,2.25,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Alignment,Medicare Advantage,,348.56,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Alignment,Medicare Advantage,,51.07,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Alignment,Medicare Advantage,,43.65,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Alignment,Medicare Advantage,,201.50,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Alignment,Medicare Advantage,,234.00,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Alignment,Medicare Advantage,,402.12,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Alignment,Medicare Advantage,,403.59,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Alignment,Medicare Advantage,,127.43,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Alignment,Medicare Advantage,,74.33,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Alignment,Medicare Advantage,,94.74,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Alignment,Medicare Advantage,,345.57,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Alignment,Medicare Advantage,,335.38,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Alignment,Medicare Advantage,,177.25,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Alignment,Medicare Advantage,,169.90,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Alignment,Medicare Advantage,,123.68,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Alignment,Medicare Advantage,,246.52,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Alignment,Medicare Advantage,,124.64,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Alignment,Medicare Advantage,,300.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Alignment,Medicare Advantage,,193.25,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Alignment,Medicare Advantage,,295.79,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Alignment,Medicare Advantage,,16.77,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Alignment,Medicare Advantage,,5.04,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Alignment,Medicare Advantage,,8.74,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Alignment,Medicare Advantage,,9.66,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Alignment,Medicare Advantage,,7.52,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Alignment,Medicare Advantage,,4.31,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Alignment,Medicare Advantage,,62.14,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Alignment,Medicare Advantage,,8.46,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Alignment,Medicare Advantage,,7.01,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Alignment,Medicare Advantage,,13.39,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Alignment,Medicare Advantage,,62.14,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Alignment,Medicare Advantage,,62.14,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Alignment,Medicare Advantage,,62.14,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Alignment,Medicare Advantage,,62.14,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Alignment,Medicare Advantage,,62.14,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Alignment,Medicare Advantage,,15.08,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Alignment,Medicare Advantage,,15.08,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,15.08,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,14.57,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,13.28,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,13.54,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Alignment,Medicare Advantage,,16.38,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Alignment,Medicare Advantage,,16.38,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Alignment,Medicare Advantage,,16.38,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Alignment,Medicare Advantage,,14.69,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.61,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Alignment,Medicare Advantage,,15.30,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,13.25,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Alignment,Medicare Advantage,,13.76,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Alignment,Medicare Advantage,,13.73,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Alignment,Medicare Advantage,,13.73,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Alignment,Medicare Advantage,,14.14,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Alignment,Medicare Advantage,,16.13,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Alignment,Medicare Advantage,,16.13,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Alignment,Medicare Advantage,,16.13,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Alignment,Medicare Advantage,,13.54,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Alignment,Medicare Advantage,,13.54,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Alignment,Medicare Advantage,,13.54,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Alignment,Medicare Advantage,,32.62,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Alignment,Medicare Advantage,,4.52,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Alignment,Medicare Advantage,,8.17,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,8.17,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,4.95,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Alignment,Medicare Advantage,,7.78,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Alignment,Medicare Advantage,,5.78,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Alignment,Medicare Advantage,,5.78,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Alignment,Medicare Advantage,,17.27,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Alignment,Medicare Advantage,,13.44,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Alignment,Medicare Advantage,,16.77,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,14.57,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Alignment,Medicare Advantage,,6.48,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Alignment,Medicare Advantage,,6.48,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Alignment,Medicare Advantage,,6.48,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Alignment,Medicare Advantage,,16.18,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Alignment,Medicare Advantage,,5.02,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Alignment,Medicare Advantage,,5.02,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,5.02,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Alignment,Medicare Advantage,,4.38,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Alignment,Medicare Advantage,,5.32,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Alignment,Medicare Advantage,,4.23,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Alignment,Medicare Advantage,,29.60,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Alignment,Medicare Advantage,,5.16,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Alignment,Medicare Advantage,,5.16,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Alignment,Medicare Advantage,,6.03,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Alignment,Medicare Advantage,,4.88,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,12.32,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,12.32,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Alignment,Medicare Advantage,,18.96,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Alignment,Medicare Advantage,,10.74,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,14.12,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,14.12,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,4.60,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,5.75,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,5.75,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Alignment,Medicare Advantage,,5.00,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Alignment,Medicare Advantage,,4.35,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Alignment,Medicare Advantage,,38.57,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Alignment,Medicare Advantage,,27.11,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Alignment,Medicare Advantage,,27.11,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Alignment,Medicare Advantage,,18.64,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Alignment,Medicare Advantage,,16.30,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Alignment,Medicare Advantage,,13.73,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,6.51,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Alignment,Medicare Advantage,,11.55,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Alignment,Medicare Advantage,,5.12,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Alignment,Medicare Advantage,,27.94,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Alignment,Medicare Advantage,,14.90,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Alignment,Medicare Advantage,,5.10,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Alignment,Medicare Advantage,,13.63,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Alignment,Medicare Advantage,,64.41,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Alignment,Medicare Advantage,,14.70,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alignment,Medicare Advantage,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alignment,Medicare Advantage,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alignment,Medicare Advantage,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alignment,Medicare Advantage,,9.30,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Alignment,Medicare Advantage,,11.00,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Alignment,Medicare Advantage,,26.07,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alignment,Medicare Advantage,,78.77,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alignment,Medicare Advantage,,78.77,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alignment,Medicare Advantage,,78.77,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alignment,Medicare Advantage,,78.77,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,9.77,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Alignment,Medicare Advantage,,3.93,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Alignment,Medicare Advantage,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Alignment,Medicare Advantage,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Alignment,Medicare Advantage,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Alignment,Medicare Advantage,,3.93,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Alignment,Medicare Advantage,,4.75,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Alignment,Medicare Advantage,,12.87,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Alignment,Medicare Advantage,,3.92,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Alignment,Medicare Advantage,,3.92,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Alignment,Medicare Advantage,,7.20,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Alignment,Medicare Advantage,,18.58,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Alignment,Medicare Advantage,,18.52,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Alignment,Medicare Advantage,,12.58,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Alignment,Medicare Advantage,,12.87,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Alignment,Medicare Advantage,,18.06,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Alignment,Medicare Advantage,,8.00,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,9.71,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Alignment,Medicare Advantage,,8.20,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Alignment,Medicare Advantage,,8.20,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Alignment,Medicare Advantage,,4.75,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Alignment,Medicare Advantage,,17.92,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Alignment,Medicare Advantage,,25.45,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Alignment,Medicare Advantage,,11.53,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Alignment,Medicare Advantage,,11.53,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Alignment,Medicare Advantage,,11.43,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.47,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,11.57,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Alignment,Medicare Advantage,,6.04,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Alignment,Medicare Advantage,,6.04,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,19.70,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Alignment,Medicare Advantage,,19.32,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Alignment,Medicare Advantage,,6.89,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Alignment,Medicare Advantage,,6.89,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Alignment,Medicare Advantage,,8.19,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Alignment,Medicare Advantage,,10.50,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,6.70,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,6.70,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Alignment,Medicare Advantage,,6.70,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Alignment,Medicare Advantage,,12.92,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Alignment,Medicare Advantage,,39.26,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Alignment,Medicare Advantage,,17.27,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,17.27,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Alignment,Medicare Advantage,,6.61,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,6.82,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Alignment,Medicare Advantage,,41.28,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Alignment,Medicare Advantage,,41.28,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Alignment,Medicare Advantage,,3.58,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Alignment,Medicare Advantage,,3.58,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Alignment,Medicare Advantage,,3.58,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,4.74,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Alignment,Medicare Advantage,,5.78,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Alignment,Medicare Advantage,,5.78,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Alignment,Medicare Advantage,,98.11,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Alignment,Medicare Advantage,,4.76,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,4.73,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,4.73,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,4.73,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,14.59,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Alignment,Medicare Advantage,,20.86,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Alignment,Medicare Advantage,,19.38,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Alignment,Medicare Advantage,,18.39,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Alignment,Medicare Advantage,,18.39,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Alignment,Medicare Advantage,,3.67,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,3.67,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,3.67,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Alignment,Medicare Advantage,,4.00,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Alignment,Medicare Advantage,,10.74,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Alignment,Medicare Advantage,,17.83,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Alignment,Medicare Advantage,,17.83,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Alignment,Medicare Advantage,,4.81,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Alignment,Medicare Advantage,,5.06,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Alignment,Medicare Advantage,,5.06,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Alignment,Medicare Advantage,,4.86,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Alignment,Medicare Advantage,,3.28,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Alignment,Medicare Advantage,,25.81,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Alignment,Medicare Advantage,,6.87,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Alignment,Medicare Advantage,,9.02,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Alignment,Medicare Advantage,,16.80,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Alignment,Medicare Advantage,,5.30,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Alignment,Medicare Advantage,,12.76,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Alignment,Medicare Advantage,,5.74,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Alignment,Medicare Advantage,,14.18,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Alignment,Medicare Advantage,,16.94,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Alignment,Medicare Advantage,,12.47,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,3.95,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Alignment,Medicare Advantage,,5.56,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,4.52,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Alignment,Medicare Advantage,,5.08,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Alignment,Medicare Advantage,,5.08,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Alignment,Medicare Advantage,,62.14,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Alignment,Medicare Advantage,,62.14,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,15.05,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Alignment,Medicare Advantage,,7.87,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Alignment,Medicare Advantage,,5.22,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Alignment,Medicare Advantage,,15.05,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Alignment,Medicare Advantage,,15.05,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Alignment,Medicare Advantage,,18.37,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Alignment,Medicare Advantage,,11.16,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Alignment,Medicare Advantage,,12.95,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Alignment,Medicare Advantage,,25.45,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,25.45,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,25.45,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Alignment,Medicare Advantage,,12.00,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Alignment,Medicare Advantage,,13.74,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Alignment,Medicare Advantage,,13.74,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Alignment,Medicare Advantage,,17.93,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Alignment,Medicare Advantage,,17.93,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Alignment,Medicare Advantage,,12.05,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Alignment,Medicare Advantage,,12.05,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Alignment,Medicare Advantage,,20.81,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Alignment,Medicare Advantage,,20.81,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Alignment,Medicare Advantage,,29.92,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Alignment,Medicare Advantage,,22.34,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Alignment,Medicare Advantage,,29.35,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Alignment,Medicare Advantage,,37.73,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Alignment,Medicare Advantage,,26.78,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,26.78,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,356.78,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Alignment,Medicare Advantage,,37.73,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Alignment,Medicare Advantage,,37.73,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Alignment,Medicare Advantage,,46.98,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Alignment,Medicare Advantage,,77.78,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Alignment,Medicare Advantage,,14.55,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Alignment,Medicare Advantage,,11.54,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Alignment,Medicare Advantage,,11.54,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Alignment,Medicare Advantage,,10.64,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Alignment,Medicare Advantage,,5.67,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Alignment,Medicare Advantage,,61.98,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Alignment,Medicare Advantage,,24.29,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Alignment,Medicare Advantage,,4.40,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Alignment,Medicare Advantage,,4.40,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Alignment,Medicare Advantage,,17.03,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Alignment,Medicare Advantage,,14.39,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Alignment,Medicare Advantage,,16.85,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Alignment,Medicare Advantage,,15.29,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Alignment,Medicare Advantage,,18.14,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Alignment,Medicare Advantage,,18.14,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,10.18,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Alignment,Medicare Advantage,,10.18,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Alignment,Medicare Advantage,,16.85,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Alignment,Medicare Advantage,,16.85,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Alignment,Medicare Advantage,,9.09,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Alignment,Medicare Advantage,,13.19,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Alignment,Medicare Advantage,,19.35,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Alignment,Medicare Advantage,,8.89,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Alignment,Medicare Advantage,,13.71,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Alignment,Medicare Advantage,,11.77,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Alignment,Medicare Advantage,,10.74,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,12.39,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Alignment,Medicare Advantage,,11.26,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Alignment,Medicare Advantage,,12.39,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Alignment,Medicare Advantage,,19.35,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,19.35,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Alignment,Medicare Advantage,,12.88,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Alignment,Medicare Advantage,,14.39,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Alignment,Medicare Advantage,,14.41,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,13.24,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Alignment,Medicare Advantage,,12.88,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,14.27,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Alignment,Medicare Advantage,,109.49,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Alignment,Medicare Advantage,,64.19,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Alignment,Medicare Advantage,,64.19,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Alignment,Medicare Advantage,,323.75,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Alignment,Medicare Advantage,,325.80,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alignment,Medicare Advantage,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Alignment,Medicare Advantage,,169.96,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Alignment,Medicare Advantage,,356.78,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Alignment,Medicare Advantage,,5.39,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Alignment,Medicare Advantage,,5.39,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Alignment,Medicare Advantage,,5.39,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Alignment,Medicare Advantage,,2.99,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,2.99,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Alignment,Medicare Advantage,,6.35,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Alignment,Medicare Advantage,,6.35,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Alignment,Medicare Advantage,,3.83,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Alignment,Medicare Advantage,,169.96,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,169.96,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Alignment,Medicare Advantage,,58.92,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Alignment,Medicare Advantage,,58.92,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Alignment,Medicare Advantage,,24.29,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Alignment,Medicare Advantage,,13.91,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Alignment,Medicare Advantage,,3.80,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,2.37,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,2.37,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Alignment,Medicare Advantage,,7.77,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,6.47,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,3.99,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Alignment,Medicare Advantage,,5.57,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Alignment,Medicare Advantage,,2.54,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,4.48,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Alignment,Medicare Advantage,,810.23,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Alignment,Medicare Advantage,,810.23,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Alignment,Medicare Advantage,,12.98,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Alignment,Medicare Advantage,,17.65,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Alignment,Medicare Advantage,,17.90,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Alignment,Medicare Advantage,,17.90,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Alignment,Medicare Advantage,,11.89,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Alignment,Medicare Advantage,,22.94,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,22.94,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Alignment,Medicare Advantage,,22.94,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Alignment,Medicare Advantage,,30.86,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Alignment,Medicare Advantage,,22.94,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Alignment,Medicare Advantage,,19.04,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Alignment,Medicare Advantage,,17.90,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Alignment,Medicare Advantage,,17.90,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Alignment,Medicare Advantage,,19.35,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Alignment,Medicare Advantage,,9.11,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Alignment,Medicare Advantage,,18.93,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Alignment,Medicare Advantage,,18.93,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Alignment,Medicare Advantage,,11.85,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Alignment,Medicare Advantage,,13.84,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Alignment,Medicare Advantage,,15.32,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Alignment,Medicare Advantage,,30.86,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Alignment,Medicare Advantage,,15.32,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Alignment,Medicare Advantage,,12.87,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Alignment,Medicare Advantage,,12.87,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Alignment,Medicare Advantage,,12.87,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Alignment,Medicare Advantage,,4.28,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Alignment,Medicare Advantage,,6.89,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Alignment,Medicare Advantage,,10.18,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Alignment,Medicare Advantage,,9.72,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Alignment,Medicare Advantage,,17.19,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,9.36,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Alignment,Medicare Advantage,,13.09,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Alignment,Medicare Advantage,,13.09,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Alignment,Medicare Advantage,,24.91,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Alignment,Medicare Advantage,,24.91,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Alignment,Medicare Advantage,,17.98,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Alignment,Medicare Advantage,,17.98,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Alignment,Medicare Advantage,,4.29,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Alignment,Medicare Advantage,,3.94,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Alignment,Medicare Advantage,,9.58,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Alignment,Medicare Advantage,,9.58,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Alignment,Medicare Advantage,,17.98,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Alignment,Medicare Advantage,,9.85,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Alignment,Medicare Advantage,,18.64,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,5.51,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Alignment,Medicare Advantage,,5.77,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Alignment,Medicare Advantage,,5.77,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,6.01,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,6.01,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Alignment,Medicare Advantage,,6.47,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Alignment,Medicare Advantage,,6.47,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Alignment,Medicare Advantage,,11.67,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,6.68,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Alignment,Medicare Advantage,,10.32,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Alignment,Medicare Advantage,,10.32,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Alignment,Medicare Advantage,,9.44,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,9.44,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Alignment,Medicare Advantage,,9.44,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Alignment,Medicare Advantage,,8.62,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Alignment,Medicare Advantage,,9.89,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Alignment,Medicare Advantage,,9.47,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Alignment,Medicare Advantage,,9.47,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Alignment,Medicare Advantage,,9.47,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Alignment,Medicare Advantage,,8.08,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Alignment,Medicare Advantage,,8.08,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Alignment,Medicare Advantage,,8.08,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,8.08,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Alignment,Medicare Advantage,,6.63,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Alignment,Medicare Advantage,,6.63,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Alignment,Medicare Advantage,,8.07,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Alignment,Medicare Advantage,,7.71,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.41,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Alignment,Medicare Advantage,,10.32,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,10.32,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Alignment,Medicare Advantage,,115.36,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Alignment,Medicare Advantage,,4.31,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,5.88,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Alignment,Medicare Advantage,,8.90,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Alignment,Medicare Advantage,,4.75,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Alignment,Medicare Advantage,,7.48,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Alignment,Medicare Advantage,,4.75,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alignment,Medicare Advantage,,8.65,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alignment,Medicare Advantage,,8.65,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alignment,Medicare Advantage,,8.65,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alignment,Medicare Advantage,,8.65,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Alignment,Medicare Advantage,,8.65,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,5.39,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Alignment,Medicare Advantage,,5.39,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,5.39,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Alignment,Medicare Advantage,,5.99,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Alignment,Medicare Advantage,,17.98,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Alignment,Medicare Advantage,,5.82,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,5.82,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Alignment,Medicare Advantage,,11.98,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Alignment,Medicare Advantage,,11.98,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,11.98,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Alignment,Medicare Advantage,,11.98,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Alignment,Medicare Advantage,,13.82,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Alignment,Medicare Advantage,,10.33,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Alignment,Medicare Advantage,,10.33,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,24.08,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Alignment,Medicare Advantage,,24.08,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Alignment,Medicare Advantage,,11.98,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Alignment,Medicare Advantage,,11.98,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Alignment,Medicare Advantage,,11.98,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Alignment,Medicare Advantage,,37.27,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Alignment,Medicare Advantage,,42.84,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Alignment,Medicare Advantage,,42.84,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Alignment,Medicare Advantage,,42.84,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Alignment,Medicare Advantage,,35.09,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Alignment,Medicare Advantage,,85.10,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Alignment,Medicare Advantage,,35.09,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Alignment,Medicare Advantage,,35.09,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Alignment,Medicare Advantage,,95.80,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Alignment,Medicare Advantage,,142.63,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Alignment,Medicare Advantage,,416.78,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Alignment,Medicare Advantage,,35.09,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Alignment,Medicare Advantage,,35.09,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Alignment,Medicare Advantage,,35.09,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,35.09,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Alignment,Medicare Advantage,,35.09,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Alignment,Medicare Advantage,,42.84,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Alignment,Medicare Advantage,,262.99,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Alignment,Medicare Advantage,,15.29,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Alignment,Medicare Advantage,,16.53,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Alignment,Medicare Advantage,,16.07,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Alignment,Medicare Advantage,,16.07,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Alignment,Medicare Advantage,,16.07,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Alignment,Medicare Advantage,,257.45,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Alignment,Medicare Advantage,,257.45,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Alignment,Medicare Advantage,,3.17,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Alignment,Medicare Advantage,,3.17,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,3.48,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,3.48,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Alignment,Medicare Advantage,,3.48,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Alignment,Medicare Advantage,,8.61,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Alignment,Medicare Advantage,,169.96,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Alignment,Medicare Advantage,,5.60,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,7.33,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Alignment,Medicare Advantage,,5.79,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Alignment,Medicare Advantage,,91.66,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Alignment,Medicare Advantage,,18.05,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Alignment,Medicare Advantage,,24.18,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Alignment,Medicare Advantage,,12.39,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Alignment,Medicare Advantage,,4.72,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Alignment,Medicare Advantage,,13.25,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,16.46,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Alignment,Medicare Advantage,,11.53,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Alignment,Medicare Advantage,,5.22,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Alignment,Medicare Advantage,,17.93,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Alignment,Medicare Advantage,,4.27,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Alignment,Medicare Advantage,,13.05,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Alignment,Medicare Advantage,,12.88,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Alignment,Medicare Advantage,,5.18,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Alignment,Medicare Advantage,,14.38,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Alignment,Medicare Advantage,,8.08,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Alignment,Medicare Advantage,,8.08,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Alignment,Medicare Advantage,,13.61,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Alignment,Medicare Advantage,,8.61,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Alignment,Medicare Advantage,,13.19,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,6.68,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Alignment,Medicare Advantage,,5.18,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Alignment,Medicare Advantage,,13.39,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Alignment,Medicare Advantage,,4.75,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Alignment,Medicare Advantage,,4.75,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Alignment,Medicare Advantage,,12.87,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Alignment,Medicare Advantage,,4.29,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,6.14,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Alignment,Medicare Advantage,,13.24,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Alignment,Medicare Advantage,,6.63,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Alignment,Medicare Advantage,,169.96,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Alignment,Medicare Advantage,,169.96,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Alignment,Medicare Advantage,,123.68,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Alignment,Medicare Advantage,,14.61,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,15.05,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Alignment,Medicare Advantage,,7.31,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Alignment,Medicare Advantage,,25.81,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Alignment,Medicare Advantage,,759.53,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,35.09,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,15.92,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Alignment,Medicare Advantage,,5.50,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Alignment,Medicare Advantage,,27.22,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Alignment,Medicare Advantage,,2.70,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Alignment,Medicare Advantage,,11.98,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Alignment,Medicare Advantage,,16.55,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Alignment,Medicare Advantage,,16.55,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Alignment,Medicare Advantage,,9.09,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Alignment,Medicare Advantage,,9.09,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Alignment,Medicare Advantage,,9.09,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Alignment,Medicare Advantage,,35.09,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Alignment,Medicare Advantage,,121.63,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Alignment,Medicare Advantage,,185.20,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Alignment,Medicare Advantage,,83.00,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Alignment,Medicare Advantage,,641.85,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Alignment,Medicare Advantage,,1824.88,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Alignment,Medicare Advantage,,375.25,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Alignment,Medicare Advantage,,9.09,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Alignment,Medicare Advantage,,11.15,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Alignment,Medicare Advantage,,6.47,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Alignment,Medicare Advantage,,5.51,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Alignment,Medicare Advantage,,18.52,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,26.78,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Alignment,Medicare Advantage,,185.20,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,20.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Alignment,Medicare Advantage,,35.09,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Alignment,Medicare Advantage,,137.00,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Alignment,Medicare Advantage,,759.53,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Alignment,Medicare Advantage,,218.06,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,35.09,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Alignment,Medicare Advantage,,70.20,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Alignment,Medicare Advantage,,121.63,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Alignment,Medicare Advantage,,185.20,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Alignment,Medicare Advantage,,24.91,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Alignment,Medicare Advantage,QW,24.91,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Alignment,Medicare Advantage,,14.38,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Alignment,Medicare Advantage,,62.14,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Alignment,Medicare Advantage,,1160.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Alignment,Medicare Advantage,,416.78,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Alignment,Medicare Advantage,,91.66,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,20.81,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Alignment,Medicare Advantage,,233.07,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Alignment,Medicare Advantage,,41.76,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Alignment,Medicare Advantage,,42.84,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Alignment,Medicare Advantage,,16.07,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Alignment,Medicare Advantage,,5.22,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Alignment,Medicare Advantage,,29.21,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Alignment,Medicare Advantage,QW,51.31,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Alignment,Medicare Advantage,,42.13,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Alignment,Medicare Advantage,,17.27,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Alignment,Medicare Advantage,,416.78,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Alignment,Medicare Advantage,,142.63,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Alignment,Medicare Advantage,,10.32,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Alignment,Medicare Advantage,,18.64,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Alignment,Medicare Advantage,,18.64,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Alignment,Medicare Advantage,,27.11,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Alignment,Medicare Advantage,,38.57,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Alignment,Medicare Advantage,,8.65,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Alignment,Medicare Advantage,,142.63,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Alignment,Medicare Advantage,,39.26,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Alignment,Medicare Advantage,,21.73,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Alignment,Medicare Advantage,,20.81,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Alignment,Medicare Advantage,,137.00,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Alignment,Medicare Advantage,,12.00,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Alignment,Medicare Advantage,,12.00,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Alignment,Medicare Advantage,,20.32,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Alignment,Medicare Advantage,,11.53,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,17.27,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Alignment,Medicare Advantage,,22.34,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Alignment,Medicare Advantage,,29.35,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Alignment,Medicare Advantage,,27.39,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Alignment,Medicare Advantage,,128.29,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Alignment,Medicare Advantage,,11.53,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Alignment,Medicare Advantage,,51.31,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,35.09,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Alignment,Medicare Advantage,,35.09,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,9.71,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Alignment,Medicare Advantage,,11.57,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Alignment,Medicare Advantage,,2.25,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Alignment,Medicare Advantage,,35.09,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Alignment,Medicare Advantage,,35.09,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Alignment,Medicare Advantage,,137.00,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Alignment,Medicare Advantage,,8.62,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Alignment,Medicare Advantage,,262.99,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Alignment,Medicare Advantage,,70.20,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Alignment,Medicare Advantage,,52.99,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Alignment,Medicare Advantage,,2.37,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Alignment,Medicare Advantage,,38.93,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Alignment,Medicare Advantage,,38.93,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Alignment,Medicare Advantage,,52.99,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Alignment,Medicare Advantage,,52.99,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Alignment,Medicare Advantage,,20.26,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Alignment,Medicare Advantage,,24.29,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Alignment,Medicare Advantage,,169.96,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Alignment,Medicare Advantage,,52.99,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,26.61,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Alignment,Medicare Advantage,,26.61,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Alignment,Medicare Advantage,,26.61,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Alignment,Medicare Advantage,,356.78,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Alignment,Medicare Advantage,,356.78,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Alignment,Medicare Advantage,,116.49,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Alignment,Medicare Advantage,,116.49,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Alignment,Medicare Advantage,,140.73,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Alignment,Medicare Advantage,,150.30,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Alignment,Medicare Advantage,,150.30,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Alignment,Medicare Advantage,,143.75,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Alignment,Medicare Advantage,,13.07,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Alignment,Medicare Advantage,,264.34,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Alignment,Medicare Advantage,,125.49,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Alignment,Medicare Advantage,,144.61,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Alignment,Medicare Advantage,,188.57,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Alignment,Medicare Advantage,,21.42,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alignment,Medicare Advantage,,21.42,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Alignment,Medicare Advantage,,34.81,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Alignment,Medicare Advantage,,42.38,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Alignment,Medicare Advantage,,51.19,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Alignment,Medicare Advantage,,33.47,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Alignment,Medicare Advantage,,68.60,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Alignment,Medicare Advantage,,26.91,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Alignment,Medicare Advantage,,52.99,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Alignment,Medicare Advantage,,38.93,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Alignment,Medicare Advantage,,24.29,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Alignment,Medicare Advantage,,38.93,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Alignment,Medicare Advantage,,52.99,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Alignment,Medicare Advantage,,52.99,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Alignment,Medicare Advantage,,52.99,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Alignment,Medicare Advantage,,356.78,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Alignment,Medicare Advantage,,810.23,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Alignment,Medicare Advantage,,127.85,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Alignment,Medicare Advantage,,810.23,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Alignment,Medicare Advantage,,52.99,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Alignment,Medicare Advantage,,169.96,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Alignment,Medicare Advantage,,810.23,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Alignment,Medicare Advantage,,169.96,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Alignment,Medicare Advantage,,12.05,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Alignment,Medicare Advantage,,169.96,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Alignment,Medicare Advantage,,169.96,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Alignment,Medicare Advantage,,169.96,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Alignment,Medicare Advantage,,169.96,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Alignment,Medicare Advantage,,102.26,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Alignment,Medicare Advantage,,5.02,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Alignment,Medicare Advantage,,169.96,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Alignment,Medicare Advantage,,143.75,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Alignment,Medicare Advantage,,140.73,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Alignment,Medicare Advantage,,143.75,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Alignment,Medicare Advantage,,51.19,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Alignment,Medicare Advantage,,144.61,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Alignment,Medicare Advantage,,356.78,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Alignment,Medicare Advantage,,169.96,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Alignment,Medicare Advantage,,51.19,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alignment,Medicare Advantage,,21.42,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Alignment,Medicare Advantage,,169.96,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Alignment,Medicare Advantage,,52.99,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Alignment,Medicare Advantage,,127.85,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Alignment,Medicare Advantage,,356.78,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Alignment,Medicare Advantage,,51.19,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alignment,Medicare Advantage,,21.42,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Alignment,Medicare Advantage,,169.96,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Alignment,Medicare Advantage,,169.96,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Alignment,Medicare Advantage,,169.96,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Alignment,Medicare Advantage,,21.42,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Alignment,Medicare Advantage,,21.42,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Alignment,Medicare Advantage,,21.42,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Alignment,Medicare Advantage,,51.19,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alignment,Medicare Advantage,,21.42,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Alignment,Medicare Advantage,,42.38,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Alignment,Medicare Advantage,,169.96,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Alignment,Medicare Advantage,,169.96,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,169.96,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Alignment,Medicare Advantage,,38.93,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Alignment,Medicare Advantage,,169.96,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Alignment,Medicare Advantage,,180.51,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Alignment,Medicare Advantage,,180.51,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Alignment,Medicare Advantage,,180.51,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Alignment,Medicare Advantage,,180.51,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Alignment,Medicare Advantage,,83.60,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Alignment,Medicare Advantage,,83.60,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Alignment,Medicare Advantage,,83.60,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Alignment,Medicare Advantage,,143.14,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Alignment,Medicare Advantage,,393.63,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alignment,Medicare Advantage,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Alignment,Medicare Advantage,,670.15,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Alignment,Medicare Advantage,,648.41,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Alignment,Medicare Advantage,,253.71,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Alignment,Medicare Advantage,,146.10,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Alignment,Medicare Advantage,,771.15,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Alignment,Medicare Advantage,,240.46,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Alignment,Medicare Advantage,,70.51,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Alignment,Medicare Advantage,,582.49,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Alignment,Medicare Advantage,,2.99,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alignment,Medicare Advantage,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alignment,Medicare Advantage,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alignment,Medicare Advantage,,9.77,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alignment,Medicare Advantage,,5.72,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alignment,Medicare Advantage,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alignment,Medicare Advantage,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alignment,Medicare Advantage,,670.15,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alignment,Medicare Advantage,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alignment,Medicare Advantage,,5361.59,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alignment,Medicare Advantage,,8208.45,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alignment,Medicare Advantage,,8208.45,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Alignment,Medicare Advantage,,5361.59,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Alignment,Medicare Advantage,,5361.59,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alignment,Medicare Advantage,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Alignment,Medicare Advantage,,5655.00,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Alignment,Medicare Advantage,,5655.00,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Alignment,Medicare Advantage,,5655.00,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Alignment,Medicare Advantage,,5655.00,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Alignment,Medicare Advantage,,17810.19,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Alignment,Medicare Advantage,,17810.19,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Alignment,Medicare Advantage,,11248.03,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Alignment,Medicare Advantage,,17810.19,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Alignment,Medicare Advantage,,17810.19,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Alignment,Medicare Advantage,,11248.03,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Alignment,Medicare Advantage,,17810.19,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Alignment,Medicare Advantage,,17810.19,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Alignment,Medicare Advantage,,17810.19,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Alignment,Medicare Advantage,,17810.19,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Alignment,Medicare Advantage,,17810.19,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Alignment,Medicare Advantage,,17810.19,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Alignment,Medicare Advantage,,11248.03,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Alignment,Medicare Advantage,,11248.03,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Alignment,Medicare Advantage,,649.04,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Alignment,Medicare Advantage,,649.04,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Alignment,Medicare Advantage,,328.98,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Alignment,Medicare Advantage,,5655.00,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Alignment,Medicare Advantage,,11248.03,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Alignment,Medicare Advantage,,3190.16,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Alignment,Medicare Advantage,,3190.16,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Alignment,Medicare Advantage,,3190.16,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Alignment,Medicare Advantage,,3190.16,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Alignment,Medicare Advantage,,3190.16,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Alignment,Medicare Advantage,,3190.16,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Alignment,Medicare Advantage,,3190.16,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Alignment,Medicare Advantage,,3190.16,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Alignment,Medicare Advantage,,3190.16,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Alignment,Medicare Advantage,,3190.16,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Alignment,Medicare Advantage,,3190.16,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Alignment,Medicare Advantage,,1540.76,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Alignment,Medicare Advantage,,17810.19,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Alignment,Medicare Advantage,,7526.18,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Alignment,Medicare Advantage,,17810.19,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Alignment,Medicare Advantage,,17810.19,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Alignment,Medicare Advantage,,10379.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Alignment,Medicare Advantage,,10379.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Alignment,Medicare Advantage,,10379.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Alignment,Medicare Advantage,,8208.45,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Alignment,Medicare Advantage,,10379.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Alignment,Medicare Advantage,,10379.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Alignment,Medicare Advantage,,3121.82,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Alignment,Medicare Advantage,,8208.45,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Alignment,Medicare Advantage,,8208.45,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Alignment,Medicare Advantage,,3609.60,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Alignment,Medicare Advantage,,3609.60,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Alignment,Medicare Advantage,,1814.30,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Alignment,Medicare Advantage,,1814.30,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Alignment,Medicare Advantage,,10379.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Alignment,Medicare Advantage,,3121.82,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Alignment,Medicare Advantage,,8208.45,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Alignment,Medicare Advantage,,10379.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Alignment,Medicare Advantage,,18915.54,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Alignment,Medicare Advantage,,8208.45,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Alignment,Medicare Advantage,,3609.60,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Alignment,Medicare Advantage,,3609.60,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Alignment,Medicare Advantage,,22263.03,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Alignment,Medicare Advantage,,3609.60,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Alignment,Medicare Advantage,,3609.60,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Alignment,Medicare Advantage,,31799.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Alignment,Medicare Advantage,,8208.45,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Alignment,Medicare Advantage,,697.85,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Alignment,Medicare Advantage,,7526.18,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Alignment,Medicare Advantage,,7526.18,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Alignment,Medicare Advantage,,1204.08,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Alignment,Medicare Advantage,,7526.18,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Alignment,Medicare Advantage,,7526.18,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Alignment,Medicare Advantage,,1204.08,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Alignment,Medicare Advantage,,7526.18,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Alignment,Medicare Advantage,,7526.18,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Alignment,Medicare Advantage,,1204.08,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Alignment,Medicare Advantage,,7526.18,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Alignment,Medicare Advantage,,526.27,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Alignment,Medicare Advantage,,18915.54,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Alignment,Medicare Advantage,,31799.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Alignment,Medicare Advantage,,22263.03,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Alignment,Medicare Advantage,,22263.03,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Alignment,Medicare Advantage,,31799.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Alignment,Medicare Advantage,,28196.35,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Alignment,Medicare Advantage,,395.78,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Alignment,Medicare Advantage,,155.18,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Alignment,Medicare Advantage,,3121.82,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Alignment,Medicare Advantage,,1540.76,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Alignment,Medicare Advantage,,17810.19,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Alignment,Medicare Advantage,,17810.19,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Alignment,Medicare Advantage,,17810.19,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Alignment,Medicare Advantage,,31799.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Alignment,Medicare Advantage,,11248.03,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Alignment,Medicare Advantage,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Alignment,Medicare Advantage,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Alignment,Medicare Advantage,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Alignment,Medicare Advantage,,3190.16,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Alignment,Medicare Advantage,,3190.16,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Alignment,Medicare Advantage,,24332.12,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Alignment,Medicare Advantage,,24332.12,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Alignment,Medicare Advantage,,24332.12,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Alignment,Medicare Advantage,,5655.00,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Alignment,Medicare Advantage,,613.21,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Alignment,Medicare Advantage,,31799.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Alignment,Medicare Advantage,,5655.00,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Alignment,Medicare Advantage,,105.47,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Alignment,Medicare Advantage,,18915.54,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Alignment,Medicare Advantage,,308.86,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Alignment,Medicare Advantage,,543.83,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Alignment,Medicare Advantage,,543.83,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Alignment,Medicare Advantage,,239.75,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Alignment,Medicare Advantage,,239.75,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Alignment,Medicare Advantage,,239.75,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Alignment,Medicare Advantage,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Alignment,Medicare Advantage,,36.99,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Alignment,Medicare Advantage,,127.85,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Alignment,Medicare Advantage,,58.92,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Alignment,Medicare Advantage,,91.04,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Alignment,Medicare Advantage,,239.75,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Alignment,Medicare Advantage,,124.88,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Alignment,Medicare Advantage,,124.88,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Alignment,Medicare Advantage,,58.92,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Alignment,Medicare Advantage,,58.92,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Alignment,Medicare Advantage,,3656.86,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Alignment,Medicare Advantage,,3121.82,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Alignment,Medicare Advantage,,7085.44,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Alignment,Medicare Advantage,,697.85,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Alignment,Medicare Advantage,,8208.45,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Alignment,Medicare Advantage,,3609.60,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Alignment,Medicare Advantage,,3609.60,,,,,,,422.62,17457.00,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Alliance,Medicaid,,542.68,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Alliance,Medicaid,,542.68,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Alliance,Medicaid,,0.02803,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Alliance,Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Alliance,Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Alliance,Medicaid,,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Alliance,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Alliance,Medicaid,,4.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Alliance,Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Alliance,Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Alliance,Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Alliance,Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Alliance,Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Alliance,Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Alliance,Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Alliance,Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Alliance,Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Alliance,Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Alliance,Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Alliance,Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Alliance,Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Alliance,Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Alliance,Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Alliance,Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Alliance,Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Alliance,Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Alliance,Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Alliance,Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Alliance,Medicaid,,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Alliance,Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Alliance,Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Alliance,Medicaid,,6.26,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Alliance,Medicaid,,4.07,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Alliance,Medicaid,,55.85,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Alliance,Medicaid,,4.33,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Alliance,Medicaid,,0.00601,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Alliance,Medicaid,,4.29,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Alliance,Medicaid,,8.13,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Alliance,Medicaid,,4.08,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Alliance,Medicaid,,3.98,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Alliance,Medicaid,,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Alliance,Medicaid,,13.07,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Alliance,Medicaid,,35.68,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Alliance,Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Alliance,Medicaid,,1.27,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Alliance,Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Alliance,Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Alliance,Medicaid,,40.04,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Alliance,Medicaid,,5.94,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Alliance,Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Alliance,Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Alliance,Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Alliance,Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Alliance,Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Alliance,Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Alliance,Medicaid,,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Alliance,Medicaid,,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Alliance,Medicaid,,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Alliance,Medicaid,,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Alliance,Medicaid,,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Alliance,Medicaid,,93.29,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Alliance,Medicaid,,5.50,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Alliance,Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Alliance,Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Alliance,Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Alliance,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Alliance,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Alliance,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Alliance,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Alliance,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Alliance,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Alliance,Medicaid,,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Alliance,Medicaid,,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Alliance,Medicaid,,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Alliance,Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Alliance,Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Alliance,Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Alliance,Medicaid,,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Alliance,Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Alliance,Medicaid,,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Alliance,Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Alliance,Medicaid,,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Alliance,Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Alliance,Medicaid,,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Alliance,Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Alliance,Medicaid,,54.45,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Alliance,Medicaid,,43.28,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Alliance,Medicaid,,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Alliance,Medicaid,,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Alliance,Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Alliance,Medicaid,,30.79,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Alliance,Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Alliance,Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Alliance,Medicaid,,174.60,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Alliance,Medicaid,,214.26,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Alliance,Medicaid,,0.43644,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Alliance,Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Alliance,Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Alliance,Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Alliance,Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Alliance,Medicaid,,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Alliance,Medicaid,,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Alliance,Medicaid,,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Alliance,Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Alliance,Medicaid,,0.62062,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Alliance,Medicaid,,1.97,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Alliance,Medicaid,,38.56,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Alliance,Medicaid,,13.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Alliance,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Alliance,Medicaid,,47.59,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Alliance,Medicaid,,54.83,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Alliance,Medicaid,,31.77,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Alliance,Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Alliance,Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Alliance,Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Alliance,Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Alliance,Medicaid,,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Alliance,Medicaid,,66.15,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Alliance,Medicaid,,65.92,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Alliance,Medicaid,,30.66,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Alliance,Medicaid,,31.80,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Alliance,Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Alliance,Medicaid,,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Alliance,Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Alliance,Medicaid,,0.02402,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Alliance,Medicaid,,0.05405,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Alliance,Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Alliance,Medicaid,,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Alliance,Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Alliance,Medicaid,,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Alliance,Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Alliance,Medicaid,,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Alliance,Medicaid,,64.52,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Alliance,Medicaid,,16.24,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Alliance,Medicaid,,10.71,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Alliance,Medicaid,,25.23,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Alliance,Medicaid,,6.18,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Alliance,Medicaid,,3.33,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Alliance,Medicaid,,23.38,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Alliance,Medicaid,,6.74,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Alliance,Medicaid,,19.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Alliance,Medicaid,,55.06,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Alliance,Medicaid,,8.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Alliance,Medicaid,,10.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Alliance,Medicaid,,33.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Alliance,Medicaid,,25.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Alliance,Medicaid,,30.87,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Alliance,Medicaid,,29.30,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Alliance,Medicaid,,5.23,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Alliance,Medicaid,,5.72,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Alliance,Medicaid,,13.62,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Alliance,Medicaid,,28.18,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Alliance,Medicaid,,0.10210,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Alliance,Medicaid,,5.25,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Alliance,Medicaid,,1.19,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Alliance,Medicaid,,2.11,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Alliance,Medicaid,,0.02202,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Alliance,Medicaid,,0.16016,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Alliance,Medicaid,,1.55,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Alliance,Medicaid,,0.15816,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Alliance,Medicaid,,0.09409,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Alliance,Medicaid,,0.12813,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Alliance,Medicaid,,333.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Alliance,Medicaid,,0.00400,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Alliance,Medicaid,,0.01802,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Alliance,Medicaid,,0.51451,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Alliance,Medicaid,,5.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Alliance,Medicaid,,16.31,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Alliance,Medicaid,,0.01401,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Alliance,Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Alliance,Medicaid,,1.23,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Alliance,Medicaid,,0.22422,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Alliance,Medicaid,,0.32232,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Alliance,Medicaid,,0.51251,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Alliance,Medicaid,,0.35836,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Alliance,Medicaid,,0.00400,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Alliance,Medicaid,,4.42,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Alliance,Medicaid,,220.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Alliance,Medicaid,,15.42,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Alliance,Medicaid,,27.01,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Alliance,Medicaid,,33.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Alliance,Medicaid,,3.46,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Alliance,Medicaid,,0.02603,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Alliance,Medicaid,,7.28,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Alliance,Medicaid,,13.07,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Alliance,Medicaid,,28.81,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Alliance,Medicaid,,12.73,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Alliance,Medicaid,,49.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Alliance,Medicaid,,2.25,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Alliance,Medicaid,,5.10,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Alliance,Medicaid,,0.15015,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Alliance,Medicaid,,0.00801,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Alliance,Medicaid,,3.03,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Alliance,Medicaid,,2.67,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Alliance,Medicaid,,2.38,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Alliance,Medicaid,,3.54,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Alliance,Medicaid,,6.68,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Alliance,Medicaid,,11.00,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Alliance,Medicaid,,27.86,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Alliance,Medicaid,,109.85,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Alliance,Medicaid,,63.31,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Alliance,Medicaid,,74.32,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Alliance,Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Alliance,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Alliance,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Alliance,Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Alliance,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Alliance,Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Alliance,Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Alliance,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Alliance,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Alliance,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Alliance,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Alliance,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Alliance,Medicaid,,25.72,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Alliance,Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Alliance,Medicaid,,70.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Alliance,Medicaid,,77.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Alliance,Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Alliance,Medicaid,,709.51,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Alliance,Medicaid,,60.91,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Alliance,Medicaid,,8.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Alliance,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Alliance,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Alliance,Medicaid,,483.34,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Alliance,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Alliance,Medicaid,,94.40,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Alliance,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Alliance,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Alliance,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Alliance,Medicaid,,1045.12,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Alliance,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Alliance,Medicaid,,16.00,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Alliance,Medicaid,,6.74,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Alliance,Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Alliance,Medicaid,,9.41,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Alliance,Medicaid,,3.97,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Alliance,Medicaid,,5.05,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Alliance,Medicaid,,16.08,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Alliance,Medicaid,,6.49,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Alliance,Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Alliance,Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Alliance,Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Alliance,Medicaid,,87.43,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Alliance,Medicaid,,149.79,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Alliance,Medicaid,,457.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Alliance,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Alliance,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Alliance,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Alliance,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Alliance,Medicaid,,9.90,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Alliance,Medicaid,,11.52,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Alliance,Medicaid,,113.81,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Alliance,Medicaid,,4.36,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Alliance,Medicaid,,4.93,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Alliance,Medicaid,,1.40,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Alliance,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Alliance,Medicaid,,0.52052,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Alliance,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Alliance,Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Alliance,Medicaid,,5.36,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Alliance,Medicaid,,6.19,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Alliance,Medicaid,,4.76,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Alliance,Medicaid,,9.52,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Alliance,Medicaid,,5.88,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Alliance,Medicaid,,6.48,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Alliance,Medicaid,,548.82,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Alliance,Medicaid,,3.55,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Alliance,Medicaid,,3.35,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Alliance,Medicaid,,3.40,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Alliance,Medicaid,,4.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Alliance,Medicaid,,8.17,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Alliance,Medicaid,,368.29,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Alliance,Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Alliance,Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Alliance,Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Alliance,Medicaid,,6.56,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Alliance,Medicaid,,49.43,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Alliance,Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Alliance,Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Alliance,Medicaid,,4.55,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Alliance,Medicaid,,4068.51,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Alliance,Medicaid,,6.41,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Alliance,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Alliance,Medicaid,,31.60,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Alliance,Medicaid,,60.24,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Alliance,Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Alliance,Medicaid,,14.07,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Alliance,Medicaid,,16.98,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Alliance,Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Alliance,Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Alliance,Medicaid,,155.02,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Alliance,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Alliance,Medicaid,,10.18,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Alliance,Medicaid,,13.78,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Alliance,Medicaid,,13.34,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Alliance,Medicaid,,14.46,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Alliance,Medicaid,,7.94,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Alliance,Medicaid,,5.64,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Alliance,Medicaid,,12179.59,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Alliance,Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Alliance,Medicaid,,31.70,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Alliance,Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Alliance,Medicaid,,104.15,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Alliance,Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Alliance,Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Alliance,Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Alliance,Medicaid,,9.99,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Alliance,Medicaid,,12.25,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Alliance,Medicaid,,16.79,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Alliance,Medicaid,,21.31,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Alliance,Medicaid,,25.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Alliance,Medicaid,,14.18,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Alliance,Medicaid,,15.24,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Alliance,Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Alliance,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Alliance,Medicaid,,247.33,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Alliance,Medicaid,,468.68,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Alliance,Medicaid,,1.70,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Alliance,Medicaid,,34.23,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Alliance,Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Alliance,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Alliance,Medicaid,,4.12,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Alliance,Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Alliance,Medicaid,,7.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Alliance,Medicaid,,14.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Alliance,Medicaid,,24.62,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Alliance,Medicaid,,611.76,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Alliance,Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Alliance,Medicaid,,269.35,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Alliance,Medicaid,,4.30,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Alliance,Medicaid,,12.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Alliance,Medicaid,,7.13,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Alliance,Medicaid,,6.68,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Alliance,Medicaid,,6.82,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Alliance,Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Alliance,Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Alliance,Medicaid,,484.62,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Alliance,Medicaid,,1297.10,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Alliance,Medicaid,,33.63,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Alliance,Medicaid,,5.52,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Alliance,Medicaid,,12.75,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Alliance,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Alliance,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Alliance,Medicaid,,5.51,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Alliance,Medicaid,,6.30,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Alliance,Medicaid,,31.51,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Alliance,Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Alliance,Medicaid,,20.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Alliance,Medicaid,,117.13,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Alliance,Medicaid,,36.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Alliance,Medicaid,,52.11,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Alliance,Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alliance,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Alliance,Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Alliance,Medicaid,,20.21,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Alliance,Medicaid,,35.74,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Alliance,Medicaid,,105.20,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Alliance,Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Alliance,Medicaid,,20.25,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Alliance,Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Alliance,Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Alliance,Medicaid,,176.48,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Alliance,Medicaid,,11.71,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Alliance,Medicaid,,179.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Alliance,Medicaid,,285.22,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Alliance,Medicaid,,426.24,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Alliance,Medicaid,,708.25,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Alliance,Medicaid,,1413.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Alliance,Medicaid,,2118.34,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Alliance,Medicaid,,339.37,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Alliance,Medicaid,,1650.91,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Alliance,Medicaid,,6438.44,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Alliance,Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Alliance,Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Alliance,Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Alliance,Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Alliance,Medicaid,,1763.13,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Alliance,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Alliance,Medicaid,,16.68,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Alliance,Medicaid,,20.29,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Alliance,Medicaid,,30.82,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Alliance,Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Alliance,Medicaid,,3.74,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Alliance,Medicaid,,23.20,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Alliance,Medicaid,,28.42,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Alliance,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Alliance,Medicaid,,177.12,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Alliance,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Alliance,Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Alliance,Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Alliance,Medicaid,,197.30,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Alliance,Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Alliance,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Alliance,Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Alliance,Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Alliance,Medicaid,,20.15,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Alliance,Medicaid,,38.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Alliance,Medicaid,,2654.78,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Alliance,Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Alliance,Medicaid,,2.75,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Alliance,Medicaid,,449.52,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Alliance,Medicaid,,17.23,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Alliance,Medicaid,,142.12,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Alliance,Medicaid,,42.80,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Alliance,Medicaid,,12.13,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Alliance,Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Alliance,Medicaid,,36.93,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Alliance,Medicaid,,44.98,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Alliance,Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Alliance,Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Alliance,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Alliance,Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Alliance,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Alliance,Medicaid,,0.62062,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Alliance,Medicaid,,16.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Alliance,Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Alliance,Medicaid,,15.28,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Alliance,Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Alliance,Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Alliance,Medicaid,,21.02,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Alliance,Medicaid,,94.41,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Alliance,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Alliance,Medicaid,,56.41,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Alliance,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Alliance,Medicaid,,11220.92,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Alliance,Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Alliance,Medicaid,,893.81,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Alliance,Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Alliance,Medicaid,,14.13,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Alliance,Medicaid,,5.40,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Alliance,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Alliance,Medicaid,,6.29,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Alliance,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Alliance,Medicaid,,13.56,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Alliance,Medicaid,,5.97,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Alliance,Medicaid,,223.00,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Alliance,Medicaid,,366.37,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Alliance,Medicaid,,63.28,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Alliance,Medicaid,,94.95,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Alliance,Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Alliance,Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Alliance,Medicaid,,142.19,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Alliance,Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Alliance,Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Alliance,Medicaid,,113.11,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Alliance,Medicaid,,239.91,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Alliance,Medicaid,,0.82082,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Alliance,Medicaid,,113.87,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Alliance,Medicaid,,22.42,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Alliance,Medicaid,,33.63,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Alliance,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Alliance,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Alliance,Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Alliance,Medicaid,,122.05,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Alliance,Medicaid,,31.90,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Alliance,Medicaid,,17.42,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Alliance,Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Alliance,Medicaid,,4.22,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Alliance,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Alliance,Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Alliance,Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Alliance,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Alliance,Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Alliance,Medicaid,,6.85,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Alliance,Medicaid,,24.72,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Alliance,Medicaid,,25.00,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Alliance,Medicaid,,9.78,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Alliance,Medicaid,,12.40,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Alliance,Medicaid,,6.32,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Alliance,Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Alliance,Medicaid,,76.08,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Alliance,Medicaid,,182.24,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Alliance,Medicaid,,33.58,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Alliance,Medicaid,,64.10,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Alliance,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Alliance,Medicaid,,120.93,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Alliance,Medicaid,,5085.99,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Alliance,Medicaid,,371.29,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Alliance,Medicaid,,4.20,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Alliance,Medicaid,,192.56,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Alliance,Medicaid,,4.99,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Alliance,Medicaid,,16.95,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Alliance,Medicaid,,7.22,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Alliance,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Alliance,Medicaid,,330.57,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Alliance,Medicaid,,6063.10,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Alliance,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Alliance,Medicaid,,6.34,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Alliance,Medicaid,,10.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Alliance,Medicaid,,7.62,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Alliance,Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Alliance,Medicaid,,14.42,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Alliance,Medicaid,,15.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Alliance,Medicaid,,37.17,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Alliance,Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Alliance,Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Alliance,Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Alliance,Medicaid,,64.17,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Alliance,Medicaid,,87.69,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Alliance,Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Alliance,Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Alliance,Medicaid,,413.11,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Alliance,Medicaid,,549.75,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Alliance,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Alliance,Medicaid,,39.28,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Alliance,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Alliance,Medicaid,,0.54054,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Alliance,Medicaid,,12.01,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Alliance,Medicaid,,6.45,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Alliance,Medicaid,,4.46,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Alliance,Medicaid,,17.53,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Alliance,Medicaid,,23.06,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Alliance,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Alliance,Medicaid,,9.95,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Alliance,Medicaid,,7.23,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Alliance,Medicaid,,29.62,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Alliance,Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Alliance,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Alliance,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Alliance,Medicaid,,41.45,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Alliance,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Alliance,Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Alliance,Medicaid,,6.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Alliance,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Alliance,Medicaid,,110.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Alliance,Medicaid,,5.37,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Alliance,Medicaid,,4.79,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Alliance,Medicaid,,5.90,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Alliance,Medicaid,,8.63,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Alliance,Medicaid,,10.70,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Alliance,Medicaid,,12.18,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Alliance,Medicaid,,35.74,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Alliance,Medicaid,,101.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Alliance,Medicaid,,10.63,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Alliance,Medicaid,,4.94,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Alliance,Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Alliance,Medicaid,,12.26,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Alliance,Medicaid,,5.59,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Alliance,Medicaid,,34.07,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Alliance,Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Alliance,Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Alliance,Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Alliance,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Alliance,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Alliance,Medicaid,,23675.99,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Alliance,Medicaid,,25.12,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Alliance,Medicaid,,150.32,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Alliance,Medicaid,,2.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Alliance,Medicaid,,2.99,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Alliance,Medicaid,,15.35,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Alliance,Medicaid,,1.07,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Alliance,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Alliance,Medicaid,,8.04,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Alliance,Medicaid,,8.95,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Alliance,Medicaid,,7.29,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Alliance,Medicaid,,17.00,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Alliance,Medicaid,,16.97,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Alliance,Medicaid,,17.00,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Alliance,Medicaid,,16.61,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Alliance,Medicaid,,210.68,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Alliance,Medicaid,,1079.07,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Alliance,Medicaid,,728.09,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Alliance,Medicaid,,6.63,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Alliance,Medicaid,,3156.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Alliance,Medicaid,,0.58058,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Alliance,Medicaid,,4.21,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Alliance,Medicaid,,86.25,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Alliance,Medicaid,,47.35,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Alliance,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Alliance,Medicaid,,21.62,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Alliance,Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Alliance,Medicaid,,28.88,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Alliance,Medicaid,,58.02,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Alliance,Medicaid,,535.27,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Alliance,Medicaid,,17.52,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Alliance,Medicaid,,1.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Alliance,Medicaid,,667.95,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Alliance,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Alliance,Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Alliance,Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Alliance,Medicaid,,163.80,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Alliance,Medicaid,,64.00,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Alliance,Medicaid,,197.18,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Alliance,Medicaid,,5.03,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Alliance,Medicaid,,272.42,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Alliance,Medicaid,,17.52,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Alliance,Medicaid,,43.51,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Alliance,Medicaid,,7.69,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Alliance,Medicaid,,7.85,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Alliance,Medicaid,,1250.81,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Alliance,Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Alliance,Medicaid,,4.16,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Alliance,Medicaid,,1902.78,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Alliance,Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Alliance,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Alliance,Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Alliance,Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Alliance,Medicaid,,52.45,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Alliance,Medicaid,,70.57,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Alliance,Medicaid,,2.17,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Alliance,Medicaid,,59.78,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Alliance,Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Alliance,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Alliance,Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Alliance,Medicaid,,9.27,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Alliance,Medicaid,,43.77,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Alliance,Medicaid,,35.92,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Alliance,Medicaid,,19.98,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Alliance,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Alliance,Medicaid,,31.22,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Alliance,Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Alliance,Medicaid,,4.40,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Alliance,Medicaid,,12.96,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Alliance,Medicaid,,2397.64,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Alliance,Medicaid,,11.54,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Alliance,Medicaid,,6.85,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Alliance,Medicaid,,16.12,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Alliance,Medicaid,,4.73,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Alliance,Medicaid,,1945.70,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Alliance,Medicaid,,50.03,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Alliance,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Alliance,Medicaid,,1.47,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Alliance,Medicaid,,27.60,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Alliance,Medicaid,,3.70,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Alliance,Medicaid,,16.17,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Alliance,Medicaid,,17.22,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Alliance,Medicaid,,36.04,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Alliance,Medicaid,,19.45,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Alliance,Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Alliance,Medicaid,,31.84,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Alliance,Medicaid,,18.79,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Alliance,Medicaid,,14.10,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Alliance,Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Alliance,Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Alliance,Medicaid,,16.83,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Alliance,Medicaid,,2.36,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Alliance,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Alliance,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Alliance,Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Alliance,Medicaid,,2.21,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Alliance,Medicaid,,1641.62,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Alliance,Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Alliance,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Alliance,Medicaid,,12.35,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Alliance,Medicaid,,74.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Alliance,Medicaid,,38.55,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Alliance,Medicaid,,14.08,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Alliance,Medicaid,,13.27,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Alliance,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Alliance,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Alliance,Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Alliance,Medicaid,,5.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Alliance,Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Alliance,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Alliance,Medicaid,,22.60,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Alliance,Medicaid,,26.46,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Alliance,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Alliance,Medicaid,,18.05,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Alliance,Medicaid,,29.76,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Alliance,Medicaid,,8.92,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Alliance,Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Alliance,Medicaid,,4.05,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Alliance,Medicaid,,69.27,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Alliance,Medicaid,,253.03,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Alliance,Medicaid,,4.61,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Alliance,Medicaid,,90.65,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Alliance,Medicaid,,181.74,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Alliance,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Alliance,Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Alliance,Medicaid,,1.78,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Alliance,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Alliance,Medicaid,,48.18,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Alliance,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Alliance,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Alliance,Medicaid,,18.93,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Alliance,Medicaid,,5.67,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Alliance,Medicaid,,26.98,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Alliance,Medicaid,,28.38,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Alliance,Medicaid,,8.76,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Alliance,Medicaid,,69.80,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Alliance,Medicaid,,4.19,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Alliance,Medicaid,,3.75,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Alliance,Medicaid,,28.38,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Alliance,Medicaid,,32.93,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Alliance,Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Alliance,Medicaid,,0.64064,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Alliance,Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Alliance,Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Alliance,Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Alliance,Medicaid,,18.36,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Alliance,Medicaid,,15.96,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Alliance,Medicaid,,94.29,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Alliance,Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Alliance,Medicaid,,4.64,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Alliance,Medicaid,,4.70,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Alliance,Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Alliance,Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Alliance,Medicaid,,2779.01,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Alliance,Medicaid,,60.82,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Alliance,Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Alliance,Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Alliance,Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Alliance,Medicaid,,813.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Alliance,Medicaid,,22.63,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Alliance,Medicaid,,23.59,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Alliance,Medicaid,,3569.45,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Alliance,Medicaid,,5678.07,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Alliance,Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Alliance,Medicaid,,1.23,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Alliance,Medicaid,,29.52,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Alliance,Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Alliance,Medicaid,,8.31,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Alliance,Medicaid,,4.74,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Alliance,Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Alliance,Medicaid,,32.33,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Alliance,Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Alliance,Medicaid,,19.60,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Alliance,Medicaid,,18.87,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Alliance,Medicaid,,916.12,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Alliance,Medicaid,,30.63,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Alliance,Medicaid,,4.81,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Alliance,Medicaid,,0.96096,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Alliance,Medicaid,,65.28,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Alliance,Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Alliance,Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Alliance,Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Alliance,Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Alliance,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Alliance,Medicaid,,110.10,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Alliance,Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Alliance,Medicaid,,4.47,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Alliance,Medicaid,,0.37037,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Alliance,Medicaid,,16.84,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Alliance,Medicaid,,64.93,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Alliance,Medicaid,,98.80,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Alliance,Medicaid,,4.09,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Alliance,Medicaid,,71.50,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Alliance,Medicaid,,105.65,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Alliance,Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Alliance,Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Alliance,Medicaid,,73.80,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Alliance,Medicaid,,1279.76,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Alliance,Medicaid,,5.69,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Alliance,Medicaid,,1377.08,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Alliance,Medicaid,,6665.14,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Alliance,Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Alliance,Medicaid,,11.01,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Alliance,Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Alliance,Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Alliance,Medicaid,,7882.80,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Alliance,Medicaid,,1623.83,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Alliance,Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Alliance,Medicaid,,76.35,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Alliance,Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Alliance,Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Alliance,Medicaid,,419.08,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Alliance,Medicaid,,2799.47,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Alliance,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Alliance,Medicaid,,92.54,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Alliance,Medicaid,,219.22,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Alliance,Medicaid,,49.55,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Alliance,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Alliance,Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Alliance,Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Alliance,Medicaid,,48.28,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Alliance,Medicaid,,61.64,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Alliance,Medicaid,,81.44,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alliance,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Alliance,Medicaid,,162.03,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Alliance,Medicaid,,1221.21,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Alliance,Medicaid,,2970.42,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Alliance,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Alliance,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Alliance,Medicaid,,146.38,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Alliance,Medicaid,,7.91,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Alliance,Medicaid,,9.55,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Alliance,Medicaid,,10.92,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Alliance,Medicaid,,15.56,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Alliance,Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Alliance,Medicaid,,5250.24,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Alliance,Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Alliance,Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Alliance,Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Alliance,Medicaid,,21.88,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Alliance,Medicaid,,356.36,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Alliance,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Alliance,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Alliance,Medicaid,,4208.24,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Alliance,Medicaid,,6299.92,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Alliance,Medicaid,,3212.74,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Alliance,Medicaid,,361.87,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Alliance,Medicaid,,750.14,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Alliance,Medicaid,,1.62,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Alliance,Medicaid,,18.92,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Alliance,Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Alliance,Medicaid,,783.62,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Alliance,Medicaid,,16833.42,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Alliance,Medicaid,,396.12,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Alliance,Medicaid,,98.74,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Alliance,Medicaid,,926.81,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Alliance,Medicaid,,1838.20,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Alliance,Medicaid,,915.21,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Alliance,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Alliance,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Alliance,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Alliance,Medicaid,,403.08,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Alliance,Medicaid,,253.12,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Alliance,Medicaid,,8.87,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Alliance,Medicaid,,25.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Alliance,Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Alliance,Medicaid,,16.86,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Alliance,Medicaid,,15.22,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Alliance,Medicaid,,2157.77,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Alliance,Medicaid,,2679.20,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Alliance,Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Alliance,Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Alliance,Medicaid,,11.51,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Alliance,Medicaid,,3285.05,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Alliance,Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Alliance,Medicaid,,19.57,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Alliance,Medicaid,,29.49,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Alliance,Medicaid,,11.91,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Alliance,Medicaid,,2234.18,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Alliance,Medicaid,,208.06,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Alliance,Medicaid,,127.22,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Alliance,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Alliance,Medicaid,,43.75,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Alliance,Medicaid,,3.83,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Alliance,Medicaid,,175.64,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Alliance,Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Alliance,Medicaid,,808.29,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Alliance,Medicaid,,331.70,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Alliance,Medicaid,,61.99,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Alliance,Medicaid,,2704.88,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Alliance,Medicaid,,15.43,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Alliance,Medicaid,,57.14,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Alliance,Medicaid,,109.23,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Alliance,Medicaid,,930.37,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Alliance,Medicaid,,42.32,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Alliance,Medicaid,,19.15,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Alliance,Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Alliance,Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Alliance,Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Alliance,Medicaid,,270.30,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Alliance,Medicaid,,24.52,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Alliance,Medicaid,,549.99,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Alliance,Medicaid,,12.28,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Alliance,Medicaid,,216.72,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Alliance,Medicaid,,12.27,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Alliance,Medicaid,,3207.80,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Alliance,Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Alliance,Medicaid,,38.37,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Alliance,Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Alliance,Medicaid,,73.53,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Alliance,Medicaid,,11.51,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Alliance,Medicaid,,6.86,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Alliance,Medicaid,,7.99,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Alliance,Medicaid,,17993.44,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Alliance,Medicaid,,1899.64,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Alliance,Medicaid,,17368.36,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Alliance,Medicaid,,8.97,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Alliance,Medicaid,,1427.85,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Alliance,Medicaid,,179.52,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Alliance,Medicaid,,3838.14,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Alliance,Medicaid,,963.00,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Alliance,Medicaid,,5848.24,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Alliance,Medicaid,,1.33,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Alliance,Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Alliance,Medicaid,,6675.83,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Alliance,Medicaid,,14.27,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Alliance,Medicaid,,13.75,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Alliance,Medicaid,,262.81,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Alliance,Medicaid,,903.18,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Alliance,Medicaid,,9.57,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Alliance,Medicaid,,9727.12,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Alliance,Medicaid,,21122.14,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Alliance,Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Alliance,Medicaid,,26.35,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Alliance,Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Alliance,Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Alliance,Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Alliance,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Alliance,Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Alliance,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Alliance,Medicaid,,39.94,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Alliance,Medicaid,,199.70,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Alliance,Medicaid,,13.23,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Alliance,Medicaid,,133.84,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Alliance,Medicaid,,0.94094,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Alliance,Medicaid,,3.68,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Alliance,Medicaid,,394.84,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Alliance,Medicaid,,5329.34,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Alliance,Medicaid,,1179.31,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Alliance,Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Alliance,Medicaid,,7051.96,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Alliance,Medicaid,,16.03,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Alliance,Medicaid,,48.44,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Alliance,Medicaid,,77.98,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Alliance,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Alliance,Medicaid,,11.70,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Alliance,Medicaid,,23.30,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Alliance,Medicaid,,33.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Alliance,Medicaid,,43.39,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Alliance,Medicaid,,103.68,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Alliance,Medicaid,,405.10,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Alliance,Medicaid,,1904.73,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Alliance,Medicaid,,105.11,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Alliance,Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Alliance,Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Alliance,Medicaid,,97.95,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Alliance,Medicaid,,4267.77,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Alliance,Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Alliance,Medicaid,,322.39,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Alliance,Medicaid,,69.02,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Alliance,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Alliance,Medicaid,,11.19,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Alliance,Medicaid,,1030.23,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Alliance,Medicaid,,9678.64,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Alliance,Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Alliance,Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Alliance,Medicaid,,909.56,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Alliance,Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Alliance,Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Alliance,Medicaid,,7220.03,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Alliance,Medicaid,,586.19,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Alliance,Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Alliance,Medicaid,,4173.39,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Alliance,Medicaid,,40.64,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Alliance,Medicaid,,57.46,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Alliance,Medicaid,,83.99,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Alliance,Medicaid,,356.56,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Alliance,Medicaid,,16449.48,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Alliance,Medicaid,,2513.50,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Alliance,Medicaid,,669.68,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Alliance,Medicaid,,40.29,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Alliance,Medicaid,,9.61,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Alliance,Medicaid,,4.77,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Alliance,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Alliance,Medicaid,,799.89,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Alliance,Medicaid,,3779.20,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Alliance,Medicaid,,3471.11,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Alliance,Medicaid,,10388.06,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Alliance,Medicaid,,2075.14,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Alliance,Medicaid,,1257.11,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Alliance,Medicaid,,21.45,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Alliance,Medicaid,,2529.45,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alliance,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Alliance,Medicaid,,2773.87,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Alliance,Medicaid,,2216.38,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Alliance,Medicaid,,595.39,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Alliance,Medicaid,,686.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Alliance,Medicaid,,3212.13,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Alliance,Medicaid,,15163.67,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Alliance,Medicaid,,3042.20,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Alliance,Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Alliance,Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Alliance,Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Alliance,Medicaid,,1643.90,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Alliance,Medicaid,,3886.53,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Alliance,Medicaid,,821.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Alliance,Medicaid,,29.85,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Alliance,Medicaid,,2313.19,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Alliance,Medicaid,,22028.61,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Alliance,Medicaid,,433.03,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Alliance,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Alliance,Medicaid,,8.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Alliance,Medicaid,,35.29,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Alliance,Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Alliance,Medicaid,,12313.86,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Alliance,Medicaid,,8227.27,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Alliance,Medicaid,,13.14,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Alliance,Medicaid,,1284.65,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Alliance,Medicaid,,3568.15,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Alliance,Medicaid,,20151.54,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Alliance,Medicaid,,5505.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Alliance,Medicaid,,204.15,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Alliance,Medicaid,,1350.05,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Alliance,Medicaid,,1121.90,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Alliance,Medicaid,,1845.18,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Alliance,Medicaid,,25003.11,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Alliance,Medicaid,,10652.28,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Alliance,Medicaid,,4098.29,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Alliance,Medicaid,,3408.28,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Alliance,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Alliance,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Alliance,Medicaid,,16.27,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Alliance,Medicaid,,174.05,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Alliance,Medicaid,,6574.28,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Alliance,Medicaid,,21.51,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Alliance,Medicaid,,82.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Alliance,Medicaid,,3271.31,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Alliance,Medicaid,,7294.04,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Alliance,Medicaid,,6.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Alliance,Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Alliance,Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Alliance,Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Alliance,Medicaid,,148.04,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Alliance,Medicaid,,234.94,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Alliance,Medicaid,,13639.98,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Alliance,Medicaid,,15.22,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Alliance,Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Alliance,Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Alliance,Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Alliance,Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Alliance,Medicaid,,20.83,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Alliance,Medicaid,,9258.10,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Alliance,Medicaid,,1859.57,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Alliance,Medicaid,,104.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Alliance,Medicaid,,6029.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Alliance,Medicaid,,604.94,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Alliance,Medicaid,,16551.88,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Alliance,Medicaid,,13041.87,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Alliance,Medicaid,,2395.89,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Alliance,Medicaid,,4788.40,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Alliance,Medicaid,,5984.79,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Alliance,Medicaid,,13645.27,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Alliance,Medicaid,,188.67,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Alliance,Medicaid,,509.79,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Alliance,Medicaid,,509.80,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Alliance,Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Alliance,Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Alliance,Medicaid,,818.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Alliance,Medicaid,,295.46,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Alliance,Medicaid,,41.72,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Alliance,Medicaid,,51.15,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Alliance,Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Alliance,Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Alliance,Medicaid,,13.87,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Alliance,Medicaid,,12710.40,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Alliance,Medicaid,,46.93,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Alliance,Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Alliance,Medicaid,,70.56,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Alliance,Medicaid,,5351.96,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Alliance,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Alliance,Medicaid,,2200.82,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Alliance,Medicaid,,8765.41,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Alliance,Medicaid,,176.78,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Alliance,Medicaid,,12260.66,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Alliance,Medicaid,,1464.46,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Alliance,Medicaid,,51.51,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Alliance,Medicaid,,16.27,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Alliance,Medicaid,,3.41,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Alliance,Medicaid,,3.35,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Alliance,Medicaid,,7051.96,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Alliance,Medicaid,,4363.51,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Alliance,Medicaid,,0.27027,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Alliance,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Alliance,Medicaid,,72.96,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Alliance,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Alliance,Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Alliance,Medicaid,,93.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Alliance,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Alliance,Medicaid,,9.83,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Alliance,Medicaid,,17.85,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Alliance,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Alliance,Medicaid,,14.69,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Alliance,Medicaid,,65.63,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Alliance,Medicaid,,7.70,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Alliance,Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Alliance,Medicaid,,5.46,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Alliance,Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Alliance,Medicaid,,0.59059,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Alliance,Medicaid,,38.62,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Alliance,Medicaid,,2.22,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Alliance,Medicaid,,3.91,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Alliance,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Alliance,Medicaid,,18.87,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Alliance,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Alliance,Medicaid,,5.45,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Alliance,Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Alliance,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Alliance,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Alliance,Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Alliance,Medicaid,,18.23,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Alliance,Medicaid,,280.27,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Alliance,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Alliance,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Alliance,Medicaid,,882.66,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Alliance,Medicaid,,4193.08,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Alliance,Medicaid,,13.60,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Alliance,Medicaid,,1273.87,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Alliance,Medicaid,,16.80,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Alliance,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Alliance,Medicaid,,39.60,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Alliance,Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Alliance,Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Alliance,Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Alliance,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Alliance,Medicaid,,837.33,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Alliance,Medicaid,,16.33,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Alliance,Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Alliance,Medicaid,,25.36,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Alliance,Medicaid,,94.67,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Alliance,Medicaid,,1.93,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Alliance,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Alliance,Medicaid,,222.82,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Alliance,Medicaid,,4.01,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Alliance,Medicaid,,4.98,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Alliance,Medicaid,,35.58,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Alliance,Medicaid,,2.37,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Alliance,Medicaid,,17.42,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Alliance,Medicaid,,16.37,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Alliance,Medicaid,,21.32,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Alliance,Medicaid,,21.96,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Alliance,Medicaid,,130.98,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Alliance,Medicaid,,14.23,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Alliance,Medicaid,,14.35,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Alliance,Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Alliance,Medicaid,,14.26,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Alliance,Medicaid,,15.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Alliance,Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Alliance,Medicaid,,15.62,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Alliance,Medicaid,,412.01,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Alliance,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Alliance,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Alliance,Medicaid,,103.41,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Alliance,Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Alliance,Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Alliance,Medicaid,,10.79,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Alliance,Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Alliance,Medicaid,,3.75,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Alliance,Medicaid,,28.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Alliance,Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Alliance,Medicaid,,84.56,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Alliance,Medicaid,,10.15,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Alliance,Medicaid,,17.75,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Alliance,Medicaid,,4.28,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Alliance,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Alliance,Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Alliance,Medicaid,,18.21,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Alliance,Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Alliance,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Alliance,Medicaid,,0.38038,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Alliance,Medicaid,,4.79,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Alliance,Medicaid,,4.48,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Alliance,Medicaid,,39.36,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Alliance,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Alliance,Medicaid,,9.69,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Alliance,Medicaid,,5.95,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Alliance,Medicaid,,1.50,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Alliance,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Alliance,Medicaid,,4.15,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Alliance,Medicaid,,16.30,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Alliance,Medicaid,,0.67067,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Alliance,Medicaid,,2.88,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Alliance,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Alliance,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Alliance,Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Alliance,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Alliance,Medicaid,,6.53,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Alliance,Medicaid,,15.99,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Alliance,Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Alliance,Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Alliance,Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Alliance,Medicaid,,3.98,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Alliance,Medicaid,,32.93,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Alliance,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Alliance,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Alliance,Medicaid,,16.89,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Alliance,Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Alliance,Medicaid,,1470.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Alliance,Medicaid,,5.63,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Alliance,Medicaid,,15.38,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Alliance,Medicaid,,6.35,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Alliance,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Alliance,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Alliance,Medicaid,,548.81,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Alliance,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Alliance,Medicaid,,7.99,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Alliance,Medicaid,,5.28,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Alliance,Medicaid,,19.45,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Alliance,Medicaid,,20.34,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Alliance,Medicaid,,29.43,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Alliance,Medicaid,,5.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Alliance,Medicaid,,236.14,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Alliance,Medicaid,,451.45,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Alliance,Medicaid,,1156.15,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Alliance,Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Alliance,Medicaid,,443.79,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Alliance,Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Alliance,Medicaid,,45.65,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Alliance,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Alliance,Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Alliance,Medicaid,,52.77,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Alliance,Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Alliance,Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Alliance,Medicaid,,4.62,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Alliance,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Alliance,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Alliance,Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Alliance,Medicaid,,20.26,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Alliance,Medicaid,,121.53,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Alliance,Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Alliance,Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Alliance,Medicaid,,38.94,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Alliance,Medicaid,,39.17,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Alliance,Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Alliance,Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Alliance,Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Alliance,Medicaid,,0.78078,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Alliance,Medicaid,,7.14,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Alliance,Medicaid,,8.69,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Alliance,Medicaid,,12.01,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Alliance,Medicaid,,16.44,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Alliance,Medicaid,,20.96,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Alliance,Medicaid,,44.19,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Alliance,Medicaid,,2.68,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Alliance,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Alliance,Medicaid,,202.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Alliance,Medicaid,,1.61,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Alliance,Medicaid,,22.82,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Alliance,Medicaid,,4.63,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Alliance,Medicaid,,5.31,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Alliance,Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Alliance,Medicaid,,150.68,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Alliance,Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Alliance,Medicaid,,61.74,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Alliance,Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Alliance,Medicaid,,18.48,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Alliance,Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Alliance,Medicaid,,4.57,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Alliance,Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Alliance,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Alliance,Medicaid,,9.24,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Alliance,Medicaid,,10.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Alliance,Medicaid,,53.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Alliance,Medicaid,,5.59,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Alliance,Medicaid,,12.64,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Alliance,Medicaid,,119.95,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Alliance,Medicaid,,7.56,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Alliance,Medicaid,,12.50,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Alliance,Medicaid,,704.70,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Alliance,Medicaid,,310.71,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Alliance,Medicaid,,241.06,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Alliance,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Alliance,Medicaid,,43.24,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Alliance,Medicaid,,23.07,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Alliance,Medicaid,,104.89,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Alliance,Medicaid,,139.84,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Alliance,Medicaid,,240.04,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Alliance,Medicaid,,67.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Alliance,Medicaid,,69.97,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Alliance,Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Alliance,Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Alliance,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Alliance,Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Alliance,Medicaid,,3.86,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Alliance,Medicaid,,2576.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Alliance,Medicaid,,10.49,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Alliance,Medicaid,,71.52,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Alliance,Medicaid,,13.33,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Alliance,Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Alliance,Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Alliance,Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Alliance,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Alliance,Medicaid,,5.43,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Alliance,Medicaid,,138.74,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Alliance,Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Alliance,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Alliance,Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Alliance,Medicaid,,4.32,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Alliance,Medicaid,,16.64,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Alliance,Medicaid,,74.00,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Alliance,Medicaid,,84.08,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Alliance,Medicaid,,5.74,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Alliance,Medicaid,,8.49,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Alliance,Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Alliance,Medicaid,,10.70,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Alliance,Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Alliance,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Alliance,Medicaid,,24.00,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Alliance,Medicaid,,1.26,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Alliance,Medicaid,,18.82,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Alliance,Medicaid,,17.32,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Alliance,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Alliance,Medicaid,,93.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Alliance,Medicaid,,63.86,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Alliance,Medicaid,,168.96,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Alliance,Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Alliance,Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Alliance,Medicaid,,53.06,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Alliance,Medicaid,,171.88,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Alliance,Medicaid,,3998.59,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Alliance,Medicaid,,6.77,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Alliance,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Alliance,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Alliance,Medicaid,,36.67,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Alliance,Medicaid,,23.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Alliance,Medicaid,,5.99,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Alliance,Medicaid,,25.10,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Alliance,Medicaid,,14.31,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Alliance,Medicaid,,38.06,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Alliance,Medicaid,,16.93,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Alliance,Medicaid,,104.36,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Alliance,Medicaid,,11.95,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Alliance,Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Alliance,Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Alliance,Medicaid,,24.23,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Alliance,Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Alliance,Medicaid,,7.34,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Alliance,Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Alliance,Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Alliance,Medicaid,,18.69,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Alliance,Medicaid,,596.21,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Alliance,Medicaid,,7.17,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Alliance,Medicaid,,25.76,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Alliance,Medicaid,,452.94,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Alliance,Medicaid,,8.53,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Alliance,Medicaid,,7.02,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Alliance,Medicaid,,5.88,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Alliance,Medicaid,,11.06,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Alliance,Medicaid,,7.25,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Alliance,Medicaid,,1047.11,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Alliance,Medicaid,,2612.95,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Alliance,Medicaid,,5222.67,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Alliance,Medicaid,,10442.13,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Alliance,Medicaid,,36.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Alliance,Medicaid,,80.00,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Alliance,Medicaid,,5.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Alliance,Medicaid,,10.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Alliance,Medicaid,,29.59,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Alliance,Medicaid,,63.32,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Alliance,Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Alliance,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Alliance,Medicaid,,9.69,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Alliance,Medicaid,,10.10,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Alliance,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Alliance,Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Alliance,Medicaid,,943.42,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Alliance,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Alliance,Medicaid,,11.48,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Alliance,Medicaid,,26.93,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Alliance,Medicaid,,7.44,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Alliance,Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Alliance,Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Alliance,Medicaid,,4.38,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Alliance,Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Alliance,Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Alliance,Medicaid,,64.39,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Alliance,Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Alliance,Medicaid,,5.26,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Alliance,Medicaid,,7.43,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Alliance,Medicaid,,5.58,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Alliance,Medicaid,,93.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Alliance,Medicaid,,2.26,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Alliance,Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Alliance,Medicaid,,207.18,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Alliance,Medicaid,,4.97,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Alliance,Medicaid,,4.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Alliance,Medicaid,,50.45,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Alliance,Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Alliance,Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Alliance,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Alliance,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Alliance,Medicaid,,3.65,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Alliance,Medicaid,,3.93,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Alliance,Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Alliance,Medicaid,,3.53,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Alliance,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Alliance,Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Alliance,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Alliance,Medicaid,,17.52,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Alliance,Medicaid,,1250.97,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Alliance,Medicaid,,17.53,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Alliance,Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Alliance,Medicaid,,19.40,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Alliance,Medicaid,,21.10,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Alliance,Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Alliance,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Alliance,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Alliance,Medicaid,,14.13,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Alliance,Medicaid,,0.97097,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Alliance,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Alliance,Medicaid,,5.69,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Alliance,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Alliance,Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Alliance,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Alliance,Medicaid,,4.72,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Alliance,Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Alliance,Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Alliance,Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Alliance,Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Alliance,Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Alliance,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Alliance,Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Alliance,Medicaid,,4.66,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Alliance,Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Alliance,Medicaid,,1.67,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Alliance,Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Alliance,Medicaid,,3.22,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Alliance,Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Alliance,Medicaid,,33.91,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Alliance,Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Alliance,Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Alliance,Medicaid,,3616.45,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alliance,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Alliance,Medicaid,,6.19,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Alliance,Medicaid,,151.67,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Alliance,Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Alliance,Medicaid,,28.78,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Alliance,Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Alliance,Medicaid,,301.87,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Alliance,Medicaid,,0.70070,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Alliance,Medicaid,,21.87,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Alliance,Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Alliance,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Alliance,Medicaid,,5.49,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Alliance,Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Alliance,Medicaid,,8.20,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Alliance,Medicaid,,278.53,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Alliance,Medicaid,,12.20,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Alliance,Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Alliance,Medicaid,,4.76,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Alliance,Medicaid,,75.53,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Alliance,Medicaid,,96.61,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Alliance,Medicaid,,66.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Alliance,Medicaid,,107.18,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Alliance,Medicaid,,23.54,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Alliance,Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Alliance,Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Alliance,Medicaid,,5.02,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Alliance,Medicaid,,23.24,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Alliance,Medicaid,,137.38,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Alliance,Medicaid,,321.76,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Alliance,Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Alliance,Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Alliance,Medicaid,,13.36,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Alliance,Medicaid,,13.96,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Alliance,Medicaid,,13.51,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Alliance,Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Alliance,Medicaid,,13.96,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Alliance,Medicaid,,13.51,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Alliance,Medicaid,,30.03,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Alliance,Medicaid,,14.71,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Alliance,Medicaid,,13.96,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Alliance,Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Alliance,Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Alliance,Medicaid,,13.36,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Alliance,Medicaid,,13.96,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Alliance,Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Alliance,Medicaid,,13.36,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Alliance,Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Alliance,Medicaid,,204.90,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Alliance,Medicaid,,4.53,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Alliance,Medicaid,,1446.91,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Alliance,Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Alliance,Medicaid,,1119.21,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Alliance,Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Alliance,Medicaid,,3.78,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Alliance,Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Alliance,Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Alliance,Medicaid,,70.11,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Alliance,Medicaid,,248.85,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Alliance,Medicaid,,4.56,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Alliance,Medicaid,,9.25,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Alliance,Medicaid,,1407.53,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Alliance,Medicaid,,66.53,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Alliance,Medicaid,,61.72,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Alliance,Medicaid,,134.84,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Alliance,Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Alliance,Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Alliance,Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Alliance,Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Alliance,Medicaid,,5370.02,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Alliance,Medicaid,,64.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Alliance,Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Alliance,Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Alliance,Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Alliance,Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Alliance,Medicaid,,407.41,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Alliance,Medicaid,,99.10,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Alliance,Medicaid,,199.52,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Alliance,Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Alliance,Medicaid,,15.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Alliance,Medicaid,,67.55,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Alliance,Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Alliance,Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Alliance,Medicaid,,21.09,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Alliance,Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Alliance,Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Alliance,Medicaid,,3.81,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Alliance,Medicaid,,5.34,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Alliance,Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Alliance,Medicaid,,15.22,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Alliance,Medicaid,,58.63,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Alliance,Medicaid,,4.16,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Alliance,Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Alliance,Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Alliance,Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Alliance,Medicaid,,3.90,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Alliance,Medicaid,,3.85,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Alliance,Medicaid,,20.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Alliance,Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Alliance,Medicaid,,14.29,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Alliance,Medicaid,,15.17,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Alliance,Medicaid,,14.14,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Alliance,Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Alliance,Medicaid,,12.62,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Alliance,Medicaid,,21.90,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Alliance,Medicaid,,0.95095,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Alliance,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alliance,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Alliance,Medicaid,,217.46,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Alliance,Medicaid,,8.91,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Alliance,Medicaid,,9.31,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Alliance,Medicaid,,6.32,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Alliance,Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Alliance,Medicaid,,7322.31,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Alliance,Medicaid,,63.69,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Alliance,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Alliance,Medicaid,,12.78,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Alliance,Medicaid,,23.12,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Alliance,Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Alliance,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Alliance,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Alliance,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Alliance,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Alliance,Medicaid,,15.04,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Alliance,Medicaid,,21.65,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Alliance,Medicaid,,30.68,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Alliance,Medicaid,,4.37,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Alliance,Medicaid,,3.92,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Alliance,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Alliance,Medicaid,,40.90,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Alliance,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Alliance,Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Alliance,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Alliance,Medicaid,,4.79,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Alliance,Medicaid,,2740.12,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Alliance,Medicaid,,560.36,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Alliance,Medicaid,,15.95,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Alliance,Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Alliance,Medicaid,,5.65,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Alliance,Medicaid,,15.26,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Alliance,Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Alliance,Medicaid,,20.90,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Alliance,Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Alliance,Medicaid,,12.73,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Alliance,Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Alliance,Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Alliance,Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Alliance,Medicaid,,5.71,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Alliance,Medicaid,,4.13,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Alliance,Medicaid,,4.03,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Alliance,Medicaid,,4.05,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Alliance,Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Alliance,Medicaid,,1.42,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Alliance,Medicaid,,30.78,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Alliance,Medicaid,,81.09,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Alliance,Medicaid,,31.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Alliance,Medicaid,,160.86,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Alliance,Medicaid,,13.25,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Alliance,Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Alliance,Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Alliance,Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Alliance,Medicaid,,14.97,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Alliance,Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Alliance,Medicaid,,18.46,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Alliance,Medicaid,,75.28,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Alliance,Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Alliance,Medicaid,,12.88,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Alliance,Medicaid,,5.42,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Alliance,Medicaid,,22.97,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Alliance,Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Alliance,Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Alliance,Medicaid,,3.48,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Alliance,Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Alliance,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Alliance,Medicaid,,3.47,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Alliance,Medicaid,,18.92,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Alliance,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Alliance,Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Alliance,Medicaid,,43.16,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Alliance,Medicaid,,67.81,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Alliance,Medicaid,,167.17,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Alliance,Medicaid,,13.06,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Alliance,Medicaid,,16.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Alliance,Medicaid,,44.56,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Alliance,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Alliance,Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Alliance,Medicaid,,25.74,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Alliance,Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Alliance,Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Alliance,Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Alliance,Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Alliance,Medicaid,,63.86,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Alliance,Medicaid,,33.71,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Alliance,Medicaid,,12.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Alliance,Medicaid,,14.55,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Alliance,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Alliance,Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Alliance,Medicaid,,17.61,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Alliance,Medicaid,,74.49,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Alliance,Medicaid,,3.85,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Alliance,Medicaid,,13.49,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Alliance,Medicaid,,13.69,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Alliance,Medicaid,,19.34,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Alliance,Medicaid,,6.15,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Alliance,Medicaid,,21.33,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Alliance,Medicaid,,34.39,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Alliance,Medicaid,,20.81,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Alliance,Medicaid,,50.13,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Alliance,Medicaid,,34.22,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Alliance,Medicaid,,16.15,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Alliance,Medicaid,,14.08,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Alliance,Medicaid,,20.81,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Alliance,Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Alliance,Medicaid,,19.34,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Alliance,Medicaid,,21.86,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Alliance,Medicaid,,95.86,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Alliance,Medicaid,,23.59,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Alliance,Medicaid,,113.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Alliance,Medicaid,,233.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Alliance,Medicaid,,248.73,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Alliance,Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Alliance,Medicaid,,16.74,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Alliance,Medicaid,,14.88,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Alliance,Medicaid,,30.69,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Alliance,Medicaid,,43.74,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Alliance,Medicaid,,102.58,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Alliance,Medicaid,,192.55,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Alliance,Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Alliance,Medicaid,,20.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Alliance,Medicaid,,49.60,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Alliance,Medicaid,,13.37,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Alliance,Medicaid,,15.65,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Alliance,Medicaid,,147.18,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Alliance,Medicaid,,3.51,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Alliance,Medicaid,,55.10,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Alliance,Medicaid,,12.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Alliance,Medicaid,,21.04,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Alliance,Medicaid,,58.02,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Alliance,Medicaid,,35.32,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Alliance,Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Alliance,Medicaid,,24.13,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Alliance,Medicaid,,14.29,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Alliance,Medicaid,,15.69,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Alliance,Medicaid,,36.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Alliance,Medicaid,,34.39,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Alliance,Medicaid,,15.14,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Alliance,Medicaid,,5.85,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Alliance,Medicaid,,6.96,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Alliance,Medicaid,,14.29,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Alliance,Medicaid,,357.36,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Alliance,Medicaid,,19.93,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Alliance,Medicaid,,5.04,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Alliance,Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Alliance,Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Alliance,Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Alliance,Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Alliance,Medicaid,,34.83,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Alliance,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Alliance,Medicaid,,4.49,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Alliance,Medicaid,,4.50,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Alliance,Medicaid,,5.13,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Alliance,Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Alliance,Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Alliance,Medicaid,,26.24,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Alliance,Medicaid,,18.92,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Alliance,Medicaid,,27.96,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Alliance,Medicaid,,5.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Alliance,Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Alliance,Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Alliance,Medicaid,,3.55,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Alliance,Medicaid,,13.67,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Alliance,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Alliance,Medicaid,,11.19,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Alliance,Medicaid,,16.47,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Alliance,Medicaid,,21.29,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Alliance,Medicaid,,62.22,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Alliance,Medicaid,,15.97,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Alliance,Medicaid,,63.91,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Alliance,Medicaid,,12.84,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Alliance,Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Alliance,Medicaid,,21.02,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Alliance,Medicaid,,14.96,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Alliance,Medicaid,,10.41,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Alliance,Medicaid,,32.35,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Alliance,Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Alliance,Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Alliance,Medicaid,,90.46,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Alliance,Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Alliance,Medicaid,,55.38,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Alliance,Medicaid,,47.93,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Alliance,Medicaid,,14.79,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Alliance,Medicaid,,13.15,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Alliance,Medicaid,,15.94,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Alliance,Medicaid,,11.97,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Alliance,Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Alliance,Medicaid,,49.57,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Alliance,Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Alliance,Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Alliance,Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Alliance,Medicaid,,30.76,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Alliance,Medicaid,,72.92,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Alliance,Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Alliance,Medicaid,,79.00,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Alliance,Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Alliance,Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Alliance,Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Alliance,Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Alliance,Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Alliance,Medicaid,,73.55,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Alliance,Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Alliance,Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Alliance,Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Alliance,Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Alliance,Medicaid,,20.26,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Alliance,Medicaid,,23.05,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Alliance,Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Alliance,Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Alliance,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Alliance,Medicaid,,39.10,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Alliance,Medicaid,,29.27,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alliance,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Alliance,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Alliance,Medicaid,,14.73,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Alliance,Medicaid,,12.90,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Alliance,Medicaid,,82.51,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Alliance,Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Alliance,Medicaid,,34.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Alliance,Medicaid,,12.65,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Alliance,Medicaid,,23.05,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Alliance,Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Alliance,Medicaid,,5.16,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Alliance,Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Alliance,Medicaid,,317.29,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Alliance,Medicaid,,7.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Alliance,Medicaid,,95.78,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Alliance,Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Alliance,Medicaid,,3.44,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Alliance,Medicaid,,28.89,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Alliance,Medicaid,,276.31,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Alliance,Medicaid,,14.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Alliance,Medicaid,,43.04,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Alliance,Medicaid,,119.57,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Alliance,Medicaid,,21.86,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Alliance,Medicaid,,23.12,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Alliance,Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Alliance,Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Alliance,Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Alliance,Medicaid,,13.22,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Alliance,Medicaid,,7.31,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Alliance,Medicaid,,13.22,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Alliance,Medicaid,,9.70,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Alliance,Medicaid,,17.78,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Alliance,Medicaid,,52.13,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Alliance,Medicaid,,23.96,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Alliance,Medicaid,,23.67,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Alliance,Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Alliance,Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Alliance,Medicaid,,6.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Alliance,Medicaid,,16.67,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Alliance,Medicaid,,13.03,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Alliance,Medicaid,,35.71,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Alliance,Medicaid,,10.13,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Alliance,Medicaid,,46.39,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Alliance,Medicaid,,47.60,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Alliance,Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Alliance,Medicaid,,13.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Alliance,Medicaid,,4.42,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Alliance,Medicaid,,4.56,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Alliance,Medicaid,,91.88,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Alliance,Medicaid,,5.22,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Alliance,Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Alliance,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Alliance,Medicaid,,12.64,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Alliance,Medicaid,,12.66,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Alliance,Medicaid,,12.67,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Alliance,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Alliance,Medicaid,,29.01,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Alliance,Medicaid,,3.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Alliance,Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Alliance,Medicaid,,13.25,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Alliance,Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Alliance,Medicaid,,91.32,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Alliance,Medicaid,,92.51,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Alliance,Medicaid,,72.28,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Alliance,Medicaid,,15.98,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alliance,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Alliance,Medicaid,,15.14,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Alliance,Medicaid,,15.77,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Alliance,Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Alliance,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Alliance,Medicaid,,4.97,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Alliance,Medicaid,,31.76,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Alliance,Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Alliance,Medicaid,,25.14,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Alliance,Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Alliance,Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Alliance,Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Alliance,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Alliance,Medicaid,,4.99,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Alliance,Medicaid,,146.20,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Alliance,Medicaid,,20.36,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Alliance,Medicaid,,20.72,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Alliance,Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Alliance,Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Alliance,Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Alliance,Medicaid,,7.81,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Alliance,Medicaid,,12.31,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Alliance,Medicaid,,5.29,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Alliance,Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Alliance,Medicaid,,42.04,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Alliance,Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Alliance,Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Alliance,Medicaid,,16.48,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Alliance,Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Alliance,Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Alliance,Medicaid,,13.40,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Alliance,Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Alliance,Medicaid,,6.89,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Alliance,Medicaid,,4.13,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Alliance,Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Alliance,Medicaid,,4.79,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Alliance,Medicaid,,5.25,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Alliance,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Alliance,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Alliance,Medicaid,,106.37,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Alliance,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Alliance,Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alliance,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alliance,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alliance,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alliance,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Alliance,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Alliance,Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Alliance,Medicaid,,80.87,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Alliance,Medicaid,,21.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Alliance,Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Alliance,Medicaid,,4.61,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Alliance,Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Alliance,Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Alliance,Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Alliance,Medicaid,,151.55,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Alliance,Medicaid,,9.79,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Alliance,Medicaid,,5.16,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Alliance,Medicaid,,5.23,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Alliance,Medicaid,,55.71,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Alliance,Medicaid,,11.69,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Alliance,Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Alliance,Medicaid,,3.37,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Alliance,Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Alliance,Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Alliance,Medicaid,,0.83083,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Alliance,Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Alliance,Medicaid,,55.41,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Alliance,Medicaid,,59.75,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Alliance,Medicaid,,47.78,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Alliance,Medicaid,,52.17,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Alliance,Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Alliance,Medicaid,,58.32,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Alliance,Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Alliance,Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Alliance,Medicaid,,15.58,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Alliance,Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Alliance,Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Alliance,Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Alliance,Medicaid,,9036.23,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Alliance,Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Alliance,Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Alliance,Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Alliance,Medicaid,,111.31,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Alliance,Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Alliance,Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Alliance,Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Alliance,Medicaid,,9367.61,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Alliance,Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alliance,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Alliance,Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alliance,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Alliance,Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Alliance,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Alliance,Medicaid,,202.69,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alliance,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alliance,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Alliance,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Alliance,Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Alliance,Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Alliance,Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Alliance,Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Alliance,Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Alliance,Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Alliance,Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Alliance,Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Alliance,Medicaid,,55.83,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Alliance,Medicaid,,8.83,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Alliance,Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Alliance,Medicaid,,38405.96,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Alliance,Medicaid,,25.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Alliance,Medicaid,,14.11,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Alliance,Medicaid,,14.86,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Alliance,Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Alliance,Medicaid,,14.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Alliance,Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Alliance,Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Alliance,Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Alliance,Medicaid,,134.33,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Alliance,Medicaid,,29.04,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Alliance,Medicaid,,147.35,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Alliance,Medicaid,,52.74,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Alliance,Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Alliance,Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Alliance,Medicaid,,1.02,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Alliance,Medicaid,,2.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Alliance,Medicaid,,16.00,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Alliance,Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Alliance,Medicaid,,92.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Alliance,Medicaid,,15.62,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Alliance,Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Alliance,Medicaid,,11.85,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Alliance,Medicaid,,7.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Alliance,Medicaid,,87.28,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Alliance,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Alliance,Medicaid,,21.34,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Alliance,Medicaid,,116.72,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Alliance,Medicaid,,62.81,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Alliance,Medicaid,,10.37,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Alliance,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Alliance,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Alliance,Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Alliance,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Alliance,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Alliance,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Alliance,Medicaid,,6.11,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Alliance,Medicaid,,6.13,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Alliance,Medicaid,,6.84,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Alliance,Medicaid,,7.61,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Alliance,Medicaid,,23.04,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Alliance,Medicaid,,9.83,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Alliance,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Alliance,Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Alliance,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Alliance,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Alliance,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Alliance,Medicaid,,0.43043,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Alliance,Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Alliance,Medicaid,,23.36,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Alliance,Medicaid,,46.93,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Alliance,Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Alliance,Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Alliance,Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Alliance,Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Alliance,Medicaid,,6.26,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Alliance,Medicaid,,5.94,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Alliance,Medicaid,,37.17,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Alliance,Medicaid,,15.45,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Alliance,Medicaid,,5.99,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Alliance,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Alliance,Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Alliance,Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Alliance,Medicaid,,17.47,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Alliance,Medicaid,,17.83,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Alliance,Medicaid,,4.68,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Alliance,Medicaid,,10.72,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Alliance,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Alliance,Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Alliance,Medicaid,,61.46,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Alliance,Medicaid,,94.69,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Alliance,Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Alliance,Medicaid,,5.80,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Alliance,Medicaid,,21.17,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Alliance,Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Alliance,Medicaid,,3.81,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Alliance,Medicaid,,4.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Alliance,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Alliance,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Alliance,Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Alliance,Medicaid,,14.85,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Alliance,Medicaid,,2.70,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Alliance,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Alliance,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Alliance,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Alliance,Medicaid,,5.33,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Alliance,Medicaid,,6.14,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Alliance,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Alliance,Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Alliance,Medicaid,,5.23,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Alliance,Medicaid,,4.66,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Alliance,Medicaid,,6.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Alliance,Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Alliance,Medicaid,,33.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Alliance,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Alliance,Medicaid,,25.70,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Alliance,Medicaid,,10.75,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Alliance,Medicaid,,5.15,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Alliance,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Alliance,Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Alliance,Medicaid,,4.65,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Alliance,Medicaid,,2.10,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Alliance,Medicaid,,4.19,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Alliance,Medicaid,,3.59,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Alliance,Medicaid,,40.93,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Alliance,Medicaid,,49.56,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Alliance,Medicaid,,14.79,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Alliance,Medicaid,,8.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Alliance,Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Alliance,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Alliance,Medicaid,,4.86,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Alliance,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Alliance,Medicaid,,45.49,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Alliance,Medicaid,,20.24,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Alliance,Medicaid,,6.85,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Alliance,Medicaid,,42.58,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Alliance,Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Alliance,Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Alliance,Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Alliance,Medicaid,,4.47,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Alliance,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Alliance,Medicaid,,14.47,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Alliance,Medicaid,,50.57,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Alliance,Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Alliance,Medicaid,,53.99,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Alliance,Medicaid,,31.11,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Alliance,Medicaid,,17.16,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Alliance,Medicaid,,22.03,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Alliance,Medicaid,,14.54,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Alliance,Medicaid,,37.87,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Alliance,Medicaid,,8.98,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Alliance,Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Alliance,Medicaid,,0.61061,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Alliance,Medicaid,,82.18,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Alliance,Medicaid,,4.41,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Alliance,Medicaid,,4.89,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Alliance,Medicaid,,29.78,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Alliance,Medicaid,,251.45,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Alliance,Medicaid,,3.39,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Alliance,Medicaid,,4.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Alliance,Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Alliance,Medicaid,,40.54,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Alliance,Medicaid,,4.44,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Alliance,Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Alliance,Medicaid,,3.51,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Alliance,Medicaid,,4.89,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Alliance,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Alliance,Medicaid,,24.28,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Alliance,Medicaid,,32.33,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Alliance,Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Alliance,Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Alliance,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Alliance,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Alliance,Medicaid,,51.39,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Alliance,Medicaid,,17.31,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Alliance,Medicaid,,5.05,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Alliance,Medicaid,,13.10,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Alliance,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Alliance,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Alliance,Medicaid,,0.57057,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Alliance,Medicaid,,1.53,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Alliance,Medicaid,,18.79,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Alliance,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Alliance,Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Alliance,Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Alliance,Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Alliance,Medicaid,,189.66,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Alliance,Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Alliance,Medicaid,,71.39,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Alliance,Medicaid,,81.01,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Alliance,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Alliance,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Alliance,Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Alliance,Medicaid,,20.97,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Alliance,Medicaid,,13.41,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Alliance,Medicaid,,23.35,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Alliance,Medicaid,,22.43,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Alliance,Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Alliance,Medicaid,,15.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Alliance,Medicaid,,16.52,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Alliance,Medicaid,,16.51,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Alliance,Medicaid,,19.05,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Alliance,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Alliance,Medicaid,,27.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Alliance,Medicaid,,14.86,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Alliance,Medicaid,,85.70,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Alliance,Medicaid,,79.04,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Alliance,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Alliance,Medicaid,,13.81,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Alliance,Medicaid,,16.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Alliance,Medicaid,,23.16,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Alliance,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Alliance,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Alliance,Medicaid,,1060.77,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Alliance,Medicaid,,54.03,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Alliance,Medicaid,,143.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Alliance,Medicaid,,17.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Alliance,Medicaid,,9.15,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Alliance,Medicaid,,9.92,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Alliance,Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Alliance,Medicaid,,81.63,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Alliance,Medicaid,,396.25,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Alliance,Medicaid,,73.63,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Alliance,Medicaid,,1.38,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Alliance,Medicaid,,129.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Alliance,Medicaid,,5.32,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Alliance,Medicaid,,15.98,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Alliance,Medicaid,,23.79,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Alliance,Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Alliance,Medicaid,,18.98,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Alliance,Medicaid,,169.85,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Alliance,Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Alliance,Medicaid,,5.60,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Alliance,Medicaid,,5.75,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Alliance,Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Alliance,Medicaid,,1.25,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Alliance,Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Alliance,Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Alliance,Medicaid,,10.70,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Alliance,Medicaid,,570.59,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Alliance,Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Alliance,Medicaid,,4.56,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Alliance,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Alliance,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Alliance,Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Alliance,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Alliance,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Alliance,Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Alliance,Medicaid,,8.13,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Alliance,Medicaid,,6.00,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Alliance,Medicaid,,11.73,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Alliance,Medicaid,,11.10,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Alliance,Medicaid,,9.11,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Alliance,Medicaid,,41.93,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Alliance,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Alliance,Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Alliance,Medicaid,,86.34,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Alliance,Medicaid,,98.82,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Alliance,Medicaid,,5497.41,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Alliance,Medicaid,,18.50,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Alliance,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Alliance,Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Alliance,Medicaid,,61.08,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Alliance,Medicaid,,1817.11,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Alliance,Medicaid,,5.48,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Alliance,Medicaid,,24.14,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Alliance,Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Alliance,Medicaid,,21.52,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Alliance,Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Alliance,Medicaid,,11.36,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Alliance,Medicaid,,26.31,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Alliance,Medicaid,,19.48,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Alliance,Medicaid,,88.51,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Alliance,Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Alliance,Medicaid,,12.31,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Alliance,Medicaid,,9.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Alliance,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Alliance,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Alliance,Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Alliance,Medicaid,,102.41,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Alliance,Medicaid,,70.69,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Alliance,Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Alliance,Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Alliance,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Alliance,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Alliance,Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Alliance,Medicaid,,6.69,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Alliance,Medicaid,,8103.63,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Alliance,Medicaid,,113.70,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Alliance,Medicaid,,8.19,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Alliance,Medicaid,,19.64,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Alliance,Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Alliance,Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Alliance,Medicaid,,31.01,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Alliance,Medicaid,,11.84,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Alliance,Medicaid,,5378.81,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Alliance,Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Alliance,Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Alliance,Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Alliance,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Alliance,Medicaid,,19.84,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Alliance,Medicaid,,767.34,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Alliance,Medicaid,,0.65065,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Alliance,Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Alliance,Medicaid,,217.13,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Alliance,Medicaid,,8.14,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Alliance,Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Alliance,Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Alliance,Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Alliance,Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Alliance,Medicaid,,157.47,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Alliance,Medicaid,,8019.54,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Alliance,Medicaid,,4011.38,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Alliance,Medicaid,,0.79079,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Alliance,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Alliance,Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Alliance,Medicaid,,20.41,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Alliance,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Alliance,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Alliance,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Alliance,Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Alliance,Medicaid,,6.81,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Alliance,Medicaid,,19.62,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Alliance,Medicaid,,25.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Alliance,Medicaid,,74.41,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Alliance,Medicaid,,18.99,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Alliance,Medicaid,,42.04,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Alliance,Medicaid,,5.26,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Alliance,Medicaid,,10.00,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Alliance,Medicaid,,35.09,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Alliance,Medicaid,,6.19,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Alliance,Medicaid,,162.77,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Alliance,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Alliance,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Alliance,Medicaid,,106.41,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Alliance,Medicaid,,16.03,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Alliance,Medicaid,,7.52,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Alliance,Medicaid,,3.75,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Alliance,Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Alliance,Medicaid,,55.32,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Alliance,Medicaid,,9.68,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Alliance,Medicaid,,53.33,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Alliance,Medicaid,,0.81081,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Alliance,Medicaid,,32.01,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alliance,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alliance,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Alliance,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Alliance,Medicaid,,105.45,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Alliance,Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Alliance,Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Alliance,Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Alliance,Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Alliance,Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Alliance,Medicaid,,15.03,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Alliance,Medicaid,,15.11,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Alliance,Medicaid,,14.30,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Alliance,Medicaid,,5.81,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Alliance,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Alliance,Medicaid,,4.19,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Alliance,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Alliance,Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Alliance,Medicaid,,7.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Alliance,Medicaid,,731.93,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Alliance,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Alliance,Medicaid,,2510.96,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Alliance,Medicaid,,5018.69,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Alliance,Medicaid,,414.16,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Alliance,Medicaid,,551.21,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Alliance,Medicaid,,616.62,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Alliance,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Alliance,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Alliance,Medicaid,,86.74,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Alliance,Medicaid,,4.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Alliance,Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Alliance,Medicaid,,3.41,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Alliance,Medicaid,,3.50,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Alliance,Medicaid,,130.73,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Alliance,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Alliance,Medicaid,,17.24,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Alliance,Medicaid,,12.13,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Alliance,Medicaid,,149.34,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Alliance,Medicaid,,21.02,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Alliance,Medicaid,,7.95,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Alliance,Medicaid,,12.31,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Alliance,Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Alliance,Medicaid,,4.34,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Alliance,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Alliance,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Alliance,Medicaid,,17.02,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Alliance,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Alliance,Medicaid,,44.63,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Alliance,Medicaid,,63.06,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Alliance,Medicaid,,2.96,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Alliance,Medicaid,,332.95,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Alliance,Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Alliance,Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Alliance,Medicaid,,16.42,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Alliance,Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Alliance,Medicaid,,438.24,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Alliance,Medicaid,,7.20,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Alliance,Medicaid,,53.01,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Alliance,Medicaid,,20.92,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Alliance,Medicaid,,22.77,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Alliance,Medicaid,,9.22,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Alliance,Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Alliance,Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Alliance,Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Alliance,Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Alliance,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Alliance,Medicaid,,83.52,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Alliance,Medicaid,,307.07,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Alliance,Medicaid,,7.71,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Alliance,Medicaid,,12.38,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Alliance,Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Alliance,Medicaid,,19.29,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Alliance,Medicaid,,60.65,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Alliance,Medicaid,,726.37,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Alliance,Medicaid,,25.45,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Alliance,Medicaid,,42.27,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Alliance,Medicaid,,17.83,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Alliance,Medicaid,,6.87,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Alliance,Medicaid,,12.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Alliance,Medicaid,,6.26,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Alliance,Medicaid,,40.30,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Alliance,Medicaid,,34.84,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Alliance,Medicaid,,12.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Alliance,Medicaid,,12.98,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Alliance,Medicaid,,12.95,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Alliance,Medicaid,,47.84,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Alliance,Medicaid,,18.24,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Alliance,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Alliance,Medicaid,,132.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Alliance,Medicaid,,77.12,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Alliance,Medicaid,,363.01,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Alliance,Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Alliance,Medicaid,,0.92092,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Alliance,Medicaid,,435.35,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Alliance,Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Alliance,Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Alliance,Medicaid,,18.92,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Alliance,Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Alliance,Medicaid,,6.65,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Alliance,Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Alliance,Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Alliance,Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Alliance,Medicaid,,15.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Alliance,Medicaid,,71.27,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Alliance,Medicaid,,11.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Alliance,Medicaid,,9.80,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Alliance,Medicaid,,1016.27,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Alliance,Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Alliance,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Alliance,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Alliance,Medicaid,,128.67,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Alliance,Medicaid,,51.03,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Alliance,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Alliance,Medicaid,,19.13,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Alliance,Medicaid,,5.04,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Alliance,Medicaid,,33.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Alliance,Medicaid,,17.08,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Alliance,Medicaid,,20.59,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Alliance,Medicaid,,5.10,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Alliance,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Alliance,Medicaid,,483.85,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Alliance,Medicaid,,805.26,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Alliance,Medicaid,,97.34,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Alliance,Medicaid,,143.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Alliance,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Alliance,Medicaid,,210.27,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Alliance,Medicaid,,10.78,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Alliance,Medicaid,,346.52,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Alliance,Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Alliance,Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Alliance,Medicaid,,22.78,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Alliance,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Alliance,Medicaid,,330.39,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Alliance,Medicaid,,9091.99,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Alliance,Medicaid,,31273.72,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Alliance,Medicaid,,51551.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Alliance,Medicaid,,2234.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Alliance,Medicaid,,1479.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Alliance,Medicaid,,51.85,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Alliance,Medicaid,,2.73,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Alliance,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Alliance,Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Alliance,Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Alliance,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Alliance,Medicaid,,103.90,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Alliance,Medicaid,,257.66,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Alliance,Medicaid,,385.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Alliance,Medicaid,,578.78,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Alliance,Medicaid,,694.49,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Alliance,Medicaid,,833.23,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Alliance,Medicaid,,1000.20,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Alliance,Medicaid,,413.41,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Alliance,Medicaid,,607.21,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Alliance,Medicaid,,1104.30,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Alliance,Medicaid,,32.03,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Alliance,Medicaid,,126.73,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Alliance,Medicaid,,34.63,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,,23.42,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Alliance,Medicaid,,5.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Alliance,Medicaid,,28.63,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Alliance,Medicaid,,31.63,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Alliance,Medicaid,,104.90,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Alliance,Medicaid,,119.52,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Alliance,Medicaid,,101.70,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Alliance,Medicaid,,18.42,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Alliance,Medicaid,,14.61,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Alliance,Medicaid,,46.05,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Alliance,Medicaid,,42.24,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Alliance,Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Alliance,Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Alliance,Medicaid,,997.40,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Alliance,Medicaid,,357.56,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Alliance,Medicaid,,601.60,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Alliance,Medicaid,,305.51,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Alliance,Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Alliance,Medicaid,,218.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Alliance,Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Alliance,Medicaid,,247.45,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Alliance,Medicaid,,181.98,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Alliance,Medicaid,,60.66,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Alliance,Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Alliance,Medicaid,,187.79,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Alliance,Medicaid,,53.25,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Alliance,Medicaid,,40.84,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Alliance,Medicaid,,218.62,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Alliance,Medicaid,,189.79,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Alliance,Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Alliance,Medicaid,,8.61,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Alliance,Medicaid,,7.01,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Alliance,Medicaid,,28.03,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Alliance,Medicaid,,94.89,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Alliance,Medicaid,,25.23,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Alliance,Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Alliance,Medicaid,,26.83,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Alliance,Medicaid,,2.20,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Alliance,Medicaid,,998.00,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Alliance,Medicaid,,4024.02,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Alliance,Medicaid,,1015.81,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Alliance,Medicaid,,848.85,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Alliance,Medicaid,,696.30,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Alliance,Medicaid,,92.69,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Alliance,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Alliance,Medicaid,,906.91,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Alliance,Medicaid,,893.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Alliance,Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Alliance,Medicaid,,1168.17,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Alliance,Medicaid,,829.43,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Alliance,Medicaid,,829.43,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Alliance,Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Alliance,Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Alliance,Medicaid,,1174.37,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Alliance,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Alliance,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Alliance,Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Alliance,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Alliance,Medicaid,,349.35,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Alliance,Medicaid,,822.82,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Alliance,Medicaid,,338.54,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Alliance,Medicaid,,1301.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Alliance,Medicaid,,237.04,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Alliance,Medicaid,,486.89,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Alliance,Medicaid,,737.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Alliance,Medicaid,,860.26,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Alliance,Medicaid,,24.22,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Alliance,Medicaid,,341.54,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Alliance,Medicaid,,685.89,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Alliance,Medicaid,,16.62,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Alliance,Medicaid,,93.49,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Alliance,Medicaid,,137.94,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Alliance,Medicaid,,311.71,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Alliance,Medicaid,,236.04,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Alliance,Medicaid,,15.82,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Alliance,Medicaid,GP,4.20,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Alliance,Medicaid,,66.67,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Alliance,Medicaid,,300.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Alliance,Medicaid,,284.68,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Alliance,Medicaid,,228.23,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Alliance,Medicaid,,171.77,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Alliance,Medicaid,,115.32,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Alliance,Medicaid,,58.86,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Alliance,Medicaid,,327.93,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Alliance,Medicaid,,979.98,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Alliance,Medicaid,,1299.70,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Alliance,Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Alliance,Medicaid,,521.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Alliance,Medicaid,,5236.83,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Alliance,Medicaid,,5485.28,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Alliance,Medicaid,,5773.17,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Alliance,Medicaid,,6020.81,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Alliance,Medicaid,,6269.46,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Alliance,Medicaid,,6517.31,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Alliance,Medicaid,,6724.92,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Alliance,Medicaid,,7012.81,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Alliance,Medicaid,,7260.85,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Alliance,Medicaid,,7508.90,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Alliance,Medicaid,,7757.15,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Alliance,Medicaid,,77.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Alliance,Medicaid,,106.91,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Alliance,Medicaid,,165.97,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Alliance,Medicaid,,167.37,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Alliance,Medicaid,,807.81,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Alliance,Medicaid,,1938.94,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Alliance,Medicaid,,2083.48,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Alliance,Medicaid,,2238.04,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Alliance,Medicaid,,1220.02,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Alliance,Medicaid,,1576.17,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Alliance,Medicaid,,1792.79,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Alliance,Medicaid,,2308.31,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Alliance,Medicaid,,2369.57,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Alliance,Medicaid,,2427.22,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Alliance,Medicaid,,2485.08,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Alliance,Medicaid,,2542.74,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Alliance,Medicaid,,990.19,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Alliance,Medicaid,,133.73,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Alliance,Medicaid,,882.08,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Alliance,Medicaid,,1190.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Alliance,Medicaid,,1630.83,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Alliance,Medicaid,,2066.86,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Alliance,Medicaid,,2359.76,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Alliance,Medicaid,,2672.67,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Alliance,Medicaid,,3048.85,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Alliance,Medicaid,,3268.06,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Alliance,Medicaid,,3591.59,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Alliance,Medicaid,,3767.56,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Alliance,Medicaid,,3997.99,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Alliance,Medicaid,,4146.34,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Alliance,Medicaid,,4183.58,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Alliance,Medicaid,,4245.64,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Alliance,Medicaid,,4369.36,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Alliance,Medicaid,,4493.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Alliance,Medicaid,,4617.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Alliance,Medicaid,,4741.74,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Alliance,Medicaid,,4865.26,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Alliance,Medicaid,,4989.38,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Alliance,Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Alliance,Medicaid,,2274.67,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Alliance,Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Alliance,Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Alliance,Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Alliance,Medicaid,,1297.30,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Alliance,Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Alliance,Medicaid,,1513.91,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Alliance,Medicaid,,1705.90,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Alliance,Medicaid,,60.66,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Alliance,Medicaid,,254.45,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Alliance,Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Alliance,Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Alliance,Medicaid,,161.76,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Alliance,Medicaid,,2160.96,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Alliance,Medicaid,,378.38,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Alliance,Medicaid,,245.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Alliance,Medicaid,,1436.23,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Alliance,Medicaid,,59.26,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Alliance,Medicaid,,151.35,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Alliance,Medicaid,,0.60060,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Alliance,Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Alliance,Medicaid,,425.83,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Alliance,Medicaid,,521.92,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Alliance,Medicaid,,617.62,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Alliance,Medicaid,,713.51,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Alliance,Medicaid,,809.41,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Alliance,Medicaid,,905.10,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Alliance,Medicaid,,132.33,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Alliance,Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Alliance,Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Alliance,Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Alliance,Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Alliance,Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Alliance,Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Alliance,Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Alliance,Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Alliance,Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Alliance,Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Alliance,Medicaid,,191.79,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Alliance,Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Alliance,Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Alliance,Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Alliance,Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Alliance,Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Alliance,Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Alliance,Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Alliance,Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Alliance,Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Alliance,Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Alliance,Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Alliance,Medicaid,,57.06,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Alliance,Medicaid,,271.67,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Alliance,Medicaid,,307.71,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Alliance,Medicaid,,344.14,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Alliance,Medicaid,,380.58,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Alliance,Medicaid,,417.42,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Alliance,Medicaid,,454.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Alliance,Medicaid,,490.49,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Alliance,Medicaid,,526.73,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Alliance,Medicaid,,562.96,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Alliance,Medicaid,,599.80,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Alliance,Medicaid,,636.04,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Alliance,Medicaid,,683.48,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Alliance,Medicaid,,720.32,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Alliance,Medicaid,,859.46,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Alliance,Medicaid,,915.71,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Alliance,Medicaid,,958.36,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Alliance,Medicaid,,994.79,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Alliance,Medicaid,,1031.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Alliance,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Alliance,Medicaid,,928.13,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Alliance,Medicaid,,825.42,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Alliance,Medicaid,,523.12,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Alliance,Medicaid,,565.57,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Alliance,Medicaid,,497.70,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Alliance,Medicaid,,669.07,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Alliance,Medicaid,,67.47,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Alliance,Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Alliance,Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Alliance,Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Alliance,Medicaid,,255.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Alliance,Medicaid,,419.62,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Alliance,Medicaid,,466.27,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Alliance,Medicaid,,253.05,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Alliance,Medicaid,,1500.30,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Alliance,Medicaid,,203.40,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Alliance,Medicaid,,80.88,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Alliance,Medicaid,,915.71,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Alliance,Medicaid,,2169.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Alliance,Medicaid,,1055.85,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Alliance,Medicaid,,61.46,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Alliance,Medicaid,,8004.80,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Alliance,Medicaid,,8252.64,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Alliance,Medicaid,,377.38,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Alliance,Medicaid,,111.51,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Alliance,Medicaid,,583.58,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Alliance,Medicaid,,17.22,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Alliance,Medicaid,,36.64,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Alliance,Medicaid,,19.82,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Alliance,Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Alliance,Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Alliance,Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Alliance,Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Alliance,Medicaid,,275.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Alliance,Medicaid,,3917.71,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Alliance,Medicaid,,1825.82,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Alliance,Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Alliance,Medicaid,,991.79,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Alliance,Medicaid,,1489.09,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Alliance,Medicaid,,1685.28,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Alliance,Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Alliance,Medicaid,,1270.87,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Alliance,Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Alliance,Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Alliance,Medicaid,,41.84,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Alliance,Medicaid,,29.03,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Alliance,Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Alliance,Medicaid,,25.23,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Alliance,Medicaid,,30.23,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Alliance,Medicaid,,36.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Alliance,Medicaid,,59.06,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Alliance,Medicaid,,71.07,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Alliance,Medicaid,,209.81,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Alliance,Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Alliance,Medicaid,,85.08,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Alliance,Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Alliance,Medicaid,,214.81,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Alliance,Medicaid,,189.79,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Alliance,Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Alliance,Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Alliance,Medicaid,,154.95,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Alliance,Medicaid,,1025.02,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Alliance,Medicaid,,100.70,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Alliance,Medicaid,,90.49,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Alliance,Medicaid,,270.07,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Alliance,Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Alliance,Medicaid,,297.10,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Alliance,Medicaid,,276.08,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Alliance,Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Alliance,Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Alliance,Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Alliance,Medicaid,,1345.34,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Alliance,Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Alliance,Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Alliance,Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Alliance,Medicaid,,243.24,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Alliance,Medicaid,,326.53,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Alliance,Medicaid,,580.38,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Alliance,Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Alliance,Medicaid,,92.69,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Alliance,Medicaid,,28.03,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Alliance,Medicaid,,33.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Alliance,Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Alliance,Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Alliance,Medicaid,,205.00,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Alliance,Medicaid,,127.53,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Alliance,Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Alliance,Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Alliance,Medicaid,,59.46,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Alliance,Medicaid,,61.66,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Alliance,Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Alliance,Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Alliance,Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Alliance,Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Alliance,Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Alliance,Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Alliance,Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Alliance,Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Alliance,Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Alliance,Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Alliance,Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Alliance,Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Alliance,Medicaid,,1897.10,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Alliance,Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Alliance,Medicaid,,539.74,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Alliance,Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Alliance,Medicaid,,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Alliance,Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Alliance,Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Alliance,Medicaid,,1227.43,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Alliance,Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Alliance,Medicaid,,251.25,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Alliance,Medicaid,,107.51,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Alliance,Medicaid,,1345.34,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Alliance,Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Alliance,Medicaid,,188.19,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Alliance,Medicaid,,44.04,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Alliance,Medicaid,,111.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Alliance,Medicaid,,1088.29,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Alliance,Medicaid,,3972.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Alliance,Medicaid,,5483.48,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Alliance,Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Alliance,Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Alliance,Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Alliance,Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Alliance,Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Alliance,Medicaid,,625.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Alliance,Medicaid,,234.63,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Alliance,Medicaid,,301.70,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Alliance,Medicaid,,283.28,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Alliance,Medicaid,,274.27,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Alliance,Medicaid,,1994.79,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Alliance,Medicaid,Q1,1268.27,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Alliance,Medicaid,Q0,759.76,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Alliance,Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Alliance,Medicaid,,84.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Alliance,Medicaid,,109.91,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Alliance,Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Alliance,Medicaid,,117.12,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Alliance,Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Alliance,Medicaid,,75.48,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Alliance,Medicaid,,18.42,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Alliance,Medicaid,,57.66,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Alliance,Medicaid,,87.49,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Alliance,Medicaid,,52.45,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Alliance,Medicaid,,46.85,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Alliance,Medicaid,,130.53,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Alliance,Medicaid,,6.61,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Alliance,Medicaid,,380.18,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Alliance,Medicaid,,48.05,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Alliance,Medicaid,,72.07,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Alliance,Medicaid,,92.69,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Alliance,Medicaid,,84.08,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Alliance,Medicaid,,389.79,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Alliance,Medicaid,,398.40,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Alliance,Medicaid,,186.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Alliance,Medicaid,,281.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Alliance,Medicaid,,292.29,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Alliance,Medicaid,,345.14,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Alliance,Medicaid,,420.02,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Alliance,Medicaid,,704.50,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Alliance,Medicaid,,1249.65,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Alliance,Medicaid,,1347.55,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Alliance,Medicaid,,127.13,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Alliance,Medicaid,,170.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Alliance,Medicaid,,1271.67,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Alliance,Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Alliance,Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Alliance,Medicaid,,339.94,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Alliance,Medicaid,,554.35,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Alliance,Medicaid,,146.95,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Alliance,Medicaid,,219.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Alliance,Medicaid,,93.89,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Alliance,Medicaid,,193.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Alliance,Medicaid,,137.54,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Alliance,Medicaid,,309.31,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Alliance,Medicaid,,214.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Alliance,Medicaid,,372.77,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Alliance,Medicaid,,90.09,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Alliance,Medicaid,,241.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Alliance,Medicaid,,1499.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Alliance,Medicaid,,1492.29,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Alliance,Medicaid,,480.08,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Alliance,Medicaid,,349.55,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Alliance,Medicaid,,620.62,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Alliance,Medicaid,,1686.28,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Alliance,Medicaid,,85.08,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Alliance,Medicaid,,113.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Alliance,Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Alliance,Medicaid,,418.82,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Alliance,Medicaid,,927.93,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Alliance,Medicaid,,492.09,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Alliance,Medicaid,,600.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Alliance,Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Alliance,Medicaid,,64.26,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Alliance,Medicaid,,215.42,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Alliance,Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Alliance,Medicaid,,120.72,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Alliance,Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Alliance,Medicaid,,307.71,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Alliance,Medicaid,,123.12,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Alliance,Medicaid,,146.95,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Alliance,Medicaid,,91.49,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Alliance,Medicaid,,66.27,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Alliance,Medicaid,,104.70,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Alliance,Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Alliance,Medicaid,,206.61,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Alliance,Medicaid,,177.98,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Alliance,Medicaid,,232.83,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Alliance,Medicaid,,210.41,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Alliance,Medicaid,,281.48,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Alliance,Medicaid,76,281.48,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Alliance,Medicaid,,750.35,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Alliance,Medicaid,76,750.35,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Alliance,Medicaid,,789.79,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Alliance,Medicaid,76,789.79,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Alliance,Medicaid,,407.21,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Alliance,Medicaid,,452.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Alliance,Medicaid,,477.08,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Alliance,Medicaid,,526.33,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Alliance,Medicaid,,366.97,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Alliance,Medicaid,,524.92,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Alliance,Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Alliance,Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Alliance,Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Alliance,Medicaid,,58.46,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Alliance,Medicaid,,568.97,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Alliance,Medicaid,,5465.26,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Alliance,Medicaid,,751.35,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Alliance,Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Alliance,Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Alliance,Medicaid,,129.73,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Alliance,Medicaid,,141.74,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Alliance,Medicaid,,245.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Alliance,Medicaid,,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Alliance,Medicaid,,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Alliance,Medicaid,,187.79,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Alliance,Medicaid,,128.33,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Alliance,Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Alliance,Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Alliance,Medicaid,,72.67,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Alliance,Medicaid,,91.09,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Alliance,Medicaid,76,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Alliance,Medicaid,76,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Alliance,Medicaid,,99.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Alliance,Medicaid,,209.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Alliance,Medicaid,,326.13,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Alliance,Medicaid,,469.07,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Alliance,Medicaid,,1384.18,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Alliance,Medicaid,,146.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Alliance,Medicaid,,1214.61,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Alliance,Medicaid,,451.25,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Alliance,Medicaid,,567.97,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Alliance,Medicaid,,369.97,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Alliance,Medicaid,,174.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Alliance,Medicaid,,109.91,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Alliance,Medicaid,,161.16,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Alliance,Medicaid,,250.65,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Alliance,Medicaid,,1634.43,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Alliance,Medicaid,,482.48,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Alliance,Medicaid,,81.08,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Alliance,Medicaid,,112.11,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Alliance,Medicaid,,332.73,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Alliance,Medicaid,,384.98,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Alliance,Medicaid,,255.05,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Alliance,Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Alliance,Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Alliance,Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alliance,Medicaid,,625.22,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Alliance,Medicaid,,70.27,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Alliance,Medicaid,,211.01,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Alliance,Medicaid,,6.81,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Alliance,Medicaid,,93.09,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Alliance,Medicaid,,205.81,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Alliance,Medicaid,,242.64,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Alliance,Medicaid,,64.46,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Alliance,Medicaid,,151.55,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Alliance,Medicaid,,32.43,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Alliance,Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Alliance,Medicaid,,59.86,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Alliance,Medicaid,,119.12,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Alliance,Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Alliance,Medicaid,,60.46,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Alliance,Medicaid,,21.82,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Alliance,Medicaid,,40.04,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Alliance,Medicaid,,32.23,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Alliance,Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Alliance,Medicaid,,26.63,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Alliance,Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Alliance,Medicaid,,87.69,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Alliance,Medicaid,,10.01,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Alliance,Medicaid,,82.68,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Alliance,Medicaid,,57.66,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Alliance,Medicaid,,38.24,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Alliance,Medicaid,,53.85,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Alliance,Medicaid,GP,13.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Alliance,Medicaid,GP,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Alliance,Medicaid,GP,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Alliance,Medicaid,GP,24.22,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,GP,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Alliance,Medicaid,GP,3.20,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Alliance,Medicaid,GP,30.63,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Alliance,Medicaid,GP,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Alliance,Medicaid,GP,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,GP,22.02,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,GP,11.81,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Alliance,Medicaid,GP,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Alliance,Medicaid,GP,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Alliance,Medicaid,GP,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,GP,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Alliance,Medicaid,GP,27.83,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Alliance,Medicaid,GP,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,GP,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Alliance,Medicaid,GP,30.23,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Alliance,Medicaid,GP,9.41,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,GP,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Alliance,Medicaid,GP,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Alliance,Medicaid,GP,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Alliance,Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Alliance,Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,GP,17.82,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Alliance,Medicaid,GP,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Alliance,Medicaid,GP,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Alliance,Medicaid,GP,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Alliance,Medicaid,GP,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Alliance,Medicaid,GP,61.26,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Alliance,Medicaid,GP,84.68,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Alliance,Medicaid,GP,86.89,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Alliance,Medicaid,GP,57.66,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,GO,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,GO,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,GO,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Alliance,Medicaid,GO,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Alliance,Medicaid,GO,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Alliance,Medicaid,GO,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Alliance,Medicaid,GO,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Alliance,Medicaid,GO,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,GO,12.41,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Alliance,Medicaid,GO,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Alliance,Medicaid,GO,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Alliance,Medicaid,GO,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,GO,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,GO,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Alliance,Medicaid,GO,44.84,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Alliance,Medicaid,GO,30.43,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Alliance,Medicaid,GO,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Alliance,Medicaid,GO,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Alliance,Medicaid,GO,63.66,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Alliance,Medicaid,GO,80.68,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Alliance,Medicaid,GO,83.08,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Alliance,Medicaid,GO,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Alliance,Medicaid,GN,71.27,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Alliance,Medicaid,GN,67.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Alliance,Medicaid,GN,37.44,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Alliance,Medicaid,GN,53.85,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Alliance,Medicaid,GN,40.04,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Alliance,Medicaid,GN,63.06,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Alliance,Medicaid,GN,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Alliance,Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Alliance,Medicaid,GN,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Alliance,Medicaid,GN,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Alliance,Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,GN,27.23,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Alliance,Medicaid,GN,131.13,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Alliance,Medicaid,GN,51.85,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Alliance,Medicaid,GN,13.61,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Alliance,Medicaid,GN,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Alliance,Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Alliance,Medicaid,GN,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Alliance,Medicaid,GN,42.84,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Alliance,Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Alliance,Medicaid,GN,21.42,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Alliance,Medicaid,GN,70.67,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Alliance,Medicaid,GN,109.91,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Alliance,Medicaid,GN,118.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Alliance,Medicaid,,172.97,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Alliance,Medicaid,,109.91,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Alliance,Medicaid,,177.18,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Alliance,Medicaid,,100.90,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Alliance,Medicaid,,149.15,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Alliance,Medicaid,,751.95,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Alliance,Medicaid,,8.61,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Alliance,Medicaid,,29.63,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Alliance,Medicaid,,105.11,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Alliance,Medicaid,,104.70,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Alliance,Medicaid,,112.71,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Alliance,Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Alliance,Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Alliance,Medicaid,,271.67,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Alliance,Medicaid,,83.68,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Alliance,Medicaid,,162.56,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Alliance,Medicaid,,113.51,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Alliance,Medicaid,,95.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Alliance,Medicaid,,130.53,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Alliance,Medicaid,,91.69,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Alliance,Medicaid,,31.23,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Alliance,Medicaid,,36.04,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Alliance,Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Alliance,Medicaid,,26.23,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Alliance,Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Alliance,Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Alliance,Medicaid,,52.85,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Alliance,Medicaid,,52.85,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Alliance,Medicaid,,400.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alliance,Medicaid,,625.22,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Alliance,Medicaid,,140.14,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Alliance,Medicaid,,454.85,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Alliance,Medicaid,,166.37,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Alliance,Medicaid,,101.10,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Alliance,Medicaid,,44.44,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Alliance,Medicaid,,66.67,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Alliance,Medicaid,,67.67,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Alliance,Medicaid,,37.04,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Alliance,Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Alliance,Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Alliance,Medicaid,,203.60,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Alliance,Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Alliance,Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Alliance,Medicaid,,854.05,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Alliance,Medicaid,,231.03,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Alliance,Medicaid,,110.51,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Alliance,Medicaid,,113.11,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Alliance,Medicaid,,270.27,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Alliance,Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Alliance,Medicaid,,110.11,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Alliance,Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Alliance,Medicaid,,210.41,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Alliance,Medicaid,,90.69,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Alliance,Medicaid,,254.45,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Alliance,Medicaid,,232.03,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Alliance,Medicaid,,145.75,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Alliance,Medicaid,,96.30,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Alliance,Medicaid,,225.43,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Alliance,Medicaid,,63.26,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Alliance,Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Alliance,Medicaid,,24.82,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Alliance,Medicaid,,191.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Alliance,Medicaid,,114.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Alliance,Medicaid,,92.89,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Alliance,Medicaid,,107.91,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Alliance,Medicaid,,100.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Alliance,Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Alliance,Medicaid,,81.08,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Alliance,Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Alliance,Medicaid,,81.08,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Alliance,Medicaid,,74.67,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Alliance,Medicaid,,134.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Alliance,Medicaid,,164.56,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Alliance,Medicaid,,171.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Alliance,Medicaid,,177.78,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Alliance,Medicaid,,107.91,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Alliance,Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Alliance,Medicaid,,59.06,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Alliance,Medicaid,,87.49,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Alliance,Medicaid,,50.65,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Alliance,Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Alliance,Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Alliance,Medicaid,,109.51,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Alliance,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Alliance,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Alliance,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Alliance,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Alliance,Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Alliance,Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Alliance,Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Alliance,Medicaid,,53.45,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Alliance,Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Alliance,Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Alliance,Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Alliance,Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Alliance,Medicaid,,91.49,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Alliance,Medicaid,,91.09,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Alliance,Medicaid,,298.50,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Alliance,Medicaid,,305.51,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Alliance,Medicaid,,169.77,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Alliance,Medicaid,,246.85,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Alliance,Medicaid,,84.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Alliance,Medicaid,,199.60,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Alliance,Medicaid,,92.69,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Alliance,Medicaid,,108.91,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Alliance,Medicaid,,263.26,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Alliance,Medicaid,,317.92,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Alliance,Medicaid,,390.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Alliance,Medicaid,,553.95,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Alliance,Medicaid,,608.41,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Alliance,Medicaid,,771.97,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Alliance,Medicaid,,454.05,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Alliance,Medicaid,,508.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Alliance,Medicaid,,572.17,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Alliance,Medicaid,,908.11,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Alliance,Medicaid,,1017.02,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Alliance,Medicaid,,1135.13,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Alliance,Medicaid,,208.61,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Alliance,Medicaid,,45.05,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Alliance,Medicaid,,58.46,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Alliance,Medicaid,,58.86,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Alliance,Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Alliance,Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Alliance,Medicaid,,21.22,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Alliance,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Alliance,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Alliance,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Alliance,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Alliance,Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Alliance,Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Alliance,Medicaid,GP,13.35,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Alliance,Medicaid,,95.90,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Alliance,Medicaid,,549.35,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Alliance,Medicaid,,549.35,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Alliance,Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Alliance,Medicaid,,217.22,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Alliance,Medicaid,,217.22,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Alliance,Medicaid,,493.29,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Alliance,Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Alliance,Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Alliance,Medicaid,,638.64,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Alliance,Medicaid,,86.09,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Alliance,Medicaid,,96.10,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Alliance,Medicaid,,107.31,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Alliance,Medicaid,,91.69,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Alliance,Medicaid,,23.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Alliance,Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Alliance,Medicaid,,32.63,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Alliance,Medicaid,,61.46,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Alliance,Medicaid,,104.10,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Alliance,Medicaid,,100.90,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Alliance,Medicaid,,123.72,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Alliance,Medicaid,,81.88,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Alliance,Medicaid,,154.15,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Alliance,Medicaid,,154.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Alliance,Medicaid,,127.73,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Alliance,Medicaid,,120.72,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Alliance,Medicaid,,180.58,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Alliance,Medicaid,,36.44,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Alliance,Medicaid,,30.43,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Alliance,Medicaid,,56.06,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Alliance,Medicaid,,77.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Alliance,Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Alliance,Medicaid,,151.95,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Alliance,Medicaid,,459.46,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Alliance,Medicaid,,121.52,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Alliance,Medicaid,,372.97,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Alliance,Medicaid,,372.97,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Alliance,Medicaid,,426.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Alliance,Medicaid,,107.31,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alliance,Medicaid,,207.61,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Alliance,Medicaid,,2503.90,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Alliance,Medicaid,,304.30,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Alliance,Medicaid,,386.99,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Alliance,Medicaid,,166.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Alliance,Medicaid,,173.97,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Alliance,Medicaid,,185.19,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Alliance,Medicaid,,307.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Alliance,Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Alliance,Medicaid,,1956.75,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Alliance,Medicaid,,132.13,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Alliance,Medicaid,,132.13,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Alliance,Medicaid,,638.44,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Alliance,Medicaid,,638.44,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Alliance,Medicaid,,305.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Alliance,Medicaid,,305.91,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Alliance,Medicaid,,345.75,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Alliance,Medicaid,,428.83,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Alliance,Medicaid,,428.83,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Alliance,Medicaid,,279.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Alliance,Medicaid,,279.68,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Alliance,Medicaid,,124.32,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Alliance,Medicaid,,124.32,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Alliance,Medicaid,,144.14,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Alliance,Medicaid,,144.14,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Alliance,Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Alliance,Medicaid,,448.45,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Alliance,Medicaid,JW,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Alliance,Medicaid,,117.32,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Alliance,Medicaid,,99.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Alliance,Medicaid,,120.92,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Alliance,Medicaid,,99.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Alliance,Medicaid,,117.32,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Alliance,Medicaid,,164.56,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Alliance,Medicaid,,273.07,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Alliance,Medicaid,,70.47,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alliance,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alliance,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alliance,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Alliance,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Alliance,Medicaid,,390.39,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Alliance,Medicaid,,390.39,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Alliance,Medicaid,,621.22,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Alliance,Medicaid,,621.22,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Alliance,Medicaid,,344.94,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Alliance,Medicaid,,426.83,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Alliance,Medicaid,,560.56,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Alliance,Medicaid,,108.71,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Alliance,Medicaid,,877.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Alliance,Medicaid,,970.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Alliance,Medicaid,,1147.95,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Alliance,Medicaid,,160.96,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Alliance,Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Alliance,Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Alliance,Medicaid,,384.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Alliance,Medicaid,,340.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Alliance,Medicaid,,116.52,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Alliance,Medicaid,,454.05,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Alliance,Medicaid,,253.25,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Alliance,Medicaid,,467.07,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Alliance,Medicaid,,467.07,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Alliance,Medicaid,,409.81,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Alliance,Medicaid,,267.27,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Alliance,Medicaid,,169.57,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Alliance,Medicaid,,356.56,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Alliance,Medicaid,,356.56,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Alliance,Medicaid,,339.94,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Alliance,Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Alliance,Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Alliance,Medicaid,,359.16,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Alliance,Medicaid,,359.16,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Alliance,Medicaid,,824.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Alliance,Medicaid,,824.62,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Alliance,Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Alliance,Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Alliance,Medicaid,,102.50,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Alliance,Medicaid,,118.92,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Alliance,Medicaid,52,220.22,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Alliance,Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Alliance,Medicaid,,142.34,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Alliance,Medicaid,,292.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Alliance,Medicaid,,25.43,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Alliance,Medicaid,,183.98,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Alliance,Medicaid,,183.98,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Alliance,Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Alliance,Medicaid,,63.46,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Alliance,Medicaid,,139.54,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Alliance,Medicaid,,278.88,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Alliance,Medicaid,,475.48,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Alliance,Medicaid,,634.03,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Alliance,Medicaid,,803.00,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Alliance,Medicaid,,265.06,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Alliance,Medicaid,,241.64,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Alliance,Medicaid,,72.27,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Alliance,Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Alliance,Medicaid,,37.84,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Alliance,Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Alliance,Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Alliance,Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Alliance,Medicaid,,40.24,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Alliance,Medicaid,,49.85,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Alliance,Medicaid,,48.05,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Alliance,Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Alliance,Medicaid,,79.88,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Alliance,Medicaid,,74.27,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Alliance,Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Alliance,Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Alliance,Medicaid,,45.45,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Alliance,Medicaid,,53.45,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Alliance,Medicaid,,50.05,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Alliance,Medicaid,,81.28,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Alliance,Medicaid,,87.09,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Alliance,Medicaid,,87.49,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Alliance,Medicaid,,79.48,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Alliance,Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Alliance,Medicaid,,50.85,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Alliance,Medicaid,,77.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Alliance,Medicaid,,97.90,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Alliance,Medicaid,,13.21,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Alliance,Medicaid,,21.22,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Alliance,Medicaid,,35.24,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Alliance,Medicaid,,52.05,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Alliance,Medicaid,,68.67,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Alliance,Medicaid,,46.25,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Alliance,Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Alliance,Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Alliance,Medicaid,,115.32,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Alliance,Medicaid,,27.43,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Alliance,Medicaid,,22.42,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Alliance,Medicaid,,9.61,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Alliance,Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Alliance,Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Alliance,Medicaid,JW,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Alliance,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,JW,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Alliance,Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Alliance,Medicaid,,55.05,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Alliance,Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Alliance,Medicaid,JW,40.04,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Alliance,Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Alliance,Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Alliance,Medicaid,JW,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Alliance,Medicaid,JW,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Alliance,Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Alliance,Medicaid,JW,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Alliance,Medicaid,JW,54.65,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Alliance,Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Alliance,Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Alliance,Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Alliance,Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Alliance,Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Alliance,Medicaid,JW,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Alliance,Medicaid,JW,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Alliance,Medicaid,JW,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Alliance,Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Alliance,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Alliance,Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Alliance,Medicaid,JW,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Alliance,Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Alliance,Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Alliance,Medicaid,JW,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Alliance,Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Alliance,Medicaid,JW,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Alliance,Medicaid,JW,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Alliance,Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Alliance,Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Alliance,Medicaid,JW,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Alliance,Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Alliance,Medicaid,JW,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Alliance,Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Alliance,Medicaid,JW,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,JW,13.01,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Alliance,Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Alliance,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Alliance,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Alliance,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Alliance,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Alliance,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Alliance,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Alliance,Medicaid,JW,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Alliance,Medicaid,JW,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Alliance,Medicaid,JW,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Alliance,Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Alliance,Medicaid,JW,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Alliance,Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Alliance,Medicaid,JW,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Alliance,Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Alliance,Medicaid,JW,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Alliance,Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Alliance,Medicaid,JW,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Alliance,Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Alliance,Medicaid,JW,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Alliance,Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Alliance,Medicaid,JW,54.45,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Alliance,Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Alliance,Medicaid,,59.06,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Alliance,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Alliance,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Alliance,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Alliance,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Alliance,Medicaid,,54.05,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Alliance,Medicaid,,849.45,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Alliance,Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Alliance,Medicaid,,49.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Alliance,Medicaid,,515.92,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Alliance,Medicaid,,41.84,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Alliance,Medicaid,,60.66,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Alliance,Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Alliance,Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Alliance,Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Alliance,Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Alliance,Medicaid,,67.47,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Alliance,Medicaid,,56.06,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Alliance,Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Alliance,Medicaid,,1877.68,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Alliance,Medicaid,,222.82,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alliance,Medicaid,,207.61,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Alliance,Medicaid,,239.64,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Alliance,Medicaid,,161.36,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Alliance,Medicaid,,397.40,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Alliance,Medicaid,,397.40,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Alliance,Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Alliance,Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Alliance,Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Alliance,Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Alliance,Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Alliance,Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Alliance,Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Alliance,Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Alliance,Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Alliance,Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Alliance,Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Alliance,Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Alliance,Medicaid,,118.92,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Alliance,Medicaid,,102.50,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Alliance,Medicaid,,154.35,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Alliance,Medicaid,,136.34,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Alliance,Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Alliance,Medicaid,,28.63,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Alliance,Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Alliance,Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Alliance,Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Alliance,Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Alliance,Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Alliance,Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Alliance,Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,,33.03,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Alliance,Medicaid,,189.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Alliance,Medicaid,,96.90,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Alliance,Medicaid,,25.63,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Alliance,Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Alliance,Medicaid,,31.63,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Alliance,Medicaid,,18.42,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Alliance,Medicaid,,18.42,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Alliance,Medicaid,,42.44,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Alliance,Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Alliance,Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Alliance,Medicaid,,30.03,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Alliance,Medicaid,,17.02,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Alliance,Medicaid,,26.63,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Alliance,Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Alliance,Medicaid,,8008.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Alliance,Medicaid,,155.56,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Alliance,Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Alliance,Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Alliance,Medicaid,,989.19,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Alliance,Medicaid,,58.46,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Alliance,Medicaid,,176.98,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Alliance,Medicaid,,41.04,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Alliance,Medicaid,,41.04,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Alliance,Medicaid,,194.19,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Alliance,Medicaid,,246.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Alliance,Medicaid,,64.86,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Alliance,Medicaid,,1253.05,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alliance,Medicaid,,625.22,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Alliance,Medicaid,,97.30,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Alliance,Medicaid,,4128.92,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Alliance,Medicaid,,625.22,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Alliance,Medicaid,,168.57,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Alliance,Medicaid,,467.67,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Alliance,Medicaid,,463.86,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Alliance,Medicaid,,464.86,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Alliance,Medicaid,,2388.19,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Alliance,Medicaid,,104.90,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Alliance,Medicaid,,114.71,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Alliance,Medicaid,,266.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Alliance,Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Alliance,Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Alliance,Medicaid,,379.38,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Alliance,Medicaid,,379.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Alliance,Medicaid,,691.89,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Alliance,Medicaid,,691.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Alliance,Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Alliance,Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Alliance,Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Alliance,Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Alliance,Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Alliance,Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Alliance,Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Alliance,Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Alliance,Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Alliance,Medicaid,JW,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Alliance,Medicaid,JW,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Alliance,Medicaid,JW,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Alliance,Medicaid,JW,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Alliance,Medicaid,JW,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Alliance,Medicaid,JW,93.29,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Alliance,Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Alliance,Medicaid,,35.84,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Alliance,Medicaid,,159.56,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Alliance,Medicaid,,197.80,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Alliance,Medicaid,,286.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Alliance,Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Alliance,Medicaid,,35.84,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Alliance,Medicaid,,365.97,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Alliance,Medicaid,,519.32,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Alliance,Medicaid,,189.19,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Alliance,Medicaid,,577.18,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Alliance,Medicaid,,191.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Alliance,Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Alliance,Medicaid,,280.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Alliance,Medicaid,,435.23,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Alliance,Medicaid,,847.25,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Alliance,Medicaid,,3830.23,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Alliance,Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Alliance,Medicaid,,90.49,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Alliance,Medicaid,,80.28,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Alliance,Medicaid,,133.13,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Alliance,Medicaid,,63.66,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Alliance,Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Alliance,Medicaid,,64.86,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Alliance,Medicaid,,109.11,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Alliance,Medicaid,,70.47,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Alliance,Medicaid,,96.30,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Alliance,Medicaid,,120.32,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Alliance,Medicaid,,78.88,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Alliance,Medicaid,,88.49,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Alliance,Medicaid,,100.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Alliance,Medicaid,,30.43,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Alliance,Medicaid,,54.05,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Alliance,Medicaid,,24.02,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Alliance,Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Alliance,Medicaid,,134.33,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Alliance,Medicaid,,35.84,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Alliance,Medicaid,,60.46,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Alliance,Medicaid,,72.47,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Alliance,Medicaid,,96.70,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Alliance,Medicaid,,116.92,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Alliance,Medicaid,,216.02,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Alliance,Medicaid,,117.12,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Alliance,Medicaid,,61.06,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Alliance,Medicaid,,88.49,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Alliance,Medicaid,,99.30,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Alliance,Medicaid,,132.13,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Alliance,Medicaid,,185.99,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Alliance,Medicaid,,87.49,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Alliance,Medicaid,,65.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Alliance,Medicaid,,112.91,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Alliance,Medicaid,,98.50,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Alliance,Medicaid,,142.14,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Alliance,Medicaid,,175.18,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Alliance,Medicaid,,116.52,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Alliance,Medicaid,,68.27,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Alliance,Medicaid,,108.31,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Alliance,Medicaid,,73.87,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Alliance,Medicaid,,73.67,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Alliance,Medicaid,,242.44,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Alliance,Medicaid,,150.55,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Alliance,Medicaid,,267.47,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Alliance,Medicaid,,378.78,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Alliance,Medicaid,,416.62,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Alliance,Medicaid,,85.08,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Alliance,Medicaid,,76.48,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Alliance,Medicaid,,91.89,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Alliance,Medicaid,,92.49,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Alliance,Medicaid,,254.45,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Alliance,Medicaid,,104.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Alliance,Medicaid,,88.09,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Alliance,Medicaid,,81.28,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Alliance,Medicaid,,88.49,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Alliance,Medicaid,,97.50,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Alliance,Medicaid,,75.88,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Alliance,Medicaid,,59.66,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Alliance,Medicaid,,75.08,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Alliance,Medicaid,,69.47,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Alliance,Medicaid,,130.73,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Alliance,Medicaid,,86.29,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Alliance,Medicaid,,78.88,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Alliance,Medicaid,,55.26,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Alliance,Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Alliance,Medicaid,,85.49,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Alliance,Medicaid,,74.27,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Alliance,Medicaid,,96.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Alliance,Medicaid,,63.26,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Alliance,Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Alliance,Medicaid,,70.87,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Alliance,Medicaid,,43.64,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Alliance,Medicaid,,89.09,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Alliance,Medicaid,,92.69,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Alliance,Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Alliance,Medicaid,,106.11,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Alliance,Medicaid,,92.69,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Alliance,Medicaid,,80.28,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Alliance,Medicaid,,64.86,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Alliance,Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Alliance,Medicaid,,156.56,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Alliance,Medicaid,,64.46,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Alliance,Medicaid,,49.45,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Alliance,Medicaid,,211.21,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Alliance,Medicaid,,145.75,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Alliance,Medicaid,,177.78,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Alliance,Medicaid,,99.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Alliance,Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Alliance,Medicaid,,197.80,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alliance,Medicaid,,208.41,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Alliance,Medicaid,,215.01,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Alliance,Medicaid,,107.51,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Alliance,Medicaid,,19.62,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Alliance,Medicaid,,116.12,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Alliance,Medicaid,,128.73,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Alliance,Medicaid,,163.76,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Alliance,Medicaid,,133.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Alliance,Medicaid,,162.16,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Alliance,Medicaid,,418.02,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Alliance,Medicaid,,929.93,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Alliance,Medicaid,,716.12,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Alliance,Medicaid,,37.04,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Alliance,Medicaid,,273.87,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Alliance,Medicaid,,279.28,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Alliance,Medicaid,,810.21,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Alliance,Medicaid,,1150.35,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Alliance,Medicaid,,265.47,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Alliance,Medicaid,,514.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Alliance,Medicaid,,206.41,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Alliance,Medicaid,,240.64,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Alliance,Medicaid,,321.92,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Alliance,Medicaid,,160.96,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Alliance,Medicaid,,323.52,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Alliance,Medicaid,,193.59,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Alliance,Medicaid,,159.96,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Alliance,Medicaid,,221.42,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Alliance,Medicaid,,467.07,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Alliance,Medicaid,,275.48,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Alliance,Medicaid,,40.84,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Alliance,Medicaid,,35.03,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Alliance,Medicaid,,241.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Alliance,Medicaid,,154.35,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Alliance,Medicaid,,211.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Alliance,Medicaid,,71.67,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Alliance,Medicaid,,190.79,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Alliance,Medicaid,,33.83,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Alliance,Medicaid,,187.39,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Alliance,Medicaid,,61.26,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Alliance,Medicaid,,68.27,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Alliance,Medicaid,,28.63,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Alliance,Medicaid,,148.95,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Alliance,Medicaid,,132.53,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Alliance,Medicaid,,131.53,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Alliance,Medicaid,,64.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Alliance,Medicaid,,129.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Alliance,Medicaid,,69.27,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Alliance,Medicaid,,48.65,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Alliance,Medicaid,,53.65,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Alliance,Medicaid,,185.59,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Alliance,Medicaid,,61.26,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Alliance,Medicaid,,182.38,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Alliance,Medicaid,,58.26,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Alliance,Medicaid,,157.76,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Alliance,Medicaid,,469.07,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Alliance,Medicaid,,808.61,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Alliance,Medicaid,,668.27,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Alliance,Medicaid,,720.32,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Alliance,Medicaid,,407.41,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Alliance,Medicaid,,903.70,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Alliance,Medicaid,,903.70,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Alliance,Medicaid,,903.70,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Alliance,Medicaid,,611.21,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Alliance,Medicaid,,357.56,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Alliance,Medicaid,,281.08,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Alliance,Medicaid,,53.65,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Alliance,Medicaid,,74.87,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Alliance,Medicaid,,66.47,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Alliance,Medicaid,,166.37,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Alliance,Medicaid,,32.63,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Alliance,Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Alliance,Medicaid,,416.62,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Alliance,Medicaid,,123.52,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Alliance,Medicaid,,162.56,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Alliance,Medicaid,,172.37,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Alliance,Medicaid,,93.49,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Alliance,Medicaid,,98.90,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Alliance,Medicaid,,104.70,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Alliance,Medicaid,,151.75,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Alliance,Medicaid,,147.35,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Alliance,Medicaid,,216.02,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Alliance,Medicaid,,45.85,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Alliance,Medicaid,,86.49,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Alliance,Medicaid,,212.81,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Alliance,Medicaid,,123.12,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Alliance,Medicaid,,157.16,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Alliance,Medicaid,,7507.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Alliance,Medicaid,,43.44,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Alliance,Medicaid,,370.97,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Alliance,Medicaid,,451.05,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Alliance,Medicaid,,84.08,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Alliance,Medicaid,,110.11,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Alliance,Medicaid,,108.11,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Alliance,Medicaid,,80.28,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Alliance,Medicaid,,119.32,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Alliance,Medicaid,,99.50,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Alliance,Medicaid,,150.55,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Alliance,Medicaid,,116.32,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Alliance,Medicaid,,185.79,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Alliance,Medicaid,,276.68,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Alliance,Medicaid,,54.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Alliance,Medicaid,,165.97,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Alliance,Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Alliance,Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Alliance,Medicaid,,271.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Alliance,Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Alliance,Medicaid,,137.14,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Alliance,Medicaid,,221.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Alliance,Medicaid,,116.72,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Alliance,Medicaid,,583.98,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Alliance,Medicaid,,299.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Alliance,Medicaid,,218.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Alliance,Medicaid,,195.40,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Alliance,Medicaid,,143.54,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Alliance,Medicaid,,373.57,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Alliance,Medicaid,,203.00,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Alliance,Medicaid,,416.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Alliance,Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Alliance,Medicaid,,458.46,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Alliance,Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Alliance,Medicaid,,476.08,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Alliance,Medicaid,,547.15,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Alliance,Medicaid,,171.37,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Alliance,Medicaid,,313.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Alliance,Medicaid,,246.25,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Alliance,Medicaid,,449.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Alliance,Medicaid,,208.61,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Alliance,Medicaid,,229.83,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Alliance,Medicaid,,251.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Alliance,Medicaid,,357.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Alliance,Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Alliance,Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Alliance,Medicaid,,499.90,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Alliance,Medicaid,,775.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Alliance,Medicaid,,969.77,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Alliance,Medicaid,,166.37,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Alliance,Medicaid,,288.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Alliance,Medicaid,,259.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Alliance,Medicaid,,318.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Alliance,Medicaid,,497.70,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Alliance,Medicaid,,155.76,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Alliance,Medicaid,,293.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Alliance,Medicaid,,172.97,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Alliance,Medicaid,,218.22,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Alliance,Medicaid,,159.96,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alliance,Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Alliance,Medicaid,,264.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alliance,Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Alliance,Medicaid,,322.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Alliance,Medicaid,,254.45,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Alliance,Medicaid,,184.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Alliance,Medicaid,,468.67,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Alliance,Medicaid,,589.19,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Alliance,Medicaid,,55.46,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Alliance,Medicaid,,19.82,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Alliance,Medicaid,,406.41,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Alliance,Medicaid,,197.80,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Alliance,Medicaid,,41.64,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Alliance,Medicaid,,559.36,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Alliance,Medicaid,,2501.10,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Alliance,Medicaid,,328.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Alliance,Medicaid,,103.90,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Alliance,Medicaid,,407.01,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Alliance,Medicaid,,94.09,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Alliance,Medicaid,,2476.67,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Alliance,Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Alliance,Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Alliance,Medicaid,,17.42,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Alliance,Medicaid,,175.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Alliance,Medicaid,,23.82,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Alliance,Medicaid,,116.92,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Alliance,Medicaid,,64.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Alliance,Medicaid,,8.81,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Alliance,Medicaid,,1057.06,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Alliance,Medicaid,,1.20,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Alliance,Medicaid,,129.93,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Alliance,Medicaid,,24.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Alliance,Medicaid,,8.41,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Alliance,Medicaid,,16.42,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Alliance,Medicaid,,50.85,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Alliance,Medicaid,,1212.81,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Alliance,Medicaid,,36.64,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Alliance,Medicaid,,215.22,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Alliance,Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Alliance,Medicaid,,285.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Alliance,Medicaid,,61.06,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Alliance,Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Alliance,Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Alliance,Medicaid,,268.87,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Alliance,Medicaid,,97.50,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Alliance,Medicaid,,87.09,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Alliance,Medicaid,,448.45,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Alliance,Medicaid,,321.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Alliance,Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Alliance,Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Alliance,Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Alliance,Medicaid,,262.06,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Alliance,Medicaid,,386.19,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Alliance,Medicaid,,214.01,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Alliance,Medicaid,,381.98,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Alliance,Medicaid,,246.25,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Alliance,Medicaid,,804.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Alliance,Medicaid,,662.66,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Alliance,Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Alliance,Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Alliance,Medicaid,,813.21,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Alliance,Medicaid,,206.81,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Alliance,Medicaid,,225.43,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Alliance,Medicaid,,64.86,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Alliance,Medicaid,,507.91,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Alliance,Medicaid,,258.06,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Alliance,Medicaid,,227.83,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Alliance,Medicaid,,254.05,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Alliance,Medicaid,,452.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Alliance,Medicaid,,534.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Alliance,Medicaid,,653.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Alliance,Medicaid,,490.49,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Alliance,Medicaid,,588.99,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Alliance,Medicaid,,657.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Alliance,Medicaid,,507.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Alliance,Medicaid,,619.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Alliance,Medicaid,,701.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Alliance,Medicaid,,517.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Alliance,Medicaid,,617.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Alliance,Medicaid,,703.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Alliance,Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Alliance,Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Alliance,Medicaid,,466.67,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Alliance,Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Alliance,Medicaid,,688.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Alliance,Medicaid,,775.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Alliance,Medicaid,,574.97,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Alliance,Medicaid,,724.32,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Alliance,Medicaid,,741.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Alliance,Medicaid,,448.85,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Alliance,Medicaid,,546.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Alliance,Medicaid,,637.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Alliance,Medicaid,,524.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Alliance,Medicaid,,638.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Alliance,Medicaid,,745.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Alliance,Medicaid,,604.20,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Alliance,Medicaid,,458.86,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Alliance,Medicaid,,573.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Alliance,Medicaid,,614.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Alliance,Medicaid,,587.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Alliance,Medicaid,,805.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Alliance,Medicaid,,869.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Alliance,Medicaid,,795.59,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Alliance,Medicaid,,502.70,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Alliance,Medicaid,,646.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Alliance,Medicaid,,847.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Alliance,Medicaid,,986.39,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Alliance,Medicaid,,499.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Alliance,Medicaid,,635.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Alliance,Medicaid,,752.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Alliance,Medicaid,,1473.67,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Alliance,Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Alliance,Medicaid,,1072.07,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Alliance,Medicaid,,1277.08,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Alliance,Medicaid,,1484.48,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Alliance,Medicaid,,262.06,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Alliance,Medicaid,,812.61,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Alliance,Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Alliance,Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Alliance,Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Alliance,Medicaid,,560.56,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Alliance,Medicaid,,95.50,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Alliance,Medicaid,,234.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Alliance,Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Alliance,Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Alliance,Medicaid,,290.29,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Alliance,Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Alliance,Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Alliance,Medicaid,,380.58,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Alliance,Medicaid,,95.09,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Alliance,Medicaid,,67.47,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Alliance,Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Alliance,Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Alliance,Medicaid,,6299.49,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Alliance,Medicaid,,53.85,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Alliance,Medicaid,,145.75,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Alliance,Medicaid,,125.93,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Alliance,Medicaid,,399.00,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Alliance,Medicaid,,1022.02,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Alliance,Medicaid,,108.71,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Alliance,Medicaid,,277.68,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Alliance,Medicaid,,176.18,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Alliance,Medicaid,,11521.71,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Alliance,Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Alliance,Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Alliance,Medicaid,,5912.91,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Alliance,Medicaid,,222.22,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Alliance,Medicaid,,600.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Alliance,Medicaid,,31.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Alliance,Medicaid,,31.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Alliance,Medicaid,,84.28,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Alliance,Medicaid,,584.78,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Alliance,Medicaid,,125.93,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Alliance,Medicaid,,91.29,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Alliance,Medicaid,,46.45,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Alliance,Medicaid,,40.24,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Alliance,Medicaid,,96.30,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Alliance,Medicaid,,222.02,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Alliance,Medicaid,,91.69,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Alliance,Medicaid,,57.06,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Alliance,Medicaid,,280.28,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Alliance,Medicaid,,316.72,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Alliance,Medicaid,,316.72,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Alliance,Medicaid,,466.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Alliance,Medicaid,,466.47,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Alliance,Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Alliance,Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Alliance,Medicaid,,160.96,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Alliance,Medicaid,,160.96,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Alliance,Medicaid,,144.54,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Alliance,Medicaid,,115.52,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Alliance,Medicaid,,115.52,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Alliance,Medicaid,,944.94,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Alliance,Medicaid,,676.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Alliance,Medicaid,,142.54,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Alliance,Medicaid,,113.11,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Alliance,Medicaid,,283.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Alliance,Medicaid,,153.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Alliance,Medicaid,,258.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Alliance,Medicaid,,116.32,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Alliance,Medicaid,,255.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Alliance,Medicaid,,255.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Alliance,Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Alliance,Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Alliance,Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Alliance,Medicaid,,60.06,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Alliance,Medicaid,,388.99,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Alliance,Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Alliance,Medicaid,,166.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Alliance,Medicaid,,324.92,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Alliance,Medicaid,,354.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Alliance,Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Alliance,Medicaid,,362.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Alliance,Medicaid,,421.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Alliance,Medicaid,,421.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Alliance,Medicaid,,135.54,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Alliance,Medicaid,,135.54,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Alliance,Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Alliance,Medicaid,,136.94,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Alliance,Medicaid,,136.94,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Alliance,Medicaid,,538.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Alliance,Medicaid,,551.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Alliance,Medicaid,,551.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Alliance,Medicaid,,319.12,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Alliance,Medicaid,,319.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Alliance,Medicaid,,183.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Alliance,Medicaid,,183.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Alliance,Medicaid,,226.23,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Alliance,Medicaid,,226.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Alliance,Medicaid,,230.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Alliance,Medicaid,,230.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Alliance,Medicaid,,1012.81,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Alliance,Medicaid,,985.99,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Alliance,Medicaid,,159.16,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Alliance,Medicaid,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Alliance,Medicaid,,163.76,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Alliance,Medicaid,,148.55,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Alliance,Medicaid,,449.85,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Alliance,Medicaid,,148.55,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Alliance,Medicaid,,745.34,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Alliance,Medicaid,,177.38,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Alliance,Medicaid,,137.34,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Alliance,Medicaid,,39.04,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Alliance,Medicaid,,106.71,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Alliance,Medicaid,,111.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Alliance,Medicaid,,118.12,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Alliance,Medicaid,,116.72,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Alliance,Medicaid,,133.13,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Alliance,Medicaid,,833.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Alliance,Medicaid,,426.03,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Alliance,Medicaid,,268.87,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Alliance,Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Alliance,Medicaid,,138.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Alliance,Medicaid,,117.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Alliance,Medicaid,,121.32,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Alliance,Medicaid,,176.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Alliance,Medicaid,,176.98,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Alliance,Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Alliance,Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Alliance,Medicaid,,2814.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Alliance,Medicaid,,1238.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alliance,Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alliance,Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alliance,Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Alliance,Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Alliance,Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Alliance,Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Alliance,Medicaid,,1536.13,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Alliance,Medicaid,,1581.98,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Alliance,Medicaid,,1581.98,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Alliance,Medicaid,,960.96,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Alliance,Medicaid,,895.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Alliance,Medicaid,,1213.61,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Alliance,Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Alliance,Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Alliance,Medicaid,,879.68,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Alliance,Medicaid,,483.88,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Alliance,Medicaid,,495.50,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Alliance,Medicaid,,322.92,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Alliance,Medicaid,,158.56,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alliance,Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Alliance,Medicaid,,75.88,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Alliance,Medicaid,,96.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Alliance,Medicaid,,56.46,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Alliance,Medicaid,,108.51,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Alliance,Medicaid,,1059.86,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Alliance,Medicaid,,255.66,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Alliance,Medicaid,,1500.30,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Alliance,Medicaid,,79.08,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Alliance,Medicaid,,328.33,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Alliance,Medicaid,,328.33,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Alliance,Medicaid,,427.63,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Alliance,Medicaid,,182.38,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Alliance,Medicaid,,616.02,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Alliance,Medicaid,,448.25,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Alliance,Medicaid,,107.11,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Alliance,Medicaid,,203.40,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Alliance,Medicaid,,771.57,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Alliance,Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Alliance,Medicaid,,160.56,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Alliance,Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Alliance,Medicaid,,139.14,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Alliance,Medicaid,,1059.86,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Alliance,Medicaid,,476.08,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Alliance,Medicaid,,500.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Alliance,Medicaid,,496.10,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Alliance,Medicaid,,127.33,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alliance,Medicaid,,232.23,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Alliance,Medicaid,,35.03,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Alliance,Medicaid,,1259.46,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Alliance,Medicaid,,1554.95,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Alliance,Medicaid,,498.70,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Alliance,Medicaid,,58.86,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Alliance,Medicaid,,46.25,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Alliance,Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Alliance,Medicaid,,80.88,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Alliance,Medicaid,,81.68,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alliance,Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Alliance,Medicaid,,40.44,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Alliance,Medicaid,,318.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Alliance,Medicaid,,900.30,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Alliance,Medicaid,,847.65,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Alliance,Medicaid,,584.78,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Alliance,Medicaid,,915.71,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Alliance,Medicaid,,211.21,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Alliance,Medicaid,,211.21,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Alliance,Medicaid,,294.49,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Alliance,Medicaid,,57.66,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Alliance,Medicaid,,57.66,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Alliance,Medicaid,,383.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Alliance,Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Alliance,Medicaid,,234.83,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Alliance,Medicaid,,502.70,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Alliance,Medicaid,,502.70,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Alliance,Medicaid,,407.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Alliance,Medicaid,,407.21,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Alliance,Medicaid,,347.95,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Alliance,Medicaid,,347.95,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Alliance,Medicaid,,316.92,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Alliance,Medicaid,,316.92,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Alliance,Medicaid,,329.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Alliance,Medicaid,,329.53,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Alliance,Medicaid,,342.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Alliance,Medicaid,,303.30,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Alliance,Medicaid,,303.30,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Alliance,Medicaid,,302.10,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Alliance,Medicaid,,302.10,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Alliance,Medicaid,,665.06,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Alliance,Medicaid,,665.06,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Alliance,Medicaid,,372.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Alliance,Medicaid,,372.37,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Alliance,Medicaid,,363.96,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Alliance,Medicaid,,363.96,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Alliance,Medicaid,,461.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Alliance,Medicaid,,73.67,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Alliance,Medicaid,,972.37,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Alliance,Medicaid,,44.04,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Alliance,Medicaid,,568.77,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Alliance,Medicaid,,598.60,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Alliance,Medicaid,,4031.43,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Alliance,Medicaid,,2143.34,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Alliance,Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Alliance,Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Alliance,Medicaid,,215.01,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Alliance,Medicaid,,138.74,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Alliance,Medicaid,,155.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Alliance,Medicaid,,1092.69,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Alliance,Medicaid,,743.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Alliance,Medicaid,,944.74,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Alliance,Medicaid,,774.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Alliance,Medicaid,,973.77,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Alliance,Medicaid,,798.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Alliance,Medicaid,,337.94,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Alliance,Medicaid,,114.71,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Alliance,Medicaid,,1493.89,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Alliance,Medicaid,,398.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Alliance,Medicaid,,298.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Alliance,Medicaid,,531.13,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Alliance,Medicaid,,5758.95,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Alliance,Medicaid,,838.24,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Alliance,Medicaid,,2658.46,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Alliance,Medicaid,,1771.37,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Alliance,Medicaid,,696.50,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Alliance,Medicaid,,248.45,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Alliance,Medicaid,,339.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Alliance,Medicaid,,339.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Alliance,Medicaid,,375.58,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Alliance,Medicaid,,375.58,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Alliance,Medicaid,,346.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Alliance,Medicaid,,346.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Alliance,Medicaid,,258.06,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Alliance,Medicaid,,146.75,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Alliance,Medicaid,,246.05,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Alliance,Medicaid,,1434.43,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Alliance,Medicaid,,358.56,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Alliance,Medicaid,,315.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Alliance,Medicaid,,371.17,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Alliance,Medicaid,,209.41,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Alliance,Medicaid,,717.92,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Alliance,Medicaid,,717.92,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Alliance,Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Alliance,Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Alliance,Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Alliance,Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Alliance,Medicaid,,693.69,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Alliance,Medicaid,,596.60,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Alliance,Medicaid,,1230.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Alliance,Medicaid,,1430.23,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Alliance,Medicaid,,1059.26,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Alliance,Medicaid,,954.35,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Alliance,Medicaid,,238.64,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Alliance,Medicaid,,1609.21,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Alliance,Medicaid,,1660.86,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Alliance,Medicaid,,2496.49,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Alliance,Medicaid,,1392.39,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Alliance,Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Alliance,Medicaid,,369.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Alliance,Medicaid,,178.38,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Alliance,Medicaid,,322.52,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Alliance,Medicaid,,238.44,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Alliance,Medicaid,,741.14,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Alliance,Medicaid,,650.85,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Alliance,Medicaid,,651.45,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Alliance,Medicaid,,561.56,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Alliance,Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Alliance,Medicaid,,954.75,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Alliance,Medicaid,,1107.51,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Alliance,Medicaid,,1623.02,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Alliance,Medicaid,,150.35,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Alliance,Medicaid,,2177.58,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Alliance,Medicaid,,1567.77,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Alliance,Medicaid,,762.16,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Alliance,Medicaid,,3427.62,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Alliance,Medicaid,,1466.87,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Alliance,Medicaid,,180.58,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Alliance,Medicaid,,696.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Alliance,Medicaid,,696.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Alliance,Medicaid,,3451.05,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Alliance,Medicaid,,3239.64,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Alliance,Medicaid,,3239.64,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Alliance,Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Alliance,Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Alliance,Medicaid,,1866.26,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Alliance,Medicaid,,1866.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Alliance,Medicaid,,2488.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Alliance,Medicaid,,1808.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Alliance,Medicaid,,582.58,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Alliance,Medicaid,,474.07,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Alliance,Medicaid,,474.07,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Alliance,Medicaid,,160.96,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Alliance,Medicaid,,1313.31,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Alliance,Medicaid,,337.54,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Alliance,Medicaid,,404.60,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Alliance,Medicaid,,642.84,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Alliance,Medicaid,,97.50,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alliance,Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alliance,Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Alliance,Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Alliance,Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Alliance,Medicaid,,1990.79,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Alliance,Medicaid,,1990.79,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Alliance,Medicaid,,803.60,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Alliance,Medicaid,,1219.62,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Alliance,Medicaid,,691.09,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Alliance,Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Alliance,Medicaid,,125.93,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alliance,Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Alliance,Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Alliance,Medicaid,,812.41,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Alliance,Medicaid,,392.19,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Alliance,Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Alliance,Medicaid,,91.89,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Alliance,Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Alliance,Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Alliance,Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Alliance,Medicaid,,64.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Alliance,Medicaid,,178.98,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Alliance,Medicaid,,114.91,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Alliance,Medicaid,,228.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Alliance,Medicaid,,187.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Alliance,Medicaid,,211.81,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Alliance,Medicaid,,154.35,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Alliance,Medicaid,,167.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Alliance,Medicaid,,63.06,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Alliance,Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Alliance,Medicaid,,62.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Alliance,Medicaid,,165.16,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Alliance,Medicaid,,192.39,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Alliance,Medicaid,,103.90,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Alliance,Medicaid,,127.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Alliance,Medicaid,,85.49,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Alliance,Medicaid,,167.17,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Alliance,Medicaid,,133.73,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Alliance,Medicaid,,107.91,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Alliance,Medicaid,,131.73,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alliance,Medicaid,,207.61,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Alliance,Medicaid,,164.76,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Alliance,Medicaid,,183.98,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Alliance,Medicaid,,60.26,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Alliance,Medicaid,,235.84,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Alliance,Medicaid,,152.95,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Alliance,Medicaid,,50.05,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Alliance,Medicaid,,46.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Alliance,Medicaid,,37.24,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Alliance,Medicaid,,220.62,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Alliance,Medicaid,,165.16,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Alliance,Medicaid,,39.84,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Alliance,Medicaid,,136.94,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Alliance,Medicaid,,84.48,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Alliance,Medicaid,,193.59,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Alliance,Medicaid,,144.94,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Alliance,Medicaid,,82.68,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Alliance,Medicaid,,98.50,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Alliance,Medicaid,,91.89,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Alliance,Medicaid,,27.83,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Alliance,Medicaid,,13.41,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Alliance,Medicaid,,21.82,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Alliance,Medicaid,,1278.48,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Alliance,Medicaid,,931.73,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Alliance,Medicaid,,837.24,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Alliance,Medicaid,,1299.50,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Alliance,Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Alliance,Medicaid,,538.14,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Alliance,Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Alliance,Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Alliance,Medicaid,,186.39,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Alliance,Medicaid,,306.51,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Alliance,Medicaid,,612.81,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Alliance,Medicaid,,932.93,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Alliance,Medicaid,,836.04,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Alliance,Medicaid,,1211.61,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Alliance,Medicaid,,1780.98,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Alliance,Medicaid,,105.51,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Alliance,Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Alliance,Medicaid,,114.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Alliance,Medicaid,,202.60,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Alliance,Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Alliance,Medicaid,,494.29,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Alliance,Medicaid,,96.30,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Alliance,Medicaid,,563.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Alliance,Medicaid,,659.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Alliance,Medicaid,,1014.81,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Alliance,Medicaid,,1226.63,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Alliance,Medicaid,,692.49,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Alliance,Medicaid,,1035.63,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Alliance,Medicaid,,1078.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Alliance,Medicaid,,721.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Alliance,Medicaid,,753.75,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Alliance,Medicaid,,1032.63,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Alliance,Medicaid,,695.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Alliance,Medicaid,,816.02,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Alliance,Medicaid,,940.74,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Alliance,Medicaid,,742.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Alliance,Medicaid,,779.18,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Alliance,Medicaid,,1067.47,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Alliance,Medicaid,,735.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Alliance,Medicaid,,743.14,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Alliance,Medicaid,,1032.63,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Alliance,Medicaid,,852.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Alliance,Medicaid,,901.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Alliance,Medicaid,,1047.85,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Alliance,Medicaid,,584.38,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Alliance,Medicaid,,837.84,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Alliance,Medicaid,,635.03,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Alliance,Medicaid,,50.65,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Alliance,Medicaid,52,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Alliance,Medicaid,52,787.39,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Alliance,Medicaid,,769.37,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Alliance,Medicaid,,881.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Alliance,Medicaid,,1040.24,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Alliance,Medicaid,,805.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Alliance,Medicaid,,827.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Alliance,Medicaid,,703.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Alliance,Medicaid,,855.65,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Alliance,Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Alliance,Medicaid,,811.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Alliance,Medicaid,,1021.82,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Alliance,Medicaid,,983.38,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Alliance,Medicaid,,1091.89,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Alliance,Medicaid,,838.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Alliance,Medicaid,,928.33,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Alliance,Medicaid,,1118.32,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Alliance,Medicaid,,694.29,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Alliance,Medicaid,,734.93,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Alliance,Medicaid,,1069.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Alliance,Medicaid,,649.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Alliance,Medicaid,,720.52,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Alliance,Medicaid,,1000.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Alliance,Medicaid,,845.85,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Alliance,Medicaid,,647.85,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Alliance,Medicaid,,895.29,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Alliance,Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Alliance,Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Alliance,Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Alliance,Medicaid,,707.71,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Alliance,Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Alliance,Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Alliance,Medicaid,,899.50,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Alliance,Medicaid,,650.65,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Alliance,Medicaid,,919.72,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Alliance,Medicaid,,894.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Alliance,Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Alliance,Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Alliance,Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Alliance,Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Alliance,Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Alliance,Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Alliance,Medicaid,,206.81,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Alliance,Medicaid,,480.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Alliance,Medicaid,,477.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Alliance,Medicaid,,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Alliance,Medicaid,,375.38,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Alliance,Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Alliance,Medicaid,,64.86,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Alliance,Medicaid,,79.88,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Alliance,Medicaid,,349.35,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Alliance,Medicaid,,349.35,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Alliance,Medicaid,,31.63,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Alliance,Medicaid,,366.57,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Alliance,Medicaid,,366.57,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Alliance,Medicaid,,181.18,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Alliance,Medicaid,,108.11,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Alliance,Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Alliance,Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Alliance,Medicaid,,260.06,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Alliance,Medicaid,,207.61,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Alliance,Medicaid,,169.57,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Alliance,Medicaid,,123.32,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Alliance,Medicaid,,119.92,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Alliance,Medicaid,,58.46,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Alliance,Medicaid,,86.29,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Alliance,Medicaid,,63.46,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Alliance,Medicaid,,57.66,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Alliance,Medicaid,,136.14,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Alliance,Medicaid,,56.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Alliance,Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Alliance,Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Alliance,Medicaid,,287.49,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Alliance,Medicaid,,150.55,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Alliance,Medicaid,,373.57,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Alliance,Medicaid,,870.87,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Alliance,Medicaid,,50.45,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Alliance,Medicaid,,35.44,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Alliance,Medicaid,,73.87,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Alliance,Medicaid,,36.64,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Alliance,Medicaid,,85.49,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Alliance,Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Alliance,Medicaid,,55.05,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Alliance,Medicaid,,79.88,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Alliance,Medicaid,,126.33,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Alliance,Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Alliance,Medicaid,,174.97,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Alliance,Medicaid,,112.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Alliance,Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Alliance,Medicaid,,72.47,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Alliance,Medicaid,,151.35,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Alliance,Medicaid,,61.06,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Alliance,Medicaid,,133.13,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Alliance,Medicaid,,84.48,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Alliance,Medicaid,,191.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Alliance,Medicaid,,119.92,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Alliance,Medicaid,,84.48,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Alliance,Medicaid,,91.69,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Alliance,Medicaid,,72.87,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Alliance,Medicaid,,505.30,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Alliance,Medicaid,,434.23,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Alliance,Medicaid,,221.42,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Alliance,Medicaid,,104.30,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Alliance,Medicaid,,110.71,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Alliance,Medicaid,,67.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Alliance,Medicaid,,25.63,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Alliance,Medicaid,,102.50,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Alliance,Medicaid,,80.88,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Alliance,Medicaid,,80.88,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Alliance,Medicaid,,481.28,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Alliance,Medicaid,,9.41,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Alliance,Medicaid,,2.80,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Alliance,Medicaid,,22.42,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Alliance,Medicaid,,32.63,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Alliance,Medicaid,,26.43,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Alliance,Medicaid,,5.21,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Alliance,Medicaid,,8.81,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Alliance,Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Alliance,Medicaid,,53.05,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Alliance,Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Alliance,Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Alliance,Medicaid,,79.48,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Alliance,Medicaid,,31.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Alliance,Medicaid,,107.11,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Alliance,Medicaid,,14.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Alliance,Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Alliance,Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Alliance,Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Alliance,Medicaid,,5.81,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Alliance,Medicaid,,35.44,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Alliance,Medicaid,,24.82,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Alliance,Medicaid,,7.81,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Alliance,Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Alliance,Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Alliance,Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Alliance,Medicaid,,30.83,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Alliance,Medicaid,,5.81,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Alliance,Medicaid,,8.61,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Alliance,Medicaid,,8.41,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Alliance,Medicaid,,9.61,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Alliance,Medicaid,,32.43,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Alliance,Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Alliance,Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Alliance,Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Alliance,Medicaid,,8.41,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Alliance,Medicaid,,12.01,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Alliance,Medicaid,,8.01,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Alliance,Medicaid,,8.01,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Alliance,Medicaid,,33.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Alliance,Medicaid,,13.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Alliance,Medicaid,,10.61,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Alliance,Medicaid,,51.65,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Alliance,Medicaid,,13.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Alliance,Medicaid,,48.65,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Alliance,Medicaid,,36.04,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Alliance,Medicaid,,29.23,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Alliance,Medicaid,,15.82,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Alliance,Medicaid,,7.81,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Alliance,Medicaid,,59.86,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Alliance,Medicaid,,1.20,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Alliance,Medicaid,,40.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Alliance,Medicaid,,115.92,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Alliance,Medicaid,,31.43,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alliance,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alliance,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alliance,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Alliance,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Alliance,Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alliance,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alliance,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alliance,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Alliance,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Alliance,Medicaid,,6.01,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Alliance,Medicaid,,14.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Alliance,Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Alliance,Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Alliance,Medicaid,,15.62,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Alliance,Medicaid,,47.65,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Alliance,Medicaid,,31.23,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Alliance,Medicaid,,44.24,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Alliance,Medicaid,,24.02,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Alliance,Medicaid,,30.43,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Alliance,Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Alliance,Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Alliance,Medicaid,,39.44,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Alliance,Medicaid,,26.43,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Alliance,Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Alliance,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Alliance,Medicaid,,8.41,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Alliance,Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Alliance,Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Alliance,Medicaid,,29.83,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Alliance,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Alliance,Medicaid,,28.63,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Alliance,Medicaid,,16.62,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Alliance,Medicaid,,28.63,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Alliance,Medicaid,,35.44,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Alliance,Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Alliance,Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Alliance,Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Alliance,Medicaid,,0.40040,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Alliance,Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Alliance,Medicaid,,11.01,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Alliance,Medicaid,,29.23,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Alliance,Medicaid,,45.45,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Alliance,Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Alliance,Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Alliance,Medicaid,,9.01,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Alliance,Medicaid,,10.61,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Alliance,Medicaid,,10.01,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Alliance,Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Alliance,Medicaid,,9.01,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Alliance,Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Alliance,Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Alliance,Medicaid,,8.61,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Alliance,Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Alliance,Medicaid,,33.43,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Alliance,Medicaid,,9.01,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Alliance,Medicaid,,32.03,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Alliance,Medicaid,,38.04,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Alliance,Medicaid,,13.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Alliance,Medicaid,,26.83,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Alliance,Medicaid,,26.03,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Alliance,Medicaid,,21.62,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Alliance,Medicaid,,7.61,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Alliance,Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Alliance,Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Alliance,Medicaid,,26.03,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Alliance,Medicaid,,38.64,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Alliance,Medicaid,,15.82,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Alliance,Medicaid,,2.40,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Alliance,Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Alliance,Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Alliance,Medicaid,,45.05,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Alliance,Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Alliance,Medicaid,,28.03,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Alliance,Medicaid,,22.62,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Alliance,Medicaid,,19.42,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Alliance,Medicaid,,27.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Alliance,Medicaid,,24.02,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Alliance,Medicaid,,1.60,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Alliance,Medicaid,,4.40,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Alliance,Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Alliance,Medicaid,,34.83,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Alliance,Medicaid,,25.63,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Alliance,Medicaid,,53.45,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Alliance,Medicaid,,29.43,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Alliance,Medicaid,,54.65,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Alliance,Medicaid,,41.44,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Alliance,Medicaid,,10.01,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Alliance,Medicaid,,47.45,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Alliance,Medicaid,,41.24,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Alliance,Medicaid,,8.21,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Alliance,Medicaid,,58.66,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Alliance,Medicaid,,40.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Alliance,Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Alliance,Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Alliance,Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Alliance,Medicaid,,10.01,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Alliance,Medicaid,,27.03,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Alliance,Medicaid,,44.64,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Alliance,Medicaid,,4.20,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Alliance,Medicaid,,11.41,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Alliance,Medicaid,,29.03,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Alliance,Medicaid,,13.61,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,,23.42,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Alliance,Medicaid,,34.63,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Alliance,Medicaid,,19.42,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Alliance,Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Alliance,Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Alliance,Medicaid,,3.00,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Alliance,Medicaid,,7.01,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Alliance,Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Alliance,Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Alliance,Medicaid,,92.29,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Alliance,Medicaid,,24.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Alliance,Medicaid,,39.04,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Alliance,Medicaid,,16.62,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Alliance,Medicaid,,2.20,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Alliance,Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Alliance,Medicaid,,27.03,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Alliance,Medicaid,,21.62,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Alliance,Medicaid,,158.96,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Alliance,Medicaid,,89.49,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Alliance,Medicaid,,53.25,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Alliance,Medicaid,,114.11,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Alliance,Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Alliance,Medicaid,,59.26,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Alliance,Medicaid,,72.27,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Alliance,Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Alliance,Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Alliance,Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Alliance,Medicaid,,46.65,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Alliance,Medicaid,,29.03,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Alliance,Medicaid,,24.62,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Alliance,Medicaid,,26.83,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Alliance,Medicaid,,39.24,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Alliance,Medicaid,,34.63,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Alliance,Medicaid,,100.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Alliance,Medicaid,,147.55,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Alliance,Medicaid,,25.23,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Alliance,Medicaid,,27.83,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Alliance,Medicaid,,30.03,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Alliance,Medicaid,,18.62,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Alliance,Medicaid,,32.43,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Alliance,Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Alliance,Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Alliance,Medicaid,,64.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Alliance,Medicaid,,55.05,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Alliance,Medicaid,,58.26,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Alliance,Medicaid,,52.85,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Alliance,Medicaid,,122.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Alliance,Medicaid,,32.23,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Alliance,Medicaid,,47.45,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Alliance,Medicaid,,39.84,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Alliance,Medicaid,,19.82,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Alliance,Medicaid,,65.06,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Alliance,Medicaid,,54.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Alliance,Medicaid,,64.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Alliance,Medicaid,,50.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Alliance,Medicaid,,36.44,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Alliance,Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Alliance,Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Alliance,Medicaid,,49.45,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Alliance,Medicaid,,8.81,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Alliance,Medicaid,,30.03,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Alliance,Medicaid,,39.24,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Alliance,Medicaid,,93.69,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Alliance,Medicaid,,56.66,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Alliance,Medicaid,,7.01,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Alliance,Medicaid,,14.41,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Alliance,Medicaid,,22.62,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Alliance,Medicaid,,71.27,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Alliance,Medicaid,,29.23,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Alliance,Medicaid,,40.44,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Alliance,Medicaid,,28.63,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Alliance,Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Alliance,Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Alliance,Medicaid,,20.42,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Alliance,Medicaid,,17.02,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Alliance,Medicaid,,19.62,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Alliance,Medicaid,,44.84,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Alliance,Medicaid,,7.81,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Alliance,Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Alliance,Medicaid,,9.41,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Alliance,Medicaid,,3.00,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Alliance,Medicaid,,8.21,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Alliance,Medicaid,,37.64,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Alliance,Medicaid,,24.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Alliance,Medicaid,,26.03,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Alliance,Medicaid,,14.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Alliance,Medicaid,,31.43,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Alliance,Medicaid,,5.41,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Alliance,Medicaid,,10.61,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Alliance,Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Alliance,Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Alliance,Medicaid,,19.42,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Alliance,Medicaid,,42.64,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Alliance,Medicaid,,40.84,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Alliance,Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Alliance,Medicaid,,40.84,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Alliance,Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Alliance,Medicaid,,14.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Alliance,Medicaid,,29.03,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Alliance,Medicaid,,18.42,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Alliance,Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Alliance,Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Alliance,Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Alliance,Medicaid,,5.21,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,,25.83,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Alliance,Medicaid,,23.22,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Alliance,Medicaid,,15.82,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Alliance,Medicaid,,67.87,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Alliance,Medicaid,,13.61,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,,17.82,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Alliance,Medicaid,,3.20,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Alliance,Medicaid,,49.05,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Alliance,Medicaid,,30.83,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Alliance,Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Alliance,Medicaid,,19.82,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Alliance,Medicaid,,15.62,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Alliance,Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Alliance,Medicaid,,11.41,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Alliance,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Alliance,Medicaid,,12.61,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Alliance,Medicaid,,36.04,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Alliance,Medicaid,,6.61,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Alliance,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Alliance,Medicaid,,45.65,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Alliance,Medicaid,,33.83,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Alliance,Medicaid,,92.29,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Alliance,Medicaid,,42.64,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Alliance,Medicaid,,42.64,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Alliance,Medicaid,,125.93,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Alliance,Medicaid,,116.32,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Alliance,Medicaid,,34.83,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Alliance,Medicaid,,32.23,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Alliance,Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Alliance,Medicaid,,42.44,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Alliance,Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Alliance,Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Alliance,Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Alliance,Medicaid,,51.45,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Alliance,Medicaid,,154.15,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Alliance,Medicaid,,17.42,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Alliance,Medicaid,,16.62,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Alliance,Medicaid,,9.61,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Alliance,Medicaid,,22.42,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Alliance,Medicaid,,115.92,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Alliance,Medicaid,,55.86,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Alliance,Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Alliance,Medicaid,,30.83,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Alliance,Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Alliance,Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Alliance,Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Alliance,Medicaid,,92.69,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Alliance,Medicaid,,58.86,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Alliance,Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Alliance,Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Alliance,Medicaid,,25.23,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Alliance,Medicaid,,2.40,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Alliance,Medicaid,,30.03,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Alliance,Medicaid,,24.02,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Alliance,Medicaid,,109.71,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Alliance,Medicaid,,61.86,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Alliance,Medicaid,,25.43,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Alliance,Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Alliance,Medicaid,,4.40,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Alliance,Medicaid,,46.05,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Alliance,Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Alliance,Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Alliance,Medicaid,,11.61,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Alliance,Medicaid,,7.01,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Alliance,Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Alliance,Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Alliance,Medicaid,,12.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Alliance,Medicaid,,12.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Alliance,Medicaid,,9.21,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Alliance,Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Alliance,Medicaid,,14.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Alliance,Medicaid,,3.00,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Alliance,Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Alliance,Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Alliance,Medicaid,,26.83,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Alliance,Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Alliance,Medicaid,,5.21,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Alliance,Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Alliance,Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Alliance,Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Alliance,Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Alliance,Medicaid,,0.40040,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Alliance,Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Alliance,Medicaid,,16.22,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Alliance,Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Alliance,Medicaid,,32.23,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Alliance,Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Alliance,Medicaid,,28.23,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Alliance,Medicaid,,6.81,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Alliance,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Alliance,Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Alliance,Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Alliance,Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Alliance,Medicaid,,7.01,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Alliance,Medicaid,,15.02,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Alliance,Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Alliance,Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Alliance,Medicaid,,153.55,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Alliance,Medicaid,,26.83,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Alliance,Medicaid,,361.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Alliance,Medicaid,,251.85,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Alliance,Medicaid,,58.66,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Alliance,Medicaid,,23.22,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Alliance,Medicaid,,386.59,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Alliance,Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Alliance,Medicaid,,51.85,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Alliance,Medicaid,,9.21,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Alliance,Medicaid,,361.96,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Alliance,Medicaid,,141.54,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Alliance,Medicaid,,102.70,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Alliance,Medicaid,,37.84,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Alliance,Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Alliance,Medicaid,,22.82,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Alliance,Medicaid,,64.86,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Alliance,Medicaid,,38.84,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Alliance,Medicaid,,190.79,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Alliance,Medicaid,,127.93,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Alliance,Medicaid,,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Alliance,Medicaid,QW,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Alliance,Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Alliance,Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Alliance,Medicaid,,318.12,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Alliance,Medicaid,,237.64,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Alliance,Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Alliance,Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Alliance,Medicaid,,95.70,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Alliance,Medicaid,,40.84,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Alliance,Medicaid,,85.29,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Alliance,Medicaid,,10.01,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Alliance,Medicaid,QW,20.02,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Alliance,Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Alliance,Medicaid,,32.63,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Alliance,Medicaid,,181.58,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Alliance,Medicaid,,55.05,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Alliance,Medicaid,,26.43,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,,33.03,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Alliance,Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Alliance,Medicaid,,8.61,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Alliance,Medicaid,,56.06,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Alliance,Medicaid,,15.82,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Alliance,Medicaid,,38.84,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Alliance,Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Alliance,Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Alliance,Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Alliance,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Alliance,Medicaid,,42.64,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Alliance,Medicaid,,43.84,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Alliance,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Alliance,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Alliance,Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Alliance,Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Alliance,Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Alliance,Medicaid,,15.22,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Alliance,Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Alliance,Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Alliance,Medicaid,,20.22,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Alliance,Medicaid,,29.83,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Alliance,Medicaid,,265.87,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Alliance,Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Alliance,Medicaid,,21.62,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Alliance,Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Alliance,Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Alliance,Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Alliance,Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Alliance,Medicaid,,33.43,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Alliance,Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Alliance,Medicaid,,63.86,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Alliance,Medicaid,,103.10,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Alliance,Medicaid,,105.31,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Alliance,Medicaid,,42.04,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Alliance,Medicaid,,5.41,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Alliance,Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Alliance,Medicaid,,37.24,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Alliance,Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Alliance,Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Alliance,Medicaid,,7.81,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Alliance,Medicaid,,39.64,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Alliance,Medicaid,,23.82,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Alliance,Medicaid,,51.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Alliance,Medicaid,,52.25,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Alliance,Medicaid,,15.62,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Alliance,Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Alliance,Medicaid,,41.84,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Alliance,Medicaid,,41.44,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Alliance,Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Alliance,Medicaid,,29.63,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Alliance,Medicaid,,91.29,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Alliance,Medicaid,,119.52,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Alliance,Medicaid,,151.15,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Alliance,Medicaid,,112.31,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Alliance,Medicaid,,65.06,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Alliance,Medicaid,,45.05,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Alliance,Medicaid,,204.00,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Alliance,Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Alliance,Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Alliance,Medicaid,,44.84,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Alliance,Medicaid,,26.43,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Alliance,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Alliance,Medicaid,,109.71,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Alliance,Medicaid,,20.42,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Alliance,Medicaid,,35.03,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Alliance,Medicaid,,73.47,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Alliance,Medicaid,,132.13,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Alliance,Medicaid,,0.00200,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Alliance,Medicaid,,24.82,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Alliance,Medicaid,,45.25,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Alliance,Medicaid,,74.07,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Alliance,Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Alliance,Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Alliance,Medicaid,,118.72,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Alliance,Medicaid,,109.71,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Alliance,Medicaid,,19.42,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Alliance,Medicaid,,78.88,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Alliance,Medicaid,,62.66,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Alliance,Medicaid,,49.85,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Alliance,Medicaid,,15.42,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Alliance,Medicaid,,76.88,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Alliance,Medicaid,,26.43,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Alliance,Medicaid,,135.13,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Alliance,Medicaid,,37.84,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Alliance,Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Alliance,Medicaid,,51.25,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Alliance,Medicaid,,52.25,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Alliance,Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Alliance,Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Alliance,Medicaid,,107.91,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Alliance,Medicaid,,27.83,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Alliance,Medicaid,,32.83,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Alliance,Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Alliance,Medicaid,,82.88,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Alliance,Medicaid,,49.45,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Alliance,Medicaid,,438.64,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Alliance,Medicaid,,70.67,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Alliance,Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Alliance,Medicaid,,141.74,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Alliance,Medicaid,,103.70,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Alliance,Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Alliance,Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Alliance,Medicaid,,103.90,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Alliance,Medicaid,,257.26,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Alliance,Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Alliance,Medicaid,,62.46,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Alliance,Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Alliance,Medicaid,,248.85,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Alliance,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Alliance,Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Alliance,Medicaid,,181.78,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Alliance,Medicaid,,132.13,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Alliance,Medicaid,,94.89,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Alliance,Medicaid,,71.27,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Alliance,Medicaid,,25.02,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Alliance,Medicaid,,30.03,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Alliance,Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Alliance,Medicaid,,33.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Alliance,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Alliance,Medicaid,,31.83,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Alliance,Medicaid,,318.12,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Alliance,Medicaid,,159.76,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Alliance,Medicaid,,65.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Alliance,Medicaid,,13.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Alliance,Medicaid,,8.41,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Alliance,Medicaid,,21.02,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Alliance,Medicaid,,49.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Alliance,Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Alliance,Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Alliance,Medicaid,,55.46,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Alliance,Medicaid,,113.31,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Alliance,Medicaid,,11.41,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Alliance,Medicaid,,135.94,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Alliance,Medicaid,,130.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alliance,Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Alliance,Medicaid,,214.21,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Alliance,Medicaid,,43.04,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Alliance,Medicaid,,83.88,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Alliance,Medicaid,,58.86,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Alliance,Medicaid,,189.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Alliance,Medicaid,,248.25,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Alliance,Medicaid,,120.12,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Alliance,Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Alliance,Medicaid,,305.91,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Alliance,Medicaid,,5.61,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Alliance,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Alliance,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alliance,Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Alliance,Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Alliance,Medicaid,,232.23,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Alliance,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Alliance,Medicaid,,523.72,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alliance,Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alliance,Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alliance,Medicaid,,1715.71,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alliance,Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alliance,Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Alliance,Medicaid,,7102.50,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Alliance,Medicaid,,1203.60,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alliance,Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Alliance,Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Alliance,Medicaid,,1344.34,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Alliance,Medicaid,,409.01,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Alliance,Medicaid,,674.27,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Alliance,Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Alliance,Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Alliance,Medicaid,,396.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Alliance,Medicaid,,396.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Alliance,Medicaid,,834.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Alliance,Medicaid,,834.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Alliance,Medicaid,,379.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Alliance,Medicaid,,379.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Alliance,Medicaid,,89.49,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Alliance,Medicaid,,164.76,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Alliance,Medicaid,,359.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Alliance,Medicaid,,359.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Alliance,Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Alliance,Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Alliance,Medicaid,,317.52,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Alliance,Medicaid,,317.52,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Alliance,Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Alliance,Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Alliance,Medicaid,,1544.94,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Alliance,Medicaid,,772.37,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Alliance,Medicaid,,772.37,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Alliance,Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Alliance,Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alliance,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alliance,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Alliance,Medicaid,,275.88,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Alliance,Medicaid,,275.88,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alliance,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Alliance,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Alliance,Medicaid,,532.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alliance,Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Alliance,Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Alliance,Medicaid,,158.96,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Alliance,Medicaid,,5817.21,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Alliance,Medicaid,,879.68,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Alliance,Medicaid,,879.68,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Alliance,Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Alliance,Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Alliance,Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Alliance,Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Alliance,Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Alliance,Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Alliance,Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Alliance,Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Alliance,Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Alliance,Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Alliance,Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Alliance,Medicaid,,4633.03,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Alliance,Medicaid,,4633.03,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Alliance,Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Alliance,Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Alliance,Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Alliance,Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Alliance,Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Alliance,Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Alliance,Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Alliance,Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Alliance,Medicaid,,2468.07,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Alliance,Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Alliance,Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Alliance,Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Alliance,Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Alliance,Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Alliance,Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Alliance,Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Alliance,Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Alliance,Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Alliance,Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Alliance,Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Alliance,Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Alliance,Medicaid,,4121.72,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Alliance,Medicaid,LM,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Alliance,Medicaid,RI,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Alliance,Medicaid,RC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Alliance,Medicaid,LD,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Alliance,Medicaid,LC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Alliance,Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Alliance,Medicaid,RI,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Alliance,Medicaid,RC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Alliance,Medicaid,LD,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Alliance,Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Alliance,Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Alliance,Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,LM,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,RI,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Alliance,Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LM,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,RI,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Alliance,Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Alliance,Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Alliance,Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Alliance,Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Alliance,Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Alliance,Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LM,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,RI,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,RC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LD,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Alliance,Medicaid,LC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Alliance,Medicaid,,78.68,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Alliance,Medicaid,,333.13,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Alliance,Medicaid,,373.37,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Alliance,Medicaid,,84.48,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Alliance,Medicaid,,505.91,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Alliance,Medicaid,,197.40,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Alliance,Medicaid,,2316.71,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Alliance,Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Alliance,Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Alliance,Medicaid,,2044.04,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Alliance,Medicaid,,850.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Alliance,Medicaid,,1474.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Alliance,Medicaid,,2180.78,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Alliance,Medicaid,,1936.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Alliance,Medicaid,,2067.27,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Alliance,Medicaid,,909.51,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Alliance,Medicaid,,2126.92,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Alliance,Medicaid,,2652.85,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Alliance,Medicaid,,2389.79,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Alliance,Medicaid,,2549.35,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Alliance,Medicaid,,2592.59,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Alliance,Medicaid,,3178.58,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Alliance,Medicaid,,1356.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Alliance,Medicaid,,40.64,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Alliance,Medicaid,,19.42,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Alliance,Medicaid,,300.90,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Alliance,Medicaid,,826.43,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Alliance,Medicaid,,1614.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Alliance,Medicaid,,96.90,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Alliance,Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Alliance,Medicaid,,43.04,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Alliance,Medicaid,,1535.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Alliance,Medicaid,,7834.43,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Alliance,Medicaid,,2458.86,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Alliance,Medicaid,,505.50,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Alliance,Medicaid,,565.36,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Alliance,Medicaid,,253.45,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Alliance,Medicaid,,105.71,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Alliance,Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Alliance,Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Alliance,Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Alliance,Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Alliance,Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Alliance,Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Alliance,Medicaid,,3657.05,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Alliance,Medicaid,,2656.25,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Alliance,Medicaid,,3018.42,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Alliance,Medicaid,,3642.44,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Alliance,Medicaid,,639.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Alliance,Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Alliance,Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Alliance,Medicaid,,2045.04,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Alliance,Medicaid,,589.39,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Alliance,Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Alliance,Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Alliance,Medicaid,,4082.48,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Alliance,Medicaid,,2987.99,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Alliance,Medicaid,,473.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Alliance,Medicaid,,4761.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Alliance,Medicaid,,4909.10,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Alliance,Medicaid,,5350.95,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Alliance,Medicaid,,1703.30,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Alliance,Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Alliance,Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Alliance,Medicaid,,9987.38,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Alliance,Medicaid,,1151.15,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Alliance,Medicaid,,764.96,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Alliance,Medicaid,,11551.14,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Alliance,Medicaid,,528.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Alliance,Medicaid,,2335.73,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Alliance,Medicaid,,417.62,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Alliance,Medicaid,,838.44,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Alliance,Medicaid,,1297.30,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Alliance,Medicaid,,1297.30,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Alliance,Medicaid,,647.05,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Alliance,Medicaid,,459.46,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Alliance,Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Alliance,Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Alliance,Medicaid,,609.21,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Alliance,Medicaid,,557.96,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Alliance,Medicaid,,1917.92,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Alliance,Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Alliance,Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Alliance,Medicaid,,325.12,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Alliance,Medicaid,,1618.42,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Alliance,Medicaid,,331.93,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Alliance,Medicaid,,631.83,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Alliance,Medicaid,,5093.49,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Alliance,Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Alliance,Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Alliance,Medicaid,,605.61,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Alliance,Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Alliance,Medicaid,,4031.43,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Alliance,Medicaid,,4480.68,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Alliance,Medicaid,,496.90,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Alliance,Medicaid,,386.59,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Alliance,Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Alliance,Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Alliance,Medicaid,,1276.68,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Alliance,Medicaid,,515.51,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Alliance,Medicaid,,2746.94,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Alliance,Medicaid,,960.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Alliance,Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Alliance,Medicaid,,425.83,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Alliance,Medicaid,,567.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Alliance,Medicaid,,1594.59,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Alliance,Medicaid,,3708.10,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Alliance,Medicaid,,1846.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Alliance,Medicaid,,1294.69,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Alliance,Medicaid,,1496.70,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Alliance,Medicaid,,57.66,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Alliance,Medicaid,,283.88,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Alliance,Medicaid,,1595.59,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Alliance,Medicaid,,608.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Alliance,Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Alliance,Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Alliance,Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Alliance,Medicaid,,2662.86,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Alliance,Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Alliance,Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Alliance,Medicaid,,8574.37,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Alliance,Medicaid,,6999.39,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Alliance,Medicaid,,1897.10,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Alliance,Medicaid,,869.87,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Alliance,Medicaid,,4285.48,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Alliance,Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Alliance,Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Alliance,Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Alliance,Medicaid,,6481.07,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Alliance,Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Alliance,Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Alliance,Medicaid,,21.42,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Alliance,Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Alliance,Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Alliance,Medicaid,,9598.39,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Alliance,Medicaid,,480.28,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Alliance,Medicaid,,1300.10,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Alliance,Medicaid,,2169.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Alliance,Medicaid,LD,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Alliance,Medicaid,RC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Alliance,Medicaid,RI,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Alliance,Medicaid,LM,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Alliance,Medicaid,LD,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Alliance,Medicaid,RC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Alliance,Medicaid,RI,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Alliance,Medicaid,LM,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Alliance,Medicaid,LD,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Alliance,Medicaid,RC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Alliance,Medicaid,RI,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Alliance,Medicaid,LM,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,LD,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,RC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,RI,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,LM,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Alliance,Medicaid,LC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Alliance,Medicaid,LC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Alliance,Medicaid,LC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Alliance,Medicaid,LC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Alliance,Medicaid,,6528.72,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Alliance,Medicaid,,12359.75,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Alliance,Medicaid,,2282.88,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Alliance,Medicaid,,570.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Alliance,Medicaid,,115.11,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Alliance,Medicaid,,805.00,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Alliance,Medicaid,,661.46,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Alliance,Medicaid,,258.26,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Alliance,Medicaid,,312.91,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Alliance,Medicaid,,231.63,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Alliance,Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Alliance,Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Alliance,Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Alliance,Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Alliance,Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Alliance,Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Alliance,Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Alliance,Medicaid,,99.30,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Alliance,Medicaid,,77.08,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Alliance,Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Alliance,Medicaid,,11.01,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Alliance,Medicaid,,273.87,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Alliance,Medicaid,,48.65,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Alliance,Medicaid,,175.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Alliance,Medicaid,,124.52,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Alliance,Medicaid,,32.43,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Alliance,Medicaid,,38.64,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Alliance,Medicaid,,255.46,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Alliance,Medicaid,,57.06,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Alliance,Medicaid,,43.64,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Alliance,Medicaid,,59.46,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Alliance,Medicaid,,21.82,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Alliance,Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Alliance,Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Alliance,Medicaid,,1301.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Alliance,Medicaid,,725.52,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Alliance,Medicaid,,1598.40,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Alliance,Medicaid,,521.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Alliance,Medicaid,,422.62,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Alliance,Medicaid,,422.62,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Alliance,Medicaid,,422.62,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Alliance,Medicaid,,1276.28,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Alliance,Medicaid,,1690.29,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Alliance,Medicaid,,1897.30,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Alliance,Medicaid,,1567.77,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Alliance,Medicaid,,2031.83,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Alliance,Medicaid,,2263.86,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Alliance,Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Alliance,Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Alliance,Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Alliance,Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Alliance,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Alliance,Medicaid,,48.05,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Alliance,Medicaid,,74.87,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Alliance,Medicaid,,264.26,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Alliance,Medicaid,,285.29,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Alliance,Medicaid,,446.85,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Alliance,Medicaid,,58.66,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Alliance,Medicaid,,134.53,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Alliance,Medicaid,,20.82,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Alliance,Medicaid,,203.40,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Alliance,Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Alliance,Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Alliance,Medicaid,,38.44,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Alliance,Medicaid,,633.03,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Alliance,Medicaid,,60.46,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Alliance,Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Alliance,Medicaid,,61.86,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Alliance,Medicaid,,57.06,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Alliance,Medicaid,,68.27,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Alliance,Medicaid,,86.49,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Alliance,Medicaid,,123.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Alliance,Medicaid,,8.81,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Alliance,Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Alliance,Medicaid,,14.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Alliance,Medicaid,,44.24,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Alliance,Medicaid,,80.48,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Alliance,Medicaid,,178.18,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Alliance,Medicaid,,14.81,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Alliance,Medicaid,,10.81,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Alliance,Medicaid,,53.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Alliance,Medicaid,,8.01,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Alliance,Medicaid,,150.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Alliance,Medicaid,,235.24,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Alliance,Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Alliance,Medicaid,,245.04,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Alliance,Medicaid,,359.16,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Alliance,Medicaid,,454.25,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Alliance,Medicaid,,98.50,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Alliance,Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Alliance,Medicaid,,140.14,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Alliance,Medicaid,,156.16,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Alliance,Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Alliance,Medicaid,,319.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Alliance,Medicaid,,514.31,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Alliance,Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Alliance,Medicaid,,800.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Alliance,Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Alliance,Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Alliance,Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Alliance,Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Alliance,Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Alliance,Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Alliance,Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Alliance,Medicaid,GP,47.65,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Alliance,Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Alliance,Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Alliance,Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Alliance,Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Alliance,Medicaid,,2600.00,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Alliance,Medicaid,,2657.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Alliance,Medicaid,,2714.71,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Alliance,Medicaid,,2772.37,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Alliance,Medicaid,,2829.83,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Alliance,Medicaid,,2887.08,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Alliance,Medicaid,,2944.54,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Alliance,Medicaid,,3002.00,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Alliance,Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Alliance,Medicaid,,49.25,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Alliance,Medicaid,,40.04,,,,,,,34.82,150.00,percent of total billed charges,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,823.98,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,526.87,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Amerihealth Caritas,Managed Medicaid,,526.87,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Amerihealth Caritas,Managed Medicaid,,0.02803,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Amerihealth Caritas,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Amerihealth Caritas,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Amerihealth Caritas,Managed Medicaid,,4.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Amerihealth Caritas,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Amerihealth Caritas,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Amerihealth Caritas,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Amerihealth Caritas,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Amerihealth Caritas,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Amerihealth Caritas,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Amerihealth Caritas,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Amerihealth Caritas,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Amerihealth Caritas,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Amerihealth Caritas,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Amerihealth Caritas,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Amerihealth Caritas,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Amerihealth Caritas,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Amerihealth Caritas,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Amerihealth Caritas,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Amerihealth Caritas,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Amerihealth Caritas,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Amerihealth Caritas,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Amerihealth Caritas,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Amerihealth Caritas,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Amerihealth Caritas,Managed Medicaid,,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Amerihealth Caritas,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Amerihealth Caritas,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Amerihealth Caritas,Managed Medicaid,,6.26,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Amerihealth Caritas,Managed Medicaid,,4.07,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Amerihealth Caritas,Managed Medicaid,,55.85,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Amerihealth Caritas,Managed Medicaid,,4.33,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Amerihealth Caritas,Managed Medicaid,,0.00601,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Amerihealth Caritas,Managed Medicaid,,4.29,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Amerihealth Caritas,Managed Medicaid,,8.13,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Amerihealth Caritas,Managed Medicaid,,4.08,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Amerihealth Caritas,Managed Medicaid,,3.98,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Amerihealth Caritas,Managed Medicaid,,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Amerihealth Caritas,Managed Medicaid,,13.07,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Amerihealth Caritas,Managed Medicaid,,35.68,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Amerihealth Caritas,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Amerihealth Caritas,Managed Medicaid,,1.27,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Amerihealth Caritas,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Amerihealth Caritas,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Amerihealth Caritas,Managed Medicaid,,40.04,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Amerihealth Caritas,Managed Medicaid,,5.94,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Amerihealth Caritas,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Amerihealth Caritas,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Amerihealth Caritas,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Amerihealth Caritas,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Amerihealth Caritas,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Amerihealth Caritas,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Amerihealth Caritas,Managed Medicaid,,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Amerihealth Caritas,Managed Medicaid,,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Amerihealth Caritas,Managed Medicaid,,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Amerihealth Caritas,Managed Medicaid,,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Amerihealth Caritas,Managed Medicaid,,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Amerihealth Caritas,Managed Medicaid,,93.29,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Amerihealth Caritas,Managed Medicaid,,5.50,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Amerihealth Caritas,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Amerihealth Caritas,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Amerihealth Caritas,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Amerihealth Caritas,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Amerihealth Caritas,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Amerihealth Caritas,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Amerihealth Caritas,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Amerihealth Caritas,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Amerihealth Caritas,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Amerihealth Caritas,Managed Medicaid,,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Amerihealth Caritas,Managed Medicaid,,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Amerihealth Caritas,Managed Medicaid,,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Amerihealth Caritas,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Amerihealth Caritas,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Amerihealth Caritas,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Amerihealth Caritas,Managed Medicaid,,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Amerihealth Caritas,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Amerihealth Caritas,Managed Medicaid,,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Amerihealth Caritas,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Amerihealth Caritas,Managed Medicaid,,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Amerihealth Caritas,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Amerihealth Caritas,Managed Medicaid,,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Amerihealth Caritas,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Amerihealth Caritas,Managed Medicaid,,54.45,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Amerihealth Caritas,Managed Medicaid,,43.28,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Amerihealth Caritas,Managed Medicaid,,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Amerihealth Caritas,Managed Medicaid,,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Amerihealth Caritas,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Amerihealth Caritas,Managed Medicaid,,30.79,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Amerihealth Caritas,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Amerihealth Caritas,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Amerihealth Caritas,Managed Medicaid,,174.60,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Amerihealth Caritas,Managed Medicaid,,214.26,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Amerihealth Caritas,Managed Medicaid,,0.43644,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Amerihealth Caritas,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Amerihealth Caritas,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Amerihealth Caritas,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Amerihealth Caritas,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Amerihealth Caritas,Managed Medicaid,,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Amerihealth Caritas,Managed Medicaid,,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Amerihealth Caritas,Managed Medicaid,,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Amerihealth Caritas,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Amerihealth Caritas,Managed Medicaid,,0.62062,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Amerihealth Caritas,Managed Medicaid,,1.97,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Amerihealth Caritas,Managed Medicaid,,38.56,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Amerihealth Caritas,Managed Medicaid,,13.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Amerihealth Caritas,Managed Medicaid,,47.59,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Amerihealth Caritas,Managed Medicaid,,54.83,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Amerihealth Caritas,Managed Medicaid,,31.77,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Amerihealth Caritas,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Amerihealth Caritas,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Amerihealth Caritas,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Amerihealth Caritas,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Amerihealth Caritas,Managed Medicaid,,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Amerihealth Caritas,Managed Medicaid,,66.15,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Amerihealth Caritas,Managed Medicaid,,65.92,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Amerihealth Caritas,Managed Medicaid,,30.66,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Amerihealth Caritas,Managed Medicaid,,31.80,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Amerihealth Caritas,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Amerihealth Caritas,Managed Medicaid,,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Amerihealth Caritas,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Amerihealth Caritas,Managed Medicaid,,0.02402,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Amerihealth Caritas,Managed Medicaid,,0.05405,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Amerihealth Caritas,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Amerihealth Caritas,Managed Medicaid,,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Amerihealth Caritas,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Amerihealth Caritas,Managed Medicaid,,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Amerihealth Caritas,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Amerihealth Caritas,Managed Medicaid,,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Amerihealth Caritas,Managed Medicaid,,64.52,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Amerihealth Caritas,Managed Medicaid,,16.24,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Amerihealth Caritas,Managed Medicaid,,10.71,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Amerihealth Caritas,Managed Medicaid,,25.23,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Amerihealth Caritas,Managed Medicaid,,6.18,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Amerihealth Caritas,Managed Medicaid,,3.33,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Amerihealth Caritas,Managed Medicaid,,23.38,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Amerihealth Caritas,Managed Medicaid,,6.74,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Amerihealth Caritas,Managed Medicaid,,19.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Amerihealth Caritas,Managed Medicaid,,55.06,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Amerihealth Caritas,Managed Medicaid,,8.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Amerihealth Caritas,Managed Medicaid,,10.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Amerihealth Caritas,Managed Medicaid,,33.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Amerihealth Caritas,Managed Medicaid,,25.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Amerihealth Caritas,Managed Medicaid,,30.87,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Amerihealth Caritas,Managed Medicaid,,29.30,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Amerihealth Caritas,Managed Medicaid,,5.23,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Amerihealth Caritas,Managed Medicaid,,5.72,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Amerihealth Caritas,Managed Medicaid,,13.62,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Amerihealth Caritas,Managed Medicaid,,28.18,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Amerihealth Caritas,Managed Medicaid,,0.10210,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Amerihealth Caritas,Managed Medicaid,,5.25,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Amerihealth Caritas,Managed Medicaid,,1.19,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Amerihealth Caritas,Managed Medicaid,,2.11,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Amerihealth Caritas,Managed Medicaid,,0.02202,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Amerihealth Caritas,Managed Medicaid,,0.16016,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Amerihealth Caritas,Managed Medicaid,,1.55,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Amerihealth Caritas,Managed Medicaid,,0.15816,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Amerihealth Caritas,Managed Medicaid,,0.09409,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Amerihealth Caritas,Managed Medicaid,,0.12813,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Amerihealth Caritas,Managed Medicaid,,333.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00400,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Amerihealth Caritas,Managed Medicaid,,0.01802,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Amerihealth Caritas,Managed Medicaid,,0.51451,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Amerihealth Caritas,Managed Medicaid,,5.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Amerihealth Caritas,Managed Medicaid,,16.31,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Amerihealth Caritas,Managed Medicaid,,0.01401,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Amerihealth Caritas,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Amerihealth Caritas,Managed Medicaid,,1.23,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Amerihealth Caritas,Managed Medicaid,,0.22422,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Amerihealth Caritas,Managed Medicaid,,0.32232,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Amerihealth Caritas,Managed Medicaid,,0.51251,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Amerihealth Caritas,Managed Medicaid,,0.35836,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00400,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Amerihealth Caritas,Managed Medicaid,,4.42,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Amerihealth Caritas,Managed Medicaid,,220.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Amerihealth Caritas,Managed Medicaid,,27.01,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Amerihealth Caritas,Managed Medicaid,,33.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Amerihealth Caritas,Managed Medicaid,,0.02603,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Amerihealth Caritas,Managed Medicaid,,7.28,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Amerihealth Caritas,Managed Medicaid,,13.07,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Amerihealth Caritas,Managed Medicaid,,28.81,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Amerihealth Caritas,Managed Medicaid,,12.73,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Amerihealth Caritas,Managed Medicaid,,49.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Amerihealth Caritas,Managed Medicaid,,2.25,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Amerihealth Caritas,Managed Medicaid,,5.10,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Amerihealth Caritas,Managed Medicaid,,0.15015,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Amerihealth Caritas,Managed Medicaid,,0.00801,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Amerihealth Caritas,Managed Medicaid,,3.03,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Amerihealth Caritas,Managed Medicaid,,2.67,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Amerihealth Caritas,Managed Medicaid,,2.38,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Amerihealth Caritas,Managed Medicaid,,3.54,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Amerihealth Caritas,Managed Medicaid,,6.68,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Amerihealth Caritas,Managed Medicaid,,11.00,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Amerihealth Caritas,Managed Medicaid,,27.86,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Amerihealth Caritas,Managed Medicaid,,109.85,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Amerihealth Caritas,Managed Medicaid,,63.31,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Amerihealth Caritas,Managed Medicaid,,74.32,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Amerihealth Caritas,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Amerihealth Caritas,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Amerihealth Caritas,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Amerihealth Caritas,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Amerihealth Caritas,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Amerihealth Caritas,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Amerihealth Caritas,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Amerihealth Caritas,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Amerihealth Caritas,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Amerihealth Caritas,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Amerihealth Caritas,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Amerihealth Caritas,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Amerihealth Caritas,Managed Medicaid,,25.72,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Amerihealth Caritas,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Amerihealth Caritas,Managed Medicaid,,70.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Amerihealth Caritas,Managed Medicaid,,77.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Amerihealth Caritas,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Amerihealth Caritas,Managed Medicaid,,709.51,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Amerihealth Caritas,Managed Medicaid,,60.91,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Amerihealth Caritas,Managed Medicaid,,8.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Amerihealth Caritas,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Amerihealth Caritas,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Amerihealth Caritas,Managed Medicaid,,483.34,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Amerihealth Caritas,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Amerihealth Caritas,Managed Medicaid,,94.40,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Amerihealth Caritas,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Amerihealth Caritas,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Amerihealth Caritas,Managed Medicaid,,1045.12,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Amerihealth Caritas,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Amerihealth Caritas,Managed Medicaid,,16.00,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Amerihealth Caritas,Managed Medicaid,,6.74,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Amerihealth Caritas,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,,9.41,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Amerihealth Caritas,Managed Medicaid,,3.97,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Amerihealth Caritas,Managed Medicaid,,5.05,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Amerihealth Caritas,Managed Medicaid,,16.08,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Amerihealth Caritas,Managed Medicaid,,6.49,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Amerihealth Caritas,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Amerihealth Caritas,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Amerihealth Caritas,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Amerihealth Caritas,Managed Medicaid,,87.43,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Amerihealth Caritas,Managed Medicaid,,149.79,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Amerihealth Caritas,Managed Medicaid,,457.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Amerihealth Caritas,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Amerihealth Caritas,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Amerihealth Caritas,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Amerihealth Caritas,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Amerihealth Caritas,Managed Medicaid,,9.90,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Amerihealth Caritas,Managed Medicaid,,11.52,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Amerihealth Caritas,Managed Medicaid,,113.81,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Amerihealth Caritas,Managed Medicaid,,4.36,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Amerihealth Caritas,Managed Medicaid,,4.93,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Amerihealth Caritas,Managed Medicaid,,1.40,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Amerihealth Caritas,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Amerihealth Caritas,Managed Medicaid,,0.52052,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Amerihealth Caritas,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Amerihealth Caritas,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Amerihealth Caritas,Managed Medicaid,,5.36,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Amerihealth Caritas,Managed Medicaid,,6.19,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Amerihealth Caritas,Managed Medicaid,,4.76,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Amerihealth Caritas,Managed Medicaid,,9.52,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Amerihealth Caritas,Managed Medicaid,,5.88,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Amerihealth Caritas,Managed Medicaid,,6.48,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Amerihealth Caritas,Managed Medicaid,,548.82,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Amerihealth Caritas,Managed Medicaid,,3.55,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Amerihealth Caritas,Managed Medicaid,,3.35,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Amerihealth Caritas,Managed Medicaid,,3.40,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Amerihealth Caritas,Managed Medicaid,,4.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Amerihealth Caritas,Managed Medicaid,,8.17,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Amerihealth Caritas,Managed Medicaid,,368.29,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Amerihealth Caritas,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Amerihealth Caritas,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Amerihealth Caritas,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Amerihealth Caritas,Managed Medicaid,,6.56,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Amerihealth Caritas,Managed Medicaid,,49.43,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Amerihealth Caritas,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Amerihealth Caritas,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Amerihealth Caritas,Managed Medicaid,,4.55,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Amerihealth Caritas,Managed Medicaid,,4068.51,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Amerihealth Caritas,Managed Medicaid,,6.41,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Amerihealth Caritas,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Amerihealth Caritas,Managed Medicaid,,31.60,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Amerihealth Caritas,Managed Medicaid,,60.24,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Amerihealth Caritas,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Amerihealth Caritas,Managed Medicaid,,14.07,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Amerihealth Caritas,Managed Medicaid,,16.98,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Amerihealth Caritas,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Amerihealth Caritas,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Amerihealth Caritas,Managed Medicaid,,155.02,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Amerihealth Caritas,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Amerihealth Caritas,Managed Medicaid,,10.18,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Amerihealth Caritas,Managed Medicaid,,13.78,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Amerihealth Caritas,Managed Medicaid,,13.34,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Amerihealth Caritas,Managed Medicaid,,14.46,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Amerihealth Caritas,Managed Medicaid,,7.94,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Amerihealth Caritas,Managed Medicaid,,5.64,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Amerihealth Caritas,Managed Medicaid,,12179.59,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Amerihealth Caritas,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Amerihealth Caritas,Managed Medicaid,,31.70,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Amerihealth Caritas,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Amerihealth Caritas,Managed Medicaid,,104.15,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Amerihealth Caritas,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Amerihealth Caritas,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Amerihealth Caritas,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Amerihealth Caritas,Managed Medicaid,,9.99,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Amerihealth Caritas,Managed Medicaid,,12.25,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Amerihealth Caritas,Managed Medicaid,,16.79,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Amerihealth Caritas,Managed Medicaid,,21.31,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Amerihealth Caritas,Managed Medicaid,,25.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Amerihealth Caritas,Managed Medicaid,,14.18,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Amerihealth Caritas,Managed Medicaid,,15.24,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Amerihealth Caritas,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Amerihealth Caritas,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Amerihealth Caritas,Managed Medicaid,,247.33,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Amerihealth Caritas,Managed Medicaid,,468.68,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Amerihealth Caritas,Managed Medicaid,,1.70,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Amerihealth Caritas,Managed Medicaid,,34.23,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Amerihealth Caritas,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Amerihealth Caritas,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Amerihealth Caritas,Managed Medicaid,,4.12,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Amerihealth Caritas,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Amerihealth Caritas,Managed Medicaid,,7.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Amerihealth Caritas,Managed Medicaid,,14.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,,24.62,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Amerihealth Caritas,Managed Medicaid,,611.76,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Amerihealth Caritas,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Amerihealth Caritas,Managed Medicaid,,269.35,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Amerihealth Caritas,Managed Medicaid,,4.30,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Amerihealth Caritas,Managed Medicaid,,12.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Amerihealth Caritas,Managed Medicaid,,7.13,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Amerihealth Caritas,Managed Medicaid,,6.68,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Amerihealth Caritas,Managed Medicaid,,6.82,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Amerihealth Caritas,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Amerihealth Caritas,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Amerihealth Caritas,Managed Medicaid,,484.62,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Amerihealth Caritas,Managed Medicaid,,1297.10,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Amerihealth Caritas,Managed Medicaid,,33.63,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Amerihealth Caritas,Managed Medicaid,,5.52,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Amerihealth Caritas,Managed Medicaid,,12.75,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Amerihealth Caritas,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Amerihealth Caritas,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Amerihealth Caritas,Managed Medicaid,,5.51,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Amerihealth Caritas,Managed Medicaid,,6.30,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Amerihealth Caritas,Managed Medicaid,,31.51,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Amerihealth Caritas,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Amerihealth Caritas,Managed Medicaid,,20.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Amerihealth Caritas,Managed Medicaid,,117.13,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Amerihealth Caritas,Managed Medicaid,,36.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Amerihealth Caritas,Managed Medicaid,,52.11,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Amerihealth Caritas,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Amerihealth Caritas,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Amerihealth Caritas,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Amerihealth Caritas,Managed Medicaid,,20.21,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Amerihealth Caritas,Managed Medicaid,,35.74,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Amerihealth Caritas,Managed Medicaid,,105.20,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Amerihealth Caritas,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Amerihealth Caritas,Managed Medicaid,,20.25,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Amerihealth Caritas,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Amerihealth Caritas,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Amerihealth Caritas,Managed Medicaid,,176.48,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Amerihealth Caritas,Managed Medicaid,,11.71,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Amerihealth Caritas,Managed Medicaid,,179.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Amerihealth Caritas,Managed Medicaid,,285.22,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Amerihealth Caritas,Managed Medicaid,,426.24,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Amerihealth Caritas,Managed Medicaid,,708.25,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Amerihealth Caritas,Managed Medicaid,,1413.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Amerihealth Caritas,Managed Medicaid,,2118.34,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Amerihealth Caritas,Managed Medicaid,,339.37,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Amerihealth Caritas,Managed Medicaid,,1650.91,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Amerihealth Caritas,Managed Medicaid,,6438.44,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Amerihealth Caritas,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Amerihealth Caritas,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Amerihealth Caritas,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Amerihealth Caritas,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Amerihealth Caritas,Managed Medicaid,,1763.13,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Amerihealth Caritas,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Amerihealth Caritas,Managed Medicaid,,16.68,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Amerihealth Caritas,Managed Medicaid,,20.29,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Amerihealth Caritas,Managed Medicaid,,30.82,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Amerihealth Caritas,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Amerihealth Caritas,Managed Medicaid,,3.74,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Amerihealth Caritas,Managed Medicaid,,23.20,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Amerihealth Caritas,Managed Medicaid,,28.42,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Amerihealth Caritas,Managed Medicaid,,177.12,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Amerihealth Caritas,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Amerihealth Caritas,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Amerihealth Caritas,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Amerihealth Caritas,Managed Medicaid,,197.30,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Amerihealth Caritas,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Amerihealth Caritas,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Amerihealth Caritas,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Amerihealth Caritas,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Amerihealth Caritas,Managed Medicaid,,20.15,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Amerihealth Caritas,Managed Medicaid,,38.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Amerihealth Caritas,Managed Medicaid,,2654.78,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Amerihealth Caritas,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Amerihealth Caritas,Managed Medicaid,,2.75,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Amerihealth Caritas,Managed Medicaid,,449.52,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Amerihealth Caritas,Managed Medicaid,,17.23,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Amerihealth Caritas,Managed Medicaid,,142.12,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Amerihealth Caritas,Managed Medicaid,,42.80,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Amerihealth Caritas,Managed Medicaid,,12.13,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Amerihealth Caritas,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Amerihealth Caritas,Managed Medicaid,,36.93,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Amerihealth Caritas,Managed Medicaid,,44.98,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Amerihealth Caritas,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Amerihealth Caritas,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Amerihealth Caritas,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Amerihealth Caritas,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Amerihealth Caritas,Managed Medicaid,,0.62062,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Amerihealth Caritas,Managed Medicaid,,16.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Amerihealth Caritas,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Amerihealth Caritas,Managed Medicaid,,15.28,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Amerihealth Caritas,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Amerihealth Caritas,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Amerihealth Caritas,Managed Medicaid,,21.02,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Amerihealth Caritas,Managed Medicaid,,94.41,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Amerihealth Caritas,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Amerihealth Caritas,Managed Medicaid,,56.41,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Amerihealth Caritas,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Amerihealth Caritas,Managed Medicaid,,11220.92,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Amerihealth Caritas,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Amerihealth Caritas,Managed Medicaid,,893.81,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Amerihealth Caritas,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Amerihealth Caritas,Managed Medicaid,,14.13,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Amerihealth Caritas,Managed Medicaid,,5.40,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Amerihealth Caritas,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Amerihealth Caritas,Managed Medicaid,,6.29,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Amerihealth Caritas,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Amerihealth Caritas,Managed Medicaid,,13.56,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Amerihealth Caritas,Managed Medicaid,,5.97,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Amerihealth Caritas,Managed Medicaid,,223.00,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Amerihealth Caritas,Managed Medicaid,,366.37,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Amerihealth Caritas,Managed Medicaid,,63.28,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Amerihealth Caritas,Managed Medicaid,,94.95,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Amerihealth Caritas,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Amerihealth Caritas,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Amerihealth Caritas,Managed Medicaid,,142.19,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Amerihealth Caritas,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Amerihealth Caritas,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Amerihealth Caritas,Managed Medicaid,,113.11,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Amerihealth Caritas,Managed Medicaid,,239.91,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Amerihealth Caritas,Managed Medicaid,,0.82082,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Amerihealth Caritas,Managed Medicaid,,113.87,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Amerihealth Caritas,Managed Medicaid,,22.42,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Amerihealth Caritas,Managed Medicaid,,33.63,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Amerihealth Caritas,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Amerihealth Caritas,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Amerihealth Caritas,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Amerihealth Caritas,Managed Medicaid,,122.05,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Amerihealth Caritas,Managed Medicaid,,31.90,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Amerihealth Caritas,Managed Medicaid,,17.42,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Amerihealth Caritas,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Amerihealth Caritas,Managed Medicaid,,4.22,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Amerihealth Caritas,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Amerihealth Caritas,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Amerihealth Caritas,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Amerihealth Caritas,Managed Medicaid,,6.85,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Amerihealth Caritas,Managed Medicaid,,24.72,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Amerihealth Caritas,Managed Medicaid,,25.00,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Amerihealth Caritas,Managed Medicaid,,9.78,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Amerihealth Caritas,Managed Medicaid,,12.40,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Amerihealth Caritas,Managed Medicaid,,6.32,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Amerihealth Caritas,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Amerihealth Caritas,Managed Medicaid,,76.08,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Amerihealth Caritas,Managed Medicaid,,182.24,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Amerihealth Caritas,Managed Medicaid,,33.58,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Amerihealth Caritas,Managed Medicaid,,64.10,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Amerihealth Caritas,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Amerihealth Caritas,Managed Medicaid,,120.93,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Amerihealth Caritas,Managed Medicaid,,5085.99,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Amerihealth Caritas,Managed Medicaid,,371.29,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Amerihealth Caritas,Managed Medicaid,,4.20,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Amerihealth Caritas,Managed Medicaid,,192.56,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Amerihealth Caritas,Managed Medicaid,,4.99,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Amerihealth Caritas,Managed Medicaid,,16.95,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Amerihealth Caritas,Managed Medicaid,,7.22,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Amerihealth Caritas,Managed Medicaid,,330.57,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Amerihealth Caritas,Managed Medicaid,,6063.10,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Amerihealth Caritas,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Amerihealth Caritas,Managed Medicaid,,6.34,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Amerihealth Caritas,Managed Medicaid,,10.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Amerihealth Caritas,Managed Medicaid,,7.62,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Amerihealth Caritas,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Amerihealth Caritas,Managed Medicaid,,14.42,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Amerihealth Caritas,Managed Medicaid,,15.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Amerihealth Caritas,Managed Medicaid,,37.17,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Amerihealth Caritas,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Amerihealth Caritas,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Amerihealth Caritas,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Amerihealth Caritas,Managed Medicaid,,64.17,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Amerihealth Caritas,Managed Medicaid,,87.69,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Amerihealth Caritas,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Amerihealth Caritas,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Amerihealth Caritas,Managed Medicaid,,413.11,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Amerihealth Caritas,Managed Medicaid,,549.75,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Amerihealth Caritas,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Amerihealth Caritas,Managed Medicaid,,39.28,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Amerihealth Caritas,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Amerihealth Caritas,Managed Medicaid,,0.54054,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Amerihealth Caritas,Managed Medicaid,,12.01,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Amerihealth Caritas,Managed Medicaid,,6.45,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Amerihealth Caritas,Managed Medicaid,,4.46,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Amerihealth Caritas,Managed Medicaid,,17.53,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Amerihealth Caritas,Managed Medicaid,,23.06,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Amerihealth Caritas,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Amerihealth Caritas,Managed Medicaid,,9.95,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Amerihealth Caritas,Managed Medicaid,,7.23,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Amerihealth Caritas,Managed Medicaid,,29.62,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Amerihealth Caritas,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Amerihealth Caritas,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Amerihealth Caritas,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Amerihealth Caritas,Managed Medicaid,,41.45,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Amerihealth Caritas,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Amerihealth Caritas,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Amerihealth Caritas,Managed Medicaid,,6.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Amerihealth Caritas,Managed Medicaid,,110.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Amerihealth Caritas,Managed Medicaid,,5.37,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Amerihealth Caritas,Managed Medicaid,,4.79,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Amerihealth Caritas,Managed Medicaid,,5.90,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Amerihealth Caritas,Managed Medicaid,,8.63,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Amerihealth Caritas,Managed Medicaid,,10.70,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Amerihealth Caritas,Managed Medicaid,,12.18,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Amerihealth Caritas,Managed Medicaid,,35.74,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Amerihealth Caritas,Managed Medicaid,,101.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Amerihealth Caritas,Managed Medicaid,,10.63,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Amerihealth Caritas,Managed Medicaid,,4.94,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Amerihealth Caritas,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Amerihealth Caritas,Managed Medicaid,,12.26,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Amerihealth Caritas,Managed Medicaid,,5.59,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Amerihealth Caritas,Managed Medicaid,,34.07,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Amerihealth Caritas,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Amerihealth Caritas,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Amerihealth Caritas,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Amerihealth Caritas,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Amerihealth Caritas,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Amerihealth Caritas,Managed Medicaid,,23675.99,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Amerihealth Caritas,Managed Medicaid,,25.12,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Amerihealth Caritas,Managed Medicaid,,150.32,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Amerihealth Caritas,Managed Medicaid,,2.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Amerihealth Caritas,Managed Medicaid,,2.99,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Amerihealth Caritas,Managed Medicaid,,15.35,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Amerihealth Caritas,Managed Medicaid,,1.07,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Amerihealth Caritas,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Amerihealth Caritas,Managed Medicaid,,8.04,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Amerihealth Caritas,Managed Medicaid,,8.95,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Amerihealth Caritas,Managed Medicaid,,7.29,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Amerihealth Caritas,Managed Medicaid,,17.00,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Amerihealth Caritas,Managed Medicaid,,16.97,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Amerihealth Caritas,Managed Medicaid,,17.00,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Amerihealth Caritas,Managed Medicaid,,16.61,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Amerihealth Caritas,Managed Medicaid,,210.68,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Amerihealth Caritas,Managed Medicaid,,1079.07,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Amerihealth Caritas,Managed Medicaid,,728.09,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Amerihealth Caritas,Managed Medicaid,,6.63,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Amerihealth Caritas,Managed Medicaid,,3156.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Amerihealth Caritas,Managed Medicaid,,0.58058,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Amerihealth Caritas,Managed Medicaid,,4.21,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Amerihealth Caritas,Managed Medicaid,,86.25,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Amerihealth Caritas,Managed Medicaid,,47.35,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Amerihealth Caritas,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Amerihealth Caritas,Managed Medicaid,,21.62,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Amerihealth Caritas,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Amerihealth Caritas,Managed Medicaid,,28.88,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Amerihealth Caritas,Managed Medicaid,,58.02,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Amerihealth Caritas,Managed Medicaid,,535.27,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Amerihealth Caritas,Managed Medicaid,,17.52,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Amerihealth Caritas,Managed Medicaid,,1.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Amerihealth Caritas,Managed Medicaid,,667.95,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Amerihealth Caritas,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Amerihealth Caritas,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Amerihealth Caritas,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Amerihealth Caritas,Managed Medicaid,,163.80,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Amerihealth Caritas,Managed Medicaid,,64.00,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Amerihealth Caritas,Managed Medicaid,,197.18,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Amerihealth Caritas,Managed Medicaid,,5.03,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Amerihealth Caritas,Managed Medicaid,,272.42,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Amerihealth Caritas,Managed Medicaid,,17.52,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Amerihealth Caritas,Managed Medicaid,,43.51,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Amerihealth Caritas,Managed Medicaid,,7.69,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Amerihealth Caritas,Managed Medicaid,,7.85,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Amerihealth Caritas,Managed Medicaid,,1250.81,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Amerihealth Caritas,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Amerihealth Caritas,Managed Medicaid,,4.16,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Amerihealth Caritas,Managed Medicaid,,1902.78,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Amerihealth Caritas,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Amerihealth Caritas,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Amerihealth Caritas,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Amerihealth Caritas,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Amerihealth Caritas,Managed Medicaid,,52.45,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Amerihealth Caritas,Managed Medicaid,,70.57,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Amerihealth Caritas,Managed Medicaid,,2.17,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Amerihealth Caritas,Managed Medicaid,,59.78,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Amerihealth Caritas,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Amerihealth Caritas,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Amerihealth Caritas,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Amerihealth Caritas,Managed Medicaid,,9.27,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Amerihealth Caritas,Managed Medicaid,,43.77,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Amerihealth Caritas,Managed Medicaid,,35.92,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Amerihealth Caritas,Managed Medicaid,,19.98,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Amerihealth Caritas,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Amerihealth Caritas,Managed Medicaid,,31.22,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Amerihealth Caritas,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Amerihealth Caritas,Managed Medicaid,,4.40,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Amerihealth Caritas,Managed Medicaid,,12.96,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Amerihealth Caritas,Managed Medicaid,,2397.64,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Amerihealth Caritas,Managed Medicaid,,11.54,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Amerihealth Caritas,Managed Medicaid,,6.85,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Amerihealth Caritas,Managed Medicaid,,16.12,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Amerihealth Caritas,Managed Medicaid,,4.73,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Amerihealth Caritas,Managed Medicaid,,1945.70,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Amerihealth Caritas,Managed Medicaid,,50.03,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Amerihealth Caritas,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Amerihealth Caritas,Managed Medicaid,,1.47,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Amerihealth Caritas,Managed Medicaid,,27.60,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Amerihealth Caritas,Managed Medicaid,,3.70,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Amerihealth Caritas,Managed Medicaid,,16.17,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Amerihealth Caritas,Managed Medicaid,,17.22,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Amerihealth Caritas,Managed Medicaid,,36.04,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Amerihealth Caritas,Managed Medicaid,,19.45,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Amerihealth Caritas,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Amerihealth Caritas,Managed Medicaid,,31.84,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Amerihealth Caritas,Managed Medicaid,,18.79,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Amerihealth Caritas,Managed Medicaid,,14.10,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Amerihealth Caritas,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Amerihealth Caritas,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Amerihealth Caritas,Managed Medicaid,,16.83,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Amerihealth Caritas,Managed Medicaid,,2.36,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Amerihealth Caritas,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Amerihealth Caritas,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Amerihealth Caritas,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Amerihealth Caritas,Managed Medicaid,,2.21,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Amerihealth Caritas,Managed Medicaid,,1641.62,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Amerihealth Caritas,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Amerihealth Caritas,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Amerihealth Caritas,Managed Medicaid,,12.35,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Amerihealth Caritas,Managed Medicaid,,74.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Amerihealth Caritas,Managed Medicaid,,38.55,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Amerihealth Caritas,Managed Medicaid,,14.08,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Amerihealth Caritas,Managed Medicaid,,13.27,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Amerihealth Caritas,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Amerihealth Caritas,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Amerihealth Caritas,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Amerihealth Caritas,Managed Medicaid,,5.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Amerihealth Caritas,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Amerihealth Caritas,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Amerihealth Caritas,Managed Medicaid,,22.60,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Amerihealth Caritas,Managed Medicaid,,26.46,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Amerihealth Caritas,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Amerihealth Caritas,Managed Medicaid,,18.05,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Amerihealth Caritas,Managed Medicaid,,29.76,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Amerihealth Caritas,Managed Medicaid,,8.92,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Amerihealth Caritas,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Amerihealth Caritas,Managed Medicaid,,4.05,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Amerihealth Caritas,Managed Medicaid,,69.27,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Amerihealth Caritas,Managed Medicaid,,253.03,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Amerihealth Caritas,Managed Medicaid,,4.61,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Amerihealth Caritas,Managed Medicaid,,90.65,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Amerihealth Caritas,Managed Medicaid,,181.74,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Amerihealth Caritas,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Amerihealth Caritas,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Amerihealth Caritas,Managed Medicaid,,1.78,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Amerihealth Caritas,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Amerihealth Caritas,Managed Medicaid,,48.18,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Amerihealth Caritas,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Amerihealth Caritas,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Amerihealth Caritas,Managed Medicaid,,18.93,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Amerihealth Caritas,Managed Medicaid,,5.67,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Amerihealth Caritas,Managed Medicaid,,26.98,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Amerihealth Caritas,Managed Medicaid,,28.38,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Amerihealth Caritas,Managed Medicaid,,8.76,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Amerihealth Caritas,Managed Medicaid,,69.80,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Amerihealth Caritas,Managed Medicaid,,4.19,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Amerihealth Caritas,Managed Medicaid,,3.75,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Amerihealth Caritas,Managed Medicaid,,28.38,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Amerihealth Caritas,Managed Medicaid,,32.93,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Amerihealth Caritas,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Amerihealth Caritas,Managed Medicaid,,0.64064,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Amerihealth Caritas,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Amerihealth Caritas,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Amerihealth Caritas,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Amerihealth Caritas,Managed Medicaid,,18.36,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Amerihealth Caritas,Managed Medicaid,,15.96,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Amerihealth Caritas,Managed Medicaid,,94.29,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Amerihealth Caritas,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Amerihealth Caritas,Managed Medicaid,,4.64,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Amerihealth Caritas,Managed Medicaid,,4.70,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Amerihealth Caritas,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Amerihealth Caritas,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Amerihealth Caritas,Managed Medicaid,,2779.01,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Amerihealth Caritas,Managed Medicaid,,60.82,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Amerihealth Caritas,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Amerihealth Caritas,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Amerihealth Caritas,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Amerihealth Caritas,Managed Medicaid,,813.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Amerihealth Caritas,Managed Medicaid,,22.63,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Amerihealth Caritas,Managed Medicaid,,23.59,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Amerihealth Caritas,Managed Medicaid,,3569.45,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Amerihealth Caritas,Managed Medicaid,,5678.07,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Amerihealth Caritas,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Amerihealth Caritas,Managed Medicaid,,1.23,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Amerihealth Caritas,Managed Medicaid,,29.52,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Amerihealth Caritas,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Amerihealth Caritas,Managed Medicaid,,8.31,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Amerihealth Caritas,Managed Medicaid,,4.74,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Amerihealth Caritas,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Amerihealth Caritas,Managed Medicaid,,32.33,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Amerihealth Caritas,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Amerihealth Caritas,Managed Medicaid,,19.60,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Amerihealth Caritas,Managed Medicaid,,18.87,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Amerihealth Caritas,Managed Medicaid,,916.12,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Amerihealth Caritas,Managed Medicaid,,30.63,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Amerihealth Caritas,Managed Medicaid,,4.81,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Amerihealth Caritas,Managed Medicaid,,0.96096,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Amerihealth Caritas,Managed Medicaid,,65.28,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Amerihealth Caritas,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Amerihealth Caritas,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Amerihealth Caritas,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Amerihealth Caritas,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Amerihealth Caritas,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Amerihealth Caritas,Managed Medicaid,,110.10,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Amerihealth Caritas,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Amerihealth Caritas,Managed Medicaid,,4.47,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Amerihealth Caritas,Managed Medicaid,,0.37037,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Amerihealth Caritas,Managed Medicaid,,16.84,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Amerihealth Caritas,Managed Medicaid,,64.93,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Amerihealth Caritas,Managed Medicaid,,98.80,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Amerihealth Caritas,Managed Medicaid,,4.09,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Amerihealth Caritas,Managed Medicaid,,71.50,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Amerihealth Caritas,Managed Medicaid,,105.65,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Amerihealth Caritas,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Amerihealth Caritas,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Amerihealth Caritas,Managed Medicaid,,73.80,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Amerihealth Caritas,Managed Medicaid,,1279.76,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Amerihealth Caritas,Managed Medicaid,,5.69,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Amerihealth Caritas,Managed Medicaid,,1377.08,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Amerihealth Caritas,Managed Medicaid,,6665.14,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Amerihealth Caritas,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Amerihealth Caritas,Managed Medicaid,,11.01,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Amerihealth Caritas,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Amerihealth Caritas,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Amerihealth Caritas,Managed Medicaid,,7882.80,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Amerihealth Caritas,Managed Medicaid,,1623.83,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Amerihealth Caritas,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Amerihealth Caritas,Managed Medicaid,,76.35,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Amerihealth Caritas,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Amerihealth Caritas,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Amerihealth Caritas,Managed Medicaid,,419.08,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Amerihealth Caritas,Managed Medicaid,,2799.47,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Amerihealth Caritas,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Amerihealth Caritas,Managed Medicaid,,92.54,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Amerihealth Caritas,Managed Medicaid,,219.22,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Amerihealth Caritas,Managed Medicaid,,49.55,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Amerihealth Caritas,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Amerihealth Caritas,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Amerihealth Caritas,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Amerihealth Caritas,Managed Medicaid,,48.28,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Amerihealth Caritas,Managed Medicaid,,61.64,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Amerihealth Caritas,Managed Medicaid,,81.44,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Amerihealth Caritas,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Amerihealth Caritas,Managed Medicaid,,162.03,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Amerihealth Caritas,Managed Medicaid,,1221.21,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Amerihealth Caritas,Managed Medicaid,,2970.42,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Amerihealth Caritas,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Amerihealth Caritas,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Amerihealth Caritas,Managed Medicaid,,146.38,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Amerihealth Caritas,Managed Medicaid,,7.91,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Amerihealth Caritas,Managed Medicaid,,9.55,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Amerihealth Caritas,Managed Medicaid,,10.92,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Amerihealth Caritas,Managed Medicaid,,15.56,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Amerihealth Caritas,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Amerihealth Caritas,Managed Medicaid,,5250.24,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Amerihealth Caritas,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Amerihealth Caritas,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Amerihealth Caritas,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Amerihealth Caritas,Managed Medicaid,,21.88,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Amerihealth Caritas,Managed Medicaid,,356.36,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Amerihealth Caritas,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Amerihealth Caritas,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Amerihealth Caritas,Managed Medicaid,,4208.24,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Amerihealth Caritas,Managed Medicaid,,6299.92,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Amerihealth Caritas,Managed Medicaid,,3212.74,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Amerihealth Caritas,Managed Medicaid,,361.87,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Amerihealth Caritas,Managed Medicaid,,750.14,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Amerihealth Caritas,Managed Medicaid,,1.62,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Amerihealth Caritas,Managed Medicaid,,18.92,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Amerihealth Caritas,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Amerihealth Caritas,Managed Medicaid,,783.62,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Amerihealth Caritas,Managed Medicaid,,16833.42,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Amerihealth Caritas,Managed Medicaid,,396.12,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Amerihealth Caritas,Managed Medicaid,,98.74,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Amerihealth Caritas,Managed Medicaid,,926.81,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Amerihealth Caritas,Managed Medicaid,,1838.20,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Amerihealth Caritas,Managed Medicaid,,915.21,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Amerihealth Caritas,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Amerihealth Caritas,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Amerihealth Caritas,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Amerihealth Caritas,Managed Medicaid,,403.08,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Amerihealth Caritas,Managed Medicaid,,253.12,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Amerihealth Caritas,Managed Medicaid,,8.87,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Amerihealth Caritas,Managed Medicaid,,25.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Amerihealth Caritas,Managed Medicaid,,16.86,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Amerihealth Caritas,Managed Medicaid,,15.22,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Amerihealth Caritas,Managed Medicaid,,2157.77,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Amerihealth Caritas,Managed Medicaid,,2679.20,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Amerihealth Caritas,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Amerihealth Caritas,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Amerihealth Caritas,Managed Medicaid,,11.51,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Amerihealth Caritas,Managed Medicaid,,3285.05,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Amerihealth Caritas,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Amerihealth Caritas,Managed Medicaid,,19.57,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Amerihealth Caritas,Managed Medicaid,,29.49,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Amerihealth Caritas,Managed Medicaid,,11.91,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Amerihealth Caritas,Managed Medicaid,,2234.18,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Amerihealth Caritas,Managed Medicaid,,208.06,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Amerihealth Caritas,Managed Medicaid,,127.22,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Amerihealth Caritas,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Amerihealth Caritas,Managed Medicaid,,43.75,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Amerihealth Caritas,Managed Medicaid,,3.83,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Amerihealth Caritas,Managed Medicaid,,175.64,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Amerihealth Caritas,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Amerihealth Caritas,Managed Medicaid,,808.29,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Amerihealth Caritas,Managed Medicaid,,331.70,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Amerihealth Caritas,Managed Medicaid,,61.99,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Amerihealth Caritas,Managed Medicaid,,2704.88,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Amerihealth Caritas,Managed Medicaid,,15.43,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Amerihealth Caritas,Managed Medicaid,,57.14,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Amerihealth Caritas,Managed Medicaid,,109.23,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Amerihealth Caritas,Managed Medicaid,,930.37,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Amerihealth Caritas,Managed Medicaid,,42.32,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Amerihealth Caritas,Managed Medicaid,,19.15,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Amerihealth Caritas,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Amerihealth Caritas,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Amerihealth Caritas,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Amerihealth Caritas,Managed Medicaid,,270.30,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Amerihealth Caritas,Managed Medicaid,,24.52,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Amerihealth Caritas,Managed Medicaid,,549.99,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Amerihealth Caritas,Managed Medicaid,,12.28,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Amerihealth Caritas,Managed Medicaid,,216.72,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Amerihealth Caritas,Managed Medicaid,,12.27,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Amerihealth Caritas,Managed Medicaid,,3207.80,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Amerihealth Caritas,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Amerihealth Caritas,Managed Medicaid,,38.37,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Amerihealth Caritas,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Amerihealth Caritas,Managed Medicaid,,73.53,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Amerihealth Caritas,Managed Medicaid,,11.51,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Amerihealth Caritas,Managed Medicaid,,6.86,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Amerihealth Caritas,Managed Medicaid,,7.99,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Amerihealth Caritas,Managed Medicaid,,17993.44,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Amerihealth Caritas,Managed Medicaid,,1899.64,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Amerihealth Caritas,Managed Medicaid,,17368.36,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Amerihealth Caritas,Managed Medicaid,,8.97,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Amerihealth Caritas,Managed Medicaid,,1427.85,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Amerihealth Caritas,Managed Medicaid,,179.52,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Amerihealth Caritas,Managed Medicaid,,3838.14,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Amerihealth Caritas,Managed Medicaid,,963.00,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Amerihealth Caritas,Managed Medicaid,,5848.24,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Amerihealth Caritas,Managed Medicaid,,1.33,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Amerihealth Caritas,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Amerihealth Caritas,Managed Medicaid,,6675.83,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Amerihealth Caritas,Managed Medicaid,,14.27,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Amerihealth Caritas,Managed Medicaid,,13.75,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Amerihealth Caritas,Managed Medicaid,,262.81,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Amerihealth Caritas,Managed Medicaid,,903.18,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Amerihealth Caritas,Managed Medicaid,,9.57,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Amerihealth Caritas,Managed Medicaid,,9727.12,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Amerihealth Caritas,Managed Medicaid,,21122.14,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Amerihealth Caritas,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Amerihealth Caritas,Managed Medicaid,,26.35,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Amerihealth Caritas,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Amerihealth Caritas,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Amerihealth Caritas,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Amerihealth Caritas,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Amerihealth Caritas,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Amerihealth Caritas,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Amerihealth Caritas,Managed Medicaid,,39.94,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Amerihealth Caritas,Managed Medicaid,,199.70,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Amerihealth Caritas,Managed Medicaid,,13.23,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Amerihealth Caritas,Managed Medicaid,,133.84,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Amerihealth Caritas,Managed Medicaid,,0.94094,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Amerihealth Caritas,Managed Medicaid,,3.68,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Amerihealth Caritas,Managed Medicaid,,394.84,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Amerihealth Caritas,Managed Medicaid,,5329.34,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Amerihealth Caritas,Managed Medicaid,,1179.31,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Amerihealth Caritas,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Amerihealth Caritas,Managed Medicaid,,7051.96,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Amerihealth Caritas,Managed Medicaid,,16.03,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Amerihealth Caritas,Managed Medicaid,,48.44,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Amerihealth Caritas,Managed Medicaid,,77.98,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Amerihealth Caritas,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Amerihealth Caritas,Managed Medicaid,,11.70,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Amerihealth Caritas,Managed Medicaid,,23.30,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Amerihealth Caritas,Managed Medicaid,,33.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Amerihealth Caritas,Managed Medicaid,,43.39,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Amerihealth Caritas,Managed Medicaid,,103.68,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Amerihealth Caritas,Managed Medicaid,,405.10,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Amerihealth Caritas,Managed Medicaid,,1904.73,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Amerihealth Caritas,Managed Medicaid,,105.11,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Amerihealth Caritas,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Amerihealth Caritas,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Amerihealth Caritas,Managed Medicaid,,97.95,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Amerihealth Caritas,Managed Medicaid,,4267.77,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Amerihealth Caritas,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Amerihealth Caritas,Managed Medicaid,,322.39,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Amerihealth Caritas,Managed Medicaid,,69.02,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Amerihealth Caritas,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Amerihealth Caritas,Managed Medicaid,,11.19,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Amerihealth Caritas,Managed Medicaid,,1030.23,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Amerihealth Caritas,Managed Medicaid,,9678.64,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Amerihealth Caritas,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Amerihealth Caritas,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Amerihealth Caritas,Managed Medicaid,,909.56,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Amerihealth Caritas,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Amerihealth Caritas,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Amerihealth Caritas,Managed Medicaid,,7220.03,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Amerihealth Caritas,Managed Medicaid,,586.19,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Amerihealth Caritas,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Amerihealth Caritas,Managed Medicaid,,4173.39,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Amerihealth Caritas,Managed Medicaid,,40.64,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Amerihealth Caritas,Managed Medicaid,,57.46,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Amerihealth Caritas,Managed Medicaid,,83.99,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Amerihealth Caritas,Managed Medicaid,,356.56,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Amerihealth Caritas,Managed Medicaid,,16449.48,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Amerihealth Caritas,Managed Medicaid,,2513.50,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Amerihealth Caritas,Managed Medicaid,,669.68,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Amerihealth Caritas,Managed Medicaid,,40.29,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Amerihealth Caritas,Managed Medicaid,,9.61,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Amerihealth Caritas,Managed Medicaid,,4.77,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Amerihealth Caritas,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Amerihealth Caritas,Managed Medicaid,,799.89,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Amerihealth Caritas,Managed Medicaid,,3779.20,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Amerihealth Caritas,Managed Medicaid,,3471.11,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Amerihealth Caritas,Managed Medicaid,,10388.06,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Amerihealth Caritas,Managed Medicaid,,2075.14,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Amerihealth Caritas,Managed Medicaid,,1257.11,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Amerihealth Caritas,Managed Medicaid,,21.45,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Amerihealth Caritas,Managed Medicaid,,2529.45,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Amerihealth Caritas,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Amerihealth Caritas,Managed Medicaid,,2773.87,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Amerihealth Caritas,Managed Medicaid,,2216.38,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Amerihealth Caritas,Managed Medicaid,,595.39,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Amerihealth Caritas,Managed Medicaid,,686.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Amerihealth Caritas,Managed Medicaid,,3212.13,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Amerihealth Caritas,Managed Medicaid,,15163.67,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Amerihealth Caritas,Managed Medicaid,,3042.20,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Amerihealth Caritas,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Amerihealth Caritas,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Amerihealth Caritas,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Amerihealth Caritas,Managed Medicaid,,1643.90,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Amerihealth Caritas,Managed Medicaid,,3886.53,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Amerihealth Caritas,Managed Medicaid,,821.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Amerihealth Caritas,Managed Medicaid,,29.85,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Amerihealth Caritas,Managed Medicaid,,2313.19,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Amerihealth Caritas,Managed Medicaid,,22028.61,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Amerihealth Caritas,Managed Medicaid,,433.03,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Amerihealth Caritas,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Amerihealth Caritas,Managed Medicaid,,8.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Amerihealth Caritas,Managed Medicaid,,35.29,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Amerihealth Caritas,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Amerihealth Caritas,Managed Medicaid,,12313.86,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Amerihealth Caritas,Managed Medicaid,,8227.27,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Amerihealth Caritas,Managed Medicaid,,13.14,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Amerihealth Caritas,Managed Medicaid,,1284.65,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Amerihealth Caritas,Managed Medicaid,,3568.15,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Amerihealth Caritas,Managed Medicaid,,20151.54,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Amerihealth Caritas,Managed Medicaid,,5505.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Amerihealth Caritas,Managed Medicaid,,204.15,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Amerihealth Caritas,Managed Medicaid,,1350.05,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Amerihealth Caritas,Managed Medicaid,,1121.90,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Amerihealth Caritas,Managed Medicaid,,1845.18,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Amerihealth Caritas,Managed Medicaid,,25003.11,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Amerihealth Caritas,Managed Medicaid,,10652.28,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Amerihealth Caritas,Managed Medicaid,,4098.29,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Amerihealth Caritas,Managed Medicaid,,3408.28,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Amerihealth Caritas,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Amerihealth Caritas,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Amerihealth Caritas,Managed Medicaid,,16.27,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Amerihealth Caritas,Managed Medicaid,,174.05,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Amerihealth Caritas,Managed Medicaid,,6574.28,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Amerihealth Caritas,Managed Medicaid,,21.51,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Amerihealth Caritas,Managed Medicaid,,82.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Amerihealth Caritas,Managed Medicaid,,3271.31,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Amerihealth Caritas,Managed Medicaid,,7294.04,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Amerihealth Caritas,Managed Medicaid,,6.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Amerihealth Caritas,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Amerihealth Caritas,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Amerihealth Caritas,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Amerihealth Caritas,Managed Medicaid,,148.04,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Amerihealth Caritas,Managed Medicaid,,234.94,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Amerihealth Caritas,Managed Medicaid,,13639.98,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Amerihealth Caritas,Managed Medicaid,,15.22,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Amerihealth Caritas,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Amerihealth Caritas,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Amerihealth Caritas,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Amerihealth Caritas,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Amerihealth Caritas,Managed Medicaid,,20.83,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Amerihealth Caritas,Managed Medicaid,,9258.10,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Amerihealth Caritas,Managed Medicaid,,1859.57,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Amerihealth Caritas,Managed Medicaid,,104.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Amerihealth Caritas,Managed Medicaid,,6029.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Amerihealth Caritas,Managed Medicaid,,604.94,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Amerihealth Caritas,Managed Medicaid,,16551.88,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Amerihealth Caritas,Managed Medicaid,,13041.87,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Amerihealth Caritas,Managed Medicaid,,2395.89,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Amerihealth Caritas,Managed Medicaid,,4788.40,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Amerihealth Caritas,Managed Medicaid,,5984.79,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Amerihealth Caritas,Managed Medicaid,,13645.27,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Amerihealth Caritas,Managed Medicaid,,188.67,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Amerihealth Caritas,Managed Medicaid,,509.79,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Amerihealth Caritas,Managed Medicaid,,509.80,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Amerihealth Caritas,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Amerihealth Caritas,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Amerihealth Caritas,Managed Medicaid,,818.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Amerihealth Caritas,Managed Medicaid,,295.46,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Amerihealth Caritas,Managed Medicaid,,41.72,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Amerihealth Caritas,Managed Medicaid,,51.15,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Amerihealth Caritas,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Amerihealth Caritas,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Amerihealth Caritas,Managed Medicaid,,13.87,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Amerihealth Caritas,Managed Medicaid,,12710.40,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Amerihealth Caritas,Managed Medicaid,,46.93,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Amerihealth Caritas,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Amerihealth Caritas,Managed Medicaid,,70.56,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Amerihealth Caritas,Managed Medicaid,,5351.96,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Amerihealth Caritas,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Amerihealth Caritas,Managed Medicaid,,2200.82,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Amerihealth Caritas,Managed Medicaid,,8765.41,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Amerihealth Caritas,Managed Medicaid,,176.78,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Amerihealth Caritas,Managed Medicaid,,12260.66,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Amerihealth Caritas,Managed Medicaid,,1464.46,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Amerihealth Caritas,Managed Medicaid,,51.51,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Amerihealth Caritas,Managed Medicaid,,16.27,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Amerihealth Caritas,Managed Medicaid,,3.41,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Amerihealth Caritas,Managed Medicaid,,3.35,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Amerihealth Caritas,Managed Medicaid,,7051.96,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Amerihealth Caritas,Managed Medicaid,,4363.51,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Amerihealth Caritas,Managed Medicaid,,0.27027,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Amerihealth Caritas,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Amerihealth Caritas,Managed Medicaid,,72.96,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Amerihealth Caritas,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Amerihealth Caritas,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Amerihealth Caritas,Managed Medicaid,,93.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Amerihealth Caritas,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Amerihealth Caritas,Managed Medicaid,,9.83,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Amerihealth Caritas,Managed Medicaid,,17.85,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Amerihealth Caritas,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Amerihealth Caritas,Managed Medicaid,,14.69,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Amerihealth Caritas,Managed Medicaid,,65.63,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Amerihealth Caritas,Managed Medicaid,,7.70,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Amerihealth Caritas,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Amerihealth Caritas,Managed Medicaid,,5.46,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Amerihealth Caritas,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Amerihealth Caritas,Managed Medicaid,,0.59059,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Amerihealth Caritas,Managed Medicaid,,38.62,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Amerihealth Caritas,Managed Medicaid,,2.22,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Amerihealth Caritas,Managed Medicaid,,3.91,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Amerihealth Caritas,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Amerihealth Caritas,Managed Medicaid,,18.87,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Amerihealth Caritas,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Amerihealth Caritas,Managed Medicaid,,5.45,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Amerihealth Caritas,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Amerihealth Caritas,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Amerihealth Caritas,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Amerihealth Caritas,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Amerihealth Caritas,Managed Medicaid,,18.23,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Amerihealth Caritas,Managed Medicaid,,280.27,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Amerihealth Caritas,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Amerihealth Caritas,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Amerihealth Caritas,Managed Medicaid,,882.66,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Amerihealth Caritas,Managed Medicaid,,4193.08,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Amerihealth Caritas,Managed Medicaid,,13.60,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Amerihealth Caritas,Managed Medicaid,,1273.87,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Amerihealth Caritas,Managed Medicaid,,16.80,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Amerihealth Caritas,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Amerihealth Caritas,Managed Medicaid,,39.60,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Amerihealth Caritas,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Amerihealth Caritas,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Amerihealth Caritas,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Amerihealth Caritas,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Amerihealth Caritas,Managed Medicaid,,837.33,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Amerihealth Caritas,Managed Medicaid,,16.33,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Amerihealth Caritas,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Amerihealth Caritas,Managed Medicaid,,25.36,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Amerihealth Caritas,Managed Medicaid,,94.67,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Amerihealth Caritas,Managed Medicaid,,1.93,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Amerihealth Caritas,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Amerihealth Caritas,Managed Medicaid,,222.82,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Amerihealth Caritas,Managed Medicaid,,4.01,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Amerihealth Caritas,Managed Medicaid,,4.98,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Amerihealth Caritas,Managed Medicaid,,35.58,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Amerihealth Caritas,Managed Medicaid,,2.37,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Amerihealth Caritas,Managed Medicaid,,17.42,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Amerihealth Caritas,Managed Medicaid,,16.37,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Amerihealth Caritas,Managed Medicaid,,21.32,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Amerihealth Caritas,Managed Medicaid,,21.96,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Amerihealth Caritas,Managed Medicaid,,130.98,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Amerihealth Caritas,Managed Medicaid,,14.23,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Amerihealth Caritas,Managed Medicaid,,14.35,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Amerihealth Caritas,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Amerihealth Caritas,Managed Medicaid,,14.26,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Amerihealth Caritas,Managed Medicaid,,15.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Amerihealth Caritas,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Amerihealth Caritas,Managed Medicaid,,15.62,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Amerihealth Caritas,Managed Medicaid,,412.01,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Amerihealth Caritas,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Amerihealth Caritas,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Amerihealth Caritas,Managed Medicaid,,103.41,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Amerihealth Caritas,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Amerihealth Caritas,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Amerihealth Caritas,Managed Medicaid,,10.79,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Amerihealth Caritas,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Amerihealth Caritas,Managed Medicaid,,3.75,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Amerihealth Caritas,Managed Medicaid,,28.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Amerihealth Caritas,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Amerihealth Caritas,Managed Medicaid,,84.56,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Amerihealth Caritas,Managed Medicaid,,10.15,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Amerihealth Caritas,Managed Medicaid,,17.75,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Amerihealth Caritas,Managed Medicaid,,4.28,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Amerihealth Caritas,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Amerihealth Caritas,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Amerihealth Caritas,Managed Medicaid,,18.21,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Amerihealth Caritas,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Amerihealth Caritas,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Amerihealth Caritas,Managed Medicaid,,0.38038,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Amerihealth Caritas,Managed Medicaid,,4.79,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Amerihealth Caritas,Managed Medicaid,,4.48,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Amerihealth Caritas,Managed Medicaid,,39.36,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Amerihealth Caritas,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Amerihealth Caritas,Managed Medicaid,,9.69,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Amerihealth Caritas,Managed Medicaid,,5.95,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Amerihealth Caritas,Managed Medicaid,,1.50,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Amerihealth Caritas,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Amerihealth Caritas,Managed Medicaid,,4.15,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Amerihealth Caritas,Managed Medicaid,,16.30,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Amerihealth Caritas,Managed Medicaid,,0.67067,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Amerihealth Caritas,Managed Medicaid,,2.88,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Amerihealth Caritas,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Amerihealth Caritas,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Amerihealth Caritas,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Amerihealth Caritas,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Amerihealth Caritas,Managed Medicaid,,6.53,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Amerihealth Caritas,Managed Medicaid,,15.99,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Amerihealth Caritas,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Amerihealth Caritas,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Amerihealth Caritas,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Amerihealth Caritas,Managed Medicaid,,3.98,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Amerihealth Caritas,Managed Medicaid,,32.93,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Amerihealth Caritas,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Amerihealth Caritas,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Amerihealth Caritas,Managed Medicaid,,16.89,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Amerihealth Caritas,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Amerihealth Caritas,Managed Medicaid,,1470.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Amerihealth Caritas,Managed Medicaid,,5.63,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Amerihealth Caritas,Managed Medicaid,,15.38,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Amerihealth Caritas,Managed Medicaid,,6.35,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Amerihealth Caritas,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Amerihealth Caritas,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Amerihealth Caritas,Managed Medicaid,,548.81,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Amerihealth Caritas,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Amerihealth Caritas,Managed Medicaid,,7.99,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Amerihealth Caritas,Managed Medicaid,,5.28,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Amerihealth Caritas,Managed Medicaid,,19.45,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Amerihealth Caritas,Managed Medicaid,,20.34,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Amerihealth Caritas,Managed Medicaid,,29.43,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Amerihealth Caritas,Managed Medicaid,,5.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Amerihealth Caritas,Managed Medicaid,,236.14,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Amerihealth Caritas,Managed Medicaid,,451.45,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Amerihealth Caritas,Managed Medicaid,,1156.15,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Amerihealth Caritas,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Amerihealth Caritas,Managed Medicaid,,443.79,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Amerihealth Caritas,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Amerihealth Caritas,Managed Medicaid,,45.65,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Amerihealth Caritas,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Amerihealth Caritas,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Amerihealth Caritas,Managed Medicaid,,52.77,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Amerihealth Caritas,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Amerihealth Caritas,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Amerihealth Caritas,Managed Medicaid,,4.62,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Amerihealth Caritas,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Amerihealth Caritas,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Amerihealth Caritas,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Amerihealth Caritas,Managed Medicaid,,20.26,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Amerihealth Caritas,Managed Medicaid,,121.53,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Amerihealth Caritas,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Amerihealth Caritas,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Amerihealth Caritas,Managed Medicaid,,38.94,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Amerihealth Caritas,Managed Medicaid,,39.17,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Amerihealth Caritas,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Amerihealth Caritas,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Amerihealth Caritas,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Amerihealth Caritas,Managed Medicaid,,0.78078,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Amerihealth Caritas,Managed Medicaid,,7.14,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Amerihealth Caritas,Managed Medicaid,,8.69,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Amerihealth Caritas,Managed Medicaid,,12.01,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Amerihealth Caritas,Managed Medicaid,,16.44,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Amerihealth Caritas,Managed Medicaid,,20.96,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Amerihealth Caritas,Managed Medicaid,,44.19,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Amerihealth Caritas,Managed Medicaid,,2.68,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Amerihealth Caritas,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Amerihealth Caritas,Managed Medicaid,,202.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Amerihealth Caritas,Managed Medicaid,,1.61,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Amerihealth Caritas,Managed Medicaid,,22.82,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Amerihealth Caritas,Managed Medicaid,,4.63,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Amerihealth Caritas,Managed Medicaid,,5.31,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Amerihealth Caritas,Managed Medicaid,,150.68,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Amerihealth Caritas,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Amerihealth Caritas,Managed Medicaid,,61.74,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Amerihealth Caritas,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Amerihealth Caritas,Managed Medicaid,,18.48,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Amerihealth Caritas,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Amerihealth Caritas,Managed Medicaid,,4.57,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Amerihealth Caritas,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Amerihealth Caritas,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Amerihealth Caritas,Managed Medicaid,,9.24,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Amerihealth Caritas,Managed Medicaid,,10.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Amerihealth Caritas,Managed Medicaid,,53.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Amerihealth Caritas,Managed Medicaid,,5.59,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Amerihealth Caritas,Managed Medicaid,,12.64,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Amerihealth Caritas,Managed Medicaid,,119.95,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Amerihealth Caritas,Managed Medicaid,,7.56,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Amerihealth Caritas,Managed Medicaid,,12.50,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Amerihealth Caritas,Managed Medicaid,,704.70,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Amerihealth Caritas,Managed Medicaid,,310.71,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Amerihealth Caritas,Managed Medicaid,,241.06,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Amerihealth Caritas,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Amerihealth Caritas,Managed Medicaid,,43.24,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Amerihealth Caritas,Managed Medicaid,,23.07,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Amerihealth Caritas,Managed Medicaid,,104.89,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Amerihealth Caritas,Managed Medicaid,,139.84,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Amerihealth Caritas,Managed Medicaid,,240.04,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Amerihealth Caritas,Managed Medicaid,,67.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Amerihealth Caritas,Managed Medicaid,,69.97,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Amerihealth Caritas,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Amerihealth Caritas,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Amerihealth Caritas,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Amerihealth Caritas,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Amerihealth Caritas,Managed Medicaid,,3.86,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Amerihealth Caritas,Managed Medicaid,,2576.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Amerihealth Caritas,Managed Medicaid,,10.49,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Amerihealth Caritas,Managed Medicaid,,71.52,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Amerihealth Caritas,Managed Medicaid,,13.33,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Amerihealth Caritas,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Amerihealth Caritas,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Amerihealth Caritas,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Amerihealth Caritas,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Amerihealth Caritas,Managed Medicaid,,5.43,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Amerihealth Caritas,Managed Medicaid,,138.74,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Amerihealth Caritas,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Amerihealth Caritas,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Amerihealth Caritas,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Amerihealth Caritas,Managed Medicaid,,4.32,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Amerihealth Caritas,Managed Medicaid,,16.64,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Amerihealth Caritas,Managed Medicaid,,74.00,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Amerihealth Caritas,Managed Medicaid,,84.08,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Amerihealth Caritas,Managed Medicaid,,5.74,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Amerihealth Caritas,Managed Medicaid,,8.49,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Amerihealth Caritas,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Amerihealth Caritas,Managed Medicaid,,10.70,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Amerihealth Caritas,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Amerihealth Caritas,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Amerihealth Caritas,Managed Medicaid,,24.00,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Amerihealth Caritas,Managed Medicaid,,1.26,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Amerihealth Caritas,Managed Medicaid,,18.82,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Amerihealth Caritas,Managed Medicaid,,17.32,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Amerihealth Caritas,Managed Medicaid,,93.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Amerihealth Caritas,Managed Medicaid,,63.86,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Amerihealth Caritas,Managed Medicaid,,168.96,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Amerihealth Caritas,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Amerihealth Caritas,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Amerihealth Caritas,Managed Medicaid,,53.06,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Amerihealth Caritas,Managed Medicaid,,171.88,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Amerihealth Caritas,Managed Medicaid,,3998.59,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Amerihealth Caritas,Managed Medicaid,,6.77,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Amerihealth Caritas,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Amerihealth Caritas,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Amerihealth Caritas,Managed Medicaid,,36.67,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Amerihealth Caritas,Managed Medicaid,,23.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Amerihealth Caritas,Managed Medicaid,,5.99,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Amerihealth Caritas,Managed Medicaid,,25.10,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Amerihealth Caritas,Managed Medicaid,,14.31,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Amerihealth Caritas,Managed Medicaid,,38.06,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Amerihealth Caritas,Managed Medicaid,,16.93,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Amerihealth Caritas,Managed Medicaid,,104.36,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Amerihealth Caritas,Managed Medicaid,,11.95,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Amerihealth Caritas,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Amerihealth Caritas,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Amerihealth Caritas,Managed Medicaid,,24.23,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Amerihealth Caritas,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Amerihealth Caritas,Managed Medicaid,,7.34,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Amerihealth Caritas,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Amerihealth Caritas,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Amerihealth Caritas,Managed Medicaid,,18.69,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Amerihealth Caritas,Managed Medicaid,,596.21,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Amerihealth Caritas,Managed Medicaid,,7.17,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Amerihealth Caritas,Managed Medicaid,,25.76,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Amerihealth Caritas,Managed Medicaid,,452.94,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Amerihealth Caritas,Managed Medicaid,,8.53,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Amerihealth Caritas,Managed Medicaid,,7.02,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Amerihealth Caritas,Managed Medicaid,,5.88,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Amerihealth Caritas,Managed Medicaid,,11.06,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Amerihealth Caritas,Managed Medicaid,,7.25,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Amerihealth Caritas,Managed Medicaid,,1047.11,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Amerihealth Caritas,Managed Medicaid,,2612.95,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Amerihealth Caritas,Managed Medicaid,,5222.67,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Amerihealth Caritas,Managed Medicaid,,10442.13,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Amerihealth Caritas,Managed Medicaid,,36.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Amerihealth Caritas,Managed Medicaid,,80.00,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Amerihealth Caritas,Managed Medicaid,,5.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Amerihealth Caritas,Managed Medicaid,,10.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Amerihealth Caritas,Managed Medicaid,,29.59,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Amerihealth Caritas,Managed Medicaid,,63.32,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Amerihealth Caritas,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Amerihealth Caritas,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Amerihealth Caritas,Managed Medicaid,,9.69,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Amerihealth Caritas,Managed Medicaid,,10.10,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Amerihealth Caritas,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Amerihealth Caritas,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Amerihealth Caritas,Managed Medicaid,,943.42,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Amerihealth Caritas,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Amerihealth Caritas,Managed Medicaid,,11.48,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Amerihealth Caritas,Managed Medicaid,,26.93,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Amerihealth Caritas,Managed Medicaid,,7.44,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Amerihealth Caritas,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Amerihealth Caritas,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Amerihealth Caritas,Managed Medicaid,,4.38,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Amerihealth Caritas,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Amerihealth Caritas,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Amerihealth Caritas,Managed Medicaid,,64.39,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Amerihealth Caritas,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Amerihealth Caritas,Managed Medicaid,,5.26,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Amerihealth Caritas,Managed Medicaid,,7.43,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Amerihealth Caritas,Managed Medicaid,,5.58,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Amerihealth Caritas,Managed Medicaid,,93.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Amerihealth Caritas,Managed Medicaid,,2.26,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Amerihealth Caritas,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Amerihealth Caritas,Managed Medicaid,,207.18,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Amerihealth Caritas,Managed Medicaid,,4.97,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Amerihealth Caritas,Managed Medicaid,,4.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Amerihealth Caritas,Managed Medicaid,,50.45,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Amerihealth Caritas,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Amerihealth Caritas,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Amerihealth Caritas,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Amerihealth Caritas,Managed Medicaid,,3.65,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Amerihealth Caritas,Managed Medicaid,,3.93,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Amerihealth Caritas,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Amerihealth Caritas,Managed Medicaid,,3.53,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Amerihealth Caritas,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Amerihealth Caritas,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Amerihealth Caritas,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Amerihealth Caritas,Managed Medicaid,,17.52,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Amerihealth Caritas,Managed Medicaid,,1250.97,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Amerihealth Caritas,Managed Medicaid,,17.53,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Amerihealth Caritas,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Amerihealth Caritas,Managed Medicaid,,19.40,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Amerihealth Caritas,Managed Medicaid,,21.10,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Amerihealth Caritas,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Amerihealth Caritas,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Amerihealth Caritas,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Amerihealth Caritas,Managed Medicaid,,14.13,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Amerihealth Caritas,Managed Medicaid,,0.97097,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Amerihealth Caritas,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Amerihealth Caritas,Managed Medicaid,,5.69,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Amerihealth Caritas,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Amerihealth Caritas,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Amerihealth Caritas,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Amerihealth Caritas,Managed Medicaid,,4.72,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Amerihealth Caritas,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Amerihealth Caritas,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Amerihealth Caritas,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Amerihealth Caritas,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Amerihealth Caritas,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Amerihealth Caritas,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Amerihealth Caritas,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Amerihealth Caritas,Managed Medicaid,,4.66,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Amerihealth Caritas,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Amerihealth Caritas,Managed Medicaid,,1.67,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Amerihealth Caritas,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Amerihealth Caritas,Managed Medicaid,,3.22,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Amerihealth Caritas,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Amerihealth Caritas,Managed Medicaid,,33.91,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Amerihealth Caritas,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Amerihealth Caritas,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Amerihealth Caritas,Managed Medicaid,,3616.45,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Amerihealth Caritas,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Amerihealth Caritas,Managed Medicaid,,6.19,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Amerihealth Caritas,Managed Medicaid,,151.67,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Amerihealth Caritas,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Amerihealth Caritas,Managed Medicaid,,28.78,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Amerihealth Caritas,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Amerihealth Caritas,Managed Medicaid,,301.87,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Amerihealth Caritas,Managed Medicaid,,0.70070,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Amerihealth Caritas,Managed Medicaid,,21.87,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Amerihealth Caritas,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Amerihealth Caritas,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Amerihealth Caritas,Managed Medicaid,,5.49,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Amerihealth Caritas,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Amerihealth Caritas,Managed Medicaid,,8.20,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Amerihealth Caritas,Managed Medicaid,,278.53,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Amerihealth Caritas,Managed Medicaid,,12.20,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Amerihealth Caritas,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Amerihealth Caritas,Managed Medicaid,,4.76,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Amerihealth Caritas,Managed Medicaid,,75.53,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Amerihealth Caritas,Managed Medicaid,,96.61,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Amerihealth Caritas,Managed Medicaid,,66.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Amerihealth Caritas,Managed Medicaid,,107.18,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Amerihealth Caritas,Managed Medicaid,,23.54,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Amerihealth Caritas,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Amerihealth Caritas,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Amerihealth Caritas,Managed Medicaid,,5.02,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Amerihealth Caritas,Managed Medicaid,,23.24,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Amerihealth Caritas,Managed Medicaid,,137.38,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Amerihealth Caritas,Managed Medicaid,,321.76,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Amerihealth Caritas,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Amerihealth Caritas,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Amerihealth Caritas,Managed Medicaid,,13.36,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Amerihealth Caritas,Managed Medicaid,,13.96,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Amerihealth Caritas,Managed Medicaid,,13.51,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Amerihealth Caritas,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Amerihealth Caritas,Managed Medicaid,,13.96,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Amerihealth Caritas,Managed Medicaid,,13.51,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Amerihealth Caritas,Managed Medicaid,,30.03,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Amerihealth Caritas,Managed Medicaid,,14.71,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Amerihealth Caritas,Managed Medicaid,,13.96,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Amerihealth Caritas,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Amerihealth Caritas,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Amerihealth Caritas,Managed Medicaid,,13.36,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Amerihealth Caritas,Managed Medicaid,,13.96,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Amerihealth Caritas,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Amerihealth Caritas,Managed Medicaid,,13.36,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Amerihealth Caritas,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Amerihealth Caritas,Managed Medicaid,,204.90,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Amerihealth Caritas,Managed Medicaid,,4.53,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Amerihealth Caritas,Managed Medicaid,,1446.91,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Amerihealth Caritas,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Amerihealth Caritas,Managed Medicaid,,1119.21,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Amerihealth Caritas,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Amerihealth Caritas,Managed Medicaid,,3.78,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Amerihealth Caritas,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Amerihealth Caritas,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Amerihealth Caritas,Managed Medicaid,,70.11,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Amerihealth Caritas,Managed Medicaid,,248.85,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Amerihealth Caritas,Managed Medicaid,,4.56,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Amerihealth Caritas,Managed Medicaid,,9.25,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Amerihealth Caritas,Managed Medicaid,,1407.53,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Amerihealth Caritas,Managed Medicaid,,66.53,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Amerihealth Caritas,Managed Medicaid,,61.72,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Amerihealth Caritas,Managed Medicaid,,134.84,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Amerihealth Caritas,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Amerihealth Caritas,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Amerihealth Caritas,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Amerihealth Caritas,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Amerihealth Caritas,Managed Medicaid,,5370.02,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Amerihealth Caritas,Managed Medicaid,,64.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Amerihealth Caritas,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Amerihealth Caritas,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Amerihealth Caritas,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Amerihealth Caritas,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Amerihealth Caritas,Managed Medicaid,,407.41,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,,99.10,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Amerihealth Caritas,Managed Medicaid,,199.52,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Amerihealth Caritas,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Amerihealth Caritas,Managed Medicaid,,15.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Amerihealth Caritas,Managed Medicaid,,67.55,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Amerihealth Caritas,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Amerihealth Caritas,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Amerihealth Caritas,Managed Medicaid,,21.09,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Amerihealth Caritas,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Amerihealth Caritas,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Amerihealth Caritas,Managed Medicaid,,3.81,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Amerihealth Caritas,Managed Medicaid,,5.34,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Amerihealth Caritas,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Amerihealth Caritas,Managed Medicaid,,15.22,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Amerihealth Caritas,Managed Medicaid,,58.63,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Amerihealth Caritas,Managed Medicaid,,4.16,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Amerihealth Caritas,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Amerihealth Caritas,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Amerihealth Caritas,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Amerihealth Caritas,Managed Medicaid,,3.90,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Amerihealth Caritas,Managed Medicaid,,3.85,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Amerihealth Caritas,Managed Medicaid,,20.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Amerihealth Caritas,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Amerihealth Caritas,Managed Medicaid,,14.29,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Amerihealth Caritas,Managed Medicaid,,15.17,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Amerihealth Caritas,Managed Medicaid,,14.14,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Amerihealth Caritas,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Amerihealth Caritas,Managed Medicaid,,12.62,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Amerihealth Caritas,Managed Medicaid,,21.90,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Amerihealth Caritas,Managed Medicaid,,0.95095,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Amerihealth Caritas,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Amerihealth Caritas,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Amerihealth Caritas,Managed Medicaid,,217.46,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Amerihealth Caritas,Managed Medicaid,,8.91,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Amerihealth Caritas,Managed Medicaid,,9.31,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Amerihealth Caritas,Managed Medicaid,,6.32,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Amerihealth Caritas,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Amerihealth Caritas,Managed Medicaid,,7322.31,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Amerihealth Caritas,Managed Medicaid,,63.69,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Amerihealth Caritas,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Amerihealth Caritas,Managed Medicaid,,12.78,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Amerihealth Caritas,Managed Medicaid,,23.12,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Amerihealth Caritas,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Amerihealth Caritas,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Amerihealth Caritas,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Amerihealth Caritas,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Amerihealth Caritas,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Amerihealth Caritas,Managed Medicaid,,15.04,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Amerihealth Caritas,Managed Medicaid,,21.65,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Amerihealth Caritas,Managed Medicaid,,30.68,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Amerihealth Caritas,Managed Medicaid,,4.37,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Amerihealth Caritas,Managed Medicaid,,3.92,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Amerihealth Caritas,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Amerihealth Caritas,Managed Medicaid,,40.90,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Amerihealth Caritas,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Amerihealth Caritas,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Amerihealth Caritas,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Amerihealth Caritas,Managed Medicaid,,4.79,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Amerihealth Caritas,Managed Medicaid,,2740.12,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Amerihealth Caritas,Managed Medicaid,,560.36,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Amerihealth Caritas,Managed Medicaid,,15.95,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Amerihealth Caritas,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Amerihealth Caritas,Managed Medicaid,,5.65,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Amerihealth Caritas,Managed Medicaid,,15.26,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Amerihealth Caritas,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Amerihealth Caritas,Managed Medicaid,,20.90,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Amerihealth Caritas,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Amerihealth Caritas,Managed Medicaid,,12.73,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Amerihealth Caritas,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Amerihealth Caritas,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Amerihealth Caritas,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Amerihealth Caritas,Managed Medicaid,,5.71,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Amerihealth Caritas,Managed Medicaid,,4.13,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Amerihealth Caritas,Managed Medicaid,,4.03,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Amerihealth Caritas,Managed Medicaid,,4.05,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Amerihealth Caritas,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Amerihealth Caritas,Managed Medicaid,,1.42,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Amerihealth Caritas,Managed Medicaid,,30.78,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Amerihealth Caritas,Managed Medicaid,,81.09,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Amerihealth Caritas,Managed Medicaid,,31.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Amerihealth Caritas,Managed Medicaid,,160.86,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Amerihealth Caritas,Managed Medicaid,,13.25,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Amerihealth Caritas,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Amerihealth Caritas,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Amerihealth Caritas,Managed Medicaid,,14.97,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Amerihealth Caritas,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Amerihealth Caritas,Managed Medicaid,,18.46,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Amerihealth Caritas,Managed Medicaid,,75.28,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Amerihealth Caritas,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Amerihealth Caritas,Managed Medicaid,,12.88,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Amerihealth Caritas,Managed Medicaid,,5.42,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Amerihealth Caritas,Managed Medicaid,,22.97,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Amerihealth Caritas,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Amerihealth Caritas,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Amerihealth Caritas,Managed Medicaid,,3.48,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Amerihealth Caritas,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Amerihealth Caritas,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Amerihealth Caritas,Managed Medicaid,,3.47,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Amerihealth Caritas,Managed Medicaid,,18.92,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Amerihealth Caritas,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Amerihealth Caritas,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Amerihealth Caritas,Managed Medicaid,,43.16,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Amerihealth Caritas,Managed Medicaid,,67.81,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Amerihealth Caritas,Managed Medicaid,,167.17,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Amerihealth Caritas,Managed Medicaid,,13.06,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Amerihealth Caritas,Managed Medicaid,,16.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Amerihealth Caritas,Managed Medicaid,,44.56,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Amerihealth Caritas,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Amerihealth Caritas,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Amerihealth Caritas,Managed Medicaid,,25.74,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Amerihealth Caritas,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Amerihealth Caritas,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Amerihealth Caritas,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Amerihealth Caritas,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Amerihealth Caritas,Managed Medicaid,,63.86,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Amerihealth Caritas,Managed Medicaid,,33.71,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Amerihealth Caritas,Managed Medicaid,,12.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Amerihealth Caritas,Managed Medicaid,,14.55,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Amerihealth Caritas,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Amerihealth Caritas,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Amerihealth Caritas,Managed Medicaid,,17.61,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Amerihealth Caritas,Managed Medicaid,,74.49,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Amerihealth Caritas,Managed Medicaid,,3.85,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Amerihealth Caritas,Managed Medicaid,,13.49,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Amerihealth Caritas,Managed Medicaid,,13.69,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Amerihealth Caritas,Managed Medicaid,,19.34,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Amerihealth Caritas,Managed Medicaid,,6.15,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Amerihealth Caritas,Managed Medicaid,,21.33,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Amerihealth Caritas,Managed Medicaid,,34.39,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Amerihealth Caritas,Managed Medicaid,,20.81,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Amerihealth Caritas,Managed Medicaid,,50.13,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Amerihealth Caritas,Managed Medicaid,,34.22,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Amerihealth Caritas,Managed Medicaid,,16.15,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Amerihealth Caritas,Managed Medicaid,,14.08,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Amerihealth Caritas,Managed Medicaid,,20.81,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Amerihealth Caritas,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Amerihealth Caritas,Managed Medicaid,,19.34,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Amerihealth Caritas,Managed Medicaid,,21.86,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Amerihealth Caritas,Managed Medicaid,,95.86,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Amerihealth Caritas,Managed Medicaid,,23.59,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Amerihealth Caritas,Managed Medicaid,,113.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Amerihealth Caritas,Managed Medicaid,,233.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Amerihealth Caritas,Managed Medicaid,,248.73,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Amerihealth Caritas,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Amerihealth Caritas,Managed Medicaid,,16.74,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Amerihealth Caritas,Managed Medicaid,,14.88,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Amerihealth Caritas,Managed Medicaid,,30.69,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Amerihealth Caritas,Managed Medicaid,,43.74,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Amerihealth Caritas,Managed Medicaid,,102.58,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Amerihealth Caritas,Managed Medicaid,,192.55,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Amerihealth Caritas,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Amerihealth Caritas,Managed Medicaid,,20.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Amerihealth Caritas,Managed Medicaid,,49.60,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Amerihealth Caritas,Managed Medicaid,,13.37,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Amerihealth Caritas,Managed Medicaid,,15.65,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Amerihealth Caritas,Managed Medicaid,,147.18,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Amerihealth Caritas,Managed Medicaid,,3.51,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Amerihealth Caritas,Managed Medicaid,,55.10,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Amerihealth Caritas,Managed Medicaid,,12.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Amerihealth Caritas,Managed Medicaid,,21.04,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Amerihealth Caritas,Managed Medicaid,,58.02,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Amerihealth Caritas,Managed Medicaid,,35.32,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Amerihealth Caritas,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Amerihealth Caritas,Managed Medicaid,,24.13,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Amerihealth Caritas,Managed Medicaid,,14.29,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Amerihealth Caritas,Managed Medicaid,,15.69,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Amerihealth Caritas,Managed Medicaid,,36.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Amerihealth Caritas,Managed Medicaid,,34.39,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Amerihealth Caritas,Managed Medicaid,,15.14,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Amerihealth Caritas,Managed Medicaid,,5.85,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Amerihealth Caritas,Managed Medicaid,,6.96,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Amerihealth Caritas,Managed Medicaid,,14.29,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Amerihealth Caritas,Managed Medicaid,,357.36,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Amerihealth Caritas,Managed Medicaid,,19.93,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Amerihealth Caritas,Managed Medicaid,,5.04,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Amerihealth Caritas,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Amerihealth Caritas,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Amerihealth Caritas,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Amerihealth Caritas,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Amerihealth Caritas,Managed Medicaid,,34.83,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Amerihealth Caritas,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Amerihealth Caritas,Managed Medicaid,,4.49,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Amerihealth Caritas,Managed Medicaid,,4.50,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Amerihealth Caritas,Managed Medicaid,,5.13,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Amerihealth Caritas,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Amerihealth Caritas,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Amerihealth Caritas,Managed Medicaid,,26.24,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Amerihealth Caritas,Managed Medicaid,,18.92,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Amerihealth Caritas,Managed Medicaid,,27.96,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Amerihealth Caritas,Managed Medicaid,,5.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Amerihealth Caritas,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Amerihealth Caritas,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Amerihealth Caritas,Managed Medicaid,,3.55,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Amerihealth Caritas,Managed Medicaid,,13.67,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Amerihealth Caritas,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Amerihealth Caritas,Managed Medicaid,,11.19,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Amerihealth Caritas,Managed Medicaid,,16.47,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Amerihealth Caritas,Managed Medicaid,,21.29,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Amerihealth Caritas,Managed Medicaid,,62.22,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Amerihealth Caritas,Managed Medicaid,,15.97,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Amerihealth Caritas,Managed Medicaid,,63.91,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Amerihealth Caritas,Managed Medicaid,,12.84,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Amerihealth Caritas,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Amerihealth Caritas,Managed Medicaid,,21.02,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Amerihealth Caritas,Managed Medicaid,,14.96,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Amerihealth Caritas,Managed Medicaid,,10.41,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Amerihealth Caritas,Managed Medicaid,,32.35,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Amerihealth Caritas,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Amerihealth Caritas,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Amerihealth Caritas,Managed Medicaid,,90.46,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Amerihealth Caritas,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Amerihealth Caritas,Managed Medicaid,,55.38,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Amerihealth Caritas,Managed Medicaid,,47.93,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Amerihealth Caritas,Managed Medicaid,,14.79,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Amerihealth Caritas,Managed Medicaid,,13.15,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Amerihealth Caritas,Managed Medicaid,,15.94,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Amerihealth Caritas,Managed Medicaid,,11.97,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Amerihealth Caritas,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Amerihealth Caritas,Managed Medicaid,,49.57,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Amerihealth Caritas,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Amerihealth Caritas,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Amerihealth Caritas,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Amerihealth Caritas,Managed Medicaid,,30.76,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Amerihealth Caritas,Managed Medicaid,,72.92,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Amerihealth Caritas,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Amerihealth Caritas,Managed Medicaid,,79.00,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Amerihealth Caritas,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Amerihealth Caritas,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Amerihealth Caritas,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Amerihealth Caritas,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Amerihealth Caritas,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Amerihealth Caritas,Managed Medicaid,,73.55,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Amerihealth Caritas,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Amerihealth Caritas,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Amerihealth Caritas,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Amerihealth Caritas,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Amerihealth Caritas,Managed Medicaid,,20.26,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Amerihealth Caritas,Managed Medicaid,,23.05,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Amerihealth Caritas,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Amerihealth Caritas,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Amerihealth Caritas,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Amerihealth Caritas,Managed Medicaid,,39.10,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Amerihealth Caritas,Managed Medicaid,,29.27,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Amerihealth Caritas,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Amerihealth Caritas,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Amerihealth Caritas,Managed Medicaid,,14.73,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Amerihealth Caritas,Managed Medicaid,,12.90,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Amerihealth Caritas,Managed Medicaid,,82.51,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Amerihealth Caritas,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Amerihealth Caritas,Managed Medicaid,,34.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Amerihealth Caritas,Managed Medicaid,,12.65,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Amerihealth Caritas,Managed Medicaid,,23.05,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Amerihealth Caritas,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Amerihealth Caritas,Managed Medicaid,,5.16,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Amerihealth Caritas,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Amerihealth Caritas,Managed Medicaid,,317.29,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Amerihealth Caritas,Managed Medicaid,,7.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Amerihealth Caritas,Managed Medicaid,,95.78,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Amerihealth Caritas,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Amerihealth Caritas,Managed Medicaid,,3.44,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Amerihealth Caritas,Managed Medicaid,,28.89,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Amerihealth Caritas,Managed Medicaid,,276.31,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Amerihealth Caritas,Managed Medicaid,,14.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Amerihealth Caritas,Managed Medicaid,,43.04,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Amerihealth Caritas,Managed Medicaid,,119.57,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Amerihealth Caritas,Managed Medicaid,,21.86,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Amerihealth Caritas,Managed Medicaid,,23.12,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Amerihealth Caritas,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Amerihealth Caritas,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Amerihealth Caritas,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Amerihealth Caritas,Managed Medicaid,,13.22,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Amerihealth Caritas,Managed Medicaid,,7.31,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Amerihealth Caritas,Managed Medicaid,,13.22,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Amerihealth Caritas,Managed Medicaid,,9.70,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Amerihealth Caritas,Managed Medicaid,,17.78,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Amerihealth Caritas,Managed Medicaid,,52.13,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Amerihealth Caritas,Managed Medicaid,,23.96,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Amerihealth Caritas,Managed Medicaid,,23.67,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Amerihealth Caritas,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Amerihealth Caritas,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Amerihealth Caritas,Managed Medicaid,,6.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Amerihealth Caritas,Managed Medicaid,,16.67,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Amerihealth Caritas,Managed Medicaid,,13.03,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Amerihealth Caritas,Managed Medicaid,,35.71,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Amerihealth Caritas,Managed Medicaid,,10.13,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Amerihealth Caritas,Managed Medicaid,,46.39,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Amerihealth Caritas,Managed Medicaid,,47.60,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Amerihealth Caritas,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Amerihealth Caritas,Managed Medicaid,,13.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Amerihealth Caritas,Managed Medicaid,,4.42,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Amerihealth Caritas,Managed Medicaid,,4.56,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Amerihealth Caritas,Managed Medicaid,,91.88,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Amerihealth Caritas,Managed Medicaid,,5.22,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Amerihealth Caritas,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Amerihealth Caritas,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Amerihealth Caritas,Managed Medicaid,,12.64,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Amerihealth Caritas,Managed Medicaid,,12.66,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Amerihealth Caritas,Managed Medicaid,,12.67,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Amerihealth Caritas,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Amerihealth Caritas,Managed Medicaid,,29.01,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Amerihealth Caritas,Managed Medicaid,,3.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Amerihealth Caritas,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Amerihealth Caritas,Managed Medicaid,,13.25,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Amerihealth Caritas,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Amerihealth Caritas,Managed Medicaid,,91.32,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Amerihealth Caritas,Managed Medicaid,,92.51,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Amerihealth Caritas,Managed Medicaid,,72.28,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Amerihealth Caritas,Managed Medicaid,,15.98,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Amerihealth Caritas,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Amerihealth Caritas,Managed Medicaid,,15.14,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Amerihealth Caritas,Managed Medicaid,,15.77,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Amerihealth Caritas,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Amerihealth Caritas,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Amerihealth Caritas,Managed Medicaid,,4.97,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Amerihealth Caritas,Managed Medicaid,,31.76,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Amerihealth Caritas,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Amerihealth Caritas,Managed Medicaid,,25.14,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Amerihealth Caritas,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Amerihealth Caritas,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Amerihealth Caritas,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Amerihealth Caritas,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Amerihealth Caritas,Managed Medicaid,,4.99,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Amerihealth Caritas,Managed Medicaid,,146.20,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Amerihealth Caritas,Managed Medicaid,,20.36,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Amerihealth Caritas,Managed Medicaid,,20.72,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Amerihealth Caritas,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Amerihealth Caritas,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Amerihealth Caritas,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Amerihealth Caritas,Managed Medicaid,,7.81,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Amerihealth Caritas,Managed Medicaid,,12.31,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Amerihealth Caritas,Managed Medicaid,,5.29,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Amerihealth Caritas,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Amerihealth Caritas,Managed Medicaid,,42.04,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Amerihealth Caritas,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Amerihealth Caritas,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Amerihealth Caritas,Managed Medicaid,,16.48,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Amerihealth Caritas,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Amerihealth Caritas,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Amerihealth Caritas,Managed Medicaid,,13.40,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Amerihealth Caritas,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Amerihealth Caritas,Managed Medicaid,,6.89,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Amerihealth Caritas,Managed Medicaid,,4.13,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Amerihealth Caritas,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Amerihealth Caritas,Managed Medicaid,,4.79,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Amerihealth Caritas,Managed Medicaid,,5.25,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Amerihealth Caritas,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Amerihealth Caritas,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Amerihealth Caritas,Managed Medicaid,,106.37,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Amerihealth Caritas,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Amerihealth Caritas,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Amerihealth Caritas,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Amerihealth Caritas,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Amerihealth Caritas,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Amerihealth Caritas,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Amerihealth Caritas,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Amerihealth Caritas,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Amerihealth Caritas,Managed Medicaid,,80.87,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Amerihealth Caritas,Managed Medicaid,,21.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Amerihealth Caritas,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Amerihealth Caritas,Managed Medicaid,,4.61,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Amerihealth Caritas,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Amerihealth Caritas,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Amerihealth Caritas,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Amerihealth Caritas,Managed Medicaid,,151.55,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Amerihealth Caritas,Managed Medicaid,,9.79,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Amerihealth Caritas,Managed Medicaid,,5.16,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Amerihealth Caritas,Managed Medicaid,,5.23,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Amerihealth Caritas,Managed Medicaid,,55.71,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Amerihealth Caritas,Managed Medicaid,,11.69,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Amerihealth Caritas,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Amerihealth Caritas,Managed Medicaid,,3.37,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Amerihealth Caritas,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Amerihealth Caritas,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Amerihealth Caritas,Managed Medicaid,,0.83083,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Amerihealth Caritas,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Amerihealth Caritas,Managed Medicaid,,55.41,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Amerihealth Caritas,Managed Medicaid,,59.75,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Amerihealth Caritas,Managed Medicaid,,47.78,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Amerihealth Caritas,Managed Medicaid,,52.17,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Amerihealth Caritas,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Amerihealth Caritas,Managed Medicaid,,58.32,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Amerihealth Caritas,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Amerihealth Caritas,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Amerihealth Caritas,Managed Medicaid,,15.58,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Amerihealth Caritas,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Amerihealth Caritas,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Amerihealth Caritas,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Amerihealth Caritas,Managed Medicaid,,9036.23,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Amerihealth Caritas,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Amerihealth Caritas,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Amerihealth Caritas,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Amerihealth Caritas,Managed Medicaid,,111.31,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Amerihealth Caritas,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Amerihealth Caritas,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Amerihealth Caritas,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Amerihealth Caritas,Managed Medicaid,,9367.61,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Amerihealth Caritas,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Amerihealth Caritas,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Amerihealth Caritas,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Amerihealth Caritas,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Amerihealth Caritas,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Amerihealth Caritas,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Amerihealth Caritas,Managed Medicaid,,202.69,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Amerihealth Caritas,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Amerihealth Caritas,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Amerihealth Caritas,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Amerihealth Caritas,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Amerihealth Caritas,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Amerihealth Caritas,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Amerihealth Caritas,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Amerihealth Caritas,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Amerihealth Caritas,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Amerihealth Caritas,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Amerihealth Caritas,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Amerihealth Caritas,Managed Medicaid,,55.83,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Amerihealth Caritas,Managed Medicaid,,8.83,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Amerihealth Caritas,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Amerihealth Caritas,Managed Medicaid,,38405.96,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Amerihealth Caritas,Managed Medicaid,,25.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Amerihealth Caritas,Managed Medicaid,,14.11,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Amerihealth Caritas,Managed Medicaid,,14.86,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Amerihealth Caritas,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Amerihealth Caritas,Managed Medicaid,,14.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Amerihealth Caritas,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Amerihealth Caritas,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Amerihealth Caritas,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Amerihealth Caritas,Managed Medicaid,,134.33,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Amerihealth Caritas,Managed Medicaid,,29.04,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Amerihealth Caritas,Managed Medicaid,,147.35,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Amerihealth Caritas,Managed Medicaid,,52.74,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Amerihealth Caritas,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Amerihealth Caritas,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Amerihealth Caritas,Managed Medicaid,,1.02,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Amerihealth Caritas,Managed Medicaid,,2.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Amerihealth Caritas,Managed Medicaid,,16.00,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Amerihealth Caritas,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Amerihealth Caritas,Managed Medicaid,,92.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Amerihealth Caritas,Managed Medicaid,,15.62,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Amerihealth Caritas,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Amerihealth Caritas,Managed Medicaid,,11.85,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Amerihealth Caritas,Managed Medicaid,,7.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Amerihealth Caritas,Managed Medicaid,,87.28,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Amerihealth Caritas,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Amerihealth Caritas,Managed Medicaid,,21.34,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Amerihealth Caritas,Managed Medicaid,,116.72,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Amerihealth Caritas,Managed Medicaid,,62.81,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Amerihealth Caritas,Managed Medicaid,,10.37,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Amerihealth Caritas,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Amerihealth Caritas,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Amerihealth Caritas,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Amerihealth Caritas,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Amerihealth Caritas,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Amerihealth Caritas,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Amerihealth Caritas,Managed Medicaid,,6.11,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Amerihealth Caritas,Managed Medicaid,,6.13,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Amerihealth Caritas,Managed Medicaid,,6.84,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Amerihealth Caritas,Managed Medicaid,,7.61,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Amerihealth Caritas,Managed Medicaid,,23.04,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Amerihealth Caritas,Managed Medicaid,,9.83,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Amerihealth Caritas,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Amerihealth Caritas,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Amerihealth Caritas,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Amerihealth Caritas,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Amerihealth Caritas,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Amerihealth Caritas,Managed Medicaid,,0.43043,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Amerihealth Caritas,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Amerihealth Caritas,Managed Medicaid,,23.36,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Amerihealth Caritas,Managed Medicaid,,46.93,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Amerihealth Caritas,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Amerihealth Caritas,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Amerihealth Caritas,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Amerihealth Caritas,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Amerihealth Caritas,Managed Medicaid,,6.26,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Amerihealth Caritas,Managed Medicaid,,5.94,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Amerihealth Caritas,Managed Medicaid,,37.17,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Amerihealth Caritas,Managed Medicaid,,15.45,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Amerihealth Caritas,Managed Medicaid,,5.99,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Amerihealth Caritas,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Amerihealth Caritas,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Amerihealth Caritas,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Amerihealth Caritas,Managed Medicaid,,17.47,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Amerihealth Caritas,Managed Medicaid,,17.83,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Amerihealth Caritas,Managed Medicaid,,4.68,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Amerihealth Caritas,Managed Medicaid,,10.72,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Amerihealth Caritas,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Amerihealth Caritas,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Amerihealth Caritas,Managed Medicaid,,61.46,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Amerihealth Caritas,Managed Medicaid,,94.69,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Amerihealth Caritas,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Amerihealth Caritas,Managed Medicaid,,5.80,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Amerihealth Caritas,Managed Medicaid,,21.17,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Amerihealth Caritas,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Amerihealth Caritas,Managed Medicaid,,3.81,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Amerihealth Caritas,Managed Medicaid,,4.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Amerihealth Caritas,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Amerihealth Caritas,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Amerihealth Caritas,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Amerihealth Caritas,Managed Medicaid,,14.85,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Amerihealth Caritas,Managed Medicaid,,2.70,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Amerihealth Caritas,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Amerihealth Caritas,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Amerihealth Caritas,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Amerihealth Caritas,Managed Medicaid,,5.33,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Amerihealth Caritas,Managed Medicaid,,6.14,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Amerihealth Caritas,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Amerihealth Caritas,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Amerihealth Caritas,Managed Medicaid,,5.23,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Amerihealth Caritas,Managed Medicaid,,4.66,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Amerihealth Caritas,Managed Medicaid,,6.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Amerihealth Caritas,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Amerihealth Caritas,Managed Medicaid,,33.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Amerihealth Caritas,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Amerihealth Caritas,Managed Medicaid,,25.70,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Amerihealth Caritas,Managed Medicaid,,10.75,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Amerihealth Caritas,Managed Medicaid,,5.15,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Amerihealth Caritas,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Amerihealth Caritas,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Amerihealth Caritas,Managed Medicaid,,4.65,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Amerihealth Caritas,Managed Medicaid,,2.10,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Amerihealth Caritas,Managed Medicaid,,4.19,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Amerihealth Caritas,Managed Medicaid,,3.59,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Amerihealth Caritas,Managed Medicaid,,40.93,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Amerihealth Caritas,Managed Medicaid,,49.56,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Amerihealth Caritas,Managed Medicaid,,14.79,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Amerihealth Caritas,Managed Medicaid,,8.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Amerihealth Caritas,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Amerihealth Caritas,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Amerihealth Caritas,Managed Medicaid,,4.86,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Amerihealth Caritas,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Amerihealth Caritas,Managed Medicaid,,45.49,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Amerihealth Caritas,Managed Medicaid,,20.24,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Amerihealth Caritas,Managed Medicaid,,6.85,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Amerihealth Caritas,Managed Medicaid,,42.58,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Amerihealth Caritas,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Amerihealth Caritas,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Amerihealth Caritas,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Amerihealth Caritas,Managed Medicaid,,4.47,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Amerihealth Caritas,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Amerihealth Caritas,Managed Medicaid,,14.47,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Amerihealth Caritas,Managed Medicaid,,50.57,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Amerihealth Caritas,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Amerihealth Caritas,Managed Medicaid,,53.99,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Amerihealth Caritas,Managed Medicaid,,31.11,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Amerihealth Caritas,Managed Medicaid,,17.16,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Amerihealth Caritas,Managed Medicaid,,22.03,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Amerihealth Caritas,Managed Medicaid,,14.54,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Amerihealth Caritas,Managed Medicaid,,37.87,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Amerihealth Caritas,Managed Medicaid,,8.98,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Amerihealth Caritas,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Amerihealth Caritas,Managed Medicaid,,0.61061,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Amerihealth Caritas,Managed Medicaid,,82.18,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Amerihealth Caritas,Managed Medicaid,,4.41,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Amerihealth Caritas,Managed Medicaid,,4.89,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Amerihealth Caritas,Managed Medicaid,,29.78,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Amerihealth Caritas,Managed Medicaid,,251.45,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Amerihealth Caritas,Managed Medicaid,,3.39,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Amerihealth Caritas,Managed Medicaid,,4.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Amerihealth Caritas,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Amerihealth Caritas,Managed Medicaid,,40.54,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Amerihealth Caritas,Managed Medicaid,,4.44,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Amerihealth Caritas,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Amerihealth Caritas,Managed Medicaid,,3.51,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Amerihealth Caritas,Managed Medicaid,,4.89,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Amerihealth Caritas,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Amerihealth Caritas,Managed Medicaid,,24.28,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Amerihealth Caritas,Managed Medicaid,,32.33,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Amerihealth Caritas,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Amerihealth Caritas,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Amerihealth Caritas,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Amerihealth Caritas,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Amerihealth Caritas,Managed Medicaid,,51.39,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Amerihealth Caritas,Managed Medicaid,,17.31,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Amerihealth Caritas,Managed Medicaid,,5.05,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Amerihealth Caritas,Managed Medicaid,,13.10,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Amerihealth Caritas,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Amerihealth Caritas,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Amerihealth Caritas,Managed Medicaid,,0.57057,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Amerihealth Caritas,Managed Medicaid,,1.53,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Amerihealth Caritas,Managed Medicaid,,18.79,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Amerihealth Caritas,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Amerihealth Caritas,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Amerihealth Caritas,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Amerihealth Caritas,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Amerihealth Caritas,Managed Medicaid,,189.66,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Amerihealth Caritas,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Amerihealth Caritas,Managed Medicaid,,71.39,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Amerihealth Caritas,Managed Medicaid,,81.01,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Amerihealth Caritas,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Amerihealth Caritas,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Amerihealth Caritas,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Amerihealth Caritas,Managed Medicaid,,20.97,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Amerihealth Caritas,Managed Medicaid,,13.41,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Amerihealth Caritas,Managed Medicaid,,23.35,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Amerihealth Caritas,Managed Medicaid,,22.43,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Amerihealth Caritas,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Amerihealth Caritas,Managed Medicaid,,15.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Amerihealth Caritas,Managed Medicaid,,16.52,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Amerihealth Caritas,Managed Medicaid,,16.51,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Amerihealth Caritas,Managed Medicaid,,19.05,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Amerihealth Caritas,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Amerihealth Caritas,Managed Medicaid,,27.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Amerihealth Caritas,Managed Medicaid,,14.86,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Amerihealth Caritas,Managed Medicaid,,85.70,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Amerihealth Caritas,Managed Medicaid,,79.04,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Amerihealth Caritas,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Amerihealth Caritas,Managed Medicaid,,13.81,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Amerihealth Caritas,Managed Medicaid,,16.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Amerihealth Caritas,Managed Medicaid,,23.16,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Amerihealth Caritas,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Amerihealth Caritas,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Amerihealth Caritas,Managed Medicaid,,1060.77,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Amerihealth Caritas,Managed Medicaid,,54.03,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Amerihealth Caritas,Managed Medicaid,,143.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Amerihealth Caritas,Managed Medicaid,,17.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Amerihealth Caritas,Managed Medicaid,,9.15,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Amerihealth Caritas,Managed Medicaid,,9.92,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Amerihealth Caritas,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Amerihealth Caritas,Managed Medicaid,,81.63,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Amerihealth Caritas,Managed Medicaid,,396.25,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Amerihealth Caritas,Managed Medicaid,,73.63,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Amerihealth Caritas,Managed Medicaid,,1.38,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Amerihealth Caritas,Managed Medicaid,,129.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Amerihealth Caritas,Managed Medicaid,,5.32,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Amerihealth Caritas,Managed Medicaid,,15.98,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Amerihealth Caritas,Managed Medicaid,,23.79,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Amerihealth Caritas,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Amerihealth Caritas,Managed Medicaid,,18.98,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Amerihealth Caritas,Managed Medicaid,,169.85,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Amerihealth Caritas,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Amerihealth Caritas,Managed Medicaid,,5.60,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Amerihealth Caritas,Managed Medicaid,,5.75,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Amerihealth Caritas,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Amerihealth Caritas,Managed Medicaid,,1.25,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Amerihealth Caritas,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Amerihealth Caritas,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Amerihealth Caritas,Managed Medicaid,,10.70,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Amerihealth Caritas,Managed Medicaid,,570.59,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Amerihealth Caritas,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Amerihealth Caritas,Managed Medicaid,,4.56,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Amerihealth Caritas,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Amerihealth Caritas,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Amerihealth Caritas,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Amerihealth Caritas,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Amerihealth Caritas,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Amerihealth Caritas,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Amerihealth Caritas,Managed Medicaid,,8.13,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Amerihealth Caritas,Managed Medicaid,,6.00,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Amerihealth Caritas,Managed Medicaid,,11.73,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Amerihealth Caritas,Managed Medicaid,,11.10,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Amerihealth Caritas,Managed Medicaid,,9.11,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Amerihealth Caritas,Managed Medicaid,,41.93,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Amerihealth Caritas,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Amerihealth Caritas,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Amerihealth Caritas,Managed Medicaid,,86.34,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Amerihealth Caritas,Managed Medicaid,,98.82,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Amerihealth Caritas,Managed Medicaid,,5497.41,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Amerihealth Caritas,Managed Medicaid,,18.50,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Amerihealth Caritas,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Amerihealth Caritas,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Amerihealth Caritas,Managed Medicaid,,61.08,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Amerihealth Caritas,Managed Medicaid,,1817.11,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Amerihealth Caritas,Managed Medicaid,,5.48,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Amerihealth Caritas,Managed Medicaid,,24.14,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Amerihealth Caritas,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Amerihealth Caritas,Managed Medicaid,,21.52,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Amerihealth Caritas,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Amerihealth Caritas,Managed Medicaid,,11.36,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Amerihealth Caritas,Managed Medicaid,,26.31,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Amerihealth Caritas,Managed Medicaid,,19.48,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Amerihealth Caritas,Managed Medicaid,,88.51,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Amerihealth Caritas,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Amerihealth Caritas,Managed Medicaid,,12.31,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Amerihealth Caritas,Managed Medicaid,,9.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Amerihealth Caritas,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Amerihealth Caritas,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Amerihealth Caritas,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Amerihealth Caritas,Managed Medicaid,,102.41,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Amerihealth Caritas,Managed Medicaid,,70.69,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Amerihealth Caritas,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Amerihealth Caritas,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Amerihealth Caritas,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Amerihealth Caritas,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Amerihealth Caritas,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Amerihealth Caritas,Managed Medicaid,,6.69,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Amerihealth Caritas,Managed Medicaid,,8103.63,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Amerihealth Caritas,Managed Medicaid,,113.70,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Amerihealth Caritas,Managed Medicaid,,8.19,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Amerihealth Caritas,Managed Medicaid,,19.64,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Amerihealth Caritas,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Amerihealth Caritas,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Amerihealth Caritas,Managed Medicaid,,31.01,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Amerihealth Caritas,Managed Medicaid,,11.84,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Amerihealth Caritas,Managed Medicaid,,5378.81,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Amerihealth Caritas,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Amerihealth Caritas,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Amerihealth Caritas,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Amerihealth Caritas,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Amerihealth Caritas,Managed Medicaid,,19.84,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Amerihealth Caritas,Managed Medicaid,,767.34,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Amerihealth Caritas,Managed Medicaid,,0.65065,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Amerihealth Caritas,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Amerihealth Caritas,Managed Medicaid,,217.13,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Amerihealth Caritas,Managed Medicaid,,8.14,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Amerihealth Caritas,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Amerihealth Caritas,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Amerihealth Caritas,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Amerihealth Caritas,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Amerihealth Caritas,Managed Medicaid,,157.47,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Amerihealth Caritas,Managed Medicaid,,8019.54,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Amerihealth Caritas,Managed Medicaid,,4011.38,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Amerihealth Caritas,Managed Medicaid,,0.79079,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Amerihealth Caritas,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Amerihealth Caritas,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Amerihealth Caritas,Managed Medicaid,,20.41,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Amerihealth Caritas,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Amerihealth Caritas,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Amerihealth Caritas,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Amerihealth Caritas,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Amerihealth Caritas,Managed Medicaid,,6.81,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Amerihealth Caritas,Managed Medicaid,,19.62,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Amerihealth Caritas,Managed Medicaid,,25.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Amerihealth Caritas,Managed Medicaid,,74.41,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Amerihealth Caritas,Managed Medicaid,,18.99,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Amerihealth Caritas,Managed Medicaid,,42.04,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Amerihealth Caritas,Managed Medicaid,,5.26,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Amerihealth Caritas,Managed Medicaid,,10.00,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Amerihealth Caritas,Managed Medicaid,,35.09,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Amerihealth Caritas,Managed Medicaid,,6.19,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Amerihealth Caritas,Managed Medicaid,,162.77,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Amerihealth Caritas,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Amerihealth Caritas,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Amerihealth Caritas,Managed Medicaid,,106.41,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Amerihealth Caritas,Managed Medicaid,,16.03,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Amerihealth Caritas,Managed Medicaid,,7.52,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Amerihealth Caritas,Managed Medicaid,,3.75,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Amerihealth Caritas,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Amerihealth Caritas,Managed Medicaid,,55.32,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Amerihealth Caritas,Managed Medicaid,,9.68,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Amerihealth Caritas,Managed Medicaid,,53.33,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Amerihealth Caritas,Managed Medicaid,,0.81081,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Amerihealth Caritas,Managed Medicaid,,32.01,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Amerihealth Caritas,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Amerihealth Caritas,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Amerihealth Caritas,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Amerihealth Caritas,Managed Medicaid,,105.45,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Amerihealth Caritas,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Amerihealth Caritas,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Amerihealth Caritas,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Amerihealth Caritas,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Amerihealth Caritas,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Amerihealth Caritas,Managed Medicaid,,15.03,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Amerihealth Caritas,Managed Medicaid,,15.11,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Amerihealth Caritas,Managed Medicaid,,14.30,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Amerihealth Caritas,Managed Medicaid,,5.81,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Amerihealth Caritas,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Amerihealth Caritas,Managed Medicaid,,4.19,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Amerihealth Caritas,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Amerihealth Caritas,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Amerihealth Caritas,Managed Medicaid,,7.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Amerihealth Caritas,Managed Medicaid,,731.93,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Amerihealth Caritas,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Amerihealth Caritas,Managed Medicaid,,2510.96,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Amerihealth Caritas,Managed Medicaid,,5018.69,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Amerihealth Caritas,Managed Medicaid,,414.16,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Amerihealth Caritas,Managed Medicaid,,551.21,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Amerihealth Caritas,Managed Medicaid,,616.62,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Amerihealth Caritas,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Amerihealth Caritas,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Amerihealth Caritas,Managed Medicaid,,86.74,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Amerihealth Caritas,Managed Medicaid,,4.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Amerihealth Caritas,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Amerihealth Caritas,Managed Medicaid,,3.41,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Amerihealth Caritas,Managed Medicaid,,3.50,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Amerihealth Caritas,Managed Medicaid,,130.73,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Amerihealth Caritas,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Amerihealth Caritas,Managed Medicaid,,17.24,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Amerihealth Caritas,Managed Medicaid,,12.13,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Amerihealth Caritas,Managed Medicaid,,149.34,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Amerihealth Caritas,Managed Medicaid,,21.02,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Amerihealth Caritas,Managed Medicaid,,7.95,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Amerihealth Caritas,Managed Medicaid,,12.31,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Amerihealth Caritas,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Amerihealth Caritas,Managed Medicaid,,4.34,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Amerihealth Caritas,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Amerihealth Caritas,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,,17.02,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Amerihealth Caritas,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Amerihealth Caritas,Managed Medicaid,,44.63,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Amerihealth Caritas,Managed Medicaid,,63.06,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Amerihealth Caritas,Managed Medicaid,,2.96,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Amerihealth Caritas,Managed Medicaid,,332.95,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Amerihealth Caritas,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Amerihealth Caritas,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Amerihealth Caritas,Managed Medicaid,,16.42,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Amerihealth Caritas,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Amerihealth Caritas,Managed Medicaid,,438.24,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Amerihealth Caritas,Managed Medicaid,,7.20,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Amerihealth Caritas,Managed Medicaid,,53.01,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Amerihealth Caritas,Managed Medicaid,,20.92,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Amerihealth Caritas,Managed Medicaid,,22.77,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Amerihealth Caritas,Managed Medicaid,,9.22,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Amerihealth Caritas,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Amerihealth Caritas,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Amerihealth Caritas,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Amerihealth Caritas,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Amerihealth Caritas,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Amerihealth Caritas,Managed Medicaid,,83.52,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Amerihealth Caritas,Managed Medicaid,,307.07,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Amerihealth Caritas,Managed Medicaid,,7.71,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Amerihealth Caritas,Managed Medicaid,,12.38,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Amerihealth Caritas,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Amerihealth Caritas,Managed Medicaid,,19.29,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Amerihealth Caritas,Managed Medicaid,,60.65,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Amerihealth Caritas,Managed Medicaid,,726.37,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Amerihealth Caritas,Managed Medicaid,,25.45,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Amerihealth Caritas,Managed Medicaid,,42.27,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Amerihealth Caritas,Managed Medicaid,,17.83,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Amerihealth Caritas,Managed Medicaid,,6.87,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Amerihealth Caritas,Managed Medicaid,,12.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Amerihealth Caritas,Managed Medicaid,,6.26,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Amerihealth Caritas,Managed Medicaid,,40.30,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Amerihealth Caritas,Managed Medicaid,,34.84,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Amerihealth Caritas,Managed Medicaid,,12.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Amerihealth Caritas,Managed Medicaid,,12.98,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Amerihealth Caritas,Managed Medicaid,,12.95,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Amerihealth Caritas,Managed Medicaid,,47.84,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Amerihealth Caritas,Managed Medicaid,,18.24,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Amerihealth Caritas,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Amerihealth Caritas,Managed Medicaid,,132.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Amerihealth Caritas,Managed Medicaid,,77.12,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Amerihealth Caritas,Managed Medicaid,,363.01,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Amerihealth Caritas,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Amerihealth Caritas,Managed Medicaid,,0.92092,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Amerihealth Caritas,Managed Medicaid,,435.35,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Amerihealth Caritas,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Amerihealth Caritas,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Amerihealth Caritas,Managed Medicaid,,18.92,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Amerihealth Caritas,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Amerihealth Caritas,Managed Medicaid,,6.65,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Amerihealth Caritas,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Amerihealth Caritas,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Amerihealth Caritas,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Amerihealth Caritas,Managed Medicaid,,15.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Amerihealth Caritas,Managed Medicaid,,71.27,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Amerihealth Caritas,Managed Medicaid,,11.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Amerihealth Caritas,Managed Medicaid,,9.80,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Amerihealth Caritas,Managed Medicaid,,1016.27,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Amerihealth Caritas,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Amerihealth Caritas,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Amerihealth Caritas,Managed Medicaid,,128.67,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Amerihealth Caritas,Managed Medicaid,,51.03,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Amerihealth Caritas,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Amerihealth Caritas,Managed Medicaid,,19.13,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Amerihealth Caritas,Managed Medicaid,,5.04,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Amerihealth Caritas,Managed Medicaid,,33.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Amerihealth Caritas,Managed Medicaid,,17.08,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Amerihealth Caritas,Managed Medicaid,,20.59,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Amerihealth Caritas,Managed Medicaid,,5.10,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Amerihealth Caritas,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Amerihealth Caritas,Managed Medicaid,,483.85,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Amerihealth Caritas,Managed Medicaid,,805.26,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Amerihealth Caritas,Managed Medicaid,,97.34,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Amerihealth Caritas,Managed Medicaid,,143.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Amerihealth Caritas,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Amerihealth Caritas,Managed Medicaid,,210.27,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Amerihealth Caritas,Managed Medicaid,,10.78,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Amerihealth Caritas,Managed Medicaid,,346.52,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Amerihealth Caritas,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Amerihealth Caritas,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Amerihealth Caritas,Managed Medicaid,,22.78,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Amerihealth Caritas,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Amerihealth Caritas,Managed Medicaid,,330.39,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Amerihealth Caritas,Managed Medicaid,,9091.99,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Amerihealth Caritas,Managed Medicaid,,31273.72,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Amerihealth Caritas,Managed Medicaid,,51551.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Amerihealth Caritas,Managed Medicaid,,2234.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Amerihealth Caritas,Managed Medicaid,,1479.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Amerihealth Caritas,Managed Medicaid,,51.85,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Amerihealth Caritas,Managed Medicaid,,2.73,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Amerihealth Caritas,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Amerihealth Caritas,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Amerihealth Caritas,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Amerihealth Caritas,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Amerihealth Caritas,Managed Medicaid,,103.90,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Amerihealth Caritas,Managed Medicaid,,257.66,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Amerihealth Caritas,Managed Medicaid,,385.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Amerihealth Caritas,Managed Medicaid,,578.78,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Amerihealth Caritas,Managed Medicaid,,694.49,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Amerihealth Caritas,Managed Medicaid,,833.23,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Amerihealth Caritas,Managed Medicaid,,1000.20,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Amerihealth Caritas,Managed Medicaid,,413.41,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Amerihealth Caritas,Managed Medicaid,,607.21,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Amerihealth Caritas,Managed Medicaid,,1104.30,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Amerihealth Caritas,Managed Medicaid,,32.03,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Amerihealth Caritas,Managed Medicaid,,126.73,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Amerihealth Caritas,Managed Medicaid,,34.63,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,,23.42,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Amerihealth Caritas,Managed Medicaid,,5.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Amerihealth Caritas,Managed Medicaid,,28.63,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Amerihealth Caritas,Managed Medicaid,,31.63,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Amerihealth Caritas,Managed Medicaid,,104.90,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Amerihealth Caritas,Managed Medicaid,,119.52,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Amerihealth Caritas,Managed Medicaid,,101.70,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Amerihealth Caritas,Managed Medicaid,,18.42,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Amerihealth Caritas,Managed Medicaid,,14.61,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Amerihealth Caritas,Managed Medicaid,,46.05,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Amerihealth Caritas,Managed Medicaid,,42.24,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Amerihealth Caritas,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Amerihealth Caritas,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Amerihealth Caritas,Managed Medicaid,,997.40,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Amerihealth Caritas,Managed Medicaid,,357.56,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Amerihealth Caritas,Managed Medicaid,,601.60,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Amerihealth Caritas,Managed Medicaid,,305.51,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Amerihealth Caritas,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Amerihealth Caritas,Managed Medicaid,,218.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Amerihealth Caritas,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Amerihealth Caritas,Managed Medicaid,,247.45,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Amerihealth Caritas,Managed Medicaid,,181.98,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Amerihealth Caritas,Managed Medicaid,,60.66,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Amerihealth Caritas,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Amerihealth Caritas,Managed Medicaid,,187.79,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Amerihealth Caritas,Managed Medicaid,,53.25,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Amerihealth Caritas,Managed Medicaid,,40.84,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Amerihealth Caritas,Managed Medicaid,,218.62,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Amerihealth Caritas,Managed Medicaid,,189.79,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Amerihealth Caritas,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Amerihealth Caritas,Managed Medicaid,,8.61,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Amerihealth Caritas,Managed Medicaid,,7.01,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Amerihealth Caritas,Managed Medicaid,,28.03,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Amerihealth Caritas,Managed Medicaid,,94.89,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Amerihealth Caritas,Managed Medicaid,,25.23,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Amerihealth Caritas,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Amerihealth Caritas,Managed Medicaid,,26.83,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Amerihealth Caritas,Managed Medicaid,,2.20,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Amerihealth Caritas,Managed Medicaid,,998.00,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Amerihealth Caritas,Managed Medicaid,,4024.02,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Amerihealth Caritas,Managed Medicaid,,1015.81,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Amerihealth Caritas,Managed Medicaid,,848.85,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Amerihealth Caritas,Managed Medicaid,,696.30,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Amerihealth Caritas,Managed Medicaid,,92.69,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Amerihealth Caritas,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Amerihealth Caritas,Managed Medicaid,,906.91,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Amerihealth Caritas,Managed Medicaid,,893.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Amerihealth Caritas,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Amerihealth Caritas,Managed Medicaid,,1168.17,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Amerihealth Caritas,Managed Medicaid,,829.43,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Amerihealth Caritas,Managed Medicaid,,829.43,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Amerihealth Caritas,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Amerihealth Caritas,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Amerihealth Caritas,Managed Medicaid,,1174.37,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Amerihealth Caritas,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Amerihealth Caritas,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Amerihealth Caritas,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Amerihealth Caritas,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Amerihealth Caritas,Managed Medicaid,,349.35,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Amerihealth Caritas,Managed Medicaid,,822.82,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Amerihealth Caritas,Managed Medicaid,,338.54,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Amerihealth Caritas,Managed Medicaid,,1301.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Amerihealth Caritas,Managed Medicaid,,237.04,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Amerihealth Caritas,Managed Medicaid,,486.89,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Amerihealth Caritas,Managed Medicaid,,737.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Amerihealth Caritas,Managed Medicaid,,860.26,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Amerihealth Caritas,Managed Medicaid,,24.22,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Amerihealth Caritas,Managed Medicaid,,341.54,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Amerihealth Caritas,Managed Medicaid,,685.89,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Amerihealth Caritas,Managed Medicaid,,16.62,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Amerihealth Caritas,Managed Medicaid,,93.49,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Amerihealth Caritas,Managed Medicaid,,137.94,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Amerihealth Caritas,Managed Medicaid,,311.71,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Amerihealth Caritas,Managed Medicaid,,236.04,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Amerihealth Caritas,Managed Medicaid,,15.82,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Amerihealth Caritas,Managed Medicaid,GP,4.20,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Amerihealth Caritas,Managed Medicaid,,66.67,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Amerihealth Caritas,Managed Medicaid,,300.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Amerihealth Caritas,Managed Medicaid,,284.68,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Amerihealth Caritas,Managed Medicaid,,228.23,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Amerihealth Caritas,Managed Medicaid,,171.77,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Amerihealth Caritas,Managed Medicaid,,115.32,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Amerihealth Caritas,Managed Medicaid,,58.86,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Amerihealth Caritas,Managed Medicaid,,327.93,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Amerihealth Caritas,Managed Medicaid,,979.98,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Amerihealth Caritas,Managed Medicaid,,1299.70,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Amerihealth Caritas,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Amerihealth Caritas,Managed Medicaid,,521.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Amerihealth Caritas,Managed Medicaid,,5236.83,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Amerihealth Caritas,Managed Medicaid,,5485.28,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Amerihealth Caritas,Managed Medicaid,,5773.17,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Amerihealth Caritas,Managed Medicaid,,6020.81,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Amerihealth Caritas,Managed Medicaid,,6269.46,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Amerihealth Caritas,Managed Medicaid,,6517.31,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Amerihealth Caritas,Managed Medicaid,,6724.92,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Amerihealth Caritas,Managed Medicaid,,7012.81,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Amerihealth Caritas,Managed Medicaid,,7260.85,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Amerihealth Caritas,Managed Medicaid,,7508.90,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Amerihealth Caritas,Managed Medicaid,,7757.15,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Amerihealth Caritas,Managed Medicaid,,77.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Amerihealth Caritas,Managed Medicaid,,106.91,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Amerihealth Caritas,Managed Medicaid,,165.97,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Amerihealth Caritas,Managed Medicaid,,167.37,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Amerihealth Caritas,Managed Medicaid,,807.81,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Amerihealth Caritas,Managed Medicaid,,1938.94,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Amerihealth Caritas,Managed Medicaid,,2083.48,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Amerihealth Caritas,Managed Medicaid,,2238.04,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Amerihealth Caritas,Managed Medicaid,,1220.02,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Amerihealth Caritas,Managed Medicaid,,1576.17,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Amerihealth Caritas,Managed Medicaid,,1792.79,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Amerihealth Caritas,Managed Medicaid,,2308.31,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Amerihealth Caritas,Managed Medicaid,,2369.57,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Amerihealth Caritas,Managed Medicaid,,2427.22,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Amerihealth Caritas,Managed Medicaid,,2485.08,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Amerihealth Caritas,Managed Medicaid,,2542.74,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Amerihealth Caritas,Managed Medicaid,,990.19,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Amerihealth Caritas,Managed Medicaid,,133.73,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Amerihealth Caritas,Managed Medicaid,,882.08,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Amerihealth Caritas,Managed Medicaid,,1190.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Amerihealth Caritas,Managed Medicaid,,1630.83,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Amerihealth Caritas,Managed Medicaid,,2066.86,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Amerihealth Caritas,Managed Medicaid,,2359.76,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Amerihealth Caritas,Managed Medicaid,,2672.67,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Amerihealth Caritas,Managed Medicaid,,3048.85,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Amerihealth Caritas,Managed Medicaid,,3268.06,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Amerihealth Caritas,Managed Medicaid,,3591.59,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Amerihealth Caritas,Managed Medicaid,,3767.56,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Amerihealth Caritas,Managed Medicaid,,3997.99,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Amerihealth Caritas,Managed Medicaid,,4146.34,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Amerihealth Caritas,Managed Medicaid,,4183.58,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Amerihealth Caritas,Managed Medicaid,,4245.64,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Amerihealth Caritas,Managed Medicaid,,4369.36,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Amerihealth Caritas,Managed Medicaid,,4493.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Amerihealth Caritas,Managed Medicaid,,4617.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Amerihealth Caritas,Managed Medicaid,,4741.74,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Amerihealth Caritas,Managed Medicaid,,4865.26,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Amerihealth Caritas,Managed Medicaid,,4989.38,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Amerihealth Caritas,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Amerihealth Caritas,Managed Medicaid,,2274.67,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Amerihealth Caritas,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Amerihealth Caritas,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Amerihealth Caritas,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Amerihealth Caritas,Managed Medicaid,,1297.30,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Amerihealth Caritas,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Amerihealth Caritas,Managed Medicaid,,1513.91,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Amerihealth Caritas,Managed Medicaid,,1705.90,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Amerihealth Caritas,Managed Medicaid,,60.66,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Amerihealth Caritas,Managed Medicaid,,254.45,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Amerihealth Caritas,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Amerihealth Caritas,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Amerihealth Caritas,Managed Medicaid,,161.76,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Amerihealth Caritas,Managed Medicaid,,2160.96,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Amerihealth Caritas,Managed Medicaid,,378.38,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Amerihealth Caritas,Managed Medicaid,,245.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Amerihealth Caritas,Managed Medicaid,,1436.23,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Amerihealth Caritas,Managed Medicaid,,59.26,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Amerihealth Caritas,Managed Medicaid,,151.35,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Amerihealth Caritas,Managed Medicaid,,0.60060,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Amerihealth Caritas,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Amerihealth Caritas,Managed Medicaid,,425.83,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Amerihealth Caritas,Managed Medicaid,,521.92,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Amerihealth Caritas,Managed Medicaid,,617.62,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Amerihealth Caritas,Managed Medicaid,,713.51,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Amerihealth Caritas,Managed Medicaid,,809.41,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Amerihealth Caritas,Managed Medicaid,,905.10,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Amerihealth Caritas,Managed Medicaid,,132.33,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Amerihealth Caritas,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Amerihealth Caritas,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Amerihealth Caritas,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Amerihealth Caritas,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Amerihealth Caritas,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Amerihealth Caritas,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Amerihealth Caritas,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Amerihealth Caritas,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Amerihealth Caritas,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Amerihealth Caritas,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Amerihealth Caritas,Managed Medicaid,,191.79,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Amerihealth Caritas,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Amerihealth Caritas,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Amerihealth Caritas,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Amerihealth Caritas,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Amerihealth Caritas,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Amerihealth Caritas,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Amerihealth Caritas,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Amerihealth Caritas,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Amerihealth Caritas,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Amerihealth Caritas,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Amerihealth Caritas,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Amerihealth Caritas,Managed Medicaid,,57.06,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Amerihealth Caritas,Managed Medicaid,,271.67,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Amerihealth Caritas,Managed Medicaid,,307.71,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Amerihealth Caritas,Managed Medicaid,,344.14,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Amerihealth Caritas,Managed Medicaid,,380.58,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Amerihealth Caritas,Managed Medicaid,,417.42,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Amerihealth Caritas,Managed Medicaid,,454.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Amerihealth Caritas,Managed Medicaid,,490.49,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Amerihealth Caritas,Managed Medicaid,,526.73,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Amerihealth Caritas,Managed Medicaid,,562.96,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Amerihealth Caritas,Managed Medicaid,,599.80,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Amerihealth Caritas,Managed Medicaid,,636.04,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Amerihealth Caritas,Managed Medicaid,,683.48,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Amerihealth Caritas,Managed Medicaid,,720.32,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Amerihealth Caritas,Managed Medicaid,,859.46,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Amerihealth Caritas,Managed Medicaid,,915.71,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Amerihealth Caritas,Managed Medicaid,,958.36,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Amerihealth Caritas,Managed Medicaid,,994.79,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Amerihealth Caritas,Managed Medicaid,,1031.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Amerihealth Caritas,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Amerihealth Caritas,Managed Medicaid,,928.13,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Amerihealth Caritas,Managed Medicaid,,825.42,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Amerihealth Caritas,Managed Medicaid,,523.12,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Amerihealth Caritas,Managed Medicaid,,565.57,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Amerihealth Caritas,Managed Medicaid,,497.70,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Amerihealth Caritas,Managed Medicaid,,669.07,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Amerihealth Caritas,Managed Medicaid,,67.47,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Amerihealth Caritas,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Amerihealth Caritas,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Amerihealth Caritas,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Amerihealth Caritas,Managed Medicaid,,255.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Amerihealth Caritas,Managed Medicaid,,419.62,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Amerihealth Caritas,Managed Medicaid,,466.27,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Amerihealth Caritas,Managed Medicaid,,253.05,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Amerihealth Caritas,Managed Medicaid,,1500.30,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Amerihealth Caritas,Managed Medicaid,,203.40,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Amerihealth Caritas,Managed Medicaid,,80.88,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Amerihealth Caritas,Managed Medicaid,,915.71,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Amerihealth Caritas,Managed Medicaid,,2169.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Amerihealth Caritas,Managed Medicaid,,1055.85,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Amerihealth Caritas,Managed Medicaid,,61.46,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Amerihealth Caritas,Managed Medicaid,,8004.80,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Amerihealth Caritas,Managed Medicaid,,8252.64,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Amerihealth Caritas,Managed Medicaid,,377.38,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Amerihealth Caritas,Managed Medicaid,,111.51,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Amerihealth Caritas,Managed Medicaid,,583.58,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Amerihealth Caritas,Managed Medicaid,,17.22,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Amerihealth Caritas,Managed Medicaid,,36.64,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Amerihealth Caritas,Managed Medicaid,,19.82,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Amerihealth Caritas,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Amerihealth Caritas,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Amerihealth Caritas,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Amerihealth Caritas,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Amerihealth Caritas,Managed Medicaid,,275.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Amerihealth Caritas,Managed Medicaid,,3917.71,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Amerihealth Caritas,Managed Medicaid,,1825.82,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Amerihealth Caritas,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Amerihealth Caritas,Managed Medicaid,,991.79,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Amerihealth Caritas,Managed Medicaid,,1489.09,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Amerihealth Caritas,Managed Medicaid,,1685.28,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Amerihealth Caritas,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Amerihealth Caritas,Managed Medicaid,,1270.87,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Amerihealth Caritas,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Amerihealth Caritas,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Amerihealth Caritas,Managed Medicaid,,41.84,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Amerihealth Caritas,Managed Medicaid,,29.03,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Amerihealth Caritas,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Amerihealth Caritas,Managed Medicaid,,25.23,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Amerihealth Caritas,Managed Medicaid,,30.23,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Amerihealth Caritas,Managed Medicaid,,36.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Amerihealth Caritas,Managed Medicaid,,59.06,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Amerihealth Caritas,Managed Medicaid,,71.07,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Amerihealth Caritas,Managed Medicaid,,209.81,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Amerihealth Caritas,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Amerihealth Caritas,Managed Medicaid,,85.08,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Amerihealth Caritas,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Amerihealth Caritas,Managed Medicaid,,214.81,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Amerihealth Caritas,Managed Medicaid,,189.79,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Amerihealth Caritas,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Amerihealth Caritas,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Amerihealth Caritas,Managed Medicaid,,154.95,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Amerihealth Caritas,Managed Medicaid,,1025.02,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Amerihealth Caritas,Managed Medicaid,,100.70,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Amerihealth Caritas,Managed Medicaid,,90.49,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Amerihealth Caritas,Managed Medicaid,,270.07,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Amerihealth Caritas,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Amerihealth Caritas,Managed Medicaid,,297.10,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Amerihealth Caritas,Managed Medicaid,,276.08,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Amerihealth Caritas,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Amerihealth Caritas,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Amerihealth Caritas,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Amerihealth Caritas,Managed Medicaid,,1345.34,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Amerihealth Caritas,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Amerihealth Caritas,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Amerihealth Caritas,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Amerihealth Caritas,Managed Medicaid,,243.24,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Amerihealth Caritas,Managed Medicaid,,326.53,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Amerihealth Caritas,Managed Medicaid,,580.38,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Amerihealth Caritas,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Amerihealth Caritas,Managed Medicaid,,92.69,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Amerihealth Caritas,Managed Medicaid,,28.03,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Amerihealth Caritas,Managed Medicaid,,33.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Amerihealth Caritas,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Amerihealth Caritas,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Amerihealth Caritas,Managed Medicaid,,205.00,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Amerihealth Caritas,Managed Medicaid,,127.53,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Amerihealth Caritas,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Amerihealth Caritas,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Amerihealth Caritas,Managed Medicaid,,59.46,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Amerihealth Caritas,Managed Medicaid,,61.66,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Amerihealth Caritas,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Amerihealth Caritas,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Amerihealth Caritas,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Amerihealth Caritas,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Amerihealth Caritas,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Amerihealth Caritas,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Amerihealth Caritas,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Amerihealth Caritas,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Amerihealth Caritas,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Amerihealth Caritas,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Amerihealth Caritas,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Amerihealth Caritas,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Amerihealth Caritas,Managed Medicaid,,1897.10,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Amerihealth Caritas,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Amerihealth Caritas,Managed Medicaid,,539.74,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Amerihealth Caritas,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Amerihealth Caritas,Managed Medicaid,,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Amerihealth Caritas,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Amerihealth Caritas,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Amerihealth Caritas,Managed Medicaid,,1227.43,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Amerihealth Caritas,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Amerihealth Caritas,Managed Medicaid,,251.25,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Amerihealth Caritas,Managed Medicaid,,107.51,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Amerihealth Caritas,Managed Medicaid,,1345.34,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Amerihealth Caritas,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Amerihealth Caritas,Managed Medicaid,,188.19,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Amerihealth Caritas,Managed Medicaid,,44.04,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Amerihealth Caritas,Managed Medicaid,,111.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Amerihealth Caritas,Managed Medicaid,,1088.29,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Amerihealth Caritas,Managed Medicaid,,3972.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Amerihealth Caritas,Managed Medicaid,,5483.48,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Amerihealth Caritas,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Amerihealth Caritas,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Amerihealth Caritas,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Amerihealth Caritas,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Amerihealth Caritas,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Amerihealth Caritas,Managed Medicaid,,625.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Amerihealth Caritas,Managed Medicaid,,234.63,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Amerihealth Caritas,Managed Medicaid,,301.70,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Amerihealth Caritas,Managed Medicaid,,283.28,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Amerihealth Caritas,Managed Medicaid,,274.27,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Amerihealth Caritas,Managed Medicaid,,1994.79,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Amerihealth Caritas,Managed Medicaid,Q1,1268.27,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Amerihealth Caritas,Managed Medicaid,Q0,759.76,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Amerihealth Caritas,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Amerihealth Caritas,Managed Medicaid,,84.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Amerihealth Caritas,Managed Medicaid,,109.91,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Amerihealth Caritas,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Amerihealth Caritas,Managed Medicaid,,117.12,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Amerihealth Caritas,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Amerihealth Caritas,Managed Medicaid,,75.48,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Amerihealth Caritas,Managed Medicaid,,18.42,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Amerihealth Caritas,Managed Medicaid,,57.66,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Amerihealth Caritas,Managed Medicaid,,87.49,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Amerihealth Caritas,Managed Medicaid,,52.45,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Amerihealth Caritas,Managed Medicaid,,46.85,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Amerihealth Caritas,Managed Medicaid,,130.53,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Amerihealth Caritas,Managed Medicaid,,6.61,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Amerihealth Caritas,Managed Medicaid,,380.18,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Amerihealth Caritas,Managed Medicaid,,48.05,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Amerihealth Caritas,Managed Medicaid,,72.07,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Amerihealth Caritas,Managed Medicaid,,92.69,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Amerihealth Caritas,Managed Medicaid,,84.08,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Amerihealth Caritas,Managed Medicaid,,389.79,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Amerihealth Caritas,Managed Medicaid,,398.40,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Amerihealth Caritas,Managed Medicaid,,186.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Amerihealth Caritas,Managed Medicaid,,281.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Amerihealth Caritas,Managed Medicaid,,292.29,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Amerihealth Caritas,Managed Medicaid,,345.14,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Amerihealth Caritas,Managed Medicaid,,420.02,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Amerihealth Caritas,Managed Medicaid,,704.50,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Amerihealth Caritas,Managed Medicaid,,1249.65,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Amerihealth Caritas,Managed Medicaid,,1347.55,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Amerihealth Caritas,Managed Medicaid,,127.13,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Amerihealth Caritas,Managed Medicaid,,170.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Amerihealth Caritas,Managed Medicaid,,1271.67,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Amerihealth Caritas,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Amerihealth Caritas,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Amerihealth Caritas,Managed Medicaid,,339.94,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Amerihealth Caritas,Managed Medicaid,,554.35,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Amerihealth Caritas,Managed Medicaid,,146.95,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Amerihealth Caritas,Managed Medicaid,,219.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Amerihealth Caritas,Managed Medicaid,,93.89,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Amerihealth Caritas,Managed Medicaid,,193.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Amerihealth Caritas,Managed Medicaid,,137.54,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Amerihealth Caritas,Managed Medicaid,,309.31,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Amerihealth Caritas,Managed Medicaid,,214.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Amerihealth Caritas,Managed Medicaid,,372.77,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Amerihealth Caritas,Managed Medicaid,,90.09,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Amerihealth Caritas,Managed Medicaid,,241.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Amerihealth Caritas,Managed Medicaid,,1499.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Amerihealth Caritas,Managed Medicaid,,1492.29,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Amerihealth Caritas,Managed Medicaid,,480.08,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Amerihealth Caritas,Managed Medicaid,,349.55,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Amerihealth Caritas,Managed Medicaid,,620.62,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Amerihealth Caritas,Managed Medicaid,,1686.28,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Amerihealth Caritas,Managed Medicaid,,85.08,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Amerihealth Caritas,Managed Medicaid,,113.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Amerihealth Caritas,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Amerihealth Caritas,Managed Medicaid,,418.82,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Amerihealth Caritas,Managed Medicaid,,927.93,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Amerihealth Caritas,Managed Medicaid,,492.09,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Amerihealth Caritas,Managed Medicaid,,600.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Amerihealth Caritas,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Amerihealth Caritas,Managed Medicaid,,64.26,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Amerihealth Caritas,Managed Medicaid,,215.42,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Amerihealth Caritas,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Amerihealth Caritas,Managed Medicaid,,120.72,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Amerihealth Caritas,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Amerihealth Caritas,Managed Medicaid,,307.71,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Amerihealth Caritas,Managed Medicaid,,123.12,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Amerihealth Caritas,Managed Medicaid,,146.95,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Amerihealth Caritas,Managed Medicaid,,91.49,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Amerihealth Caritas,Managed Medicaid,,66.27,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Amerihealth Caritas,Managed Medicaid,,104.70,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Amerihealth Caritas,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Amerihealth Caritas,Managed Medicaid,,206.61,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Amerihealth Caritas,Managed Medicaid,,177.98,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Amerihealth Caritas,Managed Medicaid,,232.83,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Amerihealth Caritas,Managed Medicaid,,210.41,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Amerihealth Caritas,Managed Medicaid,,281.48,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Amerihealth Caritas,Managed Medicaid,76,281.48,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Amerihealth Caritas,Managed Medicaid,,750.35,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Amerihealth Caritas,Managed Medicaid,76,750.35,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Amerihealth Caritas,Managed Medicaid,,789.79,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Amerihealth Caritas,Managed Medicaid,76,789.79,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Amerihealth Caritas,Managed Medicaid,,407.21,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Amerihealth Caritas,Managed Medicaid,,452.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Amerihealth Caritas,Managed Medicaid,,477.08,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Amerihealth Caritas,Managed Medicaid,,526.33,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Amerihealth Caritas,Managed Medicaid,,366.97,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Amerihealth Caritas,Managed Medicaid,,524.92,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Amerihealth Caritas,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Amerihealth Caritas,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Amerihealth Caritas,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Amerihealth Caritas,Managed Medicaid,,58.46,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Amerihealth Caritas,Managed Medicaid,,568.97,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Amerihealth Caritas,Managed Medicaid,,5465.26,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Amerihealth Caritas,Managed Medicaid,,751.35,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Amerihealth Caritas,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Amerihealth Caritas,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Amerihealth Caritas,Managed Medicaid,,129.73,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Amerihealth Caritas,Managed Medicaid,,141.74,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Amerihealth Caritas,Managed Medicaid,,245.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Amerihealth Caritas,Managed Medicaid,,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Amerihealth Caritas,Managed Medicaid,,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Amerihealth Caritas,Managed Medicaid,,187.79,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Amerihealth Caritas,Managed Medicaid,,128.33,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Amerihealth Caritas,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Amerihealth Caritas,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Amerihealth Caritas,Managed Medicaid,,72.67,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Amerihealth Caritas,Managed Medicaid,,91.09,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Amerihealth Caritas,Managed Medicaid,76,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Amerihealth Caritas,Managed Medicaid,76,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Amerihealth Caritas,Managed Medicaid,,99.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Amerihealth Caritas,Managed Medicaid,,209.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Amerihealth Caritas,Managed Medicaid,,326.13,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Amerihealth Caritas,Managed Medicaid,,469.07,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Amerihealth Caritas,Managed Medicaid,,1384.18,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Amerihealth Caritas,Managed Medicaid,,146.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Amerihealth Caritas,Managed Medicaid,,1214.61,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Amerihealth Caritas,Managed Medicaid,,451.25,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Amerihealth Caritas,Managed Medicaid,,567.97,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Amerihealth Caritas,Managed Medicaid,,369.97,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Amerihealth Caritas,Managed Medicaid,,174.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Amerihealth Caritas,Managed Medicaid,,109.91,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Amerihealth Caritas,Managed Medicaid,,161.16,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Amerihealth Caritas,Managed Medicaid,,250.65,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Amerihealth Caritas,Managed Medicaid,,1634.43,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Amerihealth Caritas,Managed Medicaid,,482.48,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Amerihealth Caritas,Managed Medicaid,,81.08,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Amerihealth Caritas,Managed Medicaid,,112.11,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Amerihealth Caritas,Managed Medicaid,,332.73,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Amerihealth Caritas,Managed Medicaid,,384.98,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Amerihealth Caritas,Managed Medicaid,,255.05,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Amerihealth Caritas,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Amerihealth Caritas,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Amerihealth Caritas,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Amerihealth Caritas,Managed Medicaid,,625.22,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Amerihealth Caritas,Managed Medicaid,,70.27,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Amerihealth Caritas,Managed Medicaid,,211.01,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Amerihealth Caritas,Managed Medicaid,,6.81,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Amerihealth Caritas,Managed Medicaid,,93.09,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Amerihealth Caritas,Managed Medicaid,,205.81,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Amerihealth Caritas,Managed Medicaid,,242.64,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Amerihealth Caritas,Managed Medicaid,,64.46,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Amerihealth Caritas,Managed Medicaid,,151.55,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Amerihealth Caritas,Managed Medicaid,,32.43,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Amerihealth Caritas,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Amerihealth Caritas,Managed Medicaid,,59.86,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Amerihealth Caritas,Managed Medicaid,,119.12,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Amerihealth Caritas,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Amerihealth Caritas,Managed Medicaid,,60.46,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Amerihealth Caritas,Managed Medicaid,,21.82,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Amerihealth Caritas,Managed Medicaid,,40.04,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Amerihealth Caritas,Managed Medicaid,,32.23,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Amerihealth Caritas,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Amerihealth Caritas,Managed Medicaid,,26.63,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Amerihealth Caritas,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Amerihealth Caritas,Managed Medicaid,,87.69,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Amerihealth Caritas,Managed Medicaid,,10.01,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Amerihealth Caritas,Managed Medicaid,,82.68,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Amerihealth Caritas,Managed Medicaid,,57.66,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Amerihealth Caritas,Managed Medicaid,,38.24,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Amerihealth Caritas,Managed Medicaid,,53.85,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Amerihealth Caritas,Managed Medicaid,GP,13.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,GP,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Amerihealth Caritas,Managed Medicaid,GP,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Amerihealth Caritas,Managed Medicaid,GP,24.22,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,GP,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Amerihealth Caritas,Managed Medicaid,GP,3.20,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Amerihealth Caritas,Managed Medicaid,GP,30.63,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Amerihealth Caritas,Managed Medicaid,GP,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Amerihealth Caritas,Managed Medicaid,GP,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,GP,22.02,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,GP,11.81,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Amerihealth Caritas,Managed Medicaid,GP,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Amerihealth Caritas,Managed Medicaid,GP,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Amerihealth Caritas,Managed Medicaid,GP,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,GP,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Amerihealth Caritas,Managed Medicaid,GP,27.83,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Amerihealth Caritas,Managed Medicaid,GP,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,GP,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Amerihealth Caritas,Managed Medicaid,GP,30.23,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,GP,9.41,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,GP,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,GP,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Amerihealth Caritas,Managed Medicaid,GP,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Amerihealth Caritas,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Amerihealth Caritas,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,GP,17.82,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Amerihealth Caritas,Managed Medicaid,GP,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Amerihealth Caritas,Managed Medicaid,GP,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,GP,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,GP,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Amerihealth Caritas,Managed Medicaid,GP,61.26,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Amerihealth Caritas,Managed Medicaid,GP,84.68,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Amerihealth Caritas,Managed Medicaid,GP,86.89,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Amerihealth Caritas,Managed Medicaid,GP,57.66,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,GO,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,GO,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,GO,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,GO,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Amerihealth Caritas,Managed Medicaid,GO,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Amerihealth Caritas,Managed Medicaid,GO,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Amerihealth Caritas,Managed Medicaid,GO,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Amerihealth Caritas,Managed Medicaid,GO,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,GO,12.41,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Amerihealth Caritas,Managed Medicaid,GO,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Amerihealth Caritas,Managed Medicaid,GO,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Amerihealth Caritas,Managed Medicaid,GO,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,GO,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,GO,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Amerihealth Caritas,Managed Medicaid,GO,44.84,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Amerihealth Caritas,Managed Medicaid,GO,30.43,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Amerihealth Caritas,Managed Medicaid,GO,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,GO,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Amerihealth Caritas,Managed Medicaid,GO,63.66,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Amerihealth Caritas,Managed Medicaid,GO,80.68,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Amerihealth Caritas,Managed Medicaid,GO,83.08,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Amerihealth Caritas,Managed Medicaid,GO,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Amerihealth Caritas,Managed Medicaid,GN,71.27,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Amerihealth Caritas,Managed Medicaid,GN,67.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Amerihealth Caritas,Managed Medicaid,GN,37.44,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Amerihealth Caritas,Managed Medicaid,GN,53.85,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Amerihealth Caritas,Managed Medicaid,GN,40.04,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Amerihealth Caritas,Managed Medicaid,GN,63.06,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Amerihealth Caritas,Managed Medicaid,GN,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,GN,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Amerihealth Caritas,Managed Medicaid,GN,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Amerihealth Caritas,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,GN,27.23,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Amerihealth Caritas,Managed Medicaid,GN,131.13,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Amerihealth Caritas,Managed Medicaid,GN,51.85,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Amerihealth Caritas,Managed Medicaid,GN,13.61,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Amerihealth Caritas,Managed Medicaid,GN,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,GN,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Amerihealth Caritas,Managed Medicaid,GN,42.84,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Amerihealth Caritas,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,GN,21.42,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Amerihealth Caritas,Managed Medicaid,GN,70.67,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Amerihealth Caritas,Managed Medicaid,GN,109.91,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Amerihealth Caritas,Managed Medicaid,GN,118.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Amerihealth Caritas,Managed Medicaid,,172.97,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Amerihealth Caritas,Managed Medicaid,,109.91,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Amerihealth Caritas,Managed Medicaid,,177.18,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Amerihealth Caritas,Managed Medicaid,,100.90,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Amerihealth Caritas,Managed Medicaid,,149.15,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Amerihealth Caritas,Managed Medicaid,,751.95,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Amerihealth Caritas,Managed Medicaid,,8.61,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Amerihealth Caritas,Managed Medicaid,,29.63,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Amerihealth Caritas,Managed Medicaid,,105.11,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Amerihealth Caritas,Managed Medicaid,,104.70,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Amerihealth Caritas,Managed Medicaid,,112.71,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Amerihealth Caritas,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Amerihealth Caritas,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Amerihealth Caritas,Managed Medicaid,,271.67,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Amerihealth Caritas,Managed Medicaid,,83.68,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Amerihealth Caritas,Managed Medicaid,,162.56,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Amerihealth Caritas,Managed Medicaid,,113.51,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Amerihealth Caritas,Managed Medicaid,,95.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Amerihealth Caritas,Managed Medicaid,,130.53,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Amerihealth Caritas,Managed Medicaid,,91.69,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Amerihealth Caritas,Managed Medicaid,,31.23,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Amerihealth Caritas,Managed Medicaid,,36.04,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Amerihealth Caritas,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Amerihealth Caritas,Managed Medicaid,,26.23,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Amerihealth Caritas,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Amerihealth Caritas,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Amerihealth Caritas,Managed Medicaid,,52.85,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Amerihealth Caritas,Managed Medicaid,,52.85,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Amerihealth Caritas,Managed Medicaid,,400.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Amerihealth Caritas,Managed Medicaid,,625.22,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Amerihealth Caritas,Managed Medicaid,,140.14,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Amerihealth Caritas,Managed Medicaid,,454.85,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Amerihealth Caritas,Managed Medicaid,,166.37,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Amerihealth Caritas,Managed Medicaid,,101.10,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Amerihealth Caritas,Managed Medicaid,,44.44,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Amerihealth Caritas,Managed Medicaid,,66.67,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Amerihealth Caritas,Managed Medicaid,,67.67,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Amerihealth Caritas,Managed Medicaid,,37.04,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Amerihealth Caritas,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Amerihealth Caritas,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Amerihealth Caritas,Managed Medicaid,,203.60,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Amerihealth Caritas,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Amerihealth Caritas,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Amerihealth Caritas,Managed Medicaid,,854.05,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Amerihealth Caritas,Managed Medicaid,,231.03,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Amerihealth Caritas,Managed Medicaid,,110.51,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Amerihealth Caritas,Managed Medicaid,,113.11,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Amerihealth Caritas,Managed Medicaid,,270.27,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Amerihealth Caritas,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Amerihealth Caritas,Managed Medicaid,,110.11,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Amerihealth Caritas,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Amerihealth Caritas,Managed Medicaid,,210.41,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Amerihealth Caritas,Managed Medicaid,,90.69,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Amerihealth Caritas,Managed Medicaid,,254.45,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Amerihealth Caritas,Managed Medicaid,,232.03,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Amerihealth Caritas,Managed Medicaid,,145.75,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Amerihealth Caritas,Managed Medicaid,,96.30,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Amerihealth Caritas,Managed Medicaid,,225.43,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Amerihealth Caritas,Managed Medicaid,,63.26,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Amerihealth Caritas,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Amerihealth Caritas,Managed Medicaid,,24.82,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Amerihealth Caritas,Managed Medicaid,,191.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Amerihealth Caritas,Managed Medicaid,,114.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Amerihealth Caritas,Managed Medicaid,,92.89,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Amerihealth Caritas,Managed Medicaid,,107.91,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Amerihealth Caritas,Managed Medicaid,,100.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Amerihealth Caritas,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Amerihealth Caritas,Managed Medicaid,,81.08,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Amerihealth Caritas,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Amerihealth Caritas,Managed Medicaid,,81.08,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Amerihealth Caritas,Managed Medicaid,,74.67,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Amerihealth Caritas,Managed Medicaid,,134.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Amerihealth Caritas,Managed Medicaid,,164.56,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Amerihealth Caritas,Managed Medicaid,,171.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Amerihealth Caritas,Managed Medicaid,,177.78,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Amerihealth Caritas,Managed Medicaid,,107.91,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Amerihealth Caritas,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Amerihealth Caritas,Managed Medicaid,,59.06,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Amerihealth Caritas,Managed Medicaid,,87.49,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Amerihealth Caritas,Managed Medicaid,,50.65,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Amerihealth Caritas,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Amerihealth Caritas,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Amerihealth Caritas,Managed Medicaid,,109.51,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Amerihealth Caritas,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Amerihealth Caritas,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Amerihealth Caritas,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Amerihealth Caritas,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Amerihealth Caritas,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Amerihealth Caritas,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Amerihealth Caritas,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Amerihealth Caritas,Managed Medicaid,,53.45,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Amerihealth Caritas,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Amerihealth Caritas,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Amerihealth Caritas,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Amerihealth Caritas,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Amerihealth Caritas,Managed Medicaid,,91.49,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Amerihealth Caritas,Managed Medicaid,,91.09,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Amerihealth Caritas,Managed Medicaid,,298.50,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Amerihealth Caritas,Managed Medicaid,,305.51,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Amerihealth Caritas,Managed Medicaid,,169.77,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Amerihealth Caritas,Managed Medicaid,,246.85,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Amerihealth Caritas,Managed Medicaid,,84.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Amerihealth Caritas,Managed Medicaid,,199.60,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Amerihealth Caritas,Managed Medicaid,,92.69,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Amerihealth Caritas,Managed Medicaid,,108.91,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Amerihealth Caritas,Managed Medicaid,,263.26,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Amerihealth Caritas,Managed Medicaid,,317.92,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Amerihealth Caritas,Managed Medicaid,,390.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Amerihealth Caritas,Managed Medicaid,,553.95,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Amerihealth Caritas,Managed Medicaid,,608.41,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Amerihealth Caritas,Managed Medicaid,,771.97,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Amerihealth Caritas,Managed Medicaid,,454.05,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Amerihealth Caritas,Managed Medicaid,,508.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Amerihealth Caritas,Managed Medicaid,,572.17,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Amerihealth Caritas,Managed Medicaid,,908.11,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Amerihealth Caritas,Managed Medicaid,,1017.02,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Amerihealth Caritas,Managed Medicaid,,1135.13,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Amerihealth Caritas,Managed Medicaid,,208.61,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Amerihealth Caritas,Managed Medicaid,,45.05,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Amerihealth Caritas,Managed Medicaid,,58.46,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Amerihealth Caritas,Managed Medicaid,,58.86,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Amerihealth Caritas,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Amerihealth Caritas,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Amerihealth Caritas,Managed Medicaid,,21.22,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Amerihealth Caritas,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Amerihealth Caritas,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Amerihealth Caritas,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Amerihealth Caritas,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Amerihealth Caritas,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Amerihealth Caritas,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Amerihealth Caritas,Managed Medicaid,GP,13.35,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Amerihealth Caritas,Managed Medicaid,,95.90,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Amerihealth Caritas,Managed Medicaid,,549.35,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Amerihealth Caritas,Managed Medicaid,,549.35,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Amerihealth Caritas,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Amerihealth Caritas,Managed Medicaid,,217.22,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Amerihealth Caritas,Managed Medicaid,,217.22,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Amerihealth Caritas,Managed Medicaid,,493.29,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Amerihealth Caritas,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Amerihealth Caritas,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Amerihealth Caritas,Managed Medicaid,,638.64,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Amerihealth Caritas,Managed Medicaid,,86.09,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Amerihealth Caritas,Managed Medicaid,,96.10,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Amerihealth Caritas,Managed Medicaid,,107.31,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Amerihealth Caritas,Managed Medicaid,,91.69,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Amerihealth Caritas,Managed Medicaid,,23.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Amerihealth Caritas,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Amerihealth Caritas,Managed Medicaid,,32.63,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Amerihealth Caritas,Managed Medicaid,,61.46,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Amerihealth Caritas,Managed Medicaid,,104.10,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Amerihealth Caritas,Managed Medicaid,,100.90,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Amerihealth Caritas,Managed Medicaid,,123.72,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Amerihealth Caritas,Managed Medicaid,,81.88,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Amerihealth Caritas,Managed Medicaid,,154.15,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Amerihealth Caritas,Managed Medicaid,,154.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Amerihealth Caritas,Managed Medicaid,,127.73,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Amerihealth Caritas,Managed Medicaid,,120.72,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Amerihealth Caritas,Managed Medicaid,,180.58,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Amerihealth Caritas,Managed Medicaid,,36.44,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Amerihealth Caritas,Managed Medicaid,,30.43,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Amerihealth Caritas,Managed Medicaid,,56.06,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Amerihealth Caritas,Managed Medicaid,,77.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Amerihealth Caritas,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Amerihealth Caritas,Managed Medicaid,,151.95,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Amerihealth Caritas,Managed Medicaid,,459.46,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Amerihealth Caritas,Managed Medicaid,,121.52,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Amerihealth Caritas,Managed Medicaid,,372.97,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Amerihealth Caritas,Managed Medicaid,,372.97,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Amerihealth Caritas,Managed Medicaid,,426.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Amerihealth Caritas,Managed Medicaid,,107.31,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Amerihealth Caritas,Managed Medicaid,,207.61,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Amerihealth Caritas,Managed Medicaid,,2503.90,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Amerihealth Caritas,Managed Medicaid,,304.30,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Amerihealth Caritas,Managed Medicaid,,386.99,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Amerihealth Caritas,Managed Medicaid,,166.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Amerihealth Caritas,Managed Medicaid,,173.97,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Amerihealth Caritas,Managed Medicaid,,185.19,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Amerihealth Caritas,Managed Medicaid,,307.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Amerihealth Caritas,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Amerihealth Caritas,Managed Medicaid,,1956.75,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Amerihealth Caritas,Managed Medicaid,,132.13,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Amerihealth Caritas,Managed Medicaid,,132.13,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Amerihealth Caritas,Managed Medicaid,,638.44,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Amerihealth Caritas,Managed Medicaid,,638.44,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Amerihealth Caritas,Managed Medicaid,,305.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Amerihealth Caritas,Managed Medicaid,,305.91,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Amerihealth Caritas,Managed Medicaid,,345.75,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Amerihealth Caritas,Managed Medicaid,,428.83,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Amerihealth Caritas,Managed Medicaid,,428.83,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Amerihealth Caritas,Managed Medicaid,,279.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Amerihealth Caritas,Managed Medicaid,,279.68,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Amerihealth Caritas,Managed Medicaid,,124.32,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Amerihealth Caritas,Managed Medicaid,,124.32,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Amerihealth Caritas,Managed Medicaid,,144.14,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Amerihealth Caritas,Managed Medicaid,,144.14,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Amerihealth Caritas,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Amerihealth Caritas,Managed Medicaid,,448.45,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Amerihealth Caritas,Managed Medicaid,JW,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Amerihealth Caritas,Managed Medicaid,,117.32,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Amerihealth Caritas,Managed Medicaid,,99.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Amerihealth Caritas,Managed Medicaid,,120.92,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Amerihealth Caritas,Managed Medicaid,,99.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Amerihealth Caritas,Managed Medicaid,,117.32,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Amerihealth Caritas,Managed Medicaid,,164.56,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Amerihealth Caritas,Managed Medicaid,,273.07,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Amerihealth Caritas,Managed Medicaid,,70.47,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Amerihealth Caritas,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Amerihealth Caritas,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Amerihealth Caritas,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Amerihealth Caritas,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Amerihealth Caritas,Managed Medicaid,,390.39,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Amerihealth Caritas,Managed Medicaid,,390.39,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Amerihealth Caritas,Managed Medicaid,,621.22,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Amerihealth Caritas,Managed Medicaid,,621.22,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Amerihealth Caritas,Managed Medicaid,,344.94,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Amerihealth Caritas,Managed Medicaid,,426.83,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Amerihealth Caritas,Managed Medicaid,,560.56,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Amerihealth Caritas,Managed Medicaid,,108.71,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Amerihealth Caritas,Managed Medicaid,,877.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Amerihealth Caritas,Managed Medicaid,,970.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Amerihealth Caritas,Managed Medicaid,,1147.95,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Amerihealth Caritas,Managed Medicaid,,160.96,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Amerihealth Caritas,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Amerihealth Caritas,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Amerihealth Caritas,Managed Medicaid,,384.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Amerihealth Caritas,Managed Medicaid,,340.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Amerihealth Caritas,Managed Medicaid,,116.52,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Amerihealth Caritas,Managed Medicaid,,454.05,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Amerihealth Caritas,Managed Medicaid,,253.25,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Amerihealth Caritas,Managed Medicaid,,467.07,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Amerihealth Caritas,Managed Medicaid,,467.07,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Amerihealth Caritas,Managed Medicaid,,409.81,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Amerihealth Caritas,Managed Medicaid,,267.27,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Amerihealth Caritas,Managed Medicaid,,169.57,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Amerihealth Caritas,Managed Medicaid,,356.56,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Amerihealth Caritas,Managed Medicaid,,356.56,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Amerihealth Caritas,Managed Medicaid,,339.94,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Amerihealth Caritas,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Amerihealth Caritas,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Amerihealth Caritas,Managed Medicaid,,359.16,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Amerihealth Caritas,Managed Medicaid,,359.16,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Amerihealth Caritas,Managed Medicaid,,824.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Amerihealth Caritas,Managed Medicaid,,824.62,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Amerihealth Caritas,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Amerihealth Caritas,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Amerihealth Caritas,Managed Medicaid,,102.50,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Amerihealth Caritas,Managed Medicaid,,118.92,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Amerihealth Caritas,Managed Medicaid,52,220.22,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Amerihealth Caritas,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Amerihealth Caritas,Managed Medicaid,,142.34,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Amerihealth Caritas,Managed Medicaid,,292.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Amerihealth Caritas,Managed Medicaid,,25.43,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Amerihealth Caritas,Managed Medicaid,,183.98,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Amerihealth Caritas,Managed Medicaid,,183.98,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Amerihealth Caritas,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Amerihealth Caritas,Managed Medicaid,,63.46,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Amerihealth Caritas,Managed Medicaid,,139.54,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Amerihealth Caritas,Managed Medicaid,,278.88,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Amerihealth Caritas,Managed Medicaid,,475.48,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Amerihealth Caritas,Managed Medicaid,,634.03,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Amerihealth Caritas,Managed Medicaid,,803.00,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Amerihealth Caritas,Managed Medicaid,,265.06,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Amerihealth Caritas,Managed Medicaid,,241.64,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Amerihealth Caritas,Managed Medicaid,,72.27,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Amerihealth Caritas,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Amerihealth Caritas,Managed Medicaid,,37.84,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Amerihealth Caritas,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Amerihealth Caritas,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Amerihealth Caritas,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Amerihealth Caritas,Managed Medicaid,,40.24,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Amerihealth Caritas,Managed Medicaid,,49.85,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Amerihealth Caritas,Managed Medicaid,,48.05,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Amerihealth Caritas,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Amerihealth Caritas,Managed Medicaid,,79.88,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Amerihealth Caritas,Managed Medicaid,,74.27,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Amerihealth Caritas,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Amerihealth Caritas,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Amerihealth Caritas,Managed Medicaid,,45.45,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Amerihealth Caritas,Managed Medicaid,,53.45,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Amerihealth Caritas,Managed Medicaid,,50.05,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Amerihealth Caritas,Managed Medicaid,,81.28,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Amerihealth Caritas,Managed Medicaid,,87.09,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Amerihealth Caritas,Managed Medicaid,,87.49,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Amerihealth Caritas,Managed Medicaid,,79.48,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Amerihealth Caritas,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Amerihealth Caritas,Managed Medicaid,,50.85,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Amerihealth Caritas,Managed Medicaid,,77.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Amerihealth Caritas,Managed Medicaid,,97.90,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Amerihealth Caritas,Managed Medicaid,,13.21,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Amerihealth Caritas,Managed Medicaid,,21.22,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Amerihealth Caritas,Managed Medicaid,,35.24,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Amerihealth Caritas,Managed Medicaid,,52.05,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Amerihealth Caritas,Managed Medicaid,,68.67,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Amerihealth Caritas,Managed Medicaid,,46.25,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Amerihealth Caritas,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Amerihealth Caritas,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Amerihealth Caritas,Managed Medicaid,,115.32,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Amerihealth Caritas,Managed Medicaid,,27.43,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Amerihealth Caritas,Managed Medicaid,,22.42,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Amerihealth Caritas,Managed Medicaid,,9.61,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Amerihealth Caritas,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Amerihealth Caritas,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,JW,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,JW,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Amerihealth Caritas,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Amerihealth Caritas,Managed Medicaid,,55.05,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Amerihealth Caritas,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Amerihealth Caritas,Managed Medicaid,JW,40.04,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Amerihealth Caritas,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Amerihealth Caritas,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Amerihealth Caritas,Managed Medicaid,JW,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Amerihealth Caritas,Managed Medicaid,JW,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Amerihealth Caritas,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Amerihealth Caritas,Managed Medicaid,JW,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,JW,54.65,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Amerihealth Caritas,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Amerihealth Caritas,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Amerihealth Caritas,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Amerihealth Caritas,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Amerihealth Caritas,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Amerihealth Caritas,Managed Medicaid,JW,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Amerihealth Caritas,Managed Medicaid,JW,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Amerihealth Caritas,Managed Medicaid,JW,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Amerihealth Caritas,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Amerihealth Caritas,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Amerihealth Caritas,Managed Medicaid,JW,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Amerihealth Caritas,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Amerihealth Caritas,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Amerihealth Caritas,Managed Medicaid,JW,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Amerihealth Caritas,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Amerihealth Caritas,Managed Medicaid,JW,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,JW,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Amerihealth Caritas,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Amerihealth Caritas,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Amerihealth Caritas,Managed Medicaid,JW,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Amerihealth Caritas,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Amerihealth Caritas,Managed Medicaid,JW,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Amerihealth Caritas,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Amerihealth Caritas,Managed Medicaid,JW,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,JW,13.01,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Amerihealth Caritas,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Amerihealth Caritas,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Amerihealth Caritas,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Amerihealth Caritas,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Amerihealth Caritas,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Amerihealth Caritas,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Amerihealth Caritas,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Amerihealth Caritas,Managed Medicaid,JW,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Amerihealth Caritas,Managed Medicaid,JW,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Amerihealth Caritas,Managed Medicaid,JW,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Amerihealth Caritas,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Amerihealth Caritas,Managed Medicaid,JW,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Amerihealth Caritas,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Amerihealth Caritas,Managed Medicaid,JW,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Amerihealth Caritas,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Amerihealth Caritas,Managed Medicaid,JW,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Amerihealth Caritas,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Amerihealth Caritas,Managed Medicaid,JW,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Amerihealth Caritas,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Amerihealth Caritas,Managed Medicaid,JW,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Amerihealth Caritas,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Amerihealth Caritas,Managed Medicaid,JW,54.45,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Amerihealth Caritas,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Amerihealth Caritas,Managed Medicaid,,59.06,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Amerihealth Caritas,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Amerihealth Caritas,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Amerihealth Caritas,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Amerihealth Caritas,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Amerihealth Caritas,Managed Medicaid,,54.05,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Amerihealth Caritas,Managed Medicaid,,849.45,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Amerihealth Caritas,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Amerihealth Caritas,Managed Medicaid,,49.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Amerihealth Caritas,Managed Medicaid,,515.92,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Amerihealth Caritas,Managed Medicaid,,41.84,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Amerihealth Caritas,Managed Medicaid,,60.66,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Amerihealth Caritas,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Amerihealth Caritas,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Amerihealth Caritas,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Amerihealth Caritas,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Amerihealth Caritas,Managed Medicaid,,67.47,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Amerihealth Caritas,Managed Medicaid,,56.06,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Amerihealth Caritas,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Amerihealth Caritas,Managed Medicaid,,1877.68,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Amerihealth Caritas,Managed Medicaid,,222.82,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Amerihealth Caritas,Managed Medicaid,,207.61,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Amerihealth Caritas,Managed Medicaid,,239.64,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Amerihealth Caritas,Managed Medicaid,,161.36,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Amerihealth Caritas,Managed Medicaid,,397.40,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Amerihealth Caritas,Managed Medicaid,,397.40,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Amerihealth Caritas,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Amerihealth Caritas,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Amerihealth Caritas,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Amerihealth Caritas,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Amerihealth Caritas,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Amerihealth Caritas,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Amerihealth Caritas,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Amerihealth Caritas,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Amerihealth Caritas,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Amerihealth Caritas,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Amerihealth Caritas,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Amerihealth Caritas,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Amerihealth Caritas,Managed Medicaid,,118.92,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Amerihealth Caritas,Managed Medicaid,,102.50,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Amerihealth Caritas,Managed Medicaid,,154.35,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Amerihealth Caritas,Managed Medicaid,,136.34,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Amerihealth Caritas,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Amerihealth Caritas,Managed Medicaid,,28.63,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Amerihealth Caritas,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Amerihealth Caritas,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Amerihealth Caritas,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Amerihealth Caritas,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Amerihealth Caritas,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Amerihealth Caritas,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Amerihealth Caritas,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,,33.03,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Amerihealth Caritas,Managed Medicaid,,189.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Amerihealth Caritas,Managed Medicaid,,96.90,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Amerihealth Caritas,Managed Medicaid,,25.63,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Amerihealth Caritas,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Amerihealth Caritas,Managed Medicaid,,31.63,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Amerihealth Caritas,Managed Medicaid,,18.42,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Amerihealth Caritas,Managed Medicaid,,18.42,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Amerihealth Caritas,Managed Medicaid,,42.44,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Amerihealth Caritas,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Amerihealth Caritas,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Amerihealth Caritas,Managed Medicaid,,30.03,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,,17.02,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Amerihealth Caritas,Managed Medicaid,,26.63,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Amerihealth Caritas,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Amerihealth Caritas,Managed Medicaid,,8008.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Amerihealth Caritas,Managed Medicaid,,155.56,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Amerihealth Caritas,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Amerihealth Caritas,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Amerihealth Caritas,Managed Medicaid,,989.19,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Amerihealth Caritas,Managed Medicaid,,58.46,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Amerihealth Caritas,Managed Medicaid,,176.98,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Amerihealth Caritas,Managed Medicaid,,41.04,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Amerihealth Caritas,Managed Medicaid,,41.04,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Amerihealth Caritas,Managed Medicaid,,194.19,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Amerihealth Caritas,Managed Medicaid,,246.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Amerihealth Caritas,Managed Medicaid,,64.86,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Amerihealth Caritas,Managed Medicaid,,1253.05,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Amerihealth Caritas,Managed Medicaid,,625.22,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Amerihealth Caritas,Managed Medicaid,,97.30,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Amerihealth Caritas,Managed Medicaid,,4128.92,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Amerihealth Caritas,Managed Medicaid,,625.22,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Amerihealth Caritas,Managed Medicaid,,168.57,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Amerihealth Caritas,Managed Medicaid,,467.67,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Amerihealth Caritas,Managed Medicaid,,463.86,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Amerihealth Caritas,Managed Medicaid,,464.86,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Amerihealth Caritas,Managed Medicaid,,2388.19,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Amerihealth Caritas,Managed Medicaid,,104.90,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Amerihealth Caritas,Managed Medicaid,,114.71,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Amerihealth Caritas,Managed Medicaid,,266.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Amerihealth Caritas,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Amerihealth Caritas,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Amerihealth Caritas,Managed Medicaid,,379.38,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Amerihealth Caritas,Managed Medicaid,,379.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Amerihealth Caritas,Managed Medicaid,,691.89,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Amerihealth Caritas,Managed Medicaid,,691.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Amerihealth Caritas,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Amerihealth Caritas,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Amerihealth Caritas,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Amerihealth Caritas,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Amerihealth Caritas,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Amerihealth Caritas,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Amerihealth Caritas,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Amerihealth Caritas,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Amerihealth Caritas,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Amerihealth Caritas,Managed Medicaid,JW,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Amerihealth Caritas,Managed Medicaid,JW,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Amerihealth Caritas,Managed Medicaid,JW,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Amerihealth Caritas,Managed Medicaid,JW,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Amerihealth Caritas,Managed Medicaid,JW,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Amerihealth Caritas,Managed Medicaid,JW,93.29,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Amerihealth Caritas,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Amerihealth Caritas,Managed Medicaid,,35.84,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Amerihealth Caritas,Managed Medicaid,,159.56,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Amerihealth Caritas,Managed Medicaid,,197.80,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Amerihealth Caritas,Managed Medicaid,,286.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Amerihealth Caritas,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Amerihealth Caritas,Managed Medicaid,,35.84,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Amerihealth Caritas,Managed Medicaid,,365.97,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Amerihealth Caritas,Managed Medicaid,,519.32,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Amerihealth Caritas,Managed Medicaid,,189.19,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Amerihealth Caritas,Managed Medicaid,,577.18,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Amerihealth Caritas,Managed Medicaid,,191.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Amerihealth Caritas,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Amerihealth Caritas,Managed Medicaid,,280.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Amerihealth Caritas,Managed Medicaid,,435.23,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Amerihealth Caritas,Managed Medicaid,,847.25,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Amerihealth Caritas,Managed Medicaid,,3830.23,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Amerihealth Caritas,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Amerihealth Caritas,Managed Medicaid,,90.49,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Amerihealth Caritas,Managed Medicaid,,80.28,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Amerihealth Caritas,Managed Medicaid,,133.13,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Amerihealth Caritas,Managed Medicaid,,63.66,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Amerihealth Caritas,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Amerihealth Caritas,Managed Medicaid,,64.86,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Amerihealth Caritas,Managed Medicaid,,109.11,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Amerihealth Caritas,Managed Medicaid,,70.47,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Amerihealth Caritas,Managed Medicaid,,96.30,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Amerihealth Caritas,Managed Medicaid,,120.32,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Amerihealth Caritas,Managed Medicaid,,78.88,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Amerihealth Caritas,Managed Medicaid,,88.49,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Amerihealth Caritas,Managed Medicaid,,100.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Amerihealth Caritas,Managed Medicaid,,30.43,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Amerihealth Caritas,Managed Medicaid,,54.05,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Amerihealth Caritas,Managed Medicaid,,24.02,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Amerihealth Caritas,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Amerihealth Caritas,Managed Medicaid,,134.33,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Amerihealth Caritas,Managed Medicaid,,35.84,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Amerihealth Caritas,Managed Medicaid,,60.46,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Amerihealth Caritas,Managed Medicaid,,72.47,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Amerihealth Caritas,Managed Medicaid,,96.70,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Amerihealth Caritas,Managed Medicaid,,116.92,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Amerihealth Caritas,Managed Medicaid,,216.02,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Amerihealth Caritas,Managed Medicaid,,117.12,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Amerihealth Caritas,Managed Medicaid,,61.06,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Amerihealth Caritas,Managed Medicaid,,88.49,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Amerihealth Caritas,Managed Medicaid,,99.30,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Amerihealth Caritas,Managed Medicaid,,132.13,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Amerihealth Caritas,Managed Medicaid,,185.99,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Amerihealth Caritas,Managed Medicaid,,87.49,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Amerihealth Caritas,Managed Medicaid,,65.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Amerihealth Caritas,Managed Medicaid,,112.91,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Amerihealth Caritas,Managed Medicaid,,98.50,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Amerihealth Caritas,Managed Medicaid,,142.14,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Amerihealth Caritas,Managed Medicaid,,175.18,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Amerihealth Caritas,Managed Medicaid,,116.52,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Amerihealth Caritas,Managed Medicaid,,68.27,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Amerihealth Caritas,Managed Medicaid,,108.31,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Amerihealth Caritas,Managed Medicaid,,73.87,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Amerihealth Caritas,Managed Medicaid,,73.67,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Amerihealth Caritas,Managed Medicaid,,242.44,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Amerihealth Caritas,Managed Medicaid,,150.55,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Amerihealth Caritas,Managed Medicaid,,267.47,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Amerihealth Caritas,Managed Medicaid,,378.78,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Amerihealth Caritas,Managed Medicaid,,416.62,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Amerihealth Caritas,Managed Medicaid,,85.08,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Amerihealth Caritas,Managed Medicaid,,76.48,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Amerihealth Caritas,Managed Medicaid,,91.89,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Amerihealth Caritas,Managed Medicaid,,92.49,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Amerihealth Caritas,Managed Medicaid,,254.45,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Amerihealth Caritas,Managed Medicaid,,104.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Amerihealth Caritas,Managed Medicaid,,88.09,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Amerihealth Caritas,Managed Medicaid,,81.28,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Amerihealth Caritas,Managed Medicaid,,88.49,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Amerihealth Caritas,Managed Medicaid,,97.50,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Amerihealth Caritas,Managed Medicaid,,75.88,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Amerihealth Caritas,Managed Medicaid,,59.66,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Amerihealth Caritas,Managed Medicaid,,75.08,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Amerihealth Caritas,Managed Medicaid,,69.47,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Amerihealth Caritas,Managed Medicaid,,130.73,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Amerihealth Caritas,Managed Medicaid,,86.29,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Amerihealth Caritas,Managed Medicaid,,78.88,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Amerihealth Caritas,Managed Medicaid,,55.26,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Amerihealth Caritas,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Amerihealth Caritas,Managed Medicaid,,85.49,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Amerihealth Caritas,Managed Medicaid,,74.27,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Amerihealth Caritas,Managed Medicaid,,96.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Amerihealth Caritas,Managed Medicaid,,63.26,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Amerihealth Caritas,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Amerihealth Caritas,Managed Medicaid,,70.87,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Amerihealth Caritas,Managed Medicaid,,43.64,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Amerihealth Caritas,Managed Medicaid,,89.09,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Amerihealth Caritas,Managed Medicaid,,92.69,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Amerihealth Caritas,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Amerihealth Caritas,Managed Medicaid,,106.11,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Amerihealth Caritas,Managed Medicaid,,92.69,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Amerihealth Caritas,Managed Medicaid,,80.28,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Amerihealth Caritas,Managed Medicaid,,64.86,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Amerihealth Caritas,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Amerihealth Caritas,Managed Medicaid,,156.56,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Amerihealth Caritas,Managed Medicaid,,64.46,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Amerihealth Caritas,Managed Medicaid,,49.45,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Amerihealth Caritas,Managed Medicaid,,211.21,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Amerihealth Caritas,Managed Medicaid,,145.75,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Amerihealth Caritas,Managed Medicaid,,177.78,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Amerihealth Caritas,Managed Medicaid,,99.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Amerihealth Caritas,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Amerihealth Caritas,Managed Medicaid,,197.80,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Amerihealth Caritas,Managed Medicaid,,208.41,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Amerihealth Caritas,Managed Medicaid,,215.01,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Amerihealth Caritas,Managed Medicaid,,107.51,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Amerihealth Caritas,Managed Medicaid,,19.62,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Amerihealth Caritas,Managed Medicaid,,116.12,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Amerihealth Caritas,Managed Medicaid,,128.73,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Amerihealth Caritas,Managed Medicaid,,163.76,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Amerihealth Caritas,Managed Medicaid,,133.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Amerihealth Caritas,Managed Medicaid,,162.16,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Amerihealth Caritas,Managed Medicaid,,418.02,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Amerihealth Caritas,Managed Medicaid,,929.93,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Amerihealth Caritas,Managed Medicaid,,716.12,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Amerihealth Caritas,Managed Medicaid,,37.04,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Amerihealth Caritas,Managed Medicaid,,273.87,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Amerihealth Caritas,Managed Medicaid,,279.28,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Amerihealth Caritas,Managed Medicaid,,810.21,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Amerihealth Caritas,Managed Medicaid,,1150.35,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Amerihealth Caritas,Managed Medicaid,,265.47,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Amerihealth Caritas,Managed Medicaid,,514.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Amerihealth Caritas,Managed Medicaid,,206.41,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Amerihealth Caritas,Managed Medicaid,,240.64,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Amerihealth Caritas,Managed Medicaid,,321.92,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Amerihealth Caritas,Managed Medicaid,,160.96,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Amerihealth Caritas,Managed Medicaid,,323.52,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Amerihealth Caritas,Managed Medicaid,,193.59,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Amerihealth Caritas,Managed Medicaid,,159.96,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Amerihealth Caritas,Managed Medicaid,,221.42,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Amerihealth Caritas,Managed Medicaid,,467.07,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Amerihealth Caritas,Managed Medicaid,,275.48,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Amerihealth Caritas,Managed Medicaid,,40.84,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Amerihealth Caritas,Managed Medicaid,,35.03,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Amerihealth Caritas,Managed Medicaid,,241.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Amerihealth Caritas,Managed Medicaid,,154.35,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Amerihealth Caritas,Managed Medicaid,,211.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Amerihealth Caritas,Managed Medicaid,,71.67,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Amerihealth Caritas,Managed Medicaid,,190.79,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Amerihealth Caritas,Managed Medicaid,,33.83,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Amerihealth Caritas,Managed Medicaid,,187.39,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Amerihealth Caritas,Managed Medicaid,,61.26,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Amerihealth Caritas,Managed Medicaid,,68.27,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Amerihealth Caritas,Managed Medicaid,,28.63,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Amerihealth Caritas,Managed Medicaid,,148.95,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Amerihealth Caritas,Managed Medicaid,,132.53,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Amerihealth Caritas,Managed Medicaid,,131.53,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Amerihealth Caritas,Managed Medicaid,,64.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Amerihealth Caritas,Managed Medicaid,,129.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Amerihealth Caritas,Managed Medicaid,,69.27,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Amerihealth Caritas,Managed Medicaid,,48.65,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Amerihealth Caritas,Managed Medicaid,,53.65,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Amerihealth Caritas,Managed Medicaid,,185.59,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Amerihealth Caritas,Managed Medicaid,,61.26,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Amerihealth Caritas,Managed Medicaid,,182.38,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Amerihealth Caritas,Managed Medicaid,,58.26,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Amerihealth Caritas,Managed Medicaid,,157.76,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Amerihealth Caritas,Managed Medicaid,,469.07,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Amerihealth Caritas,Managed Medicaid,,808.61,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Amerihealth Caritas,Managed Medicaid,,668.27,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Amerihealth Caritas,Managed Medicaid,,720.32,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Amerihealth Caritas,Managed Medicaid,,407.41,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Amerihealth Caritas,Managed Medicaid,,903.70,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Amerihealth Caritas,Managed Medicaid,,903.70,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Amerihealth Caritas,Managed Medicaid,,903.70,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Amerihealth Caritas,Managed Medicaid,,611.21,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Amerihealth Caritas,Managed Medicaid,,357.56,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Amerihealth Caritas,Managed Medicaid,,281.08,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Amerihealth Caritas,Managed Medicaid,,53.65,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Amerihealth Caritas,Managed Medicaid,,74.87,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Amerihealth Caritas,Managed Medicaid,,66.47,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Amerihealth Caritas,Managed Medicaid,,166.37,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Amerihealth Caritas,Managed Medicaid,,32.63,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Amerihealth Caritas,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Amerihealth Caritas,Managed Medicaid,,416.62,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Amerihealth Caritas,Managed Medicaid,,123.52,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Amerihealth Caritas,Managed Medicaid,,162.56,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Amerihealth Caritas,Managed Medicaid,,172.37,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Amerihealth Caritas,Managed Medicaid,,93.49,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Amerihealth Caritas,Managed Medicaid,,98.90,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Amerihealth Caritas,Managed Medicaid,,104.70,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Amerihealth Caritas,Managed Medicaid,,151.75,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Amerihealth Caritas,Managed Medicaid,,147.35,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Amerihealth Caritas,Managed Medicaid,,216.02,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Amerihealth Caritas,Managed Medicaid,,45.85,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Amerihealth Caritas,Managed Medicaid,,86.49,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Amerihealth Caritas,Managed Medicaid,,212.81,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Amerihealth Caritas,Managed Medicaid,,123.12,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Amerihealth Caritas,Managed Medicaid,,157.16,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Amerihealth Caritas,Managed Medicaid,,7507.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Amerihealth Caritas,Managed Medicaid,,43.44,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Amerihealth Caritas,Managed Medicaid,,370.97,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Amerihealth Caritas,Managed Medicaid,,451.05,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Amerihealth Caritas,Managed Medicaid,,84.08,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Amerihealth Caritas,Managed Medicaid,,110.11,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Amerihealth Caritas,Managed Medicaid,,108.11,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Amerihealth Caritas,Managed Medicaid,,80.28,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Amerihealth Caritas,Managed Medicaid,,119.32,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Amerihealth Caritas,Managed Medicaid,,99.50,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Amerihealth Caritas,Managed Medicaid,,150.55,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Amerihealth Caritas,Managed Medicaid,,116.32,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Amerihealth Caritas,Managed Medicaid,,185.79,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Amerihealth Caritas,Managed Medicaid,,276.68,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Amerihealth Caritas,Managed Medicaid,,54.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Amerihealth Caritas,Managed Medicaid,,165.97,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Amerihealth Caritas,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Amerihealth Caritas,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Amerihealth Caritas,Managed Medicaid,,271.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Amerihealth Caritas,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Amerihealth Caritas,Managed Medicaid,,137.14,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Amerihealth Caritas,Managed Medicaid,,221.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Amerihealth Caritas,Managed Medicaid,,116.72,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Amerihealth Caritas,Managed Medicaid,,583.98,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Amerihealth Caritas,Managed Medicaid,,299.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Amerihealth Caritas,Managed Medicaid,,218.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Amerihealth Caritas,Managed Medicaid,,195.40,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Amerihealth Caritas,Managed Medicaid,,143.54,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Amerihealth Caritas,Managed Medicaid,,373.57,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Amerihealth Caritas,Managed Medicaid,,203.00,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Amerihealth Caritas,Managed Medicaid,,416.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Amerihealth Caritas,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Amerihealth Caritas,Managed Medicaid,,458.46,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Amerihealth Caritas,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Amerihealth Caritas,Managed Medicaid,,476.08,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Amerihealth Caritas,Managed Medicaid,,547.15,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Amerihealth Caritas,Managed Medicaid,,171.37,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Amerihealth Caritas,Managed Medicaid,,313.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Amerihealth Caritas,Managed Medicaid,,246.25,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Amerihealth Caritas,Managed Medicaid,,449.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Amerihealth Caritas,Managed Medicaid,,208.61,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Amerihealth Caritas,Managed Medicaid,,229.83,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Amerihealth Caritas,Managed Medicaid,,251.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Amerihealth Caritas,Managed Medicaid,,357.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Amerihealth Caritas,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Amerihealth Caritas,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Amerihealth Caritas,Managed Medicaid,,499.90,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Amerihealth Caritas,Managed Medicaid,,775.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Amerihealth Caritas,Managed Medicaid,,969.77,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Amerihealth Caritas,Managed Medicaid,,166.37,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Amerihealth Caritas,Managed Medicaid,,288.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Amerihealth Caritas,Managed Medicaid,,259.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Amerihealth Caritas,Managed Medicaid,,318.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Amerihealth Caritas,Managed Medicaid,,497.70,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Amerihealth Caritas,Managed Medicaid,,155.76,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Amerihealth Caritas,Managed Medicaid,,293.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Amerihealth Caritas,Managed Medicaid,,172.97,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Amerihealth Caritas,Managed Medicaid,,218.22,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Amerihealth Caritas,Managed Medicaid,,159.96,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Amerihealth Caritas,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Amerihealth Caritas,Managed Medicaid,,264.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Amerihealth Caritas,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Amerihealth Caritas,Managed Medicaid,,322.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Amerihealth Caritas,Managed Medicaid,,254.45,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Amerihealth Caritas,Managed Medicaid,,184.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Amerihealth Caritas,Managed Medicaid,,468.67,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Amerihealth Caritas,Managed Medicaid,,589.19,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Amerihealth Caritas,Managed Medicaid,,55.46,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Amerihealth Caritas,Managed Medicaid,,19.82,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Amerihealth Caritas,Managed Medicaid,,406.41,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Amerihealth Caritas,Managed Medicaid,,197.80,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Amerihealth Caritas,Managed Medicaid,,41.64,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Amerihealth Caritas,Managed Medicaid,,559.36,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Amerihealth Caritas,Managed Medicaid,,2501.10,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Amerihealth Caritas,Managed Medicaid,,328.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Amerihealth Caritas,Managed Medicaid,,103.90,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Amerihealth Caritas,Managed Medicaid,,407.01,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Amerihealth Caritas,Managed Medicaid,,94.09,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Amerihealth Caritas,Managed Medicaid,,2476.67,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Amerihealth Caritas,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Amerihealth Caritas,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Amerihealth Caritas,Managed Medicaid,,17.42,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Amerihealth Caritas,Managed Medicaid,,175.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Amerihealth Caritas,Managed Medicaid,,23.82,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Amerihealth Caritas,Managed Medicaid,,116.92,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Amerihealth Caritas,Managed Medicaid,,64.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Amerihealth Caritas,Managed Medicaid,,8.81,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Amerihealth Caritas,Managed Medicaid,,1057.06,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Amerihealth Caritas,Managed Medicaid,,1.20,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Amerihealth Caritas,Managed Medicaid,,129.93,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Amerihealth Caritas,Managed Medicaid,,24.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Amerihealth Caritas,Managed Medicaid,,8.41,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Amerihealth Caritas,Managed Medicaid,,16.42,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Amerihealth Caritas,Managed Medicaid,,50.85,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Amerihealth Caritas,Managed Medicaid,,1212.81,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Amerihealth Caritas,Managed Medicaid,,36.64,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Amerihealth Caritas,Managed Medicaid,,215.22,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Amerihealth Caritas,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Amerihealth Caritas,Managed Medicaid,,285.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Amerihealth Caritas,Managed Medicaid,,61.06,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Amerihealth Caritas,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Amerihealth Caritas,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Amerihealth Caritas,Managed Medicaid,,268.87,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Amerihealth Caritas,Managed Medicaid,,97.50,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Amerihealth Caritas,Managed Medicaid,,87.09,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Amerihealth Caritas,Managed Medicaid,,448.45,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Amerihealth Caritas,Managed Medicaid,,321.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Amerihealth Caritas,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Amerihealth Caritas,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Amerihealth Caritas,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Amerihealth Caritas,Managed Medicaid,,262.06,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Amerihealth Caritas,Managed Medicaid,,386.19,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Amerihealth Caritas,Managed Medicaid,,214.01,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Amerihealth Caritas,Managed Medicaid,,381.98,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Amerihealth Caritas,Managed Medicaid,,246.25,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Amerihealth Caritas,Managed Medicaid,,804.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Amerihealth Caritas,Managed Medicaid,,662.66,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Amerihealth Caritas,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Amerihealth Caritas,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Amerihealth Caritas,Managed Medicaid,,813.21,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Amerihealth Caritas,Managed Medicaid,,206.81,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Amerihealth Caritas,Managed Medicaid,,225.43,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Amerihealth Caritas,Managed Medicaid,,64.86,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Amerihealth Caritas,Managed Medicaid,,507.91,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Amerihealth Caritas,Managed Medicaid,,258.06,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Amerihealth Caritas,Managed Medicaid,,227.83,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Amerihealth Caritas,Managed Medicaid,,254.05,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Amerihealth Caritas,Managed Medicaid,,452.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Amerihealth Caritas,Managed Medicaid,,534.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Amerihealth Caritas,Managed Medicaid,,653.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Amerihealth Caritas,Managed Medicaid,,490.49,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Amerihealth Caritas,Managed Medicaid,,588.99,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Amerihealth Caritas,Managed Medicaid,,657.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Amerihealth Caritas,Managed Medicaid,,507.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Amerihealth Caritas,Managed Medicaid,,619.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Amerihealth Caritas,Managed Medicaid,,701.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Amerihealth Caritas,Managed Medicaid,,517.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Amerihealth Caritas,Managed Medicaid,,617.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Amerihealth Caritas,Managed Medicaid,,703.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Amerihealth Caritas,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Amerihealth Caritas,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Amerihealth Caritas,Managed Medicaid,,466.67,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Amerihealth Caritas,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Amerihealth Caritas,Managed Medicaid,,688.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Amerihealth Caritas,Managed Medicaid,,775.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Amerihealth Caritas,Managed Medicaid,,574.97,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Amerihealth Caritas,Managed Medicaid,,724.32,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Amerihealth Caritas,Managed Medicaid,,741.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Amerihealth Caritas,Managed Medicaid,,448.85,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Amerihealth Caritas,Managed Medicaid,,546.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Amerihealth Caritas,Managed Medicaid,,637.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Amerihealth Caritas,Managed Medicaid,,524.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Amerihealth Caritas,Managed Medicaid,,638.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Amerihealth Caritas,Managed Medicaid,,745.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Amerihealth Caritas,Managed Medicaid,,604.20,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Amerihealth Caritas,Managed Medicaid,,458.86,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Amerihealth Caritas,Managed Medicaid,,573.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Amerihealth Caritas,Managed Medicaid,,614.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Amerihealth Caritas,Managed Medicaid,,587.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Amerihealth Caritas,Managed Medicaid,,805.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Amerihealth Caritas,Managed Medicaid,,869.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Amerihealth Caritas,Managed Medicaid,,795.59,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Amerihealth Caritas,Managed Medicaid,,502.70,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Amerihealth Caritas,Managed Medicaid,,646.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Amerihealth Caritas,Managed Medicaid,,847.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Amerihealth Caritas,Managed Medicaid,,986.39,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Amerihealth Caritas,Managed Medicaid,,499.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Amerihealth Caritas,Managed Medicaid,,635.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Amerihealth Caritas,Managed Medicaid,,752.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Amerihealth Caritas,Managed Medicaid,,1473.67,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Amerihealth Caritas,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Amerihealth Caritas,Managed Medicaid,,1072.07,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Amerihealth Caritas,Managed Medicaid,,1277.08,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Amerihealth Caritas,Managed Medicaid,,1484.48,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Amerihealth Caritas,Managed Medicaid,,262.06,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Amerihealth Caritas,Managed Medicaid,,812.61,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Amerihealth Caritas,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Amerihealth Caritas,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Amerihealth Caritas,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Amerihealth Caritas,Managed Medicaid,,560.56,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Amerihealth Caritas,Managed Medicaid,,95.50,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Amerihealth Caritas,Managed Medicaid,,234.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Amerihealth Caritas,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Amerihealth Caritas,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Amerihealth Caritas,Managed Medicaid,,290.29,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Amerihealth Caritas,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Amerihealth Caritas,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Amerihealth Caritas,Managed Medicaid,,380.58,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Amerihealth Caritas,Managed Medicaid,,95.09,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Amerihealth Caritas,Managed Medicaid,,67.47,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Amerihealth Caritas,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Amerihealth Caritas,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Amerihealth Caritas,Managed Medicaid,,6299.49,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Amerihealth Caritas,Managed Medicaid,,53.85,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Amerihealth Caritas,Managed Medicaid,,145.75,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Amerihealth Caritas,Managed Medicaid,,125.93,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Amerihealth Caritas,Managed Medicaid,,399.00,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Amerihealth Caritas,Managed Medicaid,,1022.02,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Amerihealth Caritas,Managed Medicaid,,108.71,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Amerihealth Caritas,Managed Medicaid,,277.68,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Amerihealth Caritas,Managed Medicaid,,176.18,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Amerihealth Caritas,Managed Medicaid,,11521.71,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Amerihealth Caritas,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Amerihealth Caritas,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Amerihealth Caritas,Managed Medicaid,,5912.91,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Amerihealth Caritas,Managed Medicaid,,222.22,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Amerihealth Caritas,Managed Medicaid,,600.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Amerihealth Caritas,Managed Medicaid,,31.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Amerihealth Caritas,Managed Medicaid,,31.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Amerihealth Caritas,Managed Medicaid,,84.28,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Amerihealth Caritas,Managed Medicaid,,584.78,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Amerihealth Caritas,Managed Medicaid,,125.93,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Amerihealth Caritas,Managed Medicaid,,91.29,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Amerihealth Caritas,Managed Medicaid,,46.45,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Amerihealth Caritas,Managed Medicaid,,40.24,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Amerihealth Caritas,Managed Medicaid,,96.30,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Amerihealth Caritas,Managed Medicaid,,222.02,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Amerihealth Caritas,Managed Medicaid,,91.69,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Amerihealth Caritas,Managed Medicaid,,57.06,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Amerihealth Caritas,Managed Medicaid,,280.28,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Amerihealth Caritas,Managed Medicaid,,316.72,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Amerihealth Caritas,Managed Medicaid,,316.72,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Amerihealth Caritas,Managed Medicaid,,466.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Amerihealth Caritas,Managed Medicaid,,466.47,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Amerihealth Caritas,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Amerihealth Caritas,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Amerihealth Caritas,Managed Medicaid,,160.96,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Amerihealth Caritas,Managed Medicaid,,160.96,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Amerihealth Caritas,Managed Medicaid,,144.54,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Amerihealth Caritas,Managed Medicaid,,115.52,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Amerihealth Caritas,Managed Medicaid,,115.52,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Amerihealth Caritas,Managed Medicaid,,944.94,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Amerihealth Caritas,Managed Medicaid,,676.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Amerihealth Caritas,Managed Medicaid,,142.54,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Amerihealth Caritas,Managed Medicaid,,113.11,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Amerihealth Caritas,Managed Medicaid,,283.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Amerihealth Caritas,Managed Medicaid,,153.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Amerihealth Caritas,Managed Medicaid,,258.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Amerihealth Caritas,Managed Medicaid,,116.32,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Amerihealth Caritas,Managed Medicaid,,255.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Amerihealth Caritas,Managed Medicaid,,255.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Amerihealth Caritas,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Amerihealth Caritas,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Amerihealth Caritas,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Amerihealth Caritas,Managed Medicaid,,60.06,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Amerihealth Caritas,Managed Medicaid,,388.99,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Amerihealth Caritas,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Amerihealth Caritas,Managed Medicaid,,166.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Amerihealth Caritas,Managed Medicaid,,324.92,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Amerihealth Caritas,Managed Medicaid,,354.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Amerihealth Caritas,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Amerihealth Caritas,Managed Medicaid,,362.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Amerihealth Caritas,Managed Medicaid,,421.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Amerihealth Caritas,Managed Medicaid,,421.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Amerihealth Caritas,Managed Medicaid,,135.54,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Amerihealth Caritas,Managed Medicaid,,135.54,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Amerihealth Caritas,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Amerihealth Caritas,Managed Medicaid,,136.94,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Amerihealth Caritas,Managed Medicaid,,136.94,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Amerihealth Caritas,Managed Medicaid,,538.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Amerihealth Caritas,Managed Medicaid,,551.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Amerihealth Caritas,Managed Medicaid,,551.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Amerihealth Caritas,Managed Medicaid,,319.12,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Amerihealth Caritas,Managed Medicaid,,319.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Amerihealth Caritas,Managed Medicaid,,183.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Amerihealth Caritas,Managed Medicaid,,183.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Amerihealth Caritas,Managed Medicaid,,226.23,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Amerihealth Caritas,Managed Medicaid,,226.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Amerihealth Caritas,Managed Medicaid,,230.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Amerihealth Caritas,Managed Medicaid,,230.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Amerihealth Caritas,Managed Medicaid,,1012.81,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Amerihealth Caritas,Managed Medicaid,,985.99,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Amerihealth Caritas,Managed Medicaid,,159.16,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Amerihealth Caritas,Managed Medicaid,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Amerihealth Caritas,Managed Medicaid,,163.76,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Amerihealth Caritas,Managed Medicaid,,148.55,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Amerihealth Caritas,Managed Medicaid,,449.85,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Amerihealth Caritas,Managed Medicaid,,148.55,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Amerihealth Caritas,Managed Medicaid,,745.34,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Amerihealth Caritas,Managed Medicaid,,177.38,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Amerihealth Caritas,Managed Medicaid,,137.34,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Amerihealth Caritas,Managed Medicaid,,39.04,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Amerihealth Caritas,Managed Medicaid,,106.71,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Amerihealth Caritas,Managed Medicaid,,111.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Amerihealth Caritas,Managed Medicaid,,118.12,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Amerihealth Caritas,Managed Medicaid,,116.72,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Amerihealth Caritas,Managed Medicaid,,133.13,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Amerihealth Caritas,Managed Medicaid,,833.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Amerihealth Caritas,Managed Medicaid,,426.03,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Amerihealth Caritas,Managed Medicaid,,268.87,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Amerihealth Caritas,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Amerihealth Caritas,Managed Medicaid,,138.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Amerihealth Caritas,Managed Medicaid,,117.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Amerihealth Caritas,Managed Medicaid,,121.32,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Amerihealth Caritas,Managed Medicaid,,176.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Amerihealth Caritas,Managed Medicaid,,176.98,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Amerihealth Caritas,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Amerihealth Caritas,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Amerihealth Caritas,Managed Medicaid,,2814.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Amerihealth Caritas,Managed Medicaid,,1238.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Amerihealth Caritas,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Amerihealth Caritas,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Amerihealth Caritas,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Amerihealth Caritas,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Amerihealth Caritas,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Amerihealth Caritas,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Amerihealth Caritas,Managed Medicaid,,1536.13,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Amerihealth Caritas,Managed Medicaid,,1581.98,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Amerihealth Caritas,Managed Medicaid,,1581.98,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Amerihealth Caritas,Managed Medicaid,,960.96,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Amerihealth Caritas,Managed Medicaid,,895.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Amerihealth Caritas,Managed Medicaid,,1213.61,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Amerihealth Caritas,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Amerihealth Caritas,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Amerihealth Caritas,Managed Medicaid,,879.68,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Amerihealth Caritas,Managed Medicaid,,483.88,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Amerihealth Caritas,Managed Medicaid,,495.50,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Amerihealth Caritas,Managed Medicaid,,322.92,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Amerihealth Caritas,Managed Medicaid,,158.56,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Amerihealth Caritas,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Amerihealth Caritas,Managed Medicaid,,75.88,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Amerihealth Caritas,Managed Medicaid,,96.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Amerihealth Caritas,Managed Medicaid,,56.46,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Amerihealth Caritas,Managed Medicaid,,108.51,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Amerihealth Caritas,Managed Medicaid,,1059.86,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Amerihealth Caritas,Managed Medicaid,,255.66,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Amerihealth Caritas,Managed Medicaid,,1500.30,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Amerihealth Caritas,Managed Medicaid,,79.08,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Amerihealth Caritas,Managed Medicaid,,328.33,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Amerihealth Caritas,Managed Medicaid,,328.33,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Amerihealth Caritas,Managed Medicaid,,427.63,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Amerihealth Caritas,Managed Medicaid,,182.38,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Amerihealth Caritas,Managed Medicaid,,616.02,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Amerihealth Caritas,Managed Medicaid,,448.25,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Amerihealth Caritas,Managed Medicaid,,107.11,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Amerihealth Caritas,Managed Medicaid,,203.40,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Amerihealth Caritas,Managed Medicaid,,771.57,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Amerihealth Caritas,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Amerihealth Caritas,Managed Medicaid,,160.56,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Amerihealth Caritas,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Amerihealth Caritas,Managed Medicaid,,139.14,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Amerihealth Caritas,Managed Medicaid,,1059.86,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Amerihealth Caritas,Managed Medicaid,,476.08,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Amerihealth Caritas,Managed Medicaid,,500.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Amerihealth Caritas,Managed Medicaid,,496.10,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Amerihealth Caritas,Managed Medicaid,,127.33,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Amerihealth Caritas,Managed Medicaid,,232.23,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Amerihealth Caritas,Managed Medicaid,,35.03,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Amerihealth Caritas,Managed Medicaid,,1259.46,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Amerihealth Caritas,Managed Medicaid,,1554.95,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Amerihealth Caritas,Managed Medicaid,,498.70,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Amerihealth Caritas,Managed Medicaid,,58.86,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Amerihealth Caritas,Managed Medicaid,,46.25,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Amerihealth Caritas,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Amerihealth Caritas,Managed Medicaid,,80.88,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Amerihealth Caritas,Managed Medicaid,,81.68,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Amerihealth Caritas,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Amerihealth Caritas,Managed Medicaid,,40.44,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Amerihealth Caritas,Managed Medicaid,,318.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Amerihealth Caritas,Managed Medicaid,,900.30,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Amerihealth Caritas,Managed Medicaid,,847.65,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Amerihealth Caritas,Managed Medicaid,,584.78,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Amerihealth Caritas,Managed Medicaid,,915.71,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Amerihealth Caritas,Managed Medicaid,,211.21,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Amerihealth Caritas,Managed Medicaid,,211.21,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Amerihealth Caritas,Managed Medicaid,,294.49,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Amerihealth Caritas,Managed Medicaid,,57.66,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Amerihealth Caritas,Managed Medicaid,,57.66,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Amerihealth Caritas,Managed Medicaid,,383.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Amerihealth Caritas,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Amerihealth Caritas,Managed Medicaid,,234.83,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Amerihealth Caritas,Managed Medicaid,,502.70,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Amerihealth Caritas,Managed Medicaid,,502.70,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Amerihealth Caritas,Managed Medicaid,,407.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Amerihealth Caritas,Managed Medicaid,,407.21,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Amerihealth Caritas,Managed Medicaid,,347.95,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Amerihealth Caritas,Managed Medicaid,,347.95,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Amerihealth Caritas,Managed Medicaid,,316.92,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Amerihealth Caritas,Managed Medicaid,,316.92,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Amerihealth Caritas,Managed Medicaid,,329.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Amerihealth Caritas,Managed Medicaid,,329.53,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Amerihealth Caritas,Managed Medicaid,,342.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Amerihealth Caritas,Managed Medicaid,,303.30,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Amerihealth Caritas,Managed Medicaid,,303.30,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Amerihealth Caritas,Managed Medicaid,,302.10,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Amerihealth Caritas,Managed Medicaid,,302.10,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Amerihealth Caritas,Managed Medicaid,,665.06,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Amerihealth Caritas,Managed Medicaid,,665.06,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Amerihealth Caritas,Managed Medicaid,,372.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Amerihealth Caritas,Managed Medicaid,,372.37,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Amerihealth Caritas,Managed Medicaid,,363.96,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Amerihealth Caritas,Managed Medicaid,,363.96,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Amerihealth Caritas,Managed Medicaid,,461.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Amerihealth Caritas,Managed Medicaid,,73.67,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Amerihealth Caritas,Managed Medicaid,,972.37,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Amerihealth Caritas,Managed Medicaid,,44.04,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Amerihealth Caritas,Managed Medicaid,,568.77,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Amerihealth Caritas,Managed Medicaid,,598.60,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Amerihealth Caritas,Managed Medicaid,,4031.43,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Amerihealth Caritas,Managed Medicaid,,2143.34,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Amerihealth Caritas,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Amerihealth Caritas,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Amerihealth Caritas,Managed Medicaid,,215.01,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Amerihealth Caritas,Managed Medicaid,,138.74,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Amerihealth Caritas,Managed Medicaid,,155.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Amerihealth Caritas,Managed Medicaid,,1092.69,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Amerihealth Caritas,Managed Medicaid,,743.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Amerihealth Caritas,Managed Medicaid,,944.74,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Amerihealth Caritas,Managed Medicaid,,774.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Amerihealth Caritas,Managed Medicaid,,973.77,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Amerihealth Caritas,Managed Medicaid,,798.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Amerihealth Caritas,Managed Medicaid,,337.94,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Amerihealth Caritas,Managed Medicaid,,114.71,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Amerihealth Caritas,Managed Medicaid,,1493.89,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Amerihealth Caritas,Managed Medicaid,,398.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Amerihealth Caritas,Managed Medicaid,,298.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Amerihealth Caritas,Managed Medicaid,,531.13,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Amerihealth Caritas,Managed Medicaid,,5758.95,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Amerihealth Caritas,Managed Medicaid,,838.24,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Amerihealth Caritas,Managed Medicaid,,2658.46,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Amerihealth Caritas,Managed Medicaid,,1771.37,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Amerihealth Caritas,Managed Medicaid,,696.50,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Amerihealth Caritas,Managed Medicaid,,248.45,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Amerihealth Caritas,Managed Medicaid,,339.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Amerihealth Caritas,Managed Medicaid,,339.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Amerihealth Caritas,Managed Medicaid,,375.58,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Amerihealth Caritas,Managed Medicaid,,375.58,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Amerihealth Caritas,Managed Medicaid,,346.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Amerihealth Caritas,Managed Medicaid,,346.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Amerihealth Caritas,Managed Medicaid,,258.06,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Amerihealth Caritas,Managed Medicaid,,146.75,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Amerihealth Caritas,Managed Medicaid,,246.05,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Amerihealth Caritas,Managed Medicaid,,1434.43,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Amerihealth Caritas,Managed Medicaid,,358.56,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Amerihealth Caritas,Managed Medicaid,,315.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Amerihealth Caritas,Managed Medicaid,,371.17,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Amerihealth Caritas,Managed Medicaid,,209.41,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Amerihealth Caritas,Managed Medicaid,,717.92,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Amerihealth Caritas,Managed Medicaid,,717.92,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Amerihealth Caritas,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Amerihealth Caritas,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Amerihealth Caritas,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Amerihealth Caritas,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Amerihealth Caritas,Managed Medicaid,,693.69,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Amerihealth Caritas,Managed Medicaid,,596.60,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Amerihealth Caritas,Managed Medicaid,,1230.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Amerihealth Caritas,Managed Medicaid,,1430.23,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Amerihealth Caritas,Managed Medicaid,,1059.26,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Amerihealth Caritas,Managed Medicaid,,954.35,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Amerihealth Caritas,Managed Medicaid,,238.64,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Amerihealth Caritas,Managed Medicaid,,1609.21,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Amerihealth Caritas,Managed Medicaid,,1660.86,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Amerihealth Caritas,Managed Medicaid,,2496.49,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Amerihealth Caritas,Managed Medicaid,,1392.39,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Amerihealth Caritas,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Amerihealth Caritas,Managed Medicaid,,369.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Amerihealth Caritas,Managed Medicaid,,178.38,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Amerihealth Caritas,Managed Medicaid,,322.52,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Amerihealth Caritas,Managed Medicaid,,238.44,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Amerihealth Caritas,Managed Medicaid,,741.14,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Amerihealth Caritas,Managed Medicaid,,650.85,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Amerihealth Caritas,Managed Medicaid,,651.45,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Amerihealth Caritas,Managed Medicaid,,561.56,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Amerihealth Caritas,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Amerihealth Caritas,Managed Medicaid,,954.75,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Amerihealth Caritas,Managed Medicaid,,1107.51,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Amerihealth Caritas,Managed Medicaid,,1623.02,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Amerihealth Caritas,Managed Medicaid,,150.35,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Amerihealth Caritas,Managed Medicaid,,2177.58,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Amerihealth Caritas,Managed Medicaid,,1567.77,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Amerihealth Caritas,Managed Medicaid,,762.16,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Amerihealth Caritas,Managed Medicaid,,3427.62,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Amerihealth Caritas,Managed Medicaid,,1466.87,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Amerihealth Caritas,Managed Medicaid,,180.58,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Amerihealth Caritas,Managed Medicaid,,696.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Amerihealth Caritas,Managed Medicaid,,696.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Amerihealth Caritas,Managed Medicaid,,3451.05,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Amerihealth Caritas,Managed Medicaid,,3239.64,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Amerihealth Caritas,Managed Medicaid,,3239.64,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Amerihealth Caritas,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Amerihealth Caritas,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Amerihealth Caritas,Managed Medicaid,,1866.26,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Amerihealth Caritas,Managed Medicaid,,1866.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Amerihealth Caritas,Managed Medicaid,,2488.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Amerihealth Caritas,Managed Medicaid,,1808.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Amerihealth Caritas,Managed Medicaid,,582.58,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Amerihealth Caritas,Managed Medicaid,,474.07,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Amerihealth Caritas,Managed Medicaid,,474.07,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Amerihealth Caritas,Managed Medicaid,,160.96,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Amerihealth Caritas,Managed Medicaid,,1313.31,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Amerihealth Caritas,Managed Medicaid,,337.54,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Amerihealth Caritas,Managed Medicaid,,404.60,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Amerihealth Caritas,Managed Medicaid,,642.84,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Amerihealth Caritas,Managed Medicaid,,97.50,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Amerihealth Caritas,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Amerihealth Caritas,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Amerihealth Caritas,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Amerihealth Caritas,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Amerihealth Caritas,Managed Medicaid,,1990.79,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Amerihealth Caritas,Managed Medicaid,,1990.79,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Amerihealth Caritas,Managed Medicaid,,803.60,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Amerihealth Caritas,Managed Medicaid,,1219.62,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Amerihealth Caritas,Managed Medicaid,,691.09,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Amerihealth Caritas,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Amerihealth Caritas,Managed Medicaid,,125.93,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Amerihealth Caritas,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Amerihealth Caritas,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Amerihealth Caritas,Managed Medicaid,,812.41,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Amerihealth Caritas,Managed Medicaid,,392.19,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Amerihealth Caritas,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Amerihealth Caritas,Managed Medicaid,,91.89,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Amerihealth Caritas,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Amerihealth Caritas,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Amerihealth Caritas,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Amerihealth Caritas,Managed Medicaid,,64.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Amerihealth Caritas,Managed Medicaid,,178.98,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Amerihealth Caritas,Managed Medicaid,,114.91,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Amerihealth Caritas,Managed Medicaid,,228.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Amerihealth Caritas,Managed Medicaid,,187.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Amerihealth Caritas,Managed Medicaid,,211.81,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Amerihealth Caritas,Managed Medicaid,,154.35,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Amerihealth Caritas,Managed Medicaid,,167.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Amerihealth Caritas,Managed Medicaid,,63.06,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Amerihealth Caritas,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Amerihealth Caritas,Managed Medicaid,,62.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Amerihealth Caritas,Managed Medicaid,,165.16,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Amerihealth Caritas,Managed Medicaid,,192.39,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Amerihealth Caritas,Managed Medicaid,,103.90,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Amerihealth Caritas,Managed Medicaid,,127.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Amerihealth Caritas,Managed Medicaid,,85.49,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Amerihealth Caritas,Managed Medicaid,,167.17,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Amerihealth Caritas,Managed Medicaid,,133.73,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Amerihealth Caritas,Managed Medicaid,,107.91,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Amerihealth Caritas,Managed Medicaid,,131.73,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Amerihealth Caritas,Managed Medicaid,,207.61,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Amerihealth Caritas,Managed Medicaid,,164.76,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Amerihealth Caritas,Managed Medicaid,,183.98,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Amerihealth Caritas,Managed Medicaid,,60.26,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Amerihealth Caritas,Managed Medicaid,,235.84,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Amerihealth Caritas,Managed Medicaid,,152.95,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Amerihealth Caritas,Managed Medicaid,,50.05,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Amerihealth Caritas,Managed Medicaid,,46.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Amerihealth Caritas,Managed Medicaid,,37.24,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Amerihealth Caritas,Managed Medicaid,,220.62,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Amerihealth Caritas,Managed Medicaid,,165.16,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Amerihealth Caritas,Managed Medicaid,,39.84,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Amerihealth Caritas,Managed Medicaid,,136.94,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Amerihealth Caritas,Managed Medicaid,,84.48,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Amerihealth Caritas,Managed Medicaid,,193.59,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Amerihealth Caritas,Managed Medicaid,,144.94,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Amerihealth Caritas,Managed Medicaid,,82.68,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Amerihealth Caritas,Managed Medicaid,,98.50,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Amerihealth Caritas,Managed Medicaid,,91.89,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Amerihealth Caritas,Managed Medicaid,,27.83,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Amerihealth Caritas,Managed Medicaid,,13.41,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Amerihealth Caritas,Managed Medicaid,,21.82,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Amerihealth Caritas,Managed Medicaid,,1278.48,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Amerihealth Caritas,Managed Medicaid,,931.73,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Amerihealth Caritas,Managed Medicaid,,837.24,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Amerihealth Caritas,Managed Medicaid,,1299.50,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Amerihealth Caritas,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Amerihealth Caritas,Managed Medicaid,,538.14,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Amerihealth Caritas,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Amerihealth Caritas,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Amerihealth Caritas,Managed Medicaid,,186.39,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Amerihealth Caritas,Managed Medicaid,,306.51,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Amerihealth Caritas,Managed Medicaid,,612.81,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Amerihealth Caritas,Managed Medicaid,,932.93,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Amerihealth Caritas,Managed Medicaid,,836.04,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Amerihealth Caritas,Managed Medicaid,,1211.61,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Amerihealth Caritas,Managed Medicaid,,1780.98,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Amerihealth Caritas,Managed Medicaid,,105.51,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Amerihealth Caritas,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Amerihealth Caritas,Managed Medicaid,,114.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Amerihealth Caritas,Managed Medicaid,,202.60,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Amerihealth Caritas,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Amerihealth Caritas,Managed Medicaid,,494.29,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Amerihealth Caritas,Managed Medicaid,,96.30,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Amerihealth Caritas,Managed Medicaid,,563.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Amerihealth Caritas,Managed Medicaid,,659.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Amerihealth Caritas,Managed Medicaid,,1014.81,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Amerihealth Caritas,Managed Medicaid,,1226.63,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Amerihealth Caritas,Managed Medicaid,,692.49,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Amerihealth Caritas,Managed Medicaid,,1035.63,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Amerihealth Caritas,Managed Medicaid,,1078.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Amerihealth Caritas,Managed Medicaid,,721.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Amerihealth Caritas,Managed Medicaid,,753.75,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Amerihealth Caritas,Managed Medicaid,,1032.63,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Amerihealth Caritas,Managed Medicaid,,695.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Amerihealth Caritas,Managed Medicaid,,816.02,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Amerihealth Caritas,Managed Medicaid,,940.74,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Amerihealth Caritas,Managed Medicaid,,742.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Amerihealth Caritas,Managed Medicaid,,779.18,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Amerihealth Caritas,Managed Medicaid,,1067.47,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Amerihealth Caritas,Managed Medicaid,,735.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Amerihealth Caritas,Managed Medicaid,,743.14,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Amerihealth Caritas,Managed Medicaid,,1032.63,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Amerihealth Caritas,Managed Medicaid,,852.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Amerihealth Caritas,Managed Medicaid,,901.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Amerihealth Caritas,Managed Medicaid,,1047.85,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Amerihealth Caritas,Managed Medicaid,,584.38,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Amerihealth Caritas,Managed Medicaid,,837.84,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Amerihealth Caritas,Managed Medicaid,,635.03,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Amerihealth Caritas,Managed Medicaid,,50.65,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Amerihealth Caritas,Managed Medicaid,52,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Amerihealth Caritas,Managed Medicaid,52,787.39,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Amerihealth Caritas,Managed Medicaid,,769.37,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Amerihealth Caritas,Managed Medicaid,,881.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Amerihealth Caritas,Managed Medicaid,,1040.24,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Amerihealth Caritas,Managed Medicaid,,805.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Amerihealth Caritas,Managed Medicaid,,827.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Amerihealth Caritas,Managed Medicaid,,703.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Amerihealth Caritas,Managed Medicaid,,855.65,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Amerihealth Caritas,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Amerihealth Caritas,Managed Medicaid,,811.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Amerihealth Caritas,Managed Medicaid,,1021.82,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Amerihealth Caritas,Managed Medicaid,,983.38,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Amerihealth Caritas,Managed Medicaid,,1091.89,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Amerihealth Caritas,Managed Medicaid,,838.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Amerihealth Caritas,Managed Medicaid,,928.33,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Amerihealth Caritas,Managed Medicaid,,1118.32,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Amerihealth Caritas,Managed Medicaid,,694.29,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Amerihealth Caritas,Managed Medicaid,,734.93,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Amerihealth Caritas,Managed Medicaid,,1069.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Amerihealth Caritas,Managed Medicaid,,649.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Amerihealth Caritas,Managed Medicaid,,720.52,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Amerihealth Caritas,Managed Medicaid,,1000.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Amerihealth Caritas,Managed Medicaid,,845.85,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Amerihealth Caritas,Managed Medicaid,,647.85,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Amerihealth Caritas,Managed Medicaid,,895.29,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Amerihealth Caritas,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Amerihealth Caritas,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Amerihealth Caritas,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Amerihealth Caritas,Managed Medicaid,,707.71,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Amerihealth Caritas,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Amerihealth Caritas,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Amerihealth Caritas,Managed Medicaid,,899.50,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Amerihealth Caritas,Managed Medicaid,,650.65,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Amerihealth Caritas,Managed Medicaid,,919.72,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Amerihealth Caritas,Managed Medicaid,,894.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Amerihealth Caritas,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Amerihealth Caritas,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Amerihealth Caritas,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Amerihealth Caritas,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Amerihealth Caritas,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Amerihealth Caritas,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Amerihealth Caritas,Managed Medicaid,,206.81,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Amerihealth Caritas,Managed Medicaid,,480.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Amerihealth Caritas,Managed Medicaid,,477.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Amerihealth Caritas,Managed Medicaid,,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Amerihealth Caritas,Managed Medicaid,,375.38,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Amerihealth Caritas,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Amerihealth Caritas,Managed Medicaid,,64.86,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Amerihealth Caritas,Managed Medicaid,,79.88,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Amerihealth Caritas,Managed Medicaid,,349.35,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Amerihealth Caritas,Managed Medicaid,,349.35,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Amerihealth Caritas,Managed Medicaid,,31.63,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Amerihealth Caritas,Managed Medicaid,,366.57,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Amerihealth Caritas,Managed Medicaid,,366.57,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Amerihealth Caritas,Managed Medicaid,,181.18,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Amerihealth Caritas,Managed Medicaid,,108.11,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Amerihealth Caritas,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Amerihealth Caritas,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Amerihealth Caritas,Managed Medicaid,,260.06,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Amerihealth Caritas,Managed Medicaid,,207.61,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Amerihealth Caritas,Managed Medicaid,,169.57,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Amerihealth Caritas,Managed Medicaid,,123.32,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Amerihealth Caritas,Managed Medicaid,,119.92,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Amerihealth Caritas,Managed Medicaid,,58.46,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Amerihealth Caritas,Managed Medicaid,,86.29,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Amerihealth Caritas,Managed Medicaid,,63.46,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Amerihealth Caritas,Managed Medicaid,,57.66,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Amerihealth Caritas,Managed Medicaid,,136.14,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Amerihealth Caritas,Managed Medicaid,,56.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Amerihealth Caritas,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Amerihealth Caritas,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Amerihealth Caritas,Managed Medicaid,,287.49,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Amerihealth Caritas,Managed Medicaid,,150.55,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Amerihealth Caritas,Managed Medicaid,,373.57,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Amerihealth Caritas,Managed Medicaid,,870.87,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Amerihealth Caritas,Managed Medicaid,,50.45,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Amerihealth Caritas,Managed Medicaid,,35.44,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Amerihealth Caritas,Managed Medicaid,,73.87,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Amerihealth Caritas,Managed Medicaid,,36.64,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Amerihealth Caritas,Managed Medicaid,,85.49,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Amerihealth Caritas,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Amerihealth Caritas,Managed Medicaid,,55.05,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Amerihealth Caritas,Managed Medicaid,,79.88,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Amerihealth Caritas,Managed Medicaid,,126.33,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Amerihealth Caritas,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Amerihealth Caritas,Managed Medicaid,,174.97,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Amerihealth Caritas,Managed Medicaid,,112.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Amerihealth Caritas,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Amerihealth Caritas,Managed Medicaid,,72.47,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Amerihealth Caritas,Managed Medicaid,,151.35,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Amerihealth Caritas,Managed Medicaid,,61.06,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Amerihealth Caritas,Managed Medicaid,,133.13,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Amerihealth Caritas,Managed Medicaid,,84.48,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Amerihealth Caritas,Managed Medicaid,,191.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Amerihealth Caritas,Managed Medicaid,,119.92,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Amerihealth Caritas,Managed Medicaid,,84.48,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Amerihealth Caritas,Managed Medicaid,,91.69,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Amerihealth Caritas,Managed Medicaid,,72.87,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Amerihealth Caritas,Managed Medicaid,,505.30,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Amerihealth Caritas,Managed Medicaid,,434.23,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Amerihealth Caritas,Managed Medicaid,,221.42,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Amerihealth Caritas,Managed Medicaid,,104.30,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Amerihealth Caritas,Managed Medicaid,,110.71,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Amerihealth Caritas,Managed Medicaid,,67.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Amerihealth Caritas,Managed Medicaid,,25.63,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Amerihealth Caritas,Managed Medicaid,,102.50,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Amerihealth Caritas,Managed Medicaid,,80.88,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Amerihealth Caritas,Managed Medicaid,,80.88,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Amerihealth Caritas,Managed Medicaid,,481.28,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,,9.41,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Amerihealth Caritas,Managed Medicaid,,2.80,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Amerihealth Caritas,Managed Medicaid,,22.42,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Amerihealth Caritas,Managed Medicaid,,32.63,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Amerihealth Caritas,Managed Medicaid,,26.43,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Amerihealth Caritas,Managed Medicaid,,5.21,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Amerihealth Caritas,Managed Medicaid,,8.81,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Amerihealth Caritas,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Amerihealth Caritas,Managed Medicaid,,53.05,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Amerihealth Caritas,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Amerihealth Caritas,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Amerihealth Caritas,Managed Medicaid,,79.48,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Amerihealth Caritas,Managed Medicaid,,31.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Amerihealth Caritas,Managed Medicaid,,107.11,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Amerihealth Caritas,Managed Medicaid,,14.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Amerihealth Caritas,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Amerihealth Caritas,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Amerihealth Caritas,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Amerihealth Caritas,Managed Medicaid,,5.81,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Amerihealth Caritas,Managed Medicaid,,35.44,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Amerihealth Caritas,Managed Medicaid,,24.82,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Amerihealth Caritas,Managed Medicaid,,7.81,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Amerihealth Caritas,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Amerihealth Caritas,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Amerihealth Caritas,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Amerihealth Caritas,Managed Medicaid,,30.83,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Amerihealth Caritas,Managed Medicaid,,5.81,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Amerihealth Caritas,Managed Medicaid,,8.61,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Amerihealth Caritas,Managed Medicaid,,8.41,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Amerihealth Caritas,Managed Medicaid,,9.61,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Amerihealth Caritas,Managed Medicaid,,32.43,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Amerihealth Caritas,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Amerihealth Caritas,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Amerihealth Caritas,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Amerihealth Caritas,Managed Medicaid,,8.41,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Amerihealth Caritas,Managed Medicaid,,12.01,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Amerihealth Caritas,Managed Medicaid,,8.01,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Amerihealth Caritas,Managed Medicaid,,8.01,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Amerihealth Caritas,Managed Medicaid,,33.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Amerihealth Caritas,Managed Medicaid,,13.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Amerihealth Caritas,Managed Medicaid,,10.61,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Amerihealth Caritas,Managed Medicaid,,51.65,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Amerihealth Caritas,Managed Medicaid,,13.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Amerihealth Caritas,Managed Medicaid,,48.65,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Amerihealth Caritas,Managed Medicaid,,36.04,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Amerihealth Caritas,Managed Medicaid,,29.23,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Amerihealth Caritas,Managed Medicaid,,15.82,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Amerihealth Caritas,Managed Medicaid,,7.81,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Amerihealth Caritas,Managed Medicaid,,59.86,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Amerihealth Caritas,Managed Medicaid,,1.20,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Amerihealth Caritas,Managed Medicaid,,40.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Amerihealth Caritas,Managed Medicaid,,115.92,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Amerihealth Caritas,Managed Medicaid,,31.43,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Amerihealth Caritas,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Amerihealth Caritas,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Amerihealth Caritas,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Amerihealth Caritas,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Amerihealth Caritas,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Amerihealth Caritas,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Amerihealth Caritas,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Amerihealth Caritas,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Amerihealth Caritas,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,,6.01,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Amerihealth Caritas,Managed Medicaid,,14.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Amerihealth Caritas,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Amerihealth Caritas,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Amerihealth Caritas,Managed Medicaid,,15.62,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Amerihealth Caritas,Managed Medicaid,,47.65,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Amerihealth Caritas,Managed Medicaid,,31.23,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Amerihealth Caritas,Managed Medicaid,,44.24,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Amerihealth Caritas,Managed Medicaid,,24.02,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Amerihealth Caritas,Managed Medicaid,,30.43,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Amerihealth Caritas,Managed Medicaid,,39.44,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Amerihealth Caritas,Managed Medicaid,,26.43,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Amerihealth Caritas,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Amerihealth Caritas,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Amerihealth Caritas,Managed Medicaid,,8.41,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Amerihealth Caritas,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Amerihealth Caritas,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Amerihealth Caritas,Managed Medicaid,,29.83,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Amerihealth Caritas,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Amerihealth Caritas,Managed Medicaid,,28.63,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Amerihealth Caritas,Managed Medicaid,,16.62,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Amerihealth Caritas,Managed Medicaid,,28.63,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Amerihealth Caritas,Managed Medicaid,,35.44,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Amerihealth Caritas,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Amerihealth Caritas,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Amerihealth Caritas,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Amerihealth Caritas,Managed Medicaid,,0.40040,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Amerihealth Caritas,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Amerihealth Caritas,Managed Medicaid,,11.01,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Amerihealth Caritas,Managed Medicaid,,29.23,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Amerihealth Caritas,Managed Medicaid,,45.45,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Amerihealth Caritas,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Amerihealth Caritas,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Amerihealth Caritas,Managed Medicaid,,9.01,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Amerihealth Caritas,Managed Medicaid,,10.61,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Amerihealth Caritas,Managed Medicaid,,10.01,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Amerihealth Caritas,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Amerihealth Caritas,Managed Medicaid,,9.01,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Amerihealth Caritas,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Amerihealth Caritas,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Amerihealth Caritas,Managed Medicaid,,8.61,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Amerihealth Caritas,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Amerihealth Caritas,Managed Medicaid,,33.43,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Amerihealth Caritas,Managed Medicaid,,9.01,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Amerihealth Caritas,Managed Medicaid,,32.03,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Amerihealth Caritas,Managed Medicaid,,38.04,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Amerihealth Caritas,Managed Medicaid,,13.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Amerihealth Caritas,Managed Medicaid,,26.83,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Amerihealth Caritas,Managed Medicaid,,26.03,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Amerihealth Caritas,Managed Medicaid,,21.62,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Amerihealth Caritas,Managed Medicaid,,7.61,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Amerihealth Caritas,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Amerihealth Caritas,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Amerihealth Caritas,Managed Medicaid,,26.03,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Amerihealth Caritas,Managed Medicaid,,38.64,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Amerihealth Caritas,Managed Medicaid,,15.82,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Amerihealth Caritas,Managed Medicaid,,2.40,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Amerihealth Caritas,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Amerihealth Caritas,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Amerihealth Caritas,Managed Medicaid,,45.05,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Amerihealth Caritas,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Amerihealth Caritas,Managed Medicaid,,28.03,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Amerihealth Caritas,Managed Medicaid,,22.62,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Amerihealth Caritas,Managed Medicaid,,19.42,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Amerihealth Caritas,Managed Medicaid,,27.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Amerihealth Caritas,Managed Medicaid,,24.02,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Amerihealth Caritas,Managed Medicaid,,1.60,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Amerihealth Caritas,Managed Medicaid,,4.40,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Amerihealth Caritas,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Amerihealth Caritas,Managed Medicaid,,34.83,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Amerihealth Caritas,Managed Medicaid,,25.63,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Amerihealth Caritas,Managed Medicaid,,53.45,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Amerihealth Caritas,Managed Medicaid,,29.43,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Amerihealth Caritas,Managed Medicaid,,54.65,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Amerihealth Caritas,Managed Medicaid,,41.44,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Amerihealth Caritas,Managed Medicaid,,10.01,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Amerihealth Caritas,Managed Medicaid,,47.45,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Amerihealth Caritas,Managed Medicaid,,41.24,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Amerihealth Caritas,Managed Medicaid,,8.21,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Amerihealth Caritas,Managed Medicaid,,58.66,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Amerihealth Caritas,Managed Medicaid,,40.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Amerihealth Caritas,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Amerihealth Caritas,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Amerihealth Caritas,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Amerihealth Caritas,Managed Medicaid,,10.01,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Amerihealth Caritas,Managed Medicaid,,27.03,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Amerihealth Caritas,Managed Medicaid,,44.64,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Amerihealth Caritas,Managed Medicaid,,4.20,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Amerihealth Caritas,Managed Medicaid,,11.41,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Amerihealth Caritas,Managed Medicaid,,29.03,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Amerihealth Caritas,Managed Medicaid,,13.61,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,,23.42,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Amerihealth Caritas,Managed Medicaid,,34.63,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Amerihealth Caritas,Managed Medicaid,,19.42,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Amerihealth Caritas,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Amerihealth Caritas,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Amerihealth Caritas,Managed Medicaid,,3.00,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Amerihealth Caritas,Managed Medicaid,,7.01,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Amerihealth Caritas,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Amerihealth Caritas,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Amerihealth Caritas,Managed Medicaid,,92.29,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Amerihealth Caritas,Managed Medicaid,,24.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Amerihealth Caritas,Managed Medicaid,,39.04,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Amerihealth Caritas,Managed Medicaid,,16.62,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Amerihealth Caritas,Managed Medicaid,,2.20,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Amerihealth Caritas,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Amerihealth Caritas,Managed Medicaid,,27.03,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Amerihealth Caritas,Managed Medicaid,,21.62,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Amerihealth Caritas,Managed Medicaid,,158.96,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Amerihealth Caritas,Managed Medicaid,,89.49,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Amerihealth Caritas,Managed Medicaid,,53.25,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Amerihealth Caritas,Managed Medicaid,,114.11,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Amerihealth Caritas,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Amerihealth Caritas,Managed Medicaid,,59.26,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Amerihealth Caritas,Managed Medicaid,,72.27,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Amerihealth Caritas,Managed Medicaid,,46.65,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Amerihealth Caritas,Managed Medicaid,,29.03,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Amerihealth Caritas,Managed Medicaid,,24.62,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Amerihealth Caritas,Managed Medicaid,,26.83,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Amerihealth Caritas,Managed Medicaid,,39.24,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Amerihealth Caritas,Managed Medicaid,,34.63,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Amerihealth Caritas,Managed Medicaid,,100.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Amerihealth Caritas,Managed Medicaid,,147.55,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Amerihealth Caritas,Managed Medicaid,,25.23,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Amerihealth Caritas,Managed Medicaid,,27.83,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Amerihealth Caritas,Managed Medicaid,,30.03,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Amerihealth Caritas,Managed Medicaid,,18.62,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Amerihealth Caritas,Managed Medicaid,,32.43,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Amerihealth Caritas,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Amerihealth Caritas,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Amerihealth Caritas,Managed Medicaid,,64.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Amerihealth Caritas,Managed Medicaid,,55.05,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Amerihealth Caritas,Managed Medicaid,,58.26,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Amerihealth Caritas,Managed Medicaid,,52.85,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Amerihealth Caritas,Managed Medicaid,,122.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Amerihealth Caritas,Managed Medicaid,,32.23,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Amerihealth Caritas,Managed Medicaid,,47.45,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Amerihealth Caritas,Managed Medicaid,,39.84,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Amerihealth Caritas,Managed Medicaid,,19.82,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Amerihealth Caritas,Managed Medicaid,,65.06,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Amerihealth Caritas,Managed Medicaid,,54.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Amerihealth Caritas,Managed Medicaid,,64.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Amerihealth Caritas,Managed Medicaid,,50.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Amerihealth Caritas,Managed Medicaid,,36.44,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Amerihealth Caritas,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Amerihealth Caritas,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Amerihealth Caritas,Managed Medicaid,,49.45,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Amerihealth Caritas,Managed Medicaid,,8.81,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Amerihealth Caritas,Managed Medicaid,,30.03,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Amerihealth Caritas,Managed Medicaid,,39.24,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Amerihealth Caritas,Managed Medicaid,,93.69,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Amerihealth Caritas,Managed Medicaid,,56.66,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Amerihealth Caritas,Managed Medicaid,,7.01,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Amerihealth Caritas,Managed Medicaid,,14.41,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Amerihealth Caritas,Managed Medicaid,,22.62,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Amerihealth Caritas,Managed Medicaid,,71.27,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Amerihealth Caritas,Managed Medicaid,,29.23,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Amerihealth Caritas,Managed Medicaid,,40.44,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Amerihealth Caritas,Managed Medicaid,,28.63,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Amerihealth Caritas,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Amerihealth Caritas,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Amerihealth Caritas,Managed Medicaid,,20.42,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Amerihealth Caritas,Managed Medicaid,,17.02,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Amerihealth Caritas,Managed Medicaid,,19.62,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Amerihealth Caritas,Managed Medicaid,,44.84,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Amerihealth Caritas,Managed Medicaid,,7.81,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Amerihealth Caritas,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Amerihealth Caritas,Managed Medicaid,,9.41,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Amerihealth Caritas,Managed Medicaid,,3.00,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Amerihealth Caritas,Managed Medicaid,,8.21,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Amerihealth Caritas,Managed Medicaid,,37.64,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Amerihealth Caritas,Managed Medicaid,,24.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Amerihealth Caritas,Managed Medicaid,,26.03,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Amerihealth Caritas,Managed Medicaid,,14.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Amerihealth Caritas,Managed Medicaid,,31.43,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Amerihealth Caritas,Managed Medicaid,,5.41,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Amerihealth Caritas,Managed Medicaid,,10.61,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Amerihealth Caritas,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Amerihealth Caritas,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Amerihealth Caritas,Managed Medicaid,,19.42,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Amerihealth Caritas,Managed Medicaid,,42.64,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Amerihealth Caritas,Managed Medicaid,,40.84,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Amerihealth Caritas,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Amerihealth Caritas,Managed Medicaid,,40.84,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Amerihealth Caritas,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,,14.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Amerihealth Caritas,Managed Medicaid,,29.03,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Amerihealth Caritas,Managed Medicaid,,18.42,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Amerihealth Caritas,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Amerihealth Caritas,Managed Medicaid,,5.21,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,,25.83,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Amerihealth Caritas,Managed Medicaid,,23.22,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Amerihealth Caritas,Managed Medicaid,,15.82,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Amerihealth Caritas,Managed Medicaid,,67.87,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Amerihealth Caritas,Managed Medicaid,,13.61,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,,17.82,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Amerihealth Caritas,Managed Medicaid,,3.20,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Amerihealth Caritas,Managed Medicaid,,49.05,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Amerihealth Caritas,Managed Medicaid,,30.83,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Amerihealth Caritas,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Amerihealth Caritas,Managed Medicaid,,19.82,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Amerihealth Caritas,Managed Medicaid,,15.62,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Amerihealth Caritas,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Amerihealth Caritas,Managed Medicaid,,11.41,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Amerihealth Caritas,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Amerihealth Caritas,Managed Medicaid,,12.61,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Amerihealth Caritas,Managed Medicaid,,36.04,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Amerihealth Caritas,Managed Medicaid,,6.61,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Amerihealth Caritas,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Amerihealth Caritas,Managed Medicaid,,45.65,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Amerihealth Caritas,Managed Medicaid,,33.83,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Amerihealth Caritas,Managed Medicaid,,92.29,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Amerihealth Caritas,Managed Medicaid,,42.64,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Amerihealth Caritas,Managed Medicaid,,42.64,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Amerihealth Caritas,Managed Medicaid,,125.93,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Amerihealth Caritas,Managed Medicaid,,116.32,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Amerihealth Caritas,Managed Medicaid,,34.83,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Amerihealth Caritas,Managed Medicaid,,32.23,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Amerihealth Caritas,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Amerihealth Caritas,Managed Medicaid,,42.44,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Amerihealth Caritas,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Amerihealth Caritas,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Amerihealth Caritas,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Amerihealth Caritas,Managed Medicaid,,51.45,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Amerihealth Caritas,Managed Medicaid,,154.15,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Amerihealth Caritas,Managed Medicaid,,17.42,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Amerihealth Caritas,Managed Medicaid,,16.62,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Amerihealth Caritas,Managed Medicaid,,9.61,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Amerihealth Caritas,Managed Medicaid,,22.42,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Amerihealth Caritas,Managed Medicaid,,115.92,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Amerihealth Caritas,Managed Medicaid,,55.86,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Amerihealth Caritas,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Amerihealth Caritas,Managed Medicaid,,30.83,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Amerihealth Caritas,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Amerihealth Caritas,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Amerihealth Caritas,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Amerihealth Caritas,Managed Medicaid,,92.69,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Amerihealth Caritas,Managed Medicaid,,58.86,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Amerihealth Caritas,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Amerihealth Caritas,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Amerihealth Caritas,Managed Medicaid,,25.23,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Amerihealth Caritas,Managed Medicaid,,2.40,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Amerihealth Caritas,Managed Medicaid,,30.03,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Amerihealth Caritas,Managed Medicaid,,24.02,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Amerihealth Caritas,Managed Medicaid,,109.71,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Amerihealth Caritas,Managed Medicaid,,61.86,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Amerihealth Caritas,Managed Medicaid,,25.43,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Amerihealth Caritas,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Amerihealth Caritas,Managed Medicaid,,4.40,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Amerihealth Caritas,Managed Medicaid,,46.05,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Amerihealth Caritas,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Amerihealth Caritas,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Amerihealth Caritas,Managed Medicaid,,11.61,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Amerihealth Caritas,Managed Medicaid,,7.01,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Amerihealth Caritas,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Amerihealth Caritas,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Amerihealth Caritas,Managed Medicaid,,12.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Amerihealth Caritas,Managed Medicaid,,12.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Amerihealth Caritas,Managed Medicaid,,9.21,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Amerihealth Caritas,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Amerihealth Caritas,Managed Medicaid,,14.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Amerihealth Caritas,Managed Medicaid,,3.00,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Amerihealth Caritas,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Amerihealth Caritas,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Amerihealth Caritas,Managed Medicaid,,26.83,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Amerihealth Caritas,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Amerihealth Caritas,Managed Medicaid,,5.21,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Amerihealth Caritas,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Amerihealth Caritas,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Amerihealth Caritas,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Amerihealth Caritas,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Amerihealth Caritas,Managed Medicaid,,0.40040,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Amerihealth Caritas,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Amerihealth Caritas,Managed Medicaid,,16.22,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Amerihealth Caritas,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Amerihealth Caritas,Managed Medicaid,,32.23,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Amerihealth Caritas,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Amerihealth Caritas,Managed Medicaid,,28.23,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Amerihealth Caritas,Managed Medicaid,,6.81,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Amerihealth Caritas,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Amerihealth Caritas,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Amerihealth Caritas,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Amerihealth Caritas,Managed Medicaid,,7.01,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Amerihealth Caritas,Managed Medicaid,,15.02,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Amerihealth Caritas,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Amerihealth Caritas,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Amerihealth Caritas,Managed Medicaid,,153.55,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Amerihealth Caritas,Managed Medicaid,,26.83,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Amerihealth Caritas,Managed Medicaid,,361.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Amerihealth Caritas,Managed Medicaid,,251.85,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Amerihealth Caritas,Managed Medicaid,,58.66,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Amerihealth Caritas,Managed Medicaid,,23.22,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Amerihealth Caritas,Managed Medicaid,,386.59,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Amerihealth Caritas,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Amerihealth Caritas,Managed Medicaid,,51.85,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Amerihealth Caritas,Managed Medicaid,,9.21,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Amerihealth Caritas,Managed Medicaid,,361.96,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Amerihealth Caritas,Managed Medicaid,,141.54,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Amerihealth Caritas,Managed Medicaid,,102.70,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Amerihealth Caritas,Managed Medicaid,,37.84,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Amerihealth Caritas,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Amerihealth Caritas,Managed Medicaid,,22.82,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Amerihealth Caritas,Managed Medicaid,,64.86,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Amerihealth Caritas,Managed Medicaid,,38.84,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Amerihealth Caritas,Managed Medicaid,,190.79,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Amerihealth Caritas,Managed Medicaid,,127.93,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Amerihealth Caritas,Managed Medicaid,,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Amerihealth Caritas,Managed Medicaid,QW,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Amerihealth Caritas,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Amerihealth Caritas,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Amerihealth Caritas,Managed Medicaid,,318.12,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Amerihealth Caritas,Managed Medicaid,,237.64,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Amerihealth Caritas,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Amerihealth Caritas,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Amerihealth Caritas,Managed Medicaid,,95.70,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Amerihealth Caritas,Managed Medicaid,,40.84,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Amerihealth Caritas,Managed Medicaid,,85.29,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Amerihealth Caritas,Managed Medicaid,,10.01,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,QW,20.02,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Amerihealth Caritas,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Amerihealth Caritas,Managed Medicaid,,32.63,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Amerihealth Caritas,Managed Medicaid,,181.58,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Amerihealth Caritas,Managed Medicaid,,55.05,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Amerihealth Caritas,Managed Medicaid,,26.43,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,,33.03,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Amerihealth Caritas,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Amerihealth Caritas,Managed Medicaid,,8.61,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Amerihealth Caritas,Managed Medicaid,,56.06,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Amerihealth Caritas,Managed Medicaid,,15.82,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Amerihealth Caritas,Managed Medicaid,,38.84,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Amerihealth Caritas,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Amerihealth Caritas,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Amerihealth Caritas,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Amerihealth Caritas,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Amerihealth Caritas,Managed Medicaid,,42.64,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Amerihealth Caritas,Managed Medicaid,,43.84,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Amerihealth Caritas,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Amerihealth Caritas,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Amerihealth Caritas,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Amerihealth Caritas,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Amerihealth Caritas,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Amerihealth Caritas,Managed Medicaid,,15.22,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Amerihealth Caritas,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Amerihealth Caritas,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Amerihealth Caritas,Managed Medicaid,,20.22,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Amerihealth Caritas,Managed Medicaid,,29.83,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Amerihealth Caritas,Managed Medicaid,,265.87,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Amerihealth Caritas,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Amerihealth Caritas,Managed Medicaid,,21.62,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Amerihealth Caritas,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Amerihealth Caritas,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Amerihealth Caritas,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Amerihealth Caritas,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Amerihealth Caritas,Managed Medicaid,,33.43,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Amerihealth Caritas,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Amerihealth Caritas,Managed Medicaid,,63.86,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Amerihealth Caritas,Managed Medicaid,,103.10,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Amerihealth Caritas,Managed Medicaid,,105.31,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Amerihealth Caritas,Managed Medicaid,,42.04,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Amerihealth Caritas,Managed Medicaid,,5.41,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Amerihealth Caritas,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Amerihealth Caritas,Managed Medicaid,,37.24,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Amerihealth Caritas,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Amerihealth Caritas,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Amerihealth Caritas,Managed Medicaid,,7.81,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Amerihealth Caritas,Managed Medicaid,,39.64,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Amerihealth Caritas,Managed Medicaid,,23.82,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Amerihealth Caritas,Managed Medicaid,,51.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Amerihealth Caritas,Managed Medicaid,,52.25,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Amerihealth Caritas,Managed Medicaid,,15.62,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Amerihealth Caritas,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Amerihealth Caritas,Managed Medicaid,,41.84,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Amerihealth Caritas,Managed Medicaid,,41.44,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Amerihealth Caritas,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Amerihealth Caritas,Managed Medicaid,,29.63,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Amerihealth Caritas,Managed Medicaid,,91.29,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Amerihealth Caritas,Managed Medicaid,,119.52,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Amerihealth Caritas,Managed Medicaid,,151.15,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Amerihealth Caritas,Managed Medicaid,,112.31,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Amerihealth Caritas,Managed Medicaid,,65.06,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Amerihealth Caritas,Managed Medicaid,,45.05,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Amerihealth Caritas,Managed Medicaid,,204.00,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Amerihealth Caritas,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Amerihealth Caritas,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Amerihealth Caritas,Managed Medicaid,,44.84,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Amerihealth Caritas,Managed Medicaid,,26.43,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Amerihealth Caritas,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Amerihealth Caritas,Managed Medicaid,,109.71,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Amerihealth Caritas,Managed Medicaid,,20.42,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Amerihealth Caritas,Managed Medicaid,,35.03,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Amerihealth Caritas,Managed Medicaid,,73.47,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Amerihealth Caritas,Managed Medicaid,,132.13,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Amerihealth Caritas,Managed Medicaid,,0.00200,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Amerihealth Caritas,Managed Medicaid,,24.82,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Amerihealth Caritas,Managed Medicaid,,45.25,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Amerihealth Caritas,Managed Medicaid,,74.07,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Amerihealth Caritas,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Amerihealth Caritas,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Amerihealth Caritas,Managed Medicaid,,118.72,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Amerihealth Caritas,Managed Medicaid,,109.71,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Amerihealth Caritas,Managed Medicaid,,19.42,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Amerihealth Caritas,Managed Medicaid,,78.88,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Amerihealth Caritas,Managed Medicaid,,62.66,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Amerihealth Caritas,Managed Medicaid,,49.85,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Amerihealth Caritas,Managed Medicaid,,15.42,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Amerihealth Caritas,Managed Medicaid,,76.88,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Amerihealth Caritas,Managed Medicaid,,26.43,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Amerihealth Caritas,Managed Medicaid,,135.13,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Amerihealth Caritas,Managed Medicaid,,37.84,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Amerihealth Caritas,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Amerihealth Caritas,Managed Medicaid,,51.25,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Amerihealth Caritas,Managed Medicaid,,52.25,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Amerihealth Caritas,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Amerihealth Caritas,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Amerihealth Caritas,Managed Medicaid,,107.91,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Amerihealth Caritas,Managed Medicaid,,27.83,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Amerihealth Caritas,Managed Medicaid,,32.83,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Amerihealth Caritas,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Amerihealth Caritas,Managed Medicaid,,82.88,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Amerihealth Caritas,Managed Medicaid,,49.45,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Amerihealth Caritas,Managed Medicaid,,438.64,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Amerihealth Caritas,Managed Medicaid,,70.67,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Amerihealth Caritas,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Amerihealth Caritas,Managed Medicaid,,141.74,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Amerihealth Caritas,Managed Medicaid,,103.70,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Amerihealth Caritas,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Amerihealth Caritas,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Amerihealth Caritas,Managed Medicaid,,103.90,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Amerihealth Caritas,Managed Medicaid,,257.26,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Amerihealth Caritas,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Amerihealth Caritas,Managed Medicaid,,62.46,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Amerihealth Caritas,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Amerihealth Caritas,Managed Medicaid,,248.85,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Amerihealth Caritas,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Amerihealth Caritas,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Amerihealth Caritas,Managed Medicaid,,181.78,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Amerihealth Caritas,Managed Medicaid,,132.13,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Amerihealth Caritas,Managed Medicaid,,94.89,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Amerihealth Caritas,Managed Medicaid,,71.27,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Amerihealth Caritas,Managed Medicaid,,25.02,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Amerihealth Caritas,Managed Medicaid,,30.03,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Amerihealth Caritas,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Amerihealth Caritas,Managed Medicaid,,33.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Amerihealth Caritas,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Amerihealth Caritas,Managed Medicaid,,31.83,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Amerihealth Caritas,Managed Medicaid,,318.12,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Amerihealth Caritas,Managed Medicaid,,159.76,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Amerihealth Caritas,Managed Medicaid,,65.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Amerihealth Caritas,Managed Medicaid,,13.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Amerihealth Caritas,Managed Medicaid,,8.41,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Amerihealth Caritas,Managed Medicaid,,21.02,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Amerihealth Caritas,Managed Medicaid,,49.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Amerihealth Caritas,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Amerihealth Caritas,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Amerihealth Caritas,Managed Medicaid,,55.46,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Amerihealth Caritas,Managed Medicaid,,113.31,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Amerihealth Caritas,Managed Medicaid,,11.41,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Amerihealth Caritas,Managed Medicaid,,135.94,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Amerihealth Caritas,Managed Medicaid,,130.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Amerihealth Caritas,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Amerihealth Caritas,Managed Medicaid,,214.21,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Amerihealth Caritas,Managed Medicaid,,43.04,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Amerihealth Caritas,Managed Medicaid,,83.88,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Amerihealth Caritas,Managed Medicaid,,58.86,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Amerihealth Caritas,Managed Medicaid,,189.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Amerihealth Caritas,Managed Medicaid,,248.25,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Amerihealth Caritas,Managed Medicaid,,120.12,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Amerihealth Caritas,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Amerihealth Caritas,Managed Medicaid,,305.91,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Amerihealth Caritas,Managed Medicaid,,5.61,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Amerihealth Caritas,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Amerihealth Caritas,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Amerihealth Caritas,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Amerihealth Caritas,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Amerihealth Caritas,Managed Medicaid,,232.23,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Amerihealth Caritas,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Amerihealth Caritas,Managed Medicaid,,523.72,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Amerihealth Caritas,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Amerihealth Caritas,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Amerihealth Caritas,Managed Medicaid,,1715.71,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Amerihealth Caritas,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Amerihealth Caritas,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Amerihealth Caritas,Managed Medicaid,,7102.50,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Amerihealth Caritas,Managed Medicaid,,1203.60,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Amerihealth Caritas,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Amerihealth Caritas,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Amerihealth Caritas,Managed Medicaid,,1344.34,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Amerihealth Caritas,Managed Medicaid,,409.01,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Amerihealth Caritas,Managed Medicaid,,674.27,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Amerihealth Caritas,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Amerihealth Caritas,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Amerihealth Caritas,Managed Medicaid,,396.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Amerihealth Caritas,Managed Medicaid,,396.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Amerihealth Caritas,Managed Medicaid,,834.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Amerihealth Caritas,Managed Medicaid,,834.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Amerihealth Caritas,Managed Medicaid,,379.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Amerihealth Caritas,Managed Medicaid,,379.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Amerihealth Caritas,Managed Medicaid,,89.49,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Amerihealth Caritas,Managed Medicaid,,164.76,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Amerihealth Caritas,Managed Medicaid,,359.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Amerihealth Caritas,Managed Medicaid,,359.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Amerihealth Caritas,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Amerihealth Caritas,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Amerihealth Caritas,Managed Medicaid,,317.52,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Amerihealth Caritas,Managed Medicaid,,317.52,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Amerihealth Caritas,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Amerihealth Caritas,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Amerihealth Caritas,Managed Medicaid,,1544.94,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Amerihealth Caritas,Managed Medicaid,,772.37,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Amerihealth Caritas,Managed Medicaid,,772.37,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Amerihealth Caritas,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Amerihealth Caritas,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Amerihealth Caritas,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Amerihealth Caritas,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Amerihealth Caritas,Managed Medicaid,,275.88,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Amerihealth Caritas,Managed Medicaid,,275.88,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Amerihealth Caritas,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Amerihealth Caritas,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Amerihealth Caritas,Managed Medicaid,,532.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Amerihealth Caritas,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Amerihealth Caritas,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Amerihealth Caritas,Managed Medicaid,,158.96,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Amerihealth Caritas,Managed Medicaid,,5817.21,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Amerihealth Caritas,Managed Medicaid,,879.68,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Amerihealth Caritas,Managed Medicaid,,879.68,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Amerihealth Caritas,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Amerihealth Caritas,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Amerihealth Caritas,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Amerihealth Caritas,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Amerihealth Caritas,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Amerihealth Caritas,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Amerihealth Caritas,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Amerihealth Caritas,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Amerihealth Caritas,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Amerihealth Caritas,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Amerihealth Caritas,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Amerihealth Caritas,Managed Medicaid,,4633.03,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Amerihealth Caritas,Managed Medicaid,,4633.03,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Amerihealth Caritas,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Amerihealth Caritas,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Amerihealth Caritas,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Amerihealth Caritas,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Amerihealth Caritas,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Amerihealth Caritas,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Amerihealth Caritas,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Amerihealth Caritas,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Amerihealth Caritas,Managed Medicaid,,2468.07,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Amerihealth Caritas,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Amerihealth Caritas,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Amerihealth Caritas,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Amerihealth Caritas,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Amerihealth Caritas,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Amerihealth Caritas,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Amerihealth Caritas,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Amerihealth Caritas,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Amerihealth Caritas,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Amerihealth Caritas,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Amerihealth Caritas,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Amerihealth Caritas,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Amerihealth Caritas,Managed Medicaid,,4121.72,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Amerihealth Caritas,Managed Medicaid,LM,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Amerihealth Caritas,Managed Medicaid,RI,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Amerihealth Caritas,Managed Medicaid,RC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Amerihealth Caritas,Managed Medicaid,LD,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Amerihealth Caritas,Managed Medicaid,LC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Amerihealth Caritas,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Amerihealth Caritas,Managed Medicaid,RI,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Amerihealth Caritas,Managed Medicaid,RC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Amerihealth Caritas,Managed Medicaid,LD,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Amerihealth Caritas,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Amerihealth Caritas,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Amerihealth Caritas,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,LM,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,RI,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Amerihealth Caritas,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LM,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,RI,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Amerihealth Caritas,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Amerihealth Caritas,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Amerihealth Caritas,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Amerihealth Caritas,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Amerihealth Caritas,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Amerihealth Caritas,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LM,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,RI,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,RC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LD,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Amerihealth Caritas,Managed Medicaid,LC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Amerihealth Caritas,Managed Medicaid,,78.68,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Amerihealth Caritas,Managed Medicaid,,333.13,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Amerihealth Caritas,Managed Medicaid,,373.37,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Amerihealth Caritas,Managed Medicaid,,84.48,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Amerihealth Caritas,Managed Medicaid,,505.91,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Amerihealth Caritas,Managed Medicaid,,197.40,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Amerihealth Caritas,Managed Medicaid,,2316.71,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Amerihealth Caritas,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Amerihealth Caritas,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Amerihealth Caritas,Managed Medicaid,,2044.04,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Amerihealth Caritas,Managed Medicaid,,850.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Amerihealth Caritas,Managed Medicaid,,1474.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Amerihealth Caritas,Managed Medicaid,,2180.78,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Amerihealth Caritas,Managed Medicaid,,1936.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Amerihealth Caritas,Managed Medicaid,,2067.27,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Amerihealth Caritas,Managed Medicaid,,909.51,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Amerihealth Caritas,Managed Medicaid,,2126.92,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Amerihealth Caritas,Managed Medicaid,,2652.85,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Amerihealth Caritas,Managed Medicaid,,2389.79,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Amerihealth Caritas,Managed Medicaid,,2549.35,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Amerihealth Caritas,Managed Medicaid,,2592.59,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Amerihealth Caritas,Managed Medicaid,,3178.58,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Amerihealth Caritas,Managed Medicaid,,1356.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Amerihealth Caritas,Managed Medicaid,,40.64,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Amerihealth Caritas,Managed Medicaid,,19.42,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Amerihealth Caritas,Managed Medicaid,,300.90,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Amerihealth Caritas,Managed Medicaid,,826.43,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Amerihealth Caritas,Managed Medicaid,,1614.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Amerihealth Caritas,Managed Medicaid,,96.90,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Amerihealth Caritas,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Amerihealth Caritas,Managed Medicaid,,43.04,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Amerihealth Caritas,Managed Medicaid,,1535.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Amerihealth Caritas,Managed Medicaid,,7834.43,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Amerihealth Caritas,Managed Medicaid,,2458.86,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Amerihealth Caritas,Managed Medicaid,,505.50,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Amerihealth Caritas,Managed Medicaid,,565.36,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Amerihealth Caritas,Managed Medicaid,,253.45,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Amerihealth Caritas,Managed Medicaid,,105.71,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Amerihealth Caritas,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Amerihealth Caritas,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Amerihealth Caritas,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Amerihealth Caritas,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Amerihealth Caritas,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Amerihealth Caritas,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Amerihealth Caritas,Managed Medicaid,,3657.05,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Amerihealth Caritas,Managed Medicaid,,2656.25,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Amerihealth Caritas,Managed Medicaid,,3018.42,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Amerihealth Caritas,Managed Medicaid,,3642.44,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Amerihealth Caritas,Managed Medicaid,,639.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Amerihealth Caritas,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Amerihealth Caritas,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Amerihealth Caritas,Managed Medicaid,,2045.04,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Amerihealth Caritas,Managed Medicaid,,589.39,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Amerihealth Caritas,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Amerihealth Caritas,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Amerihealth Caritas,Managed Medicaid,,4082.48,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Amerihealth Caritas,Managed Medicaid,,2987.99,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Amerihealth Caritas,Managed Medicaid,,473.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Amerihealth Caritas,Managed Medicaid,,4761.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Amerihealth Caritas,Managed Medicaid,,4909.10,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Amerihealth Caritas,Managed Medicaid,,5350.95,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Amerihealth Caritas,Managed Medicaid,,1703.30,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Amerihealth Caritas,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Amerihealth Caritas,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Amerihealth Caritas,Managed Medicaid,,9987.38,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Amerihealth Caritas,Managed Medicaid,,1151.15,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Amerihealth Caritas,Managed Medicaid,,764.96,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Amerihealth Caritas,Managed Medicaid,,11551.14,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Amerihealth Caritas,Managed Medicaid,,528.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Amerihealth Caritas,Managed Medicaid,,2335.73,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Amerihealth Caritas,Managed Medicaid,,417.62,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Amerihealth Caritas,Managed Medicaid,,838.44,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Amerihealth Caritas,Managed Medicaid,,1297.30,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Amerihealth Caritas,Managed Medicaid,,1297.30,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Amerihealth Caritas,Managed Medicaid,,647.05,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Amerihealth Caritas,Managed Medicaid,,459.46,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Amerihealth Caritas,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Amerihealth Caritas,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Amerihealth Caritas,Managed Medicaid,,609.21,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Amerihealth Caritas,Managed Medicaid,,557.96,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Amerihealth Caritas,Managed Medicaid,,1917.92,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Amerihealth Caritas,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Amerihealth Caritas,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Amerihealth Caritas,Managed Medicaid,,325.12,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Amerihealth Caritas,Managed Medicaid,,1618.42,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Amerihealth Caritas,Managed Medicaid,,331.93,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Amerihealth Caritas,Managed Medicaid,,631.83,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Amerihealth Caritas,Managed Medicaid,,5093.49,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Amerihealth Caritas,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Amerihealth Caritas,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Amerihealth Caritas,Managed Medicaid,,605.61,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Amerihealth Caritas,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Amerihealth Caritas,Managed Medicaid,,4031.43,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Amerihealth Caritas,Managed Medicaid,,4480.68,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Amerihealth Caritas,Managed Medicaid,,496.90,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Amerihealth Caritas,Managed Medicaid,,386.59,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Amerihealth Caritas,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Amerihealth Caritas,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Amerihealth Caritas,Managed Medicaid,,1276.68,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Amerihealth Caritas,Managed Medicaid,,515.51,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Amerihealth Caritas,Managed Medicaid,,2746.94,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Amerihealth Caritas,Managed Medicaid,,960.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Amerihealth Caritas,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Amerihealth Caritas,Managed Medicaid,,425.83,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Amerihealth Caritas,Managed Medicaid,,567.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Amerihealth Caritas,Managed Medicaid,,1594.59,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Amerihealth Caritas,Managed Medicaid,,3708.10,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Amerihealth Caritas,Managed Medicaid,,1846.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Amerihealth Caritas,Managed Medicaid,,1294.69,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Amerihealth Caritas,Managed Medicaid,,1496.70,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Amerihealth Caritas,Managed Medicaid,,57.66,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Amerihealth Caritas,Managed Medicaid,,283.88,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Amerihealth Caritas,Managed Medicaid,,1595.59,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Amerihealth Caritas,Managed Medicaid,,608.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Amerihealth Caritas,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Amerihealth Caritas,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Amerihealth Caritas,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Amerihealth Caritas,Managed Medicaid,,2662.86,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Amerihealth Caritas,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Amerihealth Caritas,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Amerihealth Caritas,Managed Medicaid,,8574.37,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Amerihealth Caritas,Managed Medicaid,,6999.39,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Amerihealth Caritas,Managed Medicaid,,1897.10,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Amerihealth Caritas,Managed Medicaid,,869.87,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Amerihealth Caritas,Managed Medicaid,,4285.48,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Amerihealth Caritas,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Amerihealth Caritas,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Amerihealth Caritas,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Amerihealth Caritas,Managed Medicaid,,6481.07,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Amerihealth Caritas,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Amerihealth Caritas,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Amerihealth Caritas,Managed Medicaid,,21.42,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Amerihealth Caritas,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Amerihealth Caritas,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Amerihealth Caritas,Managed Medicaid,,9598.39,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Amerihealth Caritas,Managed Medicaid,,480.28,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Amerihealth Caritas,Managed Medicaid,,1300.10,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Amerihealth Caritas,Managed Medicaid,,2169.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Amerihealth Caritas,Managed Medicaid,LD,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Amerihealth Caritas,Managed Medicaid,RC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Amerihealth Caritas,Managed Medicaid,RI,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Amerihealth Caritas,Managed Medicaid,LM,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Amerihealth Caritas,Managed Medicaid,LD,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Amerihealth Caritas,Managed Medicaid,RC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Amerihealth Caritas,Managed Medicaid,RI,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Amerihealth Caritas,Managed Medicaid,LM,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Amerihealth Caritas,Managed Medicaid,LD,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Amerihealth Caritas,Managed Medicaid,RC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Amerihealth Caritas,Managed Medicaid,RI,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Amerihealth Caritas,Managed Medicaid,LM,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,LD,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,RC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,RI,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,LM,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Amerihealth Caritas,Managed Medicaid,LC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Amerihealth Caritas,Managed Medicaid,LC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Amerihealth Caritas,Managed Medicaid,LC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Amerihealth Caritas,Managed Medicaid,LC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Amerihealth Caritas,Managed Medicaid,,6528.72,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Amerihealth Caritas,Managed Medicaid,,12359.75,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Amerihealth Caritas,Managed Medicaid,,2282.88,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Amerihealth Caritas,Managed Medicaid,,570.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Amerihealth Caritas,Managed Medicaid,,115.11,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Amerihealth Caritas,Managed Medicaid,,805.00,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Amerihealth Caritas,Managed Medicaid,,661.46,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Amerihealth Caritas,Managed Medicaid,,258.26,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Amerihealth Caritas,Managed Medicaid,,312.91,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Amerihealth Caritas,Managed Medicaid,,231.63,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Amerihealth Caritas,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Amerihealth Caritas,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Amerihealth Caritas,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Amerihealth Caritas,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Amerihealth Caritas,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Amerihealth Caritas,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Amerihealth Caritas,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Amerihealth Caritas,Managed Medicaid,,99.30,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Amerihealth Caritas,Managed Medicaid,,77.08,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Amerihealth Caritas,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Amerihealth Caritas,Managed Medicaid,,11.01,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Amerihealth Caritas,Managed Medicaid,,273.87,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Amerihealth Caritas,Managed Medicaid,,48.65,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Amerihealth Caritas,Managed Medicaid,,175.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Amerihealth Caritas,Managed Medicaid,,124.52,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Amerihealth Caritas,Managed Medicaid,,32.43,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Amerihealth Caritas,Managed Medicaid,,38.64,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Amerihealth Caritas,Managed Medicaid,,255.46,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Amerihealth Caritas,Managed Medicaid,,57.06,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Amerihealth Caritas,Managed Medicaid,,43.64,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Amerihealth Caritas,Managed Medicaid,,59.46,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Amerihealth Caritas,Managed Medicaid,,21.82,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Amerihealth Caritas,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Amerihealth Caritas,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Amerihealth Caritas,Managed Medicaid,,1301.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Amerihealth Caritas,Managed Medicaid,,725.52,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Amerihealth Caritas,Managed Medicaid,,1598.40,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Amerihealth Caritas,Managed Medicaid,,521.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Amerihealth Caritas,Managed Medicaid,,422.62,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Amerihealth Caritas,Managed Medicaid,,422.62,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Amerihealth Caritas,Managed Medicaid,,422.62,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Amerihealth Caritas,Managed Medicaid,,1276.28,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Amerihealth Caritas,Managed Medicaid,,1690.29,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Amerihealth Caritas,Managed Medicaid,,1897.30,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Amerihealth Caritas,Managed Medicaid,,1567.77,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Amerihealth Caritas,Managed Medicaid,,2031.83,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Amerihealth Caritas,Managed Medicaid,,2263.86,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Amerihealth Caritas,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Amerihealth Caritas,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Amerihealth Caritas,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Amerihealth Caritas,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Amerihealth Caritas,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Amerihealth Caritas,Managed Medicaid,,48.05,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Amerihealth Caritas,Managed Medicaid,,74.87,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Amerihealth Caritas,Managed Medicaid,,264.26,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Amerihealth Caritas,Managed Medicaid,,285.29,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Amerihealth Caritas,Managed Medicaid,,446.85,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Amerihealth Caritas,Managed Medicaid,,58.66,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Amerihealth Caritas,Managed Medicaid,,134.53,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Amerihealth Caritas,Managed Medicaid,,20.82,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Amerihealth Caritas,Managed Medicaid,,203.40,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Amerihealth Caritas,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Amerihealth Caritas,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Amerihealth Caritas,Managed Medicaid,,38.44,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Amerihealth Caritas,Managed Medicaid,,633.03,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Amerihealth Caritas,Managed Medicaid,,60.46,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Amerihealth Caritas,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Amerihealth Caritas,Managed Medicaid,,61.86,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Amerihealth Caritas,Managed Medicaid,,57.06,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Amerihealth Caritas,Managed Medicaid,,68.27,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Amerihealth Caritas,Managed Medicaid,,86.49,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Amerihealth Caritas,Managed Medicaid,,123.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Amerihealth Caritas,Managed Medicaid,,8.81,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Amerihealth Caritas,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Amerihealth Caritas,Managed Medicaid,,14.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Amerihealth Caritas,Managed Medicaid,,44.24,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Amerihealth Caritas,Managed Medicaid,,80.48,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Amerihealth Caritas,Managed Medicaid,,178.18,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Amerihealth Caritas,Managed Medicaid,,14.81,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Amerihealth Caritas,Managed Medicaid,,10.81,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Amerihealth Caritas,Managed Medicaid,,53.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Amerihealth Caritas,Managed Medicaid,,8.01,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Amerihealth Caritas,Managed Medicaid,,150.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Amerihealth Caritas,Managed Medicaid,,235.24,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Amerihealth Caritas,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Amerihealth Caritas,Managed Medicaid,,245.04,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Amerihealth Caritas,Managed Medicaid,,359.16,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Amerihealth Caritas,Managed Medicaid,,454.25,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Amerihealth Caritas,Managed Medicaid,,98.50,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Amerihealth Caritas,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Amerihealth Caritas,Managed Medicaid,,140.14,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Amerihealth Caritas,Managed Medicaid,,156.16,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Amerihealth Caritas,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Amerihealth Caritas,Managed Medicaid,,319.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Amerihealth Caritas,Managed Medicaid,,514.31,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Amerihealth Caritas,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Amerihealth Caritas,Managed Medicaid,,800.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Amerihealth Caritas,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Amerihealth Caritas,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Amerihealth Caritas,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Amerihealth Caritas,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Amerihealth Caritas,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Amerihealth Caritas,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Amerihealth Caritas,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Amerihealth Caritas,Managed Medicaid,GP,47.65,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Amerihealth Caritas,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Amerihealth Caritas,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Amerihealth Caritas,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Amerihealth Caritas,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Amerihealth Caritas,Managed Medicaid,,2600.00,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Amerihealth Caritas,Managed Medicaid,,2657.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Amerihealth Caritas,Managed Medicaid,,2714.71,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Amerihealth Caritas,Managed Medicaid,,2772.37,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Amerihealth Caritas,Managed Medicaid,,2829.83,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Amerihealth Caritas,Managed Medicaid,,2887.08,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Amerihealth Caritas,Managed Medicaid,,2944.54,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Amerihealth Caritas,Managed Medicaid,,3002.00,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Amerihealth Caritas,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Amerihealth Caritas,Managed Medicaid,,49.25,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Amerihealth Caritas,Managed Medicaid,,40.04,,,,,,,34.82,150.00,percent of total billed charges,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,BCBS NC,Blue Select/HMO/PPO,,0.04115,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,38.21,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,7.35,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,36.15,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,36.15,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,BCBS NC,Blue Select/HMO/PPO,,6.49,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Select/HMO/PPO,,41.73,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Select/HMO/PPO,,11629.62,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Select/HMO/PPO,,4997.48,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.29684,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Select/HMO/PPO,,563.99,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Select/HMO/PPO,,2131.36,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Select/HMO/PPO,,509.62,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Select/HMO/PPO,,968.40,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Select/HMO/PPO,,11820.66,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Select/HMO/PPO,,3678.75,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Select/HMO/PPO,,3268.17,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Select/HMO/PPO,,4603.94,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Select/HMO/PPO,,9280.77,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,775.60,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Select/HMO/PPO,,3267.29,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Select/HMO/PPO,,4714.74,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,792.35,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Select/HMO/PPO,,2458.77,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Select/HMO/PPO,,2621.59,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Select/HMO/PPO,,3314.31,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,38.79,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,133.72,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,267.74,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,BCBS NC,Blue Select/HMO/PPO,,9.19,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,BCBS NC,Blue Select/HMO/PPO,,5.98,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,BCBS NC,Blue Select/HMO/PPO,,81.99,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,BCBS NC,Blue Select/HMO/PPO,,6.36,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,BCBS NC,Blue Select/HMO/PPO,,0.00882,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,BCBS NC,Blue Select/HMO/PPO,,6.30,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,BCBS NC,Blue Select/HMO/PPO,,11.94,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,BCBS NC,Blue Select/HMO/PPO,,5.99,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,BCBS NC,Blue Select/HMO/PPO,,5.85,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,290.37,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Select/HMO/PPO,,19.18,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,BCBS NC,Blue Select/HMO/PPO,,52.38,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Select/HMO/PPO,,4553.98,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,BCBS NC,Blue Select/HMO/PPO,,1.86,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,53.49,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,58.78,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,58.78,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.71,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,362.97,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,308.01,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,207.79,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,161.65,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,129.90,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,136.96,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,362.97,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,308.01,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,207.79,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,161.65,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,129.90,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,136.96,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,BCBS NC,Blue Select/HMO/PPO,,8.07,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,167.82,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,77.00,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,725.64,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,205.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,205.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,180.75,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,180.75,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,117.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,117.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Select/HMO/PPO,,694.49,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,167.82,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,77.00,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,91.99,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,91.99,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,462.89,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,462.89,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,367.96,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,367.96,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,188.39,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,188.39,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,99.93,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,99.93,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,79.94,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,79.94,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,BCBS NC,Blue Select/HMO/PPO,,63.53,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,267.74,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,133.72,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Select/HMO/PPO,,1524.46,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,BCBS NC,Blue Select/HMO/PPO,,45.20,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Select/HMO/PPO,,752.97,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,290.37,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,BCBS NC,Blue Select/HMO/PPO,,256.32,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,BCBS NC,Blue Select/HMO/PPO,,314.54,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,BCBS NC,Blue Select/HMO/PPO,,0.64070,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Select/HMO/PPO,,610.72,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,809.40,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,357.38,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,181.04,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,809.40,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,357.38,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,181.04,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,826.74,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,BCBS NC,Blue Select/HMO/PPO,,0.91109,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,BCBS NC,Blue Select/HMO/PPO,,2.89,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,BCBS NC,Blue Select/HMO/PPO,,56.61,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,BCBS NC,Blue Select/HMO/PPO,,19.52,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,36.15,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,BCBS NC,Blue Select/HMO/PPO,,69.86,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,BCBS NC,Blue Select/HMO/PPO,,80.50,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,BCBS NC,Blue Select/HMO/PPO,,46.64,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,100.51,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,100.51,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,454.37,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Select/HMO/PPO,,909.33,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,454.37,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,BCBS NC,Blue Select/HMO/PPO,,97.10,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,BCBS NC,Blue Select/HMO/PPO,,96.78,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,BCBS NC,Blue Select/HMO/PPO,,45.01,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,BCBS NC,Blue Select/HMO/PPO,,46.68,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,125.79,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,125.79,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,2.94,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,BCBS NC,Blue Select/HMO/PPO,,0.03527,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,BCBS NC,Blue Select/HMO/PPO,,0.07935,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,734.16,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,734.16,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,595.15,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,595.15,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,501.98,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,501.98,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,BCBS NC,Blue Select/HMO/PPO,,94.72,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,BCBS NC,Blue Select/HMO/PPO,,23.84,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,BCBS NC,Blue Select/HMO/PPO,,15.73,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,BCBS NC,Blue Select/HMO/PPO,,37.04,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,BCBS NC,Blue Select/HMO/PPO,,9.07,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,BCBS NC,Blue Select/HMO/PPO,,34.32,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,BCBS NC,Blue Select/HMO/PPO,,9.89,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,BCBS NC,Blue Select/HMO/PPO,,28.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,BCBS NC,Blue Select/HMO/PPO,,80.83,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,BCBS NC,Blue Select/HMO/PPO,,12.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,BCBS NC,Blue Select/HMO/PPO,,15.11,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,BCBS NC,Blue Select/HMO/PPO,,48.81,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,BCBS NC,Blue Select/HMO/PPO,,37.85,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,BCBS NC,Blue Select/HMO/PPO,,45.31,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,BCBS NC,Blue Select/HMO/PPO,,43.01,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,BCBS NC,Blue Select/HMO/PPO,,7.68,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,BCBS NC,Blue Select/HMO/PPO,,8.39,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,BCBS NC,Blue Select/HMO/PPO,,20.00,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,BCBS NC,Blue Select/HMO/PPO,,41.37,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,BCBS NC,Blue Select/HMO/PPO,,0.14989,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,BCBS NC,Blue Select/HMO/PPO,,7.71,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,BCBS NC,Blue Select/HMO/PPO,,1.74,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,BCBS NC,Blue Select/HMO/PPO,,3.09,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,BCBS NC,Blue Select/HMO/PPO,,0.03233,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,BCBS NC,Blue Select/HMO/PPO,,0.23512,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,BCBS NC,Blue Select/HMO/PPO,,2.28,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,BCBS NC,Blue Select/HMO/PPO,,0.23218,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,BCBS NC,Blue Select/HMO/PPO,,0.13813,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,BCBS NC,Blue Select/HMO/PPO,,0.18810,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,BCBS NC,Blue Select/HMO/PPO,,489.87,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00588,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,BCBS NC,Blue Select/HMO/PPO,,0.02645,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,BCBS NC,Blue Select/HMO/PPO,,0.75532,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,BCBS NC,Blue Select/HMO/PPO,,7.57,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,BCBS NC,Blue Select/HMO/PPO,,23.94,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,BCBS NC,Blue Select/HMO/PPO,,0.02057,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,1.25,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,BCBS NC,Blue Select/HMO/PPO,,1.80,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,BCBS NC,Blue Select/HMO/PPO,,0.32917,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,BCBS NC,Blue Select/HMO/PPO,,0.47318,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,BCBS NC,Blue Select/HMO/PPO,,0.75238,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,BCBS NC,Blue Select/HMO/PPO,,0.52608,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00588,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.50,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,BCBS NC,Blue Select/HMO/PPO,,323.50,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,BCBS NC,Blue Select/HMO/PPO,,22.64,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,BCBS NC,Blue Select/HMO/PPO,,39.65,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,BCBS NC,Blue Select/HMO/PPO,,48.91,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,BCBS NC,Blue Select/HMO/PPO,,0.03821,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,BCBS NC,Blue Select/HMO/PPO,,10.68,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Select/HMO/PPO,,19.18,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,BCBS NC,Blue Select/HMO/PPO,,42.29,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,BCBS NC,Blue Select/HMO/PPO,,18.68,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,BCBS NC,Blue Select/HMO/PPO,,73.20,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,BCBS NC,Blue Select/HMO/PPO,,3.30,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,BCBS NC,Blue Select/HMO/PPO,,7.49,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,BCBS NC,Blue Select/HMO/PPO,,0.22043,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,BCBS NC,Blue Select/HMO/PPO,,0.01176,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,BCBS NC,Blue Select/HMO/PPO,,4.44,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,BCBS NC,Blue Select/HMO/PPO,,3.92,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,BCBS NC,Blue Select/HMO/PPO,,3.49,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,BCBS NC,Blue Select/HMO/PPO,,5.20,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,BCBS NC,Blue Select/HMO/PPO,,9.80,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,BCBS NC,Blue Select/HMO/PPO,,16.15,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,BCBS NC,Blue Select/HMO/PPO,,40.90,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,BCBS NC,Blue Select/HMO/PPO,,161.26,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,BCBS NC,Blue Select/HMO/PPO,,92.95,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,BCBS NC,Blue Select/HMO/PPO,,109.11,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,24.38,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,19.07,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,19.07,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,13.96,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.35268,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Select/HMO/PPO,,861.05,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Select/HMO/PPO,,5716.90,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.38,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.88,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,24.72,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,BCBS NC,Blue Select/HMO/PPO,,103.07,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,BCBS NC,Blue Select/HMO/PPO,,113.31,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Select/HMO/PPO,,5.70,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,BCBS NC,Blue Select/HMO/PPO,,1041.58,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,BCBS NC,Blue Select/HMO/PPO,,89.42,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,BCBS NC,Blue Select/HMO/PPO,,12.77,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.78,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,BCBS NC,Blue Select/HMO/PPO,,709.56,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.30,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,BCBS NC,Blue Select/HMO/PPO,,138.59,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.95,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,BCBS NC,Blue Select/HMO/PPO,,1534.28,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.95,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,BCBS NC,Blue Select/HMO/PPO,,23.48,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,BCBS NC,Blue Select/HMO/PPO,,9.89,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,BCBS NC,Blue Select/HMO/PPO,,10.24,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.81,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,BCBS NC,Blue Select/HMO/PPO,,5.83,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,BCBS NC,Blue Select/HMO/PPO,,7.41,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,BCBS NC,Blue Select/HMO/PPO,,23.60,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,BCBS NC,Blue Select/HMO/PPO,,9.52,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.99,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,8.43,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,BCBS NC,Blue Select/HMO/PPO,,0.66127,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,BCBS NC,Blue Select/HMO/PPO,,128.35,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,BCBS NC,Blue Select/HMO/PPO,,219.90,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,BCBS NC,Blue Select/HMO/PPO,,671.43,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,64.36,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,64.36,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,64.36,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.44085,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,BCBS NC,Blue Select/HMO/PPO,,14.53,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,BCBS NC,Blue Select/HMO/PPO,,16.91,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,BCBS NC,Blue Select/HMO/PPO,,167.08,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,BCBS NC,Blue Select/HMO/PPO,,6.41,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,BCBS NC,Blue Select/HMO/PPO,,7.24,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,BCBS NC,Blue Select/HMO/PPO,,2.06,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.38,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,BCBS NC,Blue Select/HMO/PPO,,0.76414,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.30,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.41,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,BCBS NC,Blue Select/HMO/PPO,,7.86,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,9.08,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.99,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,BCBS NC,Blue Select/HMO/PPO,,13.97,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,BCBS NC,Blue Select/HMO/PPO,,8.63,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,9.51,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,BCBS NC,Blue Select/HMO/PPO,,805.68,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,5.22,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.92,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,BCBS NC,Blue Select/HMO/PPO,,11.99,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,BCBS NC,Blue Select/HMO/PPO,,540.66,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,5.10,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,5.22,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,BCBS NC,Blue Select/HMO/PPO,,9.63,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,BCBS NC,Blue Select/HMO/PPO,,72.56,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,0.48494,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,6.82,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,BCBS NC,Blue Select/HMO/PPO,,6.69,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,BCBS NC,Blue Select/HMO/PPO,,5972.71,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,9.40,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.42616,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,BCBS NC,Blue Select/HMO/PPO,,46.39,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,BCBS NC,Blue Select/HMO/PPO,,88.43,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,727.40,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,BCBS NC,Blue Select/HMO/PPO,,20.66,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,BCBS NC,Blue Select/HMO/PPO,,24.92,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Select/HMO/PPO,,11.08,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Select/HMO/PPO,,13.55,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,BCBS NC,Blue Select/HMO/PPO,,227.58,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,BCBS NC,Blue Select/HMO/PPO,,14.94,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,BCBS NC,Blue Select/HMO/PPO,,20.24,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,BCBS NC,Blue Select/HMO/PPO,,19.59,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,BCBS NC,Blue Select/HMO/PPO,,21.23,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,BCBS NC,Blue Select/HMO/PPO,,11.65,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,BCBS NC,Blue Select/HMO/PPO,,8.27,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,BCBS NC,Blue Select/HMO/PPO,,17880.02,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Select/HMO/PPO,,234.55,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,BCBS NC,Blue Select/HMO/PPO,,46.54,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Select/HMO/PPO,,67.93,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,BCBS NC,Blue Select/HMO/PPO,,152.90,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,5.76,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.94,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,BCBS NC,Blue Select/HMO/PPO,,8.36,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,BCBS NC,Blue Select/HMO/PPO,,14.67,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,BCBS NC,Blue Select/HMO/PPO,,17.99,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,BCBS NC,Blue Select/HMO/PPO,,24.64,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,BCBS NC,Blue Select/HMO/PPO,,31.29,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,BCBS NC,Blue Select/HMO/PPO,,37.93,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,BCBS NC,Blue Select/HMO/PPO,,22.37,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Select/HMO/PPO,,6.23,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,BCBS NC,Blue Select/HMO/PPO,,363.08,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,BCBS NC,Blue Select/HMO/PPO,,688.03,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,BCBS NC,Blue Select/HMO/PPO,,2.50,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,50.26,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,BCBS NC,Blue Select/HMO/PPO,,6.05,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,BCBS NC,Blue Select/HMO/PPO,,10.89,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,BCBS NC,Blue Select/HMO/PPO,,10.95,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,BCBS NC,Blue Select/HMO/PPO,,20.59,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,36.15,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,BCBS NC,Blue Select/HMO/PPO,,898.08,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Select/HMO/PPO,,1715.33,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,BCBS NC,Blue Select/HMO/PPO,,395.41,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,6.32,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,18.97,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,BCBS NC,Blue Select/HMO/PPO,,10.46,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,BCBS NC,Blue Select/HMO/PPO,,9.80,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,BCBS NC,Blue Select/HMO/PPO,,10.01,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,8.60,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,8.60,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,BCBS NC,Blue Select/HMO/PPO,,711.44,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,BCBS NC,Blue Select/HMO/PPO,,1904.18,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,BCBS NC,Blue Select/HMO/PPO,,49.38,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,BCBS NC,Blue Select/HMO/PPO,,8.10,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,BCBS NC,Blue Select/HMO/PPO,,18.72,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.44085,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.42616,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,BCBS NC,Blue Select/HMO/PPO,,8.08,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,BCBS NC,Blue Select/HMO/PPO,,9.24,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,BCBS NC,Blue Select/HMO/PPO,,46.26,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,6.89,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,BCBS NC,Blue Select/HMO/PPO,,30.26,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,BCBS NC,Blue Select/HMO/PPO,,171.95,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,BCBS NC,Blue Select/HMO/PPO,,53.17,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,BCBS NC,Blue Select/HMO/PPO,,76.50,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Select/HMO/PPO,,60.31,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,336.32,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Select/HMO/PPO,,5.35,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,BCBS NC,Blue Select/HMO/PPO,,29.67,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,BCBS NC,Blue Select/HMO/PPO,,52.46,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,BCBS NC,Blue Select/HMO/PPO,,154.43,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,0.45554,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,BCBS NC,Blue Select/HMO/PPO,,29.73,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,BCBS NC,Blue Select/HMO/PPO,,77.35,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,BCBS NC,Blue Select/HMO/PPO,,77.35,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,BCBS NC,Blue Select/HMO/PPO,,259.07,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,BCBS NC,Blue Select/HMO/PPO,,17.19,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,BCBS NC,Blue Select/HMO/PPO,,263.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,BCBS NC,Blue Select/HMO/PPO,,418.72,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,BCBS NC,Blue Select/HMO/PPO,,625.73,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,BCBS NC,Blue Select/HMO/PPO,,1039.73,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,BCBS NC,Blue Select/HMO/PPO,,2074.76,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,BCBS NC,Blue Select/HMO/PPO,,3109.79,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,BCBS NC,Blue Select/HMO/PPO,,498.20,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,BCBS NC,Blue Select/HMO/PPO,,2423.59,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,BCBS NC,Blue Select/HMO/PPO,,9451.84,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Select/HMO/PPO,,1657.67,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Select/HMO/PPO,,3296.81,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Select/HMO/PPO,,93.71,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Select/HMO/PPO,,93.71,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,BCBS NC,Blue Select/HMO/PPO,,2588.33,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,BCBS NC,Blue Select/HMO/PPO,,24.48,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,BCBS NC,Blue Select/HMO/PPO,,29.79,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,BCBS NC,Blue Select/HMO/PPO,,45.25,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,BCBS NC,Blue Select/HMO/PPO,,6.86,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,BCBS NC,Blue Select/HMO/PPO,,34.06,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,BCBS NC,Blue Select/HMO/PPO,,41.72,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,BCBS NC,Blue Select/HMO/PPO,,260.01,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.41146,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Select/HMO/PPO,,11790.06,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Select/HMO/PPO,,46917.64,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,BCBS NC,Blue Select/HMO/PPO,,289.64,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.58780,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.51433,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,0.49963,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,0.47024,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,BCBS NC,Blue Select/HMO/PPO,,29.58,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,BCBS NC,Blue Select/HMO/PPO,,56.96,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,BCBS NC,Blue Select/HMO/PPO,,3897.31,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,31.15,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,BCBS NC,Blue Select/HMO/PPO,,4.04,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,BCBS NC,Blue Select/HMO/PPO,,659.91,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,BCBS NC,Blue Select/HMO/PPO,,25.29,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,BCBS NC,Blue Select/HMO/PPO,,208.64,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,BCBS NC,Blue Select/HMO/PPO,,62.84,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,BCBS NC,Blue Select/HMO/PPO,,17.81,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,28.14,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,BCBS NC,Blue Select/HMO/PPO,,54.21,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,BCBS NC,Blue Select/HMO/PPO,,66.04,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,BCBS NC,Blue Select/HMO/PPO,,17.71,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,310.65,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.42616,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.81,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.35268,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,BCBS NC,Blue Select/HMO/PPO,,0.91109,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,BCBS NC,Blue Select/HMO/PPO,,23.56,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Select/HMO/PPO,,22.73,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,BCBS NC,Blue Select/HMO/PPO,,22.42,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Select/HMO/PPO,,22.73,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,29.83,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,30.86,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,BCBS NC,Blue Select/HMO/PPO,,138.60,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.38,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,BCBS NC,Blue Select/HMO/PPO,,82.81,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.67,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,BCBS NC,Blue Select/HMO/PPO,,16472.67,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,16.16,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,BCBS NC,Blue Select/HMO/PPO,,1312.15,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,16.16,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,BCBS NC,Blue Select/HMO/PPO,,20.75,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,BCBS NC,Blue Select/HMO/PPO,,7.92,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.44085,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,BCBS NC,Blue Select/HMO/PPO,,9.23,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.67,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,BCBS NC,Blue Select/HMO/PPO,,19.91,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,8.76,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,BCBS NC,Blue Select/HMO/PPO,,327.38,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,BCBS NC,Blue Select/HMO/PPO,,537.84,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,BCBS NC,Blue Select/HMO/PPO,,92.90,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,BCBS NC,Blue Select/HMO/PPO,,139.40,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,28.14,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,28.14,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,BCBS NC,Blue Select/HMO/PPO,,208.74,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,8.45,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,6.89,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,166.05,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,BCBS NC,Blue Select/HMO/PPO,,352.20,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,BCBS NC,Blue Select/HMO/PPO,,1.20,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,BCBS NC,Blue Select/HMO/PPO,,167.17,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,32.92,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,BCBS NC,Blue Select/HMO/PPO,,49.38,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Select/HMO/PPO,,60.31,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,BCBS NC,Blue Select/HMO/PPO,,179.18,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,BCBS NC,Blue Select/HMO/PPO,,46.83,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,25.57,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,1.26,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,BCBS NC,Blue Select/HMO/PPO,,6.20,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.95,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,8.45,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,8.45,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,10.05,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,BCBS NC,Blue Select/HMO/PPO,,36.30,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,BCBS NC,Blue Select/HMO/PPO,,36.71,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,BCBS NC,Blue Select/HMO/PPO,,14.36,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,BCBS NC,Blue Select/HMO/PPO,,18.21,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,BCBS NC,Blue Select/HMO/PPO,,9.27,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,22.79,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,111.68,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,BCBS NC,Blue Select/HMO/PPO,,267.54,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,BCBS NC,Blue Select/HMO/PPO,,49.30,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,BCBS NC,Blue Select/HMO/PPO,,94.11,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,25.92,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,BCBS NC,Blue Select/HMO/PPO,,177.53,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,BCBS NC,Blue Select/HMO/PPO,,7466.40,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,BCBS NC,Blue Select/HMO/PPO,,545.07,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,,6.17,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,BCBS NC,Blue Select/HMO/PPO,,282.69,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,BCBS NC,Blue Select/HMO/PPO,,7.33,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,24.88,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,BCBS NC,Blue Select/HMO/PPO,,10.60,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,BCBS NC,Blue Select/HMO/PPO,,485.29,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,BCBS NC,Blue Select/HMO/PPO,,8900.82,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,BCBS NC,Blue Select/HMO/PPO,,9.30,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,BCBS NC,Blue Select/HMO/PPO,,15.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,BCBS NC,Blue Select/HMO/PPO,,11.18,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,BCBS NC,Blue Select/HMO/PPO,,14.14,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,BCBS NC,Blue Select/HMO/PPO,,21.18,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,BCBS NC,Blue Select/HMO/PPO,,22.75,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,BCBS NC,Blue Select/HMO/PPO,,54.56,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,BCBS NC,Blue Select/HMO/PPO,,6.02,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,6.55,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,BCBS NC,Blue Select/HMO/PPO,,94.21,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,BCBS NC,Blue Select/HMO/PPO,,128.73,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Select/HMO/PPO,,4654.98,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,31.58,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,BCBS NC,Blue Select/HMO/PPO,,606.46,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,BCBS NC,Blue Select/HMO/PPO,,807.05,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.74,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,BCBS NC,Blue Select/HMO/PPO,,57.66,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.32,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,BCBS NC,Blue Select/HMO/PPO,,0.79353,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,17.63,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,9.46,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,6.55,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,BCBS NC,Blue Select/HMO/PPO,,25.73,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,BCBS NC,Blue Select/HMO/PPO,,33.86,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.38207,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,BCBS NC,Blue Select/HMO/PPO,,14.61,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,BCBS NC,Blue Select/HMO/PPO,,10.61,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,BCBS NC,Blue Select/HMO/PPO,,43.48,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,0.45554,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.51433,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.81,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,BCBS NC,Blue Select/HMO/PPO,,60.85,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Select/HMO/PPO,,7.23,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,BCBS NC,Blue Select/HMO/PPO,,9.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,BCBS NC,Blue Select/HMO/PPO,,161.97,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,BCBS NC,Blue Select/HMO/PPO,,7.88,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,7.04,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,BCBS NC,Blue Select/HMO/PPO,,8.66,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,BCBS NC,Blue Select/HMO/PPO,,12.67,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,15.71,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,BCBS NC,Blue Select/HMO/PPO,,17.88,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,BCBS NC,Blue Select/HMO/PPO,,52.46,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,BCBS NC,Blue Select/HMO/PPO,,149.33,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,BCBS NC,Blue Select/HMO/PPO,,15.61,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,BCBS NC,Blue Select/HMO/PPO,,7.26,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,8.76,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,BCBS NC,Blue Select/HMO/PPO,,8.20,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,BCBS NC,Blue Select/HMO/PPO,,50.02,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,105.00,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Select/HMO/PPO,,339.76,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,BCBS NC,Blue Select/HMO/PPO,,2.53,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,BCBS NC,Blue Select/HMO/PPO,,34757.11,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,BCBS NC,Blue Select/HMO/PPO,,36.87,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,BCBS NC,Blue Select/HMO/PPO,,220.67,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,2.94,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,BCBS NC,Blue Select/HMO/PPO,,4.39,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,BCBS NC,Blue Select/HMO/PPO,,22.53,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,BCBS NC,Blue Select/HMO/PPO,,1.57,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,5.06,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,BCBS NC,Blue Select/HMO/PPO,,11.80,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,BCBS NC,Blue Select/HMO/PPO,,13.14,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,BCBS NC,Blue Select/HMO/PPO,,10.70,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Select/HMO/PPO,,24.95,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,BCBS NC,Blue Select/HMO/PPO,,24.91,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Select/HMO/PPO,,24.95,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,24.38,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,BCBS NC,Blue Select/HMO/PPO,,309.29,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,BCBS NC,Blue Select/HMO/PPO,,1584.11,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,BCBS NC,Blue Select/HMO/PPO,,1068.86,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,BCBS NC,Blue Select/HMO/PPO,,9.73,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,BCBS NC,Blue Select/HMO/PPO,,4633.33,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,BCBS NC,Blue Select/HMO/PPO,,0.85231,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,BCBS NC,Blue Select/HMO/PPO,,6.19,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,BCBS NC,Blue Select/HMO/PPO,,126.61,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,BCBS NC,Blue Select/HMO/PPO,,69.51,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,19.07,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,31.74,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,BCBS NC,Blue Select/HMO/PPO,,3.64,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,BCBS NC,Blue Select/HMO/PPO,,42.40,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,85.17,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,BCBS NC,Blue Select/HMO/PPO,,785.80,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,25.72,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,BCBS NC,Blue Select/HMO/PPO,,2.87,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,BCBS NC,Blue Select/HMO/PPO,,980.57,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,9.08,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Select/HMO/PPO,,100.75,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,BCBS NC,Blue Select/HMO/PPO,,240.47,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,BCBS NC,Blue Select/HMO/PPO,,93.96,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,BCBS NC,Blue Select/HMO/PPO,,289.46,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,7.38,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,BCBS NC,Blue Select/HMO/PPO,,399.92,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,25.72,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,BCBS NC,Blue Select/HMO/PPO,,63.88,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,BCBS NC,Blue Select/HMO/PPO,,11.29,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,BCBS NC,Blue Select/HMO/PPO,,11.52,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,BCBS NC,Blue Select/HMO/PPO,,1836.23,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Select/HMO/PPO,,5.53,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Select/HMO/PPO,,6.11,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,BCBS NC,Blue Select/HMO/PPO,,2793.34,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,BCBS NC,Blue Select/HMO/PPO,,1.13,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Select/HMO/PPO,,13.36,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,77.00,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,BCBS NC,Blue Select/HMO/PPO,,103.60,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,BCBS NC,Blue Select/HMO/PPO,,3.19,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,BCBS NC,Blue Select/HMO/PPO,,87.76,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,0.48494,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.41146,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,0.47024,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,BCBS NC,Blue Select/HMO/PPO,,13.61,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,BCBS NC,Blue Select/HMO/PPO,,64.26,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,BCBS NC,Blue Select/HMO/PPO,,52.73,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,BCBS NC,Blue Select/HMO/PPO,,29.33,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.38207,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,BCBS NC,Blue Select/HMO/PPO,,45.83,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Select/HMO/PPO,,11.86,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.47,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,BCBS NC,Blue Select/HMO/PPO,,19.03,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,BCBS NC,Blue Select/HMO/PPO,,3519.81,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,BCBS NC,Blue Select/HMO/PPO,,16.94,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,10.05,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,BCBS NC,Blue Select/HMO/PPO,,23.66,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,BCBS NC,Blue Select/HMO/PPO,,2856.36,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,BCBS NC,Blue Select/HMO/PPO,,73.45,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.38207,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,BCBS NC,Blue Select/HMO/PPO,,2.16,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,BCBS NC,Blue Select/HMO/PPO,,40.51,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,BCBS NC,Blue Select/HMO/PPO,,5.44,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,BCBS NC,Blue Select/HMO/PPO,,23.73,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,BCBS NC,Blue Select/HMO/PPO,,25.28,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,52.90,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,BCBS NC,Blue Select/HMO/PPO,,28.55,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Select/HMO/PPO,,5716.90,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,BCBS NC,Blue Select/HMO/PPO,,46.74,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,BCBS NC,Blue Select/HMO/PPO,,27.58,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,BCBS NC,Blue Select/HMO/PPO,,20.71,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,21.85,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,21.85,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,BCBS NC,Blue Select/HMO/PPO,,24.70,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,BCBS NC,Blue Select/HMO/PPO,,3.47,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.30,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Select/HMO/PPO,,7.08,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,BCBS NC,Blue Select/HMO/PPO,,3.25,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,BCBS NC,Blue Select/HMO/PPO,,2409.95,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,5.92,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.92,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,BCBS NC,Blue Select/HMO/PPO,,18.13,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,BCBS NC,Blue Select/HMO/PPO,,109.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,BCBS NC,Blue Select/HMO/PPO,,56.59,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,BCBS NC,Blue Select/HMO/PPO,,20.68,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,BCBS NC,Blue Select/HMO/PPO,,19.49,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.92,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.92,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,6.54,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,5.33,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.81,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,BCBS NC,Blue Select/HMO/PPO,,33.18,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,BCBS NC,Blue Select/HMO/PPO,,38.84,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.41146,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,BCBS NC,Blue Select/HMO/PPO,,26.50,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,BCBS NC,Blue Select/HMO/PPO,,43.69,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,BCBS NC,Blue Select/HMO/PPO,,13.09,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,BCBS NC,Blue Select/HMO/PPO,,30.65,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,BCBS NC,Blue Select/HMO/PPO,,5.95,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,BCBS NC,Blue Select/HMO/PPO,,101.69,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,BCBS NC,Blue Select/HMO/PPO,,371.46,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,BCBS NC,Blue Select/HMO/PPO,,6.77,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,BCBS NC,Blue Select/HMO/PPO,,133.08,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,BCBS NC,Blue Select/HMO/PPO,,266.80,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.51433,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,0.49963,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,BCBS NC,Blue Select/HMO/PPO,,2.62,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.47,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,BCBS NC,Blue Select/HMO/PPO,,70.73,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.78,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,BCBS NC,Blue Select/HMO/PPO,,27.79,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,BCBS NC,Blue Select/HMO/PPO,,8.32,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,BCBS NC,Blue Select/HMO/PPO,,39.60,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Select/HMO/PPO,,41.66,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,BCBS NC,Blue Select/HMO/PPO,,12.86,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,BCBS NC,Blue Select/HMO/PPO,,102.47,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,6.16,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,5.51,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Select/HMO/PPO,,41.66,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,BCBS NC,Blue Select/HMO/PPO,,48.35,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,51.43,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,BCBS NC,Blue Select/HMO/PPO,,0.94048,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,29.83,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,36.44,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,36.44,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,BCBS NC,Blue Select/HMO/PPO,,26.95,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,BCBS NC,Blue Select/HMO/PPO,,23.42,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,BCBS NC,Blue Select/HMO/PPO,,138.43,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,7.70,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,6.82,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,BCBS NC,Blue Select/HMO/PPO,,6.91,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Select/HMO/PPO,,6.64,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,BCBS NC,Blue Select/HMO/PPO,,4079.67,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,BCBS NC,Blue Select/HMO/PPO,,89.29,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,1.25,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Select/HMO/PPO,,16.59,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Select/HMO/PPO,,16.59,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,BCBS NC,Blue Select/HMO/PPO,,1194.87,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,BCBS NC,Blue Select/HMO/PPO,,33.23,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,BCBS NC,Blue Select/HMO/PPO,,34.64,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,BCBS NC,Blue Select/HMO/PPO,,5240.06,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,BCBS NC,Blue Select/HMO/PPO,,8335.59,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Select/HMO/PPO,,19.21,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,BCBS NC,Blue Select/HMO/PPO,,1.81,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,BCBS NC,Blue Select/HMO/PPO,,43.34,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,7.36,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,BCBS NC,Blue Select/HMO/PPO,,12.20,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,BCBS NC,Blue Select/HMO/PPO,,6.97,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,5.64,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,BCBS NC,Blue Select/HMO/PPO,,47.46,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Select/HMO/PPO,,143.04,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,BCBS NC,Blue Select/HMO/PPO,,28.77,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,BCBS NC,Blue Select/HMO/PPO,,27.70,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,BCBS NC,Blue Select/HMO/PPO,,1344.89,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,BCBS NC,Blue Select/HMO/PPO,,44.97,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,BCBS NC,Blue Select/HMO/PPO,,7.07,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,BCBS NC,Blue Select/HMO/PPO,,1.41,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,BCBS NC,Blue Select/HMO/PPO,,95.83,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Select/HMO/PPO,,24.86,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Select/HMO/PPO,,24.86,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Select/HMO/PPO,,189.02,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Select/HMO/PPO,,189.02,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,5.06,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,BCBS NC,Blue Select/HMO/PPO,,161.63,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.67,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,BCBS NC,Blue Select/HMO/PPO,,0.54371,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,24.72,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,BCBS NC,Blue Select/HMO/PPO,,95.33,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,BCBS NC,Blue Select/HMO/PPO,,145.04,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,BCBS NC,Blue Select/HMO/PPO,,6.01,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,BCBS NC,Blue Select/HMO/PPO,,104.97,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,BCBS NC,Blue Select/HMO/PPO,,155.09,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Select/HMO/PPO,,29.38,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Select/HMO/PPO,,29.38,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,BCBS NC,Blue Select/HMO/PPO,,108.35,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,BCBS NC,Blue Select/HMO/PPO,,1878.73,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,8.35,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,BCBS NC,Blue Select/HMO/PPO,,2021.59,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,BCBS NC,Blue Select/HMO/PPO,,9784.64,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,6.67,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,16.16,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,0.49963,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,26.14,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,BCBS NC,Blue Select/HMO/PPO,,11572.21,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,BCBS NC,Blue Select/HMO/PPO,,2383.84,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,26.14,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,BCBS NC,Blue Select/HMO/PPO,,112.08,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,22.22,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Select/HMO/PPO,,25.80,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,BCBS NC,Blue Select/HMO/PPO,,615.22,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,BCBS NC,Blue Select/HMO/PPO,,4109.71,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,5.23,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,BCBS NC,Blue Select/HMO/PPO,,135.86,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,BCBS NC,Blue Select/HMO/PPO,,321.82,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,BCBS NC,Blue Select/HMO/PPO,,72.74,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,11.39,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,11.39,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,BCBS NC,Blue Select/HMO/PPO,,70.87,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,BCBS NC,Blue Select/HMO/PPO,,90.49,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,BCBS NC,Blue Select/HMO/PPO,,119.56,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,7266.62,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,BCBS NC,Blue Select/HMO/PPO,,237.87,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,BCBS NC,Blue Select/HMO/PPO,,1792.78,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,BCBS NC,Blue Select/HMO/PPO,,4360.67,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.78,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,BCBS NC,Blue Select/HMO/PPO,,214.88,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,BCBS NC,Blue Select/HMO/PPO,,11.61,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,BCBS NC,Blue Select/HMO/PPO,,16.03,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,BCBS NC,Blue Select/HMO/PPO,,22.84,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Select/HMO/PPO,,8587.14,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,BCBS NC,Blue Select/HMO/PPO,,7707.53,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,7.35,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,21.81,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,21.81,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,BCBS NC,Blue Select/HMO/PPO,,32.12,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,BCBS NC,Blue Select/HMO/PPO,,523.14,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,BCBS NC,Blue Select/HMO/PPO,,6177.84,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,BCBS NC,Blue Select/HMO/PPO,,9248.49,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,BCBS NC,Blue Select/HMO/PPO,,4716.40,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,BCBS NC,Blue Select/HMO/PPO,,531.24,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,BCBS NC,Blue Select/HMO/PPO,,1101.23,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,BCBS NC,Blue Select/HMO/PPO,,2.38,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,27.77,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Select/HMO/PPO,,143.04,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,BCBS NC,Blue Select/HMO/PPO,,1150.38,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,BCBS NC,Blue Select/HMO/PPO,,24711.99,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,BCBS NC,Blue Select/HMO/PPO,,581.51,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,BCBS NC,Blue Select/HMO/PPO,,144.95,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,BCBS NC,Blue Select/HMO/PPO,,1360.58,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,BCBS NC,Blue Select/HMO/PPO,,2698.53,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,BCBS NC,Blue Select/HMO/PPO,,1343.56,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,BCBS NC,Blue Select/HMO/PPO,,591.74,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,BCBS NC,Blue Select/HMO/PPO,,371.59,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,13.02,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,BCBS NC,Blue Select/HMO/PPO,,37.97,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.81,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,BCBS NC,Blue Select/HMO/PPO,,24.75,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,22.34,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,BCBS NC,Blue Select/HMO/PPO,,3167.67,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,BCBS NC,Blue Select/HMO/PPO,,3933.15,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,BCBS NC,Blue Select/HMO/PPO,,16.90,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,BCBS NC,Blue Select/HMO/PPO,,4822.56,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Select/HMO/PPO,,169.92,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,BCBS NC,Blue Select/HMO/PPO,,28.73,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,BCBS NC,Blue Select/HMO/PPO,,43.29,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,BCBS NC,Blue Select/HMO/PPO,,3279.85,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,BCBS NC,Blue Select/HMO/PPO,,305.44,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,BCBS NC,Blue Select/HMO/PPO,,186.76,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,BCBS NC,Blue Select/HMO/PPO,,64.23,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,BCBS NC,Blue Select/HMO/PPO,,5.63,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,BCBS NC,Blue Select/HMO/PPO,,257.84,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,5.76,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,BCBS NC,Blue Select/HMO/PPO,,1186.59,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,BCBS NC,Blue Select/HMO/PPO,,486.95,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,BCBS NC,Blue Select/HMO/PPO,,91.01,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,BCBS NC,Blue Select/HMO/PPO,,3970.85,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,BCBS NC,Blue Select/HMO/PPO,,22.64,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,BCBS NC,Blue Select/HMO/PPO,,83.88,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,BCBS NC,Blue Select/HMO/PPO,,160.35,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,BCBS NC,Blue Select/HMO/PPO,,1365.81,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,BCBS NC,Blue Select/HMO/PPO,,62.13,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,BCBS NC,Blue Select/HMO/PPO,,28.11,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Select/HMO/PPO,,43.54,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Select/HMO/PPO,,15067.72,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.47,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,BCBS NC,Blue Select/HMO/PPO,,396.81,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,BCBS NC,Blue Select/HMO/PPO,,36.00,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,BCBS NC,Blue Select/HMO/PPO,,807.40,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,BCBS NC,Blue Select/HMO/PPO,,18.03,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,BCBS NC,Blue Select/HMO/PPO,,318.15,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,BCBS NC,Blue Select/HMO/PPO,,18.02,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,BCBS NC,Blue Select/HMO/PPO,,4709.16,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Select/HMO/PPO,,12.09,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,BCBS NC,Blue Select/HMO/PPO,,56.33,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Select/HMO/PPO,,19.47,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,BCBS NC,Blue Select/HMO/PPO,,107.95,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,BCBS NC,Blue Select/HMO/PPO,,16.90,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,BCBS NC,Blue Select/HMO/PPO,,10.07,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,BCBS NC,Blue Select/HMO/PPO,,11.73,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,BCBS NC,Blue Select/HMO/PPO,,26414.94,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,BCBS NC,Blue Select/HMO/PPO,,2788.73,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,BCBS NC,Blue Select/HMO/PPO,,25497.31,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,BCBS NC,Blue Select/HMO/PPO,,13.17,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,BCBS NC,Blue Select/HMO/PPO,,2096.12,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,BCBS NC,Blue Select/HMO/PPO,,263.54,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,BCBS NC,Blue Select/HMO/PPO,,5634.52,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,BCBS NC,Blue Select/HMO/PPO,,1413.72,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,BCBS NC,Blue Select/HMO/PPO,,8585.41,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,BCBS NC,Blue Select/HMO/PPO,,1.95,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,21.09,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,BCBS NC,Blue Select/HMO/PPO,,9800.33,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,BCBS NC,Blue Select/HMO/PPO,,20.96,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,BCBS NC,Blue Select/HMO/PPO,,20.19,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,BCBS NC,Blue Select/HMO/PPO,,385.82,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,BCBS NC,Blue Select/HMO/PPO,,1325.90,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,BCBS NC,Blue Select/HMO/PPO,,14.05,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,BCBS NC,Blue Select/HMO/PPO,,14279.72,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,BCBS NC,Blue Select/HMO/PPO,,31007.98,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,5.13,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,BCBS NC,Blue Select/HMO/PPO,,38.68,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Select/HMO/PPO,,28.01,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Select/HMO/PPO,,28.01,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,26.54,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.95,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,8.19,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,5.20,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,BCBS NC,Blue Select/HMO/PPO,,58.63,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,BCBS NC,Blue Select/HMO/PPO,,293.17,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,BCBS NC,Blue Select/HMO/PPO,,19.43,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,BCBS NC,Blue Select/HMO/PPO,,196.49,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,BCBS NC,Blue Select/HMO/PPO,,1.38,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.41,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,BCBS NC,Blue Select/HMO/PPO,,579.64,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,BCBS NC,Blue Select/HMO/PPO,,7823.65,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,BCBS NC,Blue Select/HMO/PPO,,1731.26,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Select/HMO/PPO,,5.61,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,BCBS NC,Blue Select/HMO/PPO,,10352.51,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,BCBS NC,Blue Select/HMO/PPO,,23.53,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,BCBS NC,Blue Select/HMO/PPO,,71.11,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,BCBS NC,Blue Select/HMO/PPO,,114.47,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.74,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,BCBS NC,Blue Select/HMO/PPO,,17.18,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,BCBS NC,Blue Select/HMO/PPO,,34.21,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,BCBS NC,Blue Select/HMO/PPO,,48.96,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,BCBS NC,Blue Select/HMO/PPO,,63.70,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,BCBS NC,Blue Select/HMO/PPO,,152.21,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,BCBS NC,Blue Select/HMO/PPO,,594.71,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,BCBS NC,Blue Select/HMO/PPO,,2796.21,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,BCBS NC,Blue Select/HMO/PPO,,154.30,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Select/HMO/PPO,,38.47,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Select/HMO/PPO,,38.47,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,BCBS NC,Blue Select/HMO/PPO,,143.79,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,BCBS NC,Blue Select/HMO/PPO,,6265.23,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,297.56,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,BCBS NC,Blue Select/HMO/PPO,,473.28,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,BCBS NC,Blue Select/HMO/PPO,,101.32,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,BCBS NC,Blue Select/HMO/PPO,,16.43,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,BCBS NC,Blue Select/HMO/PPO,,1512.41,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,BCBS NC,Blue Select/HMO/PPO,,14208.55,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Select/HMO/PPO,,5587.70,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,BCBS NC,Blue Select/HMO/PPO,,14.14,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,BCBS NC,Blue Select/HMO/PPO,,1335.26,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Select/HMO/PPO,,2961.63,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,297.56,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,BCBS NC,Blue Select/HMO/PPO,,10599.24,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,BCBS NC,Blue Select/HMO/PPO,,860.54,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Select/HMO/PPO,,10571.67,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,BCBS NC,Blue Select/HMO/PPO,,6126.67,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,59.66,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,BCBS NC,Blue Select/HMO/PPO,,84.35,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,BCBS NC,Blue Select/HMO/PPO,,123.31,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,523.44,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,BCBS NC,Blue Select/HMO/PPO,,24148.37,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,BCBS NC,Blue Select/HMO/PPO,,3689.90,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,BCBS NC,Blue Select/HMO/PPO,,983.11,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,BCBS NC,Blue Select/HMO/PPO,,59.15,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,14.11,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,BCBS NC,Blue Select/HMO/PPO,,7.01,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,5.23,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,BCBS NC,Blue Select/HMO/PPO,,1174.26,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,BCBS NC,Blue Select/HMO/PPO,,5547.98,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,BCBS NC,Blue Select/HMO/PPO,,5095.70,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,BCBS NC,Blue Select/HMO/PPO,,15250.00,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,BCBS NC,Blue Select/HMO/PPO,,3046.38,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,BCBS NC,Blue Select/HMO/PPO,,1845.47,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,BCBS NC,Blue Select/HMO/PPO,,31.49,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,BCBS NC,Blue Select/HMO/PPO,,3713.31,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5529.55,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,BCBS NC,Blue Select/HMO/PPO,,4072.13,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,BCBS NC,Blue Select/HMO/PPO,,3253.72,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,BCBS NC,Blue Select/HMO/PPO,,874.06,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,BCBS NC,Blue Select/HMO/PPO,,1007.77,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,BCBS NC,Blue Select/HMO/PPO,,4715.51,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,BCBS NC,Blue Select/HMO/PPO,,22260.75,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,BCBS NC,Blue Select/HMO/PPO,,4466.05,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Select/HMO/PPO,,42.19,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Select/HMO/PPO,,42.19,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,BCBS NC,Blue Select/HMO/PPO,,8.41,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,BCBS NC,Blue Select/HMO/PPO,,2413.30,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,BCBS NC,Blue Select/HMO/PPO,,5705.55,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,BCBS NC,Blue Select/HMO/PPO,,1205.77,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,BCBS NC,Blue Select/HMO/PPO,,43.82,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,BCBS NC,Blue Select/HMO/PPO,,3395.84,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,BCBS NC,Blue Select/HMO/PPO,,32338.70,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,BCBS NC,Blue Select/HMO/PPO,,635.71,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,BCBS NC,Blue Select/HMO/PPO,,12.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,BCBS NC,Blue Select/HMO/PPO,,51.80,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,5.26,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,BCBS NC,Blue Select/HMO/PPO,,18077.14,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,BCBS NC,Blue Select/HMO/PPO,,12077.89,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,BCBS NC,Blue Select/HMO/PPO,,19.29,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,BCBS NC,Blue Select/HMO/PPO,,1885.91,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,BCBS NC,Blue Select/HMO/PPO,,5238.17,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,BCBS NC,Blue Select/HMO/PPO,,29583.11,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,BCBS NC,Blue Select/HMO/PPO,,8081.59,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,BCBS NC,Blue Select/HMO/PPO,,299.70,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,BCBS NC,Blue Select/HMO/PPO,,1981.91,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,BCBS NC,Blue Select/HMO/PPO,,1646.99,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,BCBS NC,Blue Select/HMO/PPO,,2708.79,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,BCBS NC,Blue Select/HMO/PPO,,36705.36,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,BCBS NC,Blue Select/HMO/PPO,,15637.89,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,BCBS NC,Blue Select/HMO/PPO,,6016.43,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,BCBS NC,Blue Select/HMO/PPO,,5003.47,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,BCBS NC,Blue Select/HMO/PPO,,23.88,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,BCBS NC,Blue Select/HMO/PPO,,255.52,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,BCBS NC,Blue Select/HMO/PPO,,9651.25,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,31.58,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,BCBS NC,Blue Select/HMO/PPO,,121.48,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,BCBS NC,Blue Select/HMO/PPO,,4802.38,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,BCBS NC,Blue Select/HMO/PPO,,10707.88,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,BCBS NC,Blue Select/HMO/PPO,,10.04,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Select/HMO/PPO,,25.75,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Select/HMO/PPO,,24.32,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Select/HMO/PPO,,24.32,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,BCBS NC,Blue Select/HMO/PPO,,217.32,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,BCBS NC,Blue Select/HMO/PPO,,344.91,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,BCBS NC,Blue Select/HMO/PPO,,20023.92,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,22.34,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Select/HMO/PPO,,771.87,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Select/HMO/PPO,,333.87,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Select/HMO/PPO,,333.87,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Select/HMO/PPO,,771.87,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,BCBS NC,Blue Select/HMO/PPO,,30.58,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,BCBS NC,Blue Select/HMO/PPO,,13591.19,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,BCBS NC,Blue Select/HMO/PPO,,2729.90,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,BCBS NC,Blue Select/HMO/PPO,,152.83,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,BCBS NC,Blue Select/HMO/PPO,,8851.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,BCBS NC,Blue Select/HMO/PPO,,888.08,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,BCBS NC,Blue Select/HMO/PPO,,24298.68,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,BCBS NC,Blue Select/HMO/PPO,,19145.88,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,BCBS NC,Blue Select/HMO/PPO,,3517.25,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,BCBS NC,Blue Select/HMO/PPO,,7029.53,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,BCBS NC,Blue Select/HMO/PPO,,8785.86,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,BCBS NC,Blue Select/HMO/PPO,,20031.69,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,BCBS NC,Blue Select/HMO/PPO,,276.97,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,BCBS NC,Blue Select/HMO/PPO,,748.39,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,BCBS NC,Blue Select/HMO/PPO,,748.40,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,BCBS NC,Blue Select/HMO/PPO,,18.37,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Select/HMO/PPO,,15020.74,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,BCBS NC,Blue Select/HMO/PPO,,1201.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,BCBS NC,Blue Select/HMO/PPO,,433.74,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,BCBS NC,Blue Select/HMO/PPO,,61.25,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,BCBS NC,Blue Select/HMO/PPO,,75.09,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,9.08,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,31.15,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,BCBS NC,Blue Select/HMO/PPO,,20.37,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,BCBS NC,Blue Select/HMO/PPO,,18659.27,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,BCBS NC,Blue Select/HMO/PPO,,68.89,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Select/HMO/PPO,,5587.70,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,BCBS NC,Blue Select/HMO/PPO,,103.59,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,BCBS NC,Blue Select/HMO/PPO,,7856.84,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,BCBS NC,Blue Select/HMO/PPO,,3230.87,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,BCBS NC,Blue Select/HMO/PPO,,12867.90,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,BCBS NC,Blue Select/HMO/PPO,,259.51,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,BCBS NC,Blue Select/HMO/PPO,,17999.04,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,BCBS NC,Blue Select/HMO/PPO,,2149.88,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,BCBS NC,Blue Select/HMO/PPO,,75.62,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,BCBS NC,Blue Select/HMO/PPO,,23.88,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.92,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,BCBS NC,Blue Select/HMO/PPO,,10352.51,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,BCBS NC,Blue Select/HMO/PPO,,6405.77,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,BCBS NC,Blue Select/HMO/PPO,,0.39676,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.38207,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,BCBS NC,Blue Select/HMO/PPO,,107.11,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.78,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,11100.18,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,BCBS NC,Blue Select/HMO/PPO,,136.69,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.78,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,BCBS NC,Blue Select/HMO/PPO,,14.43,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,BCBS NC,Blue Select/HMO/PPO,,26.20,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,BCBS NC,Blue Select/HMO/PPO,,21.57,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,BCBS NC,Blue Select/HMO/PPO,,96.34,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,BCBS NC,Blue Select/HMO/PPO,,11.30,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,6.89,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,BCBS NC,Blue Select/HMO/PPO,,8.01,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,9.46,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,BCBS NC,Blue Select/HMO/PPO,,0.86701,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,BCBS NC,Blue Select/HMO/PPO,,56.69,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,BCBS NC,Blue Select/HMO/PPO,,3.26,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,BCBS NC,Blue Select/HMO/PPO,,5.75,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.78,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,BCBS NC,Blue Select/HMO/PPO,,27.70,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,5.07,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,BCBS NC,Blue Select/HMO/PPO,,7.99,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,7.70,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.38,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,5.06,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,5.26,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,BCBS NC,Blue Select/HMO/PPO,,26.76,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,BCBS NC,Blue Select/HMO/PPO,,411.45,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.47,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,BCBS NC,Blue Select/HMO/PPO,,1295.78,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,BCBS NC,Blue Select/HMO/PPO,,6155.57,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,BCBS NC,Blue Select/HMO/PPO,,19.97,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,BCBS NC,Blue Select/HMO/PPO,,1870.09,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,BCBS NC,Blue Select/HMO/PPO,,24.66,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,BCBS NC,Blue Select/HMO/PPO,,58.13,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Select/HMO/PPO,,13.55,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Select/HMO/PPO,,13.45,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,5.10,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,BCBS NC,Blue Select/HMO/PPO,,1229.22,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,BCBS NC,Blue Select/HMO/PPO,,23.97,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Select/HMO/PPO,,5.53,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,BCBS NC,Blue Select/HMO/PPO,,37.22,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,BCBS NC,Blue Select/HMO/PPO,,138.99,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,BCBS NC,Blue Select/HMO/PPO,,2.84,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,6.00,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,BCBS NC,Blue Select/HMO/PPO,,327.11,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,BCBS NC,Blue Select/HMO/PPO,,5.89,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,BCBS NC,Blue Select/HMO/PPO,,7.32,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,BCBS NC,Blue Select/HMO/PPO,,52.23,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,BCBS NC,Blue Select/HMO/PPO,,3.48,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,25.57,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,BCBS NC,Blue Select/HMO/PPO,,24.03,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,BCBS NC,Blue Select/HMO/PPO,,31.30,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,BCBS NC,Blue Select/HMO/PPO,,32.24,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,BCBS NC,Blue Select/HMO/PPO,,192.28,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,BCBS NC,Blue Select/HMO/PPO,,20.90,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,BCBS NC,Blue Select/HMO/PPO,,21.07,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,23.14,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,BCBS NC,Blue Select/HMO/PPO,,20.94,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,22.48,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,11.67,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,22.92,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,BCBS NC,Blue Select/HMO/PPO,,604.85,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,6.00,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,6.00,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,BCBS NC,Blue Select/HMO/PPO,,151.81,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,6.54,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,6.54,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,BCBS NC,Blue Select/HMO/PPO,,15.84,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,BCBS NC,Blue Select/HMO/PPO,,2.53,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,5.51,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,BCBS NC,Blue Select/HMO/PPO,,41.76,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,BCBS NC,Blue Select/HMO/PPO,,124.14,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,BCBS NC,Blue Select/HMO/PPO,,14.90,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,BCBS NC,Blue Select/HMO/PPO,,26.05,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,BCBS NC,Blue Select/HMO/PPO,,6.29,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,BCBS NC,Blue Select/HMO/PPO,,26.73,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Select/HMO/PPO,,6.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,BCBS NC,Blue Select/HMO/PPO,,0.55841,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,7.04,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,BCBS NC,Blue Select/HMO/PPO,,6.58,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,BCBS NC,Blue Select/HMO/PPO,,57.78,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,BCBS NC,Blue Select/HMO/PPO,,14.22,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,BCBS NC,Blue Select/HMO/PPO,,8.73,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,BCBS NC,Blue Select/HMO/PPO,,2.20,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,5.07,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,BCBS NC,Blue Select/HMO/PPO,,6.10,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,BCBS NC,Blue Select/HMO/PPO,,23.92,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,BCBS NC,Blue Select/HMO/PPO,,0.98457,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,BCBS NC,Blue Select/HMO/PPO,,4.23,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.38207,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,BCBS NC,Blue Select/HMO/PPO,,9.58,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,BCBS NC,Blue Select/HMO/PPO,,23.47,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,6.73,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,5.33,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Select/HMO/PPO,,5.54,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,BCBS NC,Blue Select/HMO/PPO,,5.85,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,BCBS NC,Blue Select/HMO/PPO,,48.35,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,5.06,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,BCBS NC,Blue Select/HMO/PPO,,24.79,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,BCBS NC,Blue Select/HMO/PPO,,9.21,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,BCBS NC,Blue Select/HMO/PPO,,2159.09,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,BCBS NC,Blue Select/HMO/PPO,,8.26,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,BCBS NC,Blue Select/HMO/PPO,,22.57,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,BCBS NC,Blue Select/HMO/PPO,,9.32,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.95,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,BCBS NC,Blue Select/HMO/PPO,,805.67,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,25.92,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,BCBS NC,Blue Select/HMO/PPO,,11.73,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.74,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,BCBS NC,Blue Select/HMO/PPO,,28.55,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,BCBS NC,Blue Select/HMO/PPO,,29.86,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,43.20,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,BCBS NC,Blue Select/HMO/PPO,,7.60,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,BCBS NC,Blue Select/HMO/PPO,,346.66,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,BCBS NC,Blue Select/HMO/PPO,,662.74,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,BCBS NC,Blue Select/HMO/PPO,,1697.27,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Select/HMO/PPO,,1.73,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,BCBS NC,Blue Select/HMO/PPO,,651.50,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Select/HMO/PPO,,5.54,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,BCBS NC,Blue Select/HMO/PPO,,67.01,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.67,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,5.92,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,BCBS NC,Blue Select/HMO/PPO,,77.47,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Select/HMO/PPO,,6.23,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Select/HMO/PPO,,5.70,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,BCBS NC,Blue Select/HMO/PPO,,6.79,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.88,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,BCBS NC,Blue Select/HMO/PPO,,7.61,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,BCBS NC,Blue Select/HMO/PPO,,29.74,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,BCBS NC,Blue Select/HMO/PPO,,178.41,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Select/HMO/PPO,,53.15,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Select/HMO/PPO,,53.15,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,BCBS NC,Blue Select/HMO/PPO,,57.16,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,BCBS NC,Blue Select/HMO/PPO,,57.50,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,22.92,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Select/HMO/PPO,,1.09,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Select/HMO/PPO,,1.09,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,BCBS NC,Blue Select/HMO/PPO,,1.15,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,BCBS NC,Blue Select/HMO/PPO,,10.48,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,BCBS NC,Blue Select/HMO/PPO,,12.76,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,17.63,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,BCBS NC,Blue Select/HMO/PPO,,24.13,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,BCBS NC,Blue Select/HMO/PPO,,30.77,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,BCBS NC,Blue Select/HMO/PPO,,64.88,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,BCBS NC,Blue Select/HMO/PPO,,3.94,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.42616,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,BCBS NC,Blue Select/HMO/PPO,,297.37,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,BCBS NC,Blue Select/HMO/PPO,,2.37,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,BCBS NC,Blue Select/HMO/PPO,,33.50,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,BCBS NC,Blue Select/HMO/PPO,,6.80,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,BCBS NC,Blue Select/HMO/PPO,,7.79,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,BCBS NC,Blue Select/HMO/PPO,,221.20,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Select/HMO/PPO,,5.39,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,90.64,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Select/HMO/PPO,,7.08,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,BCBS NC,Blue Select/HMO/PPO,,27.13,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,26.54,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,BCBS NC,Blue Select/HMO/PPO,,6.72,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,BCBS NC,Blue Select/HMO/PPO,,5.97,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.32,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,BCBS NC,Blue Select/HMO/PPO,,13.56,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,BCBS NC,Blue Select/HMO/PPO,,15.14,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,BCBS NC,Blue Select/HMO/PPO,,78.68,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,BCBS NC,Blue Select/HMO/PPO,,8.20,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,BCBS NC,Blue Select/HMO/PPO,,18.56,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,BCBS NC,Blue Select/HMO/PPO,,176.09,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,BCBS NC,Blue Select/HMO/PPO,,11.09,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,BCBS NC,Blue Select/HMO/PPO,,18.35,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,BCBS NC,Blue Select/HMO/PPO,,1034.53,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,BCBS NC,Blue Select/HMO/PPO,,456.13,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,BCBS NC,Blue Select/HMO/PPO,,353.88,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,5.23,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,BCBS NC,Blue Select/HMO/PPO,,63.48,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,BCBS NC,Blue Select/HMO/PPO,,153.99,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,BCBS NC,Blue Select/HMO/PPO,,205.29,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,BCBS NC,Blue Select/HMO/PPO,,352.39,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,BCBS NC,Blue Select/HMO/PPO,,98.69,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,BCBS NC,Blue Select/HMO/PPO,,102.72,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Select/HMO/PPO,,5.61,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,BCBS NC,Blue Select/HMO/PPO,,8.36,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.67,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,BCBS NC,Blue Select/HMO/PPO,,3782.20,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,BCBS NC,Blue Select/HMO/PPO,,15.40,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,105.00,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,BCBS NC,Blue Select/HMO/PPO,,19.57,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,5.22,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,BCBS NC,Blue Select/HMO/PPO,,0.72006,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,BCBS NC,Blue Select/HMO/PPO,,1.31,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,BCBS NC,Blue Select/HMO/PPO,,7.96,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,BCBS NC,Blue Select/HMO/PPO,,203.67,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,5.73,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,5.73,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,BCBS NC,Blue Select/HMO/PPO,,6.35,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,BCBS NC,Blue Select/HMO/PPO,,24.42,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,BCBS NC,Blue Select/HMO/PPO,,108.64,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,123.44,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,BCBS NC,Blue Select/HMO/PPO,,8.42,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,BCBS NC,Blue Select/HMO/PPO,,12.46,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,8.35,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,15.71,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,BCBS NC,Blue Select/HMO/PPO,,7.63,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.51433,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,BCBS NC,Blue Select/HMO/PPO,,35.24,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,BCBS NC,Blue Select/HMO/PPO,,1.85,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,BCBS NC,Blue Select/HMO/PPO,,27.63,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,BCBS NC,Blue Select/HMO/PPO,,25.42,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,BCBS NC,Blue Select/HMO/PPO,,136.68,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,93.75,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,BCBS NC,Blue Select/HMO/PPO,,248.04,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,BCBS NC,Blue Select/HMO/PPO,,6.02,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,BCBS NC,Blue Select/HMO/PPO,,77.90,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,BCBS NC,Blue Select/HMO/PPO,,252.33,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,BCBS NC,Blue Select/HMO/PPO,,5870.06,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,BCBS NC,Blue Select/HMO/PPO,,9.93,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,BCBS NC,Blue Select/HMO/PPO,,53.83,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,BCBS NC,Blue Select/HMO/PPO,,34.18,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,BCBS NC,Blue Select/HMO/PPO,,8.79,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,BCBS NC,Blue Select/HMO/PPO,,36.84,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,BCBS NC,Blue Select/HMO/PPO,,21.01,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,BCBS NC,Blue Select/HMO/PPO,,55.87,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,BCBS NC,Blue Select/HMO/PPO,,24.85,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,BCBS NC,Blue Select/HMO/PPO,,153.21,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,BCBS NC,Blue Select/HMO/PPO,,17.55,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.47,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,BCBS NC,Blue Select/HMO/PPO,,8.41,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,BCBS NC,Blue Select/HMO/PPO,,35.58,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Select/HMO/PPO,,8587.14,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,BCBS NC,Blue Select/HMO/PPO,,10.77,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,BCBS NC,Blue Select/HMO/PPO,,6.51,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,BCBS NC,Blue Select/HMO/PPO,,27.44,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,BCBS NC,Blue Select/HMO/PPO,,875.25,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,BCBS NC,Blue Select/HMO/PPO,,10.52,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,BCBS NC,Blue Select/HMO/PPO,,37.81,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,BCBS NC,Blue Select/HMO/PPO,,664.93,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,BCBS NC,Blue Select/HMO/PPO,,12.52,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,BCBS NC,Blue Select/HMO/PPO,,10.30,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,BCBS NC,Blue Select/HMO/PPO,,8.63,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,BCBS NC,Blue Select/HMO/PPO,,16.24,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,BCBS NC,Blue Select/HMO/PPO,,10.64,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,BCBS NC,Blue Select/HMO/PPO,,1537.19,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,BCBS NC,Blue Select/HMO/PPO,,3835.89,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,BCBS NC,Blue Select/HMO/PPO,,7667.04,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,BCBS NC,Blue Select/HMO/PPO,,15329.38,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,BCBS NC,Blue Select/HMO/PPO,,53.18,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,BCBS NC,Blue Select/HMO/PPO,,117.44,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,BCBS NC,Blue Select/HMO/PPO,,7.49,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,BCBS NC,Blue Select/HMO/PPO,,14.74,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,BCBS NC,Blue Select/HMO/PPO,,43.44,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,BCBS NC,Blue Select/HMO/PPO,,92.96,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.41,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,5.23,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,BCBS NC,Blue Select/HMO/PPO,,14.22,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,BCBS NC,Blue Select/HMO/PPO,,14.83,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,5.28,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,BCBS NC,Blue Select/HMO/PPO,,1384.97,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,BCBS NC,Blue Select/HMO/PPO,,16.86,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,BCBS NC,Blue Select/HMO/PPO,,39.53,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,BCBS NC,Blue Select/HMO/PPO,,10.92,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Select/HMO/PPO,,49.27,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,14.37,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,BCBS NC,Blue Select/HMO/PPO,,6.44,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,6.73,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,BCBS NC,Blue Select/HMO/PPO,,94.53,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,6.32,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,BCBS NC,Blue Select/HMO/PPO,,7.71,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,BCBS NC,Blue Select/HMO/PPO,,10.90,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,8.19,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,BCBS NC,Blue Select/HMO/PPO,,136.68,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,BCBS NC,Blue Select/HMO/PPO,,3.32,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,0.48494,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,BCBS NC,Blue Select/HMO/PPO,,304.14,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,BCBS NC,Blue Select/HMO/PPO,,7.30,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,BCBS NC,Blue Select/HMO/PPO,,7.29,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,BCBS NC,Blue Select/HMO/PPO,,74.06,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,9.51,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,5.20,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,BCBS NC,Blue Select/HMO/PPO,,5.36,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,BCBS NC,Blue Select/HMO/PPO,,5.78,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Select/HMO/PPO,,2153.76,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.32,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,BCBS NC,Blue Select/HMO/PPO,,5.94,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.92,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,25.72,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,BCBS NC,Blue Select/HMO/PPO,,1836.46,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,BCBS NC,Blue Select/HMO/PPO,,25.73,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,14.37,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,BCBS NC,Blue Select/HMO/PPO,,28.48,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,BCBS NC,Blue Select/HMO/PPO,,30.98,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Select/HMO/PPO,,6.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.44085,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,BCBS NC,Blue Select/HMO/PPO,,20.75,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,BCBS NC,Blue Select/HMO/PPO,,1.43,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,8.35,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.95,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,5.28,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,BCBS NC,Blue Select/HMO/PPO,,6.94,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,1.26,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,BCBS NC,Blue Select/HMO/PPO,,8.07,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,1.26,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,BCBS NC,Blue Select/HMO/PPO,,7.61,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Select/HMO/PPO,,5.04,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.51433,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Select/HMO/PPO,,6.63,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,BCBS NC,Blue Select/HMO/PPO,,6.85,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Select/HMO/PPO,,6.63,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,BCBS NC,Blue Select/HMO/PPO,,2.45,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,6.67,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,BCBS NC,Blue Select/HMO/PPO,,33.36,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,BCBS NC,Blue Select/HMO/PPO,,49.79,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,8.19,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,BCBS NC,Blue Select/HMO/PPO,,9.21,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,BCBS NC,Blue Select/HMO/PPO,,5309.07,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1162.55,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,9.08,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,BCBS NC,Blue Select/HMO/PPO,,222.66,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Select/HMO/PPO,,67.93,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,BCBS NC,Blue Select/HMO/PPO,,42.25,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Select/HMO/PPO,,805.46,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,BCBS NC,Blue Select/HMO/PPO,,443.16,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,BCBS NC,Blue Select/HMO/PPO,,1.03,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,BCBS NC,Blue Select/HMO/PPO,,32.11,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,0.47024,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,BCBS NC,Blue Select/HMO/PPO,,8.05,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,BCBS NC,Blue Select/HMO/PPO,,5.94,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,BCBS NC,Blue Select/HMO/PPO,,12.04,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,BCBS NC,Blue Select/HMO/PPO,,408.89,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,BCBS NC,Blue Select/HMO/PPO,,17.91,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,BCBS NC,Blue Select/HMO/PPO,,10.89,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.99,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,BCBS NC,Blue Select/HMO/PPO,,110.87,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,BCBS NC,Blue Select/HMO/PPO,,141.82,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,BCBS NC,Blue Select/HMO/PPO,,98.16,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,BCBS NC,Blue Select/HMO/PPO,,157.34,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,BCBS NC,Blue Select/HMO/PPO,,34.56,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,26.54,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,7.36,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,BCBS NC,Blue Select/HMO/PPO,,34.12,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,BCBS NC,Blue Select/HMO/PPO,,201.67,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,BCBS NC,Blue Select/HMO/PPO,,472.36,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,5.13,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Select/HMO/PPO,,5.48,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,19.62,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,20.50,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,19.84,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,23.14,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,20.50,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,19.84,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,44.09,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,BCBS NC,Blue Select/HMO/PPO,,21.60,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,20.50,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,19.84,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,19.84,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,19.62,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,20.50,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,23.14,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,19.62,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,BCBS NC,Blue Select/HMO/PPO,,300.81,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,BCBS NC,Blue Select/HMO/PPO,,2124.10,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,BCBS NC,Blue Select/HMO/PPO,,7779.05,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,BCBS NC,Blue Select/HMO/PPO,,1643.03,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,BCBS NC,Blue Select/HMO/PPO,,7779.05,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,BCBS NC,Blue Select/HMO/PPO,,5.55,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,5.64,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Select/HMO/PPO,,2153.76,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,BCBS NC,Blue Select/HMO/PPO,,102.92,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,BCBS NC,Blue Select/HMO/PPO,,365.32,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,6.70,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,BCBS NC,Blue Select/HMO/PPO,,13.58,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,BCBS NC,Blue Select/HMO/PPO,,2066.29,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,BCBS NC,Blue Select/HMO/PPO,,97.66,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,BCBS NC,Blue Select/HMO/PPO,,90.61,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,BCBS NC,Blue Select/HMO/PPO,,197.96,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Select/HMO/PPO,,11790.06,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Select/HMO/PPO,,46917.64,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Select/HMO/PPO,,432.42,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Select/HMO/PPO,,861.05,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,BCBS NC,Blue Select/HMO/PPO,,7883.37,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,BCBS NC,Blue Select/HMO/PPO,,94.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Select/HMO/PPO,,85.25,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Select/HMO/PPO,,92.51,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,85.17,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Select/HMO/PPO,,123.82,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,BCBS NC,Blue Select/HMO/PPO,,598.09,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,145.48,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,BCBS NC,Blue Select/HMO/PPO,,292.90,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,6.73,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,22.79,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,BCBS NC,Blue Select/HMO/PPO,,99.16,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Select/HMO/PPO,,1657.67,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Select/HMO/PPO,,3296.81,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,BCBS NC,Blue Select/HMO/PPO,,30.96,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Select/HMO/PPO,,13.36,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,BCBS NC,Blue Select/HMO/PPO,,5.60,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,BCBS NC,Blue Select/HMO/PPO,,7.83,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Select/HMO/PPO,,100.75,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,22.34,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,BCBS NC,Blue Select/HMO/PPO,,86.07,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Select/HMO/PPO,,6.11,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Select/HMO/PPO,,12.73,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,7.38,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,5.73,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,BCBS NC,Blue Select/HMO/PPO,,30.37,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,22.92,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,20.98,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,BCBS NC,Blue Select/HMO/PPO,,22.26,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,BCBS NC,Blue Select/HMO/PPO,,20.76,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Select/HMO/PPO,,84.20,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,BCBS NC,Blue Select/HMO/PPO,,32.15,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,BCBS NC,Blue Select/HMO/PPO,,1.40,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,64.36,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,336.32,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,BCBS NC,Blue Select/HMO/PPO,,319.23,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,BCBS NC,Blue Select/HMO/PPO,,13.08,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,BCBS NC,Blue Select/HMO/PPO,,13.67,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,BCBS NC,Blue Select/HMO/PPO,,9.27,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,BCBS NC,Blue Select/HMO/PPO,,0.82292,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,BCBS NC,Blue Select/HMO/PPO,,10749.39,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,BCBS NC,Blue Select/HMO/PPO,,93.50,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,64.36,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,BCBS NC,Blue Select/HMO/PPO,,18.77,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,BCBS NC,Blue Select/HMO/PPO,,33.95,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Select/HMO/PPO,,8.16,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.45,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.45,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.45,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.45,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,BCBS NC,Blue Select/HMO/PPO,,22.07,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,BCBS NC,Blue Select/HMO/PPO,,31.79,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,BCBS NC,Blue Select/HMO/PPO,,45.04,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,BCBS NC,Blue Select/HMO/PPO,,6.42,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,5.76,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,BCBS NC,Blue Select/HMO/PPO,,60.04,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,BCBS NC,Blue Select/HMO/PPO,,15.64,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,7.04,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,BCBS NC,Blue Select/HMO/PPO,,4022.58,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,BCBS NC,Blue Select/HMO/PPO,,822.63,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,BCBS NC,Blue Select/HMO/PPO,,23.41,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,14.21,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,BCBS NC,Blue Select/HMO/PPO,,8.29,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,BCBS NC,Blue Select/HMO/PPO,,22.40,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Select/HMO/PPO,,13.45,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,BCBS NC,Blue Select/HMO/PPO,,30.68,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,71.42,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,BCBS NC,Blue Select/HMO/PPO,,18.69,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,71.42,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,8.76,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Select/HMO/PPO,,169.92,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,BCBS NC,Blue Select/HMO/PPO,,8.38,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,BCBS NC,Blue Select/HMO/PPO,,6.07,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,5.92,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,BCBS NC,Blue Select/HMO/PPO,,5.95,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.74,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,BCBS NC,Blue Select/HMO/PPO,,2.09,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,BCBS NC,Blue Select/HMO/PPO,,45.19,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,BCBS NC,Blue Select/HMO/PPO,,119.04,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,45.55,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,BCBS NC,Blue Select/HMO/PPO,,236.15,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,BCBS NC,Blue Select/HMO/PPO,,19.46,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,7.35,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.58,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,20.57,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,BCBS NC,Blue Select/HMO/PPO,,21.98,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Select/HMO/PPO,,17.75,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,BCBS NC,Blue Select/HMO/PPO,,27.10,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,BCBS NC,Blue Select/HMO/PPO,,110.51,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.58,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,BCBS NC,Blue Select/HMO/PPO,,18.91,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,BCBS NC,Blue Select/HMO/PPO,,7.95,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,BCBS NC,Blue Select/HMO/PPO,,33.73,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,71.42,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,13.96,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,8.43,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,5.10,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,27.77,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,BCBS NC,Blue Select/HMO/PPO,,6.86,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,BCBS NC,Blue Select/HMO/PPO,,63.36,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,BCBS NC,Blue Select/HMO/PPO,,99.54,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,BCBS NC,Blue Select/HMO/PPO,,245.41,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,BCBS NC,Blue Select/HMO/PPO,,19.18,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,BCBS NC,Blue Select/HMO/PPO,,24.09,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,BCBS NC,Blue Select/HMO/PPO,,65.42,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,25.92,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Select/HMO/PPO,,25.88,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,BCBS NC,Blue Select/HMO/PPO,,37.78,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Select/HMO/PPO,,1.73,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Select/HMO/PPO,,15.02,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,8.35,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,11100.18,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,93.75,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,BCBS NC,Blue Select/HMO/PPO,,49.49,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,18.97,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,BCBS NC,Blue Select/HMO/PPO,,21.37,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,19.07,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Select/HMO/PPO,,17.75,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,BCBS NC,Blue Select/HMO/PPO,,25.85,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,BCBS NC,Blue Select/HMO/PPO,,109.36,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,BCBS NC,Blue Select/HMO/PPO,,19.81,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,BCBS NC,Blue Select/HMO/PPO,,20.10,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,BCBS NC,Blue Select/HMO/PPO,,28.39,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,BCBS NC,Blue Select/HMO/PPO,,9.02,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,BCBS NC,Blue Select/HMO/PPO,,31.32,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,BCBS NC,Blue Select/HMO/PPO,,50.49,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,BCBS NC,Blue Select/HMO/PPO,,30.55,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,BCBS NC,Blue Select/HMO/PPO,,73.59,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,BCBS NC,Blue Select/HMO/PPO,,50.24,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,BCBS NC,Blue Select/HMO/PPO,,23.70,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,BCBS NC,Blue Select/HMO/PPO,,20.68,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,BCBS NC,Blue Select/HMO/PPO,,30.55,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,BCBS NC,Blue Select/HMO/PPO,,24.07,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,BCBS NC,Blue Select/HMO/PPO,,28.39,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Select/HMO/PPO,,32.09,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,BCBS NC,Blue Select/HMO/PPO,,140.72,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,BCBS NC,Blue Select/HMO/PPO,,34.64,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,166.64,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,BCBS NC,Blue Select/HMO/PPO,,342.60,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,BCBS NC,Blue Select/HMO/PPO,,365.14,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,10.73,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,24.57,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,21.85,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,BCBS NC,Blue Select/HMO/PPO,,45.05,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,BCBS NC,Blue Select/HMO/PPO,,64.22,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,BCBS NC,Blue Select/HMO/PPO,,150.59,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,BCBS NC,Blue Select/HMO/PPO,,282.67,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,26.54,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,BCBS NC,Blue Select/HMO/PPO,,30.32,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,BCBS NC,Blue Select/HMO/PPO,,72.81,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,BCBS NC,Blue Select/HMO/PPO,,19.63,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,BCBS NC,Blue Select/HMO/PPO,,22.97,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,BCBS NC,Blue Select/HMO/PPO,,216.06,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,BCBS NC,Blue Select/HMO/PPO,,80.88,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,BCBS NC,Blue Select/HMO/PPO,,30.89,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,85.17,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,BCBS NC,Blue Select/HMO/PPO,,51.84,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,BCBS NC,Blue Select/HMO/PPO,,7.11,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,BCBS NC,Blue Select/HMO/PPO,,35.43,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,20.98,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,BCBS NC,Blue Select/HMO/PPO,,23.03,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,BCBS NC,Blue Select/HMO/PPO,,53.08,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,BCBS NC,Blue Select/HMO/PPO,,50.49,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,22.22,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,BCBS NC,Blue Select/HMO/PPO,,10.21,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,20.98,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,BCBS NC,Blue Select/HMO/PPO,,524.61,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,BCBS NC,Blue Select/HMO/PPO,,29.26,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,BCBS NC,Blue Select/HMO/PPO,,7.39,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,BCBS NC,Blue Select/HMO/PPO,,10.24,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,21.09,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Select/HMO/PPO,,8.16,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Select/HMO/PPO,,18.55,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,51.14,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,25.92,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,BCBS NC,Blue Select/HMO/PPO,,6.60,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,BCBS NC,Blue Select/HMO/PPO,,7.52,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.67,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,BCBS NC,Blue Select/HMO/PPO,,38.52,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,27.77,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,BCBS NC,Blue Select/HMO/PPO,,41.04,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,BCBS NC,Blue Select/HMO/PPO,,8.57,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,BCBS NC,Blue Select/HMO/PPO,,30.65,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,BCBS NC,Blue Select/HMO/PPO,,24.07,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,5.22,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,BCBS NC,Blue Select/HMO/PPO,,20.07,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,5.07,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,BCBS NC,Blue Select/HMO/PPO,,16.43,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,BCBS NC,Blue Select/HMO/PPO,,24.17,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,BCBS NC,Blue Select/HMO/PPO,,31.26,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,BCBS NC,Blue Select/HMO/PPO,,91.34,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,BCBS NC,Blue Select/HMO/PPO,,23.44,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,BCBS NC,Blue Select/HMO/PPO,,93.83,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,BCBS NC,Blue Select/HMO/PPO,,18.85,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,11.67,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,30.86,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,BCBS NC,Blue Select/HMO/PPO,,21.97,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,BCBS NC,Blue Select/HMO/PPO,,15.28,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,BCBS NC,Blue Select/HMO/PPO,,47.49,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,BCBS NC,Blue Select/HMO/PPO,,6.51,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Select/HMO/PPO,,18.55,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,BCBS NC,Blue Select/HMO/PPO,,132.80,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Select/HMO/PPO,,49.27,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,BCBS NC,Blue Select/HMO/PPO,,81.29,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,BCBS NC,Blue Select/HMO/PPO,,70.36,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,BCBS NC,Blue Select/HMO/PPO,,21.72,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,BCBS NC,Blue Select/HMO/PPO,,19.31,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,BCBS NC,Blue Select/HMO/PPO,,23.39,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,BCBS NC,Blue Select/HMO/PPO,,17.58,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,BCBS NC,Blue Select/HMO/PPO,,72.77,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Select/HMO/PPO,,2961.63,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Select/HMO/PPO,,25.75,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Select/HMO/PPO,,44.20,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,BCBS NC,Blue Select/HMO/PPO,,45.16,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,BCBS NC,Blue Select/HMO/PPO,,107.05,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Select/HMO/PPO,,4654.98,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,BCBS NC,Blue Select/HMO/PPO,,115.97,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Select/HMO/PPO,,164.86,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Select/HMO/PPO,,91.49,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Select/HMO/PPO,,142.28,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Select/HMO/PPO,,132.95,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Select/HMO/PPO,,119.62,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,BCBS NC,Blue Select/HMO/PPO,,107.98,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Select/HMO/PPO,,164.86,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Select/HMO/PPO,,91.49,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Select/HMO/PPO,,142.28,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Select/HMO/PPO,,805.46,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,BCBS NC,Blue Select/HMO/PPO,,29.74,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,BCBS NC,Blue Select/HMO/PPO,,33.84,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,7.38,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.71,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,25.92,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,BCBS NC,Blue Select/HMO/PPO,,57.40,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,BCBS NC,Blue Select/HMO/PPO,,42.97,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,336.32,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,336.32,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,BCBS NC,Blue Select/HMO/PPO,,21.63,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,BCBS NC,Blue Select/HMO/PPO,,18.94,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,BCBS NC,Blue Select/HMO/PPO,,121.13,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Select/HMO/PPO,,11.86,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,BCBS NC,Blue Select/HMO/PPO,,50.92,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,BCBS NC,Blue Select/HMO/PPO,,18.57,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,BCBS NC,Blue Select/HMO/PPO,,33.84,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,14.37,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Select/HMO/PPO,,7.57,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,9.51,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,BCBS NC,Blue Select/HMO/PPO,,465.79,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,11.39,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,BCBS NC,Blue Select/HMO/PPO,,140.60,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Select/HMO/PPO,,758.39,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,5.06,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,BCBS NC,Blue Select/HMO/PPO,,42.41,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,BCBS NC,Blue Select/HMO/PPO,,405.63,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,BCBS NC,Blue Select/HMO/PPO,,21.69,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,63.19,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,BCBS NC,Blue Select/HMO/PPO,,175.53,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Select/HMO/PPO,,32.09,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,BCBS NC,Blue Select/HMO/PPO,,33.95,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Select/HMO/PPO,,12.73,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Select/HMO/PPO,,19.21,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Select/HMO/PPO,,13.95,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Select/HMO/PPO,,19.41,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,10.73,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Select/HMO/PPO,,19.41,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,BCBS NC,Blue Select/HMO/PPO,,14.24,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,BCBS NC,Blue Select/HMO/PPO,,26.10,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,BCBS NC,Blue Select/HMO/PPO,,76.53,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,BCBS NC,Blue Select/HMO/PPO,,35.18,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,BCBS NC,Blue Select/HMO/PPO,,34.75,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Select/HMO/PPO,,1996.46,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,BCBS NC,Blue Select/HMO/PPO,,9.10,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,BCBS NC,Blue Select/HMO/PPO,,24.47,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,BCBS NC,Blue Select/HMO/PPO,,19.13,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,BCBS NC,Blue Select/HMO/PPO,,52.42,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,BCBS NC,Blue Select/HMO/PPO,,14.87,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,BCBS NC,Blue Select/HMO/PPO,,68.10,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,BCBS NC,Blue Select/HMO/PPO,,69.87,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Select/HMO/PPO,,44.20,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,BCBS NC,Blue Select/HMO/PPO,,20.06,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.50,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,6.70,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,BCBS NC,Blue Select/HMO/PPO,,134.89,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,BCBS NC,Blue Select/HMO/PPO,,7.66,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Select/HMO/PPO,,1715.33,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,BCBS NC,Blue Select/HMO/PPO,,18.56,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,BCBS NC,Blue Select/HMO/PPO,,18.59,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,BCBS NC,Blue Select/HMO/PPO,,18.60,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,BCBS NC,Blue Select/HMO/PPO,,42.59,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,BCBS NC,Blue Select/HMO/PPO,,5.69,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,BCBS NC,Blue Select/HMO/PPO,,19.46,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Select/HMO/PPO,,14.71,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,BCBS NC,Blue Select/HMO/PPO,,134.06,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,BCBS NC,Blue Select/HMO/PPO,,135.81,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,BCBS NC,Blue Select/HMO/PPO,,106.11,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,BCBS NC,Blue Select/HMO/PPO,,23.45,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,25.94,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,22.22,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,23.14,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,BCBS NC,Blue Select/HMO/PPO,,7.30,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,BCBS NC,Blue Select/HMO/PPO,,46.63,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,26.14,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,BCBS NC,Blue Select/HMO/PPO,,36.90,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,24.72,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,105.00,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Select/HMO/PPO,,339.76,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.74,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,BCBS NC,Blue Select/HMO/PPO,,7.33,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,BCBS NC,Blue Select/HMO/PPO,,214.62,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,BCBS NC,Blue Select/HMO/PPO,,29.89,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,BCBS NC,Blue Select/HMO/PPO,,30.42,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,BCBS NC,Blue Select/HMO/PPO,,18.24,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Select/HMO/PPO,,44.45,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Select/HMO/PPO,,84.20,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,11.46,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,18.07,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,BCBS NC,Blue Select/HMO/PPO,,7.76,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,10.73,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,61.72,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,22.22,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Select/HMO/PPO,,25.80,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,BCBS NC,Blue Select/HMO/PPO,,24.19,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,7.38,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.71,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,BCBS NC,Blue Select/HMO/PPO,,19.68,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,6.82,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,BCBS NC,Blue Select/HMO/PPO,,10.11,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,BCBS NC,Blue Select/HMO/PPO,,6.07,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,7.04,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,7.70,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.81,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,BCBS NC,Blue Select/HMO/PPO,,156.15,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Select/HMO/PPO,,758.39,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,7266.62,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,7266.62,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,7266.62,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,7266.62,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,7266.62,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,11100.18,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,BCBS NC,Blue Select/HMO/PPO,,118.72,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,BCBS NC,Blue Select/HMO/PPO,,31.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.71,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,BCBS NC,Blue Select/HMO/PPO,,6.77,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Select/HMO/PPO,,43.54,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,BCBS NC,Blue Select/HMO/PPO,,3.64,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,BCBS NC,Blue Select/HMO/PPO,,222.48,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,14.37,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Select/HMO/PPO,,7.57,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.67,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,BCBS NC,Blue Select/HMO/PPO,,81.78,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,BCBS NC,Blue Select/HMO/PPO,,17.16,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,22.79,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.95,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Select/HMO/PPO,,158.65,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,90.64,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,BCBS NC,Blue Select/HMO/PPO,,1.22,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,BCBS NC,Blue Select/HMO/PPO,,0.82292,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,BCBS NC,Blue Select/HMO/PPO,,81.34,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,BCBS NC,Blue Select/HMO/PPO,,87.71,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,BCBS NC,Blue Select/HMO/PPO,,70.14,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,BCBS NC,Blue Select/HMO/PPO,,76.59,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,BCBS NC,Blue Select/HMO/PPO,,0.66127,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,BCBS NC,Blue Select/HMO/PPO,,85.61,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Select/HMO/PPO,,12.09,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Select/HMO/PPO,,19.47,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,BCBS NC,Blue Select/HMO/PPO,,22.87,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,8.43,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Select/HMO/PPO,,11.08,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Select/HMO/PPO,,10.93,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,BCBS NC,Blue Select/HMO/PPO,,13265.47,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Select/HMO/PPO,,10571.67,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Select/HMO/PPO,,15067.72,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,BCBS NC,Blue Select/HMO/PPO,,8.07,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,BCBS NC,Blue Select/HMO/PPO,,163.41,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Select/HMO/PPO,,92.51,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,85.17,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Select/HMO/PPO,,123.82,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,BCBS NC,Blue Select/HMO/PPO,,13751.95,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,2244.28,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1162.55,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,2244.28,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1162.55,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,2244.28,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1162.55,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,297.56,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5529.55,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5529.55,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5529.55,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Select/HMO/PPO,,15020.74,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,727.40,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Select/HMO/PPO,,1227.22,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Select/HMO/PPO,,2435.93,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Select/HMO/PPO,,502.01,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Select/HMO/PPO,,1227.22,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Select/HMO/PPO,,2435.93,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Select/HMO/PPO,,502.01,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,BCBS NC,Blue Select/HMO/PPO,,81.95,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Select/HMO/PPO,,8.74,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,BCBS NC,Blue Select/HMO/PPO,,56381.17,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,BCBS NC,Blue Select/HMO/PPO,,37.88,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,BCBS NC,Blue Select/HMO/PPO,,20.72,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,BCBS NC,Blue Select/HMO/PPO,,21.82,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Select/HMO/PPO,,432.42,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,BCBS NC,Blue Select/HMO/PPO,,20.79,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,BCBS NC,Blue Select/HMO/PPO,,5.97,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,6.32,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,BCBS NC,Blue Select/HMO/PPO,,197.21,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,BCBS NC,Blue Select/HMO/PPO,,42.63,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,BCBS NC,Blue Select/HMO/PPO,,216.31,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,BCBS NC,Blue Select/HMO/PPO,,77.43,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Select/HMO/PPO,,16.28,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Select/HMO/PPO,,16.28,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,BCBS NC,Blue Select/HMO/PPO,,1.50,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,BCBS NC,Blue Select/HMO/PPO,,3.81,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,BCBS NC,Blue Select/HMO/PPO,,23.48,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,BCBS NC,Blue Select/HMO/PPO,,17.71,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,BCBS NC,Blue Select/HMO/PPO,,135.41,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,22.92,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Select/HMO/PPO,,5.04,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,BCBS NC,Blue Select/HMO/PPO,,17.40,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,BCBS NC,Blue Select/HMO/PPO,,11.24,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,BCBS NC,Blue Select/HMO/PPO,,128.13,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.38,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,BCBS NC,Blue Select/HMO/PPO,,31.33,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,171.34,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,BCBS NC,Blue Select/HMO/PPO,,92.21,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,BCBS NC,Blue Select/HMO/PPO,,15.22,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,6.00,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,5.23,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Select/HMO/PPO,,5.35,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,5.20,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,BCBS NC,Blue Select/HMO/PPO,,8.96,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,BCBS NC,Blue Select/HMO/PPO,,8.99,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,BCBS NC,Blue Select/HMO/PPO,,10.04,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,BCBS NC,Blue Select/HMO/PPO,,33.83,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,BCBS NC,Blue Select/HMO/PPO,,14.43,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.78,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,5.33,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,5.03,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,BCBS NC,Blue Select/HMO/PPO,,0.63189,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.99,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,BCBS NC,Blue Select/HMO/PPO,,34.30,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,BCBS NC,Blue Select/HMO/PPO,,68.89,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Select/HMO/PPO,,13.95,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,1.25,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,14.21,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.74,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Select/HMO/PPO,,9.18,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.71,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,BCBS NC,Blue Select/HMO/PPO,,54.56,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,BCBS NC,Blue Select/HMO/PPO,,22.67,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,BCBS NC,Blue Select/HMO/PPO,,8.79,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,5.03,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.71,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,BCBS NC,Blue Select/HMO/PPO,,25.64,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,BCBS NC,Blue Select/HMO/PPO,,26.17,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,BCBS NC,Blue Select/HMO/PPO,,6.88,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,BCBS NC,Blue Select/HMO/PPO,,15.74,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.81,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Select/HMO/PPO,,10.93,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,90.23,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,BCBS NC,Blue Select/HMO/PPO,,139.01,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Select/HMO/PPO,,6.64,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,BCBS NC,Blue Select/HMO/PPO,,8.51,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,BCBS NC,Blue Select/HMO/PPO,,31.08,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,5.64,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,BCBS NC,Blue Select/HMO/PPO,,5.60,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,BCBS NC,Blue Select/HMO/PPO,,6.04,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Select/HMO/PPO,,5.48,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,21.81,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,BCBS NC,Blue Select/HMO/PPO,,3.97,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,5.03,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.47,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.32,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,BCBS NC,Blue Select/HMO/PPO,,7.82,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,BCBS NC,Blue Select/HMO/PPO,,9.01,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.74,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.50,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.67,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,BCBS NC,Blue Select/HMO/PPO,,6.85,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,BCBS NC,Blue Select/HMO/PPO,,9.49,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Select/HMO/PPO,,25.88,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,BCBS NC,Blue Select/HMO/PPO,,48.83,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,BCBS NC,Blue Select/HMO/PPO,,37.72,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,BCBS NC,Blue Select/HMO/PPO,,15.78,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,BCBS NC,Blue Select/HMO/PPO,,7.55,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,5.03,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.41,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,BCBS NC,Blue Select/HMO/PPO,,6.83,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,BCBS NC,Blue Select/HMO/PPO,,3.09,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,6.16,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,5.28,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,BCBS NC,Blue Select/HMO/PPO,,60.09,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,BCBS NC,Blue Select/HMO/PPO,,72.75,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,BCBS NC,Blue Select/HMO/PPO,,21.72,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Select/HMO/PPO,,1996.46,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,BCBS NC,Blue Select/HMO/PPO,,7.14,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,BCBS NC,Blue Select/HMO/PPO,,66.77,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,BCBS NC,Blue Select/HMO/PPO,,29.71,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,10.05,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,BCBS NC,Blue Select/HMO/PPO,,62.51,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Select/HMO/PPO,,1.88,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Select/HMO/PPO,,1.88,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,BCBS NC,Blue Select/HMO/PPO,,33.36,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,BCBS NC,Blue Select/HMO/PPO,,21.25,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,BCBS NC,Blue Select/HMO/PPO,,74.24,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,75.83,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,BCBS NC,Blue Select/HMO/PPO,,79.26,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,BCBS NC,Blue Select/HMO/PPO,,45.67,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,BCBS NC,Blue Select/HMO/PPO,,25.19,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,BCBS NC,Blue Select/HMO/PPO,,32.34,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,BCBS NC,Blue Select/HMO/PPO,,21.35,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,BCBS NC,Blue Select/HMO/PPO,,55.59,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,BCBS NC,Blue Select/HMO/PPO,,13.18,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,BCBS NC,Blue Select/HMO/PPO,,1.13,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,BCBS NC,Blue Select/HMO/PPO,,0.89640,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,BCBS NC,Blue Select/HMO/PPO,,120.65,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,BCBS NC,Blue Select/HMO/PPO,,6.48,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,BCBS NC,Blue Select/HMO/PPO,,7.19,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,BCBS NC,Blue Select/HMO/PPO,,43.72,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,BCBS NC,Blue Select/HMO/PPO,,369.14,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,BCBS NC,Blue Select/HMO/PPO,,6.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,5.13,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,BCBS NC,Blue Select/HMO/PPO,,59.51,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,6.52,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,BCBS NC,Blue Select/HMO/PPO,,7.19,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,5.20,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,BCBS NC,Blue Select/HMO/PPO,,35.65,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,BCBS NC,Blue Select/HMO/PPO,,47.46,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.42,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,BCBS NC,Blue Select/HMO/PPO,,75.44,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,BCBS NC,Blue Select/HMO/PPO,,25.41,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,BCBS NC,Blue Select/HMO/PPO,,7.41,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,BCBS NC,Blue Select/HMO/PPO,,19.24,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.41146,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.41146,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,BCBS NC,Blue Select/HMO/PPO,,0.83761,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,BCBS NC,Blue Select/HMO/PPO,,2.25,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,BCBS NC,Blue Select/HMO/PPO,,27.58,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,5.06,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,24.57,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,24.57,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,24.57,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,BCBS NC,Blue Select/HMO/PPO,,278.43,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,6.52,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,BCBS NC,Blue Select/HMO/PPO,,104.80,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,BCBS NC,Blue Select/HMO/PPO,,118.93,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.35268,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,BCBS NC,Blue Select/HMO/PPO,,15.64,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,BCBS NC,Blue Select/HMO/PPO,,30.79,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,,19.69,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,BCBS NC,Blue Select/HMO/PPO,,34.28,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,BCBS NC,Blue Select/HMO/PPO,,32.93,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,23.14,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,22.48,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,BCBS NC,Blue Select/HMO/PPO,,24.25,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,BCBS NC,Blue Select/HMO/PPO,,24.23,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,BCBS NC,Blue Select/HMO/PPO,,27.96,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,BCBS NC,Blue Select/HMO/PPO,,40.16,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,BCBS NC,Blue Select/HMO/PPO,,21.82,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,BCBS NC,Blue Select/HMO/PPO,,125.80,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,BCBS NC,Blue Select/HMO/PPO,,116.03,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,20.28,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,BCBS NC,Blue Select/HMO/PPO,,23.56,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,BCBS NC,Blue Select/HMO/PPO,,34.00,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,5.07,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,BCBS NC,Blue Select/HMO/PPO,,1557.24,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,BCBS NC,Blue Select/HMO/PPO,,79.32,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,BCBS NC,Blue Select/HMO/PPO,,210.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,BCBS NC,Blue Select/HMO/PPO,,25.01,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,BCBS NC,Blue Select/HMO/PPO,,13.43,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,BCBS NC,Blue Select/HMO/PPO,,14.56,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,0.45554,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,BCBS NC,Blue Select/HMO/PPO,,119.84,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,BCBS NC,Blue Select/HMO/PPO,,581.70,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,BCBS NC,Blue Select/HMO/PPO,,108.10,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,BCBS NC,Blue Select/HMO/PPO,,2.03,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,BCBS NC,Blue Select/HMO/PPO,,189.86,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,BCBS NC,Blue Select/HMO/PPO,,7.80,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,BCBS NC,Blue Select/HMO/PPO,,23.45,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,BCBS NC,Blue Select/HMO/PPO,,34.93,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,6.55,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,BCBS NC,Blue Select/HMO/PPO,,27.86,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,BCBS NC,Blue Select/HMO/PPO,,249.34,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,9.46,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,BCBS NC,Blue Select/HMO/PPO,,8.21,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,8.43,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,84.06,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,BCBS NC,Blue Select/HMO/PPO,,1.84,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,7.36,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,7.36,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,15.71,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,BCBS NC,Blue Select/HMO/PPO,,837.64,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,BCBS NC,Blue Select/HMO/PPO,,18.24,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,6.70,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,BCBS NC,Blue Select/HMO/PPO,,18.37,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.85,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,7.35,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,BCBS NC,Blue Select/HMO/PPO,,11.93,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,BCBS NC,Blue Select/HMO/PPO,,17.22,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,BCBS NC,Blue Select/HMO/PPO,,16.30,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,BCBS NC,Blue Select/HMO/PPO,,13.37,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,BCBS NC,Blue Select/HMO/PPO,,61.56,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,5.03,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,BCBS NC,Blue Select/HMO/PPO,,7.63,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,BCBS NC,Blue Select/HMO/PPO,,126.74,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,BCBS NC,Blue Select/HMO/PPO,,145.07,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,BCBS NC,Blue Select/HMO/PPO,,8070.38,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,BCBS NC,Blue Select/HMO/PPO,,27.16,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Select/HMO/PPO,,85.25,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,BCBS NC,Blue Select/HMO/PPO,,89.67,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,BCBS NC,Blue Select/HMO/PPO,,2667.57,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,BCBS NC,Blue Select/HMO/PPO,,8.04,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,BCBS NC,Blue Select/HMO/PPO,,35.44,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,31.15,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,BCBS NC,Blue Select/HMO/PPO,,31.59,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,31.58,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,BCBS NC,Blue Select/HMO/PPO,,16.68,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,BCBS NC,Blue Select/HMO/PPO,,38.62,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,BCBS NC,Blue Select/HMO/PPO,,28.60,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,BCBS NC,Blue Select/HMO/PPO,,129.93,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,BCBS NC,Blue Select/HMO/PPO,,1.31,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,18.07,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,BCBS NC,Blue Select/HMO/PPO,,13.28,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,5.07,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,BCBS NC,Blue Select/HMO/PPO,,1.54,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,BCBS NC,Blue Select/HMO/PPO,,150.34,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,BCBS NC,Blue Select/HMO/PPO,,103.78,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,5.26,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Select/HMO/PPO,,5.39,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,BCBS NC,Blue Select/HMO/PPO,,9.82,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,BCBS NC,Blue Select/HMO/PPO,,11896.38,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,BCBS NC,Blue Select/HMO/PPO,,166.92,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,BCBS NC,Blue Select/HMO/PPO,,12.02,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,BCBS NC,Blue Select/HMO/PPO,,28.83,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Select/HMO/PPO,,132.95,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Select/HMO/PPO,,119.62,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,BCBS NC,Blue Select/HMO/PPO,,45.53,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,BCBS NC,Blue Select/HMO/PPO,,17.38,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,BCBS NC,Blue Select/HMO/PPO,,7896.27,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,21.09,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Select/HMO/PPO,,234.55,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,BCBS NC,Blue Select/HMO/PPO,,2.69,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.41146,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,BCBS NC,Blue Select/HMO/PPO,,29.13,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,BCBS NC,Blue Select/HMO/PPO,,1126.47,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,BCBS NC,Blue Select/HMO/PPO,,0.95517,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,BCBS NC,Blue Select/HMO/PPO,,0.72006,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,BCBS NC,Blue Select/HMO/PPO,,318.75,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,BCBS NC,Blue Select/HMO/PPO,,11.95,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Select/HMO/PPO,,158.65,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,90.64,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,128.43,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,128.43,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,BCBS NC,Blue Select/HMO/PPO,,231.17,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,BCBS NC,Blue Select/HMO/PPO,,11772.94,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,BCBS NC,Blue Select/HMO/PPO,,5888.83,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,BCBS NC,Blue Select/HMO/PPO,,1.16,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.36738,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.58780,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,BCBS NC,Blue Select/HMO/PPO,,29.96,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.88,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Select/HMO/PPO,,15.02,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,28.80,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,BCBS NC,Blue Select/HMO/PPO,,37.93,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,BCBS NC,Blue Select/HMO/PPO,,109.24,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,BCBS NC,Blue Select/HMO/PPO,,27.88,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,61.72,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,BCBS NC,Blue Select/HMO/PPO,,7.71,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,BCBS NC,Blue Select/HMO/PPO,,14.68,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,BCBS NC,Blue Select/HMO/PPO,,51.51,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,9.08,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,BCBS NC,Blue Select/HMO/PPO,,238.96,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.30860,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.88,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,BCBS NC,Blue Select/HMO/PPO,,156.21,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,BCBS NC,Blue Select/HMO/PPO,,23.53,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,BCBS NC,Blue Select/HMO/PPO,,11.04,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,5.51,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Select/HMO/PPO,,44.45,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,BCBS NC,Blue Select/HMO/PPO,,81.20,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,14.21,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,BCBS NC,Blue Select/HMO/PPO,,78.29,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,BCBS NC,Blue Select/HMO/PPO,,1.19,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,BCBS NC,Blue Select/HMO/PPO,,46.99,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,25.94,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,25.94,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,25.94,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,BCBS NC,Blue Select/HMO/PPO,,154.80,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,8.60,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,24.88,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,24.88,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,BCBS NC,Blue Select/HMO/PPO,,1.54,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Select/HMO/PPO,,8.74,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,BCBS NC,Blue Select/HMO/PPO,,22.06,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,BCBS NC,Blue Select/HMO/PPO,,22.17,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,BCBS NC,Blue Select/HMO/PPO,,21.00,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.52,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,6.16,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,BCBS NC,Blue Select/HMO/PPO,,11.48,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,BCBS NC,Blue Select/HMO/PPO,,1074.50,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,BCBS NC,Blue Select/HMO/PPO,,3686.17,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,BCBS NC,Blue Select/HMO/PPO,,7367.60,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,BCBS NC,Blue Select/HMO/PPO,,608.01,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,BCBS NC,Blue Select/HMO/PPO,,809.19,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,BCBS NC,Blue Select/HMO/PPO,,905.21,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.32329,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.30,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,BCBS NC,Blue Select/HMO/PPO,,127.33,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,6.52,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,BCBS NC,Blue Select/HMO/PPO,,191.92,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.33798,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,BCBS NC,Blue Select/HMO/PPO,,25.30,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,BCBS NC,Blue Select/HMO/PPO,,17.81,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,BCBS NC,Blue Select/HMO/PPO,,219.23,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,30.86,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,11.67,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,18.07,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,BCBS NC,Blue Select/HMO/PPO,,65.53,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,92.58,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,BCBS NC,Blue Select/HMO/PPO,,4.35,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,BCBS NC,Blue Select/HMO/PPO,,488.79,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,BCBS NC,Blue Select/HMO/PPO,,23.12,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,BCBS NC,Blue Select/HMO/PPO,,7.11,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,BCBS NC,Blue Select/HMO/PPO,,24.10,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,13.96,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,BCBS NC,Blue Select/HMO/PPO,,643.35,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,BCBS NC,Blue Select/HMO/PPO,,10.57,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,BCBS NC,Blue Select/HMO/PPO,,77.82,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,BCBS NC,Blue Select/HMO/PPO,,30.71,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,BCBS NC,Blue Select/HMO/PPO,,33.43,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,BCBS NC,Blue Select/HMO/PPO,,13.53,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.50,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.94,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,6.67,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.47,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,BCBS NC,Blue Select/HMO/PPO,,122.62,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,BCBS NC,Blue Select/HMO/PPO,,450.78,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,BCBS NC,Blue Select/HMO/PPO,,11.32,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,BCBS NC,Blue Select/HMO/PPO,,18.18,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,BCBS NC,Blue Select/HMO/PPO,,23.12,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,BCBS NC,Blue Select/HMO/PPO,,28.32,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,BCBS NC,Blue Select/HMO/PPO,,89.04,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,BCBS NC,Blue Select/HMO/PPO,,1066.33,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,BCBS NC,Blue Select/HMO/PPO,,37.35,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,BCBS NC,Blue Select/HMO/PPO,,62.06,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,BCBS NC,Blue Select/HMO/PPO,,26.17,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,BCBS NC,Blue Select/HMO/PPO,,10.08,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,BCBS NC,Blue Select/HMO/PPO,,17.65,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Select/HMO/PPO,,9.18,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,BCBS NC,Blue Select/HMO/PPO,,59.16,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,BCBS NC,Blue Select/HMO/PPO,,51.15,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,18.97,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,BCBS NC,Blue Select/HMO/PPO,,19.06,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,BCBS NC,Blue Select/HMO/PPO,,19.02,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,BCBS NC,Blue Select/HMO/PPO,,70.23,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,BCBS NC,Blue Select/HMO/PPO,,26.77,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.42616,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,BCBS NC,Blue Select/HMO/PPO,,194.36,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,BCBS NC,Blue Select/HMO/PPO,,113.21,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,BCBS NC,Blue Select/HMO/PPO,,532.91,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,24.38,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,BCBS NC,Blue Select/HMO/PPO,,1.35,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,BCBS NC,Blue Select/HMO/PPO,,639.11,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,29.83,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,28.80,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,27.77,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Select/HMO/PPO,,7.23,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,BCBS NC,Blue Select/HMO/PPO,,9.76,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Select/HMO/PPO,,14.71,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,28.80,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,28.80,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,22.48,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,104.63,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,BCBS NC,Blue Select/HMO/PPO,,14.39,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,BCBS NC,Blue Select/HMO/PPO,,1491.91,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,20.57,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.88,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.67,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,BCBS NC,Blue Select/HMO/PPO,,188.89,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,BCBS NC,Blue Select/HMO/PPO,,74.92,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,5.06,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,BCBS NC,Blue Select/HMO/PPO,,28.08,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,BCBS NC,Blue Select/HMO/PPO,,7.39,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,BCBS NC,Blue Select/HMO/PPO,,48.86,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,BCBS NC,Blue Select/HMO/PPO,,25.07,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,BCBS NC,Blue Select/HMO/PPO,,30.23,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,BCBS NC,Blue Select/HMO/PPO,,7.48,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.41146,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,BCBS NC,Blue Select/HMO/PPO,,710.31,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,BCBS NC,Blue Select/HMO/PPO,,1182.15,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,BCBS NC,Blue Select/HMO/PPO,,142.89,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,BCBS NC,Blue Select/HMO/PPO,,210.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,5.07,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,BCBS NC,Blue Select/HMO/PPO,,308.68,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,BCBS NC,Blue Select/HMO/PPO,,15.83,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,BCBS NC,Blue Select/HMO/PPO,,508.70,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,13.02,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,13.02,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,BCBS NC,Blue Select/HMO/PPO,,33.45,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,BCBS NC,Blue Select/HMO/PPO,,485.02,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,BCBS NC,Blue Select/HMO/PPO,,13347.34,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,BCBS NC,Blue Select/HMO/PPO,,45910.82,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,BCBS NC,Blue Select/HMO/PPO,,75679.25,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,BCBS NC,Blue Select/HMO/PPO,,3279.85,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,BCBS NC,Blue Select/HMO/PPO,,2171.98,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,,76.12,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,BCBS NC,Blue Select/HMO/PPO,,4.01,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.35268,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,BCBS NC,Blue Select/HMO/PPO,,2.69,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05878,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,152.53,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,BCBS NC,Blue Select/HMO/PPO,,378.25,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,BCBS NC,Blue Select/HMO/PPO,,565.76,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,BCBS NC,Blue Select/HMO/PPO,,849.66,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,BCBS NC,Blue Select/HMO/PPO,,1019.54,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,BCBS NC,Blue Select/HMO/PPO,,1223.21,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,BCBS NC,Blue Select/HMO/PPO,,1468.32,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,BCBS NC,Blue Select/HMO/PPO,,606.90,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,BCBS NC,Blue Select/HMO/PPO,,891.40,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,BCBS NC,Blue Select/HMO/PPO,,1621.15,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,,47.02,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,BCBS NC,Blue Select/HMO/PPO,,186.04,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,50.84,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,34.39,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.64,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,42.03,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,46.44,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Select/HMO/PPO,,154.00,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Select/HMO/PPO,,175.46,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,149.30,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,27.04,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,BCBS NC,Blue Select/HMO/PPO,,21.45,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Select/HMO/PPO,,67.60,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,BCBS NC,Blue Select/HMO/PPO,,62.01,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Select/HMO/PPO,,1537.98,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Select/HMO/PPO,,1537.98,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,BCBS NC,Blue Select/HMO/PPO,,1464.21,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Select/HMO/PPO,,524.91,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,BCBS NC,Blue Select/HMO/PPO,,883.17,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Select/HMO/PPO,,448.49,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,91.99,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Select/HMO/PPO,,321.23,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,100.51,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,BCBS NC,Blue Select/HMO/PPO,,363.26,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,267.16,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,89.05,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,146.95,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Select/HMO/PPO,,275.68,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Select/HMO/PPO,,78.18,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,59.96,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,BCBS NC,Blue Select/HMO/PPO,,320.94,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Select/HMO/PPO,,278.62,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,84.06,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,12.64,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,41.15,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Select/HMO/PPO,,139.31,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,37.03,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,84.06,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,39.38,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Select/HMO/PPO,,3.23,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,BCBS NC,Blue Select/HMO/PPO,,1465.09,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,BCBS NC,Blue Select/HMO/PPO,,5907.39,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,BCBS NC,Blue Select/HMO/PPO,,1491.25,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,BCBS NC,Blue Select/HMO/PPO,,1246.14,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,BCBS NC,Blue Select/HMO/PPO,,1022.18,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,136.08,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1162.08,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,BCBS NC,Blue Select/HMO/PPO,,1331.37,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,BCBS NC,Blue Select/HMO/PPO,,1311.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Select/HMO/PPO,,1037.76,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,BCBS NC,Blue Select/HMO/PPO,,1714.91,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Select/HMO/PPO,,1217.63,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Select/HMO/PPO,,1217.63,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Select/HMO/PPO,,1416.89,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Select/HMO/PPO,,1416.89,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,BCBS NC,Blue Select/HMO/PPO,,1724.02,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1162.08,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1162.08,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Select/HMO/PPO,,1037.76,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1162.08,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,512.86,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,BCBS NC,Blue Select/HMO/PPO,,1207.93,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,BCBS NC,Blue Select/HMO/PPO,,496.98,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Select/HMO/PPO,,1910.06,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,BCBS NC,Blue Select/HMO/PPO,,347.98,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,BCBS NC,Blue Select/HMO/PPO,,714.76,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,BCBS NC,Blue Select/HMO/PPO,,1082.73,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,BCBS NC,Blue Select/HMO/PPO,,1262.89,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Select/HMO/PPO,,35.56,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,BCBS NC,Blue Select/HMO/PPO,,501.39,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,BCBS NC,Blue Select/HMO/PPO,,1006.90,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,24.39,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Select/HMO/PPO,,137.25,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,BCBS NC,Blue Select/HMO/PPO,,202.50,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,BCBS NC,Blue Select/HMO/PPO,,457.60,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,BCBS NC,Blue Select/HMO/PPO,,346.51,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,GP,6.17,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Select/HMO/PPO,,97.87,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,BCBS NC,Blue Select/HMO/PPO,,441.44,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,BCBS NC,Blue Select/HMO/PPO,,417.93,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,BCBS NC,Blue Select/HMO/PPO,,335.05,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,BCBS NC,Blue Select/HMO/PPO,,252.17,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Select/HMO/PPO,,169.29,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,86.41,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,BCBS NC,Blue Select/HMO/PPO,,481.41,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,BCBS NC,Blue Select/HMO/PPO,,1438.64,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,BCBS NC,Blue Select/HMO/PPO,,1908.00,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Select/HMO/PPO,,1008.08,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,BCBS NC,Blue Select/HMO/PPO,,765.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,BCBS NC,Blue Select/HMO/PPO,,7687.84,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,BCBS NC,Blue Select/HMO/PPO,,8052.57,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,BCBS NC,Blue Select/HMO/PPO,,8475.19,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,BCBS NC,Blue Select/HMO/PPO,,8838.75,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,BCBS NC,Blue Select/HMO/PPO,,9203.77,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,BCBS NC,Blue Select/HMO/PPO,,9567.62,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,BCBS NC,Blue Select/HMO/PPO,,9872.39,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,BCBS NC,Blue Select/HMO/PPO,,10295.02,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,BCBS NC,Blue Select/HMO/PPO,,10659.17,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,BCBS NC,Blue Select/HMO/PPO,,11023.31,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,BCBS NC,Blue Select/HMO/PPO,,11387.74,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,114.03,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,BCBS NC,Blue Select/HMO/PPO,,156.94,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Select/HMO/PPO,,243.64,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,BCBS NC,Blue Select/HMO/PPO,,245.70,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,BCBS NC,Blue Select/HMO/PPO,,1185.89,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,BCBS NC,Blue Select/HMO/PPO,,2846.42,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,BCBS NC,Blue Select/HMO/PPO,,3058.62,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,BCBS NC,Blue Select/HMO/PPO,,3285.51,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,BCBS NC,Blue Select/HMO/PPO,,1791.03,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,BCBS NC,Blue Select/HMO/PPO,,2313.87,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,BCBS NC,Blue Select/HMO/PPO,,2631.87,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,BCBS NC,Blue Select/HMO/PPO,,3388.67,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,BCBS NC,Blue Select/HMO/PPO,,3478.60,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,BCBS NC,Blue Select/HMO/PPO,,3563.24,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,BCBS NC,Blue Select/HMO/PPO,,3648.18,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,BCBS NC,Blue Select/HMO/PPO,,3732.82,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,BCBS NC,Blue Select/HMO/PPO,,1453.63,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Select/HMO/PPO,,196.33,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,BCBS NC,Blue Select/HMO/PPO,,1294.92,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,BCBS NC,Blue Select/HMO/PPO,,1748.41,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,BCBS NC,Blue Select/HMO/PPO,,2394.11,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,BCBS NC,Blue Select/HMO/PPO,,3034.22,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,BCBS NC,Blue Select/HMO/PPO,,3464.20,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,BCBS NC,Blue Select/HMO/PPO,,3923.57,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,BCBS NC,Blue Select/HMO/PPO,,4475.80,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,BCBS NC,Blue Select/HMO/PPO,,4797.62,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,BCBS NC,Blue Select/HMO/PPO,,5272.57,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,BCBS NC,Blue Select/HMO/PPO,,5530.90,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,BCBS NC,Blue Select/HMO/PPO,,5869.18,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,BCBS NC,Blue Select/HMO/PPO,,6086.96,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,BCBS NC,Blue Select/HMO/PPO,,6141.63,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,BCBS NC,Blue Select/HMO/PPO,,6232.74,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,BCBS NC,Blue Select/HMO/PPO,,6414.37,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,BCBS NC,Blue Select/HMO/PPO,,6596.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,BCBS NC,Blue Select/HMO/PPO,,6777.92,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,BCBS NC,Blue Select/HMO/PPO,,6961.02,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,BCBS NC,Blue Select/HMO/PPO,,7142.36,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,BCBS NC,Blue Select/HMO/PPO,,7324.58,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Select/HMO/PPO,,3940.02,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,BCBS NC,Blue Select/HMO/PPO,,3339.29,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,2069.94,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,2069.94,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,2069.94,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,1904.47,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Select/HMO/PPO,,3940.02,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,BCBS NC,Blue Select/HMO/PPO,,2222.47,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,BCBS NC,Blue Select/HMO/PPO,,2504.32,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,89.05,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,373.55,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,149.30,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,149.30,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,BCBS NC,Blue Select/HMO/PPO,,237.47,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,BCBS NC,Blue Select/HMO/PPO,,3172.36,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,BCBS NC,Blue Select/HMO/PPO,,555.47,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Select/HMO/PPO,,360.03,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,BCBS NC,Blue Select/HMO/PPO,,2108.44,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,86.99,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Select/HMO/PPO,,222.19,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,BCBS NC,Blue Select/HMO/PPO,,0.88170,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Select/HMO/PPO,,484.64,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Select/HMO/PPO,,625.13,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Select/HMO/PPO,,766.20,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,BCBS NC,Blue Select/HMO/PPO,,906.68,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,BCBS NC,Blue Select/HMO/PPO,,1047.46,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,BCBS NC,Blue Select/HMO/PPO,,1188.24,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,BCBS NC,Blue Select/HMO/PPO,,1328.72,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,BCBS NC,Blue Select/HMO/PPO,,194.27,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Select/HMO/PPO,,963.99,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Select/HMO/PPO,,1270.24,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,380.31,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Select/HMO/PPO,,518.15,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Select/HMO/PPO,,577.81,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Select/HMO/PPO,,639.82,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Select/HMO/PPO,,701.54,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Select/HMO/PPO,,762.96,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Select/HMO/PPO,,824.98,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Select/HMO/PPO,,484.64,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Select/HMO/PPO,,281.56,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Select/HMO/PPO,,701.54,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,380.31,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Select/HMO/PPO,,518.15,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Select/HMO/PPO,,577.81,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Select/HMO/PPO,,639.82,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Select/HMO/PPO,,762.96,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Select/HMO/PPO,,824.98,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Select/HMO/PPO,,963.99,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Select/HMO/PPO,,1270.24,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,146.66,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Select/HMO/PPO,,1008.08,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,83.76,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,398.82,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Select/HMO/PPO,,451.72,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,BCBS NC,Blue Select/HMO/PPO,,505.21,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Select/HMO/PPO,,558.70,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,BCBS NC,Blue Select/HMO/PPO,,612.78,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,666.57,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Select/HMO/PPO,,720.05,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,BCBS NC,Blue Select/HMO/PPO,,773.25,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,BCBS NC,Blue Select/HMO/PPO,,826.45,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,BCBS NC,Blue Select/HMO/PPO,,880.52,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,BCBS NC,Blue Select/HMO/PPO,,933.72,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,BCBS NC,Blue Select/HMO/PPO,,1003.37,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Select/HMO/PPO,,1057.45,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,BCBS NC,Blue Select/HMO/PPO,,1261.71,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,1344.30,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,BCBS NC,Blue Select/HMO/PPO,,1406.90,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,BCBS NC,Blue Select/HMO/PPO,,1460.39,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,BCBS NC,Blue Select/HMO/PPO,,1513.59,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1284.05,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,BCBS NC,Blue Select/HMO/PPO,,1362.52,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,BCBS NC,Blue Select/HMO/PPO,,1211.75,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,BCBS NC,Blue Select/HMO/PPO,,767.96,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,BCBS NC,Blue Select/HMO/PPO,,830.27,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Select/HMO/PPO,,730.64,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,BCBS NC,Blue Select/HMO/PPO,,982.21,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,99.04,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,2963.10,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,2963.10,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,2963.10,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,374.72,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,BCBS NC,Blue Select/HMO/PPO,,616.01,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,BCBS NC,Blue Select/HMO/PPO,,684.49,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,BCBS NC,Blue Select/HMO/PPO,,371.49,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Select/HMO/PPO,,2202.49,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,298.60,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,118.74,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,1344.30,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Select/HMO/PPO,,3184.99,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,BCBS NC,Blue Select/HMO/PPO,,1550.03,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,90.23,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,BCBS NC,Blue Select/HMO/PPO,,11751.30,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,BCBS NC,Blue Select/HMO/PPO,,12115.15,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,BCBS NC,Blue Select/HMO/PPO,,554.00,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,BCBS NC,Blue Select/HMO/PPO,,163.70,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,BCBS NC,Blue Select/HMO/PPO,,856.72,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,BCBS NC,Blue Select/HMO/PPO,,25.28,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,53.78,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,29.10,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,Q0,0.29684,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,Q0,0.29684,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,176.34,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,219.25,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,BCBS NC,Blue Select/HMO/PPO,,404.11,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,BCBS NC,Blue Select/HMO/PPO,,5751.33,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,BCBS NC,Blue Select/HMO/PPO,,2680.37,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1504.77,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,BCBS NC,Blue Select/HMO/PPO,,1455.98,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,BCBS NC,Blue Select/HMO/PPO,,2186.03,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,BCBS NC,Blue Select/HMO/PPO,,2474.05,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1504.77,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,BCBS NC,Blue Select/HMO/PPO,,1865.68,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,93.46,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Select/HMO/PPO,,30.27,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,61.43,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,42.62,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,93.46,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,37.03,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Select/HMO/PPO,,44.38,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,BCBS NC,Blue Select/HMO/PPO,,54.08,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,86.70,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,BCBS NC,Blue Select/HMO/PPO,,104.33,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,308.01,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Select/HMO/PPO,,30.27,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,124.91,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,176.34,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,BCBS NC,Blue Select/HMO/PPO,,315.35,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Select/HMO/PPO,,278.62,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,219.25,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,219.25,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,BCBS NC,Blue Select/HMO/PPO,,227.48,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1504.77,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Select/HMO/PPO,,147.83,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Select/HMO/PPO,,132.84,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,BCBS NC,Blue Select/HMO/PPO,,396.47,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1504.77,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,BCBS NC,Blue Select/HMO/PPO,,436.15,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,BCBS NC,Blue Select/HMO/PPO,,405.29,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,157.24,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,157.24,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,157.24,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Select/HMO/PPO,,1975.01,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,270.98,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,270.98,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,270.98,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,BCBS NC,Blue Select/HMO/PPO,,357.09,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,BCBS NC,Blue Select/HMO/PPO,,479.35,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,BCBS NC,Blue Select/HMO/PPO,,852.02,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,102.86,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,136.08,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,41.15,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,48.79,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,102.86,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Select/HMO/PPO,,1548.85,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,BCBS NC,Blue Select/HMO/PPO,,300.95,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,187.21,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Select/HMO/PPO,,11629.62,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Select/HMO/PPO,,4997.48,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Select/HMO/PPO,,87.29,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,BCBS NC,Blue Select/HMO/PPO,,90.52,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Select/HMO/PPO,,563.99,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Select/HMO/PPO,,2131.36,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Select/HMO/PPO,,509.62,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Select/HMO/PPO,,968.40,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Select/HMO/PPO,,11820.66,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Select/HMO/PPO,,3678.75,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Select/HMO/PPO,,3268.17,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Select/HMO/PPO,,4603.94,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Select/HMO/PPO,,9280.77,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,775.60,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Select/HMO/PPO,,3267.29,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Select/HMO/PPO,,4714.74,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Select/HMO/PPO,,2785.00,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,792.35,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,792.35,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Select/HMO/PPO,,2458.77,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.29684,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Select/HMO/PPO,,2621.59,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Select/HMO/PPO,,3314.31,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,BCBS NC,Blue Select/HMO/PPO,,1801.90,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Select/HMO/PPO,,4553.98,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Select/HMO/PPO,,368.84,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Select/HMO/PPO,,157.82,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Select/HMO/PPO,,1975.01,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Select/HMO/PPO,,1548.85,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,BCBS NC,Blue Select/HMO/PPO,,276.27,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Select/HMO/PPO,,64.66,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Select/HMO/PPO,,163.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,BCBS NC,Blue Select/HMO/PPO,,1597.64,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,BCBS NC,Blue Select/HMO/PPO,,5832.45,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,BCBS NC,Blue Select/HMO/PPO,,8049.92,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,82.59,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,82.59,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,77.30,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,77.30,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,77.30,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,BCBS NC,Blue Select/HMO/PPO,,918.44,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,BCBS NC,Blue Select/HMO/PPO,,344.45,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,BCBS NC,Blue Select/HMO/PPO,,442.91,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,BCBS NC,Blue Select/HMO/PPO,,415.87,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,BCBS NC,Blue Select/HMO/PPO,,402.64,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,BCBS NC,Blue Select/HMO/PPO,,2928.42,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,BCBS NC,Blue Select/HMO/PPO,Q1,1861.86,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,BCBS NC,Blue Select/HMO/PPO,Q0,1115.35,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,53.49,,,,,,,36.44,147.97,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,161.35,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,110.80,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Select/HMO/PPO,,171.93,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,110.80,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,110.80,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,27.04,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,84.64,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,128.43,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,77.00,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,BCBS NC,Blue Select/HMO/PPO,,68.77,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Select/HMO/PPO,,191.62,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Select/HMO/PPO,,9.70,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,BCBS NC,Blue Select/HMO/PPO,,558.12,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,34.39,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,34.39,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,70.54,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,BCBS NC,Blue Select/HMO/PPO,,105.80,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,136.08,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,123.44,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,BCBS NC,Blue Select/HMO/PPO,,572.22,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Select/HMO/PPO,,584.86,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,BCBS NC,Blue Select/HMO/PPO,,273.91,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,BCBS NC,Blue Select/HMO/PPO,,413.52,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,BCBS NC,Blue Select/HMO/PPO,,429.09,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,BCBS NC,Blue Select/HMO/PPO,,506.68,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,BCBS NC,Blue Select/HMO/PPO,,616.60,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,BCBS NC,Blue Select/HMO/PPO,,1034.23,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,BCBS NC,Blue Select/HMO/PPO,,1834.52,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,BCBS NC,Blue Select/HMO/PPO,,1978.24,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,BCBS NC,Blue Select/HMO/PPO,,186.63,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,BCBS NC,Blue Select/HMO/PPO,,250.11,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,BCBS NC,Blue Select/HMO/PPO,,1866.85,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,2096.98,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,2096.98,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Select/HMO/PPO,,499.04,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,BCBS NC,Blue Select/HMO/PPO,,813.81,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Select/HMO/PPO,,215.72,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,BCBS NC,Blue Select/HMO/PPO,,322.11,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,BCBS NC,Blue Select/HMO/PPO,,137.84,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,BCBS NC,Blue Select/HMO/PPO,,284.50,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,BCBS NC,Blue Select/HMO/PPO,,201.91,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,BCBS NC,Blue Select/HMO/PPO,,454.08,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,BCBS NC,Blue Select/HMO/PPO,,314.77,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,BCBS NC,Blue Select/HMO/PPO,,547.24,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,BCBS NC,Blue Select/HMO/PPO,,132.25,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Select/HMO/PPO,,353.86,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,BCBS NC,Blue Select/HMO/PPO,,2201.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,BCBS NC,Blue Select/HMO/PPO,,2190.73,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,BCBS NC,Blue Select/HMO/PPO,,704.77,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,BCBS NC,Blue Select/HMO/PPO,,513.15,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,BCBS NC,Blue Select/HMO/PPO,,911.09,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,BCBS NC,Blue Select/HMO/PPO,,2475.52,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,124.91,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,166.64,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Select/HMO/PPO,,640.11,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,BCBS NC,Blue Select/HMO/PPO,,614.84,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,BCBS NC,Blue Select/HMO/PPO,,1362.23,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,BCBS NC,Blue Select/HMO/PPO,,722.41,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Select/HMO/PPO,,881.41,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,92.87,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,BCBS NC,Blue Select/HMO/PPO,,94.34,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,BCBS NC,Blue Select/HMO/PPO,,316.24,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,145.77,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Select/HMO/PPO,,177.22,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,145.77,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Select/HMO/PPO,,451.72,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,180.75,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Select/HMO/PPO,,215.72,,,,,,,146.95,3466.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,153.71,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,2096.98,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,BCBS NC,Blue Select/HMO/PPO,,303.30,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,BCBS NC,Blue Select/HMO/PPO,,261.28,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,BCBS NC,Blue Select/HMO/PPO,,341.81,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Select/HMO/PPO,,308.89,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Select/HMO/PPO,,413.22,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Select/HMO/PPO,76,413.22,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,548.12,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Select/HMO/PPO,,1101.54,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Select/HMO/PPO,76,1101.54,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Select/HMO/PPO,,1159.44,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Select/HMO/PPO,76,1159.44,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,597.79,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Select/HMO/PPO,,664.51,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,BCBS NC,Blue Select/HMO/PPO,,700.36,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,BCBS NC,Blue Select/HMO/PPO,,772.66,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,BCBS NC,Blue Select/HMO/PPO,,538.72,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Select/HMO/PPO,,770.61,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,100.81,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,121.38,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,121.38,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,85.82,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,BCBS NC,Blue Select/HMO/PPO,,835.26,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,BCBS NC,Blue Select/HMO/PPO,,8023.18,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,BCBS NC,Blue Select/HMO/PPO,,1103.01,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Select/HMO/PPO,,1268.47,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Select/HMO/PPO,,1268.47,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,BCBS NC,Blue Select/HMO/PPO,,190.45,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Select/HMO/PPO,,208.08,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Select/HMO/PPO,,360.03,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Select/HMO/PPO,,252.75,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Select/HMO/PPO,,268.62,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Select/HMO/PPO,,275.68,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,188.39,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,548.12,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,548.12,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,548.12,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,548.12,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,100.81,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Select/HMO/PPO,,191.03,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,BCBS NC,Blue Select/HMO/PPO,,106.69,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,548.12,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,548.12,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,133.72,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Select/HMO/PPO,76,252.75,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Select/HMO/PPO,76,268.62,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,146.66,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,BCBS NC,Blue Select/HMO/PPO,,306.83,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,BCBS NC,Blue Select/HMO/PPO,,478.76,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Select/HMO/PPO,,688.61,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,BCBS NC,Blue Select/HMO/PPO,,2032.02,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Select/HMO/PPO,,215.43,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,BCBS NC,Blue Select/HMO/PPO,,1783.09,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,BCBS NC,Blue Select/HMO/PPO,,662.45,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,BCBS NC,Blue Select/HMO/PPO,,833.79,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Select/HMO/PPO,,543.13,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,BCBS NC,Blue Select/HMO/PPO,,255.99,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,161.35,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,BCBS NC,Blue Select/HMO/PPO,,236.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,367.96,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,BCBS NC,Blue Select/HMO/PPO,,2399.40,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,BCBS NC,Blue Select/HMO/PPO,,708.30,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,119.03,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,BCBS NC,Blue Select/HMO/PPO,,164.58,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,BCBS NC,Blue Select/HMO/PPO,,488.46,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,BCBS NC,Blue Select/HMO/PPO,,565.17,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,BCBS NC,Blue Select/HMO/PPO,,374.43,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,92.87,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Select/HMO/PPO,,191.03,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Select/HMO/PPO,,640.11,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,917.85,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,BCBS NC,Blue Select/HMO/PPO,,103.16,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,BCBS NC,Blue Select/HMO/PPO,,309.77,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,BCBS NC,Blue Select/HMO/PPO,,136.66,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,BCBS NC,Blue Select/HMO/PPO,,302.13,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,BCBS NC,Blue Select/HMO/PPO,,356.21,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Select/HMO/PPO,,94.64,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,BCBS NC,Blue Select/HMO/PPO,,222.48,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,47.61,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Select/HMO/PPO,,343.86,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Select/HMO/PPO,,87.88,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,BCBS NC,Blue Select/HMO/PPO,,174.87,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,33.21,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,88.76,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,32.04,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,58.78,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,47.32,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,33.21,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,39.09,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,33.21,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,BCBS NC,Blue Select/HMO/PPO,,128.73,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,14.70,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,121.38,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,84.64,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,BCBS NC,Blue Select/HMO/PPO,,56.13,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,79.06,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,GP,19.69,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,GP,22.04,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,GP,3.53,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Select/HMO/PPO,GP,35.56,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,GP,14.40,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Select/HMO/PPO,GP,4.70,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,BCBS NC,Blue Select/HMO/PPO,GP,44.97,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,GP,47.91,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GP,37.62,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,GP,32.33,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,GP,17.34,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,GP,48.20,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,GP,47.02,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Select/HMO/PPO,GP,42.32,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,GP,48.49,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,GP,40.85,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,GP,59.37,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,GP,34.39,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GP,37.91,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Select/HMO/PPO,GP,44.38,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,GP,13.81,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,GP,34.68,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,GP,24.98,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GP,37.91,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GP,29.10,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,GP,52.90,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,GP,52.90,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GP,26.74,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GP,26.74,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,GP,26.16,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,GP,37.33,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,GP,38.21,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GP,20.57,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,GP,8.82,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,GP,89.93,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Select/HMO/PPO,GP,124.32,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,BCBS NC,Blue Select/HMO/PPO,GP,127.55,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,GP,84.64,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GO,26.74,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,GO,34.39,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GO,37.91,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,GO,34.68,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GO,20.57,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GO,37.91,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GO,29.10,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,GO,3.53,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,GO,47.91,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GO,37.62,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,GO,18.22,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,GO,48.20,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,GO,47.02,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Select/HMO/PPO,GO,42.32,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,GO,48.49,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,GO,14.40,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,GO,65.83,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,GO,44.67,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,GO,37.33,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,GO,22.04,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,GO,93.46,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,BCBS NC,Blue Select/HMO/PPO,GO,118.44,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,BCBS NC,Blue Select/HMO/PPO,GO,121.97,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,GO,59.37,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,GN,104.63,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Select/HMO/PPO,GN,98.75,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,GN,54.96,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,GN,79.06,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,GN,58.78,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,GN,92.58,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GN,37.62,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GN,20.57,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,GN,24.98,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GN,29.10,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,GN,67.30,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,GN,39.97,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,BCBS NC,Blue Select/HMO/PPO,GN,192.50,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,GN,76.12,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,GN,19.99,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,GN,38.21,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GN,20.57,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,GN,8.82,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,BCBS NC,Blue Select/HMO/PPO,GN,62.89,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,GN,67.30,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,GN,31.45,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Select/HMO/PPO,GN,103.75,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,GN,161.35,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,BCBS NC,Blue Select/HMO/PPO,GN,173.69,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Select/HMO/PPO,,253.93,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,161.35,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,BCBS NC,Blue Select/HMO/PPO,,260.10,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Select/HMO/PPO,,148.13,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,BCBS NC,Blue Select/HMO/PPO,,218.96,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,BCBS NC,Blue Select/HMO/PPO,,1103.89,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,12.64,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Select/HMO/PPO,,43.50,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,BCBS NC,Blue Select/HMO/PPO,,154.30,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,153.71,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,BCBS NC,Blue Select/HMO/PPO,,165.47,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,110.80,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,110.80,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,398.82,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,BCBS NC,Blue Select/HMO/PPO,,122.85,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Select/HMO/PPO,,238.65,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,166.64,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,BCBS NC,Blue Select/HMO/PPO,,139.90,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Select/HMO/PPO,,191.62,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,134.61,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,45.85,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,52.90,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Select/HMO/PPO,,343.86,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,BCBS NC,Blue Select/HMO/PPO,,38.50,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Select/HMO/PPO,,453.19,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Select/HMO/PPO,,453.19,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,77.59,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,77.59,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,BCBS NC,Blue Select/HMO/PPO,,587.80,,,,,,,186.78,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Select/HMO/PPO,,205.73,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,BCBS NC,Blue Select/HMO/PPO,,667.74,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,244.23,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,BCBS NC,Blue Select/HMO/PPO,,148.42,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,BCBS NC,Blue Select/HMO/PPO,,65.25,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Select/HMO/PPO,,97.87,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,BCBS NC,Blue Select/HMO/PPO,,99.34,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Select/HMO/PPO,,54.37,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Select/HMO/PPO,,1776.04,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Select/HMO/PPO,,1776.04,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,BCBS NC,Blue Select/HMO/PPO,,298.90,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Select/HMO/PPO,,1234.38,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Select/HMO/PPO,,1234.38,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,BCBS NC,Blue Select/HMO/PPO,,1253.78,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,BCBS NC,Blue Select/HMO/PPO,,339.16,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,BCBS NC,Blue Select/HMO/PPO,,162.23,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,166.05,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,BCBS NC,Blue Select/HMO/PPO,,396.76,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Select/HMO/PPO,,283.03,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,161.65,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Select/HMO/PPO,,283.03,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Select/HMO/PPO,,308.89,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,BCBS NC,Blue Select/HMO/PPO,,133.14,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,373.55,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,BCBS NC,Blue Select/HMO/PPO,,340.63,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,213.96,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,141.37,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Select/HMO/PPO,,330.93,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,92.87,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,222.78,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,36.44,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Select/HMO/PPO,,281.56,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,167.82,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,BCBS NC,Blue Select/HMO/PPO,,136.37,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,158.41,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Select/HMO/PPO,,147.83,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Select/HMO/PPO,,462.01,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,119.03,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Select/HMO/PPO,,462.01,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,119.03,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,109.62,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,BCBS NC,Blue Select/HMO/PPO,,198.09,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Select/HMO/PPO,,241.59,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,BCBS NC,Blue Select/HMO/PPO,,251.28,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Select/HMO/PPO,,260.98,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,158.41,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Select/HMO/PPO,,126.08,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,86.70,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,128.43,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,74.36,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Select/HMO/PPO,,180.45,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Select/HMO/PPO,,180.45,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,BCBS NC,Blue Select/HMO/PPO,,160.76,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,62.31,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,62.31,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,62.31,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,62.31,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,117.56,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,117.56,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,117.56,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,78.47,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Select/HMO/PPO,,107.57,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Select/HMO/PPO,,107.57,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Select/HMO/PPO,,480.53,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Select/HMO/PPO,,480.53,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Blue Select/HMO/PPO,,134.31,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,133.72,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,BCBS NC,Blue Select/HMO/PPO,,438.20,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Select/HMO/PPO,,448.49,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,BCBS NC,Blue Select/HMO/PPO,,249.23,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,BCBS NC,Blue Select/HMO/PPO,,362.38,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Select/HMO/PPO,,124.32,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,BCBS NC,Blue Select/HMO/PPO,,293.02,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,136.08,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,BCBS NC,Blue Select/HMO/PPO,,159.88,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,BCBS NC,Blue Select/HMO/PPO,,386.48,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,BCBS NC,Blue Select/HMO/PPO,,466.71,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,573.11,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,BCBS NC,Blue Select/HMO/PPO,,813.22,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,BCBS NC,Blue Select/HMO/PPO,,893.16,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,BCBS NC,Blue Select/HMO/PPO,,1133.28,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,666.57,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,BCBS NC,Blue Select/HMO/PPO,,746.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,BCBS NC,Blue Select/HMO/PPO,,839.97,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,BCBS NC,Blue Select/HMO/PPO,,1333.13,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,BCBS NC,Blue Select/HMO/PPO,,1493.01,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,BCBS NC,Blue Select/HMO/PPO,,1666.41,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Select/HMO/PPO,,306.24,,,,,,,208.61,954.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,10.97,1090.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,85.82,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,86.41,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,14.11,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,14.11,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,31.15,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,227.77,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,227.77,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,227.77,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,227.77,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,227.77,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,227.77,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,BCBS NC,Blue Select/HMO/PPO,GP,19.59,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,BCBS NC,Blue Select/HMO/PPO,,140.78,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Select/HMO/PPO,,806.46,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Select/HMO/PPO,,806.46,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Select/HMO/PPO,,1138.86,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Select/HMO/PPO,,318.88,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Select/HMO/PPO,,318.88,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,BCBS NC,Blue Select/HMO/PPO,,724.17,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Select/HMO/PPO,,305.36,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Select/HMO/PPO,,305.36,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,BCBS NC,Blue Select/HMO/PPO,,937.54,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,BCBS NC,Blue Select/HMO/PPO,,126.38,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,141.07,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Select/HMO/PPO,,157.53,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,134.61,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,34.97,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,37.91,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,37.91,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,61.13,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,47.91,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,90.23,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,BCBS NC,Blue Select/HMO/PPO,,152.83,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Select/HMO/PPO,,148.13,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,BCBS NC,Blue Select/HMO/PPO,,181.63,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,BCBS NC,Blue Select/HMO/PPO,,120.21,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,226.30,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,226.30,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,BCBS NC,Blue Select/HMO/PPO,,187.51,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Select/HMO/PPO,,177.22,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Select/HMO/PPO,,265.10,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,53.49,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,44.67,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,82.29,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,114.03,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,223.07,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,223.07,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Select/HMO/PPO,,674.50,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,BCBS NC,Blue Select/HMO/PPO,,178.40,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Select/HMO/PPO,,547.54,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Select/HMO/PPO,,547.54,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Select/HMO/PPO,,626.59,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Select/HMO/PPO,,157.53,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,304.77,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,BCBS NC,Blue Select/HMO/PPO,,3675.81,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,BCBS NC,Blue Select/HMO/PPO,,446.73,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,BCBS NC,Blue Select/HMO/PPO,,568.11,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Select/HMO/PPO,,245.11,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,BCBS NC,Blue Select/HMO/PPO,,255.40,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,BCBS NC,Blue Select/HMO/PPO,,271.86,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,BCBS NC,Blue Select/HMO/PPO,,452.02,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,563.70,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,BCBS NC,Blue Select/HMO/PPO,,2872.58,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,193.97,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,193.97,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,937.25,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,937.25,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,449.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,449.08,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,BCBS NC,Blue Select/HMO/PPO,,507.57,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Select/HMO/PPO,,629.53,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Select/HMO/PPO,,629.53,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Select/HMO/PPO,,410.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Select/HMO/PPO,,410.58,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Select/HMO/PPO,,182.51,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Select/HMO/PPO,,182.51,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Select/HMO/PPO,,211.61,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Select/HMO/PPO,,211.61,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,109.62,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Select/HMO/PPO,,658.34,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,JW,38.79,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Select/HMO/PPO,,172.23,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,146.66,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,BCBS NC,Blue Select/HMO/PPO,,177.52,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,146.66,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Select/HMO/PPO,,172.23,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Select/HMO/PPO,,241.59,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,BCBS NC,Blue Select/HMO/PPO,,400.88,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Select/HMO/PPO,,103.45,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1158.26,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1158.26,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1158.26,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1158.26,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,573.11,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,573.11,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Select/HMO/PPO,,911.97,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Select/HMO/PPO,,911.97,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,BCBS NC,Blue Select/HMO/PPO,,506.39,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Select/HMO/PPO,,626.59,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Select/HMO/PPO,,822.92,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Select/HMO/PPO,,159.59,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,BCBS NC,Blue Select/HMO/PPO,,1288.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,BCBS NC,Blue Select/HMO/PPO,,1425.41,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,BCBS NC,Blue Select/HMO/PPO,,1685.22,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,236.30,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Select/HMO/PPO,,459.95,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Select/HMO/PPO,,459.95,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,BCBS NC,Blue Select/HMO/PPO,,564.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,BCBS NC,Blue Select/HMO/PPO,,499.92,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,171.05,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,666.57,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,BCBS NC,Blue Select/HMO/PPO,,371.78,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,685.67,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,685.67,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,BCBS NC,Blue Select/HMO/PPO,,601.61,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,BCBS NC,Blue Select/HMO/PPO,,392.36,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Select/HMO/PPO,,248.93,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,523.44,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,523.44,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Select/HMO/PPO,,499.04,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Select/HMO/PPO,,405.88,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Select/HMO/PPO,,405.88,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,527.26,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,527.26,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Select/HMO/PPO,,1210.57,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Select/HMO/PPO,,1210.57,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Select/HMO/PPO,,1021.30,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Select/HMO/PPO,,1021.30,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,150.48,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Select/HMO/PPO,,174.58,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,BCBS NC,Blue Select/HMO/PPO,52,323.29,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,223.07,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,BCBS NC,Blue Select/HMO/PPO,,208.96,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,BCBS NC,Blue Select/HMO/PPO,,429.39,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,,37.33,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,270.09,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,270.09,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,109.62,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,93.17,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,BCBS NC,Blue Select/HMO/PPO,,204.85,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,BCBS NC,Blue Select/HMO/PPO,,409.40,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,BCBS NC,Blue Select/HMO/PPO,,698.01,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,BCBS NC,Blue Select/HMO/PPO,,930.78,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,BCBS NC,Blue Select/HMO/PPO,,1178.83,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,BCBS NC,Blue Select/HMO/PPO,,389.12,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,BCBS NC,Blue Select/HMO/PPO,,354.74,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Select/HMO/PPO,,106.10,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,86.99,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,55.55,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,45.85,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,45.85,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,804.11,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,59.07,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,55.25,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Select/HMO/PPO,,73.18,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,70.54,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,93.17,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,117.27,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,109.04,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,139.60,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,53.20,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Select/HMO/PPO,,66.72,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,78.47,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Select/HMO/PPO,,73.47,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Select/HMO/PPO,,119.32,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Select/HMO/PPO,,127.85,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,128.43,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Select/HMO/PPO,,116.68,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,53.20,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Select/HMO/PPO,,74.65,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,114.03,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,BCBS NC,Blue Select/HMO/PPO,,143.72,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,31.15,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,BCBS NC,Blue Select/HMO/PPO,,51.73,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,BCBS NC,Blue Select/HMO/PPO,,76.41,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,100.81,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,67.89,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,93.17,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,139.60,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Select/HMO/PPO,,169.29,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Select/HMO/PPO,,40.26,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,32.92,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,14.11,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,38.21,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,7.35,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,JW,36.15,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,36.15,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,JW,27.92,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Select/HMO/PPO,,41.73,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,80.82,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,58.78,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,JW,58.78,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,133.72,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,267.74,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,JW,267.74,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,JW,133.72,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,290.37,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,JW,290.37,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,JW,80.23,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,167.82,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,77.00,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,809.40,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,357.38,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,181.04,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,JW,809.40,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,JW,357.38,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,JW,181.04,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,826.74,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,36.15,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,100.51,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,JW,100.51,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,454.37,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Select/HMO/PPO,,909.33,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,JW,454.37,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,125.79,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,JW,125.79,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,JW,141.95,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,2.94,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,734.16,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,JW,734.16,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,595.15,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,JW,595.15,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,501.98,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,JW,501.98,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,JW,19.10,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,725.64,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,205.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,205.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,180.75,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,180.75,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,117.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,117.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Select/HMO/PPO,JW,694.49,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,JW,167.82,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,JW,77.00,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,91.99,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,JW,91.99,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,462.89,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,JW,462.89,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,367.96,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,JW,367.96,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,188.39,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,JW,188.39,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,99.93,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,JW,99.93,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,79.94,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,JW,79.94,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Select/HMO/PPO,,752.97,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,86.70,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,187.21,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,187.21,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,187.21,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,187.21,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,79.35,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,BCBS NC,Blue Select/HMO/PPO,,1247.02,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,53.20,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Select/HMO/PPO,,72.30,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,BCBS NC,Blue Select/HMO/PPO,,757.38,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,61.43,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,89.05,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Select/HMO/PPO,,580.75,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Select/HMO/PPO,,580.75,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,126.96,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,126.96,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,99.04,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,82.29,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,79.06,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,BCBS NC,Blue Select/HMO/PPO,,2756.49,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,BCBS NC,Blue Select/HMO/PPO,,327.11,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,304.77,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,BCBS NC,Blue Select/HMO/PPO,,351.80,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,BCBS NC,Blue Select/HMO/PPO,,236.88,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Select/HMO/PPO,,583.39,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Select/HMO/PPO,,583.39,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Select/HMO/PPO,,3431.58,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Select/HMO/PPO,,3431.58,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Select/HMO/PPO,,5970.87,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Select/HMO/PPO,,5970.87,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Select/HMO/PPO,,2539.30,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Select/HMO/PPO,,2539.30,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Select/HMO/PPO,,5387.48,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Select/HMO/PPO,,5387.48,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Select/HMO/PPO,,8716.19,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Select/HMO/PPO,,8716.19,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,79.06,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Select/HMO/PPO,,120.50,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Select/HMO/PPO,,174.58,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,150.48,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,226.60,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,BCBS NC,Blue Select/HMO/PPO,,200.15,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Select/HMO/PPO,,1138.86,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,42.03,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,92.58,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,57.31,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,92.58,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,57.31,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,92.58,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,57.31,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,151.36,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,48.49,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Select/HMO/PPO,,278.91,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Select/HMO/PPO,,142.25,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,37.62,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,41.44,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,46.44,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,27.04,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,27.04,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,62.31,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Select/HMO/PPO,,120.50,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,151.36,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,44.09,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,14.80,1090.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,151.36,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,BCBS NC,Blue Select/HMO/PPO,,11756.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,BCBS NC,Blue Select/HMO/PPO,,228.36,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Select/HMO/PPO,,2579.85,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Select/HMO/PPO,,2579.85,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,BCBS NC,Blue Select/HMO/PPO,,1452.16,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,85.82,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,259.81,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Select/HMO/PPO,,60.25,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Select/HMO/PPO,,60.25,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,BCBS NC,Blue Select/HMO/PPO,,285.08,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,361.50,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,BCBS NC,Blue Select/HMO/PPO,,1839.52,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,917.85,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,BCBS NC,Blue Select/HMO/PPO,,142.84,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,BCBS NC,Blue Select/HMO/PPO,,6061.39,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,917.85,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,BCBS NC,Blue Select/HMO/PPO,,247.46,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,BCBS NC,Blue Select/HMO/PPO,,686.55,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,BCBS NC,Blue Select/HMO/PPO,,680.97,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,BCBS NC,Blue Select/HMO/PPO,,682.44,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,BCBS NC,Blue Select/HMO/PPO,,3505.93,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Select/HMO/PPO,,154.00,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Select/HMO/PPO,,168.40,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,BCBS NC,Blue Select/HMO/PPO,,391.18,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,752.68,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,752.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Select/HMO/PPO,,556.94,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Select/HMO/PPO,,556.94,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Select/HMO/PPO,,1015.72,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Select/HMO/PPO,,1015.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,752.68,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,752.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Select/HMO/PPO,,1524.46,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,362.97,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,308.01,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,207.79,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,161.65,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,129.90,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,136.96,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,JW,362.97,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,JW,308.01,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,JW,207.79,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,JW,161.65,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,JW,129.90,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,JW,136.96,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Select/HMO/PPO,,610.72,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,52.61,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,55.25,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,BCBS NC,Blue Select/HMO/PPO,,234.24,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,290.37,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,BCBS NC,Blue Select/HMO/PPO,,420.86,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,260.40,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,52.61,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,BCBS NC,Blue Select/HMO/PPO,,537.25,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,BCBS NC,Blue Select/HMO/PPO,,762.38,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,BCBS NC,Blue Select/HMO/PPO,,277.74,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,BCBS NC,Blue Select/HMO/PPO,,847.31,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Select/HMO/PPO,,280.97,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,260.40,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,BCBS NC,Blue Select/HMO/PPO,,412.05,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,BCBS NC,Blue Select/HMO/PPO,,638.94,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,BCBS NC,Blue Select/HMO/PPO,,1243.78,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,BCBS NC,Blue Select/HMO/PPO,,5622.89,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Select/HMO/PPO,,126.08,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Select/HMO/PPO,,132.84,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,117.85,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,195.44,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,93.46,,,,,,,55.36,1831.00,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,89.64,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,BCBS NC,Blue Select/HMO/PPO,,160.18,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Select/HMO/PPO,,103.45,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,141.37,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,BCBS NC,Blue Select/HMO/PPO,,176.63,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,115.80,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,129.90,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,146.95,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,44.67,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,79.35,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,35.27,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,147.24,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,BCBS NC,Blue Select/HMO/PPO,,197.21,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,52.61,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,88.76,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Select/HMO/PPO,,106.39,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,141.95,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Select/HMO/PPO,,171.64,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Select/HMO/PPO,,317.12,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Select/HMO/PPO,,171.93,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,89.64,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,129.90,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,145.77,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,193.97,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,BCBS NC,Blue Select/HMO/PPO,,273.03,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,128.43,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,BCBS NC,Blue Select/HMO/PPO,,96.11,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,BCBS NC,Blue Select/HMO/PPO,,165.76,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,144.60,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,BCBS NC,Blue Select/HMO/PPO,,208.67,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Select/HMO/PPO,,257.16,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,171.05,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,100.22,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,BCBS NC,Blue Select/HMO/PPO,,159.00,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Select/HMO/PPO,,108.45,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Select/HMO/PPO,,108.16,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,BCBS NC,Blue Select/HMO/PPO,,355.91,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,221.01,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,BCBS NC,Blue Select/HMO/PPO,,392.65,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,BCBS NC,Blue Select/HMO/PPO,,556.06,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Select/HMO/PPO,,611.61,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,124.91,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,BCBS NC,Blue Select/HMO/PPO,,112.27,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,134.90,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,BCBS NC,Blue Select/HMO/PPO,,135.78,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,373.55,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,BCBS NC,Blue Select/HMO/PPO,,153.42,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,BCBS NC,Blue Select/HMO/PPO,,129.32,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Select/HMO/PPO,,119.32,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,129.90,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,143.13,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Select/HMO/PPO,,111.39,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,BCBS NC,Blue Select/HMO/PPO,,87.58,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,BCBS NC,Blue Select/HMO/PPO,,110.21,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,BCBS NC,Blue Select/HMO/PPO,,101.98,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,BCBS NC,Blue Select/HMO/PPO,,191.92,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Select/HMO/PPO,,126.67,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,115.80,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,BCBS NC,Blue Select/HMO/PPO,,81.12,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Select/HMO/PPO,,247.17,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,125.50,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,109.04,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Select/HMO/PPO,,141.66,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,92.87,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,111.68,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,104.04,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,64.07,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,BCBS NC,Blue Select/HMO/PPO,,130.79,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,136.08,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,111.68,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,BCBS NC,Blue Select/HMO/PPO,,155.77,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,136.08,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,117.85,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,125.20,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,145.48,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,145.48,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,145.48,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,BCBS NC,Blue Select/HMO/PPO,,229.83,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Select/HMO/PPO,,94.64,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,72.59,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,310.06,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,213.96,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Select/HMO/PPO,,260.98,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,BCBS NC,Blue Select/HMO/PPO,,146.36,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Select/HMO/PPO,,155.47,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,290.37,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,305.95,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Select/HMO/PPO,,315.65,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Select/HMO/PPO,,157.82,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,28.80,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,BCBS NC,Blue Select/HMO/PPO,,170.46,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,BCBS NC,Blue Select/HMO/PPO,,188.98,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Select/HMO/PPO,,240.41,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,BCBS NC,Blue Select/HMO/PPO,,195.74,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,BCBS NC,Blue Select/HMO/PPO,,238.06,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,BCBS NC,Blue Select/HMO/PPO,,613.66,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,BCBS NC,Blue Select/HMO/PPO,,1365.17,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,BCBS NC,Blue Select/HMO/PPO,,1051.28,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Select/HMO/PPO,,54.37,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Select/HMO/PPO,,402.06,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,BCBS NC,Blue Select/HMO/PPO,,409.99,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,BCBS NC,Blue Select/HMO/PPO,,1189.41,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,BCBS NC,Blue Select/HMO/PPO,,1688.75,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,BCBS NC,Blue Select/HMO/PPO,,389.71,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,BCBS NC,Blue Select/HMO/PPO,,755.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,BCBS NC,Blue Select/HMO/PPO,,303.01,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,BCBS NC,Blue Select/HMO/PPO,,353.27,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,BCBS NC,Blue Select/HMO/PPO,,472.59,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,236.30,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,BCBS NC,Blue Select/HMO/PPO,,474.94,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Select/HMO/PPO,,284.20,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Select/HMO/PPO,,234.83,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Select/HMO/PPO,,325.05,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,685.67,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,BCBS NC,Blue Select/HMO/PPO,,404.41,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,59.96,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,51.43,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Select/HMO/PPO,,353.86,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,226.60,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,310.65,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,BCBS NC,Blue Select/HMO/PPO,,105.22,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Select/HMO/PPO,,280.09,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Select/HMO/PPO,,49.67,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Select/HMO/PPO,,275.09,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,,89.93,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,100.22,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,42.03,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,BCBS NC,Blue Select/HMO/PPO,,218.66,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,BCBS NC,Blue Select/HMO/PPO,,194.56,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,BCBS NC,Blue Select/HMO/PPO,,193.09,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,94.93,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,BCBS NC,Blue Select/HMO/PPO,,189.86,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,BCBS NC,Blue Select/HMO/PPO,,101.69,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,71.42,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Select/HMO/PPO,,78.77,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,BCBS NC,Blue Select/HMO/PPO,,272.45,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,,89.93,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,267.74,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Select/HMO/PPO,,85.52,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,BCBS NC,Blue Select/HMO/PPO,,231.59,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Select/HMO/PPO,,688.61,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,BCBS NC,Blue Select/HMO/PPO,,1187.06,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,BCBS NC,Blue Select/HMO/PPO,,981.04,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Select/HMO/PPO,,1057.45,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,BCBS NC,Blue Select/HMO/PPO,,598.09,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,1326.66,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,1326.66,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,1326.66,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,BCBS NC,Blue Select/HMO/PPO,,897.28,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Select/HMO/PPO,,524.91,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,BCBS NC,Blue Select/HMO/PPO,,412.64,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Select/HMO/PPO,,78.77,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Select/HMO/PPO,,109.92,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,BCBS NC,Blue Select/HMO/PPO,,97.57,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,244.23,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,47.91,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,147.24,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Select/HMO/PPO,,611.61,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Select/HMO/PPO,,181.34,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Select/HMO/PPO,,238.65,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,BCBS NC,Blue Select/HMO/PPO,,253.05,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Select/HMO/PPO,,137.25,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,BCBS NC,Blue Select/HMO/PPO,,145.19,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,153.71,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,222.78,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,BCBS NC,Blue Select/HMO/PPO,,216.31,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Select/HMO/PPO,,317.12,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,,67.30,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,126.96,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,BCBS NC,Blue Select/HMO/PPO,,312.42,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,180.75,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,BCBS NC,Blue Select/HMO/PPO,,230.71,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,BCBS NC,Blue Select/HMO/PPO,,11021.25,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,BCBS NC,Blue Select/HMO/PPO,,63.78,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,BCBS NC,Blue Select/HMO/PPO,,544.60,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,BCBS NC,Blue Select/HMO/PPO,,662.16,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,123.44,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,161.65,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Select/HMO/PPO,,158.71,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,117.85,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,BCBS NC,Blue Select/HMO/PPO,,175.16,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,BCBS NC,Blue Select/HMO/PPO,,146.07,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,221.01,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,170.76,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,BCBS NC,Blue Select/HMO/PPO,,272.74,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,BCBS NC,Blue Select/HMO/PPO,,406.17,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,79.35,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Select/HMO/PPO,,243.64,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,100.81,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,121.38,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,398.82,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,198.97,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,BCBS NC,Blue Select/HMO/PPO,,201.32,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,BCBS NC,Blue Select/HMO/PPO,,324.47,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,171.34,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,BCBS NC,Blue Select/HMO/PPO,,857.31,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,BCBS NC,Blue Select/HMO/PPO,,439.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Select/HMO/PPO,,321.23,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,BCBS NC,Blue Select/HMO/PPO,,286.85,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,BCBS NC,Blue Select/HMO/PPO,,210.73,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Select/HMO/PPO,,548.42,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,BCBS NC,Blue Select/HMO/PPO,,298.01,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,BCBS NC,Blue Select/HMO/PPO,,611.02,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Select/HMO/PPO,,470.83,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,BCBS NC,Blue Select/HMO/PPO,,673.03,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Select/HMO/PPO,,470.83,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Select/HMO/PPO,,698.89,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,BCBS NC,Blue Select/HMO/PPO,,803.23,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,BCBS NC,Blue Select/HMO/PPO,,251.58,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,BCBS NC,Blue Select/HMO/PPO,,460.54,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,361.50,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,BCBS NC,Blue Select/HMO/PPO,,659.81,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Select/HMO/PPO,,306.24,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,BCBS NC,Blue Select/HMO/PPO,,337.40,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Select/HMO/PPO,,368.84,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,BCBS NC,Blue Select/HMO/PPO,,524.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Select/HMO/PPO,,774.72,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Select/HMO/PPO,,774.72,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,BCBS NC,Blue Select/HMO/PPO,,733.87,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,BCBS NC,Blue Select/HMO/PPO,,1139.16,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,BCBS NC,Blue Select/HMO/PPO,,1423.65,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,244.23,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,BCBS NC,Blue Select/HMO/PPO,,422.92,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,380.31,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Select/HMO/PPO,,467.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Select/HMO/PPO,,730.64,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,BCBS NC,Blue Select/HMO/PPO,,228.65,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,430.27,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Select/HMO/PPO,,253.93,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,BCBS NC,Blue Select/HMO/PPO,,320.35,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Select/HMO/PPO,,234.83,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,340.92,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,BCBS NC,Blue Select/HMO/PPO,,388.24,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,340.92,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Select/HMO/PPO,,473.47,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,373.55,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,BCBS NC,Blue Select/HMO/PPO,,271.27,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,BCBS NC,Blue Select/HMO/PPO,,688.02,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,BCBS NC,Blue Select/HMO/PPO,,864.95,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Select/HMO/PPO,,81.41,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,29.10,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,BCBS NC,Blue Select/HMO/PPO,,596.62,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,290.37,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,61.13,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,55.25,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,BCBS NC,Blue Select/HMO/PPO,,821.16,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,BCBS NC,Blue Select/HMO/PPO,,3671.69,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,BCBS NC,Blue Select/HMO/PPO,,482.88,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,152.53,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,BCBS NC,Blue Select/HMO/PPO,,597.50,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,BCBS NC,Blue Select/HMO/PPO,,138.13,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,BCBS NC,Blue Select/HMO/PPO,,3635.84,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,198.97,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.29684,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,25.57,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,BCBS NC,Blue Select/HMO/PPO,,258.04,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,34.97,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Select/HMO/PPO,,171.64,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,94.93,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,BCBS NC,Blue Select/HMO/PPO,,1551.79,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Select/HMO/PPO,,1.76,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,BCBS NC,Blue Select/HMO/PPO,,190.74,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,35.86,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,BCBS NC,Blue Select/HMO/PPO,,24.10,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Select/HMO/PPO,,74.65,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,BCBS NC,Blue Select/HMO/PPO,,1780.45,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,53.78,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,BCBS NC,Blue Select/HMO/PPO,,315.94,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,89.64,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,BCBS NC,Blue Select/HMO/PPO,,419.69,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,89.64,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Select/HMO/PPO,,592.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Select/HMO/PPO,,592.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Select/HMO/PPO,,394.71,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,143.13,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Select/HMO/PPO,,127.85,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Select/HMO/PPO,,658.34,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,BCBS NC,Blue Select/HMO/PPO,,471.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,982.80,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,982.80,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,982.80,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Select/HMO/PPO,,384.72,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,BCBS NC,Blue Select/HMO/PPO,,566.93,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,BCBS NC,Blue Select/HMO/PPO,,314.18,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,BCBS NC,Blue Select/HMO/PPO,,560.76,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,361.50,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,BCBS NC,Blue Select/HMO/PPO,,1180.89,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,BCBS NC,Blue Select/HMO/PPO,,972.81,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Select/HMO/PPO,,1217.33,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Select/HMO/PPO,,1217.33,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,BCBS NC,Blue Select/HMO/PPO,,1193.82,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Select/HMO/PPO,,303.60,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Select/HMO/PPO,,330.93,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,BCBS NC,Blue Select/HMO/PPO,,745.62,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Select/HMO/PPO,,378.84,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,BCBS NC,Blue Select/HMO/PPO,,334.46,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,BCBS NC,Blue Select/HMO/PPO,,372.96,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Select/HMO/PPO,,664.51,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,BCBS NC,Blue Select/HMO/PPO,,784.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,BCBS NC,Blue Select/HMO/PPO,,959.29,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Select/HMO/PPO,,720.05,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,BCBS NC,Blue Select/HMO/PPO,,864.65,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,BCBS NC,Blue Select/HMO/PPO,,964.58,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,BCBS NC,Blue Select/HMO/PPO,,745.33,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,BCBS NC,Blue Select/HMO/PPO,,909.91,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,BCBS NC,Blue Select/HMO/PPO,,1029.24,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,BCBS NC,Blue Select/HMO/PPO,,759.44,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,BCBS NC,Blue Select/HMO/PPO,,905.80,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,BCBS NC,Blue Select/HMO/PPO,,1032.18,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,1230.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Select/HMO/PPO,,1167.08,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,BCBS NC,Blue Select/HMO/PPO,,685.08,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Select/HMO/PPO,,859.66,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,BCBS NC,Blue Select/HMO/PPO,,1011.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,BCBS NC,Blue Select/HMO/PPO,,1138.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,BCBS NC,Blue Select/HMO/PPO,,844.08,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,BCBS NC,Blue Select/HMO/PPO,,1063.33,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,BCBS NC,Blue Select/HMO/PPO,,1088.61,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,BCBS NC,Blue Select/HMO/PPO,,658.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,BCBS NC,Blue Select/HMO/PPO,,802.05,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,BCBS NC,Blue Select/HMO/PPO,,935.78,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Select/HMO/PPO,,770.61,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,937.25,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Select/HMO/PPO,,1094.19,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,BCBS NC,Blue Select/HMO/PPO,,886.99,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,BCBS NC,Blue Select/HMO/PPO,,673.62,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,BCBS NC,Blue Select/HMO/PPO,,842.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,BCBS NC,Blue Select/HMO/PPO,,902.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,BCBS NC,Blue Select/HMO/PPO,,862.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,BCBS NC,Blue Select/HMO/PPO,,1182.07,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,BCBS NC,Blue Select/HMO/PPO,,1276.41,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,BCBS NC,Blue Select/HMO/PPO,,1167.96,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,737.98,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,BCBS NC,Blue Select/HMO/PPO,,949.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,BCBS NC,Blue Select/HMO/PPO,,1244.67,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,BCBS NC,Blue Select/HMO/PPO,,1448.05,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,BCBS NC,Blue Select/HMO/PPO,,732.99,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,BCBS NC,Blue Select/HMO/PPO,,932.84,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,BCBS NC,Blue Select/HMO/PPO,,1104.48,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,BCBS NC,Blue Select/HMO/PPO,,2163.40,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,10128.68,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,BCBS NC,Blue Select/HMO/PPO,,1573.83,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,BCBS NC,Blue Select/HMO/PPO,,1874.79,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,BCBS NC,Blue Select/HMO/PPO,,2179.27,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Select/HMO/PPO,,384.72,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,BCBS NC,Blue Select/HMO/PPO,,1192.94,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Select/HMO/PPO,,1167.08,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,1230.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Select/HMO/PPO,,859.66,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Select/HMO/PPO,,822.92,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,BCBS NC,Blue Select/HMO/PPO,,140.19,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Select/HMO/PPO,,344.74,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Select/HMO/PPO,,391.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Select/HMO/PPO,,391.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,BCBS NC,Blue Select/HMO/PPO,,426.15,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Select/HMO/PPO,,518.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Select/HMO/PPO,,518.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Select/HMO/PPO,,558.70,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,139.60,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,99.04,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,10128.68,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,10128.68,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,BCBS NC,Blue Select/HMO/PPO,,9247.86,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,79.06,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,213.96,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,184.86,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,BCBS NC,Blue Select/HMO/PPO,,585.74,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,BCBS NC,Blue Select/HMO/PPO,,1500.36,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Select/HMO/PPO,,159.59,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,BCBS NC,Blue Select/HMO/PPO,,407.64,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,BCBS NC,Blue Select/HMO/PPO,,258.63,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,BCBS NC,Blue Select/HMO/PPO,,16914.24,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,1427.47,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,1427.47,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,BCBS NC,Blue Select/HMO/PPO,,8680.34,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,BCBS NC,Blue Select/HMO/PPO,,326.23,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Select/HMO/PPO,,881.41,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,45.55,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,45.55,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,BCBS NC,Blue Select/HMO/PPO,,123.73,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Select/HMO/PPO,,858.48,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,184.86,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Select/HMO/PPO,,134.02,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,BCBS NC,Blue Select/HMO/PPO,,68.18,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,59.07,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,141.37,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,BCBS NC,Blue Select/HMO/PPO,,325.94,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,134.61,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,83.76,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,BCBS NC,Blue Select/HMO/PPO,,411.46,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Select/HMO/PPO,,464.95,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Select/HMO/PPO,,464.95,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Select/HMO/PPO,,684.79,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Select/HMO/PPO,,684.79,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Select/HMO/PPO,,91.40,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Select/HMO/PPO,,91.40,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,236.30,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,236.30,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,BCBS NC,Blue Select/HMO/PPO,,212.20,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Select/HMO/PPO,,169.58,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Select/HMO/PPO,,169.58,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,BCBS NC,Blue Select/HMO/PPO,,1387.21,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,BCBS NC,Blue Select/HMO/PPO,,992.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,BCBS NC,Blue Select/HMO/PPO,,209.26,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,166.05,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,BCBS NC,Blue Select/HMO/PPO,,415.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,BCBS NC,Blue Select/HMO/PPO,,224.83,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,BCBS NC,Blue Select/HMO/PPO,,379.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,170.76,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,374.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,374.72,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Select/HMO/PPO,,343.28,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Select/HMO/PPO,,887.28,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Select/HMO/PPO,,887.28,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,88.17,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,BCBS NC,Blue Select/HMO/PPO,,571.05,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,430.27,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Select/HMO/PPO,,245.11,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,BCBS NC,Blue Select/HMO/PPO,,477.00,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,BCBS NC,Blue Select/HMO/PPO,,520.20,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,531.67,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,531.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Select/HMO/PPO,,618.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Select/HMO/PPO,,618.66,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,198.97,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,198.97,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,152.53,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,201.03,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,201.03,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,BCBS NC,Blue Select/HMO/PPO,,790.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Select/HMO/PPO,,809.99,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Select/HMO/PPO,,809.99,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Select/HMO/PPO,,468.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Select/HMO/PPO,,468.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Select/HMO/PPO,,269.21,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Select/HMO/PPO,,269.21,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Select/HMO/PPO,,332.11,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Select/HMO/PPO,,332.11,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Select/HMO/PPO,,338.87,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Select/HMO/PPO,,338.87,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,BCBS NC,Blue Select/HMO/PPO,,1486.84,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,BCBS NC,Blue Select/HMO/PPO,,1447.46,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,BCBS NC,Blue Select/HMO/PPO,,233.65,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,BCBS NC,Blue Select/HMO/PPO,,213.08,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Select/HMO/PPO,,240.41,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Select/HMO/PPO,,218.07,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,BCBS NC,Blue Select/HMO/PPO,,660.39,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Select/HMO/PPO,,218.07,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Select/HMO/PPO,,1094.19,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,260.40,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,BCBS NC,Blue Select/HMO/PPO,,201.62,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,57.31,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,BCBS NC,Blue Select/HMO/PPO,,156.65,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Select/HMO/PPO,,163.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,BCBS NC,Blue Select/HMO/PPO,,173.40,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,171.34,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,195.44,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,BCBS NC,Blue Select/HMO/PPO,,1223.51,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,BCBS NC,Blue Select/HMO/PPO,,625.42,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Select/HMO/PPO,,394.71,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,430.27,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,BCBS NC,Blue Select/HMO/PPO,,203.97,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,BCBS NC,Blue Select/HMO/PPO,,172.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,BCBS NC,Blue Select/HMO/PPO,,178.10,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,259.81,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,259.81,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,4131.65,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,4131.65,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,4131.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,BCBS NC,Blue Select/HMO/PPO,,1818.07,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,3090.06,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,3090.06,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,3090.06,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,3090.06,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Select/HMO/PPO,,3365.74,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Select/HMO/PPO,,3365.74,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,BCBS NC,Blue Select/HMO/PPO,,2255.09,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Select/HMO/PPO,,2322.40,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Select/HMO/PPO,,2322.40,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Select/HMO/PPO,,1410.72,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,BCBS NC,Blue Select/HMO/PPO,,1314.03,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,1781.62,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,1781.62,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,1781.62,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,1291.40,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,BCBS NC,Blue Select/HMO/PPO,,710.36,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,727.40,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,BCBS NC,Blue Select/HMO/PPO,,474.06,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,BCBS NC,Blue Select/HMO/PPO,,232.77,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,727.11,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Select/HMO/PPO,,111.39,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Select/HMO/PPO,,141.66,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,BCBS NC,Blue Select/HMO/PPO,,82.88,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,BCBS NC,Blue Select/HMO/PPO,,159.29,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Select/HMO/PPO,,1555.91,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,BCBS NC,Blue Select/HMO/PPO,,375.31,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Select/HMO/PPO,,2202.49,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,BCBS NC,Blue Select/HMO/PPO,,116.09,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Select/HMO/PPO,,482.00,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Select/HMO/PPO,,482.00,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,BCBS NC,Blue Select/HMO/PPO,,627.77,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,267.74,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,BCBS NC,Blue Select/HMO/PPO,,904.33,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,BCBS NC,Blue Select/HMO/PPO,,658.04,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,157.24,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,298.60,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,BCBS NC,Blue Select/HMO/PPO,,1132.69,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Select/HMO/PPO,,188.68,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,BCBS NC,Blue Select/HMO/PPO,,235.71,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Select/HMO/PPO,,188.68,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,BCBS NC,Blue Select/HMO/PPO,,204.26,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Select/HMO/PPO,,1555.91,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Select/HMO/PPO,,698.89,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,BCBS NC,Blue Select/HMO/PPO,,735.34,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,BCBS NC,Blue Select/HMO/PPO,,728.28,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,BCBS NC,Blue Select/HMO/PPO,,186.92,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,340.92,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,51.43,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,BCBS NC,Blue Select/HMO/PPO,,1848.92,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,BCBS NC,Blue Select/HMO/PPO,,2282.72,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,BCBS NC,Blue Select/HMO/PPO,,732.10,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,86.41,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,67.89,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,61.13,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,118.74,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,BCBS NC,Blue Select/HMO/PPO,,119.91,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,727.11,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,,59.37,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Select/HMO/PPO,,467.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,BCBS NC,Blue Select/HMO/PPO,,1321.67,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,BCBS NC,Blue Select/HMO/PPO,,1244.37,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Select/HMO/PPO,,858.48,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,1344.30,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,310.06,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,310.06,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,BCBS NC,Blue Select/HMO/PPO,,432.33,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,84.64,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,84.64,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,563.70,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,563.70,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Select/HMO/PPO,,344.74,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,737.98,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,737.98,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,597.79,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,597.79,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Select/HMO/PPO,,510.80,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Select/HMO/PPO,,510.80,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Select/HMO/PPO,,465.24,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Select/HMO/PPO,,465.24,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Select/HMO/PPO,,483.76,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Select/HMO/PPO,,483.76,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,BCBS NC,Blue Select/HMO/PPO,,502.57,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Select/HMO/PPO,,445.26,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Select/HMO/PPO,,445.26,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Select/HMO/PPO,,443.50,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Select/HMO/PPO,,443.50,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Select/HMO/PPO,,976.34,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Select/HMO/PPO,,976.34,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Select/HMO/PPO,,546.65,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Select/HMO/PPO,,546.65,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Select/HMO/PPO,,534.31,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Select/HMO/PPO,,534.31,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,BCBS NC,Blue Select/HMO/PPO,,677.73,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Select/HMO/PPO,,108.16,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,1427.47,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Select/HMO/PPO,,64.66,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,BCBS NC,Blue Select/HMO/PPO,,834.97,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,BCBS NC,Blue Select/HMO/PPO,,878.76,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Select/HMO/PPO,,5918.26,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,3146.49,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,152.53,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Select/HMO/PPO,,343.28,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Select/HMO/PPO,,315.65,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,BCBS NC,Blue Select/HMO/PPO,,203.67,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,BCBS NC,Blue Select/HMO/PPO,,228.07,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,BCBS NC,Blue Select/HMO/PPO,,1604.11,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Select/HMO/PPO,,1090.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,BCBS NC,Blue Select/HMO/PPO,,1386.91,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,BCBS NC,Blue Select/HMO/PPO,,1137.10,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,BCBS NC,Blue Select/HMO/PPO,,1429.53,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,BCBS NC,Blue Select/HMO/PPO,,1172.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,BCBS NC,Blue Select/HMO/PPO,,496.10,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Select/HMO/PPO,,168.40,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,BCBS NC,Blue Select/HMO/PPO,,2193.08,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Select/HMO/PPO,,584.86,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,BCBS NC,Blue Select/HMO/PPO,,438.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,BCBS NC,Blue Select/HMO/PPO,,779.72,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,BCBS NC,Blue Select/HMO/PPO,,8454.33,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,BCBS NC,Blue Select/HMO/PPO,,1230.56,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,BCBS NC,Blue Select/HMO/PPO,,3902.70,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,BCBS NC,Blue Select/HMO/PPO,,2600.43,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,BCBS NC,Blue Select/HMO/PPO,,1022.48,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,BCBS NC,Blue Select/HMO/PPO,,364.73,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Select/HMO/PPO,,498.45,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Select/HMO/PPO,,498.45,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Select/HMO/PPO,,551.36,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Select/HMO/PPO,,551.36,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Select/HMO/PPO,,509.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Select/HMO/PPO,,509.03,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Select/HMO/PPO,,378.84,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Select/HMO/PPO,,215.43,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,BCBS NC,Blue Select/HMO/PPO,,361.20,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,BCBS NC,Blue Select/HMO/PPO,,2105.79,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,BCBS NC,Blue Select/HMO/PPO,,526.37,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,BCBS NC,Blue Select/HMO/PPO,,463.19,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,BCBS NC,Blue Select/HMO/PPO,,544.89,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,BCBS NC,Blue Select/HMO/PPO,,307.42,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Select/HMO/PPO,,1053.93,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Select/HMO/PPO,,1053.93,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,764.73,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,764.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,764.73,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,764.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,BCBS NC,Blue Select/HMO/PPO,,1018.36,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,BCBS NC,Blue Select/HMO/PPO,,875.82,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,BCBS NC,Blue Select/HMO/PPO,,1805.72,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,BCBS NC,Blue Select/HMO/PPO,,2099.62,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,BCBS NC,Blue Select/HMO/PPO,,1555.02,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,BCBS NC,Blue Select/HMO/PPO,,1401.02,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,BCBS NC,Blue Select/HMO/PPO,,350.33,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,BCBS NC,Blue Select/HMO/PPO,,2362.37,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,BCBS NC,Blue Select/HMO/PPO,,2438.19,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,BCBS NC,Blue Select/HMO/PPO,,3664.93,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,BCBS NC,Blue Select/HMO/PPO,,2044.07,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Select/HMO/PPO,,781.19,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Select/HMO/PPO,,543.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,BCBS NC,Blue Select/HMO/PPO,,261.86,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Select/HMO/PPO,,473.47,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,BCBS NC,Blue Select/HMO/PPO,,350.03,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,BCBS NC,Blue Select/HMO/PPO,,1088.02,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,BCBS NC,Blue Select/HMO/PPO,,955.47,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,BCBS NC,Blue Select/HMO/PPO,,956.35,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,BCBS NC,Blue Select/HMO/PPO,,824.39,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Select/HMO/PPO,,781.19,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,BCBS NC,Blue Select/HMO/PPO,,1401.61,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,BCBS NC,Blue Select/HMO/PPO,,1625.85,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,BCBS NC,Blue Select/HMO/PPO,,2382.65,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,BCBS NC,Blue Select/HMO/PPO,,220.72,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,BCBS NC,Blue Select/HMO/PPO,,3196.75,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Select/HMO/PPO,,2301.53,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,BCBS NC,Blue Select/HMO/PPO,,1118.88,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,BCBS NC,Blue Select/HMO/PPO,,5031.86,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,BCBS NC,Blue Select/HMO/PPO,,2153.41,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Select/HMO/PPO,,265.10,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Select/HMO/PPO,,1023.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Select/HMO/PPO,,1023.07,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,BCBS NC,Blue Select/HMO/PPO,,5066.25,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Select/HMO/PPO,,4755.89,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Select/HMO/PPO,,4755.89,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Select/HMO/PPO,,2584.85,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Select/HMO/PPO,,2584.85,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Select/HMO/PPO,,2739.74,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Select/HMO/PPO,,2739.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,BCBS NC,Blue Select/HMO/PPO,,3652.59,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,BCBS NC,Blue Select/HMO/PPO,,2655.39,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,BCBS NC,Blue Select/HMO/PPO,,855.25,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Select/HMO/PPO,,695.96,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Select/HMO/PPO,,695.96,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,236.30,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,BCBS NC,Blue Select/HMO/PPO,,1927.98,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,BCBS NC,Blue Select/HMO/PPO,,495.52,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,BCBS NC,Blue Select/HMO/PPO,,593.97,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,BCBS NC,Blue Select/HMO/PPO,,943.71,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,143.13,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,840.26,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,840.26,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,64.07,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,64.07,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Select/HMO/PPO,,2922.54,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Select/HMO/PPO,,2922.54,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,BCBS NC,Blue Select/HMO/PPO,,1179.71,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,BCBS NC,Blue Select/HMO/PPO,,1790.44,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,BCBS NC,Blue Select/HMO/PPO,,1014.54,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,531.67,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,184.86,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,840.26,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,840.26,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,BCBS NC,Blue Select/HMO/PPO,,1192.65,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,BCBS NC,Blue Select/HMO/PPO,,575.75,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Select/HMO/PPO,,115.21,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,134.90,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,109.62,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,109.62,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Select/HMO/PPO,,115.21,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,BCBS NC,Blue Select/HMO/PPO,,94.05,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,BCBS NC,Blue Select/HMO/PPO,,262.75,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,BCBS NC,Blue Select/HMO/PPO,,168.70,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,BCBS NC,Blue Select/HMO/PPO,,335.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Select/HMO/PPO,,275.09,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,BCBS NC,Blue Select/HMO/PPO,,310.95,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,226.60,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,BCBS NC,Blue Select/HMO/PPO,,245.99,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,92.58,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,222.78,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,BCBS NC,Blue Select/HMO/PPO,,91.11,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Select/HMO/PPO,,242.47,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,BCBS NC,Blue Select/HMO/PPO,,282.44,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,152.53,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,187.21,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,125.50,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,BCBS NC,Blue Select/HMO/PPO,,245.41,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Select/HMO/PPO,,196.33,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,158.41,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,BCBS NC,Blue Select/HMO/PPO,,193.39,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,304.77,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Select/HMO/PPO,,241.88,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,270.09,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,BCBS NC,Blue Select/HMO/PPO,,88.46,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,BCBS NC,Blue Select/HMO/PPO,,346.21,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,BCBS NC,Blue Select/HMO/PPO,,224.54,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Select/HMO/PPO,,73.47,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,67.89,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,54.67,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,BCBS NC,Blue Select/HMO/PPO,,323.88,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Select/HMO/PPO,,242.47,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Select/HMO/PPO,,58.49,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,201.03,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,124.03,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Select/HMO/PPO,,284.20,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,BCBS NC,Blue Select/HMO/PPO,,212.78,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,121.38,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,144.60,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,134.90,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,40.85,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,,19.69,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,32.04,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,BCBS NC,Blue Select/HMO/PPO,,1876.85,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,BCBS NC,Blue Select/HMO/PPO,,1367.81,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,BCBS NC,Blue Select/HMO/PPO,,1229.09,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,BCBS NC,Blue Select/HMO/PPO,,1907.70,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,1807.48,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,BCBS NC,Blue Select/HMO/PPO,,790.00,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,1807.48,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,1807.48,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,BCBS NC,Blue Select/HMO/PPO,,273.62,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,BCBS NC,Blue Select/HMO/PPO,,449.96,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,BCBS NC,Blue Select/HMO/PPO,,899.63,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,BCBS NC,Blue Select/HMO/PPO,,1369.57,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,BCBS NC,Blue Select/HMO/PPO,,1227.33,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,BCBS NC,Blue Select/HMO/PPO,,1778.68,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,BCBS NC,Blue Select/HMO/PPO,,2614.53,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,BCBS NC,Blue Select/HMO/PPO,,154.89,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Select/HMO/PPO,,264.22,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,167.82,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,BCBS NC,Blue Select/HMO/PPO,,297.43,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,804.11,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,725.64,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,141.37,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,826.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,BCBS NC,Blue Select/HMO/PPO,,967.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,BCBS NC,Blue Select/HMO/PPO,,1489.78,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,BCBS NC,Blue Select/HMO/PPO,,1800.73,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,BCBS NC,Blue Select/HMO/PPO,,1016.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,BCBS NC,Blue Select/HMO/PPO,,1520.34,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,BCBS NC,Blue Select/HMO/PPO,,1583.53,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,BCBS NC,Blue Select/HMO/PPO,,1059.22,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,BCBS NC,Blue Select/HMO/PPO,,1106.53,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Select/HMO/PPO,,1515.94,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,BCBS NC,Blue Select/HMO/PPO,,1020.42,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,BCBS NC,Blue Select/HMO/PPO,,1197.94,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,BCBS NC,Blue Select/HMO/PPO,,1381.04,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,BCBS NC,Blue Select/HMO/PPO,,1089.78,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,BCBS NC,Blue Select/HMO/PPO,,1143.86,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,BCBS NC,Blue Select/HMO/PPO,,1567.07,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,BCBS NC,Blue Select/HMO/PPO,,1080.08,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Select/HMO/PPO,,1090.96,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Select/HMO/PPO,,1515.94,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,BCBS NC,Blue Select/HMO/PPO,,1250.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,BCBS NC,Blue Select/HMO/PPO,,1322.84,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,BCBS NC,Blue Select/HMO/PPO,,1538.27,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,BCBS NC,Blue Select/HMO/PPO,,857.89,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,BCBS NC,Blue Select/HMO/PPO,,1229.97,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,BCBS NC,Blue Select/HMO/PPO,,932.25,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,74.36,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Select/HMO/PPO,52,1161.49,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,BCBS NC,Blue Select/HMO/PPO,52,1155.91,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,BCBS NC,Blue Select/HMO/PPO,,1129.46,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,BCBS NC,Blue Select/HMO/PPO,,1294.63,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,BCBS NC,Blue Select/HMO/PPO,,1527.10,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,BCBS NC,Blue Select/HMO/PPO,,1182.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,BCBS NC,Blue Select/HMO/PPO,,1215.28,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,BCBS NC,Blue Select/HMO/PPO,,1033.35,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,BCBS NC,Blue Select/HMO/PPO,,1256.13,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Select/HMO/PPO,,1035.41,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,BCBS NC,Blue Select/HMO/PPO,,1190.59,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,BCBS NC,Blue Select/HMO/PPO,,1500.07,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,BCBS NC,Blue Select/HMO/PPO,,1443.64,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,BCBS NC,Blue Select/HMO/PPO,,1602.93,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,BCBS NC,Blue Select/HMO/PPO,,1231.44,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,BCBS NC,Blue Select/HMO/PPO,,1362.81,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,BCBS NC,Blue Select/HMO/PPO,,1641.73,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,BCBS NC,Blue Select/HMO/PPO,,1019.25,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,BCBS NC,Blue Select/HMO/PPO,,1078.91,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,BCBS NC,Blue Select/HMO/PPO,,1569.43,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,BCBS NC,Blue Select/HMO/PPO,,953.71,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,BCBS NC,Blue Select/HMO/PPO,,1057.75,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,BCBS NC,Blue Select/HMO/PPO,,1469.21,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,BCBS NC,Blue Select/HMO/PPO,,1241.73,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,BCBS NC,Blue Select/HMO/PPO,,951.06,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,BCBS NC,Blue Select/HMO/PPO,,1314.32,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,1245.55,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,1245.55,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,1245.55,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,BCBS NC,Blue Select/HMO/PPO,,1038.94,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Select/HMO/PPO,,1195.59,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Select/HMO/PPO,,1195.59,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,BCBS NC,Blue Select/HMO/PPO,,1320.49,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,BCBS NC,Blue Select/HMO/PPO,,955.17,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,BCBS NC,Blue Select/HMO/PPO,,1350.18,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,BCBS NC,Blue Select/HMO/PPO,,1312.56,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Select/HMO/PPO,,1241.14,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Select/HMO/PPO,,1241.14,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,1334.31,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,1334.31,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,1334.31,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Select/HMO/PPO,,1035.41,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Select/HMO/PPO,,303.60,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,BCBS NC,Blue Select/HMO/PPO,,705.36,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,BCBS NC,Blue Select/HMO/PPO,,700.95,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Select/HMO/PPO,,1161.49,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,BCBS NC,Blue Select/HMO/PPO,,551.06,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,125.20,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,117.27,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,512.86,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,512.86,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,46.44,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Select/HMO/PPO,,538.13,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Select/HMO/PPO,,538.13,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,BCBS NC,Blue Select/HMO/PPO,,265.98,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Select/HMO/PPO,,158.71,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,139.60,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,139.60,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,BCBS NC,Blue Select/HMO/PPO,,381.78,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,304.77,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Select/HMO/PPO,,248.93,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,181.04,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Select/HMO/PPO,,176.05,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,85.82,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Select/HMO/PPO,,126.67,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,93.17,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,84.64,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,BCBS NC,Blue Select/HMO/PPO,,199.85,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,82.59,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,171.05,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,171.05,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,BCBS NC,Blue Select/HMO/PPO,,422.04,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,221.01,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Select/HMO/PPO,,548.42,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,BCBS NC,Blue Select/HMO/PPO,,1278.46,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,BCBS NC,Blue Select/HMO/PPO,,74.06,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,52.02,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Select/HMO/PPO,,108.45,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,53.78,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,125.50,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Select/HMO/PPO,,96.69,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,80.82,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,117.27,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,BCBS NC,Blue Select/HMO/PPO,,185.45,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,152.24,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,BCBS NC,Blue Select/HMO/PPO,,256.87,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,BCBS NC,Blue Select/HMO/PPO,,165.17,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Select/HMO/PPO,,106.39,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Select/HMO/PPO,,222.19,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,89.64,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,195.44,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,124.03,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Select/HMO/PPO,,280.97,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Select/HMO/PPO,,176.05,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,124.03,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,134.61,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,BCBS NC,Blue Select/HMO/PPO,,106.98,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,BCBS NC,Blue Select/HMO/PPO,,741.80,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,BCBS NC,Blue Select/HMO/PPO,,637.47,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Select/HMO/PPO,,325.05,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,BCBS NC,Blue Select/HMO/PPO,,153.12,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,BCBS NC,Blue Select/HMO/PPO,,162.53,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Select/HMO/PPO,,98.75,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,37.62,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,150.48,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,118.74,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,118.74,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,BCBS NC,Blue Select/HMO/PPO,,706.54,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.81,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,BCBS NC,Blue Select/HMO/PPO,,4.11,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,32.92,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,47.91,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,38.79,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.64,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,55.55,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Select/HMO/PPO,,77.88,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,74.36,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,55.55,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Select/HMO/PPO,,116.68,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,45.55,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,157.24,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,20.87,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,39.09,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,39.09,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,39.09,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.52,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,52.02,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,36.44,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,11.46,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,42.62,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,42.62,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,42.62,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,45.26,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.52,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,12.64,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,55.25,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,14.11,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,47.61,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,33.80,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,33.80,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,33.80,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,17.63,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.76,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.76,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,48.79,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,15.58,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,75.83,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,71.42,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,52.90,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,42.91,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,11.46,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Select/HMO/PPO,,87.88,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Select/HMO/PPO,,1.76,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,59.07,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Select/HMO/PPO,,170.17,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,46.14,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,35.86,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,35.86,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,35.86,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,35.86,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,11.46,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,55.25,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,59.66,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,59.66,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,59.66,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,59.66,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,20.87,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,50.26,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,47.61,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,22.92,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Select/HMO/PPO,,69.95,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,45.85,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Select/HMO/PPO,,64.95,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,35.27,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,44.67,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.81,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.81,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,BCBS NC,Blue Select/HMO/PPO,,57.90,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,38.79,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.76,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,46.44,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,46.44,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Select/HMO/PPO,,43.79,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,42.03,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,24.39,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,42.03,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,52.02,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.64,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.64,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.64,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.58780,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Select/HMO/PPO,,96.69,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,16.16,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,42.91,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Select/HMO/PPO,,66.72,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,63.19,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,63.19,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,15.58,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,14.70,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,9.40,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,9.40,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,12.64,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.41,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Select/HMO/PPO,,49.08,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,,47.02,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,BCBS NC,Blue Select/HMO/PPO,,55.84,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,39.38,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,38.21,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,31.74,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,33.80,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,33.80,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,38.21,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Select/HMO/PPO,,56.72,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,,3.53,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,109.04,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,109.04,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Select/HMO/PPO,,66.13,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,9.40,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,41.15,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,33.21,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,28.51,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Select/HMO/PPO,,40.26,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,35.27,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,BCBS NC,Blue Select/HMO/PPO,,2.35,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.47,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,31.15,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,51.14,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,37.62,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,78.47,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,43.20,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,80.23,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Select/HMO/PPO,,60.84,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,14.70,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Select/HMO/PPO,,69.65,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,55.25,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,BCBS NC,Blue Select/HMO/PPO,,60.54,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Select/HMO/PPO,,12.05,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,86.11,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,59.07,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,33.21,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,33.21,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,14.70,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,39.68,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,BCBS NC,Blue Select/HMO/PPO,,65.54,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,,6.17,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,42.62,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,34.39,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,50.84,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,28.51,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,34.09,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,34.09,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.41,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,20.28,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Select/HMO/PPO,,135.49,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,35.86,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,57.31,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,24.39,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Select/HMO/PPO,,3.23,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,39.68,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,31.74,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Select/HMO/PPO,,233.36,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Select/HMO/PPO,,131.37,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Select/HMO/PPO,,78.18,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,BCBS NC,Blue Select/HMO/PPO,,167.52,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Select/HMO/PPO,,247.17,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,48.49,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,86.99,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Select/HMO/PPO,,106.10,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,BCBS NC,Blue Select/HMO/PPO,,68.48,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,42.62,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,36.15,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,39.38,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Select/HMO/PPO,,57.60,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,50.84,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,147.24,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,BCBS NC,Blue Select/HMO/PPO,,216.60,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,37.03,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,40.85,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,44.09,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,27.33,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,47.61,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Select/HMO/PPO,,127.26,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Select/HMO/PPO,,127.26,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,94.93,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,80.82,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Select/HMO/PPO,,85.52,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,77.59,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,BCBS NC,Blue Select/HMO/PPO,,179.87,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,47.32,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Select/HMO/PPO,,69.65,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Select/HMO/PPO,,58.49,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,29.10,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Select/HMO/PPO,,95.52,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,79.65,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,94.93,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,BCBS NC,Blue Select/HMO/PPO,,73.77,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,53.49,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,54.67,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,54.67,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,72.59,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,44.09,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Select/HMO/PPO,,57.60,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,BCBS NC,Blue Select/HMO/PPO,,137.55,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,BCBS NC,Blue Select/HMO/PPO,,83.17,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,21.16,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,33.21,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,104.63,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,42.91,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,,59.37,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,42.03,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,34.39,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,34.39,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Select/HMO/PPO,,29.98,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,28.80,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,,65.83,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,11.46,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.58,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.81,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.41,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Select/HMO/PPO,,12.05,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,55.25,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,35.86,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,38.21,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,20.87,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,46.14,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.94,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,15.58,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,,54.96,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,,54.96,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,28.51,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,62.60,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,59.96,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,9.40,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,59.96,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,9.11,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,20.57,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,42.62,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,27.04,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,11.46,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.64,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,37.91,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,34.09,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,BCBS NC,Blue Select/HMO/PPO,,99.63,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Select/HMO/PPO,,4.70,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,BCBS NC,Blue Select/HMO/PPO,,72.01,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,45.26,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.87,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,29.10,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,22.92,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.76,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,52.90,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Select/HMO/PPO,,9.70,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,BCBS NC,Blue Select/HMO/PPO,,67.01,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Select/HMO/PPO,,49.67,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Select/HMO/PPO,,135.49,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,62.60,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,62.60,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,184.86,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,170.76,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,51.14,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,47.32,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,102.86,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,62.31,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,48.20,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,48.20,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,80.82,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,BCBS NC,Blue Select/HMO/PPO,,75.53,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,226.30,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,25.57,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,24.39,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,14.11,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,32.92,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Select/HMO/PPO,,170.17,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,BCBS NC,Blue Select/HMO/PPO,,82.00,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,16.16,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,45.26,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,28.21,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,28.21,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,28.21,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,136.08,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,86.41,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,25.86,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,37.03,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,,3.53,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,44.09,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,35.27,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,161.06,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Select/HMO/PPO,,90.82,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,,37.33,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,10.58,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.47,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Select/HMO/PPO,,67.60,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.52,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,31.15,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,17.05,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.58,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,17.93,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,16.46,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,20.87,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.41,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,74.36,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,39.38,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,50.26,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.64,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,47.61,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.52,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,121.67,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.58780,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,152.24,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,23.81,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.52,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,47.32,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Select/HMO/PPO,,576.04,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,41.44,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,20.57,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,20.57,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.41,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,14.40,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Select/HMO/PPO,,155.47,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,BCBS NC,Blue Select/HMO/PPO,,225.42,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,39.38,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,BCBS NC,Blue Select/HMO/PPO,,530.49,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,BCBS NC,Blue Select/HMO/PPO,,369.73,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,86.11,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,34.09,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Select/HMO/PPO,,567.52,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.76,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,,76.12,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,BCBS NC,Blue Select/HMO/PPO,,531.37,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,207.79,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,BCBS NC,Blue Select/HMO/PPO,,150.77,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,55.55,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Select/HMO/PPO,,576.04,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,BCBS NC,Blue Select/HMO/PPO,,33.50,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Select/HMO/PPO,,57.02,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Select/HMO/PPO,,280.09,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,BCBS NC,Blue Select/HMO/PPO,,187.80,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,41.15,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,QW,41.15,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Select/HMO/PPO,,81.70,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Select/HMO/PPO,,467.01,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,BCBS NC,Blue Select/HMO/PPO,,348.86,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Select/HMO/PPO,,81.70,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Select/HMO/PPO,,178.99,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,BCBS NC,Blue Select/HMO/PPO,,140.48,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,59.96,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,125.20,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,14.70,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,QW,29.39,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,29.39,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,47.91,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,BCBS NC,Blue Select/HMO/PPO,,266.57,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,80.82,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,38.79,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,48.49,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,12.64,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,82.29,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Select/HMO/PPO,,57.02,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,20.28,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,102.86,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,39.68,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,62.60,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,64.36,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,39.68,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,39.68,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,80.82,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,22.34,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,12.64,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,29.68,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Select/HMO/PPO,,43.79,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,BCBS NC,Blue Select/HMO/PPO,,390.30,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,16.16,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,31.74,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,34.68,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,19.10,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,79.65,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Select/HMO/PPO,,49.08,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,79.65,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,93.75,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,151.36,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,BCBS NC,Blue Select/HMO/PPO,,154.59,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,61.72,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.94,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,32.33,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,54.67,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,43.20,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,43.20,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,11.46,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,BCBS NC,Blue Select/HMO/PPO,,58.19,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,34.97,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,BCBS NC,Blue Select/HMO/PPO,,74.94,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Select/HMO/PPO,,76.71,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,22.92,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,39.97,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,61.43,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Select/HMO/PPO,,60.84,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,152.24,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Select/HMO/PPO,,43.50,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Select/HMO/PPO,,134.02,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Select/HMO/PPO,,175.46,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,BCBS NC,Blue Select/HMO/PPO,,221.89,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,BCBS NC,Blue Select/HMO/PPO,,164.88,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Select/HMO/PPO,,95.52,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Select/HMO/PPO,,66.13,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,BCBS NC,Blue Select/HMO/PPO,,299.48,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,104.04,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Select/HMO/PPO,,178.99,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,,65.83,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,38.79,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,39.68,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,161.06,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Select/HMO/PPO,,29.98,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,51.43,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,107.86,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,193.97,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00294,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,36.44,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,BCBS NC,Blue Select/HMO/PPO,,66.42,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,BCBS NC,Blue Select/HMO/PPO,,108.74,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,93.75,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,93.75,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,BCBS NC,Blue Select/HMO/PPO,,174.28,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,161.06,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,28.51,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,37.91,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,115.80,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,91.99,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Select/HMO/PPO,,73.18,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,22.63,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,BCBS NC,Blue Select/HMO/PPO,,112.86,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,38.79,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,BCBS NC,Blue Select/HMO/PPO,,198.38,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,55.55,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,121.67,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,BCBS NC,Blue Select/HMO/PPO,,75.24,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Select/HMO/PPO,,76.71,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,46.14,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,46.14,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,158.41,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,40.85,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,48.20,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,121.67,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,72.59,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,BCBS NC,Blue Select/HMO/PPO,,643.93,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Select/HMO/PPO,,103.75,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,56.43,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Select/HMO/PPO,,208.08,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,152.24,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,104.04,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,107.86,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,152.53,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,BCBS NC,Blue Select/HMO/PPO,,377.66,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,107.86,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,BCBS NC,Blue Select/HMO/PPO,,91.70,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,37.91,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,BCBS NC,Blue Select/HMO/PPO,,365.32,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,7.05,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,56.43,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,BCBS NC,Blue Select/HMO/PPO,,266.86,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,193.97,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Select/HMO/PPO,,139.31,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,104.63,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,BCBS NC,Blue Select/HMO/PPO,,36.74,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,44.09,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,27.92,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,48.79,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,23.51,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,BCBS NC,Blue Select/HMO/PPO,,46.73,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Select/HMO/PPO,,467.01,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,BCBS NC,Blue Select/HMO/PPO,,234.53,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,BCBS NC,Blue Select/HMO/PPO,,95.81,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,30.86,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,BCBS NC,Blue Select/HMO/PPO,,72.89,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,88.17,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,88.17,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Select/HMO/PPO,,81.41,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,BCBS NC,Blue Select/HMO/PPO,,166.35,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,BCBS NC,Blue Select/HMO/PPO,,199.56,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,BCBS NC,Blue Select/HMO/PPO,,191.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,305.95,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,BCBS NC,Blue Select/HMO/PPO,,314.47,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,63.19,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,BCBS NC,Blue Select/HMO/PPO,,123.14,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,86.41,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Select/HMO/PPO,,278.91,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,BCBS NC,Blue Select/HMO/PPO,,364.44,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,176.34,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,26.74,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,449.08,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,48.49,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,48.49,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,48.49,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,305.95,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,305.95,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,340.92,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,BCBS NC,Blue Select/HMO/PPO,,768.84,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2518.72,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2518.72,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2518.72,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2518.72,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2518.72,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,BCBS NC,Blue Select/HMO/PPO,,10426.69,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,BCBS NC,Blue Select/HMO/PPO,,1766.93,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,727.11,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,727.11,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,BCBS NC,Blue Select/HMO/PPO,,1973.54,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,BCBS NC,Blue Select/HMO/PPO,,600.44,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,BCBS NC,Blue Select/HMO/PPO,,989.86,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,267.16,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,267.16,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Select/HMO/PPO,,582.22,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Select/HMO/PPO,,582.22,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Select/HMO/PPO,,1224.39,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Select/HMO/PPO,,1224.39,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Select/HMO/PPO,,557.23,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Select/HMO/PPO,,557.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Select/HMO/PPO,,131.37,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Select/HMO/PPO,,241.88,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,527.26,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,527.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,416.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,416.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Select/HMO/PPO,,466.13,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Select/HMO/PPO,,466.13,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,416.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,416.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,BCBS NC,Blue Select/HMO/PPO,,2268.03,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Select/HMO/PPO,,1133.87,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Select/HMO/PPO,,1133.87,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Select/HMO/PPO,,2106.09,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Select/HMO/PPO,,2106.09,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1619.98,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1619.98,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Select/HMO/PPO,,404.99,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Select/HMO/PPO,,404.99,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1619.98,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1619.98,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,BCBS NC,Blue Select/HMO/PPO,,781.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2518.72,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2518.72,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Select/HMO/PPO,,233.36,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,BCBS NC,Blue Select/HMO/PPO,,8539.85,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,1291.40,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,1291.40,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,129.02,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,663.33,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,663.33,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,663.33,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,663.33,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Select/HMO/PPO,,4916.65,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Select/HMO/PPO,,4916.65,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Select/HMO/PPO,,8194.52,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Select/HMO/PPO,,8194.52,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Select/HMO/PPO,,2949.87,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Select/HMO/PPO,,2949.87,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Select/HMO/PPO,,6801.43,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Select/HMO/PPO,,6801.43,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Select/HMO/PPO,,2735.33,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Select/HMO/PPO,,2735.33,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Select/HMO/PPO,,6900.48,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Select/HMO/PPO,,6900.48,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Select/HMO/PPO,,6216.57,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Select/HMO/PPO,,6216.57,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Select/HMO/PPO,,8268.29,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Select/HMO/PPO,,8268.29,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,BCBS NC,Blue Select/HMO/PPO,,3623.20,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Select/HMO/PPO,,6847.87,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Select/HMO/PPO,,6847.87,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Select/HMO/PPO,,6231.86,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Select/HMO/PPO,,6231.86,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Select/HMO/PPO,,7065.36,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Select/HMO/PPO,,7065.36,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Select/HMO/PPO,,2789.99,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Select/HMO/PPO,,2789.99,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Select/HMO/PPO,,6014.37,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Select/HMO/PPO,,6014.37,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Select/HMO/PPO,,5181.16,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Select/HMO/PPO,,5181.16,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,BCBS NC,Blue Select/HMO/PPO,,6050.81,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LM,4760.89,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,RI,4760.89,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,RC,4760.89,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LD,4760.89,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LC,4760.89,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LC,2456.12,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,RI,2456.12,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,RC,2456.12,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LD,2456.12,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LC,2456.12,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LM,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RI,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RC,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LD,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LC,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LM,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RI,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RC,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LD,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LC,4219.82,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LM,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RI,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RC,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LD,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LC,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LM,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RI,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RC,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LD,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LC,6298.28,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LM,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RI,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RC,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LD,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LC,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RC,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LD,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LC,6675.94,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11903.54,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11903.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Select/HMO/PPO,,6801.73,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Select/HMO/PPO,,6801.73,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Select/HMO/PPO,,6991.00,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Select/HMO/PPO,,6991.00,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LM,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RI,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RC,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LD,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LC,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LM,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RI,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RC,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LD,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LC,7305.77,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,7620.83,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,7620.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,7620.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,7620.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,7620.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,7620.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,BCBS NC,Blue Select/HMO/PPO,,115.50,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,BCBS NC,Blue Select/HMO/PPO,,489.05,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,548.12,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,124.03,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,BCBS NC,Blue Select/HMO/PPO,,742.69,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,BCBS NC,Blue Select/HMO/PPO,,289.79,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,BCBS NC,Blue Select/HMO/PPO,,3401.01,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,3146.49,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,3146.49,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,BCBS NC,Blue Select/HMO/PPO,,3000.72,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,BCBS NC,Blue Select/HMO/PPO,,1249.08,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,BCBS NC,Blue Select/HMO/PPO,,2165.16,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,BCBS NC,Blue Select/HMO/PPO,,3201.45,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,BCBS NC,Blue Select/HMO/PPO,,2842.89,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,BCBS NC,Blue Select/HMO/PPO,,3034.81,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,BCBS NC,Blue Select/HMO/PPO,,1335.19,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,BCBS NC,Blue Select/HMO/PPO,,3122.39,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,BCBS NC,Blue Select/HMO/PPO,,3894.47,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,BCBS NC,Blue Select/HMO/PPO,,3508.28,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,BCBS NC,Blue Select/HMO/PPO,,3742.52,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,BCBS NC,Blue Select/HMO/PPO,,3806.01,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,BCBS NC,Blue Select/HMO/PPO,,4666.25,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,BCBS NC,Blue Select/HMO/PPO,,1992.05,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,59.66,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,28.51,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,BCBS NC,Blue Select/HMO/PPO,,441.73,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,BCBS NC,Blue Select/HMO/PPO,,1213.22,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,BCBS NC,Blue Select/HMO/PPO,,2370.01,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Select/HMO/PPO,,142.25,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,183.98,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,63.19,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,BCBS NC,Blue Select/HMO/PPO,,2254.51,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,BCBS NC,Blue Select/HMO/PPO,,11501.19,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,BCBS NC,Blue Select/HMO/PPO,,3609.68,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,BCBS NC,Blue Select/HMO/PPO,,742.10,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,BCBS NC,Blue Select/HMO/PPO,,829.97,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,BCBS NC,Blue Select/HMO/PPO,,372.08,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,155.18,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,155.18,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,155.18,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Select/HMO/PPO,,2316.52,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Select/HMO/PPO,,2316.52,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Select/HMO/PPO,,4402.33,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Select/HMO/PPO,,4402.33,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,BCBS NC,Blue Select/HMO/PPO,,5368.67,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,BCBS NC,Blue Select/HMO/PPO,,3899.47,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,BCBS NC,Blue Select/HMO/PPO,,4431.13,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,BCBS NC,Blue Select/HMO/PPO,,5347.22,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,BCBS NC,Blue Select/HMO/PPO,,938.42,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Select/HMO/PPO,,4140.76,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Select/HMO/PPO,,4140.76,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,BCBS NC,Blue Select/HMO/PPO,,3002.19,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,BCBS NC,Blue Select/HMO/PPO,,865.24,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Select/HMO/PPO,,852.90,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Select/HMO/PPO,,852.90,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,BCBS NC,Blue Select/HMO/PPO,,5993.21,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,BCBS NC,Blue Select/HMO/PPO,,4386.46,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,BCBS NC,Blue Select/HMO/PPO,,695.66,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,BCBS NC,Blue Select/HMO/PPO,,6990.71,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,BCBS NC,Blue Select/HMO/PPO,,7206.72,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,BCBS NC,Blue Select/HMO/PPO,,7855.36,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,BCBS NC,Blue Select/HMO/PPO,,2500.50,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Select/HMO/PPO,,3350.75,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Select/HMO/PPO,,3350.75,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,BCBS NC,Blue Select/HMO/PPO,,14661.79,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,BCBS NC,Blue Select/HMO/PPO,,1689.92,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,BCBS NC,Blue Select/HMO/PPO,,1122.99,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,BCBS NC,Blue Select/HMO/PPO,,16957.44,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,775.60,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,BCBS NC,Blue Select/HMO/PPO,,3428.93,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,BCBS NC,Blue Select/HMO/PPO,,613.08,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,1230.85,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,1904.47,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,1904.47,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,949.88,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Select/HMO/PPO,,674.50,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,949.88,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,949.88,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,BCBS NC,Blue Select/HMO/PPO,,894.34,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,BCBS NC,Blue Select/HMO/PPO,,819.10,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,BCBS NC,Blue Select/HMO/PPO,,2815.56,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Select/HMO/PPO,,4476.10,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Select/HMO/PPO,,4476.10,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,BCBS NC,Blue Select/HMO/PPO,,477.29,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,BCBS NC,Blue Select/HMO/PPO,,2375.89,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,BCBS NC,Blue Select/HMO/PPO,,487.29,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,BCBS NC,Blue Select/HMO/PPO,,927.55,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,BCBS NC,Blue Select/HMO/PPO,,7477.40,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Select/HMO/PPO,,6622.74,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Select/HMO/PPO,,6622.74,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,BCBS NC,Blue Select/HMO/PPO,,889.05,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,416.75,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Select/HMO/PPO,,5918.26,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,BCBS NC,Blue Select/HMO/PPO,,6577.78,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,BCBS NC,Blue Select/HMO/PPO,,729.46,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Select/HMO/PPO,,567.52,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Select/HMO/PPO,,1630.56,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Select/HMO/PPO,,1630.56,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,BCBS NC,Blue Select/HMO/PPO,,1874.20,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,BCBS NC,Blue Select/HMO/PPO,,756.79,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,BCBS NC,Blue Select/HMO/PPO,,4032.60,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Select/HMO/PPO,,1410.72,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,416.75,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Select/HMO/PPO,,625.13,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,BCBS NC,Blue Select/HMO/PPO,,833.50,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,BCBS NC,Blue Select/HMO/PPO,,2340.91,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,BCBS NC,Blue Select/HMO/PPO,,5443.62,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,BCBS NC,Blue Select/HMO/PPO,,2710.93,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,BCBS NC,Blue Select/HMO/PPO,,1900.65,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,BCBS NC,Blue Select/HMO/PPO,,2197.20,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,84.64,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,416.75,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,BCBS NC,Blue Select/HMO/PPO,,2342.38,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,893.75,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,893.75,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,893.75,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,893.75,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,BCBS NC,Blue Select/HMO/PPO,,3909.16,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Select/HMO/PPO,,7818.33,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Select/HMO/PPO,,7818.33,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,BCBS NC,Blue Select/HMO/PPO,,12587.44,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,BCBS NC,Blue Select/HMO/PPO,,10275.33,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Select/HMO/PPO,,2785.00,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,BCBS NC,Blue Select/HMO/PPO,,1277.00,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,BCBS NC,Blue Select/HMO/PPO,,6291.22,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,10063.43,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,10063.43,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,10063.43,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,BCBS NC,Blue Select/HMO/PPO,,9514.42,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Select/HMO/PPO,,1988.53,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Select/HMO/PPO,,1988.53,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,31.45,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Select/HMO/PPO,,11503.83,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Select/HMO/PPO,,11503.83,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,BCBS NC,Blue Select/HMO/PPO,,14090.74,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,BCBS NC,Blue Select/HMO/PPO,,705.07,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,BCBS NC,Blue Select/HMO/PPO,,1908.59,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Select/HMO/PPO,,3184.99,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LD,1009.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,RC,1009.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,RI,1009.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LM,1009.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LD,807.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,RC,807.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,RI,807.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LM,807.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LD,692.43,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,RC,692.43,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,RI,692.43,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LM,692.43,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LD,145.48,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,RC,145.48,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,RI,145.48,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LM,145.48,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LC,1009.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LC,807.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LC,692.43,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LC,145.48,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,BCBS NC,Blue Select/HMO/PPO,,9584.37,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,BCBS NC,Blue Select/HMO/PPO,,18144.50,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,BCBS NC,Blue Select/HMO/PPO,,3351.34,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,BCBS NC,Blue Select/HMO/PPO,,837.91,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,BCBS NC,Blue Select/HMO/PPO,,168.99,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,BCBS NC,Blue Select/HMO/PPO,,1181.77,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,BCBS NC,Blue Select/HMO/PPO,,971.05,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,BCBS NC,Blue Select/HMO/PPO,,379.13,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,BCBS NC,Blue Select/HMO/PPO,,459.37,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,BCBS NC,Blue Select/HMO/PPO,,340.04,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Select/HMO/PPO,,655.10,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Select/HMO/PPO,,655.10,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Select/HMO/PPO,,264.22,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Select/HMO/PPO,,213.37,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Select/HMO/PPO,,213.37,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Select/HMO/PPO,,751.80,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Select/HMO/PPO,,751.80,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,145.77,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,113.15,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,804.11,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,16.16,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Select/HMO/PPO,,402.06,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,71.42,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Select/HMO/PPO,,257.16,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,BCBS NC,Blue Select/HMO/PPO,,182.81,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,47.61,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Select/HMO/PPO,,56.72,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,BCBS NC,Blue Select/HMO/PPO,,375.02,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,83.76,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,64.07,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Select/HMO/PPO,,87.29,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,32.04,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,41.44,,,,,,,24.55,269.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Select/HMO/PPO,,1910.06,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,BCBS NC,Blue Select/HMO/PPO,,1065.09,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,BCBS NC,Blue Select/HMO/PPO,,2346.50,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Select/HMO/PPO,,766.20,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,620.42,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,620.42,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,620.42,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,BCBS NC,Blue Select/HMO/PPO,,1873.61,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,BCBS NC,Blue Select/HMO/PPO,,2481.40,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,BCBS NC,Blue Select/HMO/PPO,,2785.29,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Select/HMO/PPO,,2301.53,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,BCBS NC,Blue Select/HMO/PPO,,2982.79,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,BCBS NC,Blue Select/HMO/PPO,,3323.42,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,141.07,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,88.17,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,141.07,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,88.17,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,70.54,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Select/HMO/PPO,,109.92,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,BCBS NC,Blue Select/HMO/PPO,,387.95,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,BCBS NC,Blue Select/HMO/PPO,,418.81,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,BCBS NC,Blue Select/HMO/PPO,,655.98,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,86.11,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,BCBS NC,Blue Select/HMO/PPO,,197.50,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,BCBS NC,Blue Select/HMO/PPO,,30.57,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,298.60,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,51.43,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,75.83,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,56.43,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,BCBS NC,Blue Select/HMO/PPO,,929.31,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,88.76,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,86.99,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Select/HMO/PPO,,90.82,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,83.76,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,100.22,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,126.96,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Select/HMO/PPO,,181.34,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,20.87,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Select/HMO/PPO,,64.95,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,BCBS NC,Blue Select/HMO/PPO,,118.15,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,BCBS NC,Blue Select/HMO/PPO,,261.57,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,15.87,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Select/HMO/PPO,,77.88,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.76,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,BCBS NC,Blue Select/HMO/PPO,,220.43,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,BCBS NC,Blue Select/HMO/PPO,,345.33,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Select/HMO/PPO,,1178.54,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,BCBS NC,Blue Select/HMO/PPO,,359.73,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,527.26,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,BCBS NC,Blue Select/HMO/PPO,,666.86,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,144.60,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Select/HMO/PPO,,1178.54,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Select/HMO/PPO,,205.73,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,BCBS NC,Blue Select/HMO/PPO,,229.24,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,26.45,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,BCBS NC,Blue Select/HMO/PPO,,469.65,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,BCBS NC,Blue Select/HMO/PPO,,755.03,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,146.95,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,BCBS NC,Blue Select/HMO/PPO,,1175.60,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Select/HMO/PPO,,712.71,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Select/HMO/PPO,,529.02,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Select/HMO/PPO,,712.71,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Select/HMO/PPO,,529.02,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Select/HMO/PPO,,346.80,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Select/HMO/PPO,,346.80,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,310.65,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Select/HMO/PPO,GP,69.95,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Select/HMO/PPO,,9082.39,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Select/HMO/PPO,,4391.75,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Select/HMO/PPO,,9082.39,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Select/HMO/PPO,,4391.75,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,BCBS NC,Blue Select/HMO/PPO,,3816.88,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,BCBS NC,Blue Select/HMO/PPO,,3900.93,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,BCBS NC,Blue Select/HMO/PPO,,3985.28,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,BCBS NC,Blue Select/HMO/PPO,,4069.93,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,BCBS NC,Blue Select/HMO/PPO,,4154.28,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,BCBS NC,Blue Select/HMO/PPO,,4238.33,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,BCBS NC,Blue Select/HMO/PPO,,4322.68,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,BCBS NC,Blue Select/HMO/PPO,,4407.03,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,146.66,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Select/HMO/PPO,,72.30,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,58.78,,,,,,,34.82,150.00,percent of total billed charges,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,BCBS NC,Blue Select/HMO/PPO,,0.03886,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,36.09,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,6.94,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,34.14,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,34.14,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,BCBS NC,Blue Select/HMO/PPO,,6.13,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Select/HMO/PPO,,39.42,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Select/HMO/PPO,,10984.63,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Select/HMO/PPO,,4720.31,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.28038,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Select/HMO/PPO,,532.71,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Select/HMO/PPO,,2013.16,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Select/HMO/PPO,,481.36,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Select/HMO/PPO,,914.69,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Select/HMO/PPO,,11165.07,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Select/HMO/PPO,,3474.72,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Select/HMO/PPO,,3086.91,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Select/HMO/PPO,,4348.60,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Select/HMO/PPO,,8766.05,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,732.59,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Select/HMO/PPO,,3086.08,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Select/HMO/PPO,,4453.26,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,748.41,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Select/HMO/PPO,,2322.40,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Select/HMO/PPO,,2476.19,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Select/HMO/PPO,,3130.50,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,126.31,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,252.89,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,BCBS NC,Blue Select/HMO/PPO,,8.68,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,BCBS NC,Blue Select/HMO/PPO,,5.65,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,BCBS NC,Blue Select/HMO/PPO,,77.44,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,BCBS NC,Blue Select/HMO/PPO,,6.01,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,BCBS NC,Blue Select/HMO/PPO,,0.00833,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,BCBS NC,Blue Select/HMO/PPO,,5.95,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,BCBS NC,Blue Select/HMO/PPO,,11.27,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,BCBS NC,Blue Select/HMO/PPO,,5.65,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,BCBS NC,Blue Select/HMO/PPO,,5.52,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,274.27,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Select/HMO/PPO,,18.12,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,BCBS NC,Blue Select/HMO/PPO,,49.47,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Select/HMO/PPO,,4301.41,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,BCBS NC,Blue Select/HMO/PPO,,1.76,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,50.52,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,55.52,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,55.52,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,342.84,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,290.92,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,196.26,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,152.68,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,122.70,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,129.36,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,342.84,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,290.92,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,196.26,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,152.68,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,122.70,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,129.36,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,BCBS NC,Blue Select/HMO/PPO,,7.63,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,158.51,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,72.73,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,685.39,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,193.76,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,193.76,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,170.72,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,170.72,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,110.76,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,110.76,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Select/HMO/PPO,,655.97,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,158.51,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,72.73,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,86.89,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,86.89,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,437.22,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,437.22,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,347.56,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,347.56,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,177.94,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,177.94,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,94.38,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,94.38,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,75.51,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,75.51,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,BCBS NC,Blue Select/HMO/PPO,,60.01,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,252.89,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,126.31,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Select/HMO/PPO,,1439.91,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,BCBS NC,Blue Select/HMO/PPO,,42.69,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Select/HMO/PPO,,711.21,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,274.27,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,BCBS NC,Blue Select/HMO/PPO,,242.11,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,BCBS NC,Blue Select/HMO/PPO,,297.10,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,BCBS NC,Blue Select/HMO/PPO,,0.60517,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Select/HMO/PPO,,576.85,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,764.51,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,337.56,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,171.00,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,764.51,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,337.56,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,171.00,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,780.89,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,BCBS NC,Blue Select/HMO/PPO,,0.86056,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,BCBS NC,Blue Select/HMO/PPO,,2.73,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,BCBS NC,Blue Select/HMO/PPO,,53.47,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,BCBS NC,Blue Select/HMO/PPO,,18.44,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,34.14,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,BCBS NC,Blue Select/HMO/PPO,,65.98,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,BCBS NC,Blue Select/HMO/PPO,,76.03,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,BCBS NC,Blue Select/HMO/PPO,,44.06,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,94.94,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,94.94,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,429.17,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Select/HMO/PPO,,858.89,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,429.17,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,BCBS NC,Blue Select/HMO/PPO,,91.72,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,BCBS NC,Blue Select/HMO/PPO,,91.41,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,BCBS NC,Blue Select/HMO/PPO,,42.52,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,BCBS NC,Blue Select/HMO/PPO,,44.09,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,118.81,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,118.81,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,2.78,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,BCBS NC,Blue Select/HMO/PPO,,0.03331,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,BCBS NC,Blue Select/HMO/PPO,,0.07495,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,693.44,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,693.44,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,562.14,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,562.14,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,474.14,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,474.14,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,BCBS NC,Blue Select/HMO/PPO,,89.46,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,BCBS NC,Blue Select/HMO/PPO,,22.52,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,BCBS NC,Blue Select/HMO/PPO,,14.86,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,BCBS NC,Blue Select/HMO/PPO,,34.99,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,BCBS NC,Blue Select/HMO/PPO,,8.57,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,BCBS NC,Blue Select/HMO/PPO,,4.62,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,BCBS NC,Blue Select/HMO/PPO,,32.42,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,BCBS NC,Blue Select/HMO/PPO,,9.34,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,BCBS NC,Blue Select/HMO/PPO,,26.66,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,BCBS NC,Blue Select/HMO/PPO,,76.35,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,BCBS NC,Blue Select/HMO/PPO,,11.83,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,BCBS NC,Blue Select/HMO/PPO,,14.27,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,BCBS NC,Blue Select/HMO/PPO,,46.10,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,BCBS NC,Blue Select/HMO/PPO,,35.75,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,BCBS NC,Blue Select/HMO/PPO,,42.80,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,BCBS NC,Blue Select/HMO/PPO,,40.62,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,BCBS NC,Blue Select/HMO/PPO,,7.26,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,BCBS NC,Blue Select/HMO/PPO,,7.93,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,BCBS NC,Blue Select/HMO/PPO,,18.89,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,BCBS NC,Blue Select/HMO/PPO,,39.07,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,BCBS NC,Blue Select/HMO/PPO,,0.14158,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,BCBS NC,Blue Select/HMO/PPO,,7.28,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,BCBS NC,Blue Select/HMO/PPO,,1.64,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,BCBS NC,Blue Select/HMO/PPO,,2.92,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,BCBS NC,Blue Select/HMO/PPO,,0.03054,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,BCBS NC,Blue Select/HMO/PPO,,0.22208,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,BCBS NC,Blue Select/HMO/PPO,,2.15,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,BCBS NC,Blue Select/HMO/PPO,,0.21930,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,BCBS NC,Blue Select/HMO/PPO,,0.13047,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,BCBS NC,Blue Select/HMO/PPO,,0.17766,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,BCBS NC,Blue Select/HMO/PPO,,462.70,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00555,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,BCBS NC,Blue Select/HMO/PPO,,0.02498,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,BCBS NC,Blue Select/HMO/PPO,,0.71343,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,BCBS NC,Blue Select/HMO/PPO,,7.15,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,BCBS NC,Blue Select/HMO/PPO,,22.61,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,BCBS NC,Blue Select/HMO/PPO,,0.01943,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,1.18,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,BCBS NC,Blue Select/HMO/PPO,,1.70,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,BCBS NC,Blue Select/HMO/PPO,,0.31091,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,BCBS NC,Blue Select/HMO/PPO,,0.44694,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,BCBS NC,Blue Select/HMO/PPO,,0.71066,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,BCBS NC,Blue Select/HMO/PPO,,0.49690,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00555,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.13,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,BCBS NC,Blue Select/HMO/PPO,,305.56,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,BCBS NC,Blue Select/HMO/PPO,,37.45,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,BCBS NC,Blue Select/HMO/PPO,,46.20,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,BCBS NC,Blue Select/HMO/PPO,,0.03609,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,BCBS NC,Blue Select/HMO/PPO,,10.09,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Select/HMO/PPO,,18.12,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,BCBS NC,Blue Select/HMO/PPO,,39.95,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,BCBS NC,Blue Select/HMO/PPO,,17.65,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,BCBS NC,Blue Select/HMO/PPO,,69.14,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,BCBS NC,Blue Select/HMO/PPO,,3.12,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,BCBS NC,Blue Select/HMO/PPO,,7.07,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,BCBS NC,Blue Select/HMO/PPO,,0.20820,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,BCBS NC,Blue Select/HMO/PPO,,0.01110,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,BCBS NC,Blue Select/HMO/PPO,,4.20,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,BCBS NC,Blue Select/HMO/PPO,,3.71,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,BCBS NC,Blue Select/HMO/PPO,,3.30,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,BCBS NC,Blue Select/HMO/PPO,,9.26,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,BCBS NC,Blue Select/HMO/PPO,,15.26,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,BCBS NC,Blue Select/HMO/PPO,,38.63,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,BCBS NC,Blue Select/HMO/PPO,,152.32,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,BCBS NC,Blue Select/HMO/PPO,,87.79,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,BCBS NC,Blue Select/HMO/PPO,,103.06,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,23.03,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,18.02,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,18.02,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.33312,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Select/HMO/PPO,,813.30,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Select/HMO/PPO,,5399.83,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.59,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.55,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,5.93,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,BCBS NC,Blue Select/HMO/PPO,,35.66,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,23.35,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,BCBS NC,Blue Select/HMO/PPO,,97.35,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,BCBS NC,Blue Select/HMO/PPO,,107.03,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Select/HMO/PPO,,5.39,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,BCBS NC,Blue Select/HMO/PPO,,983.81,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,BCBS NC,Blue Select/HMO/PPO,,84.46,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,BCBS NC,Blue Select/HMO/PPO,,12.06,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.51,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.50,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,BCBS NC,Blue Select/HMO/PPO,,670.21,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,BCBS NC,Blue Select/HMO/PPO,,130.90,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.59,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,BCBS NC,Blue Select/HMO/PPO,,1449.18,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,BCBS NC,Blue Select/HMO/PPO,,22.18,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,BCBS NC,Blue Select/HMO/PPO,,9.34,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,BCBS NC,Blue Select/HMO/PPO,,9.67,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.05,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,BCBS NC,Blue Select/HMO/PPO,,5.51,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,BCBS NC,Blue Select/HMO/PPO,,7.00,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,BCBS NC,Blue Select/HMO/PPO,,22.29,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,BCBS NC,Blue Select/HMO/PPO,,8.99,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,7.97,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,BCBS NC,Blue Select/HMO/PPO,,0.62460,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,BCBS NC,Blue Select/HMO/PPO,,121.23,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,BCBS NC,Blue Select/HMO/PPO,,207.70,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,BCBS NC,Blue Select/HMO/PPO,,634.19,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.41640,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,BCBS NC,Blue Select/HMO/PPO,,13.73,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,BCBS NC,Blue Select/HMO/PPO,,15.98,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,BCBS NC,Blue Select/HMO/PPO,,157.82,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,BCBS NC,Blue Select/HMO/PPO,,6.05,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,BCBS NC,Blue Select/HMO/PPO,,6.84,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,BCBS NC,Blue Select/HMO/PPO,,1.94,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,BCBS NC,Blue Select/HMO/PPO,,0.72176,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,BCBS NC,Blue Select/HMO/PPO,,7.43,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,BCBS NC,Blue Select/HMO/PPO,,13.20,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,BCBS NC,Blue Select/HMO/PPO,,8.15,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,8.98,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,BCBS NC,Blue Select/HMO/PPO,,761.00,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,4.93,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.65,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,5.93,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,BCBS NC,Blue Select/HMO/PPO,,11.33,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,BCBS NC,Blue Select/HMO/PPO,,510.67,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,4.48,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,4.93,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,BCBS NC,Blue Select/HMO/PPO,,9.09,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,BCBS NC,Blue Select/HMO/PPO,,68.54,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,0.45804,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,6.44,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,BCBS NC,Blue Select/HMO/PPO,,6.32,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,BCBS NC,Blue Select/HMO/PPO,,5641.46,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,8.88,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.40252,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,BCBS NC,Blue Select/HMO/PPO,,43.82,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,BCBS NC,Blue Select/HMO/PPO,,83.53,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,687.06,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,BCBS NC,Blue Select/HMO/PPO,,19.52,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,BCBS NC,Blue Select/HMO/PPO,,23.54,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Select/HMO/PPO,,10.47,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Select/HMO/PPO,,12.80,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,BCBS NC,Blue Select/HMO/PPO,,214.96,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.50,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,BCBS NC,Blue Select/HMO/PPO,,14.12,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,BCBS NC,Blue Select/HMO/PPO,,19.11,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,BCBS NC,Blue Select/HMO/PPO,,18.50,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,BCBS NC,Blue Select/HMO/PPO,,20.06,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,BCBS NC,Blue Select/HMO/PPO,,11.01,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,BCBS NC,Blue Select/HMO/PPO,,7.81,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,BCBS NC,Blue Select/HMO/PPO,,16888.38,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Select/HMO/PPO,,221.54,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,BCBS NC,Blue Select/HMO/PPO,,43.96,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Select/HMO/PPO,,64.17,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,BCBS NC,Blue Select/HMO/PPO,,144.42,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,5.44,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.50,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,BCBS NC,Blue Select/HMO/PPO,,7.90,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,BCBS NC,Blue Select/HMO/PPO,,13.85,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,BCBS NC,Blue Select/HMO/PPO,,16.99,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,BCBS NC,Blue Select/HMO/PPO,,23.28,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,BCBS NC,Blue Select/HMO/PPO,,29.55,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,BCBS NC,Blue Select/HMO/PPO,,35.82,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,BCBS NC,Blue Select/HMO/PPO,,19.67,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,BCBS NC,Blue Select/HMO/PPO,,21.13,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Select/HMO/PPO,,5.89,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,BCBS NC,Blue Select/HMO/PPO,,342.95,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,BCBS NC,Blue Select/HMO/PPO,,649.88,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,BCBS NC,Blue Select/HMO/PPO,,2.36,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,47.47,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,11.85,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,BCBS NC,Blue Select/HMO/PPO,,5.72,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,BCBS NC,Blue Select/HMO/PPO,,10.34,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,BCBS NC,Blue Select/HMO/PPO,,19.45,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,34.14,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,BCBS NC,Blue Select/HMO/PPO,,848.28,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Select/HMO/PPO,,1620.20,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,BCBS NC,Blue Select/HMO/PPO,,373.48,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,5.97,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,17.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,BCBS NC,Blue Select/HMO/PPO,,9.88,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,BCBS NC,Blue Select/HMO/PPO,,9.26,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,BCBS NC,Blue Select/HMO/PPO,,9.45,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,8.12,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,8.12,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,BCBS NC,Blue Select/HMO/PPO,,671.99,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,BCBS NC,Blue Select/HMO/PPO,,1798.57,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,BCBS NC,Blue Select/HMO/PPO,,46.64,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,BCBS NC,Blue Select/HMO/PPO,,7.65,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,BCBS NC,Blue Select/HMO/PPO,,17.68,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.41640,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.40252,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,BCBS NC,Blue Select/HMO/PPO,,7.63,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,BCBS NC,Blue Select/HMO/PPO,,8.73,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,BCBS NC,Blue Select/HMO/PPO,,43.69,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,6.51,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,BCBS NC,Blue Select/HMO/PPO,,28.58,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,BCBS NC,Blue Select/HMO/PPO,,162.41,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,BCBS NC,Blue Select/HMO/PPO,,50.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,BCBS NC,Blue Select/HMO/PPO,,72.26,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Select/HMO/PPO,,56.96,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,317.67,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Select/HMO/PPO,,5.05,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,BCBS NC,Blue Select/HMO/PPO,,28.02,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,BCBS NC,Blue Select/HMO/PPO,,49.55,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,BCBS NC,Blue Select/HMO/PPO,,145.86,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,0.43028,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,BCBS NC,Blue Select/HMO/PPO,,28.08,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,BCBS NC,Blue Select/HMO/PPO,,73.06,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,BCBS NC,Blue Select/HMO/PPO,,73.06,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,BCBS NC,Blue Select/HMO/PPO,,244.70,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,BCBS NC,Blue Select/HMO/PPO,,16.24,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,BCBS NC,Blue Select/HMO/PPO,,248.85,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,BCBS NC,Blue Select/HMO/PPO,,395.50,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,BCBS NC,Blue Select/HMO/PPO,,591.02,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,BCBS NC,Blue Select/HMO/PPO,,982.07,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,BCBS NC,Blue Select/HMO/PPO,,1959.69,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,BCBS NC,Blue Select/HMO/PPO,,2937.31,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,BCBS NC,Blue Select/HMO/PPO,,470.57,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,BCBS NC,Blue Select/HMO/PPO,,2289.17,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,BCBS NC,Blue Select/HMO/PPO,,8927.63,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Select/HMO/PPO,,1565.73,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Select/HMO/PPO,,3113.96,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Select/HMO/PPO,,88.51,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Select/HMO/PPO,,88.51,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,BCBS NC,Blue Select/HMO/PPO,,2444.78,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.52,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,BCBS NC,Blue Select/HMO/PPO,,23.12,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,BCBS NC,Blue Select/HMO/PPO,,28.13,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,BCBS NC,Blue Select/HMO/PPO,,42.74,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,BCBS NC,Blue Select/HMO/PPO,,6.48,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,BCBS NC,Blue Select/HMO/PPO,,32.17,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,BCBS NC,Blue Select/HMO/PPO,,39.41,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,BCBS NC,Blue Select/HMO/PPO,,245.59,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.38864,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Select/HMO/PPO,,11136.17,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Select/HMO/PPO,,44315.54,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,BCBS NC,Blue Select/HMO/PPO,,273.57,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.55520,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.48580,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,0.47192,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,0.44416,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,BCBS NC,Blue Select/HMO/PPO,,27.94,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,BCBS NC,Blue Select/HMO/PPO,,53.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,BCBS NC,Blue Select/HMO/PPO,,3681.16,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,BCBS NC,Blue Select/HMO/PPO,,3.82,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,BCBS NC,Blue Select/HMO/PPO,,623.31,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,BCBS NC,Blue Select/HMO/PPO,,23.89,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,BCBS NC,Blue Select/HMO/PPO,,197.07,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,BCBS NC,Blue Select/HMO/PPO,,59.35,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,BCBS NC,Blue Select/HMO/PPO,,16.82,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,26.58,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,BCBS NC,Blue Select/HMO/PPO,,51.20,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,BCBS NC,Blue Select/HMO/PPO,,62.38,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,BCBS NC,Blue Select/HMO/PPO,,16.73,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,293.42,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.40252,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.05,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.33312,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,BCBS NC,Blue Select/HMO/PPO,,0.86056,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,BCBS NC,Blue Select/HMO/PPO,,22.25,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Select/HMO/PPO,,21.47,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,BCBS NC,Blue Select/HMO/PPO,,21.18,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Select/HMO/PPO,,21.47,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,28.18,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,29.15,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,BCBS NC,Blue Select/HMO/PPO,,130.92,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,BCBS NC,Blue Select/HMO/PPO,,78.21,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.36,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,BCBS NC,Blue Select/HMO/PPO,,15559.08,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,15.27,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,BCBS NC,Blue Select/HMO/PPO,,1239.37,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,15.27,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,BCBS NC,Blue Select/HMO/PPO,,19.60,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,BCBS NC,Blue Select/HMO/PPO,,7.48,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.41640,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,BCBS NC,Blue Select/HMO/PPO,,8.72,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.36,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,8.27,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,BCBS NC,Blue Select/HMO/PPO,,309.22,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,BCBS NC,Blue Select/HMO/PPO,,508.01,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,BCBS NC,Blue Select/HMO/PPO,,87.75,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,BCBS NC,Blue Select/HMO/PPO,,131.67,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,26.58,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,26.58,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,BCBS NC,Blue Select/HMO/PPO,,197.17,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,7.98,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,6.51,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,156.84,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,BCBS NC,Blue Select/HMO/PPO,,332.66,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,BCBS NC,Blue Select/HMO/PPO,,1.14,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,BCBS NC,Blue Select/HMO/PPO,,157.90,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,31.09,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,BCBS NC,Blue Select/HMO/PPO,,46.64,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.71,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,4.90,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Select/HMO/PPO,,56.96,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,BCBS NC,Blue Select/HMO/PPO,,169.24,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,BCBS NC,Blue Select/HMO/PPO,,44.24,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,24.15,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,1.19,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,BCBS NC,Blue Select/HMO/PPO,,5.86,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,7.98,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,7.98,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,9.49,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,BCBS NC,Blue Select/HMO/PPO,,34.28,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,BCBS NC,Blue Select/HMO/PPO,,34.67,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,BCBS NC,Blue Select/HMO/PPO,,13.56,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,BCBS NC,Blue Select/HMO/PPO,,17.20,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,BCBS NC,Blue Select/HMO/PPO,,8.76,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,21.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,105.49,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,BCBS NC,Blue Select/HMO/PPO,,252.70,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,BCBS NC,Blue Select/HMO/PPO,,46.57,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,BCBS NC,Blue Select/HMO/PPO,,88.89,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,24.48,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,BCBS NC,Blue Select/HMO/PPO,,167.68,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,BCBS NC,Blue Select/HMO/PPO,,7052.30,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,BCBS NC,Blue Select/HMO/PPO,,514.84,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,,5.83,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,BCBS NC,Blue Select/HMO/PPO,,267.01,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,BCBS NC,Blue Select/HMO/PPO,,6.93,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,23.50,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,BCBS NC,Blue Select/HMO/PPO,,10.01,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,BCBS NC,Blue Select/HMO/PPO,,458.37,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,BCBS NC,Blue Select/HMO/PPO,,8407.17,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,BCBS NC,Blue Select/HMO/PPO,,8.79,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,BCBS NC,Blue Select/HMO/PPO,,14.81,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,BCBS NC,Blue Select/HMO/PPO,,10.56,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,BCBS NC,Blue Select/HMO/PPO,,13.35,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,BCBS NC,Blue Select/HMO/PPO,,20.00,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,BCBS NC,Blue Select/HMO/PPO,,21.49,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,BCBS NC,Blue Select/HMO/PPO,,51.54,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,BCBS NC,Blue Select/HMO/PPO,,5.69,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.20,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,6.19,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,BCBS NC,Blue Select/HMO/PPO,,88.98,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,BCBS NC,Blue Select/HMO/PPO,,121.59,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Select/HMO/PPO,,4396.81,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,29.83,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,BCBS NC,Blue Select/HMO/PPO,,572.83,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,BCBS NC,Blue Select/HMO/PPO,,762.29,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,BCBS NC,Blue Select/HMO/PPO,,54.47,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.02,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,BCBS NC,Blue Select/HMO/PPO,,0.74952,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,16.66,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,8.94,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,6.19,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,BCBS NC,Blue Select/HMO/PPO,,24.30,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,BCBS NC,Blue Select/HMO/PPO,,31.98,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.36088,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,BCBS NC,Blue Select/HMO/PPO,,13.80,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,BCBS NC,Blue Select/HMO/PPO,,10.02,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,BCBS NC,Blue Select/HMO/PPO,,41.07,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,0.43028,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.48580,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.54,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,BCBS NC,Blue Select/HMO/PPO,,57.48,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.29,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Select/HMO/PPO,,6.83,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,BCBS NC,Blue Select/HMO/PPO,,8.91,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,BCBS NC,Blue Select/HMO/PPO,,152.99,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,BCBS NC,Blue Select/HMO/PPO,,7.44,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,6.65,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,BCBS NC,Blue Select/HMO/PPO,,8.18,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,BCBS NC,Blue Select/HMO/PPO,,11.96,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,BCBS NC,Blue Select/HMO/PPO,,16.89,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,BCBS NC,Blue Select/HMO/PPO,,49.55,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,BCBS NC,Blue Select/HMO/PPO,,141.05,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,BCBS NC,Blue Select/HMO/PPO,,14.74,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,BCBS NC,Blue Select/HMO/PPO,,6.86,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,8.27,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,BCBS NC,Blue Select/HMO/PPO,,17.00,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,BCBS NC,Blue Select/HMO/PPO,,7.75,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,BCBS NC,Blue Select/HMO/PPO,,47.25,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,99.17,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Select/HMO/PPO,,320.92,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,BCBS NC,Blue Select/HMO/PPO,,2.39,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.59,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.52,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,BCBS NC,Blue Select/HMO/PPO,,32829.45,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,BCBS NC,Blue Select/HMO/PPO,,34.82,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,BCBS NC,Blue Select/HMO/PPO,,208.44,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,2.78,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,BCBS NC,Blue Select/HMO/PPO,,4.15,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,BCBS NC,Blue Select/HMO/PPO,,21.28,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,BCBS NC,Blue Select/HMO/PPO,,1.49,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,4.77,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,BCBS NC,Blue Select/HMO/PPO,,11.15,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,BCBS NC,Blue Select/HMO/PPO,,12.41,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,BCBS NC,Blue Select/HMO/PPO,,10.10,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Select/HMO/PPO,,23.57,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,BCBS NC,Blue Select/HMO/PPO,,23.53,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Select/HMO/PPO,,23.57,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,23.03,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,BCBS NC,Blue Select/HMO/PPO,,292.13,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,BCBS NC,Blue Select/HMO/PPO,,1496.25,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,BCBS NC,Blue Select/HMO/PPO,,1009.58,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,BCBS NC,Blue Select/HMO/PPO,,9.19,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,BCBS NC,Blue Select/HMO/PPO,,4376.36,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,BCBS NC,Blue Select/HMO/PPO,,0.80504,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,BCBS NC,Blue Select/HMO/PPO,,5.84,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,BCBS NC,Blue Select/HMO/PPO,,119.59,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,BCBS NC,Blue Select/HMO/PPO,,65.65,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,18.02,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,29.98,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,BCBS NC,Blue Select/HMO/PPO,,3.44,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,BCBS NC,Blue Select/HMO/PPO,,40.04,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,80.45,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,BCBS NC,Blue Select/HMO/PPO,,742.22,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,24.29,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,BCBS NC,Blue Select/HMO/PPO,,2.71,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,BCBS NC,Blue Select/HMO/PPO,,926.18,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Select/HMO/PPO,,95.16,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,BCBS NC,Blue Select/HMO/PPO,,227.13,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,BCBS NC,Blue Select/HMO/PPO,,88.75,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,BCBS NC,Blue Select/HMO/PPO,,273.41,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,6.97,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,BCBS NC,Blue Select/HMO/PPO,,377.74,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,24.29,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,BCBS NC,Blue Select/HMO/PPO,,60.34,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,BCBS NC,Blue Select/HMO/PPO,,10.66,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,BCBS NC,Blue Select/HMO/PPO,,10.88,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,BCBS NC,Blue Select/HMO/PPO,,1734.39,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Select/HMO/PPO,,5.22,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Select/HMO/PPO,,5.77,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,BCBS NC,Blue Select/HMO/PPO,,2638.42,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,BCBS NC,Blue Select/HMO/PPO,,1.07,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.03,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Select/HMO/PPO,,12.62,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,17.61,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,72.73,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,BCBS NC,Blue Select/HMO/PPO,,97.85,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,BCBS NC,Blue Select/HMO/PPO,,3.01,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,BCBS NC,Blue Select/HMO/PPO,,82.89,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,0.45804,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.38864,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,0.44416,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,BCBS NC,Blue Select/HMO/PPO,,12.85,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,BCBS NC,Blue Select/HMO/PPO,,60.70,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,BCBS NC,Blue Select/HMO/PPO,,49.80,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,BCBS NC,Blue Select/HMO/PPO,,27.70,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.36088,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,BCBS NC,Blue Select/HMO/PPO,,43.29,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Select/HMO/PPO,,11.20,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.11,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,BCBS NC,Blue Select/HMO/PPO,,17.97,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,BCBS NC,Blue Select/HMO/PPO,,3324.59,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,BCBS NC,Blue Select/HMO/PPO,,16.00,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,9.49,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,BCBS NC,Blue Select/HMO/PPO,,22.35,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,BCBS NC,Blue Select/HMO/PPO,,2697.94,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,BCBS NC,Blue Select/HMO/PPO,,69.37,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.36088,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,BCBS NC,Blue Select/HMO/PPO,,2.04,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,BCBS NC,Blue Select/HMO/PPO,,38.27,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,BCBS NC,Blue Select/HMO/PPO,,22.42,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,BCBS NC,Blue Select/HMO/PPO,,23.87,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,49.97,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,BCBS NC,Blue Select/HMO/PPO,,26.97,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Select/HMO/PPO,,5399.83,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,BCBS NC,Blue Select/HMO/PPO,,44.15,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,BCBS NC,Blue Select/HMO/PPO,,26.05,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,20.64,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,20.64,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,BCBS NC,Blue Select/HMO/PPO,,23.33,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,BCBS NC,Blue Select/HMO/PPO,,3.28,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,4.90,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Select/HMO/PPO,,6.69,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,BCBS NC,Blue Select/HMO/PPO,,3.07,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,BCBS NC,Blue Select/HMO/PPO,,2276.29,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,5.59,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.65,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,BCBS NC,Blue Select/HMO/PPO,,17.13,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,BCBS NC,Blue Select/HMO/PPO,,103.68,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,BCBS NC,Blue Select/HMO/PPO,,53.45,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,BCBS NC,Blue Select/HMO/PPO,,19.53,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,BCBS NC,Blue Select/HMO/PPO,,18.40,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.65,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.65,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,6.18,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,BCBS NC,Blue Select/HMO/PPO,,8.13,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,5.04,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.54,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,BCBS NC,Blue Select/HMO/PPO,,31.34,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,BCBS NC,Blue Select/HMO/PPO,,36.68,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.38864,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,BCBS NC,Blue Select/HMO/PPO,,25.03,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,BCBS NC,Blue Select/HMO/PPO,,41.27,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,BCBS NC,Blue Select/HMO/PPO,,12.37,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,BCBS NC,Blue Select/HMO/PPO,,28.95,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,BCBS NC,Blue Select/HMO/PPO,,5.62,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,BCBS NC,Blue Select/HMO/PPO,,96.05,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,BCBS NC,Blue Select/HMO/PPO,,350.86,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,BCBS NC,Blue Select/HMO/PPO,,6.40,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,BCBS NC,Blue Select/HMO/PPO,,125.70,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,BCBS NC,Blue Select/HMO/PPO,,252.01,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.48580,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,0.47192,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,BCBS NC,Blue Select/HMO/PPO,,2.47,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,BCBS NC,Blue Select/HMO/PPO,,66.80,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.51,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.59,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,BCBS NC,Blue Select/HMO/PPO,,26.25,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,BCBS NC,Blue Select/HMO/PPO,,7.86,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,BCBS NC,Blue Select/HMO/PPO,,37.41,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Select/HMO/PPO,,39.35,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,BCBS NC,Blue Select/HMO/PPO,,12.14,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,BCBS NC,Blue Select/HMO/PPO,,96.79,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,5.21,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Select/HMO/PPO,,39.35,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,BCBS NC,Blue Select/HMO/PPO,,45.67,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,48.58,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,BCBS NC,Blue Select/HMO/PPO,,0.88832,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,28.18,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,34.42,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,34.42,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,BCBS NC,Blue Select/HMO/PPO,,25.46,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,BCBS NC,Blue Select/HMO/PPO,,22.12,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,BCBS NC,Blue Select/HMO/PPO,,130.75,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,7.27,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,6.44,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,BCBS NC,Blue Select/HMO/PPO,,6.52,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.25,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,BCBS NC,Blue Select/HMO/PPO,,3853.41,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,BCBS NC,Blue Select/HMO/PPO,,84.33,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,1.18,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Select/HMO/PPO,,15.67,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Select/HMO/PPO,,15.67,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,BCBS NC,Blue Select/HMO/PPO,,1128.60,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,BCBS NC,Blue Select/HMO/PPO,,31.38,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,BCBS NC,Blue Select/HMO/PPO,,32.72,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,BCBS NC,Blue Select/HMO/PPO,,4949.44,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,BCBS NC,Blue Select/HMO/PPO,,7873.29,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Select/HMO/PPO,,18.14,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,BCBS NC,Blue Select/HMO/PPO,,1.71,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,BCBS NC,Blue Select/HMO/PPO,,40.93,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,BCBS NC,Blue Select/HMO/PPO,,11.52,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,BCBS NC,Blue Select/HMO/PPO,,6.58,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,5.33,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,BCBS NC,Blue Select/HMO/PPO,,44.83,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Select/HMO/PPO,,135.11,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,BCBS NC,Blue Select/HMO/PPO,,27.18,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,BCBS NC,Blue Select/HMO/PPO,,1270.30,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,BCBS NC,Blue Select/HMO/PPO,,42.47,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,BCBS NC,Blue Select/HMO/PPO,,6.68,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,BCBS NC,Blue Select/HMO/PPO,,1.33,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,BCBS NC,Blue Select/HMO/PPO,,90.51,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Select/HMO/PPO,,23.48,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Select/HMO/PPO,,23.48,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Select/HMO/PPO,,178.54,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Select/HMO/PPO,,178.54,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,4.77,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,BCBS NC,Blue Select/HMO/PPO,,152.67,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.25,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.20,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,BCBS NC,Blue Select/HMO/PPO,,0.51356,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,23.35,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,BCBS NC,Blue Select/HMO/PPO,,90.04,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,BCBS NC,Blue Select/HMO/PPO,,137.00,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,BCBS NC,Blue Select/HMO/PPO,,5.68,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,BCBS NC,Blue Select/HMO/PPO,,99.14,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,BCBS NC,Blue Select/HMO/PPO,,146.49,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Select/HMO/PPO,,27.75,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Select/HMO/PPO,,27.75,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,BCBS NC,Blue Select/HMO/PPO,,102.34,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,BCBS NC,Blue Select/HMO/PPO,,1774.53,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,7.88,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,BCBS NC,Blue Select/HMO/PPO,,1909.47,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,BCBS NC,Blue Select/HMO/PPO,,9241.97,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,6.30,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,15.27,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,0.47192,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,BCBS NC,Blue Select/HMO/PPO,,10930.40,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,BCBS NC,Blue Select/HMO/PPO,,2251.63,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,BCBS NC,Blue Select/HMO/PPO,,105.86,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,20.99,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Select/HMO/PPO,,24.37,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,BCBS NC,Blue Select/HMO/PPO,,581.10,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,BCBS NC,Blue Select/HMO/PPO,,3881.78,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,BCBS NC,Blue Select/HMO/PPO,,128.32,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,BCBS NC,Blue Select/HMO/PPO,,303.97,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,BCBS NC,Blue Select/HMO/PPO,,68.71,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.55,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,10.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,10.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,BCBS NC,Blue Select/HMO/PPO,,66.94,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,BCBS NC,Blue Select/HMO/PPO,,85.47,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,BCBS NC,Blue Select/HMO/PPO,,112.93,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,6863.60,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,BCBS NC,Blue Select/HMO/PPO,,224.68,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,BCBS NC,Blue Select/HMO/PPO,,1693.35,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,BCBS NC,Blue Select/HMO/PPO,,4118.82,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.50,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.51,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,BCBS NC,Blue Select/HMO/PPO,,202.97,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,BCBS NC,Blue Select/HMO/PPO,,10.97,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,BCBS NC,Blue Select/HMO/PPO,,13.24,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,BCBS NC,Blue Select/HMO/PPO,,15.14,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,BCBS NC,Blue Select/HMO/PPO,,21.57,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Select/HMO/PPO,,8110.89,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,BCBS NC,Blue Select/HMO/PPO,,7280.06,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,6.94,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,20.60,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,20.60,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,BCBS NC,Blue Select/HMO/PPO,,30.34,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,BCBS NC,Blue Select/HMO/PPO,,494.13,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.03,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.03,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,BCBS NC,Blue Select/HMO/PPO,,5835.21,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,BCBS NC,Blue Select/HMO/PPO,,8735.56,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,BCBS NC,Blue Select/HMO/PPO,,4454.83,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,BCBS NC,Blue Select/HMO/PPO,,501.78,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,BCBS NC,Blue Select/HMO/PPO,,1040.15,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,BCBS NC,Blue Select/HMO/PPO,,2.25,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,26.23,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Select/HMO/PPO,,135.11,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,BCBS NC,Blue Select/HMO/PPO,,1086.58,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,BCBS NC,Blue Select/HMO/PPO,,23341.44,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,BCBS NC,Blue Select/HMO/PPO,,549.26,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,BCBS NC,Blue Select/HMO/PPO,,136.91,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,BCBS NC,Blue Select/HMO/PPO,,1285.12,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,BCBS NC,Blue Select/HMO/PPO,,2548.87,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,BCBS NC,Blue Select/HMO/PPO,,1269.05,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,BCBS NC,Blue Select/HMO/PPO,,558.92,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,BCBS NC,Blue Select/HMO/PPO,,350.98,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,12.30,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,BCBS NC,Blue Select/HMO/PPO,,35.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.05,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,BCBS NC,Blue Select/HMO/PPO,,23.37,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,21.10,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,BCBS NC,Blue Select/HMO/PPO,,2991.99,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,BCBS NC,Blue Select/HMO/PPO,,3715.01,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Select/HMO/PPO,,12.38,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Select/HMO/PPO,,12.38,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,BCBS NC,Blue Select/HMO/PPO,,15.96,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,BCBS NC,Blue Select/HMO/PPO,,4555.10,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Select/HMO/PPO,,160.49,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,BCBS NC,Blue Select/HMO/PPO,,27.14,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,BCBS NC,Blue Select/HMO/PPO,,40.89,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,BCBS NC,Blue Select/HMO/PPO,,16.52,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,BCBS NC,Blue Select/HMO/PPO,,3097.95,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,BCBS NC,Blue Select/HMO/PPO,,288.50,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,BCBS NC,Blue Select/HMO/PPO,,176.40,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.57,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,BCBS NC,Blue Select/HMO/PPO,,60.67,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,BCBS NC,Blue Select/HMO/PPO,,5.32,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,BCBS NC,Blue Select/HMO/PPO,,243.54,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,5.44,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,BCBS NC,Blue Select/HMO/PPO,,1120.78,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,BCBS NC,Blue Select/HMO/PPO,,459.94,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,BCBS NC,Blue Select/HMO/PPO,,85.96,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,BCBS NC,Blue Select/HMO/PPO,,3750.63,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,BCBS NC,Blue Select/HMO/PPO,,21.39,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,BCBS NC,Blue Select/HMO/PPO,,79.23,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,BCBS NC,Blue Select/HMO/PPO,,151.46,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,BCBS NC,Blue Select/HMO/PPO,,1290.06,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,BCBS NC,Blue Select/HMO/PPO,,58.68,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,BCBS NC,Blue Select/HMO/PPO,,26.55,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Select/HMO/PPO,,41.13,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Select/HMO/PPO,,14232.05,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.11,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,BCBS NC,Blue Select/HMO/PPO,,374.80,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,BCBS NC,Blue Select/HMO/PPO,,34.01,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,BCBS NC,Blue Select/HMO/PPO,,762.62,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,BCBS NC,Blue Select/HMO/PPO,,17.03,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,BCBS NC,Blue Select/HMO/PPO,,300.50,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,BCBS NC,Blue Select/HMO/PPO,,17.02,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,BCBS NC,Blue Select/HMO/PPO,,4447.98,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Select/HMO/PPO,,11.42,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,BCBS NC,Blue Select/HMO/PPO,,53.20,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Select/HMO/PPO,,18.39,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,BCBS NC,Blue Select/HMO/PPO,,101.96,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,BCBS NC,Blue Select/HMO/PPO,,15.96,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,BCBS NC,Blue Select/HMO/PPO,,9.51,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,BCBS NC,Blue Select/HMO/PPO,,11.08,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,BCBS NC,Blue Select/HMO/PPO,,24949.94,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,BCBS NC,Blue Select/HMO/PPO,,2634.06,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,BCBS NC,Blue Select/HMO/PPO,,24083.20,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,BCBS NC,Blue Select/HMO/PPO,,1979.87,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,BCBS NC,Blue Select/HMO/PPO,,248.92,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,BCBS NC,Blue Select/HMO/PPO,,5322.02,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,BCBS NC,Blue Select/HMO/PPO,,1335.31,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,BCBS NC,Blue Select/HMO/PPO,,8109.25,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,BCBS NC,Blue Select/HMO/PPO,,1.85,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,19.92,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,BCBS NC,Blue Select/HMO/PPO,,9256.79,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,BCBS NC,Blue Select/HMO/PPO,,19.79,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,BCBS NC,Blue Select/HMO/PPO,,19.07,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,BCBS NC,Blue Select/HMO/PPO,,364.42,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,BCBS NC,Blue Select/HMO/PPO,,1252.36,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,BCBS NC,Blue Select/HMO/PPO,,13.27,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,BCBS NC,Blue Select/HMO/PPO,,13487.75,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,BCBS NC,Blue Select/HMO/PPO,,29288.24,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,4.84,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,BCBS NC,Blue Select/HMO/PPO,,36.53,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Select/HMO/PPO,,26.46,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Select/HMO/PPO,,26.46,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,25.07,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,7.73,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,BCBS NC,Blue Select/HMO/PPO,,55.38,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,BCBS NC,Blue Select/HMO/PPO,,276.91,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,BCBS NC,Blue Select/HMO/PPO,,18.35,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,BCBS NC,Blue Select/HMO/PPO,,185.59,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,BCBS NC,Blue Select/HMO/PPO,,1.30,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,BCBS NC,Blue Select/HMO/PPO,,547.50,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,BCBS NC,Blue Select/HMO/PPO,,7389.74,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,BCBS NC,Blue Select/HMO/PPO,,1635.24,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Select/HMO/PPO,,5.30,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,BCBS NC,Blue Select/HMO/PPO,,9778.35,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,BCBS NC,Blue Select/HMO/PPO,,22.22,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,BCBS NC,Blue Select/HMO/PPO,,67.17,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,BCBS NC,Blue Select/HMO/PPO,,108.13,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,BCBS NC,Blue Select/HMO/PPO,,16.23,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,BCBS NC,Blue Select/HMO/PPO,,32.31,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,BCBS NC,Blue Select/HMO/PPO,,46.25,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,BCBS NC,Blue Select/HMO/PPO,,60.17,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,BCBS NC,Blue Select/HMO/PPO,,143.77,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,BCBS NC,Blue Select/HMO/PPO,,561.72,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,BCBS NC,Blue Select/HMO/PPO,,2641.13,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,BCBS NC,Blue Select/HMO/PPO,,145.74,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Select/HMO/PPO,,36.34,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Select/HMO/PPO,,36.34,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,BCBS NC,Blue Select/HMO/PPO,,135.82,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,BCBS NC,Blue Select/HMO/PPO,,5917.75,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,281.06,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,BCBS NC,Blue Select/HMO/PPO,,447.03,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,BCBS NC,Blue Select/HMO/PPO,,95.70,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.59,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,BCBS NC,Blue Select/HMO/PPO,,15.52,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,BCBS NC,Blue Select/HMO/PPO,,1428.53,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,BCBS NC,Blue Select/HMO/PPO,,13420.53,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Select/HMO/PPO,,5277.80,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,BCBS NC,Blue Select/HMO/PPO,,13.35,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,BCBS NC,Blue Select/HMO/PPO,,1261.21,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Select/HMO/PPO,,2797.38,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,281.06,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,BCBS NC,Blue Select/HMO/PPO,,10011.39,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,BCBS NC,Blue Select/HMO/PPO,,812.81,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Select/HMO/PPO,,9985.36,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,BCBS NC,Blue Select/HMO/PPO,,5786.88,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,56.35,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,BCBS NC,Blue Select/HMO/PPO,,79.67,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,BCBS NC,Blue Select/HMO/PPO,,116.47,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,494.41,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,BCBS NC,Blue Select/HMO/PPO,,22809.07,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,BCBS NC,Blue Select/HMO/PPO,,3485.25,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,BCBS NC,Blue Select/HMO/PPO,,928.59,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,BCBS NC,Blue Select/HMO/PPO,,55.87,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,13.32,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,BCBS NC,Blue Select/HMO/PPO,,6.62,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,BCBS NC,Blue Select/HMO/PPO,,1109.14,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,BCBS NC,Blue Select/HMO/PPO,,5240.28,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,BCBS NC,Blue Select/HMO/PPO,,4813.08,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,BCBS NC,Blue Select/HMO/PPO,,14404.22,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,BCBS NC,Blue Select/HMO/PPO,,2877.42,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,BCBS NC,Blue Select/HMO/PPO,,1743.12,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,BCBS NC,Blue Select/HMO/PPO,,29.74,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,BCBS NC,Blue Select/HMO/PPO,,3507.36,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5222.88,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,BCBS NC,Blue Select/HMO/PPO,,3846.29,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,BCBS NC,Blue Select/HMO/PPO,,3073.27,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,BCBS NC,Blue Select/HMO/PPO,,825.58,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,BCBS NC,Blue Select/HMO/PPO,,951.88,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,BCBS NC,Blue Select/HMO/PPO,,4453.98,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,BCBS NC,Blue Select/HMO/PPO,,21026.15,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,BCBS NC,Blue Select/HMO/PPO,,4218.35,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Select/HMO/PPO,,39.85,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Select/HMO/PPO,,39.85,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,BCBS NC,Blue Select/HMO/PPO,,7.94,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,BCBS NC,Blue Select/HMO/PPO,,2279.46,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,BCBS NC,Blue Select/HMO/PPO,,5389.12,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,BCBS NC,Blue Select/HMO/PPO,,1138.90,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,BCBS NC,Blue Select/HMO/PPO,,41.39,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,BCBS NC,Blue Select/HMO/PPO,,3207.50,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,BCBS NC,Blue Select/HMO/PPO,,30545.16,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,BCBS NC,Blue Select/HMO/PPO,,600.45,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,BCBS NC,Blue Select/HMO/PPO,,11.87,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,BCBS NC,Blue Select/HMO/PPO,,48.93,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,BCBS NC,Blue Select/HMO/PPO,,17074.57,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,BCBS NC,Blue Select/HMO/PPO,,11408.04,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,BCBS NC,Blue Select/HMO/PPO,,18.22,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,BCBS NC,Blue Select/HMO/PPO,,1781.32,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,BCBS NC,Blue Select/HMO/PPO,,4947.65,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,BCBS NC,Blue Select/HMO/PPO,,27942.40,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,BCBS NC,Blue Select/HMO/PPO,,7633.38,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,BCBS NC,Blue Select/HMO/PPO,,283.08,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,BCBS NC,Blue Select/HMO/PPO,,1872.00,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,BCBS NC,Blue Select/HMO/PPO,,1555.64,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,BCBS NC,Blue Select/HMO/PPO,,2558.56,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,BCBS NC,Blue Select/HMO/PPO,,34669.64,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,BCBS NC,Blue Select/HMO/PPO,,14770.60,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,BCBS NC,Blue Select/HMO/PPO,,5682.75,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,BCBS NC,Blue Select/HMO/PPO,,4725.97,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,BCBS NC,Blue Select/HMO/PPO,,22.55,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,BCBS NC,Blue Select/HMO/PPO,,241.35,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,BCBS NC,Blue Select/HMO/PPO,,9115.98,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,29.83,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,BCBS NC,Blue Select/HMO/PPO,,114.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,BCBS NC,Blue Select/HMO/PPO,,4536.04,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,BCBS NC,Blue Select/HMO/PPO,,10114.01,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,BCBS NC,Blue Select/HMO/PPO,,9.48,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Select/HMO/PPO,,24.32,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Select/HMO/PPO,,22.97,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Select/HMO/PPO,,22.97,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,BCBS NC,Blue Select/HMO/PPO,,205.27,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,BCBS NC,Blue Select/HMO/PPO,,325.78,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,BCBS NC,Blue Select/HMO/PPO,,18913.37,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,21.10,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Select/HMO/PPO,,729.06,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Select/HMO/PPO,,315.35,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Select/HMO/PPO,,315.35,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Select/HMO/PPO,,729.06,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,BCBS NC,Blue Select/HMO/PPO,,28.88,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,BCBS NC,Blue Select/HMO/PPO,,12837.40,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,BCBS NC,Blue Select/HMO/PPO,,2578.50,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,BCBS NC,Blue Select/HMO/PPO,,144.35,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,BCBS NC,Blue Select/HMO/PPO,,8360.59,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,BCBS NC,Blue Select/HMO/PPO,,838.82,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,BCBS NC,Blue Select/HMO/PPO,,22951.05,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,BCBS NC,Blue Select/HMO/PPO,,18084.03,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,BCBS NC,Blue Select/HMO/PPO,,3322.18,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,BCBS NC,Blue Select/HMO/PPO,,6639.66,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,BCBS NC,Blue Select/HMO/PPO,,8298.59,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,BCBS NC,Blue Select/HMO/PPO,,18920.72,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,BCBS NC,Blue Select/HMO/PPO,,261.61,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,BCBS NC,Blue Select/HMO/PPO,,706.88,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,BCBS NC,Blue Select/HMO/PPO,,706.89,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,BCBS NC,Blue Select/HMO/PPO,,17.35,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Select/HMO/PPO,,14187.68,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,BCBS NC,Blue Select/HMO/PPO,,1134.70,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,BCBS NC,Blue Select/HMO/PPO,,409.68,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,BCBS NC,Blue Select/HMO/PPO,,57.85,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,BCBS NC,Blue Select/HMO/PPO,,70.93,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,BCBS NC,Blue Select/HMO/PPO,,19.24,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,BCBS NC,Blue Select/HMO/PPO,,17624.41,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,BCBS NC,Blue Select/HMO/PPO,,65.07,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Select/HMO/PPO,,5277.80,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,BCBS NC,Blue Select/HMO/PPO,,97.84,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,BCBS NC,Blue Select/HMO/PPO,,7421.09,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.55,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,BCBS NC,Blue Select/HMO/PPO,,3051.68,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,BCBS NC,Blue Select/HMO/PPO,,12154.23,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,BCBS NC,Blue Select/HMO/PPO,,245.12,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,BCBS NC,Blue Select/HMO/PPO,,17000.79,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,BCBS NC,Blue Select/HMO/PPO,,2030.64,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,BCBS NC,Blue Select/HMO/PPO,,71.43,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,BCBS NC,Blue Select/HMO/PPO,,22.55,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.65,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,BCBS NC,Blue Select/HMO/PPO,,9778.35,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,BCBS NC,Blue Select/HMO/PPO,,6050.50,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,BCBS NC,Blue Select/HMO/PPO,,0.37476,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.36088,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,BCBS NC,Blue Select/HMO/PPO,,101.17,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.51,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,10484.55,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,BCBS NC,Blue Select/HMO/PPO,,129.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.51,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,BCBS NC,Blue Select/HMO/PPO,,13.63,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,BCBS NC,Blue Select/HMO/PPO,,24.75,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.50,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,BCBS NC,Blue Select/HMO/PPO,,20.38,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,BCBS NC,Blue Select/HMO/PPO,,91.00,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,BCBS NC,Blue Select/HMO/PPO,,10.67,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,6.51,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,BCBS NC,Blue Select/HMO/PPO,,7.56,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,8.94,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,BCBS NC,Blue Select/HMO/PPO,,0.81892,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,BCBS NC,Blue Select/HMO/PPO,,53.55,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,BCBS NC,Blue Select/HMO/PPO,,3.08,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,BCBS NC,Blue Select/HMO/PPO,,5.43,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.51,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,BCBS NC,Blue Select/HMO/PPO,,26.16,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,BCBS NC,Blue Select/HMO/PPO,,7.55,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,7.27,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,4.77,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,BCBS NC,Blue Select/HMO/PPO,,25.28,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,BCBS NC,Blue Select/HMO/PPO,,388.63,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,BCBS NC,Blue Select/HMO/PPO,,1223.91,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,BCBS NC,Blue Select/HMO/PPO,,5814.18,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,BCBS NC,Blue Select/HMO/PPO,,18.86,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,BCBS NC,Blue Select/HMO/PPO,,1766.37,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,BCBS NC,Blue Select/HMO/PPO,,23.29,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,BCBS NC,Blue Select/HMO/PPO,,54.91,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Select/HMO/PPO,,12.80,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Select/HMO/PPO,,12.70,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,BCBS NC,Blue Select/HMO/PPO,,1161.05,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,BCBS NC,Blue Select/HMO/PPO,,22.64,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Select/HMO/PPO,,5.22,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,BCBS NC,Blue Select/HMO/PPO,,35.16,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,BCBS NC,Blue Select/HMO/PPO,,131.28,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,BCBS NC,Blue Select/HMO/PPO,,2.68,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,BCBS NC,Blue Select/HMO/PPO,,308.97,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,BCBS NC,Blue Select/HMO/PPO,,5.57,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,BCBS NC,Blue Select/HMO/PPO,,6.91,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,BCBS NC,Blue Select/HMO/PPO,,49.33,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,BCBS NC,Blue Select/HMO/PPO,,3.29,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,24.15,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,BCBS NC,Blue Select/HMO/PPO,,22.69,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,BCBS NC,Blue Select/HMO/PPO,,29.56,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,BCBS NC,Blue Select/HMO/PPO,,30.45,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,BCBS NC,Blue Select/HMO/PPO,,181.62,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,BCBS NC,Blue Select/HMO/PPO,,19.74,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,BCBS NC,Blue Select/HMO/PPO,,19.90,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,21.86,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,BCBS NC,Blue Select/HMO/PPO,,19.78,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,21.24,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,11.02,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,21.65,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,BCBS NC,Blue Select/HMO/PPO,,571.30,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,BCBS NC,Blue Select/HMO/PPO,,143.39,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,6.18,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,6.18,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,BCBS NC,Blue Select/HMO/PPO,,14.96,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,BCBS NC,Blue Select/HMO/PPO,,2.39,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,5.21,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,BCBS NC,Blue Select/HMO/PPO,,39.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Select/HMO/PPO,,4.62,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,BCBS NC,Blue Select/HMO/PPO,,117.26,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,BCBS NC,Blue Select/HMO/PPO,,14.07,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,BCBS NC,Blue Select/HMO/PPO,,24.61,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,BCBS NC,Blue Select/HMO/PPO,,5.94,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,4.87,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,BCBS NC,Blue Select/HMO/PPO,,25.25,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Select/HMO/PPO,,5.90,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,BCBS NC,Blue Select/HMO/PPO,,0.52744,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,6.65,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,BCBS NC,Blue Select/HMO/PPO,,6.22,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,BCBS NC,Blue Select/HMO/PPO,,54.58,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,BCBS NC,Blue Select/HMO/PPO,,13.44,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,BCBS NC,Blue Select/HMO/PPO,,8.24,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,BCBS NC,Blue Select/HMO/PPO,,2.08,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,BCBS NC,Blue Select/HMO/PPO,,5.76,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,BCBS NC,Blue Select/HMO/PPO,,22.60,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,BCBS NC,Blue Select/HMO/PPO,,0.92996,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,BCBS NC,Blue Select/HMO/PPO,,4.00,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.52,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.71,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.25,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.36088,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,BCBS NC,Blue Select/HMO/PPO,,9.05,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,BCBS NC,Blue Select/HMO/PPO,,22.17,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,6.36,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,5.04,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Select/HMO/PPO,,5.23,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,BCBS NC,Blue Select/HMO/PPO,,5.52,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,BCBS NC,Blue Select/HMO/PPO,,45.67,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.57,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,4.77,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,BCBS NC,Blue Select/HMO/PPO,,23.42,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,BCBS NC,Blue Select/HMO/PPO,,8.70,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,BCBS NC,Blue Select/HMO/PPO,,2039.35,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,BCBS NC,Blue Select/HMO/PPO,,7.80,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,BCBS NC,Blue Select/HMO/PPO,,21.32,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,BCBS NC,Blue Select/HMO/PPO,,760.98,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,24.48,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,BCBS NC,Blue Select/HMO/PPO,,11.08,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,BCBS NC,Blue Select/HMO/PPO,,26.97,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,BCBS NC,Blue Select/HMO/PPO,,28.20,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,40.81,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,BCBS NC,Blue Select/HMO/PPO,,7.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,BCBS NC,Blue Select/HMO/PPO,,327.43,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,BCBS NC,Blue Select/HMO/PPO,,625.99,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,BCBS NC,Blue Select/HMO/PPO,,1603.14,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Select/HMO/PPO,,1.64,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,BCBS NC,Blue Select/HMO/PPO,,615.37,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Select/HMO/PPO,,5.23,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,BCBS NC,Blue Select/HMO/PPO,,63.29,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.36,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,5.59,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,BCBS NC,Blue Select/HMO/PPO,,73.18,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Select/HMO/PPO,,5.89,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Select/HMO/PPO,,5.39,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,BCBS NC,Blue Select/HMO/PPO,,6.41,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.29,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.55,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,BCBS NC,Blue Select/HMO/PPO,,7.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,BCBS NC,Blue Select/HMO/PPO,,28.09,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,BCBS NC,Blue Select/HMO/PPO,,168.52,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Select/HMO/PPO,,50.20,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Select/HMO/PPO,,50.20,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,BCBS NC,Blue Select/HMO/PPO,,53.99,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,BCBS NC,Blue Select/HMO/PPO,,54.31,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,21.65,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Select/HMO/PPO,,1.03,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Select/HMO/PPO,,1.03,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,BCBS NC,Blue Select/HMO/PPO,,1.08,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,BCBS NC,Blue Select/HMO/PPO,,9.90,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,BCBS NC,Blue Select/HMO/PPO,,12.05,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,16.66,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,BCBS NC,Blue Select/HMO/PPO,,22.79,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,BCBS NC,Blue Select/HMO/PPO,,29.06,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,BCBS NC,Blue Select/HMO/PPO,,61.28,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,BCBS NC,Blue Select/HMO/PPO,,3.72,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.40252,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,BCBS NC,Blue Select/HMO/PPO,,280.88,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,BCBS NC,Blue Select/HMO/PPO,,2.23,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,BCBS NC,Blue Select/HMO/PPO,,31.65,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,BCBS NC,Blue Select/HMO/PPO,,6.43,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,BCBS NC,Blue Select/HMO/PPO,,7.36,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,BCBS NC,Blue Select/HMO/PPO,,208.94,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Select/HMO/PPO,,5.09,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,85.61,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Select/HMO/PPO,,6.69,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,BCBS NC,Blue Select/HMO/PPO,,25.62,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,25.07,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,BCBS NC,Blue Select/HMO/PPO,,6.34,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,BCBS NC,Blue Select/HMO/PPO,,5.64,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.02,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,BCBS NC,Blue Select/HMO/PPO,,12.81,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,BCBS NC,Blue Select/HMO/PPO,,14.30,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,BCBS NC,Blue Select/HMO/PPO,,74.31,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,BCBS NC,Blue Select/HMO/PPO,,7.75,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,BCBS NC,Blue Select/HMO/PPO,,17.53,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,BCBS NC,Blue Select/HMO/PPO,,166.32,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,BCBS NC,Blue Select/HMO/PPO,,10.48,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,BCBS NC,Blue Select/HMO/PPO,,17.34,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,BCBS NC,Blue Select/HMO/PPO,,977.15,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,BCBS NC,Blue Select/HMO/PPO,,430.84,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,BCBS NC,Blue Select/HMO/PPO,,334.26,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,BCBS NC,Blue Select/HMO/PPO,,59.96,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,BCBS NC,Blue Select/HMO/PPO,,31.99,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,BCBS NC,Blue Select/HMO/PPO,,145.45,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,BCBS NC,Blue Select/HMO/PPO,,193.90,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,BCBS NC,Blue Select/HMO/PPO,,332.84,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,BCBS NC,Blue Select/HMO/PPO,,93.22,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,BCBS NC,Blue Select/HMO/PPO,,97.02,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Select/HMO/PPO,,5.30,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.34,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,5.93,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,BCBS NC,Blue Select/HMO/PPO,,7.90,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.36,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,BCBS NC,Blue Select/HMO/PPO,,3572.43,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,BCBS NC,Blue Select/HMO/PPO,,14.55,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,99.17,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,BCBS NC,Blue Select/HMO/PPO,,18.49,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,4.93,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,BCBS NC,Blue Select/HMO/PPO,,0.68012,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,BCBS NC,Blue Select/HMO/PPO,,1.24,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,5.93,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,BCBS NC,Blue Select/HMO/PPO,,7.52,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,BCBS NC,Blue Select/HMO/PPO,,192.38,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,5.41,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,5.41,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,BCBS NC,Blue Select/HMO/PPO,,6.00,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,BCBS NC,Blue Select/HMO/PPO,,23.07,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,BCBS NC,Blue Select/HMO/PPO,,102.61,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,116.59,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,BCBS NC,Blue Select/HMO/PPO,,7.95,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,BCBS NC,Blue Select/HMO/PPO,,11.77,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,7.88,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,BCBS NC,Blue Select/HMO/PPO,,7.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.48580,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,BCBS NC,Blue Select/HMO/PPO,,33.28,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,BCBS NC,Blue Select/HMO/PPO,,1.75,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,BCBS NC,Blue Select/HMO/PPO,,26.09,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,BCBS NC,Blue Select/HMO/PPO,,24.01,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,BCBS NC,Blue Select/HMO/PPO,,129.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,88.55,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,BCBS NC,Blue Select/HMO/PPO,,234.28,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,BCBS NC,Blue Select/HMO/PPO,,5.69,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,BCBS NC,Blue Select/HMO/PPO,,73.58,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,BCBS NC,Blue Select/HMO/PPO,,238.33,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,BCBS NC,Blue Select/HMO/PPO,,5544.50,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,BCBS NC,Blue Select/HMO/PPO,,9.38,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,5.93,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,5.93,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,BCBS NC,Blue Select/HMO/PPO,,50.84,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,BCBS NC,Blue Select/HMO/PPO,,32.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,BCBS NC,Blue Select/HMO/PPO,,8.30,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,BCBS NC,Blue Select/HMO/PPO,,34.80,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,BCBS NC,Blue Select/HMO/PPO,,19.85,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,BCBS NC,Blue Select/HMO/PPO,,52.77,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,BCBS NC,Blue Select/HMO/PPO,,23.47,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,BCBS NC,Blue Select/HMO/PPO,,144.71,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,BCBS NC,Blue Select/HMO/PPO,,16.57,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.11,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,BCBS NC,Blue Select/HMO/PPO,,7.94,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,BCBS NC,Blue Select/HMO/PPO,,33.60,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Select/HMO/PPO,,8110.89,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,BCBS NC,Blue Select/HMO/PPO,,10.17,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,BCBS NC,Blue Select/HMO/PPO,,6.15,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.20,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,BCBS NC,Blue Select/HMO/PPO,,25.91,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,BCBS NC,Blue Select/HMO/PPO,,826.71,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,BCBS NC,Blue Select/HMO/PPO,,9.94,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,BCBS NC,Blue Select/HMO/PPO,,35.71,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,BCBS NC,Blue Select/HMO/PPO,,628.06,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,BCBS NC,Blue Select/HMO/PPO,,11.83,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,BCBS NC,Blue Select/HMO/PPO,,9.73,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,BCBS NC,Blue Select/HMO/PPO,,8.15,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,BCBS NC,Blue Select/HMO/PPO,,15.34,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,BCBS NC,Blue Select/HMO/PPO,,10.05,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,BCBS NC,Blue Select/HMO/PPO,,1451.93,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,BCBS NC,Blue Select/HMO/PPO,,3623.15,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,BCBS NC,Blue Select/HMO/PPO,,7241.82,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,BCBS NC,Blue Select/HMO/PPO,,14479.20,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,BCBS NC,Blue Select/HMO/PPO,,50.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,BCBS NC,Blue Select/HMO/PPO,,110.93,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,BCBS NC,Blue Select/HMO/PPO,,7.08,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,BCBS NC,Blue Select/HMO/PPO,,13.92,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,BCBS NC,Blue Select/HMO/PPO,,41.03,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,BCBS NC,Blue Select/HMO/PPO,,87.80,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,BCBS NC,Blue Select/HMO/PPO,,13.44,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,BCBS NC,Blue Select/HMO/PPO,,14.00,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,BCBS NC,Blue Select/HMO/PPO,,1308.16,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,BCBS NC,Blue Select/HMO/PPO,,15.92,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,BCBS NC,Blue Select/HMO/PPO,,37.34,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,BCBS NC,Blue Select/HMO/PPO,,10.31,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Select/HMO/PPO,,46.54,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,13.57,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,BCBS NC,Blue Select/HMO/PPO,,6.08,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.25,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,6.36,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,BCBS NC,Blue Select/HMO/PPO,,89.29,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,5.97,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,BCBS NC,Blue Select/HMO/PPO,,7.29,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,BCBS NC,Blue Select/HMO/PPO,,10.30,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,7.73,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,BCBS NC,Blue Select/HMO/PPO,,129.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,BCBS NC,Blue Select/HMO/PPO,,3.14,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,0.45804,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,BCBS NC,Blue Select/HMO/PPO,,287.27,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,BCBS NC,Blue Select/HMO/PPO,,6.90,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,BCBS NC,Blue Select/HMO/PPO,,6.88,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,BCBS NC,Blue Select/HMO/PPO,,69.96,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,8.98,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,4.90,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,BCBS NC,Blue Select/HMO/PPO,,5.07,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,BCBS NC,Blue Select/HMO/PPO,,5.45,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Select/HMO/PPO,,2034.31,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,4.90,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.02,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,BCBS NC,Blue Select/HMO/PPO,,5.61,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,4.65,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,24.29,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,BCBS NC,Blue Select/HMO/PPO,,1734.61,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,BCBS NC,Blue Select/HMO/PPO,,24.30,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,13.57,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,BCBS NC,Blue Select/HMO/PPO,,26.90,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,BCBS NC,Blue Select/HMO/PPO,,29.26,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Select/HMO/PPO,,5.90,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,0.41640,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,BCBS NC,Blue Select/HMO/PPO,,19.60,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,BCBS NC,Blue Select/HMO/PPO,,1.35,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.71,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,7.88,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.50,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,BCBS NC,Blue Select/HMO/PPO,,6.55,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,1.19,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,BCBS NC,Blue Select/HMO/PPO,,7.62,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,1.19,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,BCBS NC,Blue Select/HMO/PPO,,7.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,0.48580,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Select/HMO/PPO,,6.26,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,BCBS NC,Blue Select/HMO/PPO,,6.47,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Select/HMO/PPO,,6.26,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,BCBS NC,Blue Select/HMO/PPO,,2.32,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,6.30,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,BCBS NC,Blue Select/HMO/PPO,,4.47,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,BCBS NC,Blue Select/HMO/PPO,,47.03,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,7.73,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,BCBS NC,Blue Select/HMO/PPO,,8.70,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,BCBS NC,Blue Select/HMO/PPO,,5014.62,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1098.07,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,BCBS NC,Blue Select/HMO/PPO,,210.31,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Select/HMO/PPO,,64.17,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,BCBS NC,Blue Select/HMO/PPO,,39.91,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Select/HMO/PPO,,760.79,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,BCBS NC,Blue Select/HMO/PPO,,418.58,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,BCBS NC,Blue Select/HMO/PPO,,0.97160,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,BCBS NC,Blue Select/HMO/PPO,,30.33,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,0.44416,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.52,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,BCBS NC,Blue Select/HMO/PPO,,7.61,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,BCBS NC,Blue Select/HMO/PPO,,5.61,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,BCBS NC,Blue Select/HMO/PPO,,11.37,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,BCBS NC,Blue Select/HMO/PPO,,386.21,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,BCBS NC,Blue Select/HMO/PPO,,16.92,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,BCBS NC,Blue Select/HMO/PPO,,104.72,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,BCBS NC,Blue Select/HMO/PPO,,133.96,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,BCBS NC,Blue Select/HMO/PPO,,92.72,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,BCBS NC,Blue Select/HMO/PPO,,148.61,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,BCBS NC,Blue Select/HMO/PPO,,32.65,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,25.07,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.46,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,BCBS NC,Blue Select/HMO/PPO,,32.23,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,BCBS NC,Blue Select/HMO/PPO,,190.49,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,BCBS NC,Blue Select/HMO/PPO,,446.16,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,4.84,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Select/HMO/PPO,,5.18,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,19.36,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,18.74,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,21.86,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,19.36,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,18.74,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,41.64,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,BCBS NC,Blue Select/HMO/PPO,,20.40,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,19.36,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,18.74,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,18.74,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,19.36,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,21.86,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,18.53,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,4.48,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,BCBS NC,Blue Select/HMO/PPO,,284.12,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.29,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,BCBS NC,Blue Select/HMO/PPO,,2006.30,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,BCBS NC,Blue Select/HMO/PPO,,7347.61,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,BCBS NC,Blue Select/HMO/PPO,,1551.91,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,BCBS NC,Blue Select/HMO/PPO,,7347.61,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,5.33,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Select/HMO/PPO,,2034.31,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,BCBS NC,Blue Select/HMO/PPO,,97.22,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,BCBS NC,Blue Select/HMO/PPO,,345.06,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,6.33,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,BCBS NC,Blue Select/HMO/PPO,,12.83,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,BCBS NC,Blue Select/HMO/PPO,,1951.69,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,BCBS NC,Blue Select/HMO/PPO,,92.25,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,BCBS NC,Blue Select/HMO/PPO,,85.58,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,BCBS NC,Blue Select/HMO/PPO,,186.98,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Select/HMO/PPO,,11136.17,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Select/HMO/PPO,,44315.54,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Select/HMO/PPO,,408.43,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Select/HMO/PPO,,813.30,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,BCBS NC,Blue Select/HMO/PPO,,7446.15,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,BCBS NC,Blue Select/HMO/PPO,,88.87,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Select/HMO/PPO,,80.52,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Select/HMO/PPO,,87.37,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,80.45,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Select/HMO/PPO,,116.95,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,BCBS NC,Blue Select/HMO/PPO,,564.92,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,137.41,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,BCBS NC,Blue Select/HMO/PPO,,276.66,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,6.36,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,21.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,BCBS NC,Blue Select/HMO/PPO,,93.66,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Select/HMO/PPO,,1565.73,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Select/HMO/PPO,,3113.96,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,BCBS NC,Blue Select/HMO/PPO,,29.25,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Select/HMO/PPO,,12.62,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,17.61,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,BCBS NC,Blue Select/HMO/PPO,,7.40,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Select/HMO/PPO,,95.16,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,21.10,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,BCBS NC,Blue Select/HMO/PPO,,81.30,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Select/HMO/PPO,,5.77,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Select/HMO/PPO,,12.02,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,6.97,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,8.11,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,5.41,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.34,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,BCBS NC,Blue Select/HMO/PPO,,28.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,21.65,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,19.82,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,BCBS NC,Blue Select/HMO/PPO,,21.03,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,BCBS NC,Blue Select/HMO/PPO,,19.61,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Select/HMO/PPO,,79.53,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,BCBS NC,Blue Select/HMO/PPO,,30.37,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,BCBS NC,Blue Select/HMO/PPO,,1.32,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,317.67,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,BCBS NC,Blue Select/HMO/PPO,,301.53,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,BCBS NC,Blue Select/HMO/PPO,,12.35,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,BCBS NC,Blue Select/HMO/PPO,,12.91,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,BCBS NC,Blue Select/HMO/PPO,,8.76,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,BCBS NC,Blue Select/HMO/PPO,,0.77728,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,BCBS NC,Blue Select/HMO/PPO,,10153.22,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,BCBS NC,Blue Select/HMO/PPO,,88.32,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,BCBS NC,Blue Select/HMO/PPO,,17.72,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,BCBS NC,Blue Select/HMO/PPO,,32.06,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Select/HMO/PPO,,7.70,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.26,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.26,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.26,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,3.26,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,BCBS NC,Blue Select/HMO/PPO,,20.85,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,BCBS NC,Blue Select/HMO/PPO,,30.02,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,BCBS NC,Blue Select/HMO/PPO,,42.54,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,BCBS NC,Blue Select/HMO/PPO,,6.07,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,5.44,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,16.03,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,BCBS NC,Blue Select/HMO/PPO,,56.71,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.55,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,BCBS NC,Blue Select/HMO/PPO,,14.77,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,4.50,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,6.65,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,BCBS NC,Blue Select/HMO/PPO,,3799.48,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,BCBS NC,Blue Select/HMO/PPO,,777.00,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,BCBS NC,Blue Select/HMO/PPO,,22.11,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,13.42,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,BCBS NC,Blue Select/HMO/PPO,,7.83,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,BCBS NC,Blue Select/HMO/PPO,,21.15,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Select/HMO/PPO,,12.70,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,BCBS NC,Blue Select/HMO/PPO,,28.98,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,67.46,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,BCBS NC,Blue Select/HMO/PPO,,17.66,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,67.46,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,8.27,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Select/HMO/PPO,,160.49,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,BCBS NC,Blue Select/HMO/PPO,,7.91,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,BCBS NC,Blue Select/HMO/PPO,,5.73,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,5.59,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,BCBS NC,Blue Select/HMO/PPO,,5.62,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,BCBS NC,Blue Select/HMO/PPO,,1.97,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,BCBS NC,Blue Select/HMO/PPO,,42.68,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,BCBS NC,Blue Select/HMO/PPO,,112.44,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,43.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,BCBS NC,Blue Select/HMO/PPO,,223.05,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,BCBS NC,Blue Select/HMO/PPO,,18.38,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,6.94,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.27,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,19.43,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,BCBS NC,Blue Select/HMO/PPO,,20.76,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Select/HMO/PPO,,16.77,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,BCBS NC,Blue Select/HMO/PPO,,25.59,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,BCBS NC,Blue Select/HMO/PPO,,104.38,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.27,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,BCBS NC,Blue Select/HMO/PPO,,17.86,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,BCBS NC,Blue Select/HMO/PPO,,7.51,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,BCBS NC,Blue Select/HMO/PPO,,31.85,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,67.46,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,7.97,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.55,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,4.82,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,26.23,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.44,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,BCBS NC,Blue Select/HMO/PPO,,6.48,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,BCBS NC,Blue Select/HMO/PPO,,59.85,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,BCBS NC,Blue Select/HMO/PPO,,94.02,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,BCBS NC,Blue Select/HMO/PPO,,231.80,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,BCBS NC,Blue Select/HMO/PPO,,18.11,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,BCBS NC,Blue Select/HMO/PPO,,22.75,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,BCBS NC,Blue Select/HMO/PPO,,61.79,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,24.48,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Select/HMO/PPO,,24.44,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,BCBS NC,Blue Select/HMO/PPO,,35.69,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Select/HMO/PPO,,1.64,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Select/HMO/PPO,,14.19,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,7.88,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,10484.55,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,88.55,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,BCBS NC,Blue Select/HMO/PPO,,46.75,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,17.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,BCBS NC,Blue Select/HMO/PPO,,20.18,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,18.02,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Select/HMO/PPO,,16.77,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,BCBS NC,Blue Select/HMO/PPO,,24.41,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,BCBS NC,Blue Select/HMO/PPO,,103.29,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.34,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,BCBS NC,Blue Select/HMO/PPO,,18.71,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,BCBS NC,Blue Select/HMO/PPO,,18.99,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,BCBS NC,Blue Select/HMO/PPO,,26.82,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,BCBS NC,Blue Select/HMO/PPO,,8.52,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,BCBS NC,Blue Select/HMO/PPO,,29.58,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,BCBS NC,Blue Select/HMO/PPO,,47.69,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,BCBS NC,Blue Select/HMO/PPO,,28.86,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,BCBS NC,Blue Select/HMO/PPO,,69.51,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,BCBS NC,Blue Select/HMO/PPO,,47.46,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,BCBS NC,Blue Select/HMO/PPO,,22.39,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,BCBS NC,Blue Select/HMO/PPO,,19.53,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,BCBS NC,Blue Select/HMO/PPO,,28.86,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,BCBS NC,Blue Select/HMO/PPO,,22.74,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,BCBS NC,Blue Select/HMO/PPO,,26.82,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Select/HMO/PPO,,30.31,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,BCBS NC,Blue Select/HMO/PPO,,132.91,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,BCBS NC,Blue Select/HMO/PPO,,32.72,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,157.40,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,BCBS NC,Blue Select/HMO/PPO,,323.60,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,BCBS NC,Blue Select/HMO/PPO,,344.89,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,10.13,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,23.21,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,20.64,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,BCBS NC,Blue Select/HMO/PPO,,42.56,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,BCBS NC,Blue Select/HMO/PPO,,60.66,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,BCBS NC,Blue Select/HMO/PPO,,142.24,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,BCBS NC,Blue Select/HMO/PPO,,267.00,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,25.07,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,BCBS NC,Blue Select/HMO/PPO,,28.63,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,BCBS NC,Blue Select/HMO/PPO,,68.78,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,BCBS NC,Blue Select/HMO/PPO,,18.54,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,BCBS NC,Blue Select/HMO/PPO,,21.69,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,BCBS NC,Blue Select/HMO/PPO,,204.08,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,4.87,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,BCBS NC,Blue Select/HMO/PPO,,76.40,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,17.61,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,BCBS NC,Blue Select/HMO/PPO,,29.18,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,80.45,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,BCBS NC,Blue Select/HMO/PPO,,48.97,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,BCBS NC,Blue Select/HMO/PPO,,6.72,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,BCBS NC,Blue Select/HMO/PPO,,33.46,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,19.82,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,BCBS NC,Blue Select/HMO/PPO,,50.13,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,BCBS NC,Blue Select/HMO/PPO,,47.69,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,20.99,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,8.11,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,BCBS NC,Blue Select/HMO/PPO,,9.65,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,19.82,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,BCBS NC,Blue Select/HMO/PPO,,495.52,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,BCBS NC,Blue Select/HMO/PPO,,27.64,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,BCBS NC,Blue Select/HMO/PPO,,6.98,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,BCBS NC,Blue Select/HMO/PPO,,9.67,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,19.92,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Select/HMO/PPO,,7.70,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Select/HMO/PPO,,17.52,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,48.30,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,24.48,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,BCBS NC,Blue Select/HMO/PPO,,6.23,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,6.25,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,BCBS NC,Blue Select/HMO/PPO,,7.11,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,11.85,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.25,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,BCBS NC,Blue Select/HMO/PPO,,36.38,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,26.23,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,BCBS NC,Blue Select/HMO/PPO,,38.77,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,BCBS NC,Blue Select/HMO/PPO,,8.09,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,BCBS NC,Blue Select/HMO/PPO,,28.95,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,BCBS NC,Blue Select/HMO/PPO,,22.74,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,4.93,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,BCBS NC,Blue Select/HMO/PPO,,18.96,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,BCBS NC,Blue Select/HMO/PPO,,15.52,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,BCBS NC,Blue Select/HMO/PPO,,22.83,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,BCBS NC,Blue Select/HMO/PPO,,29.52,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,BCBS NC,Blue Select/HMO/PPO,,86.28,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,BCBS NC,Blue Select/HMO/PPO,,22.14,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,BCBS NC,Blue Select/HMO/PPO,,88.62,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,BCBS NC,Blue Select/HMO/PPO,,17.81,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,11.02,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,29.15,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,BCBS NC,Blue Select/HMO/PPO,,20.75,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,BCBS NC,Blue Select/HMO/PPO,,14.44,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,BCBS NC,Blue Select/HMO/PPO,,44.86,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,BCBS NC,Blue Select/HMO/PPO,,6.15,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Select/HMO/PPO,,17.52,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,BCBS NC,Blue Select/HMO/PPO,,125.43,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Select/HMO/PPO,,46.54,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,BCBS NC,Blue Select/HMO/PPO,,76.78,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,BCBS NC,Blue Select/HMO/PPO,,66.46,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,BCBS NC,Blue Select/HMO/PPO,,20.51,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,BCBS NC,Blue Select/HMO/PPO,,18.24,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,BCBS NC,Blue Select/HMO/PPO,,22.10,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,BCBS NC,Blue Select/HMO/PPO,,16.60,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.46,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,BCBS NC,Blue Select/HMO/PPO,,68.73,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Select/HMO/PPO,,2797.38,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Select/HMO/PPO,,24.32,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Select/HMO/PPO,,41.75,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,BCBS NC,Blue Select/HMO/PPO,,42.65,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,BCBS NC,Blue Select/HMO/PPO,,101.12,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Select/HMO/PPO,,4396.81,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,BCBS NC,Blue Select/HMO/PPO,,109.54,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Select/HMO/PPO,,155.72,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Select/HMO/PPO,,86.42,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Select/HMO/PPO,,134.39,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Select/HMO/PPO,,125.57,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Select/HMO/PPO,,112.98,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,BCBS NC,Blue Select/HMO/PPO,,101.99,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Select/HMO/PPO,,155.72,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Select/HMO/PPO,,86.42,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Select/HMO/PPO,,134.39,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Select/HMO/PPO,,760.79,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,BCBS NC,Blue Select/HMO/PPO,,28.09,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,BCBS NC,Blue Select/HMO/PPO,,31.97,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,6.97,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,24.48,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,BCBS NC,Blue Select/HMO/PPO,,54.22,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,BCBS NC,Blue Select/HMO/PPO,,40.59,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,317.67,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,317.67,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,BCBS NC,Blue Select/HMO/PPO,,20.43,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,BCBS NC,Blue Select/HMO/PPO,,17.89,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,BCBS NC,Blue Select/HMO/PPO,,114.41,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Select/HMO/PPO,,11.20,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,BCBS NC,Blue Select/HMO/PPO,,48.09,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,BCBS NC,Blue Select/HMO/PPO,,17.54,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,BCBS NC,Blue Select/HMO/PPO,,31.97,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,13.57,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Select/HMO/PPO,,7.15,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,8.98,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,BCBS NC,Blue Select/HMO/PPO,,439.95,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,10.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,BCBS NC,Blue Select/HMO/PPO,,132.80,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Select/HMO/PPO,,716.33,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,4.77,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,BCBS NC,Blue Select/HMO/PPO,,40.06,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,BCBS NC,Blue Select/HMO/PPO,,383.13,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,BCBS NC,Blue Select/HMO/PPO,,20.49,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,59.68,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,BCBS NC,Blue Select/HMO/PPO,,165.80,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Select/HMO/PPO,,30.31,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,BCBS NC,Blue Select/HMO/PPO,,32.06,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Select/HMO/PPO,,12.02,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Select/HMO/PPO,,18.14,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Select/HMO/PPO,,13.17,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Select/HMO/PPO,,18.34,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,10.13,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Select/HMO/PPO,,18.34,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,BCBS NC,Blue Select/HMO/PPO,,13.45,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,BCBS NC,Blue Select/HMO/PPO,,24.65,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,BCBS NC,Blue Select/HMO/PPO,,72.29,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,BCBS NC,Blue Select/HMO/PPO,,33.23,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,BCBS NC,Blue Select/HMO/PPO,,32.83,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.46,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Select/HMO/PPO,,1885.74,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,BCBS NC,Blue Select/HMO/PPO,,8.59,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,BCBS NC,Blue Select/HMO/PPO,,23.11,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,BCBS NC,Blue Select/HMO/PPO,,18.07,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,BCBS NC,Blue Select/HMO/PPO,,14.05,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,BCBS NC,Blue Select/HMO/PPO,,64.32,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,BCBS NC,Blue Select/HMO/PPO,,66.00,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Select/HMO/PPO,,41.75,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,BCBS NC,Blue Select/HMO/PPO,,18.95,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.13,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,6.33,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,BCBS NC,Blue Select/HMO/PPO,,127.40,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,BCBS NC,Blue Select/HMO/PPO,,7.23,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Select/HMO/PPO,,1620.20,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,BCBS NC,Blue Select/HMO/PPO,,17.53,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,BCBS NC,Blue Select/HMO/PPO,,17.56,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,BCBS NC,Blue Select/HMO/PPO,,17.57,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,BCBS NC,Blue Select/HMO/PPO,,40.22,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,BCBS NC,Blue Select/HMO/PPO,,5.37,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.46,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,BCBS NC,Blue Select/HMO/PPO,,18.38,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Select/HMO/PPO,,13.89,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,BCBS NC,Blue Select/HMO/PPO,,126.63,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,BCBS NC,Blue Select/HMO/PPO,,128.28,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,BCBS NC,Blue Select/HMO/PPO,,100.23,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,BCBS NC,Blue Select/HMO/PPO,,22.15,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,24.50,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,20.99,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,21.86,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,4.46,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.29,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,BCBS NC,Blue Select/HMO/PPO,,6.90,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,BCBS NC,Blue Select/HMO/PPO,,44.04,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,24.69,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,BCBS NC,Blue Select/HMO/PPO,,34.85,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,23.35,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,99.17,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Select/HMO/PPO,,320.92,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,BCBS NC,Blue Select/HMO/PPO,,6.93,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,BCBS NC,Blue Select/HMO/PPO,,202.72,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,BCBS NC,Blue Select/HMO/PPO,,28.23,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,BCBS NC,Blue Select/HMO/PPO,,28.73,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Select/HMO/PPO,,41.99,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Select/HMO/PPO,,79.53,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,10.83,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,17.07,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,BCBS NC,Blue Select/HMO/PPO,,7.33,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,10.13,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,58.30,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,20.99,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Select/HMO/PPO,,24.37,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,BCBS NC,Blue Select/HMO/PPO,,22.85,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,6.97,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,BCBS NC,Blue Select/HMO/PPO,,18.59,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,6.44,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,BCBS NC,Blue Select/HMO/PPO,,9.55,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,BCBS NC,Blue Select/HMO/PPO,,5.73,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,11.85,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,6.65,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,7.27,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,4.90,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.54,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,BCBS NC,Blue Select/HMO/PPO,,147.49,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.44,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Select/HMO/PPO,,716.33,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,6863.60,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,6863.60,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,6863.60,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,6863.60,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,6863.60,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,10484.55,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,BCBS NC,Blue Select/HMO/PPO,,112.14,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,BCBS NC,Blue Select/HMO/PPO,,29.62,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,BCBS NC,Blue Select/HMO/PPO,,6.40,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Select/HMO/PPO,,41.13,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,8.31,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,BCBS NC,Blue Select/HMO/PPO,,3.44,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,BCBS NC,Blue Select/HMO/PPO,,210.14,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,13.57,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Select/HMO/PPO,,7.15,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.25,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,BCBS NC,Blue Select/HMO/PPO,,77.24,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,BCBS NC,Blue Select/HMO/PPO,,16.21,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,21.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Select/HMO/PPO,,149.85,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,85.61,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,BCBS NC,Blue Select/HMO/PPO,,1.15,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,BCBS NC,Blue Select/HMO/PPO,,0.77728,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,BCBS NC,Blue Select/HMO/PPO,,76.83,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,BCBS NC,Blue Select/HMO/PPO,,82.85,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,BCBS NC,Blue Select/HMO/PPO,,66.25,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,BCBS NC,Blue Select/HMO/PPO,,72.34,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,BCBS NC,Blue Select/HMO/PPO,,0.62460,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,BCBS NC,Blue Select/HMO/PPO,,80.86,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Select/HMO/PPO,,11.42,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Select/HMO/PPO,,18.39,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,BCBS NC,Blue Select/HMO/PPO,,21.60,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,7.97,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Select/HMO/PPO,,10.47,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Select/HMO/PPO,,10.33,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,BCBS NC,Blue Select/HMO/PPO,,12529.75,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Select/HMO/PPO,,9985.36,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Select/HMO/PPO,,14232.05,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,BCBS NC,Blue Select/HMO/PPO,,7.62,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,BCBS NC,Blue Select/HMO/PPO,,154.35,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Select/HMO/PPO,,87.37,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,80.45,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Select/HMO/PPO,,116.95,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,BCBS NC,Blue Select/HMO/PPO,,12989.25,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,2119.81,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1098.07,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,2119.81,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1098.07,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,2119.81,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,1098.07,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,281.06,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5222.88,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5222.88,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,5222.88,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Select/HMO/PPO,,14187.68,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,687.06,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Select/HMO/PPO,,1159.16,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Select/HMO/PPO,,2300.83,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Select/HMO/PPO,,474.17,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Select/HMO/PPO,,1159.16,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Select/HMO/PPO,,2300.83,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Select/HMO/PPO,,474.17,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,BCBS NC,Blue Select/HMO/PPO,,77.41,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,BCBS NC,Blue Select/HMO/PPO,,12.24,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Select/HMO/PPO,,8.26,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,BCBS NC,Blue Select/HMO/PPO,,53254.21,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,BCBS NC,Blue Select/HMO/PPO,,35.78,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,BCBS NC,Blue Select/HMO/PPO,,19.57,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,BCBS NC,Blue Select/HMO/PPO,,20.61,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Select/HMO/PPO,,408.43,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,BCBS NC,Blue Select/HMO/PPO,,19.64,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,BCBS NC,Blue Select/HMO/PPO,,5.64,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,5.97,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,5.34,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,BCBS NC,Blue Select/HMO/PPO,,186.27,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,BCBS NC,Blue Select/HMO/PPO,,40.27,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,BCBS NC,Blue Select/HMO/PPO,,204.31,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,BCBS NC,Blue Select/HMO/PPO,,73.13,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Select/HMO/PPO,,15.38,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Select/HMO/PPO,,15.38,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,BCBS NC,Blue Select/HMO/PPO,,1.42,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,BCBS NC,Blue Select/HMO/PPO,,3.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,BCBS NC,Blue Select/HMO/PPO,,22.18,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,BCBS NC,Blue Select/HMO/PPO,,16.73,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,BCBS NC,Blue Select/HMO/PPO,,127.90,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,21.65,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Select/HMO/PPO,,4.76,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,BCBS NC,Blue Select/HMO/PPO,,16.43,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,BCBS NC,Blue Select/HMO/PPO,,10.62,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,BCBS NC,Blue Select/HMO/PPO,,121.02,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,5.08,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,BCBS NC,Blue Select/HMO/PPO,,29.59,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,161.84,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,BCBS NC,Blue Select/HMO/PPO,,87.10,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,BCBS NC,Blue Select/HMO/PPO,,14.38,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,5.66,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,4.94,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Select/HMO/PPO,,5.05,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,6.29,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.44,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,BCBS NC,Blue Select/HMO/PPO,,8.47,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,BCBS NC,Blue Select/HMO/PPO,,8.49,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,BCBS NC,Blue Select/HMO/PPO,,9.48,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,10.55,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,BCBS NC,Blue Select/HMO/PPO,,31.95,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,BCBS NC,Blue Select/HMO/PPO,,13.63,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,4.51,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,5.04,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.55,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.57,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,BCBS NC,Blue Select/HMO/PPO,,0.59684,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,6.61,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,BCBS NC,Blue Select/HMO/PPO,,32.40,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,BCBS NC,Blue Select/HMO/PPO,,65.07,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Select/HMO/PPO,,13.17,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,1.18,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,13.42,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Select/HMO/PPO,,8.68,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,BCBS NC,Blue Select/HMO/PPO,,51.54,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,BCBS NC,Blue Select/HMO/PPO,,21.42,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,BCBS NC,Blue Select/HMO/PPO,,8.30,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,8.23,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,8.31,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,BCBS NC,Blue Select/HMO/PPO,,24.22,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,BCBS NC,Blue Select/HMO/PPO,,24.72,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,BCBS NC,Blue Select/HMO/PPO,,6.50,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,BCBS NC,Blue Select/HMO/PPO,,14.87,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,4.54,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Select/HMO/PPO,,10.33,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,85.22,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,BCBS NC,Blue Select/HMO/PPO,,131.30,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Select/HMO/PPO,,6.27,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,BCBS NC,Blue Select/HMO/PPO,,8.04,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,BCBS NC,Blue Select/HMO/PPO,,29.36,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,5.33,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,BCBS NC,Blue Select/HMO/PPO,,5.29,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,BCBS NC,Blue Select/HMO/PPO,,5.70,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.57,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,4.90,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Select/HMO/PPO,,5.18,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,20.60,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,BCBS NC,Blue Select/HMO/PPO,,3.75,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,5.02,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,BCBS NC,Blue Select/HMO/PPO,,7.38,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,BCBS NC,Blue Select/HMO/PPO,,8.51,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.13,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,7.25,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,BCBS NC,Blue Select/HMO/PPO,,6.47,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,BCBS NC,Blue Select/HMO/PPO,,8.97,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Select/HMO/PPO,,24.44,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,BCBS NC,Blue Select/HMO/PPO,,46.12,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,BCBS NC,Blue Select/HMO/PPO,,35.63,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,BCBS NC,Blue Select/HMO/PPO,,14.91,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,BCBS NC,Blue Select/HMO/PPO,,7.13,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,5.11,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,BCBS NC,Blue Select/HMO/PPO,,6.45,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,BCBS NC,Blue Select/HMO/PPO,,2.91,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,BCBS NC,Blue Select/HMO/PPO,,56.76,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,BCBS NC,Blue Select/HMO/PPO,,68.72,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,BCBS NC,Blue Select/HMO/PPO,,20.51,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,11.85,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Select/HMO/PPO,,1885.74,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,BCBS NC,Blue Select/HMO/PPO,,6.75,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,BCBS NC,Blue Select/HMO/PPO,,63.07,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,BCBS NC,Blue Select/HMO/PPO,,28.07,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,9.49,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,BCBS NC,Blue Select/HMO/PPO,,59.05,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Select/HMO/PPO,,1.78,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Select/HMO/PPO,,1.78,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.20,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,BCBS NC,Blue Select/HMO/PPO,,20.07,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,BCBS NC,Blue Select/HMO/PPO,,70.12,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,71.62,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,BCBS NC,Blue Select/HMO/PPO,,74.87,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,BCBS NC,Blue Select/HMO/PPO,,43.14,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,BCBS NC,Blue Select/HMO/PPO,,23.79,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,BCBS NC,Blue Select/HMO/PPO,,30.55,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,BCBS NC,Blue Select/HMO/PPO,,20.17,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,BCBS NC,Blue Select/HMO/PPO,,52.51,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,BCBS NC,Blue Select/HMO/PPO,,12.45,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,BCBS NC,Blue Select/HMO/PPO,,1.07,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,BCBS NC,Blue Select/HMO/PPO,,0.84668,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,BCBS NC,Blue Select/HMO/PPO,,113.95,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,BCBS NC,Blue Select/HMO/PPO,,6.12,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,BCBS NC,Blue Select/HMO/PPO,,6.79,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,BCBS NC,Blue Select/HMO/PPO,,41.29,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,BCBS NC,Blue Select/HMO/PPO,,348.67,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.71,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,BCBS NC,Blue Select/HMO/PPO,,5.91,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,4.84,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,BCBS NC,Blue Select/HMO/PPO,,56.21,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,6.16,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,4.87,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,BCBS NC,Blue Select/HMO/PPO,,6.79,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,4.91,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,BCBS NC,Blue Select/HMO/PPO,,33.67,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,BCBS NC,Blue Select/HMO/PPO,,44.83,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Select/HMO/PPO,,4.62,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,4.83,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,5.12,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,BCBS NC,Blue Select/HMO/PPO,,71.26,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,BCBS NC,Blue Select/HMO/PPO,,24.00,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,BCBS NC,Blue Select/HMO/PPO,,7.00,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,BCBS NC,Blue Select/HMO/PPO,,18.17,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.38864,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.38864,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,BCBS NC,Blue Select/HMO/PPO,,0.79116,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,BCBS NC,Blue Select/HMO/PPO,,2.12,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,BCBS NC,Blue Select/HMO/PPO,,26.05,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,4.77,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,23.21,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,23.21,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,23.21,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,BCBS NC,Blue Select/HMO/PPO,,262.98,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,6.16,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,BCBS NC,Blue Select/HMO/PPO,,98.99,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,BCBS NC,Blue Select/HMO/PPO,,112.33,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.33312,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.55,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,BCBS NC,Blue Select/HMO/PPO,,14.77,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,BCBS NC,Blue Select/HMO/PPO,,29.08,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,,18.60,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,BCBS NC,Blue Select/HMO/PPO,,32.38,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,BCBS NC,Blue Select/HMO/PPO,,31.11,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,21.86,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,21.24,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,BCBS NC,Blue Select/HMO/PPO,,22.90,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,BCBS NC,Blue Select/HMO/PPO,,22.89,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,BCBS NC,Blue Select/HMO/PPO,,26.41,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,BCBS NC,Blue Select/HMO/PPO,,37.93,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,BCBS NC,Blue Select/HMO/PPO,,20.61,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,BCBS NC,Blue Select/HMO/PPO,,118.83,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,BCBS NC,Blue Select/HMO/PPO,,109.60,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,4.71,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,19.15,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,BCBS NC,Blue Select/HMO/PPO,,22.25,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,BCBS NC,Blue Select/HMO/PPO,,32.12,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,4.66,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,BCBS NC,Blue Select/HMO/PPO,,1470.88,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,BCBS NC,Blue Select/HMO/PPO,,74.92,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,BCBS NC,Blue Select/HMO/PPO,,198.48,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,BCBS NC,Blue Select/HMO/PPO,,23.62,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,BCBS NC,Blue Select/HMO/PPO,,12.69,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,BCBS NC,Blue Select/HMO/PPO,,13.76,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,0.43028,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,BCBS NC,Blue Select/HMO/PPO,,113.19,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,BCBS NC,Blue Select/HMO/PPO,,549.44,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,BCBS NC,Blue Select/HMO/PPO,,102.10,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,BCBS NC,Blue Select/HMO/PPO,,1.92,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,BCBS NC,Blue Select/HMO/PPO,,179.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,BCBS NC,Blue Select/HMO/PPO,,7.37,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,BCBS NC,Blue Select/HMO/PPO,,22.15,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,BCBS NC,Blue Select/HMO/PPO,,32.99,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,6.19,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,BCBS NC,Blue Select/HMO/PPO,,26.32,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,BCBS NC,Blue Select/HMO/PPO,,235.52,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,8.94,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,BCBS NC,Blue Select/HMO/PPO,,7.76,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,7.97,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,79.39,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,BCBS NC,Blue Select/HMO/PPO,,1.74,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,6.95,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,BCBS NC,Blue Select/HMO/PPO,,791.19,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,6.33,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,6.57,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,BCBS NC,Blue Select/HMO/PPO,,17.35,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,4.58,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,4.59,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,6.94,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,BCBS NC,Blue Select/HMO/PPO,,11.27,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,8.31,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,BCBS NC,Blue Select/HMO/PPO,,16.27,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,BCBS NC,Blue Select/HMO/PPO,,15.39,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,BCBS NC,Blue Select/HMO/PPO,,12.63,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,BCBS NC,Blue Select/HMO/PPO,,58.14,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,4.75,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,BCBS NC,Blue Select/HMO/PPO,,7.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,BCBS NC,Blue Select/HMO/PPO,,119.72,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,BCBS NC,Blue Select/HMO/PPO,,137.02,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,BCBS NC,Blue Select/HMO/PPO,,7622.78,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,BCBS NC,Blue Select/HMO/PPO,,25.65,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,5.19,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Select/HMO/PPO,,80.52,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,BCBS NC,Blue Select/HMO/PPO,,84.70,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,BCBS NC,Blue Select/HMO/PPO,,2519.62,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,BCBS NC,Blue Select/HMO/PPO,,7.59,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,BCBS NC,Blue Select/HMO/PPO,,33.48,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,BCBS NC,Blue Select/HMO/PPO,,29.84,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,29.83,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,BCBS NC,Blue Select/HMO/PPO,,15.75,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,BCBS NC,Blue Select/HMO/PPO,,36.48,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,BCBS NC,Blue Select/HMO/PPO,,27.01,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,BCBS NC,Blue Select/HMO/PPO,,122.73,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,BCBS NC,Blue Select/HMO/PPO,,1.24,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,17.07,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,4.55,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,BCBS NC,Blue Select/HMO/PPO,,1.46,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,BCBS NC,Blue Select/HMO/PPO,,142.01,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,BCBS NC,Blue Select/HMO/PPO,,98.02,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,4.97,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,4.87,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,4.89,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,4.90,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Select/HMO/PPO,,5.09,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,BCBS NC,Blue Select/HMO/PPO,,9.27,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,BCBS NC,Blue Select/HMO/PPO,,11236.60,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,BCBS NC,Blue Select/HMO/PPO,,157.66,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,BCBS NC,Blue Select/HMO/PPO,,11.35,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,BCBS NC,Blue Select/HMO/PPO,,27.23,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Select/HMO/PPO,,125.57,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Select/HMO/PPO,,112.98,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,BCBS NC,Blue Select/HMO/PPO,,43.00,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,BCBS NC,Blue Select/HMO/PPO,,16.42,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,BCBS NC,Blue Select/HMO/PPO,,7458.33,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,19.92,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Select/HMO/PPO,,221.54,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,BCBS NC,Blue Select/HMO/PPO,,2.54,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.38864,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,BCBS NC,Blue Select/HMO/PPO,,27.51,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,BCBS NC,Blue Select/HMO/PPO,,1064.00,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,BCBS NC,Blue Select/HMO/PPO,,0.90220,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,BCBS NC,Blue Select/HMO/PPO,,0.68012,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,BCBS NC,Blue Select/HMO/PPO,,301.07,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,BCBS NC,Blue Select/HMO/PPO,,11.28,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Select/HMO/PPO,,149.85,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,85.61,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,121.31,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,121.31,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,BCBS NC,Blue Select/HMO/PPO,,218.35,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,BCBS NC,Blue Select/HMO/PPO,,11120.00,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,BCBS NC,Blue Select/HMO/PPO,,5562.23,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,BCBS NC,Blue Select/HMO/PPO,,1.10,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.34700,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.55520,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,BCBS NC,Blue Select/HMO/PPO,,28.30,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,4.57,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Select/HMO/PPO,,14.19,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.44,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,27.20,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,BCBS NC,Blue Select/HMO/PPO,,35.82,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,BCBS NC,Blue Select/HMO/PPO,,103.18,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,BCBS NC,Blue Select/HMO/PPO,,26.33,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,58.30,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,BCBS NC,Blue Select/HMO/PPO,,7.29,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,BCBS NC,Blue Select/HMO/PPO,,13.87,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,BCBS NC,Blue Select/HMO/PPO,,48.65,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,8.58,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,BCBS NC,Blue Select/HMO/PPO,,225.70,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.29148,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.55,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,BCBS NC,Blue Select/HMO/PPO,,147.54,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,BCBS NC,Blue Select/HMO/PPO,,22.22,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,BCBS NC,Blue Select/HMO/PPO,,10.42,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,5.21,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Select/HMO/PPO,,41.99,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,BCBS NC,Blue Select/HMO/PPO,,76.70,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,13.42,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,BCBS NC,Blue Select/HMO/PPO,,73.95,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,BCBS NC,Blue Select/HMO/PPO,,1.12,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,BCBS NC,Blue Select/HMO/PPO,,44.39,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,24.50,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,24.50,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,24.50,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,BCBS NC,Blue Select/HMO/PPO,,146.21,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,8.12,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,23.50,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,23.50,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,BCBS NC,Blue Select/HMO/PPO,,1.46,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Select/HMO/PPO,,8.26,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,BCBS NC,Blue Select/HMO/PPO,,20.83,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,BCBS NC,Blue Select/HMO/PPO,,20.94,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,BCBS NC,Blue Select/HMO/PPO,,19.83,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.05,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,5.82,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,4.52,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,4.48,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,BCBS NC,Blue Select/HMO/PPO,,10.84,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,BCBS NC,Blue Select/HMO/PPO,,1014.91,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,5.50,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,BCBS NC,Blue Select/HMO/PPO,,3481.73,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,BCBS NC,Blue Select/HMO/PPO,,6958.99,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,BCBS NC,Blue Select/HMO/PPO,,574.28,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,BCBS NC,Blue Select/HMO/PPO,,764.32,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,BCBS NC,Blue Select/HMO/PPO,,855.01,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.30536,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,5.01,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,BCBS NC,Blue Select/HMO/PPO,,120.27,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Select/HMO/PPO,,6.02,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,6.16,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,4.73,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,4.86,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,BCBS NC,Blue Select/HMO/PPO,,181.27,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.31924,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,BCBS NC,Blue Select/HMO/PPO,,23.90,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,BCBS NC,Blue Select/HMO/PPO,,16.82,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,BCBS NC,Blue Select/HMO/PPO,,207.08,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,29.15,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,11.02,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,17.07,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,8.11,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Select/HMO/PPO,,6.02,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,4.64,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,4.69,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,23.60,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,5.15,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,BCBS NC,Blue Select/HMO/PPO,,61.89,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,87.44,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,BCBS NC,Blue Select/HMO/PPO,,4.11,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,BCBS NC,Blue Select/HMO/PPO,,461.68,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,BCBS NC,Blue Select/HMO/PPO,,21.83,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,BCBS NC,Blue Select/HMO/PPO,,6.72,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,BCBS NC,Blue Select/HMO/PPO,,22.76,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,BCBS NC,Blue Select/HMO/PPO,,607.67,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,BCBS NC,Blue Select/HMO/PPO,,9.98,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,BCBS NC,Blue Select/HMO/PPO,,73.51,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,BCBS NC,Blue Select/HMO/PPO,,29.01,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,BCBS NC,Blue Select/HMO/PPO,,31.58,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,BCBS NC,Blue Select/HMO/PPO,,12.78,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,6.13,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,6.20,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.50,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,6.30,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,5.16,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,BCBS NC,Blue Select/HMO/PPO,,115.81,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,BCBS NC,Blue Select/HMO/PPO,,425.78,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,BCBS NC,Blue Select/HMO/PPO,,10.69,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,BCBS NC,Blue Select/HMO/PPO,,17.17,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,BCBS NC,Blue Select/HMO/PPO,,21.83,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,BCBS NC,Blue Select/HMO/PPO,,26.75,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,BCBS NC,Blue Select/HMO/PPO,,84.10,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,BCBS NC,Blue Select/HMO/PPO,,1007.19,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,BCBS NC,Blue Select/HMO/PPO,,35.28,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,BCBS NC,Blue Select/HMO/PPO,,58.62,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,BCBS NC,Blue Select/HMO/PPO,,24.72,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,BCBS NC,Blue Select/HMO/PPO,,9.52,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,BCBS NC,Blue Select/HMO/PPO,,16.67,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Select/HMO/PPO,,8.68,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,BCBS NC,Blue Select/HMO/PPO,,55.88,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,BCBS NC,Blue Select/HMO/PPO,,48.32,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,17.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,BCBS NC,Blue Select/HMO/PPO,,17.96,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,BCBS NC,Blue Select/HMO/PPO,,66.33,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,BCBS NC,Blue Select/HMO/PPO,,25.29,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,0.40252,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,BCBS NC,Blue Select/HMO/PPO,,183.58,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,BCBS NC,Blue Select/HMO/PPO,,106.93,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,BCBS NC,Blue Select/HMO/PPO,,503.36,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,23.03,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,BCBS NC,Blue Select/HMO/PPO,,1.28,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,BCBS NC,Blue Select/HMO/PPO,,603.67,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,28.18,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,27.20,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,26.23,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Select/HMO/PPO,,6.83,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,BCBS NC,Blue Select/HMO/PPO,,9.22,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Select/HMO/PPO,,13.89,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,27.20,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,27.20,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,21.24,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,98.83,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,BCBS NC,Blue Select/HMO/PPO,,16.25,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,BCBS NC,Blue Select/HMO/PPO,,13.59,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,BCBS NC,Blue Select/HMO/PPO,,1409.17,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,19.43,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,5.55,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,5.36,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,BCBS NC,Blue Select/HMO/PPO,,178.41,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,BCBS NC,Blue Select/HMO/PPO,,70.76,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,4.77,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,BCBS NC,Blue Select/HMO/PPO,,26.52,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,BCBS NC,Blue Select/HMO/PPO,,6.98,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,BCBS NC,Blue Select/HMO/PPO,,46.15,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,BCBS NC,Blue Select/HMO/PPO,,23.68,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,BCBS NC,Blue Select/HMO/PPO,,28.55,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,BCBS NC,Blue Select/HMO/PPO,,7.06,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,0.38864,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,BCBS NC,Blue Select/HMO/PPO,,670.92,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,BCBS NC,Blue Select/HMO/PPO,,1116.59,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,BCBS NC,Blue Select/HMO/PPO,,134.97,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,BCBS NC,Blue Select/HMO/PPO,,198.48,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,4.79,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,BCBS NC,Blue Select/HMO/PPO,,291.56,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,BCBS NC,Blue Select/HMO/PPO,,14.95,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,BCBS NC,Blue Select/HMO/PPO,,480.48,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,12.30,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,12.30,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,BCBS NC,Blue Select/HMO/PPO,,31.59,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,4.96,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,BCBS NC,Blue Select/HMO/PPO,,458.12,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,BCBS NC,Blue Select/HMO/PPO,,12607.08,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,BCBS NC,Blue Select/HMO/PPO,,43364.56,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,BCBS NC,Blue Select/HMO/PPO,,71482.00,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,BCBS NC,Blue Select/HMO/PPO,,3097.94,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,BCBS NC,Blue Select/HMO/PPO,,2051.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,,71.90,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,BCBS NC,Blue Select/HMO/PPO,,3.79,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.33312,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,BCBS NC,Blue Select/HMO/PPO,,2.54,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,11.66,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.05552,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,144.07,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,BCBS NC,Blue Select/HMO/PPO,,357.27,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,BCBS NC,Blue Select/HMO/PPO,,534.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,BCBS NC,Blue Select/HMO/PPO,,802.54,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,BCBS NC,Blue Select/HMO/PPO,,962.99,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,BCBS NC,Blue Select/HMO/PPO,,1155.37,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,BCBS NC,Blue Select/HMO/PPO,,1386.89,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,BCBS NC,Blue Select/HMO/PPO,,573.24,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,BCBS NC,Blue Select/HMO/PPO,,841.96,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,BCBS NC,Blue Select/HMO/PPO,,1531.24,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,,44.42,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,BCBS NC,Blue Select/HMO/PPO,,175.72,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,48.02,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,32.48,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.22,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,39.70,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,43.86,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Select/HMO/PPO,,145.46,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Select/HMO/PPO,,165.73,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,141.02,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,25.54,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,BCBS NC,Blue Select/HMO/PPO,,20.26,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Select/HMO/PPO,,63.85,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,BCBS NC,Blue Select/HMO/PPO,,58.57,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Select/HMO/PPO,,1452.68,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Select/HMO/PPO,,1452.68,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,BCBS NC,Blue Select/HMO/PPO,,1383.00,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Select/HMO/PPO,,495.79,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,BCBS NC,Blue Select/HMO/PPO,,834.19,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Select/HMO/PPO,,423.62,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,86.89,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Select/HMO/PPO,,303.42,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,94.94,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,BCBS NC,Blue Select/HMO/PPO,,343.11,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,252.34,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,84.11,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,138.80,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Select/HMO/PPO,,260.39,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Select/HMO/PPO,,73.84,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,56.63,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,BCBS NC,Blue Select/HMO/PPO,,303.14,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Select/HMO/PPO,,263.16,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,79.39,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,11.94,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,9.72,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,38.86,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Select/HMO/PPO,,131.58,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,34.98,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,79.39,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,37.20,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Select/HMO/PPO,,3.05,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,BCBS NC,Blue Select/HMO/PPO,,1383.84,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,BCBS NC,Blue Select/HMO/PPO,,5579.76,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,BCBS NC,Blue Select/HMO/PPO,,1408.54,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,BCBS NC,Blue Select/HMO/PPO,,1177.02,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,BCBS NC,Blue Select/HMO/PPO,,965.49,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,128.53,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1097.63,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,BCBS NC,Blue Select/HMO/PPO,,1257.53,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,BCBS NC,Blue Select/HMO/PPO,,1238.37,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Select/HMO/PPO,,980.21,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,BCBS NC,Blue Select/HMO/PPO,,1619.80,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Select/HMO/PPO,,1150.10,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Select/HMO/PPO,,1150.10,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Select/HMO/PPO,,1338.31,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Select/HMO/PPO,,1338.31,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,BCBS NC,Blue Select/HMO/PPO,,1628.40,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1097.63,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1097.63,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Select/HMO/PPO,,980.21,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,1097.63,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,484.41,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,BCBS NC,Blue Select/HMO/PPO,,1140.94,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,BCBS NC,Blue Select/HMO/PPO,,469.42,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Select/HMO/PPO,,1804.12,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,BCBS NC,Blue Select/HMO/PPO,,328.68,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,BCBS NC,Blue Select/HMO/PPO,,675.12,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,BCBS NC,Blue Select/HMO/PPO,,1022.68,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,BCBS NC,Blue Select/HMO/PPO,,1192.85,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Select/HMO/PPO,,33.59,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,BCBS NC,Blue Select/HMO/PPO,,473.59,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,BCBS NC,Blue Select/HMO/PPO,,951.06,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,23.04,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Select/HMO/PPO,,129.64,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,BCBS NC,Blue Select/HMO/PPO,,191.27,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,BCBS NC,Blue Select/HMO/PPO,,432.22,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,BCBS NC,Blue Select/HMO/PPO,,327.29,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,21.93,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,GP,5.83,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Select/HMO/PPO,,92.44,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,BCBS NC,Blue Select/HMO/PPO,,416.96,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,BCBS NC,Blue Select/HMO/PPO,,394.75,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,BCBS NC,Blue Select/HMO/PPO,,316.46,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,BCBS NC,Blue Select/HMO/PPO,,238.18,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Select/HMO/PPO,,159.90,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,81.61,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,BCBS NC,Blue Select/HMO/PPO,,454.71,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,BCBS NC,Blue Select/HMO/PPO,,1358.85,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,BCBS NC,Blue Select/HMO/PPO,,1802.18,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Select/HMO/PPO,,952.17,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,BCBS NC,Blue Select/HMO/PPO,,722.87,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,BCBS NC,Blue Select/HMO/PPO,,7261.46,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,BCBS NC,Blue Select/HMO/PPO,,7605.96,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,BCBS NC,Blue Select/HMO/PPO,,8005.15,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,BCBS NC,Blue Select/HMO/PPO,,8348.54,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,BCBS NC,Blue Select/HMO/PPO,,8693.32,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,BCBS NC,Blue Select/HMO/PPO,,9036.99,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,BCBS NC,Blue Select/HMO/PPO,,9324.86,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,BCBS NC,Blue Select/HMO/PPO,,9724.05,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,BCBS NC,Blue Select/HMO/PPO,,10068.00,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,BCBS NC,Blue Select/HMO/PPO,,10411.94,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,BCBS NC,Blue Select/HMO/PPO,,10756.17,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,107.71,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,BCBS NC,Blue Select/HMO/PPO,,148.24,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Select/HMO/PPO,,230.13,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,BCBS NC,Blue Select/HMO/PPO,,232.07,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,BCBS NC,Blue Select/HMO/PPO,,1120.12,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,BCBS NC,Blue Select/HMO/PPO,,2688.56,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,BCBS NC,Blue Select/HMO/PPO,,2888.98,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,BCBS NC,Blue Select/HMO/PPO,,3103.29,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,BCBS NC,Blue Select/HMO/PPO,,1691.69,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,BCBS NC,Blue Select/HMO/PPO,,2185.54,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,BCBS NC,Blue Select/HMO/PPO,,2485.91,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,BCBS NC,Blue Select/HMO/PPO,,3200.73,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,BCBS NC,Blue Select/HMO/PPO,,3285.67,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,BCBS NC,Blue Select/HMO/PPO,,3365.62,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,BCBS NC,Blue Select/HMO/PPO,,3445.85,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,BCBS NC,Blue Select/HMO/PPO,,3525.80,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,BCBS NC,Blue Select/HMO/PPO,,1373.01,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Select/HMO/PPO,,185.44,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,BCBS NC,Blue Select/HMO/PPO,,1223.11,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,BCBS NC,Blue Select/HMO/PPO,,1651.44,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,BCBS NC,Blue Select/HMO/PPO,,2261.33,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,BCBS NC,Blue Select/HMO/PPO,,2865.94,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,BCBS NC,Blue Select/HMO/PPO,,3272.07,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,BCBS NC,Blue Select/HMO/PPO,,3705.96,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,BCBS NC,Blue Select/HMO/PPO,,4227.57,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,BCBS NC,Blue Select/HMO/PPO,,4531.54,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,BCBS NC,Blue Select/HMO/PPO,,4980.14,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,BCBS NC,Blue Select/HMO/PPO,,5224.15,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,BCBS NC,Blue Select/HMO/PPO,,5543.67,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,BCBS NC,Blue Select/HMO/PPO,,5749.37,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,BCBS NC,Blue Select/HMO/PPO,,5801.01,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,BCBS NC,Blue Select/HMO/PPO,,5887.06,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,BCBS NC,Blue Select/HMO/PPO,,6058.62,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,BCBS NC,Blue Select/HMO/PPO,,6230.45,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,BCBS NC,Blue Select/HMO/PPO,,6402.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,BCBS NC,Blue Select/HMO/PPO,,6574.96,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,BCBS NC,Blue Select/HMO/PPO,,6746.24,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,BCBS NC,Blue Select/HMO/PPO,,6918.35,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Select/HMO/PPO,,3721.51,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,BCBS NC,Blue Select/HMO/PPO,,3154.09,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,1955.14,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,1955.14,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,1955.14,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,1798.85,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Select/HMO/PPO,,3721.51,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,BCBS NC,Blue Select/HMO/PPO,,2099.21,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,BCBS NC,Blue Select/HMO/PPO,,2365.43,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,84.11,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,352.83,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,141.02,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,141.02,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,BCBS NC,Blue Select/HMO/PPO,,224.30,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,BCBS NC,Blue Select/HMO/PPO,,2996.41,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,BCBS NC,Blue Select/HMO/PPO,,524.66,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Select/HMO/PPO,,340.06,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,BCBS NC,Blue Select/HMO/PPO,,1991.50,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,82.17,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Select/HMO/PPO,,209.87,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,BCBS NC,Blue Select/HMO/PPO,,0.83280,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Select/HMO/PPO,,457.76,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Select/HMO/PPO,,590.46,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Select/HMO/PPO,,723.70,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,BCBS NC,Blue Select/HMO/PPO,,856.40,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,BCBS NC,Blue Select/HMO/PPO,,989.37,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,BCBS NC,Blue Select/HMO/PPO,,1122.34,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,BCBS NC,Blue Select/HMO/PPO,,1255.03,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,BCBS NC,Blue Select/HMO/PPO,,183.49,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Select/HMO/PPO,,910.53,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Select/HMO/PPO,,1199.79,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,359.21,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Select/HMO/PPO,,489.41,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Select/HMO/PPO,,545.76,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Select/HMO/PPO,,604.34,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Select/HMO/PPO,,662.63,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Select/HMO/PPO,,720.65,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Select/HMO/PPO,,779.22,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Select/HMO/PPO,,457.76,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Select/HMO/PPO,,265.94,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Select/HMO/PPO,,662.63,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,359.21,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Select/HMO/PPO,,489.41,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Select/HMO/PPO,,545.76,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Select/HMO/PPO,,604.34,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Select/HMO/PPO,,720.65,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Select/HMO/PPO,,779.22,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Select/HMO/PPO,,910.53,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Select/HMO/PPO,,1199.79,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,138.52,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Select/HMO/PPO,,952.17,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,79.12,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,376.70,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Select/HMO/PPO,,426.67,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,BCBS NC,Blue Select/HMO/PPO,,477.19,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Select/HMO/PPO,,527.72,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,BCBS NC,Blue Select/HMO/PPO,,578.80,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,629.60,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Select/HMO/PPO,,680.12,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,BCBS NC,Blue Select/HMO/PPO,,730.37,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,BCBS NC,Blue Select/HMO/PPO,,780.61,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,BCBS NC,Blue Select/HMO/PPO,,831.69,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,BCBS NC,Blue Select/HMO/PPO,,881.94,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,BCBS NC,Blue Select/HMO/PPO,,947.73,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Select/HMO/PPO,,998.80,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,BCBS NC,Blue Select/HMO/PPO,,1191.74,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,1269.74,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,BCBS NC,Blue Select/HMO/PPO,,1328.87,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,BCBS NC,Blue Select/HMO/PPO,,1379.39,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,BCBS NC,Blue Select/HMO/PPO,,1429.64,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,1212.83,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,BCBS NC,Blue Select/HMO/PPO,,1286.95,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,BCBS NC,Blue Select/HMO/PPO,,1144.54,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,BCBS NC,Blue Select/HMO/PPO,,725.37,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,BCBS NC,Blue Select/HMO/PPO,,784.22,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Select/HMO/PPO,,690.11,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,BCBS NC,Blue Select/HMO/PPO,,927.74,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,93.55,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,2798.76,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,2798.76,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,2798.76,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,353.94,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,BCBS NC,Blue Select/HMO/PPO,,581.85,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,BCBS NC,Blue Select/HMO/PPO,,646.53,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,BCBS NC,Blue Select/HMO/PPO,,350.89,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Select/HMO/PPO,,2080.33,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,282.04,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,112.15,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,1269.74,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Select/HMO/PPO,,3008.35,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,BCBS NC,Blue Select/HMO/PPO,,1464.06,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,85.22,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,BCBS NC,Blue Select/HMO/PPO,,11099.56,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,BCBS NC,Blue Select/HMO/PPO,,11443.23,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,BCBS NC,Blue Select/HMO/PPO,,523.28,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,BCBS NC,Blue Select/HMO/PPO,,154.62,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,BCBS NC,Blue Select/HMO/PPO,,809.20,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,BCBS NC,Blue Select/HMO/PPO,,23.87,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,27.48,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,Q0,0.28038,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,Q0,0.28038,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,166.56,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,207.09,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,BCBS NC,Blue Select/HMO/PPO,,381.70,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,BCBS NC,Blue Select/HMO/PPO,,5432.35,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,BCBS NC,Blue Select/HMO/PPO,,2531.71,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1421.31,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,BCBS NC,Blue Select/HMO/PPO,,1375.23,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,BCBS NC,Blue Select/HMO/PPO,,2064.79,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,BCBS NC,Blue Select/HMO/PPO,,2336.84,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1421.31,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,BCBS NC,Blue Select/HMO/PPO,,1762.20,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,88.28,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Select/HMO/PPO,,28.59,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,58.02,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,40.25,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,88.28,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,34.98,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Select/HMO/PPO,,41.92,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,BCBS NC,Blue Select/HMO/PPO,,51.08,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,81.89,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,BCBS NC,Blue Select/HMO/PPO,,98.55,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,290.92,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Select/HMO/PPO,,28.59,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,117.98,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,166.56,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,BCBS NC,Blue Select/HMO/PPO,,297.86,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Select/HMO/PPO,,263.16,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,207.09,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,207.09,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,BCBS NC,Blue Select/HMO/PPO,,214.86,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1421.31,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Select/HMO/PPO,,139.63,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Select/HMO/PPO,,125.48,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,BCBS NC,Blue Select/HMO/PPO,,374.48,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,1421.31,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,BCBS NC,Blue Select/HMO/PPO,,411.96,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,BCBS NC,Blue Select/HMO/PPO,,382.81,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,148.52,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,148.52,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,148.52,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Select/HMO/PPO,,1865.47,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,255.95,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,255.95,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,255.95,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,BCBS NC,Blue Select/HMO/PPO,,337.28,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,BCBS NC,Blue Select/HMO/PPO,,452.77,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,BCBS NC,Blue Select/HMO/PPO,,804.76,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,97.16,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,128.53,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,38.86,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,46.08,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,97.16,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Select/HMO/PPO,,1462.95,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,BCBS NC,Blue Select/HMO/PPO,,284.26,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,176.83,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Select/HMO/PPO,,10984.63,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Select/HMO/PPO,,4720.31,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Select/HMO/PPO,,82.45,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,BCBS NC,Blue Select/HMO/PPO,,85.50,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Select/HMO/PPO,,532.71,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Select/HMO/PPO,,2013.16,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Select/HMO/PPO,,481.36,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Select/HMO/PPO,,914.69,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Select/HMO/PPO,,11165.07,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Select/HMO/PPO,,3474.72,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Select/HMO/PPO,,3086.91,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Select/HMO/PPO,,4348.60,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Select/HMO/PPO,,8766.05,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,732.59,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Select/HMO/PPO,,3086.08,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Select/HMO/PPO,,4453.26,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Select/HMO/PPO,,2630.54,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,748.41,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,748.41,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Select/HMO/PPO,,2322.40,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.28038,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Select/HMO/PPO,,2476.19,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Select/HMO/PPO,,3130.50,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,BCBS NC,Blue Select/HMO/PPO,,1701.97,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Select/HMO/PPO,,4301.41,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Select/HMO/PPO,,348.39,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Select/HMO/PPO,,149.07,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Select/HMO/PPO,,1865.47,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Select/HMO/PPO,,1462.95,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,BCBS NC,Blue Select/HMO/PPO,,260.94,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Select/HMO/PPO,,61.07,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Select/HMO/PPO,,154.07,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,BCBS NC,Blue Select/HMO/PPO,,1509.03,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,BCBS NC,Blue Select/HMO/PPO,,5508.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,BCBS NC,Blue Select/HMO/PPO,,7603.46,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,78.01,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,78.01,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,73.01,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,73.01,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,73.01,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,BCBS NC,Blue Select/HMO/PPO,,867.50,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,BCBS NC,Blue Select/HMO/PPO,,325.35,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,BCBS NC,Blue Select/HMO/PPO,,418.34,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,BCBS NC,Blue Select/HMO/PPO,,392.80,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,BCBS NC,Blue Select/HMO/PPO,,380.31,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,BCBS NC,Blue Select/HMO/PPO,,2766.01,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,BCBS NC,Blue Select/HMO/PPO,Q1,1758.60,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,BCBS NC,Blue Select/HMO/PPO,Q0,1053.49,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,50.52,,,,,,,36.44,147.97,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,152.40,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,104.66,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Select/HMO/PPO,,162.40,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,104.66,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,104.66,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,25.54,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,79.95,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,121.31,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,72.73,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,BCBS NC,Blue Select/HMO/PPO,,64.96,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Select/HMO/PPO,,181.00,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Select/HMO/PPO,,9.16,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,BCBS NC,Blue Select/HMO/PPO,,527.16,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,32.48,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,32.48,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,66.62,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,BCBS NC,Blue Select/HMO/PPO,,99.94,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,128.53,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,116.59,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,BCBS NC,Blue Select/HMO/PPO,,540.49,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Select/HMO/PPO,,552.42,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,BCBS NC,Blue Select/HMO/PPO,,258.72,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,BCBS NC,Blue Select/HMO/PPO,,390.58,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,BCBS NC,Blue Select/HMO/PPO,,405.30,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,BCBS NC,Blue Select/HMO/PPO,,478.58,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,BCBS NC,Blue Select/HMO/PPO,,582.40,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,BCBS NC,Blue Select/HMO/PPO,,976.87,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,BCBS NC,Blue Select/HMO/PPO,,1732.78,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,BCBS NC,Blue Select/HMO/PPO,,1868.53,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,BCBS NC,Blue Select/HMO/PPO,,176.28,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,BCBS NC,Blue Select/HMO/PPO,,236.24,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,BCBS NC,Blue Select/HMO/PPO,,1763.32,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,1980.68,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,1980.68,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Select/HMO/PPO,,471.36,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,BCBS NC,Blue Select/HMO/PPO,,768.67,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Select/HMO/PPO,,203.76,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,BCBS NC,Blue Select/HMO/PPO,,304.25,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,BCBS NC,Blue Select/HMO/PPO,,130.19,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,BCBS NC,Blue Select/HMO/PPO,,268.72,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,BCBS NC,Blue Select/HMO/PPO,,190.71,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,BCBS NC,Blue Select/HMO/PPO,,428.89,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,BCBS NC,Blue Select/HMO/PPO,,297.31,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,BCBS NC,Blue Select/HMO/PPO,,516.89,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,BCBS NC,Blue Select/HMO/PPO,,124.92,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Select/HMO/PPO,,334.23,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,BCBS NC,Blue Select/HMO/PPO,,2079.78,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,BCBS NC,Blue Select/HMO/PPO,,2069.23,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,BCBS NC,Blue Select/HMO/PPO,,665.68,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,BCBS NC,Blue Select/HMO/PPO,,484.69,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,BCBS NC,Blue Select/HMO/PPO,,860.56,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,BCBS NC,Blue Select/HMO/PPO,,2338.22,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,117.98,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,157.40,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Select/HMO/PPO,,604.61,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,BCBS NC,Blue Select/HMO/PPO,,580.74,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,BCBS NC,Blue Select/HMO/PPO,,1286.68,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,BCBS NC,Blue Select/HMO/PPO,,682.34,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Select/HMO/PPO,,832.52,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,87.72,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,BCBS NC,Blue Select/HMO/PPO,,89.11,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,BCBS NC,Blue Select/HMO/PPO,,298.70,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,137.69,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Select/HMO/PPO,,167.39,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,137.69,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Select/HMO/PPO,,426.67,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,170.72,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Select/HMO/PPO,,203.76,,,,,,,146.95,3466.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,145.18,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,1980.68,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,BCBS NC,Blue Select/HMO/PPO,,286.48,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,BCBS NC,Blue Select/HMO/PPO,,246.79,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,BCBS NC,Blue Select/HMO/PPO,,322.85,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Select/HMO/PPO,,291.76,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Select/HMO/PPO,,390.31,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Select/HMO/PPO,76,390.31,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,517.72,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Select/HMO/PPO,,1040.44,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Select/HMO/PPO,76,1040.44,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Select/HMO/PPO,,1095.13,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Select/HMO/PPO,76,1095.13,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,564.64,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Select/HMO/PPO,,627.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,BCBS NC,Blue Select/HMO/PPO,,661.52,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,BCBS NC,Blue Select/HMO/PPO,,729.81,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,BCBS NC,Blue Select/HMO/PPO,,508.84,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Select/HMO/PPO,,727.87,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,114.65,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,114.65,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,81.06,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,BCBS NC,Blue Select/HMO/PPO,,788.94,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,BCBS NC,Blue Select/HMO/PPO,,7578.20,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,BCBS NC,Blue Select/HMO/PPO,,1041.83,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Select/HMO/PPO,,1198.12,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Select/HMO/PPO,,1198.12,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,BCBS NC,Blue Select/HMO/PPO,,179.88,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Select/HMO/PPO,,196.54,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Select/HMO/PPO,,340.06,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Select/HMO/PPO,,238.74,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Select/HMO/PPO,,253.73,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Select/HMO/PPO,,260.39,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,177.94,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,517.72,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,517.72,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,517.72,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,517.72,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Select/HMO/PPO,,180.44,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,BCBS NC,Blue Select/HMO/PPO,,100.77,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,517.72,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,517.72,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,126.31,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Select/HMO/PPO,76,238.74,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Select/HMO/PPO,76,253.73,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,138.52,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,BCBS NC,Blue Select/HMO/PPO,,289.81,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,BCBS NC,Blue Select/HMO/PPO,,452.21,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Select/HMO/PPO,,650.42,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,BCBS NC,Blue Select/HMO/PPO,,1919.33,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Select/HMO/PPO,,203.48,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,BCBS NC,Blue Select/HMO/PPO,,1684.20,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,BCBS NC,Blue Select/HMO/PPO,,625.71,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,BCBS NC,Blue Select/HMO/PPO,,787.55,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Select/HMO/PPO,,513.00,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,BCBS NC,Blue Select/HMO/PPO,,241.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,152.40,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,BCBS NC,Blue Select/HMO/PPO,,223.47,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,347.56,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,BCBS NC,Blue Select/HMO/PPO,,2266.33,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,BCBS NC,Blue Select/HMO/PPO,,669.02,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,112.43,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,BCBS NC,Blue Select/HMO/PPO,,155.46,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,BCBS NC,Blue Select/HMO/PPO,,461.37,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,BCBS NC,Blue Select/HMO/PPO,,533.82,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,BCBS NC,Blue Select/HMO/PPO,,353.66,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,87.72,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Select/HMO/PPO,,180.44,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Select/HMO/PPO,,604.61,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,866.94,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,BCBS NC,Blue Select/HMO/PPO,,97.44,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,BCBS NC,Blue Select/HMO/PPO,,292.59,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.44,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,BCBS NC,Blue Select/HMO/PPO,,129.08,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,BCBS NC,Blue Select/HMO/PPO,,285.37,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,BCBS NC,Blue Select/HMO/PPO,,336.45,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Select/HMO/PPO,,89.39,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,BCBS NC,Blue Select/HMO/PPO,,210.14,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,44.97,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Select/HMO/PPO,,324.79,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Select/HMO/PPO,,83.00,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,BCBS NC,Blue Select/HMO/PPO,,165.17,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,31.37,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,83.84,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,30.26,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,55.52,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,44.69,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,31.37,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,36.92,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,31.37,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,BCBS NC,Blue Select/HMO/PPO,,121.59,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,13.88,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,114.65,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,79.95,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,BCBS NC,Blue Select/HMO/PPO,,53.02,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,74.67,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,GP,18.60,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,GP,20.82,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,GP,3.33,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Select/HMO/PPO,GP,33.59,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,GP,13.60,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Select/HMO/PPO,GP,4.44,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,BCBS NC,Blue Select/HMO/PPO,GP,42.47,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,GP,45.25,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GP,35.53,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,GP,30.54,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,GP,16.38,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,GP,45.53,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,GP,44.42,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Select/HMO/PPO,GP,39.97,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,GP,45.80,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,GP,38.59,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,GP,56.08,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,GP,32.48,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GP,35.81,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Select/HMO/PPO,GP,41.92,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,GP,13.05,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,GP,32.76,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,GP,23.60,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GP,35.81,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GP,27.48,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,GP,49.97,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,GP,49.97,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GP,25.26,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GP,25.26,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,GP,24.71,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,GP,35.26,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,GP,36.09,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GP,19.43,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,GP,8.33,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,GP,84.95,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Select/HMO/PPO,GP,117.42,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,BCBS NC,Blue Select/HMO/PPO,GP,120.48,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,GP,79.95,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GO,25.26,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,GO,32.48,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GO,35.81,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,GO,32.76,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GO,19.43,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GO,35.81,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GO,27.48,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,GO,3.33,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,GO,45.25,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GO,35.53,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,GO,17.21,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,GO,45.53,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,GO,44.42,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Select/HMO/PPO,GO,39.97,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,GO,45.80,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,GO,13.60,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,GO,62.18,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,GO,42.20,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,GO,35.26,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,GO,20.82,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,GO,88.28,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,BCBS NC,Blue Select/HMO/PPO,GO,111.87,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,BCBS NC,Blue Select/HMO/PPO,GO,115.20,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,GO,56.08,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,GN,98.83,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Select/HMO/PPO,GN,93.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,GN,51.91,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,GN,74.67,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,GN,55.52,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,GN,87.44,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GN,35.53,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GN,19.43,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,GN,23.60,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GN,27.48,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,GN,63.57,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,GN,37.75,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,BCBS NC,Blue Select/HMO/PPO,GN,181.83,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,GN,71.90,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,GN,18.88,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,GN,36.09,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GN,19.43,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,GN,8.33,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,BCBS NC,Blue Select/HMO/PPO,GN,59.41,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,GN,63.57,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,GN,29.70,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Select/HMO/PPO,GN,97.99,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,GN,152.40,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,BCBS NC,Blue Select/HMO/PPO,GN,164.06,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Select/HMO/PPO,,239.85,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,152.40,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,BCBS NC,Blue Select/HMO/PPO,,245.68,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Select/HMO/PPO,,139.91,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,BCBS NC,Blue Select/HMO/PPO,,206.81,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,BCBS NC,Blue Select/HMO/PPO,,1042.67,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,11.94,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Select/HMO/PPO,,41.08,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,BCBS NC,Blue Select/HMO/PPO,,145.74,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,145.18,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,BCBS NC,Blue Select/HMO/PPO,,156.29,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,104.66,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,104.66,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,376.70,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,BCBS NC,Blue Select/HMO/PPO,,116.04,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Select/HMO/PPO,,225.41,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,157.40,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,BCBS NC,Blue Select/HMO/PPO,,132.14,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Select/HMO/PPO,,181.00,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,127.14,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,43.31,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,49.97,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Select/HMO/PPO,,324.79,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,BCBS NC,Blue Select/HMO/PPO,,36.37,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Select/HMO/PPO,,428.06,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Select/HMO/PPO,,428.06,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,73.29,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,73.29,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,BCBS NC,Blue Select/HMO/PPO,,555.20,,,,,,,186.78,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Select/HMO/PPO,,194.32,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,BCBS NC,Blue Select/HMO/PPO,,630.71,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,230.69,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,BCBS NC,Blue Select/HMO/PPO,,140.19,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,BCBS NC,Blue Select/HMO/PPO,,61.63,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Select/HMO/PPO,,92.44,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,BCBS NC,Blue Select/HMO/PPO,,93.83,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Select/HMO/PPO,,51.36,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Select/HMO/PPO,,1677.54,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Select/HMO/PPO,,1677.54,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,BCBS NC,Blue Select/HMO/PPO,,282.32,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Select/HMO/PPO,,1165.92,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Select/HMO/PPO,,1165.92,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,BCBS NC,Blue Select/HMO/PPO,,1184.24,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,BCBS NC,Blue Select/HMO/PPO,,320.35,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,BCBS NC,Blue Select/HMO/PPO,,153.24,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,156.84,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,BCBS NC,Blue Select/HMO/PPO,,374.76,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Select/HMO/PPO,,267.33,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,152.68,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Select/HMO/PPO,,267.33,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Select/HMO/PPO,,291.76,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,BCBS NC,Blue Select/HMO/PPO,,125.75,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,352.83,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,BCBS NC,Blue Select/HMO/PPO,,321.74,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,202.09,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,133.53,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Select/HMO/PPO,,312.58,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,87.72,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,210.42,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,34.42,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Select/HMO/PPO,,265.94,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,158.51,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,BCBS NC,Blue Select/HMO/PPO,,128.81,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,149.63,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Select/HMO/PPO,,139.63,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Select/HMO/PPO,,436.39,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,112.43,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Select/HMO/PPO,,436.39,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,112.43,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,103.54,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,BCBS NC,Blue Select/HMO/PPO,,187.10,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Select/HMO/PPO,,228.19,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,BCBS NC,Blue Select/HMO/PPO,,237.35,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Select/HMO/PPO,,246.51,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,149.63,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Select/HMO/PPO,,119.09,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,81.89,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,121.31,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,70.23,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Select/HMO/PPO,,170.45,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Select/HMO/PPO,,170.45,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,BCBS NC,Blue Select/HMO/PPO,,151.85,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,58.85,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,58.85,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,58.85,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,58.85,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,111.04,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,111.04,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,111.04,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,74.12,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Select/HMO/PPO,,101.60,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Select/HMO/PPO,,101.60,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Select/HMO/PPO,,453.88,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Select/HMO/PPO,,453.88,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Blue Select/HMO/PPO,,126.86,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,126.31,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,BCBS NC,Blue Select/HMO/PPO,,413.90,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Select/HMO/PPO,,423.62,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,BCBS NC,Blue Select/HMO/PPO,,235.40,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,BCBS NC,Blue Select/HMO/PPO,,342.28,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Select/HMO/PPO,,117.42,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,BCBS NC,Blue Select/HMO/PPO,,276.77,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,128.53,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,BCBS NC,Blue Select/HMO/PPO,,151.01,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,BCBS NC,Blue Select/HMO/PPO,,365.04,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,BCBS NC,Blue Select/HMO/PPO,,440.83,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,541.32,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,BCBS NC,Blue Select/HMO/PPO,,768.12,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,BCBS NC,Blue Select/HMO/PPO,,843.63,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,BCBS NC,Blue Select/HMO/PPO,,1070.43,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,629.60,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,BCBS NC,Blue Select/HMO/PPO,,705.10,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,BCBS NC,Blue Select/HMO/PPO,,793.38,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,BCBS NC,Blue Select/HMO/PPO,,1259.19,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,BCBS NC,Blue Select/HMO/PPO,,1410.21,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,BCBS NC,Blue Select/HMO/PPO,,1573.99,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Select/HMO/PPO,,289.26,,,,,,,208.61,954.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,10.97,1090.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,81.06,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,81.61,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,13.32,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,13.32,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,215.14,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,215.14,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,215.14,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,215.14,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,215.14,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,215.14,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,BCBS NC,Blue Select/HMO/PPO,GP,18.51,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,BCBS NC,Blue Select/HMO/PPO,,132.97,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Select/HMO/PPO,,761.73,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Select/HMO/PPO,,761.73,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Select/HMO/PPO,,1075.70,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Select/HMO/PPO,,301.20,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Select/HMO/PPO,,301.20,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,BCBS NC,Blue Select/HMO/PPO,,684.01,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Select/HMO/PPO,,288.43,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Select/HMO/PPO,,288.43,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,BCBS NC,Blue Select/HMO/PPO,,885.54,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,BCBS NC,Blue Select/HMO/PPO,,119.37,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,133.25,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Select/HMO/PPO,,148.79,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,127.14,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,33.03,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,35.81,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,35.81,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,57.74,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,45.25,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,85.22,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,BCBS NC,Blue Select/HMO/PPO,,144.35,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Select/HMO/PPO,,139.91,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,BCBS NC,Blue Select/HMO/PPO,,171.56,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,BCBS NC,Blue Select/HMO/PPO,,113.54,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,213.75,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,213.75,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,BCBS NC,Blue Select/HMO/PPO,,177.11,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Select/HMO/PPO,,167.39,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Select/HMO/PPO,,250.40,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,50.52,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,42.20,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,77.73,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,107.71,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,210.70,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,210.70,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Select/HMO/PPO,,637.09,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,BCBS NC,Blue Select/HMO/PPO,,168.50,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Select/HMO/PPO,,517.17,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Select/HMO/PPO,,517.17,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Select/HMO/PPO,,591.84,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Select/HMO/PPO,,148.79,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,287.87,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,BCBS NC,Blue Select/HMO/PPO,,3471.94,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,BCBS NC,Blue Select/HMO/PPO,,421.95,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,BCBS NC,Blue Select/HMO/PPO,,536.60,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Select/HMO/PPO,,231.52,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,BCBS NC,Blue Select/HMO/PPO,,241.23,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,BCBS NC,Blue Select/HMO/PPO,,256.78,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,BCBS NC,Blue Select/HMO/PPO,,426.95,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,532.44,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,BCBS NC,Blue Select/HMO/PPO,,2713.26,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,183.22,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,183.22,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,885.27,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,885.27,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,424.17,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,424.17,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,BCBS NC,Blue Select/HMO/PPO,,479.42,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Select/HMO/PPO,,594.62,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Select/HMO/PPO,,594.62,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Select/HMO/PPO,,387.81,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Select/HMO/PPO,,387.81,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Select/HMO/PPO,,172.39,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Select/HMO/PPO,,172.39,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Select/HMO/PPO,,199.87,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Select/HMO/PPO,,199.87,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,103.54,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Select/HMO/PPO,,621.82,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,JW,36.64,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Select/HMO/PPO,,162.67,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,138.52,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,BCBS NC,Blue Select/HMO/PPO,,167.67,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,138.52,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Select/HMO/PPO,,162.67,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Select/HMO/PPO,,228.19,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,BCBS NC,Blue Select/HMO/PPO,,378.65,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Select/HMO/PPO,,97.72,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1094.02,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1094.02,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1094.02,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1094.02,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,541.32,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,541.32,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Select/HMO/PPO,,861.39,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Select/HMO/PPO,,861.39,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,BCBS NC,Blue Select/HMO/PPO,,478.30,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Select/HMO/PPO,,591.84,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Select/HMO/PPO,,777.28,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Select/HMO/PPO,,150.74,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,BCBS NC,Blue Select/HMO/PPO,,1217.28,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,BCBS NC,Blue Select/HMO/PPO,,1346.36,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,BCBS NC,Blue Select/HMO/PPO,,1591.76,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,223.19,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Select/HMO/PPO,,434.44,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Select/HMO/PPO,,434.44,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,BCBS NC,Blue Select/HMO/PPO,,533.27,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,BCBS NC,Blue Select/HMO/PPO,,472.20,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,161.56,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,629.60,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,BCBS NC,Blue Select/HMO/PPO,,351.16,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,647.64,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,647.64,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,BCBS NC,Blue Select/HMO/PPO,,568.25,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,BCBS NC,Blue Select/HMO/PPO,,370.60,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Select/HMO/PPO,,235.13,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,494.41,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,494.41,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Select/HMO/PPO,,471.36,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Select/HMO/PPO,,383.37,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Select/HMO/PPO,,383.37,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,498.01,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,498.01,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Select/HMO/PPO,,1143.43,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Select/HMO/PPO,,1143.43,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Select/HMO/PPO,,964.66,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Select/HMO/PPO,,964.66,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,142.13,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Select/HMO/PPO,,164.89,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,BCBS NC,Blue Select/HMO/PPO,52,305.36,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,210.70,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,BCBS NC,Blue Select/HMO/PPO,,197.37,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,BCBS NC,Blue Select/HMO/PPO,,405.57,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,,35.26,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,255.11,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,255.11,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,103.54,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,88.00,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,BCBS NC,Blue Select/HMO/PPO,,193.49,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,BCBS NC,Blue Select/HMO/PPO,,386.70,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,BCBS NC,Blue Select/HMO/PPO,,659.30,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,BCBS NC,Blue Select/HMO/PPO,,879.16,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,BCBS NC,Blue Select/HMO/PPO,,1113.45,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,BCBS NC,Blue Select/HMO/PPO,,367.54,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,BCBS NC,Blue Select/HMO/PPO,,335.06,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Select/HMO/PPO,,100.21,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,82.17,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,52.47,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,43.31,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,43.31,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,759.51,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,55.80,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,52.19,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Select/HMO/PPO,,69.12,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,66.62,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,88.00,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,110.76,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,102.99,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,131.86,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,50.25,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Select/HMO/PPO,,63.02,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,74.12,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Select/HMO/PPO,,69.40,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Select/HMO/PPO,,112.71,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Select/HMO/PPO,,120.76,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,121.31,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Select/HMO/PPO,,110.21,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,50.25,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Select/HMO/PPO,,70.51,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,107.71,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,BCBS NC,Blue Select/HMO/PPO,,135.75,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,BCBS NC,Blue Select/HMO/PPO,,48.86,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,BCBS NC,Blue Select/HMO/PPO,,72.18,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,64.13,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,88.00,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,131.86,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Select/HMO/PPO,,159.90,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Select/HMO/PPO,,38.03,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,31.09,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,13.32,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,36.09,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,6.94,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,JW,34.14,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,34.14,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,JW,26.37,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Select/HMO/PPO,,39.42,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,76.34,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,55.52,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,JW,55.52,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,126.31,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,252.89,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,JW,252.89,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,JW,126.31,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,274.27,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,JW,274.27,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,JW,75.78,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,158.51,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,72.73,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,764.51,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,337.56,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,171.00,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,JW,764.51,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,JW,337.56,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,JW,171.00,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,780.89,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,34.14,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,94.94,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,JW,94.94,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,429.17,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Select/HMO/PPO,,858.89,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,JW,429.17,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,118.81,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,JW,118.81,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,JW,134.08,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,2.78,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,693.44,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,JW,693.44,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,562.14,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,JW,562.14,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,474.14,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,JW,474.14,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,JW,18.04,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,685.39,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,193.76,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,193.76,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,170.72,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,170.72,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,110.76,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,110.76,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Select/HMO/PPO,JW,655.97,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,JW,158.51,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,JW,72.73,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,86.89,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,JW,86.89,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,437.22,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,JW,437.22,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,347.56,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,JW,347.56,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,177.94,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,JW,177.94,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,94.38,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,JW,94.38,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,75.51,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,JW,75.51,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Select/HMO/PPO,,711.21,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,81.89,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,176.83,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,176.83,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,176.83,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,176.83,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,74.95,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,BCBS NC,Blue Select/HMO/PPO,,1177.86,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,50.25,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Select/HMO/PPO,,68.29,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,BCBS NC,Blue Select/HMO/PPO,,715.38,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,58.02,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,84.11,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Select/HMO/PPO,,548.54,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Select/HMO/PPO,,548.54,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,119.92,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,119.92,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,93.55,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,77.73,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,74.67,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,BCBS NC,Blue Select/HMO/PPO,,2603.61,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,BCBS NC,Blue Select/HMO/PPO,,308.97,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,287.87,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,BCBS NC,Blue Select/HMO/PPO,,332.29,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,BCBS NC,Blue Select/HMO/PPO,,223.75,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Select/HMO/PPO,,551.04,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Select/HMO/PPO,,551.04,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Select/HMO/PPO,,3241.26,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Select/HMO/PPO,,3241.26,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Select/HMO/PPO,,5639.72,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Select/HMO/PPO,,5639.72,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Select/HMO/PPO,,2398.46,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Select/HMO/PPO,,2398.46,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Select/HMO/PPO,,5088.69,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Select/HMO/PPO,,5088.69,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Select/HMO/PPO,,8232.78,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Select/HMO/PPO,,8232.78,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,74.67,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Select/HMO/PPO,,113.82,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Select/HMO/PPO,,164.89,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,142.13,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,214.03,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,BCBS NC,Blue Select/HMO/PPO,,189.05,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Select/HMO/PPO,,1075.70,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,39.70,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,87.44,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,54.13,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,87.44,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,54.13,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,87.44,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,54.13,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,142.96,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,45.80,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Select/HMO/PPO,,263.44,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Select/HMO/PPO,,134.36,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,35.53,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,39.14,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,43.86,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,25.54,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,25.54,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,58.85,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Select/HMO/PPO,,113.82,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,142.96,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,41.64,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,23.60,,,,,,,14.80,1090.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,142.96,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,BCBS NC,Blue Select/HMO/PPO,,11104.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,BCBS NC,Blue Select/HMO/PPO,,215.70,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Select/HMO/PPO,,2436.77,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Select/HMO/PPO,,2436.77,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,BCBS NC,Blue Select/HMO/PPO,,1371.62,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,81.06,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,245.40,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Select/HMO/PPO,,56.91,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Select/HMO/PPO,,56.91,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,BCBS NC,Blue Select/HMO/PPO,,269.27,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,341.45,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,89.94,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,BCBS NC,Blue Select/HMO/PPO,,1737.50,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,866.94,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,BCBS NC,Blue Select/HMO/PPO,,134.91,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,BCBS NC,Blue Select/HMO/PPO,,5725.22,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,866.94,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,BCBS NC,Blue Select/HMO/PPO,,233.74,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,BCBS NC,Blue Select/HMO/PPO,,648.47,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,BCBS NC,Blue Select/HMO/PPO,,643.20,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,BCBS NC,Blue Select/HMO/PPO,,644.59,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,BCBS NC,Blue Select/HMO/PPO,,3311.49,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Select/HMO/PPO,,145.46,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Select/HMO/PPO,,159.06,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,BCBS NC,Blue Select/HMO/PPO,,369.49,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,710.93,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,710.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Select/HMO/PPO,,526.05,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Select/HMO/PPO,,526.05,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Select/HMO/PPO,,959.39,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Select/HMO/PPO,,959.39,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,710.93,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,710.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Select/HMO/PPO,,1439.91,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,342.84,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,290.92,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,196.26,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,152.68,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,122.70,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,129.36,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,JW,342.84,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,JW,290.92,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,JW,196.26,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,JW,152.68,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,JW,122.70,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,JW,129.36,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Select/HMO/PPO,,576.85,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,49.69,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,52.19,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,BCBS NC,Blue Select/HMO/PPO,,221.25,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,274.27,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,BCBS NC,Blue Select/HMO/PPO,,397.52,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,245.95,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,49.69,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,BCBS NC,Blue Select/HMO/PPO,,507.45,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,BCBS NC,Blue Select/HMO/PPO,,720.09,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,BCBS NC,Blue Select/HMO/PPO,,262.33,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,BCBS NC,Blue Select/HMO/PPO,,800.32,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Select/HMO/PPO,,265.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,245.95,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,BCBS NC,Blue Select/HMO/PPO,,389.20,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,BCBS NC,Blue Select/HMO/PPO,,603.50,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,BCBS NC,Blue Select/HMO/PPO,,1174.80,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,BCBS NC,Blue Select/HMO/PPO,,5311.04,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Select/HMO/PPO,,119.09,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Select/HMO/PPO,,125.48,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,111.32,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,184.60,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,88.28,,,,,,,55.36,1831.00,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,84.67,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,89.94,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,BCBS NC,Blue Select/HMO/PPO,,151.29,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Select/HMO/PPO,,97.72,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,133.53,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,BCBS NC,Blue Select/HMO/PPO,,166.84,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,109.37,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,122.70,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,138.80,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,42.20,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,74.95,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,33.31,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,139.08,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,BCBS NC,Blue Select/HMO/PPO,,186.27,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,49.69,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,83.84,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Select/HMO/PPO,,100.49,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,134.08,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Select/HMO/PPO,,162.12,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Select/HMO/PPO,,299.53,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Select/HMO/PPO,,162.40,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,84.67,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,122.70,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,137.69,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,183.22,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,BCBS NC,Blue Select/HMO/PPO,,257.89,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,121.31,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,BCBS NC,Blue Select/HMO/PPO,,90.78,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,BCBS NC,Blue Select/HMO/PPO,,156.57,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,136.58,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,BCBS NC,Blue Select/HMO/PPO,,197.10,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Select/HMO/PPO,,242.90,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,161.56,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,94.66,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,BCBS NC,Blue Select/HMO/PPO,,150.18,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Select/HMO/PPO,,102.43,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Select/HMO/PPO,,102.16,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,BCBS NC,Blue Select/HMO/PPO,,336.17,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,208.76,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,BCBS NC,Blue Select/HMO/PPO,,370.87,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,BCBS NC,Blue Select/HMO/PPO,,525.22,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Select/HMO/PPO,,577.69,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,117.98,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,BCBS NC,Blue Select/HMO/PPO,,106.04,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,127.42,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,BCBS NC,Blue Select/HMO/PPO,,128.25,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,352.83,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,BCBS NC,Blue Select/HMO/PPO,,144.91,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,BCBS NC,Blue Select/HMO/PPO,,122.14,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Select/HMO/PPO,,112.71,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,122.70,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,135.19,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Select/HMO/PPO,,105.21,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,BCBS NC,Blue Select/HMO/PPO,,82.72,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,BCBS NC,Blue Select/HMO/PPO,,104.10,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,BCBS NC,Blue Select/HMO/PPO,,96.33,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,BCBS NC,Blue Select/HMO/PPO,,181.27,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Select/HMO/PPO,,119.65,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,109.37,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,BCBS NC,Blue Select/HMO/PPO,,76.62,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Select/HMO/PPO,,233.46,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,118.54,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,102.99,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Select/HMO/PPO,,133.80,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,87.72,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,105.49,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,98.27,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,60.52,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,BCBS NC,Blue Select/HMO/PPO,,123.53,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,128.53,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,105.49,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,BCBS NC,Blue Select/HMO/PPO,,147.13,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,128.53,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,111.32,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,89.94,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,118.26,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,137.41,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,137.41,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,137.41,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,BCBS NC,Blue Select/HMO/PPO,,217.08,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Select/HMO/PPO,,89.39,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,68.57,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,292.87,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,202.09,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Select/HMO/PPO,,246.51,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,BCBS NC,Blue Select/HMO/PPO,,138.24,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Select/HMO/PPO,,146.85,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,274.27,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,288.98,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Select/HMO/PPO,,298.14,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Select/HMO/PPO,,149.07,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,27.20,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,BCBS NC,Blue Select/HMO/PPO,,161.01,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,BCBS NC,Blue Select/HMO/PPO,,178.50,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Select/HMO/PPO,,227.08,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,BCBS NC,Blue Select/HMO/PPO,,184.88,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,BCBS NC,Blue Select/HMO/PPO,,224.86,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,BCBS NC,Blue Select/HMO/PPO,,579.63,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,BCBS NC,Blue Select/HMO/PPO,,1289.45,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,BCBS NC,Blue Select/HMO/PPO,,992.98,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Select/HMO/PPO,,51.36,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Select/HMO/PPO,,379.76,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,BCBS NC,Blue Select/HMO/PPO,,387.25,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,BCBS NC,Blue Select/HMO/PPO,,1123.45,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,BCBS NC,Blue Select/HMO/PPO,,1595.09,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,BCBS NC,Blue Select/HMO/PPO,,368.10,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,BCBS NC,Blue Select/HMO/PPO,,713.99,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,BCBS NC,Blue Select/HMO/PPO,,286.21,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,BCBS NC,Blue Select/HMO/PPO,,333.68,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,BCBS NC,Blue Select/HMO/PPO,,446.38,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,223.19,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,BCBS NC,Blue Select/HMO/PPO,,448.60,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Select/HMO/PPO,,268.44,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Select/HMO/PPO,,221.80,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Select/HMO/PPO,,307.03,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,647.64,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,BCBS NC,Blue Select/HMO/PPO,,381.98,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,56.63,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,48.58,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Select/HMO/PPO,,334.23,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,214.03,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,293.42,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,BCBS NC,Blue Select/HMO/PPO,,99.38,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Select/HMO/PPO,,264.55,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Select/HMO/PPO,,46.91,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Select/HMO/PPO,,259.83,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,,84.95,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,94.66,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,39.70,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,BCBS NC,Blue Select/HMO/PPO,,206.53,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,BCBS NC,Blue Select/HMO/PPO,,183.77,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,BCBS NC,Blue Select/HMO/PPO,,182.38,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,89.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,BCBS NC,Blue Select/HMO/PPO,,179.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,BCBS NC,Blue Select/HMO/PPO,,96.05,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,67.46,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Select/HMO/PPO,,74.40,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,BCBS NC,Blue Select/HMO/PPO,,257.34,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,,84.95,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,252.89,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Select/HMO/PPO,,80.78,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,BCBS NC,Blue Select/HMO/PPO,,218.75,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Select/HMO/PPO,,650.42,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,BCBS NC,Blue Select/HMO/PPO,,1121.23,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,BCBS NC,Blue Select/HMO/PPO,,926.63,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Select/HMO/PPO,,998.80,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,BCBS NC,Blue Select/HMO/PPO,,564.92,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,1253.09,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,1253.09,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,1253.09,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,BCBS NC,Blue Select/HMO/PPO,,847.51,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Select/HMO/PPO,,495.79,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,BCBS NC,Blue Select/HMO/PPO,,389.75,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Select/HMO/PPO,,74.40,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Select/HMO/PPO,,103.82,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,BCBS NC,Blue Select/HMO/PPO,,92.16,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,230.69,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,45.25,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,139.08,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Select/HMO/PPO,,577.69,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Select/HMO/PPO,,171.28,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Select/HMO/PPO,,225.41,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,BCBS NC,Blue Select/HMO/PPO,,239.01,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Select/HMO/PPO,,129.64,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,BCBS NC,Blue Select/HMO/PPO,,137.13,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,145.18,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,210.42,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,BCBS NC,Blue Select/HMO/PPO,,204.31,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Select/HMO/PPO,,299.53,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,,63.57,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,119.92,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,BCBS NC,Blue Select/HMO/PPO,,295.09,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,170.72,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,BCBS NC,Blue Select/HMO/PPO,,217.92,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,BCBS NC,Blue Select/HMO/PPO,,10410.00,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,BCBS NC,Blue Select/HMO/PPO,,60.24,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,BCBS NC,Blue Select/HMO/PPO,,514.39,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,BCBS NC,Blue Select/HMO/PPO,,625.43,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,116.59,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,152.68,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Select/HMO/PPO,,149.90,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,111.32,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,BCBS NC,Blue Select/HMO/PPO,,165.45,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,BCBS NC,Blue Select/HMO/PPO,,137.97,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,208.76,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,161.29,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,BCBS NC,Blue Select/HMO/PPO,,257.61,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,BCBS NC,Blue Select/HMO/PPO,,383.64,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,74.95,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Select/HMO/PPO,,230.13,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,95.22,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,114.65,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,376.70,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,187.94,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,BCBS NC,Blue Select/HMO/PPO,,190.16,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,BCBS NC,Blue Select/HMO/PPO,,306.47,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,161.84,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,BCBS NC,Blue Select/HMO/PPO,,809.76,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,BCBS NC,Blue Select/HMO/PPO,,414.73,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Select/HMO/PPO,,303.42,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,BCBS NC,Blue Select/HMO/PPO,,270.94,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,BCBS NC,Blue Select/HMO/PPO,,199.04,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Select/HMO/PPO,,518.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,BCBS NC,Blue Select/HMO/PPO,,281.49,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,BCBS NC,Blue Select/HMO/PPO,,577.13,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Select/HMO/PPO,,444.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,BCBS NC,Blue Select/HMO/PPO,,635.70,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Select/HMO/PPO,,444.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Select/HMO/PPO,,660.13,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,BCBS NC,Blue Select/HMO/PPO,,758.68,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,BCBS NC,Blue Select/HMO/PPO,,237.63,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,BCBS NC,Blue Select/HMO/PPO,,435.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,341.45,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,BCBS NC,Blue Select/HMO/PPO,,623.21,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Select/HMO/PPO,,289.26,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,BCBS NC,Blue Select/HMO/PPO,,318.68,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Select/HMO/PPO,,348.39,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,BCBS NC,Blue Select/HMO/PPO,,495.24,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Select/HMO/PPO,,731.75,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Select/HMO/PPO,,731.75,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,BCBS NC,Blue Select/HMO/PPO,,693.17,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,BCBS NC,Blue Select/HMO/PPO,,1075.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,BCBS NC,Blue Select/HMO/PPO,,1344.69,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,230.69,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,BCBS NC,Blue Select/HMO/PPO,,399.47,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,359.21,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Select/HMO/PPO,,441.94,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Select/HMO/PPO,,690.11,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,BCBS NC,Blue Select/HMO/PPO,,215.97,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,406.41,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Select/HMO/PPO,,239.85,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,BCBS NC,Blue Select/HMO/PPO,,302.58,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Select/HMO/PPO,,221.80,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,322.02,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,BCBS NC,Blue Select/HMO/PPO,,366.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,322.02,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Select/HMO/PPO,,447.21,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,352.83,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,BCBS NC,Blue Select/HMO/PPO,,256.22,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,BCBS NC,Blue Select/HMO/PPO,,649.86,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,BCBS NC,Blue Select/HMO/PPO,,816.98,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Select/HMO/PPO,,76.90,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,27.48,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,BCBS NC,Blue Select/HMO/PPO,,563.53,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,274.27,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,57.74,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,52.19,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,BCBS NC,Blue Select/HMO/PPO,,775.61,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,BCBS NC,Blue Select/HMO/PPO,,3468.06,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,BCBS NC,Blue Select/HMO/PPO,,456.10,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,144.07,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,BCBS NC,Blue Select/HMO/PPO,,564.36,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,BCBS NC,Blue Select/HMO/PPO,,130.47,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,BCBS NC,Blue Select/HMO/PPO,,3434.19,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,187.94,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.28038,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,24.15,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,BCBS NC,Blue Select/HMO/PPO,,243.73,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,33.03,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Select/HMO/PPO,,162.12,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,89.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,BCBS NC,Blue Select/HMO/PPO,,1465.73,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Select/HMO/PPO,,1.67,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,BCBS NC,Blue Select/HMO/PPO,,180.16,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,11.66,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,BCBS NC,Blue Select/HMO/PPO,,22.76,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Select/HMO/PPO,,70.51,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,BCBS NC,Blue Select/HMO/PPO,,1681.70,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,BCBS NC,Blue Select/HMO/PPO,,298.42,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,84.67,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,BCBS NC,Blue Select/HMO/PPO,,396.41,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,84.67,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Select/HMO/PPO,,559.64,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Select/HMO/PPO,,559.64,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Select/HMO/PPO,,372.82,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,135.19,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Select/HMO/PPO,,120.76,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Select/HMO/PPO,,621.82,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,BCBS NC,Blue Select/HMO/PPO,,445.55,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,928.29,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,928.29,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,928.29,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Select/HMO/PPO,,363.38,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,BCBS NC,Blue Select/HMO/PPO,,535.49,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,BCBS NC,Blue Select/HMO/PPO,,296.75,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,BCBS NC,Blue Select/HMO/PPO,,529.66,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,341.45,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,BCBS NC,Blue Select/HMO/PPO,,1115.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,BCBS NC,Blue Select/HMO/PPO,,918.86,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Select/HMO/PPO,,1149.82,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Select/HMO/PPO,,1149.82,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,BCBS NC,Blue Select/HMO/PPO,,1127.61,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Select/HMO/PPO,,286.76,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Select/HMO/PPO,,312.58,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,89.94,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,BCBS NC,Blue Select/HMO/PPO,,704.27,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Select/HMO/PPO,,357.83,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,BCBS NC,Blue Select/HMO/PPO,,315.91,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,BCBS NC,Blue Select/HMO/PPO,,352.27,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Select/HMO/PPO,,627.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,BCBS NC,Blue Select/HMO/PPO,,740.64,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,BCBS NC,Blue Select/HMO/PPO,,906.09,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Select/HMO/PPO,,680.12,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,BCBS NC,Blue Select/HMO/PPO,,816.70,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,BCBS NC,Blue Select/HMO/PPO,,911.08,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,BCBS NC,Blue Select/HMO/PPO,,703.99,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,BCBS NC,Blue Select/HMO/PPO,,859.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,BCBS NC,Blue Select/HMO/PPO,,972.16,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,BCBS NC,Blue Select/HMO/PPO,,717.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,BCBS NC,Blue Select/HMO/PPO,,855.56,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,BCBS NC,Blue Select/HMO/PPO,,974.93,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,1162.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Select/HMO/PPO,,1102.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,BCBS NC,Blue Select/HMO/PPO,,647.09,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Select/HMO/PPO,,811.98,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,BCBS NC,Blue Select/HMO/PPO,,954.94,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,BCBS NC,Blue Select/HMO/PPO,,1075.42,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,BCBS NC,Blue Select/HMO/PPO,,797.27,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,BCBS NC,Blue Select/HMO/PPO,,1004.36,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,BCBS NC,Blue Select/HMO/PPO,,1028.23,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,BCBS NC,Blue Select/HMO/PPO,,622.38,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,BCBS NC,Blue Select/HMO/PPO,,757.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,BCBS NC,Blue Select/HMO/PPO,,883.88,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Select/HMO/PPO,,727.87,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,885.27,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Select/HMO/PPO,,1033.50,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,BCBS NC,Blue Select/HMO/PPO,,837.80,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,BCBS NC,Blue Select/HMO/PPO,,636.26,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,BCBS NC,Blue Select/HMO/PPO,,795.32,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,BCBS NC,Blue Select/HMO/PPO,,852.51,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,BCBS NC,Blue Select/HMO/PPO,,814.48,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,BCBS NC,Blue Select/HMO/PPO,,1116.51,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,BCBS NC,Blue Select/HMO/PPO,,1205.62,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,BCBS NC,Blue Select/HMO/PPO,,1103.18,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,697.05,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,BCBS NC,Blue Select/HMO/PPO,,896.93,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,BCBS NC,Blue Select/HMO/PPO,,1175.64,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,BCBS NC,Blue Select/HMO/PPO,,1367.74,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,BCBS NC,Blue Select/HMO/PPO,,692.33,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,BCBS NC,Blue Select/HMO/PPO,,881.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,BCBS NC,Blue Select/HMO/PPO,,1043.22,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,BCBS NC,Blue Select/HMO/PPO,,2043.41,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,9566.93,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,BCBS NC,Blue Select/HMO/PPO,,1486.55,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,BCBS NC,Blue Select/HMO/PPO,,1770.81,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,BCBS NC,Blue Select/HMO/PPO,,2058.40,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Select/HMO/PPO,,363.38,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,BCBS NC,Blue Select/HMO/PPO,,1126.78,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Select/HMO/PPO,,1102.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,1162.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Select/HMO/PPO,,811.98,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Select/HMO/PPO,,777.28,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,BCBS NC,Blue Select/HMO/PPO,,132.42,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Select/HMO/PPO,,325.62,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Select/HMO/PPO,,369.76,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Select/HMO/PPO,,369.76,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,BCBS NC,Blue Select/HMO/PPO,,402.52,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Select/HMO/PPO,,489.69,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Select/HMO/PPO,,489.69,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Select/HMO/PPO,,527.72,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,131.86,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,93.55,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,9566.93,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,9566.93,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,BCBS NC,Blue Select/HMO/PPO,,8734.96,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,74.67,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,202.09,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,174.61,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,BCBS NC,Blue Select/HMO/PPO,,553.26,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,BCBS NC,Blue Select/HMO/PPO,,1417.15,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Select/HMO/PPO,,150.74,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,BCBS NC,Blue Select/HMO/PPO,,385.03,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,BCBS NC,Blue Select/HMO/PPO,,244.29,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,BCBS NC,Blue Select/HMO/PPO,,15976.16,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,1348.30,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,1348.30,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,BCBS NC,Blue Select/HMO/PPO,,8198.92,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,BCBS NC,Blue Select/HMO/PPO,,308.14,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Select/HMO/PPO,,832.52,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,43.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,43.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,BCBS NC,Blue Select/HMO/PPO,,116.87,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Select/HMO/PPO,,810.87,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,174.61,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Select/HMO/PPO,,126.59,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,BCBS NC,Blue Select/HMO/PPO,,64.40,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,55.80,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,133.53,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,BCBS NC,Blue Select/HMO/PPO,,307.86,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,127.14,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,79.12,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,BCBS NC,Blue Select/HMO/PPO,,388.64,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Select/HMO/PPO,,439.16,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Select/HMO/PPO,,439.16,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Select/HMO/PPO,,646.81,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Select/HMO/PPO,,646.81,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Select/HMO/PPO,,86.33,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Select/HMO/PPO,,86.33,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,223.19,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,223.19,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,BCBS NC,Blue Select/HMO/PPO,,200.43,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Select/HMO/PPO,,160.18,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Select/HMO/PPO,,160.18,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,BCBS NC,Blue Select/HMO/PPO,,1310.27,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,BCBS NC,Blue Select/HMO/PPO,,937.46,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,BCBS NC,Blue Select/HMO/PPO,,197.65,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,156.84,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,BCBS NC,Blue Select/HMO/PPO,,392.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,BCBS NC,Blue Select/HMO/PPO,,212.36,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,BCBS NC,Blue Select/HMO/PPO,,358.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,161.29,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,353.94,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,353.94,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Select/HMO/PPO,,324.24,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Select/HMO/PPO,,838.07,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Select/HMO/PPO,,838.07,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,83.28,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,BCBS NC,Blue Select/HMO/PPO,,539.38,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,406.41,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Select/HMO/PPO,,231.52,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,BCBS NC,Blue Select/HMO/PPO,,450.54,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,BCBS NC,Blue Select/HMO/PPO,,491.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,502.18,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,502.18,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Select/HMO/PPO,,584.35,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Select/HMO/PPO,,584.35,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,187.94,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,187.94,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,144.07,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,189.88,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,189.88,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,BCBS NC,Blue Select/HMO/PPO,,747.02,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Select/HMO/PPO,,765.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Select/HMO/PPO,,765.07,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Select/HMO/PPO,,442.49,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Select/HMO/PPO,,442.49,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Select/HMO/PPO,,254.28,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Select/HMO/PPO,,254.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Select/HMO/PPO,,313.69,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Select/HMO/PPO,,313.69,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Select/HMO/PPO,,320.07,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Select/HMO/PPO,,320.07,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,BCBS NC,Blue Select/HMO/PPO,,1404.38,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,BCBS NC,Blue Select/HMO/PPO,,1367.18,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,BCBS NC,Blue Select/HMO/PPO,,220.69,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,BCBS NC,Blue Select/HMO/PPO,,201.26,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Select/HMO/PPO,,227.08,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Select/HMO/PPO,,205.98,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,BCBS NC,Blue Select/HMO/PPO,,623.77,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Select/HMO/PPO,,205.98,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Select/HMO/PPO,,1033.50,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,245.95,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,BCBS NC,Blue Select/HMO/PPO,,190.43,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,54.13,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,BCBS NC,Blue Select/HMO/PPO,,147.96,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Select/HMO/PPO,,154.07,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,BCBS NC,Blue Select/HMO/PPO,,163.78,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,161.84,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,184.60,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,BCBS NC,Blue Select/HMO/PPO,,1155.65,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,BCBS NC,Blue Select/HMO/PPO,,590.73,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Select/HMO/PPO,,372.82,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,406.41,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,BCBS NC,Blue Select/HMO/PPO,,192.65,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,BCBS NC,Blue Select/HMO/PPO,,162.95,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,BCBS NC,Blue Select/HMO/PPO,,168.23,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,245.40,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,245.40,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,3902.50,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,3902.50,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,3902.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,BCBS NC,Blue Select/HMO/PPO,,1717.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,2918.69,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,2918.69,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,2918.69,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,2918.69,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Select/HMO/PPO,,3179.08,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Select/HMO/PPO,,3179.08,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,BCBS NC,Blue Select/HMO/PPO,,2130.02,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Select/HMO/PPO,,2193.60,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Select/HMO/PPO,,2193.60,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Select/HMO/PPO,,1332.48,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,BCBS NC,Blue Select/HMO/PPO,,1241.15,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,1682.81,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,1682.81,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,1682.81,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,1219.77,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,BCBS NC,Blue Select/HMO/PPO,,670.96,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,687.06,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,BCBS NC,Blue Select/HMO/PPO,,447.77,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,BCBS NC,Blue Select/HMO/PPO,,219.86,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,686.78,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Select/HMO/PPO,,105.21,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Select/HMO/PPO,,133.80,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,BCBS NC,Blue Select/HMO/PPO,,78.28,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,BCBS NC,Blue Select/HMO/PPO,,150.46,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Select/HMO/PPO,,1469.61,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,BCBS NC,Blue Select/HMO/PPO,,354.50,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Select/HMO/PPO,,2080.33,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,BCBS NC,Blue Select/HMO/PPO,,109.65,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Select/HMO/PPO,,455.26,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Select/HMO/PPO,,455.26,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,BCBS NC,Blue Select/HMO/PPO,,592.95,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,252.89,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,BCBS NC,Blue Select/HMO/PPO,,854.18,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,BCBS NC,Blue Select/HMO/PPO,,621.55,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,148.52,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,282.04,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,BCBS NC,Blue Select/HMO/PPO,,1069.87,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Select/HMO/PPO,,178.22,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,BCBS NC,Blue Select/HMO/PPO,,222.64,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Select/HMO/PPO,,178.22,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,BCBS NC,Blue Select/HMO/PPO,,192.93,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Select/HMO/PPO,,1469.61,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Select/HMO/PPO,,660.13,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,BCBS NC,Blue Select/HMO/PPO,,694.56,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,BCBS NC,Blue Select/HMO/PPO,,687.89,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,BCBS NC,Blue Select/HMO/PPO,,176.55,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,322.02,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,48.58,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,BCBS NC,Blue Select/HMO/PPO,,1746.38,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,BCBS NC,Blue Select/HMO/PPO,,2156.12,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,BCBS NC,Blue Select/HMO/PPO,,691.50,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,81.61,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,64.13,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,57.74,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,112.15,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,BCBS NC,Blue Select/HMO/PPO,,113.26,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,686.78,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,,56.08,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Select/HMO/PPO,,441.94,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,BCBS NC,Blue Select/HMO/PPO,,1248.37,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,BCBS NC,Blue Select/HMO/PPO,,1175.36,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Select/HMO/PPO,,810.87,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,1269.74,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,292.87,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,292.87,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,BCBS NC,Blue Select/HMO/PPO,,408.35,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,79.95,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,79.95,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,532.44,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,532.44,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Select/HMO/PPO,,325.62,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,697.05,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,697.05,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,564.64,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,564.64,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Select/HMO/PPO,,482.47,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Select/HMO/PPO,,482.47,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Select/HMO/PPO,,439.44,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Select/HMO/PPO,,439.44,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Select/HMO/PPO,,456.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Select/HMO/PPO,,456.93,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,BCBS NC,Blue Select/HMO/PPO,,474.70,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Select/HMO/PPO,,420.56,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Select/HMO/PPO,,420.56,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Select/HMO/PPO,,418.90,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Select/HMO/PPO,,418.90,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Select/HMO/PPO,,922.19,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Select/HMO/PPO,,922.19,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Select/HMO/PPO,,516.34,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Select/HMO/PPO,,516.34,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Select/HMO/PPO,,504.68,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Select/HMO/PPO,,504.68,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,BCBS NC,Blue Select/HMO/PPO,,640.15,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Select/HMO/PPO,,102.16,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,1348.30,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Select/HMO/PPO,,61.07,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,BCBS NC,Blue Select/HMO/PPO,,788.66,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,BCBS NC,Blue Select/HMO/PPO,,830.02,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Select/HMO/PPO,,5590.03,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,2971.99,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,144.07,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Select/HMO/PPO,,324.24,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Select/HMO/PPO,,298.14,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,BCBS NC,Blue Select/HMO/PPO,,192.38,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,BCBS NC,Blue Select/HMO/PPO,,215.42,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,BCBS NC,Blue Select/HMO/PPO,,1515.14,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Select/HMO/PPO,,1030.45,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,BCBS NC,Blue Select/HMO/PPO,,1309.99,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,BCBS NC,Blue Select/HMO/PPO,,1074.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,BCBS NC,Blue Select/HMO/PPO,,1350.25,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,BCBS NC,Blue Select/HMO/PPO,,1107.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,BCBS NC,Blue Select/HMO/PPO,,468.59,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Select/HMO/PPO,,159.06,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,BCBS NC,Blue Select/HMO/PPO,,2071.45,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Select/HMO/PPO,,552.42,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,BCBS NC,Blue Select/HMO/PPO,,414.18,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,BCBS NC,Blue Select/HMO/PPO,,736.47,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,BCBS NC,Blue Select/HMO/PPO,,7985.44,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,BCBS NC,Blue Select/HMO/PPO,,1162.31,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,BCBS NC,Blue Select/HMO/PPO,,3686.25,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,BCBS NC,Blue Select/HMO/PPO,,2456.20,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,BCBS NC,Blue Select/HMO/PPO,,965.77,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,BCBS NC,Blue Select/HMO/PPO,,344.50,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Select/HMO/PPO,,470.81,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Select/HMO/PPO,,470.81,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Select/HMO/PPO,,520.78,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Select/HMO/PPO,,520.78,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Select/HMO/PPO,,480.80,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Select/HMO/PPO,,480.80,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Select/HMO/PPO,,357.83,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Select/HMO/PPO,,203.48,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,BCBS NC,Blue Select/HMO/PPO,,341.17,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,BCBS NC,Blue Select/HMO/PPO,,1989.00,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,BCBS NC,Blue Select/HMO/PPO,,497.18,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,BCBS NC,Blue Select/HMO/PPO,,437.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,BCBS NC,Blue Select/HMO/PPO,,514.67,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,BCBS NC,Blue Select/HMO/PPO,,290.37,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Select/HMO/PPO,,995.47,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Select/HMO/PPO,,995.47,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,722.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,722.32,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,722.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,722.32,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,BCBS NC,Blue Select/HMO/PPO,,961.88,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,BCBS NC,Blue Select/HMO/PPO,,827.25,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,BCBS NC,Blue Select/HMO/PPO,,1705.57,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,BCBS NC,Blue Select/HMO/PPO,,1983.17,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,BCBS NC,Blue Select/HMO/PPO,,1468.78,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,BCBS NC,Blue Select/HMO/PPO,,1323.32,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,BCBS NC,Blue Select/HMO/PPO,,330.90,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,BCBS NC,Blue Select/HMO/PPO,,2231.35,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,BCBS NC,Blue Select/HMO/PPO,,2302.97,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,BCBS NC,Blue Select/HMO/PPO,,3461.67,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,BCBS NC,Blue Select/HMO/PPO,,1930.71,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Select/HMO/PPO,,737.86,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Select/HMO/PPO,,513.00,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,BCBS NC,Blue Select/HMO/PPO,,247.34,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Select/HMO/PPO,,447.21,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,BCBS NC,Blue Select/HMO/PPO,,330.62,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,BCBS NC,Blue Select/HMO/PPO,,1027.68,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,BCBS NC,Blue Select/HMO/PPO,,902.48,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,BCBS NC,Blue Select/HMO/PPO,,903.31,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,BCBS NC,Blue Select/HMO/PPO,,778.67,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Select/HMO/PPO,,737.86,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,BCBS NC,Blue Select/HMO/PPO,,1323.87,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,BCBS NC,Blue Select/HMO/PPO,,1535.68,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,BCBS NC,Blue Select/HMO/PPO,,2250.50,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,BCBS NC,Blue Select/HMO/PPO,,208.48,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,BCBS NC,Blue Select/HMO/PPO,,3019.46,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Select/HMO/PPO,,2173.89,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,BCBS NC,Blue Select/HMO/PPO,,1056.82,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,BCBS NC,Blue Select/HMO/PPO,,4752.79,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,BCBS NC,Blue Select/HMO/PPO,,2033.98,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Select/HMO/PPO,,250.40,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Select/HMO/PPO,,966.33,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Select/HMO/PPO,,966.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,BCBS NC,Blue Select/HMO/PPO,,4785.27,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Select/HMO/PPO,,4492.12,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Select/HMO/PPO,,4492.12,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Select/HMO/PPO,,2441.49,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Select/HMO/PPO,,2441.49,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Select/HMO/PPO,,2587.79,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Select/HMO/PPO,,2587.79,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,BCBS NC,Blue Select/HMO/PPO,,3450.01,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,BCBS NC,Blue Select/HMO/PPO,,2508.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,BCBS NC,Blue Select/HMO/PPO,,807.82,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Select/HMO/PPO,,657.36,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Select/HMO/PPO,,657.36,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,223.19,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,BCBS NC,Blue Select/HMO/PPO,,1821.06,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,BCBS NC,Blue Select/HMO/PPO,,468.03,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,BCBS NC,Blue Select/HMO/PPO,,561.03,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,BCBS NC,Blue Select/HMO/PPO,,891.37,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,135.19,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,793.66,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,793.66,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,60.52,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,60.52,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Select/HMO/PPO,,2760.45,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Select/HMO/PPO,,2760.45,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,BCBS NC,Blue Select/HMO/PPO,,1114.29,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,BCBS NC,Blue Select/HMO/PPO,,1691.14,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,BCBS NC,Blue Select/HMO/PPO,,958.28,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,502.18,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,174.61,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,793.66,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,793.66,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,BCBS NC,Blue Select/HMO/PPO,,1126.50,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,BCBS NC,Blue Select/HMO/PPO,,543.82,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Select/HMO/PPO,,108.82,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,127.42,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,103.54,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,103.54,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Select/HMO/PPO,,108.82,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,BCBS NC,Blue Select/HMO/PPO,,88.83,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,BCBS NC,Blue Select/HMO/PPO,,248.17,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,BCBS NC,Blue Select/HMO/PPO,,159.34,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,BCBS NC,Blue Select/HMO/PPO,,317.02,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Select/HMO/PPO,,259.83,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,BCBS NC,Blue Select/HMO/PPO,,293.70,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,214.03,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,BCBS NC,Blue Select/HMO/PPO,,232.35,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,87.44,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,210.42,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,BCBS NC,Blue Select/HMO/PPO,,86.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Select/HMO/PPO,,229.02,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,BCBS NC,Blue Select/HMO/PPO,,266.77,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,144.07,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,176.83,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,118.54,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,BCBS NC,Blue Select/HMO/PPO,,231.80,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Select/HMO/PPO,,185.44,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,149.63,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,BCBS NC,Blue Select/HMO/PPO,,182.66,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,287.87,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Select/HMO/PPO,,228.46,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,255.11,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,BCBS NC,Blue Select/HMO/PPO,,83.56,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,BCBS NC,Blue Select/HMO/PPO,,327.01,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,BCBS NC,Blue Select/HMO/PPO,,212.09,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Select/HMO/PPO,,69.40,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,64.13,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,51.63,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,BCBS NC,Blue Select/HMO/PPO,,305.92,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Select/HMO/PPO,,229.02,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Select/HMO/PPO,,55.24,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,189.88,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,117.15,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Select/HMO/PPO,,268.44,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,BCBS NC,Blue Select/HMO/PPO,,200.98,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,114.65,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,136.58,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,127.42,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,38.59,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,,18.60,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,30.26,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,BCBS NC,Blue Select/HMO/PPO,,1772.75,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,BCBS NC,Blue Select/HMO/PPO,,1291.95,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,BCBS NC,Blue Select/HMO/PPO,,1160.92,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,BCBS NC,Blue Select/HMO/PPO,,1801.90,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,1707.24,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,BCBS NC,Blue Select/HMO/PPO,,746.19,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,1707.24,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,1707.24,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,BCBS NC,Blue Select/HMO/PPO,,258.45,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,BCBS NC,Blue Select/HMO/PPO,,425.01,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,BCBS NC,Blue Select/HMO/PPO,,849.73,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,BCBS NC,Blue Select/HMO/PPO,,1293.62,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,BCBS NC,Blue Select/HMO/PPO,,1159.26,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,BCBS NC,Blue Select/HMO/PPO,,1680.04,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,BCBS NC,Blue Select/HMO/PPO,,2469.53,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,BCBS NC,Blue Select/HMO/PPO,,146.30,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Select/HMO/PPO,,249.56,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,158.51,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,BCBS NC,Blue Select/HMO/PPO,,280.93,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,759.51,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,685.39,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,133.53,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,780.89,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,BCBS NC,Blue Select/HMO/PPO,,913.86,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,BCBS NC,Blue Select/HMO/PPO,,1407.15,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,BCBS NC,Blue Select/HMO/PPO,,1700.86,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,BCBS NC,Blue Select/HMO/PPO,,960.22,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,BCBS NC,Blue Select/HMO/PPO,,1436.02,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,BCBS NC,Blue Select/HMO/PPO,,1495.71,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,BCBS NC,Blue Select/HMO/PPO,,1000.47,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,BCBS NC,Blue Select/HMO/PPO,,1045.16,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Select/HMO/PPO,,1431.86,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,BCBS NC,Blue Select/HMO/PPO,,963.83,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,BCBS NC,Blue Select/HMO/PPO,,1131.50,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,BCBS NC,Blue Select/HMO/PPO,,1304.44,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,BCBS NC,Blue Select/HMO/PPO,,1029.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,BCBS NC,Blue Select/HMO/PPO,,1080.42,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,BCBS NC,Blue Select/HMO/PPO,,1480.16,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,BCBS NC,Blue Select/HMO/PPO,,1020.18,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Select/HMO/PPO,,1030.45,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Select/HMO/PPO,,1431.86,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,BCBS NC,Blue Select/HMO/PPO,,1181.47,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,BCBS NC,Blue Select/HMO/PPO,,1249.48,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,BCBS NC,Blue Select/HMO/PPO,,1452.96,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,BCBS NC,Blue Select/HMO/PPO,,810.31,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,BCBS NC,Blue Select/HMO/PPO,,1161.76,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,BCBS NC,Blue Select/HMO/PPO,,880.55,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,70.23,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Select/HMO/PPO,52,1097.08,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,BCBS NC,Blue Select/HMO/PPO,52,1091.80,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,BCBS NC,Blue Select/HMO/PPO,,1066.82,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,BCBS NC,Blue Select/HMO/PPO,,1222.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,BCBS NC,Blue Select/HMO/PPO,,1442.41,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,BCBS NC,Blue Select/HMO/PPO,,1117.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,BCBS NC,Blue Select/HMO/PPO,,1147.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,BCBS NC,Blue Select/HMO/PPO,,976.04,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,BCBS NC,Blue Select/HMO/PPO,,1186.46,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Select/HMO/PPO,,977.98,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,BCBS NC,Blue Select/HMO/PPO,,1124.56,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,BCBS NC,Blue Select/HMO/PPO,,1416.87,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,BCBS NC,Blue Select/HMO/PPO,,1363.57,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,BCBS NC,Blue Select/HMO/PPO,,1514.03,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,BCBS NC,Blue Select/HMO/PPO,,1163.14,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,BCBS NC,Blue Select/HMO/PPO,,1287.23,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,BCBS NC,Blue Select/HMO/PPO,,1550.67,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,BCBS NC,Blue Select/HMO/PPO,,962.72,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,BCBS NC,Blue Select/HMO/PPO,,1019.07,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,BCBS NC,Blue Select/HMO/PPO,,1482.38,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,BCBS NC,Blue Select/HMO/PPO,,900.81,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,BCBS NC,Blue Select/HMO/PPO,,999.08,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,BCBS NC,Blue Select/HMO/PPO,,1387.72,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,BCBS NC,Blue Select/HMO/PPO,,1172.86,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,BCBS NC,Blue Select/HMO/PPO,,898.31,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,BCBS NC,Blue Select/HMO/PPO,,1241.43,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,1176.47,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,1176.47,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,1176.47,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,BCBS NC,Blue Select/HMO/PPO,,981.32,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Select/HMO/PPO,,1129.28,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Select/HMO/PPO,,1129.28,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,BCBS NC,Blue Select/HMO/PPO,,1247.26,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,BCBS NC,Blue Select/HMO/PPO,,902.20,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,BCBS NC,Blue Select/HMO/PPO,,1275.29,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,BCBS NC,Blue Select/HMO/PPO,,1239.76,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Select/HMO/PPO,,1172.30,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Select/HMO/PPO,,1172.30,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,1260.30,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,1260.30,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,1260.30,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Select/HMO/PPO,,977.98,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Select/HMO/PPO,,286.76,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,BCBS NC,Blue Select/HMO/PPO,,666.24,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,BCBS NC,Blue Select/HMO/PPO,,662.08,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Select/HMO/PPO,,1097.08,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,BCBS NC,Blue Select/HMO/PPO,,520.50,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,118.26,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,89.94,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,110.76,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,484.41,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,484.41,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,43.86,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Select/HMO/PPO,,508.29,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Select/HMO/PPO,,508.29,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,BCBS NC,Blue Select/HMO/PPO,,251.23,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Select/HMO/PPO,,149.90,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,131.86,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,131.86,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,BCBS NC,Blue Select/HMO/PPO,,360.60,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,287.87,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Select/HMO/PPO,,235.13,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,171.00,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Select/HMO/PPO,,166.28,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,81.06,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Select/HMO/PPO,,119.65,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,88.00,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,79.95,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,BCBS NC,Blue Select/HMO/PPO,,188.77,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,78.01,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,161.56,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,161.56,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,BCBS NC,Blue Select/HMO/PPO,,398.63,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,208.76,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Select/HMO/PPO,,518.00,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,BCBS NC,Blue Select/HMO/PPO,,1207.56,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,BCBS NC,Blue Select/HMO/PPO,,69.96,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,49.14,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Select/HMO/PPO,,102.43,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,118.54,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Select/HMO/PPO,,91.33,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,76.34,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,110.76,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,BCBS NC,Blue Select/HMO/PPO,,175.17,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,143.80,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,BCBS NC,Blue Select/HMO/PPO,,242.62,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,BCBS NC,Blue Select/HMO/PPO,,156.01,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,15.82,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Select/HMO/PPO,,100.49,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Select/HMO/PPO,,209.87,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,84.67,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,184.60,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,117.15,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Select/HMO/PPO,,265.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Select/HMO/PPO,,166.28,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,117.15,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,127.14,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,BCBS NC,Blue Select/HMO/PPO,,101.05,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,BCBS NC,Blue Select/HMO/PPO,,700.66,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,BCBS NC,Blue Select/HMO/PPO,,602.11,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Select/HMO/PPO,,307.03,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,BCBS NC,Blue Select/HMO/PPO,,144.63,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,BCBS NC,Blue Select/HMO/PPO,,153.51,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Select/HMO/PPO,,93.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,35.53,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,142.13,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,112.15,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,112.15,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,BCBS NC,Blue Select/HMO/PPO,,667.35,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.05,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,BCBS NC,Blue Select/HMO/PPO,,3.89,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,31.09,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,45.25,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.22,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,52.47,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Select/HMO/PPO,,73.56,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,70.23,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,52.47,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Select/HMO/PPO,,110.21,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,43.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,148.52,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,19.71,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,36.92,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,36.92,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,36.92,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.05,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,49.14,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,34.42,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,10.83,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,40.25,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,40.25,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,40.25,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,42.75,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.05,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,11.94,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,11.66,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,52.19,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,13.32,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,44.97,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,31.92,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,31.92,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,31.92,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,11.66,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,16.66,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.10,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.10,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,46.08,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,24.71,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,24.71,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,14.71,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,71.62,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,67.46,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,49.97,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,40.53,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,21.93,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,10.83,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Select/HMO/PPO,,83.00,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Select/HMO/PPO,,1.67,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,55.80,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Select/HMO/PPO,,160.73,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,43.58,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,10.83,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,52.19,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,56.35,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,56.35,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,56.35,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,56.35,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,19.71,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,47.47,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,44.97,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,21.65,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Select/HMO/PPO,,66.07,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,43.31,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Select/HMO/PPO,,61.35,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,33.31,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,42.20,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.05,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.05,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,BCBS NC,Blue Select/HMO/PPO,,54.69,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.10,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,10.55,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,11.66,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,43.86,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,43.86,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Select/HMO/PPO,,41.36,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,10.55,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,39.70,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,23.04,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,39.70,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,49.14,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.22,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.22,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.22,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.55520,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Select/HMO/PPO,,91.33,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,15.27,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,40.53,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Select/HMO/PPO,,63.02,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,59.68,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,59.68,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,12.49,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,14.71,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,13.88,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,12.49,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,8.88,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,8.88,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,11.94,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.16,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Select/HMO/PPO,,46.36,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,12.49,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,,44.42,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,BCBS NC,Blue Select/HMO/PPO,,52.74,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,37.20,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,36.09,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,29.98,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,10.55,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,31.92,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,31.92,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,36.09,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Select/HMO/PPO,,53.58,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,21.93,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,,3.33,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,102.99,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,102.99,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Select/HMO/PPO,,62.46,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,8.88,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,38.86,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,31.37,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,26.93,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Select/HMO/PPO,,38.03,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,33.31,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,BCBS NC,Blue Select/HMO/PPO,,2.22,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.11,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,48.30,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,35.53,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,74.12,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,40.81,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,75.78,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Select/HMO/PPO,,57.46,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,13.88,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Select/HMO/PPO,,65.79,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,52.19,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,BCBS NC,Blue Select/HMO/PPO,,57.19,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Select/HMO/PPO,,11.38,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,81.34,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,55.80,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,12.77,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,31.37,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,31.37,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,13.88,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,37.48,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,BCBS NC,Blue Select/HMO/PPO,,61.90,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,,5.83,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,15.82,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,40.25,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,,18.88,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,32.48,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,48.02,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,26.93,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,32.20,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,32.20,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.16,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,24.71,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,24.71,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,9.72,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,12.49,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,19.15,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Select/HMO/PPO,,127.97,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,54.13,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,23.04,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Select/HMO/PPO,,3.05,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,9.72,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,37.48,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,29.98,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Select/HMO/PPO,,220.41,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Select/HMO/PPO,,124.09,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Select/HMO/PPO,,73.84,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,BCBS NC,Blue Select/HMO/PPO,,158.23,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Select/HMO/PPO,,233.46,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,45.80,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,82.17,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Select/HMO/PPO,,100.21,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,23.60,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,23.60,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,23.60,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,BCBS NC,Blue Select/HMO/PPO,,64.68,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,40.25,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,34.14,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,37.20,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Select/HMO/PPO,,54.41,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,48.02,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,139.08,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,BCBS NC,Blue Select/HMO/PPO,,204.59,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,34.98,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,38.59,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,41.64,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,25.82,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,44.97,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Select/HMO/PPO,,120.20,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Select/HMO/PPO,,120.20,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,89.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,76.34,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Select/HMO/PPO,,80.78,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,73.29,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,BCBS NC,Blue Select/HMO/PPO,,169.89,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,44.69,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Select/HMO/PPO,,65.79,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Select/HMO/PPO,,55.24,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,27.48,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Select/HMO/PPO,,90.22,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,75.23,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,89.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,BCBS NC,Blue Select/HMO/PPO,,69.68,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,50.52,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,51.63,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,51.63,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,68.57,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,41.64,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Select/HMO/PPO,,54.41,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,BCBS NC,Blue Select/HMO/PPO,,129.92,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,BCBS NC,Blue Select/HMO/PPO,,78.56,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,9.72,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,19.99,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,31.37,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,98.83,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,40.53,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,,56.08,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,39.70,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,32.48,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,32.48,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,21.93,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Select/HMO/PPO,,28.32,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,23.60,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,27.20,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,,62.18,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,10.83,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.27,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,13.05,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.16,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Select/HMO/PPO,,11.38,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,52.19,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,36.09,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,19.71,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,43.58,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.50,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,14.71,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,,51.91,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,,51.91,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,26.93,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,59.13,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,56.63,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,8.88,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,56.63,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,8.61,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,19.43,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,40.25,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,25.54,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,10.83,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.22,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,35.81,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,32.20,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,21.93,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,BCBS NC,Blue Select/HMO/PPO,,94.11,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,,18.88,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,24.71,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Select/HMO/PPO,,4.44,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,BCBS NC,Blue Select/HMO/PPO,,68.01,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,42.75,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,10.27,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,27.48,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,21.65,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.10,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,15.82,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,10.55,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,17.49,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,49.97,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Select/HMO/PPO,,9.16,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,10.55,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,BCBS NC,Blue Select/HMO/PPO,,63.29,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Select/HMO/PPO,,46.91,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Select/HMO/PPO,,127.97,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,59.13,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,59.13,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,174.61,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,161.29,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,48.30,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,44.69,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,97.16,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,58.85,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,45.53,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,45.53,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,76.34,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,BCBS NC,Blue Select/HMO/PPO,,71.34,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,213.75,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,24.15,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,23.04,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,13.32,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,31.09,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Select/HMO/PPO,,160.73,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,BCBS NC,Blue Select/HMO/PPO,,77.45,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,15.27,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,42.75,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,26.65,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,26.65,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,26.65,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,128.53,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,81.61,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,34.98,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,,3.33,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,41.64,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,33.31,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,152.12,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Select/HMO/PPO,,85.78,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,,35.26,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,9.99,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,6.11,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Select/HMO/PPO,,63.85,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.05,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,16.10,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,9.72,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,9.72,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,5.27,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,17.77,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,12.77,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,19.71,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.16,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,70.23,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,37.20,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,47.47,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,7.22,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,44.97,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,21.93,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.05,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,114.93,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,0.55520,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,143.80,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,22.49,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,8.05,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,44.69,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Select/HMO/PPO,,544.10,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,39.14,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,24.71,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.44,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,10.55,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,19.43,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,19.43,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,4.16,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,9.72,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,20.82,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Select/HMO/PPO,,146.85,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,BCBS NC,Blue Select/HMO/PPO,,212.92,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,37.20,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,BCBS NC,Blue Select/HMO/PPO,,501.07,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,BCBS NC,Blue Select/HMO/PPO,,349.22,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,81.34,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,32.20,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Select/HMO/PPO,,536.05,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,6.38,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,,71.90,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,12.77,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,BCBS NC,Blue Select/HMO/PPO,,501.90,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,196.26,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,BCBS NC,Blue Select/HMO/PPO,,142.41,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,52.47,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Select/HMO/PPO,,544.10,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,BCBS NC,Blue Select/HMO/PPO,,31.65,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,89.94,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Select/HMO/PPO,,53.85,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Select/HMO/PPO,,264.55,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,BCBS NC,Blue Select/HMO/PPO,,177.39,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,38.86,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,QW,38.86,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,12.77,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Select/HMO/PPO,,77.17,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Select/HMO/PPO,,441.11,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,BCBS NC,Blue Select/HMO/PPO,,329.51,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Select/HMO/PPO,,77.17,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Select/HMO/PPO,,169.06,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,BCBS NC,Blue Select/HMO/PPO,,132.69,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,56.63,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,118.26,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,13.88,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,QW,27.76,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,45.25,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,BCBS NC,Blue Select/HMO/PPO,,251.78,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,76.34,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,45.80,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,24.71,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,11.94,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,77.73,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,21.93,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Select/HMO/PPO,,53.85,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,19.15,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,97.16,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,37.48,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,59.13,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,37.48,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,37.48,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,76.34,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,12.49,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,12.49,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,21.10,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,11.94,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,23.32,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,28.04,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Select/HMO/PPO,,41.36,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,BCBS NC,Blue Select/HMO/PPO,,368.65,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,15.27,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,29.98,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,32.76,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,18.04,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,15.82,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,75.23,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Select/HMO/PPO,,46.36,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,75.23,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,88.55,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,142.96,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,BCBS NC,Blue Select/HMO/PPO,,146.02,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,58.30,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,7.50,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,51.63,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,40.81,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,40.81,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,10.83,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,BCBS NC,Blue Select/HMO/PPO,,54.96,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,33.03,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,BCBS NC,Blue Select/HMO/PPO,,70.79,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Select/HMO/PPO,,72.45,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,21.65,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,37.75,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,58.02,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Select/HMO/PPO,,57.46,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,143.80,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Select/HMO/PPO,,41.08,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Select/HMO/PPO,,126.59,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Select/HMO/PPO,,165.73,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,BCBS NC,Blue Select/HMO/PPO,,209.59,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,BCBS NC,Blue Select/HMO/PPO,,155.73,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Select/HMO/PPO,,90.22,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Select/HMO/PPO,,62.46,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,BCBS NC,Blue Select/HMO/PPO,,282.87,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,98.27,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Select/HMO/PPO,,169.06,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,,62.18,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,37.48,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,152.12,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Select/HMO/PPO,,28.32,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,48.58,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,101.88,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,183.22,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00278,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,34.42,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,BCBS NC,Blue Select/HMO/PPO,,62.74,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,BCBS NC,Blue Select/HMO/PPO,,102.71,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,88.55,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,88.55,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,BCBS NC,Blue Select/HMO/PPO,,164.62,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,152.12,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,26.93,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,35.81,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,109.37,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,86.89,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Select/HMO/PPO,,69.12,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,21.38,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,BCBS NC,Blue Select/HMO/PPO,,106.60,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,BCBS NC,Blue Select/HMO/PPO,,187.38,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,52.47,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,114.93,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,BCBS NC,Blue Select/HMO/PPO,,71.07,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Select/HMO/PPO,,72.45,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,43.58,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,43.58,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,149.63,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,38.59,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,45.53,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,5.00,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,114.93,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,68.57,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,BCBS NC,Blue Select/HMO/PPO,,608.22,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Select/HMO/PPO,,97.99,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,53.30,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Select/HMO/PPO,,196.54,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,143.80,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,98.27,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,101.88,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,144.07,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,BCBS NC,Blue Select/HMO/PPO,,356.72,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,101.88,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,BCBS NC,Blue Select/HMO/PPO,,86.61,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,35.81,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,BCBS NC,Blue Select/HMO/PPO,,345.06,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,6.66,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,53.30,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,BCBS NC,Blue Select/HMO/PPO,,252.06,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,183.22,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Select/HMO/PPO,,131.58,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,98.83,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,BCBS NC,Blue Select/HMO/PPO,,34.70,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,41.64,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,26.37,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,46.08,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,22.21,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,BCBS NC,Blue Select/HMO/PPO,,44.14,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Select/HMO/PPO,,441.11,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,BCBS NC,Blue Select/HMO/PPO,,221.52,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,BCBS NC,Blue Select/HMO/PPO,,90.50,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,11.66,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,29.15,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,BCBS NC,Blue Select/HMO/PPO,,68.84,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,83.28,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,83.28,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Select/HMO/PPO,,76.90,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,BCBS NC,Blue Select/HMO/PPO,,157.12,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,15.82,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,BCBS NC,Blue Select/HMO/PPO,,188.49,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,BCBS NC,Blue Select/HMO/PPO,,180.72,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,288.98,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,BCBS NC,Blue Select/HMO/PPO,,297.03,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,59.68,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,BCBS NC,Blue Select/HMO/PPO,,116.31,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,81.61,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Select/HMO/PPO,,263.44,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,BCBS NC,Blue Select/HMO/PPO,,344.22,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,166.56,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,25.26,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,424.17,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,7.77,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,45.80,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,45.80,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,45.80,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,288.98,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,288.98,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,322.02,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,17.21,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,BCBS NC,Blue Select/HMO/PPO,,726.20,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2379.03,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2379.03,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2379.03,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2379.03,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2379.03,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,BCBS NC,Blue Select/HMO/PPO,,9848.42,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,BCBS NC,Blue Select/HMO/PPO,,1668.93,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,686.78,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,686.78,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,BCBS NC,Blue Select/HMO/PPO,,1864.08,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,BCBS NC,Blue Select/HMO/PPO,,567.14,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,BCBS NC,Blue Select/HMO/PPO,,934.96,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,252.34,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,252.34,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Select/HMO/PPO,,549.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Select/HMO/PPO,,549.93,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Select/HMO/PPO,,1156.48,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Select/HMO/PPO,,1156.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Select/HMO/PPO,,526.33,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Select/HMO/PPO,,526.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Select/HMO/PPO,,124.09,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Select/HMO/PPO,,228.46,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,498.01,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,498.01,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,393.08,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,393.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Select/HMO/PPO,,440.27,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Select/HMO/PPO,,440.27,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,393.08,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,393.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,BCBS NC,Blue Select/HMO/PPO,,2142.24,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Select/HMO/PPO,,1070.98,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Select/HMO/PPO,,1070.98,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Select/HMO/PPO,,1989.28,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Select/HMO/PPO,,1989.28,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1530.13,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1530.13,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Select/HMO/PPO,,382.53,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Select/HMO/PPO,,382.53,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1530.13,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,1530.13,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,BCBS NC,Blue Select/HMO/PPO,,738.14,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2379.03,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,2379.03,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Select/HMO/PPO,,220.41,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,BCBS NC,Blue Select/HMO/PPO,,8066.22,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,1219.77,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,1219.77,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,121.87,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,626.54,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,626.54,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,626.54,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,626.54,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Select/HMO/PPO,,4643.97,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Select/HMO/PPO,,4643.97,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Select/HMO/PPO,,7740.04,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Select/HMO/PPO,,7740.04,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Select/HMO/PPO,,2786.27,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Select/HMO/PPO,,2786.27,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Select/HMO/PPO,,6424.22,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Select/HMO/PPO,,6424.22,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Select/HMO/PPO,,2583.62,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Select/HMO/PPO,,2583.62,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Select/HMO/PPO,,6517.77,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Select/HMO/PPO,,6517.77,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Select/HMO/PPO,,5871.80,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Select/HMO/PPO,,5871.80,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Select/HMO/PPO,,7809.72,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Select/HMO/PPO,,7809.72,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,BCBS NC,Blue Select/HMO/PPO,,3422.25,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Select/HMO/PPO,,6468.08,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Select/HMO/PPO,,6468.08,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Select/HMO/PPO,,5886.23,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Select/HMO/PPO,,5886.23,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Select/HMO/PPO,,6673.50,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Select/HMO/PPO,,6673.50,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Select/HMO/PPO,,2635.26,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Select/HMO/PPO,,2635.26,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Select/HMO/PPO,,5680.81,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Select/HMO/PPO,,5680.81,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Select/HMO/PPO,,4893.81,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Select/HMO/PPO,,4893.81,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,BCBS NC,Blue Select/HMO/PPO,,5715.23,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LM,4496.84,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,RI,4496.84,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,RC,4496.84,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LD,4496.84,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LC,4496.84,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LC,2319.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,RI,2319.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,RC,2319.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LD,2319.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LC,2319.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LM,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RI,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RC,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LD,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LC,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LM,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RI,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RC,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LD,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LC,3985.78,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LM,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RI,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RC,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LD,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LC,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LM,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RI,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RC,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LD,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LC,5948.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LM,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RI,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RC,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LD,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LC,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RC,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LD,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LC,6305.68,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11243.36,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,11243.36,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Select/HMO/PPO,,6424.50,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Select/HMO/PPO,,6424.50,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Select/HMO/PPO,,6603.27,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Select/HMO/PPO,,6603.27,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LM,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RI,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RC,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LD,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LC,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LM,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RI,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RC,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LD,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LC,6900.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,7198.17,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,7198.17,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,7198.17,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,7198.17,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,7198.17,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,7198.17,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,BCBS NC,Blue Select/HMO/PPO,,109.10,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,BCBS NC,Blue Select/HMO/PPO,,461.93,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,517.72,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,117.15,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,BCBS NC,Blue Select/HMO/PPO,,701.50,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,BCBS NC,Blue Select/HMO/PPO,,273.71,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,BCBS NC,Blue Select/HMO/PPO,,3212.39,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,2971.99,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,2971.99,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,BCBS NC,Blue Select/HMO/PPO,,2834.30,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,BCBS NC,Blue Select/HMO/PPO,,1179.80,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,BCBS NC,Blue Select/HMO/PPO,,2045.08,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,BCBS NC,Blue Select/HMO/PPO,,3023.90,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,BCBS NC,Blue Select/HMO/PPO,,2685.22,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,BCBS NC,Blue Select/HMO/PPO,,2866.50,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,BCBS NC,Blue Select/HMO/PPO,,1261.14,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,BCBS NC,Blue Select/HMO/PPO,,2949.22,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,BCBS NC,Blue Select/HMO/PPO,,3678.48,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,BCBS NC,Blue Select/HMO/PPO,,3313.71,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,BCBS NC,Blue Select/HMO/PPO,,3534.96,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,BCBS NC,Blue Select/HMO/PPO,,3594.92,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,BCBS NC,Blue Select/HMO/PPO,,4407.46,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,BCBS NC,Blue Select/HMO/PPO,,1881.57,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,56.35,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,26.93,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,BCBS NC,Blue Select/HMO/PPO,,417.23,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,BCBS NC,Blue Select/HMO/PPO,,1145.93,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,BCBS NC,Blue Select/HMO/PPO,,2238.57,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Select/HMO/PPO,,134.36,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,173.78,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,59.68,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,BCBS NC,Blue Select/HMO/PPO,,2129.47,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,BCBS NC,Blue Select/HMO/PPO,,10863.32,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,BCBS NC,Blue Select/HMO/PPO,,3409.48,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,BCBS NC,Blue Select/HMO/PPO,,700.94,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,BCBS NC,Blue Select/HMO/PPO,,783.94,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,BCBS NC,Blue Select/HMO/PPO,,351.44,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,146.57,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,146.57,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,146.57,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Select/HMO/PPO,,2188.04,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Select/HMO/PPO,,2188.04,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Select/HMO/PPO,,4158.17,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Select/HMO/PPO,,4158.17,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,BCBS NC,Blue Select/HMO/PPO,,5070.92,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,BCBS NC,Blue Select/HMO/PPO,,3683.20,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,BCBS NC,Blue Select/HMO/PPO,,4185.38,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,BCBS NC,Blue Select/HMO/PPO,,5050.65,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,BCBS NC,Blue Select/HMO/PPO,,886.38,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Select/HMO/PPO,,3911.11,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Select/HMO/PPO,,3911.11,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,BCBS NC,Blue Select/HMO/PPO,,2835.68,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,BCBS NC,Blue Select/HMO/PPO,,817.25,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Select/HMO/PPO,,805.60,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Select/HMO/PPO,,805.60,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,BCBS NC,Blue Select/HMO/PPO,,5660.82,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,BCBS NC,Blue Select/HMO/PPO,,4143.18,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,BCBS NC,Blue Select/HMO/PPO,,657.08,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,BCBS NC,Blue Select/HMO/PPO,,6602.99,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,BCBS NC,Blue Select/HMO/PPO,,6807.03,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,BCBS NC,Blue Select/HMO/PPO,,7419.69,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,BCBS NC,Blue Select/HMO/PPO,,2361.82,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Select/HMO/PPO,,3164.92,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Select/HMO/PPO,,3164.92,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,BCBS NC,Blue Select/HMO/PPO,,13848.63,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,BCBS NC,Blue Select/HMO/PPO,,1596.20,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,BCBS NC,Blue Select/HMO/PPO,,1060.71,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,BCBS NC,Blue Select/HMO/PPO,,16016.96,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,732.59,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,BCBS NC,Blue Select/HMO/PPO,,3238.76,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,BCBS NC,Blue Select/HMO/PPO,,579.07,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,1162.59,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,1798.85,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,1798.85,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,897.20,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Select/HMO/PPO,,637.09,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,897.20,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,897.20,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,BCBS NC,Blue Select/HMO/PPO,,844.74,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,BCBS NC,Blue Select/HMO/PPO,,773.67,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,BCBS NC,Blue Select/HMO/PPO,,2659.41,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Select/HMO/PPO,,4227.85,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Select/HMO/PPO,,4227.85,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,BCBS NC,Blue Select/HMO/PPO,,450.82,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,BCBS NC,Blue Select/HMO/PPO,,2244.12,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,BCBS NC,Blue Select/HMO/PPO,,460.26,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,BCBS NC,Blue Select/HMO/PPO,,876.11,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,BCBS NC,Blue Select/HMO/PPO,,7062.70,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Select/HMO/PPO,,6255.44,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Select/HMO/PPO,,6255.44,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,BCBS NC,Blue Select/HMO/PPO,,839.74,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,393.64,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Select/HMO/PPO,,5590.03,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,BCBS NC,Blue Select/HMO/PPO,,6212.97,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,BCBS NC,Blue Select/HMO/PPO,,689.00,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Select/HMO/PPO,,536.05,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Select/HMO/PPO,,1540.12,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Select/HMO/PPO,,1540.12,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,BCBS NC,Blue Select/HMO/PPO,,1770.26,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,BCBS NC,Blue Select/HMO/PPO,,714.82,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,BCBS NC,Blue Select/HMO/PPO,,3808.95,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Select/HMO/PPO,,1332.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,393.64,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Select/HMO/PPO,,590.46,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,BCBS NC,Blue Select/HMO/PPO,,787.27,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,BCBS NC,Blue Select/HMO/PPO,,2211.08,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,BCBS NC,Blue Select/HMO/PPO,,5141.71,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,BCBS NC,Blue Select/HMO/PPO,,2560.58,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,BCBS NC,Blue Select/HMO/PPO,,1795.24,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,BCBS NC,Blue Select/HMO/PPO,,2075.34,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,79.95,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,393.64,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,BCBS NC,Blue Select/HMO/PPO,,2212.47,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,844.18,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,844.18,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,844.18,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,844.18,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,BCBS NC,Blue Select/HMO/PPO,,3692.36,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Select/HMO/PPO,,7384.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Select/HMO/PPO,,7384.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,BCBS NC,Blue Select/HMO/PPO,,11889.33,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,BCBS NC,Blue Select/HMO/PPO,,9705.45,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Select/HMO/PPO,,2630.54,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,BCBS NC,Blue Select/HMO/PPO,,1206.17,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,BCBS NC,Blue Select/HMO/PPO,,5942.31,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,9505.30,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,9505.30,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,9505.30,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,BCBS NC,Blue Select/HMO/PPO,,8986.74,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Select/HMO/PPO,,1878.24,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Select/HMO/PPO,,1878.24,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,29.70,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Select/HMO/PPO,,10865.82,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Select/HMO/PPO,,10865.82,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,BCBS NC,Blue Select/HMO/PPO,,13309.25,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,BCBS NC,Blue Select/HMO/PPO,,665.96,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,BCBS NC,Blue Select/HMO/PPO,,1802.73,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Select/HMO/PPO,,3008.35,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LD,953.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,RC,953.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,RI,953.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LM,953.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LD,762.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,RC,762.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,RI,762.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LM,762.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LD,654.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,RC,654.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,RI,654.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LM,654.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LD,137.41,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,RC,137.41,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,RI,137.41,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LM,137.41,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LC,953.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LC,762.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LC,654.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LC,137.41,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,BCBS NC,Blue Select/HMO/PPO,,9052.81,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,BCBS NC,Blue Select/HMO/PPO,,17138.19,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,BCBS NC,Blue Select/HMO/PPO,,3165.47,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,BCBS NC,Blue Select/HMO/PPO,,791.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,BCBS NC,Blue Select/HMO/PPO,,159.62,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,BCBS NC,Blue Select/HMO/PPO,,1116.23,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,BCBS NC,Blue Select/HMO/PPO,,917.19,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,BCBS NC,Blue Select/HMO/PPO,,358.10,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,BCBS NC,Blue Select/HMO/PPO,,433.89,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,BCBS NC,Blue Select/HMO/PPO,,321.18,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Select/HMO/PPO,,618.77,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Select/HMO/PPO,,618.77,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Select/HMO/PPO,,249.56,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Select/HMO/PPO,,201.54,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Select/HMO/PPO,,201.54,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Select/HMO/PPO,,710.10,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Select/HMO/PPO,,710.10,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,137.69,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,106.88,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,759.51,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,15.27,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Select/HMO/PPO,,379.76,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,67.46,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Select/HMO/PPO,,242.90,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,BCBS NC,Blue Select/HMO/PPO,,172.67,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,44.97,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Select/HMO/PPO,,53.58,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,BCBS NC,Blue Select/HMO/PPO,,354.22,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,79.12,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,60.52,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Select/HMO/PPO,,82.45,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,30.26,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,39.14,,,,,,,24.55,269.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Select/HMO/PPO,,1804.12,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,BCBS NC,Blue Select/HMO/PPO,,1006.02,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,BCBS NC,Blue Select/HMO/PPO,,2216.36,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Select/HMO/PPO,,723.70,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,586.01,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,586.01,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,586.01,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,BCBS NC,Blue Select/HMO/PPO,,1769.70,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,BCBS NC,Blue Select/HMO/PPO,,2343.78,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,BCBS NC,Blue Select/HMO/PPO,,2630.82,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Select/HMO/PPO,,2173.89,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,BCBS NC,Blue Select/HMO/PPO,,2817.36,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,BCBS NC,Blue Select/HMO/PPO,,3139.10,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,133.25,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,83.28,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,133.25,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,83.28,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,9.44,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,66.62,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Select/HMO/PPO,,103.82,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,BCBS NC,Blue Select/HMO/PPO,,366.43,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,BCBS NC,Blue Select/HMO/PPO,,395.58,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,BCBS NC,Blue Select/HMO/PPO,,619.60,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,81.34,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,BCBS NC,Blue Select/HMO/PPO,,186.55,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,BCBS NC,Blue Select/HMO/PPO,,28.87,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,282.04,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,48.58,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,71.62,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,53.30,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,BCBS NC,Blue Select/HMO/PPO,,877.77,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,83.84,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,82.17,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Select/HMO/PPO,,85.78,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,79.12,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,94.66,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,119.92,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Select/HMO/PPO,,171.28,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,11.66,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,19.71,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Select/HMO/PPO,,61.35,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,BCBS NC,Blue Select/HMO/PPO,,111.60,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,BCBS NC,Blue Select/HMO/PPO,,247.06,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,20.54,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Select/HMO/PPO,,73.56,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,11.10,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,BCBS NC,Blue Select/HMO/PPO,,208.20,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,BCBS NC,Blue Select/HMO/PPO,,326.18,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Select/HMO/PPO,,1113.18,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,BCBS NC,Blue Select/HMO/PPO,,339.78,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,498.01,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,BCBS NC,Blue Select/HMO/PPO,,629.87,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,136.58,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Select/HMO/PPO,,1113.18,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Select/HMO/PPO,,194.32,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,BCBS NC,Blue Select/HMO/PPO,,216.53,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,BCBS NC,Blue Select/HMO/PPO,,443.60,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,BCBS NC,Blue Select/HMO/PPO,,713.15,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,138.80,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,BCBS NC,Blue Select/HMO/PPO,,1110.40,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Select/HMO/PPO,,673.18,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Select/HMO/PPO,,499.68,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Select/HMO/PPO,,673.18,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Select/HMO/PPO,,499.68,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Select/HMO/PPO,,327.57,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Select/HMO/PPO,,327.57,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,293.42,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Select/HMO/PPO,GP,66.07,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Select/HMO/PPO,,8578.67,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Select/HMO/PPO,,4148.18,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Select/HMO/PPO,,8578.67,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Select/HMO/PPO,,4148.18,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,BCBS NC,Blue Select/HMO/PPO,,3605.19,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,BCBS NC,Blue Select/HMO/PPO,,3684.58,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,BCBS NC,Blue Select/HMO/PPO,,3764.26,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,BCBS NC,Blue Select/HMO/PPO,,3844.20,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,BCBS NC,Blue Select/HMO/PPO,,3923.88,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,BCBS NC,Blue Select/HMO/PPO,,4003.27,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,BCBS NC,Blue Select/HMO/PPO,,4082.94,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,BCBS NC,Blue Select/HMO/PPO,,4162.61,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,138.52,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Select/HMO/PPO,,68.29,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,55.52,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,207040.57,,,,,,,199000.36,360919.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,83719.34,,,,,,,80975.46,145942.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,156811.78,,,,,,,150928.76,397739.02,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,102334.14,,,,,,,98790.80,259561.38,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,76173.97,,,,,,,73754.16,132788.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,34258.16,,,,,,,33638.50,59719.92,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,95676.08,,,,,,,92418.69,166785.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,41406.78,,,,,,,40480.12,72181.64,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22680.42,,,,,,,22680.42,56375.49,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,40294.89,,,,,,,39415.99,102204.38,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31147.81,,,,,,,30661.75,79003.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21290.74,,,,,,,21228.00,54002.05,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,88788.25,,,,,,,85826.67,154778.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,43808.62,,,,,,,42778.80,76368.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,35745.36,,,,,,,35745.36,62312.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,319034.53,,,,,,,306184.44,556151.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,48961.75,,,,,,,48961.75,85351.71,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,58134.69,,,,,,,56489.61,147453.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,39110.59,,,,,,,38282.54,99200.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22718.84,,,,,,,22718.84,57624.30,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,42335.46,,,,,,,41368.91,107380.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,28901.12,,,,,,,28511.54,73305.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33591.02,,,,,,,33000.02,85200.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22970.77,,,,,,,22835.89,58263.30,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18639.19,,,,,,,18639.19,47276.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,44389.32,,,,,,,43334.56,112589.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25204.90,,,,,,,24974.06,63929.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16218.14,,,,,,,16218.14,41135.85,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33101.93,,,,,,,32531.94,83960.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15743.83,,,,,,,15743.83,39932.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12285.51,,,,,,,12285.51,31161.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,28596.73,,,,,,,28220.24,72533.05,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17661.01,,,,,,,17661.01,44795.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14353.41,,,,,,,14353.41,36406.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,24322.03,,,,,,,24129.11,61690.66,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11987.77,,,,,,,11987.77,30405.90,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8684.59,,,,,,,8684.59,22027.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,28526.55,,,,,,,28153.06,72355.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16244.00,,,,,,,16244.00,41201.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12764.25,,,,,,,12764.25,32375.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13156.55,,,,,,,13156.55,33370.41,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7234.33,,,,,,,7234.33,18349.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11280.74,,,,,,,11280.74,28612.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7532.80,,,,,,,7532.80,19106.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17163.06,,,,,,,17163.06,43532.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9571.89,,,,,,,9571.89,24278.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12629.79,,,,,,,12629.79,32034.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9167.77,,,,,,,9167.77,23253.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6795.48,,,,,,,6795.48,17236.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20369.45,,,,,,,20346.30,51665.30,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12982.19,,,,,,,12982.19,32928.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10371.27,,,,,,,10371.27,26305.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14857.27,,,,,,,14857.27,37684.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7464.10,,,,,,,7464.10,18932.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5056.35,,,,,,,5056.35,12824.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10850.76,,,,,,,10850.76,27521.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6386.19,,,,,,,6386.19,16197.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5901.53,,,,,,,5901.53,14968.71,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12299.54,,,,,,,12299.54,31196.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7580.09,,,,,,,7580.09,19226.21,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5586.81,,,,,,,5586.81,14170.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11852.57,,,,,,,11852.57,30062.98,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7615.55,,,,,,,7615.55,19316.16,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14166.49,,,,,,,14166.49,35932.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5532.13,,,,,,,5532.13,14031.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13372.28,,,,,,,13372.28,33917.59,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6616.69,,,,,,,6616.69,16782.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16886.01,,,,,,,16886.01,42829.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10312.17,,,,,,,10312.17,26155.90,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7061.45,,,,,,,7061.45,17910.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16784.80,,,,,,,16784.80,42573.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9624.35,,,,,,,9624.35,24411.30,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6757.80,,,,,,,6757.80,17140.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9987.10,,,,,,,9987.10,25331.38,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8116.46,,,,,,,8116.46,20586.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6081.80,,,,,,,6081.80,15425.94,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12974.81,,,,,,,12974.81,32909.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7557.92,,,,,,,7557.92,19170.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5883.06,,,,,,,5883.06,14921.87,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26001.33,,,,,,,25736.28,65950.04,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19055.13,,,,,,,19055.13,48331.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19055.13,,,,,,,19055.13,48331.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26683.98,,,,,,,26389.63,67681.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16954.72,,,,,,,16954.72,43004.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10065.41,,,,,,,10065.41,25530.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14309.08,,,,,,,14309.08,36293.70,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6668.41,,,,,,,6668.41,16913.82,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8281.21,,,,,,,8281.21,21004.55,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6178.58,,,,,,,6178.58,15671.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17369.93,,,,,,,17369.93,44057.26,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9995.96,,,,,,,9995.96,25353.87,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11339.84,,,,,,,11339.84,28762.49,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13358.24,,,,,,,13358.24,33881.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8015.24,,,,,,,8015.24,20329.94,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8594.46,,,,,,,8594.46,21799.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5805.49,,,,,,,5805.49,14725.11,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5900.06,,,,,,,5900.06,14964.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9775.06,,,,,,,9775.06,24793.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5672.51,,,,,,,5672.51,14387.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15627.10,,,,,,,15627.10,39636.73,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7501.04,,,,,,,7501.04,19025.71,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11031.76,,,,,,,11031.76,27981.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6547.25,,,,,,,6547.25,16606.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8929.14,,,,,,,8929.14,22647.96,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31512.04,,,,,,,31010.33,79927.46,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16113.97,,,,,,,16113.97,40871.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11794.20,,,,,,,11794.20,29914.94,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27679.88,,,,,,,27342.76,70207.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12802.67,,,,,,,12802.67,32472.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8882.59,,,,,,,8882.59,22529.90,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15643.35,,,,,,,15643.35,39677.96,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9393.84,,,,,,,9393.84,23826.64,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5888.97,,,,,,,5888.97,14936.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5552.82,,,,,,,5552.82,14084.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9837.12,,,,,,,9837.12,24950.98,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5422.79,,,,,,,5422.79,13754.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8734.09,,,,,,,8734.09,22153.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5453.82,,,,,,,5453.82,13833.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11551.14,,,,,,,11551.14,29298.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6771.10,,,,,,,6771.10,17174.29,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5105.85,,,,,,,5105.85,12950.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12683.72,,,,,,,12683.72,32171.12,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6721.60,,,,,,,6721.60,17048.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5234.40,,,,,,,5234.40,13276.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33111.54,,,,,,,32541.14,83984.45,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18647.31,,,,,,,18647.31,47297.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14142.11,,,,,,,14142.11,35870.19,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27614.13,,,,,,,27279.81,70040.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13323.52,,,,,,,13323.52,33793.91,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10094.96,,,,,,,10094.96,25604.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21989.64,,,,,,,21896.90,55774.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10148.16,,,,,,,10148.16,25739.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5947.34,,,,,,,5947.34,15084.90,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11545.23,,,,,,,11545.23,29283.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7210.69,,,,,,,7210.69,18289.26,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5577.94,,,,,,,5577.94,14147.94,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13047.21,,,,,,,13047.21,33093.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7912.55,,,,,,,7912.55,20069.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5496.67,,,,,,,5496.67,13941.82,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11302.90,,,,,,,11302.90,28668.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7861.57,,,,,,,7861.57,19940.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5810.66,,,,,,,5810.66,14738.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11514.20,,,,,,,11514.20,29204.73,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7307.47,,,,,,,7307.47,18534.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5298.67,,,,,,,5298.67,13439.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9127.14,,,,,,,9127.14,23150.16,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8183.69,,,,,,,8183.69,20757.19,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6228.08,,,,,,,6228.08,15796.98,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4743.10,,,,,,,4743.10,12030.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9710.79,,,,,,,9710.79,24630.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5953.99,,,,,,,5953.99,15101.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4643.36,,,,,,,4643.36,11777.46,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13942.63,,,,,,,13942.63,35364.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7011.95,,,,,,,7011.95,17785.18,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5291.29,,,,,,,5291.29,13420.87,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13033.17,,,,,,,13033.17,33057.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8121.63,,,,,,,8121.63,20599.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5283.16,,,,,,,5283.16,13400.26,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7175.23,,,,,,,7175.23,18199.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4949.96,,,,,,,4949.96,12555.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5965.07,,,,,,,5965.07,15129.87,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13527.43,,,,,,,13527.43,34311.11,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6952.85,,,,,,,6952.85,17635.27,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,47539.56,,,,,,,46349.51,120579.84,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20307.40,,,,,,,20286.88,51507.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,83623.29,,,,,,,80883.55,212102.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,80337.85,,,,,,,77739.20,203769.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,42162.58,,,,,,,41203.47,106941.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,73562.32,,,,,,,71254.67,186584.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,72275.33,,,,,,,70022.93,183319.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,48578.32,,,,,,,47343.65,123214.55,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,48578.32,,,,,,,47343.65,123214.55,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,56727.28,,,,,,,55142.64,143883.66,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,39398.73,,,,,,,38558.31,99931.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,37237.00,,,,,,,36489.42,94448.31,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,36551.39,,,,,,,35833.26,92709.33,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23268.51,,,,,,,23120.82,59018.48,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,62280.10,,,,,,,60456.99,157967.90,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,44790.49,,,,,,,43718.51,113607.06,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,56482.74,,,,,,,54908.59,143263.40,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,40358.43,,,,,,,39476.79,102365.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,43357.22,,,,,,,42346.80,109971.70,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,30946.85,,,,,,,30469.42,78493.92,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,36361.52,,,,,,,35651.54,92227.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21059.49,,,,,,,21006.71,53415.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10227.95,,,,,,,10227.95,25942.27,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23588.41,,,,,,,23426.99,59829.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15743.09,,,,,,,15743.09,44147.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13353.81,,,,,,,13353.81,33870.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33707.01,,,,,,,33111.02,85494.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16124.31,,,,,,,16124.31,40897.87,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11041.37,,,,,,,11041.37,28005.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25771.56,,,,,,,25516.39,65367.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19176.29,,,,,,,19176.29,48638.95,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13163.20,,,,,,,13163.20,33387.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19928.39,,,,,,,19924.18,50546.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12544.09,,,,,,,12544.09,31816.95,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8069.17,,,,,,,8069.17,20466.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23213.83,,,,,,,23068.51,58879.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14939.27,,,,,,,14939.27,37892.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,24031.69,,,,,,,22172.00,60954.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13967.01,,,,,,,13967.01,35426.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12041.70,,,,,,,12041.70,30542.70,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22588.07,,,,,,,22469.61,57292.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,24680.35,,,,,,,24472.05,62599.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26731.26,,,,,,,26434.87,67801.45,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,45276.62,,,,,,,44183.77,114840.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,35172.79,,,,,,,34513.86,89212.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,50813.93,,,,,,,49483.25,128884.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31201.00,,,,,,,30712.64,79138.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,38981.30,,,,,,,38158.82,98872.59,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26273.94,,,,,,,25997.21,66641.51,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18861.56,,,,,,,18861.56,47840.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,30479.19,,,,,,,30021.84,77307.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,24319.08,,,,,,,24126.28,61683.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,52679.40,,,,,,,51268.60,133616.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,44376.76,,,,,,,43322.54,112557.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,34121.48,,,,,,,33507.69,86546.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,41123.09,,,,,,,40208.61,104305.02,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26644.08,,,,,,,26351.43,67580.33,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11851.09,,,,,,,11851.09,30059.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6790.31,,,,,,,6790.31,17223.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5342.26,,,,,,,5342.26,13550.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14634.15,,,,,,,14634.15,37118.21,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5113.97,,,,,,,5113.97,12971.14,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4424.67,,,,,,,4424.67,11222.79,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16348.17,,,,,,,16348.17,41465.66,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7905.90,,,,,,,7905.90,20052.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19993.41,,,,,,,19986.40,50711.48,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12610.58,,,,,,,12610.58,31985.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6868.62,,,,,,,6868.62,17421.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9484.71,,,,,,,9484.71,24057.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6272.41,,,,,,,6272.41,15909.41,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4181.61,,,,,,,4181.61,10606.27,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11539.32,,,,,,,11539.32,29268.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4606.42,,,,,,,4606.42,11683.77,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,3362.28,,,,,,,3362.28,8528.12,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12062.39,,,,,,,12062.39,30595.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7886.69,,,,,,,7886.69,20003.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5317.14,,,,,,,5317.14,13486.46,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8840.48,,,,,,,8840.48,22423.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4973.60,,,,,,,4973.60,12615.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8791.72,,,,,,,8791.72,22299.41,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5578.68,,,,,,,5578.68,14149.82,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11642.01,,,,,,,11642.01,29528.92,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6746.72,,,,,,,6746.72,17112.45,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8895.15,,,,,,,8895.15,22561.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5435.35,,,,,,,5435.35,13786.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4182.35,,,,,,,4182.35,10608.15,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5185.64,,,,,,,5185.64,13152.90,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6439.38,,,,,,,6439.38,16332.91,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5319.36,,,,,,,5319.36,13492.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15405.46,,,,,,,15405.46,39074.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7116.86,,,,,,,7116.86,18051.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5039.35,,,,,,,5039.35,12781.87,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,49399.86,,,,,,,48129.92,125298.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17895.21,,,,,,,17895.21,45389.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,32971.91,,,,,,,32407.49,83630.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17770.36,,,,,,,17770.36,45072.92,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20101.27,,,,,,,20089.63,50985.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13025.04,,,,,,,13025.04,33036.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31970.83,,,,,,,31449.41,81091.15,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23279.59,,,,,,,23131.43,59046.59,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23718.44,,,,,,,23551.45,60159.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,36846.91,,,,,,,36116.09,93458.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18057.75,,,,,,,18057.75,45801.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11837.79,,,,,,,11837.79,30025.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33958.94,,,,,,,33352.15,86133.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17710.51,,,,,,,17710.51,44921.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12433.27,,,,,,,12433.27,31535.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26749.73,,,,,,,26452.56,67848.30,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17304.17,,,,,,,17304.17,43890.49,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12100.81,,,,,,,12100.81,30692.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26381.81,,,,,,,26100.45,66915.10,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15579.08,,,,,,,15579.08,39514.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11340.58,,,,,,,11340.58,28764.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19081.73,,,,,,,19081.73,48399.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11116.72,,,,,,,11116.72,28196.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8763.65,,,,,,,8763.65,22228.20,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16959.89,,,,,,,16959.89,43017.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9669.41,,,,,,,9669.41,24525.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6431.99,,,,,,,6431.99,16314.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18410.16,,,,,,,18410.16,46695.71,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11263.01,,,,,,,11263.01,28567.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8627.71,,,,,,,8627.71,21883.40,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21439.98,,,,,,,21370.84,54380.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12429.57,,,,,,,12429.57,31526.49,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9936.86,,,,,,,9936.86,25203.96,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,32454.01,,,,,,,31911.85,82316.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17180.79,,,,,,,17180.79,43577.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10327.69,,,,,,,10327.69,26195.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25404.38,,,,,,,25164.98,64435.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17836.85,,,,,,,17836.85,45241.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11760.96,,,,,,,11760.96,29830.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7389.48,,,,,,,7389.48,18742.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5177.51,,,,,,,5177.51,13132.29,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13099.66,,,,,,,13099.66,33226.12,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7543.15,,,,,,,7543.15,19132.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5374.03,,,,,,,5374.03,13630.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15800.72,,,,,,,15800.72,40077.10,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8936.52,,,,,,,8936.52,22666.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6828.73,,,,,,,6828.73,17320.46,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13505.26,,,,,,,13505.26,34254.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7245.41,,,,,,,7245.41,18377.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4657.40,,,,,,,4657.40,11813.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14496.73,,,,,,,14496.73,36769.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8004.90,,,,,,,8004.90,20303.71,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5914.83,,,,,,,5914.83,15002.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10200.61,,,,,,,10200.61,25872.94,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6315.26,,,,,,,6315.26,16018.10,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11690.03,,,,,,,11690.03,29650.72,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7212.90,,,,,,,7212.90,18294.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5033.44,,,,,,,5033.44,12766.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10910.60,,,,,,,10910.60,27673.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5835.04,,,,,,,5835.04,14800.06,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4019.07,,,,,,,4019.07,10194.02,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9370.20,,,,,,,9370.20,23766.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5759.68,,,,,,,5759.68,14608.92,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11815.63,,,,,,,11815.63,29969.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6912.95,,,,,,,6912.95,17534.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4794.81,,,,,,,4794.81,12161.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17693.52,,,,,,,17693.52,44878.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11182.48,,,,,,,11182.48,28363.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8457.04,,,,,,,8457.04,21450.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,29703.45,,,,,,,29279.42,75340.15,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,40416.05,,,,,,,39531.94,102511.70,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21426.68,,,,,,,21358.11,54346.85,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16398.40,,,,,,,16398.40,41593.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26342.65,,,,,,,26062.95,66815.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16085.89,,,,,,,16085.89,40800.42,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11729.93,,,,,,,11729.93,29751.91,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,24404.78,,,,,,,24208.31,61900.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15533.27,,,,,,,15533.27,39398.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12267.77,,,,,,,12267.77,31116.11,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26320.49,,,,,,,26041.75,66759.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15268.78,,,,,,,15268.78,38727.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10072.06,,,,,,,10072.06,25546.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17630.72,,,,,,,17630.72,44718.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12497.54,,,,,,,12497.54,31698.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10090.53,,,,,,,10090.53,25593.73,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25171.65,,,,,,,24942.24,63845.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12836.65,,,,,,,12836.65,32559.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10339.51,,,,,,,10339.51,26225.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,30682.36,,,,,,,30216.30,77823.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16164.21,,,,,,,16164.21,40999.06,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11084.22,,,,,,,11084.22,28114.12,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,81424.63,,,,,,,78779.31,206526.27,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,53331.02,,,,,,,51892.24,135269.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,41535.34,,,,,,,40603.15,105350.66,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,66562.92,,,,,,,64555.88,168830.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,42607.33,,,,,,,41629.10,108069.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14541.06,,,,,,,14541.06,36882.10,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7803.21,,,,,,,7803.21,19792.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5263.95,,,,,,,5263.95,13351.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13569.54,,,,,,,13569.54,34417.92,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8356.57,,,,,,,8356.57,21195.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6304.18,,,,,,,6304.18,15989.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12043.92,,,,,,,12043.92,30548.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6214.79,,,,,,,6214.79,15763.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4590.90,,,,,,,4590.90,11644.41,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13259.24,,,,,,,13259.24,33630.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7131.64,,,,,,,7131.64,18088.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5169.38,,,,,,,5169.38,13111.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12344.61,,,,,,,12344.61,31311.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8085.43,,,,,,,8085.43,20507.96,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6112.09,,,,,,,6112.09,15502.77,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,49363.66,,,,,,,48095.26,125206.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31331.03,,,,,,,30837.10,79468.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,39375.08,,,,,,,38535.67,99871.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23866.20,,,,,,,23692.85,60534.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,62084.32,,,,,,,60269.61,157471.31,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,44055.38,,,,,,,43014.97,111742.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,30827.17,,,,,,,30354.87,78190.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,39604.11,,,,,,,39604.11,100452.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19652.08,,,,,,,19652.08,49845.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,42107.91,,,,,,,41151.13,106802.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23011.40,,,,,,,22874.77,58366.36,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13473.50,,,,,,,13473.50,34174.31,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,38457.50,,,,,,,32841.00,97543.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26054.52,,,,,,,25787.19,66084.96,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20302.22,,,,,,,20281.95,51494.77,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22409.28,,,,,,,22298.52,56839.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18490.00,,,,,,,14490.34,36145.66,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,35674.44,,,,,,,34993.95,90485.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21765.79,,,,,,,21682.65,55206.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18036.32,,,,,,,18036.32,45747.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31715.95,,,,,,,31205.47,80444.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16812.87,,,,,,,16812.87,42644.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8719.32,,,,,,,8719.32,22115.77,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25522.58,,,,,,,25278.10,64735.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18168.57,,,,,,,18168.57,46082.95,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13733.55,,,,,,,13733.55,34833.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21516.07,,,,,,,21443.67,54573.59,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15474.17,,,,,,,15474.17,39248.84,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12049.83,,,,,,,12049.83,30563.31,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20478.80,,,,,,,20450.94,51942.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23841.81,,,,,,,23669.52,60472.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15449.05,,,,,,,15449.05,39185.12,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11571.09,,,,,,,11571.09,29349.02,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11256.36,,,,,,,11256.36,28550.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8250.92,,,,,,,8250.92,20927.72,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27125.78,,,,,,,26812.44,68802.11,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18736.71,,,,,,,18736.71,47523.98,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14824.02,,,,,,,14824.02,37599.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26786.67,,,,,,,26487.90,67941.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13327.21,,,,,,,13327.21,33803.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8508.76,,,,,,,8508.76,21581.71,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22288.12,,,,,,,22182.53,56531.82,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14885.34,,,,,,,14885.34,37755.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23381.54,,,,,,,23229.03,59305.19,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12914.96,,,,,,,12914.96,32757.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9943.51,,,,,,,9943.51,25220.82,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20620.65,,,,,,,20586.69,52302.42,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13809.65,,,,,,,13809.65,35026.94,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13245.21,,,,,,,13245.21,33595.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8862.64,,,,,,,8862.64,22479.30,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13345.68,,,,,,,13345.68,33850.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11188.39,,,,,,,11188.39,28378.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22315.45,,,,,,,22208.72,56601.15,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15362.61,,,,,,,15362.61,38965.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12230.10,,,,,,,12230.10,31020.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11630.93,,,,,,,11630.93,29500.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7552.75,,,,,,,7552.75,19156.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23544.82,,,,,,,23385.28,59719.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15353.00,,,,,,,15353.00,38941.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11353.14,,,,,,,11353.14,28796.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27611.17,,,,,,,27276.98,70033.26,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14777.48,,,,,,,14777.48,37481.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11036.93,,,,,,,11036.93,27994.19,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21205.04,,,,,,,21145.99,53784.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15645.57,,,,,,,15645.57,39683.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11582.17,,,,,,,11582.17,29377.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5955.47,,,,,,,5955.47,15105.51,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9471.42,,,,,,,9471.42,24023.40,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5966.55,,,,,,,5966.55,15133.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7050.37,,,,,,,7050.37,17882.63,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5321.58,,,,,,,5321.58,13497.70,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14552.14,,,,,,,14552.14,36910.21,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9577.06,,,,,,,9577.06,24291.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5699.84,,,,,,,5699.84,14457.14,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13050.90,,,,,,,13050.90,33102.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7594.86,,,,,,,7594.86,19263.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5574.98,,,,,,,5574.98,14140.45,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18334.80,,,,,,,18334.80,46504.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8521.32,,,,,,,8521.32,21613.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6177.85,,,,,,,6177.85,15669.55,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14265.49,,,,,,,14265.49,36183.14,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8918.79,,,,,,,8918.79,22621.72,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6457.85,,,,,,,6457.85,16379.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12383.03,,,,,,,12383.03,31408.44,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7102.08,,,,,,,7102.08,18013.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9577.06,,,,,,,9577.06,24291.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6132.78,,,,,,,6132.78,15555.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9765.46,,,,,,,9765.46,24769.21,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6136.47,,,,,,,6136.47,15564.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10985.22,,,,,,,10985.22,27863.02,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6598.96,,,,,,,6598.96,16737.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13777.88,,,,,,,13777.88,34946.36,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8319.63,,,,,,,8319.63,21101.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5939.21,,,,,,,5939.21,15064.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10526.42,,,,,,,10526.42,26699.33,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6615.95,,,,,,,6615.95,16780.77,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11404.12,,,,,,,11404.12,28925.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7198.87,,,,,,,7198.87,18259.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5535.83,,,,,,,5535.83,14041.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21728.85,,,,,,,21647.31,55113.27,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12482.03,,,,,,,12482.03,31659.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8468.86,,,,,,,8468.86,21480.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,48401.74,,,,,,,47174.67,122766.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25646.70,,,,,,,25396.90,65050.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12069.04,,,,,,,12069.04,30612.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,36210.07,,,,,,,35506.60,91843.59,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19583.37,,,,,,,19583.37,49671.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11868.08,,,,,,,11868.08,30102.33,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23926.04,,,,,,,23750.13,60686.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12766.46,,,,,,,12766.46,32380.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10661.62,,,,,,,10661.62,27042.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14233.72,,,,,,,14233.72,36102.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12739.87,,,,,,,12739.87,32313.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15815.49,,,,,,,15815.49,40114.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14252.19,,,,,,,14252.19,36149.40,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14298.00,,,,,,,14298.00,36265.59,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8764.38,,,,,,,8764.38,22230.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6403.92,,,,,,,6403.92,16242.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15667.73,,,,,,,15667.73,39739.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7997.51,,,,,,,7997.51,20284.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12316.53,,,,,,,12316.53,31239.79,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8358.04,,,,,,,8358.04,21199.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5416.88,,,,,,,5416.88,13739.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7695.34,,,,,,,7695.34,19518.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4469.74,,,,,,,4469.74,11337.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10500.56,,,,,,,10500.56,26633.74,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6434.21,,,,,,,6434.21,16319.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10875.87,,,,,,,10875.87,27585.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6767.41,,,,,,,6767.41,17164.92,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11179.52,,,,,,,11179.52,28355.85,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6696.48,,,,,,,6696.48,16985.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16193.02,,,,,,,16193.02,41072.14,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10338.03,,,,,,,10338.03,26221.48,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25764.91,,,,,,,25510.02,65350.39,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13817.78,,,,,,,13817.78,35047.55,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10478.40,,,,,,,10478.40,26577.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16490.00,,,,,,,16490.00,54106.99,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11823.02,,,,,,,11823.02,35030.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11144.06,,,,,,,11144.06,35030.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26295.37,,,,,,,26017.71,66695.85,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13253.33,,,,,,,13253.33,33615.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9249.04,,,,,,,9249.04,23459.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22312.50,,,,,,,22205.88,56593.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11077.57,,,,,,,11077.57,28097.26,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9813.48,,,,,,,9813.48,24891.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27533.60,,,,,,,27202.76,69836.51,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16096.97,,,,,,,16096.97,40828.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10782.79,,,,,,,10782.79,27349.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10614.34,,,,,,,10614.34,26922.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6621.13,,,,,,,6621.13,16793.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4589.43,,,,,,,4589.43,11640.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9867.41,,,,,,,9867.41,25027.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5749.34,,,,,,,5749.34,14582.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10506.47,,,,,,,10506.47,26648.73,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12161.39,,,,,,,12161.39,30846.27,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7572.70,,,,,,,7572.70,19207.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5676.20,,,,,,,5676.20,14397.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,34733.94,,,,,,,34093.86,60549.33,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27378.45,,,,,,,27054.26,47727.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23859.55,,,,,,,23686.49,41592.73,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,38391.00,,,,,,,37593.86,97375.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20681.23,,,,,,,20644.67,52456.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15637.44,,,,,,,15637.44,39662.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23521.91,,,,,,,23363.36,59661.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13520.04,,,,,,,13520.04,34292.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11464.70,,,,,,,11464.70,29079.18,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18772.17,,,,,,,18772.17,47613.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9764.72,,,,,,,9764.72,24767.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7649.54,,,,,,,7649.54,19402.36,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,22618.36,,,,,,,22498.61,57369.45,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11231.24,,,,,,,11231.24,28487.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7734.50,,,,,,,7734.50,19617.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23059.43,,,,,,,22920.74,58488.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12923.83,,,,,,,12923.83,32780.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8172.61,,,,,,,8172.61,20729.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21572.96,,,,,,,21498.11,54717.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11466.18,,,,,,,11466.18,29082.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7220.29,,,,,,,7220.29,18313.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13261.46,,,,,,,13261.46,33636.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7975.35,,,,,,,7975.35,20228.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31041.42,,,,,,,30559.94,78733.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17277.58,,,,,,,17277.58,43823.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12126.66,,,,,,,12126.66,30758.19,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10941.63,,,,,,,10941.63,27752.46,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6470.41,,,,,,,6470.41,16411.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4435.02,,,,,,,4435.02,11249.02,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13325.74,,,,,,,13325.74,33799.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7741.15,,,,,,,7741.15,19634.72,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5838.74,,,,,,,5838.74,14809.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8572.30,,,,,,,8572.30,21742.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5980.59,,,,,,,5980.59,15169.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9933.17,,,,,,,9933.17,25194.59,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5775.20,,,,,,,5775.20,14648.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8450.39,,,,,,,8450.39,21433.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5090.33,,,,,,,5090.33,12911.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7962.79,,,,,,,7962.79,20196.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12222.71,,,,,,,12222.71,31001.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7498.82,,,,,,,7498.82,19020.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5096.98,,,,,,,5096.98,12928.04,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14778.22,,,,,,,14778.22,37483.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11334.67,,,,,,,11334.67,28749.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17192.61,,,,,,,17192.61,43607.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10352.07,,,,,,,10352.07,26257.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15395.11,,,,,,,15395.11,39048.33,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8124.58,,,,,,,8124.58,20607.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11107.12,,,,,,,11107.12,28172.21,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7812.07,,,,,,,7812.07,19814.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16529.17,,,,,,,16529.17,41924.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10867.75,,,,,,,10867.75,27565.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13967.01,,,,,,,13967.01,35426.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9922.82,,,,,,,9922.82,25168.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13370.06,,,,,,,13370.06,33911.97,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8442.27,,,,,,,8442.27,21413.06,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4519.24,,,,,,,4519.24,11462.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8645.44,,,,,,,8645.44,21928.38,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5334.14,,,,,,,5334.14,13529.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10955.67,,,,,,,10955.67,27788.06,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5993.15,,,,,,,5993.15,15201.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7821.68,,,,,,,7821.68,19838.98,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4964.74,,,,,,,4964.74,12592.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15736.44,,,,,,,15736.44,39914.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9940.55,,,,,,,9940.55,25213.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26408.41,,,,,,,26125.88,66982.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15223.71,,,,,,,15223.71,38613.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10849.28,,,,,,,10849.28,27518.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26052.30,,,,,,,26052.30,66079.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13369.32,,,,,,,13369.32,33910.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10536.03,,,,,,,10536.03,26723.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13555.50,,,,,,,13555.50,34382.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9166.29,,,,,,,9166.29,23249.48,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15138.75,,,,,,,15138.75,38398.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8403.85,,,,,,,8403.85,21315.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12833.69,,,,,,,12833.69,32551.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6202.23,,,,,,,6202.23,15731.39,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10249.37,,,,,,,10249.37,25996.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18969.43,,,,,,,18969.43,48114.26,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10903.21,,,,,,,10903.21,27655.02,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13606.48,,,,,,,13606.48,34511.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8036.67,,,,,,,8036.67,20384.28,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7096.17,,,,,,,7096.17,17998.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10578.88,,,,,,,10578.88,26832.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7232.85,,,,,,,7232.85,18345.48,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4902.68,,,,,,,4902.68,12435.20,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7443.41,,,,,,,7443.41,18879.54,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4208.20,,,,,,,4208.20,10673.73,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4433.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12484.24,,,,,,,12484.24,31665.16,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7407.95,,,,,,,7407.95,18789.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4836.92,,,,,,,4836.92,12268.42,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5268.38,,,,,,,5268.38,13362.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7209.00,,,,,,,5414.00,31619.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7209.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7209.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7209.00,,,,,,,5414.00,21243.91,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7209.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7209.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13314.65,,,,,,,1810.00,33771.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,43910.58,,,,,,,1810.00,111375.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,29987.89,,,,,,,1810.00,76061.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18094.69,,,,,,,1810.00,45895.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,30805.00,,,,,,,1810.00,78134.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,375.00,,,,,,,375.00,27656.89,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,314.00,,,,,,,314.00,3744.05,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4433.00,,,,,,,4210.00,9947.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4433.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4433.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33459.51,,,,,,,32874.17,84867.06,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20755.85,,,,,,,20716.09,52645.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14102.95,,,,,,,14102.95,35770.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,29434.53,,,,,,,29022.04,74658.05,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13733.55,,,,,,,13733.55,34833.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10018.13,,,,,,,10018.13,25410.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4433.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4433.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4433.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16311.97,,,,,,,16311.97,41373.84,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9352.47,,,,,,,9352.47,23721.70,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7732.28,,,,,,,7732.28,19612.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10374.97,,,,,,,10374.97,26315.18,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6783.66,,,,,,,6783.66,17206.15,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11268.92,,,,,,,11268.92,28582.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15712.06,,,,,,,15712.06,39852.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7491.43,,,,,,,7491.43,19001.35,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4669.22,,,,,,,4669.22,11843.05,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12470.94,,,,,,,12470.94,31631.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7788.43,,,,,,,7788.43,19754.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6352.94,,,,,,,6352.94,16113.67,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,43329.14,,,,,,,42319.93,109900.49,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16538.78,,,,,,,16538.78,41949.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8895.15,,,,,,,8895.15,22561.76,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33872.50,,,,,,,33269.41,85914.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16738.25,,,,,,,16738.25,42455.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9969.37,,,,,,,9969.37,25286.41,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,34559.59,,,,,,,33926.98,87657.29,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17075.15,,,,,,,17075.15,43309.58,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12587.67,,,,,,,12587.67,31927.51,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23346.08,,,,,,,23195.07,59215.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11118.94,,,,,,,11118.94,28202.19,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8884.07,,,,,,,8884.07,22533.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5331.18,,,,,,,5331.18,13522.06,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,3863.19,,,,,,,3863.19,9798.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,40559.38,,,,,,,39669.12,102875.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15409.89,,,,,,,15409.89,39085.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9009.67,,,,,,,9009.67,22852.21,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,35494.17,,,,,,,34821.45,90027.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15421.71,,,,,,,15421.71,39115.79,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10667.53,,,,,,,10667.53,27057.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23899.44,,,,,,,23724.68,60618.79,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12052.78,,,,,,,12052.78,30570.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7464.84,,,,,,,7464.84,18933.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14737.58,,,,,,,14737.58,37380.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8994.15,,,,,,,8994.15,22812.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6291.62,,,,,,,6291.62,15958.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19153.39,,,,,,,19153.39,48580.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9664.98,,,,,,,9664.98,24514.36,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6275.37,,,,,,,6275.37,15916.91,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20017.79,,,,,,,20009.72,50773.32,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,63976.39,,,,,,,62080.42,162270.37,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,36486.38,,,,,,,35771.03,92544.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14761.96,,,,,,,14761.96,37442.40,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11061.31,,,,,,,11061.31,28056.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,33605.80,,,,,,,33014.15,85238.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15821.40,,,,,,,15821.40,40129.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10290.75,,,,,,,10290.75,26101.55,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13473.50,,,,,,,13473.50,34174.31,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7372.49,,,,,,,7372.49,18699.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6558.33,,,,,,,6558.33,16634.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11069.44,,,,,,,11069.44,28076.64,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6424.60,,,,,,,6424.60,16295.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15464.56,,,,,,,15464.56,39224.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7617.77,,,,,,,7617.77,19321.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5391.02,,,,,,,5391.02,13673.85,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,51064.38,,,,,,,49722.96,129520.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14351.19,,,,,,,14351.19,36400.51,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7560.14,,,,,,,7560.14,19175.62,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,28553.88,,,,,,,823.98,72424.36,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7093.96,,,,,,,823.98,17993.19,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6951.37,,,,,,,823.98,17631.53,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7933.23,,,,,,,823.98,20121.94,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14527.02,,,,,,,823.98,36846.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11886.55,,,,,,,823.98,30149.18,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10319.56,,,,,,,823.98,26174.64,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15332.32,,,,,,,823.98,38889.05,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7911.81,,,,,,,823.98,20067.60,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4557.66,,,,,,,823.98,11560.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10458.45,,,,,,,823.98,26526.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12892.80,,,,,,,823.98,32701.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6522.13,,,,,,,823.98,16542.79,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31004.48,,,,,,,30524.57,78640.09,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14144.33,,,,,,,14144.33,35875.82,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8641.00,,,,,,,8641.00,21917.13,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27136.86,,,,,,,26823.05,68830.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,10578.14,,,,,,,10578.14,26830.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13020.61,,,,,,,13020.61,33025.61,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,28364.75,,,,,,,27998.19,71944.64,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14740.54,,,,,,,14740.54,37388.05,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9698.23,,,,,,,9698.23,24598.69,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12076.42,,,,,,,12076.42,30630.77,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6542.07,,,,,,,6542.07,16593.38,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12423.66,,,,,,,12423.66,31511.50,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4922.62,,,,,,,4922.62,12485.80,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11587.34,,,,,,,11587.34,29390.25,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6332.25,,,,,,,6332.25,16061.20,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,13525.95,,,,,,,13525.95,34307.36,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7404.99,,,,,,,7404.99,18782.10,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5085.90,,,,,,,5085.90,12899.93,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12924.57,,,,,,,12924.57,32782.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,7518.77,,,,,,,7518.77,19070.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,136162.32,,,,,,,136162.32,345363.52,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,52991.91,,,,,,,51567.69,134409.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,23795.27,,,,,,,23624.98,60354.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,28197.78,,,,,,,28197.78,71521.14,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,16331.91,,,,,,,16331.91,41424.43,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,15219.28,,,,,,,15219.28,38602.34,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,26807.36,,,,,,,26507.70,67994.46,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,17265.02,,,,,,,17265.02,43791.17,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,14980.65,,,,,,,14980.65,37997.07,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11441.06,,,,,,,526.87,29019.22,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8472.56,,,,,,,526.87,21489.89,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9378.33,,,,,,,9378.33,23787.29,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,5914.09,,,,,,,5914.09,15000.57,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8789.50,,,,,,,8789.50,22293.79,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4637.45,,,,,,,4637.45,11762.47,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,4107.73,,,,,,,4107.73,10418.88,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,49729.37,,,,,,,48445.28,126134.08,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,27801.04,,,,,,,27458.71,70514.86,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,56295.82,,,,,,,54729.71,142789.31,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,31132.29,,,,,,,30646.88,78964.27,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21751.01,,,,,,,21668.51,55169.49,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,20197.31,,,,,,,20181.55,51228.68,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,11322.85,,,,,,,11322.85,28719.39,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6948.41,,,,,,,6948.41,17624.03,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,45224.16,,,,,,,44133.55,114707.04,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,19485.11,,,,,,,19485.11,49422.24,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,21321.77,,,,,,,21257.70,54080.75,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9567.46,,,,,,,9567.46,24267.01,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,6608.57,,,,,,,6608.57,16762.04,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,9365.03,,,,,,,9365.03,23753.56,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,34663.02,,,,,,,34025.97,87919.64,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,18163.40,,,,,,,18163.40,46069.83,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12663.03,,,,,,,12663.03,32118.65,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,25329.02,,,,,,,25092.85,64244.79,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,12142.92,,,,,,,12142.92,30799.42,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Individual,,8859.69,,,,,,,8859.69,22471.81,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,BCBS NC,Blue Value Individual,,0.04159,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Individual,,38.62,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Value Individual,,7.43,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,28.22,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,16.04,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Individual,,36.90,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Individual,,36.54,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,BCBS NC,Blue Value Individual,,6.56,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,28.50,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Value Individual,,42.19,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Value Individual,,11756.25,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Value Individual,,5051.89,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Individual,,0.30300,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Value Individual,,570.13,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Value Individual,,2154.57,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Value Individual,,515.17,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Value Individual,,978.94,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Value Individual,,11949.36,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Value Individual,,3718.80,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Value Individual,,3303.75,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Value Individual,,4654.07,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Value Individual,,9381.82,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Value Individual,,784.05,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Value Individual,,3302.86,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Value Individual,,4766.08,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Value Individual,,800.98,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Value Individual,,2485.54,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Value Individual,,2650.13,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Value Individual,,3350.40,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Individual,,39.60,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Individual,,135.18,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Individual,,270.66,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,BCBS NC,Blue Value Individual,,9.29,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,BCBS NC,Blue Value Individual,,6.04,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,BCBS NC,Blue Value Individual,,82.88,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,BCBS NC,Blue Value Individual,,6.43,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,BCBS NC,Blue Value Individual,,0.00891,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,BCBS NC,Blue Value Individual,,6.36,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,BCBS NC,Blue Value Individual,,12.07,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,BCBS NC,Blue Value Individual,,6.05,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,BCBS NC,Blue Value Individual,,5.91,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Individual,,296.40,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.90,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Value Individual,,19.39,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,BCBS NC,Blue Value Individual,,53.46,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Value Individual,,4603.56,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,BCBS NC,Blue Value Individual,,1.88,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Individual,,54.60,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Individual,,59.42,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Individual,,60.00,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,BCBS NC,Blue Value Individual,,8.81,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Individual,,366.92,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Individual,,311.36,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Individual,,210.05,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Individual,,163.41,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Individual,,131.32,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Individual,,138.45,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Individual,,370.50,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Individual,,314.40,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Individual,,212.10,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Individual,,165.00,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Individual,,132.60,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Individual,,139.80,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,BCBS NC,Blue Value Individual,,8.16,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Individual,,169.64,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Individual,,77.84,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Value Individual,,733.54,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Individual,,207.38,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Individual,,209.40,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,185.98,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,187.80,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Individual,,182.72,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Individual,,184.50,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,130.43,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,131.70,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Individual,,118.54,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Individual,,119.70,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Value Individual,,708.90,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Individual,,171.30,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Individual,,78.60,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Individual,,92.99,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Individual,,93.90,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Individual,,467.93,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Individual,,472.50,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Individual,,371.97,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Individual,,375.60,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Individual,,190.44,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Individual,,192.30,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Individual,,101.01,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Individual,,102.00,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Individual,,80.81,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Individual,,81.60,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,BCBS NC,Blue Value Individual,,64.22,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Individual,,273.30,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Individual,,136.50,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Value Individual,,1541.06,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,BCBS NC,Blue Value Individual,,45.69,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Value Individual,,761.17,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Individual,,293.53,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,185.98,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.11,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,BCBS NC,Blue Value Individual,,259.11,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,BCBS NC,Blue Value Individual,,317.97,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,BCBS NC,Blue Value Individual,,0.64768,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Value Individual,,617.37,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Individual,,818.21,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Individual,,361.27,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Individual,,183.01,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Individual,,826.20,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Individual,,364.80,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Individual,,184.80,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Value Individual,,835.74,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,BCBS NC,Blue Value Individual,,0.92101,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,BCBS NC,Blue Value Individual,,2.92,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,BCBS NC,Blue Value Individual,,57.78,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,BCBS NC,Blue Value Individual,,19.74,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Individual,,36.54,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,BCBS NC,Blue Value Individual,,70.62,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,BCBS NC,Blue Value Individual,,81.38,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,BCBS NC,Blue Value Individual,,47.15,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Individual,,101.61,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Individual,,102.60,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Individual,,459.32,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Value Individual,,919.23,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Individual,,463.80,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,BCBS NC,Blue Value Individual,,98.16,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,BCBS NC,Blue Value Individual,,97.83,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,BCBS NC,Blue Value Individual,,45.50,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,BCBS NC,Blue Value Individual,,47.19,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Individual,,127.16,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Individual,,128.40,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Individual,,143.50,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Individual,,144.90,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Value Individual,,2.97,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,BCBS NC,Blue Value Individual,,0.03600,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,BCBS NC,Blue Value Individual,,0.08100,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Individual,,742.16,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Individual,,749.40,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Individual,,601.63,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Individual,,607.50,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Individual,,507.45,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Individual,,512.40,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,BCBS NC,Blue Value Individual,,95.75,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,19.31,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,19.50,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,BCBS NC,Blue Value Individual,,24.10,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,BCBS NC,Blue Value Individual,,15.90,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,BCBS NC,Blue Value Individual,,37.44,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,BCBS NC,Blue Value Individual,,9.17,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,BCBS NC,Blue Value Individual,,4.94,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,BCBS NC,Blue Value Individual,,34.70,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,BCBS NC,Blue Value Individual,,10.00,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,BCBS NC,Blue Value Individual,,28.53,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,BCBS NC,Blue Value Individual,,81.71,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,BCBS NC,Blue Value Individual,,12.66,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,BCBS NC,Blue Value Individual,,15.28,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,BCBS NC,Blue Value Individual,,49.34,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,BCBS NC,Blue Value Individual,,38.26,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,BCBS NC,Blue Value Individual,,45.81,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,BCBS NC,Blue Value Individual,,43.47,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,BCBS NC,Blue Value Individual,,7.77,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,BCBS NC,Blue Value Individual,,8.49,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,BCBS NC,Blue Value Individual,,20.22,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,BCBS NC,Blue Value Individual,,41.82,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,BCBS NC,Blue Value Individual,,0.15152,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,BCBS NC,Blue Value Individual,,7.79,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,BCBS NC,Blue Value Individual,,1.76,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,BCBS NC,Blue Value Individual,,3.16,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,BCBS NC,Blue Value Individual,,0.03268,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,BCBS NC,Blue Value Individual,,0.23768,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,BCBS NC,Blue Value Individual,,2.31,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,BCBS NC,Blue Value Individual,,0.23471,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,BCBS NC,Blue Value Individual,,0.13964,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,BCBS NC,Blue Value Individual,,0.19014,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,BCBS NC,Blue Value Individual,,495.20,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Value Individual,,0.00594,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,BCBS NC,Blue Value Individual,,0.02700,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,BCBS NC,Blue Value Individual,,0.77100,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,BCBS NC,Blue Value Individual,,7.66,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,BCBS NC,Blue Value Individual,,24.20,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,BCBS NC,Blue Value Individual,,0.02080,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,BCBS NC,Blue Value Individual,,1.26,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,BCBS NC,Blue Value Individual,,1.82,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,BCBS NC,Blue Value Individual,,0.33275,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,BCBS NC,Blue Value Individual,,0.47833,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,BCBS NC,Blue Value Individual,,0.76058,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,BCBS NC,Blue Value Individual,,0.53181,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Value Individual,,0.00594,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,BCBS NC,Blue Value Individual,,6.57,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,BCBS NC,Blue Value Individual,,327.03,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,BCBS NC,Blue Value Individual,,22.89,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,BCBS NC,Blue Value Individual,,40.08,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,BCBS NC,Blue Value Individual,,49.45,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,BCBS NC,Blue Value Individual,,5.13,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,BCBS NC,Blue Value Individual,,0.03862,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,BCBS NC,Blue Value Individual,,10.80,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Value Individual,,19.39,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,BCBS NC,Blue Value Individual,,42.75,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,BCBS NC,Blue Value Individual,,18.89,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,BCBS NC,Blue Value Individual,,74.00,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,BCBS NC,Blue Value Individual,,3.34,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,BCBS NC,Blue Value Individual,,7.57,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,BCBS NC,Blue Value Individual,,0.22282,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,BCBS NC,Blue Value Individual,,0.01188,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,BCBS NC,Blue Value Individual,,4.54,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,BCBS NC,Blue Value Individual,,3.97,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,BCBS NC,Blue Value Individual,,3.53,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,BCBS NC,Blue Value Individual,,5.26,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,BCBS NC,Blue Value Individual,,9.91,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,BCBS NC,Blue Value Individual,,16.33,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,BCBS NC,Blue Value Individual,,41.34,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,BCBS NC,Blue Value Individual,,163.02,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,BCBS NC,Blue Value Individual,,93.96,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,BCBS NC,Blue Value Individual,,110.30,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Value Individual,,24.64,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Value Individual,,19.28,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Value Individual,,19.28,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,BCBS NC,Blue Value Individual,,14.25,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Value Individual,,0.36000,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Value Individual,,870.43,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Value Individual,,5779.14,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Individual,,4.96,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Individual,,5.94,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Individual,,5.49,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Individual,,6.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Value Individual,,6.41,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,BCBS NC,Blue Value Individual,,38.16,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Value Individual,,24.99,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,BCBS NC,Blue Value Individual,,105.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,BCBS NC,Blue Value Individual,,115.67,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Value Individual,,5.82,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,BCBS NC,Blue Value Individual,,1052.92,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,BCBS NC,Blue Value Individual,,90.39,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,BCBS NC,Blue Value Individual,,13.04,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Individual,,4.88,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Individual,,4.86,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,BCBS NC,Blue Value Individual,,717.29,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Value Individual,,5.42,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,BCBS NC,Blue Value Individual,,140.10,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Individual,,5.19,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Individual,,5.05,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Individual,,4.96,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,BCBS NC,Blue Value Individual,,1550.98,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Individual,,5.05,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,BCBS NC,Blue Value Individual,,23.74,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,BCBS NC,Blue Value Individual,,10.00,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,BCBS NC,Blue Value Individual,,10.35,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,BCBS NC,Blue Value Individual,,13.96,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,BCBS NC,Blue Value Individual,,5.90,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,BCBS NC,Blue Value Individual,,7.49,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,BCBS NC,Blue Value Individual,,24.09,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,BCBS NC,Blue Value Individual,,9.72,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Value Individual,,7.14,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Value Individual,,8.61,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,BCBS NC,Blue Value Individual,,0.67500,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,BCBS NC,Blue Value Individual,,129.74,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,BCBS NC,Blue Value Individual,,222.29,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,BCBS NC,Blue Value Individual,,685.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Individual,,65.06,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Individual,,65.06,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Individual,,65.06,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Value Individual,,0.45000,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,BCBS NC,Blue Value Individual,,14.84,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,BCBS NC,Blue Value Individual,,17.27,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,BCBS NC,Blue Value Individual,,168.90,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,BCBS NC,Blue Value Individual,,6.54,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,BCBS NC,Blue Value Individual,,8.40,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,BCBS NC,Blue Value Individual,,7.39,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.36,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,BCBS NC,Blue Value Individual,,2.10,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Individual,,5.49,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,BCBS NC,Blue Value Individual,,0.78000,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Value Individual,,5.42,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Value Individual,,5.52,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,BCBS NC,Blue Value Individual,,7.95,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,BCBS NC,Blue Value Individual,,9.18,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,BCBS NC,Blue Value Individual,,7.07,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,BCBS NC,Blue Value Individual,,14.13,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,BCBS NC,Blue Value Individual,,8.72,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Value Individual,,9.61,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,BCBS NC,Blue Value Individual,,814.46,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,BCBS NC,Blue Value Individual,,5.27,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Value Individual,,4.98,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,BCBS NC,Blue Value Individual,,5.05,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,BCBS NC,Blue Value Individual,,6.34,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,BCBS NC,Blue Value Individual,,12.24,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,BCBS NC,Blue Value Individual,,551.88,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Value Individual,,4.84,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Value Individual,,5.21,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Value Individual,,5.33,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,BCBS NC,Blue Value Individual,,9.82,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,BCBS NC,Blue Value Individual,,74.07,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,BCBS NC,Blue Value Individual,,0.49500,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Value Individual,,6.89,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,BCBS NC,Blue Value Individual,,6.76,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,BCBS NC,Blue Value Individual,,6037.74,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,BCBS NC,Blue Value Individual,,9.60,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Individual,,0.43500,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,BCBS NC,Blue Value Individual,,47.35,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,BCBS NC,Blue Value Individual,,89.40,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Value Individual,,735.32,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,BCBS NC,Blue Value Individual,,20.89,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,BCBS NC,Blue Value Individual,,25.19,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Value Individual,,11.31,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Value Individual,,13.83,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,BCBS NC,Blue Value Individual,,114.38,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,BCBS NC,Blue Value Individual,,230.06,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Individual,,4.86,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,BCBS NC,Blue Value Individual,,15.26,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,BCBS NC,Blue Value Individual,,20.66,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,BCBS NC,Blue Value Individual,,19.80,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,BCBS NC,Blue Value Individual,,21.47,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,BCBS NC,Blue Value Individual,,11.78,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,BCBS NC,Blue Value Individual,,8.36,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,BCBS NC,Blue Value Individual,,18074.70,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Value Individual,,239.41,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,BCBS NC,Blue Value Individual,,47.05,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Value Individual,,69.34,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,BCBS NC,Blue Value Individual,,154.57,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Value Individual,,5.88,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Value Individual,,8.10,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,BCBS NC,Blue Value Individual,,8.54,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,BCBS NC,Blue Value Individual,,14.83,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,BCBS NC,Blue Value Individual,,18.18,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,BCBS NC,Blue Value Individual,,24.91,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,BCBS NC,Blue Value Individual,,31.63,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,BCBS NC,Blue Value Individual,,38.34,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,BCBS NC,Blue Value Individual,,21.05,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,BCBS NC,Blue Value Individual,,22.83,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Value Individual,,6.36,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Individual,,5.94,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,BCBS NC,Blue Value Individual,,367.04,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,BCBS NC,Blue Value Individual,,695.53,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,BCBS NC,Blue Value Individual,,2.55,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,BCBS NC,Blue Value Individual,,51.30,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Value Individual,,12.69,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Individual,,5.10,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,BCBS NC,Blue Value Individual,,6.18,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,BCBS NC,Blue Value Individual,,11.12,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,BCBS NC,Blue Value Individual,,11.18,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,BCBS NC,Blue Value Individual,,21.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,BCBS NC,Blue Value Individual,,36.54,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,BCBS NC,Blue Value Individual,,907.86,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Value Individual,,1734.01,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,BCBS NC,Blue Value Individual,,399.72,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,BCBS NC,Blue Value Individual,,6.39,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Value Individual,,19.18,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,BCBS NC,Blue Value Individual,,10.58,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,BCBS NC,Blue Value Individual,,10.01,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,BCBS NC,Blue Value Individual,,10.21,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Value Individual,,8.78,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Value Individual,,8.78,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,BCBS NC,Blue Value Individual,,719.19,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,BCBS NC,Blue Value Individual,,1924.91,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,BCBS NC,Blue Value Individual,,49.91,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,BCBS NC,Blue Value Individual,,8.27,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,BCBS NC,Blue Value Individual,,19.11,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Value Individual,,0.45000,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Individual,,0.43500,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,BCBS NC,Blue Value Individual,,8.25,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,BCBS NC,Blue Value Individual,,9.44,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,BCBS NC,Blue Value Individual,,47.22,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Value Individual,,7.04,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,BCBS NC,Blue Value Individual,,30.89,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,BCBS NC,Blue Value Individual,,175.51,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,BCBS NC,Blue Value Individual,,54.27,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,BCBS NC,Blue Value Individual,,78.09,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Value Individual,,61.56,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Individual,,339.99,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Value Individual,,5.46,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,BCBS NC,Blue Value Individual,,30.29,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,BCBS NC,Blue Value Individual,,53.55,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,BCBS NC,Blue Value Individual,,157.63,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,BCBS NC,Blue Value Individual,,0.46500,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,BCBS NC,Blue Value Individual,,30.05,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,BCBS NC,Blue Value Individual,,78.20,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,BCBS NC,Blue Value Individual,,78.20,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,BCBS NC,Blue Value Individual,,261.89,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,BCBS NC,Blue Value Individual,,17.55,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,BCBS NC,Blue Value Individual,,266.34,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,BCBS NC,Blue Value Individual,,423.28,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,BCBS NC,Blue Value Individual,,632.54,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,BCBS NC,Blue Value Individual,,1051.05,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,BCBS NC,Blue Value Individual,,2097.35,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,BCBS NC,Blue Value Individual,,3143.64,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,BCBS NC,Blue Value Individual,,503.63,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,BCBS NC,Blue Value Individual,,2449.98,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,BCBS NC,Blue Value Individual,,9554.75,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Value Individual,,1675.72,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Value Individual,,3332.70,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Value Individual,,94.73,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Value Individual,,94.73,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,BCBS NC,Blue Value Individual,,2616.52,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,BCBS NC,Blue Value Individual,,4.89,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,BCBS NC,Blue Value Individual,,24.75,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,BCBS NC,Blue Value Individual,,30.11,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,BCBS NC,Blue Value Individual,,45.74,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.90,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,BCBS NC,Blue Value Individual,,7.00,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,BCBS NC,Blue Value Individual,,5.56,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,BCBS NC,Blue Value Individual,,34.77,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,BCBS NC,Blue Value Individual,,42.17,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Individual,,5.19,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,BCBS NC,Blue Value Individual,,262.84,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Individual,,0.42000,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Value Individual,,11918.43,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Value Individual,,47428.48,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,BCBS NC,Blue Value Individual,,292.79,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,BCBS NC,Blue Value Individual,,0.60000,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,BCBS NC,Blue Value Individual,,0.52500,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,BCBS NC,Blue Value Individual,,0.51000,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,BCBS NC,Blue Value Individual,,0.48000,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,BCBS NC,Blue Value Individual,,29.90,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,BCBS NC,Blue Value Individual,,57.58,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,BCBS NC,Blue Value Individual,,3939.74,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,BCBS NC,Blue Value Individual,,31.80,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,BCBS NC,Blue Value Individual,,4.12,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,BCBS NC,Blue Value Individual,,23.10,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,BCBS NC,Blue Value Individual,,667.09,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,BCBS NC,Blue Value Individual,,25.82,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,BCBS NC,Blue Value Individual,,210.91,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,BCBS NC,Blue Value Individual,,64.14,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,BCBS NC,Blue Value Individual,,18.00,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Value Individual,,28.73,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,BCBS NC,Blue Value Individual,,54.80,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,BCBS NC,Blue Value Individual,,66.76,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,BCBS NC,Blue Value Individual,,18.07,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,BCBS NC,Blue Value Individual,,317.10,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Individual,,0.43500,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Value Individual,,14.10,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Value Individual,,0.36000,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,BCBS NC,Blue Value Individual,,0.93000,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,BCBS NC,Blue Value Individual,,24.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Value Individual,,22.98,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,BCBS NC,Blue Value Individual,,22.67,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Value Individual,,22.98,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Value Individual,,30.16,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,BCBS NC,Blue Value Individual,,31.20,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,BCBS NC,Blue Value Individual,,141.48,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Individual,,5.49,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,BCBS NC,Blue Value Individual,,84.53,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Individual,,5.79,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,BCBS NC,Blue Value Individual,,16652.02,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Value Individual,,16.50,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,BCBS NC,Blue Value Individual,,1326.43,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Value Individual,,16.50,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,BCBS NC,Blue Value Individual,,20.98,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,BCBS NC,Blue Value Individual,,8.01,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Value Individual,,0.45000,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,BCBS NC,Blue Value Individual,,9.42,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Individual,,5.79,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,BCBS NC,Blue Value Individual,,20.32,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,BCBS NC,Blue Value Individual,,8.94,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,BCBS NC,Blue Value Individual,,330.94,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,BCBS NC,Blue Value Individual,,543.69,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,BCBS NC,Blue Value Individual,,93.91,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,BCBS NC,Blue Value Individual,,140.91,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Value Individual,,28.73,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Value Individual,,28.73,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,BCBS NC,Blue Value Individual,,211.02,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,BCBS NC,Blue Value Individual,,8.62,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Value Individual,,7.04,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,BCBS NC,Blue Value Individual,,169.50,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,BCBS NC,Blue Value Individual,,359.50,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Value Individual,,27.90,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,BCBS NC,Blue Value Individual,,1.23,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,BCBS NC,Blue Value Individual,,168.99,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,BCBS NC,Blue Value Individual,,33.28,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,BCBS NC,Blue Value Individual,,49.91,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Individual,,5.08,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Individual,,5.29,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Value Individual,,61.56,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,BCBS NC,Blue Value Individual,,181.13,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Value Individual,,19.01,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,BCBS NC,Blue Value Individual,,47.34,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Value Individual,,26.10,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.90,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,BCBS NC,Blue Value Individual,,1.29,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,BCBS NC,Blue Value Individual,,6.33,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.28,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Individual,,5.05,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Value Individual,,8.62,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Value Individual,,8.62,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Individual,,5.19,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Value Individual,,9.00,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Value Individual,,10.16,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,BCBS NC,Blue Value Individual,,37.05,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,BCBS NC,Blue Value Individual,,37.47,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,BCBS NC,Blue Value Individual,,14.65,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,BCBS NC,Blue Value Individual,,18.59,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,BCBS NC,Blue Value Individual,,9.46,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Value Individual,,23.27,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,BCBS NC,Blue Value Individual,,112.90,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,BCBS NC,Blue Value Individual,,273.09,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,BCBS NC,Blue Value Individual,,50.33,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,BCBS NC,Blue Value Individual,,96.06,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Value Individual,,26.46,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,BCBS NC,Blue Value Individual,,181.22,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,BCBS NC,Blue Value Individual,,7547.69,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,BCBS NC,Blue Value Individual,,551.00,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,BCBS NC,Blue Value Individual,,6.30,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,BCBS NC,Blue Value Individual,,285.77,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,BCBS NC,Blue Value Individual,,7.49,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Value Individual,,25.39,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,BCBS NC,Blue Value Individual,,10.71,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Individual,,5.19,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,BCBS NC,Blue Value Individual,,495.36,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,BCBS NC,Blue Value Individual,,8997.73,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Individual,,5.25,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,BCBS NC,Blue Value Individual,,9.49,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,BCBS NC,Blue Value Individual,,16.00,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,BCBS NC,Blue Value Individual,,11.41,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.36,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,BCBS NC,Blue Value Individual,,14.43,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,BCBS NC,Blue Value Individual,,21.41,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,BCBS NC,Blue Value Individual,,23.22,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,BCBS NC,Blue Value Individual,,55.16,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,BCBS NC,Blue Value Individual,,6.15,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Value Individual,,6.71,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Value Individual,,6.69,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,BCBS NC,Blue Value Individual,,95.24,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,BCBS NC,Blue Value Individual,,130.13,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Value Individual,,4705.66,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Value Individual,,32.23,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,BCBS NC,Blue Value Individual,,619.05,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,BCBS NC,Blue Value Individual,,823.80,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Individual,,7.83,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,BCBS NC,Blue Value Individual,,58.86,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,BCBS NC,Blue Value Individual,,5.43,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,BCBS NC,Blue Value Individual,,0.81000,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Value Individual,,17.83,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,BCBS NC,Blue Value Individual,,9.57,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,BCBS NC,Blue Value Individual,,6.63,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,BCBS NC,Blue Value Individual,,26.01,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,BCBS NC,Blue Value Individual,,34.56,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,BCBS NC,Blue Value Individual,,0.39000,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,BCBS NC,Blue Value Individual,,14.91,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,BCBS NC,Blue Value Individual,,10.83,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,BCBS NC,Blue Value Individual,,43.96,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Value Individual,,0.46500,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Value Individual,,0.52500,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,BCBS NC,Blue Value Individual,,4.91,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,BCBS NC,Blue Value Individual,,62.12,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,BCBS NC,Blue Value Individual,,6.79,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Value Individual,,7.38,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,BCBS NC,Blue Value Individual,,9.54,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Individual,,5.19,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,BCBS NC,Blue Value Individual,,165.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,BCBS NC,Blue Value Individual,,7.96,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,BCBS NC,Blue Value Individual,,7.12,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,BCBS NC,Blue Value Individual,,8.75,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,BCBS NC,Blue Value Individual,,12.81,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,BCBS NC,Blue Value Individual,,15.88,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,BCBS NC,Blue Value Individual,,18.25,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,BCBS NC,Blue Value Individual,,53.03,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,BCBS NC,Blue Value Individual,,152.43,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,BCBS NC,Blue Value Individual,,15.78,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,BCBS NC,Blue Value Individual,,7.34,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Value Individual,,8.85,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,BCBS NC,Blue Value Individual,,18.38,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,BCBS NC,Blue Value Individual,,8.37,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,BCBS NC,Blue Value Individual,,50.57,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Value Individual,,106.14,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Value Individual,,343.46,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,BCBS NC,Blue Value Individual,,2.58,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,BCBS NC,Blue Value Individual,,4.96,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Individual,,4.89,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,BCBS NC,Blue Value Individual,,35135.55,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,BCBS NC,Blue Value Individual,,37.63,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,BCBS NC,Blue Value Individual,,225.25,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,BCBS NC,Blue Value Individual,,3.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,BCBS NC,Blue Value Individual,,4.49,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,BCBS NC,Blue Value Individual,,22.77,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,BCBS NC,Blue Value Individual,,25.20,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,BCBS NC,Blue Value Individual,,1.60,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,BCBS NC,Blue Value Individual,,5.16,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,BCBS NC,Blue Value Individual,,11.93,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,BCBS NC,Blue Value Individual,,13.28,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,BCBS NC,Blue Value Individual,,10.81,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Value Individual,,25.47,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,BCBS NC,Blue Value Individual,,25.43,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Value Individual,,25.47,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,BCBS NC,Blue Value Individual,,24.89,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,BCBS NC,Blue Value Individual,,312.65,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,BCBS NC,Blue Value Individual,,1616.98,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,BCBS NC,Blue Value Individual,,1080.49,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,BCBS NC,Blue Value Individual,,9.83,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,BCBS NC,Blue Value Individual,,4683.78,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,BCBS NC,Blue Value Individual,,0.87000,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,BCBS NC,Blue Value Individual,,6.25,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,BCBS NC,Blue Value Individual,,127.99,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,BCBS NC,Blue Value Individual,,70.26,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Value Individual,,19.28,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,BCBS NC,Blue Value Individual,,32.09,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,BCBS NC,Blue Value Individual,,3.72,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,BCBS NC,Blue Value Individual,,42.86,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,BCBS NC,Blue Value Individual,,86.94,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,BCBS NC,Blue Value Individual,,794.36,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Value Individual,,26.00,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,BCBS NC,Blue Value Individual,,2.92,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,BCBS NC,Blue Value Individual,,991.24,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,BCBS NC,Blue Value Individual,,7.09,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,BCBS NC,Blue Value Individual,,9.27,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Value Individual,,101.85,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,BCBS NC,Blue Value Individual,,243.09,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,BCBS NC,Blue Value Individual,,94.98,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,BCBS NC,Blue Value Individual,,295.47,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Individual,,7.53,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,BCBS NC,Blue Value Individual,,404.28,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,BCBS NC,Blue Value Individual,,26.00,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,BCBS NC,Blue Value Individual,,65.20,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,BCBS NC,Blue Value Individual,,11.41,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,BCBS NC,Blue Value Individual,,11.76,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,BCBS NC,Blue Value Individual,,1856.22,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Value Individual,,5.64,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Value Individual,,6.24,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,BCBS NC,Blue Value Individual,,2851.32,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,BCBS NC,Blue Value Individual,,1.16,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,BCBS NC,Blue Value Individual,,17.32,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Value Individual,,13.50,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Value Individual,,18.85,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,BCBS NC,Blue Value Individual,,77.84,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,BCBS NC,Blue Value Individual,,104.73,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,BCBS NC,Blue Value Individual,,3.25,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,BCBS NC,Blue Value Individual,,89.58,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,BCBS NC,Blue Value Individual,,0.49500,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,BCBS NC,Blue Value Individual,,0.42000,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,BCBS NC,Blue Value Individual,,0.48000,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,BCBS NC,Blue Value Individual,,13.76,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,BCBS NC,Blue Value Individual,,64.96,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,BCBS NC,Blue Value Individual,,53.82,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,BCBS NC,Blue Value Individual,,29.65,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Value Individual,,0.39000,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,BCBS NC,Blue Value Individual,,46.33,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Value Individual,,12.11,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Value Individual,,6.54,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,BCBS NC,Blue Value Individual,,19.24,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,BCBS NC,Blue Value Individual,,3558.13,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,BCBS NC,Blue Value Individual,,17.30,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,BCBS NC,Blue Value Individual,,10.16,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,BCBS NC,Blue Value Individual,,23.92,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,BCBS NC,Blue Value Individual,,7.03,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,BCBS NC,Blue Value Individual,,2887.46,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,BCBS NC,Blue Value Individual,,74.25,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,BCBS NC,Blue Value Individual,,0.39000,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,BCBS NC,Blue Value Individual,,2.21,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,BCBS NC,Blue Value Individual,,40.96,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,BCBS NC,Blue Value Individual,,5.55,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,BCBS NC,Blue Value Individual,,24.23,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,BCBS NC,Blue Value Individual,,25.80,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,BCBS NC,Blue Value Individual,,54.00,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,BCBS NC,Blue Value Individual,,29.14,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Value Individual,,5779.14,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,BCBS NC,Blue Value Individual,,47.72,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,BCBS NC,Blue Value Individual,,27.88,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,BCBS NC,Blue Value Individual,,20.93,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Value Individual,,22.09,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Value Individual,,22.09,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,BCBS NC,Blue Value Individual,,24.97,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.28,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,BCBS NC,Blue Value Individual,,3.54,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Value Individual,,5.42,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Individual,,5.29,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Value Individual,,7.23,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,BCBS NC,Blue Value Individual,,3.31,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,BCBS NC,Blue Value Individual,,2436.19,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Value Individual,,6.04,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Value Individual,,5.03,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,BCBS NC,Blue Value Individual,,18.51,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,BCBS NC,Blue Value Individual,,112.05,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,BCBS NC,Blue Value Individual,,114.38,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,BCBS NC,Blue Value Individual,,57.77,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,BCBS NC,Blue Value Individual,,20.90,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,BCBS NC,Blue Value Individual,,19.70,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,BCBS NC,Blue Value Individual,,27.30,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Value Individual,,5.03,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Value Individual,,5.03,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Value Individual,,6.67,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,BCBS NC,Blue Value Individual,,8.71,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Value Individual,,5.45,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Value Individual,,4.91,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,BCBS NC,Blue Value Individual,,33.54,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,BCBS NC,Blue Value Individual,,39.26,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Individual,,0.42000,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,BCBS NC,Blue Value Individual,,26.78,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,BCBS NC,Blue Value Individual,,44.59,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,BCBS NC,Blue Value Individual,,13.37,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,BCBS NC,Blue Value Individual,,31.29,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,BCBS NC,Blue Value Individual,,6.08,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.30,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,BCBS NC,Blue Value Individual,,103.80,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,BCBS NC,Blue Value Individual,,375.50,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,BCBS NC,Blue Value Individual,,6.92,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,BCBS NC,Blue Value Individual,,134.53,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,BCBS NC,Blue Value Individual,,269.71,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,BCBS NC,Blue Value Individual,,0.52500,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,BCBS NC,Blue Value Individual,,0.51000,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,BCBS NC,Blue Value Individual,,2.67,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.90,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Individual,,5.58,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,BCBS NC,Blue Value Individual,,72.19,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Individual,,4.88,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Individual,,4.96,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,BCBS NC,Blue Value Individual,,28.36,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,BCBS NC,Blue Value Individual,,8.41,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,BCBS NC,Blue Value Individual,,40.03,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Value Individual,,42.11,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,BCBS NC,Blue Value Individual,,13.12,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,BCBS NC,Blue Value Individual,,104.59,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.90,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,BCBS NC,Blue Value Individual,,6.22,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,BCBS NC,Blue Value Individual,,5.57,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Value Individual,,42.11,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,BCBS NC,Blue Value Individual,,48.87,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,BCBS NC,Blue Value Individual,,52.50,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,BCBS NC,Blue Value Individual,,0.96000,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Value Individual,,30.16,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,BCBS NC,Blue Value Individual,,37.20,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,BCBS NC,Blue Value Individual,,37.20,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,BCBS NC,Blue Value Individual,,27.24,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,BCBS NC,Blue Value Individual,,23.91,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,BCBS NC,Blue Value Individual,,141.30,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Value Individual,,7.86,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Value Individual,,6.96,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,BCBS NC,Blue Value Individual,,7.05,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Value Individual,,6.75,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Value Individual,,6.78,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,BCBS NC,Blue Value Individual,,4124.09,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,BCBS NC,Blue Value Individual,,91.14,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,BCBS NC,Blue Value Individual,,1.27,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Value Individual,,16.93,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Value Individual,,16.93,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,BCBS NC,Blue Value Individual,,1207.87,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,BCBS NC,Blue Value Individual,,33.59,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,BCBS NC,Blue Value Individual,,35.01,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,BCBS NC,Blue Value Individual,,5297.11,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,BCBS NC,Blue Value Individual,,8426.35,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Value Individual,,19.42,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,BCBS NC,Blue Value Individual,,1.84,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,BCBS NC,Blue Value Individual,,43.81,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,BCBS NC,Blue Value Individual,,7.51,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,BCBS NC,Blue Value Individual,,12.45,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,BCBS NC,Blue Value Individual,,7.11,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Value Individual,,5.76,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,BCBS NC,Blue Value Individual,,47.98,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.11,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Value Individual,,146.01,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,BCBS NC,Blue Value Individual,,29.09,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,BCBS NC,Blue Value Individual,,28.27,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,BCBS NC,Blue Value Individual,,1359.53,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,BCBS NC,Blue Value Individual,,45.90,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,BCBS NC,Blue Value Individual,,7.21,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,BCBS NC,Blue Value Individual,,1.44,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,BCBS NC,Blue Value Individual,,97.81,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Value Individual,,25.38,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Value Individual,,25.38,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Value Individual,,192.94,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Value Individual,,192.94,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Individual,,5.16,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,BCBS NC,Blue Value Individual,,163.39,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Value Individual,,7.75,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,BCBS NC,Blue Value Individual,,6.64,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,BCBS NC,Blue Value Individual,,0.55500,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,BCBS NC,Blue Value Individual,,25.23,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,BCBS NC,Blue Value Individual,,96.36,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,BCBS NC,Blue Value Individual,,146.62,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,BCBS NC,Blue Value Individual,,6.13,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,BCBS NC,Blue Value Individual,,107.14,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,BCBS NC,Blue Value Individual,,158.31,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Value Individual,,29.98,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Value Individual,,29.98,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,BCBS NC,Blue Value Individual,,110.59,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,BCBS NC,Blue Value Individual,,1899.18,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,BCBS NC,Blue Value Individual,,8.44,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,BCBS NC,Blue Value Individual,,2043.60,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,BCBS NC,Blue Value Individual,,9891.17,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Value Individual,,6.81,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Value Individual,,16.34,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,BCBS NC,Blue Value Individual,,23.77,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,BCBS NC,Blue Value Individual,,0.51000,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Value Individual,,26.43,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,BCBS NC,Blue Value Individual,,11698.21,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,BCBS NC,Blue Value Individual,,2409.79,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Value Individual,,26.43,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,BCBS NC,Blue Value Individual,,114.41,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Value Individual,,22.46,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Value Individual,,26.09,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,BCBS NC,Blue Value Individual,,621.92,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,BCBS NC,Blue Value Individual,,4195.01,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Individual,,5.34,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,BCBS NC,Blue Value Individual,,137.33,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,BCBS NC,Blue Value Individual,,325.32,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,BCBS NC,Blue Value Individual,,74.25,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Individual,,4.92,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.40,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Value Individual,,11.51,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Value Individual,,11.51,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,BCBS NC,Blue Value Individual,,72.34,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,BCBS NC,Blue Value Individual,,92.37,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,BCBS NC,Blue Value Individual,,122.04,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Individual,,7345.74,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,BCBS NC,Blue Value Individual,,240.46,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,BCBS NC,Blue Value Individual,,1812.30,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,BCBS NC,Blue Value Individual,,4408.15,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Individual,,4.86,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Individual,,4.88,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,BCBS NC,Blue Value Individual,,217.22,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,BCBS NC,Blue Value Individual,,11.85,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,BCBS NC,Blue Value Individual,,14.31,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,BCBS NC,Blue Value Individual,,16.36,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,BCBS NC,Blue Value Individual,,23.31,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Value Individual,,8680.64,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,BCBS NC,Blue Value Individual,,7791.45,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,BCBS NC,Blue Value Individual,,7.50,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Value Individual,,22.26,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Value Individual,,22.26,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,BCBS NC,Blue Value Individual,,32.79,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,BCBS NC,Blue Value Individual,,534.00,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Value Individual,,17.32,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Value Individual,,17.32,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,BCBS NC,Blue Value Individual,,6245.10,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,BCBS NC,Blue Value Individual,,9349.19,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,BCBS NC,Blue Value Individual,,4767.76,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,BCBS NC,Blue Value Individual,,537.02,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,BCBS NC,Blue Value Individual,,1113.22,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,BCBS NC,Blue Value Individual,,2.43,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Value Individual,,28.08,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Value Individual,,146.01,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,BCBS NC,Blue Value Individual,,1162.91,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,BCBS NC,Blue Value Individual,,24981.06,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,BCBS NC,Blue Value Individual,,587.84,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,BCBS NC,Blue Value Individual,,146.53,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,BCBS NC,Blue Value Individual,,1375.39,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,BCBS NC,Blue Value Individual,,2727.91,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,BCBS NC,Blue Value Individual,,1358.19,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Value Individual,,18.91,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Value Individual,,18.91,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Value Individual,,18.91,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,BCBS NC,Blue Value Individual,,598.18,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,BCBS NC,Blue Value Individual,,375.64,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Value Individual,,13.16,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,BCBS NC,Blue Value Individual,,38.39,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Value Individual,,14.10,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,BCBS NC,Blue Value Individual,,25.26,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Value Individual,,22.58,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Value Individual,,26.14,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,BCBS NC,Blue Value Individual,,3202.16,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,BCBS NC,Blue Value Individual,,3975.97,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Value Individual,,13.38,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Value Individual,,13.38,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,BCBS NC,Blue Value Individual,,17.25,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,BCBS NC,Blue Value Individual,,4875.07,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Value Individual,,173.44,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,BCBS NC,Blue Value Individual,,29.32,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,BCBS NC,Blue Value Individual,,44.19,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,BCBS NC,Blue Value Individual,,17.85,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,BCBS NC,Blue Value Individual,,3315.56,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,BCBS NC,Blue Value Individual,,311.77,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,BCBS NC,Blue Value Individual,,190.63,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,BCBS NC,Blue Value Individual,,4.93,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,BCBS NC,Blue Value Individual,,65.56,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,BCBS NC,Blue Value Individual,,5.75,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,BCBS NC,Blue Value Individual,,260.65,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Value Individual,,5.88,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,BCBS NC,Blue Value Individual,,1199.51,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,BCBS NC,Blue Value Individual,,492.25,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,BCBS NC,Blue Value Individual,,92.00,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,BCBS NC,Blue Value Individual,,4053.27,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,BCBS NC,Blue Value Individual,,23.11,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,BCBS NC,Blue Value Individual,,85.62,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,BCBS NC,Blue Value Individual,,163.68,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,BCBS NC,Blue Value Individual,,1380.68,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,BCBS NC,Blue Value Individual,,63.42,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,BCBS NC,Blue Value Individual,,28.70,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Value Individual,,44.45,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Value Individual,,15231.78,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Value Individual,,6.60,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,BCBS NC,Blue Value Individual,,405.05,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,BCBS NC,Blue Value Individual,,36.39,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,BCBS NC,Blue Value Individual,,824.16,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,BCBS NC,Blue Value Individual,,18.23,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,BCBS NC,Blue Value Individual,,321.61,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,BCBS NC,Blue Value Individual,,18.39,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,BCBS NC,Blue Value Individual,,4760.43,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Value Individual,,12.23,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,BCBS NC,Blue Value Individual,,56.94,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Value Individual,,19.68,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,BCBS NC,Blue Value Individual,,109.12,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,BCBS NC,Blue Value Individual,,17.08,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,BCBS NC,Blue Value Individual,,10.18,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,BCBS NC,Blue Value Individual,,11.85,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,BCBS NC,Blue Value Individual,,26702.55,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,BCBS NC,Blue Value Individual,,2819.09,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,BCBS NC,Blue Value Individual,,25774.93,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,BCBS NC,Blue Value Individual,,13.44,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,BCBS NC,Blue Value Individual,,2118.95,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,BCBS NC,Blue Value Individual,,269.01,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,BCBS NC,Blue Value Individual,,5695.87,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,BCBS NC,Blue Value Individual,,1429.11,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,BCBS NC,Blue Value Individual,,8678.89,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,BCBS NC,Blue Value Individual,,2.00,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,BCBS NC,Blue Value Individual,,21.52,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,BCBS NC,Blue Value Individual,,9907.04,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,BCBS NC,Blue Value Individual,,21.39,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,BCBS NC,Blue Value Individual,,20.61,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,BCBS NC,Blue Value Individual,,393.82,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,BCBS NC,Blue Value Individual,,1353.42,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,BCBS NC,Blue Value Individual,,14.34,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,BCBS NC,Blue Value Individual,,14435.20,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,BCBS NC,Blue Value Individual,,31345.59,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Value Individual,,5.24,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,BCBS NC,Blue Value Individual,,39.48,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Value Individual,,28.59,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Value Individual,,28.59,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Value Individual,,26.83,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Individual,,5.05,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,5.01,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Value Individual,,8.36,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Individual,,5.31,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,BCBS NC,Blue Value Individual,,59.27,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,BCBS NC,Blue Value Individual,,296.36,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,BCBS NC,Blue Value Individual,,19.83,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,BCBS NC,Blue Value Individual,,198.63,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,BCBS NC,Blue Value Individual,,1.41,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,BCBS NC,Blue Value Individual,,5.47,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,BCBS NC,Blue Value Individual,,585.96,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,BCBS NC,Blue Value Individual,,7908.83,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,BCBS NC,Blue Value Individual,,1750.11,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Value Individual,,5.73,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,BCBS NC,Blue Value Individual,,10465.23,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,BCBS NC,Blue Value Individual,,23.78,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,BCBS NC,Blue Value Individual,,72.58,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,BCBS NC,Blue Value Individual,,116.85,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Individual,,7.83,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,BCBS NC,Blue Value Individual,,17.37,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,BCBS NC,Blue Value Individual,,115.50,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,BCBS NC,Blue Value Individual,,34.58,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,BCBS NC,Blue Value Individual,,49.50,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,BCBS NC,Blue Value Individual,,64.40,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,BCBS NC,Blue Value Individual,,153.87,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,BCBS NC,Blue Value Individual,,601.18,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,BCBS NC,Blue Value Individual,,2826.65,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,BCBS NC,Blue Value Individual,,157.50,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Value Individual,,39.27,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Value Individual,,39.27,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,BCBS NC,Blue Value Individual,,145.36,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,BCBS NC,Blue Value Individual,,6333.44,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,BCBS NC,Blue Value Individual,,300.80,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,BCBS NC,Blue Value Individual,,478.43,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,BCBS NC,Blue Value Individual,,102.43,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Individual,,4.96,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,BCBS NC,Blue Value Individual,,16.77,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,BCBS NC,Blue Value Individual,,1543.80,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,BCBS NC,Blue Value Individual,,14363.25,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Value Individual,,5648.54,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,BCBS NC,Blue Value Individual,,14.43,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,BCBS NC,Blue Value Individual,,1362.97,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Value Individual,,2993.88,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Value Individual,,300.80,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,BCBS NC,Blue Value Individual,,10714.64,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,BCBS NC,Blue Value Individual,,869.91,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Value Individual,,10686.78,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,BCBS NC,Blue Value Individual,,6193.38,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,BCBS NC,Blue Value Individual,,60.90,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,BCBS NC,Blue Value Individual,,86.10,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,BCBS NC,Blue Value Individual,,124.65,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,BCBS NC,Blue Value Individual,,534.30,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,BCBS NC,Blue Value Individual,,24411.30,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,BCBS NC,Blue Value Individual,,3730.08,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,BCBS NC,Blue Value Individual,,993.81,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,BCBS NC,Blue Value Individual,,59.79,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,BCBS NC,Blue Value Individual,,14.40,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,BCBS NC,Blue Value Individual,,7.16,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Individual,,5.34,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,BCBS NC,Blue Value Individual,,1187.05,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,BCBS NC,Blue Value Individual,,5608.39,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,BCBS NC,Blue Value Individual,,5151.18,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,BCBS NC,Blue Value Individual,,15416.04,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,BCBS NC,Blue Value Individual,,3079.55,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,BCBS NC,Blue Value Individual,,1865.57,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,BCBS NC,Blue Value Individual,,32.15,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,BCBS NC,Blue Value Individual,,3753.74,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Individual,,5589.76,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,BCBS NC,Blue Value Individual,,4116.47,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,BCBS NC,Blue Value Individual,,3289.15,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,BCBS NC,Blue Value Individual,,883.58,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,BCBS NC,Blue Value Individual,,1018.74,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,BCBS NC,Blue Value Individual,,4766.85,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,BCBS NC,Blue Value Individual,,22503.13,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,BCBS NC,Blue Value Individual,,4514.67,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Value Individual,,43.06,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Value Individual,,43.06,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,BCBS NC,Blue Value Individual,,8.58,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,BCBS NC,Blue Value Individual,,2439.58,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,BCBS NC,Blue Value Individual,,5767.68,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,BCBS NC,Blue Value Individual,,1218.90,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,BCBS NC,Blue Value Individual,,44.73,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,BCBS NC,Blue Value Individual,,3432.81,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,BCBS NC,Blue Value Individual,,32690.80,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,BCBS NC,Blue Value Individual,,642.63,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Individual,,5.10,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,BCBS NC,Blue Value Individual,,12.82,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,BCBS NC,Blue Value Individual,,52.88,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Value Individual,,5.37,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,BCBS NC,Blue Value Individual,,18273.97,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,BCBS NC,Blue Value Individual,,12209.40,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,BCBS NC,Blue Value Individual,,19.50,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,BCBS NC,Blue Value Individual,,26.14,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,BCBS NC,Blue Value Individual,,1906.45,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,BCBS NC,Blue Value Individual,,5295.20,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,BCBS NC,Blue Value Individual,,29905.21,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,BCBS NC,Blue Value Individual,,8169.58,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,BCBS NC,Blue Value Individual,,302.97,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,BCBS NC,Blue Value Individual,,2003.49,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,BCBS NC,Blue Value Individual,,1664.92,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,BCBS NC,Blue Value Individual,,2738.28,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,BCBS NC,Blue Value Individual,,37105.01,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,BCBS NC,Blue Value Individual,,15808.16,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,BCBS NC,Blue Value Individual,,6081.93,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,BCBS NC,Blue Value Individual,,5057.95,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Individual,,5.25,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Individual,,5.10,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,BCBS NC,Blue Value Individual,,24.38,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,BCBS NC,Blue Value Individual,,258.30,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,BCBS NC,Blue Value Individual,,9756.33,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,BCBS NC,Blue Value Individual,,31.92,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,BCBS NC,Blue Value Individual,,124.00,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,BCBS NC,Blue Value Individual,,4854.67,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,BCBS NC,Blue Value Individual,,10824.47,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,BCBS NC,Blue Value Individual,,10.24,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.11,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Value Individual,,26.03,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Value Individual,,24.59,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Value Individual,,24.59,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,BCBS NC,Blue Value Individual,,219.69,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,BCBS NC,Blue Value Individual,,348.66,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,BCBS NC,Blue Value Individual,,20241.94,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,BCBS NC,Blue Value Individual,,22.80,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Value Individual,,787.89,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Value Individual,,340.80,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Value Individual,,340.80,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Value Individual,,787.89,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.28,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,BCBS NC,Blue Value Individual,,30.91,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,BCBS NC,Blue Value Individual,,13739.17,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,BCBS NC,Blue Value Individual,,2759.63,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,BCBS NC,Blue Value Individual,,154.49,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,BCBS NC,Blue Value Individual,,8947.88,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,BCBS NC,Blue Value Individual,,897.75,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,BCBS NC,Blue Value Individual,,24563.25,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,BCBS NC,Blue Value Individual,,19354.34,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,BCBS NC,Blue Value Individual,,3555.54,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,BCBS NC,Blue Value Individual,,7106.07,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,BCBS NC,Blue Value Individual,,8881.52,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,BCBS NC,Blue Value Individual,,20249.80,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,BCBS NC,Blue Value Individual,,279.99,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,BCBS NC,Blue Value Individual,,756.54,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,BCBS NC,Blue Value Individual,,756.55,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,BCBS NC,Blue Value Individual,,18.75,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Value Individual,,15184.29,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,BCBS NC,Blue Value Individual,,1214.41,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,BCBS NC,Blue Value Individual,,442.74,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,BCBS NC,Blue Value Individual,,62.52,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,BCBS NC,Blue Value Individual,,30.00,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,BCBS NC,Blue Value Individual,,75.91,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Value Individual,,9.27,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,BCBS NC,Blue Value Individual,,31.80,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,BCBS NC,Blue Value Individual,,20.79,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,BCBS NC,Blue Value Individual,,18862.43,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,BCBS NC,Blue Value Individual,,69.64,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Value Individual,,5648.54,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,BCBS NC,Blue Value Individual,,104.71,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,BCBS NC,Blue Value Individual,,7942.39,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Individual,,4.92,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,BCBS NC,Blue Value Individual,,3266.05,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,BCBS NC,Blue Value Individual,,13008.00,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,BCBS NC,Blue Value Individual,,262.34,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,BCBS NC,Blue Value Individual,,18195.01,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,BCBS NC,Blue Value Individual,,2173.29,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,BCBS NC,Blue Value Individual,,76.44,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,BCBS NC,Blue Value Individual,,24.14,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,BCBS NC,Blue Value Individual,,5.07,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.02,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,BCBS NC,Blue Value Individual,,4.98,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,BCBS NC,Blue Value Individual,,10465.23,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,BCBS NC,Blue Value Individual,,6475.52,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,BCBS NC,Blue Value Individual,,0.40500,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Value Individual,,0.39000,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,BCBS NC,Blue Value Individual,,108.28,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Individual,,4.88,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Value Individual,,11221.04,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,BCBS NC,Blue Value Individual,,138.18,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Individual,,4.88,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,BCBS NC,Blue Value Individual,,14.73,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,BCBS NC,Blue Value Individual,,26.75,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,5.01,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Individual,,4.86,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,BCBS NC,Blue Value Individual,,22.02,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,BCBS NC,Blue Value Individual,,97.39,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,BCBS NC,Blue Value Individual,,11.54,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Value Individual,,7.04,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,BCBS NC,Blue Value Individual,,8.18,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,BCBS NC,Blue Value Individual,,9.66,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,BCBS NC,Blue Value Individual,,0.88500,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,BCBS NC,Blue Value Individual,,57.31,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,BCBS NC,Blue Value Individual,,3.33,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,BCBS NC,Blue Value Individual,,5.87,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Individual,,4.88,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,BCBS NC,Blue Value Individual,,28.00,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.90,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Individual,,5.17,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,BCBS NC,Blue Value Individual,,8.16,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.28,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Value Individual,,7.86,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Individual,,5.49,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Individual,,5.16,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Value Individual,,5.37,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,BCBS NC,Blue Value Individual,,27.05,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,BCBS NC,Blue Value Individual,,415.93,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Individual,,5.12,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Individual,,5.58,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,BCBS NC,Blue Value Individual,,1309.88,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,BCBS NC,Blue Value Individual,,6222.60,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,BCBS NC,Blue Value Individual,,20.39,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,BCBS NC,Blue Value Individual,,1890.45,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,BCBS NC,Blue Value Individual,,25.17,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Value Individual,,5.61,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,BCBS NC,Blue Value Individual,,59.34,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Value Individual,,13.83,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Value Individual,,13.59,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Value Individual,,5.21,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Individual,,5.94,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,BCBS NC,Blue Value Individual,,1242.61,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,BCBS NC,Blue Value Individual,,24.46,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Value Individual,,5.64,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,BCBS NC,Blue Value Individual,,37.63,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,BCBS NC,Blue Value Individual,,141.87,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,BCBS NC,Blue Value Individual,,2.90,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Individual,,6.12,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,BCBS NC,Blue Value Individual,,330.67,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,BCBS NC,Blue Value Individual,,19.01,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,4.96,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.23,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,BCBS NC,Blue Value Individual,,5.96,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,BCBS NC,Blue Value Individual,,7.40,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,BCBS NC,Blue Value Individual,,53.31,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,BCBS NC,Blue Value Individual,,3.56,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Value Individual,,26.10,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,BCBS NC,Blue Value Individual,,24.52,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,BCBS NC,Blue Value Individual,,31.95,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,BCBS NC,Blue Value Individual,,32.91,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,BCBS NC,Blue Value Individual,,194.38,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,BCBS NC,Blue Value Individual,,21.33,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,BCBS NC,Blue Value Individual,,21.51,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Individual,,23.62,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,BCBS NC,Blue Value Individual,,21.38,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Value Individual,,22.95,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Value Individual,,11.91,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,BCBS NC,Blue Value Individual,,23.40,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,BCBS NC,Blue Value Individual,,611.43,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Individual,,6.12,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Individual,,6.12,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,BCBS NC,Blue Value Individual,,153.47,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Value Individual,,6.67,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Value Individual,,6.67,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,BCBS NC,Blue Value Individual,,16.17,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,BCBS NC,Blue Value Individual,,2.58,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Value Individual,,5.62,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,BCBS NC,Blue Value Individual,,42.63,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Value Individual,,5.00,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,BCBS NC,Blue Value Individual,,126.72,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,5.01,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,BCBS NC,Blue Value Individual,,15.21,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,BCBS NC,Blue Value Individual,,26.59,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,BCBS NC,Blue Value Individual,,6.42,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Individual,,5.25,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Value Individual,,7.20,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Value Individual,,5.26,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,BCBS NC,Blue Value Individual,,27.29,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Value Individual,,6.38,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Individual,,5.25,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,BCBS NC,Blue Value Individual,,0.57000,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Value Individual,,7.12,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,BCBS NC,Blue Value Individual,,6.72,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,BCBS NC,Blue Value Individual,,58.41,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,BCBS NC,Blue Value Individual,,5.10,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,BCBS NC,Blue Value Individual,,14.38,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,BCBS NC,Blue Value Individual,,8.82,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,BCBS NC,Blue Value Individual,,2.25,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Individual,,5.17,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,5.04,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,BCBS NC,Blue Value Individual,,6.22,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,BCBS NC,Blue Value Individual,,24.18,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,BCBS NC,Blue Value Individual,,1.00,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,BCBS NC,Blue Value Individual,,4.32,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Individual,,4.89,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Individual,,5.08,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Value Individual,,6.75,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Value Individual,,0.39000,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,BCBS NC,Blue Value Individual,,9.78,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,BCBS NC,Blue Value Individual,,23.72,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Value Individual,,6.87,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Value Individual,,5.45,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Value Individual,,5.66,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,BCBS NC,Blue Value Individual,,5.97,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,BCBS NC,Blue Value Individual,,48.87,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Value Individual,,4.93,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Individual,,5.16,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,BCBS NC,Blue Value Individual,,25.06,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,BCBS NC,Blue Value Individual,,9.40,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,BCBS NC,Blue Value Individual,,2182.60,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,BCBS NC,Blue Value Individual,,8.35,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,BCBS NC,Blue Value Individual,,23.04,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,BCBS NC,Blue Value Individual,,9.51,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Individual,,5.10,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Individual,,5.05,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,BCBS NC,Blue Value Individual,,822.39,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Value Individual,,26.46,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,BCBS NC,Blue Value Individual,,11.85,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,BCBS NC,Blue Value Individual,,7.91,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,BCBS NC,Blue Value Individual,,28.86,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,BCBS NC,Blue Value Individual,,30.19,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,BCBS NC,Blue Value Individual,,43.67,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,BCBS NC,Blue Value Individual,,7.68,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,BCBS NC,Blue Value Individual,,350.43,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,BCBS NC,Blue Value Individual,,669.96,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,BCBS NC,Blue Value Individual,,1715.75,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Value Individual,,1.77,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,BCBS NC,Blue Value Individual,,665.02,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Value Individual,,5.66,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,BCBS NC,Blue Value Individual,,68.40,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Individual,,5.79,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Value Individual,,6.04,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,BCBS NC,Blue Value Individual,,79.08,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Value Individual,,6.36,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Value Individual,,5.82,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,BCBS NC,Blue Value Individual,,6.93,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Value Individual,,6.79,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Individual,,6.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,BCBS NC,Blue Value Individual,,7.77,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,BCBS NC,Blue Value Individual,,30.36,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,BCBS NC,Blue Value Individual,,182.12,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Value Individual,,53.73,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Value Individual,,53.73,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,BCBS NC,Blue Value Individual,,57.79,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,BCBS NC,Blue Value Individual,,58.13,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Value Individual,,23.40,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.36,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Value Individual,,1.11,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Value Individual,,1.11,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,BCBS NC,Blue Value Individual,,1.17,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,BCBS NC,Blue Value Individual,,10.70,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,BCBS NC,Blue Value Individual,,13.02,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Value Individual,,18.00,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,BCBS NC,Blue Value Individual,,24.63,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,BCBS NC,Blue Value Individual,,31.41,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,BCBS NC,Blue Value Individual,,66.22,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,BCBS NC,Blue Value Individual,,4.02,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Individual,,0.43500,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,BCBS NC,Blue Value Individual,,303.54,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,BCBS NC,Blue Value Individual,,2.42,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,BCBS NC,Blue Value Individual,,34.20,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,BCBS NC,Blue Value Individual,,6.95,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,BCBS NC,Blue Value Individual,,7.95,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Value Individual,,9.00,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,BCBS NC,Blue Value Individual,,225.79,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Value Individual,,5.50,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,BCBS NC,Blue Value Individual,,91.63,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Value Individual,,7.23,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Value Individual,,27.90,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,BCBS NC,Blue Value Individual,,27.69,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Value Individual,,27.09,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,BCBS NC,Blue Value Individual,,6.79,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,BCBS NC,Blue Value Individual,,6.09,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Value Individual,,5.43,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,BCBS NC,Blue Value Individual,,13.85,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,BCBS NC,Blue Value Individual,,15.45,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,BCBS NC,Blue Value Individual,,80.31,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,BCBS NC,Blue Value Individual,,8.29,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,BCBS NC,Blue Value Individual,,18.76,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,BCBS NC,Blue Value Individual,,179.75,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,BCBS NC,Blue Value Individual,,11.32,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,BCBS NC,Blue Value Individual,,18.73,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,BCBS NC,Blue Value Individual,,1045.79,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,BCBS NC,Blue Value Individual,,465.60,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,BCBS NC,Blue Value Individual,,357.74,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Individual,,5.34,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,BCBS NC,Blue Value Individual,,64.80,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,BCBS NC,Blue Value Individual,,34.58,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,BCBS NC,Blue Value Individual,,155.67,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,BCBS NC,Blue Value Individual,,207.52,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,BCBS NC,Blue Value Individual,,356.22,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,BCBS NC,Blue Value Individual,,99.77,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,BCBS NC,Blue Value Individual,,104.85,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Value Individual,,5.73,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Value Individual,,5.78,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Value Individual,,6.41,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,BCBS NC,Blue Value Individual,,8.54,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,BCBS NC,Blue Value Individual,,5.73,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,BCBS NC,Blue Value Individual,,3823.38,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,BCBS NC,Blue Value Individual,,15.57,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,BCBS NC,Blue Value Individual,,106.14,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,BCBS NC,Blue Value Individual,,19.98,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Value Individual,,5.33,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,BCBS NC,Blue Value Individual,,0.73500,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,BCBS NC,Blue Value Individual,,1.33,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Value Individual,,6.41,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,BCBS NC,Blue Value Individual,,8.13,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,BCBS NC,Blue Value Individual,,205.89,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Value Individual,,5.85,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Individual,,5.12,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Value Individual,,5.85,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,BCBS NC,Blue Value Individual,,6.48,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,BCBS NC,Blue Value Individual,,24.69,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,BCBS NC,Blue Value Individual,,110.89,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,BCBS NC,Blue Value Individual,,126.00,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,BCBS NC,Blue Value Individual,,8.51,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,BCBS NC,Blue Value Individual,,12.60,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Value Individual,,8.44,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,BCBS NC,Blue Value Individual,,15.88,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,BCBS NC,Blue Value Individual,,9.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,BCBS NC,Blue Value Individual,,7.79,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Value Individual,,0.52500,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,BCBS NC,Blue Value Individual,,35.97,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,BCBS NC,Blue Value Individual,,1.89,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,BCBS NC,Blue Value Individual,,27.93,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,BCBS NC,Blue Value Individual,,25.95,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Individual,,5.19,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,BCBS NC,Blue Value Individual,,138.17,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,BCBS NC,Blue Value Individual,,94.77,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,BCBS NC,Blue Value Individual,,250.74,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,BCBS NC,Blue Value Individual,,6.15,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Individual,,5.22,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.36,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,BCBS NC,Blue Value Individual,,79.52,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,BCBS NC,Blue Value Individual,,255.08,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,BCBS NC,Blue Value Individual,,5933.98,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,BCBS NC,Blue Value Individual,,10.14,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Value Individual,,6.41,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Value Individual,,6.41,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,BCBS NC,Blue Value Individual,,54.95,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,BCBS NC,Blue Value Individual,,34.89,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,BCBS NC,Blue Value Individual,,8.97,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,BCBS NC,Blue Value Individual,,37.60,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,BCBS NC,Blue Value Individual,,21.45,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,BCBS NC,Blue Value Individual,,57.03,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,BCBS NC,Blue Value Individual,,25.12,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,BCBS NC,Blue Value Individual,,156.39,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,BCBS NC,Blue Value Individual,,17.74,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Value Individual,,6.60,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,BCBS NC,Blue Value Individual,,8.58,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,BCBS NC,Blue Value Individual,,35.96,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Value Individual,,8680.64,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.48,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,BCBS NC,Blue Value Individual,,10.99,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,5.04,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,BCBS NC,Blue Value Individual,,6.64,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Value Individual,,6.71,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,BCBS NC,Blue Value Individual,,27.73,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,BCBS NC,Blue Value Individual,,884.78,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,BCBS NC,Blue Value Individual,,10.74,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,BCBS NC,Blue Value Individual,,38.22,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,BCBS NC,Blue Value Individual,,672.17,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,BCBS NC,Blue Value Individual,,12.66,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,BCBS NC,Blue Value Individual,,10.41,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,BCBS NC,Blue Value Individual,,8.72,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,BCBS NC,Blue Value Individual,,16.57,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,BCBS NC,Blue Value Individual,,10.86,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,BCBS NC,Blue Value Individual,,1553.92,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,BCBS NC,Blue Value Individual,,3877.66,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,BCBS NC,Blue Value Individual,,7750.52,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,BCBS NC,Blue Value Individual,,15496.29,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,5.04,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,BCBS NC,Blue Value Individual,,53.76,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,BCBS NC,Blue Value Individual,,119.88,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,BCBS NC,Blue Value Individual,,7.65,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,BCBS NC,Blue Value Individual,,15.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,BCBS NC,Blue Value Individual,,44.34,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,BCBS NC,Blue Value Individual,,93.97,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Value Individual,,5.52,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Individual,,5.34,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,BCBS NC,Blue Value Individual,,14.52,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,BCBS NC,Blue Value Individual,,15.13,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Individual,,5.10,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Value Individual,,5.38,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,BCBS NC,Blue Value Individual,,1400.05,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Individual,,5.12,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,BCBS NC,Blue Value Individual,,17.20,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,BCBS NC,Blue Value Individual,,40.35,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,BCBS NC,Blue Value Individual,,11.04,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Value Individual,,49.81,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Value Individual,,14.67,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,BCBS NC,Blue Value Individual,,6.57,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Value Individual,,6.75,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Value Individual,,6.87,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,BCBS NC,Blue Value Individual,,95.56,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,BCBS NC,Blue Value Individual,,6.45,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,BCBS NC,Blue Value Individual,,7.88,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,BCBS NC,Blue Value Individual,,11.02,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,BCBS NC,Blue Value Individual,,8.27,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,BCBS NC,Blue Value Individual,,139.51,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,BCBS NC,Blue Value Individual,,3.39,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,BCBS NC,Blue Value Individual,,0.49500,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,BCBS NC,Blue Value Individual,,307.45,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,BCBS NC,Blue Value Individual,,7.46,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,BCBS NC,Blue Value Individual,,7.44,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,BCBS NC,Blue Value Individual,,74.87,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Value Individual,,9.00,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,BCBS NC,Blue Value Individual,,9.71,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Individual,,5.31,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Individual,,5.29,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,BCBS NC,Blue Value Individual,,5.47,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,BCBS NC,Blue Value Individual,,5.89,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Value Individual,,2177.21,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,BCBS NC,Blue Value Individual,,5.24,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,BCBS NC,Blue Value Individual,,5.43,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,BCBS NC,Blue Value Individual,,6.06,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Value Individual,,5.03,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Value Individual,,26.00,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,BCBS NC,Blue Value Individual,,1856.46,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,BCBS NC,Blue Value Individual,,26.27,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Value Individual,,7.20,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Value Individual,,14.67,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,BCBS NC,Blue Value Individual,,29.07,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,BCBS NC,Blue Value Individual,,31.62,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Value Individual,,6.38,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,BCBS NC,Blue Value Individual,,0.45000,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Value Individual,,5.61,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,BCBS NC,Blue Value Individual,,20.98,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,BCBS NC,Blue Value Individual,,1.46,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Individual,,5.08,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,BCBS NC,Blue Value Individual,,8.52,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Individual,,5.05,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,BCBS NC,Blue Value Individual,,143.50,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Value Individual,,5.38,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Individual,,4.86,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,BCBS NC,Blue Value Individual,,7.08,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Value Individual,,1.29,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,BCBS NC,Blue Value Individual,,8.23,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Value Individual,,1.29,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,BCBS NC,Blue Value Individual,,7.77,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Value Individual,,5.14,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,BCBS NC,Blue Value Individual,,18.60,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,BCBS NC,Blue Value Individual,,0.52500,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Value Individual,,6.76,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,BCBS NC,Blue Value Individual,,6.92,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Value Individual,,6.76,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,BCBS NC,Blue Value Individual,,2.50,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Value Individual,,6.81,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,BCBS NC,Blue Value Individual,,4.83,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,BCBS NC,Blue Value Individual,,34.05,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,BCBS NC,Blue Value Individual,,50.33,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Value Individual,,8.36,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,BCBS NC,Blue Value Individual,,9.40,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,BCBS NC,Blue Value Individual,,5366.87,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Individual,,1175.21,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Value Individual,,9.18,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,BCBS NC,Blue Value Individual,,225.08,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Value Individual,,69.34,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,BCBS NC,Blue Value Individual,,42.71,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Value Individual,,814.23,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,BCBS NC,Blue Value Individual,,447.98,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,BCBS NC,Blue Value Individual,,1.05,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,BCBS NC,Blue Value Individual,,32.46,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,BCBS NC,Blue Value Individual,,0.48000,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Individual,,4.89,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,BCBS NC,Blue Value Individual,,8.22,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,BCBS NC,Blue Value Individual,,6.06,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,BCBS NC,Blue Value Individual,,12.17,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,BCBS NC,Blue Value Individual,,417.38,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,BCBS NC,Blue Value Individual,,18.29,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,BCBS NC,Blue Value Individual,,11.12,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Value Individual,,7.07,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,BCBS NC,Blue Value Individual,,112.08,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,BCBS NC,Blue Value Individual,,143.37,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,BCBS NC,Blue Value Individual,,99.23,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,BCBS NC,Blue Value Individual,,159.05,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,BCBS NC,Blue Value Individual,,35.28,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,BCBS NC,Blue Value Individual,,27.09,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,BCBS NC,Blue Value Individual,,4.82,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,BCBS NC,Blue Value Individual,,7.44,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,BCBS NC,Blue Value Individual,,34.49,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,BCBS NC,Blue Value Individual,,205.86,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,BCBS NC,Blue Value Individual,,482.16,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Value Individual,,5.24,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Value Individual,,5.59,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Value Individual,,20.02,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Individual,,20.93,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Individual,,20.25,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Individual,,23.62,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Individual,,20.93,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Individual,,20.25,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,BCBS NC,Blue Value Individual,,45.00,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,BCBS NC,Blue Value Individual,,22.05,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Individual,,20.93,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Individual,,20.25,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Individual,,20.25,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Value Individual,,20.02,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Value Individual,,21.60,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Individual,,20.93,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Individual,,23.62,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Value Individual,,20.02,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,BCBS NC,Blue Value Individual,,4.84,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,BCBS NC,Blue Value Individual,,307.05,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,BCBS NC,Blue Value Individual,,6.73,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.28,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,BCBS NC,Blue Value Individual,,2147.23,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,BCBS NC,Blue Value Individual,,7863.75,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,BCBS NC,Blue Value Individual,,1660.92,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,BCBS NC,Blue Value Individual,,7863.75,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,BCBS NC,Blue Value Individual,,5.67,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Value Individual,,5.76,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,BCBS NC,Blue Value Individual,,31.79,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Value Individual,,2177.21,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,BCBS NC,Blue Value Individual,,104.04,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,BCBS NC,Blue Value Individual,,369.30,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,BCBS NC,Blue Value Individual,,6.84,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,BCBS NC,Blue Value Individual,,13.86,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,BCBS NC,Blue Value Individual,,2088.79,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,BCBS NC,Blue Value Individual,,98.73,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,BCBS NC,Blue Value Individual,,91.60,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,BCBS NC,Blue Value Individual,,200.11,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Value Individual,,11918.43,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Value Individual,,47428.48,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Value Individual,,437.12,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Value Individual,,870.43,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,BCBS NC,Blue Value Individual,,7969.20,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,BCBS NC,Blue Value Individual,,95.12,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Value Individual,,86.17,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Value Individual,,93.51,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Value Individual,,86.10,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Value Individual,,125.17,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,BCBS NC,Blue Value Individual,,604.60,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,BCBS NC,Blue Value Individual,,147.06,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,BCBS NC,Blue Value Individual,,296.09,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,BCBS NC,Blue Value Individual,,6.87,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,BCBS NC,Blue Value Individual,,23.04,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,BCBS NC,Blue Value Individual,,100.24,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Value Individual,,1675.72,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Value Individual,,3332.70,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,BCBS NC,Blue Value Individual,,31.61,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Value Individual,,13.50,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Value Individual,,18.85,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,BCBS NC,Blue Value Individual,,5.66,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Value Individual,,24.96,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,BCBS NC,Blue Value Individual,,8.00,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Value Individual,,101.85,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,BCBS NC,Blue Value Individual,,18.12,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Value Individual,,22.58,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,BCBS NC,Blue Value Individual,,87.01,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Value Individual,,6.18,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Value Individual,,12.86,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Individual,,7.46,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Value Individual,,8.68,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Value Individual,,5.79,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Value Individual,,5.72,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,5.01,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,5.04,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,BCBS NC,Blue Value Individual,,30.71,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,BCBS NC,Blue Value Individual,,21.60,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Value Individual,,23.40,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,BCBS NC,Blue Value Individual,,21.42,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,BCBS NC,Blue Value Individual,,22.73,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,BCBS NC,Blue Value Individual,,21.20,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Individual,,22.50,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Value Individual,,85.12,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,BCBS NC,Blue Value Individual,,18.73,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,BCBS NC,Blue Value Individual,,32.82,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,BCBS NC,Blue Value Individual,,1.43,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Individual,,65.06,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Individual,,339.99,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,BCBS NC,Blue Value Individual,,325.86,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,BCBS NC,Blue Value Individual,,13.35,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,BCBS NC,Blue Value Individual,,13.82,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,BCBS NC,Blue Value Individual,,9.37,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,BCBS NC,Blue Value Individual,,0.84000,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,BCBS NC,Blue Value Individual,,10866.43,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,BCBS NC,Blue Value Individual,,94.52,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Individual,,65.06,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,BCBS NC,Blue Value Individual,,18.97,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,BCBS NC,Blue Value Individual,,34.32,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Value Individual,,8.24,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Individual,,3.52,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Individual,,3.52,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Individual,,3.52,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Individual,,3.52,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,BCBS NC,Blue Value Individual,,22.31,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,BCBS NC,Blue Value Individual,,32.13,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,BCBS NC,Blue Value Individual,,45.53,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,BCBS NC,Blue Value Individual,,6.49,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,BCBS NC,Blue Value Individual,,5.82,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,BCBS NC,Blue Value Individual,,17.32,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,BCBS NC,Blue Value Individual,,61.29,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Individual,,4.92,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,BCBS NC,Blue Value Individual,,15.96,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Individual,,4.86,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Value Individual,,7.18,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,BCBS NC,Blue Value Individual,,4066.38,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,BCBS NC,Blue Value Individual,,831.58,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,BCBS NC,Blue Value Individual,,23.66,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Value Individual,,14.36,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,BCBS NC,Blue Value Individual,,8.38,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,BCBS NC,Blue Value Individual,,22.86,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Value Individual,,13.59,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,BCBS NC,Blue Value Individual,,31.32,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Value Individual,,72.90,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,BCBS NC,Blue Value Individual,,18.90,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Value Individual,,72.90,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Value Individual,,8.85,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Value Individual,,173.44,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,BCBS NC,Blue Value Individual,,8.47,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.90,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.90,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,BCBS NC,Blue Value Individual,,6.14,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,BCBS NC,Blue Value Individual,,5.99,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,BCBS NC,Blue Value Individual,,6.02,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Value Individual,,7.83,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,BCBS NC,Blue Value Individual,,2.13,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,BCBS NC,Blue Value Individual,,45.68,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,BCBS NC,Blue Value Individual,,120.34,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,BCBS NC,Blue Value Individual,,46.50,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,BCBS NC,Blue Value Individual,,241.05,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,BCBS NC,Blue Value Individual,,19.67,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,BCBS NC,Blue Value Individual,,7.50,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,BCBS NC,Blue Value Individual,,5.70,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,BCBS NC,Blue Value Individual,,21.00,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,BCBS NC,Blue Value Individual,,26.40,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,BCBS NC,Blue Value Individual,,22.44,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Value Individual,,18.12,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,BCBS NC,Blue Value Individual,,27.66,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,BCBS NC,Blue Value Individual,,112.80,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,BCBS NC,Blue Value Individual,,5.70,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,BCBS NC,Blue Value Individual,,19.30,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,BCBS NC,Blue Value Individual,,8.12,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,BCBS NC,Blue Value Individual,,7.20,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,BCBS NC,Blue Value Individual,,34.09,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.90,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Value Individual,,72.90,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,BCBS NC,Blue Value Individual,,14.25,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Individual,,5.17,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,BCBS NC,Blue Value Individual,,19.01,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Value Individual,,8.61,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Individual,,4.92,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,BCBS NC,Blue Value Individual,,5.15,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,BCBS NC,Blue Value Individual,,28.08,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,BCBS NC,Blue Value Individual,,10.20,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,BCBS NC,Blue Value Individual,,7.00,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,BCBS NC,Blue Value Individual,,64.05,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,BCBS NC,Blue Value Individual,,101.61,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,BCBS NC,Blue Value Individual,,248.08,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,BCBS NC,Blue Value Individual,,19.39,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,BCBS NC,Blue Value Individual,,24.35,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,BCBS NC,Blue Value Individual,,66.13,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,BCBS NC,Blue Value Individual,,26.46,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Value Individual,,26.16,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,BCBS NC,Blue Value Individual,,38.56,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Value Individual,,1.77,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Value Individual,,15.18,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Value Individual,,8.44,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Value Individual,,11221.04,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,BCBS NC,Blue Value Individual,,94.77,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,BCBS NC,Blue Value Individual,,50.52,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,BCBS NC,Blue Value Individual,,19.18,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,BCBS NC,Blue Value Individual,,21.60,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,BCBS NC,Blue Value Individual,,19.28,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,BCBS NC,Blue Value Individual,,22.28,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Value Individual,,18.12,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,BCBS NC,Blue Value Individual,,26.39,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,BCBS NC,Blue Value Individual,,111.63,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,BCBS NC,Blue Value Individual,,5.72,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,BCBS NC,Blue Value Individual,,20.22,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,BCBS NC,Blue Value Individual,,20.32,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,BCBS NC,Blue Value Individual,,28.70,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,BCBS NC,Blue Value Individual,,9.12,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,BCBS NC,Blue Value Individual,,31.96,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,BCBS NC,Blue Value Individual,,51.54,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,BCBS NC,Blue Value Individual,,30.88,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,BCBS NC,Blue Value Individual,,74.39,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,BCBS NC,Blue Value Individual,,50.79,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,BCBS NC,Blue Value Individual,,23.96,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,BCBS NC,Blue Value Individual,,20.90,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,BCBS NC,Blue Value Individual,,30.88,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,BCBS NC,Blue Value Individual,,24.33,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,BCBS NC,Blue Value Individual,,28.70,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Value Individual,,32.44,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,BCBS NC,Blue Value Individual,,142.25,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,BCBS NC,Blue Value Individual,,35.01,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,BCBS NC,Blue Value Individual,,168.46,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,BCBS NC,Blue Value Individual,,346.33,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,BCBS NC,Blue Value Individual,,369.12,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Value Individual,,10.84,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,BCBS NC,Blue Value Individual,,25.08,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,BCBS NC,Blue Value Individual,,22.09,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,BCBS NC,Blue Value Individual,,45.55,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,BCBS NC,Blue Value Individual,,64.92,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,BCBS NC,Blue Value Individual,,152.23,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,BCBS NC,Blue Value Individual,,285.75,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Value Individual,,26.83,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,BCBS NC,Blue Value Individual,,30.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,BCBS NC,Blue Value Individual,,73.61,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,BCBS NC,Blue Value Individual,,19.85,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,BCBS NC,Blue Value Individual,,23.22,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,BCBS NC,Blue Value Individual,,218.41,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Value Individual,,5.21,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,BCBS NC,Blue Value Individual,,81.76,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,BCBS NC,Blue Value Individual,,18.85,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,BCBS NC,Blue Value Individual,,31.23,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,BCBS NC,Blue Value Individual,,86.10,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,BCBS NC,Blue Value Individual,,52.41,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,BCBS NC,Blue Value Individual,,7.26,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,BCBS NC,Blue Value Individual,,35.82,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,BCBS NC,Blue Value Individual,,21.21,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,BCBS NC,Blue Value Individual,,23.50,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,BCBS NC,Blue Value Individual,,54.18,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,BCBS NC,Blue Value Individual,,51.04,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,BCBS NC,Blue Value Individual,,22.46,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,BCBS NC,Blue Value Individual,,8.76,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,BCBS NC,Blue Value Individual,,10.32,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,BCBS NC,Blue Value Individual,,21.21,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,BCBS NC,Blue Value Individual,,530.32,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,BCBS NC,Blue Value Individual,,29.58,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,BCBS NC,Blue Value Individual,,7.47,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,BCBS NC,Blue Value Individual,,10.35,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,BCBS NC,Blue Value Individual,,21.52,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Value Individual,,8.24,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Value Individual,,18.75,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,BCBS NC,Blue Value Individual,,52.20,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,BCBS NC,Blue Value Individual,,19.20,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Value Individual,,26.46,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,BCBS NC,Blue Value Individual,,6.67,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,BCBS NC,Blue Value Individual,,6.68,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,BCBS NC,Blue Value Individual,,7.61,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Value Individual,,12.69,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Value Individual,,7.75,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.11,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,BCBS NC,Blue Value Individual,,38.93,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Value Individual,,28.08,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,BCBS NC,Blue Value Individual,,41.90,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,BCBS NC,Blue Value Individual,,8.74,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,BCBS NC,Blue Value Individual,,31.29,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,BCBS NC,Blue Value Individual,,32.10,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,BCBS NC,Blue Value Individual,,24.33,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,BCBS NC,Blue Value Individual,,5.27,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,BCBS NC,Blue Value Individual,,20.29,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,BCBS NC,Blue Value Individual,,5.17,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,BCBS NC,Blue Value Individual,,16.61,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,BCBS NC,Blue Value Individual,,24.44,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,BCBS NC,Blue Value Individual,,31.91,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,BCBS NC,Blue Value Individual,,92.34,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,BCBS NC,Blue Value Individual,,23.69,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,BCBS NC,Blue Value Individual,,94.85,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Individual,,22.28,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,BCBS NC,Blue Value Individual,,19.06,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Value Individual,,11.91,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,BCBS NC,Blue Value Individual,,31.20,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,BCBS NC,Blue Value Individual,,22.43,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,BCBS NC,Blue Value Individual,,15.45,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,BCBS NC,Blue Value Individual,,48.01,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,BCBS NC,Blue Value Individual,,6.64,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Value Individual,,18.75,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,BCBS NC,Blue Value Individual,,134.24,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Value Individual,,49.81,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,BCBS NC,Blue Value Individual,,82.18,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,BCBS NC,Blue Value Individual,,71.82,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,BCBS NC,Blue Value Individual,,22.17,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,BCBS NC,Blue Value Individual,,19.52,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,BCBS NC,Blue Value Individual,,23.65,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,BCBS NC,Blue Value Individual,,17.94,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,BCBS NC,Blue Value Individual,,4.82,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,BCBS NC,Blue Value Individual,,73.56,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Value Individual,,2993.88,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Value Individual,,26.03,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Value Individual,,44.68,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,BCBS NC,Blue Value Individual,,46.09,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,BCBS NC,Blue Value Individual,,108.22,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Value Individual,,4705.66,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,BCBS NC,Blue Value Individual,,117.24,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Value Individual,,166.66,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Value Individual,,92.49,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Value Individual,,143.83,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Value Individual,,134.39,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Value Individual,,120.92,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,BCBS NC,Blue Value Individual,,109.15,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Value Individual,,166.66,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Value Individual,,92.49,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Value Individual,,143.83,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Value Individual,,814.23,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,BCBS NC,Blue Value Individual,,30.07,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,BCBS NC,Blue Value Individual,,34.55,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Individual,,7.46,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Value Individual,,8.81,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Value Individual,,26.46,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,BCBS NC,Blue Value Individual,,58.02,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,BCBS NC,Blue Value Individual,,43.86,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Individual,,339.99,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Individual,,339.99,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,BCBS NC,Blue Value Individual,,21.87,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,BCBS NC,Blue Value Individual,,19.15,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,BCBS NC,Blue Value Individual,,123.64,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Value Individual,,12.11,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,BCBS NC,Blue Value Individual,,51.47,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,BCBS NC,Blue Value Individual,,18.78,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,BCBS NC,Blue Value Individual,,34.55,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Value Individual,,14.67,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Value Individual,,7.72,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Value Individual,,9.71,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,BCBS NC,Blue Value Individual,,475.45,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,BCBS NC,Blue Value Individual,,11.51,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,BCBS NC,Blue Value Individual,,143.52,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Value Individual,,26.14,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Value Individual,,766.65,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,BCBS NC,Blue Value Individual,,5.11,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,BCBS NC,Blue Value Individual,,43.29,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,BCBS NC,Blue Value Individual,,414.05,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,BCBS NC,Blue Value Individual,,21.93,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,BCBS NC,Blue Value Individual,,64.50,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,BCBS NC,Blue Value Individual,,177.44,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Value Individual,,32.44,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,BCBS NC,Blue Value Individual,,34.32,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Value Individual,,12.86,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Value Individual,,19.42,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Value Individual,,14.10,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Value Individual,,19.62,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Value Individual,,10.84,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Value Individual,,19.62,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,BCBS NC,Blue Value Individual,,14.39,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,BCBS NC,Blue Value Individual,,26.38,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,BCBS NC,Blue Value Individual,,77.36,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,BCBS NC,Blue Value Individual,,35.91,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,BCBS NC,Blue Value Individual,,35.13,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Value Individual,,4.82,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Value Individual,,2018.20,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,BCBS NC,Blue Value Individual,,9.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,BCBS NC,Blue Value Individual,,24.73,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,BCBS NC,Blue Value Individual,,19.53,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,BCBS NC,Blue Value Individual,,52.99,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,BCBS NC,Blue Value Individual,,15.03,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,BCBS NC,Blue Value Individual,,69.51,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,BCBS NC,Blue Value Individual,,70.64,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Value Individual,,44.68,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Value Individual,,143.50,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,BCBS NC,Blue Value Individual,,20.28,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Value Individual,,6.57,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,BCBS NC,Blue Value Individual,,6.77,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,BCBS NC,Blue Value Individual,,137.69,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,BCBS NC,Blue Value Individual,,7.74,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Value Individual,,1734.01,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,BCBS NC,Blue Value Individual,,18.91,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,BCBS NC,Blue Value Individual,,18.76,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,BCBS NC,Blue Value Individual,,18.98,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,BCBS NC,Blue Value Individual,,18.81,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,BCBS NC,Blue Value Individual,,18.91,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,BCBS NC,Blue Value Individual,,43.05,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,BCBS NC,Blue Value Individual,,5.75,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Value Individual,,4.77,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,BCBS NC,Blue Value Individual,,19.67,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Value Individual,,15.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,BCBS NC,Blue Value Individual,,135.52,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,BCBS NC,Blue Value Individual,,137.29,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,BCBS NC,Blue Value Individual,,107.27,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,BCBS NC,Blue Value Individual,,23.94,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Individual,,26.22,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,BCBS NC,Blue Value Individual,,11.10,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,BCBS NC,Blue Value Individual,,22.68,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Individual,,23.62,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Individual,,22.50,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Value Individual,,4.77,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,BCBS NC,Blue Value Individual,,6.79,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,BCBS NC,Blue Value Individual,,7.38,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,BCBS NC,Blue Value Individual,,47.13,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Value Individual,,26.43,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,BCBS NC,Blue Value Individual,,37.30,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Value Individual,,24.99,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Value Individual,,106.14,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Value Individual,,343.46,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Individual,,7.83,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,BCBS NC,Blue Value Individual,,7.41,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,BCBS NC,Blue Value Individual,,216.96,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,BCBS NC,Blue Value Individual,,30.51,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Value Individual,,19.01,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,BCBS NC,Blue Value Individual,,30.75,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,BCBS NC,Blue Value Individual,,18.61,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Value Individual,,44.94,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Value Individual,,85.12,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,BCBS NC,Blue Value Individual,,11.59,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Value Individual,,18.27,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,BCBS NC,Blue Value Individual,,7.84,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Value Individual,,10.84,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,BCBS NC,Blue Value Individual,,62.39,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Value Individual,,22.46,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Value Individual,,26.09,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,BCBS NC,Blue Value Individual,,24.45,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Individual,,7.46,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Value Individual,,8.81,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,BCBS NC,Blue Value Individual,,19.89,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,BCBS NC,Blue Value Individual,,24.96,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Value Individual,,6.89,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,BCBS NC,Blue Value Individual,,10.32,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,BCBS NC,Blue Value Individual,,6.20,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Value Individual,,12.69,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,BCBS NC,Blue Value Individual,,7.12,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,BCBS NC,Blue Value Individual,,7.78,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,BCBS NC,Blue Value Individual,,5.29,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,BCBS NC,Blue Value Individual,,4.91,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,BCBS NC,Blue Value Individual,,157.85,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,BCBS NC,Blue Value Individual,,10.20,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,BCBS NC,Blue Value Individual,,26.40,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Value Individual,,766.65,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Individual,,7345.74,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Individual,,7345.74,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Individual,,7345.74,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Individual,,7345.74,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Individual,,7345.74,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Value Individual,,11221.04,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,BCBS NC,Blue Value Individual,,120.01,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,BCBS NC,Blue Value Individual,,31.70,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Value Individual,,8.81,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,BCBS NC,Blue Value Individual,,6.85,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Value Individual,,44.45,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Value Individual,,8.90,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,BCBS NC,Blue Value Individual,,3.72,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Value Individual,,143.50,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,BCBS NC,Blue Value Individual,,224.90,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Value Individual,,14.53,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Value Individual,,7.65,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Value Individual,,7.75,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,BCBS NC,Blue Value Individual,,82.67,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,BCBS NC,Blue Value Individual,,17.52,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Value Individual,,23.27,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,BCBS NC,Blue Value Individual,,5.01,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,BCBS NC,Blue Value Individual,,26.40,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Value Individual,,160.37,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Value Individual,,91.63,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,BCBS NC,Blue Value Individual,,1.25,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,BCBS NC,Blue Value Individual,,0.84000,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,BCBS NC,Blue Value Individual,,82.22,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,BCBS NC,Blue Value Individual,,88.67,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,BCBS NC,Blue Value Individual,,70.90,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,BCBS NC,Blue Value Individual,,77.42,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,BCBS NC,Blue Value Individual,,0.67500,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,BCBS NC,Blue Value Individual,,86.55,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.83,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.83,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Value Individual,,12.23,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Value Individual,,19.68,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,BCBS NC,Blue Value Individual,,23.34,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Value Individual,,8.61,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Value Individual,,11.31,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Value Individual,,11.05,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,BCBS NC,Blue Value Individual,,13409.91,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Value Individual,,10686.78,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Value Individual,,15231.78,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,BCBS NC,Blue Value Individual,,8.23,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,BCBS NC,Blue Value Individual,,166.80,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Value Individual,,93.51,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Value Individual,,86.10,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Value Individual,,125.17,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,BCBS NC,Blue Value Individual,,13901.68,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Value Individual,,2268.72,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Individual,,1175.21,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Value Individual,,2268.72,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Individual,,1175.21,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Value Individual,,2268.72,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Individual,,1175.21,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Value Individual,,300.80,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Individual,,5589.76,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Individual,,5589.76,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Individual,,5589.76,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Value Individual,,15184.29,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Value Individual,,735.32,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Value Individual,,1240.59,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Value Individual,,2462.45,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Value Individual,,507.48,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Value Individual,,1240.59,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Value Individual,,2462.45,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Value Individual,,507.48,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,BCBS NC,Blue Value Individual,,82.85,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,BCBS NC,Blue Value Individual,,13.10,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Value Individual,,8.84,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,BCBS NC,Blue Value Individual,,57551.39,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,BCBS NC,Blue Value Individual,,38.67,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,BCBS NC,Blue Value Individual,,21.15,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,BCBS NC,Blue Value Individual,,22.50,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,BCBS NC,Blue Value Individual,,22.27,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Individual,,22.50,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Value Individual,,437.12,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,BCBS NC,Blue Value Individual,,21.23,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,BCBS NC,Blue Value Individual,,6.09,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,BCBS NC,Blue Value Individual,,6.45,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,BCBS NC,Blue Value Individual,,5.78,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,BCBS NC,Blue Value Individual,,199.35,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,BCBS NC,Blue Value Individual,,43.52,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,BCBS NC,Blue Value Individual,,220.80,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,BCBS NC,Blue Value Individual,,79.03,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Value Individual,,16.62,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Value Individual,,16.62,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,BCBS NC,Blue Value Individual,,1.53,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,BCBS NC,Blue Value Individual,,3.88,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,BCBS NC,Blue Value Individual,,23.97,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,BCBS NC,Blue Value Individual,,18.07,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,BCBS NC,Blue Value Individual,,138.22,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Value Individual,,23.40,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Value Individual,,5.14,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,BCBS NC,Blue Value Individual,,17.76,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,BCBS NC,Blue Value Individual,,11.47,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,BCBS NC,Blue Value Individual,,130.78,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Individual,,5.49,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,BCBS NC,Blue Value Individual,,31.98,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,BCBS NC,Blue Value Individual,,31.79,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,BCBS NC,Blue Value Individual,,173.21,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,BCBS NC,Blue Value Individual,,93.22,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,BCBS NC,Blue Value Individual,,15.54,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Individual,,6.12,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Individual,,5.34,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Value Individual,,5.46,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Individual,,5.31,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Individual,,5.40,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Value Individual,,6.79,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,BCBS NC,Blue Value Individual,,10.20,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,BCBS NC,Blue Value Individual,,9.06,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,BCBS NC,Blue Value Individual,,9.09,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,BCBS NC,Blue Value Individual,,10.15,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,BCBS NC,Blue Value Individual,,11.29,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,BCBS NC,Blue Value Individual,,34.20,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,BCBS NC,Blue Value Individual,,14.59,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Individual,,4.88,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Value Individual,,5.45,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Individual,,4.92,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Individual,,5.13,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,BCBS NC,Blue Value Individual,,4.93,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,BCBS NC,Blue Value Individual,,0.64500,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,BCBS NC,Blue Value Individual,,7.14,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,BCBS NC,Blue Value Individual,,35.01,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,BCBS NC,Blue Value Individual,,69.64,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Value Individual,,14.10,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,BCBS NC,Blue Value Individual,,1.27,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,BCBS NC,Blue Value Individual,,27.04,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Value Individual,,14.36,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Value Individual,,7.83,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Value Individual,,9.28,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Value Individual,,8.81,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,BCBS NC,Blue Value Individual,,55.70,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,BCBS NC,Blue Value Individual,,23.14,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,BCBS NC,Blue Value Individual,,8.97,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Individual,,5.13,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Value Individual,,8.81,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Value Individual,,8.90,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,BCBS NC,Blue Value Individual,,25.92,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,BCBS NC,Blue Value Individual,,26.46,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.90,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,BCBS NC,Blue Value Individual,,35.40,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,BCBS NC,Blue Value Individual,,7.02,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,BCBS NC,Blue Value Individual,,15.91,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Value Individual,,4.91,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Value Individual,,11.05,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,BCBS NC,Blue Value Individual,,91.21,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,BCBS NC,Blue Value Individual,,140.53,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Value Individual,,6.78,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,BCBS NC,Blue Value Individual,,8.60,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,BCBS NC,Blue Value Individual,,31.42,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Value Individual,,5.76,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,BCBS NC,Blue Value Individual,,5.71,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,BCBS NC,Blue Value Individual,,6.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Value Individual,,4.93,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Individual,,5.29,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Value Individual,,5.59,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,BCBS NC,Blue Value Individual,,22.04,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,BCBS NC,Blue Value Individual,,4.05,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Individual,,5.13,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Individual,,5.58,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Value Individual,,5.43,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,BCBS NC,Blue Value Individual,,7.90,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,BCBS NC,Blue Value Individual,,9.11,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Individual,,7.83,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,BCBS NC,Blue Value Individual,,6.63,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Value Individual,,7.83,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,BCBS NC,Blue Value Individual,,27.30,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,BCBS NC,Blue Value Individual,,6.99,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,BCBS NC,Blue Value Individual,,11.10,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,BCBS NC,Blue Value Individual,,9.60,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Value Individual,,26.16,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,BCBS NC,Blue Value Individual,,49.36,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Individual,,5.12,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,BCBS NC,Blue Value Individual,,38.13,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,BCBS NC,Blue Value Individual,,16.11,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,BCBS NC,Blue Value Individual,,7.71,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,5.04,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Individual,,5.13,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.40,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.40,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Value Individual,,5.52,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,BCBS NC,Blue Value Individual,,6.97,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,BCBS NC,Blue Value Individual,,3.15,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,BCBS NC,Blue Value Individual,,6.22,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,BCBS NC,Blue Value Individual,,5.33,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,BCBS NC,Blue Value Individual,,60.74,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,BCBS NC,Blue Value Individual,,73.55,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,BCBS NC,Blue Value Individual,,21.96,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,BCBS NC,Blue Value Individual,,12.81,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,5.04,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Value Individual,,2018.20,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.36,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Individual,,5.19,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,BCBS NC,Blue Value Individual,,7.29,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Value Individual,,7.09,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,BCBS NC,Blue Value Individual,,67.50,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,BCBS NC,Blue Value Individual,,30.04,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Value Individual,,10.16,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,BCBS NC,Blue Value Individual,,63.19,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,BCBS NC,Blue Value Individual,,31.79,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Value Individual,,1.92,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Value Individual,,1.92,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,BCBS NC,Blue Value Individual,,34.05,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,BCBS NC,Blue Value Individual,,6.64,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Value Individual,,7.09,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,BCBS NC,Blue Value Individual,,21.48,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,BCBS NC,Blue Value Individual,,75.78,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,BCBS NC,Blue Value Individual,,77.40,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,BCBS NC,Blue Value Individual,,80.91,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,BCBS NC,Blue Value Individual,,46.62,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,BCBS NC,Blue Value Individual,,25.71,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,BCBS NC,Blue Value Individual,,33.02,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,BCBS NC,Blue Value Individual,,21.58,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,BCBS NC,Blue Value Individual,,56.74,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,BCBS NC,Blue Value Individual,,13.46,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,BCBS NC,Blue Value Individual,,1.16,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,BCBS NC,Blue Value Individual,,0.91500,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,BCBS NC,Blue Value Individual,,121.96,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,BCBS NC,Blue Value Individual,,6.62,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,BCBS NC,Blue Value Individual,,7.33,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,BCBS NC,Blue Value Individual,,44.62,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,BCBS NC,Blue Value Individual,,373.16,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.02,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.02,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Individual,,5.04,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,4.99,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,BCBS NC,Blue Value Individual,,6.39,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Value Individual,,5.24,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,BCBS NC,Blue Value Individual,,60.16,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,BCBS NC,Blue Value Individual,,6.60,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Individual,,5.22,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,BCBS NC,Blue Value Individual,,5.21,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,BCBS NC,Blue Value Individual,,7.26,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Individual,,5.31,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,BCBS NC,Blue Value Individual,,36.39,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,BCBS NC,Blue Value Individual,,48.45,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Value Individual,,5.00,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Individual,,5.22,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Individual,,5.12,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Individual,,5.54,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,BCBS NC,Blue Value Individual,,76.27,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,BCBS NC,Blue Value Individual,,25.68,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,BCBS NC,Blue Value Individual,,7.56,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,BCBS NC,Blue Value Individual,,19.45,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Individual,,0.42000,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Individual,,0.42000,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,BCBS NC,Blue Value Individual,,0.85500,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,BCBS NC,Blue Value Individual,,2.29,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,BCBS NC,Blue Value Individual,,28.16,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Individual,,5.16,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.28,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Value Individual,,24.84,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Value Individual,,24.84,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Value Individual,,24.84,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,BCBS NC,Blue Value Individual,,284.20,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,BCBS NC,Blue Value Individual,,6.66,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,BCBS NC,Blue Value Individual,,106.98,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,BCBS NC,Blue Value Individual,,120.22,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,BCBS NC,Blue Value Individual,,0.36000,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,5.01,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Individual,,4.92,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,BCBS NC,Blue Value Individual,,15.96,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,BCBS NC,Blue Value Individual,,29.71,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,BCBS NC,Blue Value Individual,,31.12,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,BCBS NC,Blue Value Individual,,20.10,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,BCBS NC,Blue Value Individual,,30.00,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,BCBS NC,Blue Value Individual,,34.99,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,BCBS NC,Blue Value Individual,,33.62,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Individual,,23.62,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Value Individual,,22.95,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,BCBS NC,Blue Value Individual,,24.51,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,BCBS NC,Blue Value Individual,,24.50,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,BCBS NC,Blue Value Individual,,28.27,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Value Individual,,5.61,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,BCBS NC,Blue Value Individual,,40.99,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,BCBS NC,Blue Value Individual,,22.27,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,BCBS NC,Blue Value Individual,,128.41,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,BCBS NC,Blue Value Individual,,117.30,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Individual,,5.08,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Value Individual,,21.60,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,BCBS NC,Blue Value Individual,,20.70,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,BCBS NC,Blue Value Individual,,24.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,BCBS NC,Blue Value Individual,,34.37,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Individual,,5.04,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Individual,,5.17,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,BCBS NC,Blue Value Individual,,1574.20,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,BCBS NC,Blue Value Individual,,80.19,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,BCBS NC,Blue Value Individual,,212.43,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,BCBS NC,Blue Value Individual,,25.28,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,BCBS NC,Blue Value Individual,,13.71,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,BCBS NC,Blue Value Individual,,14.87,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Value Individual,,0.46500,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,BCBS NC,Blue Value Individual,,122.33,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.90,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,BCBS NC,Blue Value Individual,,593.77,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,BCBS NC,Blue Value Individual,,109.27,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,BCBS NC,Blue Value Individual,,2.07,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,BCBS NC,Blue Value Individual,,191.93,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,BCBS NC,Blue Value Individual,,7.96,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,BCBS NC,Blue Value Individual,,23.71,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,BCBS NC,Blue Value Individual,,35.66,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Value Individual,,6.69,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,BCBS NC,Blue Value Individual,,28.44,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,BCBS NC,Blue Value Individual,,252.06,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,BCBS NC,Blue Value Individual,,9.66,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,BCBS NC,Blue Value Individual,,8.30,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,BCBS NC,Blue Value Individual,,8.53,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,BCBS NC,Blue Value Individual,,85.80,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,BCBS NC,Blue Value Individual,,1.88,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Value Individual,,7.51,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Value Individual,,7.51,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,BCBS NC,Blue Value Individual,,16.04,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,BCBS NC,Blue Value Individual,,846.76,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,BCBS NC,Blue Value Individual,,18.61,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,BCBS NC,Blue Value Individual,,6.77,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Individual,,5.94,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Value Individual,,7.09,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,BCBS NC,Blue Value Individual,,18.75,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Individual,,4.96,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,BCBS NC,Blue Value Individual,,7.50,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,BCBS NC,Blue Value Individual,,12.18,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,BCBS NC,Blue Value Individual,,8.98,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,BCBS NC,Blue Value Individual,,17.41,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,BCBS NC,Blue Value Individual,,16.47,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,BCBS NC,Blue Value Individual,,13.52,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,BCBS NC,Blue Value Individual,,62.84,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Individual,,5.13,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,BCBS NC,Blue Value Individual,,7.79,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,BCBS NC,Blue Value Individual,,129.38,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,BCBS NC,Blue Value Individual,,148.08,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,BCBS NC,Blue Value Individual,,8158.25,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,BCBS NC,Blue Value Individual,,27.45,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Value Individual,,5.61,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Value Individual,,86.17,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,BCBS NC,Blue Value Individual,,90.65,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,BCBS NC,Blue Value Individual,,2696.61,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,BCBS NC,Blue Value Individual,,8.13,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,BCBS NC,Blue Value Individual,,35.83,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,BCBS NC,Blue Value Individual,,31.80,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,BCBS NC,Blue Value Individual,,32.25,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Value Individual,,32.23,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,BCBS NC,Blue Value Individual,,17.02,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,BCBS NC,Blue Value Individual,,39.04,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,BCBS NC,Blue Value Individual,,28.91,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,BCBS NC,Blue Value Individual,,131.35,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,BCBS NC,Blue Value Individual,,1.33,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,BCBS NC,Blue Value Individual,,18.45,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,BCBS NC,Blue Value Individual,,13.56,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Individual,,4.92,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Individual,,5.17,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,BCBS NC,Blue Value Individual,,1.57,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,BCBS NC,Blue Value Individual,,151.98,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,BCBS NC,Blue Value Individual,,104.91,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Value Individual,,5.37,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Value Individual,,5.26,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Individual,,5.28,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Individual,,5.29,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Value Individual,,5.50,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,BCBS NC,Blue Value Individual,,10.02,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,BCBS NC,Blue Value Individual,,12025.91,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,BCBS NC,Blue Value Individual,,168.74,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,BCBS NC,Blue Value Individual,,12.15,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,BCBS NC,Blue Value Individual,,29.43,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Value Individual,,134.39,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Value Individual,,120.92,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,BCBS NC,Blue Value Individual,,46.47,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,BCBS NC,Blue Value Individual,,17.75,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,BCBS NC,Blue Value Individual,,7982.25,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,BCBS NC,Blue Value Individual,,21.52,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Value Individual,,239.41,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,BCBS NC,Blue Value Individual,,2.75,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Individual,,0.42000,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,BCBS NC,Blue Value Individual,,29.73,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,BCBS NC,Blue Value Individual,,1138.74,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,BCBS NC,Blue Value Individual,,0.97500,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,BCBS NC,Blue Value Individual,,0.73500,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,BCBS NC,Blue Value Individual,,27.00,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,BCBS NC,Blue Value Individual,,325.37,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,BCBS NC,Blue Value Individual,,12.20,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,BCBS NC,Blue Value Individual,,40.80,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Value Individual,,160.37,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Value Individual,,91.63,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Value Individual,,129.83,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Value Individual,,129.83,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,BCBS NC,Blue Value Individual,,233.68,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,BCBS NC,Blue Value Individual,,11901.13,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,BCBS NC,Blue Value Individual,,5952.95,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,BCBS NC,Blue Value Individual,,1.19,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Value Individual,,0.37500,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,BCBS NC,Blue Value Individual,,0.60000,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,BCBS NC,Blue Value Individual,,30.59,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Individual,,5.25,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Value Individual,,4.93,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Individual,,4.98,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,5.01,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Value Individual,,15.18,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,BCBS NC,Blue Value Individual,,10.10,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,BCBS NC,Blue Value Individual,,29.40,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,BCBS NC,Blue Value Individual,,38.34,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,BCBS NC,Blue Value Individual,,110.43,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,BCBS NC,Blue Value Individual,,28.18,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,BCBS NC,Blue Value Individual,,63.00,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,BCBS NC,Blue Value Individual,,7.80,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,BCBS NC,Blue Value Individual,,14.84,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,BCBS NC,Blue Value Individual,,52.07,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,BCBS NC,Blue Value Individual,,9.18,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,BCBS NC,Blue Value Individual,,241.56,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Individual,,0.31500,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Individual,,6.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,BCBS NC,Blue Value Individual,,157.91,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,BCBS NC,Blue Value Individual,,24.02,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,BCBS NC,Blue Value Individual,,11.27,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Value Individual,,5.57,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Value Individual,,44.94,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,BCBS NC,Blue Value Individual,,82.09,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,BCBS NC,Blue Value Individual,,14.51,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,BCBS NC,Blue Value Individual,,79.15,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,BCBS NC,Blue Value Individual,,1.22,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,BCBS NC,Blue Value Individual,,47.97,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Individual,,26.22,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Individual,,26.22,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Individual,,26.22,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,BCBS NC,Blue Value Individual,,156.48,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Value Individual,,8.78,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Value Individual,,25.15,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Value Individual,,25.15,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,BCBS NC,Blue Value Individual,,1.57,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Value Individual,,8.84,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,BCBS NC,Blue Value Individual,,22.30,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,BCBS NC,Blue Value Individual,,22.42,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,BCBS NC,Blue Value Individual,,21.23,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.36,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,BCBS NC,Blue Value Individual,,8.62,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Individual,,5.25,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,BCBS NC,Blue Value Individual,,6.29,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Individual,,4.89,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Value Individual,,4.84,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,BCBS NC,Blue Value Individual,,11.60,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,BCBS NC,Blue Value Individual,,1086.20,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Individual,,5.94,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,BCBS NC,Blue Value Individual,,3726.30,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,BCBS NC,Blue Value Individual,,7447.82,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,BCBS NC,Blue Value Individual,,614.63,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,BCBS NC,Blue Value Individual,,818.01,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,BCBS NC,Blue Value Individual,,915.07,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Individual,,0.33000,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,BCBS NC,Blue Value Individual,,5.42,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,BCBS NC,Blue Value Individual,,128.72,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Value Individual,,6.51,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,BCBS NC,Blue Value Individual,,6.66,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Individual,,5.20,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,BCBS NC,Blue Value Individual,,194.01,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Individual,,0.34500,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,BCBS NC,Blue Value Individual,,25.83,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,BCBS NC,Blue Value Individual,,18.00,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,BCBS NC,Blue Value Individual,,221.62,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,BCBS NC,Blue Value Individual,,31.20,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,BCBS NC,Blue Value Individual,,11.79,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Value Individual,,18.27,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Value Individual,,8.68,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Value Individual,,6.45,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Individual,,5.01,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Individual,,5.07,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,BCBS NC,Blue Value Individual,,25.50,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,BCBS NC,Blue Value Individual,,5.57,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,BCBS NC,Blue Value Individual,,66.89,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,BCBS NC,Blue Value Individual,,93.59,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,BCBS NC,Blue Value Individual,,4.44,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,BCBS NC,Blue Value Individual,,494.11,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,BCBS NC,Blue Value Individual,,23.59,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,BCBS NC,Blue Value Individual,,7.26,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,BCBS NC,Blue Value Individual,,24.60,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,BCBS NC,Blue Value Individual,,14.25,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.40,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,BCBS NC,Blue Value Individual,,650.35,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,BCBS NC,Blue Value Individual,,10.79,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,BCBS NC,Blue Value Individual,,79.44,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,BCBS NC,Blue Value Individual,,31.05,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,BCBS NC,Blue Value Individual,,33.80,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,BCBS NC,Blue Value Individual,,13.81,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Value Individual,,6.63,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Value Individual,,6.71,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Value Individual,,8.10,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Value Individual,,6.81,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Individual,,5.58,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,BCBS NC,Blue Value Individual,,123.95,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,BCBS NC,Blue Value Individual,,460.14,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,BCBS NC,Blue Value Individual,,11.55,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,BCBS NC,Blue Value Individual,,18.55,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,BCBS NC,Blue Value Individual,,23.59,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,BCBS NC,Blue Value Individual,,28.63,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,BCBS NC,Blue Value Individual,,90.01,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,BCBS NC,Blue Value Individual,,1077.94,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,BCBS NC,Blue Value Individual,,38.13,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,BCBS NC,Blue Value Individual,,63.34,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,BCBS NC,Blue Value Individual,,26.46,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,BCBS NC,Blue Value Individual,,10.19,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,BCBS NC,Blue Value Individual,,18.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Value Individual,,9.38,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,BCBS NC,Blue Value Individual,,59.81,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,BCBS NC,Blue Value Individual,,51.71,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Value Individual,,19.18,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,BCBS NC,Blue Value Individual,,19.27,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,BCBS NC,Blue Value Individual,,19.22,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,BCBS NC,Blue Value Individual,,70.99,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,BCBS NC,Blue Value Individual,,27.07,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Individual,,0.43500,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,BCBS NC,Blue Value Individual,,198.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,BCBS NC,Blue Value Individual,,114.44,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,BCBS NC,Blue Value Individual,,538.72,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Value Individual,,24.64,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,BCBS NC,Blue Value Individual,,1.38,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,BCBS NC,Blue Value Individual,,652.38,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Value Individual,,30.16,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Value Individual,,29.12,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Value Individual,,27.90,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,BCBS NC,Blue Value Individual,,28.08,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Value Individual,,24.96,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Value Individual,,7.38,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,BCBS NC,Blue Value Individual,,9.96,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Value Individual,,15.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Value Individual,,29.12,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Value Individual,,29.12,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.30,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Value Individual,,22.95,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,BCBS NC,Blue Value Individual,,105.77,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,BCBS NC,Blue Value Individual,,17.57,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,BCBS NC,Blue Value Individual,,14.69,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,BCBS NC,Blue Value Individual,,1508.15,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,BCBS NC,Blue Value Individual,,21.00,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Individual,,6.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Individual,,5.79,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,BCBS NC,Blue Value Individual,,190.95,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,BCBS NC,Blue Value Individual,,75.73,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Individual,,5.16,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,BCBS NC,Blue Value Individual,,28.39,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,BCBS NC,Blue Value Individual,,7.54,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,BCBS NC,Blue Value Individual,,49.88,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,BCBS NC,Blue Value Individual,,25.59,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,BCBS NC,Blue Value Individual,,30.86,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,BCBS NC,Blue Value Individual,,7.63,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,BCBS NC,Blue Value Individual,,0.42000,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,BCBS NC,Blue Value Individual,,725.05,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,BCBS NC,Blue Value Individual,,1195.03,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,BCBS NC,Blue Value Individual,,144.45,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,BCBS NC,Blue Value Individual,,212.43,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Individual,,5.17,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,BCBS NC,Blue Value Individual,,315.09,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,BCBS NC,Blue Value Individual,,16.16,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,BCBS NC,Blue Value Individual,,514.24,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Value Individual,,13.29,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Value Individual,,13.29,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,BCBS NC,Blue Value Individual,,34.14,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Individual,,5.36,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,BCBS NC,Blue Value Individual,,490.30,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,BCBS NC,Blue Value Individual,,13492.67,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,BCBS NC,Blue Value Individual,,46410.70,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,BCBS NC,Blue Value Individual,,76503.25,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,BCBS NC,Blue Value Individual,,3315.56,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,BCBS NC,Blue Value Individual,,2195.63,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,BCBS NC,Blue Value Individual,,77.70,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,BCBS NC,Blue Value Individual,,4.09,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Value Individual,,0.36000,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,BCBS NC,Blue Value Individual,,2.75,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,BCBS NC,Blue Value Individual,,12.48,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.05942,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,BCBS NC,Blue Value Individual,,0.06000,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Individual,,106.08,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,BCBS NC,Blue Value Individual,,263.06,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,BCBS NC,Blue Value Individual,,393.47,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,BCBS NC,Blue Value Individual,,590.92,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,BCBS NC,Blue Value Individual,,709.06,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,BCBS NC,Blue Value Individual,,850.71,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,BCBS NC,Blue Value Individual,,1021.18,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,BCBS NC,Blue Value Individual,,422.09,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,BCBS NC,Blue Value Individual,,619.95,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,BCBS NC,Blue Value Individual,,1127.47,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Individual,,47.57,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,BCBS NC,Blue Value Individual,,188.19,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Value Individual,,51.43,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,,34.78,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,18.43,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Individual,,7.73,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Individual,,42.51,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,18.73,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.08,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Individual,,46.97,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Value Individual,,155.79,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Value Individual,,177.49,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Value Individual,,151.03,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Individual,,27.35,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,BCBS NC,Blue Value Individual,,21.70,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Value Individual,,68.38,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,BCBS NC,Blue Value Individual,,62.73,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Value Individual,,1555.77,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Value Individual,,1555.77,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,BCBS NC,Blue Value Individual,,1481.15,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Value Individual,,530.98,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.24,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,BCBS NC,Blue Value Individual,,893.39,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Value Individual,,453.68,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Individual,,93.05,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,24.08,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,18.73,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Value Individual,,324.95,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Individual,,101.68,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,BCBS NC,Blue Value Individual,,367.46,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Value Individual,,270.25,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Value Individual,,90.08,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Value Individual,,148.65,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Value Individual,,278.87,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Value Individual,,79.08,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Individual,,60.65,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,BCBS NC,Blue Value Individual,,324.65,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Value Individual,,281.84,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Value Individual,,85.03,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Individual,,12.78,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Individual,,10.41,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Individual,,41.62,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Value Individual,,140.92,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Individual,,37.46,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Value Individual,,85.03,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Individual,,39.84,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Value Individual,,3.27,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,BCBS NC,Blue Value Individual,,1482.04,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,BCBS NC,Blue Value Individual,,5975.73,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,BCBS NC,Blue Value Individual,,1508.50,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,BCBS NC,Blue Value Individual,,1260.55,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,BCBS NC,Blue Value Individual,,1034.01,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Individual,,137.65,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Individual,,1105.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,BCBS NC,Blue Value Individual,,1266.59,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,BCBS NC,Blue Value Individual,,1247.30,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Value Individual,,987.27,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,BCBS NC,Blue Value Individual,,1631.47,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Value Individual,,1266.52,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Value Individual,,1158.38,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Value Individual,,1347.95,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Value Individual,,1347.95,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,BCBS NC,Blue Value Individual,,1640.13,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Individual,,1105.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Individual,,1105.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Value Individual,,987.27,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Individual,,1105.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Value Individual,,487.90,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,BCBS NC,Blue Value Individual,,1149.16,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,BCBS NC,Blue Value Individual,,472.80,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Value Individual,,1817.12,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,BCBS NC,Blue Value Individual,,322.88,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,BCBS NC,Blue Value Individual,,663.21,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,BCBS NC,Blue Value Individual,,1004.63,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,BCBS NC,Blue Value Individual,,1171.79,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Value Individual,,35.97,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,BCBS NC,Blue Value Individual,,348.71,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,BCBS NC,Blue Value Individual,,700.27,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Individual,,16.97,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Value Individual,,95.45,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,BCBS NC,Blue Value Individual,,119.95,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,BCBS NC,Blue Value Individual,,271.07,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,BCBS NC,Blue Value Individual,,205.26,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Individual,,13.75,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Individual,,15.32,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Value Individual,GP,3.66,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Value Individual,,93.11,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,BCBS NC,Blue Value Individual,,280.12,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,BCBS NC,Blue Value Individual,,265.20,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,BCBS NC,Blue Value Individual,,212.61,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,BCBS NC,Blue Value Individual,,160.02,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Value Individual,,107.42,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Individual,,54.83,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,BCBS NC,Blue Value Individual,,457.98,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,BCBS NC,Blue Value Individual,,1368.64,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,BCBS NC,Blue Value Individual,,1815.16,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Value Individual,,1048.55,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,BCBS NC,Blue Value Individual,,796.04,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,BCBS NC,Blue Value Individual,,7313.78,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,BCBS NC,Blue Value Individual,,7660.76,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,BCBS NC,Blue Value Individual,,8062.83,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,BCBS NC,Blue Value Individual,,8408.69,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,BCBS NC,Blue Value Individual,,8755.95,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,BCBS NC,Blue Value Individual,,9102.10,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,BCBS NC,Blue Value Individual,,9392.04,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,BCBS NC,Blue Value Individual,,9794.11,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,BCBS NC,Blue Value Individual,,10140.53,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,BCBS NC,Blue Value Individual,,10486.96,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,BCBS NC,Blue Value Individual,,10833.66,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Value Individual,,108.48,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,BCBS NC,Blue Value Individual,,149.31,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Value Individual,,231.79,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,BCBS NC,Blue Value Individual,,233.75,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,BCBS NC,Blue Value Individual,,1128.19,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,BCBS NC,Blue Value Individual,,2707.93,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,BCBS NC,Blue Value Individual,,2909.80,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,BCBS NC,Blue Value Individual,,3125.65,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,BCBS NC,Blue Value Individual,,1703.88,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,BCBS NC,Blue Value Individual,,2201.29,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,BCBS NC,Blue Value Individual,,2503.82,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,BCBS NC,Blue Value Individual,,3223.79,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,BCBS NC,Blue Value Individual,,3309.35,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,BCBS NC,Blue Value Individual,,3389.87,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,BCBS NC,Blue Value Individual,,3470.67,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,BCBS NC,Blue Value Individual,,3551.20,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,BCBS NC,Blue Value Individual,,1382.90,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Value Individual,,186.77,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,BCBS NC,Blue Value Individual,,1231.92,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,BCBS NC,Blue Value Individual,,1663.34,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,BCBS NC,Blue Value Individual,,2277.62,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,BCBS NC,Blue Value Individual,,2886.59,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,BCBS NC,Blue Value Individual,,3295.65,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,BCBS NC,Blue Value Individual,,3732.66,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,BCBS NC,Blue Value Individual,,4258.03,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,BCBS NC,Blue Value Individual,,4564.19,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,BCBS NC,Blue Value Individual,,5016.02,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,BCBS NC,Blue Value Individual,,5261.79,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,BCBS NC,Blue Value Individual,,5583.61,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,BCBS NC,Blue Value Individual,,5790.80,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,BCBS NC,Blue Value Individual,,5842.80,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,BCBS NC,Blue Value Individual,,5929.48,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,BCBS NC,Blue Value Individual,,6102.27,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,BCBS NC,Blue Value Individual,,6275.34,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,BCBS NC,Blue Value Individual,,6448.14,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,BCBS NC,Blue Value Individual,,6622.33,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,BCBS NC,Blue Value Individual,,6794.84,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,BCBS NC,Blue Value Individual,,6968.19,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Value Individual,,3748.32,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,BCBS NC,Blue Value Individual,,3176.82,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Value Individual,,1969.22,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Value Individual,,1969.22,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Value Individual,,1969.22,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Value Individual,,1811.81,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Value Individual,,3748.32,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,BCBS NC,Blue Value Individual,,2114.34,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,BCBS NC,Blue Value Individual,,2382.47,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Value Individual,,84.72,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Individual,,355.37,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Value Individual,,142.04,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Value Individual,,142.04,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,BCBS NC,Blue Value Individual,,225.92,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,BCBS NC,Blue Value Individual,,3018.00,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,BCBS NC,Blue Value Individual,,528.44,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Value Individual,,342.51,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,BCBS NC,Blue Value Individual,,2132.83,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Individual,,82.76,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Value Individual,,206.16,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,BCBS NC,Blue Value Individual,,0.81810,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Value Individual,,373.00,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Value Individual,,481.13,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Value Individual,,589.70,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,BCBS NC,Blue Value Individual,,697.83,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,BCBS NC,Blue Value Individual,,806.18,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,BCBS NC,Blue Value Individual,,914.53,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,BCBS NC,Blue Value Individual,,1022.65,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,BCBS NC,Blue Value Individual,,149.52,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Value Individual,,741.94,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Value Individual,,977.64,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Value Individual,,292.70,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Value Individual,,398.79,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Value Individual,,444.71,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Value Individual,,492.44,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Value Individual,,539.94,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Value Individual,,587.22,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Value Individual,,634.94,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Value Individual,,373.00,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Value Individual,,216.70,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Value Individual,,539.94,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Value Individual,,292.70,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Value Individual,,398.79,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Value Individual,,444.71,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Value Individual,,492.44,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Value Individual,,587.22,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Value Individual,,634.94,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Value Individual,,741.94,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Value Individual,,977.64,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Individual,,112.87,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Value Individual,,1048.55,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Individual,,87.12,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Value Individual,,414.83,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Value Individual,,469.86,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,BCBS NC,Blue Value Individual,,525.50,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Value Individual,,581.14,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,BCBS NC,Blue Value Individual,,637.38,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Value Individual,,693.33,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Value Individual,,748.97,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,BCBS NC,Blue Value Individual,,804.30,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,BCBS NC,Blue Value Individual,,859.63,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,BCBS NC,Blue Value Individual,,915.88,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,BCBS NC,Blue Value Individual,,971.21,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,BCBS NC,Blue Value Individual,,1043.66,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Value Individual,,1099.91,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,BCBS NC,Blue Value Individual,,1312.37,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Value Individual,,1398.27,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,BCBS NC,Blue Value Individual,,1463.39,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,BCBS NC,Blue Value Individual,,1519.02,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,BCBS NC,Blue Value Individual,,1574.36,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Individual,,1221.57,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,BCBS NC,Blue Value Individual,,1296.23,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,BCBS NC,Blue Value Individual,,1260.40,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,BCBS NC,Blue Value Individual,,798.79,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,BCBS NC,Blue Value Individual,,863.60,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Value Individual,,759.97,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,BCBS NC,Blue Value Individual,,1021.65,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Value Individual,,94.23,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Value Individual,,2818.93,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Value Individual,,2818.93,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Value Individual,,2818.93,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Value Individual,,356.49,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,BCBS NC,Blue Value Individual,,586.04,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,BCBS NC,Blue Value Individual,,651.19,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,BCBS NC,Blue Value Individual,,353.41,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Individual,,135.05,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Individual,,105.83,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Value Individual,,2095.32,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Value Individual,,284.07,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Individual,,112.96,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Value Individual,,1278.89,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Value Individual,,3030.03,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,BCBS NC,Blue Value Individual,,1474.61,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Value Individual,,53.45,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00261,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,BCBS NC,Blue Value Individual,,11179.53,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,BCBS NC,Blue Value Individual,,11525.67,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,BCBS NC,Blue Value Individual,,527.05,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,BCBS NC,Blue Value Individual,,155.74,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,BCBS NC,Blue Value Individual,,815.03,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,19.97,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,10.56,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,BCBS NC,Blue Value Individual,,16.21,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Value Individual,,34.50,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Individual,,18.85,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Individual,,18.66,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Individual,Q0,0.35956,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Individual,Q0,0.35956,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Value Individual,,178.38,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Value Individual,,221.79,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,BCBS NC,Blue Value Individual,,408.79,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,BCBS NC,Blue Value Individual,,5817.86,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,BCBS NC,Blue Value Individual,,2711.38,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Individual,,1522.18,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,BCBS NC,Blue Value Individual,,1472.82,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,BCBS NC,Blue Value Individual,,2211.32,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,BCBS NC,Blue Value Individual,,2502.67,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Individual,,1522.18,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,BCBS NC,Blue Value Individual,,1887.26,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Individual,,94.54,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Value Individual,,30.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Value Individual,,62.14,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,8.32,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Individual,,43.11,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Individual,,94.54,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Individual,,37.46,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Value Individual,,44.89,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,BCBS NC,Blue Value Individual,,54.70,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Value Individual,,87.70,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,BCBS NC,Blue Value Individual,,105.54,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Individual,,311.57,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Value Individual,,30.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Value Individual,,126.35,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Value Individual,,178.38,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,BCBS NC,Blue Value Individual,,319.00,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Value Individual,,281.84,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Value Individual,,221.79,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Value Individual,,221.79,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.16,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,BCBS NC,Blue Value Individual,,230.11,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Individual,,1522.18,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Value Individual,,149.54,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Value Individual,,134.38,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,BCBS NC,Blue Value Individual,,401.06,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Individual,,1522.18,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,BCBS NC,Blue Value Individual,,441.19,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,BCBS NC,Blue Value Individual,,409.98,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.24,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.24,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.24,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,17.24,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Individual,,159.06,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Individual,,159.06,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Individual,,159.06,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Value Individual,,1997.86,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Value Individual,,274.11,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Value Individual,,274.11,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Value Individual,,274.11,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,BCBS NC,Blue Value Individual,,361.22,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,BCBS NC,Blue Value Individual,,484.90,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,BCBS NC,Blue Value Individual,,861.87,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Individual,,104.06,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Individual,,137.65,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Individual,,41.62,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,28.24,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Value Individual,,49.35,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Individual,,104.06,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,27.05,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,30.03,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Value Individual,,1566.77,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,BCBS NC,Blue Value Individual,,304.44,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Individual,,189.38,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Value Individual,,11756.25,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Value Individual,,5051.89,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Value Individual,,88.30,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,BCBS NC,Blue Value Individual,,91.57,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Value Individual,,570.13,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Value Individual,,2154.57,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Value Individual,,515.17,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Value Individual,,978.94,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Value Individual,,11949.36,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Value Individual,,3718.80,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Value Individual,,3303.75,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Value Individual,,4654.07,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Value Individual,,9381.82,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Value Individual,,784.05,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Value Individual,,3302.86,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Value Individual,,4766.08,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Value Individual,,2817.21,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Value Individual,,800.98,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Value Individual,,801.52,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Value Individual,,2485.54,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Individual,,0.35956,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Value Individual,,2650.13,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Value Individual,,3350.40,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,BCBS NC,Blue Value Individual,,1822.75,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Value Individual,,4603.56,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Value Individual,,373.11,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Value Individual,,159.65,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Value Individual,,1997.86,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Value Individual,,1566.77,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,BCBS NC,Blue Value Individual,,279.46,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Value Individual,,65.41,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Value Individual,,165.00,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,BCBS NC,Blue Value Individual,,1616.12,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,BCBS NC,Blue Value Individual,,5899.92,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,BCBS NC,Blue Value Individual,,8143.05,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Value Individual,,83.54,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Value Individual,,83.54,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Value Individual,,78.19,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Value Individual,,78.19,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Value Individual,,78.19,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00297,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,BCBS NC,Blue Value Individual,,929.06,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,BCBS NC,Blue Value Individual,,348.44,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,BCBS NC,Blue Value Individual,,448.03,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,BCBS NC,Blue Value Individual,,420.68,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,BCBS NC,Blue Value Individual,,407.30,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,BCBS NC,Blue Value Individual,,3547.18,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,BCBS NC,Blue Value Individual,Q1,2255.26,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,BCBS NC,Blue Value Individual,Q0,1351.02,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Individual,,54.60,,,,,,,36.44,147.97,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Individual,,95.58,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Individual,,65.64,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Value Individual,,101.85,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Individual,,65.64,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Individual,,65.64,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Individual,,16.02,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Individual,,50.14,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Individual,,76.08,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Individual,,45.61,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,BCBS NC,Blue Value Individual,,40.74,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Value Individual,,113.51,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,32.70,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Value Individual,,8.60,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,BCBS NC,Blue Value Individual,,385.50,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,,23.75,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,,23.75,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Value Individual,,48.72,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,BCBS NC,Blue Value Individual,,73.08,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Individual,,93.99,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Value Individual,,85.26,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,BCBS NC,Blue Value Individual,,395.24,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Value Individual,,403.97,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,BCBS NC,Blue Value Individual,,189.20,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,BCBS NC,Blue Value Individual,,285.62,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,BCBS NC,Blue Value Individual,,296.38,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,BCBS NC,Blue Value Individual,,349.97,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,BCBS NC,Blue Value Individual,,425.89,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,BCBS NC,Blue Value Individual,,714.36,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,BCBS NC,Blue Value Individual,,1267.13,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,BCBS NC,Blue Value Individual,,1366.39,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,BCBS NC,Blue Value Individual,,128.91,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,BCBS NC,Blue Value Individual,,172.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,BCBS NC,Blue Value Individual,,1289.46,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Value Individual,,1448.40,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Value Individual,,1448.40,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Value Individual,,344.69,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,BCBS NC,Blue Value Individual,,562.11,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Value Individual,,149.00,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,BCBS NC,Blue Value Individual,,222.49,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,BCBS NC,Blue Value Individual,,95.21,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,BCBS NC,Blue Value Individual,,196.50,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,BCBS NC,Blue Value Individual,,139.46,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,BCBS NC,Blue Value Individual,,313.63,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,BCBS NC,Blue Value Individual,,217.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,BCBS NC,Blue Value Individual,,377.99,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,BCBS NC,Blue Value Individual,,91.35,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Value Individual,,244.41,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,BCBS NC,Blue Value Individual,,1520.88,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,BCBS NC,Blue Value Individual,,1513.16,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,BCBS NC,Blue Value Individual,,486.79,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,BCBS NC,Blue Value Individual,,354.44,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,BCBS NC,Blue Value Individual,,629.30,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,BCBS NC,Blue Value Individual,,1709.87,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Value Individual,,86.28,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Value Individual,,115.10,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Value Individual,,442.13,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,BCBS NC,Blue Value Individual,,424.68,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,BCBS NC,Blue Value Individual,,940.90,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,BCBS NC,Blue Value Individual,,498.97,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Value Individual,,608.80,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Individual,,64.15,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,BCBS NC,Blue Value Individual,,65.16,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,BCBS NC,Blue Value Individual,,218.43,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Individual,,100.69,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Value Individual,,122.41,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Individual,,100.69,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Value Individual,,312.01,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Individual,,124.84,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Value Individual,,149.00,,,,,,,146.95,3466.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Value Individual,,106.17,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Value Individual,,1448.40,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,BCBS NC,Blue Value Individual,,209.50,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,BCBS NC,Blue Value Individual,,180.47,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,BCBS NC,Blue Value Individual,,236.09,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Value Individual,,213.35,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Value Individual,,285.42,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Value Individual,76,285.42,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,,378.60,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Value Individual,,760.84,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Value Individual,76,760.84,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Value Individual,,800.84,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Value Individual,76,800.84,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Value Individual,,412.90,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Value Individual,,458.98,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,BCBS NC,Blue Value Individual,,483.75,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,BCBS NC,Blue Value Individual,,533.69,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,BCBS NC,Blue Value Individual,,372.10,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Value Individual,,532.27,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Individual,,69.63,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Individual,,83.84,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Individual,,83.84,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Individual,,59.28,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,BCBS NC,Blue Value Individual,,576.93,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,BCBS NC,Blue Value Individual,,5541.70,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,BCBS NC,Blue Value Individual,,761.86,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Value Individual,,876.15,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Value Individual,,876.15,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,BCBS NC,Blue Value Individual,,131.54,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Value Individual,,143.72,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Value Individual,,248.68,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Value Individual,,174.58,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Value Individual,,185.54,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Value Individual,,190.41,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Individual,,130.12,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,,378.60,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,76,378.60,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,,378.60,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,76,378.60,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Individual,,69.63,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Value Individual,,131.95,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,BCBS NC,Blue Value Individual,,73.69,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,,378.60,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,76,378.60,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Individual,,92.36,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Value Individual,76,174.58,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Value Individual,76,185.54,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Individual,,101.30,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,BCBS NC,Blue Value Individual,,211.93,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,BCBS NC,Blue Value Individual,,330.69,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Value Individual,,475.63,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,BCBS NC,Blue Value Individual,,1403.54,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Value Individual,,148.80,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,BCBS NC,Blue Value Individual,,1231.60,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,BCBS NC,Blue Value Individual,,457.56,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,BCBS NC,Blue Value Individual,,575.91,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Value Individual,,375.14,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,BCBS NC,Blue Value Individual,,176.81,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Individual,,111.45,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,BCBS NC,Blue Value Individual,,163.41,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Individual,,254.16,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,BCBS NC,Blue Value Individual,,1657.29,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,BCBS NC,Blue Value Individual,,489.23,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Value Individual,,82.22,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,BCBS NC,Blue Value Individual,,113.68,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,BCBS NC,Blue Value Individual,,337.39,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,BCBS NC,Blue Value Individual,,390.37,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,BCBS NC,Blue Value Individual,,258.62,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Individual,,64.15,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Value Individual,,131.95,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Value Individual,,442.13,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Value Individual,,873.19,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,BCBS NC,Blue Value Individual,,61.11,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,BCBS NC,Blue Value Individual,,294.70,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Value Individual,,6.41,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,BCBS NC,Blue Value Individual,,130.01,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,BCBS NC,Blue Value Individual,,193.78,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,BCBS NC,Blue Value Individual,,228.46,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Value Individual,,90.03,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,BCBS NC,Blue Value Individual,,211.66,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Individual,,45.30,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Value Individual,,203.70,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Value Individual,,75.59,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,BCBS NC,Blue Value Individual,,103.59,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,10.97,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Individual,,19.67,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,4.87,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,4.87,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Value Individual,,52.58,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Individual,,6.44,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Individual,,6.44,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Value Individual,,4.00,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,10.10,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,9.75,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Value Individual,,18.98,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Individual,,34.82,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Individual,,28.03,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Individual,,19.67,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Individual,,23.16,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Individual,,19.67,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,BCBS NC,Blue Value Individual,,76.26,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Individual,,8.71,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Individual,,71.90,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Individual,,50.14,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,9.40,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Individual,,6.44,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,BCBS NC,Blue Value Individual,,33.25,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Individual,,46.83,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Value Individual,GP,10.44,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Individual,GP,11.69,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Individual,GP,1.87,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Value Individual,GP,18.85,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,GP,7.63,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Value Individual,GP,2.49,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,BCBS NC,Blue Value Individual,GP,23.84,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Individual,GP,25.40,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Individual,GP,19.94,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,GP,17.14,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,GP,9.19,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Individual,GP,25.55,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Individual,GP,24.93,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Value Individual,GP,22.44,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,GP,25.71,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Individual,GP,21.66,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Individual,GP,31.47,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,GP,18.23,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,GP,20.10,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Value Individual,GP,23.53,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Individual,GP,7.32,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,GP,18.38,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Individual,GP,13.24,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,GP,20.10,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Individual,GP,15.42,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Individual,GP,28.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Individual,GP,28.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,GP,14.18,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,GP,14.18,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,GP,13.87,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Individual,GP,19.79,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Individual,GP,20.25,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Individual,GP,10.91,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Individual,GP,4.67,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Value Individual,GP,47.67,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Value Individual,GP,65.90,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,BCBS NC,Blue Value Individual,GP,67.62,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Individual,GP,44.87,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,GO,14.18,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,GO,18.23,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,GO,20.10,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,GO,18.38,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Individual,GO,10.91,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,GO,20.10,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Individual,GO,15.42,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Individual,GO,1.87,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Individual,GO,25.40,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Individual,GO,19.94,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,GO,9.66,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Individual,GO,25.55,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Individual,GO,24.93,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Value Individual,GO,22.44,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,GO,25.71,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,GO,7.63,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Value Individual,GO,34.90,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Individual,GO,23.68,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Individual,GO,19.79,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Individual,GO,11.69,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Individual,GO,49.54,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,BCBS NC,Blue Value Individual,GO,62.79,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,BCBS NC,Blue Value Individual,GO,64.66,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Individual,GO,31.47,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Value Individual,GN,55.46,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Value Individual,GN,52.35,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Value Individual,GN,29.13,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Individual,GN,41.91,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Individual,GN,31.16,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Individual,GN,49.08,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Individual,GN,19.94,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Individual,GN,10.91,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Individual,GN,13.24,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Individual,GN,15.42,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Value Individual,GN,35.68,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,GN,21.19,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,BCBS NC,Blue Value Individual,GN,102.05,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Value Individual,GN,40.35,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Value Individual,GN,10.59,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Individual,GN,20.25,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Individual,GN,10.91,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Individual,GN,4.67,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,BCBS NC,Blue Value Individual,GN,33.34,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Value Individual,GN,35.68,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Individual,GN,16.67,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Value Individual,GN,55.00,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Individual,GN,85.53,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,BCBS NC,Blue Value Individual,GN,92.08,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Value Individual,,150.42,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Individual,,95.58,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,BCBS NC,Blue Value Individual,,154.08,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Value Individual,,87.75,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,BCBS NC,Blue Value Individual,,129.70,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,BCBS NC,Blue Value Individual,,653.92,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Individual,,7.49,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Value Individual,,25.77,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,BCBS NC,Blue Value Individual,,91.40,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Value Individual,,91.05,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,BCBS NC,Blue Value Individual,,98.02,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Individual,,65.64,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Individual,,65.64,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Value Individual,,236.25,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,BCBS NC,Blue Value Individual,,72.77,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Value Individual,,141.37,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Individual,,18.63,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Value Individual,,98.71,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,BCBS NC,Blue Value Individual,,82.87,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Value Individual,,113.51,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Individual,,79.74,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Individual,,27.16,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Individual,,31.34,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Value Individual,,203.70,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,BCBS NC,Blue Value Individual,,22.81,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Value Individual,,268.46,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Value Individual,,268.46,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Value Individual,,45.96,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Value Individual,,45.96,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,BCBS NC,Blue Value Individual,,377.00,,,,,,,186.78,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Value Individual,,121.87,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,BCBS NC,Blue Value Individual,,303.99,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Value Individual,,144.68,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,BCBS NC,Blue Value Individual,,87.92,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,BCBS NC,Blue Value Individual,,38.65,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Value Individual,,57.98,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,BCBS NC,Blue Value Individual,,58.85,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Value Individual,,32.21,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Value Individual,,1566.95,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Value Individual,,1566.95,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,BCBS NC,Blue Value Individual,,263.71,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Value Individual,,1089.06,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Value Individual,,1089.06,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,BCBS NC,Blue Value Individual,,1106.17,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,BCBS NC,Blue Value Individual,,200.91,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,BCBS NC,Blue Value Individual,,143.13,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Value Individual,,98.37,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,BCBS NC,Blue Value Individual,,235.03,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Value Individual,,249.71,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Individual,,95.75,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Value Individual,,249.71,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Value Individual,,182.98,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,BCBS NC,Blue Value Individual,,117.46,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Individual,,221.28,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,BCBS NC,Blue Value Individual,,300.53,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Value Individual,,126.74,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Individual,,124.72,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Value Individual,,196.04,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Individual,,81.94,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Value Individual,,131.97,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Value Individual,,32.15,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Value Individual,,166.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Individual,,99.41,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,BCBS NC,Blue Value Individual,,80.78,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Individual,,93.84,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Value Individual,,87.57,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Value Individual,,273.69,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Value Individual,,105.02,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Value Individual,,273.69,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Value Individual,,105.02,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Individual,,96.72,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,BCBS NC,Blue Value Individual,,117.34,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Value Individual,,143.11,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,BCBS NC,Blue Value Individual,,148.86,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Value Individual,,154.60,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Individual,,93.84,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Value Individual,,74.69,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Value Individual,,51.36,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Individual,,76.08,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Individual,,44.05,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Value Individual,,106.90,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Value Individual,,106.90,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,BCBS NC,Blue Value Individual,,95.23,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Individual,,36.91,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Individual,,36.91,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Individual,,36.91,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Individual,,36.91,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Value Individual,,69.64,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Value Individual,,69.64,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Value Individual,,69.64,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Value Individual,,46.48,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Value Individual,,63.72,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Value Individual,,63.72,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Value Individual,,284.65,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Value Individual,,284.65,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Blue Value Individual,,79.56,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Individual,,79.22,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,BCBS NC,Blue Value Individual,,259.58,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Value Individual,,265.68,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,BCBS NC,Blue Value Individual,,147.64,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,BCBS NC,Blue Value Individual,,214.67,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Value Individual,,73.64,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,BCBS NC,Blue Value Individual,,258.52,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Individual,,117.05,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,BCBS NC,Blue Value Individual,,141.06,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,BCBS NC,Blue Value Individual,,340.98,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,BCBS NC,Blue Value Individual,,411.77,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Value Individual,,505.63,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,BCBS NC,Blue Value Individual,,717.48,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,BCBS NC,Blue Value Individual,,788.01,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,BCBS NC,Blue Value Individual,,999.86,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Value Individual,,588.09,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,BCBS NC,Blue Value Individual,,658.62,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,BCBS NC,Blue Value Individual,,741.08,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,BCBS NC,Blue Value Individual,,1176.18,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,BCBS NC,Blue Value Individual,,1317.24,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,BCBS NC,Blue Value Individual,,1470.23,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Value Individual,,270.19,,,,,,,208.61,954.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,10.97,,,,,,,10.97,1090.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Individual,,50.84,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Individual,,51.19,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Individual,,8.36,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Individual,,8.36,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,20.54,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,20.54,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,20.54,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,20.54,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Individual,,18.45,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,20.54,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Individual,,134.93,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Individual,,134.93,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Individual,,134.93,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Individual,,134.93,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Individual,,134.93,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Individual,,134.93,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Individual,,13.06,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,BCBS NC,Blue Value Individual,GP,10.39,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,BCBS NC,Blue Value Individual,,90.29,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Value Individual,,767.22,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Value Individual,,517.24,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Value Individual,,730.44,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Value Individual,,303.37,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Value Individual,,204.52,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,BCBS NC,Blue Value Individual,,464.46,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Value Individual,,195.85,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Value Individual,,195.85,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,BCBS NC,Blue Value Individual,,601.32,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,BCBS NC,Blue Value Individual,,81.06,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Value Individual,,90.48,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Value Individual,,101.04,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Individual,,86.33,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Value Individual,,22.43,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,,24.32,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,,24.32,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Value Individual,,39.21,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Individual,,30.73,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Value Individual,,57.87,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,BCBS NC,Blue Value Individual,,98.02,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Value Individual,,95.00,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,BCBS NC,Blue Value Individual,,116.49,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,BCBS NC,Blue Value Individual,,77.10,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Value Individual,,215.29,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Value Individual,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,BCBS NC,Blue Value Individual,,178.38,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Value Individual,,113.67,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Value Individual,,170.03,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Individual,,50.89,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Individual,,42.50,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Value Individual,,78.29,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Value Individual,,73.14,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Value Individual,,212.22,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Value Individual,,143.07,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Value Individual,,641.68,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,BCBS NC,Blue Value Individual,,114.42,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Value Individual,,520.89,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Value Individual,,351.18,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Value Individual,,596.11,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Value Individual,,101.04,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Individual,,195.47,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,BCBS NC,Blue Value Individual,,2357.57,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,BCBS NC,Blue Value Individual,,286.52,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,BCBS NC,Blue Value Individual,,364.37,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Value Individual,,157.21,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,BCBS NC,Blue Value Individual,,163.81,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,BCBS NC,Blue Value Individual,,174.36,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,BCBS NC,Blue Value Individual,,289.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Value Individual,,361.54,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,BCBS NC,Blue Value Individual,,1842.40,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Individual,,184.54,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Individual,,124.41,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Value Individual,,891.64,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Value Individual,,601.13,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Value Individual,,427.23,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Value Individual,,288.03,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,BCBS NC,Blue Value Individual,,325.54,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Value Individual,,598.90,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Value Individual,,403.77,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Value Individual,,390.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Value Individual,,263.33,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Value Individual,,173.63,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Value Individual,,117.06,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Value Individual,,201.31,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Value Individual,,135.72,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,17.06,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,11.50,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Individual,,104.29,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Value Individual,,422.24,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Individual,JW,39.60,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Value Individual,,110.46,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Individual,,139.52,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,BCBS NC,Blue Value Individual,,168.88,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Individual,,94.06,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Value Individual,,163.85,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Value Individual,,154.95,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,BCBS NC,Blue Value Individual,,257.11,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Value Individual,,66.35,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Individual,,1101.90,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Individual,,742.88,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Individual,,1101.90,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Individual,,742.88,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Value Individual,,545.22,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Value Individual,,367.57,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Value Individual,,867.60,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Value Individual,,584.92,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,BCBS NC,Blue Value Individual,,324.79,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Value Individual,,401.88,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Value Individual,,527.80,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Value Individual,,151.82,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,BCBS NC,Blue Value Individual,,1226.05,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,BCBS NC,Blue Value Individual,,1356.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,BCBS NC,Blue Value Individual,,1603.23,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Individual,,224.80,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Value Individual,,295.00,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Value Individual,,295.00,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,BCBS NC,Blue Value Individual,,362.11,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,BCBS NC,Blue Value Individual,,320.64,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Individual,,109.71,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Value Individual,,427.52,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,BCBS NC,Blue Value Individual,,238.45,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Value Individual,,652.31,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Value Individual,,439.77,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,BCBS NC,Blue Value Individual,,385.86,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,BCBS NC,Blue Value Individual,,251.65,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Value Individual,,159.66,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Value Individual,,497.97,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Value Individual,,335.72,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Value Individual,,320.07,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Value Individual,,260.32,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Value Individual,,260.32,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Individual,,338.17,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Individual,,501.60,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Value Individual,,776.43,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Value Individual,,1151.67,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Value Individual,,971.61,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Value Individual,,971.61,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Value Individual,,143.16,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Value Individual,,166.08,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,17.06,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,BCBS NC,Blue Value Individual,52,307.56,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Value Individual,,212.22,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,BCBS NC,Blue Value Individual,,123.79,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,BCBS NC,Blue Value Individual,,254.36,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Individual,,22.11,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Value Individual,,256.95,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Value Individual,,173.23,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Individual,,104.29,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Individual,,59.12,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,BCBS NC,Blue Value Individual,,129.99,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,BCBS NC,Blue Value Individual,,259.79,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,BCBS NC,Blue Value Individual,,442.94,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,BCBS NC,Blue Value Individual,,590.65,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,BCBS NC,Blue Value Individual,,748.05,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,BCBS NC,Blue Value Individual,,246.93,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,BCBS NC,Blue Value Individual,,161.50,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Value Individual,,98.44,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Individual,,80.72,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Individual,,51.54,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Individual,,20.87,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Individual,,20.87,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Value Individual,,383.86,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Individual,,34.99,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Individual,,32.73,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Value Individual,,43.35,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Value Individual,,41.78,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Individual,,55.19,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Individual,,69.47,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Individual,,64.59,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Individual,,82.70,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Value Individual,,31.51,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Individual,,12.54,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Value Individual,,39.52,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Individual,,17.41,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Value Individual,,46.48,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Value Individual,,43.52,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Value Individual,,70.68,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Value Individual,,75.73,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Individual,,76.08,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Value Individual,,69.12,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Value Individual,,31.51,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Value Individual,,44.22,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Value Individual,,67.55,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,BCBS NC,Blue Value Individual,,85.13,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Individual,,11.49,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Individual,,18.45,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,BCBS NC,Blue Value Individual,,30.64,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,BCBS NC,Blue Value Individual,,45.27,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Individual,,59.72,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Value Individual,,40.22,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Individual,,55.19,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Individual,,82.70,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Value Individual,,100.28,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,8.53,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Individual,,16.19,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Value Individual,,23.85,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Value Individual,,19.50,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Individual,,8.36,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Individual,,38.62,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Value Individual,,7.43,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,28.22,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,16.04,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Individual,JW,36.90,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Individual,,36.54,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,JW,28.50,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Value Individual,,42.19,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Individual,,81.76,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Individual,,59.42,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Individual,JW,60.00,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Individual,,135.18,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Individual,,270.66,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Individual,JW,273.30,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Individual,JW,136.50,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Individual,,293.53,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,185.98,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Individual,,81.11,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Individual,JW,296.40,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Individual,JW,81.90,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Individual,,169.64,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Individual,,77.84,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Individual,,818.21,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Individual,,361.27,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Individual,,183.01,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Individual,JW,826.20,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Individual,JW,364.80,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Individual,JW,184.80,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Value Individual,,835.74,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Individual,,36.54,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Individual,,101.61,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Individual,JW,102.60,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Individual,,459.32,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Value Individual,,919.23,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Individual,JW,463.80,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Individual,,127.16,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Individual,JW,128.40,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Individual,,143.50,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Individual,JW,144.90,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Value Individual,,2.97,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Individual,,742.16,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Individual,JW,749.40,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Individual,,601.63,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Individual,JW,607.50,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Individual,,507.45,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Individual,JW,512.40,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,19.31,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,JW,19.50,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Value Individual,,733.54,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Individual,,207.38,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Individual,,209.40,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,185.98,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,187.80,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Individual,,182.72,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Individual,,184.50,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,130.43,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,131.70,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Individual,,118.54,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Individual,,119.70,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Value Individual,JW,708.90,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Individual,JW,171.30,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Individual,JW,78.60,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Individual,,92.99,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Individual,JW,93.90,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Individual,,467.93,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Individual,JW,472.50,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Individual,,371.97,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Individual,JW,375.60,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Individual,,190.44,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Individual,JW,192.30,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Individual,,101.01,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Individual,JW,102.00,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Individual,,80.81,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Individual,JW,81.60,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Value Individual,,761.17,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Value Individual,,76.49,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Individual,,165.17,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Individual,,165.17,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Individual,,165.17,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Individual,,165.17,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Value Individual,,50.90,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,BCBS NC,Blue Value Individual,,799.81,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Value Individual,,31.51,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Value Individual,,46.37,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,BCBS NC,Blue Value Individual,,485.76,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Value Individual,,55.22,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Value Individual,,57.12,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Value Individual,,372.48,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Value Individual,,372.48,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Individual,,81.43,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Individual,,81.43,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Value Individual,,63.52,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Value Individual,,52.78,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Individual,,50.71,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,BCBS NC,Blue Value Individual,,2054.94,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,BCBS NC,Blue Value Individual,,227.50,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Individual,,195.47,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,BCBS NC,Blue Value Individual,,225.63,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,BCBS NC,Blue Value Individual,,151.93,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Value Individual,,555.01,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Value Individual,,434.91,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Value Individual,,3264.61,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Value Individual,,2558.21,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Value Individual,,5680.35,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Value Individual,,4451.24,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Value Individual,,2415.74,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Value Individual,,1893.02,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Value Individual,,5125.35,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Value Individual,,4016.32,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Value Individual,,8292.10,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Value Individual,,6497.85,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Individual,,50.71,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Value Individual,,77.28,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Value Individual,,111.97,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Value Individual,,96.51,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Value Individual,,145.33,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,BCBS NC,Blue Value Individual,,128.37,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Value Individual,,730.44,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Individual,,26.96,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Individual,,59.38,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Individual,,36.76,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Individual,,59.38,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Individual,,36.76,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Individual,,59.38,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Individual,,36.76,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Individual,,97.08,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,,28.73,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Value Individual,,165.22,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Value Individual,,84.26,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Individual,,22.28,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Value Individual,,24.55,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Individual,,27.51,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Individual,,16.02,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Individual,,16.02,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Individual,,36.91,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Value Individual,,77.28,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Individual,,97.08,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Value Individual,,11.14,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Value Individual,,11.14,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,4.87,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Individual,,26.11,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Individual,,14.80,,,,,,,14.80,1090.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Individual,,97.08,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,BCBS NC,Blue Value Individual,,11892.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,BCBS NC,Blue Value Individual,,217.25,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Value Individual,,1923.26,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Value Individual,,1923.26,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,BCBS NC,Blue Value Individual,,661.11,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Individual,,81.64,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Value Individual,,247.17,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Value Individual,,38.64,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Value Individual,,38.23,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,BCBS NC,Blue Value Individual,,271.21,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Value Individual,,343.91,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Individual,,90.59,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,BCBS NC,Blue Value Individual,,1750.02,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Value Individual,,588.69,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,BCBS NC,Blue Value Individual,,135.89,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,BCBS NC,Blue Value Individual,,3590.64,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Value Individual,,588.69,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,BCBS NC,Blue Value Individual,,235.42,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,BCBS NC,Blue Value Individual,,653.15,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,BCBS NC,Blue Value Individual,,647.83,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,BCBS NC,Blue Value Individual,,649.23,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,BCBS NC,Blue Value Individual,,3335.35,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Value Individual,,146.51,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Value Individual,,144.85,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,BCBS NC,Blue Value Individual,,372.15,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Individual,,716.06,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Individual,,716.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Value Individual,,529.84,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Value Individual,,529.84,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Value Individual,,966.30,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Value Individual,,966.30,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Individual,,716.06,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Individual,,716.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Value Individual,,1541.06,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Individual,,366.92,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Individual,,311.36,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Individual,,210.05,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Individual,,163.41,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Individual,,131.32,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Individual,,138.45,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Individual,JW,370.50,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Individual,JW,314.40,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Individual,JW,212.10,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Individual,JW,165.00,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Individual,JW,132.60,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Individual,JW,139.80,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Value Individual,,617.37,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Value Individual,,33.74,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Individual,,35.44,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,BCBS NC,Blue Value Individual,,243.64,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Individual,,302.03,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,BCBS NC,Blue Value Individual,,437.76,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Value Individual,,270.85,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Value Individual,,54.72,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,BCBS NC,Blue Value Individual,,558.82,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,BCBS NC,Blue Value Individual,,792.99,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,BCBS NC,Blue Value Individual,,288.89,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,BCBS NC,Blue Value Individual,,881.33,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Value Individual,,292.25,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Value Individual,,270.85,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,BCBS NC,Blue Value Individual,,428.59,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,BCBS NC,Blue Value Individual,,409.80,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,BCBS NC,Blue Value Individual,,736.79,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,BCBS NC,Blue Value Individual,,3330.88,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Value Individual,,74.69,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Value Individual,,78.69,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Value Individual,,69.81,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Value Individual,,115.78,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Individual,,55.36,,,,,,,55.36,1831.00,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Individual,,80.58,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Individual,,72.84,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,BCBS NC,Blue Value Individual,,122.52,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Value Individual,,79.13,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Individual,,108.13,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,BCBS NC,Blue Value Individual,,135.10,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Value Individual,,88.57,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Individual,,99.36,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Value Individual,,112.40,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Individual,,34.17,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Value Individual,,60.70,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Individual,,26.98,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Value Individual,,112.62,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,BCBS NC,Blue Value Individual,,150.84,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Value Individual,,40.24,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Value Individual,,67.89,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Value Individual,,81.38,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Individual,,108.58,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Value Individual,,131.28,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Value Individual,,242.56,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Value Individual,,131.51,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Individual,,86.55,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Individual,,68.56,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Individual,,99.36,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Individual,,111.50,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Individual,,148.37,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,BCBS NC,Blue Value Individual,,208.84,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Individual,,98.24,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,BCBS NC,Blue Value Individual,,73.51,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,BCBS NC,Blue Value Individual,,126.79,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Value Individual,,110.60,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,BCBS NC,Blue Value Individual,,159.61,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Value Individual,,196.70,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Individual,,130.83,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Value Individual,,76.66,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,BCBS NC,Blue Value Individual,,121.62,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Value Individual,,82.95,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Value Individual,,82.73,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,BCBS NC,Blue Value Individual,,272.23,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Value Individual,,169.05,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,BCBS NC,Blue Value Individual,,300.33,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,BCBS NC,Blue Value Individual,,425.32,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Value Individual,,467.81,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Value Individual,,95.54,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,BCBS NC,Blue Value Individual,,85.87,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Value Individual,,103.18,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,BCBS NC,Blue Value Individual,,103.86,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Individual,,285.72,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,BCBS NC,Blue Value Individual,,117.35,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,BCBS NC,Blue Value Individual,,98.91,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Value Individual,,91.27,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Individual,,99.36,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Value Individual,,109.48,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Value Individual,,85.20,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,BCBS NC,Blue Value Individual,,66.99,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,BCBS NC,Blue Value Individual,,84.30,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,BCBS NC,Blue Value Individual,,78.01,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,BCBS NC,Blue Value Individual,,146.79,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Value Individual,,96.89,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Value Individual,,88.57,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,BCBS NC,Blue Value Individual,,62.04,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Value Individual,,189.06,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Value Individual,,95.99,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Individual,,83.40,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Value Individual,,108.35,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Individual,,71.04,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Value Individual,,85.42,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Value Individual,,79.58,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Individual,,49.01,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,BCBS NC,Blue Value Individual,,100.04,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Individual,,104.08,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Value Individual,,85.42,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,BCBS NC,Blue Value Individual,,119.14,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Individual,,104.08,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Value Individual,,90.14,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Individual,,72.84,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Value Individual,,95.76,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,,111.28,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,,111.28,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,,111.28,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,BCBS NC,Blue Value Individual,,175.79,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Value Individual,,72.39,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Value Individual,,55.53,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Value Individual,,237.16,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Value Individual,,163.65,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Value Individual,,199.62,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,BCBS NC,Blue Value Individual,,111.95,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Value Individual,,118.92,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Individual,,222.10,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Individual,,234.02,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Value Individual,,241.44,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Value Individual,,120.72,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Value Individual,,22.03,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,BCBS NC,Blue Value Individual,,130.38,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,BCBS NC,Blue Value Individual,,144.55,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Value Individual,,183.89,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,BCBS NC,Blue Value Individual,,149.72,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,BCBS NC,Blue Value Individual,,182.09,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,BCBS NC,Blue Value Individual,,469.38,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,BCBS NC,Blue Value Individual,,1044.20,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,BCBS NC,Blue Value Individual,,804.11,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Value Individual,,41.59,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Value Individual,,307.53,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,BCBS NC,Blue Value Individual,,313.60,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,BCBS NC,Blue Value Individual,,909.77,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,BCBS NC,Blue Value Individual,,1291.70,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,BCBS NC,Blue Value Individual,,298.08,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,BCBS NC,Blue Value Individual,,578.19,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,BCBS NC,Blue Value Individual,,231.77,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,BCBS NC,Blue Value Individual,,270.21,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,BCBS NC,Blue Value Individual,,361.48,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Individual,,180.74,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,BCBS NC,Blue Value Individual,,363.28,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Value Individual,,217.38,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Value Individual,,179.62,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Value Individual,,248.63,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Value Individual,,524.46,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,BCBS NC,Blue Value Individual,,309.32,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Individual,,45.86,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Individual,,39.34,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Value Individual,,270.66,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Value Individual,,173.32,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Value Individual,,237.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,BCBS NC,Blue Value Individual,,80.48,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Value Individual,,214.23,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Value Individual,,37.99,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Value Individual,,210.41,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Value Individual,,68.79,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Value Individual,,76.66,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Individual,,32.15,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,BCBS NC,Blue Value Individual,,167.25,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,BCBS NC,Blue Value Individual,,148.82,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,BCBS NC,Blue Value Individual,,147.69,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Individual,,72.61,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,BCBS NC,Blue Value Individual,,145.22,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,BCBS NC,Blue Value Individual,,77.78,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Value Individual,,54.63,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Value Individual,,60.25,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,BCBS NC,Blue Value Individual,,208.39,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Value Individual,,68.79,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Individual,,204.79,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Value Individual,,65.42,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,BCBS NC,Blue Value Individual,,177.14,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Value Individual,,526.71,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,BCBS NC,Blue Value Individual,,907.97,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,BCBS NC,Blue Value Individual,,750.38,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Value Individual,,808.83,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,BCBS NC,Blue Value Individual,,457.47,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Value Individual,,1014.75,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Value Individual,,1014.75,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Value Individual,,1014.75,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,BCBS NC,Blue Value Individual,,686.31,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Value Individual,,401.49,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,BCBS NC,Blue Value Individual,,307.62,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Value Individual,,60.25,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Value Individual,,84.08,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,BCBS NC,Blue Value Individual,,74.63,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Value Individual,,186.81,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Individual,,43.06,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Value Individual,,112.62,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Value Individual,,467.81,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Value Individual,,138.70,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Value Individual,,182.54,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,BCBS NC,Blue Value Individual,,193.55,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Value Individual,,104.98,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,BCBS NC,Blue Value Individual,,111.05,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Value Individual,,117.57,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Value Individual,,170.40,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,BCBS NC,Blue Value Individual,,165.45,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Value Individual,,242.56,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Value Individual,,51.48,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Individual,,97.11,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,BCBS NC,Blue Value Individual,,238.96,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Individual,,138.25,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,BCBS NC,Blue Value Individual,,176.47,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,BCBS NC,Blue Value Individual,,11148.75,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,BCBS NC,Blue Value Individual,,54.86,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,BCBS NC,Blue Value Individual,,416.55,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,BCBS NC,Blue Value Individual,,629.94,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Value Individual,,94.42,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Individual,,123.64,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Value Individual,,121.39,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Value Individual,,90.14,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,BCBS NC,Blue Value Individual,,133.98,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,BCBS NC,Blue Value Individual,,111.73,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Value Individual,,169.05,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Value Individual,,130.61,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,BCBS NC,Blue Value Individual,,208.61,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,BCBS NC,Blue Value Individual,,310.67,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Value Individual,,61.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Value Individual,,168.29,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Individual,,69.63,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Individual,,83.84,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Value Individual,,358.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Individual,,178.86,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,BCBS NC,Blue Value Individual,,180.98,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,BCBS NC,Blue Value Individual,,291.68,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Value Individual,,154.03,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,BCBS NC,Blue Value Individual,,770.67,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,BCBS NC,Blue Value Individual,,394.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Value Individual,,288.77,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,BCBS NC,Blue Value Individual,,257.86,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,BCBS NC,Blue Value Individual,,189.43,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Value Individual,,493.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,BCBS NC,Blue Value Individual,,267.90,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,BCBS NC,Blue Value Individual,,549.27,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Value Individual,,423.25,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,BCBS NC,Blue Value Individual,,605.02,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Value Individual,,423.25,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Value Individual,,628.27,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,BCBS NC,Blue Value Individual,,722.06,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,BCBS NC,Blue Value Individual,,226.16,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,BCBS NC,Blue Value Individual,,414.00,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Value Individual,,324.97,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,BCBS NC,Blue Value Individual,,593.13,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Value Individual,,275.30,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,BCBS NC,Blue Value Individual,,303.30,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Value Individual,,331.57,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,BCBS NC,Blue Value Individual,,471.33,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Value Individual,,696.43,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Value Individual,,696.43,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,BCBS NC,Blue Value Individual,,659.71,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,BCBS NC,Blue Value Individual,,1024.04,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,BCBS NC,Blue Value Individual,,1279.78,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Value Individual,,219.55,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,BCBS NC,Blue Value Individual,,380.18,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Value Individual,,341.87,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Value Individual,,420.61,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Value Individual,,656.80,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,BCBS NC,Blue Value Individual,,205.55,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Value Individual,,386.79,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Value Individual,,228.27,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,BCBS NC,Blue Value Individual,,287.98,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Value Individual,,211.10,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Individual,,306.47,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,BCBS NC,Blue Value Individual,,349.01,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Individual,,306.47,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Value Individual,,425.63,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Individual,,335.80,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,BCBS NC,Blue Value Individual,,243.86,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,BCBS NC,Blue Value Individual,,618.49,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,BCBS NC,Blue Value Individual,,777.54,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Value Individual,,73.18,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.47,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Individual,,26.16,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,BCBS NC,Blue Value Individual,,536.33,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Individual,,261.03,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Individual,,28.27,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Value Individual,,54.95,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Individual,,49.67,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,BCBS NC,Blue Value Individual,,738.17,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,BCBS NC,Blue Value Individual,,3300.65,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,BCBS NC,Blue Value Individual,,434.08,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Individual,,137.12,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,BCBS NC,Blue Value Individual,,537.12,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,BCBS NC,Blue Value Individual,,124.17,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,BCBS NC,Blue Value Individual,,3268.42,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Individual,,178.86,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Individual,,0.30300,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Value Individual,,22.99,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,BCBS NC,Blue Value Individual,,231.97,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Value Individual,,31.44,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Value Individual,,154.29,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Individual,,85.34,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Individual,,11.62,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,BCBS NC,Blue Value Individual,,1394.98,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Value Individual,,1.59,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,BCBS NC,Blue Value Individual,,171.47,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Individual,,32.23,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Individual,,11.10,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,BCBS NC,Blue Value Individual,,21.66,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Value Individual,,67.11,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.34,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,BCBS NC,Blue Value Individual,,1600.52,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Value Individual,,48.35,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,BCBS NC,Blue Value Individual,,284.01,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Individual,,80.58,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,BCBS NC,Blue Value Individual,,377.28,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Individual,,80.58,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Value Individual,,532.63,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Value Individual,,532.63,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Value Individual,,354.82,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Value Individual,,128.67,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Value Individual,,114.93,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Value Individual,,591.81,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,BCBS NC,Blue Value Individual,,424.04,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Value Individual,,883.48,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Value Individual,,883.48,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Value Individual,,883.48,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Value Individual,,345.84,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,BCBS NC,Blue Value Individual,,509.64,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,BCBS NC,Blue Value Individual,,282.43,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,BCBS NC,Blue Value Individual,,504.09,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Value Individual,,324.97,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,BCBS NC,Blue Value Individual,,908.47,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,BCBS NC,Blue Value Individual,,748.39,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Value Individual,,936.51,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Value Individual,,936.51,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,BCBS NC,Blue Value Individual,,918.42,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Value Individual,,233.56,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Value Individual,,254.59,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Individual,,73.26,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,BCBS NC,Blue Value Individual,,573.62,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Value Individual,,291.44,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,BCBS NC,Blue Value Individual,,257.30,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,BCBS NC,Blue Value Individual,,286.92,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Value Individual,,511.21,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,BCBS NC,Blue Value Individual,,603.23,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,BCBS NC,Blue Value Individual,,737.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Value Individual,,553.95,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,BCBS NC,Blue Value Individual,,665.19,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,BCBS NC,Blue Value Individual,,742.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,BCBS NC,Blue Value Individual,,573.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,BCBS NC,Blue Value Individual,,700.01,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,BCBS NC,Blue Value Individual,,791.80,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,BCBS NC,Blue Value Individual,,584.24,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,BCBS NC,Blue Value Individual,,696.84,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,BCBS NC,Blue Value Individual,,794.06,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Value Individual,,946.91,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Value Individual,,897.84,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,BCBS NC,Blue Value Individual,,527.04,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Value Individual,,661.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,BCBS NC,Blue Value Individual,,777.78,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,BCBS NC,Blue Value Individual,,875.91,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,BCBS NC,Blue Value Individual,,649.36,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,BCBS NC,Blue Value Individual,,818.03,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,BCBS NC,Blue Value Individual,,837.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,BCBS NC,Blue Value Individual,,506.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,BCBS NC,Blue Value Individual,,617.03,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,BCBS NC,Blue Value Individual,,719.90,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Value Individual,,592.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Value Individual,,721.03,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Value Individual,,841.77,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,BCBS NC,Blue Value Individual,,682.37,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,BCBS NC,Blue Value Individual,,518.22,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,BCBS NC,Blue Value Individual,,647.78,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,BCBS NC,Blue Value Individual,,694.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,BCBS NC,Blue Value Individual,,663.38,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,BCBS NC,Blue Value Individual,,909.37,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,BCBS NC,Blue Value Individual,,981.95,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,BCBS NC,Blue Value Individual,,898.52,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Value Individual,,567.74,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,BCBS NC,Blue Value Individual,,730.53,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,BCBS NC,Blue Value Individual,,957.53,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,BCBS NC,Blue Value Individual,,1113.99,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,BCBS NC,Blue Value Individual,,563.89,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,BCBS NC,Blue Value Individual,,717.64,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,BCBS NC,Blue Value Individual,,849.68,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,BCBS NC,Blue Value Individual,,1664.32,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Value Individual,,7550.84,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,BCBS NC,Blue Value Individual,,1210.77,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,BCBS NC,Blue Value Individual,,1442.29,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,BCBS NC,Blue Value Individual,,1676.53,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Value Individual,,295.96,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,BCBS NC,Blue Value Individual,,917.74,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Value Individual,,897.84,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Value Individual,,946.91,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Value Individual,,661.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Value Individual,,633.08,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,BCBS NC,Blue Value Individual,,96.83,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Value Individual,,265.22,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Value Individual,,301.17,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Value Individual,,301.17,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,BCBS NC,Blue Value Individual,,327.85,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Value Individual,,398.84,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Value Individual,,398.84,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Value Individual,,429.82,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Individual,,107.40,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Value Individual,,94.23,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Value Individual,,7550.84,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Value Individual,,7550.84,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,BCBS NC,Blue Value Individual,,6894.20,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Individual,,75.21,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Value Individual,,203.55,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Individual,,175.87,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,BCBS NC,Blue Value Individual,,557.24,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,BCBS NC,Blue Value Individual,,1427.36,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Value Individual,,151.82,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,BCBS NC,Blue Value Individual,,387.81,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,BCBS NC,Blue Value Individual,,246.05,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,BCBS NC,Blue Value Individual,,12609.42,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Value Individual,,1064.17,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Value Individual,,1064.17,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,BCBS NC,Blue Value Individual,,6471.12,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,BCBS NC,Blue Value Individual,,310.36,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Value Individual,,838.52,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Value Individual,,43.34,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Value Individual,,29.22,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,BCBS NC,Blue Value Individual,,117.71,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Value Individual,,816.71,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Individual,,175.87,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Value Individual,,127.50,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,BCBS NC,Blue Value Individual,,64.87,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Individual,,56.20,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Individual,,134.49,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,BCBS NC,Blue Value Individual,,310.08,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Individual,,128.06,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Individual,,79.69,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,28.24,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,BCBS NC,Blue Value Individual,,391.44,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Value Individual,,442.33,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Value Individual,,298.21,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Value Individual,,651.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Value Individual,,439.20,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Value Individual,,86.96,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Value Individual,,86.96,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Individual,,224.80,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Individual,,151.55,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,BCBS NC,Blue Value Individual,,136.10,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Value Individual,,161.33,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Value Individual,,108.76,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,BCBS NC,Blue Value Individual,,1319.71,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,BCBS NC,Blue Value Individual,,944.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,BCBS NC,Blue Value Individual,,199.08,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Value Individual,,157.97,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,BCBS NC,Blue Value Individual,,395.35,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,BCBS NC,Blue Value Individual,,213.89,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,BCBS NC,Blue Value Individual,,361.24,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Value Individual,,162.45,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Value Individual,,356.49,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Value Individual,,240.34,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Value Individual,,326.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Value Individual,,844.11,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Value Individual,,844.11,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Individual,,83.88,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,BCBS NC,Blue Value Individual,,543.26,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Value Individual,,409.33,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Value Individual,,233.19,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,BCBS NC,Blue Value Individual,,453.79,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,BCBS NC,Blue Value Individual,,494.89,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Value Individual,,505.80,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Value Individual,,396.35,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Value Individual,,588.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Value Individual,,461.21,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Individual,,189.29,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Individual,,148.33,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Individual,,113.71,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Value Individual,,191.25,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Value Individual,,149.86,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,BCBS NC,Blue Value Individual,,589.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Value Individual,,770.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Value Individual,,603.84,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Value Individual,,445.68,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Value Individual,,349.25,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Value Individual,,256.11,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Value Individual,,200.70,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Value Individual,,315.95,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Value Individual,,247.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Value Individual,,322.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Value Individual,,252.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,BCBS NC,Blue Value Individual,,1414.50,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,BCBS NC,Blue Value Individual,,928.36,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,BCBS NC,Blue Value Individual,,222.28,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,BCBS NC,Blue Value Individual,,202.71,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Value Individual,,228.71,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Value Individual,,207.46,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,BCBS NC,Blue Value Individual,,628.26,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Value Individual,,207.46,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Value Individual,,1040.95,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Value Individual,,247.73,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,BCBS NC,Blue Value Individual,,191.81,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Individual,,54.52,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,BCBS NC,Blue Value Individual,,149.03,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Value Individual,,155.18,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,BCBS NC,Blue Value Individual,,164.96,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Value Individual,,163.01,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Value Individual,,185.93,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,BCBS NC,Blue Value Individual,,1163.97,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,BCBS NC,Blue Value Individual,,594.99,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Value Individual,,375.50,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Value Individual,,409.33,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,BCBS NC,Blue Value Individual,,194.04,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,BCBS NC,Blue Value Individual,,164.13,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,BCBS NC,Blue Value Individual,,169.44,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Value Individual,,247.17,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Value Individual,,166.63,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Value Individual,,3930.62,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Value Individual,,3080.11,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Value Individual,,3080.11,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,BCBS NC,Blue Value Individual,,1355.35,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Individual,,2939.71,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Individual,,2303.62,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Individual,,2939.71,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Individual,,2303.62,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Value Individual,,3201.98,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Value Individual,,2509.13,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,BCBS NC,Blue Value Individual,,2145.37,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Value Individual,,2209.40,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Value Individual,,1731.33,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Value Individual,,1051.68,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,BCBS NC,Blue Value Individual,,1250.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Value Individual,,1328.18,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Value Individual,,1694.94,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Value Individual,,1328.18,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Value Individual,,962.73,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,BCBS NC,Blue Value Individual,,675.79,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,BCBS NC,Blue Value Individual,,692.01,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,BCBS NC,Blue Value Individual,,450.99,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,BCBS NC,Blue Value Individual,,221.44,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Individual,,691.73,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Value Individual,,105.97,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Value Individual,,134.77,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,BCBS NC,Blue Value Individual,,78.85,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,BCBS NC,Blue Value Individual,,151.54,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Value Individual,,1480.20,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,BCBS NC,Blue Value Individual,,357.05,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Value Individual,,2095.32,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,BCBS NC,Blue Value Individual,,110.44,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Value Individual,,458.54,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Value Individual,,309.14,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,BCBS NC,Blue Value Individual,,597.23,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Individual,,171.72,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,BCBS NC,Blue Value Individual,,860.33,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,BCBS NC,Blue Value Individual,,626.02,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Individual,,149.59,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Value Individual,,284.07,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,BCBS NC,Blue Value Individual,,1077.58,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Value Individual,,179.50,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,BCBS NC,Blue Value Individual,,224.24,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Value Individual,,179.50,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,BCBS NC,Blue Value Individual,,194.32,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Value Individual,,1480.20,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Value Individual,,664.89,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,BCBS NC,Blue Value Individual,,699.56,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,BCBS NC,Blue Value Individual,,692.85,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,BCBS NC,Blue Value Individual,,177.83,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Individual,,324.34,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Individual,,48.93,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,BCBS NC,Blue Value Individual,,1758.96,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,BCBS NC,Blue Value Individual,,2171.65,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,25.16,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,BCBS NC,Blue Value Individual,,696.48,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Individual,,82.20,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Value Individual,,64.59,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Value Individual,,39.21,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Individual,,112.96,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,BCBS NC,Blue Value Individual,,114.08,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Individual,,691.73,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Individual,,56.48,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Value Individual,,445.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,BCBS NC,Blue Value Individual,,1257.36,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,BCBS NC,Blue Value Individual,,1183.83,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Value Individual,,816.71,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Value Individual,,1278.89,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Value Individual,,294.98,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Value Individual,,198.87,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,BCBS NC,Blue Value Individual,,411.29,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Individual,,80.52,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Individual,,54.29,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Value Individual,,536.27,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Value Individual,,361.54,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Value Individual,,221.11,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Value Individual,,702.08,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Value Individual,,473.32,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Value Individual,,568.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Value Individual,,383.41,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Value Individual,,485.94,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Value Individual,,327.61,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Value Individual,,442.61,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Value Individual,,298.40,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Value Individual,,460.22,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Value Individual,,310.27,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,BCBS NC,Blue Value Individual,,322.33,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Value Individual,,423.59,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Value Individual,,285.58,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Value Individual,,421.92,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Value Individual,,284.45,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Value Individual,,928.83,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Value Individual,,626.20,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Value Individual,,520.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Value Individual,,350.61,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Value Individual,,508.31,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Value Individual,,342.69,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,BCBS NC,Blue Value Individual,,644.76,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Value Individual,,102.89,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Value Individual,,915.54,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Value Individual,,61.51,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,BCBS NC,Blue Value Individual,,794.34,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,BCBS NC,Blue Value Individual,,836.00,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Value Individual,,5630.31,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Value Individual,,2993.40,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Individual,,113.71,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Value Individual,,326.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Value Individual,,300.29,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,BCBS NC,Blue Value Individual,,193.76,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,BCBS NC,Blue Value Individual,,216.97,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,BCBS NC,Blue Value Individual,,1526.06,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Value Individual,,1037.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,BCBS NC,Blue Value Individual,,1319.43,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,BCBS NC,Blue Value Individual,,1081.77,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,BCBS NC,Blue Value Individual,,1359.97,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,BCBS NC,Blue Value Individual,,1115.04,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,BCBS NC,Blue Value Individual,,471.96,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Value Individual,,160.21,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,BCBS NC,Blue Value Individual,,2086.38,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Value Individual,,556.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,BCBS NC,Blue Value Individual,,417.16,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,BCBS NC,Blue Value Individual,,741.78,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,BCBS NC,Blue Value Individual,,6302.63,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,BCBS NC,Blue Value Individual,,917.37,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,BCBS NC,Blue Value Individual,,2909.43,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,BCBS NC,Blue Value Individual,,1938.60,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,BCBS NC,Blue Value Individual,,972.73,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,BCBS NC,Blue Value Individual,,346.98,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Value Individual,,474.20,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Value Individual,,319.70,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Value Individual,,524.53,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Value Individual,,353.63,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Value Individual,,484.27,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Value Individual,,326.48,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Value Individual,,360.40,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Value Individual,,204.95,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,BCBS NC,Blue Value Individual,,343.63,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,BCBS NC,Blue Value Individual,,2003.33,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,BCBS NC,Blue Value Individual,,500.76,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,BCBS NC,Blue Value Individual,,440.65,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,BCBS NC,Blue Value Individual,,518.38,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,BCBS NC,Blue Value Individual,,292.46,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Value Individual,,1002.65,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Value Individual,,785.69,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Individual,,727.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Individual,,570.10,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Individual,,727.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Individual,,570.10,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,BCBS NC,Blue Value Individual,,968.81,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,BCBS NC,Blue Value Individual,,833.21,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,BCBS NC,Blue Value Individual,,1717.86,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,BCBS NC,Blue Value Individual,,1997.46,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,BCBS NC,Blue Value Individual,,1479.36,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,BCBS NC,Blue Value Individual,,1332.85,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,BCBS NC,Blue Value Individual,,333.28,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,BCBS NC,Blue Value Individual,,2247.42,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,BCBS NC,Blue Value Individual,,2319.56,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,BCBS NC,Blue Value Individual,,3486.61,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,BCBS NC,Blue Value Individual,,1944.62,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Value Individual,,743.18,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Value Individual,,516.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,BCBS NC,Blue Value Individual,,249.12,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Value Individual,,450.44,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,BCBS NC,Blue Value Individual,,333.00,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,BCBS NC,Blue Value Individual,,1035.08,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,BCBS NC,Blue Value Individual,,908.98,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,BCBS NC,Blue Value Individual,,909.82,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,BCBS NC,Blue Value Individual,,784.28,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Value Individual,,743.18,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,BCBS NC,Blue Value Individual,,1333.41,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,BCBS NC,Blue Value Individual,,1546.75,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,BCBS NC,Blue Value Individual,,2266.72,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,BCBS NC,Blue Value Individual,,209.98,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,BCBS NC,Blue Value Individual,,3041.21,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Value Individual,,2189.55,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,BCBS NC,Blue Value Individual,,1064.44,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,BCBS NC,Blue Value Individual,,3751.21,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,BCBS NC,Blue Value Individual,,1605.35,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Value Individual,,252.20,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Value Individual,,973.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Value Individual,,762.69,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,BCBS NC,Blue Value Individual,,3776.85,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Value Individual,,4524.49,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Value Individual,,3545.48,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Value Individual,,2459.08,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Value Individual,,1926.98,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Value Individual,,2606.43,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Value Individual,,2042.45,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,BCBS NC,Blue Value Individual,,2722.97,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,BCBS NC,Blue Value Individual,,1979.57,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,BCBS NC,Blue Value Individual,,813.64,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Value Individual,,662.09,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Value Individual,,662.09,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Individual,,224.80,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,BCBS NC,Blue Value Individual,,1834.18,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,BCBS NC,Blue Value Individual,,317.81,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,BCBS NC,Blue Value Individual,,565.07,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,BCBS NC,Blue Value Individual,,703.53,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Value Individual,,136.17,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Individual,,799.38,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Individual,,799.38,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Individual,,60.95,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Individual,,60.95,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Value Individual,,2780.34,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Value Individual,,2780.34,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,BCBS NC,Blue Value Individual,,1122.31,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,BCBS NC,Blue Value Individual,,1703.32,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,BCBS NC,Blue Value Individual,,965.18,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Value Individual,,505.80,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Individual,,175.87,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Individual,,799.38,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Individual,,799.38,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,BCBS NC,Blue Value Individual,,917.51,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,BCBS NC,Blue Value Individual,,547.74,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Value Individual,,115.33,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Value Individual,,135.04,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Individual,,92.35,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Individual,,92.35,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Value Individual,,115.33,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,BCBS NC,Blue Value Individual,,80.90,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,BCBS NC,Blue Value Individual,,226.00,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,BCBS NC,Blue Value Individual,,145.11,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,BCBS NC,Blue Value Individual,,288.70,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Value Individual,,236.62,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,BCBS NC,Blue Value Individual,,267.46,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Value Individual,,194.91,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,BCBS NC,Blue Value Individual,,211.59,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Individual,,79.63,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Value Individual,,191.62,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,BCBS NC,Blue Value Individual,,78.37,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Value Individual,,208.56,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,BCBS NC,Blue Value Individual,,242.94,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Individual,,131.20,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Individual,,161.03,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Value Individual,,107.95,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,BCBS NC,Blue Value Individual,,211.09,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Value Individual,,168.87,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Individual,,136.26,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,BCBS NC,Blue Value Individual,,166.34,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Individual,,262.15,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Value Individual,,208.05,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Value Individual,,232.32,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,BCBS NC,Blue Value Individual,,76.09,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,BCBS NC,Blue Value Individual,,297.80,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,BCBS NC,Blue Value Individual,,193.14,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Value Individual,,63.20,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Value Individual,,58.40,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Individual,,47.02,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,BCBS NC,Blue Value Individual,,278.59,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Value Individual,,208.56,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Value Individual,,50.31,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,12.89,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Value Individual,,172.92,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Individual,,106.68,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Value Individual,,244.46,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,BCBS NC,Blue Value Individual,,183.03,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Individual,,104.41,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Value Individual,,124.38,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Value Individual,,116.04,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,27.81,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Individual,,34.42,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Value Individual,,19.71,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Value Individual,,32.07,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,BCBS NC,Blue Value Individual,,1113.08,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,BCBS NC,Blue Value Individual,,811.19,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,BCBS NC,Blue Value Individual,,728.92,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,BCBS NC,Blue Value Individual,,1131.38,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Value Individual,,1071.94,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,BCBS NC,Blue Value Individual,,710.17,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Value Individual,,1071.94,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Value Individual,,1071.94,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,BCBS NC,Blue Value Individual,,162.27,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,BCBS NC,Blue Value Individual,,266.85,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,BCBS NC,Blue Value Individual,,533.53,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,BCBS NC,Blue Value Individual,,812.24,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,BCBS NC,Blue Value Individual,,727.88,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,BCBS NC,Blue Value Individual,,1054.86,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,BCBS NC,Blue Value Individual,,1550.57,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,BCBS NC,Blue Value Individual,,73.94,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Value Individual,,126.13,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Individual,,80.11,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,BCBS NC,Blue Value Individual,,141.98,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Value Individual,,383.86,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Value Individual,,346.40,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Individual,,67.48,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Value Individual,,592.14,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,BCBS NC,Blue Value Individual,,692.97,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,BCBS NC,Blue Value Individual,,1067.02,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,BCBS NC,Blue Value Individual,,1289.73,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,BCBS NC,Blue Value Individual,,728.12,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,BCBS NC,Blue Value Individual,,1088.92,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,BCBS NC,Blue Value Individual,,1134.17,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,BCBS NC,Blue Value Individual,,758.64,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,BCBS NC,Blue Value Individual,,792.53,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Value Individual,,1085.76,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,BCBS NC,Blue Value Individual,,730.86,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,BCBS NC,Blue Value Individual,,858.00,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,BCBS NC,Blue Value Individual,,989.14,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,BCBS NC,Blue Value Individual,,780.53,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,BCBS NC,Blue Value Individual,,819.27,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,BCBS NC,Blue Value Individual,,1122.39,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,BCBS NC,Blue Value Individual,,773.59,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Value Individual,,781.38,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Value Individual,,1085.76,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,BCBS NC,Blue Value Individual,,895.89,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,BCBS NC,Blue Value Individual,,947.46,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,BCBS NC,Blue Value Individual,,1101.76,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,BCBS NC,Blue Value Individual,,614.45,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,BCBS NC,Blue Value Individual,,880.94,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,BCBS NC,Blue Value Individual,,667.71,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Individual,,53.26,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Value Individual,52,831.90,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,BCBS NC,Blue Value Individual,52,827.90,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,BCBS NC,Blue Value Individual,,808.95,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,BCBS NC,Blue Value Individual,,927.25,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,BCBS NC,Blue Value Individual,,1093.76,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,BCBS NC,Blue Value Individual,,847.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,BCBS NC,Blue Value Individual,,870.42,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,BCBS NC,Blue Value Individual,,740.12,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,BCBS NC,Blue Value Individual,,899.68,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Value Individual,,741.59,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,BCBS NC,Blue Value Individual,,852.74,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,BCBS NC,Blue Value Individual,,1074.39,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,BCBS NC,Blue Value Individual,,1033.98,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,BCBS NC,Blue Value Individual,,1148.07,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,BCBS NC,Blue Value Individual,,882.00,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,BCBS NC,Blue Value Individual,,976.09,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,BCBS NC,Blue Value Individual,,1175.85,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,BCBS NC,Blue Value Individual,,730.01,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,BCBS NC,Blue Value Individual,,772.75,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,BCBS NC,Blue Value Individual,,1124.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,BCBS NC,Blue Value Individual,,683.07,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,BCBS NC,Blue Value Individual,,757.59,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,BCBS NC,Blue Value Individual,,1052.29,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,BCBS NC,Blue Value Individual,,889.36,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,BCBS NC,Blue Value Individual,,681.18,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,BCBS NC,Blue Value Individual,,941.36,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Value Individual,,892.10,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Value Individual,,892.10,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Value Individual,,892.10,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,BCBS NC,Blue Value Individual,,744.12,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Value Individual,,856.31,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Value Individual,,856.31,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,BCBS NC,Blue Value Individual,,945.78,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,BCBS NC,Blue Value Individual,,684.12,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,BCBS NC,Blue Value Individual,,967.04,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,BCBS NC,Blue Value Individual,,940.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Value Individual,,888.94,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Value Individual,,888.94,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Value Individual,,955.67,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Value Individual,,955.67,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Value Individual,,955.67,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Value Individual,,741.59,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Value Individual,,217.45,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,BCBS NC,Blue Value Individual,,505.20,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,BCBS NC,Blue Value Individual,,502.04,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Value Individual,,831.90,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,BCBS NC,Blue Value Individual,,394.69,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Value Individual,,95.76,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Individual,,84.01,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Individual,,103.46,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Value Individual,,487.90,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Value Individual,,328.93,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Individual,,29.78,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Value Individual,,511.95,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Value Individual,,345.14,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,BCBS NC,Blue Value Individual,,157.56,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Value Individual,,94.01,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Individual,,82.70,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Individual,,82.70,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,BCBS NC,Blue Value Individual,,226.16,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Individual,,180.54,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Value Individual,,147.46,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Individual,,107.25,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Value Individual,,104.29,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Individual,,50.84,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Value Individual,,112.36,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Individual,,82.64,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Individual,,75.08,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,BCBS NC,Blue Value Individual,,177.28,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Value Individual,,73.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Individual,,151.73,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Individual,,151.73,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,BCBS NC,Blue Value Individual,,374.37,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Value Individual,,196.05,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Value Individual,,486.47,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,BCBS NC,Blue Value Individual,,1134.05,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,BCBS NC,Blue Value Individual,,65.70,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Value Individual,,46.14,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Value Individual,,96.20,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Value Individual,,47.71,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Value Individual,,111.32,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Value Individual,,85.77,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Individual,,71.69,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Individual,,104.02,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,BCBS NC,Blue Value Individual,,164.50,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Individual,,135.04,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,BCBS NC,Blue Value Individual,,227.85,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,BCBS NC,Blue Value Individual,,146.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Individual,,14.86,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Value Individual,,94.37,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Value Individual,,197.09,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Individual,,79.51,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Value Individual,,173.37,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Individual,,110.02,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Value Individual,,249.23,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Value Individual,,156.16,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Individual,,110.02,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Individual,,119.40,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,BCBS NC,Blue Value Individual,,94.89,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,BCBS NC,Blue Value Individual,,658.01,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,BCBS NC,Blue Value Individual,,565.46,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Value Individual,,288.33,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,BCBS NC,Blue Value Individual,,135.82,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,BCBS NC,Blue Value Individual,,144.17,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Value Individual,,87.60,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Individual,,33.37,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Value Individual,,133.48,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Individual,,105.32,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Individual,,105.32,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,BCBS NC,Blue Value Individual,,626.72,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Individual,,12.25,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,BCBS NC,Blue Value Individual,,3.65,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Value Individual,,29.20,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Individual,,42.49,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Individual,,34.41,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Individual,,6.78,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Individual,,11.47,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Individual,,49.27,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Value Individual,,69.09,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00261,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Individual,,22.94,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Individual,,65.96,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Individual,,49.27,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Value Individual,,103.50,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Value Individual,,40.41,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Individual,,24.25,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Individual,,139.47,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,23.72,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,23.72,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Individual,,18.51,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Individual,,34.67,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Individual,,34.67,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Individual,,34.67,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,16.42,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Individual,,7.56,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Individual,,18.77,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Value Individual,,46.14,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Value Individual,,32.33,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Individual,,10.17,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Individual,,37.80,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Individual,,37.80,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Individual,,37.80,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,23.46,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,23.46,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,23.46,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Value Individual,,40.15,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Individual,,7.56,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Individual,,11.21,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Individual,,10.95,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Individual,,49.01,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Individual,,12.51,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Individual,,42.23,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Individual,,29.98,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Individual,,29.98,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Individual,,29.98,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Individual,,26.07,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Individual,,10.95,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Individual,,24.25,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,BCBS NC,Blue Value Individual,,15.64,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Individual,,10.43,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Individual,,10.43,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Value Individual,,43.28,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,,23.20,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,,23.20,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Individual,,17.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Value Individual,,13.82,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Value Individual,,67.26,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,16.42,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,24.77,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,24.77,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,6.26,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Individual,,17.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Value Individual,,63.35,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,23.46,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,23.46,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Individual,,46.93,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Individual,,24.25,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Value Individual,,38.06,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Individual,,20.60,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Individual,,10.17,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Value Individual,,77.95,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Value Individual,,1.56,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Individual,,24.25,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Individual,,52.40,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Value Individual,,150.95,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Individual,,40.93,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Individual,,31.81,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Individual,,31.81,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Individual,,31.81,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Individual,,31.81,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Individual,,10.17,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Individual,,49.01,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Individual,,52.92,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Individual,,52.92,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Individual,,52.92,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Individual,,52.92,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Individual,,7.82,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,28.68,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,28.68,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,28.68,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Individual,,18.51,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Value Individual,,44.58,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Individual,,42.23,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Value Individual,,20.33,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Value Individual,,62.05,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Individual,,40.67,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Individual,,24.25,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Value Individual,,57.61,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Individual,,31.28,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Individual,,39.63,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Individual,,12.25,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Individual,,12.25,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.00,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,BCBS NC,Blue Value Individual,,51.36,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Individual,,34.41,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Individual,,10.43,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Individual,,21.90,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Individual,,9.91,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Individual,,20.86,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Individual,,20.86,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Individual,,10.95,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Individual,,41.19,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Individual,,41.19,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Value Individual,,38.84,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Individual,,18.77,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Individual,,9.91,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Individual,,26.07,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Individual,,37.28,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Individual,,21.64,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,24.77,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Individual,,37.28,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Value Individual,,46.14,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Individual,,6.78,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Individual,,6.78,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Individual,,6.78,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,15.12,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Individual,,27.89,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Value Individual,,0.52140,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Value Individual,,85.77,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Individual,,14.34,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.07,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Value Individual,,38.06,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Value Individual,,59.18,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Individual,,56.05,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Individual,,56.05,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Individual,,11.73,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,15.90,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,15.90,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Value Individual,,13.82,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Individual,,26.07,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Individual,,13.04,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Individual,,17.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Individual,,11.73,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Individual,,8.34,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Individual,,8.34,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Individual,,11.21,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Individual,,3.91,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Value Individual,,43.54,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Individual,,11.73,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Individual,,41.71,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,BCBS NC,Blue Value Individual,,49.53,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,15.90,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Individual,,18.77,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,19.29,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Individual,,17.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Individual,,34.93,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Individual,,33.89,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Value Individual,,28.16,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Individual,,9.91,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.07,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Individual,,29.98,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Individual,,29.98,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Individual,,33.89,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Value Individual,,50.32,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Individual,,20.60,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Individual,,3.13,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Individual,,96.72,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Individual,,96.72,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Value Individual,,58.66,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Individual,,8.34,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Individual,,36.50,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Individual,,29.46,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Individual,,25.29,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Value Individual,,35.72,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Individual,,31.28,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,BCBS NC,Blue Value Individual,,2.09,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Value Individual,,5.74,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Individual,,27.63,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Value Individual,,45.36,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Individual,,9.65,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Individual,,33.37,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Value Individual,,69.61,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Value Individual,,38.32,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Individual,,71.17,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Value Individual,,53.96,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Individual,,13.04,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Value Individual,,61.79,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Individual,,49.01,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,30.76,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,19.45,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,5.76,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,BCBS NC,Blue Value Individual,,53.70,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Value Individual,,10.69,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Value Individual,,76.39,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Individual,,52.40,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Individual,,11.99,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Individual,,29.46,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Individual,,29.46,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Individual,,13.04,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Individual,,35.19,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,BCBS NC,Blue Value Individual,,58.14,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Value Individual,,5.47,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,14.60,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Individual,,14.86,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Individual,,37.80,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Value Individual,,17.73,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,,30.50,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Value Individual,,45.10,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Individual,,25.29,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Individual,,30.24,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Individual,,30.24,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.07,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Individual,,3.91,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,,23.20,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,,23.20,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Individual,,9.12,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Individual,,11.73,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Value Individual,,17.99,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Value Individual,,120.18,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,16.42,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Individual,,31.81,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Individual,,18.77,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Individual,,50.84,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Individual,,21.64,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Value Individual,,2.87,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Individual,,9.12,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Individual,,35.19,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Value Individual,,28.16,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,14.60,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.07,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Value Individual,,207.00,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Value Individual,,116.53,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Value Individual,,69.35,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,BCBS NC,Blue Value Individual,,148.60,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Value Individual,,219.25,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,,43.02,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Individual,,77.17,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Value Individual,,94.11,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Individual,,22.16,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Individual,,22.16,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Individual,,22.16,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,BCBS NC,Blue Value Individual,,60.74,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Individual,,37.80,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Individual,,32.07,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Individual,,34.93,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Value Individual,,51.10,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Value Individual,,45.10,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,15.90,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Value Individual,,130.61,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,BCBS NC,Blue Value Individual,,192.14,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Individual,,32.85,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Individual,,36.24,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Individual,,9.65,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Individual,,39.10,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,30.76,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Individual,,24.25,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Individual,,42.23,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.07,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Value Individual,,112.88,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Value Individual,,112.88,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Individual,,84.21,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Individual,,71.69,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Value Individual,,75.86,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Value Individual,,68.82,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,BCBS NC,Blue Value Individual,,159.55,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Individual,,41.97,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.07,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Value Individual,,61.79,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Value Individual,,51.88,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Individual,,25.81,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Value Individual,,84.73,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Value Individual,,70.65,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Individual,,84.21,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,BCBS NC,Blue Value Individual,,65.44,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Individual,,47.45,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Individual,,48.49,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Individual,,48.49,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Value Individual,,64.39,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Individual,,18.77,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Individual,,11.47,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Individual,,39.10,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Value Individual,,51.10,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,BCBS NC,Blue Value Individual,,122.01,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,BCBS NC,Blue Value Individual,,73.78,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,19.29,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Individual,,9.12,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,14.60,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Individual,,18.77,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Individual,,29.46,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Value Individual,,92.81,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Value Individual,,38.06,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,16.42,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Individual,,52.66,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Individual,,37.28,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,,30.50,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Individual,,30.50,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Individual,,20.60,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Value Individual,,26.59,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,14.60,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Individual,,22.16,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Value Individual,,25.55,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,14.60,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Value Individual,,58.40,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Individual,,20.86,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Individual,,10.17,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,24.77,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,24.77,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Individual,,12.25,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Individual,,3.91,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Value Individual,,10.69,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,15.90,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Individual,,49.01,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Individual,,31.81,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Individual,,33.89,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Individual,,18.51,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Individual,,40.93,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Value Individual,,7.04,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Value Individual,,13.82,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Value Individual,,48.75,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Value Individual,,48.75,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Individual,,25.29,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Individual,,55.53,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Individual,,53.18,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,19.29,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Individual,,8.34,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Individual,,53.18,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Individual,,8.08,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Individual,,18.25,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Individual,,37.80,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Individual,,23.98,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Individual,,10.17,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Individual,,7.82,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Individual,,7.82,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Individual,,6.78,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,6.26,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,,33.63,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Individual,,30.24,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Individual,,20.60,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,28.68,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Value Individual,,4.69,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,19.29,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,19.29,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,19.29,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,19.29,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,BCBS NC,Blue Value Individual,,88.38,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Value Individual,,17.73,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Individual,,21.90,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,,23.20,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,15.90,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Value Individual,,4.17,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,BCBS NC,Blue Value Individual,,63.87,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Individual,,21.90,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Value Individual,,40.15,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Individual,,9.65,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Individual,,25.81,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Value Individual,,20.33,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Individual,,10.43,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Individual,,14.86,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Individual,,9.91,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,24.77,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Individual,,16.42,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Individual,,46.93,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Value Individual,,8.60,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Individual,,9.91,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,BCBS NC,Blue Value Individual,,59.44,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Value Individual,,44.06,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Value Individual,,120.18,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Individual,,55.53,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Individual,,55.53,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Individual,,163.98,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Value Individual,,151.47,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Value Individual,,45.36,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Individual,,41.97,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Individual,,91.25,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Individual,,55.27,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Individual,,42.75,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Individual,,42.75,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Individual,,71.69,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,BCBS NC,Blue Value Individual,,67.00,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Value Individual,,200.74,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Value Individual,,22.68,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Individual,,21.64,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Individual,,12.51,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Value Individual,,29.20,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Value Individual,,150.95,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,BCBS NC,Blue Value Individual,,72.74,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Individual,,14.34,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Value Individual,,40.15,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Value Individual,,25.03,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Value Individual,,25.03,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Value Individual,,25.03,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Individual,,120.70,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Individual,,76.65,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Individual,,22.94,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Individual,,22.94,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Individual,,13.30,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Individual,,32.85,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Individual,,3.13,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Individual,,39.10,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Individual,,31.28,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Value Individual,,131.57,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Value Individual,,80.56,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Individual,,33.11,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Individual,,9.39,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Value Individual,,5.74,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Value Individual,,59.96,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,20.07,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Individual,,7.56,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Value Individual,,4.69,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Individual,,27.63,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Individual,,15.12,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Individual,,9.12,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Individual,,9.12,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Value Individual,,4.95,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Individual,,15.90,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Value Individual,,16.68,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Individual,,11.99,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Individual,,14.60,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Individual,,18.51,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Individual,,3.91,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Individual,,7.82,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Individual,,65.96,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Individual,,34.93,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Value Individual,,44.58,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Individual,,6.78,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Individual,,42.23,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Individual,,20.60,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,14.08,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Individual,,7.56,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00240,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Value Individual,,99.40,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Value Individual,,0.52140,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Individual,,135.04,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Individual,,21.12,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Individual,,7.56,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Individual,,41.97,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Value Individual,,510.97,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,24.77,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Value Individual,,36.76,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,,23.20,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Value Individual,,8.86,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Individual,,9.91,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Individual,,18.25,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Individual,,18.25,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Individual,,3.91,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Individual,,9.12,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Individual,,19.55,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Individual,,12.77,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Value Individual,,137.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,BCBS NC,Blue Value Individual,,199.96,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Individual,,34.93,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,BCBS NC,Blue Value Individual,,470.56,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,BCBS NC,Blue Value Individual,,302.05,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Value Individual,,70.35,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Individual,,30.24,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Value Individual,,503.41,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Value Individual,,6.00,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Value Individual,,67.52,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Individual,,11.99,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,BCBS NC,Blue Value Individual,,471.35,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Individual,,184.31,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,16.16,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Individual,,27.89,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,BCBS NC,Blue Value Individual,,133.74,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Individual,,49.27,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Value Individual,,510.97,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,BCBS NC,Blue Value Individual,,29.72,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Individual,,84.47,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,35.46,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Value Individual,,50.58,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Value Individual,,248.45,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,BCBS NC,Blue Value Individual,,166.59,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Individual,,36.50,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Individual,QW,36.50,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Individual,,11.99,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Value Individual,,72.47,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Value Individual,,414.25,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,BCBS NC,Blue Value Individual,,309.45,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Value Individual,,66.75,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Value Individual,,158.77,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,BCBS NC,Blue Value Individual,,124.61,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Individual,,53.18,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Value Individual,,111.06,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Individual,,13.04,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,28.68,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Individual,QW,26.07,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Individual,,26.07,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Individual,,42.49,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,BCBS NC,Blue Value Individual,,236.45,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Individual,,71.69,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Individual,,34.41,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,,43.02,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Individual,,23.20,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Individual,,11.21,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Value Individual,,73.00,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Individual,,20.60,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Value Individual,,50.58,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,23.72,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Value Individual,,17.99,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Individual,,17.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Individual,,91.25,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Individual,,35.19,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Individual,,55.53,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,BCBS NC,Blue Value Individual,,57.09,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Individual,,35.19,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Individual,,35.19,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Individual,,71.69,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Individual,,11.73,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Individual,,11.73,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,BCBS NC,Blue Value Individual,,19.81,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Individual,,11.21,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Individual,,21.90,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Individual,,26.33,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Value Individual,,38.84,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,BCBS NC,Blue Value Individual,,346.21,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Individual,,14.34,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Value Individual,,28.16,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,30.76,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Individual,,30.76,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Individual,,16.95,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Individual,,14.86,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Value Individual,,70.65,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Value Individual,,43.54,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Value Individual,,70.65,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Value Individual,,83.16,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Individual,,143.99,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,BCBS NC,Blue Value Individual,,137.13,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,BCBS NC,Blue Value Individual,,54.75,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00240,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Value Individual,,7.04,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Individual,,26.41,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Individual,,44.66,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Value Individual,,35.29,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Value Individual,,35.29,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Individual,,9.36,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,BCBS NC,Blue Value Individual,,47.54,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Value Individual,,28.57,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,BCBS NC,Blue Value Individual,,61.23,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Value Individual,,62.67,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,32.65,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Value Individual,,18.73,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Individual,,32.65,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Value Individual,,50.18,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Value Individual,,49.70,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Individual,,124.37,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Value Individual,,35.53,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Value Individual,,109.49,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Value Individual,,143.34,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,BCBS NC,Blue Value Individual,,181.28,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,BCBS NC,Blue Value Individual,,134.70,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Value Individual,,78.03,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Value Individual,,54.02,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,BCBS NC,Blue Value Individual,,244.66,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Value Individual,,85.00,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Value Individual,,146.22,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Value Individual,,53.78,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Individual,,19.21,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Individual,,31.69,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Individual,,32.41,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Value Individual,,131.57,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Value Individual,,24.49,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Individual,,42.02,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Value Individual,,88.12,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Individual,,158.47,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Individual,,0.00240,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Value Individual,,29.77,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,BCBS NC,Blue Value Individual,,54.26,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,BCBS NC,Blue Value Individual,,88.84,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Value Individual,,76.59,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Value Individual,,76.59,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,BCBS NC,Blue Value Individual,,142.38,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Value Individual,,131.57,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Individual,,23.29,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,,30.97,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Value Individual,,94.60,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Individual,,75.15,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Value Individual,,59.78,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Individual,,18.49,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,BCBS NC,Blue Value Individual,,92.20,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Individual,,31.69,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,BCBS NC,Blue Value Individual,,162.07,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Individual,,45.38,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Value Individual,,99.40,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,BCBS NC,Blue Value Individual,,66.74,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Value Individual,,62.67,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Individual,,37.70,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Individual,,37.70,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Individual,,129.41,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Individual,,33.37,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Individual,,39.38,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Value Individual,,4.32,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Value Individual,,99.40,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,21.85,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Value Individual,,59.30,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,BCBS NC,Blue Value Individual,,526.06,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Value Individual,,84.76,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Value Individual,,46.10,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Value Individual,,169.99,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Individual,,124.37,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Value Individual,,85.00,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Individual,,92.44,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Value Individual,,88.12,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Individual,,92.44,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Individual,,124.61,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,BCBS NC,Blue Value Individual,,308.53,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Individual,,19.21,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Individual,,92.44,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Value Individual,,88.12,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,BCBS NC,Blue Value Individual,,74.91,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Individual,,30.97,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,BCBS NC,Blue Value Individual,,298.44,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,5.76,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,5.76,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,5.76,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,5.76,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,5.76,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Individual,,5.76,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Value Individual,,46.10,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Individual,,19.21,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,BCBS NC,Blue Value Individual,,218.01,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Individual,,158.47,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Value Individual,,113.81,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Value Individual,,85.48,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,BCBS NC,Blue Value Individual,,30.01,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Individual,,36.02,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Individual,,22.81,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Value Individual,,39.86,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Individual,,19.21,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,BCBS NC,Blue Value Individual,,38.18,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Value Individual,,381.52,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,BCBS NC,Blue Value Individual,,191.60,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,BCBS NC,Blue Value Individual,,78.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Individual,,17.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Individual,,10.95,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,BCBS NC,Blue Value Individual,,27.37,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,BCBS NC,Blue Value Individual,,64.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,10.79,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Individual,,52.23,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Individual,,52.23,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Value Individual,,48.23,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,BCBS NC,Blue Value Individual,,98.54,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,15.84,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,15.84,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Individual,,9.92,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,BCBS NC,Blue Value Individual,,118.21,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,BCBS NC,Blue Value Individual,,113.34,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Individual,,181.24,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,BCBS NC,Blue Value Individual,,186.29,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Individual,,37.43,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,BCBS NC,Blue Value Individual,,72.95,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Individual,,51.19,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Value Individual,,165.22,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,BCBS NC,Blue Value Individual,,215.88,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Value Individual,,104.46,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Individual,,15.84,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Value Individual,,266.02,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Individual,,7.30,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,,43.02,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,,43.02,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Individual,,43.02,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Individual,,15.38,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Individual,,181.24,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Individual,,181.24,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Individual,,201.96,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,10.79,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,10.79,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,10.79,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,10.79,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Individual,,10.79,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,BCBS NC,Blue Value Individual,,573.17,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Individual,,2396.17,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Individual,,1877.69,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Individual,,2396.17,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Individual,,2396.17,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Individual,,1877.69,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,BCBS NC,Blue Value Individual,,7773.01,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,BCBS NC,Blue Value Individual,,1317.23,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Individual,,542.05,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Individual,,691.73,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,BCBS NC,Blue Value Individual,,1471.26,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,BCBS NC,Blue Value Individual,,447.62,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,BCBS NC,Blue Value Individual,,737.93,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Value Individual,,199.16,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Value Individual,,199.16,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Value Individual,,553.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Value Individual,,434.04,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Value Individual,,1164.81,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Value Individual,,912.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Value Individual,,530.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Value Individual,,415.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Value Individual,,124.98,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Value Individual,,180.32,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Individual,,501.60,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Individual,,393.07,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Individual,,395.91,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Individual,,310.25,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Value Individual,,443.45,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Value Individual,,347.49,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Individual,,395.91,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Individual,,310.25,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,BCBS NC,Blue Value Individual,,1690.79,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Value Individual,,1078.70,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Value Individual,,845.29,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Value Individual,,2003.61,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Value Individual,,1570.07,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Individual,,1541.16,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Individual,,1207.68,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Value Individual,,385.29,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Value Individual,,301.92,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Individual,,1541.16,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Individual,,1207.68,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,BCBS NC,Blue Value Individual,,582.59,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Individual,,2396.17,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Individual,,1877.69,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Value Individual,,222.00,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,BCBS NC,Blue Value Individual,,6366.39,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Value Individual,,1228.56,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Value Individual,,962.73,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,122.74,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,96.18,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,122.74,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Individual,,96.18,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Individual,,631.06,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Individual,,494.51,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Individual,,631.06,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Individual,,494.51,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Value Individual,,4677.43,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Value Individual,,3665.32,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Value Individual,,7795.81,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Value Individual,,6108.95,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Value Individual,,2806.35,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Value Individual,,2199.11,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Value Individual,,6470.50,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Value Individual,,5070.41,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Value Individual,,2602.24,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Value Individual,,2039.16,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Value Individual,,6564.73,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Value Individual,,5144.25,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Value Individual,,5914.10,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Value Individual,,4634.40,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Value Individual,,7865.99,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Value Individual,,6163.94,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,BCBS NC,Blue Value Individual,,2701.06,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Value Individual,,6514.68,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Value Individual,,5105.03,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Value Individual,,5928.64,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Value Individual,,4645.80,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Value Individual,,6721.58,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Value Individual,,5267.16,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Value Individual,,2654.24,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Value Individual,,2079.92,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Value Individual,,5721.73,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Value Individual,,4483.66,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Value Individual,,4929.07,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Value Individual,,3862.51,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,BCBS NC,Blue Value Individual,,5756.40,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Individual,LM,3549.20,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Individual,RI,3549.20,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Individual,RC,3549.20,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Individual,LD,3549.20,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Individual,LC,3549.20,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Individual,LC,1831.02,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Individual,RI,1831.02,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Individual,RC,1831.02,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Individual,LD,1831.02,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Individual,LC,1831.02,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,LM,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,RI,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,RC,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,LD,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,LC,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,LM,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,RI,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,RC,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,LD,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Individual,LC,3145.84,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,LM,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,RI,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,RC,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,LD,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,LC,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,LM,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,RI,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,RC,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,LD,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Individual,LC,4695.31,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,LM,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,RI,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,RC,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,LD,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,LC,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,RC,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,LD,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Individual,LC,4976.86,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LM,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,RI,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,RC,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LD,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LC,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LM,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,RI,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,RC,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LD,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LC,8873.99,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LM,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,RI,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,RC,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LD,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LC,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,RC,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LD,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Individual,LC,8873.99,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Value Individual,,5070.63,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Value Individual,,5070.63,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Value Individual,,5211.73,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Value Individual,,5211.73,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,LM,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,RI,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,RC,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,LD,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,LC,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,LM,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,RI,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,RC,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,LD,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Individual,LC,5446.39,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LM,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,RI,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,RC,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LD,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LC,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LM,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,RI,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,RC,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LD,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LC,5681.26,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LM,5681.26,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,RI,5681.26,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,RC,5681.26,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LD,5681.26,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Individual,LC,5681.26,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,BCBS NC,Blue Value Individual,,86.11,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,BCBS NC,Blue Value Individual,,222.64,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Individual,,408.62,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Individual,,92.46,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,BCBS NC,Blue Value Individual,,553.67,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,BCBS NC,Blue Value Individual,,216.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,BCBS NC,Blue Value Individual,,2535.43,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Value Individual,,2345.68,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Value Individual,,2345.68,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,BCBS NC,Blue Value Individual,,2237.01,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,BCBS NC,Blue Value Individual,,931.17,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,BCBS NC,Blue Value Individual,,1614.11,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,BCBS NC,Blue Value Individual,,2386.66,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,BCBS NC,Blue Value Individual,,2119.35,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,BCBS NC,Blue Value Individual,,2262.43,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,BCBS NC,Blue Value Individual,,995.37,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,BCBS NC,Blue Value Individual,,2327.72,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,BCBS NC,Blue Value Individual,,2903.29,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,BCBS NC,Blue Value Individual,,2615.40,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,BCBS NC,Blue Value Individual,,2790.02,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,BCBS NC,Blue Value Individual,,2837.34,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,BCBS NC,Blue Value Individual,,3478.65,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,BCBS NC,Blue Value Individual,,1485.06,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Individual,,44.48,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Individual,,21.25,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,BCBS NC,Blue Value Individual,,329.31,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,BCBS NC,Blue Value Individual,,904.44,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,BCBS NC,Blue Value Individual,,1766.82,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Value Individual,,106.04,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,137.16,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Individual,,137.16,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Individual,,47.11,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,BCBS NC,Blue Value Individual,,1680.72,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,BCBS NC,Blue Value Individual,,8574.04,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,BCBS NC,Blue Value Individual,,1643.33,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,BCBS NC,Blue Value Individual,,337.85,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,BCBS NC,Blue Value Individual,,377.85,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,BCBS NC,Blue Value Individual,,277.38,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Value Individual,,147.63,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Value Individual,,115.68,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Value Individual,,115.68,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Value Individual,,2203.81,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Value Individual,,1726.95,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Value Individual,,4188.13,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Value Individual,,4188.13,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,BCBS NC,Blue Value Individual,,5107.45,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,BCBS NC,Blue Value Individual,,3709.73,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,BCBS NC,Blue Value Individual,,4215.53,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,BCBS NC,Blue Value Individual,,5087.04,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,BCBS NC,Blue Value Individual,,892.76,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Value Individual,,3939.28,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Value Individual,,3939.28,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,BCBS NC,Blue Value Individual,,2856.11,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,BCBS NC,Blue Value Individual,,823.14,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Value Individual,,811.40,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Value Individual,,811.40,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,BCBS NC,Blue Value Individual,,5701.60,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,BCBS NC,Blue Value Individual,,4173.03,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,BCBS NC,Blue Value Individual,,661.81,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,BCBS NC,Blue Value Individual,,6650.57,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,BCBS NC,Blue Value Individual,,6856.07,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,BCBS NC,Blue Value Individual,,7473.15,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,BCBS NC,Blue Value Individual,,2378.84,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Value Individual,,3187.72,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Value Individual,,3187.72,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,BCBS NC,Blue Value Individual,,13948.41,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,BCBS NC,Blue Value Individual,,1607.70,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,BCBS NC,Blue Value Individual,,1068.35,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,BCBS NC,Blue Value Individual,,16132.36,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Value Individual,,737.86,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,BCBS NC,Blue Value Individual,,2199.23,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,BCBS NC,Blue Value Individual,,583.25,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Value Individual,,1170.96,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Value Individual,,867.02,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Value Individual,,867.02,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Value Individual,,432.44,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Value Individual,,307.07,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Value Individual,,432.44,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Value Individual,,432.44,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,BCBS NC,Blue Value Individual,,407.15,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,BCBS NC,Blue Value Individual,,372.90,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,BCBS NC,Blue Value Individual,,1281.80,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Value Individual,,2037.77,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Value Individual,,2037.77,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,BCBS NC,Blue Value Individual,,217.29,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,BCBS NC,Blue Value Individual,,1081.64,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,BCBS NC,Blue Value Individual,,221.84,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,BCBS NC,Blue Value Individual,,422.27,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,BCBS NC,Blue Value Individual,,3404.14,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Value Individual,,3015.05,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Value Individual,,3015.05,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,BCBS NC,Blue Value Individual,,404.75,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Value Individual,,189.73,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Value Individual,,4412.02,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,BCBS NC,Blue Value Individual,,6257.73,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,BCBS NC,Blue Value Individual,,693.97,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Value Individual,,423.08,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Value Individual,,1551.22,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Value Individual,,1551.22,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,BCBS NC,Blue Value Individual,,1783.01,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,BCBS NC,Blue Value Individual,,564.18,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,BCBS NC,Blue Value Individual,,3006.27,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Value Individual,,1051.68,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Value Individual,,189.73,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Value Individual,,466.03,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,BCBS NC,Blue Value Individual,,621.37,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,BCBS NC,Blue Value Individual,,1745.13,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,BCBS NC,Blue Value Individual,,4058.17,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,BCBS NC,Blue Value Individual,,2020.98,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,BCBS NC,Blue Value Individual,,1416.92,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,BCBS NC,Blue Value Individual,,1637.99,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Individual,,63.10,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Value Individual,,396.47,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,BCBS NC,Blue Value Individual,,2228.41,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Individual,,406.89,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Individual,,406.89,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Individual,,406.89,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Individual,,406.89,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,BCBS NC,Blue Value Individual,,2914.25,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Value Individual,,5828.50,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Value Individual,,5828.50,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,BCBS NC,Blue Value Individual,,9383.83,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,BCBS NC,Blue Value Individual,,7660.17,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Value Individual,,2649.49,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,BCBS NC,Blue Value Individual,,951.99,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,BCBS NC,Blue Value Individual,,4690.05,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Value Individual,,7502.20,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Value Individual,,7502.20,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Value Individual,,7502.20,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,BCBS NC,Blue Value Individual,,9051.49,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Value Individual,,1482.43,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Value Individual,,1482.43,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Individual,,23.44,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Value Individual,,5237.20,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Value Individual,,5237.20,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,BCBS NC,Blue Value Individual,,6414.91,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,BCBS NC,Blue Value Individual,,525.62,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,BCBS NC,Blue Value Individual,,1422.84,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Value Individual,,2374.39,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Individual,LD,752.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Individual,RC,752.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Individual,RI,752.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Individual,LM,752.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Individual,LD,602.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Individual,RC,602.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Individual,RI,602.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Individual,LM,602.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Individual,LD,516.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Individual,RC,516.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Individual,RI,516.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Individual,LM,516.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,LD,108.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,RC,108.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,RI,108.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,LM,108.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Individual,LC,752.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Individual,LC,602.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Individual,LC,516.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Individual,LC,108.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,BCBS NC,Blue Value Individual,,7145.07,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,BCBS NC,Blue Value Individual,,13526.58,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,BCBS NC,Blue Value Individual,,2498.40,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,BCBS NC,Blue Value Individual,,624.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,BCBS NC,Blue Value Individual,,145.36,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,BCBS NC,Blue Value Individual,,538.01,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,BCBS NC,Blue Value Individual,,442.08,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,BCBS NC,Blue Value Individual,,198.53,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,BCBS NC,Blue Value Individual,,219.29,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,BCBS NC,Blue Value Individual,,162.33,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Value Individual,,312.73,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Value Individual,,312.73,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Value Individual,,126.13,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Value Individual,,101.86,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Value Individual,,101.86,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Value Individual,,358.89,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Value Individual,,358.89,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Individual,,69.59,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Individual,,54.02,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Value Individual,,383.86,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Individual,,7.72,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Value Individual,,191.93,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Value Individual,,63.01,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Value Individual,,226.89,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,BCBS NC,Blue Value Individual,,161.28,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Individual,,42.01,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Value Individual,,33.60,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,BCBS NC,Blue Value Individual,,222.15,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Individual,,49.62,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Individual,,37.95,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Value Individual,,51.71,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Value Individual,,18.98,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Value Individual,,24.55,,,,,,,24.55,269.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Value Individual,,1817.12,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,BCBS NC,Blue Value Individual,,1013.27,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,BCBS NC,Blue Value Individual,,2232.33,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Value Individual,,728.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Value Individual,,590.24,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Value Individual,,590.24,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Value Individual,,590.24,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,BCBS NC,Blue Value Individual,,1303.05,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,BCBS NC,Blue Value Individual,,1725.75,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,BCBS NC,Blue Value Individual,,1937.10,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Value Individual,,1600.66,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,BCBS NC,Blue Value Individual,,2074.46,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,BCBS NC,Blue Value Individual,,2311.36,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Value Individual,,142.70,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Individual,,89.19,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Value Individual,,142.70,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Individual,,89.19,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Value Individual,,10.11,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,26.76,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Value Individual,,71.35,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Value Individual,,111.19,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,BCBS NC,Blue Value Individual,,392.44,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,BCBS NC,Blue Value Individual,,423.65,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,BCBS NC,Blue Value Individual,,663.57,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Value Individual,,87.11,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,BCBS NC,Blue Value Individual,,199.79,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,BCBS NC,Blue Value Individual,,30.92,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Value Individual,,302.06,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Individual,,52.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Value Individual,,76.70,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Value Individual,,57.08,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,BCBS NC,Blue Value Individual,,940.06,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Value Individual,,89.78,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Individual,,88.00,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Value Individual,,91.87,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Individual,,84.73,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Value Individual,,101.38,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Individual,,128.43,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Value Individual,,183.43,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Individual,,13.08,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Individual,,12.49,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Individual,,21.11,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Value Individual,,65.70,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,BCBS NC,Blue Value Individual,,119.51,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,BCBS NC,Blue Value Individual,,264.60,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Individual,,22.00,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Individual,,16.05,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Value Individual,,78.78,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Individual,,11.89,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,BCBS NC,Blue Value Individual,,222.97,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,BCBS NC,Blue Value Individual,,349.33,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Value Individual,,1192.17,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,BCBS NC,Blue Value Individual,,363.90,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Individual,,533.36,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,BCBS NC,Blue Value Individual,,674.57,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Value Individual,,146.27,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Value Individual,,1192.17,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Value Individual,,208.11,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,BCBS NC,Blue Value Individual,,231.89,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Individual,,26.76,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,BCBS NC,Blue Value Individual,,475.09,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,BCBS NC,Blue Value Individual,,763.76,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Value Individual,,148.65,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,BCBS NC,Blue Value Individual,,1189.20,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Value Individual,,720.95,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Value Individual,,535.14,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Value Individual,,720.95,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Value Individual,,535.14,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Value Individual,,350.81,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Value Individual,,350.81,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Value Individual,,314.25,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Value Individual,GP,37.08,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Value Individual,,8640.48,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Value Individual,,4178.06,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Value Individual,,8640.48,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Value Individual,,4178.06,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,BCBS NC,Blue Value Individual,,3631.17,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,BCBS NC,Blue Value Individual,,3711.13,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,BCBS NC,Blue Value Individual,,3791.38,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,BCBS NC,Blue Value Individual,,3871.90,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,BCBS NC,Blue Value Individual,,3952.15,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,BCBS NC,Blue Value Individual,,4032.11,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,BCBS NC,Blue Value Individual,,4112.36,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,BCBS NC,Blue Value Individual,,4192.60,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Individual,,112.87,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Value Individual,,55.65,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Individual,,34.82,,,,,,,34.82,150.00,percent of total billed charges,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,36099.00,,,,,,,14490.34,36145.66,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,30219.00,,,,,,,16490.00,54106.99,case rate,"Outlier payment may apply if charges exceed a DRG-specific threshold. FOR BLUE SELECT ONLY: When billed with ICD-10-PCS code 0DB64Z3, payment is $24,569. When billed with ICD-10-PCS code 0D164ZA, payment is $26,015."
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,30219.00,,,,,,,11823.02,35030.00,case rate,"Outlier payment may apply if charges exceed a DRG-specific threshold. FOR BLUE SELECT ONLY: When billed with ICD-10-PCS code 0DB64Z3, payment is $24,569. When billed with ICD-10-PCS code 0D164ZA, payment is $26,015."
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,30219.00,,,,,,,11144.06,35030.00,case rate,"Outlier payment may apply if charges exceed a DRG-specific threshold. FOR BLUE SELECT ONLY: When billed with ICD-10-PCS code 0DB64Z3, payment is $24,569. When billed with ICD-10-PCS code 0D164ZA, payment is $26,015."
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,14404.00,,,,,,,5414.00,31619.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,14404.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,14404.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,14404.00,,,,,,,5414.00,21243.91,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,14404.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,14404.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,2406.00,,,,,,,1810.00,33771.43,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,2406.00,,,,,,,1810.00,111375.25,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,2406.00,,,,,,,1810.00,76061.60,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,2406.00,,,,,,,1810.00,45895.56,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,2406.00,,,,,,,1810.00,78134.13,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,2406.00,,,,,,,375.00,27656.89,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,730.00,,,,,,,314.00,3744.05,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,8856.00,,,,,,,4210.00,9947.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,8856.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,8856.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,8856.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,8856.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Select/HMO/PPO,,8856.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,BCBS NC,Blue Select/HMO/PPO,,0.10391,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,96.49,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,18.55,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,70.51,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,40.08,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,92.16,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,91.29,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,BCBS NC,Blue Select/HMO/PPO,,16.38,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,71.18,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Select/HMO/PPO,,105.39,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Select/HMO/PPO,,29368.85,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Select/HMO/PPO,,12620.37,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.75679,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Select/HMO/PPO,,1424.28,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Select/HMO/PPO,,5382.43,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Select/HMO/PPO,,1286.97,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Select/HMO/PPO,,2445.55,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Select/HMO/PPO,,29851.28,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Select/HMO/PPO,,9290.12,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Select/HMO/PPO,,8253.26,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Select/HMO/PPO,,11626.56,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Select/HMO/PPO,,23437.19,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,1958.67,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Select/HMO/PPO,,8251.04,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Select/HMO/PPO,,11906.37,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,2000.97,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Select/HMO/PPO,,6209.25,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Select/HMO/PPO,,6620.42,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Select/HMO/PPO,,8369.79,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,98.91,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,337.70,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,676.14,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,BCBS NC,Blue Select/HMO/PPO,,23.22,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,BCBS NC,Blue Select/HMO/PPO,,15.10,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,BCBS NC,Blue Select/HMO/PPO,,207.04,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,BCBS NC,Blue Select/HMO/PPO,,16.06,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,BCBS NC,Blue Select/HMO/PPO,,0.02227,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,BCBS NC,Blue Select/HMO/PPO,,15.90,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,BCBS NC,Blue Select/HMO/PPO,,30.14,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,BCBS NC,Blue Select/HMO/PPO,,15.12,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,BCBS NC,Blue Select/HMO/PPO,,14.77,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,740.31,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,204.56,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Select/HMO/PPO,,48.44,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,BCBS NC,Blue Select/HMO/PPO,,133.53,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Select/HMO/PPO,,11500.39,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,BCBS NC,Blue Select/HMO/PPO,,4.70,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,136.37,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,148.44,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,149.86,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,22.01,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,916.62,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,777.83,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,524.74,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,408.21,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,328.05,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,345.87,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,925.39,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,785.27,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,529.76,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,412.12,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,331.19,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,349.17,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,BCBS NC,Blue Select/HMO/PPO,,20.39,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,423.80,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,194.46,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,1832.49,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,518.06,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,523.01,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,464.62,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,469.06,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,456.45,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,460.82,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,325.83,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,328.94,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,296.14,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,298.97,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Select/HMO/PPO,,1770.60,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,427.85,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,196.32,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,232.31,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,234.53,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,1168.96,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,1180.15,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,929.23,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,938.12,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,475.75,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,480.30,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,252.35,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,254.76,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,201.88,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,203.81,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,BCBS NC,Blue Select/HMO/PPO,,160.44,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,682.61,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,340.93,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Select/HMO/PPO,,3849.79,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,BCBS NC,Blue Select/HMO/PPO,,114.15,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Select/HMO/PPO,,1901.52,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,733.29,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,464.62,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,202.62,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,BCBS NC,Blue Select/HMO/PPO,,647.30,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,BCBS NC,Blue Select/HMO/PPO,,794.32,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,BCBS NC,Blue Select/HMO/PPO,,1.62,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Select/HMO/PPO,,1542.29,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,2044.02,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,902.52,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,457.20,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,2063.57,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,911.15,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,461.57,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,2087.81,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,BCBS NC,Blue Select/HMO/PPO,,2.30,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,BCBS NC,Blue Select/HMO/PPO,,7.30,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,BCBS NC,Blue Select/HMO/PPO,,144.32,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,BCBS NC,Blue Select/HMO/PPO,,49.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,91.29,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,BCBS NC,Blue Select/HMO/PPO,,176.41,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,BCBS NC,Blue Select/HMO/PPO,,203.29,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,BCBS NC,Blue Select/HMO/PPO,,117.79,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,253.83,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,256.26,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,1147.44,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Select/HMO/PPO,,2296.37,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,1158.42,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,BCBS NC,Blue Select/HMO/PPO,,245.22,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,BCBS NC,Blue Select/HMO/PPO,,244.39,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,BCBS NC,Blue Select/HMO/PPO,,113.68,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,BCBS NC,Blue Select/HMO/PPO,,117.88,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,317.66,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,320.70,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,358.48,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,361.91,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,7.42,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,BCBS NC,Blue Select/HMO/PPO,,0.08992,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,BCBS NC,Blue Select/HMO/PPO,,0.20231,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,1854.02,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,1871.75,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,1502.95,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,1517.33,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,1267.68,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,1279.80,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00742,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,BCBS NC,Blue Select/HMO/PPO,,239.20,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,48.24,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,48.70,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,BCBS NC,Blue Select/HMO/PPO,,60.21,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,BCBS NC,Blue Select/HMO/PPO,,39.72,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,BCBS NC,Blue Select/HMO/PPO,,93.54,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,BCBS NC,Blue Select/HMO/PPO,,22.90,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,BCBS NC,Blue Select/HMO/PPO,,12.34,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,BCBS NC,Blue Select/HMO/PPO,,86.68,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,BCBS NC,Blue Select/HMO/PPO,,71.28,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,BCBS NC,Blue Select/HMO/PPO,,204.12,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,BCBS NC,Blue Select/HMO/PPO,,31.63,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,BCBS NC,Blue Select/HMO/PPO,,38.16,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,BCBS NC,Blue Select/HMO/PPO,,123.26,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,BCBS NC,Blue Select/HMO/PPO,,95.59,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,BCBS NC,Blue Select/HMO/PPO,,114.43,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,BCBS NC,Blue Select/HMO/PPO,,108.61,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,BCBS NC,Blue Select/HMO/PPO,,19.40,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,BCBS NC,Blue Select/HMO/PPO,,21.20,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,BCBS NC,Blue Select/HMO/PPO,,50.51,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,BCBS NC,Blue Select/HMO/PPO,,104.46,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,BCBS NC,Blue Select/HMO/PPO,,0.37852,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,BCBS NC,Blue Select/HMO/PPO,,19.47,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,BCBS NC,Blue Select/HMO/PPO,,4.39,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,BCBS NC,Blue Select/HMO/PPO,,7.88,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,BCBS NC,Blue Select/HMO/PPO,,0.08164,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,BCBS NC,Blue Select/HMO/PPO,,0.59376,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,BCBS NC,Blue Select/HMO/PPO,,5.76,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,BCBS NC,Blue Select/HMO/PPO,,0.58634,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,BCBS NC,Blue Select/HMO/PPO,,0.34883,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,BCBS NC,Blue Select/HMO/PPO,,0.47501,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,BCBS NC,Blue Select/HMO/PPO,,1237.08,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.01484,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,BCBS NC,Blue Select/HMO/PPO,,0.06744,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,BCBS NC,Blue Select/HMO/PPO,,1.93,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,BCBS NC,Blue Select/HMO/PPO,,19.13,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,BCBS NC,Blue Select/HMO/PPO,,60.46,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,BCBS NC,Blue Select/HMO/PPO,,0.05195,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,3.15,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,BCBS NC,Blue Select/HMO/PPO,,4.54,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,BCBS NC,Blue Select/HMO/PPO,,0.83126,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,BCBS NC,Blue Select/HMO/PPO,,1.19,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,BCBS NC,Blue Select/HMO/PPO,,1.90,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,BCBS NC,Blue Select/HMO/PPO,,1.33,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.01484,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,16.40,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,BCBS NC,Blue Select/HMO/PPO,,816.96,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,BCBS NC,Blue Select/HMO/PPO,,57.17,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,BCBS NC,Blue Select/HMO/PPO,,100.14,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,BCBS NC,Blue Select/HMO/PPO,,123.52,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,BCBS NC,Blue Select/HMO/PPO,,12.83,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,BCBS NC,Blue Select/HMO/PPO,,0.09649,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,BCBS NC,Blue Select/HMO/PPO,,26.97,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Select/HMO/PPO,,48.44,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,BCBS NC,Blue Select/HMO/PPO,,106.80,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,BCBS NC,Blue Select/HMO/PPO,,47.18,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,BCBS NC,Blue Select/HMO/PPO,,184.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,BCBS NC,Blue Select/HMO/PPO,,8.33,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,BCBS NC,Blue Select/HMO/PPO,,18.91,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,BCBS NC,Blue Select/HMO/PPO,,0.55665,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,BCBS NC,Blue Select/HMO/PPO,,0.02969,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,BCBS NC,Blue Select/HMO/PPO,,11.33,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,BCBS NC,Blue Select/HMO/PPO,,9.91,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,BCBS NC,Blue Select/HMO/PPO,,8.82,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,BCBS NC,Blue Select/HMO/PPO,,13.13,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,BCBS NC,Blue Select/HMO/PPO,,24.75,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,BCBS NC,Blue Select/HMO/PPO,,40.79,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,BCBS NC,Blue Select/HMO/PPO,,103.28,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,BCBS NC,Blue Select/HMO/PPO,,407.25,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,BCBS NC,Blue Select/HMO/PPO,,234.72,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,BCBS NC,Blue Select/HMO/PPO,,275.54,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,61.57,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,48.17,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,48.17,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,35.59,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.89916,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Select/HMO/PPO,,2174.46,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Select/HMO/PPO,,14437.16,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,12.40,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,13.71,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,16.00,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,BCBS NC,Blue Select/HMO/PPO,,95.34,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,62.42,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,BCBS NC,Blue Select/HMO/PPO,,262.78,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,BCBS NC,Blue Select/HMO/PPO,,288.89,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Select/HMO/PPO,,14.54,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,BCBS NC,Blue Select/HMO/PPO,,2630.36,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,BCBS NC,Blue Select/HMO/PPO,,225.81,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,BCBS NC,Blue Select/HMO/PPO,,32.56,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,12.18,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,12.14,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,BCBS NC,Blue Select/HMO/PPO,,1791.89,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,BCBS NC,Blue Select/HMO/PPO,,349.98,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,12.63,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,12.40,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,BCBS NC,Blue Select/HMO/PPO,,3874.58,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,12.63,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,BCBS NC,Blue Select/HMO/PPO,,59.30,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,BCBS NC,Blue Select/HMO/PPO,,24.98,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,BCBS NC,Blue Select/HMO/PPO,,25.87,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,34.88,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,BCBS NC,Blue Select/HMO/PPO,,14.73,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,BCBS NC,Blue Select/HMO/PPO,,18.70,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,BCBS NC,Blue Select/HMO/PPO,,60.17,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,BCBS NC,Blue Select/HMO/PPO,,24.28,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,17.83,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,21.50,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,BCBS NC,Blue Select/HMO/PPO,,1.69,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,BCBS NC,Blue Select/HMO/PPO,,324.12,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,BCBS NC,Blue Select/HMO/PPO,,555.31,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,BCBS NC,Blue Select/HMO/PPO,,1711.81,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,162.54,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,162.54,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,162.54,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,1.12,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,BCBS NC,Blue Select/HMO/PPO,,37.05,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,BCBS NC,Blue Select/HMO/PPO,,43.12,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,BCBS NC,Blue Select/HMO/PPO,,421.94,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,BCBS NC,Blue Select/HMO/PPO,,16.33,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,20.98,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,BCBS NC,Blue Select/HMO/PPO,,18.47,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.38,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,BCBS NC,Blue Select/HMO/PPO,,5.25,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,13.71,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,BCBS NC,Blue Select/HMO/PPO,,1.95,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,13.79,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,BCBS NC,Blue Select/HMO/PPO,,19.85,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,22.93,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,17.66,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,BCBS NC,Blue Select/HMO/PPO,,35.29,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,BCBS NC,Blue Select/HMO/PPO,,21.78,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,24.01,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,BCBS NC,Blue Select/HMO/PPO,,2034.63,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,13.17,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,12.43,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,12.62,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,15.85,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,BCBS NC,Blue Select/HMO/PPO,,30.57,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,BCBS NC,Blue Select/HMO/PPO,,1378.41,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,12.10,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,13.00,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,13.30,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,BCBS NC,Blue Select/HMO/PPO,,24.54,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,BCBS NC,Blue Select/HMO/PPO,,185.00,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,1.24,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,17.22,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,BCBS NC,Blue Select/HMO/PPO,,16.89,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,BCBS NC,Blue Select/HMO/PPO,,15083.17,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,23.98,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,1.09,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,BCBS NC,Blue Select/HMO/PPO,,118.28,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,BCBS NC,Blue Select/HMO/PPO,,223.33,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,1836.94,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,BCBS NC,Blue Select/HMO/PPO,,52.18,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,BCBS NC,Blue Select/HMO/PPO,,62.94,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Select/HMO/PPO,,28.25,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Select/HMO/PPO,,34.54,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,285.75,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,BCBS NC,Blue Select/HMO/PPO,,574.72,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,12.14,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,BCBS NC,Blue Select/HMO/PPO,,38.10,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,BCBS NC,Blue Select/HMO/PPO,,51.59,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,BCBS NC,Blue Select/HMO/PPO,,49.47,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,BCBS NC,Blue Select/HMO/PPO,,53.62,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,BCBS NC,Blue Select/HMO/PPO,,29.43,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,BCBS NC,Blue Select/HMO/PPO,,20.89,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,BCBS NC,Blue Select/HMO/PPO,,45153.30,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Select/HMO/PPO,,597.98,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,BCBS NC,Blue Select/HMO/PPO,,117.53,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Select/HMO/PPO,,173.20,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,BCBS NC,Blue Select/HMO/PPO,,386.13,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,14.69,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,20.23,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,BCBS NC,Blue Select/HMO/PPO,,21.32,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,BCBS NC,Blue Select/HMO/PPO,,37.04,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,BCBS NC,Blue Select/HMO/PPO,,45.42,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,BCBS NC,Blue Select/HMO/PPO,,62.23,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,BCBS NC,Blue Select/HMO/PPO,,79.01,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,BCBS NC,Blue Select/HMO/PPO,,95.78,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,BCBS NC,Blue Select/HMO/PPO,,52.58,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,BCBS NC,Blue Select/HMO/PPO,,57.02,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Select/HMO/PPO,,15.89,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,BCBS NC,Blue Select/HMO/PPO,,916.91,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,BCBS NC,Blue Select/HMO/PPO,,1737.53,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,BCBS NC,Blue Select/HMO/PPO,,6.37,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,128.13,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,31.69,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,12.74,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,BCBS NC,Blue Select/HMO/PPO,,15.44,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,BCBS NC,Blue Select/HMO/PPO,,27.91,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,BCBS NC,Blue Select/HMO/PPO,,52.49,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,91.29,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,BCBS NC,Blue Select/HMO/PPO,,2267.98,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Select/HMO/PPO,,4331.81,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,BCBS NC,Blue Select/HMO/PPO,,998.56,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,15.96,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,47.91,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,BCBS NC,Blue Select/HMO/PPO,,26.42,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,BCBS NC,Blue Select/HMO/PPO,,24.99,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,BCBS NC,Blue Select/HMO/PPO,,25.51,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,21.92,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,21.92,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,BCBS NC,Blue Select/HMO/PPO,,1796.64,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,BCBS NC,Blue Select/HMO/PPO,,4808.71,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,BCBS NC,Blue Select/HMO/PPO,,124.69,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,BCBS NC,Blue Select/HMO/PPO,,20.64,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,BCBS NC,Blue Select/HMO/PPO,,47.73,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,1.12,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,1.09,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,BCBS NC,Blue Select/HMO/PPO,,20.61,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,BCBS NC,Blue Select/HMO/PPO,,23.57,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,BCBS NC,Blue Select/HMO/PPO,,117.94,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,17.57,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,BCBS NC,Blue Select/HMO/PPO,,77.14,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,BCBS NC,Blue Select/HMO/PPO,,438.38,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,BCBS NC,Blue Select/HMO/PPO,,135.55,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,BCBS NC,Blue Select/HMO/PPO,,195.04,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Select/HMO/PPO,,153.76,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,849.34,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Select/HMO/PPO,,13.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,BCBS NC,Blue Select/HMO/PPO,,75.64,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,BCBS NC,Blue Select/HMO/PPO,,133.75,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,BCBS NC,Blue Select/HMO/PPO,,393.72,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,1.16,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,BCBS NC,Blue Select/HMO/PPO,,75.07,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,BCBS NC,Blue Select/HMO/PPO,,195.35,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,BCBS NC,Blue Select/HMO/PPO,,195.35,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,BCBS NC,Blue Select/HMO/PPO,,654.25,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,BCBS NC,Blue Select/HMO/PPO,,43.83,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,BCBS NC,Blue Select/HMO/PPO,,665.35,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,BCBS NC,Blue Select/HMO/PPO,,1057.41,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,BCBS NC,Blue Select/HMO/PPO,,1580.18,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,BCBS NC,Blue Select/HMO/PPO,,2625.68,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,BCBS NC,Blue Select/HMO/PPO,,5239.49,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,BCBS NC,Blue Select/HMO/PPO,,7853.29,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,BCBS NC,Blue Select/HMO/PPO,,1258.14,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,BCBS NC,Blue Select/HMO/PPO,,6120.40,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,BCBS NC,Blue Select/HMO/PPO,,23869.19,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Select/HMO/PPO,,4186.19,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Select/HMO/PPO,,8325.59,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Select/HMO/PPO,,236.65,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Select/HMO/PPO,,236.65,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,BCBS NC,Blue Select/HMO/PPO,,6536.44,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,BCBS NC,Blue Select/HMO/PPO,,61.83,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,BCBS NC,Blue Select/HMO/PPO,,75.22,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,BCBS NC,Blue Select/HMO/PPO,,114.26,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,13.88,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,BCBS NC,Blue Select/HMO/PPO,,86.84,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,BCBS NC,Blue Select/HMO/PPO,,105.36,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,BCBS NC,Blue Select/HMO/PPO,,656.62,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,1.05,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Select/HMO/PPO,,29774.02,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Select/HMO/PPO,,118483.40,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,BCBS NC,Blue Select/HMO/PPO,,731.44,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,1.50,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,1.31,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,1.27,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,1.20,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,BCBS NC,Blue Select/HMO/PPO,,74.70,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,BCBS NC,Blue Select/HMO/PPO,,143.84,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,BCBS NC,Blue Select/HMO/PPO,,9842.05,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,79.43,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,BCBS NC,Blue Select/HMO/PPO,,10.30,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,57.70,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,BCBS NC,Blue Select/HMO/PPO,,1666.50,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,BCBS NC,Blue Select/HMO/PPO,,64.48,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,BCBS NC,Blue Select/HMO/PPO,,526.89,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,BCBS NC,Blue Select/HMO/PPO,,160.20,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,BCBS NC,Blue Select/HMO/PPO,,44.98,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,71.75,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,BCBS NC,Blue Select/HMO/PPO,,136.90,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,BCBS NC,Blue Select/HMO/PPO,,166.77,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,BCBS NC,Blue Select/HMO/PPO,,45.15,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,792.01,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,1.09,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,35.22,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.89916,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,BCBS NC,Blue Select/HMO/PPO,,2.32,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,BCBS NC,Blue Select/HMO/PPO,,60.06,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Select/HMO/PPO,,57.41,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,BCBS NC,Blue Select/HMO/PPO,,56.63,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Select/HMO/PPO,,57.41,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,75.33,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,77.93,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,BCBS NC,Blue Select/HMO/PPO,,353.37,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,13.71,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,BCBS NC,Blue Select/HMO/PPO,,211.12,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,14.46,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,BCBS NC,Blue Select/HMO/PPO,,41599.23,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,41.21,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,BCBS NC,Blue Select/HMO/PPO,,3313.63,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,41.21,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,BCBS NC,Blue Select/HMO/PPO,,52.40,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,BCBS NC,Blue Select/HMO/PPO,,20.00,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,1.12,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,BCBS NC,Blue Select/HMO/PPO,,23.53,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,14.46,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,BCBS NC,Blue Select/HMO/PPO,,50.77,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,22.33,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,BCBS NC,Blue Select/HMO/PPO,,826.74,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,BCBS NC,Blue Select/HMO/PPO,,1358.23,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,BCBS NC,Blue Select/HMO/PPO,,234.61,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,BCBS NC,Blue Select/HMO/PPO,,352.03,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,71.75,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Select/HMO/PPO,,71.75,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,BCBS NC,Blue Select/HMO/PPO,,527.15,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,21.54,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,17.57,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,423.35,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,BCBS NC,Blue Select/HMO/PPO,,897.92,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,69.68,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,BCBS NC,Blue Select/HMO/PPO,,3.07,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,BCBS NC,Blue Select/HMO/PPO,,422.16,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,83.13,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,BCBS NC,Blue Select/HMO/PPO,,124.69,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,12.70,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Select/HMO/PPO,,153.76,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,BCBS NC,Blue Select/HMO/PPO,,452.48,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,47.50,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,BCBS NC,Blue Select/HMO/PPO,,118.27,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,65.19,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,204.56,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,3.22,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,BCBS NC,Blue Select/HMO/PPO,,15.81,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,12.63,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,21.54,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Select/HMO/PPO,,21.54,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,22.48,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,25.38,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,BCBS NC,Blue Select/HMO/PPO,,92.54,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,BCBS NC,Blue Select/HMO/PPO,,93.59,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,BCBS NC,Blue Select/HMO/PPO,,36.60,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,BCBS NC,Blue Select/HMO/PPO,,46.42,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,BCBS NC,Blue Select/HMO/PPO,,23.64,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,58.11,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,282.04,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,BCBS NC,Blue Select/HMO/PPO,,682.09,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,BCBS NC,Blue Select/HMO/PPO,,125.70,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,BCBS NC,Blue Select/HMO/PPO,,239.93,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,66.09,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,BCBS NC,Blue Select/HMO/PPO,,452.61,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,BCBS NC,Blue Select/HMO/PPO,,18855.26,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,BCBS NC,Blue Select/HMO/PPO,,1376.48,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,,15.74,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,BCBS NC,Blue Select/HMO/PPO,,713.89,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,BCBS NC,Blue Select/HMO/PPO,,18.70,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,63.43,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,BCBS NC,Blue Select/HMO/PPO,,26.76,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,BCBS NC,Blue Select/HMO/PPO,,1237.24,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,BCBS NC,Blue Select/HMO/PPO,,22477.68,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,BCBS NC,Blue Select/HMO/PPO,,23.72,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,BCBS NC,Blue Select/HMO/PPO,,39.98,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,BCBS NC,Blue Select/HMO/PPO,,28.51,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.38,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,BCBS NC,Blue Select/HMO/PPO,,36.04,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,BCBS NC,Blue Select/HMO/PPO,,53.48,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,BCBS NC,Blue Select/HMO/PPO,,58.00,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,BCBS NC,Blue Select/HMO/PPO,,137.79,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,BCBS NC,Blue Select/HMO/PPO,,15.36,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,16.71,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,BCBS NC,Blue Select/HMO/PPO,,237.91,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,BCBS NC,Blue Select/HMO/PPO,,325.08,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Select/HMO/PPO,,11755.45,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,80.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,BCBS NC,Blue Select/HMO/PPO,,1546.18,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,BCBS NC,Blue Select/HMO/PPO,,2057.58,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,BCBS NC,Blue Select/HMO/PPO,,147.01,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,13.56,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,BCBS NC,Blue Select/HMO/PPO,,2.02,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,44.53,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,23.90,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,16.55,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,BCBS NC,Blue Select/HMO/PPO,,64.98,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,BCBS NC,Blue Select/HMO/PPO,,86.32,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.97409,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,BCBS NC,Blue Select/HMO/PPO,,37.24,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,BCBS NC,Blue Select/HMO/PPO,,27.05,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,BCBS NC,Blue Select/HMO/PPO,,109.81,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,1.16,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,1.31,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,12.25,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,BCBS NC,Blue Select/HMO/PPO,,155.14,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Select/HMO/PPO,,18.43,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,BCBS NC,Blue Select/HMO/PPO,,23.82,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,BCBS NC,Blue Select/HMO/PPO,,412.94,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,BCBS NC,Blue Select/HMO/PPO,,19.89,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,17.78,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,BCBS NC,Blue Select/HMO/PPO,,21.86,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,BCBS NC,Blue Select/HMO/PPO,,31.99,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,39.67,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,BCBS NC,Blue Select/HMO/PPO,,45.59,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,BCBS NC,Blue Select/HMO/PPO,,132.48,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,BCBS NC,Blue Select/HMO/PPO,,380.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,BCBS NC,Blue Select/HMO/PPO,,39.41,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,BCBS NC,Blue Select/HMO/PPO,,18.33,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,22.12,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,BCBS NC,Blue Select/HMO/PPO,,45.89,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,BCBS NC,Blue Select/HMO/PPO,,20.91,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,BCBS NC,Blue Select/HMO/PPO,,126.32,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,265.15,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Select/HMO/PPO,,858.02,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,BCBS NC,Blue Select/HMO/PPO,,6.44,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,12.40,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,BCBS NC,Blue Select/HMO/PPO,,87773.83,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,BCBS NC,Blue Select/HMO/PPO,,94.00,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,BCBS NC,Blue Select/HMO/PPO,,562.61,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,7.49,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,BCBS NC,Blue Select/HMO/PPO,,11.20,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,BCBS NC,Blue Select/HMO/PPO,,56.89,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,62.94,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,BCBS NC,Blue Select/HMO/PPO,,4.01,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,12.89,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,BCBS NC,Blue Select/HMO/PPO,,29.80,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,BCBS NC,Blue Select/HMO/PPO,,33.18,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,BCBS NC,Blue Select/HMO/PPO,,27.02,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Select/HMO/PPO,,63.62,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,BCBS NC,Blue Select/HMO/PPO,,63.50,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Select/HMO/PPO,,63.62,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,62.15,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,BCBS NC,Blue Select/HMO/PPO,,781.05,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,BCBS NC,Blue Select/HMO/PPO,,4038.69,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,BCBS NC,Blue Select/HMO/PPO,,2699.23,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,BCBS NC,Blue Select/HMO/PPO,,24.57,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,BCBS NC,Blue Select/HMO/PPO,,11700.78,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,BCBS NC,Blue Select/HMO/PPO,,2.17,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,BCBS NC,Blue Select/HMO/PPO,,15.62,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,BCBS NC,Blue Select/HMO/PPO,,319.74,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,BCBS NC,Blue Select/HMO/PPO,,175.53,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,48.17,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,80.16,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,BCBS NC,Blue Select/HMO/PPO,,9.29,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,BCBS NC,Blue Select/HMO/PPO,,107.06,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,217.15,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,BCBS NC,Blue Select/HMO/PPO,,1984.42,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,BCBS NC,Blue Select/HMO/PPO,,7.31,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,BCBS NC,Blue Select/HMO/PPO,,2476.28,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,17.72,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Select/HMO/PPO,,254.43,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,BCBS NC,Blue Select/HMO/PPO,,607.27,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,BCBS NC,Blue Select/HMO/PPO,,237.28,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,BCBS NC,Blue Select/HMO/PPO,,737.99,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,18.81,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,BCBS NC,Blue Select/HMO/PPO,,1009.95,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,BCBS NC,Blue Select/HMO/PPO,,162.86,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,BCBS NC,Blue Select/HMO/PPO,,28.50,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,BCBS NC,Blue Select/HMO/PPO,,29.37,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,BCBS NC,Blue Select/HMO/PPO,,4637.12,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Select/HMO/PPO,,14.09,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Select/HMO/PPO,,15.59,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,BCBS NC,Blue Select/HMO/PPO,,7121.65,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,BCBS NC,Blue Select/HMO/PPO,,2.88,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,43.27,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Select/HMO/PPO,,33.73,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,47.09,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,194.46,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,BCBS NC,Blue Select/HMO/PPO,,261.63,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,BCBS NC,Blue Select/HMO/PPO,,8.13,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,BCBS NC,Blue Select/HMO/PPO,,223.74,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,1.24,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,1.05,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,1.20,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,BCBS NC,Blue Select/HMO/PPO,,34.36,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,BCBS NC,Blue Select/HMO/PPO,,162.28,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,BCBS NC,Blue Select/HMO/PPO,,134.42,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,BCBS NC,Blue Select/HMO/PPO,,74.07,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.97409,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,BCBS NC,Blue Select/HMO/PPO,,115.75,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Select/HMO/PPO,,30.23,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,16.33,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,BCBS NC,Blue Select/HMO/PPO,,48.06,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,BCBS NC,Blue Select/HMO/PPO,,8888.74,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,BCBS NC,Blue Select/HMO/PPO,,43.20,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,25.38,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,BCBS NC,Blue Select/HMO/PPO,,59.75,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,17.55,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,BCBS NC,Blue Select/HMO/PPO,,7213.29,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,BCBS NC,Blue Select/HMO/PPO,,185.48,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.97409,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,BCBS NC,Blue Select/HMO/PPO,,5.51,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,BCBS NC,Blue Select/HMO/PPO,,102.31,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,BCBS NC,Blue Select/HMO/PPO,,13.86,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,BCBS NC,Blue Select/HMO/PPO,,60.51,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,BCBS NC,Blue Select/HMO/PPO,,64.44,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,134.87,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,BCBS NC,Blue Select/HMO/PPO,,72.79,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Select/HMO/PPO,,14437.16,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,BCBS NC,Blue Select/HMO/PPO,,119.18,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,BCBS NC,Blue Select/HMO/PPO,,69.66,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,BCBS NC,Blue Select/HMO/PPO,,52.29,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,55.18,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,55.18,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,BCBS NC,Blue Select/HMO/PPO,,62.38,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,BCBS NC,Blue Select/HMO/PPO,,8.84,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Select/HMO/PPO,,18.06,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,BCBS NC,Blue Select/HMO/PPO,,8.28,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,BCBS NC,Blue Select/HMO/PPO,,6085.97,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,15.10,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,BCBS NC,Blue Select/HMO/PPO,,46.23,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,BCBS NC,Blue Select/HMO/PPO,,279.86,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,285.75,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,BCBS NC,Blue Select/HMO/PPO,,144.28,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,BCBS NC,Blue Select/HMO/PPO,,52.21,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,BCBS NC,Blue Select/HMO/PPO,,49.21,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,68.19,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,16.67,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,BCBS NC,Blue Select/HMO/PPO,,21.75,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,12.25,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,BCBS NC,Blue Select/HMO/PPO,,83.79,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,BCBS NC,Blue Select/HMO/PPO,,98.08,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,1.05,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,BCBS NC,Blue Select/HMO/PPO,,66.91,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,BCBS NC,Blue Select/HMO/PPO,,111.38,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,BCBS NC,Blue Select/HMO/PPO,,33.38,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,BCBS NC,Blue Select/HMO/PPO,,78.15,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,BCBS NC,Blue Select/HMO/PPO,,15.17,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.25,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,BCBS NC,Blue Select/HMO/PPO,,259.26,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,BCBS NC,Blue Select/HMO/PPO,,938.07,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,BCBS NC,Blue Select/HMO/PPO,,17.27,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,BCBS NC,Blue Select/HMO/PPO,,336.07,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,BCBS NC,Blue Select/HMO/PPO,,673.77,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,1.31,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,1.27,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,BCBS NC,Blue Select/HMO/PPO,,6.67,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,13.94,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,BCBS NC,Blue Select/HMO/PPO,,180.32,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,12.18,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,12.40,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,BCBS NC,Blue Select/HMO/PPO,,70.85,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,BCBS NC,Blue Select/HMO/PPO,,21.00,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,BCBS NC,Blue Select/HMO/PPO,,100.01,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Select/HMO/PPO,,105.21,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,BCBS NC,Blue Select/HMO/PPO,,32.78,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,BCBS NC,Blue Select/HMO/PPO,,261.24,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,13.92,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Select/HMO/PPO,,105.21,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,BCBS NC,Blue Select/HMO/PPO,,122.09,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,131.13,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,BCBS NC,Blue Select/HMO/PPO,,2.40,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,75.33,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,92.91,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,92.91,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,BCBS NC,Blue Select/HMO/PPO,,68.06,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,BCBS NC,Blue Select/HMO/PPO,,59.72,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,BCBS NC,Blue Select/HMO/PPO,,352.92,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,19.63,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,17.38,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,BCBS NC,Blue Select/HMO/PPO,,17.61,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,16.86,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,BCBS NC,Blue Select/HMO/PPO,,10302.59,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,BCBS NC,Blue Select/HMO/PPO,,227.64,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,3.18,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Select/HMO/PPO,,42.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Select/HMO/PPO,,42.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,BCBS NC,Blue Select/HMO/PPO,,3017.45,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,BCBS NC,Blue Select/HMO/PPO,,83.91,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,BCBS NC,Blue Select/HMO/PPO,,87.47,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,BCBS NC,Blue Select/HMO/PPO,,13232.98,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,BCBS NC,Blue Select/HMO/PPO,,21050.28,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Select/HMO/PPO,,48.50,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,BCBS NC,Blue Select/HMO/PPO,,4.61,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,BCBS NC,Blue Select/HMO/PPO,,109.44,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,18.77,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,BCBS NC,Blue Select/HMO/PPO,,31.10,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,BCBS NC,Blue Select/HMO/PPO,,17.76,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,14.39,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,BCBS NC,Blue Select/HMO/PPO,,119.87,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,202.62,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Select/HMO/PPO,,364.68,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,BCBS NC,Blue Select/HMO/PPO,,72.66,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,BCBS NC,Blue Select/HMO/PPO,,70.62,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,BCBS NC,Blue Select/HMO/PPO,,3396.31,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,BCBS NC,Blue Select/HMO/PPO,,114.64,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,BCBS NC,Blue Select/HMO/PPO,,18.02,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,BCBS NC,Blue Select/HMO/PPO,,3.60,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,BCBS NC,Blue Select/HMO/PPO,,244.31,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Select/HMO/PPO,,63.39,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Select/HMO/PPO,,63.39,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Select/HMO/PPO,,481.91,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Select/HMO/PPO,,481.91,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,12.89,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,BCBS NC,Blue Select/HMO/PPO,,408.17,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,19.37,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,16.59,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,BCBS NC,Blue Select/HMO/PPO,,1.39,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,63.02,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,BCBS NC,Blue Select/HMO/PPO,,240.73,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,BCBS NC,Blue Select/HMO/PPO,,366.28,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,BCBS NC,Blue Select/HMO/PPO,,15.32,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,BCBS NC,Blue Select/HMO/PPO,,267.61,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,BCBS NC,Blue Select/HMO/PPO,,395.41,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Select/HMO/PPO,,74.89,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Select/HMO/PPO,,74.89,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,BCBS NC,Blue Select/HMO/PPO,,276.23,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,BCBS NC,Blue Select/HMO/PPO,,4744.44,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,21.08,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,BCBS NC,Blue Select/HMO/PPO,,5105.22,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,BCBS NC,Blue Select/HMO/PPO,,24709.62,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,17.01,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,40.82,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,59.38,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,BCBS NC,Blue Select/HMO/PPO,,1.27,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,66.02,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,BCBS NC,Blue Select/HMO/PPO,,29223.87,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,BCBS NC,Blue Select/HMO/PPO,,6020.02,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,66.02,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,BCBS NC,Blue Select/HMO/PPO,,285.75,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,56.11,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Select/HMO/PPO,,65.17,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,BCBS NC,Blue Select/HMO/PPO,,1553.65,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,BCBS NC,Blue Select/HMO/PPO,,10477.72,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,13.34,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,BCBS NC,Blue Select/HMO/PPO,,343.08,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,BCBS NC,Blue Select/HMO/PPO,,812.71,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,BCBS NC,Blue Select/HMO/PPO,,185.45,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,12.29,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,43.46,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,28.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,28.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,BCBS NC,Blue Select/HMO/PPO,,180.69,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,BCBS NC,Blue Select/HMO/PPO,,230.71,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,BCBS NC,Blue Select/HMO/PPO,,304.82,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,18350.75,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,BCBS NC,Blue Select/HMO/PPO,,600.70,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,BCBS NC,Blue Select/HMO/PPO,,4527.38,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,BCBS NC,Blue Select/HMO/PPO,,11012.21,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,12.14,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,12.18,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,BCBS NC,Blue Select/HMO/PPO,,542.66,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,BCBS NC,Blue Select/HMO/PPO,,29.60,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,BCBS NC,Blue Select/HMO/PPO,,35.74,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,BCBS NC,Blue Select/HMO/PPO,,40.87,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,BCBS NC,Blue Select/HMO/PPO,,58.22,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Select/HMO/PPO,,21685.53,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,BCBS NC,Blue Select/HMO/PPO,,19464.19,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,18.73,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,55.60,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,55.60,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,BCBS NC,Blue Select/HMO/PPO,,81.90,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,BCBS NC,Blue Select/HMO/PPO,,1333.75,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,43.27,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,43.27,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,BCBS NC,Blue Select/HMO/PPO,,15601.19,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,BCBS NC,Blue Select/HMO/PPO,,23355.66,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,BCBS NC,Blue Select/HMO/PPO,,11910.57,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,BCBS NC,Blue Select/HMO/PPO,,1341.56,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,BCBS NC,Blue Select/HMO/PPO,,2780.99,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,BCBS NC,Blue Select/HMO/PPO,,6.07,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,70.14,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Select/HMO/PPO,,364.68,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,BCBS NC,Blue Select/HMO/PPO,,2905.12,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,BCBS NC,Blue Select/HMO/PPO,,62406.40,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,BCBS NC,Blue Select/HMO/PPO,,1468.52,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,BCBS NC,Blue Select/HMO/PPO,,366.05,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,BCBS NC,Blue Select/HMO/PPO,,3435.94,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,BCBS NC,Blue Select/HMO/PPO,,6814.73,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,BCBS NC,Blue Select/HMO/PPO,,3392.97,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,47.24,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,47.24,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,47.24,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,BCBS NC,Blue Select/HMO/PPO,,1494.35,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,BCBS NC,Blue Select/HMO/PPO,,938.40,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,32.88,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,BCBS NC,Blue Select/HMO/PPO,,95.89,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,35.22,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,BCBS NC,Blue Select/HMO/PPO,,63.09,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,56.41,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,65.31,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,BCBS NC,Blue Select/HMO/PPO,,7999.47,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,BCBS NC,Blue Select/HMO/PPO,,9932.57,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Select/HMO/PPO,,33.42,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Select/HMO/PPO,,33.42,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,BCBS NC,Blue Select/HMO/PPO,,43.08,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,BCBS NC,Blue Select/HMO/PPO,,12178.65,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Select/HMO/PPO,,433.21,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,BCBS NC,Blue Select/HMO/PPO,,73.24,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,BCBS NC,Blue Select/HMO/PPO,,110.37,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,BCBS NC,Blue Select/HMO/PPO,,44.58,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,BCBS NC,Blue Select/HMO/PPO,,8282.77,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,BCBS NC,Blue Select/HMO/PPO,,778.71,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,BCBS NC,Blue Select/HMO/PPO,,476.14,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,12.33,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,BCBS NC,Blue Select/HMO/PPO,,163.76,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,BCBS NC,Blue Select/HMO/PPO,,14.35,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,BCBS NC,Blue Select/HMO/PPO,,651.13,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,14.69,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,BCBS NC,Blue Select/HMO/PPO,,2996.56,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,BCBS NC,Blue Select/HMO/PPO,,1229.71,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,BCBS NC,Blue Select/HMO/PPO,,229.82,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,BCBS NC,Blue Select/HMO/PPO,,10123.72,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,BCBS NC,Blue Select/HMO/PPO,,57.73,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,BCBS NC,Blue Select/HMO/PPO,,213.85,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,BCBS NC,Blue Select/HMO/PPO,,408.82,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,BCBS NC,Blue Select/HMO/PPO,,3449.15,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,BCBS NC,Blue Select/HMO/PPO,,158.40,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,BCBS NC,Blue Select/HMO/PPO,,71.67,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Select/HMO/PPO,,111.01,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Select/HMO/PPO,,38051.26,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,16.48,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,BCBS NC,Blue Select/HMO/PPO,,1011.67,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,BCBS NC,Blue Select/HMO/PPO,,90.92,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,BCBS NC,Blue Select/HMO/PPO,,2058.48,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,BCBS NC,Blue Select/HMO/PPO,,45.53,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,BCBS NC,Blue Select/HMO/PPO,,803.43,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,BCBS NC,Blue Select/HMO/PPO,,45.93,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,BCBS NC,Blue Select/HMO/PPO,,11892.27,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,BCBS NC,Blue Select/HMO/PPO,,142.24,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Select/HMO/PPO,,49.17,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,BCBS NC,Blue Select/HMO/PPO,,272.61,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,BCBS NC,Blue Select/HMO/PPO,,42.68,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,BCBS NC,Blue Select/HMO/PPO,,25.42,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,BCBS NC,Blue Select/HMO/PPO,,29.61,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,BCBS NC,Blue Select/HMO/PPO,,66706.93,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,BCBS NC,Blue Select/HMO/PPO,,7042.51,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,BCBS NC,Blue Select/HMO/PPO,,64389.60,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,BCBS NC,Blue Select/HMO/PPO,,33.57,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,BCBS NC,Blue Select/HMO/PPO,,5293.44,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,BCBS NC,Blue Select/HMO/PPO,,671.90,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,BCBS NC,Blue Select/HMO/PPO,,14229.12,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,BCBS NC,Blue Select/HMO/PPO,,3570.13,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,BCBS NC,Blue Select/HMO/PPO,,21681.15,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,BCBS NC,Blue Select/HMO/PPO,,4.98,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,53.76,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,BCBS NC,Blue Select/HMO/PPO,,24749.25,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,BCBS NC,Blue Select/HMO/PPO,,53.43,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,BCBS NC,Blue Select/HMO/PPO,,51.48,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,BCBS NC,Blue Select/HMO/PPO,,983.64,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,BCBS NC,Blue Select/HMO/PPO,,3380.39,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,BCBS NC,Blue Select/HMO/PPO,,35.82,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,BCBS NC,Blue Select/HMO/PPO,,36061.27,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,BCBS NC,Blue Select/HMO/PPO,,78305.96,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,13.08,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,BCBS NC,Blue Select/HMO/PPO,,98.61,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Select/HMO/PPO,,71.41,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Select/HMO/PPO,,71.41,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,67.02,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,12.63,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,20.87,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,13.26,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,BCBS NC,Blue Select/HMO/PPO,,148.07,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,BCBS NC,Blue Select/HMO/PPO,,740.34,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,BCBS NC,Blue Select/HMO/PPO,,49.53,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,BCBS NC,Blue Select/HMO/PPO,,496.20,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,BCBS NC,Blue Select/HMO/PPO,,3.52,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,13.66,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,BCBS NC,Blue Select/HMO/PPO,,1463.80,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,BCBS NC,Blue Select/HMO/PPO,,19757.44,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,BCBS NC,Blue Select/HMO/PPO,,4372.04,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Select/HMO/PPO,,14.31,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,BCBS NC,Blue Select/HMO/PPO,,26143.70,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,BCBS NC,Blue Select/HMO/PPO,,59.41,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,BCBS NC,Blue Select/HMO/PPO,,181.29,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,BCBS NC,Blue Select/HMO/PPO,,291.85,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,BCBS NC,Blue Select/HMO/PPO,,43.38,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,288.48,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,BCBS NC,Blue Select/HMO/PPO,,86.39,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,BCBS NC,Blue Select/HMO/PPO,,123.65,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,BCBS NC,Blue Select/HMO/PPO,,160.87,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,BCBS NC,Blue Select/HMO/PPO,,384.39,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,BCBS NC,Blue Select/HMO/PPO,,1501.84,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,BCBS NC,Blue Select/HMO/PPO,,7061.40,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,BCBS NC,Blue Select/HMO/PPO,,393.38,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Select/HMO/PPO,,98.08,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Select/HMO/PPO,,98.08,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,BCBS NC,Blue Select/HMO/PPO,,363.12,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,BCBS NC,Blue Select/HMO/PPO,,15821.89,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,751.44,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,BCBS NC,Blue Select/HMO/PPO,,1195.20,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,BCBS NC,Blue Select/HMO/PPO,,255.87,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,12.40,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,BCBS NC,Blue Select/HMO/PPO,,41.89,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,BCBS NC,Blue Select/HMO/PPO,,3855.90,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,BCBS NC,Blue Select/HMO/PPO,,35881.55,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Select/HMO/PPO,,14110.89,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,BCBS NC,Blue Select/HMO/PPO,,36.04,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,BCBS NC,Blue Select/HMO/PPO,,3404.26,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Select/HMO/PPO,,7479.15,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,751.44,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,BCBS NC,Blue Select/HMO/PPO,,26766.78,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,BCBS NC,Blue Select/HMO/PPO,,2173.16,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Select/HMO/PPO,,26697.16,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,BCBS NC,Blue Select/HMO/PPO,,15471.98,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,152.11,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,BCBS NC,Blue Select/HMO/PPO,,215.05,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,BCBS NC,Blue Select/HMO/PPO,,311.39,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,1334.50,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,BCBS NC,Blue Select/HMO/PPO,,60983.05,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,BCBS NC,Blue Select/HMO/PPO,,9318.28,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,BCBS NC,Blue Select/HMO/PPO,,2482.70,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,BCBS NC,Blue Select/HMO/PPO,,149.37,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,35.97,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,BCBS NC,Blue Select/HMO/PPO,,17.87,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,13.34,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,BCBS NC,Blue Select/HMO/PPO,,2965.42,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,BCBS NC,Blue Select/HMO/PPO,,14010.58,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,BCBS NC,Blue Select/HMO/PPO,,12868.41,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,BCBS NC,Blue Select/HMO/PPO,,38511.57,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,BCBS NC,Blue Select/HMO/PPO,,7693.16,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,BCBS NC,Blue Select/HMO/PPO,,4660.46,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,BCBS NC,Blue Select/HMO/PPO,,80.29,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,BCBS NC,Blue Select/HMO/PPO,,9377.40,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,13964.05,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,BCBS NC,Blue Select/HMO/PPO,,10283.55,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,BCBS NC,Blue Select/HMO/PPO,,8216.78,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,BCBS NC,Blue Select/HMO/PPO,,2207.30,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,BCBS NC,Blue Select/HMO/PPO,,2544.97,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,BCBS NC,Blue Select/HMO/PPO,,11908.30,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,BCBS NC,Blue Select/HMO/PPO,,56216.16,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,BCBS NC,Blue Select/HMO/PPO,,11278.32,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Select/HMO/PPO,,107.56,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Select/HMO/PPO,,107.56,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,BCBS NC,Blue Select/HMO/PPO,,21.43,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,BCBS NC,Blue Select/HMO/PPO,,6094.43,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,BCBS NC,Blue Select/HMO/PPO,,14408.51,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,BCBS NC,Blue Select/HMO/PPO,,3044.99,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,BCBS NC,Blue Select/HMO/PPO,,111.72,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,BCBS NC,Blue Select/HMO/PPO,,8575.68,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,BCBS NC,Blue Select/HMO/PPO,,81666.49,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,BCBS NC,Blue Select/HMO/PPO,,1605.38,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,12.74,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,BCBS NC,Blue Select/HMO/PPO,,32.03,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,BCBS NC,Blue Select/HMO/PPO,,132.06,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,13.41,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,BCBS NC,Blue Select/HMO/PPO,,45651.09,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,BCBS NC,Blue Select/HMO/PPO,,30500.89,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,BCBS NC,Blue Select/HMO/PPO,,48.73,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,65.31,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,BCBS NC,Blue Select/HMO/PPO,,4762.59,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,BCBS NC,Blue Select/HMO/PPO,,13228.19,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,BCBS NC,Blue Select/HMO/PPO,,74707.66,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,BCBS NC,Blue Select/HMO/PPO,,20408.83,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,BCBS NC,Blue Select/HMO/PPO,,756.86,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,BCBS NC,Blue Select/HMO/PPO,,5005.03,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,BCBS NC,Blue Select/HMO/PPO,,4159.21,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,BCBS NC,Blue Select/HMO/PPO,,6840.63,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,BCBS NC,Blue Select/HMO/PPO,,92693.84,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,BCBS NC,Blue Select/HMO/PPO,,39491.13,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,BCBS NC,Blue Select/HMO/PPO,,15193.58,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,BCBS NC,Blue Select/HMO/PPO,,12635.51,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,12.74,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,BCBS NC,Blue Select/HMO/PPO,,60.88,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,BCBS NC,Blue Select/HMO/PPO,,645.27,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,BCBS NC,Blue Select/HMO/PPO,,24372.77,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,79.75,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,BCBS NC,Blue Select/HMO/PPO,,309.72,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,BCBS NC,Blue Select/HMO/PPO,,12127.70,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,BCBS NC,Blue Select/HMO/PPO,,27041.13,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,BCBS NC,Blue Select/HMO/PPO,,25.59,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,202.62,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Select/HMO/PPO,,65.02,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Select/HMO/PPO,,61.42,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Select/HMO/PPO,,61.42,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,BCBS NC,Blue Select/HMO/PPO,,548.82,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,BCBS NC,Blue Select/HMO/PPO,,871.01,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,BCBS NC,Blue Select/HMO/PPO,,50567.38,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,56.95,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Select/HMO/PPO,,1967.89,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Select/HMO/PPO,,851.20,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Select/HMO/PPO,,851.20,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Select/HMO/PPO,,1967.89,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,BCBS NC,Blue Select/HMO/PPO,,77.23,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,BCBS NC,Blue Select/HMO/PPO,,34322.48,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,BCBS NC,Blue Select/HMO/PPO,,6893.96,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,BCBS NC,Blue Select/HMO/PPO,,385.94,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,BCBS NC,Blue Select/HMO/PPO,,22353.13,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,BCBS NC,Blue Select/HMO/PPO,,2242.71,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,BCBS NC,Blue Select/HMO/PPO,,61362.65,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,BCBS NC,Blue Select/HMO/PPO,,48350.03,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,BCBS NC,Blue Select/HMO/PPO,,8882.28,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,BCBS NC,Blue Select/HMO/PPO,,17752.01,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,BCBS NC,Blue Select/HMO/PPO,,22187.36,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,BCBS NC,Blue Select/HMO/PPO,,50587.02,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,BCBS NC,Blue Select/HMO/PPO,,699.45,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,BCBS NC,Blue Select/HMO/PPO,,1889.94,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,BCBS NC,Blue Select/HMO/PPO,,1889.98,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,BCBS NC,Blue Select/HMO/PPO,,46.83,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Select/HMO/PPO,,37932.62,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,BCBS NC,Blue Select/HMO/PPO,,3033.78,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,BCBS NC,Blue Select/HMO/PPO,,1105.82,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,BCBS NC,Blue Select/HMO/PPO,,156.15,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,74.93,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,BCBS NC,Blue Select/HMO/PPO,,189.63,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,79.43,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,BCBS NC,Blue Select/HMO/PPO,,51.93,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,BCBS NC,Blue Select/HMO/PPO,,47121.16,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,BCBS NC,Blue Select/HMO/PPO,,173.97,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Select/HMO/PPO,,14110.89,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,BCBS NC,Blue Select/HMO/PPO,,261.59,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,BCBS NC,Blue Select/HMO/PPO,,19841.27,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,12.29,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,BCBS NC,Blue Select/HMO/PPO,,8159.08,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,BCBS NC,Blue Select/HMO/PPO,,32495.93,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,BCBS NC,Blue Select/HMO/PPO,,655.36,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,BCBS NC,Blue Select/HMO/PPO,,45453.85,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,BCBS NC,Blue Select/HMO/PPO,,5429.19,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,BCBS NC,Blue Select/HMO/PPO,,190.97,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,BCBS NC,Blue Select/HMO/PPO,,60.30,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,12.65,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.54,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,12.43,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,BCBS NC,Blue Select/HMO/PPO,,26143.70,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,BCBS NC,Blue Select/HMO/PPO,,16176.81,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,BCBS NC,Blue Select/HMO/PPO,,1.01,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.97409,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,BCBS NC,Blue Select/HMO/PPO,,270.49,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,12.18,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,28031.82,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,BCBS NC,Blue Select/HMO/PPO,,345.20,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,12.18,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,BCBS NC,Blue Select/HMO/PPO,,36.79,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,BCBS NC,Blue Select/HMO/PPO,,66.80,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,12.14,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,BCBS NC,Blue Select/HMO/PPO,,55.00,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,BCBS NC,Blue Select/HMO/PPO,,243.29,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,BCBS NC,Blue Select/HMO/PPO,,28.81,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Select/HMO/PPO,,17.57,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,BCBS NC,Blue Select/HMO/PPO,,20.42,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,24.13,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,BCBS NC,Blue Select/HMO/PPO,,2.21,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,BCBS NC,Blue Select/HMO/PPO,,143.17,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,BCBS NC,Blue Select/HMO/PPO,,8.32,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,BCBS NC,Blue Select/HMO/PPO,,14.65,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,12.18,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,BCBS NC,Blue Select/HMO/PPO,,69.95,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,BCBS NC,Blue Select/HMO/PPO,,20.38,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,19.63,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,13.71,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,12.89,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,13.41,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,BCBS NC,Blue Select/HMO/PPO,,67.58,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,BCBS NC,Blue Select/HMO/PPO,,1039.04,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,12.78,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,13.94,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,BCBS NC,Blue Select/HMO/PPO,,3272.29,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,BCBS NC,Blue Select/HMO/PPO,,15544.97,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,BCBS NC,Blue Select/HMO/PPO,,50.91,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,BCBS NC,Blue Select/HMO/PPO,,4722.62,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,BCBS NC,Blue Select/HMO/PPO,,62.87,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,14.01,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,BCBS NC,Blue Select/HMO/PPO,,148.21,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Select/HMO/PPO,,34.54,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Select/HMO/PPO,,33.96,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,13.00,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,BCBS NC,Blue Select/HMO/PPO,,3104.21,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,BCBS NC,Blue Select/HMO/PPO,,61.11,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Select/HMO/PPO,,14.09,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,BCBS NC,Blue Select/HMO/PPO,,94.00,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,BCBS NC,Blue Select/HMO/PPO,,354.34,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,BCBS NC,Blue Select/HMO/PPO,,7.23,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,15.29,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,BCBS NC,Blue Select/HMO/PPO,,826.07,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,47.50,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.39,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.06,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,BCBS NC,Blue Select/HMO/PPO,,14.88,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,BCBS NC,Blue Select/HMO/PPO,,18.48,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,BCBS NC,Blue Select/HMO/PPO,,133.15,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,BCBS NC,Blue Select/HMO/PPO,,8.88,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,65.19,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,BCBS NC,Blue Select/HMO/PPO,,61.26,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,BCBS NC,Blue Select/HMO/PPO,,79.80,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,BCBS NC,Blue Select/HMO/PPO,,82.20,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,BCBS NC,Blue Select/HMO/PPO,,485.58,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,BCBS NC,Blue Select/HMO/PPO,,53.28,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,BCBS NC,Blue Select/HMO/PPO,,53.72,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,59.01,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,BCBS NC,Blue Select/HMO/PPO,,53.39,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,57.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,29.75,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,58.45,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,BCBS NC,Blue Select/HMO/PPO,,1527.45,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,15.29,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,15.29,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,BCBS NC,Blue Select/HMO/PPO,,383.38,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,16.67,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Select/HMO/PPO,,16.67,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,BCBS NC,Blue Select/HMO/PPO,,40.39,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,BCBS NC,Blue Select/HMO/PPO,,6.44,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,14.05,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,BCBS NC,Blue Select/HMO/PPO,,106.48,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Select/HMO/PPO,,12.48,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,BCBS NC,Blue Select/HMO/PPO,,316.50,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,BCBS NC,Blue Select/HMO/PPO,,37.99,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,BCBS NC,Blue Select/HMO/PPO,,66.43,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,BCBS NC,Blue Select/HMO/PPO,,16.04,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,17.98,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,13.15,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,BCBS NC,Blue Select/HMO/PPO,,68.15,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Select/HMO/PPO,,15.92,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,BCBS NC,Blue Select/HMO/PPO,,1.42,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,17.78,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,BCBS NC,Blue Select/HMO/PPO,,16.78,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,BCBS NC,Blue Select/HMO/PPO,,145.92,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,12.74,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,BCBS NC,Blue Select/HMO/PPO,,35.92,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,BCBS NC,Blue Select/HMO/PPO,,22.04,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,BCBS NC,Blue Select/HMO/PPO,,5.62,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.59,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,BCBS NC,Blue Select/HMO/PPO,,60.42,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,BCBS NC,Blue Select/HMO/PPO,,2.51,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,BCBS NC,Blue Select/HMO/PPO,,10.79,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,12.70,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,16.86,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Select/HMO/PPO,,0.97409,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,BCBS NC,Blue Select/HMO/PPO,,59.26,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,17.16,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Select/HMO/PPO,,14.12,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,BCBS NC,Blue Select/HMO/PPO,,14.91,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,BCBS NC,Blue Select/HMO/PPO,,122.09,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,12.33,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,12.89,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,BCBS NC,Blue Select/HMO/PPO,,62.60,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,BCBS NC,Blue Select/HMO/PPO,,23.49,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,BCBS NC,Blue Select/HMO/PPO,,5452.46,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,BCBS NC,Blue Select/HMO/PPO,,20.86,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,BCBS NC,Blue Select/HMO/PPO,,57.55,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,BCBS NC,Blue Select/HMO/PPO,,23.75,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,12.74,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,12.63,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,BCBS NC,Blue Select/HMO/PPO,,2054.06,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,66.09,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,BCBS NC,Blue Select/HMO/PPO,,29.61,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,19.74,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,BCBS NC,Blue Select/HMO/PPO,,72.10,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,BCBS NC,Blue Select/HMO/PPO,,75.41,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,109.10,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,BCBS NC,Blue Select/HMO/PPO,,19.19,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,BCBS NC,Blue Select/HMO/PPO,,875.42,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,BCBS NC,Blue Select/HMO/PPO,,1673.66,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,BCBS NC,Blue Select/HMO/PPO,,4286.20,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Select/HMO/PPO,,4.42,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,BCBS NC,Blue Select/HMO/PPO,,1661.01,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Select/HMO/PPO,,14.12,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,BCBS NC,Blue Select/HMO/PPO,,170.84,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,14.46,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,15.10,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,BCBS NC,Blue Select/HMO/PPO,,197.52,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Select/HMO/PPO,,15.89,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Select/HMO/PPO,,14.54,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,BCBS NC,Blue Select/HMO/PPO,,17.31,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,BCBS NC,Blue Select/HMO/PPO,,19.41,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,BCBS NC,Blue Select/HMO/PPO,,75.83,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,BCBS NC,Blue Select/HMO/PPO,,454.86,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Select/HMO/PPO,,134.23,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Select/HMO/PPO,,134.23,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,BCBS NC,Blue Select/HMO/PPO,,144.36,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,BCBS NC,Blue Select/HMO/PPO,,145.21,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,58.45,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.38,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Select/HMO/PPO,,2.77,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Select/HMO/PPO,,2.77,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,BCBS NC,Blue Select/HMO/PPO,,2.92,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,BCBS NC,Blue Select/HMO/PPO,,26.71,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,BCBS NC,Blue Select/HMO/PPO,,32.52,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,44.96,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,BCBS NC,Blue Select/HMO/PPO,,61.52,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,BCBS NC,Blue Select/HMO/PPO,,78.45,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,BCBS NC,Blue Select/HMO/PPO,,165.41,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,BCBS NC,Blue Select/HMO/PPO,,10.04,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,1.09,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,BCBS NC,Blue Select/HMO/PPO,,758.14,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,BCBS NC,Blue Select/HMO/PPO,,6.03,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,BCBS NC,Blue Select/HMO/PPO,,85.42,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,BCBS NC,Blue Select/HMO/PPO,,17.35,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,BCBS NC,Blue Select/HMO/PPO,,19.86,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,22.48,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,BCBS NC,Blue Select/HMO/PPO,,563.96,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Select/HMO/PPO,,13.75,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,228.89,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Select/HMO/PPO,,18.06,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,69.68,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,BCBS NC,Blue Select/HMO/PPO,,69.16,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,67.66,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,BCBS NC,Blue Select/HMO/PPO,,16.96,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,BCBS NC,Blue Select/HMO/PPO,,15.21,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,13.56,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,BCBS NC,Blue Select/HMO/PPO,,34.58,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,BCBS NC,Blue Select/HMO/PPO,,38.59,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,BCBS NC,Blue Select/HMO/PPO,,200.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,BCBS NC,Blue Select/HMO/PPO,,20.71,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,BCBS NC,Blue Select/HMO/PPO,,46.87,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,BCBS NC,Blue Select/HMO/PPO,,448.94,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,BCBS NC,Blue Select/HMO/PPO,,28.29,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,BCBS NC,Blue Select/HMO/PPO,,46.79,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,BCBS NC,Blue Select/HMO/PPO,,2612.54,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,BCBS NC,Blue Select/HMO/PPO,,1162.91,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,BCBS NC,Blue Select/HMO/PPO,,893.68,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,13.34,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,BCBS NC,Blue Select/HMO/PPO,,161.85,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,BCBS NC,Blue Select/HMO/PPO,,86.36,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,BCBS NC,Blue Select/HMO/PPO,,388.88,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,BCBS NC,Blue Select/HMO/PPO,,518.43,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,BCBS NC,Blue Select/HMO/PPO,,889.90,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,BCBS NC,Blue Select/HMO/PPO,,249.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,BCBS NC,Blue Select/HMO/PPO,,261.88,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Select/HMO/PPO,,14.31,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,14.42,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,16.00,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,BCBS NC,Blue Select/HMO/PPO,,21.32,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,14.32,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,BCBS NC,Blue Select/HMO/PPO,,9551.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,BCBS NC,Blue Select/HMO/PPO,,38.89,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,265.15,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,BCBS NC,Blue Select/HMO/PPO,,49.90,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,13.30,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,BCBS NC,Blue Select/HMO/PPO,,1.84,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,BCBS NC,Blue Select/HMO/PPO,,3.33,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,16.00,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,BCBS NC,Blue Select/HMO/PPO,,20.31,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,BCBS NC,Blue Select/HMO/PPO,,514.34,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,14.61,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,12.78,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,14.61,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,BCBS NC,Blue Select/HMO/PPO,,16.18,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,BCBS NC,Blue Select/HMO/PPO,,61.68,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,BCBS NC,Blue Select/HMO/PPO,,276.98,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,314.71,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,BCBS NC,Blue Select/HMO/PPO,,21.26,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,BCBS NC,Blue Select/HMO/PPO,,31.47,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,21.08,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,39.67,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,23.01,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,BCBS NC,Blue Select/HMO/PPO,,19.44,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,1.31,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,BCBS NC,Blue Select/HMO/PPO,,89.84,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,BCBS NC,Blue Select/HMO/PPO,,4.72,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,BCBS NC,Blue Select/HMO/PPO,,69.77,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,BCBS NC,Blue Select/HMO/PPO,,64.81,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,BCBS NC,Blue Select/HMO/PPO,,345.16,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,236.76,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,BCBS NC,Blue Select/HMO/PPO,,626.38,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,BCBS NC,Blue Select/HMO/PPO,,15.36,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,13.04,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.38,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,BCBS NC,Blue Select/HMO/PPO,,198.60,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,BCBS NC,Blue Select/HMO/PPO,,637.22,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,BCBS NC,Blue Select/HMO/PPO,,14823.96,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,BCBS NC,Blue Select/HMO/PPO,,25.33,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,16.00,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Select/HMO/PPO,,16.00,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,BCBS NC,Blue Select/HMO/PPO,,137.23,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,BCBS NC,Blue Select/HMO/PPO,,87.14,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,BCBS NC,Blue Select/HMO/PPO,,22.40,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,BCBS NC,Blue Select/HMO/PPO,,93.92,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,BCBS NC,Blue Select/HMO/PPO,,53.57,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,BCBS NC,Blue Select/HMO/PPO,,142.44,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,BCBS NC,Blue Select/HMO/PPO,,62.75,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,BCBS NC,Blue Select/HMO/PPO,,390.61,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,BCBS NC,Blue Select/HMO/PPO,,44.31,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,16.48,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,BCBS NC,Blue Select/HMO/PPO,,21.43,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,BCBS NC,Blue Select/HMO/PPO,,89.84,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Select/HMO/PPO,,21685.53,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,BCBS NC,Blue Select/HMO/PPO,,27.46,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.59,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,BCBS NC,Blue Select/HMO/PPO,,16.60,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,BCBS NC,Blue Select/HMO/PPO,,69.28,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,BCBS NC,Blue Select/HMO/PPO,,2210.31,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,BCBS NC,Blue Select/HMO/PPO,,26.82,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,BCBS NC,Blue Select/HMO/PPO,,95.48,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,BCBS NC,Blue Select/HMO/PPO,,1679.19,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,BCBS NC,Blue Select/HMO/PPO,,31.62,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,BCBS NC,Blue Select/HMO/PPO,,26.01,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,BCBS NC,Blue Select/HMO/PPO,,21.78,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,BCBS NC,Blue Select/HMO/PPO,,41.40,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,BCBS NC,Blue Select/HMO/PPO,,27.12,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,BCBS NC,Blue Select/HMO/PPO,,3881.93,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,BCBS NC,Blue Select/HMO/PPO,,9686.97,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,BCBS NC,Blue Select/HMO/PPO,,19361.96,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,BCBS NC,Blue Select/HMO/PPO,,38712.04,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.59,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,BCBS NC,Blue Select/HMO/PPO,,134.30,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,BCBS NC,Blue Select/HMO/PPO,,299.42,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,BCBS NC,Blue Select/HMO/PPO,,19.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,BCBS NC,Blue Select/HMO/PPO,,37.58,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,BCBS NC,Blue Select/HMO/PPO,,110.75,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,BCBS NC,Blue Select/HMO/PPO,,234.76,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,13.79,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,13.34,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,BCBS NC,Blue Select/HMO/PPO,,36.27,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,BCBS NC,Blue Select/HMO/PPO,,37.80,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Select/HMO/PPO,,12.74,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,13.45,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,BCBS NC,Blue Select/HMO/PPO,,3497.54,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,12.78,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,BCBS NC,Blue Select/HMO/PPO,,42.97,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,BCBS NC,Blue Select/HMO/PPO,,100.78,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,BCBS NC,Blue Select/HMO/PPO,,27.57,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Select/HMO/PPO,,124.43,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,BCBS NC,Blue Select/HMO/PPO,,16.41,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,16.86,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,17.16,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,BCBS NC,Blue Select/HMO/PPO,,238.73,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,16.11,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,BCBS NC,Blue Select/HMO/PPO,,19.67,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,BCBS NC,Blue Select/HMO/PPO,,27.54,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,20.67,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,BCBS NC,Blue Select/HMO/PPO,,348.46,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,BCBS NC,Blue Select/HMO/PPO,,8.47,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,BCBS NC,Blue Select/HMO/PPO,,1.24,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,BCBS NC,Blue Select/HMO/PPO,,768.07,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,BCBS NC,Blue Select/HMO/PPO,,18.62,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,BCBS NC,Blue Select/HMO/PPO,,18.58,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,BCBS NC,Blue Select/HMO/PPO,,187.03,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,22.48,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,24.24,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,13.26,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,BCBS NC,Blue Select/HMO/PPO,,13.67,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,BCBS NC,Blue Select/HMO/PPO,,14.72,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Select/HMO/PPO,,5438.99,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,13.10,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,13.56,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,BCBS NC,Blue Select/HMO/PPO,,15.14,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Select/HMO/PPO,,12.55,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,BCBS NC,Blue Select/HMO/PPO,,4637.71,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,BCBS NC,Blue Select/HMO/PPO,,65.60,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,17.98,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,BCBS NC,Blue Select/HMO/PPO,,72.61,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,BCBS NC,Blue Select/HMO/PPO,,78.98,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Select/HMO/PPO,,15.92,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,BCBS NC,Blue Select/HMO/PPO,,1.12,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,14.01,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,BCBS NC,Blue Select/HMO/PPO,,52.40,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,BCBS NC,Blue Select/HMO/PPO,,3.63,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,12.70,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,21.28,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,12.63,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,358.48,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,13.45,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,12.14,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,BCBS NC,Blue Select/HMO/PPO,,17.68,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,3.22,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,BCBS NC,Blue Select/HMO/PPO,,20.57,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Select/HMO/PPO,,3.22,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,BCBS NC,Blue Select/HMO/PPO,,19.41,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Select/HMO/PPO,,12.85,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,46.46,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,BCBS NC,Blue Select/HMO/PPO,,1.31,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Select/HMO/PPO,,16.90,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,BCBS NC,Blue Select/HMO/PPO,,17.29,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Select/HMO/PPO,,16.90,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,BCBS NC,Blue Select/HMO/PPO,,6.26,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,17.01,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,BCBS NC,Blue Select/HMO/PPO,,12.06,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,BCBS NC,Blue Select/HMO/PPO,,85.05,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,BCBS NC,Blue Select/HMO/PPO,,125.73,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Select/HMO/PPO,,20.87,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,BCBS NC,Blue Select/HMO/PPO,,23.49,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,BCBS NC,Blue Select/HMO/PPO,,13407.25,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,2935.85,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,22.93,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,BCBS NC,Blue Select/HMO/PPO,,562.29,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Select/HMO/PPO,,173.20,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,BCBS NC,Blue Select/HMO/PPO,,106.69,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Select/HMO/PPO,,2034.07,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,BCBS NC,Blue Select/HMO/PPO,,1119.13,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,BCBS NC,Blue Select/HMO/PPO,,2.62,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,BCBS NC,Blue Select/HMO/PPO,,81.09,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,BCBS NC,Blue Select/HMO/PPO,,1.20,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,BCBS NC,Blue Select/HMO/PPO,,20.53,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,BCBS NC,Blue Select/HMO/PPO,,15.14,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,BCBS NC,Blue Select/HMO/PPO,,30.39,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,BCBS NC,Blue Select/HMO/PPO,,1042.46,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,BCBS NC,Blue Select/HMO/PPO,,45.67,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,BCBS NC,Blue Select/HMO/PPO,,27.76,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,17.66,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,BCBS NC,Blue Select/HMO/PPO,,279.99,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,BCBS NC,Blue Select/HMO/PPO,,358.15,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,BCBS NC,Blue Select/HMO/PPO,,247.89,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,BCBS NC,Blue Select/HMO/PPO,,397.34,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,BCBS NC,Blue Select/HMO/PPO,,88.12,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,67.66,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,12.03,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,18.59,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,BCBS NC,Blue Select/HMO/PPO,,86.17,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,BCBS NC,Blue Select/HMO/PPO,,514.17,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,BCBS NC,Blue Select/HMO/PPO,,1204.27,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,13.08,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Select/HMO/PPO,,13.97,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,50.02,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,52.26,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,50.58,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,59.01,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,52.26,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,50.58,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,112.39,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,BCBS NC,Blue Select/HMO/PPO,,55.07,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,52.26,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,50.58,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Select/HMO/PPO,,50.58,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,50.02,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,53.95,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Select/HMO/PPO,,52.26,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,59.01,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Select/HMO/PPO,,50.02,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,12.10,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,BCBS NC,Blue Select/HMO/PPO,,766.91,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,16.81,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,BCBS NC,Blue Select/HMO/PPO,,5364.10,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,BCBS NC,Blue Select/HMO/PPO,,19644.81,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,BCBS NC,Blue Select/HMO/PPO,,4149.23,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,BCBS NC,Blue Select/HMO/PPO,,19644.81,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,BCBS NC,Blue Select/HMO/PPO,,14.16,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,14.39,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,79.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Select/HMO/PPO,,5438.99,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,BCBS NC,Blue Select/HMO/PPO,,259.92,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,BCBS NC,Blue Select/HMO/PPO,,922.55,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,17.08,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,BCBS NC,Blue Select/HMO/PPO,,34.62,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,BCBS NC,Blue Select/HMO/PPO,,5218.11,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,BCBS NC,Blue Select/HMO/PPO,,246.63,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,BCBS NC,Blue Select/HMO/PPO,,228.82,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,BCBS NC,Blue Select/HMO/PPO,,499.91,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Select/HMO/PPO,,29774.02,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Select/HMO/PPO,,118483.40,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Select/HMO/PPO,,1092.00,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Select/HMO/PPO,,2174.46,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,BCBS NC,Blue Select/HMO/PPO,,19908.25,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,BCBS NC,Blue Select/HMO/PPO,,237.62,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Select/HMO/PPO,,215.28,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Select/HMO/PPO,,233.61,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,215.09,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Select/HMO/PPO,,312.69,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,BCBS NC,Blue Select/HMO/PPO,,1510.38,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,367.39,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,BCBS NC,Blue Select/HMO/PPO,,739.68,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,BCBS NC,Blue Select/HMO/PPO,,17.16,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,57.56,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,BCBS NC,Blue Select/HMO/PPO,,250.42,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Select/HMO/PPO,,4186.19,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Select/HMO/PPO,,8325.59,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,BCBS NC,Blue Select/HMO/PPO,,78.94,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Select/HMO/PPO,,33.73,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,47.09,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,BCBS NC,Blue Select/HMO/PPO,,14.14,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,62.34,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,BCBS NC,Blue Select/HMO/PPO,,19.97,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Select/HMO/PPO,,254.43,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,45.27,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,56.41,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,BCBS NC,Blue Select/HMO/PPO,,217.35,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Select/HMO/PPO,,15.44,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Select/HMO/PPO,,32.14,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,18.63,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,21.67,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Select/HMO/PPO,,14.47,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,14.29,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.59,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,BCBS NC,Blue Select/HMO/PPO,,76.71,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,53.95,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,58.45,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,53.50,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,BCBS NC,Blue Select/HMO/PPO,,56.76,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,BCBS NC,Blue Select/HMO/PPO,,52.94,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,56.20,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Select/HMO/PPO,,212.64,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,46.80,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,BCBS NC,Blue Select/HMO/PPO,,81.97,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,BCBS NC,Blue Select/HMO/PPO,,3.56,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,162.54,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,849.34,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,BCBS NC,Blue Select/HMO/PPO,,813.89,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,BCBS NC,Blue Select/HMO/PPO,,33.34,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,BCBS NC,Blue Select/HMO/PPO,,34.51,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,BCBS NC,Blue Select/HMO/PPO,,23.42,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,BCBS NC,Blue Select/HMO/PPO,,2.10,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,BCBS NC,Blue Select/HMO/PPO,,27145.97,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,BCBS NC,Blue Select/HMO/PPO,,236.13,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,162.54,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,BCBS NC,Blue Select/HMO/PPO,,47.39,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,BCBS NC,Blue Select/HMO/PPO,,85.72,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Select/HMO/PPO,,20.60,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Select/HMO/PPO,,8.80,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,BCBS NC,Blue Select/HMO/PPO,,55.74,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,BCBS NC,Blue Select/HMO/PPO,,80.27,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,BCBS NC,Blue Select/HMO/PPO,,113.74,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,BCBS NC,Blue Select/HMO/PPO,,16.22,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,BCBS NC,Blue Select/HMO/PPO,,14.55,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,BCBS NC,Blue Select/HMO/PPO,,43.27,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,BCBS NC,Blue Select/HMO/PPO,,153.08,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,12.29,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,BCBS NC,Blue Select/HMO/PPO,,39.86,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Select/HMO/PPO,,12.14,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,17.95,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,BCBS NC,Blue Select/HMO/PPO,,10158.42,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,BCBS NC,Blue Select/HMO/PPO,,2077.42,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,BCBS NC,Blue Select/HMO/PPO,,59.12,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,35.89,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,BCBS NC,Blue Select/HMO/PPO,,20.93,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,BCBS NC,Blue Select/HMO/PPO,,57.10,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Select/HMO/PPO,,33.96,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,BCBS NC,Blue Select/HMO/PPO,,78.23,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,182.08,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,BCBS NC,Blue Select/HMO/PPO,,47.20,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,182.08,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Select/HMO/PPO,,22.12,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Select/HMO/PPO,,433.21,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,BCBS NC,Blue Select/HMO/PPO,,21.15,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,204.56,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,204.56,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,BCBS NC,Blue Select/HMO/PPO,,15.33,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,BCBS NC,Blue Select/HMO/PPO,,14.96,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,BCBS NC,Blue Select/HMO/PPO,,15.03,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,BCBS NC,Blue Select/HMO/PPO,,5.32,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,BCBS NC,Blue Select/HMO/PPO,,114.11,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,BCBS NC,Blue Select/HMO/PPO,,300.63,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,116.14,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,BCBS NC,Blue Select/HMO/PPO,,602.06,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,BCBS NC,Blue Select/HMO/PPO,,49.13,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,18.73,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,14.24,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,52.45,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,65.94,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,BCBS NC,Blue Select/HMO/PPO,,56.05,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Select/HMO/PPO,,45.26,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,BCBS NC,Blue Select/HMO/PPO,,69.09,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,BCBS NC,Blue Select/HMO/PPO,,281.74,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,14.24,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,BCBS NC,Blue Select/HMO/PPO,,48.22,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,BCBS NC,Blue Select/HMO/PPO,,20.27,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,17.98,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,BCBS NC,Blue Select/HMO/PPO,,85.17,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,204.56,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,182.08,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,35.59,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,12.91,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,47.50,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,21.50,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,12.29,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,BCBS NC,Blue Select/HMO/PPO,,12.88,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,70.14,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,25.48,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,BCBS NC,Blue Select/HMO/PPO,,17.50,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,BCBS NC,Blue Select/HMO/PPO,,160.02,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,BCBS NC,Blue Select/HMO/PPO,,253.79,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,BCBS NC,Blue Select/HMO/PPO,,619.74,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,BCBS NC,Blue Select/HMO/PPO,,48.43,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,BCBS NC,Blue Select/HMO/PPO,,60.82,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,BCBS NC,Blue Select/HMO/PPO,,165.21,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,66.09,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Select/HMO/PPO,,65.35,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,BCBS NC,Blue Select/HMO/PPO,,96.32,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Select/HMO/PPO,,4.42,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Select/HMO/PPO,,37.93,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Select/HMO/PPO,,21.08,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,28031.82,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,236.76,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,BCBS NC,Blue Select/HMO/PPO,,126.18,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,47.91,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,BCBS NC,Blue Select/HMO/PPO,,53.96,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,BCBS NC,Blue Select/HMO/PPO,,48.17,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,55.66,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Select/HMO/PPO,,45.26,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,BCBS NC,Blue Select/HMO/PPO,,65.90,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,BCBS NC,Blue Select/HMO/PPO,,278.81,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,14.29,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,BCBS NC,Blue Select/HMO/PPO,,50.50,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,BCBS NC,Blue Select/HMO/PPO,,50.77,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,BCBS NC,Blue Select/HMO/PPO,,71.70,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,BCBS NC,Blue Select/HMO/PPO,,22.79,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,BCBS NC,Blue Select/HMO/PPO,,79.84,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,BCBS NC,Blue Select/HMO/PPO,,128.73,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,BCBS NC,Blue Select/HMO/PPO,,77.15,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,BCBS NC,Blue Select/HMO/PPO,,185.85,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,BCBS NC,Blue Select/HMO/PPO,,126.88,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,BCBS NC,Blue Select/HMO/PPO,,59.86,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,BCBS NC,Blue Select/HMO/PPO,,52.21,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,BCBS NC,Blue Select/HMO/PPO,,77.15,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,BCBS NC,Blue Select/HMO/PPO,,71.70,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Select/HMO/PPO,,81.05,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,BCBS NC,Blue Select/HMO/PPO,,355.37,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,BCBS NC,Blue Select/HMO/PPO,,87.47,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,420.83,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,BCBS NC,Blue Select/HMO/PPO,,865.18,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,BCBS NC,Blue Select/HMO/PPO,,922.11,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,27.09,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,62.64,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,BCBS NC,Blue Select/HMO/PPO,,55.18,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,BCBS NC,Blue Select/HMO/PPO,,113.78,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,BCBS NC,Blue Select/HMO/PPO,,162.17,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,BCBS NC,Blue Select/HMO/PPO,,380.30,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,BCBS NC,Blue Select/HMO/PPO,,713.85,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Select/HMO/PPO,,67.02,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,BCBS NC,Blue Select/HMO/PPO,,76.56,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,BCBS NC,Blue Select/HMO/PPO,,183.88,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,BCBS NC,Blue Select/HMO/PPO,,49.58,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,BCBS NC,Blue Select/HMO/PPO,,58.00,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,BCBS NC,Blue Select/HMO/PPO,,545.63,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,13.03,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,BCBS NC,Blue Select/HMO/PPO,,204.25,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,BCBS NC,Blue Select/HMO/PPO,,47.09,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,BCBS NC,Blue Select/HMO/PPO,,78.01,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,215.09,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,BCBS NC,Blue Select/HMO/PPO,,130.92,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,BCBS NC,Blue Select/HMO/PPO,,18.13,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,BCBS NC,Blue Select/HMO/PPO,,89.47,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,52.99,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,BCBS NC,Blue Select/HMO/PPO,,58.71,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,BCBS NC,Blue Select/HMO/PPO,,135.32,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,BCBS NC,Blue Select/HMO/PPO,,127.51,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,56.11,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,21.88,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,BCBS NC,Blue Select/HMO/PPO,,25.79,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,BCBS NC,Blue Select/HMO/PPO,,52.99,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,BCBS NC,Blue Select/HMO/PPO,,1324.83,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,BCBS NC,Blue Select/HMO/PPO,,73.89,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,BCBS NC,Blue Select/HMO/PPO,,18.67,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,BCBS NC,Blue Select/HMO/PPO,,25.87,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,53.76,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Select/HMO/PPO,,20.60,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Select/HMO/PPO,,46.83,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,130.38,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,47.96,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,66.09,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,BCBS NC,Blue Select/HMO/PPO,,16.66,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,BCBS NC,Blue Select/HMO/PPO,,16.70,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,BCBS NC,Blue Select/HMO/PPO,,19.00,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,31.69,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,19.37,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,202.62,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,BCBS NC,Blue Select/HMO/PPO,,97.27,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,70.14,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,BCBS NC,Blue Select/HMO/PPO,,104.64,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,BCBS NC,Blue Select/HMO/PPO,,21.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,BCBS NC,Blue Select/HMO/PPO,,78.15,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,80.18,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,BCBS NC,Blue Select/HMO/PPO,,60.79,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,BCBS NC,Blue Select/HMO/PPO,,13.17,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,BCBS NC,Blue Select/HMO/PPO,,50.69,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,BCBS NC,Blue Select/HMO/PPO,,41.49,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,BCBS NC,Blue Select/HMO/PPO,,61.05,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,BCBS NC,Blue Select/HMO/PPO,,79.69,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,BCBS NC,Blue Select/HMO/PPO,,230.68,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,BCBS NC,Blue Select/HMO/PPO,,59.19,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,BCBS NC,Blue Select/HMO/PPO,,236.95,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,55.66,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,BCBS NC,Blue Select/HMO/PPO,,47.61,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,29.75,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,77.93,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,BCBS NC,Blue Select/HMO/PPO,,56.01,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,BCBS NC,Blue Select/HMO/PPO,,38.59,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,BCBS NC,Blue Select/HMO/PPO,,119.94,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,BCBS NC,Blue Select/HMO/PPO,,16.60,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Select/HMO/PPO,,46.83,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,BCBS NC,Blue Select/HMO/PPO,,335.36,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Select/HMO/PPO,,124.43,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,BCBS NC,Blue Select/HMO/PPO,,205.29,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,BCBS NC,Blue Select/HMO/PPO,,179.38,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,BCBS NC,Blue Select/HMO/PPO,,55.37,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,BCBS NC,Blue Select/HMO/PPO,,48.76,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,BCBS NC,Blue Select/HMO/PPO,,59.08,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,BCBS NC,Blue Select/HMO/PPO,,44.81,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,12.03,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,BCBS NC,Blue Select/HMO/PPO,,183.77,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Select/HMO/PPO,,7479.15,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Select/HMO/PPO,,65.02,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Select/HMO/PPO,,111.63,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,BCBS NC,Blue Select/HMO/PPO,,115.13,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,BCBS NC,Blue Select/HMO/PPO,,270.35,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Select/HMO/PPO,,11755.45,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,BCBS NC,Blue Select/HMO/PPO,,292.87,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Select/HMO/PPO,,416.34,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Select/HMO/PPO,,231.05,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Select/HMO/PPO,,359.30,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Select/HMO/PPO,,335.73,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Select/HMO/PPO,,302.08,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,BCBS NC,Blue Select/HMO/PPO,,272.68,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Select/HMO/PPO,,416.34,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Select/HMO/PPO,,231.05,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Select/HMO/PPO,,359.30,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Select/HMO/PPO,,2034.07,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,BCBS NC,Blue Select/HMO/PPO,,75.11,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,BCBS NC,Blue Select/HMO/PPO,,86.28,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,18.63,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,22.01,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Select/HMO/PPO,,66.09,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,BCBS NC,Blue Select/HMO/PPO,,144.95,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,BCBS NC,Blue Select/HMO/PPO,,109.55,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,849.34,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Select/HMO/PPO,,849.34,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,BCBS NC,Blue Select/HMO/PPO,,54.63,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,BCBS NC,Blue Select/HMO/PPO,,47.83,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,BCBS NC,Blue Select/HMO/PPO,,308.82,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Select/HMO/PPO,,30.23,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,BCBS NC,Blue Select/HMO/PPO,,128.59,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,BCBS NC,Blue Select/HMO/PPO,,46.91,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,BCBS NC,Blue Select/HMO/PPO,,86.28,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,36.64,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Select/HMO/PPO,,19.29,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Select/HMO/PPO,,24.24,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,BCBS NC,Blue Select/HMO/PPO,,1187.53,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,BCBS NC,Blue Select/HMO/PPO,,28.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,BCBS NC,Blue Select/HMO/PPO,,358.47,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,65.31,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Select/HMO/PPO,,1915.21,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,12.77,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,BCBS NC,Blue Select/HMO/PPO,,108.12,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,BCBS NC,Blue Select/HMO/PPO,,1034.15,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,BCBS NC,Blue Select/HMO/PPO,,54.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,161.10,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,BCBS NC,Blue Select/HMO/PPO,,443.28,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Select/HMO/PPO,,81.05,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,BCBS NC,Blue Select/HMO/PPO,,85.72,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Select/HMO/PPO,,32.14,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Select/HMO/PPO,,48.50,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Select/HMO/PPO,,35.22,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Select/HMO/PPO,,49.02,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,27.09,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Select/HMO/PPO,,49.02,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,BCBS NC,Blue Select/HMO/PPO,,35.96,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,BCBS NC,Blue Select/HMO/PPO,,65.91,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,BCBS NC,Blue Select/HMO/PPO,,193.27,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,BCBS NC,Blue Select/HMO/PPO,,89.69,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,BCBS NC,Blue Select/HMO/PPO,,87.77,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,12.03,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Select/HMO/PPO,,5041.76,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,BCBS NC,Blue Select/HMO/PPO,,22.97,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,BCBS NC,Blue Select/HMO/PPO,,61.79,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,BCBS NC,Blue Select/HMO/PPO,,48.78,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,BCBS NC,Blue Select/HMO/PPO,,132.37,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,BCBS NC,Blue Select/HMO/PPO,,37.56,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,BCBS NC,Blue Select/HMO/PPO,,173.61,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,BCBS NC,Blue Select/HMO/PPO,,176.46,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Select/HMO/PPO,,111.63,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,358.48,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,BCBS NC,Blue Select/HMO/PPO,,50.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,16.40,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,16.92,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,BCBS NC,Blue Select/HMO/PPO,,343.89,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,BCBS NC,Blue Select/HMO/PPO,,19.33,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Select/HMO/PPO,,4331.81,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,47.24,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,BCBS NC,Blue Select/HMO/PPO,,46.87,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,BCBS NC,Blue Select/HMO/PPO,,47.39,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,BCBS NC,Blue Select/HMO/PPO,,46.98,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,BCBS NC,Blue Select/HMO/PPO,,47.24,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,BCBS NC,Blue Select/HMO/PPO,,107.54,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,BCBS NC,Blue Select/HMO/PPO,,14.36,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,11.91,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,BCBS NC,Blue Select/HMO/PPO,,49.13,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Select/HMO/PPO,,37.50,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,BCBS NC,Blue Select/HMO/PPO,,338.55,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,BCBS NC,Blue Select/HMO/PPO,,342.97,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,BCBS NC,Blue Select/HMO/PPO,,267.97,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,BCBS NC,Blue Select/HMO/PPO,,59.79,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,65.50,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,27.72,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,56.65,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,59.01,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,56.20,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Select/HMO/PPO,,11.91,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,BCBS NC,Blue Select/HMO/PPO,,18.44,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,BCBS NC,Blue Select/HMO/PPO,,117.75,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Select/HMO/PPO,,66.02,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,BCBS NC,Blue Select/HMO/PPO,,93.18,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Select/HMO/PPO,,62.42,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Select/HMO/PPO,,265.15,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Select/HMO/PPO,,858.02,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,BCBS NC,Blue Select/HMO/PPO,,18.52,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,BCBS NC,Blue Select/HMO/PPO,,541.99,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,BCBS NC,Blue Select/HMO/PPO,,76.20,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,47.50,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,BCBS NC,Blue Select/HMO/PPO,,76.82,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,BCBS NC,Blue Select/HMO/PPO,,46.49,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Select/HMO/PPO,,112.26,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Select/HMO/PPO,,212.64,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,28.95,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,45.65,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,BCBS NC,Blue Select/HMO/PPO,,19.59,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Select/HMO/PPO,,27.09,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,155.86,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Select/HMO/PPO,,56.11,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Select/HMO/PPO,,65.17,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,BCBS NC,Blue Select/HMO/PPO,,61.08,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Select/HMO/PPO,,18.63,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,22.01,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,BCBS NC,Blue Select/HMO/PPO,,49.69,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,62.34,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Select/HMO/PPO,,17.22,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,BCBS NC,Blue Select/HMO/PPO,,25.78,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,BCBS NC,Blue Select/HMO/PPO,,15.47,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,31.69,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,BCBS NC,Blue Select/HMO/PPO,,17.78,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,BCBS NC,Blue Select/HMO/PPO,,19.45,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,12.25,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,BCBS NC,Blue Select/HMO/PPO,,394.33,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,25.48,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,65.94,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Select/HMO/PPO,,1915.21,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,18350.75,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,18350.75,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,18350.75,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,18350.75,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Select/HMO/PPO,,18350.75,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Select/HMO/PPO,,28031.82,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,BCBS NC,Blue Select/HMO/PPO,,299.81,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,BCBS NC,Blue Select/HMO/PPO,,79.19,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,22.01,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,BCBS NC,Blue Select/HMO/PPO,,17.11,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Select/HMO/PPO,,111.01,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,22.23,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,BCBS NC,Blue Select/HMO/PPO,,9.29,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,358.48,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,BCBS NC,Blue Select/HMO/PPO,,561.85,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Select/HMO/PPO,,36.29,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Select/HMO/PPO,,19.11,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,19.37,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,BCBS NC,Blue Select/HMO/PPO,,206.52,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,BCBS NC,Blue Select/HMO/PPO,,43.76,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Select/HMO/PPO,,58.11,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,65.94,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Select/HMO/PPO,,400.64,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,228.89,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,BCBS NC,Blue Select/HMO/PPO,,3.11,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,BCBS NC,Blue Select/HMO/PPO,,2.10,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,BCBS NC,Blue Select/HMO/PPO,,205.40,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,BCBS NC,Blue Select/HMO/PPO,,221.51,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,BCBS NC,Blue Select/HMO/PPO,,177.13,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,BCBS NC,Blue Select/HMO/PPO,,193.42,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,BCBS NC,Blue Select/HMO/PPO,,1.69,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,BCBS NC,Blue Select/HMO/PPO,,216.20,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.07,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.07,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Select/HMO/PPO,,30.54,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Select/HMO/PPO,,49.17,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,BCBS NC,Blue Select/HMO/PPO,,58.30,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,21.50,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Select/HMO/PPO,,28.25,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Select/HMO/PPO,,27.61,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,BCBS NC,Blue Select/HMO/PPO,,33499.94,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Select/HMO/PPO,,26697.16,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Select/HMO/PPO,,38051.26,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,BCBS NC,Blue Select/HMO/PPO,,20.57,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,BCBS NC,Blue Select/HMO/PPO,,416.61,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Select/HMO/PPO,,233.61,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Select/HMO/PPO,,215.09,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Select/HMO/PPO,,312.69,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,BCBS NC,Blue Select/HMO/PPO,,34728.47,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,5667.59,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,2935.85,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,5667.59,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,2935.85,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Select/HMO/PPO,,5667.59,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Select/HMO/PPO,,2935.85,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Select/HMO/PPO,,751.44,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,13964.05,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,13964.05,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Select/HMO/PPO,,13964.05,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Select/HMO/PPO,,37932.62,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,1836.94,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Select/HMO/PPO,,3099.17,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Select/HMO/PPO,,6151.58,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Select/HMO/PPO,,1267.75,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Select/HMO/PPO,,3099.17,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Select/HMO/PPO,,6151.58,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Select/HMO/PPO,,1267.75,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,BCBS NC,Blue Select/HMO/PPO,,206.96,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,BCBS NC,Blue Select/HMO/PPO,,32.73,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Select/HMO/PPO,,22.08,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,BCBS NC,Blue Select/HMO/PPO,,143744.18,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,BCBS NC,Blue Select/HMO/PPO,,96.58,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,BCBS NC,Blue Select/HMO/PPO,,52.83,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,56.20,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,BCBS NC,Blue Select/HMO/PPO,,55.64,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,56.20,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Select/HMO/PPO,,1092.00,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,BCBS NC,Blue Select/HMO/PPO,,53.01,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,BCBS NC,Blue Select/HMO/PPO,,15.21,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,BCBS NC,Blue Select/HMO/PPO,,16.11,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,BCBS NC,Blue Select/HMO/PPO,,14.42,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,BCBS NC,Blue Select/HMO/PPO,,498.02,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,BCBS NC,Blue Select/HMO/PPO,,108.69,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,BCBS NC,Blue Select/HMO/PPO,,551.48,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,BCBS NC,Blue Select/HMO/PPO,,197.40,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Select/HMO/PPO,,41.51,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Select/HMO/PPO,,41.51,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,BCBS NC,Blue Select/HMO/PPO,,3.82,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,BCBS NC,Blue Select/HMO/PPO,,9.70,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,BCBS NC,Blue Select/HMO/PPO,,59.87,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,BCBS NC,Blue Select/HMO/PPO,,45.15,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,BCBS NC,Blue Select/HMO/PPO,,345.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,58.45,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Select/HMO/PPO,,12.85,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,BCBS NC,Blue Select/HMO/PPO,,44.36,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,BCBS NC,Blue Select/HMO/PPO,,28.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,BCBS NC,Blue Select/HMO/PPO,,326.66,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Select/HMO/PPO,,13.71,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,BCBS NC,Blue Select/HMO/PPO,,79.88,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,79.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,432.70,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,BCBS NC,Blue Select/HMO/PPO,,232.87,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,BCBS NC,Blue Select/HMO/PPO,,38.81,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Select/HMO/PPO,,15.29,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Select/HMO/PPO,,13.34,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Select/HMO/PPO,,13.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,13.26,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,13.49,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Select/HMO/PPO,,16.97,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,25.48,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,BCBS NC,Blue Select/HMO/PPO,,22.64,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,BCBS NC,Blue Select/HMO/PPO,,22.71,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,BCBS NC,Blue Select/HMO/PPO,,25.35,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,28.20,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,BCBS NC,Blue Select/HMO/PPO,,85.43,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,BCBS NC,Blue Select/HMO/PPO,,36.44,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Select/HMO/PPO,,12.18,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Select/HMO/PPO,,13.60,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,12.29,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,12.81,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,12.33,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,BCBS NC,Blue Select/HMO/PPO,,1.61,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,BCBS NC,Blue Select/HMO/PPO,,17.83,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,BCBS NC,Blue Select/HMO/PPO,,87.44,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,BCBS NC,Blue Select/HMO/PPO,,173.97,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Select/HMO/PPO,,35.22,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,BCBS NC,Blue Select/HMO/PPO,,3.18,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,67.54,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,35.89,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Select/HMO/PPO,,23.19,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,22.01,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,BCBS NC,Blue Select/HMO/PPO,,139.11,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,BCBS NC,Blue Select/HMO/PPO,,57.81,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,BCBS NC,Blue Select/HMO/PPO,,22.40,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,12.81,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Select/HMO/PPO,,22.01,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,22.23,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,BCBS NC,Blue Select/HMO/PPO,,64.76,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,BCBS NC,Blue Select/HMO/PPO,,66.09,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,88.42,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,BCBS NC,Blue Select/HMO/PPO,,17.53,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,BCBS NC,Blue Select/HMO/PPO,,39.74,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Select/HMO/PPO,,12.25,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Select/HMO/PPO,,27.61,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,227.86,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,BCBS NC,Blue Select/HMO/PPO,,351.06,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Select/HMO/PPO,,16.93,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,BCBS NC,Blue Select/HMO/PPO,,21.49,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,BCBS NC,Blue Select/HMO/PPO,,78.49,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Select/HMO/PPO,,14.39,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,BCBS NC,Blue Select/HMO/PPO,,14.27,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,BCBS NC,Blue Select/HMO/PPO,,15.25,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,12.33,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Select/HMO/PPO,,13.97,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,BCBS NC,Blue Select/HMO/PPO,,55.07,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,BCBS NC,Blue Select/HMO/PPO,,10.12,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,12.81,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,13.94,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Select/HMO/PPO,,13.56,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,BCBS NC,Blue Select/HMO/PPO,,19.74,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,BCBS NC,Blue Select/HMO/PPO,,22.75,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,16.56,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Select/HMO/PPO,,19.56,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,68.19,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,BCBS NC,Blue Select/HMO/PPO,,17.46,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,27.72,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,BCBS NC,Blue Select/HMO/PPO,,23.97,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Select/HMO/PPO,,65.35,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,BCBS NC,Blue Select/HMO/PPO,,123.32,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,12.78,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,BCBS NC,Blue Select/HMO/PPO,,95.26,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,BCBS NC,Blue Select/HMO/PPO,,40.24,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,BCBS NC,Blue Select/HMO/PPO,,19.26,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.59,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,12.81,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,43.46,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,43.46,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Select/HMO/PPO,,13.79,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,BCBS NC,Blue Select/HMO/PPO,,17.42,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,BCBS NC,Blue Select/HMO/PPO,,7.87,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,15.55,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,BCBS NC,Blue Select/HMO/PPO,,13.32,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,BCBS NC,Blue Select/HMO/PPO,,151.74,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,BCBS NC,Blue Select/HMO/PPO,,183.73,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,BCBS NC,Blue Select/HMO/PPO,,54.85,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,BCBS NC,Blue Select/HMO/PPO,,32.00,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.59,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Select/HMO/PPO,,5041.76,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.38,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Select/HMO/PPO,,12.96,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,BCBS NC,Blue Select/HMO/PPO,,18.21,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,17.72,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,BCBS NC,Blue Select/HMO/PPO,,168.63,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,BCBS NC,Blue Select/HMO/PPO,,75.04,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Select/HMO/PPO,,25.38,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,BCBS NC,Blue Select/HMO/PPO,,157.87,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,79.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Select/HMO/PPO,,4.80,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,BCBS NC,Blue Select/HMO/PPO,,85.05,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,16.59,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,17.72,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,BCBS NC,Blue Select/HMO/PPO,,53.66,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,BCBS NC,Blue Select/HMO/PPO,,189.27,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,193.32,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,BCBS NC,Blue Select/HMO/PPO,,202.09,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,BCBS NC,Blue Select/HMO/PPO,,116.44,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,BCBS NC,Blue Select/HMO/PPO,,64.22,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,BCBS NC,Blue Select/HMO/PPO,,82.46,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,BCBS NC,Blue Select/HMO/PPO,,53.92,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,BCBS NC,Blue Select/HMO/PPO,,141.73,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,BCBS NC,Blue Select/HMO/PPO,,33.61,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,BCBS NC,Blue Select/HMO/PPO,,2.88,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,BCBS NC,Blue Select/HMO/PPO,,2.29,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,BCBS NC,Blue Select/HMO/PPO,,304.67,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,BCBS NC,Blue Select/HMO/PPO,,16.52,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,BCBS NC,Blue Select/HMO/PPO,,18.32,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,BCBS NC,Blue Select/HMO/PPO,,111.46,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,BCBS NC,Blue Select/HMO/PPO,,932.20,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.54,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.54,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,12.58,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.47,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,BCBS NC,Blue Select/HMO/PPO,,15.96,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Select/HMO/PPO,,13.08,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,BCBS NC,Blue Select/HMO/PPO,,150.30,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,16.48,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,13.04,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,13.03,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,BCBS NC,Blue Select/HMO/PPO,,18.15,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Select/HMO/PPO,,13.26,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,BCBS NC,Blue Select/HMO/PPO,,90.89,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,BCBS NC,Blue Select/HMO/PPO,,121.01,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Select/HMO/PPO,,12.48,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Select/HMO/PPO,,13.04,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,12.78,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Select/HMO/PPO,,13.82,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,BCBS NC,Blue Select/HMO/PPO,,190.52,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,BCBS NC,Blue Select/HMO/PPO,,64.16,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,BCBS NC,Blue Select/HMO/PPO,,18.88,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,BCBS NC,Blue Select/HMO/PPO,,48.58,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,1.05,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,1.05,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,BCBS NC,Blue Select/HMO/PPO,,2.14,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,BCBS NC,Blue Select/HMO/PPO,,5.73,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,BCBS NC,Blue Select/HMO/PPO,,70.32,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,12.89,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,62.05,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,62.05,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Select/HMO/PPO,,62.05,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,BCBS NC,Blue Select/HMO/PPO,,709.85,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,16.63,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,BCBS NC,Blue Select/HMO/PPO,,267.20,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,BCBS NC,Blue Select/HMO/PPO,,300.33,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.89916,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,12.29,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,BCBS NC,Blue Select/HMO/PPO,,39.86,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,74.22,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,BCBS NC,Blue Select/HMO/PPO,,77.75,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,,50.20,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,74.93,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,BCBS NC,Blue Select/HMO/PPO,,87.41,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,BCBS NC,Blue Select/HMO/PPO,,83.96,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Select/HMO/PPO,,59.01,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,57.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,BCBS NC,Blue Select/HMO/PPO,,61.23,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,BCBS NC,Blue Select/HMO/PPO,,61.19,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,BCBS NC,Blue Select/HMO/PPO,,70.62,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,14.01,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,BCBS NC,Blue Select/HMO/PPO,,102.39,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,BCBS NC,Blue Select/HMO/PPO,,55.64,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,BCBS NC,Blue Select/HMO/PPO,,320.74,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,BCBS NC,Blue Select/HMO/PPO,,293.02,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Select/HMO/PPO,,12.70,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,53.95,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,51.70,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,BCBS NC,Blue Select/HMO/PPO,,60.06,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,BCBS NC,Blue Select/HMO/PPO,,85.87,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Select/HMO/PPO,,12.59,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,BCBS NC,Blue Select/HMO/PPO,,3932.58,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,BCBS NC,Blue Select/HMO/PPO,,200.32,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,BCBS NC,Blue Select/HMO/PPO,,530.67,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,BCBS NC,Blue Select/HMO/PPO,,63.16,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,BCBS NC,Blue Select/HMO/PPO,,34.24,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,BCBS NC,Blue Select/HMO/PPO,,37.13,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Select/HMO/PPO,,1.16,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,BCBS NC,Blue Select/HMO/PPO,,305.53,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,17.23,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,BCBS NC,Blue Select/HMO/PPO,,1483.05,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,BCBS NC,Blue Select/HMO/PPO,,272.98,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,BCBS NC,Blue Select/HMO/PPO,,5.17,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,BCBS NC,Blue Select/HMO/PPO,,479.46,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,BCBS NC,Blue Select/HMO/PPO,,19.89,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,BCBS NC,Blue Select/HMO/PPO,,59.23,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,BCBS NC,Blue Select/HMO/PPO,,89.05,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Select/HMO/PPO,,16.71,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,BCBS NC,Blue Select/HMO/PPO,,71.03,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,BCBS NC,Blue Select/HMO/PPO,,629.68,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,BCBS NC,Blue Select/HMO/PPO,,24.13,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,BCBS NC,Blue Select/HMO/PPO,,20.74,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,BCBS NC,Blue Select/HMO/PPO,,21.30,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,214.30,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,BCBS NC,Blue Select/HMO/PPO,,4.68,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,18.77,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Select/HMO/PPO,,18.77,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,BCBS NC,Blue Select/HMO/PPO,,40.05,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,BCBS NC,Blue Select/HMO/PPO,,2115.34,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,BCBS NC,Blue Select/HMO/PPO,,46.49,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,BCBS NC,Blue Select/HMO/PPO,,16.92,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Select/HMO/PPO,,17.72,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,BCBS NC,Blue Select/HMO/PPO,,46.83,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Select/HMO/PPO,,12.36,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Select/HMO/PPO,,12.40,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,18.73,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,BCBS NC,Blue Select/HMO/PPO,,30.42,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,BCBS NC,Blue Select/HMO/PPO,,22.44,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,BCBS NC,Blue Select/HMO/PPO,,43.49,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,BCBS NC,Blue Select/HMO/PPO,,41.15,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,BCBS NC,Blue Select/HMO/PPO,,33.77,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,BCBS NC,Blue Select/HMO/PPO,,156.94,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Select/HMO/PPO,,12.81,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,BCBS NC,Blue Select/HMO/PPO,,19.44,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,BCBS NC,Blue Select/HMO/PPO,,323.14,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,BCBS NC,Blue Select/HMO/PPO,,369.85,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,BCBS NC,Blue Select/HMO/PPO,,20380.52,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,BCBS NC,Blue Select/HMO/PPO,,68.58,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Select/HMO/PPO,,14.01,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Select/HMO/PPO,,215.28,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,BCBS NC,Blue Select/HMO/PPO,,226.45,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,BCBS NC,Blue Select/HMO/PPO,,6736.54,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,BCBS NC,Blue Select/HMO/PPO,,20.30,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,BCBS NC,Blue Select/HMO/PPO,,89.51,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,79.43,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,BCBS NC,Blue Select/HMO/PPO,,80.55,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Select/HMO/PPO,,80.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,BCBS NC,Blue Select/HMO/PPO,,42.52,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,BCBS NC,Blue Select/HMO/PPO,,97.53,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,BCBS NC,Blue Select/HMO/PPO,,72.22,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,BCBS NC,Blue Select/HMO/PPO,,328.13,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,BCBS NC,Blue Select/HMO/PPO,,3.33,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,46.08,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,BCBS NC,Blue Select/HMO/PPO,,33.87,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Select/HMO/PPO,,12.29,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,BCBS NC,Blue Select/HMO/PPO,,3.93,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,BCBS NC,Blue Select/HMO/PPO,,379.67,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,BCBS NC,Blue Select/HMO/PPO,,262.07,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Select/HMO/PPO,,13.41,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Select/HMO/PPO,,13.15,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Select/HMO/PPO,,13.19,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Select/HMO/PPO,,13.23,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Select/HMO/PPO,,13.75,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,BCBS NC,Blue Select/HMO/PPO,,25.03,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,BCBS NC,Blue Select/HMO/PPO,,30042.51,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,BCBS NC,Blue Select/HMO/PPO,,421.53,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,BCBS NC,Blue Select/HMO/PPO,,30.36,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,BCBS NC,Blue Select/HMO/PPO,,73.51,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Select/HMO/PPO,,335.73,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Select/HMO/PPO,,302.08,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,BCBS NC,Blue Select/HMO/PPO,,116.07,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,BCBS NC,Blue Select/HMO/PPO,,44.32,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,BCBS NC,Blue Select/HMO/PPO,,19940.84,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,BCBS NC,Blue Select/HMO/PPO,,53.76,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Select/HMO/PPO,,597.98,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,BCBS NC,Blue Select/HMO/PPO,,6.86,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,1.05,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,BCBS NC,Blue Select/HMO/PPO,,74.26,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,BCBS NC,Blue Select/HMO/PPO,,2844.74,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,BCBS NC,Blue Select/HMO/PPO,,2.44,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,BCBS NC,Blue Select/HMO/PPO,,1.84,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,67.44,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,BCBS NC,Blue Select/HMO/PPO,,812.65,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,BCBS NC,Blue Select/HMO/PPO,,30.46,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,101.90,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Select/HMO/PPO,,400.64,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Select/HMO/PPO,,228.89,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,324.34,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,324.34,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,BCBS NC,Blue Select/HMO/PPO,,583.78,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,BCBS NC,Blue Select/HMO/PPO,,29730.79,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,BCBS NC,Blue Select/HMO/PPO,,14871.35,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,BCBS NC,Blue Select/HMO/PPO,,2.96,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Select/HMO/PPO,,0.93663,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,1.50,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,BCBS NC,Blue Select/HMO/PPO,,76.39,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Select/HMO/PPO,,12.33,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Select/HMO/PPO,,12.44,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Select/HMO/PPO,,37.93,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,25.23,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,73.43,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,BCBS NC,Blue Select/HMO/PPO,,95.78,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,BCBS NC,Blue Select/HMO/PPO,,275.88,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,BCBS NC,Blue Select/HMO/PPO,,70.40,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,157.35,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,BCBS NC,Blue Select/HMO/PPO,,19.48,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,BCBS NC,Blue Select/HMO/PPO,,37.07,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,BCBS NC,Blue Select/HMO/PPO,,130.07,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,BCBS NC,Blue Select/HMO/PPO,,22.93,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,BCBS NC,Blue Select/HMO/PPO,,603.45,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Select/HMO/PPO,,0.78677,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,BCBS NC,Blue Select/HMO/PPO,,394.48,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,BCBS NC,Blue Select/HMO/PPO,,59.98,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,BCBS NC,Blue Select/HMO/PPO,,28.14,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Select/HMO/PPO,,13.92,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Select/HMO/PPO,,112.26,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,BCBS NC,Blue Select/HMO/PPO,,205.07,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,BCBS NC,Blue Select/HMO/PPO,,36.23,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,BCBS NC,Blue Select/HMO/PPO,,197.72,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,BCBS NC,Blue Select/HMO/PPO,,3.03,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,BCBS NC,Blue Select/HMO/PPO,,119.81,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,65.50,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,65.50,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Select/HMO/PPO,,65.50,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,BCBS NC,Blue Select/HMO/PPO,,390.92,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Select/HMO/PPO,,21.92,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,62.83,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Select/HMO/PPO,,62.83,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,BCBS NC,Blue Select/HMO/PPO,,3.93,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Select/HMO/PPO,,22.08,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,BCBS NC,Blue Select/HMO/PPO,,55.70,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,BCBS NC,Blue Select/HMO/PPO,,56.00,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,BCBS NC,Blue Select/HMO/PPO,,53.03,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.38,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,21.52,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,13.11,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,BCBS NC,Blue Select/HMO/PPO,,15.70,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Select/HMO/PPO,,12.21,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Select/HMO/PPO,,12.10,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,BCBS NC,Blue Select/HMO/PPO,,28.98,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,BCBS NC,Blue Select/HMO/PPO,,2713.48,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Select/HMO/PPO,,14.84,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,BCBS NC,Blue Select/HMO/PPO,,9308.86,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,BCBS NC,Blue Select/HMO/PPO,,18605.77,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,BCBS NC,Blue Select/HMO/PPO,,1535.43,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,BCBS NC,Blue Select/HMO/PPO,,2043.50,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,BCBS NC,Blue Select/HMO/PPO,,2285.98,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Select/HMO/PPO,,0.82423,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,BCBS NC,Blue Select/HMO/PPO,,13.52,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,BCBS NC,Blue Select/HMO/PPO,,321.56,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Select/HMO/PPO,,16.26,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,BCBS NC,Blue Select/HMO/PPO,,16.63,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Select/HMO/PPO,,12.65,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Select/HMO/PPO,,12.99,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,BCBS NC,Blue Select/HMO/PPO,,484.66,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Select/HMO/PPO,,0.86169,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,BCBS NC,Blue Select/HMO/PPO,,64.51,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,BCBS NC,Blue Select/HMO/PPO,,44.98,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,BCBS NC,Blue Select/HMO/PPO,,553.64,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,77.93,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,BCBS NC,Blue Select/HMO/PPO,,29.47,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Select/HMO/PPO,,45.65,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Select/HMO/PPO,,21.67,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Select/HMO/PPO,,16.11,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Select/HMO/PPO,,12.51,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Select/HMO/PPO,,12.66,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,63.69,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,BCBS NC,Blue Select/HMO/PPO,,13.90,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,BCBS NC,Blue Select/HMO/PPO,,167.06,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,233.79,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,BCBS NC,Blue Select/HMO/PPO,,11.09,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,BCBS NC,Blue Select/HMO/PPO,,1234.35,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,BCBS NC,Blue Select/HMO/PPO,,58.93,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,BCBS NC,Blue Select/HMO/PPO,,18.13,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,BCBS NC,Blue Select/HMO/PPO,,61.44,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,BCBS NC,Blue Select/HMO/PPO,,35.59,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,43.46,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,BCBS NC,Blue Select/HMO/PPO,,1624.68,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,BCBS NC,Blue Select/HMO/PPO,,26.94,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,BCBS NC,Blue Select/HMO/PPO,,198.41,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,BCBS NC,Blue Select/HMO/PPO,,77.56,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,BCBS NC,Blue Select/HMO/PPO,,84.43,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,BCBS NC,Blue Select/HMO/PPO,,34.51,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Select/HMO/PPO,,16.56,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Select/HMO/PPO,,16.75,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,20.23,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Select/HMO/PPO,,17.01,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Select/HMO/PPO,,13.94,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,BCBS NC,Blue Select/HMO/PPO,,309.65,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,BCBS NC,Blue Select/HMO/PPO,,1149.28,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,BCBS NC,Blue Select/HMO/PPO,,28.85,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,BCBS NC,Blue Select/HMO/PPO,,46.34,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,BCBS NC,Blue Select/HMO/PPO,,58.93,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,BCBS NC,Blue Select/HMO/PPO,,71.51,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,BCBS NC,Blue Select/HMO/PPO,,224.85,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,BCBS NC,Blue Select/HMO/PPO,,2692.85,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,BCBS NC,Blue Select/HMO/PPO,,95.24,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,BCBS NC,Blue Select/HMO/PPO,,158.21,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,BCBS NC,Blue Select/HMO/PPO,,66.09,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,BCBS NC,Blue Select/HMO/PPO,,25.46,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,BCBS NC,Blue Select/HMO/PPO,,45.00,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Select/HMO/PPO,,23.42,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,BCBS NC,Blue Select/HMO/PPO,,149.40,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,BCBS NC,Blue Select/HMO/PPO,,129.18,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Select/HMO/PPO,,47.91,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,BCBS NC,Blue Select/HMO/PPO,,48.13,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,BCBS NC,Blue Select/HMO/PPO,,48.02,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,BCBS NC,Blue Select/HMO/PPO,,177.35,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,BCBS NC,Blue Select/HMO/PPO,,67.61,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Select/HMO/PPO,,1.09,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,BCBS NC,Blue Select/HMO/PPO,,495.51,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,BCBS NC,Blue Select/HMO/PPO,,285.90,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,BCBS NC,Blue Select/HMO/PPO,,1345.79,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Select/HMO/PPO,,61.57,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,BCBS NC,Blue Select/HMO/PPO,,3.45,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,BCBS NC,Blue Select/HMO/PPO,,1629.43,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Select/HMO/PPO,,75.33,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,72.74,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,69.68,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,BCBS NC,Blue Select/HMO/PPO,,70.14,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,62.34,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Select/HMO/PPO,,18.43,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,BCBS NC,Blue Select/HMO/PPO,,24.88,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Select/HMO/PPO,,37.50,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,72.74,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,72.74,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,60.69,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Select/HMO/PPO,,57.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,264.22,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,BCBS NC,Blue Select/HMO/PPO,,43.87,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,BCBS NC,Blue Select/HMO/PPO,,36.68,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,BCBS NC,Blue Select/HMO/PPO,,3767.59,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,52.45,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Select/HMO/PPO,,14.99,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Select/HMO/PPO,,14.46,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,BCBS NC,Blue Select/HMO/PPO,,477.01,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,BCBS NC,Blue Select/HMO/PPO,,189.19,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Select/HMO/PPO,,12.89,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,BCBS NC,Blue Select/HMO/PPO,,70.92,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,BCBS NC,Blue Select/HMO/PPO,,18.84,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,BCBS NC,Blue Select/HMO/PPO,,124.57,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,BCBS NC,Blue Select/HMO/PPO,,63.92,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,BCBS NC,Blue Select/HMO/PPO,,77.07,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,BCBS NC,Blue Select/HMO/PPO,,19.07,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,BCBS NC,Blue Select/HMO/PPO,,1.05,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,BCBS NC,Blue Select/HMO/PPO,,1810.95,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,BCBS NC,Blue Select/HMO/PPO,,2985.35,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,BCBS NC,Blue Select/HMO/PPO,,360.86,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,BCBS NC,Blue Select/HMO/PPO,,530.67,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Select/HMO/PPO,,12.93,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,BCBS NC,Blue Select/HMO/PPO,,786.99,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,BCBS NC,Blue Select/HMO/PPO,,40.35,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,BCBS NC,Blue Select/HMO/PPO,,1284.64,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,33.19,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Select/HMO/PPO,,33.19,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,BCBS NC,Blue Select/HMO/PPO,,85.27,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Select/HMO/PPO,,13.38,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,BCBS NC,Blue Select/HMO/PPO,,1224.85,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,BCBS NC,Blue Select/HMO/PPO,,33706.69,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,BCBS NC,Blue Select/HMO/PPO,,115940.83,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,BCBS NC,Blue Select/HMO/PPO,,191116.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,BCBS NC,Blue Select/HMO/PPO,,8282.76,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,BCBS NC,Blue Select/HMO/PPO,,5485.01,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,,194.07,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,BCBS NC,Blue Select/HMO/PPO,,10.23,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Select/HMO/PPO,,0.89916,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,BCBS NC,Blue Select/HMO/PPO,,6.86,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,31.17,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14844,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,BCBS NC,Blue Select/HMO/PPO,,0.14986,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,258.05,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,BCBS NC,Blue Select/HMO/PPO,,639.90,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,BCBS NC,Blue Select/HMO/PPO,,957.11,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,BCBS NC,Blue Select/HMO/PPO,,1437.41,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,BCBS NC,Blue Select/HMO/PPO,,1724.79,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,BCBS NC,Blue Select/HMO/PPO,,2069.35,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,BCBS NC,Blue Select/HMO/PPO,,2484.01,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,BCBS NC,Blue Select/HMO/PPO,,1026.72,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,BCBS NC,Blue Select/HMO/PPO,,1508.01,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,BCBS NC,Blue Select/HMO/PPO,,2742.56,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,,117.79,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,BCBS NC,Blue Select/HMO/PPO,,466.01,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,127.36,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,86.14,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,45.64,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,19.14,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,105.28,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,46.38,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,59.63,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,116.32,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Select/HMO/PPO,,385.77,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Select/HMO/PPO,,439.51,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,373.99,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,67.73,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,BCBS NC,Blue Select/HMO/PPO,,53.74,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Select/HMO/PPO,,169.33,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,BCBS NC,Blue Select/HMO/PPO,,155.34,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Select/HMO/PPO,,3852.53,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Select/HMO/PPO,,3852.53,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,BCBS NC,Blue Select/HMO/PPO,,3667.75,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Select/HMO/PPO,,1314.85,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,42.70,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,BCBS NC,Blue Select/HMO/PPO,,2212.28,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Select/HMO/PPO,,1123.44,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,230.43,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,59.63,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,46.38,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Select/HMO/PPO,,804.67,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,251.78,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,BCBS NC,Blue Select/HMO/PPO,,909.94,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,669.21,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,223.07,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,368.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Select/HMO/PPO,,690.56,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Select/HMO/PPO,,195.83,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,150.18,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,BCBS NC,Blue Select/HMO/PPO,,803.93,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Select/HMO/PPO,,697.92,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,210.55,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,31.66,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,25.77,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,103.07,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Select/HMO/PPO,,348.96,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,92.76,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Select/HMO/PPO,,210.55,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,98.65,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Select/HMO/PPO,,8.10,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,BCBS NC,Blue Select/HMO/PPO,,3669.96,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,BCBS NC,Blue Select/HMO/PPO,,14797.62,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,BCBS NC,Blue Select/HMO/PPO,,3735.48,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,BCBS NC,Blue Select/HMO/PPO,,3121.49,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,BCBS NC,Blue Select/HMO/PPO,,2560.50,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,340.86,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,2735.77,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,BCBS NC,Blue Select/HMO/PPO,,3134.31,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,BCBS NC,Blue Select/HMO/PPO,,3086.57,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Select/HMO/PPO,,2443.10,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,BCBS NC,Blue Select/HMO/PPO,,4037.24,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Select/HMO/PPO,,3080.32,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Select/HMO/PPO,,2866.54,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Select/HMO/PPO,,3335.65,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Select/HMO/PPO,,3335.65,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,BCBS NC,Blue Select/HMO/PPO,,4058.69,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,2735.77,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,2735.77,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Select/HMO/PPO,,2443.10,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Select/HMO/PPO,,2735.77,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,1207.37,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,BCBS NC,Blue Select/HMO/PPO,,2843.71,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,BCBS NC,Blue Select/HMO/PPO,,1170.00,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Select/HMO/PPO,,4496.66,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,BCBS NC,Blue Select/HMO/PPO,,786.29,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,BCBS NC,Blue Select/HMO/PPO,,1615.09,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,BCBS NC,Blue Select/HMO/PPO,,2446.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,BCBS NC,Blue Select/HMO/PPO,,2853.64,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Select/HMO/PPO,,89.08,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,BCBS NC,Blue Select/HMO/PPO,,848.22,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,BCBS NC,Blue Select/HMO/PPO,,1703.41,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,41.27,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Select/HMO/PPO,,232.19,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,BCBS NC,Blue Select/HMO/PPO,,274.91,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,BCBS NC,Blue Select/HMO/PPO,,621.24,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,BCBS NC,Blue Select/HMO/PPO,,470.42,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,31.52,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,35.11,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,GP,8.38,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Select/HMO/PPO,,230.40,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,BCBS NC,Blue Select/HMO/PPO,,940.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,BCBS NC,Blue Select/HMO/PPO,,890.60,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,BCBS NC,Blue Select/HMO/PPO,,713.98,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,BCBS NC,Blue Select/HMO/PPO,,537.37,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Select/HMO/PPO,,360.75,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,184.13,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,BCBS NC,Blue Select/HMO/PPO,,1133.33,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,BCBS NC,Blue Select/HMO/PPO,,3386.85,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,BCBS NC,Blue Select/HMO/PPO,,4491.81,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Select/HMO/PPO,,2550.20,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,BCBS NC,Blue Select/HMO/PPO,,1936.07,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,BCBS NC,Blue Select/HMO/PPO,,18098.72,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,BCBS NC,Blue Select/HMO/PPO,,18957.37,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,BCBS NC,Blue Select/HMO/PPO,,19952.32,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,BCBS NC,Blue Select/HMO/PPO,,20808.20,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,BCBS NC,Blue Select/HMO/PPO,,21667.54,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,BCBS NC,Blue Select/HMO/PPO,,22524.11,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,BCBS NC,Blue Select/HMO/PPO,,23241.61,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,BCBS NC,Blue Select/HMO/PPO,,24236.57,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,BCBS NC,Blue Select/HMO/PPO,,25093.83,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,BCBS NC,Blue Select/HMO/PPO,,25951.09,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,BCBS NC,Blue Select/HMO/PPO,,26809.05,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,268.46,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,BCBS NC,Blue Select/HMO/PPO,,369.47,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Select/HMO/PPO,,573.59,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,BCBS NC,Blue Select/HMO/PPO,,578.43,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,BCBS NC,Blue Select/HMO/PPO,,2791.82,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,BCBS NC,Blue Select/HMO/PPO,,6701.05,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,BCBS NC,Blue Select/HMO/PPO,,7200.60,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,BCBS NC,Blue Select/HMO/PPO,,7734.75,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,BCBS NC,Blue Select/HMO/PPO,,4216.44,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,BCBS NC,Blue Select/HMO/PPO,,5447.33,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,BCBS NC,Blue Select/HMO/PPO,,6195.96,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,BCBS NC,Blue Select/HMO/PPO,,7977.61,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,BCBS NC,Blue Select/HMO/PPO,,8189.33,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,BCBS NC,Blue Select/HMO/PPO,,8388.60,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,BCBS NC,Blue Select/HMO/PPO,,8588.55,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,BCBS NC,Blue Select/HMO/PPO,,8787.82,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,BCBS NC,Blue Select/HMO/PPO,,3422.14,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Select/HMO/PPO,,462.19,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,BCBS NC,Blue Select/HMO/PPO,,3048.51,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,BCBS NC,Blue Select/HMO/PPO,,4116.11,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,BCBS NC,Blue Select/HMO/PPO,,5636.22,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,BCBS NC,Blue Select/HMO/PPO,,7143.18,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,BCBS NC,Blue Select/HMO/PPO,,8155.43,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,BCBS NC,Blue Select/HMO/PPO,,9236.86,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,BCBS NC,Blue Select/HMO/PPO,,10536.95,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,BCBS NC,Blue Select/HMO/PPO,,11294.58,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,BCBS NC,Blue Select/HMO/PPO,,12412.69,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,BCBS NC,Blue Select/HMO/PPO,,13020.87,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,BCBS NC,Blue Select/HMO/PPO,,13817.24,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,BCBS NC,Blue Select/HMO/PPO,,14329.94,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,BCBS NC,Blue Select/HMO/PPO,,14458.63,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,BCBS NC,Blue Select/HMO/PPO,,14673.12,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,BCBS NC,Blue Select/HMO/PPO,,15100.72,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,BCBS NC,Blue Select/HMO/PPO,,15529.00,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,BCBS NC,Blue Select/HMO/PPO,,15956.60,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,BCBS NC,Blue Select/HMO/PPO,,16387.65,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,BCBS NC,Blue Select/HMO/PPO,,16814.55,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,BCBS NC,Blue Select/HMO/PPO,,17243.53,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Select/HMO/PPO,,9275.61,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,BCBS NC,Blue Select/HMO/PPO,,7861.37,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,4873.05,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,4873.05,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Select/HMO/PPO,,4873.05,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,4483.51,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Select/HMO/PPO,,9275.61,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,BCBS NC,Blue Select/HMO/PPO,,5232.15,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,BCBS NC,Blue Select/HMO/PPO,,5895.68,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,209.65,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,879.40,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,351.49,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Select/HMO/PPO,,351.49,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,BCBS NC,Blue Select/HMO/PPO,,559.06,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,BCBS NC,Blue Select/HMO/PPO,,7468.37,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,BCBS NC,Blue Select/HMO/PPO,,1307.69,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Select/HMO/PPO,,847.58,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,BCBS NC,Blue Select/HMO/PPO,,5281.50,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,204.80,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Select/HMO/PPO,,502.06,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,BCBS NC,Blue Select/HMO/PPO,,1.99,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Select/HMO/PPO,,1014.46,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Select/HMO/PPO,,1308.53,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Select/HMO/PPO,,1603.83,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,BCBS NC,Blue Select/HMO/PPO,,1897.89,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,BCBS NC,Blue Select/HMO/PPO,,2192.57,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,BCBS NC,Blue Select/HMO/PPO,,2487.25,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,BCBS NC,Blue Select/HMO/PPO,,2781.32,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,BCBS NC,Blue Select/HMO/PPO,,406.65,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Select/HMO/PPO,,2017.86,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Select/HMO/PPO,,2658.89,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,796.07,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Select/HMO/PPO,,1084.60,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Select/HMO/PPO,,1209.48,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Select/HMO/PPO,,1339.29,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Select/HMO/PPO,,1468.48,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Select/HMO/PPO,,1597.06,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Select/HMO/PPO,,1726.87,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Select/HMO/PPO,,1014.46,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Select/HMO/PPO,,589.36,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Select/HMO/PPO,,1468.48,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,796.07,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Select/HMO/PPO,,1084.60,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Select/HMO/PPO,,1209.48,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Select/HMO/PPO,,1339.29,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Select/HMO/PPO,,1597.06,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Select/HMO/PPO,,1726.87,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Select/HMO/PPO,,2017.86,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Select/HMO/PPO,,2658.89,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,306.98,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Select/HMO/PPO,,2550.20,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,211.90,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,1008.93,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Select/HMO/PPO,,1142.76,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,BCBS NC,Blue Select/HMO/PPO,,1278.08,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Select/HMO/PPO,,1413.39,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,BCBS NC,Blue Select/HMO/PPO,,1550.20,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,1686.26,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Select/HMO/PPO,,1821.58,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,BCBS NC,Blue Select/HMO/PPO,,1956.15,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,BCBS NC,Blue Select/HMO/PPO,,2090.72,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,BCBS NC,Blue Select/HMO/PPO,,2227.53,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,BCBS NC,Blue Select/HMO/PPO,,2362.10,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,BCBS NC,Blue Select/HMO/PPO,,2538.31,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Select/HMO/PPO,,2675.11,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,BCBS NC,Blue Select/HMO/PPO,,3191.85,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,3400.77,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,BCBS NC,Blue Select/HMO/PPO,,3559.13,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,BCBS NC,Blue Select/HMO/PPO,,3694.45,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,BCBS NC,Blue Select/HMO/PPO,,3829.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Select/HMO/PPO,,3022.91,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,BCBS NC,Blue Select/HMO/PPO,,3207.65,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,BCBS NC,Blue Select/HMO/PPO,,3065.45,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,BCBS NC,Blue Select/HMO/PPO,,1942.77,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,BCBS NC,Blue Select/HMO/PPO,,2100.39,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Select/HMO/PPO,,1848.34,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,BCBS NC,Blue Select/HMO/PPO,,2484.78,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,233.17,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,6975.74,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,6975.74,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Select/HMO/PPO,,6975.74,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,882.17,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,BCBS NC,Blue Select/HMO/PPO,,1450.22,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,BCBS NC,Blue Select/HMO/PPO,,1611.44,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,BCBS NC,Blue Select/HMO/PPO,,874.56,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,334.19,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,260.58,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Select/HMO/PPO,,5185.10,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,702.97,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,279.53,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,3164.75,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Select/HMO/PPO,,7498.12,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,BCBS NC,Blue Select/HMO/PPO,,3649.08,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,122.49,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00643,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,BCBS NC,Blue Select/HMO/PPO,,27664.93,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,BCBS NC,Blue Select/HMO/PPO,,28521.50,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,BCBS NC,Blue Select/HMO/PPO,,1304.23,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,BCBS NC,Blue Select/HMO/PPO,,385.39,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,BCBS NC,Blue Select/HMO/PPO,,2016.89,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,53.03,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,26.20,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,BCBS NC,Blue Select/HMO/PPO,,40.23,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,85.61,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,46.78,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,46.31,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,Q0,0.70134,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,Q0,0.70134,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,441.72,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,549.21,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,BCBS NC,Blue Select/HMO/PPO,,1012.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,BCBS NC,Blue Select/HMO/PPO,,14406.70,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,BCBS NC,Blue Select/HMO/PPO,,6714.14,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,3769.34,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,BCBS NC,Blue Select/HMO/PPO,,3647.13,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,BCBS NC,Blue Select/HMO/PPO,,5475.86,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,BCBS NC,Blue Select/HMO/PPO,,6197.33,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,3769.34,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,BCBS NC,Blue Select/HMO/PPO,,4673.40,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,234.11,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Select/HMO/PPO,,75.83,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,153.87,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,20.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,106.75,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,234.11,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,92.76,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Select/HMO/PPO,,111.17,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,BCBS NC,Blue Select/HMO/PPO,,135.46,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,217.18,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,BCBS NC,Blue Select/HMO/PPO,,261.35,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,771.54,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Select/HMO/PPO,,75.83,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,312.88,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,441.72,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,BCBS NC,Blue Select/HMO/PPO,,789.94,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Select/HMO/PPO,,697.92,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,549.21,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Select/HMO/PPO,,549.21,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,200.98,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,BCBS NC,Blue Select/HMO/PPO,,569.82,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,3769.34,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Select/HMO/PPO,,370.31,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Select/HMO/PPO,,332.76,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,BCBS NC,Blue Select/HMO/PPO,,993.13,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Select/HMO/PPO,,3769.34,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,BCBS NC,Blue Select/HMO/PPO,,1092.52,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,BCBS NC,Blue Select/HMO/PPO,,1015.22,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,42.70,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,42.70,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,42.70,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,42.70,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,393.87,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,393.87,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,393.87,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00736,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Select/HMO/PPO,,4947.26,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,678.78,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,678.78,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Select/HMO/PPO,,678.78,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,BCBS NC,Blue Select/HMO/PPO,,894.48,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,BCBS NC,Blue Select/HMO/PPO,,1200.74,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,BCBS NC,Blue Select/HMO/PPO,,2134.24,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,257.67,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,340.86,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,103.07,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,69.94,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,122.21,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,257.67,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,66.99,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,74.36,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Select/HMO/PPO,,3879.77,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,BCBS NC,Blue Select/HMO/PPO,,753.87,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,468.96,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Select/HMO/PPO,,29368.85,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Select/HMO/PPO,,12620.37,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Select/HMO/PPO,,218.65,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,BCBS NC,Blue Select/HMO/PPO,,226.75,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Select/HMO/PPO,,1424.28,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Select/HMO/PPO,,5382.43,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Select/HMO/PPO,,1286.97,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Select/HMO/PPO,,2445.55,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Select/HMO/PPO,,29851.28,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Select/HMO/PPO,,9290.12,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Select/HMO/PPO,,8253.26,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Select/HMO/PPO,,11626.56,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Select/HMO/PPO,,23437.19,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,1958.67,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Select/HMO/PPO,,8251.04,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Select/HMO/PPO,,11906.37,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Select/HMO/PPO,,6976.23,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,2000.97,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Select/HMO/PPO,,1984.80,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Select/HMO/PPO,,6209.25,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.70134,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Select/HMO/PPO,,6620.42,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Select/HMO/PPO,,8369.79,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,BCBS NC,Blue Select/HMO/PPO,,4513.64,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Select/HMO/PPO,,11500.39,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Select/HMO/PPO,,923.93,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Select/HMO/PPO,,395.34,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Select/HMO/PPO,,4947.26,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Select/HMO/PPO,,3879.77,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,BCBS NC,Blue Select/HMO/PPO,,692.03,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Select/HMO/PPO,,161.96,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Select/HMO/PPO,,408.59,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,BCBS NC,Blue Select/HMO/PPO,,4001.98,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,BCBS NC,Blue Select/HMO/PPO,,14609.89,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,BCBS NC,Blue Select/HMO/PPO,,20164.52,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,206.87,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,206.87,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,193.62,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,193.62,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Select/HMO/PPO,,193.62,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00736,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,BCBS NC,Blue Select/HMO/PPO,,2300.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,BCBS NC,Blue Select/HMO/PPO,,862.83,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,BCBS NC,Blue Select/HMO/PPO,,1109.45,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,BCBS NC,Blue Select/HMO/PPO,,1041.72,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,BCBS NC,Blue Select/HMO/PPO,,1008.59,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,BCBS NC,Blue Select/HMO/PPO,,6919.00,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,BCBS NC,Blue Select/HMO/PPO,Q1,4399.02,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,BCBS NC,Blue Select/HMO/PPO,Q0,2635.25,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,136.37,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Select/HMO/PPO,,168.78,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,219.05,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,150.42,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Select/HMO/PPO,,233.41,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,150.42,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,150.42,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,36.71,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,114.91,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,174.36,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,104.54,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,BCBS NC,Blue Select/HMO/PPO,,93.37,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Select/HMO/PPO,,260.15,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,80.98,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Select/HMO/PPO,,21.22,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,BCBS NC,Blue Select/HMO/PPO,,949.69,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,58.51,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,58.51,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,120.02,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,BCBS NC,Blue Select/HMO/PPO,,180.04,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,231.55,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,210.04,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,BCBS NC,Blue Select/HMO/PPO,,973.69,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Select/HMO/PPO,,995.20,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,BCBS NC,Blue Select/HMO/PPO,,466.09,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,BCBS NC,Blue Select/HMO/PPO,,703.64,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,BCBS NC,Blue Select/HMO/PPO,,730.15,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,BCBS NC,Blue Select/HMO/PPO,,862.17,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,BCBS NC,Blue Select/HMO/PPO,,1049.21,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,BCBS NC,Blue Select/HMO/PPO,,1759.85,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,BCBS NC,Blue Select/HMO/PPO,,3121.62,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,BCBS NC,Blue Select/HMO/PPO,,3366.17,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,BCBS NC,Blue Select/HMO/PPO,,317.56,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,BCBS NC,Blue Select/HMO/PPO,,425.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,BCBS NC,Blue Select/HMO/PPO,,3176.64,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,3568.21,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,3568.21,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Select/HMO/PPO,,849.17,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,BCBS NC,Blue Select/HMO/PPO,,1384.78,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Select/HMO/PPO,,367.07,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,BCBS NC,Blue Select/HMO/PPO,,548.11,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,BCBS NC,Blue Select/HMO/PPO,,234.55,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,BCBS NC,Blue Select/HMO/PPO,,484.10,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,BCBS NC,Blue Select/HMO/PPO,,343.57,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,BCBS NC,Blue Select/HMO/PPO,,772.65,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,BCBS NC,Blue Select/HMO/PPO,,535.61,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,BCBS NC,Blue Select/HMO/PPO,,931.19,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,BCBS NC,Blue Select/HMO/PPO,,225.04,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Select/HMO/PPO,,602.12,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,BCBS NC,Blue Select/HMO/PPO,,3746.75,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,BCBS NC,Blue Select/HMO/PPO,,3727.75,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,BCBS NC,Blue Select/HMO/PPO,,1199.24,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,BCBS NC,Blue Select/HMO/PPO,,873.17,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,BCBS NC,Blue Select/HMO/PPO,,1550.31,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,BCBS NC,Blue Select/HMO/PPO,,4212.34,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,212.54,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,283.56,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Select/HMO/PPO,,1089.22,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,BCBS NC,Blue Select/HMO/PPO,,1046.21,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,BCBS NC,Blue Select/HMO/PPO,,2317.96,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,BCBS NC,Blue Select/HMO/PPO,,1229.25,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Select/HMO/PPO,,1499.80,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,158.03,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,BCBS NC,Blue Select/HMO/PPO,,160.53,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,BCBS NC,Blue Select/HMO/PPO,,538.11,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,248.05,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Select/HMO/PPO,,301.56,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,248.05,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Select/HMO/PPO,,768.65,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,307.56,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Select/HMO/PPO,,367.07,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Blue Select/HMO/PPO,,182.34,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,BCBS NC,Blue Select/HMO/PPO,,132.07,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,261.55,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Select/HMO/PPO,,3568.21,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,BCBS NC,Blue Select/HMO/PPO,,516.10,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,BCBS NC,Blue Select/HMO/PPO,,444.59,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,BCBS NC,Blue Select/HMO/PPO,,581.62,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Select/HMO/PPO,,525.61,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Select/HMO/PPO,,703.14,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Select/HMO/PPO,76,703.14,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,932.69,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Select/HMO/PPO,,1874.37,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Select/HMO/PPO,76,1874.37,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Select/HMO/PPO,,1972.89,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Select/HMO/PPO,76,1972.89,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,1017.20,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Select/HMO/PPO,,1130.73,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,BCBS NC,Blue Select/HMO/PPO,,1191.74,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,BCBS NC,Blue Select/HMO/PPO,,1314.76,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,BCBS NC,Blue Select/HMO/PPO,,916.68,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Select/HMO/PPO,,1311.26,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,171.53,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,206.54,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,206.54,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,146.03,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,BCBS NC,Blue Select/HMO/PPO,,1421.28,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,BCBS NC,Blue Select/HMO/PPO,,13652.23,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,BCBS NC,Blue Select/HMO/PPO,,1876.88,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Select/HMO/PPO,,2158.43,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Select/HMO/PPO,,2158.43,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,BCBS NC,Blue Select/HMO/PPO,,324.06,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Select/HMO/PPO,,354.07,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Select/HMO/PPO,,612.62,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Select/HMO/PPO,,430.09,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Select/HMO/PPO,,457.09,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Select/HMO/PPO,,469.09,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,320.56,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,932.69,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,932.69,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,932.69,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,932.69,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,171.53,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Select/HMO/PPO,,325.06,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,BCBS NC,Blue Select/HMO/PPO,,181.54,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,932.69,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,76,932.69,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,227.55,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Select/HMO/PPO,76,430.09,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Select/HMO/PPO,76,457.09,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,249.55,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,BCBS NC,Blue Select/HMO/PPO,,522.10,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,BCBS NC,Blue Select/HMO/PPO,,814.66,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Select/HMO/PPO,,1171.73,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,BCBS NC,Blue Select/HMO/PPO,,3457.69,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Select/HMO/PPO,,366.57,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,BCBS NC,Blue Select/HMO/PPO,,3034.11,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,BCBS NC,Blue Select/HMO/PPO,,1127.23,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,BCBS NC,Blue Select/HMO/PPO,,1418.78,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Select/HMO/PPO,,924.18,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,BCBS NC,Blue Select/HMO/PPO,,435.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,274.55,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,BCBS NC,Blue Select/HMO/PPO,,402.58,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,626.13,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,BCBS NC,Blue Select/HMO/PPO,,4082.82,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,BCBS NC,Blue Select/HMO/PPO,,1205.24,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,202.54,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,BCBS NC,Blue Select/HMO/PPO,,280.06,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,BCBS NC,Blue Select/HMO/PPO,,831.17,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,BCBS NC,Blue Select/HMO/PPO,,961.69,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,BCBS NC,Blue Select/HMO/PPO,,637.13,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,158.03,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Select/HMO/PPO,,325.06,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Select/HMO/PPO,,1089.22,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,2160.80,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,BCBS NC,Blue Select/HMO/PPO,,140.05,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,BCBS NC,Blue Select/HMO/PPO,,729.26,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,15.91,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,BCBS NC,Blue Select/HMO/PPO,,321.73,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,BCBS NC,Blue Select/HMO/PPO,,480.90,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,BCBS NC,Blue Select/HMO/PPO,,566.97,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Select/HMO/PPO,,222.79,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,BCBS NC,Blue Select/HMO/PPO,,523.77,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,112.09,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Select/HMO/PPO,,466.83,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Select/HMO/PPO,,184.12,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,BCBS NC,Blue Select/HMO/PPO,,237.41,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,25.14,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,45.09,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,120.50,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,14.76,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,14.76,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,9.18,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,23.14,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,22.34,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,43.49,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,79.80,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,64.24,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,45.09,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,53.07,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,45.09,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,BCBS NC,Blue Select/HMO/PPO,,174.76,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,19.95,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,164.79,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,114.91,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,21.55,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,14.76,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,BCBS NC,Blue Select/HMO/PPO,,76.21,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,107.33,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,GP,25.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,GP,28.45,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,GP,4.55,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Select/HMO/PPO,GP,45.90,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,GP,18.59,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Select/HMO/PPO,GP,6.07,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,BCBS NC,Blue Select/HMO/PPO,GP,58.03,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,GP,61.83,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GP,48.55,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,GP,41.72,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,GP,22.38,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,GP,62.21,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,GP,60.69,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Select/HMO/PPO,GP,54.62,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,GP,62.58,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,GP,52.72,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,GP,76.62,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,GP,44.38,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GP,48.93,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Select/HMO/PPO,GP,57.27,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,GP,17.83,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,GP,44.76,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,GP,32.24,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GP,48.93,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GP,37.55,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,GP,68.27,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,GP,68.27,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GP,34.52,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GP,34.52,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,GP,33.76,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,GP,48.17,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,GP,49.31,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GP,26.55,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,GP,11.38,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,GP,116.07,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Select/HMO/PPO,GP,160.44,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,BCBS NC,Blue Select/HMO/PPO,GP,164.62,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,GP,109.24,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,GO,34.52,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,GO,44.38,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GO,48.93,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,GO,44.76,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GO,26.55,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,GO,48.93,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GO,37.55,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,GO,4.55,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,GO,61.83,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GO,48.55,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,GO,23.52,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,GO,62.21,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,GO,60.69,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Select/HMO/PPO,GO,54.62,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,GO,62.58,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,GO,18.59,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,GO,84.96,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,GO,57.65,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,GO,48.17,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,GO,28.45,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,GO,120.62,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,BCBS NC,Blue Select/HMO/PPO,GO,152.86,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,BCBS NC,Blue Select/HMO/PPO,GO,157.41,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,GO,76.62,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,GN,135.03,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Select/HMO/PPO,GN,127.44,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,GN,70.93,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,GN,102.03,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,GN,75.86,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,GN,119.48,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,GN,48.55,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GN,26.55,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,GN,32.24,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,GN,37.55,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,GN,86.86,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,GN,51.58,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,BCBS NC,Blue Select/HMO/PPO,GN,248.44,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,GN,98.24,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,GN,25.79,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,GN,49.31,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,GN,26.55,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,GN,11.38,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,BCBS NC,Blue Select/HMO/PPO,GN,81.17,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,GN,86.86,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,GN,40.59,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Select/HMO/PPO,GN,133.89,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,GN,208.24,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,BCBS NC,Blue Select/HMO/PPO,GN,224.17,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Select/HMO/PPO,,344.74,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Select/HMO/PPO,,219.05,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,BCBS NC,Blue Select/HMO/PPO,,353.12,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Select/HMO/PPO,,201.10,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,BCBS NC,Blue Select/HMO/PPO,,297.25,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,BCBS NC,Blue Select/HMO/PPO,,1498.64,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,17.16,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Select/HMO/PPO,,59.05,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,BCBS NC,Blue Select/HMO/PPO,,209.47,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,208.68,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,BCBS NC,Blue Select/HMO/PPO,,224.64,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,150.42,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Select/HMO/PPO,,150.42,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,541.44,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,BCBS NC,Blue Select/HMO/PPO,,166.78,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Select/HMO/PPO,,323.99,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,42.69,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Select/HMO/PPO,,226.23,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,BCBS NC,Blue Select/HMO/PPO,,189.92,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Select/HMO/PPO,,260.15,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,182.74,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,62.24,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,71.82,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Select/HMO/PPO,,466.83,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,BCBS NC,Blue Select/HMO/PPO,,52.27,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Select/HMO/PPO,,615.26,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Select/HMO/PPO,,615.26,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,105.34,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,105.34,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,BCBS NC,Blue Select/HMO/PPO,,935.60,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,1246.08,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Select/HMO/PPO,,279.30,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,BCBS NC,Blue Select/HMO/PPO,,975.60,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,331.57,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,BCBS NC,Blue Select/HMO/PPO,,201.50,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,BCBS NC,Blue Select/HMO/PPO,,88.58,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Select/HMO/PPO,,132.87,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,BCBS NC,Blue Select/HMO/PPO,,134.86,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Select/HMO/PPO,,73.81,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Select/HMO/PPO,,4161.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Select/HMO/PPO,,4161.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,BCBS NC,Blue Select/HMO/PPO,,700.41,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Select/HMO/PPO,,2892.54,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Select/HMO/PPO,,2892.54,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,BCBS NC,Blue Select/HMO/PPO,,2937.99,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,BCBS NC,Blue Select/HMO/PPO,,460.45,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,BCBS NC,Blue Select/HMO/PPO,,380.16,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,225.44,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,BCBS NC,Blue Select/HMO/PPO,,538.65,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Select/HMO/PPO,,663.22,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,219.45,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Select/HMO/PPO,,663.22,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Select/HMO/PPO,,419.35,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,BCBS NC,Blue Select/HMO/PPO,,311.98,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,507.13,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,BCBS NC,Blue Select/HMO/PPO,,798.20,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,290.47,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,331.26,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Select/HMO/PPO,,449.27,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,217.63,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,302.44,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,85.40,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Select/HMO/PPO,,382.24,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,227.83,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,BCBS NC,Blue Select/HMO/PPO,,185.14,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,215.06,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Select/HMO/PPO,,200.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Select/HMO/PPO,,627.23,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,278.92,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Select/HMO/PPO,,627.23,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Select/HMO/PPO,,278.92,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,256.89,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,BCBS NC,Blue Select/HMO/PPO,,268.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Select/HMO/PPO,,327.98,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,BCBS NC,Blue Select/HMO/PPO,,341.14,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Select/HMO/PPO,,354.31,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,215.06,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Select/HMO/PPO,,171.17,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,117.70,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,174.36,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,100.95,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Select/HMO/PPO,,244.99,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Select/HMO/PPO,,244.99,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,BCBS NC,Blue Select/HMO/PPO,,218.25,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,84.59,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,84.59,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,84.59,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,84.59,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,159.60,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,159.60,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Select/HMO/PPO,,159.60,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,106.53,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Select/HMO/PPO,,146.03,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Select/HMO/PPO,,146.03,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Select/HMO/PPO,,652.37,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Select/HMO/PPO,,652.37,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Blue Select/HMO/PPO,,182.34,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,181.54,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,BCBS NC,Blue Select/HMO/PPO,,594.91,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Select/HMO/PPO,,608.87,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,BCBS NC,Blue Select/HMO/PPO,,338.35,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,BCBS NC,Blue Select/HMO/PPO,,491.97,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Select/HMO/PPO,,168.78,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,BCBS NC,Blue Select/HMO/PPO,,686.63,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,285.12,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,BCBS NC,Blue Select/HMO/PPO,,374.65,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,BCBS NC,Blue Select/HMO/PPO,,905.64,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,BCBS NC,Blue Select/HMO/PPO,,1093.66,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,1342.96,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,BCBS NC,Blue Select/HMO/PPO,,1905.63,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,BCBS NC,Blue Select/HMO/PPO,,2092.96,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,BCBS NC,Blue Select/HMO/PPO,,2655.63,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,1561.97,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,BCBS NC,Blue Select/HMO/PPO,,1749.30,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,BCBS NC,Blue Select/HMO/PPO,,1968.30,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,BCBS NC,Blue Select/HMO/PPO,,3123.94,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,BCBS NC,Blue Select/HMO/PPO,,3498.60,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,BCBS NC,Blue Select/HMO/PPO,,3904.93,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Select/HMO/PPO,,717.63,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,75.01,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,75.01,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,25.14,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Select/HMO/PPO,,89.78,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,116.51,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,117.31,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,19.15,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,19.15,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,47.08,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,47.08,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,47.08,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,47.08,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,42.29,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,47.08,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,309.23,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,309.23,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,309.23,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,309.23,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,309.23,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Select/HMO/PPO,,309.23,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,29.93,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,BCBS NC,Blue Select/HMO/PPO,GP,25.29,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,BCBS NC,Blue Select/HMO/PPO,,224.08,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Select/HMO/PPO,,1898.57,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Select/HMO/PPO,,1283.64,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Select/HMO/PPO,,1812.72,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Select/HMO/PPO,,750.71,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Select/HMO/PPO,,507.56,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,BCBS NC,Blue Select/HMO/PPO,,1152.66,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Select/HMO/PPO,,486.04,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Select/HMO/PPO,,486.04,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,BCBS NC,Blue Select/HMO/PPO,,1492.28,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,BCBS NC,Blue Select/HMO/PPO,,201.15,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,224.54,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Select/HMO/PPO,,250.74,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,214.25,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,55.67,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,60.35,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,60.35,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,97.30,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,76.25,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Select/HMO/PPO,,143.61,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,BCBS NC,Blue Select/HMO/PPO,,243.26,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Select/HMO/PPO,,235.77,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,BCBS NC,Blue Select/HMO/PPO,,289.10,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,BCBS NC,Blue Select/HMO/PPO,,191.33,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,532.76,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,360.21,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,BCBS NC,Blue Select/HMO/PPO,,441.43,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Select/HMO/PPO,,282.08,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Select/HMO/PPO,,421.96,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,125.93,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,105.17,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,193.73,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,181.51,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,525.15,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,355.06,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Select/HMO/PPO,,1587.91,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,BCBS NC,Blue Select/HMO/PPO,,283.95,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Select/HMO/PPO,,1289.01,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Select/HMO/PPO,,871.51,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Select/HMO/PPO,,1475.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Select/HMO/PPO,,250.74,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,485.11,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,BCBS NC,Blue Select/HMO/PPO,,5850.77,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,BCBS NC,Blue Select/HMO/PPO,,711.06,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,BCBS NC,Blue Select/HMO/PPO,,904.26,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Select/HMO/PPO,,390.15,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,BCBS NC,Blue Select/HMO/PPO,,406.52,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,BCBS NC,Blue Select/HMO/PPO,,432.71,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,BCBS NC,Blue Select/HMO/PPO,,719.48,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,897.24,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,BCBS NC,Blue Select/HMO/PPO,,4572.28,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,456.65,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,308.75,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,2206.47,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,1491.81,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,1057.22,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,714.80,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,BCBS NC,Blue Select/HMO/PPO,,807.89,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Select/HMO/PPO,,1482.05,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Select/HMO/PPO,,1002.03,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Select/HMO/PPO,,966.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Select/HMO/PPO,,653.52,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Select/HMO/PPO,,429.67,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Select/HMO/PPO,,290.50,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Select/HMO/PPO,,498.17,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Select/HMO/PPO,,336.82,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,42.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,28.54,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,258.08,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Select/HMO/PPO,,1047.87,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,JW,98.91,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Select/HMO/PPO,,274.13,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,345.26,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,BCBS NC,Blue Select/HMO/PPO,,417.91,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,233.43,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Select/HMO/PPO,,405.45,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Select/HMO/PPO,,384.53,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,BCBS NC,Blue Select/HMO/PPO,,638.08,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Select/HMO/PPO,,164.67,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,2726.78,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1843.60,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,2726.78,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Select/HMO/PPO,,1843.60,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,1349.20,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Select/HMO/PPO,,912.21,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Select/HMO/PPO,,2146.97,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Select/HMO/PPO,,1451.58,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,BCBS NC,Blue Select/HMO/PPO,,806.02,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Select/HMO/PPO,,997.35,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Select/HMO/PPO,,1309.84,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Select/HMO/PPO,,375.70,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,BCBS NC,Blue Select/HMO/PPO,,3033.98,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,BCBS NC,Blue Select/HMO/PPO,,3355.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,BCBS NC,Blue Select/HMO/PPO,,3967.35,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,556.29,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Select/HMO/PPO,,732.11,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Select/HMO/PPO,,732.11,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,BCBS NC,Blue Select/HMO/PPO,,898.64,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,BCBS NC,Blue Select/HMO/PPO,,795.73,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,272.26,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Select/HMO/PPO,,1060.97,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,BCBS NC,Blue Select/HMO/PPO,,591.77,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,1614.20,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,1091.38,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,BCBS NC,Blue Select/HMO/PPO,,957.59,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,BCBS NC,Blue Select/HMO/PPO,,624.51,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Select/HMO/PPO,,396.23,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,1232.27,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Select/HMO/PPO,,833.15,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Select/HMO/PPO,,794.32,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Select/HMO/PPO,,646.03,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Select/HMO/PPO,,646.03,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,839.23,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,1241.27,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Select/HMO/PPO,,1926.87,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Select/HMO/PPO,,2849.94,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Select/HMO/PPO,,2404.35,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Select/HMO/PPO,,2404.35,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,354.25,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Select/HMO/PPO,,410.99,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,42.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,BCBS NC,Blue Select/HMO/PPO,52,761.09,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Select/HMO/PPO,,525.15,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,BCBS NC,Blue Select/HMO/PPO,,283.69,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,BCBS NC,Blue Select/HMO/PPO,,582.94,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,,50.67,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,635.86,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,429.91,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,258.08,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,114.00,,,,,,,59.12,365.00,per diem,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,BCBS NC,Blue Select/HMO/PPO,,227.00,,,,,,,129.99,624.00,per diem,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,BCBS NC,Blue Select/HMO/PPO,,568.00,,,,,,,259.79,1295.00,per diem,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,BCBS NC,Blue Select/HMO/PPO,,1202.00,,,,,,,409.68,3235.00,per diem,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,BCBS NC,Blue Select/HMO/PPO,,1429.00,,,,,,,589.86,3709.00,per diem,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,BCBS NC,Blue Select/HMO/PPO,,2512.09,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,BCBS NC,Blue Select/HMO/PPO,,829.22,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,BCBS NC,Blue Select/HMO/PPO,,518.29,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Select/HMO/PPO,,239.74,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,196.57,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,125.51,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,66.99,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,66.99,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,948.57,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,80.20,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,75.01,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Select/HMO/PPO,,99.35,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,95.76,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,126.48,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,159.20,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,148.03,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,189.53,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,72.22,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,28.73,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Select/HMO/PPO,,90.57,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,39.90,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,106.53,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Select/HMO/PPO,,99.75,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Select/HMO/PPO,,161.99,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Select/HMO/PPO,,173.56,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,174.36,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Select/HMO/PPO,,158.40,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,72.22,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Select/HMO/PPO,,101.35,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Select/HMO/PPO,,154.81,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,BCBS NC,Blue Select/HMO/PPO,,195.11,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,26.33,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,42.29,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,BCBS NC,Blue Select/HMO/PPO,,70.22,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,BCBS NC,Blue Select/HMO/PPO,,103.74,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,136.86,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,92.17,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,126.48,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,189.53,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Select/HMO/PPO,,229.82,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,19.55,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,37.11,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Select/HMO/PPO,,54.66,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,44.69,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,19.15,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,96.49,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Select/HMO/PPO,,18.55,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,70.51,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,40.08,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,JW,92.16,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,91.29,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,JW,71.18,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Select/HMO/PPO,,105.39,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,202.46,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,148.44,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,JW,149.86,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,,337.70,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,676.14,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,JW,682.61,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Select/HMO/PPO,JW,340.93,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,733.29,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,464.62,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,202.62,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,JW,740.31,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,JW,204.56,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,423.80,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,,194.46,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,,2044.02,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,,902.52,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,457.20,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Select/HMO/PPO,JW,2063.57,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Select/HMO/PPO,JW,911.15,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,JW,461.57,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,2087.81,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,91.29,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,,253.83,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Select/HMO/PPO,JW,256.26,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,,1147.44,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Select/HMO/PPO,,2296.37,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Select/HMO/PPO,JW,1158.42,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,,317.66,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Select/HMO/PPO,JW,320.70,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,358.48,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,JW,361.91,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Select/HMO/PPO,,7.42,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,,1854.02,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Select/HMO/PPO,JW,1871.75,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,,1502.95,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Select/HMO/PPO,JW,1517.33,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,,1267.68,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Select/HMO/PPO,JW,1279.80,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,48.24,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,JW,48.70,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,1832.49,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,518.06,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Select/HMO/PPO,,523.01,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,464.62,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,469.06,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,456.45,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,460.82,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,325.83,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,328.94,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,296.14,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,298.97,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Select/HMO/PPO,JW,1770.60,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,JW,427.85,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Select/HMO/PPO,JW,196.32,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,232.31,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,JW,234.53,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,,1168.96,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Select/HMO/PPO,JW,1180.15,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,,929.23,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Select/HMO/PPO,JW,938.12,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,,475.75,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Select/HMO/PPO,JW,480.30,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,,252.35,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Select/HMO/PPO,JW,254.76,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,,201.88,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Select/HMO/PPO,JW,203.81,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Select/HMO/PPO,,1901.52,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Select/HMO/PPO,,203.17,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,438.70,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,438.70,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,438.70,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,438.70,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,126.31,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,BCBS NC,Blue Select/HMO/PPO,,1984.88,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Select/HMO/PPO,,72.22,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Select/HMO/PPO,,115.08,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,BCBS NC,Blue Select/HMO/PPO,,1205.52,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,134.37,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Select/HMO/PPO,,141.74,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Select/HMO/PPO,,924.37,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Select/HMO/PPO,,924.37,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,202.09,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,202.09,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,157.65,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,130.98,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,125.84,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,BCBS NC,Blue Select/HMO/PPO,,5059.97,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,BCBS NC,Blue Select/HMO/PPO,,553.38,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,485.11,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,BCBS NC,Blue Select/HMO/PPO,,559.96,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,BCBS NC,Blue Select/HMO/PPO,,377.05,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Select/HMO/PPO,,1373.42,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Select/HMO/PPO,,1070.91,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Select/HMO/PPO,,8078.62,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Select/HMO/PPO,,6299.20,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Select/HMO/PPO,,14056.64,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Select/HMO/PPO,,10960.48,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Select/HMO/PPO,,5978.02,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Select/HMO/PPO,,4661.28,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Select/HMO/PPO,,12683.22,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Select/HMO/PPO,,9889.57,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Select/HMO/PPO,,20519.68,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Select/HMO/PPO,,15999.95,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,125.84,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Select/HMO/PPO,,191.80,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Select/HMO/PPO,,277.87,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,239.51,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,360.67,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,BCBS NC,Blue Select/HMO/PPO,,318.57,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Select/HMO/PPO,,1812.72,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,66.90,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,147.36,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,91.22,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,147.36,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,91.22,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,147.36,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,91.22,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,240.92,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,65.83,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Select/HMO/PPO,,378.65,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Select/HMO/PPO,,193.12,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,51.07,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,56.26,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,63.04,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,36.71,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,36.71,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,84.59,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Select/HMO/PPO,,191.80,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,240.92,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,25.54,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,25.54,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,11.17,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,59.85,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,33.91,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,53.07,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,240.92,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,BCBS NC,Blue Select/HMO/PPO,,29448.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,BCBS NC,Blue Select/HMO/PPO,,537.61,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Select/HMO/PPO,,4735.73,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Select/HMO/PPO,,4735.73,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,BCBS NC,Blue Select/HMO/PPO,,2121.67,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,202.03,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,611.64,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Select/HMO/PPO,,95.90,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Select/HMO/PPO,,128.39,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,BCBS NC,Blue Select/HMO/PPO,,671.14,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,851.04,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,224.18,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,BCBS NC,Blue Select/HMO/PPO,,4330.60,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,1460.94,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,BCBS NC,Blue Select/HMO/PPO,,336.26,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,BCBS NC,Blue Select/HMO/PPO,,8228.98,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Select/HMO/PPO,,1460.94,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,BCBS NC,Blue Select/HMO/PPO,,582.58,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,BCBS NC,Blue Select/HMO/PPO,,1616.28,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,BCBS NC,Blue Select/HMO/PPO,,1603.13,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,BCBS NC,Blue Select/HMO/PPO,,1606.59,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,BCBS NC,Blue Select/HMO/PPO,,8253.68,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Select/HMO/PPO,,362.56,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Select/HMO/PPO,,352.85,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,BCBS NC,Blue Select/HMO/PPO,,920.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,1771.96,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,1771.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Select/HMO/PPO,,1311.15,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Select/HMO/PPO,,1311.15,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Select/HMO/PPO,,2391.21,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Select/HMO/PPO,,2391.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,1771.96,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Select/HMO/PPO,,1771.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Select/HMO/PPO,,3849.79,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,,916.62,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,,777.83,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,524.74,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,408.21,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,328.05,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,,345.87,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Select/HMO/PPO,JW,925.39,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Select/HMO/PPO,JW,785.27,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,JW,529.76,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,JW,412.12,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,JW,331.19,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Select/HMO/PPO,JW,349.17,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Select/HMO/PPO,,1542.29,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,83.74,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,87.95,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,BCBS NC,Blue Select/HMO/PPO,,592.57,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,734.58,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,BCBS NC,Blue Select/HMO/PPO,,1064.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,658.74,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,133.09,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,BCBS NC,Blue Select/HMO/PPO,,1359.12,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,BCBS NC,Blue Select/HMO/PPO,,1928.64,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,BCBS NC,Blue Select/HMO/PPO,,702.61,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,BCBS NC,Blue Select/HMO/PPO,,2143.51,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Select/HMO/PPO,,710.79,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,658.74,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,BCBS NC,Blue Select/HMO/PPO,,1042.39,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,BCBS NC,Blue Select/HMO/PPO,,1017.00,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,BCBS NC,Blue Select/HMO/PPO,,1688.57,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,BCBS NC,Blue Select/HMO/PPO,,7633.67,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Select/HMO/PPO,,171.17,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Select/HMO/PPO,,180.35,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,160.00,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,265.33,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Select/HMO/PPO,,126.88,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,21.55,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,196.08,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,177.23,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,BCBS NC,Blue Select/HMO/PPO,,298.12,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Select/HMO/PPO,,192.54,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,263.11,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,BCBS NC,Blue Select/HMO/PPO,,328.75,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,215.52,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,241.77,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,273.50,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,83.14,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,147.69,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,65.64,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,274.05,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,BCBS NC,Blue Select/HMO/PPO,,367.04,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Select/HMO/PPO,,97.91,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,165.19,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Select/HMO/PPO,,198.01,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Select/HMO/PPO,,264.20,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Select/HMO/PPO,,319.45,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Select/HMO/PPO,,590.21,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Select/HMO/PPO,,320.00,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,210.59,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,166.84,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,241.77,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,271.31,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,361.02,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,BCBS NC,Blue Select/HMO/PPO,,508.16,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Select/HMO/PPO,,239.04,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,BCBS NC,Blue Select/HMO/PPO,,178.87,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,BCBS NC,Blue Select/HMO/PPO,,308.51,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,269.12,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,BCBS NC,Blue Select/HMO/PPO,,388.37,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Select/HMO/PPO,,478.62,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,318.35,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,186.53,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,BCBS NC,Blue Select/HMO/PPO,,295.93,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Select/HMO/PPO,,201.84,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Select/HMO/PPO,,201.30,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,BCBS NC,Blue Select/HMO/PPO,,662.42,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,411.34,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,BCBS NC,Blue Select/HMO/PPO,,730.79,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,BCBS NC,Blue Select/HMO/PPO,,1034.92,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Select/HMO/PPO,,1138.31,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Select/HMO/PPO,,232.47,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,BCBS NC,Blue Select/HMO/PPO,,208.95,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,251.07,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,BCBS NC,Blue Select/HMO/PPO,,252.71,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,695.24,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,BCBS NC,Blue Select/HMO/PPO,,285.53,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,BCBS NC,Blue Select/HMO/PPO,,240.68,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Select/HMO/PPO,,222.08,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Select/HMO/PPO,,241.77,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,266.39,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Select/HMO/PPO,,207.31,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,BCBS NC,Blue Select/HMO/PPO,,163.01,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,BCBS NC,Blue Select/HMO/PPO,,205.12,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,BCBS NC,Blue Select/HMO/PPO,,189.81,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,BCBS NC,Blue Select/HMO/PPO,,357.19,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Select/HMO/PPO,,235.76,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,215.52,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,BCBS NC,Blue Select/HMO/PPO,,150.97,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Select/HMO/PPO,,460.03,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,233.57,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,202.94,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Select/HMO/PPO,,263.65,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Select/HMO/PPO,,172.85,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,207.86,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,193.64,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,119.25,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,BCBS NC,Blue Select/HMO/PPO,,243.41,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,253.26,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Select/HMO/PPO,,207.86,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,BCBS NC,Blue Select/HMO/PPO,,289.91,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,253.26,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,219.35,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,177.23,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,233.02,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,270.76,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,270.76,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,,270.76,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,BCBS NC,Blue Select/HMO/PPO,,427.75,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Select/HMO/PPO,,176.13,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,135.11,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,577.09,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,398.22,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Select/HMO/PPO,,485.74,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,BCBS NC,Blue Select/HMO/PPO,,272.41,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Select/HMO/PPO,,289.36,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,540.44,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,569.43,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Select/HMO/PPO,,587.48,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Select/HMO/PPO,,293.74,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,53.61,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,BCBS NC,Blue Select/HMO/PPO,,317.26,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,BCBS NC,Blue Select/HMO/PPO,,351.72,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Select/HMO/PPO,,447.45,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,BCBS NC,Blue Select/HMO/PPO,,364.30,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,BCBS NC,Blue Select/HMO/PPO,,443.07,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,BCBS NC,Blue Select/HMO/PPO,,1142.14,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,BCBS NC,Blue Select/HMO/PPO,,2540.82,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,BCBS NC,Blue Select/HMO/PPO,,1956.62,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Select/HMO/PPO,,101.19,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Select/HMO/PPO,,748.30,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,BCBS NC,Blue Select/HMO/PPO,,763.07,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,BCBS NC,Blue Select/HMO/PPO,,2213.71,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,BCBS NC,Blue Select/HMO/PPO,,3143.06,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,BCBS NC,Blue Select/HMO/PPO,,725.32,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,BCBS NC,Blue Select/HMO/PPO,,1406.88,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,BCBS NC,Blue Select/HMO/PPO,,563.96,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,BCBS NC,Blue Select/HMO/PPO,,657.49,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,BCBS NC,Blue Select/HMO/PPO,,879.58,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,439.79,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,BCBS NC,Blue Select/HMO/PPO,,883.95,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Select/HMO/PPO,,528.95,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Select/HMO/PPO,,437.05,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Select/HMO/PPO,,604.98,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Select/HMO/PPO,,1276.15,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,BCBS NC,Blue Select/HMO/PPO,,752.67,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,111.59,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,95.72,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Select/HMO/PPO,,658.59,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,421.74,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,578.18,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,BCBS NC,Blue Select/HMO/PPO,,195.83,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Select/HMO/PPO,,521.29,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Select/HMO/PPO,,92.44,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Select/HMO/PPO,,511.99,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,,167.38,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,186.53,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,78.22,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,BCBS NC,Blue Select/HMO/PPO,,406.97,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,BCBS NC,Blue Select/HMO/PPO,,362.11,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,BCBS NC,Blue Select/HMO/PPO,,359.38,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,176.68,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,BCBS NC,Blue Select/HMO/PPO,,353.36,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,BCBS NC,Blue Select/HMO/PPO,,189.26,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,132.92,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Select/HMO/PPO,,146.60,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,BCBS NC,Blue Select/HMO/PPO,,507.07,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Select/HMO/PPO,,167.38,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,498.32,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Select/HMO/PPO,,159.18,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,BCBS NC,Blue Select/HMO/PPO,,431.04,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Select/HMO/PPO,,1281.62,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,BCBS NC,Blue Select/HMO/PPO,,2209.33,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,BCBS NC,Blue Select/HMO/PPO,,1825.89,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Select/HMO/PPO,,1968.11,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,BCBS NC,Blue Select/HMO/PPO,,1113.14,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,2469.16,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,2469.16,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Select/HMO/PPO,,2469.16,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,BCBS NC,Blue Select/HMO/PPO,,1669.99,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Select/HMO/PPO,,976.94,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,BCBS NC,Blue Select/HMO/PPO,,757.46,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Select/HMO/PPO,,146.60,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Select/HMO/PPO,,204.58,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,BCBS NC,Blue Select/HMO/PPO,,181.60,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,454.56,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,104.79,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,274.05,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Select/HMO/PPO,,1138.31,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Select/HMO/PPO,,337.50,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Select/HMO/PPO,,444.16,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,BCBS NC,Blue Select/HMO/PPO,,470.97,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Select/HMO/PPO,,255.45,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,BCBS NC,Blue Select/HMO/PPO,,270.22,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Select/HMO/PPO,,286.08,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,414.63,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,BCBS NC,Blue Select/HMO/PPO,,402.59,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Select/HMO/PPO,,590.21,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Select/HMO/PPO,,125.26,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,236.30,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,BCBS NC,Blue Select/HMO/PPO,,581.46,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Select/HMO/PPO,,336.40,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,BCBS NC,Blue Select/HMO/PPO,,429.39,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,BCBS NC,Blue Select/HMO/PPO,,27607.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,BCBS NC,Blue Select/HMO/PPO,,133.63,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,BCBS NC,Blue Select/HMO/PPO,,1013.59,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,BCBS NC,Blue Select/HMO/PPO,,1558.85,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Select/HMO/PPO,,229.74,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Select/HMO/PPO,,300.85,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Select/HMO/PPO,,295.38,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Select/HMO/PPO,,219.35,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,BCBS NC,Blue Select/HMO/PPO,,326.01,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,BCBS NC,Blue Select/HMO/PPO,,271.86,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,411.34,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,317.81,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,BCBS NC,Blue Select/HMO/PPO,,507.62,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,BCBS NC,Blue Select/HMO/PPO,,755.95,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Select/HMO/PPO,,148.63,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Select/HMO/PPO,,414.58,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Select/HMO/PPO,,171.53,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,206.54,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Select/HMO/PPO,,872.42,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,435.24,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,BCBS NC,Blue Select/HMO/PPO,,440.39,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,BCBS NC,Blue Select/HMO/PPO,,709.76,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,374.81,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,BCBS NC,Blue Select/HMO/PPO,,1875.34,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,BCBS NC,Blue Select/HMO/PPO,,960.49,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Select/HMO/PPO,,702.69,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,BCBS NC,Blue Select/HMO/PPO,,627.47,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,BCBS NC,Blue Select/HMO/PPO,,460.96,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Select/HMO/PPO,,1199.65,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,BCBS NC,Blue Select/HMO/PPO,,651.90,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,BCBS NC,Blue Select/HMO/PPO,,1336.59,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Select/HMO/PPO,,1029.93,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,BCBS NC,Blue Select/HMO/PPO,,1472.24,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Select/HMO/PPO,,1029.93,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Select/HMO/PPO,,1528.82,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,BCBS NC,Blue Select/HMO/PPO,,1757.05,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,BCBS NC,Blue Select/HMO/PPO,,550.32,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,BCBS NC,Blue Select/HMO/PPO,,1007.42,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,790.77,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,BCBS NC,Blue Select/HMO/PPO,,1443.31,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Select/HMO/PPO,,669.90,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,BCBS NC,Blue Select/HMO/PPO,,738.05,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Select/HMO/PPO,,806.84,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,BCBS NC,Blue Select/HMO/PPO,,1146.93,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Select/HMO/PPO,,1694.68,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Select/HMO/PPO,,1694.68,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,BCBS NC,Blue Select/HMO/PPO,,1605.32,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,BCBS NC,Blue Select/HMO/PPO,,2491.88,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,BCBS NC,Blue Select/HMO/PPO,,3114.21,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Select/HMO/PPO,,534.25,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,BCBS NC,Blue Select/HMO/PPO,,925.13,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Select/HMO/PPO,,831.91,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Select/HMO/PPO,,1023.50,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Select/HMO/PPO,,1598.25,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,BCBS NC,Blue Select/HMO/PPO,,500.18,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,941.21,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Select/HMO/PPO,,555.47,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,BCBS NC,Blue Select/HMO/PPO,,700.76,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Select/HMO/PPO,,513.68,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,745.76,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,BCBS NC,Blue Select/HMO/PPO,,849.27,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,745.76,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Select/HMO/PPO,,1035.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Select/HMO/PPO,,817.13,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,BCBS NC,Blue Select/HMO/PPO,,593.40,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,BCBS NC,Blue Select/HMO/PPO,,1505.03,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,BCBS NC,Blue Select/HMO/PPO,,1892.05,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Select/HMO/PPO,,178.08,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,63.65,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,BCBS NC,Blue Select/HMO/PPO,,1305.09,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Select/HMO/PPO,,635.19,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,68.79,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,133.72,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,120.87,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,BCBS NC,Blue Select/HMO/PPO,,1796.26,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,BCBS NC,Blue Select/HMO/PPO,,8031.75,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,BCBS NC,Blue Select/HMO/PPO,,1056.28,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,333.67,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,BCBS NC,Blue Select/HMO/PPO,,1307.02,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,BCBS NC,Blue Select/HMO/PPO,,302.16,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,BCBS NC,Blue Select/HMO/PPO,,7953.32,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,435.24,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Select/HMO/PPO,,0.75679,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,55.93,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,BCBS NC,Blue Select/HMO/PPO,,564.47,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,76.51,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Select/HMO/PPO,,375.45,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,207.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,28.29,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,BCBS NC,Blue Select/HMO/PPO,,3394.51,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Select/HMO/PPO,,3.86,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,BCBS NC,Blue Select/HMO/PPO,,417.24,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,78.43,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,27.00,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,BCBS NC,Blue Select/HMO/PPO,,52.72,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Select/HMO/PPO,,163.30,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.50,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,BCBS NC,Blue Select/HMO/PPO,,3894.69,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,117.65,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,BCBS NC,Blue Select/HMO/PPO,,691.12,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,196.08,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,BCBS NC,Blue Select/HMO/PPO,,918.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,196.08,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Select/HMO/PPO,,1296.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Select/HMO/PPO,,1296.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Select/HMO/PPO,,863.41,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,313.09,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Select/HMO/PPO,,279.66,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Select/HMO/PPO,,1440.10,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,BCBS NC,Blue Select/HMO/PPO,,1031.85,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,2149.86,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,2149.86,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Select/HMO/PPO,,2149.86,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Select/HMO/PPO,,841.56,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,BCBS NC,Blue Select/HMO/PPO,,1240.15,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,BCBS NC,Blue Select/HMO/PPO,,687.26,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,BCBS NC,Blue Select/HMO/PPO,,1226.65,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Select/HMO/PPO,,790.77,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,BCBS NC,Blue Select/HMO/PPO,,2211.91,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,BCBS NC,Blue Select/HMO/PPO,,2351.30,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Select/HMO/PPO,,2942.87,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Select/HMO/PPO,,2942.87,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,BCBS NC,Blue Select/HMO/PPO,,3501.50,,,,,,,171.27,3501.50,fee schedule,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Select/HMO/PPO,,568.67,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Select/HMO/PPO,,619.86,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,178.36,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,BCBS NC,Blue Select/HMO/PPO,,1396.62,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Select/HMO/PPO,,709.59,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,BCBS NC,Blue Select/HMO/PPO,,626.47,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,BCBS NC,Blue Select/HMO/PPO,,698.58,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Select/HMO/PPO,,1031.93,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,BCBS NC,Blue Select/HMO/PPO,,1496.17,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,BCBS NC,Blue Select/HMO/PPO,,1800.73,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Select/HMO/PPO,,1645.96,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,BCBS NC,Blue Select/HMO/PPO,,2908.74,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,BCBS NC,Blue Select/HMO/PPO,,3211.99,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,BCBS NC,Blue Select/HMO/PPO,,1356.46,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,BCBS NC,Blue Select/HMO/PPO,,1565.97,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,BCBS NC,Blue Select/HMO/PPO,,1980.32,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,BCBS NC,Blue Select/HMO/PPO,,1461.27,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,BCBS NC,Blue Select/HMO/PPO,,1885.46,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,BCBS NC,Blue Select/HMO/PPO,,2304.84,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,2892.50,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Select/HMO/PPO,,2882.55,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,BCBS NC,Blue Select/HMO/PPO,,1471.29,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Select/HMO/PPO,,1890.49,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,BCBS NC,Blue Select/HMO/PPO,,1893.72,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,BCBS NC,Blue Select/HMO/PPO,,2942.40,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,BCBS NC,Blue Select/HMO/PPO,,1645.96,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,BCBS NC,Blue Select/HMO/PPO,,2349.64,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,BCBS NC,Blue Select/HMO/PPO,,2039.05,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,BCBS NC,Blue Select/HMO/PPO,,1645.96,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,BCBS NC,Blue Select/HMO/PPO,,2364.69,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,BCBS NC,Blue Select/HMO/PPO,,1752.79,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Select/HMO/PPO,,1645.96,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Select/HMO/PPO,,2349.64,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Select/HMO/PPO,,2898.79,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,BCBS NC,Blue Select/HMO/PPO,,3037.26,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,BCBS NC,Blue Select/HMO/PPO,,1286.60,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,BCBS NC,Blue Select/HMO/PPO,,2359.65,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,BCBS NC,Blue Select/HMO/PPO,,1690.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,BCBS NC,Blue Select/HMO/PPO,,1645.96,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,BCBS NC,Blue Select/HMO/PPO,,2314.80,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,BCBS NC,Blue Select/HMO/PPO,,2390.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,BCBS NC,Blue Select/HMO/PPO,,3356.74,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,1645.96,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,BCBS NC,Blue Select/HMO/PPO,,2359.65,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,BCBS NC,Blue Select/HMO/PPO,,3008.52,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,BCBS NC,Blue Select/HMO/PPO,,3500.13,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,BCBS NC,Blue Select/HMO/PPO,,1266.51,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,BCBS NC,Blue Select/HMO/PPO,,2354.73,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,BCBS NC,Blue Select/HMO/PPO,,2709.06,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,BCBS NC,Blue Select/HMO/PPO,,3501.50,,,,,,,343.59,4490.21,fee schedule,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,18592.79,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,BCBS NC,Blue Select/HMO/PPO,,1596.07,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,BCBS NC,Blue Select/HMO/PPO,,3103.38,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,BCBS NC,Blue Select/HMO/PPO,,3501.50,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Select/HMO/PPO,,720.60,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,BCBS NC,Blue Select/HMO/PPO,,3052.31,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Select/HMO/PPO,,2882.55,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,2892.50,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Select/HMO/PPO,,1890.49,,,,,,,171.27,2905.00,fee schedule,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Select/HMO/PPO,,1541.40,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,BCBS NC,Blue Select/HMO/PPO,,238.55,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Select/HMO/PPO,,645.74,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Select/HMO/PPO,,733.27,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Select/HMO/PPO,,733.27,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,BCBS NC,Blue Select/HMO/PPO,,798.23,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Select/HMO/PPO,,971.08,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Select/HMO/PPO,,971.08,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Select/HMO/PPO,,1046.50,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,261.49,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Select/HMO/PPO,,233.17,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,18592.79,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Select/HMO/PPO,,18592.79,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,BCBS NC,Blue Select/HMO/PPO,,16975.91,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Select/HMO/PPO,,186.12,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Select/HMO/PPO,,503.70,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,435.21,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,BCBS NC,Blue Select/HMO/PPO,,1378.96,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,BCBS NC,Blue Select/HMO/PPO,,3532.15,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Select/HMO/PPO,,375.70,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,BCBS NC,Blue Select/HMO/PPO,,959.67,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,BCBS NC,Blue Select/HMO/PPO,,608.87,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,BCBS NC,Blue Select/HMO/PPO,,31048.76,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,2620.35,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,2620.35,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,BCBS NC,Blue Select/HMO/PPO,,15934.13,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,BCBS NC,Blue Select/HMO/PPO,,768.01,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Select/HMO/PPO,,2075.01,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,107.24,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,72.51,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,BCBS NC,Blue Select/HMO/PPO,,291.29,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Select/HMO/PPO,,2021.04,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,435.21,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Select/HMO/PPO,,315.51,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,BCBS NC,Blue Select/HMO/PPO,,160.52,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,139.07,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,332.80,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,BCBS NC,Blue Select/HMO/PPO,,767.32,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,316.89,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,197.19,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,69.88,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,BCBS NC,Blue Select/HMO/PPO,,968.66,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Select/HMO/PPO,,1094.59,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Select/HMO/PPO,,740.06,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Select/HMO/PPO,,1612.13,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Select/HMO/PPO,,1089.97,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Select/HMO/PPO,,215.18,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Select/HMO/PPO,,215.18,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,556.29,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,376.11,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,BCBS NC,Blue Select/HMO/PPO,,337.75,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Select/HMO/PPO,,399.23,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Select/HMO/PPO,,269.92,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,BCBS NC,Blue Select/HMO/PPO,,3265.77,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,BCBS NC,Blue Select/HMO/PPO,,2336.55,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,BCBS NC,Blue Select/HMO/PPO,,492.63,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Select/HMO/PPO,,390.92,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,BCBS NC,Blue Select/HMO/PPO,,978.35,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,BCBS NC,Blue Select/HMO/PPO,,529.30,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,BCBS NC,Blue Select/HMO/PPO,,893.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,401.99,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,882.17,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Select/HMO/PPO,,596.45,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Select/HMO/PPO,,808.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Select/HMO/PPO,,2088.85,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Select/HMO/PPO,,2088.85,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,207.57,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,BCBS NC,Blue Select/HMO/PPO,,1344.36,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,1012.94,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Select/HMO/PPO,,577.04,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,BCBS NC,Blue Select/HMO/PPO,,1122.95,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,BCBS NC,Blue Select/HMO/PPO,,1224.66,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,1251.65,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,975.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Select/HMO/PPO,,1456.45,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Select/HMO/PPO,,1135.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,468.42,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Select/HMO/PPO,,365.24,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,280.00,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,473.26,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,369.02,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,BCBS NC,Blue Select/HMO/PPO,,1451.79,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Select/HMO/PPO,,1906.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Select/HMO/PPO,,1486.86,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Select/HMO/PPO,,1102.89,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Select/HMO/PPO,,859.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Select/HMO/PPO,,633.78,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Select/HMO/PPO,,494.18,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Select/HMO/PPO,,781.85,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Select/HMO/PPO,,609.63,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Select/HMO/PPO,,797.76,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Select/HMO/PPO,,622.04,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,BCBS NC,Blue Select/HMO/PPO,,3500.32,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,BCBS NC,Blue Select/HMO/PPO,,2303.91,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,BCBS NC,Blue Select/HMO/PPO,,550.06,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,BCBS NC,Blue Select/HMO/PPO,,501.63,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Select/HMO/PPO,,565.97,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Select/HMO/PPO,,513.39,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,BCBS NC,Blue Select/HMO/PPO,,1554.70,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Select/HMO/PPO,,513.39,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Select/HMO/PPO,,2575.94,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Select/HMO/PPO,,613.02,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,BCBS NC,Blue Select/HMO/PPO,,474.64,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,134.92,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,BCBS NC,Blue Select/HMO/PPO,,368.78,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Select/HMO/PPO,,384.00,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,BCBS NC,Blue Select/HMO/PPO,,408.22,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Select/HMO/PPO,,403.38,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,460.11,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,BCBS NC,Blue Select/HMO/PPO,,2880.38,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,BCBS NC,Blue Select/HMO/PPO,,1472.36,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Select/HMO/PPO,,929.22,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Select/HMO/PPO,,1012.94,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,BCBS NC,Blue Select/HMO/PPO,,480.18,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,BCBS NC,Blue Select/HMO/PPO,,406.15,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,BCBS NC,Blue Select/HMO/PPO,,419.29,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,611.64,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Select/HMO/PPO,,413.54,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,9726.73,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,7584.29,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Select/HMO/PPO,,7584.29,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,BCBS NC,Blue Select/HMO/PPO,,3337.35,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,7274.64,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,5672.30,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,7274.64,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Select/HMO/PPO,,5672.30,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Select/HMO/PPO,,7923.64,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Select/HMO/PPO,,6178.35,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,BCBS NC,Blue Select/HMO/PPO,,5308.95,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Select/HMO/PPO,,5467.39,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Select/HMO/PPO,,4263.13,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Select/HMO/PPO,,2589.60,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,BCBS NC,Blue Select/HMO/PPO,,3093.48,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,3270.45,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,4194.30,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Select/HMO/PPO,,3270.45,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,2370.56,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,BCBS NC,Blue Select/HMO/PPO,,1672.32,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,BCBS NC,Blue Select/HMO/PPO,,1712.45,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,BCBS NC,Blue Select/HMO/PPO,,1116.03,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,BCBS NC,Blue Select/HMO/PPO,,547.98,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,1711.76,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Select/HMO/PPO,,262.23,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Select/HMO/PPO,,333.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,BCBS NC,Blue Select/HMO/PPO,,195.12,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,BCBS NC,Blue Select/HMO/PPO,,375.01,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Select/HMO/PPO,,3662.92,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,BCBS NC,Blue Select/HMO/PPO,,883.56,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Select/HMO/PPO,,5185.10,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,BCBS NC,Blue Select/HMO/PPO,,273.30,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Select/HMO/PPO,,1134.72,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Select/HMO/PPO,,767.19,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,BCBS NC,Blue Select/HMO/PPO,,1477.90,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Select/HMO/PPO,,426.17,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,BCBS NC,Blue Select/HMO/PPO,,2128.98,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,BCBS NC,Blue Select/HMO/PPO,,1549.16,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,370.17,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,702.97,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,BCBS NC,Blue Select/HMO/PPO,,2666.58,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Select/HMO/PPO,,444.20,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,BCBS NC,Blue Select/HMO/PPO,,554.90,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Select/HMO/PPO,,444.20,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,BCBS NC,Blue Select/HMO/PPO,,480.87,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Select/HMO/PPO,,3662.92,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Select/HMO/PPO,,1645.34,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,BCBS NC,Blue Select/HMO/PPO,,1731.13,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,BCBS NC,Blue Select/HMO/PPO,,1714.53,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,BCBS NC,Blue Select/HMO/PPO,,440.05,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,802.60,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,121.08,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,BCBS NC,Blue Select/HMO/PPO,,4352.74,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,BCBS NC,Blue Select/HMO/PPO,,5373.99,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,62.27,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,BCBS NC,Blue Select/HMO/PPO,,1723.52,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,203.42,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,159.83,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Select/HMO/PPO,,97.30,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,279.53,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,BCBS NC,Blue Select/HMO/PPO,,282.30,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,1711.76,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,,139.76,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Select/HMO/PPO,,1101.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,BCBS NC,Blue Select/HMO/PPO,,3111.47,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,BCBS NC,Blue Select/HMO/PPO,,2929.50,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Select/HMO/PPO,,2021.04,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Select/HMO/PPO,,3164.75,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,729.95,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Select/HMO/PPO,,493.53,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,BCBS NC,Blue Select/HMO/PPO,,1017.78,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,199.27,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,134.73,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,1327.06,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Select/HMO/PPO,,897.24,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Select/HMO/PPO,,548.73,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,1737.36,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Select/HMO/PPO,,1174.65,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,1407.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Select/HMO/PPO,,951.51,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Select/HMO/PPO,,1202.52,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Select/HMO/PPO,,813.04,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Select/HMO/PPO,,1095.28,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Select/HMO/PPO,,740.53,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Select/HMO/PPO,,1138.87,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Select/HMO/PPO,,770.00,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,BCBS NC,Blue Select/HMO/PPO,,799.94,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Select/HMO/PPO,,1048.23,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Select/HMO/PPO,,708.72,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Select/HMO/PPO,,1044.08,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Select/HMO/PPO,,705.91,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Select/HMO/PPO,,2298.49,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Select/HMO/PPO,,1554.03,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Select/HMO/PPO,,1286.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Select/HMO/PPO,,870.11,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Select/HMO/PPO,,1257.87,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Select/HMO/PPO,,850.46,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,BCBS NC,Blue Select/HMO/PPO,,1595.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Select/HMO/PPO,,254.62,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Select/HMO/PPO,,2272.10,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Select/HMO/PPO,,152.22,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,BCBS NC,Blue Select/HMO/PPO,,1965.69,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,BCBS NC,Blue Select/HMO/PPO,,2068.78,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Select/HMO/PPO,,13932.79,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,7407.48,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,280.00,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Select/HMO/PPO,,808.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Select/HMO/PPO,,743.10,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,BCBS NC,Blue Select/HMO/PPO,,479.49,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,BCBS NC,Blue Select/HMO/PPO,,536.91,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,BCBS NC,Blue Select/HMO/PPO,,3776.39,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Select/HMO/PPO,,2568.33,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,BCBS NC,Blue Select/HMO/PPO,,3265.08,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,BCBS NC,Blue Select/HMO/PPO,,2676.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,BCBS NC,Blue Select/HMO/PPO,,3365.40,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,BCBS NC,Blue Select/HMO/PPO,,2759.30,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,BCBS NC,Blue Select/HMO/PPO,,1167.93,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Select/HMO/PPO,,396.46,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,BCBS NC,Blue Select/HMO/PPO,,5162.96,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Select/HMO/PPO,,1376.88,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,BCBS NC,Blue Select/HMO/PPO,,1032.31,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,BCBS NC,Blue Select/HMO/PPO,,1835.61,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,BCBS NC,Blue Select/HMO/PPO,,15519.26,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,BCBS NC,Blue Select/HMO/PPO,,2258.89,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,BCBS NC,Blue Select/HMO/PPO,,7164.02,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,BCBS NC,Blue Select/HMO/PPO,,4773.50,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,BCBS NC,Blue Select/HMO/PPO,,2407.12,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,BCBS NC,Blue Select/HMO/PPO,,858.65,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Select/HMO/PPO,,1173.46,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Select/HMO/PPO,,793.39,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Select/HMO/PPO,,1298.00,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Select/HMO/PPO,,877.59,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Select/HMO/PPO,,1198.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Select/HMO/PPO,,810.23,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Select/HMO/PPO,,891.86,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Select/HMO/PPO,,507.16,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,BCBS NC,Blue Select/HMO/PPO,,850.35,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,BCBS NC,Blue Select/HMO/PPO,,4957.46,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,BCBS NC,Blue Select/HMO/PPO,,1239.19,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,BCBS NC,Blue Select/HMO/PPO,,1090.43,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,BCBS NC,Blue Select/HMO/PPO,,1282.78,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,BCBS NC,Blue Select/HMO/PPO,,723.73,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Select/HMO/PPO,,2481.15,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Select/HMO/PPO,,1934.65,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,1800.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,1403.78,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,1800.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Select/HMO/PPO,,1403.78,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,BCBS NC,Blue Select/HMO/PPO,,2397.43,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,BCBS NC,Blue Select/HMO/PPO,,2061.86,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,BCBS NC,Blue Select/HMO/PPO,,4251.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,BCBS NC,Blue Select/HMO/PPO,,4942.93,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,BCBS NC,Blue Select/HMO/PPO,,3660.84,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,BCBS NC,Blue Select/HMO/PPO,,3298.29,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,BCBS NC,Blue Select/HMO/PPO,,824.74,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,BCBS NC,Blue Select/HMO/PPO,,5561.49,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,BCBS NC,Blue Select/HMO/PPO,,5740.00,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,BCBS NC,Blue Select/HMO/PPO,,8627.99,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,BCBS NC,Blue Select/HMO/PPO,,4812.16,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Select/HMO/PPO,,1839.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Select/HMO/PPO,,1278.63,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,BCBS NC,Blue Select/HMO/PPO,,616.48,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Select/HMO/PPO,,1114.65,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,BCBS NC,Blue Select/HMO/PPO,,824.05,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,BCBS NC,Blue Select/HMO/PPO,,2561.41,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,BCBS NC,Blue Select/HMO/PPO,,2249.37,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,BCBS NC,Blue Select/HMO/PPO,,2251.44,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,BCBS NC,Blue Select/HMO/PPO,,1940.78,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Select/HMO/PPO,,1839.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,BCBS NC,Blue Select/HMO/PPO,,3299.67,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,BCBS NC,Blue Select/HMO/PPO,,3827.59,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,BCBS NC,Blue Select/HMO/PPO,,5609.23,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,BCBS NC,Blue Select/HMO/PPO,,519.62,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,BCBS NC,Blue Select/HMO/PPO,,7525.80,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Select/HMO/PPO,,5418.27,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,BCBS NC,Blue Select/HMO/PPO,,2634.06,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,BCBS NC,Blue Select/HMO/PPO,,9236.78,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,BCBS NC,Blue Select/HMO/PPO,,3952.92,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Select/HMO/PPO,,624.09,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Select/HMO/PPO,,2408.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Select/HMO/PPO,,1878.00,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,BCBS NC,Blue Select/HMO/PPO,,9299.90,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Select/HMO/PPO,,11196.33,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Select/HMO/PPO,,8730.19,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Select/HMO/PPO,,6085.26,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Select/HMO/PPO,,4744.90,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Select/HMO/PPO,,6449.89,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Select/HMO/PPO,,5029.22,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,BCBS NC,Blue Select/HMO/PPO,,6704.91,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,BCBS NC,Blue Select/HMO/PPO,,4874.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,BCBS NC,Blue Select/HMO/PPO,,2013.43,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Select/HMO/PPO,,1638.42,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Select/HMO/PPO,,1638.42,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Select/HMO/PPO,,556.29,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,BCBS NC,Blue Select/HMO/PPO,,4538.86,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,BCBS NC,Blue Select/HMO/PPO,,788.71,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,BCBS NC,Blue Select/HMO/PPO,,1398.33,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,BCBS NC,Blue Select/HMO/PPO,,1732.33,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Select/HMO/PPO,,336.96,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,1978.14,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,1978.14,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,150.83,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,150.83,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Select/HMO/PPO,,6880.25,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Select/HMO/PPO,,6880.25,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,BCBS NC,Blue Select/HMO/PPO,,2777.29,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,BCBS NC,Blue Select/HMO/PPO,,4215.05,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,BCBS NC,Blue Select/HMO/PPO,,2388.44,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Select/HMO/PPO,,1251.65,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,435.21,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,1978.14,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Select/HMO/PPO,,1978.14,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,BCBS NC,Blue Select/HMO/PPO,,2233.93,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,BCBS NC,Blue Select/HMO/PPO,,1355.43,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Select/HMO/PPO,,281.06,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,329.10,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,225.03,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Select/HMO/PPO,,225.03,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Select/HMO/PPO,,281.06,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,BCBS NC,Blue Select/HMO/PPO,,197.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,BCBS NC,Blue Select/HMO/PPO,,550.53,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,BCBS NC,Blue Select/HMO/PPO,,353.47,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,BCBS NC,Blue Select/HMO/PPO,,703.24,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Select/HMO/PPO,,576.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,BCBS NC,Blue Select/HMO/PPO,,651.52,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Select/HMO/PPO,,474.78,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,BCBS NC,Blue Select/HMO/PPO,,515.42,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Select/HMO/PPO,,193.98,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Select/HMO/PPO,,466.78,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,BCBS NC,Blue Select/HMO/PPO,,190.90,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Select/HMO/PPO,,508.04,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,BCBS NC,Blue Select/HMO/PPO,,591.78,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,319.60,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Select/HMO/PPO,,392.26,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,262.95,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,BCBS NC,Blue Select/HMO/PPO,,514.19,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Select/HMO/PPO,,411.35,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,331.92,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,BCBS NC,Blue Select/HMO/PPO,,405.20,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,638.58,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Select/HMO/PPO,,506.80,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Select/HMO/PPO,,565.92,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,BCBS NC,Blue Select/HMO/PPO,,185.36,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,BCBS NC,Blue Select/HMO/PPO,,725.41,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,BCBS NC,Blue Select/HMO/PPO,,470.47,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Select/HMO/PPO,,153.95,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Select/HMO/PPO,,142.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,114.54,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,BCBS NC,Blue Select/HMO/PPO,,678.61,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Select/HMO/PPO,,508.04,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Select/HMO/PPO,,122.54,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,31.41,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Select/HMO/PPO,,421.21,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,259.87,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Select/HMO/PPO,,595.48,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,BCBS NC,Blue Select/HMO/PPO,,445.84,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Select/HMO/PPO,,254.33,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,302.97,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Select/HMO/PPO,,282.65,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,67.74,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,83.86,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Select/HMO/PPO,,48.04,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,78.15,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,BCBS NC,Blue Select/HMO/PPO,,2711.50,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,BCBS NC,Blue Select/HMO/PPO,,1976.09,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,BCBS NC,Blue Select/HMO/PPO,,1775.68,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,BCBS NC,Blue Select/HMO/PPO,,2756.08,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,2611.29,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,BCBS NC,Blue Select/HMO/PPO,,1728.12,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,2611.29,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Select/HMO/PPO,,2611.29,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,BCBS NC,Blue Select/HMO/PPO,,395.30,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,BCBS NC,Blue Select/HMO/PPO,,650.06,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,BCBS NC,Blue Select/HMO/PPO,,1299.70,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,BCBS NC,Blue Select/HMO/PPO,,1978.64,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,BCBS NC,Blue Select/HMO/PPO,,1773.13,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,BCBS NC,Blue Select/HMO/PPO,,2569.68,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,BCBS NC,Blue Select/HMO/PPO,,3777.24,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,BCBS NC,Blue Select/HMO/PPO,,182.71,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Select/HMO/PPO,,311.68,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Select/HMO/PPO,,197.97,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,BCBS NC,Blue Select/HMO/PPO,,350.86,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,948.57,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Select/HMO/PPO,,856.00,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Select/HMO/PPO,,166.76,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Select/HMO/PPO,,2337.43,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,BCBS NC,Blue Select/HMO/PPO,,2338.36,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,BCBS NC,Blue Select/HMO/PPO,,3601.53,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,BCBS NC,Blue Select/HMO/PPO,,4352.85,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,BCBS NC,Blue Select/HMO/PPO,,2338.36,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,BCBS NC,Blue Select/HMO/PPO,,2533.31,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,BCBS NC,Blue Select/HMO/PPO,,3069.09,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,BCBS NC,Blue Select/HMO/PPO,,2340.93,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,BCBS NC,Blue Select/HMO/PPO,,3127.52,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Select/HMO/PPO,,3810.99,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,BCBS NC,Blue Select/HMO/PPO,,1643.60,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,BCBS NC,Blue Select/HMO/PPO,,2893.96,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,BCBS NC,Blue Select/HMO/PPO,,3525.98,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,BCBS NC,Blue Select/HMO/PPO,,2324.62,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,BCBS NC,Blue Select/HMO/PPO,,2409.60,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,BCBS NC,Blue Select/HMO/PPO,,3089.68,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,BCBS NC,Blue Select/HMO/PPO,,1643.60,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Select/HMO/PPO,,2917.94,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Select/HMO/PPO,,3522.51,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,BCBS NC,Blue Select/HMO/PPO,,2032.63,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,BCBS NC,Blue Select/HMO/PPO,,2876.72,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,BCBS NC,Blue Select/HMO/PPO,,3079.45,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,BCBS NC,Blue Select/HMO/PPO,,2073.86,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,BCBS NC,Blue Select/HMO/PPO,,2972.99,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,BCBS NC,Blue Select/HMO/PPO,,1625.97,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,129.69,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Select/HMO/PPO,52,2807.64,,,,,,,791.19,2825.00,fee schedule,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,BCBS NC,Blue Select/HMO/PPO,52,2793.94,,,,,,,787.39,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,BCBS NC,Blue Select/HMO/PPO,,1520.83,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,BCBS NC,Blue Select/HMO/PPO,,2244.70,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,BCBS NC,Blue Select/HMO/PPO,,2560.75,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,BCBS NC,Blue Select/HMO/PPO,,1459.01,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,BCBS NC,Blue Select/HMO/PPO,,2299.63,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,BCBS NC,Blue Select/HMO/PPO,,1462.40,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,BCBS NC,Blue Select/HMO/PPO,,2190.85,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Select/HMO/PPO,,1459.01,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,BCBS NC,Blue Select/HMO/PPO,,2076.54,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,BCBS NC,Blue Select/HMO/PPO,,2581.38,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,BCBS NC,Blue Select/HMO/PPO,,2588.23,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,BCBS NC,Blue Select/HMO/PPO,,2571.03,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,BCBS NC,Blue Select/HMO/PPO,,1977.71,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,BCBS NC,Blue Select/HMO/PPO,,2334.04,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,BCBS NC,Blue Select/HMO/PPO,,2883.61,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,BCBS NC,Blue Select/HMO/PPO,,2337.43,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,BCBS NC,Blue Select/HMO/PPO,,2409.60,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,BCBS NC,Blue Select/HMO/PPO,,3981.96,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,BCBS NC,Blue Select/HMO/PPO,,2337.43,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,BCBS NC,Blue Select/HMO/PPO,,2409.60,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,BCBS NC,Blue Select/HMO/PPO,,4009.45,,,,,,,343.59,4009.45,fee schedule,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,BCBS NC,Blue Select/HMO/PPO,,3021.02,,,,,,,845.85,3021.02,fee schedule,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,BCBS NC,Blue Select/HMO/PPO,,3021.02,,,,,,,647.85,3021.02,fee schedule,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,BCBS NC,Blue Select/HMO/PPO,,3021.02,,,,,,,895.29,3021.02,fee schedule,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,3010.70,,,,,,,848.45,3010.70,fee schedule,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,3010.70,,,,,,,848.45,3010.70,fee schedule,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Select/HMO/PPO,,3010.70,,,,,,,848.45,3010.70,fee schedule,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,BCBS NC,Blue Select/HMO/PPO,,1812.04,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Select/HMO/PPO,,2085.26,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Select/HMO/PPO,,2085.26,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,BCBS NC,Blue Select/HMO/PPO,,3027.91,,,,,,,899.50,3027.91,fee schedule,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,BCBS NC,Blue Select/HMO/PPO,,3027.91,,,,,,,650.65,3027.91,fee schedule,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,BCBS NC,Blue Select/HMO/PPO,,3027.91,,,,,,,919.72,3027.91,fee schedule,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,BCBS NC,Blue Select/HMO/PPO,,2409.60,,,,,,,894.09,2825.00,fee schedule,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Select/HMO/PPO,,2409.60,,,,,,,845.44,2825.00,fee schedule,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Select/HMO/PPO,,2409.60,,,,,,,845.44,2825.00,fee schedule,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,3048.50,,,,,,,908.91,3048.50,fee schedule,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,3048.50,,,,,,,908.91,3048.50,fee schedule,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Select/HMO/PPO,,3048.50,,,,,,,908.91,3048.50,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Select/HMO/PPO,,1459.01,,,,,,,232.56,2825.00,fee schedule,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Select/HMO/PPO,,529.52,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,BCBS NC,Blue Select/HMO/PPO,,1704.68,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,BCBS NC,Blue Select/HMO/PPO,,1694.45,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Select/HMO/PPO,,2807.64,,,,,,,791.19,2825.00,fee schedule,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,BCBS NC,Blue Select/HMO/PPO,,2793.94,,,,,,,375.38,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,233.02,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,223.14,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,274.79,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,1207.37,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Select/HMO/PPO,,816.31,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,73.91,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Select/HMO/PPO,,1266.87,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Select/HMO/PPO,,856.54,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,BCBS NC,Blue Select/HMO/PPO,,361.10,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Select/HMO/PPO,,215.46,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,189.53,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Select/HMO/PPO,,189.53,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,BCBS NC,Blue Select/HMO/PPO,,518.30,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Select/HMO/PPO,,413.76,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Select/HMO/PPO,,337.95,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Select/HMO/PPO,,245.78,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Select/HMO/PPO,,239.00,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Select/HMO/PPO,,116.51,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Select/HMO/PPO,,277.13,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Select/HMO/PPO,,203.83,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,185.18,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,BCBS NC,Blue Select/HMO/PPO,,437.24,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Select/HMO/PPO,,180.68,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,374.23,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Select/HMO/PPO,,374.23,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,BCBS NC,Blue Select/HMO/PPO,,923.35,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Select/HMO/PPO,,483.54,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Select/HMO/PPO,,1199.84,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,BCBS NC,Blue Select/HMO/PPO,,2797.05,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,BCBS NC,Blue Select/HMO/PPO,,162.04,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,113.81,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Select/HMO/PPO,,237.27,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Select/HMO/PPO,,117.67,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Select/HMO/PPO,,274.56,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Select/HMO/PPO,,211.55,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,176.82,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Select/HMO/PPO,,256.56,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,BCBS NC,Blue Select/HMO/PPO,,405.73,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,333.07,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,BCBS NC,Blue Select/HMO/PPO,,561.98,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,BCBS NC,Blue Select/HMO/PPO,,361.37,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,36.65,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Select/HMO/PPO,,232.77,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Select/HMO/PPO,,486.11,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Select/HMO/PPO,,196.12,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Select/HMO/PPO,,427.60,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,271.35,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Select/HMO/PPO,,614.71,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Select/HMO/PPO,,385.16,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,271.35,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Select/HMO/PPO,,294.49,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,BCBS NC,Blue Select/HMO/PPO,,234.05,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,BCBS NC,Blue Select/HMO/PPO,,1622.93,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,BCBS NC,Blue Select/HMO/PPO,,1394.67,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Select/HMO/PPO,,711.16,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,BCBS NC,Blue Select/HMO/PPO,,335.00,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,BCBS NC,Blue Select/HMO/PPO,,355.58,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Select/HMO/PPO,,216.05,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,82.30,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Select/HMO/PPO,,329.22,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,259.77,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Select/HMO/PPO,,259.77,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,BCBS NC,Blue Select/HMO/PPO,,1545.77,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,30.22,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,BCBS NC,Blue Select/HMO/PPO,,9.00,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,72.02,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,104.81,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,84.88,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,16.72,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,28.29,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,121.53,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Select/HMO/PPO,,170.40,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00643,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,56.58,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,162.68,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,121.53,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Select/HMO/PPO,,255.27,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Select/HMO/PPO,,99.67,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,59.80,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Select/HMO/PPO,,344.00,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,58.51,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,58.51,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,45.65,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,85.52,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,85.52,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Select/HMO/PPO,,85.52,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,40.51,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,46.30,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,113.81,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,79.73,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,25.08,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,93.23,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,93.23,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,93.23,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,57.87,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,57.87,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,57.87,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,99.02,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,27.65,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,27.01,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,120.88,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,30.86,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,104.17,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,73.94,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,73.94,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,73.94,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,64.30,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,27.01,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,59.80,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,BCBS NC,Blue Select/HMO/PPO,,38.58,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,25.72,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,25.72,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,106.74,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,57.23,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,57.23,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,42.44,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,34.08,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,165.89,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,40.51,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,61.09,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,61.09,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,15.43,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,42.44,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,156.25,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,57.87,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,57.87,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,115.74,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,59.80,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,93.88,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,25.08,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Select/HMO/PPO,,192.26,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Select/HMO/PPO,,3.86,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,59.80,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,129.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Select/HMO/PPO,,372.30,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,100.95,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,78.45,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,78.45,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,78.45,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,78.45,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,25.08,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,120.88,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,130.53,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,130.53,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,130.53,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,130.53,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,19.29,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,70.73,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,70.73,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,70.73,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,45.65,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,109.95,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,104.17,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,50.15,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Select/HMO/PPO,,153.03,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Select/HMO/PPO,,100.31,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,59.80,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Select/HMO/PPO,,142.10,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,77.16,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Select/HMO/PPO,,97.74,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,30.22,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,30.22,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,14.79,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,BCBS NC,Blue Select/HMO/PPO,,126.67,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,84.88,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,25.72,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,54.01,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,51.44,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,51.44,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,27.01,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,101.59,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Select/HMO/PPO,,101.59,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Select/HMO/PPO,,95.81,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,46.30,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,64.30,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,91.95,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,53.37,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,61.09,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,91.95,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Select/HMO/PPO,,113.81,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,16.72,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,16.72,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,16.72,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,37.29,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,68.80,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,1.29,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Select/HMO/PPO,,211.55,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,35.37,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,93.88,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Select/HMO/PPO,,145.96,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,138.25,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,138.25,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,28.93,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,39.22,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,39.22,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,34.08,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,64.30,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,32.15,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,42.44,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,28.93,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,20.58,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,20.58,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,27.65,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,9.64,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Select/HMO/PPO,,107.38,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,28.93,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Select/HMO/PPO,,102.88,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,BCBS NC,Blue Select/HMO/PPO,,122.17,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,39.22,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,46.30,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,47.58,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,42.44,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,86.16,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,83.59,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,69.44,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,73.94,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Select/HMO/PPO,,73.94,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,83.59,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Select/HMO/PPO,,124.10,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,,7.72,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,238.55,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Select/HMO/PPO,,238.55,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Select/HMO/PPO,,144.68,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,20.58,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,90.02,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,72.66,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,62.37,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Select/HMO/PPO,,88.09,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,77.16,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,BCBS NC,Blue Select/HMO/PPO,,5.14,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,14.15,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,68.16,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,111.88,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,23.79,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Select/HMO/PPO,,82.30,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Select/HMO/PPO,,171.68,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,94.52,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Select/HMO/PPO,,175.54,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Select/HMO/PPO,,133.10,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,32.15,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Select/HMO/PPO,,152.39,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,120.88,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,75.87,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,47.32,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,BCBS NC,Blue Select/HMO/PPO,,132.46,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Select/HMO/PPO,,26.36,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,188.40,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Select/HMO/PPO,,129.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,29.58,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,72.66,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,72.66,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,32.15,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,86.81,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,BCBS NC,Blue Select/HMO/PPO,,143.39,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Select/HMO/PPO,,13.50,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,36.01,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,36.65,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,93.23,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,,43.72,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,75.23,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,111.24,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,62.37,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,74.59,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,74.59,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,9.64,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,57.23,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,57.23,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,22.50,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,28.93,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,44.37,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Select/HMO/PPO,,296.42,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,40.51,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,78.45,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,46.30,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Select/HMO/PPO,,125.39,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,53.37,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Select/HMO/PPO,,7.07,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,22.50,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,86.81,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,69.44,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,36.01,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Select/HMO/PPO,,510.54,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Select/HMO/PPO,,287.42,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Select/HMO/PPO,,171.04,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,BCBS NC,Blue Select/HMO/PPO,,366.51,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Select/HMO/PPO,,540.76,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,106.09,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,190.33,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Select/HMO/PPO,,232.12,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,54.66,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,54.66,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,54.66,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,BCBS NC,Blue Select/HMO/PPO,,149.82,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,93.23,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Select/HMO/PPO,,79.09,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,86.16,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Select/HMO/PPO,,126.03,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Select/HMO/PPO,,111.24,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,39.22,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Select/HMO/PPO,,322.14,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,BCBS NC,Blue Select/HMO/PPO,,473.89,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,81.02,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,89.38,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,23.79,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,96.45,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,75.87,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Select/HMO/PPO,,59.80,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,104.17,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Select/HMO/PPO,,278.42,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Select/HMO/PPO,,278.42,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,207.69,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,176.82,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Select/HMO/PPO,,187.11,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Select/HMO/PPO,,169.75,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,BCBS NC,Blue Select/HMO/PPO,,393.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,103.52,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Select/HMO/PPO,,152.39,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Select/HMO/PPO,,127.96,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,63.66,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Select/HMO/PPO,,208.97,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,174.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Select/HMO/PPO,,207.69,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,BCBS NC,Blue Select/HMO/PPO,,161.39,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Select/HMO/PPO,,117.03,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,119.60,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,119.60,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,158.82,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,46.30,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,28.29,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,96.45,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Select/HMO/PPO,,126.03,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,BCBS NC,Blue Select/HMO/PPO,,300.92,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,BCBS NC,Blue Select/HMO/PPO,,181.97,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,47.58,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,22.50,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,36.01,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Select/HMO/PPO,,46.30,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Select/HMO/PPO,,72.66,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,228.91,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Select/HMO/PPO,,93.88,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,40.51,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Select/HMO/PPO,,129.89,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Select/HMO/PPO,,91.95,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,75.23,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Select/HMO/PPO,,75.23,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Select/HMO/PPO,,65.59,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,36.01,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Select/HMO/PPO,,54.66,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Select/HMO/PPO,,63.01,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,36.01,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,,144.03,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,51.44,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,25.08,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,12.22,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,61.09,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,61.09,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Select/HMO/PPO,,30.22,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,9.64,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Select/HMO/PPO,,26.36,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,39.22,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Select/HMO/PPO,,120.88,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Select/HMO/PPO,,78.45,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Select/HMO/PPO,,83.59,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,45.65,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,100.95,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,17.36,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Select/HMO/PPO,,34.08,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,,120.24,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Select/HMO/PPO,,120.24,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,62.37,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,136.96,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,131.17,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,47.58,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Select/HMO/PPO,,20.58,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,131.17,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Select/HMO/PPO,,19.93,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,45.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Select/HMO/PPO,,93.23,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Select/HMO/PPO,,59.16,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,25.08,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,19.29,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,19.29,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,16.72,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,15.43,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,82.95,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,74.59,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,70.73,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,11.57,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,47.58,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,47.58,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,47.58,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,47.58,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,BCBS NC,Blue Select/HMO/PPO,,217.98,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Select/HMO/PPO,,43.72,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,54.01,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,57.23,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,39.22,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Select/HMO/PPO,,10.29,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,BCBS NC,Blue Select/HMO/PPO,,157.53,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,54.01,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,99.02,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Select/HMO/PPO,,23.79,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Select/HMO/PPO,,63.66,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,50.15,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,25.72,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,36.65,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,61.09,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Select/HMO/PPO,,40.51,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Select/HMO/PPO,,115.74,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Select/HMO/PPO,,21.22,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,BCBS NC,Blue Select/HMO/PPO,,146.60,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Select/HMO/PPO,,108.67,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Select/HMO/PPO,,296.42,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,136.96,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,136.96,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Select/HMO/PPO,,404.45,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Select/HMO/PPO,,373.58,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Select/HMO/PPO,,111.88,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,103.52,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,225.05,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Select/HMO/PPO,,136.32,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,105.45,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,105.45,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,176.82,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,BCBS NC,Blue Select/HMO/PPO,,165.25,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Select/HMO/PPO,,495.11,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Select/HMO/PPO,,55.94,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Select/HMO/PPO,,53.37,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Select/HMO/PPO,,30.86,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Select/HMO/PPO,,72.02,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Select/HMO/PPO,,372.30,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,BCBS NC,Blue Select/HMO/PPO,,179.40,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,35.37,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Select/HMO/PPO,,99.02,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,61.73,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,61.73,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Select/HMO/PPO,,61.73,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Select/HMO/PPO,,297.71,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,189.04,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,56.58,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Select/HMO/PPO,,56.58,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Select/HMO/PPO,,32.79,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Select/HMO/PPO,,81.02,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Select/HMO/PPO,,7.72,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,96.45,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Select/HMO/PPO,,77.16,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,320.14,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Select/HMO/PPO,,198.69,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Select/HMO/PPO,,81.66,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Select/HMO/PPO,,23.15,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Select/HMO/PPO,,14.15,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Select/HMO/PPO,,147.89,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,49.51,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,11.57,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Select/HMO/PPO,,68.16,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Select/HMO/PPO,,37.29,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,22.50,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,22.50,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Select/HMO/PPO,,12.22,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Select/HMO/PPO,,39.22,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Select/HMO/PPO,,41.15,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,29.58,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Select/HMO/PPO,,36.01,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,45.65,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,9.64,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Select/HMO/PPO,,19.29,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Select/HMO/PPO,,162.68,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,86.16,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Select/HMO/PPO,,109.95,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Select/HMO/PPO,,16.72,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,104.17,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,34.72,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00584,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,241.86,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Select/HMO/PPO,,1.29,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,333.07,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Select/HMO/PPO,,52.08,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Select/HMO/PPO,,18.65,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Select/HMO/PPO,,103.52,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Select/HMO/PPO,,1260.28,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,61.09,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,90.66,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,57.23,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,21.86,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Select/HMO/PPO,,24.43,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,45.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Select/HMO/PPO,,45.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Select/HMO/PPO,,9.64,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Select/HMO/PPO,,22.50,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Select/HMO/PPO,,48.23,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Select/HMO/PPO,,31.51,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Select/HMO/PPO,,340.15,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,BCBS NC,Blue Select/HMO/PPO,,493.18,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Select/HMO/PPO,,86.16,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,BCBS NC,Blue Select/HMO/PPO,,1160.62,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,BCBS NC,Blue Select/HMO/PPO,,734.92,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,171.17,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Select/HMO/PPO,,74.59,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Select/HMO/PPO,,1241.63,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Select/HMO/PPO,,14.79,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Select/HMO/PPO,,166.54,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,29.58,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,BCBS NC,Blue Select/HMO/PPO,,1162.54,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Select/HMO/PPO,,454.60,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,39.87,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,68.80,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,BCBS NC,Blue Select/HMO/PPO,,329.86,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,121.53,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Select/HMO/PPO,,1260.28,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,BCBS NC,Blue Select/HMO/PPO,,73.30,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Select/HMO/PPO,,208.33,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,87.45,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Select/HMO/PPO,,124.74,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Select/HMO/PPO,,612.78,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,BCBS NC,Blue Select/HMO/PPO,,410.88,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,,90.02,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Select/HMO/PPO,QW,90.02,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Select/HMO/PPO,,29.58,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Select/HMO/PPO,,178.75,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Select/HMO/PPO,,1021.73,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,BCBS NC,Blue Select/HMO/PPO,,763.24,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Select/HMO/PPO,,162.41,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Select/HMO/PPO,,391.59,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,BCBS NC,Blue Select/HMO/PPO,,307.35,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Select/HMO/PPO,,131.17,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Select/HMO/PPO,,273.92,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Select/HMO/PPO,,32.15,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,70.73,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,QW,64.30,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Select/HMO/PPO,,64.30,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Select/HMO/PPO,,104.81,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,BCBS NC,Blue Select/HMO/PPO,,583.20,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,176.82,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,84.88,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,106.09,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Select/HMO/PPO,,57.23,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,27.65,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Select/HMO/PPO,,180.04,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Select/HMO/PPO,,50.80,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Select/HMO/PPO,,124.74,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,58.51,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Select/HMO/PPO,,44.37,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,42.44,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Select/HMO/PPO,,225.05,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,86.81,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Select/HMO/PPO,,136.96,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,BCBS NC,Blue Select/HMO/PPO,,140.82,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,86.81,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,86.81,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Select/HMO/PPO,,176.82,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,28.93,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Select/HMO/PPO,,28.93,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,BCBS NC,Blue Select/HMO/PPO,,48.87,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,27.65,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Select/HMO/PPO,,54.01,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Select/HMO/PPO,,64.94,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Select/HMO/PPO,,95.81,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,BCBS NC,Blue Select/HMO/PPO,,853.90,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,35.37,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Select/HMO/PPO,,69.44,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,75.87,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Select/HMO/PPO,,75.87,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Select/HMO/PPO,,41.80,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,36.65,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,174.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Select/HMO/PPO,,107.38,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Select/HMO/PPO,,174.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,205.12,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Select/HMO/PPO,,356.33,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,BCBS NC,Blue Select/HMO/PPO,,338.22,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,BCBS NC,Blue Select/HMO/PPO,,135.03,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00584,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Select/HMO/PPO,,17.36,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Select/HMO/PPO,,64.26,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Select/HMO/PPO,,108.66,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,85.88,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Select/HMO/PPO,,85.88,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Select/HMO/PPO,,22.78,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,BCBS NC,Blue Select/HMO/PPO,,115.67,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Select/HMO/PPO,,69.52,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,BCBS NC,Blue Select/HMO/PPO,,148.97,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Select/HMO/PPO,,152.48,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,79.45,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Select/HMO/PPO,,45.57,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Select/HMO/PPO,,79.45,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Select/HMO/PPO,,122.10,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Select/HMO/PPO,,120.93,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,302.62,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Select/HMO/PPO,,86.46,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Select/HMO/PPO,,266.40,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Select/HMO/PPO,,348.77,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,BCBS NC,Blue Select/HMO/PPO,,441.07,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,BCBS NC,Blue Select/HMO/PPO,,327.74,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Select/HMO/PPO,,189.87,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Select/HMO/PPO,,131.44,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,BCBS NC,Blue Select/HMO/PPO,,595.30,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,206.81,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Select/HMO/PPO,,355.78,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Select/HMO/PPO,,130.86,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,46.74,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,77.11,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Select/HMO/PPO,,78.87,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,320.14,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Select/HMO/PPO,,59.59,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,102.23,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,214.40,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,385.57,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Select/HMO/PPO,,0.00584,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Select/HMO/PPO,,72.44,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,BCBS NC,Blue Select/HMO/PPO,,132.03,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,BCBS NC,Blue Select/HMO/PPO,,216.15,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,186.36,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Select/HMO/PPO,,186.36,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,BCBS NC,Blue Select/HMO/PPO,,346.43,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Select/HMO/PPO,,320.14,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,56.67,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,75.36,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Select/HMO/PPO,,230.17,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Select/HMO/PPO,,182.85,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Select/HMO/PPO,,145.47,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Select/HMO/PPO,,44.98,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,BCBS NC,Blue Select/HMO/PPO,,224.33,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Select/HMO/PPO,,77.11,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,BCBS NC,Blue Select/HMO/PPO,,394.33,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Select/HMO/PPO,,110.41,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,241.86,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,BCBS NC,Blue Select/HMO/PPO,,164.61,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Select/HMO/PPO,,152.48,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,91.72,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Select/HMO/PPO,,91.72,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Select/HMO/PPO,,314.88,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Select/HMO/PPO,,81.20,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Select/HMO/PPO,,95.81,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Select/HMO/PPO,,10.52,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Select/HMO/PPO,,241.86,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,53.16,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Select/HMO/PPO,,144.30,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,BCBS NC,Blue Select/HMO/PPO,,1279.98,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Select/HMO/PPO,,206.22,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,112.17,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Select/HMO/PPO,,413.61,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Select/HMO/PPO,,302.62,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Select/HMO/PPO,,206.81,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,224.92,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,214.40,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,224.92,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Select/HMO/PPO,,303.20,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,BCBS NC,Blue Select/HMO/PPO,,750.70,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,46.74,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,224.92,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Select/HMO/PPO,,214.40,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,BCBS NC,Blue Select/HMO/PPO,,182.27,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Select/HMO/PPO,,75.36,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,BCBS NC,Blue Select/HMO/PPO,,726.16,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Select/HMO/PPO,,14.02,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,112.17,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,46.74,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,BCBS NC,Blue Select/HMO/PPO,,530.45,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Select/HMO/PPO,,385.57,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Select/HMO/PPO,,276.91,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Select/HMO/PPO,,207.98,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,BCBS NC,Blue Select/HMO/PPO,,73.03,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Select/HMO/PPO,,87.63,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Select/HMO/PPO,,55.50,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Select/HMO/PPO,,96.98,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Select/HMO/PPO,,46.74,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,BCBS NC,Blue Select/HMO/PPO,,92.89,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Select/HMO/PPO,,928.29,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,BCBS NC,Blue Select/HMO/PPO,,466.19,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,BCBS NC,Blue Select/HMO/PPO,,190.45,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Select/HMO/PPO,,42.44,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,27.01,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,BCBS NC,Blue Select/HMO/PPO,,67.52,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,BCBS NC,Blue Select/HMO/PPO,,159.46,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,24.74,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,119.70,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,119.70,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Select/HMO/PPO,,110.52,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,BCBS NC,Blue Select/HMO/PPO,,225.83,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,36.31,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,36.31,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Select/HMO/PPO,,22.74,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,BCBS NC,Blue Select/HMO/PPO,,270.92,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,BCBS NC,Blue Select/HMO/PPO,,259.75,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,415.36,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,BCBS NC,Blue Select/HMO/PPO,,426.93,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,85.78,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,BCBS NC,Blue Select/HMO/PPO,,167.18,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Select/HMO/PPO,,117.31,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Select/HMO/PPO,,378.65,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,BCBS NC,Blue Select/HMO/PPO,,494.76,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Select/HMO/PPO,,239.40,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Select/HMO/PPO,,36.31,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Select/HMO/PPO,,609.67,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Select/HMO/PPO,,18.00,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,106.09,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,106.09,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Select/HMO/PPO,,106.09,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Select/HMO/PPO,,37.94,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,415.36,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Select/HMO/PPO,,415.36,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Select/HMO/PPO,,462.84,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,24.74,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,24.74,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,24.74,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,24.74,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Select/HMO/PPO,,24.74,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,BCBS NC,Blue Select/HMO/PPO,,1411.33,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,5929.58,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,4623.52,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,5929.58,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,5929.58,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,4623.52,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,BCBS NC,Blue Select/HMO/PPO,,19139.84,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,BCBS NC,Blue Select/HMO/PPO,,3243.47,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,1334.72,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Select/HMO/PPO,,1711.76,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,BCBS NC,Blue Select/HMO/PPO,,3622.74,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,BCBS NC,Blue Select/HMO/PPO,,1102.20,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,BCBS NC,Blue Select/HMO/PPO,,1817.04,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,490.41,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Select/HMO/PPO,,490.41,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Select/HMO/PPO,,1370.65,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Select/HMO/PPO,,1068.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Select/HMO/PPO,,2882.46,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Select/HMO/PPO,,2247.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Select/HMO/PPO,,1311.84,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Select/HMO/PPO,,1022.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Select/HMO/PPO,,309.28,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Select/HMO/PPO,,444.01,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,1241.27,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,967.86,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,979.73,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,763.93,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Select/HMO/PPO,,1097.35,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Select/HMO/PPO,,855.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,979.73,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Select/HMO/PPO,,763.93,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,BCBS NC,Blue Select/HMO/PPO,,4163.32,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Select/HMO/PPO,,2669.35,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Select/HMO/PPO,,2081.39,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Select/HMO/PPO,,4958.16,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Select/HMO/PPO,,3866.06,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,3813.75,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,2973.72,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Select/HMO/PPO,,953.44,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Select/HMO/PPO,,743.43,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,3813.75,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Select/HMO/PPO,,2973.72,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,BCBS NC,Blue Select/HMO/PPO,,1434.53,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,5929.58,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Select/HMO/PPO,,4623.52,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Select/HMO/PPO,,549.37,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,BCBS NC,Blue Select/HMO/PPO,,15676.25,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,3040.21,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Select/HMO/PPO,,2370.56,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,303.74,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,236.84,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,303.74,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Select/HMO/PPO,,236.84,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,1561.62,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,1217.65,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,1561.62,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Select/HMO/PPO,,1217.65,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Select/HMO/PPO,,11574.80,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Select/HMO/PPO,,9025.30,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Select/HMO/PPO,,19291.56,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Select/HMO/PPO,,15042.34,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Select/HMO/PPO,,6944.60,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Select/HMO/PPO,,5414.96,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Select/HMO/PPO,,16011.95,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Select/HMO/PPO,,12485.11,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Select/HMO/PPO,,6439.51,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Select/HMO/PPO,,5021.13,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Select/HMO/PPO,,16245.12,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Select/HMO/PPO,,12666.92,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Select/HMO/PPO,,14635.07,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Select/HMO/PPO,,11411.50,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Select/HMO/PPO,,19465.22,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Select/HMO/PPO,,15177.75,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,BCBS NC,Blue Select/HMO/PPO,,6650.96,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Select/HMO/PPO,,16121.27,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Select/HMO/PPO,,12570.35,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Select/HMO/PPO,,14671.05,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Select/HMO/PPO,,11439.56,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Select/HMO/PPO,,16633.28,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Select/HMO/PPO,,12969.58,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Select/HMO/PPO,,6568.21,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Select/HMO/PPO,,5121.47,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Select/HMO/PPO,,14159.04,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Select/HMO/PPO,,11040.33,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Select/HMO/PPO,,12197.51,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Select/HMO/PPO,,9510.85,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,BCBS NC,Blue Select/HMO/PPO,,14244.84,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LM,8739.36,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,RI,8739.36,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,RC,8739.36,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LD,8739.36,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Select/HMO/PPO,LC,8739.36,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LC,4508.60,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,RI,4508.60,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,RC,4508.60,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LD,4508.60,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Select/HMO/PPO,LC,4508.60,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LM,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RI,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RC,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LD,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LC,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LM,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RI,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,RC,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LD,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Select/HMO/PPO,LC,7746.14,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LM,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RI,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RC,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LD,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LC,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LM,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RI,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,RC,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LD,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Select/HMO/PPO,LC,11561.49,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LM,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RI,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RC,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LD,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LC,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,RC,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LD,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Select/HMO/PPO,LC,12254.74,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,21850.83,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LM,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RI,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,RC,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LD,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Select/HMO/PPO,LC,21850.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Select/HMO/PPO,,12485.65,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Select/HMO/PPO,,12485.65,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Select/HMO/PPO,,12833.09,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Select/HMO/PPO,,12833.09,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LM,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RI,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RC,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LD,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LC,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LM,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RI,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,RC,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LD,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Select/HMO/PPO,LC,13410.89,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,13989.24,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LM,13989.24,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RI,13989.24,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,RC,13989.24,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LD,13989.24,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Select/HMO/PPO,LC,13989.24,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,BCBS NC,Blue Select/HMO/PPO,,212.02,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,BCBS NC,Blue Select/HMO/PPO,,714.52,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Select/HMO/PPO,,1006.17,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Select/HMO/PPO,,227.67,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,BCBS NC,Blue Select/HMO/PPO,,1363.32,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,BCBS NC,Blue Select/HMO/PPO,,531.95,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,BCBS NC,Blue Select/HMO/PPO,,6243.09,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,5775.89,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Select/HMO/PPO,,5775.89,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,BCBS NC,Blue Select/HMO/PPO,,5508.30,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,BCBS NC,Blue Select/HMO/PPO,,2292.88,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,BCBS NC,Blue Select/HMO/PPO,,3974.50,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,BCBS NC,Blue Select/HMO/PPO,,5876.77,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,BCBS NC,Blue Select/HMO/PPO,,5218.58,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,BCBS NC,Blue Select/HMO/PPO,,5570.88,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,BCBS NC,Blue Select/HMO/PPO,,2450.95,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,BCBS NC,Blue Select/HMO/PPO,,5731.65,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,BCBS NC,Blue Select/HMO/PPO,,7148.91,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,BCBS NC,Blue Select/HMO/PPO,,6440.01,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,BCBS NC,Blue Select/HMO/PPO,,6869.99,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,BCBS NC,Blue Select/HMO/PPO,,6986.52,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,BCBS NC,Blue Select/HMO/PPO,,8565.64,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,BCBS NC,Blue Select/HMO/PPO,,3656.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Select/HMO/PPO,,109.52,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Select/HMO/PPO,,52.33,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,BCBS NC,Blue Select/HMO/PPO,,810.87,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,BCBS NC,Blue Select/HMO/PPO,,2227.06,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,BCBS NC,Blue Select/HMO/PPO,,4350.53,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Select/HMO/PPO,,261.12,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,337.73,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Select/HMO/PPO,,337.73,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Select/HMO/PPO,,115.99,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,BCBS NC,Blue Select/HMO/PPO,,4138.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,BCBS NC,Blue Select/HMO/PPO,,21112.25,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,BCBS NC,Blue Select/HMO/PPO,,5273.89,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,BCBS NC,Blue Select/HMO/PPO,,1084.23,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,BCBS NC,Blue Select/HMO/PPO,,1212.63,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,BCBS NC,Blue Select/HMO/PPO,,683.01,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,365.32,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,284.86,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Select/HMO/PPO,,284.86,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Select/HMO/PPO,,5453.56,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Select/HMO/PPO,,4252.34,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Select/HMO/PPO,,10363.97,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Select/HMO/PPO,,10363.97,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,BCBS NC,Blue Select/HMO/PPO,,12638.94,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,BCBS NC,Blue Select/HMO/PPO,,9180.13,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,BCBS NC,Blue Select/HMO/PPO,,10431.78,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,BCBS NC,Blue Select/HMO/PPO,,12588.43,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,BCBS NC,Blue Select/HMO/PPO,,2209.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Select/HMO/PPO,,9748.18,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Select/HMO/PPO,,9748.18,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,BCBS NC,Blue Select/HMO/PPO,,7067.76,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,BCBS NC,Blue Select/HMO/PPO,,2036.95,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Select/HMO/PPO,,2007.89,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Select/HMO/PPO,,2007.89,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,BCBS NC,Blue Select/HMO/PPO,,14109.22,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,BCBS NC,Blue Select/HMO/PPO,,10326.61,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,BCBS NC,Blue Select/HMO/PPO,,1637.73,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,BCBS NC,Blue Select/HMO/PPO,,16457.53,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,BCBS NC,Blue Select/HMO/PPO,,16966.08,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,BCBS NC,Blue Select/HMO/PPO,,18493.10,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,BCBS NC,Blue Select/HMO/PPO,,5886.69,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Select/HMO/PPO,,7888.35,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Select/HMO/PPO,,7888.35,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,BCBS NC,Blue Select/HMO/PPO,,34516.82,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,BCBS NC,Blue Select/HMO/PPO,,3978.43,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,BCBS NC,Blue Select/HMO/PPO,,2643.75,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,BCBS NC,Blue Select/HMO/PPO,,39921.25,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Select/HMO/PPO,,1825.92,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,BCBS NC,Blue Select/HMO/PPO,,5457.82,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,BCBS NC,Blue Select/HMO/PPO,,1443.30,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Select/HMO/PPO,,2897.68,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,2782.51,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Select/HMO/PPO,,2782.51,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,1387.82,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Select/HMO/PPO,,985.47,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,1387.82,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Select/HMO/PPO,,1387.82,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,BCBS NC,Blue Select/HMO/PPO,,1306.66,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,BCBS NC,Blue Select/HMO/PPO,,1196.74,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,BCBS NC,Blue Select/HMO/PPO,,4113.65,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Select/HMO/PPO,,6539.76,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Select/HMO/PPO,,6539.76,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,BCBS NC,Blue Select/HMO/PPO,,697.35,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,BCBS NC,Blue Select/HMO/PPO,,3471.27,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,BCBS NC,Blue Select/HMO/PPO,,711.95,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,BCBS NC,Blue Select/HMO/PPO,,1355.19,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,BCBS NC,Blue Select/HMO/PPO,,10924.79,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Select/HMO/PPO,,9676.10,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Select/HMO/PPO,,9676.10,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,BCBS NC,Blue Select/HMO/PPO,,1298.93,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,608.89,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Select/HMO/PPO,,10863.91,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,BCBS NC,Blue Select/HMO/PPO,,15485.41,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,BCBS NC,Blue Select/HMO/PPO,,1717.30,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Select/HMO/PPO,,1041.77,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Select/HMO/PPO,,3838.66,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Select/HMO/PPO,,3838.66,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,BCBS NC,Blue Select/HMO/PPO,,4412.25,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,BCBS NC,Blue Select/HMO/PPO,,1389.21,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,BCBS NC,Blue Select/HMO/PPO,,7402.48,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Select/HMO/PPO,,2589.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,608.89,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Select/HMO/PPO,,1147.52,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,BCBS NC,Blue Select/HMO/PPO,,1530.02,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,BCBS NC,Blue Select/HMO/PPO,,4297.12,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,BCBS NC,Blue Select/HMO/PPO,,9992.62,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,BCBS NC,Blue Select/HMO/PPO,,4976.35,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,BCBS NC,Blue Select/HMO/PPO,,3488.95,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,BCBS NC,Blue Select/HMO/PPO,,4033.30,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Select/HMO/PPO,,155.38,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Select/HMO/PPO,,981.11,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,BCBS NC,Blue Select/HMO/PPO,,5514.44,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,1305.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,1305.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,1305.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Select/HMO/PPO,,1305.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,BCBS NC,Blue Select/HMO/PPO,,7175.89,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Select/HMO/PPO,,14351.78,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Select/HMO/PPO,,14351.78,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,BCBS NC,Blue Select/HMO/PPO,,23106.25,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,BCBS NC,Blue Select/HMO/PPO,,18862.00,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Select/HMO/PPO,,6556.44,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,BCBS NC,Blue Select/HMO/PPO,,2344.13,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,BCBS NC,Blue Select/HMO/PPO,,11548.54,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,18473.02,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,18473.02,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Select/HMO/PPO,,18473.02,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,BCBS NC,Blue Select/HMO/PPO,,22398.88,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Select/HMO/PPO,,3650.26,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Select/HMO/PPO,,3650.26,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Select/HMO/PPO,,57.73,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Select/HMO/PPO,,16807.57,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Select/HMO/PPO,,16807.57,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,BCBS NC,Blue Select/HMO/PPO,,20587.15,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,BCBS NC,Blue Select/HMO/PPO,,1294.26,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,BCBS NC,Blue Select/HMO/PPO,,3503.51,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Select/HMO/PPO,,5846.56,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LD,1853.72,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,RC,1853.72,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,RI,1853.72,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LM,1853.72,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LD,1482.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,RC,1482.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,RI,1482.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LM,1482.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LD,1271.06,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,RC,1271.06,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,RI,1271.06,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LM,1271.06,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LD,267.05,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,RC,267.05,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,RI,267.05,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LM,267.05,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Select/HMO/PPO,LC,1853.72,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Select/HMO/PPO,LC,1482.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Select/HMO/PPO,LC,1271.06,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Select/HMO/PPO,LC,267.05,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,BCBS NC,Blue Select/HMO/PPO,,17593.63,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,BCBS NC,Blue Select/HMO/PPO,,33307.11,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,BCBS NC,Blue Select/HMO/PPO,,6151.92,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,BCBS NC,Blue Select/HMO/PPO,,1538.11,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,BCBS NC,Blue Select/HMO/PPO,,354.08,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,BCBS NC,Blue Select/HMO/PPO,,1726.62,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,BCBS NC,Blue Select/HMO/PPO,,1418.74,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,BCBS NC,Blue Select/HMO/PPO,,490.72,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,BCBS NC,Blue Select/HMO/PPO,,541.89,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,BCBS NC,Blue Select/HMO/PPO,,401.13,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Select/HMO/PPO,,772.79,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Select/HMO/PPO,,772.79,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Select/HMO/PPO,,311.68,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Select/HMO/PPO,,251.70,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Select/HMO/PPO,,251.70,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Select/HMO/PPO,,886.86,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Select/HMO/PPO,,886.86,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Select/HMO/PPO,,171.96,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Select/HMO/PPO,,133.48,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Select/HMO/PPO,,948.57,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Select/HMO/PPO,,19.07,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Select/HMO/PPO,,474.29,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Select/HMO/PPO,,167.35,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Select/HMO/PPO,,602.61,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,BCBS NC,Blue Select/HMO/PPO,,428.37,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Select/HMO/PPO,,111.57,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Select/HMO/PPO,,77.01,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,BCBS NC,Blue Select/HMO/PPO,,509.12,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,113.72,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Select/HMO/PPO,,86.98,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Select/HMO/PPO,,118.50,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Select/HMO/PPO,,43.49,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Select/HMO/PPO,,56.26,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Select/HMO/PPO,,17.16,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Select/HMO/PPO,,4496.66,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,BCBS NC,Blue Select/HMO/PPO,,2507.45,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,BCBS NC,Blue Select/HMO/PPO,,5524.13,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Select/HMO/PPO,,1803.78,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,1460.60,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,1460.60,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Select/HMO/PPO,,1460.60,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,BCBS NC,Blue Select/HMO/PPO,,3169.65,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,BCBS NC,Blue Select/HMO/PPO,,4197.86,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,BCBS NC,Blue Select/HMO/PPO,,4711.96,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Select/HMO/PPO,,3893.57,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,BCBS NC,Blue Select/HMO/PPO,,5046.08,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,BCBS NC,Blue Select/HMO/PPO,,5622.34,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,353.38,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,220.86,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Select/HMO/PPO,,353.38,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Select/HMO/PPO,,220.86,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Select/HMO/PPO,,25.03,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,66.26,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Select/HMO/PPO,,176.69,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Select/HMO/PPO,,275.34,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,BCBS NC,Blue Select/HMO/PPO,,971.78,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,BCBS NC,Blue Select/HMO/PPO,,1049.09,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,BCBS NC,Blue Select/HMO/PPO,,1643.20,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Select/HMO/PPO,,215.71,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,BCBS NC,Blue Select/HMO/PPO,,494.73,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,BCBS NC,Blue Select/HMO/PPO,,76.56,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Select/HMO/PPO,,747.98,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Select/HMO/PPO,,128.84,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Select/HMO/PPO,,189.94,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Select/HMO/PPO,,141.35,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,BCBS NC,Blue Select/HMO/PPO,,2327.86,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Select/HMO/PPO,,222.33,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Select/HMO/PPO,,217.92,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Select/HMO/PPO,,227.49,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Select/HMO/PPO,,209.82,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Select/HMO/PPO,,251.04,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Select/HMO/PPO,,318.04,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Select/HMO/PPO,,454.24,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Select/HMO/PPO,,32.39,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Select/HMO/PPO,,30.92,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Select/HMO/PPO,,52.27,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Select/HMO/PPO,,162.70,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,BCBS NC,Blue Select/HMO/PPO,,295.95,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,BCBS NC,Blue Select/HMO/PPO,,655.22,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Select/HMO/PPO,,54.48,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Select/HMO/PPO,,39.75,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Select/HMO/PPO,,195.09,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Select/HMO/PPO,,29.45,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,BCBS NC,Blue Select/HMO/PPO,,552.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,BCBS NC,Blue Select/HMO/PPO,,865.03,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Select/HMO/PPO,,2952.16,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,BCBS NC,Blue Select/HMO/PPO,,901.11,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Select/HMO/PPO,,1320.74,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,BCBS NC,Blue Select/HMO/PPO,,1670.44,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Select/HMO/PPO,,362.21,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Select/HMO/PPO,,2952.16,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Select/HMO/PPO,,515.34,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,BCBS NC,Blue Select/HMO/PPO,,574.24,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Select/HMO/PPO,,66.26,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,BCBS NC,Blue Select/HMO/PPO,,1176.45,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,BCBS NC,Blue Select/HMO/PPO,,1891.30,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Select/HMO/PPO,,368.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,BCBS NC,Blue Select/HMO/PPO,,2944.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Select/HMO/PPO,,1785.29,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Select/HMO/PPO,,1325.16,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Select/HMO/PPO,,1785.29,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Select/HMO/PPO,,1325.16,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Select/HMO/PPO,,868.72,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Select/HMO/PPO,,868.72,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Select/HMO/PPO,,778.16,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Select/HMO/PPO,GP,90.27,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Select/HMO/PPO,,21381.79,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Select/HMO/PPO,,10339.06,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Select/HMO/PPO,,21381.79,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Select/HMO/PPO,,10339.06,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,BCBS NC,Blue Select/HMO/PPO,,8985.71,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,BCBS NC,Blue Select/HMO/PPO,,9183.59,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,BCBS NC,Blue Select/HMO/PPO,,9382.16,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,BCBS NC,Blue Select/HMO/PPO,,9581.43,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,BCBS NC,Blue Select/HMO/PPO,,9780.01,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,BCBS NC,Blue Select/HMO/PPO,,9977.89,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,BCBS NC,Blue Select/HMO/PPO,,10176.47,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,BCBS NC,Blue Select/HMO/PPO,,10375.04,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Select/HMO/PPO,,306.98,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Select/HMO/PPO,,151.34,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Select/HMO/PPO,,79.80,,,,,,,34.82,150.00,percent of total billed charges,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,26044.00,,,,,,,14490.34,36145.66,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,23178.00,,,,,,,16490.00,54106.99,case rate,"Outlier payment may apply if charges exceed a DRG-specific threshold. FOR BLUE SELECT ONLY: When billed with ICD-10-PCS code 0DB64Z3, payment is $24,569. When billed with ICD-10-PCS code 0D164ZA, payment is $26,015."
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,23178.00,,,,,,,11823.02,35030.00,case rate,"Outlier payment may apply if charges exceed a DRG-specific threshold. FOR BLUE SELECT ONLY: When billed with ICD-10-PCS code 0DB64Z3, payment is $24,569. When billed with ICD-10-PCS code 0D164ZA, payment is $26,015."
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,23178.00,,,,,,,11144.06,35030.00,case rate,"Outlier payment may apply if charges exceed a DRG-specific threshold. FOR BLUE SELECT ONLY: When billed with ICD-10-PCS code 0DB64Z3, payment is $24,569. When billed with ICD-10-PCS code 0D164ZA, payment is $26,015."
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,10440.00,,,,,,,5414.00,31619.23,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,10440.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,10440.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,10440.00,,,,,,,5414.00,21243.91,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,10440.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,10440.00,,,,,,,5414.00,15908.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,1810.00,,,,,,,1810.00,33771.43,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,1810.00,,,,,,,1810.00,111375.25,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,1810.00,,,,,,,1810.00,76061.60,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,1810.00,,,,,,,1810.00,45895.56,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,1810.00,,,,,,,1810.00,78134.13,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,1810.00,,,,,,,375.00,27656.89,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,529.00,,,,,,,314.00,3744.05,per diem,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,6419.00,,,,,,,4210.00,9947.78,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,6419.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,6419.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,6419.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,6419.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Blue Value Group,,6419.00,,,,,,,4210.00,9518.00,case rate,Outlier payment may apply if charges exceed a DRG-specific threshold.
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,BCBS NC,Blue Value Group,,0.07245,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Group,,67.28,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Value Group,,12.94,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,49.16,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,27.95,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Group,,64.26,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Group,,63.65,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,BCBS NC,Blue Value Group,,11.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,49.63,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Value Group,,73.48,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Value Group,,20477.47,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Value Group,,8799.57,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Group,,0.52762,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Value Group,,993.08,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Value Group,,3752.91,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Value Group,,897.35,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Value Group,,1705.16,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Value Group,,20813.85,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Value Group,,6477.55,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Value Group,,5754.60,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Value Group,,8106.64,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Value Group,,16341.61,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Value Group,,1365.68,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Value Group,,5753.05,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Value Group,,8301.74,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Value Group,,1395.18,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Value Group,,4329.40,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Value Group,,4616.10,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Value Group,,5835.85,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Group,,68.96,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Group,,235.46,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Group,,471.44,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,BCBS NC,Blue Value Group,,16.19,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,BCBS NC,Blue Value Group,,10.53,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,BCBS NC,Blue Value Group,,144.36,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,BCBS NC,Blue Value Group,,11.20,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,BCBS NC,Blue Value Group,,0.01553,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,BCBS NC,Blue Value Group,,11.08,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,BCBS NC,Blue Value Group,,21.02,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,BCBS NC,Blue Value Group,,10.54,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,BCBS NC,Blue Value Group,,10.30,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Group,,516.13,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Group,,142.62,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Value Group,,33.77,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,BCBS NC,Blue Value Group,,93.10,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Value Group,,8018.66,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,BCBS NC,Blue Value Group,,3.28,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Group,,95.08,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Group,,103.50,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Group,,104.48,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,BCBS NC,Blue Value Group,,15.34,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Group,,639.11,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Group,,542.34,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Group,,365.87,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Group,,284.62,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Group,,228.74,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Group,,241.16,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Group,,645.16,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Group,,547.48,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Group,,369.34,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Group,,287.32,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Group,,230.90,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Group,,243.44,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,BCBS NC,Blue Value Group,,14.22,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Group,,295.49,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Group,,135.59,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Value Group,,1277.71,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Group,,361.21,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Group,,364.64,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,323.95,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,327.02,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Group,,318.26,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Group,,321.28,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,227.18,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,229.33,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Group,,206.48,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Group,,208.44,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Value Group,,1234.43,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Group,,298.29,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Group,,136.87,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Group,,161.98,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Group,,163.51,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Group,,815.06,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Group,,822.78,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Group,,647.91,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Group,,654.04,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Group,,331.72,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Group,,334.86,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Group,,175.95,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Group,,177.62,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Group,,140.76,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Group,,142.09,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,BCBS NC,Blue Value Group,,111.87,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Group,,475.91,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Group,,237.69,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Value Group,,2684.27,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,BCBS NC,Blue Value Group,,79.59,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Value Group,,1325.84,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Group,,511.29,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,323.95,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Group,,141.28,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,BCBS NC,Blue Value Group,,451.33,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,BCBS NC,Blue Value Group,,553.84,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,BCBS NC,Blue Value Group,,1.13,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Value Group,,1075.37,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Group,,1425.19,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Group,,629.28,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Group,,318.78,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Group,,1438.69,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Group,,635.24,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Group,,321.80,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Value Group,,1455.73,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,BCBS NC,Blue Value Group,,1.60,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,BCBS NC,Blue Value Group,,5.09,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,BCBS NC,Blue Value Group,,100.62,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,BCBS NC,Blue Value Group,,34.38,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Group,,63.65,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,BCBS NC,Blue Value Group,,123.00,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,BCBS NC,Blue Value Group,,141.74,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,BCBS NC,Blue Value Group,,82.13,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Group,,176.99,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Group,,178.66,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Group,,800.05,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Value Group,,1601.14,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Group,,807.63,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,BCBS NC,Blue Value Group,,170.98,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,BCBS NC,Blue Value Group,,170.40,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,BCBS NC,Blue Value Group,,79.26,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,BCBS NC,Blue Value Group,,82.19,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Group,,221.49,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Group,,223.59,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Group,,249.95,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Group,,252.32,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Value Group,,5.17,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,BCBS NC,Blue Value Group,,0.06269,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,BCBS NC,Blue Value Group,,0.14105,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Group,,1292.71,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Group,,1304.96,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Group,,1047.94,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Group,,1057.86,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Group,,883.89,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Group,,892.26,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00517,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,BCBS NC,Blue Value Group,,166.78,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,33.64,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,33.96,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,BCBS NC,Blue Value Group,,41.98,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,BCBS NC,Blue Value Group,,27.70,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,BCBS NC,Blue Value Group,,65.22,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,BCBS NC,Blue Value Group,,15.97,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,BCBS NC,Blue Value Group,,8.61,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,BCBS NC,Blue Value Group,,60.44,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,BCBS NC,Blue Value Group,,17.41,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,BCBS NC,Blue Value Group,,49.70,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,BCBS NC,Blue Value Group,,142.32,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,BCBS NC,Blue Value Group,,22.06,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,BCBS NC,Blue Value Group,,26.61,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,BCBS NC,Blue Value Group,,85.95,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,BCBS NC,Blue Value Group,,66.65,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,BCBS NC,Blue Value Group,,79.79,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,BCBS NC,Blue Value Group,,75.73,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,BCBS NC,Blue Value Group,,13.53,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,BCBS NC,Blue Value Group,,14.78,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,BCBS NC,Blue Value Group,,35.22,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,BCBS NC,Blue Value Group,,72.84,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,BCBS NC,Blue Value Group,,0.26393,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,BCBS NC,Blue Value Group,,13.57,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,BCBS NC,Blue Value Group,,3.06,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,BCBS NC,Blue Value Group,,5.50,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,BCBS NC,Blue Value Group,,0.05693,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,BCBS NC,Blue Value Group,,0.41400,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,BCBS NC,Blue Value Group,,4.02,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,BCBS NC,Blue Value Group,,0.40882,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,BCBS NC,Blue Value Group,,0.24322,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,BCBS NC,Blue Value Group,,0.33120,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,BCBS NC,Blue Value Group,,862.56,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Value Group,,0.01035,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,BCBS NC,Blue Value Group,,0.04702,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,BCBS NC,Blue Value Group,,1.34,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,BCBS NC,Blue Value Group,,13.34,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,BCBS NC,Blue Value Group,,42.16,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,BCBS NC,Blue Value Group,,0.03623,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,BCBS NC,Blue Value Group,,2.20,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,BCBS NC,Blue Value Group,,3.17,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,BCBS NC,Blue Value Group,,0.57960,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,BCBS NC,Blue Value Group,,0.83317,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,BCBS NC,Blue Value Group,,1.32,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,BCBS NC,Blue Value Group,,0.92632,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,BCBS NC,Blue Value Group,,0.01035,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,BCBS NC,Blue Value Group,,11.44,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,BCBS NC,Blue Value Group,,569.63,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,BCBS NC,Blue Value Group,,39.86,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,BCBS NC,Blue Value Group,,69.82,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,BCBS NC,Blue Value Group,,86.13,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,BCBS NC,Blue Value Group,,8.94,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,BCBS NC,Blue Value Group,,0.06728,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,BCBS NC,Blue Value Group,,18.81,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,BCBS NC,Blue Value Group,,33.77,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,BCBS NC,Blue Value Group,,74.47,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,BCBS NC,Blue Value Group,,32.90,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,BCBS NC,Blue Value Group,,128.89,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,BCBS NC,Blue Value Group,,5.81,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,BCBS NC,Blue Value Group,,13.19,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,BCBS NC,Blue Value Group,,0.38812,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,BCBS NC,Blue Value Group,,0.02070,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,BCBS NC,Blue Value Group,,7.90,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,BCBS NC,Blue Value Group,,6.91,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,BCBS NC,Blue Value Group,,6.15,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,BCBS NC,Blue Value Group,,9.15,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,BCBS NC,Blue Value Group,,17.26,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,BCBS NC,Blue Value Group,,28.44,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,BCBS NC,Blue Value Group,,72.01,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,BCBS NC,Blue Value Group,,283.95,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,BCBS NC,Blue Value Group,,163.66,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,BCBS NC,Blue Value Group,,192.12,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Value Group,,42.93,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Value Group,,33.59,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Value Group,,33.59,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,BCBS NC,Blue Value Group,,24.81,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Value Group,,0.62688,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Value Group,,1516.15,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Value Group,,10066.33,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Group,,8.65,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Group,,10.34,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Group,,9.56,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Group,,10.45,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Value Group,,11.15,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,BCBS NC,Blue Value Group,,66.47,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Value Group,,43.52,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,BCBS NC,Blue Value Group,,183.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,BCBS NC,Blue Value Group,,201.41,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Value Group,,10.13,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,BCBS NC,Blue Value Group,,1834.02,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,BCBS NC,Blue Value Group,,157.45,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,BCBS NC,Blue Value Group,,22.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Group,,8.49,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Group,,8.46,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,BCBS NC,Blue Value Group,,1249.40,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Value Group,,9.43,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,BCBS NC,Blue Value Group,,244.03,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Group,,9.04,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Group,,8.80,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Group,,8.65,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,BCBS NC,Blue Value Group,,2701.56,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Group,,8.80,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,BCBS NC,Blue Value Group,,41.35,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,BCBS NC,Blue Value Group,,17.41,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,BCBS NC,Blue Value Group,,18.03,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,BCBS NC,Blue Value Group,,24.32,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,BCBS NC,Blue Value Group,,10.27,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,BCBS NC,Blue Value Group,,13.04,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,BCBS NC,Blue Value Group,,41.95,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,BCBS NC,Blue Value Group,,16.93,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Value Group,,12.43,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Value Group,,14.99,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,BCBS NC,Blue Value Group,,1.18,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,BCBS NC,Blue Value Group,,225.99,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,BCBS NC,Blue Value Group,,387.19,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,BCBS NC,Blue Value Group,,1193.45,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Group,,113.33,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Group,,113.33,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Group,,113.33,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Value Group,,0.78360,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,BCBS NC,Blue Value Group,,25.83,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,BCBS NC,Blue Value Group,,30.06,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,BCBS NC,Blue Value Group,,294.20,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,BCBS NC,Blue Value Group,,11.39,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,BCBS NC,Blue Value Group,,14.63,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,BCBS NC,Blue Value Group,,12.88,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Group,,9.32,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,BCBS NC,Blue Value Group,,3.66,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Group,,9.56,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,BCBS NC,Blue Value Group,,1.36,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Value Group,,9.43,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Value Group,,9.61,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,BCBS NC,Blue Value Group,,13.84,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,BCBS NC,Blue Value Group,,15.99,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,BCBS NC,Blue Value Group,,12.32,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,BCBS NC,Blue Value Group,,24.61,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,BCBS NC,Blue Value Group,,15.19,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Value Group,,16.74,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,BCBS NC,Blue Value Group,,1418.65,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,BCBS NC,Blue Value Group,,9.19,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Value Group,,8.67,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,BCBS NC,Blue Value Group,,8.80,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,BCBS NC,Blue Value Group,,11.05,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,BCBS NC,Blue Value Group,,21.31,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,BCBS NC,Blue Value Group,,961.01,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Value Group,,8.44,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Value Group,,9.06,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Value Group,,9.27,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,BCBS NC,Blue Value Group,,17.11,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,BCBS NC,Blue Value Group,,128.98,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,BCBS NC,Blue Value Group,,0.86196,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Value Group,,12.01,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,BCBS NC,Blue Value Group,,11.77,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,BCBS NC,Blue Value Group,,10516.76,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,BCBS NC,Blue Value Group,,16.72,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Group,,0.75748,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,BCBS NC,Blue Value Group,,82.46,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,BCBS NC,Blue Value Group,,155.72,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Value Group,,1280.81,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,BCBS NC,Blue Value Group,,36.38,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,BCBS NC,Blue Value Group,,43.88,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Value Group,,19.69,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Value Group,,24.08,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,BCBS NC,Blue Value Group,,199.24,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,BCBS NC,Blue Value Group,,400.73,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Group,,8.46,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,BCBS NC,Blue Value Group,,26.56,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,BCBS NC,Blue Value Group,,35.97,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,BCBS NC,Blue Value Group,,34.49,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,BCBS NC,Blue Value Group,,37.39,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,BCBS NC,Blue Value Group,,20.52,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,BCBS NC,Blue Value Group,,14.57,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,BCBS NC,Blue Value Group,,31483.20,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Value Group,,416.90,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,BCBS NC,Blue Value Group,,81.95,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Value Group,,120.75,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,BCBS NC,Blue Value Group,,269.23,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Value Group,,10.24,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Value Group,,14.10,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,BCBS NC,Blue Value Group,,14.86,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,BCBS NC,Blue Value Group,,25.82,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,BCBS NC,Blue Value Group,,31.67,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,BCBS NC,Blue Value Group,,43.39,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,BCBS NC,Blue Value Group,,55.09,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,BCBS NC,Blue Value Group,,66.78,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,BCBS NC,Blue Value Group,,36.66,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,BCBS NC,Blue Value Group,,39.75,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Value Group,,11.07,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Group,,10.34,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,BCBS NC,Blue Value Group,,639.32,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,BCBS NC,Blue Value Group,,1211.49,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,BCBS NC,Blue Value Group,,4.44,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,BCBS NC,Blue Value Group,,89.33,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Value Group,,22.10,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Group,,8.88,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,BCBS NC,Blue Value Group,,10.76,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,BCBS NC,Blue Value Group,,19.35,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,BCBS NC,Blue Value Group,,19.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,BCBS NC,Blue Value Group,,36.59,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,BCBS NC,Blue Value Group,,63.65,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,BCBS NC,Blue Value Group,,1581.35,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Value Group,,3020.36,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,BCBS NC,Blue Value Group,,696.24,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,BCBS NC,Blue Value Group,,11.13,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Value Group,,33.40,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,BCBS NC,Blue Value Group,,18.42,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,BCBS NC,Blue Value Group,,17.42,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,BCBS NC,Blue Value Group,,17.79,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Value Group,,15.28,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Value Group,,15.28,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,BCBS NC,Blue Value Group,,1252.71,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,BCBS NC,Blue Value Group,,3352.88,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,BCBS NC,Blue Value Group,,86.94,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,BCBS NC,Blue Value Group,,14.39,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,BCBS NC,Blue Value Group,,33.28,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Value Group,,0.78360,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Group,,0.75748,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,BCBS NC,Blue Value Group,,14.37,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,BCBS NC,Blue Value Group,,16.43,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,BCBS NC,Blue Value Group,,82.23,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Value Group,,12.25,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,BCBS NC,Blue Value Group,,53.78,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,BCBS NC,Blue Value Group,,305.63,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,BCBS NC,Blue Value Group,,94.50,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,BCBS NC,Blue Value Group,,135.98,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Value Group,,107.20,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Group,,592.20,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Value Group,,9.51,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,BCBS NC,Blue Value Group,,52.74,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,BCBS NC,Blue Value Group,,93.25,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,BCBS NC,Blue Value Group,,274.50,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,BCBS NC,Blue Value Group,,0.80972,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,BCBS NC,Blue Value Group,,52.35,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,BCBS NC,Blue Value Group,,136.21,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,BCBS NC,Blue Value Group,,136.21,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,BCBS NC,Blue Value Group,,456.18,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,BCBS NC,Blue Value Group,,30.56,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,BCBS NC,Blue Value Group,,463.91,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,BCBS NC,Blue Value Group,,737.28,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,BCBS NC,Blue Value Group,,1101.78,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,BCBS NC,Blue Value Group,,1830.76,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,BCBS NC,Blue Value Group,,3653.24,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,BCBS NC,Blue Value Group,,5475.72,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,BCBS NC,Blue Value Group,,877.24,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,BCBS NC,Blue Value Group,,4267.46,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,BCBS NC,Blue Value Group,,16642.83,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Value Group,,2918.83,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Value Group,,5805.03,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Value Group,,165.00,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Blue Value Group,,165.00,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,BCBS NC,Blue Value Group,,4557.54,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,BCBS NC,Blue Value Group,,8.52,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,BCBS NC,Blue Value Group,,43.11,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,BCBS NC,Blue Value Group,,52.45,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,BCBS NC,Blue Value Group,,79.67,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,12.02,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,BCBS NC,Blue Value Group,,12.20,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,BCBS NC,Blue Value Group,,9.68,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,BCBS NC,Blue Value Group,,60.55,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,BCBS NC,Blue Value Group,,73.46,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Group,,9.04,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,BCBS NC,Blue Value Group,,457.83,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Group,,0.73136,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Value Group,,20759.98,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Value Group,,82612.72,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,BCBS NC,Blue Value Group,,510.00,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,BCBS NC,Blue Value Group,,1.04,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,BCBS NC,Blue Value Group,,0.91420,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,BCBS NC,Blue Value Group,,0.88808,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,BCBS NC,Blue Value Group,,0.83584,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,BCBS NC,Blue Value Group,,52.09,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,BCBS NC,Blue Value Group,,100.29,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,BCBS NC,Blue Value Group,,6862.39,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,BCBS NC,Blue Value Group,,55.37,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,BCBS NC,Blue Value Group,,7.18,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,BCBS NC,Blue Value Group,,40.22,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,BCBS NC,Blue Value Group,,1161.97,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,BCBS NC,Blue Value Group,,44.95,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,BCBS NC,Blue Value Group,,367.37,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,BCBS NC,Blue Value Group,,111.69,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,BCBS NC,Blue Value Group,,31.36,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Value Group,,50.02,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,BCBS NC,Blue Value Group,,95.45,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,BCBS NC,Blue Value Group,,116.28,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,BCBS NC,Blue Value Group,,31.47,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,BCBS NC,Blue Value Group,,552.18,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Group,,0.75748,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Value Group,,24.55,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Value Group,,0.62688,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,BCBS NC,Blue Value Group,,1.62,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,BCBS NC,Blue Value Group,,41.87,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Value Group,,40.03,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,BCBS NC,Blue Value Group,,39.49,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,BCBS NC,Blue Value Group,,40.03,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Value Group,,52.53,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,BCBS NC,Blue Value Group,,54.34,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,BCBS NC,Blue Value Group,,246.36,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Group,,9.56,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,BCBS NC,Blue Value Group,,147.19,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Group,,10.08,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,BCBS NC,Blue Value Group,,29005.12,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Value Group,,28.73,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,BCBS NC,Blue Value Group,,2310.43,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Value Group,,28.73,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,BCBS NC,Blue Value Group,,36.54,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,BCBS NC,Blue Value Group,,13.95,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,BCBS NC,Blue Value Group,,0.78360,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,BCBS NC,Blue Value Group,,16.40,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Group,,10.08,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,BCBS NC,Blue Value Group,,35.39,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,BCBS NC,Blue Value Group,,15.57,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,BCBS NC,Blue Value Group,,576.44,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,BCBS NC,Blue Value Group,,947.02,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,BCBS NC,Blue Value Group,,163.58,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,BCBS NC,Blue Value Group,,245.45,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Value Group,,50.02,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,BCBS NC,Blue Value Group,,50.02,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,BCBS NC,Blue Value Group,,367.55,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,BCBS NC,Blue Value Group,,15.02,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Value Group,,12.25,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,BCBS NC,Blue Value Group,,295.16,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,BCBS NC,Blue Value Group,,626.02,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Value Group,,48.58,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,BCBS NC,Blue Value Group,,2.14,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,BCBS NC,Blue Value Group,,294.35,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,BCBS NC,Blue Value Group,,57.96,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,BCBS NC,Blue Value Group,,86.94,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Group,,8.85,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Group,,9.22,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,BCBS NC,Blue Value Group,,107.20,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,BCBS NC,Blue Value Group,,315.49,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Value Group,,33.12,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,BCBS NC,Blue Value Group,,82.46,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Value Group,,45.45,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,BCBS NC,Blue Value Group,,142.62,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,BCBS NC,Blue Value Group,,2.25,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,BCBS NC,Blue Value Group,,11.02,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.19,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Group,,8.80,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Value Group,,15.02,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,BCBS NC,Blue Value Group,,15.02,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Group,,9.04,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Value Group,,15.67,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Value Group,,17.70,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,BCBS NC,Blue Value Group,,64.52,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,BCBS NC,Blue Value Group,,65.25,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,BCBS NC,Blue Value Group,,25.52,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,BCBS NC,Blue Value Group,,32.36,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,BCBS NC,Blue Value Group,,16.48,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Value Group,,40.51,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,BCBS NC,Blue Value Group,,196.65,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,BCBS NC,Blue Value Group,,475.54,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,BCBS NC,Blue Value Group,,87.63,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,BCBS NC,Blue Value Group,,167.27,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Value Group,,46.08,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,BCBS NC,Blue Value Group,,315.56,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,BCBS NC,Blue Value Group,,13146.85,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,BCBS NC,Blue Value Group,,959.76,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,BCBS NC,Blue Value Group,,10.97,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,BCBS NC,Blue Value Group,,497.76,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,BCBS NC,Blue Value Group,,13.03,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Value Group,,44.22,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,BCBS NC,Blue Value Group,,18.66,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Group,,9.04,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,BCBS NC,Blue Value Group,,862.59,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,BCBS NC,Blue Value Group,,15672.59,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Group,,9.14,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,BCBS NC,Blue Value Group,,16.53,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,BCBS NC,Blue Value Group,,27.87,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,BCBS NC,Blue Value Group,,19.88,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,BCBS NC,Blue Value Group,,9.32,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,BCBS NC,Blue Value Group,,25.13,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,BCBS NC,Blue Value Group,,37.29,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,BCBS NC,Blue Value Group,,40.43,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,BCBS NC,Blue Value Group,,96.07,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,BCBS NC,Blue Value Group,,10.71,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Value Group,,11.68,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Value Group,,11.65,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,BCBS NC,Blue Value Group,,165.88,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,BCBS NC,Blue Value Group,,226.66,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Value Group,,8196.50,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Value Group,,56.13,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,BCBS NC,Blue Value Group,,1077.97,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,BCBS NC,Blue Value Group,,1434.51,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Group,,13.64,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,BCBS NC,Blue Value Group,,102.49,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,BCBS NC,Blue Value Group,,9.46,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,BCBS NC,Blue Value Group,,1.41,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Value Group,,31.05,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,BCBS NC,Blue Value Group,,16.66,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,BCBS NC,Blue Value Group,,11.54,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,BCBS NC,Blue Value Group,,45.31,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,BCBS NC,Blue Value Group,,60.18,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,BCBS NC,Blue Value Group,,0.67912,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,BCBS NC,Blue Value Group,,25.96,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,BCBS NC,Blue Value Group,,18.86,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,BCBS NC,Blue Value Group,,76.56,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Value Group,,0.80972,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Value Group,,0.91420,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,BCBS NC,Blue Value Group,,8.54,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,BCBS NC,Blue Value Group,,108.16,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,BCBS NC,Blue Value Group,,11.83,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Value Group,,12.85,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,BCBS NC,Blue Value Group,,16.61,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Group,,9.04,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,BCBS NC,Blue Value Group,,287.89,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,BCBS NC,Blue Value Group,,13.87,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,BCBS NC,Blue Value Group,,12.39,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,BCBS NC,Blue Value Group,,15.24,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,BCBS NC,Blue Value Group,,22.30,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,BCBS NC,Blue Value Group,,27.66,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,BCBS NC,Blue Value Group,,31.79,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,BCBS NC,Blue Value Group,,92.37,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,BCBS NC,Blue Value Group,,265.43,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,BCBS NC,Blue Value Group,,27.48,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,BCBS NC,Blue Value Group,,12.78,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Value Group,,15.42,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,BCBS NC,Blue Value Group,,32.00,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,BCBS NC,Blue Value Group,,14.57,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,BCBS NC,Blue Value Group,,88.08,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Value Group,,184.88,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Value Group,,598.26,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,BCBS NC,Blue Value Group,,4.49,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,BCBS NC,Blue Value Group,,8.65,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Group,,8.52,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,BCBS NC,Blue Value Group,,61200.43,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,BCBS NC,Blue Value Group,,65.54,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,BCBS NC,Blue Value Group,,392.24,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,BCBS NC,Blue Value Group,,5.22,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,BCBS NC,Blue Value Group,,7.81,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,BCBS NC,Blue Value Group,,39.67,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,BCBS NC,Blue Value Group,,43.88,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,BCBS NC,Blue Value Group,,2.79,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,BCBS NC,Blue Value Group,,8.99,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,BCBS NC,Blue Value Group,,20.78,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,BCBS NC,Blue Value Group,,23.13,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,BCBS NC,Blue Value Group,,18.84,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Value Group,,44.35,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,BCBS NC,Blue Value Group,,44.27,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,BCBS NC,Blue Value Group,,44.35,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,BCBS NC,Blue Value Group,,43.33,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,BCBS NC,Blue Value Group,,544.59,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,BCBS NC,Blue Value Group,,2815.71,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,BCBS NC,Blue Value Group,,1882.04,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,BCBS NC,Blue Value Group,,17.13,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,BCBS NC,Blue Value Group,,8158.39,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,BCBS NC,Blue Value Group,,1.51,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,BCBS NC,Blue Value Group,,10.89,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,BCBS NC,Blue Value Group,,222.94,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,BCBS NC,Blue Value Group,,122.39,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,BCBS NC,Blue Value Group,,33.59,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,BCBS NC,Blue Value Group,,55.89,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,BCBS NC,Blue Value Group,,6.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,BCBS NC,Blue Value Group,,74.65,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,BCBS NC,Blue Value Group,,151.39,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,BCBS NC,Blue Value Group,,1383.64,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Value Group,,45.28,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,BCBS NC,Blue Value Group,,5.09,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,BCBS NC,Blue Value Group,,1726.59,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,BCBS NC,Blue Value Group,,12.35,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,BCBS NC,Blue Value Group,,16.14,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Value Group,,177.40,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,BCBS NC,Blue Value Group,,423.42,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,BCBS NC,Blue Value Group,,165.44,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,BCBS NC,Blue Value Group,,514.51,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Group,,13.11,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,BCBS NC,Blue Value Group,,704.19,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,BCBS NC,Blue Value Group,,45.28,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,BCBS NC,Blue Value Group,,113.54,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,BCBS NC,Blue Value Group,,19.87,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,BCBS NC,Blue Value Group,,20.48,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,BCBS NC,Blue Value Group,,3233.24,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Value Group,,9.82,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Value Group,,10.87,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,BCBS NC,Blue Value Group,,4965.10,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,BCBS NC,Blue Value Group,,2.01,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,BCBS NC,Blue Value Group,,30.17,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Value Group,,23.52,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Value Group,,32.84,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,BCBS NC,Blue Value Group,,135.59,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,BCBS NC,Blue Value Group,,182.42,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,BCBS NC,Blue Value Group,,5.67,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,BCBS NC,Blue Value Group,,155.99,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,BCBS NC,Blue Value Group,,0.86196,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,BCBS NC,Blue Value Group,,0.73136,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,BCBS NC,Blue Value Group,,0.83584,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,BCBS NC,Blue Value Group,,23.96,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,BCBS NC,Blue Value Group,,113.15,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,BCBS NC,Blue Value Group,,93.72,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,BCBS NC,Blue Value Group,,51.65,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Value Group,,0.67912,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,BCBS NC,Blue Value Group,,80.70,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Value Group,,21.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Value Group,,11.38,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,BCBS NC,Blue Value Group,,33.51,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,BCBS NC,Blue Value Group,,6197.68,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,BCBS NC,Blue Value Group,,30.12,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,BCBS NC,Blue Value Group,,17.70,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,BCBS NC,Blue Value Group,,41.66,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,BCBS NC,Blue Value Group,,12.24,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,BCBS NC,Blue Value Group,,5029.48,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,BCBS NC,Blue Value Group,,129.32,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,BCBS NC,Blue Value Group,,0.67912,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,BCBS NC,Blue Value Group,,3.84,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,BCBS NC,Blue Value Group,,71.34,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,BCBS NC,Blue Value Group,,9.66,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,BCBS NC,Blue Value Group,,42.18,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,BCBS NC,Blue Value Group,,44.93,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,BCBS NC,Blue Value Group,,94.03,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,BCBS NC,Blue Value Group,,50.75,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Blue Value Group,,10066.33,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,BCBS NC,Blue Value Group,,83.09,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,BCBS NC,Blue Value Group,,48.57,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,BCBS NC,Blue Value Group,,36.46,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Value Group,,38.48,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,BCBS NC,Blue Value Group,,38.48,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,BCBS NC,Blue Value Group,,43.50,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.19,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,BCBS NC,Blue Value Group,,6.16,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,BCBS NC,Blue Value Group,,9.43,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Group,,9.22,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Value Group,,12.59,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,BCBS NC,Blue Value Group,,5.77,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,BCBS NC,Blue Value Group,,4243.45,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Value Group,,10.53,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Value Group,,8.75,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,BCBS NC,Blue Value Group,,32.23,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,BCBS NC,Blue Value Group,,195.12,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,BCBS NC,Blue Value Group,,199.24,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,BCBS NC,Blue Value Group,,100.59,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,BCBS NC,Blue Value Group,,36.41,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,BCBS NC,Blue Value Group,,34.31,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,BCBS NC,Blue Value Group,,47.54,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Value Group,,8.75,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,BCBS NC,Blue Value Group,,8.75,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Value Group,,11.62,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,BCBS NC,Blue Value Group,,15.16,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Value Group,,9.48,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Value Group,,8.54,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,BCBS NC,Blue Value Group,,58.43,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,BCBS NC,Blue Value Group,,68.39,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Group,,0.73136,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,BCBS NC,Blue Value Group,,46.65,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,BCBS NC,Blue Value Group,,77.65,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,BCBS NC,Blue Value Group,,23.27,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,BCBS NC,Blue Value Group,,54.49,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,BCBS NC,Blue Value Group,,10.58,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Group,,9.24,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,BCBS NC,Blue Value Group,,180.75,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,BCBS NC,Blue Value Group,,654.07,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,BCBS NC,Blue Value Group,,12.04,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,BCBS NC,Blue Value Group,,234.32,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,BCBS NC,Blue Value Group,,469.79,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,BCBS NC,Blue Value Group,,0.91420,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,BCBS NC,Blue Value Group,,0.88808,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,BCBS NC,Blue Value Group,,4.65,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,12.02,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Group,,9.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,BCBS NC,Blue Value Group,,125.72,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Group,,8.49,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Group,,8.65,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,BCBS NC,Blue Value Group,,49.39,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,BCBS NC,Blue Value Group,,14.65,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,BCBS NC,Blue Value Group,,69.73,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Value Group,,73.36,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,BCBS NC,Blue Value Group,,22.86,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,BCBS NC,Blue Value Group,,182.13,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,12.02,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,BCBS NC,Blue Value Group,,10.84,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,BCBS NC,Blue Value Group,,9.70,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,BCBS NC,Blue Value Group,,73.36,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,BCBS NC,Blue Value Group,,85.13,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,BCBS NC,Blue Value Group,,91.42,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,BCBS NC,Blue Value Group,,1.67,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Value Group,,52.53,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,BCBS NC,Blue Value Group,,64.78,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,BCBS NC,Blue Value Group,,64.78,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,BCBS NC,Blue Value Group,,47.45,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,BCBS NC,Blue Value Group,,41.64,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,BCBS NC,Blue Value Group,,246.05,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Value Group,,13.69,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Value Group,,12.12,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,BCBS NC,Blue Value Group,,12.28,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Value Group,,11.75,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Value Group,,11.81,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,BCBS NC,Blue Value Group,,7183.50,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,BCBS NC,Blue Value Group,,158.71,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,BCBS NC,Blue Value Group,,2.22,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Value Group,,29.49,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,BCBS NC,Blue Value Group,,29.49,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,BCBS NC,Blue Value Group,,2103.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,BCBS NC,Blue Value Group,,58.50,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,BCBS NC,Blue Value Group,,60.99,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,BCBS NC,Blue Value Group,,9226.71,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,BCBS NC,Blue Value Group,,14677.33,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Value Group,,33.82,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,BCBS NC,Blue Value Group,,3.21,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,BCBS NC,Blue Value Group,,76.31,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,BCBS NC,Blue Value Group,,13.09,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,BCBS NC,Blue Value Group,,21.68,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,BCBS NC,Blue Value Group,,12.38,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Value Group,,10.03,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,BCBS NC,Blue Value Group,,83.58,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Value Group,,141.28,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Value Group,,254.25,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,BCBS NC,Blue Value Group,,50.66,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,BCBS NC,Blue Value Group,,49.24,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,BCBS NC,Blue Value Group,,2368.08,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,BCBS NC,Blue Value Group,,79.93,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,BCBS NC,Blue Value Group,,12.56,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,BCBS NC,Blue Value Group,,2.51,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,BCBS NC,Blue Value Group,,170.33,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Value Group,,44.20,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,BCBS NC,Blue Value Group,,44.20,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Value Group,,335.98,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,BCBS NC,Blue Value Group,,335.98,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Group,,8.99,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,BCBS NC,Blue Value Group,,284.60,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Value Group,,13.51,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,BCBS NC,Blue Value Group,,11.57,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,BCBS NC,Blue Value Group,,0.96644,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,BCBS NC,Blue Value Group,,43.93,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,BCBS NC,Blue Value Group,,167.85,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,BCBS NC,Blue Value Group,,255.39,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,BCBS NC,Blue Value Group,,10.68,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,BCBS NC,Blue Value Group,,186.58,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,BCBS NC,Blue Value Group,,275.67,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Value Group,,52.21,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,BCBS NC,Blue Value Group,,52.21,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,BCBS NC,Blue Value Group,,192.58,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,BCBS NC,Blue Value Group,,3308.07,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,BCBS NC,Blue Value Group,,14.70,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,BCBS NC,Blue Value Group,,3559.62,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,BCBS NC,Blue Value Group,,17228.82,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Value Group,,11.86,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,BCBS NC,Blue Value Group,,28.46,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,BCBS NC,Blue Value Group,,41.40,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,BCBS NC,Blue Value Group,,0.88808,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Value Group,,46.03,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,BCBS NC,Blue Value Group,,20376.38,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,BCBS NC,Blue Value Group,,4197.47,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Value Group,,46.03,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,BCBS NC,Blue Value Group,,199.22,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Value Group,,39.12,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Value Group,,45.44,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,BCBS NC,Blue Value Group,,1083.28,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,BCBS NC,Blue Value Group,,7304.90,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Group,,9.30,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,BCBS NC,Blue Value Group,,239.21,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,BCBS NC,Blue Value Group,,566.66,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,BCBS NC,Blue Value Group,,129.29,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Group,,8.57,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,BCBS NC,Blue Value Group,,30.30,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Value Group,,20.05,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,BCBS NC,Blue Value Group,,20.05,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,BCBS NC,Blue Value Group,,125.98,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,BCBS NC,Blue Value Group,,160.85,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,BCBS NC,Blue Value Group,,212.51,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Group,,12795.08,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,BCBS NC,Blue Value Group,,418.84,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,BCBS NC,Blue Value Group,,3156.72,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,BCBS NC,Blue Value Group,,7678.28,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Group,,8.46,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Group,,8.49,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,BCBS NC,Blue Value Group,,378.37,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,BCBS NC,Blue Value Group,,20.63,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,BCBS NC,Blue Value Group,,24.92,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,BCBS NC,Blue Value Group,,28.50,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,BCBS NC,Blue Value Group,,40.59,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Value Group,,15120.26,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,BCBS NC,Blue Value Group,,13571.44,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,BCBS NC,Blue Value Group,,13.06,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Value Group,,38.76,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,BCBS NC,Blue Value Group,,38.76,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,BCBS NC,Blue Value Group,,57.10,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,BCBS NC,Blue Value Group,,929.87,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Value Group,,30.17,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,BCBS NC,Blue Value Group,,30.17,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,BCBS NC,Blue Value Group,,10877.95,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,BCBS NC,Blue Value Group,,16284.77,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,BCBS NC,Blue Value Group,,8304.66,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,BCBS NC,Blue Value Group,,935.41,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,BCBS NC,Blue Value Group,,1939.05,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,BCBS NC,Blue Value Group,,4.23,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Value Group,,48.90,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,BCBS NC,Blue Value Group,,254.25,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,BCBS NC,Blue Value Group,,2025.60,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,BCBS NC,Blue Value Group,,43512.95,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,BCBS NC,Blue Value Group,,1023.93,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,BCBS NC,Blue Value Group,,255.23,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,BCBS NC,Blue Value Group,,2395.71,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,BCBS NC,Blue Value Group,,4751.58,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,BCBS NC,Blue Value Group,,2365.75,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Value Group,,32.94,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Value Group,,32.94,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,BCBS NC,Blue Value Group,,32.94,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,BCBS NC,Blue Value Group,,1041.93,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,BCBS NC,Blue Value Group,,654.30,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Value Group,,22.93,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,BCBS NC,Blue Value Group,,66.86,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,BCBS NC,Blue Value Group,,24.55,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,BCBS NC,Blue Value Group,,43.99,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Value Group,,39.33,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Value Group,,45.54,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,BCBS NC,Blue Value Group,,5577.64,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,BCBS NC,Blue Value Group,,6925.50,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Value Group,,23.30,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,BCBS NC,Blue Value Group,,23.30,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,BCBS NC,Blue Value Group,,30.04,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,BCBS NC,Blue Value Group,,8491.58,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Value Group,,302.03,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,BCBS NC,Blue Value Group,,51.06,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,BCBS NC,Blue Value Group,,76.95,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,BCBS NC,Blue Value Group,,31.08,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,BCBS NC,Blue Value Group,,5775.17,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,BCBS NC,Blue Value Group,,542.90,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,BCBS NC,Blue Value Group,,331.96,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,BCBS NC,Blue Value Group,,8.59,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,BCBS NC,Blue Value Group,,114.17,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,BCBS NC,Blue Value Group,,10.00,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,BCBS NC,Blue Value Group,,454.00,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,BCBS NC,Blue Value Group,,10.24,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,BCBS NC,Blue Value Group,,2089.35,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,BCBS NC,Blue Value Group,,857.42,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,BCBS NC,Blue Value Group,,160.24,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,BCBS NC,Blue Value Group,,7058.09,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,BCBS NC,Blue Value Group,,40.25,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,BCBS NC,Blue Value Group,,149.09,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,BCBS NC,Blue Value Group,,285.02,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,BCBS NC,Blue Value Group,,2404.93,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,BCBS NC,Blue Value Group,,110.44,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,BCBS NC,Blue Value Group,,49.97,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Value Group,,77.39,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Value Group,,26531.29,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Value Group,,11.49,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,BCBS NC,Blue Value Group,,705.32,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,BCBS NC,Blue Value Group,,63.39,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,BCBS NC,Blue Value Group,,1435.14,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,BCBS NC,Blue Value Group,,31.75,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,BCBS NC,Blue Value Group,,560.19,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,BCBS NC,Blue Value Group,,32.02,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,BCBS NC,Blue Value Group,,8291.90,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Value Group,,21.30,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,BCBS NC,Blue Value Group,,99.18,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Value Group,,34.28,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,BCBS NC,Blue Value Group,,190.08,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,BCBS NC,Blue Value Group,,29.76,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,BCBS NC,Blue Value Group,,17.72,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,BCBS NC,Blue Value Group,,20.65,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,BCBS NC,Blue Value Group,,46511.50,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,BCBS NC,Blue Value Group,,4910.40,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,BCBS NC,Blue Value Group,,44895.74,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,BCBS NC,Blue Value Group,,23.40,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,BCBS NC,Blue Value Group,,3690.86,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,BCBS NC,Blue Value Group,,468.44,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,BCBS NC,Blue Value Group,,9921.28,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,BCBS NC,Blue Value Group,,2489.28,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,BCBS NC,Blue Value Group,,15117.21,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,BCBS NC,Blue Value Group,,3.47,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,BCBS NC,Blue Value Group,,37.48,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,BCBS NC,Blue Value Group,,17256.45,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,BCBS NC,Blue Value Group,,37.25,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,BCBS NC,Blue Value Group,,35.89,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,BCBS NC,Blue Value Group,,685.78,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,BCBS NC,Blue Value Group,,2356.76,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,BCBS NC,Blue Value Group,,24.97,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,BCBS NC,Blue Value Group,,25143.77,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,BCBS NC,Blue Value Group,,54598.94,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Value Group,,9.12,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,BCBS NC,Blue Value Group,,68.75,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Value Group,,49.78,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,BCBS NC,Blue Value Group,,49.78,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Value Group,,46.73,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Group,,8.80,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.72,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Value Group,,14.55,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Group,,9.25,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,BCBS NC,Blue Value Group,,103.24,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,BCBS NC,Blue Value Group,,516.21,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,BCBS NC,Blue Value Group,,34.53,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,BCBS NC,Blue Value Group,,345.97,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,BCBS NC,Blue Value Group,,2.46,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,BCBS NC,Blue Value Group,,9.52,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,BCBS NC,Blue Value Group,,1020.64,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,BCBS NC,Blue Value Group,,13775.90,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,BCBS NC,Blue Value Group,,3048.41,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Value Group,,9.98,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,BCBS NC,Blue Value Group,,18228.73,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,BCBS NC,Blue Value Group,,41.43,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,BCBS NC,Blue Value Group,,126.39,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,BCBS NC,Blue Value Group,,203.47,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Group,,13.64,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,BCBS NC,Blue Value Group,,30.25,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,BCBS NC,Blue Value Group,,201.12,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,BCBS NC,Blue Value Group,,60.24,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,BCBS NC,Blue Value Group,,86.22,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,BCBS NC,Blue Value Group,,112.17,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,BCBS NC,Blue Value Group,,268.01,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,BCBS NC,Blue Value Group,,1047.16,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,BCBS NC,Blue Value Group,,4923.57,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,BCBS NC,Blue Value Group,,274.26,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Value Group,,68.38,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,BCBS NC,Blue Value Group,,68.38,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,BCBS NC,Blue Value Group,,253.19,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,BCBS NC,Blue Value Group,,11031.83,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,BCBS NC,Blue Value Group,,523.94,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,BCBS NC,Blue Value Group,,833.36,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,BCBS NC,Blue Value Group,,178.41,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Group,,8.65,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,BCBS NC,Blue Value Group,,29.20,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,BCBS NC,Blue Value Group,,2688.27,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,BCBS NC,Blue Value Group,,25018.46,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Value Group,,9838.84,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,BCBS NC,Blue Value Group,,25.13,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,BCBS NC,Blue Value Group,,2373.39,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Value Group,,5214.85,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Value Group,,523.94,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,BCBS NC,Blue Value Group,,18663.17,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,BCBS NC,Blue Value Group,,1515.24,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Value Group,,18614.63,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,BCBS NC,Blue Value Group,,10787.86,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,BCBS NC,Blue Value Group,,106.05,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,BCBS NC,Blue Value Group,,149.93,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,BCBS NC,Blue Value Group,,217.12,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,BCBS NC,Blue Value Group,,930.39,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,BCBS NC,Blue Value Group,,42520.52,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,BCBS NC,Blue Value Group,,6497.19,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,BCBS NC,Blue Value Group,,1731.06,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,BCBS NC,Blue Value Group,,104.15,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,BCBS NC,Blue Value Group,,25.08,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,BCBS NC,Blue Value Group,,12.46,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Group,,9.30,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,BCBS NC,Blue Value Group,,2067.65,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,BCBS NC,Blue Value Group,,9768.90,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,BCBS NC,Blue Value Group,,8972.52,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,BCBS NC,Blue Value Group,,26852.25,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,BCBS NC,Blue Value Group,,5364.07,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,BCBS NC,Blue Value Group,,3249.51,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,BCBS NC,Blue Value Group,,55.98,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,BCBS NC,Blue Value Group,,6538.41,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Group,,9736.45,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,BCBS NC,Blue Value Group,,7170.22,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,BCBS NC,Blue Value Group,,5729.16,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,BCBS NC,Blue Value Group,,1539.05,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,BCBS NC,Blue Value Group,,1774.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,BCBS NC,Blue Value Group,,8303.08,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,BCBS NC,Blue Value Group,,39196.80,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,BCBS NC,Blue Value Group,,7863.83,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Value Group,,74.99,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,BCBS NC,Blue Value Group,,74.99,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,BCBS NC,Blue Value Group,,14.94,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,BCBS NC,Blue Value Group,,4249.35,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,BCBS NC,Blue Value Group,,10046.36,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,BCBS NC,Blue Value Group,,2123.12,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,BCBS NC,Blue Value Group,,77.89,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,BCBS NC,Blue Value Group,,5979.40,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,BCBS NC,Blue Value Group,,56942.08,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,BCBS NC,Blue Value Group,,1119.35,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Group,,8.88,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,BCBS NC,Blue Value Group,,22.33,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,BCBS NC,Blue Value Group,,92.07,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Value Group,,9.35,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,BCBS NC,Blue Value Group,,31830.29,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,BCBS NC,Blue Value Group,,21266.79,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,BCBS NC,Blue Value Group,,33.97,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,BCBS NC,Blue Value Group,,45.54,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,BCBS NC,Blue Value Group,,3320.72,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,BCBS NC,Blue Value Group,,9223.38,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,BCBS NC,Blue Value Group,,52090.02,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,BCBS NC,Blue Value Group,,14230.09,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,BCBS NC,Blue Value Group,,527.72,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,BCBS NC,Blue Value Group,,3489.76,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,BCBS NC,Blue Value Group,,2900.02,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,BCBS NC,Blue Value Group,,4769.64,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,BCBS NC,Blue Value Group,,64630.91,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,BCBS NC,Blue Value Group,,27535.24,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,BCBS NC,Blue Value Group,,10593.74,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,BCBS NC,Blue Value Group,,8810.13,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Group,,9.14,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Group,,8.88,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,BCBS NC,Blue Value Group,,42.45,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,BCBS NC,Blue Value Group,,449.91,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,BCBS NC,Blue Value Group,,16993.95,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,BCBS NC,Blue Value Group,,55.61,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,BCBS NC,Blue Value Group,,215.93,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,BCBS NC,Blue Value Group,,8456.05,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,BCBS NC,Blue Value Group,,18854.47,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,BCBS NC,Blue Value Group,,17.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Value Group,,141.28,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Value Group,,45.33,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Value Group,,42.82,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,BCBS NC,Blue Value Group,,42.82,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,BCBS NC,Blue Value Group,,382.67,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,BCBS NC,Blue Value Group,,607.31,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,BCBS NC,Blue Value Group,,35258.18,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,BCBS NC,Blue Value Group,,39.70,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Value Group,,1371.98,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Value Group,,593.45,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,BCBS NC,Blue Value Group,,593.45,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,BCBS NC,Blue Value Group,,1371.98,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.19,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,BCBS NC,Blue Value Group,,53.85,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,BCBS NC,Blue Value Group,,23931.40,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,BCBS NC,Blue Value Group,,4806.82,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,BCBS NC,Blue Value Group,,269.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,BCBS NC,Blue Value Group,,15585.75,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,BCBS NC,Blue Value Group,,1563.73,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,BCBS NC,Blue Value Group,,42785.19,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,BCBS NC,Blue Value Group,,33712.12,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,BCBS NC,Blue Value Group,,6193.18,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,BCBS NC,Blue Value Group,,12377.62,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,BCBS NC,Blue Value Group,,15470.17,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,BCBS NC,Blue Value Group,,35271.87,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,BCBS NC,Blue Value Group,,487.69,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,BCBS NC,Blue Value Group,,1317.76,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,BCBS NC,Blue Value Group,,1317.79,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,BCBS NC,Blue Value Group,,32.65,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Value Group,,26448.57,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,BCBS NC,Blue Value Group,,2115.31,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,BCBS NC,Blue Value Group,,770.96,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,BCBS NC,Blue Value Group,,108.87,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,BCBS NC,Blue Value Group,,52.24,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,BCBS NC,Blue Value Group,,132.22,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Value Group,,16.14,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,BCBS NC,Blue Value Group,,55.37,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,BCBS NC,Blue Value Group,,36.20,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,BCBS NC,Blue Value Group,,32855.30,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,BCBS NC,Blue Value Group,,121.30,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Blue Value Group,,9838.84,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,BCBS NC,Blue Value Group,,182.39,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,BCBS NC,Blue Value Group,,13834.35,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Group,,8.57,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,BCBS NC,Blue Value Group,,5688.93,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,BCBS NC,Blue Value Group,,22657.83,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,BCBS NC,Blue Value Group,,456.95,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,BCBS NC,Blue Value Group,,31692.76,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,BCBS NC,Blue Value Group,,3785.51,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,BCBS NC,Blue Value Group,,133.15,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,BCBS NC,Blue Value Group,,42.05,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,BCBS NC,Blue Value Group,,8.82,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,BCBS NC,Blue Value Group,,8.75,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,BCBS NC,Blue Value Group,,8.67,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,BCBS NC,Blue Value Group,,18228.73,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,BCBS NC,Blue Value Group,,11279.30,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,BCBS NC,Blue Value Group,,0.70524,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Value Group,,0.67912,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,BCBS NC,Blue Value Group,,188.60,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Group,,8.49,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Value Group,,19545.22,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,BCBS NC,Blue Value Group,,240.69,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Group,,8.49,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,BCBS NC,Blue Value Group,,25.65,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,BCBS NC,Blue Value Group,,46.57,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.72,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Group,,8.46,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,BCBS NC,Blue Value Group,,38.34,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,BCBS NC,Blue Value Group,,169.64,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,BCBS NC,Blue Value Group,,20.09,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,BCBS NC,Blue Value Group,,12.25,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,BCBS NC,Blue Value Group,,14.24,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,BCBS NC,Blue Value Group,,16.82,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,BCBS NC,Blue Value Group,,1.54,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,BCBS NC,Blue Value Group,,99.83,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,BCBS NC,Blue Value Group,,5.80,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,BCBS NC,Blue Value Group,,10.21,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Group,,8.49,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,BCBS NC,Blue Value Group,,48.77,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,12.02,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Group,,9.01,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,BCBS NC,Blue Value Group,,14.21,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.19,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,BCBS NC,Blue Value Group,,13.69,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Group,,9.56,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Group,,8.99,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Value Group,,9.35,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,BCBS NC,Blue Value Group,,47.12,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,BCBS NC,Blue Value Group,,724.47,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Group,,8.91,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Group,,9.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,BCBS NC,Blue Value Group,,2281.61,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,BCBS NC,Blue Value Group,,10838.75,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,BCBS NC,Blue Value Group,,35.50,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,BCBS NC,Blue Value Group,,3292.85,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,BCBS NC,Blue Value Group,,43.83,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Value Group,,9.77,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,BCBS NC,Blue Value Group,,103.33,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,BCBS NC,Blue Value Group,,24.08,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Value Group,,23.68,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,BCBS NC,Blue Value Group,,9.06,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Group,,10.34,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,BCBS NC,Blue Value Group,,2164.42,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,BCBS NC,Blue Value Group,,42.60,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,BCBS NC,Blue Value Group,,9.82,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,BCBS NC,Blue Value Group,,65.54,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,BCBS NC,Blue Value Group,,247.04,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,BCBS NC,Blue Value Group,,5.04,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Group,,10.66,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,BCBS NC,Blue Value Group,,575.98,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,BCBS NC,Blue Value Group,,33.12,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.64,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.11,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,BCBS NC,Blue Value Group,,10.38,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,BCBS NC,Blue Value Group,,12.89,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,BCBS NC,Blue Value Group,,92.83,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,BCBS NC,Blue Value Group,,6.19,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,BCBS NC,Blue Value Group,,45.45,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,BCBS NC,Blue Value Group,,42.71,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,BCBS NC,Blue Value Group,,55.64,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,BCBS NC,Blue Value Group,,57.31,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,BCBS NC,Blue Value Group,,338.57,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,BCBS NC,Blue Value Group,,37.14,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,BCBS NC,Blue Value Group,,37.46,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Group,,41.14,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,BCBS NC,Blue Value Group,,37.22,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Value Group,,39.96,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Value Group,,20.74,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,BCBS NC,Blue Value Group,,40.75,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,BCBS NC,Blue Value Group,,1065.02,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Group,,10.66,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Group,,10.66,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,BCBS NC,Blue Value Group,,267.31,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Value Group,,11.62,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,BCBS NC,Blue Value Group,,11.62,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,BCBS NC,Blue Value Group,,28.16,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,BCBS NC,Blue Value Group,,4.49,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Value Group,,9.79,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,BCBS NC,Blue Value Group,,74.23,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Value Group,,8.70,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,BCBS NC,Blue Value Group,,220.66,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.72,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,BCBS NC,Blue Value Group,,26.49,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,BCBS NC,Blue Value Group,,46.31,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,BCBS NC,Blue Value Group,,11.18,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Group,,9.14,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Value Group,,12.54,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Value Group,,9.17,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,BCBS NC,Blue Value Group,,47.51,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Value Group,,11.10,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Group,,9.14,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,BCBS NC,Blue Value Group,,0.99256,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Value Group,,12.39,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,BCBS NC,Blue Value Group,,11.70,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,BCBS NC,Blue Value Group,,101.74,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,BCBS NC,Blue Value Group,,8.88,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,BCBS NC,Blue Value Group,,25.05,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,BCBS NC,Blue Value Group,,15.37,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,BCBS NC,Blue Value Group,,3.92,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Group,,9.01,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.78,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,BCBS NC,Blue Value Group,,10.84,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,BCBS NC,Blue Value Group,,42.12,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,BCBS NC,Blue Value Group,,1.75,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,BCBS NC,Blue Value Group,,7.52,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Group,,8.52,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Group,,8.85,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Value Group,,11.75,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,BCBS NC,Blue Value Group,,0.67912,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,BCBS NC,Blue Value Group,,17.03,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,BCBS NC,Blue Value Group,,41.32,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Value Group,,11.96,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Value Group,,9.48,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Value Group,,9.85,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,BCBS NC,Blue Value Group,,10.40,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,BCBS NC,Blue Value Group,,85.13,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Value Group,,8.59,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Group,,8.99,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,BCBS NC,Blue Value Group,,43.65,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,BCBS NC,Blue Value Group,,16.38,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,BCBS NC,Blue Value Group,,3801.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,BCBS NC,Blue Value Group,,14.54,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,BCBS NC,Blue Value Group,,40.12,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,BCBS NC,Blue Value Group,,16.56,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Group,,8.88,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Group,,8.80,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,BCBS NC,Blue Value Group,,1432.06,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Value Group,,46.08,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,BCBS NC,Blue Value Group,,20.65,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,BCBS NC,Blue Value Group,,13.77,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,BCBS NC,Blue Value Group,,50.28,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,BCBS NC,Blue Value Group,,52.58,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,BCBS NC,Blue Value Group,,76.07,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,BCBS NC,Blue Value Group,,13.38,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,BCBS NC,Blue Value Group,,610.39,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,BCBS NC,Blue Value Group,,1166.96,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,BCBS NC,Blue Value Group,,2988.56,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Value Group,,3.08,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,BCBS NC,Blue Value Group,,1158.03,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,BCBS NC,Blue Value Group,,9.85,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,BCBS NC,Blue Value Group,,119.11,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Group,,10.08,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,BCBS NC,Blue Value Group,,10.53,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,BCBS NC,Blue Value Group,,137.70,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,BCBS NC,Blue Value Group,,11.07,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,BCBS NC,Blue Value Group,,10.13,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,BCBS NC,Blue Value Group,,12.07,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Value Group,,11.83,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Group,,10.45,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,BCBS NC,Blue Value Group,,13.53,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,BCBS NC,Blue Value Group,,52.87,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,BCBS NC,Blue Value Group,,317.12,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Value Group,,93.59,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,BCBS NC,Blue Value Group,,93.59,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,BCBS NC,Blue Value Group,,100.65,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,BCBS NC,Blue Value Group,,101.25,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Value Group,,40.75,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Group,,9.32,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Value Group,,1.93,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,BCBS NC,Blue Value Group,,1.93,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,BCBS NC,Blue Value Group,,2.04,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,BCBS NC,Blue Value Group,,18.62,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,BCBS NC,Blue Value Group,,22.67,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,BCBS NC,Blue Value Group,,31.34,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,BCBS NC,Blue Value Group,,42.89,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,BCBS NC,Blue Value Group,,54.70,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,BCBS NC,Blue Value Group,,115.32,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,BCBS NC,Blue Value Group,,7.00,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Group,,0.75748,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,BCBS NC,Blue Value Group,,528.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,BCBS NC,Blue Value Group,,4.21,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,BCBS NC,Blue Value Group,,59.55,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,BCBS NC,Blue Value Group,,12.09,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,BCBS NC,Blue Value Group,,13.84,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Value Group,,15.67,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,BCBS NC,Blue Value Group,,393.18,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Value Group,,9.59,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,BCBS NC,Blue Value Group,,159.60,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,BCBS NC,Blue Value Group,,12.59,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Value Group,,48.58,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,BCBS NC,Blue Value Group,,48.22,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Value Group,,47.17,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,BCBS NC,Blue Value Group,,11.82,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,BCBS NC,Blue Value Group,,10.60,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Value Group,,9.46,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,BCBS NC,Blue Value Group,,24.11,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,BCBS NC,Blue Value Group,,26.90,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,BCBS NC,Blue Value Group,,139.85,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,BCBS NC,Blue Value Group,,14.44,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,BCBS NC,Blue Value Group,,32.68,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,BCBS NC,Blue Value Group,,313.00,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,BCBS NC,Blue Value Group,,19.72,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,BCBS NC,Blue Value Group,,32.62,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,BCBS NC,Blue Value Group,,1821.60,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,BCBS NC,Blue Value Group,,810.76,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,BCBS NC,Blue Value Group,,623.12,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Group,,9.30,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,BCBS NC,Blue Value Group,,112.84,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,BCBS NC,Blue Value Group,,60.21,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,BCBS NC,Blue Value Group,,271.14,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,BCBS NC,Blue Value Group,,361.47,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,BCBS NC,Blue Value Group,,620.48,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,BCBS NC,Blue Value Group,,173.78,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,BCBS NC,Blue Value Group,,182.58,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,BCBS NC,Blue Value Group,,9.98,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Value Group,,10.06,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Value Group,,11.15,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,BCBS NC,Blue Value Group,,14.86,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,BCBS NC,Blue Value Group,,9.99,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,BCBS NC,Blue Value Group,,6659.71,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,BCBS NC,Blue Value Group,,27.12,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,BCBS NC,Blue Value Group,,184.88,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,BCBS NC,Blue Value Group,,34.79,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,BCBS NC,Blue Value Group,,9.27,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,BCBS NC,Blue Value Group,,1.28,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,BCBS NC,Blue Value Group,,2.32,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,BCBS NC,Blue Value Group,,11.15,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,BCBS NC,Blue Value Group,,14.16,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,BCBS NC,Blue Value Group,,358.63,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Value Group,,10.19,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Group,,8.91,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Value Group,,10.19,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,BCBS NC,Blue Value Group,,11.28,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,BCBS NC,Blue Value Group,,43.00,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,BCBS NC,Blue Value Group,,193.11,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,BCBS NC,Blue Value Group,,219.41,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,BCBS NC,Blue Value Group,,14.83,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,BCBS NC,Blue Value Group,,21.94,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Value Group,,14.70,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,BCBS NC,Blue Value Group,,27.66,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,BCBS NC,Blue Value Group,,16.04,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,BCBS NC,Blue Value Group,,13.56,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,BCBS NC,Blue Value Group,,0.91420,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,BCBS NC,Blue Value Group,,62.64,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,BCBS NC,Blue Value Group,,3.29,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,BCBS NC,Blue Value Group,,48.65,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,BCBS NC,Blue Value Group,,45.19,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Group,,9.04,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,BCBS NC,Blue Value Group,,240.66,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,BCBS NC,Blue Value Group,,165.08,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,BCBS NC,Blue Value Group,,436.74,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,BCBS NC,Blue Value Group,,10.71,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Group,,9.09,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Group,,9.32,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,BCBS NC,Blue Value Group,,138.46,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,BCBS NC,Blue Value Group,,444.30,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,BCBS NC,Blue Value Group,,10336.03,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,BCBS NC,Blue Value Group,,17.66,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Value Group,,11.15,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,BCBS NC,Blue Value Group,,11.15,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,BCBS NC,Blue Value Group,,95.68,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,BCBS NC,Blue Value Group,,60.76,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,BCBS NC,Blue Value Group,,15.62,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,BCBS NC,Blue Value Group,,65.48,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,BCBS NC,Blue Value Group,,37.35,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,BCBS NC,Blue Value Group,,99.31,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,BCBS NC,Blue Value Group,,43.75,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,BCBS NC,Blue Value Group,,272.33,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,BCBS NC,Blue Value Group,,30.89,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,BCBS NC,Blue Value Group,,11.49,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,BCBS NC,Blue Value Group,,14.94,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,BCBS NC,Blue Value Group,,62.64,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Blue Value Group,,15120.26,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,BCBS NC,Blue Value Group,,9.55,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,BCBS NC,Blue Value Group,,19.15,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.78,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,BCBS NC,Blue Value Group,,11.57,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Value Group,,11.68,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,BCBS NC,Blue Value Group,,48.31,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,BCBS NC,Blue Value Group,,1541.14,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,BCBS NC,Blue Value Group,,18.70,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,BCBS NC,Blue Value Group,,66.58,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,BCBS NC,Blue Value Group,,1170.82,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,BCBS NC,Blue Value Group,,22.05,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,BCBS NC,Blue Value Group,,18.14,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,BCBS NC,Blue Value Group,,15.19,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,BCBS NC,Blue Value Group,,28.86,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,BCBS NC,Blue Value Group,,18.91,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,BCBS NC,Blue Value Group,,2706.68,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,BCBS NC,Blue Value Group,,6754.25,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,BCBS NC,Blue Value Group,,13500.15,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,BCBS NC,Blue Value Group,,26992.02,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.78,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,BCBS NC,Blue Value Group,,93.64,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,BCBS NC,Blue Value Group,,208.75,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,BCBS NC,Blue Value Group,,13.32,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,BCBS NC,Blue Value Group,,26.20,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,BCBS NC,Blue Value Group,,77.21,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,BCBS NC,Blue Value Group,,163.69,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Value Group,,9.61,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Group,,9.30,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,BCBS NC,Blue Value Group,,25.28,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,BCBS NC,Blue Value Group,,26.36,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,BCBS NC,Blue Value Group,,8.88,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Value Group,,9.38,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,BCBS NC,Blue Value Group,,2438.67,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Group,,8.91,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,BCBS NC,Blue Value Group,,29.96,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,BCBS NC,Blue Value Group,,70.26,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,BCBS NC,Blue Value Group,,19.23,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Value Group,,86.76,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Value Group,,25.55,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,BCBS NC,Blue Value Group,,11.44,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,BCBS NC,Blue Value Group,,11.75,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,BCBS NC,Blue Value Group,,11.96,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,BCBS NC,Blue Value Group,,166.45,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,BCBS NC,Blue Value Group,,11.23,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,BCBS NC,Blue Value Group,,13.71,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,BCBS NC,Blue Value Group,,19.20,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,BCBS NC,Blue Value Group,,14.41,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,BCBS NC,Blue Value Group,,242.94,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,BCBS NC,Blue Value Group,,5.90,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,BCBS NC,Blue Value Group,,0.86196,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,BCBS NC,Blue Value Group,,535.53,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,BCBS NC,Blue Value Group,,12.98,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,BCBS NC,Blue Value Group,,12.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,BCBS NC,Blue Value Group,,130.41,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,BCBS NC,Blue Value Group,,15.67,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,BCBS NC,Blue Value Group,,16.90,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Group,,9.25,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Group,,9.22,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,BCBS NC,Blue Value Group,,9.53,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,BCBS NC,Blue Value Group,,10.27,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Value Group,,3792.34,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,BCBS NC,Blue Value Group,,9.13,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,BCBS NC,Blue Value Group,,9.46,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,BCBS NC,Blue Value Group,,10.55,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,BCBS NC,Blue Value Group,,8.75,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,BCBS NC,Blue Value Group,,45.28,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,BCBS NC,Blue Value Group,,3233.65,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,BCBS NC,Blue Value Group,,45.74,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,BCBS NC,Blue Value Group,,12.54,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,BCBS NC,Blue Value Group,,25.55,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,BCBS NC,Blue Value Group,,50.62,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,BCBS NC,Blue Value Group,,55.06,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,BCBS NC,Blue Value Group,,11.10,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,BCBS NC,Blue Value Group,,0.78360,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,BCBS NC,Blue Value Group,,9.77,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,BCBS NC,Blue Value Group,,36.54,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,BCBS NC,Blue Value Group,,2.53,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Group,,8.85,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,BCBS NC,Blue Value Group,,14.84,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,BCBS NC,Blue Value Group,,8.80,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,BCBS NC,Blue Value Group,,249.95,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,BCBS NC,Blue Value Group,,9.38,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Group,,8.46,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,BCBS NC,Blue Value Group,,12.33,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Value Group,,2.25,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,BCBS NC,Blue Value Group,,14.34,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,BCBS NC,Blue Value Group,,2.25,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,BCBS NC,Blue Value Group,,13.53,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Value Group,,8.96,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,BCBS NC,Blue Value Group,,32.39,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,BCBS NC,Blue Value Group,,0.91420,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Value Group,,11.78,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,BCBS NC,Blue Value Group,,12.06,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,BCBS NC,Blue Value Group,,11.78,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,BCBS NC,Blue Value Group,,4.36,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Value Group,,11.86,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,BCBS NC,Blue Value Group,,8.41,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,BCBS NC,Blue Value Group,,59.29,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,BCBS NC,Blue Value Group,,87.66,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,BCBS NC,Blue Value Group,,14.55,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,BCBS NC,Blue Value Group,,16.38,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,BCBS NC,Blue Value Group,,9348.22,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Group,,2047.02,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,BCBS NC,Blue Value Group,,15.99,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,BCBS NC,Blue Value Group,,392.06,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,BCBS NC,Blue Value Group,,120.75,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,BCBS NC,Blue Value Group,,74.39,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Value Group,,1418.26,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,BCBS NC,Blue Value Group,,780.31,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,BCBS NC,Blue Value Group,,1.83,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,BCBS NC,Blue Value Group,,56.54,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,BCBS NC,Blue Value Group,,0.83584,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Group,,8.52,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,BCBS NC,Blue Value Group,,14.31,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,BCBS NC,Blue Value Group,,10.55,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,BCBS NC,Blue Value Group,,21.19,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,BCBS NC,Blue Value Group,,726.79,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,BCBS NC,Blue Value Group,,31.84,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,BCBS NC,Blue Value Group,,19.35,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Blue Value Group,,12.32,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,BCBS NC,Blue Value Group,,195.23,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,BCBS NC,Blue Value Group,,249.72,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,BCBS NC,Blue Value Group,,172.84,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,BCBS NC,Blue Value Group,,277.04,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,BCBS NC,Blue Value Group,,61.43,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,BCBS NC,Blue Value Group,,47.17,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,BCBS NC,Blue Value Group,,8.38,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,BCBS NC,Blue Value Group,,12.96,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,BCBS NC,Blue Value Group,,60.08,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,BCBS NC,Blue Value Group,,358.47,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,BCBS NC,Blue Value Group,,839.60,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Value Group,,9.12,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Value Group,,9.74,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Value Group,,34.87,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Group,,36.44,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Group,,35.26,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Group,,41.14,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Group,,36.44,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Group,,35.26,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,BCBS NC,Blue Value Group,,78.36,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,BCBS NC,Blue Value Group,,38.40,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Group,,36.44,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Group,,35.26,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,BCBS NC,Blue Value Group,,35.26,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Value Group,,34.87,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Value Group,,37.61,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,BCBS NC,Blue Value Group,,36.44,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Group,,41.14,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,BCBS NC,Blue Value Group,,34.87,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,BCBS NC,Blue Value Group,,8.44,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,BCBS NC,Blue Value Group,,534.68,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,BCBS NC,Blue Value Group,,11.72,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.19,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,BCBS NC,Blue Value Group,,3740.13,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,BCBS NC,Blue Value Group,,13697.37,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,BCBS NC,Blue Value Group,,2893.06,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,BCBS NC,Blue Value Group,,13697.37,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,BCBS NC,Blue Value Group,,9.87,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Value Group,,10.03,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,BCBS NC,Blue Value Group,,55.37,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,BCBS NC,Blue Value Group,,3792.34,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,BCBS NC,Blue Value Group,,181.23,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,BCBS NC,Blue Value Group,,643.25,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,BCBS NC,Blue Value Group,,11.91,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,BCBS NC,Blue Value Group,,24.13,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,BCBS NC,Blue Value Group,,3638.34,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,BCBS NC,Blue Value Group,,171.97,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,BCBS NC,Blue Value Group,,159.55,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,BCBS NC,Blue Value Group,,348.56,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Blue Value Group,,20759.98,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Blue Value Group,,82612.72,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Value Group,,761.40,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Blue Value Group,,1516.15,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,BCBS NC,Blue Value Group,,13881.06,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,BCBS NC,Blue Value Group,,165.68,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Value Group,,150.10,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Value Group,,162.88,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Value Group,,149.97,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Value Group,,218.02,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,BCBS NC,Blue Value Group,,1053.11,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,BCBS NC,Blue Value Group,,256.16,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,BCBS NC,Blue Value Group,,515.74,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,BCBS NC,Blue Value Group,,11.96,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,BCBS NC,Blue Value Group,,40.13,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,BCBS NC,Blue Value Group,,174.60,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Blue Value Group,,2918.83,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Blue Value Group,,5805.03,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,BCBS NC,Blue Value Group,,55.03,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Blue Value Group,,23.52,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Blue Value Group,,32.84,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,BCBS NC,Blue Value Group,,9.86,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Value Group,,43.47,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,BCBS NC,Blue Value Group,,13.92,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,BCBS NC,Blue Value Group,,177.40,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,BCBS NC,Blue Value Group,,31.57,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,BCBS NC,Blue Value Group,,39.33,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,BCBS NC,Blue Value Group,,151.55,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,BCBS NC,Blue Value Group,,10.76,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Value Group,,22.41,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Group,,12.99,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Value Group,,15.11,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,BCBS NC,Blue Value Group,,10.09,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,BCBS NC,Blue Value Group,,9.96,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.72,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.78,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,BCBS NC,Blue Value Group,,53.48,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,BCBS NC,Blue Value Group,,37.61,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Value Group,,40.75,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,BCBS NC,Blue Value Group,,37.30,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,BCBS NC,Blue Value Group,,39.57,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,BCBS NC,Blue Value Group,,36.91,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Group,,39.18,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Value Group,,148.26,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,BCBS NC,Blue Value Group,,32.63,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,BCBS NC,Blue Value Group,,57.15,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,BCBS NC,Blue Value Group,,2.48,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Group,,113.33,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Group,,592.20,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,BCBS NC,Blue Value Group,,567.43,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,BCBS NC,Blue Value Group,,23.25,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,BCBS NC,Blue Value Group,,24.06,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,BCBS NC,Blue Value Group,,16.33,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,BCBS NC,Blue Value Group,,1.46,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,BCBS NC,Blue Value Group,,18927.56,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,BCBS NC,Blue Value Group,,164.64,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,BCBS NC,Blue Value Group,,113.33,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,BCBS NC,Blue Value Group,,33.04,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,BCBS NC,Blue Value Group,,59.77,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Value Group,,14.36,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Group,,6.14,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Group,,6.14,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Group,,6.14,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,BCBS NC,Blue Value Group,,6.14,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,BCBS NC,Blue Value Group,,38.86,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,BCBS NC,Blue Value Group,,55.97,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,BCBS NC,Blue Value Group,,79.31,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,BCBS NC,Blue Value Group,,11.31,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,BCBS NC,Blue Value Group,,10.14,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,BCBS NC,Blue Value Group,,30.17,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,BCBS NC,Blue Value Group,,106.73,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Group,,8.57,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,BCBS NC,Blue Value Group,,27.79,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,BCBS NC,Blue Value Group,,8.46,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,BCBS NC,Blue Value Group,,12.51,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,BCBS NC,Blue Value Group,,7082.97,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,BCBS NC,Blue Value Group,,1448.48,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,BCBS NC,Blue Value Group,,41.22,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Value Group,,25.02,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,BCBS NC,Blue Value Group,,14.59,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,BCBS NC,Blue Value Group,,39.81,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Blue Value Group,,23.68,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,BCBS NC,Blue Value Group,,54.54,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Value Group,,126.94,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,BCBS NC,Blue Value Group,,32.91,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Value Group,,126.94,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,BCBS NC,Blue Value Group,,15.42,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,BCBS NC,Blue Value Group,,302.03,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,BCBS NC,Blue Value Group,,14.75,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Value Group,,142.62,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Value Group,,142.62,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,BCBS NC,Blue Value Group,,10.69,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,BCBS NC,Blue Value Group,,10.43,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,BCBS NC,Blue Value Group,,10.48,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Value Group,,13.64,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,BCBS NC,Blue Value Group,,3.71,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,BCBS NC,Blue Value Group,,79.57,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,BCBS NC,Blue Value Group,,209.61,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,BCBS NC,Blue Value Group,,80.97,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,BCBS NC,Blue Value Group,,419.75,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,BCBS NC,Blue Value Group,,34.26,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,BCBS NC,Blue Value Group,,13.06,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,BCBS NC,Blue Value Group,,9.93,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,BCBS NC,Blue Value Group,,36.57,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,BCBS NC,Blue Value Group,,45.97,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,BCBS NC,Blue Value Group,,39.08,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Value Group,,31.55,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,BCBS NC,Blue Value Group,,48.17,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,BCBS NC,Blue Value Group,,196.42,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,BCBS NC,Blue Value Group,,9.93,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,BCBS NC,Blue Value Group,,33.62,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,BCBS NC,Blue Value Group,,14.13,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,BCBS NC,Blue Value Group,,12.54,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,BCBS NC,Blue Value Group,,59.38,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,BCBS NC,Blue Value Group,,142.62,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,BCBS NC,Blue Value Group,,126.94,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,BCBS NC,Blue Value Group,,24.81,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Group,,9.00,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,BCBS NC,Blue Value Group,,33.12,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Value Group,,14.99,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Group,,8.57,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,BCBS NC,Blue Value Group,,8.98,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,BCBS NC,Blue Value Group,,48.90,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,BCBS NC,Blue Value Group,,17.76,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,BCBS NC,Blue Value Group,,12.20,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,BCBS NC,Blue Value Group,,111.57,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,BCBS NC,Blue Value Group,,176.94,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,BCBS NC,Blue Value Group,,432.11,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,BCBS NC,Blue Value Group,,33.77,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,BCBS NC,Blue Value Group,,42.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,BCBS NC,Blue Value Group,,115.20,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,BCBS NC,Blue Value Group,,46.08,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Value Group,,45.57,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,BCBS NC,Blue Value Group,,67.15,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,BCBS NC,Blue Value Group,,3.08,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Value Group,,26.44,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,BCBS NC,Blue Value Group,,14.70,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Value Group,,19545.22,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,BCBS NC,Blue Value Group,,165.08,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,BCBS NC,Blue Value Group,,87.97,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,BCBS NC,Blue Value Group,,33.40,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,BCBS NC,Blue Value Group,,37.62,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,BCBS NC,Blue Value Group,,33.59,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,BCBS NC,Blue Value Group,,38.81,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,BCBS NC,Blue Value Group,,31.55,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,BCBS NC,Blue Value Group,,45.95,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,BCBS NC,Blue Value Group,,194.39,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,BCBS NC,Blue Value Group,,9.96,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,BCBS NC,Blue Value Group,,35.21,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,BCBS NC,Blue Value Group,,35.40,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,BCBS NC,Blue Value Group,,49.99,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,BCBS NC,Blue Value Group,,15.89,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,BCBS NC,Blue Value Group,,55.66,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,BCBS NC,Blue Value Group,,89.75,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,BCBS NC,Blue Value Group,,53.79,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,BCBS NC,Blue Value Group,,129.58,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,BCBS NC,Blue Value Group,,88.47,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,BCBS NC,Blue Value Group,,41.74,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,BCBS NC,Blue Value Group,,36.41,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,BCBS NC,Blue Value Group,,53.79,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,BCBS NC,Blue Value Group,,42.38,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,BCBS NC,Blue Value Group,,49.99,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Value Group,,56.51,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,BCBS NC,Blue Value Group,,247.78,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,BCBS NC,Blue Value Group,,60.99,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,BCBS NC,Blue Value Group,,293.42,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,BCBS NC,Blue Value Group,,603.25,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,BCBS NC,Blue Value Group,,642.94,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Value Group,,18.89,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,BCBS NC,Blue Value Group,,43.67,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,BCBS NC,Blue Value Group,,38.48,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,BCBS NC,Blue Value Group,,79.33,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,BCBS NC,Blue Value Group,,113.07,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,BCBS NC,Blue Value Group,,265.17,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,BCBS NC,Blue Value Group,,497.73,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,BCBS NC,Blue Value Group,,46.73,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,BCBS NC,Blue Value Group,,53.38,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,BCBS NC,Blue Value Group,,128.21,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,BCBS NC,Blue Value Group,,34.57,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,BCBS NC,Blue Value Group,,40.44,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,BCBS NC,Blue Value Group,,380.44,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Value Group,,9.08,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,BCBS NC,Blue Value Group,,142.42,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,BCBS NC,Blue Value Group,,32.84,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,BCBS NC,Blue Value Group,,54.39,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,BCBS NC,Blue Value Group,,149.97,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,BCBS NC,Blue Value Group,,91.29,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,BCBS NC,Blue Value Group,,12.64,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,BCBS NC,Blue Value Group,,62.38,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,BCBS NC,Blue Value Group,,36.95,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,BCBS NC,Blue Value Group,,40.93,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,BCBS NC,Blue Value Group,,94.35,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,BCBS NC,Blue Value Group,,88.91,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,BCBS NC,Blue Value Group,,39.12,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,BCBS NC,Blue Value Group,,15.25,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,BCBS NC,Blue Value Group,,17.98,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,BCBS NC,Blue Value Group,,36.95,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,BCBS NC,Blue Value Group,,923.74,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,BCBS NC,Blue Value Group,,51.52,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,BCBS NC,Blue Value Group,,13.02,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,BCBS NC,Blue Value Group,,18.03,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,BCBS NC,Blue Value Group,,37.48,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,BCBS NC,Blue Value Group,,14.36,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Value Group,,32.65,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,BCBS NC,Blue Value Group,,90.90,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,BCBS NC,Blue Value Group,,33.43,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,BCBS NC,Blue Value Group,,46.08,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,BCBS NC,Blue Value Group,,11.62,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,BCBS NC,Blue Value Group,,11.64,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,BCBS NC,Blue Value Group,,13.25,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Value Group,,22.10,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,BCBS NC,Blue Value Group,,13.51,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,BCBS NC,Blue Value Group,,141.28,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,BCBS NC,Blue Value Group,,67.82,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,BCBS NC,Blue Value Group,,48.90,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,BCBS NC,Blue Value Group,,72.95,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,BCBS NC,Blue Value Group,,15.23,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,BCBS NC,Blue Value Group,,54.49,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,BCBS NC,Blue Value Group,,55.90,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,BCBS NC,Blue Value Group,,42.38,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,BCBS NC,Blue Value Group,,9.19,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,BCBS NC,Blue Value Group,,35.35,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,BCBS NC,Blue Value Group,,9.01,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,BCBS NC,Blue Value Group,,28.93,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,BCBS NC,Blue Value Group,,42.56,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,BCBS NC,Blue Value Group,,55.56,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,BCBS NC,Blue Value Group,,160.84,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,BCBS NC,Blue Value Group,,41.27,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,BCBS NC,Blue Value Group,,165.21,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Group,,38.81,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,BCBS NC,Blue Value Group,,33.20,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,BCBS NC,Blue Value Group,,20.74,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,BCBS NC,Blue Value Group,,54.34,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,BCBS NC,Blue Value Group,,39.05,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,BCBS NC,Blue Value Group,,26.91,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,BCBS NC,Blue Value Group,,83.63,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,BCBS NC,Blue Value Group,,11.57,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,BCBS NC,Blue Value Group,,32.65,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,BCBS NC,Blue Value Group,,233.83,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,BCBS NC,Blue Value Group,,86.76,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,BCBS NC,Blue Value Group,,143.14,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,BCBS NC,Blue Value Group,,125.06,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,BCBS NC,Blue Value Group,,38.61,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,BCBS NC,Blue Value Group,,34.00,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,BCBS NC,Blue Value Group,,41.19,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,BCBS NC,Blue Value Group,,31.24,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,BCBS NC,Blue Value Group,,8.38,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,BCBS NC,Blue Value Group,,128.13,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Blue Value Group,,5214.85,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,BCBS NC,Blue Value Group,,45.33,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Value Group,,77.83,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,BCBS NC,Blue Value Group,,80.27,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,BCBS NC,Blue Value Group,,188.50,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Blue Value Group,,8196.50,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,BCBS NC,Blue Value Group,,204.21,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Value Group,,290.29,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Value Group,,161.10,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Value Group,,250.52,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Value Group,,234.09,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Value Group,,210.62,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,BCBS NC,Blue Value Group,,190.13,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,BCBS NC,Blue Value Group,,290.29,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,BCBS NC,Blue Value Group,,161.10,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,BCBS NC,Blue Value Group,,250.52,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Blue Value Group,,1418.26,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,BCBS NC,Blue Value Group,,52.37,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,BCBS NC,Blue Value Group,,60.15,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Group,,12.99,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Value Group,,15.34,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,BCBS NC,Blue Value Group,,46.08,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,BCBS NC,Blue Value Group,,101.07,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,BCBS NC,Blue Value Group,,76.37,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Group,,592.20,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Blue Value Group,,592.20,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,BCBS NC,Blue Value Group,,38.09,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,BCBS NC,Blue Value Group,,33.35,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,BCBS NC,Blue Value Group,,215.31,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,BCBS NC,Blue Value Group,,21.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,BCBS NC,Blue Value Group,,89.66,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,BCBS NC,Blue Value Group,,32.71,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,BCBS NC,Blue Value Group,,60.15,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Value Group,,25.55,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Value Group,,13.45,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,BCBS NC,Blue Value Group,,16.90,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,BCBS NC,Blue Value Group,,827.93,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,BCBS NC,Blue Value Group,,20.05,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,BCBS NC,Blue Value Group,,249.92,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,BCBS NC,Blue Value Group,,45.54,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Value Group,,1335.38,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,BCBS NC,Blue Value Group,,8.90,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,BCBS NC,Blue Value Group,,75.38,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,BCBS NC,Blue Value Group,,720.99,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,BCBS NC,Blue Value Group,,38.19,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,BCBS NC,Blue Value Group,,112.32,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,BCBS NC,Blue Value Group,,309.08,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,BCBS NC,Blue Value Group,,56.51,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,BCBS NC,Blue Value Group,,59.77,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,BCBS NC,Blue Value Group,,22.41,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,BCBS NC,Blue Value Group,,33.82,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Value Group,,24.56,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Value Group,,34.18,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Value Group,,18.89,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,BCBS NC,Blue Value Group,,34.18,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,BCBS NC,Blue Value Group,,25.07,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,BCBS NC,Blue Value Group,,45.95,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,BCBS NC,Blue Value Group,,134.76,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,BCBS NC,Blue Value Group,,62.53,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,BCBS NC,Blue Value Group,,61.19,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Value Group,,8.38,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Value Group,,3515.38,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,BCBS NC,Blue Value Group,,16.02,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,BCBS NC,Blue Value Group,,43.08,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,BCBS NC,Blue Value Group,,34.01,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,BCBS NC,Blue Value Group,,92.30,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,BCBS NC,Blue Value Group,,26.19,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,BCBS NC,Blue Value Group,,121.04,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,BCBS NC,Blue Value Group,,123.04,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,BCBS NC,Blue Value Group,,77.83,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Value Group,,249.95,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,BCBS NC,Blue Value Group,,35.32,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Value Group,,11.44,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,BCBS NC,Blue Value Group,,11.80,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,BCBS NC,Blue Value Group,,239.76,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,BCBS NC,Blue Value Group,,13.48,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Blue Value Group,,3020.36,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,BCBS NC,Blue Value Group,,32.94,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,BCBS NC,Blue Value Group,,32.68,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,BCBS NC,Blue Value Group,,33.04,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,BCBS NC,Blue Value Group,,32.76,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,BCBS NC,Blue Value Group,,32.94,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,BCBS NC,Blue Value Group,,74.99,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,BCBS NC,Blue Value Group,,10.01,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Value Group,,8.31,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,BCBS NC,Blue Value Group,,34.26,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Value Group,,26.15,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,BCBS NC,Blue Value Group,,236.06,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,BCBS NC,Blue Value Group,,239.14,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,BCBS NC,Blue Value Group,,186.84,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,BCBS NC,Blue Value Group,,41.69,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Group,,45.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,BCBS NC,Blue Value Group,,19.33,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,BCBS NC,Blue Value Group,,39.49,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Group,,41.14,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Group,,39.18,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,BCBS NC,Blue Value Group,,8.31,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,BCBS NC,Blue Value Group,,11.83,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,BCBS NC,Blue Value Group,,12.86,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,BCBS NC,Blue Value Group,,82.10,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Blue Value Group,,46.03,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,BCBS NC,Blue Value Group,,64.97,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,BCBS NC,Blue Value Group,,43.52,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,BCBS NC,Blue Value Group,,184.88,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,BCBS NC,Blue Value Group,,598.26,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Group,,13.64,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,BCBS NC,Blue Value Group,,12.91,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,BCBS NC,Blue Value Group,,377.90,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,BCBS NC,Blue Value Group,,53.13,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,BCBS NC,Blue Value Group,,33.12,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,BCBS NC,Blue Value Group,,53.56,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,BCBS NC,Blue Value Group,,32.41,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Value Group,,78.27,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,BCBS NC,Blue Value Group,,148.26,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,BCBS NC,Blue Value Group,,20.18,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Value Group,,31.83,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,BCBS NC,Blue Value Group,,13.66,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,BCBS NC,Blue Value Group,,18.89,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,BCBS NC,Blue Value Group,,108.67,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,BCBS NC,Blue Value Group,,39.12,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,BCBS NC,Blue Value Group,,45.44,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,BCBS NC,Blue Value Group,,42.59,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,BCBS NC,Blue Value Group,,12.99,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Value Group,,15.34,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,BCBS NC,Blue Value Group,,34.65,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,BCBS NC,Blue Value Group,,43.47,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,BCBS NC,Blue Value Group,,12.01,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,BCBS NC,Blue Value Group,,17.97,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,BCBS NC,Blue Value Group,,10.79,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,BCBS NC,Blue Value Group,,22.10,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,BCBS NC,Blue Value Group,,12.39,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,BCBS NC,Blue Value Group,,13.56,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,BCBS NC,Blue Value Group,,9.22,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,BCBS NC,Blue Value Group,,8.54,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,BCBS NC,Blue Value Group,,274.95,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,BCBS NC,Blue Value Group,,17.76,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,BCBS NC,Blue Value Group,,45.97,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Blue Value Group,,1335.38,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Group,,12795.08,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Group,,12795.08,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Group,,12795.08,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Group,,12795.08,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Blue Value Group,,12795.08,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Blue Value Group,,19545.22,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,BCBS NC,Blue Value Group,,209.04,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,BCBS NC,Blue Value Group,,55.22,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Value Group,,15.34,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,BCBS NC,Blue Value Group,,11.93,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,BCBS NC,Blue Value Group,,77.39,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Value Group,,15.50,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,BCBS NC,Blue Value Group,,6.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Blue Value Group,,249.95,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,BCBS NC,Blue Value Group,,391.75,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,BCBS NC,Blue Value Group,,25.31,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,BCBS NC,Blue Value Group,,13.33,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Value Group,,13.51,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,BCBS NC,Blue Value Group,,143.99,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,BCBS NC,Blue Value Group,,30.51,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,BCBS NC,Blue Value Group,,40.51,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,BCBS NC,Blue Value Group,,8.72,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,BCBS NC,Blue Value Group,,45.97,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Value Group,,279.35,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Value Group,,159.60,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,BCBS NC,Blue Value Group,,2.17,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,BCBS NC,Blue Value Group,,1.46,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,BCBS NC,Blue Value Group,,143.22,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,BCBS NC,Blue Value Group,,154.45,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,BCBS NC,Blue Value Group,,123.50,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,BCBS NC,Blue Value Group,,134.86,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,BCBS NC,Blue Value Group,,1.18,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,BCBS NC,Blue Value Group,,150.75,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,11.90,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,11.90,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,BCBS NC,Blue Value Group,,21.30,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,BCBS NC,Blue Value Group,,34.28,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,BCBS NC,Blue Value Group,,40.64,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,BCBS NC,Blue Value Group,,14.99,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,BCBS NC,Blue Value Group,,19.69,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Value Group,,19.25,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,BCBS NC,Blue Value Group,,23357.88,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Blue Value Group,,18614.63,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Blue Value Group,,26531.29,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,BCBS NC,Blue Value Group,,14.34,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,BCBS NC,Blue Value Group,,290.45,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,BCBS NC,Blue Value Group,,162.88,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,BCBS NC,Blue Value Group,,149.97,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,BCBS NC,Blue Value Group,,218.02,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,BCBS NC,Blue Value Group,,24214.47,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Value Group,,3951.73,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Group,,2047.02,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Value Group,,3951.73,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Group,,2047.02,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Blue Value Group,,3951.73,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Blue Value Group,,2047.02,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Blue Value Group,,523.94,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Group,,9736.45,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Group,,9736.45,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Blue Value Group,,9736.45,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Blue Value Group,,26448.57,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Blue Value Group,,1280.81,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Value Group,,2160.90,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Value Group,,4289.20,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Value Group,,883.94,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Blue Value Group,,2160.90,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Blue Value Group,,4289.20,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Blue Value Group,,883.94,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,BCBS NC,Blue Value Group,,144.30,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,BCBS NC,Blue Value Group,,22.82,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Value Group,,15.40,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,BCBS NC,Blue Value Group,,100216.15,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,BCBS NC,Blue Value Group,,67.34,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,BCBS NC,Blue Value Group,,36.83,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,BCBS NC,Blue Value Group,,39.18,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,BCBS NC,Blue Value Group,,38.79,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,BCBS NC,Blue Value Group,,39.18,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Blue Value Group,,761.40,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,BCBS NC,Blue Value Group,,36.96,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,BCBS NC,Blue Value Group,,10.60,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,BCBS NC,Blue Value Group,,11.23,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,BCBS NC,Blue Value Group,,10.06,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,BCBS NC,Blue Value Group,,347.24,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,BCBS NC,Blue Value Group,,75.77,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,BCBS NC,Blue Value Group,,384.49,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,BCBS NC,Blue Value Group,,137.63,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Value Group,,28.94,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,BCBS NC,Blue Value Group,,28.94,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,BCBS NC,Blue Value Group,,2.66,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,BCBS NC,Blue Value Group,,6.77,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,BCBS NC,Blue Value Group,,41.74,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,BCBS NC,Blue Value Group,,31.47,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,BCBS NC,Blue Value Group,,240.70,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,BCBS NC,Blue Value Group,,40.75,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,BCBS NC,Blue Value Group,,8.96,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,BCBS NC,Blue Value Group,,30.93,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,BCBS NC,Blue Value Group,,19.98,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,BCBS NC,Blue Value Group,,227.74,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,BCBS NC,Blue Value Group,,9.56,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,BCBS NC,Blue Value Group,,55.69,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,BCBS NC,Blue Value Group,,55.37,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,BCBS NC,Blue Value Group,,301.70,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,BCBS NC,Blue Value Group,,162.37,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,BCBS NC,Blue Value Group,,27.06,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,BCBS NC,Blue Value Group,,10.66,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,BCBS NC,Blue Value Group,,9.30,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,BCBS NC,Blue Value Group,,9.51,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Group,,9.25,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,BCBS NC,Blue Value Group,,9.40,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,BCBS NC,Blue Value Group,,11.83,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,BCBS NC,Blue Value Group,,17.76,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,BCBS NC,Blue Value Group,,15.78,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,BCBS NC,Blue Value Group,,15.84,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,BCBS NC,Blue Value Group,,17.67,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,BCBS NC,Blue Value Group,,19.66,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,BCBS NC,Blue Value Group,,59.56,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,BCBS NC,Blue Value Group,,25.41,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,BCBS NC,Blue Value Group,,8.49,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,BCBS NC,Blue Value Group,,9.48,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Group,,8.57,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Group,,8.93,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,BCBS NC,Blue Value Group,,8.59,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,BCBS NC,Blue Value Group,,1.12,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,BCBS NC,Blue Value Group,,12.43,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,BCBS NC,Blue Value Group,,60.96,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,BCBS NC,Blue Value Group,,121.30,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,BCBS NC,Blue Value Group,,24.56,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,BCBS NC,Blue Value Group,,2.22,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,BCBS NC,Blue Value Group,,47.09,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,BCBS NC,Blue Value Group,,25.02,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,BCBS NC,Blue Value Group,,13.64,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Value Group,,16.17,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,BCBS NC,Blue Value Group,,15.34,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,BCBS NC,Blue Value Group,,96.98,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,BCBS NC,Blue Value Group,,40.30,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,BCBS NC,Blue Value Group,,15.62,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Group,,8.93,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,BCBS NC,Blue Value Group,,15.34,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,BCBS NC,Blue Value Group,,15.50,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,BCBS NC,Blue Value Group,,45.15,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,BCBS NC,Blue Value Group,,46.08,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,12.02,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,BCBS NC,Blue Value Group,,61.64,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,BCBS NC,Blue Value Group,,12.22,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,BCBS NC,Blue Value Group,,27.71,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,BCBS NC,Blue Value Group,,8.54,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,BCBS NC,Blue Value Group,,19.25,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,BCBS NC,Blue Value Group,,158.87,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,BCBS NC,Blue Value Group,,244.78,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,BCBS NC,Blue Value Group,,11.81,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,BCBS NC,Blue Value Group,,14.98,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,BCBS NC,Blue Value Group,,54.73,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,BCBS NC,Blue Value Group,,10.03,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,BCBS NC,Blue Value Group,,9.95,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,BCBS NC,Blue Value Group,,10.63,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Value Group,,8.59,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Group,,9.22,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,BCBS NC,Blue Value Group,,9.74,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,BCBS NC,Blue Value Group,,38.40,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,BCBS NC,Blue Value Group,,7.05,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Group,,8.93,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Group,,9.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,BCBS NC,Blue Value Group,,9.46,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,BCBS NC,Blue Value Group,,13.77,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,BCBS NC,Blue Value Group,,15.86,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,BCBS NC,Blue Value Group,,13.64,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,BCBS NC,Blue Value Group,,11.55,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,BCBS NC,Blue Value Group,,13.63,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,BCBS NC,Blue Value Group,,47.54,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,BCBS NC,Blue Value Group,,12.17,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,BCBS NC,Blue Value Group,,19.33,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,BCBS NC,Blue Value Group,,16.72,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,BCBS NC,Blue Value Group,,45.57,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,BCBS NC,Blue Value Group,,85.98,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Group,,8.91,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,BCBS NC,Blue Value Group,,66.42,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,BCBS NC,Blue Value Group,,28.05,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,BCBS NC,Blue Value Group,,13.43,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.78,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Group,,8.93,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Value Group,,30.30,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,BCBS NC,Blue Value Group,,30.30,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,BCBS NC,Blue Value Group,,9.61,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,BCBS NC,Blue Value Group,,12.15,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,BCBS NC,Blue Value Group,,5.49,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,BCBS NC,Blue Value Group,,10.84,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,BCBS NC,Blue Value Group,,9.29,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,BCBS NC,Blue Value Group,,105.80,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,BCBS NC,Blue Value Group,,128.11,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,BCBS NC,Blue Value Group,,38.24,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,BCBS NC,Blue Value Group,,22.31,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.78,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,BCBS NC,Blue Value Group,,3515.38,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Group,,9.32,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,BCBS NC,Blue Value Group,,9.04,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,BCBS NC,Blue Value Group,,12.69,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Value Group,,12.35,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,BCBS NC,Blue Value Group,,117.58,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,BCBS NC,Blue Value Group,,52.32,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,BCBS NC,Blue Value Group,,17.70,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,BCBS NC,Blue Value Group,,110.07,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,BCBS NC,Blue Value Group,,55.37,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Value Group,,3.34,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,BCBS NC,Blue Value Group,,3.34,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,BCBS NC,Blue Value Group,,59.29,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,BCBS NC,Blue Value Group,,11.57,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Value Group,,12.35,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,BCBS NC,Blue Value Group,,37.42,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,BCBS NC,Blue Value Group,,131.96,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,BCBS NC,Blue Value Group,,134.78,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,BCBS NC,Blue Value Group,,140.89,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,BCBS NC,Blue Value Group,,81.18,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,BCBS NC,Blue Value Group,,44.77,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,BCBS NC,Blue Value Group,,57.49,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,BCBS NC,Blue Value Group,,37.60,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,BCBS NC,Blue Value Group,,98.81,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,BCBS NC,Blue Value Group,,23.43,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,BCBS NC,Blue Value Group,,2.01,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,BCBS NC,Blue Value Group,,1.59,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,BCBS NC,Blue Value Group,,212.43,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,BCBS NC,Blue Value Group,,11.52,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,BCBS NC,Blue Value Group,,12.77,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,BCBS NC,Blue Value Group,,77.71,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,BCBS NC,Blue Value Group,,649.98,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.75,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.75,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Group,,8.77,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.69,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,BCBS NC,Blue Value Group,,11.13,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,BCBS NC,Blue Value Group,,9.12,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,BCBS NC,Blue Value Group,,104.79,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,BCBS NC,Blue Value Group,,11.49,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Group,,9.09,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,BCBS NC,Blue Value Group,,9.08,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,BCBS NC,Blue Value Group,,12.65,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,BCBS NC,Blue Value Group,,9.25,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,BCBS NC,Blue Value Group,,63.37,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,BCBS NC,Blue Value Group,,84.37,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,BCBS NC,Blue Value Group,,8.70,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,BCBS NC,Blue Value Group,,9.09,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Group,,8.91,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,BCBS NC,Blue Value Group,,9.64,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,BCBS NC,Blue Value Group,,132.84,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,BCBS NC,Blue Value Group,,44.74,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,BCBS NC,Blue Value Group,,13.16,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,BCBS NC,Blue Value Group,,33.87,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Group,,0.73136,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Group,,0.73136,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,BCBS NC,Blue Value Group,,1.49,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,BCBS NC,Blue Value Group,,4.00,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,BCBS NC,Blue Value Group,,49.03,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Group,,8.99,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.19,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Value Group,,43.26,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Value Group,,43.26,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Blue Value Group,,43.26,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,BCBS NC,Blue Value Group,,494.90,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,BCBS NC,Blue Value Group,,11.60,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,BCBS NC,Blue Value Group,,186.29,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,BCBS NC,Blue Value Group,,209.41,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,BCBS NC,Blue Value Group,,0.62688,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.72,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Group,,8.57,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,BCBS NC,Blue Value Group,,27.79,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,BCBS NC,Blue Value Group,,51.75,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,BCBS NC,Blue Value Group,,54.21,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,BCBS NC,Blue Value Group,,35.00,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,BCBS NC,Blue Value Group,,52.24,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,BCBS NC,Blue Value Group,,60.94,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,BCBS NC,Blue Value Group,,58.53,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,BCBS NC,Blue Value Group,,41.14,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Value Group,,39.96,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,BCBS NC,Blue Value Group,,42.69,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,BCBS NC,Blue Value Group,,42.67,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,BCBS NC,Blue Value Group,,49.24,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Value Group,,9.77,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,BCBS NC,Blue Value Group,,71.39,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,BCBS NC,Blue Value Group,,38.79,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,BCBS NC,Blue Value Group,,223.61,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,BCBS NC,Blue Value Group,,204.31,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,BCBS NC,Blue Value Group,,8.85,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,BCBS NC,Blue Value Group,,37.61,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,BCBS NC,Blue Value Group,,36.05,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,BCBS NC,Blue Value Group,,41.87,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,BCBS NC,Blue Value Group,,59.87,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,BCBS NC,Blue Value Group,,8.78,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Group,,9.01,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,BCBS NC,Blue Value Group,,2742.00,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,BCBS NC,Blue Value Group,,139.67,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,BCBS NC,Blue Value Group,,370.01,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,BCBS NC,Blue Value Group,,44.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,BCBS NC,Blue Value Group,,23.87,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,BCBS NC,Blue Value Group,,25.88,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,BCBS NC,Blue Value Group,,0.80972,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,BCBS NC,Blue Value Group,,213.01,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,BCBS NC,Blue Value Group,,12.02,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,BCBS NC,Blue Value Group,,1033.96,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,BCBS NC,Blue Value Group,,190.34,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,BCBS NC,Blue Value Group,,3.60,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,BCBS NC,Blue Value Group,,334.31,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,BCBS NC,Blue Value Group,,13.87,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,BCBS NC,Blue Value Group,,41.30,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,BCBS NC,Blue Value Group,,62.09,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,BCBS NC,Blue Value Group,,11.65,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,BCBS NC,Blue Value Group,,49.52,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,BCBS NC,Blue Value Group,,439.05,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,BCBS NC,Blue Value Group,,16.82,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,BCBS NC,Blue Value Group,,14.46,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,BCBS NC,Blue Value Group,,14.85,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,BCBS NC,Blue Value Group,,149.41,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,BCBS NC,Blue Value Group,,3.27,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Value Group,,13.09,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,BCBS NC,Blue Value Group,,13.09,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,BCBS NC,Blue Value Group,,27.92,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,BCBS NC,Blue Value Group,,1474.93,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,BCBS NC,Blue Value Group,,32.41,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,BCBS NC,Blue Value Group,,11.80,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Group,,10.34,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,BCBS NC,Blue Value Group,,12.35,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,BCBS NC,Blue Value Group,,32.65,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,BCBS NC,Blue Value Group,,8.62,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,BCBS NC,Blue Value Group,,8.65,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,BCBS NC,Blue Value Group,,13.06,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,BCBS NC,Blue Value Group,,21.21,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,BCBS NC,Blue Value Group,,15.65,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,BCBS NC,Blue Value Group,,30.33,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,BCBS NC,Blue Value Group,,28.70,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,BCBS NC,Blue Value Group,,23.55,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,BCBS NC,Blue Value Group,,109.42,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,BCBS NC,Blue Value Group,,8.93,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,BCBS NC,Blue Value Group,,13.56,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,BCBS NC,Blue Value Group,,225.28,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,BCBS NC,Blue Value Group,,257.86,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,BCBS NC,Blue Value Group,,14210.34,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,BCBS NC,Blue Value Group,,47.82,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,BCBS NC,Blue Value Group,,9.77,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,BCBS NC,Blue Value Group,,150.10,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,BCBS NC,Blue Value Group,,157.89,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,BCBS NC,Blue Value Group,,4697.06,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,BCBS NC,Blue Value Group,,14.15,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,BCBS NC,Blue Value Group,,62.41,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,BCBS NC,Blue Value Group,,55.37,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,BCBS NC,Blue Value Group,,56.16,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,BCBS NC,Blue Value Group,,56.13,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,BCBS NC,Blue Value Group,,29.65,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,BCBS NC,Blue Value Group,,68.00,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,BCBS NC,Blue Value Group,,50.35,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,BCBS NC,Blue Value Group,,228.79,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,BCBS NC,Blue Value Group,,2.32,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,BCBS NC,Blue Value Group,,32.13,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,BCBS NC,Blue Value Group,,23.61,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,BCBS NC,Blue Value Group,,8.57,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Group,,9.01,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,BCBS NC,Blue Value Group,,2.74,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,BCBS NC,Blue Value Group,,264.73,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,BCBS NC,Blue Value Group,,182.73,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,BCBS NC,Blue Value Group,,9.35,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,BCBS NC,Blue Value Group,,9.17,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,BCBS NC,Blue Value Group,,9.19,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,BCBS NC,Blue Value Group,,9.22,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,BCBS NC,Blue Value Group,,9.59,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,BCBS NC,Blue Value Group,,17.45,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,BCBS NC,Blue Value Group,,20947.18,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,BCBS NC,Blue Value Group,,293.91,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,BCBS NC,Blue Value Group,,21.17,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,BCBS NC,Blue Value Group,,51.25,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,BCBS NC,Blue Value Group,,234.09,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,BCBS NC,Blue Value Group,,210.62,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,BCBS NC,Blue Value Group,,80.92,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,BCBS NC,Blue Value Group,,30.90,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,BCBS NC,Blue Value Group,,13903.78,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,BCBS NC,Blue Value Group,,37.48,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,BCBS NC,Blue Value Group,,416.90,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,BCBS NC,Blue Value Group,,4.78,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,BCBS NC,Blue Value Group,,0.73136,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,BCBS NC,Blue Value Group,,51.77,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,BCBS NC,Blue Value Group,,1983.50,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,BCBS NC,Blue Value Group,,1.70,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,BCBS NC,Blue Value Group,,1.28,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,BCBS NC,Blue Value Group,,47.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,BCBS NC,Blue Value Group,,566.57,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,BCBS NC,Blue Value Group,,21.24,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,BCBS NC,Blue Value Group,,71.05,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,BCBS NC,Blue Value Group,,279.35,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,BCBS NC,Blue Value Group,,159.60,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Value Group,,226.15,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Blue Value Group,,226.15,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,BCBS NC,Blue Value Group,,407.04,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,BCBS NC,Blue Value Group,,20729.83,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,BCBS NC,Blue Value Group,,10369.07,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,BCBS NC,Blue Value Group,,2.06,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,BCBS NC,Blue Value Group,,0.65300,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,BCBS NC,Blue Value Group,,1.04,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,BCBS NC,Blue Value Group,,53.26,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Group,,9.14,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,BCBS NC,Blue Value Group,,8.59,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,BCBS NC,Blue Value Group,,8.67,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.72,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,BCBS NC,Blue Value Group,,26.44,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,BCBS NC,Blue Value Group,,17.59,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,BCBS NC,Blue Value Group,,51.20,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,BCBS NC,Blue Value Group,,66.78,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,BCBS NC,Blue Value Group,,192.35,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,BCBS NC,Blue Value Group,,49.08,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,BCBS NC,Blue Value Group,,109.70,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,BCBS NC,Blue Value Group,,13.58,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,BCBS NC,Blue Value Group,,25.85,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,BCBS NC,Blue Value Group,,90.69,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,BCBS NC,Blue Value Group,,15.99,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,BCBS NC,Blue Value Group,,420.75,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,BCBS NC,Blue Value Group,,0.54852,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Group,,10.45,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,BCBS NC,Blue Value Group,,275.05,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,BCBS NC,Blue Value Group,,41.82,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,BCBS NC,Blue Value Group,,19.62,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,BCBS NC,Blue Value Group,,9.70,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,BCBS NC,Blue Value Group,,78.27,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,BCBS NC,Blue Value Group,,142.99,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,BCBS NC,Blue Value Group,,25.26,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,BCBS NC,Blue Value Group,,137.86,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,BCBS NC,Blue Value Group,,2.12,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,BCBS NC,Blue Value Group,,83.53,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Group,,45.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Group,,45.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Blue Value Group,,45.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,BCBS NC,Blue Value Group,,272.57,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,BCBS NC,Blue Value Group,,15.28,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Value Group,,43.81,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Blue Value Group,,43.81,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,BCBS NC,Blue Value Group,,2.74,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Blue Value Group,,15.40,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,BCBS NC,Blue Value Group,,38.84,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,BCBS NC,Blue Value Group,,39.05,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,BCBS NC,Blue Value Group,,36.98,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Group,,9.32,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,BCBS NC,Blue Value Group,,15.01,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Group,,9.14,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,BCBS NC,Blue Value Group,,10.94,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,BCBS NC,Blue Value Group,,8.52,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,BCBS NC,Blue Value Group,,8.44,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,BCBS NC,Blue Value Group,,20.21,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,BCBS NC,Blue Value Group,,1891.98,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,BCBS NC,Blue Value Group,,10.34,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,BCBS NC,Blue Value Group,,6490.61,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,BCBS NC,Blue Value Group,,12972.90,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,BCBS NC,Blue Value Group,,1070.58,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,BCBS NC,Blue Value Group,,1424.83,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,BCBS NC,Blue Value Group,,1593.90,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,BCBS NC,Blue Value Group,,0.57464,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,BCBS NC,Blue Value Group,,9.43,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,BCBS NC,Blue Value Group,,224.21,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Value Group,,11.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,BCBS NC,Blue Value Group,,11.60,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,BCBS NC,Blue Value Group,,8.82,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,BCBS NC,Blue Value Group,,9.06,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,BCBS NC,Blue Value Group,,337.93,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,BCBS NC,Blue Value Group,,0.60076,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,BCBS NC,Blue Value Group,,44.98,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,BCBS NC,Blue Value Group,,31.36,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,BCBS NC,Blue Value Group,,386.03,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,BCBS NC,Blue Value Group,,54.34,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,BCBS NC,Blue Value Group,,20.54,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,BCBS NC,Blue Value Group,,31.83,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,BCBS NC,Blue Value Group,,15.11,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,BCBS NC,Blue Value Group,,11.23,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,BCBS NC,Blue Value Group,,8.72,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,BCBS NC,Blue Value Group,,8.83,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,BCBS NC,Blue Value Group,,44.40,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,BCBS NC,Blue Value Group,,9.69,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,BCBS NC,Blue Value Group,,116.47,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,BCBS NC,Blue Value Group,,163.01,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,BCBS NC,Blue Value Group,,7.73,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,BCBS NC,Blue Value Group,,860.65,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,BCBS NC,Blue Value Group,,41.09,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,BCBS NC,Blue Value Group,,12.64,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,BCBS NC,Blue Value Group,,42.84,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,BCBS NC,Blue Value Group,,24.81,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,BCBS NC,Blue Value Group,,30.30,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,BCBS NC,Blue Value Group,,1132.81,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,BCBS NC,Blue Value Group,,18.78,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,BCBS NC,Blue Value Group,,138.33,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,BCBS NC,Blue Value Group,,54.08,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,BCBS NC,Blue Value Group,,58.87,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,BCBS NC,Blue Value Group,,24.06,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,BCBS NC,Blue Value Group,,11.55,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,BCBS NC,Blue Value Group,,11.68,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,BCBS NC,Blue Value Group,,14.10,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,BCBS NC,Blue Value Group,,11.86,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,BCBS NC,Blue Value Group,,9.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,BCBS NC,Blue Value Group,,215.90,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,BCBS NC,Blue Value Group,,801.26,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,BCBS NC,Blue Value Group,,20.11,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,BCBS NC,Blue Value Group,,32.31,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,BCBS NC,Blue Value Group,,41.09,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,BCBS NC,Blue Value Group,,49.86,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,BCBS NC,Blue Value Group,,156.78,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,BCBS NC,Blue Value Group,,1877.59,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,BCBS NC,Blue Value Group,,66.40,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,BCBS NC,Blue Value Group,,110.30,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,BCBS NC,Blue Value Group,,46.08,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,BCBS NC,Blue Value Group,,17.75,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,BCBS NC,Blue Value Group,,31.37,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,BCBS NC,Blue Value Group,,16.32,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,BCBS NC,Blue Value Group,,104.17,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,BCBS NC,Blue Value Group,,90.07,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,BCBS NC,Blue Value Group,,33.40,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,BCBS NC,Blue Value Group,,33.56,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,BCBS NC,Blue Value Group,,33.48,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,BCBS NC,Blue Value Group,,123.66,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,BCBS NC,Blue Value Group,,47.14,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,BCBS NC,Blue Value Group,,0.75748,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,BCBS NC,Blue Value Group,,345.46,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,BCBS NC,Blue Value Group,,199.34,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,BCBS NC,Blue Value Group,,938.36,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Blue Value Group,,42.93,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,BCBS NC,Blue Value Group,,2.40,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,BCBS NC,Blue Value Group,,1136.01,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,BCBS NC,Blue Value Group,,52.53,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Value Group,,50.72,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,BCBS NC,Blue Value Group,,48.58,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,BCBS NC,Blue Value Group,,48.90,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,BCBS NC,Blue Value Group,,43.47,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,BCBS NC,Blue Value Group,,12.85,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,BCBS NC,Blue Value Group,,17.34,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,BCBS NC,Blue Value Group,,26.15,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Value Group,,50.72,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,BCBS NC,Blue Value Group,,50.72,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,BCBS NC,Blue Value Group,,42.31,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,BCBS NC,Blue Value Group,,39.96,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,BCBS NC,Blue Value Group,,184.23,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,BCBS NC,Blue Value Group,,30.59,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,BCBS NC,Blue Value Group,,25.57,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,BCBS NC,Blue Value Group,,2626.96,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,BCBS NC,Blue Value Group,,36.57,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,BCBS NC,Blue Value Group,,10.45,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,BCBS NC,Blue Value Group,,10.08,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,BCBS NC,Blue Value Group,,332.60,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,BCBS NC,Blue Value Group,,131.91,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,BCBS NC,Blue Value Group,,8.99,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,BCBS NC,Blue Value Group,,49.45,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,BCBS NC,Blue Value Group,,13.14,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,BCBS NC,Blue Value Group,,86.85,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,BCBS NC,Blue Value Group,,44.56,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,BCBS NC,Blue Value Group,,53.73,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,BCBS NC,Blue Value Group,,13.30,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,BCBS NC,Blue Value Group,,0.73136,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,BCBS NC,Blue Value Group,,1262.56,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,BCBS NC,Blue Value Group,,2081.54,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,BCBS NC,Blue Value Group,,251.61,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,BCBS NC,Blue Value Group,,370.01,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,BCBS NC,Blue Value Group,,9.01,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,BCBS NC,Blue Value Group,,548.68,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,BCBS NC,Blue Value Group,,28.13,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,BCBS NC,Blue Value Group,,895.71,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Value Group,,23.14,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,BCBS NC,Blue Value Group,,23.14,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,BCBS NC,Blue Value Group,,59.45,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,BCBS NC,Blue Value Group,,9.32,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,BCBS NC,Blue Value Group,,854.03,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,BCBS NC,Blue Value Group,,23502.03,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,BCBS NC,Blue Value Group,,80839.91,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,BCBS NC,Blue Value Group,,133256.25,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,BCBS NC,Blue Value Group,,5775.17,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,BCBS NC,Blue Value Group,,3824.43,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,BCBS NC,Blue Value Group,,135.30,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,BCBS NC,Blue Value Group,,7.13,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,BCBS NC,Blue Value Group,,0.62688,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,BCBS NC,Blue Value Group,,4.78,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,BCBS NC,Blue Value Group,,21.73,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10350,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,BCBS NC,Blue Value Group,,0.10448,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Group,,179.94,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,BCBS NC,Blue Value Group,,446.20,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,BCBS NC,Blue Value Group,,667.40,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,BCBS NC,Blue Value Group,,1002.31,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,BCBS NC,Blue Value Group,,1202.70,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,BCBS NC,Blue Value Group,,1442.97,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,BCBS NC,Blue Value Group,,1732.11,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,BCBS NC,Blue Value Group,,715.94,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,BCBS NC,Blue Value Group,,1051.54,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,BCBS NC,Blue Value Group,,1912.40,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Group,,82.14,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,BCBS NC,Blue Value Group,,324.98,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Value Group,,88.82,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,,60.07,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,31.83,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Group,,13.35,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Group,,73.42,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,32.34,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,41.59,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Group,,81.12,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Value Group,,269.02,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Value Group,,306.50,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Value Group,,260.81,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Group,,47.23,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,BCBS NC,Blue Value Group,,37.48,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Value Group,,118.08,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,BCBS NC,Blue Value Group,,108.33,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Value Group,,2686.62,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,BCBS NC,Blue Value Group,,2686.62,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,BCBS NC,Blue Value Group,,2557.76,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Value Group,,916.93,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,29.78,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,BCBS NC,Blue Value Group,,1542.77,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Value Group,,783.45,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Group,,160.69,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,41.59,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,32.34,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Value Group,,561.15,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Group,,175.58,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,BCBS NC,Blue Value Group,,634.56,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Value Group,,466.68,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Value Group,,155.56,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Value Group,,256.70,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Value Group,,481.57,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Value Group,,136.56,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Group,,104.73,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,BCBS NC,Blue Value Group,,560.63,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Value Group,,486.70,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Value Group,,146.83,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Group,,22.08,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Group,,17.97,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Group,,71.88,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Value Group,,243.35,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Group,,64.69,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,BCBS NC,Blue Value Group,,146.83,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Group,,68.80,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Value Group,,5.65,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,BCBS NC,Blue Value Group,,2559.30,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,BCBS NC,Blue Value Group,,10319.34,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,BCBS NC,Blue Value Group,,2604.99,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,BCBS NC,Blue Value Group,,2176.82,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,BCBS NC,Blue Value Group,,1785.61,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Group,,237.70,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Group,,1903.85,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,BCBS NC,Blue Value Group,,2181.20,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,BCBS NC,Blue Value Group,,2147.97,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Value Group,,1700.18,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,BCBS NC,Blue Value Group,,2809.55,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Value Group,,2148.15,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,BCBS NC,Blue Value Group,,1994.85,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Value Group,,2321.31,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,BCBS NC,Blue Value Group,,2321.31,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,BCBS NC,Blue Value Group,,2824.48,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Group,,1903.85,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Group,,1903.85,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,BCBS NC,Blue Value Group,,1700.18,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,BCBS NC,Blue Value Group,,1903.85,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Value Group,,840.22,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,BCBS NC,Blue Value Group,,1978.96,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,BCBS NC,Blue Value Group,,814.22,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Value Group,,3129.27,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,BCBS NC,Blue Value Group,,548.31,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,BCBS NC,Blue Value Group,,1126.26,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,BCBS NC,Blue Value Group,,1706.06,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,BCBS NC,Blue Value Group,,1989.94,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Value Group,,62.12,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,BCBS NC,Blue Value Group,,591.47,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,BCBS NC,Blue Value Group,,1187.79,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Group,,28.78,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Value Group,,161.91,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,BCBS NC,Blue Value Group,,191.68,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,BCBS NC,Blue Value Group,,433.16,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,BCBS NC,Blue Value Group,,328.00,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Group,,21.98,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Group,,24.48,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Value Group,GP,5.84,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Value Group,,160.34,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,BCBS NC,Blue Value Group,,655.92,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,BCBS NC,Blue Value Group,,620.99,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,BCBS NC,Blue Value Group,,497.84,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,BCBS NC,Blue Value Group,,374.69,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Value Group,,251.54,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Group,,128.39,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,BCBS NC,Blue Value Group,,788.70,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,BCBS NC,Blue Value Group,,2356.94,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,BCBS NC,Blue Value Group,,3125.90,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Value Group,,1778.45,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,BCBS NC,Blue Value Group,,1350.17,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,BCBS NC,Blue Value Group,,12595.08,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,BCBS NC,Blue Value Group,,13192.62,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,BCBS NC,Blue Value Group,,13885.02,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,BCBS NC,Blue Value Group,,14480.63,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,BCBS NC,Blue Value Group,,15078.65,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,BCBS NC,Blue Value Group,,15674.75,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,BCBS NC,Blue Value Group,,16174.07,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,BCBS NC,Blue Value Group,,16866.46,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,BCBS NC,Blue Value Group,,17463.04,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,BCBS NC,Blue Value Group,,18059.62,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,BCBS NC,Blue Value Group,,18656.68,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Value Group,,186.82,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,BCBS NC,Blue Value Group,,257.12,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Value Group,,399.16,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,BCBS NC,Blue Value Group,,402.53,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,BCBS NC,Blue Value Group,,1942.85,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,BCBS NC,Blue Value Group,,4663.33,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,BCBS NC,Blue Value Group,,5010.97,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,BCBS NC,Blue Value Group,,5382.69,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,BCBS NC,Blue Value Group,,2934.26,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,BCBS NC,Blue Value Group,,3790.85,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,BCBS NC,Blue Value Group,,4311.83,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,BCBS NC,Blue Value Group,,5551.69,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,BCBS NC,Blue Value Group,,5699.03,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,BCBS NC,Blue Value Group,,5837.71,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,BCBS NC,Blue Value Group,,5976.86,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,BCBS NC,Blue Value Group,,6115.53,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,BCBS NC,Blue Value Group,,2381.50,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Value Group,,321.64,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,BCBS NC,Blue Value Group,,2121.49,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,BCBS NC,Blue Value Group,,2864.44,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,BCBS NC,Blue Value Group,,3922.30,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,BCBS NC,Blue Value Group,,4971.01,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,BCBS NC,Blue Value Group,,5675.44,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,BCBS NC,Blue Value Group,,6428.02,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,BCBS NC,Blue Value Group,,7332.76,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,BCBS NC,Blue Value Group,,7860.01,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,BCBS NC,Blue Value Group,,8638.11,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,BCBS NC,Blue Value Group,,9061.35,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,BCBS NC,Blue Value Group,,9615.56,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,BCBS NC,Blue Value Group,,9972.35,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,BCBS NC,Blue Value Group,,10061.91,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,BCBS NC,Blue Value Group,,10211.17,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,BCBS NC,Blue Value Group,,10508.74,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,BCBS NC,Blue Value Group,,10806.79,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,BCBS NC,Blue Value Group,,11104.35,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,BCBS NC,Blue Value Group,,11404.33,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,BCBS NC,Blue Value Group,,11701.41,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,BCBS NC,Blue Value Group,,11999.94,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Value Group,,6454.99,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,BCBS NC,Blue Value Group,,5470.80,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Value Group,,3391.20,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Value Group,,3391.20,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,BCBS NC,Blue Value Group,,3391.20,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Value Group,,3120.12,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,BCBS NC,Blue Value Group,,6454.99,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,BCBS NC,Blue Value Group,,3641.10,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,BCBS NC,Blue Value Group,,4102.86,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Value Group,,145.89,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Group,,611.99,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Value Group,,244.60,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,BCBS NC,Blue Value Group,,244.60,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,BCBS NC,Blue Value Group,,389.05,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,BCBS NC,Blue Value Group,,5197.31,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,BCBS NC,Blue Value Group,,910.03,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Value Group,,589.84,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,BCBS NC,Blue Value Group,,3683.13,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Group,,142.52,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Value Group,,350.10,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,BCBS NC,Blue Value Group,,1.39,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Value Group,,707.42,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Value Group,,912.48,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Value Group,,1118.40,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,BCBS NC,Blue Value Group,,1323.46,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,BCBS NC,Blue Value Group,,1528.96,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,BCBS NC,Blue Value Group,,1734.45,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,BCBS NC,Blue Value Group,,1939.51,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,BCBS NC,Blue Value Group,,283.57,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Value Group,,1407.12,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Value Group,,1854.14,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Value Group,,555.13,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Value Group,,756.33,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Value Group,,843.41,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Value Group,,933.93,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Value Group,,1024.02,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Value Group,,1113.68,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Value Group,,1204.20,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,BCBS NC,Blue Value Group,,707.42,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Value Group,,410.98,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,BCBS NC,Blue Value Group,,1024.02,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Value Group,,555.13,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,BCBS NC,Blue Value Group,,756.33,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,BCBS NC,Blue Value Group,,843.41,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,BCBS NC,Blue Value Group,,933.93,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,BCBS NC,Blue Value Group,,1113.68,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,BCBS NC,Blue Value Group,,1204.20,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,BCBS NC,Blue Value Group,,1407.12,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,BCBS NC,Blue Value Group,,1854.14,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Group,,214.07,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,BCBS NC,Blue Value Group,,1778.45,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Group,,147.77,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Value Group,,703.60,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Value Group,,796.93,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,BCBS NC,Blue Value Group,,891.30,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Value Group,,985.67,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,BCBS NC,Blue Value Group,,1081.07,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Value Group,,1175.96,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Value Group,,1270.33,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,BCBS NC,Blue Value Group,,1364.17,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,BCBS NC,Blue Value Group,,1458.02,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,BCBS NC,Blue Value Group,,1553.43,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,BCBS NC,Blue Value Group,,1647.27,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,BCBS NC,Blue Value Group,,1770.16,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Value Group,,1865.56,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,BCBS NC,Blue Value Group,,2225.92,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Value Group,,2371.62,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,BCBS NC,Blue Value Group,,2482.06,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,BCBS NC,Blue Value Group,,2576.43,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,BCBS NC,Blue Value Group,,2670.28,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,BCBS NC,Blue Value Group,,2103.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,BCBS NC,Blue Value Group,,2232.23,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,BCBS NC,Blue Value Group,,2137.78,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,BCBS NC,Blue Value Group,,1354.84,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,BCBS NC,Blue Value Group,,1464.76,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Value Group,,1288.99,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,BCBS NC,Blue Value Group,,1732.83,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Value Group,,162.27,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Value Group,,4854.48,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Value Group,,4854.48,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,BCBS NC,Blue Value Group,,4854.48,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Value Group,,613.91,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,BCBS NC,Blue Value Group,,1009.22,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,BCBS NC,Blue Value Group,,1121.41,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,BCBS NC,Blue Value Group,,608.62,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Group,,232.56,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Group,,181.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Value Group,,3608.36,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Value Group,,489.20,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Group,,194.53,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Value Group,,2202.38,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Value Group,,5218.02,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,BCBS NC,Blue Value Group,,2539.43,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Value Group,,85.41,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00448,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,BCBS NC,Blue Value Group,,19252.30,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,BCBS NC,Blue Value Group,,19848.39,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,BCBS NC,Blue Value Group,,907.63,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,BCBS NC,Blue Value Group,,268.20,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,BCBS NC,Blue Value Group,,1403.57,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,36.98,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,18.27,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,BCBS NC,Blue Value Group,,28.05,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Value Group,,59.69,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Group,,32.62,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Group,,32.29,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Group,Q0,0.48904,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Group,Q0,0.48904,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Value Group,,308.04,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Value Group,,383.00,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,BCBS NC,Blue Value Group,,705.92,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,BCBS NC,Blue Value Group,,10046.72,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,BCBS NC,Blue Value Group,,4682.21,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Group,,2628.61,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,BCBS NC,Blue Value Group,,2543.38,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,BCBS NC,Blue Value Group,,3818.67,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,BCBS NC,Blue Value Group,,4321.80,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Group,,2628.61,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,BCBS NC,Blue Value Group,,3259.06,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Group,,163.26,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Value Group,,52.88,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Value Group,,107.30,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,14.38,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Group,,74.44,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Group,,163.26,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Group,,64.69,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Value Group,,77.52,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,BCBS NC,Blue Value Group,,94.47,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Value Group,,151.45,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,BCBS NC,Blue Value Group,,182.26,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Group,,538.04,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,BCBS NC,Blue Value Group,,52.88,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Value Group,,218.19,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Value Group,,308.04,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,BCBS NC,Blue Value Group,,550.88,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,BCBS NC,Blue Value Group,,486.70,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Value Group,,383.00,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,BCBS NC,Blue Value Group,,383.00,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Group,,140.16,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,BCBS NC,Blue Value Group,,397.37,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Group,,2628.61,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Value Group,,258.24,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Value Group,,232.06,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,BCBS NC,Blue Value Group,,692.58,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,BCBS NC,Blue Value Group,,2628.61,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,BCBS NC,Blue Value Group,,761.89,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,BCBS NC,Blue Value Group,,707.98,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,29.78,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,29.78,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,29.78,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,29.78,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Group,,274.67,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Group,,274.67,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Group,,274.67,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00513,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Value Group,,3450.05,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Value Group,,473.35,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Value Group,,473.35,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,BCBS NC,Blue Value Group,,473.35,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,BCBS NC,Blue Value Group,,623.78,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,BCBS NC,Blue Value Group,,837.36,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,BCBS NC,Blue Value Group,,1488.35,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Group,,179.69,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Group,,237.70,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Group,,71.88,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,48.77,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Value Group,,85.22,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Group,,179.69,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,46.72,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,51.85,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Value Group,,2705.62,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,BCBS NC,Blue Value Group,,525.72,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Group,,327.04,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,BCBS NC,Blue Value Group,,20477.47,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,BCBS NC,Blue Value Group,,8799.57,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Value Group,,152.48,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,BCBS NC,Blue Value Group,,158.13,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,BCBS NC,Blue Value Group,,993.08,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,BCBS NC,Blue Value Group,,3752.91,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,BCBS NC,Blue Value Group,,897.35,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,BCBS NC,Blue Value Group,,1705.16,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,BCBS NC,Blue Value Group,,20813.85,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,BCBS NC,Blue Value Group,,6477.55,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,BCBS NC,Blue Value Group,,5754.60,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,BCBS NC,Blue Value Group,,8106.64,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,BCBS NC,Blue Value Group,,16341.61,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Value Group,,1365.68,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,BCBS NC,Blue Value Group,,5753.05,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,BCBS NC,Blue Value Group,,8301.74,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Value Group,,4864.98,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Value Group,,1395.18,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,BCBS NC,Blue Value Group,,1384.13,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,BCBS NC,Blue Value Group,,4329.40,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Group,,0.48904,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,BCBS NC,Blue Value Group,,4616.10,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,BCBS NC,Blue Value Group,,5835.85,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,BCBS NC,Blue Value Group,,3147.66,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,BCBS NC,Blue Value Group,,8018.66,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Value Group,,644.32,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Value Group,,275.70,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,BCBS NC,Blue Value Group,,3450.05,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,BCBS NC,Blue Value Group,,2705.62,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,BCBS NC,Blue Value Group,,482.60,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Value Group,,112.95,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Value Group,,284.94,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,BCBS NC,Blue Value Group,,2790.84,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,BCBS NC,Blue Value Group,,10188.42,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,BCBS NC,Blue Value Group,,14062.03,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Value Group,,144.27,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Value Group,,144.27,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Value Group,,135.02,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Value Group,,135.02,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,BCBS NC,Blue Value Group,,135.02,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00513,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,BCBS NC,Blue Value Group,,1604.38,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,BCBS NC,Blue Value Group,,601.70,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,BCBS NC,Blue Value Group,,773.69,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,BCBS NC,Blue Value Group,,726.46,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,BCBS NC,Blue Value Group,,703.36,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,BCBS NC,Blue Value Group,,4824.57,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,BCBS NC,Blue Value Group,Q1,3067.41,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,BCBS NC,Blue Value Group,Q0,1837.54,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Group,,95.08,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Value Group,,117.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Group,,152.73,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Group,,104.88,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Value Group,,162.75,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Group,,104.88,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Group,,104.88,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Group,,25.59,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Group,,80.12,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Group,,121.57,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Group,,72.89,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,BCBS NC,Blue Value Group,,65.10,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Value Group,,181.39,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,56.47,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Value Group,,14.80,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,BCBS NC,Blue Value Group,,662.37,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,,40.81,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,,40.81,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Value Group,,83.71,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,BCBS NC,Blue Value Group,,125.57,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Group,,161.49,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Value Group,,146.50,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,BCBS NC,Blue Value Group,,679.11,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Value Group,,694.11,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,BCBS NC,Blue Value Group,,325.08,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,BCBS NC,Blue Value Group,,490.76,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,BCBS NC,Blue Value Group,,509.25,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,BCBS NC,Blue Value Group,,601.33,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,BCBS NC,Blue Value Group,,731.78,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,BCBS NC,Blue Value Group,,1227.43,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,BCBS NC,Blue Value Group,,2177.21,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,BCBS NC,Blue Value Group,,2347.77,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,BCBS NC,Blue Value Group,,221.49,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,BCBS NC,Blue Value Group,,296.83,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,BCBS NC,Blue Value Group,,2215.58,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Value Group,,2488.69,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Value Group,,2488.69,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Value Group,,592.26,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,BCBS NC,Blue Value Group,,965.83,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Value Group,,256.02,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,BCBS NC,Blue Value Group,,382.28,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,BCBS NC,Blue Value Group,,163.59,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,BCBS NC,Blue Value Group,,337.64,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,BCBS NC,Blue Value Group,,239.63,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,BCBS NC,Blue Value Group,,538.90,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,BCBS NC,Blue Value Group,,373.56,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,BCBS NC,Blue Value Group,,649.47,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,BCBS NC,Blue Value Group,,156.96,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Value Group,,419.96,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,BCBS NC,Blue Value Group,,2613.21,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,BCBS NC,Blue Value Group,,2599.96,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,BCBS NC,Blue Value Group,,836.42,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,BCBS NC,Blue Value Group,,609.00,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,BCBS NC,Blue Value Group,,1081.28,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,BCBS NC,Blue Value Group,,2937.94,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Value Group,,148.24,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Value Group,,197.77,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Value Group,,759.69,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,BCBS NC,Blue Value Group,,729.69,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,BCBS NC,Blue Value Group,,1616.69,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,BCBS NC,Blue Value Group,,857.35,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Value Group,,1046.05,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Group,,110.22,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,BCBS NC,Blue Value Group,,111.96,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,BCBS NC,Blue Value Group,,375.31,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Group,,173.00,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Value Group,,210.33,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Group,,173.00,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Blue Value Group,,536.11,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Group,,214.51,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Blue Value Group,,256.02,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Blue Value Group,,127.14,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,BCBS NC,Blue Value Group,,92.08,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Value Group,,182.42,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Blue Value Group,,2488.69,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,BCBS NC,Blue Value Group,,359.96,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,BCBS NC,Blue Value Group,,310.08,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,BCBS NC,Blue Value Group,,405.65,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Value Group,,366.59,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Value Group,,490.41,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Blue Value Group,76,490.41,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,,650.51,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Value Group,,1307.30,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Blue Value Group,76,1307.30,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Value Group,,1376.02,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Blue Value Group,76,1376.02,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Value Group,,709.46,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Value Group,,788.64,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,BCBS NC,Blue Value Group,,831.19,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,BCBS NC,Blue Value Group,,917.00,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,BCBS NC,Blue Value Group,,639.35,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Value Group,,914.55,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Group,,119.64,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Group,,144.05,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Group,,144.05,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Group,,101.85,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,BCBS NC,Blue Value Group,,991.29,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,BCBS NC,Blue Value Group,,9521.89,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,BCBS NC,Blue Value Group,,1309.05,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Value Group,,1505.42,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Blue Value Group,,1505.42,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,BCBS NC,Blue Value Group,,226.02,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Value Group,,246.95,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,BCBS NC,Blue Value Group,,427.28,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Value Group,,299.97,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Value Group,,318.80,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,BCBS NC,Blue Value Group,,327.17,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Group,,223.58,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,,650.51,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,76,650.51,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,,650.51,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,76,650.51,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Group,,119.64,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Value Group,,226.72,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,BCBS NC,Blue Value Group,,126.61,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,,650.51,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,76,650.51,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Group,,158.70,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,BCBS NC,Blue Value Group,76,299.97,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,BCBS NC,Blue Value Group,76,318.80,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Group,,174.05,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,BCBS NC,Blue Value Group,,364.15,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,BCBS NC,Blue Value Group,,568.20,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Value Group,,817.24,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,BCBS NC,Blue Value Group,,2411.60,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Value Group,,255.67,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,BCBS NC,Blue Value Group,,2116.17,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,BCBS NC,Blue Value Group,,786.20,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,BCBS NC,Blue Value Group,,989.55,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Value Group,,644.58,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,BCBS NC,Blue Value Group,,303.80,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Group,,191.49,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,BCBS NC,Blue Value Group,,280.78,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Group,,436.70,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,BCBS NC,Blue Value Group,,2847.60,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,BCBS NC,Blue Value Group,,840.61,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Value Group,,141.26,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,BCBS NC,Blue Value Group,,195.33,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,BCBS NC,Blue Value Group,,579.71,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,BCBS NC,Blue Value Group,,670.74,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,BCBS NC,Blue Value Group,,444.37,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Group,,110.22,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,BCBS NC,Blue Value Group,,226.72,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,BCBS NC,Blue Value Group,,759.69,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Value Group,,1503.72,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,BCBS NC,Blue Value Group,,97.65,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,BCBS NC,Blue Value Group,,507.50,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Value Group,,11.09,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,BCBS NC,Blue Value Group,,223.90,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,BCBS NC,Blue Value Group,,335.33,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,BCBS NC,Blue Value Group,,395.35,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Value Group,,155.04,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,BCBS NC,Blue Value Group,,364.50,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Group,,78.00,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Value Group,,325.49,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Value Group,,128.39,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,BCBS NC,Blue Value Group,,165.53,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,17.53,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Group,,31.44,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,7.79,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,7.79,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Value Group,,84.02,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Group,,10.29,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Group,,10.29,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Value Group,,6.40,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,16.14,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,15.58,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Value Group,,30.32,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Group,,55.64,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Group,,44.79,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Group,,31.44,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Group,,37.00,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Group,,31.44,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,BCBS NC,Blue Value Group,,121.85,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Group,,13.91,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Group,,114.90,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Group,,80.12,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,15.02,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Group,,10.29,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,BCBS NC,Blue Value Group,,53.14,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Group,,74.84,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Value Group,GP,17.72,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Group,GP,19.84,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Group,GP,3.17,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,BCBS NC,Blue Value Group,GP,32.00,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,GP,12.96,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Value Group,GP,4.23,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,BCBS NC,Blue Value Group,GP,40.47,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Group,GP,43.11,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Group,GP,33.86,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,GP,29.09,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,GP,15.61,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Group,GP,43.38,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Group,GP,42.32,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Value Group,GP,38.09,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,GP,43.64,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Group,GP,36.77,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Group,GP,53.43,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,GP,30.95,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,GP,34.12,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,BCBS NC,Blue Value Group,GP,39.94,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Group,GP,12.43,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,GP,31.21,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Group,GP,22.48,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,GP,34.12,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Group,GP,26.19,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Group,GP,47.61,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Group,GP,47.61,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,GP,24.07,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,GP,24.07,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,GP,23.54,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Group,GP,33.59,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Group,GP,34.38,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Group,GP,18.52,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Group,GP,7.93,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Value Group,GP,80.94,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Value Group,GP,111.88,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,BCBS NC,Blue Value Group,GP,114.79,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Group,GP,76.18,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,GO,24.07,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,GO,30.95,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,GO,34.12,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,GO,31.21,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Group,GO,18.52,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,GO,34.12,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Group,GO,26.19,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Group,GO,3.17,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Group,GO,43.11,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Group,GO,33.86,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,GO,16.40,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Group,GO,43.38,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Group,GO,42.32,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,BCBS NC,Blue Value Group,GO,38.09,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,GO,43.64,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,GO,12.96,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Value Group,GO,59.25,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Group,GO,40.20,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Group,GO,33.59,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Group,GO,19.84,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Group,GO,84.11,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,BCBS NC,Blue Value Group,GO,106.59,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,BCBS NC,Blue Value Group,GO,109.77,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Group,GO,53.43,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Value Group,GN,94.16,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Value Group,GN,88.87,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Value Group,GN,49.46,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Group,GN,71.15,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Group,GN,52.90,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Group,GN,83.32,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Group,GN,33.86,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Group,GN,18.52,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Group,GN,22.48,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Group,GN,26.19,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Value Group,GN,60.57,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,GN,35.97,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,BCBS NC,Blue Value Group,GN,173.25,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Value Group,GN,68.51,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Value Group,GN,17.99,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Group,GN,34.38,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Group,GN,18.52,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Group,GN,7.93,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,BCBS NC,Blue Value Group,GN,56.60,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Value Group,GN,60.57,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Group,GN,28.30,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Value Group,GN,93.37,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Group,GN,145.21,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,BCBS NC,Blue Value Group,GN,156.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Value Group,,240.36,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Blue Value Group,,152.73,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,BCBS NC,Blue Value Group,,246.21,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Value Group,,140.21,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,BCBS NC,Blue Value Group,,207.26,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,BCBS NC,Blue Value Group,,1044.92,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Group,,11.96,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Value Group,,41.17,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,BCBS NC,Blue Value Group,,146.06,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Value Group,,145.50,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,BCBS NC,Blue Value Group,,156.63,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Group,,104.88,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Blue Value Group,,104.88,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Value Group,,377.52,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,BCBS NC,Blue Value Group,,116.29,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Value Group,,225.90,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Group,,29.77,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Blue Value Group,,157.74,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,BCBS NC,Blue Value Group,,132.42,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Blue Value Group,,181.39,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Group,,127.42,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Group,,43.40,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Group,,50.08,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Blue Value Group,,325.49,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,BCBS NC,Blue Value Group,,36.44,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Value Group,,428.98,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Blue Value Group,,428.98,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Value Group,,73.44,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Value Group,,73.44,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,BCBS NC,Blue Value Group,,652.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Value Group,,868.82,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Value Group,,194.74,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,BCBS NC,Blue Value Group,,680.46,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Value Group,,231.18,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,BCBS NC,Blue Value Group,,140.49,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,BCBS NC,Blue Value Group,,61.76,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Blue Value Group,,92.64,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,BCBS NC,Blue Value Group,,94.03,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Value Group,,51.47,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Value Group,,2901.85,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Blue Value Group,,2901.85,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,BCBS NC,Blue Value Group,,488.36,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Value Group,,2016.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Blue Value Group,,2016.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,BCBS NC,Blue Value Group,,2048.53,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,BCBS NC,Blue Value Group,,321.04,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,BCBS NC,Blue Value Group,,265.07,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Value Group,,157.18,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,BCBS NC,Blue Value Group,,375.57,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Value Group,,462.43,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Group,,153.01,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Blue Value Group,,462.43,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Blue Value Group,,292.39,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,BCBS NC,Blue Value Group,,217.53,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Group,,353.59,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,BCBS NC,Blue Value Group,,556.55,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Value Group,,202.53,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Group,,230.98,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Value Group,,313.25,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Group,,151.74,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Value Group,,210.88,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Value Group,,59.54,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Blue Value Group,,266.52,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Group,,158.85,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,BCBS NC,Blue Value Group,,129.08,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Group,,149.95,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Blue Value Group,,139.93,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Value Group,,437.33,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Value Group,,194.48,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Blue Value Group,,437.33,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Blue Value Group,,194.48,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Group,,179.11,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,BCBS NC,Blue Value Group,,187.51,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Value Group,,228.68,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,BCBS NC,Blue Value Group,,237.86,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Value Group,,247.04,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Group,,149.95,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Value Group,,119.35,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Value Group,,82.07,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Group,,121.57,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Group,,70.38,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Value Group,,170.81,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,BCBS NC,Blue Value Group,,170.81,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,BCBS NC,Blue Value Group,,152.18,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Group,,58.98,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Group,,58.98,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Group,,58.98,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Group,,58.98,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Value Group,,111.28,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Value Group,,111.28,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Blue Value Group,,111.28,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Value Group,,74.28,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Value Group,,101.82,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Blue Value Group,,101.82,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Value Group,,454.86,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Blue Value Group,,454.86,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Blue Value Group,,127.14,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Group,,126.58,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,BCBS NC,Blue Value Group,,414.80,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Blue Value Group,,424.53,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,BCBS NC,Blue Value Group,,235.91,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,BCBS NC,Blue Value Group,,343.02,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Blue Value Group,,117.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,BCBS NC,Blue Value Group,,478.76,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Group,,198.81,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,BCBS NC,Blue Value Group,,261.23,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,BCBS NC,Blue Value Group,,631.46,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,BCBS NC,Blue Value Group,,762.56,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Value Group,,936.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,BCBS NC,Blue Value Group,,1328.71,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,BCBS NC,Blue Value Group,,1459.33,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,BCBS NC,Blue Value Group,,1851.65,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Value Group,,1089.09,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,BCBS NC,Blue Value Group,,1219.71,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,BCBS NC,Blue Value Group,,1372.41,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,BCBS NC,Blue Value Group,,2178.19,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,BCBS NC,Blue Value Group,,2439.42,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,BCBS NC,Blue Value Group,,2722.73,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Value Group,,500.37,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,52.30,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,52.30,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,17.53,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Value Group,,62.59,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Group,,81.23,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Group,,81.79,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Group,,13.35,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Group,,13.35,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,32.83,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,32.83,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,32.83,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,32.83,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Group,,29.49,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,32.83,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Group,,215.60,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Group,,215.60,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Group,,215.60,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Group,,215.60,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Group,,215.60,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,BCBS NC,Blue Value Group,,215.60,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Group,,20.86,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,BCBS NC,Blue Value Group,GP,17.63,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,BCBS NC,Blue Value Group,,156.25,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Value Group,,1321.24,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Blue Value Group,,895.09,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Value Group,,1264.03,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Value Group,,522.43,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Blue Value Group,,353.93,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,BCBS NC,Blue Value Group,,803.76,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Value Group,,338.92,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,BCBS NC,Blue Value Group,,338.92,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,BCBS NC,Blue Value Group,,1040.58,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,BCBS NC,Blue Value Group,,140.27,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Value Group,,156.58,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Value Group,,174.84,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Group,,149.40,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Value Group,,38.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,,42.08,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,,42.08,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Value Group,,67.85,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Group,,53.17,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Blue Value Group,,100.14,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,BCBS NC,Blue Value Group,,169.62,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Blue Value Group,,164.40,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,BCBS NC,Blue Value Group,,201.59,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,BCBS NC,Blue Value Group,,133.42,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Value Group,,370.75,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Value Group,,251.17,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,BCBS NC,Blue Value Group,,307.20,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Blue Value Group,,196.70,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Value Group,,294.23,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Group,,87.63,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Group,,73.19,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Value Group,,134.82,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Value Group,,126.57,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Value Group,,365.46,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Value Group,,247.59,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Value Group,,1105.04,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,BCBS NC,Blue Value Group,,198.00,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Value Group,,897.03,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Blue Value Group,,607.71,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Value Group,,1026.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Blue Value Group,,174.84,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Group,,338.27,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,BCBS NC,Blue Value Group,,4079.78,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,BCBS NC,Blue Value Group,,495.82,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,BCBS NC,Blue Value Group,,630.54,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Value Group,,272.05,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,BCBS NC,Blue Value Group,,283.47,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,BCBS NC,Blue Value Group,,301.74,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,BCBS NC,Blue Value Group,,501.70,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Value Group,,625.65,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,BCBS NC,Blue Value Group,,3188.28,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Group,,317.79,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Group,,215.29,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Value Group,,1535.50,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Value Group,,1040.25,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Value Group,,735.73,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Value Group,,498.43,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,BCBS NC,Blue Value Group,,563.35,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Value Group,,1031.37,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Blue Value Group,,698.72,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Value Group,,672.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Blue Value Group,,455.70,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Value Group,,299.01,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Blue Value Group,,202.57,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Value Group,,346.68,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,BCBS NC,Blue Value Group,,234.86,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,29.37,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,19.90,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Group,,179.60,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Value Group,,730.69,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Group,JW,68.96,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Value Group,,191.15,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Group,,240.27,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,BCBS NC,Blue Value Group,,290.83,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Group,,162.77,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Blue Value Group,,282.16,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Blue Value Group,,268.14,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,BCBS NC,Blue Value Group,,444.94,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Value Group,,114.82,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Group,,1897.59,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Group,,1285.55,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Group,,1897.59,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Blue Value Group,,1285.55,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Value Group,,938.92,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Blue Value Group,,636.09,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Value Group,,1494.09,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Blue Value Group,,1012.20,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,BCBS NC,Blue Value Group,,562.04,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Blue Value Group,,695.46,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Value Group,,913.36,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Value Group,,261.45,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,BCBS NC,Blue Value Group,,2111.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,BCBS NC,Blue Value Group,,2335.28,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,BCBS NC,Blue Value Group,,2760.92,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Group,,387.13,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Value Group,,510.50,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,BCBS NC,Blue Value Group,,510.50,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,BCBS NC,Blue Value Group,,626.63,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,BCBS NC,Blue Value Group,,554.87,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Group,,189.85,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Blue Value Group,,739.82,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,BCBS NC,Blue Value Group,,412.64,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Value Group,,1123.34,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Value Group,,761.02,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,BCBS NC,Blue Value Group,,667.73,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,BCBS NC,Blue Value Group,,435.48,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Value Group,,276.29,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Value Group,,857.55,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Blue Value Group,,580.96,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Blue Value Group,,553.89,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Value Group,,450.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Blue Value Group,,450.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Group,,585.20,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Group,,863.81,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Value Group,,1343.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Blue Value Group,,1983.30,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Value Group,,1673.21,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Blue Value Group,,1673.21,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Value Group,,246.53,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Value Group,,286.01,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,29.37,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,BCBS NC,Blue Value Group,52,529.65,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Blue Value Group,,365.46,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,BCBS NC,Blue Value Group,,197.80,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,BCBS NC,Blue Value Group,,406.45,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Group,,35.33,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Value Group,,442.50,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Value Group,,299.78,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Group,,179.60,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Group,,83.00,,,,,,,59.12,365.00,per diem,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,BCBS NC,Blue Value Group,,164.00,,,,,,,129.99,624.00,per diem,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,BCBS NC,Blue Value Group,,412.00,,,,,,,259.79,1295.00,per diem,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,BCBS NC,Blue Value Group,,871.00,,,,,,,409.68,3235.00,per diem,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,BCBS NC,Blue Value Group,,1036.00,,,,,,,589.86,3709.00,per diem,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,BCBS NC,Blue Value Group,,1751.60,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,BCBS NC,Blue Value Group,,578.19,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,BCBS NC,Blue Value Group,,361.50,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Value Group,,167.18,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Group,,137.08,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Group,,87.53,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Group,,46.72,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Group,,46.72,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Value Group,,661.56,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Group,,55.92,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,52.30,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Value Group,,69.27,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Value Group,,66.77,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Group,,88.19,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Group,,111.00,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Group,,103.21,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Group,,132.15,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Value Group,,50.35,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Group,,20.03,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Value Group,,63.15,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Group,,27.82,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Value Group,,74.28,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Value Group,,69.55,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Value Group,,112.95,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Value Group,,121.02,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Group,,121.57,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Value Group,,110.45,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Value Group,,50.35,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Value Group,,70.66,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Blue Value Group,,107.94,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,BCBS NC,Blue Value Group,,136.04,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Group,,18.36,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Group,,29.49,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,BCBS NC,Blue Value Group,,48.96,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,BCBS NC,Blue Value Group,,72.33,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Group,,95.42,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Value Group,,64.26,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Group,,88.19,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Group,,132.15,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,BCBS NC,Blue Value Group,,160.24,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,13.63,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Group,,25.87,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Value Group,,38.11,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Value Group,,31.16,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Group,,13.35,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Group,,67.28,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,BCBS NC,Blue Value Group,,12.94,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,49.16,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,27.95,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Group,JW,64.26,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Group,,63.65,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,JW,49.63,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,BCBS NC,Blue Value Group,,73.48,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Group,,141.19,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Group,,103.50,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Group,JW,104.48,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Group,,235.46,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Group,,471.44,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Group,JW,475.91,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Blue Value Group,JW,237.69,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Group,,511.29,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,323.95,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Group,,141.28,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Group,JW,516.13,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Group,JW,142.62,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Group,,295.49,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Group,,135.59,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Group,,1425.19,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Group,,629.28,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Group,,318.78,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,BCBS NC,Blue Value Group,JW,1438.69,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,BCBS NC,Blue Value Group,JW,635.24,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Group,JW,321.80,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Value Group,,1455.73,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Group,,63.65,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Group,,176.99,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,BCBS NC,Blue Value Group,JW,178.66,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Group,,800.05,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,BCBS NC,Blue Value Group,,1601.14,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,BCBS NC,Blue Value Group,JW,807.63,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Group,,221.49,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,BCBS NC,Blue Value Group,JW,223.59,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Group,,249.95,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Group,JW,252.32,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,BCBS NC,Blue Value Group,,5.17,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Group,,1292.71,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,BCBS NC,Blue Value Group,JW,1304.96,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Group,,1047.94,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,BCBS NC,Blue Value Group,JW,1057.86,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Group,,883.89,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,BCBS NC,Blue Value Group,JW,892.26,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,33.64,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,JW,33.96,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Value Group,,1277.71,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Group,,361.21,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,BCBS NC,Blue Value Group,,364.64,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,323.95,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,327.02,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Group,,318.26,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Group,,321.28,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,227.18,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,229.33,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Group,,206.48,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Group,,208.44,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,BCBS NC,Blue Value Group,JW,1234.43,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Group,JW,298.29,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Blue Value Group,JW,136.87,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Group,,161.98,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Group,JW,163.51,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Group,,815.06,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,BCBS NC,Blue Value Group,JW,822.78,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Group,,647.91,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Blue Value Group,JW,654.04,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Group,,331.72,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,BCBS NC,Blue Value Group,JW,334.86,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Group,,175.95,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,BCBS NC,Blue Value Group,JW,177.62,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Group,,140.76,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,BCBS NC,Blue Value Group,JW,142.09,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,BCBS NC,Blue Value Group,,1325.84,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Blue Value Group,,141.66,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Group,,305.89,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Group,,305.89,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Group,,305.89,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Group,,305.89,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Value Group,,88.07,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,BCBS NC,Blue Value Group,,1384.07,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,BCBS NC,Blue Value Group,,50.35,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Value Group,,80.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,BCBS NC,Blue Value Group,,840.62,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Value Group,,93.69,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Blue Value Group,,98.84,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Value Group,,644.57,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Blue Value Group,,644.57,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Group,,140.92,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Group,,140.92,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Value Group,,109.93,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Value Group,,91.34,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Group,,87.75,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,BCBS NC,Blue Value Group,,3528.38,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,BCBS NC,Blue Value Group,,385.88,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Group,,338.27,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,BCBS NC,Blue Value Group,,390.46,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,BCBS NC,Blue Value Group,,262.92,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Value Group,,955.78,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Blue Value Group,,746.76,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Value Group,,5621.99,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Blue Value Group,,4392.51,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Value Group,,9782.15,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Blue Value Group,,7642.88,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Value Group,,4160.16,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Blue Value Group,,3250.37,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Value Group,,8826.38,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Blue Value Group,,6896.12,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Value Group,,14279.85,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Blue Value Group,,11156.96,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Group,,87.75,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Value Group,,133.74,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,BCBS NC,Blue Value Group,,193.76,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Value Group,,167.01,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Value Group,,251.50,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,BCBS NC,Blue Value Group,,222.14,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Blue Value Group,,1264.03,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Group,,46.65,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Group,,102.75,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Group,,63.61,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Group,,102.75,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Group,,63.61,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Group,,102.75,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Group,,63.61,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Group,,167.99,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,,45.90,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Value Group,,264.01,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Value Group,,134.65,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Group,,35.61,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Value Group,,39.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Group,,43.96,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Group,,25.59,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Group,,25.59,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Group,,58.98,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Blue Value Group,,133.74,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Group,,167.99,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Value Group,,17.80,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Value Group,,17.80,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,7.79,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Group,,41.73,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Group,,23.65,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Group,,37.00,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Group,,167.99,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,BCBS NC,Blue Value Group,,20536.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,BCBS NC,Blue Value Group,,374.13,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Value Group,,3302.28,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,BCBS NC,Blue Value Group,,3302.28,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,BCBS NC,Blue Value Group,,1479.83,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Group,,140.60,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Value Group,,425.65,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Value Group,,66.87,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Blue Value Group,,89.52,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,BCBS NC,Blue Value Group,,467.06,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Value Group,,592.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Group,,156.01,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,BCBS NC,Blue Value Group,,3013.71,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Value Group,,1018.72,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,BCBS NC,Blue Value Group,,234.01,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,BCBS NC,Blue Value Group,,5737.60,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Blue Value Group,,1018.72,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,BCBS NC,Blue Value Group,,405.42,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,BCBS NC,Blue Value Group,,1124.78,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,BCBS NC,Blue Value Group,,1115.64,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,BCBS NC,Blue Value Group,,1118.04,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,BCBS NC,Blue Value Group,,5743.81,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Blue Value Group,,252.31,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Value Group,,246.05,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,BCBS NC,Blue Value Group,,640.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Group,,1233.12,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Group,,1233.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Value Group,,912.44,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Blue Value Group,,912.44,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Value Group,,1664.06,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Blue Value Group,,1664.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Group,,1233.12,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Blue Value Group,,1233.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,BCBS NC,Blue Value Group,,2684.27,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Group,,639.11,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Group,,542.34,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Group,,365.87,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Group,,284.62,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Group,,228.74,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Group,,241.16,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,BCBS NC,Blue Value Group,JW,645.16,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,BCBS NC,Blue Value Group,JW,547.48,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Group,JW,369.34,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Group,JW,287.32,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Group,JW,230.90,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,BCBS NC,Blue Value Group,JW,243.44,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,BCBS NC,Blue Value Group,,1075.37,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Value Group,,58.39,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,61.33,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,BCBS NC,Blue Value Group,,413.24,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Group,,512.28,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,BCBS NC,Blue Value Group,,742.49,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Value Group,,459.39,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Value Group,,92.81,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,BCBS NC,Blue Value Group,,947.82,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,BCBS NC,Blue Value Group,,1344.99,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,BCBS NC,Blue Value Group,,489.98,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,BCBS NC,Blue Value Group,,1494.84,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Value Group,,495.69,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Value Group,,459.39,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,BCBS NC,Blue Value Group,,726.94,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,BCBS NC,Blue Value Group,,709.16,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,BCBS NC,Blue Value Group,,1177.34,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,BCBS NC,Blue Value Group,,5322.52,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Blue Value Group,,119.35,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Blue Value Group,,125.75,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Value Group,,111.56,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Value Group,,185.00,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Blue Value Group,,88.47,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,15.02,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Group,,136.73,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Group,,123.61,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,BCBS NC,Blue Value Group,,207.92,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Blue Value Group,,134.29,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Group,,183.50,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,BCBS NC,Blue Value Group,,229.28,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Value Group,,150.31,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Group,,168.62,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Value Group,,190.75,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Group,,57.99,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Value Group,,103.00,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Group,,45.78,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Value Group,,191.13,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,BCBS NC,Blue Value Group,,255.99,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Blue Value Group,,68.29,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Value Group,,115.21,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Value Group,,138.10,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Blue Value Group,,184.26,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Value Group,,222.80,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Value Group,,411.64,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Blue Value Group,,223.18,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Group,,146.88,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Group,,116.36,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Group,,168.62,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Group,,189.22,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Group,,251.79,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,BCBS NC,Blue Value Group,,354.41,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Blue Value Group,,166.72,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,BCBS NC,Blue Value Group,,124.75,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,BCBS NC,Blue Value Group,,215.17,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Value Group,,187.70,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,BCBS NC,Blue Value Group,,270.87,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Value Group,,333.81,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Group,,222.03,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Value Group,,130.09,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,BCBS NC,Blue Value Group,,206.39,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Value Group,,140.77,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Value Group,,140.39,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,BCBS NC,Blue Value Group,,462.00,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Value Group,,286.89,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,BCBS NC,Blue Value Group,,509.68,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,BCBS NC,Blue Value Group,,721.80,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Value Group,,793.90,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Blue Value Group,,162.14,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,BCBS NC,Blue Value Group,,145.73,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Value Group,,175.11,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,BCBS NC,Blue Value Group,,176.25,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Group,,484.89,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,BCBS NC,Blue Value Group,,199.14,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,BCBS NC,Blue Value Group,,167.86,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Blue Value Group,,154.89,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Blue Value Group,,168.62,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Value Group,,185.79,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Value Group,,144.59,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,BCBS NC,Blue Value Group,,113.69,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,BCBS NC,Blue Value Group,,143.06,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,BCBS NC,Blue Value Group,,132.38,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,BCBS NC,Blue Value Group,,249.12,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Value Group,,164.43,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Value Group,,150.31,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,BCBS NC,Blue Value Group,,105.29,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Value Group,,320.84,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Value Group,,162.90,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Group,,141.54,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Value Group,,183.88,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Blue Value Group,,120.55,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Value Group,,144.97,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Value Group,,135.05,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Group,,83.17,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,BCBS NC,Blue Value Group,,169.77,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Group,,176.63,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Blue Value Group,,144.97,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,BCBS NC,Blue Value Group,,202.19,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Group,,176.63,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Value Group,,152.98,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Group,,123.61,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Value Group,,162.52,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,,188.84,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,,188.84,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,,188.84,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,BCBS NC,Blue Value Group,,298.33,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Blue Value Group,,122.84,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Value Group,,94.23,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Value Group,,402.48,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Value Group,,277.73,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Blue Value Group,,338.77,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,BCBS NC,Blue Value Group,,189.99,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Value Group,,201.81,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Group,,376.92,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Group,,397.14,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Value Group,,409.73,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Blue Value Group,,204.87,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Value Group,,37.39,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,BCBS NC,Blue Value Group,,221.27,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,BCBS NC,Blue Value Group,,245.30,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Value Group,,312.07,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,BCBS NC,Blue Value Group,,254.08,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,BCBS NC,Blue Value Group,,309.01,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,BCBS NC,Blue Value Group,,796.57,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,BCBS NC,Blue Value Group,,1772.07,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,BCBS NC,Blue Value Group,,1364.63,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Blue Value Group,,70.58,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Value Group,,521.89,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,BCBS NC,Blue Value Group,,532.19,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,BCBS NC,Blue Value Group,,1543.93,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,BCBS NC,Blue Value Group,,2192.10,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,BCBS NC,Blue Value Group,,505.87,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,BCBS NC,Blue Value Group,,981.22,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,BCBS NC,Blue Value Group,,393.33,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,BCBS NC,Blue Value Group,,458.56,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,BCBS NC,Blue Value Group,,613.45,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Group,,306.73,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,BCBS NC,Blue Value Group,,616.50,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Value Group,,368.91,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Value Group,,304.82,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Value Group,,421.94,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Blue Value Group,,890.04,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,BCBS NC,Blue Value Group,,524.94,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Group,,77.83,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Group,,66.76,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Blue Value Group,,459.33,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Value Group,,294.14,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Value Group,,403.25,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,BCBS NC,Blue Value Group,,136.58,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Value Group,,363.57,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Value Group,,64.47,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Value Group,,357.08,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Value Group,,116.74,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Value Group,,130.09,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Group,,54.55,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,BCBS NC,Blue Value Group,,283.84,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,BCBS NC,Blue Value Group,,252.55,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,BCBS NC,Blue Value Group,,250.65,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Group,,123.22,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,BCBS NC,Blue Value Group,,246.45,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,BCBS NC,Blue Value Group,,132.00,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Value Group,,92.70,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Value Group,,102.24,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,BCBS NC,Blue Value Group,,353.65,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Blue Value Group,,116.74,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Group,,347.55,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Value Group,,111.02,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,BCBS NC,Blue Value Group,,300.62,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Blue Value Group,,893.85,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,BCBS NC,Blue Value Group,,1540.88,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,BCBS NC,Blue Value Group,,1273.45,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Blue Value Group,,1372.64,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,BCBS NC,Blue Value Group,,776.35,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Value Group,,1722.09,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Value Group,,1722.09,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Blue Value Group,,1722.09,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,BCBS NC,Blue Value Group,,1164.72,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,BCBS NC,Blue Value Group,,681.36,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,BCBS NC,Blue Value Group,,528.18,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Blue Value Group,,102.24,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Value Group,,142.68,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,BCBS NC,Blue Value Group,,126.66,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Value Group,,317.03,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Group,,73.07,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Value Group,,191.13,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Blue Value Group,,793.90,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Value Group,,235.39,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Blue Value Group,,309.78,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,BCBS NC,Blue Value Group,,328.47,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Blue Value Group,,178.16,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,BCBS NC,Blue Value Group,,188.46,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Blue Value Group,,199.52,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Value Group,,289.18,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,BCBS NC,Blue Value Group,,280.78,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Blue Value Group,,411.64,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Blue Value Group,,87.36,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Group,,164.81,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,BCBS NC,Blue Value Group,,405.53,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Blue Value Group,,234.62,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,BCBS NC,Blue Value Group,,299.48,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,BCBS NC,Blue Value Group,,19252.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,BCBS NC,Blue Value Group,,93.18,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,BCBS NC,Blue Value Group,,706.92,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,BCBS NC,Blue Value Group,,1084.82,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Blue Value Group,,160.23,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Blue Value Group,,209.82,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Value Group,,206.01,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Blue Value Group,,152.98,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,BCBS NC,Blue Value Group,,227.37,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,BCBS NC,Blue Value Group,,189.61,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Value Group,,286.89,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Value Group,,221.65,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,BCBS NC,Blue Value Group,,354.03,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,BCBS NC,Blue Value Group,,527.23,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Blue Value Group,,103.65,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Blue Value Group,,289.16,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,BCBS NC,Blue Value Group,,119.64,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Group,,144.05,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Blue Value Group,,608.34,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Group,,303.50,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,BCBS NC,Blue Value Group,,307.09,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,BCBS NC,Blue Value Group,,494.92,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Value Group,,261.36,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,BCBS NC,Blue Value Group,,1307.69,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,BCBS NC,Blue Value Group,,669.76,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Blue Value Group,,489.99,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,BCBS NC,Blue Value Group,,437.54,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,BCBS NC,Blue Value Group,,321.43,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Value Group,,836.53,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,BCBS NC,Blue Value Group,,454.58,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,BCBS NC,Blue Value Group,,932.02,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Value Group,,718.18,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,BCBS NC,Blue Value Group,,1026.61,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Blue Value Group,,718.18,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Value Group,,1066.06,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,BCBS NC,Blue Value Group,,1225.20,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,BCBS NC,Blue Value Group,,383.74,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,BCBS NC,Blue Value Group,,702.49,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Value Group,,551.41,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,BCBS NC,Blue Value Group,,1006.43,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Blue Value Group,,467.13,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,BCBS NC,Blue Value Group,,514.65,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Blue Value Group,,562.62,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,BCBS NC,Blue Value Group,,799.77,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Value Group,,1181.72,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Blue Value Group,,1181.72,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,BCBS NC,Blue Value Group,,1119.41,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,BCBS NC,Blue Value Group,,1737.61,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,BCBS NC,Blue Value Group,,2171.57,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Blue Value Group,,372.54,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,BCBS NC,Blue Value Group,,645.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Blue Value Group,,580.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Value Group,,713.69,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Blue Value Group,,1114.47,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,BCBS NC,Blue Value Group,,348.78,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Value Group,,656.31,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Blue Value Group,,387.33,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,BCBS NC,Blue Value Group,,488.65,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Blue Value Group,,358.19,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Group,,520.03,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,BCBS NC,Blue Value Group,,592.20,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Group,,520.03,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Value Group,,722.21,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Blue Value Group,,569.79,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,BCBS NC,Blue Value Group,,413.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,BCBS NC,Blue Value Group,,1049.47,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,BCBS NC,Blue Value Group,,1319.35,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Value Group,,124.18,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.86,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Group,,44.38,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,BCBS NC,Blue Value Group,,910.05,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Blue Value Group,,442.92,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Group,,47.97,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Value Group,,93.25,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,84.28,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,BCBS NC,Blue Value Group,,1252.55,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,BCBS NC,Blue Value Group,,5600.61,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,BCBS NC,Blue Value Group,,736.56,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Group,,232.67,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,BCBS NC,Blue Value Group,,911.39,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,BCBS NC,Blue Value Group,,210.70,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,BCBS NC,Blue Value Group,,5545.92,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Group,,303.50,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Blue Value Group,,0.52762,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Value Group,,39.00,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,BCBS NC,Blue Value Group,,393.61,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Value Group,,53.35,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Blue Value Group,,261.81,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Group,,144.80,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Group,,19.73,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,BCBS NC,Blue Value Group,,2367.02,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Value Group,,2.69,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,BCBS NC,Blue Value Group,,290.95,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Group,,54.69,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Group,,18.83,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,BCBS NC,Blue Value Group,,36.76,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,BCBS NC,Blue Value Group,,113.87,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.52,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,BCBS NC,Blue Value Group,,2715.80,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Value Group,,82.04,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,BCBS NC,Blue Value Group,,481.92,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Group,,136.73,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,BCBS NC,Blue Value Group,,640.17,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Group,,136.73,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Value Group,,903.77,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Blue Value Group,,903.77,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Value Group,,602.07,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Value Group,,218.32,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Blue Value Group,,195.01,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Blue Value Group,,1004.19,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,BCBS NC,Blue Value Group,,719.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Value Group,,1499.12,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Value Group,,1499.12,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Blue Value Group,,1499.12,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Value Group,,586.82,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,BCBS NC,Blue Value Group,,864.77,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,BCBS NC,Blue Value Group,,479.23,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,BCBS NC,Blue Value Group,,855.36,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Blue Value Group,,551.41,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,BCBS NC,Blue Value Group,,1542.51,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,BCBS NC,Blue Value Group,,1769.07,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Value Group,,2214.16,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Blue Value Group,,2214.16,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,BCBS NC,Blue Value Group,,2634.46,,,,,,,171.27,3501.50,fee schedule,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Value Group,,396.57,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Blue Value Group,,432.27,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Group,,124.38,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,BCBS NC,Blue Value Group,,973.95,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Value Group,,494.85,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,BCBS NC,Blue Value Group,,436.88,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,BCBS NC,Blue Value Group,,487.17,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Blue Value Group,,776.40,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,BCBS NC,Blue Value Group,,1125.69,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,BCBS NC,Blue Value Group,,1354.83,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Blue Value Group,,1238.39,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,BCBS NC,Blue Value Group,,2188.48,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,BCBS NC,Blue Value Group,,2416.64,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,BCBS NC,Blue Value Group,,1020.57,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,BCBS NC,Blue Value Group,,1178.20,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,BCBS NC,Blue Value Group,,1489.95,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,BCBS NC,Blue Value Group,,1099.43,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,BCBS NC,Blue Value Group,,1418.58,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,BCBS NC,Blue Value Group,,1734.11,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Value Group,,2176.26,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Value Group,,2168.77,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,BCBS NC,Blue Value Group,,1106.97,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Value Group,,1422.37,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,BCBS NC,Blue Value Group,,1320.62,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,BCBS NC,Blue Value Group,,2213.80,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,BCBS NC,Blue Value Group,,1238.39,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,BCBS NC,Blue Value Group,,1767.82,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,BCBS NC,Blue Value Group,,1421.97,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,BCBS NC,Blue Value Group,,1238.39,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,BCBS NC,Blue Value Group,,1779.14,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,BCBS NC,Blue Value Group,,1222.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Blue Value Group,,1238.39,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Blue Value Group,,1767.82,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Value Group,,2180.99,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,BCBS NC,Blue Value Group,,2285.17,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,BCBS NC,Blue Value Group,,968.01,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,BCBS NC,Blue Value Group,,1775.35,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,BCBS NC,Blue Value Group,,1178.96,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,BCBS NC,Blue Value Group,,1238.39,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,BCBS NC,Blue Value Group,,1741.61,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,BCBS NC,Blue Value Group,,1667.28,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,BCBS NC,Blue Value Group,,2525.54,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Value Group,,1238.39,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,BCBS NC,Blue Value Group,,1775.35,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,BCBS NC,Blue Value Group,,2263.55,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,BCBS NC,Blue Value Group,,2633.43,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,BCBS NC,Blue Value Group,,952.90,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,BCBS NC,Blue Value Group,,1771.65,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,BCBS NC,Blue Value Group,,2038.24,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,BCBS NC,Blue Value Group,,2634.46,,,,,,,343.59,4490.21,fee schedule,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Value Group,,12964.98,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,BCBS NC,Blue Value Group,,1200.85,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,BCBS NC,Blue Value Group,,2334.92,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,BCBS NC,Blue Value Group,,2634.46,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Blue Value Group,,502.53,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,BCBS NC,Blue Value Group,,2296.50,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Blue Value Group,,2168.77,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Value Group,,2176.26,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Blue Value Group,,1422.37,,,,,,,171.27,2905.00,fee schedule,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Blue Value Group,,1074.92,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,BCBS NC,Blue Value Group,,166.38,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Value Group,,450.31,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Value Group,,511.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Blue Value Group,,511.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,BCBS NC,Blue Value Group,,556.65,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Value Group,,677.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Blue Value Group,,677.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,BCBS NC,Blue Value Group,,729.79,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Group,,182.35,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Blue Value Group,,162.27,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Value Group,,12964.98,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,BCBS NC,Blue Value Group,,12964.98,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,BCBS NC,Blue Value Group,,11837.51,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Blue Value Group,,129.52,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Blue Value Group,,350.53,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Group,,302.86,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,BCBS NC,Blue Value Group,,959.63,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,BCBS NC,Blue Value Group,,2458.06,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,BCBS NC,Blue Value Group,,261.45,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,BCBS NC,Blue Value Group,,667.84,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,BCBS NC,Blue Value Group,,423.72,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,BCBS NC,Blue Value Group,,21650.69,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Value Group,,1827.20,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Value Group,,1827.20,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,BCBS NC,Blue Value Group,,11111.07,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,BCBS NC,Blue Value Group,,534.47,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Blue Value Group,,1444.02,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Value Group,,74.63,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Value Group,,50.56,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,BCBS NC,Blue Value Group,,202.71,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Value Group,,1406.46,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Group,,302.86,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Value Group,,219.56,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,BCBS NC,Blue Value Group,,111.71,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Group,,96.78,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Group,,231.60,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,BCBS NC,Blue Value Group,,533.98,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Group,,220.53,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Group,,137.23,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,48.63,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,BCBS NC,Blue Value Group,,674.10,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Value Group,,761.73,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Blue Value Group,,516.05,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Value Group,,1121.89,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Blue Value Group,,760.05,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Value Group,,149.75,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Blue Value Group,,149.75,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Group,,387.13,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Group,,262.26,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,BCBS NC,Blue Value Group,,235.52,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Value Group,,277.83,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Blue Value Group,,188.22,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,BCBS NC,Blue Value Group,,2272.68,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,BCBS NC,Blue Value Group,,1626.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,BCBS NC,Blue Value Group,,342.83,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Blue Value Group,,272.05,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,BCBS NC,Blue Value Group,,680.84,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,BCBS NC,Blue Value Group,,368.35,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,BCBS NC,Blue Value Group,,622.10,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Value Group,,279.75,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Value Group,,613.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,BCBS NC,Blue Value Group,,415.90,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Value Group,,562.39,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Value Group,,1453.65,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Blue Value Group,,1453.65,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Group,,144.45,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,BCBS NC,Blue Value Group,,935.55,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Value Group,,704.92,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Blue Value Group,,401.57,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,BCBS NC,Blue Value Group,,781.47,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,BCBS NC,Blue Value Group,,852.25,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Value Group,,871.03,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Value Group,,680.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Value Group,,1013.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,BCBS NC,Blue Value Group,,791.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Group,,325.98,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Blue Value Group,,254.69,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Group,,195.25,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Value Group,,329.35,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Value Group,,257.32,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,BCBS NC,Blue Value Group,,1012.35,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Value Group,,1327.01,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,BCBS NC,Blue Value Group,,1036.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Value Group,,767.51,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,BCBS NC,Blue Value Group,,599.66,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Value Group,,441.05,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,BCBS NC,Blue Value Group,,344.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Value Group,,544.10,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,BCBS NC,Blue Value Group,,425.11,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Value Group,,555.17,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,BCBS NC,Blue Value Group,,433.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,BCBS NC,Blue Value Group,,2435.91,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,BCBS NC,Blue Value Group,,1606.54,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,BCBS NC,Blue Value Group,,382.79,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,BCBS NC,Blue Value Group,,349.09,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Blue Value Group,,393.87,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Value Group,,357.27,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,BCBS NC,Blue Value Group,,1081.93,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Blue Value Group,,357.27,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Blue Value Group,,1792.62,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Blue Value Group,,426.61,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,BCBS NC,Blue Value Group,,330.31,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Group,,93.89,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,BCBS NC,Blue Value Group,,256.64,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Blue Value Group,,267.23,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,BCBS NC,Blue Value Group,,284.08,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Blue Value Group,,280.71,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Value Group,,320.20,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,BCBS NC,Blue Value Group,,2004.48,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,BCBS NC,Blue Value Group,,1024.63,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Blue Value Group,,646.65,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Blue Value Group,,704.92,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,BCBS NC,Blue Value Group,,334.16,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,BCBS NC,Blue Value Group,,282.64,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,BCBS NC,Blue Value Group,,291.79,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Value Group,,425.65,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Blue Value Group,,288.36,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Value Group,,6768.93,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Value Group,,5288.62,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Blue Value Group,,5288.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,BCBS NC,Blue Value Group,,2327.17,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Group,,5062.49,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Group,,3955.37,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Group,,5062.49,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Blue Value Group,,3955.37,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Value Group,,5514.14,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Blue Value Group,,4308.24,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,BCBS NC,Blue Value Group,,3694.55,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Value Group,,3804.81,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Blue Value Group,,2972.73,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Value Group,,1805.76,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,BCBS NC,Blue Value Group,,2152.79,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Value Group,,2280.52,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Value Group,,2918.85,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Blue Value Group,,2280.52,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Value Group,,1653.02,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,BCBS NC,Blue Value Group,,1163.79,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,BCBS NC,Blue Value Group,,1191.71,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,BCBS NC,Blue Value Group,,776.66,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,BCBS NC,Blue Value Group,,381.35,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Group,,1191.23,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Blue Value Group,,182.49,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Blue Value Group,,232.08,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,BCBS NC,Blue Value Group,,135.78,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,BCBS NC,Blue Value Group,,260.97,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Value Group,,2549.06,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,BCBS NC,Blue Value Group,,614.88,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Blue Value Group,,3608.36,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,BCBS NC,Blue Value Group,,190.19,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Value Group,,789.66,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Blue Value Group,,534.97,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,BCBS NC,Blue Value Group,,1028.48,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Blue Value Group,,297.17,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,BCBS NC,Blue Value Group,,1481.58,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,BCBS NC,Blue Value Group,,1078.08,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Group,,257.60,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Value Group,,489.20,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,BCBS NC,Blue Value Group,,1855.70,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Value Group,,309.12,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,BCBS NC,Blue Value Group,,386.16,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Blue Value Group,,309.12,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,BCBS NC,Blue Value Group,,334.64,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Blue Value Group,,2549.06,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Blue Value Group,,1145.01,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,BCBS NC,Blue Value Group,,1204.71,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,BCBS NC,Blue Value Group,,1193.16,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,BCBS NC,Blue Value Group,,306.23,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Group,,558.54,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Group,,84.26,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,BCBS NC,Blue Value Group,,3029.12,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,BCBS NC,Blue Value Group,,3739.81,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,43.34,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,BCBS NC,Blue Value Group,,1199.42,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Group,,141.56,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Value Group,,111.23,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Blue Value Group,,67.85,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Group,,194.53,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,BCBS NC,Blue Value Group,,196.45,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Group,,1191.23,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Group,,97.26,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Blue Value Group,,766.55,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,BCBS NC,Blue Value Group,,2165.31,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,BCBS NC,Blue Value Group,,2038.67,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Blue Value Group,,1406.46,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,BCBS NC,Blue Value Group,,2202.38,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Value Group,,507.98,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Blue Value Group,,344.14,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,BCBS NC,Blue Value Group,,708.29,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Group,,138.67,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Group,,93.95,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Value Group,,923.52,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Blue Value Group,,625.65,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Blue Value Group,,382.63,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Value Group,,1209.05,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Blue Value Group,,819.09,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Value Group,,979.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Blue Value Group,,663.49,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Value Group,,836.85,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Blue Value Group,,566.94,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Value Group,,762.21,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Blue Value Group,,516.37,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Value Group,,792.55,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,BCBS NC,Blue Value Group,,536.93,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,BCBS NC,Blue Value Group,,557.80,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Value Group,,729.47,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Blue Value Group,,494.19,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Value Group,,726.58,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Blue Value Group,,492.24,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Value Group,,1599.54,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Blue Value Group,,1083.64,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Value Group,,895.59,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,BCBS NC,Blue Value Group,,606.73,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Value Group,,875.37,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Blue Value Group,,593.03,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,BCBS NC,Blue Value Group,,1110.34,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Blue Value Group,,177.19,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Blue Value Group,,1584.35,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,BCBS NC,Blue Value Group,,105.93,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,BCBS NC,Blue Value Group,,1367.94,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,BCBS NC,Blue Value Group,,1439.68,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Value Group,,9695.97,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Value Group,,5154.94,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Group,,195.25,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,BCBS NC,Blue Value Group,,562.39,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Blue Value Group,,517.13,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,BCBS NC,Blue Value Group,,333.68,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,BCBS NC,Blue Value Group,,373.64,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,BCBS NC,Blue Value Group,,2628.03,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Value Group,,1787.33,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,BCBS NC,Blue Value Group,,2272.20,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,BCBS NC,Blue Value Group,,1862.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,BCBS NC,Blue Value Group,,2342.02,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,BCBS NC,Blue Value Group,,1920.22,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,BCBS NC,Blue Value Group,,812.77,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,BCBS NC,Blue Value Group,,275.90,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,BCBS NC,Blue Value Group,,3592.95,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Blue Value Group,,958.18,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,BCBS NC,Blue Value Group,,718.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,BCBS NC,Blue Value Group,,1277.42,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,BCBS NC,Blue Value Group,,10821.77,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,BCBS NC,Blue Value Group,,1575.15,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,BCBS NC,Blue Value Group,,4995.56,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,BCBS NC,Blue Value Group,,3328.62,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,BCBS NC,Blue Value Group,,1675.14,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,BCBS NC,Blue Value Group,,597.54,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Value Group,,816.62,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Blue Value Group,,553.24,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Value Group,,903.29,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Blue Value Group,,611.95,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Value Group,,833.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Blue Value Group,,564.98,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Blue Value Group,,620.65,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Blue Value Group,,352.94,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,BCBS NC,Blue Value Group,,591.76,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,BCBS NC,Blue Value Group,,3449.95,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,BCBS NC,Blue Value Group,,862.37,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,BCBS NC,Blue Value Group,,758.84,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,BCBS NC,Blue Value Group,,892.70,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,BCBS NC,Blue Value Group,,503.65,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Value Group,,1726.66,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,BCBS NC,Blue Value Group,,1349.05,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Group,,1252.86,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Group,,978.87,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Group,,1252.86,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,BCBS NC,Blue Value Group,,978.87,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,BCBS NC,Blue Value Group,,1668.40,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,BCBS NC,Blue Value Group,,1434.87,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,BCBS NC,Blue Value Group,,2958.34,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,BCBS NC,Blue Value Group,,3439.84,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,BCBS NC,Blue Value Group,,2547.62,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,BCBS NC,Blue Value Group,,2295.31,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,BCBS NC,Blue Value Group,,573.95,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,BCBS NC,Blue Value Group,,3870.30,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,BCBS NC,Blue Value Group,,3994.52,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,BCBS NC,Blue Value Group,,6004.31,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,BCBS NC,Blue Value Group,,3348.83,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Value Group,,1279.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Blue Value Group,,889.81,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,BCBS NC,Blue Value Group,,429.02,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Blue Value Group,,775.70,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,BCBS NC,Blue Value Group,,573.47,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,BCBS NC,Blue Value Group,,1782.51,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,BCBS NC,Blue Value Group,,1565.36,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,BCBS NC,Blue Value Group,,1566.80,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,BCBS NC,Blue Value Group,,1350.61,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,BCBS NC,Blue Value Group,,1279.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,BCBS NC,Blue Value Group,,2296.27,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,BCBS NC,Blue Value Group,,2663.66,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,BCBS NC,Blue Value Group,,3903.52,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,BCBS NC,Blue Value Group,,361.61,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,BCBS NC,Blue Value Group,,5237.28,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Value Group,,3770.63,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,BCBS NC,Blue Value Group,,1833.07,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,BCBS NC,Blue Value Group,,6440.92,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,BCBS NC,Blue Value Group,,2756.42,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Blue Value Group,,434.31,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Value Group,,1676.10,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,BCBS NC,Blue Value Group,,1309.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,BCBS NC,Blue Value Group,,6484.94,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Value Group,,7791.63,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,BCBS NC,Blue Value Group,,6087.67,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Value Group,,4234.79,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Blue Value Group,,3308.68,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Value Group,,4488.54,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,BCBS NC,Blue Value Group,,3506.94,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,BCBS NC,Blue Value Group,,4675.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,BCBS NC,Blue Value Group,,3398.97,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,BCBS NC,Blue Value Group,,1401.16,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Value Group,,1140.19,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,BCBS NC,Blue Value Group,,1140.19,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Blue Value Group,,387.13,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,BCBS NC,Blue Value Group,,3158.64,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,BCBS NC,Blue Value Group,,549.97,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,BCBS NC,Blue Value Group,,973.11,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,BCBS NC,Blue Value Group,,1207.98,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Blue Value Group,,234.49,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Group,,1376.61,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Group,,1376.61,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Group,,104.97,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Group,,104.97,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Value Group,,4788.04,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Blue Value Group,,4788.04,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,BCBS NC,Blue Value Group,,1932.74,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,BCBS NC,Blue Value Group,,2933.30,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,BCBS NC,Blue Value Group,,1662.14,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,BCBS NC,Blue Value Group,,871.03,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Group,,302.86,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Group,,1376.61,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Blue Value Group,,1376.61,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,BCBS NC,Blue Value Group,,1557.87,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,BCBS NC,Blue Value Group,,943.26,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Value Group,,196.00,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Value Group,,229.50,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Group,,156.96,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Blue Value Group,,156.96,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,BCBS NC,Blue Value Group,,196.00,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,BCBS NC,Blue Value Group,,137.41,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,BCBS NC,Blue Value Group,,383.88,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,BCBS NC,Blue Value Group,,246.48,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,BCBS NC,Blue Value Group,,490.37,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Blue Value Group,,401.92,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,BCBS NC,Blue Value Group,,454.31,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Blue Value Group,,331.07,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,BCBS NC,Blue Value Group,,359.41,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Blue Value Group,,135.26,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Blue Value Group,,325.49,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,BCBS NC,Blue Value Group,,133.11,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Value Group,,354.25,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,BCBS NC,Blue Value Group,,412.65,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Group,,222.86,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Blue Value Group,,273.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Value Group,,183.35,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,BCBS NC,Blue Value Group,,358.55,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Blue Value Group,,286.84,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Group,,231.45,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,BCBS NC,Blue Value Group,,282.55,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Group,,445.29,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Value Group,,353.40,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Blue Value Group,,394.62,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,BCBS NC,Blue Value Group,,129.25,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,BCBS NC,Blue Value Group,,505.83,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,BCBS NC,Blue Value Group,,328.06,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Blue Value Group,,107.35,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Blue Value Group,,99.19,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Group,,79.87,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,BCBS NC,Blue Value Group,,473.20,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Blue Value Group,,354.25,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Value Group,,85.45,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,21.90,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,BCBS NC,Blue Value Group,,293.71,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Group,,181.21,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Blue Value Group,,415.23,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,BCBS NC,Blue Value Group,,310.89,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Blue Value Group,,177.34,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Value Group,,211.26,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Blue Value Group,,197.09,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,47.23,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Group,,58.49,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,BCBS NC,Blue Value Group,,33.50,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Value Group,,54.50,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,BCBS NC,Blue Value Group,,1890.89,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,BCBS NC,Blue Value Group,,1378.05,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,BCBS NC,Blue Value Group,,1238.29,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,BCBS NC,Blue Value Group,,1921.99,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Value Group,,1821.02,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,BCBS NC,Blue Value Group,,1205.03,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Value Group,,1821.02,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Blue Value Group,,1821.02,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,BCBS NC,Blue Value Group,,275.67,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,BCBS NC,Blue Value Group,,453.33,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,BCBS NC,Blue Value Group,,906.36,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,BCBS NC,Blue Value Group,,1379.83,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,BCBS NC,Blue Value Group,,1236.51,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,BCBS NC,Blue Value Group,,1792.00,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,BCBS NC,Blue Value Group,,2634.11,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,BCBS NC,Blue Value Group,,127.43,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Value Group,,217.38,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Blue Value Group,,138.07,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,BCBS NC,Blue Value Group,,244.70,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Value Group,,661.56,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Blue Value Group,,597.00,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Blue Value Group,,116.31,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Blue Value Group,,1758.62,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,BCBS NC,Blue Value Group,,1759.32,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,BCBS NC,Blue Value Group,,2709.69,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,BCBS NC,Blue Value Group,,3274.97,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,BCBS NC,Blue Value Group,,1759.32,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,BCBS NC,Blue Value Group,,1905.99,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,BCBS NC,Blue Value Group,,2309.10,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,BCBS NC,Blue Value Group,,1761.25,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,BCBS NC,Blue Value Group,,2353.06,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Value Group,,2867.29,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,BCBS NC,Blue Value Group,,1236.60,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,BCBS NC,Blue Value Group,,2177.34,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,BCBS NC,Blue Value Group,,2652.85,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,BCBS NC,Blue Value Group,,1748.98,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,BCBS NC,Blue Value Group,,1812.92,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,BCBS NC,Blue Value Group,,2324.59,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,BCBS NC,Blue Value Group,,1236.60,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Blue Value Group,,2195.38,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Blue Value Group,,2650.24,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,BCBS NC,Blue Value Group,,1529.30,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,BCBS NC,Blue Value Group,,2164.37,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,BCBS NC,Blue Value Group,,2316.89,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,BCBS NC,Blue Value Group,,1560.32,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,BCBS NC,Blue Value Group,,2236.80,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,BCBS NC,Blue Value Group,,1133.67,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Group,,90.42,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Value Group,52,2112.39,,,,,,,791.19,2825.00,fee schedule,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,BCBS NC,Blue Value Group,52,2102.08,,,,,,,787.39,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,BCBS NC,Blue Value Group,,1144.23,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,BCBS NC,Blue Value Group,,1688.85,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,BCBS NC,Blue Value Group,,1926.64,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,BCBS NC,Blue Value Group,,1097.72,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,BCBS NC,Blue Value Group,,1730.18,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,BCBS NC,Blue Value Group,,1100.27,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,BCBS NC,Blue Value Group,,1527.53,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Value Group,,1097.72,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,BCBS NC,Blue Value Group,,1447.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,BCBS NC,Blue Value Group,,1942.16,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,BCBS NC,Blue Value Group,,1947.31,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,BCBS NC,Blue Value Group,,1934.37,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,BCBS NC,Blue Value Group,,1487.98,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,BCBS NC,Blue Value Group,,1756.07,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,BCBS NC,Blue Value Group,,2169.55,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,BCBS NC,Blue Value Group,,1758.62,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,BCBS NC,Blue Value Group,,1812.92,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,BCBS NC,Blue Value Group,,2995.92,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,BCBS NC,Blue Value Group,,1758.62,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,BCBS NC,Blue Value Group,,1812.92,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,BCBS NC,Blue Value Group,,3016.60,,,,,,,343.59,4009.45,fee schedule,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,BCBS NC,Blue Value Group,,2272.93,,,,,,,845.85,3021.02,fee schedule,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,BCBS NC,Blue Value Group,,2272.93,,,,,,,647.85,3021.02,fee schedule,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,BCBS NC,Blue Value Group,,2272.93,,,,,,,895.29,3021.02,fee schedule,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Value Group,,2265.17,,,,,,,848.45,3010.70,fee schedule,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Value Group,,2265.17,,,,,,,848.45,3010.70,fee schedule,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,BCBS NC,Blue Value Group,,2265.17,,,,,,,848.45,3010.70,fee schedule,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,BCBS NC,Blue Value Group,,1263.41,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Value Group,,1453.90,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,BCBS NC,Blue Value Group,,1453.90,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,BCBS NC,Blue Value Group,,2278.12,,,,,,,899.50,3027.91,fee schedule,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,BCBS NC,Blue Value Group,,2278.12,,,,,,,650.65,3027.91,fee schedule,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,BCBS NC,Blue Value Group,,2278.12,,,,,,,919.72,3027.91,fee schedule,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,BCBS NC,Blue Value Group,,1812.92,,,,,,,894.09,2825.00,fee schedule,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Value Group,,1812.92,,,,,,,845.44,2825.00,fee schedule,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,BCBS NC,Blue Value Group,,1812.92,,,,,,,845.44,2825.00,fee schedule,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Value Group,,2293.61,,,,,,,908.91,3048.50,fee schedule,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Value Group,,2293.61,,,,,,,908.91,3048.50,fee schedule,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,BCBS NC,Blue Value Group,,2293.61,,,,,,,908.91,3048.50,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Blue Value Group,,1097.72,,,,,,,232.56,2825.00,fee schedule,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,BCBS NC,Blue Value Group,,369.19,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,BCBS NC,Blue Value Group,,1282.55,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,BCBS NC,Blue Value Group,,1274.86,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,BCBS NC,Blue Value Group,,2112.39,,,,,,,791.19,2825.00,fee schedule,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,BCBS NC,Blue Value Group,,2102.08,,,,,,,375.38,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Value Group,,162.52,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Group,,155.58,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Group,,191.60,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Value Group,,840.22,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Blue Value Group,,569.22,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Group,,51.54,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Value Group,,881.63,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Blue Value Group,,597.27,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,BCBS NC,Blue Value Group,,251.77,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Blue Value Group,,150.23,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Group,,132.15,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Blue Value Group,,132.15,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,BCBS NC,Blue Value Group,,361.38,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Blue Value Group,,288.49,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Blue Value Group,,235.64,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Blue Value Group,,171.37,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Value Group,,166.64,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Blue Value Group,,81.23,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Blue Value Group,,193.26,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Blue Value Group,,142.14,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Group,,129.14,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,BCBS NC,Blue Value Group,,304.91,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Blue Value Group,,126.00,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Group,,260.97,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Blue Value Group,,260.97,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,BCBS NC,Blue Value Group,,643.90,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Blue Value Group,,337.20,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Blue Value Group,,836.71,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,BCBS NC,Blue Value Group,,1950.54,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,BCBS NC,Blue Value Group,,113.00,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Value Group,,79.37,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Blue Value Group,,165.46,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Blue Value Group,,82.06,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Blue Value Group,,191.47,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Value Group,,147.52,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Group,,123.31,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Blue Value Group,,178.91,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,BCBS NC,Blue Value Group,,282.94,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Group,,232.27,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,BCBS NC,Blue Value Group,,391.90,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,BCBS NC,Blue Value Group,,252.00,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Group,,25.56,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Blue Value Group,,162.32,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Blue Value Group,,338.99,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Blue Value Group,,136.76,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Blue Value Group,,298.19,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Group,,189.22,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Blue Value Group,,428.67,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Blue Value Group,,268.59,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Group,,189.22,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Blue Value Group,,205.37,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,BCBS NC,Blue Value Group,,163.22,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,BCBS NC,Blue Value Group,,1131.76,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,BCBS NC,Blue Value Group,,972.58,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Blue Value Group,,495.93,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,BCBS NC,Blue Value Group,,233.62,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,BCBS NC,Blue Value Group,,247.97,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Blue Value Group,,150.66,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Group,,57.40,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Blue Value Group,,229.58,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Group,,181.15,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Blue Value Group,,181.15,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,BCBS NC,Blue Value Group,,1077.95,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Group,,21.07,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,BCBS NC,Blue Value Group,,6.28,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Value Group,,50.22,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Group,,73.09,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Group,,59.19,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Group,,11.66,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Group,,19.73,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Group,,84.75,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Value Group,,118.83,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00448,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Group,,39.46,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Group,,113.45,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Group,,84.75,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Blue Value Group,,178.01,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Blue Value Group,,69.50,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Group,,41.70,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Blue Value Group,,239.89,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,40.80,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,40.80,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Group,,31.84,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Group,,59.64,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Group,,59.64,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Blue Value Group,,59.64,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,28.25,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Group,,13.00,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Group,,32.28,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Value Group,,79.37,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Value Group,,55.60,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Group,,17.49,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Group,,65.02,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Group,,65.02,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Group,,65.02,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,40.36,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,40.36,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,40.36,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Value Group,,69.05,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Group,,13.00,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Group,,19.28,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Group,,18.83,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,84.30,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Group,,21.52,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Group,,72.64,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Group,,51.57,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Group,,51.57,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Group,,51.57,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Group,,44.84,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Group,,18.83,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Group,,41.70,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,BCBS NC,Blue Value Group,,26.90,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Group,,17.94,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Group,,17.94,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Value Group,,74.43,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,,39.91,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,,39.91,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Group,,29.59,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Value Group,,23.77,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Value Group,,115.69,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,28.25,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,42.60,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,42.60,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,10.76,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Group,,29.59,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Value Group,,108.96,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,40.36,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,40.36,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Group,,80.71,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Group,,41.70,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Value Group,,65.47,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Group,,35.42,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Group,,17.49,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Blue Value Group,,134.07,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Blue Value Group,,2.69,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Group,,41.70,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Group,,90.13,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Value Group,,259.62,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Group,,70.40,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Group,,54.70,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Group,,54.70,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Group,,54.70,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Group,,54.70,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Group,,17.49,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,84.30,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Group,,91.03,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Group,,91.03,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Group,,91.03,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Group,,91.03,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Group,,13.45,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,49.32,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,49.32,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,49.32,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Group,,31.84,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Value Group,,76.68,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Group,,72.64,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Value Group,,34.98,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Value Group,,106.72,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Blue Value Group,,69.95,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Group,,41.70,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Value Group,,99.10,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Group,,53.81,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Blue Value Group,,68.16,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Group,,21.07,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Group,,21.07,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Value Group,,10.31,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,BCBS NC,Blue Value Group,,88.33,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Group,,59.19,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Group,,17.94,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Group,,37.67,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Group,,17.04,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Group,,35.87,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Group,,35.87,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Group,,18.83,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Group,,70.85,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Blue Value Group,,70.85,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Value Group,,66.81,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Group,,32.28,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Group,,17.04,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Group,,44.84,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Group,,64.12,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Group,,37.22,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,42.60,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Group,,64.12,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Blue Value Group,,79.37,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Group,,11.66,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Group,,11.66,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Group,,11.66,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,26.01,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Group,,47.98,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Value Group,,0.89680,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Blue Value Group,,147.52,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Group,,24.66,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.53,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Value Group,,65.47,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Blue Value Group,,101.79,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Group,,96.41,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Group,,96.41,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Group,,20.18,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,27.35,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,27.35,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Value Group,,23.77,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Group,,44.84,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Group,,22.42,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Group,,29.59,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Group,,20.18,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Group,,14.35,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Group,,14.35,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Group,,19.28,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Group,,6.73,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Value Group,,74.88,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Group,,20.18,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Blue Value Group,,71.74,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,BCBS NC,Blue Value Group,,85.20,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,27.35,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Group,,32.28,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,33.18,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Group,,29.59,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Group,,60.09,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Group,,58.29,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Value Group,,48.43,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Group,,17.04,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.53,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Group,,51.57,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Blue Value Group,,51.57,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Group,,58.29,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Value Group,,86.54,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Group,,35.42,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Group,,5.38,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Group,,166.36,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Blue Value Group,,166.36,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Value Group,,100.89,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Group,,14.35,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Group,,62.78,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Group,,50.67,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Group,,43.49,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Blue Value Group,,61.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Group,,53.81,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,BCBS NC,Blue Value Group,,3.59,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Value Group,,9.86,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Group,,47.53,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Value Group,,78.02,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Group,,16.59,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Blue Value Group,,57.40,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Blue Value Group,,119.72,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Value Group,,65.91,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Blue Value Group,,122.41,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Value Group,,92.82,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Group,,22.42,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Value Group,,106.27,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,84.30,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,52.91,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,33.00,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,9.78,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,BCBS NC,Blue Value Group,,92.37,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Value Group,,18.38,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Value Group,,131.38,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Blue Value Group,,90.13,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Group,,20.63,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Group,,50.67,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Group,,50.67,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Group,,22.42,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Group,,60.53,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,BCBS NC,Blue Value Group,,99.99,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Blue Value Group,,9.42,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,25.11,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Group,,25.56,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Group,,65.02,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Value Group,,30.49,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,,52.46,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Value Group,,77.57,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Group,,43.49,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Group,,52.01,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Group,,52.01,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.53,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Group,,6.73,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,,39.91,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,,39.91,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Group,,15.69,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Group,,20.18,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Value Group,,30.94,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Value Group,,206.71,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,28.25,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Group,,54.70,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Group,,32.28,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Blue Value Group,,87.44,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Group,,37.22,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Blue Value Group,,4.93,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Group,,15.69,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Group,,60.53,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Value Group,,48.43,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,25.11,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.53,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Value Group,,356.03,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Value Group,,200.43,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Blue Value Group,,119.27,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,BCBS NC,Blue Value Group,,255.59,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Blue Value Group,,377.10,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,,73.99,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Group,,132.73,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Blue Value Group,,161.87,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Group,,38.11,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Group,,38.11,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Group,,38.11,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,BCBS NC,Blue Value Group,,104.48,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Group,,65.02,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Blue Value Group,,55.15,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Group,,60.09,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Value Group,,87.89,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Blue Value Group,,77.57,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,27.35,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Blue Value Group,,224.65,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,BCBS NC,Blue Value Group,,330.47,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Group,,56.50,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Group,,62.33,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Group,,16.59,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Group,,67.26,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,52.91,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Blue Value Group,,41.70,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Group,,72.64,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.53,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Value Group,,194.16,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Blue Value Group,,194.16,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Group,,144.83,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Group,,123.31,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Blue Value Group,,130.48,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Blue Value Group,,118.38,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,BCBS NC,Blue Value Group,,274.42,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Group,,72.19,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.53,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Blue Value Group,,106.27,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Blue Value Group,,89.23,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Group,,44.39,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Value Group,,145.73,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Value Group,,121.52,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Blue Value Group,,144.83,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,BCBS NC,Blue Value Group,,112.55,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Blue Value Group,,81.61,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Group,,83.40,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Group,,83.40,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Value Group,,110.75,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Group,,32.28,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Group,,19.73,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Group,,67.26,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Blue Value Group,,87.89,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,BCBS NC,Blue Value Group,,209.85,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,BCBS NC,Blue Value Group,,126.90,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,33.18,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Group,,15.69,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,25.11,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Blue Value Group,,32.28,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Blue Value Group,,50.67,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Value Group,,159.63,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Blue Value Group,,65.47,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,28.25,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Blue Value Group,,90.58,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Blue Value Group,,64.12,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,,52.46,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Blue Value Group,,52.46,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Group,,35.42,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Value Group,,45.74,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,25.11,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Blue Value Group,,38.11,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Blue Value Group,,43.94,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,25.11,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Value Group,,100.44,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Group,,35.87,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Group,,17.49,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Value Group,,8.52,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,42.60,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,42.60,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Blue Value Group,,21.07,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Group,,6.73,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Blue Value Group,,18.38,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,27.35,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Blue Value Group,,84.30,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Blue Value Group,,54.70,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Blue Value Group,,58.29,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Group,,31.84,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Group,,70.40,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Value Group,,12.11,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Blue Value Group,,23.77,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Value Group,,83.85,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Blue Value Group,,83.85,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Group,,43.49,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Group,,95.51,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Group,,91.47,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,33.18,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Blue Value Group,,14.35,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Group,,91.47,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Blue Value Group,,13.90,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Group,,31.39,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Blue Value Group,,65.02,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Blue Value Group,,41.25,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Group,,17.49,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Group,,13.45,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Group,,13.45,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Group,,11.66,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,10.76,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,,57.84,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Group,,52.01,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Group,,35.42,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,49.32,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Value Group,,8.07,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,33.18,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,33.18,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,33.18,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,33.18,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,BCBS NC,Blue Value Group,,152.01,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Blue Value Group,,30.49,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Group,,37.67,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,,39.91,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,27.35,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Blue Value Group,,7.17,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,BCBS NC,Blue Value Group,,109.86,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Group,,37.67,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Value Group,,69.05,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Blue Value Group,,16.59,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Blue Value Group,,44.39,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Value Group,,34.98,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Group,,17.94,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Group,,25.56,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Group,,17.04,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,42.60,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Blue Value Group,,28.25,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Blue Value Group,,80.71,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Blue Value Group,,14.80,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Group,,17.04,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,BCBS NC,Blue Value Group,,102.24,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Blue Value Group,,75.78,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Blue Value Group,,206.71,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Group,,95.51,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Group,,95.51,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Blue Value Group,,282.04,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Blue Value Group,,260.52,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Blue Value Group,,78.02,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Group,,72.19,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Group,,156.94,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Blue Value Group,,95.06,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Group,,73.54,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Group,,73.54,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Group,,123.31,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,BCBS NC,Blue Value Group,,115.24,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Blue Value Group,,345.27,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Blue Value Group,,39.01,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Blue Value Group,,37.22,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Blue Value Group,,21.52,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Blue Value Group,,50.22,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Blue Value Group,,259.62,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,BCBS NC,Blue Value Group,,125.10,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Group,,24.66,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Blue Value Group,,69.05,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Value Group,,43.05,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Value Group,,43.05,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Blue Value Group,,43.05,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Blue Value Group,,207.61,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Group,,131.83,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Group,,39.46,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Blue Value Group,,39.46,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Blue Value Group,,22.87,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Blue Value Group,,56.50,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Blue Value Group,,5.38,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Group,,67.26,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Blue Value Group,,53.81,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Value Group,,223.26,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Value Group,,138.56,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Blue Value Group,,56.95,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Blue Value Group,,16.14,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Blue Value Group,,9.86,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Blue Value Group,,103.13,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,34.53,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Group,,13.00,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Value Group,,8.07,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Blue Value Group,,47.53,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Blue Value Group,,26.01,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Group,,15.69,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Group,,15.69,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Blue Value Group,,8.52,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Blue Value Group,,27.35,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Blue Value Group,,28.70,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Group,,20.63,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Blue Value Group,,25.11,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Group,,31.84,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Group,,6.73,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Blue Value Group,,13.45,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Blue Value Group,,113.45,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Group,,60.09,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Blue Value Group,,76.68,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Blue Value Group,,11.66,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Group,,72.64,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Group,,35.42,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,24.21,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Group,,13.00,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00407,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Value Group,,168.66,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Blue Value Group,,0.89680,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Group,,232.27,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Blue Value Group,,36.32,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Blue Value Group,,13.00,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Blue Value Group,,72.19,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Value Group,,878.86,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,42.60,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Value Group,,63.22,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,,39.91,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Value Group,,15.25,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Blue Value Group,,17.04,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Group,,31.39,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Blue Value Group,,31.39,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Blue Value Group,,6.73,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Blue Value Group,,15.69,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Blue Value Group,,33.63,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Blue Value Group,,21.97,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Blue Value Group,,237.20,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,BCBS NC,Blue Value Group,,343.92,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Blue Value Group,,60.09,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,BCBS NC,Blue Value Group,,809.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,BCBS NC,Blue Value Group,,512.51,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Value Group,,119.37,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Blue Value Group,,52.01,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Value Group,,865.86,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Blue Value Group,,10.31,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Blue Value Group,,116.14,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Group,,20.63,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,BCBS NC,Blue Value Group,,810.71,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Blue Value Group,,317.02,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,27.80,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Group,,47.98,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,BCBS NC,Blue Value Group,,230.03,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Group,,84.75,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Blue Value Group,,878.86,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,BCBS NC,Blue Value Group,,51.12,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Blue Value Group,,145.28,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,60.98,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Value Group,,86.99,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Blue Value Group,,427.33,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,BCBS NC,Blue Value Group,,286.53,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Group,,62.78,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Blue Value Group,QW,62.78,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Blue Value Group,,20.63,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Value Group,,124.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Value Group,,712.51,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,BCBS NC,Blue Value Group,,532.25,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Blue Value Group,,113.26,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Value Group,,273.08,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,BCBS NC,Blue Value Group,,214.34,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Blue Value Group,,91.47,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Blue Value Group,,191.02,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Blue Value Group,,22.42,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,49.32,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Group,QW,44.84,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Blue Value Group,,44.84,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Blue Value Group,,73.09,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,BCBS NC,Blue Value Group,,406.70,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Group,,123.31,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Group,,59.19,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,,73.99,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Blue Value Group,,39.91,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Group,,19.28,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Blue Value Group,,125.55,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Blue Value Group,,35.42,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Blue Value Group,,86.99,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,40.80,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Blue Value Group,,30.94,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Group,,29.59,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Blue Value Group,,156.94,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Group,,60.53,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Blue Value Group,,95.51,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,BCBS NC,Blue Value Group,,98.20,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Group,,60.53,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Group,,60.53,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Blue Value Group,,123.31,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Group,,20.18,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Blue Value Group,,20.18,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,BCBS NC,Blue Value Group,,34.08,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Group,,19.28,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Blue Value Group,,37.67,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Blue Value Group,,45.29,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Blue Value Group,,66.81,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,BCBS NC,Blue Value Group,,595.48,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Group,,24.66,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Blue Value Group,,48.43,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,52.91,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Blue Value Group,,52.91,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Blue Value Group,,29.15,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Group,,25.56,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Value Group,,121.52,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Blue Value Group,,74.88,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Blue Value Group,,121.52,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Value Group,,143.04,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Blue Value Group,,247.97,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,BCBS NC,Blue Value Group,,235.86,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,BCBS NC,Blue Value Group,,94.16,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00407,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Blue Value Group,,12.11,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Blue Value Group,,44.81,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Blue Value Group,,75.78,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Value Group,,59.89,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Blue Value Group,,59.89,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Blue Value Group,,15.89,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,BCBS NC,Blue Value Group,,80.67,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Blue Value Group,,48.48,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,BCBS NC,Blue Value Group,,103.89,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Value Group,,106.33,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,55.41,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Blue Value Group,,31.78,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Blue Value Group,,55.41,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Blue Value Group,,85.15,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Blue Value Group,,84.33,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Group,,211.03,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Blue Value Group,,60.30,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Blue Value Group,,185.77,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Blue Value Group,,243.22,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,BCBS NC,Blue Value Group,,307.59,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,BCBS NC,Blue Value Group,,228.55,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Blue Value Group,,132.41,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Blue Value Group,,91.67,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,BCBS NC,Blue Value Group,,415.14,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Value Group,,144.22,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Blue Value Group,,248.11,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Blue Value Group,,91.26,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Group,,32.59,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Group,,53.78,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Blue Value Group,,55.00,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Value Group,,223.26,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Blue Value Group,,41.55,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Group,,71.30,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Value Group,,149.52,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Group,,268.88,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Blue Value Group,,0.00407,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Blue Value Group,,50.52,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,BCBS NC,Blue Value Group,,92.07,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,BCBS NC,Blue Value Group,,150.74,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Value Group,,129.96,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Blue Value Group,,129.96,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,BCBS NC,Blue Value Group,,241.59,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Blue Value Group,,223.26,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Group,,39.52,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,,52.55,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Blue Value Group,,160.52,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,BCBS NC,Blue Value Group,,127.52,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Blue Value Group,,101.44,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Blue Value Group,,31.37,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,BCBS NC,Blue Value Group,,156.44,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Blue Value Group,,53.78,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,BCBS NC,Blue Value Group,,275.00,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Blue Value Group,,77.00,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Value Group,,168.66,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,BCBS NC,Blue Value Group,,114.79,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Blue Value Group,,106.33,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Group,,63.96,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Blue Value Group,,63.96,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Blue Value Group,,219.59,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Blue Value Group,,56.63,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Blue Value Group,,66.81,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Blue Value Group,,7.33,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Blue Value Group,,168.66,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,37.07,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Blue Value Group,,100.63,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,BCBS NC,Blue Value Group,,892.61,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Blue Value Group,,143.81,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Value Group,,78.22,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,BCBS NC,Blue Value Group,,288.44,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Blue Value Group,,211.03,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Blue Value Group,,144.22,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Group,,156.85,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Value Group,,149.52,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Group,,156.85,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Blue Value Group,,211.44,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,BCBS NC,Blue Value Group,,523.51,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Group,,32.59,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Group,,156.85,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Blue Value Group,,149.52,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,BCBS NC,Blue Value Group,,127.11,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Blue Value Group,,52.55,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,BCBS NC,Blue Value Group,,506.40,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,9.78,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,9.78,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,9.78,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,9.78,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,9.78,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Blue Value Group,,9.78,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Value Group,,78.22,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Group,,32.59,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,BCBS NC,Blue Value Group,,369.92,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Blue Value Group,,268.88,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,BCBS NC,Blue Value Group,,193.11,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Blue Value Group,,145.03,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,BCBS NC,Blue Value Group,,50.92,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Blue Value Group,,61.11,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Blue Value Group,,38.70,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Blue Value Group,,67.63,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Blue Value Group,,32.59,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,BCBS NC,Blue Value Group,,64.78,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Blue Value Group,,647.36,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,BCBS NC,Blue Value Group,,325.11,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,BCBS NC,Blue Value Group,,132.81,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Blue Value Group,,29.59,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Group,,18.83,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,BCBS NC,Blue Value Group,,47.08,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,BCBS NC,Blue Value Group,,111.20,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,17.25,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Group,,83.46,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Group,,83.46,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Blue Value Group,,77.06,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,BCBS NC,Blue Value Group,,157.46,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,25.32,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,25.32,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Blue Value Group,,15.86,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,BCBS NC,Blue Value Group,,188.90,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,BCBS NC,Blue Value Group,,181.11,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Group,,289.61,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,BCBS NC,Blue Value Group,,297.67,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Group,,59.81,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,BCBS NC,Blue Value Group,,116.57,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Blue Value Group,,81.79,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Blue Value Group,,264.01,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,BCBS NC,Blue Value Group,,344.97,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Blue Value Group,,166.92,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Blue Value Group,,25.32,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Blue Value Group,,425.09,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Blue Value Group,,12.56,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,,73.99,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,,73.99,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Blue Value Group,,73.99,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Blue Value Group,,26.46,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Group,,289.61,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Blue Value Group,,289.61,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Blue Value Group,,322.71,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,17.25,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,17.25,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,17.25,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,17.25,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Blue Value Group,,17.25,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,BCBS NC,Blue Value Group,,984.14,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Group,,4126.45,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Group,,3224.03,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Group,,4126.45,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Group,,4126.45,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Group,,3224.03,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,BCBS NC,Blue Value Group,,13346.45,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,BCBS NC,Blue Value Group,,2261.71,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Group,,930.72,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Blue Value Group,,1191.23,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,BCBS NC,Blue Value Group,,2526.18,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,BCBS NC,Blue Value Group,,768.58,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,BCBS NC,Blue Value Group,,1267.04,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Value Group,,341.97,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,BCBS NC,Blue Value Group,,341.97,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Value Group,,953.85,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,BCBS NC,Blue Value Group,,745.25,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Value Group,,2005.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,BCBS NC,Blue Value Group,,1567.25,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Value Group,,912.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,BCBS NC,Blue Value Group,,713.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Blue Value Group,,215.23,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Blue Value Group,,309.61,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Group,,863.81,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Group,,674.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Group,,681.80,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Group,,532.70,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Value Group,,763.66,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,BCBS NC,Blue Value Group,,596.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Group,,681.80,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,BCBS NC,Blue Value Group,,532.70,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,BCBS NC,Blue Value Group,,2903.14,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Value Group,,1857.63,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Blue Value Group,,1451.38,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Value Group,,3450.43,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Blue Value Group,,2695.85,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Group,,2654.03,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Group,,2073.61,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Value Group,,663.51,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Blue Value Group,,518.40,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Group,,2654.03,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Blue Value Group,,2073.61,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,BCBS NC,Blue Value Group,,1000.32,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Group,,4126.45,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Blue Value Group,,3224.03,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Blue Value Group,,382.31,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,BCBS NC,Blue Value Group,,10931.24,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Value Group,,2115.71,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Blue Value Group,,1653.02,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,211.38,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,165.15,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,211.38,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Blue Value Group,,165.15,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Group,,1086.75,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Group,,849.08,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Group,,1086.75,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,BCBS NC,Blue Value Group,,849.08,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Value Group,,8055.01,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Blue Value Group,,6293.45,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Value Group,,13425.18,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Blue Value Group,,10489.21,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Value Group,,4832.82,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,BCBS NC,Blue Value Group,,3775.92,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Value Group,,11142.87,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,BCBS NC,Blue Value Group,,8706.02,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Value Group,,4481.32,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Blue Value Group,,3501.29,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Value Group,,11305.14,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Blue Value Group,,8832.80,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Value Group,,10184.69,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Blue Value Group,,7957.38,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Value Group,,13546.04,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Blue Value Group,,10583.63,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,BCBS NC,Blue Value Group,,4637.79,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Value Group,,11218.95,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Blue Value Group,,8765.46,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Value Group,,10209.73,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Blue Value Group,,7976.94,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Value Group,,11575.26,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Blue Value Group,,9043.85,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Value Group,,4570.88,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,BCBS NC,Blue Value Group,,3571.27,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Value Group,,9853.42,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,BCBS NC,Blue Value Group,,7698.56,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Value Group,,8488.36,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,BCBS NC,Blue Value Group,,6632.03,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,BCBS NC,Blue Value Group,,9913.12,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Group,LM,6094.06,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Group,RI,6094.06,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Group,RC,6094.06,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Group,LD,6094.06,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,BCBS NC,Blue Value Group,LC,6094.06,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Group,LC,3143.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Group,RI,3143.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Group,RC,3143.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Group,LD,3143.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,BCBS NC,Blue Value Group,LC,3143.90,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,LM,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,RI,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,RC,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,LD,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,LC,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,LM,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,RI,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,RC,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,LD,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,BCBS NC,Blue Value Group,LC,5401.48,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,LM,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,RI,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,RC,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,LD,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,LC,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,LM,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,RI,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,RC,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,LD,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,BCBS NC,Blue Value Group,LC,8061.97,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,LM,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,RI,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,RC,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,LD,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,LC,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,RC,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,LD,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,BCBS NC,Blue Value Group,LC,8545.38,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LM,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,RI,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,RC,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LD,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LC,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LM,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,RI,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,RC,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LD,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LC,15236.85,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LM,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,RI,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,RC,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LD,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LC,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,RC,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LD,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,BCBS NC,Blue Value Group,LC,15236.85,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Value Group,,8706.40,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Blue Value Group,,8706.40,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Value Group,,8948.67,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,BCBS NC,Blue Value Group,,8948.67,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,LM,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,RI,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,RC,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,LD,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,LC,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,LM,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,RI,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,RC,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,LD,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,BCBS NC,Blue Value Group,LC,9351.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LM,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,RI,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,RC,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LD,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LC,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LM,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,RI,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,RC,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LD,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LC,9754.87,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LM,9754.87,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,RI,9754.87,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,RC,9754.87,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LD,9754.87,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,BCBS NC,Blue Value Group,LC,9754.87,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,BCBS NC,Blue Value Group,,147.85,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,BCBS NC,Blue Value Group,,498.37,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Blue Value Group,,701.61,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Blue Value Group,,158.76,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,BCBS NC,Blue Value Group,,950.66,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,BCBS NC,Blue Value Group,,370.93,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,BCBS NC,Blue Value Group,,4353.39,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Value Group,,4027.60,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Blue Value Group,,4027.60,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,BCBS NC,Blue Value Group,,3841.00,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,BCBS NC,Blue Value Group,,1598.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,BCBS NC,Blue Value Group,,2771.47,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,BCBS NC,Blue Value Group,,4097.95,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,BCBS NC,Blue Value Group,,3638.98,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,BCBS NC,Blue Value Group,,3884.64,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,BCBS NC,Blue Value Group,,1709.08,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,BCBS NC,Blue Value Group,,3996.75,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,BCBS NC,Blue Value Group,,4985.03,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,BCBS NC,Blue Value Group,,4490.70,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,BCBS NC,Blue Value Group,,4790.53,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,BCBS NC,Blue Value Group,,4871.79,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,BCBS NC,Blue Value Group,,5972.93,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,BCBS NC,Blue Value Group,,2549.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Blue Value Group,,76.37,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Blue Value Group,,36.49,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,BCBS NC,Blue Value Group,,565.43,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,BCBS NC,Blue Value Group,,1552.95,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,BCBS NC,Blue Value Group,,3033.68,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Blue Value Group,,182.08,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,235.50,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,BCBS NC,Blue Value Group,,235.50,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Blue Value Group,,80.88,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,BCBS NC,Blue Value Group,,2885.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,BCBS NC,Blue Value Group,,14721.83,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,BCBS NC,Blue Value Group,,3678.46,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,BCBS NC,Blue Value Group,,756.24,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,BCBS NC,Blue Value Group,,845.79,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,BCBS NC,Blue Value Group,,476.27,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Value Group,,254.23,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Value Group,,198.63,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,BCBS NC,Blue Value Group,,198.63,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Value Group,,3795.18,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Blue Value Group,,2965.21,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Value Group,,7212.39,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Blue Value Group,,7212.39,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,BCBS NC,Blue Value Group,,8795.56,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,BCBS NC,Blue Value Group,,6388.54,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,BCBS NC,Blue Value Group,,7259.58,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,BCBS NC,Blue Value Group,,8760.41,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,BCBS NC,Blue Value Group,,1537.43,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Value Group,,6783.85,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Blue Value Group,,6783.85,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,BCBS NC,Blue Value Group,,4918.52,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,BCBS NC,Blue Value Group,,1417.54,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Value Group,,1397.31,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Blue Value Group,,1397.31,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,BCBS NC,Blue Value Group,,9818.75,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,BCBS NC,Blue Value Group,,7186.39,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,BCBS NC,Blue Value Group,,1139.71,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,BCBS NC,Blue Value Group,,11452.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,BCBS NC,Blue Value Group,,11806.86,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,BCBS NC,Blue Value Group,,12869.53,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,BCBS NC,Blue Value Group,,4096.60,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Value Group,,5489.58,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Blue Value Group,,5489.58,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,BCBS NC,Blue Value Group,,24020.59,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,BCBS NC,Blue Value Group,,2768.62,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,BCBS NC,Blue Value Group,,1839.81,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,BCBS NC,Blue Value Group,,27781.59,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,BCBS NC,Blue Value Group,,1270.68,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,BCBS NC,Blue Value Group,,3805.78,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,BCBS NC,Blue Value Group,,1004.41,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Blue Value Group,,2016.52,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Value Group,,1940.76,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Blue Value Group,,1940.76,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Value Group,,967.98,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Blue Value Group,,687.35,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Value Group,,967.98,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Blue Value Group,,967.98,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,BCBS NC,Blue Value Group,,911.38,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,BCBS NC,Blue Value Group,,834.71,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,BCBS NC,Blue Value Group,,2869.21,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Value Group,,4561.39,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,BCBS NC,Blue Value Group,,4561.39,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,BCBS NC,Blue Value Group,,486.39,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,BCBS NC,Blue Value Group,,2421.16,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,BCBS NC,Blue Value Group,,496.57,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,BCBS NC,Blue Value Group,,945.22,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,BCBS NC,Blue Value Group,,7619.88,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Value Group,,6748.93,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,BCBS NC,Blue Value Group,,6748.93,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,BCBS NC,Blue Value Group,,905.99,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Value Group,,424.69,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Blue Value Group,,7575.54,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,BCBS NC,Blue Value Group,,10776.45,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,BCBS NC,Blue Value Group,,1195.08,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Blue Value Group,,726.44,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Value Group,,2671.36,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Blue Value Group,,2671.36,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,BCBS NC,Blue Value Group,,3070.53,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,BCBS NC,Blue Value Group,,968.72,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,BCBS NC,Blue Value Group,,5161.84,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Blue Value Group,,1805.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Value Group,,424.69,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Blue Value Group,,800.18,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,BCBS NC,Blue Value Group,,1066.90,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,BCBS NC,Blue Value Group,,2996.43,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,BCBS NC,Blue Value Group,,6967.98,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,BCBS NC,Blue Value Group,,3470.07,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,BCBS NC,Blue Value Group,,2432.89,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,BCBS NC,Blue Value Group,,2812.47,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Blue Value Group,,108.35,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Blue Value Group,,682.77,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,BCBS NC,Blue Value Group,,3837.55,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Group,,910.78,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Group,,910.78,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Group,,910.78,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Blue Value Group,,910.78,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,BCBS NC,Blue Value Group,,5003.84,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Value Group,,10007.67,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Blue Value Group,,10007.67,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,BCBS NC,Blue Value Group,,16112.27,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,BCBS NC,Blue Value Group,,13152.70,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Blue Value Group,,4562.69,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,BCBS NC,Blue Value Group,,1634.59,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,BCBS NC,Blue Value Group,,8052.94,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Value Group,,12881.46,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Value Group,,12881.46,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Blue Value Group,,12881.46,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,BCBS NC,Blue Value Group,,15587.60,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Value Group,,2545.37,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Blue Value Group,,2545.37,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Blue Value Group,,40.25,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Value Group,,11723.03,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Blue Value Group,,11723.03,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,BCBS NC,Blue Value Group,,14359.23,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,BCBS NC,Blue Value Group,,902.50,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,BCBS NC,Blue Value Group,,2443.04,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Blue Value Group,,4076.88,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Group,LD,1292.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Group,RC,1292.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Group,RI,1292.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Group,LM,1292.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Group,LD,1033.80,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Group,RC,1033.80,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Group,RI,1033.80,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Group,LM,1033.80,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Group,LD,886.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Group,RC,886.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Group,RI,886.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Group,LM,886.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,LD,186.22,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,RC,186.22,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,RI,186.22,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,LM,186.22,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,BCBS NC,Blue Value Group,LC,1292.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,BCBS NC,Blue Value Group,LC,1033.80,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,BCBS NC,Blue Value Group,LC,886.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Blue Value Group,LC,186.22,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,BCBS NC,Blue Value Group,,12268.26,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,BCBS NC,Blue Value Group,,23225.46,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,BCBS NC,Blue Value Group,,4289.81,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,BCBS NC,Blue Value Group,,1072.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,BCBS NC,Blue Value Group,,246.91,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,BCBS NC,Blue Value Group,,1204.29,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,BCBS NC,Blue Value Group,,989.55,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,BCBS NC,Blue Value Group,,342.11,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,BCBS NC,Blue Value Group,,377.93,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,BCBS NC,Blue Value Group,,279.76,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Value Group,,538.97,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Blue Value Group,,538.97,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Blue Value Group,,217.38,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Value Group,,175.55,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Blue Value Group,,175.55,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Value Group,,618.52,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Blue Value Group,,618.52,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Blue Value Group,,119.93,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Blue Value Group,,93.09,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Blue Value Group,,661.56,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Blue Value Group,,13.30,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Blue Value Group,,330.78,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Blue Value Group,,116.69,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Blue Value Group,,420.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,BCBS NC,Blue Value Group,,298.68,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Blue Value Group,,77.79,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Blue Value Group,,53.69,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,BCBS NC,Blue Value Group,,354.98,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Group,,79.29,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Blue Value Group,,60.65,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Blue Value Group,,82.63,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Blue Value Group,,30.32,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Blue Value Group,,39.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Blue Value Group,,11.96,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Blue Value Group,,3129.27,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,BCBS NC,Blue Value Group,,1744.96,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,BCBS NC,Blue Value Group,,3844.30,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Blue Value Group,,1255.27,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Value Group,,1016.45,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Value Group,,1016.45,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Blue Value Group,,1016.45,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,BCBS NC,Blue Value Group,,2210.21,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,BCBS NC,Blue Value Group,,2927.19,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,BCBS NC,Blue Value Group,,3285.68,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,BCBS NC,Blue Value Group,,2715.01,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,BCBS NC,Blue Value Group,,3518.66,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,BCBS NC,Blue Value Group,,3920.48,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Value Group,,246.43,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Group,,154.02,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Blue Value Group,,246.43,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Blue Value Group,,154.02,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Blue Value Group,,17.46,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,46.21,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Blue Value Group,,123.22,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Blue Value Group,,192.01,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,BCBS NC,Blue Value Group,,677.69,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,BCBS NC,Blue Value Group,,731.60,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,BCBS NC,Blue Value Group,,1145.91,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Blue Value Group,,150.43,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,BCBS NC,Blue Value Group,,345.00,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,BCBS NC,Blue Value Group,,53.39,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Blue Value Group,,521.61,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Blue Value Group,,89.84,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Blue Value Group,,132.46,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Blue Value Group,,98.57,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,BCBS NC,Blue Value Group,,1623.37,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Blue Value Group,,155.05,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Blue Value Group,,151.97,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Blue Value Group,,158.64,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,BCBS NC,Blue Value Group,,146.32,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Blue Value Group,,175.07,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Blue Value Group,,221.79,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Blue Value Group,,316.77,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Blue Value Group,,22.59,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Blue Value Group,,21.56,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Blue Value Group,,36.45,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Blue Value Group,,113.46,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,BCBS NC,Blue Value Group,,206.39,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,BCBS NC,Blue Value Group,,456.93,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Blue Value Group,,37.99,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Blue Value Group,,27.72,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Blue Value Group,,136.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Blue Value Group,,20.54,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,BCBS NC,Blue Value Group,,385.05,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,BCBS NC,Blue Value Group,,603.25,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Value Group,,2058.73,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,BCBS NC,Blue Value Group,,628.40,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Blue Value Group,,921.04,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,BCBS NC,Blue Value Group,,1164.90,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Blue Value Group,,252.59,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,BCBS NC,Blue Value Group,,2058.73,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Blue Value Group,,359.38,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,BCBS NC,Blue Value Group,,400.45,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Blue Value Group,,46.21,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,BCBS NC,Blue Value Group,,820.41,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,BCBS NC,Blue Value Group,,1318.92,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Blue Value Group,,256.70,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,BCBS NC,Blue Value Group,,2053.60,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Value Group,,1244.99,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Value Group,,924.12,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,BCBS NC,Blue Value Group,,1244.99,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,BCBS NC,Blue Value Group,,924.12,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Value Group,,605.81,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,BCBS NC,Blue Value Group,,605.81,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,BCBS NC,Blue Value Group,,542.66,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Blue Value Group,GP,62.95,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Value Group,,14879.79,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Value Group,,7195.05,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,BCBS NC,Blue Value Group,,14879.79,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,BCBS NC,Blue Value Group,,7195.05,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,BCBS NC,Blue Value Group,,6253.24,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,BCBS NC,Blue Value Group,,6390.95,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,BCBS NC,Blue Value Group,,6529.14,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,BCBS NC,Blue Value Group,,6667.81,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,BCBS NC,Blue Value Group,,6806.00,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,BCBS NC,Blue Value Group,,6943.71,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,BCBS NC,Blue Value Group,,7081.90,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,BCBS NC,Blue Value Group,,7220.09,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Blue Value Group,,214.07,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Blue Value Group,,105.53,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Blue Value Group,,55.64,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,199000.36,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,80975.46,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,150928.76,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,98790.80,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,73754.16,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33638.50,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,92418.69,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,40480.12,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,51588.89,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,39415.99,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30661.75,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21228.00,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,85826.67,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,42778.80,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,39261.83,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,306184.44,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,51298.29,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,56489.61,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,38282.54,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23318.11,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,41368.91,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,28511.54,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33000.02,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22835.89,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18690.33,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,43334.56,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,24974.06,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16373.26,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,32531.94,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15919.33,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12609.52,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,28220.24,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17754.17,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14588.62,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,24129.11,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12324.58,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9163.26,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,28153.06,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16398.01,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13067.70,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13658.82,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7775.28,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11647.92,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8060.94,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17277.60,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10012.46,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12939.01,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9625.68,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7355.29,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20346.30,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13276.29,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10777.51,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15070.84,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7995.19,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5690.84,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11236.39,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6963.57,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6499.73,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12622.95,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8106.19,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6198.51,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12195.18,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8140.13,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14409.72,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6686.40,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13649.64,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7184.17,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17012.45,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10720.94,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7609.84,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16915.59,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10062.65,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7319.23,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10409.84,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8619.53,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6672.26,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13269.23,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8084.97,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6482.04,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25736.28,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19088.43,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19088.43,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26389.63,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17078.23,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10484.77,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14546.20,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7233.67,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8777.20,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6764.88,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17475.58,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10418.31,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11704.49,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13636.18,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8522.65,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9077.01,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6407.81,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6498.31,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10206.90,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6280.54,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16195.07,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8030.53,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11409.62,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7117.71,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9588.92,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,31010.33,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16273.57,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12139.33,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,27342.76,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13104.49,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9352.77,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15823.16,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9842.05,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6487.72,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6166.00,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10266.30,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6041.55,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9210.63,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6071.25,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11906.69,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7331.95,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5738.21,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12990.64,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7284.57,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5861.24,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,32541.14,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18698.11,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14386.41,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,27279.81,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13602.95,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10513.04,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21896.90,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10563.97,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6543.57,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11901.04,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7752.67,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6190.04,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13338.52,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8424.37,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6181.55,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11669.13,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8375.58,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6412.77,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11871.35,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7845.27,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5922.76,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9586.79,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8683.88,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6812.25,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5391.05,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10145.39,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6549.93,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5295.59,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14195.49,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7562.46,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5915.69,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13325.08,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8624.47,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5907.92,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7718.73,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5589.03,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6560.55,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13798.11,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7505.90,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,46349.51,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20286.88,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,80883.55,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,77739.20,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,41203.47,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,71254.67,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,70022.93,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,47343.65,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,47343.65,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,55142.64,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,38558.31,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,36489.42,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,35833.26,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23120.82,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,60456.99,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,43718.51,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,54908.59,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,39476.79,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,42346.80,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30469.42,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,35651.54,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21006.71,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10640.34,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23426.99,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15918.61,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13631.94,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33111.02,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16283.45,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11418.81,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25516.39,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19204.37,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13449.53,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19924.18,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12857.00,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8574.27,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23068.51,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15149.32,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23851.23,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14218.81,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12376.19,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22469.61,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,24472.05,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26434.87,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,44183.77,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,34513.86,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,49483.25,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30712.64,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,38158.82,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25997.21,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18903.16,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30021.84,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,24126.28,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,51268.60,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,43322.54,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33507.69,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,40208.61,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26351.43,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12193.77,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7350.34,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5964.47,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14857.30,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5745.99,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5086.30,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16497.70,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8418.00,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19986.40,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12920.64,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7425.28,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9929.02,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6854.69,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,4853.67,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11895.39,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5334.48,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,4069.52,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12395.99,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8399.62,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5940.44,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9312.48,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5611.65,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9265.79,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6190.73,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11993.66,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7308.62,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9364.79,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6053.57,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,4854.36,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5814.57,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7014.49,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5942.55,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15595.50,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7662.86,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5674.58,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,48129.92,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17978.31,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,32407.49,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17858.82,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20089.63,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13317.29,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,31449.41,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23131.43,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23551.45,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,36116.09,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18133.85,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12181.05,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33352.15,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17801.54,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12750.94,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26452.56,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17412.64,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12432.76,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26100.45,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15761.66,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11705.18,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19113.87,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11490.94,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9238.92,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17083.16,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10105.78,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7007.41,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18471.14,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11630.94,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9108.83,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21370.84,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12747.41,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10361.74,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,31911.85,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17294.59,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10735.78,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25164.98,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17922.46,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12107.51,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7923.77,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5806.80,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13388.73,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8070.84,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5994.87,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15973.77,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9404.37,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7387.10,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13776.89,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7785.89,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5309.01,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14725.77,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8512.76,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6512.46,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10614.18,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6895.68,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12039.64,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7754.79,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5668.93,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11293.65,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6436.09,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,4698.12,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9819.42,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6363.98,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12159.82,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7467.71,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5440.55,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17785.27,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11553.85,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8945.49,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,29279.42,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,39531.94,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21358.11,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16545.78,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26062.95,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16246.70,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12077.80,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,24208.31,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15717.81,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12592.56,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26041.75,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15464.68,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10491.14,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17725.18,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12812.46,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10508.82,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,24942.24,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13137.00,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10747.11,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30216.30,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16321.65,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11459.84,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,78779.31,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,51892.24,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,40603.15,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,64555.88,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,41629.10,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14768.21,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8319.72,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5889.54,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13838.41,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8849.32,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6885.08,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12378.31,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6799.53,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5245.39,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13541.45,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7677.00,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5799.02,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12666.08,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8589.83,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6701.24,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,48095.26,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30837.10,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,38535.67,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23692.85,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,60269.61,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,43014.97,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30354.87,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,39903.14,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19659.73,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,41151.13,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22874.77,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13746.50,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,37657.50,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25787.19,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20281.95,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22298.52,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14490.34,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,34993.95,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21682.65,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18113.35,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,31205.47,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16942.47,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9196.49,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25278.10,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18239.93,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13995.38,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21443.67,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15661.23,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12383.98,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20450.94,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23669.52,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15637.21,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11925.79,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13359.01,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8748.22,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26812.44,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18783.67,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15039.04,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26487.90,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13606.49,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9395.18,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22182.53,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15097.70,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23229.03,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13211.93,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10368.11,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20586.69,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14068.21,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13528.02,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10391.45,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13624.17,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11559.54,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22208.72,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15554.46,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12556.50,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11983.07,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8080.04,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23385.28,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15545.29,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11717.19,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,27276.98,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14994.46,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11414.58,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21145.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15825.28,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11936.38,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6551.34,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9916.29,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6561.95,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7599.23,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5944.68,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14778.82,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10017.39,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6419.12,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13342.05,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8120.34,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6187.20,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18399.02,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9007.00,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6764.17,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14504.48,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9387.40,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7032.15,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12702.87,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7648.72,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10017.39,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6721.04,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10197.71,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6724.57,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11365.07,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7167.19,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14037.83,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8813.97,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6535.78,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10925.99,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7183.46,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11765.99,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7741.34,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6149.73,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21647.31,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12797.61,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8956.81,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,47174.67,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25396.90,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13557.71,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,35506.60,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19593.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12210.03,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23750.13,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13069.84,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11055.38,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14474.06,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13044.38,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15987.91,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14491.74,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14535.58,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9239.62,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6980.54,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15846.49,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8505.69,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12639.22,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8850.73,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6291.85,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8216.49,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5129.42,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10901.24,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7009.53,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11260.43,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7328.42,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11551.03,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7260.54,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16349.22,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10745.70,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25510.02,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14075.99,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10880.02,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21267.60,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12166.88,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11517.10,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26017.71,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13535.80,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9703.46,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22205.88,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11453.46,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10243.68,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,27202.76,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16257.30,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11171.33,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11010.14,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7188.42,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5243.98,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10295.29,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6354.06,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10906.90,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12490.74,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8099.11,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6284.06,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,34093.86,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,27054.26,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23686.49,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,37593.86,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20644.67,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15817.51,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23363.36,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13791.04,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11823.97,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18817.59,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10197.00,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8172.66,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22498.61,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11600.54,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8253.97,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,22920.74,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13220.42,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8673.25,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21498.11,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11825.39,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7761.84,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13543.57,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8484.48,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30559.94,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17387.20,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12457.51,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11323.36,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7044.17,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5096.20,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13605.08,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8260.34,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6439.63,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9055.79,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6575.40,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10358.22,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6378.82,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8939.11,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5723.36,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8472.46,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12549.43,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8028.42,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5729.72,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14995.19,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11699.53,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17305.90,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10759.13,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15585.59,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8627.30,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11481.75,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8328.21,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16670.94,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11252.65,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14218.81,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10348.31,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13647.50,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8931.33,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5487.91,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9125.79,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5956.71,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11336.81,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6587.40,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8337.40,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5603.17,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15912.26,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10365.28,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26125.88,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15421.55,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11234.98,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26184.58,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13646.80,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10935.19,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13824.97,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9624.28,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15340.25,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8894.58,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13134.17,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6930.34,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10660.84,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19006.39,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11286.60,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13873.77,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8543.17,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7643.06,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10976.19,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7773.86,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5543.77,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7975.38,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,4885.49,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8428.61,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12799.72,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7941.44,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5480.85,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6800.23,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18210.94,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8347.31,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7623.97,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12514.78,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8748.22,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7631.05,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13594.48,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,42876.40,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,29551.64,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18169.22,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30333.67,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11287.31,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,2264.38,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9103.16,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7925.18,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7619.02,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,32874.17,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20716.09,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14348.92,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,29022.04,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13995.38,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10439.52,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8482.36,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6182.96,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5618.72,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16463.04,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9802.45,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8251.85,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10781.04,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7343.97,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11636.60,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15888.92,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8021.34,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5320.32,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16984.18,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9048.01,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6931.76,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,42319.93,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16680.12,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9364.79,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33269.41,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16871.04,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10392.85,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33926.98,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17193.47,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12898.72,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23195.07,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11493.07,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9354.18,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5953.87,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,4548.92,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,39669.12,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15599.71,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9474.37,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,34821.45,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15611.05,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11061.05,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23724.68,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12386.79,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7995.90,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14956.29,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9459.52,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6873.07,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19182.45,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10101.55,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6857.51,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20009.72,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,62080.42,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,35771.03,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14979.62,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11437.91,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,33014.15,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15993.56,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10700.43,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13746.50,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7907.52,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7128.32,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11445.69,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7000.33,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15652.05,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8142.26,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6011.14,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,49722.96,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14586.49,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8087.11,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,28179.23,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7640.92,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7504.47,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8444.17,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14754.78,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12227.71,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10728.01,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15525.49,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8423.68,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5213.57,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10860.93,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13190.75,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7093.67,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30524.57,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14388.50,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9121.55,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26823.05,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11340.34,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14740.63,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,27998.19,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,14959.12,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10133.38,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12409.44,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7112.76,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12741.75,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5562.87,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11941.35,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6911.94,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13796.70,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7938.62,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5719.12,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,13221.14,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8047.51,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,151814.71,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,51567.69,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,23624.98,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,28386.39,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,16482.14,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15417.30,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,26507.70,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,17375.18,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,15188.91,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11801.35,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,8960.35,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9827.21,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,6511.76,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9263.66,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,5289.92,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,4782.95,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,48445.28,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,27458.71,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,54729.71,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,30646.88,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21668.51,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,20181.55,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,11688.22,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7501.63,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,44133.55,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,19499.93,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,21257.70,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10008.21,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,7234.39,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,10027.30,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,34025.97,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,18234.98,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12970.84,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,25092.85,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,12473.07,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,BCBS NC,Medicare Advantage,,9330.83,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,16738.69,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6003.17,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4964.08,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,20631.32,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7114.44,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4964.08,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,9206.24,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1494.54,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,29318.18,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6314.07,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,23602.16,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,20631.32,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7114.44,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,642.16,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,642.16,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6314.07,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4964.08,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5727.11,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,292.66,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5727.11,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,19365.38,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,29318.18,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,43294.30,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3308.62,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,223.42,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,510.48,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3308.62,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,386.59,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,23602.16,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,19365.38,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17275.88,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3308.62,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,837.72,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6003.17,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,9206.24,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5727.11,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5485.35,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,489.94,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5727.11,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6003.17,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,23602.16,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3308.62,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,931.82,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6314.07,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,21595.14,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,19365.38,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17275.88,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,837.72,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,193.54,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,30845.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1494.54,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17004.00,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,527.80,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5727.11,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,57.15,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7962.20,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,931.82,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,193.54,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,642.16,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,837.72,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,292.66,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7962.20,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,186.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,383.91,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,124.01,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,57.15,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6274.19,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12499.81,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,19365.38,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,30845.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10068.53,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,383.91,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5727.11,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7300.39,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,527.80,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,11997.49,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6314.07,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,223.42,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5485.35,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6161.26,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,292.66,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,84.71,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,193.54,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,642.16,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,931.82,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,931.82,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4964.08,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1494.54,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5485.35,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4507.53,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,11997.49,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6161.26,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,527.80,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7962.20,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7300.39,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7300.39,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17275.88,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6161.26,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6003.17,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3870.33,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,527.80,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,931.82,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,223.42,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,489.94,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,383.91,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3501.31,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,124.01,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,124.01,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17275.88,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12499.81,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,292.66,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,837.72,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10068.53,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7962.20,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,223.42,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,629.57,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,88.31,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,8896.54,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7114.44,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,223.42,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6660.00,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5727.11,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,186.78,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3660.29,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,292.66,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3547.15,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,223.42,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,489.94,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5691.37,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,124.01,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1425.11,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3120.11,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,489.94,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,223.42,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,420.60,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4749.28,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,383.91,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,193.54,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3684.09,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17275.88,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17275.88,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,383.91,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17275.88,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5485.35,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10910.59,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1970.84,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,642.16,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,193.54,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3058.98,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,193.54,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12499.81,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,10016.47,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,642.16,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5485.35,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,12378.98,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3395.25,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,292.66,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1659.09,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5613.15,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3028.17,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,588.93,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,383.91,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,124.01,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3318.21,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,191.17,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,124.01,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1759.87,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,383.91,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4964.08,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2638.41,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,5200.74,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,527.80,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2753.54,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1134.38,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,877.14,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,17692.79,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2194.26,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1316.38,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3501.31,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3501.31,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1539.73,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,287.60,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,931.82,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3522.17,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7962.20,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3628.02,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,1825.06,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,7962.20,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,2244.50,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,6872.88,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,233.99,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,4890.88,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,,3121.59,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,BCBS NC,Medicare Advantage,,28.50,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Medicare Advantage,,55119.81,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,BCBS NC,Medicare Advantage,,7.06,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,BCBS NC,Medicare Advantage,,3.25,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,BCBS NC,Medicare Advantage,,11.71,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,BCBS NC,Medicare Advantage,,0.11640,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,BCBS NC,Medicare Advantage,,1678.41,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,BCBS NC,Medicare Advantage,,109.08,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,BCBS NC,Medicare Advantage,,111.10,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,BCBS NC,Medicare Advantage,,6.57,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,BCBS NC,Medicare Advantage,,7.71,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,BCBS NC,Medicare Advantage,,29.11,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,BCBS NC,Medicare Advantage,,14.66,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Medicare Advantage,,1.65,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Medicare Advantage,,60.36,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Medicare Advantage,,73.58,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,BCBS NC,Medicare Advantage,,1.82,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,BCBS NC,Medicare Advantage,,167.14,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,BCBS NC,Medicare Advantage,,711.66,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,BCBS NC,Medicare Advantage,,8.47,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,BCBS NC,Medicare Advantage,,3.32,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,BCBS NC,Medicare Advantage,,4981.04,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Medicare Advantage,,93.02,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,BCBS NC,Medicare Advantage,,220.46,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,BCBS NC,Medicare Advantage,,5.40,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,BCBS NC,Medicare Advantage,,5.40,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,BCBS NC,Medicare Advantage,,19.74,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Medicare Advantage,,19.74,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,BCBS NC,Medicare Advantage,,19.74,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,BCBS NC,Medicare Advantage,,8.49,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,BCBS NC,Medicare Advantage,,86.66,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Medicare Advantage,,4.10,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,BCBS NC,Medicare Advantage,,2.84,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,BCBS NC,Medicare Advantage,,2.84,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,BCBS NC,Medicare Advantage,,2.84,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,BCBS NC,Medicare Advantage,,2.84,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,BCBS NC,Medicare Advantage,,2.84,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,BCBS NC,Medicare Advantage,,2.84,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,BCBS NC,Medicare Advantage,,29.11,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,BCBS NC,Medicare Advantage,,167.84,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,BCBS NC,Medicare Advantage,,167.84,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Medicare Advantage,,5.54,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Medicare Advantage,,5.54,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Medicare Advantage,,71.00,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,BCBS NC,Medicare Advantage,,71.00,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,BCBS NC,Medicare Advantage,,6.53,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,BCBS NC,Medicare Advantage,,175.78,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Medicare Advantage,,177.98,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Medicare Advantage,,177.98,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,BCBS NC,Medicare Advantage,,29.11,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,BCBS NC,Medicare Advantage,,2529.92,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,BCBS NC,Medicare Advantage,,419.06,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,BCBS NC,Medicare Advantage,,2.16,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,BCBS NC,Medicare Advantage,,250.88,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,BCBS NC,Medicare Advantage,,5.03,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,BCBS NC,Medicare Advantage,,1.42,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,BCBS NC,Medicare Advantage,,1.42,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,BCBS NC,Medicare Advantage,,60.36,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,BCBS NC,Medicare Advantage,,16.51,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Medicare Advantage,,53.98,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,BCBS NC,Medicare Advantage,,27571.34,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,BCBS NC,Medicare Advantage,,64.64,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,BCBS NC,Medicare Advantage,,88.98,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,BCBS NC,Medicare Advantage,,130.16,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,BCBS NC,Medicare Advantage,,575.21,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,BCBS NC,Medicare Advantage,,726.38,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,BCBS NC,Medicare Advantage,,2.76,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,BCBS NC,Medicare Advantage,,137.63,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,BCBS NC,Medicare Advantage,,7.71,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,BCBS NC,Medicare Advantage,,255.26,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,BCBS NC,Medicare Advantage,,47.49,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,BCBS NC,Medicare Advantage,,171.16,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,BCBS NC,Medicare Advantage,,73.58,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,BCBS NC,Medicare Advantage,,1678.41,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,BCBS NC,Medicare Advantage,,61.17,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,BCBS NC,Medicare Advantage,,711.66,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,BCBS NC,Medicare Advantage,,40.90,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,BCBS NC,Medicare Advantage,,40.90,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,BCBS NC,Medicare Advantage,,299.42,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,BCBS NC,Medicare Advantage,,72.13,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,BCBS NC,Medicare Advantage,,72.13,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Medicare Advantage,,2.08,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,BCBS NC,Medicare Advantage,,20.67,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,BCBS NC,Medicare Advantage,,15.14,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Medicare Advantage,,2.08,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,BCBS NC,Medicare Advantage,,7.71,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,BCBS NC,Medicare Advantage,,162.29,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Medicare Advantage,,159.32,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,BCBS NC,Medicare Advantage,,8.80,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,BCBS NC,Medicare Advantage,,31.97,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,BCBS NC,Medicare Advantage,,31.97,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Medicare Advantage,,86.66,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,BCBS NC,Medicare Advantage,,58.48,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,BCBS NC,Medicare Advantage,,197.47,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,BCBS NC,Medicare Advantage,,197.47,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,BCBS NC,Medicare Advantage,,197.47,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,BCBS NC,Medicare Advantage,,101.59,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,BCBS NC,Medicare Advantage,,49.22,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,BCBS NC,Medicare Advantage,,47.56,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,BCBS NC,Medicare Advantage,,47.56,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,BCBS NC,Medicare Advantage,,76.44,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,BCBS NC,Medicare Advantage,,76.44,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,BCBS NC,Medicare Advantage,,19.38,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,BCBS NC,Medicare Advantage,,0.44620,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,BCBS NC,Medicare Advantage,,0.44620,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,BCBS NC,Medicare Advantage,,64.02,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,BCBS NC,Medicare Advantage,,30.33,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,BCBS NC,Medicare Advantage,,13.09,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,BCBS NC,Medicare Advantage,,19.39,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,BCBS NC,Medicare Advantage,,109.08,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,BCBS NC,Medicare Advantage,,69.18,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Medicare Advantage,,88.60,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,BCBS NC,Medicare Advantage,,1.78,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,BCBS NC,Medicare Advantage,,8.47,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,BCBS NC,Medicare Advantage,,38.64,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,BCBS NC,Medicare Advantage,,137.35,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,BCBS NC,Medicare Advantage,,97.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,BCBS NC,Medicare Advantage,,57.63,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,BCBS NC,Medicare Advantage,,72.78,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,BCBS NC,Medicare Advantage,,82.57,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,BCBS NC,Medicare Advantage,,82.57,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,BCBS NC,Medicare Advantage,,35.59,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,BCBS NC,Medicare Advantage,,35.59,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,BCBS NC,Medicare Advantage,,248.41,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,BCBS NC,Medicare Advantage,,2617.11,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,BCBS NC,Medicare Advantage,,2.11,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,BCBS NC,Medicare Advantage,,1.59,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,BCBS NC,Medicare Advantage,,159.65,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,BCBS NC,Medicare Advantage,,7.91,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,BCBS NC,Medicare Advantage,,31.97,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,BCBS NC,Medicare Advantage,,17.57,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,BCBS NC,Medicare Advantage,,7.61,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,BCBS NC,Medicare Advantage,,7.61,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,BCBS NC,Medicare Advantage,,7.61,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,BCBS NC,Medicare Advantage,,7.61,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,BCBS NC,Medicare Advantage,,7.61,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,BCBS NC,Medicare Advantage,,96.16,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,BCBS NC,Medicare Advantage,,241.04,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,BCBS NC,Medicare Advantage,,28.41,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Medicare Advantage,,103.14,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Medicare Advantage,,127.44,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,BCBS NC,Medicare Advantage,,99.04,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Medicare Advantage,,88.60,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,BCBS NC,Medicare Advantage,,59.60,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,BCBS NC,Medicare Advantage,,6.63,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,BCBS NC,Medicare Advantage,,132.57,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,BCBS NC,Medicare Advantage,,27.02,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,BCBS NC,Medicare Advantage,,27.02,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,BCBS NC,Medicare Advantage,,28.50,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,BCBS NC,Medicare Advantage,,28.50,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,BCBS NC,Medicare Advantage,,40.72,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,BCBS NC,Medicare Advantage,,40.72,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,BCBS NC,Medicare Advantage,,125.60,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,BCBS NC,Medicare Advantage,,10.68,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,BCBS NC,Medicare Advantage,,35.64,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Medicare Advantage,,35.64,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,BCBS NC,Medicare Advantage,,29.08,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,BCBS NC,Medicare Advantage,,25.00,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,BCBS NC,Medicare Advantage,,25.00,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,BCBS NC,Medicare Advantage,,27.01,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,BCBS NC,Medicare Advantage,,27.01,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,BCBS NC,Medicare Advantage,,348.41,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,BCBS NC,Medicare Advantage,,27.15,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,BCBS NC,Medicare Advantage,,19.37,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,BCBS NC,Medicare Advantage,,79.44,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,BCBS NC,Medicare Advantage,,79.44,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,BCBS NC,Medicare Advantage,,35.19,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,BCBS NC,Medicare Advantage,,308.97,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,BCBS NC,Medicare Advantage,,19.80,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,BCBS NC,Medicare Advantage,,60.24,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,BCBS NC,Medicare Advantage,,60.24,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,BCBS NC,Medicare Advantage,,13.88,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,BCBS NC,Medicare Advantage,,132.57,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,BCBS NC,Medicare Advantage,,218.36,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,BCBS NC,Medicare Advantage,,218.36,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,BCBS NC,Medicare Advantage,,7.61,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,BCBS NC,Medicare Advantage,,5.30,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,BCBS NC,Medicare Advantage,,27.15,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,BCBS NC,Medicare Advantage,,2052.83,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,BCBS NC,Medicare Advantage,,210.39,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,BCBS NC,Medicare Advantage,,236.40,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,BCBS NC,Medicare Advantage,,21.86,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,BCBS NC,Medicare Advantage,,183.10,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,BCBS NC,Medicare Advantage,,11.95,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,BCBS NC,Medicare Advantage,,82.03,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,BCBS NC,Medicare Advantage,,0.36860,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,BCBS NC,Medicare Advantage,,0.36860,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,BCBS NC,Medicare Advantage,,191.90,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,BCBS NC,Medicare Advantage,,32.57,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,BCBS NC,Medicare Advantage,,32.57,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,BCBS NC,Medicare Advantage,,67.41,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,BCBS NC,Medicare Advantage,,634.99,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,BCBS NC,Medicare Advantage,,634.99,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,BCBS NC,Medicare Advantage,,29.64,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,BCBS NC,Medicare Advantage,,24.29,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,BCBS NC,Medicare Advantage,,24.29,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,BCBS NC,Medicare Advantage,,24.29,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,BCBS NC,Medicare Advantage,,61442.01,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Medicare Advantage,,70.44,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,BCBS NC,Medicare Advantage,,70.44,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,BCBS NC,Medicare Advantage,,189.85,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,BCBS NC,Medicare Advantage,,8.47,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,BCBS NC,Medicare Advantage,,103.14,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,BCBS NC,Medicare Advantage,,1.78,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,BCBS NC,Medicare Advantage,,55.32,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,BCBS NC,Medicare Advantage,,55.32,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,BCBS NC,Medicare Advantage,,73.69,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,BCBS NC,Medicare Advantage,,32.43,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,BCBS NC,Medicare Advantage,,26.54,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,BCBS NC,Medicare Advantage,,50.01,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Medicare Advantage,,167.05,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,BCBS NC,Medicare Advantage,,20.84,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,BCBS NC,Medicare Advantage,,72.96,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,BCBS NC,Medicare Advantage,,72.96,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,BCBS NC,Medicare Advantage,,6.09,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,BCBS NC,Medicare Advantage,,30.16,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,BCBS NC,Medicare Advantage,,41.89,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,BCBS NC,Medicare Advantage,,105.22,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,BCBS NC,Medicare Advantage,,105.22,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,BCBS NC,Medicare Advantage,,318.49,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,BCBS NC,Medicare Advantage,,0.77600,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,BCBS NC,Medicare Advantage,,7.91,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,BCBS NC,Medicare Advantage,,1773.86,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,BCBS NC,Medicare Advantage,,1.65,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,BCBS NC,Medicare Advantage,,91.62,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,BCBS NC,Medicare Advantage,,5013.18,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,BCBS NC,Medicare Advantage,,7.12,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,BCBS NC,Medicare Advantage,,86.66,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,BCBS NC,Medicare Advantage,,6.30,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,BCBS NC,Medicare Advantage,,171.16,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,BCBS NC,Medicare Advantage,,53.07,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,BCBS NC,Medicare Advantage,,53.07,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,BCBS NC,Medicare Advantage,,53.07,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,BCBS NC,Medicare Advantage,,53.07,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,BCBS NC,Medicare Advantage,,366.19,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,BCBS NC,Medicare Advantage,,0.44620,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,BCBS NC,Medicare Advantage,,43.26,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,BCBS NC,Medicare Advantage,,4.23,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Medicare Advantage,,76.02,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Medicare Advantage,,0.46560,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,BCBS NC,Medicare Advantage,,0.46560,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,BCBS NC,Medicare Advantage,,1.68,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,BCBS NC,Medicare Advantage,,10.22,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,BCBS NC,Medicare Advantage,,9.84,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,BCBS NC,Medicare Advantage,,9.84,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,BCBS NC,Medicare Advantage,,9.84,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,2356.99,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,BCBS NC,Medicare Advantage,,19.74,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,BCBS NC,Medicare Advantage,,177.98,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,BCBS NC,Medicare Advantage,,177.98,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Medicare Advantage,,66.15,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,BCBS NC,Medicare Advantage,,60.36,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,BCBS NC,Medicare Advantage,,60.36,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,BCBS NC,Medicare Advantage,,5.54,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,BCBS NC,Medicare Advantage,,5.54,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,250.88,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Medicare Advantage,,4.10,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,BCBS NC,Medicare Advantage,,200.92,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,BCBS NC,Medicare Advantage,,271.45,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,BCBS NC,Medicare Advantage,,271.45,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,BCBS NC,Medicare Advantage,,17.57,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Medicare Advantage,,167.05,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,BCBS NC,Medicare Advantage,,144.52,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,BCBS NC,Medicare Advantage,,176.98,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,BCBS NC,Medicare Advantage,,0.20370,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,68.63,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,BCBS NC,Medicare Advantage,,91.62,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,68.63,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,68.63,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,BCBS NC,Medicare Advantage,,127.44,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,BCBS NC,Medicare Advantage,,91.62,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,88.60,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Medicare Advantage,,1678.41,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,BCBS NC,Medicare Advantage,,1678.41,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,BCBS NC,Medicare Advantage,,35.19,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,82.57,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,BCBS NC,Medicare Advantage,,53.98,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,BCBS NC,Medicare Advantage,,0.46560,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Medicare Advantage,,4.10,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,BCBS NC,Medicare Advantage,,4.10,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,BCBS NC,Medicare Advantage,,0.35890,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Medicare Advantage,,6.53,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Medicare Advantage,,0.77600,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,BCBS NC,Medicare Advantage,,19.74,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,BCBS NC,Medicare Advantage,,91.62,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Medicare Advantage,,2.58,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,BCBS NC,Medicare Advantage,,2.08,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,58.48,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,BCBS NC,Medicare Advantage,,6.53,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Medicare Advantage,,159.32,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Medicare Advantage,,159.32,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Medicare Advantage,,159.32,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Medicare Advantage,,159.32,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,BCBS NC,Medicare Advantage,,159.32,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,BCBS NC,Medicare Advantage,,167.05,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,BCBS NC,Medicare Advantage,,72.78,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,59.60,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,60.24,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,60.24,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,BCBS NC,Medicare Advantage,,4.23,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,58.48,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,58.48,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,BCBS NC,Medicare Advantage,,0.77600,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,BCBS NC,Medicare Advantage,,1.78,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,BCBS NC,Medicare Advantage,,229.52,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,BCBS NC,Medicare Advantage,,88.60,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,BCBS NC,Medicare Advantage,,88.60,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,BCBS NC,Medicare Advantage,,53.90,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Medicare Advantage,,76.02,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Medicare Advantage,,76.02,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Medicare Advantage,,76.02,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Medicare Advantage,,76.02,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,BCBS NC,Medicare Advantage,,76.02,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,BCBS NC,Medicare Advantage,,76.02,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,BCBS NC,Medicare Advantage,,2356.99,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,BCBS NC,Medicare Advantage,,0.27160,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Medicare Advantage,,35.64,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Medicare Advantage,,35.64,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,BCBS NC,Medicare Advantage,,35.64,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,BCBS NC,Medicare Advantage,,70.44,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,BCBS NC,Medicare Advantage,,93.02,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Medicare Advantage,,4.29,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Medicare Advantage,,4.29,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Medicare Advantage,,4.29,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,BCBS NC,Medicare Advantage,,4.29,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,BCBS NC,Medicare Advantage,,4.29,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,BCBS NC,Medicare Advantage,,4.29,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Medicare Advantage,,0.35890,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,BCBS NC,Medicare Advantage,,66.15,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,BCBS NC,Medicare Advantage,,0.11640,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,BCBS NC,Medicare Advantage,,0.11640,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,BCBS NC,Medicare Advantage,,285.85,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Medicare Advantage,,1.45,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Medicare Advantage,,1.45,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,BCBS NC,Medicare Advantage,,1.45,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,BCBS NC,Medicare Advantage,,2.84,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,BCBS NC,Medicare Advantage,,1.56,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,BCBS NC,Medicare Advantage,,43.48,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,BCBS NC,Medicare Advantage,,25.91,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,BCBS NC,Medicare Advantage,,28.94,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,BCBS NC,Medicare Advantage,,135.03,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,BCBS NC,Medicare Advantage,,4.23,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Medicare Advantage,,51.49,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,BCBS NC,Medicare Advantage,,51.49,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,BCBS NC,Medicare Advantage,,91.62,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,BCBS NC,Medicare Advantage,,91.62,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,BCBS NC,Medicare Advantage,,3.98,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,BCBS NC,Medicare Advantage,,0.29100,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Medicare Advantage,,2.58,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Medicare Advantage,,2.58,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,BCBS NC,Medicare Advantage,,2.58,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Medicare Advantage,,1.62,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,BCBS NC,Medicare Advantage,,1.62,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,BCBS NC,Medicare Advantage,,0.35890,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,BCBS NC,Medicare Advantage,,470.42,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,BCBS NC,Medicare Advantage,,10.68,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,BCBS NC,Medicare Advantage,,10.68,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,BCBS NC,Medicare Advantage,,23.16,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,BCBS NC,Medicare Advantage,,23.16,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,BCBS NC,Medicare Advantage,,23.16,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,BCBS NC,Medicare Advantage,,2.76,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,BCBS NC,Medicare Advantage,,49.52,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,BCBS NC,Medicare Advantage,,6.30,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,BCBS NC,Medicare Advantage,,10.36,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,BCBS NC,Medicare Advantage,,4.32,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,BCBS NC,Medicare Advantage,,3.41,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,BCBS NC,Medicare Advantage,,3.41,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,BCBS NC,Medicare Advantage,,1.65,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,BCBS NC,Medicare Advantage,,0.31040,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,BCBS NC,Medicare Advantage,,8.49,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,BCBS NC,Medicare Advantage,,380.30,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,BCBS NC,Medicare Advantage,,493.69,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Medicare Advantage,,589.86,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Medicare Advantage,,329.41,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Medicare Advantage,,33.78,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,BCBS NC,Medicare Advantage,,33.78,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Medicare Advantage,,35.64,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Medicare Advantage,,124.01,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Medicare Advantage,,202.70,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Medicare Advantage,,44.39,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Medicare Advantage,,202.70,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Medicare Advantage,,44.39,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Medicare Advantage,,68.47,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Medicare Advantage,,202.70,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Medicare Advantage,,202.70,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,BCBS NC,Medicare Advantage,,44.39,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Medicare Advantage,,319.11,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Medicare Advantage,,8.82,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,BCBS NC,Medicare Advantage,,319.11,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Medicare Advantage,,68.47,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Medicare Advantage,,68.47,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,BCBS NC,Medicare Advantage,,68.47,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,BCBS NC,Medicare Advantage,,202.70,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Medicare Advantage,,319.11,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Medicare Advantage,,68.47,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,BCBS NC,Medicare Advantage,,319.11,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Medicare Advantage,,319.11,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,BCBS NC,Medicare Advantage,,352.19,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Medicare Advantage,,352.19,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,BCBS NC,Medicare Advantage,,127.74,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,BCBS NC,Medicare Advantage,,352.19,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,BCBS NC,Medicare Advantage,,127.74,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,BCBS NC,Medicare Advantage,,1689.33,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,BCBS NC,Medicare Advantage,,1689.33,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,BCBS NC,Medicare Advantage,,556.54,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,BCBS NC,Medicare Advantage,,556.54,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,BCBS NC,Medicare Advantage,,556.54,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Medicare Advantage,,667.51,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Medicare Advantage,,105.35,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,BCBS NC,Medicare Advantage,,319.11,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Medicare Advantage,,68.47,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Medicare Advantage,,319.11,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Medicare Advantage,,68.47,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,BCBS NC,Medicare Advantage,,319.11,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Medicare Advantage,,44.39,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,BCBS NC,Medicare Advantage,,319.11,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Medicare Advantage,,202.70,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,BCBS NC,Medicare Advantage,,202.70,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Medicare Advantage,,319.11,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,BCBS NC,Medicare Advantage,,105.35,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,BCBS NC,Medicare Advantage,,253.01,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Medicare Advantage,,253.01,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,BCBS NC,Medicare Advantage,,253.01,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,BCBS NC,Medicare Advantage,,556.54,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,BCBS NC,Medicare Advantage,,556.54,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,BCBS NC,Medicare Advantage,,556.54,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Medicare Advantage,,319.11,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,BCBS NC,Medicare Advantage,,7354.65,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,BCBS NC,Medicare Advantage,,7354.65,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,BCBS NC,Medicare Advantage,,667.51,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Medicare Advantage,,667.51,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,BCBS NC,Medicare Advantage,,667.51,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Medicare Advantage,,319.11,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Medicare Advantage,,127.74,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,BCBS NC,Medicare Advantage,,127.74,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,BCBS NC,Medicare Advantage,,352.19,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,BCBS NC,Medicare Advantage,,352.19,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,BCBS NC,Medicare Advantage,,556.54,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Medicare Advantage,,1577.12,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,BCBS NC,Medicare Advantage,,193.54,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,BCBS NC,Medicare Advantage,,3058.98,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Medicare Advantage,,195.68,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,BCBS NC,Medicare Advantage,,223.42,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,BCBS NC,Medicare Advantage,,186.78,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,BCBS NC,Medicare Advantage,,186.78,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,BCBS NC,Medicare Advantage,,4749.28,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,BCBS NC,Medicare Advantage,,292.66,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Medicare Advantage,,420.60,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,BCBS NC,Medicare Advantage,,223.42,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,124.01,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,124.01,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Medicare Advantage,,195.68,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Medicare Advantage,,124.01,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Medicare Advantage,,124.01,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Medicare Advantage,,23.56,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Medicare Advantage,,23.56,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Medicare Advantage,,37.76,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,BCBS NC,Medicare Advantage,,124.01,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Medicare Advantage,,195.68,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Medicare Advantage,,195.68,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,195.68,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Medicare Advantage,,195.68,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,BCBS NC,Medicare Advantage,,35.88,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Medicare Advantage,,35.88,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,BCBS NC,Medicare Advantage,,150.52,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Medicare Advantage,,510.48,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,BCBS NC,Medicare Advantage,,299.59,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Medicare Advantage,,150.52,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Medicare Advantage,,57.15,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Medicare Advantage,,124.01,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,BCBS NC,Medicare Advantage,,124.01,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Medicare Advantage,,124.01,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,BCBS NC,Medicare Advantage,,124.01,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,BCBS NC,Medicare Advantage,,150.52,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Medicare Advantage,,57.15,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,BCBS NC,Medicare Advantage,,150.52,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,BCBS NC,Medicare Advantage,,150.52,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Medicare Advantage,,150.52,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,BCBS NC,Medicare Advantage,,420.60,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Medicare Advantage,,299.59,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,BCBS NC,Medicare Advantage,,186.78,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Medicare Advantage,,1577.12,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,BCBS NC,Medicare Advantage,,673.19,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Medicare Advantage,,409.68,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,BCBS NC,Medicare Advantage,,510.48,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,BCBS NC,Medicare Advantage,,383.91,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Medicare Advantage,,150.52,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Medicare Advantage,,978.82,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,BCBS NC,Medicare Advantage,,978.82,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,BCBS NC,Medicare Advantage,,978.82,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Medicare Advantage,,299.59,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Medicare Advantage,,124.01,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,BCBS NC,Medicare Advantage,,299.59,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,BCBS NC,Medicare Advantage,,299.59,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,BCBS NC,Medicare Advantage,,510.48,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Medicare Advantage,,299.59,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Medicare Advantage,,57.15,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Medicare Advantage,,978.82,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,BCBS NC,Medicare Advantage,,978.82,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,BCBS NC,Medicare Advantage,,978.82,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Medicare Advantage,,150.52,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,BCBS NC,Medicare Advantage,,124.01,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Medicare Advantage,,124.01,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,BCBS NC,Medicare Advantage,,150.52,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Medicare Advantage,,124.01,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Medicare Advantage,,299.59,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Medicare Advantage,,124.01,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Medicare Advantage,,150.52,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Medicare Advantage,,510.48,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Medicare Advantage,,510.48,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,BCBS NC,Medicare Advantage,,510.48,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Medicare Advantage,,150.52,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Medicare Advantage,,124.01,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,BCBS NC,Medicare Advantage,,124.01,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,BCBS NC,Medicare Advantage,,978.82,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,BCBS NC,Medicare Advantage,,510.48,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,BCBS NC,Medicare Advantage,,299.59,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,BCBS NC,Medicare Advantage,,510.48,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,BCBS NC,Medicare Advantage,,978.82,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,BCBS NC,Medicare Advantage,,299.59,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,BCBS NC,Medicare Advantage,,510.48,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,BCBS NC,Medicare Advantage,,150.52,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,BCBS NC,Medicare Advantage,,299.59,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Medicare Advantage,,299.59,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,BCBS NC,Medicare Advantage,,510.48,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,BCBS NC,Medicare Advantage,,978.82,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Medicare Advantage,,28.66,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Medicare Advantage,,44.39,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Medicare Advantage,,39.94,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,BCBS NC,Medicare Advantage,,191.17,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Medicare Advantage,,2753.54,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Medicare Advantage,,588.93,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,BCBS NC,Medicare Advantage,,588.93,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,BCBS NC,Medicare Advantage,,191.17,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,BCBS NC,Medicare Advantage,,191.17,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Medicare Advantage,,191.17,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Medicare Advantage,,384.38,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Medicare Advantage,,57.15,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Medicare Advantage,,57.15,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Medicare Advantage,,57.15,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Medicare Advantage,,191.17,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,BCBS NC,Medicare Advantage,,191.17,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,BCBS NC,Medicare Advantage,,191.17,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,BCBS NC,Medicare Advantage,,676.91,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,BCBS NC,Medicare Advantage,,284.00,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,BCBS NC,Medicare Advantage,,284.00,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Medicare Advantage,,284.00,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Medicare Advantage,,284.00,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,BCBS NC,Medicare Advantage,,284.00,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,BCBS NC,Medicare Advantage,,255.51,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Medicare Advantage,,223.42,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Medicare Advantage,,384.38,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Medicare Advantage,,384.38,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Medicare Advantage,,384.38,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,BCBS NC,Medicare Advantage,,124.01,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Medicare Advantage,,319.11,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Medicare Advantage,,319.11,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,BCBS NC,Medicare Advantage,,666.26,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,BCBS NC,Medicare Advantage,,288.54,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Medicare Advantage,,288.54,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,BCBS NC,Medicare Advantage,,6314.07,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,BCBS NC,Medicare Advantage,,284.00,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,BCBS NC,Medicare Advantage,,284.00,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,BCBS NC,Medicare Advantage,,6314.07,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Medicare Advantage,,284.00,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Medicare Advantage,,284.00,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,BCBS NC,Medicare Advantage,,856.54,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Medicare Advantage,,856.54,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,BCBS NC,Medicare Advantage,,856.54,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Medicare Advantage,,191.17,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,BCBS NC,Medicare Advantage,,191.17,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,191.17,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,191.17,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Medicare Advantage,,676.91,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Medicare Advantage,,856.54,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,BCBS NC,Medicare Advantage,,666.26,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,BCBS NC,Medicare Advantage,,856.54,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Medicare Advantage,,384.38,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Medicare Advantage,,856.54,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,BCBS NC,Medicare Advantage,,856.54,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,BCBS NC,Medicare Advantage,,856.54,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,BCBS NC,Medicare Advantage,,856.54,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,BCBS NC,Medicare Advantage,,856.54,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,BCBS NC,Medicare Advantage,,284.00,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,BCBS NC,Medicare Advantage,,284.00,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,BCBS NC,Medicare Advantage,,666.26,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,BCBS NC,Medicare Advantage,,856.54,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,BCBS NC,Medicare Advantage,,666.26,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Medicare Advantage,,856.54,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,BCBS NC,Medicare Advantage,,666.26,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Medicare Advantage,,191.17,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,191.17,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,BCBS NC,Medicare Advantage,,319.11,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,BCBS NC,Medicare Advantage,,132.67,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Medicare Advantage,,124.01,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Medicare Advantage,,384.38,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,BCBS NC,Medicare Advantage,,186.78,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,BCBS NC,Medicare Advantage,,152.36,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,BCBS NC,Medicare Advantage,,266.39,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,BCBS NC,Medicare Advantage,,409.68,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,BCBS NC,Medicare Advantage,,589.86,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,BCBS NC,Medicare Advantage,,810.66,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Medicare Advantage,,124.01,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Medicare Advantage,,124.01,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,BCBS NC,Medicare Advantage,,57.15,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Medicare Advantage,,37.76,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Medicare Advantage,,37.76,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Medicare Advantage,,37.76,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Medicare Advantage,,37.76,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Medicare Advantage,,191.17,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,BCBS NC,Medicare Advantage,,1134.38,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,BCBS NC,Medicare Advantage,,384.38,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Medicare Advantage,,49.56,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,BCBS NC,Medicare Advantage,,191.17,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Medicare Advantage,,151.81,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Medicare Advantage,,151.81,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Medicare Advantage,,151.81,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,BCBS NC,Medicare Advantage,,3058.98,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Medicare Advantage,,288.54,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,BCBS NC,Medicare Advantage,,588.93,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Medicare Advantage,,151.81,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Medicare Advantage,,191.17,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Medicare Advantage,,191.17,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,BCBS NC,Medicare Advantage,,384.38,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,BCBS NC,Medicare Advantage,,2753.54,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Medicare Advantage,,37.76,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Medicare Advantage,,191.17,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Medicare Advantage,,384.38,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Medicare Advantage,,588.93,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Medicare Advantage,,384.38,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Medicare Advantage,,124.01,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,BCBS NC,Medicare Advantage,,88.31,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,BCBS NC,Medicare Advantage,,88.31,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Medicare Advantage,,35.88,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Medicare Advantage,,35.88,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Medicare Advantage,,35.88,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Medicare Advantage,,35.88,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Medicare Advantage,,35.88,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Medicare Advantage,,23.56,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,BCBS NC,Medicare Advantage,,191.17,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Medicare Advantage,,384.38,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Medicare Advantage,,57.15,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Medicare Advantage,,384.38,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,BCBS NC,Medicare Advantage,,16822.15,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,BCBS NC,Medicare Advantage,,6872.88,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Medicare Advantage,,124.01,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,BCBS NC,Medicare Advantage,,124.01,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Medicare Advantage,,902.01,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Medicare Advantage,,233.99,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Medicare Advantage,,420.60,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,BCBS NC,Medicare Advantage,,3318.21,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,BCBS NC,Medicare Advantage,,1577.12,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,BCBS NC,Medicare Advantage,,676.91,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,BCBS NC,Medicare Advantage,,594.81,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Medicare Advantage,,676.91,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,BCBS NC,Medicare Advantage,,676.91,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,BCBS NC,Medicare Advantage,,676.91,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Medicare Advantage,,57.15,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Medicare Advantage,,68.47,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,BCBS NC,Medicare Advantage,,510.48,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Medicare Advantage,,510.48,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,BCBS NC,Medicare Advantage,,510.48,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Medicare Advantage,,299.59,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Medicare Advantage,,150.52,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,BCBS NC,Medicare Advantage,,902.01,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,BCBS NC,Medicare Advantage,,902.01,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,BCBS NC,Medicare Advantage,,902.01,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Medicare Advantage,,299.59,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Medicare Advantage,,510.48,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,BCBS NC,Medicare Advantage,,510.48,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,BCBS NC,Medicare Advantage,,2244.50,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,BCBS NC,Medicare Advantage,,299.59,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,BCBS NC,Medicare Advantage,,299.59,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Medicare Advantage,,150.52,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,BCBS NC,Medicare Advantage,,299.59,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Medicare Advantage,,232.56,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,BCBS NC,Medicare Advantage,,760.10,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Medicare Advantage,,760.10,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,BCBS NC,Medicare Advantage,,760.10,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,BCBS NC,Medicare Advantage,,760.10,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,BCBS NC,Medicare Advantage,,343.59,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Medicare Advantage,,527.52,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Medicare Advantage,,527.52,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,BCBS NC,Medicare Advantage,,527.52,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Medicare Advantage,,343.59,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Medicare Advantage,,527.52,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Medicare Advantage,,527.52,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,BCBS NC,Medicare Advantage,,171.27,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,BCBS NC,Medicare Advantage,,171.27,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,BCBS NC,Medicare Advantage,,16822.15,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,BCBS NC,Medicare Advantage,,760.10,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,BCBS NC,Medicare Advantage,,319.11,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,BCBS NC,Medicare Advantage,,386.59,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,BCBS NC,Medicare Advantage,,517.86,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,BCBS NC,Medicare Advantage,,386.59,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,BCBS NC,Medicare Advantage,,517.86,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,BCBS NC,Medicare Advantage,,517.86,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Medicare Advantage,,517.86,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,22.44,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,BCBS NC,Medicare Advantage,,693.83,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,BCBS NC,Medicare Advantage,,1857.17,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,BCBS NC,Medicare Advantage,,2012.57,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,BCBS NC,Medicare Advantage,,215.63,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,BCBS NC,Medicare Advantage,,215.63,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,BCBS NC,Medicare Advantage,,215.63,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,BCBS NC,Medicare Advantage,,215.63,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,BCBS NC,Medicare Advantage,,4185.46,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,BCBS NC,Medicare Advantage,,55119.81,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,BCBS NC,Medicare Advantage,,1000.45,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,BCBS NC,Medicare Advantage,,2128.78,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Medicare Advantage,,167.05,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,BCBS NC,Medicare Advantage,,517.86,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,BCBS NC,Medicare Advantage,,260.37,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Medicare Advantage,,483.71,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,BCBS NC,Medicare Advantage,,577.25,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,BCBS NC,Medicare Advantage,,322.47,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,BCBS NC,Medicare Advantage,,369.58,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,BCBS NC,Medicare Advantage,,651.08,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,BCBS NC,Medicare Advantage,,84.71,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,BCBS NC,Medicare Advantage,,84.71,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,BCBS NC,Medicare Advantage,,171.27,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Medicare Advantage,,914.46,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,BCBS NC,Medicare Advantage,,1825.06,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,BCBS NC,Medicare Advantage,,1825.06,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Medicare Advantage,,6003.17,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,BCBS NC,Medicare Advantage,,837.72,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Medicare Advantage,,384.38,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Medicare Advantage,,384.38,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,BCBS NC,Medicare Advantage,,594.81,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Medicare Advantage,,5613.15,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Medicare Advantage,,6003.17,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,BCBS NC,Medicare Advantage,,1825.06,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,BCBS NC,Medicare Advantage,,902.01,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,BCBS NC,Medicare Advantage,,1425.11,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Medicare Advantage,,284.00,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,BCBS NC,Medicare Advantage,,284.00,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,BCBS NC,Medicare Advantage,,12378.98,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,BCBS NC,Medicare Advantage,,230.78,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Medicare Advantage,,3121.59,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,BCBS NC,Medicare Advantage,,3121.59,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Medicare Advantage,,594.81,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,BCBS NC,Medicare Advantage,,594.81,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Medicare Advantage,,594.81,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,BCBS NC,Medicare Advantage,,594.81,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Medicare Advantage,,202.70,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,BCBS NC,Medicare Advantage,,202.70,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,BCBS NC,Medicare Advantage,,594.81,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,BCBS NC,Medicare Advantage,,386.59,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Medicare Advantage,,420.60,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,BCBS NC,Medicare Advantage,,383.91,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,BCBS NC,Medicare Advantage,,902.01,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Medicare Advantage,,10016.47,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,BCBS NC,Medicare Advantage,,10016.47,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Medicare Advantage,,902.01,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,BCBS NC,Medicare Advantage,,902.01,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,BCBS NC,Medicare Advantage,,1316.38,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Medicare Advantage,,1825.06,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,BCBS NC,Medicare Advantage,,1825.06,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,BCBS NC,Medicare Advantage,,1825.06,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Medicare Advantage,,902.01,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,BCBS NC,Medicare Advantage,,902.01,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,BCBS NC,Medicare Advantage,,902.01,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,BCBS NC,Medicare Advantage,,902.01,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Medicare Advantage,,642.16,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Medicare Advantage,,676.91,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,BCBS NC,Medicare Advantage,,5613.15,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,BCBS NC,Medicare Advantage,,10016.47,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,BCBS NC,Medicare Advantage,,124.01,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Medicare Advantage,,233.99,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Medicare Advantage,,193.54,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Medicare Advantage,,676.91,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Medicare Advantage,,676.91,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,BCBS NC,Medicare Advantage,,676.91,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Medicare Advantage,,856.54,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,BCBS NC,Medicare Advantage,,856.54,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Medicare Advantage,,856.54,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,BCBS NC,Medicare Advantage,,856.54,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Medicare Advantage,,856.54,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,BCBS NC,Medicare Advantage,,856.54,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,BCBS NC,Medicare Advantage,,1878.73,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,BCBS NC,Medicare Advantage,,856.54,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,BCBS NC,Medicare Advantage,,1134.38,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,BCBS NC,Medicare Advantage,,6872.88,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,BCBS NC,Medicare Advantage,,6872.88,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,BCBS NC,Medicare Advantage,,676.91,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,BCBS NC,Medicare Advantage,,420.60,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,BCBS NC,Medicare Advantage,,676.91,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,BCBS NC,Medicare Advantage,,10016.47,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,BCBS NC,Medicare Advantage,,676.91,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,BCBS NC,Medicare Advantage,,676.91,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,BCBS NC,Medicare Advantage,,676.91,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,BCBS NC,Medicare Advantage,,284.00,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,BCBS NC,Medicare Advantage,,284.00,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,BCBS NC,Medicare Advantage,,3121.59,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,BCBS NC,Medicare Advantage,,3121.59,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,BCBS NC,Medicare Advantage,,6872.88,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,BCBS NC,Medicare Advantage,,6872.88,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,BCBS NC,Medicare Advantage,,760.10,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,BCBS NC,Medicare Advantage,,760.10,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,BCBS NC,Medicare Advantage,,3395.25,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,BCBS NC,Medicare Advantage,,902.01,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,BCBS NC,Medicare Advantage,,5613.15,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,BCBS NC,Medicare Advantage,,5613.15,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,BCBS NC,Medicare Advantage,,5613.15,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,BCBS NC,Medicare Advantage,,6003.17,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,BCBS NC,Medicare Advantage,,642.16,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,BCBS NC,Medicare Advantage,,642.16,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,BCBS NC,Medicare Advantage,,3318.21,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,BCBS NC,Medicare Advantage,,1970.84,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,BCBS NC,Medicare Advantage,,3318.21,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,BCBS NC,Medicare Advantage,,3318.21,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,BCBS NC,Medicare Advantage,,3318.21,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,BCBS NC,Medicare Advantage,,676.91,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,BCBS NC,Medicare Advantage,,2753.54,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Medicare Advantage,,594.81,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Medicare Advantage,,233.99,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Medicare Advantage,,233.99,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Medicare Advantage,,3318.21,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,BCBS NC,Medicare Advantage,,3318.21,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,BCBS NC,Medicare Advantage,,1558.81,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,BCBS NC,Medicare Advantage,,6161.26,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Medicare Advantage,,594.81,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,BCBS NC,Medicare Advantage,,978.82,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,BCBS NC,Medicare Advantage,,760.10,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,BCBS NC,Medicare Advantage,,102.31,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,BCBS NC,Medicare Advantage,,84.71,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,BCBS NC,Medicare Advantage,,102.31,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,BCBS NC,Medicare Advantage,,1255.99,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,BCBS NC,Medicare Advantage,,386.59,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,BCBS NC,Medicare Advantage,,1403.29,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,BCBS NC,Medicare Advantage,,2165.18,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,BCBS NC,Medicare Advantage,,1876.54,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,BCBS NC,Medicare Advantage,,527.52,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,BCBS NC,Medicare Advantage,,527.52,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,BCBS NC,Medicare Advantage,,760.10,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,BCBS NC,Medicare Advantage,,760.10,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,BCBS NC,Medicare Advantage,,760.10,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,BCBS NC,Medicare Advantage,,84.71,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,BCBS NC,Medicare Advantage,,343.59,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,BCBS NC,Medicare Advantage,,232.56,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Medicare Advantage,,84.71,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Medicare Advantage,,57.15,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Medicare Advantage,,666.26,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,BCBS NC,Medicare Advantage,,666.26,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,BCBS NC,Medicare Advantage,,666.26,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,BCBS NC,Medicare Advantage,,232.56,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,BCBS NC,Medicare Advantage,,102.31,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,BCBS NC,Medicare Advantage,,102.31,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,BCBS NC,Medicare Advantage,,10.24,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,BCBS NC,Medicare Advantage,,46.38,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Medicare Advantage,,8.42,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,BCBS NC,Medicare Advantage,,46.20,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,BCBS NC,Medicare Advantage,,7.92,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Medicare Advantage,,159.04,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,BCBS NC,Medicare Advantage,,140.49,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,BCBS NC,Medicare Advantage,,539.90,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,BCBS NC,Medicare Advantage,,282.62,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,BCBS NC,Medicare Advantage,,1125.20,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,BCBS NC,Medicare Advantage,,1125.20,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,BCBS NC,Medicare Advantage,,63.72,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Medicare Advantage,,71.17,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,BCBS NC,Medicare Advantage,,55.33,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,BCBS NC,Medicare Advantage,,43.54,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,BCBS NC,Medicare Advantage,,160.54,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Medicare Advantage,,98.09,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Medicare Advantage,,33.95,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,BCBS NC,Medicare Advantage,,63.40,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,BCBS NC,Medicare Advantage,,192.05,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Medicare Advantage,,167.55,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,BCBS NC,Medicare Advantage,,226.08,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,BCBS NC,Medicare Advantage,,226.08,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Medicare Advantage,,2.18,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,BCBS NC,Medicare Advantage,,338.10,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,BCBS NC,Medicare Advantage,,49.54,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,BCBS NC,Medicare Advantage,,42.34,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,BCBS NC,Medicare Advantage,,195.46,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Medicare Advantage,,226.98,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,BCBS NC,Medicare Advantage,,390.06,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,BCBS NC,Medicare Advantage,,391.48,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,BCBS NC,Medicare Advantage,,123.61,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,BCBS NC,Medicare Advantage,,72.10,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,BCBS NC,Medicare Advantage,,91.90,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,BCBS NC,Medicare Advantage,,335.20,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,BCBS NC,Medicare Advantage,,325.32,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,BCBS NC,Medicare Advantage,,171.93,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,BCBS NC,Medicare Advantage,,164.80,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,BCBS NC,Medicare Advantage,,119.97,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,BCBS NC,Medicare Advantage,,239.12,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Medicare Advantage,,120.90,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,BCBS NC,Medicare Advantage,,291.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Medicare Advantage,,187.45,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,BCBS NC,Medicare Advantage,,286.92,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Medicare Advantage,,16.27,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,BCBS NC,Medicare Advantage,,4.89,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Medicare Advantage,,8.48,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Medicare Advantage,,9.37,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Medicare Advantage,,7.29,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Medicare Advantage,,4.18,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Medicare Advantage,,60.28,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,BCBS NC,Medicare Advantage,,8.21,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Medicare Advantage,,6.80,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Medicare Advantage,,12.99,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Medicare Advantage,,60.28,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,BCBS NC,Medicare Advantage,,60.28,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,BCBS NC,Medicare Advantage,,60.28,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Medicare Advantage,,60.28,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,BCBS NC,Medicare Advantage,,60.28,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Medicare Advantage,,14.63,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Medicare Advantage,,14.63,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,14.63,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,14.13,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,12.88,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,13.13,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Medicare Advantage,,15.89,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Medicare Advantage,,15.89,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,BCBS NC,Medicare Advantage,,15.89,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Medicare Advantage,,14.25,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.41,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Medicare Advantage,,14.84,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,12.85,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Medicare Advantage,,13.35,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Medicare Advantage,,13.32,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Medicare Advantage,,13.32,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Medicare Advantage,,13.72,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Medicare Advantage,,15.65,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Medicare Advantage,,15.65,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Medicare Advantage,,15.65,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Medicare Advantage,,13.13,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Medicare Advantage,,13.13,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Medicare Advantage,,13.13,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Medicare Advantage,,31.64,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Medicare Advantage,,4.38,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Medicare Advantage,,7.92,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,7.92,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,4.80,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Medicare Advantage,,7.55,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Medicare Advantage,,5.61,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Medicare Advantage,,5.61,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Medicare Advantage,,16.75,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Medicare Advantage,,13.04,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Medicare Advantage,,16.27,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,14.13,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Medicare Advantage,,6.29,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Medicare Advantage,,6.29,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Medicare Advantage,,6.29,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Medicare Advantage,,15.69,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Medicare Advantage,,4.87,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Medicare Advantage,,4.87,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,4.87,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,BCBS NC,Medicare Advantage,,4.25,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Medicare Advantage,,5.16,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Medicare Advantage,,4.10,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Medicare Advantage,,28.71,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Medicare Advantage,,5.01,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Medicare Advantage,,5.01,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Medicare Advantage,,5.85,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Medicare Advantage,,4.73,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,11.95,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,11.95,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,BCBS NC,Medicare Advantage,,18.39,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Medicare Advantage,,10.42,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,13.70,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,13.70,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,4.46,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,5.58,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,5.58,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Medicare Advantage,,4.85,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Medicare Advantage,,4.22,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Medicare Advantage,,37.41,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Medicare Advantage,,26.30,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,BCBS NC,Medicare Advantage,,26.30,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Medicare Advantage,,18.08,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Medicare Advantage,,15.81,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Medicare Advantage,,13.32,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,6.31,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Medicare Advantage,,11.20,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Medicare Advantage,,4.97,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,BCBS NC,Medicare Advantage,,27.10,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,BCBS NC,Medicare Advantage,,14.45,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Medicare Advantage,,4.95,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Medicare Advantage,,13.22,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Medicare Advantage,,62.48,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Medicare Advantage,,14.26,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Medicare Advantage,,9.02,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Medicare Advantage,,9.02,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Medicare Advantage,,9.02,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Medicare Advantage,,9.02,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Medicare Advantage,,10.67,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Medicare Advantage,,25.29,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Medicare Advantage,,76.41,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Medicare Advantage,,76.41,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Medicare Advantage,,76.41,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,BCBS NC,Medicare Advantage,,76.41,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,9.48,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Medicare Advantage,,3.81,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Medicare Advantage,,3.81,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Medicare Advantage,,3.81,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Medicare Advantage,,3.81,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Medicare Advantage,,3.81,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Medicare Advantage,,4.61,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Medicare Advantage,,12.48,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Medicare Advantage,,3.80,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Medicare Advantage,,3.80,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Medicare Advantage,,6.98,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,BCBS NC,Medicare Advantage,,18.02,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,BCBS NC,Medicare Advantage,,17.96,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Medicare Advantage,,12.20,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,BCBS NC,Medicare Advantage,,12.48,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Medicare Advantage,,17.52,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,BCBS NC,Medicare Advantage,,7.76,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,9.42,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Medicare Advantage,,7.95,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Medicare Advantage,,7.95,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Medicare Advantage,,4.61,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,BCBS NC,Medicare Advantage,,17.38,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Medicare Advantage,,24.69,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Medicare Advantage,,11.18,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Medicare Advantage,,11.18,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Medicare Advantage,,11.09,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.28,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,11.22,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Medicare Advantage,,5.86,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Medicare Advantage,,5.86,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,19.11,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Medicare Advantage,,18.74,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Medicare Advantage,,6.68,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,BCBS NC,Medicare Advantage,,6.68,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Medicare Advantage,,7.94,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Medicare Advantage,,10.19,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,6.50,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,6.50,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Medicare Advantage,,6.50,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Medicare Advantage,,12.53,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Medicare Advantage,,38.08,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Medicare Advantage,,16.75,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,16.75,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Medicare Advantage,,6.41,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,6.62,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Medicare Advantage,,40.04,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,BCBS NC,Medicare Advantage,,40.04,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Medicare Advantage,,3.47,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Medicare Advantage,,3.47,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Medicare Advantage,,3.47,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,4.60,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Medicare Advantage,,5.61,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,BCBS NC,Medicare Advantage,,5.61,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,BCBS NC,Medicare Advantage,,95.17,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Medicare Advantage,,4.62,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,4.59,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,4.59,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,4.59,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,14.15,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Medicare Advantage,,20.23,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,BCBS NC,Medicare Advantage,,18.80,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Medicare Advantage,,17.84,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Medicare Advantage,,17.84,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Medicare Advantage,,3.56,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,3.56,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,3.56,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Medicare Advantage,,3.88,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Medicare Advantage,,10.42,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Medicare Advantage,,17.30,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Medicare Advantage,,17.30,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Medicare Advantage,,4.67,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Medicare Advantage,,4.91,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Medicare Advantage,,4.91,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Medicare Advantage,,4.71,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Medicare Advantage,,3.18,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Medicare Advantage,,25.04,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Medicare Advantage,,6.66,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,BCBS NC,Medicare Advantage,,8.75,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,BCBS NC,Medicare Advantage,,16.30,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Medicare Advantage,,5.14,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Medicare Advantage,,12.38,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Medicare Advantage,,5.57,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Medicare Advantage,,13.75,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Medicare Advantage,,16.43,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Medicare Advantage,,12.10,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,3.83,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Medicare Advantage,,5.39,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,4.38,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Medicare Advantage,,4.93,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,BCBS NC,Medicare Advantage,,4.93,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Medicare Advantage,,60.28,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,BCBS NC,Medicare Advantage,,60.28,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,14.60,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Medicare Advantage,,7.63,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Medicare Advantage,,5.06,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Medicare Advantage,,14.60,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,BCBS NC,Medicare Advantage,,14.60,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Medicare Advantage,,17.82,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Medicare Advantage,,10.83,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Medicare Advantage,,12.56,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Medicare Advantage,,24.69,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,24.69,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,24.69,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,BCBS NC,Medicare Advantage,,11.64,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Medicare Advantage,,13.33,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,BCBS NC,Medicare Advantage,,13.33,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Medicare Advantage,,17.39,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Medicare Advantage,,17.39,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Medicare Advantage,,11.69,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Medicare Advantage,,11.69,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,BCBS NC,Medicare Advantage,,20.19,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,BCBS NC,Medicare Advantage,,20.19,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,BCBS NC,Medicare Advantage,,29.02,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Medicare Advantage,,21.67,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Medicare Advantage,,28.47,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Medicare Advantage,,36.60,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Medicare Advantage,,25.98,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,25.98,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,346.08,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,BCBS NC,Medicare Advantage,,36.60,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Medicare Advantage,,36.60,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Medicare Advantage,,45.57,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,BCBS NC,Medicare Advantage,,75.45,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Medicare Advantage,,14.11,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Medicare Advantage,,11.19,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Medicare Advantage,,11.19,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Medicare Advantage,,10.32,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Medicare Advantage,,5.50,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,BCBS NC,Medicare Advantage,,60.12,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,BCBS NC,Medicare Advantage,,23.56,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Medicare Advantage,,4.27,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Medicare Advantage,,4.27,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Medicare Advantage,,16.52,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Medicare Advantage,,13.96,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Medicare Advantage,,16.34,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Medicare Advantage,,14.83,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Medicare Advantage,,17.60,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Medicare Advantage,,17.60,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,9.87,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Medicare Advantage,,9.87,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Medicare Advantage,,16.34,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Medicare Advantage,,16.34,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Medicare Advantage,,8.82,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Medicare Advantage,,12.79,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Medicare Advantage,,18.77,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Medicare Advantage,,8.62,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Medicare Advantage,,13.30,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Medicare Advantage,,11.42,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Medicare Advantage,,10.42,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,12.02,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,BCBS NC,Medicare Advantage,,10.92,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Medicare Advantage,,12.02,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,BCBS NC,Medicare Advantage,,18.77,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,18.77,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Medicare Advantage,,12.49,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Medicare Advantage,,13.96,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Medicare Advantage,,13.98,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,12.84,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Medicare Advantage,,12.49,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,13.84,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Medicare Advantage,,106.21,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,BCBS NC,Medicare Advantage,,62.26,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,BCBS NC,Medicare Advantage,,62.26,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,BCBS NC,Medicare Advantage,,314.04,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,BCBS NC,Medicare Advantage,,316.03,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Medicare Advantage,,9.48,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,BCBS NC,Medicare Advantage,,164.86,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,BCBS NC,Medicare Advantage,,346.08,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Medicare Advantage,,5.23,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Medicare Advantage,,5.23,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Medicare Advantage,,5.23,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Medicare Advantage,,2.90,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,2.90,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,BCBS NC,Medicare Advantage,,6.16,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Medicare Advantage,,6.16,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Medicare Advantage,,3.72,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,BCBS NC,Medicare Advantage,,164.86,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,164.86,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,BCBS NC,Medicare Advantage,,57.15,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,BCBS NC,Medicare Advantage,,57.15,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Medicare Advantage,,23.56,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,BCBS NC,Medicare Advantage,,13.49,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Medicare Advantage,,3.69,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,2.30,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,2.30,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Medicare Advantage,,7.54,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,6.28,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,3.87,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,BCBS NC,Medicare Advantage,,5.40,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Medicare Advantage,,2.46,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,4.35,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Medicare Advantage,,785.92,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,BCBS NC,Medicare Advantage,,785.92,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Medicare Advantage,,12.59,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Medicare Advantage,,17.12,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,BCBS NC,Medicare Advantage,,17.36,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,BCBS NC,Medicare Advantage,,17.36,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,BCBS NC,Medicare Advantage,,11.53,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Medicare Advantage,,22.25,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,22.25,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,BCBS NC,Medicare Advantage,,22.25,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,BCBS NC,Medicare Advantage,,29.93,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Medicare Advantage,,22.25,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Medicare Advantage,,18.47,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Medicare Advantage,,17.36,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,BCBS NC,Medicare Advantage,,17.36,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,BCBS NC,Medicare Advantage,,18.77,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,BCBS NC,Medicare Advantage,,8.84,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Medicare Advantage,,18.36,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Medicare Advantage,,18.36,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Medicare Advantage,,11.49,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Medicare Advantage,,13.42,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,BCBS NC,Medicare Advantage,,14.86,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Medicare Advantage,,29.93,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,BCBS NC,Medicare Advantage,,14.86,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,BCBS NC,Medicare Advantage,,12.48,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,BCBS NC,Medicare Advantage,,12.48,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Medicare Advantage,,12.48,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Medicare Advantage,,4.15,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Medicare Advantage,,6.68,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,BCBS NC,Medicare Advantage,,9.87,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,BCBS NC,Medicare Advantage,,9.43,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Medicare Advantage,,16.67,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,9.08,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,BCBS NC,Medicare Advantage,,12.70,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Medicare Advantage,,12.70,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,BCBS NC,Medicare Advantage,,24.16,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,BCBS NC,Medicare Advantage,,24.16,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Medicare Advantage,,17.44,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,BCBS NC,Medicare Advantage,,17.44,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Medicare Advantage,,4.16,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Medicare Advantage,,3.82,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Medicare Advantage,,9.29,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,BCBS NC,Medicare Advantage,,9.29,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,BCBS NC,Medicare Advantage,,17.44,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Medicare Advantage,,9.55,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Medicare Advantage,,18.08,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,5.34,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Medicare Advantage,,5.60,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Medicare Advantage,,5.60,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,5.83,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,5.83,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,BCBS NC,Medicare Advantage,,6.28,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Medicare Advantage,,6.28,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,BCBS NC,Medicare Advantage,,11.32,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,6.48,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,BCBS NC,Medicare Advantage,,10.01,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,BCBS NC,Medicare Advantage,,10.01,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,BCBS NC,Medicare Advantage,,9.16,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,9.16,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Medicare Advantage,,9.16,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Medicare Advantage,,8.36,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,BCBS NC,Medicare Advantage,,9.59,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Medicare Advantage,,9.19,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,BCBS NC,Medicare Advantage,,9.19,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,BCBS NC,Medicare Advantage,,9.19,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Medicare Advantage,,7.84,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Medicare Advantage,,7.84,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Medicare Advantage,,7.84,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,7.84,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Medicare Advantage,,6.43,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,BCBS NC,Medicare Advantage,,7.83,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,BCBS NC,Medicare Advantage,,7.48,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.16,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,BCBS NC,Medicare Advantage,,10.01,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,10.01,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Medicare Advantage,,111.90,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,BCBS NC,Medicare Advantage,,4.18,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,5.70,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Medicare Advantage,,8.63,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Medicare Advantage,,4.61,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Medicare Advantage,,7.26,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Medicare Advantage,,4.61,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Medicare Advantage,,8.39,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Medicare Advantage,,8.39,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Medicare Advantage,,8.39,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,BCBS NC,Medicare Advantage,,8.39,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,BCBS NC,Medicare Advantage,,8.39,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,5.23,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,BCBS NC,Medicare Advantage,,5.23,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,5.23,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,BCBS NC,Medicare Advantage,,5.81,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Medicare Advantage,,17.44,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Medicare Advantage,,5.65,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,5.65,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,BCBS NC,Medicare Advantage,,11.62,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,BCBS NC,Medicare Advantage,,11.62,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,11.62,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Medicare Advantage,,11.62,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,BCBS NC,Medicare Advantage,,13.41,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Medicare Advantage,,10.02,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Medicare Advantage,,10.02,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,23.36,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,BCBS NC,Medicare Advantage,,23.36,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,BCBS NC,Medicare Advantage,,11.62,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,BCBS NC,Medicare Advantage,,11.62,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Medicare Advantage,,11.62,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,BCBS NC,Medicare Advantage,,36.15,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Medicare Advantage,,41.55,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,BCBS NC,Medicare Advantage,,41.55,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,BCBS NC,Medicare Advantage,,41.55,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Medicare Advantage,,34.04,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Medicare Advantage,,82.55,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Medicare Advantage,,34.04,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Medicare Advantage,,34.04,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Medicare Advantage,,92.93,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,BCBS NC,Medicare Advantage,,138.35,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,BCBS NC,Medicare Advantage,,404.28,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,BCBS NC,Medicare Advantage,,34.04,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,BCBS NC,Medicare Advantage,,34.04,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,BCBS NC,Medicare Advantage,,34.04,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,34.04,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,BCBS NC,Medicare Advantage,,34.04,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,BCBS NC,Medicare Advantage,,41.55,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,BCBS NC,Medicare Advantage,,255.10,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Medicare Advantage,,14.83,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,BCBS NC,Medicare Advantage,,16.03,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Medicare Advantage,,15.59,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Medicare Advantage,,15.59,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,BCBS NC,Medicare Advantage,,15.59,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,BCBS NC,Medicare Advantage,,249.73,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Medicare Advantage,,249.73,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Medicare Advantage,,3.07,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,BCBS NC,Medicare Advantage,,3.07,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,3.38,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,3.38,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,BCBS NC,Medicare Advantage,,3.38,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,BCBS NC,Medicare Advantage,,8.35,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,BCBS NC,Medicare Advantage,,164.86,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Medicare Advantage,,5.43,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,7.11,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,BCBS NC,Medicare Advantage,,5.62,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Medicare Advantage,,88.91,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,BCBS NC,Medicare Advantage,,17.51,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,BCBS NC,Medicare Advantage,,23.45,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,BCBS NC,Medicare Advantage,,12.02,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,BCBS NC,Medicare Advantage,,4.58,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,BCBS NC,Medicare Advantage,,12.85,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,15.97,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Medicare Advantage,,11.18,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Medicare Advantage,,5.06,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,BCBS NC,Medicare Advantage,,17.39,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,BCBS NC,Medicare Advantage,,4.14,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Medicare Advantage,,12.66,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Medicare Advantage,,12.49,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,BCBS NC,Medicare Advantage,,5.02,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,BCBS NC,Medicare Advantage,,13.95,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,BCBS NC,Medicare Advantage,,7.84,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Medicare Advantage,,7.84,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,BCBS NC,Medicare Advantage,,13.20,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,BCBS NC,Medicare Advantage,,8.35,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Medicare Advantage,,12.79,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,6.48,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,BCBS NC,Medicare Advantage,,5.02,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,BCBS NC,Medicare Advantage,,12.99,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,BCBS NC,Medicare Advantage,,4.61,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,BCBS NC,Medicare Advantage,,4.61,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Medicare Advantage,,12.48,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Medicare Advantage,,4.16,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,5.96,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,BCBS NC,Medicare Advantage,,12.84,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Medicare Advantage,,6.43,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Medicare Advantage,,164.86,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Medicare Advantage,,164.86,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Medicare Advantage,,119.97,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,BCBS NC,Medicare Advantage,,14.17,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,14.60,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,BCBS NC,Medicare Advantage,,7.09,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,BCBS NC,Medicare Advantage,,25.04,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Medicare Advantage,,736.74,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,34.04,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,15.44,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Medicare Advantage,,5.33,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Medicare Advantage,,26.40,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,BCBS NC,Medicare Advantage,,2.62,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,BCBS NC,Medicare Advantage,,11.62,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Medicare Advantage,,16.05,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,BCBS NC,Medicare Advantage,,16.05,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,BCBS NC,Medicare Advantage,,8.82,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,BCBS NC,Medicare Advantage,,8.82,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,BCBS NC,Medicare Advantage,,8.82,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,BCBS NC,Medicare Advantage,,34.04,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,BCBS NC,Medicare Advantage,,117.98,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,BCBS NC,Medicare Advantage,,179.64,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,BCBS NC,Medicare Advantage,,80.51,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,BCBS NC,Medicare Advantage,,622.59,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,BCBS NC,Medicare Advantage,,1770.13,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,BCBS NC,Medicare Advantage,,363.99,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,BCBS NC,Medicare Advantage,,8.82,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,BCBS NC,Medicare Advantage,,10.82,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,BCBS NC,Medicare Advantage,,6.28,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,BCBS NC,Medicare Advantage,,5.34,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Medicare Advantage,,17.96,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,25.98,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,25.98,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,25.98,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,25.98,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,25.98,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,BCBS NC,Medicare Advantage,,179.64,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,19.45,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,BCBS NC,Medicare Advantage,,34.04,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,BCBS NC,Medicare Advantage,,132.89,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,BCBS NC,Medicare Advantage,,736.74,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,BCBS NC,Medicare Advantage,,211.52,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,34.04,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Medicare Advantage,,68.09,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,BCBS NC,Medicare Advantage,,117.98,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,BCBS NC,Medicare Advantage,,179.64,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Medicare Advantage,,24.16,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,BCBS NC,Medicare Advantage,QW,24.16,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,BCBS NC,Medicare Advantage,,13.95,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Medicare Advantage,,60.28,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,BCBS NC,Medicare Advantage,,1125.20,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,BCBS NC,Medicare Advantage,,404.28,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,BCBS NC,Medicare Advantage,,88.91,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,20.19,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Medicare Advantage,,226.08,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,BCBS NC,Medicare Advantage,,40.51,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,BCBS NC,Medicare Advantage,,41.55,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,BCBS NC,Medicare Advantage,,15.59,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,BCBS NC,Medicare Advantage,,5.06,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Medicare Advantage,,28.33,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Medicare Advantage,QW,49.77,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,BCBS NC,Medicare Advantage,,40.87,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,BCBS NC,Medicare Advantage,,16.75,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,BCBS NC,Medicare Advantage,,404.28,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,BCBS NC,Medicare Advantage,,138.35,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Medicare Advantage,,10.01,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Medicare Advantage,,18.08,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,BCBS NC,Medicare Advantage,,18.08,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Medicare Advantage,,26.30,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,BCBS NC,Medicare Advantage,,37.41,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,BCBS NC,Medicare Advantage,,8.39,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,BCBS NC,Medicare Advantage,,138.35,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Medicare Advantage,,38.08,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,BCBS NC,Medicare Advantage,,21.08,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Medicare Advantage,,20.19,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,BCBS NC,Medicare Advantage,,132.89,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Medicare Advantage,,11.64,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,BCBS NC,Medicare Advantage,,11.64,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,BCBS NC,Medicare Advantage,,19.71,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,BCBS NC,Medicare Advantage,,11.18,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,16.75,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,BCBS NC,Medicare Advantage,,21.67,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,BCBS NC,Medicare Advantage,,28.47,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,BCBS NC,Medicare Advantage,,26.57,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,BCBS NC,Medicare Advantage,,124.44,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,BCBS NC,Medicare Advantage,,11.18,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,BCBS NC,Medicare Advantage,,49.77,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,34.04,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,BCBS NC,Medicare Advantage,,34.04,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,9.42,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,BCBS NC,Medicare Advantage,,11.22,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Medicare Advantage,,2.18,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,BCBS NC,Medicare Advantage,,34.04,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,BCBS NC,Medicare Advantage,,34.04,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Medicare Advantage,,132.89,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,BCBS NC,Medicare Advantage,,8.36,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,BCBS NC,Medicare Advantage,,255.10,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,BCBS NC,Medicare Advantage,,68.09,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Medicare Advantage,,51.40,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,BCBS NC,Medicare Advantage,,2.30,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,BCBS NC,Medicare Advantage,,37.76,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,BCBS NC,Medicare Advantage,,37.76,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Medicare Advantage,,51.40,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,BCBS NC,Medicare Advantage,,51.40,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,BCBS NC,Medicare Advantage,,19.65,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,BCBS NC,Medicare Advantage,,23.56,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,BCBS NC,Medicare Advantage,,164.86,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Medicare Advantage,,51.40,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,25.81,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,BCBS NC,Medicare Advantage,,25.81,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,BCBS NC,Medicare Advantage,,25.81,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,BCBS NC,Medicare Advantage,,346.08,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,BCBS NC,Medicare Advantage,,346.08,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,BCBS NC,Medicare Advantage,,113.00,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,BCBS NC,Medicare Advantage,,113.00,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,BCBS NC,Medicare Advantage,,136.51,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,BCBS NC,Medicare Advantage,,145.79,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,BCBS NC,Medicare Advantage,,145.79,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,BCBS NC,Medicare Advantage,,139.44,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,BCBS NC,Medicare Advantage,,12.68,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,BCBS NC,Medicare Advantage,,256.41,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,BCBS NC,Medicare Advantage,,121.73,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Medicare Advantage,,140.27,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,BCBS NC,Medicare Advantage,,182.91,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,BCBS NC,Medicare Advantage,,20.78,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Medicare Advantage,,20.78,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,BCBS NC,Medicare Advantage,,33.77,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,BCBS NC,Medicare Advantage,,41.11,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Medicare Advantage,,49.65,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,BCBS NC,Medicare Advantage,,32.47,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,BCBS NC,Medicare Advantage,,66.54,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,BCBS NC,Medicare Advantage,,26.10,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Medicare Advantage,,51.40,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,BCBS NC,Medicare Advantage,,37.76,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,BCBS NC,Medicare Advantage,,23.56,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,BCBS NC,Medicare Advantage,,37.76,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,BCBS NC,Medicare Advantage,,51.40,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Medicare Advantage,,51.40,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,BCBS NC,Medicare Advantage,,51.40,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,BCBS NC,Medicare Advantage,,346.08,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,BCBS NC,Medicare Advantage,,785.92,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Medicare Advantage,,124.01,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,BCBS NC,Medicare Advantage,,785.92,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,BCBS NC,Medicare Advantage,,51.40,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,BCBS NC,Medicare Advantage,,164.86,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,BCBS NC,Medicare Advantage,,785.92,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Medicare Advantage,,164.86,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,BCBS NC,Medicare Advantage,,11.69,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,BCBS NC,Medicare Advantage,,164.86,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Medicare Advantage,,164.86,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,BCBS NC,Medicare Advantage,,164.86,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,BCBS NC,Medicare Advantage,,164.86,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,BCBS NC,Medicare Advantage,,99.19,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,BCBS NC,Medicare Advantage,,4.87,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,BCBS NC,Medicare Advantage,,164.86,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,BCBS NC,Medicare Advantage,,139.44,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,BCBS NC,Medicare Advantage,,136.51,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,BCBS NC,Medicare Advantage,,139.44,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Medicare Advantage,,49.65,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,BCBS NC,Medicare Advantage,,140.27,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Medicare Advantage,,346.08,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Medicare Advantage,,164.86,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,BCBS NC,Medicare Advantage,,49.65,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Medicare Advantage,,20.78,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,BCBS NC,Medicare Advantage,,164.86,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,BCBS NC,Medicare Advantage,,51.40,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,BCBS NC,Medicare Advantage,,124.01,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,BCBS NC,Medicare Advantage,,346.08,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,BCBS NC,Medicare Advantage,,49.65,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Medicare Advantage,,20.78,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,BCBS NC,Medicare Advantage,,164.86,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,BCBS NC,Medicare Advantage,,164.86,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,BCBS NC,Medicare Advantage,,164.86,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,BCBS NC,Medicare Advantage,,20.78,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,BCBS NC,Medicare Advantage,,20.78,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,BCBS NC,Medicare Advantage,,20.78,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,BCBS NC,Medicare Advantage,,49.65,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,BCBS NC,Medicare Advantage,,20.78,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,BCBS NC,Medicare Advantage,,41.11,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,BCBS NC,Medicare Advantage,,164.86,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,BCBS NC,Medicare Advantage,,164.86,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,164.86,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,BCBS NC,Medicare Advantage,,37.76,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,BCBS NC,Medicare Advantage,,164.86,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,61.16,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Medicare Advantage,,175.09,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,BCBS NC,Medicare Advantage,,175.09,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,BCBS NC,Medicare Advantage,,175.09,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,BCBS NC,Medicare Advantage,,175.09,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Medicare Advantage,,81.09,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Medicare Advantage,,81.09,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,BCBS NC,Medicare Advantage,,81.09,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,BCBS NC,Medicare Advantage,,138.85,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,BCBS NC,Medicare Advantage,,381.82,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Medicare Advantage,,468.64,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,BCBS NC,Medicare Advantage,,650.05,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,BCBS NC,Medicare Advantage,,628.96,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,BCBS NC,Medicare Advantage,,246.10,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,BCBS NC,Medicare Advantage,,141.72,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,BCBS NC,Medicare Advantage,,748.02,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,BCBS NC,Medicare Advantage,,233.25,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,BCBS NC,Medicare Advantage,,68.39,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,BCBS NC,Medicare Advantage,,565.02,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,BCBS NC,Medicare Advantage,,2.90,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Medicare Advantage,,9.48,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Medicare Advantage,,9.48,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,BCBS NC,Medicare Advantage,,9.48,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,BCBS NC,Medicare Advantage,,5.55,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Medicare Advantage,,468.64,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,BCBS NC,Medicare Advantage,,468.64,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,BCBS NC,Medicare Advantage,,650.05,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,61.16,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,61.16,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,61.16,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,61.16,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,BCBS NC,Medicare Advantage,,61.16,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,BCBS NC,Medicare Advantage,,5200.74,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,BCBS NC,Medicare Advantage,,629.57,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,BCBS NC,Medicare Advantage,,629.57,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,BCBS NC,Medicare Advantage,,319.11,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Medicare Advantage,,10068.53,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,BCBS NC,Medicare Advantage,,10068.53,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,BCBS NC,Medicare Advantage,,10068.53,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,BCBS NC,Medicare Advantage,,10068.53,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,BCBS NC,Medicare Advantage,,10068.53,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,BCBS NC,Medicare Advantage,,1759.87,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,BCBS NC,Medicare Advantage,,10068.53,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,BCBS NC,Medicare Advantage,,10068.53,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,BCBS NC,Medicare Advantage,,18348.07,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,BCBS NC,Medicare Advantage,,21595.14,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,BCBS NC,Medicare Advantage,,30845.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,BCBS NC,Medicare Advantage,,676.91,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Medicare Advantage,,1167.96,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,BCBS NC,Medicare Advantage,,1167.96,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,BCBS NC,Medicare Advantage,,1167.96,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,BCBS NC,Medicare Advantage,,7300.39,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,BCBS NC,Medicare Advantage,,510.48,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,BCBS NC,Medicare Advantage,,18348.07,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,BCBS NC,Medicare Advantage,,30845.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Medicare Advantage,,21595.14,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,BCBS NC,Medicare Advantage,,21595.14,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,BCBS NC,Medicare Advantage,,30845.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,BCBS NC,Medicare Advantage,,27350.46,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,BCBS NC,Medicare Advantage,,383.91,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,BCBS NC,Medicare Advantage,,150.52,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,BCBS NC,Medicare Advantage,,1494.54,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,BCBS NC,Medicare Advantage,,30845.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,BCBS NC,Medicare Advantage,,10910.59,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,BCBS NC,Medicare Advantage,,17275.88,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,BCBS NC,Medicare Advantage,,3094.46,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Medicare Advantage,,23602.16,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,BCBS NC,Medicare Advantage,,23602.16,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,BCBS NC,Medicare Advantage,,23602.16,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,BCBS NC,Medicare Advantage,,594.81,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,BCBS NC,Medicare Advantage,,30845.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,BCBS NC,Medicare Advantage,,5485.35,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,BCBS NC,Medicare Advantage,,102.31,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,BCBS NC,Medicare Advantage,,18348.07,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,BCBS NC,Medicare Advantage,,299.59,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,BCBS NC,Medicare Advantage,,527.52,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,BCBS NC,Medicare Advantage,,527.52,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,BCBS NC,Medicare Advantage,,232.56,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,BCBS NC,Medicare Advantage,,527.52,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,BCBS NC,Medicare Advantage,,35.88,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,BCBS NC,Medicare Advantage,,124.01,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,BCBS NC,Medicare Advantage,,57.15,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,BCBS NC,Medicare Advantage,,88.31,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,BCBS NC,Medicare Advantage,,232.56,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,BCBS NC,Medicare Advantage,,121.13,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,BCBS NC,Medicare Advantage,,121.13,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,BCBS NC,Medicare Advantage,,57.15,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,BCBS NC,Medicare Advantage,,57.15,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,BCBS NC,Medicare Advantage,,3547.15,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,BCBS NC,Medicare Advantage,,3028.17,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,BCBS NC,Medicare Advantage,,6872.88,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,BCBS NC,Medicare Advantage,,676.91,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Medicare Advantage,,7962.20,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,BCBS NC,Medicare Advantage,,3501.31,,,,,,,422.62,17457.00,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,823.98,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,526.87,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Carolina Complete Health,Managed Medicaid,,526.87,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Carolina Complete Health,Managed Medicaid,,0.02803,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Carolina Complete Health,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Carolina Complete Health,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Carolina Complete Health,Managed Medicaid,,4.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Carolina Complete Health,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Carolina Complete Health,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Carolina Complete Health,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Carolina Complete Health,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Carolina Complete Health,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Carolina Complete Health,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Carolina Complete Health,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Carolina Complete Health,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Carolina Complete Health,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Carolina Complete Health,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Carolina Complete Health,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Carolina Complete Health,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Carolina Complete Health,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Carolina Complete Health,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Carolina Complete Health,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Carolina Complete Health,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Carolina Complete Health,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Carolina Complete Health,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Carolina Complete Health,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Carolina Complete Health,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Carolina Complete Health,Managed Medicaid,,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Carolina Complete Health,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Carolina Complete Health,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Carolina Complete Health,Managed Medicaid,,6.26,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Carolina Complete Health,Managed Medicaid,,4.07,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Carolina Complete Health,Managed Medicaid,,55.85,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Carolina Complete Health,Managed Medicaid,,4.33,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Carolina Complete Health,Managed Medicaid,,0.00601,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Carolina Complete Health,Managed Medicaid,,4.29,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Carolina Complete Health,Managed Medicaid,,8.13,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Carolina Complete Health,Managed Medicaid,,4.08,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Carolina Complete Health,Managed Medicaid,,3.98,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Carolina Complete Health,Managed Medicaid,,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Carolina Complete Health,Managed Medicaid,,13.07,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Carolina Complete Health,Managed Medicaid,,35.68,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Carolina Complete Health,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Carolina Complete Health,Managed Medicaid,,1.27,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Carolina Complete Health,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Carolina Complete Health,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Carolina Complete Health,Managed Medicaid,,40.04,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Carolina Complete Health,Managed Medicaid,,5.94,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Carolina Complete Health,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Carolina Complete Health,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Carolina Complete Health,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Carolina Complete Health,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Carolina Complete Health,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Carolina Complete Health,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Carolina Complete Health,Managed Medicaid,,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Carolina Complete Health,Managed Medicaid,,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Carolina Complete Health,Managed Medicaid,,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Carolina Complete Health,Managed Medicaid,,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Carolina Complete Health,Managed Medicaid,,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Carolina Complete Health,Managed Medicaid,,93.29,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Carolina Complete Health,Managed Medicaid,,5.50,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Carolina Complete Health,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Carolina Complete Health,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Carolina Complete Health,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Carolina Complete Health,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Carolina Complete Health,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Carolina Complete Health,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Carolina Complete Health,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Carolina Complete Health,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Carolina Complete Health,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Carolina Complete Health,Managed Medicaid,,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Carolina Complete Health,Managed Medicaid,,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Carolina Complete Health,Managed Medicaid,,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Carolina Complete Health,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Carolina Complete Health,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Carolina Complete Health,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Carolina Complete Health,Managed Medicaid,,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Carolina Complete Health,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Carolina Complete Health,Managed Medicaid,,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Carolina Complete Health,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Carolina Complete Health,Managed Medicaid,,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Carolina Complete Health,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Carolina Complete Health,Managed Medicaid,,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Carolina Complete Health,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Carolina Complete Health,Managed Medicaid,,54.45,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Carolina Complete Health,Managed Medicaid,,43.28,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Carolina Complete Health,Managed Medicaid,,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Carolina Complete Health,Managed Medicaid,,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Carolina Complete Health,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Carolina Complete Health,Managed Medicaid,,30.79,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Carolina Complete Health,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Carolina Complete Health,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Carolina Complete Health,Managed Medicaid,,174.60,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Carolina Complete Health,Managed Medicaid,,214.26,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Carolina Complete Health,Managed Medicaid,,0.43644,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Carolina Complete Health,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Carolina Complete Health,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Carolina Complete Health,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Carolina Complete Health,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Carolina Complete Health,Managed Medicaid,,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Carolina Complete Health,Managed Medicaid,,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Carolina Complete Health,Managed Medicaid,,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Carolina Complete Health,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Carolina Complete Health,Managed Medicaid,,0.62062,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Carolina Complete Health,Managed Medicaid,,1.97,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Carolina Complete Health,Managed Medicaid,,38.56,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Carolina Complete Health,Managed Medicaid,,13.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Carolina Complete Health,Managed Medicaid,,47.59,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Carolina Complete Health,Managed Medicaid,,54.83,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Carolina Complete Health,Managed Medicaid,,31.77,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Carolina Complete Health,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Carolina Complete Health,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Carolina Complete Health,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Carolina Complete Health,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Carolina Complete Health,Managed Medicaid,,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Carolina Complete Health,Managed Medicaid,,66.15,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Carolina Complete Health,Managed Medicaid,,65.92,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Carolina Complete Health,Managed Medicaid,,30.66,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Carolina Complete Health,Managed Medicaid,,31.80,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Carolina Complete Health,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Carolina Complete Health,Managed Medicaid,,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Carolina Complete Health,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Carolina Complete Health,Managed Medicaid,,0.02402,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Carolina Complete Health,Managed Medicaid,,0.05405,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Carolina Complete Health,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Carolina Complete Health,Managed Medicaid,,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Carolina Complete Health,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Carolina Complete Health,Managed Medicaid,,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Carolina Complete Health,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Carolina Complete Health,Managed Medicaid,,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Carolina Complete Health,Managed Medicaid,,64.52,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Carolina Complete Health,Managed Medicaid,,16.24,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Carolina Complete Health,Managed Medicaid,,10.71,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Carolina Complete Health,Managed Medicaid,,25.23,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Carolina Complete Health,Managed Medicaid,,6.18,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Carolina Complete Health,Managed Medicaid,,3.33,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Carolina Complete Health,Managed Medicaid,,23.38,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Carolina Complete Health,Managed Medicaid,,6.74,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Carolina Complete Health,Managed Medicaid,,19.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Carolina Complete Health,Managed Medicaid,,55.06,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Carolina Complete Health,Managed Medicaid,,8.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Carolina Complete Health,Managed Medicaid,,10.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Carolina Complete Health,Managed Medicaid,,33.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Carolina Complete Health,Managed Medicaid,,25.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Carolina Complete Health,Managed Medicaid,,30.87,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Carolina Complete Health,Managed Medicaid,,29.30,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Carolina Complete Health,Managed Medicaid,,5.23,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Carolina Complete Health,Managed Medicaid,,5.72,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Carolina Complete Health,Managed Medicaid,,13.62,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Carolina Complete Health,Managed Medicaid,,28.18,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Carolina Complete Health,Managed Medicaid,,0.10210,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Carolina Complete Health,Managed Medicaid,,5.25,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Carolina Complete Health,Managed Medicaid,,1.19,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Carolina Complete Health,Managed Medicaid,,2.11,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Carolina Complete Health,Managed Medicaid,,0.02202,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Carolina Complete Health,Managed Medicaid,,0.16016,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Carolina Complete Health,Managed Medicaid,,1.55,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Carolina Complete Health,Managed Medicaid,,0.15816,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Carolina Complete Health,Managed Medicaid,,0.09409,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Carolina Complete Health,Managed Medicaid,,0.12813,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Carolina Complete Health,Managed Medicaid,,333.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00400,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Carolina Complete Health,Managed Medicaid,,0.01802,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Carolina Complete Health,Managed Medicaid,,0.51451,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Carolina Complete Health,Managed Medicaid,,5.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Carolina Complete Health,Managed Medicaid,,16.31,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Carolina Complete Health,Managed Medicaid,,0.01401,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Carolina Complete Health,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Carolina Complete Health,Managed Medicaid,,1.23,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Carolina Complete Health,Managed Medicaid,,0.22422,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Carolina Complete Health,Managed Medicaid,,0.32232,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Carolina Complete Health,Managed Medicaid,,0.51251,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Carolina Complete Health,Managed Medicaid,,0.35836,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00400,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Carolina Complete Health,Managed Medicaid,,4.42,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Carolina Complete Health,Managed Medicaid,,220.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Carolina Complete Health,Managed Medicaid,,27.01,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Carolina Complete Health,Managed Medicaid,,33.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Carolina Complete Health,Managed Medicaid,,0.02603,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Carolina Complete Health,Managed Medicaid,,7.28,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Carolina Complete Health,Managed Medicaid,,13.07,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Carolina Complete Health,Managed Medicaid,,28.81,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Carolina Complete Health,Managed Medicaid,,12.73,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Carolina Complete Health,Managed Medicaid,,49.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Carolina Complete Health,Managed Medicaid,,2.25,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Carolina Complete Health,Managed Medicaid,,5.10,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Carolina Complete Health,Managed Medicaid,,0.15015,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Carolina Complete Health,Managed Medicaid,,0.00801,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Carolina Complete Health,Managed Medicaid,,3.03,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Carolina Complete Health,Managed Medicaid,,2.67,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Carolina Complete Health,Managed Medicaid,,2.38,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Carolina Complete Health,Managed Medicaid,,3.54,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Carolina Complete Health,Managed Medicaid,,6.68,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Carolina Complete Health,Managed Medicaid,,11.00,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Carolina Complete Health,Managed Medicaid,,27.86,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Carolina Complete Health,Managed Medicaid,,109.85,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Carolina Complete Health,Managed Medicaid,,63.31,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Carolina Complete Health,Managed Medicaid,,74.32,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Carolina Complete Health,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Carolina Complete Health,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Carolina Complete Health,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Carolina Complete Health,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Carolina Complete Health,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Carolina Complete Health,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Carolina Complete Health,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Carolina Complete Health,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Carolina Complete Health,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Carolina Complete Health,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Carolina Complete Health,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Carolina Complete Health,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Carolina Complete Health,Managed Medicaid,,25.72,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Carolina Complete Health,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Carolina Complete Health,Managed Medicaid,,70.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Carolina Complete Health,Managed Medicaid,,77.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Carolina Complete Health,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Carolina Complete Health,Managed Medicaid,,709.51,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Carolina Complete Health,Managed Medicaid,,60.91,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Carolina Complete Health,Managed Medicaid,,8.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Carolina Complete Health,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Carolina Complete Health,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Carolina Complete Health,Managed Medicaid,,483.34,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Carolina Complete Health,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Carolina Complete Health,Managed Medicaid,,94.40,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Carolina Complete Health,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Carolina Complete Health,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Carolina Complete Health,Managed Medicaid,,1045.12,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Carolina Complete Health,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Carolina Complete Health,Managed Medicaid,,16.00,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Carolina Complete Health,Managed Medicaid,,6.74,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Carolina Complete Health,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,,9.41,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Carolina Complete Health,Managed Medicaid,,3.97,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Carolina Complete Health,Managed Medicaid,,5.05,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Carolina Complete Health,Managed Medicaid,,16.08,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Carolina Complete Health,Managed Medicaid,,6.49,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Carolina Complete Health,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Carolina Complete Health,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Carolina Complete Health,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Carolina Complete Health,Managed Medicaid,,87.43,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Carolina Complete Health,Managed Medicaid,,149.79,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Carolina Complete Health,Managed Medicaid,,457.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Carolina Complete Health,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Carolina Complete Health,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Carolina Complete Health,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Carolina Complete Health,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Carolina Complete Health,Managed Medicaid,,9.90,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Carolina Complete Health,Managed Medicaid,,11.52,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Carolina Complete Health,Managed Medicaid,,113.81,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Carolina Complete Health,Managed Medicaid,,4.36,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Carolina Complete Health,Managed Medicaid,,4.93,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Carolina Complete Health,Managed Medicaid,,1.40,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Carolina Complete Health,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Carolina Complete Health,Managed Medicaid,,0.52052,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Carolina Complete Health,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Carolina Complete Health,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Carolina Complete Health,Managed Medicaid,,5.36,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Carolina Complete Health,Managed Medicaid,,6.19,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Carolina Complete Health,Managed Medicaid,,4.76,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Carolina Complete Health,Managed Medicaid,,9.52,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Carolina Complete Health,Managed Medicaid,,5.88,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Carolina Complete Health,Managed Medicaid,,6.48,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Carolina Complete Health,Managed Medicaid,,548.82,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Carolina Complete Health,Managed Medicaid,,3.55,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Carolina Complete Health,Managed Medicaid,,3.35,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Carolina Complete Health,Managed Medicaid,,3.40,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Carolina Complete Health,Managed Medicaid,,4.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Carolina Complete Health,Managed Medicaid,,8.17,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Carolina Complete Health,Managed Medicaid,,368.29,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Carolina Complete Health,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Carolina Complete Health,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Carolina Complete Health,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Carolina Complete Health,Managed Medicaid,,6.56,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Carolina Complete Health,Managed Medicaid,,49.43,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Carolina Complete Health,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Carolina Complete Health,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Carolina Complete Health,Managed Medicaid,,4.55,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Carolina Complete Health,Managed Medicaid,,4068.51,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Carolina Complete Health,Managed Medicaid,,6.41,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Carolina Complete Health,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Carolina Complete Health,Managed Medicaid,,31.60,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Carolina Complete Health,Managed Medicaid,,60.24,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Carolina Complete Health,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Carolina Complete Health,Managed Medicaid,,14.07,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Carolina Complete Health,Managed Medicaid,,16.98,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Carolina Complete Health,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Carolina Complete Health,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Carolina Complete Health,Managed Medicaid,,155.02,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Carolina Complete Health,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Carolina Complete Health,Managed Medicaid,,10.18,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Carolina Complete Health,Managed Medicaid,,13.78,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Carolina Complete Health,Managed Medicaid,,13.34,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Carolina Complete Health,Managed Medicaid,,14.46,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Carolina Complete Health,Managed Medicaid,,7.94,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Carolina Complete Health,Managed Medicaid,,5.64,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Carolina Complete Health,Managed Medicaid,,12179.59,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Carolina Complete Health,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Carolina Complete Health,Managed Medicaid,,31.70,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Carolina Complete Health,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Carolina Complete Health,Managed Medicaid,,104.15,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Carolina Complete Health,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Carolina Complete Health,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Carolina Complete Health,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Carolina Complete Health,Managed Medicaid,,9.99,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Carolina Complete Health,Managed Medicaid,,12.25,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Carolina Complete Health,Managed Medicaid,,16.79,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Carolina Complete Health,Managed Medicaid,,21.31,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Carolina Complete Health,Managed Medicaid,,25.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Carolina Complete Health,Managed Medicaid,,14.18,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Carolina Complete Health,Managed Medicaid,,15.24,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Carolina Complete Health,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Carolina Complete Health,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Carolina Complete Health,Managed Medicaid,,247.33,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Carolina Complete Health,Managed Medicaid,,468.68,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Carolina Complete Health,Managed Medicaid,,1.70,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Carolina Complete Health,Managed Medicaid,,34.23,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Carolina Complete Health,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Carolina Complete Health,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Carolina Complete Health,Managed Medicaid,,4.12,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Carolina Complete Health,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Carolina Complete Health,Managed Medicaid,,7.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Carolina Complete Health,Managed Medicaid,,14.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,,24.62,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Carolina Complete Health,Managed Medicaid,,611.76,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Carolina Complete Health,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Carolina Complete Health,Managed Medicaid,,269.35,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Carolina Complete Health,Managed Medicaid,,4.30,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Carolina Complete Health,Managed Medicaid,,12.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Carolina Complete Health,Managed Medicaid,,7.13,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Carolina Complete Health,Managed Medicaid,,6.68,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Carolina Complete Health,Managed Medicaid,,6.82,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Carolina Complete Health,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Carolina Complete Health,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Carolina Complete Health,Managed Medicaid,,484.62,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Carolina Complete Health,Managed Medicaid,,1297.10,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Carolina Complete Health,Managed Medicaid,,33.63,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Carolina Complete Health,Managed Medicaid,,5.52,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Carolina Complete Health,Managed Medicaid,,12.75,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Carolina Complete Health,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Carolina Complete Health,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Carolina Complete Health,Managed Medicaid,,5.51,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Carolina Complete Health,Managed Medicaid,,6.30,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Carolina Complete Health,Managed Medicaid,,31.51,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Carolina Complete Health,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Carolina Complete Health,Managed Medicaid,,20.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Carolina Complete Health,Managed Medicaid,,117.13,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Carolina Complete Health,Managed Medicaid,,36.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Carolina Complete Health,Managed Medicaid,,52.11,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Carolina Complete Health,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Carolina Complete Health,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Carolina Complete Health,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Carolina Complete Health,Managed Medicaid,,20.21,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Carolina Complete Health,Managed Medicaid,,35.74,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Carolina Complete Health,Managed Medicaid,,105.20,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Carolina Complete Health,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Carolina Complete Health,Managed Medicaid,,20.25,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Carolina Complete Health,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Carolina Complete Health,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Carolina Complete Health,Managed Medicaid,,176.48,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Carolina Complete Health,Managed Medicaid,,11.71,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Carolina Complete Health,Managed Medicaid,,179.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Carolina Complete Health,Managed Medicaid,,285.22,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Carolina Complete Health,Managed Medicaid,,426.24,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Carolina Complete Health,Managed Medicaid,,708.25,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Carolina Complete Health,Managed Medicaid,,1413.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Carolina Complete Health,Managed Medicaid,,2118.34,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Carolina Complete Health,Managed Medicaid,,339.37,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Carolina Complete Health,Managed Medicaid,,1650.91,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Carolina Complete Health,Managed Medicaid,,6438.44,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Carolina Complete Health,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Carolina Complete Health,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Carolina Complete Health,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Carolina Complete Health,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Carolina Complete Health,Managed Medicaid,,1763.13,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Carolina Complete Health,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Carolina Complete Health,Managed Medicaid,,16.68,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Carolina Complete Health,Managed Medicaid,,20.29,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Carolina Complete Health,Managed Medicaid,,30.82,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Carolina Complete Health,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Carolina Complete Health,Managed Medicaid,,3.74,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Carolina Complete Health,Managed Medicaid,,23.20,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Carolina Complete Health,Managed Medicaid,,28.42,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Carolina Complete Health,Managed Medicaid,,177.12,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Carolina Complete Health,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Carolina Complete Health,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Carolina Complete Health,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Carolina Complete Health,Managed Medicaid,,197.30,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Carolina Complete Health,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Carolina Complete Health,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Carolina Complete Health,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Carolina Complete Health,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Carolina Complete Health,Managed Medicaid,,20.15,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Carolina Complete Health,Managed Medicaid,,38.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Carolina Complete Health,Managed Medicaid,,2654.78,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Carolina Complete Health,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Carolina Complete Health,Managed Medicaid,,2.75,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Carolina Complete Health,Managed Medicaid,,449.52,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Carolina Complete Health,Managed Medicaid,,17.23,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Carolina Complete Health,Managed Medicaid,,142.12,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Carolina Complete Health,Managed Medicaid,,42.80,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Carolina Complete Health,Managed Medicaid,,12.13,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Carolina Complete Health,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Carolina Complete Health,Managed Medicaid,,36.93,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Carolina Complete Health,Managed Medicaid,,44.98,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Carolina Complete Health,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Carolina Complete Health,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Carolina Complete Health,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Carolina Complete Health,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Carolina Complete Health,Managed Medicaid,,0.62062,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Carolina Complete Health,Managed Medicaid,,16.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Carolina Complete Health,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Carolina Complete Health,Managed Medicaid,,15.28,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Carolina Complete Health,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Carolina Complete Health,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Carolina Complete Health,Managed Medicaid,,21.02,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Carolina Complete Health,Managed Medicaid,,94.41,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Carolina Complete Health,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Carolina Complete Health,Managed Medicaid,,56.41,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Carolina Complete Health,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Carolina Complete Health,Managed Medicaid,,11220.92,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Carolina Complete Health,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Carolina Complete Health,Managed Medicaid,,893.81,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Carolina Complete Health,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Carolina Complete Health,Managed Medicaid,,14.13,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Carolina Complete Health,Managed Medicaid,,5.40,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Carolina Complete Health,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Carolina Complete Health,Managed Medicaid,,6.29,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Carolina Complete Health,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Carolina Complete Health,Managed Medicaid,,13.56,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Carolina Complete Health,Managed Medicaid,,5.97,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Carolina Complete Health,Managed Medicaid,,223.00,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Carolina Complete Health,Managed Medicaid,,366.37,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Carolina Complete Health,Managed Medicaid,,63.28,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Carolina Complete Health,Managed Medicaid,,94.95,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Carolina Complete Health,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Carolina Complete Health,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Carolina Complete Health,Managed Medicaid,,142.19,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Carolina Complete Health,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Carolina Complete Health,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Carolina Complete Health,Managed Medicaid,,113.11,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Carolina Complete Health,Managed Medicaid,,239.91,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Carolina Complete Health,Managed Medicaid,,0.82082,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Carolina Complete Health,Managed Medicaid,,113.87,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Carolina Complete Health,Managed Medicaid,,22.42,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Carolina Complete Health,Managed Medicaid,,33.63,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Carolina Complete Health,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Carolina Complete Health,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Carolina Complete Health,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Carolina Complete Health,Managed Medicaid,,122.05,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Carolina Complete Health,Managed Medicaid,,31.90,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Carolina Complete Health,Managed Medicaid,,17.42,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Carolina Complete Health,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Carolina Complete Health,Managed Medicaid,,4.22,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Carolina Complete Health,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Carolina Complete Health,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Carolina Complete Health,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Carolina Complete Health,Managed Medicaid,,6.85,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Carolina Complete Health,Managed Medicaid,,24.72,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Carolina Complete Health,Managed Medicaid,,25.00,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Carolina Complete Health,Managed Medicaid,,9.78,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Carolina Complete Health,Managed Medicaid,,12.40,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Carolina Complete Health,Managed Medicaid,,6.32,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Carolina Complete Health,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Carolina Complete Health,Managed Medicaid,,76.08,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Carolina Complete Health,Managed Medicaid,,182.24,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Carolina Complete Health,Managed Medicaid,,33.58,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Carolina Complete Health,Managed Medicaid,,64.10,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Carolina Complete Health,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Carolina Complete Health,Managed Medicaid,,120.93,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Carolina Complete Health,Managed Medicaid,,5085.99,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Carolina Complete Health,Managed Medicaid,,371.29,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Carolina Complete Health,Managed Medicaid,,4.20,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Carolina Complete Health,Managed Medicaid,,192.56,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Carolina Complete Health,Managed Medicaid,,4.99,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Carolina Complete Health,Managed Medicaid,,16.95,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Carolina Complete Health,Managed Medicaid,,7.22,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Carolina Complete Health,Managed Medicaid,,330.57,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Carolina Complete Health,Managed Medicaid,,6063.10,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Carolina Complete Health,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Carolina Complete Health,Managed Medicaid,,6.34,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Carolina Complete Health,Managed Medicaid,,10.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Carolina Complete Health,Managed Medicaid,,7.62,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Carolina Complete Health,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Carolina Complete Health,Managed Medicaid,,14.42,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Carolina Complete Health,Managed Medicaid,,15.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Carolina Complete Health,Managed Medicaid,,37.17,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Carolina Complete Health,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Carolina Complete Health,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Carolina Complete Health,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Carolina Complete Health,Managed Medicaid,,64.17,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Carolina Complete Health,Managed Medicaid,,87.69,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Carolina Complete Health,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Carolina Complete Health,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Carolina Complete Health,Managed Medicaid,,413.11,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Carolina Complete Health,Managed Medicaid,,549.75,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Carolina Complete Health,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Carolina Complete Health,Managed Medicaid,,39.28,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Carolina Complete Health,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Carolina Complete Health,Managed Medicaid,,0.54054,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Carolina Complete Health,Managed Medicaid,,12.01,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Carolina Complete Health,Managed Medicaid,,6.45,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Carolina Complete Health,Managed Medicaid,,4.46,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Carolina Complete Health,Managed Medicaid,,17.53,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Carolina Complete Health,Managed Medicaid,,23.06,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Carolina Complete Health,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Carolina Complete Health,Managed Medicaid,,9.95,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Carolina Complete Health,Managed Medicaid,,7.23,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Carolina Complete Health,Managed Medicaid,,29.62,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Carolina Complete Health,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Carolina Complete Health,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Carolina Complete Health,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Carolina Complete Health,Managed Medicaid,,41.45,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Carolina Complete Health,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Carolina Complete Health,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Carolina Complete Health,Managed Medicaid,,6.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Carolina Complete Health,Managed Medicaid,,110.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Carolina Complete Health,Managed Medicaid,,5.37,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Carolina Complete Health,Managed Medicaid,,4.79,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Carolina Complete Health,Managed Medicaid,,5.90,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Carolina Complete Health,Managed Medicaid,,8.63,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Carolina Complete Health,Managed Medicaid,,10.70,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Carolina Complete Health,Managed Medicaid,,12.18,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Carolina Complete Health,Managed Medicaid,,35.74,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Carolina Complete Health,Managed Medicaid,,101.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Carolina Complete Health,Managed Medicaid,,10.63,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Carolina Complete Health,Managed Medicaid,,4.94,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Carolina Complete Health,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Carolina Complete Health,Managed Medicaid,,12.26,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Carolina Complete Health,Managed Medicaid,,5.59,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Carolina Complete Health,Managed Medicaid,,34.07,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Carolina Complete Health,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Carolina Complete Health,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Carolina Complete Health,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Carolina Complete Health,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Carolina Complete Health,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Carolina Complete Health,Managed Medicaid,,23675.99,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Carolina Complete Health,Managed Medicaid,,25.12,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Carolina Complete Health,Managed Medicaid,,150.32,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Carolina Complete Health,Managed Medicaid,,2.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Carolina Complete Health,Managed Medicaid,,2.99,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Carolina Complete Health,Managed Medicaid,,15.35,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Carolina Complete Health,Managed Medicaid,,1.07,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Carolina Complete Health,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Carolina Complete Health,Managed Medicaid,,8.04,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Carolina Complete Health,Managed Medicaid,,8.95,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Carolina Complete Health,Managed Medicaid,,7.29,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Carolina Complete Health,Managed Medicaid,,17.00,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Carolina Complete Health,Managed Medicaid,,16.97,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Carolina Complete Health,Managed Medicaid,,17.00,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Carolina Complete Health,Managed Medicaid,,16.61,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Carolina Complete Health,Managed Medicaid,,210.68,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Carolina Complete Health,Managed Medicaid,,1079.07,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Carolina Complete Health,Managed Medicaid,,728.09,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Carolina Complete Health,Managed Medicaid,,6.63,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Carolina Complete Health,Managed Medicaid,,3156.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Carolina Complete Health,Managed Medicaid,,0.58058,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Carolina Complete Health,Managed Medicaid,,4.21,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Carolina Complete Health,Managed Medicaid,,86.25,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Carolina Complete Health,Managed Medicaid,,47.35,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Carolina Complete Health,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Carolina Complete Health,Managed Medicaid,,21.62,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Carolina Complete Health,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Carolina Complete Health,Managed Medicaid,,28.88,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Carolina Complete Health,Managed Medicaid,,58.02,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Carolina Complete Health,Managed Medicaid,,535.27,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Carolina Complete Health,Managed Medicaid,,17.52,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Carolina Complete Health,Managed Medicaid,,1.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Carolina Complete Health,Managed Medicaid,,667.95,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Carolina Complete Health,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Carolina Complete Health,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Carolina Complete Health,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Carolina Complete Health,Managed Medicaid,,163.80,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Carolina Complete Health,Managed Medicaid,,64.00,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Carolina Complete Health,Managed Medicaid,,197.18,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Carolina Complete Health,Managed Medicaid,,5.03,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Carolina Complete Health,Managed Medicaid,,272.42,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Carolina Complete Health,Managed Medicaid,,17.52,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Carolina Complete Health,Managed Medicaid,,43.51,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Carolina Complete Health,Managed Medicaid,,7.69,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Carolina Complete Health,Managed Medicaid,,7.85,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Carolina Complete Health,Managed Medicaid,,1250.81,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Carolina Complete Health,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Carolina Complete Health,Managed Medicaid,,4.16,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Carolina Complete Health,Managed Medicaid,,1902.78,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Carolina Complete Health,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Carolina Complete Health,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Carolina Complete Health,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Carolina Complete Health,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Carolina Complete Health,Managed Medicaid,,52.45,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Carolina Complete Health,Managed Medicaid,,70.57,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Carolina Complete Health,Managed Medicaid,,2.17,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Carolina Complete Health,Managed Medicaid,,59.78,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Carolina Complete Health,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Carolina Complete Health,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Carolina Complete Health,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Carolina Complete Health,Managed Medicaid,,9.27,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Carolina Complete Health,Managed Medicaid,,43.77,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Carolina Complete Health,Managed Medicaid,,35.92,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Carolina Complete Health,Managed Medicaid,,19.98,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Carolina Complete Health,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Carolina Complete Health,Managed Medicaid,,31.22,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Carolina Complete Health,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Carolina Complete Health,Managed Medicaid,,4.40,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Carolina Complete Health,Managed Medicaid,,12.96,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Carolina Complete Health,Managed Medicaid,,2397.64,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Carolina Complete Health,Managed Medicaid,,11.54,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Carolina Complete Health,Managed Medicaid,,6.85,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Carolina Complete Health,Managed Medicaid,,16.12,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Carolina Complete Health,Managed Medicaid,,4.73,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Carolina Complete Health,Managed Medicaid,,1945.70,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Carolina Complete Health,Managed Medicaid,,50.03,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Carolina Complete Health,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Carolina Complete Health,Managed Medicaid,,1.47,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Carolina Complete Health,Managed Medicaid,,27.60,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Carolina Complete Health,Managed Medicaid,,3.70,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Carolina Complete Health,Managed Medicaid,,16.17,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Carolina Complete Health,Managed Medicaid,,17.22,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Carolina Complete Health,Managed Medicaid,,36.04,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Carolina Complete Health,Managed Medicaid,,19.45,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Carolina Complete Health,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Carolina Complete Health,Managed Medicaid,,31.84,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Carolina Complete Health,Managed Medicaid,,18.79,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Carolina Complete Health,Managed Medicaid,,14.10,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Carolina Complete Health,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Carolina Complete Health,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Carolina Complete Health,Managed Medicaid,,16.83,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Carolina Complete Health,Managed Medicaid,,2.36,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Carolina Complete Health,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Carolina Complete Health,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Carolina Complete Health,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Carolina Complete Health,Managed Medicaid,,2.21,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Carolina Complete Health,Managed Medicaid,,1641.62,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Carolina Complete Health,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Carolina Complete Health,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Carolina Complete Health,Managed Medicaid,,12.35,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Carolina Complete Health,Managed Medicaid,,74.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Carolina Complete Health,Managed Medicaid,,38.55,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Carolina Complete Health,Managed Medicaid,,14.08,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Carolina Complete Health,Managed Medicaid,,13.27,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Carolina Complete Health,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Carolina Complete Health,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Carolina Complete Health,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Carolina Complete Health,Managed Medicaid,,5.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Carolina Complete Health,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Carolina Complete Health,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Carolina Complete Health,Managed Medicaid,,22.60,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Carolina Complete Health,Managed Medicaid,,26.46,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Carolina Complete Health,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Carolina Complete Health,Managed Medicaid,,18.05,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Carolina Complete Health,Managed Medicaid,,29.76,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Carolina Complete Health,Managed Medicaid,,8.92,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Carolina Complete Health,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Carolina Complete Health,Managed Medicaid,,4.05,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Carolina Complete Health,Managed Medicaid,,69.27,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Carolina Complete Health,Managed Medicaid,,253.03,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Carolina Complete Health,Managed Medicaid,,4.61,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Carolina Complete Health,Managed Medicaid,,90.65,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Carolina Complete Health,Managed Medicaid,,181.74,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Carolina Complete Health,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Carolina Complete Health,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Carolina Complete Health,Managed Medicaid,,1.78,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Carolina Complete Health,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Carolina Complete Health,Managed Medicaid,,48.18,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Carolina Complete Health,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Carolina Complete Health,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Carolina Complete Health,Managed Medicaid,,18.93,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Carolina Complete Health,Managed Medicaid,,5.67,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Carolina Complete Health,Managed Medicaid,,26.98,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Carolina Complete Health,Managed Medicaid,,28.38,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Carolina Complete Health,Managed Medicaid,,8.76,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Carolina Complete Health,Managed Medicaid,,69.80,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Carolina Complete Health,Managed Medicaid,,4.19,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Carolina Complete Health,Managed Medicaid,,3.75,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Carolina Complete Health,Managed Medicaid,,28.38,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Carolina Complete Health,Managed Medicaid,,32.93,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Carolina Complete Health,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Carolina Complete Health,Managed Medicaid,,0.64064,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Carolina Complete Health,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Carolina Complete Health,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Carolina Complete Health,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Carolina Complete Health,Managed Medicaid,,18.36,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Carolina Complete Health,Managed Medicaid,,15.96,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Carolina Complete Health,Managed Medicaid,,94.29,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Carolina Complete Health,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Carolina Complete Health,Managed Medicaid,,4.64,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Carolina Complete Health,Managed Medicaid,,4.70,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Carolina Complete Health,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Carolina Complete Health,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Carolina Complete Health,Managed Medicaid,,2779.01,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Carolina Complete Health,Managed Medicaid,,60.82,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Carolina Complete Health,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Carolina Complete Health,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Carolina Complete Health,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Carolina Complete Health,Managed Medicaid,,813.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Carolina Complete Health,Managed Medicaid,,22.63,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Carolina Complete Health,Managed Medicaid,,23.59,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Carolina Complete Health,Managed Medicaid,,3569.45,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Carolina Complete Health,Managed Medicaid,,5678.07,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Carolina Complete Health,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Carolina Complete Health,Managed Medicaid,,1.23,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Carolina Complete Health,Managed Medicaid,,29.52,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Carolina Complete Health,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Carolina Complete Health,Managed Medicaid,,8.31,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Carolina Complete Health,Managed Medicaid,,4.74,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Carolina Complete Health,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Carolina Complete Health,Managed Medicaid,,32.33,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Carolina Complete Health,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Carolina Complete Health,Managed Medicaid,,19.60,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Carolina Complete Health,Managed Medicaid,,18.87,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Carolina Complete Health,Managed Medicaid,,916.12,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Carolina Complete Health,Managed Medicaid,,30.63,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Carolina Complete Health,Managed Medicaid,,4.81,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Carolina Complete Health,Managed Medicaid,,0.96096,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Carolina Complete Health,Managed Medicaid,,65.28,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Carolina Complete Health,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Carolina Complete Health,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Carolina Complete Health,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Carolina Complete Health,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Carolina Complete Health,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Carolina Complete Health,Managed Medicaid,,110.10,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Carolina Complete Health,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Carolina Complete Health,Managed Medicaid,,4.47,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Carolina Complete Health,Managed Medicaid,,0.37037,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Carolina Complete Health,Managed Medicaid,,16.84,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Carolina Complete Health,Managed Medicaid,,64.93,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Carolina Complete Health,Managed Medicaid,,98.80,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Carolina Complete Health,Managed Medicaid,,4.09,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Carolina Complete Health,Managed Medicaid,,71.50,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Carolina Complete Health,Managed Medicaid,,105.65,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Carolina Complete Health,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Carolina Complete Health,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Carolina Complete Health,Managed Medicaid,,73.80,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Carolina Complete Health,Managed Medicaid,,1279.76,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Carolina Complete Health,Managed Medicaid,,5.69,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Carolina Complete Health,Managed Medicaid,,1377.08,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Carolina Complete Health,Managed Medicaid,,6665.14,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Carolina Complete Health,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Carolina Complete Health,Managed Medicaid,,11.01,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Carolina Complete Health,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Carolina Complete Health,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Carolina Complete Health,Managed Medicaid,,7882.80,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Carolina Complete Health,Managed Medicaid,,1623.83,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Carolina Complete Health,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Carolina Complete Health,Managed Medicaid,,76.35,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Carolina Complete Health,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Carolina Complete Health,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Carolina Complete Health,Managed Medicaid,,419.08,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Carolina Complete Health,Managed Medicaid,,2799.47,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Carolina Complete Health,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Carolina Complete Health,Managed Medicaid,,92.54,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Carolina Complete Health,Managed Medicaid,,219.22,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Carolina Complete Health,Managed Medicaid,,49.55,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Carolina Complete Health,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Carolina Complete Health,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Carolina Complete Health,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Carolina Complete Health,Managed Medicaid,,48.28,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Carolina Complete Health,Managed Medicaid,,61.64,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Carolina Complete Health,Managed Medicaid,,81.44,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Carolina Complete Health,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Carolina Complete Health,Managed Medicaid,,162.03,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Carolina Complete Health,Managed Medicaid,,1221.21,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Carolina Complete Health,Managed Medicaid,,2970.42,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Carolina Complete Health,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Carolina Complete Health,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Carolina Complete Health,Managed Medicaid,,146.38,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Carolina Complete Health,Managed Medicaid,,7.91,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Carolina Complete Health,Managed Medicaid,,9.55,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Carolina Complete Health,Managed Medicaid,,10.92,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Carolina Complete Health,Managed Medicaid,,15.56,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Carolina Complete Health,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Carolina Complete Health,Managed Medicaid,,5250.24,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Carolina Complete Health,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Carolina Complete Health,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Carolina Complete Health,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Carolina Complete Health,Managed Medicaid,,21.88,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Carolina Complete Health,Managed Medicaid,,356.36,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Carolina Complete Health,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Carolina Complete Health,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Carolina Complete Health,Managed Medicaid,,4208.24,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Carolina Complete Health,Managed Medicaid,,6299.92,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Carolina Complete Health,Managed Medicaid,,3212.74,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Carolina Complete Health,Managed Medicaid,,361.87,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Carolina Complete Health,Managed Medicaid,,750.14,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Carolina Complete Health,Managed Medicaid,,1.62,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Carolina Complete Health,Managed Medicaid,,18.92,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Carolina Complete Health,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Carolina Complete Health,Managed Medicaid,,783.62,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Carolina Complete Health,Managed Medicaid,,16833.42,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Carolina Complete Health,Managed Medicaid,,396.12,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Carolina Complete Health,Managed Medicaid,,98.74,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Carolina Complete Health,Managed Medicaid,,926.81,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Carolina Complete Health,Managed Medicaid,,1838.20,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Carolina Complete Health,Managed Medicaid,,915.21,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Carolina Complete Health,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Carolina Complete Health,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Carolina Complete Health,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Carolina Complete Health,Managed Medicaid,,403.08,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Carolina Complete Health,Managed Medicaid,,253.12,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Carolina Complete Health,Managed Medicaid,,8.87,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Carolina Complete Health,Managed Medicaid,,25.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Carolina Complete Health,Managed Medicaid,,16.86,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Carolina Complete Health,Managed Medicaid,,15.22,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Carolina Complete Health,Managed Medicaid,,2157.77,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Carolina Complete Health,Managed Medicaid,,2679.20,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Carolina Complete Health,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Carolina Complete Health,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Carolina Complete Health,Managed Medicaid,,11.51,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Carolina Complete Health,Managed Medicaid,,3285.05,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Carolina Complete Health,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Carolina Complete Health,Managed Medicaid,,19.57,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Carolina Complete Health,Managed Medicaid,,29.49,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Carolina Complete Health,Managed Medicaid,,11.91,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Carolina Complete Health,Managed Medicaid,,2234.18,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Carolina Complete Health,Managed Medicaid,,208.06,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Carolina Complete Health,Managed Medicaid,,127.22,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Carolina Complete Health,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Carolina Complete Health,Managed Medicaid,,43.75,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Carolina Complete Health,Managed Medicaid,,3.83,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Carolina Complete Health,Managed Medicaid,,175.64,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Carolina Complete Health,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Carolina Complete Health,Managed Medicaid,,808.29,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Carolina Complete Health,Managed Medicaid,,331.70,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Carolina Complete Health,Managed Medicaid,,61.99,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Carolina Complete Health,Managed Medicaid,,2704.88,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Carolina Complete Health,Managed Medicaid,,15.43,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Carolina Complete Health,Managed Medicaid,,57.14,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Carolina Complete Health,Managed Medicaid,,109.23,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Carolina Complete Health,Managed Medicaid,,930.37,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Carolina Complete Health,Managed Medicaid,,42.32,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Carolina Complete Health,Managed Medicaid,,19.15,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Carolina Complete Health,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Carolina Complete Health,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Carolina Complete Health,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Carolina Complete Health,Managed Medicaid,,270.30,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Carolina Complete Health,Managed Medicaid,,24.52,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Carolina Complete Health,Managed Medicaid,,549.99,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Carolina Complete Health,Managed Medicaid,,12.28,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Carolina Complete Health,Managed Medicaid,,216.72,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Carolina Complete Health,Managed Medicaid,,12.27,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Carolina Complete Health,Managed Medicaid,,3207.80,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Carolina Complete Health,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Carolina Complete Health,Managed Medicaid,,38.37,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Carolina Complete Health,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Carolina Complete Health,Managed Medicaid,,73.53,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Carolina Complete Health,Managed Medicaid,,11.51,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Carolina Complete Health,Managed Medicaid,,6.86,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Carolina Complete Health,Managed Medicaid,,7.99,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Carolina Complete Health,Managed Medicaid,,17993.44,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Carolina Complete Health,Managed Medicaid,,1899.64,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Carolina Complete Health,Managed Medicaid,,17368.36,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Carolina Complete Health,Managed Medicaid,,8.97,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Carolina Complete Health,Managed Medicaid,,1427.85,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Carolina Complete Health,Managed Medicaid,,179.52,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Carolina Complete Health,Managed Medicaid,,3838.14,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Carolina Complete Health,Managed Medicaid,,963.00,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Carolina Complete Health,Managed Medicaid,,5848.24,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Carolina Complete Health,Managed Medicaid,,1.33,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Carolina Complete Health,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Carolina Complete Health,Managed Medicaid,,6675.83,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Carolina Complete Health,Managed Medicaid,,14.27,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Carolina Complete Health,Managed Medicaid,,13.75,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Carolina Complete Health,Managed Medicaid,,262.81,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Carolina Complete Health,Managed Medicaid,,903.18,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Carolina Complete Health,Managed Medicaid,,9.57,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Carolina Complete Health,Managed Medicaid,,9727.12,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Carolina Complete Health,Managed Medicaid,,21122.14,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Carolina Complete Health,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Carolina Complete Health,Managed Medicaid,,26.35,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Carolina Complete Health,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Carolina Complete Health,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Carolina Complete Health,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Carolina Complete Health,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Carolina Complete Health,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Carolina Complete Health,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Carolina Complete Health,Managed Medicaid,,39.94,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Carolina Complete Health,Managed Medicaid,,199.70,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Carolina Complete Health,Managed Medicaid,,13.23,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Carolina Complete Health,Managed Medicaid,,133.84,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Carolina Complete Health,Managed Medicaid,,0.94094,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Carolina Complete Health,Managed Medicaid,,3.68,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Carolina Complete Health,Managed Medicaid,,394.84,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Carolina Complete Health,Managed Medicaid,,5329.34,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Carolina Complete Health,Managed Medicaid,,1179.31,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Carolina Complete Health,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Carolina Complete Health,Managed Medicaid,,7051.96,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Carolina Complete Health,Managed Medicaid,,16.03,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Carolina Complete Health,Managed Medicaid,,48.44,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Carolina Complete Health,Managed Medicaid,,77.98,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Carolina Complete Health,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Carolina Complete Health,Managed Medicaid,,11.70,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Carolina Complete Health,Managed Medicaid,,23.30,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Carolina Complete Health,Managed Medicaid,,33.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Carolina Complete Health,Managed Medicaid,,43.39,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Carolina Complete Health,Managed Medicaid,,103.68,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Carolina Complete Health,Managed Medicaid,,405.10,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Carolina Complete Health,Managed Medicaid,,1904.73,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Carolina Complete Health,Managed Medicaid,,105.11,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Carolina Complete Health,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Carolina Complete Health,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Carolina Complete Health,Managed Medicaid,,97.95,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Carolina Complete Health,Managed Medicaid,,4267.77,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Carolina Complete Health,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Carolina Complete Health,Managed Medicaid,,322.39,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Carolina Complete Health,Managed Medicaid,,69.02,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Carolina Complete Health,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Carolina Complete Health,Managed Medicaid,,11.19,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Carolina Complete Health,Managed Medicaid,,1030.23,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Carolina Complete Health,Managed Medicaid,,9678.64,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Carolina Complete Health,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Carolina Complete Health,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Carolina Complete Health,Managed Medicaid,,909.56,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Carolina Complete Health,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Carolina Complete Health,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Carolina Complete Health,Managed Medicaid,,7220.03,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Carolina Complete Health,Managed Medicaid,,586.19,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Carolina Complete Health,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Carolina Complete Health,Managed Medicaid,,4173.39,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Carolina Complete Health,Managed Medicaid,,40.64,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Carolina Complete Health,Managed Medicaid,,57.46,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Carolina Complete Health,Managed Medicaid,,83.99,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Carolina Complete Health,Managed Medicaid,,356.56,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Carolina Complete Health,Managed Medicaid,,16449.48,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Carolina Complete Health,Managed Medicaid,,2513.50,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Carolina Complete Health,Managed Medicaid,,669.68,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Carolina Complete Health,Managed Medicaid,,40.29,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Carolina Complete Health,Managed Medicaid,,9.61,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Carolina Complete Health,Managed Medicaid,,4.77,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Carolina Complete Health,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Carolina Complete Health,Managed Medicaid,,799.89,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Carolina Complete Health,Managed Medicaid,,3779.20,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Carolina Complete Health,Managed Medicaid,,3471.11,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Carolina Complete Health,Managed Medicaid,,10388.06,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Carolina Complete Health,Managed Medicaid,,2075.14,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Carolina Complete Health,Managed Medicaid,,1257.11,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Carolina Complete Health,Managed Medicaid,,21.45,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Carolina Complete Health,Managed Medicaid,,2529.45,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Carolina Complete Health,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Carolina Complete Health,Managed Medicaid,,2773.87,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Carolina Complete Health,Managed Medicaid,,2216.38,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Carolina Complete Health,Managed Medicaid,,595.39,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Carolina Complete Health,Managed Medicaid,,686.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Carolina Complete Health,Managed Medicaid,,3212.13,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Carolina Complete Health,Managed Medicaid,,15163.67,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Carolina Complete Health,Managed Medicaid,,3042.20,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Carolina Complete Health,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Carolina Complete Health,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Carolina Complete Health,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Carolina Complete Health,Managed Medicaid,,1643.90,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Carolina Complete Health,Managed Medicaid,,3886.53,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Carolina Complete Health,Managed Medicaid,,821.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Carolina Complete Health,Managed Medicaid,,29.85,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Carolina Complete Health,Managed Medicaid,,2313.19,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Carolina Complete Health,Managed Medicaid,,22028.61,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Carolina Complete Health,Managed Medicaid,,433.03,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Carolina Complete Health,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Carolina Complete Health,Managed Medicaid,,8.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Carolina Complete Health,Managed Medicaid,,35.29,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Carolina Complete Health,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Carolina Complete Health,Managed Medicaid,,12313.86,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Carolina Complete Health,Managed Medicaid,,8227.27,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Carolina Complete Health,Managed Medicaid,,13.14,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Carolina Complete Health,Managed Medicaid,,1284.65,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Carolina Complete Health,Managed Medicaid,,3568.15,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Carolina Complete Health,Managed Medicaid,,20151.54,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Carolina Complete Health,Managed Medicaid,,5505.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Carolina Complete Health,Managed Medicaid,,204.15,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Carolina Complete Health,Managed Medicaid,,1350.05,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Carolina Complete Health,Managed Medicaid,,1121.90,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Carolina Complete Health,Managed Medicaid,,1845.18,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Carolina Complete Health,Managed Medicaid,,25003.11,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Carolina Complete Health,Managed Medicaid,,10652.28,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Carolina Complete Health,Managed Medicaid,,4098.29,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Carolina Complete Health,Managed Medicaid,,3408.28,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Carolina Complete Health,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Carolina Complete Health,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Carolina Complete Health,Managed Medicaid,,16.27,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Carolina Complete Health,Managed Medicaid,,174.05,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Carolina Complete Health,Managed Medicaid,,6574.28,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Carolina Complete Health,Managed Medicaid,,21.51,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Carolina Complete Health,Managed Medicaid,,82.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Carolina Complete Health,Managed Medicaid,,3271.31,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Carolina Complete Health,Managed Medicaid,,7294.04,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Carolina Complete Health,Managed Medicaid,,6.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Carolina Complete Health,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Carolina Complete Health,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Carolina Complete Health,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Carolina Complete Health,Managed Medicaid,,148.04,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Carolina Complete Health,Managed Medicaid,,234.94,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Carolina Complete Health,Managed Medicaid,,13639.98,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Carolina Complete Health,Managed Medicaid,,15.22,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Carolina Complete Health,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Carolina Complete Health,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Carolina Complete Health,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Carolina Complete Health,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Carolina Complete Health,Managed Medicaid,,20.83,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Carolina Complete Health,Managed Medicaid,,9258.10,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Carolina Complete Health,Managed Medicaid,,1859.57,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Carolina Complete Health,Managed Medicaid,,104.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Carolina Complete Health,Managed Medicaid,,6029.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Carolina Complete Health,Managed Medicaid,,604.94,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Carolina Complete Health,Managed Medicaid,,16551.88,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Carolina Complete Health,Managed Medicaid,,13041.87,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Carolina Complete Health,Managed Medicaid,,2395.89,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Carolina Complete Health,Managed Medicaid,,4788.40,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Carolina Complete Health,Managed Medicaid,,5984.79,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Carolina Complete Health,Managed Medicaid,,13645.27,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Carolina Complete Health,Managed Medicaid,,188.67,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Carolina Complete Health,Managed Medicaid,,509.79,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Carolina Complete Health,Managed Medicaid,,509.80,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Carolina Complete Health,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Carolina Complete Health,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Carolina Complete Health,Managed Medicaid,,818.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Carolina Complete Health,Managed Medicaid,,295.46,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Carolina Complete Health,Managed Medicaid,,41.72,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Carolina Complete Health,Managed Medicaid,,51.15,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Carolina Complete Health,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Carolina Complete Health,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Carolina Complete Health,Managed Medicaid,,13.87,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Carolina Complete Health,Managed Medicaid,,12710.40,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Carolina Complete Health,Managed Medicaid,,46.93,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Carolina Complete Health,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Carolina Complete Health,Managed Medicaid,,70.56,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Carolina Complete Health,Managed Medicaid,,5351.96,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Carolina Complete Health,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Carolina Complete Health,Managed Medicaid,,2200.82,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Carolina Complete Health,Managed Medicaid,,8765.41,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Carolina Complete Health,Managed Medicaid,,176.78,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Carolina Complete Health,Managed Medicaid,,12260.66,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Carolina Complete Health,Managed Medicaid,,1464.46,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Carolina Complete Health,Managed Medicaid,,51.51,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Carolina Complete Health,Managed Medicaid,,16.27,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Carolina Complete Health,Managed Medicaid,,3.41,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Carolina Complete Health,Managed Medicaid,,3.35,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Carolina Complete Health,Managed Medicaid,,7051.96,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Carolina Complete Health,Managed Medicaid,,4363.51,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Carolina Complete Health,Managed Medicaid,,0.27027,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Carolina Complete Health,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Carolina Complete Health,Managed Medicaid,,72.96,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Carolina Complete Health,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Carolina Complete Health,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Carolina Complete Health,Managed Medicaid,,93.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Carolina Complete Health,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Carolina Complete Health,Managed Medicaid,,9.83,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Carolina Complete Health,Managed Medicaid,,17.85,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Carolina Complete Health,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Carolina Complete Health,Managed Medicaid,,14.69,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Carolina Complete Health,Managed Medicaid,,65.63,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Carolina Complete Health,Managed Medicaid,,7.70,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Carolina Complete Health,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Carolina Complete Health,Managed Medicaid,,5.46,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Carolina Complete Health,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Carolina Complete Health,Managed Medicaid,,0.59059,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Carolina Complete Health,Managed Medicaid,,38.62,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Carolina Complete Health,Managed Medicaid,,2.22,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Carolina Complete Health,Managed Medicaid,,3.91,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Carolina Complete Health,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Carolina Complete Health,Managed Medicaid,,18.87,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Carolina Complete Health,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Carolina Complete Health,Managed Medicaid,,5.45,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Carolina Complete Health,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Carolina Complete Health,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Carolina Complete Health,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Carolina Complete Health,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Carolina Complete Health,Managed Medicaid,,18.23,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Carolina Complete Health,Managed Medicaid,,280.27,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Carolina Complete Health,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Carolina Complete Health,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Carolina Complete Health,Managed Medicaid,,882.66,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Carolina Complete Health,Managed Medicaid,,4193.08,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Carolina Complete Health,Managed Medicaid,,13.60,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Carolina Complete Health,Managed Medicaid,,1273.87,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Carolina Complete Health,Managed Medicaid,,16.80,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Carolina Complete Health,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Carolina Complete Health,Managed Medicaid,,39.60,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Carolina Complete Health,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Carolina Complete Health,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Carolina Complete Health,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Carolina Complete Health,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Carolina Complete Health,Managed Medicaid,,837.33,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Carolina Complete Health,Managed Medicaid,,16.33,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Carolina Complete Health,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Carolina Complete Health,Managed Medicaid,,25.36,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Carolina Complete Health,Managed Medicaid,,94.67,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Carolina Complete Health,Managed Medicaid,,1.93,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Carolina Complete Health,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Carolina Complete Health,Managed Medicaid,,222.82,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Carolina Complete Health,Managed Medicaid,,4.01,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Carolina Complete Health,Managed Medicaid,,4.98,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Carolina Complete Health,Managed Medicaid,,35.58,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Carolina Complete Health,Managed Medicaid,,2.37,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Carolina Complete Health,Managed Medicaid,,17.42,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Carolina Complete Health,Managed Medicaid,,16.37,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Carolina Complete Health,Managed Medicaid,,21.32,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Carolina Complete Health,Managed Medicaid,,21.96,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Carolina Complete Health,Managed Medicaid,,130.98,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Carolina Complete Health,Managed Medicaid,,14.23,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Carolina Complete Health,Managed Medicaid,,14.35,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Carolina Complete Health,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Carolina Complete Health,Managed Medicaid,,14.26,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Carolina Complete Health,Managed Medicaid,,15.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Carolina Complete Health,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Carolina Complete Health,Managed Medicaid,,15.62,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Carolina Complete Health,Managed Medicaid,,412.01,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Carolina Complete Health,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Carolina Complete Health,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Carolina Complete Health,Managed Medicaid,,103.41,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Carolina Complete Health,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Carolina Complete Health,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Carolina Complete Health,Managed Medicaid,,10.79,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Carolina Complete Health,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Carolina Complete Health,Managed Medicaid,,3.75,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Carolina Complete Health,Managed Medicaid,,28.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Carolina Complete Health,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Carolina Complete Health,Managed Medicaid,,84.56,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Carolina Complete Health,Managed Medicaid,,10.15,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Carolina Complete Health,Managed Medicaid,,17.75,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Carolina Complete Health,Managed Medicaid,,4.28,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Carolina Complete Health,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Carolina Complete Health,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Carolina Complete Health,Managed Medicaid,,18.21,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Carolina Complete Health,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Carolina Complete Health,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Carolina Complete Health,Managed Medicaid,,0.38038,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Carolina Complete Health,Managed Medicaid,,4.79,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Carolina Complete Health,Managed Medicaid,,4.48,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Carolina Complete Health,Managed Medicaid,,39.36,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Carolina Complete Health,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Carolina Complete Health,Managed Medicaid,,9.69,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Carolina Complete Health,Managed Medicaid,,5.95,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Carolina Complete Health,Managed Medicaid,,1.50,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Carolina Complete Health,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Carolina Complete Health,Managed Medicaid,,4.15,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Carolina Complete Health,Managed Medicaid,,16.30,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Carolina Complete Health,Managed Medicaid,,0.67067,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Carolina Complete Health,Managed Medicaid,,2.88,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Carolina Complete Health,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Carolina Complete Health,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Carolina Complete Health,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Carolina Complete Health,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Carolina Complete Health,Managed Medicaid,,6.53,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Carolina Complete Health,Managed Medicaid,,15.99,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Carolina Complete Health,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Carolina Complete Health,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Carolina Complete Health,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Carolina Complete Health,Managed Medicaid,,3.98,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Carolina Complete Health,Managed Medicaid,,32.93,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Carolina Complete Health,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Carolina Complete Health,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Carolina Complete Health,Managed Medicaid,,16.89,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Carolina Complete Health,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Carolina Complete Health,Managed Medicaid,,1470.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Carolina Complete Health,Managed Medicaid,,5.63,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Carolina Complete Health,Managed Medicaid,,15.38,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Carolina Complete Health,Managed Medicaid,,6.35,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Carolina Complete Health,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Carolina Complete Health,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Carolina Complete Health,Managed Medicaid,,548.81,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Carolina Complete Health,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Carolina Complete Health,Managed Medicaid,,7.99,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Carolina Complete Health,Managed Medicaid,,5.28,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Carolina Complete Health,Managed Medicaid,,19.45,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Carolina Complete Health,Managed Medicaid,,20.34,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Carolina Complete Health,Managed Medicaid,,29.43,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Carolina Complete Health,Managed Medicaid,,5.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Carolina Complete Health,Managed Medicaid,,236.14,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Carolina Complete Health,Managed Medicaid,,451.45,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Carolina Complete Health,Managed Medicaid,,1156.15,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Carolina Complete Health,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Carolina Complete Health,Managed Medicaid,,443.79,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Carolina Complete Health,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Carolina Complete Health,Managed Medicaid,,45.65,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Carolina Complete Health,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Carolina Complete Health,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Carolina Complete Health,Managed Medicaid,,52.77,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Carolina Complete Health,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Carolina Complete Health,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Carolina Complete Health,Managed Medicaid,,4.62,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Carolina Complete Health,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Carolina Complete Health,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Carolina Complete Health,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Carolina Complete Health,Managed Medicaid,,20.26,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Carolina Complete Health,Managed Medicaid,,121.53,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Carolina Complete Health,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Carolina Complete Health,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Carolina Complete Health,Managed Medicaid,,38.94,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Carolina Complete Health,Managed Medicaid,,39.17,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Carolina Complete Health,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Carolina Complete Health,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Carolina Complete Health,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Carolina Complete Health,Managed Medicaid,,0.78078,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Carolina Complete Health,Managed Medicaid,,7.14,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Carolina Complete Health,Managed Medicaid,,8.69,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Carolina Complete Health,Managed Medicaid,,12.01,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Carolina Complete Health,Managed Medicaid,,16.44,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Carolina Complete Health,Managed Medicaid,,20.96,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Carolina Complete Health,Managed Medicaid,,44.19,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Carolina Complete Health,Managed Medicaid,,2.68,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Carolina Complete Health,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Carolina Complete Health,Managed Medicaid,,202.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Carolina Complete Health,Managed Medicaid,,1.61,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Carolina Complete Health,Managed Medicaid,,22.82,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Carolina Complete Health,Managed Medicaid,,4.63,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Carolina Complete Health,Managed Medicaid,,5.31,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Carolina Complete Health,Managed Medicaid,,150.68,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Carolina Complete Health,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Carolina Complete Health,Managed Medicaid,,61.74,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Carolina Complete Health,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Carolina Complete Health,Managed Medicaid,,18.48,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Carolina Complete Health,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Carolina Complete Health,Managed Medicaid,,4.57,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Carolina Complete Health,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Carolina Complete Health,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Carolina Complete Health,Managed Medicaid,,9.24,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Carolina Complete Health,Managed Medicaid,,10.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Carolina Complete Health,Managed Medicaid,,53.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Carolina Complete Health,Managed Medicaid,,5.59,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Carolina Complete Health,Managed Medicaid,,12.64,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Carolina Complete Health,Managed Medicaid,,119.95,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Carolina Complete Health,Managed Medicaid,,7.56,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Carolina Complete Health,Managed Medicaid,,12.50,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Carolina Complete Health,Managed Medicaid,,704.70,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Carolina Complete Health,Managed Medicaid,,310.71,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Carolina Complete Health,Managed Medicaid,,241.06,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Carolina Complete Health,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Carolina Complete Health,Managed Medicaid,,43.24,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Carolina Complete Health,Managed Medicaid,,23.07,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Carolina Complete Health,Managed Medicaid,,104.89,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Carolina Complete Health,Managed Medicaid,,139.84,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Carolina Complete Health,Managed Medicaid,,240.04,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Carolina Complete Health,Managed Medicaid,,67.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Carolina Complete Health,Managed Medicaid,,69.97,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Carolina Complete Health,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Carolina Complete Health,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Carolina Complete Health,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Carolina Complete Health,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Carolina Complete Health,Managed Medicaid,,3.86,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Carolina Complete Health,Managed Medicaid,,2576.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Carolina Complete Health,Managed Medicaid,,10.49,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Carolina Complete Health,Managed Medicaid,,71.52,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Carolina Complete Health,Managed Medicaid,,13.33,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Carolina Complete Health,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Carolina Complete Health,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Carolina Complete Health,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Carolina Complete Health,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Carolina Complete Health,Managed Medicaid,,5.43,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Carolina Complete Health,Managed Medicaid,,138.74,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Carolina Complete Health,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Carolina Complete Health,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Carolina Complete Health,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Carolina Complete Health,Managed Medicaid,,4.32,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Carolina Complete Health,Managed Medicaid,,16.64,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Carolina Complete Health,Managed Medicaid,,74.00,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Carolina Complete Health,Managed Medicaid,,84.08,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Carolina Complete Health,Managed Medicaid,,5.74,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Carolina Complete Health,Managed Medicaid,,8.49,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Carolina Complete Health,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Carolina Complete Health,Managed Medicaid,,10.70,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Carolina Complete Health,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Carolina Complete Health,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Carolina Complete Health,Managed Medicaid,,24.00,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Carolina Complete Health,Managed Medicaid,,1.26,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Carolina Complete Health,Managed Medicaid,,18.82,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Carolina Complete Health,Managed Medicaid,,17.32,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Carolina Complete Health,Managed Medicaid,,93.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Carolina Complete Health,Managed Medicaid,,63.86,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Carolina Complete Health,Managed Medicaid,,168.96,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Carolina Complete Health,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Carolina Complete Health,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Carolina Complete Health,Managed Medicaid,,53.06,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Carolina Complete Health,Managed Medicaid,,171.88,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Carolina Complete Health,Managed Medicaid,,3998.59,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Carolina Complete Health,Managed Medicaid,,6.77,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Carolina Complete Health,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Carolina Complete Health,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Carolina Complete Health,Managed Medicaid,,36.67,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Carolina Complete Health,Managed Medicaid,,23.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Carolina Complete Health,Managed Medicaid,,5.99,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Carolina Complete Health,Managed Medicaid,,25.10,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Carolina Complete Health,Managed Medicaid,,14.31,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Carolina Complete Health,Managed Medicaid,,38.06,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Carolina Complete Health,Managed Medicaid,,16.93,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Carolina Complete Health,Managed Medicaid,,104.36,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Carolina Complete Health,Managed Medicaid,,11.95,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Carolina Complete Health,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Carolina Complete Health,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Carolina Complete Health,Managed Medicaid,,24.23,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Carolina Complete Health,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Carolina Complete Health,Managed Medicaid,,7.34,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Carolina Complete Health,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Carolina Complete Health,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Carolina Complete Health,Managed Medicaid,,18.69,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Carolina Complete Health,Managed Medicaid,,596.21,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Carolina Complete Health,Managed Medicaid,,7.17,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Carolina Complete Health,Managed Medicaid,,25.76,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Carolina Complete Health,Managed Medicaid,,452.94,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Carolina Complete Health,Managed Medicaid,,8.53,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Carolina Complete Health,Managed Medicaid,,7.02,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Carolina Complete Health,Managed Medicaid,,5.88,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Carolina Complete Health,Managed Medicaid,,11.06,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Carolina Complete Health,Managed Medicaid,,7.25,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Carolina Complete Health,Managed Medicaid,,1047.11,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Carolina Complete Health,Managed Medicaid,,2612.95,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Carolina Complete Health,Managed Medicaid,,5222.67,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Carolina Complete Health,Managed Medicaid,,10442.13,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Carolina Complete Health,Managed Medicaid,,36.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Carolina Complete Health,Managed Medicaid,,80.00,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Carolina Complete Health,Managed Medicaid,,5.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Carolina Complete Health,Managed Medicaid,,10.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Carolina Complete Health,Managed Medicaid,,29.59,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Carolina Complete Health,Managed Medicaid,,63.32,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Carolina Complete Health,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Carolina Complete Health,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Carolina Complete Health,Managed Medicaid,,9.69,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Carolina Complete Health,Managed Medicaid,,10.10,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Carolina Complete Health,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Carolina Complete Health,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Carolina Complete Health,Managed Medicaid,,943.42,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Carolina Complete Health,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Carolina Complete Health,Managed Medicaid,,11.48,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Carolina Complete Health,Managed Medicaid,,26.93,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Carolina Complete Health,Managed Medicaid,,7.44,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Carolina Complete Health,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Carolina Complete Health,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Carolina Complete Health,Managed Medicaid,,4.38,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Carolina Complete Health,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Carolina Complete Health,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Carolina Complete Health,Managed Medicaid,,64.39,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Carolina Complete Health,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Carolina Complete Health,Managed Medicaid,,5.26,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Carolina Complete Health,Managed Medicaid,,7.43,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Carolina Complete Health,Managed Medicaid,,5.58,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Carolina Complete Health,Managed Medicaid,,93.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Carolina Complete Health,Managed Medicaid,,2.26,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Carolina Complete Health,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Carolina Complete Health,Managed Medicaid,,207.18,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Carolina Complete Health,Managed Medicaid,,4.97,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Carolina Complete Health,Managed Medicaid,,4.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Carolina Complete Health,Managed Medicaid,,50.45,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Carolina Complete Health,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Carolina Complete Health,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Carolina Complete Health,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Carolina Complete Health,Managed Medicaid,,3.65,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Carolina Complete Health,Managed Medicaid,,3.93,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Carolina Complete Health,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Carolina Complete Health,Managed Medicaid,,3.53,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Carolina Complete Health,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Carolina Complete Health,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Carolina Complete Health,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Carolina Complete Health,Managed Medicaid,,17.52,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Carolina Complete Health,Managed Medicaid,,1250.97,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Carolina Complete Health,Managed Medicaid,,17.53,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Carolina Complete Health,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Carolina Complete Health,Managed Medicaid,,19.40,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Carolina Complete Health,Managed Medicaid,,21.10,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Carolina Complete Health,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Carolina Complete Health,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Carolina Complete Health,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Carolina Complete Health,Managed Medicaid,,14.13,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Carolina Complete Health,Managed Medicaid,,0.97097,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Carolina Complete Health,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Carolina Complete Health,Managed Medicaid,,5.69,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Carolina Complete Health,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Carolina Complete Health,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Carolina Complete Health,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Carolina Complete Health,Managed Medicaid,,4.72,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Carolina Complete Health,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Carolina Complete Health,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Carolina Complete Health,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Carolina Complete Health,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Carolina Complete Health,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Carolina Complete Health,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Carolina Complete Health,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Carolina Complete Health,Managed Medicaid,,4.66,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Carolina Complete Health,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Carolina Complete Health,Managed Medicaid,,1.67,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Carolina Complete Health,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Carolina Complete Health,Managed Medicaid,,3.22,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Carolina Complete Health,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Carolina Complete Health,Managed Medicaid,,33.91,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Carolina Complete Health,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Carolina Complete Health,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Carolina Complete Health,Managed Medicaid,,3616.45,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Carolina Complete Health,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Carolina Complete Health,Managed Medicaid,,6.19,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Carolina Complete Health,Managed Medicaid,,151.67,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Carolina Complete Health,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Carolina Complete Health,Managed Medicaid,,28.78,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Carolina Complete Health,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Carolina Complete Health,Managed Medicaid,,301.87,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Carolina Complete Health,Managed Medicaid,,0.70070,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Carolina Complete Health,Managed Medicaid,,21.87,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Carolina Complete Health,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Carolina Complete Health,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Carolina Complete Health,Managed Medicaid,,5.49,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Carolina Complete Health,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Carolina Complete Health,Managed Medicaid,,8.20,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Carolina Complete Health,Managed Medicaid,,278.53,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Carolina Complete Health,Managed Medicaid,,12.20,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Carolina Complete Health,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Carolina Complete Health,Managed Medicaid,,4.76,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Carolina Complete Health,Managed Medicaid,,75.53,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Carolina Complete Health,Managed Medicaid,,96.61,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Carolina Complete Health,Managed Medicaid,,66.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Carolina Complete Health,Managed Medicaid,,107.18,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Carolina Complete Health,Managed Medicaid,,23.54,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Carolina Complete Health,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Carolina Complete Health,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Carolina Complete Health,Managed Medicaid,,5.02,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Carolina Complete Health,Managed Medicaid,,23.24,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Carolina Complete Health,Managed Medicaid,,137.38,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Carolina Complete Health,Managed Medicaid,,321.76,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Carolina Complete Health,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Carolina Complete Health,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Carolina Complete Health,Managed Medicaid,,13.36,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Carolina Complete Health,Managed Medicaid,,13.96,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Carolina Complete Health,Managed Medicaid,,13.51,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Carolina Complete Health,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Carolina Complete Health,Managed Medicaid,,13.96,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Carolina Complete Health,Managed Medicaid,,13.51,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Carolina Complete Health,Managed Medicaid,,30.03,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Carolina Complete Health,Managed Medicaid,,14.71,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Carolina Complete Health,Managed Medicaid,,13.96,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Carolina Complete Health,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Carolina Complete Health,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Carolina Complete Health,Managed Medicaid,,13.36,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Carolina Complete Health,Managed Medicaid,,13.96,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Carolina Complete Health,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Carolina Complete Health,Managed Medicaid,,13.36,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Carolina Complete Health,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Carolina Complete Health,Managed Medicaid,,204.90,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Carolina Complete Health,Managed Medicaid,,4.53,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Carolina Complete Health,Managed Medicaid,,1446.91,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Carolina Complete Health,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Carolina Complete Health,Managed Medicaid,,1119.21,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Carolina Complete Health,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Carolina Complete Health,Managed Medicaid,,3.78,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Carolina Complete Health,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Carolina Complete Health,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Carolina Complete Health,Managed Medicaid,,70.11,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Carolina Complete Health,Managed Medicaid,,248.85,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Carolina Complete Health,Managed Medicaid,,4.56,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Carolina Complete Health,Managed Medicaid,,9.25,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Carolina Complete Health,Managed Medicaid,,1407.53,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Carolina Complete Health,Managed Medicaid,,66.53,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Carolina Complete Health,Managed Medicaid,,61.72,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Carolina Complete Health,Managed Medicaid,,134.84,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Carolina Complete Health,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Carolina Complete Health,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Carolina Complete Health,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Carolina Complete Health,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Carolina Complete Health,Managed Medicaid,,5370.02,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Carolina Complete Health,Managed Medicaid,,64.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Carolina Complete Health,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Carolina Complete Health,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Carolina Complete Health,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Carolina Complete Health,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Carolina Complete Health,Managed Medicaid,,407.41,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,,99.10,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Carolina Complete Health,Managed Medicaid,,199.52,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Carolina Complete Health,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Carolina Complete Health,Managed Medicaid,,15.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Carolina Complete Health,Managed Medicaid,,67.55,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Carolina Complete Health,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Carolina Complete Health,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Carolina Complete Health,Managed Medicaid,,21.09,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Carolina Complete Health,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Carolina Complete Health,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Carolina Complete Health,Managed Medicaid,,3.81,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Carolina Complete Health,Managed Medicaid,,5.34,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Carolina Complete Health,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Carolina Complete Health,Managed Medicaid,,15.22,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Carolina Complete Health,Managed Medicaid,,58.63,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Carolina Complete Health,Managed Medicaid,,4.16,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Carolina Complete Health,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Carolina Complete Health,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Carolina Complete Health,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Carolina Complete Health,Managed Medicaid,,3.90,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Carolina Complete Health,Managed Medicaid,,3.85,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Carolina Complete Health,Managed Medicaid,,20.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Carolina Complete Health,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Carolina Complete Health,Managed Medicaid,,14.29,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Carolina Complete Health,Managed Medicaid,,15.17,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Carolina Complete Health,Managed Medicaid,,14.14,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Carolina Complete Health,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Carolina Complete Health,Managed Medicaid,,12.62,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Carolina Complete Health,Managed Medicaid,,21.90,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Carolina Complete Health,Managed Medicaid,,0.95095,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Carolina Complete Health,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Carolina Complete Health,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Carolina Complete Health,Managed Medicaid,,217.46,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Carolina Complete Health,Managed Medicaid,,8.91,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Carolina Complete Health,Managed Medicaid,,9.31,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Carolina Complete Health,Managed Medicaid,,6.32,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Carolina Complete Health,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Carolina Complete Health,Managed Medicaid,,7322.31,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Carolina Complete Health,Managed Medicaid,,63.69,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Carolina Complete Health,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Carolina Complete Health,Managed Medicaid,,12.78,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Carolina Complete Health,Managed Medicaid,,23.12,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Carolina Complete Health,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Carolina Complete Health,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Carolina Complete Health,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Carolina Complete Health,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Carolina Complete Health,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Carolina Complete Health,Managed Medicaid,,15.04,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Carolina Complete Health,Managed Medicaid,,21.65,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Carolina Complete Health,Managed Medicaid,,30.68,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Carolina Complete Health,Managed Medicaid,,4.37,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Carolina Complete Health,Managed Medicaid,,3.92,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Carolina Complete Health,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Carolina Complete Health,Managed Medicaid,,40.90,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Carolina Complete Health,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Carolina Complete Health,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Carolina Complete Health,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Carolina Complete Health,Managed Medicaid,,4.79,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Carolina Complete Health,Managed Medicaid,,2740.12,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Carolina Complete Health,Managed Medicaid,,560.36,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Carolina Complete Health,Managed Medicaid,,15.95,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Carolina Complete Health,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Carolina Complete Health,Managed Medicaid,,5.65,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Carolina Complete Health,Managed Medicaid,,15.26,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Carolina Complete Health,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Carolina Complete Health,Managed Medicaid,,20.90,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Carolina Complete Health,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Carolina Complete Health,Managed Medicaid,,12.73,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Carolina Complete Health,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Carolina Complete Health,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Carolina Complete Health,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Carolina Complete Health,Managed Medicaid,,5.71,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Carolina Complete Health,Managed Medicaid,,4.13,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Carolina Complete Health,Managed Medicaid,,4.03,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Carolina Complete Health,Managed Medicaid,,4.05,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Carolina Complete Health,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Carolina Complete Health,Managed Medicaid,,1.42,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Carolina Complete Health,Managed Medicaid,,30.78,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Carolina Complete Health,Managed Medicaid,,81.09,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Carolina Complete Health,Managed Medicaid,,31.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Carolina Complete Health,Managed Medicaid,,160.86,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Carolina Complete Health,Managed Medicaid,,13.25,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Carolina Complete Health,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Carolina Complete Health,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Carolina Complete Health,Managed Medicaid,,14.97,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Carolina Complete Health,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Carolina Complete Health,Managed Medicaid,,18.46,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Carolina Complete Health,Managed Medicaid,,75.28,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Carolina Complete Health,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Carolina Complete Health,Managed Medicaid,,12.88,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Carolina Complete Health,Managed Medicaid,,5.42,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Carolina Complete Health,Managed Medicaid,,22.97,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Carolina Complete Health,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Carolina Complete Health,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Carolina Complete Health,Managed Medicaid,,3.48,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Carolina Complete Health,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Carolina Complete Health,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Carolina Complete Health,Managed Medicaid,,3.47,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Carolina Complete Health,Managed Medicaid,,18.92,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Carolina Complete Health,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Carolina Complete Health,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Carolina Complete Health,Managed Medicaid,,43.16,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Carolina Complete Health,Managed Medicaid,,67.81,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Carolina Complete Health,Managed Medicaid,,167.17,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Carolina Complete Health,Managed Medicaid,,13.06,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Carolina Complete Health,Managed Medicaid,,16.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Carolina Complete Health,Managed Medicaid,,44.56,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Carolina Complete Health,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Carolina Complete Health,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Carolina Complete Health,Managed Medicaid,,25.74,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Carolina Complete Health,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Carolina Complete Health,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Carolina Complete Health,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Carolina Complete Health,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Carolina Complete Health,Managed Medicaid,,63.86,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Carolina Complete Health,Managed Medicaid,,33.71,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Carolina Complete Health,Managed Medicaid,,12.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Carolina Complete Health,Managed Medicaid,,14.55,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Carolina Complete Health,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Carolina Complete Health,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Carolina Complete Health,Managed Medicaid,,17.61,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Carolina Complete Health,Managed Medicaid,,74.49,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Carolina Complete Health,Managed Medicaid,,3.85,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Carolina Complete Health,Managed Medicaid,,13.49,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Carolina Complete Health,Managed Medicaid,,13.69,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Carolina Complete Health,Managed Medicaid,,19.34,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Carolina Complete Health,Managed Medicaid,,6.15,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Carolina Complete Health,Managed Medicaid,,21.33,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Carolina Complete Health,Managed Medicaid,,34.39,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Carolina Complete Health,Managed Medicaid,,20.81,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Carolina Complete Health,Managed Medicaid,,50.13,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Carolina Complete Health,Managed Medicaid,,34.22,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Carolina Complete Health,Managed Medicaid,,16.15,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Carolina Complete Health,Managed Medicaid,,14.08,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Carolina Complete Health,Managed Medicaid,,20.81,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Carolina Complete Health,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Carolina Complete Health,Managed Medicaid,,19.34,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Carolina Complete Health,Managed Medicaid,,21.86,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Carolina Complete Health,Managed Medicaid,,95.86,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Carolina Complete Health,Managed Medicaid,,23.59,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Carolina Complete Health,Managed Medicaid,,113.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Carolina Complete Health,Managed Medicaid,,233.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Carolina Complete Health,Managed Medicaid,,248.73,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Carolina Complete Health,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Carolina Complete Health,Managed Medicaid,,16.74,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Carolina Complete Health,Managed Medicaid,,14.88,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Carolina Complete Health,Managed Medicaid,,30.69,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Carolina Complete Health,Managed Medicaid,,43.74,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Carolina Complete Health,Managed Medicaid,,102.58,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Carolina Complete Health,Managed Medicaid,,192.55,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Carolina Complete Health,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Carolina Complete Health,Managed Medicaid,,20.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Carolina Complete Health,Managed Medicaid,,49.60,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Carolina Complete Health,Managed Medicaid,,13.37,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Carolina Complete Health,Managed Medicaid,,15.65,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Carolina Complete Health,Managed Medicaid,,147.18,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Carolina Complete Health,Managed Medicaid,,3.51,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Carolina Complete Health,Managed Medicaid,,55.10,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Carolina Complete Health,Managed Medicaid,,12.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Carolina Complete Health,Managed Medicaid,,21.04,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Carolina Complete Health,Managed Medicaid,,58.02,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Carolina Complete Health,Managed Medicaid,,35.32,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Carolina Complete Health,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Carolina Complete Health,Managed Medicaid,,24.13,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Carolina Complete Health,Managed Medicaid,,14.29,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Carolina Complete Health,Managed Medicaid,,15.69,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Carolina Complete Health,Managed Medicaid,,36.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Carolina Complete Health,Managed Medicaid,,34.39,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Carolina Complete Health,Managed Medicaid,,15.14,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Carolina Complete Health,Managed Medicaid,,5.85,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Carolina Complete Health,Managed Medicaid,,6.96,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Carolina Complete Health,Managed Medicaid,,14.29,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Carolina Complete Health,Managed Medicaid,,357.36,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Carolina Complete Health,Managed Medicaid,,19.93,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Carolina Complete Health,Managed Medicaid,,5.04,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Carolina Complete Health,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Carolina Complete Health,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Carolina Complete Health,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Carolina Complete Health,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Carolina Complete Health,Managed Medicaid,,34.83,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Carolina Complete Health,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Carolina Complete Health,Managed Medicaid,,4.49,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Carolina Complete Health,Managed Medicaid,,4.50,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Carolina Complete Health,Managed Medicaid,,5.13,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Carolina Complete Health,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Carolina Complete Health,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Carolina Complete Health,Managed Medicaid,,26.24,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Carolina Complete Health,Managed Medicaid,,18.92,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Carolina Complete Health,Managed Medicaid,,27.96,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Carolina Complete Health,Managed Medicaid,,5.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Carolina Complete Health,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Carolina Complete Health,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Carolina Complete Health,Managed Medicaid,,3.55,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Carolina Complete Health,Managed Medicaid,,13.67,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Carolina Complete Health,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Carolina Complete Health,Managed Medicaid,,11.19,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Carolina Complete Health,Managed Medicaid,,16.47,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Carolina Complete Health,Managed Medicaid,,21.29,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Carolina Complete Health,Managed Medicaid,,62.22,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Carolina Complete Health,Managed Medicaid,,15.97,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Carolina Complete Health,Managed Medicaid,,63.91,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Carolina Complete Health,Managed Medicaid,,12.84,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Carolina Complete Health,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Carolina Complete Health,Managed Medicaid,,21.02,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Carolina Complete Health,Managed Medicaid,,14.96,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Carolina Complete Health,Managed Medicaid,,10.41,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Carolina Complete Health,Managed Medicaid,,32.35,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Carolina Complete Health,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Carolina Complete Health,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Carolina Complete Health,Managed Medicaid,,90.46,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Carolina Complete Health,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Carolina Complete Health,Managed Medicaid,,55.38,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Carolina Complete Health,Managed Medicaid,,47.93,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Carolina Complete Health,Managed Medicaid,,14.79,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Carolina Complete Health,Managed Medicaid,,13.15,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Carolina Complete Health,Managed Medicaid,,15.94,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Carolina Complete Health,Managed Medicaid,,11.97,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Carolina Complete Health,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Carolina Complete Health,Managed Medicaid,,49.57,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Carolina Complete Health,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Carolina Complete Health,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Carolina Complete Health,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Carolina Complete Health,Managed Medicaid,,30.76,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Carolina Complete Health,Managed Medicaid,,72.92,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Carolina Complete Health,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Carolina Complete Health,Managed Medicaid,,79.00,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Carolina Complete Health,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Carolina Complete Health,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Carolina Complete Health,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Carolina Complete Health,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Carolina Complete Health,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Carolina Complete Health,Managed Medicaid,,73.55,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Carolina Complete Health,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Carolina Complete Health,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Carolina Complete Health,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Carolina Complete Health,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Carolina Complete Health,Managed Medicaid,,20.26,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Carolina Complete Health,Managed Medicaid,,23.05,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Carolina Complete Health,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Carolina Complete Health,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Carolina Complete Health,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Carolina Complete Health,Managed Medicaid,,39.10,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Carolina Complete Health,Managed Medicaid,,29.27,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Carolina Complete Health,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Carolina Complete Health,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Carolina Complete Health,Managed Medicaid,,14.73,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Carolina Complete Health,Managed Medicaid,,12.90,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Carolina Complete Health,Managed Medicaid,,82.51,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Carolina Complete Health,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Carolina Complete Health,Managed Medicaid,,34.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Carolina Complete Health,Managed Medicaid,,12.65,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Carolina Complete Health,Managed Medicaid,,23.05,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Carolina Complete Health,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Carolina Complete Health,Managed Medicaid,,5.16,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Carolina Complete Health,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Carolina Complete Health,Managed Medicaid,,317.29,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Carolina Complete Health,Managed Medicaid,,7.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Carolina Complete Health,Managed Medicaid,,95.78,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Carolina Complete Health,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Carolina Complete Health,Managed Medicaid,,3.44,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Carolina Complete Health,Managed Medicaid,,28.89,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Carolina Complete Health,Managed Medicaid,,276.31,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Carolina Complete Health,Managed Medicaid,,14.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Carolina Complete Health,Managed Medicaid,,43.04,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Carolina Complete Health,Managed Medicaid,,119.57,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Carolina Complete Health,Managed Medicaid,,21.86,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Carolina Complete Health,Managed Medicaid,,23.12,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Carolina Complete Health,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Carolina Complete Health,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Carolina Complete Health,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Carolina Complete Health,Managed Medicaid,,13.22,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Carolina Complete Health,Managed Medicaid,,7.31,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Carolina Complete Health,Managed Medicaid,,13.22,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Carolina Complete Health,Managed Medicaid,,9.70,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Carolina Complete Health,Managed Medicaid,,17.78,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Carolina Complete Health,Managed Medicaid,,52.13,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Carolina Complete Health,Managed Medicaid,,23.96,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Carolina Complete Health,Managed Medicaid,,23.67,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Carolina Complete Health,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Carolina Complete Health,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Carolina Complete Health,Managed Medicaid,,6.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Carolina Complete Health,Managed Medicaid,,16.67,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Carolina Complete Health,Managed Medicaid,,13.03,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Carolina Complete Health,Managed Medicaid,,35.71,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Carolina Complete Health,Managed Medicaid,,10.13,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Carolina Complete Health,Managed Medicaid,,46.39,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Carolina Complete Health,Managed Medicaid,,47.60,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Carolina Complete Health,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Carolina Complete Health,Managed Medicaid,,13.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Carolina Complete Health,Managed Medicaid,,4.42,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Carolina Complete Health,Managed Medicaid,,4.56,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Carolina Complete Health,Managed Medicaid,,91.88,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Carolina Complete Health,Managed Medicaid,,5.22,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Carolina Complete Health,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Carolina Complete Health,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Carolina Complete Health,Managed Medicaid,,12.64,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Carolina Complete Health,Managed Medicaid,,12.66,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Carolina Complete Health,Managed Medicaid,,12.67,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Carolina Complete Health,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Carolina Complete Health,Managed Medicaid,,29.01,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Carolina Complete Health,Managed Medicaid,,3.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Carolina Complete Health,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Carolina Complete Health,Managed Medicaid,,13.25,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Carolina Complete Health,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Carolina Complete Health,Managed Medicaid,,91.32,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Carolina Complete Health,Managed Medicaid,,92.51,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Carolina Complete Health,Managed Medicaid,,72.28,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Carolina Complete Health,Managed Medicaid,,15.98,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Carolina Complete Health,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Carolina Complete Health,Managed Medicaid,,15.14,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Carolina Complete Health,Managed Medicaid,,15.77,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Carolina Complete Health,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Carolina Complete Health,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Carolina Complete Health,Managed Medicaid,,4.97,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Carolina Complete Health,Managed Medicaid,,31.76,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Carolina Complete Health,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Carolina Complete Health,Managed Medicaid,,25.14,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Carolina Complete Health,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Carolina Complete Health,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Carolina Complete Health,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Carolina Complete Health,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Carolina Complete Health,Managed Medicaid,,4.99,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Carolina Complete Health,Managed Medicaid,,146.20,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Carolina Complete Health,Managed Medicaid,,20.36,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Carolina Complete Health,Managed Medicaid,,20.72,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Carolina Complete Health,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Carolina Complete Health,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Carolina Complete Health,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Carolina Complete Health,Managed Medicaid,,7.81,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Carolina Complete Health,Managed Medicaid,,12.31,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Carolina Complete Health,Managed Medicaid,,5.29,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Carolina Complete Health,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Carolina Complete Health,Managed Medicaid,,42.04,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Carolina Complete Health,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Carolina Complete Health,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Carolina Complete Health,Managed Medicaid,,16.48,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Carolina Complete Health,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Carolina Complete Health,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Carolina Complete Health,Managed Medicaid,,13.40,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Carolina Complete Health,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Carolina Complete Health,Managed Medicaid,,6.89,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Carolina Complete Health,Managed Medicaid,,4.13,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Carolina Complete Health,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Carolina Complete Health,Managed Medicaid,,4.79,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Carolina Complete Health,Managed Medicaid,,5.25,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Carolina Complete Health,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Carolina Complete Health,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Carolina Complete Health,Managed Medicaid,,106.37,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Carolina Complete Health,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Carolina Complete Health,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Carolina Complete Health,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Carolina Complete Health,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Carolina Complete Health,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Carolina Complete Health,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Carolina Complete Health,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Carolina Complete Health,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Carolina Complete Health,Managed Medicaid,,80.87,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Carolina Complete Health,Managed Medicaid,,21.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Carolina Complete Health,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Carolina Complete Health,Managed Medicaid,,4.61,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Carolina Complete Health,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Carolina Complete Health,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Carolina Complete Health,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Carolina Complete Health,Managed Medicaid,,151.55,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Carolina Complete Health,Managed Medicaid,,9.79,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Carolina Complete Health,Managed Medicaid,,5.16,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Carolina Complete Health,Managed Medicaid,,5.23,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Carolina Complete Health,Managed Medicaid,,55.71,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Carolina Complete Health,Managed Medicaid,,11.69,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Carolina Complete Health,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Carolina Complete Health,Managed Medicaid,,3.37,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Carolina Complete Health,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Carolina Complete Health,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Carolina Complete Health,Managed Medicaid,,0.83083,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Carolina Complete Health,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Carolina Complete Health,Managed Medicaid,,55.41,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Carolina Complete Health,Managed Medicaid,,59.75,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Carolina Complete Health,Managed Medicaid,,47.78,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Carolina Complete Health,Managed Medicaid,,52.17,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Carolina Complete Health,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Carolina Complete Health,Managed Medicaid,,58.32,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Carolina Complete Health,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Carolina Complete Health,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Carolina Complete Health,Managed Medicaid,,15.58,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Carolina Complete Health,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Carolina Complete Health,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Carolina Complete Health,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Carolina Complete Health,Managed Medicaid,,9036.23,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Carolina Complete Health,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Carolina Complete Health,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Carolina Complete Health,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Carolina Complete Health,Managed Medicaid,,111.31,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Carolina Complete Health,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Carolina Complete Health,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Carolina Complete Health,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Carolina Complete Health,Managed Medicaid,,9367.61,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Carolina Complete Health,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Carolina Complete Health,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Carolina Complete Health,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Carolina Complete Health,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Carolina Complete Health,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Carolina Complete Health,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Carolina Complete Health,Managed Medicaid,,202.69,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Carolina Complete Health,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Carolina Complete Health,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Carolina Complete Health,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Carolina Complete Health,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Carolina Complete Health,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Carolina Complete Health,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Carolina Complete Health,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Carolina Complete Health,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Carolina Complete Health,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Carolina Complete Health,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Carolina Complete Health,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Carolina Complete Health,Managed Medicaid,,55.83,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Carolina Complete Health,Managed Medicaid,,8.83,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Carolina Complete Health,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Carolina Complete Health,Managed Medicaid,,38405.96,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Carolina Complete Health,Managed Medicaid,,25.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Carolina Complete Health,Managed Medicaid,,14.11,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Carolina Complete Health,Managed Medicaid,,14.86,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Carolina Complete Health,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Carolina Complete Health,Managed Medicaid,,14.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Carolina Complete Health,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Carolina Complete Health,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Carolina Complete Health,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Carolina Complete Health,Managed Medicaid,,134.33,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Carolina Complete Health,Managed Medicaid,,29.04,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Carolina Complete Health,Managed Medicaid,,147.35,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Carolina Complete Health,Managed Medicaid,,52.74,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Carolina Complete Health,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Carolina Complete Health,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Carolina Complete Health,Managed Medicaid,,1.02,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Carolina Complete Health,Managed Medicaid,,2.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Carolina Complete Health,Managed Medicaid,,16.00,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Carolina Complete Health,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Carolina Complete Health,Managed Medicaid,,92.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Carolina Complete Health,Managed Medicaid,,15.62,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Carolina Complete Health,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Carolina Complete Health,Managed Medicaid,,11.85,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Carolina Complete Health,Managed Medicaid,,7.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Carolina Complete Health,Managed Medicaid,,87.28,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Carolina Complete Health,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Carolina Complete Health,Managed Medicaid,,21.34,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Carolina Complete Health,Managed Medicaid,,116.72,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Carolina Complete Health,Managed Medicaid,,62.81,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Carolina Complete Health,Managed Medicaid,,10.37,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Carolina Complete Health,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Carolina Complete Health,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Carolina Complete Health,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Carolina Complete Health,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Carolina Complete Health,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Carolina Complete Health,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Carolina Complete Health,Managed Medicaid,,6.11,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Carolina Complete Health,Managed Medicaid,,6.13,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Carolina Complete Health,Managed Medicaid,,6.84,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Carolina Complete Health,Managed Medicaid,,7.61,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Carolina Complete Health,Managed Medicaid,,23.04,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Carolina Complete Health,Managed Medicaid,,9.83,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Carolina Complete Health,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Carolina Complete Health,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Carolina Complete Health,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Carolina Complete Health,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Carolina Complete Health,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Carolina Complete Health,Managed Medicaid,,0.43043,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Carolina Complete Health,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Carolina Complete Health,Managed Medicaid,,23.36,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Carolina Complete Health,Managed Medicaid,,46.93,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Carolina Complete Health,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Carolina Complete Health,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Carolina Complete Health,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Carolina Complete Health,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Carolina Complete Health,Managed Medicaid,,6.26,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Carolina Complete Health,Managed Medicaid,,5.94,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Carolina Complete Health,Managed Medicaid,,37.17,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Carolina Complete Health,Managed Medicaid,,15.45,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Carolina Complete Health,Managed Medicaid,,5.99,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Carolina Complete Health,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Carolina Complete Health,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Carolina Complete Health,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Carolina Complete Health,Managed Medicaid,,17.47,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Carolina Complete Health,Managed Medicaid,,17.83,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Carolina Complete Health,Managed Medicaid,,4.68,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Carolina Complete Health,Managed Medicaid,,10.72,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Carolina Complete Health,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Carolina Complete Health,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Carolina Complete Health,Managed Medicaid,,61.46,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Carolina Complete Health,Managed Medicaid,,94.69,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Carolina Complete Health,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Carolina Complete Health,Managed Medicaid,,5.80,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Carolina Complete Health,Managed Medicaid,,21.17,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Carolina Complete Health,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Carolina Complete Health,Managed Medicaid,,3.81,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Carolina Complete Health,Managed Medicaid,,4.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Carolina Complete Health,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Carolina Complete Health,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Carolina Complete Health,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Carolina Complete Health,Managed Medicaid,,14.85,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Carolina Complete Health,Managed Medicaid,,2.70,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Carolina Complete Health,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Carolina Complete Health,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Carolina Complete Health,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Carolina Complete Health,Managed Medicaid,,5.33,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Carolina Complete Health,Managed Medicaid,,6.14,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Carolina Complete Health,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Carolina Complete Health,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Carolina Complete Health,Managed Medicaid,,5.23,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Carolina Complete Health,Managed Medicaid,,4.66,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Carolina Complete Health,Managed Medicaid,,6.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Carolina Complete Health,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Carolina Complete Health,Managed Medicaid,,33.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Carolina Complete Health,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Carolina Complete Health,Managed Medicaid,,25.70,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Carolina Complete Health,Managed Medicaid,,10.75,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Carolina Complete Health,Managed Medicaid,,5.15,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Carolina Complete Health,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Carolina Complete Health,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Carolina Complete Health,Managed Medicaid,,4.65,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Carolina Complete Health,Managed Medicaid,,2.10,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Carolina Complete Health,Managed Medicaid,,4.19,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Carolina Complete Health,Managed Medicaid,,3.59,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Carolina Complete Health,Managed Medicaid,,40.93,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Carolina Complete Health,Managed Medicaid,,49.56,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Carolina Complete Health,Managed Medicaid,,14.79,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Carolina Complete Health,Managed Medicaid,,8.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Carolina Complete Health,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Carolina Complete Health,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Carolina Complete Health,Managed Medicaid,,4.86,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Carolina Complete Health,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Carolina Complete Health,Managed Medicaid,,45.49,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Carolina Complete Health,Managed Medicaid,,20.24,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Carolina Complete Health,Managed Medicaid,,6.85,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Carolina Complete Health,Managed Medicaid,,42.58,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Carolina Complete Health,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Carolina Complete Health,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Carolina Complete Health,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Carolina Complete Health,Managed Medicaid,,4.47,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Carolina Complete Health,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Carolina Complete Health,Managed Medicaid,,14.47,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Carolina Complete Health,Managed Medicaid,,50.57,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Carolina Complete Health,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Carolina Complete Health,Managed Medicaid,,53.99,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Carolina Complete Health,Managed Medicaid,,31.11,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Carolina Complete Health,Managed Medicaid,,17.16,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Carolina Complete Health,Managed Medicaid,,22.03,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Carolina Complete Health,Managed Medicaid,,14.54,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Carolina Complete Health,Managed Medicaid,,37.87,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Carolina Complete Health,Managed Medicaid,,8.98,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Carolina Complete Health,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Carolina Complete Health,Managed Medicaid,,0.61061,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Carolina Complete Health,Managed Medicaid,,82.18,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Carolina Complete Health,Managed Medicaid,,4.41,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Carolina Complete Health,Managed Medicaid,,4.89,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Carolina Complete Health,Managed Medicaid,,29.78,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Carolina Complete Health,Managed Medicaid,,251.45,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Carolina Complete Health,Managed Medicaid,,3.39,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Carolina Complete Health,Managed Medicaid,,4.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Carolina Complete Health,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Carolina Complete Health,Managed Medicaid,,40.54,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Carolina Complete Health,Managed Medicaid,,4.44,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Carolina Complete Health,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Carolina Complete Health,Managed Medicaid,,3.51,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Carolina Complete Health,Managed Medicaid,,4.89,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Carolina Complete Health,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Carolina Complete Health,Managed Medicaid,,24.28,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Carolina Complete Health,Managed Medicaid,,32.33,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Carolina Complete Health,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Carolina Complete Health,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Carolina Complete Health,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Carolina Complete Health,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Carolina Complete Health,Managed Medicaid,,51.39,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Carolina Complete Health,Managed Medicaid,,17.31,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Carolina Complete Health,Managed Medicaid,,5.05,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Carolina Complete Health,Managed Medicaid,,13.10,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Carolina Complete Health,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Carolina Complete Health,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Carolina Complete Health,Managed Medicaid,,0.57057,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Carolina Complete Health,Managed Medicaid,,1.53,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Carolina Complete Health,Managed Medicaid,,18.79,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Carolina Complete Health,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Carolina Complete Health,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Carolina Complete Health,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Carolina Complete Health,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Carolina Complete Health,Managed Medicaid,,189.66,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Carolina Complete Health,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Carolina Complete Health,Managed Medicaid,,71.39,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Carolina Complete Health,Managed Medicaid,,81.01,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Carolina Complete Health,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Carolina Complete Health,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Carolina Complete Health,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Carolina Complete Health,Managed Medicaid,,20.97,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Carolina Complete Health,Managed Medicaid,,13.41,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Carolina Complete Health,Managed Medicaid,,23.35,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Carolina Complete Health,Managed Medicaid,,22.43,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Carolina Complete Health,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Carolina Complete Health,Managed Medicaid,,15.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Carolina Complete Health,Managed Medicaid,,16.52,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Carolina Complete Health,Managed Medicaid,,16.51,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Carolina Complete Health,Managed Medicaid,,19.05,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Carolina Complete Health,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Carolina Complete Health,Managed Medicaid,,27.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Carolina Complete Health,Managed Medicaid,,14.86,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Carolina Complete Health,Managed Medicaid,,85.70,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Carolina Complete Health,Managed Medicaid,,79.04,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Carolina Complete Health,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Carolina Complete Health,Managed Medicaid,,13.81,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Carolina Complete Health,Managed Medicaid,,16.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Carolina Complete Health,Managed Medicaid,,23.16,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Carolina Complete Health,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Carolina Complete Health,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Carolina Complete Health,Managed Medicaid,,1060.77,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Carolina Complete Health,Managed Medicaid,,54.03,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Carolina Complete Health,Managed Medicaid,,143.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Carolina Complete Health,Managed Medicaid,,17.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Carolina Complete Health,Managed Medicaid,,9.15,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Carolina Complete Health,Managed Medicaid,,9.92,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Carolina Complete Health,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Carolina Complete Health,Managed Medicaid,,81.63,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Carolina Complete Health,Managed Medicaid,,396.25,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Carolina Complete Health,Managed Medicaid,,73.63,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Carolina Complete Health,Managed Medicaid,,1.38,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Carolina Complete Health,Managed Medicaid,,129.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Carolina Complete Health,Managed Medicaid,,5.32,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Carolina Complete Health,Managed Medicaid,,15.98,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Carolina Complete Health,Managed Medicaid,,23.79,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Carolina Complete Health,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Carolina Complete Health,Managed Medicaid,,18.98,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Carolina Complete Health,Managed Medicaid,,169.85,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Carolina Complete Health,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Carolina Complete Health,Managed Medicaid,,5.60,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Carolina Complete Health,Managed Medicaid,,5.75,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Carolina Complete Health,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Carolina Complete Health,Managed Medicaid,,1.25,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Carolina Complete Health,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Carolina Complete Health,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Carolina Complete Health,Managed Medicaid,,10.70,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Carolina Complete Health,Managed Medicaid,,570.59,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Carolina Complete Health,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Carolina Complete Health,Managed Medicaid,,4.56,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Carolina Complete Health,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Carolina Complete Health,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Carolina Complete Health,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Carolina Complete Health,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Carolina Complete Health,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Carolina Complete Health,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Carolina Complete Health,Managed Medicaid,,8.13,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Carolina Complete Health,Managed Medicaid,,6.00,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Carolina Complete Health,Managed Medicaid,,11.73,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Carolina Complete Health,Managed Medicaid,,11.10,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Carolina Complete Health,Managed Medicaid,,9.11,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Carolina Complete Health,Managed Medicaid,,41.93,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Carolina Complete Health,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Carolina Complete Health,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Carolina Complete Health,Managed Medicaid,,86.34,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Carolina Complete Health,Managed Medicaid,,98.82,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Carolina Complete Health,Managed Medicaid,,5497.41,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Carolina Complete Health,Managed Medicaid,,18.50,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Carolina Complete Health,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Carolina Complete Health,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Carolina Complete Health,Managed Medicaid,,61.08,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Carolina Complete Health,Managed Medicaid,,1817.11,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Carolina Complete Health,Managed Medicaid,,5.48,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Carolina Complete Health,Managed Medicaid,,24.14,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Carolina Complete Health,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Carolina Complete Health,Managed Medicaid,,21.52,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Carolina Complete Health,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Carolina Complete Health,Managed Medicaid,,11.36,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Carolina Complete Health,Managed Medicaid,,26.31,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Carolina Complete Health,Managed Medicaid,,19.48,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Carolina Complete Health,Managed Medicaid,,88.51,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Carolina Complete Health,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Carolina Complete Health,Managed Medicaid,,12.31,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Carolina Complete Health,Managed Medicaid,,9.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Carolina Complete Health,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Carolina Complete Health,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Carolina Complete Health,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Carolina Complete Health,Managed Medicaid,,102.41,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Carolina Complete Health,Managed Medicaid,,70.69,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Carolina Complete Health,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Carolina Complete Health,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Carolina Complete Health,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Carolina Complete Health,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Carolina Complete Health,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Carolina Complete Health,Managed Medicaid,,6.69,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Carolina Complete Health,Managed Medicaid,,8103.63,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Carolina Complete Health,Managed Medicaid,,113.70,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Carolina Complete Health,Managed Medicaid,,8.19,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Carolina Complete Health,Managed Medicaid,,19.64,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Carolina Complete Health,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Carolina Complete Health,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Carolina Complete Health,Managed Medicaid,,31.01,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Carolina Complete Health,Managed Medicaid,,11.84,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Carolina Complete Health,Managed Medicaid,,5378.81,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Carolina Complete Health,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Carolina Complete Health,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Carolina Complete Health,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Carolina Complete Health,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Carolina Complete Health,Managed Medicaid,,19.84,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Carolina Complete Health,Managed Medicaid,,767.34,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Carolina Complete Health,Managed Medicaid,,0.65065,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Carolina Complete Health,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Carolina Complete Health,Managed Medicaid,,217.13,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Carolina Complete Health,Managed Medicaid,,8.14,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Carolina Complete Health,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Carolina Complete Health,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Carolina Complete Health,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Carolina Complete Health,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Carolina Complete Health,Managed Medicaid,,157.47,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Carolina Complete Health,Managed Medicaid,,8019.54,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Carolina Complete Health,Managed Medicaid,,4011.38,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Carolina Complete Health,Managed Medicaid,,0.79079,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Carolina Complete Health,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Carolina Complete Health,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Carolina Complete Health,Managed Medicaid,,20.41,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Carolina Complete Health,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Carolina Complete Health,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Carolina Complete Health,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Carolina Complete Health,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Carolina Complete Health,Managed Medicaid,,6.81,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Carolina Complete Health,Managed Medicaid,,19.62,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Carolina Complete Health,Managed Medicaid,,25.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Carolina Complete Health,Managed Medicaid,,74.41,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Carolina Complete Health,Managed Medicaid,,18.99,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Carolina Complete Health,Managed Medicaid,,42.04,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Carolina Complete Health,Managed Medicaid,,5.26,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Carolina Complete Health,Managed Medicaid,,10.00,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Carolina Complete Health,Managed Medicaid,,35.09,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Carolina Complete Health,Managed Medicaid,,6.19,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Carolina Complete Health,Managed Medicaid,,162.77,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Carolina Complete Health,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Carolina Complete Health,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Carolina Complete Health,Managed Medicaid,,106.41,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Carolina Complete Health,Managed Medicaid,,16.03,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Carolina Complete Health,Managed Medicaid,,7.52,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Carolina Complete Health,Managed Medicaid,,3.75,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Carolina Complete Health,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Carolina Complete Health,Managed Medicaid,,55.32,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Carolina Complete Health,Managed Medicaid,,9.68,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Carolina Complete Health,Managed Medicaid,,53.33,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Carolina Complete Health,Managed Medicaid,,0.81081,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Carolina Complete Health,Managed Medicaid,,32.01,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Carolina Complete Health,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Carolina Complete Health,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Carolina Complete Health,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Carolina Complete Health,Managed Medicaid,,105.45,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Carolina Complete Health,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Carolina Complete Health,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Carolina Complete Health,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Carolina Complete Health,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Carolina Complete Health,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Carolina Complete Health,Managed Medicaid,,15.03,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Carolina Complete Health,Managed Medicaid,,15.11,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Carolina Complete Health,Managed Medicaid,,14.30,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Carolina Complete Health,Managed Medicaid,,5.81,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Carolina Complete Health,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Carolina Complete Health,Managed Medicaid,,4.19,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Carolina Complete Health,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Carolina Complete Health,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Carolina Complete Health,Managed Medicaid,,7.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Carolina Complete Health,Managed Medicaid,,731.93,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Carolina Complete Health,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Carolina Complete Health,Managed Medicaid,,2510.96,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Carolina Complete Health,Managed Medicaid,,5018.69,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Carolina Complete Health,Managed Medicaid,,414.16,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Carolina Complete Health,Managed Medicaid,,551.21,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Carolina Complete Health,Managed Medicaid,,616.62,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Carolina Complete Health,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Carolina Complete Health,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Carolina Complete Health,Managed Medicaid,,86.74,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Carolina Complete Health,Managed Medicaid,,4.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Carolina Complete Health,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Carolina Complete Health,Managed Medicaid,,3.41,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Carolina Complete Health,Managed Medicaid,,3.50,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Carolina Complete Health,Managed Medicaid,,130.73,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Carolina Complete Health,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Carolina Complete Health,Managed Medicaid,,17.24,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Carolina Complete Health,Managed Medicaid,,12.13,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Carolina Complete Health,Managed Medicaid,,149.34,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Carolina Complete Health,Managed Medicaid,,21.02,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Carolina Complete Health,Managed Medicaid,,7.95,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Carolina Complete Health,Managed Medicaid,,12.31,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Carolina Complete Health,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Carolina Complete Health,Managed Medicaid,,4.34,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Carolina Complete Health,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Carolina Complete Health,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,,17.02,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Carolina Complete Health,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Carolina Complete Health,Managed Medicaid,,44.63,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Carolina Complete Health,Managed Medicaid,,63.06,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Carolina Complete Health,Managed Medicaid,,2.96,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Carolina Complete Health,Managed Medicaid,,332.95,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Carolina Complete Health,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Carolina Complete Health,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Carolina Complete Health,Managed Medicaid,,16.42,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Carolina Complete Health,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Carolina Complete Health,Managed Medicaid,,438.24,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Carolina Complete Health,Managed Medicaid,,7.20,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Carolina Complete Health,Managed Medicaid,,53.01,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Carolina Complete Health,Managed Medicaid,,20.92,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Carolina Complete Health,Managed Medicaid,,22.77,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Carolina Complete Health,Managed Medicaid,,9.22,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Carolina Complete Health,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Carolina Complete Health,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Carolina Complete Health,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Carolina Complete Health,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Carolina Complete Health,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Carolina Complete Health,Managed Medicaid,,83.52,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Carolina Complete Health,Managed Medicaid,,307.07,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Carolina Complete Health,Managed Medicaid,,7.71,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Carolina Complete Health,Managed Medicaid,,12.38,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Carolina Complete Health,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Carolina Complete Health,Managed Medicaid,,19.29,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Carolina Complete Health,Managed Medicaid,,60.65,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Carolina Complete Health,Managed Medicaid,,726.37,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Carolina Complete Health,Managed Medicaid,,25.45,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Carolina Complete Health,Managed Medicaid,,42.27,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Carolina Complete Health,Managed Medicaid,,17.83,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Carolina Complete Health,Managed Medicaid,,6.87,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Carolina Complete Health,Managed Medicaid,,12.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Carolina Complete Health,Managed Medicaid,,6.26,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Carolina Complete Health,Managed Medicaid,,40.30,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Carolina Complete Health,Managed Medicaid,,34.84,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Carolina Complete Health,Managed Medicaid,,12.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Carolina Complete Health,Managed Medicaid,,12.98,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Carolina Complete Health,Managed Medicaid,,12.95,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Carolina Complete Health,Managed Medicaid,,47.84,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Carolina Complete Health,Managed Medicaid,,18.24,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Carolina Complete Health,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Carolina Complete Health,Managed Medicaid,,132.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Carolina Complete Health,Managed Medicaid,,77.12,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Carolina Complete Health,Managed Medicaid,,363.01,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Carolina Complete Health,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Carolina Complete Health,Managed Medicaid,,0.92092,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Carolina Complete Health,Managed Medicaid,,435.35,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Carolina Complete Health,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Carolina Complete Health,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Carolina Complete Health,Managed Medicaid,,18.92,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Carolina Complete Health,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Carolina Complete Health,Managed Medicaid,,6.65,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Carolina Complete Health,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Carolina Complete Health,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Carolina Complete Health,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Carolina Complete Health,Managed Medicaid,,15.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Carolina Complete Health,Managed Medicaid,,71.27,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Carolina Complete Health,Managed Medicaid,,11.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Carolina Complete Health,Managed Medicaid,,9.80,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Carolina Complete Health,Managed Medicaid,,1016.27,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Carolina Complete Health,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Carolina Complete Health,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Carolina Complete Health,Managed Medicaid,,128.67,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Carolina Complete Health,Managed Medicaid,,51.03,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Carolina Complete Health,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Carolina Complete Health,Managed Medicaid,,19.13,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Carolina Complete Health,Managed Medicaid,,5.04,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Carolina Complete Health,Managed Medicaid,,33.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Carolina Complete Health,Managed Medicaid,,17.08,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Carolina Complete Health,Managed Medicaid,,20.59,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Carolina Complete Health,Managed Medicaid,,5.10,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Carolina Complete Health,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Carolina Complete Health,Managed Medicaid,,483.85,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Carolina Complete Health,Managed Medicaid,,805.26,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Carolina Complete Health,Managed Medicaid,,97.34,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Carolina Complete Health,Managed Medicaid,,143.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Carolina Complete Health,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Carolina Complete Health,Managed Medicaid,,210.27,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Carolina Complete Health,Managed Medicaid,,10.78,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Carolina Complete Health,Managed Medicaid,,346.52,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Carolina Complete Health,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Carolina Complete Health,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Carolina Complete Health,Managed Medicaid,,22.78,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Carolina Complete Health,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Carolina Complete Health,Managed Medicaid,,330.39,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Carolina Complete Health,Managed Medicaid,,9091.99,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Carolina Complete Health,Managed Medicaid,,31273.72,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Carolina Complete Health,Managed Medicaid,,51551.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Carolina Complete Health,Managed Medicaid,,2234.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Carolina Complete Health,Managed Medicaid,,1479.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Carolina Complete Health,Managed Medicaid,,51.85,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Carolina Complete Health,Managed Medicaid,,2.73,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Carolina Complete Health,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Carolina Complete Health,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Carolina Complete Health,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Carolina Complete Health,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Carolina Complete Health,Managed Medicaid,,103.90,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Carolina Complete Health,Managed Medicaid,,257.66,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Carolina Complete Health,Managed Medicaid,,385.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Carolina Complete Health,Managed Medicaid,,578.78,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Carolina Complete Health,Managed Medicaid,,694.49,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Carolina Complete Health,Managed Medicaid,,833.23,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Carolina Complete Health,Managed Medicaid,,1000.20,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Carolina Complete Health,Managed Medicaid,,413.41,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Carolina Complete Health,Managed Medicaid,,607.21,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Carolina Complete Health,Managed Medicaid,,1104.30,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Carolina Complete Health,Managed Medicaid,,32.03,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Carolina Complete Health,Managed Medicaid,,126.73,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Carolina Complete Health,Managed Medicaid,,34.63,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,,23.42,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Carolina Complete Health,Managed Medicaid,,5.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Carolina Complete Health,Managed Medicaid,,28.63,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Carolina Complete Health,Managed Medicaid,,31.63,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Carolina Complete Health,Managed Medicaid,,104.90,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Carolina Complete Health,Managed Medicaid,,119.52,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Carolina Complete Health,Managed Medicaid,,101.70,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Carolina Complete Health,Managed Medicaid,,18.42,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Carolina Complete Health,Managed Medicaid,,14.61,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Carolina Complete Health,Managed Medicaid,,46.05,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Carolina Complete Health,Managed Medicaid,,42.24,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Carolina Complete Health,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Carolina Complete Health,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Carolina Complete Health,Managed Medicaid,,997.40,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Carolina Complete Health,Managed Medicaid,,357.56,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Carolina Complete Health,Managed Medicaid,,601.60,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Carolina Complete Health,Managed Medicaid,,305.51,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Carolina Complete Health,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Carolina Complete Health,Managed Medicaid,,218.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Carolina Complete Health,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Carolina Complete Health,Managed Medicaid,,247.45,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Carolina Complete Health,Managed Medicaid,,181.98,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Carolina Complete Health,Managed Medicaid,,60.66,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Carolina Complete Health,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Carolina Complete Health,Managed Medicaid,,187.79,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Carolina Complete Health,Managed Medicaid,,53.25,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Carolina Complete Health,Managed Medicaid,,40.84,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Carolina Complete Health,Managed Medicaid,,218.62,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Carolina Complete Health,Managed Medicaid,,189.79,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Carolina Complete Health,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Carolina Complete Health,Managed Medicaid,,8.61,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Carolina Complete Health,Managed Medicaid,,7.01,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Carolina Complete Health,Managed Medicaid,,28.03,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Carolina Complete Health,Managed Medicaid,,94.89,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Carolina Complete Health,Managed Medicaid,,25.23,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Carolina Complete Health,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Carolina Complete Health,Managed Medicaid,,26.83,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Carolina Complete Health,Managed Medicaid,,2.20,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Carolina Complete Health,Managed Medicaid,,998.00,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Carolina Complete Health,Managed Medicaid,,4024.02,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Carolina Complete Health,Managed Medicaid,,1015.81,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Carolina Complete Health,Managed Medicaid,,848.85,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Carolina Complete Health,Managed Medicaid,,696.30,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Carolina Complete Health,Managed Medicaid,,92.69,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Carolina Complete Health,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Carolina Complete Health,Managed Medicaid,,906.91,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Carolina Complete Health,Managed Medicaid,,893.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Carolina Complete Health,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Carolina Complete Health,Managed Medicaid,,1168.17,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Carolina Complete Health,Managed Medicaid,,829.43,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Carolina Complete Health,Managed Medicaid,,829.43,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Carolina Complete Health,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Carolina Complete Health,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Carolina Complete Health,Managed Medicaid,,1174.37,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Carolina Complete Health,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Carolina Complete Health,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Carolina Complete Health,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Carolina Complete Health,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Carolina Complete Health,Managed Medicaid,,349.35,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Carolina Complete Health,Managed Medicaid,,822.82,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Carolina Complete Health,Managed Medicaid,,338.54,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Carolina Complete Health,Managed Medicaid,,1301.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Carolina Complete Health,Managed Medicaid,,237.04,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Carolina Complete Health,Managed Medicaid,,486.89,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Carolina Complete Health,Managed Medicaid,,737.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Carolina Complete Health,Managed Medicaid,,860.26,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Carolina Complete Health,Managed Medicaid,,24.22,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Carolina Complete Health,Managed Medicaid,,341.54,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Carolina Complete Health,Managed Medicaid,,685.89,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Carolina Complete Health,Managed Medicaid,,16.62,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Carolina Complete Health,Managed Medicaid,,93.49,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Carolina Complete Health,Managed Medicaid,,137.94,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Carolina Complete Health,Managed Medicaid,,311.71,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Carolina Complete Health,Managed Medicaid,,236.04,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Carolina Complete Health,Managed Medicaid,,15.82,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Carolina Complete Health,Managed Medicaid,GP,4.20,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Carolina Complete Health,Managed Medicaid,,66.67,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Carolina Complete Health,Managed Medicaid,,300.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Carolina Complete Health,Managed Medicaid,,284.68,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Carolina Complete Health,Managed Medicaid,,228.23,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Carolina Complete Health,Managed Medicaid,,171.77,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Carolina Complete Health,Managed Medicaid,,115.32,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Carolina Complete Health,Managed Medicaid,,58.86,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Carolina Complete Health,Managed Medicaid,,327.93,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Carolina Complete Health,Managed Medicaid,,979.98,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Carolina Complete Health,Managed Medicaid,,1299.70,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Carolina Complete Health,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Carolina Complete Health,Managed Medicaid,,521.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Carolina Complete Health,Managed Medicaid,,5236.83,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Carolina Complete Health,Managed Medicaid,,5485.28,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Carolina Complete Health,Managed Medicaid,,5773.17,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Carolina Complete Health,Managed Medicaid,,6020.81,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Carolina Complete Health,Managed Medicaid,,6269.46,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Carolina Complete Health,Managed Medicaid,,6517.31,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Carolina Complete Health,Managed Medicaid,,6724.92,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Carolina Complete Health,Managed Medicaid,,7012.81,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Carolina Complete Health,Managed Medicaid,,7260.85,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Carolina Complete Health,Managed Medicaid,,7508.90,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Carolina Complete Health,Managed Medicaid,,7757.15,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Carolina Complete Health,Managed Medicaid,,77.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Carolina Complete Health,Managed Medicaid,,106.91,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Carolina Complete Health,Managed Medicaid,,165.97,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Carolina Complete Health,Managed Medicaid,,167.37,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Carolina Complete Health,Managed Medicaid,,807.81,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Carolina Complete Health,Managed Medicaid,,1938.94,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Carolina Complete Health,Managed Medicaid,,2083.48,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Carolina Complete Health,Managed Medicaid,,2238.04,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Carolina Complete Health,Managed Medicaid,,1220.02,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Carolina Complete Health,Managed Medicaid,,1576.17,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Carolina Complete Health,Managed Medicaid,,1792.79,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Carolina Complete Health,Managed Medicaid,,2308.31,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Carolina Complete Health,Managed Medicaid,,2369.57,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Carolina Complete Health,Managed Medicaid,,2427.22,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Carolina Complete Health,Managed Medicaid,,2485.08,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Carolina Complete Health,Managed Medicaid,,2542.74,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Carolina Complete Health,Managed Medicaid,,990.19,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Carolina Complete Health,Managed Medicaid,,133.73,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Carolina Complete Health,Managed Medicaid,,882.08,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Carolina Complete Health,Managed Medicaid,,1190.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Carolina Complete Health,Managed Medicaid,,1630.83,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Carolina Complete Health,Managed Medicaid,,2066.86,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Carolina Complete Health,Managed Medicaid,,2359.76,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Carolina Complete Health,Managed Medicaid,,2672.67,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Carolina Complete Health,Managed Medicaid,,3048.85,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Carolina Complete Health,Managed Medicaid,,3268.06,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Carolina Complete Health,Managed Medicaid,,3591.59,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Carolina Complete Health,Managed Medicaid,,3767.56,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Carolina Complete Health,Managed Medicaid,,3997.99,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Carolina Complete Health,Managed Medicaid,,4146.34,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Carolina Complete Health,Managed Medicaid,,4183.58,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Carolina Complete Health,Managed Medicaid,,4245.64,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Carolina Complete Health,Managed Medicaid,,4369.36,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Carolina Complete Health,Managed Medicaid,,4493.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Carolina Complete Health,Managed Medicaid,,4617.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Carolina Complete Health,Managed Medicaid,,4741.74,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Carolina Complete Health,Managed Medicaid,,4865.26,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Carolina Complete Health,Managed Medicaid,,4989.38,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Carolina Complete Health,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Carolina Complete Health,Managed Medicaid,,2274.67,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Carolina Complete Health,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Carolina Complete Health,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Carolina Complete Health,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Carolina Complete Health,Managed Medicaid,,1297.30,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Carolina Complete Health,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Carolina Complete Health,Managed Medicaid,,1513.91,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Carolina Complete Health,Managed Medicaid,,1705.90,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Carolina Complete Health,Managed Medicaid,,60.66,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Carolina Complete Health,Managed Medicaid,,254.45,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Carolina Complete Health,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Carolina Complete Health,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Carolina Complete Health,Managed Medicaid,,161.76,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Carolina Complete Health,Managed Medicaid,,2160.96,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Carolina Complete Health,Managed Medicaid,,378.38,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Carolina Complete Health,Managed Medicaid,,245.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Carolina Complete Health,Managed Medicaid,,1436.23,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Carolina Complete Health,Managed Medicaid,,59.26,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Carolina Complete Health,Managed Medicaid,,151.35,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Carolina Complete Health,Managed Medicaid,,0.60060,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Carolina Complete Health,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Carolina Complete Health,Managed Medicaid,,425.83,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Carolina Complete Health,Managed Medicaid,,521.92,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Carolina Complete Health,Managed Medicaid,,617.62,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Carolina Complete Health,Managed Medicaid,,713.51,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Carolina Complete Health,Managed Medicaid,,809.41,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Carolina Complete Health,Managed Medicaid,,905.10,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Carolina Complete Health,Managed Medicaid,,132.33,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Carolina Complete Health,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Carolina Complete Health,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Carolina Complete Health,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Carolina Complete Health,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Carolina Complete Health,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Carolina Complete Health,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Carolina Complete Health,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Carolina Complete Health,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Carolina Complete Health,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Carolina Complete Health,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Carolina Complete Health,Managed Medicaid,,191.79,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Carolina Complete Health,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Carolina Complete Health,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Carolina Complete Health,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Carolina Complete Health,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Carolina Complete Health,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Carolina Complete Health,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Carolina Complete Health,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Carolina Complete Health,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Carolina Complete Health,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Carolina Complete Health,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Carolina Complete Health,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Carolina Complete Health,Managed Medicaid,,57.06,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Carolina Complete Health,Managed Medicaid,,271.67,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Carolina Complete Health,Managed Medicaid,,307.71,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Carolina Complete Health,Managed Medicaid,,344.14,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Carolina Complete Health,Managed Medicaid,,380.58,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Carolina Complete Health,Managed Medicaid,,417.42,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Carolina Complete Health,Managed Medicaid,,454.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Carolina Complete Health,Managed Medicaid,,490.49,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Carolina Complete Health,Managed Medicaid,,526.73,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Carolina Complete Health,Managed Medicaid,,562.96,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Carolina Complete Health,Managed Medicaid,,599.80,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Carolina Complete Health,Managed Medicaid,,636.04,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Carolina Complete Health,Managed Medicaid,,683.48,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Carolina Complete Health,Managed Medicaid,,720.32,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Carolina Complete Health,Managed Medicaid,,859.46,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Carolina Complete Health,Managed Medicaid,,915.71,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Carolina Complete Health,Managed Medicaid,,958.36,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Carolina Complete Health,Managed Medicaid,,994.79,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Carolina Complete Health,Managed Medicaid,,1031.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Carolina Complete Health,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Carolina Complete Health,Managed Medicaid,,928.13,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Carolina Complete Health,Managed Medicaid,,825.42,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Carolina Complete Health,Managed Medicaid,,523.12,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Carolina Complete Health,Managed Medicaid,,565.57,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Carolina Complete Health,Managed Medicaid,,497.70,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Carolina Complete Health,Managed Medicaid,,669.07,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Carolina Complete Health,Managed Medicaid,,67.47,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Carolina Complete Health,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Carolina Complete Health,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Carolina Complete Health,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Carolina Complete Health,Managed Medicaid,,255.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Carolina Complete Health,Managed Medicaid,,419.62,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Carolina Complete Health,Managed Medicaid,,466.27,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Carolina Complete Health,Managed Medicaid,,253.05,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Carolina Complete Health,Managed Medicaid,,1500.30,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Carolina Complete Health,Managed Medicaid,,203.40,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Carolina Complete Health,Managed Medicaid,,80.88,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Carolina Complete Health,Managed Medicaid,,915.71,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Carolina Complete Health,Managed Medicaid,,2169.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Carolina Complete Health,Managed Medicaid,,1055.85,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Carolina Complete Health,Managed Medicaid,,61.46,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Carolina Complete Health,Managed Medicaid,,8004.80,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Carolina Complete Health,Managed Medicaid,,8252.64,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Carolina Complete Health,Managed Medicaid,,377.38,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Carolina Complete Health,Managed Medicaid,,111.51,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Carolina Complete Health,Managed Medicaid,,583.58,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Carolina Complete Health,Managed Medicaid,,17.22,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Carolina Complete Health,Managed Medicaid,,36.64,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Carolina Complete Health,Managed Medicaid,,19.82,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Carolina Complete Health,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Carolina Complete Health,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Carolina Complete Health,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Carolina Complete Health,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Carolina Complete Health,Managed Medicaid,,275.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Carolina Complete Health,Managed Medicaid,,3917.71,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Carolina Complete Health,Managed Medicaid,,1825.82,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Carolina Complete Health,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Carolina Complete Health,Managed Medicaid,,991.79,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Carolina Complete Health,Managed Medicaid,,1489.09,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Carolina Complete Health,Managed Medicaid,,1685.28,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Carolina Complete Health,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Carolina Complete Health,Managed Medicaid,,1270.87,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Carolina Complete Health,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Carolina Complete Health,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Carolina Complete Health,Managed Medicaid,,41.84,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Carolina Complete Health,Managed Medicaid,,29.03,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Carolina Complete Health,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Carolina Complete Health,Managed Medicaid,,25.23,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Carolina Complete Health,Managed Medicaid,,30.23,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Carolina Complete Health,Managed Medicaid,,36.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Carolina Complete Health,Managed Medicaid,,59.06,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Carolina Complete Health,Managed Medicaid,,71.07,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Carolina Complete Health,Managed Medicaid,,209.81,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Carolina Complete Health,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Carolina Complete Health,Managed Medicaid,,85.08,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Carolina Complete Health,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Carolina Complete Health,Managed Medicaid,,214.81,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Carolina Complete Health,Managed Medicaid,,189.79,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Carolina Complete Health,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Carolina Complete Health,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Carolina Complete Health,Managed Medicaid,,154.95,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Carolina Complete Health,Managed Medicaid,,1025.02,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Carolina Complete Health,Managed Medicaid,,100.70,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Carolina Complete Health,Managed Medicaid,,90.49,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Carolina Complete Health,Managed Medicaid,,270.07,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Carolina Complete Health,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Carolina Complete Health,Managed Medicaid,,297.10,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Carolina Complete Health,Managed Medicaid,,276.08,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Carolina Complete Health,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Carolina Complete Health,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Carolina Complete Health,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Carolina Complete Health,Managed Medicaid,,1345.34,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Carolina Complete Health,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Carolina Complete Health,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Carolina Complete Health,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Carolina Complete Health,Managed Medicaid,,243.24,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Carolina Complete Health,Managed Medicaid,,326.53,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Carolina Complete Health,Managed Medicaid,,580.38,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Carolina Complete Health,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Carolina Complete Health,Managed Medicaid,,92.69,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Carolina Complete Health,Managed Medicaid,,28.03,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Carolina Complete Health,Managed Medicaid,,33.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Carolina Complete Health,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Carolina Complete Health,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Carolina Complete Health,Managed Medicaid,,205.00,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Carolina Complete Health,Managed Medicaid,,127.53,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Carolina Complete Health,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Carolina Complete Health,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Carolina Complete Health,Managed Medicaid,,59.46,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Carolina Complete Health,Managed Medicaid,,61.66,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Carolina Complete Health,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Carolina Complete Health,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Carolina Complete Health,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Carolina Complete Health,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Carolina Complete Health,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Carolina Complete Health,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Carolina Complete Health,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Carolina Complete Health,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Carolina Complete Health,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Carolina Complete Health,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Carolina Complete Health,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Carolina Complete Health,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Carolina Complete Health,Managed Medicaid,,1897.10,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Carolina Complete Health,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Carolina Complete Health,Managed Medicaid,,539.74,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Carolina Complete Health,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Carolina Complete Health,Managed Medicaid,,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Carolina Complete Health,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Carolina Complete Health,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Carolina Complete Health,Managed Medicaid,,1227.43,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Carolina Complete Health,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Carolina Complete Health,Managed Medicaid,,251.25,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Carolina Complete Health,Managed Medicaid,,107.51,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Carolina Complete Health,Managed Medicaid,,1345.34,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Carolina Complete Health,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Carolina Complete Health,Managed Medicaid,,188.19,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Carolina Complete Health,Managed Medicaid,,44.04,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Carolina Complete Health,Managed Medicaid,,111.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Carolina Complete Health,Managed Medicaid,,1088.29,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Carolina Complete Health,Managed Medicaid,,3972.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Carolina Complete Health,Managed Medicaid,,5483.48,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Carolina Complete Health,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Carolina Complete Health,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Carolina Complete Health,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Carolina Complete Health,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Carolina Complete Health,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Carolina Complete Health,Managed Medicaid,,625.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Carolina Complete Health,Managed Medicaid,,234.63,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Carolina Complete Health,Managed Medicaid,,301.70,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Carolina Complete Health,Managed Medicaid,,283.28,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Carolina Complete Health,Managed Medicaid,,274.27,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Carolina Complete Health,Managed Medicaid,,1994.79,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Carolina Complete Health,Managed Medicaid,Q1,1268.27,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Carolina Complete Health,Managed Medicaid,Q0,759.76,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Carolina Complete Health,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Carolina Complete Health,Managed Medicaid,,84.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Carolina Complete Health,Managed Medicaid,,109.91,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Carolina Complete Health,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Carolina Complete Health,Managed Medicaid,,117.12,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Carolina Complete Health,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Carolina Complete Health,Managed Medicaid,,75.48,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Carolina Complete Health,Managed Medicaid,,18.42,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Carolina Complete Health,Managed Medicaid,,57.66,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Carolina Complete Health,Managed Medicaid,,87.49,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Carolina Complete Health,Managed Medicaid,,52.45,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Carolina Complete Health,Managed Medicaid,,46.85,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Carolina Complete Health,Managed Medicaid,,130.53,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Carolina Complete Health,Managed Medicaid,,6.61,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Carolina Complete Health,Managed Medicaid,,380.18,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Carolina Complete Health,Managed Medicaid,,48.05,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Carolina Complete Health,Managed Medicaid,,72.07,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Carolina Complete Health,Managed Medicaid,,92.69,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Carolina Complete Health,Managed Medicaid,,84.08,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Carolina Complete Health,Managed Medicaid,,389.79,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Carolina Complete Health,Managed Medicaid,,398.40,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Carolina Complete Health,Managed Medicaid,,186.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Carolina Complete Health,Managed Medicaid,,281.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Carolina Complete Health,Managed Medicaid,,292.29,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Carolina Complete Health,Managed Medicaid,,345.14,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Carolina Complete Health,Managed Medicaid,,420.02,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Carolina Complete Health,Managed Medicaid,,704.50,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Carolina Complete Health,Managed Medicaid,,1249.65,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Carolina Complete Health,Managed Medicaid,,1347.55,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Carolina Complete Health,Managed Medicaid,,127.13,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Carolina Complete Health,Managed Medicaid,,170.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Carolina Complete Health,Managed Medicaid,,1271.67,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Carolina Complete Health,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Carolina Complete Health,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Carolina Complete Health,Managed Medicaid,,339.94,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Carolina Complete Health,Managed Medicaid,,554.35,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Carolina Complete Health,Managed Medicaid,,146.95,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Carolina Complete Health,Managed Medicaid,,219.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Carolina Complete Health,Managed Medicaid,,93.89,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Carolina Complete Health,Managed Medicaid,,193.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Carolina Complete Health,Managed Medicaid,,137.54,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Carolina Complete Health,Managed Medicaid,,309.31,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Carolina Complete Health,Managed Medicaid,,214.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Carolina Complete Health,Managed Medicaid,,372.77,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Carolina Complete Health,Managed Medicaid,,90.09,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Carolina Complete Health,Managed Medicaid,,241.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Carolina Complete Health,Managed Medicaid,,1499.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Carolina Complete Health,Managed Medicaid,,1492.29,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Carolina Complete Health,Managed Medicaid,,480.08,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Carolina Complete Health,Managed Medicaid,,349.55,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Carolina Complete Health,Managed Medicaid,,620.62,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Carolina Complete Health,Managed Medicaid,,1686.28,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Carolina Complete Health,Managed Medicaid,,85.08,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Carolina Complete Health,Managed Medicaid,,113.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Carolina Complete Health,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Carolina Complete Health,Managed Medicaid,,418.82,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Carolina Complete Health,Managed Medicaid,,927.93,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Carolina Complete Health,Managed Medicaid,,492.09,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Carolina Complete Health,Managed Medicaid,,600.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Carolina Complete Health,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Carolina Complete Health,Managed Medicaid,,64.26,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Carolina Complete Health,Managed Medicaid,,215.42,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Carolina Complete Health,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Carolina Complete Health,Managed Medicaid,,120.72,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Carolina Complete Health,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Carolina Complete Health,Managed Medicaid,,307.71,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Carolina Complete Health,Managed Medicaid,,123.12,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Carolina Complete Health,Managed Medicaid,,146.95,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Carolina Complete Health,Managed Medicaid,,91.49,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Carolina Complete Health,Managed Medicaid,,66.27,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Carolina Complete Health,Managed Medicaid,,104.70,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Carolina Complete Health,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Carolina Complete Health,Managed Medicaid,,206.61,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Carolina Complete Health,Managed Medicaid,,177.98,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Carolina Complete Health,Managed Medicaid,,232.83,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Carolina Complete Health,Managed Medicaid,,210.41,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Carolina Complete Health,Managed Medicaid,,281.48,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Carolina Complete Health,Managed Medicaid,76,281.48,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Carolina Complete Health,Managed Medicaid,,750.35,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Carolina Complete Health,Managed Medicaid,76,750.35,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Carolina Complete Health,Managed Medicaid,,789.79,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Carolina Complete Health,Managed Medicaid,76,789.79,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Carolina Complete Health,Managed Medicaid,,407.21,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Carolina Complete Health,Managed Medicaid,,452.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Carolina Complete Health,Managed Medicaid,,477.08,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Carolina Complete Health,Managed Medicaid,,526.33,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Carolina Complete Health,Managed Medicaid,,366.97,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Carolina Complete Health,Managed Medicaid,,524.92,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Carolina Complete Health,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Carolina Complete Health,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Carolina Complete Health,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Carolina Complete Health,Managed Medicaid,,58.46,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Carolina Complete Health,Managed Medicaid,,568.97,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Carolina Complete Health,Managed Medicaid,,5465.26,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Carolina Complete Health,Managed Medicaid,,751.35,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Carolina Complete Health,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Carolina Complete Health,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Carolina Complete Health,Managed Medicaid,,129.73,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Carolina Complete Health,Managed Medicaid,,141.74,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Carolina Complete Health,Managed Medicaid,,245.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Carolina Complete Health,Managed Medicaid,,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Carolina Complete Health,Managed Medicaid,,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Carolina Complete Health,Managed Medicaid,,187.79,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Carolina Complete Health,Managed Medicaid,,128.33,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Carolina Complete Health,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Carolina Complete Health,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Carolina Complete Health,Managed Medicaid,,72.67,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Carolina Complete Health,Managed Medicaid,,91.09,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Carolina Complete Health,Managed Medicaid,76,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Carolina Complete Health,Managed Medicaid,76,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Carolina Complete Health,Managed Medicaid,,99.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Carolina Complete Health,Managed Medicaid,,209.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Carolina Complete Health,Managed Medicaid,,326.13,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Carolina Complete Health,Managed Medicaid,,469.07,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Carolina Complete Health,Managed Medicaid,,1384.18,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Carolina Complete Health,Managed Medicaid,,146.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Carolina Complete Health,Managed Medicaid,,1214.61,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Carolina Complete Health,Managed Medicaid,,451.25,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Carolina Complete Health,Managed Medicaid,,567.97,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Carolina Complete Health,Managed Medicaid,,369.97,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Carolina Complete Health,Managed Medicaid,,174.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Carolina Complete Health,Managed Medicaid,,109.91,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Carolina Complete Health,Managed Medicaid,,161.16,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Carolina Complete Health,Managed Medicaid,,250.65,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Carolina Complete Health,Managed Medicaid,,1634.43,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Carolina Complete Health,Managed Medicaid,,482.48,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Carolina Complete Health,Managed Medicaid,,81.08,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Carolina Complete Health,Managed Medicaid,,112.11,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Carolina Complete Health,Managed Medicaid,,332.73,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Carolina Complete Health,Managed Medicaid,,384.98,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Carolina Complete Health,Managed Medicaid,,255.05,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Carolina Complete Health,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Carolina Complete Health,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Carolina Complete Health,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Carolina Complete Health,Managed Medicaid,,625.22,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Carolina Complete Health,Managed Medicaid,,70.27,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Carolina Complete Health,Managed Medicaid,,211.01,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Carolina Complete Health,Managed Medicaid,,6.81,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Carolina Complete Health,Managed Medicaid,,93.09,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Carolina Complete Health,Managed Medicaid,,205.81,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Carolina Complete Health,Managed Medicaid,,242.64,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Carolina Complete Health,Managed Medicaid,,64.46,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Carolina Complete Health,Managed Medicaid,,151.55,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Carolina Complete Health,Managed Medicaid,,32.43,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Carolina Complete Health,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Carolina Complete Health,Managed Medicaid,,59.86,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Carolina Complete Health,Managed Medicaid,,119.12,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Carolina Complete Health,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Carolina Complete Health,Managed Medicaid,,60.46,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Carolina Complete Health,Managed Medicaid,,21.82,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Carolina Complete Health,Managed Medicaid,,40.04,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Carolina Complete Health,Managed Medicaid,,32.23,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Carolina Complete Health,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Carolina Complete Health,Managed Medicaid,,26.63,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Carolina Complete Health,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Carolina Complete Health,Managed Medicaid,,87.69,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Carolina Complete Health,Managed Medicaid,,10.01,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Carolina Complete Health,Managed Medicaid,,82.68,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Carolina Complete Health,Managed Medicaid,,57.66,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Carolina Complete Health,Managed Medicaid,,38.24,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Carolina Complete Health,Managed Medicaid,,53.85,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Carolina Complete Health,Managed Medicaid,GP,13.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,GP,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Carolina Complete Health,Managed Medicaid,GP,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Carolina Complete Health,Managed Medicaid,GP,24.22,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,GP,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Carolina Complete Health,Managed Medicaid,GP,3.20,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Carolina Complete Health,Managed Medicaid,GP,30.63,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Carolina Complete Health,Managed Medicaid,GP,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Carolina Complete Health,Managed Medicaid,GP,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,GP,22.02,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,GP,11.81,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Carolina Complete Health,Managed Medicaid,GP,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Carolina Complete Health,Managed Medicaid,GP,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Carolina Complete Health,Managed Medicaid,GP,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,GP,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Carolina Complete Health,Managed Medicaid,GP,27.83,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Carolina Complete Health,Managed Medicaid,GP,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,GP,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Carolina Complete Health,Managed Medicaid,GP,30.23,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,GP,9.41,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,GP,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,GP,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Carolina Complete Health,Managed Medicaid,GP,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Carolina Complete Health,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Carolina Complete Health,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,GP,17.82,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Carolina Complete Health,Managed Medicaid,GP,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Carolina Complete Health,Managed Medicaid,GP,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,GP,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,GP,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Carolina Complete Health,Managed Medicaid,GP,61.26,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Carolina Complete Health,Managed Medicaid,GP,84.68,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Carolina Complete Health,Managed Medicaid,GP,86.89,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Carolina Complete Health,Managed Medicaid,GP,57.66,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,GO,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,GO,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,GO,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,GO,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Carolina Complete Health,Managed Medicaid,GO,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Carolina Complete Health,Managed Medicaid,GO,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Carolina Complete Health,Managed Medicaid,GO,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Carolina Complete Health,Managed Medicaid,GO,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,GO,12.41,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Carolina Complete Health,Managed Medicaid,GO,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Carolina Complete Health,Managed Medicaid,GO,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Carolina Complete Health,Managed Medicaid,GO,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,GO,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,GO,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Carolina Complete Health,Managed Medicaid,GO,44.84,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Carolina Complete Health,Managed Medicaid,GO,30.43,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Carolina Complete Health,Managed Medicaid,GO,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,GO,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Carolina Complete Health,Managed Medicaid,GO,63.66,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Carolina Complete Health,Managed Medicaid,GO,80.68,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Carolina Complete Health,Managed Medicaid,GO,83.08,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Carolina Complete Health,Managed Medicaid,GO,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Carolina Complete Health,Managed Medicaid,GN,71.27,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Carolina Complete Health,Managed Medicaid,GN,67.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Carolina Complete Health,Managed Medicaid,GN,37.44,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Carolina Complete Health,Managed Medicaid,GN,53.85,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Carolina Complete Health,Managed Medicaid,GN,40.04,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Carolina Complete Health,Managed Medicaid,GN,63.06,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Carolina Complete Health,Managed Medicaid,GN,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,GN,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Carolina Complete Health,Managed Medicaid,GN,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Carolina Complete Health,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,GN,27.23,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Carolina Complete Health,Managed Medicaid,GN,131.13,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Carolina Complete Health,Managed Medicaid,GN,51.85,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Carolina Complete Health,Managed Medicaid,GN,13.61,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Carolina Complete Health,Managed Medicaid,GN,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,GN,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Carolina Complete Health,Managed Medicaid,GN,42.84,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Carolina Complete Health,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,GN,21.42,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Carolina Complete Health,Managed Medicaid,GN,70.67,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Carolina Complete Health,Managed Medicaid,GN,109.91,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Carolina Complete Health,Managed Medicaid,GN,118.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Carolina Complete Health,Managed Medicaid,,172.97,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Carolina Complete Health,Managed Medicaid,,109.91,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Carolina Complete Health,Managed Medicaid,,177.18,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Carolina Complete Health,Managed Medicaid,,100.90,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Carolina Complete Health,Managed Medicaid,,149.15,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Carolina Complete Health,Managed Medicaid,,751.95,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Carolina Complete Health,Managed Medicaid,,8.61,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Carolina Complete Health,Managed Medicaid,,29.63,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Carolina Complete Health,Managed Medicaid,,105.11,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Carolina Complete Health,Managed Medicaid,,104.70,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Carolina Complete Health,Managed Medicaid,,112.71,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Carolina Complete Health,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Carolina Complete Health,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Carolina Complete Health,Managed Medicaid,,271.67,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Carolina Complete Health,Managed Medicaid,,83.68,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Carolina Complete Health,Managed Medicaid,,162.56,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Carolina Complete Health,Managed Medicaid,,113.51,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Carolina Complete Health,Managed Medicaid,,95.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Carolina Complete Health,Managed Medicaid,,130.53,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Carolina Complete Health,Managed Medicaid,,91.69,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Carolina Complete Health,Managed Medicaid,,31.23,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Carolina Complete Health,Managed Medicaid,,36.04,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Carolina Complete Health,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Carolina Complete Health,Managed Medicaid,,26.23,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Carolina Complete Health,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Carolina Complete Health,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Carolina Complete Health,Managed Medicaid,,52.85,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Carolina Complete Health,Managed Medicaid,,52.85,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Carolina Complete Health,Managed Medicaid,,400.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Carolina Complete Health,Managed Medicaid,,625.22,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Carolina Complete Health,Managed Medicaid,,140.14,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Carolina Complete Health,Managed Medicaid,,454.85,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Carolina Complete Health,Managed Medicaid,,166.37,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Carolina Complete Health,Managed Medicaid,,101.10,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Carolina Complete Health,Managed Medicaid,,44.44,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Carolina Complete Health,Managed Medicaid,,66.67,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Carolina Complete Health,Managed Medicaid,,67.67,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Carolina Complete Health,Managed Medicaid,,37.04,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Carolina Complete Health,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Carolina Complete Health,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Carolina Complete Health,Managed Medicaid,,203.60,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Carolina Complete Health,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Carolina Complete Health,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Carolina Complete Health,Managed Medicaid,,854.05,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Carolina Complete Health,Managed Medicaid,,231.03,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Carolina Complete Health,Managed Medicaid,,110.51,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Carolina Complete Health,Managed Medicaid,,113.11,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Carolina Complete Health,Managed Medicaid,,270.27,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Carolina Complete Health,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Carolina Complete Health,Managed Medicaid,,110.11,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Carolina Complete Health,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Carolina Complete Health,Managed Medicaid,,210.41,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Carolina Complete Health,Managed Medicaid,,90.69,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Carolina Complete Health,Managed Medicaid,,254.45,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Carolina Complete Health,Managed Medicaid,,232.03,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Carolina Complete Health,Managed Medicaid,,145.75,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Carolina Complete Health,Managed Medicaid,,96.30,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Carolina Complete Health,Managed Medicaid,,225.43,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Carolina Complete Health,Managed Medicaid,,63.26,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Carolina Complete Health,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Carolina Complete Health,Managed Medicaid,,24.82,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Carolina Complete Health,Managed Medicaid,,191.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Carolina Complete Health,Managed Medicaid,,114.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Carolina Complete Health,Managed Medicaid,,92.89,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Carolina Complete Health,Managed Medicaid,,107.91,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Carolina Complete Health,Managed Medicaid,,100.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Carolina Complete Health,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Carolina Complete Health,Managed Medicaid,,81.08,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Carolina Complete Health,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Carolina Complete Health,Managed Medicaid,,81.08,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Carolina Complete Health,Managed Medicaid,,74.67,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Carolina Complete Health,Managed Medicaid,,134.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Carolina Complete Health,Managed Medicaid,,164.56,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Carolina Complete Health,Managed Medicaid,,171.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Carolina Complete Health,Managed Medicaid,,177.78,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Carolina Complete Health,Managed Medicaid,,107.91,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Carolina Complete Health,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Carolina Complete Health,Managed Medicaid,,59.06,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Carolina Complete Health,Managed Medicaid,,87.49,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Carolina Complete Health,Managed Medicaid,,50.65,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Carolina Complete Health,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Carolina Complete Health,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Carolina Complete Health,Managed Medicaid,,109.51,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Carolina Complete Health,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Carolina Complete Health,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Carolina Complete Health,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Carolina Complete Health,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Carolina Complete Health,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Carolina Complete Health,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Carolina Complete Health,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Carolina Complete Health,Managed Medicaid,,53.45,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Carolina Complete Health,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Carolina Complete Health,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Carolina Complete Health,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Carolina Complete Health,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Carolina Complete Health,Managed Medicaid,,91.49,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Carolina Complete Health,Managed Medicaid,,91.09,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Carolina Complete Health,Managed Medicaid,,298.50,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Carolina Complete Health,Managed Medicaid,,305.51,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Carolina Complete Health,Managed Medicaid,,169.77,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Carolina Complete Health,Managed Medicaid,,246.85,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Carolina Complete Health,Managed Medicaid,,84.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Carolina Complete Health,Managed Medicaid,,199.60,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Carolina Complete Health,Managed Medicaid,,92.69,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Carolina Complete Health,Managed Medicaid,,108.91,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Carolina Complete Health,Managed Medicaid,,263.26,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Carolina Complete Health,Managed Medicaid,,317.92,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Carolina Complete Health,Managed Medicaid,,390.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Carolina Complete Health,Managed Medicaid,,553.95,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Carolina Complete Health,Managed Medicaid,,608.41,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Carolina Complete Health,Managed Medicaid,,771.97,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Carolina Complete Health,Managed Medicaid,,454.05,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Carolina Complete Health,Managed Medicaid,,508.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Carolina Complete Health,Managed Medicaid,,572.17,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Carolina Complete Health,Managed Medicaid,,908.11,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Carolina Complete Health,Managed Medicaid,,1017.02,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Carolina Complete Health,Managed Medicaid,,1135.13,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Carolina Complete Health,Managed Medicaid,,208.61,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Carolina Complete Health,Managed Medicaid,,45.05,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Carolina Complete Health,Managed Medicaid,,58.46,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Carolina Complete Health,Managed Medicaid,,58.86,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Carolina Complete Health,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Carolina Complete Health,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Carolina Complete Health,Managed Medicaid,,21.22,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Carolina Complete Health,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Carolina Complete Health,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Carolina Complete Health,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Carolina Complete Health,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Carolina Complete Health,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Carolina Complete Health,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Carolina Complete Health,Managed Medicaid,GP,13.35,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Carolina Complete Health,Managed Medicaid,,95.90,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Carolina Complete Health,Managed Medicaid,,549.35,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Carolina Complete Health,Managed Medicaid,,549.35,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Carolina Complete Health,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Carolina Complete Health,Managed Medicaid,,217.22,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Carolina Complete Health,Managed Medicaid,,217.22,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Carolina Complete Health,Managed Medicaid,,493.29,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Carolina Complete Health,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Carolina Complete Health,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Carolina Complete Health,Managed Medicaid,,638.64,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Carolina Complete Health,Managed Medicaid,,86.09,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Carolina Complete Health,Managed Medicaid,,96.10,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Carolina Complete Health,Managed Medicaid,,107.31,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Carolina Complete Health,Managed Medicaid,,91.69,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Carolina Complete Health,Managed Medicaid,,23.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Carolina Complete Health,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Carolina Complete Health,Managed Medicaid,,32.63,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Carolina Complete Health,Managed Medicaid,,61.46,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Carolina Complete Health,Managed Medicaid,,104.10,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Carolina Complete Health,Managed Medicaid,,100.90,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Carolina Complete Health,Managed Medicaid,,123.72,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Carolina Complete Health,Managed Medicaid,,81.88,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Carolina Complete Health,Managed Medicaid,,154.15,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Carolina Complete Health,Managed Medicaid,,154.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Carolina Complete Health,Managed Medicaid,,127.73,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Carolina Complete Health,Managed Medicaid,,120.72,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Carolina Complete Health,Managed Medicaid,,180.58,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Carolina Complete Health,Managed Medicaid,,36.44,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Carolina Complete Health,Managed Medicaid,,30.43,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Carolina Complete Health,Managed Medicaid,,56.06,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Carolina Complete Health,Managed Medicaid,,77.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Carolina Complete Health,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Carolina Complete Health,Managed Medicaid,,151.95,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Carolina Complete Health,Managed Medicaid,,459.46,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Carolina Complete Health,Managed Medicaid,,121.52,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Carolina Complete Health,Managed Medicaid,,372.97,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Carolina Complete Health,Managed Medicaid,,372.97,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Carolina Complete Health,Managed Medicaid,,426.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Carolina Complete Health,Managed Medicaid,,107.31,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Carolina Complete Health,Managed Medicaid,,207.61,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Carolina Complete Health,Managed Medicaid,,2503.90,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Carolina Complete Health,Managed Medicaid,,304.30,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Carolina Complete Health,Managed Medicaid,,386.99,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Carolina Complete Health,Managed Medicaid,,166.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Carolina Complete Health,Managed Medicaid,,173.97,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Carolina Complete Health,Managed Medicaid,,185.19,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Carolina Complete Health,Managed Medicaid,,307.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Carolina Complete Health,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Carolina Complete Health,Managed Medicaid,,1956.75,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Carolina Complete Health,Managed Medicaid,,132.13,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Carolina Complete Health,Managed Medicaid,,132.13,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Carolina Complete Health,Managed Medicaid,,638.44,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Carolina Complete Health,Managed Medicaid,,638.44,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Carolina Complete Health,Managed Medicaid,,305.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Carolina Complete Health,Managed Medicaid,,305.91,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Carolina Complete Health,Managed Medicaid,,345.75,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Carolina Complete Health,Managed Medicaid,,428.83,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Carolina Complete Health,Managed Medicaid,,428.83,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Carolina Complete Health,Managed Medicaid,,279.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Carolina Complete Health,Managed Medicaid,,279.68,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Carolina Complete Health,Managed Medicaid,,124.32,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Carolina Complete Health,Managed Medicaid,,124.32,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Carolina Complete Health,Managed Medicaid,,144.14,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Carolina Complete Health,Managed Medicaid,,144.14,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Carolina Complete Health,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Carolina Complete Health,Managed Medicaid,,448.45,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Carolina Complete Health,Managed Medicaid,JW,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Carolina Complete Health,Managed Medicaid,,117.32,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Carolina Complete Health,Managed Medicaid,,99.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Carolina Complete Health,Managed Medicaid,,120.92,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Carolina Complete Health,Managed Medicaid,,99.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Carolina Complete Health,Managed Medicaid,,117.32,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Carolina Complete Health,Managed Medicaid,,164.56,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Carolina Complete Health,Managed Medicaid,,273.07,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Carolina Complete Health,Managed Medicaid,,70.47,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Carolina Complete Health,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Carolina Complete Health,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Carolina Complete Health,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Carolina Complete Health,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Carolina Complete Health,Managed Medicaid,,390.39,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Carolina Complete Health,Managed Medicaid,,390.39,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Carolina Complete Health,Managed Medicaid,,621.22,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Carolina Complete Health,Managed Medicaid,,621.22,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Carolina Complete Health,Managed Medicaid,,344.94,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Carolina Complete Health,Managed Medicaid,,426.83,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Carolina Complete Health,Managed Medicaid,,560.56,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Carolina Complete Health,Managed Medicaid,,108.71,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Carolina Complete Health,Managed Medicaid,,877.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Carolina Complete Health,Managed Medicaid,,970.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Carolina Complete Health,Managed Medicaid,,1147.95,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Carolina Complete Health,Managed Medicaid,,160.96,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Carolina Complete Health,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Carolina Complete Health,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Carolina Complete Health,Managed Medicaid,,384.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Carolina Complete Health,Managed Medicaid,,340.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Carolina Complete Health,Managed Medicaid,,116.52,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Carolina Complete Health,Managed Medicaid,,454.05,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Carolina Complete Health,Managed Medicaid,,253.25,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Carolina Complete Health,Managed Medicaid,,467.07,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Carolina Complete Health,Managed Medicaid,,467.07,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Carolina Complete Health,Managed Medicaid,,409.81,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Carolina Complete Health,Managed Medicaid,,267.27,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Carolina Complete Health,Managed Medicaid,,169.57,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Carolina Complete Health,Managed Medicaid,,356.56,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Carolina Complete Health,Managed Medicaid,,356.56,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Carolina Complete Health,Managed Medicaid,,339.94,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Carolina Complete Health,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Carolina Complete Health,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Carolina Complete Health,Managed Medicaid,,359.16,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Carolina Complete Health,Managed Medicaid,,359.16,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Carolina Complete Health,Managed Medicaid,,824.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Carolina Complete Health,Managed Medicaid,,824.62,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Carolina Complete Health,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Carolina Complete Health,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Carolina Complete Health,Managed Medicaid,,102.50,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Carolina Complete Health,Managed Medicaid,,118.92,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Carolina Complete Health,Managed Medicaid,52,220.22,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Carolina Complete Health,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Carolina Complete Health,Managed Medicaid,,142.34,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Carolina Complete Health,Managed Medicaid,,292.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Carolina Complete Health,Managed Medicaid,,25.43,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Carolina Complete Health,Managed Medicaid,,183.98,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Carolina Complete Health,Managed Medicaid,,183.98,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Carolina Complete Health,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Carolina Complete Health,Managed Medicaid,,63.46,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Carolina Complete Health,Managed Medicaid,,139.54,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Carolina Complete Health,Managed Medicaid,,278.88,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Carolina Complete Health,Managed Medicaid,,475.48,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Carolina Complete Health,Managed Medicaid,,634.03,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Carolina Complete Health,Managed Medicaid,,803.00,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Carolina Complete Health,Managed Medicaid,,265.06,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Carolina Complete Health,Managed Medicaid,,241.64,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Carolina Complete Health,Managed Medicaid,,72.27,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Carolina Complete Health,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Carolina Complete Health,Managed Medicaid,,37.84,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Carolina Complete Health,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Carolina Complete Health,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Carolina Complete Health,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Carolina Complete Health,Managed Medicaid,,40.24,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Carolina Complete Health,Managed Medicaid,,49.85,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Carolina Complete Health,Managed Medicaid,,48.05,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Carolina Complete Health,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Carolina Complete Health,Managed Medicaid,,79.88,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Carolina Complete Health,Managed Medicaid,,74.27,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Carolina Complete Health,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Carolina Complete Health,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Carolina Complete Health,Managed Medicaid,,45.45,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Carolina Complete Health,Managed Medicaid,,53.45,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Carolina Complete Health,Managed Medicaid,,50.05,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Carolina Complete Health,Managed Medicaid,,81.28,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Carolina Complete Health,Managed Medicaid,,87.09,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Carolina Complete Health,Managed Medicaid,,87.49,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Carolina Complete Health,Managed Medicaid,,79.48,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Carolina Complete Health,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Carolina Complete Health,Managed Medicaid,,50.85,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Carolina Complete Health,Managed Medicaid,,77.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Carolina Complete Health,Managed Medicaid,,97.90,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Carolina Complete Health,Managed Medicaid,,13.21,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Carolina Complete Health,Managed Medicaid,,21.22,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Carolina Complete Health,Managed Medicaid,,35.24,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Carolina Complete Health,Managed Medicaid,,52.05,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Carolina Complete Health,Managed Medicaid,,68.67,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Carolina Complete Health,Managed Medicaid,,46.25,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Carolina Complete Health,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Carolina Complete Health,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Carolina Complete Health,Managed Medicaid,,115.32,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Carolina Complete Health,Managed Medicaid,,27.43,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Carolina Complete Health,Managed Medicaid,,22.42,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Carolina Complete Health,Managed Medicaid,,9.61,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Carolina Complete Health,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Carolina Complete Health,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,JW,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,JW,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Carolina Complete Health,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Carolina Complete Health,Managed Medicaid,,55.05,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Carolina Complete Health,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Carolina Complete Health,Managed Medicaid,JW,40.04,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Carolina Complete Health,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Carolina Complete Health,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Carolina Complete Health,Managed Medicaid,JW,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Carolina Complete Health,Managed Medicaid,JW,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Carolina Complete Health,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Carolina Complete Health,Managed Medicaid,JW,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,JW,54.65,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Carolina Complete Health,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Carolina Complete Health,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Carolina Complete Health,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Carolina Complete Health,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Carolina Complete Health,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Carolina Complete Health,Managed Medicaid,JW,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Carolina Complete Health,Managed Medicaid,JW,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Carolina Complete Health,Managed Medicaid,JW,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Carolina Complete Health,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Carolina Complete Health,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Carolina Complete Health,Managed Medicaid,JW,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Carolina Complete Health,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Carolina Complete Health,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Carolina Complete Health,Managed Medicaid,JW,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Carolina Complete Health,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Carolina Complete Health,Managed Medicaid,JW,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,JW,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Carolina Complete Health,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Carolina Complete Health,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Carolina Complete Health,Managed Medicaid,JW,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Carolina Complete Health,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Carolina Complete Health,Managed Medicaid,JW,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Carolina Complete Health,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Carolina Complete Health,Managed Medicaid,JW,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,JW,13.01,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Carolina Complete Health,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Carolina Complete Health,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Carolina Complete Health,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Carolina Complete Health,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Carolina Complete Health,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Carolina Complete Health,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Carolina Complete Health,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Carolina Complete Health,Managed Medicaid,JW,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Carolina Complete Health,Managed Medicaid,JW,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Carolina Complete Health,Managed Medicaid,JW,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Carolina Complete Health,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Carolina Complete Health,Managed Medicaid,JW,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Carolina Complete Health,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Carolina Complete Health,Managed Medicaid,JW,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Carolina Complete Health,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Carolina Complete Health,Managed Medicaid,JW,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Carolina Complete Health,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Carolina Complete Health,Managed Medicaid,JW,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Carolina Complete Health,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Carolina Complete Health,Managed Medicaid,JW,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Carolina Complete Health,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Carolina Complete Health,Managed Medicaid,JW,54.45,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Carolina Complete Health,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Carolina Complete Health,Managed Medicaid,,59.06,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Carolina Complete Health,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Carolina Complete Health,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Carolina Complete Health,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Carolina Complete Health,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Carolina Complete Health,Managed Medicaid,,54.05,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Carolina Complete Health,Managed Medicaid,,849.45,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Carolina Complete Health,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Carolina Complete Health,Managed Medicaid,,49.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Carolina Complete Health,Managed Medicaid,,515.92,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Carolina Complete Health,Managed Medicaid,,41.84,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Carolina Complete Health,Managed Medicaid,,60.66,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Carolina Complete Health,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Carolina Complete Health,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Carolina Complete Health,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Carolina Complete Health,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Carolina Complete Health,Managed Medicaid,,67.47,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Carolina Complete Health,Managed Medicaid,,56.06,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Carolina Complete Health,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Carolina Complete Health,Managed Medicaid,,1877.68,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Carolina Complete Health,Managed Medicaid,,222.82,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Carolina Complete Health,Managed Medicaid,,207.61,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Carolina Complete Health,Managed Medicaid,,239.64,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Carolina Complete Health,Managed Medicaid,,161.36,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Carolina Complete Health,Managed Medicaid,,397.40,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Carolina Complete Health,Managed Medicaid,,397.40,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Carolina Complete Health,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Carolina Complete Health,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Carolina Complete Health,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Carolina Complete Health,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Carolina Complete Health,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Carolina Complete Health,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Carolina Complete Health,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Carolina Complete Health,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Carolina Complete Health,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Carolina Complete Health,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Carolina Complete Health,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Carolina Complete Health,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Carolina Complete Health,Managed Medicaid,,118.92,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Carolina Complete Health,Managed Medicaid,,102.50,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Carolina Complete Health,Managed Medicaid,,154.35,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Carolina Complete Health,Managed Medicaid,,136.34,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Carolina Complete Health,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Carolina Complete Health,Managed Medicaid,,28.63,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Carolina Complete Health,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Carolina Complete Health,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Carolina Complete Health,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Carolina Complete Health,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Carolina Complete Health,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Carolina Complete Health,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Carolina Complete Health,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,,33.03,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Carolina Complete Health,Managed Medicaid,,189.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Carolina Complete Health,Managed Medicaid,,96.90,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Carolina Complete Health,Managed Medicaid,,25.63,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Carolina Complete Health,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Carolina Complete Health,Managed Medicaid,,31.63,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Carolina Complete Health,Managed Medicaid,,18.42,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Carolina Complete Health,Managed Medicaid,,18.42,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Carolina Complete Health,Managed Medicaid,,42.44,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Carolina Complete Health,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Carolina Complete Health,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Carolina Complete Health,Managed Medicaid,,30.03,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,,17.02,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Carolina Complete Health,Managed Medicaid,,26.63,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Carolina Complete Health,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Carolina Complete Health,Managed Medicaid,,8008.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Carolina Complete Health,Managed Medicaid,,155.56,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Carolina Complete Health,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Carolina Complete Health,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Carolina Complete Health,Managed Medicaid,,989.19,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Carolina Complete Health,Managed Medicaid,,58.46,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Carolina Complete Health,Managed Medicaid,,176.98,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Carolina Complete Health,Managed Medicaid,,41.04,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Carolina Complete Health,Managed Medicaid,,41.04,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Carolina Complete Health,Managed Medicaid,,194.19,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Carolina Complete Health,Managed Medicaid,,246.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Carolina Complete Health,Managed Medicaid,,64.86,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Carolina Complete Health,Managed Medicaid,,1253.05,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Carolina Complete Health,Managed Medicaid,,625.22,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Carolina Complete Health,Managed Medicaid,,97.30,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Carolina Complete Health,Managed Medicaid,,4128.92,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Carolina Complete Health,Managed Medicaid,,625.22,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Carolina Complete Health,Managed Medicaid,,168.57,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Carolina Complete Health,Managed Medicaid,,467.67,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Carolina Complete Health,Managed Medicaid,,463.86,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Carolina Complete Health,Managed Medicaid,,464.86,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Carolina Complete Health,Managed Medicaid,,2388.19,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Carolina Complete Health,Managed Medicaid,,104.90,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Carolina Complete Health,Managed Medicaid,,114.71,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Carolina Complete Health,Managed Medicaid,,266.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Carolina Complete Health,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Carolina Complete Health,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Carolina Complete Health,Managed Medicaid,,379.38,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Carolina Complete Health,Managed Medicaid,,379.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Carolina Complete Health,Managed Medicaid,,691.89,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Carolina Complete Health,Managed Medicaid,,691.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Carolina Complete Health,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Carolina Complete Health,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Carolina Complete Health,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Carolina Complete Health,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Carolina Complete Health,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Carolina Complete Health,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Carolina Complete Health,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Carolina Complete Health,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Carolina Complete Health,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Carolina Complete Health,Managed Medicaid,JW,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Carolina Complete Health,Managed Medicaid,JW,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Carolina Complete Health,Managed Medicaid,JW,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Carolina Complete Health,Managed Medicaid,JW,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Carolina Complete Health,Managed Medicaid,JW,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Carolina Complete Health,Managed Medicaid,JW,93.29,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Carolina Complete Health,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Carolina Complete Health,Managed Medicaid,,35.84,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Carolina Complete Health,Managed Medicaid,,159.56,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Carolina Complete Health,Managed Medicaid,,197.80,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Carolina Complete Health,Managed Medicaid,,286.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Carolina Complete Health,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Carolina Complete Health,Managed Medicaid,,35.84,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Carolina Complete Health,Managed Medicaid,,365.97,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Carolina Complete Health,Managed Medicaid,,519.32,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Carolina Complete Health,Managed Medicaid,,189.19,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Carolina Complete Health,Managed Medicaid,,577.18,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Carolina Complete Health,Managed Medicaid,,191.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Carolina Complete Health,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Carolina Complete Health,Managed Medicaid,,280.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Carolina Complete Health,Managed Medicaid,,435.23,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Carolina Complete Health,Managed Medicaid,,847.25,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Carolina Complete Health,Managed Medicaid,,3830.23,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Carolina Complete Health,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Carolina Complete Health,Managed Medicaid,,90.49,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Carolina Complete Health,Managed Medicaid,,80.28,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Carolina Complete Health,Managed Medicaid,,133.13,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Carolina Complete Health,Managed Medicaid,,63.66,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Carolina Complete Health,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Carolina Complete Health,Managed Medicaid,,64.86,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Carolina Complete Health,Managed Medicaid,,109.11,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Carolina Complete Health,Managed Medicaid,,70.47,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Carolina Complete Health,Managed Medicaid,,96.30,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Carolina Complete Health,Managed Medicaid,,120.32,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Carolina Complete Health,Managed Medicaid,,78.88,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Carolina Complete Health,Managed Medicaid,,88.49,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Carolina Complete Health,Managed Medicaid,,100.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Carolina Complete Health,Managed Medicaid,,30.43,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Carolina Complete Health,Managed Medicaid,,54.05,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Carolina Complete Health,Managed Medicaid,,24.02,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Carolina Complete Health,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Carolina Complete Health,Managed Medicaid,,134.33,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Carolina Complete Health,Managed Medicaid,,35.84,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Carolina Complete Health,Managed Medicaid,,60.46,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Carolina Complete Health,Managed Medicaid,,72.47,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Carolina Complete Health,Managed Medicaid,,96.70,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Carolina Complete Health,Managed Medicaid,,116.92,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Carolina Complete Health,Managed Medicaid,,216.02,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Carolina Complete Health,Managed Medicaid,,117.12,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Carolina Complete Health,Managed Medicaid,,61.06,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Carolina Complete Health,Managed Medicaid,,88.49,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Carolina Complete Health,Managed Medicaid,,99.30,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Carolina Complete Health,Managed Medicaid,,132.13,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Carolina Complete Health,Managed Medicaid,,185.99,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Carolina Complete Health,Managed Medicaid,,87.49,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Carolina Complete Health,Managed Medicaid,,65.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Carolina Complete Health,Managed Medicaid,,112.91,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Carolina Complete Health,Managed Medicaid,,98.50,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Carolina Complete Health,Managed Medicaid,,142.14,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Carolina Complete Health,Managed Medicaid,,175.18,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Carolina Complete Health,Managed Medicaid,,116.52,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Carolina Complete Health,Managed Medicaid,,68.27,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Carolina Complete Health,Managed Medicaid,,108.31,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Carolina Complete Health,Managed Medicaid,,73.87,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Carolina Complete Health,Managed Medicaid,,73.67,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Carolina Complete Health,Managed Medicaid,,242.44,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Carolina Complete Health,Managed Medicaid,,150.55,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Carolina Complete Health,Managed Medicaid,,267.47,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Carolina Complete Health,Managed Medicaid,,378.78,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Carolina Complete Health,Managed Medicaid,,416.62,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Carolina Complete Health,Managed Medicaid,,85.08,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Carolina Complete Health,Managed Medicaid,,76.48,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Carolina Complete Health,Managed Medicaid,,91.89,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Carolina Complete Health,Managed Medicaid,,92.49,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Carolina Complete Health,Managed Medicaid,,254.45,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Carolina Complete Health,Managed Medicaid,,104.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Carolina Complete Health,Managed Medicaid,,88.09,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Carolina Complete Health,Managed Medicaid,,81.28,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Carolina Complete Health,Managed Medicaid,,88.49,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Carolina Complete Health,Managed Medicaid,,97.50,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Carolina Complete Health,Managed Medicaid,,75.88,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Carolina Complete Health,Managed Medicaid,,59.66,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Carolina Complete Health,Managed Medicaid,,75.08,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Carolina Complete Health,Managed Medicaid,,69.47,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Carolina Complete Health,Managed Medicaid,,130.73,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Carolina Complete Health,Managed Medicaid,,86.29,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Carolina Complete Health,Managed Medicaid,,78.88,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Carolina Complete Health,Managed Medicaid,,55.26,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Carolina Complete Health,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Carolina Complete Health,Managed Medicaid,,85.49,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Carolina Complete Health,Managed Medicaid,,74.27,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Carolina Complete Health,Managed Medicaid,,96.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Carolina Complete Health,Managed Medicaid,,63.26,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Carolina Complete Health,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Carolina Complete Health,Managed Medicaid,,70.87,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Carolina Complete Health,Managed Medicaid,,43.64,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Carolina Complete Health,Managed Medicaid,,89.09,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Carolina Complete Health,Managed Medicaid,,92.69,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Carolina Complete Health,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Carolina Complete Health,Managed Medicaid,,106.11,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Carolina Complete Health,Managed Medicaid,,92.69,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Carolina Complete Health,Managed Medicaid,,80.28,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Carolina Complete Health,Managed Medicaid,,64.86,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Carolina Complete Health,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Carolina Complete Health,Managed Medicaid,,156.56,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Carolina Complete Health,Managed Medicaid,,64.46,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Carolina Complete Health,Managed Medicaid,,49.45,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Carolina Complete Health,Managed Medicaid,,211.21,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Carolina Complete Health,Managed Medicaid,,145.75,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Carolina Complete Health,Managed Medicaid,,177.78,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Carolina Complete Health,Managed Medicaid,,99.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Carolina Complete Health,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Carolina Complete Health,Managed Medicaid,,197.80,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Carolina Complete Health,Managed Medicaid,,208.41,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Carolina Complete Health,Managed Medicaid,,215.01,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Carolina Complete Health,Managed Medicaid,,107.51,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Carolina Complete Health,Managed Medicaid,,19.62,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Carolina Complete Health,Managed Medicaid,,116.12,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Carolina Complete Health,Managed Medicaid,,128.73,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Carolina Complete Health,Managed Medicaid,,163.76,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Carolina Complete Health,Managed Medicaid,,133.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Carolina Complete Health,Managed Medicaid,,162.16,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Carolina Complete Health,Managed Medicaid,,418.02,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Carolina Complete Health,Managed Medicaid,,929.93,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Carolina Complete Health,Managed Medicaid,,716.12,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Carolina Complete Health,Managed Medicaid,,37.04,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Carolina Complete Health,Managed Medicaid,,273.87,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Carolina Complete Health,Managed Medicaid,,279.28,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Carolina Complete Health,Managed Medicaid,,810.21,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Carolina Complete Health,Managed Medicaid,,1150.35,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Carolina Complete Health,Managed Medicaid,,265.47,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Carolina Complete Health,Managed Medicaid,,514.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Carolina Complete Health,Managed Medicaid,,206.41,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Carolina Complete Health,Managed Medicaid,,240.64,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Carolina Complete Health,Managed Medicaid,,321.92,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Carolina Complete Health,Managed Medicaid,,160.96,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Carolina Complete Health,Managed Medicaid,,323.52,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Carolina Complete Health,Managed Medicaid,,193.59,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Carolina Complete Health,Managed Medicaid,,159.96,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Carolina Complete Health,Managed Medicaid,,221.42,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Carolina Complete Health,Managed Medicaid,,467.07,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Carolina Complete Health,Managed Medicaid,,275.48,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Carolina Complete Health,Managed Medicaid,,40.84,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Carolina Complete Health,Managed Medicaid,,35.03,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Carolina Complete Health,Managed Medicaid,,241.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Carolina Complete Health,Managed Medicaid,,154.35,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Carolina Complete Health,Managed Medicaid,,211.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Carolina Complete Health,Managed Medicaid,,71.67,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Carolina Complete Health,Managed Medicaid,,190.79,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Carolina Complete Health,Managed Medicaid,,33.83,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Carolina Complete Health,Managed Medicaid,,187.39,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Carolina Complete Health,Managed Medicaid,,61.26,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Carolina Complete Health,Managed Medicaid,,68.27,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Carolina Complete Health,Managed Medicaid,,28.63,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Carolina Complete Health,Managed Medicaid,,148.95,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Carolina Complete Health,Managed Medicaid,,132.53,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Carolina Complete Health,Managed Medicaid,,131.53,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Carolina Complete Health,Managed Medicaid,,64.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Carolina Complete Health,Managed Medicaid,,129.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Carolina Complete Health,Managed Medicaid,,69.27,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Carolina Complete Health,Managed Medicaid,,48.65,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Carolina Complete Health,Managed Medicaid,,53.65,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Carolina Complete Health,Managed Medicaid,,185.59,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Carolina Complete Health,Managed Medicaid,,61.26,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Carolina Complete Health,Managed Medicaid,,182.38,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Carolina Complete Health,Managed Medicaid,,58.26,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Carolina Complete Health,Managed Medicaid,,157.76,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Carolina Complete Health,Managed Medicaid,,469.07,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Carolina Complete Health,Managed Medicaid,,808.61,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Carolina Complete Health,Managed Medicaid,,668.27,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Carolina Complete Health,Managed Medicaid,,720.32,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Carolina Complete Health,Managed Medicaid,,407.41,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Carolina Complete Health,Managed Medicaid,,903.70,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Carolina Complete Health,Managed Medicaid,,903.70,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Carolina Complete Health,Managed Medicaid,,903.70,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Carolina Complete Health,Managed Medicaid,,611.21,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Carolina Complete Health,Managed Medicaid,,357.56,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Carolina Complete Health,Managed Medicaid,,281.08,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Carolina Complete Health,Managed Medicaid,,53.65,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Carolina Complete Health,Managed Medicaid,,74.87,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Carolina Complete Health,Managed Medicaid,,66.47,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Carolina Complete Health,Managed Medicaid,,166.37,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Carolina Complete Health,Managed Medicaid,,32.63,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Carolina Complete Health,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Carolina Complete Health,Managed Medicaid,,416.62,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Carolina Complete Health,Managed Medicaid,,123.52,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Carolina Complete Health,Managed Medicaid,,162.56,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Carolina Complete Health,Managed Medicaid,,172.37,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Carolina Complete Health,Managed Medicaid,,93.49,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Carolina Complete Health,Managed Medicaid,,98.90,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Carolina Complete Health,Managed Medicaid,,104.70,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Carolina Complete Health,Managed Medicaid,,151.75,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Carolina Complete Health,Managed Medicaid,,147.35,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Carolina Complete Health,Managed Medicaid,,216.02,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Carolina Complete Health,Managed Medicaid,,45.85,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Carolina Complete Health,Managed Medicaid,,86.49,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Carolina Complete Health,Managed Medicaid,,212.81,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Carolina Complete Health,Managed Medicaid,,123.12,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Carolina Complete Health,Managed Medicaid,,157.16,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Carolina Complete Health,Managed Medicaid,,7507.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Carolina Complete Health,Managed Medicaid,,43.44,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Carolina Complete Health,Managed Medicaid,,370.97,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Carolina Complete Health,Managed Medicaid,,451.05,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Carolina Complete Health,Managed Medicaid,,84.08,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Carolina Complete Health,Managed Medicaid,,110.11,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Carolina Complete Health,Managed Medicaid,,108.11,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Carolina Complete Health,Managed Medicaid,,80.28,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Carolina Complete Health,Managed Medicaid,,119.32,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Carolina Complete Health,Managed Medicaid,,99.50,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Carolina Complete Health,Managed Medicaid,,150.55,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Carolina Complete Health,Managed Medicaid,,116.32,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Carolina Complete Health,Managed Medicaid,,185.79,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Carolina Complete Health,Managed Medicaid,,276.68,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Carolina Complete Health,Managed Medicaid,,54.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Carolina Complete Health,Managed Medicaid,,165.97,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Carolina Complete Health,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Carolina Complete Health,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Carolina Complete Health,Managed Medicaid,,271.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Carolina Complete Health,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Carolina Complete Health,Managed Medicaid,,137.14,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Carolina Complete Health,Managed Medicaid,,221.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Carolina Complete Health,Managed Medicaid,,116.72,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Carolina Complete Health,Managed Medicaid,,583.98,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Carolina Complete Health,Managed Medicaid,,299.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Carolina Complete Health,Managed Medicaid,,218.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Carolina Complete Health,Managed Medicaid,,195.40,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Carolina Complete Health,Managed Medicaid,,143.54,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Carolina Complete Health,Managed Medicaid,,373.57,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Carolina Complete Health,Managed Medicaid,,203.00,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Carolina Complete Health,Managed Medicaid,,416.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Carolina Complete Health,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Carolina Complete Health,Managed Medicaid,,458.46,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Carolina Complete Health,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Carolina Complete Health,Managed Medicaid,,476.08,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Carolina Complete Health,Managed Medicaid,,547.15,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Carolina Complete Health,Managed Medicaid,,171.37,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Carolina Complete Health,Managed Medicaid,,313.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Carolina Complete Health,Managed Medicaid,,246.25,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Carolina Complete Health,Managed Medicaid,,449.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Carolina Complete Health,Managed Medicaid,,208.61,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Carolina Complete Health,Managed Medicaid,,229.83,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Carolina Complete Health,Managed Medicaid,,251.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Carolina Complete Health,Managed Medicaid,,357.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Carolina Complete Health,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Carolina Complete Health,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Carolina Complete Health,Managed Medicaid,,499.90,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Carolina Complete Health,Managed Medicaid,,775.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Carolina Complete Health,Managed Medicaid,,969.77,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Carolina Complete Health,Managed Medicaid,,166.37,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Carolina Complete Health,Managed Medicaid,,288.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Carolina Complete Health,Managed Medicaid,,259.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Carolina Complete Health,Managed Medicaid,,318.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Carolina Complete Health,Managed Medicaid,,497.70,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Carolina Complete Health,Managed Medicaid,,155.76,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Carolina Complete Health,Managed Medicaid,,293.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Carolina Complete Health,Managed Medicaid,,172.97,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Carolina Complete Health,Managed Medicaid,,218.22,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Carolina Complete Health,Managed Medicaid,,159.96,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Carolina Complete Health,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Carolina Complete Health,Managed Medicaid,,264.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Carolina Complete Health,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Carolina Complete Health,Managed Medicaid,,322.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Carolina Complete Health,Managed Medicaid,,254.45,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Carolina Complete Health,Managed Medicaid,,184.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Carolina Complete Health,Managed Medicaid,,468.67,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Carolina Complete Health,Managed Medicaid,,589.19,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Carolina Complete Health,Managed Medicaid,,55.46,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Carolina Complete Health,Managed Medicaid,,19.82,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Carolina Complete Health,Managed Medicaid,,406.41,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Carolina Complete Health,Managed Medicaid,,197.80,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Carolina Complete Health,Managed Medicaid,,41.64,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Carolina Complete Health,Managed Medicaid,,559.36,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Carolina Complete Health,Managed Medicaid,,2501.10,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Carolina Complete Health,Managed Medicaid,,328.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Carolina Complete Health,Managed Medicaid,,103.90,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Carolina Complete Health,Managed Medicaid,,407.01,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Carolina Complete Health,Managed Medicaid,,94.09,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Carolina Complete Health,Managed Medicaid,,2476.67,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Carolina Complete Health,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Carolina Complete Health,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Carolina Complete Health,Managed Medicaid,,17.42,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Carolina Complete Health,Managed Medicaid,,175.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Carolina Complete Health,Managed Medicaid,,23.82,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Carolina Complete Health,Managed Medicaid,,116.92,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Carolina Complete Health,Managed Medicaid,,64.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Carolina Complete Health,Managed Medicaid,,8.81,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Carolina Complete Health,Managed Medicaid,,1057.06,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Carolina Complete Health,Managed Medicaid,,1.20,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Carolina Complete Health,Managed Medicaid,,129.93,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Carolina Complete Health,Managed Medicaid,,24.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Carolina Complete Health,Managed Medicaid,,8.41,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Carolina Complete Health,Managed Medicaid,,16.42,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Carolina Complete Health,Managed Medicaid,,50.85,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Carolina Complete Health,Managed Medicaid,,1212.81,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Carolina Complete Health,Managed Medicaid,,36.64,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Carolina Complete Health,Managed Medicaid,,215.22,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Carolina Complete Health,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Carolina Complete Health,Managed Medicaid,,285.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Carolina Complete Health,Managed Medicaid,,61.06,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Carolina Complete Health,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Carolina Complete Health,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Carolina Complete Health,Managed Medicaid,,268.87,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Carolina Complete Health,Managed Medicaid,,97.50,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Carolina Complete Health,Managed Medicaid,,87.09,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Carolina Complete Health,Managed Medicaid,,448.45,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Carolina Complete Health,Managed Medicaid,,321.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Carolina Complete Health,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Carolina Complete Health,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Carolina Complete Health,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Carolina Complete Health,Managed Medicaid,,262.06,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Carolina Complete Health,Managed Medicaid,,386.19,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Carolina Complete Health,Managed Medicaid,,214.01,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Carolina Complete Health,Managed Medicaid,,381.98,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Carolina Complete Health,Managed Medicaid,,246.25,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Carolina Complete Health,Managed Medicaid,,804.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Carolina Complete Health,Managed Medicaid,,662.66,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Carolina Complete Health,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Carolina Complete Health,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Carolina Complete Health,Managed Medicaid,,813.21,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Carolina Complete Health,Managed Medicaid,,206.81,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Carolina Complete Health,Managed Medicaid,,225.43,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Carolina Complete Health,Managed Medicaid,,64.86,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Carolina Complete Health,Managed Medicaid,,507.91,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Carolina Complete Health,Managed Medicaid,,258.06,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Carolina Complete Health,Managed Medicaid,,227.83,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Carolina Complete Health,Managed Medicaid,,254.05,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Carolina Complete Health,Managed Medicaid,,452.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Carolina Complete Health,Managed Medicaid,,534.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Carolina Complete Health,Managed Medicaid,,653.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Carolina Complete Health,Managed Medicaid,,490.49,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Carolina Complete Health,Managed Medicaid,,588.99,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Carolina Complete Health,Managed Medicaid,,657.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Carolina Complete Health,Managed Medicaid,,507.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Carolina Complete Health,Managed Medicaid,,619.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Carolina Complete Health,Managed Medicaid,,701.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Carolina Complete Health,Managed Medicaid,,517.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Carolina Complete Health,Managed Medicaid,,617.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Carolina Complete Health,Managed Medicaid,,703.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Carolina Complete Health,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Carolina Complete Health,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Carolina Complete Health,Managed Medicaid,,466.67,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Carolina Complete Health,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Carolina Complete Health,Managed Medicaid,,688.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Carolina Complete Health,Managed Medicaid,,775.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Carolina Complete Health,Managed Medicaid,,574.97,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Carolina Complete Health,Managed Medicaid,,724.32,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Carolina Complete Health,Managed Medicaid,,741.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Carolina Complete Health,Managed Medicaid,,448.85,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Carolina Complete Health,Managed Medicaid,,546.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Carolina Complete Health,Managed Medicaid,,637.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Carolina Complete Health,Managed Medicaid,,524.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Carolina Complete Health,Managed Medicaid,,638.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Carolina Complete Health,Managed Medicaid,,745.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Carolina Complete Health,Managed Medicaid,,604.20,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Carolina Complete Health,Managed Medicaid,,458.86,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Carolina Complete Health,Managed Medicaid,,573.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Carolina Complete Health,Managed Medicaid,,614.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Carolina Complete Health,Managed Medicaid,,587.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Carolina Complete Health,Managed Medicaid,,805.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Carolina Complete Health,Managed Medicaid,,869.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Carolina Complete Health,Managed Medicaid,,795.59,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Carolina Complete Health,Managed Medicaid,,502.70,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Carolina Complete Health,Managed Medicaid,,646.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Carolina Complete Health,Managed Medicaid,,847.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Carolina Complete Health,Managed Medicaid,,986.39,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Carolina Complete Health,Managed Medicaid,,499.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Carolina Complete Health,Managed Medicaid,,635.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Carolina Complete Health,Managed Medicaid,,752.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Carolina Complete Health,Managed Medicaid,,1473.67,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Carolina Complete Health,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Carolina Complete Health,Managed Medicaid,,1072.07,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Carolina Complete Health,Managed Medicaid,,1277.08,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Carolina Complete Health,Managed Medicaid,,1484.48,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Carolina Complete Health,Managed Medicaid,,262.06,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Carolina Complete Health,Managed Medicaid,,812.61,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Carolina Complete Health,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Carolina Complete Health,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Carolina Complete Health,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Carolina Complete Health,Managed Medicaid,,560.56,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Carolina Complete Health,Managed Medicaid,,95.50,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Carolina Complete Health,Managed Medicaid,,234.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Carolina Complete Health,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Carolina Complete Health,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Carolina Complete Health,Managed Medicaid,,290.29,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Carolina Complete Health,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Carolina Complete Health,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Carolina Complete Health,Managed Medicaid,,380.58,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Carolina Complete Health,Managed Medicaid,,95.09,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Carolina Complete Health,Managed Medicaid,,67.47,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Carolina Complete Health,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Carolina Complete Health,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Carolina Complete Health,Managed Medicaid,,6299.49,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Carolina Complete Health,Managed Medicaid,,53.85,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Carolina Complete Health,Managed Medicaid,,145.75,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Carolina Complete Health,Managed Medicaid,,125.93,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Carolina Complete Health,Managed Medicaid,,399.00,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Carolina Complete Health,Managed Medicaid,,1022.02,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Carolina Complete Health,Managed Medicaid,,108.71,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Carolina Complete Health,Managed Medicaid,,277.68,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Carolina Complete Health,Managed Medicaid,,176.18,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Carolina Complete Health,Managed Medicaid,,11521.71,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Carolina Complete Health,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Carolina Complete Health,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Carolina Complete Health,Managed Medicaid,,5912.91,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Carolina Complete Health,Managed Medicaid,,222.22,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Carolina Complete Health,Managed Medicaid,,600.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Carolina Complete Health,Managed Medicaid,,31.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Carolina Complete Health,Managed Medicaid,,31.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Carolina Complete Health,Managed Medicaid,,84.28,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Carolina Complete Health,Managed Medicaid,,584.78,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Carolina Complete Health,Managed Medicaid,,125.93,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Carolina Complete Health,Managed Medicaid,,91.29,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Carolina Complete Health,Managed Medicaid,,46.45,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Carolina Complete Health,Managed Medicaid,,40.24,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Carolina Complete Health,Managed Medicaid,,96.30,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Carolina Complete Health,Managed Medicaid,,222.02,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Carolina Complete Health,Managed Medicaid,,91.69,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Carolina Complete Health,Managed Medicaid,,57.06,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Carolina Complete Health,Managed Medicaid,,280.28,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Carolina Complete Health,Managed Medicaid,,316.72,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Carolina Complete Health,Managed Medicaid,,316.72,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Carolina Complete Health,Managed Medicaid,,466.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Carolina Complete Health,Managed Medicaid,,466.47,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Carolina Complete Health,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Carolina Complete Health,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Carolina Complete Health,Managed Medicaid,,160.96,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Carolina Complete Health,Managed Medicaid,,160.96,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Carolina Complete Health,Managed Medicaid,,144.54,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Carolina Complete Health,Managed Medicaid,,115.52,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Carolina Complete Health,Managed Medicaid,,115.52,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Carolina Complete Health,Managed Medicaid,,944.94,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Carolina Complete Health,Managed Medicaid,,676.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Carolina Complete Health,Managed Medicaid,,142.54,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Carolina Complete Health,Managed Medicaid,,113.11,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Carolina Complete Health,Managed Medicaid,,283.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Carolina Complete Health,Managed Medicaid,,153.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Carolina Complete Health,Managed Medicaid,,258.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Carolina Complete Health,Managed Medicaid,,116.32,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Carolina Complete Health,Managed Medicaid,,255.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Carolina Complete Health,Managed Medicaid,,255.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Carolina Complete Health,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Carolina Complete Health,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Carolina Complete Health,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Carolina Complete Health,Managed Medicaid,,60.06,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Carolina Complete Health,Managed Medicaid,,388.99,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Carolina Complete Health,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Carolina Complete Health,Managed Medicaid,,166.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Carolina Complete Health,Managed Medicaid,,324.92,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Carolina Complete Health,Managed Medicaid,,354.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Carolina Complete Health,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Carolina Complete Health,Managed Medicaid,,362.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Carolina Complete Health,Managed Medicaid,,421.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Carolina Complete Health,Managed Medicaid,,421.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Carolina Complete Health,Managed Medicaid,,135.54,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Carolina Complete Health,Managed Medicaid,,135.54,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Carolina Complete Health,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Carolina Complete Health,Managed Medicaid,,136.94,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Carolina Complete Health,Managed Medicaid,,136.94,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Carolina Complete Health,Managed Medicaid,,538.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Carolina Complete Health,Managed Medicaid,,551.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Carolina Complete Health,Managed Medicaid,,551.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Carolina Complete Health,Managed Medicaid,,319.12,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Carolina Complete Health,Managed Medicaid,,319.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Carolina Complete Health,Managed Medicaid,,183.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Carolina Complete Health,Managed Medicaid,,183.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Carolina Complete Health,Managed Medicaid,,226.23,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Carolina Complete Health,Managed Medicaid,,226.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Carolina Complete Health,Managed Medicaid,,230.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Carolina Complete Health,Managed Medicaid,,230.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Carolina Complete Health,Managed Medicaid,,1012.81,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Carolina Complete Health,Managed Medicaid,,985.99,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Carolina Complete Health,Managed Medicaid,,159.16,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Carolina Complete Health,Managed Medicaid,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Carolina Complete Health,Managed Medicaid,,163.76,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Carolina Complete Health,Managed Medicaid,,148.55,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Carolina Complete Health,Managed Medicaid,,449.85,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Carolina Complete Health,Managed Medicaid,,148.55,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Carolina Complete Health,Managed Medicaid,,745.34,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Carolina Complete Health,Managed Medicaid,,177.38,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Carolina Complete Health,Managed Medicaid,,137.34,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Carolina Complete Health,Managed Medicaid,,39.04,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Carolina Complete Health,Managed Medicaid,,106.71,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Carolina Complete Health,Managed Medicaid,,111.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Carolina Complete Health,Managed Medicaid,,118.12,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Carolina Complete Health,Managed Medicaid,,116.72,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Carolina Complete Health,Managed Medicaid,,133.13,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Carolina Complete Health,Managed Medicaid,,833.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Carolina Complete Health,Managed Medicaid,,426.03,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Carolina Complete Health,Managed Medicaid,,268.87,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Carolina Complete Health,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Carolina Complete Health,Managed Medicaid,,138.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Carolina Complete Health,Managed Medicaid,,117.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Carolina Complete Health,Managed Medicaid,,121.32,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Carolina Complete Health,Managed Medicaid,,176.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Carolina Complete Health,Managed Medicaid,,176.98,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Carolina Complete Health,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Carolina Complete Health,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Carolina Complete Health,Managed Medicaid,,2814.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Carolina Complete Health,Managed Medicaid,,1238.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Carolina Complete Health,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Carolina Complete Health,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Carolina Complete Health,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Carolina Complete Health,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Carolina Complete Health,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Carolina Complete Health,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Carolina Complete Health,Managed Medicaid,,1536.13,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Carolina Complete Health,Managed Medicaid,,1581.98,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Carolina Complete Health,Managed Medicaid,,1581.98,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Carolina Complete Health,Managed Medicaid,,960.96,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Carolina Complete Health,Managed Medicaid,,895.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Carolina Complete Health,Managed Medicaid,,1213.61,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Carolina Complete Health,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Carolina Complete Health,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Carolina Complete Health,Managed Medicaid,,879.68,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Carolina Complete Health,Managed Medicaid,,483.88,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Carolina Complete Health,Managed Medicaid,,495.50,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Carolina Complete Health,Managed Medicaid,,322.92,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Carolina Complete Health,Managed Medicaid,,158.56,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Carolina Complete Health,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Carolina Complete Health,Managed Medicaid,,75.88,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Carolina Complete Health,Managed Medicaid,,96.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Carolina Complete Health,Managed Medicaid,,56.46,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Carolina Complete Health,Managed Medicaid,,108.51,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Carolina Complete Health,Managed Medicaid,,1059.86,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Carolina Complete Health,Managed Medicaid,,255.66,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Carolina Complete Health,Managed Medicaid,,1500.30,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Carolina Complete Health,Managed Medicaid,,79.08,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Carolina Complete Health,Managed Medicaid,,328.33,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Carolina Complete Health,Managed Medicaid,,328.33,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Carolina Complete Health,Managed Medicaid,,427.63,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Carolina Complete Health,Managed Medicaid,,182.38,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Carolina Complete Health,Managed Medicaid,,616.02,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Carolina Complete Health,Managed Medicaid,,448.25,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Carolina Complete Health,Managed Medicaid,,107.11,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Carolina Complete Health,Managed Medicaid,,203.40,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Carolina Complete Health,Managed Medicaid,,771.57,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Carolina Complete Health,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Carolina Complete Health,Managed Medicaid,,160.56,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Carolina Complete Health,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Carolina Complete Health,Managed Medicaid,,139.14,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Carolina Complete Health,Managed Medicaid,,1059.86,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Carolina Complete Health,Managed Medicaid,,476.08,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Carolina Complete Health,Managed Medicaid,,500.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Carolina Complete Health,Managed Medicaid,,496.10,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Carolina Complete Health,Managed Medicaid,,127.33,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Carolina Complete Health,Managed Medicaid,,232.23,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Carolina Complete Health,Managed Medicaid,,35.03,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Carolina Complete Health,Managed Medicaid,,1259.46,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Carolina Complete Health,Managed Medicaid,,1554.95,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Carolina Complete Health,Managed Medicaid,,498.70,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Carolina Complete Health,Managed Medicaid,,58.86,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Carolina Complete Health,Managed Medicaid,,46.25,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Carolina Complete Health,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Carolina Complete Health,Managed Medicaid,,80.88,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Carolina Complete Health,Managed Medicaid,,81.68,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Carolina Complete Health,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Carolina Complete Health,Managed Medicaid,,40.44,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Carolina Complete Health,Managed Medicaid,,318.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Carolina Complete Health,Managed Medicaid,,900.30,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Carolina Complete Health,Managed Medicaid,,847.65,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Carolina Complete Health,Managed Medicaid,,584.78,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Carolina Complete Health,Managed Medicaid,,915.71,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Carolina Complete Health,Managed Medicaid,,211.21,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Carolina Complete Health,Managed Medicaid,,211.21,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Carolina Complete Health,Managed Medicaid,,294.49,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Carolina Complete Health,Managed Medicaid,,57.66,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Carolina Complete Health,Managed Medicaid,,57.66,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Carolina Complete Health,Managed Medicaid,,383.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Carolina Complete Health,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Carolina Complete Health,Managed Medicaid,,234.83,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Carolina Complete Health,Managed Medicaid,,502.70,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Carolina Complete Health,Managed Medicaid,,502.70,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Carolina Complete Health,Managed Medicaid,,407.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Carolina Complete Health,Managed Medicaid,,407.21,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Carolina Complete Health,Managed Medicaid,,347.95,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Carolina Complete Health,Managed Medicaid,,347.95,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Carolina Complete Health,Managed Medicaid,,316.92,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Carolina Complete Health,Managed Medicaid,,316.92,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Carolina Complete Health,Managed Medicaid,,329.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Carolina Complete Health,Managed Medicaid,,329.53,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Carolina Complete Health,Managed Medicaid,,342.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Carolina Complete Health,Managed Medicaid,,303.30,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Carolina Complete Health,Managed Medicaid,,303.30,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Carolina Complete Health,Managed Medicaid,,302.10,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Carolina Complete Health,Managed Medicaid,,302.10,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Carolina Complete Health,Managed Medicaid,,665.06,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Carolina Complete Health,Managed Medicaid,,665.06,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Carolina Complete Health,Managed Medicaid,,372.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Carolina Complete Health,Managed Medicaid,,372.37,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Carolina Complete Health,Managed Medicaid,,363.96,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Carolina Complete Health,Managed Medicaid,,363.96,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Carolina Complete Health,Managed Medicaid,,461.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Carolina Complete Health,Managed Medicaid,,73.67,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Carolina Complete Health,Managed Medicaid,,972.37,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Carolina Complete Health,Managed Medicaid,,44.04,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Carolina Complete Health,Managed Medicaid,,568.77,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Carolina Complete Health,Managed Medicaid,,598.60,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Carolina Complete Health,Managed Medicaid,,4031.43,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Carolina Complete Health,Managed Medicaid,,2143.34,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Carolina Complete Health,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Carolina Complete Health,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Carolina Complete Health,Managed Medicaid,,215.01,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Carolina Complete Health,Managed Medicaid,,138.74,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Carolina Complete Health,Managed Medicaid,,155.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Carolina Complete Health,Managed Medicaid,,1092.69,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Carolina Complete Health,Managed Medicaid,,743.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Carolina Complete Health,Managed Medicaid,,944.74,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Carolina Complete Health,Managed Medicaid,,774.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Carolina Complete Health,Managed Medicaid,,973.77,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Carolina Complete Health,Managed Medicaid,,798.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Carolina Complete Health,Managed Medicaid,,337.94,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Carolina Complete Health,Managed Medicaid,,114.71,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Carolina Complete Health,Managed Medicaid,,1493.89,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Carolina Complete Health,Managed Medicaid,,398.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Carolina Complete Health,Managed Medicaid,,298.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Carolina Complete Health,Managed Medicaid,,531.13,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Carolina Complete Health,Managed Medicaid,,5758.95,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Carolina Complete Health,Managed Medicaid,,838.24,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Carolina Complete Health,Managed Medicaid,,2658.46,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Carolina Complete Health,Managed Medicaid,,1771.37,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Carolina Complete Health,Managed Medicaid,,696.50,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Carolina Complete Health,Managed Medicaid,,248.45,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Carolina Complete Health,Managed Medicaid,,339.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Carolina Complete Health,Managed Medicaid,,339.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Carolina Complete Health,Managed Medicaid,,375.58,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Carolina Complete Health,Managed Medicaid,,375.58,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Carolina Complete Health,Managed Medicaid,,346.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Carolina Complete Health,Managed Medicaid,,346.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Carolina Complete Health,Managed Medicaid,,258.06,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Carolina Complete Health,Managed Medicaid,,146.75,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Carolina Complete Health,Managed Medicaid,,246.05,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Carolina Complete Health,Managed Medicaid,,1434.43,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Carolina Complete Health,Managed Medicaid,,358.56,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Carolina Complete Health,Managed Medicaid,,315.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Carolina Complete Health,Managed Medicaid,,371.17,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Carolina Complete Health,Managed Medicaid,,209.41,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Carolina Complete Health,Managed Medicaid,,717.92,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Carolina Complete Health,Managed Medicaid,,717.92,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Carolina Complete Health,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Carolina Complete Health,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Carolina Complete Health,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Carolina Complete Health,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Carolina Complete Health,Managed Medicaid,,693.69,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Carolina Complete Health,Managed Medicaid,,596.60,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Carolina Complete Health,Managed Medicaid,,1230.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Carolina Complete Health,Managed Medicaid,,1430.23,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Carolina Complete Health,Managed Medicaid,,1059.26,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Carolina Complete Health,Managed Medicaid,,954.35,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Carolina Complete Health,Managed Medicaid,,238.64,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Carolina Complete Health,Managed Medicaid,,1609.21,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Carolina Complete Health,Managed Medicaid,,1660.86,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Carolina Complete Health,Managed Medicaid,,2496.49,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Carolina Complete Health,Managed Medicaid,,1392.39,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Carolina Complete Health,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Carolina Complete Health,Managed Medicaid,,369.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Carolina Complete Health,Managed Medicaid,,178.38,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Carolina Complete Health,Managed Medicaid,,322.52,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Carolina Complete Health,Managed Medicaid,,238.44,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Carolina Complete Health,Managed Medicaid,,741.14,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Carolina Complete Health,Managed Medicaid,,650.85,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Carolina Complete Health,Managed Medicaid,,651.45,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Carolina Complete Health,Managed Medicaid,,561.56,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Carolina Complete Health,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Carolina Complete Health,Managed Medicaid,,954.75,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Carolina Complete Health,Managed Medicaid,,1107.51,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Carolina Complete Health,Managed Medicaid,,1623.02,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Carolina Complete Health,Managed Medicaid,,150.35,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Carolina Complete Health,Managed Medicaid,,2177.58,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Carolina Complete Health,Managed Medicaid,,1567.77,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Carolina Complete Health,Managed Medicaid,,762.16,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Carolina Complete Health,Managed Medicaid,,3427.62,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Carolina Complete Health,Managed Medicaid,,1466.87,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Carolina Complete Health,Managed Medicaid,,180.58,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Carolina Complete Health,Managed Medicaid,,696.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Carolina Complete Health,Managed Medicaid,,696.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Carolina Complete Health,Managed Medicaid,,3451.05,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Carolina Complete Health,Managed Medicaid,,3239.64,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Carolina Complete Health,Managed Medicaid,,3239.64,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Carolina Complete Health,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Carolina Complete Health,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Carolina Complete Health,Managed Medicaid,,1866.26,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Carolina Complete Health,Managed Medicaid,,1866.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Carolina Complete Health,Managed Medicaid,,2488.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Carolina Complete Health,Managed Medicaid,,1808.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Carolina Complete Health,Managed Medicaid,,582.58,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Carolina Complete Health,Managed Medicaid,,474.07,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Carolina Complete Health,Managed Medicaid,,474.07,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Carolina Complete Health,Managed Medicaid,,160.96,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Carolina Complete Health,Managed Medicaid,,1313.31,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Carolina Complete Health,Managed Medicaid,,337.54,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Carolina Complete Health,Managed Medicaid,,404.60,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Carolina Complete Health,Managed Medicaid,,642.84,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Carolina Complete Health,Managed Medicaid,,97.50,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Carolina Complete Health,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Carolina Complete Health,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Carolina Complete Health,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Carolina Complete Health,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Carolina Complete Health,Managed Medicaid,,1990.79,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Carolina Complete Health,Managed Medicaid,,1990.79,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Carolina Complete Health,Managed Medicaid,,803.60,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Carolina Complete Health,Managed Medicaid,,1219.62,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Carolina Complete Health,Managed Medicaid,,691.09,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Carolina Complete Health,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Carolina Complete Health,Managed Medicaid,,125.93,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Carolina Complete Health,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Carolina Complete Health,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Carolina Complete Health,Managed Medicaid,,812.41,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Carolina Complete Health,Managed Medicaid,,392.19,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Carolina Complete Health,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Carolina Complete Health,Managed Medicaid,,91.89,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Carolina Complete Health,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Carolina Complete Health,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Carolina Complete Health,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Carolina Complete Health,Managed Medicaid,,64.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Carolina Complete Health,Managed Medicaid,,178.98,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Carolina Complete Health,Managed Medicaid,,114.91,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Carolina Complete Health,Managed Medicaid,,228.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Carolina Complete Health,Managed Medicaid,,187.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Carolina Complete Health,Managed Medicaid,,211.81,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Carolina Complete Health,Managed Medicaid,,154.35,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Carolina Complete Health,Managed Medicaid,,167.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Carolina Complete Health,Managed Medicaid,,63.06,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Carolina Complete Health,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Carolina Complete Health,Managed Medicaid,,62.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Carolina Complete Health,Managed Medicaid,,165.16,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Carolina Complete Health,Managed Medicaid,,192.39,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Carolina Complete Health,Managed Medicaid,,103.90,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Carolina Complete Health,Managed Medicaid,,127.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Carolina Complete Health,Managed Medicaid,,85.49,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Carolina Complete Health,Managed Medicaid,,167.17,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Carolina Complete Health,Managed Medicaid,,133.73,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Carolina Complete Health,Managed Medicaid,,107.91,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Carolina Complete Health,Managed Medicaid,,131.73,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Carolina Complete Health,Managed Medicaid,,207.61,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Carolina Complete Health,Managed Medicaid,,164.76,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Carolina Complete Health,Managed Medicaid,,183.98,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Carolina Complete Health,Managed Medicaid,,60.26,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Carolina Complete Health,Managed Medicaid,,235.84,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Carolina Complete Health,Managed Medicaid,,152.95,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Carolina Complete Health,Managed Medicaid,,50.05,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Carolina Complete Health,Managed Medicaid,,46.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Carolina Complete Health,Managed Medicaid,,37.24,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Carolina Complete Health,Managed Medicaid,,220.62,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Carolina Complete Health,Managed Medicaid,,165.16,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Carolina Complete Health,Managed Medicaid,,39.84,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Carolina Complete Health,Managed Medicaid,,136.94,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Carolina Complete Health,Managed Medicaid,,84.48,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Carolina Complete Health,Managed Medicaid,,193.59,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Carolina Complete Health,Managed Medicaid,,144.94,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Carolina Complete Health,Managed Medicaid,,82.68,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Carolina Complete Health,Managed Medicaid,,98.50,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Carolina Complete Health,Managed Medicaid,,91.89,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Carolina Complete Health,Managed Medicaid,,27.83,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Carolina Complete Health,Managed Medicaid,,13.41,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Carolina Complete Health,Managed Medicaid,,21.82,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Carolina Complete Health,Managed Medicaid,,1278.48,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Carolina Complete Health,Managed Medicaid,,931.73,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Carolina Complete Health,Managed Medicaid,,837.24,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Carolina Complete Health,Managed Medicaid,,1299.50,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Carolina Complete Health,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Carolina Complete Health,Managed Medicaid,,538.14,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Carolina Complete Health,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Carolina Complete Health,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Carolina Complete Health,Managed Medicaid,,186.39,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Carolina Complete Health,Managed Medicaid,,306.51,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Carolina Complete Health,Managed Medicaid,,612.81,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Carolina Complete Health,Managed Medicaid,,932.93,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Carolina Complete Health,Managed Medicaid,,836.04,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Carolina Complete Health,Managed Medicaid,,1211.61,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Carolina Complete Health,Managed Medicaid,,1780.98,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Carolina Complete Health,Managed Medicaid,,105.51,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Carolina Complete Health,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Carolina Complete Health,Managed Medicaid,,114.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Carolina Complete Health,Managed Medicaid,,202.60,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Carolina Complete Health,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Carolina Complete Health,Managed Medicaid,,494.29,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Carolina Complete Health,Managed Medicaid,,96.30,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Carolina Complete Health,Managed Medicaid,,563.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Carolina Complete Health,Managed Medicaid,,659.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Carolina Complete Health,Managed Medicaid,,1014.81,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Carolina Complete Health,Managed Medicaid,,1226.63,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Carolina Complete Health,Managed Medicaid,,692.49,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Carolina Complete Health,Managed Medicaid,,1035.63,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Carolina Complete Health,Managed Medicaid,,1078.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Carolina Complete Health,Managed Medicaid,,721.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Carolina Complete Health,Managed Medicaid,,753.75,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Carolina Complete Health,Managed Medicaid,,1032.63,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Carolina Complete Health,Managed Medicaid,,695.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Carolina Complete Health,Managed Medicaid,,816.02,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Carolina Complete Health,Managed Medicaid,,940.74,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Carolina Complete Health,Managed Medicaid,,742.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Carolina Complete Health,Managed Medicaid,,779.18,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Carolina Complete Health,Managed Medicaid,,1067.47,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Carolina Complete Health,Managed Medicaid,,735.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Carolina Complete Health,Managed Medicaid,,743.14,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Carolina Complete Health,Managed Medicaid,,1032.63,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Carolina Complete Health,Managed Medicaid,,852.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Carolina Complete Health,Managed Medicaid,,901.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Carolina Complete Health,Managed Medicaid,,1047.85,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Carolina Complete Health,Managed Medicaid,,584.38,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Carolina Complete Health,Managed Medicaid,,837.84,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Carolina Complete Health,Managed Medicaid,,635.03,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Carolina Complete Health,Managed Medicaid,,50.65,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Carolina Complete Health,Managed Medicaid,52,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Carolina Complete Health,Managed Medicaid,52,787.39,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Carolina Complete Health,Managed Medicaid,,769.37,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Carolina Complete Health,Managed Medicaid,,881.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Carolina Complete Health,Managed Medicaid,,1040.24,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Carolina Complete Health,Managed Medicaid,,805.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Carolina Complete Health,Managed Medicaid,,827.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Carolina Complete Health,Managed Medicaid,,703.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Carolina Complete Health,Managed Medicaid,,855.65,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Carolina Complete Health,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Carolina Complete Health,Managed Medicaid,,811.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Carolina Complete Health,Managed Medicaid,,1021.82,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Carolina Complete Health,Managed Medicaid,,983.38,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Carolina Complete Health,Managed Medicaid,,1091.89,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Carolina Complete Health,Managed Medicaid,,838.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Carolina Complete Health,Managed Medicaid,,928.33,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Carolina Complete Health,Managed Medicaid,,1118.32,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Carolina Complete Health,Managed Medicaid,,694.29,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Carolina Complete Health,Managed Medicaid,,734.93,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Carolina Complete Health,Managed Medicaid,,1069.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Carolina Complete Health,Managed Medicaid,,649.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Carolina Complete Health,Managed Medicaid,,720.52,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Carolina Complete Health,Managed Medicaid,,1000.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Carolina Complete Health,Managed Medicaid,,845.85,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Carolina Complete Health,Managed Medicaid,,647.85,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Carolina Complete Health,Managed Medicaid,,895.29,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Carolina Complete Health,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Carolina Complete Health,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Carolina Complete Health,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Carolina Complete Health,Managed Medicaid,,707.71,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Carolina Complete Health,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Carolina Complete Health,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Carolina Complete Health,Managed Medicaid,,899.50,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Carolina Complete Health,Managed Medicaid,,650.65,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Carolina Complete Health,Managed Medicaid,,919.72,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Carolina Complete Health,Managed Medicaid,,894.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Carolina Complete Health,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Carolina Complete Health,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Carolina Complete Health,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Carolina Complete Health,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Carolina Complete Health,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Carolina Complete Health,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Carolina Complete Health,Managed Medicaid,,206.81,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Carolina Complete Health,Managed Medicaid,,480.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Carolina Complete Health,Managed Medicaid,,477.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Carolina Complete Health,Managed Medicaid,,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Carolina Complete Health,Managed Medicaid,,375.38,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Carolina Complete Health,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Carolina Complete Health,Managed Medicaid,,64.86,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Carolina Complete Health,Managed Medicaid,,79.88,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Carolina Complete Health,Managed Medicaid,,349.35,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Carolina Complete Health,Managed Medicaid,,349.35,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Carolina Complete Health,Managed Medicaid,,31.63,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Carolina Complete Health,Managed Medicaid,,366.57,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Carolina Complete Health,Managed Medicaid,,366.57,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Carolina Complete Health,Managed Medicaid,,181.18,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Carolina Complete Health,Managed Medicaid,,108.11,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Carolina Complete Health,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Carolina Complete Health,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Carolina Complete Health,Managed Medicaid,,260.06,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Carolina Complete Health,Managed Medicaid,,207.61,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Carolina Complete Health,Managed Medicaid,,169.57,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Carolina Complete Health,Managed Medicaid,,123.32,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Carolina Complete Health,Managed Medicaid,,119.92,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Carolina Complete Health,Managed Medicaid,,58.46,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Carolina Complete Health,Managed Medicaid,,86.29,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Carolina Complete Health,Managed Medicaid,,63.46,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Carolina Complete Health,Managed Medicaid,,57.66,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Carolina Complete Health,Managed Medicaid,,136.14,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Carolina Complete Health,Managed Medicaid,,56.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Carolina Complete Health,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Carolina Complete Health,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Carolina Complete Health,Managed Medicaid,,287.49,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Carolina Complete Health,Managed Medicaid,,150.55,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Carolina Complete Health,Managed Medicaid,,373.57,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Carolina Complete Health,Managed Medicaid,,870.87,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Carolina Complete Health,Managed Medicaid,,50.45,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Carolina Complete Health,Managed Medicaid,,35.44,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Carolina Complete Health,Managed Medicaid,,73.87,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Carolina Complete Health,Managed Medicaid,,36.64,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Carolina Complete Health,Managed Medicaid,,85.49,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Carolina Complete Health,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Carolina Complete Health,Managed Medicaid,,55.05,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Carolina Complete Health,Managed Medicaid,,79.88,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Carolina Complete Health,Managed Medicaid,,126.33,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Carolina Complete Health,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Carolina Complete Health,Managed Medicaid,,174.97,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Carolina Complete Health,Managed Medicaid,,112.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Carolina Complete Health,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Carolina Complete Health,Managed Medicaid,,72.47,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Carolina Complete Health,Managed Medicaid,,151.35,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Carolina Complete Health,Managed Medicaid,,61.06,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Carolina Complete Health,Managed Medicaid,,133.13,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Carolina Complete Health,Managed Medicaid,,84.48,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Carolina Complete Health,Managed Medicaid,,191.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Carolina Complete Health,Managed Medicaid,,119.92,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Carolina Complete Health,Managed Medicaid,,84.48,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Carolina Complete Health,Managed Medicaid,,91.69,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Carolina Complete Health,Managed Medicaid,,72.87,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Carolina Complete Health,Managed Medicaid,,505.30,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Carolina Complete Health,Managed Medicaid,,434.23,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Carolina Complete Health,Managed Medicaid,,221.42,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Carolina Complete Health,Managed Medicaid,,104.30,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Carolina Complete Health,Managed Medicaid,,110.71,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Carolina Complete Health,Managed Medicaid,,67.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Carolina Complete Health,Managed Medicaid,,25.63,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Carolina Complete Health,Managed Medicaid,,102.50,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Carolina Complete Health,Managed Medicaid,,80.88,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Carolina Complete Health,Managed Medicaid,,80.88,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Carolina Complete Health,Managed Medicaid,,481.28,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,,9.41,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Carolina Complete Health,Managed Medicaid,,2.80,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Carolina Complete Health,Managed Medicaid,,22.42,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Carolina Complete Health,Managed Medicaid,,32.63,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Carolina Complete Health,Managed Medicaid,,26.43,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Carolina Complete Health,Managed Medicaid,,5.21,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Carolina Complete Health,Managed Medicaid,,8.81,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Carolina Complete Health,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Carolina Complete Health,Managed Medicaid,,53.05,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Carolina Complete Health,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Carolina Complete Health,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Carolina Complete Health,Managed Medicaid,,79.48,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Carolina Complete Health,Managed Medicaid,,31.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Carolina Complete Health,Managed Medicaid,,107.11,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Carolina Complete Health,Managed Medicaid,,14.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Carolina Complete Health,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Carolina Complete Health,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Carolina Complete Health,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Carolina Complete Health,Managed Medicaid,,5.81,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Carolina Complete Health,Managed Medicaid,,35.44,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Carolina Complete Health,Managed Medicaid,,24.82,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Carolina Complete Health,Managed Medicaid,,7.81,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Carolina Complete Health,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Carolina Complete Health,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Carolina Complete Health,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Carolina Complete Health,Managed Medicaid,,30.83,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Carolina Complete Health,Managed Medicaid,,5.81,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Carolina Complete Health,Managed Medicaid,,8.61,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Carolina Complete Health,Managed Medicaid,,8.41,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Carolina Complete Health,Managed Medicaid,,9.61,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Carolina Complete Health,Managed Medicaid,,32.43,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Carolina Complete Health,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Carolina Complete Health,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Carolina Complete Health,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Carolina Complete Health,Managed Medicaid,,8.41,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Carolina Complete Health,Managed Medicaid,,12.01,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Carolina Complete Health,Managed Medicaid,,8.01,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Carolina Complete Health,Managed Medicaid,,8.01,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Carolina Complete Health,Managed Medicaid,,33.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Carolina Complete Health,Managed Medicaid,,13.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Carolina Complete Health,Managed Medicaid,,10.61,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Carolina Complete Health,Managed Medicaid,,51.65,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Carolina Complete Health,Managed Medicaid,,13.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Carolina Complete Health,Managed Medicaid,,48.65,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Carolina Complete Health,Managed Medicaid,,36.04,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Carolina Complete Health,Managed Medicaid,,29.23,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Carolina Complete Health,Managed Medicaid,,15.82,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Carolina Complete Health,Managed Medicaid,,7.81,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Carolina Complete Health,Managed Medicaid,,59.86,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Carolina Complete Health,Managed Medicaid,,1.20,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Carolina Complete Health,Managed Medicaid,,40.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Carolina Complete Health,Managed Medicaid,,115.92,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Carolina Complete Health,Managed Medicaid,,31.43,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Carolina Complete Health,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Carolina Complete Health,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Carolina Complete Health,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Carolina Complete Health,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Carolina Complete Health,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Carolina Complete Health,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Carolina Complete Health,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Carolina Complete Health,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Carolina Complete Health,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,,6.01,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Carolina Complete Health,Managed Medicaid,,14.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Carolina Complete Health,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Carolina Complete Health,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Carolina Complete Health,Managed Medicaid,,15.62,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Carolina Complete Health,Managed Medicaid,,47.65,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Carolina Complete Health,Managed Medicaid,,31.23,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Carolina Complete Health,Managed Medicaid,,44.24,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Carolina Complete Health,Managed Medicaid,,24.02,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Carolina Complete Health,Managed Medicaid,,30.43,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Carolina Complete Health,Managed Medicaid,,39.44,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Carolina Complete Health,Managed Medicaid,,26.43,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Carolina Complete Health,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Carolina Complete Health,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Carolina Complete Health,Managed Medicaid,,8.41,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Carolina Complete Health,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Carolina Complete Health,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Carolina Complete Health,Managed Medicaid,,29.83,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Carolina Complete Health,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Carolina Complete Health,Managed Medicaid,,28.63,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Carolina Complete Health,Managed Medicaid,,16.62,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Carolina Complete Health,Managed Medicaid,,28.63,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Carolina Complete Health,Managed Medicaid,,35.44,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Carolina Complete Health,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Carolina Complete Health,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Carolina Complete Health,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Carolina Complete Health,Managed Medicaid,,0.40040,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Carolina Complete Health,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Carolina Complete Health,Managed Medicaid,,11.01,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Carolina Complete Health,Managed Medicaid,,29.23,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Carolina Complete Health,Managed Medicaid,,45.45,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Carolina Complete Health,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Carolina Complete Health,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Carolina Complete Health,Managed Medicaid,,9.01,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Carolina Complete Health,Managed Medicaid,,10.61,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Carolina Complete Health,Managed Medicaid,,10.01,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Carolina Complete Health,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Carolina Complete Health,Managed Medicaid,,9.01,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Carolina Complete Health,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Carolina Complete Health,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Carolina Complete Health,Managed Medicaid,,8.61,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Carolina Complete Health,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Carolina Complete Health,Managed Medicaid,,33.43,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Carolina Complete Health,Managed Medicaid,,9.01,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Carolina Complete Health,Managed Medicaid,,32.03,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Carolina Complete Health,Managed Medicaid,,38.04,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Carolina Complete Health,Managed Medicaid,,13.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Carolina Complete Health,Managed Medicaid,,26.83,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Carolina Complete Health,Managed Medicaid,,26.03,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Carolina Complete Health,Managed Medicaid,,21.62,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Carolina Complete Health,Managed Medicaid,,7.61,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Carolina Complete Health,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Carolina Complete Health,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Carolina Complete Health,Managed Medicaid,,26.03,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Carolina Complete Health,Managed Medicaid,,38.64,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Carolina Complete Health,Managed Medicaid,,15.82,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Carolina Complete Health,Managed Medicaid,,2.40,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Carolina Complete Health,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Carolina Complete Health,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Carolina Complete Health,Managed Medicaid,,45.05,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Carolina Complete Health,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Carolina Complete Health,Managed Medicaid,,28.03,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Carolina Complete Health,Managed Medicaid,,22.62,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Carolina Complete Health,Managed Medicaid,,19.42,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Carolina Complete Health,Managed Medicaid,,27.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Carolina Complete Health,Managed Medicaid,,24.02,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Carolina Complete Health,Managed Medicaid,,1.60,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Carolina Complete Health,Managed Medicaid,,4.40,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Carolina Complete Health,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Carolina Complete Health,Managed Medicaid,,34.83,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Carolina Complete Health,Managed Medicaid,,25.63,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Carolina Complete Health,Managed Medicaid,,53.45,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Carolina Complete Health,Managed Medicaid,,29.43,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Carolina Complete Health,Managed Medicaid,,54.65,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Carolina Complete Health,Managed Medicaid,,41.44,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Carolina Complete Health,Managed Medicaid,,10.01,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Carolina Complete Health,Managed Medicaid,,47.45,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Carolina Complete Health,Managed Medicaid,,41.24,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Carolina Complete Health,Managed Medicaid,,8.21,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Carolina Complete Health,Managed Medicaid,,58.66,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Carolina Complete Health,Managed Medicaid,,40.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Carolina Complete Health,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Carolina Complete Health,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Carolina Complete Health,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Carolina Complete Health,Managed Medicaid,,10.01,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Carolina Complete Health,Managed Medicaid,,27.03,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Carolina Complete Health,Managed Medicaid,,44.64,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Carolina Complete Health,Managed Medicaid,,4.20,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Carolina Complete Health,Managed Medicaid,,11.41,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Carolina Complete Health,Managed Medicaid,,29.03,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Carolina Complete Health,Managed Medicaid,,13.61,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,,23.42,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Carolina Complete Health,Managed Medicaid,,34.63,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Carolina Complete Health,Managed Medicaid,,19.42,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Carolina Complete Health,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Carolina Complete Health,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Carolina Complete Health,Managed Medicaid,,3.00,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Carolina Complete Health,Managed Medicaid,,7.01,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Carolina Complete Health,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Carolina Complete Health,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Carolina Complete Health,Managed Medicaid,,92.29,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Carolina Complete Health,Managed Medicaid,,24.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Carolina Complete Health,Managed Medicaid,,39.04,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Carolina Complete Health,Managed Medicaid,,16.62,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Carolina Complete Health,Managed Medicaid,,2.20,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Carolina Complete Health,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Carolina Complete Health,Managed Medicaid,,27.03,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Carolina Complete Health,Managed Medicaid,,21.62,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Carolina Complete Health,Managed Medicaid,,158.96,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Carolina Complete Health,Managed Medicaid,,89.49,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Carolina Complete Health,Managed Medicaid,,53.25,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Carolina Complete Health,Managed Medicaid,,114.11,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Carolina Complete Health,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Carolina Complete Health,Managed Medicaid,,59.26,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Carolina Complete Health,Managed Medicaid,,72.27,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Carolina Complete Health,Managed Medicaid,,46.65,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Carolina Complete Health,Managed Medicaid,,29.03,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Carolina Complete Health,Managed Medicaid,,24.62,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Carolina Complete Health,Managed Medicaid,,26.83,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Carolina Complete Health,Managed Medicaid,,39.24,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Carolina Complete Health,Managed Medicaid,,34.63,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Carolina Complete Health,Managed Medicaid,,100.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Carolina Complete Health,Managed Medicaid,,147.55,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Carolina Complete Health,Managed Medicaid,,25.23,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Carolina Complete Health,Managed Medicaid,,27.83,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Carolina Complete Health,Managed Medicaid,,30.03,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Carolina Complete Health,Managed Medicaid,,18.62,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Carolina Complete Health,Managed Medicaid,,32.43,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Carolina Complete Health,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Carolina Complete Health,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Carolina Complete Health,Managed Medicaid,,64.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Carolina Complete Health,Managed Medicaid,,55.05,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Carolina Complete Health,Managed Medicaid,,58.26,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Carolina Complete Health,Managed Medicaid,,52.85,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Carolina Complete Health,Managed Medicaid,,122.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Carolina Complete Health,Managed Medicaid,,32.23,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Carolina Complete Health,Managed Medicaid,,47.45,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Carolina Complete Health,Managed Medicaid,,39.84,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Carolina Complete Health,Managed Medicaid,,19.82,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Carolina Complete Health,Managed Medicaid,,65.06,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Carolina Complete Health,Managed Medicaid,,54.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Carolina Complete Health,Managed Medicaid,,64.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Carolina Complete Health,Managed Medicaid,,50.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Carolina Complete Health,Managed Medicaid,,36.44,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Carolina Complete Health,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Carolina Complete Health,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Carolina Complete Health,Managed Medicaid,,49.45,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Carolina Complete Health,Managed Medicaid,,8.81,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Carolina Complete Health,Managed Medicaid,,30.03,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Carolina Complete Health,Managed Medicaid,,39.24,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Carolina Complete Health,Managed Medicaid,,93.69,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Carolina Complete Health,Managed Medicaid,,56.66,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Carolina Complete Health,Managed Medicaid,,7.01,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Carolina Complete Health,Managed Medicaid,,14.41,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Carolina Complete Health,Managed Medicaid,,22.62,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Carolina Complete Health,Managed Medicaid,,71.27,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Carolina Complete Health,Managed Medicaid,,29.23,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Carolina Complete Health,Managed Medicaid,,40.44,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Carolina Complete Health,Managed Medicaid,,28.63,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Carolina Complete Health,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Carolina Complete Health,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Carolina Complete Health,Managed Medicaid,,20.42,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Carolina Complete Health,Managed Medicaid,,17.02,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Carolina Complete Health,Managed Medicaid,,19.62,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Carolina Complete Health,Managed Medicaid,,44.84,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Carolina Complete Health,Managed Medicaid,,7.81,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Carolina Complete Health,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Carolina Complete Health,Managed Medicaid,,9.41,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Carolina Complete Health,Managed Medicaid,,3.00,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Carolina Complete Health,Managed Medicaid,,8.21,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Carolina Complete Health,Managed Medicaid,,37.64,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Carolina Complete Health,Managed Medicaid,,24.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Carolina Complete Health,Managed Medicaid,,26.03,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Carolina Complete Health,Managed Medicaid,,14.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Carolina Complete Health,Managed Medicaid,,31.43,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Carolina Complete Health,Managed Medicaid,,5.41,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Carolina Complete Health,Managed Medicaid,,10.61,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Carolina Complete Health,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Carolina Complete Health,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Carolina Complete Health,Managed Medicaid,,19.42,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Carolina Complete Health,Managed Medicaid,,42.64,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Carolina Complete Health,Managed Medicaid,,40.84,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Carolina Complete Health,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Carolina Complete Health,Managed Medicaid,,40.84,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Carolina Complete Health,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,,14.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Carolina Complete Health,Managed Medicaid,,29.03,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Carolina Complete Health,Managed Medicaid,,18.42,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Carolina Complete Health,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Carolina Complete Health,Managed Medicaid,,5.21,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,,25.83,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Carolina Complete Health,Managed Medicaid,,23.22,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Carolina Complete Health,Managed Medicaid,,15.82,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Carolina Complete Health,Managed Medicaid,,67.87,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Carolina Complete Health,Managed Medicaid,,13.61,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,,17.82,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Carolina Complete Health,Managed Medicaid,,3.20,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Carolina Complete Health,Managed Medicaid,,49.05,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Carolina Complete Health,Managed Medicaid,,30.83,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Carolina Complete Health,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Carolina Complete Health,Managed Medicaid,,19.82,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Carolina Complete Health,Managed Medicaid,,15.62,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Carolina Complete Health,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Carolina Complete Health,Managed Medicaid,,11.41,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Carolina Complete Health,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Carolina Complete Health,Managed Medicaid,,12.61,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Carolina Complete Health,Managed Medicaid,,36.04,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Carolina Complete Health,Managed Medicaid,,6.61,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Carolina Complete Health,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Carolina Complete Health,Managed Medicaid,,45.65,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Carolina Complete Health,Managed Medicaid,,33.83,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Carolina Complete Health,Managed Medicaid,,92.29,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Carolina Complete Health,Managed Medicaid,,42.64,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Carolina Complete Health,Managed Medicaid,,42.64,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Carolina Complete Health,Managed Medicaid,,125.93,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Carolina Complete Health,Managed Medicaid,,116.32,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Carolina Complete Health,Managed Medicaid,,34.83,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Carolina Complete Health,Managed Medicaid,,32.23,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Carolina Complete Health,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Carolina Complete Health,Managed Medicaid,,42.44,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Carolina Complete Health,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Carolina Complete Health,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Carolina Complete Health,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Carolina Complete Health,Managed Medicaid,,51.45,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Carolina Complete Health,Managed Medicaid,,154.15,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Carolina Complete Health,Managed Medicaid,,17.42,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Carolina Complete Health,Managed Medicaid,,16.62,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Carolina Complete Health,Managed Medicaid,,9.61,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Carolina Complete Health,Managed Medicaid,,22.42,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Carolina Complete Health,Managed Medicaid,,115.92,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Carolina Complete Health,Managed Medicaid,,55.86,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Carolina Complete Health,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Carolina Complete Health,Managed Medicaid,,30.83,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Carolina Complete Health,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Carolina Complete Health,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Carolina Complete Health,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Carolina Complete Health,Managed Medicaid,,92.69,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Carolina Complete Health,Managed Medicaid,,58.86,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Carolina Complete Health,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Carolina Complete Health,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Carolina Complete Health,Managed Medicaid,,25.23,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Carolina Complete Health,Managed Medicaid,,2.40,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Carolina Complete Health,Managed Medicaid,,30.03,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Carolina Complete Health,Managed Medicaid,,24.02,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Carolina Complete Health,Managed Medicaid,,109.71,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Carolina Complete Health,Managed Medicaid,,61.86,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Carolina Complete Health,Managed Medicaid,,25.43,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Carolina Complete Health,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Carolina Complete Health,Managed Medicaid,,4.40,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Carolina Complete Health,Managed Medicaid,,46.05,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Carolina Complete Health,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Carolina Complete Health,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Carolina Complete Health,Managed Medicaid,,11.61,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Carolina Complete Health,Managed Medicaid,,7.01,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Carolina Complete Health,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Carolina Complete Health,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Carolina Complete Health,Managed Medicaid,,12.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Carolina Complete Health,Managed Medicaid,,12.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Carolina Complete Health,Managed Medicaid,,9.21,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Carolina Complete Health,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Carolina Complete Health,Managed Medicaid,,14.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Carolina Complete Health,Managed Medicaid,,3.00,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Carolina Complete Health,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Carolina Complete Health,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Carolina Complete Health,Managed Medicaid,,26.83,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Carolina Complete Health,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Carolina Complete Health,Managed Medicaid,,5.21,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Carolina Complete Health,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Carolina Complete Health,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Carolina Complete Health,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Carolina Complete Health,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Carolina Complete Health,Managed Medicaid,,0.40040,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Carolina Complete Health,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Carolina Complete Health,Managed Medicaid,,16.22,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Carolina Complete Health,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Carolina Complete Health,Managed Medicaid,,32.23,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Carolina Complete Health,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Carolina Complete Health,Managed Medicaid,,28.23,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Carolina Complete Health,Managed Medicaid,,6.81,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Carolina Complete Health,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Carolina Complete Health,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Carolina Complete Health,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Carolina Complete Health,Managed Medicaid,,7.01,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Carolina Complete Health,Managed Medicaid,,15.02,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Carolina Complete Health,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Carolina Complete Health,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Carolina Complete Health,Managed Medicaid,,153.55,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Carolina Complete Health,Managed Medicaid,,26.83,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Carolina Complete Health,Managed Medicaid,,361.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Carolina Complete Health,Managed Medicaid,,251.85,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Carolina Complete Health,Managed Medicaid,,58.66,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Carolina Complete Health,Managed Medicaid,,23.22,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Carolina Complete Health,Managed Medicaid,,386.59,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Carolina Complete Health,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Carolina Complete Health,Managed Medicaid,,51.85,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Carolina Complete Health,Managed Medicaid,,9.21,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Carolina Complete Health,Managed Medicaid,,361.96,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Carolina Complete Health,Managed Medicaid,,141.54,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Carolina Complete Health,Managed Medicaid,,102.70,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Carolina Complete Health,Managed Medicaid,,37.84,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Carolina Complete Health,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Carolina Complete Health,Managed Medicaid,,22.82,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Carolina Complete Health,Managed Medicaid,,64.86,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Carolina Complete Health,Managed Medicaid,,38.84,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Carolina Complete Health,Managed Medicaid,,190.79,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Carolina Complete Health,Managed Medicaid,,127.93,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Carolina Complete Health,Managed Medicaid,,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Carolina Complete Health,Managed Medicaid,QW,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Carolina Complete Health,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Carolina Complete Health,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Carolina Complete Health,Managed Medicaid,,318.12,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Carolina Complete Health,Managed Medicaid,,237.64,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Carolina Complete Health,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Carolina Complete Health,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Carolina Complete Health,Managed Medicaid,,95.70,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Carolina Complete Health,Managed Medicaid,,40.84,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Carolina Complete Health,Managed Medicaid,,85.29,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Carolina Complete Health,Managed Medicaid,,10.01,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,QW,20.02,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Carolina Complete Health,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Carolina Complete Health,Managed Medicaid,,32.63,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Carolina Complete Health,Managed Medicaid,,181.58,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Carolina Complete Health,Managed Medicaid,,55.05,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Carolina Complete Health,Managed Medicaid,,26.43,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,,33.03,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Carolina Complete Health,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Carolina Complete Health,Managed Medicaid,,8.61,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Carolina Complete Health,Managed Medicaid,,56.06,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Carolina Complete Health,Managed Medicaid,,15.82,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Carolina Complete Health,Managed Medicaid,,38.84,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Carolina Complete Health,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Carolina Complete Health,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Carolina Complete Health,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Carolina Complete Health,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Carolina Complete Health,Managed Medicaid,,42.64,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Carolina Complete Health,Managed Medicaid,,43.84,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Carolina Complete Health,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Carolina Complete Health,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Carolina Complete Health,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Carolina Complete Health,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Carolina Complete Health,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Carolina Complete Health,Managed Medicaid,,15.22,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Carolina Complete Health,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Carolina Complete Health,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Carolina Complete Health,Managed Medicaid,,20.22,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Carolina Complete Health,Managed Medicaid,,29.83,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Carolina Complete Health,Managed Medicaid,,265.87,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Carolina Complete Health,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Carolina Complete Health,Managed Medicaid,,21.62,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Carolina Complete Health,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Carolina Complete Health,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Carolina Complete Health,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Carolina Complete Health,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Carolina Complete Health,Managed Medicaid,,33.43,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Carolina Complete Health,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Carolina Complete Health,Managed Medicaid,,63.86,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Carolina Complete Health,Managed Medicaid,,103.10,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Carolina Complete Health,Managed Medicaid,,105.31,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Carolina Complete Health,Managed Medicaid,,42.04,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Carolina Complete Health,Managed Medicaid,,5.41,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Carolina Complete Health,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Carolina Complete Health,Managed Medicaid,,37.24,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Carolina Complete Health,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Carolina Complete Health,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Carolina Complete Health,Managed Medicaid,,7.81,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Carolina Complete Health,Managed Medicaid,,39.64,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Carolina Complete Health,Managed Medicaid,,23.82,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Carolina Complete Health,Managed Medicaid,,51.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Carolina Complete Health,Managed Medicaid,,52.25,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Carolina Complete Health,Managed Medicaid,,15.62,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Carolina Complete Health,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Carolina Complete Health,Managed Medicaid,,41.84,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Carolina Complete Health,Managed Medicaid,,41.44,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Carolina Complete Health,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Carolina Complete Health,Managed Medicaid,,29.63,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Carolina Complete Health,Managed Medicaid,,91.29,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Carolina Complete Health,Managed Medicaid,,119.52,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Carolina Complete Health,Managed Medicaid,,151.15,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Carolina Complete Health,Managed Medicaid,,112.31,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Carolina Complete Health,Managed Medicaid,,65.06,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Carolina Complete Health,Managed Medicaid,,45.05,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Carolina Complete Health,Managed Medicaid,,204.00,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Carolina Complete Health,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Carolina Complete Health,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Carolina Complete Health,Managed Medicaid,,44.84,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Carolina Complete Health,Managed Medicaid,,26.43,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Carolina Complete Health,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Carolina Complete Health,Managed Medicaid,,109.71,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Carolina Complete Health,Managed Medicaid,,20.42,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Carolina Complete Health,Managed Medicaid,,35.03,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Carolina Complete Health,Managed Medicaid,,73.47,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Carolina Complete Health,Managed Medicaid,,132.13,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Carolina Complete Health,Managed Medicaid,,0.00200,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Carolina Complete Health,Managed Medicaid,,24.82,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Carolina Complete Health,Managed Medicaid,,45.25,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Carolina Complete Health,Managed Medicaid,,74.07,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Carolina Complete Health,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Carolina Complete Health,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Carolina Complete Health,Managed Medicaid,,118.72,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Carolina Complete Health,Managed Medicaid,,109.71,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Carolina Complete Health,Managed Medicaid,,19.42,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Carolina Complete Health,Managed Medicaid,,78.88,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Carolina Complete Health,Managed Medicaid,,62.66,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Carolina Complete Health,Managed Medicaid,,49.85,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Carolina Complete Health,Managed Medicaid,,15.42,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Carolina Complete Health,Managed Medicaid,,76.88,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Carolina Complete Health,Managed Medicaid,,26.43,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Carolina Complete Health,Managed Medicaid,,135.13,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Carolina Complete Health,Managed Medicaid,,37.84,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Carolina Complete Health,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Carolina Complete Health,Managed Medicaid,,51.25,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Carolina Complete Health,Managed Medicaid,,52.25,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Carolina Complete Health,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Carolina Complete Health,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Carolina Complete Health,Managed Medicaid,,107.91,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Carolina Complete Health,Managed Medicaid,,27.83,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Carolina Complete Health,Managed Medicaid,,32.83,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Carolina Complete Health,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Carolina Complete Health,Managed Medicaid,,82.88,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Carolina Complete Health,Managed Medicaid,,49.45,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Carolina Complete Health,Managed Medicaid,,438.64,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Carolina Complete Health,Managed Medicaid,,70.67,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Carolina Complete Health,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Carolina Complete Health,Managed Medicaid,,141.74,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Carolina Complete Health,Managed Medicaid,,103.70,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Carolina Complete Health,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Carolina Complete Health,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Carolina Complete Health,Managed Medicaid,,103.90,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Carolina Complete Health,Managed Medicaid,,257.26,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Carolina Complete Health,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Carolina Complete Health,Managed Medicaid,,62.46,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Carolina Complete Health,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Carolina Complete Health,Managed Medicaid,,248.85,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Carolina Complete Health,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Carolina Complete Health,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Carolina Complete Health,Managed Medicaid,,181.78,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Carolina Complete Health,Managed Medicaid,,132.13,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Carolina Complete Health,Managed Medicaid,,94.89,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Carolina Complete Health,Managed Medicaid,,71.27,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Carolina Complete Health,Managed Medicaid,,25.02,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Carolina Complete Health,Managed Medicaid,,30.03,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Carolina Complete Health,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Carolina Complete Health,Managed Medicaid,,33.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Carolina Complete Health,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Carolina Complete Health,Managed Medicaid,,31.83,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Carolina Complete Health,Managed Medicaid,,318.12,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Carolina Complete Health,Managed Medicaid,,159.76,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Carolina Complete Health,Managed Medicaid,,65.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Carolina Complete Health,Managed Medicaid,,13.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Carolina Complete Health,Managed Medicaid,,8.41,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Carolina Complete Health,Managed Medicaid,,21.02,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Carolina Complete Health,Managed Medicaid,,49.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Carolina Complete Health,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Carolina Complete Health,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Carolina Complete Health,Managed Medicaid,,55.46,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Carolina Complete Health,Managed Medicaid,,113.31,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Carolina Complete Health,Managed Medicaid,,11.41,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Carolina Complete Health,Managed Medicaid,,135.94,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Carolina Complete Health,Managed Medicaid,,130.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Carolina Complete Health,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Carolina Complete Health,Managed Medicaid,,214.21,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Carolina Complete Health,Managed Medicaid,,43.04,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Carolina Complete Health,Managed Medicaid,,83.88,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Carolina Complete Health,Managed Medicaid,,58.86,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Carolina Complete Health,Managed Medicaid,,189.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Carolina Complete Health,Managed Medicaid,,248.25,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Carolina Complete Health,Managed Medicaid,,120.12,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Carolina Complete Health,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Carolina Complete Health,Managed Medicaid,,305.91,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Carolina Complete Health,Managed Medicaid,,5.61,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Carolina Complete Health,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Carolina Complete Health,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Carolina Complete Health,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Carolina Complete Health,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Carolina Complete Health,Managed Medicaid,,232.23,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Carolina Complete Health,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Carolina Complete Health,Managed Medicaid,,523.72,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Carolina Complete Health,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Carolina Complete Health,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Carolina Complete Health,Managed Medicaid,,1715.71,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Carolina Complete Health,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Carolina Complete Health,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Carolina Complete Health,Managed Medicaid,,7102.50,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Carolina Complete Health,Managed Medicaid,,1203.60,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Carolina Complete Health,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Carolina Complete Health,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Carolina Complete Health,Managed Medicaid,,1344.34,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Carolina Complete Health,Managed Medicaid,,409.01,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Carolina Complete Health,Managed Medicaid,,674.27,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Carolina Complete Health,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Carolina Complete Health,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Carolina Complete Health,Managed Medicaid,,396.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Carolina Complete Health,Managed Medicaid,,396.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Carolina Complete Health,Managed Medicaid,,834.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Carolina Complete Health,Managed Medicaid,,834.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Carolina Complete Health,Managed Medicaid,,379.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Carolina Complete Health,Managed Medicaid,,379.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Carolina Complete Health,Managed Medicaid,,89.49,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Carolina Complete Health,Managed Medicaid,,164.76,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Carolina Complete Health,Managed Medicaid,,359.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Carolina Complete Health,Managed Medicaid,,359.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Carolina Complete Health,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Carolina Complete Health,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Carolina Complete Health,Managed Medicaid,,317.52,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Carolina Complete Health,Managed Medicaid,,317.52,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Carolina Complete Health,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Carolina Complete Health,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Carolina Complete Health,Managed Medicaid,,1544.94,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Carolina Complete Health,Managed Medicaid,,772.37,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Carolina Complete Health,Managed Medicaid,,772.37,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Carolina Complete Health,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Carolina Complete Health,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Carolina Complete Health,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Carolina Complete Health,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Carolina Complete Health,Managed Medicaid,,275.88,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Carolina Complete Health,Managed Medicaid,,275.88,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Carolina Complete Health,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Carolina Complete Health,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Carolina Complete Health,Managed Medicaid,,532.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Carolina Complete Health,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Carolina Complete Health,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Carolina Complete Health,Managed Medicaid,,158.96,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Carolina Complete Health,Managed Medicaid,,5817.21,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Carolina Complete Health,Managed Medicaid,,879.68,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Carolina Complete Health,Managed Medicaid,,879.68,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Carolina Complete Health,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Carolina Complete Health,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Carolina Complete Health,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Carolina Complete Health,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Carolina Complete Health,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Carolina Complete Health,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Carolina Complete Health,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Carolina Complete Health,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Carolina Complete Health,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Carolina Complete Health,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Carolina Complete Health,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Carolina Complete Health,Managed Medicaid,,4633.03,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Carolina Complete Health,Managed Medicaid,,4633.03,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Carolina Complete Health,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Carolina Complete Health,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Carolina Complete Health,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Carolina Complete Health,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Carolina Complete Health,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Carolina Complete Health,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Carolina Complete Health,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Carolina Complete Health,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Carolina Complete Health,Managed Medicaid,,2468.07,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Carolina Complete Health,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Carolina Complete Health,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Carolina Complete Health,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Carolina Complete Health,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Carolina Complete Health,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Carolina Complete Health,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Carolina Complete Health,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Carolina Complete Health,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Carolina Complete Health,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Carolina Complete Health,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Carolina Complete Health,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Carolina Complete Health,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Carolina Complete Health,Managed Medicaid,,4121.72,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Carolina Complete Health,Managed Medicaid,LM,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Carolina Complete Health,Managed Medicaid,RI,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Carolina Complete Health,Managed Medicaid,RC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Carolina Complete Health,Managed Medicaid,LD,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Carolina Complete Health,Managed Medicaid,LC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Carolina Complete Health,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Carolina Complete Health,Managed Medicaid,RI,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Carolina Complete Health,Managed Medicaid,RC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Carolina Complete Health,Managed Medicaid,LD,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Carolina Complete Health,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Carolina Complete Health,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Carolina Complete Health,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,LM,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,RI,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Carolina Complete Health,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LM,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,RI,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Carolina Complete Health,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Carolina Complete Health,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Carolina Complete Health,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Carolina Complete Health,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Carolina Complete Health,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Carolina Complete Health,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LM,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,RI,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,RC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LD,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Carolina Complete Health,Managed Medicaid,LC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Carolina Complete Health,Managed Medicaid,,78.68,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Carolina Complete Health,Managed Medicaid,,333.13,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Carolina Complete Health,Managed Medicaid,,373.37,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Carolina Complete Health,Managed Medicaid,,84.48,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Carolina Complete Health,Managed Medicaid,,505.91,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Carolina Complete Health,Managed Medicaid,,197.40,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Carolina Complete Health,Managed Medicaid,,2316.71,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Carolina Complete Health,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Carolina Complete Health,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Carolina Complete Health,Managed Medicaid,,2044.04,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Carolina Complete Health,Managed Medicaid,,850.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Carolina Complete Health,Managed Medicaid,,1474.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Carolina Complete Health,Managed Medicaid,,2180.78,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Carolina Complete Health,Managed Medicaid,,1936.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Carolina Complete Health,Managed Medicaid,,2067.27,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Carolina Complete Health,Managed Medicaid,,909.51,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Carolina Complete Health,Managed Medicaid,,2126.92,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Carolina Complete Health,Managed Medicaid,,2652.85,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Carolina Complete Health,Managed Medicaid,,2389.79,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Carolina Complete Health,Managed Medicaid,,2549.35,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Carolina Complete Health,Managed Medicaid,,2592.59,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Carolina Complete Health,Managed Medicaid,,3178.58,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Carolina Complete Health,Managed Medicaid,,1356.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Carolina Complete Health,Managed Medicaid,,40.64,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Carolina Complete Health,Managed Medicaid,,19.42,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Carolina Complete Health,Managed Medicaid,,300.90,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Carolina Complete Health,Managed Medicaid,,826.43,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Carolina Complete Health,Managed Medicaid,,1614.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Carolina Complete Health,Managed Medicaid,,96.90,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Carolina Complete Health,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Carolina Complete Health,Managed Medicaid,,43.04,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Carolina Complete Health,Managed Medicaid,,1535.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Carolina Complete Health,Managed Medicaid,,7834.43,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Carolina Complete Health,Managed Medicaid,,2458.86,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Carolina Complete Health,Managed Medicaid,,505.50,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Carolina Complete Health,Managed Medicaid,,565.36,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Carolina Complete Health,Managed Medicaid,,253.45,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Carolina Complete Health,Managed Medicaid,,105.71,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Carolina Complete Health,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Carolina Complete Health,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Carolina Complete Health,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Carolina Complete Health,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Carolina Complete Health,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Carolina Complete Health,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Carolina Complete Health,Managed Medicaid,,3657.05,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Carolina Complete Health,Managed Medicaid,,2656.25,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Carolina Complete Health,Managed Medicaid,,3018.42,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Carolina Complete Health,Managed Medicaid,,3642.44,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Carolina Complete Health,Managed Medicaid,,639.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Carolina Complete Health,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Carolina Complete Health,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Carolina Complete Health,Managed Medicaid,,2045.04,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Carolina Complete Health,Managed Medicaid,,589.39,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Carolina Complete Health,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Carolina Complete Health,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Carolina Complete Health,Managed Medicaid,,4082.48,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Carolina Complete Health,Managed Medicaid,,2987.99,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Carolina Complete Health,Managed Medicaid,,473.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Carolina Complete Health,Managed Medicaid,,4761.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Carolina Complete Health,Managed Medicaid,,4909.10,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Carolina Complete Health,Managed Medicaid,,5350.95,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Carolina Complete Health,Managed Medicaid,,1703.30,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Carolina Complete Health,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Carolina Complete Health,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Carolina Complete Health,Managed Medicaid,,9987.38,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Carolina Complete Health,Managed Medicaid,,1151.15,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Carolina Complete Health,Managed Medicaid,,764.96,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Carolina Complete Health,Managed Medicaid,,11551.14,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Carolina Complete Health,Managed Medicaid,,528.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Carolina Complete Health,Managed Medicaid,,2335.73,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Carolina Complete Health,Managed Medicaid,,417.62,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Carolina Complete Health,Managed Medicaid,,838.44,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Carolina Complete Health,Managed Medicaid,,1297.30,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Carolina Complete Health,Managed Medicaid,,1297.30,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Carolina Complete Health,Managed Medicaid,,647.05,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Carolina Complete Health,Managed Medicaid,,459.46,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Carolina Complete Health,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Carolina Complete Health,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Carolina Complete Health,Managed Medicaid,,609.21,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Carolina Complete Health,Managed Medicaid,,557.96,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Carolina Complete Health,Managed Medicaid,,1917.92,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Carolina Complete Health,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Carolina Complete Health,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Carolina Complete Health,Managed Medicaid,,325.12,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Carolina Complete Health,Managed Medicaid,,1618.42,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Carolina Complete Health,Managed Medicaid,,331.93,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Carolina Complete Health,Managed Medicaid,,631.83,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Carolina Complete Health,Managed Medicaid,,5093.49,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Carolina Complete Health,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Carolina Complete Health,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Carolina Complete Health,Managed Medicaid,,605.61,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Carolina Complete Health,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Carolina Complete Health,Managed Medicaid,,4031.43,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Carolina Complete Health,Managed Medicaid,,4480.68,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Carolina Complete Health,Managed Medicaid,,496.90,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Carolina Complete Health,Managed Medicaid,,386.59,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Carolina Complete Health,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Carolina Complete Health,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Carolina Complete Health,Managed Medicaid,,1276.68,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Carolina Complete Health,Managed Medicaid,,515.51,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Carolina Complete Health,Managed Medicaid,,2746.94,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Carolina Complete Health,Managed Medicaid,,960.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Carolina Complete Health,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Carolina Complete Health,Managed Medicaid,,425.83,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Carolina Complete Health,Managed Medicaid,,567.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Carolina Complete Health,Managed Medicaid,,1594.59,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Carolina Complete Health,Managed Medicaid,,3708.10,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Carolina Complete Health,Managed Medicaid,,1846.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Carolina Complete Health,Managed Medicaid,,1294.69,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Carolina Complete Health,Managed Medicaid,,1496.70,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Carolina Complete Health,Managed Medicaid,,57.66,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Carolina Complete Health,Managed Medicaid,,283.88,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Carolina Complete Health,Managed Medicaid,,1595.59,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Carolina Complete Health,Managed Medicaid,,608.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Carolina Complete Health,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Carolina Complete Health,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Carolina Complete Health,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Carolina Complete Health,Managed Medicaid,,2662.86,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Carolina Complete Health,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Carolina Complete Health,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Carolina Complete Health,Managed Medicaid,,8574.37,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Carolina Complete Health,Managed Medicaid,,6999.39,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Carolina Complete Health,Managed Medicaid,,1897.10,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Carolina Complete Health,Managed Medicaid,,869.87,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Carolina Complete Health,Managed Medicaid,,4285.48,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Carolina Complete Health,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Carolina Complete Health,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Carolina Complete Health,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Carolina Complete Health,Managed Medicaid,,6481.07,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Carolina Complete Health,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Carolina Complete Health,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Carolina Complete Health,Managed Medicaid,,21.42,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Carolina Complete Health,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Carolina Complete Health,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Carolina Complete Health,Managed Medicaid,,9598.39,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Carolina Complete Health,Managed Medicaid,,480.28,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Carolina Complete Health,Managed Medicaid,,1300.10,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Carolina Complete Health,Managed Medicaid,,2169.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Carolina Complete Health,Managed Medicaid,LD,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Carolina Complete Health,Managed Medicaid,RC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Carolina Complete Health,Managed Medicaid,RI,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Carolina Complete Health,Managed Medicaid,LM,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Carolina Complete Health,Managed Medicaid,LD,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Carolina Complete Health,Managed Medicaid,RC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Carolina Complete Health,Managed Medicaid,RI,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Carolina Complete Health,Managed Medicaid,LM,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Carolina Complete Health,Managed Medicaid,LD,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Carolina Complete Health,Managed Medicaid,RC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Carolina Complete Health,Managed Medicaid,RI,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Carolina Complete Health,Managed Medicaid,LM,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,LD,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,RC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,RI,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,LM,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Carolina Complete Health,Managed Medicaid,LC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Carolina Complete Health,Managed Medicaid,LC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Carolina Complete Health,Managed Medicaid,LC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Carolina Complete Health,Managed Medicaid,LC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Carolina Complete Health,Managed Medicaid,,6528.72,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Carolina Complete Health,Managed Medicaid,,12359.75,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Carolina Complete Health,Managed Medicaid,,2282.88,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Carolina Complete Health,Managed Medicaid,,570.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Carolina Complete Health,Managed Medicaid,,115.11,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Carolina Complete Health,Managed Medicaid,,805.00,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Carolina Complete Health,Managed Medicaid,,661.46,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Carolina Complete Health,Managed Medicaid,,258.26,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Carolina Complete Health,Managed Medicaid,,312.91,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Carolina Complete Health,Managed Medicaid,,231.63,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Carolina Complete Health,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Carolina Complete Health,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Carolina Complete Health,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Carolina Complete Health,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Carolina Complete Health,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Carolina Complete Health,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Carolina Complete Health,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Carolina Complete Health,Managed Medicaid,,99.30,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Carolina Complete Health,Managed Medicaid,,77.08,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Carolina Complete Health,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Carolina Complete Health,Managed Medicaid,,11.01,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Carolina Complete Health,Managed Medicaid,,273.87,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Carolina Complete Health,Managed Medicaid,,48.65,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Carolina Complete Health,Managed Medicaid,,175.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Carolina Complete Health,Managed Medicaid,,124.52,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Carolina Complete Health,Managed Medicaid,,32.43,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Carolina Complete Health,Managed Medicaid,,38.64,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Carolina Complete Health,Managed Medicaid,,255.46,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Carolina Complete Health,Managed Medicaid,,57.06,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Carolina Complete Health,Managed Medicaid,,43.64,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Carolina Complete Health,Managed Medicaid,,59.46,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Carolina Complete Health,Managed Medicaid,,21.82,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Carolina Complete Health,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Carolina Complete Health,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Carolina Complete Health,Managed Medicaid,,1301.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Carolina Complete Health,Managed Medicaid,,725.52,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Carolina Complete Health,Managed Medicaid,,1598.40,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Carolina Complete Health,Managed Medicaid,,521.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Carolina Complete Health,Managed Medicaid,,422.62,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Carolina Complete Health,Managed Medicaid,,422.62,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Carolina Complete Health,Managed Medicaid,,422.62,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Carolina Complete Health,Managed Medicaid,,1276.28,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Carolina Complete Health,Managed Medicaid,,1690.29,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Carolina Complete Health,Managed Medicaid,,1897.30,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Carolina Complete Health,Managed Medicaid,,1567.77,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Carolina Complete Health,Managed Medicaid,,2031.83,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Carolina Complete Health,Managed Medicaid,,2263.86,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Carolina Complete Health,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Carolina Complete Health,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Carolina Complete Health,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Carolina Complete Health,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Carolina Complete Health,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Carolina Complete Health,Managed Medicaid,,48.05,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Carolina Complete Health,Managed Medicaid,,74.87,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Carolina Complete Health,Managed Medicaid,,264.26,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Carolina Complete Health,Managed Medicaid,,285.29,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Carolina Complete Health,Managed Medicaid,,446.85,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Carolina Complete Health,Managed Medicaid,,58.66,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Carolina Complete Health,Managed Medicaid,,134.53,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Carolina Complete Health,Managed Medicaid,,20.82,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Carolina Complete Health,Managed Medicaid,,203.40,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Carolina Complete Health,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Carolina Complete Health,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Carolina Complete Health,Managed Medicaid,,38.44,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Carolina Complete Health,Managed Medicaid,,633.03,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Carolina Complete Health,Managed Medicaid,,60.46,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Carolina Complete Health,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Carolina Complete Health,Managed Medicaid,,61.86,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Carolina Complete Health,Managed Medicaid,,57.06,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Carolina Complete Health,Managed Medicaid,,68.27,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Carolina Complete Health,Managed Medicaid,,86.49,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Carolina Complete Health,Managed Medicaid,,123.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Carolina Complete Health,Managed Medicaid,,8.81,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Carolina Complete Health,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Carolina Complete Health,Managed Medicaid,,14.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Carolina Complete Health,Managed Medicaid,,44.24,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Carolina Complete Health,Managed Medicaid,,80.48,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Carolina Complete Health,Managed Medicaid,,178.18,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Carolina Complete Health,Managed Medicaid,,14.81,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Carolina Complete Health,Managed Medicaid,,10.81,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Carolina Complete Health,Managed Medicaid,,53.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Carolina Complete Health,Managed Medicaid,,8.01,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Carolina Complete Health,Managed Medicaid,,150.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Carolina Complete Health,Managed Medicaid,,235.24,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Carolina Complete Health,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Carolina Complete Health,Managed Medicaid,,245.04,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Carolina Complete Health,Managed Medicaid,,359.16,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Carolina Complete Health,Managed Medicaid,,454.25,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Carolina Complete Health,Managed Medicaid,,98.50,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Carolina Complete Health,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Carolina Complete Health,Managed Medicaid,,140.14,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Carolina Complete Health,Managed Medicaid,,156.16,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Carolina Complete Health,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Carolina Complete Health,Managed Medicaid,,319.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Carolina Complete Health,Managed Medicaid,,514.31,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Carolina Complete Health,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Carolina Complete Health,Managed Medicaid,,800.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Carolina Complete Health,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Carolina Complete Health,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Carolina Complete Health,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Carolina Complete Health,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Carolina Complete Health,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Carolina Complete Health,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Carolina Complete Health,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Carolina Complete Health,Managed Medicaid,GP,47.65,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Carolina Complete Health,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Carolina Complete Health,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Carolina Complete Health,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Carolina Complete Health,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Carolina Complete Health,Managed Medicaid,,2600.00,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Carolina Complete Health,Managed Medicaid,,2657.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Carolina Complete Health,Managed Medicaid,,2714.71,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Carolina Complete Health,Managed Medicaid,,2772.37,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Carolina Complete Health,Managed Medicaid,,2829.83,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Carolina Complete Health,Managed Medicaid,,2887.08,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Carolina Complete Health,Managed Medicaid,,2944.54,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Carolina Complete Health,Managed Medicaid,,3002.00,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Carolina Complete Health,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Carolina Complete Health,Managed Medicaid,,49.25,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Carolina Complete Health,Managed Medicaid,,40.04,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,360919.81,,,,,,,199000.36,360919.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,145942.25,,,,,,,80975.46,145942.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,273359.35,,,,,,,150928.76,397739.02,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,178392.18,,,,,,,98790.80,259561.38,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,132788.93,,,,,,,73754.16,132788.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,59719.92,,,,,,,33638.50,59719.92,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,166785.63,,,,,,,92418.69,166785.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,72181.64,,,,,,,40480.12,72181.64,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,39537.24,,,,,,,22680.42,56375.49,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,70243.35,,,,,,,39415.99,102204.38,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,54297.86,,,,,,,30661.75,79003.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37114.70,,,,,,,21228.00,54002.05,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,154778.53,,,,,,,85826.67,154778.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,76368.61,,,,,,,42778.80,76368.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,62312.47,,,,,,,35745.36,62312.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,556151.28,,,,,,,306184.44,556151.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,85351.71,,,,,,,48961.75,85351.71,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,101342.28,,,,,,,56489.61,147453.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,68178.85,,,,,,,38282.54,99200.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,39604.21,,,,,,,22718.84,57624.30,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,73800.53,,,,,,,41368.91,107380.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,50381.36,,,,,,,28511.54,73305.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,58556.95,,,,,,,33000.02,85200.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40043.39,,,,,,,22835.89,58263.30,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,32492.43,,,,,,,18639.19,47276.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,77380.90,,,,,,,43334.56,112589.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,43938.00,,,,,,,24974.06,63929.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28271.98,,,,,,,16218.14,41135.85,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,57704.36,,,,,,,32531.94,83960.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27445.15,,,,,,,15743.83,39932.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21416.49,,,,,,,12285.51,31161.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,49850.75,,,,,,,28220.24,72533.05,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30787.25,,,,,,,17661.01,44795.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25021.32,,,,,,,14353.41,36406.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,42398.96,,,,,,,24129.11,61690.66,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20897.47,,,,,,,11987.77,30405.90,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15139.26,,,,,,,8684.59,22027.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,49728.39,,,,,,,28153.06,72355.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28317.06,,,,,,,16244.00,41201.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22251.05,,,,,,,12764.25,32375.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22934.92,,,,,,,13156.55,33370.41,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12611.12,,,,,,,7234.33,18349.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19664.95,,,,,,,11280.74,28612.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13131.43,,,,,,,7532.80,19106.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29919.20,,,,,,,17163.06,43532.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16686.03,,,,,,,9571.89,24278.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22016.65,,,,,,,12629.79,32034.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15981.55,,,,,,,9167.77,23253.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11846.10,,,,,,,6795.48,17236.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35508.69,,,,,,,20346.30,51665.30,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22630.98,,,,,,,12982.19,32928.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18079.54,,,,,,,10371.27,26305.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25899.67,,,,,,,14857.27,37684.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13011.65,,,,,,,7464.10,18932.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8814.39,,,,,,,5056.35,12824.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18915.39,,,,,,,10850.76,27521.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11132.61,,,,,,,6386.19,16197.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10287.75,,,,,,,5901.53,14968.71,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21440.96,,,,,,,12299.54,31196.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13213.85,,,,,,,7580.09,19226.21,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9739.10,,,,,,,5586.81,14170.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20661.78,,,,,,,11852.57,30062.98,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13275.67,,,,,,,7615.55,19316.16,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24695.48,,,,,,,14166.49,35932.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9643.80,,,,,,,5532.13,14031.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23310.99,,,,,,,13372.28,33917.59,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11534.43,,,,,,,6616.69,16782.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29436.24,,,,,,,16886.01,42829.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17976.51,,,,,,,10312.17,26155.90,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12309.75,,,,,,,7061.45,17910.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29259.80,,,,,,,16784.80,42573.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16777.47,,,,,,,9624.35,24411.30,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11780.42,,,,,,,6757.80,17140.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17409.83,,,,,,,9987.10,25331.38,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14148.87,,,,,,,8116.46,20586.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10601.99,,,,,,,6081.80,15425.94,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22618.10,,,,,,,12974.81,32909.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13175.22,,,,,,,7557.92,19170.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10255.55,,,,,,,5883.06,14921.87,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45326.35,,,,,,,25736.28,65950.04,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,33217.52,,,,,,,19055.13,48331.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,33217.52,,,,,,,19055.13,48331.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,46516.37,,,,,,,26389.63,67681.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29556.02,,,,,,,16954.72,43004.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17546.35,,,,,,,10065.41,25530.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24944.05,,,,,,,14309.08,36293.70,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11624.59,,,,,,,6668.41,16913.82,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14436.07,,,,,,,8281.21,21004.55,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10770.71,,,,,,,6178.58,15671.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30279.82,,,,,,,17369.93,44057.26,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17425.29,,,,,,,9995.96,25353.87,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19767.98,,,,,,,11339.84,28762.49,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23286.52,,,,,,,13358.24,33881.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13972.43,,,,,,,8015.24,20329.94,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14982.14,,,,,,,8594.46,21799.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10120.32,,,,,,,5805.49,14725.11,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10285.17,,,,,,,5900.06,14964.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17040.20,,,,,,,9775.06,24793.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9888.50,,,,,,,5672.51,14387.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27241.66,,,,,,,15627.10,39636.73,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13076.05,,,,,,,7501.04,19025.71,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19230.92,,,,,,,11031.76,27981.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11413.37,,,,,,,6547.25,16606.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15565.56,,,,,,,8929.14,22647.96,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,54932.80,,,,,,,31010.33,79927.46,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28090.39,,,,,,,16113.97,40871.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20560.04,,,,,,,11794.20,29914.94,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,48252.46,,,,,,,27342.76,70207.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22318.02,,,,,,,12802.67,32472.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15484.42,,,,,,,8882.59,22529.90,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27269.99,,,,,,,15643.35,39677.96,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16375.65,,,,,,,9393.84,23826.64,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10265.85,,,,,,,5888.97,14936.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9679.86,,,,,,,5552.82,14084.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17148.39,,,,,,,9837.12,24950.98,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9453.19,,,,,,,5422.79,13754.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15225.55,,,,,,,8734.09,22153.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9507.28,,,,,,,5453.82,13833.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20136.32,,,,,,,11551.14,29298.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11803.60,,,,,,,6771.10,17174.29,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8900.68,,,,,,,5105.85,12950.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22110.67,,,,,,,12683.72,32171.12,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11717.31,,,,,,,6721.60,17048.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9124.77,,,,,,,5234.40,13276.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,57721.10,,,,,,,32541.14,83984.45,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,32506.60,,,,,,,18647.31,47297.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24652.98,,,,,,,14142.11,35870.19,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,48137.84,,,,,,,27279.81,70040.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23225.99,,,,,,,13323.52,33793.91,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17597.87,,,,,,,10094.96,25604.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,38333.06,,,,,,,21896.90,55774.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17690.59,,,,,,,10148.16,25739.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10367.59,,,,,,,5947.34,15084.90,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20126.01,,,,,,,11545.23,29283.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12569.90,,,,,,,7210.69,18289.26,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9723.65,,,,,,,5577.94,14147.94,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22744.31,,,,,,,13047.21,33093.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13793.41,,,,,,,7912.55,20069.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9581.98,,,,,,,5496.67,13941.82,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19703.58,,,,,,,11302.90,28668.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13704.54,,,,,,,7861.57,19940.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10129.33,,,,,,,5810.66,14738.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20071.92,,,,,,,11514.20,29204.73,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12738.62,,,,,,,7307.47,18534.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9236.82,,,,,,,5298.67,13439.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15910.72,,,,,,,9127.14,23150.16,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14266.07,,,,,,,8183.69,20757.19,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10857.00,,,,,,,6228.08,15796.98,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8268.32,,,,,,,4743.10,12030.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16928.16,,,,,,,9710.79,24630.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10379.19,,,,,,,5953.99,15101.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8094.45,,,,,,,4643.36,11777.46,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24305.25,,,,,,,13942.63,35364.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12223.46,,,,,,,7011.95,17785.18,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9223.94,,,,,,,5291.29,13420.87,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22719.84,,,,,,,13033.17,33057.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14157.88,,,,,,,8121.63,20599.78,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9209.77,,,,,,,5283.16,13400.26,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12508.08,,,,,,,7175.23,18199.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8628.93,,,,,,,4949.96,12555.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10398.50,,,,,,,5965.07,15129.87,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23581.45,,,,,,,13527.43,34311.11,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12120.43,,,,,,,6952.85,17635.27,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,82872.50,,,,,,,46349.51,120579.84,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35400.51,,,,,,,20286.88,51507.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,145774.83,,,,,,,80883.55,212102.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,140047.53,,,,,,,77739.20,203769.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,73499.17,,,,,,,41203.47,106941.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,128236.20,,,,,,,71254.67,186584.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,125992.68,,,,,,,70022.93,183319.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,84683.29,,,,,,,47343.65,123214.55,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,84683.29,,,,,,,47343.65,123214.55,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,98888.83,,,,,,,55142.64,143883.66,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,68681.13,,,,,,,38558.31,99931.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,64912.74,,,,,,,36489.42,94448.31,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,63717.56,,,,,,,35833.26,92709.33,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40562.41,,,,,,,23120.82,59018.48,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,108568.68,,,,,,,60456.99,157967.90,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,78080.23,,,,,,,43718.51,113607.06,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,98462.53,,,,,,,54908.59,143263.40,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,70354.11,,,,,,,39476.79,102365.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,75581.70,,,,,,,42346.80,109971.70,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,53947.56,,,,,,,30469.42,78493.92,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,63386.57,,,,,,,35651.54,92227.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,36711.59,,,,,,,21006.71,53415.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17829.69,,,,,,,10227.95,25942.27,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41120.07,,,,,,,23426.99,59829.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27443.86,,,,,,,15743.09,44147.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23278.79,,,,,,,13353.81,33870.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,58759.15,,,,,,,33111.02,85494.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28108.42,,,,,,,16124.31,40897.87,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19247.67,,,,,,,11041.37,28005.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,44925.82,,,,,,,25516.39,65367.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,33428.73,,,,,,,19176.29,48638.95,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22946.51,,,,,,,13163.20,33387.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,34739.81,,,,,,,19924.18,50546.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21867.25,,,,,,,12544.09,31816.95,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14066.44,,,,,,,8069.17,20466.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40467.11,,,,,,,23068.51,58879.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26042.63,,,,,,,14939.27,37892.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41892.81,,,,,,,22172.00,60954.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24347.75,,,,,,,13967.01,35426.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20991.48,,,,,,,12041.70,30542.70,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,39376.25,,,,,,,22469.61,57292.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,43023.59,,,,,,,24472.05,62599.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,46598.80,,,,,,,26434.87,67801.45,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,78927.66,,,,,,,44183.77,114840.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,61314.34,,,,,,,34513.86,89212.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,88580.47,,,,,,,49483.25,128884.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,54390.59,,,,,,,30712.64,79138.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,67953.47,,,,,,,38158.82,98872.59,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45801.59,,,,,,,25997.21,66641.51,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,32880.09,,,,,,,18861.56,47840.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,53132.31,,,,,,,30021.84,77307.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,42393.80,,,,,,,24126.28,61683.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,91832.42,,,,,,,51268.60,133616.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,77359.00,,,,,,,43322.54,112557.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,59481.66,,,,,,,33507.69,86546.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,71687.09,,,,,,,40208.61,104305.02,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,46446.83,,,,,,,26351.43,67580.33,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20659.20,,,,,,,11851.09,30059.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11837.09,,,,,,,6790.31,17223.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9312.80,,,,,,,5342.26,13550.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25510.72,,,,,,,14634.15,37118.21,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8914.84,,,,,,,5113.97,12971.14,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7713.23,,,,,,,4424.67,11222.79,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28498.65,,,,,,,16348.17,41465.66,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13781.82,,,,,,,7905.90,20052.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,34853.15,,,,,,,19986.40,50711.48,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21983.17,,,,,,,12610.58,31985.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11973.61,,,,,,,6868.62,17421.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16534.06,,,,,,,9484.71,24057.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10934.27,,,,,,,6272.41,15909.41,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7289.51,,,,,,,4181.61,10606.27,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20115.71,,,,,,,11539.32,29268.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8030.06,,,,,,,4606.42,11683.77,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,5861.23,,,,,,,3362.28,8528.12,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21027.54,,,,,,,12062.39,30595.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13748.33,,,,,,,7886.69,20003.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9269.02,,,,,,,5317.14,13486.46,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15411.01,,,,,,,8840.48,22423.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8670.14,,,,,,,4973.60,12615.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15326.01,,,,,,,8791.72,22299.41,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9724.93,,,,,,,5578.68,14149.82,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20294.73,,,,,,,11642.01,29528.92,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11761.10,,,,,,,6746.72,17112.45,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15506.32,,,,,,,8895.15,22561.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9475.08,,,,,,,5435.35,13786.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7290.80,,,,,,,4182.35,10608.15,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9039.77,,,,,,,5185.64,13152.90,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11225.34,,,,,,,6439.38,16332.91,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9272.88,,,,,,,5319.36,13492.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26855.29,,,,,,,15405.46,39074.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12406.34,,,,,,,7116.86,18051.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8784.77,,,,,,,5039.35,12781.87,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,86115.43,,,,,,,48129.92,125298.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31195.51,,,,,,,17895.21,45389.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,57477.69,,,,,,,32407.49,83630.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30977.86,,,,,,,17770.36,45072.92,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35041.18,,,,,,,20089.63,50985.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22705.68,,,,,,,13025.04,33036.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,55732.58,,,,,,,31449.41,81091.15,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40581.73,,,,,,,23131.43,59046.59,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41346.74,,,,,,,23551.45,60159.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,64232.72,,,,,,,36116.09,93458.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31478.85,,,,,,,18057.75,45801.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20636.02,,,,,,,11837.79,30025.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,59198.32,,,,,,,33352.15,86133.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30873.54,,,,,,,17710.51,44921.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21674.07,,,,,,,12433.27,31535.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,46631.00,,,,,,,26452.56,67848.30,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30165.19,,,,,,,17304.17,43890.49,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21094.51,,,,,,,12100.81,30692.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45989.62,,,,,,,26100.45,66915.10,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27157.95,,,,,,,15579.08,39514.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19769.26,,,,,,,11340.58,28764.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,33263.88,,,,,,,19081.73,48399.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19379.03,,,,,,,11116.72,28196.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15277.07,,,,,,,8763.65,22228.20,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29565.03,,,,,,,16959.89,43017.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16856.04,,,,,,,9669.41,24525.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11212.46,,,,,,,6431.99,16314.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,32093.18,,,,,,,18410.16,46695.71,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19634.04,,,,,,,11263.01,28567.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15040.10,,,,,,,8627.71,21883.40,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37374.86,,,,,,,21370.84,54380.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21667.63,,,,,,,12429.57,31526.49,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17322.26,,,,,,,9936.86,25203.96,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,56574.87,,,,,,,31911.85,82316.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29950.11,,,,,,,17180.79,43577.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18003.55,,,,,,,10327.69,26195.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,44285.73,,,,,,,25164.98,64435.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31093.77,,,,,,,17836.85,45241.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20502.08,,,,,,,11760.96,29830.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12881.58,,,,,,,7389.48,18742.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9025.60,,,,,,,5177.51,13132.29,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22835.75,,,,,,,13099.66,33226.12,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13149.46,,,,,,,7543.15,19132.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9368.18,,,,,,,5374.03,13630.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27544.32,,,,,,,15800.72,40077.10,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15578.44,,,,,,,8936.52,22666.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11904.06,,,,,,,6828.73,17320.46,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23542.81,,,,,,,13505.26,34254.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12630.44,,,,,,,7245.41,18377.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8118.92,,,,,,,4657.40,11813.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25271.17,,,,,,,14496.73,36769.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13954.40,,,,,,,8004.90,20303.71,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10310.93,,,,,,,5914.83,15002.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17782.04,,,,,,,10200.61,25872.94,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11008.97,,,,,,,6315.26,16018.10,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20378.44,,,,,,,11690.03,29650.72,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12573.77,,,,,,,7212.90,18294.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8774.46,,,,,,,5033.44,12766.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19019.71,,,,,,,10910.60,27673.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10171.83,,,,,,,5835.04,14800.06,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7006.18,,,,,,,4019.07,10194.02,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16334.44,,,,,,,9370.20,23766.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10040.47,,,,,,,5759.68,14608.92,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20597.38,,,,,,,11815.63,29969.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12050.88,,,,,,,6912.95,17534.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8358.47,,,,,,,4794.81,12161.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30843.92,,,,,,,17693.52,44878.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19493.65,,,,,,,11182.48,28363.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14742.59,,,,,,,8457.04,21450.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,51780.02,,,,,,,29279.42,75340.15,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,70454.57,,,,,,,39531.94,102511.70,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37351.68,,,,,,,21358.11,54346.85,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28586.23,,,,,,,16398.40,41593.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45921.36,,,,,,,26062.95,66815.78,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28041.45,,,,,,,16085.89,40800.42,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20447.99,,,,,,,11729.93,29751.91,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,42543.20,,,,,,,24208.31,61900.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27078.10,,,,,,,15533.27,39398.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21385.58,,,,,,,12267.77,31116.11,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45882.73,,,,,,,26041.75,66759.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26617.03,,,,,,,15268.78,38727.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17557.94,,,,,,,10072.06,25546.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30734.45,,,,,,,17630.72,44718.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21786.12,,,,,,,12497.54,31698.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17590.14,,,,,,,10090.53,25593.73,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,43880.04,,,,,,,24942.24,63845.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22377.26,,,,,,,12836.65,32559.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18024.16,,,,,,,10339.51,26225.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,53486.49,,,,,,,30216.30,77823.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28177.96,,,,,,,16164.21,40999.06,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19322.36,,,,,,,11084.22,28114.12,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,141942.03,,,,,,,78779.31,206526.27,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,92968.35,,,,,,,51892.24,135269.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,72405.74,,,,,,,40603.15,105350.66,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,116034.64,,,,,,,64555.88,168830.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,74274.48,,,,,,,41629.10,108069.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25348.45,,,,,,,14541.06,36882.10,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13602.80,,,,,,,7803.21,19792.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9176.29,,,,,,,5263.95,13351.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23654.86,,,,,,,13569.54,34417.92,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14567.44,,,,,,,8356.57,21195.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10989.65,,,,,,,6304.18,15989.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20995.35,,,,,,,12043.92,30548.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10833.81,,,,,,,6214.79,15763.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8003.01,,,,,,,4590.90,11644.41,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23113.94,,,,,,,13259.24,33630.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12432.10,,,,,,,7131.64,18088.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9011.44,,,,,,,5169.38,13111.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21519.52,,,,,,,12344.61,31311.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14094.78,,,,,,,8085.43,20507.96,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10654.80,,,,,,,6112.09,15502.77,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,86052.33,,,,,,,48095.26,125206.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,54617.26,,,,,,,30837.10,79468.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,68639.92,,,,,,,38535.67,99871.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41604.32,,,,,,,23692.85,60534.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,108227.39,,,,,,,60269.61,157471.31,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,76798.76,,,,,,,43014.97,111742.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,53738.92,,,,,,,30354.87,78190.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,69039.17,,,,,,,39604.11,100452.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,34258.14,,,,,,,19652.08,49845.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,73403.86,,,,,,,41151.13,106802.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40114.22,,,,,,,22874.77,58366.36,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23487.43,,,,,,,13473.50,34174.31,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,67040.35,,,,,,,32841.00,97543.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45419.08,,,,,,,25787.19,66084.96,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35391.49,,,,,,,20281.95,51494.77,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,39064.58,,,,,,,22298.52,56839.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24842.30,,,,,,,14490.34,36145.66,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,62188.83,,,,,,,34993.95,90485.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37942.82,,,,,,,21682.65,55206.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31441.50,,,,,,,18036.32,45747.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,55288.26,,,,,,,31205.47,80444.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29308.74,,,,,,,16812.87,42644.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15199.80,,,,,,,8719.32,22115.77,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,44491.79,,,,,,,25278.10,64735.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31672.04,,,,,,,18168.57,46082.95,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23940.77,,,,,,,13733.55,34833.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37507.51,,,,,,,21443.67,54573.59,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26975.07,,,,,,,15474.17,39248.84,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21005.65,,,,,,,12049.83,30563.31,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35699.30,,,,,,,20450.94,51942.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41561.82,,,,,,,23669.52,60472.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26931.28,,,,,,,15449.05,39185.12,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20171.09,,,,,,,11571.09,29349.02,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19622.44,,,,,,,11256.36,28550.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14383.27,,,,,,,8250.92,20927.72,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,47286.54,,,,,,,26812.44,68802.11,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,32662.43,,,,,,,18736.71,47523.98,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25841.71,,,,,,,14824.02,37599.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,46695.39,,,,,,,26487.90,67941.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23232.43,,,,,,,13327.21,33803.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14832.74,,,,,,,8508.76,21581.71,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,38853.37,,,,,,,22182.53,56531.82,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25948.61,,,,,,,14885.34,37755.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40759.46,,,,,,,23229.03,59305.19,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22513.78,,,,,,,12914.96,32757.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17333.85,,,,,,,9943.51,25220.82,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35946.58,,,,,,,20586.69,52302.42,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24073.43,,,,,,,13809.65,35026.94,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23089.47,,,,,,,13245.21,33595.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15449.65,,,,,,,8862.64,22479.30,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23264.63,,,,,,,13345.68,33850.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19503.96,,,,,,,11188.39,28378.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,38901.02,,,,,,,22208.72,56601.15,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26780.59,,,,,,,15362.61,38965.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21319.90,,,,,,,12230.10,31020.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20275.41,,,,,,,11630.93,29500.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13166.20,,,,,,,7552.75,19156.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41044.09,,,,,,,23385.28,59719.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26763.85,,,,,,,15353.00,38941.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19791.16,,,,,,,11353.14,28796.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,48132.69,,,,,,,27276.98,70033.26,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25760.58,,,,,,,14777.48,37481.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19239.94,,,,,,,11036.93,27994.19,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,36965.31,,,,,,,21145.99,53784.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27273.86,,,,,,,15645.57,39683.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20190.41,,,,,,,11582.17,29377.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10381.76,,,,,,,5955.47,15105.51,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16510.88,,,,,,,9471.42,24023.40,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10401.08,,,,,,,5966.55,15133.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12290.43,,,,,,,7050.37,17882.63,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9276.74,,,,,,,5321.58,13497.70,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25367.77,,,,,,,14552.14,36910.21,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16695.05,,,,,,,9577.06,24291.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9936.15,,,,,,,5699.84,14457.14,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22750.75,,,,,,,13050.90,33102.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13239.61,,,,,,,7594.86,19263.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9718.49,,,,,,,5574.98,14140.45,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31961.81,,,,,,,18334.80,46504.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14854.64,,,,,,,8521.32,21613.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10769.42,,,,,,,6177.85,15669.55,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24868.06,,,,,,,14265.49,36183.14,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15547.53,,,,,,,8918.79,22621.72,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11257.53,,,,,,,6457.85,16379.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21586.49,,,,,,,12383.03,31408.44,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12380.58,,,,,,,7102.08,18013.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16695.05,,,,,,,9577.06,24291.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10690.86,,,,,,,6132.78,15555.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17023.46,,,,,,,9765.46,24769.21,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10697.30,,,,,,,6136.47,15564.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19149.79,,,,,,,10985.22,27863.02,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11503.52,,,,,,,6598.96,16737.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24018.05,,,,,,,13777.88,34946.36,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14503.04,,,,,,,8319.63,21101.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10353.43,,,,,,,5939.21,15064.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18350.00,,,,,,,10526.42,26699.33,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11533.14,,,,,,,6615.95,16780.77,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19880.02,,,,,,,11404.12,28925.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12549.30,,,,,,,7198.87,18259.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9650.23,,,,,,,5535.83,14041.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37878.43,,,,,,,21647.31,55113.27,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21759.07,,,,,,,12482.03,31659.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14763.20,,,,,,,8468.86,21480.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,84375.48,,,,,,,47174.67,122766.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,44708.16,,,,,,,25396.90,65050.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21039.13,,,,,,,12069.04,30612.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,63122.55,,,,,,,35506.60,91843.59,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,34138.37,,,,,,,19583.37,49671.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20688.83,,,,,,,11868.08,30102.33,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41708.64,,,,,,,23750.13,60686.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22254.91,,,,,,,12766.46,32380.99,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18585.68,,,,,,,10661.62,27042.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24812.68,,,,,,,14233.72,36102.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22208.55,,,,,,,12739.87,32313.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27570.08,,,,,,,15815.49,40114.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24844.88,,,,,,,14252.19,36149.40,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24924.73,,,,,,,14298.00,36265.59,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15278.36,,,,,,,8764.38,22230.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11163.52,,,,,,,6403.92,16242.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27312.50,,,,,,,15667.73,39739.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13941.52,,,,,,,7997.51,20284.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21470.58,,,,,,,12316.53,31239.79,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14570.01,,,,,,,8358.04,21199.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9442.88,,,,,,,5416.88,13739.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13414.77,,,,,,,7695.34,19518.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7791.80,,,,,,,4469.74,11337.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18304.92,,,,,,,10500.56,26633.74,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11216.32,,,,,,,6434.21,16319.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18959.18,,,,,,,10875.87,27585.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11797.16,,,,,,,6767.41,17164.92,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19488.50,,,,,,,11179.52,28355.85,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11673.53,,,,,,,6696.48,16985.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28228.19,,,,,,,16193.02,41072.14,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18021.58,,,,,,,10338.03,26221.48,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,44914.22,,,,,,,25510.02,65350.39,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24087.59,,,,,,,13817.78,35047.55,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18266.29,,,,,,,10478.40,26577.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35030.00,,,,,,,16490.00,54106.99,case rate,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35030.00,,,,,,,11823.02,35030.00,case rate,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35030.00,,,,,,,11144.06,35030.00,case rate,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45838.94,,,,,,,26017.71,66695.85,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23103.64,,,,,,,13253.33,33615.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16123.22,,,,,,,9249.04,23459.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,38895.87,,,,,,,22205.88,56593.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19310.77,,,,,,,11077.57,28097.26,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17107.18,,,,,,,9813.48,24891.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,47997.46,,,,,,,27202.76,69836.51,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28060.77,,,,,,,16096.97,40828.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18796.90,,,,,,,10782.79,27349.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18503.26,,,,,,,10614.34,26922.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11542.16,,,,,,,6621.13,16793.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8000.43,,,,,,,4589.43,11640.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17201.19,,,,,,,9867.41,25027.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10022.44,,,,,,,5749.34,14582.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18315.23,,,,,,,10506.47,26648.73,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21200.12,,,,,,,12161.39,30846.27,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13200.98,,,,,,,7572.70,19207.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9894.94,,,,,,,5676.20,14397.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,60549.33,,,,,,,34093.86,60549.33,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,47727.00,,,,,,,27054.26,47727.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41592.73,,,,,,,23686.49,41592.73,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,66924.44,,,,,,,37593.86,97375.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,36052.18,,,,,,,20644.67,52456.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27259.69,,,,,,,15637.44,39662.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41004.16,,,,,,,23363.36,59661.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23568.57,,,,,,,13520.04,34292.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19985.63,,,,,,,11464.70,29079.18,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,32724.25,,,,,,,18772.17,47613.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17022.17,,,,,,,9764.72,24767.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13334.92,,,,,,,7649.54,19402.36,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,39429.06,,,,,,,22498.61,57369.45,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19578.66,,,,,,,11231.24,28487.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13483.03,,,,,,,7734.50,19617.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40197.93,,,,,,,22920.74,58488.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22529.23,,,,,,,12923.83,32780.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14246.75,,,,,,,8172.61,20729.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37606.68,,,,,,,21498.11,54717.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19988.21,,,,,,,11466.18,29082.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12586.65,,,,,,,7220.29,18313.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23117.81,,,,,,,13261.46,33636.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13902.88,,,,,,,7975.35,20228.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,54112.41,,,,,,,30559.94,78733.78,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30118.83,,,,,,,17277.58,43823.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21139.59,,,,,,,12126.66,30758.19,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19073.80,,,,,,,10941.63,27752.46,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11279.43,,,,,,,6470.41,16411.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7731.26,,,,,,,4435.02,11249.02,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23229.85,,,,,,,13325.74,33799.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13494.62,,,,,,,7741.15,19634.72,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10178.27,,,,,,,5838.74,14809.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14943.50,,,,,,,8572.30,21742.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10425.55,,,,,,,5980.59,15169.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17315.82,,,,,,,9933.17,25194.59,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10067.51,,,,,,,5775.20,14648.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14731.00,,,,,,,8450.39,21433.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8873.63,,,,,,,5090.33,12911.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13880.99,,,,,,,7962.79,20196.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21307.02,,,,,,,12222.71,31001.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13072.18,,,,,,,7498.82,19020.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8885.22,,,,,,,5096.98,12928.04,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25761.86,,,,,,,14778.22,37483.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19758.96,,,,,,,11334.67,28749.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29970.72,,,,,,,17192.61,43607.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18046.05,,,,,,,10352.07,26257.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26837.26,,,,,,,15395.11,39048.33,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14163.04,,,,,,,8124.58,20607.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19362.29,,,,,,,11107.12,28172.21,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13618.25,,,,,,,7812.07,19814.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28814.19,,,,,,,16529.17,41924.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18945.01,,,,,,,10867.75,27565.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24347.75,,,,,,,13967.01,35426.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17297.78,,,,,,,9922.82,25168.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23307.13,,,,,,,13370.06,33911.97,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14716.83,,,,,,,8442.27,21413.06,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7878.08,,,,,,,4519.24,11462.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15071.01,,,,,,,8645.44,21928.38,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9298.64,,,,,,,5334.14,13529.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19098.27,,,,,,,10955.67,27788.06,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10447.44,,,,,,,5993.15,15201.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13635.00,,,,,,,7821.68,19838.98,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8654.69,,,,,,,4964.74,12592.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27432.27,,,,,,,15736.44,39914.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17328.69,,,,,,,9940.55,25213.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,46035.99,,,,,,,26125.88,66982.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26538.47,,,,,,,15223.71,38613.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18912.81,,,,,,,10849.28,27518.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,45415.22,,,,,,,26052.30,66079.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23305.84,,,,,,,13369.32,33910.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18366.74,,,,,,,10536.03,26723.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23630.39,,,,,,,13555.50,34382.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15978.98,,,,,,,9166.29,23249.48,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26390.36,,,,,,,15138.75,38398.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14649.86,,,,,,,8403.85,21315.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22372.11,,,,,,,12833.69,32551.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10811.92,,,,,,,6202.23,15731.39,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17867.04,,,,,,,10249.37,25996.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,33068.12,,,,,,,18969.43,48114.26,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19006.83,,,,,,,10903.21,27655.02,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23719.25,,,,,,,13606.48,34511.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14009.78,,,,,,,8036.67,20384.28,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12370.28,,,,,,,7096.17,17998.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18441.44,,,,,,,10578.88,26832.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12608.54,,,,,,,7232.85,18345.48,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8546.50,,,,,,,4902.68,12435.20,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12975.59,,,,,,,7443.41,18879.54,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7335.88,,,,,,,4208.20,10673.73,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8243.00,,"Case Rate up to day 4. Additional days paid at $2,656 per diem.",,,,0,4210.00,9518.00,case rate,"Case Rate up to day 4. Additional days paid at $2,656 per diem.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21762.93,,,,,,,12484.24,31665.16,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12913.77,,,,,,,7407.95,18789.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8431.88,,,,,,,4836.92,12268.42,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9184.01,,,,,,,5268.38,13362.78,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31619.23,,,,,,,5414.00,31619.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13653.03,,,,,,,5414.00,15908.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12335.51,,,,,,,5414.00,15908.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21243.91,,,,,,,5414.00,21243.91,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14383.27,,,,,,,5414.00,15908.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12348.39,,,,,,,5414.00,15908.00,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23210.53,,,,,,,1810.00,33771.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,76546.34,,,,,,,1810.00,111375.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,52275.86,,,,,,,1810.00,76061.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31543.25,,,,,,,1810.00,45895.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,53700.28,,,,,,,1810.00,78134.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19008.12,,,,,,,375.00,27656.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,2573.22,,,,,,,314.00,3744.05,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8243.00,,"Case Rate up to day 4. Additional days paid at $2,656 per diem.",,,,0,4210.00,9947.78,case rate,"Case Rate up to day 4. Additional days paid at $2,656 per diem.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8243.00,,"Case Rate up to day 4. Additional days paid at $2,656 per diem.",,,,0,4210.00,9518.00,case rate,"Case Rate up to day 4. Additional days paid at $2,656 per diem.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8243.00,,"Case Rate up to day 4. Additional days paid at $2,656 per diem.",,,,0,4210.00,9518.00,case rate,"Case Rate up to day 4. Additional days paid at $2,656 per diem.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,58327.70,,,,,,,32874.17,84867.06,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,36182.26,,,,,,,20716.09,52645.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24584.72,,,,,,,14102.95,35770.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,51311.22,,,,,,,29022.04,74658.05,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23940.77,,,,,,,13733.55,34833.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17463.92,,,,,,,10018.13,25410.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8243.00,,"Case Rate up to day 4. Additional days paid at $2,656 per diem.",,,,0,4210.00,9518.00,case rate,"Case Rate up to day 4. Additional days paid at $2,656 per diem.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8243.00,,"Case Rate up to day 4. Additional days paid at $2,656 per diem.",,,,0,4210.00,9518.00,case rate,"Case Rate up to day 4. Additional days paid at $2,656 per diem.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8243.00,,"Case Rate up to day 4. Additional days paid at $2,656 per diem.",,,,0,4210.00,9518.00,case rate,"Case Rate up to day 4. Additional days paid at $2,656 per diem.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28435.54,,,,,,,16311.97,41373.84,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16303.53,,,,,,,9352.47,23721.70,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13479.16,,,,,,,7732.28,19612.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18085.98,,,,,,,10374.97,26315.18,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11825.50,,,,,,,6783.66,17206.15,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19644.34,,,,,,,11268.92,28582.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27389.77,,,,,,,15712.06,39852.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13059.31,,,,,,,7491.43,19001.35,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8139.53,,,,,,,4669.22,11843.05,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21739.75,,,,,,,12470.94,31631.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13577.04,,,,,,,7788.43,19754.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11074.65,,,,,,,6352.94,16113.67,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,75532.76,,,,,,,42319.93,109900.49,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28830.93,,,,,,,16538.78,41949.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15506.32,,,,,,,8895.15,22561.76,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,59047.64,,,,,,,33269.41,85914.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29178.66,,,,,,,16738.25,42455.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17378.92,,,,,,,9969.37,25286.41,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,60245.39,,,,,,,33926.98,87657.29,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,29765.94,,,,,,,17075.15,43309.58,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21943.24,,,,,,,12587.67,31927.51,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,40697.64,,,,,,,23195.07,59215.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19382.90,,,,,,,11118.94,28202.19,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15487.00,,,,,,,8884.07,22533.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9293.49,,,,,,,5331.18,13522.06,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,6734.43,,,,,,,3863.19,9798.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,70704.42,,,,,,,39669.12,102875.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26863.02,,,,,,,15409.89,39085.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15705.94,,,,,,,9009.67,22852.21,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,61874.58,,,,,,,34821.45,90027.78,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26883.62,,,,,,,15421.71,39115.79,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18595.99,,,,,,,10667.53,27057.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41662.28,,,,,,,23724.68,60618.79,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21010.80,,,,,,,12052.78,30570.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13012.94,,,,,,,7464.84,18933.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25691.03,,,,,,,14737.58,37380.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15678.89,,,,,,,8994.15,22812.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10967.76,,,,,,,6291.62,15958.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,33388.81,,,,,,,19153.39,48580.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16848.31,,,,,,,9664.98,24514.36,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10939.42,,,,,,,6275.37,15916.91,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,34895.65,,,,,,,20009.72,50773.32,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,111525.70,,,,,,,62080.42,162270.37,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,63604.23,,,,,,,35771.03,92544.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25733.53,,,,,,,14761.96,37442.40,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19282.44,,,,,,,11061.31,28056.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,58582.71,,,,,,,33014.15,85238.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,27580.38,,,,,,,15821.40,40129.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17939.16,,,,,,,10290.75,26101.55,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23487.43,,,,,,,13473.50,34174.31,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12851.95,,,,,,,7372.49,18699.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11432.69,,,,,,,6558.33,16634.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19296.61,,,,,,,11069.44,28076.64,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11199.58,,,,,,,6424.60,16295.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26958.32,,,,,,,15464.56,39224.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13279.54,,,,,,,7617.77,19321.78,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,9397.81,,,,,,,5391.02,13673.85,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,89017.07,,,,,,,49722.96,129520.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25017.46,,,,,,,14351.19,36400.51,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13179.08,,,,,,,7560.14,19175.62,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,49776.05,,,,,,,823.98,72424.36,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12366.42,,,,,,,823.98,17993.19,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12117.85,,,,,,,823.98,17631.53,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13829.47,,,,,,,823.98,20121.94,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25323.98,,,,,,,823.98,36846.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20721.02,,,,,,,823.98,30149.18,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,17989.39,,,,,,,823.98,26174.64,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26727.79,,,,,,,823.98,38889.05,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13792.12,,,,,,,823.98,20067.60,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7945.06,,,,,,,823.98,11560.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18231.51,,,,,,,823.98,26526.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22475.14,,,,,,,823.98,32701.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11369.58,,,,,,,823.98,16542.79,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,54048.01,,,,,,,30524.57,78640.09,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,24656.85,,,,,,,14144.33,35875.82,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15063.28,,,,,,,8641.00,21917.13,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,47305.85,,,,,,,26823.05,68830.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,18440.15,,,,,,,10578.14,26830.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22697.95,,,,,,,13020.61,33025.61,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,49446.34,,,,,,,27998.19,71944.64,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,25696.18,,,,,,,14740.54,37388.05,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16906.26,,,,,,,9698.23,24598.69,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21052.01,,,,,,,12076.42,30630.77,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11404.35,,,,,,,6542.07,16593.38,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21657.33,,,,,,,12423.66,31511.50,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8581.28,,,,,,,4922.62,12485.80,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,20199.42,,,,,,,11587.34,29390.25,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11038.59,,,,,,,6332.25,16061.20,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,23578.87,,,,,,,13525.95,34307.36,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12908.62,,,,,,,7404.99,18782.10,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8865.90,,,,,,,5085.90,12899.93,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22530.52,,,,,,,12924.57,32782.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,13106.96,,,,,,,7518.77,19070.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,237362.55,,,,,,,136162.32,345363.52,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,92377.20,,,,,,,51567.69,134409.23,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,41480.68,,,,,,,23624.98,60354.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,49155.28,,,,,,,28197.78,71521.14,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,28470.32,,,,,,,16331.91,41424.43,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26530.74,,,,,,,15219.28,38602.34,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,46731.45,,,,,,,26507.70,67994.46,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,30096.94,,,,,,,17265.02,43791.17,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,26114.75,,,,,,,14980.65,37997.07,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19944.42,,,,,,,526.87,29019.22,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,14769.64,,,,,,,526.87,21489.89,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16348.60,,,,,,,9378.33,23787.29,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,10309.64,,,,,,,5914.09,15000.57,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15322.15,,,,,,,8789.50,22293.79,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,8084.15,,,,,,,4637.45,11762.47,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,7160.72,,,,,,,4107.73,10418.88,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,86689.84,,,,,,,48445.28,126134.08,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,48463.68,,,,,,,27458.71,70514.86,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,98136.69,,,,,,,54729.71,142789.31,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,54270.82,,,,,,,30646.88,78964.27,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37917.06,,,,,,,21668.51,55169.49,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,35208.61,,,,,,,20181.55,51228.68,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,19738.36,,,,,,,11322.85,28719.39,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,12112.70,,,,,,,6948.41,17624.03,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,78836.22,,,,,,,44133.55,114707.04,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,33967.07,,,,,,,19485.11,49422.24,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,37168.79,,,,,,,21257.70,54080.75,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16678.31,,,,,,,9567.46,24267.01,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,11520.27,,,,,,,6608.57,16762.04,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,16325.42,,,,,,,9365.03,23753.56,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,60425.69,,,,,,,34025.97,87919.64,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,31663.02,,,,,,,18163.40,46069.83,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,22074.61,,,,,,,12663.03,32118.65,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,44154.36,,,,,,,25092.85,64244.79,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,21167.92,,,,,,,12142.92,30799.42,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Cigna,Commercial,,15444.50,,,,,,,8859.69,22471.81,case rate,"If Hospital's Billed Charges for Covered Services exceed $194,316.00 for a single admission, the contract rate will a reduction of 46.2% from billed charges."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12686.00,,,,,,,2194.26,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12021.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,18291.76,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12686.00,,,,,,,2194.26,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",361,RC,31654,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4964.08,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6274.19,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,1825.06,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6274.19,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2025.00,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31633,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,27871.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3870.33,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,4964.08,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1494.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12021.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6314.07,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,9423.00,39682.00,per diem,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3870.33,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,29826,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,1759.87,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63048,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,173.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6314.07,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93655,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12686.00,,,,,,,4964.08,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3660.29,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93623,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,10768.00,,,,,,,2194.26,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1425.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,3788.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31632,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3870.33,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,6274.19,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,1970.84,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3395.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1970.84,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,2638.41,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93657,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5691.37,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,9423.00,39682.00,per diem,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,4121.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,10768.00,,,,,,,2194.26,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC/DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93662,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,7277.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6636.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3870.33,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1970.84,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,2244.50,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1134.38,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63035,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,173.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3395.25,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6274.19,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1558.81,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3120.11,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,4749.28,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,9423.00,39682.00,per diem,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3308.62,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5200.74,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3547.15,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2194.26,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,2194.26,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6274.19,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4376.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1878.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,27871.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,990.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3318.21,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3395.25,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,1878.73,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3120.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,6258.49,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8700.96,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,27871.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,1759.87,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,1539.73,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,4121.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2025.00,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3547.15,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),750,RC,43273,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5691.37,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,6258.49,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG-ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9601,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,27871.00,,,,,,,173.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,7300.39,13852.00,per diem,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12021.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,1878.73,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63044,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,4311.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,54.52,,,,,,,54.52,92.57,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,642.16,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,931.82,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12686.00,,,,,,,4964.08,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4507.53,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,4121.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (OMENTAL TACKING PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49326,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,1970.84,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3318.21,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,990.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,4121.00,13110.66,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1878.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,527.80,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,990.00,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3120.11,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4376.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,4311.00,24600.00,per diem,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,7300.39,13852.00,per diem,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,7300.39,13852.00,per diem,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3660.29,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,856.54,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,4749.28,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12021.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,1970.84,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,2194.26,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2194.26,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,877.14,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,1558.81,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2753.54,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,527.80,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,931.82,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6636.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,7277.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3788.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,990.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3028.17,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,27871.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12021.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,4121.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,990.00,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4311.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,4121.00,9721.99,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6636.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1425.11,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,3120.11,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1825.06,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3120.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1878.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1425.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANTATION OR REPLACEMENT; WITH TESTING OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR",481,RC,93641,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9423.00,,,,,,,173.00,12247.00,per diem,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; EACH ADDITIONAL BRANCH SUBTENDED BY THE BYPASS GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9605,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,27871.00,,,,,,,173.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2025.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,150.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,990.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6636.00,10945.84,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,642.16,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,8213.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,13652.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3395.25,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3028.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,856.54,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3395.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,990.00,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,856.54,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,1759.87,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,588.93,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,4964.08,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2194.26,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,12408.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,17457.00,,,,,,,4311.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,1316.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,9350.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,8213.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,6649.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Cigna,Commercial,,5152.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Cigna,Commercial,,1.35,,,,,,,0.02803,1.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Cigna,Commercial,,71.34,,,,,,,26.03,96.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Cigna,Commercial,,28.04,,,,,,,5.00,31.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,106.06,,,,,,,19.02,138.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,5.99,,,,,,,5.99,40.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Cigna,Commercial,,124.49,,,,,,,24.62,124.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Cigna,Commercial,,124.49,,,,,,,24.62,132.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Cigna,Commercial,,69.34,,,,,,,4.42,81.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.02360,,,,,,,0.00200,0.03300,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,106.06,,,,,,,19.02,106.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Cigna,Commercial,,202.87,,,,,,,28.43,371.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Cigna,Commercial,,25878.78,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Cigna,Commercial,,162.39,,,,,,,162.39,12620.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Cigna,Commercial,,163224.30,,,,,,,0.20220,163224.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Cigna,Commercial,,1255.03,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Cigna,Commercial,,4742.81,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Cigna,Commercial,,1134.04,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Cigna,Commercial,,2154.93,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Cigna,Commercial,,26303.88,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Cigna,Commercial,,8186.12,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Cigna,Commercial,,7272.48,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Cigna,Commercial,,10244.91,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Cigna,Commercial,,20652.01,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Cigna,Commercial,,1725.91,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Cigna,Commercial,,7270.52,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Cigna,Commercial,,10491.47,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Cigna,Commercial,,1763.18,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Cigna,Commercial,,5471.36,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Cigna,Commercial,,5833.68,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Cigna,Commercial,,7375.16,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Cigna,Commercial,,71.34,,,,,,,26.43,107.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Cigna,Commercial,,5.88,,,,,,,5.88,337.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Cigna,Commercial,,5.88,,,,,,,5.88,676.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Cigna,Commercial,,79.56,,,,,,,6.26,79.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Cigna,Commercial,,13.30,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Cigna,Commercial,,869.85,,,,,,,55.85,1004.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Cigna,Commercial,,50.50,,,,,,,4.33,50.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Cigna,Commercial,,0.07080,,,,,,,0.00601,0.08250,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Cigna,Commercial,,52.16,,,,,,,4.29,52.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Cigna,Commercial,,227.93,,,,,,,8.13,232.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Cigna,Commercial,,24.38,,,,,,,4.08,24.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Cigna,Commercial,,48.73,,,,,,,3.98,48.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Cigna,Commercial,,238.43,,,,,,,197.80,803.24,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Cigna,Commercial,,238.43,,,,,,,54.65,238.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Cigna,Commercial,,170.51,,,,,,,13.07,170.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Cigna,Commercial,,569.63,,,,,,,35.68,569.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Cigna,Commercial,,10133.73,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Cigna,Commercial,,17.18,,,,,,,1.27,20.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Cigna,Commercial,,161.64,,,,,,,40.04,186.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Cigna,Commercial,,161.64,,,,,,,40.04,162.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Cigna,Commercial,,75.38,,,,,,,5.94,75.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Cigna,Commercial,,292.17,,,,,,,247.25,916.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Cigna,Commercial,,292.17,,,,,,,209.81,777.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Cigna,Commercial,,292.17,,,,,,,141.54,524.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Cigna,Commercial,,292.17,,,,,,,110.11,408.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Cigna,Commercial,,292.17,,,,,,,88.49,343.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Cigna,Commercial,,292.17,,,,,,,93.29,345.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Cigna,Commercial,,292.17,,,,,,,247.25,1004.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Cigna,Commercial,,292.17,,,,,,,209.81,852.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Cigna,Commercial,,292.17,,,,,,,141.54,574.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Cigna,Commercial,,292.17,,,,,,,110.11,447.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Cigna,Commercial,,292.17,,,,,,,88.49,359.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Cigna,Commercial,,292.17,,,,,,,93.29,378.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Cigna,Commercial,,154.34,,,,,,,114.31,423.80,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Cigna,Commercial,,154.34,,,,,,,52.45,194.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Cigna,Commercial,,6571.14,,,,,,,494.29,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Cigna,Commercial,,6571.14,,,,,,,139.74,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Cigna,Commercial,,6571.14,,,,,,,139.74,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,6571.14,,,,,,,125.33,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,6571.14,,,,,,,125.33,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Cigna,Commercial,,6571.14,,,,,,,123.12,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Cigna,Commercial,,6571.14,,,,,,,123.12,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,6571.14,,,,,,,87.89,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,6571.14,,,,,,,87.89,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Cigna,Commercial,,6571.14,,,,,,,79.88,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Cigna,Commercial,,6571.14,,,,,,,79.88,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Cigna,Commercial,,154.34,,,,,,,154.34,1921.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Cigna,Commercial,,154.34,,,,,,,114.31,464.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Cigna,Commercial,,154.34,,,,,,,52.45,213.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Cigna,Commercial,,154.34,,,,,,,62.66,232.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Cigna,Commercial,,154.34,,,,,,,62.66,254.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Cigna,Commercial,,240.06,,,,,,,240.06,1168.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Cigna,Commercial,,240.06,,,,,,,240.06,1280.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Cigna,Commercial,,240.06,,,,,,,240.06,929.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Cigna,Commercial,,240.06,,,,,,,240.06,1017.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Cigna,Commercial,,240.06,,,,,,,128.33,475.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Cigna,Commercial,,240.06,,,,,,,128.33,521.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Cigna,Commercial,,240.06,,,,,,,68.07,274.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Cigna,Commercial,,240.06,,,,,,,68.07,276.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Cigna,Commercial,,240.06,,,,,,,54.45,274.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Cigna,Commercial,,240.06,,,,,,,54.45,240.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Cigna,Commercial,,626.79,,,,,,,43.28,774.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Cigna,Commercial,,5.88,,,,,,,5.88,740.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Cigna,Commercial,,5.88,,,,,,,5.88,369.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Cigna,Commercial,,120.36,,,,,,,120.36,3849.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Cigna,Commercial,,413.97,,,,,,,30.79,509.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Cigna,Commercial,,240.06,,,,,,,240.06,1901.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Cigna,Commercial,,238.43,,,,,,,197.80,733.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,238.43,,,,,,,125.33,464.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Cigna,Commercial,,238.43,,,,,,,54.65,268.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Cigna,Commercial,,2242.87,,,,,,,174.60,3043.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Cigna,Commercial,,2923.87,,,,,,,214.26,3968.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Cigna,Commercial,,1.65,,,,,,,0.43644,1.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Cigna,Commercial,,162.39,,,,,,,162.39,1542.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Cigna,Commercial,,240.06,,,,,,,240.06,2044.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Cigna,Commercial,,240.06,,,,,,,240.06,902.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Cigna,Commercial,,240.06,,,,,,,123.32,457.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Cigna,Commercial,,240.06,,,,,,,240.06,2239.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Cigna,Commercial,,240.06,,,,,,,240.06,988.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Cigna,Commercial,,240.06,,,,,,,123.32,500.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Cigna,Commercial,,238.43,,,,,,,238.43,2087.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Cigna,Commercial,,7.91,,,,,,,0.62062,9.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Cigna,Commercial,,28.49,,,,,,,1.97,33.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Cigna,Commercial,,454.56,,,,,,,38.56,454.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Cigna,Commercial,,179.69,,,,,,,13.30,179.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Cigna,Commercial,,124.49,,,,,,,24.62,132.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Cigna,Commercial,,636.00,,,,,,,47.59,728.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Cigna,Commercial,,725.82,,,,,,,54.83,872.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Cigna,Commercial,,444.98,,,,,,,31.77,450.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Cigna,Commercial,,70.59,,,,,,,68.47,253.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Cigna,Commercial,,70.59,,,,,,,68.47,278.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Cigna,Commercial,,327.43,,,,,,,309.51,1147.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Cigna,Commercial,,327.43,,,,,,,327.43,2296.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Cigna,Commercial,,327.43,,,,,,,309.51,1256.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Cigna,Commercial,,810.94,,,,,,,66.15,1002.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.02360,,,,,,,0.00200,0.03300,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Cigna,Commercial,,809.74,,,,,,,65.92,1000.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Cigna,Commercial,,390.37,,,,,,,30.66,434.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Cigna,Commercial,,374.82,,,,,,,31.80,450.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Cigna,Commercial,,70.59,,,,,,,70.59,317.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Cigna,Commercial,,70.59,,,,,,,70.59,347.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Cigna,Commercial,,70.59,,,,,,,70.59,358.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Cigna,Commercial,,70.59,,,,,,,70.59,392.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Cigna,Commercial,,5.99,,,,,,,2.00,7.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Cigna,Commercial,,0.28320,,,,,,,0.02402,0.28320,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Cigna,Commercial,,0.49560,,,,,,,0.05405,0.49560,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Cigna,Commercial,,794.40,,,,,,,500.10,1854.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Cigna,Commercial,,794.40,,,,,,,500.10,2030.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Cigna,Commercial,,794.40,,,,,,,405.40,1502.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Cigna,Commercial,,794.40,,,,,,,405.40,1646.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Cigna,Commercial,,794.40,,,,,,,341.94,1267.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Cigna,Commercial,,794.40,,,,,,,341.94,1388.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.02360,,,,,,,0.00200,0.16500,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Cigna,Commercial,,798.51,,,,,,,64.52,914.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,28.04,,,,,,,13.01,48.24,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,28.04,,,,,,,13.01,52.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Cigna,Commercial,,221.32,,,,,,,16.24,221.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Cigna,Commercial,,103.44,,,,,,,10.71,115.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Cigna,Commercial,,350.04,,,,,,,25.23,431.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Cigna,Commercial,,83.19,,,,,,,6.18,99.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Cigna,Commercial,,34.81,,,,,,,3.33,42.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Cigna,Commercial,,317.35,,,,,,,23.38,367.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Cigna,Commercial,,78.21,,,,,,,6.74,97.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Cigna,Commercial,,251.62,,,,,,,19.23,309.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Cigna,Commercial,,764.33,,,,,,,55.06,907.10,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Cigna,Commercial,,118.24,,,,,,,8.53,145.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Cigna,Commercial,,128.86,,,,,,,10.29,128.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Cigna,Commercial,,507.80,,,,,,,33.25,597.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Cigna,Commercial,,309.47,,,,,,,25.78,372.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Cigna,Commercial,,440.75,,,,,,,30.87,544.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Cigna,Commercial,,518.30,,,,,,,29.30,518.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Cigna,Commercial,,190.88,,,,,,,5.23,209.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Cigna,Commercial,,77.31,,,,,,,5.72,88.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Cigna,Commercial,,190.88,,,,,,,13.62,196.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Cigna,Commercial,,381.90,,,,,,,28.18,392.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Cigna,Commercial,,1.01,,,,,,,0.10210,1.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Cigna,Commercial,,42.88,,,,,,,5.25,48.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Cigna,Commercial,,3.87,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Cigna,Commercial,,6.88,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Cigna,Commercial,,0.21240,,,,,,,0.02202,0.33000,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Cigna,Commercial,,1.79,,,,,,,0.16016,2.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Cigna,Commercial,,10.38,,,,,,,1.55,12.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Cigna,Commercial,,1.39,,,,,,,0.15816,1.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Cigna,Commercial,,0.70800,,,,,,,0.09409,0.95700,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Cigna,Commercial,,0.41856,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Cigna,Commercial,,4083.56,,,,,,,333.69,4844.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Cigna,Commercial,,0.01308,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Cigna,Commercial,,1.94,,,,,,,0.01802,1.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Cigna,Commercial,,6.96,,,,,,,0.51451,6.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Cigna,Commercial,,60.39,,,,,,,5.16,75.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Cigna,Commercial,,194.87,,,,,,,16.31,224.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Cigna,Commercial,,0.11800,,,,,,,0.01401,0.16500,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Cigna,Commercial,,2.78,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Cigna,Commercial,,4.00,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Cigna,Commercial,,1.98,,,,,,,0.22422,2.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Cigna,Commercial,,2.36,,,,,,,0.32232,2.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Cigna,Commercial,,4.60,,,,,,,0.51251,6.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Cigna,Commercial,,4.27,,,,,,,0.35836,5.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Cigna,Commercial,,0.92040,,,,,,,0.04004,1.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Cigna,Commercial,,0.04720,,,,,,,0.00400,3.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Cigna,Commercial,,54.16,,,,,,,4.42,62.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Cigna,Commercial,,2923.87,,,,,,,220.37,3968.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Cigna,Commercial,,168.79,,,,,,,15.42,199.80,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Cigna,Commercial,,265.38,,,,,,,27.01,319.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Cigna,Commercial,,270.31,,,,,,,33.32,272.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Cigna,Commercial,,15.98,,,,,,,3.46,18.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Cigna,Commercial,,0.47200,,,,,,,0.02603,0.54450,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Cigna,Commercial,,115.07,,,,,,,7.28,115.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Cigna,Commercial,,227.93,,,,,,,13.07,232.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Cigna,Commercial,,388.60,,,,,,,28.81,479.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Cigna,Commercial,,166.05,,,,,,,12.73,208.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Cigna,Commercial,,598.50,,,,,,,49.86,719.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Cigna,Commercial,,18.76,,,,,,,2.25,25.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Cigna,Commercial,,53.27,,,,,,,5.10,53.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Cigna,Commercial,,0.40120,,,,,,,0.15015,0.55665,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Cigna,Commercial,,0.18880,,,,,,,0.00801,0.21450,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Cigna,Commercial,,70.82,,,,,,,3.03,70.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Cigna,Commercial,,35.66,,,,,,,2.67,42.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Cigna,Commercial,,28.06,,,,,,,2.38,71.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Cigna,Commercial,,41.35,,,,,,,3.54,41.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Cigna,Commercial,,111.68,,,,,,,6.68,111.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Cigna,Commercial,,227.93,,,,,,,11.00,232.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Cigna,Commercial,,411.68,,,,,,,27.86,495.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Cigna,Commercial,,2.22,,,,,,,2.22,407.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Cigna,Commercial,,2.22,,,,,,,2.22,234.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Cigna,Commercial,,182.81,,,,,,,74.32,275.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Cigna,Commercial,,4.01,,,,,,,1.65,61.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Cigna,Commercial,,0.02360,,,,,,,0.02360,48.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Cigna,Commercial,,0.02360,,,,,,,0.02360,48.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Cigna,Commercial,,145.23,,,,,,,60.36,2174.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Cigna,Commercial,,179.03,,,,,,,73.58,14437.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Cigna,Commercial,,5.33,,,,,,,5.33,95.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Cigna,Commercial,,1.13,,,,,,,1.13,62.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Cigna,Commercial,,4.44,,,,,,,1.82,2630.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Cigna,Commercial,,0.89680,,,,,,,0.89680,247.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Cigna,Commercial,,733.04,,,,,,,167.14,1791.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Cigna,Commercial,,93.31,,,,,,,93.31,349.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Cigna,Commercial,,1731.46,,,,,,,711.66,3874.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Cigna,Commercial,,10.38,,,,,,,10.38,59.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Cigna,Commercial,,0.49560,,,,,,,0.49560,24.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Cigna,Commercial,,0.49560,,,,,,,0.49560,25.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Cigna,Commercial,,0.49560,,,,,,,0.49560,34.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Cigna,Commercial,,0.49560,,,,,,,0.49560,14.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Cigna,Commercial,,0.49560,,,,,,,0.49560,18.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Cigna,Commercial,,59.47,,,,,,,59.47,324.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Cigna,Commercial,,59.47,,,,,,,59.47,555.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Cigna,Commercial,,0.54280,,,,,,,0.54280,162.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Cigna,Commercial,,0.54280,,,,,,,0.54280,162.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Cigna,Commercial,,0.54280,,,,,,,0.54280,162.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Cigna,Commercial,,1.06,,,,,,,1.06,40.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Cigna,Commercial,,0.35400,,,,,,,0.35400,46.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Cigna,Commercial,,6.49,,,,,,,6.49,421.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Cigna,Commercial,,0.02360,,,,,,,0.02360,19.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Cigna,Commercial,,0.02360,,,,,,,0.02360,22.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Cigna,Commercial,,0.02360,,,,,,,0.02360,17.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Cigna,Commercial,,0.02360,,,,,,,0.02360,35.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Cigna,Commercial,,0.02360,,,,,,,0.02360,21.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Cigna,Commercial,,0.02360,,,,,,,0.02360,24.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Cigna,Commercial,,8.07,,,,,,,3.32,2034.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Cigna,Commercial,,0.02360,,,,,,,0.02360,13.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Cigna,Commercial,,0.02360,,,,,,,0.02360,12.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Cigna,Commercial,,0.02360,,,,,,,0.02360,12.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Cigna,Commercial,,0.02360,,,,,,,0.02360,15.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Cigna,Commercial,,3.26,,,,,,,3.26,17.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Cigna,Commercial,,3.26,,,,,,,3.26,16.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Cigna,Commercial,,12118.81,,,,,,,4068.51,15083.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Cigna,Commercial,,2.05,,,,,,,2.05,26.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Cigna,Commercial,,251.62,,,,,,,60.24,309.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Cigna,Commercial,,226.32,,,,,,,93.02,1836.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Cigna,Commercial,,22.04,,,,,,,14.07,52.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Cigna,Commercial,,9.32,,,,,,,9.32,62.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Cigna,Commercial,,4.39,,,,,,,3.61,285.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Cigna,Commercial,,7.39,,,,,,,7.39,574.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Cigna,Commercial,,9.32,,,,,,,9.32,49.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Cigna,Commercial,,9.32,,,,,,,9.32,53.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Cigna,Commercial,,0.02360,,,,,,,0.02360,29.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Cigna,Commercial,,0.02360,,,,,,,0.02360,20.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Cigna,Commercial,,536.38,,,,,,,220.46,45153.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Cigna,Commercial,,48.90,,,,,,,31.70,117.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Cigna,Commercial,,0.49560,,,,,,,0.20370,386.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Cigna,Commercial,,1.39,,,,,,,1.39,37.04,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Cigna,Commercial,,1.39,,,,,,,1.39,45.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Cigna,Commercial,,1.39,,,,,,,1.39,62.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Cigna,Commercial,,1.39,,,,,,,1.39,79.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Cigna,Commercial,,1.39,,,,,,,1.39,95.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Cigna,Commercial,,1.39,,,,,,,1.39,52.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Cigna,Commercial,,13.15,,,,,,,5.40,916.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Cigna,Commercial,,13.15,,,,,,,5.40,1737.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Cigna,Commercial,,0.35400,,,,,,,0.35400,31.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Cigna,Commercial,,17.35,,,,,,,16.80,91.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Cigna,Commercial,,48.03,,,,,,,19.74,2267.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Cigna,Commercial,,48.03,,,,,,,19.74,4331.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Cigna,Commercial,,48.03,,,,,,,19.74,998.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Cigna,Commercial,,1.94,,,,,,,0.24750,15.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Cigna,Commercial,,1.94,,,,,,,0.24750,47.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Cigna,Commercial,,0.02360,,,,,,,0.02360,26.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Cigna,Commercial,,20.65,,,,,,,8.49,1796.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Cigna,Commercial,,210.84,,,,,,,86.66,4808.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Cigna,Commercial,,0.23600,,,,,,,0.23600,124.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Cigna,Commercial,,9.98,,,,,,,4.10,849.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Cigna,Commercial,,0.14160,,,,,,,0.13200,75.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Cigna,Commercial,,1.70,,,,,,,1.70,195.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Cigna,Commercial,,1.70,,,,,,,1.70,195.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Cigna,Commercial,,39.03,,,,,,,39.03,654.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Cigna,Commercial,,6.70,,,,,,,2.84,665.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Cigna,Commercial,,6.70,,,,,,,2.84,1057.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Cigna,Commercial,,6.70,,,,,,,2.84,1580.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Cigna,Commercial,,6.70,,,,,,,2.84,2625.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Cigna,Commercial,,6.70,,,,,,,2.84,5239.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Cigna,Commercial,,6.70,,,,,,,2.84,7853.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Cigna,Commercial,,70.82,,,,,,,29.11,1258.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Cigna,Commercial,,408.35,,,,,,,167.84,6120.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Cigna,Commercial,,408.35,,,,,,,167.84,23869.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Cigna,Commercial,,13.48,,,,,,,5.54,4186.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Cigna,Commercial,,13.48,,,,,,,5.54,8325.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Cigna,Commercial,,172.75,,,,,,,63.83,236.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Cigna,Commercial,,172.75,,,,,,,63.83,236.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Cigna,Commercial,,15.88,,,,,,,6.53,6536.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Cigna,Commercial,,5.99,,,,,,,5.33,61.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Cigna,Commercial,,5.99,,,,,,,5.33,75.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Cigna,Commercial,,118.24,,,,,,,30.82,145.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Cigna,Commercial,,427.68,,,,,,,3.74,490.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Cigna,Commercial,,22.75,,,,,,,22.75,105.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Cigna,Commercial,,5.99,,,,,,,3.65,656.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Cigna,Commercial,,433.01,,,,,,,177.98,29774.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Cigna,Commercial,,433.01,,,,,,,177.98,118483.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Cigna,Commercial,,70.82,,,,,,,29.11,731.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Cigna,Commercial,,1.86,,,,,,,1.86,74.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Cigna,Commercial,,2.90,,,,,,,2.90,143.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Cigna,Commercial,,6155.26,,,,,,,2529.92,9842.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Cigna,Commercial,,1019.57,,,,,,,419.06,1666.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Cigna,Commercial,,4.72,,,,,,,2.16,526.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Cigna,Commercial,,6.44,,,,,,,6.44,44.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Cigna,Commercial,,6.16,,,,,,,6.16,136.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Cigna,Commercial,,6.16,,,,,,,6.16,166.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Cigna,Commercial,,0.25960,,,,,,,0.25960,60.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Cigna,Commercial,,0.25960,,,,,,,0.25960,57.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Cigna,Commercial,,0.25960,,,,,,,0.25960,56.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Cigna,Commercial,,0.25960,,,,,,,0.25960,57.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Cigna,Commercial,,0.25960,,,,,,,0.25960,75.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Cigna,Commercial,,0.25960,,,,,,,0.25960,77.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Cigna,Commercial,,610.39,,,,,,,250.88,41599.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Cigna,Commercial,,12.63,,,,,,,5.03,3313.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Cigna,Commercial,,0.21240,,,,,,,0.21240,52.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Cigna,Commercial,,0.21240,,,,,,,0.21240,20.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Cigna,Commercial,,3.47,,,,,,,1.42,826.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Cigna,Commercial,,3.47,,,,,,,1.42,1358.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Cigna,Commercial,,7.39,,,,,,,7.39,234.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Cigna,Commercial,,7.39,,,,,,,7.39,352.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Cigna,Commercial,,0.33040,,,,,,,0.33040,527.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Cigna,Commercial,,5.69,,,,,,,5.69,69.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Cigna,Commercial,,507.80,,,,,,,113.87,597.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Cigna,Commercial,,0.09440,,,,,,,0.09440,83.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Cigna,Commercial,,0.09440,,,,,,,0.09440,124.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Cigna,Commercial,,291.13,,,,,,,122.05,452.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Cigna,Commercial,,1.89,,,,,,,1.89,47.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Cigna,Commercial,,46.82,,,,,,,31.90,118.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Cigna,Commercial,,17.44,,,,,,,6.85,25.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Cigna,Commercial,,5.59,,,,,,,5.59,282.04,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Cigna,Commercial,,145.23,,,,,,,60.36,18855.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Cigna,Commercial,,1035.10,,,,,,,371.29,1376.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Cigna,Commercial,,0.07080,,,,,,,0.07080,713.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Cigna,Commercial,,0.21240,,,,,,,0.21240,26.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Cigna,Commercial,,40.17,,,,,,,16.51,22477.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Cigna,Commercial,,0.21240,,,,,,,0.21240,53.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Cigna,Commercial,,3.56,,,,,,,3.56,137.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Cigna,Commercial,,6.66,,,,,,,6.15,237.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Cigna,Commercial,,6.66,,,,,,,6.15,325.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Cigna,Commercial,,131.33,,,,,,,53.98,11755.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Cigna,Commercial,,20.65,,,,,,,5.28,22.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Cigna,Commercial,,34.81,,,,,,,12.01,44.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Cigna,Commercial,,0.02360,,,,,,,0.02360,23.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Cigna,Commercial,,21.36,,,,,,,4.46,21.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Cigna,Commercial,,0.04720,,,,,,,0.04720,64.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Cigna,Commercial,,0.07080,,,,,,,0.07080,109.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Cigna,Commercial,,0.21240,,,,,,,0.21240,23.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Cigna,Commercial,,0.02360,,,,,,,0.02360,19.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Cigna,Commercial,,0.02360,,,,,,,0.02360,17.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Cigna,Commercial,,0.02360,,,,,,,0.02360,21.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Cigna,Commercial,,0.02360,,,,,,,0.02360,31.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Cigna,Commercial,,0.02360,,,,,,,0.02360,39.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Cigna,Commercial,,8.43,,,,,,,8.43,132.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Cigna,Commercial,,1.13,,,,,,,1.13,39.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Cigna,Commercial,,3.26,,,,,,,3.26,18.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Cigna,Commercial,,0.21240,,,,,,,0.21240,22.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Cigna,Commercial,,0.16520,,,,,,,0.16520,126.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Cigna,Commercial,,2.50,,,,,,,2.50,265.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Cigna,Commercial,,1.13,,,,,,,1.13,858.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Cigna,Commercial,,67080.78,,,,,,,23675.99,87773.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Cigna,Commercial,,1.89,,,,,,,1.89,56.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Cigna,Commercial,,3.37,,,,,,,3.37,68.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Cigna,Commercial,,37.03,,,,,,,8.04,42.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Cigna,Commercial,,37.03,,,,,,,8.95,42.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Cigna,Commercial,,37.03,,,,,,,7.29,42.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Cigna,Commercial,,4.27,,,,,,,4.27,63.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Cigna,Commercial,,4.27,,,,,,,4.27,62.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Cigna,Commercial,,7.69,,,,,,,7.69,781.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Cigna,Commercial,,157.27,,,,,,,64.64,2699.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Cigna,Commercial,,0.02360,,,,,,,0.02360,24.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Cigna,Commercial,,2.50,,,,,,,2.50,15.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Cigna,Commercial,,417.81,,,,,,,86.25,417.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Cigna,Commercial,,190.88,,,,,,,47.35,196.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Cigna,Commercial,,0.02360,,,,,,,0.02360,48.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Cigna,Commercial,,1.13,,,,,,,1.13,80.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Cigna,Commercial,,111.68,,,,,,,28.88,111.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Cigna,Commercial,,1399.48,,,,,,,535.27,1984.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Cigna,Commercial,,0.49560,,,,,,,0.49560,64.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Cigna,Commercial,,1767.26,,,,,,,667.95,2476.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Cigna,Commercial,,19.40,,,,,,,19.40,254.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Cigna,Commercial,,8.50,,,,,,,2.76,665.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Cigna,Commercial,,7.13,,,,,,,7.13,237.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Cigna,Commercial,,442.67,,,,,,,137.63,800.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Cigna,Commercial,,1710.46,,,,,,,272.42,1710.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Cigna,Commercial,,1.96,,,,,,,1.80,64.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Cigna,Commercial,,2.60,,,,,,,2.60,28.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Cigna,Commercial,,18.76,,,,,,,7.71,4637.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Cigna,Commercial,,1878.77,,,,,,,1878.77,7727.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Cigna,Commercial,,0.49560,,,,,,,0.20370,33.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Cigna,Commercial,,0.49560,,,,,,,0.20370,47.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Cigna,Commercial,,0.49560,,,,,,,0.20370,194.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Cigna,Commercial,,0.49560,,,,,,,0.20370,261.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Cigna,Commercial,,5.14,,,,,,,5.14,34.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Cigna,Commercial,,50.29,,,,,,,43.77,162.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Cigna,Commercial,,2.17,,,,,,,2.17,74.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Cigna,Commercial,,2.60,,,,,,,2.60,115.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Cigna,Commercial,,0.40120,,,,,,,0.40120,16.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Cigna,Commercial,,621.03,,,,,,,12.96,731.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Cigna,Commercial,,115.55,,,,,,,47.49,8888.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Cigna,Commercial,,0.49560,,,,,,,0.49560,25.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Cigna,Commercial,,1.01,,,,,,,1.01,59.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Cigna,Commercial,,1.44,,,,,,,1.44,17.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Cigna,Commercial,,416.42,,,,,,,171.16,7213.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Cigna,Commercial,,38.23,,,,,,,38.23,185.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Cigna,Commercial,,0.02360,,,,,,,0.02360,102.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Cigna,Commercial,,179.03,,,,,,,73.58,14437.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Cigna,Commercial,,0.07080,,,,,,,0.07080,69.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Cigna,Commercial,,0.23600,,,,,,,0.19800,52.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Cigna,Commercial,,0.09440,,,,,,,0.09440,55.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Cigna,Commercial,,0.09440,,,,,,,0.09440,55.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Cigna,Commercial,,0.09440,,,,,,,0.09440,62.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Cigna,Commercial,,4083.56,,,,,,,1641.62,6085.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Cigna,Commercial,,18.12,,,,,,,5.33,285.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Cigna,Commercial,,1.89,,,,,,,1.89,52.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Cigna,Commercial,,1.89,,,,,,,1.89,49.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Cigna,Commercial,,4.37,,,,,,,4.37,21.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Cigna,Commercial,,1.96,,,,,,,1.80,83.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Cigna,Commercial,,1.96,,,,,,,1.80,98.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Cigna,Commercial,,0.02360,,,,,,,0.02360,66.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Cigna,Commercial,,0.37760,,,,,,,0.37760,13.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Cigna,Commercial,,148.82,,,,,,,61.17,938.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Cigna,Commercial,,1.32,,,,,,,1.25,336.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Cigna,Commercial,,1.32,,,,,,,1.25,673.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Cigna,Commercial,,28.44,,,,,,,5.67,29.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Cigna,Commercial,,3.52,,,,,,,3.52,100.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Cigna,Commercial,,3.52,,,,,,,3.52,105.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Cigna,Commercial,,0.02360,,,,,,,0.02360,15.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Cigna,Commercial,,0.02360,,,,,,,0.02360,13.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Cigna,Commercial,,16.71,,,,,,,16.71,105.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Cigna,Commercial,,16.71,,,,,,,16.71,122.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Cigna,Commercial,,0.25960,,,,,,,0.25960,75.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Cigna,Commercial,,1.13,,,,,,,1.13,68.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Cigna,Commercial,,1731.46,,,,,,,711.66,10302.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Cigna,Commercial,,2434.60,,,,,,,813.92,3304.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Cigna,Commercial,,0.09440,,,,,,,0.09440,83.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Cigna,Commercial,,0.09440,,,,,,,0.09440,87.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Cigna,Commercial,,99.50,,,,,,,40.90,13232.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Cigna,Commercial,,99.50,,,,,,,40.90,21050.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Cigna,Commercial,,2.88,,,,,,,2.88,48.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Cigna,Commercial,,59.64,,,,,,,29.52,109.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Cigna,Commercial,,128.86,,,,,,,32.33,128.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Cigna,Commercial,,11.94,,,,,,,11.94,202.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Cigna,Commercial,,1.82,,,,,,,1.82,72.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Cigna,Commercial,,2740.20,,,,,,,916.12,3718.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Cigna,Commercial,,50.79,,,,,,,50.79,408.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Cigna,Commercial,,0.35400,,,,,,,0.35400,19.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Cigna,Commercial,,0.35400,,,,,,,0.35400,16.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Cigna,Commercial,,7.39,,,,,,,7.39,240.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Cigna,Commercial,,7.39,,,,,,,7.39,366.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Cigna,Commercial,,728.48,,,,,,,299.42,4744.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Cigna,Commercial,,5.14,,,,,,,5.14,21.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Cigna,Commercial,,175.49,,,,,,,72.13,5105.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Cigna,Commercial,,175.49,,,,,,,72.13,24709.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Cigna,Commercial,,2.60,,,,,,,2.60,40.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Cigna,Commercial,,2.60,,,,,,,2.60,59.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Cigna,Commercial,,7.17,,,,,,,2.08,66.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Cigna,Commercial,,50.29,,,,,,,20.67,29223.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Cigna,Commercial,,36.84,,,,,,,15.14,6020.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Cigna,Commercial,,7.17,,,,,,,2.08,66.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Cigna,Commercial,,0.99120,,,,,,,0.99120,56.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Cigna,Commercial,,0.99120,,,,,,,0.99120,65.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Cigna,Commercial,,18.76,,,,,,,7.71,1553.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Cigna,Commercial,,0.54280,,,,,,,0.54280,343.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Cigna,Commercial,,150.45,,,,,,,150.45,812.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Cigna,Commercial,,2.19,,,,,,,2.19,28.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Cigna,Commercial,,2.19,,,,,,,2.19,28.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Cigna,Commercial,,387.63,,,,,,,159.32,18350.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Cigna,Commercial,,21.41,,,,,,,8.80,600.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Cigna,Commercial,,77.79,,,,,,,31.97,4527.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Cigna,Commercial,,77.79,,,,,,,31.97,11012.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Cigna,Commercial,,626.79,,,,,,,146.38,774.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Cigna,Commercial,,210.84,,,,,,,86.66,21685.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Cigna,Commercial,,142.28,,,,,,,58.48,19464.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Cigna,Commercial,,480.45,,,,,,,197.47,15601.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Cigna,Commercial,,480.45,,,,,,,197.47,23355.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Cigna,Commercial,,480.45,,,,,,,197.47,11910.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Cigna,Commercial,,247.16,,,,,,,101.59,1341.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Cigna,Commercial,,2242.87,,,,,,,750.14,3043.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Cigna,Commercial,,1.89,,,,,,,1.89,70.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Cigna,Commercial,,119.75,,,,,,,49.22,2905.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Cigna,Commercial,,54990.28,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Cigna,Commercial,,115.71,,,,,,,47.56,1468.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Cigna,Commercial,,115.71,,,,,,,47.56,366.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Cigna,Commercial,,185.94,,,,,,,76.44,3435.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Cigna,Commercial,,185.94,,,,,,,76.44,6814.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Cigna,Commercial,,48.21,,,,,,,19.38,3392.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Cigna,Commercial,,1.09,,,,,,,0.44620,1494.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Cigna,Commercial,,1.09,,,,,,,0.44620,938.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Cigna,Commercial,,4.32,,,,,,,4.32,32.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Cigna,Commercial,,4.32,,,,,,,4.32,95.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Cigna,Commercial,,0.47200,,,,,,,0.46200,56.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Cigna,Commercial,,0.47200,,,,,,,0.46200,65.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Cigna,Commercial,,155.76,,,,,,,64.02,9932.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Cigna,Commercial,,73.80,,,,,,,30.33,12178.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Cigna,Commercial,,31.84,,,,,,,13.09,8282.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Cigna,Commercial,,0.54280,,,,,,,0.54280,651.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Cigna,Commercial,,47.18,,,,,,,19.39,2996.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Cigna,Commercial,,265.38,,,,,,,109.08,1229.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Cigna,Commercial,,168.32,,,,,,,61.99,229.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Cigna,Commercial,,2923.87,,,,,,,930.37,3968.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Cigna,Commercial,,215.56,,,,,,,88.60,38051.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Cigna,Commercial,,0.49560,,,,,,,0.49560,90.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Cigna,Commercial,,4.79,,,,,,,1.78,45.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Cigna,Commercial,,6.49,,,,,,,6.49,803.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Cigna,Commercial,,94.00,,,,,,,38.64,11892.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Cigna,Commercial,,0.11800,,,,,,,0.11800,30.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Cigna,Commercial,,0.11800,,,,,,,0.11800,142.24,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Cigna,Commercial,,0.11800,,,,,,,0.11800,49.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Cigna,Commercial,,0.11800,,,,,,,0.11800,272.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Cigna,Commercial,,0.11800,,,,,,,0.11800,42.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Cigna,Commercial,,0.11800,,,,,,,0.11800,25.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Cigna,Commercial,,0.11800,,,,,,,0.11800,29.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Cigna,Commercial,,334.18,,,,,,,137.35,66706.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Cigna,Commercial,,236.21,,,,,,,97.09,7042.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Cigna,Commercial,,140.21,,,,,,,57.63,64389.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Cigna,Commercial,,177.05,,,,,,,72.78,5293.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Cigna,Commercial,,200.88,,,,,,,82.57,14229.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Cigna,Commercial,,200.88,,,,,,,82.57,3570.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Cigna,Commercial,,86.59,,,,,,,35.59,21681.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Cigna,Commercial,,86.59,,,,,,,35.59,24749.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Cigna,Commercial,,604.37,,,,,,,248.41,36061.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Cigna,Commercial,,6367.40,,,,,,,2617.11,78305.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Cigna,Commercial,,2.53,,,,,,,2.53,67.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Cigna,Commercial,,16.71,,,,,,,16.71,148.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Cigna,Commercial,,5.36,,,,,,,2.11,740.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Cigna,Commercial,,569.63,,,,,,,133.84,569.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Cigna,Commercial,,1.13,,,,,,,1.13,13.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Cigna,Commercial,,3.87,,,,,,,1.59,1463.80,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Cigna,Commercial,,388.43,,,,,,,159.65,19757.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Cigna,Commercial,,19.23,,,,,,,7.91,4372.04,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Cigna,Commercial,,77.79,,,,,,,31.97,26143.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Cigna,Commercial,,0.21240,,,,,,,0.21240,59.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Cigna,Commercial,,20.65,,,,,,,5.28,22.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Cigna,Commercial,,42.74,,,,,,,11.70,50.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Cigna,Commercial,,18.53,,,,,,,7.61,94.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Cigna,Commercial,,18.53,,,,,,,7.61,135.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Cigna,Commercial,,18.53,,,,,,,7.61,176.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Cigna,Commercial,,18.53,,,,,,,7.61,421.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Cigna,Commercial,,18.53,,,,,,,7.61,1645.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Cigna,Commercial,,233.95,,,,,,,96.16,7061.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Cigna,Commercial,,411.68,,,,,,,97.95,495.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Cigna,Commercial,,586.46,,,,,,,241.04,15821.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Cigna,Commercial,,0.70800,,,,,,,0.29100,751.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Cigna,Commercial,,0.70800,,,,,,,0.29100,1195.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Cigna,Commercial,,3.14,,,,,,,3.14,255.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Cigna,Commercial,,69.12,,,,,,,28.41,35881.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Cigna,Commercial,,250.94,,,,,,,103.14,14110.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Cigna,Commercial,,300.90,,,,,,,127.44,7479.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Cigna,Commercial,,0.70800,,,,,,,0.29100,751.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Cigna,Commercial,,1875.80,,,,,,,1875.80,26766.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Cigna,Commercial,,242.94,,,,,,,99.04,2173.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Cigna,Commercial,,215.56,,,,,,,88.60,26697.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Cigna,Commercial,,145.00,,,,,,,59.60,15471.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Cigna,Commercial,,16.12,,,,,,,6.63,311.39,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Cigna,Commercial,,322.54,,,,,,,132.57,60983.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Cigna,Commercial,,65.75,,,,,,,27.02,9318.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Cigna,Commercial,,65.75,,,,,,,27.02,2482.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Cigna,Commercial,,0.21240,,,,,,,0.21240,149.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Cigna,Commercial,,69.34,,,,,,,28.50,2965.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Cigna,Commercial,,69.34,,,,,,,28.50,14010.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Cigna,Commercial,,99.07,,,,,,,40.72,12868.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Cigna,Commercial,,99.07,,,,,,,40.72,38511.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Cigna,Commercial,,305.57,,,,,,,125.60,7693.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Cigna,Commercial,,25.98,,,,,,,10.68,4660.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Cigna,Commercial,,86.71,,,,,,,35.64,9377.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Cigna,Commercial,,86.71,,,,,,,35.64,13964.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Cigna,Commercial,,70.75,,,,,,,29.08,10283.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Cigna,Commercial,,60.82,,,,,,,25.00,8216.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Cigna,Commercial,,60.82,,,,,,,25.00,2207.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Cigna,Commercial,,65.73,,,,,,,27.01,2544.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Cigna,Commercial,,65.73,,,,,,,27.01,11908.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Cigna,Commercial,,847.69,,,,,,,348.41,56216.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Cigna,Commercial,,66.06,,,,,,,27.15,11278.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Cigna,Commercial,,47.13,,,,,,,19.37,6094.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Cigna,Commercial,,193.28,,,,,,,79.44,14408.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Cigna,Commercial,,193.28,,,,,,,79.44,3044.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Cigna,Commercial,,85.62,,,,,,,35.19,8575.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Cigna,Commercial,,751.73,,,,,,,308.97,81666.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Cigna,Commercial,,48.17,,,,,,,19.80,1605.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Cigna,Commercial,,146.56,,,,,,,60.24,45651.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Cigna,Commercial,,146.56,,,,,,,60.24,30500.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Cigna,Commercial,,0.23600,,,,,,,0.19800,48.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Cigna,Commercial,,0.35400,,,,,,,0.35400,65.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Cigna,Commercial,,33.77,,,,,,,13.88,4762.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Cigna,Commercial,,322.54,,,,,,,132.57,13228.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Cigna,Commercial,,531.26,,,,,,,218.36,74707.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Cigna,Commercial,,531.26,,,,,,,218.36,20408.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Cigna,Commercial,,18.53,,,,,,,7.61,829.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Cigna,Commercial,,12.89,,,,,,,5.30,5005.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Cigna,Commercial,,66.06,,,,,,,27.15,4159.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Cigna,Commercial,,4994.52,,,,,,,1845.18,6840.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Cigna,Commercial,,511.88,,,,,,,210.39,92693.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Cigna,Commercial,,575.16,,,,,,,236.40,39491.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Cigna,Commercial,,53.19,,,,,,,21.86,12635.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Cigna,Commercial,,725.82,,,,,,,174.05,872.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Cigna,Commercial,,445.47,,,,,,,183.10,24372.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Cigna,Commercial,,0.21240,,,,,,,0.21240,79.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Cigna,Commercial,,29.08,,,,,,,11.95,12127.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Cigna,Commercial,,199.59,,,,,,,82.03,27041.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Cigna,Commercial,,2.19,,,,,,,2.19,202.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Cigna,Commercial,,1.89,,,,,,,1.89,65.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Cigna,Commercial,,42.88,,,,,,,16.57,61.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Cigna,Commercial,,42.88,,,,,,,16.57,61.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Cigna,Commercial,,0.89680,,,,,,,0.36860,548.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Cigna,Commercial,,0.89680,,,,,,,0.36860,871.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Cigna,Commercial,,466.88,,,,,,,191.90,50567.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Cigna,Commercial,,1717.60,,,,,,,525.79,2135.18,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Cigna,Commercial,,78.21,,,,,,,20.83,97.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Cigna,Commercial,,79.23,,,,,,,32.57,34322.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Cigna,Commercial,,79.23,,,,,,,32.57,6893.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Cigna,Commercial,,440.75,,,,,,,104.10,544.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Cigna,Commercial,,164.00,,,,,,,67.41,22353.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Cigna,Commercial,,1544.93,,,,,,,604.94,2242.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Cigna,Commercial,,1544.93,,,,,,,634.99,61362.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Cigna,Commercial,,72.12,,,,,,,29.64,48350.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Cigna,Commercial,,59.09,,,,,,,24.29,8882.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Cigna,Commercial,,59.09,,,,,,,24.29,17752.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Cigna,Commercial,,59.09,,,,,,,24.29,22187.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Cigna,Commercial,,143724.00,,,,,,,13645.27,176902.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Cigna,Commercial,,810.94,,,,,,,188.67,1002.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Cigna,Commercial,,1469.97,,,,,,,509.79,1889.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Cigna,Commercial,,1469.97,,,,,,,509.80,1889.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Cigna,Commercial,,171.38,,,,,,,70.44,37932.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Cigna,Commercial,,171.38,,,,,,,70.44,3033.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Cigna,Commercial,,1.35,,,,,,,1.35,189.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Cigna,Commercial,,41521.48,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Cigna,Commercial,,6.49,,,,,,,6.49,173.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Cigna,Commercial,,250.94,,,,,,,103.14,14110.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Cigna,Commercial,,4.79,,,,,,,1.78,261.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Cigna,Commercial,,15286.14,,,,,,,5351.96,20188.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Cigna,Commercial,,134.59,,,,,,,55.32,8159.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Cigna,Commercial,,134.59,,,,,,,55.32,32495.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Cigna,Commercial,,798.51,,,,,,,176.78,914.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Cigna,Commercial,,179.29,,,,,,,73.69,45453.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Cigna,Commercial,,79.56,,,,,,,32.43,5429.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Cigna,Commercial,,227.93,,,,,,,51.51,232.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Cigna,Commercial,,54.16,,,,,,,16.27,62.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Cigna,Commercial,,2.36,,,,,,,2.36,12.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Cigna,Commercial,,2.36,,,,,,,2.36,12.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Cigna,Commercial,,2.36,,,,,,,2.36,12.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Cigna,Commercial,,64.57,,,,,,,26.54,26143.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Cigna,Commercial,,121.68,,,,,,,50.01,17719.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Cigna,Commercial,,1.96,,,,,,,1.96,270.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Cigna,Commercial,,406.44,,,,,,,167.05,28031.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Cigna,Commercial,,390.37,,,,,,,93.11,434.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Cigna,Commercial,,8.14,,,,,,,8.14,243.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Cigna,Commercial,,55.72,,,,,,,38.62,143.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Cigna,Commercial,,4.81,,,,,,,4.81,69.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Cigna,Commercial,,117.88,,,,,,,18.23,182.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Cigna,Commercial,,50.69,,,,,,,20.84,1039.04,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Cigna,Commercial,,177.52,,,,,,,72.96,3272.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Cigna,Commercial,,177.52,,,,,,,72.96,15544.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Cigna,Commercial,,30.42,,,,,,,6.09,4722.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Cigna,Commercial,,0.70800,,,,,,,0.29100,33.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Cigna,Commercial,,100.21,,,,,,,100.21,3104.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Cigna,Commercial,,2.24,,,,,,,1.83,94.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Cigna,Commercial,,24.07,,,,,,,24.07,826.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Cigna,Commercial,,0.04720,,,,,,,0.04720,47.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Cigna,Commercial,,0.04720,,,,,,,0.04720,12.39,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Cigna,Commercial,,0.04720,,,,,,,0.04720,13.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Cigna,Commercial,,0.04720,,,,,,,0.04720,14.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Cigna,Commercial,,0.21240,,,,,,,0.21240,18.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Cigna,Commercial,,7.60,,,,,,,7.60,485.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Cigna,Commercial,,7.34,,,,,,,7.34,60.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Cigna,Commercial,,4.27,,,,,,,4.27,57.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Cigna,Commercial,,73.37,,,,,,,30.16,1527.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Cigna,Commercial,,0.84960,,,,,,,0.84960,383.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Cigna,Commercial,,0.40120,,,,,,,0.40120,17.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Cigna,Commercial,,4.77,,,,,,,4.77,145.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Cigna,Commercial,,0.37760,,,,,,,0.37760,35.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Cigna,Commercial,,1.79,,,,,,,1.79,22.04,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Cigna,Commercial,,3.07,,,,,,,3.07,60.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Cigna,Commercial,,1.96,,,,,,,1.80,59.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Cigna,Commercial,,0.25960,,,,,,,0.25960,122.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Cigna,Commercial,,4.55,,,,,,,4.55,62.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Cigna,Commercial,,101.93,,,,,,,41.89,5452.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Cigna,Commercial,,18.01,,,,,,,5.63,20.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Cigna,Commercial,,42.88,,,,,,,7.99,48.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Cigna,Commercial,,3.42,,,,,,,3.42,72.10,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Cigna,Commercial,,3.42,,,,,,,3.42,75.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Cigna,Commercial,,3.42,,,,,,,3.42,109.10,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Cigna,Commercial,,5.14,,,,,,,5.14,19.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Cigna,Commercial,,28.44,,,,,,,28.44,875.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Cigna,Commercial,,255.99,,,,,,,105.22,1673.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Cigna,Commercial,,255.99,,,,,,,105.22,4286.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Cigna,Commercial,,118.28,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Cigna,Commercial,,118.28,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Cigna,Commercial,,127.20,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Cigna,Commercial,,127.96,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Cigna,Commercial,,4.60,,,,,,,4.60,58.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Cigna,Commercial,,0.54280,,,,,,,0.54280,228.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Cigna,Commercial,,1.13,,,,,,,1.13,16.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Cigna,Commercial,,1.89,,,,,,,1.89,20.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Cigna,Commercial,,4.81,,,,,,,4.81,46.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Cigna,Commercial,,774.88,,,,,,,318.49,2612.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Cigna,Commercial,,1.89,,,,,,,0.77600,893.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Cigna,Commercial,,152.50,,,,,,,104.89,388.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Cigna,Commercial,,1.13,,,,,,,1.13,518.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Cigna,Commercial,,19.23,,,,,,,7.91,889.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Cigna,Commercial,,0.54280,,,,,,,0.54280,249.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Cigna,Commercial,,0.54280,,,,,,,0.54280,14.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Cigna,Commercial,,4315.76,,,,,,,1773.86,9551.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Cigna,Commercial,,23.46,,,,,,,10.49,38.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Cigna,Commercial,,0.40120,,,,,,,0.40120,265.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Cigna,Commercial,,0.51920,,,,,,,0.51920,514.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Cigna,Commercial,,4.01,,,,,,,1.65,61.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Cigna,Commercial,,2.60,,,,,,,2.60,21.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Cigna,Commercial,,2.60,,,,,,,2.60,31.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Cigna,Commercial,,2.60,,,,,,,2.60,21.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Cigna,Commercial,,2.60,,,,,,,2.60,39.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Cigna,Commercial,,2.60,,,,,,,2.60,23.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Cigna,Commercial,,2.60,,,,,,,2.60,69.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Cigna,Commercial,,0.33040,,,,,,,0.29700,345.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Cigna,Commercial,,0.33040,,,,,,,0.29700,236.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Cigna,Commercial,,0.33040,,,,,,,0.29700,626.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Cigna,Commercial,,95.93,,,,,,,53.06,215.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Cigna,Commercial,,222.90,,,,,,,91.62,637.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Cigna,Commercial,,12197.02,,,,,,,3998.59,14823.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Cigna,Commercial,,1.39,,,,,,,1.39,62.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Cigna,Commercial,,17.32,,,,,,,7.12,44.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Cigna,Commercial,,1.70,,,,,,,1.70,89.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Cigna,Commercial,,210.84,,,,,,,86.66,21685.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Cigna,Commercial,,0.14160,,,,,,,0.14160,13.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Cigna,Commercial,,22.75,,,,,,,18.69,69.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Cigna,Commercial,,14.75,,,,,,,6.30,2210.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Cigna,Commercial,,22.75,,,,,,,22.75,95.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Cigna,Commercial,,416.42,,,,,,,171.16,1679.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Cigna,Commercial,,0.04720,,,,,,,0.04720,31.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Cigna,Commercial,,0.04720,,,,,,,0.04720,26.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Cigna,Commercial,,0.04720,,,,,,,0.04720,21.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Cigna,Commercial,,129.12,,,,,,,53.07,3881.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Cigna,Commercial,,129.12,,,,,,,53.07,9686.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Cigna,Commercial,,129.12,,,,,,,53.07,19361.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Cigna,Commercial,,129.12,,,,,,,53.07,38712.04,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Cigna,Commercial,,3.42,,,,,,,3.42,134.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Cigna,Commercial,,1.82,,,,,,,1.82,234.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Cigna,Commercial,,890.95,,,,,,,366.19,3497.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Cigna,Commercial,,5.22,,,,,,,5.22,27.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Cigna,Commercial,,5.22,,,,,,,5.22,124.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Cigna,Commercial,,273.88,,,,,,,64.39,336.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Cigna,Commercial,,1.09,,,,,,,0.44620,20.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Cigna,Commercial,,6.44,,,,,,,6.44,768.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Cigna,Commercial,,11.94,,,,,,,11.94,187.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Cigna,Commercial,,6.58,,,,,,,4.32,5438.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Cigna,Commercial,,1.89,,,,,,,1.89,13.10,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Cigna,Commercial,,0.25960,,,,,,,0.25960,64.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Cigna,Commercial,,105.26,,,,,,,43.26,4637.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Cigna,Commercial,,13.22,,,,,,,13.22,52.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Cigna,Commercial,,0.07080,,,,,,,0.07080,358.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Cigna,Commercial,,0.21240,,,,,,,0.21240,17.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Cigna,Commercial,,5.46,,,,,,,1.67,6.79,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Cigna,Commercial,,36.11,,,,,,,33.91,125.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Cigna,Commercial,,10.29,,,,,,,4.23,13407.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Cigna,Commercial,,184.95,,,,,,,76.02,2935.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Cigna,Commercial,,0.80240,,,,,,,0.80240,22.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Cigna,Commercial,,11.47,,,,,,,11.47,562.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Cigna,Commercial,,2.05,,,,,,,2.05,106.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Cigna,Commercial,,1.13,,,,,,,0.46560,2034.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Cigna,Commercial,,1.13,,,,,,,0.46560,1119.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Cigna,Commercial,,0.89680,,,,,,,0.89680,81.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Cigna,Commercial,,1.32,,,,,,,1.25,30.39,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Cigna,Commercial,,4.08,,,,,,,1.68,17.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Cigna,Commercial,,5.83,,,,,,,5.74,279.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Cigna,Commercial,,5.83,,,,,,,5.74,358.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Cigna,Commercial,,5.83,,,,,,,5.74,247.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Cigna,Commercial,,5.83,,,,,,,5.74,397.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Cigna,Commercial,,5.59,,,,,,,5.02,18.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Cigna,Commercial,,5.59,,,,,,,5.59,86.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Cigna,Commercial,,4.60,,,,,,,4.60,50.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Cigna,Commercial,,2.97,,,,,,,2.97,52.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Cigna,Commercial,,2.97,,,,,,,2.97,50.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Cigna,Commercial,,2.97,,,,,,,2.97,59.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Cigna,Commercial,,4.27,,,,,,,4.27,52.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Cigna,Commercial,,7.34,,,,,,,7.34,50.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Cigna,Commercial,,3.33,,,,,,,3.33,52.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Cigna,Commercial,,3.33,,,,,,,3.33,50.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Cigna,Commercial,,3.33,,,,,,,3.33,50.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Cigna,Commercial,,5.69,,,,,,,5.69,50.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Cigna,Commercial,,19.21,,,,,,,16.22,60.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Cigna,Commercial,,19.21,,,,,,,14.41,53.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Cigna,Commercial,,4.04,,,,,,,4.04,16.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Cigna,Commercial,,24.87,,,,,,,10.22,5364.10,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Cigna,Commercial,,23.93,,,,,,,9.84,19644.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Cigna,Commercial,,23.93,,,,,,,9.84,4149.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Cigna,Commercial,,23.93,,,,,,,9.84,19644.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Cigna,Commercial,,5734.54,,,,,,,0.04004,6806.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Cigna,Commercial,,24.40,,,,,,,21.42,79.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Cigna,Commercial,,6.58,,,,,,,4.32,5438.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Cigna,Commercial,,50.79,,,,,,,50.79,259.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Cigna,Commercial,,48.03,,,,,,,19.74,922.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Cigna,Commercial,,2.88,,,,,,,2.88,5218.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Cigna,Commercial,,7.39,,,,,,,7.39,246.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Cigna,Commercial,,7.39,,,,,,,7.39,228.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Cigna,Commercial,,7.39,,,,,,,7.39,499.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Cigna,Commercial,,433.01,,,,,,,177.98,29774.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Cigna,Commercial,,433.01,,,,,,,177.98,118483.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Cigna,Commercial,,160.95,,,,,,,66.15,1092.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Cigna,Commercial,,145.23,,,,,,,60.36,2174.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Cigna,Commercial,,145.23,,,,,,,60.36,19908.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Cigna,Commercial,,7.13,,,,,,,7.13,237.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Cigna,Commercial,,4.70,,,,,,,4.69,215.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Cigna,Commercial,,6.66,,,,,,,6.15,233.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Cigna,Commercial,,6.66,,,,,,,6.15,215.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Cigna,Commercial,,6.66,,,,,,,6.15,312.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Cigna,Commercial,,1.42,,,,,,,1.04,1510.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Cigna,Commercial,,1.42,,,,,,,1.04,367.39,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Cigna,Commercial,,1.42,,,,,,,1.04,739.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Cigna,Commercial,,93.31,,,,,,,15.53,107.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Cigna,Commercial,,7.39,,,,,,,7.39,250.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Cigna,Commercial,,13.48,,,,,,,5.54,4186.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Cigna,Commercial,,13.48,,,,,,,5.54,8325.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Cigna,Commercial,,0.49560,,,,,,,0.20370,33.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Cigna,Commercial,,0.49560,,,,,,,0.20370,47.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Cigna,Commercial,,0.02360,,,,,,,0.02360,14.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Cigna,Commercial,,0.49560,,,,,,,0.49560,62.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Cigna,Commercial,,19.40,,,,,,,19.40,254.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Cigna,Commercial,,5.14,,,,,,,5.14,45.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Cigna,Commercial,,0.35400,,,,,,,0.35400,56.41,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Cigna,Commercial,,7.60,,,,,,,7.60,217.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Cigna,Commercial,,1.89,,,,,,,1.89,15.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Cigna,Commercial,,2.88,,,,,,,2.88,32.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Cigna,Commercial,,1.01,,,,,,,1.01,18.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Cigna,Commercial,,1.01,,,,,,,1.01,21.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Cigna,Commercial,,1.01,,,,,,,1.01,14.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Cigna,Commercial,,1.01,,,,,,,1.01,14.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Cigna,Commercial,,3.52,,,,,,,0.04004,3.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,0.49560,,,,,,,0.04004,0.59400,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Cigna,Commercial,,0.14160,,,,,,,0.13200,76.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Cigna,Commercial,,0.21240,,,,,,,0.04004,0.33000,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,0.04720,,,,,,,0.04004,0.14844,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,0.04720,,,,,,,0.04004,0.14844,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Cigna,Commercial,,1.53,,,,,,,0.04004,1.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Cigna,Commercial,,4.60,,,,,,,0.04004,4.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Cigna,Commercial,,1.53,,,,,,,0.04004,1.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Cigna,Commercial,,1.53,,,,,,,0.04004,1.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Cigna,Commercial,,1.53,,,,,,,0.04004,1.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Cigna,Commercial,,2.97,,,,,,,0.04004,2.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Cigna,Commercial,,2.97,,,,,,,2.97,53.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Cigna,Commercial,,4.60,,,,,,,4.60,58.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Cigna,Commercial,,2.97,,,,,,,2.97,53.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Cigna,Commercial,,1.53,,,,,,,1.53,56.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Cigna,Commercial,,2.97,,,,,,,2.97,52.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Cigna,Commercial,,2.97,,,,,,,2.97,56.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Cigna,Commercial,,1.53,,,,,,,0.04004,1.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Cigna,Commercial,,0.02360,,,,,,,0.02360,0.14844,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Cigna,Commercial,,0.21240,,,,,,,0.04004,0.33000,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Cigna,Commercial,,5.97,,,,,,,5.97,212.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,1.79,,,,,,,0.04004,2.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,0.49560,,,,,,,0.04004,0.71810,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Cigna,Commercial,,3.71,,,,,,,3.71,46.80,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Cigna,Commercial,,2.90,,,,,,,2.90,88.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,610.39,,,,,,,0.04004,720.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Cigna,Commercial,,0.54280,,,,,,,0.54280,162.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Cigna,Commercial,,9.98,,,,,,,4.10,849.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Cigna,Commercial,,0.02360,,,,,,,0.02360,34.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Cigna,Commercial,,0.21240,,,,,,,0.21240,23.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Cigna,Commercial,,488.83,,,,,,,200.92,27145.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Cigna,Commercial,,0.54280,,,,,,,0.54280,236.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Cigna,Commercial,,0.54280,,,,,,,0.54280,162.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Cigna,Commercial,,0.02360,,,,,,,0.02360,47.39,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Cigna,Commercial,,0.02360,,,,,,,0.02360,85.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Cigna,Commercial,,2.60,,,,,,,2.60,20.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Cigna,Commercial,,0.63720,,,,,,,0.63720,9.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Cigna,Commercial,,0.63720,,,,,,,0.63720,9.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Cigna,Commercial,,0.63720,,,,,,,0.63720,9.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Cigna,Commercial,,0.63720,,,,,,,0.63720,9.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,0.33040,,,,,,,0.04004,0.33040,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Cigna,Commercial,,0.21240,,,,,,,0.21240,55.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Cigna,Commercial,,23.46,,,,,,,21.65,80.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Cigna,Commercial,,23.46,,,,,,,23.46,113.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Cigna,Commercial,,1.94,,,,,,,0.24750,16.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Cigna,Commercial,,1.94,,,,,,,0.24750,14.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Cigna,Commercial,,886.06,,,,,,,271.45,10158.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Cigna,Commercial,,886.06,,,,,,,271.45,2077.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Cigna,Commercial,,0.80240,,,,,,,0.80240,59.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Cigna,Commercial,,1.30,,,,,,,1.30,35.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Cigna,Commercial,,1.30,,,,,,,1.30,20.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Cigna,Commercial,,0.70800,,,,,,,0.29100,33.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Cigna,Commercial,,2.53,,,,,,,2.53,47.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Cigna,Commercial,,0.21240,,,,,,,0.21240,22.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Cigna,Commercial,,3.42,,,,,,,3.42,21.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Cigna,Commercial,,5.59,,,,,,,4.13,15.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Cigna,Commercial,,1.13,,,,,,,1.13,14.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Cigna,Commercial,,1.13,,,,,,,1.13,15.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Cigna,Commercial,,1.13,,,,,,,1.13,19.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Cigna,Commercial,,0.21240,,,,,,,0.21240,114.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Cigna,Commercial,,0.40120,,,,,,,0.40120,300.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Cigna,Commercial,,21.36,,,,,,,10.89,49.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Cigna,Commercial,,0.21240,,,,,,,0.21240,85.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Cigna,Commercial,,0.14160,,,,,,,0.14160,12.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Cigna,Commercial,,59.87,,,,,,,12.81,76.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Cigna,Commercial,,1.79,,,,,,,1.79,12.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Cigna,Commercial,,0.49560,,,,,,,0.49560,70.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Cigna,Commercial,,42.74,,,,,,,17.57,619.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Cigna,Commercial,,1.89,,,,,,,1.89,48.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Cigna,Commercial,,4.37,,,,,,,4.37,60.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Cigna,Commercial,,8.43,,,,,,,8.43,165.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Cigna,Commercial,,0.18880,,,,,,,0.18880,65.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Cigna,Commercial,,6.44,,,,,,,6.44,104.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Cigna,Commercial,,3.28,,,,,,,3.28,37.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Cigna,Commercial,,2.60,,,,,,,2.60,21.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Cigna,Commercial,,406.44,,,,,,,167.05,28031.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Cigna,Commercial,,7.60,,,,,,,7.60,236.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Cigna,Commercial,,1.96,,,,,,,1.80,47.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Cigna,Commercial,,1.96,,,,,,,1.80,53.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Cigna,Commercial,,0.02360,,,,,,,0.02360,48.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Cigna,Commercial,,0.49560,,,,,,,0.49560,55.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Cigna,Commercial,,0.70800,,,,,,,0.29100,14.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Cigna,Commercial,,3.42,,,,,,,3.42,50.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Cigna,Commercial,,3.42,,,,,,,3.42,71.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Cigna,Commercial,,28.44,,,,,,,6.15,29.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Cigna,Commercial,,0.54280,,,,,,,0.54280,185.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Cigna,Commercial,,0.02360,,,,,,,0.02360,126.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Cigna,Commercial,,5.99,,,,,,,5.33,59.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Cigna,Commercial,,0.07080,,,,,,,0.07080,52.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Cigna,Commercial,,23.60,,,,,,,19.39,77.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Cigna,Commercial,,23.60,,,,,,,16.40,60.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Cigna,Commercial,,11.28,,,,,,,11.28,71.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Cigna,Commercial,,3.71,,,,,,,3.71,81.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Cigna,Commercial,,2.88,,,,,,,2.88,355.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Cigna,Commercial,,4.32,,,,,,,4.32,87.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Cigna,Commercial,,0.99120,,,,,,,0.99120,420.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Cigna,Commercial,,351.62,,,,,,,144.52,865.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Cigna,Commercial,,430.58,,,,,,,176.98,922.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Cigna,Commercial,,4.37,,,,,,,4.37,27.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Cigna,Commercial,,0.25960,,,,,,,0.25960,62.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Cigna,Commercial,,0.25960,,,,,,,0.25960,55.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Cigna,Commercial,,0.09440,,,,,,,0.09440,113.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Cigna,Commercial,,1.01,,,,,,,1.01,162.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Cigna,Commercial,,0.07080,,,,,,,0.07080,380.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Cigna,Commercial,,0.07080,,,,,,,0.07080,713.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Cigna,Commercial,,2.53,,,,,,,2.53,67.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Cigna,Commercial,,50.29,,,,,,,20.65,76.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Cigna,Commercial,,0.49560,,,,,,,0.20370,183.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Cigna,Commercial,,13.22,,,,,,,13.22,49.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Cigna,Commercial,,13.22,,,,,,,13.22,58.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Cigna,Commercial,,93.10,,,,,,,93.10,545.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Cigna,Commercial,,1.13,,,,,,,1.13,13.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Cigna,Commercial,,4.70,,,,,,,4.69,204.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Cigna,Commercial,,0.07080,,,,,,,0.07080,47.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Cigna,Commercial,,0.09440,,,,,,,0.09440,78.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Cigna,Commercial,,0.09440,,,,,,,0.09440,215.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Cigna,Commercial,,0.09440,,,,,,,0.09440,130.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Cigna,Commercial,,1.39,,,,,,,1.39,89.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Cigna,Commercial,,0.02360,,,,,,,0.02360,52.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Cigna,Commercial,,0.51920,,,,,,,0.51920,127.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Cigna,Commercial,,2.60,,,,,,,0.04004,2.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Cigna,Commercial,,2.60,,,,,,,0.04004,2.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Cigna,Commercial,,127.13,,,,,,,0.04004,173.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Cigna,Commercial,,0.54280,,,,,,,0.54280,56.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Cigna,Commercial,,0.04720,,,,,,,0.04720,25.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Cigna,Commercial,,50.29,,,,,,,14.29,57.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Cigna,Commercial,,0.49560,,,,,,,0.20370,1324.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Cigna,Commercial,,0.21240,,,,,,,0.21240,73.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Cigna,Commercial,,28.44,,,,,,,5.04,29.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Cigna,Commercial,,0.49560,,,,,,,0.49560,25.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Cigna,Commercial,,2.60,,,,,,,2.60,20.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Cigna,Commercial,,3.52,,,,,,,3.52,46.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Cigna,Commercial,,0.35400,,,,,,,0.35400,16.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Cigna,Commercial,,0.35400,,,,,,,0.35400,16.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Cigna,Commercial,,0.35400,,,,,,,0.35400,19.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Cigna,Commercial,,0.35400,,,,,,,0.35400,31.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Cigna,Commercial,,0.35400,,,,,,,0.35400,19.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Cigna,Commercial,,11.94,,,,,,,11.94,202.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Cigna,Commercial,,1.13,,,,,,,1.13,97.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Cigna,Commercial,,1.13,,,,,,,1.13,70.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Cigna,Commercial,,0.21240,,,,,,,0.21240,23.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Cigna,Commercial,,16.71,,,,,,,16.40,60.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Cigna,Commercial,,0.04720,,,,,,,0.04720,13.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Cigna,Commercial,,0.04720,,,,,,,0.04720,50.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Cigna,Commercial,,2.17,,,,,,,2.17,41.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Cigna,Commercial,,0.49560,,,,,,,0.49560,61.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Cigna,Commercial,,1.30,,,,,,,1.30,230.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Cigna,Commercial,,1.32,,,,,,,1.25,59.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Cigna,Commercial,,0.47200,,,,,,,0.47200,236.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Cigna,Commercial,,0.40120,,,,,,,0.28050,55.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Cigna,Commercial,,0.54280,,,,,,,0.54280,47.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Cigna,Commercial,,2.57,,,,,,,2.57,77.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Cigna,Commercial,,34.01,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Cigna,Commercial,,3.28,,,,,,,3.28,119.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Cigna,Commercial,,166.97,,,,,,,0.04004,200.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Cigna,Commercial,,3.52,,,,,,,3.52,46.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Cigna,Commercial,,222.90,,,,,,,90.46,335.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Cigna,Commercial,,5.22,,,,,,,5.22,124.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Cigna,Commercial,,0.16520,,,,,,,0.16520,205.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Cigna,Commercial,,1.96,,,,,,,1.80,48.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Cigna,Commercial,,1.96,,,,,,,1.80,59.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Cigna,Commercial,,166.97,,,,,,,0.04004,200.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Cigna,Commercial,,166.97,,,,,,,0.04004,200.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Cigna,Commercial,,0.35400,,,,,,,0.35400,183.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Cigna,Commercial,,300.90,,,,,,,127.44,7479.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Cigna,Commercial,,1.89,,,,,,,1.89,65.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Cigna,Commercial,,5.33,,,,,,,5.33,111.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Cigna,Commercial,,222.90,,,,,,,72.92,270.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Cigna,Commercial,,215.56,,,,,,,0.04004,215.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Cigna,Commercial,,0.21240,,,,,,,0.04004,0.33000,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,4083.56,,,,,,,0.04004,4844.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,4083.56,,,,,,,0.04004,4844.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Cigna,Commercial,,85.62,,,,,,,0.04004,101.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,200.88,,,,,,,0.04004,237.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Cigna,Commercial,,131.33,,,,,,,53.98,11755.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Cigna,Commercial,,5.83,,,,,,,5.74,292.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Cigna,Commercial,,5.83,,,,,,,5.74,416.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Cigna,Commercial,,5.83,,,,,,,5.74,231.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Cigna,Commercial,,5.83,,,,,,,5.74,359.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Cigna,Commercial,,5.40,,,,,,,5.31,335.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Cigna,Commercial,,5.40,,,,,,,5.31,302.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Cigna,Commercial,,5.83,,,,,,,5.74,272.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Cigna,Commercial,,5.83,,,,,,,5.74,416.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Cigna,Commercial,,5.83,,,,,,,5.74,231.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Cigna,Commercial,,5.83,,,,,,,5.74,359.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Cigna,Commercial,,1.13,,,,,,,0.46560,2034.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Cigna,Commercial,,0.80240,,,,,,,0.80240,75.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Cigna,Commercial,,1.01,,,,,,,1.01,18.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Cigna,Commercial,,1.01,,,,,,,1.01,22.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Cigna,Commercial,,46.82,,,,,,,39.10,144.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Cigna,Commercial,,9.98,,,,,,,4.10,849.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Cigna,Commercial,,9.98,,,,,,,4.10,849.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Cigna,Commercial,,0.21240,,,,,,,0.21240,54.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Cigna,Commercial,,3.52,,,,,,,3.52,47.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Cigna,Commercial,,0.87320,,,,,,,0.35890,128.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Cigna,Commercial,,3.52,,,,,,,3.52,46.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Cigna,Commercial,,0.54280,,,,,,,0.54280,93.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Cigna,Commercial,,1.13,,,,,,,1.13,28.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Cigna,Commercial,,2.60,,,,,,,2.60,65.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Cigna,Commercial,,15.88,,,,,,,6.53,1915.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Cigna,Commercial,,1.86,,,,,,,1.86,12.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Cigna,Commercial,,1.86,,,,,,,1.86,54.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Cigna,Commercial,,4.77,,,,,,,4.77,443.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Cigna,Commercial,,0.11800,,,,,,,0.11800,81.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Cigna,Commercial,,0.11800,,,,,,,0.11800,85.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Cigna,Commercial,,2.88,,,,,,,2.88,32.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Cigna,Commercial,,2.88,,,,,,,2.88,48.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Cigna,Commercial,,1.30,,,,,,,1.30,35.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Cigna,Commercial,,1.30,,,,,,,1.30,49.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Cigna,Commercial,,3.71,,,,,,,3.71,27.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Cigna,Commercial,,3.71,,,,,,,3.71,49.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Cigna,Commercial,,0.21240,,,,,,,0.21240,35.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Cigna,Commercial,,1.49,,,,,,,1.49,65.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Cigna,Commercial,,0.02360,,,,,,,0.02360,193.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Cigna,Commercial,,1.13,,,,,,,1.13,87.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Cigna,Commercial,,127.13,,,,,,,127.13,5041.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Cigna,Commercial,,0.02360,,,,,,,0.02360,22.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Cigna,Commercial,,21.26,,,,,,,16.67,61.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Cigna,Commercial,,55.72,,,,,,,35.71,132.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Cigna,Commercial,,1.13,,,,,,,1.13,37.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Cigna,Commercial,,5.33,,,,,,,5.33,176.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Cigna,Commercial,,5.33,,,,,,,5.33,111.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Cigna,Commercial,,1.89,,,,,,,0.77600,358.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Cigna,Commercial,,1.89,,,,,,,1.89,50.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Cigna,Commercial,,4.37,,,,,,,4.37,16.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Cigna,Commercial,,0.07080,,,,,,,0.07080,16.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Cigna,Commercial,,2.60,,,,,,,2.60,19.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Cigna,Commercial,,48.03,,,,,,,19.74,4331.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Cigna,Commercial,,0.16520,,,,,,,0.16520,46.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Cigna,Commercial,,3.52,,,,,,,3.52,46.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Cigna,Commercial,,0.40120,,,,,,,0.40120,107.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Cigna,Commercial,,222.90,,,,,,,3.87,262.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Cigna,Commercial,,102.45,,,,,,,3.21,102.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Cigna,Commercial,,0.02360,,,,,,,0.02360,49.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Cigna,Commercial,,1.98,,,,,,,1.98,338.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Cigna,Commercial,,1.98,,,,,,,1.98,342.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Cigna,Commercial,,1.98,,,,,,,1.98,267.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Cigna,Commercial,,6.25,,,,,,,2.58,65.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Cigna,Commercial,,1.53,,,,,,,1.53,59.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Cigna,Commercial,,2.97,,,,,,,2.97,56.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Cigna,Commercial,,102.45,,,,,,,3.21,102.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Cigna,Commercial,,2.60,,,,,,,2.60,18.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Cigna,Commercial,,0.18880,,,,,,,0.18880,117.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Cigna,Commercial,,7.17,,,,,,,2.08,66.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Cigna,Commercial,,50.29,,,,,,,25.14,93.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Cigna,Commercial,,1.13,,,,,,,1.13,62.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Cigna,Commercial,,2.50,,,,,,,2.50,265.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Cigna,Commercial,,1.13,,,,,,,1.13,858.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Cigna,Commercial,,20.65,,,,,,,5.28,22.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Cigna,Commercial,,5.14,,,,,,,4.99,18.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Cigna,Commercial,,0.33040,,,,,,,0.33040,541.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Cigna,Commercial,,1.89,,,,,,,1.89,47.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Cigna,Commercial,,77.31,,,,,,,20.72,88.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Cigna,Commercial,,5.97,,,,,,,5.97,112.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Cigna,Commercial,,5.97,,,,,,,5.97,212.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Cigna,Commercial,,2.88,,,,,,,2.88,28.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Cigna,Commercial,,2.88,,,,,,,2.88,45.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Cigna,Commercial,,4.37,,,,,,,4.37,19.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Cigna,Commercial,,4.37,,,,,,,4.37,27.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Cigna,Commercial,,0.07080,,,,,,,0.07080,155.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Cigna,Commercial,,0.99120,,,,,,,0.99120,56.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Cigna,Commercial,,0.99120,,,,,,,0.99120,65.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Cigna,Commercial,,3.28,,,,,,,3.28,61.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Cigna,Commercial,,1.01,,,,,,,1.01,18.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Cigna,Commercial,,1.01,,,,,,,1.01,22.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Cigna,Commercial,,16.71,,,,,,,13.40,49.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Cigna,Commercial,,16.71,,,,,,,16.71,62.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Cigna,Commercial,,3.26,,,,,,,3.26,17.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Cigna,Commercial,,0.35400,,,,,,,0.35400,31.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Cigna,Commercial,,0.35400,,,,,,,0.35400,17.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Cigna,Commercial,,0.35400,,,,,,,0.35400,19.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Cigna,Commercial,,0.11800,,,,,,,0.11800,394.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Cigna,Commercial,,142.28,,,,,,,0.04004,163.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Cigna,Commercial,,15.88,,,,,,,6.53,1915.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Cigna,Commercial,,387.63,,,,,,,159.32,18350.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Cigna,Commercial,,387.63,,,,,,,159.32,18350.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Cigna,Commercial,,387.63,,,,,,,159.32,18350.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Cigna,Commercial,,387.63,,,,,,,159.32,18350.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Cigna,Commercial,,387.63,,,,,,,159.32,18350.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Cigna,Commercial,,406.44,,,,,,,167.05,28031.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Cigna,Commercial,,177.05,,,,,,,0.04004,212.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Cigna,Commercial,,145.00,,,,,,,0.04004,175.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Cigna,Commercial,,146.56,,,,,,,0.04004,176.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Cigna,Commercial,,146.56,,,,,,,0.04004,176.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Cigna,Commercial,,4.70,,,,,,,4.69,299.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Cigna,Commercial,,5.83,,,,,,,0.04004,5.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Cigna,Commercial,,5.40,,,,,,,0.04004,5.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Cigna,Commercial,,10.29,,,,,,,0.04004,10.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Cigna,Commercial,,142.28,,,,,,,0.04004,163.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Cigna,Commercial,,142.28,,,,,,,0.04004,163.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Cigna,Commercial,,0.04720,,,,,,,0.04004,0.14844,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Cigna,Commercial,,1.42,,,,,,,0.04004,1.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Cigna,Commercial,,1.42,,,,,,,0.04004,1.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Cigna,Commercial,,5.33,,,,,,,5.33,79.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Cigna,Commercial,,37.03,,,,,,,5.94,42.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Cigna,Commercial,,0.21240,,,,,,,0.21240,17.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Cigna,Commercial,,37.03,,,,,,,6.00,42.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Cigna,Commercial,,1.89,,,,,,,0.77600,358.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Cigna,Commercial,,4.06,,,,,,,4.06,561.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Cigna,Commercial,,0.02360,,,,,,,0.02360,36.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Cigna,Commercial,,0.02360,,,,,,,0.02360,19.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Cigna,Commercial,,0.02360,,,,,,,0.02360,19.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Cigna,Commercial,,221.32,,,,,,,55.71,221.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Cigna,Commercial,,1.89,,,,,,,1.89,12.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Cigna,Commercial,,108.32,,,,,,,108.07,400.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Cigna,Commercial,,108.32,,,,,,,61.74,228.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Cigna,Commercial,,0.07080,,,,,,,0.07080,205.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Cigna,Commercial,,0.07080,,,,,,,0.07080,221.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Cigna,Commercial,,0.07080,,,,,,,0.07080,177.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Cigna,Commercial,,0.07080,,,,,,,0.07080,193.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Cigna,Commercial,,4.79,,,,,,,1.78,216.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Cigna,Commercial,,0.35400,,,,,,,0.35400,17.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Cigna,Commercial,,0.35400,,,,,,,0.35400,17.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Cigna,Commercial,,0.11800,,,,,,,0.11800,30.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Cigna,Commercial,,0.11800,,,,,,,0.11800,49.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Cigna,Commercial,,0.44840,,,,,,,0.44840,27.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Cigna,Commercial,,558.42,,,,,,,229.52,33499.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Cigna,Commercial,,215.56,,,,,,,88.60,26697.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Cigna,Commercial,,215.56,,,,,,,88.60,38051.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Cigna,Commercial,,6.66,,,,,,,6.15,233.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Cigna,Commercial,,6.66,,,,,,,6.15,215.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Cigna,Commercial,,6.66,,,,,,,6.15,312.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Cigna,Commercial,,131.15,,,,,,,53.90,34728.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Cigna,Commercial,,184.95,,,,,,,76.02,5667.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Cigna,Commercial,,184.95,,,,,,,76.02,2935.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Cigna,Commercial,,184.95,,,,,,,76.02,5667.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Cigna,Commercial,,184.95,,,,,,,76.02,2935.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Cigna,Commercial,,184.95,,,,,,,76.02,5667.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Cigna,Commercial,,184.95,,,,,,,76.02,2935.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Cigna,Commercial,,5734.54,,,,,,,0.04004,6806.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Cigna,Commercial,,0.66080,,,,,,,0.27160,751.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Cigna,Commercial,,86.71,,,,,,,35.64,13964.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Cigna,Commercial,,86.71,,,,,,,35.64,13964.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Cigna,Commercial,,86.71,,,,,,,35.64,13964.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Cigna,Commercial,,171.38,,,,,,,70.44,37932.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Cigna,Commercial,,226.32,,,,,,,93.02,1836.94,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Cigna,Commercial,,10.43,,,,,,,4.29,3099.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Cigna,Commercial,,10.43,,,,,,,4.29,6151.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Cigna,Commercial,,10.43,,,,,,,4.29,1267.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Cigna,Commercial,,10.43,,,,,,,4.29,3099.17,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Cigna,Commercial,,10.43,,,,,,,4.29,6151.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Cigna,Commercial,,10.43,,,,,,,4.29,1267.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Cigna,Commercial,,6.18,,,,,,,6.18,206.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Cigna,Commercial,,5.22,,,,,,,5.22,32.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Cigna,Commercial,,0.87320,,,,,,,0.35890,22.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Cigna,Commercial,,7.34,,,,,,,7.34,56.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Cigna,Commercial,,4.27,,,,,,,4.27,56.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Cigna,Commercial,,160.95,,,,,,,66.15,1092.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Cigna,Commercial,,18.12,,,,,,,5.33,498.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Cigna,Commercial,,5.69,,,,,,,5.69,58.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Cigna,Commercial,,7.60,,,,,,,7.60,79.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Cigna,Commercial,,7.60,,,,,,,7.60,432.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Cigna,Commercial,,7.60,,,,,,,7.60,232.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Cigna,Commercial,,0.02360,,,,,,,0.02360,22.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Cigna,Commercial,,0.02360,,,,,,,0.02360,22.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Cigna,Commercial,,0.02360,,,,,,,0.02360,25.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Cigna,Commercial,,0.02360,,,,,,,0.02360,28.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Cigna,Commercial,,0.02360,,,,,,,0.02360,85.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Cigna,Commercial,,0.02360,,,,,,,0.02360,36.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Cigna,Commercial,,102.45,,,,,,,46.93,173.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Cigna,Commercial,,1.30,,,,,,,1.30,35.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Cigna,Commercial,,1.13,,,,,,,1.13,67.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Cigna,Commercial,,1.30,,,,,,,1.30,35.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Cigna,Commercial,,1.13,,,,,,,1.13,19.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Cigna,Commercial,,1.30,,,,,,,1.30,23.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Cigna,Commercial,,1.30,,,,,,,1.30,22.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Cigna,Commercial,,0.14160,,,,,,,0.14160,57.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Cigna,Commercial,,0.14160,,,,,,,0.14160,22.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Cigna,Commercial,,37.03,,,,,,,5.94,42.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Cigna,Commercial,,37.03,,,,,,,6.00,42.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Cigna,Commercial,,9.32,,,,,,,9.32,64.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Cigna,Commercial,,9.32,,,,,,,9.32,66.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Cigna,Commercial,,11.30,,,,,,,10.72,39.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Cigna,Commercial,,0.44840,,,,,,,0.44840,27.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Cigna,Commercial,,6.66,,,,,,,6.15,227.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Cigna,Commercial,,6.66,,,,,,,6.15,351.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Cigna,Commercial,,0.28320,,,,,,,0.11640,21.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Cigna,Commercial,,0.28320,,,,,,,0.11640,78.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Cigna,Commercial,,0.28320,,,,,,,0.28320,15.25,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Cigna,Commercial,,0.07080,,,,,,,0.07080,55.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Cigna,Commercial,,20.65,,,,,,,5.33,22.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Cigna,Commercial,,20.65,,,,,,,6.14,22.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Cigna,Commercial,,20.65,,,,,,,5.28,22.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Cigna,Commercial,,8.73,,,,,,,6.47,23.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Cigna,Commercial,,0.18880,,,,,,,0.18880,65.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Cigna,Commercial,,0.18880,,,,,,,0.18880,123.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Cigna,Commercial,,3.52,,,,,,,3.52,95.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Cigna,Commercial,,3.37,,,,,,,3.37,15.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Cigna,Commercial,,3.37,,,,,,,3.37,13.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Cigna,Commercial,,90.27,,,,,,,40.93,151.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Cigna,Commercial,,1.86,,,,,,,1.86,183.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Cigna,Commercial,,1.86,,,,,,,1.86,54.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Cigna,Commercial,,127.13,,,,,,,127.13,5041.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Cigna,Commercial,,71.20,,,,,,,45.49,168.63,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Cigna,Commercial,,71.20,,,,,,,20.24,75.04,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Cigna,Commercial,,0.02360,,,,,,,0.02360,25.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Cigna,Commercial,,0.02360,,,,,,,0.02360,157.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Cigna,Commercial,,0.02360,,,,,,,0.02360,79.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Cigna,Commercial,,1.06,,,,,,,1.06,16.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Cigna,Commercial,,6.44,,,,,,,6.44,53.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Cigna,Commercial,,0.25960,,,,,,,0.25960,53.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Cigna,Commercial,,208.69,,,,,,,82.18,304.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Cigna,Commercial,,0.02360,,,,,,,0.02360,932.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Cigna,Commercial,,0.02360,,,,,,,0.02360,12.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Cigna,Commercial,,0.02360,,,,,,,0.02360,12.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Cigna,Commercial,,0.02360,,,,,,,0.02360,12.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Cigna,Commercial,,0.02360,,,,,,,0.02360,12.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Cigna,Commercial,,695.47,,,,,,,40.54,695.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Cigna,Commercial,,4.27,,,,,,,4.27,16.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Cigna,Commercial,,1.65,,,,,,,1.65,13.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Cigna,Commercial,,6.96,,,,,,,4.89,18.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Cigna,Commercial,,4.11,,,,,,,4.11,190.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Cigna,Commercial,,4.11,,,,,,,4.11,64.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Cigna,Commercial,,14.28,,,,,,,13.10,48.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Cigna,Commercial,,3.52,,,,,,,1.45,62.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Cigna,Commercial,,3.52,,,,,,,1.45,62.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Cigna,Commercial,,3.52,,,,,,,1.45,62.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Cigna,Commercial,,0.54280,,,,,,,0.54280,300.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Cigna,Commercial,,0.23600,,,,,,,0.19800,74.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Cigna,Commercial,,0.23600,,,,,,,0.19800,77.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Cigna,Commercial,,2.97,,,,,,,2.97,60.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Cigna,Commercial,,2.97,,,,,,,2.97,59.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Cigna,Commercial,,2.97,,,,,,,2.97,57.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Cigna,Commercial,,0.40120,,,,,,,0.28050,61.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Cigna,Commercial,,0.40120,,,,,,,0.28050,61.19,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Cigna,Commercial,,0.40120,,,,,,,0.28050,70.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Cigna,Commercial,,1.94,,,,,,,1.94,293.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Cigna,Commercial,,0.11800,,,,,,,0.11800,85.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Cigna,Commercial,,6.70,,,,,,,2.84,3932.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Cigna,Commercial,,0.84960,,,,,,,0.84960,200.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Cigna,Commercial,,1.84,,,,,,,1.84,530.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Cigna,Commercial,,3.80,,,,,,,1.56,63.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Cigna,Commercial,,6.44,,,,,,,6.44,272.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Cigna,Commercial,,28.44,,,,,,,28.44,479.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Cigna,Commercial,,0.09440,,,,,,,0.09440,59.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Cigna,Commercial,,0.61360,,,,,,,0.61360,629.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Cigna,Commercial,,0.07080,,,,,,,0.07080,20.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Cigna,Commercial,,0.07080,,,,,,,0.07080,21.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Cigna,Commercial,,1.35,,,,,,,0.57750,2115.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Cigna,Commercial,,4.30,,,,,,,4.30,16.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Cigna,Commercial,,1.98,,,,,,,1.98,43.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Cigna,Commercial,,1.98,,,,,,,1.98,41.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Cigna,Commercial,,1.98,,,,,,,1.98,33.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Cigna,Commercial,,105.78,,,,,,,43.48,20380.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Cigna,Commercial,,0.51920,,,,,,,0.51920,68.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Cigna,Commercial,,4.70,,,,,,,4.69,215.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Cigna,Commercial,,4.70,,,,,,,4.69,226.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Cigna,Commercial,,63.04,,,,,,,25.91,6736.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Cigna,Commercial,,4.32,,,,,,,4.32,20.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Cigna,Commercial,,4.32,,,,,,,4.32,89.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Cigna,Commercial,,0.07080,,,,,,,0.07080,97.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Cigna,Commercial,,0.07080,,,,,,,0.07080,72.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Cigna,Commercial,,0.07080,,,,,,,0.07080,328.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Cigna,Commercial,,12.51,,,,,,,12.51,379.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Cigna,Commercial,,19.40,,,,,,,19.40,262.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Cigna,Commercial,,70.42,,,,,,,28.94,30042.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Cigna,Commercial,,6.18,,,,,,,6.18,421.53,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Cigna,Commercial,,6.18,,,,,,,6.18,30.36,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Cigna,Commercial,,5.40,,,,,,,5.31,335.73,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Cigna,Commercial,,5.40,,,,,,,5.31,302.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Cigna,Commercial,,328.54,,,,,,,135.03,19940.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Cigna,Commercial,,10.29,,,,,,,4.23,2844.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Cigna,Commercial,,108.32,,,,,,,108.07,400.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Cigna,Commercial,,108.32,,,,,,,61.74,228.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Cigna,Commercial,,112.08,,,,,,,51.49,324.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Cigna,Commercial,,112.08,,,,,,,51.49,324.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Cigna,Commercial,,24.73,,,,,,,1.30,583.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Cigna,Commercial,,222.90,,,,,,,91.62,29730.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Cigna,Commercial,,222.90,,,,,,,91.62,14871.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Cigna,Commercial,,3.28,,,,,,,3.28,37.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Cigna,Commercial,,3.28,,,,,,,3.28,25.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Cigna,Commercial,,11.28,,,,,,,11.28,95.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Cigna,Commercial,,4.13,,,,,,,3.81,275.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Cigna,Commercial,,9.68,,,,,,,3.98,70.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Cigna,Commercial,,1.44,,,,,,,1.44,19.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Cigna,Commercial,,1.44,,,,,,,1.44,37.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Cigna,Commercial,,1.44,,,,,,,1.44,130.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Cigna,Commercial,,0.70800,,,,,,,0.29100,22.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Cigna,Commercial,,7.13,,,,,,,7.13,603.45,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Cigna,Commercial,,3.42,,,,,,,3.42,394.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Cigna,Commercial,,0.14160,,,,,,,0.14160,13.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Cigna,Commercial,,5.97,,,,,,,5.97,112.26,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Cigna,Commercial,,5.97,,,,,,,5.97,205.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Cigna,Commercial,,16.43,,,,,,,16.43,197.72,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Cigna,Commercial,,6.25,,,,,,,2.58,65.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Cigna,Commercial,,6.25,,,,,,,2.58,65.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Cigna,Commercial,,6.25,,,,,,,2.58,65.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Cigna,Commercial,,50.79,,,,,,,50.79,390.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Cigna,Commercial,,3.94,,,,,,,1.62,62.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Cigna,Commercial,,3.94,,,,,,,1.62,62.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Cigna,Commercial,,0.87320,,,,,,,0.35890,22.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Cigna,Commercial,,1.01,,,,,,,1.01,55.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Cigna,Commercial,,1.01,,,,,,,1.01,56.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Cigna,Commercial,,1.01,,,,,,,1.01,53.03,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Cigna,Commercial,,0.02360,,,,,,,0.02360,21.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Cigna,Commercial,,15.17,,,,,,,7.82,28.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Cigna,Commercial,,1925.76,,,,,,,470.42,2713.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Cigna,Commercial,,25.98,,,,,,,10.68,9308.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Cigna,Commercial,,25.98,,,,,,,10.68,18605.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Cigna,Commercial,,56.36,,,,,,,23.16,1535.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Cigna,Commercial,,56.36,,,,,,,23.16,2043.50,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Cigna,Commercial,,56.36,,,,,,,23.16,2285.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Cigna,Commercial,,8.50,,,,,,,2.76,352.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Cigna,Commercial,,101.69,,,,,,,49.52,530.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Cigna,Commercial,,23.60,,,,,,,12.13,44.98,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Cigna,Commercial,,0.16520,,,,,,,0.16520,553.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Cigna,Commercial,,11.28,,,,,,,11.28,77.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Cigna,Commercial,,3.71,,,,,,,3.71,29.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Cigna,Commercial,,3.71,,,,,,,3.71,45.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Cigna,Commercial,,1.01,,,,,,,1.01,21.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Cigna,Commercial,,1.01,,,,,,,1.01,16.11,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Cigna,Commercial,,93.10,,,,,,,63.06,233.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Cigna,Commercial,,14.75,,,,,,,6.30,1234.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Cigna,Commercial,,25.20,,,,,,,10.36,1624.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Cigna,Commercial,,4.32,,,,,,,4.32,77.56,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Cigna,Commercial,,4.32,,,,,,,4.32,84.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Cigna,Commercial,,59.87,,,,,,,59.87,309.65,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Cigna,Commercial,,0.47200,,,,,,,0.47200,71.51,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Cigna,Commercial,,1.96,,,,,,,1.96,224.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Cigna,Commercial,,10.50,,,,,,,4.32,2692.85,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Cigna,Commercial,,4.81,,,,,,,4.81,66.09,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Cigna,Commercial,,1.89,,,,,,,1.89,25.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Cigna,Commercial,,21.26,,,,,,,21.26,149.40,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Cigna,Commercial,,21.26,,,,,,,21.26,129.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Cigna,Commercial,,0.07080,,,,,,,0.07080,47.91,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Cigna,Commercial,,0.07080,,,,,,,0.07080,48.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Cigna,Commercial,,0.07080,,,,,,,0.07080,48.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Cigna,Commercial,,89.07,,,,,,,47.84,445.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Cigna,Commercial,,0.07080,,,,,,,0.07080,67.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Cigna,Commercial,,8.31,,,,,,,3.41,285.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Cigna,Commercial,,8.31,,,,,,,3.41,1345.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Cigna,Commercial,,4.01,,,,,,,1.65,61.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Cigna,Commercial,,19.21,,,,,,,16.22,60.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Cigna,Commercial,,19.21,,,,,,,16.22,60.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Cigna,Commercial,,0.25960,,,,,,,0.25960,75.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Cigna,Commercial,,0.25960,,,,,,,0.25960,72.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Cigna,Commercial,,0.25960,,,,,,,0.25960,69.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Cigna,Commercial,,0.25960,,,,,,,0.25960,70.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Cigna,Commercial,,0.25960,,,,,,,0.25960,62.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Cigna,Commercial,,0.25960,,,,,,,0.25960,72.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Cigna,Commercial,,0.25960,,,,,,,0.25960,72.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Cigna,Commercial,,3.33,,,,,,,3.33,60.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Cigna,Commercial,,3.33,,,,,,,3.33,57.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Cigna,Commercial,,4.70,,,,,,,4.69,264.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Cigna,Commercial,,0.75520,,,,,,,0.31040,3767.59,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Cigna,Commercial,,21.36,,,,,,,10.89,477.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Cigna,Commercial,,141.60,,,,,,,51.03,264.28,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Cigna,Commercial,,16.71,,,,,,,16.71,70.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Cigna,Commercial,,20.65,,,,,,,8.49,2985.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Cigna,Commercial,,0.18880,,,,,,,0.18880,360.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Cigna,Commercial,,0.18880,,,,,,,0.18880,530.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Cigna,Commercial,,925.26,,,,,,,346.52,1284.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Cigna,Commercial,,1201.15,,,,,,,330.39,1448.89,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Cigna,Commercial,,162.39,,,,,,,162.39,33706.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Cigna,Commercial,,167954.36,,,,,,,31273.72,215040.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Cigna,Commercial,,167954.36,,,,,,,51551.50,215040.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Cigna,Commercial,,327.43,,,,,,,327.43,8282.76,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Cigna,Commercial,,327.43,,,,,,,327.43,5485.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Cigna,Commercial,,169.39,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Cigna,Commercial,,8.93,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Cigna,Commercial,,0.78480,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Cigna,Commercial,,5.98,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Cigna,Commercial,,27.47,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Cigna,Commercial,,0.13080,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX CONTINUED NEONATAL CARE PRIVATE ROOM,11710001,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,Cigna,Commercial,,974.00,,,,,,,974.00,1558.44,case rate,
HC REX LEVEL 1 NURSERY ROOM,11710002,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,Cigna,Commercial,,974.00,,,,,,,974.00,1558.44,case rate,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Cigna,Commercial,,339.43,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Cigna,Commercial,,841.70,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Cigna,Commercial,,1258.95,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Cigna,Commercial,,1890.71,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Cigna,Commercial,,2268.73,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Cigna,Commercial,,2721.95,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Cigna,Commercial,,3267.38,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX LEVEL 3 INTERMEDIATE NURSERY ROOM,11733001,CDM,173,RC,,,,,facility,inpatient,,,4517.00000,2710.20000,Cigna,Commercial,,4741.00,,,,,,,2890.88,5493.00,case rate,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Cigna,Commercial,,1350.51,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Cigna,Commercial,,1983.58,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Cigna,Commercial,,3607.46,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Cigna,Commercial,,104.64,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Cigna,Commercial,,413.98,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Cigna,Commercial,,113.14,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,,76.52,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,40.55,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Cigna,Commercial,,17.00,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Cigna,Commercial,,93.52,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,41.20,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,52.97,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Cigna,Commercial,,103.33,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Cigna,Commercial,,342.70,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Cigna,Commercial,,390.44,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Cigna,Commercial,,332.23,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Cigna,Commercial,,60.17,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Cigna,Commercial,,47.74,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Cigna,Commercial,,150.42,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Cigna,Commercial,,137.99,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Cigna,Commercial,,3422.38,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Cigna,Commercial,,3422.38,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Cigna,Commercial,,3258.23,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Cigna,Commercial,,1168.04,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,37.93,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Cigna,Commercial,,1965.27,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Cigna,Commercial,,998.00,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Cigna,Commercial,,204.70,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,52.97,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,41.20,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Cigna,Commercial,,714.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Cigna,Commercial,,223.67,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Cigna,Commercial,,808.34,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Cigna,Commercial,,594.49,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Cigna,Commercial,,198.16,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Cigna,Commercial,,327.00,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Cigna,Commercial,,613.45,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Cigna,Commercial,,173.96,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Cigna,Commercial,,133.42,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Cigna,Commercial,,714.17,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Cigna,Commercial,,619.99,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Cigna,Commercial,,187.04,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Cigna,Commercial,,28.12,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Cigna,Commercial,,22.89,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Cigna,Commercial,,91.56,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Cigna,Commercial,,310.00,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Cigna,Commercial,,82.40,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Cigna,Commercial,,187.04,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Cigna,Commercial,,87.64,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Cigna,Commercial,,7.19,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Cigna,Commercial,,2298.09,,,,,,,633.10,3669.96,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Cigna,Commercial,,9266.10,,,,,,,2552.70,14797.62,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Cigna,Commercial,,2339.11,,,,,,,644.40,3735.48,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Cigna,Commercial,,1954.64,,,,,,,538.48,3121.49,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Cigna,Commercial,,1603.36,,,,,,,441.71,2560.50,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Cigna,Commercial,,302.80,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Cigna,Commercial,,905.47,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Cigna,Commercial,,1037.37,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Cigna,Commercial,,1021.57,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Cigna,Commercial,,808.60,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Cigna,Commercial,,1336.21,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Cigna,Commercial,,948.75,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Cigna,Commercial,,948.75,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Cigna,Commercial,,1104.01,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Cigna,Commercial,,1104.01,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Cigna,Commercial,,1343.31,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Cigna,Commercial,,905.47,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Cigna,Commercial,,905.47,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Cigna,Commercial,,808.60,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Cigna,Commercial,,905.47,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Cigna,Commercial,,399.61,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Cigna,Commercial,,941.19,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Cigna,Commercial,,387.24,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Cigna,Commercial,,1488.27,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Cigna,Commercial,,774.34,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Cigna,Commercial,,1590.53,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Cigna,Commercial,,2409.34,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Cigna,Commercial,,2810.24,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Cigna,Commercial,,79.13,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Cigna,Commercial,,1115.72,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Cigna,Commercial,,2240.60,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Cigna,Commercial,,54.28,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Cigna,Commercial,,305.42,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Cigna,Commercial,,450.61,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Cigna,Commercial,,1018.28,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Cigna,Commercial,,771.07,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Cigna,Commercial,,51.67,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Cigna,Commercial,,57.55,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Cigna,Commercial,GP,13.73,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Cigna,Commercial,,76.26,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Cigna,Commercial,,982.31,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Cigna,Commercial,,929.99,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Cigna,Commercial,,745.56,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Cigna,Commercial,,561.13,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Cigna,Commercial,,376.70,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Cigna,Commercial,,192.28,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Cigna,Commercial,,375.10,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Cigna,Commercial,,1120.95,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Cigna,Commercial,,1486.67,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Cigna,Commercial,,785.47,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Cigna,Commercial,,596.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Cigna,Commercial,,5990.18,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Cigna,Commercial,,6274.37,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Cigna,Commercial,,6603.67,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Cigna,Commercial,,6886.95,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Cigna,Commercial,,7171.36,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Cigna,Commercial,,7454.87,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Cigna,Commercial,,7692.34,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Cigna,Commercial,,8021.64,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Cigna,Commercial,,8305.37,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Cigna,Commercial,,8589.10,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Cigna,Commercial,,8873.06,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Cigna,Commercial,,88.85,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Cigna,Commercial,,122.29,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Cigna,Commercial,,189.84,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Cigna,Commercial,,191.44,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Cigna,Commercial,,924.01,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Cigna,Commercial,,2217.86,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Cigna,Commercial,,2383.20,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Cigna,Commercial,,2559.99,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Cigna,Commercial,,1395.53,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Cigna,Commercial,,1802.92,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Cigna,Commercial,,2050.70,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Cigna,Commercial,,2640.37,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Cigna,Commercial,,2710.44,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Cigna,Commercial,,2776.40,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Cigna,Commercial,,2842.58,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Cigna,Commercial,,2908.53,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Cigna,Commercial,,1132.63,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Cigna,Commercial,,152.97,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Cigna,Commercial,,1008.97,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Cigna,Commercial,,1362.32,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Cigna,Commercial,,1865.43,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Cigna,Commercial,,2364.20,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Cigna,Commercial,,2699.22,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Cigna,Commercial,,3057.15,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Cigna,Commercial,,3487.44,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Cigna,Commercial,,3738.20,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Cigna,Commercial,,4108.26,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Cigna,Commercial,,4309.55,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Cigna,Commercial,,4573.13,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Cigna,Commercial,,4742.82,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Cigna,Commercial,,4785.41,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Cigna,Commercial,,4856.40,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Cigna,Commercial,,4997.93,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Cigna,Commercial,,5139.68,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Cigna,Commercial,,5281.20,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Cigna,Commercial,,5423.86,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Cigna,Commercial,,5565.16,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Cigna,Commercial,,5707.14,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Cigna,Commercial,,3069.97,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Cigna,Commercial,,2601.90,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Cigna,Commercial,,1612.85,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Cigna,Commercial,,1612.85,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Cigna,Commercial,,1612.85,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Cigna,Commercial,,1483.92,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Cigna,Commercial,,3069.97,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Cigna,Commercial,,1731.70,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Cigna,Commercial,,1951.31,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Cigna,Commercial,,69.39,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Cigna,Commercial,,291.06,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Cigna,Commercial,,116.33,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Cigna,Commercial,,116.33,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Cigna,Commercial,,185.03,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Cigna,Commercial,,2471.83,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Cigna,Commercial,,432.81,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Cigna,Commercial,,280.52,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Cigna,Commercial,,4691.80,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Cigna,Commercial,,67.78,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Cigna,Commercial,,494.42,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Cigna,Commercial,,1.96,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Cigna,Commercial,,1078.45,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Cigna,Commercial,,1391.06,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Cigna,Commercial,,1704.98,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Cigna,Commercial,,2017.59,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Cigna,Commercial,,2330.86,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Cigna,Commercial,,2644.12,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Cigna,Commercial,,2956.73,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Cigna,Commercial,,432.29,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Cigna,Commercial,,2145.12,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Cigna,Commercial,,2826.59,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Cigna,Commercial,,846.28,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Cigna,Commercial,,1153.00,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Cigna,Commercial,,1285.76,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Cigna,Commercial,,1423.76,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Cigna,Commercial,,1561.10,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Cigna,Commercial,,1697.78,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Cigna,Commercial,,1835.78,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Cigna,Commercial,,1078.45,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Cigna,Commercial,,626.53,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Cigna,Commercial,,1561.10,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Cigna,Commercial,,846.28,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Cigna,Commercial,,1153.00,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Cigna,Commercial,,1285.76,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Cigna,Commercial,,1423.76,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Cigna,Commercial,,1697.78,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Cigna,Commercial,,1835.78,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Cigna,Commercial,,2145.12,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Cigna,Commercial,,2826.59,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Cigna,Commercial,,326.35,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Cigna,Commercial,,785.47,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Cigna,Commercial,,65.27,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Cigna,Commercial,,310.75,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Cigna,Commercial,,351.97,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Cigna,Commercial,,393.65,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Cigna,Commercial,,435.33,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Cigna,Commercial,,477.46,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Cigna,Commercial,,519.37,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Cigna,Commercial,,561.05,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Cigna,Commercial,,602.50,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Cigna,Commercial,,643.95,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Cigna,Commercial,,686.08,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Cigna,Commercial,,727.53,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Cigna,Commercial,,781.81,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Cigna,Commercial,,823.94,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Cigna,Commercial,,983.10,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Cigna,Commercial,,1047.45,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Cigna,Commercial,,1096.22,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Cigna,Commercial,,1137.90,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Cigna,Commercial,,1179.35,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Cigna,Commercial,,1000.50,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Cigna,Commercial,,1061.64,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Cigna,Commercial,,944.17,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Cigna,Commercial,,598.38,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Cigna,Commercial,,646.92,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Cigna,Commercial,,569.29,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Cigna,Commercial,,765.32,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Cigna,Commercial,,77.17,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Cigna,Commercial,,2308.78,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Cigna,Commercial,,2308.78,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Cigna,Commercial,,2308.78,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Cigna,Commercial,,291.98,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Cigna,Commercial,,479.98,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Cigna,Commercial,,533.34,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Cigna,Commercial,,289.46,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Cigna,Commercial,,110.61,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Cigna,Commercial,,9423.00,,,,,,,96.70,9423.00,per diem,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Cigna,Commercial,,1716.13,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Cigna,Commercial,,232.66,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Cigna,Commercial,,92.52,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Cigna,Commercial,,1047.45,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Cigna,Commercial,,2481.67,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Cigna,Commercial,,1207.75,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Cigna,Commercial,,200.78,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Cigna,Commercial,,9156.34,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Cigna,Commercial,,9439.84,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Cigna,Commercial,,431.67,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Cigna,Commercial,,127.55,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Cigna,Commercial,,667.53,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,50.36,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,32.65,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Cigna,Commercial,,50.14,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Cigna,Commercial,,106.69,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Cigna,Commercial,,58.30,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Cigna,Commercial,,57.72,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Cigna,Commercial,Q0,0.66054,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Cigna,Commercial,Q0,0.66054,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Cigna,Commercial,,276.60,,,,,,,76.20,441.72,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Cigna,Commercial,,343.91,,,,,,,94.74,549.21,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Cigna,Commercial,,633.88,,,,,,,174.62,1012.27,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Cigna,Commercial,,9021.31,,,,,,,2485.26,14406.70,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Cigna,Commercial,,4204.32,,,,,,,1158.24,6714.14,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Cigna,Commercial,,2360.32,,,,,,,650.24,3769.34,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Cigna,Commercial,,2283.79,,,,,,,629.16,3647.13,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Cigna,Commercial,,3428.92,,,,,,,944.63,5475.86,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Cigna,Commercial,,3880.70,,,,,,,1069.09,6197.33,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Cigna,Commercial,,2360.32,,,,,,,650.24,3769.34,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Cigna,Commercial,,2926.43,,,,,,,806.20,4673.40,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Cigna,Commercial,,146.60,,,,,,,40.39,234.11,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Cigna,Commercial,,47.48,,,,,,,13.08,75.83,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Cigna,Commercial,,96.35,,,,,,,26.54,153.87,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,18.31,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Cigna,Commercial,,66.84,,,,,,,18.41,106.75,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Cigna,Commercial,,146.60,,,,,,,40.39,234.11,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Cigna,Commercial,,58.09,,,,,,,16.00,92.76,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Cigna,Commercial,,69.61,,,,,,,19.18,111.17,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Cigna,Commercial,,84.82,,,,,,,23.37,135.46,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Cigna,Commercial,,136.00,,,,,,,37.47,217.18,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Cigna,Commercial,,163.66,,,,,,,45.09,261.35,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Cigna,Commercial,,483.13,,,,,,,133.10,771.54,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Cigna,Commercial,,47.48,,,,,,,13.08,75.83,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Cigna,Commercial,,195.93,,,,,,,53.98,312.88,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Cigna,Commercial,,276.60,,,,,,,76.20,441.72,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Cigna,Commercial,,494.65,,,,,,,136.27,789.94,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Cigna,Commercial,,437.03,,,,,,,120.40,697.92,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Cigna,Commercial,,343.91,,,,,,,94.74,549.21,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Cigna,Commercial,,343.91,,,,,,,94.74,549.21,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Cigna,Commercial,,125.85,,,,,,,34.67,200.98,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Cigna,Commercial,,356.81,,,,,,,98.30,569.82,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Cigna,Commercial,,3348.48,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Cigna,Commercial,,231.88,,,,,,,63.88,370.31,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Cigna,Commercial,,295.61,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Cigna,Commercial,,621.89,,,,,,,171.32,993.13,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Cigna,Commercial,,2360.32,,,,,,,650.24,3769.34,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Cigna,Commercial,,684.12,,,,,,,188.47,1092.52,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Cigna,Commercial,,635.72,,,,,,,175.13,1015.22,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,26.74,,,,,,,7.37,42.70,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,26.74,,,,,,,7.37,42.70,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,26.74,,,,,,,7.37,42.70,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,26.74,,,,,,,7.37,42.70,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Cigna,Commercial,,246.63,,,,,,,67.94,393.87,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Cigna,Commercial,,246.63,,,,,,,67.94,393.87,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Cigna,Commercial,,246.63,,,,,,,67.94,393.87,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00654,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Cigna,Commercial,,4394.88,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Cigna,Commercial,,425.04,,,,,,,117.09,678.78,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Cigna,Commercial,,425.04,,,,,,,117.09,678.78,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Cigna,Commercial,,425.04,,,,,,,117.09,678.78,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Cigna,Commercial,,560.12,,,,,,,154.31,894.48,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Cigna,Commercial,,751.89,,,,,,,207.14,1200.74,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Cigna,Commercial,,1895.95,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Cigna,Commercial,,161.35,,,,,,,44.45,257.67,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Cigna,Commercial,,213.44,,,,,,,58.80,340.86,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Cigna,Commercial,,64.54,,,,,,,17.78,103.07,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,43.80,,,,,,,12.06,69.94,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Cigna,Commercial,,76.53,,,,,,,21.08,122.21,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Cigna,Commercial,,161.35,,,,,,,44.45,257.67,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,41.95,,,,,,,11.56,66.99,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,46.56,,,,,,,12.83,74.36,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Cigna,Commercial,,2429.47,,,,,,,669.29,3879.77,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Cigna,Commercial,,472.06,,,,,,,130.05,753.87,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Cigna,Commercial,,293.66,,,,,,,80.90,468.96,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Cigna,Commercial,,25878.78,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Cigna,Commercial,,162.39,,,,,,,162.39,12620.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Cigna,Commercial,,136.92,,,,,,,33.78,218.65,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Cigna,Commercial,,141.99,,,,,,,33.78,226.75,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Cigna,Commercial,,1255.03,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Cigna,Commercial,,4742.81,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Cigna,Commercial,,1134.04,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Cigna,Commercial,,2154.93,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Cigna,Commercial,,26303.88,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Cigna,Commercial,,8186.12,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Cigna,Commercial,,7272.48,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Cigna,Commercial,,10244.91,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Cigna,Commercial,,20652.01,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Cigna,Commercial,,1725.91,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Cigna,Commercial,,7270.52,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Cigna,Commercial,,10491.47,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Cigna,Commercial,,4368.44,,,,,,,1203.45,6976.23,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Cigna,Commercial,,1763.18,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Cigna,Commercial,,1242.86,,,,,,,342.39,1984.80,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Cigna,Commercial,,5471.36,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Cigna,Commercial,,0.66054,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Cigna,Commercial,,5833.68,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Cigna,Commercial,,7375.16,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Cigna,Commercial,,2826.39,,,,,,,778.64,4513.64,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Cigna,Commercial,,10133.73,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Cigna,Commercial,,578.55,,,,,,,35.64,923.93,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Cigna,Commercial,,247.56,,,,,,,68.20,395.34,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Cigna,Commercial,,3097.92,,,,,,,853.44,4947.26,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Cigna,Commercial,,2429.47,,,,,,,669.29,3879.77,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Cigna,Commercial,,433.34,,,,,,,119.38,692.03,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Cigna,Commercial,,101.42,,,,,,,27.94,161.96,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Cigna,Commercial,,255.85,,,,,,,70.48,408.59,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Cigna,Commercial,,2506.00,,,,,,,690.37,4001.98,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Cigna,Commercial,,9148.55,,,,,,,2520.32,14609.89,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Cigna,Commercial,,12626.79,,,,,,,3478.53,20164.52,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Cigna,Commercial,,129.54,,,,,,,35.69,206.87,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Cigna,Commercial,,129.54,,,,,,,35.69,206.87,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Cigna,Commercial,,121.24,,,,,,,33.40,193.62,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Cigna,Commercial,,121.24,,,,,,,33.40,193.62,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Cigna,Commercial,,121.24,,,,,,,33.40,193.62,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,0.00461,,,,,,,0.00127,0.00736,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Cigna,Commercial,,1440.62,,,,,,,396.88,2300.62,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Cigna,Commercial,,766.49,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Cigna,Commercial,,985.58,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Cigna,Commercial,,925.41,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Cigna,Commercial,,895.98,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Cigna,Commercial,,6516.46,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Cigna,Commercial,Q1,4143.09,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Cigna,Commercial,Q0,2481.93,,,,,,,759.76,2846.25,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Cigna,Commercial,,276.64,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Cigna,Commercial,,359.05,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Cigna,Commercial,,246.56,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Cigna,Commercial,,382.59,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Cigna,Commercial,,246.56,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Cigna,Commercial,,246.56,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Cigna,Commercial,,60.17,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Cigna,Commercial,,188.35,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Cigna,Commercial,,285.80,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Cigna,Commercial,,171.35,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Cigna,Commercial,,153.04,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Cigna,Commercial,,426.41,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,50.71,,,,,,,13.97,80.98,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Cigna,Commercial,,3.90,,,,,,,3.90,24.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Cigna,Commercial,,1241.95,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,,76.52,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,,76.52,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Cigna,Commercial,,156.96,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Cigna,Commercial,,235.44,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Cigna,Commercial,,302.80,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Cigna,Commercial,,274.68,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Cigna,Commercial,,1273.34,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Cigna,Commercial,,1301.46,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Cigna,Commercial,,609.53,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Cigna,Commercial,,920.18,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Cigna,Commercial,,954.84,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Cigna,Commercial,,1127.50,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Cigna,Commercial,,1372.09,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Cigna,Commercial,,2301.43,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Cigna,Commercial,,4082.27,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Cigna,Commercial,,4402.07,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Cigna,Commercial,,415.29,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Cigna,Commercial,,556.55,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Cigna,Commercial,,4154.21,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Cigna,Commercial,,4666.29,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Cigna,Commercial,,4666.29,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Cigna,Commercial,,1110.49,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Cigna,Commercial,,1810.93,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Cigna,Commercial,,480.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Cigna,Commercial,,716.78,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Cigna,Commercial,,306.73,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Cigna,Commercial,,633.07,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Cigna,Commercial,,449.30,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Cigna,Commercial,,1010.43,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Cigna,Commercial,,700.43,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Cigna,Commercial,,1217.75,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Cigna,Commercial,,294.30,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Cigna,Commercial,,787.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Cigna,Commercial,,4899.77,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Cigna,Commercial,,4874.92,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Cigna,Commercial,,1568.29,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Cigna,Commercial,,1141.88,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Cigna,Commercial,,2027.40,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Cigna,Commercial,,5508.64,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Cigna,Commercial,,277.95,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Cigna,Commercial,,370.82,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Cigna,Commercial,,1424.41,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Cigna,Commercial,,1368.17,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Cigna,Commercial,,3031.29,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Cigna,Commercial,,1607.53,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Cigna,Commercial,,1961.35,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Cigna,Commercial,,206.66,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Cigna,Commercial,,209.93,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Cigna,Commercial,,703.70,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Cigna,Commercial,,324.38,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Cigna,Commercial,,394.36,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Cigna,Commercial,,324.38,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Cigna,Commercial,,1005.20,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Cigna,Commercial,,402.21,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Cigna,Commercial,,480.04,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Cigna,Commercial,,298.88,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Cigna,Commercial,,216.47,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Cigna,Commercial,,342.04,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Cigna,Commercial,,4666.29,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Cigna,Commercial,,674.93,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Cigna,Commercial,,581.41,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Cigna,Commercial,,760.60,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Cigna,Commercial,,687.35,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Cigna,Commercial,,919.52,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Cigna,Commercial,76,919.52,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,,1219.71,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Cigna,Commercial,,2451.19,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Cigna,Commercial,76,2451.19,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Cigna,Commercial,,2580.03,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Cigna,Commercial,76,2580.03,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Cigna,Commercial,,1330.24,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Cigna,Commercial,,1478.69,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Cigna,Commercial,,1558.48,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Cigna,Commercial,,1719.37,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Cigna,Commercial,,1198.78,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Cigna,Commercial,,1714.79,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Cigna,Commercial,,224.32,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Cigna,Commercial,,270.10,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Cigna,Commercial,,270.10,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Cigna,Commercial,,190.97,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Cigna,Commercial,,1858.67,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Cigna,Commercial,,17853.55,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Cigna,Commercial,,2454.46,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Cigna,Commercial,,2822.66,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Cigna,Commercial,,2822.66,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Cigna,Commercial,,423.79,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Cigna,Commercial,,463.03,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Cigna,Commercial,,801.15,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Cigna,Commercial,,562.44,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Cigna,Commercial,,597.76,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Cigna,Commercial,,613.45,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Cigna,Commercial,,419.21,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,,1219.71,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,76,1219.71,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,,1219.71,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,76,1219.71,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Cigna,Commercial,,224.32,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Cigna,Commercial,,425.10,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Cigna,Commercial,,237.40,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,,1219.71,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,76,1219.71,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Cigna,Commercial,,297.57,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Cigna,Commercial,76,562.44,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Cigna,Commercial,76,597.76,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Cigna,Commercial,,326.35,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Cigna,Commercial,,682.78,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Cigna,Commercial,,1065.37,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Cigna,Commercial,,1532.32,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Cigna,Commercial,,4521.76,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Cigna,Commercial,,479.38,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Cigna,Commercial,,3967.82,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Cigna,Commercial,,1474.12,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Cigna,Commercial,,1855.40,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Cigna,Commercial,,1208.59,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Cigna,Commercial,,569.63,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Cigna,Commercial,,359.05,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Cigna,Commercial,,526.47,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Cigna,Commercial,,818.81,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Cigna,Commercial,,5339.26,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Cigna,Commercial,,1576.14,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Cigna,Commercial,,264.87,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Cigna,Commercial,,366.24,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Cigna,Commercial,,1086.95,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Cigna,Commercial,,1257.64,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Cigna,Commercial,,833.20,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Cigna,Commercial,,206.66,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Cigna,Commercial,,425.10,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Cigna,Commercial,,1424.41,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Cigna,Commercial,,715.17,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Cigna,Commercial,,229.55,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Cigna,Commercial,,4121.00,,,,,,,211.01,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Cigna,Commercial,,22.24,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Cigna,Commercial,,4121.00,,,,,,,93.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Cigna,Commercial,,672.31,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Cigna,Commercial,,792.65,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Cigna,Commercial,,5152.00,,,,,,,64.46,5189.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Cigna,Commercial,,4121.00,,,,,,,151.55,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Cigna,Commercial,,37.10,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Cigna,Commercial,,765.18,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Cigna,Commercial,,195.55,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Cigna,Commercial,,389.13,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,41.20,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Cigna,Commercial,,73.90,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,18.31,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,18.31,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Cigna,Commercial,,197.51,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Cigna,Commercial,,24.20,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Cigna,Commercial,,24.20,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Cigna,Commercial,,15.04,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,37.93,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,36.62,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Cigna,Commercial,,71.29,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Cigna,Commercial,,130.80,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Cigna,Commercial,,105.29,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Cigna,Commercial,,73.90,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Cigna,Commercial,,86.98,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Cigna,Commercial,,73.90,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Cigna,Commercial,,286.45,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Cigna,Commercial,,32.70,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Cigna,Commercial,,270.10,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Cigna,Commercial,,188.35,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,35.32,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Cigna,Commercial,,24.20,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Cigna,Commercial,,124.91,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Cigna,Commercial,,175.93,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Cigna,Commercial,GP,182.00,,,,,,,10.44,276.00,per diem,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Cigna,Commercial,GP,182.00,,,,,,,11.69,276.00,per diem,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Cigna,Commercial,GP,182.00,,,,,,,1.87,276.00,per diem,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Cigna,Commercial,GP,182.00,,,,,,,18.85,276.00,per diem,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,GP,182.00,,,,,,,7.63,276.00,per diem,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Cigna,Commercial,GP,182.00,,,,,,,2.49,276.00,per diem,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Cigna,Commercial,GP,182.00,,,,,,,23.84,276.00,per diem,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Cigna,Commercial,GP,182.00,,,,,,,25.40,276.00,per diem,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Cigna,Commercial,GP,182.00,,,,,,,19.94,276.00,per diem,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,GP,182.00,,,,,,,17.14,276.00,per diem,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,GP,182.00,,,,,,,9.19,276.00,per diem,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Cigna,Commercial,GP,182.00,,,,,,,25.55,276.00,per diem,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Cigna,Commercial,GP,182.00,,,,,,,24.93,276.00,per diem,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Cigna,Commercial,GP,182.00,,,,,,,22.44,276.00,per diem,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,GP,182.00,,,,,,,25.71,276.00,per diem,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Cigna,Commercial,GP,182.00,,,,,,,21.66,276.00,per diem,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Cigna,Commercial,GP,182.00,,,,,,,31.47,276.00,per diem,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,GP,182.00,,,,,,,18.23,276.00,per diem,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,GP,182.00,,,,,,,20.10,276.00,per diem,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Cigna,Commercial,GP,182.00,,,,,,,23.53,276.00,per diem,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Cigna,Commercial,GP,182.00,,,,,,,7.32,276.00,per diem,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,GP,182.00,,,,,,,18.38,276.00,per diem,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Cigna,Commercial,GP,182.00,,,,,,,13.24,276.00,per diem,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,GP,182.00,,,,,,,20.10,276.00,per diem,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Cigna,Commercial,GP,182.00,,,,,,,15.42,276.00,per diem,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Cigna,Commercial,GP,182.00,,,,,,,28.04,4311.00,per diem,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Cigna,Commercial,GP,182.00,,,,,,,28.04,4311.00,per diem,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,GP,182.00,,,,,,,14.18,276.00,per diem,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,GP,182.00,,,,,,,14.18,276.00,per diem,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,GP,182.00,,,,,,,13.87,276.00,per diem,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Cigna,Commercial,GP,182.00,,,,,,,19.79,276.00,per diem,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Cigna,Commercial,GP,182.00,,,,,,,20.25,276.00,per diem,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Cigna,Commercial,GP,182.00,,,,,,,10.91,276.00,per diem,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Cigna,Commercial,GP,182.00,,,,,,,4.67,276.00,per diem,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Cigna,Commercial,GP,182.00,,,,,,,47.67,276.00,per diem,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Cigna,Commercial,GP,182.00,,,,,,,65.90,276.00,per diem,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Cigna,Commercial,GP,182.00,,,,,,,67.62,276.00,per diem,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Cigna,Commercial,GP,182.00,,,,,,,44.87,276.00,per diem,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,GO,182.00,,,,,,,14.18,276.00,per diem,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,GO,182.00,,,,,,,18.23,276.00,per diem,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,GO,182.00,,,,,,,20.10,276.00,per diem,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,GO,182.00,,,,,,,18.38,276.00,per diem,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Cigna,Commercial,GO,182.00,,,,,,,10.91,276.00,per diem,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,GO,182.00,,,,,,,20.10,276.00,per diem,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Cigna,Commercial,GO,182.00,,,,,,,15.42,276.00,per diem,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Cigna,Commercial,GO,182.00,,,,,,,1.87,276.00,per diem,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Cigna,Commercial,GO,182.00,,,,,,,25.40,276.00,per diem,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Cigna,Commercial,GO,182.00,,,,,,,19.94,276.00,per diem,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,GO,182.00,,,,,,,9.66,276.00,per diem,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Cigna,Commercial,GO,182.00,,,,,,,25.55,276.00,per diem,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Cigna,Commercial,GO,182.00,,,,,,,24.93,276.00,per diem,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Cigna,Commercial,GO,182.00,,,,,,,22.44,276.00,per diem,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,GO,182.00,,,,,,,25.71,276.00,per diem,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,GO,182.00,,,,,,,7.63,276.00,per diem,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Cigna,Commercial,GO,182.00,,,,,,,34.90,276.00,per diem,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Cigna,Commercial,GO,182.00,,,,,,,23.68,276.00,per diem,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Cigna,Commercial,GO,182.00,,,,,,,19.79,276.00,per diem,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Cigna,Commercial,GO,182.00,,,,,,,11.69,276.00,per diem,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Cigna,Commercial,GO,182.00,,,,,,,49.54,276.00,per diem,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Cigna,Commercial,GO,182.00,,,,,,,62.79,276.00,per diem,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Cigna,Commercial,GO,182.00,,,,,,,64.66,276.00,per diem,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Cigna,Commercial,GO,182.00,,,,,,,31.47,276.00,per diem,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Cigna,Commercial,GN,182.00,,,,,,,55.46,276.00,per diem,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Cigna,Commercial,GN,182.00,,,,,,,52.35,276.00,per diem,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Cigna,Commercial,GN,182.00,,,,,,,29.13,276.00,per diem,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Cigna,Commercial,GN,182.00,,,,,,,41.91,276.00,per diem,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Cigna,Commercial,GN,182.00,,,,,,,31.16,276.00,per diem,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Cigna,Commercial,GN,182.00,,,,,,,49.08,276.00,per diem,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Cigna,Commercial,GN,182.00,,,,,,,19.94,276.00,per diem,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Cigna,Commercial,GN,182.00,,,,,,,10.91,276.00,per diem,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Cigna,Commercial,GN,182.00,,,,,,,13.24,276.00,per diem,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Cigna,Commercial,GN,182.00,,,,,,,15.42,276.00,per diem,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Cigna,Commercial,GN,182.00,,,,,,,35.68,276.00,per diem,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,GN,182.00,,,,,,,21.19,276.00,per diem,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Cigna,Commercial,GN,182.00,,,,,,,102.05,399.55,per diem,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Cigna,Commercial,GN,182.00,,,,,,,40.35,276.00,per diem,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Cigna,Commercial,GN,182.00,,,,,,,10.59,276.00,per diem,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Cigna,Commercial,GN,182.00,,,,,,,20.25,276.00,per diem,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Cigna,Commercial,GN,182.00,,,,,,,10.91,276.00,per diem,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Cigna,Commercial,GN,182.00,,,,,,,4.67,276.00,per diem,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Cigna,Commercial,GN,182.00,,,,,,,33.34,276.00,per diem,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Cigna,Commercial,GN,182.00,,,,,,,35.68,276.00,per diem,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Cigna,Commercial,GN,182.00,,,,,,,16.67,276.00,per diem,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Cigna,Commercial,GN,182.00,,,,,,,55.00,276.00,per diem,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Cigna,Commercial,GN,182.00,,,,,,,85.53,411.75,per diem,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Cigna,Commercial,GN,182.00,,,,,,,92.08,443.25,per diem,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Cigna,Commercial,,565.06,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Cigna,Commercial,,359.05,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Cigna,Commercial,,578.79,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Cigna,Commercial,,329.62,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Cigna,Commercial,,487.23,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Cigna,Commercial,,2456.42,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Cigna,Commercial,,28.12,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Cigna,Commercial,,96.79,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Cigna,Commercial,,343.35,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Cigna,Commercial,,342.04,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Cigna,Commercial,,368.20,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Cigna,Commercial,,246.56,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Cigna,Commercial,,246.56,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Cigna,Commercial,,887.48,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Cigna,Commercial,,273.37,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Cigna,Commercial,,531.05,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Cigna,Commercial,,69.98,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Cigna,Commercial,,370.82,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Cigna,Commercial,,311.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Cigna,Commercial,,426.41,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Cigna,Commercial,,299.53,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Cigna,Commercial,,102.02,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Cigna,Commercial,,117.72,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Cigna,Commercial,,765.18,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Cigna,Commercial,,85.67,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Cigna,Commercial,,1008.47,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Cigna,Commercial,,1008.47,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Cigna,Commercial,,172.66,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Cigna,Commercial,,172.66,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Cigna,Commercial,,1308.00,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Cigna,Commercial,,2042.44,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Cigna,Commercial,,457.80,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Cigna,Commercial,,1485.89,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Cigna,Commercial,,543.47,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Cigna,Commercial,,330.27,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Cigna,Commercial,,145.19,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Cigna,Commercial,,217.78,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Cigna,Commercial,,221.05,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Cigna,Commercial,,120.99,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Cigna,Commercial,,3952.12,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Cigna,Commercial,,3952.12,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Cigna,Commercial,,665.12,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Cigna,Commercial,,2746.80,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Cigna,Commercial,,2746.80,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Cigna,Commercial,,2789.96,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Cigna,Commercial,,296.58,,,,,,,175.00,865.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Cigna,Commercial,,361.01,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Cigna,Commercial,,195.74,,,,,,,98.37,423.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Cigna,Commercial,,432.60,,,,,,,175.00,1012.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Cigna,Commercial,,629.80,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Cigna,Commercial,,134.16,,,,,,,95.75,412.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Cigna,Commercial,,629.80,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Cigna,Commercial,,204.74,,,,,,,150.52,788.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Cigna,Commercial,,296.26,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Cigna,Commercial,,396.00,,,,,,,175.00,953.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Cigna,Commercial,,757.99,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Cigna,Commercial,,233.00,,,,,,,102.31,546.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Cigna,Commercial,,314.57,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Cigna,Commercial,,306.72,,,,,,,175.00,844.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Cigna,Commercial,,206.66,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Cigna,Commercial,,195.10,,,,,,,102.31,568.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Cigna,Commercial,,81.10,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Cigna,Commercial,,189.96,,,,,,,102.31,718.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Cigna,Commercial,,277.16,,,,,,,99.41,428.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Cigna,Commercial,,182.26,,,,,,,80.78,348.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Cigna,Commercial,,93.70,,,,,,,93.70,404.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Cigna,Commercial,,240.06,,,,,,,87.57,377.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Cigna,Commercial,,1028.09,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Cigna,Commercial,,264.87,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Cigna,Commercial,,1028.09,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Cigna,Commercial,,264.87,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Cigna,Commercial,,243.94,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Cigna,Commercial,,440.80,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Cigna,Commercial,,537.59,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Cigna,Commercial,,559.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Cigna,Commercial,,580.75,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Cigna,Commercial,,352.51,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Cigna,Commercial,,280.57,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Cigna,Commercial,,192.93,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Cigna,Commercial,,285.80,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Cigna,Commercial,,165.46,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Cigna,Commercial,,401.56,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Cigna,Commercial,,401.56,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Cigna,Commercial,,357.74,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Cigna,Commercial,,138.65,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Cigna,Commercial,,138.65,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Cigna,Commercial,,138.65,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Cigna,Commercial,,138.65,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Cigna,Commercial,,261.60,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Cigna,Commercial,,261.60,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Cigna,Commercial,,261.60,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Cigna,Commercial,,174.62,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Cigna,Commercial,,239.36,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Cigna,Commercial,,239.36,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Cigna,Commercial,,1069.29,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Cigna,Commercial,,1069.29,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Cigna,Commercial,,298.88,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Cigna,Commercial,,297.57,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Cigna,Commercial,,975.11,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Cigna,Commercial,,998.00,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Cigna,Commercial,,554.59,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Cigna,Commercial,,806.38,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Cigna,Commercial,,276.64,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Cigna,Commercial,,652.04,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Cigna,Commercial,,156.00,,,,,,,92.69,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Cigna,Commercial,,355.78,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Cigna,Commercial,,860.01,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Cigna,Commercial,,1038.55,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Cigna,Commercial,,1275.30,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Cigna,Commercial,,1809.62,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Cigna,Commercial,,1987.51,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Cigna,Commercial,,2521.82,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Cigna,Commercial,,1483.27,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Cigna,Commercial,,1661.16,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Cigna,Commercial,,1869.13,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Cigna,Commercial,,2966.54,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Cigna,Commercial,,3322.32,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Cigna,Commercial,,3708.18,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Cigna,Commercial,,681.47,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,122.95,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,122.95,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,41.20,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Cigna,Commercial,,147.15,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Cigna,Commercial,,190.97,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Cigna,Commercial,,192.28,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Cigna,Commercial,,31.39,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Cigna,Commercial,,31.39,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,77.17,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,77.17,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,77.17,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,77.17,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Cigna,Commercial,,69.32,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,77.17,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Cigna,Commercial,,506.85,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Cigna,Commercial,,506.85,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Cigna,Commercial,,506.85,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Cigna,Commercial,,506.85,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Cigna,Commercial,,506.85,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Cigna,Commercial,,506.85,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Cigna,Commercial,,49.05,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Cigna,Commercial,GP,182.00,,,,,,,10.39,4311.00,per diem,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Cigna,Commercial,,313.27,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Cigna,Commercial,,628.38,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Cigna,Commercial,,1794.58,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Cigna,Commercial,,2534.25,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Cigna,Commercial,,709.59,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Cigna,Commercial,,1611.46,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Cigna,Commercial,,679.51,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Cigna,Commercial,,679.51,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Cigna,Commercial,,2086.26,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Cigna,Commercial,,281.22,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Cigna,Commercial,,313.92,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Cigna,Commercial,,350.54,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Cigna,Commercial,,299.53,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Cigna,Commercial,,77.83,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,,84.37,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,,84.37,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Cigna,Commercial,,136.03,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Cigna,Commercial,,106.60,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Cigna,Commercial,,200.78,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Cigna,Commercial,,340.08,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Cigna,Commercial,,329.62,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Cigna,Commercial,,404.17,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Cigna,Commercial,,267.49,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Cigna,Commercial,,4121.00,,,,,,,154.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Cigna,Commercial,,503.58,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Cigna,Commercial,,4121.00,,,,,,,127.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Cigna,Commercial,,394.36,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Cigna,Commercial,,589.91,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Cigna,Commercial,,41.68,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Cigna,Commercial,,34.81,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Cigna,Commercial,,64.12,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Cigna,Commercial,,253.75,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Cigna,Commercial,,173.81,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Cigna,Commercial,,496.39,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Cigna,Commercial,,4121.00,,,,,,,459.46,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Cigna,Commercial,,396.98,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Cigna,Commercial,,4121.00,,,,,,,372.97,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Cigna,Commercial,,1218.40,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Cigna,Commercial,,488.23,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Cigna,Commercial,,350.54,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Cigna,Commercial,,678.20,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Cigna,Commercial,,8179.58,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Cigna,Commercial,,994.08,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Cigna,Commercial,,1264.18,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Cigna,Commercial,,545.44,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Cigna,Commercial,,568.33,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Cigna,Commercial,,604.95,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Cigna,Commercial,,1005.85,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Cigna,Commercial,,1254.37,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Cigna,Commercial,,6392.20,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Cigna,Commercial,,151.14,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Cigna,Commercial,,431.64,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Cigna,Commercial,,4121.00,,,,,,,638.44,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Cigna,Commercial,,2085.61,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Cigna,Commercial,,349.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Cigna,Commercial,,999.31,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Cigna,Commercial,,1129.46,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Cigna,Commercial,,5152.00,,,,,,,428.83,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Cigna,Commercial,,1400.87,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Cigna,Commercial,,319.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Cigna,Commercial,,913.64,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Cigna,Commercial,,142.21,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Cigna,Commercial,,406.13,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Cigna,Commercial,,164.88,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Cigna,Commercial,,470.88,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,13.97,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,39.89,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Cigna,Commercial,,4121.00,,,,,,,74.67,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Cigna,Commercial,,1464.96,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Cigna,Commercial,JW,71.34,,,,,,,26.43,107.32,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Cigna,Commercial,,383.24,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Cigna,Commercial,,114.27,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Cigna,Commercial,,138.32,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Cigna,Commercial,,326.35,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Cigna,Commercial,,134.19,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Cigna,Commercial,,537.59,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Cigna,Commercial,,892.06,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Cigna,Commercial,,230.21,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Cigna,Commercial,,2577.41,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Cigna,Commercial,,4121.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Cigna,Commercial,,2577.41,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Cigna,Commercial,,4121.00,,,,,,,390.39,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Cigna,Commercial,,1275.30,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Cigna,Commercial,,4121.00,,,,,,,621.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Cigna,Commercial,,2029.36,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Cigna,Commercial,,1126.84,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Cigna,Commercial,,1394.33,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Cigna,Commercial,,1831.20,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Cigna,Commercial,,124.35,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Cigna,Commercial,,1004.16,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Cigna,Commercial,,1110.65,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Cigna,Commercial,,4121.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Cigna,Commercial,,184.12,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Cigna,Commercial,,1023.51,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Cigna,Commercial,,1023.51,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Cigna,Commercial,,1256.33,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Cigna,Commercial,,1112.45,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Cigna,Commercial,,380.63,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Cigna,Commercial,,1483.27,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Cigna,Commercial,,827.31,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Cigna,Commercial,,4121.00,,,,,,,467.07,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Cigna,Commercial,,1525.78,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Cigna,Commercial,,1338.74,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Cigna,Commercial,,873.09,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Cigna,Commercial,,553.94,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Cigna,Commercial,,4121.00,,,,,,,356.56,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Cigna,Commercial,,1164.77,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Cigna,Commercial,,1110.49,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Cigna,Commercial,,903.17,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Cigna,Commercial,,903.17,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Cigna,Commercial,,1173.28,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Cigna,Commercial,,4121.00,,,,,,,359.16,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Cigna,Commercial,,2693.83,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Cigna,Commercial,,12408.00,,,,,,,824.62,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Cigna,Commercial,,17457.00,,,,,,,695.70,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Cigna,Commercial,,17457.00,,,,,,,695.70,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Cigna,Commercial,,117.25,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Cigna,Commercial,,136.03,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,13.97,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Cigna,Commercial,52,5152.00,,,,,,,220.22,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Cigna,Commercial,,173.81,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Cigna,Commercial,,464.99,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Cigna,Commercial,,955.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Cigna,Commercial,,83.06,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Cigna,Commercial,,5152.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Cigna,Commercial,,601.03,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Cigna,Commercial,,85.42,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Cigna,Commercial,,327.00,,,,,,,59.12,365.00,per diem,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Cigna,Commercial,,372.00,,,,,,,129.99,624.00,per diem,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Cigna,Commercial,,1236.00,,,,,,,259.79,1295.00,per diem,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Cigna,Commercial,,3235.00,,,,,,,409.68,3235.00,per diem,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Cigna,Commercial,,3709.00,,,,,,,589.86,3709.00,per diem,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Cigna,Commercial,,5152.00,,,,,,,748.05,5152.00,per diem,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Cigna,Commercial,,5152.00,,,,,,,246.93,5152.00,per diem,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Cigna,Commercial,,789.38,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Cigna,Commercial,,236.09,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Cigna,Commercial,,193.58,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Cigna,Commercial,,123.61,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Cigna,Commercial,,102.02,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Cigna,Commercial,,102.02,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Cigna,Commercial,,1789.34,,,,,,,266.00,2052.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Cigna,Commercial,,71.34,,,,,,,26.03,96.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Cigna,Commercial,,28.04,,,,,,,5.00,31.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,106.06,,,,,,,19.02,138.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,5.99,,,,,,,5.99,40.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Cigna,Commercial,JW,124.49,,,,,,,24.62,124.49,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Cigna,Commercial,,124.49,,,,,,,24.62,132.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,JW,106.06,,,,,,,19.02,106.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Cigna,Commercial,,202.87,,,,,,,28.43,371.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Cigna,Commercial,,124.49,,,,,,,34.92,202.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Cigna,Commercial,,161.64,,,,,,,40.04,186.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Cigna,Commercial,JW,161.64,,,,,,,40.04,162.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Cigna,Commercial,,5.88,,,,,,,5.88,337.70,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Cigna,Commercial,,5.88,,,,,,,5.88,676.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Cigna,Commercial,JW,5.88,,,,,,,5.88,740.64,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Cigna,Commercial,JW,5.88,,,,,,,5.88,369.92,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Cigna,Commercial,,238.43,,,,,,,197.80,733.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,238.43,,,,,,,125.33,464.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Cigna,Commercial,,238.43,,,,,,,54.65,268.27,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Cigna,Commercial,JW,238.43,,,,,,,197.80,803.24,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Cigna,Commercial,JW,238.43,,,,,,,54.65,238.43,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Cigna,Commercial,,154.34,,,,,,,114.31,423.80,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Cigna,Commercial,,154.34,,,,,,,52.45,194.46,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Cigna,Commercial,,240.06,,,,,,,240.06,2044.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Cigna,Commercial,,240.06,,,,,,,240.06,902.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Cigna,Commercial,,240.06,,,,,,,123.32,457.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Cigna,Commercial,JW,240.06,,,,,,,240.06,2239.00,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Cigna,Commercial,JW,240.06,,,,,,,240.06,988.61,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Cigna,Commercial,JW,240.06,,,,,,,123.32,500.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Cigna,Commercial,,238.43,,,,,,,238.43,2087.81,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Cigna,Commercial,,124.49,,,,,,,24.62,132.99,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Cigna,Commercial,,70.59,,,,,,,68.47,253.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Cigna,Commercial,JW,70.59,,,,,,,68.47,278.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Cigna,Commercial,,327.43,,,,,,,309.51,1147.44,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Cigna,Commercial,,327.43,,,,,,,327.43,2296.37,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Cigna,Commercial,JW,327.43,,,,,,,309.51,1256.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Cigna,Commercial,,70.59,,,,,,,70.59,317.66,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Cigna,Commercial,JW,70.59,,,,,,,70.59,347.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Cigna,Commercial,,70.59,,,,,,,70.59,358.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Cigna,Commercial,JW,70.59,,,,,,,70.59,392.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Cigna,Commercial,,5.99,,,,,,,2.00,7.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Cigna,Commercial,,794.40,,,,,,,500.10,1854.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Cigna,Commercial,JW,794.40,,,,,,,500.10,2030.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Cigna,Commercial,,794.40,,,,,,,405.40,1502.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Cigna,Commercial,JW,794.40,,,,,,,405.40,1646.33,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Cigna,Commercial,,794.40,,,,,,,341.94,1267.68,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Cigna,Commercial,JW,794.40,,,,,,,341.94,1388.60,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,28.04,,,,,,,13.01,48.24,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,JW,28.04,,,,,,,13.01,52.84,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Cigna,Commercial,,6571.14,,,,,,,494.29,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Cigna,Commercial,,6571.14,,,,,,,139.74,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Cigna,Commercial,,6571.14,,,,,,,139.74,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,6571.14,,,,,,,125.33,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,6571.14,,,,,,,125.33,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Cigna,Commercial,,6571.14,,,,,,,123.12,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Cigna,Commercial,,6571.14,,,,,,,123.12,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,6571.14,,,,,,,87.89,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,6571.14,,,,,,,87.89,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Cigna,Commercial,,6571.14,,,,,,,79.88,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Cigna,Commercial,,6571.14,,,,,,,79.88,6571.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Cigna,Commercial,JW,154.34,,,,,,,154.34,1921.12,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Cigna,Commercial,JW,154.34,,,,,,,114.31,464.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Cigna,Commercial,JW,154.34,,,,,,,52.45,213.01,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Cigna,Commercial,,154.34,,,,,,,62.66,232.31,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Cigna,Commercial,JW,154.34,,,,,,,62.66,254.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Cigna,Commercial,,240.06,,,,,,,240.06,1168.96,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Cigna,Commercial,JW,240.06,,,,,,,240.06,1280.47,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Cigna,Commercial,,240.06,,,,,,,240.06,929.23,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Cigna,Commercial,JW,240.06,,,,,,,240.06,1017.88,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Cigna,Commercial,,240.06,,,,,,,128.33,475.75,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Cigna,Commercial,JW,240.06,,,,,,,128.33,521.13,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Cigna,Commercial,,240.06,,,,,,,68.07,274.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Cigna,Commercial,JW,240.06,,,,,,,68.07,276.42,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Cigna,Commercial,,240.06,,,,,,,54.45,274.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Cigna,Commercial,JW,240.06,,,,,,,54.45,240.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Cigna,Commercial,,240.06,,,,,,,240.06,1901.52,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Cigna,Commercial,,192.93,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Cigna,Commercial,,416.60,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Cigna,Commercial,,416.60,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Cigna,Commercial,,416.60,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Cigna,Commercial,,416.60,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Cigna,Commercial,,176.58,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Cigna,Commercial,,2774.92,,,,,,,799.81,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Cigna,Commercial,,160.88,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Cigna,Commercial,,1685.36,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Cigna,Commercial,,139.07,,,,,,,41.84,142.48,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Cigna,Commercial,,198.16,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Cigna,Commercial,,1292.30,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Cigna,Commercial,,1292.30,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Cigna,Commercial,,282.53,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Cigna,Commercial,,282.53,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Cigna,Commercial,,220.40,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Cigna,Commercial,,183.12,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Cigna,Commercial,,175.93,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Cigna,Commercial,,9423.00,,,,,,,1877.68,9423.00,per diem,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Cigna,Commercial,,727.90,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Cigna,Commercial,,678.20,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Cigna,Commercial,,782.84,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Cigna,Commercial,,527.12,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Cigna,Commercial,,454.56,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Cigna,Commercial,,9423.00,,,,,,,397.40,9423.00,per diem,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Cigna,Commercial,,2673.80,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Cigna,Commercial,,9423.00,,,,,,,2337.54,13852.00,per diem,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Cigna,Commercial,,4652.36,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Cigna,Commercial,,9423.00,,,,,,,4067.26,24600.00,per diem,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Cigna,Commercial,,1978.56,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Cigna,Commercial,,9423.00,,,,,,,1729.73,13852.00,per diem,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Cigna,Commercial,,4197.80,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Cigna,Commercial,,9423.00,,,,,,,3669.87,24600.00,per diem,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Cigna,Commercial,,6791.45,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Cigna,Commercial,,9423.00,,,,,,,5937.33,52940.00,per diem,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Cigna,Commercial,,175.93,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Cigna,Commercial,,268.14,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Cigna,Commercial,,388.48,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Cigna,Commercial,,334.85,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Cigna,Commercial,,504.23,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Cigna,Commercial,,445.37,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Cigna,Commercial,,2534.25,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Cigna,Commercial,,93.52,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Cigna,Commercial,,206.01,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Cigna,Commercial,,127.53,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Cigna,Commercial,,206.01,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Cigna,Commercial,,127.53,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Cigna,Commercial,,206.01,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Cigna,Commercial,,127.53,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Cigna,Commercial,,336.81,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,,107.91,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Cigna,Commercial,,620.65,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Cigna,Commercial,,316.54,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Cigna,Commercial,,83.71,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Cigna,Commercial,,92.21,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Cigna,Commercial,,103.33,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Cigna,Commercial,,60.17,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Cigna,Commercial,,60.17,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Cigna,Commercial,,138.65,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Cigna,Commercial,,268.14,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Cigna,Commercial,,336.81,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Cigna,Commercial,,41.86,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Cigna,Commercial,,41.86,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,18.31,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Cigna,Commercial,,98.10,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Cigna,Commercial,,55.59,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Cigna,Commercial,,86.98,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Cigna,Commercial,,336.81,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Cigna,Commercial,,18440.00,,,,,,,5080.00,29448.00,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Cigna,Commercial,,12408.00,,,,,,,155.56,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Cigna,Commercial,,9423.00,,,,,,,1757.36,9423.00,per diem,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Cigna,Commercial,,9423.00,,,,,,,1757.36,9423.00,per diem,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Cigna,Commercial,,3231.41,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Cigna,Commercial,,66.87,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Cigna,Commercial,,4121.00,,,,,,,176.98,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Cigna,Commercial,,134.07,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Cigna,Commercial,,134.07,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Cigna,Commercial,,4121.00,,,,,,,194.19,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Cigna,Commercial,,4121.00,,,,,,,246.25,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Cigna,Commercial,,74.20,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Cigna,Commercial,,5152.00,,,,,,,1253.05,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Cigna,Commercial,,2042.44,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Cigna,Commercial,,4121.00,,,,,,,97.30,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Cigna,Commercial,,17457.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Cigna,Commercial,,2042.44,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Cigna,Commercial,,192.82,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Cigna,Commercial,,17457.00,,,,,,,467.67,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Cigna,Commercial,,17457.00,,,,,,,463.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Cigna,Commercial,,6649.00,,,,,,,464.86,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Cigna,Commercial,,2731.74,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Cigna,Commercial,,4121.00,,,,,,,104.90,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Cigna,Commercial,,374.74,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Cigna,Commercial,,304.80,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Cigna,Commercial,,4121.00,,,,,,,512.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Cigna,Commercial,,586.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Cigna,Commercial,,4121.00,,,,,,,379.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Cigna,Commercial,,433.95,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Cigna,Commercial,,4121.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Cigna,Commercial,,791.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Cigna,Commercial,,4121.00,,,,,,,512.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Cigna,Commercial,,586.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Cigna,Commercial,,120.36,,,,,,,120.36,3849.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Cigna,Commercial,,292.17,,,,,,,247.25,916.62,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Cigna,Commercial,,292.17,,,,,,,209.81,777.83,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Cigna,Commercial,,292.17,,,,,,,141.54,524.74,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Cigna,Commercial,,292.17,,,,,,,110.11,408.21,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Cigna,Commercial,,292.17,,,,,,,88.49,343.20,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Cigna,Commercial,,292.17,,,,,,,93.29,345.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Cigna,Commercial,JW,292.17,,,,,,,247.25,1004.05,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Cigna,Commercial,JW,292.17,,,,,,,209.81,852.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Cigna,Commercial,JW,292.17,,,,,,,141.54,574.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Cigna,Commercial,JW,292.17,,,,,,,110.11,447.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Cigna,Commercial,JW,292.17,,,,,,,88.49,359.35,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Cigna,Commercial,JW,292.17,,,,,,,93.29,378.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Cigna,Commercial,,162.39,,,,,,,162.39,1542.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Cigna,Commercial,,117.07,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,122.95,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Cigna,Commercial,,182.51,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Cigna,Commercial,,226.25,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Cigna,Commercial,,327.93,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Cigna,Commercial,,202.89,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Cigna,Commercial,,40.99,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Cigna,Commercial,,418.61,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Cigna,Commercial,,594.03,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Cigna,Commercial,,216.41,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Cigna,Commercial,,660.21,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Cigna,Commercial,,218.92,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Cigna,Commercial,,202.89,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Cigna,Commercial,,321.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Cigna,Commercial,,1421.80,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Cigna,Commercial,,2767.73,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Cigna,Commercial,,12512.33,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Cigna,Commercial,,280.57,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Cigna,Commercial,,295.61,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Cigna,Commercial,,262.25,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Cigna,Commercial,,434.91,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Cigna,Commercial,,207.97,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,35.32,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Cigna,Commercial,,722.16,,,,,,,61.06,722.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Cigna,Commercial,,45.52,,,,,,,45.52,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Cigna,Commercial,,61.58,,,,,,,61.58,408.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Cigna,Commercial,,89.20,,,,,,,70.47,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Cigna,Commercial,,42.96,,,,,,,42.96,360.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Cigna,Commercial,,67.36,,,,,,,67.36,450.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Cigna,Commercial,,57.08,,,,,,,57.08,295.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Cigna,Commercial,,65.78,,,,,,,65.78,331.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Cigna,Commercial,,67.36,,,,,,,67.36,375.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Cigna,Commercial,,46.16,,,,,,,30.43,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Cigna,Commercial,,52.60,,,,,,,52.60,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Cigna,Commercial,,46.16,,,,,,,24.02,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Cigna,Commercial,,51.96,,,,,,,51.96,375.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Cigna,Commercial,,60.30,,,,,,,60.30,503.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Cigna,Commercial,,80.86,,,,,,,35.84,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Cigna,Commercial,,15.34,,,,,,,15.34,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Cigna,Commercial,,43.60,,,,,,,43.60,271.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Cigna,Commercial,,50.02,,,,,,,50.02,362.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Cigna,Commercial,,56.44,,,,,,,56.44,438.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Cigna,Commercial,,57.74,,,,,,,57.74,809.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Cigna,Commercial,,71.86,,,,,,,71.86,438.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Cigna,Commercial,,46.82,,,,,,,46.82,288.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Cigna,Commercial,,59.66,,,,,,,59.66,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Cigna,Commercial,,32.04,,,,,,,32.04,331.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Cigna,Commercial,,55.16,,,,,,,55.16,372.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Cigna,Commercial,,77.00,,,,,,,77.00,495.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Cigna,Commercial,,91.78,,,,,,,91.78,696.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Cigna,Commercial,,44.24,,,,,,,44.24,327.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Cigna,Commercial,,54.52,,,,,,,54.52,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Cigna,Commercial,,47.46,,,,,,,47.46,423.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Cigna,Commercial,,55.80,,,,,,,55.80,369.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Cigna,Commercial,,74.44,,,,,,,74.44,532.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Cigna,Commercial,,91.12,,,,,,,91.12,656.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Cigna,Commercial,,57.74,,,,,,,57.74,436.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Cigna,Commercial,,37.18,,,,,,,37.18,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Cigna,Commercial,,57.74,,,,,,,57.74,405.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Cigna,Commercial,,54.52,,,,,,,54.52,276.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Cigna,Commercial,,46.16,,,,,,,46.16,276.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Cigna,Commercial,,138.66,,,,,,,138.66,908.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Cigna,Commercial,,141.22,,,,,,,141.22,830.63,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Cigna,Commercial,,135.44,,,,,,,135.44,1002.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Cigna,Commercial,,195.18,,,,,,,195.18,1419.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Cigna,Commercial,,139.30,,,,,,,139.30,2053.05,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Cigna,Commercial,,46.16,,,,,,,46.16,318.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Cigna,Commercial,,28.82,,,,,,,28.82,286.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Cigna,Commercial,,26.90,,,,,,,26.90,344.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Cigna,Commercial,,48.74,,,,,,,48.74,346.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Cigna,Commercial,,204.18,,,,,,,204.18,953.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Cigna,Commercial,,37.18,,,,,,,37.18,391.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Cigna,Commercial,,46.16,,,,,,,46.16,330.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Cigna,Commercial,,40.38,,,,,,,40.38,304.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Cigna,Commercial,,46.16,,,,,,,46.16,331.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Cigna,Commercial,,166.28,,,,,,,97.50,375.47,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Cigna,Commercial,,41.04,,,,,,,41.04,284.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Cigna,Commercial,,46.16,,,,,,,46.16,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Cigna,Commercial,,49.38,,,,,,,49.38,281.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Cigna,Commercial,,62.22,,,,,,,62.22,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Cigna,Commercial,,213.16,,,,,,,130.73,489.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Cigna,Commercial,,44.24,,,,,,,44.24,323.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Cigna,Commercial,,53.88,,,,,,,53.88,295.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Cigna,Commercial,,59.02,,,,,,,55.26,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Cigna,Commercial,,206.10,,,,,,,168.37,630.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Cigna,Commercial,,50.02,,,,,,,50.02,320.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Cigna,Commercial,,60.94,,,,,,,60.94,278.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Cigna,Commercial,,68.00,,,,,,,68.00,361.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Cigna,Commercial,,61.58,,,,,,,61.58,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Cigna,Commercial,,233.08,,,,,,,76.08,375.47,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Cigna,Commercial,,45.52,,,,,,,45.52,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Cigna,Commercial,,46.16,,,,,,,43.64,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Cigna,Commercial,,46.82,,,,,,,46.82,333.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Cigna,Commercial,,54.52,,,,,,,54.52,347.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Cigna,Commercial,,205.46,,,,,,,76.08,375.47,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Cigna,Commercial,,39.74,,,,,,,39.74,397.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Cigna,Commercial,,50.66,,,,,,,50.66,347.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Cigna,Commercial,,40.38,,,,,,,40.38,300.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Cigna,Commercial,,43.60,,,,,,,43.60,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Cigna,Commercial,,41.04,,,,,,,41.04,319.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,,63.20,,,,,,,63.20,576.46,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,,63.20,,,,,,,63.20,576.46,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,,63.20,,,,,,,63.20,576.46,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Cigna,Commercial,,138.66,,,,,,,138.66,586.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Cigna,Commercial,,210.59,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Cigna,Commercial,,311.44,,,,,,,49.45,311.44,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Cigna,Commercial,,689.97,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Cigna,Commercial,,476.11,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Cigna,Commercial,,580.75,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Cigna,Commercial,,325.69,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Cigna,Commercial,,345.97,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Cigna,Commercial,,221.52,,,,,,,171.27,741.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Cigna,Commercial,,259.42,,,,,,,171.27,780.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Cigna,Commercial,,100.76,,,,,,,100.76,805.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Cigna,Commercial,,222.16,,,,,,,107.51,402.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Cigna,Commercial,,49.38,,,,,,,19.62,375.47,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Cigna,Commercial,,156.64,,,,,,,116.12,435.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Cigna,Commercial,,98.30,,,,,,,98.30,482.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Cigna,Commercial,,175.28,,,,,,,163.76,613.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Cigna,Commercial,,157.28,,,,,,,133.33,2153.70,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Cigna,Commercial,,154.08,,,,,,,154.08,607.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Cigna,Commercial,,130.88,,,,,,,130.88,5683.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Cigna,Commercial,,116.82,,,,,,,116.82,3483.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Cigna,Commercial,,125.18,,,,,,,125.18,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Cigna,Commercial,,114.26,,,,,,,37.04,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Cigna,Commercial,,117.46,,,,,,,117.46,1633.21,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Cigna,Commercial,,126.46,,,,,,,126.46,1633.21,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Cigna,Commercial,,118.74,,,,,,,118.74,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Cigna,Commercial,,129.02,,,,,,,129.02,4309.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Cigna,Commercial,,130.96,,,,,,,130.96,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Cigna,Commercial,,150.14,,,,,,,150.14,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Cigna,Commercial,,143.80,,,,,,,143.80,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Cigna,Commercial,,167.48,,,,,,,167.48,5683.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Cigna,Commercial,,139.94,,,,,,,139.94,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Cigna,Commercial,,197.10,,,,,,,160.96,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Cigna,Commercial,,139.94,,,,,,,139.94,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Cigna,Commercial,,138.66,,,,,,,138.66,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Cigna,Commercial,,139.30,,,,,,,139.30,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Cigna,Commercial,,150.22,,,,,,,150.22,5683.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Cigna,Commercial,,1525.78,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Cigna,Commercial,,82.40,,,,,,,82.40,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Cigna,Commercial,,133.42,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Cigna,Commercial,,114.45,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Cigna,Commercial,,787.42,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Cigna,Commercial,,504.23,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Cigna,Commercial,,691.28,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Cigna,Commercial,,234.13,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Cigna,Commercial,,53.24,,,,,,,53.24,714.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Cigna,Commercial,,40.38,,,,,,,33.83,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Cigna,Commercial,,68.64,,,,,,,68.64,702.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Cigna,Commercial,,48.74,,,,,,,48.74,576.46,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Cigna,Commercial,,119.40,,,,,,,68.27,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Cigna,Commercial,,71.60,,,,,,,28.63,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Cigna,Commercial,,486.58,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Cigna,Commercial,,432.95,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Cigna,Commercial,,429.68,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Cigna,Commercial,,69.30,,,,,,,64.66,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Cigna,Commercial,,91.12,,,,,,,91.12,484.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Cigna,Commercial,,32.68,,,,,,,32.68,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Cigna,Commercial,,61.58,,,,,,,48.65,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Cigna,Commercial,,85.34,,,,,,,53.65,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Cigna,Commercial,,140.58,,,,,,,102.31,695.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Cigna,Commercial,,141.88,,,,,,,61.26,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Cigna,Commercial,,52.60,,,,,,,52.60,683.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Cigna,Commercial,,40.38,,,,,,,40.38,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Cigna,Commercial,,248.42,,,,,,,157.76,5683.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Cigna,Commercial,,133.52,,,,,,,133.52,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Cigna,Commercial,,137.94,,,,,,,137.94,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Cigna,Commercial,,148.86,,,,,,,148.86,5683.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Cigna,Commercial,,186.12,,,,,,,186.12,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Cigna,Commercial,,170.70,,,,,,,170.70,5683.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Cigna,Commercial,,136.10,,,,,,,136.10,3385.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Cigna,Commercial,,138.58,,,,,,,138.58,3385.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Cigna,Commercial,,155.28,,,,,,,155.28,3385.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Cigna,Commercial,,198.96,,,,,,,198.96,3309.13,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Cigna,Commercial,,1168.04,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Cigna,Commercial,,9423.00,,,,,,,281.08,9423.00,per diem,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Cigna,Commercial,,32.68,,,,,,,32.68,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Cigna,Commercial,,44.24,,,,,,,44.24,280.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Cigna,Commercial,,60.30,,,,,,,60.30,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Cigna,Commercial,,197.10,,,,,,,166.37,623.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Cigna,Commercial,,75.43,,,,,,,32.63,104.79,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Cigna,Commercial,,51.96,,,,,,,51.96,375.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Cigna,Commercial,,137.38,,,,,,,137.38,2053.05,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Cigna,Commercial,,57.74,,,,,,,57.74,462.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Cigna,Commercial,,105.90,,,,,,,102.31,609.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Cigna,Commercial,,118.10,,,,,,,102.31,645.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Cigna,Commercial,,44.88,,,,,,,44.88,350.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Cigna,Commercial,,69.30,,,,,,,69.30,370.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Cigna,Commercial,,87.92,,,,,,,87.92,392.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Cigna,Commercial,,58.38,,,,,,,58.38,568.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Cigna,Commercial,,75.72,,,,,,,75.72,552.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Cigna,Commercial,,89.20,,,,,,,89.20,809.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Cigna,Commercial,,40.38,,,,,,,40.38,268.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Cigna,Commercial,,50.66,,,,,,,50.66,324.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Cigna,Commercial,,695.20,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Cigna,Commercial,,169.48,,,,,,,123.12,461.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Cigna,Commercial,,154.08,,,,,,,154.08,588.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Cigna,Commercial,,17287.50,,,,,,,4762.50,27607.50,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Cigna,Commercial,,141.92,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Cigna,Commercial,,170.70,,,,,,,170.70,5683.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Cigna,Commercial,,8213.00,,,,,,,451.05,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Cigna,Commercial,,56.44,,,,,,,56.44,315.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Cigna,Commercial,,49.38,,,,,,,49.38,412.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Cigna,Commercial,,58.38,,,,,,,58.38,405.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Cigna,Commercial,,201.60,,,,,,,80.28,300.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Cigna,Commercial,,195.18,,,,,,,119.32,447.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Cigna,Commercial,,168.20,,,,,,,99.50,372.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Cigna,Commercial,,66.72,,,,,,,66.72,564.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Cigna,Commercial,,633.86,,,,,,,116.32,633.86,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Cigna,Commercial,,209.96,,,,,,,171.27,696.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Cigna,Commercial,,323.64,,,,,,,171.27,1036.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Cigna,Commercial,,2905.00,,,,,,,54.05,2905.00,per diem,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Cigna,Commercial,,542.17,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Cigna,Commercial,,224.32,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Cigna,Commercial,,270.10,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Cigna,Commercial,,887.48,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Cigna,Commercial,,442.76,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Cigna,Commercial,,447.99,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Cigna,Commercial,,722.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Cigna,Commercial,,381.28,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Cigna,Commercial,,1907.72,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Cigna,Commercial,,977.08,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Cigna,Commercial,,714.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Cigna,Commercial,,638.30,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Cigna,Commercial,,468.92,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Cigna,Commercial,,1220.36,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Cigna,Commercial,,663.16,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Cigna,Commercial,,1359.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Cigna,Commercial,,1047.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Cigna,Commercial,,1497.66,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Cigna,Commercial,,1047.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Cigna,Commercial,,1555.21,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Cigna,Commercial,,1787.38,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Cigna,Commercial,,559.82,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Cigna,Commercial,,1024.82,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Cigna,Commercial,,804.42,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Cigna,Commercial,,1468.23,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Cigna,Commercial,,681.47,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Cigna,Commercial,,750.79,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Cigna,Commercial,,820.77,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Cigna,Commercial,,1166.74,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Cigna,Commercial,,1723.94,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Cigna,Commercial,,1723.94,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Cigna,Commercial,,1633.04,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Cigna,Commercial,,2534.90,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Cigna,Commercial,,3167.98,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Cigna,Commercial,,543.47,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Cigna,Commercial,,941.11,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Cigna,Commercial,,846.28,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Cigna,Commercial,,1041.17,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Cigna,Commercial,,1625.84,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Cigna,Commercial,,508.81,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Cigna,Commercial,,957.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Cigna,Commercial,,565.06,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Cigna,Commercial,,712.86,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Cigna,Commercial,,522.55,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Cigna,Commercial,,758.64,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Cigna,Commercial,,863.93,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Cigna,Commercial,,758.64,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Cigna,Commercial,,1053.59,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Cigna,Commercial,,831.23,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Cigna,Commercial,,603.64,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Cigna,Commercial,,1531.01,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Cigna,Commercial,,1924.72,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Cigna,Commercial,,72.22,,,,,,,55.46,178.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,208.95,,,,,,,10.21,208.95,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Cigna,Commercial,,154.18,,,,,,,19.82,154.18,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Cigna,Commercial,,2131.58,,,,,,,406.41,2131.58,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Cigna,Commercial,,1039.60,,,,,,,197.80,1410.77,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Cigna,Commercial,,325.02,,,,,,,21.42,325.02,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Cigna,Commercial,,614.07,,,,,,,41.64,807.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,40.88,,,,,,,37.64,120.87,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Cigna,Commercial,,9315.86,,,,,,,559.36,9315.86,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Cigna,Commercial,,12296.97,,,,,,,2012.57,12296.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Cigna,Commercial,,1074.52,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Cigna,Commercial,,339.43,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Cigna,Commercial,,1329.58,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Cigna,Commercial,,307.38,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Cigna,Commercial,,39196.15,,,,,,,2476.67,39196.15,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Cigna,Commercial,,442.76,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Cigna,Commercial,,163224.30,,,,,,,0.20220,163224.30,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Cigna,Commercial,,643.60,,,,,,,17.42,2045.69,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Cigna,Commercial,,255.73,,,,,,,23.82,318.78,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Cigna,Commercial,,338.09,,,,,,,116.92,458.82,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Cigna,Commercial,,189.48,,,,,,,64.66,257.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Cigna,Commercial,,8.43,,,,,,,8.43,28.29,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Cigna,Commercial,,10134.22,,,,,,,1000.45,10134.22,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Cigna,Commercial,,4.08,,,,,,,1.20,29.06,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Cigna,Commercial,,78.61,,,,,,,24.42,132.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Cigna,Commercial,,31.29,,,,,,,8.41,161.14,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Cigna,Commercial,,259.58,,,,,,,16.42,1226.71,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Cigna,Commercial,,224.84,,,,,,,50.85,287.08,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,133.15,,,,,,,15.42,308.90,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Cigna,Commercial,,6878.34,,,,,,,1212.81,6878.34,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Cigna,Commercial,,105.92,,,,,,,36.64,137.38,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Cigna,Commercial,,703.05,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Cigna,Commercial,,722.16,,,,,,,61.06,722.16,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Cigna,Commercial,,933.91,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Cigna,Commercial,,406.86,,,,,,,61.06,479.07,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Cigna,Commercial,,1318.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Cigna,Commercial,,1318.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Cigna,Commercial,,1592.55,,,,,,,268.87,1592.55,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Cigna,Commercial,,1243.67,,,,,,,97.50,1243.67,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Cigna,Commercial,,284.49,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Cigna,Commercial,,1464.96,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Cigna,Commercial,,1049.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Cigna,Commercial,,2186.98,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Cigna,Commercial,,2186.98,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Cigna,Commercial,,2186.98,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Cigna,Commercial,,1851.54,,,,,,,262.06,1851.54,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Cigna,Commercial,,2316.93,,,,,,,386.19,2316.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Cigna,Commercial,,1480.57,,,,,,,214.01,1480.57,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Cigna,Commercial,,1473.49,,,,,,,369.58,2435.93,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Cigna,Commercial,,1524.30,,,,,,,246.25,1871.97,fee schedule,Reimbursed at 71.1% of Billed Charges if no fee available on Cigna National Injectable Immunizations Fee Schedule
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Cigna,Commercial,,2905.00,,,,,,,84.71,2905.00,per diem,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Cigna,Commercial,,2905.00,,,,,,,343.59,2905.00,per diem,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Cigna,Commercial,,2905.00,,,,,,,343.59,2942.87,per diem,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Cigna,Commercial,,2905.00,,,,,,,343.59,2942.87,per diem,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,3501.50,per diem,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Cigna,Commercial,,2905.00,,,,,,,206.81,2905.00,per diem,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Cigna,Commercial,,2905.00,,,,,,,225.43,2905.00,per diem,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Cigna,Commercial,,2905.00,,,,,,,64.86,2905.00,per diem,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Cigna,Commercial,,2905.00,,,,,,,507.91,2905.00,per diem,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Cigna,Commercial,,2905.00,,,,,,,258.06,2905.00,per diem,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Cigna,Commercial,,2905.00,,,,,,,227.83,2905.00,per diem,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Cigna,Commercial,,2905.00,,,,,,,254.05,2905.00,per diem,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,2908.74,per diem,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,3211.99,per diem,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,2942.40,per diem,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Cigna,Commercial,,2905.00,,,,,,,343.59,2905.00,per diem,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Cigna,Commercial,,2905.00,,,,,,,343.59,2905.00,per diem,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Cigna,Commercial,,2905.00,,,,,,,171.27,3037.26,per diem,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Cigna,Commercial,,2905.00,,,,,,,343.59,2905.00,per diem,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,3356.74,per diem,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Cigna,Commercial,,2905.00,,,,,,,171.27,3008.52,per diem,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,3500.13,per diem,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Cigna,Commercial,,2905.00,,,,,,,343.59,4490.21,per diem,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Cigna,Commercial,,9423.00,,,,,,,2025.00,21022.43,per diem,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Cigna,Commercial,,2905.00,,,,,,,232.56,3266.55,per diem,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Cigna,Commercial,,2905.00,,,,,,,343.59,3891.19,per diem,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Cigna,Commercial,,2905.00,,,,,,,343.59,4523.15,per diem,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Cigna,Commercial,,2905.00,,,,,,,84.71,2905.00,per diem,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Cigna,Commercial,,2905.00,,,,,,,171.27,3052.31,per diem,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Cigna,Commercial,,2905.00,,,,,,,560.56,2905.00,per diem,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Cigna,Commercial,,311.96,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Cigna,Commercial,,2905.00,,,,,,,102.31,2905.00,per diem,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Cigna,Commercial,,2905.00,,,,,,,171.27,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Cigna,Commercial,,2905.00,,,,,,,232.56,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Cigna,Commercial,,2905.00,,,,,,,343.59,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Cigna,Commercial,,2905.00,,,,,,,343.59,2905.00,per diem,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Cigna,Commercial,,2905.00,,,,,,,380.58,2905.00,per diem,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Cigna,Commercial,,2905.00,,,,,,,95.09,2905.00,per diem,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Cigna,Commercial,,4121.00,,,,,,,67.47,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Cigna,Commercial,,9423.00,,,,,,,2025.00,21022.43,per diem,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Cigna,Commercial,,9423.00,,,,,,,2025.00,21022.43,per diem,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Cigna,Commercial,,9423.00,,,,,,,2025.00,19194.26,per diem,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Cigna,Commercial,,5152.00,,,,,,,53.85,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Cigna,Commercial,,5152.00,,,,,,,145.75,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Cigna,Commercial,,5152.00,,,,,,,125.93,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Cigna,Commercial,,4121.00,,,,,,,399.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Cigna,Commercial,,17457.00,,,,,,,1022.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Cigna,Commercial,,124.35,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Cigna,Commercial,,317.62,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Cigna,Commercial,,4121.00,,,,,,,176.18,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Cigna,Commercial,,9423.00,,,,,,,2025.00,35106.11,per diem,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Cigna,Commercial,,9423.00,,,,,,,972.37,13852.00,per diem,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Cigna,Commercial,,9423.00,,,,,,,972.37,13852.00,per diem,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Cigna,Commercial,,9423.00,,,,,,,2025.00,18016.35,per diem,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Cigna,Commercial,,4121.00,,,,,,,222.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Cigna,Commercial,,5152.00,,,,,,,600.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Cigna,Commercial,,35.49,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Cigna,Commercial,,101.37,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Cigna,Commercial,,4121.00,,,,,,,84.28,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Cigna,Commercial,,668.91,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Cigna,Commercial,,6649.00,,,,,,,125.93,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Cigna,Commercial,,104.42,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Cigna,Commercial,,53.13,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Cigna,Commercial,,46.03,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Cigna,Commercial,,4121.00,,,,,,,96.30,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Cigna,Commercial,,4121.00,,,,,,,222.02,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Cigna,Commercial,,104.88,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Cigna,Commercial,,65.27,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,23.13,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Cigna,Commercial,,4121.00,,,,,,,280.28,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Cigna,Commercial,,4121.00,,,,,,,316.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Cigna,Commercial,,1034.63,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Cigna,Commercial,,5152.00,,,,,,,466.47,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Cigna,Commercial,,1523.82,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Cigna,Commercial,,71.22,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Cigna,Commercial,,71.22,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Cigna,Commercial,,4121.00,,,,,,,160.96,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Cigna,Commercial,,525.82,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Cigna,Commercial,,472.19,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Cigna,Commercial,,4121.00,,,,,,,115.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Cigna,Commercial,,377.36,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Cigna,Commercial,,1080.88,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Cigna,Commercial,,773.33,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Cigna,Commercial,,4121.00,,,,,,,142.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Cigna,Commercial,,129.38,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Cigna,Commercial,,323.81,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Cigna,Commercial,,175.19,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Cigna,Commercial,,295.87,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Cigna,Commercial,,133.05,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Cigna,Commercial,,291.98,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Cigna,Commercial,,833.85,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Cigna,Commercial,,267.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Cigna,Commercial,,5152.00,,,,,,,604.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Cigna,Commercial,,5152.00,,,,,,,604.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Cigna,Commercial,,4121.00,,,,,,,60.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Cigna,Commercial,,17457.00,,,,,,,388.99,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Cigna,Commercial,,335.26,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Cigna,Commercial,,9350.00,,,,,,,166.97,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Cigna,Commercial,,4121.00,,,,,,,324.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Cigna,Commercial,,4121.00,,,,,,,354.35,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Cigna,Commercial,,414.26,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Cigna,Commercial,,482.05,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Cigna,Commercial,,155.03,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Cigna,Commercial,,9423.00,,,,,,,135.54,9423.00,per diem,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Cigna,Commercial,,9423.00,,,,,,,103.90,9423.00,per diem,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Cigna,Commercial,,156.64,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Cigna,Commercial,,9423.00,,,,,,,136.94,9423.00,per diem,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Cigna,Commercial,,631.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Cigna,Commercial,,365.03,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Cigna,Commercial,,209.76,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Cigna,Commercial,,258.77,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Cigna,Commercial,,264.04,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Cigna,Commercial,,17457.00,,,,,,,1012.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Cigna,Commercial,,3220.95,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Cigna,Commercial,,182.06,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Cigna,Commercial,,166.03,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Cigna,Commercial,,4121.00,,,,,,,163.76,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Cigna,Commercial,,5152.00,,,,,,,148.55,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Cigna,Commercial,,5152.00,,,,,,,449.85,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Cigna,Commercial,,6649.00,,,,,,,148.55,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Cigna,Commercial,,6649.00,,,,,,,745.34,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Cigna,Commercial,,4121.00,,,,,,,177.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Cigna,Commercial,,4121.00,,,,,,,137.34,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Cigna,Commercial,,5152.00,,,,,,,39.04,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Cigna,Commercial,,5152.00,,,,,,,106.71,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Cigna,Commercial,,5152.00,,,,,,,111.11,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Cigna,Commercial,,4121.00,,,,,,,118.12,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Cigna,Commercial,,5152.00,,,,,,,116.72,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Cigna,Commercial,,6649.00,,,,,,,133.13,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Cigna,Commercial,,6649.00,,,,,,,833.43,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Cigna,Commercial,,4121.00,,,,,,,426.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Cigna,Commercial,,4121.00,,,,,,,268.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Cigna,Commercial,,4121.00,,,,,,,293.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Cigna,Commercial,,4121.00,,,,,,,138.94,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Cigna,Commercial,,4121.00,,,,,,,117.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Cigna,Commercial,,4121.00,,,,,,,121.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Cigna,Commercial,,4121.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Cigna,Commercial,,578.14,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Cigna,Commercial,,17457.00,,,,,,,2814.41,18878.80,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Cigna,Commercial,,9423.00,,,,,,,2814.41,18878.80,per diem,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Cigna,Commercial,,17457.00,,,,,,,2104.90,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Cigna,Commercial,,9423.00,,,,,,,2104.90,15260.00,per diem,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Cigna,Commercial,,17457.00,,,,,,,2104.90,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Cigna,Commercial,,9423.00,,,,,,,2104.90,15260.00,per diem,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Cigna,Commercial,,2622.51,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Cigna,Commercial,,9423.00,,,,,,,2292.69,13852.00,per diem,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Cigna,Commercial,,1757.12,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Cigna,Commercial,,1809.56,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Cigna,Commercial,,9423.00,,,,,,,1581.98,9423.00,per diem,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Cigna,Commercial,,9423.00,,,,,,,960.96,9423.00,per diem,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Cigna,Commercial,,4121.00,,,,,,,895.09,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Cigna,Commercial,,9423.00,,,,,,,1213.61,24600.00,per diem,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Cigna,Commercial,,1388.20,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Cigna,Commercial,,9423.00,,,,,,,1213.61,13852.00,per diem,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Cigna,Commercial,,9423.00,,,,,,,879.68,13852.00,per diem,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Cigna,Commercial,,553.49,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Cigna,Commercial,,4121.00,,,,,,,495.50,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Cigna,Commercial,,4121.00,,,,,,,322.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Cigna,Commercial,,4121.00,,,,,,,158.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Cigna,Commercial,,566.55,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Cigna,Commercial,,86.79,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Cigna,Commercial,,110.38,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Cigna,Commercial,,4121.00,,,,,,,56.46,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Cigna,Commercial,,124.12,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Cigna,Commercial,,17457.00,,,,,,,1059.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Cigna,Commercial,,292.43,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Cigna,Commercial,,17457.00,,,,,,,1500.30,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Cigna,Commercial,,4121.00,,,,,,,79.08,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Cigna,Commercial,,4121.00,,,,,,,328.33,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Cigna,Commercial,,1072.56,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Cigna,Commercial,,4121.00,,,,,,,427.63,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Cigna,Commercial,,595.79,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Cigna,Commercial,,17457.00,,,,,,,616.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Cigna,Commercial,,4121.00,,,,,,,448.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Cigna,Commercial,,4121.00,,,,,,,107.11,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Cigna,Commercial,,4121.00,,,,,,,203.40,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Cigna,Commercial,,4121.00,,,,,,,771.57,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Cigna,Commercial,,4121.00,,,,,,,128.53,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Cigna,Commercial,,4121.00,,,,,,,160.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Cigna,Commercial,,4121.00,,,,,,,128.53,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Cigna,Commercial,,159.16,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Cigna,Commercial,,1212.33,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Cigna,Commercial,,4121.00,,,,,,,476.08,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Cigna,Commercial,,5152.00,,,,,,,500.90,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Cigna,Commercial,,4121.00,,,,,,,496.10,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Cigna,Commercial,,5152.00,,,,,,,127.33,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Cigna,Commercial,,4121.00,,,,,,,232.23,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Cigna,Commercial,,4121.00,,,,,,,35.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Cigna,Commercial,,4121.00,,,,,,,1259.46,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Cigna,Commercial,,17457.00,,,,,,,1554.95,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,20.61,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Cigna,Commercial,,5152.00,,,,,,,498.70,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Cigna,Commercial,,67.33,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Cigna,Commercial,,52.90,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Cigna,Commercial,,136.03,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Cigna,Commercial,,4121.00,,,,,,,80.88,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Cigna,Commercial,,93.43,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Cigna,Commercial,,566.55,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Cigna,Commercial,,4121.00,,,,,,,40.44,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Cigna,Commercial,,4121.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Cigna,Commercial,,1029.81,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Cigna,Commercial,,969.59,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Cigna,Commercial,,668.91,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Cigna,Commercial,,6649.00,,,,,,,915.71,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Cigna,Commercial,,4121.00,,,,,,,211.21,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Cigna,Commercial,,689.97,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Cigna,Commercial,,4121.00,,,,,,,294.49,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Cigna,Commercial,,65.95,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Cigna,Commercial,,188.35,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Cigna,Commercial,,4121.00,,,,,,,383.98,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Cigna,Commercial,,1254.37,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Cigna,Commercial,,767.14,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Cigna,Commercial,,4121.00,,,,,,,502.70,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Cigna,Commercial,,1642.19,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Cigna,Commercial,,465.79,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Cigna,Commercial,,1330.24,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Cigna,Commercial,,4121.00,,,,,,,347.95,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Cigna,Commercial,,1136.65,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Cigna,Commercial,,4121.00,,,,,,,316.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Cigna,Commercial,,1035.28,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Cigna,Commercial,,376.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Cigna,Commercial,,1076.48,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Cigna,Commercial,,1118.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Cigna,Commercial,,4121.00,,,,,,,303.30,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Cigna,Commercial,,990.81,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Cigna,Commercial,,4121.00,,,,,,,302.10,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Cigna,Commercial,,986.89,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Cigna,Commercial,,9350.00,,,,,,,665.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Cigna,Commercial,,2172.59,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Cigna,Commercial,,425.94,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Cigna,Commercial,,1216.44,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Cigna,Commercial,,5152.00,,,,,,,363.96,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Cigna,Commercial,,1188.97,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Cigna,Commercial,,528.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Cigna,Commercial,,84.27,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Cigna,Commercial,,3176.48,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Cigna,Commercial,,50.38,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Cigna,Commercial,,12408.00,,,,,,,568.77,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Cigna,Commercial,,17457.00,,,,,,,598.60,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Cigna,Commercial,,4611.37,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Cigna,Commercial,,2451.67,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Cigna,Commercial,,9423.00,,,,,,,103.90,9423.00,per diem,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Cigna,Commercial,,267.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Cigna,Commercial,,5152.00,,,,,,,215.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Cigna,Commercial,,158.70,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Cigna,Commercial,,4121.00,,,,,,,155.36,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Cigna,Commercial,,6649.00,,,,,,,1092.69,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Cigna,Commercial,,850.05,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Cigna,Commercial,,6649.00,,,,,,,944.74,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Cigna,Commercial,,886.00,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Cigna,Commercial,,6649.00,,,,,,,973.77,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Cigna,Commercial,,913.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Cigna,Commercial,,4121.00,,,,,,,337.94,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Cigna,Commercial,,131.22,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Cigna,Commercial,,1708.80,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Cigna,Commercial,,4121.00,,,,,,,398.40,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Cigna,Commercial,,341.67,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Cigna,Commercial,,4121.00,,,,,,,531.13,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Cigna,Commercial,,9423.00,,,,,,,4311.00,17547.26,per diem,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Cigna,Commercial,,9423.00,,,,,,,838.24,24600.00,per diem,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Cigna,Commercial,,9423.00,,,,,,,2658.46,24600.00,per diem,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Cigna,Commercial,,9423.00,,,,,,,1771.37,24600.00,per diem,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Cigna,Commercial,,4121.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Cigna,Commercial,,5152.00,,,,,,,248.45,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Cigna,Commercial,,388.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Cigna,Commercial,,1109.18,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Cigna,Commercial,,429.60,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Cigna,Commercial,,1226.90,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Cigna,Commercial,,396.63,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Cigna,Commercial,,1132.73,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Cigna,Commercial,,17457.00,,,,,,,258.06,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Cigna,Commercial,,17457.00,,,,,,,146.75,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Cigna,Commercial,,17457.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Cigna,Commercial,,1640.79,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Cigna,Commercial,,410.14,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Cigna,Commercial,,360.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Cigna,Commercial,,8213.00,,,,,,,371.17,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Cigna,Commercial,,8213.00,,,,,,,209.41,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Cigna,Commercial,,821.19,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Cigna,Commercial,,9423.00,,,,,,,717.92,9423.00,per diem,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Cigna,Commercial,,595.86,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Cigna,Commercial,,595.86,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Cigna,Commercial,,4121.00,,,,,,,693.69,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Cigna,Commercial,,17457.00,,,,,,,596.60,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Cigna,Commercial,,17457.00,,,,,,,1230.03,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Cigna,Commercial,,17457.00,,,,,,,1430.23,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Cigna,Commercial,,17457.00,,,,,,,1059.26,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Cigna,Commercial,,17457.00,,,,,,,954.35,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Cigna,Commercial,,4121.00,,,,,,,238.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Cigna,Commercial,,17457.00,,,,,,,1609.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Cigna,Commercial,,17457.00,,,,,,,1660.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Cigna,Commercial,,17457.00,,,,,,,2496.49,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Cigna,Commercial,,17457.00,,,,,,,1392.39,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Cigna,Commercial,,608.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Cigna,Commercial,,423.19,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Cigna,Commercial,,12408.00,,,,,,,178.38,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Cigna,Commercial,,6649.00,,,,,,,322.52,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Cigna,Commercial,,6649.00,,,,,,,238.44,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Cigna,Commercial,,12408.00,,,,,,,741.14,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Cigna,Commercial,,12408.00,,,,,,,650.85,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Cigna,Commercial,,6649.00,,,,,,,651.45,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Cigna,Commercial,,6649.00,,,,,,,561.56,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Cigna,Commercial,,608.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Cigna,Commercial,,17457.00,,,,,,,954.75,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Cigna,Commercial,,17457.00,,,,,,,1107.51,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Cigna,Commercial,,17457.00,,,,,,,1623.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Cigna,Commercial,,171.98,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Cigna,Commercial,,2490.83,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Cigna,Commercial,,1793.30,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Cigna,Commercial,,871.80,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Cigna,Commercial,,9423.00,,,,,,,3427.62,52940.00,per diem,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Cigna,Commercial,,9423.00,,,,,,,1466.87,13852.00,per diem,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Cigna,Commercial,,4121.00,,,,,,,180.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Cigna,Commercial,,797.15,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Cigna,Commercial,,9423.00,,,,,,,3451.05,13852.00,per diem,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Cigna,Commercial,,3705.68,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Cigna,Commercial,,9423.00,,,,,,,173.00,9871.02,per diem,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Cigna,Commercial,,2014.06,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Cigna,Commercial,,9423.00,,,,,,,1760.76,13852.00,per diem,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Cigna,Commercial,,2134.74,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Cigna,Commercial,,4121.00,,,,,,,582.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Cigna,Commercial,,542.27,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Cigna,Commercial,,542.27,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Cigna,Commercial,,184.12,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Cigna,Commercial,,4121.00,,,,,,,990.00,4538.86,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Cigna,Commercial,,1102.64,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Cigna,Commercial,,4121.00,,,,,,,404.60,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Cigna,Commercial,,9423.00,,,,,,,594.81,9423.00,per diem,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Cigna,Commercial,,111.52,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Cigna,Commercial,,6649.00,,,,,,,572.37,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Cigna,Commercial,,10768.00,,,,,,,572.37,10768.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Cigna,Commercial,,4121.00,,,,,,,43.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Cigna,Commercial,,4121.00,,,,,,,43.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Cigna,Commercial,,17457.00,,,,,,,1990.79,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Cigna,Commercial,,2277.18,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Cigna,Commercial,,12408.00,,,,,,,803.60,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Cigna,Commercial,,1395.07,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Cigna,Commercial,,790.51,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Cigna,Commercial,,414.26,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Cigna,Commercial,,4121.00,,,,,,,125.93,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Cigna,Commercial,,6649.00,,,,,,,572.37,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Cigna,Commercial,,10768.00,,,,,,,572.37,10768.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Cigna,Commercial,,2905.00,,,,,,,651.00,2905.00,per diem,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Cigna,Commercial,,8213.00,,,,,,,392.19,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Cigna,Commercial,,168.20,,,,,,,78.48,294.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Cigna,Commercial,,214.44,,,,,,,91.89,344.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Cigna,Commercial,,177.20,,,,,,,74.67,279.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Cigna,Commercial,,177.20,,,,,,,74.67,279.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Cigna,Commercial,,168.20,,,,,,,78.48,294.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Cigna,Commercial,,164.36,,,,,,,64.06,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Cigna,Commercial,,164.36,,,,,,,102.31,670.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Cigna,Commercial,,59.02,,,,,,,59.02,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Cigna,Commercial,,153.44,,,,,,,102.31,856.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Cigna,Commercial,,115.54,,,,,,,102.31,702.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Cigna,Commercial,,143.16,,,,,,,102.31,793.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Cigna,Commercial,,58.38,,,,,,,58.38,578.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Cigna,Commercial,,219.52,,,,,,,102.31,627.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Cigna,Commercial,,168.84,,,,,,,63.06,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Cigna,Commercial,,136.74,,,,,,,102.31,568.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Cigna,Commercial,,202.74,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Cigna,Commercial,,170.14,,,,,,,102.31,618.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Cigna,Commercial,,160.28,,,,,,,160.28,720.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Cigna,Commercial,,339.43,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Cigna,Commercial,,97.56,,,,,,,97.56,477.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Cigna,Commercial,,133.52,,,,,,,85.49,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Cigna,Commercial,,110.40,,,,,,,102.31,626.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Cigna,Commercial,,123.82,,,,,,,102.31,501.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Cigna,Commercial,,89.84,,,,,,,89.84,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Cigna,Commercial,,159.22,,,,,,,131.73,493.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Cigna,Commercial,,141.88,,,,,,,102.31,777.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Cigna,Commercial,,46.82,,,,,,,46.82,617.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Cigna,Commercial,,136.74,,,,,,,102.31,689.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Cigna,Commercial,,331.28,,,,,,,60.26,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Cigna,Commercial,,54.52,,,,,,,54.52,883.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Cigna,Commercial,,63.52,,,,,,,63.52,573.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Cigna,Commercial,,198.32,,,,,,,50.05,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Cigna,Commercial,,138.02,,,,,,,46.25,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Cigna,Commercial,,121.64,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Cigna,Commercial,,720.71,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Cigna,Commercial,,539.55,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Cigna,Commercial,,130.15,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,8.28,,,,,,,8.28,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Cigna,Commercial,,447.34,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Cigna,Commercial,,145.42,,,,,,,84.48,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Cigna,Commercial,,168.84,,,,,,,102.31,725.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Cigna,Commercial,,473.50,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Cigna,Commercial,,270.10,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Cigna,Commercial,,101.40,,,,,,,84.71,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Cigna,Commercial,,132.88,,,,,,,91.89,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,71.94,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Cigna,Commercial,,44.96,,,,,,,27.83,246.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Cigna,Commercial,,168.20,,,,,,,13.41,246.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Cigna,Commercial,,214.44,,,,,,,21.82,246.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Cigna,Commercial,,3673.00,,,,,,,1113.08,5598.00,per diem,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Cigna,Commercial,,3673.00,,,,,,,811.19,5598.00,per diem,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Cigna,Commercial,,3673.00,,,,,,,728.92,5598.00,per diem,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Cigna,Commercial,,3673.00,,,,,,,1131.38,5598.00,per diem,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Cigna,Commercial,,3673.00,,,,,,,1071.94,5598.00,per diem,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Cigna,Commercial,,1757.95,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Cigna,Commercial,,3673.00,,,,,,,1071.94,5598.00,per diem,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Cigna,Commercial,,3673.00,,,,,,,1071.94,5598.00,per diem,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Cigna,Commercial,,3673.00,,,,,,,162.27,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Cigna,Commercial,,3673.00,,,,,,,266.85,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Cigna,Commercial,,3673.00,,,,,,,533.53,5598.00,per diem,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Cigna,Commercial,,3673.00,,,,,,,812.24,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Cigna,Commercial,,3673.00,,,,,,,727.88,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Cigna,Commercial,,3673.00,,,,,,,1054.86,5598.00,per diem,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Cigna,Commercial,,3673.00,,,,,,,1550.57,5598.00,per diem,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Cigna,Commercial,,344.66,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Cigna,Commercial,,587.95,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Cigna,Commercial,,373.43,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Cigna,Commercial,,661.85,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Cigna,Commercial,,1789.34,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Cigna,Commercial,,1614.73,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Cigna,Commercial,,314.57,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Cigna,Commercial,,2825.00,,,,,,,760.10,3601.53,per diem,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Cigna,Commercial,,2825.00,,,,,,,343.59,4352.85,per diem,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Cigna,Commercial,,2825.00,,,,,,,343.59,3155.53,per diem,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Cigna,Commercial,,2825.00,,,,,,,343.59,3286.68,per diem,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Cigna,Commercial,,2825.00,,,,,,,343.59,3127.52,per diem,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Cigna,Commercial,,2825.00,,,,,,,343.59,3810.99,per diem,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Cigna,Commercial,,2825.00,,,,,,,760.10,2893.96,per diem,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Cigna,Commercial,,2825.00,,,,,,,343.59,3525.98,per diem,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Cigna,Commercial,,2825.00,,,,,,,343.59,2825.00,per diem,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Cigna,Commercial,,2825.00,,,,,,,343.59,3252.52,per diem,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Cigna,Commercial,,2825.00,,,,,,,743.14,2917.94,per diem,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Cigna,Commercial,,2825.00,,,,,,,343.59,3522.51,per diem,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Cigna,Commercial,,2825.00,,,,,,,343.59,2876.72,per diem,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Cigna,Commercial,,2825.00,,,,,,,343.59,3192.74,per diem,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Cigna,Commercial,,2825.00,,,,,,,343.59,2972.99,per diem,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Cigna,Commercial,,2825.00,,,,,,,84.71,2825.00,per diem,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Cigna,Commercial,,2825.00,,,,,,,50.65,2825.00,per diem,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Cigna,Commercial,52,2825.00,,,,,,,791.19,2825.00,per diem,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Cigna,Commercial,52,2825.00,,,,,,,787.39,2825.00,per diem,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Cigna,Commercial,,2825.00,,,,,,,343.59,2825.00,per diem,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Cigna,Commercial,,2825.00,,,,,,,343.59,3169.56,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Cigna,Commercial,,2825.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Cigna,Commercial,,2825.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Cigna,Commercial,,2825.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Cigna,Commercial,,2825.00,,,,,,,343.59,3113.44,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Cigna,Commercial,,2825.00,,,,,,,343.59,2996.32,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Cigna,Commercial,,2825.00,,,,,,,343.59,3326.94,per diem,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Cigna,Commercial,,2825.00,,,,,,,343.59,2828.57,per diem,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Cigna,Commercial,,2825.00,,,,,,,343.59,3407.46,per diem,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Cigna,Commercial,,2825.00,,,,,,,343.59,2825.00,per diem,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Cigna,Commercial,,2825.00,,,,,,,343.59,3981.96,per diem,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Cigna,Commercial,,2825.00,,,,,,,343.59,2825.00,per diem,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Cigna,Commercial,,2825.00,,,,,,,343.59,4009.45,per diem,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Cigna,Commercial,,2825.00,,,,,,,845.85,3021.02,per diem,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Cigna,Commercial,,2825.00,,,,,,,647.85,3021.02,per diem,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Cigna,Commercial,,2825.00,,,,,,,895.29,3021.02,per diem,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Cigna,Commercial,,2825.00,,,,,,,848.45,3010.70,per diem,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Cigna,Commercial,,2825.00,,,,,,,848.45,3010.70,per diem,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Cigna,Commercial,,2825.00,,,,,,,848.45,3010.70,per diem,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Cigna,Commercial,,2825.00,,,,,,,707.71,2825.00,per diem,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Cigna,Commercial,,2825.00,,,,,,,814.41,2825.00,per diem,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Cigna,Commercial,,2825.00,,,,,,,814.41,2825.00,per diem,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Cigna,Commercial,,2825.00,,,,,,,899.50,3027.91,per diem,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Cigna,Commercial,,2825.00,,,,,,,650.65,3027.91,per diem,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Cigna,Commercial,,2825.00,,,,,,,919.72,3027.91,per diem,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Cigna,Commercial,,2825.00,,,,,,,894.09,2825.00,per diem,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Cigna,Commercial,,2825.00,,,,,,,845.44,2825.00,per diem,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Cigna,Commercial,,2825.00,,,,,,,845.44,2825.00,per diem,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Cigna,Commercial,,2825.00,,,,,,,908.91,3048.50,per diem,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Cigna,Commercial,,2825.00,,,,,,,908.91,3048.50,per diem,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Cigna,Commercial,,2825.00,,,,,,,908.91,3048.50,per diem,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Cigna,Commercial,,2825.00,,,,,,,206.81,2825.00,per diem,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Cigna,Commercial,,2825.00,,,,,,,232.56,2825.00,per diem,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Cigna,Commercial,,2825.00,,,,,,,791.19,2825.00,per diem,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Cigna,Commercial,,2825.00,,,,,,,375.38,2825.00,per diem,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Cigna,Commercial,,41.04,,,,,,,41.04,319.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Cigna,Commercial,,211.90,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Cigna,Commercial,,260.95,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Cigna,Commercial,,4121.00,,,,,,,349.35,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Cigna,Commercial,,1141.23,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Cigna,Commercial,,103.33,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Cigna,Commercial,,4121.00,,,,,,,366.57,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Cigna,Commercial,,1197.47,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Cigna,Commercial,,261.90,,,,,,,102.31,678.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Cigna,Commercial,,353.16,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Cigna,Commercial,,310.65,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Cigna,Commercial,,310.65,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Cigna,Commercial,,257.90,,,,,,,150.52,974.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Cigna,Commercial,,408.84,,,,,,,175.00,777.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Cigna,Commercial,,233.00,,,,,,,102.31,635.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Cigna,Commercial,,109.12,,,,,,,102.31,462.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Cigna,Commercial,,412.70,,,,,,,104.29,449.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Cigna,Commercial,,242.64,,,,,,,50.84,269.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,4.04,,,,,,,4.01,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Cigna,Commercial,,19.92,,,,,,,10.24,323.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Cigna,Commercial,,88.64,,,,,,,46.38,237.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Cigna,Commercial,,16.06,,,,,,,8.42,216.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Cigna,Commercial,,88.64,,,,,,,46.20,510.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Cigna,Commercial,,15.42,,,,,,,7.92,210.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Cigna,Commercial,,304.44,,,,,,,116.52,436.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Cigna,Commercial,,269.12,,,,,,,116.52,436.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Cigna,Commercial,,1032.80,,,,,,,287.49,1077.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Cigna,Commercial,,540.80,,,,,,,150.55,564.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Cigna,Commercial,,2152.96,,,,,,,373.57,2152.96,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Cigna,Commercial,,2152.96,,,,,,,870.87,3262.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Cigna,Commercial,,122.04,,,,,,,50.45,189.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Cigna,Commercial,,136.16,,,,,,,35.44,136.16,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Cigna,Commercial,,105.98,,,,,,,55.33,276.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Cigna,Commercial,,83.50,,,,,,,36.64,137.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Cigna,Commercial,,307.02,,,,,,,85.49,320.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Cigna,Commercial,,187.54,,,,,,,65.87,246.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Cigna,Commercial,,64.88,,,,,,,33.95,206.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Cigna,Commercial,,121.40,,,,,,,63.40,299.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Cigna,Commercial,,367.40,,,,,,,126.33,473.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Cigna,Commercial,,320.50,,,,,,,103.70,388.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Cigna,Commercial,,432.26,,,,,,,174.97,655.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Cigna,Commercial,,432.26,,,,,,,112.51,436.66,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Cigna,Commercial,,4.50,,,,,,,2.18,42.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Cigna,Commercial,,646.78,,,,,,,72.47,646.78,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Cigna,Commercial,,95.06,,,,,,,49.54,567.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Cigna,Commercial,,80.92,,,,,,,42.34,228.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Cigna,Commercial,,373.82,,,,,,,133.13,498.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Cigna,Commercial,,434.18,,,,,,,84.48,434.18,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Cigna,Commercial,,746.34,,,,,,,191.39,816.53,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Cigna,Commercial,,748.92,,,,,,,119.92,748.92,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Cigna,Commercial,,236.36,,,,,,,84.48,316.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Cigna,Commercial,,138.10,,,,,,,72.10,343.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Cigna,Commercial,,175.98,,,,,,,72.87,273.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Cigna,Commercial,,641.64,,,,,,,335.20,1893.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Cigna,Commercial,,622.38,,,,,,,325.32,1626.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Cigna,Commercial,,328.86,,,,,,,171.93,829.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Cigna,Commercial,,315.36,,,,,,,104.30,390.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Cigna,Commercial,,229.30,,,,,,,110.71,414.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Cigna,Commercial,,457.32,,,,,,,67.27,457.32,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Cigna,Commercial,,83.71,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Cigna,Commercial,,556.86,,,,,,,102.50,556.86,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Cigna,Commercial,,358.40,,,,,,,80.88,358.40,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Cigna,Commercial,,549.16,,,,,,,80.88,549.16,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Cigna,Commercial,,218.46,,,,,,,218.46,1803.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Cigna,Commercial,,30.82,,,,,,,9.41,35.77,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Cigna,Commercial,,9.64,,,,,,,2.80,10.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Cigna,Commercial,,16.06,,,,,,,8.48,84.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Cigna,Commercial,,17.98,,,,,,,9.37,122.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Cigna,Commercial,,14.14,,,,,,,7.29,99.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Cigna,Commercial,,7.70,,,,,,,4.18,19.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Cigna,Commercial,,7.70,,,,,,,4.14,33.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Cigna,Commercial,,115.62,,,,,,,37.84,141.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Cigna,Commercial,,15.42,,,,,,,8.21,198.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,76.44,,,,,,,0.00200,76.44,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Cigna,Commercial,,12.84,,,,,,,6.80,66.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Cigna,Commercial,,25.04,,,,,,,12.99,189.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Cigna,Commercial,,115.62,,,,,,,37.84,141.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Cigna,Commercial,,115.62,,,,,,,60.28,297.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Cigna,Commercial,,115.62,,,,,,,31.03,118.79,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Cigna,Commercial,,115.62,,,,,,,18.62,118.79,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Cigna,Commercial,,115.62,,,,,,,60.28,401.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,28.26,,,,,,,14.63,68.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,28.26,,,,,,,14.63,68.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,28.26,,,,,,,14.63,60.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Cigna,Commercial,,46.43,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,26.98,,,,,,,14.13,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,24.40,,,,,,,10.21,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,25.04,,,,,,,13.13,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Cigna,Commercial,,30.18,,,,,,,15.89,99.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Cigna,Commercial,,30.18,,,,,,,15.89,99.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Cigna,Commercial,,30.18,,,,,,,15.89,99.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,26.98,,,,,,,12.61,47.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.41,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Cigna,Commercial,,28.26,,,,,,,5.81,28.26,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,24.40,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Cigna,Commercial,,25.70,,,,,,,13.35,54.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Cigna,Commercial,,25.70,,,,,,,13.32,132.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Cigna,Commercial,,25.70,,,,,,,13.32,93.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Cigna,Commercial,,26.34,,,,,,,7.81,30.17,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Cigna,Commercial,,30.18,,,,,,,15.65,108.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Cigna,Commercial,,30.18,,,,,,,15.65,108.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Cigna,Commercial,,30.18,,,,,,,15.65,108.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,25.04,,,,,,,13.13,67.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,25.04,,,,,,,13.13,67.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,25.04,,,,,,,13.13,67.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Cigna,Commercial,,60.38,,,,,,,30.83,115.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Cigna,Commercial,,8.34,,,,,,,4.38,21.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Cigna,Commercial,,15.42,,,,,,,7.92,32.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,15.42,,,,,,,7.92,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,9.00,,,,,,,4.80,36.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Cigna,Commercial,,14.14,,,,,,,7.55,31.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,10.92,,,,,,,5.61,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,10.92,,,,,,,5.61,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,32.12,,,,,,,16.75,141.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Cigna,Commercial,,25.04,,,,,,,9.61,36.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Cigna,Commercial,,30.82,,,,,,,16.27,121.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,26.98,,,,,,,14.13,60.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Cigna,Commercial,,12.20,,,,,,,6.29,86.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Cigna,Commercial,,12.20,,,,,,,6.29,86.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Cigna,Commercial,,12.20,,,,,,,6.29,86.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Cigna,Commercial,,30.18,,,,,,,15.69,75.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Cigna,Commercial,,9.64,,,,,,,4.87,31.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Cigna,Commercial,,9.64,,,,,,,4.87,69.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,9.64,,,,,,,4.87,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Cigna,Commercial,,8.34,,,,,,,4.25,45.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Cigna,Commercial,,9.64,,,,,,,5.16,30.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Cigna,Commercial,,7.70,,,,,,,4.10,30.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Cigna,Commercial,,55.24,,,,,,,28.71,124.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,,9.64,,,,,,,5.01,66.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,,9.64,,,,,,,5.01,66.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Cigna,Commercial,,10.92,,,,,,,5.85,49.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Cigna,Commercial,,9.00,,,,,,,4.73,39.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,23.12,,,,,,,11.95,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,23.12,,,,,,,11.95,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Cigna,Commercial,,35.32,,,,,,,18.39,193.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,19.92,,,,,,,10.42,47.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,26.34,,,,,,,13.70,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,26.34,,,,,,,13.70,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,8.34,,,,,,,4.46,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,10.92,,,,,,,5.58,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,10.92,,,,,,,5.58,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,9.00,,,,,,,4.80,18.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Cigna,Commercial,,8.34,,,,,,,4.22,49.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Cigna,Commercial,,71.30,,,,,,,28.73,182.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,50.10,,,,,,,18.02,67.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,50.10,,,,,,,18.02,67.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Cigna,Commercial,,34.68,,,,,,,18.08,135.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Cigna,Commercial,,30.18,,,,,,,15.81,69.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Cigna,Commercial,,25.70,,,,,,,13.32,109.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,12.20,,,,,,,6.31,36.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Cigna,Commercial,,21.20,,,,,,,11.20,59.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Cigna,Commercial,,9.64,,,,,,,4.97,29.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,9.64,,,,,,,5.02,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,9.64,,,,,,,5.02,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Cigna,Commercial,,52.02,,,,,,,27.10,224.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Cigna,Commercial,,27.62,,,,,,,1.20,31.74,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Cigna,Commercial,,9.64,,,,,,,4.95,69.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Cigna,Commercial,,25.04,,,,,,,13.22,150.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Cigna,Commercial,,119.46,,,,,,,62.48,434.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Cigna,Commercial,,26.98,,,,,,,14.26,117.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Cigna,Commercial,,17.34,,,,,,,9.02,91.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Cigna,Commercial,,17.34,,,,,,,9.02,91.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Cigna,Commercial,,17.34,,,,,,,9.02,91.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Cigna,Commercial,,17.34,,,,,,,9.02,91.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Cigna,Commercial,,20.56,,,,,,,7.81,29.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,48.18,,,,,,,25.29,141.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Cigna,Commercial,,146.44,,,,,,,40.64,152.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Cigna,Commercial,,146.44,,,,,,,40.64,152.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Cigna,Commercial,,146.44,,,,,,,40.64,152.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Cigna,Commercial,,146.44,,,,,,,40.64,152.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,17.98,,,,,,,9.48,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Cigna,Commercial,,7.06,,,,,,,3.81,22.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,7.06,,,,,,,3.81,82.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,7.06,,,,,,,3.81,82.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,7.06,,,,,,,3.81,82.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Cigna,Commercial,,7.06,,,,,,,3.81,53.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Cigna,Commercial,,9.00,,,,,,,4.61,128.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Cigna,Commercial,,23.76,,,,,,,12.48,121.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,7.06,,,,,,,3.80,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,7.06,,,,,,,3.80,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Cigna,Commercial,,13.48,,,,,,,6.98,58.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Cigna,Commercial,,34.68,,,,,,,18.02,178.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Cigna,Commercial,,34.68,,,,,,,17.96,117.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Cigna,Commercial,,23.12,,,,,,,12.20,69.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Cigna,Commercial,,23.76,,,,,,,12.48,165.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Cigna,Commercial,,33.40,,,,,,,17.52,90.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Cigna,Commercial,,14.78,,,,,,,7.76,114.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,17.98,,,,,,,9.42,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Cigna,Commercial,,15.42,,,,,,,7.95,35.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Cigna,Commercial,,15.42,,,,,,,7.95,35.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Cigna,Commercial,,9.00,,,,,,,4.60,17.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Cigna,Commercial,,33.40,,,,,,,17.38,147.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Cigna,Commercial,,23.38,,,,,,,23.38,99.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Cigna,Commercial,,21.20,,,,,,,8.01,30.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Cigna,Commercial,,21.20,,,,,,,11.18,63.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Cigna,Commercial,,21.20,,,,,,,7.61,28.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.28,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,21.20,,,,,,,11.22,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Cigna,Commercial,,10.92,,,,,,,5.86,60.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Cigna,Commercial,,10.92,,,,,,,5.86,60.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,36.62,,,,,,,10.81,41.83,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Cigna,Commercial,,35.96,,,,,,,8.41,40.33,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Cigna,Commercial,,12.84,,,,,,,6.68,118.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Cigna,Commercial,,12.84,,,,,,,6.68,118.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Cigna,Commercial,,15.42,,,,,,,7.94,111.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Cigna,Commercial,,19.26,,,,,,,10.19,54.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,12.20,,,,,,,6.50,40.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,12.20,,,,,,,6.50,40.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,12.20,,,,,,,6.21,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Cigna,Commercial,,23.76,,,,,,,7.61,28.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Cigna,Commercial,,72.58,,,,,,,20.02,75.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Cigna,Commercial,,22.46,,,,,,,16.75,107.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,22.46,,,,,,,16.22,60.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Cigna,Commercial,,12.20,,,,,,,6.41,62.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,12.84,,,,,,,6.62,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Cigna,Commercial,,76.44,,,,,,,28.63,107.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Cigna,Commercial,,76.44,,,,,,,35.44,132.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Cigna,Commercial,,6.42,,,,,,,3.47,19.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Cigna,Commercial,,6.42,,,,,,,3.47,19.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Cigna,Commercial,,6.42,,,,,,,3.47,19.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,9.64,,,,,,,5.02,43.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,9.00,,,,,,,4.60,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Cigna,Commercial,,10.92,,,,,,,5.61,80.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Cigna,Commercial,,10.92,,,,,,,0.40040,11.03,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Cigna,Commercial,,182.42,,,,,,,65.87,246.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Cigna,Commercial,,9.00,,,,,,,4.62,41.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,9.00,,,,,,,4.59,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,9.00,,,,,,,4.59,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,9.00,,,,,,,4.59,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,26.98,,,,,,,14.15,57.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Cigna,Commercial,,38.54,,,,,,,20.23,109.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Cigna,Commercial,,35.96,,,,,,,18.80,170.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Cigna,Commercial,,34.04,,,,,,,17.84,161.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Cigna,Commercial,,34.04,,,,,,,17.84,161.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Cigna,Commercial,,7.06,,,,,,,3.56,33.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,7.06,,,,,,,3.56,45.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,7.06,,,,,,,3.56,45.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Cigna,Commercial,,7.70,,,,,,,3.88,39.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Cigna,Commercial,,19.92,,,,,,,10.42,75.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Cigna,Commercial,,33.40,,,,,,,10.01,38.02,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Cigna,Commercial,,33.40,,,,,,,13.21,49.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Cigna,Commercial,,9.00,,,,,,,4.67,33.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Cigna,Commercial,,9.64,,,,,,,4.91,24.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Cigna,Commercial,,9.64,,,,,,,4.91,24.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Cigna,Commercial,,9.00,,,,,,,4.71,32.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Cigna,Commercial,,5.78,,,,,,,3.00,11.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Cigna,Commercial,,48.18,,,,,,,25.04,125.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Cigna,Commercial,,12.84,,,,,,,6.66,33.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Cigna,Commercial,,16.70,,,,,,,8.75,120.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Cigna,Commercial,,31.48,,,,,,,16.30,142.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,9.64,,,,,,,5.02,45.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Cigna,Commercial,,9.64,,,,,,,5.14,54.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,23.76,,,,,,,12.38,55.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Cigna,Commercial,,10.92,,,,,,,5.57,49.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Cigna,Commercial,,26.34,,,,,,,13.75,100.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Cigna,Commercial,,31.48,,,,,,,16.43,97.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Cigna,Commercial,,23.12,,,,,,,12.10,81.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,7.06,,,,,,,3.83,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Cigna,Commercial,,10.28,,,,,,,5.39,28.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,8.34,,,,,,,4.38,57.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Cigna,Commercial,,9.64,,,,,,,4.93,86.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Cigna,Commercial,,9.64,,,,,,,4.93,86.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Cigna,Commercial,,115.62,,,,,,,26.03,118.79,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Cigna,Commercial,,115.62,,,,,,,38.64,144.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,27.62,,,,,,,10.81,40.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Cigna,Commercial,,14.78,,,,,,,7.63,59.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Cigna,Commercial,,9.64,,,,,,,2.40,11.11,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Cigna,Commercial,,27.62,,,,,,,14.60,278.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Cigna,Commercial,,27.62,,,,,,,14.60,278.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Cigna,Commercial,,34.04,,,,,,,17.82,168.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Cigna,Commercial,,20.56,,,,,,,6.41,24.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Cigna,Commercial,,9.64,,,,,,,5.02,105.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Cigna,Commercial,,23.76,,,,,,,12.56,84.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Cigna,Commercial,,47.52,,,,,,,19.42,72.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,47.52,,,,,,,16.22,60.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,47.52,,,,,,,16.22,60.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Cigna,Commercial,,22.48,,,,,,,11.64,102.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Cigna,Commercial,,25.70,,,,,,,13.33,90.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Cigna,Commercial,,25.70,,,,,,,1.60,29.29,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Cigna,Commercial,,33.40,,,,,,,4.40,38.23,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Cigna,Commercial,,33.40,,,,,,,17.39,79.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Cigna,Commercial,,22.48,,,,,,,11.69,130.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Cigna,Commercial,,22.48,,,,,,,7.41,27.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Cigna,Commercial,,38.54,,,,,,,20.19,96.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Cigna,Commercial,,38.54,,,,,,,20.19,200.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Cigna,Commercial,,9.64,,,,,,,5.02,110.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Cigna,Commercial,,55.24,,,,,,,29.02,204.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Cigna,Commercial,,41.74,,,,,,,21.67,155.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Cigna,Commercial,,54.60,,,,,,,10.01,62.57,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Cigna,Commercial,,70.00,,,,,,,36.60,177.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,49.46,,,,,,,25.98,141.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,49.46,,,,,,,23.62,88.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,128.30,,,,,,,16.22,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,41.10,,,,,,,4.80,41.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Cigna,Commercial,,70.00,,,,,,,36.60,154.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Cigna,Commercial,,70.00,,,,,,,8.21,80.42,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Cigna,Commercial,,87.36,,,,,,,45.57,219.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Cigna,Commercial,,144.52,,,,,,,40.24,150.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Cigna,Commercial,,26.98,,,,,,,9.21,34.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Cigna,Commercial,,21.20,,,,,,,11.19,84.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Cigna,Commercial,,21.20,,,,,,,11.19,84.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Cigna,Commercial,,19.92,,,,,,,10.01,37.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Cigna,Commercial,,10.28,,,,,,,5.50,101.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Cigna,Commercial,,114.98,,,,,,,44.64,167.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Cigna,Commercial,,19.84,,,,,,,4.20,25.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,7.70,,,,,,,4.14,42.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Cigna,Commercial,,8.34,,,,,,,4.27,42.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Cigna,Commercial,,8.34,,,,,,,4.27,108.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Cigna,Commercial,,31.48,,,,,,,13.61,51.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,,26.98,,,,,,,13.96,87.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Cigna,Commercial,,31.48,,,,,,,16.34,129.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Cigna,Commercial,,28.26,,,,,,,14.83,72.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Cigna,Commercial,,33.40,,,,,,,17.60,87.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Cigna,Commercial,,33.40,,,,,,,17.60,87.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,18.62,,,,,,,9.87,57.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Cigna,Commercial,,18.62,,,,,,,3.00,21.69,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,,31.48,,,,,,,16.34,66.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,,31.48,,,,,,,16.34,66.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Cigna,Commercial,,16.70,,,,,,,7.01,26.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Cigna,Commercial,,24.40,,,,,,,9.01,33.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Cigna,Commercial,,35.96,,,,,,,13.81,51.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Cigna,Commercial,,16.70,,,,,,,8.62,345.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,25.70,,,,,,,12.61,47.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Cigna,Commercial,,21.84,,,,,,,11.42,91.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Cigna,Commercial,,19.92,,,,,,,10.42,54.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,23.12,,,,,,,7.21,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Cigna,Commercial,,21.20,,,,,,,10.92,146.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Cigna,Commercial,,23.12,,,,,,,12.02,62.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Cigna,Commercial,,35.96,,,,,,,2.20,41.26,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,35.96,,,,,,,5.61,41.26,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Cigna,Commercial,,23.76,,,,,,,7.01,27.47,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Cigna,Commercial,,26.98,,,,,,,13.96,101.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Cigna,Commercial,,26.98,,,,,,,13.98,81.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,24.40,,,,,,,10.81,40.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,23.76,,,,,,,11.21,42.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,26.34,,,,,,,13.84,57.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Cigna,Commercial,,202.96,,,,,,,106.21,595.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Cigna,Commercial,,118.82,,,,,,,62.26,335.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Cigna,Commercial,,118.82,,,,,,,53.25,199.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Cigna,Commercial,,601.18,,,,,,,114.11,601.18,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Cigna,Commercial,,604.40,,,,,,,168.37,630.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,,17.98,,,,,,,9.48,123.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Cigna,Commercial,,59.10,,,,,,,37.47,222.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Cigna,Commercial,,80.92,,,,,,,37.47,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Cigna,Commercial,,10.28,,,,,,,5.23,63.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Cigna,Commercial,,10.28,,,,,,,5.23,63.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Cigna,Commercial,,10.28,,,,,,,5.23,63.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Cigna,Commercial,,9.64,,,,,,,5.02,174.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Cigna,Commercial,,5.78,,,,,,,2.90,108.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,5.78,,,,,,,2.90,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Cigna,Commercial,,11.56,,,,,,,6.16,92.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Cigna,Commercial,,11.56,,,,,,,6.16,100.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Cigna,Commercial,,7.06,,,,,,,3.72,147.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Cigna,Commercial,,65.52,,,,,,,22.03,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,52.66,,,,,,,12.21,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Cigna,Commercial,,65.52,,,,,,,37.47,375.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Cigna,Commercial,,65.52,,,,,,,37.47,552.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Cigna,Commercial,,32.80,,,,,,,22.03,94.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Cigna,Commercial,,25.70,,,,,,,13.49,104.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Cigna,Commercial,,7.06,,,,,,,3.69,27.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,4.50,,,,,,,2.30,36.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,4.50,,,,,,,2.30,36.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Cigna,Commercial,,14.14,,,,,,,7.54,112.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,12.20,,,,,,,6.28,88.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,7.70,,,,,,,3.87,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Cigna,Commercial,,10.28,,,,,,,5.40,69.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Cigna,Commercial,,4.50,,,,,,,2.46,121.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,8.34,,,,,,,4.35,57.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Cigna,Commercial,,62.98,,,,,,,53.18,858.84,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Cigna,Commercial,,62.98,,,,,,,53.18,858.84,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Cigna,Commercial,,24.40,,,,,,,12.59,242.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Cigna,Commercial,,32.76,,,,,,,17.12,206.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Cigna,Commercial,,33.40,,,,,,,17.36,218.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Cigna,Commercial,,33.40,,,,,,,17.36,198.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Cigna,Commercial,,21.84,,,,,,,11.53,459.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Cigna,Commercial,,42.40,,,,,,,22.25,120.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,42.40,,,,,,,15.42,57.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Cigna,Commercial,,42.40,,,,,,,22.25,177.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Cigna,Commercial,,57.16,,,,,,,29.93,149.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Cigna,Commercial,,42.40,,,,,,,19.82,74.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Cigna,Commercial,,35.32,,,,,,,18.47,243.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Cigna,Commercial,,33.40,,,,,,,17.36,203.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Cigna,Commercial,,33.40,,,,,,,17.36,242.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Cigna,Commercial,,35.96,,,,,,,18.77,188.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Cigna,Commercial,,16.70,,,,,,,8.84,136.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Cigna,Commercial,,35.32,,,,,,,18.36,139.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Cigna,Commercial,,35.32,,,,,,,18.36,139.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Cigna,Commercial,,21.84,,,,,,,11.49,185.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Cigna,Commercial,,25.70,,,,,,,13.42,54.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Cigna,Commercial,,28.26,,,,,,,8.81,33.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Cigna,Commercial,,57.16,,,,,,,29.93,112.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Cigna,Commercial,,28.26,,,,,,,14.86,147.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Cigna,Commercial,,23.76,,,,,,,12.48,351.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Cigna,Commercial,,23.76,,,,,,,12.48,212.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,23.76,,,,,,,12.48,55.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Cigna,Commercial,,7.70,,,,,,,4.15,26.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,12.84,,,,,,,6.68,42.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Cigna,Commercial,,18.62,,,,,,,9.87,54.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Cigna,Commercial,,17.98,,,,,,,9.43,84.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Cigna,Commercial,,32.12,,,,,,,16.67,267.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,17.34,,,,,,,9.08,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Cigna,Commercial,,24.40,,,,,,,12.70,109.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,24.40,,,,,,,12.61,47.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Cigna,Commercial,,46.24,,,,,,,24.16,151.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Cigna,Commercial,,46.24,,,,,,,24.16,107.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,,33.40,,,,,,,17.44,87.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Cigna,Commercial,,33.40,,,,,,,17.44,87.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Cigna,Commercial,,7.70,,,,,,,4.16,59.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Cigna,Commercial,,7.06,,,,,,,3.82,76.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,17.98,,,,,,,9.29,42.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Cigna,Commercial,,17.98,,,,,,,9.29,63.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Cigna,Commercial,,33.40,,,,,,,17.44,73.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,17.98,,,,,,,9.55,42.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Cigna,Commercial,,34.68,,,,,,,18.08,168.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Cigna,Commercial,,7.70,,,,,,,4.14,60.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,10.28,,,,,,,5.34,40.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Cigna,Commercial,,10.92,,,,,,,5.60,29.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Cigna,Commercial,,10.92,,,,,,,3.80,14.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,10.92,,,,,,,5.83,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,10.92,,,,,,,5.83,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Cigna,Commercial,,12.20,,,,,,,6.28,35.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Cigna,Commercial,,12.20,,,,,,,3.00,13.80,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Cigna,Commercial,,21.84,,,,,,,8.21,30.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,12.20,,,,,,,6.48,45.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Cigna,Commercial,,19.26,,,,,,,10.01,141.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Cigna,Commercial,,19.26,,,,,,,10.01,91.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Cigna,Commercial,,17.34,,,,,,,9.16,97.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,17.34,,,,,,,9.16,40.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Cigna,Commercial,,17.34,,,,,,,9.16,53.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Cigna,Commercial,,16.06,,,,,,,8.36,117.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Cigna,Commercial,,16.06,,,,,,,5.41,20.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Cigna,Commercial,,18.62,,,,,,,9.59,39.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Cigna,Commercial,,17.34,,,,,,,9.19,140.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Cigna,Commercial,,17.34,,,,,,,9.19,140.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Cigna,Commercial,,17.34,,,,,,,9.19,72.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Cigna,Commercial,,14.78,,,,,,,7.84,159.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Cigna,Commercial,,14.78,,,,,,,7.84,153.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,14.78,,,,,,,7.84,55.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,14.78,,,,,,,7.84,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.43,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.43,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Cigna,Commercial,,12.20,,,,,,,6.41,24.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.43,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.43,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Cigna,Commercial,,12.20,,,,,,,6.43,153.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,12.20,,,,,,,6.21,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Cigna,Commercial,,12.20,,,,,,,6.21,23.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.43,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,12.20,,,,,,,6.43,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Cigna,Commercial,,12.20,,,,,,,6.43,52.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Cigna,Commercial,,14.78,,,,,,,7.83,108.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Cigna,Commercial,,14.14,,,,,,,7.48,69.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,15.42,,,,,,,8.16,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Cigna,Commercial,,19.26,,,,,,,7.81,29.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,19.26,,,,,,,10.01,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Cigna,Commercial,,9.64,,,,,,,5.02,22.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Cigna,Commercial,,9.64,,,,,,,5.02,22.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Cigna,Commercial,,213.88,,,,,,,5.21,245.92,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,7.70,,,,,,,4.18,18.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,,7.70,,,,,,,4.14,96.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,10.92,,,,,,,5.70,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Cigna,Commercial,,16.70,,,,,,,8.63,87.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Cigna,Commercial,,9.00,,,,,,,4.61,59.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,14.14,,,,,,,7.26,82.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Cigna,Commercial,,9.00,,,,,,,3.60,13.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,16.06,,,,,,,8.39,55.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,16.06,,,,,,,8.39,55.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,16.06,,,,,,,8.39,55.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,16.06,,,,,,,8.39,55.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Cigna,Commercial,,16.06,,,,,,,8.39,254.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Cigna,Commercial,,7.70,,,,,,,4.14,51.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Cigna,Commercial,,7.70,,,,,,,4.14,63.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,,7.70,,,,,,,4.14,66.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,10.28,,,,,,,5.23,45.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Cigna,Commercial,,10.28,,,,,,,3.20,12.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,10.28,,,,,,,5.23,36.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Cigna,Commercial,,10.92,,,,,,,5.81,183.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Cigna,Commercial,,33.40,,,,,,,16.82,63.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Cigna,Commercial,,10.92,,,,,,,5.65,115.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,10.92,,,,,,,5.65,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Cigna,Commercial,,22.48,,,,,,,7.41,27.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Cigna,Commercial,,22.48,,,,,,,11.62,74.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,22.48,,,,,,,11.62,60.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Cigna,Commercial,,22.48,,,,,,,11.62,58.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Cigna,Commercial,,25.70,,,,,,,8.01,30.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Cigna,Commercial,,19.26,,,,,,,10.02,42.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Cigna,Commercial,,19.26,,,,,,,7.61,28.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,44.96,,,,,,,19.02,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Cigna,Commercial,,44.96,,,,,,,12.61,50.79,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Cigna,Commercial,,22.48,,,,,,,11.62,135.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Cigna,Commercial,,22.48,,,,,,,6.61,25.57,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Cigna,Commercial,,22.48,,,,,,,7.61,28.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Cigna,Commercial,,64.88,,,,,,,34.04,171.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Cigna,Commercial,,69.36,,,,,,,33.83,126.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Cigna,Commercial,,64.88,,,,,,,34.04,345.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Cigna,Commercial,,79.64,,,,,,,41.55,159.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Cigna,Commercial,,64.88,,,,,,,34.04,159.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Cigna,Commercial,,79.64,,,,,,,41.55,471.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Cigna,Commercial,,79.64,,,,,,,41.55,435.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Cigna,Commercial,,64.88,,,,,,,34.04,130.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Cigna,Commercial,,64.88,,,,,,,32.23,120.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Cigna,Commercial,,158.00,,,,,,,70.07,262.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Cigna,Commercial,,64.88,,,,,,,34.04,159.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Cigna,Commercial,,64.88,,,,,,,32.83,123.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Cigna,Commercial,,64.88,,,,,,,32.83,123.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Cigna,Commercial,,177.92,,,,,,,55.05,206.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Cigna,Commercial,,264.62,,,,,,,51.45,264.62,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Cigna,Commercial,,773.32,,,,,,,154.15,852.72,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Cigna,Commercial,,64.88,,,,,,,17.42,74.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Cigna,Commercial,,64.88,,,,,,,16.62,74.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Cigna,Commercial,,64.88,,,,,,,9.61,74.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,64.88,,,,,,,16.22,74.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Cigna,Commercial,,64.88,,,,,,,22.42,84.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Cigna,Commercial,,79.64,,,,,,,41.55,434.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Cigna,Commercial,,488.14,,,,,,,55.86,488.14,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Cigna,Commercial,,28.26,,,,,,,11.01,41.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Cigna,Commercial,,30.82,,,,,,,16.03,115.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Cigna,Commercial,,29.54,,,,,,,15.59,72.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Cigna,Commercial,,29.54,,,,,,,15.59,72.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Cigna,Commercial,,29.54,,,,,,,15.59,72.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Cigna,Commercial,,477.86,,,,,,,92.69,548.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Cigna,Commercial,,477.86,,,,,,,58.86,548.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Cigna,Commercial,,5.78,,,,,,,3.07,66.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Cigna,Commercial,,5.78,,,,,,,3.07,66.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,6.42,,,,,,,3.38,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,6.42,,,,,,,3.38,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Cigna,Commercial,,6.42,,,,,,,3.38,38.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Cigna,Commercial,,16.06,,,,,,,8.35,94.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Cigna,Commercial,,70.00,,,,,,,2.40,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Cigna,Commercial,,10.28,,,,,,,5.43,112.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,13.48,,,,,,,7.11,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Cigna,Commercial,,10.92,,,,,,,5.62,90.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Cigna,Commercial,,170.20,,,,,,,88.91,411.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Cigna,Commercial,,33.40,,,,,,,17.51,231.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Cigna,Commercial,,44.96,,,,,,,23.45,95.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Cigna,Commercial,,23.12,,,,,,,7.21,27.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Cigna,Commercial,,9.00,,,,,,,4.40,16.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Cigna,Commercial,,24.40,,,,,,,12.85,172.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,30.82,,,,,,,15.42,57.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Cigna,Commercial,,17.36,,,,,,,5.81,21.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Cigna,Commercial,,9.64,,,,,,,3.60,13.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Cigna,Commercial,,33.40,,,,,,,17.39,79.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Cigna,Commercial,,7.70,,,,,,,4.14,43.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Cigna,Commercial,,24.40,,,,,,,7.01,27.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Cigna,Commercial,,23.76,,,,,,,7.01,27.47,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Cigna,Commercial,,9.64,,,,,,,3.80,14.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Cigna,Commercial,,26.98,,,,,,,12.21,45.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Cigna,Commercial,,14.78,,,,,,,7.84,48.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Cigna,Commercial,,14.78,,,,,,,7.84,34.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Cigna,Commercial,,25.04,,,,,,,11.21,42.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Cigna,Commercial,,16.06,,,,,,,8.35,53.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Cigna,Commercial,,24.40,,,,,,,3.00,28.12,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,12.20,,,,,,,6.48,36.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Cigna,Commercial,,9.64,,,,,,,5.02,22.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Cigna,Commercial,,25.04,,,,,,,12.99,189.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Cigna,Commercial,,87.64,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Cigna,Commercial,,9.00,,,,,,,4.61,128.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Cigna,Commercial,,9.00,,,,,,,4.61,19.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Cigna,Commercial,,23.76,,,,,,,12.48,121.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Cigna,Commercial,,7.70,,,,,,,4.16,59.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,11.56,,,,,,,5.61,21.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,24.40,,,,,,,10.81,40.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Cigna,Commercial,,12.20,,,,,,,5.81,21.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,222.16,,,,,,,0.00200,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Cigna,Commercial,,222.16,,,,,,,53.18,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Cigna,Commercial,,45.98,,,,,,,0.40040,45.98,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Cigna,Commercial,,229.30,,,,,,,103.70,388.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Cigna,Commercial,,26.98,,,,,,,14.17,60.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,27.62,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Cigna,Commercial,,13.48,,,,,,,5.81,21.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Cigna,Commercial,,48.18,,,,,,,25.04,120.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Cigna,Commercial,,1409.82,,,,,,,133.70,1470.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,64.88,,,,,,,9.81,74.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,29.54,,,,,,,15.44,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Cigna,Commercial,,10.28,,,,,,,5.33,105.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,,50.74,,,,,,,17.82,66.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Cigna,Commercial,,5.14,,,,,,,2.62,25.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,16.06,,,,,,,8.36,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Cigna,Commercial,,22.48,,,,,,,7.61,28.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Cigna,Commercial,,30.82,,,,,,,14.01,52.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Cigna,Commercial,,30.82,,,,,,,14.01,52.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Cigna,Commercial,,3.90,,,,,,,3.00,11.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Cigna,Commercial,,3.90,,,,,,,3.90,26.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Cigna,Commercial,,3.90,,,,,,,3.90,56.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Cigna,Commercial,,64.88,,,,,,,9.81,74.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Cigna,Commercial,,225.44,,,,,,,105.91,396.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Cigna,Commercial,,343.62,,,,,,,153.55,575.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Cigna,Commercial,,154.14,,,,,,,26.83,154.14,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Cigna,Commercial,,1191.44,,,,,,,361.36,1353.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Cigna,Commercial,,3386.80,,,,,,,251.85,3699.95,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Cigna,Commercial,,696.24,,,,,,,58.66,696.24,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Cigna,Commercial,,5.78,,,,,,,4.18,4311.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Cigna,Commercial,,20.56,,,,,,,10.82,1448.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Cigna,Commercial,,12.20,,,,,,,4.60,17.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Cigna,Commercial,,10.28,,,,,,,5.34,194.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Cigna,Commercial,,34.68,,,,,,,9.21,34.68,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,49.46,,,,,,,5.61,57.08,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,49.46,,,,,,,5.61,57.08,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,49.46,,,,,,,5.61,57.08,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,49.46,,,,,,,5.61,57.08,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,49.46,,,,,,,5.61,57.08,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Cigna,Commercial,,218.46,,,,,,,218.46,1356.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Cigna,Commercial,,343.62,,,,,,,141.54,530.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,37.26,,,,,,,12.41,46.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Cigna,Commercial,,64.88,,,,,,,21.42,80.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Cigna,Commercial,,254.34,,,,,,,102.70,384.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Cigna,Commercial,,64.88,,,,,,,34.04,141.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Cigna,Commercial,,1409.82,,,,,,,133.70,1470.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Cigna,Commercial,,283.48,,,,,,,22.82,324.56,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Cigna,Commercial,,64.88,,,,,,,34.04,243.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,64.88,,,,,,,27.23,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Cigna,Commercial,,130.38,,,,,,,38.84,145.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Cigna,Commercial,,225.44,,,,,,,117.98,714.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Cigna,Commercial,,343.62,,,,,,,127.93,479.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Cigna,Commercial,,46.24,,,,,,,24.16,105.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Cigna,Commercial,QW,46.24,,,,,,,24.16,105.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Cigna,Commercial,,26.98,,,,,,,9.21,34.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Cigna,Commercial,,115.62,,,,,,,55.66,208.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Cigna,Commercial,,2152.96,,,,,,,318.12,2152.96,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Cigna,Commercial,,773.32,,,,,,,237.64,890.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Cigna,Commercial,,170.20,,,,,,,55.66,208.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,38.54,,,,,,,20.19,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Cigna,Commercial,,432.26,,,,,,,121.92,456.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Cigna,Commercial,,77.72,,,,,,,40.51,358.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Cigna,Commercial,,79.64,,,,,,,40.84,153.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Cigna,Commercial,,29.54,,,,,,,15.59,319.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Cigna,Commercial,,9.64,,,,,,,5.06,37.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,53.96,,,,,,,22.02,82.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Cigna,Commercial,QW,65.40,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Cigna,Commercial,,65.40,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Cigna,Commercial,,22.46,,,,,,,16.75,122.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Cigna,Commercial,,593.18,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Cigna,Commercial,,179.85,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Cigna,Commercial,,19.26,,,,,,,10.01,99.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,,34.68,,,,,,,18.08,123.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Cigna,Commercial,,34.68,,,,,,,17.82,66.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Cigna,Commercial,,50.10,,,,,,,8.61,50.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Cigna,Commercial,,71.30,,,,,,,37.41,210.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Cigna,Commercial,,16.06,,,,,,,8.39,59.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Cigna,Commercial,,264.62,,,,,,,38.84,264.62,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,72.58,,,,,,,18.22,72.58,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Cigna,Commercial,,40.46,,,,,,,13.81,51.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Cigna,Commercial,,38.54,,,,,,,13.21,49.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Cigna,Commercial,,254.34,,,,,,,70.07,262.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Cigna,Commercial,,88.29,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Cigna,Commercial,,139.30,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Cigna,Commercial,,143.23,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Cigna,Commercial,,88.29,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Cigna,Commercial,,88.29,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Cigna,Commercial,,179.85,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Cigna,Commercial,,22.48,,,,,,,9.01,33.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Cigna,Commercial,,22.48,,,,,,,9.01,33.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Cigna,Commercial,,37.90,,,,,,,15.22,57.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Cigna,Commercial,,21.20,,,,,,,8.61,32.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,32.12,,,,,,,13.01,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Cigna,Commercial,,41.74,,,,,,,16.82,63.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Cigna,Commercial,,54.60,,,,,,,20.22,75.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Cigna,Commercial,,50.74,,,,,,,26.57,111.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Cigna,Commercial,,238.28,,,,,,,124.44,996.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Cigna,Commercial,,21.20,,,,,,,11.01,41.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Cigna,Commercial,,70.63,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,64.88,,,,,,,23.62,88.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Cigna,Commercial,,64.88,,,,,,,23.62,88.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,17.98,,,,,,,9.42,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Cigna,Commercial,,21.20,,,,,,,11.22,48.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Cigna,Commercial,,4.50,,,,,,,2.18,42.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Cigna,Commercial,,64.88,,,,,,,34.04,203.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Cigna,Commercial,,64.88,,,,,,,33.43,125.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Cigna,Commercial,,177.23,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Cigna,Commercial,,254.34,,,,,,,63.86,254.34,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Cigna,Commercial,,117.94,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Cigna,Commercial,,344.00,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Cigna,Commercial,,137.34,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,65.98,,,,,,,0.00200,70.99,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Cigna,Commercial,,4.50,,,,,,,2.30,20.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Cigna,Commercial,,75.72,,,,,,,22.02,82.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Cigna,Commercial,,79.56,,,,,,,24.90,139.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Cigna,Commercial,,73.78,,,,,,,29.43,110.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Cigna,Commercial,,73.78,,,,,,,29.43,110.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Cigna,Commercial,,29.24,,,,,,,7.81,47.45,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Cigna,Commercial,,37.90,,,,,,,19.65,148.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Cigna,Commercial,,87.28,,,,,,,23.56,89.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Cigna,Commercial,,36.54,,,,,,,36.54,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Cigna,Commercial,,165.40,,,,,,,51.40,195.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,49.46,,,,,,,25.81,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Cigna,Commercial,,49.46,,,,,,,15.62,58.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Cigna,Commercial,,49.46,,,,,,,25.81,102.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Cigna,Commercial,,128.30,,,,,,,24.90,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Cigna,Commercial,,128.30,,,,,,,24.90,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Cigna,Commercial,,216.46,,,,,,,103.70,388.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Cigna,Commercial,,216.46,,,,,,,29.63,248.36,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Cigna,Commercial,,261.42,,,,,,,91.29,342.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Cigna,Commercial,,278.76,,,,,,,119.52,447.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Cigna,Commercial,,278.76,,,,,,,145.79,566.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Cigna,Commercial,,266.56,,,,,,,112.31,420.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Cigna,Commercial,,24.40,,,,,,,12.68,243.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Cigna,Commercial,,490.72,,,,,,,45.05,490.72,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Cigna,Commercial,,233.16,,,,,,,121.73,764.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Cigna,Commercial,,268.48,,,,,,,70.87,268.48,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Cigna,Commercial,,350.04,,,,,,,121.92,456.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Cigna,Commercial,,39.82,,,,,,,20.78,168.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Cigna,Commercial,,39.82,,,,,,,16.02,60.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Cigna,Commercial,,64.88,,,,,,,26.43,99.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Cigna,Commercial,,78.36,,,,,,,27.03,101.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Cigna,Commercial,,95.06,,,,,,,49.65,411.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Cigna,Commercial,,62.30,,,,,,,20.42,76.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Cigna,Commercial,,127.18,,,,,,,35.03,146.24,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Cigna,Commercial,,50.10,,,,,,,26.10,275.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Cigna,Commercial,,65.98,,,,,,,15.51,495.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Cigna,Commercial,,109.32,,,,,,,0.00200,109.32,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Cigna,Commercial,,20.48,,,,,,,20.48,93.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Cigna,Commercial,,46.82,,,,,,,24.90,169.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Cigna,Commercial,,57.08,,,,,,,51.40,277.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Cigna,Commercial,,64.16,,,,,,,51.40,239.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Cigna,Commercial,,64.16,,,,,,,51.40,239.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Cigna,Commercial,,386.36,,,,,,,80.53,444.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Cigna,Commercial,,550.78,,,,,,,80.53,858.84,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Cigna,Commercial,,15.98,,,,,,,12.54,72.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,,130.30,,,,,,,24.90,135.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Cigna,Commercial,,147.00,,,,,,,24.90,295.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Cigna,Commercial,,147.00,,,,,,,24.90,234.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Cigna,Commercial,,213.74,,,,,,,49.85,858.84,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Cigna,Commercial,,50.66,,,,,,,15.42,70.99,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Cigna,Commercial,,77.00,,,,,,,53.18,288.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Cigna,Commercial,,45.52,,,,,,,24.90,99.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Cigna,Commercial,,60.94,,,,,,,24.90,858.84,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Cigna,Commercial,,35.96,,,,,,,23.59,141.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Cigna,Commercial,,222.16,,,,,,,53.18,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Cigna,Commercial,,15.66,,,,,,,11.69,192.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Cigna,Commercial,,150.22,,,,,,,52.25,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Cigna,Commercial,,150.22,,,,,,,31.43,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Cigna,Commercial,,150.22,,,,,,,31.43,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Cigna,Commercial,,258.06,,,,,,,80.53,404.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Cigna,Commercial,,43.64,,,,,,,27.83,104.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Cigna,Commercial,,189.48,,,,,,,32.83,189.48,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Cigna,Commercial,,9.64,,,,,,,3.60,13.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Cigna,Commercial,,150.22,,,,,,,53.18,310.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,41.10,,,,,,,18.22,68.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Cigna,Commercial,,266.56,,,,,,,49.45,269.27,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Cigna,Commercial,,261.42,,,,,,,136.51,1643.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Cigna,Commercial,,266.56,,,,,,,70.67,269.27,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Cigna,Commercial,,95.06,,,,,,,38.44,144.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Cigna,Commercial,,81.88,,,,,,,53.18,531.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Cigna,Commercial,,109.78,,,,,,,53.18,388.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Cigna,Commercial,,268.48,,,,,,,70.87,268.48,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Cigna,Commercial,,250.42,,,,,,,77.08,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Cigna,Commercial,,114.32,,,,,,,67.67,275.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Cigna,Commercial,,125.82,,,,,,,53.18,288.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Cigna,Commercial,,196.46,,,,,,,103.90,389.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Cigna,Commercial,,95.06,,,,,,,49.65,963.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Cigna,Commercial,,39.82,,,,,,,16.02,60.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Cigna,Commercial,,125.82,,,,,,,53.18,288.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Cigna,Commercial,,114.32,,,,,,,67.67,275.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Cigna,Commercial,,163.70,,,,,,,24.90,234.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Cigna,Commercial,,130.30,,,,,,,24.90,135.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Cigna,Commercial,,128.30,,,,,,,24.90,932.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,41.10,,,,,,,4.80,41.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,41.10,,,,,,,4.80,41.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,41.10,,,,,,,4.80,41.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,41.10,,,,,,,4.80,41.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,41.10,,,,,,,4.80,41.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Cigna,Commercial,,41.10,,,,,,,4.80,41.10,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Cigna,Commercial,,95.06,,,,,,,38.44,144.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Cigna,Commercial,,39.82,,,,,,,16.02,60.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Cigna,Commercial,,535.60,,,,,,,164.86,681.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Cigna,Commercial,,646.00,,,,,,,132.13,646.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Cigna,Commercial,,218.46,,,,,,,94.89,355.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Cigna,Commercial,,176.36,,,,,,,70.99,267.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Cigna,Commercial,,39.82,,,,,,,20.78,93.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Cigna,Commercial,,39.82,,,,,,,20.78,112.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Cigna,Commercial,,39.82,,,,,,,19.02,71.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Cigna,Commercial,,95.06,,,,,,,33.23,124.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Cigna,Commercial,,39.82,,,,,,,16.02,60.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Cigna,Commercial,,78.36,,,,,,,31.83,119.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Cigna,Commercial,,218.46,,,,,,,218.46,1191.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Cigna,Commercial,,218.46,,,,,,,159.76,598.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Cigna,Commercial,,218.46,,,,,,,65.27,244.50,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Cigna,Commercial,,64.78,,,,,,,13.21,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Cigna,Commercial,,37.26,,,,,,,8.41,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,164.42,,,,,,,5.61,381.82,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Cigna,Commercial,,54.60,,,,,,,21.02,78.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Cigna,Commercial,,61.02,,,,,,,37.47,201.52,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,40.55,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Cigna,Commercial,,196.20,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Cigna,Commercial,,196.20,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Cigna,Commercial,,181.16,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Cigna,Commercial,,370.16,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,59.51,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,59.51,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Cigna,Commercial,,37.28,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Cigna,Commercial,,444.07,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Cigna,Commercial,,425.75,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Cigna,Commercial,,680.81,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Cigna,Commercial,,699.78,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Cigna,Commercial,,140.61,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Cigna,Commercial,,274.03,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Cigna,Commercial,,192.28,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Cigna,Commercial,,620.65,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Cigna,Commercial,,810.96,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Cigna,Commercial,,392.40,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Cigna,Commercial,,59.51,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Cigna,Commercial,,999.31,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Cigna,Commercial,,5.78,,,,,,,2.90,21.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,,17.98,,,,,,,9.48,123.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,,17.98,,,,,,,9.48,123.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Cigna,Commercial,,17.98,,,,,,,9.48,123.75,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Cigna,Commercial,,10.92,,,,,,,5.55,44.25,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Cigna,Commercial,,680.81,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Cigna,Commercial,,680.81,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Cigna,Commercial,,758.64,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,40.55,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,40.55,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,40.55,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,40.55,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Cigna,Commercial,,40.55,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Cigna,Commercial,,9423.00,,,,,,,523.72,9423.00,per diem,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Cigna,Commercial,,1962.53,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Cigna,Commercial,,9423.00,,,,,,,1715.71,9423.00,per diem,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Cigna,Commercial,,1962.53,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Cigna,Commercial,,1962.53,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Cigna,Commercial,,9423.00,,,,,,,1715.71,9423.00,per diem,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Cigna,Commercial,,9423.00,,,,,,,150.52,21640.97,per diem,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Cigna,Commercial,,9423.00,,,,,,,150.52,9423.00,per diem,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Cigna,Commercial,,9423.00,,,,,,,495.29,13852.00,per diem,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Cigna,Commercial,,566.55,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Cigna,Commercial,,9423.00,,,,,,,1344.34,52940.00,per diem,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Cigna,Commercial,,9423.00,,,,,,,409.01,52940.00,per diem,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Cigna,Commercial,,9423.00,,,,,,,674.27,9423.00,per diem,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Cigna,Commercial,,9423.00,,,,,,,181.98,9423.00,per diem,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Cigna,Commercial,,9423.00,,,,,,,181.98,9423.00,per diem,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Cigna,Commercial,,453.65,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Cigna,Commercial,,954.01,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Cigna,Commercial,,434.18,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Cigna,Commercial,,102.36,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Cigna,Commercial,,9423.00,,,,,,,164.76,9423.00,per diem,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Cigna,Commercial,,410.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Cigna,Commercial,,324.26,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Cigna,Commercial,,363.19,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Cigna,Commercial,,324.26,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Cigna,Commercial,,9423.00,,,,,,,1544.94,9423.00,per diem,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Cigna,Commercial,,883.48,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Cigna,Commercial,,9423.00,,,,,,,772.37,9423.00,per diem,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Cigna,Commercial,,1641.01,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Cigna,Commercial,,9423.00,,,,,,,1434.63,13852.00,per diem,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Cigna,Commercial,,1262.25,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Cigna,Commercial,,9423.00,,,,,,,1103.50,13852.00,per diem,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Cigna,Commercial,,315.56,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Cigna,Commercial,,9423.00,,,,,,,275.88,9423.00,per diem,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Cigna,Commercial,,1262.25,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Cigna,Commercial,,9423.00,,,,,,,1103.50,13852.00,per diem,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Cigna,Commercial,,1962.53,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Cigna,Commercial,,9423.00,,,,,,,1715.71,9423.00,per diem,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Cigna,Commercial,,4121.00,,,,,,,158.96,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Cigna,Commercial,,9423.00,,,,,,,5817.21,24600.00,per diem,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Cigna,Commercial,,8213.00,,,,,,,879.68,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Cigna,Commercial,,9423.00,,,,,,,879.68,9423.00,per diem,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,17457.00,,,,,,,87.89,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,9423.00,,,,,,,87.89,9423.00,per diem,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,17457.00,,,,,,,87.89,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Cigna,Commercial,,9423.00,,,,,,,87.89,9423.00,per diem,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Cigna,Commercial,,516.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Cigna,Commercial,,9423.00,,,,,,,451.85,9423.00,per diem,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Cigna,Commercial,,516.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Cigna,Commercial,,9423.00,,,,,,,451.85,9423.00,per diem,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Cigna,Commercial,,3830.94,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Cigna,Commercial,,9423.00,,,,,,,3349.15,13852.00,per diem,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Cigna,Commercial,,6384.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Cigna,Commercial,,9423.00,,,,,,,5581.98,24600.00,per diem,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Cigna,Commercial,,2298.47,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Cigna,Commercial,,9423.00,,,,,,,2009.41,13852.00,per diem,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Cigna,Commercial,,5299.52,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Cigna,Commercial,,9423.00,,,,,,,4311.00,14116.62,per diem,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Cigna,Commercial,,2131.30,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Cigna,Commercial,,9423.00,,,,,,,1863.26,13852.00,per diem,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Cigna,Commercial,,5376.69,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Cigna,Commercial,,9423.00,,,,,,,4700.50,24600.00,per diem,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Cigna,Commercial,,4843.81,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Cigna,Commercial,,9423.00,,,,,,,4234.63,24600.00,per diem,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Cigna,Commercial,,6442.46,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Cigna,Commercial,,9423.00,,,,,,,5632.23,52940.00,per diem,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Cigna,Commercial,,9423.00,,,,,,,2468.07,13852.00,per diem,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Cigna,Commercial,,5335.70,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Cigna,Commercial,,9423.00,,,,,,,4664.66,24600.00,per diem,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Cigna,Commercial,,4855.72,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Cigna,Commercial,,9423.00,,,,,,,4245.04,24600.00,per diem,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Cigna,Commercial,,5505.16,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Cigna,Commercial,,9423.00,,,,,,,4812.81,52940.00,per diem,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Cigna,Commercial,,2173.90,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Cigna,Commercial,,9423.00,,,,,,,1900.50,13852.00,per diem,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Cigna,Commercial,,4686.26,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Cigna,Commercial,,9423.00,,,,,,,4096.89,24600.00,per diem,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Cigna,Commercial,,4037.04,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Cigna,Commercial,,9423.00,,,,,,,3529.33,13852.00,per diem,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Cigna,Commercial,,4714.65,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Cigna,Commercial,LM,27871.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Cigna,Commercial,RI,27871.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Cigna,Commercial,RC,27871.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Cigna,Commercial,LD,27871.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Cigna,Commercial,LC,27871.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Cigna,Commercial,LC,27871.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Cigna,Commercial,RI,27871.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Cigna,Commercial,RC,27871.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Cigna,Commercial,LD,27871.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Cigna,Commercial,LC,27871.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,LM,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,RI,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,RC,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,LD,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,LC,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,LM,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,RI,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,RC,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,LD,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Cigna,Commercial,LC,27871.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,LM,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,RI,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,RC,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,LD,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,LC,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,LM,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,RI,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,RC,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,LD,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Cigna,Commercial,LC,27871.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,LM,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,RI,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,RC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,LD,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,LC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,RC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,LD,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Cigna,Commercial,LC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LM,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,RI,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,RC,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LD,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LC,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LM,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,RI,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,RC,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LD,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LC,27871.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LM,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,RI,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,RC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LD,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,RC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LD,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Cigna,Commercial,LC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Cigna,Commercial,,27871.00,,,,,,,4633.23,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Cigna,Commercial,,27871.00,,,,,,,4633.23,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Cigna,Commercial,,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Cigna,Commercial,,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,LM,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,RI,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,RC,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,LD,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,LC,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,LM,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,RI,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,RC,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,LD,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Cigna,Commercial,LC,27871.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LM,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,RI,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,RC,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LD,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LC,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LM,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,RI,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,RC,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LD,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LC,27871.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LM,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,RI,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,RC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LD,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Cigna,Commercial,LC,27871.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Cigna,Commercial,,9423.00,,,,,,,78.68,9423.00,per diem,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Cigna,Commercial,,1088.26,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Cigna,Commercial,,9423.00,,,,,,,373.37,9423.00,per diem,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Cigna,Commercial,,9423.00,,,,,,,84.48,9423.00,per diem,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Cigna,Commercial,,9423.00,,,,,,,505.91,9423.00,per diem,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Cigna,Commercial,,27871.00,,,,,,,2316.71,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Cigna,Commercial,,27871.00,,,,,,,2143.34,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Cigna,Commercial,,27871.00,,,,,,,2143.34,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Cigna,Commercial,,27871.00,,,,,,,2044.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Cigna,Commercial,,27871.00,,,,,,,850.85,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Cigna,Commercial,,9423.00,,,,,,,1474.87,10022.00,per diem,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Cigna,Commercial,,9423.00,,,,,,,2180.78,12247.00,per diem,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Cigna,Commercial,,9423.00,,,,,,,1936.53,12247.00,per diem,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Cigna,Commercial,,9423.00,,,,,,,2067.27,12247.00,per diem,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Cigna,Commercial,,9423.00,,,,,,,909.51,12247.00,per diem,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Cigna,Commercial,,9423.00,,,,,,,2126.92,12247.00,per diem,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Cigna,Commercial,,9423.00,,,,,,,2652.85,12247.00,per diem,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Cigna,Commercial,,9423.00,,,,,,,2389.79,12247.00,per diem,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Cigna,Commercial,,9423.00,,,,,,,2549.35,12247.00,per diem,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Cigna,Commercial,,9423.00,,,,,,,2592.59,12247.00,per diem,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Cigna,Commercial,,9423.00,,,,,,,3094.46,12247.00,per diem,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Cigna,Commercial,,9423.00,,,,,,,40.64,9423.00,per diem,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Cigna,Commercial,,9423.00,,,,,,,19.42,9423.00,per diem,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Cigna,Commercial,,9423.00,,,,,,,300.90,9423.00,per diem,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Cigna,Commercial,,9423.00,,,,,,,826.43,9423.00,per diem,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Cigna,Commercial,,9423.00,,,,,,,96.90,9423.00,per diem,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,9423.00,,,,,,,125.33,9423.00,per diem,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Cigna,Commercial,,9423.00,,,,,,,125.33,9423.00,per diem,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Cigna,Commercial,,9423.00,,,,,,,43.04,9423.00,per diem,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Cigna,Commercial,,27871.00,,,,,,,7834.43,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Cigna,Commercial,,8032.43,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Cigna,Commercial,,1651.35,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Cigna,Commercial,,1846.90,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Cigna,Commercial,,9423.00,,,,,,,253.45,9503.00,per diem,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Cigna,Commercial,,120.91,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Cigna,Commercial,,9423.00,,,,,,,105.71,9423.00,per diem,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Cigna,Commercial,,9423.00,,,,,,,105.71,9423.00,per diem,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Cigna,Commercial,,1804.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Cigna,Commercial,,9423.00,,,,,,,1577.98,24600.00,per diem,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Cigna,Commercial,,3430.19,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Cigna,Commercial,,3430.19,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Cigna,Commercial,,4183.14,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Cigna,Commercial,,6649.00,,,,,,,2656.25,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Cigna,Commercial,,6649.00,,,,,,,3018.42,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Cigna,Commercial,,4166.43,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Cigna,Commercial,,731.20,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Cigna,Commercial,,3226.38,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Cigna,Commercial,,3226.38,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Cigna,Commercial,,2339.24,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Cigna,Commercial,,674.18,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Cigna,Commercial,,5152.00,,,,,,,580.98,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Cigna,Commercial,,5152.00,,,,,,,580.98,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Cigna,Commercial,,4669.77,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Cigna,Commercial,,3417.82,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Cigna,Commercial,,542.04,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Cigna,Commercial,,5446.99,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Cigna,Commercial,,5615.31,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Cigna,Commercial,,6120.71,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Cigna,Commercial,,5152.00,,,,,,,1703.30,8700.96,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Cigna,Commercial,,2610.83,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Cigna,Commercial,,2610.83,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Cigna,Commercial,,11424.12,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Cigna,Commercial,,1316.75,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Cigna,Commercial,,875.01,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Cigna,Commercial,,13212.84,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Cigna,Commercial,,604.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Cigna,Commercial,,7630.22,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Cigna,Commercial,,5152.00,,,,,,,417.62,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Cigna,Commercial,,959.05,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Cigna,Commercial,,4237.92,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Cigna,Commercial,,4237.92,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Cigna,Commercial,,2113.73,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Cigna,Commercial,,1500.93,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Cigna,Commercial,,2113.73,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Cigna,Commercial,,2113.73,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Cigna,Commercial,,1990.12,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Cigna,Commercial,,1822.70,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Cigna,Commercial,,6265.32,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Cigna,Commercial,,9960.42,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Cigna,Commercial,,9960.42,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Cigna,Commercial,,1062.10,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Cigna,Commercial,,5286.94,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Cigna,Commercial,,1084.33,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Cigna,Commercial,,2064.02,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Cigna,Commercial,,16639.07,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Cigna,Commercial,,14737.24,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Cigna,Commercial,,14737.24,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Cigna,Commercial,,1978.35,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Cigna,Commercial,,927.37,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Cigna,Commercial,,9423.00,,,,,,,2025.00,12283.57,per diem,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Cigna,Commercial,,5125.25,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Cigna,Commercial,,568.38,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Cigna,Commercial,,9423.00,,,,,,,386.59,9503.00,per diem,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Cigna,Commercial,,1270.49,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Cigna,Commercial,,1270.49,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Cigna,Commercial,,1460.33,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Cigna,Commercial,,9423.00,,,,,,,515.51,82346.00,per diem,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Cigna,Commercial,,9423.00,,,,,,,2025.00,9423.00,per diem,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Cigna,Commercial,,927.37,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Cigna,Commercial,,9423.00,,,,,,,150.52,9423.00,per diem,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Cigna,Commercial,,9423.00,,,,,,,150.52,9423.00,per diem,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Cigna,Commercial,,9423.00,,,,,,,1594.59,9423.00,per diem,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Cigna,Commercial,,9423.00,,,,,,,2025.00,11298.42,per diem,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Cigna,Commercial,,9423.00,,,,,,,1846.64,9423.00,per diem,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Cigna,Commercial,,9423.00,,,,,,,1294.69,9423.00,per diem,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Cigna,Commercial,,9423.00,,,,,,,1496.70,10022.00,per diem,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Cigna,Commercial,,9423.00,,,,,,,57.66,9423.00,per diem,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Cigna,Commercial,,324.72,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Cigna,Commercial,,1825.13,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Cigna,Commercial,,1988.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Cigna,Commercial,,1988.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Cigna,Commercial,,1988.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Cigna,Commercial,,1988.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Cigna,Commercial,,9423.00,,,,,,,2662.86,13852.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Cigna,Commercial,,9423.00,,,,,,,5325.72,24600.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Cigna,Commercial,,9423.00,,,,,,,5325.72,24600.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Cigna,Commercial,,9423.00,,,,,,,8574.37,26125.69,per diem,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Cigna,Commercial,,9423.00,,,,,,,594.81,21326.82,per diem,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Cigna,Commercial,,2170.00,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Cigna,Commercial,,9423.00,,,,,,,869.87,9423.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Cigna,Commercial,,9423.00,,,,,,,4285.48,24600.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Cigna,Commercial,,9423.00,,,,,,,6855.05,24600.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Cigna,Commercial,,9423.00,,,,,,,6855.05,24600.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Cigna,Commercial,,9423.00,,,,,,,6855.05,24600.00,per diem,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Cigna,Commercial,,7413.42,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Cigna,Commercial,,9423.00,,,,,,,1354.55,12247.00,per diem,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Cigna,Commercial,,9423.00,,,,,,,1354.55,12247.00,per diem,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Cigna,Commercial,,9423.00,,,,,,,21.42,9423.00,per diem,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Cigna,Commercial,,25598.87,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Cigna,Commercial,,25598.87,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Cigna,Commercial,,31355.38,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Cigna,Commercial,,9423.00,,,,,,,480.28,9423.00,per diem,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Cigna,Commercial,,9423.00,,,,,,,1300.10,9423.00,per diem,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Cigna,Commercial,,9423.00,,,,,,,2169.57,12247.00,per diem,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Cigna,Commercial,LD,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Cigna,Commercial,RC,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Cigna,Commercial,RI,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Cigna,Commercial,LM,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Cigna,Commercial,LD,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Cigna,Commercial,RC,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Cigna,Commercial,RI,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Cigna,Commercial,LM,9423.00,,,,,,,173.00,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Cigna,Commercial,LD,9423.00,,,,,,,173.00,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Cigna,Commercial,RC,9423.00,,,,,,,173.00,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Cigna,Commercial,RI,9423.00,,,,,,,173.00,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Cigna,Commercial,LM,9423.00,,,,,,,173.00,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,LD,9423.00,,,,,,,99.10,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,RC,9423.00,,,,,,,99.10,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,RI,9423.00,,,,,,,99.10,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,LM,9423.00,,,,,,,99.10,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Cigna,Commercial,LC,9423.00,,,,,,,173.00,9423.00,per diem,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Cigna,Commercial,LC,9423.00,,,,,,,173.00,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Cigna,Commercial,LC,9423.00,,,,,,,173.00,9423.00,per diem,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Cigna,Commercial,LC,9423.00,,,,,,,99.10,9423.00,per diem,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Cigna,Commercial,,9423.00,,,,,,,594.81,19892.71,per diem,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Cigna,Commercial,,9423.00,,,,,,,9423.00,82346.00,per diem,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Cigna,Commercial,,9423.00,,,,,,,2282.88,13852.00,per diem,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Cigna,Commercial,,9423.00,,,,,,,173.00,9423.00,per diem,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Cigna,Commercial,,41.04,,,,,,,41.04,467.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Cigna,Commercial,,2629.73,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Cigna,Commercial,,2160.82,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Cigna,Commercial,,843.66,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Cigna,Commercial,,1022.20,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Cigna,Commercial,,756.68,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Cigna,Commercial,,1457.77,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Cigna,Commercial,,1457.77,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Cigna,Commercial,,587.95,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Cigna,Commercial,,474.80,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Cigna,Commercial,,474.80,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Cigna,Commercial,,1672.93,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Cigna,Commercial,,1672.93,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Cigna,Commercial,,324.38,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Cigna,Commercial,,251.79,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Cigna,Commercial,,1789.34,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Cigna,Commercial,,35.97,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Cigna,Commercial,,894.67,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Cigna,Commercial,,158.92,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Cigna,Commercial,,572.25,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Cigna,Commercial,,406.79,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Cigna,Commercial,,105.95,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Cigna,Commercial,,126.22,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Cigna,Commercial,,299.80,,,,,,,175.00,957.00,fee schedule,Reimbursed at 65.4% of Billed Charges if no fee available on Cigna RBRVS Fee Schedule
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Cigna,Commercial,,186.39,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Cigna,Commercial,,142.57,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Cigna,Commercial,,194.24,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Cigna,Commercial,,71.29,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Cigna,Commercial,,92.21,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Cigna,Commercial,,28.12,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Cigna,Commercial,,17457.00,,,,,,,1301.10,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Cigna,Commercial,,6649.00,,,,,,,725.52,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Cigna,Commercial,,1828.34,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Cigna,Commercial,,5152.00,,,,,,,521.92,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Cigna,Commercial,,483.42,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Cigna,Commercial,,483.42,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Cigna,Commercial,,17457.00,,,,,,,422.62,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Cigna,Commercial,,4169.25,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Cigna,Commercial,,5521.72,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Cigna,Commercial,,6197.96,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX LEVEL 2 NURSERY ROOM,11720015,CDM,172,RC,,,,,facility,inpatient,,,3166.00000,1899.60000,Cigna,Commercial,,3081.00,,,,,,,2026.24,3569.00,case rate,
HC REX LEVEL 4 INTENSIVE NURSERY ROOM,11740002,CDM,174,RC,,,,,facility,inpatient,,,6546.00000,3927.60000,Cigna,Commercial,,5695.00,,,,,,,4189.44,5695.00,case rate,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Cigna,Commercial,,5121.47,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Cigna,Commercial,,6637.45,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Cigna,Commercial,,7395.43,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Cigna,Commercial,,313.92,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Cigna,Commercial,,196.20,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Cigna,Commercial,,313.92,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Cigna,Commercial,,196.20,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Cigna,Commercial,,22.24,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,58.86,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Cigna,Commercial,,156.96,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Cigna,Commercial,,244.60,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Cigna,Commercial,,863.28,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Cigna,Commercial,,931.95,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Cigna,Commercial,,1459.73,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Cigna,Commercial,,135.07,,,,,,,37.21,215.71,percent of total billed charges,"Reimbursed once threshold of $11,195 is met for each revenue code"
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Cigna,Commercial,,439.49,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Cigna,Commercial,,68.02,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Cigna,Commercial,,664.46,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Cigna,Commercial,,114.45,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Cigna,Commercial,,168.73,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Cigna,Commercial,,125.57,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Cigna,Commercial,,2067.95,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Cigna,Commercial,,197.51,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Cigna,Commercial,,193.58,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Cigna,Commercial,,202.09,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Cigna,Commercial,,186.39,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Cigna,Commercial,,223.01,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Cigna,Commercial,,282.53,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Cigna,Commercial,,403.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Cigna,Commercial,,28.78,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Cigna,Commercial,,27.47,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Cigna,Commercial,,46.43,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Cigna,Commercial,,144.53,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Cigna,Commercial,,262.91,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Cigna,Commercial,,582.06,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Cigna,Commercial,,48.40,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Cigna,Commercial,,35.32,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Cigna,Commercial,,173.31,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Cigna,Commercial,,26.16,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Cigna,Commercial,,490.50,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Cigna,Commercial,,768.45,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Cigna,Commercial,,2622.54,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Cigna,Commercial,,800.50,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Cigna,Commercial,,1173.28,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Cigna,Commercial,,1483.93,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Cigna,Commercial,,321.77,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Cigna,Commercial,,2622.54,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Cigna,Commercial,,457.80,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Cigna,Commercial,,510.12,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Cigna,Commercial,,58.86,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Cigna,Commercial,,1045.09,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Cigna,Commercial,,1680.13,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Cigna,Commercial,,327.00,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Cigna,Commercial,,2616.00,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Cigna,Commercial,,1585.95,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Cigna,Commercial,,1177.20,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Cigna,Commercial,,1585.95,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Cigna,Commercial,,1177.20,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Cigna,Commercial,,771.72,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Cigna,Commercial,,771.72,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Cigna,Commercial,,691.28,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Cigna,Commercial,GP,182.00,,,,,,,37.08,276.00,per diem,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Cigna,Commercial,,7076.79,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Cigna,Commercial,,3421.95,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Cigna,Commercial,,7076.79,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Cigna,Commercial,,3421.95,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Cigna,Commercial,,2974.02,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Cigna,Commercial,,3039.52,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Cigna,Commercial,,3105.24,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Cigna,Commercial,,3171.19,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Cigna,Commercial,,3236.91,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Cigna,Commercial,,3302.41,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Cigna,Commercial,,3368.13,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Cigna,Commercial,,3433.86,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Cigna,Commercial,,326.35,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Cigna,Commercial,,160.88,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Cigna,Commercial,,130.80,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,215412.76,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,87653.85,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,163376.49,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,106938.50,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,79836.98,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36412.81,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,100040.85,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43818.68,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55843.64,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,42666.79,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33190.55,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22978.77,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,92905.15,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,46306.95,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,42499.92,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,331436.76,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55529.08,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61148.55,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,41439.87,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25241.25,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44780.78,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30863.01,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35721.67,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24719.26,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20231.80,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,46908.54,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27033.77,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17723.63,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35214.98,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17232.26,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13649.49,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30547.68,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19218.43,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15791.80,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26119.14,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13341.04,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9918.99,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30474.96,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17750.42,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14145.45,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14785.32,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8416.54,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12608.57,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8725.76,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18702.56,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10838.23,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14006.15,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10419.55,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7961.91,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22024.35,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14371.25,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11666.37,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16313.80,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8654.58,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.19,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12163.11,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7537.89,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7035.79,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13664.02,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8774.75,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6709.73,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13200.97,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8811.48,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15598.15,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7237.86,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14775.38,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7776.68,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18415.54,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11605.15,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8237.46,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18310.69,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10892.56,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7922.88,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11268.38,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9330.42,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7222.55,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14363.60,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8751.77,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7016.65,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27858.86,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28566.09,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18486.74,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11349.49,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15745.88,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7830.26,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9501.09,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7322.81,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18916.86,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11277.56,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12669.80,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14760.82,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9225.55,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9825.63,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6936.29,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7034.25,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11048.71,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6798.52,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17530.75,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8692.84,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12350.62,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7704.74,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10379.75,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33567.88,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17615.72,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13140.51,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29597.83,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14185.27,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10124.13,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17128.17,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10653.76,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7022.79,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6674.53,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11113.00,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6539.82,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9970.26,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6571.97,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12888.69,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7936.65,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6211.46,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14062.03,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7885.36,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6344.65,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35224.95,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20240.22,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15572.92,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29529.70,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14724.84,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11380.10,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23702.83,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11435.22,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7083.25,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12882.57,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8392.06,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6700.55,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14438.60,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9119.17,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6691.37,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12631.53,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9066.35,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6941.65,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12850.44,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8492.31,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6411.24,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10377.45,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9400.07,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7374.09,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5835.67,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10982.12,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7090.12,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5732.34,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15366.26,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8186.17,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6403.58,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14424.06,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9335.77,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6395.17,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8355.32,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6049.98,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7101.62,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14936.10,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8124.94,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,50172.15,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21960.03,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,87554.35,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,84150.68,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44601.69,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,77131.34,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,75798.02,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59690.48,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,41738.37,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,39498.86,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38788.59,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25027.69,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65443.13,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,47324.16,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59437.13,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,42732.61,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,45839.31,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32982.36,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38591.88,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22739.22,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11517.89,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25359.12,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17231.49,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14756.23,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35841.82,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17626.41,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12360.57,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27620.84,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20788.24,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14558.76,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21567.41,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13917.37,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9281.42,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24971.07,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16398.75,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25818.35,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13396.91,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24322.78,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26490.37,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28615.06,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,47827.79,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,37360.36,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53564.34,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33245.65,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,41305.94,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28141.31,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20462.18,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32497.87,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26116.07,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55496.94,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,46895.53,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36271.21,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43524.79,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28524.74,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13199.44,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7956.55,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6456.39,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16082.64,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6219.89,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5505.79,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17858.34,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9112.27,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21634.77,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13986.26,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8037.68,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10747.91,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7420.02,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5253.97,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12876.45,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5774.43,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4405.15,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13418.34,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9092.37,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6430.38,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10080.51,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6074.47,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10029.98,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6701.31,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12982.83,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7911.39,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6552.83,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5254.73,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6294.12,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7593.00,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6432.66,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16881.72,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8294.85,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6142.58,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,52099.39,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19461.06,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35080.27,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19331.71,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21746.51,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14415.63,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,34043.17,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25039.17,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25493.84,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,39094.73,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19629.42,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13185.67,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36102.84,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19269.71,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13802.57,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28634.21,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18848.74,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13458.14,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28253.06,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17061.59,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12670.56,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20690.27,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12438.65,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10000.89,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18492.09,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10939.25,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7585.34,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19994.53,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12590.19,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9860.08,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23133.38,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13798.74,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11216.32,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,34543.75,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18720.94,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11621.20,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27240.44,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19400.60,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13106.07,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8577.27,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6285.71,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14492.95,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8736.47,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6489.29,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17291.19,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10179.99,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7996.35,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14913.13,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8428.02,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5746.87,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15940.27,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9214.84,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7049.57,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11489.57,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7464.40,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13032.60,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8394.36,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6136.47,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12225.09,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6966.90,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5085.59,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10629.27,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6888.84,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13162.69,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8083.60,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5889.25,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19252.10,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12506.75,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9683.26,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31694.22,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,42792.31,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23119.60,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17910.39,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28212.47,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17586.64,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13073.91,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26204.87,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17014.13,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13631.12,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28189.53,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16740.12,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11356.39,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19187.05,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13869.16,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11375.53,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26999.33,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14220.47,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11633.46,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32708.36,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17667.76,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12404.98,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,85276.57,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,56172.01,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43951.87,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,69880.07,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,45062.43,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15986.21,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9005.88,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6375.27,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14979.72,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9579.16,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7452.92,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.20,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7360.31,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5678.00,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14658.27,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8310.15,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6277.29,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13710.70,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9298.26,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7253.93,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,52061.88,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33380.36,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,41713.86,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25646.90,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65240.30,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,46562.60,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32858.36,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43194.12,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21281.15,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44545.04,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24761.35,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40763.27,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27913.97,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21954.69,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24137.57,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15685.42,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,37880.05,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23470.91,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19607.24,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33779.12,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18339.78,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9954.97,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27362.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19744.25,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23212.22,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16952.88,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13405.34,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22137.61,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25621.65,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16926.87,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12909.36,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14460.79,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9469.72,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29023.77,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20332.84,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16279.37,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28672.47,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14728.68,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10170.04,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24012.02,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16342.87,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25144.82,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14301.58,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11223.21,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22284.56,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15228.48,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14643.73,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11248.47,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14747.82,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12512.90,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24040.37,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16837.31,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13592.09,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12971.36,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8746.44,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25313.97,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16827.37,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12683.56,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29526.63,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16231.12,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12355.99,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22889.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17130.46,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12920.83,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7091.66,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10734.13,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7103.15,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8225.97,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6434.97,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15997.69,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6948.53,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14442.42,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8790.05,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6697.49,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19916.46,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9749.85,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7322.04,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15700.72,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10161.62,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7612.12,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13750.53,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8279.54,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7275.36,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11038.75,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7279.18,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12302.40,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7758.30,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15195.59,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9540.90,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7074.82,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11827.11,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7775.91,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12736.38,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8379.80,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6656.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23432.65,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13853.08,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9695.51,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,51065.36,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27491.49,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14675.87,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38434.98,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21209.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13217.04,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25708.90,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14147.76,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11967.17,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15667.80,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14120.20,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17306.50,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15686.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15734.39,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10001.65,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7556.25,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17153.42,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9207.19,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13681.63,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9580.68,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6810.76,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8894.14,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5552.46,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11800.31,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7587.64,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12189.12,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7932.82,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12503.69,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7859.34,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17697.61,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11631.94,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27613.94,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15236.90,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11777.35,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23021.63,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13170.34,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12466.97,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28163.50,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14652.15,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10503.75,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24037.29,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12398.07,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11088.51,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29446.28,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17598.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12092.68,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11918.19,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7781.28,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5676.47,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11144.39,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6878.11,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11806.44,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13520.90,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8767.08,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6802.33,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36905.73,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29285.54,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25640.01,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40694.39,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22347.32,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17122.05,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25290.24,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14928.45,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12799.14,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20369.56,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11037.99,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8846.69,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24354.16,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12557.29,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8934.71,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24811.11,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14310.76,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9388.58,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23271.15,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12800.68,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8402.00,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14660.56,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9184.23,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33080.34,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18821.20,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13484.93,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12257.25,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7625.13,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5516.50,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14727.15,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8941.60,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6970.73,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9802.66,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7117.70,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11212.51,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6904.90,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9676.36,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6195.39,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9171.21,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13584.44,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8690.56,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6202.28,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16231.91,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12664.44,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18733.19,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11646.48,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16871.00,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9338.83,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12428.70,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9015.07,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18045.87,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12180.70,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11201.78,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14773.07,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9667.94,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5940.52,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9878.43,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6447.99,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12271.80,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7130.69,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9025.02,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6065.28,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17224.61,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11220.15,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28280.60,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16693.42,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12161.57,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28344.13,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14772.31,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11837.06,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14965.18,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10418.04,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16605.42,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9628.15,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14217.40,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7501.91,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11540.09,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20573.93,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12217.45,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15018.00,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9247.76,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8273.41,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11881.44,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8415.00,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6000.99,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8633.14,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5288.42,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9123.75,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13855.37,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8596.40,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5932.88,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7361.08,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19712.87,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9035.74,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8252.75,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13546.92,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9469.72,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8260.41,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14715.68,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,46412.59,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31988.89,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19667.71,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32835.41,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12218.22,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2451.13,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9853.93,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8578.80,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8247.39,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35585.44,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22424.63,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15532.33,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31415.61,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11300.51,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9181.93,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6692.90,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6082.11,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17820.82,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10610.90,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8932.41,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11670.19,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7949.65,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12596.31,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17199.35,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8682.89,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5759.11,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18384.93,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9794.24,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7503.45,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,45810.23,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18055.80,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36013.28,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18262.46,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11249.99,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36725.08,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18611.49,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13962.53,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25108.06,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12440.96,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10125.65,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6444.91,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4924.09,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,42940.80,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16886.29,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10255.76,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,37693.32,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16898.56,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11973.30,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25681.35,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13408.38,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8655.36,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16189.80,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10239.68,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.92,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20764.51,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10934.67,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7423.08,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21660.01,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,67200.45,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38721.22,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16215.06,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12381.24,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35736.97,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17312.62,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11582.94,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8559.68,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7716.22,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12389.66,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7577.68,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16942.94,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8813.78,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6506.90,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53823.82,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15789.50,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8754.09,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30503.29,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8271.10,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8123.40,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9140.60,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15971.67,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13236.18,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11612.79,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16805.94,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9118.42,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5643.55,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11756.68,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14278.65,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7678.71,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33042.06,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15575.19,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9873.84,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29035.26,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12275.62,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15956.36,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30307.32,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16192.86,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10969.12,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13432.90,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7699.38,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13792.61,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6021.67,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12926.20,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7482.00,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14934.57,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8593.35,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6190.80,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14311.54,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8711.22,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,164335.51,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55820.70,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25573.43,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30727.54,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17841.49,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16688.83,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28693.91,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18808.19,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16441.60,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12774.66,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9699.34,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10637.70,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7048.81,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10027.67,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5726.21,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5177.42,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,52440.77,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29723.35,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59243.50,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33174.46,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23455.60,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21846.01,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12652.20,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8120.32,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,47773.44,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21108.17,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23010.91,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10833.63,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7831.04,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10854.29,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36832.24,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19738.90,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14040.60,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27162.37,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13501.77,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10100.38,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18119.20,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5373.49,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22332.87,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5373.49,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9965.52,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6834.82,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22332.87,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6834.82,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,46864.96,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9965.52,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6199.45,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3581.50,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6834.82,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23376.18,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18406.40,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,316.80,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,202.19,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6791.65,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13530.72,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12986.98,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6834.82,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,316.80,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1008.67,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4879.29,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12986.98,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.33,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6669.40,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6498.27,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.33,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1008.67,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13530.72,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,681.49,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.59,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9630.27,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7701.19,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,202.19,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,530.34,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,455.29,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13530.72,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5373.49,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30.85,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.64,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.52,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.67,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.12600,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1816.84,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,118.07,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,120.27,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.11,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.35,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.51,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.87,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.78,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.34,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,79.65,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.97,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,180.93,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,770.35,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.17,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.59,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5391.84,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,100.69,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,238.64,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.85,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.85,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.37,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.37,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.37,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.19,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,93.81,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.08,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.08,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.08,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.08,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.08,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.08,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.51,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,181.68,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,181.68,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.00,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,76.86,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,76.86,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.07,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,190.28,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,192.65,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.51,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2738.57,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,453.62,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.34,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,271.57,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.45,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.53,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.53,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.34,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.87,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,58.43,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29845.26,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,69.97,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,96.32,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,140.90,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,622.65,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,786.29,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.99,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,148.98,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.35,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,276.31,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,51.41,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.27,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,79.65,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1816.84,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66.21,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,770.35,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.27,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.27,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.11,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,78.08,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,78.08,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.38,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.39,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.35,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,175.68,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.52,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,34.61,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,34.61,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,93.81,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,63.30,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,213.76,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,213.76,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,213.76,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,109.97,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.28,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,51.48,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,51.48,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.74,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.74,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.48300,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.48300,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,69.30,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32.83,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.16,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,118.07,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.89,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.91,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.92,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.17,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,41.82,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,148.68,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,105.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,62.38,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,78.78,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,89.38,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,89.38,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.52,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.52,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,268.89,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2832.95,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.29,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.72,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.82,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.56,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,34.61,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.02,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.24,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.24,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.24,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.24,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.24,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,104.09,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,260.93,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30.75,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,111.65,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,137.95,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,107.20,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.91,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,64.51,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.17,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,143.50,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29.25,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29.25,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30.85,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30.85,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.08,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.08,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,135.95,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.56,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.58,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.48,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.06,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.06,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29.24,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29.24,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,377.15,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29.39,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,86.00,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,86.00,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.09,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,334.46,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.43,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.20,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.20,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.03,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,143.50,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,236.37,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,236.37,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.24,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.73,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29.39,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2222.14,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,227.75,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,255.90,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23.67,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,198.20,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.94,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,88.80,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.39900,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.39900,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,207.72,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35.26,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35.26,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,72.96,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,687.36,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,687.36,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32.09,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.29,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.29,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.29,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66509.39,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,76.25,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,76.25,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,205.51,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.17,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,111.65,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.92,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59.88,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59.88,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,79.77,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35.10,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.73,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,54.14,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.55,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,78.98,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,78.98,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.59,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32.64,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,45.35,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,113.89,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,113.89,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,344.76,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.84000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.56,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1920.16,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.78,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,99.17,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5426.64,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.71,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,93.81,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.83,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.27,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,57.45,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,57.45,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,57.45,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,57.45,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,396.40,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.48300,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,46.83,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.58,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.50400,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.82,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.07,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.65,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.65,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.65,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.37,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,192.65,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,71.61,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.34,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.34,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.00,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,271.57,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,217.49,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,293.84,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,293.84,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.02,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,156.44,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,191.57,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.22050,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,99.17,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,137.95,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,99.17,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.91,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.09,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,89.38,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,58.43,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.38850,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.07,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.84000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.37,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,99.17,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.07,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,78.78,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,64.51,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.20,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.20,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.58,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.84000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.92,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,248.45,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.91,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.91,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,58.35,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.29400,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,76.25,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,100.69,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.64,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.64,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.38850,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,71.61,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.12600,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.12600,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,309.42,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.08,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.69,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,47.06,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.05,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.33,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,146.17,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.58,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.73,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.73,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,99.17,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,99.17,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.30,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.31500,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.75,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.75,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.38850,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,509.22,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.56,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.56,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.07,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.07,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.07,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.99,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.60,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.83,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.21,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.67,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.70,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.70,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1.78,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,0.33600,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.19,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,411.66,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,534.41,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,638.50,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,356.58,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.56,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.56,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.58,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.54,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1828.66,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1828.66,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,602.44,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,602.44,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,602.44,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,722.56,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,114.04,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,48.05,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,114.04,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,273.87,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,273.87,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,273.87,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,602.44,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,602.44,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,602.44,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7961.22,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7961.22,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,722.56,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,381.23,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,602.44,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1707.19,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5140.98,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,316.80,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.50,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.50,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.82,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1707.19,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,728.71,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,443.47,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.03,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,48.05,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43.24,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,276.58,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,241.85,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,312.33,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,312.33,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6834.82,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6834.82,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,143.61,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,202.19,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,164.92,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,288.36,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,443.47,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,638.50,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,877.52,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.64,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,164.32,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,164.32,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,164.32,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3311.27,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,312.33,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,164.32,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,637.50,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.59,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.59,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.50,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,206.93,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18209.54,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,455.29,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1707.19,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.12,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2429.62,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18209.54,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24.29,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,751.05,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2010.34,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2178.55,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,233.41,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,233.41,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4530.66,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1082.96,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2304.35,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,180.83,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,281.84,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,523.60,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,624.86,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,349.06,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,400.06,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,704.78,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,989.88,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6498.27,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,906.81,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,416.08,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6498.27,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1542.65,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13399.92,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,219.42,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,455.29,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1424.94,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1975.59,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2033.68,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,927.18,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1227.93,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,455.29,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10842.57,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3379.04,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3675.27,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,976.41,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6076.09,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6498.27,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,695.12,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2133.38,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2980.64,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3591.87,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1687.37,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6669.40,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1059.54,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1359.57,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,418.48,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1519.02,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2343.75,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2031.31,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,822.79,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,371.93,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,91.70,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,721.21,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.09,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,50.20,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.11,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,50.01,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.58,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,172.16,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,152.08,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,584.43,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,305.93,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1218.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1218.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,68.97,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,77.04,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,59.89,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,47.13,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,173.79,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,106.18,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.75,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,68.63,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,207.89,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,181.37,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,244.72,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,244.72,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.36,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,365.99,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.62,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,45.83,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,211.57,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,245.70,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,422.23,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,423.77,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,133.80,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,78.05,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,99.48,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,362.85,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,352.15,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,186.11,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.40,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,129.86,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,258.85,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,130.87,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,315.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,202.91,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,310.58,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.61,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.29,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.18,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.14,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.90,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.53,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.88,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.36,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.06,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.83,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.30,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.94,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.22,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.42,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.94,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.07,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.91,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.45,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.42,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.42,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.85,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,34.25,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.75,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.58,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.58,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.20,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.17,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.07,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.07,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.13,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.11,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.61,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.30,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.99,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.27,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.27,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.27,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.60,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.59,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.44,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.08,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.33,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.12,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.91,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.28,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.83,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.83,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.83,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.25,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.57,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.50,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.47,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.47,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.57,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.11,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.42,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.84,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.13,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.38,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29.34,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.64,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.36,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.31,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,67.63,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.44,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.55,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.37,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.26,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.13,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.13,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.99,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.51,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.12,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.12,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.56,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.51,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.45,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.21,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.51,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.96,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.40,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.20,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.61,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.61,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.99,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.82,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.72,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.11,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.11,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.00,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.79,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.15,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.68,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.29,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.23,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.23,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.60,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.03,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.04,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.57,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,41.22,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.13,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.13,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.94,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.16,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43.34,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43.34,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.98,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.07,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.07,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,103.02,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.00,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.32,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.90,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.35,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.31,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.31,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.85,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.20,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.28,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.72,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.72,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.05,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.10,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.44,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.10,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.21,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.47,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.64,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.57,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.40,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.03,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.89,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.79,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.09,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.15,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.84,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.75,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.33,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.33,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.80,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.26,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.48,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.80,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.80,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.29,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.72,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.60,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.72,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.72,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.72,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.60,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.43,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.43,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.83,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.83,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.65,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.65,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.85,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.85,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,31.42,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23.46,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30.82,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,39.62,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.12,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.12,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,374.62,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,39.62,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,39.62,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,49.33,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,81.67,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.28,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.17,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.95,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.08,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.50,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.62,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.62,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.88,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.11,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.69,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.05,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.69,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.69,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.69,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.69,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.54,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.85,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.32,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.33,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.40,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.36,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.28,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.01,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.82,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.01,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.32,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.32,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.52,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.11,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.13,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.90,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.52,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.98,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,114.96,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,67.40,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,67.40,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,339.94,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,342.09,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,374.62,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.14,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.14,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.67,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.67,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.02,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.50,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.61,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.99,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.49,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.49,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.16,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.79,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.19,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.85,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.67,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.70,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,850.74,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,850.74,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.63,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.53,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.80,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.80,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.48,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24.09,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24.09,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24.09,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32.40,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,24.09,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.99,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.80,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.80,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,20.32,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.57,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.88,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.88,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.44,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.53,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.09,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,32.40,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.09,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.51,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.51,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.51,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.49,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.23,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.69,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.21,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.05,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.83,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.74,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.74,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.16,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.16,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.88,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.88,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.50,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.14,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.06,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.06,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.88,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.34,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.57,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.79,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.06,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.06,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.31,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.31,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.79,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.79,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.25,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.01,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.84,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.84,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.91,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.91,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.91,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.38,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.94,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.48,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.48,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.48,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.48,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.47,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.10,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.83,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.84,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.84,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,121.13,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.53,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.17,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.35,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.99,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.85,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.99,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.08,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.66,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.66,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.66,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.29,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.88,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.11,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.11,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.51,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.85,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.85,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.28,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.28,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,39.13,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.98,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.98,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.98,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,89.36,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,100.59,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,149.76,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,437.62,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.98,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,276.14,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.05,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.36,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,270.32,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,270.32,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.33,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.33,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.04,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.88,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.70,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.08,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,96.24,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.95,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.39,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.01,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.96,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.91,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.28,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.11,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.48,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.83,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.48,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.70,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.52,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.10,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.48,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8.48,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.29,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.04,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.85,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.01,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,14.06,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.99,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.99,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.51,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,4.50,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.45,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.90,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.96,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,129.86,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.34,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.80,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7.68,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.10,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.72,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.78,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.58,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.83,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.58,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.38,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,17.38,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.54,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.54,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.54,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,127.71,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,194.46,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,87.15,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,673.94,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1916.12,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,394.01,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.54,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11.71,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.79,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.79,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.45,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,194.46,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,143.85,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,228.96,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,73.71,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,127.71,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,194.46,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,26.16,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,QW,26.16,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,15.10,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,65.25,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1218.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,437.62,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,96.24,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.85,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,244.72,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,43.85,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.98,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,16.87,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.48,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30.67,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,QW,53.88,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.24,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.13,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,437.62,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,149.76,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.84,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.57,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19.57,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.47,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.50,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.08,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,149.76,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,41.22,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.82,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.85,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,143.85,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.34,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.11,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18.13,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23.46,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,30.82,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.76,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.70,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.11,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.88,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.20,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.15,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.36,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.84,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,143.85,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,9.05,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,276.14,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,73.71,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,2.49,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,21.27,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.50,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.94,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.94,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,27.94,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,374.62,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,374.62,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,122.31,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,122.31,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,147.77,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,157.81,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,157.81,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,150.94,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,13.72,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,277.56,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,131.76,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,151.84,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,198.00,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,36.55,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.50,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.75,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,35.14,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,72.03,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,28.26,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25.50,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,374.62,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,850.74,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,850.74,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,850.74,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,12.65,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,107.37,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5.27,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,150.94,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,147.77,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,150.94,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.75,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,151.84,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,374.62,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.75,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,55.64,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,374.62,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.75,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,53.75,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,44.50,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,40.88,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,178.46,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,189.54,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,189.54,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,87.78,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,150.30,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,413.31,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,703.66,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,680.83,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,266.40,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,153.41,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,809.71,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,252.48,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,74.04,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,611.61,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3.14,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,703.66,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,681.49,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,681.49,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,345.43,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,10898.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19861.32,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23376.18,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33389.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1264.28,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1264.28,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1264.28,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7902.49,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,552.58,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19861.32,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33389.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33389.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,29606.17,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,415.57,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,162.94,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,1617.80,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33389.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,11810.43,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,25548.73,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,643.87,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,33389.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,5937.75,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,110.74,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,19861.32,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,324.30,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,38.84,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,134.24,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,95.59,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,251.74,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,131.12,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,131.12,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,61.87,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3839.70,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3277.91,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,7439.71,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,732.74,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,8618.87,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Healthspring (Cigna Medicare Advantage),Medicare Advantage,,3790.08,,,,,,,422.62,17457.00,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,823.98,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,526.87,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Healthy Blue NC,Managed Medicaid,,526.87,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Healthy Blue NC,Managed Medicaid,,0.02803,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Healthy Blue NC,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Healthy Blue NC,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Healthy Blue NC,Managed Medicaid,,4.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Healthy Blue NC,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Healthy Blue NC,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Healthy Blue NC,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Healthy Blue NC,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Healthy Blue NC,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Healthy Blue NC,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Healthy Blue NC,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Healthy Blue NC,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Healthy Blue NC,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Healthy Blue NC,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Healthy Blue NC,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Healthy Blue NC,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Healthy Blue NC,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Healthy Blue NC,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Healthy Blue NC,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Healthy Blue NC,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Healthy Blue NC,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Healthy Blue NC,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Healthy Blue NC,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Healthy Blue NC,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Healthy Blue NC,Managed Medicaid,,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Healthy Blue NC,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Healthy Blue NC,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Healthy Blue NC,Managed Medicaid,,6.26,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Healthy Blue NC,Managed Medicaid,,4.07,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Healthy Blue NC,Managed Medicaid,,55.85,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Healthy Blue NC,Managed Medicaid,,4.33,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Healthy Blue NC,Managed Medicaid,,0.00601,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Healthy Blue NC,Managed Medicaid,,4.29,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Healthy Blue NC,Managed Medicaid,,8.13,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Healthy Blue NC,Managed Medicaid,,4.08,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Healthy Blue NC,Managed Medicaid,,3.98,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Healthy Blue NC,Managed Medicaid,,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Healthy Blue NC,Managed Medicaid,,13.07,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Healthy Blue NC,Managed Medicaid,,35.68,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Healthy Blue NC,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Healthy Blue NC,Managed Medicaid,,1.27,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Healthy Blue NC,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Healthy Blue NC,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Healthy Blue NC,Managed Medicaid,,40.04,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Healthy Blue NC,Managed Medicaid,,5.94,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Healthy Blue NC,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Healthy Blue NC,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Healthy Blue NC,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Healthy Blue NC,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Healthy Blue NC,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Healthy Blue NC,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Healthy Blue NC,Managed Medicaid,,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Healthy Blue NC,Managed Medicaid,,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Healthy Blue NC,Managed Medicaid,,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Healthy Blue NC,Managed Medicaid,,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Healthy Blue NC,Managed Medicaid,,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Healthy Blue NC,Managed Medicaid,,93.29,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Healthy Blue NC,Managed Medicaid,,5.50,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Healthy Blue NC,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Healthy Blue NC,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Healthy Blue NC,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Healthy Blue NC,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Healthy Blue NC,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Healthy Blue NC,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Healthy Blue NC,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Healthy Blue NC,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Healthy Blue NC,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Healthy Blue NC,Managed Medicaid,,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Healthy Blue NC,Managed Medicaid,,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Healthy Blue NC,Managed Medicaid,,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Healthy Blue NC,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Healthy Blue NC,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Healthy Blue NC,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Healthy Blue NC,Managed Medicaid,,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Healthy Blue NC,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Healthy Blue NC,Managed Medicaid,,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Healthy Blue NC,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Healthy Blue NC,Managed Medicaid,,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Healthy Blue NC,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Healthy Blue NC,Managed Medicaid,,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Healthy Blue NC,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Healthy Blue NC,Managed Medicaid,,54.45,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Healthy Blue NC,Managed Medicaid,,43.28,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Healthy Blue NC,Managed Medicaid,,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Healthy Blue NC,Managed Medicaid,,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Healthy Blue NC,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Healthy Blue NC,Managed Medicaid,,30.79,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Healthy Blue NC,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Healthy Blue NC,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Healthy Blue NC,Managed Medicaid,,174.60,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Healthy Blue NC,Managed Medicaid,,214.26,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Healthy Blue NC,Managed Medicaid,,0.43644,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Healthy Blue NC,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Healthy Blue NC,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Healthy Blue NC,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Healthy Blue NC,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Healthy Blue NC,Managed Medicaid,,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Healthy Blue NC,Managed Medicaid,,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Healthy Blue NC,Managed Medicaid,,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Healthy Blue NC,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Healthy Blue NC,Managed Medicaid,,0.62062,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Healthy Blue NC,Managed Medicaid,,1.97,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Healthy Blue NC,Managed Medicaid,,38.56,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Healthy Blue NC,Managed Medicaid,,13.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Healthy Blue NC,Managed Medicaid,,47.59,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Healthy Blue NC,Managed Medicaid,,54.83,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Healthy Blue NC,Managed Medicaid,,31.77,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Healthy Blue NC,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Healthy Blue NC,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Healthy Blue NC,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Healthy Blue NC,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Healthy Blue NC,Managed Medicaid,,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Healthy Blue NC,Managed Medicaid,,66.15,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Healthy Blue NC,Managed Medicaid,,65.92,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Healthy Blue NC,Managed Medicaid,,30.66,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Healthy Blue NC,Managed Medicaid,,31.80,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Healthy Blue NC,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Healthy Blue NC,Managed Medicaid,,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Healthy Blue NC,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Healthy Blue NC,Managed Medicaid,,0.02402,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Healthy Blue NC,Managed Medicaid,,0.05405,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Healthy Blue NC,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Healthy Blue NC,Managed Medicaid,,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Healthy Blue NC,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Healthy Blue NC,Managed Medicaid,,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Healthy Blue NC,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Healthy Blue NC,Managed Medicaid,,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Healthy Blue NC,Managed Medicaid,,64.52,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Healthy Blue NC,Managed Medicaid,,16.24,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Healthy Blue NC,Managed Medicaid,,10.71,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Healthy Blue NC,Managed Medicaid,,25.23,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Healthy Blue NC,Managed Medicaid,,6.18,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Healthy Blue NC,Managed Medicaid,,3.33,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Healthy Blue NC,Managed Medicaid,,23.38,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Healthy Blue NC,Managed Medicaid,,6.74,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Healthy Blue NC,Managed Medicaid,,19.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Healthy Blue NC,Managed Medicaid,,55.06,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Healthy Blue NC,Managed Medicaid,,8.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Healthy Blue NC,Managed Medicaid,,10.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Healthy Blue NC,Managed Medicaid,,33.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Healthy Blue NC,Managed Medicaid,,25.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Healthy Blue NC,Managed Medicaid,,30.87,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Healthy Blue NC,Managed Medicaid,,29.30,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Healthy Blue NC,Managed Medicaid,,5.23,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Healthy Blue NC,Managed Medicaid,,5.72,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Healthy Blue NC,Managed Medicaid,,13.62,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Healthy Blue NC,Managed Medicaid,,28.18,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Healthy Blue NC,Managed Medicaid,,0.10210,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Healthy Blue NC,Managed Medicaid,,5.25,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Healthy Blue NC,Managed Medicaid,,1.19,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Healthy Blue NC,Managed Medicaid,,2.11,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Healthy Blue NC,Managed Medicaid,,0.02202,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Healthy Blue NC,Managed Medicaid,,0.16016,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Healthy Blue NC,Managed Medicaid,,1.55,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Healthy Blue NC,Managed Medicaid,,0.15816,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Healthy Blue NC,Managed Medicaid,,0.09409,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Healthy Blue NC,Managed Medicaid,,0.12813,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Healthy Blue NC,Managed Medicaid,,333.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00400,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Healthy Blue NC,Managed Medicaid,,0.01802,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Healthy Blue NC,Managed Medicaid,,0.51451,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Healthy Blue NC,Managed Medicaid,,5.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Healthy Blue NC,Managed Medicaid,,16.31,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Healthy Blue NC,Managed Medicaid,,0.01401,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Healthy Blue NC,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Healthy Blue NC,Managed Medicaid,,1.23,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Healthy Blue NC,Managed Medicaid,,0.22422,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Healthy Blue NC,Managed Medicaid,,0.32232,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Healthy Blue NC,Managed Medicaid,,0.51251,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Healthy Blue NC,Managed Medicaid,,0.35836,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00400,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Healthy Blue NC,Managed Medicaid,,4.42,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Healthy Blue NC,Managed Medicaid,,220.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Healthy Blue NC,Managed Medicaid,,27.01,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Healthy Blue NC,Managed Medicaid,,33.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Healthy Blue NC,Managed Medicaid,,0.02603,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Healthy Blue NC,Managed Medicaid,,7.28,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Healthy Blue NC,Managed Medicaid,,13.07,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Healthy Blue NC,Managed Medicaid,,28.81,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Healthy Blue NC,Managed Medicaid,,12.73,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Healthy Blue NC,Managed Medicaid,,49.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Healthy Blue NC,Managed Medicaid,,2.25,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Healthy Blue NC,Managed Medicaid,,5.10,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Healthy Blue NC,Managed Medicaid,,0.15015,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Healthy Blue NC,Managed Medicaid,,0.00801,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Healthy Blue NC,Managed Medicaid,,3.03,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Healthy Blue NC,Managed Medicaid,,2.67,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Healthy Blue NC,Managed Medicaid,,2.38,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Healthy Blue NC,Managed Medicaid,,3.54,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Healthy Blue NC,Managed Medicaid,,6.68,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Healthy Blue NC,Managed Medicaid,,11.00,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Healthy Blue NC,Managed Medicaid,,27.86,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Healthy Blue NC,Managed Medicaid,,109.85,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Healthy Blue NC,Managed Medicaid,,63.31,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Healthy Blue NC,Managed Medicaid,,74.32,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Healthy Blue NC,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Healthy Blue NC,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Healthy Blue NC,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Healthy Blue NC,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Healthy Blue NC,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Healthy Blue NC,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Healthy Blue NC,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Healthy Blue NC,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Healthy Blue NC,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Healthy Blue NC,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Healthy Blue NC,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Healthy Blue NC,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Healthy Blue NC,Managed Medicaid,,25.72,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Healthy Blue NC,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Healthy Blue NC,Managed Medicaid,,70.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Healthy Blue NC,Managed Medicaid,,77.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Healthy Blue NC,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Healthy Blue NC,Managed Medicaid,,709.51,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Healthy Blue NC,Managed Medicaid,,60.91,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Healthy Blue NC,Managed Medicaid,,8.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Healthy Blue NC,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Healthy Blue NC,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Healthy Blue NC,Managed Medicaid,,483.34,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Healthy Blue NC,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Healthy Blue NC,Managed Medicaid,,94.40,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Healthy Blue NC,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Healthy Blue NC,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Healthy Blue NC,Managed Medicaid,,1045.12,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Healthy Blue NC,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Healthy Blue NC,Managed Medicaid,,16.00,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Healthy Blue NC,Managed Medicaid,,6.74,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Healthy Blue NC,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,,9.41,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Healthy Blue NC,Managed Medicaid,,3.97,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Healthy Blue NC,Managed Medicaid,,5.05,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Healthy Blue NC,Managed Medicaid,,16.08,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Healthy Blue NC,Managed Medicaid,,6.49,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Healthy Blue NC,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Healthy Blue NC,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Healthy Blue NC,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Healthy Blue NC,Managed Medicaid,,87.43,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Healthy Blue NC,Managed Medicaid,,149.79,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Healthy Blue NC,Managed Medicaid,,457.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Healthy Blue NC,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Healthy Blue NC,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Healthy Blue NC,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Healthy Blue NC,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Healthy Blue NC,Managed Medicaid,,9.90,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Healthy Blue NC,Managed Medicaid,,11.52,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Healthy Blue NC,Managed Medicaid,,113.81,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Healthy Blue NC,Managed Medicaid,,4.36,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Healthy Blue NC,Managed Medicaid,,4.93,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Healthy Blue NC,Managed Medicaid,,1.40,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Healthy Blue NC,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Healthy Blue NC,Managed Medicaid,,0.52052,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Healthy Blue NC,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Healthy Blue NC,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Healthy Blue NC,Managed Medicaid,,5.36,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Healthy Blue NC,Managed Medicaid,,6.19,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Healthy Blue NC,Managed Medicaid,,4.76,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Healthy Blue NC,Managed Medicaid,,9.52,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Healthy Blue NC,Managed Medicaid,,5.88,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Healthy Blue NC,Managed Medicaid,,6.48,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Healthy Blue NC,Managed Medicaid,,548.82,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Healthy Blue NC,Managed Medicaid,,3.55,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Healthy Blue NC,Managed Medicaid,,3.35,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Healthy Blue NC,Managed Medicaid,,3.40,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Healthy Blue NC,Managed Medicaid,,4.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Healthy Blue NC,Managed Medicaid,,8.17,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Healthy Blue NC,Managed Medicaid,,368.29,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Healthy Blue NC,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Healthy Blue NC,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Healthy Blue NC,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Healthy Blue NC,Managed Medicaid,,6.56,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Healthy Blue NC,Managed Medicaid,,49.43,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Healthy Blue NC,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Healthy Blue NC,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Healthy Blue NC,Managed Medicaid,,4.55,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Healthy Blue NC,Managed Medicaid,,4068.51,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Healthy Blue NC,Managed Medicaid,,6.41,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Healthy Blue NC,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Healthy Blue NC,Managed Medicaid,,31.60,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Healthy Blue NC,Managed Medicaid,,60.24,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Healthy Blue NC,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Healthy Blue NC,Managed Medicaid,,14.07,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Healthy Blue NC,Managed Medicaid,,16.98,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Healthy Blue NC,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Healthy Blue NC,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Healthy Blue NC,Managed Medicaid,,155.02,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Healthy Blue NC,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Healthy Blue NC,Managed Medicaid,,10.18,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Healthy Blue NC,Managed Medicaid,,13.78,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Healthy Blue NC,Managed Medicaid,,13.34,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Healthy Blue NC,Managed Medicaid,,14.46,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Healthy Blue NC,Managed Medicaid,,7.94,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Healthy Blue NC,Managed Medicaid,,5.64,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Healthy Blue NC,Managed Medicaid,,12179.59,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Healthy Blue NC,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Healthy Blue NC,Managed Medicaid,,31.70,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Healthy Blue NC,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Healthy Blue NC,Managed Medicaid,,104.15,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Healthy Blue NC,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Healthy Blue NC,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Healthy Blue NC,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Healthy Blue NC,Managed Medicaid,,9.99,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Healthy Blue NC,Managed Medicaid,,12.25,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Healthy Blue NC,Managed Medicaid,,16.79,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Healthy Blue NC,Managed Medicaid,,21.31,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Healthy Blue NC,Managed Medicaid,,25.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Healthy Blue NC,Managed Medicaid,,14.18,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Healthy Blue NC,Managed Medicaid,,15.24,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Healthy Blue NC,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Healthy Blue NC,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Healthy Blue NC,Managed Medicaid,,247.33,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Healthy Blue NC,Managed Medicaid,,468.68,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Healthy Blue NC,Managed Medicaid,,1.70,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Healthy Blue NC,Managed Medicaid,,34.23,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Healthy Blue NC,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Healthy Blue NC,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Healthy Blue NC,Managed Medicaid,,4.12,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Healthy Blue NC,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Healthy Blue NC,Managed Medicaid,,7.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Healthy Blue NC,Managed Medicaid,,14.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,,24.62,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Healthy Blue NC,Managed Medicaid,,611.76,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Healthy Blue NC,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Healthy Blue NC,Managed Medicaid,,269.35,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Healthy Blue NC,Managed Medicaid,,4.30,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Healthy Blue NC,Managed Medicaid,,12.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Healthy Blue NC,Managed Medicaid,,7.13,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Healthy Blue NC,Managed Medicaid,,6.68,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Healthy Blue NC,Managed Medicaid,,6.82,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Healthy Blue NC,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Healthy Blue NC,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Healthy Blue NC,Managed Medicaid,,484.62,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Healthy Blue NC,Managed Medicaid,,1297.10,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Healthy Blue NC,Managed Medicaid,,33.63,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Healthy Blue NC,Managed Medicaid,,5.52,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Healthy Blue NC,Managed Medicaid,,12.75,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Healthy Blue NC,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Healthy Blue NC,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Healthy Blue NC,Managed Medicaid,,5.51,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Healthy Blue NC,Managed Medicaid,,6.30,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Healthy Blue NC,Managed Medicaid,,31.51,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Healthy Blue NC,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Healthy Blue NC,Managed Medicaid,,20.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Healthy Blue NC,Managed Medicaid,,117.13,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Healthy Blue NC,Managed Medicaid,,36.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Healthy Blue NC,Managed Medicaid,,52.11,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Healthy Blue NC,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthy Blue NC,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Healthy Blue NC,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Healthy Blue NC,Managed Medicaid,,20.21,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Healthy Blue NC,Managed Medicaid,,35.74,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Healthy Blue NC,Managed Medicaid,,105.20,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Healthy Blue NC,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Healthy Blue NC,Managed Medicaid,,20.25,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Healthy Blue NC,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Healthy Blue NC,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Healthy Blue NC,Managed Medicaid,,176.48,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Healthy Blue NC,Managed Medicaid,,11.71,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Healthy Blue NC,Managed Medicaid,,179.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Healthy Blue NC,Managed Medicaid,,285.22,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Healthy Blue NC,Managed Medicaid,,426.24,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Healthy Blue NC,Managed Medicaid,,708.25,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Healthy Blue NC,Managed Medicaid,,1413.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Healthy Blue NC,Managed Medicaid,,2118.34,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Healthy Blue NC,Managed Medicaid,,339.37,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Healthy Blue NC,Managed Medicaid,,1650.91,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Healthy Blue NC,Managed Medicaid,,6438.44,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Healthy Blue NC,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Healthy Blue NC,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Healthy Blue NC,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Healthy Blue NC,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Healthy Blue NC,Managed Medicaid,,1763.13,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Healthy Blue NC,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Healthy Blue NC,Managed Medicaid,,16.68,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Healthy Blue NC,Managed Medicaid,,20.29,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Healthy Blue NC,Managed Medicaid,,30.82,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Healthy Blue NC,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Healthy Blue NC,Managed Medicaid,,3.74,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Healthy Blue NC,Managed Medicaid,,23.20,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Healthy Blue NC,Managed Medicaid,,28.42,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Healthy Blue NC,Managed Medicaid,,177.12,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Healthy Blue NC,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Healthy Blue NC,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Healthy Blue NC,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Healthy Blue NC,Managed Medicaid,,197.30,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Healthy Blue NC,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Healthy Blue NC,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Healthy Blue NC,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Healthy Blue NC,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Healthy Blue NC,Managed Medicaid,,20.15,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Healthy Blue NC,Managed Medicaid,,38.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Healthy Blue NC,Managed Medicaid,,2654.78,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Healthy Blue NC,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Healthy Blue NC,Managed Medicaid,,2.75,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Healthy Blue NC,Managed Medicaid,,449.52,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Healthy Blue NC,Managed Medicaid,,17.23,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Healthy Blue NC,Managed Medicaid,,142.12,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Healthy Blue NC,Managed Medicaid,,42.80,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Healthy Blue NC,Managed Medicaid,,12.13,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Healthy Blue NC,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Healthy Blue NC,Managed Medicaid,,36.93,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Healthy Blue NC,Managed Medicaid,,44.98,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Healthy Blue NC,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Healthy Blue NC,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Healthy Blue NC,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Healthy Blue NC,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Healthy Blue NC,Managed Medicaid,,0.62062,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Healthy Blue NC,Managed Medicaid,,16.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Healthy Blue NC,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Healthy Blue NC,Managed Medicaid,,15.28,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Healthy Blue NC,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Healthy Blue NC,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Healthy Blue NC,Managed Medicaid,,21.02,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Healthy Blue NC,Managed Medicaid,,94.41,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Healthy Blue NC,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Healthy Blue NC,Managed Medicaid,,56.41,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Healthy Blue NC,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Healthy Blue NC,Managed Medicaid,,11220.92,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Healthy Blue NC,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Healthy Blue NC,Managed Medicaid,,893.81,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Healthy Blue NC,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Healthy Blue NC,Managed Medicaid,,14.13,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Healthy Blue NC,Managed Medicaid,,5.40,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Healthy Blue NC,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Healthy Blue NC,Managed Medicaid,,6.29,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Healthy Blue NC,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Healthy Blue NC,Managed Medicaid,,13.56,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Healthy Blue NC,Managed Medicaid,,5.97,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Healthy Blue NC,Managed Medicaid,,223.00,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Healthy Blue NC,Managed Medicaid,,366.37,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Healthy Blue NC,Managed Medicaid,,63.28,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Healthy Blue NC,Managed Medicaid,,94.95,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Healthy Blue NC,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Healthy Blue NC,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Healthy Blue NC,Managed Medicaid,,142.19,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Healthy Blue NC,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Healthy Blue NC,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Healthy Blue NC,Managed Medicaid,,113.11,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Healthy Blue NC,Managed Medicaid,,239.91,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Healthy Blue NC,Managed Medicaid,,0.82082,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Healthy Blue NC,Managed Medicaid,,113.87,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Healthy Blue NC,Managed Medicaid,,22.42,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Healthy Blue NC,Managed Medicaid,,33.63,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Healthy Blue NC,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Healthy Blue NC,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Healthy Blue NC,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Healthy Blue NC,Managed Medicaid,,122.05,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Healthy Blue NC,Managed Medicaid,,31.90,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Healthy Blue NC,Managed Medicaid,,17.42,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Healthy Blue NC,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Healthy Blue NC,Managed Medicaid,,4.22,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Healthy Blue NC,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Healthy Blue NC,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Healthy Blue NC,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Healthy Blue NC,Managed Medicaid,,6.85,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Healthy Blue NC,Managed Medicaid,,24.72,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Healthy Blue NC,Managed Medicaid,,25.00,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Healthy Blue NC,Managed Medicaid,,9.78,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Healthy Blue NC,Managed Medicaid,,12.40,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Healthy Blue NC,Managed Medicaid,,6.32,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Healthy Blue NC,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Healthy Blue NC,Managed Medicaid,,76.08,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Healthy Blue NC,Managed Medicaid,,182.24,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Healthy Blue NC,Managed Medicaid,,33.58,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Healthy Blue NC,Managed Medicaid,,64.10,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Healthy Blue NC,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Healthy Blue NC,Managed Medicaid,,120.93,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Healthy Blue NC,Managed Medicaid,,5085.99,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Healthy Blue NC,Managed Medicaid,,371.29,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Healthy Blue NC,Managed Medicaid,,4.20,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Healthy Blue NC,Managed Medicaid,,192.56,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Healthy Blue NC,Managed Medicaid,,4.99,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Healthy Blue NC,Managed Medicaid,,16.95,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Healthy Blue NC,Managed Medicaid,,7.22,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Healthy Blue NC,Managed Medicaid,,330.57,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Healthy Blue NC,Managed Medicaid,,6063.10,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Healthy Blue NC,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Healthy Blue NC,Managed Medicaid,,6.34,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Healthy Blue NC,Managed Medicaid,,10.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Healthy Blue NC,Managed Medicaid,,7.62,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Healthy Blue NC,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Healthy Blue NC,Managed Medicaid,,14.42,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Healthy Blue NC,Managed Medicaid,,15.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Healthy Blue NC,Managed Medicaid,,37.17,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Healthy Blue NC,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Healthy Blue NC,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Healthy Blue NC,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Healthy Blue NC,Managed Medicaid,,64.17,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Healthy Blue NC,Managed Medicaid,,87.69,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Healthy Blue NC,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Healthy Blue NC,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Healthy Blue NC,Managed Medicaid,,413.11,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Healthy Blue NC,Managed Medicaid,,549.75,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Healthy Blue NC,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Healthy Blue NC,Managed Medicaid,,39.28,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Healthy Blue NC,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Healthy Blue NC,Managed Medicaid,,0.54054,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Healthy Blue NC,Managed Medicaid,,12.01,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Healthy Blue NC,Managed Medicaid,,6.45,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Healthy Blue NC,Managed Medicaid,,4.46,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Healthy Blue NC,Managed Medicaid,,17.53,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Healthy Blue NC,Managed Medicaid,,23.06,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Healthy Blue NC,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Healthy Blue NC,Managed Medicaid,,9.95,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Healthy Blue NC,Managed Medicaid,,7.23,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Healthy Blue NC,Managed Medicaid,,29.62,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Healthy Blue NC,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Healthy Blue NC,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Healthy Blue NC,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Healthy Blue NC,Managed Medicaid,,41.45,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Healthy Blue NC,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Healthy Blue NC,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Healthy Blue NC,Managed Medicaid,,6.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Healthy Blue NC,Managed Medicaid,,110.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Healthy Blue NC,Managed Medicaid,,5.37,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Healthy Blue NC,Managed Medicaid,,4.79,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Healthy Blue NC,Managed Medicaid,,5.90,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Healthy Blue NC,Managed Medicaid,,8.63,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Healthy Blue NC,Managed Medicaid,,10.70,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Healthy Blue NC,Managed Medicaid,,12.18,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Healthy Blue NC,Managed Medicaid,,35.74,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Healthy Blue NC,Managed Medicaid,,101.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Healthy Blue NC,Managed Medicaid,,10.63,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Healthy Blue NC,Managed Medicaid,,4.94,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Healthy Blue NC,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Healthy Blue NC,Managed Medicaid,,12.26,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Healthy Blue NC,Managed Medicaid,,5.59,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Healthy Blue NC,Managed Medicaid,,34.07,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Healthy Blue NC,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Healthy Blue NC,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Healthy Blue NC,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Healthy Blue NC,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Healthy Blue NC,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Healthy Blue NC,Managed Medicaid,,23675.99,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Healthy Blue NC,Managed Medicaid,,25.12,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Healthy Blue NC,Managed Medicaid,,150.32,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Healthy Blue NC,Managed Medicaid,,2.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Healthy Blue NC,Managed Medicaid,,2.99,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Healthy Blue NC,Managed Medicaid,,15.35,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Healthy Blue NC,Managed Medicaid,,1.07,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Healthy Blue NC,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Healthy Blue NC,Managed Medicaid,,8.04,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Healthy Blue NC,Managed Medicaid,,8.95,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Healthy Blue NC,Managed Medicaid,,7.29,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Healthy Blue NC,Managed Medicaid,,17.00,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Healthy Blue NC,Managed Medicaid,,16.97,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Healthy Blue NC,Managed Medicaid,,17.00,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Healthy Blue NC,Managed Medicaid,,16.61,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Healthy Blue NC,Managed Medicaid,,210.68,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Healthy Blue NC,Managed Medicaid,,1079.07,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Healthy Blue NC,Managed Medicaid,,728.09,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Healthy Blue NC,Managed Medicaid,,6.63,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Healthy Blue NC,Managed Medicaid,,3156.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Healthy Blue NC,Managed Medicaid,,0.58058,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Healthy Blue NC,Managed Medicaid,,4.21,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Healthy Blue NC,Managed Medicaid,,86.25,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Healthy Blue NC,Managed Medicaid,,47.35,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Healthy Blue NC,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Healthy Blue NC,Managed Medicaid,,21.62,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Healthy Blue NC,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Healthy Blue NC,Managed Medicaid,,28.88,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Healthy Blue NC,Managed Medicaid,,58.02,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Healthy Blue NC,Managed Medicaid,,535.27,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Healthy Blue NC,Managed Medicaid,,17.52,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Healthy Blue NC,Managed Medicaid,,1.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Healthy Blue NC,Managed Medicaid,,667.95,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Healthy Blue NC,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Healthy Blue NC,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Healthy Blue NC,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Healthy Blue NC,Managed Medicaid,,163.80,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Healthy Blue NC,Managed Medicaid,,64.00,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Healthy Blue NC,Managed Medicaid,,197.18,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Healthy Blue NC,Managed Medicaid,,5.03,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Healthy Blue NC,Managed Medicaid,,272.42,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Healthy Blue NC,Managed Medicaid,,17.52,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Healthy Blue NC,Managed Medicaid,,43.51,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Healthy Blue NC,Managed Medicaid,,7.69,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Healthy Blue NC,Managed Medicaid,,7.85,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Healthy Blue NC,Managed Medicaid,,1250.81,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Healthy Blue NC,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Healthy Blue NC,Managed Medicaid,,4.16,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Healthy Blue NC,Managed Medicaid,,1902.78,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Healthy Blue NC,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Healthy Blue NC,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Healthy Blue NC,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Healthy Blue NC,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Healthy Blue NC,Managed Medicaid,,52.45,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Healthy Blue NC,Managed Medicaid,,70.57,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Healthy Blue NC,Managed Medicaid,,2.17,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Healthy Blue NC,Managed Medicaid,,59.78,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Healthy Blue NC,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Healthy Blue NC,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Healthy Blue NC,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Healthy Blue NC,Managed Medicaid,,9.27,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Healthy Blue NC,Managed Medicaid,,43.77,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Healthy Blue NC,Managed Medicaid,,35.92,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Healthy Blue NC,Managed Medicaid,,19.98,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Healthy Blue NC,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Healthy Blue NC,Managed Medicaid,,31.22,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Healthy Blue NC,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Healthy Blue NC,Managed Medicaid,,4.40,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Healthy Blue NC,Managed Medicaid,,12.96,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Healthy Blue NC,Managed Medicaid,,2397.64,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Healthy Blue NC,Managed Medicaid,,11.54,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Healthy Blue NC,Managed Medicaid,,6.85,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Healthy Blue NC,Managed Medicaid,,16.12,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Healthy Blue NC,Managed Medicaid,,4.73,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Healthy Blue NC,Managed Medicaid,,1945.70,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Healthy Blue NC,Managed Medicaid,,50.03,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Healthy Blue NC,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Healthy Blue NC,Managed Medicaid,,1.47,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Healthy Blue NC,Managed Medicaid,,27.60,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Healthy Blue NC,Managed Medicaid,,3.70,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Healthy Blue NC,Managed Medicaid,,16.17,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Healthy Blue NC,Managed Medicaid,,17.22,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Healthy Blue NC,Managed Medicaid,,36.04,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Healthy Blue NC,Managed Medicaid,,19.45,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Healthy Blue NC,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Healthy Blue NC,Managed Medicaid,,31.84,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Healthy Blue NC,Managed Medicaid,,18.79,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Healthy Blue NC,Managed Medicaid,,14.10,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Healthy Blue NC,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Healthy Blue NC,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Healthy Blue NC,Managed Medicaid,,16.83,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Healthy Blue NC,Managed Medicaid,,2.36,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Healthy Blue NC,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Healthy Blue NC,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Healthy Blue NC,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Healthy Blue NC,Managed Medicaid,,2.21,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Healthy Blue NC,Managed Medicaid,,1641.62,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Healthy Blue NC,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Healthy Blue NC,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Healthy Blue NC,Managed Medicaid,,12.35,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Healthy Blue NC,Managed Medicaid,,74.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Healthy Blue NC,Managed Medicaid,,38.55,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Healthy Blue NC,Managed Medicaid,,14.08,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Healthy Blue NC,Managed Medicaid,,13.27,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Healthy Blue NC,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Healthy Blue NC,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Healthy Blue NC,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Healthy Blue NC,Managed Medicaid,,5.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Healthy Blue NC,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Healthy Blue NC,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Healthy Blue NC,Managed Medicaid,,22.60,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Healthy Blue NC,Managed Medicaid,,26.46,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Healthy Blue NC,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Healthy Blue NC,Managed Medicaid,,18.05,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Healthy Blue NC,Managed Medicaid,,29.76,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Healthy Blue NC,Managed Medicaid,,8.92,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Healthy Blue NC,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Healthy Blue NC,Managed Medicaid,,4.05,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Healthy Blue NC,Managed Medicaid,,69.27,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Healthy Blue NC,Managed Medicaid,,253.03,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Healthy Blue NC,Managed Medicaid,,4.61,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Healthy Blue NC,Managed Medicaid,,90.65,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Healthy Blue NC,Managed Medicaid,,181.74,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Healthy Blue NC,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Healthy Blue NC,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Healthy Blue NC,Managed Medicaid,,1.78,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Healthy Blue NC,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Healthy Blue NC,Managed Medicaid,,48.18,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Healthy Blue NC,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Healthy Blue NC,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Healthy Blue NC,Managed Medicaid,,18.93,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Healthy Blue NC,Managed Medicaid,,5.67,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Healthy Blue NC,Managed Medicaid,,26.98,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Healthy Blue NC,Managed Medicaid,,28.38,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Healthy Blue NC,Managed Medicaid,,8.76,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Healthy Blue NC,Managed Medicaid,,69.80,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Healthy Blue NC,Managed Medicaid,,4.19,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Healthy Blue NC,Managed Medicaid,,3.75,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Healthy Blue NC,Managed Medicaid,,28.38,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Healthy Blue NC,Managed Medicaid,,32.93,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Healthy Blue NC,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Healthy Blue NC,Managed Medicaid,,0.64064,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Healthy Blue NC,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Healthy Blue NC,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Healthy Blue NC,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Healthy Blue NC,Managed Medicaid,,18.36,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Healthy Blue NC,Managed Medicaid,,15.96,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Healthy Blue NC,Managed Medicaid,,94.29,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Healthy Blue NC,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Healthy Blue NC,Managed Medicaid,,4.64,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Healthy Blue NC,Managed Medicaid,,4.70,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Healthy Blue NC,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Healthy Blue NC,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Healthy Blue NC,Managed Medicaid,,2779.01,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Healthy Blue NC,Managed Medicaid,,60.82,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Healthy Blue NC,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Healthy Blue NC,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Healthy Blue NC,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Healthy Blue NC,Managed Medicaid,,813.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Healthy Blue NC,Managed Medicaid,,22.63,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Healthy Blue NC,Managed Medicaid,,23.59,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Healthy Blue NC,Managed Medicaid,,3569.45,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Healthy Blue NC,Managed Medicaid,,5678.07,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Healthy Blue NC,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Healthy Blue NC,Managed Medicaid,,1.23,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Healthy Blue NC,Managed Medicaid,,29.52,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Healthy Blue NC,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Healthy Blue NC,Managed Medicaid,,8.31,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Healthy Blue NC,Managed Medicaid,,4.74,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Healthy Blue NC,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Healthy Blue NC,Managed Medicaid,,32.33,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Healthy Blue NC,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Healthy Blue NC,Managed Medicaid,,19.60,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Healthy Blue NC,Managed Medicaid,,18.87,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Healthy Blue NC,Managed Medicaid,,916.12,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Healthy Blue NC,Managed Medicaid,,30.63,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Healthy Blue NC,Managed Medicaid,,4.81,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Healthy Blue NC,Managed Medicaid,,0.96096,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Healthy Blue NC,Managed Medicaid,,65.28,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Healthy Blue NC,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Healthy Blue NC,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Healthy Blue NC,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Healthy Blue NC,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Healthy Blue NC,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Healthy Blue NC,Managed Medicaid,,110.10,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Healthy Blue NC,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Healthy Blue NC,Managed Medicaid,,4.47,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Healthy Blue NC,Managed Medicaid,,0.37037,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Healthy Blue NC,Managed Medicaid,,16.84,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Healthy Blue NC,Managed Medicaid,,64.93,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Healthy Blue NC,Managed Medicaid,,98.80,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Healthy Blue NC,Managed Medicaid,,4.09,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Healthy Blue NC,Managed Medicaid,,71.50,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Healthy Blue NC,Managed Medicaid,,105.65,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Healthy Blue NC,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Healthy Blue NC,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Healthy Blue NC,Managed Medicaid,,73.80,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Healthy Blue NC,Managed Medicaid,,1279.76,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Healthy Blue NC,Managed Medicaid,,5.69,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Healthy Blue NC,Managed Medicaid,,1377.08,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Healthy Blue NC,Managed Medicaid,,6665.14,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Healthy Blue NC,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Healthy Blue NC,Managed Medicaid,,11.01,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Healthy Blue NC,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Healthy Blue NC,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Healthy Blue NC,Managed Medicaid,,7882.80,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Healthy Blue NC,Managed Medicaid,,1623.83,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Healthy Blue NC,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Healthy Blue NC,Managed Medicaid,,76.35,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Healthy Blue NC,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Healthy Blue NC,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Healthy Blue NC,Managed Medicaid,,419.08,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Healthy Blue NC,Managed Medicaid,,2799.47,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Healthy Blue NC,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Healthy Blue NC,Managed Medicaid,,92.54,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Healthy Blue NC,Managed Medicaid,,219.22,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Healthy Blue NC,Managed Medicaid,,49.55,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Healthy Blue NC,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Healthy Blue NC,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Healthy Blue NC,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Healthy Blue NC,Managed Medicaid,,48.28,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Healthy Blue NC,Managed Medicaid,,61.64,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Healthy Blue NC,Managed Medicaid,,81.44,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthy Blue NC,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Healthy Blue NC,Managed Medicaid,,162.03,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Healthy Blue NC,Managed Medicaid,,1221.21,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Healthy Blue NC,Managed Medicaid,,2970.42,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Healthy Blue NC,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Healthy Blue NC,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Healthy Blue NC,Managed Medicaid,,146.38,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Healthy Blue NC,Managed Medicaid,,7.91,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Healthy Blue NC,Managed Medicaid,,9.55,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Healthy Blue NC,Managed Medicaid,,10.92,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Healthy Blue NC,Managed Medicaid,,15.56,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Healthy Blue NC,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Healthy Blue NC,Managed Medicaid,,5250.24,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Healthy Blue NC,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Healthy Blue NC,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Healthy Blue NC,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Healthy Blue NC,Managed Medicaid,,21.88,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Healthy Blue NC,Managed Medicaid,,356.36,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Healthy Blue NC,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Healthy Blue NC,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Healthy Blue NC,Managed Medicaid,,4208.24,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Healthy Blue NC,Managed Medicaid,,6299.92,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Healthy Blue NC,Managed Medicaid,,3212.74,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Healthy Blue NC,Managed Medicaid,,361.87,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Healthy Blue NC,Managed Medicaid,,750.14,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Healthy Blue NC,Managed Medicaid,,1.62,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Healthy Blue NC,Managed Medicaid,,18.92,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Healthy Blue NC,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Healthy Blue NC,Managed Medicaid,,783.62,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Healthy Blue NC,Managed Medicaid,,16833.42,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Healthy Blue NC,Managed Medicaid,,396.12,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Healthy Blue NC,Managed Medicaid,,98.74,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Healthy Blue NC,Managed Medicaid,,926.81,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Healthy Blue NC,Managed Medicaid,,1838.20,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Healthy Blue NC,Managed Medicaid,,915.21,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Healthy Blue NC,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Healthy Blue NC,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Healthy Blue NC,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Healthy Blue NC,Managed Medicaid,,403.08,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Healthy Blue NC,Managed Medicaid,,253.12,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Healthy Blue NC,Managed Medicaid,,8.87,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Healthy Blue NC,Managed Medicaid,,25.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Healthy Blue NC,Managed Medicaid,,16.86,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Healthy Blue NC,Managed Medicaid,,15.22,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Healthy Blue NC,Managed Medicaid,,2157.77,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Healthy Blue NC,Managed Medicaid,,2679.20,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Healthy Blue NC,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Healthy Blue NC,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Healthy Blue NC,Managed Medicaid,,11.51,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Healthy Blue NC,Managed Medicaid,,3285.05,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Healthy Blue NC,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Healthy Blue NC,Managed Medicaid,,19.57,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Healthy Blue NC,Managed Medicaid,,29.49,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Healthy Blue NC,Managed Medicaid,,11.91,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Healthy Blue NC,Managed Medicaid,,2234.18,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Healthy Blue NC,Managed Medicaid,,208.06,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Healthy Blue NC,Managed Medicaid,,127.22,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Healthy Blue NC,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Healthy Blue NC,Managed Medicaid,,43.75,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Healthy Blue NC,Managed Medicaid,,3.83,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Healthy Blue NC,Managed Medicaid,,175.64,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Healthy Blue NC,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Healthy Blue NC,Managed Medicaid,,808.29,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Healthy Blue NC,Managed Medicaid,,331.70,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Healthy Blue NC,Managed Medicaid,,61.99,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Healthy Blue NC,Managed Medicaid,,2704.88,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Healthy Blue NC,Managed Medicaid,,15.43,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Healthy Blue NC,Managed Medicaid,,57.14,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Healthy Blue NC,Managed Medicaid,,109.23,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Healthy Blue NC,Managed Medicaid,,930.37,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Healthy Blue NC,Managed Medicaid,,42.32,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Healthy Blue NC,Managed Medicaid,,19.15,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Healthy Blue NC,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Healthy Blue NC,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Healthy Blue NC,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Healthy Blue NC,Managed Medicaid,,270.30,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Healthy Blue NC,Managed Medicaid,,24.52,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Healthy Blue NC,Managed Medicaid,,549.99,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Healthy Blue NC,Managed Medicaid,,12.28,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Healthy Blue NC,Managed Medicaid,,216.72,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Healthy Blue NC,Managed Medicaid,,12.27,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Healthy Blue NC,Managed Medicaid,,3207.80,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Healthy Blue NC,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Healthy Blue NC,Managed Medicaid,,38.37,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Healthy Blue NC,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Healthy Blue NC,Managed Medicaid,,73.53,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Healthy Blue NC,Managed Medicaid,,11.51,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Healthy Blue NC,Managed Medicaid,,6.86,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Healthy Blue NC,Managed Medicaid,,7.99,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Healthy Blue NC,Managed Medicaid,,17993.44,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Healthy Blue NC,Managed Medicaid,,1899.64,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Healthy Blue NC,Managed Medicaid,,17368.36,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Healthy Blue NC,Managed Medicaid,,8.97,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Healthy Blue NC,Managed Medicaid,,1427.85,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Healthy Blue NC,Managed Medicaid,,179.52,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Healthy Blue NC,Managed Medicaid,,3838.14,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Healthy Blue NC,Managed Medicaid,,963.00,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Healthy Blue NC,Managed Medicaid,,5848.24,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Healthy Blue NC,Managed Medicaid,,1.33,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Healthy Blue NC,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Healthy Blue NC,Managed Medicaid,,6675.83,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Healthy Blue NC,Managed Medicaid,,14.27,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Healthy Blue NC,Managed Medicaid,,13.75,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Healthy Blue NC,Managed Medicaid,,262.81,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Healthy Blue NC,Managed Medicaid,,903.18,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Healthy Blue NC,Managed Medicaid,,9.57,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Healthy Blue NC,Managed Medicaid,,9727.12,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Healthy Blue NC,Managed Medicaid,,21122.14,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Healthy Blue NC,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Healthy Blue NC,Managed Medicaid,,26.35,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Healthy Blue NC,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Healthy Blue NC,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Healthy Blue NC,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Healthy Blue NC,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Healthy Blue NC,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Healthy Blue NC,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Healthy Blue NC,Managed Medicaid,,39.94,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Healthy Blue NC,Managed Medicaid,,199.70,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Healthy Blue NC,Managed Medicaid,,13.23,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Healthy Blue NC,Managed Medicaid,,133.84,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Healthy Blue NC,Managed Medicaid,,0.94094,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Healthy Blue NC,Managed Medicaid,,3.68,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Healthy Blue NC,Managed Medicaid,,394.84,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Healthy Blue NC,Managed Medicaid,,5329.34,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Healthy Blue NC,Managed Medicaid,,1179.31,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Healthy Blue NC,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Healthy Blue NC,Managed Medicaid,,7051.96,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Healthy Blue NC,Managed Medicaid,,16.03,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Healthy Blue NC,Managed Medicaid,,48.44,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Healthy Blue NC,Managed Medicaid,,77.98,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Healthy Blue NC,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Healthy Blue NC,Managed Medicaid,,11.70,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Healthy Blue NC,Managed Medicaid,,23.30,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Healthy Blue NC,Managed Medicaid,,33.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Healthy Blue NC,Managed Medicaid,,43.39,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Healthy Blue NC,Managed Medicaid,,103.68,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Healthy Blue NC,Managed Medicaid,,405.10,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Healthy Blue NC,Managed Medicaid,,1904.73,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Healthy Blue NC,Managed Medicaid,,105.11,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Healthy Blue NC,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Healthy Blue NC,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Healthy Blue NC,Managed Medicaid,,97.95,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Healthy Blue NC,Managed Medicaid,,4267.77,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Healthy Blue NC,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Healthy Blue NC,Managed Medicaid,,322.39,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Healthy Blue NC,Managed Medicaid,,69.02,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Healthy Blue NC,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Healthy Blue NC,Managed Medicaid,,11.19,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Healthy Blue NC,Managed Medicaid,,1030.23,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Healthy Blue NC,Managed Medicaid,,9678.64,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Healthy Blue NC,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Healthy Blue NC,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Healthy Blue NC,Managed Medicaid,,909.56,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Healthy Blue NC,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Healthy Blue NC,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Healthy Blue NC,Managed Medicaid,,7220.03,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Healthy Blue NC,Managed Medicaid,,586.19,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Healthy Blue NC,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Healthy Blue NC,Managed Medicaid,,4173.39,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Healthy Blue NC,Managed Medicaid,,40.64,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Healthy Blue NC,Managed Medicaid,,57.46,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Healthy Blue NC,Managed Medicaid,,83.99,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Healthy Blue NC,Managed Medicaid,,356.56,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Healthy Blue NC,Managed Medicaid,,16449.48,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Healthy Blue NC,Managed Medicaid,,2513.50,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Healthy Blue NC,Managed Medicaid,,669.68,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Healthy Blue NC,Managed Medicaid,,40.29,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Healthy Blue NC,Managed Medicaid,,9.61,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Healthy Blue NC,Managed Medicaid,,4.77,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Healthy Blue NC,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Healthy Blue NC,Managed Medicaid,,799.89,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Healthy Blue NC,Managed Medicaid,,3779.20,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Healthy Blue NC,Managed Medicaid,,3471.11,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Healthy Blue NC,Managed Medicaid,,10388.06,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Healthy Blue NC,Managed Medicaid,,2075.14,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Healthy Blue NC,Managed Medicaid,,1257.11,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Healthy Blue NC,Managed Medicaid,,21.45,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Healthy Blue NC,Managed Medicaid,,2529.45,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthy Blue NC,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Healthy Blue NC,Managed Medicaid,,2773.87,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Healthy Blue NC,Managed Medicaid,,2216.38,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Healthy Blue NC,Managed Medicaid,,595.39,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Healthy Blue NC,Managed Medicaid,,686.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Healthy Blue NC,Managed Medicaid,,3212.13,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Healthy Blue NC,Managed Medicaid,,15163.67,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Healthy Blue NC,Managed Medicaid,,3042.20,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Healthy Blue NC,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Healthy Blue NC,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Healthy Blue NC,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Healthy Blue NC,Managed Medicaid,,1643.90,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Healthy Blue NC,Managed Medicaid,,3886.53,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Healthy Blue NC,Managed Medicaid,,821.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Healthy Blue NC,Managed Medicaid,,29.85,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Healthy Blue NC,Managed Medicaid,,2313.19,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Healthy Blue NC,Managed Medicaid,,22028.61,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Healthy Blue NC,Managed Medicaid,,433.03,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Healthy Blue NC,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Healthy Blue NC,Managed Medicaid,,8.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Healthy Blue NC,Managed Medicaid,,35.29,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Healthy Blue NC,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Healthy Blue NC,Managed Medicaid,,12313.86,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Healthy Blue NC,Managed Medicaid,,8227.27,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Healthy Blue NC,Managed Medicaid,,13.14,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Healthy Blue NC,Managed Medicaid,,1284.65,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Healthy Blue NC,Managed Medicaid,,3568.15,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Healthy Blue NC,Managed Medicaid,,20151.54,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Healthy Blue NC,Managed Medicaid,,5505.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Healthy Blue NC,Managed Medicaid,,204.15,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Healthy Blue NC,Managed Medicaid,,1350.05,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Healthy Blue NC,Managed Medicaid,,1121.90,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Healthy Blue NC,Managed Medicaid,,1845.18,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Healthy Blue NC,Managed Medicaid,,25003.11,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Healthy Blue NC,Managed Medicaid,,10652.28,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Healthy Blue NC,Managed Medicaid,,4098.29,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Healthy Blue NC,Managed Medicaid,,3408.28,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Healthy Blue NC,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Healthy Blue NC,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Healthy Blue NC,Managed Medicaid,,16.27,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Healthy Blue NC,Managed Medicaid,,174.05,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Healthy Blue NC,Managed Medicaid,,6574.28,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Healthy Blue NC,Managed Medicaid,,21.51,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Healthy Blue NC,Managed Medicaid,,82.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Healthy Blue NC,Managed Medicaid,,3271.31,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Healthy Blue NC,Managed Medicaid,,7294.04,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Healthy Blue NC,Managed Medicaid,,6.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Healthy Blue NC,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Healthy Blue NC,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Healthy Blue NC,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Healthy Blue NC,Managed Medicaid,,148.04,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Healthy Blue NC,Managed Medicaid,,234.94,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Healthy Blue NC,Managed Medicaid,,13639.98,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Healthy Blue NC,Managed Medicaid,,15.22,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Healthy Blue NC,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Healthy Blue NC,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Healthy Blue NC,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Healthy Blue NC,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Healthy Blue NC,Managed Medicaid,,20.83,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Healthy Blue NC,Managed Medicaid,,9258.10,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Healthy Blue NC,Managed Medicaid,,1859.57,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Healthy Blue NC,Managed Medicaid,,104.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Healthy Blue NC,Managed Medicaid,,6029.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Healthy Blue NC,Managed Medicaid,,604.94,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Healthy Blue NC,Managed Medicaid,,16551.88,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Healthy Blue NC,Managed Medicaid,,13041.87,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Healthy Blue NC,Managed Medicaid,,2395.89,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Healthy Blue NC,Managed Medicaid,,4788.40,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Healthy Blue NC,Managed Medicaid,,5984.79,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Healthy Blue NC,Managed Medicaid,,13645.27,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Healthy Blue NC,Managed Medicaid,,188.67,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Healthy Blue NC,Managed Medicaid,,509.79,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Healthy Blue NC,Managed Medicaid,,509.80,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Healthy Blue NC,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Healthy Blue NC,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Healthy Blue NC,Managed Medicaid,,818.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Healthy Blue NC,Managed Medicaid,,295.46,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Healthy Blue NC,Managed Medicaid,,41.72,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Healthy Blue NC,Managed Medicaid,,51.15,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Healthy Blue NC,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Healthy Blue NC,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Healthy Blue NC,Managed Medicaid,,13.87,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Healthy Blue NC,Managed Medicaid,,12710.40,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Healthy Blue NC,Managed Medicaid,,46.93,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Healthy Blue NC,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Healthy Blue NC,Managed Medicaid,,70.56,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Healthy Blue NC,Managed Medicaid,,5351.96,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Healthy Blue NC,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Healthy Blue NC,Managed Medicaid,,2200.82,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Healthy Blue NC,Managed Medicaid,,8765.41,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Healthy Blue NC,Managed Medicaid,,176.78,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Healthy Blue NC,Managed Medicaid,,12260.66,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Healthy Blue NC,Managed Medicaid,,1464.46,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Healthy Blue NC,Managed Medicaid,,51.51,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Healthy Blue NC,Managed Medicaid,,16.27,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Healthy Blue NC,Managed Medicaid,,3.41,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Healthy Blue NC,Managed Medicaid,,3.35,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Healthy Blue NC,Managed Medicaid,,7051.96,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Healthy Blue NC,Managed Medicaid,,4363.51,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Healthy Blue NC,Managed Medicaid,,0.27027,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Healthy Blue NC,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Healthy Blue NC,Managed Medicaid,,72.96,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Healthy Blue NC,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Healthy Blue NC,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Healthy Blue NC,Managed Medicaid,,93.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Healthy Blue NC,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Healthy Blue NC,Managed Medicaid,,9.83,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Healthy Blue NC,Managed Medicaid,,17.85,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Healthy Blue NC,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Healthy Blue NC,Managed Medicaid,,14.69,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Healthy Blue NC,Managed Medicaid,,65.63,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Healthy Blue NC,Managed Medicaid,,7.70,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Healthy Blue NC,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Healthy Blue NC,Managed Medicaid,,5.46,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Healthy Blue NC,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Healthy Blue NC,Managed Medicaid,,0.59059,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Healthy Blue NC,Managed Medicaid,,38.62,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Healthy Blue NC,Managed Medicaid,,2.22,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Healthy Blue NC,Managed Medicaid,,3.91,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Healthy Blue NC,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Healthy Blue NC,Managed Medicaid,,18.87,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Healthy Blue NC,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Healthy Blue NC,Managed Medicaid,,5.45,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Healthy Blue NC,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Healthy Blue NC,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Healthy Blue NC,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Healthy Blue NC,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Healthy Blue NC,Managed Medicaid,,18.23,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Healthy Blue NC,Managed Medicaid,,280.27,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Healthy Blue NC,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Healthy Blue NC,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Healthy Blue NC,Managed Medicaid,,882.66,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Healthy Blue NC,Managed Medicaid,,4193.08,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Healthy Blue NC,Managed Medicaid,,13.60,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Healthy Blue NC,Managed Medicaid,,1273.87,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Healthy Blue NC,Managed Medicaid,,16.80,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Healthy Blue NC,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Healthy Blue NC,Managed Medicaid,,39.60,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Healthy Blue NC,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Healthy Blue NC,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Healthy Blue NC,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Healthy Blue NC,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Healthy Blue NC,Managed Medicaid,,837.33,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Healthy Blue NC,Managed Medicaid,,16.33,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Healthy Blue NC,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Healthy Blue NC,Managed Medicaid,,25.36,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Healthy Blue NC,Managed Medicaid,,94.67,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Healthy Blue NC,Managed Medicaid,,1.93,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Healthy Blue NC,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Healthy Blue NC,Managed Medicaid,,222.82,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Healthy Blue NC,Managed Medicaid,,4.01,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Healthy Blue NC,Managed Medicaid,,4.98,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Healthy Blue NC,Managed Medicaid,,35.58,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Healthy Blue NC,Managed Medicaid,,2.37,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Healthy Blue NC,Managed Medicaid,,17.42,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Healthy Blue NC,Managed Medicaid,,16.37,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Healthy Blue NC,Managed Medicaid,,21.32,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Healthy Blue NC,Managed Medicaid,,21.96,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Healthy Blue NC,Managed Medicaid,,130.98,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Healthy Blue NC,Managed Medicaid,,14.23,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Healthy Blue NC,Managed Medicaid,,14.35,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Healthy Blue NC,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Healthy Blue NC,Managed Medicaid,,14.26,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Healthy Blue NC,Managed Medicaid,,15.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Healthy Blue NC,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Healthy Blue NC,Managed Medicaid,,15.62,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Healthy Blue NC,Managed Medicaid,,412.01,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Healthy Blue NC,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Healthy Blue NC,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Healthy Blue NC,Managed Medicaid,,103.41,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Healthy Blue NC,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Healthy Blue NC,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Healthy Blue NC,Managed Medicaid,,10.79,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Healthy Blue NC,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Healthy Blue NC,Managed Medicaid,,3.75,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Healthy Blue NC,Managed Medicaid,,28.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Healthy Blue NC,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Healthy Blue NC,Managed Medicaid,,84.56,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Healthy Blue NC,Managed Medicaid,,10.15,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Healthy Blue NC,Managed Medicaid,,17.75,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Healthy Blue NC,Managed Medicaid,,4.28,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Healthy Blue NC,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Healthy Blue NC,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Healthy Blue NC,Managed Medicaid,,18.21,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Healthy Blue NC,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Healthy Blue NC,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Healthy Blue NC,Managed Medicaid,,0.38038,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Healthy Blue NC,Managed Medicaid,,4.79,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Healthy Blue NC,Managed Medicaid,,4.48,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Healthy Blue NC,Managed Medicaid,,39.36,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Healthy Blue NC,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Healthy Blue NC,Managed Medicaid,,9.69,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Healthy Blue NC,Managed Medicaid,,5.95,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Healthy Blue NC,Managed Medicaid,,1.50,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Healthy Blue NC,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Healthy Blue NC,Managed Medicaid,,4.15,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Healthy Blue NC,Managed Medicaid,,16.30,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Healthy Blue NC,Managed Medicaid,,0.67067,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Healthy Blue NC,Managed Medicaid,,2.88,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Healthy Blue NC,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Healthy Blue NC,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Healthy Blue NC,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Healthy Blue NC,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Healthy Blue NC,Managed Medicaid,,6.53,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Healthy Blue NC,Managed Medicaid,,15.99,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Healthy Blue NC,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Healthy Blue NC,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Healthy Blue NC,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Healthy Blue NC,Managed Medicaid,,3.98,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Healthy Blue NC,Managed Medicaid,,32.93,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Healthy Blue NC,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Healthy Blue NC,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Healthy Blue NC,Managed Medicaid,,16.89,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Healthy Blue NC,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Healthy Blue NC,Managed Medicaid,,1470.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Healthy Blue NC,Managed Medicaid,,5.63,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Healthy Blue NC,Managed Medicaid,,15.38,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Healthy Blue NC,Managed Medicaid,,6.35,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Healthy Blue NC,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Healthy Blue NC,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Healthy Blue NC,Managed Medicaid,,548.81,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Healthy Blue NC,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Healthy Blue NC,Managed Medicaid,,7.99,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Healthy Blue NC,Managed Medicaid,,5.28,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Healthy Blue NC,Managed Medicaid,,19.45,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Healthy Blue NC,Managed Medicaid,,20.34,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Healthy Blue NC,Managed Medicaid,,29.43,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Healthy Blue NC,Managed Medicaid,,5.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Healthy Blue NC,Managed Medicaid,,236.14,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Healthy Blue NC,Managed Medicaid,,451.45,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Healthy Blue NC,Managed Medicaid,,1156.15,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Healthy Blue NC,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Healthy Blue NC,Managed Medicaid,,443.79,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Healthy Blue NC,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Healthy Blue NC,Managed Medicaid,,45.65,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Healthy Blue NC,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Healthy Blue NC,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Healthy Blue NC,Managed Medicaid,,52.77,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Healthy Blue NC,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Healthy Blue NC,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Healthy Blue NC,Managed Medicaid,,4.62,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Healthy Blue NC,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Healthy Blue NC,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Healthy Blue NC,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Healthy Blue NC,Managed Medicaid,,20.26,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Healthy Blue NC,Managed Medicaid,,121.53,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Healthy Blue NC,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Healthy Blue NC,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Healthy Blue NC,Managed Medicaid,,38.94,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Healthy Blue NC,Managed Medicaid,,39.17,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Healthy Blue NC,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Healthy Blue NC,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Healthy Blue NC,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Healthy Blue NC,Managed Medicaid,,0.78078,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Healthy Blue NC,Managed Medicaid,,7.14,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Healthy Blue NC,Managed Medicaid,,8.69,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Healthy Blue NC,Managed Medicaid,,12.01,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Healthy Blue NC,Managed Medicaid,,16.44,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Healthy Blue NC,Managed Medicaid,,20.96,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Healthy Blue NC,Managed Medicaid,,44.19,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Healthy Blue NC,Managed Medicaid,,2.68,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Healthy Blue NC,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Healthy Blue NC,Managed Medicaid,,202.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Healthy Blue NC,Managed Medicaid,,1.61,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Healthy Blue NC,Managed Medicaid,,22.82,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Healthy Blue NC,Managed Medicaid,,4.63,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Healthy Blue NC,Managed Medicaid,,5.31,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Healthy Blue NC,Managed Medicaid,,150.68,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Healthy Blue NC,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Healthy Blue NC,Managed Medicaid,,61.74,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Healthy Blue NC,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Healthy Blue NC,Managed Medicaid,,18.48,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Healthy Blue NC,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Healthy Blue NC,Managed Medicaid,,4.57,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Healthy Blue NC,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Healthy Blue NC,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Healthy Blue NC,Managed Medicaid,,9.24,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Healthy Blue NC,Managed Medicaid,,10.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Healthy Blue NC,Managed Medicaid,,53.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Healthy Blue NC,Managed Medicaid,,5.59,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Healthy Blue NC,Managed Medicaid,,12.64,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Healthy Blue NC,Managed Medicaid,,119.95,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Healthy Blue NC,Managed Medicaid,,7.56,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Healthy Blue NC,Managed Medicaid,,12.50,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Healthy Blue NC,Managed Medicaid,,704.70,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Healthy Blue NC,Managed Medicaid,,310.71,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Healthy Blue NC,Managed Medicaid,,241.06,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Healthy Blue NC,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Healthy Blue NC,Managed Medicaid,,43.24,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Healthy Blue NC,Managed Medicaid,,23.07,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Healthy Blue NC,Managed Medicaid,,104.89,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Healthy Blue NC,Managed Medicaid,,139.84,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Healthy Blue NC,Managed Medicaid,,240.04,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Healthy Blue NC,Managed Medicaid,,67.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Healthy Blue NC,Managed Medicaid,,69.97,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Healthy Blue NC,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Healthy Blue NC,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Healthy Blue NC,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Healthy Blue NC,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Healthy Blue NC,Managed Medicaid,,3.86,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Healthy Blue NC,Managed Medicaid,,2576.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Healthy Blue NC,Managed Medicaid,,10.49,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Healthy Blue NC,Managed Medicaid,,71.52,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Healthy Blue NC,Managed Medicaid,,13.33,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Healthy Blue NC,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Healthy Blue NC,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Healthy Blue NC,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Healthy Blue NC,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Healthy Blue NC,Managed Medicaid,,5.43,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Healthy Blue NC,Managed Medicaid,,138.74,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Healthy Blue NC,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Healthy Blue NC,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Healthy Blue NC,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Healthy Blue NC,Managed Medicaid,,4.32,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Healthy Blue NC,Managed Medicaid,,16.64,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Healthy Blue NC,Managed Medicaid,,74.00,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Healthy Blue NC,Managed Medicaid,,84.08,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Healthy Blue NC,Managed Medicaid,,5.74,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Healthy Blue NC,Managed Medicaid,,8.49,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Healthy Blue NC,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Healthy Blue NC,Managed Medicaid,,10.70,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Healthy Blue NC,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Healthy Blue NC,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Healthy Blue NC,Managed Medicaid,,24.00,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Healthy Blue NC,Managed Medicaid,,1.26,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Healthy Blue NC,Managed Medicaid,,18.82,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Healthy Blue NC,Managed Medicaid,,17.32,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Healthy Blue NC,Managed Medicaid,,93.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Healthy Blue NC,Managed Medicaid,,63.86,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Healthy Blue NC,Managed Medicaid,,168.96,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Healthy Blue NC,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Healthy Blue NC,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Healthy Blue NC,Managed Medicaid,,53.06,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Healthy Blue NC,Managed Medicaid,,171.88,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Healthy Blue NC,Managed Medicaid,,3998.59,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Healthy Blue NC,Managed Medicaid,,6.77,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Healthy Blue NC,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Healthy Blue NC,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Healthy Blue NC,Managed Medicaid,,36.67,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Healthy Blue NC,Managed Medicaid,,23.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Healthy Blue NC,Managed Medicaid,,5.99,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Healthy Blue NC,Managed Medicaid,,25.10,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Healthy Blue NC,Managed Medicaid,,14.31,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Healthy Blue NC,Managed Medicaid,,38.06,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Healthy Blue NC,Managed Medicaid,,16.93,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Healthy Blue NC,Managed Medicaid,,104.36,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Healthy Blue NC,Managed Medicaid,,11.95,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Healthy Blue NC,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Healthy Blue NC,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Healthy Blue NC,Managed Medicaid,,24.23,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Healthy Blue NC,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Healthy Blue NC,Managed Medicaid,,7.34,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Healthy Blue NC,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Healthy Blue NC,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Healthy Blue NC,Managed Medicaid,,18.69,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Healthy Blue NC,Managed Medicaid,,596.21,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Healthy Blue NC,Managed Medicaid,,7.17,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Healthy Blue NC,Managed Medicaid,,25.76,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Healthy Blue NC,Managed Medicaid,,452.94,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Healthy Blue NC,Managed Medicaid,,8.53,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Healthy Blue NC,Managed Medicaid,,7.02,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Healthy Blue NC,Managed Medicaid,,5.88,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Healthy Blue NC,Managed Medicaid,,11.06,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Healthy Blue NC,Managed Medicaid,,7.25,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Healthy Blue NC,Managed Medicaid,,1047.11,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Healthy Blue NC,Managed Medicaid,,2612.95,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Healthy Blue NC,Managed Medicaid,,5222.67,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Healthy Blue NC,Managed Medicaid,,10442.13,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Healthy Blue NC,Managed Medicaid,,36.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Healthy Blue NC,Managed Medicaid,,80.00,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Healthy Blue NC,Managed Medicaid,,5.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Healthy Blue NC,Managed Medicaid,,10.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Healthy Blue NC,Managed Medicaid,,29.59,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Healthy Blue NC,Managed Medicaid,,63.32,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Healthy Blue NC,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Healthy Blue NC,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Healthy Blue NC,Managed Medicaid,,9.69,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Healthy Blue NC,Managed Medicaid,,10.10,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Healthy Blue NC,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Healthy Blue NC,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Healthy Blue NC,Managed Medicaid,,943.42,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Healthy Blue NC,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Healthy Blue NC,Managed Medicaid,,11.48,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Healthy Blue NC,Managed Medicaid,,26.93,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Healthy Blue NC,Managed Medicaid,,7.44,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Healthy Blue NC,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Healthy Blue NC,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Healthy Blue NC,Managed Medicaid,,4.38,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Healthy Blue NC,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Healthy Blue NC,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Healthy Blue NC,Managed Medicaid,,64.39,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Healthy Blue NC,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Healthy Blue NC,Managed Medicaid,,5.26,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Healthy Blue NC,Managed Medicaid,,7.43,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Healthy Blue NC,Managed Medicaid,,5.58,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Healthy Blue NC,Managed Medicaid,,93.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Healthy Blue NC,Managed Medicaid,,2.26,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Healthy Blue NC,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Healthy Blue NC,Managed Medicaid,,207.18,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Healthy Blue NC,Managed Medicaid,,4.97,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Healthy Blue NC,Managed Medicaid,,4.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Healthy Blue NC,Managed Medicaid,,50.45,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Healthy Blue NC,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Healthy Blue NC,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Healthy Blue NC,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Healthy Blue NC,Managed Medicaid,,3.65,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Healthy Blue NC,Managed Medicaid,,3.93,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Healthy Blue NC,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Healthy Blue NC,Managed Medicaid,,3.53,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Healthy Blue NC,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Healthy Blue NC,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Healthy Blue NC,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Healthy Blue NC,Managed Medicaid,,17.52,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Healthy Blue NC,Managed Medicaid,,1250.97,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Healthy Blue NC,Managed Medicaid,,17.53,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Healthy Blue NC,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Healthy Blue NC,Managed Medicaid,,19.40,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Healthy Blue NC,Managed Medicaid,,21.10,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Healthy Blue NC,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Healthy Blue NC,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Healthy Blue NC,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Healthy Blue NC,Managed Medicaid,,14.13,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Healthy Blue NC,Managed Medicaid,,0.97097,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Healthy Blue NC,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Healthy Blue NC,Managed Medicaid,,5.69,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Healthy Blue NC,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Healthy Blue NC,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Healthy Blue NC,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Healthy Blue NC,Managed Medicaid,,4.72,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Healthy Blue NC,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Healthy Blue NC,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Healthy Blue NC,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Healthy Blue NC,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Healthy Blue NC,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Healthy Blue NC,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Healthy Blue NC,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Healthy Blue NC,Managed Medicaid,,4.66,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Healthy Blue NC,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Healthy Blue NC,Managed Medicaid,,1.67,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Healthy Blue NC,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Healthy Blue NC,Managed Medicaid,,3.22,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Healthy Blue NC,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Healthy Blue NC,Managed Medicaid,,33.91,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Healthy Blue NC,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Healthy Blue NC,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Healthy Blue NC,Managed Medicaid,,3616.45,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthy Blue NC,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Healthy Blue NC,Managed Medicaid,,6.19,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Healthy Blue NC,Managed Medicaid,,151.67,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Healthy Blue NC,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Healthy Blue NC,Managed Medicaid,,28.78,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Healthy Blue NC,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Healthy Blue NC,Managed Medicaid,,301.87,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Healthy Blue NC,Managed Medicaid,,0.70070,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Healthy Blue NC,Managed Medicaid,,21.87,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Healthy Blue NC,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Healthy Blue NC,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Healthy Blue NC,Managed Medicaid,,5.49,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Healthy Blue NC,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Healthy Blue NC,Managed Medicaid,,8.20,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Healthy Blue NC,Managed Medicaid,,278.53,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Healthy Blue NC,Managed Medicaid,,12.20,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Healthy Blue NC,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Healthy Blue NC,Managed Medicaid,,4.76,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Healthy Blue NC,Managed Medicaid,,75.53,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Healthy Blue NC,Managed Medicaid,,96.61,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Healthy Blue NC,Managed Medicaid,,66.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Healthy Blue NC,Managed Medicaid,,107.18,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Healthy Blue NC,Managed Medicaid,,23.54,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Healthy Blue NC,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Healthy Blue NC,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Healthy Blue NC,Managed Medicaid,,5.02,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Healthy Blue NC,Managed Medicaid,,23.24,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Healthy Blue NC,Managed Medicaid,,137.38,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Healthy Blue NC,Managed Medicaid,,321.76,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Healthy Blue NC,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Healthy Blue NC,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Healthy Blue NC,Managed Medicaid,,13.36,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Healthy Blue NC,Managed Medicaid,,13.96,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Healthy Blue NC,Managed Medicaid,,13.51,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Healthy Blue NC,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Healthy Blue NC,Managed Medicaid,,13.96,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Healthy Blue NC,Managed Medicaid,,13.51,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Healthy Blue NC,Managed Medicaid,,30.03,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Healthy Blue NC,Managed Medicaid,,14.71,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Healthy Blue NC,Managed Medicaid,,13.96,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Healthy Blue NC,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Healthy Blue NC,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Healthy Blue NC,Managed Medicaid,,13.36,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Healthy Blue NC,Managed Medicaid,,13.96,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Healthy Blue NC,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Healthy Blue NC,Managed Medicaid,,13.36,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Healthy Blue NC,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Healthy Blue NC,Managed Medicaid,,204.90,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Healthy Blue NC,Managed Medicaid,,4.53,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Healthy Blue NC,Managed Medicaid,,1446.91,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Healthy Blue NC,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Healthy Blue NC,Managed Medicaid,,1119.21,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Healthy Blue NC,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Healthy Blue NC,Managed Medicaid,,3.78,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Healthy Blue NC,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Healthy Blue NC,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Healthy Blue NC,Managed Medicaid,,70.11,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Healthy Blue NC,Managed Medicaid,,248.85,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Healthy Blue NC,Managed Medicaid,,4.56,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Healthy Blue NC,Managed Medicaid,,9.25,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Healthy Blue NC,Managed Medicaid,,1407.53,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Healthy Blue NC,Managed Medicaid,,66.53,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Healthy Blue NC,Managed Medicaid,,61.72,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Healthy Blue NC,Managed Medicaid,,134.84,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Healthy Blue NC,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Healthy Blue NC,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Healthy Blue NC,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Healthy Blue NC,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Healthy Blue NC,Managed Medicaid,,5370.02,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Healthy Blue NC,Managed Medicaid,,64.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Healthy Blue NC,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Healthy Blue NC,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Healthy Blue NC,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Healthy Blue NC,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Healthy Blue NC,Managed Medicaid,,407.41,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,,99.10,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Healthy Blue NC,Managed Medicaid,,199.52,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Healthy Blue NC,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Healthy Blue NC,Managed Medicaid,,15.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Healthy Blue NC,Managed Medicaid,,67.55,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Healthy Blue NC,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Healthy Blue NC,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Healthy Blue NC,Managed Medicaid,,21.09,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Healthy Blue NC,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Healthy Blue NC,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Healthy Blue NC,Managed Medicaid,,3.81,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Healthy Blue NC,Managed Medicaid,,5.34,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Healthy Blue NC,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Healthy Blue NC,Managed Medicaid,,15.22,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Healthy Blue NC,Managed Medicaid,,58.63,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Healthy Blue NC,Managed Medicaid,,4.16,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Healthy Blue NC,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Healthy Blue NC,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Healthy Blue NC,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Healthy Blue NC,Managed Medicaid,,3.90,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Healthy Blue NC,Managed Medicaid,,3.85,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Healthy Blue NC,Managed Medicaid,,20.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Healthy Blue NC,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Healthy Blue NC,Managed Medicaid,,14.29,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Healthy Blue NC,Managed Medicaid,,15.17,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Healthy Blue NC,Managed Medicaid,,14.14,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Healthy Blue NC,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Healthy Blue NC,Managed Medicaid,,12.62,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Healthy Blue NC,Managed Medicaid,,21.90,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Healthy Blue NC,Managed Medicaid,,0.95095,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Healthy Blue NC,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthy Blue NC,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Healthy Blue NC,Managed Medicaid,,217.46,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Healthy Blue NC,Managed Medicaid,,8.91,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Healthy Blue NC,Managed Medicaid,,9.31,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Healthy Blue NC,Managed Medicaid,,6.32,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Healthy Blue NC,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Healthy Blue NC,Managed Medicaid,,7322.31,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Healthy Blue NC,Managed Medicaid,,63.69,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Healthy Blue NC,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Healthy Blue NC,Managed Medicaid,,12.78,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Healthy Blue NC,Managed Medicaid,,23.12,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Healthy Blue NC,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Healthy Blue NC,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Healthy Blue NC,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Healthy Blue NC,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Healthy Blue NC,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Healthy Blue NC,Managed Medicaid,,15.04,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Healthy Blue NC,Managed Medicaid,,21.65,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Healthy Blue NC,Managed Medicaid,,30.68,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Healthy Blue NC,Managed Medicaid,,4.37,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Healthy Blue NC,Managed Medicaid,,3.92,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Healthy Blue NC,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Healthy Blue NC,Managed Medicaid,,40.90,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Healthy Blue NC,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Healthy Blue NC,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Healthy Blue NC,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Healthy Blue NC,Managed Medicaid,,4.79,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Healthy Blue NC,Managed Medicaid,,2740.12,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Healthy Blue NC,Managed Medicaid,,560.36,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Healthy Blue NC,Managed Medicaid,,15.95,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Healthy Blue NC,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Healthy Blue NC,Managed Medicaid,,5.65,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Healthy Blue NC,Managed Medicaid,,15.26,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Healthy Blue NC,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Healthy Blue NC,Managed Medicaid,,20.90,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Healthy Blue NC,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Healthy Blue NC,Managed Medicaid,,12.73,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Healthy Blue NC,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Healthy Blue NC,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Healthy Blue NC,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Healthy Blue NC,Managed Medicaid,,5.71,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Healthy Blue NC,Managed Medicaid,,4.13,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Healthy Blue NC,Managed Medicaid,,4.03,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Healthy Blue NC,Managed Medicaid,,4.05,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Healthy Blue NC,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Healthy Blue NC,Managed Medicaid,,1.42,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Healthy Blue NC,Managed Medicaid,,30.78,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Healthy Blue NC,Managed Medicaid,,81.09,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Healthy Blue NC,Managed Medicaid,,31.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Healthy Blue NC,Managed Medicaid,,160.86,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Healthy Blue NC,Managed Medicaid,,13.25,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Healthy Blue NC,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Healthy Blue NC,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Healthy Blue NC,Managed Medicaid,,14.97,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Healthy Blue NC,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Healthy Blue NC,Managed Medicaid,,18.46,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Healthy Blue NC,Managed Medicaid,,75.28,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Healthy Blue NC,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Healthy Blue NC,Managed Medicaid,,12.88,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Healthy Blue NC,Managed Medicaid,,5.42,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Healthy Blue NC,Managed Medicaid,,22.97,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Healthy Blue NC,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Healthy Blue NC,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Healthy Blue NC,Managed Medicaid,,3.48,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Healthy Blue NC,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Healthy Blue NC,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Healthy Blue NC,Managed Medicaid,,3.47,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Healthy Blue NC,Managed Medicaid,,18.92,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Healthy Blue NC,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Healthy Blue NC,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Healthy Blue NC,Managed Medicaid,,43.16,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Healthy Blue NC,Managed Medicaid,,67.81,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Healthy Blue NC,Managed Medicaid,,167.17,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Healthy Blue NC,Managed Medicaid,,13.06,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Healthy Blue NC,Managed Medicaid,,16.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Healthy Blue NC,Managed Medicaid,,44.56,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Healthy Blue NC,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Healthy Blue NC,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Healthy Blue NC,Managed Medicaid,,25.74,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Healthy Blue NC,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Healthy Blue NC,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Healthy Blue NC,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Healthy Blue NC,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Healthy Blue NC,Managed Medicaid,,63.86,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Healthy Blue NC,Managed Medicaid,,33.71,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Healthy Blue NC,Managed Medicaid,,12.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Healthy Blue NC,Managed Medicaid,,14.55,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Healthy Blue NC,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Healthy Blue NC,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Healthy Blue NC,Managed Medicaid,,17.61,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Healthy Blue NC,Managed Medicaid,,74.49,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Healthy Blue NC,Managed Medicaid,,3.85,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Healthy Blue NC,Managed Medicaid,,13.49,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Healthy Blue NC,Managed Medicaid,,13.69,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Healthy Blue NC,Managed Medicaid,,19.34,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Healthy Blue NC,Managed Medicaid,,6.15,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Healthy Blue NC,Managed Medicaid,,21.33,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Healthy Blue NC,Managed Medicaid,,34.39,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Healthy Blue NC,Managed Medicaid,,20.81,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Healthy Blue NC,Managed Medicaid,,50.13,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Healthy Blue NC,Managed Medicaid,,34.22,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Healthy Blue NC,Managed Medicaid,,16.15,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Healthy Blue NC,Managed Medicaid,,14.08,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Healthy Blue NC,Managed Medicaid,,20.81,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Healthy Blue NC,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Healthy Blue NC,Managed Medicaid,,19.34,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Healthy Blue NC,Managed Medicaid,,21.86,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Healthy Blue NC,Managed Medicaid,,95.86,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Healthy Blue NC,Managed Medicaid,,23.59,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Healthy Blue NC,Managed Medicaid,,113.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Healthy Blue NC,Managed Medicaid,,233.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Healthy Blue NC,Managed Medicaid,,248.73,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Healthy Blue NC,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Healthy Blue NC,Managed Medicaid,,16.74,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Healthy Blue NC,Managed Medicaid,,14.88,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Healthy Blue NC,Managed Medicaid,,30.69,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Healthy Blue NC,Managed Medicaid,,43.74,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Healthy Blue NC,Managed Medicaid,,102.58,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Healthy Blue NC,Managed Medicaid,,192.55,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Healthy Blue NC,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Healthy Blue NC,Managed Medicaid,,20.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Healthy Blue NC,Managed Medicaid,,49.60,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Healthy Blue NC,Managed Medicaid,,13.37,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Healthy Blue NC,Managed Medicaid,,15.65,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Healthy Blue NC,Managed Medicaid,,147.18,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Healthy Blue NC,Managed Medicaid,,3.51,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Healthy Blue NC,Managed Medicaid,,55.10,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Healthy Blue NC,Managed Medicaid,,12.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Healthy Blue NC,Managed Medicaid,,21.04,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Healthy Blue NC,Managed Medicaid,,58.02,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Healthy Blue NC,Managed Medicaid,,35.32,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Healthy Blue NC,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Healthy Blue NC,Managed Medicaid,,24.13,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Healthy Blue NC,Managed Medicaid,,14.29,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Healthy Blue NC,Managed Medicaid,,15.69,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Healthy Blue NC,Managed Medicaid,,36.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Healthy Blue NC,Managed Medicaid,,34.39,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Healthy Blue NC,Managed Medicaid,,15.14,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Healthy Blue NC,Managed Medicaid,,5.85,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Healthy Blue NC,Managed Medicaid,,6.96,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Healthy Blue NC,Managed Medicaid,,14.29,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Healthy Blue NC,Managed Medicaid,,357.36,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Healthy Blue NC,Managed Medicaid,,19.93,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Healthy Blue NC,Managed Medicaid,,5.04,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Healthy Blue NC,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Healthy Blue NC,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Healthy Blue NC,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Healthy Blue NC,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Healthy Blue NC,Managed Medicaid,,34.83,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Healthy Blue NC,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Healthy Blue NC,Managed Medicaid,,4.49,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Healthy Blue NC,Managed Medicaid,,4.50,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Healthy Blue NC,Managed Medicaid,,5.13,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Healthy Blue NC,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Healthy Blue NC,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Healthy Blue NC,Managed Medicaid,,26.24,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Healthy Blue NC,Managed Medicaid,,18.92,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Healthy Blue NC,Managed Medicaid,,27.96,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Healthy Blue NC,Managed Medicaid,,5.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Healthy Blue NC,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Healthy Blue NC,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Healthy Blue NC,Managed Medicaid,,3.55,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Healthy Blue NC,Managed Medicaid,,13.67,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Healthy Blue NC,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Healthy Blue NC,Managed Medicaid,,11.19,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Healthy Blue NC,Managed Medicaid,,16.47,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Healthy Blue NC,Managed Medicaid,,21.29,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Healthy Blue NC,Managed Medicaid,,62.22,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Healthy Blue NC,Managed Medicaid,,15.97,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Healthy Blue NC,Managed Medicaid,,63.91,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Healthy Blue NC,Managed Medicaid,,12.84,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Healthy Blue NC,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Healthy Blue NC,Managed Medicaid,,21.02,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Healthy Blue NC,Managed Medicaid,,14.96,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Healthy Blue NC,Managed Medicaid,,10.41,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Healthy Blue NC,Managed Medicaid,,32.35,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Healthy Blue NC,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Healthy Blue NC,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Healthy Blue NC,Managed Medicaid,,90.46,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Healthy Blue NC,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Healthy Blue NC,Managed Medicaid,,55.38,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Healthy Blue NC,Managed Medicaid,,47.93,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Healthy Blue NC,Managed Medicaid,,14.79,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Healthy Blue NC,Managed Medicaid,,13.15,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Healthy Blue NC,Managed Medicaid,,15.94,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Healthy Blue NC,Managed Medicaid,,11.97,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Healthy Blue NC,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Healthy Blue NC,Managed Medicaid,,49.57,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Healthy Blue NC,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Healthy Blue NC,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Healthy Blue NC,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Healthy Blue NC,Managed Medicaid,,30.76,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Healthy Blue NC,Managed Medicaid,,72.92,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Healthy Blue NC,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Healthy Blue NC,Managed Medicaid,,79.00,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Healthy Blue NC,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Healthy Blue NC,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Healthy Blue NC,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Healthy Blue NC,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Healthy Blue NC,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Healthy Blue NC,Managed Medicaid,,73.55,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Healthy Blue NC,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Healthy Blue NC,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Healthy Blue NC,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Healthy Blue NC,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Healthy Blue NC,Managed Medicaid,,20.26,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Healthy Blue NC,Managed Medicaid,,23.05,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Healthy Blue NC,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Healthy Blue NC,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Healthy Blue NC,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Healthy Blue NC,Managed Medicaid,,39.10,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Healthy Blue NC,Managed Medicaid,,29.27,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthy Blue NC,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Healthy Blue NC,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Healthy Blue NC,Managed Medicaid,,14.73,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Healthy Blue NC,Managed Medicaid,,12.90,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Healthy Blue NC,Managed Medicaid,,82.51,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Healthy Blue NC,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Healthy Blue NC,Managed Medicaid,,34.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Healthy Blue NC,Managed Medicaid,,12.65,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Healthy Blue NC,Managed Medicaid,,23.05,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Healthy Blue NC,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Healthy Blue NC,Managed Medicaid,,5.16,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Healthy Blue NC,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Healthy Blue NC,Managed Medicaid,,317.29,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Healthy Blue NC,Managed Medicaid,,7.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Healthy Blue NC,Managed Medicaid,,95.78,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Healthy Blue NC,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Healthy Blue NC,Managed Medicaid,,3.44,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Healthy Blue NC,Managed Medicaid,,28.89,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Healthy Blue NC,Managed Medicaid,,276.31,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Healthy Blue NC,Managed Medicaid,,14.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Healthy Blue NC,Managed Medicaid,,43.04,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Healthy Blue NC,Managed Medicaid,,119.57,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Healthy Blue NC,Managed Medicaid,,21.86,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Healthy Blue NC,Managed Medicaid,,23.12,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Healthy Blue NC,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Healthy Blue NC,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Healthy Blue NC,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Healthy Blue NC,Managed Medicaid,,13.22,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Healthy Blue NC,Managed Medicaid,,7.31,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Healthy Blue NC,Managed Medicaid,,13.22,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Healthy Blue NC,Managed Medicaid,,9.70,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Healthy Blue NC,Managed Medicaid,,17.78,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Healthy Blue NC,Managed Medicaid,,52.13,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Healthy Blue NC,Managed Medicaid,,23.96,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Healthy Blue NC,Managed Medicaid,,23.67,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Healthy Blue NC,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Healthy Blue NC,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Healthy Blue NC,Managed Medicaid,,6.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Healthy Blue NC,Managed Medicaid,,16.67,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Healthy Blue NC,Managed Medicaid,,13.03,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Healthy Blue NC,Managed Medicaid,,35.71,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Healthy Blue NC,Managed Medicaid,,10.13,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Healthy Blue NC,Managed Medicaid,,46.39,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Healthy Blue NC,Managed Medicaid,,47.60,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Healthy Blue NC,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Healthy Blue NC,Managed Medicaid,,13.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Healthy Blue NC,Managed Medicaid,,4.42,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Healthy Blue NC,Managed Medicaid,,4.56,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Healthy Blue NC,Managed Medicaid,,91.88,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Healthy Blue NC,Managed Medicaid,,5.22,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Healthy Blue NC,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Healthy Blue NC,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Healthy Blue NC,Managed Medicaid,,12.64,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Healthy Blue NC,Managed Medicaid,,12.66,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Healthy Blue NC,Managed Medicaid,,12.67,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Healthy Blue NC,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Healthy Blue NC,Managed Medicaid,,29.01,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Healthy Blue NC,Managed Medicaid,,3.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Healthy Blue NC,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Healthy Blue NC,Managed Medicaid,,13.25,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Healthy Blue NC,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Healthy Blue NC,Managed Medicaid,,91.32,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Healthy Blue NC,Managed Medicaid,,92.51,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Healthy Blue NC,Managed Medicaid,,72.28,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Healthy Blue NC,Managed Medicaid,,15.98,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthy Blue NC,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Healthy Blue NC,Managed Medicaid,,15.14,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Healthy Blue NC,Managed Medicaid,,15.77,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Healthy Blue NC,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Healthy Blue NC,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Healthy Blue NC,Managed Medicaid,,4.97,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Healthy Blue NC,Managed Medicaid,,31.76,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Healthy Blue NC,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Healthy Blue NC,Managed Medicaid,,25.14,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Healthy Blue NC,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Healthy Blue NC,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Healthy Blue NC,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Healthy Blue NC,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Healthy Blue NC,Managed Medicaid,,4.99,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Healthy Blue NC,Managed Medicaid,,146.20,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Healthy Blue NC,Managed Medicaid,,20.36,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Healthy Blue NC,Managed Medicaid,,20.72,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Healthy Blue NC,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Healthy Blue NC,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Healthy Blue NC,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Healthy Blue NC,Managed Medicaid,,7.81,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Healthy Blue NC,Managed Medicaid,,12.31,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Healthy Blue NC,Managed Medicaid,,5.29,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Healthy Blue NC,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Healthy Blue NC,Managed Medicaid,,42.04,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Healthy Blue NC,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Healthy Blue NC,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Healthy Blue NC,Managed Medicaid,,16.48,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Healthy Blue NC,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Healthy Blue NC,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Healthy Blue NC,Managed Medicaid,,13.40,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Healthy Blue NC,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Healthy Blue NC,Managed Medicaid,,6.89,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Healthy Blue NC,Managed Medicaid,,4.13,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Healthy Blue NC,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Healthy Blue NC,Managed Medicaid,,4.79,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Healthy Blue NC,Managed Medicaid,,5.25,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Healthy Blue NC,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Healthy Blue NC,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Healthy Blue NC,Managed Medicaid,,106.37,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Healthy Blue NC,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Healthy Blue NC,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthy Blue NC,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthy Blue NC,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthy Blue NC,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthy Blue NC,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Healthy Blue NC,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Healthy Blue NC,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Healthy Blue NC,Managed Medicaid,,80.87,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Healthy Blue NC,Managed Medicaid,,21.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Healthy Blue NC,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Healthy Blue NC,Managed Medicaid,,4.61,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Healthy Blue NC,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Healthy Blue NC,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Healthy Blue NC,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Healthy Blue NC,Managed Medicaid,,151.55,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Healthy Blue NC,Managed Medicaid,,9.79,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Healthy Blue NC,Managed Medicaid,,5.16,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Healthy Blue NC,Managed Medicaid,,5.23,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Healthy Blue NC,Managed Medicaid,,55.71,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Healthy Blue NC,Managed Medicaid,,11.69,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Healthy Blue NC,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Healthy Blue NC,Managed Medicaid,,3.37,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Healthy Blue NC,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Healthy Blue NC,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Healthy Blue NC,Managed Medicaid,,0.83083,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Healthy Blue NC,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Healthy Blue NC,Managed Medicaid,,55.41,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Healthy Blue NC,Managed Medicaid,,59.75,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Healthy Blue NC,Managed Medicaid,,47.78,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Healthy Blue NC,Managed Medicaid,,52.17,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Healthy Blue NC,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Healthy Blue NC,Managed Medicaid,,58.32,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Healthy Blue NC,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Healthy Blue NC,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Healthy Blue NC,Managed Medicaid,,15.58,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Healthy Blue NC,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Healthy Blue NC,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Healthy Blue NC,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Healthy Blue NC,Managed Medicaid,,9036.23,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Healthy Blue NC,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Healthy Blue NC,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Healthy Blue NC,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Healthy Blue NC,Managed Medicaid,,111.31,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Healthy Blue NC,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Healthy Blue NC,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Healthy Blue NC,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Healthy Blue NC,Managed Medicaid,,9367.61,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Healthy Blue NC,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthy Blue NC,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Healthy Blue NC,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthy Blue NC,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Healthy Blue NC,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Healthy Blue NC,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Healthy Blue NC,Managed Medicaid,,202.69,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthy Blue NC,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthy Blue NC,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Healthy Blue NC,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Healthy Blue NC,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Healthy Blue NC,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Healthy Blue NC,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Healthy Blue NC,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Healthy Blue NC,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Healthy Blue NC,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Healthy Blue NC,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Healthy Blue NC,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Healthy Blue NC,Managed Medicaid,,55.83,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Healthy Blue NC,Managed Medicaid,,8.83,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Healthy Blue NC,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Healthy Blue NC,Managed Medicaid,,38405.96,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Healthy Blue NC,Managed Medicaid,,25.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Healthy Blue NC,Managed Medicaid,,14.11,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Healthy Blue NC,Managed Medicaid,,14.86,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Healthy Blue NC,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Healthy Blue NC,Managed Medicaid,,14.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Healthy Blue NC,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Healthy Blue NC,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Healthy Blue NC,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Healthy Blue NC,Managed Medicaid,,134.33,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Healthy Blue NC,Managed Medicaid,,29.04,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Healthy Blue NC,Managed Medicaid,,147.35,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Healthy Blue NC,Managed Medicaid,,52.74,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Healthy Blue NC,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Healthy Blue NC,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Healthy Blue NC,Managed Medicaid,,1.02,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Healthy Blue NC,Managed Medicaid,,2.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Healthy Blue NC,Managed Medicaid,,16.00,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Healthy Blue NC,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Healthy Blue NC,Managed Medicaid,,92.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Healthy Blue NC,Managed Medicaid,,15.62,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Healthy Blue NC,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Healthy Blue NC,Managed Medicaid,,11.85,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Healthy Blue NC,Managed Medicaid,,7.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Healthy Blue NC,Managed Medicaid,,87.28,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Healthy Blue NC,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Healthy Blue NC,Managed Medicaid,,21.34,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Healthy Blue NC,Managed Medicaid,,116.72,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Healthy Blue NC,Managed Medicaid,,62.81,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Healthy Blue NC,Managed Medicaid,,10.37,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Healthy Blue NC,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Healthy Blue NC,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Healthy Blue NC,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Healthy Blue NC,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Healthy Blue NC,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Healthy Blue NC,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Healthy Blue NC,Managed Medicaid,,6.11,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Healthy Blue NC,Managed Medicaid,,6.13,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Healthy Blue NC,Managed Medicaid,,6.84,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Healthy Blue NC,Managed Medicaid,,7.61,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Healthy Blue NC,Managed Medicaid,,23.04,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Healthy Blue NC,Managed Medicaid,,9.83,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Healthy Blue NC,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Healthy Blue NC,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Healthy Blue NC,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Healthy Blue NC,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Healthy Blue NC,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Healthy Blue NC,Managed Medicaid,,0.43043,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Healthy Blue NC,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Healthy Blue NC,Managed Medicaid,,23.36,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Healthy Blue NC,Managed Medicaid,,46.93,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Healthy Blue NC,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Healthy Blue NC,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Healthy Blue NC,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Healthy Blue NC,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Healthy Blue NC,Managed Medicaid,,6.26,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Healthy Blue NC,Managed Medicaid,,5.94,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Healthy Blue NC,Managed Medicaid,,37.17,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Healthy Blue NC,Managed Medicaid,,15.45,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Healthy Blue NC,Managed Medicaid,,5.99,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Healthy Blue NC,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Healthy Blue NC,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Healthy Blue NC,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Healthy Blue NC,Managed Medicaid,,17.47,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Healthy Blue NC,Managed Medicaid,,17.83,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Healthy Blue NC,Managed Medicaid,,4.68,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Healthy Blue NC,Managed Medicaid,,10.72,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Healthy Blue NC,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Healthy Blue NC,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Healthy Blue NC,Managed Medicaid,,61.46,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Healthy Blue NC,Managed Medicaid,,94.69,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Healthy Blue NC,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Healthy Blue NC,Managed Medicaid,,5.80,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Healthy Blue NC,Managed Medicaid,,21.17,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Healthy Blue NC,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Healthy Blue NC,Managed Medicaid,,3.81,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Healthy Blue NC,Managed Medicaid,,4.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Healthy Blue NC,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Healthy Blue NC,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Healthy Blue NC,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Healthy Blue NC,Managed Medicaid,,14.85,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Healthy Blue NC,Managed Medicaid,,2.70,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Healthy Blue NC,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Healthy Blue NC,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Healthy Blue NC,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Healthy Blue NC,Managed Medicaid,,5.33,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Healthy Blue NC,Managed Medicaid,,6.14,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Healthy Blue NC,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Healthy Blue NC,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Healthy Blue NC,Managed Medicaid,,5.23,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Healthy Blue NC,Managed Medicaid,,4.66,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Healthy Blue NC,Managed Medicaid,,6.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Healthy Blue NC,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Healthy Blue NC,Managed Medicaid,,33.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Healthy Blue NC,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Healthy Blue NC,Managed Medicaid,,25.70,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Healthy Blue NC,Managed Medicaid,,10.75,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Healthy Blue NC,Managed Medicaid,,5.15,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Healthy Blue NC,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Healthy Blue NC,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Healthy Blue NC,Managed Medicaid,,4.65,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Healthy Blue NC,Managed Medicaid,,2.10,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Healthy Blue NC,Managed Medicaid,,4.19,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Healthy Blue NC,Managed Medicaid,,3.59,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Healthy Blue NC,Managed Medicaid,,40.93,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Healthy Blue NC,Managed Medicaid,,49.56,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Healthy Blue NC,Managed Medicaid,,14.79,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Healthy Blue NC,Managed Medicaid,,8.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Healthy Blue NC,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Healthy Blue NC,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Healthy Blue NC,Managed Medicaid,,4.86,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Healthy Blue NC,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Healthy Blue NC,Managed Medicaid,,45.49,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Healthy Blue NC,Managed Medicaid,,20.24,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Healthy Blue NC,Managed Medicaid,,6.85,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Healthy Blue NC,Managed Medicaid,,42.58,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Healthy Blue NC,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Healthy Blue NC,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Healthy Blue NC,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Healthy Blue NC,Managed Medicaid,,4.47,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Healthy Blue NC,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Healthy Blue NC,Managed Medicaid,,14.47,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Healthy Blue NC,Managed Medicaid,,50.57,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Healthy Blue NC,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Healthy Blue NC,Managed Medicaid,,53.99,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Healthy Blue NC,Managed Medicaid,,31.11,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Healthy Blue NC,Managed Medicaid,,17.16,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Healthy Blue NC,Managed Medicaid,,22.03,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Healthy Blue NC,Managed Medicaid,,14.54,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Healthy Blue NC,Managed Medicaid,,37.87,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Healthy Blue NC,Managed Medicaid,,8.98,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Healthy Blue NC,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Healthy Blue NC,Managed Medicaid,,0.61061,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Healthy Blue NC,Managed Medicaid,,82.18,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Healthy Blue NC,Managed Medicaid,,4.41,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Healthy Blue NC,Managed Medicaid,,4.89,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Healthy Blue NC,Managed Medicaid,,29.78,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Healthy Blue NC,Managed Medicaid,,251.45,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Healthy Blue NC,Managed Medicaid,,3.39,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Healthy Blue NC,Managed Medicaid,,4.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Healthy Blue NC,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Healthy Blue NC,Managed Medicaid,,40.54,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Healthy Blue NC,Managed Medicaid,,4.44,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Healthy Blue NC,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Healthy Blue NC,Managed Medicaid,,3.51,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Healthy Blue NC,Managed Medicaid,,4.89,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Healthy Blue NC,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Healthy Blue NC,Managed Medicaid,,24.28,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Healthy Blue NC,Managed Medicaid,,32.33,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Healthy Blue NC,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Healthy Blue NC,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Healthy Blue NC,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Healthy Blue NC,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Healthy Blue NC,Managed Medicaid,,51.39,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Healthy Blue NC,Managed Medicaid,,17.31,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Healthy Blue NC,Managed Medicaid,,5.05,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Healthy Blue NC,Managed Medicaid,,13.10,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Healthy Blue NC,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Healthy Blue NC,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Healthy Blue NC,Managed Medicaid,,0.57057,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Healthy Blue NC,Managed Medicaid,,1.53,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Healthy Blue NC,Managed Medicaid,,18.79,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Healthy Blue NC,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Healthy Blue NC,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Healthy Blue NC,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Healthy Blue NC,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Healthy Blue NC,Managed Medicaid,,189.66,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Healthy Blue NC,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Healthy Blue NC,Managed Medicaid,,71.39,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Healthy Blue NC,Managed Medicaid,,81.01,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Healthy Blue NC,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Healthy Blue NC,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Healthy Blue NC,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Healthy Blue NC,Managed Medicaid,,20.97,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Healthy Blue NC,Managed Medicaid,,13.41,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Healthy Blue NC,Managed Medicaid,,23.35,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Healthy Blue NC,Managed Medicaid,,22.43,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Healthy Blue NC,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Healthy Blue NC,Managed Medicaid,,15.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Healthy Blue NC,Managed Medicaid,,16.52,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Healthy Blue NC,Managed Medicaid,,16.51,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Healthy Blue NC,Managed Medicaid,,19.05,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Healthy Blue NC,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Healthy Blue NC,Managed Medicaid,,27.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Healthy Blue NC,Managed Medicaid,,14.86,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Healthy Blue NC,Managed Medicaid,,85.70,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Healthy Blue NC,Managed Medicaid,,79.04,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Healthy Blue NC,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Healthy Blue NC,Managed Medicaid,,13.81,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Healthy Blue NC,Managed Medicaid,,16.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Healthy Blue NC,Managed Medicaid,,23.16,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Healthy Blue NC,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Healthy Blue NC,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Healthy Blue NC,Managed Medicaid,,1060.77,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Healthy Blue NC,Managed Medicaid,,54.03,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Healthy Blue NC,Managed Medicaid,,143.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Healthy Blue NC,Managed Medicaid,,17.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Healthy Blue NC,Managed Medicaid,,9.15,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Healthy Blue NC,Managed Medicaid,,9.92,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Healthy Blue NC,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Healthy Blue NC,Managed Medicaid,,81.63,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Healthy Blue NC,Managed Medicaid,,396.25,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Healthy Blue NC,Managed Medicaid,,73.63,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Healthy Blue NC,Managed Medicaid,,1.38,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Healthy Blue NC,Managed Medicaid,,129.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Healthy Blue NC,Managed Medicaid,,5.32,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Healthy Blue NC,Managed Medicaid,,15.98,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Healthy Blue NC,Managed Medicaid,,23.79,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Healthy Blue NC,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Healthy Blue NC,Managed Medicaid,,18.98,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Healthy Blue NC,Managed Medicaid,,169.85,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Healthy Blue NC,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Healthy Blue NC,Managed Medicaid,,5.60,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Healthy Blue NC,Managed Medicaid,,5.75,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Healthy Blue NC,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Healthy Blue NC,Managed Medicaid,,1.25,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Healthy Blue NC,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Healthy Blue NC,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Healthy Blue NC,Managed Medicaid,,10.70,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Healthy Blue NC,Managed Medicaid,,570.59,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Healthy Blue NC,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Healthy Blue NC,Managed Medicaid,,4.56,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Healthy Blue NC,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Healthy Blue NC,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Healthy Blue NC,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Healthy Blue NC,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Healthy Blue NC,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Healthy Blue NC,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Healthy Blue NC,Managed Medicaid,,8.13,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Healthy Blue NC,Managed Medicaid,,6.00,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Healthy Blue NC,Managed Medicaid,,11.73,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Healthy Blue NC,Managed Medicaid,,11.10,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Healthy Blue NC,Managed Medicaid,,9.11,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Healthy Blue NC,Managed Medicaid,,41.93,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Healthy Blue NC,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Healthy Blue NC,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Healthy Blue NC,Managed Medicaid,,86.34,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Healthy Blue NC,Managed Medicaid,,98.82,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Healthy Blue NC,Managed Medicaid,,5497.41,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Healthy Blue NC,Managed Medicaid,,18.50,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Healthy Blue NC,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Healthy Blue NC,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Healthy Blue NC,Managed Medicaid,,61.08,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Healthy Blue NC,Managed Medicaid,,1817.11,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Healthy Blue NC,Managed Medicaid,,5.48,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Healthy Blue NC,Managed Medicaid,,24.14,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Healthy Blue NC,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Healthy Blue NC,Managed Medicaid,,21.52,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Healthy Blue NC,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Healthy Blue NC,Managed Medicaid,,11.36,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Healthy Blue NC,Managed Medicaid,,26.31,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Healthy Blue NC,Managed Medicaid,,19.48,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Healthy Blue NC,Managed Medicaid,,88.51,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Healthy Blue NC,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Healthy Blue NC,Managed Medicaid,,12.31,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Healthy Blue NC,Managed Medicaid,,9.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Healthy Blue NC,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Healthy Blue NC,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Healthy Blue NC,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Healthy Blue NC,Managed Medicaid,,102.41,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Healthy Blue NC,Managed Medicaid,,70.69,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Healthy Blue NC,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Healthy Blue NC,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Healthy Blue NC,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Healthy Blue NC,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Healthy Blue NC,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Healthy Blue NC,Managed Medicaid,,6.69,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Healthy Blue NC,Managed Medicaid,,8103.63,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Healthy Blue NC,Managed Medicaid,,113.70,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Healthy Blue NC,Managed Medicaid,,8.19,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Healthy Blue NC,Managed Medicaid,,19.64,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Healthy Blue NC,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Healthy Blue NC,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Healthy Blue NC,Managed Medicaid,,31.01,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Healthy Blue NC,Managed Medicaid,,11.84,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Healthy Blue NC,Managed Medicaid,,5378.81,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Healthy Blue NC,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Healthy Blue NC,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Healthy Blue NC,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Healthy Blue NC,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Healthy Blue NC,Managed Medicaid,,19.84,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Healthy Blue NC,Managed Medicaid,,767.34,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Healthy Blue NC,Managed Medicaid,,0.65065,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Healthy Blue NC,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Healthy Blue NC,Managed Medicaid,,217.13,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Healthy Blue NC,Managed Medicaid,,8.14,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Healthy Blue NC,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Healthy Blue NC,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Healthy Blue NC,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Healthy Blue NC,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Healthy Blue NC,Managed Medicaid,,157.47,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Healthy Blue NC,Managed Medicaid,,8019.54,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Healthy Blue NC,Managed Medicaid,,4011.38,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Healthy Blue NC,Managed Medicaid,,0.79079,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Healthy Blue NC,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Healthy Blue NC,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Healthy Blue NC,Managed Medicaid,,20.41,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Healthy Blue NC,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Healthy Blue NC,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Healthy Blue NC,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Healthy Blue NC,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Healthy Blue NC,Managed Medicaid,,6.81,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Healthy Blue NC,Managed Medicaid,,19.62,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Healthy Blue NC,Managed Medicaid,,25.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Healthy Blue NC,Managed Medicaid,,74.41,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Healthy Blue NC,Managed Medicaid,,18.99,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Healthy Blue NC,Managed Medicaid,,42.04,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Healthy Blue NC,Managed Medicaid,,5.26,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Healthy Blue NC,Managed Medicaid,,10.00,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Healthy Blue NC,Managed Medicaid,,35.09,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Healthy Blue NC,Managed Medicaid,,6.19,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Healthy Blue NC,Managed Medicaid,,162.77,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Healthy Blue NC,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Healthy Blue NC,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Healthy Blue NC,Managed Medicaid,,106.41,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Healthy Blue NC,Managed Medicaid,,16.03,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Healthy Blue NC,Managed Medicaid,,7.52,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Healthy Blue NC,Managed Medicaid,,3.75,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Healthy Blue NC,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Healthy Blue NC,Managed Medicaid,,55.32,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Healthy Blue NC,Managed Medicaid,,9.68,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Healthy Blue NC,Managed Medicaid,,53.33,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Healthy Blue NC,Managed Medicaid,,0.81081,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Healthy Blue NC,Managed Medicaid,,32.01,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthy Blue NC,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthy Blue NC,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Healthy Blue NC,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Healthy Blue NC,Managed Medicaid,,105.45,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Healthy Blue NC,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Healthy Blue NC,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Healthy Blue NC,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Healthy Blue NC,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Healthy Blue NC,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Healthy Blue NC,Managed Medicaid,,15.03,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Healthy Blue NC,Managed Medicaid,,15.11,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Healthy Blue NC,Managed Medicaid,,14.30,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Healthy Blue NC,Managed Medicaid,,5.81,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Healthy Blue NC,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Healthy Blue NC,Managed Medicaid,,4.19,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Healthy Blue NC,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Healthy Blue NC,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Healthy Blue NC,Managed Medicaid,,7.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Healthy Blue NC,Managed Medicaid,,731.93,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Healthy Blue NC,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Healthy Blue NC,Managed Medicaid,,2510.96,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Healthy Blue NC,Managed Medicaid,,5018.69,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Healthy Blue NC,Managed Medicaid,,414.16,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Healthy Blue NC,Managed Medicaid,,551.21,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Healthy Blue NC,Managed Medicaid,,616.62,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Healthy Blue NC,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Healthy Blue NC,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Healthy Blue NC,Managed Medicaid,,86.74,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Healthy Blue NC,Managed Medicaid,,4.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Healthy Blue NC,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Healthy Blue NC,Managed Medicaid,,3.41,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Healthy Blue NC,Managed Medicaid,,3.50,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Healthy Blue NC,Managed Medicaid,,130.73,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Healthy Blue NC,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Healthy Blue NC,Managed Medicaid,,17.24,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Healthy Blue NC,Managed Medicaid,,12.13,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Healthy Blue NC,Managed Medicaid,,149.34,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Healthy Blue NC,Managed Medicaid,,21.02,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Healthy Blue NC,Managed Medicaid,,7.95,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Healthy Blue NC,Managed Medicaid,,12.31,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Healthy Blue NC,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Healthy Blue NC,Managed Medicaid,,4.34,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Healthy Blue NC,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Healthy Blue NC,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,,17.02,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Healthy Blue NC,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Healthy Blue NC,Managed Medicaid,,44.63,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Healthy Blue NC,Managed Medicaid,,63.06,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Healthy Blue NC,Managed Medicaid,,2.96,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Healthy Blue NC,Managed Medicaid,,332.95,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Healthy Blue NC,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Healthy Blue NC,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Healthy Blue NC,Managed Medicaid,,16.42,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Healthy Blue NC,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Healthy Blue NC,Managed Medicaid,,438.24,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Healthy Blue NC,Managed Medicaid,,7.20,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Healthy Blue NC,Managed Medicaid,,53.01,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Healthy Blue NC,Managed Medicaid,,20.92,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Healthy Blue NC,Managed Medicaid,,22.77,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Healthy Blue NC,Managed Medicaid,,9.22,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Healthy Blue NC,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Healthy Blue NC,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Healthy Blue NC,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Healthy Blue NC,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Healthy Blue NC,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Healthy Blue NC,Managed Medicaid,,83.52,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Healthy Blue NC,Managed Medicaid,,307.07,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Healthy Blue NC,Managed Medicaid,,7.71,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Healthy Blue NC,Managed Medicaid,,12.38,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Healthy Blue NC,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Healthy Blue NC,Managed Medicaid,,19.29,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Healthy Blue NC,Managed Medicaid,,60.65,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Healthy Blue NC,Managed Medicaid,,726.37,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Healthy Blue NC,Managed Medicaid,,25.45,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Healthy Blue NC,Managed Medicaid,,42.27,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Healthy Blue NC,Managed Medicaid,,17.83,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Healthy Blue NC,Managed Medicaid,,6.87,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Healthy Blue NC,Managed Medicaid,,12.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Healthy Blue NC,Managed Medicaid,,6.26,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Healthy Blue NC,Managed Medicaid,,40.30,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Healthy Blue NC,Managed Medicaid,,34.84,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Healthy Blue NC,Managed Medicaid,,12.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Healthy Blue NC,Managed Medicaid,,12.98,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Healthy Blue NC,Managed Medicaid,,12.95,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Healthy Blue NC,Managed Medicaid,,47.84,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Healthy Blue NC,Managed Medicaid,,18.24,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Healthy Blue NC,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Healthy Blue NC,Managed Medicaid,,132.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Healthy Blue NC,Managed Medicaid,,77.12,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Healthy Blue NC,Managed Medicaid,,363.01,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Healthy Blue NC,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Healthy Blue NC,Managed Medicaid,,0.92092,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Healthy Blue NC,Managed Medicaid,,435.35,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Healthy Blue NC,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Healthy Blue NC,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Healthy Blue NC,Managed Medicaid,,18.92,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Healthy Blue NC,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Healthy Blue NC,Managed Medicaid,,6.65,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Healthy Blue NC,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Healthy Blue NC,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Healthy Blue NC,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Healthy Blue NC,Managed Medicaid,,15.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Healthy Blue NC,Managed Medicaid,,71.27,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Healthy Blue NC,Managed Medicaid,,11.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Healthy Blue NC,Managed Medicaid,,9.80,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Healthy Blue NC,Managed Medicaid,,1016.27,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Healthy Blue NC,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Healthy Blue NC,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Healthy Blue NC,Managed Medicaid,,128.67,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Healthy Blue NC,Managed Medicaid,,51.03,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Healthy Blue NC,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Healthy Blue NC,Managed Medicaid,,19.13,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Healthy Blue NC,Managed Medicaid,,5.04,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Healthy Blue NC,Managed Medicaid,,33.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Healthy Blue NC,Managed Medicaid,,17.08,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Healthy Blue NC,Managed Medicaid,,20.59,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Healthy Blue NC,Managed Medicaid,,5.10,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Healthy Blue NC,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Healthy Blue NC,Managed Medicaid,,483.85,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Healthy Blue NC,Managed Medicaid,,805.26,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Healthy Blue NC,Managed Medicaid,,97.34,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Healthy Blue NC,Managed Medicaid,,143.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Healthy Blue NC,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Healthy Blue NC,Managed Medicaid,,210.27,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Healthy Blue NC,Managed Medicaid,,10.78,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Healthy Blue NC,Managed Medicaid,,346.52,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Healthy Blue NC,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Healthy Blue NC,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Healthy Blue NC,Managed Medicaid,,22.78,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Healthy Blue NC,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Healthy Blue NC,Managed Medicaid,,330.39,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Healthy Blue NC,Managed Medicaid,,9091.99,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Healthy Blue NC,Managed Medicaid,,31273.72,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Healthy Blue NC,Managed Medicaid,,51551.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Healthy Blue NC,Managed Medicaid,,2234.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Healthy Blue NC,Managed Medicaid,,1479.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Healthy Blue NC,Managed Medicaid,,51.85,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Healthy Blue NC,Managed Medicaid,,2.73,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Healthy Blue NC,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Healthy Blue NC,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Healthy Blue NC,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Healthy Blue NC,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Healthy Blue NC,Managed Medicaid,,103.90,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Healthy Blue NC,Managed Medicaid,,257.66,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Healthy Blue NC,Managed Medicaid,,385.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Healthy Blue NC,Managed Medicaid,,578.78,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Healthy Blue NC,Managed Medicaid,,694.49,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Healthy Blue NC,Managed Medicaid,,833.23,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Healthy Blue NC,Managed Medicaid,,1000.20,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Healthy Blue NC,Managed Medicaid,,413.41,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Healthy Blue NC,Managed Medicaid,,607.21,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Healthy Blue NC,Managed Medicaid,,1104.30,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Healthy Blue NC,Managed Medicaid,,32.03,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Healthy Blue NC,Managed Medicaid,,126.73,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Healthy Blue NC,Managed Medicaid,,34.63,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,,23.42,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Healthy Blue NC,Managed Medicaid,,5.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Healthy Blue NC,Managed Medicaid,,28.63,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Healthy Blue NC,Managed Medicaid,,31.63,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Healthy Blue NC,Managed Medicaid,,104.90,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Healthy Blue NC,Managed Medicaid,,119.52,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Healthy Blue NC,Managed Medicaid,,101.70,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Healthy Blue NC,Managed Medicaid,,18.42,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Healthy Blue NC,Managed Medicaid,,14.61,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Healthy Blue NC,Managed Medicaid,,46.05,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Healthy Blue NC,Managed Medicaid,,42.24,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Healthy Blue NC,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Healthy Blue NC,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Healthy Blue NC,Managed Medicaid,,997.40,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Healthy Blue NC,Managed Medicaid,,357.56,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Healthy Blue NC,Managed Medicaid,,601.60,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Healthy Blue NC,Managed Medicaid,,305.51,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Healthy Blue NC,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Healthy Blue NC,Managed Medicaid,,218.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Healthy Blue NC,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Healthy Blue NC,Managed Medicaid,,247.45,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Healthy Blue NC,Managed Medicaid,,181.98,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Healthy Blue NC,Managed Medicaid,,60.66,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Healthy Blue NC,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Healthy Blue NC,Managed Medicaid,,187.79,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Healthy Blue NC,Managed Medicaid,,53.25,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Healthy Blue NC,Managed Medicaid,,40.84,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Healthy Blue NC,Managed Medicaid,,218.62,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Healthy Blue NC,Managed Medicaid,,189.79,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Healthy Blue NC,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Healthy Blue NC,Managed Medicaid,,8.61,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Healthy Blue NC,Managed Medicaid,,7.01,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Healthy Blue NC,Managed Medicaid,,28.03,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Healthy Blue NC,Managed Medicaid,,94.89,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Healthy Blue NC,Managed Medicaid,,25.23,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Healthy Blue NC,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Healthy Blue NC,Managed Medicaid,,26.83,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Healthy Blue NC,Managed Medicaid,,2.20,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Healthy Blue NC,Managed Medicaid,,998.00,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Healthy Blue NC,Managed Medicaid,,4024.02,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Healthy Blue NC,Managed Medicaid,,1015.81,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Healthy Blue NC,Managed Medicaid,,848.85,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Healthy Blue NC,Managed Medicaid,,696.30,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Healthy Blue NC,Managed Medicaid,,92.69,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Healthy Blue NC,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Healthy Blue NC,Managed Medicaid,,906.91,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Healthy Blue NC,Managed Medicaid,,893.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Healthy Blue NC,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Healthy Blue NC,Managed Medicaid,,1168.17,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Healthy Blue NC,Managed Medicaid,,829.43,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Healthy Blue NC,Managed Medicaid,,829.43,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Healthy Blue NC,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Healthy Blue NC,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Healthy Blue NC,Managed Medicaid,,1174.37,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Healthy Blue NC,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Healthy Blue NC,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Healthy Blue NC,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Healthy Blue NC,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Healthy Blue NC,Managed Medicaid,,349.35,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Healthy Blue NC,Managed Medicaid,,822.82,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Healthy Blue NC,Managed Medicaid,,338.54,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Healthy Blue NC,Managed Medicaid,,1301.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Healthy Blue NC,Managed Medicaid,,237.04,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Healthy Blue NC,Managed Medicaid,,486.89,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Healthy Blue NC,Managed Medicaid,,737.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Healthy Blue NC,Managed Medicaid,,860.26,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Healthy Blue NC,Managed Medicaid,,24.22,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Healthy Blue NC,Managed Medicaid,,341.54,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Healthy Blue NC,Managed Medicaid,,685.89,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Healthy Blue NC,Managed Medicaid,,16.62,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Healthy Blue NC,Managed Medicaid,,93.49,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Healthy Blue NC,Managed Medicaid,,137.94,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Healthy Blue NC,Managed Medicaid,,311.71,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Healthy Blue NC,Managed Medicaid,,236.04,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Healthy Blue NC,Managed Medicaid,,15.82,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Healthy Blue NC,Managed Medicaid,GP,4.20,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Healthy Blue NC,Managed Medicaid,,66.67,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Healthy Blue NC,Managed Medicaid,,300.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Healthy Blue NC,Managed Medicaid,,284.68,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Healthy Blue NC,Managed Medicaid,,228.23,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Healthy Blue NC,Managed Medicaid,,171.77,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Healthy Blue NC,Managed Medicaid,,115.32,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Healthy Blue NC,Managed Medicaid,,58.86,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Healthy Blue NC,Managed Medicaid,,327.93,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Healthy Blue NC,Managed Medicaid,,979.98,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Healthy Blue NC,Managed Medicaid,,1299.70,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Healthy Blue NC,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Healthy Blue NC,Managed Medicaid,,521.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Healthy Blue NC,Managed Medicaid,,5236.83,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Healthy Blue NC,Managed Medicaid,,5485.28,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Healthy Blue NC,Managed Medicaid,,5773.17,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Healthy Blue NC,Managed Medicaid,,6020.81,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Healthy Blue NC,Managed Medicaid,,6269.46,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Healthy Blue NC,Managed Medicaid,,6517.31,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Healthy Blue NC,Managed Medicaid,,6724.92,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Healthy Blue NC,Managed Medicaid,,7012.81,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Healthy Blue NC,Managed Medicaid,,7260.85,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Healthy Blue NC,Managed Medicaid,,7508.90,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Healthy Blue NC,Managed Medicaid,,7757.15,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Healthy Blue NC,Managed Medicaid,,77.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Healthy Blue NC,Managed Medicaid,,106.91,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Healthy Blue NC,Managed Medicaid,,165.97,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Healthy Blue NC,Managed Medicaid,,167.37,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Healthy Blue NC,Managed Medicaid,,807.81,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Healthy Blue NC,Managed Medicaid,,1938.94,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Healthy Blue NC,Managed Medicaid,,2083.48,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Healthy Blue NC,Managed Medicaid,,2238.04,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Healthy Blue NC,Managed Medicaid,,1220.02,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Healthy Blue NC,Managed Medicaid,,1576.17,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Healthy Blue NC,Managed Medicaid,,1792.79,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Healthy Blue NC,Managed Medicaid,,2308.31,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Healthy Blue NC,Managed Medicaid,,2369.57,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Healthy Blue NC,Managed Medicaid,,2427.22,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Healthy Blue NC,Managed Medicaid,,2485.08,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Healthy Blue NC,Managed Medicaid,,2542.74,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Healthy Blue NC,Managed Medicaid,,990.19,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Healthy Blue NC,Managed Medicaid,,133.73,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Healthy Blue NC,Managed Medicaid,,882.08,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Healthy Blue NC,Managed Medicaid,,1190.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Healthy Blue NC,Managed Medicaid,,1630.83,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Healthy Blue NC,Managed Medicaid,,2066.86,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Healthy Blue NC,Managed Medicaid,,2359.76,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Healthy Blue NC,Managed Medicaid,,2672.67,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Healthy Blue NC,Managed Medicaid,,3048.85,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Healthy Blue NC,Managed Medicaid,,3268.06,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Healthy Blue NC,Managed Medicaid,,3591.59,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Healthy Blue NC,Managed Medicaid,,3767.56,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Healthy Blue NC,Managed Medicaid,,3997.99,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Healthy Blue NC,Managed Medicaid,,4146.34,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Healthy Blue NC,Managed Medicaid,,4183.58,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Healthy Blue NC,Managed Medicaid,,4245.64,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Healthy Blue NC,Managed Medicaid,,4369.36,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Healthy Blue NC,Managed Medicaid,,4493.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Healthy Blue NC,Managed Medicaid,,4617.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Healthy Blue NC,Managed Medicaid,,4741.74,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Healthy Blue NC,Managed Medicaid,,4865.26,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Healthy Blue NC,Managed Medicaid,,4989.38,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Healthy Blue NC,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Healthy Blue NC,Managed Medicaid,,2274.67,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Healthy Blue NC,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Healthy Blue NC,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Healthy Blue NC,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Healthy Blue NC,Managed Medicaid,,1297.30,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Healthy Blue NC,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Healthy Blue NC,Managed Medicaid,,1513.91,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Healthy Blue NC,Managed Medicaid,,1705.90,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Healthy Blue NC,Managed Medicaid,,60.66,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Healthy Blue NC,Managed Medicaid,,254.45,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Healthy Blue NC,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Healthy Blue NC,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Healthy Blue NC,Managed Medicaid,,161.76,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Healthy Blue NC,Managed Medicaid,,2160.96,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Healthy Blue NC,Managed Medicaid,,378.38,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Healthy Blue NC,Managed Medicaid,,245.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Healthy Blue NC,Managed Medicaid,,1436.23,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Healthy Blue NC,Managed Medicaid,,59.26,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Healthy Blue NC,Managed Medicaid,,151.35,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Healthy Blue NC,Managed Medicaid,,0.60060,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Healthy Blue NC,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Healthy Blue NC,Managed Medicaid,,425.83,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Healthy Blue NC,Managed Medicaid,,521.92,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Healthy Blue NC,Managed Medicaid,,617.62,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Healthy Blue NC,Managed Medicaid,,713.51,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Healthy Blue NC,Managed Medicaid,,809.41,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Healthy Blue NC,Managed Medicaid,,905.10,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Healthy Blue NC,Managed Medicaid,,132.33,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Healthy Blue NC,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Healthy Blue NC,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Healthy Blue NC,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Healthy Blue NC,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Healthy Blue NC,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Healthy Blue NC,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Healthy Blue NC,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Healthy Blue NC,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Healthy Blue NC,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Healthy Blue NC,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Healthy Blue NC,Managed Medicaid,,191.79,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Healthy Blue NC,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Healthy Blue NC,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Healthy Blue NC,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Healthy Blue NC,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Healthy Blue NC,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Healthy Blue NC,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Healthy Blue NC,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Healthy Blue NC,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Healthy Blue NC,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Healthy Blue NC,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Healthy Blue NC,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Healthy Blue NC,Managed Medicaid,,57.06,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Healthy Blue NC,Managed Medicaid,,271.67,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Healthy Blue NC,Managed Medicaid,,307.71,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Healthy Blue NC,Managed Medicaid,,344.14,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Healthy Blue NC,Managed Medicaid,,380.58,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Healthy Blue NC,Managed Medicaid,,417.42,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Healthy Blue NC,Managed Medicaid,,454.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Healthy Blue NC,Managed Medicaid,,490.49,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Healthy Blue NC,Managed Medicaid,,526.73,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Healthy Blue NC,Managed Medicaid,,562.96,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Healthy Blue NC,Managed Medicaid,,599.80,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Healthy Blue NC,Managed Medicaid,,636.04,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Healthy Blue NC,Managed Medicaid,,683.48,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Healthy Blue NC,Managed Medicaid,,720.32,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Healthy Blue NC,Managed Medicaid,,859.46,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Healthy Blue NC,Managed Medicaid,,915.71,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Healthy Blue NC,Managed Medicaid,,958.36,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Healthy Blue NC,Managed Medicaid,,994.79,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Healthy Blue NC,Managed Medicaid,,1031.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Healthy Blue NC,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Healthy Blue NC,Managed Medicaid,,928.13,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Healthy Blue NC,Managed Medicaid,,825.42,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Healthy Blue NC,Managed Medicaid,,523.12,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Healthy Blue NC,Managed Medicaid,,565.57,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Healthy Blue NC,Managed Medicaid,,497.70,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Healthy Blue NC,Managed Medicaid,,669.07,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Healthy Blue NC,Managed Medicaid,,67.47,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Healthy Blue NC,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Healthy Blue NC,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Healthy Blue NC,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Healthy Blue NC,Managed Medicaid,,255.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Healthy Blue NC,Managed Medicaid,,419.62,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Healthy Blue NC,Managed Medicaid,,466.27,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Healthy Blue NC,Managed Medicaid,,253.05,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Healthy Blue NC,Managed Medicaid,,1500.30,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Healthy Blue NC,Managed Medicaid,,203.40,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Healthy Blue NC,Managed Medicaid,,80.88,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Healthy Blue NC,Managed Medicaid,,915.71,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Healthy Blue NC,Managed Medicaid,,2169.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Healthy Blue NC,Managed Medicaid,,1055.85,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Healthy Blue NC,Managed Medicaid,,61.46,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Healthy Blue NC,Managed Medicaid,,8004.80,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Healthy Blue NC,Managed Medicaid,,8252.64,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Healthy Blue NC,Managed Medicaid,,377.38,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Healthy Blue NC,Managed Medicaid,,111.51,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Healthy Blue NC,Managed Medicaid,,583.58,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Healthy Blue NC,Managed Medicaid,,17.22,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Healthy Blue NC,Managed Medicaid,,36.64,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthy Blue NC,Managed Medicaid,,19.82,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Healthy Blue NC,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Healthy Blue NC,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Healthy Blue NC,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Healthy Blue NC,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Healthy Blue NC,Managed Medicaid,,275.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Healthy Blue NC,Managed Medicaid,,3917.71,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Healthy Blue NC,Managed Medicaid,,1825.82,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Healthy Blue NC,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Healthy Blue NC,Managed Medicaid,,991.79,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Healthy Blue NC,Managed Medicaid,,1489.09,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Healthy Blue NC,Managed Medicaid,,1685.28,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Healthy Blue NC,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Healthy Blue NC,Managed Medicaid,,1270.87,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Healthy Blue NC,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Healthy Blue NC,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Healthy Blue NC,Managed Medicaid,,41.84,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthy Blue NC,Managed Medicaid,,29.03,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Healthy Blue NC,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Healthy Blue NC,Managed Medicaid,,25.23,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Healthy Blue NC,Managed Medicaid,,30.23,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Healthy Blue NC,Managed Medicaid,,36.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Healthy Blue NC,Managed Medicaid,,59.06,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Healthy Blue NC,Managed Medicaid,,71.07,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Healthy Blue NC,Managed Medicaid,,209.81,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Healthy Blue NC,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Healthy Blue NC,Managed Medicaid,,85.08,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Healthy Blue NC,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Healthy Blue NC,Managed Medicaid,,214.81,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Healthy Blue NC,Managed Medicaid,,189.79,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Healthy Blue NC,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Healthy Blue NC,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Healthy Blue NC,Managed Medicaid,,154.95,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Healthy Blue NC,Managed Medicaid,,1025.02,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Healthy Blue NC,Managed Medicaid,,100.70,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Healthy Blue NC,Managed Medicaid,,90.49,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Healthy Blue NC,Managed Medicaid,,270.07,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Healthy Blue NC,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Healthy Blue NC,Managed Medicaid,,297.10,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Healthy Blue NC,Managed Medicaid,,276.08,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Healthy Blue NC,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Healthy Blue NC,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Healthy Blue NC,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Healthy Blue NC,Managed Medicaid,,1345.34,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Healthy Blue NC,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Healthy Blue NC,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Healthy Blue NC,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Healthy Blue NC,Managed Medicaid,,243.24,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Healthy Blue NC,Managed Medicaid,,326.53,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Healthy Blue NC,Managed Medicaid,,580.38,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Healthy Blue NC,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthy Blue NC,Managed Medicaid,,92.69,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Healthy Blue NC,Managed Medicaid,,28.03,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Healthy Blue NC,Managed Medicaid,,33.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Healthy Blue NC,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Healthy Blue NC,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Healthy Blue NC,Managed Medicaid,,205.00,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthy Blue NC,Managed Medicaid,,127.53,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Healthy Blue NC,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Healthy Blue NC,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Healthy Blue NC,Managed Medicaid,,59.46,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Healthy Blue NC,Managed Medicaid,,61.66,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Healthy Blue NC,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Healthy Blue NC,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Healthy Blue NC,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Healthy Blue NC,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Healthy Blue NC,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Healthy Blue NC,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Healthy Blue NC,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Healthy Blue NC,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Healthy Blue NC,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Healthy Blue NC,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Healthy Blue NC,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Healthy Blue NC,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Healthy Blue NC,Managed Medicaid,,1897.10,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Healthy Blue NC,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Healthy Blue NC,Managed Medicaid,,539.74,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Healthy Blue NC,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Healthy Blue NC,Managed Medicaid,,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Healthy Blue NC,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Healthy Blue NC,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Healthy Blue NC,Managed Medicaid,,1227.43,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Healthy Blue NC,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Healthy Blue NC,Managed Medicaid,,251.25,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Healthy Blue NC,Managed Medicaid,,107.51,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Healthy Blue NC,Managed Medicaid,,1345.34,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Healthy Blue NC,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Healthy Blue NC,Managed Medicaid,,188.19,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Healthy Blue NC,Managed Medicaid,,44.04,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Healthy Blue NC,Managed Medicaid,,111.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Healthy Blue NC,Managed Medicaid,,1088.29,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Healthy Blue NC,Managed Medicaid,,3972.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Healthy Blue NC,Managed Medicaid,,5483.48,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Healthy Blue NC,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Healthy Blue NC,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Healthy Blue NC,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Healthy Blue NC,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Healthy Blue NC,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Healthy Blue NC,Managed Medicaid,,625.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Healthy Blue NC,Managed Medicaid,,234.63,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Healthy Blue NC,Managed Medicaid,,301.70,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Healthy Blue NC,Managed Medicaid,,283.28,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Healthy Blue NC,Managed Medicaid,,274.27,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Healthy Blue NC,Managed Medicaid,,1994.79,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Healthy Blue NC,Managed Medicaid,Q1,1268.27,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Healthy Blue NC,Managed Medicaid,Q0,759.76,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Healthy Blue NC,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Healthy Blue NC,Managed Medicaid,,84.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Healthy Blue NC,Managed Medicaid,,109.91,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthy Blue NC,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Healthy Blue NC,Managed Medicaid,,117.12,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthy Blue NC,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthy Blue NC,Managed Medicaid,,75.48,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Healthy Blue NC,Managed Medicaid,,18.42,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthy Blue NC,Managed Medicaid,,57.66,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Healthy Blue NC,Managed Medicaid,,87.49,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Healthy Blue NC,Managed Medicaid,,52.45,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Healthy Blue NC,Managed Medicaid,,46.85,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Healthy Blue NC,Managed Medicaid,,130.53,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Healthy Blue NC,Managed Medicaid,,6.61,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Healthy Blue NC,Managed Medicaid,,380.18,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Healthy Blue NC,Managed Medicaid,,48.05,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Healthy Blue NC,Managed Medicaid,,72.07,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthy Blue NC,Managed Medicaid,,92.69,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Healthy Blue NC,Managed Medicaid,,84.08,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Healthy Blue NC,Managed Medicaid,,389.79,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Healthy Blue NC,Managed Medicaid,,398.40,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Healthy Blue NC,Managed Medicaid,,186.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Healthy Blue NC,Managed Medicaid,,281.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Healthy Blue NC,Managed Medicaid,,292.29,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Healthy Blue NC,Managed Medicaid,,345.14,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Healthy Blue NC,Managed Medicaid,,420.02,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Healthy Blue NC,Managed Medicaid,,704.50,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Healthy Blue NC,Managed Medicaid,,1249.65,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Healthy Blue NC,Managed Medicaid,,1347.55,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Healthy Blue NC,Managed Medicaid,,127.13,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Healthy Blue NC,Managed Medicaid,,170.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Healthy Blue NC,Managed Medicaid,,1271.67,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Healthy Blue NC,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Healthy Blue NC,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Healthy Blue NC,Managed Medicaid,,339.94,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Healthy Blue NC,Managed Medicaid,,554.35,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Healthy Blue NC,Managed Medicaid,,146.95,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Healthy Blue NC,Managed Medicaid,,219.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Healthy Blue NC,Managed Medicaid,,93.89,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Healthy Blue NC,Managed Medicaid,,193.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Healthy Blue NC,Managed Medicaid,,137.54,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Healthy Blue NC,Managed Medicaid,,309.31,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Healthy Blue NC,Managed Medicaid,,214.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Healthy Blue NC,Managed Medicaid,,372.77,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Healthy Blue NC,Managed Medicaid,,90.09,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Healthy Blue NC,Managed Medicaid,,241.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Healthy Blue NC,Managed Medicaid,,1499.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Healthy Blue NC,Managed Medicaid,,1492.29,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Healthy Blue NC,Managed Medicaid,,480.08,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Healthy Blue NC,Managed Medicaid,,349.55,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Healthy Blue NC,Managed Medicaid,,620.62,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Healthy Blue NC,Managed Medicaid,,1686.28,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Healthy Blue NC,Managed Medicaid,,85.08,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Healthy Blue NC,Managed Medicaid,,113.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Healthy Blue NC,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Healthy Blue NC,Managed Medicaid,,418.82,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Healthy Blue NC,Managed Medicaid,,927.93,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Healthy Blue NC,Managed Medicaid,,492.09,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Healthy Blue NC,Managed Medicaid,,600.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Healthy Blue NC,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Healthy Blue NC,Managed Medicaid,,64.26,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Healthy Blue NC,Managed Medicaid,,215.42,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Healthy Blue NC,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Healthy Blue NC,Managed Medicaid,,120.72,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Healthy Blue NC,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Healthy Blue NC,Managed Medicaid,,307.71,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Healthy Blue NC,Managed Medicaid,,123.12,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Healthy Blue NC,Managed Medicaid,,146.95,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Healthy Blue NC,Managed Medicaid,,91.49,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Healthy Blue NC,Managed Medicaid,,66.27,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Healthy Blue NC,Managed Medicaid,,104.70,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Healthy Blue NC,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Healthy Blue NC,Managed Medicaid,,206.61,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Healthy Blue NC,Managed Medicaid,,177.98,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Healthy Blue NC,Managed Medicaid,,232.83,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Healthy Blue NC,Managed Medicaid,,210.41,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Healthy Blue NC,Managed Medicaid,,281.48,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Healthy Blue NC,Managed Medicaid,76,281.48,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Healthy Blue NC,Managed Medicaid,,750.35,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Healthy Blue NC,Managed Medicaid,76,750.35,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Healthy Blue NC,Managed Medicaid,,789.79,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Healthy Blue NC,Managed Medicaid,76,789.79,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Healthy Blue NC,Managed Medicaid,,407.21,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Healthy Blue NC,Managed Medicaid,,452.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Healthy Blue NC,Managed Medicaid,,477.08,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Healthy Blue NC,Managed Medicaid,,526.33,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Healthy Blue NC,Managed Medicaid,,366.97,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Healthy Blue NC,Managed Medicaid,,524.92,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Healthy Blue NC,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Healthy Blue NC,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Healthy Blue NC,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Healthy Blue NC,Managed Medicaid,,58.46,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Healthy Blue NC,Managed Medicaid,,568.97,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Healthy Blue NC,Managed Medicaid,,5465.26,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Healthy Blue NC,Managed Medicaid,,751.35,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Healthy Blue NC,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Healthy Blue NC,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Healthy Blue NC,Managed Medicaid,,129.73,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Healthy Blue NC,Managed Medicaid,,141.74,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Healthy Blue NC,Managed Medicaid,,245.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Healthy Blue NC,Managed Medicaid,,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Healthy Blue NC,Managed Medicaid,,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Healthy Blue NC,Managed Medicaid,,187.79,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Healthy Blue NC,Managed Medicaid,,128.33,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Healthy Blue NC,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Healthy Blue NC,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Healthy Blue NC,Managed Medicaid,,72.67,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Healthy Blue NC,Managed Medicaid,,91.09,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Healthy Blue NC,Managed Medicaid,76,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Healthy Blue NC,Managed Medicaid,76,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Healthy Blue NC,Managed Medicaid,,99.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Healthy Blue NC,Managed Medicaid,,209.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Healthy Blue NC,Managed Medicaid,,326.13,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Healthy Blue NC,Managed Medicaid,,469.07,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Healthy Blue NC,Managed Medicaid,,1384.18,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Healthy Blue NC,Managed Medicaid,,146.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Healthy Blue NC,Managed Medicaid,,1214.61,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Healthy Blue NC,Managed Medicaid,,451.25,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Healthy Blue NC,Managed Medicaid,,567.97,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Healthy Blue NC,Managed Medicaid,,369.97,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Healthy Blue NC,Managed Medicaid,,174.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Healthy Blue NC,Managed Medicaid,,109.91,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Healthy Blue NC,Managed Medicaid,,161.16,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Healthy Blue NC,Managed Medicaid,,250.65,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Healthy Blue NC,Managed Medicaid,,1634.43,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Healthy Blue NC,Managed Medicaid,,482.48,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Healthy Blue NC,Managed Medicaid,,81.08,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Healthy Blue NC,Managed Medicaid,,112.11,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Healthy Blue NC,Managed Medicaid,,332.73,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Healthy Blue NC,Managed Medicaid,,384.98,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Healthy Blue NC,Managed Medicaid,,255.05,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Healthy Blue NC,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Healthy Blue NC,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Healthy Blue NC,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthy Blue NC,Managed Medicaid,,625.22,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Healthy Blue NC,Managed Medicaid,,70.27,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Healthy Blue NC,Managed Medicaid,,211.01,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Healthy Blue NC,Managed Medicaid,,6.81,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Healthy Blue NC,Managed Medicaid,,93.09,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Healthy Blue NC,Managed Medicaid,,205.81,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Healthy Blue NC,Managed Medicaid,,242.64,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Healthy Blue NC,Managed Medicaid,,64.46,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Healthy Blue NC,Managed Medicaid,,151.55,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthy Blue NC,Managed Medicaid,,32.43,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Healthy Blue NC,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Healthy Blue NC,Managed Medicaid,,59.86,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Healthy Blue NC,Managed Medicaid,,119.12,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthy Blue NC,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Healthy Blue NC,Managed Medicaid,,60.46,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Healthy Blue NC,Managed Medicaid,,21.82,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Healthy Blue NC,Managed Medicaid,,40.04,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Healthy Blue NC,Managed Medicaid,,32.23,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthy Blue NC,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthy Blue NC,Managed Medicaid,,26.63,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthy Blue NC,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Healthy Blue NC,Managed Medicaid,,87.69,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthy Blue NC,Managed Medicaid,,10.01,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Healthy Blue NC,Managed Medicaid,,82.68,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthy Blue NC,Managed Medicaid,,57.66,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Healthy Blue NC,Managed Medicaid,,38.24,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthy Blue NC,Managed Medicaid,,53.85,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Healthy Blue NC,Managed Medicaid,GP,13.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,GP,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Healthy Blue NC,Managed Medicaid,GP,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Healthy Blue NC,Managed Medicaid,GP,24.22,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,GP,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Healthy Blue NC,Managed Medicaid,GP,3.20,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Healthy Blue NC,Managed Medicaid,GP,30.63,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthy Blue NC,Managed Medicaid,GP,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthy Blue NC,Managed Medicaid,GP,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,GP,22.02,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,GP,11.81,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthy Blue NC,Managed Medicaid,GP,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Healthy Blue NC,Managed Medicaid,GP,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Healthy Blue NC,Managed Medicaid,GP,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,GP,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Healthy Blue NC,Managed Medicaid,GP,27.83,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Healthy Blue NC,Managed Medicaid,GP,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,GP,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Healthy Blue NC,Managed Medicaid,GP,30.23,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,GP,9.41,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,GP,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,GP,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthy Blue NC,Managed Medicaid,GP,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthy Blue NC,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthy Blue NC,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,GP,17.82,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Healthy Blue NC,Managed Medicaid,GP,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthy Blue NC,Managed Medicaid,GP,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,GP,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,GP,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Healthy Blue NC,Managed Medicaid,GP,61.26,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Healthy Blue NC,Managed Medicaid,GP,84.68,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Healthy Blue NC,Managed Medicaid,GP,86.89,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthy Blue NC,Managed Medicaid,GP,57.66,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,GO,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,GO,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,GO,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,GO,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthy Blue NC,Managed Medicaid,GO,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Healthy Blue NC,Managed Medicaid,GO,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthy Blue NC,Managed Medicaid,GO,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthy Blue NC,Managed Medicaid,GO,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,GO,12.41,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthy Blue NC,Managed Medicaid,GO,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Healthy Blue NC,Managed Medicaid,GO,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Healthy Blue NC,Managed Medicaid,GO,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,GO,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,GO,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Healthy Blue NC,Managed Medicaid,GO,44.84,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Healthy Blue NC,Managed Medicaid,GO,30.43,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Healthy Blue NC,Managed Medicaid,GO,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,GO,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Healthy Blue NC,Managed Medicaid,GO,63.66,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Healthy Blue NC,Managed Medicaid,GO,80.68,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Healthy Blue NC,Managed Medicaid,GO,83.08,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Healthy Blue NC,Managed Medicaid,GO,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Healthy Blue NC,Managed Medicaid,GN,71.27,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Healthy Blue NC,Managed Medicaid,GN,67.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Healthy Blue NC,Managed Medicaid,GN,37.44,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthy Blue NC,Managed Medicaid,GN,53.85,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Healthy Blue NC,Managed Medicaid,GN,40.04,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthy Blue NC,Managed Medicaid,GN,63.06,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthy Blue NC,Managed Medicaid,GN,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,GN,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthy Blue NC,Managed Medicaid,GN,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Healthy Blue NC,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,GN,27.23,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Healthy Blue NC,Managed Medicaid,GN,131.13,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Healthy Blue NC,Managed Medicaid,GN,51.85,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Healthy Blue NC,Managed Medicaid,GN,13.61,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthy Blue NC,Managed Medicaid,GN,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,GN,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Healthy Blue NC,Managed Medicaid,GN,42.84,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Healthy Blue NC,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,GN,21.42,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Healthy Blue NC,Managed Medicaid,GN,70.67,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Healthy Blue NC,Managed Medicaid,GN,109.91,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Healthy Blue NC,Managed Medicaid,GN,118.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Healthy Blue NC,Managed Medicaid,,172.97,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Healthy Blue NC,Managed Medicaid,,109.91,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Healthy Blue NC,Managed Medicaid,,177.18,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Healthy Blue NC,Managed Medicaid,,100.90,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Healthy Blue NC,Managed Medicaid,,149.15,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Healthy Blue NC,Managed Medicaid,,751.95,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthy Blue NC,Managed Medicaid,,8.61,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Healthy Blue NC,Managed Medicaid,,29.63,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Healthy Blue NC,Managed Medicaid,,105.11,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Healthy Blue NC,Managed Medicaid,,104.70,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Healthy Blue NC,Managed Medicaid,,112.71,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthy Blue NC,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Healthy Blue NC,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Healthy Blue NC,Managed Medicaid,,271.67,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Healthy Blue NC,Managed Medicaid,,83.68,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Healthy Blue NC,Managed Medicaid,,162.56,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Healthy Blue NC,Managed Medicaid,,113.51,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Healthy Blue NC,Managed Medicaid,,95.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Healthy Blue NC,Managed Medicaid,,130.53,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Healthy Blue NC,Managed Medicaid,,91.69,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthy Blue NC,Managed Medicaid,,31.23,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthy Blue NC,Managed Medicaid,,36.04,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Healthy Blue NC,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Healthy Blue NC,Managed Medicaid,,26.23,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Healthy Blue NC,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Healthy Blue NC,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Healthy Blue NC,Managed Medicaid,,52.85,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Healthy Blue NC,Managed Medicaid,,52.85,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Healthy Blue NC,Managed Medicaid,,400.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthy Blue NC,Managed Medicaid,,625.22,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Healthy Blue NC,Managed Medicaid,,140.14,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Healthy Blue NC,Managed Medicaid,,454.85,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Healthy Blue NC,Managed Medicaid,,166.37,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Healthy Blue NC,Managed Medicaid,,101.10,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Healthy Blue NC,Managed Medicaid,,44.44,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Healthy Blue NC,Managed Medicaid,,66.67,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Healthy Blue NC,Managed Medicaid,,67.67,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Healthy Blue NC,Managed Medicaid,,37.04,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Healthy Blue NC,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Healthy Blue NC,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Healthy Blue NC,Managed Medicaid,,203.60,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Healthy Blue NC,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Healthy Blue NC,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Healthy Blue NC,Managed Medicaid,,854.05,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Healthy Blue NC,Managed Medicaid,,231.03,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Healthy Blue NC,Managed Medicaid,,110.51,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Healthy Blue NC,Managed Medicaid,,113.11,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Healthy Blue NC,Managed Medicaid,,270.27,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Healthy Blue NC,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Healthy Blue NC,Managed Medicaid,,110.11,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Healthy Blue NC,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Healthy Blue NC,Managed Medicaid,,210.41,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Healthy Blue NC,Managed Medicaid,,90.69,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Healthy Blue NC,Managed Medicaid,,254.45,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Healthy Blue NC,Managed Medicaid,,232.03,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Healthy Blue NC,Managed Medicaid,,145.75,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Healthy Blue NC,Managed Medicaid,,96.30,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Healthy Blue NC,Managed Medicaid,,225.43,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Healthy Blue NC,Managed Medicaid,,63.26,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Healthy Blue NC,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Healthy Blue NC,Managed Medicaid,,24.82,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Healthy Blue NC,Managed Medicaid,,191.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Healthy Blue NC,Managed Medicaid,,114.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Healthy Blue NC,Managed Medicaid,,92.89,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthy Blue NC,Managed Medicaid,,107.91,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Healthy Blue NC,Managed Medicaid,,100.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Healthy Blue NC,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Healthy Blue NC,Managed Medicaid,,81.08,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Healthy Blue NC,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Healthy Blue NC,Managed Medicaid,,81.08,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthy Blue NC,Managed Medicaid,,74.67,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Healthy Blue NC,Managed Medicaid,,134.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Healthy Blue NC,Managed Medicaid,,164.56,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Healthy Blue NC,Managed Medicaid,,171.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Healthy Blue NC,Managed Medicaid,,177.78,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthy Blue NC,Managed Medicaid,,107.91,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Healthy Blue NC,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Healthy Blue NC,Managed Medicaid,,59.06,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Healthy Blue NC,Managed Medicaid,,87.49,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Healthy Blue NC,Managed Medicaid,,50.65,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Healthy Blue NC,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Healthy Blue NC,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Healthy Blue NC,Managed Medicaid,,109.51,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthy Blue NC,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthy Blue NC,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthy Blue NC,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthy Blue NC,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Healthy Blue NC,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Healthy Blue NC,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Healthy Blue NC,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Healthy Blue NC,Managed Medicaid,,53.45,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Healthy Blue NC,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Healthy Blue NC,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Healthy Blue NC,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Healthy Blue NC,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Healthy Blue NC,Managed Medicaid,,91.49,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Healthy Blue NC,Managed Medicaid,,91.09,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Healthy Blue NC,Managed Medicaid,,298.50,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Healthy Blue NC,Managed Medicaid,,305.51,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Healthy Blue NC,Managed Medicaid,,169.77,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Healthy Blue NC,Managed Medicaid,,246.85,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Healthy Blue NC,Managed Medicaid,,84.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Healthy Blue NC,Managed Medicaid,,199.60,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthy Blue NC,Managed Medicaid,,92.69,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Healthy Blue NC,Managed Medicaid,,108.91,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Healthy Blue NC,Managed Medicaid,,263.26,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Healthy Blue NC,Managed Medicaid,,317.92,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Healthy Blue NC,Managed Medicaid,,390.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Healthy Blue NC,Managed Medicaid,,553.95,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Healthy Blue NC,Managed Medicaid,,608.41,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Healthy Blue NC,Managed Medicaid,,771.97,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Healthy Blue NC,Managed Medicaid,,454.05,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Healthy Blue NC,Managed Medicaid,,508.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Healthy Blue NC,Managed Medicaid,,572.17,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Healthy Blue NC,Managed Medicaid,,908.11,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Healthy Blue NC,Managed Medicaid,,1017.02,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Healthy Blue NC,Managed Medicaid,,1135.13,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Healthy Blue NC,Managed Medicaid,,208.61,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Healthy Blue NC,Managed Medicaid,,45.05,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Healthy Blue NC,Managed Medicaid,,58.46,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Healthy Blue NC,Managed Medicaid,,58.86,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Healthy Blue NC,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Healthy Blue NC,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Healthy Blue NC,Managed Medicaid,,21.22,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Healthy Blue NC,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Healthy Blue NC,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Healthy Blue NC,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Healthy Blue NC,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Healthy Blue NC,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Healthy Blue NC,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Healthy Blue NC,Managed Medicaid,GP,13.35,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Healthy Blue NC,Managed Medicaid,,95.90,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Healthy Blue NC,Managed Medicaid,,549.35,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Healthy Blue NC,Managed Medicaid,,549.35,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Healthy Blue NC,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Healthy Blue NC,Managed Medicaid,,217.22,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Healthy Blue NC,Managed Medicaid,,217.22,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Healthy Blue NC,Managed Medicaid,,493.29,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Healthy Blue NC,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Healthy Blue NC,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Healthy Blue NC,Managed Medicaid,,638.64,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Healthy Blue NC,Managed Medicaid,,86.09,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Healthy Blue NC,Managed Medicaid,,96.10,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Healthy Blue NC,Managed Medicaid,,107.31,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Healthy Blue NC,Managed Medicaid,,91.69,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Healthy Blue NC,Managed Medicaid,,23.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Healthy Blue NC,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthy Blue NC,Managed Medicaid,,32.63,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Healthy Blue NC,Managed Medicaid,,61.46,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Healthy Blue NC,Managed Medicaid,,104.10,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Healthy Blue NC,Managed Medicaid,,100.90,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Healthy Blue NC,Managed Medicaid,,123.72,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Healthy Blue NC,Managed Medicaid,,81.88,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Healthy Blue NC,Managed Medicaid,,154.15,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Healthy Blue NC,Managed Medicaid,,154.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Healthy Blue NC,Managed Medicaid,,127.73,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Healthy Blue NC,Managed Medicaid,,120.72,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Healthy Blue NC,Managed Medicaid,,180.58,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Healthy Blue NC,Managed Medicaid,,36.44,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Healthy Blue NC,Managed Medicaid,,30.43,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Healthy Blue NC,Managed Medicaid,,56.06,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Healthy Blue NC,Managed Medicaid,,77.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Healthy Blue NC,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Healthy Blue NC,Managed Medicaid,,151.95,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Healthy Blue NC,Managed Medicaid,,459.46,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Healthy Blue NC,Managed Medicaid,,121.52,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Healthy Blue NC,Managed Medicaid,,372.97,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Healthy Blue NC,Managed Medicaid,,372.97,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Healthy Blue NC,Managed Medicaid,,426.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Healthy Blue NC,Managed Medicaid,,107.31,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthy Blue NC,Managed Medicaid,,207.61,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Healthy Blue NC,Managed Medicaid,,2503.90,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Healthy Blue NC,Managed Medicaid,,304.30,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Healthy Blue NC,Managed Medicaid,,386.99,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Healthy Blue NC,Managed Medicaid,,166.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Healthy Blue NC,Managed Medicaid,,173.97,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Healthy Blue NC,Managed Medicaid,,185.19,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Healthy Blue NC,Managed Medicaid,,307.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Healthy Blue NC,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Healthy Blue NC,Managed Medicaid,,1956.75,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthy Blue NC,Managed Medicaid,,132.13,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthy Blue NC,Managed Medicaid,,132.13,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Healthy Blue NC,Managed Medicaid,,638.44,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Healthy Blue NC,Managed Medicaid,,638.44,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Healthy Blue NC,Managed Medicaid,,305.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Healthy Blue NC,Managed Medicaid,,305.91,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Healthy Blue NC,Managed Medicaid,,345.75,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Healthy Blue NC,Managed Medicaid,,428.83,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Healthy Blue NC,Managed Medicaid,,428.83,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Healthy Blue NC,Managed Medicaid,,279.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Healthy Blue NC,Managed Medicaid,,279.68,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Healthy Blue NC,Managed Medicaid,,124.32,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Healthy Blue NC,Managed Medicaid,,124.32,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Healthy Blue NC,Managed Medicaid,,144.14,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Healthy Blue NC,Managed Medicaid,,144.14,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthy Blue NC,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Healthy Blue NC,Managed Medicaid,,448.45,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthy Blue NC,Managed Medicaid,JW,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Healthy Blue NC,Managed Medicaid,,117.32,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Healthy Blue NC,Managed Medicaid,,99.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Healthy Blue NC,Managed Medicaid,,120.92,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Healthy Blue NC,Managed Medicaid,,99.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Healthy Blue NC,Managed Medicaid,,117.32,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Healthy Blue NC,Managed Medicaid,,164.56,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Healthy Blue NC,Managed Medicaid,,273.07,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Healthy Blue NC,Managed Medicaid,,70.47,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthy Blue NC,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthy Blue NC,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthy Blue NC,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Healthy Blue NC,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Healthy Blue NC,Managed Medicaid,,390.39,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Healthy Blue NC,Managed Medicaid,,390.39,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Healthy Blue NC,Managed Medicaid,,621.22,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Healthy Blue NC,Managed Medicaid,,621.22,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Healthy Blue NC,Managed Medicaid,,344.94,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Healthy Blue NC,Managed Medicaid,,426.83,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Healthy Blue NC,Managed Medicaid,,560.56,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Healthy Blue NC,Managed Medicaid,,108.71,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Healthy Blue NC,Managed Medicaid,,877.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Healthy Blue NC,Managed Medicaid,,970.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Healthy Blue NC,Managed Medicaid,,1147.95,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthy Blue NC,Managed Medicaid,,160.96,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Healthy Blue NC,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Healthy Blue NC,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Healthy Blue NC,Managed Medicaid,,384.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Healthy Blue NC,Managed Medicaid,,340.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthy Blue NC,Managed Medicaid,,116.52,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Healthy Blue NC,Managed Medicaid,,454.05,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Healthy Blue NC,Managed Medicaid,,253.25,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Healthy Blue NC,Managed Medicaid,,467.07,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Healthy Blue NC,Managed Medicaid,,467.07,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Healthy Blue NC,Managed Medicaid,,409.81,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Healthy Blue NC,Managed Medicaid,,267.27,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Healthy Blue NC,Managed Medicaid,,169.57,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Healthy Blue NC,Managed Medicaid,,356.56,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Healthy Blue NC,Managed Medicaid,,356.56,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Healthy Blue NC,Managed Medicaid,,339.94,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Healthy Blue NC,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Healthy Blue NC,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Healthy Blue NC,Managed Medicaid,,359.16,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Healthy Blue NC,Managed Medicaid,,359.16,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Healthy Blue NC,Managed Medicaid,,824.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Healthy Blue NC,Managed Medicaid,,824.62,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Healthy Blue NC,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Healthy Blue NC,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Healthy Blue NC,Managed Medicaid,,102.50,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Healthy Blue NC,Managed Medicaid,,118.92,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Healthy Blue NC,Managed Medicaid,52,220.22,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Healthy Blue NC,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Healthy Blue NC,Managed Medicaid,,142.34,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Healthy Blue NC,Managed Medicaid,,292.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Healthy Blue NC,Managed Medicaid,,25.43,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Healthy Blue NC,Managed Medicaid,,183.98,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Healthy Blue NC,Managed Medicaid,,183.98,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthy Blue NC,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Healthy Blue NC,Managed Medicaid,,63.46,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Healthy Blue NC,Managed Medicaid,,139.54,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Healthy Blue NC,Managed Medicaid,,278.88,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Healthy Blue NC,Managed Medicaid,,475.48,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Healthy Blue NC,Managed Medicaid,,634.03,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Healthy Blue NC,Managed Medicaid,,803.00,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Healthy Blue NC,Managed Medicaid,,265.06,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Healthy Blue NC,Managed Medicaid,,241.64,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Healthy Blue NC,Managed Medicaid,,72.27,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Healthy Blue NC,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthy Blue NC,Managed Medicaid,,37.84,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthy Blue NC,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthy Blue NC,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Healthy Blue NC,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Healthy Blue NC,Managed Medicaid,,40.24,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Healthy Blue NC,Managed Medicaid,,49.85,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Healthy Blue NC,Managed Medicaid,,48.05,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Healthy Blue NC,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Healthy Blue NC,Managed Medicaid,,79.88,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Healthy Blue NC,Managed Medicaid,,74.27,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthy Blue NC,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Healthy Blue NC,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Healthy Blue NC,Managed Medicaid,,45.45,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Healthy Blue NC,Managed Medicaid,,53.45,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Healthy Blue NC,Managed Medicaid,,50.05,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Healthy Blue NC,Managed Medicaid,,81.28,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Healthy Blue NC,Managed Medicaid,,87.09,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Healthy Blue NC,Managed Medicaid,,87.49,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Healthy Blue NC,Managed Medicaid,,79.48,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Healthy Blue NC,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Healthy Blue NC,Managed Medicaid,,50.85,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Healthy Blue NC,Managed Medicaid,,77.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Healthy Blue NC,Managed Medicaid,,97.90,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthy Blue NC,Managed Medicaid,,13.21,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Healthy Blue NC,Managed Medicaid,,21.22,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Healthy Blue NC,Managed Medicaid,,35.24,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Healthy Blue NC,Managed Medicaid,,52.05,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Healthy Blue NC,Managed Medicaid,,68.67,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Healthy Blue NC,Managed Medicaid,,46.25,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Healthy Blue NC,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthy Blue NC,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Healthy Blue NC,Managed Medicaid,,115.32,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Healthy Blue NC,Managed Medicaid,,27.43,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Healthy Blue NC,Managed Medicaid,,22.42,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Healthy Blue NC,Managed Medicaid,,9.61,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthy Blue NC,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Healthy Blue NC,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,JW,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,JW,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Healthy Blue NC,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthy Blue NC,Managed Medicaid,,55.05,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Healthy Blue NC,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Healthy Blue NC,Managed Medicaid,JW,40.04,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Healthy Blue NC,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Healthy Blue NC,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Healthy Blue NC,Managed Medicaid,JW,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Healthy Blue NC,Managed Medicaid,JW,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Healthy Blue NC,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Healthy Blue NC,Managed Medicaid,JW,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,JW,54.65,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Healthy Blue NC,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Healthy Blue NC,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Healthy Blue NC,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Healthy Blue NC,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Healthy Blue NC,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Healthy Blue NC,Managed Medicaid,JW,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Healthy Blue NC,Managed Medicaid,JW,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Healthy Blue NC,Managed Medicaid,JW,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Healthy Blue NC,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Healthy Blue NC,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Healthy Blue NC,Managed Medicaid,JW,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Healthy Blue NC,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Healthy Blue NC,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Healthy Blue NC,Managed Medicaid,JW,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Healthy Blue NC,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Healthy Blue NC,Managed Medicaid,JW,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,JW,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Healthy Blue NC,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Healthy Blue NC,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Healthy Blue NC,Managed Medicaid,JW,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Healthy Blue NC,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Healthy Blue NC,Managed Medicaid,JW,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Healthy Blue NC,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Healthy Blue NC,Managed Medicaid,JW,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,JW,13.01,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Healthy Blue NC,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Healthy Blue NC,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Healthy Blue NC,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Healthy Blue NC,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Healthy Blue NC,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Healthy Blue NC,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Healthy Blue NC,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Healthy Blue NC,Managed Medicaid,JW,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Healthy Blue NC,Managed Medicaid,JW,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Healthy Blue NC,Managed Medicaid,JW,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Healthy Blue NC,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Healthy Blue NC,Managed Medicaid,JW,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Healthy Blue NC,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Healthy Blue NC,Managed Medicaid,JW,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Healthy Blue NC,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Healthy Blue NC,Managed Medicaid,JW,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Healthy Blue NC,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Healthy Blue NC,Managed Medicaid,JW,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Healthy Blue NC,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Healthy Blue NC,Managed Medicaid,JW,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Healthy Blue NC,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Healthy Blue NC,Managed Medicaid,JW,54.45,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Healthy Blue NC,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Healthy Blue NC,Managed Medicaid,,59.06,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthy Blue NC,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthy Blue NC,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthy Blue NC,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthy Blue NC,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Healthy Blue NC,Managed Medicaid,,54.05,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Healthy Blue NC,Managed Medicaid,,849.45,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Healthy Blue NC,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Healthy Blue NC,Managed Medicaid,,49.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Healthy Blue NC,Managed Medicaid,,515.92,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Healthy Blue NC,Managed Medicaid,,41.84,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Healthy Blue NC,Managed Medicaid,,60.66,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Healthy Blue NC,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Healthy Blue NC,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Healthy Blue NC,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Healthy Blue NC,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Healthy Blue NC,Managed Medicaid,,67.47,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Healthy Blue NC,Managed Medicaid,,56.06,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthy Blue NC,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Healthy Blue NC,Managed Medicaid,,1877.68,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Healthy Blue NC,Managed Medicaid,,222.82,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthy Blue NC,Managed Medicaid,,207.61,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Healthy Blue NC,Managed Medicaid,,239.64,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Healthy Blue NC,Managed Medicaid,,161.36,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Healthy Blue NC,Managed Medicaid,,397.40,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Healthy Blue NC,Managed Medicaid,,397.40,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Healthy Blue NC,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Healthy Blue NC,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Healthy Blue NC,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Healthy Blue NC,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Healthy Blue NC,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Healthy Blue NC,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Healthy Blue NC,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Healthy Blue NC,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Healthy Blue NC,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Healthy Blue NC,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthy Blue NC,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Healthy Blue NC,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Healthy Blue NC,Managed Medicaid,,118.92,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Healthy Blue NC,Managed Medicaid,,102.50,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Healthy Blue NC,Managed Medicaid,,154.35,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Healthy Blue NC,Managed Medicaid,,136.34,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Healthy Blue NC,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthy Blue NC,Managed Medicaid,,28.63,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthy Blue NC,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Healthy Blue NC,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthy Blue NC,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Healthy Blue NC,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthy Blue NC,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Healthy Blue NC,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthy Blue NC,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,,33.03,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Healthy Blue NC,Managed Medicaid,,189.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Healthy Blue NC,Managed Medicaid,,96.90,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthy Blue NC,Managed Medicaid,,25.63,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Healthy Blue NC,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Healthy Blue NC,Managed Medicaid,,31.63,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Healthy Blue NC,Managed Medicaid,,18.42,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Healthy Blue NC,Managed Medicaid,,18.42,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthy Blue NC,Managed Medicaid,,42.44,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Healthy Blue NC,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthy Blue NC,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthy Blue NC,Managed Medicaid,,30.03,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,,17.02,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthy Blue NC,Managed Medicaid,,26.63,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthy Blue NC,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Healthy Blue NC,Managed Medicaid,,8008.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Healthy Blue NC,Managed Medicaid,,155.56,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Healthy Blue NC,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Healthy Blue NC,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Healthy Blue NC,Managed Medicaid,,989.19,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Healthy Blue NC,Managed Medicaid,,58.46,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Healthy Blue NC,Managed Medicaid,,176.98,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Healthy Blue NC,Managed Medicaid,,41.04,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Healthy Blue NC,Managed Medicaid,,41.04,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Healthy Blue NC,Managed Medicaid,,194.19,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Healthy Blue NC,Managed Medicaid,,246.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthy Blue NC,Managed Medicaid,,64.86,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Healthy Blue NC,Managed Medicaid,,1253.05,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthy Blue NC,Managed Medicaid,,625.22,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Healthy Blue NC,Managed Medicaid,,97.30,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Healthy Blue NC,Managed Medicaid,,4128.92,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Healthy Blue NC,Managed Medicaid,,625.22,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Healthy Blue NC,Managed Medicaid,,168.57,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Healthy Blue NC,Managed Medicaid,,467.67,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Healthy Blue NC,Managed Medicaid,,463.86,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Healthy Blue NC,Managed Medicaid,,464.86,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Healthy Blue NC,Managed Medicaid,,2388.19,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Healthy Blue NC,Managed Medicaid,,104.90,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Healthy Blue NC,Managed Medicaid,,114.71,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Healthy Blue NC,Managed Medicaid,,266.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Healthy Blue NC,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Healthy Blue NC,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Healthy Blue NC,Managed Medicaid,,379.38,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Healthy Blue NC,Managed Medicaid,,379.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Healthy Blue NC,Managed Medicaid,,691.89,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Healthy Blue NC,Managed Medicaid,,691.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Healthy Blue NC,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Healthy Blue NC,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Healthy Blue NC,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Healthy Blue NC,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Healthy Blue NC,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Healthy Blue NC,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Healthy Blue NC,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthy Blue NC,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Healthy Blue NC,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Healthy Blue NC,Managed Medicaid,JW,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Healthy Blue NC,Managed Medicaid,JW,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Healthy Blue NC,Managed Medicaid,JW,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Healthy Blue NC,Managed Medicaid,JW,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthy Blue NC,Managed Medicaid,JW,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Healthy Blue NC,Managed Medicaid,JW,93.29,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Healthy Blue NC,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Healthy Blue NC,Managed Medicaid,,35.84,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Healthy Blue NC,Managed Medicaid,,159.56,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Healthy Blue NC,Managed Medicaid,,197.80,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Healthy Blue NC,Managed Medicaid,,286.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Healthy Blue NC,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Healthy Blue NC,Managed Medicaid,,35.84,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Healthy Blue NC,Managed Medicaid,,365.97,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Healthy Blue NC,Managed Medicaid,,519.32,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Healthy Blue NC,Managed Medicaid,,189.19,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Healthy Blue NC,Managed Medicaid,,577.18,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Healthy Blue NC,Managed Medicaid,,191.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Healthy Blue NC,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Healthy Blue NC,Managed Medicaid,,280.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Healthy Blue NC,Managed Medicaid,,435.23,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Healthy Blue NC,Managed Medicaid,,847.25,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Healthy Blue NC,Managed Medicaid,,3830.23,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Healthy Blue NC,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Healthy Blue NC,Managed Medicaid,,90.49,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Healthy Blue NC,Managed Medicaid,,80.28,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Healthy Blue NC,Managed Medicaid,,133.13,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Healthy Blue NC,Managed Medicaid,,63.66,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthy Blue NC,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthy Blue NC,Managed Medicaid,,64.86,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Healthy Blue NC,Managed Medicaid,,109.11,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Healthy Blue NC,Managed Medicaid,,70.47,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Healthy Blue NC,Managed Medicaid,,96.30,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Healthy Blue NC,Managed Medicaid,,120.32,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Healthy Blue NC,Managed Medicaid,,78.88,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthy Blue NC,Managed Medicaid,,88.49,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Healthy Blue NC,Managed Medicaid,,100.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Healthy Blue NC,Managed Medicaid,,30.43,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Healthy Blue NC,Managed Medicaid,,54.05,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthy Blue NC,Managed Medicaid,,24.02,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Healthy Blue NC,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Healthy Blue NC,Managed Medicaid,,134.33,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Healthy Blue NC,Managed Medicaid,,35.84,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Healthy Blue NC,Managed Medicaid,,60.46,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Healthy Blue NC,Managed Medicaid,,72.47,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Healthy Blue NC,Managed Medicaid,,96.70,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Healthy Blue NC,Managed Medicaid,,116.92,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Healthy Blue NC,Managed Medicaid,,216.02,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Healthy Blue NC,Managed Medicaid,,117.12,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthy Blue NC,Managed Medicaid,,61.06,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthy Blue NC,Managed Medicaid,,88.49,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Healthy Blue NC,Managed Medicaid,,99.30,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthy Blue NC,Managed Medicaid,,132.13,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Healthy Blue NC,Managed Medicaid,,185.99,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Healthy Blue NC,Managed Medicaid,,87.49,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Healthy Blue NC,Managed Medicaid,,65.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Healthy Blue NC,Managed Medicaid,,112.91,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Healthy Blue NC,Managed Medicaid,,98.50,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Healthy Blue NC,Managed Medicaid,,142.14,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Healthy Blue NC,Managed Medicaid,,175.18,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthy Blue NC,Managed Medicaid,,116.52,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Healthy Blue NC,Managed Medicaid,,68.27,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Healthy Blue NC,Managed Medicaid,,108.31,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Healthy Blue NC,Managed Medicaid,,73.87,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Healthy Blue NC,Managed Medicaid,,73.67,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Healthy Blue NC,Managed Medicaid,,242.44,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Healthy Blue NC,Managed Medicaid,,150.55,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Healthy Blue NC,Managed Medicaid,,267.47,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Healthy Blue NC,Managed Medicaid,,378.78,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Healthy Blue NC,Managed Medicaid,,416.62,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Healthy Blue NC,Managed Medicaid,,85.08,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Healthy Blue NC,Managed Medicaid,,76.48,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Healthy Blue NC,Managed Medicaid,,91.89,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Healthy Blue NC,Managed Medicaid,,92.49,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Healthy Blue NC,Managed Medicaid,,254.45,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Healthy Blue NC,Managed Medicaid,,104.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Healthy Blue NC,Managed Medicaid,,88.09,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Healthy Blue NC,Managed Medicaid,,81.28,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Healthy Blue NC,Managed Medicaid,,88.49,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Healthy Blue NC,Managed Medicaid,,97.50,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Healthy Blue NC,Managed Medicaid,,75.88,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Healthy Blue NC,Managed Medicaid,,59.66,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Healthy Blue NC,Managed Medicaid,,75.08,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Healthy Blue NC,Managed Medicaid,,69.47,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Healthy Blue NC,Managed Medicaid,,130.73,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Healthy Blue NC,Managed Medicaid,,86.29,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Healthy Blue NC,Managed Medicaid,,78.88,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Healthy Blue NC,Managed Medicaid,,55.26,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Healthy Blue NC,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Healthy Blue NC,Managed Medicaid,,85.49,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Healthy Blue NC,Managed Medicaid,,74.27,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Healthy Blue NC,Managed Medicaid,,96.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Healthy Blue NC,Managed Medicaid,,63.26,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Healthy Blue NC,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Healthy Blue NC,Managed Medicaid,,70.87,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthy Blue NC,Managed Medicaid,,43.64,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Healthy Blue NC,Managed Medicaid,,89.09,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthy Blue NC,Managed Medicaid,,92.69,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Healthy Blue NC,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Healthy Blue NC,Managed Medicaid,,106.11,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthy Blue NC,Managed Medicaid,,92.69,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Healthy Blue NC,Managed Medicaid,,80.28,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthy Blue NC,Managed Medicaid,,64.86,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Healthy Blue NC,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Healthy Blue NC,Managed Medicaid,,156.56,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Healthy Blue NC,Managed Medicaid,,64.46,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Healthy Blue NC,Managed Medicaid,,49.45,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Healthy Blue NC,Managed Medicaid,,211.21,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Healthy Blue NC,Managed Medicaid,,145.75,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Healthy Blue NC,Managed Medicaid,,177.78,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Healthy Blue NC,Managed Medicaid,,99.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Healthy Blue NC,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Healthy Blue NC,Managed Medicaid,,197.80,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthy Blue NC,Managed Medicaid,,208.41,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Healthy Blue NC,Managed Medicaid,,215.01,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Healthy Blue NC,Managed Medicaid,,107.51,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Healthy Blue NC,Managed Medicaid,,19.62,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Healthy Blue NC,Managed Medicaid,,116.12,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Healthy Blue NC,Managed Medicaid,,128.73,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Healthy Blue NC,Managed Medicaid,,163.76,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Healthy Blue NC,Managed Medicaid,,133.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Healthy Blue NC,Managed Medicaid,,162.16,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Healthy Blue NC,Managed Medicaid,,418.02,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Healthy Blue NC,Managed Medicaid,,929.93,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Healthy Blue NC,Managed Medicaid,,716.12,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Healthy Blue NC,Managed Medicaid,,37.04,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Healthy Blue NC,Managed Medicaid,,273.87,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Healthy Blue NC,Managed Medicaid,,279.28,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Healthy Blue NC,Managed Medicaid,,810.21,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Healthy Blue NC,Managed Medicaid,,1150.35,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Healthy Blue NC,Managed Medicaid,,265.47,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Healthy Blue NC,Managed Medicaid,,514.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Healthy Blue NC,Managed Medicaid,,206.41,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Healthy Blue NC,Managed Medicaid,,240.64,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Healthy Blue NC,Managed Medicaid,,321.92,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthy Blue NC,Managed Medicaid,,160.96,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Healthy Blue NC,Managed Medicaid,,323.52,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Healthy Blue NC,Managed Medicaid,,193.59,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Healthy Blue NC,Managed Medicaid,,159.96,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Healthy Blue NC,Managed Medicaid,,221.42,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Healthy Blue NC,Managed Medicaid,,467.07,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Healthy Blue NC,Managed Medicaid,,275.48,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Healthy Blue NC,Managed Medicaid,,40.84,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Healthy Blue NC,Managed Medicaid,,35.03,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Healthy Blue NC,Managed Medicaid,,241.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Healthy Blue NC,Managed Medicaid,,154.35,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Healthy Blue NC,Managed Medicaid,,211.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Healthy Blue NC,Managed Medicaid,,71.67,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Healthy Blue NC,Managed Medicaid,,190.79,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Healthy Blue NC,Managed Medicaid,,33.83,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Healthy Blue NC,Managed Medicaid,,187.39,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Healthy Blue NC,Managed Medicaid,,61.26,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Healthy Blue NC,Managed Medicaid,,68.27,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthy Blue NC,Managed Medicaid,,28.63,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Healthy Blue NC,Managed Medicaid,,148.95,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Healthy Blue NC,Managed Medicaid,,132.53,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Healthy Blue NC,Managed Medicaid,,131.53,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Healthy Blue NC,Managed Medicaid,,64.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Healthy Blue NC,Managed Medicaid,,129.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Healthy Blue NC,Managed Medicaid,,69.27,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Healthy Blue NC,Managed Medicaid,,48.65,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Healthy Blue NC,Managed Medicaid,,53.65,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Healthy Blue NC,Managed Medicaid,,185.59,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Healthy Blue NC,Managed Medicaid,,61.26,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Healthy Blue NC,Managed Medicaid,,182.38,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Healthy Blue NC,Managed Medicaid,,58.26,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Healthy Blue NC,Managed Medicaid,,157.76,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Healthy Blue NC,Managed Medicaid,,469.07,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Healthy Blue NC,Managed Medicaid,,808.61,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Healthy Blue NC,Managed Medicaid,,668.27,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Healthy Blue NC,Managed Medicaid,,720.32,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Healthy Blue NC,Managed Medicaid,,407.41,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Healthy Blue NC,Managed Medicaid,,903.70,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Healthy Blue NC,Managed Medicaid,,903.70,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Healthy Blue NC,Managed Medicaid,,903.70,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Healthy Blue NC,Managed Medicaid,,611.21,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Healthy Blue NC,Managed Medicaid,,357.56,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Healthy Blue NC,Managed Medicaid,,281.08,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Healthy Blue NC,Managed Medicaid,,53.65,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Healthy Blue NC,Managed Medicaid,,74.87,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Healthy Blue NC,Managed Medicaid,,66.47,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Healthy Blue NC,Managed Medicaid,,166.37,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthy Blue NC,Managed Medicaid,,32.63,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Healthy Blue NC,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Healthy Blue NC,Managed Medicaid,,416.62,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Healthy Blue NC,Managed Medicaid,,123.52,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Healthy Blue NC,Managed Medicaid,,162.56,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Healthy Blue NC,Managed Medicaid,,172.37,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Healthy Blue NC,Managed Medicaid,,93.49,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Healthy Blue NC,Managed Medicaid,,98.90,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Healthy Blue NC,Managed Medicaid,,104.70,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Healthy Blue NC,Managed Medicaid,,151.75,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Healthy Blue NC,Managed Medicaid,,147.35,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Healthy Blue NC,Managed Medicaid,,216.02,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Healthy Blue NC,Managed Medicaid,,45.85,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Healthy Blue NC,Managed Medicaid,,86.49,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Healthy Blue NC,Managed Medicaid,,212.81,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Healthy Blue NC,Managed Medicaid,,123.12,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Healthy Blue NC,Managed Medicaid,,157.16,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Healthy Blue NC,Managed Medicaid,,7507.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Healthy Blue NC,Managed Medicaid,,43.44,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Healthy Blue NC,Managed Medicaid,,370.97,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Healthy Blue NC,Managed Medicaid,,451.05,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Healthy Blue NC,Managed Medicaid,,84.08,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Healthy Blue NC,Managed Medicaid,,110.11,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Healthy Blue NC,Managed Medicaid,,108.11,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Healthy Blue NC,Managed Medicaid,,80.28,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Healthy Blue NC,Managed Medicaid,,119.32,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Healthy Blue NC,Managed Medicaid,,99.50,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Healthy Blue NC,Managed Medicaid,,150.55,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Healthy Blue NC,Managed Medicaid,,116.32,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Healthy Blue NC,Managed Medicaid,,185.79,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Healthy Blue NC,Managed Medicaid,,276.68,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Healthy Blue NC,Managed Medicaid,,54.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Healthy Blue NC,Managed Medicaid,,165.97,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Healthy Blue NC,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Healthy Blue NC,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Healthy Blue NC,Managed Medicaid,,271.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Healthy Blue NC,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Healthy Blue NC,Managed Medicaid,,137.14,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Healthy Blue NC,Managed Medicaid,,221.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Healthy Blue NC,Managed Medicaid,,116.72,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Healthy Blue NC,Managed Medicaid,,583.98,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Healthy Blue NC,Managed Medicaid,,299.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Healthy Blue NC,Managed Medicaid,,218.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Healthy Blue NC,Managed Medicaid,,195.40,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Healthy Blue NC,Managed Medicaid,,143.54,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Healthy Blue NC,Managed Medicaid,,373.57,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Healthy Blue NC,Managed Medicaid,,203.00,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Healthy Blue NC,Managed Medicaid,,416.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Healthy Blue NC,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Healthy Blue NC,Managed Medicaid,,458.46,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Healthy Blue NC,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Healthy Blue NC,Managed Medicaid,,476.08,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Healthy Blue NC,Managed Medicaid,,547.15,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Healthy Blue NC,Managed Medicaid,,171.37,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Healthy Blue NC,Managed Medicaid,,313.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Healthy Blue NC,Managed Medicaid,,246.25,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Healthy Blue NC,Managed Medicaid,,449.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Healthy Blue NC,Managed Medicaid,,208.61,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Healthy Blue NC,Managed Medicaid,,229.83,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Healthy Blue NC,Managed Medicaid,,251.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Healthy Blue NC,Managed Medicaid,,357.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Healthy Blue NC,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Healthy Blue NC,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Healthy Blue NC,Managed Medicaid,,499.90,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Healthy Blue NC,Managed Medicaid,,775.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Healthy Blue NC,Managed Medicaid,,969.77,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Healthy Blue NC,Managed Medicaid,,166.37,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Healthy Blue NC,Managed Medicaid,,288.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Healthy Blue NC,Managed Medicaid,,259.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Healthy Blue NC,Managed Medicaid,,318.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Healthy Blue NC,Managed Medicaid,,497.70,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Healthy Blue NC,Managed Medicaid,,155.76,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Healthy Blue NC,Managed Medicaid,,293.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Healthy Blue NC,Managed Medicaid,,172.97,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Healthy Blue NC,Managed Medicaid,,218.22,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Healthy Blue NC,Managed Medicaid,,159.96,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthy Blue NC,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Healthy Blue NC,Managed Medicaid,,264.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthy Blue NC,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Healthy Blue NC,Managed Medicaid,,322.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Healthy Blue NC,Managed Medicaid,,254.45,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Healthy Blue NC,Managed Medicaid,,184.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Healthy Blue NC,Managed Medicaid,,468.67,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Healthy Blue NC,Managed Medicaid,,589.19,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Healthy Blue NC,Managed Medicaid,,55.46,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthy Blue NC,Managed Medicaid,,19.82,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Healthy Blue NC,Managed Medicaid,,406.41,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Healthy Blue NC,Managed Medicaid,,197.80,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Healthy Blue NC,Managed Medicaid,,41.64,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Healthy Blue NC,Managed Medicaid,,559.36,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Healthy Blue NC,Managed Medicaid,,2501.10,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Healthy Blue NC,Managed Medicaid,,328.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Healthy Blue NC,Managed Medicaid,,103.90,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Healthy Blue NC,Managed Medicaid,,407.01,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Healthy Blue NC,Managed Medicaid,,94.09,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Healthy Blue NC,Managed Medicaid,,2476.67,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Healthy Blue NC,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Healthy Blue NC,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Healthy Blue NC,Managed Medicaid,,17.42,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Healthy Blue NC,Managed Medicaid,,175.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Healthy Blue NC,Managed Medicaid,,23.82,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Healthy Blue NC,Managed Medicaid,,116.92,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Healthy Blue NC,Managed Medicaid,,64.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Healthy Blue NC,Managed Medicaid,,8.81,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Healthy Blue NC,Managed Medicaid,,1057.06,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Healthy Blue NC,Managed Medicaid,,1.20,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Healthy Blue NC,Managed Medicaid,,129.93,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthy Blue NC,Managed Medicaid,,24.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthy Blue NC,Managed Medicaid,,8.41,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Healthy Blue NC,Managed Medicaid,,16.42,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Healthy Blue NC,Managed Medicaid,,50.85,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Healthy Blue NC,Managed Medicaid,,1212.81,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Healthy Blue NC,Managed Medicaid,,36.64,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Healthy Blue NC,Managed Medicaid,,215.22,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthy Blue NC,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Healthy Blue NC,Managed Medicaid,,285.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthy Blue NC,Managed Medicaid,,61.06,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Healthy Blue NC,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Healthy Blue NC,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Healthy Blue NC,Managed Medicaid,,268.87,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Healthy Blue NC,Managed Medicaid,,97.50,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Healthy Blue NC,Managed Medicaid,,87.09,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Healthy Blue NC,Managed Medicaid,,448.45,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Healthy Blue NC,Managed Medicaid,,321.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Healthy Blue NC,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Healthy Blue NC,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Healthy Blue NC,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Healthy Blue NC,Managed Medicaid,,262.06,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Healthy Blue NC,Managed Medicaid,,386.19,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Healthy Blue NC,Managed Medicaid,,214.01,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Healthy Blue NC,Managed Medicaid,,381.98,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Healthy Blue NC,Managed Medicaid,,246.25,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Healthy Blue NC,Managed Medicaid,,804.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Healthy Blue NC,Managed Medicaid,,662.66,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Healthy Blue NC,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Healthy Blue NC,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Healthy Blue NC,Managed Medicaid,,813.21,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Healthy Blue NC,Managed Medicaid,,206.81,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Healthy Blue NC,Managed Medicaid,,225.43,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthy Blue NC,Managed Medicaid,,64.86,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Healthy Blue NC,Managed Medicaid,,507.91,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Healthy Blue NC,Managed Medicaid,,258.06,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Healthy Blue NC,Managed Medicaid,,227.83,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Healthy Blue NC,Managed Medicaid,,254.05,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Healthy Blue NC,Managed Medicaid,,452.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Healthy Blue NC,Managed Medicaid,,534.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Healthy Blue NC,Managed Medicaid,,653.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Healthy Blue NC,Managed Medicaid,,490.49,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Healthy Blue NC,Managed Medicaid,,588.99,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Healthy Blue NC,Managed Medicaid,,657.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Healthy Blue NC,Managed Medicaid,,507.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Healthy Blue NC,Managed Medicaid,,619.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Healthy Blue NC,Managed Medicaid,,701.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Healthy Blue NC,Managed Medicaid,,517.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Healthy Blue NC,Managed Medicaid,,617.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Healthy Blue NC,Managed Medicaid,,703.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Healthy Blue NC,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Healthy Blue NC,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Healthy Blue NC,Managed Medicaid,,466.67,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Healthy Blue NC,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Healthy Blue NC,Managed Medicaid,,688.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Healthy Blue NC,Managed Medicaid,,775.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Healthy Blue NC,Managed Medicaid,,574.97,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Healthy Blue NC,Managed Medicaid,,724.32,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Healthy Blue NC,Managed Medicaid,,741.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Healthy Blue NC,Managed Medicaid,,448.85,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Healthy Blue NC,Managed Medicaid,,546.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Healthy Blue NC,Managed Medicaid,,637.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Healthy Blue NC,Managed Medicaid,,524.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Healthy Blue NC,Managed Medicaid,,638.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Healthy Blue NC,Managed Medicaid,,745.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Healthy Blue NC,Managed Medicaid,,604.20,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Healthy Blue NC,Managed Medicaid,,458.86,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Healthy Blue NC,Managed Medicaid,,573.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Healthy Blue NC,Managed Medicaid,,614.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Healthy Blue NC,Managed Medicaid,,587.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Healthy Blue NC,Managed Medicaid,,805.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Healthy Blue NC,Managed Medicaid,,869.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Healthy Blue NC,Managed Medicaid,,795.59,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Healthy Blue NC,Managed Medicaid,,502.70,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Healthy Blue NC,Managed Medicaid,,646.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Healthy Blue NC,Managed Medicaid,,847.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Healthy Blue NC,Managed Medicaid,,986.39,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Healthy Blue NC,Managed Medicaid,,499.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Healthy Blue NC,Managed Medicaid,,635.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Healthy Blue NC,Managed Medicaid,,752.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Healthy Blue NC,Managed Medicaid,,1473.67,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Healthy Blue NC,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Healthy Blue NC,Managed Medicaid,,1072.07,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Healthy Blue NC,Managed Medicaid,,1277.08,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Healthy Blue NC,Managed Medicaid,,1484.48,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Healthy Blue NC,Managed Medicaid,,262.06,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Healthy Blue NC,Managed Medicaid,,812.61,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Healthy Blue NC,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Healthy Blue NC,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Healthy Blue NC,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Healthy Blue NC,Managed Medicaid,,560.56,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Healthy Blue NC,Managed Medicaid,,95.50,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Healthy Blue NC,Managed Medicaid,,234.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Healthy Blue NC,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Healthy Blue NC,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Healthy Blue NC,Managed Medicaid,,290.29,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Healthy Blue NC,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Healthy Blue NC,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Healthy Blue NC,Managed Medicaid,,380.58,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthy Blue NC,Managed Medicaid,,95.09,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Healthy Blue NC,Managed Medicaid,,67.47,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Healthy Blue NC,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Healthy Blue NC,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Healthy Blue NC,Managed Medicaid,,6299.49,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Healthy Blue NC,Managed Medicaid,,53.85,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Healthy Blue NC,Managed Medicaid,,145.75,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthy Blue NC,Managed Medicaid,,125.93,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Healthy Blue NC,Managed Medicaid,,399.00,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Healthy Blue NC,Managed Medicaid,,1022.02,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Healthy Blue NC,Managed Medicaid,,108.71,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Healthy Blue NC,Managed Medicaid,,277.68,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Healthy Blue NC,Managed Medicaid,,176.18,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Healthy Blue NC,Managed Medicaid,,11521.71,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Healthy Blue NC,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Healthy Blue NC,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Healthy Blue NC,Managed Medicaid,,5912.91,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Healthy Blue NC,Managed Medicaid,,222.22,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Healthy Blue NC,Managed Medicaid,,600.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Healthy Blue NC,Managed Medicaid,,31.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Healthy Blue NC,Managed Medicaid,,31.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Healthy Blue NC,Managed Medicaid,,84.28,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Healthy Blue NC,Managed Medicaid,,584.78,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthy Blue NC,Managed Medicaid,,125.93,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Healthy Blue NC,Managed Medicaid,,91.29,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Healthy Blue NC,Managed Medicaid,,46.45,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Healthy Blue NC,Managed Medicaid,,40.24,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Healthy Blue NC,Managed Medicaid,,96.30,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Healthy Blue NC,Managed Medicaid,,222.02,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Healthy Blue NC,Managed Medicaid,,91.69,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Healthy Blue NC,Managed Medicaid,,57.06,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Healthy Blue NC,Managed Medicaid,,280.28,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Healthy Blue NC,Managed Medicaid,,316.72,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Healthy Blue NC,Managed Medicaid,,316.72,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Healthy Blue NC,Managed Medicaid,,466.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Healthy Blue NC,Managed Medicaid,,466.47,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Healthy Blue NC,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Healthy Blue NC,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthy Blue NC,Managed Medicaid,,160.96,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthy Blue NC,Managed Medicaid,,160.96,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Healthy Blue NC,Managed Medicaid,,144.54,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Healthy Blue NC,Managed Medicaid,,115.52,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Healthy Blue NC,Managed Medicaid,,115.52,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Healthy Blue NC,Managed Medicaid,,944.94,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Healthy Blue NC,Managed Medicaid,,676.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Healthy Blue NC,Managed Medicaid,,142.54,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Healthy Blue NC,Managed Medicaid,,113.11,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Healthy Blue NC,Managed Medicaid,,283.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Healthy Blue NC,Managed Medicaid,,153.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Healthy Blue NC,Managed Medicaid,,258.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Healthy Blue NC,Managed Medicaid,,116.32,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Healthy Blue NC,Managed Medicaid,,255.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Healthy Blue NC,Managed Medicaid,,255.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Healthy Blue NC,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Healthy Blue NC,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Healthy Blue NC,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Healthy Blue NC,Managed Medicaid,,60.06,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Healthy Blue NC,Managed Medicaid,,388.99,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Healthy Blue NC,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Healthy Blue NC,Managed Medicaid,,166.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Healthy Blue NC,Managed Medicaid,,324.92,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Healthy Blue NC,Managed Medicaid,,354.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Healthy Blue NC,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Healthy Blue NC,Managed Medicaid,,362.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Healthy Blue NC,Managed Medicaid,,421.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Healthy Blue NC,Managed Medicaid,,421.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Healthy Blue NC,Managed Medicaid,,135.54,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Healthy Blue NC,Managed Medicaid,,135.54,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Healthy Blue NC,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Healthy Blue NC,Managed Medicaid,,136.94,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Healthy Blue NC,Managed Medicaid,,136.94,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Healthy Blue NC,Managed Medicaid,,538.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Healthy Blue NC,Managed Medicaid,,551.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Healthy Blue NC,Managed Medicaid,,551.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Healthy Blue NC,Managed Medicaid,,319.12,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Healthy Blue NC,Managed Medicaid,,319.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Healthy Blue NC,Managed Medicaid,,183.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Healthy Blue NC,Managed Medicaid,,183.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Healthy Blue NC,Managed Medicaid,,226.23,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Healthy Blue NC,Managed Medicaid,,226.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Healthy Blue NC,Managed Medicaid,,230.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Healthy Blue NC,Managed Medicaid,,230.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Healthy Blue NC,Managed Medicaid,,1012.81,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Healthy Blue NC,Managed Medicaid,,985.99,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Healthy Blue NC,Managed Medicaid,,159.16,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Healthy Blue NC,Managed Medicaid,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Healthy Blue NC,Managed Medicaid,,163.76,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Healthy Blue NC,Managed Medicaid,,148.55,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Healthy Blue NC,Managed Medicaid,,449.85,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Healthy Blue NC,Managed Medicaid,,148.55,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Healthy Blue NC,Managed Medicaid,,745.34,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Healthy Blue NC,Managed Medicaid,,177.38,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Healthy Blue NC,Managed Medicaid,,137.34,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Healthy Blue NC,Managed Medicaid,,39.04,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Healthy Blue NC,Managed Medicaid,,106.71,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Healthy Blue NC,Managed Medicaid,,111.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Healthy Blue NC,Managed Medicaid,,118.12,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Healthy Blue NC,Managed Medicaid,,116.72,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Healthy Blue NC,Managed Medicaid,,133.13,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Healthy Blue NC,Managed Medicaid,,833.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Healthy Blue NC,Managed Medicaid,,426.03,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Healthy Blue NC,Managed Medicaid,,268.87,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Healthy Blue NC,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Healthy Blue NC,Managed Medicaid,,138.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Healthy Blue NC,Managed Medicaid,,117.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Healthy Blue NC,Managed Medicaid,,121.32,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Healthy Blue NC,Managed Medicaid,,176.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Healthy Blue NC,Managed Medicaid,,176.98,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Healthy Blue NC,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Healthy Blue NC,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Healthy Blue NC,Managed Medicaid,,2814.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Healthy Blue NC,Managed Medicaid,,1238.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthy Blue NC,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthy Blue NC,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthy Blue NC,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Healthy Blue NC,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Healthy Blue NC,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Healthy Blue NC,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Healthy Blue NC,Managed Medicaid,,1536.13,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Healthy Blue NC,Managed Medicaid,,1581.98,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Healthy Blue NC,Managed Medicaid,,1581.98,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Healthy Blue NC,Managed Medicaid,,960.96,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Healthy Blue NC,Managed Medicaid,,895.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Healthy Blue NC,Managed Medicaid,,1213.61,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Healthy Blue NC,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Healthy Blue NC,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Healthy Blue NC,Managed Medicaid,,879.68,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Healthy Blue NC,Managed Medicaid,,483.88,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Healthy Blue NC,Managed Medicaid,,495.50,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Healthy Blue NC,Managed Medicaid,,322.92,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Healthy Blue NC,Managed Medicaid,,158.56,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthy Blue NC,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Healthy Blue NC,Managed Medicaid,,75.88,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Healthy Blue NC,Managed Medicaid,,96.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Healthy Blue NC,Managed Medicaid,,56.46,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Healthy Blue NC,Managed Medicaid,,108.51,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Healthy Blue NC,Managed Medicaid,,1059.86,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Healthy Blue NC,Managed Medicaid,,255.66,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Healthy Blue NC,Managed Medicaid,,1500.30,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Healthy Blue NC,Managed Medicaid,,79.08,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Healthy Blue NC,Managed Medicaid,,328.33,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Healthy Blue NC,Managed Medicaid,,328.33,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Healthy Blue NC,Managed Medicaid,,427.63,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Healthy Blue NC,Managed Medicaid,,182.38,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Healthy Blue NC,Managed Medicaid,,616.02,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Healthy Blue NC,Managed Medicaid,,448.25,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Healthy Blue NC,Managed Medicaid,,107.11,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Healthy Blue NC,Managed Medicaid,,203.40,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Healthy Blue NC,Managed Medicaid,,771.57,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Healthy Blue NC,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Healthy Blue NC,Managed Medicaid,,160.56,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Healthy Blue NC,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Healthy Blue NC,Managed Medicaid,,139.14,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Healthy Blue NC,Managed Medicaid,,1059.86,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Healthy Blue NC,Managed Medicaid,,476.08,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Healthy Blue NC,Managed Medicaid,,500.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Healthy Blue NC,Managed Medicaid,,496.10,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Healthy Blue NC,Managed Medicaid,,127.33,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthy Blue NC,Managed Medicaid,,232.23,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Healthy Blue NC,Managed Medicaid,,35.03,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Healthy Blue NC,Managed Medicaid,,1259.46,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Healthy Blue NC,Managed Medicaid,,1554.95,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Healthy Blue NC,Managed Medicaid,,498.70,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Healthy Blue NC,Managed Medicaid,,58.86,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Healthy Blue NC,Managed Medicaid,,46.25,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Healthy Blue NC,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Healthy Blue NC,Managed Medicaid,,80.88,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Healthy Blue NC,Managed Medicaid,,81.68,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthy Blue NC,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Healthy Blue NC,Managed Medicaid,,40.44,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Healthy Blue NC,Managed Medicaid,,318.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Healthy Blue NC,Managed Medicaid,,900.30,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Healthy Blue NC,Managed Medicaid,,847.65,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Healthy Blue NC,Managed Medicaid,,584.78,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Healthy Blue NC,Managed Medicaid,,915.71,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Healthy Blue NC,Managed Medicaid,,211.21,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Healthy Blue NC,Managed Medicaid,,211.21,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Healthy Blue NC,Managed Medicaid,,294.49,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthy Blue NC,Managed Medicaid,,57.66,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthy Blue NC,Managed Medicaid,,57.66,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Healthy Blue NC,Managed Medicaid,,383.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Healthy Blue NC,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Healthy Blue NC,Managed Medicaid,,234.83,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Healthy Blue NC,Managed Medicaid,,502.70,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Healthy Blue NC,Managed Medicaid,,502.70,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Healthy Blue NC,Managed Medicaid,,407.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Healthy Blue NC,Managed Medicaid,,407.21,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Healthy Blue NC,Managed Medicaid,,347.95,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Healthy Blue NC,Managed Medicaid,,347.95,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Healthy Blue NC,Managed Medicaid,,316.92,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Healthy Blue NC,Managed Medicaid,,316.92,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Healthy Blue NC,Managed Medicaid,,329.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Healthy Blue NC,Managed Medicaid,,329.53,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Healthy Blue NC,Managed Medicaid,,342.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Healthy Blue NC,Managed Medicaid,,303.30,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Healthy Blue NC,Managed Medicaid,,303.30,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Healthy Blue NC,Managed Medicaid,,302.10,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Healthy Blue NC,Managed Medicaid,,302.10,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Healthy Blue NC,Managed Medicaid,,665.06,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Healthy Blue NC,Managed Medicaid,,665.06,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Healthy Blue NC,Managed Medicaid,,372.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Healthy Blue NC,Managed Medicaid,,372.37,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Healthy Blue NC,Managed Medicaid,,363.96,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Healthy Blue NC,Managed Medicaid,,363.96,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Healthy Blue NC,Managed Medicaid,,461.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Healthy Blue NC,Managed Medicaid,,73.67,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Healthy Blue NC,Managed Medicaid,,972.37,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Healthy Blue NC,Managed Medicaid,,44.04,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Healthy Blue NC,Managed Medicaid,,568.77,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Healthy Blue NC,Managed Medicaid,,598.60,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Healthy Blue NC,Managed Medicaid,,4031.43,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Healthy Blue NC,Managed Medicaid,,2143.34,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Healthy Blue NC,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Healthy Blue NC,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Healthy Blue NC,Managed Medicaid,,215.01,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Healthy Blue NC,Managed Medicaid,,138.74,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Healthy Blue NC,Managed Medicaid,,155.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Healthy Blue NC,Managed Medicaid,,1092.69,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Healthy Blue NC,Managed Medicaid,,743.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Healthy Blue NC,Managed Medicaid,,944.74,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Healthy Blue NC,Managed Medicaid,,774.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Healthy Blue NC,Managed Medicaid,,973.77,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Healthy Blue NC,Managed Medicaid,,798.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Healthy Blue NC,Managed Medicaid,,337.94,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Healthy Blue NC,Managed Medicaid,,114.71,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Healthy Blue NC,Managed Medicaid,,1493.89,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Healthy Blue NC,Managed Medicaid,,398.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Healthy Blue NC,Managed Medicaid,,298.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Healthy Blue NC,Managed Medicaid,,531.13,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Healthy Blue NC,Managed Medicaid,,5758.95,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Healthy Blue NC,Managed Medicaid,,838.24,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Healthy Blue NC,Managed Medicaid,,2658.46,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Healthy Blue NC,Managed Medicaid,,1771.37,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Healthy Blue NC,Managed Medicaid,,696.50,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Healthy Blue NC,Managed Medicaid,,248.45,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Healthy Blue NC,Managed Medicaid,,339.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Healthy Blue NC,Managed Medicaid,,339.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Healthy Blue NC,Managed Medicaid,,375.58,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Healthy Blue NC,Managed Medicaid,,375.58,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Healthy Blue NC,Managed Medicaid,,346.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Healthy Blue NC,Managed Medicaid,,346.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Healthy Blue NC,Managed Medicaid,,258.06,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Healthy Blue NC,Managed Medicaid,,146.75,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Healthy Blue NC,Managed Medicaid,,246.05,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Healthy Blue NC,Managed Medicaid,,1434.43,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Healthy Blue NC,Managed Medicaid,,358.56,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Healthy Blue NC,Managed Medicaid,,315.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Healthy Blue NC,Managed Medicaid,,371.17,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Healthy Blue NC,Managed Medicaid,,209.41,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Healthy Blue NC,Managed Medicaid,,717.92,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Healthy Blue NC,Managed Medicaid,,717.92,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Healthy Blue NC,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Healthy Blue NC,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Healthy Blue NC,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Healthy Blue NC,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Healthy Blue NC,Managed Medicaid,,693.69,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Healthy Blue NC,Managed Medicaid,,596.60,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Healthy Blue NC,Managed Medicaid,,1230.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Healthy Blue NC,Managed Medicaid,,1430.23,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Healthy Blue NC,Managed Medicaid,,1059.26,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Healthy Blue NC,Managed Medicaid,,954.35,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Healthy Blue NC,Managed Medicaid,,238.64,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Healthy Blue NC,Managed Medicaid,,1609.21,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Healthy Blue NC,Managed Medicaid,,1660.86,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Healthy Blue NC,Managed Medicaid,,2496.49,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Healthy Blue NC,Managed Medicaid,,1392.39,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Healthy Blue NC,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Healthy Blue NC,Managed Medicaid,,369.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Healthy Blue NC,Managed Medicaid,,178.38,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Healthy Blue NC,Managed Medicaid,,322.52,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Healthy Blue NC,Managed Medicaid,,238.44,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Healthy Blue NC,Managed Medicaid,,741.14,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Healthy Blue NC,Managed Medicaid,,650.85,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Healthy Blue NC,Managed Medicaid,,651.45,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Healthy Blue NC,Managed Medicaid,,561.56,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Healthy Blue NC,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Healthy Blue NC,Managed Medicaid,,954.75,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Healthy Blue NC,Managed Medicaid,,1107.51,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Healthy Blue NC,Managed Medicaid,,1623.02,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Healthy Blue NC,Managed Medicaid,,150.35,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Healthy Blue NC,Managed Medicaid,,2177.58,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Healthy Blue NC,Managed Medicaid,,1567.77,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Healthy Blue NC,Managed Medicaid,,762.16,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Healthy Blue NC,Managed Medicaid,,3427.62,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Healthy Blue NC,Managed Medicaid,,1466.87,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Healthy Blue NC,Managed Medicaid,,180.58,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Healthy Blue NC,Managed Medicaid,,696.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Healthy Blue NC,Managed Medicaid,,696.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Healthy Blue NC,Managed Medicaid,,3451.05,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Healthy Blue NC,Managed Medicaid,,3239.64,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Healthy Blue NC,Managed Medicaid,,3239.64,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Healthy Blue NC,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Healthy Blue NC,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Healthy Blue NC,Managed Medicaid,,1866.26,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Healthy Blue NC,Managed Medicaid,,1866.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Healthy Blue NC,Managed Medicaid,,2488.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Healthy Blue NC,Managed Medicaid,,1808.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Healthy Blue NC,Managed Medicaid,,582.58,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Healthy Blue NC,Managed Medicaid,,474.07,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Healthy Blue NC,Managed Medicaid,,474.07,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Healthy Blue NC,Managed Medicaid,,160.96,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Healthy Blue NC,Managed Medicaid,,1313.31,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Healthy Blue NC,Managed Medicaid,,337.54,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Healthy Blue NC,Managed Medicaid,,404.60,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Healthy Blue NC,Managed Medicaid,,642.84,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Healthy Blue NC,Managed Medicaid,,97.50,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthy Blue NC,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthy Blue NC,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthy Blue NC,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthy Blue NC,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Healthy Blue NC,Managed Medicaid,,1990.79,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Healthy Blue NC,Managed Medicaid,,1990.79,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Healthy Blue NC,Managed Medicaid,,803.60,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Healthy Blue NC,Managed Medicaid,,1219.62,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Healthy Blue NC,Managed Medicaid,,691.09,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Healthy Blue NC,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthy Blue NC,Managed Medicaid,,125.93,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthy Blue NC,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Healthy Blue NC,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Healthy Blue NC,Managed Medicaid,,812.41,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Healthy Blue NC,Managed Medicaid,,392.19,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Healthy Blue NC,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Healthy Blue NC,Managed Medicaid,,91.89,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthy Blue NC,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Healthy Blue NC,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Healthy Blue NC,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Healthy Blue NC,Managed Medicaid,,64.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Healthy Blue NC,Managed Medicaid,,178.98,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Healthy Blue NC,Managed Medicaid,,114.91,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Healthy Blue NC,Managed Medicaid,,228.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Healthy Blue NC,Managed Medicaid,,187.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Healthy Blue NC,Managed Medicaid,,211.81,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Healthy Blue NC,Managed Medicaid,,154.35,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Healthy Blue NC,Managed Medicaid,,167.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Healthy Blue NC,Managed Medicaid,,63.06,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Healthy Blue NC,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Healthy Blue NC,Managed Medicaid,,62.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Healthy Blue NC,Managed Medicaid,,165.16,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Healthy Blue NC,Managed Medicaid,,192.39,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Healthy Blue NC,Managed Medicaid,,103.90,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Healthy Blue NC,Managed Medicaid,,127.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Healthy Blue NC,Managed Medicaid,,85.49,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Healthy Blue NC,Managed Medicaid,,167.17,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Healthy Blue NC,Managed Medicaid,,133.73,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthy Blue NC,Managed Medicaid,,107.91,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Healthy Blue NC,Managed Medicaid,,131.73,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthy Blue NC,Managed Medicaid,,207.61,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Healthy Blue NC,Managed Medicaid,,164.76,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Healthy Blue NC,Managed Medicaid,,183.98,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Healthy Blue NC,Managed Medicaid,,60.26,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Healthy Blue NC,Managed Medicaid,,235.84,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Healthy Blue NC,Managed Medicaid,,152.95,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Healthy Blue NC,Managed Medicaid,,50.05,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Healthy Blue NC,Managed Medicaid,,46.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Healthy Blue NC,Managed Medicaid,,37.24,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Healthy Blue NC,Managed Medicaid,,220.62,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Healthy Blue NC,Managed Medicaid,,165.16,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Healthy Blue NC,Managed Medicaid,,39.84,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Healthy Blue NC,Managed Medicaid,,136.94,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Healthy Blue NC,Managed Medicaid,,84.48,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Healthy Blue NC,Managed Medicaid,,193.59,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Healthy Blue NC,Managed Medicaid,,144.94,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Healthy Blue NC,Managed Medicaid,,82.68,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Healthy Blue NC,Managed Medicaid,,98.50,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Healthy Blue NC,Managed Medicaid,,91.89,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Healthy Blue NC,Managed Medicaid,,27.83,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Healthy Blue NC,Managed Medicaid,,13.41,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Healthy Blue NC,Managed Medicaid,,21.82,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Healthy Blue NC,Managed Medicaid,,1278.48,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Healthy Blue NC,Managed Medicaid,,931.73,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Healthy Blue NC,Managed Medicaid,,837.24,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Healthy Blue NC,Managed Medicaid,,1299.50,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Healthy Blue NC,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Healthy Blue NC,Managed Medicaid,,538.14,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Healthy Blue NC,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Healthy Blue NC,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Healthy Blue NC,Managed Medicaid,,186.39,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Healthy Blue NC,Managed Medicaid,,306.51,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Healthy Blue NC,Managed Medicaid,,612.81,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Healthy Blue NC,Managed Medicaid,,932.93,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Healthy Blue NC,Managed Medicaid,,836.04,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Healthy Blue NC,Managed Medicaid,,1211.61,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Healthy Blue NC,Managed Medicaid,,1780.98,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Healthy Blue NC,Managed Medicaid,,105.51,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Healthy Blue NC,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Healthy Blue NC,Managed Medicaid,,114.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Healthy Blue NC,Managed Medicaid,,202.60,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Healthy Blue NC,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Healthy Blue NC,Managed Medicaid,,494.29,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Healthy Blue NC,Managed Medicaid,,96.30,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Healthy Blue NC,Managed Medicaid,,563.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Healthy Blue NC,Managed Medicaid,,659.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Healthy Blue NC,Managed Medicaid,,1014.81,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Healthy Blue NC,Managed Medicaid,,1226.63,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Healthy Blue NC,Managed Medicaid,,692.49,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Healthy Blue NC,Managed Medicaid,,1035.63,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Healthy Blue NC,Managed Medicaid,,1078.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Healthy Blue NC,Managed Medicaid,,721.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Healthy Blue NC,Managed Medicaid,,753.75,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Healthy Blue NC,Managed Medicaid,,1032.63,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Healthy Blue NC,Managed Medicaid,,695.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Healthy Blue NC,Managed Medicaid,,816.02,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Healthy Blue NC,Managed Medicaid,,940.74,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Healthy Blue NC,Managed Medicaid,,742.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Healthy Blue NC,Managed Medicaid,,779.18,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Healthy Blue NC,Managed Medicaid,,1067.47,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Healthy Blue NC,Managed Medicaid,,735.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Healthy Blue NC,Managed Medicaid,,743.14,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Healthy Blue NC,Managed Medicaid,,1032.63,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Healthy Blue NC,Managed Medicaid,,852.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Healthy Blue NC,Managed Medicaid,,901.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Healthy Blue NC,Managed Medicaid,,1047.85,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Healthy Blue NC,Managed Medicaid,,584.38,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Healthy Blue NC,Managed Medicaid,,837.84,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Healthy Blue NC,Managed Medicaid,,635.03,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Healthy Blue NC,Managed Medicaid,,50.65,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Healthy Blue NC,Managed Medicaid,52,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Healthy Blue NC,Managed Medicaid,52,787.39,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Healthy Blue NC,Managed Medicaid,,769.37,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Healthy Blue NC,Managed Medicaid,,881.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Healthy Blue NC,Managed Medicaid,,1040.24,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Healthy Blue NC,Managed Medicaid,,805.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Healthy Blue NC,Managed Medicaid,,827.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Healthy Blue NC,Managed Medicaid,,703.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Healthy Blue NC,Managed Medicaid,,855.65,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Healthy Blue NC,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Healthy Blue NC,Managed Medicaid,,811.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Healthy Blue NC,Managed Medicaid,,1021.82,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Healthy Blue NC,Managed Medicaid,,983.38,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Healthy Blue NC,Managed Medicaid,,1091.89,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Healthy Blue NC,Managed Medicaid,,838.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Healthy Blue NC,Managed Medicaid,,928.33,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Healthy Blue NC,Managed Medicaid,,1118.32,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Healthy Blue NC,Managed Medicaid,,694.29,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Healthy Blue NC,Managed Medicaid,,734.93,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Healthy Blue NC,Managed Medicaid,,1069.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Healthy Blue NC,Managed Medicaid,,649.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Healthy Blue NC,Managed Medicaid,,720.52,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Healthy Blue NC,Managed Medicaid,,1000.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Healthy Blue NC,Managed Medicaid,,845.85,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Healthy Blue NC,Managed Medicaid,,647.85,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Healthy Blue NC,Managed Medicaid,,895.29,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Healthy Blue NC,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Healthy Blue NC,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Healthy Blue NC,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Healthy Blue NC,Managed Medicaid,,707.71,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Healthy Blue NC,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Healthy Blue NC,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Healthy Blue NC,Managed Medicaid,,899.50,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Healthy Blue NC,Managed Medicaid,,650.65,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Healthy Blue NC,Managed Medicaid,,919.72,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Healthy Blue NC,Managed Medicaid,,894.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Healthy Blue NC,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Healthy Blue NC,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Healthy Blue NC,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Healthy Blue NC,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Healthy Blue NC,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Healthy Blue NC,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Healthy Blue NC,Managed Medicaid,,206.81,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Healthy Blue NC,Managed Medicaid,,480.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Healthy Blue NC,Managed Medicaid,,477.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Healthy Blue NC,Managed Medicaid,,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Healthy Blue NC,Managed Medicaid,,375.38,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Healthy Blue NC,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthy Blue NC,Managed Medicaid,,64.86,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Healthy Blue NC,Managed Medicaid,,79.88,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Healthy Blue NC,Managed Medicaid,,349.35,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Healthy Blue NC,Managed Medicaid,,349.35,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Healthy Blue NC,Managed Medicaid,,31.63,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Healthy Blue NC,Managed Medicaid,,366.57,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Healthy Blue NC,Managed Medicaid,,366.57,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Healthy Blue NC,Managed Medicaid,,181.18,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Healthy Blue NC,Managed Medicaid,,108.11,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthy Blue NC,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Healthy Blue NC,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Healthy Blue NC,Managed Medicaid,,260.06,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Healthy Blue NC,Managed Medicaid,,207.61,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Healthy Blue NC,Managed Medicaid,,169.57,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Healthy Blue NC,Managed Medicaid,,123.32,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Healthy Blue NC,Managed Medicaid,,119.92,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Healthy Blue NC,Managed Medicaid,,58.46,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Healthy Blue NC,Managed Medicaid,,86.29,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Healthy Blue NC,Managed Medicaid,,63.46,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthy Blue NC,Managed Medicaid,,57.66,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Healthy Blue NC,Managed Medicaid,,136.14,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Healthy Blue NC,Managed Medicaid,,56.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthy Blue NC,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Healthy Blue NC,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Healthy Blue NC,Managed Medicaid,,287.49,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Healthy Blue NC,Managed Medicaid,,150.55,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Healthy Blue NC,Managed Medicaid,,373.57,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Healthy Blue NC,Managed Medicaid,,870.87,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Healthy Blue NC,Managed Medicaid,,50.45,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Healthy Blue NC,Managed Medicaid,,35.44,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Healthy Blue NC,Managed Medicaid,,73.87,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Healthy Blue NC,Managed Medicaid,,36.64,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Healthy Blue NC,Managed Medicaid,,85.49,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Healthy Blue NC,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthy Blue NC,Managed Medicaid,,55.05,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Healthy Blue NC,Managed Medicaid,,79.88,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Healthy Blue NC,Managed Medicaid,,126.33,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Healthy Blue NC,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Healthy Blue NC,Managed Medicaid,,174.97,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Healthy Blue NC,Managed Medicaid,,112.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthy Blue NC,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Healthy Blue NC,Managed Medicaid,,72.47,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Healthy Blue NC,Managed Medicaid,,151.35,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Healthy Blue NC,Managed Medicaid,,61.06,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Healthy Blue NC,Managed Medicaid,,133.13,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Healthy Blue NC,Managed Medicaid,,84.48,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Healthy Blue NC,Managed Medicaid,,191.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Healthy Blue NC,Managed Medicaid,,119.92,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Healthy Blue NC,Managed Medicaid,,84.48,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Healthy Blue NC,Managed Medicaid,,91.69,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Healthy Blue NC,Managed Medicaid,,72.87,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Healthy Blue NC,Managed Medicaid,,505.30,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Healthy Blue NC,Managed Medicaid,,434.23,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Healthy Blue NC,Managed Medicaid,,221.42,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Healthy Blue NC,Managed Medicaid,,104.30,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Healthy Blue NC,Managed Medicaid,,110.71,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Healthy Blue NC,Managed Medicaid,,67.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthy Blue NC,Managed Medicaid,,25.63,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Healthy Blue NC,Managed Medicaid,,102.50,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Healthy Blue NC,Managed Medicaid,,80.88,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Healthy Blue NC,Managed Medicaid,,80.88,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Healthy Blue NC,Managed Medicaid,,481.28,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,,9.41,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Healthy Blue NC,Managed Medicaid,,2.80,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Healthy Blue NC,Managed Medicaid,,22.42,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthy Blue NC,Managed Medicaid,,32.63,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthy Blue NC,Managed Medicaid,,26.43,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthy Blue NC,Managed Medicaid,,5.21,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Healthy Blue NC,Managed Medicaid,,8.81,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthy Blue NC,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Healthy Blue NC,Managed Medicaid,,53.05,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Healthy Blue NC,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthy Blue NC,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Healthy Blue NC,Managed Medicaid,,79.48,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Healthy Blue NC,Managed Medicaid,,31.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Healthy Blue NC,Managed Medicaid,,107.11,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Healthy Blue NC,Managed Medicaid,,14.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthy Blue NC,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthy Blue NC,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Healthy Blue NC,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthy Blue NC,Managed Medicaid,,5.81,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Healthy Blue NC,Managed Medicaid,,35.44,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Healthy Blue NC,Managed Medicaid,,24.82,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthy Blue NC,Managed Medicaid,,7.81,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthy Blue NC,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthy Blue NC,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthy Blue NC,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Healthy Blue NC,Managed Medicaid,,30.83,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthy Blue NC,Managed Medicaid,,5.81,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthy Blue NC,Managed Medicaid,,8.61,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthy Blue NC,Managed Medicaid,,8.41,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Healthy Blue NC,Managed Medicaid,,9.61,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthy Blue NC,Managed Medicaid,,32.43,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthy Blue NC,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthy Blue NC,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthy Blue NC,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthy Blue NC,Managed Medicaid,,8.41,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Healthy Blue NC,Managed Medicaid,,12.01,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthy Blue NC,Managed Medicaid,,8.01,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthy Blue NC,Managed Medicaid,,8.01,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Healthy Blue NC,Managed Medicaid,,33.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthy Blue NC,Managed Medicaid,,13.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Healthy Blue NC,Managed Medicaid,,10.61,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Healthy Blue NC,Managed Medicaid,,51.65,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthy Blue NC,Managed Medicaid,,13.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Healthy Blue NC,Managed Medicaid,,48.65,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthy Blue NC,Managed Medicaid,,36.04,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Healthy Blue NC,Managed Medicaid,,29.23,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthy Blue NC,Managed Medicaid,,15.82,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthy Blue NC,Managed Medicaid,,7.81,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Healthy Blue NC,Managed Medicaid,,59.86,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Healthy Blue NC,Managed Medicaid,,1.20,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Healthy Blue NC,Managed Medicaid,,40.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Healthy Blue NC,Managed Medicaid,,115.92,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthy Blue NC,Managed Medicaid,,31.43,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthy Blue NC,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthy Blue NC,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthy Blue NC,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthy Blue NC,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthy Blue NC,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthy Blue NC,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthy Blue NC,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthy Blue NC,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthy Blue NC,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,,6.01,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Healthy Blue NC,Managed Medicaid,,14.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Healthy Blue NC,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthy Blue NC,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Healthy Blue NC,Managed Medicaid,,15.62,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Healthy Blue NC,Managed Medicaid,,47.65,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Healthy Blue NC,Managed Medicaid,,31.23,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Healthy Blue NC,Managed Medicaid,,44.24,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthy Blue NC,Managed Medicaid,,24.02,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Healthy Blue NC,Managed Medicaid,,30.43,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Healthy Blue NC,Managed Medicaid,,39.44,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthy Blue NC,Managed Medicaid,,26.43,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthy Blue NC,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthy Blue NC,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthy Blue NC,Managed Medicaid,,8.41,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Healthy Blue NC,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Healthy Blue NC,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Healthy Blue NC,Managed Medicaid,,29.83,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthy Blue NC,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthy Blue NC,Managed Medicaid,,28.63,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Healthy Blue NC,Managed Medicaid,,16.62,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthy Blue NC,Managed Medicaid,,28.63,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Healthy Blue NC,Managed Medicaid,,35.44,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthy Blue NC,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthy Blue NC,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthy Blue NC,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Healthy Blue NC,Managed Medicaid,,0.40040,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Healthy Blue NC,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Healthy Blue NC,Managed Medicaid,,11.01,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Healthy Blue NC,Managed Medicaid,,29.23,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Healthy Blue NC,Managed Medicaid,,45.45,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Healthy Blue NC,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Healthy Blue NC,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthy Blue NC,Managed Medicaid,,9.01,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Healthy Blue NC,Managed Medicaid,,10.61,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthy Blue NC,Managed Medicaid,,10.01,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthy Blue NC,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthy Blue NC,Managed Medicaid,,9.01,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthy Blue NC,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthy Blue NC,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthy Blue NC,Managed Medicaid,,8.61,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthy Blue NC,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Healthy Blue NC,Managed Medicaid,,33.43,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthy Blue NC,Managed Medicaid,,9.01,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Healthy Blue NC,Managed Medicaid,,32.03,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Healthy Blue NC,Managed Medicaid,,38.04,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthy Blue NC,Managed Medicaid,,13.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Healthy Blue NC,Managed Medicaid,,26.83,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthy Blue NC,Managed Medicaid,,26.03,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Healthy Blue NC,Managed Medicaid,,21.62,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthy Blue NC,Managed Medicaid,,7.61,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthy Blue NC,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Healthy Blue NC,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthy Blue NC,Managed Medicaid,,26.03,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Healthy Blue NC,Managed Medicaid,,38.64,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthy Blue NC,Managed Medicaid,,15.82,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Healthy Blue NC,Managed Medicaid,,2.40,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Healthy Blue NC,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Healthy Blue NC,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Healthy Blue NC,Managed Medicaid,,45.05,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthy Blue NC,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Healthy Blue NC,Managed Medicaid,,28.03,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthy Blue NC,Managed Medicaid,,22.62,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthy Blue NC,Managed Medicaid,,19.42,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Healthy Blue NC,Managed Medicaid,,27.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthy Blue NC,Managed Medicaid,,24.02,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Healthy Blue NC,Managed Medicaid,,1.60,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Healthy Blue NC,Managed Medicaid,,4.40,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Healthy Blue NC,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Healthy Blue NC,Managed Medicaid,,34.83,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Healthy Blue NC,Managed Medicaid,,25.63,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Healthy Blue NC,Managed Medicaid,,53.45,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Healthy Blue NC,Managed Medicaid,,29.43,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Healthy Blue NC,Managed Medicaid,,54.65,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Healthy Blue NC,Managed Medicaid,,41.44,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthy Blue NC,Managed Medicaid,,10.01,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Healthy Blue NC,Managed Medicaid,,47.45,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Healthy Blue NC,Managed Medicaid,,41.24,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Healthy Blue NC,Managed Medicaid,,8.21,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Healthy Blue NC,Managed Medicaid,,58.66,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Healthy Blue NC,Managed Medicaid,,40.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthy Blue NC,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthy Blue NC,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthy Blue NC,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthy Blue NC,Managed Medicaid,,10.01,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthy Blue NC,Managed Medicaid,,27.03,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Healthy Blue NC,Managed Medicaid,,44.64,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Healthy Blue NC,Managed Medicaid,,4.20,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthy Blue NC,Managed Medicaid,,11.41,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthy Blue NC,Managed Medicaid,,29.03,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Healthy Blue NC,Managed Medicaid,,13.61,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,,23.42,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Healthy Blue NC,Managed Medicaid,,34.63,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthy Blue NC,Managed Medicaid,,19.42,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthy Blue NC,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthy Blue NC,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthy Blue NC,Managed Medicaid,,3.00,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthy Blue NC,Managed Medicaid,,7.01,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthy Blue NC,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Healthy Blue NC,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Healthy Blue NC,Managed Medicaid,,92.29,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthy Blue NC,Managed Medicaid,,24.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Healthy Blue NC,Managed Medicaid,,39.04,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Healthy Blue NC,Managed Medicaid,,16.62,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Healthy Blue NC,Managed Medicaid,,2.20,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthy Blue NC,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthy Blue NC,Managed Medicaid,,27.03,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Healthy Blue NC,Managed Medicaid,,21.62,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Healthy Blue NC,Managed Medicaid,,158.96,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Healthy Blue NC,Managed Medicaid,,89.49,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Healthy Blue NC,Managed Medicaid,,53.25,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Healthy Blue NC,Managed Medicaid,,114.11,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Healthy Blue NC,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Healthy Blue NC,Managed Medicaid,,59.26,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Healthy Blue NC,Managed Medicaid,,72.27,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Healthy Blue NC,Managed Medicaid,,46.65,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthy Blue NC,Managed Medicaid,,29.03,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Healthy Blue NC,Managed Medicaid,,24.62,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Healthy Blue NC,Managed Medicaid,,26.83,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Healthy Blue NC,Managed Medicaid,,39.24,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Healthy Blue NC,Managed Medicaid,,34.63,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Healthy Blue NC,Managed Medicaid,,100.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Healthy Blue NC,Managed Medicaid,,147.55,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Healthy Blue NC,Managed Medicaid,,25.23,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Healthy Blue NC,Managed Medicaid,,27.83,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthy Blue NC,Managed Medicaid,,30.03,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Healthy Blue NC,Managed Medicaid,,18.62,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthy Blue NC,Managed Medicaid,,32.43,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Healthy Blue NC,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Healthy Blue NC,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Healthy Blue NC,Managed Medicaid,,64.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthy Blue NC,Managed Medicaid,,55.05,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Healthy Blue NC,Managed Medicaid,,58.26,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Healthy Blue NC,Managed Medicaid,,52.85,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Healthy Blue NC,Managed Medicaid,,122.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Healthy Blue NC,Managed Medicaid,,32.23,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Healthy Blue NC,Managed Medicaid,,47.45,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Healthy Blue NC,Managed Medicaid,,39.84,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthy Blue NC,Managed Medicaid,,19.82,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Healthy Blue NC,Managed Medicaid,,65.06,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Healthy Blue NC,Managed Medicaid,,54.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Healthy Blue NC,Managed Medicaid,,64.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Healthy Blue NC,Managed Medicaid,,50.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Healthy Blue NC,Managed Medicaid,,36.44,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Healthy Blue NC,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Healthy Blue NC,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Healthy Blue NC,Managed Medicaid,,49.45,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Healthy Blue NC,Managed Medicaid,,8.81,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthy Blue NC,Managed Medicaid,,30.03,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Healthy Blue NC,Managed Medicaid,,39.24,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Healthy Blue NC,Managed Medicaid,,93.69,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Healthy Blue NC,Managed Medicaid,,56.66,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthy Blue NC,Managed Medicaid,,7.01,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Healthy Blue NC,Managed Medicaid,,14.41,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Healthy Blue NC,Managed Medicaid,,22.62,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Healthy Blue NC,Managed Medicaid,,71.27,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Healthy Blue NC,Managed Medicaid,,29.23,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Healthy Blue NC,Managed Medicaid,,40.44,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Healthy Blue NC,Managed Medicaid,,28.63,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Healthy Blue NC,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthy Blue NC,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Healthy Blue NC,Managed Medicaid,,20.42,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Healthy Blue NC,Managed Medicaid,,17.02,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Healthy Blue NC,Managed Medicaid,,19.62,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Healthy Blue NC,Managed Medicaid,,44.84,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthy Blue NC,Managed Medicaid,,7.81,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Healthy Blue NC,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Healthy Blue NC,Managed Medicaid,,9.41,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthy Blue NC,Managed Medicaid,,3.00,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Healthy Blue NC,Managed Medicaid,,8.21,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Healthy Blue NC,Managed Medicaid,,37.64,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Healthy Blue NC,Managed Medicaid,,24.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Healthy Blue NC,Managed Medicaid,,26.03,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Healthy Blue NC,Managed Medicaid,,14.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthy Blue NC,Managed Medicaid,,31.43,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Healthy Blue NC,Managed Medicaid,,5.41,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Healthy Blue NC,Managed Medicaid,,10.61,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Healthy Blue NC,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Healthy Blue NC,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthy Blue NC,Managed Medicaid,,19.42,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Healthy Blue NC,Managed Medicaid,,42.64,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Healthy Blue NC,Managed Medicaid,,40.84,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Healthy Blue NC,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Healthy Blue NC,Managed Medicaid,,40.84,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Healthy Blue NC,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,,14.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Healthy Blue NC,Managed Medicaid,,29.03,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Healthy Blue NC,Managed Medicaid,,18.42,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthy Blue NC,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthy Blue NC,Managed Medicaid,,5.21,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,,25.83,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthy Blue NC,Managed Medicaid,,23.22,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthy Blue NC,Managed Medicaid,,15.82,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Healthy Blue NC,Managed Medicaid,,67.87,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Healthy Blue NC,Managed Medicaid,,13.61,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,,17.82,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Healthy Blue NC,Managed Medicaid,,3.20,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Healthy Blue NC,Managed Medicaid,,49.05,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Healthy Blue NC,Managed Medicaid,,30.83,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Healthy Blue NC,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Healthy Blue NC,Managed Medicaid,,19.82,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Healthy Blue NC,Managed Medicaid,,15.62,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Healthy Blue NC,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthy Blue NC,Managed Medicaid,,11.41,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthy Blue NC,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Healthy Blue NC,Managed Medicaid,,12.61,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Healthy Blue NC,Managed Medicaid,,36.04,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Healthy Blue NC,Managed Medicaid,,6.61,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthy Blue NC,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Healthy Blue NC,Managed Medicaid,,45.65,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Healthy Blue NC,Managed Medicaid,,33.83,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Healthy Blue NC,Managed Medicaid,,92.29,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Healthy Blue NC,Managed Medicaid,,42.64,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Healthy Blue NC,Managed Medicaid,,42.64,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Healthy Blue NC,Managed Medicaid,,125.93,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Healthy Blue NC,Managed Medicaid,,116.32,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Healthy Blue NC,Managed Medicaid,,34.83,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Healthy Blue NC,Managed Medicaid,,32.23,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Healthy Blue NC,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Healthy Blue NC,Managed Medicaid,,42.44,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthy Blue NC,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthy Blue NC,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthy Blue NC,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Healthy Blue NC,Managed Medicaid,,51.45,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Healthy Blue NC,Managed Medicaid,,154.15,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Healthy Blue NC,Managed Medicaid,,17.42,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Healthy Blue NC,Managed Medicaid,,16.62,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Healthy Blue NC,Managed Medicaid,,9.61,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Healthy Blue NC,Managed Medicaid,,22.42,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Healthy Blue NC,Managed Medicaid,,115.92,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Healthy Blue NC,Managed Medicaid,,55.86,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Healthy Blue NC,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Healthy Blue NC,Managed Medicaid,,30.83,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Healthy Blue NC,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Healthy Blue NC,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Healthy Blue NC,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Healthy Blue NC,Managed Medicaid,,92.69,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Healthy Blue NC,Managed Medicaid,,58.86,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Healthy Blue NC,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Healthy Blue NC,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Healthy Blue NC,Managed Medicaid,,25.23,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Healthy Blue NC,Managed Medicaid,,2.40,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthy Blue NC,Managed Medicaid,,30.03,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Healthy Blue NC,Managed Medicaid,,24.02,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Healthy Blue NC,Managed Medicaid,,109.71,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Healthy Blue NC,Managed Medicaid,,61.86,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Healthy Blue NC,Managed Medicaid,,25.43,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Healthy Blue NC,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Healthy Blue NC,Managed Medicaid,,4.40,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Healthy Blue NC,Managed Medicaid,,46.05,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthy Blue NC,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Healthy Blue NC,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Healthy Blue NC,Managed Medicaid,,11.61,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthy Blue NC,Managed Medicaid,,7.01,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthy Blue NC,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Healthy Blue NC,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Healthy Blue NC,Managed Medicaid,,12.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Healthy Blue NC,Managed Medicaid,,12.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthy Blue NC,Managed Medicaid,,9.21,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Healthy Blue NC,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Healthy Blue NC,Managed Medicaid,,14.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthy Blue NC,Managed Medicaid,,3.00,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Healthy Blue NC,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Healthy Blue NC,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Healthy Blue NC,Managed Medicaid,,26.83,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Healthy Blue NC,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Healthy Blue NC,Managed Medicaid,,5.21,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthy Blue NC,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthy Blue NC,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthy Blue NC,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Healthy Blue NC,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Healthy Blue NC,Managed Medicaid,,0.40040,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Healthy Blue NC,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Healthy Blue NC,Managed Medicaid,,16.22,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Healthy Blue NC,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Healthy Blue NC,Managed Medicaid,,32.23,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Healthy Blue NC,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Healthy Blue NC,Managed Medicaid,,28.23,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Healthy Blue NC,Managed Medicaid,,6.81,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Healthy Blue NC,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Healthy Blue NC,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Healthy Blue NC,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Healthy Blue NC,Managed Medicaid,,7.01,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Healthy Blue NC,Managed Medicaid,,15.02,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Healthy Blue NC,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Healthy Blue NC,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Healthy Blue NC,Managed Medicaid,,153.55,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Healthy Blue NC,Managed Medicaid,,26.83,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Healthy Blue NC,Managed Medicaid,,361.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Healthy Blue NC,Managed Medicaid,,251.85,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Healthy Blue NC,Managed Medicaid,,58.66,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Healthy Blue NC,Managed Medicaid,,23.22,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Healthy Blue NC,Managed Medicaid,,386.59,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Healthy Blue NC,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Healthy Blue NC,Managed Medicaid,,51.85,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthy Blue NC,Managed Medicaid,,9.21,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Healthy Blue NC,Managed Medicaid,,361.96,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Healthy Blue NC,Managed Medicaid,,141.54,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Healthy Blue NC,Managed Medicaid,,102.70,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthy Blue NC,Managed Medicaid,,37.84,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Healthy Blue NC,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Healthy Blue NC,Managed Medicaid,,22.82,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Healthy Blue NC,Managed Medicaid,,64.86,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Healthy Blue NC,Managed Medicaid,,38.84,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Healthy Blue NC,Managed Medicaid,,190.79,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Healthy Blue NC,Managed Medicaid,,127.93,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Healthy Blue NC,Managed Medicaid,,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Healthy Blue NC,Managed Medicaid,QW,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Healthy Blue NC,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Healthy Blue NC,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Healthy Blue NC,Managed Medicaid,,318.12,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Healthy Blue NC,Managed Medicaid,,237.64,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Healthy Blue NC,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Healthy Blue NC,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Healthy Blue NC,Managed Medicaid,,95.70,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Healthy Blue NC,Managed Medicaid,,40.84,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Healthy Blue NC,Managed Medicaid,,85.29,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Healthy Blue NC,Managed Medicaid,,10.01,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,QW,20.02,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Healthy Blue NC,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Healthy Blue NC,Managed Medicaid,,32.63,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Healthy Blue NC,Managed Medicaid,,181.58,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthy Blue NC,Managed Medicaid,,55.05,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthy Blue NC,Managed Medicaid,,26.43,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,,33.03,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Healthy Blue NC,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthy Blue NC,Managed Medicaid,,8.61,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Healthy Blue NC,Managed Medicaid,,56.06,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Healthy Blue NC,Managed Medicaid,,15.82,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Healthy Blue NC,Managed Medicaid,,38.84,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Healthy Blue NC,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthy Blue NC,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Healthy Blue NC,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthy Blue NC,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Healthy Blue NC,Managed Medicaid,,42.64,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Healthy Blue NC,Managed Medicaid,,43.84,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthy Blue NC,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthy Blue NC,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Healthy Blue NC,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthy Blue NC,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Healthy Blue NC,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Healthy Blue NC,Managed Medicaid,,15.22,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthy Blue NC,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Healthy Blue NC,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Healthy Blue NC,Managed Medicaid,,20.22,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Healthy Blue NC,Managed Medicaid,,29.83,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Healthy Blue NC,Managed Medicaid,,265.87,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Healthy Blue NC,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Healthy Blue NC,Managed Medicaid,,21.62,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Healthy Blue NC,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Healthy Blue NC,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthy Blue NC,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Healthy Blue NC,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Healthy Blue NC,Managed Medicaid,,33.43,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Healthy Blue NC,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Healthy Blue NC,Managed Medicaid,,63.86,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Healthy Blue NC,Managed Medicaid,,103.10,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Healthy Blue NC,Managed Medicaid,,105.31,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Healthy Blue NC,Managed Medicaid,,42.04,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Healthy Blue NC,Managed Medicaid,,5.41,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Healthy Blue NC,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Healthy Blue NC,Managed Medicaid,,37.24,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Healthy Blue NC,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Healthy Blue NC,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Healthy Blue NC,Managed Medicaid,,7.81,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Healthy Blue NC,Managed Medicaid,,39.64,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Healthy Blue NC,Managed Medicaid,,23.82,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Healthy Blue NC,Managed Medicaid,,51.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Healthy Blue NC,Managed Medicaid,,52.25,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Healthy Blue NC,Managed Medicaid,,15.62,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Healthy Blue NC,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Healthy Blue NC,Managed Medicaid,,41.84,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Healthy Blue NC,Managed Medicaid,,41.44,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Healthy Blue NC,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Healthy Blue NC,Managed Medicaid,,29.63,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Healthy Blue NC,Managed Medicaid,,91.29,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Healthy Blue NC,Managed Medicaid,,119.52,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Healthy Blue NC,Managed Medicaid,,151.15,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Healthy Blue NC,Managed Medicaid,,112.31,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Healthy Blue NC,Managed Medicaid,,65.06,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Healthy Blue NC,Managed Medicaid,,45.05,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Healthy Blue NC,Managed Medicaid,,204.00,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Healthy Blue NC,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Healthy Blue NC,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Healthy Blue NC,Managed Medicaid,,44.84,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthy Blue NC,Managed Medicaid,,26.43,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Healthy Blue NC,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Healthy Blue NC,Managed Medicaid,,109.71,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Healthy Blue NC,Managed Medicaid,,20.42,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Healthy Blue NC,Managed Medicaid,,35.03,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Healthy Blue NC,Managed Medicaid,,73.47,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthy Blue NC,Managed Medicaid,,132.13,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Healthy Blue NC,Managed Medicaid,,0.00200,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Healthy Blue NC,Managed Medicaid,,24.82,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Healthy Blue NC,Managed Medicaid,,45.25,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Healthy Blue NC,Managed Medicaid,,74.07,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Healthy Blue NC,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Healthy Blue NC,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Healthy Blue NC,Managed Medicaid,,118.72,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Healthy Blue NC,Managed Medicaid,,109.71,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthy Blue NC,Managed Medicaid,,19.42,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Healthy Blue NC,Managed Medicaid,,78.88,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Healthy Blue NC,Managed Medicaid,,62.66,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Healthy Blue NC,Managed Medicaid,,49.85,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Healthy Blue NC,Managed Medicaid,,15.42,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Healthy Blue NC,Managed Medicaid,,76.88,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Healthy Blue NC,Managed Medicaid,,26.43,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Healthy Blue NC,Managed Medicaid,,135.13,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Healthy Blue NC,Managed Medicaid,,37.84,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Healthy Blue NC,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Healthy Blue NC,Managed Medicaid,,51.25,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Healthy Blue NC,Managed Medicaid,,52.25,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthy Blue NC,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Healthy Blue NC,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Healthy Blue NC,Managed Medicaid,,107.91,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Healthy Blue NC,Managed Medicaid,,27.83,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Healthy Blue NC,Managed Medicaid,,32.83,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Healthy Blue NC,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Healthy Blue NC,Managed Medicaid,,82.88,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Healthy Blue NC,Managed Medicaid,,49.45,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Healthy Blue NC,Managed Medicaid,,438.64,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Healthy Blue NC,Managed Medicaid,,70.67,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Healthy Blue NC,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Healthy Blue NC,Managed Medicaid,,141.74,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Healthy Blue NC,Managed Medicaid,,103.70,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Healthy Blue NC,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Healthy Blue NC,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Healthy Blue NC,Managed Medicaid,,103.90,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Healthy Blue NC,Managed Medicaid,,257.26,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Healthy Blue NC,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Healthy Blue NC,Managed Medicaid,,62.46,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Healthy Blue NC,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Healthy Blue NC,Managed Medicaid,,248.85,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Healthy Blue NC,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Healthy Blue NC,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Healthy Blue NC,Managed Medicaid,,181.78,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Healthy Blue NC,Managed Medicaid,,132.13,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Healthy Blue NC,Managed Medicaid,,94.89,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Healthy Blue NC,Managed Medicaid,,71.27,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Healthy Blue NC,Managed Medicaid,,25.02,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Healthy Blue NC,Managed Medicaid,,30.03,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Healthy Blue NC,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Healthy Blue NC,Managed Medicaid,,33.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Healthy Blue NC,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Healthy Blue NC,Managed Medicaid,,31.83,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Healthy Blue NC,Managed Medicaid,,318.12,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Healthy Blue NC,Managed Medicaid,,159.76,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Healthy Blue NC,Managed Medicaid,,65.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Healthy Blue NC,Managed Medicaid,,13.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Healthy Blue NC,Managed Medicaid,,8.41,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Healthy Blue NC,Managed Medicaid,,21.02,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Healthy Blue NC,Managed Medicaid,,49.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Healthy Blue NC,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Healthy Blue NC,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Healthy Blue NC,Managed Medicaid,,55.46,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Healthy Blue NC,Managed Medicaid,,113.31,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Healthy Blue NC,Managed Medicaid,,11.41,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Healthy Blue NC,Managed Medicaid,,135.94,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Healthy Blue NC,Managed Medicaid,,130.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthy Blue NC,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Healthy Blue NC,Managed Medicaid,,214.21,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Healthy Blue NC,Managed Medicaid,,43.04,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Healthy Blue NC,Managed Medicaid,,83.88,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Healthy Blue NC,Managed Medicaid,,58.86,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Healthy Blue NC,Managed Medicaid,,189.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Healthy Blue NC,Managed Medicaid,,248.25,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Healthy Blue NC,Managed Medicaid,,120.12,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Healthy Blue NC,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Healthy Blue NC,Managed Medicaid,,305.91,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Healthy Blue NC,Managed Medicaid,,5.61,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Healthy Blue NC,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Healthy Blue NC,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthy Blue NC,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Healthy Blue NC,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Healthy Blue NC,Managed Medicaid,,232.23,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Healthy Blue NC,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Healthy Blue NC,Managed Medicaid,,523.72,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthy Blue NC,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthy Blue NC,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthy Blue NC,Managed Medicaid,,1715.71,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthy Blue NC,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthy Blue NC,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Healthy Blue NC,Managed Medicaid,,7102.50,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Healthy Blue NC,Managed Medicaid,,1203.60,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthy Blue NC,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Healthy Blue NC,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Healthy Blue NC,Managed Medicaid,,1344.34,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Healthy Blue NC,Managed Medicaid,,409.01,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Healthy Blue NC,Managed Medicaid,,674.27,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Healthy Blue NC,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Healthy Blue NC,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Healthy Blue NC,Managed Medicaid,,396.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Healthy Blue NC,Managed Medicaid,,396.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Healthy Blue NC,Managed Medicaid,,834.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Healthy Blue NC,Managed Medicaid,,834.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Healthy Blue NC,Managed Medicaid,,379.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Healthy Blue NC,Managed Medicaid,,379.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Healthy Blue NC,Managed Medicaid,,89.49,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Healthy Blue NC,Managed Medicaid,,164.76,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Healthy Blue NC,Managed Medicaid,,359.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Healthy Blue NC,Managed Medicaid,,359.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Healthy Blue NC,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Healthy Blue NC,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Healthy Blue NC,Managed Medicaid,,317.52,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Healthy Blue NC,Managed Medicaid,,317.52,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Healthy Blue NC,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Healthy Blue NC,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Healthy Blue NC,Managed Medicaid,,1544.94,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Healthy Blue NC,Managed Medicaid,,772.37,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Healthy Blue NC,Managed Medicaid,,772.37,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Healthy Blue NC,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Healthy Blue NC,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthy Blue NC,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthy Blue NC,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Healthy Blue NC,Managed Medicaid,,275.88,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Healthy Blue NC,Managed Medicaid,,275.88,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthy Blue NC,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Healthy Blue NC,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Healthy Blue NC,Managed Medicaid,,532.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthy Blue NC,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Healthy Blue NC,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Healthy Blue NC,Managed Medicaid,,158.96,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Healthy Blue NC,Managed Medicaid,,5817.21,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Healthy Blue NC,Managed Medicaid,,879.68,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Healthy Blue NC,Managed Medicaid,,879.68,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Healthy Blue NC,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Healthy Blue NC,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Healthy Blue NC,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Healthy Blue NC,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Healthy Blue NC,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Healthy Blue NC,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Healthy Blue NC,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Healthy Blue NC,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Healthy Blue NC,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Healthy Blue NC,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Healthy Blue NC,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Healthy Blue NC,Managed Medicaid,,4633.03,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Healthy Blue NC,Managed Medicaid,,4633.03,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Healthy Blue NC,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Healthy Blue NC,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Healthy Blue NC,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Healthy Blue NC,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Healthy Blue NC,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Healthy Blue NC,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Healthy Blue NC,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Healthy Blue NC,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Healthy Blue NC,Managed Medicaid,,2468.07,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Healthy Blue NC,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Healthy Blue NC,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Healthy Blue NC,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Healthy Blue NC,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Healthy Blue NC,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Healthy Blue NC,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Healthy Blue NC,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Healthy Blue NC,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Healthy Blue NC,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Healthy Blue NC,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Healthy Blue NC,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Healthy Blue NC,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Healthy Blue NC,Managed Medicaid,,4121.72,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Healthy Blue NC,Managed Medicaid,LM,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Healthy Blue NC,Managed Medicaid,RI,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Healthy Blue NC,Managed Medicaid,RC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Healthy Blue NC,Managed Medicaid,LD,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Healthy Blue NC,Managed Medicaid,LC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Healthy Blue NC,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Healthy Blue NC,Managed Medicaid,RI,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Healthy Blue NC,Managed Medicaid,RC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Healthy Blue NC,Managed Medicaid,LD,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Healthy Blue NC,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Healthy Blue NC,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Healthy Blue NC,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,LM,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,RI,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Healthy Blue NC,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LM,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,RI,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Healthy Blue NC,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Healthy Blue NC,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Healthy Blue NC,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Healthy Blue NC,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Healthy Blue NC,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Healthy Blue NC,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LM,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,RI,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,RC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LD,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Healthy Blue NC,Managed Medicaid,LC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Healthy Blue NC,Managed Medicaid,,78.68,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Healthy Blue NC,Managed Medicaid,,333.13,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Healthy Blue NC,Managed Medicaid,,373.37,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Healthy Blue NC,Managed Medicaid,,84.48,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Healthy Blue NC,Managed Medicaid,,505.91,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Healthy Blue NC,Managed Medicaid,,197.40,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Healthy Blue NC,Managed Medicaid,,2316.71,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Healthy Blue NC,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Healthy Blue NC,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Healthy Blue NC,Managed Medicaid,,2044.04,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Healthy Blue NC,Managed Medicaid,,850.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Healthy Blue NC,Managed Medicaid,,1474.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Healthy Blue NC,Managed Medicaid,,2180.78,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Healthy Blue NC,Managed Medicaid,,1936.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Healthy Blue NC,Managed Medicaid,,2067.27,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Healthy Blue NC,Managed Medicaid,,909.51,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Healthy Blue NC,Managed Medicaid,,2126.92,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Healthy Blue NC,Managed Medicaid,,2652.85,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Healthy Blue NC,Managed Medicaid,,2389.79,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Healthy Blue NC,Managed Medicaid,,2549.35,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Healthy Blue NC,Managed Medicaid,,2592.59,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Healthy Blue NC,Managed Medicaid,,3178.58,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Healthy Blue NC,Managed Medicaid,,1356.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Healthy Blue NC,Managed Medicaid,,40.64,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Healthy Blue NC,Managed Medicaid,,19.42,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Healthy Blue NC,Managed Medicaid,,300.90,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Healthy Blue NC,Managed Medicaid,,826.43,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Healthy Blue NC,Managed Medicaid,,1614.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Healthy Blue NC,Managed Medicaid,,96.90,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Healthy Blue NC,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Healthy Blue NC,Managed Medicaid,,43.04,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Healthy Blue NC,Managed Medicaid,,1535.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Healthy Blue NC,Managed Medicaid,,7834.43,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Healthy Blue NC,Managed Medicaid,,2458.86,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Healthy Blue NC,Managed Medicaid,,505.50,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Healthy Blue NC,Managed Medicaid,,565.36,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Healthy Blue NC,Managed Medicaid,,253.45,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Healthy Blue NC,Managed Medicaid,,105.71,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Healthy Blue NC,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Healthy Blue NC,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Healthy Blue NC,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Healthy Blue NC,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Healthy Blue NC,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Healthy Blue NC,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Healthy Blue NC,Managed Medicaid,,3657.05,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Healthy Blue NC,Managed Medicaid,,2656.25,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Healthy Blue NC,Managed Medicaid,,3018.42,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Healthy Blue NC,Managed Medicaid,,3642.44,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Healthy Blue NC,Managed Medicaid,,639.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Healthy Blue NC,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Healthy Blue NC,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Healthy Blue NC,Managed Medicaid,,2045.04,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Healthy Blue NC,Managed Medicaid,,589.39,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Healthy Blue NC,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Healthy Blue NC,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Healthy Blue NC,Managed Medicaid,,4082.48,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Healthy Blue NC,Managed Medicaid,,2987.99,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Healthy Blue NC,Managed Medicaid,,473.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Healthy Blue NC,Managed Medicaid,,4761.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Healthy Blue NC,Managed Medicaid,,4909.10,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Healthy Blue NC,Managed Medicaid,,5350.95,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Healthy Blue NC,Managed Medicaid,,1703.30,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Healthy Blue NC,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Healthy Blue NC,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Healthy Blue NC,Managed Medicaid,,9987.38,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Healthy Blue NC,Managed Medicaid,,1151.15,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Healthy Blue NC,Managed Medicaid,,764.96,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Healthy Blue NC,Managed Medicaid,,11551.14,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Healthy Blue NC,Managed Medicaid,,528.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Healthy Blue NC,Managed Medicaid,,2335.73,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Healthy Blue NC,Managed Medicaid,,417.62,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Healthy Blue NC,Managed Medicaid,,838.44,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Healthy Blue NC,Managed Medicaid,,1297.30,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Healthy Blue NC,Managed Medicaid,,1297.30,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Healthy Blue NC,Managed Medicaid,,647.05,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Healthy Blue NC,Managed Medicaid,,459.46,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Healthy Blue NC,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Healthy Blue NC,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Healthy Blue NC,Managed Medicaid,,609.21,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Healthy Blue NC,Managed Medicaid,,557.96,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Healthy Blue NC,Managed Medicaid,,1917.92,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Healthy Blue NC,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Healthy Blue NC,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Healthy Blue NC,Managed Medicaid,,325.12,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Healthy Blue NC,Managed Medicaid,,1618.42,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Healthy Blue NC,Managed Medicaid,,331.93,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Healthy Blue NC,Managed Medicaid,,631.83,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Healthy Blue NC,Managed Medicaid,,5093.49,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Healthy Blue NC,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Healthy Blue NC,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Healthy Blue NC,Managed Medicaid,,605.61,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Healthy Blue NC,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Healthy Blue NC,Managed Medicaid,,4031.43,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Healthy Blue NC,Managed Medicaid,,4480.68,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Healthy Blue NC,Managed Medicaid,,496.90,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Healthy Blue NC,Managed Medicaid,,386.59,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Healthy Blue NC,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Healthy Blue NC,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Healthy Blue NC,Managed Medicaid,,1276.68,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Healthy Blue NC,Managed Medicaid,,515.51,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Healthy Blue NC,Managed Medicaid,,2746.94,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Healthy Blue NC,Managed Medicaid,,960.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Healthy Blue NC,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Healthy Blue NC,Managed Medicaid,,425.83,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Healthy Blue NC,Managed Medicaid,,567.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Healthy Blue NC,Managed Medicaid,,1594.59,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Healthy Blue NC,Managed Medicaid,,3708.10,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Healthy Blue NC,Managed Medicaid,,1846.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Healthy Blue NC,Managed Medicaid,,1294.69,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Healthy Blue NC,Managed Medicaid,,1496.70,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Healthy Blue NC,Managed Medicaid,,57.66,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Healthy Blue NC,Managed Medicaid,,283.88,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Healthy Blue NC,Managed Medicaid,,1595.59,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Healthy Blue NC,Managed Medicaid,,608.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Healthy Blue NC,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Healthy Blue NC,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Healthy Blue NC,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Healthy Blue NC,Managed Medicaid,,2662.86,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Healthy Blue NC,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Healthy Blue NC,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Healthy Blue NC,Managed Medicaid,,8574.37,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Healthy Blue NC,Managed Medicaid,,6999.39,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Healthy Blue NC,Managed Medicaid,,1897.10,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Healthy Blue NC,Managed Medicaid,,869.87,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Healthy Blue NC,Managed Medicaid,,4285.48,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Healthy Blue NC,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Healthy Blue NC,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Healthy Blue NC,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Healthy Blue NC,Managed Medicaid,,6481.07,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Healthy Blue NC,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Healthy Blue NC,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Healthy Blue NC,Managed Medicaid,,21.42,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Healthy Blue NC,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Healthy Blue NC,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Healthy Blue NC,Managed Medicaid,,9598.39,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Healthy Blue NC,Managed Medicaid,,480.28,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Healthy Blue NC,Managed Medicaid,,1300.10,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Healthy Blue NC,Managed Medicaid,,2169.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Healthy Blue NC,Managed Medicaid,LD,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Healthy Blue NC,Managed Medicaid,RC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Healthy Blue NC,Managed Medicaid,RI,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Healthy Blue NC,Managed Medicaid,LM,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Healthy Blue NC,Managed Medicaid,LD,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Healthy Blue NC,Managed Medicaid,RC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Healthy Blue NC,Managed Medicaid,RI,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Healthy Blue NC,Managed Medicaid,LM,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Healthy Blue NC,Managed Medicaid,LD,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Healthy Blue NC,Managed Medicaid,RC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Healthy Blue NC,Managed Medicaid,RI,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Healthy Blue NC,Managed Medicaid,LM,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,LD,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,RC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,RI,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,LM,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Healthy Blue NC,Managed Medicaid,LC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Healthy Blue NC,Managed Medicaid,LC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Healthy Blue NC,Managed Medicaid,LC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Healthy Blue NC,Managed Medicaid,LC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Healthy Blue NC,Managed Medicaid,,6528.72,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Healthy Blue NC,Managed Medicaid,,12359.75,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Healthy Blue NC,Managed Medicaid,,2282.88,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Healthy Blue NC,Managed Medicaid,,570.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Healthy Blue NC,Managed Medicaid,,115.11,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Healthy Blue NC,Managed Medicaid,,805.00,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Healthy Blue NC,Managed Medicaid,,661.46,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Healthy Blue NC,Managed Medicaid,,258.26,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Healthy Blue NC,Managed Medicaid,,312.91,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Healthy Blue NC,Managed Medicaid,,231.63,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Healthy Blue NC,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Healthy Blue NC,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Healthy Blue NC,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Healthy Blue NC,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Healthy Blue NC,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Healthy Blue NC,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Healthy Blue NC,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Healthy Blue NC,Managed Medicaid,,99.30,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Healthy Blue NC,Managed Medicaid,,77.08,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Healthy Blue NC,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Healthy Blue NC,Managed Medicaid,,11.01,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Healthy Blue NC,Managed Medicaid,,273.87,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Healthy Blue NC,Managed Medicaid,,48.65,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Healthy Blue NC,Managed Medicaid,,175.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Healthy Blue NC,Managed Medicaid,,124.52,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Healthy Blue NC,Managed Medicaid,,32.43,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Healthy Blue NC,Managed Medicaid,,38.64,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Healthy Blue NC,Managed Medicaid,,255.46,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Healthy Blue NC,Managed Medicaid,,57.06,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Healthy Blue NC,Managed Medicaid,,43.64,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Healthy Blue NC,Managed Medicaid,,59.46,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Healthy Blue NC,Managed Medicaid,,21.82,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Healthy Blue NC,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Healthy Blue NC,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Healthy Blue NC,Managed Medicaid,,1301.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Healthy Blue NC,Managed Medicaid,,725.52,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Healthy Blue NC,Managed Medicaid,,1598.40,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Healthy Blue NC,Managed Medicaid,,521.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Healthy Blue NC,Managed Medicaid,,422.62,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Healthy Blue NC,Managed Medicaid,,422.62,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Healthy Blue NC,Managed Medicaid,,422.62,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Healthy Blue NC,Managed Medicaid,,1276.28,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Healthy Blue NC,Managed Medicaid,,1690.29,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Healthy Blue NC,Managed Medicaid,,1897.30,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Healthy Blue NC,Managed Medicaid,,1567.77,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Healthy Blue NC,Managed Medicaid,,2031.83,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Healthy Blue NC,Managed Medicaid,,2263.86,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Healthy Blue NC,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Healthy Blue NC,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Healthy Blue NC,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Healthy Blue NC,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Healthy Blue NC,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Healthy Blue NC,Managed Medicaid,,48.05,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Healthy Blue NC,Managed Medicaid,,74.87,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Healthy Blue NC,Managed Medicaid,,264.26,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Healthy Blue NC,Managed Medicaid,,285.29,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Healthy Blue NC,Managed Medicaid,,446.85,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Healthy Blue NC,Managed Medicaid,,58.66,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Healthy Blue NC,Managed Medicaid,,134.53,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Healthy Blue NC,Managed Medicaid,,20.82,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Healthy Blue NC,Managed Medicaid,,203.40,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Healthy Blue NC,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Healthy Blue NC,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Healthy Blue NC,Managed Medicaid,,38.44,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Healthy Blue NC,Managed Medicaid,,633.03,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Healthy Blue NC,Managed Medicaid,,60.46,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Healthy Blue NC,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Healthy Blue NC,Managed Medicaid,,61.86,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Healthy Blue NC,Managed Medicaid,,57.06,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Healthy Blue NC,Managed Medicaid,,68.27,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Healthy Blue NC,Managed Medicaid,,86.49,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Healthy Blue NC,Managed Medicaid,,123.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Healthy Blue NC,Managed Medicaid,,8.81,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Healthy Blue NC,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Healthy Blue NC,Managed Medicaid,,14.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Healthy Blue NC,Managed Medicaid,,44.24,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Healthy Blue NC,Managed Medicaid,,80.48,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Healthy Blue NC,Managed Medicaid,,178.18,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Healthy Blue NC,Managed Medicaid,,14.81,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Healthy Blue NC,Managed Medicaid,,10.81,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Healthy Blue NC,Managed Medicaid,,53.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Healthy Blue NC,Managed Medicaid,,8.01,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Healthy Blue NC,Managed Medicaid,,150.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Healthy Blue NC,Managed Medicaid,,235.24,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Healthy Blue NC,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Healthy Blue NC,Managed Medicaid,,245.04,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Healthy Blue NC,Managed Medicaid,,359.16,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Healthy Blue NC,Managed Medicaid,,454.25,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Healthy Blue NC,Managed Medicaid,,98.50,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Healthy Blue NC,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Healthy Blue NC,Managed Medicaid,,140.14,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Healthy Blue NC,Managed Medicaid,,156.16,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Healthy Blue NC,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Healthy Blue NC,Managed Medicaid,,319.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Healthy Blue NC,Managed Medicaid,,514.31,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Healthy Blue NC,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Healthy Blue NC,Managed Medicaid,,800.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Healthy Blue NC,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Healthy Blue NC,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Healthy Blue NC,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Healthy Blue NC,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Healthy Blue NC,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Healthy Blue NC,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Healthy Blue NC,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Healthy Blue NC,Managed Medicaid,GP,47.65,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Healthy Blue NC,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Healthy Blue NC,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Healthy Blue NC,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Healthy Blue NC,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Healthy Blue NC,Managed Medicaid,,2600.00,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Healthy Blue NC,Managed Medicaid,,2657.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Healthy Blue NC,Managed Medicaid,,2714.71,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Healthy Blue NC,Managed Medicaid,,2772.37,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Healthy Blue NC,Managed Medicaid,,2829.83,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Healthy Blue NC,Managed Medicaid,,2887.08,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Healthy Blue NC,Managed Medicaid,,2944.54,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Healthy Blue NC,Managed Medicaid,,3002.00,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Healthy Blue NC,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Healthy Blue NC,Managed Medicaid,,49.25,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Healthy Blue NC,Managed Medicaid,,40.04,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,215412.76,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,87653.85,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,163376.49,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,106938.50,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,79836.98,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,36412.81,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,100040.85,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,43818.68,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,55843.64,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,42666.79,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33190.55,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22978.77,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,92905.15,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,46306.95,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,42499.92,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,331436.76,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,55529.08,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,61148.55,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,41439.87,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25241.25,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,44780.78,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,30863.01,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,35721.67,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24719.26,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20231.80,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,46908.54,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27033.77,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17723.63,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,35214.98,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17232.26,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13649.49,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,30547.68,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19218.43,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15791.80,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,26119.14,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13341.04,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9918.99,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,30474.96,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17750.42,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14145.45,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14785.32,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8416.54,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12608.57,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8725.76,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18702.56,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10838.23,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14006.15,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10419.55,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7961.91,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22024.35,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14371.25,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11666.37,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16313.80,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8654.58,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6160.19,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12163.11,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7537.89,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7035.79,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13664.02,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8774.75,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6709.73,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13200.97,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8811.48,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15598.15,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7237.86,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14775.38,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7776.68,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18415.54,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11605.15,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8237.46,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18310.69,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10892.56,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7922.88,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11268.38,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9330.42,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7222.55,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14363.60,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8751.77,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7016.65,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27858.86,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28566.09,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18486.74,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11349.49,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15745.88,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7830.26,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9501.09,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7322.81,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18916.86,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11277.56,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12669.80,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14760.82,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9225.55,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9825.63,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6936.29,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7034.25,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11048.71,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6798.52,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17530.75,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8692.84,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12350.62,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7704.74,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10379.75,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33567.88,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17615.72,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13140.51,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29597.83,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14185.27,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10124.13,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17128.17,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10653.76,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7022.79,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6674.53,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11113.00,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6539.82,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9970.26,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6571.97,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12888.69,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7936.65,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6211.46,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14062.03,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7885.36,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6344.65,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,35224.95,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20240.22,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15572.92,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29529.70,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14724.84,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11380.10,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23702.83,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11435.22,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7083.25,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12882.57,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8392.06,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6700.55,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14438.60,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9119.17,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6691.37,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12631.53,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9066.35,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6941.65,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12850.44,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8492.31,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6411.24,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10377.45,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9400.07,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7374.09,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5835.67,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10982.12,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7090.12,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5732.34,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15366.26,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8186.17,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6403.58,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14424.06,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9335.77,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6395.17,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8355.32,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6049.98,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7101.62,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14936.10,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8124.94,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,50172.15,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21960.03,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,87554.35,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,84150.68,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,44601.69,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,77131.34,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,75798.02,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,59690.48,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,41738.37,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,39498.86,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,38788.59,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25027.69,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,65443.13,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,47324.16,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,59437.13,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,42732.61,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,45839.31,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,32982.36,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,38591.88,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22739.22,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11517.89,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25359.12,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17231.49,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14756.23,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,35841.82,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17626.41,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12360.57,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27620.84,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20788.24,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14558.76,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21567.41,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13917.37,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9281.42,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24971.07,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16398.75,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25818.35,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13396.91,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24322.78,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,26490.37,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28615.06,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,47827.79,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,37360.36,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,53564.34,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33245.65,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,41305.94,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28141.31,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20462.18,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,32497.87,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,26116.07,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,55496.94,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,46895.53,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,36271.21,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,43524.79,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28524.74,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13199.44,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7956.55,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6456.39,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16082.64,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6219.89,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5505.79,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17858.34,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9112.27,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21634.77,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13986.26,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8037.68,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10747.91,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7420.02,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5253.97,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12876.45,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5774.43,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,4405.15,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13418.34,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9092.37,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6430.38,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10080.51,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6074.47,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10029.98,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6701.31,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12982.83,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7911.39,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6552.83,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5254.73,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6294.12,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7593.00,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6432.66,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16881.72,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8294.85,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6142.58,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,52099.39,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19461.06,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,35080.27,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19331.71,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21746.51,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14415.63,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,34043.17,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25039.17,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25493.84,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,39094.73,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19629.42,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13185.67,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,36102.84,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19269.71,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13802.57,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28634.21,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18848.74,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13458.14,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28253.06,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17061.59,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12670.56,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20690.27,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12438.65,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10000.89,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18492.09,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10939.25,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7585.34,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19994.53,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12590.19,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9860.08,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23133.38,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13798.74,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11216.32,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,34543.75,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18720.94,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11621.20,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27240.44,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19400.60,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13106.07,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8577.27,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6285.71,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14492.95,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8736.47,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6489.29,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17291.19,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10179.99,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7996.35,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14913.13,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8428.02,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5746.87,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15940.27,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9214.84,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7049.57,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11489.57,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7464.40,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13032.60,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8394.36,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6136.47,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12225.09,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6966.90,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5085.59,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10629.27,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6888.84,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13162.69,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8083.60,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5889.25,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19252.10,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12506.75,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9683.26,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,31694.22,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,42792.31,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23119.60,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17910.39,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28212.47,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17586.64,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13073.91,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,26204.87,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17014.13,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13631.12,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28189.53,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16740.12,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11356.39,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19187.05,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13869.16,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11375.53,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,26999.33,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14220.47,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11633.46,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,32708.36,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17667.76,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12404.98,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,85276.57,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,56172.01,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,43951.87,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,69880.07,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,45062.43,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15986.21,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9005.88,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6375.27,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14979.72,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9579.16,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7452.92,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13399.20,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7360.31,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5678.00,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14658.27,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8310.15,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6277.29,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13710.70,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9298.26,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7253.93,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,52061.88,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33380.36,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,41713.86,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25646.90,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,65240.30,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,46562.60,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,32858.36,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,43194.12,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21281.15,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,44545.04,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24761.35,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,40763.27,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27913.97,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21954.69,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24137.57,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15685.42,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,37880.05,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23470.91,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19607.24,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33779.12,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18339.78,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9954.97,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27362.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19744.25,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23212.22,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16952.88,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13405.34,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22137.61,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25621.65,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16926.87,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12909.36,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14460.79,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9469.72,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29023.77,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20332.84,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16279.37,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28672.47,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14728.68,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10170.04,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24012.02,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16342.87,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25144.82,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14301.58,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11223.21,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22284.56,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15228.48,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14643.73,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11248.47,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14747.82,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12512.90,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24040.37,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16837.31,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13592.09,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12971.36,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8746.44,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25313.97,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16827.37,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12683.56,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29526.63,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16231.12,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12355.99,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22889.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17130.46,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12920.83,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7091.66,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10734.13,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7103.15,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8225.97,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6434.97,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15997.69,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6948.53,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14442.42,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8790.05,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6697.49,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19916.46,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9749.85,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7322.04,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15700.72,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10161.62,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7612.12,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13750.53,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8279.54,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7275.36,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11038.75,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7279.18,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12302.40,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7758.30,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15195.59,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9540.90,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7074.82,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11827.11,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7775.91,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12736.38,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8379.80,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6656.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23432.65,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13853.08,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9695.51,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,51065.36,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27491.49,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14675.87,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,38434.98,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21209.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13217.04,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25708.90,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14147.76,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11967.17,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15667.80,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14120.20,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17306.50,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15686.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15734.39,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10001.65,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7556.25,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17153.42,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9207.19,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13681.63,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9580.68,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6810.76,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8894.14,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5552.46,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11800.31,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7587.64,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12189.12,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7932.82,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12503.69,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7859.34,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17697.61,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11631.94,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27613.94,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15236.90,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11777.35,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23021.63,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13170.34,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12466.97,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28163.50,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14652.15,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10503.75,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24037.29,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12398.07,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11088.51,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29446.28,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17598.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12092.68,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11918.19,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7781.28,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5676.47,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11144.39,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6878.11,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11806.44,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13520.90,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8767.08,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6802.33,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,36905.73,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29285.54,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25640.01,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,40694.39,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22347.32,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17122.05,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25290.24,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14928.45,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12799.14,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20369.56,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11037.99,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8846.69,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24354.16,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12557.29,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8934.71,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,24811.11,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14310.76,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9388.58,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23271.15,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12800.68,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8402.00,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14660.56,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9184.23,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33080.34,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18821.20,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13484.93,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12257.25,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7625.13,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5516.50,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14727.15,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8941.60,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6970.73,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9802.66,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7117.70,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11212.51,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6904.90,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9676.36,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6195.39,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9171.21,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13584.44,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8690.56,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6202.28,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16231.91,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12664.44,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18733.19,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11646.48,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16871.00,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9338.83,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12428.70,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9015.07,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18045.87,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12180.70,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11201.78,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14773.07,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9667.94,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5940.52,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9878.43,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6447.99,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12271.80,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7130.69,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9025.02,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6065.28,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17224.61,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11220.15,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28280.60,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16693.42,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12161.57,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28344.13,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14772.31,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11837.06,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14965.18,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10418.04,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16605.42,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9628.15,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14217.40,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7501.91,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11540.09,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20573.93,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12217.45,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15018.00,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9247.76,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8273.41,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11881.44,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8415.00,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6000.99,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8633.14,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5288.42,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9123.75,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13855.37,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8596.40,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5932.88,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7361.08,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19712.87,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9035.74,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8252.75,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13546.92,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9469.72,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8260.41,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14715.68,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,46412.59,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,31988.89,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19667.71,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,32835.41,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12218.22,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,2451.13,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9853.93,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8578.80,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8247.39,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,35585.44,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,22424.63,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15532.33,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,31415.61,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11300.51,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9181.93,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6692.90,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6082.11,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17820.82,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10610.90,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8932.41,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11670.19,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7949.65,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12596.31,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17199.35,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8682.89,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5759.11,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18384.93,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9794.24,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7503.45,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,45810.23,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18055.80,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,36013.28,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18262.46,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11249.99,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,36725.08,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18611.49,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13962.53,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25108.06,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12440.96,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10125.65,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6444.91,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,4924.09,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,42940.80,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16886.29,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10255.76,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,37693.32,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16898.56,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11973.30,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25681.35,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13408.38,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8655.36,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16189.80,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10239.68,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7439.92,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,20764.51,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10934.67,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7423.08,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21660.01,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,67200.45,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,38721.22,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16215.06,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12381.24,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,35736.97,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17312.62,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11582.94,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8559.68,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7716.22,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12389.66,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7577.68,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16942.94,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8813.78,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6506.90,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,53823.82,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15789.50,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8754.09,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,30503.29,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8271.10,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8123.40,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9140.60,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15971.67,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13236.18,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11612.79,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16805.94,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9118.42,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5643.55,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,11756.68,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14278.65,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7678.71,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33042.06,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15575.19,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9873.84,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29035.26,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12275.62,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,15956.36,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,30307.32,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16192.86,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10969.12,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13432.90,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7699.38,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13792.61,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6021.67,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12926.20,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7482.00,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14934.57,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8593.35,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,6190.80,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14311.54,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8711.22,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,164335.51,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,55820.70,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,25573.43,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,30727.54,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,17841.49,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16688.83,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,28693.91,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,18808.19,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,16441.60,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12774.66,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,9699.34,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10637.70,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7048.81,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10027.67,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5726.21,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,5177.42,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,52440.77,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,29723.35,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,59243.50,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,33174.46,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23455.60,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21846.01,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,12652.20,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,8120.32,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,47773.44,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,21108.17,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,23010.91,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10833.63,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,7831.04,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10854.29,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,36832.24,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,19738.90,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,14040.60,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,27162.37,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,13501.77,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare HMO,,10100.38,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18119.20,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5373.49,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,22332.87,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5373.49,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9965.52,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6834.82,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,22332.87,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,695.12,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,695.12,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6834.82,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,46864.96,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,241.85,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,552.58,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,418.48,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18700.70,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9965.52,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,530.34,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6199.45,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3581.50,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6834.82,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,23376.18,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,209.51,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18406.40,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,571.33,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,61.87,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,8618.87,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,209.51,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,695.12,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,316.80,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,202.19,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,61.87,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6791.65,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13530.72,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,643.87,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10898.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,415.57,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,571.33,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,12986.98,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6834.82,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,241.85,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,316.80,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,91.70,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,209.51,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,695.12,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1008.67,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1617.80,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4879.29,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,12986.98,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,571.33,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18700.70,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6669.40,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6498.27,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,571.33,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1008.67,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,241.85,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,530.34,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,643.87,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13530.72,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10898.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,643.87,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,241.85,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,681.49,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,95.59,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,9630.27,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7701.19,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,241.85,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,202.19,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,643.87,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,241.85,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,530.34,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,134.24,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,530.34,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,241.85,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,455.29,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,209.51,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18700.70,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,11810.43,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2133.38,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,695.12,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,209.51,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,162.94,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,209.51,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13530.72,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,10842.57,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,695.12,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,416.08,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,927.18,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,732.74,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,637.50,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,134.24,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,415.57,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5373.49,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,571.33,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1424.94,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3790.08,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,311.31,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,162.94,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,8618.87,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Humana,Medicare HMO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Humana,Medicare HMO,,30.85,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Humana,Medicare HMO,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Humana,Medicare HMO,,7.64,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Humana,Medicare HMO,,3.52,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Humana,Medicare HMO,,12.67,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Humana,Medicare HMO,,0.12600,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Humana,Medicare HMO,,0.22050,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Humana,Medicare HMO,,0.31500,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Humana,Medicare HMO,,1816.84,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Humana,Medicare HMO,,118.07,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Humana,Medicare HMO,,120.27,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Humana,Medicare HMO,,7.11,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Humana,Medicare HMO,,8.35,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Humana,Medicare HMO,,31.51,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Humana,Medicare HMO,,15.87,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Humana,Medicare HMO,,1.78,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Humana,Medicare HMO,,65.34,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Humana,Medicare HMO,,79.65,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Humana,Medicare HMO,,1.97,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Humana,Medicare HMO,,180.93,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Humana,Medicare HMO,,770.35,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Humana,Medicare HMO,,9.17,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Humana,Medicare HMO,,3.59,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Humana,Medicare HMO,,5391.84,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Humana,Medicare HMO,,100.69,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Humana,Medicare HMO,,238.64,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Humana,Medicare HMO,,5.85,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Humana,Medicare HMO,,5.85,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Humana,Medicare HMO,,21.37,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Humana,Medicare HMO,,21.37,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Humana,Medicare HMO,,21.37,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Humana,Medicare HMO,,9.19,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Humana,Medicare HMO,,93.81,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare HMO,,4.44,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Humana,Medicare HMO,,3.08,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Humana,Medicare HMO,,3.08,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Humana,Medicare HMO,,3.08,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Humana,Medicare HMO,,3.08,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Humana,Medicare HMO,,3.08,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Humana,Medicare HMO,,3.08,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Humana,Medicare HMO,,31.51,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Humana,Medicare HMO,,181.68,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Humana,Medicare HMO,,181.68,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Humana,Medicare HMO,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Humana,Medicare HMO,,6.00,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Humana,Medicare HMO,,76.86,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Humana,Medicare HMO,,76.86,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Humana,Medicare HMO,,7.07,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Humana,Medicare HMO,,190.28,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Humana,Medicare HMO,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Humana,Medicare HMO,,192.65,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Humana,Medicare HMO,,31.51,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Humana,Medicare HMO,,2738.57,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Humana,Medicare HMO,,453.62,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Humana,Medicare HMO,,2.34,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Humana,Medicare HMO,,271.57,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Humana,Medicare HMO,,5.45,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Humana,Medicare HMO,,1.53,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Humana,Medicare HMO,,1.53,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Humana,Medicare HMO,,65.34,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Humana,Medicare HMO,,17.87,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Humana,Medicare HMO,,58.43,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Humana,Medicare HMO,,29845.26,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Humana,Medicare HMO,,69.97,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Humana,Medicare HMO,,96.32,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Humana,Medicare HMO,,140.90,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Humana,Medicare HMO,,622.65,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Humana,Medicare HMO,,786.29,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Humana,Medicare HMO,,2.99,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Humana,Medicare HMO,,148.98,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Humana,Medicare HMO,,8.35,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Humana,Medicare HMO,,276.31,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Humana,Medicare HMO,,51.41,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Humana,Medicare HMO,,185.27,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Humana,Medicare HMO,,79.65,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Humana,Medicare HMO,,1816.84,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Humana,Medicare HMO,,66.21,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Humana,Medicare HMO,,770.35,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Humana,Medicare HMO,,44.27,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Humana,Medicare HMO,,44.27,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Humana,Medicare HMO,,324.11,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Humana,Medicare HMO,,78.08,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Humana,Medicare HMO,,78.08,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Humana,Medicare HMO,,2.25,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Humana,Medicare HMO,,22.38,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Humana,Medicare HMO,,16.39,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Humana,Medicare HMO,,2.25,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Humana,Medicare HMO,,8.35,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Humana,Medicare HMO,,175.68,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare HMO,,172.46,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Humana,Medicare HMO,,9.52,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Humana,Medicare HMO,,34.61,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Humana,Medicare HMO,,34.61,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Humana,Medicare HMO,,93.81,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Humana,Medicare HMO,,63.30,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Humana,Medicare HMO,,213.76,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Humana,Medicare HMO,,213.76,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Humana,Medicare HMO,,213.76,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Humana,Medicare HMO,,109.97,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Humana,Medicare HMO,,53.28,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Humana,Medicare HMO,,51.48,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Humana,Medicare HMO,,51.48,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Humana,Medicare HMO,,82.74,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Humana,Medicare HMO,,82.74,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Humana,Medicare HMO,,20.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Humana,Medicare HMO,,0.48300,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Humana,Medicare HMO,,0.48300,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Humana,Medicare HMO,,69.30,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Humana,Medicare HMO,,32.83,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Humana,Medicare HMO,,14.16,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Humana,Medicare HMO,,20.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Humana,Medicare HMO,,118.07,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Humana,Medicare HMO,,74.89,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Humana,Medicare HMO,,95.91,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Humana,Medicare HMO,,1.92,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Humana,Medicare HMO,,9.17,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Humana,Medicare HMO,,41.82,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Humana,Medicare HMO,,148.68,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Humana,Medicare HMO,,105.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Humana,Medicare HMO,,62.38,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Humana,Medicare HMO,,78.78,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Humana,Medicare HMO,,89.38,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Humana,Medicare HMO,,89.38,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Humana,Medicare HMO,,38.52,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Humana,Medicare HMO,,38.52,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Humana,Medicare HMO,,268.89,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Humana,Medicare HMO,,2832.95,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Humana,Medicare HMO,,2.29,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Humana,Medicare HMO,,1.72,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Humana,Medicare HMO,,172.82,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Humana,Medicare HMO,,8.56,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Humana,Medicare HMO,,34.61,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Humana,Medicare HMO,,19.02,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Humana,Medicare HMO,,8.24,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Humana,Medicare HMO,,8.24,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Humana,Medicare HMO,,8.24,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Humana,Medicare HMO,,8.24,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Humana,Medicare HMO,,8.24,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Humana,Medicare HMO,,104.09,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Humana,Medicare HMO,,260.93,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Humana,Medicare HMO,,0.31500,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Humana,Medicare HMO,,0.31500,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Humana,Medicare HMO,,30.75,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Humana,Medicare HMO,,111.65,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Humana,Medicare HMO,,137.95,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Humana,Medicare HMO,,0.31500,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Humana,Medicare HMO,,107.20,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Humana,Medicare HMO,,95.91,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Humana,Medicare HMO,,64.51,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Humana,Medicare HMO,,7.17,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Humana,Medicare HMO,,143.50,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Humana,Medicare HMO,,29.25,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Humana,Medicare HMO,,29.25,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Humana,Medicare HMO,,30.85,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Humana,Medicare HMO,,30.85,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Humana,Medicare HMO,,44.08,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Humana,Medicare HMO,,44.08,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Humana,Medicare HMO,,135.95,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Humana,Medicare HMO,,11.56,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Humana,Medicare HMO,,38.58,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare HMO,,38.58,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Humana,Medicare HMO,,31.48,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Humana,Medicare HMO,,27.06,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Humana,Medicare HMO,,27.06,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Humana,Medicare HMO,,29.24,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Humana,Medicare HMO,,29.24,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Humana,Medicare HMO,,377.15,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Humana,Medicare HMO,,29.39,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Humana,Medicare HMO,,20.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Humana,Medicare HMO,,86.00,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Humana,Medicare HMO,,86.00,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Humana,Medicare HMO,,38.09,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Humana,Medicare HMO,,334.46,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Humana,Medicare HMO,,21.43,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Humana,Medicare HMO,,65.20,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Humana,Medicare HMO,,65.20,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Humana,Medicare HMO,,15.03,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Humana,Medicare HMO,,143.50,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Humana,Medicare HMO,,236.37,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Humana,Medicare HMO,,236.37,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Humana,Medicare HMO,,8.24,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Humana,Medicare HMO,,5.73,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Humana,Medicare HMO,,29.39,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Humana,Medicare HMO,,2222.14,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Humana,Medicare HMO,,227.75,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Humana,Medicare HMO,,255.90,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Humana,Medicare HMO,,23.67,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Humana,Medicare HMO,,198.20,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Humana,Medicare HMO,,12.94,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Humana,Medicare HMO,,88.80,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Humana,Medicare HMO,,0.39900,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Humana,Medicare HMO,,0.39900,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Humana,Medicare HMO,,207.72,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Humana,Medicare HMO,,35.26,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Humana,Medicare HMO,,35.26,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Humana,Medicare HMO,,72.96,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Humana,Medicare HMO,,687.36,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Humana,Medicare HMO,,687.36,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Humana,Medicare HMO,,32.09,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Humana,Medicare HMO,,26.29,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Humana,Medicare HMO,,26.29,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Humana,Medicare HMO,,26.29,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Humana,Medicare HMO,,66509.39,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Humana,Medicare HMO,,76.25,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Humana,Medicare HMO,,76.25,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Humana,Medicare HMO,,205.51,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Humana,Medicare HMO,,9.17,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Humana,Medicare HMO,,111.65,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Humana,Medicare HMO,,1.92,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Humana,Medicare HMO,,59.88,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Humana,Medicare HMO,,59.88,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Humana,Medicare HMO,,79.77,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Humana,Medicare HMO,,35.10,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Humana,Medicare HMO,,28.73,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Humana,Medicare HMO,,54.14,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Humana,Medicare HMO,,180.83,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Humana,Medicare HMO,,22.55,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Humana,Medicare HMO,,78.98,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Humana,Medicare HMO,,78.98,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Humana,Medicare HMO,,6.59,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Humana,Medicare HMO,,0.31500,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Humana,Medicare HMO,,32.64,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Humana,Medicare HMO,,45.35,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Humana,Medicare HMO,,113.89,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Humana,Medicare HMO,,113.89,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Humana,Medicare HMO,,344.76,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Humana,Medicare HMO,,0.84000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Humana,Medicare HMO,,8.56,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Humana,Medicare HMO,,1920.16,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Humana,Medicare HMO,,1.78,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Humana,Medicare HMO,,99.17,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Humana,Medicare HMO,,5426.64,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Humana,Medicare HMO,,7.71,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Humana,Medicare HMO,,93.81,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Humana,Medicare HMO,,6.83,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Humana,Medicare HMO,,185.27,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Humana,Medicare HMO,,57.45,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Humana,Medicare HMO,,57.45,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Humana,Medicare HMO,,57.45,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Humana,Medicare HMO,,57.45,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Humana,Medicare HMO,,396.40,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Humana,Medicare HMO,,0.48300,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Humana,Medicare HMO,,46.83,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Humana,Medicare HMO,,4.58,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare HMO,,82.29,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Humana,Medicare HMO,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Humana,Medicare HMO,,0.50400,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Humana,Medicare HMO,,1.82,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Humana,Medicare HMO,,11.07,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Humana,Medicare HMO,,10.65,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Humana,Medicare HMO,,10.65,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Humana,Medicare HMO,,10.65,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Humana,Medicare HMO,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Humana,Medicare HMO,,21.37,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Humana,Medicare HMO,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Humana,Medicare HMO,,192.65,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Humana,Medicare HMO,,71.61,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Humana,Medicare HMO,,65.34,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Humana,Medicare HMO,,65.34,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Humana,Medicare HMO,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Humana,Medicare HMO,,6.00,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Humana,Medicare HMO,,0.22050,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Humana,Medicare HMO,,271.57,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare HMO,,4.44,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Humana,Medicare HMO,,217.49,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Humana,Medicare HMO,,293.84,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Humana,Medicare HMO,,293.84,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Humana,Medicare HMO,,0.31500,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Humana,Medicare HMO,,19.02,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Humana,Medicare HMO,,180.83,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Humana,Medicare HMO,,0.31500,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Humana,Medicare HMO,,156.44,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Humana,Medicare HMO,,191.57,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Humana,Medicare HMO,,0.22050,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Humana,Medicare HMO,,74.29,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Humana,Medicare HMO,,99.17,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Humana,Medicare HMO,,74.29,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Humana,Medicare HMO,,74.29,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Humana,Medicare HMO,,137.95,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Humana,Medicare HMO,,99.17,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Humana,Medicare HMO,,95.91,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Humana,Medicare HMO,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Humana,Medicare HMO,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Humana,Medicare HMO,,38.09,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Humana,Medicare HMO,,89.38,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Humana,Medicare HMO,,58.43,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Humana,Medicare HMO,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare HMO,,4.44,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare HMO,,4.44,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Humana,Medicare HMO,,0.38850,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Humana,Medicare HMO,,7.07,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Humana,Medicare HMO,,0.84000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Humana,Medicare HMO,,21.37,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Humana,Medicare HMO,,99.17,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare HMO,,2.79,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Humana,Medicare HMO,,2.25,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Humana,Medicare HMO,,63.30,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Humana,Medicare HMO,,7.07,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare HMO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare HMO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare HMO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare HMO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare HMO,,172.46,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Humana,Medicare HMO,,180.83,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Humana,Medicare HMO,,78.78,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Humana,Medicare HMO,,64.51,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Humana,Medicare HMO,,65.20,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Humana,Medicare HMO,,65.20,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Humana,Medicare HMO,,4.58,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Humana,Medicare HMO,,63.30,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Humana,Medicare HMO,,63.30,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Humana,Medicare HMO,,0.84000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Humana,Medicare HMO,,1.92,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Humana,Medicare HMO,,248.45,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Humana,Medicare HMO,,95.91,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Humana,Medicare HMO,,95.91,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Humana,Medicare HMO,,58.35,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Humana,Medicare HMO,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare HMO,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Humana,Medicare HMO,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare HMO,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Humana,Medicare HMO,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare HMO,,82.29,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Humana,Medicare HMO,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Humana,Medicare HMO,,0.29400,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare HMO,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare HMO,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare HMO,,38.58,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Humana,Medicare HMO,,76.25,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Humana,Medicare HMO,,100.69,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Humana,Medicare HMO,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Humana,Medicare HMO,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Humana,Medicare HMO,,4.64,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Humana,Medicare HMO,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Humana,Medicare HMO,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Humana,Medicare HMO,,4.64,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Humana,Medicare HMO,,0.38850,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Humana,Medicare HMO,,71.61,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Humana,Medicare HMO,,0.12600,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Humana,Medicare HMO,,0.12600,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Humana,Medicare HMO,,309.42,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Humana,Medicare HMO,,1.56,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Humana,Medicare HMO,,1.56,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Humana,Medicare HMO,,1.56,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Humana,Medicare HMO,,3.08,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Humana,Medicare HMO,,1.69,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Humana,Medicare HMO,,47.06,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Humana,Medicare HMO,,28.05,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Humana,Medicare HMO,,31.33,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Humana,Medicare HMO,,146.17,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Humana,Medicare HMO,,4.58,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Humana,Medicare HMO,,55.73,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Humana,Medicare HMO,,55.73,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Humana,Medicare HMO,,99.17,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Humana,Medicare HMO,,99.17,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Humana,Medicare HMO,,4.30,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Humana,Medicare HMO,,0.31500,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare HMO,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare HMO,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare HMO,,2.79,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Humana,Medicare HMO,,1.75,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Humana,Medicare HMO,,1.75,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Humana,Medicare HMO,,0.38850,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Humana,Medicare HMO,,509.22,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Humana,Medicare HMO,,11.56,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Humana,Medicare HMO,,11.56,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Humana,Medicare HMO,,25.07,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Humana,Medicare HMO,,25.07,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Humana,Medicare HMO,,25.07,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Humana,Medicare HMO,,2.99,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Humana,Medicare HMO,,53.60,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Humana,Medicare HMO,,6.83,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Humana,Medicare HMO,,11.21,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Humana,Medicare HMO,,4.67,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Humana,Medicare HMO,,3.70,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Humana,Medicare HMO,,3.70,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Humana,Medicare HMO,,1.78,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Humana,Medicare HMO,,0.33600,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Humana,Medicare HMO,,9.19,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Humana,Medicare HMO,,411.66,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Humana,Medicare HMO,,534.41,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Humana,Medicare HMO,,638.50,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare HMO,,356.58,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Humana,Medicare HMO,,36.56,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Humana,Medicare HMO,,36.56,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Humana,Medicare HMO,,38.58,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Humana,Medicare HMO,,134.24,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Humana,Medicare HMO,,219.42,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare HMO,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Humana,Medicare HMO,,219.42,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare HMO,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare HMO,,74.12,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare HMO,,219.42,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Humana,Medicare HMO,,219.42,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Humana,Medicare HMO,,48.05,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Humana,Medicare HMO,,345.43,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Humana,Medicare HMO,,9.54,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Humana,Medicare HMO,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare HMO,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare HMO,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Humana,Medicare HMO,,74.12,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Humana,Medicare HMO,,219.42,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare HMO,,345.43,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Humana,Medicare HMO,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Humana,Medicare HMO,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Humana,Medicare HMO,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Humana,Medicare HMO,,381.23,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Humana,Medicare HMO,,381.23,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Humana,Medicare HMO,,381.23,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Humana,Medicare HMO,,138.27,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Humana,Medicare HMO,,381.23,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Humana,Medicare HMO,,381.23,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Humana,Medicare HMO,,138.27,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Humana,Medicare HMO,,381.23,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Humana,Medicare HMO,,138.27,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Humana,Medicare HMO,,381.23,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Humana,Medicare HMO,,381.23,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Humana,Medicare HMO,,1828.66,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Humana,Medicare HMO,,1828.66,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Humana,Medicare HMO,,602.44,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Humana,Medicare HMO,,602.44,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Humana,Medicare HMO,,602.44,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Humana,Medicare HMO,,722.56,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Humana,Medicare HMO,,114.04,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Humana,Medicare HMO,,345.43,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Humana,Medicare HMO,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Humana,Medicare HMO,,345.43,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Humana,Medicare HMO,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Humana,Medicare HMO,,345.43,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Humana,Medicare HMO,,48.05,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Humana,Medicare HMO,,345.43,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Humana,Medicare HMO,,219.42,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Humana,Medicare HMO,,219.42,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Humana,Medicare HMO,,345.43,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Humana,Medicare HMO,,114.04,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Humana,Medicare HMO,,273.87,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Humana,Medicare HMO,,273.87,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Humana,Medicare HMO,,273.87,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Humana,Medicare HMO,,602.44,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Humana,Medicare HMO,,602.44,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Humana,Medicare HMO,,602.44,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Humana,Medicare HMO,,345.43,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Humana,Medicare HMO,,7961.22,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Humana,Medicare HMO,,7961.22,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Humana,Medicare HMO,,722.56,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Humana,Medicare HMO,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Humana,Medicare HMO,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Humana,Medicare HMO,,345.43,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Humana,Medicare HMO,,381.23,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Humana,Medicare HMO,,1424.94,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Humana,Medicare HMO,,381.23,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Humana,Medicare HMO,,381.23,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Humana,Medicare HMO,,138.27,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Humana,Medicare HMO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Humana,Medicare HMO,,381.23,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Humana,Medicare HMO,,381.23,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Humana,Medicare HMO,,602.44,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare HMO,,1707.19,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Humana,Medicare HMO,,209.51,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Humana,Medicare HMO,,3311.27,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Humana,Medicare HMO,,211.82,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Humana,Medicare HMO,,241.85,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Humana,Medicare HMO,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Humana,Medicare HMO,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Humana,Medicare HMO,,5140.98,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Humana,Medicare HMO,,316.80,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Humana,Medicare HMO,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Humana,Medicare HMO,,241.85,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare HMO,,211.82,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare HMO,,211.82,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,134.24,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,134.24,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Humana,Medicare HMO,,211.82,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare HMO,,134.24,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare HMO,,134.24,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Humana,Medicare HMO,,211.82,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Humana,Medicare HMO,,25.50,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare HMO,,25.50,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Humana,Medicare HMO,,40.88,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Humana,Medicare HMO,,134.24,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare HMO,,211.82,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare HMO,,211.82,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare HMO,,211.82,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Humana,Medicare HMO,,211.82,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare HMO,,211.82,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Humana,Medicare HMO,,211.82,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare HMO,,211.82,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,211.82,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare HMO,,211.82,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Humana,Medicare HMO,,38.84,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare HMO,,38.84,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Humana,Medicare HMO,,162.94,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Humana,Medicare HMO,,162.94,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Humana,Medicare HMO,,324.30,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Humana,Medicare HMO,,552.58,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Humana,Medicare HMO,,324.30,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Humana,Medicare HMO,,324.30,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare HMO,,162.94,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Humana,Medicare HMO,,61.87,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Humana,Medicare HMO,,324.30,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Humana,Medicare HMO,,134.24,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Humana,Medicare HMO,,134.24,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare HMO,,134.24,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare HMO,,134.24,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Humana,Medicare HMO,,324.30,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Humana,Medicare HMO,,162.94,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Humana,Medicare HMO,,324.30,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Humana,Medicare HMO,,61.87,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Humana,Medicare HMO,,324.30,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Humana,Medicare HMO,,162.94,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Humana,Medicare HMO,,162.94,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare HMO,,162.94,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Humana,Medicare HMO,,324.30,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Humana,Medicare HMO,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Humana,Medicare HMO,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Humana,Medicare HMO,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Humana,Medicare HMO,,324.30,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Humana,Medicare HMO,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare HMO,,1707.19,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Humana,Medicare HMO,,728.71,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Humana,Medicare HMO,,443.47,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Humana,Medicare HMO,,552.58,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Humana,Medicare HMO,,415.57,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Humana,Medicare HMO,,162.94,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Humana,Medicare HMO,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Humana,Medicare HMO,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Humana,Medicare HMO,,162.94,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Humana,Medicare HMO,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Humana,Medicare HMO,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Humana,Medicare HMO,,1059.54,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Humana,Medicare HMO,,251.74,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Humana,Medicare HMO,,324.30,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Humana,Medicare HMO,,110.74,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Humana,Medicare HMO,,251.74,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Humana,Medicare HMO,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Humana,Medicare HMO,,134.24,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Humana,Medicare HMO,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Humana,Medicare HMO,,162.94,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Humana,Medicare HMO,,324.30,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Humana,Medicare HMO,,251.74,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Humana,Medicare HMO,,552.58,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Humana,Medicare HMO,,110.74,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Humana,Medicare HMO,,251.74,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Humana,Medicare HMO,,324.30,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Humana,Medicare HMO,,110.74,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Humana,Medicare HMO,,61.87,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Humana,Medicare HMO,,110.74,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Humana,Medicare HMO,,251.74,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Humana,Medicare HMO,,110.74,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare HMO,,110.74,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Humana,Medicare HMO,,110.74,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Humana,Medicare HMO,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Humana,Medicare HMO,,1059.54,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Humana,Medicare HMO,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Humana,Medicare HMO,,162.94,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Humana,Medicare HMO,,134.24,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Humana,Medicare HMO,,134.24,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Humana,Medicare HMO,,162.94,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Humana,Medicare HMO,,162.94,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare HMO,,134.24,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Humana,Medicare HMO,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Humana,Medicare HMO,,324.30,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Humana,Medicare HMO,,134.24,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare HMO,,162.94,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare HMO,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare HMO,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare HMO,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Humana,Medicare HMO,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Humana,Medicare HMO,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Humana,Medicare HMO,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Humana,Medicare HMO,,162.94,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Humana,Medicare HMO,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Humana,Medicare HMO,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Humana,Medicare HMO,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Humana,Medicare HMO,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Humana,Medicare HMO,,1059.54,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Humana,Medicare HMO,,552.58,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Humana,Medicare HMO,,324.30,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Humana,Medicare HMO,,552.58,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Humana,Medicare HMO,,1059.54,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Humana,Medicare HMO,,324.30,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Humana,Medicare HMO,,552.58,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare HMO,,110.74,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Humana,Medicare HMO,,162.94,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Humana,Medicare HMO,,324.30,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Humana,Medicare HMO,,324.30,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Humana,Medicare HMO,,324.30,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Humana,Medicare HMO,,552.58,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Humana,Medicare HMO,,552.58,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Humana,Medicare HMO,,552.58,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Humana,Medicare HMO,,324.30,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Humana,Medicare HMO,,324.30,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Humana,Medicare HMO,,552.58,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Humana,Medicare HMO,,552.58,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Humana,Medicare HMO,,552.58,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Humana,Medicare HMO,,1059.54,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Humana,Medicare HMO,,324.30,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare HMO,,74.12,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare HMO,,74.12,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare HMO,,31.03,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Humana,Medicare HMO,,48.05,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Humana,Medicare HMO,,43.24,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Humana,Medicare HMO,,206.93,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Humana,Medicare HMO,,1687.37,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Humana,Medicare HMO,,1687.37,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Humana,Medicare HMO,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Humana,Medicare HMO,,637.50,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Humana,Medicare HMO,,637.50,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Humana,Medicare HMO,,1687.37,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Humana,Medicare HMO,,206.93,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Humana,Medicare HMO,,206.93,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Humana,Medicare HMO,,206.93,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Humana,Medicare HMO,,416.08,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Humana,Medicare HMO,,61.87,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare HMO,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare HMO,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Humana,Medicare HMO,,206.93,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Humana,Medicare HMO,,206.93,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Humana,Medicare HMO,,206.93,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Humana,Medicare HMO,,732.74,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Humana,Medicare HMO,,307.42,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Humana,Medicare HMO,,307.42,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Humana,Medicare HMO,,307.42,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Humana,Medicare HMO,,307.42,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Humana,Medicare HMO,,307.42,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Humana,Medicare HMO,,276.58,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Humana,Medicare HMO,,241.85,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Humana,Medicare HMO,,416.08,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Humana,Medicare HMO,,416.08,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Humana,Medicare HMO,,416.08,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Humana,Medicare HMO,,134.24,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Humana,Medicare HMO,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Humana,Medicare HMO,,345.43,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Humana,Medicare HMO,,1687.37,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Humana,Medicare HMO,,721.21,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Humana,Medicare HMO,,721.21,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Humana,Medicare HMO,,721.21,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Humana,Medicare HMO,,312.33,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare HMO,,312.33,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Humana,Medicare HMO,,6834.82,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Humana,Medicare HMO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Humana,Medicare HMO,,721.21,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Humana,Medicare HMO,,307.42,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Humana,Medicare HMO,,927.18,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Humana,Medicare HMO,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Humana,Medicare HMO,,6834.82,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare HMO,,307.42,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare HMO,,307.42,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Humana,Medicare HMO,,2033.68,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Humana,Medicare HMO,,2033.68,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Humana,Medicare HMO,,927.18,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Humana,Medicare HMO,,927.18,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Humana,Medicare HMO,,927.18,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Humana,Medicare HMO,,307.42,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Humana,Medicare HMO,,206.93,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Humana,Medicare HMO,,206.93,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,206.93,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,206.93,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Humana,Medicare HMO,,732.74,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Humana,Medicare HMO,,927.18,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Humana,Medicare HMO,,721.21,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Humana,Medicare HMO,,721.21,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Humana,Medicare HMO,,721.21,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Humana,Medicare HMO,,307.42,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Humana,Medicare HMO,,927.18,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Humana,Medicare HMO,,416.08,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare HMO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Humana,Medicare HMO,,927.18,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Humana,Medicare HMO,,927.18,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Humana,Medicare HMO,,721.21,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Humana,Medicare HMO,,721.21,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Humana,Medicare HMO,,927.18,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Humana,Medicare HMO,,927.18,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Humana,Medicare HMO,,927.18,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Humana,Medicare HMO,,927.18,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Humana,Medicare HMO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Humana,Medicare HMO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare HMO,,307.42,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Humana,Medicare HMO,,927.18,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Humana,Medicare HMO,,721.21,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Humana,Medicare HMO,,721.21,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Humana,Medicare HMO,,721.21,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Humana,Medicare HMO,,927.18,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Humana,Medicare HMO,,721.21,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Humana,Medicare HMO,,927.18,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Humana,Medicare HMO,,721.21,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Humana,Medicare HMO,,721.21,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Humana,Medicare HMO,,721.21,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Humana,Medicare HMO,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Humana,Medicare HMO,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Humana,Medicare HMO,,2033.68,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Humana,Medicare HMO,,2033.68,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Humana,Medicare HMO,,2033.68,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Humana,Medicare HMO,,2033.68,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Humana,Medicare HMO,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Humana,Medicare HMO,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Humana,Medicare HMO,,206.93,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,206.93,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Humana,Medicare HMO,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Humana,Medicare HMO,,143.61,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Humana,Medicare HMO,,134.24,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Humana,Medicare HMO,,416.08,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Humana,Medicare HMO,,416.08,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Humana,Medicare HMO,,202.19,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Humana,Medicare HMO,,91.70,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Humana,Medicare HMO,,164.92,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Humana,Medicare HMO,,288.36,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Humana,Medicare HMO,,443.47,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Humana,Medicare HMO,,638.50,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Humana,Medicare HMO,,877.52,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Humana,Medicare HMO,,324.30,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare HMO,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare HMO,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Humana,Medicare HMO,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Humana,Medicare HMO,,61.87,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare HMO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare HMO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare HMO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare HMO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Humana,Medicare HMO,,206.93,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Humana,Medicare HMO,,1227.93,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Humana,Medicare HMO,,416.08,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Humana,Medicare HMO,,1687.37,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Humana,Medicare HMO,,53.64,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Humana,Medicare HMO,,206.93,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Humana,Medicare HMO,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Humana,Medicare HMO,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Humana,Medicare HMO,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Humana,Medicare HMO,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Humana,Medicare HMO,,164.32,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Humana,Medicare HMO,,164.32,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare HMO,,164.32,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Humana,Medicare HMO,,3277.91,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Humana,Medicare HMO,,3311.27,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare HMO,,312.33,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Humana,Medicare HMO,,637.50,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Humana,Medicare HMO,,721.21,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Humana,Medicare HMO,,1617.80,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Humana,Medicare HMO,,1617.80,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Humana,Medicare HMO,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Humana,Medicare HMO,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Humana,Medicare HMO,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Humana,Medicare HMO,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Humana,Medicare HMO,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Humana,Medicare HMO,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Humana,Medicare HMO,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Humana,Medicare HMO,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Humana,Medicare HMO,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Humana,Medicare HMO,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare HMO,,164.32,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Humana,Medicare HMO,,206.93,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Humana,Medicare HMO,,206.93,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Humana,Medicare HMO,,416.08,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Humana,Medicare HMO,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare HMO,,40.88,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare HMO,,206.93,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare HMO,,416.08,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare HMO,,637.50,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare HMO,,416.08,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare HMO,,134.24,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Humana,Medicare HMO,,95.59,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Humana,Medicare HMO,,95.59,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Humana,Medicare HMO,,38.84,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Humana,Medicare HMO,,38.84,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Humana,Medicare HMO,,38.84,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Humana,Medicare HMO,,38.84,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Humana,Medicare HMO,,38.84,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare HMO,,25.50,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Humana,Medicare HMO,,206.93,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare HMO,,416.08,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare HMO,,61.87,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare HMO,,416.08,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Humana,Medicare HMO,,18209.54,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Humana,Medicare HMO,,7439.71,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Humana,Medicare HMO,,1687.37,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Humana,Medicare HMO,,134.24,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Humana,Medicare HMO,,134.24,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Humana,Medicare HMO,,1687.37,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Humana,Medicare HMO,,976.41,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare HMO,,253.29,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Humana,Medicare HMO,,2133.38,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare HMO,,455.29,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Humana,Medicare HMO,,2133.38,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Humana,Medicare HMO,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare HMO,,1707.19,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Humana,Medicare HMO,,732.74,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Humana,Medicare HMO,,1687.37,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Humana,Medicare HMO,,1687.37,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Humana,Medicare HMO,,1687.37,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Humana,Medicare HMO,,11810.43,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Humana,Medicare HMO,,643.87,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Humana,Medicare HMO,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Humana,Medicare HMO,,732.74,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Humana,Medicare HMO,,732.74,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Humana,Medicare HMO,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Humana,Medicare HMO,,61.87,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare HMO,,74.12,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Humana,Medicare HMO,,552.58,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Humana,Medicare HMO,,552.58,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Humana,Medicare HMO,,552.58,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Humana,Medicare HMO,,324.30,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Humana,Medicare HMO,,162.94,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Humana,Medicare HMO,,976.41,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Humana,Medicare HMO,,976.41,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Humana,Medicare HMO,,324.30,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Humana,Medicare HMO,,976.41,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Humana,Medicare HMO,,324.30,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Humana,Medicare HMO,,552.58,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Humana,Medicare HMO,,552.58,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Humana,Medicare HMO,,2429.62,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Humana,Medicare HMO,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Humana,Medicare HMO,,324.30,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Humana,Medicare HMO,,162.94,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Humana,Medicare HMO,,324.30,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Humana,Medicare HMO,,324.30,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare HMO,,91.70,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Humana,Medicare HMO,,110.74,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Humana,Medicare HMO,,110.74,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Humana,Medicare HMO,,91.70,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Humana,Medicare HMO,,110.74,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Humana,Medicare HMO,,91.70,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Humana,Medicare HMO,,251.74,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Humana,Medicare HMO,,110.74,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Humana,Medicare HMO,,91.70,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Humana,Medicare HMO,,91.70,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare HMO,,91.70,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Humana,Medicare HMO,,110.74,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Humana,Medicare HMO,,110.74,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Humana,Medicare HMO,,91.70,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Humana,Medicare HMO,,91.70,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Humana,Medicare HMO,,91.70,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Humana,Medicare HMO,,91.70,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Humana,Medicare HMO,,110.74,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Humana,Medicare HMO,,110.74,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Humana,Medicare HMO,,110.74,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare HMO,,91.70,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Humana,Medicare HMO,,91.70,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Humana,Medicare HMO,,91.70,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Humana,Medicare HMO,,91.70,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare HMO,,110.74,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Humana,Medicare HMO,,110.74,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Humana,Medicare HMO,,110.74,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Humana,Medicare HMO,,110.74,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Humana,Medicare HMO,,91.70,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Humana,Medicare HMO,,110.74,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Humana,Medicare HMO,,110.74,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Humana,Medicare HMO,,110.74,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare HMO,,110.74,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Humana,Medicare HMO,,110.74,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Humana,Medicare HMO,,110.74,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Humana,Medicare HMO,,110.74,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Humana,Medicare HMO,,91.70,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Humana,Medicare HMO,,822.79,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Humana,Medicare HMO,,822.79,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Humana,Medicare HMO,,822.79,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Humana,Medicare HMO,,822.79,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Humana,Medicare HMO,,2033.68,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Humana,Medicare HMO,,91.70,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Humana,Medicare HMO,,110.74,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Humana,Medicare HMO,,91.70,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Humana,Medicare HMO,,91.70,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Humana,Medicare HMO,,371.93,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Humana,Medicare HMO,,91.70,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Humana,Medicare HMO,,91.70,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Humana,Medicare HMO,,91.70,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Humana,Medicare HMO,,91.70,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Humana,Medicare HMO,,371.93,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Humana,Medicare HMO,,91.70,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Humana,Medicare HMO,,110.74,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Humana,Medicare HMO,,91.70,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Humana,Medicare HMO,,91.70,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Humana,Medicare HMO,,371.93,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Humana,Medicare HMO,,110.74,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Humana,Medicare HMO,,91.70,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Humana,Medicare HMO,,91.70,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Humana,Medicare HMO,,371.93,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Humana,Medicare HMO,,91.70,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Humana,Medicare HMO,,91.70,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Humana,Medicare HMO,,110.74,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Humana,Medicare HMO,,91.70,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Humana,Medicare HMO,,371.93,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Humana,Medicare HMO,,91.70,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare HMO,,91.70,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Humana,Medicare HMO,,91.70,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare HMO,,91.70,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Humana,Medicare HMO,,371.93,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Humana,Medicare HMO,,91.70,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare HMO,,91.70,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Humana,Medicare HMO,,91.70,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare HMO,,91.70,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Humana,Medicare HMO,,91.70,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Humana,Medicare HMO,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Humana,Medicare HMO,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Humana,Medicare HMO,,571.02,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Humana,Medicare HMO,,185.40,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Humana,Medicare HMO,,185.40,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare HMO,,185.40,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Humana,Medicare HMO,,371.93,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Humana,Medicare HMO,,371.93,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Humana,Medicare HMO,,371.93,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Humana,Medicare HMO,,251.74,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Humana,Medicare HMO,,251.74,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Humana,Medicare HMO,,251.74,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Humana,Medicare HMO,,2133.38,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Humana,Medicare HMO,,251.74,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Humana,Medicare HMO,,5629.67,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Humana,Medicare HMO,,3277.91,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Humana,Medicare HMO,,3277.91,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Humana,Medicare HMO,,110.74,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Humana,Medicare HMO,,1617.80,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Humana,Medicare HMO,,1617.80,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Humana,Medicare HMO,,3277.91,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Humana,Medicare HMO,,1617.80,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Humana,Medicare HMO,,3277.91,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Humana,Medicare HMO,,3277.91,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Humana,Medicare HMO,,3277.91,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Humana,Medicare HMO,,5629.67,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Humana,Medicare HMO,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Humana,Medicare HMO,,3277.91,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Humana,Medicare HMO,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Humana,Medicare HMO,,3277.91,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Humana,Medicare HMO,,3277.91,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Humana,Medicare HMO,,5629.67,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Humana,Medicare HMO,,3277.91,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Humana,Medicare HMO,,251.74,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Humana,Medicare HMO,,91.70,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Humana,Medicare HMO,,571.02,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Humana,Medicare HMO,,571.02,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Humana,Medicare HMO,,110.74,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare HMO,,91.70,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Humana,Medicare HMO,,251.74,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Humana,Medicare HMO,,251.74,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Humana,Medicare HMO,,110.74,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Humana,Medicare HMO,,110.74,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Humana,Medicare HMO,,110.74,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Humana,Medicare HMO,,110.74,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Humana,Medicare HMO,,110.74,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Humana,Medicare HMO,,91.70,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Humana,Medicare HMO,,5629.67,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Humana,Medicare HMO,,3277.91,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Humana,Medicare HMO,,3277.91,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Humana,Medicare HMO,,5629.67,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Humana,Medicare HMO,,3277.91,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Humana,Medicare HMO,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Humana,Medicare HMO,,3277.91,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Humana,Medicare HMO,,3277.91,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Humana,Medicare HMO,,3277.91,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Humana,Medicare HMO,,3277.91,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Humana,Medicare HMO,,91.70,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Humana,Medicare HMO,,91.70,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Humana,Medicare HMO,,110.74,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Humana,Medicare HMO,,251.74,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Humana,Medicare HMO,,110.74,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Humana,Medicare HMO,,2033.68,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Humana,Medicare HMO,,91.70,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Humana,Medicare HMO,,110.74,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Humana,Medicare HMO,,91.70,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Humana,Medicare HMO,,91.70,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Humana,Medicare HMO,,110.74,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Humana,Medicare HMO,,110.74,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Humana,Medicare HMO,,110.74,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Humana,Medicare HMO,,110.74,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Humana,Medicare HMO,,91.70,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Humana,Medicare HMO,,91.70,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Humana,Medicare HMO,,185.40,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Humana,Medicare HMO,,185.40,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Humana,Medicare HMO,,18209.54,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Humana,Medicare HMO,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Humana,Medicare HMO,,822.79,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Humana,Medicare HMO,,91.70,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Humana,Medicare HMO,,110.74,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Humana,Medicare HMO,,110.74,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Humana,Medicare HMO,,185.40,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Humana,Medicare HMO,,185.40,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Humana,Medicare HMO,,185.40,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Humana,Medicare HMO,,110.74,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Humana,Medicare HMO,,185.40,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Humana,Medicare HMO,,110.74,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Humana,Medicare HMO,,345.43,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Humana,Medicare HMO,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Humana,Medicare HMO,,418.48,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Humana,Medicare HMO,,418.48,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Humana,Medicare HMO,,418.48,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Humana,Medicare HMO,,560.57,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Humana,Medicare HMO,,418.48,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Humana,Medicare HMO,,560.57,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Humana,Medicare HMO,,418.48,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Humana,Medicare HMO,,418.48,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Humana,Medicare HMO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Humana,Medicare HMO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Humana,Medicare HMO,,560.57,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Humana,Medicare HMO,,560.57,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Humana,Medicare HMO,,418.48,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Humana,Medicare HMO,,418.48,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Humana,Medicare HMO,,418.48,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Humana,Medicare HMO,,418.48,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Humana,Medicare HMO,,418.48,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Humana,Medicare HMO,,1359.57,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Humana,Medicare HMO,,1359.57,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Humana,Medicare HMO,,418.48,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Humana,Medicare HMO,,560.57,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Humana,Medicare HMO,,418.48,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Humana,Medicare HMO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Humana,Medicare HMO,,560.57,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Humana,Medicare HMO,,560.57,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Humana,Medicare HMO,,1359.57,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare HMO,,418.48,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare HMO,,560.57,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Humana,Medicare HMO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Humana,Medicare HMO,,418.48,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Humana,Medicare HMO,,418.48,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Humana,Medicare HMO,,1359.57,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Humana,Medicare HMO,,1359.57,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,24.29,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Humana,Medicare HMO,,751.05,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Humana,Medicare HMO,,2010.34,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Humana,Medicare HMO,,2178.55,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Humana,Medicare HMO,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Humana,Medicare HMO,,233.41,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Humana,Medicare HMO,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Humana,Medicare HMO,,233.41,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Humana,Medicare HMO,,4530.66,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Humana,Medicare HMO,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Humana,Medicare HMO,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Humana,Medicare HMO,,1082.96,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Humana,Medicare HMO,,2304.35,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Humana,Medicare HMO,,418.48,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Humana,Medicare HMO,,180.83,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Humana,Medicare HMO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Humana,Medicare HMO,,281.84,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Humana,Medicare HMO,,418.48,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Humana,Medicare HMO,,418.48,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Humana,Medicare HMO,,1359.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Humana,Medicare HMO,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Humana,Medicare HMO,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Humana,Medicare HMO,,1519.02,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Humana,Medicare HMO,,523.60,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Humana,Medicare HMO,,624.86,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Humana,Medicare HMO,,349.06,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Humana,Medicare HMO,,400.06,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Humana,Medicare HMO,,704.78,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Humana,Medicare HMO,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare HMO,,91.70,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Humana,Medicare HMO,,185.40,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Humana,Medicare HMO,,371.93,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Humana,Medicare HMO,,251.74,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Humana,Medicare HMO,,371.93,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Humana,Medicare HMO,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Humana,Medicare HMO,,185.40,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Humana,Medicare HMO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Humana,Medicare HMO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Humana,Medicare HMO,,989.88,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Humana,Medicare HMO,,1617.80,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare HMO,,1975.59,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Humana,Medicare HMO,,1975.59,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare HMO,,6498.27,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Humana,Medicare HMO,,3675.27,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Humana,Medicare HMO,,2033.68,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Humana,Medicare HMO,,906.81,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Humana,Medicare HMO,,1687.37,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Humana,Medicare HMO,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Humana,Medicare HMO,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Humana,Medicare HMO,,1687.37,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Humana,Medicare HMO,,1687.37,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Humana,Medicare HMO,,416.08,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Humana,Medicare HMO,,416.08,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Humana,Medicare HMO,,643.87,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Humana,Medicare HMO,,6076.09,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare HMO,,6498.27,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Humana,Medicare HMO,,1975.59,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Humana,Medicare HMO,,976.41,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Humana,Medicare HMO,,2133.38,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Humana,Medicare HMO,,1687.37,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Humana,Medicare HMO,,1687.37,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Humana,Medicare HMO,,1687.37,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Humana,Medicare HMO,,1687.37,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Humana,Medicare HMO,,1687.37,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Humana,Medicare HMO,,1542.65,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Humana,Medicare HMO,,307.42,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Humana,Medicare HMO,,307.42,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Humana,Medicare HMO,,307.42,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Humana,Medicare HMO,,307.42,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Humana,Medicare HMO,,307.42,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Humana,Medicare HMO,,13399.92,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Humana,Medicare HMO,,249.82,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Humana,Medicare HMO,,1687.37,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Humana,Medicare HMO,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Humana,Medicare HMO,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Humana,Medicare HMO,,1687.37,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Humana,Medicare HMO,,3675.27,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Humana,Medicare HMO,,643.87,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Humana,Medicare HMO,,1424.94,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Humana,Medicare HMO,,643.87,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Humana,Medicare HMO,,1617.80,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Humana,Medicare HMO,,3277.91,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Humana,Medicare HMO,,3277.91,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Humana,Medicare HMO,,5629.67,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Humana,Medicare HMO,,3277.91,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Humana,Medicare HMO,,3277.91,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Humana,Medicare HMO,,3277.91,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Humana,Medicare HMO,,1617.80,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Humana,Medicare HMO,,1617.80,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Humana,Medicare HMO,,643.87,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Humana,Medicare HMO,,1617.80,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Humana,Medicare HMO,,3277.91,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Humana,Medicare HMO,,1617.80,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Humana,Medicare HMO,,3277.91,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Humana,Medicare HMO,,5629.67,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Humana,Medicare HMO,,3277.91,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Humana,Medicare HMO,,1617.80,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Humana,Medicare HMO,,643.87,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Humana,Medicare HMO,,1617.80,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Humana,Medicare HMO,,3277.91,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Humana,Medicare HMO,,1617.80,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Humana,Medicare HMO,,1617.80,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Humana,Medicare HMO,,219.42,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Humana,Medicare HMO,,219.42,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Humana,Medicare HMO,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Humana,Medicare HMO,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare HMO,,11810.43,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare HMO,,11810.43,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare HMO,,3277.91,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare HMO,,3277.91,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Humana,Medicare HMO,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Humana,Medicare HMO,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Humana,Medicare HMO,,3277.91,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Humana,Medicare HMO,,3277.91,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Humana,Medicare HMO,,3277.91,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Humana,Medicare HMO,,3277.91,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Humana,Medicare HMO,,5629.67,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Humana,Medicare HMO,,11810.43,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Humana,Medicare HMO,,5629.67,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Humana,Medicare HMO,,643.87,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Humana,Medicare HMO,,1687.37,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Humana,Medicare HMO,,1687.37,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Humana,Medicare HMO,,418.48,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare HMO,,455.29,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Humana,Medicare HMO,,415.57,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Humana,Medicare HMO,,976.41,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Humana,Medicare HMO,,10842.57,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Humana,Medicare HMO,,3675.27,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Humana,Medicare HMO,,10842.57,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Humana,Medicare HMO,,1687.37,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Humana,Medicare HMO,,976.41,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Humana,Medicare HMO,,976.41,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Humana,Medicare HMO,,1687.37,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Humana,Medicare HMO,,1424.94,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Humana,Medicare HMO,,3675.27,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Humana,Medicare HMO,,3277.91,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Humana,Medicare HMO,,1975.59,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Humana,Medicare HMO,,1975.59,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Humana,Medicare HMO,,1975.59,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Humana,Medicare HMO,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Humana,Medicare HMO,,976.41,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Humana,Medicare HMO,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Humana,Medicare HMO,,251.74,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Humana,Medicare HMO,,976.41,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Humana,Medicare HMO,,1687.37,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Humana,Medicare HMO,,2133.38,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Humana,Medicare HMO,,2133.38,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Humana,Medicare HMO,,2133.38,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare HMO,,695.12,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Humana,Medicare HMO,,732.74,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Humana,Medicare HMO,,6076.09,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Humana,Medicare HMO,,10842.57,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Humana,Medicare HMO,,2133.38,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Humana,Medicare HMO,,134.24,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Humana,Medicare HMO,,253.29,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare HMO,,209.51,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Humana,Medicare HMO,,732.74,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Humana,Medicare HMO,,11810.43,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Humana,Medicare HMO,,11810.43,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Humana,Medicare HMO,,732.74,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Humana,Medicare HMO,,732.74,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Humana,Medicare HMO,,721.21,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Humana,Medicare HMO,,927.18,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Humana,Medicare HMO,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Humana,Medicare HMO,,927.18,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Humana,Medicare HMO,,927.18,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Humana,Medicare HMO,,927.18,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Humana,Medicare HMO,,927.18,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Humana,Medicare HMO,,927.18,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Humana,Medicare HMO,,927.18,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Humana,Medicare HMO,,927.18,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Humana,Medicare HMO,,927.18,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Humana,Medicare HMO,,927.18,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Humana,Medicare HMO,,927.18,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Humana,Medicare HMO,,2033.68,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Humana,Medicare HMO,,2033.68,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Humana,Medicare HMO,,927.18,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Humana,Medicare HMO,,927.18,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Humana,Medicare HMO,,1227.93,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Humana,Medicare HMO,,7439.71,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Humana,Medicare HMO,,7439.71,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Humana,Medicare HMO,,11810.43,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Humana,Medicare HMO,,11810.43,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Humana,Medicare HMO,,732.74,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Humana,Medicare HMO,,455.29,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Humana,Medicare HMO,,732.74,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Humana,Medicare HMO,,1687.37,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Humana,Medicare HMO,,1687.37,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Humana,Medicare HMO,,1687.37,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Humana,Medicare HMO,,1687.37,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Humana,Medicare HMO,,10842.57,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Humana,Medicare HMO,,732.74,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Humana,Medicare HMO,,732.74,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Humana,Medicare HMO,,11810.43,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Humana,Medicare HMO,,18700.70,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Humana,Medicare HMO,,11810.43,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Humana,Medicare HMO,,732.74,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Humana,Medicare HMO,,3675.27,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Humana,Medicare HMO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Humana,Medicare HMO,,721.21,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Humana,Medicare HMO,,721.21,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Humana,Medicare HMO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Humana,Medicare HMO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Humana,Medicare HMO,,3379.04,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Humana,Medicare HMO,,3379.04,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Humana,Medicare HMO,,7439.71,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Humana,Medicare HMO,,7439.71,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Humana,Medicare HMO,,822.79,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Humana,Medicare HMO,,822.79,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Humana,Medicare HMO,,3675.27,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Humana,Medicare HMO,,3675.27,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Humana,Medicare HMO,,3675.27,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Humana,Medicare HMO,,3675.27,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Humana,Medicare HMO,,3675.27,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Humana,Medicare HMO,,3675.27,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Humana,Medicare HMO,,976.41,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Humana,Medicare HMO,,6076.09,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Humana,Medicare HMO,,6076.09,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Humana,Medicare HMO,,6076.09,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Humana,Medicare HMO,,6498.27,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Humana,Medicare HMO,,1687.37,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Humana,Medicare HMO,,695.12,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Humana,Medicare HMO,,695.12,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Humana,Medicare HMO,,2133.38,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Humana,Medicare HMO,,3591.87,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Humana,Medicare HMO,,2133.38,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Humana,Medicare HMO,,2133.38,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Humana,Medicare HMO,,3591.87,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Humana,Medicare HMO,,3591.87,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Humana,Medicare HMO,,3591.87,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Humana,Medicare HMO,,18700.70,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Humana,Medicare HMO,,5629.67,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Humana,Medicare HMO,,732.74,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Humana,Medicare HMO,,5937.75,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Humana,Medicare HMO,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Humana,Medicare HMO,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Humana,Medicare HMO,,2980.64,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Humana,Medicare HMO,,1617.80,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Humana,Medicare HMO,,1617.80,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Humana,Medicare HMO,,1617.80,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Humana,Medicare HMO,,643.87,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare HMO,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare HMO,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare HMO,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare HMO,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Humana,Medicare HMO,,3591.87,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Humana,Medicare HMO,,3591.87,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Humana,Medicare HMO,,1687.37,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Humana,Medicare HMO,,6669.40,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Humana,Medicare HMO,,643.87,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare HMO,,1617.80,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare HMO,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare HMO,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Humana,Medicare HMO,,1059.54,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Humana,Medicare HMO,,822.79,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Humana,Medicare HMO,,110.74,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Humana,Medicare HMO,,110.74,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Humana,Medicare HMO,,110.74,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Humana,Medicare HMO,,110.74,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Humana,Medicare HMO,,110.74,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Humana,Medicare HMO,,110.74,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare HMO,,110.74,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Humana,Medicare HMO,,110.74,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Humana,Medicare HMO,,110.74,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Humana,Medicare HMO,,251.74,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare HMO,,110.74,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Humana,Medicare HMO,,110.74,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Humana,Medicare HMO,,110.74,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Humana,Medicare HMO,,110.74,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare HMO,,110.74,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Humana,Medicare HMO,,251.74,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Humana,Medicare HMO,,110.74,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Humana,Medicare HMO,,110.74,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Humana,Medicare HMO,,110.74,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Humana,Medicare HMO,,110.74,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Humana,Medicare HMO,,110.74,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Humana,Medicare HMO,,91.70,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Humana,Medicare HMO,,91.70,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,110.74,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Humana,Medicare HMO,,91.70,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Humana,Medicare HMO,,91.70,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Humana,Medicare HMO,,110.74,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Humana,Medicare HMO,,1359.57,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Humana,Medicare HMO,,1519.02,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Humana,Medicare HMO,,1519.02,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Humana,Medicare HMO,,1519.02,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Humana,Medicare HMO,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Humana,Medicare HMO,,418.48,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Humana,Medicare HMO,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Humana,Medicare HMO,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Humana,Medicare HMO,,1519.02,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Humana,Medicare HMO,,1519.02,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Humana,Medicare HMO,,1519.02,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Humana,Medicare HMO,,1519.02,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Humana,Medicare HMO,,1519.02,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Humana,Medicare HMO,,2343.75,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Humana,Medicare HMO,,2031.31,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Humana,Medicare HMO,,251.74,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Humana,Medicare HMO,,571.02,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Humana,Medicare HMO,,571.02,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Humana,Medicare HMO,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Humana,Medicare HMO,,571.02,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Humana,Medicare HMO,,822.79,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Humana,Medicare HMO,,822.79,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Humana,Medicare HMO,,822.79,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Humana,Medicare HMO,,91.70,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Humana,Medicare HMO,,371.93,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Humana,Medicare HMO,,371.93,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Humana,Medicare HMO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Humana,Medicare HMO,,91.70,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Humana,Medicare HMO,,61.87,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Humana,Medicare HMO,,721.21,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Humana,Medicare HMO,,721.21,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Humana,Medicare HMO,,721.21,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Humana,Medicare HMO,,721.21,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Humana,Medicare HMO,,110.74,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Humana,Medicare HMO,,110.74,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Humana,Medicare HMO,,110.74,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Humana,Medicare HMO,,162.94,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare HMO,,251.74,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Humana,Medicare HMO,,110.74,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Humana,Medicare HMO,,110.74,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Humana,Medicare HMO,,251.74,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Humana,Medicare HMO,,110.74,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Humana,Medicare HMO,,11.09,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Humana,Medicare HMO,,50.20,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare HMO,,9.11,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Humana,Medicare HMO,,50.01,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Humana,Medicare HMO,,8.58,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare HMO,,172.16,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare HMO,,152.08,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Humana,Medicare HMO,,584.43,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Humana,Medicare HMO,,305.93,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Humana,Medicare HMO,,1218.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Humana,Medicare HMO,,1218.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Humana,Medicare HMO,,68.97,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Humana,Medicare HMO,,77.04,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Humana,Medicare HMO,,59.89,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Humana,Medicare HMO,,47.13,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Humana,Medicare HMO,,173.79,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Humana,Medicare HMO,,106.18,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare HMO,,36.75,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Humana,Medicare HMO,,68.63,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Humana,Medicare HMO,,207.89,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Humana,Medicare HMO,,181.37,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Humana,Medicare HMO,,244.72,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Humana,Medicare HMO,,244.72,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare HMO,,2.36,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Humana,Medicare HMO,,365.99,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Humana,Medicare HMO,,53.62,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Humana,Medicare HMO,,45.83,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Humana,Medicare HMO,,211.57,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Humana,Medicare HMO,,245.70,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Humana,Medicare HMO,,422.23,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Humana,Medicare HMO,,423.77,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Humana,Medicare HMO,,133.80,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Humana,Medicare HMO,,78.05,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Humana,Medicare HMO,,99.48,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Humana,Medicare HMO,,362.85,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Humana,Medicare HMO,,352.15,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Humana,Medicare HMO,,186.11,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Humana,Medicare HMO,,178.40,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Humana,Medicare HMO,,129.86,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Humana,Medicare HMO,,258.85,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Humana,Medicare HMO,,130.87,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Humana,Medicare HMO,,315.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Humana,Medicare HMO,,202.91,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Humana,Medicare HMO,,310.58,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare HMO,,17.61,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Humana,Medicare HMO,,5.29,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Humana,Medicare HMO,,9.18,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Humana,Medicare HMO,,10.14,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare HMO,,7.90,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare HMO,,4.53,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Humana,Medicare HMO,,4.48,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Humana,Medicare HMO,,65.25,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Humana,Medicare HMO,,8.88,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Humana,Medicare HMO,,7.36,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Humana,Medicare HMO,,14.06,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Humana,Medicare HMO,,65.25,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Humana,Medicare HMO,,65.25,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Humana,Medicare HMO,,65.25,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare HMO,,65.25,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Humana,Medicare HMO,,65.25,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare HMO,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare HMO,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,15.83,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,15.30,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,13.94,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,14.22,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare HMO,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare HMO,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare HMO,,17.20,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare HMO,,15.42,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.94,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare HMO,,16.07,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,13.91,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare HMO,,14.45,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Humana,Medicare HMO,,14.42,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Humana,Medicare HMO,,14.42,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare HMO,,14.85,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare HMO,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare HMO,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare HMO,,16.94,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare HMO,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare HMO,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare HMO,,14.22,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Humana,Medicare HMO,,34.25,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare HMO,,4.75,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare HMO,,8.58,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,8.58,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,5.20,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare HMO,,8.17,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare HMO,,6.07,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare HMO,,6.07,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare HMO,,18.13,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Humana,Medicare HMO,,14.11,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare HMO,,17.61,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,15.30,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare HMO,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare HMO,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare HMO,,6.80,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare HMO,,16.99,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare HMO,,5.27,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare HMO,,5.27,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,5.27,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Humana,Medicare HMO,,4.60,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare HMO,,5.59,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare HMO,,4.44,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Humana,Medicare HMO,,31.08,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare HMO,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare HMO,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare HMO,,6.33,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Humana,Medicare HMO,,5.12,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Humana,Medicare HMO,,19.91,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare HMO,,11.28,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,14.83,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,14.83,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,4.83,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Humana,Medicare HMO,,5.25,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare HMO,,4.57,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Humana,Medicare HMO,,40.50,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare HMO,,28.47,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare HMO,,28.47,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Humana,Medicare HMO,,19.57,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare HMO,,17.11,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Humana,Medicare HMO,,14.42,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,6.84,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare HMO,,12.13,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare HMO,,5.38,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,5.44,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,5.44,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Humana,Medicare HMO,,29.34,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Humana,Medicare HMO,,15.64,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare HMO,,5.36,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Humana,Medicare HMO,,14.31,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Humana,Medicare HMO,,67.63,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare HMO,,15.44,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare HMO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare HMO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare HMO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare HMO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare HMO,,11.55,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare HMO,,27.37,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare HMO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare HMO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare HMO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare HMO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,10.26,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare HMO,,4.13,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare HMO,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare HMO,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare HMO,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Humana,Medicare HMO,,4.13,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Humana,Medicare HMO,,4.99,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare HMO,,13.51,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare HMO,,4.12,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare HMO,,4.12,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Humana,Medicare HMO,,7.56,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Humana,Medicare HMO,,19.51,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare HMO,,19.45,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare HMO,,13.21,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Humana,Medicare HMO,,13.51,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare HMO,,18.96,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Humana,Medicare HMO,,8.40,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,10.20,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare HMO,,8.61,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare HMO,,8.61,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Humana,Medicare HMO,,4.99,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Humana,Medicare HMO,,18.82,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare HMO,,26.72,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare HMO,,12.11,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare HMO,,12.11,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare HMO,,12.00,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.79,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,12.15,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare HMO,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare HMO,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,20.68,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare HMO,,20.29,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Humana,Medicare HMO,,7.23,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Humana,Medicare HMO,,7.23,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Humana,Medicare HMO,,8.60,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare HMO,,11.03,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare HMO,,7.04,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare HMO,,13.57,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare HMO,,41.22,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare HMO,,18.13,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,18.13,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Humana,Medicare HMO,,6.94,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,7.16,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare HMO,,43.34,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Humana,Medicare HMO,,43.34,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare HMO,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare HMO,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare HMO,,3.76,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Humana,Medicare HMO,,5.44,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,4.98,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Humana,Medicare HMO,,6.07,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Humana,Medicare HMO,,6.07,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Humana,Medicare HMO,,103.02,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Humana,Medicare HMO,,5.00,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,4.97,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,15.32,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Humana,Medicare HMO,,21.90,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Humana,Medicare HMO,,20.35,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Humana,Medicare HMO,,19.31,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Humana,Medicare HMO,,19.31,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare HMO,,3.85,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Humana,Medicare HMO,,4.20,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare HMO,,11.28,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare HMO,,18.72,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare HMO,,18.72,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare HMO,,5.05,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare HMO,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare HMO,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare HMO,,5.10,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare HMO,,3.44,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Humana,Medicare HMO,,27.10,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare HMO,,7.21,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Humana,Medicare HMO,,9.47,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Humana,Medicare HMO,,17.64,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,5.44,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare HMO,,5.57,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare HMO,,13.40,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare HMO,,6.03,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Humana,Medicare HMO,,14.89,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Humana,Medicare HMO,,17.79,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Humana,Medicare HMO,,13.09,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,4.15,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare HMO,,5.84,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,4.75,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare HMO,,5.33,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare HMO,,5.33,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Humana,Medicare HMO,,65.25,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Humana,Medicare HMO,,65.25,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,15.80,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare HMO,,8.26,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Humana,Medicare HMO,,5.48,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Humana,Medicare HMO,,15.80,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Humana,Medicare HMO,,15.80,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Humana,Medicare HMO,,19.29,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare HMO,,11.72,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Humana,Medicare HMO,,5.44,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare HMO,,13.60,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Humana,Medicare HMO,,26.72,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,26.72,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,26.72,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Humana,Medicare HMO,,12.60,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare HMO,,14.43,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Humana,Medicare HMO,,14.43,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Humana,Medicare HMO,,18.83,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Humana,Medicare HMO,,18.83,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Humana,Medicare HMO,,12.65,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare HMO,,12.65,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Humana,Medicare HMO,,21.85,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Humana,Medicare HMO,,21.85,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Humana,Medicare HMO,,5.44,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Humana,Medicare HMO,,31.42,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Humana,Medicare HMO,,23.46,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare HMO,,30.82,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Humana,Medicare HMO,,39.62,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare HMO,,28.12,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,28.12,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,374.62,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Humana,Medicare HMO,,39.62,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Humana,Medicare HMO,,39.62,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Humana,Medicare HMO,,49.33,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Humana,Medicare HMO,,81.67,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare HMO,,15.28,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare HMO,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare HMO,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare HMO,,11.17,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Humana,Medicare HMO,,5.95,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Humana,Medicare HMO,,65.08,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Humana,Medicare HMO,,25.50,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare HMO,,4.48,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare HMO,,4.62,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare HMO,,4.62,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Humana,Medicare HMO,,17.88,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare HMO,,15.11,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Humana,Medicare HMO,,17.69,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Humana,Medicare HMO,,16.05,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare HMO,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare HMO,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,10.69,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare HMO,,10.69,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare HMO,,17.69,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare HMO,,17.69,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare HMO,,9.54,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare HMO,,13.85,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Humana,Medicare HMO,,20.32,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Humana,Medicare HMO,,9.33,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare HMO,,14.40,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare HMO,,12.36,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare HMO,,11.28,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,13.01,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Humana,Medicare HMO,,11.82,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Humana,Medicare HMO,,13.01,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Humana,Medicare HMO,,20.32,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,20.32,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare HMO,,13.52,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Humana,Medicare HMO,,15.11,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Humana,Medicare HMO,,15.13,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,13.90,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare HMO,,13.52,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,14.98,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Humana,Medicare HMO,,114.96,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Humana,Medicare HMO,,67.40,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Humana,Medicare HMO,,67.40,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Humana,Medicare HMO,,339.94,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Humana,Medicare HMO,,342.09,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare HMO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Humana,Medicare HMO,,178.46,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Humana,Medicare HMO,,374.62,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare HMO,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare HMO,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare HMO,,5.66,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Humana,Medicare HMO,,5.44,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare HMO,,3.14,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,3.14,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Humana,Medicare HMO,,6.67,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Humana,Medicare HMO,,6.67,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Humana,Medicare HMO,,4.02,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Humana,Medicare HMO,,178.46,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,178.46,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Humana,Medicare HMO,,61.87,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Humana,Medicare HMO,,61.87,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Humana,Medicare HMO,,25.50,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Humana,Medicare HMO,,14.61,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare HMO,,3.99,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,2.49,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,2.49,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare HMO,,8.16,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,6.79,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,4.19,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare HMO,,5.85,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare HMO,,2.67,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,4.70,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Humana,Medicare HMO,,850.74,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Humana,Medicare HMO,,850.74,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Humana,Medicare HMO,,13.63,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare HMO,,18.53,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Humana,Medicare HMO,,18.80,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Humana,Medicare HMO,,18.80,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Humana,Medicare HMO,,12.48,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Humana,Medicare HMO,,24.09,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,24.09,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Humana,Medicare HMO,,24.09,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Humana,Medicare HMO,,32.40,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Humana,Medicare HMO,,24.09,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Humana,Medicare HMO,,19.99,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Humana,Medicare HMO,,18.80,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Humana,Medicare HMO,,18.80,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Humana,Medicare HMO,,20.32,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Humana,Medicare HMO,,9.57,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Humana,Medicare HMO,,19.88,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Humana,Medicare HMO,,19.88,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Humana,Medicare HMO,,12.44,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare HMO,,14.53,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Humana,Medicare HMO,,16.09,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare HMO,,32.40,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Humana,Medicare HMO,,16.09,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Humana,Medicare HMO,,13.51,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Humana,Medicare HMO,,13.51,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare HMO,,13.51,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare HMO,,4.49,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare HMO,,7.23,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare HMO,,10.69,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare HMO,,10.21,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Humana,Medicare HMO,,18.05,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,9.83,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Humana,Medicare HMO,,13.74,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare HMO,,13.74,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Humana,Medicare HMO,,26.16,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare HMO,,26.16,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare HMO,,18.88,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare HMO,,18.88,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare HMO,,4.50,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Humana,Medicare HMO,,4.14,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare HMO,,10.06,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare HMO,,10.06,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Humana,Medicare HMO,,18.88,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare HMO,,10.34,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Humana,Medicare HMO,,19.57,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare HMO,,4.48,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,5.79,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare HMO,,6.06,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Humana,Medicare HMO,,6.06,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,6.31,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,6.31,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare HMO,,6.79,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare HMO,,6.79,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Humana,Medicare HMO,,12.25,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,7.01,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare HMO,,10.84,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare HMO,,10.84,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Humana,Medicare HMO,,9.91,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,9.91,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Humana,Medicare HMO,,9.91,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare HMO,,9.05,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Humana,Medicare HMO,,9.05,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Humana,Medicare HMO,,10.38,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Humana,Medicare HMO,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Humana,Medicare HMO,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Humana,Medicare HMO,,9.94,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Humana,Medicare HMO,,8.48,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Humana,Medicare HMO,,8.48,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare HMO,,8.48,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,8.48,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare HMO,,6.96,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Humana,Medicare HMO,,6.96,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare HMO,,6.96,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare HMO,,6.96,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Humana,Medicare HMO,,6.96,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare HMO,,8.47,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Humana,Medicare HMO,,8.10,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,8.83,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare HMO,,10.84,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,10.84,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare HMO,,5.44,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare HMO,,5.44,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare HMO,,121.13,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Humana,Medicare HMO,,4.53,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare HMO,,4.48,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,6.17,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare HMO,,9.35,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare HMO,,4.99,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare HMO,,7.85,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Humana,Medicare HMO,,4.99,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare HMO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare HMO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare HMO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare HMO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Humana,Medicare HMO,,9.08,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Humana,Medicare HMO,,4.48,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare HMO,,4.48,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare HMO,,4.48,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,5.66,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Humana,Medicare HMO,,5.66,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,5.66,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Humana,Medicare HMO,,6.29,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare HMO,,18.88,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Humana,Medicare HMO,,6.11,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,6.11,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare HMO,,12.58,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Humana,Medicare HMO,,12.58,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,12.58,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Humana,Medicare HMO,,12.58,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare HMO,,14.51,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare HMO,,10.85,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare HMO,,10.85,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,25.28,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare HMO,,25.28,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Humana,Medicare HMO,,12.58,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Humana,Medicare HMO,,12.58,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare HMO,,12.58,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Humana,Medicare HMO,,36.84,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Humana,Medicare HMO,,39.13,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Humana,Medicare HMO,,36.84,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Humana,Medicare HMO,,44.98,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Humana,Medicare HMO,,36.84,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare HMO,,44.98,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Humana,Medicare HMO,,44.98,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Humana,Medicare HMO,,36.84,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Humana,Medicare HMO,,36.84,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Humana,Medicare HMO,,89.36,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare HMO,,36.84,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Humana,Medicare HMO,,36.84,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Humana,Medicare HMO,,36.84,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare HMO,,100.59,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Humana,Medicare HMO,,149.76,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Humana,Medicare HMO,,437.62,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Humana,Medicare HMO,,36.84,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Humana,Medicare HMO,,36.84,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Humana,Medicare HMO,,36.84,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,36.84,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Humana,Medicare HMO,,36.84,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Humana,Medicare HMO,,44.98,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Humana,Medicare HMO,,276.14,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Humana,Medicare HMO,,16.05,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Humana,Medicare HMO,,17.36,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Humana,Medicare HMO,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Humana,Medicare HMO,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Humana,Medicare HMO,,16.87,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare HMO,,270.32,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Humana,Medicare HMO,,270.32,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Humana,Medicare HMO,,3.33,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Humana,Medicare HMO,,3.33,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,3.65,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,3.65,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare HMO,,3.65,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Humana,Medicare HMO,,9.04,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Humana,Medicare HMO,,178.46,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare HMO,,5.88,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,7.70,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare HMO,,6.08,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Humana,Medicare HMO,,96.24,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Humana,Medicare HMO,,18.95,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Humana,Medicare HMO,,25.39,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare HMO,,13.01,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Humana,Medicare HMO,,4.96,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Humana,Medicare HMO,,13.91,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,17.28,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare HMO,,12.11,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Humana,Medicare HMO,,5.48,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Humana,Medicare HMO,,18.83,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Humana,Medicare HMO,,4.48,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare HMO,,13.70,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare HMO,,13.52,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Humana,Medicare HMO,,5.44,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare HMO,,15.10,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Humana,Medicare HMO,,8.48,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare HMO,,8.48,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare HMO,,14.29,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Humana,Medicare HMO,,9.04,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare HMO,,13.85,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,7.01,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare HMO,,5.44,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Humana,Medicare HMO,,14.06,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Humana,Medicare HMO,,4.99,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare HMO,,4.99,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare HMO,,13.51,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare HMO,,4.50,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,6.45,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare HMO,,13.90,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare HMO,,6.96,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Humana,Medicare HMO,,178.46,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Humana,Medicare HMO,,178.46,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Humana,Medicare HMO,,129.86,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare HMO,,15.34,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,15.80,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare HMO,,7.68,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Humana,Medicare HMO,,27.10,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Humana,Medicare HMO,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,36.84,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,16.72,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Humana,Medicare HMO,,5.78,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare HMO,,28.58,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Humana,Medicare HMO,,2.83,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare HMO,,12.58,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Humana,Medicare HMO,,17.38,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Humana,Medicare HMO,,17.38,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare HMO,,9.54,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare HMO,,9.54,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Humana,Medicare HMO,,9.54,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare HMO,,36.84,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Humana,Medicare HMO,,127.71,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Humana,Medicare HMO,,194.46,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Humana,Medicare HMO,,87.15,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Humana,Medicare HMO,,673.94,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Humana,Medicare HMO,,1916.12,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Humana,Medicare HMO,,394.01,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare HMO,,9.54,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Humana,Medicare HMO,,11.71,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Humana,Medicare HMO,,6.79,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Humana,Medicare HMO,,5.79,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare HMO,,19.45,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Humana,Medicare HMO,,194.46,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Humana,Medicare HMO,,36.84,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Humana,Medicare HMO,,143.85,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Humana,Medicare HMO,,36.84,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Humana,Medicare HMO,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Humana,Medicare HMO,,228.96,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare HMO,,36.84,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,36.84,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Humana,Medicare HMO,,73.71,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Humana,Medicare HMO,,127.71,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Humana,Medicare HMO,,194.46,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Humana,Medicare HMO,,26.16,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Humana,Medicare HMO,QW,26.16,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare HMO,,15.10,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Humana,Medicare HMO,,65.25,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Humana,Medicare HMO,,1218.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Humana,Medicare HMO,,437.62,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Humana,Medicare HMO,,96.24,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,21.85,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Humana,Medicare HMO,,244.72,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Humana,Medicare HMO,,43.85,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Humana,Medicare HMO,,44.98,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Humana,Medicare HMO,,16.87,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare HMO,,5.48,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare HMO,,30.67,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare HMO,QW,53.88,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare HMO,,44.24,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Humana,Medicare HMO,,18.13,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Humana,Medicare HMO,,437.62,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare HMO,,149.76,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare HMO,,10.84,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare HMO,,19.57,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare HMO,,19.57,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare HMO,,28.47,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Humana,Medicare HMO,,40.50,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare HMO,,9.08,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Humana,Medicare HMO,,149.76,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare HMO,,41.22,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Humana,Medicare HMO,,22.82,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare HMO,,21.85,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Humana,Medicare HMO,,143.85,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare HMO,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare HMO,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Humana,Medicare HMO,,21.34,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare HMO,,12.11,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,18.13,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare HMO,,23.46,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare HMO,,30.82,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Humana,Medicare HMO,,28.76,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Humana,Medicare HMO,,134.70,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Humana,Medicare HMO,,12.11,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Humana,Medicare HMO,,53.88,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,36.84,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare HMO,,36.84,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,10.20,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare HMO,,12.15,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare HMO,,2.36,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Humana,Medicare HMO,,36.84,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Humana,Medicare HMO,,36.84,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Humana,Medicare HMO,,36.84,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Humana,Medicare HMO,,143.85,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare HMO,,9.05,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Humana,Medicare HMO,,276.14,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Humana,Medicare HMO,,73.71,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Humana,Medicare HMO,,55.64,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Humana,Medicare HMO,,2.49,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare HMO,,40.88,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Humana,Medicare HMO,,40.88,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Humana,Medicare HMO,,55.64,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Humana,Medicare HMO,,55.64,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Humana,Medicare HMO,,21.27,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Humana,Medicare HMO,,25.50,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Humana,Medicare HMO,,178.46,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Humana,Medicare HMO,,55.64,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,27.94,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Humana,Medicare HMO,,27.94,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare HMO,,27.94,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Humana,Medicare HMO,,374.62,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Humana,Medicare HMO,,374.62,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Humana,Medicare HMO,,122.31,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Humana,Medicare HMO,,122.31,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Humana,Medicare HMO,,147.77,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Humana,Medicare HMO,,157.81,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Humana,Medicare HMO,,157.81,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Humana,Medicare HMO,,150.94,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Humana,Medicare HMO,,13.72,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Humana,Medicare HMO,,277.56,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Humana,Medicare HMO,,131.76,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Humana,Medicare HMO,,151.84,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Humana,Medicare HMO,,198.00,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Humana,Medicare HMO,,22.49,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare HMO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare HMO,,36.55,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Humana,Medicare HMO,,44.50,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Humana,Medicare HMO,,53.75,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Humana,Medicare HMO,,35.14,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Humana,Medicare HMO,,72.03,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Humana,Medicare HMO,,28.26,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare HMO,,55.64,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Humana,Medicare HMO,,40.88,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Humana,Medicare HMO,,25.50,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Humana,Medicare HMO,,40.88,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Humana,Medicare HMO,,55.64,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Humana,Medicare HMO,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Humana,Medicare HMO,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Humana,Medicare HMO,,374.62,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Humana,Medicare HMO,,850.74,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare HMO,,134.24,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Humana,Medicare HMO,,850.74,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare HMO,,55.64,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Humana,Medicare HMO,,178.46,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Humana,Medicare HMO,,850.74,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Humana,Medicare HMO,,178.46,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Humana,Medicare HMO,,12.65,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Humana,Medicare HMO,,178.46,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare HMO,,178.46,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare HMO,,178.46,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare HMO,,178.46,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Humana,Medicare HMO,,107.37,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Humana,Medicare HMO,,5.27,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Humana,Medicare HMO,,178.46,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Humana,Medicare HMO,,150.94,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Humana,Medicare HMO,,147.77,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Humana,Medicare HMO,,150.94,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Humana,Medicare HMO,,53.75,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Humana,Medicare HMO,,151.84,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare HMO,,374.62,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare HMO,,178.46,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Humana,Medicare HMO,,53.75,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare HMO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare HMO,,178.46,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Humana,Medicare HMO,,55.64,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare HMO,,134.24,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Humana,Medicare HMO,,374.62,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Humana,Medicare HMO,,53.75,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare HMO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Humana,Medicare HMO,,178.46,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare HMO,,178.46,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Humana,Medicare HMO,,178.46,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Humana,Medicare HMO,,22.49,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare HMO,,22.49,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare HMO,,22.49,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Humana,Medicare HMO,,53.75,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare HMO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Humana,Medicare HMO,,44.50,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare HMO,,178.46,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare HMO,,178.46,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,178.46,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Humana,Medicare HMO,,40.88,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Humana,Medicare HMO,,178.46,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Humana,Medicare HMO,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Humana,Medicare HMO,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Humana,Medicare HMO,,189.54,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Humana,Medicare HMO,,189.54,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare HMO,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare HMO,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare HMO,,87.78,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Humana,Medicare HMO,,150.30,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Humana,Medicare HMO,,413.31,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare HMO,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Humana,Medicare HMO,,703.66,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Humana,Medicare HMO,,680.83,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Humana,Medicare HMO,,266.40,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Humana,Medicare HMO,,153.41,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Humana,Medicare HMO,,809.71,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Humana,Medicare HMO,,252.48,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare HMO,,74.04,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Humana,Medicare HMO,,611.61,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare HMO,,3.14,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare HMO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare HMO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare HMO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare HMO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare HMO,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare HMO,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare HMO,,703.66,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare HMO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare HMO,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare HMO,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare HMO,,5629.67,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare HMO,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare HMO,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Humana,Medicare HMO,,162.94,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Humana,Medicare HMO,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare HMO,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare HMO,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Humana,Medicare HMO,,3277.91,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Humana,Medicare HMO,,3277.91,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Humana,Medicare HMO,,3277.91,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Humana,Medicare HMO,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Humana,Medicare HMO,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare HMO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare HMO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Humana,Medicare HMO,,3277.91,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Humana,Medicare HMO,,3277.91,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare HMO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare HMO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare HMO,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare HMO,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Humana,Medicare HMO,,3277.91,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Humana,Medicare HMO,,11810.43,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Humana,Medicare HMO,,3277.91,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Humana,Medicare HMO,,3277.91,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare HMO,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare HMO,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare HMO,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare HMO,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Humana,Medicare HMO,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Humana,Medicare HMO,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Humana,Medicare HMO,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Humana,Medicare HMO,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Humana,Medicare HMO,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Humana,Medicare HMO,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Humana,Medicare HMO,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Humana,Medicare HMO,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Humana,Medicare HMO,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Humana,Medicare HMO,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Humana,Medicare HMO,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Humana,Medicare HMO,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Humana,Medicare HMO,,11810.43,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Humana,Medicare HMO,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Humana,Medicare HMO,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Humana,Medicare HMO,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Humana,Medicare HMO,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Humana,Medicare HMO,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Humana,Medicare HMO,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Humana,Medicare HMO,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Humana,Medicare HMO,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Humana,Medicare HMO,,681.49,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Humana,Medicare HMO,,681.49,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Humana,Medicare HMO,,345.43,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Humana,Medicare HMO,,5937.75,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Humana,Medicare HMO,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Humana,Medicare HMO,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Humana,Medicare HMO,,11810.43,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Humana,Medicare HMO,,3349.67,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Humana,Medicare HMO,,3349.67,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Humana,Medicare HMO,,3349.67,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Humana,Medicare HMO,,3349.67,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Humana,Medicare HMO,,3349.67,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Humana,Medicare HMO,,3349.67,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Humana,Medicare HMO,,3349.67,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Humana,Medicare HMO,,3349.67,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Humana,Medicare HMO,,3349.67,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Humana,Medicare HMO,,3349.67,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Humana,Medicare HMO,,3349.67,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Humana,Medicare HMO,,1617.80,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Humana,Medicare HMO,,3277.91,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Humana,Medicare HMO,,18700.70,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Humana,Medicare HMO,,7902.49,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Humana,Medicare HMO,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Humana,Medicare HMO,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Humana,Medicare HMO,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Humana,Medicare HMO,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Humana,Medicare HMO,,10898.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Humana,Medicare HMO,,8618.87,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Humana,Medicare HMO,,10898.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Humana,Medicare HMO,,10898.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Humana,Medicare HMO,,3277.91,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Humana,Medicare HMO,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Humana,Medicare HMO,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Humana,Medicare HMO,,3790.08,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Humana,Medicare HMO,,3790.08,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Humana,Medicare HMO,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Humana,Medicare HMO,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Humana,Medicare HMO,,10898.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Humana,Medicare HMO,,3277.91,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Humana,Medicare HMO,,8618.87,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Humana,Medicare HMO,,10898.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Humana,Medicare HMO,,19861.32,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Humana,Medicare HMO,,8618.87,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Humana,Medicare HMO,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Humana,Medicare HMO,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Humana,Medicare HMO,,23376.18,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Humana,Medicare HMO,,3790.08,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Humana,Medicare HMO,,3790.08,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Humana,Medicare HMO,,33389.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Humana,Medicare HMO,,8618.87,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Humana,Medicare HMO,,732.74,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Humana,Medicare HMO,,643.87,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Humana,Medicare HMO,,7902.49,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Humana,Medicare HMO,,7902.49,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Humana,Medicare HMO,,1264.28,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Humana,Medicare HMO,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Humana,Medicare HMO,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Humana,Medicare HMO,,1264.28,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Humana,Medicare HMO,,7902.49,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Humana,Medicare HMO,,7902.49,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Humana,Medicare HMO,,1264.28,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Humana,Medicare HMO,,7902.49,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Humana,Medicare HMO,,552.58,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Humana,Medicare HMO,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Humana,Medicare HMO,,19861.32,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Humana,Medicare HMO,,33389.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Humana,Medicare HMO,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Humana,Medicare HMO,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Humana,Medicare HMO,,33389.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Humana,Medicare HMO,,29606.17,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Humana,Medicare HMO,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Humana,Medicare HMO,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Humana,Medicare HMO,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare HMO,,415.57,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Humana,Medicare HMO,,162.94,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Humana,Medicare HMO,,3277.91,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Humana,Medicare HMO,,1617.80,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Humana,Medicare HMO,,11810.43,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Humana,Medicare HMO,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Humana,Medicare HMO,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Humana,Medicare HMO,,18700.70,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Humana,Medicare HMO,,643.87,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Humana,Medicare HMO,,33389.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Humana,Medicare HMO,,11810.43,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Humana,Medicare HMO,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Humana,Medicare HMO,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Humana,Medicare HMO,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Humana,Medicare HMO,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Humana,Medicare HMO,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Humana,Medicare HMO,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Humana,Medicare HMO,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Humana,Medicare HMO,,25548.73,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Humana,Medicare HMO,,5937.75,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Humana,Medicare HMO,,643.87,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Humana,Medicare HMO,,33389.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Humana,Medicare HMO,,5937.75,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Humana,Medicare HMO,,110.74,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Humana,Medicare HMO,,19861.32,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Humana,Medicare HMO,,324.30,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Humana,Medicare HMO,,571.02,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Humana,Medicare HMO,,571.02,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Humana,Medicare HMO,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Humana,Medicare HMO,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Humana,Medicare HMO,,251.74,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Humana,Medicare HMO,,251.74,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Humana,Medicare HMO,,251.74,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Humana,Medicare HMO,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Humana,Medicare HMO,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Humana,Medicare HMO,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Humana,Medicare HMO,,38.84,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Humana,Medicare HMO,,134.24,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Humana,Medicare HMO,,61.87,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare HMO,,95.59,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Humana,Medicare HMO,,251.74,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare HMO,,131.12,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Humana,Medicare HMO,,131.12,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Humana,Medicare HMO,,61.87,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Humana,Medicare HMO,,61.87,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Humana,Medicare HMO,,3839.70,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Humana,Medicare HMO,,3277.91,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Humana,Medicare HMO,,7439.71,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Humana,Medicare HMO,,732.74,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Humana,Medicare HMO,,8618.87,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Humana,Medicare HMO,,3790.08,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Humana,Medicare HMO,,3790.08,,,,,,,422.62,17457.00,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,215412.76,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,87653.85,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,163376.49,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,106938.50,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,79836.98,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,36412.81,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,100040.85,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,43818.68,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,55843.64,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,42666.79,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33190.55,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22978.77,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,92905.15,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,46306.95,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,42499.92,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,331436.76,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,55529.08,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,61148.55,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,41439.87,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25241.25,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,44780.78,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,30863.01,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,35721.67,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24719.26,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20231.80,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,46908.54,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27033.77,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17723.63,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,35214.98,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17232.26,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13649.49,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,30547.68,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19218.43,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15791.80,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,26119.14,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13341.04,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9918.99,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,30474.96,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17750.42,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14145.45,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14785.32,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8416.54,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12608.57,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8725.76,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18702.56,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10838.23,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14006.15,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10419.55,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7961.91,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22024.35,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14371.25,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11666.37,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16313.80,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8654.58,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6160.19,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12163.11,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7537.89,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7035.79,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13664.02,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8774.75,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6709.73,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13200.97,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8811.48,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15598.15,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7237.86,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14775.38,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7776.68,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18415.54,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11605.15,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8237.46,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18310.69,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10892.56,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7922.88,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11268.38,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9330.42,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7222.55,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14363.60,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8751.77,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7016.65,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27858.86,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28566.09,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18486.74,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11349.49,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15745.88,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7830.26,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9501.09,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7322.81,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18916.86,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11277.56,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12669.80,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14760.82,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9225.55,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9825.63,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6936.29,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7034.25,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11048.71,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6798.52,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17530.75,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8692.84,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12350.62,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7704.74,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10379.75,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33567.88,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17615.72,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13140.51,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29597.83,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14185.27,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10124.13,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17128.17,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10653.76,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7022.79,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6674.53,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11113.00,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6539.82,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9970.26,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6571.97,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12888.69,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7936.65,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6211.46,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14062.03,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7885.36,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6344.65,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,35224.95,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20240.22,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15572.92,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29529.70,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14724.84,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11380.10,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23702.83,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11435.22,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7083.25,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12882.57,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8392.06,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6700.55,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14438.60,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9119.17,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6691.37,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12631.53,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9066.35,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6941.65,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12850.44,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8492.31,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6411.24,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10377.45,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9400.07,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7374.09,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5835.67,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10982.12,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7090.12,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5732.34,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15366.26,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8186.17,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6403.58,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14424.06,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9335.77,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6395.17,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8355.32,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6049.98,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7101.62,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14936.10,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8124.94,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,50172.15,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21960.03,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,87554.35,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,84150.68,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,44601.69,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,77131.34,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,75798.02,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,59690.48,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,41738.37,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,39498.86,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,38788.59,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25027.69,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,65443.13,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,47324.16,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,59437.13,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,42732.61,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,45839.31,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,32982.36,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,38591.88,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22739.22,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11517.89,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25359.12,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17231.49,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14756.23,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,35841.82,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17626.41,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12360.57,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27620.84,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20788.24,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14558.76,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21567.41,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13917.37,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9281.42,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24971.07,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16398.75,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25818.35,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13396.91,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24322.78,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,26490.37,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28615.06,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,47827.79,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,37360.36,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,53564.34,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33245.65,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,41305.94,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28141.31,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20462.18,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,32497.87,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,26116.07,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,55496.94,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,46895.53,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,36271.21,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,43524.79,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28524.74,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13199.44,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7956.55,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6456.39,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16082.64,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6219.89,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5505.79,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17858.34,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9112.27,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21634.77,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13986.26,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8037.68,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10747.91,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7420.02,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5253.97,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12876.45,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5774.43,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,4405.15,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13418.34,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9092.37,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6430.38,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10080.51,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6074.47,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10029.98,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6701.31,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12982.83,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7911.39,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6552.83,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5254.73,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6294.12,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7593.00,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6432.66,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16881.72,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8294.85,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6142.58,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,52099.39,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19461.06,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,35080.27,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19331.71,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21746.51,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14415.63,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,34043.17,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25039.17,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25493.84,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,39094.73,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19629.42,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13185.67,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,36102.84,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19269.71,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13802.57,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28634.21,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18848.74,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13458.14,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28253.06,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17061.59,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12670.56,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20690.27,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12438.65,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10000.89,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18492.09,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10939.25,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7585.34,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19994.53,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12590.19,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9860.08,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23133.38,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13798.74,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11216.32,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,34543.75,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18720.94,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11621.20,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27240.44,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19400.60,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13106.07,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8577.27,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6285.71,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14492.95,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8736.47,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6489.29,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17291.19,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10179.99,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7996.35,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14913.13,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8428.02,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5746.87,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15940.27,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9214.84,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7049.57,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11489.57,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7464.40,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13032.60,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8394.36,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6136.47,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12225.09,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6966.90,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5085.59,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10629.27,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6888.84,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13162.69,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8083.60,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5889.25,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19252.10,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12506.75,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9683.26,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,31694.22,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,42792.31,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23119.60,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17910.39,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28212.47,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17586.64,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13073.91,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,26204.87,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17014.13,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13631.12,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28189.53,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16740.12,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11356.39,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19187.05,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13869.16,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11375.53,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,26999.33,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14220.47,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11633.46,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,32708.36,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17667.76,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12404.98,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,85276.57,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,56172.01,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,43951.87,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,69880.07,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,45062.43,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15986.21,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9005.88,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6375.27,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14979.72,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9579.16,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7452.92,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13399.20,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7360.31,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5678.00,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14658.27,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8310.15,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6277.29,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13710.70,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9298.26,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7253.93,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,52061.88,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33380.36,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,41713.86,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25646.90,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,65240.30,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,46562.60,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,32858.36,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,43194.12,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21281.15,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,44545.04,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24761.35,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,40763.27,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27913.97,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21954.69,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24137.57,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15685.42,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,37880.05,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23470.91,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19607.24,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33779.12,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18339.78,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9954.97,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27362.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19744.25,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23212.22,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16952.88,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13405.34,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22137.61,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25621.65,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16926.87,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12909.36,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14460.79,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9469.72,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29023.77,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20332.84,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16279.37,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28672.47,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14728.68,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10170.04,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24012.02,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16342.87,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25144.82,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14301.58,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11223.21,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22284.56,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15228.48,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14643.73,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11248.47,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14747.82,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12512.90,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24040.37,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16837.31,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13592.09,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12971.36,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8746.44,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25313.97,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16827.37,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12683.56,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29526.63,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16231.12,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12355.99,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22889.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17130.46,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12920.83,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7091.66,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10734.13,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7103.15,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8225.97,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6434.97,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15997.69,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6948.53,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14442.42,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8790.05,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6697.49,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19916.46,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9749.85,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7322.04,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15700.72,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10161.62,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7612.12,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13750.53,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8279.54,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7275.36,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11038.75,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7279.18,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12302.40,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7758.30,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15195.59,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9540.90,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7074.82,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11827.11,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7775.91,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12736.38,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8379.80,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6656.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23432.65,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13853.08,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9695.51,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,51065.36,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27491.49,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14675.87,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,38434.98,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21209.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13217.04,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25708.90,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14147.76,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11967.17,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15667.80,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14120.20,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17306.50,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15686.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15734.39,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10001.65,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7556.25,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17153.42,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9207.19,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13681.63,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9580.68,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6810.76,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8894.14,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5552.46,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11800.31,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7587.64,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12189.12,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7932.82,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12503.69,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7859.34,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17697.61,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11631.94,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27613.94,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15236.90,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11777.35,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23021.63,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13170.34,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12466.97,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28163.50,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14652.15,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10503.75,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24037.29,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12398.07,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11088.51,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29446.28,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17598.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12092.68,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11918.19,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7781.28,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5676.47,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11144.39,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6878.11,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11806.44,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13520.90,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8767.08,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6802.33,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,36905.73,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29285.54,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25640.01,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,40694.39,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22347.32,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17122.05,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25290.24,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14928.45,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12799.14,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20369.56,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11037.99,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8846.69,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24354.16,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12557.29,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8934.71,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,24811.11,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14310.76,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9388.58,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23271.15,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12800.68,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8402.00,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14660.56,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9184.23,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33080.34,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18821.20,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13484.93,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12257.25,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7625.13,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5516.50,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14727.15,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8941.60,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6970.73,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9802.66,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7117.70,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11212.51,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6904.90,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9676.36,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6195.39,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9171.21,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13584.44,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8690.56,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6202.28,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16231.91,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12664.44,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18733.19,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11646.48,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16871.00,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9338.83,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12428.70,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9015.07,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18045.87,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12180.70,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11201.78,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14773.07,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9667.94,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5940.52,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9878.43,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6447.99,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12271.80,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7130.69,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9025.02,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6065.28,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17224.61,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11220.15,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28280.60,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16693.42,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12161.57,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28344.13,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14772.31,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11837.06,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14965.18,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10418.04,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16605.42,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9628.15,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14217.40,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7501.91,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11540.09,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20573.93,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12217.45,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15018.00,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9247.76,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8273.41,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11881.44,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8415.00,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6000.99,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8633.14,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5288.42,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9123.75,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13855.37,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8596.40,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5932.88,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7361.08,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19712.87,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9035.74,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8252.75,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13546.92,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9469.72,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8260.41,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14715.68,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,46412.59,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,31988.89,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19667.71,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,32835.41,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12218.22,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,2451.13,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9853.93,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8578.80,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8247.39,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,35585.44,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,22424.63,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15532.33,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,31415.61,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11300.51,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9181.93,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6692.90,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6082.11,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17820.82,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10610.90,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8932.41,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11670.19,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7949.65,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12596.31,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17199.35,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8682.89,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5759.11,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18384.93,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9794.24,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7503.45,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,45810.23,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18055.80,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,36013.28,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18262.46,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11249.99,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,36725.08,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18611.49,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13962.53,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25108.06,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12440.96,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10125.65,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6444.91,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,4924.09,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,42940.80,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16886.29,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10255.76,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,37693.32,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16898.56,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11973.30,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25681.35,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13408.38,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8655.36,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16189.80,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10239.68,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7439.92,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,20764.51,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10934.67,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7423.08,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21660.01,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,67200.45,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,38721.22,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16215.06,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12381.24,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,35736.97,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17312.62,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11582.94,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8559.68,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7716.22,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12389.66,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7577.68,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16942.94,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8813.78,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6506.90,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,53823.82,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15789.50,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8754.09,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,30503.29,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8271.10,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8123.40,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9140.60,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15971.67,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13236.18,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11612.79,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16805.94,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9118.42,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5643.55,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,11756.68,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14278.65,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7678.71,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33042.06,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15575.19,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9873.84,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29035.26,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12275.62,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,15956.36,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,30307.32,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16192.86,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10969.12,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13432.90,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7699.38,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13792.61,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6021.67,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12926.20,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7482.00,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14934.57,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8593.35,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,6190.80,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14311.54,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8711.22,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,164335.51,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,55820.70,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,25573.43,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,30727.54,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,17841.49,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16688.83,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,28693.91,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,18808.19,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,16441.60,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12774.66,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,9699.34,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10637.70,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7048.81,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10027.67,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5726.21,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,5177.42,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,52440.77,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,29723.35,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,59243.50,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,33174.46,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23455.60,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21846.01,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,12652.20,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,8120.32,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,47773.44,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,21108.17,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,23010.91,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10833.63,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,7831.04,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10854.29,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,36832.24,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,19738.90,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,14040.60,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,27162.37,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,13501.77,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Humana,Medicare PPO,,10100.38,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18119.20,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5373.49,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,22332.87,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5373.49,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9965.52,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6834.82,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,22332.87,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,695.12,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,695.12,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6834.82,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,46864.96,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,241.85,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,552.58,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,418.48,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18700.70,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9965.52,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,530.34,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6199.45,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3581.50,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6834.82,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,23376.18,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,209.51,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18406.40,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,571.33,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,61.87,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,8618.87,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,209.51,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,695.12,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,316.80,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,202.19,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,61.87,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6791.65,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13530.72,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,643.87,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10898.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,415.57,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,571.33,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,12986.98,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6834.82,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,241.85,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,316.80,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,91.70,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,209.51,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,695.12,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1008.67,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1617.80,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4879.29,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,12986.98,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,571.33,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18700.70,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6669.40,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6498.27,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,571.33,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1008.67,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,241.85,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,530.34,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,643.87,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13530.72,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,906.81,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10898.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,643.87,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,241.85,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,681.49,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,95.59,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,9630.27,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7701.19,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,241.85,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,202.19,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,643.87,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,241.85,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,530.34,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,134.24,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,530.34,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,241.85,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,455.29,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,209.51,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18700.70,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,11810.43,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2133.38,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,695.12,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,209.51,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,162.94,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,209.51,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13530.72,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,10842.57,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,695.12,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,316.80,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,416.08,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,927.18,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,732.74,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,637.50,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,134.24,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,206.93,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,134.24,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,415.57,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5373.49,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,571.33,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,949.48,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1424.94,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3790.08,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,311.31,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1008.67,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,162.94,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,8618.87,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,253.29,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Humana,Medicare PPO,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Humana,Medicare PPO,,30.85,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Humana,Medicare PPO,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Humana,Medicare PPO,,7.64,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Humana,Medicare PPO,,3.52,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Humana,Medicare PPO,,12.67,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Humana,Medicare PPO,,0.12600,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Humana,Medicare PPO,,0.22050,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Humana,Medicare PPO,,0.31500,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Humana,Medicare PPO,,1816.84,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Humana,Medicare PPO,,118.07,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Humana,Medicare PPO,,120.27,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Humana,Medicare PPO,,7.11,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Humana,Medicare PPO,,8.35,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Humana,Medicare PPO,,31.51,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Humana,Medicare PPO,,15.87,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Humana,Medicare PPO,,1.78,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Humana,Medicare PPO,,65.34,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Humana,Medicare PPO,,79.65,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Humana,Medicare PPO,,1.97,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Humana,Medicare PPO,,180.93,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Humana,Medicare PPO,,770.35,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Humana,Medicare PPO,,9.17,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Humana,Medicare PPO,,3.59,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Humana,Medicare PPO,,5391.84,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Humana,Medicare PPO,,100.69,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Humana,Medicare PPO,,238.64,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Humana,Medicare PPO,,5.85,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Humana,Medicare PPO,,5.85,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Humana,Medicare PPO,,21.37,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Humana,Medicare PPO,,21.37,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Humana,Medicare PPO,,21.37,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Humana,Medicare PPO,,9.19,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Humana,Medicare PPO,,93.81,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare PPO,,4.44,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Humana,Medicare PPO,,3.08,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Humana,Medicare PPO,,3.08,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Humana,Medicare PPO,,3.08,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Humana,Medicare PPO,,3.08,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Humana,Medicare PPO,,3.08,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Humana,Medicare PPO,,3.08,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Humana,Medicare PPO,,31.51,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Humana,Medicare PPO,,181.68,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Humana,Medicare PPO,,181.68,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Humana,Medicare PPO,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Humana,Medicare PPO,,6.00,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Humana,Medicare PPO,,76.86,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Humana,Medicare PPO,,76.86,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Humana,Medicare PPO,,7.07,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Humana,Medicare PPO,,190.28,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Humana,Medicare PPO,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Humana,Medicare PPO,,192.65,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Humana,Medicare PPO,,31.51,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Humana,Medicare PPO,,2738.57,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Humana,Medicare PPO,,453.62,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Humana,Medicare PPO,,2.34,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Humana,Medicare PPO,,271.57,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Humana,Medicare PPO,,5.45,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Humana,Medicare PPO,,1.53,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Humana,Medicare PPO,,1.53,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Humana,Medicare PPO,,65.34,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Humana,Medicare PPO,,17.87,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Humana,Medicare PPO,,58.43,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Humana,Medicare PPO,,29845.26,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Humana,Medicare PPO,,69.97,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Humana,Medicare PPO,,96.32,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Humana,Medicare PPO,,140.90,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Humana,Medicare PPO,,622.65,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Humana,Medicare PPO,,786.29,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Humana,Medicare PPO,,2.99,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Humana,Medicare PPO,,148.98,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Humana,Medicare PPO,,8.35,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Humana,Medicare PPO,,276.31,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Humana,Medicare PPO,,51.41,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Humana,Medicare PPO,,185.27,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Humana,Medicare PPO,,79.65,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Humana,Medicare PPO,,1816.84,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Humana,Medicare PPO,,66.21,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Humana,Medicare PPO,,770.35,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Humana,Medicare PPO,,44.27,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Humana,Medicare PPO,,44.27,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Humana,Medicare PPO,,324.11,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Humana,Medicare PPO,,78.08,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Humana,Medicare PPO,,78.08,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Humana,Medicare PPO,,2.25,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Humana,Medicare PPO,,22.38,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Humana,Medicare PPO,,16.39,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Humana,Medicare PPO,,2.25,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Humana,Medicare PPO,,8.35,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Humana,Medicare PPO,,175.68,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare PPO,,172.46,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Humana,Medicare PPO,,9.52,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Humana,Medicare PPO,,34.61,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Humana,Medicare PPO,,34.61,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Humana,Medicare PPO,,93.81,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Humana,Medicare PPO,,63.30,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Humana,Medicare PPO,,213.76,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Humana,Medicare PPO,,213.76,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Humana,Medicare PPO,,213.76,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Humana,Medicare PPO,,109.97,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Humana,Medicare PPO,,53.28,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Humana,Medicare PPO,,51.48,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Humana,Medicare PPO,,51.48,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Humana,Medicare PPO,,82.74,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Humana,Medicare PPO,,82.74,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Humana,Medicare PPO,,20.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Humana,Medicare PPO,,0.48300,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Humana,Medicare PPO,,0.48300,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Humana,Medicare PPO,,69.30,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Humana,Medicare PPO,,32.83,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Humana,Medicare PPO,,14.16,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Humana,Medicare PPO,,20.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Humana,Medicare PPO,,118.07,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Humana,Medicare PPO,,74.89,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Humana,Medicare PPO,,95.91,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Humana,Medicare PPO,,1.92,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Humana,Medicare PPO,,9.17,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Humana,Medicare PPO,,41.82,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Humana,Medicare PPO,,148.68,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Humana,Medicare PPO,,105.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Humana,Medicare PPO,,62.38,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Humana,Medicare PPO,,78.78,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Humana,Medicare PPO,,89.38,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Humana,Medicare PPO,,89.38,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Humana,Medicare PPO,,38.52,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Humana,Medicare PPO,,38.52,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Humana,Medicare PPO,,268.89,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Humana,Medicare PPO,,2832.95,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Humana,Medicare PPO,,2.29,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Humana,Medicare PPO,,1.72,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Humana,Medicare PPO,,172.82,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Humana,Medicare PPO,,8.56,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Humana,Medicare PPO,,34.61,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Humana,Medicare PPO,,19.02,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Humana,Medicare PPO,,8.24,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Humana,Medicare PPO,,8.24,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Humana,Medicare PPO,,8.24,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Humana,Medicare PPO,,8.24,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Humana,Medicare PPO,,8.24,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Humana,Medicare PPO,,104.09,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Humana,Medicare PPO,,260.93,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Humana,Medicare PPO,,0.31500,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Humana,Medicare PPO,,0.31500,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Humana,Medicare PPO,,30.75,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Humana,Medicare PPO,,111.65,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Humana,Medicare PPO,,137.95,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Humana,Medicare PPO,,0.31500,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Humana,Medicare PPO,,107.20,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Humana,Medicare PPO,,95.91,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Humana,Medicare PPO,,64.51,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Humana,Medicare PPO,,7.17,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Humana,Medicare PPO,,143.50,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Humana,Medicare PPO,,29.25,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Humana,Medicare PPO,,29.25,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Humana,Medicare PPO,,30.85,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Humana,Medicare PPO,,30.85,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Humana,Medicare PPO,,44.08,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Humana,Medicare PPO,,44.08,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Humana,Medicare PPO,,135.95,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Humana,Medicare PPO,,11.56,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Humana,Medicare PPO,,38.58,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare PPO,,38.58,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Humana,Medicare PPO,,31.48,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Humana,Medicare PPO,,27.06,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Humana,Medicare PPO,,27.06,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Humana,Medicare PPO,,29.24,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Humana,Medicare PPO,,29.24,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Humana,Medicare PPO,,377.15,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Humana,Medicare PPO,,29.39,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Humana,Medicare PPO,,20.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Humana,Medicare PPO,,86.00,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Humana,Medicare PPO,,86.00,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Humana,Medicare PPO,,38.09,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Humana,Medicare PPO,,334.46,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Humana,Medicare PPO,,21.43,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Humana,Medicare PPO,,65.20,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Humana,Medicare PPO,,65.20,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Humana,Medicare PPO,,15.03,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Humana,Medicare PPO,,143.50,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Humana,Medicare PPO,,236.37,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Humana,Medicare PPO,,236.37,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Humana,Medicare PPO,,8.24,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Humana,Medicare PPO,,5.73,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Humana,Medicare PPO,,29.39,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Humana,Medicare PPO,,2222.14,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Humana,Medicare PPO,,227.75,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Humana,Medicare PPO,,255.90,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Humana,Medicare PPO,,23.67,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Humana,Medicare PPO,,198.20,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Humana,Medicare PPO,,12.94,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Humana,Medicare PPO,,88.80,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Humana,Medicare PPO,,0.39900,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Humana,Medicare PPO,,0.39900,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Humana,Medicare PPO,,207.72,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Humana,Medicare PPO,,35.26,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Humana,Medicare PPO,,35.26,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Humana,Medicare PPO,,72.96,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Humana,Medicare PPO,,687.36,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Humana,Medicare PPO,,687.36,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Humana,Medicare PPO,,32.09,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Humana,Medicare PPO,,26.29,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Humana,Medicare PPO,,26.29,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Humana,Medicare PPO,,26.29,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Humana,Medicare PPO,,66509.39,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Humana,Medicare PPO,,76.25,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Humana,Medicare PPO,,76.25,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Humana,Medicare PPO,,205.51,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Humana,Medicare PPO,,9.17,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Humana,Medicare PPO,,111.65,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Humana,Medicare PPO,,1.92,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Humana,Medicare PPO,,59.88,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Humana,Medicare PPO,,59.88,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Humana,Medicare PPO,,79.77,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Humana,Medicare PPO,,35.10,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Humana,Medicare PPO,,28.73,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Humana,Medicare PPO,,54.14,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Humana,Medicare PPO,,180.83,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Humana,Medicare PPO,,22.55,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Humana,Medicare PPO,,78.98,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Humana,Medicare PPO,,78.98,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Humana,Medicare PPO,,6.59,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Humana,Medicare PPO,,0.31500,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Humana,Medicare PPO,,32.64,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Humana,Medicare PPO,,45.35,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Humana,Medicare PPO,,113.89,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Humana,Medicare PPO,,113.89,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Humana,Medicare PPO,,344.76,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Humana,Medicare PPO,,0.84000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Humana,Medicare PPO,,8.56,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Humana,Medicare PPO,,1920.16,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Humana,Medicare PPO,,1.78,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Humana,Medicare PPO,,99.17,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Humana,Medicare PPO,,5426.64,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Humana,Medicare PPO,,7.71,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Humana,Medicare PPO,,93.81,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Humana,Medicare PPO,,6.83,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Humana,Medicare PPO,,185.27,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Humana,Medicare PPO,,57.45,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Humana,Medicare PPO,,57.45,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Humana,Medicare PPO,,57.45,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Humana,Medicare PPO,,57.45,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Humana,Medicare PPO,,396.40,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Humana,Medicare PPO,,0.48300,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Humana,Medicare PPO,,46.83,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Humana,Medicare PPO,,4.58,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare PPO,,82.29,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Humana,Medicare PPO,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Humana,Medicare PPO,,0.50400,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Humana,Medicare PPO,,1.82,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Humana,Medicare PPO,,11.07,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Humana,Medicare PPO,,10.65,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Humana,Medicare PPO,,10.65,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Humana,Medicare PPO,,10.65,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Humana,Medicare PPO,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Humana,Medicare PPO,,21.37,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Humana,Medicare PPO,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Humana,Medicare PPO,,192.65,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Humana,Medicare PPO,,71.61,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Humana,Medicare PPO,,65.34,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Humana,Medicare PPO,,65.34,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Humana,Medicare PPO,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Humana,Medicare PPO,,6.00,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Humana,Medicare PPO,,0.22050,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Humana,Medicare PPO,,271.57,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare PPO,,4.44,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Humana,Medicare PPO,,217.49,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Humana,Medicare PPO,,293.84,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Humana,Medicare PPO,,293.84,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Humana,Medicare PPO,,0.31500,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Humana,Medicare PPO,,19.02,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Humana,Medicare PPO,,180.83,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Humana,Medicare PPO,,0.31500,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Humana,Medicare PPO,,156.44,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Humana,Medicare PPO,,191.57,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Humana,Medicare PPO,,0.22050,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Humana,Medicare PPO,,74.29,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Humana,Medicare PPO,,99.17,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Humana,Medicare PPO,,74.29,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Humana,Medicare PPO,,74.29,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Humana,Medicare PPO,,137.95,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Humana,Medicare PPO,,99.17,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Humana,Medicare PPO,,95.91,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Humana,Medicare PPO,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Humana,Medicare PPO,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Humana,Medicare PPO,,38.09,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Humana,Medicare PPO,,89.38,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Humana,Medicare PPO,,58.43,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Humana,Medicare PPO,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare PPO,,4.44,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Humana,Medicare PPO,,4.44,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Humana,Medicare PPO,,0.38850,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Humana,Medicare PPO,,7.07,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Humana,Medicare PPO,,0.84000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Humana,Medicare PPO,,21.37,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Humana,Medicare PPO,,99.17,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare PPO,,2.79,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Humana,Medicare PPO,,2.25,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Humana,Medicare PPO,,63.30,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Humana,Medicare PPO,,7.07,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare PPO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare PPO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare PPO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare PPO,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Humana,Medicare PPO,,172.46,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Humana,Medicare PPO,,180.83,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Humana,Medicare PPO,,78.78,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Humana,Medicare PPO,,64.51,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Humana,Medicare PPO,,65.20,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Humana,Medicare PPO,,65.20,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Humana,Medicare PPO,,4.58,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Humana,Medicare PPO,,63.30,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Humana,Medicare PPO,,63.30,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Humana,Medicare PPO,,0.84000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Humana,Medicare PPO,,1.92,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Humana,Medicare PPO,,248.45,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Humana,Medicare PPO,,95.91,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Humana,Medicare PPO,,95.91,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Humana,Medicare PPO,,58.35,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Humana,Medicare PPO,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare PPO,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Humana,Medicare PPO,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare PPO,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Humana,Medicare PPO,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Humana,Medicare PPO,,82.29,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Humana,Medicare PPO,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Humana,Medicare PPO,,0.29400,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare PPO,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare PPO,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Humana,Medicare PPO,,38.58,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Humana,Medicare PPO,,76.25,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Humana,Medicare PPO,,100.69,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Humana,Medicare PPO,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Humana,Medicare PPO,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Humana,Medicare PPO,,4.64,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Humana,Medicare PPO,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Humana,Medicare PPO,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Humana,Medicare PPO,,4.64,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Humana,Medicare PPO,,0.38850,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Humana,Medicare PPO,,71.61,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Humana,Medicare PPO,,0.12600,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Humana,Medicare PPO,,0.12600,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Humana,Medicare PPO,,309.42,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Humana,Medicare PPO,,1.56,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Humana,Medicare PPO,,1.56,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Humana,Medicare PPO,,1.56,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Humana,Medicare PPO,,3.08,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Humana,Medicare PPO,,1.69,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Humana,Medicare PPO,,47.06,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Humana,Medicare PPO,,28.05,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Humana,Medicare PPO,,31.33,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Humana,Medicare PPO,,146.17,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Humana,Medicare PPO,,4.58,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Humana,Medicare PPO,,55.73,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Humana,Medicare PPO,,55.73,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Humana,Medicare PPO,,99.17,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Humana,Medicare PPO,,99.17,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Humana,Medicare PPO,,4.30,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Humana,Medicare PPO,,0.31500,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare PPO,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare PPO,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Humana,Medicare PPO,,2.79,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Humana,Medicare PPO,,1.75,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Humana,Medicare PPO,,1.75,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Humana,Medicare PPO,,0.38850,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Humana,Medicare PPO,,509.22,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Humana,Medicare PPO,,11.56,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Humana,Medicare PPO,,11.56,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Humana,Medicare PPO,,25.07,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Humana,Medicare PPO,,25.07,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Humana,Medicare PPO,,25.07,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Humana,Medicare PPO,,2.99,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Humana,Medicare PPO,,53.60,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Humana,Medicare PPO,,6.83,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Humana,Medicare PPO,,11.21,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Humana,Medicare PPO,,4.67,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Humana,Medicare PPO,,3.70,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Humana,Medicare PPO,,3.70,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Humana,Medicare PPO,,1.78,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Humana,Medicare PPO,,0.33600,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Humana,Medicare PPO,,9.19,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Humana,Medicare PPO,,411.66,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Humana,Medicare PPO,,534.41,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Humana,Medicare PPO,,638.50,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare PPO,,356.58,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Humana,Medicare PPO,,36.56,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Humana,Medicare PPO,,36.56,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Humana,Medicare PPO,,38.58,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Humana,Medicare PPO,,134.24,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Humana,Medicare PPO,,219.42,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare PPO,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Humana,Medicare PPO,,219.42,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare PPO,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare PPO,,74.12,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare PPO,,219.42,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Humana,Medicare PPO,,219.42,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Humana,Medicare PPO,,48.05,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Humana,Medicare PPO,,345.43,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Humana,Medicare PPO,,9.54,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Humana,Medicare PPO,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare PPO,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare PPO,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Humana,Medicare PPO,,74.12,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Humana,Medicare PPO,,219.42,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare PPO,,345.43,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Humana,Medicare PPO,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Humana,Medicare PPO,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Humana,Medicare PPO,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Humana,Medicare PPO,,381.23,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Humana,Medicare PPO,,381.23,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Humana,Medicare PPO,,381.23,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Humana,Medicare PPO,,138.27,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Humana,Medicare PPO,,381.23,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Humana,Medicare PPO,,381.23,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Humana,Medicare PPO,,138.27,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Humana,Medicare PPO,,381.23,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Humana,Medicare PPO,,138.27,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Humana,Medicare PPO,,381.23,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Humana,Medicare PPO,,381.23,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Humana,Medicare PPO,,1828.66,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Humana,Medicare PPO,,1828.66,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Humana,Medicare PPO,,602.44,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Humana,Medicare PPO,,602.44,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Humana,Medicare PPO,,602.44,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Humana,Medicare PPO,,722.56,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Humana,Medicare PPO,,114.04,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Humana,Medicare PPO,,345.43,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Humana,Medicare PPO,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Humana,Medicare PPO,,345.43,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Humana,Medicare PPO,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Humana,Medicare PPO,,345.43,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Humana,Medicare PPO,,48.05,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Humana,Medicare PPO,,345.43,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Humana,Medicare PPO,,219.42,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Humana,Medicare PPO,,219.42,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Humana,Medicare PPO,,345.43,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Humana,Medicare PPO,,114.04,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Humana,Medicare PPO,,273.87,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Humana,Medicare PPO,,273.87,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Humana,Medicare PPO,,273.87,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Humana,Medicare PPO,,602.44,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Humana,Medicare PPO,,602.44,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Humana,Medicare PPO,,602.44,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Humana,Medicare PPO,,345.43,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Humana,Medicare PPO,,7961.22,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Humana,Medicare PPO,,7961.22,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Humana,Medicare PPO,,722.56,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Humana,Medicare PPO,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Humana,Medicare PPO,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Humana,Medicare PPO,,345.43,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Humana,Medicare PPO,,381.23,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Humana,Medicare PPO,,1424.94,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Humana,Medicare PPO,,381.23,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Humana,Medicare PPO,,381.23,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Humana,Medicare PPO,,138.27,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Humana,Medicare PPO,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Humana,Medicare PPO,,381.23,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Humana,Medicare PPO,,381.23,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Humana,Medicare PPO,,602.44,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare PPO,,1707.19,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Humana,Medicare PPO,,209.51,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Humana,Medicare PPO,,3311.27,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Humana,Medicare PPO,,211.82,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Humana,Medicare PPO,,241.85,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Humana,Medicare PPO,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Humana,Medicare PPO,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Humana,Medicare PPO,,5140.98,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Humana,Medicare PPO,,316.80,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Humana,Medicare PPO,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Humana,Medicare PPO,,241.85,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare PPO,,211.82,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare PPO,,211.82,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,134.24,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,134.24,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Humana,Medicare PPO,,211.82,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare PPO,,134.24,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare PPO,,134.24,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Humana,Medicare PPO,,211.82,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Humana,Medicare PPO,,25.50,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare PPO,,25.50,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Humana,Medicare PPO,,40.88,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Humana,Medicare PPO,,134.24,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare PPO,,211.82,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare PPO,,211.82,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare PPO,,211.82,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Humana,Medicare PPO,,211.82,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare PPO,,211.82,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Humana,Medicare PPO,,211.82,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare PPO,,211.82,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,211.82,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare PPO,,211.82,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Humana,Medicare PPO,,38.84,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare PPO,,38.84,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Humana,Medicare PPO,,162.94,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Humana,Medicare PPO,,162.94,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Humana,Medicare PPO,,324.30,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Humana,Medicare PPO,,552.58,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Humana,Medicare PPO,,324.30,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Humana,Medicare PPO,,324.30,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare PPO,,162.94,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Humana,Medicare PPO,,61.87,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Humana,Medicare PPO,,324.30,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Humana,Medicare PPO,,134.24,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Humana,Medicare PPO,,134.24,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare PPO,,134.24,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Humana,Medicare PPO,,134.24,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Humana,Medicare PPO,,324.30,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Humana,Medicare PPO,,162.94,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Humana,Medicare PPO,,324.30,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Humana,Medicare PPO,,61.87,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Humana,Medicare PPO,,324.30,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Humana,Medicare PPO,,162.94,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Humana,Medicare PPO,,162.94,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare PPO,,162.94,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Humana,Medicare PPO,,324.30,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Humana,Medicare PPO,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Humana,Medicare PPO,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Humana,Medicare PPO,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Humana,Medicare PPO,,324.30,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Humana,Medicare PPO,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare PPO,,1707.19,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Humana,Medicare PPO,,728.71,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Humana,Medicare PPO,,443.47,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Humana,Medicare PPO,,552.58,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Humana,Medicare PPO,,415.57,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Humana,Medicare PPO,,162.94,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Humana,Medicare PPO,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Humana,Medicare PPO,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Humana,Medicare PPO,,162.94,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Humana,Medicare PPO,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Humana,Medicare PPO,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Humana,Medicare PPO,,1059.54,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Humana,Medicare PPO,,251.74,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Humana,Medicare PPO,,324.30,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Humana,Medicare PPO,,110.74,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Humana,Medicare PPO,,251.74,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Humana,Medicare PPO,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Humana,Medicare PPO,,134.24,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Humana,Medicare PPO,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Humana,Medicare PPO,,162.94,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Humana,Medicare PPO,,324.30,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Humana,Medicare PPO,,251.74,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Humana,Medicare PPO,,552.58,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Humana,Medicare PPO,,110.74,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Humana,Medicare PPO,,251.74,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Humana,Medicare PPO,,324.30,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Humana,Medicare PPO,,110.74,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Humana,Medicare PPO,,61.87,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Humana,Medicare PPO,,110.74,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Humana,Medicare PPO,,251.74,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Humana,Medicare PPO,,110.74,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare PPO,,110.74,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Humana,Medicare PPO,,110.74,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Humana,Medicare PPO,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Humana,Medicare PPO,,1059.54,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Humana,Medicare PPO,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Humana,Medicare PPO,,162.94,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Humana,Medicare PPO,,134.24,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Humana,Medicare PPO,,134.24,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Humana,Medicare PPO,,162.94,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Humana,Medicare PPO,,162.94,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare PPO,,134.24,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Humana,Medicare PPO,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Humana,Medicare PPO,,324.30,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Humana,Medicare PPO,,134.24,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare PPO,,162.94,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare PPO,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare PPO,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare PPO,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Humana,Medicare PPO,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Humana,Medicare PPO,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Humana,Medicare PPO,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Humana,Medicare PPO,,162.94,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Humana,Medicare PPO,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Humana,Medicare PPO,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Humana,Medicare PPO,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Humana,Medicare PPO,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Humana,Medicare PPO,,1059.54,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Humana,Medicare PPO,,552.58,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Humana,Medicare PPO,,324.30,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Humana,Medicare PPO,,552.58,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Humana,Medicare PPO,,1059.54,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Humana,Medicare PPO,,324.30,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Humana,Medicare PPO,,552.58,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare PPO,,110.74,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Humana,Medicare PPO,,162.94,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Humana,Medicare PPO,,324.30,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Humana,Medicare PPO,,324.30,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Humana,Medicare PPO,,324.30,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Humana,Medicare PPO,,552.58,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Humana,Medicare PPO,,552.58,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Humana,Medicare PPO,,552.58,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Humana,Medicare PPO,,324.30,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Humana,Medicare PPO,,324.30,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Humana,Medicare PPO,,552.58,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Humana,Medicare PPO,,552.58,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Humana,Medicare PPO,,552.58,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Humana,Medicare PPO,,1059.54,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Humana,Medicare PPO,,324.30,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare PPO,,74.12,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare PPO,,74.12,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare PPO,,31.03,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Humana,Medicare PPO,,48.05,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,74.12,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Humana,Medicare PPO,,43.24,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Humana,Medicare PPO,,206.93,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Humana,Medicare PPO,,1687.37,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Humana,Medicare PPO,,1687.37,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Humana,Medicare PPO,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Humana,Medicare PPO,,637.50,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Humana,Medicare PPO,,637.50,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Humana,Medicare PPO,,1687.37,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Humana,Medicare PPO,,206.93,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Humana,Medicare PPO,,206.93,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Humana,Medicare PPO,,206.93,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Humana,Medicare PPO,,416.08,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Humana,Medicare PPO,,61.87,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare PPO,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare PPO,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Humana,Medicare PPO,,206.93,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Humana,Medicare PPO,,206.93,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Humana,Medicare PPO,,206.93,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Humana,Medicare PPO,,732.74,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Humana,Medicare PPO,,307.42,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Humana,Medicare PPO,,307.42,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Humana,Medicare PPO,,307.42,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Humana,Medicare PPO,,307.42,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Humana,Medicare PPO,,307.42,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Humana,Medicare PPO,,276.58,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Humana,Medicare PPO,,241.85,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Humana,Medicare PPO,,416.08,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Humana,Medicare PPO,,416.08,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Humana,Medicare PPO,,416.08,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Humana,Medicare PPO,,134.24,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Humana,Medicare PPO,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Humana,Medicare PPO,,345.43,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Humana,Medicare PPO,,1687.37,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Humana,Medicare PPO,,721.21,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Humana,Medicare PPO,,721.21,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Humana,Medicare PPO,,721.21,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Humana,Medicare PPO,,312.33,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare PPO,,312.33,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Humana,Medicare PPO,,6834.82,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Humana,Medicare PPO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Humana,Medicare PPO,,721.21,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Humana,Medicare PPO,,307.42,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Humana,Medicare PPO,,927.18,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Humana,Medicare PPO,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Humana,Medicare PPO,,6834.82,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare PPO,,307.42,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare PPO,,307.42,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Humana,Medicare PPO,,2033.68,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Humana,Medicare PPO,,2033.68,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Humana,Medicare PPO,,927.18,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Humana,Medicare PPO,,927.18,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Humana,Medicare PPO,,927.18,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Humana,Medicare PPO,,307.42,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Humana,Medicare PPO,,206.93,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Humana,Medicare PPO,,206.93,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,206.93,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,206.93,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Humana,Medicare PPO,,732.74,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Humana,Medicare PPO,,927.18,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Humana,Medicare PPO,,721.21,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Humana,Medicare PPO,,721.21,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Humana,Medicare PPO,,721.21,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Humana,Medicare PPO,,307.42,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Humana,Medicare PPO,,927.18,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Humana,Medicare PPO,,416.08,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Humana,Medicare PPO,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Humana,Medicare PPO,,927.18,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Humana,Medicare PPO,,927.18,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Humana,Medicare PPO,,721.21,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Humana,Medicare PPO,,721.21,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Humana,Medicare PPO,,927.18,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Humana,Medicare PPO,,927.18,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Humana,Medicare PPO,,927.18,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Humana,Medicare PPO,,927.18,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Humana,Medicare PPO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Humana,Medicare PPO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare PPO,,307.42,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Humana,Medicare PPO,,927.18,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Humana,Medicare PPO,,721.21,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Humana,Medicare PPO,,721.21,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Humana,Medicare PPO,,721.21,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Humana,Medicare PPO,,927.18,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Humana,Medicare PPO,,721.21,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Humana,Medicare PPO,,927.18,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Humana,Medicare PPO,,721.21,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Humana,Medicare PPO,,721.21,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Humana,Medicare PPO,,721.21,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Humana,Medicare PPO,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Humana,Medicare PPO,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Humana,Medicare PPO,,2033.68,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Humana,Medicare PPO,,2033.68,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Humana,Medicare PPO,,2033.68,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Humana,Medicare PPO,,2033.68,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Humana,Medicare PPO,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Humana,Medicare PPO,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Humana,Medicare PPO,,206.93,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,206.93,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Humana,Medicare PPO,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Humana,Medicare PPO,,143.61,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Humana,Medicare PPO,,134.24,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Humana,Medicare PPO,,416.08,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Humana,Medicare PPO,,416.08,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Humana,Medicare PPO,,202.19,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Humana,Medicare PPO,,91.70,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Humana,Medicare PPO,,164.92,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Humana,Medicare PPO,,288.36,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Humana,Medicare PPO,,443.47,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Humana,Medicare PPO,,638.50,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Humana,Medicare PPO,,877.52,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Humana,Medicare PPO,,324.30,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare PPO,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare PPO,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Humana,Medicare PPO,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Humana,Medicare PPO,,61.87,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare PPO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare PPO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare PPO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare PPO,,40.88,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Humana,Medicare PPO,,206.93,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Humana,Medicare PPO,,1227.93,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Humana,Medicare PPO,,416.08,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Humana,Medicare PPO,,1687.37,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Humana,Medicare PPO,,53.64,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Humana,Medicare PPO,,206.93,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Humana,Medicare PPO,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Humana,Medicare PPO,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Humana,Medicare PPO,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Humana,Medicare PPO,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Humana,Medicare PPO,,164.32,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Humana,Medicare PPO,,164.32,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare PPO,,164.32,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Humana,Medicare PPO,,3277.91,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Humana,Medicare PPO,,3311.27,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare PPO,,312.33,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Humana,Medicare PPO,,637.50,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Humana,Medicare PPO,,721.21,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Humana,Medicare PPO,,1617.80,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Humana,Medicare PPO,,1617.80,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Humana,Medicare PPO,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Humana,Medicare PPO,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Humana,Medicare PPO,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Humana,Medicare PPO,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Humana,Medicare PPO,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Humana,Medicare PPO,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Humana,Medicare PPO,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Humana,Medicare PPO,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Humana,Medicare PPO,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Humana,Medicare PPO,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare PPO,,164.32,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Humana,Medicare PPO,,206.93,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Humana,Medicare PPO,,206.93,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Humana,Medicare PPO,,416.08,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Humana,Medicare PPO,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare PPO,,40.88,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare PPO,,206.93,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare PPO,,416.08,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare PPO,,637.50,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare PPO,,416.08,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare PPO,,134.24,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Humana,Medicare PPO,,95.59,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Humana,Medicare PPO,,95.59,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Humana,Medicare PPO,,38.84,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Humana,Medicare PPO,,38.84,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Humana,Medicare PPO,,38.84,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Humana,Medicare PPO,,38.84,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Humana,Medicare PPO,,38.84,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare PPO,,25.50,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Humana,Medicare PPO,,206.93,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare PPO,,416.08,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare PPO,,61.87,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare PPO,,416.08,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Humana,Medicare PPO,,18209.54,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Humana,Medicare PPO,,7439.71,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Humana,Medicare PPO,,1687.37,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Humana,Medicare PPO,,134.24,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Humana,Medicare PPO,,134.24,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Humana,Medicare PPO,,1687.37,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Humana,Medicare PPO,,976.41,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare PPO,,253.29,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Humana,Medicare PPO,,2133.38,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare PPO,,455.29,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Humana,Medicare PPO,,2133.38,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Humana,Medicare PPO,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Humana,Medicare PPO,,1707.19,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Humana,Medicare PPO,,732.74,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Humana,Medicare PPO,,1687.37,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Humana,Medicare PPO,,1687.37,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Humana,Medicare PPO,,1687.37,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Humana,Medicare PPO,,11810.43,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Humana,Medicare PPO,,643.87,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Humana,Medicare PPO,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Humana,Medicare PPO,,732.74,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Humana,Medicare PPO,,732.74,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Humana,Medicare PPO,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Humana,Medicare PPO,,61.87,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare PPO,,74.12,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Humana,Medicare PPO,,552.58,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Humana,Medicare PPO,,552.58,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Humana,Medicare PPO,,552.58,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Humana,Medicare PPO,,324.30,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Humana,Medicare PPO,,162.94,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Humana,Medicare PPO,,976.41,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Humana,Medicare PPO,,976.41,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Humana,Medicare PPO,,324.30,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Humana,Medicare PPO,,976.41,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Humana,Medicare PPO,,324.30,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Humana,Medicare PPO,,552.58,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Humana,Medicare PPO,,552.58,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Humana,Medicare PPO,,2429.62,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Humana,Medicare PPO,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Humana,Medicare PPO,,324.30,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Humana,Medicare PPO,,162.94,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Humana,Medicare PPO,,324.30,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Humana,Medicare PPO,,324.30,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare PPO,,91.70,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Humana,Medicare PPO,,110.74,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Humana,Medicare PPO,,110.74,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Humana,Medicare PPO,,91.70,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Humana,Medicare PPO,,110.74,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Humana,Medicare PPO,,91.70,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Humana,Medicare PPO,,251.74,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Humana,Medicare PPO,,110.74,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Humana,Medicare PPO,,91.70,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Humana,Medicare PPO,,91.70,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare PPO,,91.70,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Humana,Medicare PPO,,110.74,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Humana,Medicare PPO,,110.74,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Humana,Medicare PPO,,91.70,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Humana,Medicare PPO,,91.70,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Humana,Medicare PPO,,91.70,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Humana,Medicare PPO,,91.70,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Humana,Medicare PPO,,110.74,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Humana,Medicare PPO,,110.74,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Humana,Medicare PPO,,110.74,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare PPO,,91.70,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Humana,Medicare PPO,,91.70,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Humana,Medicare PPO,,91.70,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Humana,Medicare PPO,,91.70,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare PPO,,110.74,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Humana,Medicare PPO,,110.74,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Humana,Medicare PPO,,110.74,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Humana,Medicare PPO,,110.74,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Humana,Medicare PPO,,91.70,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Humana,Medicare PPO,,110.74,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Humana,Medicare PPO,,110.74,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Humana,Medicare PPO,,110.74,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare PPO,,110.74,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Humana,Medicare PPO,,110.74,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Humana,Medicare PPO,,110.74,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Humana,Medicare PPO,,110.74,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Humana,Medicare PPO,,91.70,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Humana,Medicare PPO,,822.79,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Humana,Medicare PPO,,822.79,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Humana,Medicare PPO,,822.79,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Humana,Medicare PPO,,822.79,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Humana,Medicare PPO,,2033.68,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Humana,Medicare PPO,,91.70,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Humana,Medicare PPO,,110.74,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Humana,Medicare PPO,,91.70,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Humana,Medicare PPO,,91.70,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Humana,Medicare PPO,,371.93,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Humana,Medicare PPO,,91.70,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Humana,Medicare PPO,,91.70,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Humana,Medicare PPO,,91.70,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Humana,Medicare PPO,,91.70,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Humana,Medicare PPO,,371.93,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Humana,Medicare PPO,,91.70,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Humana,Medicare PPO,,110.74,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Humana,Medicare PPO,,91.70,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Humana,Medicare PPO,,91.70,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Humana,Medicare PPO,,371.93,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Humana,Medicare PPO,,110.74,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Humana,Medicare PPO,,91.70,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Humana,Medicare PPO,,91.70,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Humana,Medicare PPO,,371.93,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Humana,Medicare PPO,,91.70,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Humana,Medicare PPO,,91.70,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Humana,Medicare PPO,,110.74,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Humana,Medicare PPO,,91.70,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Humana,Medicare PPO,,371.93,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Humana,Medicare PPO,,91.70,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare PPO,,91.70,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Humana,Medicare PPO,,91.70,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare PPO,,91.70,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Humana,Medicare PPO,,371.93,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Humana,Medicare PPO,,91.70,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare PPO,,91.70,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Humana,Medicare PPO,,91.70,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare PPO,,91.70,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Humana,Medicare PPO,,91.70,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Humana,Medicare PPO,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Humana,Medicare PPO,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Humana,Medicare PPO,,571.02,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Humana,Medicare PPO,,185.40,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Humana,Medicare PPO,,185.40,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare PPO,,185.40,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Humana,Medicare PPO,,371.93,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Humana,Medicare PPO,,371.93,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Humana,Medicare PPO,,371.93,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Humana,Medicare PPO,,251.74,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Humana,Medicare PPO,,251.74,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Humana,Medicare PPO,,251.74,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Humana,Medicare PPO,,2133.38,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Humana,Medicare PPO,,251.74,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Humana,Medicare PPO,,5629.67,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Humana,Medicare PPO,,3277.91,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Humana,Medicare PPO,,3277.91,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Humana,Medicare PPO,,110.74,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Humana,Medicare PPO,,1617.80,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Humana,Medicare PPO,,1617.80,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Humana,Medicare PPO,,3277.91,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Humana,Medicare PPO,,1617.80,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Humana,Medicare PPO,,3277.91,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Humana,Medicare PPO,,3277.91,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Humana,Medicare PPO,,3277.91,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Humana,Medicare PPO,,5629.67,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Humana,Medicare PPO,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Humana,Medicare PPO,,3277.91,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Humana,Medicare PPO,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Humana,Medicare PPO,,3277.91,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Humana,Medicare PPO,,3277.91,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Humana,Medicare PPO,,5629.67,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Humana,Medicare PPO,,3277.91,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Humana,Medicare PPO,,251.74,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Humana,Medicare PPO,,91.70,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Humana,Medicare PPO,,571.02,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Humana,Medicare PPO,,571.02,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Humana,Medicare PPO,,110.74,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare PPO,,91.70,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Humana,Medicare PPO,,251.74,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Humana,Medicare PPO,,251.74,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Humana,Medicare PPO,,110.74,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Humana,Medicare PPO,,110.74,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Humana,Medicare PPO,,110.74,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Humana,Medicare PPO,,110.74,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Humana,Medicare PPO,,110.74,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Humana,Medicare PPO,,91.70,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Humana,Medicare PPO,,5629.67,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Humana,Medicare PPO,,3277.91,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Humana,Medicare PPO,,3277.91,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Humana,Medicare PPO,,5629.67,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Humana,Medicare PPO,,3277.91,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Humana,Medicare PPO,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Humana,Medicare PPO,,3277.91,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Humana,Medicare PPO,,3277.91,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Humana,Medicare PPO,,3277.91,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Humana,Medicare PPO,,3277.91,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Humana,Medicare PPO,,91.70,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Humana,Medicare PPO,,91.70,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Humana,Medicare PPO,,110.74,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Humana,Medicare PPO,,251.74,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Humana,Medicare PPO,,110.74,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Humana,Medicare PPO,,2033.68,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Humana,Medicare PPO,,91.70,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Humana,Medicare PPO,,110.74,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Humana,Medicare PPO,,91.70,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Humana,Medicare PPO,,91.70,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Humana,Medicare PPO,,110.74,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Humana,Medicare PPO,,110.74,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Humana,Medicare PPO,,110.74,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Humana,Medicare PPO,,110.74,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Humana,Medicare PPO,,91.70,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Humana,Medicare PPO,,91.70,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Humana,Medicare PPO,,185.40,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Humana,Medicare PPO,,185.40,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Humana,Medicare PPO,,18209.54,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Humana,Medicare PPO,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Humana,Medicare PPO,,822.79,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Humana,Medicare PPO,,91.70,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Humana,Medicare PPO,,110.74,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Humana,Medicare PPO,,110.74,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Humana,Medicare PPO,,185.40,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Humana,Medicare PPO,,185.40,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Humana,Medicare PPO,,185.40,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Humana,Medicare PPO,,110.74,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Humana,Medicare PPO,,185.40,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Humana,Medicare PPO,,110.74,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Humana,Medicare PPO,,345.43,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Humana,Medicare PPO,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Humana,Medicare PPO,,418.48,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Humana,Medicare PPO,,418.48,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Humana,Medicare PPO,,418.48,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Humana,Medicare PPO,,560.57,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Humana,Medicare PPO,,418.48,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Humana,Medicare PPO,,560.57,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Humana,Medicare PPO,,418.48,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Humana,Medicare PPO,,418.48,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Humana,Medicare PPO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Humana,Medicare PPO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Humana,Medicare PPO,,560.57,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Humana,Medicare PPO,,560.57,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Humana,Medicare PPO,,418.48,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Humana,Medicare PPO,,418.48,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Humana,Medicare PPO,,418.48,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Humana,Medicare PPO,,418.48,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Humana,Medicare PPO,,418.48,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Humana,Medicare PPO,,1359.57,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Humana,Medicare PPO,,1359.57,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Humana,Medicare PPO,,418.48,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Humana,Medicare PPO,,560.57,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Humana,Medicare PPO,,418.48,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Humana,Medicare PPO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Humana,Medicare PPO,,560.57,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Humana,Medicare PPO,,560.57,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Humana,Medicare PPO,,1359.57,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare PPO,,418.48,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare PPO,,560.57,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Humana,Medicare PPO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Humana,Medicare PPO,,418.48,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Humana,Medicare PPO,,418.48,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Humana,Medicare PPO,,1359.57,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Humana,Medicare PPO,,1359.57,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,24.29,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Humana,Medicare PPO,,751.05,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Humana,Medicare PPO,,2010.34,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Humana,Medicare PPO,,2178.55,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Humana,Medicare PPO,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Humana,Medicare PPO,,233.41,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Humana,Medicare PPO,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Humana,Medicare PPO,,233.41,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Humana,Medicare PPO,,4530.66,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Humana,Medicare PPO,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Humana,Medicare PPO,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Humana,Medicare PPO,,1082.96,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Humana,Medicare PPO,,2304.35,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Humana,Medicare PPO,,418.48,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Humana,Medicare PPO,,180.83,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Humana,Medicare PPO,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Humana,Medicare PPO,,281.84,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Humana,Medicare PPO,,418.48,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Humana,Medicare PPO,,418.48,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Humana,Medicare PPO,,1359.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Humana,Medicare PPO,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Humana,Medicare PPO,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Humana,Medicare PPO,,1519.02,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Humana,Medicare PPO,,523.60,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Humana,Medicare PPO,,624.86,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Humana,Medicare PPO,,349.06,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Humana,Medicare PPO,,400.06,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Humana,Medicare PPO,,704.78,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Humana,Medicare PPO,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare PPO,,91.70,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Humana,Medicare PPO,,185.40,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Humana,Medicare PPO,,371.93,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Humana,Medicare PPO,,251.74,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Humana,Medicare PPO,,371.93,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Humana,Medicare PPO,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Humana,Medicare PPO,,185.40,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Humana,Medicare PPO,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Humana,Medicare PPO,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Humana,Medicare PPO,,989.88,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Humana,Medicare PPO,,1617.80,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Humana,Medicare PPO,,1975.59,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Humana,Medicare PPO,,1975.59,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare PPO,,6498.27,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Humana,Medicare PPO,,3675.27,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Humana,Medicare PPO,,2033.68,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Humana,Medicare PPO,,906.81,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Humana,Medicare PPO,,1687.37,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Humana,Medicare PPO,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Humana,Medicare PPO,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Humana,Medicare PPO,,1687.37,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Humana,Medicare PPO,,1687.37,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Humana,Medicare PPO,,416.08,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Humana,Medicare PPO,,416.08,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Humana,Medicare PPO,,643.87,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Humana,Medicare PPO,,6076.09,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare PPO,,6498.27,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Humana,Medicare PPO,,1975.59,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Humana,Medicare PPO,,976.41,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Humana,Medicare PPO,,2133.38,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Humana,Medicare PPO,,1687.37,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Humana,Medicare PPO,,1687.37,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Humana,Medicare PPO,,1687.37,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Humana,Medicare PPO,,1687.37,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Humana,Medicare PPO,,1687.37,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Humana,Medicare PPO,,1542.65,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Humana,Medicare PPO,,307.42,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Humana,Medicare PPO,,307.42,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Humana,Medicare PPO,,307.42,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Humana,Medicare PPO,,307.42,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Humana,Medicare PPO,,307.42,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Humana,Medicare PPO,,13399.92,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Humana,Medicare PPO,,249.82,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Humana,Medicare PPO,,1687.37,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Humana,Medicare PPO,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Humana,Medicare PPO,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Humana,Medicare PPO,,1687.37,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Humana,Medicare PPO,,3675.27,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Humana,Medicare PPO,,643.87,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Humana,Medicare PPO,,1424.94,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Humana,Medicare PPO,,643.87,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Humana,Medicare PPO,,1617.80,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Humana,Medicare PPO,,3277.91,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Humana,Medicare PPO,,3277.91,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Humana,Medicare PPO,,5629.67,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Humana,Medicare PPO,,3277.91,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Humana,Medicare PPO,,3277.91,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Humana,Medicare PPO,,3277.91,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Humana,Medicare PPO,,1617.80,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Humana,Medicare PPO,,1617.80,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Humana,Medicare PPO,,643.87,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Humana,Medicare PPO,,1617.80,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Humana,Medicare PPO,,3277.91,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Humana,Medicare PPO,,1617.80,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Humana,Medicare PPO,,3277.91,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Humana,Medicare PPO,,5629.67,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Humana,Medicare PPO,,3277.91,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Humana,Medicare PPO,,1617.80,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Humana,Medicare PPO,,643.87,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Humana,Medicare PPO,,1617.80,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Humana,Medicare PPO,,3277.91,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Humana,Medicare PPO,,1617.80,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Humana,Medicare PPO,,1617.80,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Humana,Medicare PPO,,219.42,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Humana,Medicare PPO,,219.42,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Humana,Medicare PPO,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Humana,Medicare PPO,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare PPO,,11810.43,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare PPO,,11810.43,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare PPO,,3277.91,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Humana,Medicare PPO,,3277.91,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Humana,Medicare PPO,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Humana,Medicare PPO,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Humana,Medicare PPO,,3277.91,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Humana,Medicare PPO,,3277.91,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Humana,Medicare PPO,,3277.91,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Humana,Medicare PPO,,3277.91,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Humana,Medicare PPO,,5629.67,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Humana,Medicare PPO,,11810.43,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Humana,Medicare PPO,,5629.67,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Humana,Medicare PPO,,643.87,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Humana,Medicare PPO,,1687.37,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Humana,Medicare PPO,,1687.37,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Humana,Medicare PPO,,418.48,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare PPO,,455.29,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Humana,Medicare PPO,,415.57,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Humana,Medicare PPO,,976.41,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Humana,Medicare PPO,,10842.57,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Humana,Medicare PPO,,3675.27,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Humana,Medicare PPO,,10842.57,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Humana,Medicare PPO,,1687.37,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Humana,Medicare PPO,,976.41,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Humana,Medicare PPO,,976.41,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Humana,Medicare PPO,,1687.37,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Humana,Medicare PPO,,1424.94,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Humana,Medicare PPO,,3675.27,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Humana,Medicare PPO,,3277.91,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Humana,Medicare PPO,,1975.59,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Humana,Medicare PPO,,1975.59,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Humana,Medicare PPO,,1975.59,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Humana,Medicare PPO,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Humana,Medicare PPO,,976.41,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Humana,Medicare PPO,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Humana,Medicare PPO,,251.74,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Humana,Medicare PPO,,976.41,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Humana,Medicare PPO,,1687.37,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Humana,Medicare PPO,,2133.38,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Humana,Medicare PPO,,2133.38,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Humana,Medicare PPO,,2133.38,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare PPO,,695.12,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Humana,Medicare PPO,,732.74,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Humana,Medicare PPO,,6076.09,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Humana,Medicare PPO,,10842.57,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Humana,Medicare PPO,,2133.38,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Humana,Medicare PPO,,134.24,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Humana,Medicare PPO,,253.29,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare PPO,,209.51,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Humana,Medicare PPO,,732.74,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Humana,Medicare PPO,,11810.43,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Humana,Medicare PPO,,11810.43,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Humana,Medicare PPO,,732.74,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Humana,Medicare PPO,,732.74,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Humana,Medicare PPO,,721.21,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Humana,Medicare PPO,,927.18,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Humana,Medicare PPO,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Humana,Medicare PPO,,927.18,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Humana,Medicare PPO,,927.18,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Humana,Medicare PPO,,927.18,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Humana,Medicare PPO,,927.18,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Humana,Medicare PPO,,927.18,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Humana,Medicare PPO,,927.18,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Humana,Medicare PPO,,927.18,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Humana,Medicare PPO,,927.18,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Humana,Medicare PPO,,927.18,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Humana,Medicare PPO,,927.18,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Humana,Medicare PPO,,2033.68,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Humana,Medicare PPO,,2033.68,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Humana,Medicare PPO,,927.18,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Humana,Medicare PPO,,927.18,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Humana,Medicare PPO,,1227.93,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Humana,Medicare PPO,,7439.71,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Humana,Medicare PPO,,7439.71,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Humana,Medicare PPO,,11810.43,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Humana,Medicare PPO,,11810.43,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Humana,Medicare PPO,,732.74,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Humana,Medicare PPO,,455.29,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Humana,Medicare PPO,,732.74,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Humana,Medicare PPO,,1687.37,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Humana,Medicare PPO,,1687.37,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Humana,Medicare PPO,,1687.37,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Humana,Medicare PPO,,1687.37,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Humana,Medicare PPO,,10842.57,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Humana,Medicare PPO,,732.74,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Humana,Medicare PPO,,732.74,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Humana,Medicare PPO,,11810.43,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Humana,Medicare PPO,,18700.70,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Humana,Medicare PPO,,11810.43,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Humana,Medicare PPO,,732.74,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Humana,Medicare PPO,,3675.27,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Humana,Medicare PPO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Humana,Medicare PPO,,721.21,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Humana,Medicare PPO,,721.21,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Humana,Medicare PPO,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Humana,Medicare PPO,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Humana,Medicare PPO,,3379.04,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Humana,Medicare PPO,,3379.04,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Humana,Medicare PPO,,7439.71,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Humana,Medicare PPO,,7439.71,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Humana,Medicare PPO,,822.79,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Humana,Medicare PPO,,822.79,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Humana,Medicare PPO,,3675.27,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Humana,Medicare PPO,,3675.27,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Humana,Medicare PPO,,3675.27,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Humana,Medicare PPO,,3675.27,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Humana,Medicare PPO,,3675.27,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Humana,Medicare PPO,,3675.27,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Humana,Medicare PPO,,976.41,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Humana,Medicare PPO,,6076.09,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Humana,Medicare PPO,,6076.09,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Humana,Medicare PPO,,6076.09,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Humana,Medicare PPO,,6498.27,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Humana,Medicare PPO,,1687.37,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Humana,Medicare PPO,,695.12,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Humana,Medicare PPO,,695.12,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Humana,Medicare PPO,,2133.38,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Humana,Medicare PPO,,3591.87,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Humana,Medicare PPO,,2133.38,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Humana,Medicare PPO,,2133.38,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Humana,Medicare PPO,,3591.87,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Humana,Medicare PPO,,3591.87,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Humana,Medicare PPO,,3591.87,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Humana,Medicare PPO,,18700.70,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Humana,Medicare PPO,,5629.67,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Humana,Medicare PPO,,732.74,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Humana,Medicare PPO,,5937.75,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Humana,Medicare PPO,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Humana,Medicare PPO,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Humana,Medicare PPO,,2980.64,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Humana,Medicare PPO,,1617.80,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Humana,Medicare PPO,,1617.80,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Humana,Medicare PPO,,1617.80,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Humana,Medicare PPO,,643.87,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare PPO,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare PPO,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare PPO,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare PPO,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Humana,Medicare PPO,,3591.87,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Humana,Medicare PPO,,3591.87,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Humana,Medicare PPO,,1687.37,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Humana,Medicare PPO,,6669.40,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Humana,Medicare PPO,,643.87,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare PPO,,1617.80,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare PPO,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Humana,Medicare PPO,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Humana,Medicare PPO,,1059.54,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Humana,Medicare PPO,,822.79,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Humana,Medicare PPO,,110.74,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Humana,Medicare PPO,,110.74,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Humana,Medicare PPO,,110.74,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Humana,Medicare PPO,,110.74,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Humana,Medicare PPO,,110.74,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Humana,Medicare PPO,,110.74,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Humana,Medicare PPO,,110.74,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Humana,Medicare PPO,,110.74,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Humana,Medicare PPO,,110.74,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Humana,Medicare PPO,,251.74,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Humana,Medicare PPO,,110.74,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Humana,Medicare PPO,,110.74,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Humana,Medicare PPO,,110.74,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Humana,Medicare PPO,,110.74,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare PPO,,110.74,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Humana,Medicare PPO,,251.74,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Humana,Medicare PPO,,110.74,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Humana,Medicare PPO,,110.74,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Humana,Medicare PPO,,110.74,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Humana,Medicare PPO,,110.74,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Humana,Medicare PPO,,110.74,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Humana,Medicare PPO,,91.70,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Humana,Medicare PPO,,91.70,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,110.74,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Humana,Medicare PPO,,91.70,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Humana,Medicare PPO,,91.70,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Humana,Medicare PPO,,110.74,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Humana,Medicare PPO,,1359.57,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Humana,Medicare PPO,,1519.02,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Humana,Medicare PPO,,1519.02,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Humana,Medicare PPO,,1519.02,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Humana,Medicare PPO,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Humana,Medicare PPO,,418.48,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Humana,Medicare PPO,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Humana,Medicare PPO,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Humana,Medicare PPO,,1519.02,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Humana,Medicare PPO,,1519.02,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Humana,Medicare PPO,,1519.02,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Humana,Medicare PPO,,1519.02,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Humana,Medicare PPO,,1519.02,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Humana,Medicare PPO,,2343.75,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Humana,Medicare PPO,,2031.31,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Humana,Medicare PPO,,251.74,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Humana,Medicare PPO,,571.02,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Humana,Medicare PPO,,571.02,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Humana,Medicare PPO,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Humana,Medicare PPO,,571.02,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Humana,Medicare PPO,,822.79,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Humana,Medicare PPO,,822.79,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Humana,Medicare PPO,,822.79,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Humana,Medicare PPO,,91.70,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Humana,Medicare PPO,,371.93,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Humana,Medicare PPO,,371.93,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Humana,Medicare PPO,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Humana,Medicare PPO,,91.70,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Humana,Medicare PPO,,61.87,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Humana,Medicare PPO,,721.21,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Humana,Medicare PPO,,721.21,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Humana,Medicare PPO,,721.21,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Humana,Medicare PPO,,721.21,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Humana,Medicare PPO,,110.74,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Humana,Medicare PPO,,110.74,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Humana,Medicare PPO,,110.74,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Humana,Medicare PPO,,162.94,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Humana,Medicare PPO,,251.74,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Humana,Medicare PPO,,110.74,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Humana,Medicare PPO,,110.74,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Humana,Medicare PPO,,251.74,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Humana,Medicare PPO,,110.74,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Humana,Medicare PPO,,11.09,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Humana,Medicare PPO,,50.20,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare PPO,,9.11,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Humana,Medicare PPO,,50.01,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Humana,Medicare PPO,,8.58,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare PPO,,172.16,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Humana,Medicare PPO,,152.08,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Humana,Medicare PPO,,584.43,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Humana,Medicare PPO,,305.93,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Humana,Medicare PPO,,1218.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Humana,Medicare PPO,,1218.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Humana,Medicare PPO,,68.97,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Humana,Medicare PPO,,77.04,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Humana,Medicare PPO,,59.89,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Humana,Medicare PPO,,47.13,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Humana,Medicare PPO,,173.79,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Humana,Medicare PPO,,106.18,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare PPO,,36.75,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Humana,Medicare PPO,,68.63,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Humana,Medicare PPO,,207.89,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Humana,Medicare PPO,,181.37,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Humana,Medicare PPO,,244.72,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Humana,Medicare PPO,,244.72,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare PPO,,2.36,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Humana,Medicare PPO,,365.99,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Humana,Medicare PPO,,53.62,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Humana,Medicare PPO,,45.83,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Humana,Medicare PPO,,211.57,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Humana,Medicare PPO,,245.70,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Humana,Medicare PPO,,422.23,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Humana,Medicare PPO,,423.77,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Humana,Medicare PPO,,133.80,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Humana,Medicare PPO,,78.05,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Humana,Medicare PPO,,99.48,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Humana,Medicare PPO,,362.85,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Humana,Medicare PPO,,352.15,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Humana,Medicare PPO,,186.11,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Humana,Medicare PPO,,178.40,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Humana,Medicare PPO,,129.86,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Humana,Medicare PPO,,258.85,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Humana,Medicare PPO,,130.87,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Humana,Medicare PPO,,315.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Humana,Medicare PPO,,202.91,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Humana,Medicare PPO,,310.58,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare PPO,,17.61,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Humana,Medicare PPO,,5.29,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Humana,Medicare PPO,,9.18,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Humana,Medicare PPO,,10.14,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare PPO,,7.90,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare PPO,,4.53,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Humana,Medicare PPO,,4.48,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Humana,Medicare PPO,,65.25,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Humana,Medicare PPO,,8.88,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Humana,Medicare PPO,,7.36,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Humana,Medicare PPO,,14.06,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Humana,Medicare PPO,,65.25,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Humana,Medicare PPO,,65.25,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Humana,Medicare PPO,,65.25,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare PPO,,65.25,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Humana,Medicare PPO,,65.25,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare PPO,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare PPO,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,15.83,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,15.30,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,13.94,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,14.22,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare PPO,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare PPO,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Humana,Medicare PPO,,17.20,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare PPO,,15.42,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.94,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare PPO,,16.07,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,13.91,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare PPO,,14.45,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Humana,Medicare PPO,,14.42,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Humana,Medicare PPO,,14.42,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare PPO,,14.85,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare PPO,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare PPO,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare PPO,,16.94,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare PPO,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare PPO,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare PPO,,14.22,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Humana,Medicare PPO,,34.25,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare PPO,,4.75,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare PPO,,8.58,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,8.58,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,5.20,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare PPO,,8.17,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare PPO,,6.07,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare PPO,,6.07,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare PPO,,18.13,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Humana,Medicare PPO,,14.11,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare PPO,,17.61,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,15.30,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare PPO,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare PPO,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare PPO,,6.80,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare PPO,,16.99,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare PPO,,5.27,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare PPO,,5.27,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,5.27,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Humana,Medicare PPO,,4.60,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare PPO,,5.59,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare PPO,,4.44,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Humana,Medicare PPO,,31.08,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare PPO,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare PPO,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare PPO,,6.33,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Humana,Medicare PPO,,5.12,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Humana,Medicare PPO,,19.91,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare PPO,,11.28,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,14.83,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,14.83,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,4.83,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Humana,Medicare PPO,,5.25,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare PPO,,4.57,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Humana,Medicare PPO,,40.50,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare PPO,,28.47,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Humana,Medicare PPO,,28.47,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Humana,Medicare PPO,,19.57,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare PPO,,17.11,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Humana,Medicare PPO,,14.42,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,6.84,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare PPO,,12.13,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare PPO,,5.38,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,5.44,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,5.44,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Humana,Medicare PPO,,29.34,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Humana,Medicare PPO,,15.64,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare PPO,,5.36,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Humana,Medicare PPO,,14.31,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Humana,Medicare PPO,,67.63,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare PPO,,15.44,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare PPO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare PPO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare PPO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare PPO,,9.77,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare PPO,,11.55,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare PPO,,27.37,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare PPO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare PPO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare PPO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Humana,Medicare PPO,,82.71,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,10.26,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare PPO,,4.13,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare PPO,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare PPO,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare PPO,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Humana,Medicare PPO,,4.13,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Humana,Medicare PPO,,4.99,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare PPO,,13.51,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare PPO,,4.12,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare PPO,,4.12,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Humana,Medicare PPO,,7.56,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Humana,Medicare PPO,,19.51,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Humana,Medicare PPO,,19.45,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare PPO,,13.21,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Humana,Medicare PPO,,13.51,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare PPO,,18.96,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Humana,Medicare PPO,,8.40,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,10.20,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare PPO,,8.61,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare PPO,,8.61,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Humana,Medicare PPO,,4.99,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Humana,Medicare PPO,,18.82,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare PPO,,26.72,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare PPO,,12.11,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare PPO,,12.11,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare PPO,,12.00,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.79,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,12.15,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare PPO,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare PPO,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,20.68,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare PPO,,20.29,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Humana,Medicare PPO,,7.23,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Humana,Medicare PPO,,7.23,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Humana,Medicare PPO,,8.60,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare PPO,,11.03,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare PPO,,7.04,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare PPO,,13.57,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare PPO,,41.22,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare PPO,,18.13,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,18.13,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Humana,Medicare PPO,,6.94,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,7.16,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare PPO,,43.34,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Humana,Medicare PPO,,43.34,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare PPO,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare PPO,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare PPO,,3.76,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Humana,Medicare PPO,,5.44,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,4.98,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Humana,Medicare PPO,,6.07,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Humana,Medicare PPO,,6.07,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Humana,Medicare PPO,,103.02,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Humana,Medicare PPO,,5.00,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,4.97,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,15.32,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Humana,Medicare PPO,,21.90,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Humana,Medicare PPO,,20.35,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Humana,Medicare PPO,,19.31,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Humana,Medicare PPO,,19.31,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare PPO,,3.85,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Humana,Medicare PPO,,4.20,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare PPO,,11.28,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare PPO,,18.72,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare PPO,,18.72,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare PPO,,5.05,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare PPO,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare PPO,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare PPO,,5.10,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare PPO,,3.44,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Humana,Medicare PPO,,27.10,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare PPO,,7.21,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Humana,Medicare PPO,,9.47,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Humana,Medicare PPO,,17.64,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,5.44,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare PPO,,5.57,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare PPO,,13.40,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare PPO,,6.03,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Humana,Medicare PPO,,14.89,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Humana,Medicare PPO,,17.79,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Humana,Medicare PPO,,13.09,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,4.15,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare PPO,,5.84,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,4.75,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare PPO,,5.33,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Humana,Medicare PPO,,5.33,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Humana,Medicare PPO,,65.25,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Humana,Medicare PPO,,65.25,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,15.80,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare PPO,,8.26,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Humana,Medicare PPO,,5.48,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Humana,Medicare PPO,,15.80,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Humana,Medicare PPO,,15.80,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Humana,Medicare PPO,,19.29,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare PPO,,11.72,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Humana,Medicare PPO,,5.44,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare PPO,,13.60,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Humana,Medicare PPO,,26.72,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,26.72,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,26.72,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Humana,Medicare PPO,,12.60,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare PPO,,14.43,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Humana,Medicare PPO,,14.43,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Humana,Medicare PPO,,18.83,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Humana,Medicare PPO,,18.83,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Humana,Medicare PPO,,12.65,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare PPO,,12.65,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Humana,Medicare PPO,,21.85,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Humana,Medicare PPO,,21.85,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Humana,Medicare PPO,,5.44,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Humana,Medicare PPO,,31.42,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Humana,Medicare PPO,,23.46,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare PPO,,30.82,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Humana,Medicare PPO,,39.62,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare PPO,,28.12,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,28.12,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,374.62,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Humana,Medicare PPO,,39.62,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Humana,Medicare PPO,,39.62,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Humana,Medicare PPO,,49.33,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Humana,Medicare PPO,,81.67,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare PPO,,15.28,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare PPO,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare PPO,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare PPO,,11.17,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Humana,Medicare PPO,,5.95,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Humana,Medicare PPO,,65.08,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Humana,Medicare PPO,,25.50,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare PPO,,4.48,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare PPO,,4.62,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare PPO,,4.62,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Humana,Medicare PPO,,17.88,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare PPO,,15.11,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Humana,Medicare PPO,,17.69,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Humana,Medicare PPO,,16.05,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare PPO,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare PPO,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,10.69,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare PPO,,10.69,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare PPO,,17.69,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare PPO,,17.69,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare PPO,,9.54,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare PPO,,13.85,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Humana,Medicare PPO,,20.32,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Humana,Medicare PPO,,9.33,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare PPO,,14.40,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare PPO,,12.36,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare PPO,,11.28,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,13.01,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Humana,Medicare PPO,,11.82,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Humana,Medicare PPO,,13.01,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Humana,Medicare PPO,,20.32,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,20.32,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare PPO,,13.52,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Humana,Medicare PPO,,15.11,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Humana,Medicare PPO,,15.13,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,13.90,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare PPO,,13.52,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,14.98,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Humana,Medicare PPO,,114.96,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Humana,Medicare PPO,,67.40,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Humana,Medicare PPO,,67.40,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Humana,Medicare PPO,,339.94,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Humana,Medicare PPO,,342.09,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare PPO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Humana,Medicare PPO,,178.46,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Humana,Medicare PPO,,374.62,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare PPO,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare PPO,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare PPO,,5.66,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Humana,Medicare PPO,,5.44,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare PPO,,3.14,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,3.14,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Humana,Medicare PPO,,6.67,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Humana,Medicare PPO,,6.67,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Humana,Medicare PPO,,4.02,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Humana,Medicare PPO,,178.46,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,178.46,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Humana,Medicare PPO,,61.87,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Humana,Medicare PPO,,61.87,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Humana,Medicare PPO,,25.50,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Humana,Medicare PPO,,14.61,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare PPO,,3.99,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,2.49,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,2.49,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare PPO,,8.16,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,6.79,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,4.19,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Humana,Medicare PPO,,5.85,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare PPO,,2.67,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,4.70,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Humana,Medicare PPO,,850.74,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Humana,Medicare PPO,,850.74,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Humana,Medicare PPO,,13.63,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare PPO,,18.53,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Humana,Medicare PPO,,18.80,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Humana,Medicare PPO,,18.80,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Humana,Medicare PPO,,12.48,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Humana,Medicare PPO,,24.09,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,24.09,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Humana,Medicare PPO,,24.09,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Humana,Medicare PPO,,32.40,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Humana,Medicare PPO,,24.09,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Humana,Medicare PPO,,19.99,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Humana,Medicare PPO,,18.80,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Humana,Medicare PPO,,18.80,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Humana,Medicare PPO,,20.32,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Humana,Medicare PPO,,9.57,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Humana,Medicare PPO,,19.88,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Humana,Medicare PPO,,19.88,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Humana,Medicare PPO,,12.44,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare PPO,,14.53,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Humana,Medicare PPO,,16.09,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare PPO,,32.40,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Humana,Medicare PPO,,16.09,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Humana,Medicare PPO,,13.51,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Humana,Medicare PPO,,13.51,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare PPO,,13.51,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare PPO,,4.49,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare PPO,,7.23,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Humana,Medicare PPO,,10.69,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Humana,Medicare PPO,,10.21,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Humana,Medicare PPO,,18.05,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,9.83,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Humana,Medicare PPO,,13.74,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare PPO,,13.74,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Humana,Medicare PPO,,26.16,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Humana,Medicare PPO,,26.16,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare PPO,,18.88,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Humana,Medicare PPO,,18.88,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare PPO,,4.50,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Humana,Medicare PPO,,4.14,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare PPO,,10.06,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Humana,Medicare PPO,,10.06,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Humana,Medicare PPO,,18.88,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare PPO,,10.34,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Humana,Medicare PPO,,19.57,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare PPO,,4.48,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,5.79,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare PPO,,6.06,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Humana,Medicare PPO,,6.06,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,6.31,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,6.31,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Humana,Medicare PPO,,6.79,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare PPO,,6.79,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Humana,Medicare PPO,,12.25,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,7.01,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Humana,Medicare PPO,,10.84,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Humana,Medicare PPO,,10.84,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Humana,Medicare PPO,,9.91,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,9.91,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Humana,Medicare PPO,,9.91,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare PPO,,9.05,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Humana,Medicare PPO,,9.05,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Humana,Medicare PPO,,10.38,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Humana,Medicare PPO,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Humana,Medicare PPO,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Humana,Medicare PPO,,9.94,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Humana,Medicare PPO,,8.48,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Humana,Medicare PPO,,8.48,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare PPO,,8.48,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,8.48,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Humana,Medicare PPO,,6.96,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Humana,Medicare PPO,,6.96,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare PPO,,6.96,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Humana,Medicare PPO,,6.96,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Humana,Medicare PPO,,6.96,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Humana,Medicare PPO,,8.47,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Humana,Medicare PPO,,8.10,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,8.83,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Humana,Medicare PPO,,10.84,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,10.84,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare PPO,,5.44,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare PPO,,5.44,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare PPO,,121.13,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Humana,Medicare PPO,,4.53,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare PPO,,4.48,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,6.17,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare PPO,,9.35,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare PPO,,4.99,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare PPO,,7.85,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Humana,Medicare PPO,,4.99,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare PPO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare PPO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare PPO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Humana,Medicare PPO,,9.08,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Humana,Medicare PPO,,9.08,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Humana,Medicare PPO,,4.48,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare PPO,,4.48,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare PPO,,4.48,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,5.66,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Humana,Medicare PPO,,5.66,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,5.66,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Humana,Medicare PPO,,6.29,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare PPO,,18.88,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Humana,Medicare PPO,,6.11,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,6.11,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Humana,Medicare PPO,,12.58,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Humana,Medicare PPO,,12.58,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,12.58,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Humana,Medicare PPO,,12.58,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Humana,Medicare PPO,,14.51,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare PPO,,10.85,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare PPO,,10.85,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,25.28,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Humana,Medicare PPO,,25.28,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Humana,Medicare PPO,,12.58,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Humana,Medicare PPO,,12.58,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare PPO,,12.58,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Humana,Medicare PPO,,36.84,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Humana,Medicare PPO,,39.13,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Humana,Medicare PPO,,36.84,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Humana,Medicare PPO,,44.98,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Humana,Medicare PPO,,36.84,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Humana,Medicare PPO,,44.98,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Humana,Medicare PPO,,44.98,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Humana,Medicare PPO,,36.84,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Humana,Medicare PPO,,36.84,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Humana,Medicare PPO,,89.36,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Humana,Medicare PPO,,36.84,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Humana,Medicare PPO,,36.84,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Humana,Medicare PPO,,36.84,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare PPO,,100.59,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Humana,Medicare PPO,,149.76,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Humana,Medicare PPO,,437.62,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Humana,Medicare PPO,,36.84,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Humana,Medicare PPO,,36.84,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Humana,Medicare PPO,,36.84,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,36.84,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Humana,Medicare PPO,,36.84,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Humana,Medicare PPO,,44.98,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Humana,Medicare PPO,,276.14,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Humana,Medicare PPO,,16.05,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Humana,Medicare PPO,,17.36,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Humana,Medicare PPO,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Humana,Medicare PPO,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Humana,Medicare PPO,,16.87,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Humana,Medicare PPO,,270.32,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Humana,Medicare PPO,,270.32,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Humana,Medicare PPO,,3.33,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Humana,Medicare PPO,,3.33,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,3.65,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,3.65,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Humana,Medicare PPO,,3.65,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Humana,Medicare PPO,,9.04,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Humana,Medicare PPO,,178.46,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare PPO,,5.88,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,7.70,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Humana,Medicare PPO,,6.08,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Humana,Medicare PPO,,96.24,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Humana,Medicare PPO,,18.95,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Humana,Medicare PPO,,25.39,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Humana,Medicare PPO,,13.01,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Humana,Medicare PPO,,4.96,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Humana,Medicare PPO,,13.91,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,17.28,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare PPO,,12.11,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Humana,Medicare PPO,,5.48,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Humana,Medicare PPO,,18.83,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Humana,Medicare PPO,,4.48,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare PPO,,13.70,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare PPO,,13.52,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Humana,Medicare PPO,,5.44,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Humana,Medicare PPO,,15.10,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Humana,Medicare PPO,,8.48,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare PPO,,8.48,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Humana,Medicare PPO,,14.29,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Humana,Medicare PPO,,9.04,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare PPO,,13.85,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,7.01,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Humana,Medicare PPO,,5.44,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Humana,Medicare PPO,,14.06,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Humana,Medicare PPO,,4.99,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Humana,Medicare PPO,,4.99,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare PPO,,13.51,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare PPO,,4.50,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,6.45,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Humana,Medicare PPO,,13.90,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare PPO,,6.96,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Humana,Medicare PPO,,178.46,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Humana,Medicare PPO,,178.46,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Humana,Medicare PPO,,129.86,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Humana,Medicare PPO,,15.34,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,15.80,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Humana,Medicare PPO,,7.68,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Humana,Medicare PPO,,27.10,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Humana,Medicare PPO,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,36.84,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,16.72,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Humana,Medicare PPO,,5.78,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare PPO,,28.58,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Humana,Medicare PPO,,2.83,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,9.05,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Humana,Medicare PPO,,12.58,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Humana,Medicare PPO,,17.38,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Humana,Medicare PPO,,17.38,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Humana,Medicare PPO,,9.54,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Humana,Medicare PPO,,9.54,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Humana,Medicare PPO,,9.54,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Humana,Medicare PPO,,36.84,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Humana,Medicare PPO,,127.71,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Humana,Medicare PPO,,194.46,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Humana,Medicare PPO,,87.15,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Humana,Medicare PPO,,673.94,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Humana,Medicare PPO,,1916.12,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Humana,Medicare PPO,,394.01,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Humana,Medicare PPO,,9.54,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Humana,Medicare PPO,,11.71,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Humana,Medicare PPO,,6.79,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Humana,Medicare PPO,,5.79,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare PPO,,19.45,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,28.12,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Humana,Medicare PPO,,194.46,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,21.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Humana,Medicare PPO,,36.84,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Humana,Medicare PPO,,143.85,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Humana,Medicare PPO,,36.84,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Humana,Medicare PPO,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Humana,Medicare PPO,,228.96,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Humana,Medicare PPO,,36.84,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,36.84,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Humana,Medicare PPO,,73.71,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Humana,Medicare PPO,,127.71,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Humana,Medicare PPO,,194.46,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Humana,Medicare PPO,,26.16,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Humana,Medicare PPO,QW,26.16,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Humana,Medicare PPO,,15.10,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Humana,Medicare PPO,,65.25,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Humana,Medicare PPO,,1218.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Humana,Medicare PPO,,437.62,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Humana,Medicare PPO,,96.24,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,21.85,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Humana,Medicare PPO,,244.72,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Humana,Medicare PPO,,43.85,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Humana,Medicare PPO,,44.98,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Humana,Medicare PPO,,16.87,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Humana,Medicare PPO,,5.48,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare PPO,,30.67,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare PPO,QW,53.88,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Humana,Medicare PPO,,44.24,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Humana,Medicare PPO,,18.13,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Humana,Medicare PPO,,437.62,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Humana,Medicare PPO,,149.76,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare PPO,,10.84,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare PPO,,19.57,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Humana,Medicare PPO,,19.57,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare PPO,,28.47,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Humana,Medicare PPO,,40.50,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Humana,Medicare PPO,,9.08,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Humana,Medicare PPO,,149.76,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare PPO,,41.22,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Humana,Medicare PPO,,22.82,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare PPO,,21.85,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Humana,Medicare PPO,,143.85,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare PPO,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Humana,Medicare PPO,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Humana,Medicare PPO,,21.34,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Humana,Medicare PPO,,12.11,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,18.13,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Humana,Medicare PPO,,23.46,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Humana,Medicare PPO,,30.82,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Humana,Medicare PPO,,28.76,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Humana,Medicare PPO,,134.70,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Humana,Medicare PPO,,12.11,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Humana,Medicare PPO,,53.88,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,36.84,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Humana,Medicare PPO,,36.84,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,10.20,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Humana,Medicare PPO,,12.15,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare PPO,,2.36,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Humana,Medicare PPO,,36.84,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Humana,Medicare PPO,,36.84,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Humana,Medicare PPO,,36.84,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Humana,Medicare PPO,,143.85,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Humana,Medicare PPO,,9.05,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Humana,Medicare PPO,,276.14,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Humana,Medicare PPO,,73.71,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Humana,Medicare PPO,,55.64,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Humana,Medicare PPO,,2.49,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Humana,Medicare PPO,,40.88,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Humana,Medicare PPO,,40.88,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Humana,Medicare PPO,,55.64,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Humana,Medicare PPO,,55.64,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Humana,Medicare PPO,,21.27,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Humana,Medicare PPO,,25.50,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Humana,Medicare PPO,,178.46,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Humana,Medicare PPO,,55.64,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,27.94,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Humana,Medicare PPO,,27.94,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Humana,Medicare PPO,,27.94,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Humana,Medicare PPO,,374.62,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Humana,Medicare PPO,,374.62,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Humana,Medicare PPO,,122.31,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Humana,Medicare PPO,,122.31,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Humana,Medicare PPO,,147.77,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Humana,Medicare PPO,,157.81,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Humana,Medicare PPO,,157.81,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Humana,Medicare PPO,,150.94,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Humana,Medicare PPO,,13.72,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Humana,Medicare PPO,,277.56,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Humana,Medicare PPO,,131.76,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Humana,Medicare PPO,,151.84,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Humana,Medicare PPO,,198.00,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Humana,Medicare PPO,,22.49,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare PPO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Humana,Medicare PPO,,36.55,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Humana,Medicare PPO,,44.50,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Humana,Medicare PPO,,53.75,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Humana,Medicare PPO,,35.14,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Humana,Medicare PPO,,72.03,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Humana,Medicare PPO,,28.26,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare PPO,,55.64,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Humana,Medicare PPO,,40.88,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Humana,Medicare PPO,,25.50,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Humana,Medicare PPO,,40.88,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Humana,Medicare PPO,,55.64,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Humana,Medicare PPO,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Humana,Medicare PPO,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Humana,Medicare PPO,,374.62,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Humana,Medicare PPO,,850.74,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare PPO,,134.24,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Humana,Medicare PPO,,850.74,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Humana,Medicare PPO,,55.64,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Humana,Medicare PPO,,178.46,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Humana,Medicare PPO,,850.74,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Humana,Medicare PPO,,178.46,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Humana,Medicare PPO,,12.65,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Humana,Medicare PPO,,178.46,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare PPO,,178.46,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Humana,Medicare PPO,,178.46,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Humana,Medicare PPO,,178.46,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Humana,Medicare PPO,,107.37,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Humana,Medicare PPO,,5.27,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Humana,Medicare PPO,,178.46,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Humana,Medicare PPO,,150.94,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Humana,Medicare PPO,,147.77,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Humana,Medicare PPO,,150.94,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Humana,Medicare PPO,,53.75,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Humana,Medicare PPO,,151.84,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare PPO,,374.62,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare PPO,,178.46,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Humana,Medicare PPO,,53.75,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare PPO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Humana,Medicare PPO,,178.46,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Humana,Medicare PPO,,55.64,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Humana,Medicare PPO,,134.24,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Humana,Medicare PPO,,374.62,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Humana,Medicare PPO,,53.75,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare PPO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Humana,Medicare PPO,,178.46,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Humana,Medicare PPO,,178.46,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Humana,Medicare PPO,,178.46,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Humana,Medicare PPO,,22.49,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Humana,Medicare PPO,,22.49,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Humana,Medicare PPO,,22.49,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Humana,Medicare PPO,,53.75,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Humana,Medicare PPO,,22.49,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Humana,Medicare PPO,,44.50,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Humana,Medicare PPO,,178.46,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Humana,Medicare PPO,,178.46,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,178.46,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Humana,Medicare PPO,,40.88,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Humana,Medicare PPO,,178.46,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Humana,Medicare PPO,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Humana,Medicare PPO,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Humana,Medicare PPO,,189.54,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Humana,Medicare PPO,,189.54,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare PPO,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare PPO,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Humana,Medicare PPO,,87.78,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Humana,Medicare PPO,,150.30,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Humana,Medicare PPO,,413.31,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare PPO,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Humana,Medicare PPO,,703.66,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Humana,Medicare PPO,,680.83,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Humana,Medicare PPO,,266.40,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Humana,Medicare PPO,,153.41,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Humana,Medicare PPO,,809.71,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Humana,Medicare PPO,,252.48,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Humana,Medicare PPO,,74.04,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Humana,Medicare PPO,,611.61,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Humana,Medicare PPO,,3.14,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare PPO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare PPO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Humana,Medicare PPO,,10.26,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Humana,Medicare PPO,,6.01,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare PPO,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Humana,Medicare PPO,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Humana,Medicare PPO,,703.66,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Humana,Medicare PPO,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare PPO,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare PPO,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare PPO,,5629.67,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare PPO,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare PPO,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Humana,Medicare PPO,,162.94,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Humana,Medicare PPO,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare PPO,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Humana,Medicare PPO,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Humana,Medicare PPO,,3277.91,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Humana,Medicare PPO,,3277.91,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Humana,Medicare PPO,,3277.91,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Humana,Medicare PPO,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Humana,Medicare PPO,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare PPO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare PPO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Humana,Medicare PPO,,3277.91,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Humana,Medicare PPO,,3277.91,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare PPO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Humana,Medicare PPO,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare PPO,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Humana,Medicare PPO,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Humana,Medicare PPO,,3277.91,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Humana,Medicare PPO,,11810.43,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Humana,Medicare PPO,,3277.91,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Humana,Medicare PPO,,3277.91,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare PPO,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare PPO,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare PPO,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Humana,Medicare PPO,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Humana,Medicare PPO,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Humana,Medicare PPO,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Humana,Medicare PPO,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Humana,Medicare PPO,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Humana,Medicare PPO,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Humana,Medicare PPO,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Humana,Medicare PPO,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Humana,Medicare PPO,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Humana,Medicare PPO,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Humana,Medicare PPO,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Humana,Medicare PPO,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Humana,Medicare PPO,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Humana,Medicare PPO,,11810.43,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Humana,Medicare PPO,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Humana,Medicare PPO,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Humana,Medicare PPO,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Humana,Medicare PPO,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Humana,Medicare PPO,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Humana,Medicare PPO,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Humana,Medicare PPO,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Humana,Medicare PPO,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Humana,Medicare PPO,,681.49,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Humana,Medicare PPO,,681.49,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Humana,Medicare PPO,,345.43,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Humana,Medicare PPO,,5937.75,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Humana,Medicare PPO,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Humana,Medicare PPO,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Humana,Medicare PPO,,11810.43,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Humana,Medicare PPO,,3349.67,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Humana,Medicare PPO,,3349.67,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Humana,Medicare PPO,,3349.67,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Humana,Medicare PPO,,3349.67,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Humana,Medicare PPO,,3349.67,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Humana,Medicare PPO,,3349.67,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Humana,Medicare PPO,,3349.67,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Humana,Medicare PPO,,3349.67,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Humana,Medicare PPO,,3349.67,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Humana,Medicare PPO,,3349.67,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Humana,Medicare PPO,,3349.67,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Humana,Medicare PPO,,1617.80,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Humana,Medicare PPO,,3277.91,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Humana,Medicare PPO,,18700.70,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Humana,Medicare PPO,,7902.49,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Humana,Medicare PPO,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Humana,Medicare PPO,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Humana,Medicare PPO,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Humana,Medicare PPO,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Humana,Medicare PPO,,10898.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Humana,Medicare PPO,,8618.87,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Humana,Medicare PPO,,10898.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Humana,Medicare PPO,,10898.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Humana,Medicare PPO,,3277.91,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Humana,Medicare PPO,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Humana,Medicare PPO,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Humana,Medicare PPO,,3790.08,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Humana,Medicare PPO,,3790.08,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Humana,Medicare PPO,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Humana,Medicare PPO,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Humana,Medicare PPO,,10898.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Humana,Medicare PPO,,3277.91,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Humana,Medicare PPO,,8618.87,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Humana,Medicare PPO,,10898.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Humana,Medicare PPO,,19861.32,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Humana,Medicare PPO,,8618.87,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Humana,Medicare PPO,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Humana,Medicare PPO,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Humana,Medicare PPO,,23376.18,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Humana,Medicare PPO,,3790.08,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Humana,Medicare PPO,,3790.08,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Humana,Medicare PPO,,33389.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Humana,Medicare PPO,,8618.87,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Humana,Medicare PPO,,732.74,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Humana,Medicare PPO,,643.87,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Humana,Medicare PPO,,7902.49,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Humana,Medicare PPO,,7902.49,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Humana,Medicare PPO,,1264.28,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Humana,Medicare PPO,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Humana,Medicare PPO,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Humana,Medicare PPO,,1264.28,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Humana,Medicare PPO,,7902.49,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Humana,Medicare PPO,,7902.49,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Humana,Medicare PPO,,1264.28,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Humana,Medicare PPO,,7902.49,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Humana,Medicare PPO,,552.58,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Humana,Medicare PPO,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Humana,Medicare PPO,,19861.32,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Humana,Medicare PPO,,33389.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Humana,Medicare PPO,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Humana,Medicare PPO,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Humana,Medicare PPO,,33389.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Humana,Medicare PPO,,29606.17,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Humana,Medicare PPO,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Humana,Medicare PPO,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Humana,Medicare PPO,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Humana,Medicare PPO,,415.57,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Humana,Medicare PPO,,162.94,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Humana,Medicare PPO,,3277.91,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Humana,Medicare PPO,,1617.80,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Humana,Medicare PPO,,11810.43,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Humana,Medicare PPO,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Humana,Medicare PPO,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Humana,Medicare PPO,,18700.70,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Humana,Medicare PPO,,643.87,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Humana,Medicare PPO,,33389.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Humana,Medicare PPO,,11810.43,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Humana,Medicare PPO,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Humana,Medicare PPO,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Humana,Medicare PPO,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Humana,Medicare PPO,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Humana,Medicare PPO,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Humana,Medicare PPO,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Humana,Medicare PPO,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Humana,Medicare PPO,,25548.73,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Humana,Medicare PPO,,5937.75,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Humana,Medicare PPO,,643.87,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Humana,Medicare PPO,,33389.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Humana,Medicare PPO,,5937.75,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Humana,Medicare PPO,,110.74,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Humana,Medicare PPO,,19861.32,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Humana,Medicare PPO,,324.30,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Humana,Medicare PPO,,571.02,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Humana,Medicare PPO,,571.02,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Humana,Medicare PPO,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Humana,Medicare PPO,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Humana,Medicare PPO,,251.74,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Humana,Medicare PPO,,251.74,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Humana,Medicare PPO,,251.74,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Humana,Medicare PPO,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Humana,Medicare PPO,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Humana,Medicare PPO,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Humana,Medicare PPO,,38.84,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Humana,Medicare PPO,,134.24,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Humana,Medicare PPO,,61.87,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Humana,Medicare PPO,,95.59,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Humana,Medicare PPO,,251.74,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Humana,Medicare PPO,,131.12,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Humana,Medicare PPO,,131.12,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Humana,Medicare PPO,,61.87,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Humana,Medicare PPO,,61.87,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Humana,Medicare PPO,,3839.70,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Humana,Medicare PPO,,3277.91,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Humana,Medicare PPO,,7439.71,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Humana,Medicare PPO,,732.74,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Humana,Medicare PPO,,8618.87,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Humana,Medicare PPO,,3790.08,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Humana,Medicare PPO,,3790.08,,,,,,,422.62,17457.00,fee schedule,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,inpatient,,,0.14000,0.08000,MedCost,Commercial,,0.11340,,,,,,,0.04214,0.11382,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,MedCost,Commercial,,0.08540,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,130.00000,78.00000,MedCost,Commercial,,105.30,,,,,,,39.13,105.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,MedCost,Commercial,,79.30,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,25.00000,15.00000,MedCost,Commercial,,20.25,,,,,,,7.53,20.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,MedCost,Commercial,,15.25,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,28.59,77.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,16.25,43.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,MedCost,Commercial,,99.63,,,,,,,78.72,100.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,MedCost,Commercial,,75.03,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,MedCost,Commercial,,99.63,,,,,,,37.02,100.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,MedCost,Commercial,,75.03,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,22.07000,13.24000,MedCost,Commercial,,17.88,,,,,,,6.64,17.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,MedCost,Commercial,,13.46,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,77.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,142.00000,85.20000,MedCost,Commercial,,115.02,,,,,,,42.74,115.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,MedCost,Commercial,,86.62,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,inpatient,,,39570.00000,23742.00000,MedCost,Commercial,,32051.70,,,,,,,11910.57,32170.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,MedCost,Commercial,,24137.70,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,17004.00000,10202.40000,MedCost,Commercial,,13773.24,,,,,,,5118.20,13824.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,MedCost,Commercial,,10372.44,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,inpatient,,,1.01000,0.61000,MedCost,Commercial,,0.81810,,,,,,,0.64640,0.81810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,MedCost,Commercial,,0.61610,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,1919.00000,1151.40000,MedCost,Commercial,,1554.39,,,,,,,577.62,1560.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,MedCost,Commercial,,1170.59,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,7252.00000,4351.20000,MedCost,Commercial,,5874.12,,,,,,,2182.85,5895.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,MedCost,Commercial,,4423.72,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,1734.00000,1040.40000,MedCost,Commercial,,1404.54,,,,,,,521.93,1409.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,MedCost,Commercial,,1057.74,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,3295.00000,1977.00000,MedCost,Commercial,,2668.95,,,,,,,991.79,2678.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,MedCost,Commercial,,2009.95,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,40220.00000,24132.00000,MedCost,Commercial,,32578.20,,,,,,,12106.22,32698.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,MedCost,Commercial,,24534.20,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,12517.00000,7510.20000,MedCost,Commercial,,10138.77,,,,,,,3767.62,10176.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,MedCost,Commercial,,7635.37,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,11120.00000,6672.00000,MedCost,Commercial,,9007.20,,,,,,,3347.12,9040.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,MedCost,Commercial,,6783.20,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,15665.00000,9399.00000,MedCost,Commercial,,12688.65,,,,,,,4715.16,12735.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,MedCost,Commercial,,9555.65,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,31578.00000,18946.80000,MedCost,Commercial,,25578.18,,,,,,,9504.98,25672.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,MedCost,Commercial,,19262.58,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,2639.00000,1583.40000,MedCost,Commercial,,2137.59,,,,,,,794.34,2145.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,MedCost,Commercial,,1609.79,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,11117.00000,6670.20000,MedCost,Commercial,,9004.77,,,,,,,3346.22,9038.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,MedCost,Commercial,,6781.37,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,16042.00000,9625.20000,MedCost,Commercial,,12994.02,,,,,,,4828.64,13042.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,MedCost,Commercial,,9785.62,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,2696.00000,1617.60000,MedCost,Commercial,,2183.76,,,,,,,811.50,2191.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,MedCost,Commercial,,1644.56,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,8366.00000,5019.60000,MedCost,Commercial,,6776.46,,,,,,,2518.17,6801.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,MedCost,Commercial,,5103.26,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,8920.00000,5352.00000,MedCost,Commercial,,7225.20,,,,,,,2684.92,7251.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,MedCost,Commercial,,5441.20,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,11277.00000,6766.20000,MedCost,Commercial,,9134.37,,,,,,,3394.38,9168.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,MedCost,Commercial,,6878.97,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,inpatient,,,132.00000,79.20000,MedCost,Commercial,,106.92,,,,,,,84.48,107.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,MedCost,Commercial,,80.52,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,MedCost,Commercial,,368.55,,,,,,,136.96,369.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,MedCost,Commercial,,277.55,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,MedCost,Commercial,,737.91,,,,,,,274.21,740.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,MedCost,Commercial,,555.71,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,inpatient,,,31.28000,18.77000,MedCost,Commercial,,25.34,,,,,,,9.42,25.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,MedCost,Commercial,,19.08,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,inpatient,,,20.34000,12.20000,MedCost,Commercial,,16.48,,,,,,,6.12,16.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,MedCost,Commercial,,12.41,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,inpatient,,,278.96000,167.38000,MedCost,Commercial,,225.96,,,,,,,83.97,226.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,MedCost,Commercial,,170.17,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,inpatient,,,21.64000,12.98000,MedCost,Commercial,,17.53,,,,,,,6.51,17.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,MedCost,Commercial,,13.20,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,inpatient,,,0.03000,0.02000,MedCost,Commercial,,0.02430,,,,,,,0.00903,0.02439,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,MedCost,Commercial,,0.01830,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,inpatient,,,21.42000,12.85000,MedCost,Commercial,,17.35,,,,,,,6.45,17.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,MedCost,Commercial,,13.07,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,inpatient,,,40.61000,24.37000,MedCost,Commercial,,32.89,,,,,,,12.22,33.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,MedCost,Commercial,,24.77,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,inpatient,,,20.37000,12.22000,MedCost,Commercial,,16.50,,,,,,,6.13,16.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,MedCost,Commercial,,12.43,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,inpatient,,,19.90000,11.94000,MedCost,Commercial,,16.12,,,,,,,5.99,16.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,MedCost,Commercial,,12.14,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,MedCost,Commercial,,800.28,,,,,,,632.32,803.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,MedCost,Commercial,,602.68,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,174.72,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,inpatient,,,65.26000,39.16000,MedCost,Commercial,,52.86,,,,,,,19.64,53.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,MedCost,Commercial,,39.81,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,inpatient,,,178.21000,106.93000,MedCost,Commercial,,144.35,,,,,,,114.05,144.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,MedCost,Commercial,,108.71,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,inpatient,,,15495.00000,9297.00000,MedCost,Commercial,,12550.95,,,,,,,4663.99,12597.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,MedCost,Commercial,,9451.95,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,inpatient,,,6.33000,3.80000,MedCost,Commercial,,5.13,,,,,,,1.91,5.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,MedCost,Commercial,,3.86,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,,,182.00000,109.20000,MedCost,Commercial,,147.42,,,,,,,116.48,147.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,MedCost,Commercial,,111.02,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,MedCost,Commercial,,162.00,,,,,,,60.20,162.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,MedCost,Commercial,,122.00,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,MedCost,Commercial,,162.00,,,,,,,128.00,162.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,MedCost,Commercial,,122.00,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,inpatient,,,29.65000,17.79000,MedCost,Commercial,,24.02,,,,,,,8.92,24.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,MedCost,Commercial,,18.09,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Commercial,,1000.35,,,,,,,371.74,1004.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Commercial,,753.35,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Commercial,,848.88,,,,,,,315.45,852.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Commercial,,639.28,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,MedCost,Commercial,,572.67,,,,,,,212.81,574.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,MedCost,Commercial,,431.27,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,MedCost,Commercial,,445.50,,,,,,,165.55,447.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,MedCost,Commercial,,335.50,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,MedCost,Commercial,,358.02,,,,,,,133.04,359.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,MedCost,Commercial,,269.62,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,MedCost,Commercial,,377.46,,,,,,,140.27,378.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,MedCost,Commercial,,284.26,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Commercial,,1000.35,,,,,,,790.40,1004.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Commercial,,753.35,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Commercial,,848.88,,,,,,,670.72,852.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Commercial,,639.28,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,MedCost,Commercial,,572.67,,,,,,,452.48,574.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,MedCost,Commercial,,431.27,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,MedCost,Commercial,,445.50,,,,,,,352.00,447.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,MedCost,Commercial,,335.50,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,MedCost,Commercial,,358.02,,,,,,,282.88,359.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,MedCost,Commercial,,269.62,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,MedCost,Commercial,,377.46,,,,,,,298.24,378.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,MedCost,Commercial,,284.26,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,inpatient,,,27.47000,16.48000,MedCost,Commercial,,22.25,,,,,,,8.27,22.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,MedCost,Commercial,,16.76,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,MedCost,Commercial,,462.51,,,,,,,171.87,464.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,MedCost,Commercial,,348.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,MedCost,Commercial,,212.22,,,,,,,78.86,213.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,MedCost,Commercial,,159.82,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,2469.00000,1481.40000,MedCost,Commercial,,1999.89,,,,,,,743.17,2007.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,MedCost,Commercial,,1506.09,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,MedCost,Commercial,,565.38,,,,,,,210.10,567.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,MedCost,Commercial,,425.78,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,MedCost,Commercial,,565.38,,,,,,,446.72,567.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,MedCost,Commercial,,425.78,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,188.43,508.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,400.64,508.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,MedCost,Commercial,,498.15,,,,,,,185.12,500.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,MedCost,Commercial,,375.15,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,MedCost,Commercial,,498.15,,,,,,,393.60,500.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,MedCost,Commercial,,375.15,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,132.14,356.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,280.96,356.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,MedCost,Commercial,,323.19,,,,,,,120.10,324.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,MedCost,Commercial,,243.39,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,MedCost,Commercial,,323.19,,,,,,,255.36,324.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,MedCost,Commercial,,243.39,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,2363.00000,1417.80000,MedCost,Commercial,,1914.03,,,,,,,1512.32,1921.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,MedCost,Commercial,,1441.43,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,MedCost,Commercial,,462.51,,,,,,,365.44,464.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,MedCost,Commercial,,348.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,MedCost,Commercial,,212.22,,,,,,,167.68,213.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,MedCost,Commercial,,159.82,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,MedCost,Commercial,,253.53,,,,,,,94.21,254.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,MedCost,Commercial,,190.93,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,MedCost,Commercial,,253.53,,,,,,,200.32,254.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,MedCost,Commercial,,190.93,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Commercial,,1275.75,,,,,,,474.07,1280.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Commercial,,960.75,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Commercial,,1275.75,,,,,,,1008.00,1280.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Commercial,,960.75,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Commercial,,1014.12,,,,,,,376.85,1017.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Commercial,,763.72,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Commercial,,1014.12,,,,,,,801.28,1017.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Commercial,,763.72,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,MedCost,Commercial,,519.21,,,,,,,192.94,521.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,MedCost,Commercial,,391.01,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,MedCost,Commercial,,519.21,,,,,,,410.24,521.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,MedCost,Commercial,,391.01,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,MedCost,Commercial,,275.40,,,,,,,102.34,276.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,MedCost,Commercial,,207.40,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,MedCost,Commercial,,275.40,,,,,,,217.60,276.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,MedCost,Commercial,,207.40,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,MedCost,Commercial,,220.32,,,,,,,81.87,221.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,MedCost,Commercial,,165.92,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,MedCost,Commercial,,220.32,,,,,,,174.08,221.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,MedCost,Commercial,,165.92,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,inpatient,,,216.17000,129.70000,MedCost,Commercial,,175.10,,,,,,,65.07,175.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,MedCost,Commercial,,131.86,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,MedCost,Commercial,,737.91,,,,,,,583.04,740.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,MedCost,Commercial,,555.71,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,MedCost,Commercial,,368.55,,,,,,,291.20,369.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,MedCost,Commercial,,277.55,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,5187.00000,3112.20000,MedCost,Commercial,,4201.47,,,,,,,1561.29,4217.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,MedCost,Commercial,,3164.07,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,inpatient,,,153.80000,92.28000,MedCost,Commercial,,124.58,,,,,,,46.29,125.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,MedCost,Commercial,,93.82,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2562.00000,1537.20000,MedCost,Commercial,,2075.22,,,,,,,771.16,2082.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,MedCost,Commercial,,1562.82,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,MedCost,Commercial,,800.28,,,,,,,297.39,803.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,MedCost,Commercial,,602.68,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,188.43,508.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,82.17,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,inpatient,,,872.14000,523.28000,MedCost,Commercial,,706.43,,,,,,,262.51,709.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,MedCost,Commercial,,532.01,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,inpatient,,,1070.23000,642.14000,MedCost,Commercial,,866.89,,,,,,,322.14,870.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,MedCost,Commercial,,652.84,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,inpatient,,,2.18000,1.31000,MedCost,Commercial,,1.77,,,,,,,0.65618,1.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,MedCost,Commercial,,1.33,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,2078.00000,1246.80000,MedCost,Commercial,,1683.18,,,,,,,625.48,1689.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,MedCost,Commercial,,1267.58,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Commercial,,2230.74,,,,,,,828.95,2239.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Commercial,,1679.94,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Commercial,,984.96,,,,,,,366.02,988.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Commercial,,741.76,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,MedCost,Commercial,,498.96,,,,,,,185.42,500.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,MedCost,Commercial,,375.76,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Commercial,,2230.74,,,,,,,1762.56,2239.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Commercial,,1679.94,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Commercial,,984.96,,,,,,,778.24,988.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Commercial,,741.76,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,MedCost,Commercial,,498.96,,,,,,,394.24,500.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,MedCost,Commercial,,375.76,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,2813.00000,1687.80000,MedCost,Commercial,,2278.53,,,,,,,846.71,2286.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,MedCost,Commercial,,1715.93,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,inpatient,,,3.10000,1.86000,MedCost,Commercial,,2.51,,,,,,,0.93310,2.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,MedCost,Commercial,,1.89,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,9.84000,5.90000,MedCost,Commercial,,7.97,,,,,,,2.96,8.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,MedCost,Commercial,,6.00,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,inpatient,,,192.61000,115.57000,MedCost,Commercial,,156.01,,,,,,,123.27,156.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,MedCost,Commercial,,117.49,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,inpatient,,,66.43000,39.86000,MedCost,Commercial,,53.81,,,,,,,20.00,54.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,MedCost,Commercial,,40.52,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,MedCost,Commercial,,99.63,,,,,,,37.02,100.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,MedCost,Commercial,,75.03,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,inpatient,,,237.69000,142.61000,MedCost,Commercial,,192.53,,,,,,,71.54,193.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,MedCost,Commercial,,144.99,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,inpatient,,,273.90000,164.34000,MedCost,Commercial,,221.86,,,,,,,82.44,222.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,MedCost,Commercial,,167.08,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,inpatient,,,158.70000,95.22000,MedCost,Commercial,,128.55,,,,,,,47.77,129.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,MedCost,Commercial,,96.81,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,MedCost,Commercial,,277.02,,,,,,,102.94,278.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,MedCost,Commercial,,208.62,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,MedCost,Commercial,,277.02,,,,,,,218.88,278.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,MedCost,Commercial,,208.62,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Commercial,,1252.26,,,,,,,465.35,1256.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Commercial,,943.06,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,3094.00000,1856.40000,MedCost,Commercial,,2506.14,,,,,,,931.29,2515.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,MedCost,Commercial,,1887.34,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Commercial,,1252.26,,,,,,,989.44,1256.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Commercial,,943.06,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,inpatient,,,330.40000,198.24000,MedCost,Commercial,,267.62,,,,,,,99.45,268.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,MedCost,Commercial,,201.54,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,inpatient,,,329.28000,197.57000,MedCost,Commercial,,266.72,,,,,,,99.11,267.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,MedCost,Commercial,,200.86,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,inpatient,,,153.16000,91.90000,MedCost,Commercial,,124.06,,,,,,,46.10,124.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,MedCost,Commercial,,93.43,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,inpatient,,,158.82000,95.29000,MedCost,Commercial,,128.64,,,,,,,47.80,129.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,MedCost,Commercial,,96.88,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,MedCost,Commercial,,346.68,,,,,,,128.83,347.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,MedCost,Commercial,,261.08,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,MedCost,Commercial,,346.68,,,,,,,273.92,347.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,MedCost,Commercial,,261.08,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,145.38,392.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,309.12,392.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,10.00000,6.00000,MedCost,Commercial,,8.10,,,,,,,3.01,8.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,MedCost,Commercial,,6.10,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,inpatient,,,0.12000,0.07000,MedCost,Commercial,,0.09720,,,,,,,0.07680,0.09756,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,MedCost,Commercial,,0.07320,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,inpatient,,,0.27000,0.16000,MedCost,Commercial,,0.21870,,,,,,,0.17280,0.21951,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,MedCost,Commercial,,0.16470,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Commercial,,2023.38,,,,,,,751.90,2030.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Commercial,,1523.78,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Commercial,,2023.38,,,,,,,1598.72,2030.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Commercial,,1523.78,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Commercial,,1640.25,,,,,,,609.52,1646.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Commercial,,1235.25,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Commercial,,1640.25,,,,,,,1296.00,1646.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Commercial,,1235.25,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Commercial,,1383.48,,,,,,,514.11,1388.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Commercial,,1041.88,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Commercial,,1383.48,,,,,,,1093.12,1388.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Commercial,,1041.88,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00301,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,inpatient,,,322.28000,193.37000,MedCost,Commercial,,261.05,,,,,,,97.01,262.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,MedCost,Commercial,,196.59,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,19.57,52.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,inpatient,,,81.13000,48.68000,MedCost,Commercial,,65.72,,,,,,,24.42,65.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,MedCost,Commercial,,49.49,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,inpatient,,,53.52000,32.11000,MedCost,Commercial,,43.35,,,,,,,16.11,43.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,MedCost,Commercial,,32.65,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,inpatient,,,126.03000,75.62000,MedCost,Commercial,,102.08,,,,,,,37.94,102.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,MedCost,Commercial,,76.88,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,inpatient,,,30.86000,18.52000,MedCost,Commercial,,25.00,,,,,,,9.29,25.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,MedCost,Commercial,,18.82,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,inpatient,,,16.63000,9.98000,MedCost,Commercial,,13.47,,,,,,,5.01,13.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,MedCost,Commercial,,10.14,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,inpatient,,,116.79000,70.07000,MedCost,Commercial,,94.60,,,,,,,35.15,94.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,MedCost,Commercial,,71.24,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,inpatient,,,33.65000,20.19000,MedCost,Commercial,,27.26,,,,,,,10.13,27.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,MedCost,Commercial,,20.53,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,inpatient,,,96.04000,57.62000,MedCost,Commercial,,77.79,,,,,,,28.91,78.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,MedCost,Commercial,,58.58,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,inpatient,,,275.02000,165.01000,MedCost,Commercial,,222.77,,,,,,,82.78,223.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,MedCost,Commercial,,167.76,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,inpatient,,,42.62000,25.57000,MedCost,Commercial,,34.52,,,,,,,12.83,34.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,MedCost,Commercial,,26.00,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,inpatient,,,51.42000,30.85000,MedCost,Commercial,,41.65,,,,,,,15.48,41.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,MedCost,Commercial,,31.37,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,inpatient,,,166.08000,99.65000,MedCost,Commercial,,134.52,,,,,,,49.99,135.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,MedCost,Commercial,,101.31,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,inpatient,,,128.79000,77.27000,MedCost,Commercial,,104.32,,,,,,,38.77,104.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,MedCost,Commercial,,78.56,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,inpatient,,,154.18000,92.51000,MedCost,Commercial,,124.89,,,,,,,46.41,125.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,MedCost,Commercial,,94.05,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,inpatient,,,146.33000,87.80000,MedCost,Commercial,,118.53,,,,,,,44.05,118.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,MedCost,Commercial,,89.26,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,inpatient,,,26.14000,15.68000,MedCost,Commercial,,21.17,,,,,,,7.87,21.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,MedCost,Commercial,,15.95,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,inpatient,,,28.56000,17.14000,MedCost,Commercial,,23.13,,,,,,,8.60,23.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,MedCost,Commercial,,17.42,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,inpatient,,,68.05000,40.83000,MedCost,Commercial,,55.12,,,,,,,20.48,55.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,MedCost,Commercial,,41.51,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,inpatient,,,140.75000,84.45000,MedCost,Commercial,,114.01,,,,,,,42.37,114.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,MedCost,Commercial,,85.86,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,0.51000,0.31000,MedCost,Commercial,,0.41310,,,,,,,0.15351,0.41463,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,MedCost,Commercial,,0.31110,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,inpatient,,,26.23000,15.74000,MedCost,Commercial,,21.25,,,,,,,7.90,21.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,MedCost,Commercial,,16.00,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,inpatient,,,5.92000,3.55000,MedCost,Commercial,,4.80,,,,,,,1.78,4.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,MedCost,Commercial,,3.61,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,inpatient,,,10.52000,6.31000,MedCost,Commercial,,8.52,,,,,,,6.73,8.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,MedCost,Commercial,,6.42,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,inpatient,,,0.11000,0.07000,MedCost,Commercial,,0.08910,,,,,,,0.03311,0.08943,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,MedCost,Commercial,,0.06710,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,inpatient,,,0.80000,0.48000,MedCost,Commercial,,0.64800,,,,,,,0.24080,0.65040,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,MedCost,Commercial,,0.48800,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,inpatient,,,7.76000,4.66000,MedCost,Commercial,,6.29,,,,,,,2.34,6.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,MedCost,Commercial,,4.73,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,inpatient,,,0.79000,0.47000,MedCost,Commercial,,0.63990,,,,,,,0.23779,0.64227,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,MedCost,Commercial,,0.48190,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,0.47000,0.28000,MedCost,Commercial,,0.38070,,,,,,,0.14147,0.38211,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,MedCost,Commercial,,0.28670,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,inpatient,,,0.64000,0.38000,MedCost,Commercial,,0.51840,,,,,,,0.19264,0.52032,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,MedCost,Commercial,,0.39040,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,inpatient,,,1666.78000,1000.07000,MedCost,Commercial,,1350.09,,,,,,,501.70,1355.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,MedCost,Commercial,,1016.74,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,inpatient,,,0.02000,0.01000,MedCost,Commercial,,0.01620,,,,,,,0.00602,0.01626,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,MedCost,Commercial,,0.01220,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,inpatient,,,0.09000,0.05000,MedCost,Commercial,,0.07290,,,,,,,0.05760,0.07317,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,MedCost,Commercial,,0.05490,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,inpatient,,,2.57000,1.54000,MedCost,Commercial,,2.08,,,,,,,1.64,2.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,MedCost,Commercial,,1.57,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,inpatient,,,25.77000,15.46000,MedCost,Commercial,,20.87,,,,,,,7.76,20.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,MedCost,Commercial,,15.72,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,inpatient,,,81.46000,48.88000,MedCost,Commercial,,65.98,,,,,,,24.52,66.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,MedCost,Commercial,,49.69,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,0.07000,0.04000,MedCost,Commercial,,0.05670,,,,,,,0.02107,0.05691,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,MedCost,Commercial,,0.04270,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,inpatient,,,4.25000,2.55000,MedCost,Commercial,,3.44,,,,,,,1.28,3.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,MedCost,Commercial,,2.59,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,inpatient,,,6.12000,3.67000,MedCost,Commercial,,4.96,,,,,,,1.84,4.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,MedCost,Commercial,,3.73,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,inpatient,,,1.12000,0.67000,MedCost,Commercial,,0.90720,,,,,,,0.33712,0.91056,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,MedCost,Commercial,,0.68320,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,inpatient,,,1.61000,0.97000,MedCost,Commercial,,1.30,,,,,,,0.48461,1.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,MedCost,Commercial,,0.98210,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,inpatient,,,2.56000,1.54000,MedCost,Commercial,,2.07,,,,,,,0.77056,2.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,MedCost,Commercial,,1.56,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,inpatient,,,1.79000,1.07000,MedCost,Commercial,,1.45,,,,,,,0.53879,1.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,MedCost,Commercial,,1.09,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,inpatient,,,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,inpatient,,,0.02000,0.01000,MedCost,Commercial,,0.01620,,,,,,,0.00602,0.01626,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,MedCost,Commercial,,0.01220,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,inpatient,,,22.10000,13.26000,MedCost,Commercial,,17.90,,,,,,,6.65,17.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,MedCost,Commercial,,13.48,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,inpatient,,,1100.73000,660.44000,MedCost,Commercial,,891.59,,,,,,,331.32,894.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,MedCost,Commercial,,671.45,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,inpatient,,,77.03000,46.22000,MedCost,Commercial,,62.39,,,,,,,23.19,62.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,MedCost,Commercial,,46.99,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,inpatient,,,134.92000,80.95000,MedCost,Commercial,,109.29,,,,,,,40.61,109.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,MedCost,Commercial,,82.30,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,inpatient,,,166.43000,99.86000,MedCost,Commercial,,134.81,,,,,,,50.10,135.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,MedCost,Commercial,,101.52,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,inpatient,,,17.28000,10.37000,MedCost,Commercial,,14.00,,,,,,,5.20,14.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,MedCost,Commercial,,10.54,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,inpatient,,,0.13000,0.08000,MedCost,Commercial,,0.10530,,,,,,,0.03913,0.10569,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,MedCost,Commercial,,0.07930,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,inpatient,,,36.34000,21.80000,MedCost,Commercial,,29.44,,,,,,,10.94,29.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,MedCost,Commercial,,22.17,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,inpatient,,,65.26000,39.16000,MedCost,Commercial,,52.86,,,,,,,19.64,53.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,MedCost,Commercial,,39.81,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,inpatient,,,143.90000,86.34000,MedCost,Commercial,,116.56,,,,,,,43.31,116.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,MedCost,Commercial,,87.78,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,inpatient,,,63.57000,38.14000,MedCost,Commercial,,51.49,,,,,,,19.13,51.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,MedCost,Commercial,,38.78,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,inpatient,,,249.07000,149.44000,MedCost,Commercial,,201.75,,,,,,,74.97,202.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,MedCost,Commercial,,151.93,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,inpatient,,,11.23000,6.74000,MedCost,Commercial,,9.10,,,,,,,3.38,9.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,MedCost,Commercial,,6.85,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,inpatient,,,25.48000,15.29000,MedCost,Commercial,,20.64,,,,,,,7.67,20.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,MedCost,Commercial,,15.54,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,inpatient,,,0.75000,0.45000,MedCost,Commercial,,0.60750,,,,,,,0.22575,0.60975,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,MedCost,Commercial,,0.45750,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,inpatient,,,0.04000,0.02000,MedCost,Commercial,,0.03240,,,,,,,0.01204,0.03252,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,MedCost,Commercial,,0.02440,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,inpatient,,,15.12000,9.07000,MedCost,Commercial,,12.25,,,,,,,9.68,12.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,MedCost,Commercial,,9.22,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,inpatient,,,13.35000,8.01000,MedCost,Commercial,,10.81,,,,,,,4.02,10.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,MedCost,Commercial,,8.14,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,inpatient,,,11.89000,7.13000,MedCost,Commercial,,9.63,,,,,,,3.58,9.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,MedCost,Commercial,,7.25,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,inpatient,,,17.69000,10.61000,MedCost,Commercial,,14.33,,,,,,,5.32,14.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,MedCost,Commercial,,10.79,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,inpatient,,,33.35000,20.01000,MedCost,Commercial,,27.01,,,,,,,10.04,27.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,MedCost,Commercial,,20.34,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,inpatient,,,54.96000,32.98000,MedCost,Commercial,,44.52,,,,,,,16.54,44.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,MedCost,Commercial,,33.53,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,inpatient,,,139.15000,83.49000,MedCost,Commercial,,112.71,,,,,,,41.88,113.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,MedCost,Commercial,,84.88,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,inpatient,25,ML,548.70000,329.22000,MedCost,Commercial,,444.45,,,,,,,165.16,446.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,MedCost,Commercial,,334.71,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,inpatient,5,ML,316.25000,189.75000,MedCost,Commercial,,256.16,,,,,,,95.19,257.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,MedCost,Commercial,,192.91,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,inpatient,1,UN,371.25000,222.75000,MedCost,Commercial,,300.71,,,,,,,111.75,301.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,MedCost,Commercial,,226.46,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,inpatient,1,UN,82.95000,49.77000,MedCost,Commercial,,67.19,,,,,,,24.97,67.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,MedCost,Commercial,,50.60,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,inpatient,1,ML,64.90000,38.94000,MedCost,Commercial,,52.57,,,,,,,19.53,52.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,MedCost,Commercial,,39.59,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,inpatient,1,ML,64.90000,38.94000,MedCost,Commercial,,52.57,,,,,,,19.53,52.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,MedCost,Commercial,,39.59,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,inpatient,50,ML,47.50000,28.50000,MedCost,Commercial,,38.48,,,,,,,30.40,38.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,MedCost,Commercial,,28.98,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,inpatient,1,UN,1.20000,0.72000,MedCost,Commercial,,0.97200,,,,,,,0.76800,0.97560,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,MedCost,Commercial,,0.73200,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,MedCost,Commercial,,2373.10,,,,,,,881.85,2381.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,MedCost,Commercial,,1787.15,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,MedCost,Commercial,,15756.00,,,,,,,5855.01,15814.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,MedCost,Commercial,,11865.63,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,13.41,,,,,,,10.59,13.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,10.10,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,16.04,,,,,,,12.67,16.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,12.08,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,14.82,,,,,,,11.71,14.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,11.16,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,16.20,,,,,,,12.80,16.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,12.20,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,inpatient,1,UN,21.35000,12.81000,MedCost,Commercial,,17.29,,,,,,,13.66,17.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,MedCost,Commercial,,13.02,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,inpatient,100,ML,128.45000,77.07000,MedCost,Commercial,,104.04,,,,,,,38.66,104.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,MedCost,Commercial,,78.35,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,inpatient,1,ML,84.10000,50.46000,MedCost,Commercial,,68.12,,,,,,,25.31,68.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,MedCost,Commercial,,51.30,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,inpatient,1,UN,350.70000,210.42000,MedCost,Commercial,,284.07,,,,,,,224.45,285.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,MedCost,Commercial,,213.93,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,inpatient,1,UN,385.55000,231.33000,MedCost,Commercial,,312.30,,,,,,,246.75,313.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,MedCost,Commercial,,235.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,inpatient,1,UN,19.40000,11.64000,MedCost,Commercial,,15.71,,,,,,,12.42,15.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,MedCost,Commercial,,11.83,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,inpatient,1,UN,3544.00000,2126.40000,MedCost,Commercial,,2870.64,,,,,,,1066.74,2881.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,MedCost,Commercial,,2161.84,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,inpatient,5,ML,304.25000,182.55000,MedCost,Commercial,,246.44,,,,,,,91.58,247.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,MedCost,Commercial,,185.59,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,inpatient,5,ML,43.45000,26.07000,MedCost,Commercial,,35.19,,,,,,,27.81,35.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,MedCost,Commercial,,26.50,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,13.16,,,,,,,10.40,13.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,9.91,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,13.12,,,,,,,10.37,13.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,9.88,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,inpatient,10,ML,2414.30000,1448.58000,MedCost,Commercial,,1955.58,,,,,,,726.70,1962.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,MedCost,Commercial,,1472.72,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,inpatient,1,UN,18.05000,10.83000,MedCost,Commercial,,14.62,,,,,,,11.55,14.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,MedCost,Commercial,,11.01,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,inpatient,1,UN,471.55000,282.93000,MedCost,Commercial,,381.96,,,,,,,141.94,383.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,MedCost,Commercial,,287.65,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,14.01,,,,,,,11.07,14.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,10.55,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,13.65,,,,,,,10.78,13.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,10.28,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,13.41,,,,,,,10.59,13.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,10.10,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,inpatient,1,UN,5220.40000,3132.24000,MedCost,Commercial,,4228.52,,,,,,,1571.34,4244.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,MedCost,Commercial,,3184.44,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,13.65,,,,,,,10.78,13.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,10.28,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,inpatient,0.5,ML,79.90000,47.94000,MedCost,Commercial,,64.72,,,,,,,24.05,64.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,MedCost,Commercial,,48.74,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,inpatient,1,ML,33.65000,20.19000,MedCost,Commercial,,27.26,,,,,,,10.13,27.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,MedCost,Commercial,,20.53,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,inpatient,10,ML,34.85000,20.91000,MedCost,Commercial,,28.23,,,,,,,10.49,28.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,MedCost,Commercial,,21.26,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,inpatient,30,ML,47.00000,28.20000,MedCost,Commercial,,38.07,,,,,,,14.15,38.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,MedCost,Commercial,,28.67,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,inpatient,1,ML,19.85000,11.91000,MedCost,Commercial,,16.08,,,,,,,5.97,16.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,MedCost,Commercial,,12.11,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,inpatient,1,ML,25.20000,15.12000,MedCost,Commercial,,20.41,,,,,,,7.59,20.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,MedCost,Commercial,,15.37,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,inpatient,60,ML,80.30000,48.18000,MedCost,Commercial,,65.04,,,,,,,51.39,65.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,MedCost,Commercial,,48.98,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,inpatient,4,ML,32.40000,19.44000,MedCost,Commercial,,26.24,,,,,,,20.74,26.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,MedCost,Commercial,,19.76,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,inpatient,1,UN,23.80000,14.28000,MedCost,Commercial,,19.28,,,,,,,15.23,19.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,MedCost,Commercial,,14.52,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,inpatient,1,UN,28.70000,17.22000,MedCost,Commercial,,23.25,,,,,,,18.37,23.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,MedCost,Commercial,,17.51,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,inpatient,5,ML,2.25000,1.35000,MedCost,Commercial,,1.82,,,,,,,1.44,1.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,MedCost,Commercial,,1.37,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,inpatient,1,UN,436.70000,262.02000,MedCost,Commercial,,353.73,,,,,,,131.45,355.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,MedCost,Commercial,,266.39,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,inpatient,1,UN,748.20000,448.92000,MedCost,Commercial,,606.04,,,,,,,225.21,608.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,MedCost,Commercial,,456.40,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,inpatient,1,UN,2284.55000,1370.73000,MedCost,Commercial,,1850.49,,,,,,,1462.11,1857.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,MedCost,Commercial,,1393.58,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,177.39,,,,,,,65.92,178.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,133.59,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,177.39,,,,,,,65.92,178.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,133.59,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,177.39,,,,,,,65.92,178.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,133.59,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,inpatient,1,UN,1.50000,0.90000,MedCost,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,MedCost,Commercial,,0.91500,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,inpatient,50,ML,49.45000,29.67000,MedCost,Commercial,,40.05,,,,,,,31.65,40.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,MedCost,Commercial,,30.16,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,inpatient,50,ML,57.55000,34.53000,MedCost,Commercial,,46.62,,,,,,,36.83,46.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,MedCost,Commercial,,35.11,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,inpatient,0.5,ML,568.50000,341.10000,MedCost,Commercial,,460.49,,,,,,,171.12,462.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,MedCost,Commercial,,346.79,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,inpatient,1,UN,21.80000,13.08000,MedCost,Commercial,,17.66,,,,,,,13.95,17.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,MedCost,Commercial,,13.30,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,inpatient,1,UN,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,inpatient,1,UN,24.65000,14.79000,MedCost,Commercial,,19.97,,,,,,,15.78,20.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,MedCost,Commercial,,15.04,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,11.42,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,inpatient,226,GR,7.00000,4.20000,MedCost,Commercial,,5.67,,,,,,,4.48,5.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,MedCost,Commercial,,4.27,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,14.82,,,,,,,11.71,14.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,11.16,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,inpatient,1,UN,2.60000,1.56000,MedCost,Commercial,,2.11,,,,,,,1.66,2.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,MedCost,Commercial,,1.59,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,inpatient,1,UN,18.05000,10.83000,MedCost,Commercial,,14.62,,,,,,,11.55,14.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,MedCost,Commercial,,11.01,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,inpatient,1,UN,18.40000,11.04000,MedCost,Commercial,,14.90,,,,,,,11.78,14.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,MedCost,Commercial,,11.22,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,inpatient,2,ML,26.75000,16.05000,MedCost,Commercial,,21.67,,,,,,,8.05,21.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,MedCost,Commercial,,16.32,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,inpatient,30,ML,30.90000,18.54000,MedCost,Commercial,,25.03,,,,,,,9.30,25.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,MedCost,Commercial,,18.85,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,inpatient,5,ML,23.80000,14.28000,MedCost,Commercial,,19.28,,,,,,,7.16,19.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,MedCost,Commercial,,14.52,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,inpatient,10,ML,47.55000,28.53000,MedCost,Commercial,,38.52,,,,,,,14.31,38.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,MedCost,Commercial,,29.01,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,inpatient,2,ML,29.35000,17.61000,MedCost,Commercial,,23.77,,,,,,,8.83,23.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,MedCost,Commercial,,17.90,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,MedCost,Commercial,,26.20,,,,,,,9.74,26.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,MedCost,Commercial,,19.73,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,inpatient,1,UN,2741.35000,1644.81000,MedCost,Commercial,,2220.49,,,,,,,825.15,2228.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,MedCost,Commercial,,1672.22,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,inpatient,1,ML,17.75000,10.65000,MedCost,Commercial,,14.38,,,,,,,5.34,14.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,MedCost,Commercial,,10.83,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,inpatient,1,ML,16.75000,10.05000,MedCost,Commercial,,13.57,,,,,,,5.04,13.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,MedCost,Commercial,,10.22,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,inpatient,1,ML,17.00000,10.20000,MedCost,Commercial,,13.77,,,,,,,5.12,13.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,MedCost,Commercial,,10.37,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,inpatient,1,ML,21.35000,12.81000,MedCost,Commercial,,17.29,,,,,,,6.43,17.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,MedCost,Commercial,,13.02,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,inpatient,5,GR,40.80000,24.48000,MedCost,Commercial,,33.05,,,,,,,26.11,33.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,MedCost,Commercial,,24.89,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,inpatient,1,ML,1839.60000,1103.76000,MedCost,Commercial,,1490.08,,,,,,,1177.34,1495.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,MedCost,Commercial,,1122.16,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,inpatient,1,UN,16.15000,9.69000,MedCost,Commercial,,13.08,,,,,,,10.34,13.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,MedCost,Commercial,,9.85,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,inpatient,1,UN,17.35000,10.41000,MedCost,Commercial,,14.05,,,,,,,11.10,14.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,MedCost,Commercial,,10.58,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,inpatient,1,UN,17.75000,10.65000,MedCost,Commercial,,14.38,,,,,,,11.36,14.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,MedCost,Commercial,,10.83,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,inpatient,1,UN,32.75000,19.65000,MedCost,Commercial,,26.53,,,,,,,20.96,26.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,MedCost,Commercial,,19.98,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,inpatient,1,UN,246.90000,148.14000,MedCost,Commercial,,199.99,,,,,,,158.02,200.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,MedCost,Commercial,,150.61,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,inpatient,1,UN,1.65000,0.99000,MedCost,Commercial,,1.34,,,,,,,1.06,1.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,MedCost,Commercial,,1.01,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,MedCost,Commercial,,18.79,,,,,,,6.98,18.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,MedCost,Commercial,,14.15,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,inpatient,0.25,ML,22.75000,13.65000,MedCost,Commercial,,18.43,,,,,,,6.85,18.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,MedCost,Commercial,,13.88,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,inpatient,5,ML,20322.25000,12193.35000,MedCost,Commercial,,16461.02,,,,,,,6117.00,16521.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,MedCost,Commercial,,12396.57,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,inpatient,1,UN,32.00000,19.20000,MedCost,Commercial,,25.92,,,,,,,20.48,26.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,MedCost,Commercial,,19.52,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,1.17,,,,,,,0.92800,1.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,0.88450,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,inpatient,2.5,ML,157.85000,94.71000,MedCost,Commercial,,127.86,,,,,,,101.02,128.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,MedCost,Commercial,,96.29,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,inpatient,1,UN,300.90000,180.54000,MedCost,Commercial,,243.73,,,,,,,90.57,244.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,MedCost,Commercial,,183.55,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,MedCost,Commercial,,2004.75,,,,,,,744.98,2012.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,MedCost,Commercial,,1509.75,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,inpatient,1,UN,70.30000,42.18000,MedCost,Commercial,,56.94,,,,,,,21.16,57.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,MedCost,Commercial,,42.88,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,inpatient,30,ML,84.80000,50.88000,MedCost,Commercial,,68.69,,,,,,,25.52,68.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,MedCost,Commercial,,51.73,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,37.70000,22.62000,MedCost,Commercial,,30.54,,,,,,,24.13,30.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,MedCost,Commercial,,23.00,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,inpatient,60,ML,46.10000,27.66000,MedCost,Commercial,,37.34,,,,,,,29.50,37.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,MedCost,Commercial,,28.12,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,inpatient,10,ML,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,115.89,313.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,inpatient,1,UN,774.35000,464.61000,MedCost,Commercial,,627.22,,,,,,,233.08,629.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,MedCost,Commercial,,472.35,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,13.12,,,,,,,10.37,13.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,9.88,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,inpatient,10,ML,50.85000,30.51000,MedCost,Commercial,,41.19,,,,,,,32.54,41.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,MedCost,Commercial,,31.02,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,inpatient,30,ML,68.85000,41.31000,MedCost,Commercial,,55.77,,,,,,,44.06,55.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,MedCost,Commercial,,42.00,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,inpatient,30,ML,66.65000,39.99000,MedCost,Commercial,,53.99,,,,,,,20.06,54.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,MedCost,Commercial,,40.66,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,inpatient,20,ML,72.25000,43.35000,MedCost,Commercial,,58.52,,,,,,,21.75,58.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,MedCost,Commercial,,44.07,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,inpatient,10,ML,39.65000,23.79000,MedCost,Commercial,,32.12,,,,,,,11.93,32.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,MedCost,Commercial,,24.19,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,inpatient,30,ML,28.15000,16.89000,MedCost,Commercial,,22.80,,,,,,,8.47,22.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,MedCost,Commercial,,17.17,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,inpatient,6,ML,60837.10000,36502.26000,MedCost,Commercial,,49278.05,,,,,,,18311.97,49460.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,MedCost,Commercial,,37110.63,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,inpatient,1,UN,798.05000,478.83000,MedCost,Commercial,,646.42,,,,,,,510.75,648.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,MedCost,Commercial,,486.81,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,inpatient,1,ML,158.35000,95.01000,MedCost,Commercial,,128.26,,,,,,,47.66,128.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,MedCost,Commercial,,96.59,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,inpatient,1,UN,231.15000,138.69000,MedCost,Commercial,,187.23,,,,,,,147.94,187.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,MedCost,Commercial,,141.00,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,inpatient,1,UN,520.25000,312.15000,MedCost,Commercial,,421.40,,,,,,,156.60,422.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,MedCost,Commercial,,317.35,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,inpatient,1,UN,19.60000,11.76000,MedCost,Commercial,,15.88,,,,,,,12.54,15.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,MedCost,Commercial,,11.96,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,inpatient,1,UN,27.00000,16.20000,MedCost,Commercial,,21.87,,,,,,,17.28,21.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,MedCost,Commercial,,16.47,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,inpatient,1,UN,28.45000,17.07000,MedCost,Commercial,,23.04,,,,,,,18.21,23.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,MedCost,Commercial,,17.35,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,inpatient,0.3,ML,49.90000,29.94000,MedCost,Commercial,,40.42,,,,,,,15.02,40.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,MedCost,Commercial,,30.44,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,inpatient,0.4,ML,61.20000,36.72000,MedCost,Commercial,,49.57,,,,,,,18.42,49.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,MedCost,Commercial,,37.33,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,inpatient,0.6,ML,83.85000,50.31000,MedCost,Commercial,,67.92,,,,,,,25.24,68.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,MedCost,Commercial,,51.15,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,inpatient,0.8,ML,106.45000,63.87000,MedCost,Commercial,,86.22,,,,,,,32.04,86.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,MedCost,Commercial,,64.93,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,inpatient,1,ML,129.05000,77.43000,MedCost,Commercial,,104.53,,,,,,,38.84,104.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,MedCost,Commercial,,78.72,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,inpatient,0.8,ML,70.85000,42.51000,MedCost,Commercial,,57.39,,,,,,,21.33,57.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,MedCost,Commercial,,43.22,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,inpatient,70,GR,76.10000,45.66000,MedCost,Commercial,,61.64,,,,,,,48.70,61.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,MedCost,Commercial,,46.42,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,inpatient,1,UN,21.20000,12.72000,MedCost,Commercial,,17.17,,,,,,,13.57,17.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,MedCost,Commercial,,12.93,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,16.04,,,,,,,12.67,16.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,12.08,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,inpatient,1,UN,1235.40000,741.24000,MedCost,Commercial,,1000.67,,,,,,,371.86,1004.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,MedCost,Commercial,,753.59,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,inpatient,1,UN,2341.05000,1404.63000,MedCost,Commercial,,1896.25,,,,,,,704.66,1903.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,MedCost,Commercial,,1428.04,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,inpatient,71,GR,8.50000,5.10000,MedCost,Commercial,,6.88,,,,,,,5.44,6.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,MedCost,Commercial,,5.18,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,inpatient,1,UN,171.00000,102.60000,MedCost,Commercial,,138.51,,,,,,,109.44,139.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,MedCost,Commercial,,104.31,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,MedCost,Commercial,,34.59,,,,,,,12.85,34.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,MedCost,Commercial,,26.05,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,13.77,,,,,,,10.88,13.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,10.37,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,inpatient,1,UN,20.60000,12.36000,MedCost,Commercial,,16.69,,,,,,,13.18,16.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,MedCost,Commercial,,12.57,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,inpatient,1,UN,37.05000,22.23000,MedCost,Commercial,,30.01,,,,,,,23.71,30.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,MedCost,Commercial,,22.60,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,inpatient,1,UN,37.25000,22.35000,MedCost,Commercial,,30.17,,,,,,,23.84,30.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,MedCost,Commercial,,22.72,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,inpatient,3.5,GR,70.05000,42.03000,MedCost,Commercial,,56.74,,,,,,,44.83,56.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,MedCost,Commercial,,42.73,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,inpatient,2,ML,123.00000,73.80000,MedCost,Commercial,,99.63,,,,,,,37.02,100.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,MedCost,Commercial,,75.03,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,inpatient,1,UN,3055.75000,1833.45000,MedCost,Commercial,,2475.16,,,,,,,919.78,2484.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,MedCost,Commercial,,1864.01,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,MedCost,Commercial,,4727.52,,,,,,,1756.77,4745.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,MedCost,Commercial,,3560.23,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,inpatient,1,UN,1345.40000,807.24000,MedCost,Commercial,,1089.77,,,,,,,404.97,1093.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,MedCost,Commercial,,820.69,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,inpatient,2,ML,21.50000,12.90000,MedCost,Commercial,,17.41,,,,,,,6.47,17.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,MedCost,Commercial,,13.12,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,inpatient,1,ML,64.55000,38.73000,MedCost,Commercial,,52.29,,,,,,,19.43,52.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,MedCost,Commercial,,39.38,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,inpatient,50,ML,35.60000,21.36000,MedCost,Commercial,,28.84,,,,,,,10.72,28.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,MedCost,Commercial,,21.72,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,inpatient,10,ML,33.35000,20.01000,MedCost,Commercial,,27.01,,,,,,,21.34,27.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,MedCost,Commercial,,20.34,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,inpatient,30,ML,34.05000,20.43000,MedCost,Commercial,,27.58,,,,,,,21.79,27.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,MedCost,Commercial,,20.77,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,inpatient,1,UN,29.25000,17.55000,MedCost,Commercial,,23.69,,,,,,,18.72,23.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,MedCost,Commercial,,17.84,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,inpatient,1,UN,29.25000,17.55000,MedCost,Commercial,,23.69,,,,,,,18.72,23.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,MedCost,Commercial,,17.84,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,inpatient,1,UN,2420.70000,1452.42000,MedCost,Commercial,,1960.77,,,,,,,728.63,1968.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,MedCost,Commercial,,1476.63,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,inpatient,2,ML,6479.00000,3887.40000,MedCost,Commercial,,5247.99,,,,,,,1950.18,5267.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,MedCost,Commercial,,3952.19,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,inpatient,1,UN,168.00000,100.80000,MedCost,Commercial,,136.08,,,,,,,50.57,136.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,MedCost,Commercial,,102.48,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,inpatient,1,UN,27.55000,16.53000,MedCost,Commercial,,22.32,,,,,,,17.63,22.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,MedCost,Commercial,,16.81,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,inpatient,5,ML,63.70000,38.22000,MedCost,Commercial,,51.60,,,,,,,40.77,51.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,MedCost,Commercial,,38.86,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,inpatient,1,UN,1.50000,0.90000,MedCost,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,MedCost,Commercial,,0.91500,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,1.17,,,,,,,0.92800,1.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,0.88450,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,inpatient,1,UN,27.50000,16.50000,MedCost,Commercial,,22.27,,,,,,,17.60,22.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,MedCost,Commercial,,16.77,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,inpatient,1,UN,31.45000,18.87000,MedCost,Commercial,,25.47,,,,,,,20.13,25.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,MedCost,Commercial,,19.18,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,inpatient,4,ML,157.40000,94.44000,MedCost,Commercial,,127.49,,,,,,,100.74,127.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,MedCost,Commercial,,96.01,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,inpatient,1,UN,23.45000,14.07000,MedCost,Commercial,,18.99,,,,,,,15.01,19.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,MedCost,Commercial,,14.30,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,inpatient,1,UN,102.95000,61.77000,MedCost,Commercial,,83.39,,,,,,,65.89,83.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,MedCost,Commercial,,62.80,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,inpatient,473,ML,585.05000,351.03000,MedCost,Commercial,,473.89,,,,,,,374.43,475.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,MedCost,Commercial,,356.88,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,inpatient,1,UN,180.90000,108.54000,MedCost,Commercial,,146.53,,,,,,,115.78,147.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,MedCost,Commercial,,110.35,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,inpatient,1,UN,260.30000,156.18000,MedCost,Commercial,,210.84,,,,,,,166.59,211.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,MedCost,Commercial,,158.78,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,inpatient,1,UN,205.20000,123.12000,MedCost,Commercial,,166.21,,,,,,,131.33,166.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,MedCost,Commercial,,125.17,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,926.92,,,,,,,344.45,930.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,698.05,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,inpatient,1,UN,18.20000,10.92000,MedCost,Commercial,,14.74,,,,,,,11.65,14.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,MedCost,Commercial,,11.10,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,inpatient,15,ML,100.95000,60.57000,MedCost,Commercial,,81.77,,,,,,,64.61,82.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,MedCost,Commercial,,61.58,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,inpatient,500,ML,178.50000,107.10000,MedCost,Commercial,,144.59,,,,,,,114.24,145.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,MedCost,Commercial,,108.89,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,inpatient,473,ML,525.45000,315.27000,MedCost,Commercial,,425.61,,,,,,,336.29,427.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,MedCost,Commercial,,320.52,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,inpatient,1,UN,1.55000,0.93000,MedCost,Commercial,,1.26,,,,,,,0.99200,1.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,MedCost,Commercial,,0.94550,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,inpatient,100,ML,101.15000,60.69000,MedCost,Commercial,,81.93,,,,,,,30.45,82.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,MedCost,Commercial,,61.70,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,inpatient,0.6,ML,263.20000,157.92000,MedCost,Commercial,,213.19,,,,,,,79.22,213.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,MedCost,Commercial,,160.55,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,inpatient,0.8,ML,263.20000,157.92000,MedCost,Commercial,,213.19,,,,,,,79.22,213.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,MedCost,Commercial,,160.55,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,inpatient,0.6,ML,881.50000,528.90000,MedCost,Commercial,,714.01,,,,,,,265.33,716.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,MedCost,Commercial,,537.72,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,inpatient,0.025,GR,58.50000,35.10000,MedCost,Commercial,,47.38,,,,,,,37.44,47.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,MedCost,Commercial,,35.69,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,inpatient,0.42,ML,896.45000,537.87000,MedCost,Commercial,,726.12,,,,,,,269.83,728.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,MedCost,Commercial,,546.83,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,inpatient,0.4,ML,1424.70000,854.82000,MedCost,Commercial,,1154.01,,,,,,,428.83,1158.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,MedCost,Commercial,,869.07,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,inpatient,0.3,ML,2129.05000,1277.43000,MedCost,Commercial,,1724.53,,,,,,,640.84,1730.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,MedCost,Commercial,,1298.72,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,inpatient,0.5,ML,3537.70000,2122.62000,MedCost,Commercial,,2865.54,,,,,,,1064.85,2876.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,MedCost,Commercial,,2158.00,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,inpatient,0.4,ML,7059.40000,4235.64000,MedCost,Commercial,,5718.11,,,,,,,2124.88,5739.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,MedCost,Commercial,,4306.23,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,inpatient,0.6,ML,10581.10000,6348.66000,MedCost,Commercial,,8570.69,,,,,,,3184.91,8602.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,MedCost,Commercial,,6454.47,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,inpatient,2,ML,1695.15000,1017.09000,MedCost,Commercial,,1373.07,,,,,,,510.24,1378.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,MedCost,Commercial,,1034.04,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,inpatient,5,ML,8246.30000,4947.78000,MedCost,Commercial,,6679.50,,,,,,,2482.14,6704.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,MedCost,Commercial,,5030.24,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,inpatient,20,ML,32160.05000,19296.03000,MedCost,Commercial,,26049.64,,,,,,,9680.18,26146.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,MedCost,Commercial,,19617.63,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,MedCost,Commercial,,4568.60,,,,,,,1697.72,4585.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,MedCost,Commercial,,3440.55,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,MedCost,Commercial,,9086.13,,,,,,,3376.45,9119.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,MedCost,Commercial,,6842.64,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,MedCost,Commercial,,258.27,,,,,,,95.97,259.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,MedCost,Commercial,,194.50,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,MedCost,Commercial,,258.27,,,,,,,95.97,259.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,MedCost,Commercial,,194.50,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,inpatient,10,ML,8806.85000,5284.11000,MedCost,Commercial,,7133.55,,,,,,,2650.86,7159.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,MedCost,Commercial,,5372.18,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,inpatient,2.5,ML,16.30000,9.78000,MedCost,Commercial,,13.20,,,,,,,10.43,13.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,MedCost,Commercial,,9.94,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,inpatient,100,ML,83.30000,49.98000,MedCost,Commercial,,67.47,,,,,,,25.07,67.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,MedCost,Commercial,,50.81,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,inpatient,150,ML,101.35000,60.81000,MedCost,Commercial,,82.09,,,,,,,30.51,82.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,MedCost,Commercial,,61.82,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,inpatient,0.5,ML,153.95000,92.37000,MedCost,Commercial,,124.70,,,,,,,46.34,125.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,MedCost,Commercial,,93.91,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,inpatient,5,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,inpatient,1,UN,23.35000,14.01000,MedCost,Commercial,,18.91,,,,,,,14.94,18.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,MedCost,Commercial,,14.24,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,inpatient,0.05,ML,18.70000,11.22000,MedCost,Commercial,,15.15,,,,,,,5.63,15.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,MedCost,Commercial,,11.41,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,inpatient,1,UN,115.90000,69.54000,MedCost,Commercial,,93.88,,,,,,,74.18,94.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,MedCost,Commercial,,70.70,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,inpatient,1,UN,141.95000,85.17000,MedCost,Commercial,,114.98,,,,,,,42.73,115.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,MedCost,Commercial,,86.59,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,14.01,,,,,,,11.07,14.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,10.55,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,inpatient,4,ML,884.70000,530.82000,MedCost,Commercial,,716.61,,,,,,,266.29,719.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,MedCost,Commercial,,539.67,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,1.13,,,,,,,0.89600,1.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,0.85400,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,MedCost,Commercial,,32493.88,,,,,,,12074.89,32614.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,MedCost,Commercial,,24470.70,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,MedCost,Commercial,,129306.86,,,,,,,48051.07,129785.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,MedCost,Commercial,,97379.24,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,inpatient,1,ML,985.50000,591.30000,MedCost,Commercial,,798.25,,,,,,,296.64,801.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,MedCost,Commercial,,601.15,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,inpatient,30,ML,2.00000,1.20000,MedCost,Commercial,,1.62,,,,,,,1.28,1.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,MedCost,Commercial,,1.22,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,inpatient,30,ML,1.75000,1.05000,MedCost,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,MedCost,Commercial,,1.07,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,inpatient,30,ML,1.70000,1.02000,MedCost,Commercial,,1.38,,,,,,,1.09,1.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,MedCost,Commercial,,1.04,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,inpatient,30,ML,1.60000,0.96000,MedCost,Commercial,,1.30,,,,,,,1.02,1.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,MedCost,Commercial,,0.97600,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,inpatient,50,ML,100.65000,60.39000,MedCost,Commercial,,81.53,,,,,,,30.30,81.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,MedCost,Commercial,,61.40,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,193.80000,116.28000,MedCost,Commercial,,156.98,,,,,,,58.33,157.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,MedCost,Commercial,,118.22,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,inpatient,1,UN,13260.65000,7956.39000,MedCost,Commercial,,10741.13,,,,,,,3991.46,10780.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,MedCost,Commercial,,8089.00,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,inpatient,60,GR,106.00000,63.60000,MedCost,Commercial,,85.86,,,,,,,67.84,86.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,MedCost,Commercial,,64.66,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,inpatient,59,ML,13.75000,8.25000,MedCost,Commercial,,11.14,,,,,,,8.80,11.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,MedCost,Commercial,,8.39,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,inpatient,1,UN,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,inpatient,1,UN,2245.35000,1347.21000,MedCost,Commercial,,1818.73,,,,,,,675.85,1825.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,MedCost,Commercial,,1369.66,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,inpatient,1,UN,86.05000,51.63000,MedCost,Commercial,,69.70,,,,,,,55.07,69.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,MedCost,Commercial,,52.49,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,inpatient,60,ML,709.90000,425.94000,MedCost,Commercial,,575.02,,,,,,,213.68,577.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,MedCost,Commercial,,433.04,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,inpatient,1,UN,213.80000,128.28000,MedCost,Commercial,,173.18,,,,,,,136.83,173.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,MedCost,Commercial,,130.42,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,inpatient,0.2,ML,60.60000,36.36000,MedCost,Commercial,,49.09,,,,,,,18.24,49.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,MedCost,Commercial,,36.97,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,inpatient,1,UN,95.75000,57.45000,MedCost,Commercial,,77.56,,,,,,,61.28,77.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,MedCost,Commercial,,58.41,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,inpatient,100,ML,184.45000,110.67000,MedCost,Commercial,,149.40,,,,,,,55.52,149.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,MedCost,Commercial,,112.51,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,inpatient,200,ML,224.70000,134.82000,MedCost,Commercial,,182.01,,,,,,,67.63,182.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,MedCost,Commercial,,137.07,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,inpatient,1,UN,60.25000,36.15000,MedCost,Commercial,,48.80,,,,,,,38.56,48.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,MedCost,Commercial,,36.75,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,inpatient,1,UN,1057.00000,634.20000,MedCost,Commercial,,856.17,,,,,,,676.48,859.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,MedCost,Commercial,,644.77,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,1.17,,,,,,,0.92800,1.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,0.88450,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,inpatient,1,UN,47.00000,28.20000,MedCost,Commercial,,38.07,,,,,,,30.08,38.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,MedCost,Commercial,,28.67,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,inpatient,1,UN,1.20000,0.72000,MedCost,Commercial,,0.97200,,,,,,,0.76800,0.97560,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,MedCost,Commercial,,0.73200,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,inpatient,1,UN,3.10000,1.86000,MedCost,Commercial,,2.51,,,,,,,1.98,2.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,MedCost,Commercial,,1.89,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,inpatient,100,ML,80.15000,48.09000,MedCost,Commercial,,64.92,,,,,,,51.30,64.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,MedCost,Commercial,,48.89,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,inpatient,100,ML,77.35000,46.41000,MedCost,Commercial,,62.65,,,,,,,23.28,62.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,MedCost,Commercial,,47.18,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,inpatient,50,ML,76.30000,45.78000,MedCost,Commercial,,61.80,,,,,,,22.97,62.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,MedCost,Commercial,,46.54,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,inpatient,100,ML,77.35000,46.41000,MedCost,Commercial,,62.65,,,,,,,23.28,62.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,MedCost,Commercial,,47.18,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,MedCost,Commercial,,82.22,,,,,,,30.55,82.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,MedCost,Commercial,,61.91,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,inpatient,1000,ML,105.00000,63.00000,MedCost,Commercial,,85.05,,,,,,,31.61,85.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,MedCost,Commercial,,64.05,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,inpatient,60,ML,471.60000,282.96000,MedCost,Commercial,,382.00,,,,,,,301.82,383.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,MedCost,Commercial,,287.68,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,14.82,,,,,,,11.71,14.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,11.16,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,inpatient,1,UN,281.75000,169.05000,MedCost,Commercial,,228.22,,,,,,,180.32,229.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,MedCost,Commercial,,171.87,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,15.63,,,,,,,12.35,15.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,11.77,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,inpatient,1,UN,56048.55000,33629.13000,MedCost,Commercial,,45399.33,,,,,,,16870.61,45567.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,MedCost,Commercial,,34189.62,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,inpatient,1,UN,55.00000,33.00000,MedCost,Commercial,,44.55,,,,,,,35.20,44.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,MedCost,Commercial,,33.55,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,inpatient,1,UN,4464.60000,2678.76000,MedCost,Commercial,,3616.33,,,,,,,1343.84,3629.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,MedCost,Commercial,,2723.41,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,inpatient,1,UN,55.00000,33.00000,MedCost,Commercial,,44.55,,,,,,,35.20,44.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,MedCost,Commercial,,33.55,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,inpatient,100,ML,70.60000,42.36000,MedCost,Commercial,,57.19,,,,,,,21.25,57.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,MedCost,Commercial,,43.07,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,inpatient,20,ML,26.95000,16.17000,MedCost,Commercial,,21.83,,,,,,,8.11,21.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,MedCost,Commercial,,16.44,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,inpatient,1,UN,1.50000,0.90000,MedCost,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,MedCost,Commercial,,0.91500,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,inpatient,0.2,ML,31.40000,18.84000,MedCost,Commercial,,25.43,,,,,,,20.10,25.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,MedCost,Commercial,,19.15,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,15.63,,,,,,,12.35,15.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,11.77,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,inpatient,0.1,ML,67.75000,40.65000,MedCost,Commercial,,54.88,,,,,,,43.36,55.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,MedCost,Commercial,,41.33,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,inpatient,1,UN,29.80000,17.88000,MedCost,Commercial,,24.14,,,,,,,19.07,24.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,MedCost,Commercial,,18.18,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,inpatient,10,ML,1113.90000,668.34000,MedCost,Commercial,,902.26,,,,,,,335.28,905.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,MedCost,Commercial,,679.48,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,inpatient,20,ML,1830.00000,1098.00000,MedCost,Commercial,,1482.30,,,,,,,550.83,1487.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,MedCost,Commercial,,1116.30,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,inpatient,5.26,ML,316.10000,189.66000,MedCost,Commercial,,256.04,,,,,,,95.15,256.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,MedCost,Commercial,,192.82,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,inpatient,26.3,ML,474.30000,284.58000,MedCost,Commercial,,384.18,,,,,,,142.76,385.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,MedCost,Commercial,,289.32,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,inpatient,1,UN,95.75000,57.45000,MedCost,Commercial,,77.56,,,,,,,61.28,77.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,MedCost,Commercial,,58.41,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,inpatient,1,UN,95.75000,57.45000,MedCost,Commercial,,77.56,,,,,,,61.28,77.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,MedCost,Commercial,,58.41,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,inpatient,1,UN,710.25000,426.15000,MedCost,Commercial,,575.30,,,,,,,213.79,577.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,MedCost,Commercial,,433.25,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,inpatient,1,UN,28.75000,17.25000,MedCost,Commercial,,23.29,,,,,,,18.40,23.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,MedCost,Commercial,,17.54,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,inpatient,1,UN,23.45000,14.07000,MedCost,Commercial,,18.99,,,,,,,15.01,19.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,MedCost,Commercial,,14.30,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,inpatient,1,UN,565.00000,339.00000,MedCost,Commercial,,457.65,,,,,,,361.60,459.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,MedCost,Commercial,,344.65,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,inpatient,1,UN,1198.35000,719.01000,MedCost,Commercial,,970.66,,,,,,,766.94,974.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,MedCost,Commercial,,730.99,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,inpatient,1000,ML,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,inpatient,1,UN,4.10000,2.46000,MedCost,Commercial,,3.32,,,,,,,2.62,3.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,MedCost,Commercial,,2.50,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,inpatient,1,UN,568.80000,341.28000,MedCost,Commercial,,460.73,,,,,,,171.21,462.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,MedCost,Commercial,,346.97,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,inpatient,100,ML,112.00000,67.20000,MedCost,Commercial,,90.72,,,,,,,33.71,91.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,MedCost,Commercial,,68.32,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,inpatient,100,ML,168.00000,100.80000,MedCost,Commercial,,136.08,,,,,,,50.57,136.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,MedCost,Commercial,,102.48,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,13.73,,,,,,,10.85,13.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,10.34,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,14.30,,,,,,,11.30,14.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,10.77,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,inpatient,1,UN,205.20000,123.12000,MedCost,Commercial,,166.21,,,,,,,131.33,166.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,MedCost,Commercial,,125.17,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,inpatient,1,UN,609.65000,365.79000,MedCost,Commercial,,493.82,,,,,,,183.50,495.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,MedCost,Commercial,,371.89,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,19.26,52.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,inpatient,1,UN,159.35000,95.61000,MedCost,Commercial,,129.07,,,,,,,47.96,129.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,MedCost,Commercial,,97.20,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,inpatient,1000,ML,87.00000,52.20000,MedCost,Commercial,,70.47,,,,,,,55.68,70.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,MedCost,Commercial,,53.07,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,inpatient,1000,ML,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,174.72,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,inpatient,0.05,ML,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,inpatient,425,GR,4.30000,2.58000,MedCost,Commercial,,3.48,,,,,,,2.75,3.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,MedCost,Commercial,,2.62,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,inpatient,1,UN,21.10000,12.66000,MedCost,Commercial,,17.09,,,,,,,13.50,17.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,MedCost,Commercial,,12.87,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,11.26,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,13.65,,,,,,,10.78,13.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,10.28,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,inpatient,5,ML,28.75000,17.25000,MedCost,Commercial,,23.29,,,,,,,18.40,23.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,MedCost,Commercial,,17.54,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,inpatient,5,ML,28.75000,17.25000,MedCost,Commercial,,23.29,,,,,,,18.40,23.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,MedCost,Commercial,,17.54,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,14.01,,,,,,,11.07,14.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,10.55,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,inpatient,1,UN,30.00000,18.00000,MedCost,Commercial,,24.30,,,,,,,19.20,24.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,MedCost,Commercial,,18.30,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,inpatient,1,ML,34.20000,20.52000,MedCost,Commercial,,27.70,,,,,,,10.29,27.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,MedCost,Commercial,,20.86,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,inpatient,45,GR,123.50000,74.10000,MedCost,Commercial,,100.03,,,,,,,79.04,100.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,MedCost,Commercial,,75.33,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,inpatient,1,UN,124.90000,74.94000,MedCost,Commercial,,101.17,,,,,,,79.94,101.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,MedCost,Commercial,,76.19,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,inpatient,10,ML,48.85000,29.31000,MedCost,Commercial,,39.57,,,,,,,31.26,39.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,MedCost,Commercial,,29.80,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,inpatient,15,ML,61.95000,37.17000,MedCost,Commercial,,50.18,,,,,,,39.65,50.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,MedCost,Commercial,,37.79,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,inpatient,5,ML,31.55000,18.93000,MedCost,Commercial,,25.56,,,,,,,20.19,25.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,MedCost,Commercial,,19.25,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,inpatient,15,ML,77.55000,46.53000,MedCost,Commercial,,62.82,,,,,,,49.63,63.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,MedCost,Commercial,,47.31,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,inpatient,1,UN,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,114.38,308.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,MedCost,Commercial,,231.80,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,inpatient,3.5,GR,910.30000,546.18000,MedCost,Commercial,,737.34,,,,,,,582.59,740.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,MedCost,Commercial,,555.28,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,inpatient,2.5,ML,167.75000,100.65000,MedCost,Commercial,,135.88,,,,,,,107.36,136.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,MedCost,Commercial,,102.33,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,inpatient,5,ML,320.20000,192.12000,MedCost,Commercial,,259.36,,,,,,,204.93,260.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,MedCost,Commercial,,195.32,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,inpatient,10,ML,88.20000,52.92000,MedCost,Commercial,,71.44,,,,,,,56.45,71.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,MedCost,Commercial,,53.80,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,inpatient,7.5,ML,604.05000,362.43000,MedCost,Commercial,,489.28,,,,,,,386.59,491.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,MedCost,Commercial,,368.47,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,25404.55000,15242.73000,MedCost,Commercial,,20577.69,,,,,,,7646.77,20653.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,MedCost,Commercial,,15496.78,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,inpatient,1,UN,1854.60000,1112.76000,MedCost,Commercial,,1502.23,,,,,,,558.23,1507.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,MedCost,Commercial,,1131.31,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,inpatient,1,UN,21.00000,12.60000,MedCost,Commercial,,17.01,,,,,,,13.44,17.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,MedCost,Commercial,,12.81,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,inpatient,1,UN,961.85000,577.11000,MedCost,Commercial,,779.10,,,,,,,289.52,781.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,MedCost,Commercial,,586.73,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,inpatient,2.5,ML,24.95000,14.97000,MedCost,Commercial,,20.21,,,,,,,15.97,20.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,MedCost,Commercial,,15.22,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,inpatient,1,UN,84.65000,50.79000,MedCost,Commercial,,68.57,,,,,,,54.18,68.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,MedCost,Commercial,,51.64,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,inpatient,1,ML,36.05000,21.63000,MedCost,Commercial,,29.20,,,,,,,10.85,29.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,MedCost,Commercial,,21.99,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,14.01,,,,,,,11.07,14.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,10.55,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,inpatient,1,ML,1651.20000,990.72000,MedCost,Commercial,,1337.47,,,,,,,1056.77,1342.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,MedCost,Commercial,,1007.23,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,14,ML,30285.20000,18171.12000,MedCost,Commercial,,24531.01,,,,,,,9115.85,24621.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,MedCost,Commercial,,18473.97,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,14.18,,,,,,,11.20,14.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,10.68,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,inpatient,10,ML,31.65000,18.99000,MedCost,Commercial,,25.64,,,,,,,20.26,25.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,MedCost,Commercial,,19.31,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,inpatient,100,ML,53.35000,32.01000,MedCost,Commercial,,43.21,,,,,,,34.14,43.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,MedCost,Commercial,,32.54,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,inpatient,20,ML,38.05000,22.83000,MedCost,Commercial,,30.82,,,,,,,24.35,30.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,MedCost,Commercial,,23.21,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,inpatient,40,ML,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,11.42,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,inpatient,50,ML,48.10000,28.86000,MedCost,Commercial,,38.96,,,,,,,30.78,39.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,MedCost,Commercial,,29.34,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,inpatient,5,ML,72.05000,43.23000,MedCost,Commercial,,58.36,,,,,,,21.69,58.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,MedCost,Commercial,,43.95,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,inpatient,1,UN,77.40000,46.44000,MedCost,Commercial,,62.69,,,,,,,49.54,62.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,MedCost,Commercial,,47.21,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,inpatient,20,ML,185.65000,111.39000,MedCost,Commercial,,150.38,,,,,,,55.88,150.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,MedCost,Commercial,,113.25,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,inpatient,10,ML,20.50000,12.30000,MedCost,Commercial,,16.61,,,,,,,13.12,16.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,MedCost,Commercial,,12.51,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,inpatient,1,UN,22.35000,13.41000,MedCost,Commercial,,18.10,,,,,,,14.30,18.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,MedCost,Commercial,,13.63,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,inpatient,1,UN,22.30000,13.38000,MedCost,Commercial,,18.06,,,,,,,14.27,18.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,MedCost,Commercial,,13.60,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,inpatient,2,ML,320.55000,192.33000,MedCost,Commercial,,259.65,,,,,,,96.49,260.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,MedCost,Commercial,,195.54,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,inpatient,40,ML,438.00000,262.80000,MedCost,Commercial,,354.78,,,,,,,131.84,356.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,MedCost,Commercial,,267.18,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,MedCost,Commercial,,12829.31,,,,,,,4767.43,12876.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,MedCost,Commercial,,9661.58,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,inpatient,1,UN,107.45000,64.47000,MedCost,Commercial,,87.03,,,,,,,68.77,87.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,MedCost,Commercial,,65.54,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,inpatient,1,ML,2063.50000,1238.10000,MedCost,Commercial,,1671.43,,,,,,,1320.64,1677.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,MedCost,Commercial,,1258.73,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,inpatient,5,ML,2746.00000,1647.60000,MedCost,Commercial,,2224.26,,,,,,,1757.44,2232.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,MedCost,Commercial,,1675.06,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,21.34,,,,,,,7.93,21.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,16.07,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,inpatient,10,ML,196.20000,117.72000,MedCost,Commercial,,158.92,,,,,,,125.57,159.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,MedCost,Commercial,,119.68,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,inpatient,0.25,ML,18.10000,10.86000,MedCost,Commercial,,14.66,,,,,,,11.58,14.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,MedCost,Commercial,,11.04,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,inpatient,1,UN,2.70000,1.62000,MedCost,Commercial,,2.19,,,,,,,1.73,2.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,MedCost,Commercial,,1.65,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,inpatient,1,UN,60.00000,36.00000,MedCost,Commercial,,48.60,,,,,,,18.06,48.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,MedCost,Commercial,,36.60,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,inpatient,50,ML,32.20000,19.32000,MedCost,Commercial,,26.08,,,,,,,9.69,26.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,MedCost,Commercial,,19.64,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,inpatient,2.5,ML,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,inpatient,0.5,ML,22.30000,13.38000,MedCost,Commercial,,18.06,,,,,,,6.71,18.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,MedCost,Commercial,,13.60,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,inpatient,30,ML,87.55000,52.53000,MedCost,Commercial,,70.92,,,,,,,26.35,71.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,MedCost,Commercial,,53.41,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,inpatient,25,ML,115.20000,69.12000,MedCost,Commercial,,93.31,,,,,,,73.73,93.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,MedCost,Commercial,,70.27,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,inpatient,10,ML,1.30000,0.78000,MedCost,Commercial,,1.05,,,,,,,0.83200,1.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,MedCost,Commercial,,0.79300,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,inpatient,10,ML,49.70000,29.82000,MedCost,Commercial,,40.26,,,,,,,31.81,40.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,MedCost,Commercial,,30.32,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,inpatient,5,ML,36.10000,21.66000,MedCost,Commercial,,29.24,,,,,,,23.10,29.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,MedCost,Commercial,,22.02,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,inpatient,10,ML,147.95000,88.77000,MedCost,Commercial,,119.84,,,,,,,44.53,120.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,MedCost,Commercial,,90.25,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,inpatient,5,ML,1.55000,0.93000,MedCost,Commercial,,1.26,,,,,,,0.99200,1.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,MedCost,Commercial,,0.94550,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,inpatient,5,ML,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,inpatient,1,UN,1.75000,1.05000,MedCost,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,MedCost,Commercial,,1.07,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,inpatient,1,ML,16.35000,9.81000,MedCost,Commercial,,13.24,,,,,,,10.46,13.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,MedCost,Commercial,,9.97,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,inpatient,1,UN,207.05000,124.23000,MedCost,Commercial,,167.71,,,,,,,132.51,168.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,MedCost,Commercial,,126.30,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,inpatient,5,ML,22.65000,13.59000,MedCost,Commercial,,18.35,,,,,,,14.50,18.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,MedCost,Commercial,,13.82,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,inpatient,1,UN,24.60000,14.76000,MedCost,Commercial,,19.93,,,,,,,15.74,20.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,MedCost,Commercial,,15.01,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,inpatient,1,ML,32.10000,19.26000,MedCost,Commercial,,26.00,,,,,,,9.66,26.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,MedCost,Commercial,,19.58,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,14.01,,,,,,,11.07,14.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,10.55,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,inpatient,2.5,ML,551.10000,330.66000,MedCost,Commercial,,446.39,,,,,,,352.70,448.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,MedCost,Commercial,,336.17,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,inpatient,10,ML,26.80000,16.08000,MedCost,Commercial,,21.71,,,,,,,8.07,21.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,MedCost,Commercial,,16.35,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,inpatient,30,ML,23.95000,14.37000,MedCost,Commercial,,19.40,,,,,,,7.21,19.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,MedCost,Commercial,,14.61,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,inpatient,50,ML,29.45000,17.67000,MedCost,Commercial,,23.85,,,,,,,8.86,23.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,MedCost,Commercial,,17.96,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,inpatient,10,ML,43.10000,25.86000,MedCost,Commercial,,34.91,,,,,,,12.97,35.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,MedCost,Commercial,,26.29,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,inpatient,30,ML,53.45000,32.07000,MedCost,Commercial,,43.29,,,,,,,16.09,43.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,MedCost,Commercial,,32.60,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,inpatient,25,ML,60.85000,36.51000,MedCost,Commercial,,49.29,,,,,,,38.94,49.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,MedCost,Commercial,,37.12,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,inpatient,300,ML,178.50000,107.10000,MedCost,Commercial,,144.59,,,,,,,53.73,145.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,MedCost,Commercial,,108.89,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,inpatient,4,ML,508.10000,304.86000,MedCost,Commercial,,411.56,,,,,,,325.18,413.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,MedCost,Commercial,,309.94,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,inpatient,2,ML,53.10000,31.86000,MedCost,Commercial,,43.01,,,,,,,15.98,43.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,MedCost,Commercial,,32.39,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,inpatient,0.25,ML,24.70000,14.82000,MedCost,Commercial,,20.01,,,,,,,7.43,20.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,MedCost,Commercial,,15.07,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,MedCost,Commercial,,24.14,,,,,,,8.97,24.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,MedCost,Commercial,,18.18,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,inpatient,3,ML,61.25000,36.75000,MedCost,Commercial,,49.61,,,,,,,39.20,49.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,MedCost,Commercial,,37.36,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,inpatient,3,ML,27.90000,16.74000,MedCost,Commercial,,22.60,,,,,,,17.86,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,MedCost,Commercial,,17.02,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,inpatient,10,ML,170.20000,102.12000,MedCost,Commercial,,137.86,,,,,,,51.23,138.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,MedCost,Commercial,,103.82,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,MedCost,Commercial,,289.37,,,,,,,107.53,290.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,MedCost,Commercial,,217.92,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,MedCost,Commercial,,936.40,,,,,,,347.97,939.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,MedCost,Commercial,,705.19,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,inpatient,50,GR,8.60000,5.16000,MedCost,Commercial,,6.97,,,,,,,5.50,6.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,MedCost,Commercial,,5.25,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,inpatient,114,GR,16.55000,9.93000,MedCost,Commercial,,13.41,,,,,,,10.59,13.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,MedCost,Commercial,,10.10,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,13.20,,,,,,,10.43,13.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,9.94,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,inpatient,5,ML,118261.70000,70957.02000,MedCost,Commercial,,95791.98,,,,,,,35596.77,96146.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,MedCost,Commercial,,72139.64,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,inpatient,5,ML,125.45000,75.27000,MedCost,Commercial,,101.61,,,,,,,80.29,101.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,MedCost,Commercial,,76.52,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,inpatient,50,ML,750.85000,450.51000,MedCost,Commercial,,608.19,,,,,,,480.54,610.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,MedCost,Commercial,,458.02,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,inpatient,118,ML,10.00000,6.00000,MedCost,Commercial,,8.10,,,,,,,6.40,8.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,MedCost,Commercial,,6.10,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,inpatient,236,ML,14.95000,8.97000,MedCost,Commercial,,12.11,,,,,,,9.57,12.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,MedCost,Commercial,,9.12,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,inpatient,100,ML,76.65000,45.99000,MedCost,Commercial,,62.09,,,,,,,23.07,62.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,MedCost,Commercial,,46.76,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,inpatient,500,ML,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,53.76,68.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,inpatient,14.1,GR,5.35000,3.21000,MedCost,Commercial,,4.33,,,,,,,3.42,4.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,MedCost,Commercial,,3.26,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,inpatient,2.5,ML,17.20000,10.32000,MedCost,Commercial,,13.93,,,,,,,11.01,13.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,MedCost,Commercial,,10.49,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,inpatient,1,ML,40.15000,24.09000,MedCost,Commercial,,32.52,,,,,,,12.09,32.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,MedCost,Commercial,,24.49,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,inpatient,1,ML,44.70000,26.82000,MedCost,Commercial,,36.21,,,,,,,13.45,36.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,MedCost,Commercial,,27.27,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,inpatient,0.75,ML,36.40000,21.84000,MedCost,Commercial,,29.48,,,,,,,10.96,29.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,MedCost,Commercial,,22.20,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,inpatient,100,ML,84.90000,50.94000,MedCost,Commercial,,68.77,,,,,,,54.34,68.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,MedCost,Commercial,,51.79,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,inpatient,50,ML,84.75000,50.85000,MedCost,Commercial,,68.65,,,,,,,54.24,68.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,MedCost,Commercial,,51.70,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,inpatient,100,ML,84.90000,50.94000,MedCost,Commercial,,68.77,,,,,,,54.34,68.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,MedCost,Commercial,,51.79,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,inpatient,50,ML,82.95000,49.77000,MedCost,Commercial,,67.19,,,,,,,53.09,67.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,MedCost,Commercial,,50.60,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,inpatient,1,UN,1052.35000,631.41000,MedCost,Commercial,,852.40,,,,,,,316.76,855.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,MedCost,Commercial,,641.93,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,inpatient,3,ML,5389.95000,3233.97000,MedCost,Commercial,,4365.86,,,,,,,3449.57,4382.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,MedCost,Commercial,,3287.87,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,inpatient,5,ML,3636.80000,2182.08000,MedCost,Commercial,,2945.81,,,,,,,1094.68,2956.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,MedCost,Commercial,,2218.45,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,inpatient,5,ML,33.10000,19.86000,MedCost,Commercial,,26.81,,,,,,,9.96,26.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,MedCost,Commercial,,20.19,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,inpatient,1,UN,15765.00000,9459.00000,MedCost,Commercial,,12769.65,,,,,,,4745.27,12816.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,MedCost,Commercial,,9616.65,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,inpatient,1,UN,2.90000,1.74000,MedCost,Commercial,,2.35,,,,,,,1.86,2.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,MedCost,Commercial,,1.77,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,inpatient,0.1,ML,21.05000,12.63000,MedCost,Commercial,,17.05,,,,,,,6.34,17.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,MedCost,Commercial,,12.84,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,inpatient,0.5,ML,430.80000,258.48000,MedCost,Commercial,,348.95,,,,,,,129.67,350.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,MedCost,Commercial,,262.79,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,inpatient,1,ML,236.50000,141.90000,MedCost,Commercial,,191.56,,,,,,,71.19,192.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,MedCost,Commercial,,144.26,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,inpatient,1,ML,64.90000,38.94000,MedCost,Commercial,,52.57,,,,,,,19.53,52.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,MedCost,Commercial,,39.59,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,inpatient,50,ML,108.00000,64.80000,MedCost,Commercial,,87.48,,,,,,,32.51,87.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,MedCost,Commercial,,65.88,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,inpatient,3.5,GR,12.40000,7.44000,MedCost,Commercial,,10.04,,,,,,,7.94,10.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,MedCost,Commercial,,7.56,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,inpatient,0.5,ML,144.25000,86.55000,MedCost,Commercial,,116.84,,,,,,,43.42,117.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,MedCost,Commercial,,87.99,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,inpatient,500,ML,289.80000,173.88000,MedCost,Commercial,,234.74,,,,,,,185.47,235.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,MedCost,Commercial,,176.78,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,inpatient,1,ML,2673.70000,1604.22000,MedCost,Commercial,,2165.70,,,,,,,804.78,2173.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,MedCost,Commercial,,1630.96,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,inpatient,1000,ML,87.50000,52.50000,MedCost,Commercial,,70.88,,,,,,,26.34,71.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,MedCost,Commercial,,53.38,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,inpatient,44.3,ML,9.75000,5.85000,MedCost,Commercial,,7.90,,,,,,,6.24,7.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,MedCost,Commercial,,5.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,inpatient,50,ML,3336.40000,2001.84000,MedCost,Commercial,,2702.48,,,,,,,1004.26,2712.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,MedCost,Commercial,,2035.20,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,inpatient,5,ML,23.65000,14.19000,MedCost,Commercial,,19.16,,,,,,,15.14,19.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,MedCost,Commercial,,14.43,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,inpatient,5,ML,30.90000,18.54000,MedCost,Commercial,,25.03,,,,,,,19.78,25.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,MedCost,Commercial,,18.85,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,MedCost,Commercial,,277.67,,,,,,,103.18,278.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,MedCost,Commercial,,209.11,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,inpatient,100,ML,818.20000,490.92000,MedCost,Commercial,,662.74,,,,,,,246.28,665.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,MedCost,Commercial,,499.10,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,inpatient,5,ML,319.70000,191.82000,MedCost,Commercial,,258.96,,,,,,,96.23,259.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,MedCost,Commercial,,195.02,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,inpatient,2,ML,984.90000,590.94000,MedCost,Commercial,,797.77,,,,,,,630.34,800.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,MedCost,Commercial,,600.79,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,20.33,,,,,,,16.06,20.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,15.31,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,inpatient,1,UN,1360.75000,816.45000,MedCost,Commercial,,1102.21,,,,,,,409.59,1106.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,MedCost,Commercial,,830.06,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,inpatient,10,ML,87.50000,52.50000,MedCost,Commercial,,70.88,,,,,,,26.34,71.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,MedCost,Commercial,,53.38,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,inpatient,5,ML,217.35000,130.41000,MedCost,Commercial,,176.05,,,,,,,139.10,176.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,MedCost,Commercial,,132.58,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,inpatient,5,ML,38.40000,23.04000,MedCost,Commercial,,31.10,,,,,,,11.56,31.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,MedCost,Commercial,,23.42,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,inpatient,5,ML,39.20000,23.52000,MedCost,Commercial,,31.75,,,,,,,25.09,31.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,MedCost,Commercial,,23.91,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,inpatient,6,ML,6247.80000,3748.68000,MedCost,Commercial,,5060.72,,,,,,,1880.59,5079.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,MedCost,Commercial,,3811.16,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,inpatient,1,UN,18.80000,11.28000,MedCost,Commercial,,15.23,,,,,,,12.03,15.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,MedCost,Commercial,,11.47,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,inpatient,1,UN,20.80000,12.48000,MedCost,Commercial,,16.85,,,,,,,13.31,16.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,MedCost,Commercial,,12.69,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,inpatient,11.6,ML,9504.40000,5702.64000,MedCost,Commercial,,7698.56,,,,,,,6082.82,7727.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,MedCost,Commercial,,5797.68,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,inpatient,10.15,ML,3.85000,2.31000,MedCost,Commercial,,3.12,,,,,,,2.46,3.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,MedCost,Commercial,,2.35,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,inpatient,3,ML,57.75000,34.65000,MedCost,Commercial,,46.78,,,,,,,36.96,46.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,MedCost,Commercial,,35.23,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,MedCost,Commercial,,36.81,,,,,,,13.68,36.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,MedCost,Commercial,,27.72,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,MedCost,Commercial,,51.39,,,,,,,19.10,51.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,MedCost,Commercial,,38.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,inpatient,1,UN,262.00000,157.20000,MedCost,Commercial,,212.22,,,,,,,78.86,213.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,MedCost,Commercial,,159.82,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,inpatient,1,UN,352.50000,211.50000,MedCost,Commercial,,285.52,,,,,,,106.10,286.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,MedCost,Commercial,,215.03,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,inpatient,113,GR,10.85000,6.51000,MedCost,Commercial,,8.79,,,,,,,6.94,8.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,MedCost,Commercial,,6.62,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,inpatient,50,ML,298.60000,179.16000,MedCost,Commercial,,241.87,,,,,,,191.10,242.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,MedCost,Commercial,,182.15,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,inpatient,15,ML,1.65000,0.99000,MedCost,Commercial,,1.34,,,,,,,1.06,1.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,MedCost,Commercial,,1.01,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,15,ML,1.40000,0.84000,MedCost,Commercial,,1.13,,,,,,,0.89600,1.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,MedCost,Commercial,,0.85400,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,inpatient,15,ML,1.60000,0.96000,MedCost,Commercial,,1.30,,,,,,,1.02,1.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,MedCost,Commercial,,0.97600,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,inpatient,30,ML,46.30000,27.78000,MedCost,Commercial,,37.50,,,,,,,13.94,37.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,MedCost,Commercial,,28.24,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,inpatient,1,UN,218.65000,131.19000,MedCost,Commercial,,177.11,,,,,,,65.81,177.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,MedCost,Commercial,,133.38,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,inpatient,250,ML,179.40000,107.64000,MedCost,Commercial,,145.31,,,,,,,114.82,145.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,MedCost,Commercial,,109.43,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,99.80000,59.88000,MedCost,Commercial,,80.84,,,,,,,30.04,81.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,MedCost,Commercial,,60.88,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,inpatient,1,UN,1.30000,0.78000,MedCost,Commercial,,1.05,,,,,,,0.83200,1.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,MedCost,Commercial,,0.79300,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,inpatient,50,ML,155.95000,93.57000,MedCost,Commercial,,126.32,,,,,,,46.94,126.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,MedCost,Commercial,,95.13,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,inpatient,5,ML,40.35000,24.21000,MedCost,Commercial,,32.68,,,,,,,25.82,32.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,MedCost,Commercial,,24.61,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,inpatient,1,UN,22.00000,13.20000,MedCost,Commercial,,17.82,,,,,,,6.62,17.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,MedCost,Commercial,,13.42,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,inpatient,1,ML,64.75000,38.85000,MedCost,Commercial,,52.45,,,,,,,19.49,52.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,MedCost,Commercial,,39.50,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,inpatient,200,ML,11976.20000,7185.72000,MedCost,Commercial,,9700.72,,,,,,,3604.84,9736.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,MedCost,Commercial,,7305.48,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,inpatient,4,ML,57.65000,34.59000,MedCost,Commercial,,46.70,,,,,,,36.90,46.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,MedCost,Commercial,,35.17,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,inpatient,0.5,ML,34.20000,20.52000,MedCost,Commercial,,27.70,,,,,,,10.29,27.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,MedCost,Commercial,,20.86,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,inpatient,250,ML,80.50000,48.30000,MedCost,Commercial,,65.20,,,,,,,24.23,65.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,MedCost,Commercial,,49.10,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,inpatient,0.25,ML,23.65000,14.19000,MedCost,Commercial,,19.16,,,,,,,7.12,19.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,MedCost,Commercial,,14.43,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,inpatient,1,UN,9718.80000,5831.28000,MedCost,Commercial,,7872.23,,,,,,,2925.36,7901.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,MedCost,Commercial,,5928.47,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,inpatient,1,UN,249.90000,149.94000,MedCost,Commercial,,202.42,,,,,,,75.22,203.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,MedCost,Commercial,,152.44,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,inpatient,8,ML,1.30000,0.78000,MedCost,Commercial,,1.05,,,,,,,0.83200,1.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,MedCost,Commercial,,0.79300,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,inpatient,8,ML,7.35000,4.41000,MedCost,Commercial,,5.95,,,,,,,4.70,5.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,MedCost,Commercial,,4.48,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,inpatient,250,ML,137.85000,82.71000,MedCost,Commercial,,111.66,,,,,,,41.49,112.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,MedCost,Commercial,,84.09,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,inpatient,5,ML,18.50000,11.10000,MedCost,Commercial,,14.98,,,,,,,11.84,15.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,MedCost,Commercial,,11.29,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,inpatient,10,ML,80.75000,48.45000,MedCost,Commercial,,65.41,,,,,,,51.68,65.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,MedCost,Commercial,,49.26,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,inpatient,10,ML,86.00000,51.60000,MedCost,Commercial,,69.66,,,,,,,55.04,69.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,MedCost,Commercial,,52.46,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,inpatient,250,ML,180.00000,108.00000,MedCost,Commercial,,145.80,,,,,,,115.20,146.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,MedCost,Commercial,,109.80,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,inpatient,250,ML,97.15000,58.29000,MedCost,Commercial,,78.69,,,,,,,62.18,78.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,MedCost,Commercial,,59.26,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,MedCost,Commercial,,15756.00,,,,,,,5855.01,15814.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,MedCost,Commercial,,11865.63,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,inpatient,10,ML,159.05000,95.43000,MedCost,Commercial,,128.83,,,,,,,101.79,129.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,MedCost,Commercial,,97.02,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,inpatient,10,ML,93.85000,56.31000,MedCost,Commercial,,76.02,,,,,,,28.25,76.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,MedCost,Commercial,,57.25,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,inpatient,0.25,ML,70.45000,42.27000,MedCost,Commercial,,57.06,,,,,,,21.21,57.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,MedCost,Commercial,,42.97,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,5,ML,74.35000,44.61000,MedCost,Commercial,,60.22,,,,,,,22.38,60.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,MedCost,Commercial,,45.35,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,inpatient,5,ML,74.35000,44.61000,MedCost,Commercial,,60.22,,,,,,,22.38,60.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,MedCost,Commercial,,45.35,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,inpatient,5,ML,84.05000,50.43000,MedCost,Commercial,,68.08,,,,,,,25.30,68.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,MedCost,Commercial,,51.27,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,11.26,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,inpatient,60,GR,11.80000,7.08000,MedCost,Commercial,,9.56,,,,,,,7.55,9.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,MedCost,Commercial,,7.20,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,inpatient,1,UN,18.05000,10.83000,MedCost,Commercial,,14.62,,,,,,,11.55,14.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,MedCost,Commercial,,11.01,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,14.30,,,,,,,11.30,14.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,10.77,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,inpatient,1,UN,24.10000,14.46000,MedCost,Commercial,,19.52,,,,,,,15.42,19.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,MedCost,Commercial,,14.70,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,inpatient,15,ML,11.05000,6.63000,MedCost,Commercial,,8.95,,,,,,,7.07,8.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,MedCost,Commercial,,6.74,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,inpatient,1,UN,8199.90000,4919.94000,MedCost,Commercial,,6641.92,,,,,,,2468.17,6666.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,MedCost,Commercial,,5001.94,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,inpatient,1,UN,20.15000,12.09000,MedCost,Commercial,,16.32,,,,,,,12.90,16.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,MedCost,Commercial,,12.29,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,inpatient,1,UN,16.75000,10.05000,MedCost,Commercial,,13.57,,,,,,,10.72,13.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,MedCost,Commercial,,10.22,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,inpatient,1,UN,61.70000,37.02000,MedCost,Commercial,,49.98,,,,,,,39.49,50.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,MedCost,Commercial,,37.64,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,inpatient,500,ML,373.50000,224.10000,MedCost,Commercial,,302.54,,,,,,,239.04,303.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,MedCost,Commercial,,227.84,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,inpatient,1,ML,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,115.89,313.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,inpatient,35,ML,192.55000,115.53000,MedCost,Commercial,,155.97,,,,,,,123.23,156.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,MedCost,Commercial,,117.46,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,inpatient,1,UN,70.35000,42.21000,MedCost,Commercial,,56.98,,,,,,,21.18,57.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,MedCost,Commercial,,42.91,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,inpatient,1,UN,66.30000,39.78000,MedCost,Commercial,,53.70,,,,,,,19.96,53.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,MedCost,Commercial,,40.44,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,inpatient,10,ML,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,inpatient,1,UN,16.75000,10.05000,MedCost,Commercial,,13.57,,,,,,,10.72,13.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,MedCost,Commercial,,10.22,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,inpatient,1,UN,16.75000,10.05000,MedCost,Commercial,,13.57,,,,,,,10.72,13.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,MedCost,Commercial,,10.22,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,inpatient,1,UN,22.25000,13.35000,MedCost,Commercial,,18.02,,,,,,,14.24,18.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,MedCost,Commercial,,13.57,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,inpatient,1,UN,29.30000,17.58000,MedCost,Commercial,,23.73,,,,,,,8.82,23.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,MedCost,Commercial,,17.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,inpatient,1,UN,18.15000,10.89000,MedCost,Commercial,,14.70,,,,,,,11.62,14.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,MedCost,Commercial,,11.07,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,inpatient,1,UN,16.35000,9.81000,MedCost,Commercial,,13.24,,,,,,,10.46,13.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,MedCost,Commercial,,9.97,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,inpatient,250,ML,112.90000,67.74000,MedCost,Commercial,,91.45,,,,,,,33.98,91.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,MedCost,Commercial,,68.87,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,inpatient,250,ML,132.15000,79.29000,MedCost,Commercial,,107.04,,,,,,,39.78,107.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,MedCost,Commercial,,80.61,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,1.13,,,,,,,0.89600,1.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,0.85400,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,inpatient,250,ML,90.15000,54.09000,MedCost,Commercial,,73.02,,,,,,,27.14,73.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,MedCost,Commercial,,54.99,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,inpatient,5,ML,148.65000,89.19000,MedCost,Commercial,,120.41,,,,,,,95.14,120.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,MedCost,Commercial,,90.68,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,inpatient,30,ML,44.55000,26.73000,MedCost,Commercial,,36.09,,,,,,,28.51,36.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,MedCost,Commercial,,27.18,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,inpatient,50,ML,104.30000,62.58000,MedCost,Commercial,,84.48,,,,,,,66.75,84.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,MedCost,Commercial,,63.62,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,inpatient,5,ML,20.25000,12.15000,MedCost,Commercial,,16.40,,,,,,,12.96,16.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,MedCost,Commercial,,12.35,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,5.37,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,inpatient,250,ML,346.00000,207.60000,MedCost,Commercial,,280.26,,,,,,,221.44,281.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,MedCost,Commercial,,211.06,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,inpatient,1,UN,1263.90000,758.34000,MedCost,Commercial,,1023.76,,,,,,,380.43,1027.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,MedCost,Commercial,,770.98,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,inpatient,1,UN,23.05000,13.83000,MedCost,Commercial,,18.67,,,,,,,14.75,18.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,MedCost,Commercial,,14.06,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,inpatient,20,ML,452.80000,271.68000,MedCost,Commercial,,366.77,,,,,,,136.29,368.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,MedCost,Commercial,,276.21,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,inpatient,30,ML,907.80000,544.68000,MedCost,Commercial,,735.32,,,,,,,273.25,738.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,MedCost,Commercial,,553.76,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,15,ML,1.75000,1.05000,MedCost,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,MedCost,Commercial,,1.07,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,inpatient,15,ML,1.70000,1.02000,MedCost,Commercial,,1.38,,,,,,,1.09,1.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,MedCost,Commercial,,1.04,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,inpatient,30,ML,8.90000,5.34000,MedCost,Commercial,,7.21,,,,,,,5.70,7.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,MedCost,Commercial,,5.43,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,15.07,,,,,,,11.90,15.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,11.35,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,inpatient,3.7,ML,240.65000,144.39000,MedCost,Commercial,,194.93,,,,,,,154.02,195.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,MedCost,Commercial,,146.80,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,13.16,,,,,,,10.40,13.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,9.91,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,13.41,,,,,,,10.59,13.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,10.10,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,inpatient,22.5,ML,94.55000,56.73000,MedCost,Commercial,,76.59,,,,,,,60.51,76.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,MedCost,Commercial,,57.68,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,inpatient,1,ML,28.30000,16.98000,MedCost,Commercial,,22.92,,,,,,,8.52,23.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,MedCost,Commercial,,17.26,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,inpatient,250,ML,134.75000,80.85000,MedCost,Commercial,,109.15,,,,,,,40.56,109.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,MedCost,Commercial,,82.20,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,250,ML,141.75000,85.05000,MedCost,Commercial,,114.82,,,,,,,42.67,115.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,MedCost,Commercial,,86.47,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,inpatient,1,UN,43.75000,26.25000,MedCost,Commercial,,35.44,,,,,,,28.00,35.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,MedCost,Commercial,,26.69,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,inpatient,240,ML,348.65000,209.19000,MedCost,Commercial,,282.41,,,,,,,223.14,283.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,MedCost,Commercial,,212.68,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,inpatient,1,ML,20.95000,12.57000,MedCost,Commercial,,16.97,,,,,,,6.31,17.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,MedCost,Commercial,,12.78,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,inpatient,1,ML,18.75000,11.25000,MedCost,Commercial,,15.19,,,,,,,5.64,15.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,MedCost,Commercial,,11.44,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,inpatient,250,ML,141.75000,85.05000,MedCost,Commercial,,114.82,,,,,,,42.67,115.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,MedCost,Commercial,,86.47,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,inpatient,250,ML,164.50000,98.70000,MedCost,Commercial,,133.25,,,,,,,49.51,133.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,MedCost,Commercial,,100.34,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,inpatient,1000,ML,175.00000,105.00000,MedCost,Commercial,,141.75,,,,,,,112.00,142.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,MedCost,Commercial,,106.75,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,inpatient,473,ML,3.20000,1.92000,MedCost,Commercial,,2.59,,,,,,,2.05,2.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,MedCost,Commercial,,1.95,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,MedCost,Commercial,,82.22,,,,,,,30.55,82.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,MedCost,Commercial,,61.91,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,inpatient,30,ML,124.00000,74.40000,MedCost,Commercial,,100.44,,,,,,,79.36,100.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,MedCost,Commercial,,75.64,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,inpatient,15,ML,124.00000,74.40000,MedCost,Commercial,,100.44,,,,,,,79.36,100.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,MedCost,Commercial,,75.64,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,inpatient,100,ML,91.70000,55.02000,MedCost,Commercial,,74.28,,,,,,,27.60,74.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,MedCost,Commercial,,55.94,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,inpatient,5,ML,79.70000,47.82000,MedCost,Commercial,,64.56,,,,,,,51.01,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,MedCost,Commercial,,48.62,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,inpatient,20,ML,471.00000,282.60000,MedCost,Commercial,,381.51,,,,,,,301.44,382.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,MedCost,Commercial,,287.31,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,inpatient,1,UN,26.20000,15.72000,MedCost,Commercial,,21.22,,,,,,,16.77,21.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,MedCost,Commercial,,15.98,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,MedCost,Commercial,,18.79,,,,,,,14.85,18.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,MedCost,Commercial,,14.15,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,inpatient,1,UN,23.50000,14.10000,MedCost,Commercial,,19.04,,,,,,,15.04,19.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,MedCost,Commercial,,14.34,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,inpatient,1,UN,22.50000,13.50000,MedCost,Commercial,,18.23,,,,,,,14.40,18.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,MedCost,Commercial,,13.72,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,inpatient,1,UN,22.60000,13.56000,MedCost,Commercial,,18.31,,,,,,,14.46,18.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,MedCost,Commercial,,13.79,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,inpatient,1,UN,13881.15000,8328.69000,MedCost,Commercial,,11243.73,,,,,,,4178.23,11285.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,MedCost,Commercial,,8467.50,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,inpatient,1,UN,303.80000,182.28000,MedCost,Commercial,,246.08,,,,,,,194.43,246.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,MedCost,Commercial,,185.32,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,inpatient,28.4,GR,4.25000,2.55000,MedCost,Commercial,,3.44,,,,,,,2.72,3.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,MedCost,Commercial,,2.59,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,inpatient,1,UN,56.45000,33.87000,MedCost,Commercial,,45.72,,,,,,,36.13,45.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,MedCost,Commercial,,34.43,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,inpatient,1,UN,56.45000,33.87000,MedCost,Commercial,,45.72,,,,,,,36.13,45.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,MedCost,Commercial,,34.43,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,inpatient,1,UN,4065.55000,2439.33000,MedCost,Commercial,,3293.10,,,,,,,1223.73,3305.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,MedCost,Commercial,,2479.99,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,inpatient,20,ML,113.05000,67.83000,MedCost,Commercial,,91.57,,,,,,,34.03,91.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,MedCost,Commercial,,68.96,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,inpatient,20,ML,117.85000,70.71000,MedCost,Commercial,,95.46,,,,,,,35.47,95.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,MedCost,Commercial,,71.89,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,inpatient,1,UN,17829.40000,10697.64000,MedCost,Commercial,,14441.81,,,,,,,5366.65,14495.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,MedCost,Commercial,,10875.93,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,inpatient,1,UN,28362.00000,17017.20000,MedCost,Commercial,,22973.22,,,,,,,8536.96,23058.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,MedCost,Commercial,,17300.82,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,MedCost,Commercial,,52.93,,,,,,,19.67,53.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,MedCost,Commercial,,39.86,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,inpatient,118,ML,6.15000,3.69000,MedCost,Commercial,,4.98,,,,,,,3.94,5.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,MedCost,Commercial,,3.75,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,inpatient,1,ML,147.45000,88.47000,MedCost,Commercial,,119.43,,,,,,,44.38,119.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,MedCost,Commercial,,89.94,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,inpatient,1,UN,25.05000,15.03000,MedCost,Commercial,,20.29,,,,,,,16.03,20.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,MedCost,Commercial,,15.28,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,inpatient,1,UN,41.50000,24.90000,MedCost,Commercial,,33.62,,,,,,,26.56,33.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,MedCost,Commercial,,25.32,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,inpatient,1,UN,23.70000,14.22000,MedCost,Commercial,,19.20,,,,,,,15.17,19.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,MedCost,Commercial,,14.46,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,inpatient,1,UN,19.20000,11.52000,MedCost,Commercial,,15.55,,,,,,,12.29,15.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,MedCost,Commercial,,11.71,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,inpatient,0.5,ML,161.50000,96.90000,MedCost,Commercial,,130.81,,,,,,,48.61,131.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,MedCost,Commercial,,98.52,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,82.17,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,inpatient,1,UN,486.70000,292.02000,MedCost,Commercial,,394.23,,,,,,,311.49,395.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,MedCost,Commercial,,296.89,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,inpatient,10,ML,97.90000,58.74000,MedCost,Commercial,,79.30,,,,,,,29.47,79.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,MedCost,Commercial,,59.72,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,inpatient,3.75,ML,94.25000,56.55000,MedCost,Commercial,,76.34,,,,,,,60.32,76.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,MedCost,Commercial,,57.49,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,inpatient,1,UN,4576.00000,2745.60000,MedCost,Commercial,,3706.56,,,,,,,1377.38,3720.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,MedCost,Commercial,,2791.36,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,inpatient,3000,ML,153.00000,91.80000,MedCost,Commercial,,123.93,,,,,,,97.92,124.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,MedCost,Commercial,,93.33,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,inpatient,1,ML,24.05000,14.43000,MedCost,Commercial,,19.48,,,,,,,15.39,19.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,MedCost,Commercial,,14.67,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,inpatient,57,GR,4.80000,2.88000,MedCost,Commercial,,3.89,,,,,,,3.07,3.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,MedCost,Commercial,,2.93,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,inpatient,1,UN,326.05000,195.63000,MedCost,Commercial,,264.10,,,,,,,208.67,265.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,MedCost,Commercial,,198.89,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,inpatient,1,UN,84.60000,50.76000,MedCost,Commercial,,68.53,,,,,,,54.14,68.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,MedCost,Commercial,,51.61,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,inpatient,1,UN,84.60000,50.76000,MedCost,Commercial,,68.53,,,,,,,54.14,68.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,MedCost,Commercial,,51.61,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,inpatient,1,UN,643.15000,385.89000,MedCost,Commercial,,520.95,,,,,,,411.62,522.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,MedCost,Commercial,,392.32,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,inpatient,1,UN,643.15000,385.89000,MedCost,Commercial,,520.95,,,,,,,411.62,522.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,MedCost,Commercial,,392.32,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,13.93,,,,,,,11.01,13.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,10.49,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,inpatient,1,UN,549.95000,329.97000,MedCost,Commercial,,445.46,,,,,,,165.53,447.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,MedCost,Commercial,,335.47,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,MedCost,Commercial,,21.14,,,,,,,7.86,21.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,MedCost,Commercial,,15.92,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,inpatient,0.5,ML,22.35000,13.41000,MedCost,Commercial,,18.10,,,,,,,6.73,18.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,MedCost,Commercial,,13.63,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,inpatient,1,UN,1.85000,1.11000,MedCost,Commercial,,1.50,,,,,,,1.18,1.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,MedCost,Commercial,,1.13,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,inpatient,1,UN,84.10000,50.46000,MedCost,Commercial,,68.12,,,,,,,53.82,68.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,MedCost,Commercial,,51.30,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,inpatient,1,UN,324.35000,194.61000,MedCost,Commercial,,262.72,,,,,,,97.63,263.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,MedCost,Commercial,,197.85,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,inpatient,1,UN,493.50000,296.10000,MedCost,Commercial,,399.74,,,,,,,148.54,401.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,MedCost,Commercial,,301.04,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,inpatient,1,UN,20.45000,12.27000,MedCost,Commercial,,16.56,,,,,,,13.09,16.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,MedCost,Commercial,,12.47,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,inpatient,1,UN,357.15000,214.29000,MedCost,Commercial,,289.29,,,,,,,228.58,290.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,MedCost,Commercial,,217.86,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,inpatient,1,UN,527.70000,316.62000,MedCost,Commercial,,427.44,,,,,,,337.73,429.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,MedCost,Commercial,,321.90,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,inpatient,1,UN,99.95000,59.97000,MedCost,Commercial,,80.96,,,,,,,63.97,81.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,MedCost,Commercial,,60.97,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,inpatient,1,UN,99.95000,59.97000,MedCost,Commercial,,80.96,,,,,,,63.97,81.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,MedCost,Commercial,,60.97,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,inpatient,1,UN,368.65000,221.19000,MedCost,Commercial,,298.61,,,,,,,235.94,299.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,MedCost,Commercial,,224.88,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,inpatient,5,ML,6392.40000,3835.44000,MedCost,Commercial,,5177.84,,,,,,,1924.11,5197.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,MedCost,Commercial,,3899.36,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,inpatient,1,ML,28.40000,17.04000,MedCost,Commercial,,23.00,,,,,,,8.55,23.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,MedCost,Commercial,,17.32,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,inpatient,10,ML,6878.50000,4127.10000,MedCost,Commercial,,5571.59,,,,,,,2070.43,5592.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,MedCost,Commercial,,4195.89,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,inpatient,50,ML,33292.40000,19975.44000,MedCost,Commercial,,26966.84,,,,,,,10021.01,27066.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,MedCost,Commercial,,20308.36,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,inpatient,1,UN,22.70000,13.62000,MedCost,Commercial,,18.39,,,,,,,14.53,18.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,MedCost,Commercial,,13.85,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,inpatient,1,UN,55.00000,33.00000,MedCost,Commercial,,44.55,,,,,,,16.55,44.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,MedCost,Commercial,,33.55,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,inpatient,1,UN,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,24.08,65.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,inpatient,1,UN,1.70000,1.02000,MedCost,Commercial,,1.38,,,,,,,1.09,1.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,MedCost,Commercial,,1.04,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,MedCost,Commercial,,72.05,,,,,,,26.77,72.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,MedCost,Commercial,,54.26,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,inpatient,1,UN,39374.65000,23624.79000,MedCost,Commercial,,31893.47,,,,,,,11851.77,32011.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,MedCost,Commercial,,24018.54,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,inpatient,1,UN,8111.05000,4866.63000,MedCost,Commercial,,6569.95,,,,,,,2441.43,6594.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,MedCost,Commercial,,4947.74,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,inpatient,1,UN,88.95000,53.37000,MedCost,Commercial,,72.05,,,,,,,26.77,72.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,MedCost,Commercial,,54.26,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,inpatient,30,ML,381.35000,228.81000,MedCost,Commercial,,308.89,,,,,,,244.06,310.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,MedCost,Commercial,,232.62,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,inpatient,1,UN,75.60000,45.36000,MedCost,Commercial,,61.24,,,,,,,22.76,61.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,MedCost,Commercial,,46.12,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,MedCost,Commercial,,71.12,,,,,,,26.43,71.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,MedCost,Commercial,,53.56,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,inpatient,2,ML,2093.30000,1255.98000,MedCost,Commercial,,1695.57,,,,,,,630.08,1701.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,MedCost,Commercial,,1276.91,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,inpatient,1,UN,13983.35000,8390.01000,MedCost,Commercial,,11326.51,,,,,,,8949.34,11368.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,MedCost,Commercial,,8529.84,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,14.42,,,,,,,11.39,14.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,10.86,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,inpatient,10,ML,462.25000,277.35000,MedCost,Commercial,,374.42,,,,,,,139.14,375.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,MedCost,Commercial,,281.97,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,inpatient,1,ML,1095.00000,657.00000,MedCost,Commercial,,886.95,,,,,,,329.60,890.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,MedCost,Commercial,,667.95,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,inpatient,1,UN,247.50000,148.50000,MedCost,Commercial,,200.47,,,,,,,158.40,201.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,MedCost,Commercial,,150.97,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,13.28,,,,,,,10.50,13.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,10.00,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,inpatient,1,UN,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,47.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,MedCost,Commercial,,31.39,,,,,,,11.66,31.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,MedCost,Commercial,,23.64,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,MedCost,Commercial,,31.39,,,,,,,11.66,31.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,MedCost,Commercial,,23.64,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,inpatient,1,UN,241.15000,144.69000,MedCost,Commercial,,195.33,,,,,,,154.34,196.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,MedCost,Commercial,,147.10,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,inpatient,1,UN,307.90000,184.74000,MedCost,Commercial,,249.40,,,,,,,197.06,250.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,MedCost,Commercial,,187.82,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,inpatient,1,UN,406.80000,244.08000,MedCost,Commercial,,329.51,,,,,,,260.35,330.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,MedCost,Commercial,,248.15,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,20027.09,,,,,,,7442.16,20101.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,15082.13,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,inpatient,1,UN,809.35000,485.61000,MedCost,Commercial,,655.57,,,,,,,243.61,658.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,MedCost,Commercial,,493.70,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,inpatient,4,ML,6099.95000,3659.97000,MedCost,Commercial,,4940.96,,,,,,,1836.08,4959.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,MedCost,Commercial,,3720.97,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,inpatient,10,ML,14837.25000,8902.35000,MedCost,Commercial,,12018.17,,,,,,,4466.01,12062.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,MedCost,Commercial,,9050.72,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,13.12,,,,,,,10.37,13.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,9.88,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,13.16,,,,,,,10.40,13.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,9.91,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,inpatient,0.5,ML,731.15000,438.69000,MedCost,Commercial,,592.23,,,,,,,220.08,594.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,MedCost,Commercial,,446.00,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,inpatient,1,UN,39.50000,23.70000,MedCost,Commercial,,32.00,,,,,,,25.28,32.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,MedCost,Commercial,,24.09,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,inpatient,1,UN,47.70000,28.62000,MedCost,Commercial,,38.64,,,,,,,30.53,38.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,MedCost,Commercial,,29.10,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,inpatient,1,UN,54.55000,32.73000,MedCost,Commercial,,44.19,,,,,,,34.91,44.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,MedCost,Commercial,,33.28,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,inpatient,1,UN,77.70000,46.62000,MedCost,Commercial,,62.94,,,,,,,49.73,63.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,MedCost,Commercial,,47.40,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,MedCost,Commercial,,23666.50,,,,,,,8794.59,23754.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,MedCost,Commercial,,17822.92,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,4,ML,26225.00000,15735.00000,MedCost,Commercial,,21242.25,,,,,,,7893.73,21320.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,MedCost,Commercial,,15997.25,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,inpatient,1,UN,25.00000,15.00000,MedCost,Commercial,,20.25,,,,,,,16.00,20.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,MedCost,Commercial,,15.25,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,inpatient,1,UN,74.20000,44.52000,MedCost,Commercial,,60.10,,,,,,,47.49,60.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,MedCost,Commercial,,45.26,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,inpatient,1,UN,74.20000,44.52000,MedCost,Commercial,,60.10,,,,,,,47.49,60.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,MedCost,Commercial,,45.26,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,inpatient,20,ML,109.30000,65.58000,MedCost,Commercial,,88.53,,,,,,,69.95,88.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,MedCost,Commercial,,66.67,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,inpatient,250,ML,1780.00000,1068.00000,MedCost,Commercial,,1441.80,,,,,,,1139.20,1447.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,MedCost,Commercial,,1085.80,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,inpatient,1,UN,57.75000,34.65000,MedCost,Commercial,,46.78,,,,,,,36.96,46.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,MedCost,Commercial,,35.23,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,inpatient,1,UN,57.75000,34.65000,MedCost,Commercial,,46.78,,,,,,,36.96,46.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,MedCost,Commercial,,35.23,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,inpatient,1,UN,21020.20000,12612.12000,MedCost,Commercial,,17026.36,,,,,,,6327.08,17089.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,MedCost,Commercial,,12822.32,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,inpatient,1,UN,31468.15000,18880.89000,MedCost,Commercial,,25489.20,,,,,,,9471.91,25583.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,MedCost,Commercial,,19195.57,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,inpatient,1,UN,16047.65000,9628.59000,MedCost,Commercial,,12998.60,,,,,,,4830.34,13046.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,MedCost,Commercial,,9789.07,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,inpatient,1,UN,1807.55000,1084.53000,MedCost,Commercial,,1464.12,,,,,,,544.07,1469.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,MedCost,Commercial,,1102.61,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,inpatient,1,UN,3746.95000,2248.17000,MedCost,Commercial,,3035.03,,,,,,,1127.83,3046.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,MedCost,Commercial,,2285.64,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,inpatient,30,GR,8.10000,4.86000,MedCost,Commercial,,6.56,,,,,,,5.18,6.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,MedCost,Commercial,,4.94,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,inpatient,100,ML,94.50000,56.70000,MedCost,Commercial,,76.55,,,,,,,28.44,76.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,MedCost,Commercial,,57.65,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,inpatient,1,UN,486.70000,292.02000,MedCost,Commercial,,394.23,,,,,,,311.49,395.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,MedCost,Commercial,,296.89,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,inpatient,50,ML,3914.20000,2348.52000,MedCost,Commercial,,3170.50,,,,,,,1178.17,3182.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,MedCost,Commercial,,2387.66,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,inpatient,5,ML,84083.00000,50449.80000,MedCost,Commercial,,68107.23,,,,,,,25308.98,68359.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,MedCost,Commercial,,51290.63,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,inpatient,10,ML,1978.60000,1187.16000,MedCost,Commercial,,1602.67,,,,,,,595.56,1608.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,MedCost,Commercial,,1206.95,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,inpatient,2,ML,493.20000,295.92000,MedCost,Commercial,,399.49,,,,,,,148.45,400.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,MedCost,Commercial,,300.85,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,inpatient,1,UN,4629.40000,2777.64000,MedCost,Commercial,,3749.81,,,,,,,1393.45,3763.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,MedCost,Commercial,,2823.93,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,inpatient,1,UN,9181.80000,5509.08000,MedCost,Commercial,,7437.26,,,,,,,2763.72,7464.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,MedCost,Commercial,,5600.90,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,inpatient,1,UN,4571.50000,2742.90000,MedCost,Commercial,,3702.91,,,,,,,1376.02,3716.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,MedCost,Commercial,,2788.61,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,inpatient,1,UN,63.05000,37.83000,MedCost,Commercial,,51.07,,,,,,,40.35,51.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,MedCost,Commercial,,38.46,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,inpatient,1,UN,63.05000,37.83000,MedCost,Commercial,,51.07,,,,,,,40.35,51.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,MedCost,Commercial,,38.46,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,inpatient,1,UN,63.05000,37.83000,MedCost,Commercial,,51.07,,,,,,,40.35,51.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,MedCost,Commercial,,38.46,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,inpatient,0.8,ML,2013.40000,1208.04000,MedCost,Commercial,,1630.85,,,,,,,606.03,1636.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,MedCost,Commercial,,1228.17,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,inpatient,0.5,ML,1264.35000,758.61000,MedCost,Commercial,,1024.12,,,,,,,380.57,1027.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,MedCost,Commercial,,771.25,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,inpatient,1,UN,44.30000,26.58000,MedCost,Commercial,,35.88,,,,,,,13.33,36.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,MedCost,Commercial,,27.02,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,inpatient,1,UN,129.20000,77.52000,MedCost,Commercial,,104.65,,,,,,,38.89,105.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,MedCost,Commercial,,78.81,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,inpatient,1,UN,47.00000,28.20000,MedCost,Commercial,,38.07,,,,,,,30.08,38.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,MedCost,Commercial,,28.67,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,inpatient,8,GR,84.20000,50.52000,MedCost,Commercial,,68.20,,,,,,,53.89,68.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,MedCost,Commercial,,51.36,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,MedCost,Commercial,,61.56,,,,,,,22.88,61.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,MedCost,Commercial,,46.36,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,inpatient,50,ML,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,26.49,71.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,inpatient,50,ML,10778.05000,6466.83000,MedCost,Commercial,,8730.22,,,,,,,3244.19,8762.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,MedCost,Commercial,,6574.61,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,inpatient,10,ML,13382.60000,8029.56000,MedCost,Commercial,,10839.91,,,,,,,4028.16,10880.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,MedCost,Commercial,,8163.39,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,inpatient,1,UN,44.60000,26.76000,MedCost,Commercial,,36.13,,,,,,,28.54,36.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,MedCost,Commercial,,27.21,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,inpatient,1,UN,44.60000,26.76000,MedCost,Commercial,,36.13,,,,,,,28.54,36.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,MedCost,Commercial,,27.21,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,inpatient,1,UN,57.50000,34.50000,MedCost,Commercial,,46.58,,,,,,,36.80,46.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,MedCost,Commercial,,35.08,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,inpatient,1,UN,16408.85000,9845.31000,MedCost,Commercial,,13291.17,,,,,,,4939.06,13340.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,MedCost,Commercial,,10009.40,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,inpatient,1,UN,578.15000,346.89000,MedCost,Commercial,,468.30,,,,,,,370.02,470.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,MedCost,Commercial,,352.67,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,inpatient,10,ML,97.75000,58.65000,MedCost,Commercial,,79.18,,,,,,,62.56,79.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,MedCost,Commercial,,59.63,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,inpatient,15,ML,147.30000,88.38000,MedCost,Commercial,,119.31,,,,,,,94.27,119.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,MedCost,Commercial,,89.85,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,inpatient,5,ML,59.50000,35.70000,MedCost,Commercial,,48.20,,,,,,,38.08,48.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,MedCost,Commercial,,36.30,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,inpatient,4,ML,11159.75000,6695.85000,MedCost,Commercial,,9039.40,,,,,,,3359.08,9072.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,MedCost,Commercial,,6807.45,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,inpatient,1,UN,1039.25000,623.55000,MedCost,Commercial,,841.79,,,,,,,665.12,844.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,MedCost,Commercial,,633.94,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,inpatient,2,ML,635.45000,381.27000,MedCost,Commercial,,514.71,,,,,,,406.69,516.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,MedCost,Commercial,,387.62,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,inpatient,120,ML,16.45000,9.87000,MedCost,Commercial,,13.32,,,,,,,10.53,13.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,MedCost,Commercial,,10.03,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,inpatient,1,UN,218.55000,131.13000,MedCost,Commercial,,177.03,,,,,,,139.87,177.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,MedCost,Commercial,,133.32,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,inpatient,1,UN,19.15000,11.49000,MedCost,Commercial,,15.51,,,,,,,12.26,15.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,MedCost,Commercial,,11.68,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,inpatient,3,ML,877.30000,526.38000,MedCost,Commercial,,710.61,,,,,,,264.07,713.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,MedCost,Commercial,,535.15,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,inpatient,1,UN,19.60000,11.76000,MedCost,Commercial,,15.88,,,,,,,12.54,15.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,MedCost,Commercial,,11.96,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,inpatient,1,UN,4037.40000,2422.44000,MedCost,Commercial,,3270.29,,,,,,,1215.26,3282.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,MedCost,Commercial,,2462.81,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,inpatient,2,ML,1656.85000,994.11000,MedCost,Commercial,,1342.05,,,,,,,498.71,1347.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,MedCost,Commercial,,1010.68,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,inpatient,1,UN,309.65000,185.79000,MedCost,Commercial,,250.82,,,,,,,93.20,251.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,MedCost,Commercial,,188.89,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,inpatient,0.9996,UN,13510.90000,8106.54000,MedCost,Commercial,,10943.83,,,,,,,8646.98,10984.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,MedCost,Commercial,,8241.65,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,inpatient,1,UN,77.05000,46.23000,MedCost,Commercial,,62.41,,,,,,,49.31,62.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,MedCost,Commercial,,47.00,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,inpatient,1,UN,285.40000,171.24000,MedCost,Commercial,,231.17,,,,,,,182.66,232.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,MedCost,Commercial,,174.09,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,inpatient,1,UN,545.60000,327.36000,MedCost,Commercial,,441.94,,,,,,,349.18,443.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,MedCost,Commercial,,332.82,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,inpatient,1,UN,4647.20000,2788.32000,MedCost,Commercial,,3764.23,,,,,,,1398.81,3778.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,MedCost,Commercial,,2834.79,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,inpatient,5,ML,211.40000,126.84000,MedCost,Commercial,,171.23,,,,,,,135.30,171.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,MedCost,Commercial,,128.95,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,inpatient,1,UN,95.65000,57.39000,MedCost,Commercial,,77.48,,,,,,,61.22,77.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,MedCost,Commercial,,58.35,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,inpatient,1,ML,148.15000,88.89000,MedCost,Commercial,,120.00,,,,,,,94.82,120.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,MedCost,Commercial,,90.37,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,MedCost,Commercial,,41527.24,,,,,,,15431.73,41681.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,MedCost,Commercial,,31273.60,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,inpatient,1,UN,22.00000,13.20000,MedCost,Commercial,,17.82,,,,,,,14.08,17.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,MedCost,Commercial,,13.42,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,inpatient,10.7,GR,1350.15000,810.09000,MedCost,Commercial,,1093.62,,,,,,,864.10,1097.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,MedCost,Commercial,,823.59,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,inpatient,1000,ML,122.50000,73.50000,MedCost,Commercial,,99.22,,,,,,,36.87,99.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,MedCost,Commercial,,74.72,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,inpatient,150,ML,2747.20000,1648.32000,MedCost,Commercial,,2225.23,,,,,,,1758.21,2233.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,MedCost,Commercial,,1675.79,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,inpatient,0.05,ML,61.35000,36.81000,MedCost,Commercial,,49.69,,,,,,,18.47,49.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,MedCost,Commercial,,37.42,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,inpatient,10,ML,1082.50000,649.50000,MedCost,Commercial,,876.83,,,,,,,325.83,880.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,MedCost,Commercial,,660.33,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,inpatient,2.5,ML,61.30000,36.78000,MedCost,Commercial,,49.65,,,,,,,39.23,49.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,MedCost,Commercial,,37.39,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,inpatient,40,ML,16023.00000,9613.80000,MedCost,Commercial,,12978.63,,,,,,,4822.92,13026.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,MedCost,Commercial,,9774.03,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,inpatient,10,ML,41.15000,24.69000,MedCost,Commercial,,33.33,,,,,,,12.39,33.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,MedCost,Commercial,,25.10,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,inpatient,100,ML,191.65000,114.99000,MedCost,Commercial,,155.24,,,,,,,57.69,155.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,MedCost,Commercial,,116.91,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,MedCost,Commercial,,53.66,,,,,,,19.94,53.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,MedCost,Commercial,,40.41,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,inpatient,200,ML,367.30000,220.38000,MedCost,Commercial,,297.51,,,,,,,110.56,298.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,MedCost,Commercial,,224.05,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,inpatient,15,ML,57.50000,34.50000,MedCost,Commercial,,46.58,,,,,,,17.31,46.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,MedCost,Commercial,,35.08,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,inpatient,15,ML,34.25000,20.55000,MedCost,Commercial,,27.74,,,,,,,10.31,27.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,MedCost,Commercial,,20.89,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,inpatient,15,ML,39.90000,23.94000,MedCost,Commercial,,32.32,,,,,,,12.01,32.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,MedCost,Commercial,,24.34,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,inpatient,1,ML,89877.30000,53926.38000,MedCost,Commercial,,72800.61,,,,,,,27053.07,73070.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,MedCost,Commercial,,54825.15,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,inpatient,10,ML,9488.70000,5693.22000,MedCost,Commercial,,7685.85,,,,,,,2856.10,7714.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,MedCost,Commercial,,5788.11,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,10,ML,86755.05000,52053.03000,MedCost,Commercial,,70271.59,,,,,,,26113.27,70531.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,MedCost,Commercial,,52920.58,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,inpatient,1,UN,44.80000,26.88000,MedCost,Commercial,,36.29,,,,,,,28.67,36.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,MedCost,Commercial,,27.33,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,inpatient,1,UN,7132.10000,4279.26000,MedCost,Commercial,,5777.00,,,,,,,2146.76,5798.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,MedCost,Commercial,,4350.58,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,inpatient,1,UN,896.70000,538.02000,MedCost,Commercial,,726.33,,,,,,,573.89,729.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,MedCost,Commercial,,546.99,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,10,ML,19171.55000,11502.93000,MedCost,Commercial,,15528.96,,,,,,,5770.64,15586.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,MedCost,Commercial,,11694.65,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,inpatient,2.4,ML,4810.20000,2886.12000,MedCost,Commercial,,3896.26,,,,,,,1447.87,3910.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,MedCost,Commercial,,2934.22,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,inpatient,11.7,ML,29212.00000,17527.20000,MedCost,Commercial,,23661.72,,,,,,,8792.81,23749.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,MedCost,Commercial,,17819.32,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,inpatient,1,UN,6.65000,3.99000,MedCost,Commercial,,5.39,,,,,,,4.26,5.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,MedCost,Commercial,,4.06,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,inpatient,1,ML,71.75000,43.05000,MedCost,Commercial,,58.12,,,,,,,45.92,58.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,MedCost,Commercial,,43.77,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,inpatient,13.4,ML,33345.80000,20007.48000,MedCost,Commercial,,27010.10,,,,,,,10037.09,27110.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,MedCost,Commercial,,20340.94,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,inpatient,3,ML,71.30000,42.78000,MedCost,Commercial,,57.75,,,,,,,45.63,57.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,MedCost,Commercial,,43.49,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,inpatient,2,ML,68.70000,41.22000,MedCost,Commercial,,55.65,,,,,,,43.97,55.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,MedCost,Commercial,,41.91,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,inpatient,118,ML,1312.75000,787.65000,MedCost,Commercial,,1063.33,,,,,,,840.16,1067.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,MedCost,Commercial,,800.78,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,inpatient,473,ML,4511.40000,2706.84000,MedCost,Commercial,,3654.23,,,,,,,2887.30,3667.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,MedCost,Commercial,,2751.95,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,inpatient,3,ML,47.80000,28.68000,MedCost,Commercial,,38.72,,,,,,,30.59,38.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,MedCost,Commercial,,29.16,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,inpatient,1,UN,48587.00000,29152.20000,MedCost,Commercial,,39355.47,,,,,,,14624.69,39501.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,MedCost,Commercial,,29638.07,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,inpatient,1,UN,105505.20000,63303.12000,MedCost,Commercial,,85459.21,,,,,,,31757.07,85775.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,MedCost,Commercial,,64358.17,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,inpatient,1,UN,17.45000,10.47000,MedCost,Commercial,,14.13,,,,,,,11.17,14.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,MedCost,Commercial,,10.64,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,inpatient,1,ML,131.60000,78.96000,MedCost,Commercial,,106.60,,,,,,,84.22,106.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,MedCost,Commercial,,80.28,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,inpatient,5,ML,95.30000,57.18000,MedCost,Commercial,,77.19,,,,,,,60.99,77.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,MedCost,Commercial,,58.13,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,inpatient,5,ML,95.30000,57.18000,MedCost,Commercial,,77.19,,,,,,,60.99,77.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,MedCost,Commercial,,58.13,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,MedCost,Commercial,,73.14,,,,,,,27.18,73.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,MedCost,Commercial,,55.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,13.65,,,,,,,10.78,13.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,10.28,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,10.69,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,inpatient,1,UN,27.85000,16.71000,MedCost,Commercial,,22.56,,,,,,,17.82,22.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,MedCost,Commercial,,16.99,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,14.34,,,,,,,11.33,14.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,10.80,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,inpatient,250,ML,199.50000,119.70000,MedCost,Commercial,,161.59,,,,,,,60.05,162.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,MedCost,Commercial,,121.69,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,inpatient,1,UN,997.50000,598.50000,MedCost,Commercial,,807.98,,,,,,,300.25,810.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,MedCost,Commercial,,608.48,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,inpatient,60,ML,66.10000,39.66000,MedCost,Commercial,,53.54,,,,,,,42.30,53.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,MedCost,Commercial,,40.32,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,inpatient,1,UN,668.55000,401.13000,MedCost,Commercial,,541.53,,,,,,,201.23,543.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,MedCost,Commercial,,407.82,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,inpatient,1,UN,4.70000,2.82000,MedCost,Commercial,,3.81,,,,,,,3.01,3.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,MedCost,Commercial,,2.87,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,inpatient,1,ML,18.40000,11.04000,MedCost,Commercial,,14.90,,,,,,,5.54,14.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,MedCost,Commercial,,11.22,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,inpatient,18,ML,1972.25000,1183.35000,MedCost,Commercial,,1597.52,,,,,,,593.65,1603.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,MedCost,Commercial,,1203.07,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,inpatient,1,ML,26620.10000,15972.06000,MedCost,Commercial,,21562.28,,,,,,,8012.65,21642.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,MedCost,Commercial,,16238.26,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,inpatient,6,ML,5890.65000,3534.39000,MedCost,Commercial,,4771.43,,,,,,,1773.09,4789.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,MedCost,Commercial,,3593.30,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,inpatient,1,UN,19.10000,11.46000,MedCost,Commercial,,15.47,,,,,,,12.22,15.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,MedCost,Commercial,,11.65,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,inpatient,24,ML,35224.60000,21134.76000,MedCost,Commercial,,28531.93,,,,,,,10602.60,28637.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,MedCost,Commercial,,21487.01,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,inpatient,50,ML,80.05000,48.03000,MedCost,Commercial,,64.84,,,,,,,24.10,65.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,MedCost,Commercial,,48.83,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,inpatient,1,UN,241.95000,145.17000,MedCost,Commercial,,195.98,,,,,,,154.85,196.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,MedCost,Commercial,,147.59,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,inpatient,1,UN,389.50000,233.70000,MedCost,Commercial,,315.50,,,,,,,249.28,316.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,MedCost,Commercial,,237.59,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,21.34,,,,,,,7.93,21.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,16.07,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,inpatient,0.5,ML,58.45000,35.07000,MedCost,Commercial,,47.34,,,,,,,17.59,47.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,MedCost,Commercial,,35.65,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,inpatient,1,UN,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,246.40,313.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,inpatient,1,ML,116.40000,69.84000,MedCost,Commercial,,94.28,,,,,,,74.50,94.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,MedCost,Commercial,,71.00,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,inpatient,1,ML,166.60000,99.96000,MedCost,Commercial,,134.95,,,,,,,106.62,135.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,MedCost,Commercial,,101.63,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,inpatient,1,ML,216.75000,130.05000,MedCost,Commercial,,175.57,,,,,,,138.72,176.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,MedCost,Commercial,,132.22,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,inpatient,1,ML,517.90000,310.74000,MedCost,Commercial,,419.50,,,,,,,331.46,421.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,MedCost,Commercial,,315.92,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,inpatient,1,ML,2023.50000,1214.10000,MedCost,Commercial,,1639.04,,,,,,,1295.04,1645.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,MedCost,Commercial,,1234.34,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,inpatient,0.6,ML,9514.15000,5708.49000,MedCost,Commercial,,7706.46,,,,,,,2863.76,7735.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,MedCost,Commercial,,5803.63,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,inpatient,2000,ML,525.00000,315.00000,MedCost,Commercial,,425.25,,,,,,,336.00,426.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,MedCost,Commercial,,320.25,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,inpatient,1,UN,130.90000,78.54000,MedCost,Commercial,,106.03,,,,,,,83.78,106.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,MedCost,Commercial,,79.85,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,inpatient,1,UN,130.90000,78.54000,MedCost,Commercial,,106.03,,,,,,,83.78,106.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,MedCost,Commercial,,79.85,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,inpatient,0.5,ML,489.25000,293.55000,MedCost,Commercial,,396.29,,,,,,,147.26,397.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,MedCost,Commercial,,298.44,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,inpatient,5,ML,21317.55000,12790.53000,MedCost,Commercial,,17267.22,,,,,,,6416.58,17331.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,MedCost,Commercial,,13003.71,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,inpatient,0.5,ML,1012.45000,607.47000,MedCost,Commercial,,820.08,,,,,,,304.75,823.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,MedCost,Commercial,,617.59,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,inpatient,0.8,ML,1610.35000,966.21000,MedCost,Commercial,,1304.38,,,,,,,484.72,1309.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,MedCost,Commercial,,982.31,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,inpatient,1,UN,344.75000,206.85000,MedCost,Commercial,,279.25,,,,,,,103.77,280.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,MedCost,Commercial,,210.30,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,13.41,,,,,,,10.59,13.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,10.10,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,inpatient,1,UN,55.90000,33.54000,MedCost,Commercial,,45.28,,,,,,,35.78,45.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,MedCost,Commercial,,34.10,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,inpatient,100,ML,5146.00000,3087.60000,MedCost,Commercial,,4168.26,,,,,,,3293.44,4183.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,MedCost,Commercial,,3139.06,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,inpatient,7,ML,48344.85000,29006.91000,MedCost,Commercial,,39159.33,,,,,,,14551.80,39304.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,MedCost,Commercial,,29490.36,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,MedCost,Commercial,,15399.92,,,,,,,5722.69,15456.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,MedCost,Commercial,,11597.47,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,inpatient,2.5,ML,48.10000,28.86000,MedCost,Commercial,,38.96,,,,,,,30.78,39.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,MedCost,Commercial,,29.34,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,inpatient,5,ML,4543.25000,2725.95000,MedCost,Commercial,,3680.03,,,,,,,2907.68,3693.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,MedCost,Commercial,,2771.38,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,MedCost,Commercial,,8162.37,,,,,,,3033.18,8192.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,MedCost,Commercial,,6146.97,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,MedCost,Commercial,,820.08,,,,,,,304.75,823.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,MedCost,Commercial,,617.59,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,inpatient,1,UN,36064.10000,21638.46000,MedCost,Commercial,,29211.92,,,,,,,10855.29,29320.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,MedCost,Commercial,,21999.10,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,inpatient,1,UN,2928.00000,1756.80000,MedCost,Commercial,,2371.68,,,,,,,881.33,2380.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,MedCost,Commercial,,1786.08,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,MedCost,Commercial,,29135.94,,,,,,,10827.06,29243.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,MedCost,Commercial,,21941.88,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,inpatient,5,ML,20846.10000,12507.66000,MedCost,Commercial,,16885.34,,,,,,,6274.68,16947.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,MedCost,Commercial,,12716.12,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,inpatient,1000,ML,203.00000,121.80000,MedCost,Commercial,,164.43,,,,,,,129.92,165.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,MedCost,Commercial,,123.83,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,inpatient,2000,ML,287.00000,172.20000,MedCost,Commercial,,232.47,,,,,,,183.68,233.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,MedCost,Commercial,,175.07,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,inpatient,5,ML,419.55000,251.73000,MedCost,Commercial,,339.84,,,,,,,126.28,341.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,MedCost,Commercial,,255.93,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,inpatient,10,ML,1781.00000,1068.60000,MedCost,Commercial,,1442.61,,,,,,,1139.84,1447.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,MedCost,Commercial,,1086.41,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,inpatient,1,UN,82165.25000,49299.15000,MedCost,Commercial,,66553.85,,,,,,,24731.74,66800.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,MedCost,Commercial,,50120.80,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,inpatient,16,ML,12554.95000,7532.97000,MedCost,Commercial,,10169.51,,,,,,,3779.04,10207.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,MedCost,Commercial,,7658.52,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,inpatient,4,ML,3345.05000,2007.03000,MedCost,Commercial,,2709.49,,,,,,,1006.86,2719.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,MedCost,Commercial,,2040.48,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,inpatient,100,ML,201.25000,120.75000,MedCost,Commercial,,163.01,,,,,,,60.58,163.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,MedCost,Commercial,,122.76,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,inpatient,2.5,ML,48.00000,28.80000,MedCost,Commercial,,38.88,,,,,,,30.72,39.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,MedCost,Commercial,,29.28,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,inpatient,1.25,ML,23.85000,14.31000,MedCost,Commercial,,19.32,,,,,,,15.26,19.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,MedCost,Commercial,,14.55,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,14.42,,,,,,,11.39,14.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,10.86,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,inpatient,10,ML,3995.45000,2397.27000,MedCost,Commercial,,3236.31,,,,,,,1202.63,3248.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,MedCost,Commercial,,2437.22,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,inpatient,50,ML,18877.10000,11326.26000,MedCost,Commercial,,15290.45,,,,,,,5682.01,15347.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,MedCost,Commercial,,11515.03,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,inpatient,1,UN,17338.20000,10402.92000,MedCost,Commercial,,14043.94,,,,,,,5218.80,14095.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,MedCost,Commercial,,10576.30,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,inpatient,1,UN,51888.40000,31133.04000,MedCost,Commercial,,42029.60,,,,,,,15618.41,42185.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,MedCost,Commercial,,31651.92,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,inpatient,10,ML,10365.35000,6219.21000,MedCost,Commercial,,8395.93,,,,,,,3119.97,8427.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,MedCost,Commercial,,6322.86,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,inpatient,1,UN,6279.25000,3767.55000,MedCost,Commercial,,5086.19,,,,,,,1890.05,5105.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,MedCost,Commercial,,3830.34,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,inpatient,10,ML,107.15000,64.29000,MedCost,Commercial,,86.79,,,,,,,68.58,87.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,MedCost,Commercial,,65.36,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,inpatient,1,UN,12634.60000,7580.76000,MedCost,Commercial,,10234.03,,,,,,,3803.01,10271.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,MedCost,Commercial,,7707.11,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,15239.66,,,,,,,5663.13,15296.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,11476.78,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,inpatient,1,UN,13855.50000,8313.30000,MedCost,Commercial,,11222.95,,,,,,,4170.51,11264.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,MedCost,Commercial,,8451.85,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,inpatient,16,ML,11070.85000,6642.51000,MedCost,Commercial,,8967.39,,,,,,,3332.33,9000.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,MedCost,Commercial,,6753.22,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,inpatient,4,ML,2974.00000,1784.40000,MedCost,Commercial,,2408.94,,,,,,,895.17,2417.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,MedCost,Commercial,,1814.14,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,10,ML,3428.95000,2057.37000,MedCost,Commercial,,2777.45,,,,,,,1032.11,2787.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,MedCost,Commercial,,2091.66,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,50,ML,16044.60000,9626.76000,MedCost,Commercial,,12996.13,,,,,,,4829.42,13044.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,MedCost,Commercial,,9787.21,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,inpatient,1,UN,75742.60000,45445.56000,MedCost,Commercial,,61351.51,,,,,,,22798.52,61578.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,MedCost,Commercial,,46202.99,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,inpatient,1,UN,15195.80000,9117.48000,MedCost,Commercial,,12308.60,,,,,,,4573.94,12354.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,MedCost,Commercial,,9269.44,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,inpatient,1,UN,143.55000,86.13000,MedCost,Commercial,,116.28,,,,,,,91.87,116.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,MedCost,Commercial,,87.57,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,inpatient,1,UN,143.55000,86.13000,MedCost,Commercial,,116.28,,,,,,,91.87,116.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,MedCost,Commercial,,87.57,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,inpatient,2.5,ML,28.60000,17.16000,MedCost,Commercial,,23.17,,,,,,,18.30,23.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,MedCost,Commercial,,17.45,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,inpatient,1,ML,8211.30000,4926.78000,MedCost,Commercial,,6651.15,,,,,,,2471.60,6675.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,MedCost,Commercial,,5008.89,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,inpatient,25,ML,19413.25000,11647.95000,MedCost,Commercial,,15724.73,,,,,,,5843.39,15782.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,MedCost,Commercial,,11842.08,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,inpatient,5,ML,4102.65000,2461.59000,MedCost,Commercial,,3323.15,,,,,,,1234.90,3335.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,MedCost,Commercial,,2502.62,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,inpatient,2,ML,149.10000,89.46000,MedCost,Commercial,,120.77,,,,,,,95.42,121.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,MedCost,Commercial,,90.95,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,inpatient,1,UN,11554.40000,6932.64000,MedCost,Commercial,,9359.06,,,,,,,3477.87,9393.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,MedCost,Commercial,,7048.18,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,inpatient,1,UN,110033.00000,66019.80000,MedCost,Commercial,,89126.73,,,,,,,33119.93,89456.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,MedCost,Commercial,,67120.13,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,inpatient,1,UN,2163.00000,1297.80000,MedCost,Commercial,,1752.03,,,,,,,651.06,1758.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,MedCost,Commercial,,1319.43,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,13.77,,,,,,,10.88,13.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,10.37,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,inpatient,1,UN,42.75000,25.65000,MedCost,Commercial,,34.63,,,,,,,27.36,34.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,MedCost,Commercial,,26.08,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,inpatient,5,ML,176.25000,105.75000,MedCost,Commercial,,142.76,,,,,,,112.80,143.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,MedCost,Commercial,,107.51,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,inpatient,1,UN,17.90000,10.74000,MedCost,Commercial,,14.50,,,,,,,11.46,14.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,MedCost,Commercial,,10.92,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,inpatient,15,ML,61507.80000,36904.68000,MedCost,Commercial,,49821.32,,,,,,,18513.85,50005.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,MedCost,Commercial,,37519.76,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,inpatient,10,ML,41095.25000,24657.15000,MedCost,Commercial,,33287.15,,,,,,,12369.67,33410.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,MedCost,Commercial,,25068.10,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,inpatient,0.25,ML,65.65000,39.39000,MedCost,Commercial,,53.18,,,,,,,19.76,53.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,MedCost,Commercial,,40.05,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,inpatient,100,ML,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,26.49,71.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,inpatient,1,UN,6416.85000,3850.11000,MedCost,Commercial,,5197.65,,,,,,,1931.47,5216.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,MedCost,Commercial,,3914.28,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,inpatient,1,UN,17822.95000,10693.77000,MedCost,Commercial,,14436.59,,,,,,,5364.71,14490.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,MedCost,Commercial,,10872.00,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,inpatient,11,ML,100657.05000,60394.23000,MedCost,Commercial,,81532.21,,,,,,,30297.77,81834.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,MedCost,Commercial,,61400.80,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,inpatient,3,ML,27497.75000,16498.65000,MedCost,Commercial,,22273.18,,,,,,,8276.82,22355.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,MedCost,Commercial,,16773.63,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,inpatient,1,ML,1019.75000,611.85000,MedCost,Commercial,,826.00,,,,,,,652.64,829.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,MedCost,Commercial,,622.05,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,inpatient,1,UN,6743.50000,4046.10000,MedCost,Commercial,,5462.23,,,,,,,2029.79,5482.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,MedCost,Commercial,,4113.53,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,inpatient,1,UN,5603.90000,3362.34000,MedCost,Commercial,,4539.16,,,,,,,1686.77,4555.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,MedCost,Commercial,,3418.38,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,inpatient,1,UN,9216.70000,5530.02000,MedCost,Commercial,,7465.53,,,,,,,2774.23,7493.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,MedCost,Commercial,,5622.19,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,inpatient,1,UN,124890.65000,74934.39000,MedCost,Commercial,,101161.43,,,,,,,37592.09,101536.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,MedCost,Commercial,,76183.30,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,inpatient,10,ML,53208.20000,31924.92000,MedCost,Commercial,,43098.64,,,,,,,16015.67,43258.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,MedCost,Commercial,,32457.00,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,inpatient,20,ML,20471.00000,12282.60000,MedCost,Commercial,,16581.51,,,,,,,6161.77,16642.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,MedCost,Commercial,,12487.31,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,inpatient,7,ML,17024.40000,10214.64000,MedCost,Commercial,,13789.76,,,,,,,5124.34,13840.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,MedCost,Commercial,,10384.88,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,14.18,,,,,,,11.20,14.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,10.68,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,13.77,,,,,,,10.88,13.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,10.37,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,inpatient,30,ML,81.25000,48.75000,MedCost,Commercial,,65.81,,,,,,,52.00,66.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,MedCost,Commercial,,49.56,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,inpatient,0.5,ML,869.40000,521.64000,MedCost,Commercial,,704.21,,,,,,,261.69,706.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,MedCost,Commercial,,530.33,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,inpatient,1,UN,32838.55000,19703.13000,MedCost,Commercial,,26599.23,,,,,,,9884.40,26697.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,MedCost,Commercial,,20031.52,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,inpatient,100,ML,107.45000,64.47000,MedCost,Commercial,,87.03,,,,,,,32.34,87.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,MedCost,Commercial,,65.54,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,inpatient,1,UN,413.35000,248.01000,MedCost,Commercial,,334.81,,,,,,,264.54,336.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,MedCost,Commercial,,252.14,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,inpatient,1.5,ML,16340.20000,9804.12000,MedCost,Commercial,,13235.56,,,,,,,4918.40,13284.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,MedCost,Commercial,,9967.52,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,inpatient,1,UN,36433.75000,21860.25000,MedCost,Commercial,,29511.34,,,,,,,10966.56,29620.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,MedCost,Commercial,,22224.59,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,inpatient,1,ML,34.15000,20.49000,MedCost,Commercial,,27.66,,,,,,,21.86,27.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,MedCost,Commercial,,20.83,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,inpatient,100,ML,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,82.17,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,inpatient,1,UN,87.60000,52.56000,MedCost,Commercial,,70.96,,,,,,,26.37,71.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,MedCost,Commercial,,53.44,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,MedCost,Commercial,,67.03,,,,,,,24.91,67.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,MedCost,Commercial,,50.48,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,MedCost,Commercial,,67.03,,,,,,,24.91,67.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,MedCost,Commercial,,50.48,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,inpatient,0.5,ML,739.45000,443.67000,MedCost,Commercial,,598.95,,,,,,,222.57,601.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,MedCost,Commercial,,451.06,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,inpatient,0.8,ML,1173.55000,704.13000,MedCost,Commercial,,950.58,,,,,,,353.24,954.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,MedCost,Commercial,,715.87,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,inpatient,20,ML,68131.75000,40879.05000,MedCost,Commercial,,55186.72,,,,,,,20507.66,55391.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,MedCost,Commercial,,41560.37,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,inpatient,1,UN,76.00000,45.60000,MedCost,Commercial,,61.56,,,,,,,48.64,61.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,MedCost,Commercial,,46.36,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,inpatient,4,UN,2626.30000,1575.78000,MedCost,Commercial,,2127.30,,,,,,,1680.83,2135.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,MedCost,Commercial,,1602.04,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,inpatient,4,UN,1136.00000,681.60000,MedCost,Commercial,,920.16,,,,,,,727.04,923.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,MedCost,Commercial,,692.96,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,inpatient,4,UN,1136.00000,681.60000,MedCost,Commercial,,920.16,,,,,,,727.04,923.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,MedCost,Commercial,,692.96,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,inpatient,4,UN,2626.30000,1575.78000,MedCost,Commercial,,2127.30,,,,,,,1680.83,2135.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,MedCost,Commercial,,1602.04,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,11.26,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,inpatient,0.5,ML,104.05000,62.43000,MedCost,Commercial,,84.28,,,,,,,31.32,84.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,MedCost,Commercial,,63.47,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,inpatient,1.7,ML,46244.25000,27746.55000,MedCost,Commercial,,37457.84,,,,,,,13919.52,37596.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,MedCost,Commercial,,28208.99,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,inpatient,3,ML,9288.55000,5573.13000,MedCost,Commercial,,7523.73,,,,,,,2795.85,7551.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,MedCost,Commercial,,5666.02,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,inpatient,0.5,ML,520.00000,312.00000,MedCost,Commercial,,421.20,,,,,,,156.52,422.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,MedCost,Commercial,,317.20,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,inpatient,20,ML,30117.40000,18070.44000,MedCost,Commercial,,24395.09,,,,,,,9065.34,24485.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,MedCost,Commercial,,18371.61,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,inpatient,1,ML,3021.70000,1813.02000,MedCost,Commercial,,2447.58,,,,,,,909.53,2456.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,MedCost,Commercial,,1843.24,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,inpatient,30,ML,82676.70000,49606.02000,MedCost,Commercial,,66968.13,,,,,,,24885.69,67216.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,MedCost,Commercial,,50432.79,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,inpatient,20,ML,65144.20000,39086.52000,MedCost,Commercial,,52766.80,,,,,,,19608.40,52962.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,MedCost,Commercial,,39737.96,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,inpatient,0.28,ML,11967.50000,7180.50000,MedCost,Commercial,,9693.67,,,,,,,3602.22,9729.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,MedCost,Commercial,,7300.18,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,inpatient,0.56,ML,23918.10000,14350.86000,MedCost,Commercial,,19373.66,,,,,,,7199.35,19445.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,MedCost,Commercial,,14590.04,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,inpatient,0.7,ML,29894.05000,17936.43000,MedCost,Commercial,,24214.18,,,,,,,8998.11,24303.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,MedCost,Commercial,,18235.37,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,inpatient,1,UN,68158.20000,40894.92000,MedCost,Commercial,,55208.14,,,,,,,20515.62,55412.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,MedCost,Commercial,,41576.50,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,inpatient,1,UN,942.40000,565.44000,MedCost,Commercial,,763.34,,,,,,,283.66,766.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,MedCost,Commercial,,574.86,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,inpatient,0.5,ML,2546.40000,1527.84000,MedCost,Commercial,,2062.58,,,,,,,766.47,2070.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,MedCost,Commercial,,1553.30,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,inpatient,1,ML,2546.45000,1527.87000,MedCost,Commercial,,2062.62,,,,,,,766.48,2070.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,MedCost,Commercial,,1553.33,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,inpatient,0.5,ML,62.50000,37.50000,MedCost,Commercial,,50.62,,,,,,,40.00,50.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,MedCost,Commercial,,38.12,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,MedCost,Commercial,,41397.76,,,,,,,15383.61,41551.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,MedCost,Commercial,,31176.09,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,inpatient,1.5,ML,4087.55000,2452.53000,MedCost,Commercial,,3310.92,,,,,,,1230.35,3323.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,MedCost,Commercial,,2493.41,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,inpatient,30,ML,1475.80000,885.48000,MedCost,Commercial,,1195.40,,,,,,,944.51,1199.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,MedCost,Commercial,,900.24,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,inpatient,10,ML,208.40000,125.04000,MedCost,Commercial,,168.80,,,,,,,133.38,169.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,MedCost,Commercial,,127.12,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,inpatient,5,ML,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,inpatient,1,ML,255.50000,153.30000,MedCost,Commercial,,206.96,,,,,,,76.91,207.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,MedCost,Commercial,,155.85,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,inpatient,1,UN,30.90000,18.54000,MedCost,Commercial,,25.03,,,,,,,19.78,25.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,MedCost,Commercial,,18.85,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,inpatient,10,ML,106.00000,63.60000,MedCost,Commercial,,85.86,,,,,,,67.84,86.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,MedCost,Commercial,,64.66,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,inpatient,30,ML,69.30000,41.58000,MedCost,Commercial,,56.13,,,,,,,44.35,56.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,MedCost,Commercial,,42.27,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,inpatient,1,UN,63488.50000,38093.10000,MedCost,Commercial,,51425.68,,,,,,,19110.04,51616.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,MedCost,Commercial,,38727.99,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,inpatient,2,ML,234.40000,140.64000,MedCost,Commercial,,189.86,,,,,,,70.55,190.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,MedCost,Commercial,,142.98,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,MedCost,Commercial,,15399.92,,,,,,,5722.69,15456.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,MedCost,Commercial,,11597.47,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,inpatient,0.11,ML,352.45000,211.47000,MedCost,Commercial,,285.48,,,,,,,106.09,286.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,MedCost,Commercial,,214.99,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,inpatient,36,ML,26733.05000,16039.83000,MedCost,Commercial,,21653.77,,,,,,,8046.65,21733.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,MedCost,Commercial,,16307.16,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,13.28,,,,,,,10.50,13.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,10.00,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,inpatient,1,UN,10993.10000,6595.86000,MedCost,Commercial,,8904.41,,,,,,,3308.92,8937.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,MedCost,Commercial,,6705.79,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,inpatient,1,UN,43783.25000,26269.95000,MedCost,Commercial,,35464.43,,,,,,,13178.76,35595.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,MedCost,Commercial,,26707.78,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,inpatient,0.5,ML,883.00000,529.80000,MedCost,Commercial,,715.23,,,,,,,265.78,717.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,MedCost,Commercial,,538.63,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,inpatient,20,ML,61242.05000,36745.23000,MedCost,Commercial,,49606.06,,,,,,,18433.86,49789.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,MedCost,Commercial,,37357.65,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,inpatient,1,UN,7315.00000,4389.00000,MedCost,Commercial,,5925.15,,,,,,,2201.82,5947.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,MedCost,Commercial,,4462.15,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,inpatient,0.5,ML,257.30000,154.38000,MedCost,Commercial,,208.41,,,,,,,77.45,209.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,MedCost,Commercial,,156.95,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,inpatient,0.5,ML,81.25000,48.75000,MedCost,Commercial,,65.81,,,,,,,24.46,66.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,MedCost,Commercial,,49.56,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,inpatient,0.1,ML,17.05000,10.23000,MedCost,Commercial,,13.81,,,,,,,5.13,13.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,MedCost,Commercial,,10.40,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,inpatient,0.1,ML,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,5.09,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,inpatient,0.1,ML,16.75000,10.05000,MedCost,Commercial,,13.57,,,,,,,5.04,13.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,MedCost,Commercial,,10.22,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,inpatient,5,ML,35224.60000,21134.76000,MedCost,Commercial,,28531.93,,,,,,,10602.60,28637.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,MedCost,Commercial,,21487.01,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,inpatient,1,UN,21795.75000,13077.45000,MedCost,Commercial,,17654.56,,,,,,,6560.52,17719.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,MedCost,Commercial,,13295.41,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,inpatient,1,UN,1.35000,0.81000,MedCost,Commercial,,1.09,,,,,,,0.86400,1.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,MedCost,Commercial,,0.82350,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,inpatient,1,UN,1.30000,0.78000,MedCost,Commercial,,1.05,,,,,,,0.83200,1.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,MedCost,Commercial,,0.79300,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,inpatient,20,ML,364.45000,218.67000,MedCost,Commercial,,295.20,,,,,,,109.70,296.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,MedCost,Commercial,,222.31,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,13.16,,,,,,,10.40,13.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,9.91,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,MedCost,Commercial,,30592.53,,,,,,,11368.33,30705.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,MedCost,Commercial,,23038.82,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,inpatient,0.3,ML,465.10000,279.06000,MedCost,Commercial,,376.73,,,,,,,140.00,378.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,MedCost,Commercial,,283.71,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,13.16,,,,,,,10.40,13.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,9.91,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,inpatient,1,UN,49.10000,29.46000,MedCost,Commercial,,39.77,,,,,,,31.42,39.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,MedCost,Commercial,,29.95,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,inpatient,10,ML,89.15000,53.49000,MedCost,Commercial,,72.21,,,,,,,57.06,72.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,MedCost,Commercial,,54.38,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,10.69,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,13.12,,,,,,,10.37,13.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,9.88,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,inpatient,5,ML,73.40000,44.04000,MedCost,Commercial,,59.45,,,,,,,46.98,59.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,MedCost,Commercial,,44.77,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,inpatient,1,UN,327.80000,196.68000,MedCost,Commercial,,265.52,,,,,,,98.67,266.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,MedCost,Commercial,,199.96,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,inpatient,1,UN,38.45000,23.07000,MedCost,Commercial,,31.14,,,,,,,24.61,31.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,MedCost,Commercial,,23.45,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,inpatient,1,UN,23.45000,14.07000,MedCost,Commercial,,18.99,,,,,,,15.01,19.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,MedCost,Commercial,,14.30,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,inpatient,1,UN,27.25000,16.35000,MedCost,Commercial,,22.07,,,,,,,17.44,22.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,MedCost,Commercial,,16.62,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,inpatient,1,UN,32.20000,19.32000,MedCost,Commercial,,26.08,,,,,,,20.61,26.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,MedCost,Commercial,,19.64,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,inpatient,1,UN,2.95000,1.77000,MedCost,Commercial,,2.39,,,,,,,1.89,2.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,MedCost,Commercial,,1.80,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,inpatient,5,ML,192.90000,115.74000,MedCost,Commercial,,156.25,,,,,,,58.06,156.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,MedCost,Commercial,,117.67,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,inpatient,10,GR,11.10000,6.66000,MedCost,Commercial,,8.99,,,,,,,7.10,9.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,MedCost,Commercial,,6.77,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,inpatient,1,UN,19.55000,11.73000,MedCost,Commercial,,15.84,,,,,,,12.51,15.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,MedCost,Commercial,,11.93,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,13.16,,,,,,,10.40,13.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,9.91,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,inpatient,1,UN,94.25000,56.55000,MedCost,Commercial,,76.34,,,,,,,28.37,76.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,MedCost,Commercial,,57.49,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,13.97,,,,,,,11.04,14.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,10.52,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,inpatient,1,UN,27.20000,16.32000,MedCost,Commercial,,22.03,,,,,,,17.41,22.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,MedCost,Commercial,,16.59,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,11.26,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,inpatient,1,UN,26.20000,15.72000,MedCost,Commercial,,21.22,,,,,,,16.77,21.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,MedCost,Commercial,,15.98,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,14.82,,,,,,,11.71,14.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,11.16,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,13.93,,,,,,,11.01,13.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,10.49,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,inpatient,1,UN,17.90000,10.74000,MedCost,Commercial,,14.50,,,,,,,11.46,14.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,MedCost,Commercial,,10.92,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,inpatient,0.5,ML,91.05000,54.63000,MedCost,Commercial,,73.75,,,,,,,27.41,74.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,MedCost,Commercial,,55.54,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,inpatient,1,UN,1399.95000,839.97000,MedCost,Commercial,,1133.96,,,,,,,421.38,1138.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,MedCost,Commercial,,853.97,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,13.81,,,,,,,10.91,13.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,10.40,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,15.07,,,,,,,11.90,15.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,11.35,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,inpatient,10,ML,4408.90000,2645.34000,MedCost,Commercial,,3571.21,,,,,,,1327.08,3584.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,MedCost,Commercial,,2689.43,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,50,ML,20944.45000,12566.67000,MedCost,Commercial,,16965.00,,,,,,,6304.28,17027.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,MedCost,Commercial,,12776.11,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,inpatient,1,UN,67.95000,40.77000,MedCost,Commercial,,55.04,,,,,,,43.49,55.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,MedCost,Commercial,,41.45,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,inpatient,1.5,ML,6363.00000,3817.80000,MedCost,Commercial,,5154.03,,,,,,,1915.26,5173.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,MedCost,Commercial,,3881.43,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,inpatient,5,ML,83.90000,50.34000,MedCost,Commercial,,67.96,,,,,,,53.70,68.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,MedCost,Commercial,,51.18,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,inpatient,1,UN,18.70000,11.22000,MedCost,Commercial,,15.15,,,,,,,11.97,15.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,MedCost,Commercial,,11.41,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,inpatient,100,ML,197.80000,118.68000,MedCost,Commercial,,160.22,,,,,,,126.59,160.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,MedCost,Commercial,,120.66,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,inpatient,60,ML,46.10000,27.66000,MedCost,Commercial,,37.34,,,,,,,29.50,37.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,MedCost,Commercial,,28.12,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,MedCost,Commercial,,37.06,,,,,,,13.77,37.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,MedCost,Commercial,,27.91,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,inpatient,1,UN,17.35000,10.41000,MedCost,Commercial,,14.05,,,,,,,11.10,14.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,MedCost,Commercial,,10.58,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,16.04,,,,,,,12.67,16.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,12.08,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,inpatient,0.5,ML,4182.45000,2509.47000,MedCost,Commercial,,3387.78,,,,,,,1258.92,3400.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,MedCost,Commercial,,2551.29,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,inpatient,20,ML,81.55000,48.93000,MedCost,Commercial,,66.06,,,,,,,52.19,66.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,MedCost,Commercial,,49.75,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,inpatient,1,UN,18.80000,11.28000,MedCost,Commercial,,15.23,,,,,,,12.03,15.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,MedCost,Commercial,,11.47,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,inpatient,1,ML,126.65000,75.99000,MedCost,Commercial,,102.59,,,,,,,38.12,102.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,MedCost,Commercial,,77.26,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,inpatient,100,ML,472.90000,283.74000,MedCost,Commercial,,383.05,,,,,,,302.66,384.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,MedCost,Commercial,,288.47,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,inpatient,222,ML,9.65000,5.79000,MedCost,Commercial,,7.82,,,,,,,6.18,7.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,MedCost,Commercial,,5.89,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,16.52,,,,,,,13.06,16.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,12.44,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,inpatient,100,ML,1113.00000,667.80000,MedCost,Commercial,,901.53,,,,,,,335.01,904.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,MedCost,Commercial,,678.93,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,inpatient,500,ML,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,19.26,52.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,5.03,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,5.30,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,inpatient,1,UN,20.05000,12.03000,MedCost,Commercial,,16.24,,,,,,,6.04,16.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,MedCost,Commercial,,12.23,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,inpatient,5,ML,24.90000,14.94000,MedCost,Commercial,,20.17,,,,,,,7.49,20.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,MedCost,Commercial,,15.19,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,inpatient,5,ML,177.70000,106.62000,MedCost,Commercial,,143.94,,,,,,,113.73,144.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,MedCost,Commercial,,108.40,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,inpatient,5,GR,11.85000,7.11000,MedCost,Commercial,,9.60,,,,,,,7.58,9.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,MedCost,Commercial,,7.23,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,inpatient,1000,ML,87.00000,52.20000,MedCost,Commercial,,70.47,,,,,,,55.68,70.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,MedCost,Commercial,,53.07,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,inpatient,250,ML,81.75000,49.05000,MedCost,Commercial,,66.22,,,,,,,52.32,66.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,MedCost,Commercial,,49.87,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,inpatient,500,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,inpatient,500,ML,106.50000,63.90000,MedCost,Commercial,,86.27,,,,,,,68.16,86.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,MedCost,Commercial,,64.97,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,inpatient,10,ML,109.70000,65.82000,MedCost,Commercial,,88.86,,,,,,,70.21,89.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,MedCost,Commercial,,66.92,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,inpatient,1,UN,654.25000,392.55000,MedCost,Commercial,,529.94,,,,,,,196.93,531.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,MedCost,Commercial,,399.09,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,inpatient,100,ML,71.10000,42.66000,MedCost,Commercial,,57.59,,,,,,,45.50,57.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,MedCost,Commercial,,43.37,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,inpatient,25,ML,71.70000,43.02000,MedCost,Commercial,,58.08,,,,,,,45.89,58.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,MedCost,Commercial,,43.74,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,63.79,,,,,,,50.40,63.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,48.04,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,inpatient,50,ML,71.25000,42.75000,MedCost,Commercial,,57.71,,,,,,,45.60,57.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,MedCost,Commercial,,43.46,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,inpatient,500,ML,76.50000,45.90000,MedCost,Commercial,,61.97,,,,,,,48.96,61.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,MedCost,Commercial,,46.66,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,inpatient,50,ML,39.70000,23.82000,MedCost,Commercial,,32.16,,,,,,,25.41,32.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,MedCost,Commercial,,24.22,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,inpatient,500,ML,78.00000,46.80000,MedCost,Commercial,,63.18,,,,,,,49.92,63.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,MedCost,Commercial,,47.58,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,inpatient,1,UN,2058.00000,1234.80000,MedCost,Commercial,,1666.98,,,,,,,619.46,1673.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,MedCost,Commercial,,1255.38,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,16.52,,,,,,,13.06,16.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,12.44,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,16.52,,,,,,,13.06,16.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,12.44,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,inpatient,1,UN,516.55000,309.93000,MedCost,Commercial,,418.41,,,,,,,155.48,419.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,MedCost,Commercial,,315.10,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,inpatient,1,UN,22.25000,13.35000,MedCost,Commercial,,18.02,,,,,,,14.24,18.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,MedCost,Commercial,,13.57,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,inpatient,1,UN,22.25000,13.35000,MedCost,Commercial,,18.02,,,,,,,14.24,18.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,MedCost,Commercial,,13.57,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,inpatient,20,ML,53.90000,32.34000,MedCost,Commercial,,43.66,,,,,,,34.50,43.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,MedCost,Commercial,,32.88,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,inpatient,28,GR,8.60000,5.16000,MedCost,Commercial,,6.97,,,,,,,5.50,6.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,MedCost,Commercial,,5.25,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,inpatient,1,UN,18.75000,11.25000,MedCost,Commercial,,15.19,,,,,,,12.00,15.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,MedCost,Commercial,,11.44,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,inpatient,1,UN,142.10000,85.26000,MedCost,Commercial,,115.10,,,,,,,90.94,115.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,MedCost,Commercial,,86.68,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,inpatient,1,UN,16.65000,9.99000,MedCost,Commercial,,13.49,,,,,,,10.66,13.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,MedCost,Commercial,,10.16,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,inpatient,15,ML,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,inpatient,10,ML,422.40000,253.44000,MedCost,Commercial,,342.14,,,,,,,270.34,343.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,MedCost,Commercial,,257.66,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,10.69,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,inpatient,1,UN,50.70000,30.42000,MedCost,Commercial,,41.07,,,,,,,32.45,41.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,MedCost,Commercial,,30.93,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,inpatient,1,UN,88.65000,53.19000,MedCost,Commercial,,71.81,,,,,,,56.74,72.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,MedCost,Commercial,,54.08,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,inpatient,1,UN,21.40000,12.84000,MedCost,Commercial,,17.33,,,,,,,13.70,17.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,MedCost,Commercial,,13.05,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,14.18,,,,,,,11.20,14.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,10.68,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,inpatient,1,UN,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,inpatient,1,UN,17.55000,10.53000,MedCost,Commercial,,14.22,,,,,,,11.23,14.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,MedCost,Commercial,,10.71,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,inpatient,1,UN,90.95000,54.57000,MedCost,Commercial,,73.67,,,,,,,58.21,73.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,MedCost,Commercial,,55.48,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,inpatient,1,UN,21.25000,12.75000,MedCost,Commercial,,17.21,,,,,,,13.60,17.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,MedCost,Commercial,,12.96,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,14.18,,,,,,,11.20,14.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,10.68,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,inpatient,1,UN,1.90000,1.14000,MedCost,Commercial,,1.54,,,,,,,1.22,1.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,MedCost,Commercial,,1.16,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,inpatient,1,UN,23.95000,14.37000,MedCost,Commercial,,19.40,,,,,,,7.21,19.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,MedCost,Commercial,,14.61,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,inpatient,3,ML,22.40000,13.44000,MedCost,Commercial,,18.14,,,,,,,14.34,18.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,MedCost,Commercial,,13.66,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,inpatient,5,ML,196.60000,117.96000,MedCost,Commercial,,159.25,,,,,,,59.18,159.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,MedCost,Commercial,,119.93,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,inpatient,3,ML,17.00000,10.20000,MedCost,Commercial,,13.77,,,,,,,10.88,13.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,MedCost,Commercial,,10.37,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,inpatient,1.25,ML,48.40000,29.04000,MedCost,Commercial,,39.20,,,,,,,14.57,39.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,MedCost,Commercial,,29.52,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,inpatient,1,ML,29.70000,17.82000,MedCost,Commercial,,24.06,,,,,,,8.94,24.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,MedCost,Commercial,,18.12,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,inpatient,5,ML,7.50000,4.50000,MedCost,Commercial,,6.08,,,,,,,4.80,6.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,MedCost,Commercial,,4.58,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,13.97,,,,,,,11.04,14.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,10.52,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,10.75,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,inpatient,1,UN,20.75000,12.45000,MedCost,Commercial,,16.81,,,,,,,13.28,16.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,MedCost,Commercial,,12.66,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,inpatient,50,ML,81.40000,48.84000,MedCost,Commercial,,65.93,,,,,,,24.50,66.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,MedCost,Commercial,,49.65,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,inpatient,1,UN,3.35000,2.01000,MedCost,Commercial,,2.71,,,,,,,2.14,2.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,MedCost,Commercial,,2.04,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,inpatient,10,ML,14.40000,8.64000,MedCost,Commercial,,11.66,,,,,,,9.22,11.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,MedCost,Commercial,,8.78,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,13.20,,,,,,,10.43,13.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,9.94,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,13.73,,,,,,,10.85,13.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,10.34,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,inpatient,1,UN,22.50000,13.50000,MedCost,Commercial,,18.23,,,,,,,14.40,18.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,MedCost,Commercial,,13.72,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,inpatient,1,UN,1.30000,0.78000,MedCost,Commercial,,1.05,,,,,,,0.83200,1.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,MedCost,Commercial,,0.79300,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,inpatient,1,UN,32.60000,19.56000,MedCost,Commercial,,26.41,,,,,,,20.86,26.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,MedCost,Commercial,,19.89,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,inpatient,5,ML,79.85000,47.91000,MedCost,Commercial,,64.68,,,,,,,24.03,64.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,MedCost,Commercial,,48.71,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,inpatient,1,UN,22.90000,13.74000,MedCost,Commercial,,18.55,,,,,,,14.66,18.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,MedCost,Commercial,,13.97,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,inpatient,1,UN,18.15000,10.89000,MedCost,Commercial,,14.70,,,,,,,11.62,14.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,MedCost,Commercial,,11.07,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,inpatient,1,UN,18.85000,11.31000,MedCost,Commercial,,15.27,,,,,,,12.06,15.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,MedCost,Commercial,,11.50,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,inpatient,1,UN,19.90000,11.94000,MedCost,Commercial,,16.12,,,,,,,12.74,16.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,MedCost,Commercial,,12.14,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,inpatient,1,UN,164.50000,98.70000,MedCost,Commercial,,133.25,,,,,,,49.51,133.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,MedCost,Commercial,,100.34,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,inpatient,1,UN,16.45000,9.87000,MedCost,Commercial,,13.32,,,,,,,10.53,13.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,MedCost,Commercial,,10.03,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,13.93,,,,,,,11.01,13.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,10.49,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,inpatient,1,UN,84.35000,50.61000,MedCost,Commercial,,68.32,,,,,,,25.39,68.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,MedCost,Commercial,,51.45,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,inpatient,1,UN,31.35000,18.81000,MedCost,Commercial,,25.39,,,,,,,20.06,25.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,MedCost,Commercial,,19.12,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,inpatient,1,UN,7346.35000,4407.81000,MedCost,Commercial,,5950.54,,,,,,,2211.25,5972.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,MedCost,Commercial,,4481.27,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,inpatient,0.5,ML,28.10000,16.86000,MedCost,Commercial,,22.76,,,,,,,8.46,22.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,MedCost,Commercial,,17.14,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,inpatient,1,UN,76.80000,46.08000,MedCost,Commercial,,62.21,,,,,,,49.15,62.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,MedCost,Commercial,,46.85,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,inpatient,1,UN,31.70000,19.02000,MedCost,Commercial,,25.68,,,,,,,20.29,25.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,MedCost,Commercial,,19.34,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,13.77,,,,,,,10.88,13.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,10.37,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,13.65,,,,,,,10.78,13.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,10.28,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,inpatient,1.5,ML,2741.30000,1644.78000,MedCost,Commercial,,2220.45,,,,,,,1754.43,2228.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,MedCost,Commercial,,1672.19,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,inpatient,2,ML,88.20000,52.92000,MedCost,Commercial,,71.44,,,,,,,56.45,71.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,MedCost,Commercial,,53.80,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,inpatient,0.3,ML,39.90000,23.94000,MedCost,Commercial,,32.32,,,,,,,12.01,32.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,MedCost,Commercial,,24.34,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,inpatient,1,UN,26.35000,15.81000,MedCost,Commercial,,21.34,,,,,,,16.86,21.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,MedCost,Commercial,,16.07,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,inpatient,10,ML,97.15000,58.29000,MedCost,Commercial,,78.69,,,,,,,29.24,78.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,MedCost,Commercial,,59.26,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,inpatient,20,ML,101.60000,60.96000,MedCost,Commercial,,82.30,,,,,,,30.58,82.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,MedCost,Commercial,,61.98,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,inpatient,50,ML,147.00000,88.20000,MedCost,Commercial,,119.07,,,,,,,44.25,119.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,MedCost,Commercial,,89.67,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,inpatient,0.5,ML,25.85000,15.51000,MedCost,Commercial,,20.94,,,,,,,7.78,21.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,MedCost,Commercial,,15.77,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,inpatient,20,ML,1179.50000,707.70000,MedCost,Commercial,,955.39,,,,,,,355.03,958.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,MedCost,Commercial,,719.50,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,inpatient,10,ML,2255.00000,1353.00000,MedCost,Commercial,,1826.55,,,,,,,678.75,1833.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,MedCost,Commercial,,1375.55,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,inpatient,25,ML,5775.00000,3465.00000,MedCost,Commercial,,4677.75,,,,,,,1738.28,4695.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,MedCost,Commercial,,3522.75,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,inpatient,37.5,GR,5.90000,3.54000,MedCost,Commercial,,4.78,,,,,,,3.78,4.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,MedCost,Commercial,,3.60,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,inpatient,1,UN,2216.75000,1330.05000,MedCost,Commercial,,1795.57,,,,,,,1418.72,1802.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,MedCost,Commercial,,1352.22,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,inpatient,1,UN,18.85000,11.31000,MedCost,Commercial,,15.27,,,,,,,12.06,15.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,MedCost,Commercial,,11.50,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,inpatient,1,UN,228.00000,136.80000,MedCost,Commercial,,184.68,,,,,,,145.92,185.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,MedCost,Commercial,,139.08,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,15.63,,,,,,,12.35,15.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,11.77,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,inpatient,1,UN,20.15000,12.09000,MedCost,Commercial,,16.32,,,,,,,12.90,16.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,MedCost,Commercial,,12.29,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,inpatient,1,UN,263.60000,158.16000,MedCost,Commercial,,213.52,,,,,,,168.70,214.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,MedCost,Commercial,,160.80,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,inpatient,1,UN,21.20000,12.72000,MedCost,Commercial,,17.17,,,,,,,13.57,17.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,MedCost,Commercial,,12.93,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,inpatient,1,UN,19.40000,11.64000,MedCost,Commercial,,15.71,,,,,,,12.42,15.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,MedCost,Commercial,,11.83,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,inpatient,1,UN,23.10000,13.86000,MedCost,Commercial,,18.71,,,,,,,14.78,18.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,MedCost,Commercial,,14.09,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,inpatient,1,UN,22.65000,13.59000,MedCost,Commercial,,18.35,,,,,,,14.50,18.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,MedCost,Commercial,,13.82,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,16.20,,,,,,,12.80,16.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,12.20,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,inpatient,1,UN,25.90000,15.54000,MedCost,Commercial,,20.98,,,,,,,16.58,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,MedCost,Commercial,,15.80,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,inpatient,1,UN,101.20000,60.72000,MedCost,Commercial,,81.97,,,,,,,64.77,82.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,MedCost,Commercial,,61.73,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,inpatient,5,ML,607.05000,364.23000,MedCost,Commercial,,491.71,,,,,,,388.51,493.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,MedCost,Commercial,,370.30,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,inpatient,2000,ML,180.85000,108.51000,MedCost,Commercial,,146.49,,,,,,,54.44,147.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,MedCost,Commercial,,110.32,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,inpatient,2000,ML,180.85000,108.51000,MedCost,Commercial,,146.49,,,,,,,54.44,147.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,MedCost,Commercial,,110.32,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,inpatient,2000,ML,194.50000,116.70000,MedCost,Commercial,,157.54,,,,,,,58.54,158.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,MedCost,Commercial,,118.64,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,inpatient,2000,ML,195.65000,117.39000,MedCost,Commercial,,158.48,,,,,,,58.89,159.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,MedCost,Commercial,,119.35,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1000,ML,78.00000,46.80000,MedCost,Commercial,,63.18,,,,,,,49.92,63.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,MedCost,Commercial,,47.58,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,11.42,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,inpatient,1,UN,3.70000,2.22000,MedCost,Commercial,,3.00,,,,,,,2.37,3.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,MedCost,Commercial,,2.26,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,inpatient,1,UN,3.70000,2.22000,MedCost,Commercial,,3.00,,,,,,,2.37,3.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,MedCost,Commercial,,2.26,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,inpatient,1,UN,3.90000,2.34000,MedCost,Commercial,,3.16,,,,,,,2.50,3.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,MedCost,Commercial,,2.38,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,inpatient,1,UN,35.65000,21.39000,MedCost,Commercial,,28.88,,,,,,,22.82,28.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,MedCost,Commercial,,21.75,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,inpatient,1,UN,43.40000,26.04000,MedCost,Commercial,,35.15,,,,,,,27.78,35.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,MedCost,Commercial,,26.47,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,inpatient,1,UN,60.00000,36.00000,MedCost,Commercial,,48.60,,,,,,,38.40,48.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,MedCost,Commercial,,36.60,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,inpatient,1,UN,82.10000,49.26000,MedCost,Commercial,,66.50,,,,,,,52.54,66.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,MedCost,Commercial,,50.08,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,inpatient,1,UN,104.70000,62.82000,MedCost,Commercial,,84.81,,,,,,,67.01,85.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,MedCost,Commercial,,63.87,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,inpatient,1000,ML,220.75000,132.45000,MedCost,Commercial,,178.81,,,,,,,141.28,179.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,MedCost,Commercial,,134.66,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,inpatient,15,ML,13.40000,8.04000,MedCost,Commercial,,10.85,,,,,,,8.58,10.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,MedCost,Commercial,,8.17,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,1.17,,,,,,,0.92800,1.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,0.88450,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,inpatient,1,UN,1011.80000,607.08000,MedCost,Commercial,,819.56,,,,,,,647.55,822.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,MedCost,Commercial,,617.20,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,inpatient,56,GR,8.05000,4.83000,MedCost,Commercial,,6.52,,,,,,,5.15,6.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,MedCost,Commercial,,4.91,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,inpatient,1000,ML,114.00000,68.40000,MedCost,Commercial,,92.34,,,,,,,72.96,92.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,MedCost,Commercial,,69.54,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,inpatient,1,UN,23.15000,13.89000,MedCost,Commercial,,18.75,,,,,,,14.82,18.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,MedCost,Commercial,,14.12,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,inpatient,1,UN,26.50000,15.90000,MedCost,Commercial,,21.46,,,,,,,16.96,21.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,MedCost,Commercial,,16.16,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,inpatient,1,UN,30.00000,18.00000,MedCost,Commercial,,24.30,,,,,,,19.20,24.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,MedCost,Commercial,,18.30,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,inpatient,150,ML,752.65000,451.59000,MedCost,Commercial,,609.65,,,,,,,481.70,611.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,MedCost,Commercial,,459.12,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,inpatient,1,UN,18.35000,11.01000,MedCost,Commercial,,14.86,,,,,,,11.74,14.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,MedCost,Commercial,,11.19,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,inpatient,10,ML,308.40000,185.04000,MedCost,Commercial,,249.80,,,,,,,92.83,250.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,MedCost,Commercial,,188.12,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,inpatient,1,UN,24.10000,14.46000,MedCost,Commercial,,19.52,,,,,,,15.42,19.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,MedCost,Commercial,,14.70,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,inpatient,1000,ML,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,inpatient,2000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,inpatient,1,UN,92.30000,55.38000,MedCost,Commercial,,74.76,,,,,,,59.07,75.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,MedCost,Commercial,,56.30,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,inpatient,1,UN,90.30000,54.18000,MedCost,Commercial,,73.14,,,,,,,57.79,73.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,MedCost,Commercial,,55.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,0.1,ML,22.85000,13.71000,MedCost,Commercial,,18.51,,,,,,,6.88,18.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,MedCost,Commercial,,13.94,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,inpatient,1,UN,20.30000,12.18000,MedCost,Commercial,,16.44,,,,,,,12.99,16.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,MedCost,Commercial,,12.38,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,inpatient,1,UN,18.10000,10.86000,MedCost,Commercial,,14.66,,,,,,,11.58,14.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,MedCost,Commercial,,11.04,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,inpatient,2,ML,46.15000,27.69000,MedCost,Commercial,,37.38,,,,,,,29.54,37.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,MedCost,Commercial,,28.15,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,inpatient,2,ML,51.50000,30.90000,MedCost,Commercial,,41.72,,,,,,,32.96,41.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,MedCost,Commercial,,31.41,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,inpatient,10,ML,267.70000,160.62000,MedCost,Commercial,,216.84,,,,,,,171.33,217.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,MedCost,Commercial,,163.30,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,inpatient,1,UN,27.90000,16.74000,MedCost,Commercial,,22.60,,,,,,,8.40,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,MedCost,Commercial,,17.02,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,inpatient,1,UN,63.15000,37.89000,MedCost,Commercial,,51.15,,,,,,,19.01,51.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,MedCost,Commercial,,38.52,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,inpatient,10,GR,599.15000,359.49000,MedCost,Commercial,,485.31,,,,,,,383.46,487.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,MedCost,Commercial,,365.48,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,inpatient,1,GR,37.75000,22.65000,MedCost,Commercial,,30.58,,,,,,,24.16,30.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,MedCost,Commercial,,23.03,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,inpatient,1,UN,62.45000,37.47000,MedCost,Commercial,,50.58,,,,,,,39.97,50.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,MedCost,Commercial,,38.09,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,inpatient,1,UN,3520.00000,2112.00000,MedCost,Commercial,,2851.20,,,,,,,1059.52,2861.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,MedCost,Commercial,,2147.20,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,inpatient,160,ML,1552.00000,931.20000,MedCost,Commercial,,1257.12,,,,,,,993.28,1261.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,MedCost,Commercial,,946.72,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,inpatient,2.5,ML,1204.10000,722.46000,MedCost,Commercial,,975.32,,,,,,,362.43,978.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,MedCost,Commercial,,734.50,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,14.42,,,,,,,11.39,14.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,10.86,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,inpatient,1,UN,216.00000,129.60000,MedCost,Commercial,,174.96,,,,,,,138.24,175.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,MedCost,Commercial,,131.76,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,inpatient,5,ML,115.25000,69.15000,MedCost,Commercial,,93.35,,,,,,,73.76,93.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,MedCost,Commercial,,70.30,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,inpatient,1,UN,523.95000,314.37000,MedCost,Commercial,,424.40,,,,,,,157.71,425.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,MedCost,Commercial,,319.61,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,inpatient,1,UN,698.50000,419.10000,MedCost,Commercial,,565.78,,,,,,,210.25,567.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,MedCost,Commercial,,426.08,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,inpatient,10,ML,1199.00000,719.40000,MedCost,Commercial,,971.19,,,,,,,360.90,974.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,MedCost,Commercial,,731.39,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,inpatient,5,ML,335.80000,201.48000,MedCost,Commercial,,272.00,,,,,,,101.08,273.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,MedCost,Commercial,,204.84,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,inpatient,473,ML,349.50000,209.70000,MedCost,Commercial,,283.10,,,,,,,223.68,284.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,MedCost,Commercial,,213.19,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,inpatient,1,UN,19.10000,11.46000,MedCost,Commercial,,15.47,,,,,,,12.22,15.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,MedCost,Commercial,,11.65,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,inpatient,1,UN,19.25000,11.55000,MedCost,Commercial,,15.59,,,,,,,12.32,15.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,MedCost,Commercial,,11.74,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,inpatient,1,UN,21.35000,12.81000,MedCost,Commercial,,17.29,,,,,,,13.66,17.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,MedCost,Commercial,,13.02,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,inpatient,2,GR,28.45000,17.07000,MedCost,Commercial,,23.04,,,,,,,18.21,23.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,MedCost,Commercial,,17.35,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,inpatient,5,ML,19.30000,11.58000,MedCost,Commercial,,15.63,,,,,,,5.81,15.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,MedCost,Commercial,,11.77,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,inpatient,1,UN,12869.00000,7721.40000,MedCost,Commercial,,10423.89,,,,,,,3873.57,10462.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,MedCost,Commercial,,7850.09,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,inpatient,1,ML,52.40000,31.44000,MedCost,Commercial,,42.44,,,,,,,15.77,42.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,MedCost,Commercial,,31.96,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,inpatient,1,UN,357.25000,214.35000,MedCost,Commercial,,289.37,,,,,,,107.53,290.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,MedCost,Commercial,,217.92,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,inpatient,15,GR,66.60000,39.96000,MedCost,Commercial,,53.95,,,,,,,42.62,54.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,MedCost,Commercial,,40.63,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,inpatient,1,UN,17.75000,10.65000,MedCost,Commercial,,14.38,,,,,,,11.36,14.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,MedCost,Commercial,,10.83,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,inpatient,44,ML,2.45000,1.47000,MedCost,Commercial,,1.98,,,,,,,1.57,1.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,MedCost,Commercial,,1.49,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,inpatient,88,ML,4.45000,2.67000,MedCost,Commercial,,3.60,,,,,,,2.85,3.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,MedCost,Commercial,,2.71,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,inpatient,1,UN,21.35000,12.81000,MedCost,Commercial,,17.29,,,,,,,13.66,17.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,MedCost,Commercial,,13.02,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,inpatient,1,UN,27.10000,16.26000,MedCost,Commercial,,21.95,,,,,,,17.34,22.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,MedCost,Commercial,,16.53,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,inpatient,250,ML,693.00000,415.80000,MedCost,Commercial,,561.33,,,,,,,208.59,563.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,MedCost,Commercial,,422.73,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,inpatient,1,UN,19.50000,11.70000,MedCost,Commercial,,15.79,,,,,,,12.48,15.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,MedCost,Commercial,,11.89,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,13.81,,,,,,,10.91,13.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,10.40,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,inpatient,1,UN,19.50000,11.70000,MedCost,Commercial,,15.79,,,,,,,12.48,15.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,MedCost,Commercial,,11.89,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,inpatient,1,UN,21.60000,12.96000,MedCost,Commercial,,17.50,,,,,,,13.82,17.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,MedCost,Commercial,,13.18,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,inpatient,1,UN,83.10000,49.86000,MedCost,Commercial,,67.31,,,,,,,25.01,67.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,MedCost,Commercial,,50.69,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,inpatient,1,UN,369.65000,221.79000,MedCost,Commercial,,299.42,,,,,,,236.58,300.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,MedCost,Commercial,,225.49,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,inpatient,1000,ML,420.00000,252.00000,MedCost,Commercial,,340.20,,,,,,,268.80,341.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,MedCost,Commercial,,256.20,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,inpatient,1,ML,28.65000,17.19000,MedCost,Commercial,,23.21,,,,,,,8.62,23.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,MedCost,Commercial,,17.48,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,inpatient,10,ML,42.40000,25.44000,MedCost,Commercial,,34.34,,,,,,,12.76,34.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,MedCost,Commercial,,25.86,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,inpatient,2,ML,28.40000,17.04000,MedCost,Commercial,,23.00,,,,,,,8.55,23.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,MedCost,Commercial,,17.32,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,inpatient,20,ML,53.45000,32.07000,MedCost,Commercial,,43.29,,,,,,,16.09,43.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,MedCost,Commercial,,32.60,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,inpatient,5,ML,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,9.33,25.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,inpatient,5,ML,25.95000,15.57000,MedCost,Commercial,,21.02,,,,,,,16.61,21.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,MedCost,Commercial,,15.83,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,inpatient,1,UN,1.75000,1.05000,MedCost,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,MedCost,Commercial,,1.07,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,inpatient,100,ML,119.90000,71.94000,MedCost,Commercial,,97.12,,,,,,,76.74,97.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,MedCost,Commercial,,73.14,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,inpatient,5,ML,6.30000,3.78000,MedCost,Commercial,,5.10,,,,,,,4.03,5.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,MedCost,Commercial,,3.84,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,inpatient,150,ML,94.00000,56.40000,MedCost,Commercial,,76.14,,,,,,,28.29,76.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,MedCost,Commercial,,57.34,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,inpatient,100,ML,86.50000,51.90000,MedCost,Commercial,,70.06,,,,,,,55.36,70.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,MedCost,Commercial,,52.77,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,14.01,,,,,,,11.07,14.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,10.55,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,inpatient,16.7,ML,465.05000,279.03000,MedCost,Commercial,,376.69,,,,,,,139.98,378.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,MedCost,Commercial,,283.68,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,inpatient,5,ML,319.00000,191.40000,MedCost,Commercial,,258.39,,,,,,,96.02,259.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,MedCost,Commercial,,194.59,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,inpatient,50,ML,843.95000,506.37000,MedCost,Commercial,,683.60,,,,,,,254.03,686.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,MedCost,Commercial,,514.81,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,inpatient,5,ML,20.50000,12.30000,MedCost,Commercial,,16.61,,,,,,,13.12,16.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,MedCost,Commercial,,12.51,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,14.09,,,,,,,11.14,14.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,10.61,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,11.42,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,inpatient,2,ML,265.05000,159.03000,MedCost,Commercial,,214.69,,,,,,,169.63,215.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,MedCost,Commercial,,161.68,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,inpatient,1,UN,858.55000,515.13000,MedCost,Commercial,,695.43,,,,,,,258.42,698.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,MedCost,Commercial,,523.72,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,inpatient,1,UN,19973.00000,11983.80000,MedCost,Commercial,,16178.13,,,,,,,6011.87,16238.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,MedCost,Commercial,,12183.53,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,inpatient,1,UN,33.80000,20.28000,MedCost,Commercial,,27.38,,,,,,,21.63,27.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,MedCost,Commercial,,20.62,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,inpatient,3,ML,21.35000,12.81000,MedCost,Commercial,,17.29,,,,,,,13.66,17.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,MedCost,Commercial,,13.02,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,inpatient,3,ML,21.35000,12.81000,MedCost,Commercial,,17.29,,,,,,,13.66,17.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,MedCost,Commercial,,13.02,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,inpatient,1,UN,183.15000,109.89000,MedCost,Commercial,,148.35,,,,,,,117.22,148.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,MedCost,Commercial,,111.72,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,inpatient,60,ML,116.30000,69.78000,MedCost,Commercial,,94.20,,,,,,,74.43,94.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,MedCost,Commercial,,70.94,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,inpatient,1,UN,29.90000,17.94000,MedCost,Commercial,,24.22,,,,,,,19.14,24.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,MedCost,Commercial,,18.24,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,inpatient,15,GR,125.35000,75.21000,MedCost,Commercial,,101.53,,,,,,,80.22,101.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,MedCost,Commercial,,76.46,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,inpatient,15,GR,71.50000,42.90000,MedCost,Commercial,,57.91,,,,,,,45.76,58.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,MedCost,Commercial,,43.62,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,inpatient,60,ML,190.10000,114.06000,MedCost,Commercial,,153.98,,,,,,,121.66,154.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,MedCost,Commercial,,115.96,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,inpatient,1,ML,84.55000,50.73000,MedCost,Commercial,,68.49,,,,,,,25.45,68.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,MedCost,Commercial,,51.58,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,inpatient,5,ML,521.30000,312.78000,MedCost,Commercial,,422.25,,,,,,,333.63,423.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,MedCost,Commercial,,317.99,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,inpatient,0.5,ML,59.70000,35.82000,MedCost,Commercial,,48.36,,,,,,,17.97,48.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,MedCost,Commercial,,36.42,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,inpatient,1,UN,22.00000,13.20000,MedCost,Commercial,,17.82,,,,,,,14.08,17.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,MedCost,Commercial,,13.42,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,inpatient,1,UN,28.60000,17.16000,MedCost,Commercial,,23.17,,,,,,,18.30,23.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,MedCost,Commercial,,17.45,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,inpatient,0.5,ML,121.05000,72.63000,MedCost,Commercial,,98.05,,,,,,,36.44,98.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,MedCost,Commercial,,73.84,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,MedCost,Commercial,,23666.50,,,,,,,8794.59,23754.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,MedCost,Commercial,,17822.92,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,inpatient,0.2,ML,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,5.55,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,inpatient,3,ML,36.65000,21.99000,MedCost,Commercial,,29.69,,,,,,,23.46,29.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,MedCost,Commercial,,22.36,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,10.75,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,inpatient,1,UN,22.15000,13.29000,MedCost,Commercial,,17.94,,,,,,,14.18,18.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,MedCost,Commercial,,13.51,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,inpatient,1,UN,22.35000,13.41000,MedCost,Commercial,,18.10,,,,,,,14.30,18.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,MedCost,Commercial,,13.63,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,inpatient,5,ML,93.35000,56.01000,MedCost,Commercial,,75.61,,,,,,,28.10,75.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,MedCost,Commercial,,56.94,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,inpatient,1,UN,2978.05000,1786.83000,MedCost,Commercial,,2412.22,,,,,,,896.39,2421.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,MedCost,Commercial,,1816.61,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,inpatient,1,UN,35.80000,21.48000,MedCost,Commercial,,29.00,,,,,,,22.91,29.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,MedCost,Commercial,,21.84,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,inpatient,1.6666666666666665,ML,128.65000,77.19000,MedCost,Commercial,,104.21,,,,,,,38.72,104.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,MedCost,Commercial,,78.48,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,inpatient,1,UN,2262.45000,1357.47000,MedCost,Commercial,,1832.58,,,,,,,681.00,1839.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,MedCost,Commercial,,1380.09,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,inpatient,10,ML,42.60000,25.56000,MedCost,Commercial,,34.51,,,,,,,12.82,34.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,MedCost,Commercial,,25.99,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,inpatient,2,ML,35.05000,21.03000,MedCost,Commercial,,28.39,,,,,,,10.55,28.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,MedCost,Commercial,,21.38,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,inpatient,4,ML,29.35000,17.61000,MedCost,Commercial,,23.77,,,,,,,8.83,23.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,MedCost,Commercial,,17.90,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,inpatient,120,ML,55.25000,33.15000,MedCost,Commercial,,44.75,,,,,,,35.36,44.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,MedCost,Commercial,,33.70,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,inpatient,60,ML,36.20000,21.72000,MedCost,Commercial,,29.32,,,,,,,23.17,29.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,MedCost,Commercial,,22.08,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,inpatient,20,ML,5230.30000,3138.18000,MedCost,Commercial,,4236.54,,,,,,,1574.32,4252.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,MedCost,Commercial,,3190.48,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,inpatient,20,ML,13051.70000,7831.02000,MedCost,Commercial,,10571.88,,,,,,,3928.56,10611.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,MedCost,Commercial,,7961.54,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,inpatient,20,ML,26087.25000,15652.35000,MedCost,Commercial,,21130.67,,,,,,,7852.26,21208.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,MedCost,Commercial,,15913.22,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,inpatient,20,ML,52158.50000,31295.10000,MedCost,Commercial,,42248.39,,,,,,,15699.71,42404.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,MedCost,Commercial,,31816.69,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,10.75,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,inpatient,100,ML,180.95000,108.57000,MedCost,Commercial,,146.57,,,,,,,54.47,147.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,MedCost,Commercial,,110.38,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,inpatient,1,UN,399.60000,239.76000,MedCost,Commercial,,323.68,,,,,,,255.74,324.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,MedCost,Commercial,,243.76,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,inpatient,1,UN,25.50000,15.30000,MedCost,Commercial,,20.66,,,,,,,16.32,20.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,MedCost,Commercial,,15.55,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,inpatient,1,UN,50.15000,30.09000,MedCost,Commercial,,40.62,,,,,,,32.10,40.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,MedCost,Commercial,,30.59,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,inpatient,1,UN,147.80000,88.68000,MedCost,Commercial,,119.72,,,,,,,94.59,120.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,MedCost,Commercial,,90.16,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,inpatient,1,UN,316.30000,189.78000,MedCost,Commercial,,256.20,,,,,,,95.21,257.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,MedCost,Commercial,,192.94,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,inpatient,1,UN,18.40000,11.04000,MedCost,Commercial,,14.90,,,,,,,11.78,14.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,MedCost,Commercial,,11.22,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,14.42,,,,,,,11.39,14.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,10.86,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,inpatient,50,ML,48.40000,29.04000,MedCost,Commercial,,39.20,,,,,,,30.98,39.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,MedCost,Commercial,,29.52,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,inpatient,75,ML,50.45000,30.27000,MedCost,Commercial,,40.86,,,,,,,32.29,41.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,MedCost,Commercial,,30.77,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,13.77,,,,,,,10.88,13.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Commercial,,10.37,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,inpatient,1,UN,17.95000,10.77000,MedCost,Commercial,,14.54,,,,,,,11.49,14.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,MedCost,Commercial,,10.95,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,inpatient,1,UN,4712.40000,2827.44000,MedCost,Commercial,,3817.04,,,,,,,1418.43,3831.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,MedCost,Commercial,,2874.56,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,13.81,,,,,,,10.91,13.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,10.40,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,inpatient,1,UN,57.35000,34.41000,MedCost,Commercial,,46.45,,,,,,,36.70,46.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,MedCost,Commercial,,34.98,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,inpatient,15,GR,134.50000,80.70000,MedCost,Commercial,,108.94,,,,,,,86.08,109.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,MedCost,Commercial,,82.05,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,inpatient,2,ML,37.15000,22.29000,MedCost,Commercial,,30.09,,,,,,,11.18,30.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,MedCost,Commercial,,22.66,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,MedCost,Commercial,,135.80,,,,,,,50.46,136.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,MedCost,Commercial,,102.27,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,inpatient,1,UN,48.90000,29.34000,MedCost,Commercial,,39.61,,,,,,,31.30,39.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,MedCost,Commercial,,29.83,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,inpatient,1,UN,21.90000,13.14000,MedCost,Commercial,,17.74,,,,,,,14.02,17.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,MedCost,Commercial,,13.36,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,inpatient,1,UN,22.50000,13.50000,MedCost,Commercial,,18.23,,,,,,,14.40,18.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,MedCost,Commercial,,13.72,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,inpatient,1,UN,22.90000,13.74000,MedCost,Commercial,,18.55,,,,,,,14.66,18.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,MedCost,Commercial,,13.97,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,inpatient,0.5,ML,321.65000,192.99000,MedCost,Commercial,,260.54,,,,,,,96.82,261.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,MedCost,Commercial,,196.21,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,inpatient,1,UN,21.50000,12.90000,MedCost,Commercial,,17.41,,,,,,,13.76,17.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,MedCost,Commercial,,13.12,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,inpatient,1,UN,26.25000,15.75000,MedCost,Commercial,,21.26,,,,,,,16.80,21.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,MedCost,Commercial,,16.01,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,inpatient,1,UN,37.10000,22.26000,MedCost,Commercial,,30.05,,,,,,,11.17,30.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,MedCost,Commercial,,22.63,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,inpatient,1,ML,27.85000,16.71000,MedCost,Commercial,,22.56,,,,,,,8.38,22.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,MedCost,Commercial,,16.99,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,inpatient,7.5,ML,465.05000,279.03000,MedCost,Commercial,,376.69,,,,,,,297.63,378.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,MedCost,Commercial,,283.68,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,inpatient,473,ML,11.30000,6.78000,MedCost,Commercial,,9.15,,,,,,,7.23,9.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,MedCost,Commercial,,6.89,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,inpatient,2.5,ML,1.65000,0.99000,MedCost,Commercial,,1.34,,,,,,,1.06,1.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,MedCost,Commercial,,1.01,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,inpatient,2.5,ML,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,inpatient,1,UN,1034.85000,620.91000,MedCost,Commercial,,838.23,,,,,,,311.49,841.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,MedCost,Commercial,,631.26,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,inpatient,1,UN,24.85000,14.91000,MedCost,Commercial,,20.13,,,,,,,15.90,20.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,MedCost,Commercial,,15.16,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,inpatient,1,UN,24.80000,14.88000,MedCost,Commercial,,20.09,,,,,,,15.87,20.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,MedCost,Commercial,,15.13,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,inpatient,5,ML,252.00000,151.20000,MedCost,Commercial,,204.12,,,,,,,75.85,204.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,MedCost,Commercial,,153.72,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,inpatient,1,UN,30.00000,18.00000,MedCost,Commercial,,24.30,,,,,,,19.20,24.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,MedCost,Commercial,,18.30,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,inpatient,1,UN,32.35000,19.41000,MedCost,Commercial,,26.20,,,,,,,20.70,26.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,MedCost,Commercial,,19.73,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,14.34,,,,,,,11.33,14.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,10.80,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,14.30,,,,,,,11.30,14.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,10.77,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,inpatient,1,UN,18.25000,10.95000,MedCost,Commercial,,14.78,,,,,,,11.68,14.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,MedCost,Commercial,,11.13,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,inpatient,1,UN,19.65000,11.79000,MedCost,Commercial,,15.92,,,,,,,12.58,15.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,MedCost,Commercial,,11.99,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,MedCost,Commercial,,5935.84,,,,,,,2205.79,5957.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,MedCost,Commercial,,4470.20,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.4,ML,17.65000,10.59000,MedCost,Commercial,,14.30,,,,,,,5.31,14.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,MedCost,Commercial,,10.77,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,inpatient,1,ML,18.10000,10.86000,MedCost,Commercial,,14.66,,,,,,,11.58,14.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,MedCost,Commercial,,11.04,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,inpatient,1,ML,20.20000,12.12000,MedCost,Commercial,,16.36,,,,,,,12.93,16.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,MedCost,Commercial,,12.32,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,inpatient,1,ML,16.75000,10.05000,MedCost,Commercial,,13.57,,,,,,,10.72,13.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,MedCost,Commercial,,10.22,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,inpatient,1000,ML,87.50000,52.50000,MedCost,Commercial,,70.88,,,,,,,26.34,71.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,MedCost,Commercial,,53.38,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,inpatient,1,UN,6248.60000,3749.16000,MedCost,Commercial,,5061.37,,,,,,,1880.83,5080.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,MedCost,Commercial,,3811.65,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,inpatient,1,UN,87.55000,52.53000,MedCost,Commercial,,70.92,,,,,,,56.03,71.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,MedCost,Commercial,,53.41,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,inpatient,1,UN,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,inpatient,1,UN,48.90000,29.34000,MedCost,Commercial,,39.61,,,,,,,31.30,39.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,MedCost,Commercial,,29.83,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,inpatient,473,ML,96.90000,58.14000,MedCost,Commercial,,78.49,,,,,,,62.02,78.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,MedCost,Commercial,,59.11,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,inpatient,473,ML,105.40000,63.24000,MedCost,Commercial,,85.37,,,,,,,67.46,85.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,MedCost,Commercial,,64.29,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,inpatient,1,UN,21.25000,12.75000,MedCost,Commercial,,17.21,,,,,,,13.60,17.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,MedCost,Commercial,,12.96,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,10,ML,1.50000,0.90000,MedCost,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,MedCost,Commercial,,0.91500,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,inpatient,1,UN,18.70000,11.22000,MedCost,Commercial,,15.15,,,,,,,11.97,15.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,MedCost,Commercial,,11.41,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,inpatient,1,ML,70.60000,42.36000,MedCost,Commercial,,57.19,,,,,,,21.25,57.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,MedCost,Commercial,,43.07,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,inpatient,177,ML,4.85000,2.91000,MedCost,Commercial,,3.93,,,,,,,3.10,3.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,MedCost,Commercial,,2.96,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,13.73,,,,,,,10.85,13.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,10.34,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,inpatient,1,UN,28.40000,17.04000,MedCost,Commercial,,23.00,,,,,,,18.18,23.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,MedCost,Commercial,,17.32,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,13.65,,,,,,,10.78,13.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Commercial,,10.28,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,inpatient,1,UN,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,145.38,392.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,inpatient,1,UN,17.95000,10.77000,MedCost,Commercial,,14.54,,,,,,,11.49,14.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,MedCost,Commercial,,10.95,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,13.12,,,,,,,10.37,13.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,9.88,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,inpatient,5,ML,23.60000,14.16000,MedCost,Commercial,,19.12,,,,,,,15.10,19.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,MedCost,Commercial,,14.40,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,inpatient,28,GR,4.30000,2.58000,MedCost,Commercial,,3.48,,,,,,,2.75,3.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,MedCost,Commercial,,2.62,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,inpatient,28,GR,27.45000,16.47000,MedCost,Commercial,,22.23,,,,,,,17.57,22.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,MedCost,Commercial,,16.74,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,inpatient,28,GR,4.30000,2.58000,MedCost,Commercial,,3.48,,,,,,,2.75,3.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,MedCost,Commercial,,2.62,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,inpatient,28.35,GR,25.90000,15.54000,MedCost,Commercial,,20.98,,,,,,,16.58,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,MedCost,Commercial,,15.80,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,inpatient,1,UN,17.15000,10.29000,MedCost,Commercial,,13.89,,,,,,,10.98,13.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,MedCost,Commercial,,10.46,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,inpatient,1,UN,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,inpatient,473,ML,1.75000,1.05000,MedCost,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,MedCost,Commercial,,1.07,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,inpatient,1,UN,22.55000,13.53000,MedCost,Commercial,,18.27,,,,,,,14.43,18.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,MedCost,Commercial,,13.76,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,inpatient,0.1,ML,23.30000,13.98000,MedCost,Commercial,,18.87,,,,,,,7.01,18.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,MedCost,Commercial,,14.21,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,inpatient,1,UN,22.55000,13.53000,MedCost,Commercial,,18.27,,,,,,,14.43,18.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,MedCost,Commercial,,13.76,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,inpatient,30,ML,8.35000,5.01000,MedCost,Commercial,,6.76,,,,,,,5.34,6.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,MedCost,Commercial,,5.09,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,inpatient,1,UN,22.70000,13.62000,MedCost,Commercial,,18.39,,,,,,,14.53,18.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,MedCost,Commercial,,13.85,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,inpatient,1,UN,16.10000,9.66000,MedCost,Commercial,,13.04,,,,,,,10.30,13.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,MedCost,Commercial,,9.82,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,inpatient,100,ML,113.50000,68.10000,MedCost,Commercial,,91.94,,,,,,,72.64,92.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,MedCost,Commercial,,69.23,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,inpatient,1,ML,169.40000,101.64000,MedCost,Commercial,,137.21,,,,,,,50.99,137.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,MedCost,Commercial,,103.33,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,inpatient,1,UN,27.85000,16.71000,MedCost,Commercial,,22.56,,,,,,,17.82,22.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,MedCost,Commercial,,16.99,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,inpatient,10,ML,31.35000,18.81000,MedCost,Commercial,,25.39,,,,,,,20.06,25.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,MedCost,Commercial,,19.12,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,inpatient,1,UN,18064.20000,10838.52000,MedCost,Commercial,,14632.00,,,,,,,5437.32,14686.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,MedCost,Commercial,,11019.16,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,3204.04,,,,,,,1190.64,3215.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,2412.92,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,inpatient,1,UN,30.90000,18.54000,MedCost,Commercial,,25.03,,,,,,,9.30,25.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,MedCost,Commercial,,18.85,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,inpatient,2,ML,757.60000,454.56000,MedCost,Commercial,,613.66,,,,,,,228.04,615.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,MedCost,Commercial,,462.14,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,inpatient,1,UN,231.15000,138.69000,MedCost,Commercial,,187.23,,,,,,,147.94,187.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,MedCost,Commercial,,141.00,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,inpatient,1,UN,143.75000,86.25000,MedCost,Commercial,,116.44,,,,,,,43.27,116.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,MedCost,Commercial,,87.69,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,MedCost,Commercial,,2219.89,,,,,,,824.92,2228.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,MedCost,Commercial,,1671.77,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,inpatient,1,UN,1507.85000,904.71000,MedCost,Commercial,,1221.36,,,,,,,453.86,1225.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,MedCost,Commercial,,919.79,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,inpatient,15,ML,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,inpatient,15,ML,3.50000,2.10000,MedCost,Commercial,,2.83,,,,,,,2.24,2.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,MedCost,Commercial,,2.13,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,inpatient,3,ML,109.25000,65.55000,MedCost,Commercial,,88.49,,,,,,,32.88,88.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,MedCost,Commercial,,66.64,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,inpatient,1,UN,1.60000,0.96000,MedCost,Commercial,,1.30,,,,,,,1.02,1.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,MedCost,Commercial,,0.97600,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,13.20,,,,,,,10.43,13.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,9.94,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,inpatient,2.5,ML,27.40000,16.44000,MedCost,Commercial,,22.19,,,,,,,17.54,22.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,MedCost,Commercial,,16.71,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,inpatient,2.5,ML,20.20000,12.12000,MedCost,Commercial,,16.36,,,,,,,12.93,16.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,MedCost,Commercial,,12.32,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,inpatient,1,ML,40.95000,24.57000,MedCost,Commercial,,33.17,,,,,,,12.33,33.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,MedCost,Commercial,,24.98,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,inpatient,1,UN,1391.25000,834.75000,MedCost,Commercial,,1126.91,,,,,,,890.40,1131.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,MedCost,Commercial,,848.66,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,inpatient,1,UN,60.95000,36.57000,MedCost,Commercial,,49.37,,,,,,,39.01,49.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,MedCost,Commercial,,37.18,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,inpatient,15,GR,37.05000,22.23000,MedCost,Commercial,,30.01,,,,,,,23.71,30.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,MedCost,Commercial,,22.60,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,inpatient,1,UN,23.80000,14.28000,MedCost,Commercial,,19.28,,,,,,,7.16,19.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,MedCost,Commercial,,14.52,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,inpatient,15,ML,377.25000,226.35000,MedCost,Commercial,,305.57,,,,,,,113.55,306.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,MedCost,Commercial,,230.12,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,inpatient,45,ML,482.55000,289.53000,MedCost,Commercial,,390.87,,,,,,,145.25,392.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,MedCost,Commercial,,294.36,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,inpatient,5,ML,334.00000,200.40000,MedCost,Commercial,,270.54,,,,,,,100.53,271.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,MedCost,Commercial,,203.74,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,inpatient,60,ML,535.35000,321.21000,MedCost,Commercial,,433.63,,,,,,,161.14,435.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,MedCost,Commercial,,326.56,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,inpatient,10,ML,117.60000,70.56000,MedCost,Commercial,,95.26,,,,,,,75.26,95.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,MedCost,Commercial,,71.74,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,inpatient,5,ML,90.30000,54.18000,MedCost,Commercial,,73.14,,,,,,,57.79,73.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,MedCost,Commercial,,55.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,inpatient,0.01,ML,16.05000,9.63000,MedCost,Commercial,,13.00,,,,,,,10.27,13.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,MedCost,Commercial,,9.79,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,inpatient,2,ML,25.05000,15.03000,MedCost,Commercial,,20.29,,,,,,,7.54,20.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,MedCost,Commercial,,15.28,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,inpatient,30,ML,116.10000,69.66000,MedCost,Commercial,,94.04,,,,,,,34.95,94.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,MedCost,Commercial,,70.82,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,inpatient,200,ML,686.20000,411.72000,MedCost,Commercial,,555.82,,,,,,,439.17,557.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,MedCost,Commercial,,418.58,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,inpatient,480,ML,1607.20000,964.32000,MedCost,Commercial,,1301.83,,,,,,,1028.61,1306.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,MedCost,Commercial,,980.39,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,inpatient,1,UN,17.45000,10.47000,MedCost,Commercial,,14.13,,,,,,,11.17,14.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,MedCost,Commercial,,10.64,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,inpatient,1,UN,18.65000,11.19000,MedCost,Commercial,,15.11,,,,,,,11.94,15.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,MedCost,Commercial,,11.38,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,250,ML,66.75000,40.05000,MedCost,Commercial,,54.07,,,,,,,42.72,54.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,MedCost,Commercial,,40.72,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,56.50,,,,,,,44.64,56.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,42.55,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,54.67,,,,,,,43.20,54.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,41.17,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,63.79,,,,,,,50.40,63.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,48.04,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,56.50,,,,,,,44.64,56.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,42.55,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,54.67,,,,,,,43.20,54.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,41.17,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,inpatient,250,ML,150.00000,90.00000,MedCost,Commercial,,121.50,,,,,,,96.00,121.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,MedCost,Commercial,,91.50,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,inpatient,250,ML,73.50000,44.10000,MedCost,Commercial,,59.53,,,,,,,47.04,59.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,MedCost,Commercial,,44.84,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,56.50,,,,,,,44.64,56.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,42.55,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,54.67,,,,,,,43.20,54.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,41.17,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,54.67,,,,,,,43.20,54.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Commercial,,41.17,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,inpatient,250,ML,66.75000,40.05000,MedCost,Commercial,,54.07,,,,,,,42.72,54.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,MedCost,Commercial,,40.72,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,inpatient,500,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,inpatient,500,ML,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,56.50,,,,,,,44.64,56.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Commercial,,42.55,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,63.79,,,,,,,50.40,63.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,48.04,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,inpatient,250,ML,66.75000,40.05000,MedCost,Commercial,,54.07,,,,,,,42.72,54.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,MedCost,Commercial,,40.72,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,inpatient,5,ML,16.15000,9.69000,MedCost,Commercial,,13.08,,,,,,,10.34,13.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,MedCost,Commercial,,9.85,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,inpatient,473,ML,1023.50000,614.10000,MedCost,Commercial,,829.03,,,,,,,655.04,832.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,MedCost,Commercial,,624.34,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,inpatient,4,ML,22.65000,13.59000,MedCost,Commercial,,18.35,,,,,,,6.82,18.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,MedCost,Commercial,,13.82,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,11.26,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,inpatient,1,UN,7227.30000,4336.38000,MedCost,Commercial,,5854.11,,,,,,,2175.42,5875.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,MedCost,Commercial,,4408.65,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,inpatient,20,ML,26468.35000,15881.01000,MedCost,Commercial,,21439.36,,,,,,,7966.97,21518.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,MedCost,Commercial,,16145.69,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,inpatient,1,ML,5590.45000,3354.27000,MedCost,Commercial,,4528.26,,,,,,,1682.73,4545.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,MedCost,Commercial,,3410.17,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,inpatient,5,ML,26468.35000,15881.01000,MedCost,Commercial,,21439.36,,,,,,,7966.97,21518.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,MedCost,Commercial,,16145.69,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,inpatient,1,UN,18.90000,11.34000,MedCost,Commercial,,15.31,,,,,,,12.10,15.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,MedCost,Commercial,,11.53,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,inpatient,1,UN,19.20000,11.52000,MedCost,Commercial,,15.55,,,,,,,12.29,15.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,MedCost,Commercial,,11.71,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,inpatient,10,ML,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,32.21,86.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,MedCost,Commercial,,5935.84,,,,,,,2205.79,5957.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,MedCost,Commercial,,4470.20,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,inpatient,1,ML,350.20000,210.12000,MedCost,Commercial,,283.66,,,,,,,105.41,284.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,MedCost,Commercial,,213.62,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,inpatient,1,UN,1243.00000,745.80000,MedCost,Commercial,,1006.83,,,,,,,374.14,1010.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,MedCost,Commercial,,758.23,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,inpatient,2,ML,22.80000,13.68000,MedCost,Commercial,,18.47,,,,,,,14.59,18.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,MedCost,Commercial,,13.91,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,inpatient,2,ML,46.20000,27.72000,MedCost,Commercial,,37.42,,,,,,,29.57,37.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,MedCost,Commercial,,28.18,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,inpatient,1,ML,7030.60000,4218.36000,MedCost,Commercial,,5694.79,,,,,,,2116.21,5715.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,MedCost,Commercial,,4288.67,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,inpatient,26.3,ML,332.30000,199.38000,MedCost,Commercial,,269.16,,,,,,,100.02,270.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,MedCost,Commercial,,202.70,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,inpatient,5.26,ML,308.30000,184.98000,MedCost,Commercial,,249.72,,,,,,,92.80,250.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,MedCost,Commercial,,188.06,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,inpatient,52.6,ML,673.55000,404.13000,MedCost,Commercial,,545.58,,,,,,,202.74,547.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,MedCost,Commercial,,410.87,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,MedCost,Commercial,,32493.88,,,,,,,12074.89,32614.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,MedCost,Commercial,,24470.70,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,MedCost,Commercial,,129306.86,,,,,,,48051.07,129785.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,MedCost,Commercial,,97379.24,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,MedCost,Commercial,,1191.75,,,,,,,442.86,1196.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,MedCost,Commercial,,897.49,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,MedCost,Commercial,,2373.10,,,,,,,881.85,2381.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,MedCost,Commercial,,1787.15,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,26823.30000,16093.98000,MedCost,Commercial,,21726.87,,,,,,,8073.81,21807.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,MedCost,Commercial,,16362.21,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,inpatient,1,ML,320.15000,192.09000,MedCost,Commercial,,259.32,,,,,,,96.37,260.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,MedCost,Commercial,,195.29,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,MedCost,Commercial,,234.94,,,,,,,87.31,235.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,MedCost,Commercial,,176.93,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,MedCost,Commercial,,254.95,,,,,,,94.74,255.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,MedCost,Commercial,,192.00,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,MedCost,Commercial,,234.74,,,,,,,87.23,235.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,MedCost,Commercial,,176.78,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,MedCost,Commercial,,341.25,,,,,,,126.81,342.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,MedCost,Commercial,,256.99,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,inpatient,16,ML,2035.00000,1221.00000,MedCost,Commercial,,1648.35,,,,,,,612.53,1654.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,MedCost,Commercial,,1241.35,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,inpatient,2,ML,495.00000,297.00000,MedCost,Commercial,,400.95,,,,,,,149.00,402.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,MedCost,Commercial,,301.95,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,inpatient,8,ML,996.60000,597.96000,MedCost,Commercial,,807.25,,,,,,,299.98,810.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,MedCost,Commercial,,607.93,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,inpatient,0.5,ML,22.90000,13.74000,MedCost,Commercial,,18.55,,,,,,,14.66,18.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,MedCost,Commercial,,13.97,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,inpatient,0.5,ML,77.55000,46.53000,MedCost,Commercial,,62.82,,,,,,,23.34,63.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,MedCost,Commercial,,47.31,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,inpatient,26.3,ML,337.40000,202.44000,MedCost,Commercial,,273.29,,,,,,,101.56,274.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,MedCost,Commercial,,205.81,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,MedCost,Commercial,,4568.60,,,,,,,1697.72,4585.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,MedCost,Commercial,,3440.55,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,MedCost,Commercial,,9086.13,,,,,,,3376.45,9119.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,MedCost,Commercial,,6842.64,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,inpatient,2,ML,105.35000,63.21000,MedCost,Commercial,,85.33,,,,,,,67.42,85.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,MedCost,Commercial,,64.26,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,MedCost,Commercial,,36.81,,,,,,,13.68,36.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,MedCost,Commercial,,27.72,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,MedCost,Commercial,,51.39,,,,,,,19.10,51.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,MedCost,Commercial,,38.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,1,ML,19.05000,11.43000,MedCost,Commercial,,15.43,,,,,,,5.73,15.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,MedCost,Commercial,,11.62,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,inpatient,1000,ML,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,25.28,68.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,inpatient,0.5,ML,26.65000,15.99000,MedCost,Commercial,,21.59,,,,,,,17.06,21.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,MedCost,Commercial,,16.26,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,MedCost,Commercial,,277.67,,,,,,,103.18,278.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,MedCost,Commercial,,209.11,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,inpatient,100,ML,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,18.36,49.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,MedCost,Commercial,,61.56,,,,,,,22.88,61.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,MedCost,Commercial,,46.36,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,inpatient,5,ML,292.85000,175.71000,MedCost,Commercial,,237.21,,,,,,,88.15,238.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,MedCost,Commercial,,178.64,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,inpatient,1,UN,20.80000,12.48000,MedCost,Commercial,,16.85,,,,,,,6.26,16.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,MedCost,Commercial,,12.69,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,MedCost,Commercial,,35.07,,,,,,,13.03,35.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,MedCost,Commercial,,26.41,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,20.33,,,,,,,7.56,20.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,15.31,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,MedCost,Commercial,,23.65,,,,,,,8.79,23.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,MedCost,Commercial,,17.81,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,inpatient,18,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,inpatient,1,UN,19.50000,11.70000,MedCost,Commercial,,15.79,,,,,,,5.87,15.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,MedCost,Commercial,,11.89,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,inpatient,1,UN,19.25000,11.55000,MedCost,Commercial,,15.59,,,,,,,5.79,15.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,MedCost,Commercial,,11.74,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,inpatient,50,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,10.69,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,10.75,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,inpatient,250,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,inpatient,100,ML,103.35000,62.01000,MedCost,Commercial,,83.71,,,,,,,31.11,84.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,MedCost,Commercial,,63.04,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,inpatient,12,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,inpatient,40,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,inpatient,100,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1000,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,inpatient,25,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,inpatient,250,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,inpatient,50,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,inpatient,500,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,inpatient,100,ML,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1000,ML,78.00000,46.80000,MedCost,Commercial,,63.18,,,,,,,49.92,63.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,MedCost,Commercial,,47.58,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,inpatient,25,ML,71.40000,42.84000,MedCost,Commercial,,57.83,,,,,,,45.70,57.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,MedCost,Commercial,,43.55,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,inpatient,250,ML,75.75000,45.45000,MedCost,Commercial,,61.36,,,,,,,48.48,61.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,MedCost,Commercial,,46.21,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,inpatient,50,ML,70.65000,42.39000,MedCost,Commercial,,57.23,,,,,,,45.22,57.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,MedCost,Commercial,,43.10,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,inpatient,48,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,inpatient,1,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,MedCost,Commercial,,232.06,,,,,,,86.24,232.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,MedCost,Commercial,,174.76,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,inpatient,0.3,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,inpatient,0.09999,ML,63.05000,37.83000,MedCost,Commercial,,51.07,,,,,,,18.98,51.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,MedCost,Commercial,,38.46,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,109.40000,65.64000,MedCost,Commercial,,88.61,,,,,,,70.02,88.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,MedCost,Commercial,,66.73,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,inpatient,480,ML,4.75000,2.85000,MedCost,Commercial,,3.85,,,,,,,3.04,3.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,MedCost,Commercial,,2.90,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,inpatient,50,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,177.39,,,,,,,65.92,178.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,133.59,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,926.92,,,,,,,344.45,930.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,698.05,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,inpatient,5,ML,1086.20000,651.72000,MedCost,Commercial,,879.82,,,,,,,695.17,883.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,MedCost,Commercial,,662.58,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,inpatient,5,ML,44.50000,26.70000,MedCost,Commercial,,36.05,,,,,,,28.48,36.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,MedCost,Commercial,,27.14,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,10,ML,46.50000,27.90000,MedCost,Commercial,,37.66,,,,,,,14.00,37.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,MedCost,Commercial,,28.36,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,inpatient,0.5,ML,31.55000,18.93000,MedCost,Commercial,,25.56,,,,,,,9.50,25.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,MedCost,Commercial,,19.25,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,inpatient,1,UN,2.80000,1.68000,MedCost,Commercial,,2.27,,,,,,,1.79,2.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,MedCost,Commercial,,1.71,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,inpatient,1,UN,36575.00000,21945.00000,MedCost,Commercial,,29625.75,,,,,,,11009.08,29735.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,MedCost,Commercial,,22310.75,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,inpatient,10,ML,318.15000,190.89000,MedCost,Commercial,,257.70,,,,,,,95.76,258.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,MedCost,Commercial,,194.07,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,177.39,,,,,,,65.92,178.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Commercial,,133.59,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,inpatient,8,ML,63.85000,38.31000,MedCost,Commercial,,51.72,,,,,,,19.22,51.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,MedCost,Commercial,,38.95,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,inpatient,500,ML,115.50000,69.30000,MedCost,Commercial,,93.56,,,,,,,34.77,93.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,MedCost,Commercial,,70.45,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,inpatient,1,ML,27.75000,16.65000,MedCost,Commercial,,22.48,,,,,,,8.35,22.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,MedCost,Commercial,,16.93,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,inpatient,30,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,9.52,,,,,,,7.52,9.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,7.17,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,9.52,,,,,,,7.52,9.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,7.17,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,9.52,,,,,,,7.52,9.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,7.17,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,9.52,,,,,,,7.52,9.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Commercial,,7.17,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,75.10000,45.06000,MedCost,Commercial,,60.83,,,,,,,22.61,61.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,MedCost,Commercial,,45.81,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,inpatient,20,ML,108.15000,64.89000,MedCost,Commercial,,87.60,,,,,,,32.55,87.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,MedCost,Commercial,,65.97,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,inpatient,40,ML,153.25000,91.95000,MedCost,Commercial,,124.13,,,,,,,46.13,124.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,MedCost,Commercial,,93.48,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,inpatient,2,ML,21.85000,13.11000,MedCost,Commercial,,17.70,,,,,,,6.58,17.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,MedCost,Commercial,,13.33,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,inpatient,2,ML,19.60000,11.76000,MedCost,Commercial,,15.88,,,,,,,5.90,15.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,MedCost,Commercial,,11.96,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,inpatient,25,ML,57.75000,34.65000,MedCost,Commercial,,46.78,,,,,,,36.96,46.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,MedCost,Commercial,,35.23,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,inpatient,60,ML,204.30000,122.58000,MedCost,Commercial,,165.48,,,,,,,130.75,166.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,MedCost,Commercial,,124.62,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,13.28,,,,,,,10.50,13.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,10.00,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,inpatient,1,UN,53.20000,31.92000,MedCost,Commercial,,43.09,,,,,,,34.05,43.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,MedCost,Commercial,,32.45,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,13.12,,,,,,,10.37,13.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Commercial,,9.88,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,inpatient,1,UN,23.95000,14.37000,MedCost,Commercial,,19.40,,,,,,,15.33,19.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,MedCost,Commercial,,14.61,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,inpatient,5,ML,13686.90000,8212.14000,MedCost,Commercial,,11086.39,,,,,,,4119.76,11127.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,MedCost,Commercial,,8349.01,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,inpatient,1,ML,2799.00000,1679.40000,MedCost,Commercial,,2267.19,,,,,,,842.50,2275.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,MedCost,Commercial,,1707.39,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,inpatient,20,ML,79.65000,47.79000,MedCost,Commercial,,64.52,,,,,,,23.97,64.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,MedCost,Commercial,,48.59,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,inpatient,1,UN,48.35000,29.01000,MedCost,Commercial,,39.16,,,,,,,14.55,39.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,MedCost,Commercial,,29.49,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,inpatient,1,UN,28.20000,16.92000,MedCost,Commercial,,22.84,,,,,,,8.49,22.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,MedCost,Commercial,,17.20,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,inpatient,100,ML,76.20000,45.72000,MedCost,Commercial,,61.72,,,,,,,48.77,61.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,MedCost,Commercial,,46.48,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,MedCost,Commercial,,37.06,,,,,,,13.77,37.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,MedCost,Commercial,,27.91,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,inpatient,25,ML,104.40000,62.64000,MedCost,Commercial,,84.56,,,,,,,66.82,84.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,MedCost,Commercial,,63.68,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,inpatient,5000,ML,243.00000,145.80000,MedCost,Commercial,,196.83,,,,,,,155.52,197.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,MedCost,Commercial,,148.23,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,inpatient,1,UN,63.60000,38.16000,MedCost,Commercial,,51.52,,,,,,,19.14,51.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,MedCost,Commercial,,38.80,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,inpatient,5000,ML,243.00000,145.80000,MedCost,Commercial,,196.83,,,,,,,155.52,197.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,MedCost,Commercial,,148.23,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,MedCost,Commercial,,24.14,,,,,,,8.97,24.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,MedCost,Commercial,,18.18,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,inpatient,1,UN,578.15000,346.89000,MedCost,Commercial,,468.30,,,,,,,370.02,470.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,MedCost,Commercial,,352.67,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,inpatient,5,ML,28.50000,17.10000,MedCost,Commercial,,23.09,,,,,,,8.58,23.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,MedCost,Commercial,,17.39,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,inpatient,5000,ML,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,174.72,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,inpatient,5000,ML,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,174.72,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,inpatient,2,ML,20.65000,12.39000,MedCost,Commercial,,16.73,,,,,,,6.22,16.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,MedCost,Commercial,,12.60,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,inpatient,2,ML,20.15000,12.09000,MedCost,Commercial,,16.32,,,,,,,6.07,16.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,MedCost,Commercial,,12.29,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,inpatient,2,ML,20.25000,12.15000,MedCost,Commercial,,16.40,,,,,,,6.10,16.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,MedCost,Commercial,,12.35,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,MedCost,Commercial,,21.34,,,,,,,7.93,21.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,MedCost,Commercial,,16.07,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,inpatient,14.2,GR,7.10000,4.26000,MedCost,Commercial,,5.75,,,,,,,4.54,5.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,MedCost,Commercial,,4.33,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,inpatient,100,ML,153.75000,92.25000,MedCost,Commercial,,124.54,,,,,,,46.28,125.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,MedCost,Commercial,,93.79,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,inpatient,100,ML,405.05000,243.03000,MedCost,Commercial,,328.09,,,,,,,121.92,329.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,MedCost,Commercial,,247.08,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,inpatient,120,ML,155.00000,93.00000,MedCost,Commercial,,125.55,,,,,,,99.20,126.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,MedCost,Commercial,,94.55,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,inpatient,100,ML,803.50000,482.10000,MedCost,Commercial,,650.84,,,,,,,514.24,653.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,MedCost,Commercial,,490.13,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,inpatient,4,ML,66.20000,39.72000,MedCost,Commercial,,53.62,,,,,,,19.93,53.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,MedCost,Commercial,,40.38,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,inpatient,100,ML,25.00000,15.00000,MedCost,Commercial,,20.25,,,,,,,16.00,20.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,MedCost,Commercial,,15.25,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,inpatient,100,ML,19.00000,11.40000,MedCost,Commercial,,15.39,,,,,,,12.16,15.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,MedCost,Commercial,,11.59,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,inpatient,100,ML,70.00000,42.00000,MedCost,Commercial,,56.70,,,,,,,44.80,56.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,MedCost,Commercial,,42.70,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,inpatient,200,ML,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,56.32,71.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,inpatient,120,ML,74.80000,44.88000,MedCost,Commercial,,60.59,,,,,,,47.87,60.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,MedCost,Commercial,,45.63,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,inpatient,15,ML,60.40000,36.24000,MedCost,Commercial,,48.92,,,,,,,38.66,49.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,MedCost,Commercial,,36.84,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,inpatient,100,ML,92.20000,55.32000,MedCost,Commercial,,74.68,,,,,,,59.01,74.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,MedCost,Commercial,,56.24,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,inpatient,240,ML,376.00000,225.60000,MedCost,Commercial,,304.56,,,,,,,240.64,305.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,MedCost,Commercial,,229.36,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,inpatient,200,ML,19.00000,11.40000,MedCost,Commercial,,15.39,,,,,,,12.16,15.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,MedCost,Commercial,,11.59,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,inpatient,1,UN,64.35000,38.61000,MedCost,Commercial,,52.12,,,,,,,41.18,52.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,MedCost,Commercial,,39.25,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,inpatient,20,ML,27.05000,16.23000,MedCost,Commercial,,21.91,,,,,,,17.31,21.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,MedCost,Commercial,,16.50,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,inpatient,5,ML,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,inpatient,1,ML,114.75000,68.85000,MedCost,Commercial,,92.95,,,,,,,34.54,93.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,MedCost,Commercial,,70.00,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,inpatient,5000,ML,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,174.72,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,inpatient,5000,ML,243.00000,145.80000,MedCost,Commercial,,196.83,,,,,,,155.52,197.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,MedCost,Commercial,,148.23,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,inpatient,30,GR,47.50000,28.50000,MedCost,Commercial,,38.48,,,,,,,30.40,38.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,MedCost,Commercial,,28.98,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,14.09,,,,,,,5.24,14.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,10.61,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,inpatient,0.4,ML,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,19.26,52.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,28.70000,17.22000,MedCost,Commercial,,23.25,,,,,,,18.37,23.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,MedCost,Commercial,,17.51,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,13.28,,,,,,,10.50,13.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,10.00,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,inpatient,0.25,ML,17.35000,10.41000,MedCost,Commercial,,14.05,,,,,,,5.22,14.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,MedCost,Commercial,,10.58,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,inpatient,500,ML,94.50000,56.70000,MedCost,Commercial,,76.55,,,,,,,28.44,76.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,MedCost,Commercial,,57.65,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,inpatient,300,ML,34.00000,20.40000,MedCost,Commercial,,27.54,,,,,,,21.76,27.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,MedCost,Commercial,,20.74,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,inpatient,50,ML,23.35000,14.01000,MedCost,Commercial,,18.91,,,,,,,14.94,18.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,MedCost,Commercial,,14.24,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,inpatient,50,ML,215.60000,129.36000,MedCost,Commercial,,174.64,,,,,,,64.90,175.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,MedCost,Commercial,,131.52,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,inpatient,40,ML,338.70000,203.22000,MedCost,Commercial,,274.35,,,,,,,216.77,275.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,MedCost,Commercial,,206.61,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,inpatient,10,ML,835.00000,501.00000,MedCost,Commercial,,676.35,,,,,,,251.34,678.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,MedCost,Commercial,,509.35,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,inpatient,0.5,UN,65.25000,39.15000,MedCost,Commercial,,52.85,,,,,,,19.64,53.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,MedCost,Commercial,,39.80,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,81.95000,49.17000,MedCost,Commercial,,66.38,,,,,,,24.67,66.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,MedCost,Commercial,,49.99,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,inpatient,300,ML,222.60000,133.56000,MedCost,Commercial,,180.31,,,,,,,67.00,180.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,MedCost,Commercial,,135.79,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,inpatient,25,ML,88.20000,52.92000,MedCost,Commercial,,71.44,,,,,,,56.45,71.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,MedCost,Commercial,,53.80,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,MedCost,Commercial,,71.32,,,,,,,26.50,71.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,MedCost,Commercial,,53.71,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.5,ML,128.55000,77.13000,MedCost,Commercial,,104.13,,,,,,,82.27,104.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,MedCost,Commercial,,78.42,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,inpatient,37.5,GR,5.90000,3.54000,MedCost,Commercial,,4.78,,,,,,,3.78,4.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,MedCost,Commercial,,3.60,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,MedCost,Commercial,,41.39,,,,,,,15.38,41.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,MedCost,Commercial,,31.17,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,inpatient,2,ML,28.40000,17.04000,MedCost,Commercial,,23.00,,,,,,,8.55,23.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,MedCost,Commercial,,17.32,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,MedCost,Commercial,,30592.53,,,,,,,11368.33,30705.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,MedCost,Commercial,,23038.82,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,inpatient,1,UN,319.00000,191.40000,MedCost,Commercial,,258.39,,,,,,,96.02,259.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,MedCost,Commercial,,194.59,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,inpatient,8,ML,168.40000,101.04000,MedCost,Commercial,,136.40,,,,,,,107.78,136.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,MedCost,Commercial,,102.72,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,inpatient,8,ML,64.55000,38.73000,MedCost,Commercial,,52.29,,,,,,,19.43,52.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,MedCost,Commercial,,39.38,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,inpatient,50,ML,72.70000,43.62000,MedCost,Commercial,,58.89,,,,,,,21.88,59.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,MedCost,Commercial,,44.35,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,inpatient,50,ML,64.90000,38.94000,MedCost,Commercial,,52.57,,,,,,,19.53,52.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,MedCost,Commercial,,39.59,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,inpatient,50,ML,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,22.57,60.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,inpatient,15,ML,60.40000,36.24000,MedCost,Commercial,,48.92,,,,,,,38.66,49.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,MedCost,Commercial,,36.84,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,inpatient,5,ML,87.95000,52.77000,MedCost,Commercial,,71.24,,,,,,,56.29,71.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,MedCost,Commercial,,53.65,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,inpatient,50,ML,372.10000,223.26000,MedCost,Commercial,,301.40,,,,,,,238.14,302.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,MedCost,Commercial,,226.98,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,inpatient,1,ML,19.25000,11.55000,MedCost,Commercial,,15.59,,,,,,,5.79,15.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,MedCost,Commercial,,11.74,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,inpatient,4,ML,67.40000,40.44000,MedCost,Commercial,,54.59,,,,,,,43.14,54.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,MedCost,Commercial,,41.11,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,inpatient,8,ML,68.40000,41.04000,MedCost,Commercial,,55.40,,,,,,,20.59,55.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,MedCost,Commercial,,41.72,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,inpatient,50,ML,96.60000,57.96000,MedCost,Commercial,,78.25,,,,,,,29.08,78.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,MedCost,Commercial,,58.93,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,inpatient,1,ML,30.70000,18.42000,MedCost,Commercial,,24.87,,,,,,,9.24,24.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,MedCost,Commercial,,18.73,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,inpatient,40,ML,106.55000,63.93000,MedCost,Commercial,,86.31,,,,,,,68.19,86.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,MedCost,Commercial,,65.00,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,inpatient,100,ML,171.80000,103.08000,MedCost,Commercial,,139.16,,,,,,,109.95,139.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,MedCost,Commercial,,104.80,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,inpatient,50,ML,103.95000,62.37000,MedCost,Commercial,,84.20,,,,,,,31.29,84.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,MedCost,Commercial,,63.41,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,250.40000,150.24000,MedCost,Commercial,,202.82,,,,,,,75.37,203.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,MedCost,Commercial,,152.74,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,inpatient,10,ML,170.95000,102.57000,MedCost,Commercial,,138.47,,,,,,,51.46,138.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,MedCost,Commercial,,104.28,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,inpatient,50,ML,80.65000,48.39000,MedCost,Commercial,,65.33,,,,,,,24.28,65.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,MedCost,Commercial,,49.20,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,inpatient,100,ML,70.35000,42.21000,MedCost,Commercial,,56.98,,,,,,,21.18,57.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,MedCost,Commercial,,42.91,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,inpatient,1,GR,103.95000,62.37000,MedCost,Commercial,,84.20,,,,,,,31.29,84.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,MedCost,Commercial,,63.41,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,inpatient,20,ML,81.90000,49.14000,MedCost,Commercial,,66.34,,,,,,,24.65,66.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,MedCost,Commercial,,49.96,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,inpatient,1,UN,96.60000,57.96000,MedCost,Commercial,,78.25,,,,,,,29.08,78.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,MedCost,Commercial,,58.93,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,109.20000,65.52000,MedCost,Commercial,,88.45,,,,,,,32.87,88.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,MedCost,Commercial,,66.61,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,inpatient,500,ML,478.80000,287.28000,MedCost,Commercial,,387.83,,,,,,,144.12,389.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,MedCost,Commercial,,292.07,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,inpatient,50,ML,117.85000,70.71000,MedCost,Commercial,,95.46,,,,,,,35.47,95.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,MedCost,Commercial,,71.89,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,300,ML,567.00000,340.20000,MedCost,Commercial,,459.27,,,,,,,170.67,460.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,MedCost,Commercial,,345.87,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,inpatient,1,UN,1165.70000,699.42000,MedCost,Commercial,,944.22,,,,,,,350.88,947.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,MedCost,Commercial,,711.08,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,inpatient,1,UN,1242.40000,745.44000,MedCost,Commercial,,1006.34,,,,,,,373.96,1010.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,MedCost,Commercial,,757.86,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,MedCost,Commercial,,29.57,,,,,,,10.99,29.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,MedCost,Commercial,,22.27,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,inpatient,100,ML,83.60000,50.16000,MedCost,Commercial,,67.72,,,,,,,53.50,67.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,MedCost,Commercial,,51.00,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,inpatient,100,ML,74.35000,44.61000,MedCost,Commercial,,60.22,,,,,,,22.38,60.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,MedCost,Commercial,,45.35,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,inpatient,100,ML,153.30000,91.98000,MedCost,Commercial,,124.17,,,,,,,46.14,124.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,MedCost,Commercial,,93.51,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,250,ML,218.50000,131.10000,MedCost,Commercial,,176.99,,,,,,,65.77,177.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,MedCost,Commercial,,133.28,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,1000,ML,512.40000,307.44000,MedCost,Commercial,,415.04,,,,,,,154.23,416.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,MedCost,Commercial,,312.56,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,inpatient,1000,ML,961.80000,577.08000,MedCost,Commercial,,779.06,,,,,,,289.50,781.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,MedCost,Commercial,,586.70,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,MedCost,Commercial,,73.14,,,,,,,27.18,73.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,MedCost,Commercial,,55.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,inpatient,1,UN,103.15000,61.89000,MedCost,Commercial,,83.55,,,,,,,31.05,83.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,MedCost,Commercial,,62.92,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,inpatient,1,UN,247.75000,148.65000,MedCost,Commercial,,200.68,,,,,,,74.57,201.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,MedCost,Commercial,,151.13,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,inpatient,10,ML,66.80000,40.08000,MedCost,Commercial,,54.11,,,,,,,20.11,54.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,MedCost,Commercial,,40.75,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,inpatient,40,ML,78.15000,46.89000,MedCost,Commercial,,63.30,,,,,,,23.52,63.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,MedCost,Commercial,,47.67,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,inpatient,1,UN,735.15000,441.09000,MedCost,Commercial,,595.47,,,,,,,221.28,597.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,MedCost,Commercial,,448.44,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,inpatient,1,UN,17.55000,10.53000,MedCost,Commercial,,14.22,,,,,,,5.28,14.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,MedCost,Commercial,,10.71,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,0.1,ML,275.20000,165.12000,MedCost,Commercial,,222.91,,,,,,,82.84,223.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,MedCost,Commercial,,167.87,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,inpatient,0.2,ML,63.45000,38.07000,MedCost,Commercial,,51.39,,,,,,,19.10,51.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,MedCost,Commercial,,38.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,inpatient,10,ML,105.10000,63.06000,MedCost,Commercial,,85.13,,,,,,,31.64,85.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,MedCost,Commercial,,64.11,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,inpatient,100,ML,289.80000,173.88000,MedCost,Commercial,,234.74,,,,,,,87.23,235.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,MedCost,Commercial,,176.78,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,50,ML,176.40000,105.84000,MedCost,Commercial,,142.88,,,,,,,53.10,143.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,MedCost,Commercial,,107.60,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,inpatient,1,ML,24.20000,14.52000,MedCost,Commercial,,19.60,,,,,,,15.49,19.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,MedCost,Commercial,,14.76,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,inpatient,5,ML,120.55000,72.33000,MedCost,Commercial,,97.65,,,,,,,36.29,98.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,MedCost,Commercial,,73.54,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,inpatient,50,ML,71.40000,42.84000,MedCost,Commercial,,57.83,,,,,,,21.49,58.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,MedCost,Commercial,,43.55,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,inpatient,1,UN,78.35000,47.01000,MedCost,Commercial,,63.46,,,,,,,50.14,63.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,MedCost,Commercial,,47.79,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,inpatient,50,ML,180.60000,108.36000,MedCost,Commercial,,146.29,,,,,,,115.58,146.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,MedCost,Commercial,,110.17,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,inpatient,50,ML,171.80000,103.08000,MedCost,Commercial,,139.16,,,,,,,51.71,139.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,MedCost,Commercial,,104.80,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,inpatient,50,ML,75.60000,45.36000,MedCost,Commercial,,61.24,,,,,,,22.76,61.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,MedCost,Commercial,,46.12,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,inpatient,100,ML,29.20000,17.52000,MedCost,Commercial,,23.65,,,,,,,18.69,23.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,MedCost,Commercial,,17.81,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,inpatient,2,ML,34.75000,20.85000,MedCost,Commercial,,28.15,,,,,,,10.46,28.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,MedCost,Commercial,,21.20,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,inpatient,100,ML,71.40000,42.84000,MedCost,Commercial,,57.83,,,,,,,21.49,58.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,MedCost,Commercial,,43.55,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,inpatient,250,ML,1785.00000,1071.00000,MedCost,Commercial,,1445.85,,,,,,,537.28,1451.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,MedCost,Commercial,,1088.85,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,inpatient,10,ML,99.55000,59.73000,MedCost,Commercial,,80.64,,,,,,,29.96,80.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,MedCost,Commercial,,60.73,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,inpatient,0.5,ML,25.15000,15.09000,MedCost,Commercial,,20.37,,,,,,,7.57,20.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,MedCost,Commercial,,15.34,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,inpatient,0.5,ML,34.85000,20.91000,MedCost,Commercial,,28.23,,,,,,,10.49,28.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,MedCost,Commercial,,21.26,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,inpatient,8,ML,71.75000,43.05000,MedCost,Commercial,,58.12,,,,,,,45.92,58.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,MedCost,Commercial,,43.77,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,inpatient,1,ML,27.75000,16.65000,MedCost,Commercial,,22.48,,,,,,,8.35,22.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,MedCost,Commercial,,16.93,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,MedCost,Commercial,,51.11,,,,,,,18.99,51.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,MedCost,Commercial,,38.49,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,inpatient,500,ML,174.00000,104.40000,MedCost,Commercial,,140.94,,,,,,,111.36,141.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,MedCost,Commercial,,106.14,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,inpatient,8,ML,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,40.96,52.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,inpatient,2,ML,88.20000,52.92000,MedCost,Commercial,,71.44,,,,,,,56.45,71.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,MedCost,Commercial,,53.80,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,0.5,ML,22.45000,13.47000,MedCost,Commercial,,18.18,,,,,,,6.76,18.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,MedCost,Commercial,,13.69,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,0.5,ML,22.50000,13.50000,MedCost,Commercial,,18.23,,,,,,,6.77,18.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,MedCost,Commercial,,13.72,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,inpatient,1,ML,25.60000,15.36000,MedCost,Commercial,,20.74,,,,,,,7.71,20.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,MedCost,Commercial,,15.62,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,MedCost,Commercial,,34.59,,,,,,,12.85,34.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,MedCost,Commercial,,26.05,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,MedCost,Commercial,,21.14,,,,,,,7.86,21.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,MedCost,Commercial,,15.92,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,82.17,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,inpatient,50,ML,131.05000,78.63000,MedCost,Commercial,,106.15,,,,,,,39.45,106.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,MedCost,Commercial,,79.94,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,inpatient,100,ML,94.50000,56.70000,MedCost,Commercial,,76.55,,,,,,,28.44,76.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,MedCost,Commercial,,57.65,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,inpatient,50,ML,139.65000,83.79000,MedCost,Commercial,,113.12,,,,,,,89.38,113.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,MedCost,Commercial,,85.19,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,29.15000,17.49000,MedCost,Commercial,,23.61,,,,,,,18.66,23.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,MedCost,Commercial,,17.78,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,inpatient,2.5,ML,104.30000,62.58000,MedCost,Commercial,,84.48,,,,,,,66.75,84.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,MedCost,Commercial,,63.62,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,inpatient,180,ML,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,68.48,86.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,inpatient,50,ML,81.90000,49.14000,MedCost,Commercial,,66.34,,,,,,,24.65,66.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,MedCost,Commercial,,49.96,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,inpatient,3,ML,17.75000,10.65000,MedCost,Commercial,,14.38,,,,,,,5.34,14.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,MedCost,Commercial,,10.83,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,inpatient,10,ML,68.30000,40.98000,MedCost,Commercial,,55.32,,,,,,,20.56,55.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,MedCost,Commercial,,41.66,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,inpatient,2.5,ML,17.25000,10.35000,MedCost,Commercial,,13.97,,,,,,,11.04,14.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,MedCost,Commercial,,10.52,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,55.90000,33.54000,MedCost,Commercial,,45.28,,,,,,,16.83,45.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,MedCost,Commercial,,34.10,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,inpatient,500,ML,82.25000,49.35000,MedCost,Commercial,,66.62,,,,,,,24.76,66.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,MedCost,Commercial,,50.17,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,inpatient,10,ML,106.35000,63.81000,MedCost,Commercial,,86.14,,,,,,,68.06,86.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,MedCost,Commercial,,64.87,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,333.3,ML,310.80000,186.48000,MedCost,Commercial,,251.75,,,,,,,93.55,252.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,MedCost,Commercial,,189.59,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,inpatient,10,ML,79.75000,47.85000,MedCost,Commercial,,64.60,,,,,,,24.00,64.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,MedCost,Commercial,,48.65,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,inpatient,20,ML,319.25000,191.55000,MedCost,Commercial,,258.59,,,,,,,96.09,259.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,MedCost,Commercial,,194.74,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,22.57,60.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,inpatient,4,ML,64.15000,38.49000,MedCost,Commercial,,51.96,,,,,,,19.31,52.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,MedCost,Commercial,,39.13,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,inpatient,50,ML,39.70000,23.82000,MedCost,Commercial,,32.16,,,,,,,25.41,32.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,MedCost,Commercial,,24.22,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,inpatient,100,ML,105.00000,63.00000,MedCost,Commercial,,85.05,,,,,,,31.61,85.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,MedCost,Commercial,,64.05,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,inpatient,10,ML,74.75000,44.85000,MedCost,Commercial,,60.55,,,,,,,47.84,60.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,MedCost,Commercial,,45.60,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,inpatient,50,ML,52.00000,31.20000,MedCost,Commercial,,42.12,,,,,,,15.65,42.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,MedCost,Commercial,,31.72,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,inpatient,400,ML,161.60000,96.96000,MedCost,Commercial,,130.90,,,,,,,48.64,131.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,MedCost,Commercial,,98.58,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,inpatient,0.5,ML,22.15000,13.29000,MedCost,Commercial,,17.94,,,,,,,14.18,18.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,MedCost,Commercial,,13.51,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,inpatient,15,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,MedCost,Commercial,,51.11,,,,,,,18.99,51.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,MedCost,Commercial,,38.49,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,inpatient,1,ML,451.85000,271.11000,MedCost,Commercial,,366.00,,,,,,,136.01,367.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,MedCost,Commercial,,275.63,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,MedCost,Commercial,,135.80,,,,,,,50.46,136.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,MedCost,Commercial,,102.27,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,inpatient,50,ML,276.60000,165.96000,MedCost,Commercial,,224.05,,,,,,,83.26,224.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,MedCost,Commercial,,168.73,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,inpatient,300,ML,239.40000,143.64000,MedCost,Commercial,,193.91,,,,,,,153.22,194.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,MedCost,Commercial,,146.03,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,inpatient,10,ML,73.90000,44.34000,MedCost,Commercial,,59.86,,,,,,,47.30,60.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,MedCost,Commercial,,45.08,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,inpatient,8,ML,65.70000,39.42000,MedCost,Commercial,,53.22,,,,,,,19.78,53.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,MedCost,Commercial,,40.08,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,inpatient,50,ML,79.60000,47.76000,MedCost,Commercial,,64.48,,,,,,,23.96,64.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,MedCost,Commercial,,48.56,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,inpatient,36,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,inpatient,6,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,inpatient,60,GR,59.80000,35.88000,MedCost,Commercial,,48.44,,,,,,,38.27,48.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,MedCost,Commercial,,36.48,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,inpatient,6.25,ME,16.05000,9.63000,MedCost,Commercial,,13.00,,,,,,,10.27,13.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,MedCost,Commercial,,9.79,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,inpatient,100,ML,247.60000,148.56000,MedCost,Commercial,,200.56,,,,,,,74.53,201.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,MedCost,Commercial,,151.04,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,MedCost,Commercial,,8162.37,,,,,,,3033.18,8192.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,MedCost,Commercial,,6146.97,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,inpatient,1,UN,87.60000,52.56000,MedCost,Commercial,,70.96,,,,,,,26.37,71.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,MedCost,Commercial,,53.44,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,inpatient,200,ML,150.40000,90.24000,MedCost,Commercial,,121.82,,,,,,,45.27,122.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,MedCost,Commercial,,91.74,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,inpatient,1150,ML,153.65000,92.19000,MedCost,Commercial,,124.46,,,,,,,98.34,124.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,MedCost,Commercial,,93.73,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,inpatient,1,ML,364.25000,218.55000,MedCost,Commercial,,295.04,,,,,,,109.64,296.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,MedCost,Commercial,,222.19,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,inpatient,96,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,inpatient,120,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,inpatient,120,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,inpatient,180,ME,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,inpatient,0.5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,MedCost,Commercial,,12829.31,,,,,,,4767.43,12876.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,MedCost,Commercial,,9661.58,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,inpatient,15,ML,394.60000,236.76000,MedCost,Commercial,,319.63,,,,,,,118.77,320.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,MedCost,Commercial,,240.71,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,MedCost,Commercial,,454.37,,,,,,,168.85,456.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,MedCost,Commercial,,342.18,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,MedCost,Commercial,,252.15,,,,,,,93.70,253.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,MedCost,Commercial,,189.89,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,MedCost,Commercial,,392.12,,,,,,,145.71,393.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,MedCost,Commercial,,295.30,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,MedCost,Commercial,,366.40,,,,,,,136.16,367.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,MedCost,Commercial,,275.93,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,MedCost,Commercial,,329.67,,,,,,,122.51,330.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,MedCost,Commercial,,248.27,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,inpatient,15,ML,367.40000,220.44000,MedCost,Commercial,,297.59,,,,,,,110.59,298.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,MedCost,Commercial,,224.11,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,MedCost,Commercial,,454.37,,,,,,,168.85,456.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,MedCost,Commercial,,342.18,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,MedCost,Commercial,,252.15,,,,,,,93.70,253.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,MedCost,Commercial,,189.89,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,MedCost,Commercial,,392.12,,,,,,,145.71,393.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,MedCost,Commercial,,295.30,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,MedCost,Commercial,,2219.89,,,,,,,824.92,2228.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,MedCost,Commercial,,1671.77,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,inpatient,4,ML,101.20000,60.72000,MedCost,Commercial,,81.97,,,,,,,30.46,82.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,MedCost,Commercial,,61.73,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,inpatient,60,ML,115.15000,69.09000,MedCost,Commercial,,93.27,,,,,,,73.70,93.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,MedCost,Commercial,,70.24,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,20.33,,,,,,,7.56,20.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,15.31,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,MedCost,Commercial,,24.02,,,,,,,8.92,24.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,MedCost,Commercial,,18.09,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,inpatient,10,ML,88.20000,52.92000,MedCost,Commercial,,71.44,,,,,,,56.45,71.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,MedCost,Commercial,,53.80,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,inpatient,1,UN,195.30000,117.18000,MedCost,Commercial,,158.19,,,,,,,58.79,158.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,MedCost,Commercial,,119.13,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,inpatient,0.25,ML,146.20000,87.72000,MedCost,Commercial,,118.42,,,,,,,93.57,118.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,MedCost,Commercial,,89.18,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,926.92,,,,,,,344.45,930.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,698.05,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,926.92,,,,,,,344.45,930.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Commercial,,698.05,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,inpatient,50,ML,73.60000,44.16000,MedCost,Commercial,,59.62,,,,,,,22.15,59.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,MedCost,Commercial,,44.90,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,inpatient,8,ML,64.45000,38.67000,MedCost,Commercial,,52.20,,,,,,,19.40,52.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,MedCost,Commercial,,39.31,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,inpatient,118,ML,412.15000,247.29000,MedCost,Commercial,,333.84,,,,,,,263.78,335.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,MedCost,Commercial,,251.41,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,inpatient,5,ML,40.35000,24.21000,MedCost,Commercial,,32.68,,,,,,,25.82,32.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,MedCost,Commercial,,24.61,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,inpatient,80,ML,173.25000,103.95000,MedCost,Commercial,,140.33,,,,,,,52.15,140.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,MedCost,Commercial,,105.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,0.5,ML,63.20000,37.92000,MedCost,Commercial,,51.19,,,,,,,19.02,51.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,MedCost,Commercial,,38.55,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,inpatient,100,ML,115.15000,69.09000,MedCost,Commercial,,93.27,,,,,,,73.70,93.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,MedCost,Commercial,,70.24,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,MedCost,Commercial,,39.61,,,,,,,31.30,39.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,MedCost,Commercial,,29.83,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,MedCost,Commercial,,20.86,,,,,,,16.48,20.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,MedCost,Commercial,,15.71,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,MedCost,Commercial,,26.20,,,,,,,20.70,26.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,MedCost,Commercial,,19.73,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,inpatient,50,ML,1584.85000,950.91000,MedCost,Commercial,,1283.73,,,,,,,1014.30,1288.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,MedCost,Commercial,,966.76,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,inpatient,10,ML,38.75000,23.25000,MedCost,Commercial,,31.39,,,,,,,11.66,31.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,MedCost,Commercial,,23.64,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,inpatient,100,ML,478.40000,287.04000,MedCost,Commercial,,387.50,,,,,,,306.18,388.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,MedCost,Commercial,,291.82,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,inpatient,50,ML,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,26.49,71.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,MedCost,Commercial,,2090.16,,,,,,,776.72,2097.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,MedCost,Commercial,,1574.07,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,inpatient,1,ML,17.20000,10.32000,MedCost,Commercial,,13.93,,,,,,,5.18,13.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,MedCost,Commercial,,10.49,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,inpatient,1,ML,144.30000,86.58000,MedCost,Commercial,,116.88,,,,,,,92.35,117.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,MedCost,Commercial,,88.02,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,inpatient,100,ML,1380.15000,828.09000,MedCost,Commercial,,1117.92,,,,,,,883.30,1122.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,MedCost,Commercial,,841.89,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,inpatient,50,ML,73.80000,44.28000,MedCost,Commercial,,59.78,,,,,,,22.21,60.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,MedCost,Commercial,,45.02,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,inpatient,20,ML,215.00000,129.00000,MedCost,Commercial,,174.15,,,,,,,137.60,174.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,MedCost,Commercial,,131.15,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,inpatient,100,ML,597.25000,358.35000,MedCost,Commercial,,483.77,,,,,,,179.77,485.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,MedCost,Commercial,,364.32,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,inpatient,1,UN,109.20000,65.52000,MedCost,Commercial,,88.45,,,,,,,32.87,88.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,MedCost,Commercial,,66.61,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,inpatient,1,UN,115.50000,69.30000,MedCost,Commercial,,93.56,,,,,,,34.77,93.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,MedCost,Commercial,,70.45,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,MedCost,Commercial,,35.07,,,,,,,13.03,35.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,MedCost,Commercial,,26.41,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,MedCost,Commercial,,52.93,,,,,,,19.67,53.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,MedCost,Commercial,,39.86,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,inpatient,1,UN,47.45000,28.47000,MedCost,Commercial,,38.43,,,,,,,14.28,38.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,MedCost,Commercial,,28.94,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,inpatient,1,UN,66.05000,39.63000,MedCost,Commercial,,53.50,,,,,,,19.88,53.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,MedCost,Commercial,,40.29,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,inpatient,1,UN,36.50000,21.90000,MedCost,Commercial,,29.57,,,,,,,10.99,29.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,MedCost,Commercial,,22.27,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,66.05000,39.63000,MedCost,Commercial,,53.50,,,,,,,19.88,53.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,MedCost,Commercial,,40.29,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,inpatient,50,ML,48.45000,29.07000,MedCost,Commercial,,39.24,,,,,,,14.58,39.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,MedCost,Commercial,,29.55,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,inpatient,4,ML,88.80000,53.28000,MedCost,Commercial,,71.93,,,,,,,26.73,72.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,MedCost,Commercial,,54.17,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,inpatient,250,ML,260.40000,156.24000,MedCost,Commercial,,210.92,,,,,,,78.38,211.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,MedCost,Commercial,,158.84,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,inpatient,5,ML,119.70000,71.82000,MedCost,Commercial,,96.96,,,,,,,76.61,97.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,MedCost,Commercial,,73.02,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,inpatient,1,ML,118.25000,70.95000,MedCost,Commercial,,95.78,,,,,,,35.59,96.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,MedCost,Commercial,,72.13,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,MedCost,Commercial,,13.00,,,,,,,10.27,13.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,MedCost,Commercial,,9.79,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,MedCost,Commercial,,5502.33,,,,,,,2044.69,5522.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,MedCost,Commercial,,4143.73,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,inpatient,12,ML,30.95000,18.57000,MedCost,Commercial,,25.07,,,,,,,9.32,25.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,MedCost,Commercial,,18.88,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,inpatient,1,UN,83.25000,49.95000,MedCost,Commercial,,67.43,,,,,,,25.06,67.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,MedCost,Commercial,,50.78,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,inpatient,50,ML,65.10000,39.06000,MedCost,Commercial,,52.73,,,,,,,41.66,52.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,MedCost,Commercial,,39.71,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,inpatient,40,ML,178.35000,107.01000,MedCost,Commercial,,144.46,,,,,,,53.68,145.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,MedCost,Commercial,,108.79,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,inpatient,40,ML,50.60000,30.36000,MedCost,Commercial,,40.99,,,,,,,15.23,41.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,MedCost,Commercial,,30.87,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,inpatient,40,ML,231.70000,139.02000,MedCost,Commercial,,187.68,,,,,,,148.29,188.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,MedCost,Commercial,,141.34,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,inpatient,400,ML,237.75000,142.65000,MedCost,Commercial,,192.58,,,,,,,71.56,193.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,MedCost,Commercial,,145.03,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,inpatient,200,ML,150.40000,90.24000,MedCost,Commercial,,121.82,,,,,,,45.27,122.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,MedCost,Commercial,,91.74,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,145.38,392.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,inpatient,0.5,ML,68.25000,40.95000,MedCost,Commercial,,55.28,,,,,,,20.54,55.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,MedCost,Commercial,,41.63,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,inpatient,1,UN,22.10000,13.26000,MedCost,Commercial,,17.90,,,,,,,6.65,17.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,MedCost,Commercial,,13.48,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,inpatient,1,UN,22.80000,13.68000,MedCost,Commercial,,18.47,,,,,,,6.86,18.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,MedCost,Commercial,,13.91,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,inpatient,25,ML,458.95000,275.37000,MedCost,Commercial,,371.75,,,,,,,293.73,373.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,MedCost,Commercial,,279.96,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,inpatient,50,ML,26.05000,15.63000,MedCost,Commercial,,21.10,,,,,,,7.84,21.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,MedCost,Commercial,,15.89,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,MedCost,Commercial,,4727.52,,,,,,,1756.77,4745.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,MedCost,Commercial,,3560.23,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,inpatient,4,ML,63.05000,37.83000,MedCost,Commercial,,51.07,,,,,,,40.35,51.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,MedCost,Commercial,,38.46,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,inpatient,5,ML,63.15000,37.89000,MedCost,Commercial,,51.15,,,,,,,19.01,51.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,MedCost,Commercial,,38.52,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,inpatient,5,ML,63.25000,37.95000,MedCost,Commercial,,51.23,,,,,,,40.48,51.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,MedCost,Commercial,,38.58,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,inpatient,0.5,ML,63.30000,37.98000,MedCost,Commercial,,51.27,,,,,,,19.05,51.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,MedCost,Commercial,,38.61,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,inpatient,1,ML,63.05000,37.83000,MedCost,Commercial,,51.07,,,,,,,40.35,51.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,MedCost,Commercial,,38.46,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,inpatient,1,UN,144.90000,86.94000,MedCost,Commercial,,117.37,,,,,,,43.61,117.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,MedCost,Commercial,,88.39,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,inpatient,0.1,ML,19.35000,11.61000,MedCost,Commercial,,15.67,,,,,,,5.82,15.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,MedCost,Commercial,,11.80,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,MedCost,Commercial,,13.00,,,,,,,4.83,13.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,MedCost,Commercial,,9.79,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,inpatient,0.08,ML,66.20000,39.72000,MedCost,Commercial,,53.62,,,,,,,19.93,53.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,MedCost,Commercial,,40.38,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,inpatient,1,UN,50.05000,30.03000,MedCost,Commercial,,40.54,,,,,,,32.03,40.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,MedCost,Commercial,,30.53,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,10,ML,456.15000,273.69000,MedCost,Commercial,,369.48,,,,,,,137.30,370.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,MedCost,Commercial,,278.25,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,inpatient,10,ML,462.10000,277.26000,MedCost,Commercial,,374.30,,,,,,,139.09,375.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,MedCost,Commercial,,281.88,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,inpatient,10,ML,361.05000,216.63000,MedCost,Commercial,,292.45,,,,,,,108.68,293.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,MedCost,Commercial,,220.24,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,inpatient,0.5,ML,79.80000,47.88000,MedCost,Commercial,,64.64,,,,,,,51.07,64.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,MedCost,Commercial,,48.68,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,71.48,,,,,,,26.56,71.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,53.83,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,inpatient,5,ML,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,30.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,inpatient,100,ML,75.60000,45.36000,MedCost,Commercial,,61.24,,,,,,,48.38,61.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,MedCost,Commercial,,46.12,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,63.79,,,,,,,50.40,63.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,48.04,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,MedCost,Commercial,,13.00,,,,,,,4.83,13.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,MedCost,Commercial,,9.79,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,inpatient,1.25,ML,22.65000,13.59000,MedCost,Commercial,,18.35,,,,,,,14.50,18.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,MedCost,Commercial,,13.82,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,inpatient,5,ML,24.85000,14.91000,MedCost,Commercial,,20.13,,,,,,,7.48,20.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,MedCost,Commercial,,15.16,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,inpatient,2,ML,158.65000,95.19000,MedCost,Commercial,,128.51,,,,,,,47.75,128.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,MedCost,Commercial,,96.78,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,MedCost,Commercial,,72.05,,,,,,,26.77,72.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,MedCost,Commercial,,54.26,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,inpatient,1,UN,125.55000,75.33000,MedCost,Commercial,,101.70,,,,,,,37.79,102.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,MedCost,Commercial,,76.59,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,1,ML,84.10000,50.46000,MedCost,Commercial,,68.12,,,,,,,25.31,68.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,MedCost,Commercial,,51.30,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,MedCost,Commercial,,289.37,,,,,,,107.53,290.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,MedCost,Commercial,,217.92,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,MedCost,Commercial,,936.40,,,,,,,347.97,939.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,MedCost,Commercial,,705.19,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,21.34,,,,,,,7.93,21.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,16.07,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,inpatient,0.5,ML,24.95000,14.97000,MedCost,Commercial,,20.21,,,,,,,7.51,20.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,MedCost,Commercial,,15.22,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,inpatient,1,UN,730.25000,438.15000,MedCost,Commercial,,591.50,,,,,,,219.81,593.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,MedCost,Commercial,,445.45,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,inpatient,100,GR,101.70000,61.02000,MedCost,Commercial,,82.38,,,,,,,65.09,82.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,MedCost,Commercial,,62.04,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,19.26,52.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,inpatient,0.5,ML,103.50000,62.10000,MedCost,Commercial,,83.83,,,,,,,31.15,84.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,MedCost,Commercial,,63.13,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,inpatient,5,ML,62.05000,37.23000,MedCost,Commercial,,50.26,,,,,,,39.71,50.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,MedCost,Commercial,,37.85,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,MedCost,Commercial,,122.51,,,,,,,45.53,122.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,MedCost,Commercial,,92.26,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,MedCost,Commercial,,232.06,,,,,,,86.24,232.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,MedCost,Commercial,,174.76,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,inpatient,1,UN,39.00000,23.40000,MedCost,Commercial,,31.59,,,,,,,11.74,31.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,MedCost,Commercial,,23.79,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,inpatient,1,UN,61.50000,36.90000,MedCost,Commercial,,49.81,,,,,,,18.51,50.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,MedCost,Commercial,,37.52,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,inpatient,1,UN,26.40000,15.84000,MedCost,Commercial,,21.38,,,,,,,7.95,21.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,MedCost,Commercial,,16.10,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,MedCost,Commercial,,29.57,,,,,,,10.99,29.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,MedCost,Commercial,,22.27,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,inpatient,1,UN,210.00000,126.00000,MedCost,Commercial,,170.10,,,,,,,63.21,170.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,MedCost,Commercial,,128.10,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,inpatient,1,UN,75.60000,45.36000,MedCost,Commercial,,61.24,,,,,,,22.76,61.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,MedCost,Commercial,,46.12,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,MedCost,Commercial,,71.12,,,,,,,26.43,71.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,MedCost,Commercial,,53.56,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,inpatient,1,UN,82.30000,49.38000,MedCost,Commercial,,66.66,,,,,,,24.77,66.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,MedCost,Commercial,,50.20,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,20.33,,,,,,,7.56,20.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Commercial,,15.31,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,MedCost,Commercial,,24.02,,,,,,,8.92,24.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,MedCost,Commercial,,18.09,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,inpatient,8,ML,66.95000,40.17000,MedCost,Commercial,,54.23,,,,,,,20.15,54.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,MedCost,Commercial,,40.84,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,inpatient,50,ML,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,25.28,68.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,MedCost,Commercial,,18.79,,,,,,,6.98,18.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,MedCost,Commercial,,14.15,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,inpatient,120,ML,34.40000,20.64000,MedCost,Commercial,,27.86,,,,,,,22.02,27.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,MedCost,Commercial,,20.98,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,inpatient,50,ML,20.65000,12.39000,MedCost,Commercial,,16.73,,,,,,,13.22,16.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,MedCost,Commercial,,12.60,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,MedCost,Commercial,,34.59,,,,,,,12.85,34.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,MedCost,Commercial,,26.05,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,2,ML,23.95000,14.37000,MedCost,Commercial,,19.40,,,,,,,7.21,19.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,MedCost,Commercial,,14.61,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,5,ML,26.20000,15.72000,MedCost,Commercial,,21.22,,,,,,,7.89,21.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,MedCost,Commercial,,15.98,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,inpatient,5,ML,17.65000,10.59000,MedCost,Commercial,,14.30,,,,,,,11.30,14.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,MedCost,Commercial,,10.77,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,inpatient,1.25,ML,16.35000,9.81000,MedCost,Commercial,,13.24,,,,,,,10.46,13.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,MedCost,Commercial,,9.97,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,inpatient,500,ML,531.30000,318.78000,MedCost,Commercial,,430.35,,,,,,,159.92,431.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,MedCost,Commercial,,324.09,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,inpatient,120,ML,34.00000,20.40000,MedCost,Commercial,,27.54,,,,,,,21.76,27.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,MedCost,Commercial,,20.74,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,inpatient,120,ML,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,56.32,71.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,inpatient,4,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,MedCost,Commercial,,2090.16,,,,,,,776.72,2097.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,MedCost,Commercial,,1574.07,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,20027.09,,,,,,,7442.16,20101.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,15082.13,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,20027.09,,,,,,,7442.16,20101.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,15082.13,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,20027.09,,,,,,,7442.16,20101.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,15082.13,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,20027.09,,,,,,,7442.16,20101.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,15082.13,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,20027.09,,,,,,,7442.16,20101.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Commercial,,15082.13,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,MedCost,Commercial,,30592.53,,,,,,,11368.33,30705.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,MedCost,Commercial,,23038.82,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,inpatient,14,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,inpatient,150,ME,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,inpatient,15,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,inpatient,100,ML,403.95000,242.37000,MedCost,Commercial,,327.20,,,,,,,121.59,328.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,MedCost,Commercial,,246.41,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,inpatient,60,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,inpatient,100,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,inpatient,500,ME,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,inpatient,4,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,inpatient,4,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,inpatient,500,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,inpatient,16,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,inpatient,8,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,inpatient,100,ML,106.70000,64.02000,MedCost,Commercial,,86.43,,,,,,,32.12,86.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,MedCost,Commercial,,65.09,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,MedCost,Commercial,,24.02,,,,,,,8.92,24.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,MedCost,Commercial,,18.09,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,inpatient,0.1,ML,23.05000,13.83000,MedCost,Commercial,,18.67,,,,,,,6.94,18.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,MedCost,Commercial,,14.06,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,inpatient,1,ML,148.15000,88.89000,MedCost,Commercial,,120.00,,,,,,,94.82,120.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,MedCost,Commercial,,90.37,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,MedCost,Commercial,,24.26,,,,,,,9.01,24.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,MedCost,Commercial,,18.27,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,inpatient,113,GR,12.40000,7.44000,MedCost,Commercial,,10.04,,,,,,,7.94,10.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,MedCost,Commercial,,7.56,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,145.38,392.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,inpatient,4,ML,757.00000,454.20000,MedCost,Commercial,,613.17,,,,,,,227.86,615.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,MedCost,Commercial,,461.77,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,MedCost,Commercial,,39.61,,,,,,,14.72,39.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,MedCost,Commercial,,29.83,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,MedCost,Commercial,,20.86,,,,,,,7.75,20.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,MedCost,Commercial,,15.71,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,inpatient,5,ML,26.10000,15.66000,MedCost,Commercial,,21.14,,,,,,,7.86,21.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,MedCost,Commercial,,15.92,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,inpatient,1,ML,278.25000,166.95000,MedCost,Commercial,,225.38,,,,,,,83.75,226.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,MedCost,Commercial,,169.73,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,inpatient,10,ML,58.40000,35.04000,MedCost,Commercial,,47.30,,,,,,,37.38,47.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,MedCost,Commercial,,35.62,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,inpatient,15,ML,77.55000,46.53000,MedCost,Commercial,,62.82,,,,,,,49.63,63.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,MedCost,Commercial,,47.31,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.2,ML,16.85000,10.11000,MedCost,Commercial,,13.65,,,,,,,5.07,13.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,MedCost,Commercial,,10.28,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,inpatient,4000,ML,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,56.32,71.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,MedCost,Commercial,,437.24,,,,,,,162.48,438.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,MedCost,Commercial,,329.28,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,MedCost,Commercial,,249.80,,,,,,,92.83,250.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,MedCost,Commercial,,188.12,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,inpatient,20.3,ML,4.15000,2.49000,MedCost,Commercial,,3.36,,,,,,,2.66,3.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,MedCost,Commercial,,2.53,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,inpatient,5,ML,2.80000,1.68000,MedCost,Commercial,,2.27,,,,,,,1.79,2.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,MedCost,Commercial,,1.71,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,inpatient,287.5,ML,276.75000,166.05000,MedCost,Commercial,,224.17,,,,,,,83.30,225.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,MedCost,Commercial,,168.82,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,inpatient,555,ML,298.45000,179.07000,MedCost,Commercial,,241.74,,,,,,,89.83,242.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,MedCost,Commercial,,182.05,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,inpatient,557.5,ML,238.65000,143.19000,MedCost,Commercial,,193.31,,,,,,,71.83,194.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,MedCost,Commercial,,145.58,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,inpatient,560,ML,260.60000,156.36000,MedCost,Commercial,,211.09,,,,,,,78.44,211.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,MedCost,Commercial,,158.97,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,inpatient,30,ML,2.25000,1.35000,MedCost,Commercial,,1.82,,,,,,,1.44,1.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,MedCost,Commercial,,1.37,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,inpatient,0.09,ML,291.30000,174.78000,MedCost,Commercial,,235.95,,,,,,,87.68,236.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,MedCost,Commercial,,177.69,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,6.92,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,6.92,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,inpatient,10,ML,41.15000,24.69000,MedCost,Commercial,,33.33,,,,,,,12.39,33.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,MedCost,Commercial,,25.10,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,MedCost,Commercial,,53.66,,,,,,,19.94,53.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,MedCost,Commercial,,40.41,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,inpatient,50,ML,77.80000,46.68000,MedCost,Commercial,,63.02,,,,,,,49.79,63.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,MedCost,Commercial,,47.46,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,28.70000,17.22000,MedCost,Commercial,,23.25,,,,,,,18.37,23.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,MedCost,Commercial,,17.51,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,37.70000,22.62000,MedCost,Commercial,,30.54,,,,,,,24.13,30.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,MedCost,Commercial,,23.00,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,MedCost,Commercial,,30.13,,,,,,,11.20,30.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,MedCost,Commercial,,22.69,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,inpatient,1,UN,45136.00000,27081.60000,MedCost,Commercial,,36560.16,,,,,,,13585.94,36695.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,MedCost,Commercial,,27532.96,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,MedCost,Commercial,,29135.94,,,,,,,10827.06,29243.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,MedCost,Commercial,,21941.88,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,MedCost,Commercial,,41527.24,,,,,,,15431.73,41681.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,MedCost,Commercial,,31273.60,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,inpatient,1,UN,27.45000,16.47000,MedCost,Commercial,,22.23,,,,,,,17.57,22.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,MedCost,Commercial,,16.74,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,inpatient,1,UN,556.00000,333.60000,MedCost,Commercial,,450.36,,,,,,,355.84,452.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,MedCost,Commercial,,339.16,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,MedCost,Commercial,,254.95,,,,,,,94.74,255.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,MedCost,Commercial,,192.00,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,MedCost,Commercial,,234.74,,,,,,,87.23,235.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,MedCost,Commercial,,176.78,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,MedCost,Commercial,,341.25,,,,,,,126.81,342.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,MedCost,Commercial,,256.99,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,15,ML,46791.25000,28074.75000,MedCost,Commercial,,37900.91,,,,,,,14084.17,38041.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,MedCost,Commercial,,28542.66,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,MedCost,Commercial,,6185.32,,,,,,,2298.50,6208.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,MedCost,Commercial,,4658.08,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,3204.04,,,,,,,1190.64,3215.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,2412.92,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,MedCost,Commercial,,6185.32,,,,,,,2298.50,6208.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,MedCost,Commercial,,4658.08,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,3204.04,,,,,,,1190.64,3215.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,2412.92,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,MedCost,Commercial,,6185.32,,,,,,,2298.50,6208.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,MedCost,Commercial,,4658.08,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,3204.04,,,,,,,1190.64,3215.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Commercial,,2412.92,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,MedCost,Commercial,,820.08,,,,,,,304.75,823.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,MedCost,Commercial,,617.59,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,15239.66,,,,,,,5663.13,15296.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,11476.78,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,15239.66,,,,,,,5663.13,15296.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,11476.78,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,15239.66,,,,,,,5663.13,15296.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Commercial,,11476.78,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,MedCost,Commercial,,41397.76,,,,,,,15383.61,41551.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,MedCost,Commercial,,31176.09,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,MedCost,Commercial,,2004.75,,,,,,,744.98,2012.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,MedCost,Commercial,,1509.75,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,MedCost,Commercial,,3382.28,,,,,,,1256.87,3394.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,MedCost,Commercial,,2547.15,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,MedCost,Commercial,,6713.52,,,,,,,2494.78,6738.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,MedCost,Commercial,,5055.86,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,MedCost,Commercial,,1383.56,,,,,,,514.14,1388.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,MedCost,Commercial,,1041.94,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,MedCost,Commercial,,3382.28,,,,,,,1256.87,3394.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,MedCost,Commercial,,2547.15,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,MedCost,Commercial,,6713.52,,,,,,,2494.78,6738.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,MedCost,Commercial,,5055.86,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,MedCost,Commercial,,1383.56,,,,,,,514.14,1388.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,MedCost,Commercial,,1041.94,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,inpatient,67,ML,278.85000,167.31000,MedCost,Commercial,,225.87,,,,,,,83.93,226.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,MedCost,Commercial,,170.10,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,inpatient,2,ML,44.10000,26.46000,MedCost,Commercial,,35.72,,,,,,,13.27,35.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,MedCost,Commercial,,26.90,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,inpatient,4,ML,29.75000,17.85000,MedCost,Commercial,,24.10,,,,,,,8.95,24.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,MedCost,Commercial,,18.15,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,inpatient,50,ML,191837.95000,115102.77000,MedCost,Commercial,,155388.74,,,,,,,122776.29,155964.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,MedCost,Commercial,,117021.15,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,inpatient,100,ML,128.90000,77.34000,MedCost,Commercial,,104.41,,,,,,,82.50,104.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,MedCost,Commercial,,78.63,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,inpatient,100,ML,70.50000,42.30000,MedCost,Commercial,,57.10,,,,,,,45.12,57.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,MedCost,Commercial,,43.01,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,inpatient,1000,ML,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,inpatient,250,ML,74.25000,44.55000,MedCost,Commercial,,60.14,,,,,,,47.52,60.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,MedCost,Commercial,,45.29,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,MedCost,Commercial,,1191.75,,,,,,,442.86,1196.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,MedCost,Commercial,,897.49,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,inpatient,1,UN,70.75000,42.45000,MedCost,Commercial,,57.31,,,,,,,45.28,57.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,MedCost,Commercial,,43.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,inpatient,10,ML,20.30000,12.18000,MedCost,Commercial,,16.44,,,,,,,12.99,16.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,MedCost,Commercial,,12.38,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,inpatient,10,ML,21.50000,12.90000,MedCost,Commercial,,17.41,,,,,,,13.76,17.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,MedCost,Commercial,,13.12,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,inpatient,10,ML,19.25000,11.55000,MedCost,Commercial,,15.59,,,,,,,12.32,15.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,MedCost,Commercial,,11.74,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,inpatient,5,ML,671.00000,402.60000,MedCost,Commercial,,543.51,,,,,,,201.97,545.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,MedCost,Commercial,,409.31,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,inpatient,0.5,ML,145.05000,87.03000,MedCost,Commercial,,117.49,,,,,,,92.83,117.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,MedCost,Commercial,,88.48,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,inpatient,35.44,GR,736.00000,441.60000,MedCost,Commercial,,596.16,,,,,,,471.04,598.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,MedCost,Commercial,,448.96,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,inpatient,1,UN,263.45000,158.07000,MedCost,Commercial,,213.39,,,,,,,168.61,214.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,MedCost,Commercial,,160.70,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,inpatient,1,UN,55.40000,33.24000,MedCost,Commercial,,44.87,,,,,,,35.46,45.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,MedCost,Commercial,,33.79,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,inpatient,1,UN,55.40000,33.24000,MedCost,Commercial,,44.87,,,,,,,35.46,45.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,MedCost,Commercial,,33.79,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,inpatient,15,ML,5.10000,3.06000,MedCost,Commercial,,4.13,,,,,,,3.26,4.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,MedCost,Commercial,,3.11,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,inpatient,240,ML,12.95000,7.77000,MedCost,Commercial,,10.49,,,,,,,8.29,10.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,MedCost,Commercial,,7.90,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,inpatient,20,ML,79.90000,47.94000,MedCost,Commercial,,64.72,,,,,,,51.14,64.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,MedCost,Commercial,,48.74,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,inpatient,5,ML,60.25000,36.15000,MedCost,Commercial,,48.80,,,,,,,38.56,48.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,MedCost,Commercial,,36.75,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,inpatient,10,ML,460.75000,276.45000,MedCost,Commercial,,373.21,,,,,,,294.88,374.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,MedCost,Commercial,,281.06,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,inpatient,1000,ML,78.00000,46.80000,MedCost,Commercial,,63.18,,,,,,,49.92,63.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,MedCost,Commercial,,47.58,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,inpatient,1,UN,17.15000,10.29000,MedCost,Commercial,,13.89,,,,,,,10.98,13.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,MedCost,Commercial,,10.46,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,inpatient,1,UN,59.20000,35.52000,MedCost,Commercial,,47.95,,,,,,,37.89,48.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,MedCost,Commercial,,36.11,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,inpatient,1,UN,38.25000,22.95000,MedCost,Commercial,,30.98,,,,,,,24.48,31.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,MedCost,Commercial,,23.33,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,inpatient,60,ML,435.95000,261.57000,MedCost,Commercial,,353.12,,,,,,,279.01,354.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,MedCost,Commercial,,265.93,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,14.82,,,,,,,11.71,14.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Commercial,,11.16,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,inpatient,4,ML,106.60000,63.96000,MedCost,Commercial,,86.35,,,,,,,68.22,86.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,MedCost,Commercial,,65.03,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,inpatient,1,UN,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,32.21,86.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,inpatient,1,UN,583.00000,349.80000,MedCost,Commercial,,472.23,,,,,,,175.48,473.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,MedCost,Commercial,,355.63,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,inpatient,1,UN,313.75000,188.25000,MedCost,Commercial,,254.14,,,,,,,94.44,255.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,MedCost,Commercial,,191.39,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,inpatient,1,UN,51.80000,31.08000,MedCost,Commercial,,41.96,,,,,,,33.15,42.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,MedCost,Commercial,,31.60,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,16.52,,,,,,,13.06,16.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Commercial,,12.44,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,14.42,,,,,,,11.39,14.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Commercial,,10.86,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,inpatient,1,UN,18.20000,10.92000,MedCost,Commercial,,14.74,,,,,,,11.65,14.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,MedCost,Commercial,,11.10,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,14.34,,,,,,,11.33,14.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,10.80,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,inpatient,1,UN,22.65000,13.59000,MedCost,Commercial,,18.35,,,,,,,14.50,18.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,MedCost,Commercial,,13.82,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,inpatient,7.5,ML,34.00000,20.40000,MedCost,Commercial,,27.54,,,,,,,21.76,27.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,MedCost,Commercial,,20.74,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,inpatient,20,ML,30.50000,18.30000,MedCost,Commercial,,24.70,,,,,,,9.18,24.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,MedCost,Commercial,,18.61,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,inpatient,50,ML,30.60000,18.36000,MedCost,Commercial,,24.79,,,,,,,9.21,24.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,MedCost,Commercial,,18.67,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,inpatient,20,ML,34.15000,20.49000,MedCost,Commercial,,27.66,,,,,,,10.28,27.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,MedCost,Commercial,,20.83,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,inpatient,5,ML,38.00000,22.80000,MedCost,Commercial,,30.78,,,,,,,11.44,30.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,MedCost,Commercial,,23.18,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,inpatient,5,ML,115.10000,69.06000,MedCost,Commercial,,93.23,,,,,,,34.65,93.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,MedCost,Commercial,,70.21,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,inpatient,5,ML,49.10000,29.46000,MedCost,Commercial,,39.77,,,,,,,14.78,39.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,MedCost,Commercial,,29.95,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,13.16,,,,,,,10.40,13.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Commercial,,9.91,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,inpatient,1,UN,18.15000,10.89000,MedCost,Commercial,,14.70,,,,,,,11.62,14.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,MedCost,Commercial,,11.07,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,13.28,,,,,,,10.50,13.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,10.00,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,13.85,,,,,,,10.94,13.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,10.43,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,inpatient,5,ML,16.45000,9.87000,MedCost,Commercial,,13.32,,,,,,,10.53,13.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,MedCost,Commercial,,10.03,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,inpatient,5,ML,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,inpatient,1,UN,2.15000,1.29000,MedCost,Commercial,,1.74,,,,,,,1.38,1.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,MedCost,Commercial,,1.31,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,0.5,ML,23.80000,14.28000,MedCost,Commercial,,19.28,,,,,,,15.23,19.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,MedCost,Commercial,,14.52,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,inpatient,30,ML,116.70000,70.02000,MedCost,Commercial,,94.53,,,,,,,74.69,94.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,MedCost,Commercial,,71.19,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,inpatient,1,UN,234.40000,140.64000,MedCost,Commercial,,189.86,,,,,,,70.55,190.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,MedCost,Commercial,,142.98,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,inpatient,1,UN,47.45000,28.47000,MedCost,Commercial,,38.43,,,,,,,14.28,38.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,MedCost,Commercial,,28.94,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,inpatient,296,ML,4.25000,2.55000,MedCost,Commercial,,3.44,,,,,,,2.72,3.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,MedCost,Commercial,,2.59,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,inpatient,100,ML,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,27.39,73.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,inpatient,1,UN,48.35000,29.01000,MedCost,Commercial,,39.16,,,,,,,14.55,39.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,MedCost,Commercial,,29.49,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,MedCost,Commercial,,21.34,,,,,,,7.93,21.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,MedCost,Commercial,,16.07,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,inpatient,1,UN,31.25000,18.75000,MedCost,Commercial,,25.31,,,,,,,9.41,25.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,MedCost,Commercial,,19.06,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,inpatient,1,UN,29.65000,17.79000,MedCost,Commercial,,24.02,,,,,,,8.92,24.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,MedCost,Commercial,,18.09,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,inpatient,10,ML,185.65000,111.39000,MedCost,Commercial,,150.38,,,,,,,118.82,150.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,MedCost,Commercial,,113.25,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,inpatient,31.25,ML,77.15000,46.29000,MedCost,Commercial,,62.49,,,,,,,49.38,62.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,MedCost,Commercial,,47.06,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,inpatient,25,ML,29.90000,17.94000,MedCost,Commercial,,24.22,,,,,,,19.14,24.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,MedCost,Commercial,,18.24,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,13.85,,,,,,,10.94,13.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,10.43,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,MedCost,Commercial,,24.02,,,,,,,8.92,24.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,MedCost,Commercial,,18.09,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,MedCost,Commercial,,24.26,,,,,,,9.01,24.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,MedCost,Commercial,,18.27,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,inpatient,50,ML,87.25000,52.35000,MedCost,Commercial,,70.67,,,,,,,26.26,70.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,MedCost,Commercial,,53.22,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,inpatient,50,ML,89.05000,53.43000,MedCost,Commercial,,72.13,,,,,,,26.80,72.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,MedCost,Commercial,,54.32,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,inpatient,5,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,inpatient,500,ML,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,inpatient,1,UN,23.40000,14.04000,MedCost,Commercial,,18.95,,,,,,,14.98,19.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,MedCost,Commercial,,14.27,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,inpatient,5,ML,53.55000,32.13000,MedCost,Commercial,,43.38,,,,,,,16.12,43.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,MedCost,Commercial,,32.67,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,inpatient,1,UN,16.35000,9.81000,MedCost,Commercial,,13.24,,,,,,,10.46,13.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,MedCost,Commercial,,9.97,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,MedCost,Commercial,,30.13,,,,,,,11.20,30.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,MedCost,Commercial,,22.69,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,inpatient,2,ML,307.00000,184.20000,MedCost,Commercial,,248.67,,,,,,,92.41,249.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,MedCost,Commercial,,187.27,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,inpatient,1,UN,473.00000,283.80000,MedCost,Commercial,,383.13,,,,,,,142.37,384.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,MedCost,Commercial,,288.53,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,inpatient,1,UN,22.60000,13.56000,MedCost,Commercial,,18.31,,,,,,,14.46,18.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,MedCost,Commercial,,13.79,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,inpatient,0.25,ML,28.95000,17.37000,MedCost,Commercial,,23.45,,,,,,,8.71,23.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,MedCost,Commercial,,17.66,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,inpatient,1,ML,105.75000,63.45000,MedCost,Commercial,,85.66,,,,,,,31.83,85.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,MedCost,Commercial,,64.51,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,inpatient,1,UN,19.20000,11.52000,MedCost,Commercial,,15.55,,,,,,,12.29,15.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,MedCost,Commercial,,11.71,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,inpatient,1,UN,19.05000,11.43000,MedCost,Commercial,,15.43,,,,,,,12.19,15.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,MedCost,Commercial,,11.62,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,inpatient,5,ML,20.55000,12.33000,MedCost,Commercial,,16.65,,,,,,,6.19,16.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,MedCost,Commercial,,12.54,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,inpatient,1,UN,16.45000,9.87000,MedCost,Commercial,,13.32,,,,,,,10.53,13.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,MedCost,Commercial,,10.03,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,14.30,,,,,,,11.30,14.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,10.77,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,inpatient,1,UN,18.65000,11.19000,MedCost,Commercial,,15.11,,,,,,,11.94,15.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,MedCost,Commercial,,11.38,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,inpatient,100,ML,74.20000,44.52000,MedCost,Commercial,,60.10,,,,,,,22.33,60.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,MedCost,Commercial,,45.26,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,inpatient,45,GR,13.50000,8.10000,MedCost,Commercial,,10.94,,,,,,,8.64,10.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,MedCost,Commercial,,8.23,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,13.85,,,,,,,10.94,13.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,10.43,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,15.07,,,,,,,11.90,15.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,11.35,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,inpatient,1,UN,18.10000,10.86000,MedCost,Commercial,,14.66,,,,,,,11.58,14.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,MedCost,Commercial,,11.04,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,inpatient,0.5,ML,26.60000,15.96000,MedCost,Commercial,,21.55,,,,,,,8.01,21.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,MedCost,Commercial,,16.23,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,inpatient,1,ML,30.65000,18.39000,MedCost,Commercial,,24.83,,,,,,,9.23,24.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,MedCost,Commercial,,18.70,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,21.34,,,,,,,7.93,21.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Commercial,,16.07,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,inpatient,0.4,ML,22.10000,13.26000,MedCost,Commercial,,17.90,,,,,,,14.14,17.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,MedCost,Commercial,,13.48,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,inpatient,5,ML,26.10000,15.66000,MedCost,Commercial,,21.14,,,,,,,16.70,21.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,MedCost,Commercial,,15.92,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,inpatient,500,ML,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,inpatient,1,UN,23.30000,13.98000,MedCost,Commercial,,18.87,,,,,,,14.91,18.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,MedCost,Commercial,,14.21,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,inpatient,1,UN,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,30.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,inpatient,1,ML,32.30000,19.38000,MedCost,Commercial,,26.16,,,,,,,9.72,26.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,MedCost,Commercial,,19.70,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,MedCost,Commercial,,71.32,,,,,,,26.50,71.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,MedCost,Commercial,,53.71,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,inpatient,2,ML,166.15000,99.69000,MedCost,Commercial,,134.58,,,,,,,50.01,135.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,MedCost,Commercial,,101.35,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,13.81,,,,,,,10.91,13.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,10.40,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,inpatient,10,ML,128.35000,77.01000,MedCost,Commercial,,103.96,,,,,,,38.63,104.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,MedCost,Commercial,,78.29,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,inpatient,1,UN,53.70000,32.22000,MedCost,Commercial,,43.50,,,,,,,34.37,43.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,MedCost,Commercial,,32.76,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,inpatient,1,GR,25.70000,15.42000,MedCost,Commercial,,20.82,,,,,,,16.45,20.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,MedCost,Commercial,,15.68,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,10.75,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,13.85,,,,,,,10.94,13.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,10.43,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,inpatient,15,GR,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,47.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,inpatient,15,GR,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,47.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,inpatient,1,UN,18.40000,11.04000,MedCost,Commercial,,14.90,,,,,,,11.78,14.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,MedCost,Commercial,,11.22,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,inpatient,1,UN,23.25000,13.95000,MedCost,Commercial,,18.83,,,,,,,14.88,18.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,MedCost,Commercial,,14.18,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,inpatient,15,ML,10.50000,6.30000,MedCost,Commercial,,8.51,,,,,,,6.72,8.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,MedCost,Commercial,,6.41,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,inpatient,0.3,ML,20.95000,12.57000,MedCost,Commercial,,16.97,,,,,,,6.31,17.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,MedCost,Commercial,,12.78,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,inpatient,0.3,ML,17.95000,10.77000,MedCost,Commercial,,14.54,,,,,,,5.40,14.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,MedCost,Commercial,,10.95,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,inpatient,2,ML,204.45000,122.67000,MedCost,Commercial,,165.60,,,,,,,61.54,166.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,MedCost,Commercial,,124.71,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,inpatient,1,UN,247.55000,148.53000,MedCost,Commercial,,200.52,,,,,,,74.51,201.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,MedCost,Commercial,,151.01,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,inpatient,1,UN,73.90000,44.34000,MedCost,Commercial,,59.86,,,,,,,22.24,60.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,MedCost,Commercial,,45.08,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,inpatient,100,ML,42.70000,25.62000,MedCost,Commercial,,34.59,,,,,,,27.33,34.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,MedCost,Commercial,,26.05,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,10.75,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,MedCost,Commercial,,5502.33,,,,,,,2044.69,5522.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,MedCost,Commercial,,4143.73,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,11.42,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,14.01,,,,,,,11.07,14.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Commercial,,10.55,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,inpatient,5,ML,24.30000,14.58000,MedCost,Commercial,,19.68,,,,,,,15.55,19.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,MedCost,Commercial,,14.82,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,inpatient,1,UN,23.65000,14.19000,MedCost,Commercial,,19.16,,,,,,,15.14,19.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,MedCost,Commercial,,14.43,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,inpatient,1,ML,227.20000,136.32000,MedCost,Commercial,,184.03,,,,,,,68.39,184.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,MedCost,Commercial,,138.59,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,inpatient,1,ML,101.10000,60.66000,MedCost,Commercial,,81.89,,,,,,,30.43,82.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,MedCost,Commercial,,61.67,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,inpatient,1,ML,34.20000,20.52000,MedCost,Commercial,,27.70,,,,,,,10.29,27.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,MedCost,Commercial,,20.86,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,inpatient,10,ML,212.70000,127.62000,MedCost,Commercial,,172.29,,,,,,,64.02,172.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,MedCost,Commercial,,129.75,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,inpatient,5,ML,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,32.21,86.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,inpatient,15,ML,6.40000,3.84000,MedCost,Commercial,,5.18,,,,,,,4.10,5.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,MedCost,Commercial,,3.90,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,inpatient,15,ML,6.40000,3.84000,MedCost,Commercial,,5.18,,,,,,,4.10,5.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,MedCost,Commercial,,3.90,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,inpatient,2,ML,113.50000,68.10000,MedCost,Commercial,,91.94,,,,,,,72.64,92.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,MedCost,Commercial,,69.23,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,inpatient,2,ML,22.35000,13.41000,MedCost,Commercial,,18.10,,,,,,,6.73,18.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,MedCost,Commercial,,13.63,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,inpatient,1,UN,23.65000,14.19000,MedCost,Commercial,,19.16,,,,,,,15.14,19.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,MedCost,Commercial,,14.43,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.25,ML,72.30000,43.38000,MedCost,Commercial,,58.56,,,,,,,21.76,58.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,MedCost,Commercial,,44.10,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,inpatient,15,ML,252.60000,151.56000,MedCost,Commercial,,204.61,,,,,,,161.66,205.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,MedCost,Commercial,,154.09,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,inpatient,15,ML,258.00000,154.80000,MedCost,Commercial,,208.98,,,,,,,165.12,209.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,MedCost,Commercial,,157.38,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,inpatient,15,ML,269.70000,161.82000,MedCost,Commercial,,218.46,,,,,,,172.61,219.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,MedCost,Commercial,,164.52,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,inpatient,100,ML,155.40000,93.24000,MedCost,Commercial,,125.87,,,,,,,99.46,126.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,MedCost,Commercial,,94.79,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,inpatient,20,ML,85.70000,51.42000,MedCost,Commercial,,69.42,,,,,,,54.85,69.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,MedCost,Commercial,,52.28,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,inpatient,50,ML,110.05000,66.03000,MedCost,Commercial,,89.14,,,,,,,70.43,89.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,MedCost,Commercial,,67.13,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,inpatient,10,ML,72.65000,43.59000,MedCost,Commercial,,58.85,,,,,,,21.87,59.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,MedCost,Commercial,,44.32,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,inpatient,473,ML,189.15000,113.49000,MedCost,Commercial,,153.21,,,,,,,121.06,153.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,MedCost,Commercial,,115.38,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,inpatient,1,UN,44.85000,26.91000,MedCost,Commercial,,36.33,,,,,,,28.70,36.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,MedCost,Commercial,,27.36,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,inpatient,28.4,GR,3.85000,2.31000,MedCost,Commercial,,3.12,,,,,,,2.46,3.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,MedCost,Commercial,,2.35,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,inpatient,118,ML,3.05000,1.83000,MedCost,Commercial,,2.47,,,,,,,1.95,2.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,MedCost,Commercial,,1.86,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,inpatient,1,UN,410.50000,246.30000,MedCost,Commercial,,332.50,,,,,,,123.56,333.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,MedCost,Commercial,,250.41,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,inpatient,1,UN,22.05000,13.23000,MedCost,Commercial,,17.86,,,,,,,14.11,17.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,MedCost,Commercial,,13.45,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,inpatient,1,UN,24.45000,14.67000,MedCost,Commercial,,19.80,,,,,,,15.65,19.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,MedCost,Commercial,,14.91,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,inpatient,5,ML,148.75000,89.25000,MedCost,Commercial,,120.49,,,,,,,95.20,120.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,MedCost,Commercial,,90.74,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,inpatient,500,ML,1256.00000,753.60000,MedCost,Commercial,,1017.36,,,,,,,378.06,1021.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,MedCost,Commercial,,766.16,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,5.09,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,5.09,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,13.73,,,,,,,5.10,13.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,10.34,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,5.06,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,inpatient,1,UN,21.30000,12.78000,MedCost,Commercial,,17.25,,,,,,,13.63,17.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,MedCost,Commercial,,12.99,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,inpatient,1,UN,17.45000,10.47000,MedCost,Commercial,,14.13,,,,,,,11.17,14.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,MedCost,Commercial,,10.64,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,inpatient,1,ML,202.50000,121.50000,MedCost,Commercial,,164.03,,,,,,,60.95,164.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,MedCost,Commercial,,123.53,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,inpatient,0.5,ML,22.20000,13.32000,MedCost,Commercial,,17.98,,,,,,,6.68,18.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,MedCost,Commercial,,13.54,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,14.09,,,,,,,11.14,14.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,10.61,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,inpatient,0.1,ML,17.55000,10.53000,MedCost,Commercial,,14.22,,,,,,,5.28,14.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,MedCost,Commercial,,10.71,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,inpatient,1,ML,24.45000,14.67000,MedCost,Commercial,,19.80,,,,,,,7.36,19.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,MedCost,Commercial,,14.91,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,14.34,,,,,,,11.33,14.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Commercial,,10.80,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,inpatient,15,ML,121.30000,72.78000,MedCost,Commercial,,98.25,,,,,,,77.63,98.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,MedCost,Commercial,,73.99,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,inpatient,500,ML,161.50000,96.90000,MedCost,Commercial,,130.81,,,,,,,103.36,131.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,MedCost,Commercial,,98.52,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,inpatient,1,UN,16.65000,9.99000,MedCost,Commercial,,13.49,,,,,,,10.66,13.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,MedCost,Commercial,,10.16,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,14.09,,,,,,,11.14,14.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Commercial,,10.61,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,13.81,,,,,,,10.91,13.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,10.40,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,14.94,,,,,,,11.81,15.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Commercial,,11.25,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,inpatient,25,ML,256.70000,154.02000,MedCost,Commercial,,207.93,,,,,,,77.27,208.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,MedCost,Commercial,,156.59,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,inpatient,5,ML,86.45000,51.87000,MedCost,Commercial,,70.02,,,,,,,26.02,70.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,MedCost,Commercial,,52.73,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,inpatient,1,UN,25.20000,15.12000,MedCost,Commercial,,20.41,,,,,,,16.13,20.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,MedCost,Commercial,,15.37,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,inpatient,0.5,ML,65.45000,39.27000,MedCost,Commercial,,53.01,,,,,,,19.70,53.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,MedCost,Commercial,,39.92,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,1.13,,,,,,,0.89600,1.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,0.85400,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,1.13,,,,,,,0.89600,1.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,0.85400,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,inpatient,1,UN,2.85000,1.71000,MedCost,Commercial,,2.31,,,,,,,1.82,2.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,MedCost,Commercial,,1.74,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,inpatient,15,ML,7.65000,4.59000,MedCost,Commercial,,6.20,,,,,,,4.90,6.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,MedCost,Commercial,,4.67,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,inpatient,1,UN,93.85000,56.31000,MedCost,Commercial,,76.02,,,,,,,60.06,76.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,MedCost,Commercial,,57.25,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,13.93,,,,,,,11.01,13.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,10.49,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,11.26,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,inpatient,1,UN,83.60000,50.16000,MedCost,Commercial,,67.72,,,,,,,25.16,67.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,MedCost,Commercial,,51.00,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,inpatient,1,UN,83.60000,50.16000,MedCost,Commercial,,67.72,,,,,,,25.16,67.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,MedCost,Commercial,,51.00,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,inpatient,1,UN,83.60000,50.16000,MedCost,Commercial,,67.72,,,,,,,25.16,67.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,MedCost,Commercial,,51.00,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,inpatient,1,UN,947.35000,568.41000,MedCost,Commercial,,767.35,,,,,,,606.30,770.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,MedCost,Commercial,,577.88,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,inpatient,16,GR,22.20000,13.32000,MedCost,Commercial,,17.98,,,,,,,14.21,18.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,MedCost,Commercial,,13.54,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,inpatient,1,UN,356.60000,213.96000,MedCost,Commercial,,288.85,,,,,,,228.22,289.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,MedCost,Commercial,,217.53,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,inpatient,10,ML,404.65000,242.79000,MedCost,Commercial,,327.77,,,,,,,121.80,328.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,MedCost,Commercial,,246.84,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,inpatient,2.5,ML,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,inpatient,2.5,ML,1.20000,0.72000,MedCost,Commercial,,0.97200,,,,,,,0.76800,0.97560,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,MedCost,Commercial,,0.73200,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,10.69,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,13.28,,,,,,,10.50,13.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,10.00,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,inpatient,50,GR,53.20000,31.92000,MedCost,Commercial,,43.09,,,,,,,34.05,43.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,MedCost,Commercial,,32.45,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,inpatient,0.3,ML,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,inpatient,10,ML,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,30.10,81.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,inpatient,5,ML,104.75000,62.85000,MedCost,Commercial,,84.85,,,,,,,31.53,85.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,MedCost,Commercial,,63.90,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,inpatient,20,ML,67.00000,40.20000,MedCost,Commercial,,54.27,,,,,,,42.88,54.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,MedCost,Commercial,,40.87,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,inpatient,100,ML,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,inpatient,10,ML,116.65000,69.99000,MedCost,Commercial,,94.49,,,,,,,74.66,94.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,MedCost,Commercial,,71.16,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,inpatient,50,ML,112.05000,67.23000,MedCost,Commercial,,90.76,,,,,,,71.71,91.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,MedCost,Commercial,,68.35,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,63.79,,,,,,,50.40,63.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Commercial,,48.04,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,inpatient,500,ML,76.50000,45.90000,MedCost,Commercial,,61.97,,,,,,,48.96,61.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,MedCost,Commercial,,46.66,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,500,ML,82.50000,49.50000,MedCost,Commercial,,66.83,,,,,,,24.83,67.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,MedCost,Commercial,,50.33,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,inpatient,30,ML,82.45000,49.47000,MedCost,Commercial,,66.78,,,,,,,24.82,67.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,MedCost,Commercial,,50.29,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,inpatient,30,ML,95.15000,57.09000,MedCost,Commercial,,77.07,,,,,,,28.64,77.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,MedCost,Commercial,,58.04,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,inpatient,4,ML,18.70000,11.22000,MedCost,Commercial,,15.15,,,,,,,11.97,15.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,MedCost,Commercial,,11.41,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,inpatient,15,ML,136.65000,81.99000,MedCost,Commercial,,110.69,,,,,,,87.46,111.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,MedCost,Commercial,,83.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,inpatient,5,ML,74.25000,44.55000,MedCost,Commercial,,60.14,,,,,,,47.52,60.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,MedCost,Commercial,,45.29,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,inpatient,50,ML,428.05000,256.83000,MedCost,Commercial,,346.72,,,,,,,273.95,348.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,MedCost,Commercial,,261.11,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,inpatient,50,ML,394.80000,236.88000,MedCost,Commercial,,319.79,,,,,,,118.83,320.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,MedCost,Commercial,,240.83,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,13.73,,,,,,,10.85,13.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Commercial,,10.34,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,inpatient,500,ML,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,inpatient,500,ML,69.00000,41.40000,MedCost,Commercial,,55.89,,,,,,,44.16,56.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,MedCost,Commercial,,42.09,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,inpatient,1,UN,80.15000,48.09000,MedCost,Commercial,,64.92,,,,,,,51.30,65.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,MedCost,Commercial,,48.89,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,inpatient,10,ML,115.70000,69.42000,MedCost,Commercial,,93.72,,,,,,,34.83,94.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,MedCost,Commercial,,70.58,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,13.61,,,,,,,10.75,13.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Commercial,,10.25,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,13.97,,,,,,,11.04,14.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,10.52,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,inpatient,0.3,ML,5298.55000,3179.13000,MedCost,Commercial,,4291.83,,,,,,,1594.86,4307.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,MedCost,Commercial,,3232.12,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,inpatient,1,ML,269.90000,161.94000,MedCost,Commercial,,218.62,,,,,,,81.24,219.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,MedCost,Commercial,,164.64,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,inpatient,1,UN,715.00000,429.00000,MedCost,Commercial,,579.15,,,,,,,215.22,581.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,MedCost,Commercial,,436.15,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,inpatient,1,UN,85.10000,51.06000,MedCost,Commercial,,68.93,,,,,,,25.62,69.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,MedCost,Commercial,,51.91,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,inpatient,1,UN,45.70000,27.42000,MedCost,Commercial,,37.02,,,,,,,29.25,37.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,MedCost,Commercial,,27.88,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,inpatient,1,UN,49.55000,29.73000,MedCost,Commercial,,40.14,,,,,,,31.71,40.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,MedCost,Commercial,,30.23,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,inpatient,5,ML,1.55000,0.93000,MedCost,Commercial,,1.26,,,,,,,0.99200,1.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,MedCost,Commercial,,0.94550,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,inpatient,1,UN,407.75000,244.65000,MedCost,Commercial,,330.28,,,,,,,260.96,331.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,MedCost,Commercial,,248.73,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,inpatient,2,ML,1979.25000,1187.55000,MedCost,Commercial,,1603.19,,,,,,,1266.72,1609.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,MedCost,Commercial,,1207.34,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,inpatient,1,UN,367.80000,220.68000,MedCost,Commercial,,297.92,,,,,,,110.71,299.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,MedCost,Commercial,,224.36,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,inpatient,50,GR,6.90000,4.14000,MedCost,Commercial,,5.59,,,,,,,4.42,5.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,MedCost,Commercial,,4.21,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,inpatient,20,ML,646.00000,387.60000,MedCost,Commercial,,523.26,,,,,,,194.45,525.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,MedCost,Commercial,,394.06,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,inpatient,1,UN,26.55000,15.93000,MedCost,Commercial,,21.51,,,,,,,16.99,21.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,MedCost,Commercial,,16.20,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,inpatient,5,ML,79.80000,47.88000,MedCost,Commercial,,64.64,,,,,,,24.02,64.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,MedCost,Commercial,,48.68,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,inpatient,2.5,ML,118.85000,71.31000,MedCost,Commercial,,96.27,,,,,,,76.06,96.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,MedCost,Commercial,,72.50,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,inpatient,1,UN,22.30000,13.38000,MedCost,Commercial,,18.06,,,,,,,14.27,18.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,MedCost,Commercial,,13.60,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,inpatient,2,ML,94.80000,56.88000,MedCost,Commercial,,76.79,,,,,,,60.67,77.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,MedCost,Commercial,,57.83,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,inpatient,1,UN,848.40000,509.04000,MedCost,Commercial,,687.20,,,,,,,255.37,689.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,MedCost,Commercial,,517.52,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,inpatient,10,ML,32.20000,19.32000,MedCost,Commercial,,26.08,,,,,,,20.61,26.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,MedCost,Commercial,,19.64,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,inpatient,0.25,ML,27.95000,16.77000,MedCost,Commercial,,22.64,,,,,,,8.41,22.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,MedCost,Commercial,,17.05,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,inpatient,0.25,ML,28.70000,17.22000,MedCost,Commercial,,23.25,,,,,,,8.64,23.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,MedCost,Commercial,,17.51,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,inpatient,15,ML,286.00000,171.60000,MedCost,Commercial,,231.66,,,,,,,183.04,232.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,MedCost,Commercial,,174.46,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,inpatient,15,ML,6.25000,3.75000,MedCost,Commercial,,5.06,,,,,,,4.00,5.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,MedCost,Commercial,,3.81,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,inpatient,18.75,ML,25.05000,15.03000,MedCost,Commercial,,20.29,,,,,,,16.03,20.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,MedCost,Commercial,,15.28,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,18.75,ML,25.05000,15.03000,MedCost,Commercial,,20.29,,,,,,,16.03,20.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,MedCost,Commercial,,15.28,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,inpatient,1,UN,53.45000,32.07000,MedCost,Commercial,,43.29,,,,,,,34.21,43.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,MedCost,Commercial,,32.60,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,inpatient,1,UN,2850.10000,1710.06000,MedCost,Commercial,,2308.58,,,,,,,857.88,2317.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,MedCost,Commercial,,1738.56,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,inpatient,1,UN,62.05000,37.23000,MedCost,Commercial,,50.26,,,,,,,39.71,50.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,MedCost,Commercial,,37.85,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,inpatient,0.25,ML,22.80000,13.68000,MedCost,Commercial,,18.47,,,,,,,6.86,18.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,MedCost,Commercial,,13.91,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,16.04,,,,,,,12.67,16.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,12.08,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,inpatient,1,UN,23.65000,14.19000,MedCost,Commercial,,19.16,,,,,,,15.14,19.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,MedCost,Commercial,,14.43,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,inpatient,5,ML,62.50000,37.50000,MedCost,Commercial,,50.62,,,,,,,40.00,50.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,MedCost,Commercial,,38.12,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,13.37,,,,,,,10.56,13.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Commercial,,10.06,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,13.41,,,,,,,10.59,13.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Commercial,,10.10,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,inpatient,15,GR,25.00000,15.00000,MedCost,Commercial,,20.25,,,,,,,16.00,20.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,MedCost,Commercial,,15.25,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,inpatient,15,GR,40.60000,24.36000,MedCost,Commercial,,32.89,,,,,,,25.98,33.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,MedCost,Commercial,,24.77,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,inpatient,15,GR,29.95000,17.97000,MedCost,Commercial,,24.26,,,,,,,19.17,24.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,MedCost,Commercial,,18.27,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,1,ML,58.60000,35.16000,MedCost,Commercial,,47.47,,,,,,,17.64,47.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,MedCost,Commercial,,35.75,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,inpatient,1,ML,55.45000,33.27000,MedCost,Commercial,,44.91,,,,,,,16.69,45.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,MedCost,Commercial,,33.82,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,inpatient,1,ML,45.50000,27.30000,MedCost,Commercial,,36.85,,,,,,,13.70,36.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,MedCost,Commercial,,27.75,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,inpatient,5,GR,209.45000,125.67000,MedCost,Commercial,,169.65,,,,,,,134.05,170.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,MedCost,Commercial,,127.76,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,13.85,,,,,,,10.94,13.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Commercial,,10.43,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,inpatient,1,UN,25.95000,15.57000,MedCost,Commercial,,21.02,,,,,,,16.61,21.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,MedCost,Commercial,,15.83,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,inpatient,6.9,GR,431.25000,258.75000,MedCost,Commercial,,349.31,,,,,,,276.00,350.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,MedCost,Commercial,,263.06,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,inpatient,6,GR,493.60000,296.16000,MedCost,Commercial,,399.82,,,,,,,315.90,401.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,MedCost,Commercial,,301.10,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,inpatient,30,ML,27459.60000,16475.76000,MedCost,Commercial,,22242.28,,,,,,,8265.34,22324.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,MedCost,Commercial,,16750.36,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,inpatient,10,ML,92.40000,55.44000,MedCost,Commercial,,74.84,,,,,,,27.81,75.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,MedCost,Commercial,,56.36,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,inpatient,4,ML,18.70000,11.22000,MedCost,Commercial,,15.15,,,,,,,11.97,15.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,MedCost,Commercial,,11.41,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,MedCost,Commercial,,234.94,,,,,,,87.31,235.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,MedCost,Commercial,,176.93,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,inpatient,20,ML,305.10000,183.06000,MedCost,Commercial,,247.13,,,,,,,91.84,248.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,MedCost,Commercial,,186.11,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,inpatient,1,UN,9076.45000,5445.87000,MedCost,Commercial,,7351.92,,,,,,,2732.01,7379.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,MedCost,Commercial,,5536.63,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,inpatient,2,ML,27.35000,16.41000,MedCost,Commercial,,22.15,,,,,,,8.23,22.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,MedCost,Commercial,,16.68,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,inpatient,60,ML,120.60000,72.36000,MedCost,Commercial,,97.69,,,,,,,36.30,98.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,MedCost,Commercial,,73.57,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,inpatient,15,ML,106.00000,63.60000,MedCost,Commercial,,85.86,,,,,,,67.84,86.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,MedCost,Commercial,,64.66,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,inpatient,1,UN,107.50000,64.50000,MedCost,Commercial,,87.08,,,,,,,68.80,87.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,MedCost,Commercial,,65.58,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,inpatient,1,UN,107.45000,64.47000,MedCost,Commercial,,87.03,,,,,,,68.77,87.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,MedCost,Commercial,,65.54,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,inpatient,0.1,ML,56.75000,34.05000,MedCost,Commercial,,45.97,,,,,,,36.32,46.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,MedCost,Commercial,,34.62,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,inpatient,1,UN,131.40000,78.84000,MedCost,Commercial,,106.43,,,,,,,39.55,106.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,MedCost,Commercial,,80.15,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,inpatient,1,UN,97.30000,58.38000,MedCost,Commercial,,78.81,,,,,,,29.29,79.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,MedCost,Commercial,,59.35,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,inpatient,1,UN,442.10000,265.26000,MedCost,Commercial,,358.10,,,,,,,133.07,359.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,MedCost,Commercial,,269.68,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,inpatient,28.4,GR,4.45000,2.67000,MedCost,Commercial,,3.60,,,,,,,2.85,3.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,MedCost,Commercial,,2.71,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,inpatient,2,ML,61.50000,36.90000,MedCost,Commercial,,49.81,,,,,,,39.36,50.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,MedCost,Commercial,,37.52,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,inpatient,4,ML,45.20000,27.12000,MedCost,Commercial,,36.61,,,,,,,28.93,36.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,MedCost,Commercial,,27.57,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,13.28,,,,,,,10.50,13.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Commercial,,10.00,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,13.97,,,,,,,11.04,14.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,10.52,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,inpatient,28,GR,5.25000,3.15000,MedCost,Commercial,,4.25,,,,,,,3.36,4.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,MedCost,Commercial,,3.20,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,inpatient,10,ML,511.55000,306.93000,MedCost,Commercial,,414.36,,,,,,,153.98,415.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,MedCost,Commercial,,312.05,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,inpatient,1,ML,353.10000,211.86000,MedCost,Commercial,,286.01,,,,,,,106.28,287.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,MedCost,Commercial,,215.39,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,inpatient,1,UN,17.90000,10.74000,MedCost,Commercial,,14.50,,,,,,,11.46,14.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,MedCost,Commercial,,10.92,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,inpatient,1,UN,17.55000,10.53000,MedCost,Commercial,,14.22,,,,,,,11.23,14.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,MedCost,Commercial,,10.71,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,14.26,,,,,,,11.26,14.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Commercial,,10.74,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,14.30,,,,,,,11.30,14.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Commercial,,10.77,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,inpatient,1,UN,18.35000,11.01000,MedCost,Commercial,,14.86,,,,,,,11.74,14.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,MedCost,Commercial,,11.19,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,inpatient,1,UN,33.40000,20.04000,MedCost,Commercial,,27.05,,,,,,,21.38,27.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,MedCost,Commercial,,20.37,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,inpatient,0.5,ML,40477.65000,24286.59000,MedCost,Commercial,,32786.90,,,,,,,12183.77,32908.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,MedCost,Commercial,,24691.37,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,inpatient,10,ML,567.95000,340.77000,MedCost,Commercial,,460.04,,,,,,,170.95,461.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,MedCost,Commercial,,346.45,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,inpatient,2,ML,40.90000,24.54000,MedCost,Commercial,,33.13,,,,,,,12.31,33.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,MedCost,Commercial,,24.95,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,inpatient,2,ML,98.10000,58.86000,MedCost,Commercial,,79.46,,,,,,,62.78,79.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,MedCost,Commercial,,59.84,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,MedCost,Commercial,,366.40,,,,,,,136.16,367.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,MedCost,Commercial,,275.93,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,MedCost,Commercial,,329.67,,,,,,,122.51,330.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,MedCost,Commercial,,248.27,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,inpatient,1,UN,154.90000,92.94000,MedCost,Commercial,,125.47,,,,,,,99.14,125.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,MedCost,Commercial,,94.49,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,inpatient,4,ML,59.15000,35.49000,MedCost,Commercial,,47.91,,,,,,,37.86,48.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,MedCost,Commercial,,36.08,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,inpatient,1,UN,26867.20000,16120.32000,MedCost,Commercial,,21762.43,,,,,,,8087.03,21843.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,MedCost,Commercial,,16388.99,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,inpatient,1,UN,71.75000,43.05000,MedCost,Commercial,,58.12,,,,,,,45.92,58.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,MedCost,Commercial,,43.77,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,inpatient,1,UN,798.05000,478.83000,MedCost,Commercial,,646.42,,,,,,,510.75,648.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,MedCost,Commercial,,486.81,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,inpatient,28.4,GR,9.15000,5.49000,MedCost,Commercial,,7.41,,,,,,,5.86,7.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,MedCost,Commercial,,5.58,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,1.13,,,,,,,0.89600,1.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Commercial,,0.85400,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,inpatient,1,UN,99.10000,59.46000,MedCost,Commercial,,80.27,,,,,,,63.42,80.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,MedCost,Commercial,,60.45,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,inpatient,1,UN,3832.85000,2299.71000,MedCost,Commercial,,3104.61,,,,,,,1153.69,3116.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,MedCost,Commercial,,2338.04,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,inpatient,113,GR,3.25000,1.95000,MedCost,Commercial,,2.63,,,,,,,2.08,2.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,MedCost,Commercial,,1.98,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,inpatient,1,UN,2.45000,1.47000,MedCost,Commercial,,1.98,,,,,,,1.57,1.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,MedCost,Commercial,,1.49,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,inpatient,1000,ML,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,73.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,inpatient,473,ML,1084.55000,650.73000,MedCost,Commercial,,878.49,,,,,,,694.11,881.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,MedCost,Commercial,,661.58,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,inpatient,1,UN,40.65000,24.39000,MedCost,Commercial,,32.93,,,,,,,26.02,33.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,MedCost,Commercial,,24.80,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,inpatient,1,UN,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,MedCost,Commercial,,437.24,,,,,,,162.48,438.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,MedCost,Commercial,,329.28,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,MedCost,Commercial,,249.80,,,,,,,92.83,250.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,MedCost,Commercial,,188.12,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,inpatient,250,ML,437.00000,262.20000,MedCost,Commercial,,353.97,,,,,,,131.54,355.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,MedCost,Commercial,,266.57,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,inpatient,250,ML,437.00000,262.20000,MedCost,Commercial,,353.97,,,,,,,131.54,355.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,MedCost,Commercial,,266.57,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,inpatient,1,ML,786.55000,471.93000,MedCost,Commercial,,637.11,,,,,,,236.75,639.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,MedCost,Commercial,,479.80,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,inpatient,1,UN,40057.65000,24034.59000,MedCost,Commercial,,32446.70,,,,,,,12057.35,32566.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,MedCost,Commercial,,24435.17,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,inpatient,1,UN,20036.85000,12022.11000,MedCost,Commercial,,16229.85,,,,,,,6031.09,16289.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,MedCost,Commercial,,12222.48,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,inpatient,15,ML,3.95000,2.37000,MedCost,Commercial,,3.20,,,,,,,2.53,3.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,MedCost,Commercial,,2.41,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,inpatient,15,ML,1.25000,0.75000,MedCost,Commercial,,1.01,,,,,,,0.80000,1.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,MedCost,Commercial,,0.76250,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,inpatient,1,UN,2.00000,1.20000,MedCost,Commercial,,1.62,,,,,,,1.28,1.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,MedCost,Commercial,,1.22,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,inpatient,1,UN,101.95000,61.17000,MedCost,Commercial,,82.58,,,,,,,65.25,82.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,MedCost,Commercial,,62.19,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,14.18,,,,,,,11.20,14.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,10.68,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,inpatient,1,UN,16.45000,9.87000,MedCost,Commercial,,13.32,,,,,,,10.53,13.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,MedCost,Commercial,,10.03,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,13.45,,,,,,,10.62,13.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Commercial,,10.13,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,10.69,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,MedCost,Commercial,,41.39,,,,,,,15.38,41.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,MedCost,Commercial,,31.17,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,inpatient,1,UN,34.00000,20.40000,MedCost,Commercial,,27.54,,,,,,,10.23,27.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,MedCost,Commercial,,20.74,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,inpatient,250,ML,98.00000,58.80000,MedCost,Commercial,,79.38,,,,,,,62.72,79.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,MedCost,Commercial,,59.78,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,inpatient,1,UN,129.05000,77.43000,MedCost,Commercial,,104.53,,,,,,,38.84,104.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,MedCost,Commercial,,78.72,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,inpatient,5,ML,371.70000,223.02000,MedCost,Commercial,,301.08,,,,,,,111.88,302.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,MedCost,Commercial,,226.74,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,inpatient,1,UN,94.85000,56.91000,MedCost,Commercial,,76.83,,,,,,,28.55,77.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,MedCost,Commercial,,57.86,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,inpatient,300,ML,210.00000,126.00000,MedCost,Commercial,,170.10,,,,,,,134.40,170.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,MedCost,Commercial,,128.10,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,inpatient,0.5,ML,26.25000,15.75000,MedCost,Commercial,,21.26,,,,,,,7.90,21.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,MedCost,Commercial,,16.01,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,inpatient,0.75,ML,49.95000,29.97000,MedCost,Commercial,,40.46,,,,,,,15.03,40.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,MedCost,Commercial,,30.47,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,inpatient,1,ML,175.25000,105.15000,MedCost,Commercial,,141.95,,,,,,,52.75,142.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,MedCost,Commercial,,106.90,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,inpatient,2,ML,30.90000,18.54000,MedCost,Commercial,,25.03,,,,,,,9.30,25.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,MedCost,Commercial,,18.85,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,inpatient,5,ML,813.05000,487.83000,MedCost,Commercial,,658.57,,,,,,,244.73,661.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,MedCost,Commercial,,495.96,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.85050,,,,,,,0.67200,0.85365,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Commercial,,0.64050,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,16.20,,,,,,,12.80,16.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,12.20,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,inpatient,0.4,ML,531.50000,318.90000,MedCost,Commercial,,430.51,,,,,,,159.98,432.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,MedCost,Commercial,,324.21,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,inpatient,10,ML,80.05000,48.03000,MedCost,Commercial,,64.84,,,,,,,51.23,65.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,MedCost,Commercial,,48.83,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,inpatient,5,ML,37.55000,22.53000,MedCost,Commercial,,30.42,,,,,,,24.03,30.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,MedCost,Commercial,,22.91,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,inpatient,1,UN,18.75000,11.25000,MedCost,Commercial,,15.19,,,,,,,5.64,15.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,MedCost,Commercial,,11.44,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,MedCost,Commercial,,122.51,,,,,,,45.53,122.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,MedCost,Commercial,,92.26,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,inpatient,1,UN,276.30000,165.78000,MedCost,Commercial,,223.80,,,,,,,83.17,224.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,MedCost,Commercial,,168.54,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,inpatient,0.01,ML,48.35000,29.01000,MedCost,Commercial,,39.16,,,,,,,30.94,39.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,MedCost,Commercial,,29.49,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,inpatient,5,ML,266.40000,159.84000,MedCost,Commercial,,215.78,,,,,,,80.19,216.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,MedCost,Commercial,,162.50,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,inpatient,30,ML,4.05000,2.43000,MedCost,Commercial,,3.28,,,,,,,2.59,3.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,MedCost,Commercial,,2.47,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,inpatient,1,UN,159.90000,95.94000,MedCost,Commercial,,129.52,,,,,,,102.34,130.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,MedCost,Commercial,,97.54,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,71.48,,,,,,,26.56,71.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,53.83,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,71.48,,,,,,,26.56,71.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,53.83,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,71.48,,,,,,,26.56,71.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Commercial,,53.83,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,inpatient,1,UN,526.70000,316.02000,MedCost,Commercial,,426.63,,,,,,,158.54,428.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,MedCost,Commercial,,321.29,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,inpatient,1,UN,29.25000,17.55000,MedCost,Commercial,,23.69,,,,,,,18.72,23.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,MedCost,Commercial,,17.84,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,inpatient,1,UN,84.65000,50.79000,MedCost,Commercial,,68.57,,,,,,,25.48,68.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,MedCost,Commercial,,51.64,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,inpatient,1,UN,84.65000,50.79000,MedCost,Commercial,,68.57,,,,,,,25.48,68.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,MedCost,Commercial,,51.64,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,inpatient,118,ML,5.25000,3.15000,MedCost,Commercial,,4.25,,,,,,,3.36,4.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,MedCost,Commercial,,3.20,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,inpatient,4,ML,29.75000,17.85000,MedCost,Commercial,,24.10,,,,,,,8.95,24.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,MedCost,Commercial,,18.15,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,inpatient,3,ML,75.05000,45.03000,MedCost,Commercial,,60.79,,,,,,,22.59,61.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,MedCost,Commercial,,45.78,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,inpatient,3,ML,75.45000,45.27000,MedCost,Commercial,,61.11,,,,,,,22.71,61.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,MedCost,Commercial,,46.02,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,inpatient,3,ML,71.45000,42.87000,MedCost,Commercial,,57.87,,,,,,,21.51,58.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,MedCost,Commercial,,43.58,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,11.42,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,inpatient,2,ML,29.00000,17.40000,MedCost,Commercial,,23.49,,,,,,,8.73,23.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,MedCost,Commercial,,17.69,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,14.18,,,,,,,11.20,14.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,10.68,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,inpatient,1,UN,20.95000,12.57000,MedCost,Commercial,,16.97,,,,,,,13.41,17.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,MedCost,Commercial,,12.78,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,13.20,,,,,,,10.43,13.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Commercial,,9.94,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,inpatient,1,UN,16.15000,9.69000,MedCost,Commercial,,13.08,,,,,,,10.34,13.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,MedCost,Commercial,,9.85,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,inpatient,0.5,ML,39.05000,23.43000,MedCost,Commercial,,31.63,,,,,,,11.75,31.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,MedCost,Commercial,,23.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,inpatient,2,ML,3656.00000,2193.60000,MedCost,Commercial,,2961.36,,,,,,,1100.46,2972.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,MedCost,Commercial,,2230.16,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,16.04,,,,,,,12.67,16.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Commercial,,12.08,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,inpatient,1,UN,12542.25000,7525.35000,MedCost,Commercial,,10159.22,,,,,,,3775.22,10196.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,MedCost,Commercial,,7650.77,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,inpatient,1,UN,25068.40000,15041.04000,MedCost,Commercial,,20305.40,,,,,,,7545.59,20380.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,MedCost,Commercial,,15291.72,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,inpatient,10,ML,2068.75000,1241.25000,MedCost,Commercial,,1675.69,,,,,,,622.69,1681.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,MedCost,Commercial,,1261.94,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,inpatient,12.5,ML,2753.30000,1651.98000,MedCost,Commercial,,2230.17,,,,,,,828.74,2238.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,MedCost,Commercial,,1679.51,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,inpatient,15,ML,3080.00000,1848.00000,MedCost,Commercial,,2494.80,,,,,,,927.08,2504.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,MedCost,Commercial,,1878.80,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.89100,,,,,,,0.70400,0.89430,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Commercial,,0.67100,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,inpatient,3,ML,18.05000,10.83000,MedCost,Commercial,,14.62,,,,,,,11.55,14.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,MedCost,Commercial,,11.01,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,inpatient,50,ML,433.25000,259.95000,MedCost,Commercial,,350.93,,,,,,,130.41,352.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,MedCost,Commercial,,264.28,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,inpatient,1,UN,21.70000,13.02000,MedCost,Commercial,,17.58,,,,,,,13.89,17.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,MedCost,Commercial,,13.24,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,inpatient,1,UN,22.20000,13.32000,MedCost,Commercial,,17.98,,,,,,,14.21,18.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,MedCost,Commercial,,13.54,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,13.81,,,,,,,5.13,13.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Commercial,,10.40,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,14.18,,,,,,,5.27,14.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Commercial,,10.68,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,inpatient,1,ML,653.00000,391.80000,MedCost,Commercial,,528.93,,,,,,,196.55,530.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,MedCost,Commercial,,398.33,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.93150,,,,,,,0.73600,0.93495,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Commercial,,0.70150,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,inpatient,1,ML,86.10000,51.66000,MedCost,Commercial,,69.74,,,,,,,55.10,70.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,MedCost,Commercial,,52.52,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,inpatient,1,UN,60.60000,36.36000,MedCost,Commercial,,49.09,,,,,,,18.24,49.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,MedCost,Commercial,,36.97,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,inpatient,200,ML,745.95000,447.57000,MedCost,Commercial,,604.22,,,,,,,224.53,606.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,MedCost,Commercial,,455.03,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,inpatient,1,UN,105.00000,63.00000,MedCost,Commercial,,85.05,,,,,,,31.61,85.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,MedCost,Commercial,,64.05,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,inpatient,1,UN,39.70000,23.82000,MedCost,Commercial,,32.16,,,,,,,11.95,32.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,MedCost,Commercial,,24.22,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,inpatient,1,UN,61.50000,36.90000,MedCost,Commercial,,49.81,,,,,,,18.51,50.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,MedCost,Commercial,,37.52,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,MedCost,Commercial,,23.65,,,,,,,8.79,23.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,MedCost,Commercial,,17.81,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,inpatient,1,UN,21.70000,13.02000,MedCost,Commercial,,17.58,,,,,,,6.53,17.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,MedCost,Commercial,,13.24,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,13.53,,,,,,,10.69,13.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Commercial,,10.19,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,13.69,,,,,,,10.82,13.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Commercial,,10.31,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,inpatient,100,ML,85.00000,51.00000,MedCost,Commercial,,68.85,,,,,,,54.40,69.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,MedCost,Commercial,,51.85,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,inpatient,5,ML,18.55000,11.13000,MedCost,Commercial,,15.03,,,,,,,11.87,15.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,MedCost,Commercial,,11.32,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,inpatient,237,ML,222.95000,133.77000,MedCost,Commercial,,180.59,,,,,,,142.69,181.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,MedCost,Commercial,,136.00,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,inpatient,1,UN,315.00000,189.00000,MedCost,Commercial,,255.15,,,,,,,94.81,256.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,MedCost,Commercial,,192.15,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,inpatient,50,ML,14.80000,8.88000,MedCost,Commercial,,11.99,,,,,,,9.47,12.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,MedCost,Commercial,,9.03,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,inpatient,1,UN,1663.10000,997.86000,MedCost,Commercial,,1347.11,,,,,,,500.59,1352.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,MedCost,Commercial,,1014.49,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,inpatient,5,ML,78.65000,47.19000,MedCost,Commercial,,63.71,,,,,,,50.34,63.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,MedCost,Commercial,,47.98,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,inpatient,1,UN,24.20000,14.52000,MedCost,Commercial,,19.60,,,,,,,15.49,19.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,MedCost,Commercial,,14.76,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,inpatient,10,ML,82.00000,49.20000,MedCost,Commercial,,66.42,,,,,,,52.48,66.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,MedCost,Commercial,,50.02,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,inpatient,2.5,ML,47.50000,28.50000,MedCost,Commercial,,38.48,,,,,,,30.40,38.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,MedCost,Commercial,,28.98,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,inpatient,5,ML,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,47.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,inpatient,10,ML,2189.00000,1313.40000,MedCost,Commercial,,1773.09,,,,,,,658.89,1779.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,MedCost,Commercial,,1335.29,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,inpatient,1,UN,35.95000,21.57000,MedCost,Commercial,,29.12,,,,,,,23.01,29.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,MedCost,Commercial,,21.93,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,inpatient,30,GR,264.80000,158.88000,MedCost,Commercial,,214.49,,,,,,,169.47,215.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,MedCost,Commercial,,161.53,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,inpatient,50,ML,104.50000,62.70000,MedCost,Commercial,,84.64,,,,,,,31.45,84.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,MedCost,Commercial,,63.74,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,inpatient,50,ML,113.75000,68.25000,MedCost,Commercial,,92.14,,,,,,,34.24,92.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,MedCost,Commercial,,69.39,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,inpatient,15,GR,46.05000,27.63000,MedCost,Commercial,,37.30,,,,,,,29.47,37.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,MedCost,Commercial,,28.09,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,inpatient,1,UN,22.10000,13.26000,MedCost,Commercial,,17.90,,,,,,,14.14,17.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,MedCost,Commercial,,13.48,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,inpatient,1,UN,22.35000,13.41000,MedCost,Commercial,,18.10,,,,,,,14.30,18.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,MedCost,Commercial,,13.63,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,inpatient,1,UN,27.00000,16.20000,MedCost,Commercial,,21.87,,,,,,,17.28,21.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,MedCost,Commercial,,16.47,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,inpatient,1,UN,22.70000,13.62000,MedCost,Commercial,,18.39,,,,,,,14.53,18.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,MedCost,Commercial,,13.85,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,15.07,,,,,,,11.90,15.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Commercial,,11.35,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,inpatient,1,UN,417.20000,250.32000,MedCost,Commercial,,337.93,,,,,,,125.58,339.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,MedCost,Commercial,,254.49,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,inpatient,60,GR,1533.80000,920.28000,MedCost,Commercial,,1242.38,,,,,,,981.63,1246.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,MedCost,Commercial,,935.62,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,inpatient,1,UN,38.50000,23.10000,MedCost,Commercial,,31.18,,,,,,,24.64,31.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,MedCost,Commercial,,23.48,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,inpatient,1,UN,61.85000,37.11000,MedCost,Commercial,,50.10,,,,,,,39.58,50.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,MedCost,Commercial,,37.73,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,inpatient,1,UN,78.65000,47.19000,MedCost,Commercial,,63.71,,,,,,,50.34,63.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,MedCost,Commercial,,47.98,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,inpatient,5,ML,96.35000,57.81000,MedCost,Commercial,,78.04,,,,,,,29.00,78.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,MedCost,Commercial,,58.77,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,inpatient,5,ML,302.95000,181.77000,MedCost,Commercial,,245.39,,,,,,,91.19,246.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,MedCost,Commercial,,184.80,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,inpatient,1,UN,3628.20000,2176.92000,MedCost,Commercial,,2938.84,,,,,,,1092.09,2949.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,MedCost,Commercial,,2213.20,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,inpatient,2,ML,127.10000,76.26000,MedCost,Commercial,,102.95,,,,,,,81.34,103.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,MedCost,Commercial,,77.53,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,inpatient,5,ML,211.15000,126.69000,MedCost,Commercial,,171.03,,,,,,,135.14,171.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,MedCost,Commercial,,128.80,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,inpatient,1,UN,89.05000,53.43000,MedCost,Commercial,,72.13,,,,,,,26.80,72.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,MedCost,Commercial,,54.32,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,inpatient,1,UN,34.30000,20.58000,MedCost,Commercial,,27.78,,,,,,,10.32,27.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,MedCost,Commercial,,20.92,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,inpatient,1,UN,60.05000,36.03000,MedCost,Commercial,,48.64,,,,,,,38.43,48.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,MedCost,Commercial,,36.63,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,inpatient,1,UN,31.25000,18.75000,MedCost,Commercial,,25.31,,,,,,,20.00,25.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,MedCost,Commercial,,19.06,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,inpatient,1,UN,201.30000,120.78000,MedCost,Commercial,,163.05,,,,,,,60.59,163.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,MedCost,Commercial,,122.79,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,inpatient,1,UN,174.05000,104.43000,MedCost,Commercial,,140.98,,,,,,,52.39,141.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,MedCost,Commercial,,106.17,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,inpatient,1,ML,64.55000,38.73000,MedCost,Commercial,,52.29,,,,,,,19.43,52.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,MedCost,Commercial,,39.38,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,inpatient,1,ML,64.85000,38.91000,MedCost,Commercial,,52.53,,,,,,,19.52,52.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,MedCost,Commercial,,39.56,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,inpatient,1,ML,64.70000,38.82000,MedCost,Commercial,,52.41,,,,,,,19.47,52.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,MedCost,Commercial,,39.47,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,inpatient,0.5,ML,238.95000,143.37000,MedCost,Commercial,,193.55,,,,,,,71.92,194.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,MedCost,Commercial,,145.76,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,inpatient,1,UN,91.10000,54.66000,MedCost,Commercial,,73.79,,,,,,,27.42,74.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,MedCost,Commercial,,55.57,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,1.17,,,,,,,0.92800,1.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Commercial,,0.88450,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,inpatient,240,ML,661.30000,396.78000,MedCost,Commercial,,535.65,,,,,,,423.23,537.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,MedCost,Commercial,,403.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,inpatient,1,ML,385.20000,231.12000,MedCost,Commercial,,312.01,,,,,,,115.95,313.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,MedCost,Commercial,,234.97,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,inpatient,10,ML,1813.25000,1087.95000,MedCost,Commercial,,1468.73,,,,,,,545.79,1474.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,MedCost,Commercial,,1106.08,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,inpatient,1,UN,82.95000,49.77000,MedCost,Commercial,,67.19,,,,,,,24.97,67.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,MedCost,Commercial,,50.60,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,inpatient,10,ML,4.60000,2.76000,MedCost,Commercial,,3.73,,,,,,,2.94,3.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,MedCost,Commercial,,2.81,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,inpatient,500,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,inpatient,1,UN,2174.60000,1304.76000,MedCost,Commercial,,1761.43,,,,,,,1391.74,1767.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,MedCost,Commercial,,1326.51,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,inpatient,1000,ML,101.50000,60.90000,MedCost,Commercial,,82.22,,,,,,,30.55,82.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,MedCost,Commercial,,61.91,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,inpatient,1000,ML,98.00000,58.80000,MedCost,Commercial,,79.38,,,,,,,29.50,79.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,MedCost,Commercial,,59.78,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,inpatient,1000,ML,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,inpatient,1000,ML,94.50000,56.70000,MedCost,Commercial,,76.55,,,,,,,28.44,76.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,MedCost,Commercial,,57.65,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,inpatient,1000,ML,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,25.28,68.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,inpatient,1,UN,24.60000,14.76000,MedCost,Commercial,,19.93,,,,,,,15.74,20.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,MedCost,Commercial,,15.01,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,inpatient,1,UN,33.20000,19.92000,MedCost,Commercial,,26.89,,,,,,,21.25,26.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,MedCost,Commercial,,20.25,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,inpatient,1,UN,50.05000,30.03000,MedCost,Commercial,,40.54,,,,,,,32.03,40.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,MedCost,Commercial,,30.53,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,inpatient,1000,ML,98.00000,58.80000,MedCost,Commercial,,79.38,,,,,,,29.50,79.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,MedCost,Commercial,,59.78,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,inpatient,1000,ML,98.00000,58.80000,MedCost,Commercial,,79.38,,,,,,,29.50,79.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,MedCost,Commercial,,59.78,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,inpatient,500,ML,76.50000,45.90000,MedCost,Commercial,,61.97,,,,,,,48.96,61.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,MedCost,Commercial,,46.66,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,inpatient,100,ML,356.00000,213.60000,MedCost,Commercial,,288.36,,,,,,,107.16,289.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,MedCost,Commercial,,217.16,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,inpatient,1,UN,58.55000,35.13000,MedCost,Commercial,,47.43,,,,,,,37.47,47.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,MedCost,Commercial,,35.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,inpatient,1,UN,48.95000,29.37000,MedCost,Commercial,,39.65,,,,,,,31.33,39.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,MedCost,Commercial,,29.86,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,inpatient,17,ML,5076.25000,3045.75000,MedCost,Commercial,,4111.76,,,,,,,1527.95,4126.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,MedCost,Commercial,,3096.51,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,inpatient,1,UN,70.00000,42.00000,MedCost,Commercial,,56.70,,,,,,,44.80,56.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,MedCost,Commercial,,42.70,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,16.20,,,,,,,12.80,16.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Commercial,,12.20,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,15.63,,,,,,,12.35,15.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Commercial,,11.77,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,inpatient,1,ML,642.70000,385.62000,MedCost,Commercial,,520.59,,,,,,,193.45,522.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,MedCost,Commercial,,392.05,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,inpatient,0.5,ML,254.90000,152.94000,MedCost,Commercial,,206.47,,,,,,,76.72,207.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,MedCost,Commercial,,155.49,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,13.93,,,,,,,11.01,13.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Commercial,,10.49,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,inpatient,20,ML,95.55000,57.33000,MedCost,Commercial,,77.40,,,,,,,28.76,77.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,MedCost,Commercial,,58.29,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,inpatient,10,ML,25.15000,15.09000,MedCost,Commercial,,20.37,,,,,,,16.10,20.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,MedCost,Commercial,,15.34,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,inpatient,30,GR,166.25000,99.75000,MedCost,Commercial,,134.66,,,,,,,106.40,135.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,MedCost,Commercial,,101.41,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,inpatient,1,ML,85.30000,51.18000,MedCost,Commercial,,69.09,,,,,,,54.59,69.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,MedCost,Commercial,,52.03,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,inpatient,2,ML,102.85000,61.71000,MedCost,Commercial,,83.31,,,,,,,65.82,83.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,MedCost,Commercial,,62.74,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,inpatient,0.3,ML,25.45000,15.27000,MedCost,Commercial,,20.61,,,,,,,16.29,20.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,MedCost,Commercial,,15.52,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,inpatient,0.25,ML,1.40000,0.84000,MedCost,Commercial,,1.13,,,,,,,0.89600,1.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,MedCost,Commercial,,0.85400,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,inpatient,88,ML,2416.85000,1450.11000,MedCost,Commercial,,1957.65,,,,,,,1546.78,1964.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,MedCost,Commercial,,1474.28,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,inpatient,1,UN,4022.30000,2413.38000,MedCost,Commercial,,3258.06,,,,,,,1210.71,3270.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,MedCost,Commercial,,2453.60,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,inpatient,10,ML,486.20000,291.72000,MedCost,Commercial,,393.82,,,,,,,146.35,395.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,MedCost,Commercial,,296.58,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,inpatient,20,ML,715.00000,429.00000,MedCost,Commercial,,579.15,,,,,,,215.22,581.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,MedCost,Commercial,,436.15,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,13.97,,,,,,,11.04,14.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Commercial,,10.52,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,inpatient,42.5,GR,1050.30000,630.18000,MedCost,Commercial,,850.74,,,,,,,672.19,853.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,MedCost,Commercial,,640.68,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,inpatient,1,UN,53.85000,32.31000,MedCost,Commercial,,43.62,,,,,,,34.46,43.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,MedCost,Commercial,,32.85,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,inpatient,1,UN,1730.85000,1038.51000,MedCost,Commercial,,1401.99,,,,,,,520.99,1407.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,MedCost,Commercial,,1055.82,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,inpatient,1,UN,44.30000,26.58000,MedCost,Commercial,,35.88,,,,,,,28.35,36.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,MedCost,Commercial,,27.02,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,inpatient,1,UN,44.30000,26.58000,MedCost,Commercial,,35.88,,,,,,,28.35,36.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,MedCost,Commercial,,27.02,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,inpatient,1,UN,113.80000,68.28000,MedCost,Commercial,,92.18,,,,,,,72.83,92.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,MedCost,Commercial,,69.42,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,14.46,,,,,,,11.42,14.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Commercial,,10.89,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,inpatient,1.5,ML,1650.30000,990.18000,MedCost,Commercial,,1336.74,,,,,,,496.74,1341.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,MedCost,Commercial,,1006.68,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,45414.56000,27248.74000,MedCost,Commercial,,36785.79,,,,,,,13669.78,36922.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,MedCost,Commercial,,27702.88,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,156212.38000,93727.43000,MedCost,Commercial,,126532.03,,,,,,,47019.93,127000.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,MedCost,Commercial,,95289.55,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,257500.00000,154500.00000,MedCost,Commercial,,208575.00,,,,,,,77507.50,209347.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,MedCost,Commercial,,157075.00,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,11159.74000,6695.84000,MedCost,Commercial,,9039.39,,,,,,,3359.08,9072.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,MedCost,Commercial,,6807.44,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,7390.20000,4434.12000,MedCost,Commercial,,5986.06,,,,,,,2224.45,6008.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,MedCost,Commercial,,4508.02,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,inpatient,2000,ML,259.00000,155.40000,MedCost,Commercial,,209.79,,,,,,,165.76,210.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,MedCost,Commercial,,157.99,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,inpatient,3.5,GR,13.65000,8.19000,MedCost,Commercial,,11.06,,,,,,,8.74,11.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,MedCost,Commercial,,8.33,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,inpatient,1,UN,1.20000,0.72000,MedCost,Commercial,,0.97200,,,,,,,0.76800,0.97560,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,MedCost,Commercial,,0.73200,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,inpatient,59,ML,9.15000,5.49000,MedCost,Commercial,,7.41,,,,,,,5.86,7.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,MedCost,Commercial,,5.58,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,inpatient,1000,ML,42.00000,25.20000,MedCost,Commercial,,34.02,,,,,,,12.64,34.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,MedCost,Commercial,,25.62,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,inpatient,24,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,inpatient,24,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.06020,0.16260,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,inpatient,200,ME,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,inpatient,25,UN,0.20000,0.12000,MedCost,Commercial,,0.16200,,,,,,,0.12800,0.16200,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,MedCost,Commercial,,0.12200,,,,,,,0.04004,0.15000,percent of total billed charges,
HC LTC LOA SHORT TERM PRIVATE ROOM LTP,11100030,CDM,180,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA LONG TERM CARE PRIVATE ROOM LTP,11100031,CDM,180,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,324.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SHORT TERM SEMI PRIVATE ROOM LTP,11200016,CDM,180,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA LONG TERM PASS SEMI PRIVATE ROOM,11200017,CDM,180,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA MULTIDAY PASS SEMI PRIVATE ROOM,11850011,CDM,182,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA MULTIDAY PASS SHORT TERM PRIVATE,11850023,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 1,11100016,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM PRIVATE ROOM LEVEL 1,11100017,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SHORT TERM PRIVATE ROOM,11100018,CDM,180,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA LONG TERM CARE PRIVATE ROOM,11100019,CDM,180,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,324.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC BED HOLD  SHORT TERM PRIVATE ROOM,11100020,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC BED HOLD LONG TERM CARE PRIVATE ROOM,11100021,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 2,11100022,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM PRIVATE ROOM LEVEL 2,11100023,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 3,11100024,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM PRIVATE ROOM LEVEL 3,11100025,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 4,11100026,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM PRIVATE ROOM LEVEL 4,11100027,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 1,11200004,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 1,11200005,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SHORT TERM SEMI PRIVATE ROOM,11200006,CDM,180,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA LONG TERM CARE SEMI PRIVATE ROOM,11200007,CDM,180,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC BED HOLD SHORT TERM SEMI PRIVATE ROOM,11200008,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC BED HOLD LONG TERM CARE SEMI PRIVATE,11200009,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 2,11200010,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 2,11200011,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 3,11200012,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 3,11200013,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 4,11200014,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 4,11200015,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA MULTIDAY PASS PRIVATE ROOM,11820001,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SINGLE DAY PASS PRIVATE ROOM,11820002,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA BED HOLD,11820003,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA LONG TERM PASS,11830003,CDM,183,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO ED PRIVATE ROOM,11850001,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO CLINIC APPOINTMENT PRIVATE ROOM,11850002,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO OR/CATH LAB/VIR/GI PRIVATE ROOM,11850003,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO IMAGING APPT PRIVATE ROOM,11850004,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO CLINIC APPT SEMI PRIVATE ROOM,11850012,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO ED SEMI PRIVATE ROOM,11850013,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO IMAGING APPT SEMI PRIVATE ROOM,11850014,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO OR/CATH/VIR/GI SEMI PRIVATE ROOM,11850015,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SINGLE DAY PASS SEMI PRIVATE ROOM,11850016,CDM,182,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC  LOA MULTIDAY PASS SHORT TERM SEMI PRIVATE,11850017,CDM,182,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO CLINIC APPT SHORT TERM SEMI PRIVATE,11850018,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO ED SHORT TERM ED SEMI PRIVATE,11850019,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO IMAGING APPT SHORT TERM SEMI PRIVATE,11850020,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO OR/CATH/VIR/GI SHORT TERM SEMI PRIVATE,11850021,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SINGLE DAY PASS SHORT TERM SEMI PRIVATE,11850022,CDM,182,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC  LOA SEND TO CLINIC APPT SHORT TERM PRIVATE,11850024,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO ED SHORT TERM PRIVATE,11850025,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO IMAGING APPT SHORT TERM PRIVATE,11850026,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SEND TO OR/CATH/VIR/GI SHORT TERM PRIVATE,11850027,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LTC LOA SINGLE DAY PASS SHORT TERM PRIVATE,11850028,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX PRIVATE ROOM,11100002,CDM,110,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Commercial,,1075.68,,,,,,,849.92,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX OB PRIVATE ROOM,11120001,CDM,112,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Commercial,,1075.68,,,,,,,849.92,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX HOSPICE PRIVATE ROOM,11150001,CDM,115,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Commercial,,1075.68,,,,,,,849.92,2085.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX CONTINUED NEONATAL CARE PRIVATE ROOM,11710001,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,MedCost,Commercial,,1558.44,,,,,,,974.00,1558.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LEVEL 1 NURSERY ROOM,11710002,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,MedCost,Commercial,,1558.44,,,,,,,974.00,1558.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,inpatient,,,519.00000,311.40000,MedCost,Commercial,,420.39,,,,,,,332.16,420.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,MedCost,Commercial,,316.59,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,inpatient,,,1287.00000,772.20000,MedCost,Commercial,,1042.47,,,,,,,823.68,1042.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,MedCost,Commercial,,785.07,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,inpatient,,,1925.00000,1155.00000,MedCost,Commercial,,1559.25,,,,,,,1232.00,1559.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,MedCost,Commercial,,1174.25,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,inpatient,,,2891.00000,1734.60000,MedCost,Commercial,,2341.71,,,,,,,1850.24,2341.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,MedCost,Commercial,,1763.51,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,inpatient,,,3469.00000,2081.40000,MedCost,Commercial,,2809.89,,,,,,,2220.16,2809.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,MedCost,Commercial,,2116.09,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,inpatient,,,4162.00000,2497.20000,MedCost,Commercial,,3371.22,,,,,,,2663.68,3371.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,MedCost,Commercial,,2538.82,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,inpatient,,,4996.00000,2997.60000,MedCost,Commercial,,4046.76,,,,,,,3197.44,4046.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,MedCost,Commercial,,3047.56,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX LEVEL 3 INTERMEDIATE NURSERY ROOM,11733001,CDM,173,RC,,,,,facility,inpatient,,,4517.00000,2710.20000,MedCost,Commercial,,3658.77,,,,,,,2890.88,5493.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX ICU ROOM,12000002,CDM,202,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,MedCost,Commercial,,3200.00,,,,,,,1228.00,6258.00,per diem,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX ICU ROOM,12000002,CDM,210,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,MedCost,Commercial,,3200.00,,,,,,,1228.00,6258.00,per diem,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,inpatient,,,2065.00000,1239.00000,MedCost,Commercial,,1672.65,,,,,,,1321.60,1672.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,MedCost,Commercial,,1259.65,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,inpatient,,,3033.00000,1819.80000,MedCost,Commercial,,2456.73,,,,,,,1941.12,2456.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,MedCost,Commercial,,1850.13,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,inpatient,,,5516.00000,3309.60000,MedCost,Commercial,,4467.96,,,,,,,3530.24,4467.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,MedCost,Commercial,,3364.76,,,,,,,615.00,4137.00,percent of total billed charges,
HC REX INTERMEDIATE CARE ROOM,12090002,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,MedCost,Commercial,,2450.00,,,,,,,1228.00,5197.00,per diem,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTERMEDIATE CARE SEMI PRIVATE ROOM,12090004,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,MedCost,Commercial,,2450.00,,,,,,,1228.00,5197.00,per diem,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,inpatient,,,160.00000,96.00000,MedCost,Commercial,,129.60,,,,,,,102.40,130.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,MedCost,Commercial,,97.60,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,inpatient,,,633.00000,379.80000,MedCost,Commercial,,512.73,,,,,,,405.12,514.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,MedCost,Commercial,,386.13,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,inpatient,,,173.00000,103.80000,MedCost,Commercial,,140.13,,,,,,,110.72,140.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,MedCost,Commercial,,105.53,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,,94.77,,,,,,,74.88,95.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,,71.37,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,inpatient,,,26.00000,15.60000,MedCost,Commercial,,21.06,,,,,,,16.64,21.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,MedCost,Commercial,,15.86,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,inpatient,,,143.00000,85.80000,MedCost,Commercial,,115.83,,,,,,,91.52,116.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,MedCost,Commercial,,87.23,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,inpatient,,,158.00000,94.80000,MedCost,Commercial,,127.98,,,,,,,101.12,128.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,MedCost,Commercial,,96.38,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,inpatient,,,524.00000,314.40000,MedCost,Commercial,,424.44,,,,,,,335.36,426.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,MedCost,Commercial,,319.64,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,inpatient,,,597.00000,358.20000,MedCost,Commercial,,483.57,,,,,,,382.08,485.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,MedCost,Commercial,,364.17,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,inpatient,,,508.00000,304.80000,MedCost,Commercial,,411.48,,,,,,,325.12,413.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,MedCost,Commercial,,309.88,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,inpatient,,,92.00000,55.20000,MedCost,Commercial,,74.52,,,,,,,58.88,74.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,MedCost,Commercial,,56.12,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,inpatient,,,73.00000,43.80000,MedCost,Commercial,,59.13,,,,,,,46.72,59.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,MedCost,Commercial,,44.53,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,inpatient,,,230.00000,138.00000,MedCost,Commercial,,186.30,,,,,,,147.20,186.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,MedCost,Commercial,,140.30,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,inpatient,,,211.00000,126.60000,MedCost,Commercial,,170.91,,,,,,,135.04,171.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,MedCost,Commercial,,128.71,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,inpatient,,,5233.00000,3139.80000,MedCost,Commercial,,4238.73,,,,,,,3349.12,4254.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,MedCost,Commercial,,3192.13,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,inpatient,,,5233.00000,3139.80000,MedCost,Commercial,,4238.73,,,,,,,3349.12,4254.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,MedCost,Commercial,,3192.13,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,inpatient,,,4982.00000,2989.20000,MedCost,Commercial,,4035.42,,,,,,,3188.48,4050.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,MedCost,Commercial,,3039.02,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,inpatient,,,1786.00000,1071.60000,MedCost,Commercial,,1446.66,,,,,,,1143.04,1452.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,MedCost,Commercial,,1089.46,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,47.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,inpatient,,,3005.00000,1803.00000,MedCost,Commercial,,2434.05,,,,,,,1923.20,2443.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,MedCost,Commercial,,1833.05,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,inpatient,,,1526.00000,915.60000,MedCost,Commercial,,1236.06,,,,,,,976.64,1240.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,MedCost,Commercial,,930.86,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,inpatient,,,313.00000,187.80000,MedCost,Commercial,,253.53,,,,,,,200.32,254.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,MedCost,Commercial,,190.93,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,inpatient,,,1093.00000,655.80000,MedCost,Commercial,,885.33,,,,,,,699.52,888.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,MedCost,Commercial,,666.73,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,inpatient,,,342.00000,205.20000,MedCost,Commercial,,277.02,,,,,,,218.88,278.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,MedCost,Commercial,,208.62,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,inpatient,,,1236.00000,741.60000,MedCost,Commercial,,1001.16,,,,,,,791.04,1004.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,MedCost,Commercial,,753.96,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,inpatient,,,909.00000,545.40000,MedCost,Commercial,,736.29,,,,,,,581.76,739.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,MedCost,Commercial,,554.49,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,inpatient,,,303.00000,181.80000,MedCost,Commercial,,245.43,,,,,,,193.92,246.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,MedCost,Commercial,,184.83,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,inpatient,,,500.00000,300.00000,MedCost,Commercial,,405.00,,,,,,,320.00,406.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,MedCost,Commercial,,305.00,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,inpatient,,,938.00000,562.80000,MedCost,Commercial,,759.78,,,,,,,600.32,762.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,MedCost,Commercial,,572.18,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,inpatient,,,266.00000,159.60000,MedCost,Commercial,,215.46,,,,,,,170.24,216.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,MedCost,Commercial,,162.26,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,inpatient,,,204.00000,122.40000,MedCost,Commercial,,165.24,,,,,,,130.56,165.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,MedCost,Commercial,,124.44,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,inpatient,,,1092.00000,655.20000,MedCost,Commercial,,884.52,,,,,,,698.88,887.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,MedCost,Commercial,,666.12,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,inpatient,,,948.00000,568.80000,MedCost,Commercial,,767.88,,,,,,,606.72,770.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,MedCost,Commercial,,578.28,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,inpatient,,,286.00000,171.60000,MedCost,Commercial,,231.66,,,,,,,183.04,232.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,MedCost,Commercial,,174.46,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,inpatient,,,43.00000,25.80000,MedCost,Commercial,,34.83,,,,,,,27.52,34.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,MedCost,Commercial,,26.23,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,inpatient,,,35.00000,21.00000,MedCost,Commercial,,28.35,,,,,,,22.40,28.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,MedCost,Commercial,,21.35,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,inpatient,,,140.00000,84.00000,MedCost,Commercial,,113.40,,,,,,,89.60,113.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,MedCost,Commercial,,85.40,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,inpatient,,,474.00000,284.40000,MedCost,Commercial,,383.94,,,,,,,303.36,385.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,MedCost,Commercial,,289.14,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,inpatient,,,126.00000,75.60000,MedCost,Commercial,,102.06,,,,,,,80.64,102.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,MedCost,Commercial,,76.86,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,inpatient,,,286.00000,171.60000,MedCost,Commercial,,231.66,,,,,,,183.04,232.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,MedCost,Commercial,,174.46,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,inpatient,,,134.00000,80.40000,MedCost,Commercial,,108.54,,,,,,,85.76,108.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,MedCost,Commercial,,81.74,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,inpatient,,,11.00000,6.60000,MedCost,Commercial,,8.91,,,,,,,7.04,8.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,MedCost,Commercial,,6.71,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,inpatient,,,4985.00000,2991.00000,MedCost,Commercial,,4137.55,,,,,,,857.42,4137.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,MedCost,Commercial,,3040.85,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,inpatient,,,20100.00000,12060.00000,MedCost,Commercial,,16683.00,,,,,,,3457.20,16683.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,MedCost,Commercial,,12261.00,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,inpatient,,,5074.00000,3044.40000,MedCost,Commercial,,4211.42,,,,,,,872.73,4211.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,MedCost,Commercial,,3095.14,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,inpatient,,,4240.00000,2544.00000,MedCost,Commercial,,3519.20,,,,,,,729.28,3519.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,MedCost,Commercial,,2586.40,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,inpatient,,,3478.00000,2086.80000,MedCost,Commercial,,2886.74,,,,,,,598.22,2886.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,MedCost,Commercial,,2121.58,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,inpatient,,,463.00000,277.80000,MedCost,Commercial,,375.03,,,,,,,296.32,376.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,MedCost,Commercial,,282.43,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Commercial,,3202.74,,,,,,,2530.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Commercial,,2411.94,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,inpatient,,,4530.00000,2718.00000,MedCost,Commercial,,3669.30,,,,,,,2899.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,MedCost,Commercial,,2763.30,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,inpatient,,,4461.00000,2676.60000,MedCost,Commercial,,3613.41,,,,,,,2855.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,MedCost,Commercial,,2721.21,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,inpatient,,,3531.00000,2118.60000,MedCost,Commercial,,2860.11,,,,,,,2259.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,MedCost,Commercial,,2153.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,inpatient,,,5835.00000,3501.00000,MedCost,Commercial,,4726.35,,,,,,,3734.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,MedCost,Commercial,,3559.35,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,inpatient,,,4143.00000,2485.80000,MedCost,Commercial,,3355.83,,,,,,,2651.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,MedCost,Commercial,,2527.23,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,inpatient,,,4143.00000,2485.80000,MedCost,Commercial,,3355.83,,,,,,,2651.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,MedCost,Commercial,,2527.23,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,inpatient,,,4821.00000,2892.60000,MedCost,Commercial,,3905.01,,,,,,,3085.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,MedCost,Commercial,,2940.81,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,inpatient,,,4821.00000,2892.60000,MedCost,Commercial,,3905.01,,,,,,,3085.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,MedCost,Commercial,,2940.81,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,inpatient,,,5866.00000,3519.60000,MedCost,Commercial,,4751.46,,,,,,,3754.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,MedCost,Commercial,,3578.26,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Commercial,,3202.74,,,,,,,2530.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Commercial,,2411.94,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Commercial,,3202.74,,,,,,,2530.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Commercial,,2411.94,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,inpatient,,,3531.00000,2118.60000,MedCost,Commercial,,2860.11,,,,,,,2259.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,MedCost,Commercial,,2153.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Commercial,,3202.74,,,,,,,2530.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Commercial,,2411.94,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,inpatient,,,1745.00000,1047.00000,MedCost,Commercial,,1413.45,,,,,,,1116.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,MedCost,Commercial,,1064.45,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,inpatient,,,4110.00000,2466.00000,MedCost,Commercial,,3329.10,,,,,,,2630.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,MedCost,Commercial,,2507.10,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,inpatient,,,1691.00000,1014.60000,MedCost,Commercial,,1369.71,,,,,,,1082.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,MedCost,Commercial,,1031.51,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,inpatient,,,6499.00000,3899.40000,MedCost,Commercial,,5264.19,,,,,,,4159.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,MedCost,Commercial,,3964.39,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,inpatient,,,1184.00000,710.40000,MedCost,Commercial,,959.04,,,,,,,757.76,962.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,MedCost,Commercial,,722.24,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,inpatient,,,2432.00000,1459.20000,MedCost,Commercial,,1969.92,,,,,,,1556.48,1977.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,MedCost,Commercial,,1483.52,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,inpatient,,,3684.00000,2210.40000,MedCost,Commercial,,2984.04,,,,,,,2357.76,2995.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,MedCost,Commercial,,2247.24,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,inpatient,,,4297.00000,2578.20000,MedCost,Commercial,,3480.57,,,,,,,2750.08,3493.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,MedCost,Commercial,,2621.17,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,inpatient,,,121.00000,72.60000,MedCost,Commercial,,98.01,,,,,,,77.44,98.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,MedCost,Commercial,,73.81,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,inpatient,,,1706.00000,1023.60000,MedCost,Commercial,,1381.86,,,,,,,1091.84,1381.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,MedCost,Commercial,,1040.66,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,inpatient,,,3426.00000,2055.60000,MedCost,Commercial,,2775.06,,,,,,,2192.64,2775.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,MedCost,Commercial,,2089.86,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,inpatient,,,83.00000,49.80000,MedCost,Commercial,,67.23,,,,,,,53.12,67.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,MedCost,Commercial,,50.63,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,inpatient,,,467.00000,280.20000,MedCost,Commercial,,378.27,,,,,,,298.88,378.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,MedCost,Commercial,,284.87,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,inpatient,,,689.00000,413.40000,MedCost,Commercial,,558.09,,,,,,,440.96,560.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,MedCost,Commercial,,420.29,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,inpatient,,,1557.00000,934.20000,MedCost,Commercial,,1261.17,,,,,,,996.48,1265.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,MedCost,Commercial,,949.77,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,inpatient,,,1179.00000,707.40000,MedCost,Commercial,,954.99,,,,,,,754.56,958.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,MedCost,Commercial,,719.19,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,inpatient,,,79.00000,47.40000,MedCost,Commercial,,63.99,,,,,,,50.56,64.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,MedCost,Commercial,,48.19,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,inpatient,,,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,56.32,71.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,inpatient,,,21.00000,12.60000,MedCost,Commercial,GP,17.01,,,,,,,13.44,17.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,MedCost,Commercial,GP,12.81,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,inpatient,,,333.00000,199.80000,MedCost,Commercial,,269.73,,,,,,,213.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,MedCost,Commercial,,203.13,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,inpatient,,,1502.00000,901.20000,MedCost,Commercial,,1216.62,,,,,,,961.28,1216.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,MedCost,Commercial,,916.22,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,inpatient,,,1422.00000,853.20000,MedCost,Commercial,,1151.82,,,,,,,910.08,1151.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,MedCost,Commercial,,867.42,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,inpatient,,,1140.00000,684.00000,MedCost,Commercial,,923.40,,,,,,,729.60,923.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,MedCost,Commercial,,695.40,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,inpatient,,,858.00000,514.80000,MedCost,Commercial,,694.98,,,,,,,549.12,694.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,MedCost,Commercial,,523.38,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,inpatient,,,576.00000,345.60000,MedCost,Commercial,,466.56,,,,,,,368.64,466.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,MedCost,Commercial,,351.36,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,inpatient,,,294.00000,176.40000,MedCost,Commercial,,238.14,,,,,,,188.16,238.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,MedCost,Commercial,,179.34,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,inpatient,,,1638.00000,982.80000,MedCost,Commercial,,1326.78,,,,,,,1048.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,MedCost,Commercial,,999.18,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,inpatient,,,4895.00000,2937.00000,MedCost,Commercial,,3964.95,,,,,,,3132.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,MedCost,Commercial,,2985.95,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,inpatient,,,6492.00000,3895.20000,MedCost,Commercial,,5258.52,,,,,,,4154.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,MedCost,Commercial,,3960.12,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,inpatient,,,3430.00000,2058.00000,MedCost,Commercial,,2778.30,,,,,,,2195.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,MedCost,Commercial,,2092.30,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,inpatient,,,2604.00000,1562.40000,MedCost,Commercial,,2109.24,,,,,,,1666.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,MedCost,Commercial,,1588.44,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,inpatient,,,26158.00000,15694.80000,MedCost,Commercial,,21187.98,,,,,,,7039.00,21187.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,MedCost,Commercial,,15956.38,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,inpatient,,,27399.00000,16439.40000,MedCost,Commercial,,22193.19,,,,,,,7039.00,22193.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,MedCost,Commercial,,16713.39,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,inpatient,,,28837.00000,17302.20000,MedCost,Commercial,,23357.97,,,,,,,7039.00,23357.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,MedCost,Commercial,,17590.57,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,inpatient,,,30074.00000,18044.40000,MedCost,Commercial,,24359.94,,,,,,,7039.00,24359.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,MedCost,Commercial,,18345.14,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,inpatient,,,31316.00000,18789.60000,MedCost,Commercial,,25365.96,,,,,,,7039.00,25365.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,MedCost,Commercial,,19102.76,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,inpatient,,,32554.00000,19532.40000,MedCost,Commercial,,26368.74,,,,,,,7039.00,26368.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,MedCost,Commercial,,19857.94,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,inpatient,,,33591.00000,20154.60000,MedCost,Commercial,,27208.71,,,,,,,7039.00,27208.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,MedCost,Commercial,,20490.51,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,inpatient,,,35029.00000,21017.40000,MedCost,Commercial,,28373.49,,,,,,,7039.00,28373.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,MedCost,Commercial,,21367.69,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,inpatient,,,36268.00000,21760.80000,MedCost,Commercial,,29377.08,,,,,,,7039.00,29377.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,MedCost,Commercial,,22123.48,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,inpatient,,,37507.00000,22504.20000,MedCost,Commercial,,30380.67,,,,,,,7039.00,30380.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,MedCost,Commercial,,22879.27,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,inpatient,,,38747.00000,23248.20000,MedCost,Commercial,,31385.07,,,,,,,7039.00,31385.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,MedCost,Commercial,,23635.67,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,inpatient,,,388.00000,232.80000,MedCost,Commercial,,314.28,,,,,,,248.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,MedCost,Commercial,,236.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,inpatient,,,534.00000,320.40000,MedCost,Commercial,,432.54,,,,,,,341.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,MedCost,Commercial,,325.74,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,inpatient,,,829.00000,497.40000,MedCost,Commercial,,671.49,,,,,,,530.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,MedCost,Commercial,,505.69,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,inpatient,,,836.00000,501.60000,MedCost,Commercial,,677.16,,,,,,,535.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,MedCost,Commercial,,509.96,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,inpatient,,,4035.00000,2421.00000,MedCost,Commercial,,3268.35,,,,,,,2582.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,MedCost,Commercial,,2461.35,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,inpatient,,,9685.00000,5811.00000,MedCost,Commercial,,7844.85,,,,,,,6198.40,7844.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,MedCost,Commercial,,5907.85,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,inpatient,,,10407.00000,6244.20000,MedCost,Commercial,,8429.67,,,,,,,6660.48,8429.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,MedCost,Commercial,,6348.27,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,inpatient,,,11179.00000,6707.40000,MedCost,Commercial,,9054.99,,,,,,,7039.00,9054.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,MedCost,Commercial,,6819.19,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,inpatient,,,6094.00000,3656.40000,MedCost,Commercial,,4936.14,,,,,,,3900.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,MedCost,Commercial,,3717.34,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,inpatient,,,7873.00000,4723.80000,MedCost,Commercial,,6377.13,,,,,,,5038.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,MedCost,Commercial,,4802.53,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,inpatient,,,8955.00000,5373.00000,MedCost,Commercial,,7253.55,,,,,,,5731.20,7253.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,MedCost,Commercial,,5462.55,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,inpatient,,,11530.00000,6918.00000,MedCost,Commercial,,9339.30,,,,,,,7039.00,9339.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,MedCost,Commercial,,7033.30,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,inpatient,,,11836.00000,7101.60000,MedCost,Commercial,,9587.16,,,,,,,7039.00,9587.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,MedCost,Commercial,,7219.96,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,inpatient,,,12124.00000,7274.40000,MedCost,Commercial,,9820.44,,,,,,,7039.00,9820.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,MedCost,Commercial,,7395.64,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,inpatient,,,12413.00000,7447.80000,MedCost,Commercial,,10054.53,,,,,,,7039.00,10054.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,MedCost,Commercial,,7571.93,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,inpatient,,,12701.00000,7620.60000,MedCost,Commercial,,10287.81,,,,,,,7039.00,10287.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,MedCost,Commercial,,7747.61,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,inpatient,,,4946.00000,2967.60000,MedCost,Commercial,,4006.26,,,,,,,3165.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,MedCost,Commercial,,3017.06,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,inpatient,,,668.00000,400.80000,MedCost,Commercial,,541.08,,,,,,,427.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,MedCost,Commercial,,407.48,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,inpatient,,,4406.00000,2643.60000,MedCost,Commercial,,3568.86,,,,,,,2819.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,MedCost,Commercial,,2687.66,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,inpatient,,,5949.00000,3569.40000,MedCost,Commercial,,4818.69,,,,,,,3807.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,MedCost,Commercial,,3628.89,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,inpatient,,,8146.00000,4887.60000,MedCost,Commercial,,6598.26,,,,,,,5213.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,MedCost,Commercial,,4969.06,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,inpatient,,,10324.00000,6194.40000,MedCost,Commercial,,8362.44,,,,,,,6607.36,8362.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,MedCost,Commercial,,6297.64,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,inpatient,,,11787.00000,7072.20000,MedCost,Commercial,,9547.47,,,,,,,7039.00,9547.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,MedCost,Commercial,,7190.07,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,inpatient,,,13350.00000,8010.00000,MedCost,Commercial,,10813.50,,,,,,,7039.00,10813.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,MedCost,Commercial,,8143.50,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,inpatient,,,15229.00000,9137.40000,MedCost,Commercial,,12335.49,,,,,,,7039.00,12335.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,MedCost,Commercial,,9289.69,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,inpatient,,,16324.00000,9794.40000,MedCost,Commercial,,13222.44,,,,,,,7039.00,13222.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,MedCost,Commercial,,9957.64,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,inpatient,,,17940.00000,10764.00000,MedCost,Commercial,,14531.40,,,,,,,7039.00,14531.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,MedCost,Commercial,,10943.40,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,inpatient,,,18819.00000,11291.40000,MedCost,Commercial,,15243.39,,,,,,,7039.00,15243.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,MedCost,Commercial,,11479.59,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,inpatient,,,19970.00000,11982.00000,MedCost,Commercial,,16175.70,,,,,,,7039.00,16175.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,MedCost,Commercial,,12181.70,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,inpatient,,,20711.00000,12426.60000,MedCost,Commercial,,16775.91,,,,,,,7039.00,16775.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,MedCost,Commercial,,12633.71,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,inpatient,,,20897.00000,12538.20000,MedCost,Commercial,,16926.57,,,,,,,7039.00,16926.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,MedCost,Commercial,,12747.17,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,inpatient,,,21207.00000,12724.20000,MedCost,Commercial,,17177.67,,,,,,,7039.00,17177.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,MedCost,Commercial,,12936.27,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,inpatient,,,21825.00000,13095.00000,MedCost,Commercial,,17678.25,,,,,,,7039.00,17678.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,MedCost,Commercial,,13313.25,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,inpatient,,,22444.00000,13466.40000,MedCost,Commercial,,18179.64,,,,,,,7039.00,18179.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,MedCost,Commercial,,13690.84,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,inpatient,,,23062.00000,13837.20000,MedCost,Commercial,,18680.22,,,,,,,7039.00,18680.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,MedCost,Commercial,,14067.82,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,inpatient,,,23685.00000,14211.00000,MedCost,Commercial,,19184.85,,,,,,,7039.00,19184.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,MedCost,Commercial,,14447.85,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,inpatient,,,24302.00000,14581.20000,MedCost,Commercial,,19684.62,,,,,,,7039.00,19684.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,MedCost,Commercial,,14824.22,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,inpatient,,,24922.00000,14953.20000,MedCost,Commercial,,20186.82,,,,,,,7039.00,20186.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,MedCost,Commercial,,15202.42,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,inpatient,,,13406.00000,8043.60000,MedCost,Commercial,,10858.86,,,,,,,7039.00,10858.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,MedCost,Commercial,,8177.66,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,inpatient,,,11362.00000,6817.20000,MedCost,Commercial,,9203.22,,,,,,,7039.00,9203.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,MedCost,Commercial,,6930.82,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,MedCost,Commercial,,5704.83,,,,,,,4507.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,MedCost,Commercial,,4296.23,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,MedCost,Commercial,,5704.83,,,,,,,4507.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,MedCost,Commercial,,4296.23,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,MedCost,Commercial,,5704.83,,,,,,,4507.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,MedCost,Commercial,,4296.23,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,inpatient,,,6480.00000,3888.00000,MedCost,Commercial,,5248.80,,,,,,,4147.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,MedCost,Commercial,,3952.80,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,inpatient,,,13406.00000,8043.60000,MedCost,Commercial,,10858.86,,,,,,,7039.00,10858.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,MedCost,Commercial,,8177.66,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,inpatient,,,7562.00000,4537.20000,MedCost,Commercial,,6125.22,,,,,,,4839.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,MedCost,Commercial,,4612.82,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,inpatient,,,8521.00000,5112.60000,MedCost,Commercial,,6902.01,,,,,,,5453.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,MedCost,Commercial,,5197.81,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,inpatient,,,303.00000,181.80000,MedCost,Commercial,,245.43,,,,,,,193.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,MedCost,Commercial,,184.83,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Commercial,,1029.51,,,,,,,813.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Commercial,,775.31,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,inpatient,,,508.00000,304.80000,MedCost,Commercial,,411.48,,,,,,,325.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,MedCost,Commercial,,309.88,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,inpatient,,,508.00000,304.80000,MedCost,Commercial,,411.48,,,,,,,325.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,MedCost,Commercial,,309.88,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,inpatient,,,808.00000,484.80000,MedCost,Commercial,,654.48,,,,,,,517.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,MedCost,Commercial,,492.88,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,inpatient,,,10794.00000,6476.40000,MedCost,Commercial,,8743.14,,,,,,,6908.16,8743.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,MedCost,Commercial,,6584.34,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,inpatient,,,1890.00000,1134.00000,MedCost,Commercial,,1530.90,,,,,,,1209.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,MedCost,Commercial,,1152.90,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,inpatient,,,1225.00000,735.00000,MedCost,Commercial,,992.25,,,,,,,784.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,MedCost,Commercial,,747.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,inpatient,,,7174.00000,4304.40000,MedCost,Commercial,,5810.94,,,,,,,4591.36,5832.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,MedCost,Commercial,,4376.14,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,inpatient,,,296.00000,177.60000,MedCost,Commercial,,239.76,,,,,,,189.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,MedCost,Commercial,,180.56,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,inpatient,,,756.00000,453.60000,MedCost,Commercial,,612.36,,,,,,,483.84,614.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,MedCost,Commercial,,461.16,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,inpatient,,,3.00000,1.80000,MedCost,Commercial,,2.43,,,,,,,1.92,2.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,MedCost,Commercial,,1.83,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,inpatient,,,1649.00000,989.40000,MedCost,Commercial,,1335.69,,,,,,,1055.36,1340.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,MedCost,Commercial,,1005.89,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,inpatient,,,2127.00000,1276.20000,MedCost,Commercial,,1722.87,,,,,,,1361.28,1729.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,MedCost,Commercial,,1297.47,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,inpatient,,,2607.00000,1564.20000,MedCost,Commercial,,2111.67,,,,,,,1668.48,2119.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,MedCost,Commercial,,1590.27,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,inpatient,,,3085.00000,1851.00000,MedCost,Commercial,,2498.85,,,,,,,1974.40,2508.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,MedCost,Commercial,,1881.85,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,inpatient,,,3564.00000,2138.40000,MedCost,Commercial,,2886.84,,,,,,,2280.96,2897.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,MedCost,Commercial,,2174.04,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,inpatient,,,4043.00000,2425.80000,MedCost,Commercial,,3274.83,,,,,,,2587.52,3286.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,MedCost,Commercial,,2466.23,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,inpatient,,,4521.00000,2712.60000,MedCost,Commercial,,3662.01,,,,,,,2893.44,3675.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,MedCost,Commercial,,2757.81,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,inpatient,,,661.00000,396.60000,MedCost,Commercial,,535.41,,,,,,,423.04,537.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,MedCost,Commercial,,403.21,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,inpatient,,,3280.00000,1968.00000,MedCost,Commercial,,2656.80,,,,,,,2099.20,2666.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,MedCost,Commercial,,2000.80,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,inpatient,,,4322.00000,2593.20000,MedCost,Commercial,,3500.82,,,,,,,2766.08,3513.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,MedCost,Commercial,,2636.42,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,inpatient,,,1294.00000,776.40000,MedCost,Commercial,,1048.14,,,,,,,828.16,1052.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,MedCost,Commercial,,789.34,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,inpatient,,,1763.00000,1057.80000,MedCost,Commercial,,1428.03,,,,,,,1128.32,1433.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,MedCost,Commercial,,1075.43,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,inpatient,,,1966.00000,1179.60000,MedCost,Commercial,,1592.46,,,,,,,1258.24,1598.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,MedCost,Commercial,,1199.26,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,inpatient,,,2177.00000,1306.20000,MedCost,Commercial,,1763.37,,,,,,,1393.28,1769.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,MedCost,Commercial,,1327.97,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,inpatient,,,2387.00000,1432.20000,MedCost,Commercial,,1933.47,,,,,,,1527.68,1940.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,MedCost,Commercial,,1456.07,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,inpatient,,,2596.00000,1557.60000,MedCost,Commercial,,2102.76,,,,,,,1661.44,2110.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,MedCost,Commercial,,1583.56,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,inpatient,,,2807.00000,1684.20000,MedCost,Commercial,,2273.67,,,,,,,1796.48,2282.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,MedCost,Commercial,,1712.27,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,inpatient,,,1649.00000,989.40000,MedCost,Commercial,,1335.69,,,,,,,1055.36,1340.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,MedCost,Commercial,,1005.89,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,inpatient,,,958.00000,574.80000,MedCost,Commercial,,775.98,,,,,,,613.12,778.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,MedCost,Commercial,,584.38,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,inpatient,,,2387.00000,1432.20000,MedCost,Commercial,,1933.47,,,,,,,1527.68,1940.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,MedCost,Commercial,,1456.07,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,inpatient,,,1294.00000,776.40000,MedCost,Commercial,,1048.14,,,,,,,828.16,1052.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,MedCost,Commercial,,789.34,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,inpatient,,,1763.00000,1057.80000,MedCost,Commercial,,1428.03,,,,,,,1128.32,1433.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,MedCost,Commercial,,1075.43,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,inpatient,,,1966.00000,1179.60000,MedCost,Commercial,,1592.46,,,,,,,1258.24,1598.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,MedCost,Commercial,,1199.26,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,inpatient,,,2177.00000,1306.20000,MedCost,Commercial,,1763.37,,,,,,,1393.28,1769.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,MedCost,Commercial,,1327.97,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,inpatient,,,2596.00000,1557.60000,MedCost,Commercial,,2102.76,,,,,,,1661.44,2110.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,MedCost,Commercial,,1583.56,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,inpatient,,,2807.00000,1684.20000,MedCost,Commercial,,2273.67,,,,,,,1796.48,2282.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,MedCost,Commercial,,1712.27,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,inpatient,,,3280.00000,1968.00000,MedCost,Commercial,,2656.80,,,,,,,2099.20,2666.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,MedCost,Commercial,,2000.80,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,inpatient,,,4322.00000,2593.20000,MedCost,Commercial,,3500.82,,,,,,,2766.08,3513.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,MedCost,Commercial,,2636.42,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,inpatient,,,499.00000,299.40000,MedCost,Commercial,,404.19,,,,,,,319.36,405.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,MedCost,Commercial,,304.39,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,inpatient,,,3430.00000,2058.00000,MedCost,Commercial,,2778.30,,,,,,,2195.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,MedCost,Commercial,,2092.30,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,inpatient,,,285.00000,171.00000,MedCost,Commercial,,230.85,,,,,,,182.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,MedCost,Commercial,,173.85,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,inpatient,,,1357.00000,814.20000,MedCost,Commercial,,1099.17,,,,,,,868.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,MedCost,Commercial,,827.77,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,inpatient,,,1537.00000,922.20000,MedCost,Commercial,,1244.97,,,,,,,983.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,MedCost,Commercial,,937.57,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,inpatient,,,1719.00000,1031.40000,MedCost,Commercial,,1392.39,,,,,,,1100.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,MedCost,Commercial,,1048.59,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,inpatient,,,1901.00000,1140.60000,MedCost,Commercial,,1539.81,,,,,,,1216.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,MedCost,Commercial,,1159.61,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,inpatient,,,2085.00000,1251.00000,MedCost,Commercial,,1688.85,,,,,,,1334.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,MedCost,Commercial,,1271.85,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,inpatient,,,2268.00000,1360.80000,MedCost,Commercial,,1837.08,,,,,,,1451.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,MedCost,Commercial,,1383.48,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,inpatient,,,2450.00000,1470.00000,MedCost,Commercial,,1984.50,,,,,,,1568.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,MedCost,Commercial,,1494.50,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,inpatient,,,2631.00000,1578.60000,MedCost,Commercial,,2131.11,,,,,,,1683.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,MedCost,Commercial,,1604.91,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,inpatient,,,2812.00000,1687.20000,MedCost,Commercial,,2277.72,,,,,,,1799.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,MedCost,Commercial,,1715.32,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,inpatient,,,2996.00000,1797.60000,MedCost,Commercial,,2426.76,,,,,,,1917.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,MedCost,Commercial,,1827.56,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,inpatient,,,3177.00000,1906.20000,MedCost,Commercial,,2573.37,,,,,,,2033.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,MedCost,Commercial,,1937.97,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,inpatient,,,3414.00000,2048.40000,MedCost,Commercial,,2765.34,,,,,,,2184.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,MedCost,Commercial,,2082.54,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,inpatient,,,3598.00000,2158.80000,MedCost,Commercial,,2914.38,,,,,,,2302.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,MedCost,Commercial,,2194.78,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,inpatient,,,4293.00000,2575.80000,MedCost,Commercial,,3477.33,,,,,,,2747.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,MedCost,Commercial,,2618.73,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,inpatient,,,4574.00000,2744.40000,MedCost,Commercial,,3704.94,,,,,,,2927.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,MedCost,Commercial,,2790.14,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,inpatient,,,4787.00000,2872.20000,MedCost,Commercial,,3877.47,,,,,,,3063.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,MedCost,Commercial,,2920.07,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,inpatient,,,4969.00000,2981.40000,MedCost,Commercial,,4024.89,,,,,,,3180.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,MedCost,Commercial,,3031.09,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,inpatient,,,5150.00000,3090.00000,MedCost,Commercial,,4171.50,,,,,,,3296.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,MedCost,Commercial,,3141.50,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Commercial,,3538.89,,,,,,,2796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Commercial,,2665.09,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,inpatient,,,4636.00000,2781.60000,MedCost,Commercial,,3755.16,,,,,,,2967.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,MedCost,Commercial,,2827.96,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,inpatient,,,4123.00000,2473.80000,MedCost,Commercial,,3339.63,,,,,,,2638.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,MedCost,Commercial,,2515.03,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,inpatient,,,2613.00000,1567.80000,MedCost,Commercial,,2116.53,,,,,,,1672.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,MedCost,Commercial,,1593.93,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,inpatient,,,2825.00000,1695.00000,MedCost,Commercial,,2288.25,,,,,,,1808.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,MedCost,Commercial,,1723.25,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,inpatient,,,2486.00000,1491.60000,MedCost,Commercial,,2013.66,,,,,,,1591.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,MedCost,Commercial,,1516.46,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,inpatient,,,3342.00000,2005.20000,MedCost,Commercial,,2707.02,,,,,,,2138.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,MedCost,Commercial,,2038.62,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,inpatient,,,337.00000,202.20000,MedCost,Commercial,,272.97,,,,,,,215.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,MedCost,Commercial,,205.57,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,MedCost,Commercial,,8166.42,,,,,,,6452.48,8166.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,MedCost,Commercial,,6150.02,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,MedCost,Commercial,,8166.42,,,,,,,6452.48,8166.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,MedCost,Commercial,,6150.02,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,MedCost,Commercial,,8166.42,,,,,,,6452.48,8166.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,MedCost,Commercial,,6150.02,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,inpatient,,,1275.00000,765.00000,MedCost,Commercial,,1032.75,,,,,,,816.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,MedCost,Commercial,,777.75,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,inpatient,,,2096.00000,1257.60000,MedCost,Commercial,,1697.76,,,,,,,1341.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,MedCost,Commercial,,1278.56,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,inpatient,,,2329.00000,1397.40000,MedCost,Commercial,,1886.49,,,,,,,1490.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,MedCost,Commercial,,1420.69,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,inpatient,,,1264.00000,758.40000,MedCost,Commercial,,1023.84,,,,,,,808.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,MedCost,Commercial,,771.04,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,inpatient,,,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,309.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,inpatient,,,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,309.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,inpatient,,,7494.00000,4496.40000,MedCost,Commercial,,6070.14,,,,,,,4796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,MedCost,Commercial,,4571.34,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,inpatient,,,1016.00000,609.60000,MedCost,Commercial,,822.96,,,,,,,650.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,MedCost,Commercial,,619.76,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,inpatient,,,404.00000,242.40000,MedCost,Commercial,,327.24,,,,,,,258.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,MedCost,Commercial,,246.44,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,inpatient,,,4574.00000,2744.40000,MedCost,Commercial,,3704.94,,,,,,,2927.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,MedCost,Commercial,,2790.14,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,inpatient,,,10837.00000,6502.20000,MedCost,Commercial,,8777.97,,,,,,,6935.68,8777.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,MedCost,Commercial,,6610.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,inpatient,,,5274.00000,3164.40000,MedCost,Commercial,,4271.94,,,,,,,3375.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,MedCost,Commercial,,3217.14,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,inpatient,,,307.00000,184.20000,MedCost,Commercial,,248.67,,,,,,,196.48,248.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,MedCost,Commercial,,187.27,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00640,0.00810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,inpatient,,,39984.00000,23990.40000,MedCost,Commercial,,32387.04,,,,,,,7039.00,32387.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,MedCost,Commercial,,24390.24,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,inpatient,,,41222.00000,24733.20000,MedCost,Commercial,,33389.82,,,,,,,7039.00,33389.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,MedCost,Commercial,,25145.42,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,inpatient,,,1885.00000,1131.00000,MedCost,Commercial,,1526.85,,,,,,,1206.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,MedCost,Commercial,,1149.85,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,inpatient,,,557.00000,334.20000,MedCost,Commercial,,451.17,,,,,,,356.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,MedCost,Commercial,,339.77,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,inpatient,,,2915.00000,1749.00000,MedCost,Commercial,,2361.15,,,,,,,1865.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,MedCost,Commercial,,1778.15,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,86.00000,51.60000,MedCost,Commercial,,69.66,,,,,,,55.04,69.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,MedCost,Commercial,,52.46,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,183.00000,109.80000,MedCost,Commercial,,148.23,,,,,,,117.12,148.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,MedCost,Commercial,,111.63,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Commercial,,80.19,,,,,,,63.36,80.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Commercial,,60.39,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Commercial,Q0,0.81810,,,,,,,0.64640,0.81810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Commercial,Q0,0.61610,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Commercial,Q0,0.81810,,,,,,,0.64640,0.81810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Commercial,Q0,0.61610,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,498.00,,,,,,,103.20,498.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,MedCost,Commercial,,366.00,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,MedCost,Commercial,,619.18,,,,,,,128.31,619.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,MedCost,Commercial,,455.06,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,1375.00000,825.00000,MedCost,Commercial,,1141.25,,,,,,,236.50,1141.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,MedCost,Commercial,,838.75,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,19569.00000,11741.40000,MedCost,Commercial,,16242.27,,,,,,,3365.87,16242.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,MedCost,Commercial,,11937.09,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,9120.00000,5472.00000,MedCost,Commercial,,7569.60,,,,,,,1568.64,7569.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,MedCost,Commercial,,5563.20,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Commercial,,4249.60,,,,,,,880.64,4249.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Commercial,,3123.20,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,4954.00000,2972.40000,MedCost,Commercial,,4111.82,,,,,,,852.09,4111.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,MedCost,Commercial,,3021.94,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,7438.00000,4462.80000,MedCost,Commercial,,6173.54,,,,,,,1279.34,6173.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,MedCost,Commercial,,4537.18,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,8418.00000,5050.80000,MedCost,Commercial,,6986.94,,,,,,,1447.90,6986.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,MedCost,Commercial,,5134.98,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Commercial,,4249.60,,,,,,,880.64,4249.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Commercial,,3123.20,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,6348.00000,3808.80000,MedCost,Commercial,,5268.84,,,,,,,1091.86,5268.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,MedCost,Commercial,,3872.28,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Commercial,,263.94,,,,,,,54.70,263.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Commercial,,193.98,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,MedCost,Commercial,,85.49,,,,,,,17.72,85.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,MedCost,Commercial,,62.83,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,209.00000,125.40000,MedCost,Commercial,,173.47,,,,,,,35.95,173.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,MedCost,Commercial,,127.49,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Commercial,,120.35,,,,,,,24.94,120.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Commercial,,88.45,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Commercial,,263.94,,,,,,,54.70,263.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Commercial,,193.98,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,126.00000,75.60000,MedCost,Commercial,,104.58,,,,,,,21.67,104.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,MedCost,Commercial,,76.86,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,151.00000,90.60000,MedCost,Commercial,,125.33,,,,,,,25.97,125.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,MedCost,Commercial,,92.11,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,184.00000,110.40000,MedCost,Commercial,,152.72,,,,,,,31.65,152.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,MedCost,Commercial,,112.24,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,295.00000,177.00000,MedCost,Commercial,,244.85,,,,,,,50.74,244.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,MedCost,Commercial,,179.95,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,355.00000,213.00000,MedCost,Commercial,,294.65,,,,,,,61.06,294.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,MedCost,Commercial,,216.55,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Commercial,,869.84,,,,,,,180.26,869.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Commercial,,639.28,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,MedCost,Commercial,,85.49,,,,,,,17.72,85.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,MedCost,Commercial,,62.83,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,425.00000,255.00000,MedCost,Commercial,,352.75,,,,,,,73.10,352.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,MedCost,Commercial,,259.25,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,498.00,,,,,,,103.20,498.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,MedCost,Commercial,,366.00,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1073.00000,643.80000,MedCost,Commercial,,890.59,,,,,,,184.56,890.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,MedCost,Commercial,,654.53,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,948.00000,568.80000,MedCost,Commercial,,786.84,,,,,,,163.06,786.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,MedCost,Commercial,,578.28,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,MedCost,Commercial,,619.18,,,,,,,128.31,619.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,MedCost,Commercial,,455.06,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,MedCost,Commercial,,619.18,,,,,,,128.31,619.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,MedCost,Commercial,,455.06,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Commercial,,226.59,,,,,,,46.96,226.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,774.00000,464.40000,MedCost,Commercial,,642.42,,,,,,,133.13,642.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,MedCost,Commercial,,472.14,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Commercial,,4147.20,,,,,,,3276.80,4162.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Commercial,,3123.20,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,503.00000,301.80000,MedCost,Commercial,,417.49,,,,,,,86.52,417.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,MedCost,Commercial,,306.83,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,inpatient,,,452.00000,271.20000,MedCost,Commercial,,366.12,,,,,,,289.28,367.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,MedCost,Commercial,,275.72,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,1349.00000,809.40000,MedCost,Commercial,,1119.67,,,,,,,232.03,1119.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,MedCost,Commercial,,822.89,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Commercial,,4249.60,,,,,,,880.64,4249.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Commercial,,3123.20,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1484.00000,890.40000,MedCost,Commercial,,1231.72,,,,,,,255.25,1231.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,MedCost,Commercial,,905.24,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1379.00000,827.40000,MedCost,Commercial,,1144.57,,,,,,,237.19,1144.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,MedCost,Commercial,,841.19,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,48.14,,,,,,,9.98,48.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,48.14,,,,,,,9.98,48.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,48.14,,,,,,,9.98,48.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,48.14,,,,,,,9.98,48.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Commercial,,444.05,,,,,,,92.02,444.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Commercial,,326.35,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Commercial,,444.05,,,,,,,92.02,444.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Commercial,,326.35,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Commercial,,444.05,,,,,,,92.02,444.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Commercial,,326.35,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00640,0.00813,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,inpatient,,,6720.00000,4032.00000,MedCost,Commercial,,5443.20,,,,,,,4300.80,5463.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,MedCost,Commercial,,4099.20,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,MedCost,Commercial,,765.26,,,,,,,158.58,765.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,MedCost,Commercial,,562.42,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,MedCost,Commercial,,765.26,,,,,,,158.58,765.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,MedCost,Commercial,,562.42,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,MedCost,Commercial,,765.26,,,,,,,158.58,765.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,MedCost,Commercial,,562.42,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1215.00000,729.00000,MedCost,Commercial,,1008.45,,,,,,,208.98,1008.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,MedCost,Commercial,,741.15,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1631.00000,978.60000,MedCost,Commercial,,1353.73,,,,,,,280.53,1353.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,MedCost,Commercial,,994.91,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,inpatient,,,2899.00000,1739.40000,MedCost,Commercial,,2348.19,,,,,,,1855.36,2356.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,MedCost,Commercial,,1768.39,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Commercial,,290.50,,,,,,,60.20,290.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Commercial,,213.50,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Commercial,,384.29,,,,,,,79.64,384.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Commercial,,282.43,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Commercial,,116.20,,,,,,,24.08,116.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Commercial,,85.40,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,78.85,,,,,,,16.34,78.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,inpatient,,,166.00000,99.60000,MedCost,Commercial,,137.78,,,,,,,28.55,137.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,MedCost,Commercial,,101.26,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Commercial,,290.50,,,,,,,60.20,290.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Commercial,,213.50,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,75.53,,,,,,,15.65,75.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,83.83,,,,,,,17.37,83.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5270.00000,3162.00000,MedCost,Commercial,,4374.10,,,,,,,906.44,4374.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,MedCost,Commercial,,3214.70,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,1024.00000,614.40000,MedCost,Commercial,,849.92,,,,,,,176.13,849.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,MedCost,Commercial,,624.64,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Commercial,,528.71,,,,,,,109.56,528.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Commercial,,388.57,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,inpatient,,,39570.00000,23742.00000,MedCost,Commercial,,32051.70,,,,,,,11910.57,32170.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,MedCost,Commercial,,24137.70,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,17004.00000,10202.40000,MedCost,Commercial,,13773.24,,,,,,,5118.20,13824.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,MedCost,Commercial,,10372.44,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,297.00000,178.20000,MedCost,Commercial,,246.51,,,,,,,51.08,246.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,MedCost,Commercial,,181.17,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,308.00000,184.80000,MedCost,Commercial,,255.64,,,,,,,52.98,255.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,MedCost,Commercial,,187.88,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,1919.00000,1151.40000,MedCost,Commercial,,1554.39,,,,,,,577.62,1560.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,MedCost,Commercial,,1170.59,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,7252.00000,4351.20000,MedCost,Commercial,,5874.12,,,,,,,2182.85,5895.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,MedCost,Commercial,,4423.72,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,1734.00000,1040.40000,MedCost,Commercial,,1404.54,,,,,,,521.93,1409.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,MedCost,Commercial,,1057.74,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,3295.00000,1977.00000,MedCost,Commercial,,2668.95,,,,,,,991.79,2678.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,MedCost,Commercial,,2009.95,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,40220.00000,24132.00000,MedCost,Commercial,,32578.20,,,,,,,12106.22,32698.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,MedCost,Commercial,,24534.20,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,12517.00000,7510.20000,MedCost,Commercial,,10138.77,,,,,,,3767.62,10176.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,MedCost,Commercial,,7635.37,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,11120.00000,6672.00000,MedCost,Commercial,,9007.20,,,,,,,3347.12,9040.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,MedCost,Commercial,,6783.20,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,15665.00000,9399.00000,MedCost,Commercial,,12688.65,,,,,,,4715.16,12735.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,MedCost,Commercial,,9555.65,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,31578.00000,18946.80000,MedCost,Commercial,,25578.18,,,,,,,9504.98,25672.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,MedCost,Commercial,,19262.58,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,2639.00000,1583.40000,MedCost,Commercial,,2137.59,,,,,,,794.34,2145.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,MedCost,Commercial,,1609.79,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,11117.00000,6670.20000,MedCost,Commercial,,9004.77,,,,,,,3346.22,9038.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,MedCost,Commercial,,6781.37,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,16042.00000,9625.20000,MedCost,Commercial,,12994.02,,,,,,,4828.64,13042.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,MedCost,Commercial,,9785.62,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,9476.00000,5685.60000,MedCost,Commercial,,7865.08,,,,,,,1629.87,7865.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,MedCost,Commercial,,5780.36,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,MedCost,Commercial,,2183.76,,,,,,,811.50,2191.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,MedCost,Commercial,,1644.56,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,MedCost,Commercial,,2237.68,,,,,,,463.71,2237.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,MedCost,Commercial,,1644.56,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,8366.00000,5019.60000,MedCost,Commercial,,6776.46,,,,,,,2518.17,6801.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,MedCost,Commercial,,5103.26,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Commercial,,0.81810,,,,,,,0.64640,0.81810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Commercial,,0.61610,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,8920.00000,5352.00000,MedCost,Commercial,,7225.20,,,,,,,2684.92,7251.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,MedCost,Commercial,,5441.20,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,11277.00000,6766.20000,MedCost,Commercial,,9134.37,,,,,,,3394.38,9168.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,MedCost,Commercial,,6878.97,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6131.00000,3678.60000,MedCost,Commercial,,5088.73,,,,,,,1054.53,5088.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,MedCost,Commercial,,3739.91,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,inpatient,,,15495.00000,9297.00000,MedCost,Commercial,,12550.95,,,,,,,4663.99,12597.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,MedCost,Commercial,,9451.95,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,inpatient,,,1255.00000,753.00000,MedCost,Commercial,,1041.65,,,,,,,215.86,1041.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,MedCost,Commercial,,765.55,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,inpatient,,,537.00000,322.20000,MedCost,Commercial,,445.71,,,,,,,92.36,445.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,MedCost,Commercial,,327.57,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6720.00000,4032.00000,MedCost,Commercial,,5577.60,,,,,,,1155.84,5577.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,MedCost,Commercial,,4099.20,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5270.00000,3162.00000,MedCost,Commercial,,4374.10,,,,,,,906.44,4374.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,MedCost,Commercial,,3214.70,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,940.00000,564.00000,MedCost,Commercial,,780.20,,,,,,,161.68,780.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,MedCost,Commercial,,573.40,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,inpatient,,,220.00000,132.00000,MedCost,Commercial,,182.60,,,,,,,37.84,182.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,MedCost,Commercial,,134.20,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,555.00000,333.00000,MedCost,Commercial,,460.65,,,,,,,95.46,460.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,MedCost,Commercial,,338.55,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5436.00000,3261.60000,MedCost,Commercial,,4511.88,,,,,,,934.99,4511.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,MedCost,Commercial,,3315.96,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,19845.00000,11907.00000,MedCost,Commercial,,16471.35,,,,,,,3413.34,16471.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,MedCost,Commercial,,12105.45,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,27390.00000,16434.00000,MedCost,Commercial,,22733.70,,,,,,,4711.08,22733.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,MedCost,Commercial,,16707.90,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,MedCost,Commercial,,233.23,,,,,,,48.33,233.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,MedCost,Commercial,,171.41,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,MedCost,Commercial,,233.23,,,,,,,48.33,233.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,MedCost,Commercial,,171.41,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,MedCost,Commercial,,218.29,,,,,,,45.24,218.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,MedCost,Commercial,,160.43,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,MedCost,Commercial,,218.29,,,,,,,45.24,218.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,MedCost,Commercial,,160.43,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,MedCost,Commercial,,218.29,,,,,,,45.24,218.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,MedCost,Commercial,,160.43,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00830,,,,,,,0.00172,0.00830,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,3125.00000,1875.00000,MedCost,Commercial,,2593.75,,,,,,,537.50,2593.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,MedCost,Commercial,,1906.25,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1172.00000,703.20000,MedCost,Commercial,,949.32,,,,,,,750.08,952.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,MedCost,Commercial,,714.92,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1507.00000,904.20000,MedCost,Commercial,,1220.67,,,,,,,964.48,1225.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,MedCost,Commercial,,919.27,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1415.00000,849.00000,MedCost,Commercial,,1146.15,,,,,,,905.60,1150.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,MedCost,Commercial,,863.15,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1370.00000,822.00000,MedCost,Commercial,,1109.70,,,,,,,876.80,1113.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,MedCost,Commercial,,835.70,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,inpatient,,,9964.00000,5978.40000,MedCost,Commercial,,8070.84,,,,,,,6376.96,8070.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,MedCost,Commercial,,6078.04,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,inpatient,,,6335.00000,3801.00000,MedCost,Commercial,Q1,5131.35,,,,,,,4054.40,5131.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,MedCost,Commercial,Q1,3864.35,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,inpatient,,,3795.00000,2277.00000,MedCost,Commercial,Q0,3073.95,,,,,,,2428.80,3073.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,MedCost,Commercial,Q0,2314.95,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,inpatient,,,182.00000,109.20000,MedCost,Commercial,,147.42,,,,,,,116.48,147.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,MedCost,Commercial,,111.02,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,inpatient,,,423.00000,253.80000,MedCost,Commercial,,342.63,,,,,,,270.72,342.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,MedCost,Commercial,,258.03,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Commercial,,444.69,,,,,,,351.36,444.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Commercial,,334.89,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Commercial,,305.37,,,,,,,241.28,305.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Commercial,,229.97,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,inpatient,,,585.00000,351.00000,MedCost,Commercial,,473.85,,,,,,,374.40,473.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,MedCost,Commercial,,356.85,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Commercial,,305.37,,,,,,,241.28,305.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Commercial,,229.97,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Commercial,,305.37,,,,,,,241.28,305.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Commercial,,229.97,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Commercial,,74.52,,,,,,,58.88,74.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Commercial,,56.12,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Commercial,,233.28,,,,,,,184.32,233.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Commercial,,175.68,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Commercial,,353.97,,,,,,,279.68,353.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Commercial,,266.57,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,inpatient,,,262.00000,157.20000,MedCost,Commercial,,212.22,,,,,,,167.68,212.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,MedCost,Commercial,,159.82,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,inpatient,,,234.00000,140.40000,MedCost,Commercial,,189.54,,,,,,,149.76,189.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,MedCost,Commercial,,142.74,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,inpatient,,,652.00000,391.20000,MedCost,Commercial,,528.12,,,,,,,417.28,528.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,MedCost,Commercial,,397.72,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,91.30,,,,,,,18.92,91.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,inpatient,,,33.00000,19.80000,MedCost,Commercial,,26.73,,,,,,,21.12,26.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,MedCost,Commercial,,20.13,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,inpatient,,,1899.00000,1139.40000,MedCost,Commercial,,1538.19,,,,,,,1215.36,1538.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,MedCost,Commercial,,1158.39,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,,94.77,,,,,,,74.88,94.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,,71.37,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,,94.77,,,,,,,74.88,94.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,,71.37,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,inpatient,,,240.00000,144.00000,MedCost,Commercial,,194.40,,,,,,,153.60,194.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,MedCost,Commercial,,146.40,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,inpatient,,,360.00000,216.00000,MedCost,Commercial,,291.60,,,,,,,230.40,291.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,MedCost,Commercial,,219.60,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Commercial,,375.03,,,,,,,296.32,375.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Commercial,,282.43,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,inpatient,,,420.00000,252.00000,MedCost,Commercial,,340.20,,,,,,,268.80,340.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,MedCost,Commercial,,256.20,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,inpatient,,,1947.00000,1168.20000,MedCost,Commercial,,1577.07,,,,,,,1246.08,1577.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,MedCost,Commercial,,1187.67,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,inpatient,,,1990.00000,1194.00000,MedCost,Commercial,,1611.90,,,,,,,1273.60,1611.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,MedCost,Commercial,,1213.90,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,inpatient,,,932.00000,559.20000,MedCost,Commercial,,754.92,,,,,,,596.48,754.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,MedCost,Commercial,,568.52,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,inpatient,,,1407.00000,844.20000,MedCost,Commercial,,1139.67,,,,,,,900.48,1139.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,MedCost,Commercial,,858.27,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,inpatient,,,1460.00000,876.00000,MedCost,Commercial,,1182.60,,,,,,,934.40,1182.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,MedCost,Commercial,,890.60,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,inpatient,,,1724.00000,1034.40000,MedCost,Commercial,,1396.44,,,,,,,1103.36,1396.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,MedCost,Commercial,,1051.64,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,inpatient,,,2098.00000,1258.80000,MedCost,Commercial,,1699.38,,,,,,,1342.72,1699.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,MedCost,Commercial,,1279.78,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,inpatient,,,3519.00000,2111.40000,MedCost,Commercial,,2850.39,,,,,,,2252.16,2850.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,MedCost,Commercial,,2146.59,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,inpatient,,,6242.00000,3745.20000,MedCost,Commercial,,5056.02,,,,,,,3994.88,5056.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,MedCost,Commercial,,3807.62,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,inpatient,,,6731.00000,4038.60000,MedCost,Commercial,,5452.11,,,,,,,4307.84,5452.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,MedCost,Commercial,,4105.91,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,inpatient,,,635.00000,381.00000,MedCost,Commercial,,514.35,,,,,,,406.40,514.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,MedCost,Commercial,,387.35,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,inpatient,,,851.00000,510.60000,MedCost,Commercial,,689.31,,,,,,,544.64,689.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,MedCost,Commercial,,519.11,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,inpatient,,,6352.00000,3811.20000,MedCost,Commercial,,5145.12,,,,,,,4065.28,5145.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,MedCost,Commercial,,3874.72,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,inpatient,,,7135.00000,4281.00000,MedCost,Commercial,,5779.35,,,,,,,4566.40,5779.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,MedCost,Commercial,,4352.35,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,inpatient,,,7135.00000,4281.00000,MedCost,Commercial,,5779.35,,,,,,,4566.40,5779.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,MedCost,Commercial,,4352.35,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,inpatient,,,1698.00000,1018.80000,MedCost,Commercial,,1375.38,,,,,,,1086.72,1375.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,MedCost,Commercial,,1035.78,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,inpatient,,,2769.00000,1661.40000,MedCost,Commercial,,2242.89,,,,,,,1772.16,2242.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,MedCost,Commercial,,1689.09,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,inpatient,,,734.00000,440.40000,MedCost,Commercial,,594.54,,,,,,,469.76,594.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,MedCost,Commercial,,447.74,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,inpatient,,,1096.00000,657.60000,MedCost,Commercial,,887.76,,,,,,,701.44,887.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,MedCost,Commercial,,668.56,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,inpatient,,,469.00000,281.40000,MedCost,Commercial,,379.89,,,,,,,300.16,379.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,MedCost,Commercial,,286.09,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,inpatient,,,968.00000,580.80000,MedCost,Commercial,,784.08,,,,,,,619.52,784.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,MedCost,Commercial,,590.48,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,inpatient,,,687.00000,412.20000,MedCost,Commercial,,556.47,,,,,,,439.68,556.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,MedCost,Commercial,,419.07,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,inpatient,,,1545.00000,927.00000,MedCost,Commercial,,1251.45,,,,,,,988.80,1251.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,MedCost,Commercial,,942.45,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,inpatient,,,1071.00000,642.60000,MedCost,Commercial,,867.51,,,,,,,685.44,867.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,MedCost,Commercial,,653.31,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,inpatient,,,1862.00000,1117.20000,MedCost,Commercial,,1508.22,,,,,,,1191.68,1508.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,MedCost,Commercial,,1135.82,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,inpatient,,,450.00000,270.00000,MedCost,Commercial,,364.50,,,,,,,288.00,364.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,MedCost,Commercial,,274.50,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,inpatient,,,1204.00000,722.40000,MedCost,Commercial,,975.24,,,,,,,770.56,975.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,MedCost,Commercial,,734.44,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,inpatient,,,7492.00000,4495.20000,MedCost,Commercial,,6068.52,,,,,,,4794.88,6068.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,MedCost,Commercial,,4570.12,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,inpatient,,,7454.00000,4472.40000,MedCost,Commercial,,6037.74,,,,,,,4770.56,6037.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,MedCost,Commercial,,4546.94,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,inpatient,,,2398.00000,1438.80000,MedCost,Commercial,,1942.38,,,,,,,1534.72,1942.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,MedCost,Commercial,,1462.78,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,inpatient,,,1746.00000,1047.60000,MedCost,Commercial,,1414.26,,,,,,,1117.44,1414.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,MedCost,Commercial,,1065.06,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,inpatient,,,3100.00000,1860.00000,MedCost,Commercial,,2511.00,,,,,,,1984.00,2511.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,MedCost,Commercial,,1891.00,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,inpatient,,,8423.00000,5053.80000,MedCost,Commercial,,6822.63,,,,,,,5390.72,6822.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,MedCost,Commercial,,5138.03,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,inpatient,,,425.00000,255.00000,MedCost,Commercial,,344.25,,,,,,,272.00,344.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,MedCost,Commercial,,259.25,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,inpatient,,,567.00000,340.20000,MedCost,Commercial,,459.27,,,,,,,362.88,459.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,MedCost,Commercial,,345.87,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,inpatient,,,2178.00000,1306.80000,MedCost,Commercial,,1764.18,,,,,,,1393.92,1764.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,MedCost,Commercial,,1328.58,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,inpatient,,,2092.00000,1255.20000,MedCost,Commercial,,1694.52,,,,,,,1338.88,1694.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,MedCost,Commercial,,1276.12,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,inpatient,,,4635.00000,2781.00000,MedCost,Commercial,,3754.35,,,,,,,2966.40,3754.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,MedCost,Commercial,,2827.35,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,inpatient,,,2458.00000,1474.80000,MedCost,Commercial,,1990.98,,,,,,,1573.12,1990.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,MedCost,Commercial,,1499.38,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,inpatient,,,2999.00000,1799.40000,MedCost,Commercial,,2429.19,,,,,,,1919.36,2429.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,MedCost,Commercial,,1829.39,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Commercial,,255.96,,,,,,,202.24,255.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Commercial,,192.76,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,inpatient,,,321.00000,192.60000,MedCost,Commercial,,260.01,,,,,,,205.44,260.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,MedCost,Commercial,,195.81,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,inpatient,,,1076.00000,645.60000,MedCost,Commercial,,871.56,,,,,,,688.64,871.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,MedCost,Commercial,,656.36,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Commercial,,401.76,,,,,,,317.44,401.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Commercial,,302.56,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,inpatient,,,603.00000,361.80000,MedCost,Commercial,,488.43,,,,,,,385.92,488.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,MedCost,Commercial,,367.83,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Commercial,,401.76,,,,,,,317.44,401.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Commercial,,302.56,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,inpatient,,,1537.00000,922.20000,MedCost,Commercial,,1244.97,,,,,,,983.68,1244.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,MedCost,Commercial,,937.57,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Commercial,,498.15,,,,,,,393.60,498.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Commercial,,375.15,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,inpatient,,,734.00000,440.40000,MedCost,Commercial,,594.54,,,,,,,469.76,594.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,MedCost,Commercial,,447.74,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,inpatient,,,457.00000,274.20000,MedCost,Commercial,,370.17,,,,,,,292.48,370.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,MedCost,Commercial,,278.77,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,inpatient,,,331.00000,198.60000,MedCost,Commercial,,268.11,,,,,,,211.84,268.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,MedCost,Commercial,,201.91,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,inpatient,,,523.00000,313.80000,MedCost,Commercial,,423.63,,,,,,,334.72,423.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,MedCost,Commercial,,319.03,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,inpatient,,,7135.00000,4281.00000,MedCost,Commercial,,5779.35,,,,,,,4566.40,5779.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,MedCost,Commercial,,4352.35,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,inpatient,,,1032.00000,619.20000,MedCost,Commercial,,835.92,,,,,,,660.48,835.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,MedCost,Commercial,,629.52,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,inpatient,,,889.00000,533.40000,MedCost,Commercial,,720.09,,,,,,,568.96,720.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,MedCost,Commercial,,542.29,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,inpatient,,,1163.00000,697.80000,MedCost,Commercial,,942.03,,,,,,,744.32,942.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,MedCost,Commercial,,709.43,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,inpatient,,,1051.00000,630.60000,MedCost,Commercial,,851.31,,,,,,,672.64,851.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,MedCost,Commercial,,641.11,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,inpatient,,,1406.00000,843.60000,MedCost,Commercial,,1138.86,,,,,,,899.84,1138.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,MedCost,Commercial,,857.66,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,inpatient,,,1406.00000,843.60000,MedCost,Commercial,76,1138.86,,,,,,,899.84,1138.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,MedCost,Commercial,76,857.66,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1510.65,,,,,,,1193.60,1510.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1137.65,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,inpatient,,,3748.00000,2248.80000,MedCost,Commercial,,3035.88,,,,,,,2398.72,3035.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,MedCost,Commercial,,2286.28,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,inpatient,,,3748.00000,2248.80000,MedCost,Commercial,76,3035.88,,,,,,,2398.72,3035.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,MedCost,Commercial,76,2286.28,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,inpatient,,,3945.00000,2367.00000,MedCost,Commercial,,3195.45,,,,,,,2524.80,3195.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,MedCost,Commercial,,2406.45,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,inpatient,,,3945.00000,2367.00000,MedCost,Commercial,76,3195.45,,,,,,,2524.80,3195.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,MedCost,Commercial,76,2406.45,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,inpatient,,,2034.00000,1220.40000,MedCost,Commercial,,1647.54,,,,,,,1301.76,1647.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,MedCost,Commercial,,1240.74,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,inpatient,,,2261.00000,1356.60000,MedCost,Commercial,,1831.41,,,,,,,1447.04,1831.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,MedCost,Commercial,,1379.21,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,inpatient,,,2383.00000,1429.80000,MedCost,Commercial,,1930.23,,,,,,,1525.12,1930.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,MedCost,Commercial,,1453.63,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,inpatient,,,2629.00000,1577.40000,MedCost,Commercial,,2129.49,,,,,,,1682.56,2129.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,MedCost,Commercial,,1603.69,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,inpatient,,,1833.00000,1099.80000,MedCost,Commercial,,1484.73,,,,,,,1173.12,1484.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,MedCost,Commercial,,1118.13,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,inpatient,,,2622.00000,1573.20000,MedCost,Commercial,,2123.82,,,,,,,1678.08,2123.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,MedCost,Commercial,,1599.42,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Commercial,,277.83,,,,,,,219.52,277.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Commercial,,209.23,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Commercial,,334.53,,,,,,,264.32,334.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Commercial,,251.93,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Commercial,,334.53,,,,,,,264.32,334.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Commercial,,251.93,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Commercial,,236.52,,,,,,,186.88,236.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Commercial,,178.12,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,inpatient,,,2842.00000,1705.20000,MedCost,Commercial,,2302.02,,,,,,,1818.88,2302.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,MedCost,Commercial,,1733.62,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,inpatient,,,27299.00000,16379.40000,MedCost,Commercial,,22112.19,,,,,,,17471.36,22112.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,MedCost,Commercial,,16652.39,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,inpatient,,,3753.00000,2251.80000,MedCost,Commercial,,3039.93,,,,,,,2401.92,3039.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,MedCost,Commercial,,2289.33,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,inpatient,,,4316.00000,2589.60000,MedCost,Commercial,,3495.96,,,,,,,2762.24,3495.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,MedCost,Commercial,,2632.76,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,inpatient,,,4316.00000,2589.60000,MedCost,Commercial,,3495.96,,,,,,,2762.24,3495.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,MedCost,Commercial,,2632.76,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,inpatient,,,648.00000,388.80000,MedCost,Commercial,,524.88,,,,,,,414.72,524.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,MedCost,Commercial,,395.28,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,inpatient,,,708.00000,424.80000,MedCost,Commercial,,573.48,,,,,,,453.12,573.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,MedCost,Commercial,,431.88,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,inpatient,,,1225.00000,735.00000,MedCost,Commercial,,992.25,,,,,,,784.00,992.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,MedCost,Commercial,,747.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,inpatient,,,860.00000,516.00000,MedCost,Commercial,,696.60,,,,,,,550.40,696.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,MedCost,Commercial,,524.60,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,inpatient,,,914.00000,548.40000,MedCost,Commercial,,740.34,,,,,,,584.96,740.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,MedCost,Commercial,,557.54,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,inpatient,,,938.00000,562.80000,MedCost,Commercial,,759.78,,,,,,,600.32,759.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,MedCost,Commercial,,572.18,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,inpatient,,,641.00000,384.60000,MedCost,Commercial,,519.21,,,,,,,410.24,519.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,MedCost,Commercial,,391.01,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1510.65,,,,,,,1193.60,1510.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1137.65,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,76,1510.65,,,,,,,1193.60,1510.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,76,1137.65,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1510.65,,,,,,,1193.60,1510.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1137.65,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,76,1510.65,,,,,,,1193.60,1510.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,76,1137.65,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Commercial,,277.83,,,,,,,219.52,277.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Commercial,,209.23,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,inpatient,,,650.00000,390.00000,MedCost,Commercial,,526.50,,,,,,,416.00,526.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,MedCost,Commercial,,396.50,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,inpatient,,,363.00000,217.80000,MedCost,Commercial,,294.03,,,,,,,232.32,294.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,MedCost,Commercial,,221.43,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1510.65,,,,,,,1193.60,1510.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1137.65,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,76,1510.65,,,,,,,1193.60,1510.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,76,1137.65,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Commercial,,368.55,,,,,,,291.20,368.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Commercial,,277.55,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,inpatient,,,860.00000,516.00000,MedCost,Commercial,76,696.60,,,,,,,550.40,696.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,MedCost,Commercial,76,524.60,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,inpatient,,,914.00000,548.40000,MedCost,Commercial,76,740.34,,,,,,,584.96,740.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,MedCost,Commercial,76,557.54,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,inpatient,,,499.00000,299.40000,MedCost,Commercial,,404.19,,,,,,,319.36,404.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,MedCost,Commercial,,304.39,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,inpatient,,,1044.00000,626.40000,MedCost,Commercial,,845.64,,,,,,,668.16,845.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,MedCost,Commercial,,636.84,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,inpatient,,,1629.00000,977.40000,MedCost,Commercial,,1319.49,,,,,,,1042.56,1319.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,MedCost,Commercial,,993.69,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,inpatient,,,2343.00000,1405.80000,MedCost,Commercial,,1897.83,,,,,,,1499.52,1897.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,MedCost,Commercial,,1429.23,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,inpatient,,,6914.00000,4148.40000,MedCost,Commercial,,5600.34,,,,,,,4424.96,5600.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,MedCost,Commercial,,4217.54,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,inpatient,,,733.00000,439.80000,MedCost,Commercial,,593.73,,,,,,,469.12,593.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,MedCost,Commercial,,447.13,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,inpatient,,,6067.00000,3640.20000,MedCost,Commercial,,4914.27,,,,,,,3882.88,4914.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,MedCost,Commercial,,3700.87,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,inpatient,,,2254.00000,1352.40000,MedCost,Commercial,,1825.74,,,,,,,1442.56,1825.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,MedCost,Commercial,,1374.94,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,inpatient,,,2837.00000,1702.20000,MedCost,Commercial,,2297.97,,,,,,,1815.68,2297.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,MedCost,Commercial,,1730.57,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,inpatient,,,1848.00000,1108.80000,MedCost,Commercial,,1496.88,,,,,,,1182.72,1496.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,MedCost,Commercial,,1127.28,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,inpatient,,,871.00000,522.60000,MedCost,Commercial,,705.51,,,,,,,557.44,705.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,MedCost,Commercial,,531.31,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Commercial,,444.69,,,,,,,351.36,444.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Commercial,,334.89,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,inpatient,,,805.00000,483.00000,MedCost,Commercial,,652.05,,,,,,,515.20,652.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,MedCost,Commercial,,491.05,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Commercial,,1014.12,,,,,,,801.28,1014.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Commercial,,763.72,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,inpatient,,,8164.00000,4898.40000,MedCost,Commercial,,6612.84,,,,,,,5224.96,6612.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,MedCost,Commercial,,4980.04,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,inpatient,,,2410.00000,1446.00000,MedCost,Commercial,,1952.10,,,,,,,1542.40,1952.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,MedCost,Commercial,,1470.10,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,inpatient,,,405.00000,243.00000,MedCost,Commercial,,328.05,,,,,,,259.20,328.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,MedCost,Commercial,,247.05,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,inpatient,,,560.00000,336.00000,MedCost,Commercial,,453.60,,,,,,,358.40,453.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,MedCost,Commercial,,341.60,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,inpatient,,,1662.00000,997.20000,MedCost,Commercial,,1346.22,,,,,,,1063.68,1346.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,MedCost,Commercial,,1013.82,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,inpatient,,,1923.00000,1153.80000,MedCost,Commercial,,1557.63,,,,,,,1230.72,1557.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,MedCost,Commercial,,1173.03,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,inpatient,,,1274.00000,764.40000,MedCost,Commercial,,1031.94,,,,,,,815.36,1031.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,MedCost,Commercial,,777.14,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Commercial,,255.96,,,,,,,202.24,255.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Commercial,,192.76,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,inpatient,,,650.00000,390.00000,MedCost,Commercial,,526.50,,,,,,,416.00,526.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,MedCost,Commercial,,396.50,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,inpatient,,,2178.00000,1306.80000,MedCost,Commercial,,1764.18,,,,,,,1393.92,1764.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,MedCost,Commercial,,1328.58,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Commercial,,2529.63,,,,,,,1998.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Commercial,,1905.03,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,inpatient,,,351.00000,210.60000,MedCost,Commercial,,284.31,,,,,,,224.64,284.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,MedCost,Commercial,,214.11,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,inpatient,,,1054.00000,632.40000,MedCost,Commercial,,853.74,,,,,,,674.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,MedCost,Commercial,,642.94,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,inpatient,,,34.00000,20.40000,MedCost,Commercial,,27.54,,,,,,,21.76,27.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,MedCost,Commercial,,20.74,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,inpatient,,,465.00000,279.00000,MedCost,Commercial,,376.65,,,,,,,297.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,MedCost,Commercial,,283.65,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,inpatient,,,1028.00000,616.80000,MedCost,Commercial,,832.68,,,,,,,657.92,835.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,MedCost,Commercial,,627.08,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,inpatient,,,1212.00000,727.20000,MedCost,Commercial,,981.72,,,,,,,775.68,985.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,MedCost,Commercial,,739.32,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,inpatient,,,322.00000,193.20000,MedCost,Commercial,,260.82,,,,,,,206.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,MedCost,Commercial,,196.42,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,inpatient,,,757.00000,454.20000,MedCost,Commercial,,613.17,,,,,,,484.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,MedCost,Commercial,,461.77,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Commercial,,131.22,,,,,,,103.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Commercial,,98.82,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,inpatient,,,1170.00000,702.00000,MedCost,Commercial,,947.70,,,,,,,748.80,947.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,MedCost,Commercial,,713.70,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,inpatient,,,299.00000,179.40000,MedCost,Commercial,,242.19,,,,,,,191.36,242.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,MedCost,Commercial,,182.39,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,inpatient,,,595.00000,357.00000,MedCost,Commercial,,481.95,,,,,,,380.80,481.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,MedCost,Commercial,,362.95,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Commercial,,91.53,,,,,,,72.32,91.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Commercial,,68.93,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,inpatient,,,302.00000,181.20000,MedCost,Commercial,,244.62,,,,,,,193.28,244.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,MedCost,Commercial,,184.22,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,29.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,29.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,inpatient,,,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,46.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,inpatient,,,109.00000,65.40000,MedCost,Commercial,,88.29,,,,,,,69.76,88.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,MedCost,Commercial,,66.49,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Commercial,,162.00,,,,,,,128.00,162.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Commercial,,122.00,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Commercial,,130.41,,,,,,,103.04,130.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Commercial,,98.21,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Commercial,,91.53,,,,,,,72.32,91.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Commercial,,68.93,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Commercial,,107.73,,,,,,,85.12,107.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Commercial,,81.13,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Commercial,,91.53,,,,,,,72.32,91.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Commercial,,68.93,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,inpatient,,,438.00000,262.80000,MedCost,Commercial,,354.78,,,,,,,280.32,354.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,MedCost,Commercial,,267.18,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Commercial,,40.50,,,,,,,32.00,40.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Commercial,,30.50,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Commercial,,334.53,,,,,,,264.32,334.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Commercial,,251.93,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Commercial,,233.28,,,,,,,184.32,233.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Commercial,,175.68,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,29.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,inpatient,,,191.00000,114.60000,MedCost,Commercial,,154.71,,,,,,,122.24,154.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,MedCost,Commercial,,116.51,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Commercial,,217.89,,,,,,,172.16,217.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Commercial,,164.09,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,inpatient,,,67.00000,40.20000,MedCost,Commercial,GP,54.27,,,,,,,42.88,54.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,MedCost,Commercial,GP,40.87,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Commercial,GP,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Commercial,GP,45.75,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Commercial,GP,9.72,,,,,,,7.68,9.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Commercial,GP,7.32,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,inpatient,,,121.00000,72.60000,MedCost,Commercial,GP,98.01,,,,,,,77.44,98.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,MedCost,Commercial,GP,73.81,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,GP,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,GP,29.89,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,inpatient,,,16.00000,9.60000,MedCost,Commercial,GP,12.96,,,,,,,10.24,12.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,MedCost,Commercial,GP,9.76,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,inpatient,,,153.00000,91.80000,MedCost,Commercial,GP,123.93,,,,,,,97.92,123.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,MedCost,Commercial,GP,93.33,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Commercial,GP,132.03,,,,,,,104.32,132.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Commercial,GP,99.43,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Commercial,GP,103.68,,,,,,,81.92,103.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Commercial,GP,78.08,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,GP,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,GP,67.10,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,GP,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,GP,35.99,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Commercial,GP,132.84,,,,,,,104.96,132.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Commercial,GP,100.04,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,inpatient,,,160.00000,96.00000,MedCost,Commercial,GP,129.60,,,,,,,102.40,129.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,MedCost,Commercial,GP,97.60,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,inpatient,,,144.00000,86.40000,MedCost,Commercial,GP,116.64,,,,,,,92.16,116.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,MedCost,Commercial,GP,87.84,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,GP,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,GP,100.65,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Commercial,GP,112.59,,,,,,,88.96,112.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Commercial,GP,84.79,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Commercial,GP,163.62,,,,,,,129.28,163.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Commercial,GP,123.22,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,GP,94.77,,,,,,,74.88,94.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,GP,71.37,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,GP,104.49,,,,,,,82.56,104.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,GP,78.69,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,inpatient,,,151.00000,90.60000,MedCost,Commercial,GP,122.31,,,,,,,96.64,122.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,MedCost,Commercial,GP,92.11,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Commercial,GP,38.07,,,,,,,30.08,38.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Commercial,GP,28.67,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,GP,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,GP,71.98,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Commercial,GP,68.85,,,,,,,54.40,68.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Commercial,GP,51.85,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,GP,104.49,,,,,,,82.56,104.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,GP,78.69,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Commercial,GP,80.19,,,,,,,63.36,80.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Commercial,GP,60.39,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Commercial,GP,145.80,,,,,,,115.20,145.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Commercial,GP,109.80,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Commercial,GP,145.80,,,,,,,115.20,145.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Commercial,GP,109.80,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,GP,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,GP,55.51,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,GP,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,GP,55.51,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,GP,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,GP,54.29,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Commercial,GP,102.87,,,,,,,81.28,102.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Commercial,GP,77.47,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Commercial,GP,105.30,,,,,,,83.20,105.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Commercial,GP,79.30,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Commercial,GP,56.70,,,,,,,44.80,56.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Commercial,GP,42.70,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Commercial,GP,24.30,,,,,,,19.20,24.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Commercial,GP,18.30,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,inpatient,,,306.00000,183.60000,MedCost,Commercial,GP,247.86,,,,,,,195.84,247.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,MedCost,Commercial,GP,186.66,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,inpatient,,,423.00000,253.80000,MedCost,Commercial,GP,342.63,,,,,,,270.72,342.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,MedCost,Commercial,GP,258.03,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,inpatient,,,434.00000,260.40000,MedCost,Commercial,GP,351.54,,,,,,,277.76,351.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,MedCost,Commercial,GP,264.74,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Commercial,GP,233.28,,,,,,,184.32,233.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Commercial,GP,175.68,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,GO,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,GO,55.51,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,GO,94.77,,,,,,,74.88,94.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,GO,71.37,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,GO,104.49,,,,,,,82.56,104.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,GO,78.69,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,GO,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,GO,71.98,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Commercial,GO,56.70,,,,,,,44.80,56.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Commercial,GO,42.70,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,GO,104.49,,,,,,,82.56,104.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,GO,78.69,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Commercial,GO,80.19,,,,,,,63.36,80.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Commercial,GO,60.39,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Commercial,GO,9.72,,,,,,,7.68,9.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Commercial,GO,7.32,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Commercial,GO,132.03,,,,,,,104.32,132.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Commercial,GO,99.43,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Commercial,GO,103.68,,,,,,,81.92,103.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Commercial,GO,78.08,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,GO,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,GO,37.82,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Commercial,GO,132.84,,,,,,,104.96,132.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Commercial,GO,100.04,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,inpatient,,,160.00000,96.00000,MedCost,Commercial,GO,129.60,,,,,,,102.40,129.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,MedCost,Commercial,GO,97.60,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,inpatient,,,144.00000,86.40000,MedCost,Commercial,GO,116.64,,,,,,,92.16,116.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,MedCost,Commercial,GO,87.84,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,GO,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,GO,100.65,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,GO,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,GO,29.89,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,inpatient,,,224.00000,134.40000,MedCost,Commercial,GO,181.44,,,,,,,143.36,181.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,MedCost,Commercial,GO,136.64,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Commercial,GO,123.12,,,,,,,97.28,123.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Commercial,GO,92.72,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Commercial,GO,102.87,,,,,,,81.28,102.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Commercial,GO,77.47,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Commercial,GO,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Commercial,GO,45.75,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Commercial,GO,257.58,,,,,,,203.52,257.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Commercial,GO,193.98,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,inpatient,,,403.00000,241.80000,MedCost,Commercial,GO,326.43,,,,,,,257.92,326.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,MedCost,Commercial,GO,245.83,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,inpatient,,,415.00000,249.00000,MedCost,Commercial,GO,336.15,,,,,,,265.60,336.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,MedCost,Commercial,GO,253.15,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Commercial,GO,163.62,,,,,,,129.28,163.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Commercial,GO,123.22,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,inpatient,,,356.00000,213.60000,MedCost,Commercial,GN,288.36,,,,,,,227.84,288.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,MedCost,Commercial,GN,217.16,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,inpatient,,,336.00000,201.60000,MedCost,Commercial,GN,272.16,,,,,,,215.04,272.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,MedCost,Commercial,GN,204.96,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,inpatient,,,187.00000,112.20000,MedCost,Commercial,GN,151.47,,,,,,,119.68,151.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,MedCost,Commercial,GN,114.07,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Commercial,GN,217.89,,,,,,,172.16,217.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Commercial,GN,164.09,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Commercial,GN,162.00,,,,,,,128.00,162.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Commercial,GN,122.00,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Commercial,GN,255.15,,,,,,,201.60,255.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Commercial,GN,192.15,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Commercial,GN,103.68,,,,,,,81.92,103.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Commercial,GN,78.08,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Commercial,GN,56.70,,,,,,,44.80,56.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Commercial,GN,42.70,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Commercial,GN,68.85,,,,,,,54.40,68.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Commercial,GN,51.85,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Commercial,GN,80.19,,,,,,,63.36,80.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Commercial,GN,60.39,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,inpatient,,,229.00000,137.40000,MedCost,Commercial,GN,185.49,,,,,,,146.56,185.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,MedCost,Commercial,GN,139.69,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,GN,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,GN,82.96,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,inpatient,,,655.00000,393.00000,MedCost,Commercial,GN,530.55,,,,,,,419.20,530.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,MedCost,Commercial,GN,399.55,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,inpatient,,,259.00000,155.40000,MedCost,Commercial,GN,209.79,,,,,,,165.76,209.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,MedCost,Commercial,GN,157.99,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,inpatient,,,68.00000,40.80000,MedCost,Commercial,GN,55.08,,,,,,,43.52,55.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,MedCost,Commercial,GN,41.48,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Commercial,GN,105.30,,,,,,,83.20,105.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Commercial,GN,79.30,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Commercial,GN,56.70,,,,,,,44.80,56.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Commercial,GN,42.70,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Commercial,GN,24.30,,,,,,,19.20,24.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Commercial,GN,18.30,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,inpatient,,,214.00000,128.40000,MedCost,Commercial,GN,173.34,,,,,,,136.96,173.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,MedCost,Commercial,GN,130.54,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,inpatient,,,229.00000,137.40000,MedCost,Commercial,GN,185.49,,,,,,,146.56,185.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,MedCost,Commercial,GN,139.69,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Commercial,GN,86.67,,,,,,,68.48,86.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Commercial,GN,65.27,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,inpatient,,,353.00000,211.80000,MedCost,Commercial,GN,285.93,,,,,,,225.92,285.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,MedCost,Commercial,GN,215.33,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Commercial,GN,444.69,,,,,,,351.36,444.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Commercial,GN,334.89,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,inpatient,,,591.00000,354.60000,MedCost,Commercial,GN,478.71,,,,,,,378.24,478.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,MedCost,Commercial,GN,360.51,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,inpatient,,,864.00000,518.40000,MedCost,Commercial,,699.84,,,,,,,552.96,699.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,MedCost,Commercial,,527.04,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Commercial,,444.69,,,,,,,351.36,444.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Commercial,,334.89,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,inpatient,,,885.00000,531.00000,MedCost,Commercial,,716.85,,,,,,,566.40,716.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,MedCost,Commercial,,539.85,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,inpatient,,,504.00000,302.40000,MedCost,Commercial,,408.24,,,,,,,322.56,408.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,MedCost,Commercial,,307.44,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,inpatient,,,745.00000,447.00000,MedCost,Commercial,,603.45,,,,,,,476.80,603.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,MedCost,Commercial,,454.45,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,inpatient,,,3756.00000,2253.60000,MedCost,Commercial,,3042.36,,,,,,,2403.84,3042.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,MedCost,Commercial,,2291.16,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Commercial,,34.83,,,,,,,27.52,34.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Commercial,,26.23,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,inpatient,,,148.00000,88.80000,MedCost,Commercial,,119.88,,,,,,,94.72,119.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,MedCost,Commercial,,90.28,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,inpatient,,,525.00000,315.00000,MedCost,Commercial,,425.25,,,,,,,336.00,425.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,MedCost,Commercial,,320.25,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,inpatient,,,523.00000,313.80000,MedCost,Commercial,,423.63,,,,,,,334.72,423.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,MedCost,Commercial,,319.03,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,inpatient,,,563.00000,337.80000,MedCost,Commercial,,456.03,,,,,,,360.32,456.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,MedCost,Commercial,,343.43,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Commercial,,305.37,,,,,,,241.28,305.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Commercial,,229.97,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Commercial,,305.37,,,,,,,241.28,305.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Commercial,,229.97,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,inpatient,,,1357.00000,814.20000,MedCost,Commercial,,1099.17,,,,,,,868.48,1099.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,MedCost,Commercial,,827.77,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,inpatient,,,418.00000,250.80000,MedCost,Commercial,,338.58,,,,,,,267.52,338.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,MedCost,Commercial,,254.98,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,inpatient,,,812.00000,487.20000,MedCost,Commercial,,657.72,,,,,,,519.68,657.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,MedCost,Commercial,,495.32,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,68.48,86.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,inpatient,,,567.00000,340.20000,MedCost,Commercial,,459.27,,,,,,,362.88,459.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,MedCost,Commercial,,345.87,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,inpatient,,,476.00000,285.60000,MedCost,Commercial,,385.56,,,,,,,304.64,385.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,MedCost,Commercial,,290.36,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,inpatient,,,652.00000,391.20000,MedCost,Commercial,,528.12,,,,,,,417.28,528.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,MedCost,Commercial,,397.72,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Commercial,,370.98,,,,,,,293.12,370.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Commercial,,279.38,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Commercial,,126.36,,,,,,,99.84,126.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Commercial,,95.16,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Commercial,,145.80,,,,,,,115.20,145.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Commercial,,109.80,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,inpatient,,,1170.00000,702.00000,MedCost,Commercial,,947.70,,,,,,,748.80,947.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,MedCost,Commercial,,713.70,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,inpatient,,,131.00000,78.60000,MedCost,Commercial,,106.11,,,,,,,83.84,106.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,MedCost,Commercial,,79.91,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,inpatient,,,1542.00000,925.20000,MedCost,Commercial,,1249.02,,,,,,,986.88,1249.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,MedCost,Commercial,,940.62,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,inpatient,,,1542.00000,925.20000,MedCost,Commercial,,1249.02,,,,,,,986.88,1249.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,MedCost,Commercial,,940.62,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,inpatient,,,264.00000,158.40000,MedCost,Commercial,,213.84,,,,,,,168.96,213.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,MedCost,Commercial,,161.04,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,inpatient,,,264.00000,158.40000,MedCost,Commercial,,213.84,,,,,,,168.96,213.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,MedCost,Commercial,,161.04,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,inpatient,,,2000.00000,1200.00000,MedCost,Commercial,,1620.00,,,,,,,1280.00,1626.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,MedCost,Commercial,,1220.00,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Commercial,,2529.63,,,,,,,1998.72,2529.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Commercial,,1905.03,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,inpatient,,,700.00000,420.00000,MedCost,Commercial,,567.00,,,,,,,448.00,569.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,MedCost,Commercial,,427.00,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,inpatient,,,2272.00000,1363.20000,MedCost,Commercial,,1840.32,,,,,,,1454.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,MedCost,Commercial,,1385.92,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,inpatient,,,831.00000,498.60000,MedCost,Commercial,,673.11,,,,,,,531.84,675.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,MedCost,Commercial,,506.91,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,inpatient,,,505.00000,303.00000,MedCost,Commercial,,409.05,,,,,,,323.20,409.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,MedCost,Commercial,,308.05,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,inpatient,,,222.00000,133.20000,MedCost,Commercial,,179.82,,,,,,,142.08,179.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,MedCost,Commercial,,135.42,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,inpatient,,,333.00000,199.80000,MedCost,Commercial,,269.73,,,,,,,213.12,269.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,MedCost,Commercial,,203.13,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,inpatient,,,338.00000,202.80000,MedCost,Commercial,,273.78,,,,,,,216.32,273.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,MedCost,Commercial,,206.18,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,inpatient,,,185.00000,111.00000,MedCost,Commercial,,149.85,,,,,,,118.40,149.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,MedCost,Commercial,,112.85,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,inpatient,,,6043.00000,3625.80000,MedCost,Commercial,,4894.83,,,,,,,3867.52,4894.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,MedCost,Commercial,,3686.23,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,inpatient,,,6043.00000,3625.80000,MedCost,Commercial,,4894.83,,,,,,,3867.52,4894.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,MedCost,Commercial,,3686.23,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,inpatient,,,1017.00000,610.20000,MedCost,Commercial,,823.77,,,,,,,650.88,823.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,MedCost,Commercial,,620.37,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,inpatient,,,4200.00000,2520.00000,MedCost,Commercial,,3402.00,,,,,,,2688.00,3402.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,MedCost,Commercial,,2562.00,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,inpatient,,,4200.00000,2520.00000,MedCost,Commercial,,3402.00,,,,,,,2688.00,3402.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,MedCost,Commercial,,2562.00,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,inpatient,,,4266.00000,2559.60000,MedCost,Commercial,,3455.46,,,,,,,2730.24,3455.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,MedCost,Commercial,,2602.26,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,inpatient,,,1154.00000,692.40000,MedCost,Commercial,,934.74,,,,,,,738.56,934.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,MedCost,Commercial,,703.94,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,inpatient,,,552.00000,331.20000,MedCost,Commercial,,447.12,,,,,,,353.28,447.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,MedCost,Commercial,,336.72,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,inpatient,,,565.00000,339.00000,MedCost,Commercial,,457.65,,,,,,,361.60,457.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,MedCost,Commercial,,344.65,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,inpatient,,,1350.00000,810.00000,MedCost,Commercial,,1093.50,,,,,,,864.00,1093.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,MedCost,Commercial,,823.50,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,inpatient,,,963.00000,577.80000,MedCost,Commercial,,780.03,,,,,,,616.32,780.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,MedCost,Commercial,,587.43,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Commercial,,445.50,,,,,,,352.00,445.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Commercial,,335.50,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,inpatient,,,963.00000,577.80000,MedCost,Commercial,,780.03,,,,,,,616.32,780.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,MedCost,Commercial,,587.43,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,inpatient,,,1051.00000,630.60000,MedCost,Commercial,,851.31,,,,,,,672.64,851.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,MedCost,Commercial,,641.11,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,inpatient,,,453.00000,271.80000,MedCost,Commercial,,366.93,,,,,,,289.92,366.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,MedCost,Commercial,,276.33,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Commercial,,1029.51,,,,,,,813.44,1029.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Commercial,,775.31,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,inpatient,,,1159.00000,695.40000,MedCost,Commercial,,938.79,,,,,,,741.76,938.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,MedCost,Commercial,,706.99,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,inpatient,,,728.00000,436.80000,MedCost,Commercial,,589.68,,,,,,,465.92,589.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,MedCost,Commercial,,444.08,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Commercial,,389.61,,,,,,,307.84,389.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Commercial,,293.41,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,inpatient,,,1126.00000,675.60000,MedCost,Commercial,,912.06,,,,,,,720.64,912.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,MedCost,Commercial,,686.86,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Commercial,,255.96,,,,,,,202.24,255.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Commercial,,192.76,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,inpatient,,,758.00000,454.80000,MedCost,Commercial,,613.98,,,,,,,485.12,613.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,MedCost,Commercial,,462.38,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,inpatient,,,124.00000,74.40000,MedCost,Commercial,,100.44,,,,,,,79.36,100.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,MedCost,Commercial,,75.64,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,inpatient,,,958.00000,574.80000,MedCost,Commercial,,775.98,,,,,,,613.12,775.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,MedCost,Commercial,,584.38,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Commercial,,462.51,,,,,,,365.44,462.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Commercial,,348.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,inpatient,,,464.00000,278.40000,MedCost,Commercial,,375.84,,,,,,,296.96,375.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,MedCost,Commercial,,283.04,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Commercial,,436.59,,,,,,,344.96,436.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Commercial,,328.79,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,inpatient,,,503.00000,301.80000,MedCost,Commercial,,407.43,,,,,,,321.92,407.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,MedCost,Commercial,,306.83,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,inpatient,,,1572.00000,943.20000,MedCost,Commercial,,1273.32,,,,,,,1006.08,1273.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,MedCost,Commercial,,958.92,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,inpatient,,,405.00000,243.00000,MedCost,Commercial,,328.05,,,,,,,259.20,328.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,MedCost,Commercial,,247.05,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,inpatient,,,1572.00000,943.20000,MedCost,Commercial,,1273.32,,,,,,,1006.08,1273.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,MedCost,Commercial,,958.92,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,inpatient,,,405.00000,243.00000,MedCost,Commercial,,328.05,,,,,,,259.20,328.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,MedCost,Commercial,,247.05,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Commercial,,302.13,,,,,,,238.72,302.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Commercial,,227.53,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,inpatient,,,674.00000,404.40000,MedCost,Commercial,,545.94,,,,,,,431.36,545.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,MedCost,Commercial,,411.14,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,inpatient,,,822.00000,493.20000,MedCost,Commercial,,665.82,,,,,,,526.08,665.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,MedCost,Commercial,,501.42,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,inpatient,,,855.00000,513.00000,MedCost,Commercial,,692.55,,,,,,,547.20,692.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,MedCost,Commercial,,521.55,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,inpatient,,,888.00000,532.80000,MedCost,Commercial,,719.28,,,,,,,568.32,719.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,MedCost,Commercial,,541.68,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Commercial,,436.59,,,,,,,344.96,436.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Commercial,,328.79,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,inpatient,,,429.00000,257.40000,MedCost,Commercial,,347.49,,,,,,,274.56,347.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,MedCost,Commercial,,261.69,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,inpatient,,,295.00000,177.00000,MedCost,Commercial,,238.95,,,,,,,188.80,238.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,MedCost,Commercial,,179.95,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Commercial,,353.97,,,,,,,279.68,353.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Commercial,,266.57,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Commercial,,204.93,,,,,,,161.92,204.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Commercial,,154.33,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,inpatient,,,614.00000,368.40000,MedCost,Commercial,,497.34,,,,,,,392.96,497.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,MedCost,Commercial,,374.54,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,inpatient,,,614.00000,368.40000,MedCost,Commercial,,497.34,,,,,,,392.96,497.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,MedCost,Commercial,,374.54,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,inpatient,,,547.00000,328.20000,MedCost,Commercial,,443.07,,,,,,,350.08,443.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,MedCost,Commercial,,333.67,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Commercial,,171.72,,,,,,,135.68,171.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Commercial,,129.32,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Commercial,,171.72,,,,,,,135.68,171.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Commercial,,129.32,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Commercial,,171.72,,,,,,,135.68,171.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Commercial,,129.32,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Commercial,,171.72,,,,,,,135.68,171.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Commercial,,129.32,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,324.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,MedCost,Commercial,,244.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,324.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,MedCost,Commercial,,244.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,inpatient,,,400.00000,240.00000,MedCost,Commercial,,324.00,,,,,,,256.00,324.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,MedCost,Commercial,,244.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,inpatient,,,267.00000,160.20000,MedCost,Commercial,,216.27,,,,,,,170.88,216.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,MedCost,Commercial,,162.87,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,inpatient,,,366.00000,219.60000,MedCost,Commercial,,296.46,,,,,,,234.24,296.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,MedCost,Commercial,,223.26,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,inpatient,,,366.00000,219.60000,MedCost,Commercial,,296.46,,,,,,,234.24,296.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,MedCost,Commercial,,223.26,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,inpatient,,,1635.00000,981.00000,MedCost,Commercial,,1324.35,,,,,,,1046.40,1324.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,MedCost,Commercial,,997.35,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,inpatient,,,1635.00000,981.00000,MedCost,Commercial,,1324.35,,,,,,,1046.40,1324.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,MedCost,Commercial,,997.35,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,inpatient,,,457.00000,274.20000,MedCost,Commercial,,370.17,,,,,,,292.48,370.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,MedCost,Commercial,,278.77,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Commercial,,368.55,,,,,,,291.20,368.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Commercial,,277.55,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,inpatient,,,1491.00000,894.60000,MedCost,Commercial,,1207.71,,,,,,,954.24,1207.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,MedCost,Commercial,,909.51,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,inpatient,,,1526.00000,915.60000,MedCost,Commercial,,1236.06,,,,,,,976.64,1236.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,MedCost,Commercial,,930.86,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,inpatient,,,848.00000,508.80000,MedCost,Commercial,,686.88,,,,,,,542.72,686.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,MedCost,Commercial,,517.28,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,inpatient,,,1233.00000,739.80000,MedCost,Commercial,,998.73,,,,,,,789.12,998.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,MedCost,Commercial,,752.13,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,inpatient,,,423.00000,253.80000,MedCost,Commercial,,342.63,,,,,,,270.72,342.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,MedCost,Commercial,,258.03,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,inpatient,,,997.00000,598.20000,MedCost,Commercial,,807.57,,,,,,,638.08,807.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,MedCost,Commercial,,608.17,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Commercial,,375.03,,,,,,,296.32,375.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Commercial,,282.43,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,inpatient,,,544.00000,326.40000,MedCost,Commercial,,440.64,,,,,,,348.16,440.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,MedCost,Commercial,,331.84,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,inpatient,,,1315.00000,789.00000,MedCost,Commercial,,1065.15,,,,,,,841.60,1065.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,MedCost,Commercial,,802.15,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,inpatient,,,1588.00000,952.80000,MedCost,Commercial,,1286.28,,,,,,,1016.32,1286.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,MedCost,Commercial,,968.68,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,inpatient,,,1950.00000,1170.00000,MedCost,Commercial,,1579.50,,,,,,,1248.00,1579.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,MedCost,Commercial,,1189.50,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,inpatient,,,2767.00000,1660.20000,MedCost,Commercial,,2241.27,,,,,,,1770.88,2241.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,MedCost,Commercial,,1687.87,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,inpatient,,,3039.00000,1823.40000,MedCost,Commercial,,2461.59,,,,,,,1944.96,2461.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,MedCost,Commercial,,1853.79,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,inpatient,,,3856.00000,2313.60000,MedCost,Commercial,,3123.36,,,,,,,2467.84,3123.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,MedCost,Commercial,,2352.16,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,inpatient,,,2268.00000,1360.80000,MedCost,Commercial,,1837.08,,,,,,,1451.52,1837.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,MedCost,Commercial,,1383.48,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,inpatient,,,2540.00000,1524.00000,MedCost,Commercial,,2057.40,,,,,,,1625.60,2057.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,MedCost,Commercial,,1549.40,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,inpatient,,,2858.00000,1714.80000,MedCost,Commercial,,2314.98,,,,,,,1829.12,2314.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,MedCost,Commercial,,1743.38,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,inpatient,,,4536.00000,2721.60000,MedCost,Commercial,,3674.16,,,,,,,2903.04,3674.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,MedCost,Commercial,,2766.96,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,inpatient,,,5080.00000,3048.00000,MedCost,Commercial,,4114.80,,,,,,,3251.20,4114.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,MedCost,Commercial,,3098.80,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,inpatient,,,5670.00000,3402.00000,MedCost,Commercial,,4592.70,,,,,,,3628.80,4592.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,MedCost,Commercial,,3458.70,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,inpatient,,,1042.00000,625.20000,MedCost,Commercial,,844.02,,,,,,,666.88,844.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,MedCost,Commercial,,635.62,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,inpatient,,,225.00000,135.00000,MedCost,Commercial,,182.25,,,,,,,144.00,182.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,MedCost,Commercial,,137.25,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Commercial,,236.52,,,,,,,186.88,236.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Commercial,,178.12,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Commercial,,238.14,,,,,,,188.16,238.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Commercial,,179.34,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Commercial,,38.88,,,,,,,30.72,38.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Commercial,,29.28,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Commercial,,38.88,,,,,,,30.72,38.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Commercial,,29.28,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Commercial,,85.86,,,,,,,67.84,85.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Commercial,,64.66,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Commercial,,627.75,,,,,,,496.00,627.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Commercial,,472.75,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Commercial,,627.75,,,,,,,496.00,627.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Commercial,,472.75,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Commercial,,627.75,,,,,,,496.00,627.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Commercial,,472.75,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Commercial,,627.75,,,,,,,496.00,627.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Commercial,,472.75,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Commercial,,627.75,,,,,,,496.00,627.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Commercial,,472.75,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Commercial,,627.75,,,,,,,496.00,627.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Commercial,,472.75,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,inpatient,,,66.67000,40.00000,MedCost,Commercial,GP,54.00,,,,,,,42.67,54.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,MedCost,Commercial,GP,40.67,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,inpatient,,,479.00000,287.40000,MedCost,Commercial,,387.99,,,,,,,306.56,389.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,MedCost,Commercial,,292.19,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,inpatient,,,2744.00000,1646.40000,MedCost,Commercial,,2222.64,,,,,,,1756.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,MedCost,Commercial,,1673.84,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,inpatient,,,2744.00000,1646.40000,MedCost,Commercial,,2222.64,,,,,,,1756.16,2230.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,MedCost,Commercial,,1673.84,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,inpatient,,,3875.00000,2325.00000,MedCost,Commercial,,3138.75,,,,,,,2480.00,3150.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,MedCost,Commercial,,2363.75,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,inpatient,,,1085.00000,651.00000,MedCost,Commercial,,878.85,,,,,,,694.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,MedCost,Commercial,,661.85,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,inpatient,,,1085.00000,651.00000,MedCost,Commercial,,878.85,,,,,,,694.40,882.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,MedCost,Commercial,,661.85,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,inpatient,,,2464.00000,1478.40000,MedCost,Commercial,,1995.84,,,,,,,1576.96,2003.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,MedCost,Commercial,,1503.04,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,inpatient,,,1039.00000,623.40000,MedCost,Commercial,,841.59,,,,,,,664.96,844.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,MedCost,Commercial,,633.79,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,inpatient,,,1039.00000,623.40000,MedCost,Commercial,,841.59,,,,,,,664.96,844.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,MedCost,Commercial,,633.79,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,inpatient,,,3190.00000,1914.00000,MedCost,Commercial,,2583.90,,,,,,,2041.60,2593.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,MedCost,Commercial,,1945.90,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,inpatient,,,430.00000,258.00000,MedCost,Commercial,,348.30,,,,,,,275.20,349.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,MedCost,Commercial,,262.30,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,inpatient,,,480.00000,288.00000,MedCost,Commercial,,388.80,,,,,,,307.20,390.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,MedCost,Commercial,,292.80,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,inpatient,,,536.00000,321.60000,MedCost,Commercial,,434.16,,,,,,,343.04,435.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,MedCost,Commercial,,326.96,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Commercial,,370.98,,,,,,,293.12,372.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Commercial,,279.38,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,inpatient,,,119.00000,71.40000,MedCost,Commercial,,96.39,,,,,,,76.16,96.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,MedCost,Commercial,,72.59,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,,104.49,,,,,,,82.56,104.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,,78.69,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,,104.49,,,,,,,82.56,104.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,,78.69,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,inpatient,,,208.00000,124.80000,MedCost,Commercial,,168.48,,,,,,,133.12,169.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,MedCost,Commercial,,126.88,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Commercial,,132.03,,,,,,,104.32,132.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Commercial,,99.43,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,inpatient,,,307.00000,184.20000,MedCost,Commercial,,248.67,,,,,,,196.48,249.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,MedCost,Commercial,,187.27,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,inpatient,,,520.00000,312.00000,MedCost,Commercial,,421.20,,,,,,,332.80,422.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,MedCost,Commercial,,317.20,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,inpatient,,,504.00000,302.40000,MedCost,Commercial,,408.24,,,,,,,322.56,409.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,MedCost,Commercial,,307.44,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,inpatient,,,618.00000,370.80000,MedCost,Commercial,,500.58,,,,,,,395.52,502.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,MedCost,Commercial,,376.98,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,inpatient,,,409.00000,245.40000,MedCost,Commercial,,331.29,,,,,,,261.76,332.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,MedCost,Commercial,,249.49,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,inpatient,,,770.00000,462.00000,MedCost,Commercial,,623.70,,,,,,,492.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,MedCost,Commercial,,469.70,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,inpatient,,,770.00000,462.00000,MedCost,Commercial,,623.70,,,,,,,492.80,626.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,MedCost,Commercial,,469.70,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,inpatient,,,638.00000,382.80000,MedCost,Commercial,,516.78,,,,,,,408.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,MedCost,Commercial,,389.18,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,inpatient,,,603.00000,361.80000,MedCost,Commercial,,488.43,,,,,,,385.92,490.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,MedCost,Commercial,,367.83,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,inpatient,,,902.00000,541.20000,MedCost,Commercial,,730.62,,,,,,,577.28,733.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,MedCost,Commercial,,550.22,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,inpatient,,,182.00000,109.20000,MedCost,Commercial,,147.42,,,,,,,116.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,MedCost,Commercial,,111.02,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Commercial,,123.12,,,,,,,97.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Commercial,,92.72,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,inpatient,,,280.00000,168.00000,MedCost,Commercial,,226.80,,,,,,,179.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,MedCost,Commercial,,170.80,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,inpatient,,,388.00000,232.80000,MedCost,Commercial,,314.28,,,,,,,248.32,315.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,MedCost,Commercial,,236.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,MedCost,Commercial,,614.79,,,,,,,485.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,MedCost,Commercial,,462.99,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,MedCost,Commercial,,614.79,,,,,,,485.76,617.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,MedCost,Commercial,,462.99,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,inpatient,,,2295.00000,1377.00000,MedCost,Commercial,,1858.95,,,,,,,1468.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,MedCost,Commercial,,1399.95,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,inpatient,,,607.00000,364.20000,MedCost,Commercial,,491.67,,,,,,,388.48,493.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,MedCost,Commercial,,370.27,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,inpatient,,,1863.00000,1117.80000,MedCost,Commercial,,1509.03,,,,,,,1192.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,MedCost,Commercial,,1136.43,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,inpatient,,,1863.00000,1117.80000,MedCost,Commercial,,1509.03,,,,,,,1192.32,1514.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,MedCost,Commercial,,1136.43,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,inpatient,,,2132.00000,1279.20000,MedCost,Commercial,,1726.92,,,,,,,1364.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,MedCost,Commercial,,1300.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,inpatient,,,536.00000,321.60000,MedCost,Commercial,,434.16,,,,,,,343.04,435.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,MedCost,Commercial,,326.96,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Commercial,,839.97,,,,,,,663.68,843.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Commercial,,632.57,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,inpatient,,,12507.00000,7504.20000,MedCost,Commercial,,10130.67,,,,,,,8004.48,10168.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,MedCost,Commercial,,7629.27,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1520.00000,912.00000,MedCost,Commercial,,1231.20,,,,,,,972.80,1235.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,MedCost,Commercial,,927.20,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,inpatient,,,1933.00000,1159.80000,MedCost,Commercial,,1565.73,,,,,,,1237.12,1571.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,MedCost,Commercial,,1179.13,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,inpatient,,,834.00000,500.40000,MedCost,Commercial,,675.54,,,,,,,533.76,678.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,MedCost,Commercial,,508.74,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,inpatient,,,869.00000,521.40000,MedCost,Commercial,,703.89,,,,,,,556.16,706.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,MedCost,Commercial,,530.09,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,inpatient,,,925.00000,555.00000,MedCost,Commercial,,749.25,,,,,,,592.00,752.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,MedCost,Commercial,,564.25,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,inpatient,,,1538.00000,922.80000,MedCost,Commercial,,1245.78,,,,,,,984.32,1250.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,MedCost,Commercial,,938.18,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,inpatient,,,1918.00000,1150.80000,MedCost,Commercial,,1553.58,,,,,,,1227.52,1559.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,MedCost,Commercial,,1169.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,inpatient,,,9774.00000,5864.40000,MedCost,Commercial,,7916.94,,,,,,,6255.36,7946.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,MedCost,Commercial,,5962.14,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Commercial,,534.60,,,,,,,422.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Commercial,,402.60,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Commercial,,534.60,,,,,,,422.40,536.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Commercial,,402.60,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,inpatient,,,3189.00000,1913.40000,MedCost,Commercial,,2583.09,,,,,,,2040.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,MedCost,Commercial,,1945.29,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,inpatient,,,3189.00000,1913.40000,MedCost,Commercial,,2583.09,,,,,,,2040.96,2592.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,MedCost,Commercial,,1945.29,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,inpatient,,,1528.00000,916.80000,MedCost,Commercial,,1237.68,,,,,,,977.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,MedCost,Commercial,,932.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,inpatient,,,1528.00000,916.80000,MedCost,Commercial,,1237.68,,,,,,,977.92,1242.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,MedCost,Commercial,,932.08,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,inpatient,,,1727.00000,1036.20000,MedCost,Commercial,,1398.87,,,,,,,1105.28,1404.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,MedCost,Commercial,,1053.47,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,inpatient,,,2142.00000,1285.20000,MedCost,Commercial,,1735.02,,,,,,,1370.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,MedCost,Commercial,,1306.62,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,inpatient,,,2142.00000,1285.20000,MedCost,Commercial,,1735.02,,,,,,,1370.88,1741.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,MedCost,Commercial,,1306.62,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,inpatient,,,1397.00000,838.20000,MedCost,Commercial,,1131.57,,,,,,,894.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,MedCost,Commercial,,852.17,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1397.00000,838.20000,MedCost,Commercial,,1131.57,,,,,,,894.08,1135.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,MedCost,Commercial,,852.17,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,inpatient,,,621.00000,372.60000,MedCost,Commercial,,503.01,,,,,,,397.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,MedCost,Commercial,,378.81,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,inpatient,,,621.00000,372.60000,MedCost,Commercial,,503.01,,,,,,,397.44,504.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,MedCost,Commercial,,378.81,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,inpatient,,,720.00000,432.00000,MedCost,Commercial,,583.20,,,,,,,460.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,MedCost,Commercial,,439.20,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,inpatient,,,720.00000,432.00000,MedCost,Commercial,,583.20,,,,,,,460.80,585.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,MedCost,Commercial,,439.20,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Commercial,,302.13,,,,,,,238.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Commercial,,227.53,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,inpatient,,,2240.00000,1344.00000,MedCost,Commercial,,1814.40,,,,,,,1433.60,1821.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,MedCost,Commercial,,1366.40,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Commercial,JW,106.92,,,,,,,84.48,107.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Commercial,JW,80.52,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,inpatient,,,586.00000,351.60000,MedCost,Commercial,,474.66,,,,,,,375.04,476.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,MedCost,Commercial,,357.46,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,inpatient,,,499.00000,299.40000,MedCost,Commercial,,404.19,,,,,,,319.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,MedCost,Commercial,,304.39,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,inpatient,,,604.00000,362.40000,MedCost,Commercial,,489.24,,,,,,,386.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,MedCost,Commercial,,368.44,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,inpatient,,,499.00000,299.40000,MedCost,Commercial,,404.19,,,,,,,319.36,405.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,MedCost,Commercial,,304.39,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,inpatient,,,586.00000,351.60000,MedCost,Commercial,,474.66,,,,,,,375.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,MedCost,Commercial,,357.46,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,inpatient,,,822.00000,493.20000,MedCost,Commercial,,665.82,,,,,,,526.08,668.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,MedCost,Commercial,,501.42,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,inpatient,,,1364.00000,818.40000,MedCost,Commercial,,1104.84,,,,,,,872.96,1108.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,MedCost,Commercial,,832.04,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,inpatient,,,352.00000,211.20000,MedCost,Commercial,,285.12,,,,,,,225.28,286.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,MedCost,Commercial,,214.72,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Commercial,,3192.21,,,,,,,2522.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Commercial,,2404.01,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Commercial,,3192.21,,,,,,,2522.24,3204.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Commercial,,2404.01,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Commercial,,3192.21,,,,,,,2522.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Commercial,,2404.01,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Commercial,,3192.21,,,,,,,2522.24,3204.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Commercial,,2404.01,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,inpatient,,,1950.00000,1170.00000,MedCost,Commercial,,1579.50,,,,,,,1248.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,MedCost,Commercial,,1189.50,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,inpatient,,,1950.00000,1170.00000,MedCost,Commercial,,1579.50,,,,,,,1248.00,1585.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,MedCost,Commercial,,1189.50,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,inpatient,,,3103.00000,1861.80000,MedCost,Commercial,,2513.43,,,,,,,1985.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,MedCost,Commercial,,1892.83,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,inpatient,,,3103.00000,1861.80000,MedCost,Commercial,,2513.43,,,,,,,1985.92,2522.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,MedCost,Commercial,,1892.83,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,inpatient,,,1723.00000,1033.80000,MedCost,Commercial,,1395.63,,,,,,,1102.72,1400.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,MedCost,Commercial,,1051.03,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,inpatient,,,2132.00000,1279.20000,MedCost,Commercial,,1726.92,,,,,,,1364.48,1733.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,MedCost,Commercial,,1300.52,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,inpatient,,,2800.00000,1680.00000,MedCost,Commercial,,2268.00,,,,,,,1792.00,2276.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,MedCost,Commercial,,1708.00,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,inpatient,,,543.00000,325.80000,MedCost,Commercial,,439.83,,,,,,,347.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,MedCost,Commercial,,331.23,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,inpatient,,,4385.00000,2631.00000,MedCost,Commercial,,3551.85,,,,,,,2806.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,MedCost,Commercial,,2674.85,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,inpatient,,,4850.00000,2910.00000,MedCost,Commercial,,3928.50,,,,,,,3104.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,MedCost,Commercial,,2958.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,inpatient,,,5734.00000,3440.40000,MedCost,Commercial,,4644.54,,,,,,,3669.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,MedCost,Commercial,,3497.74,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Commercial,,651.24,,,,,,,514.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Commercial,,490.44,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,inpatient,,,1565.00000,939.00000,MedCost,Commercial,,1267.65,,,,,,,1001.60,1272.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,MedCost,Commercial,,954.65,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,inpatient,,,1565.00000,939.00000,MedCost,Commercial,,1267.65,,,,,,,1001.60,1272.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,MedCost,Commercial,,954.65,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1921.00000,1152.60000,MedCost,Commercial,,1556.01,,,,,,,1229.44,1561.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,MedCost,Commercial,,1171.81,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,inpatient,,,1701.00000,1020.60000,MedCost,Commercial,,1377.81,,,,,,,1088.64,1382.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,MedCost,Commercial,,1037.61,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Commercial,,471.42,,,,,,,372.48,473.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Commercial,,355.02,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,inpatient,,,2268.00000,1360.80000,MedCost,Commercial,,1837.08,,,,,,,1451.52,1843.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,MedCost,Commercial,,1383.48,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,inpatient,,,1265.00000,759.00000,MedCost,Commercial,,1024.65,,,,,,,809.60,1028.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,MedCost,Commercial,,771.65,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,inpatient,,,2333.00000,1399.80000,MedCost,Commercial,,1889.73,,,,,,,1493.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,MedCost,Commercial,,1423.13,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,inpatient,,,2333.00000,1399.80000,MedCost,Commercial,,1889.73,,,,,,,1493.12,1896.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,MedCost,Commercial,,1423.13,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,inpatient,,,2047.00000,1228.20000,MedCost,Commercial,,1658.07,,,,,,,1310.08,1664.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,MedCost,Commercial,,1248.67,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,inpatient,,,1335.00000,801.00000,MedCost,Commercial,,1081.35,,,,,,,854.40,1085.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,MedCost,Commercial,,814.35,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,inpatient,,,847.00000,508.20000,MedCost,Commercial,,686.07,,,,,,,542.08,688.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,MedCost,Commercial,,516.67,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,inpatient,,,1781.00000,1068.60000,MedCost,Commercial,,1442.61,,,,,,,1139.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,MedCost,Commercial,,1086.41,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,inpatient,,,1781.00000,1068.60000,MedCost,Commercial,,1442.61,,,,,,,1139.84,1447.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,MedCost,Commercial,,1086.41,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,inpatient,,,1698.00000,1018.80000,MedCost,Commercial,,1375.38,,,,,,,1086.72,1380.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,MedCost,Commercial,,1035.78,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,inpatient,,,1381.00000,828.60000,MedCost,Commercial,,1118.61,,,,,,,883.84,1122.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,MedCost,Commercial,,842.41,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,inpatient,,,1381.00000,828.60000,MedCost,Commercial,,1118.61,,,,,,,883.84,1122.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,MedCost,Commercial,,842.41,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1453.14,,,,,,,1148.16,1458.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1094.34,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1453.14,,,,,,,1148.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1094.34,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,inpatient,,,4119.00000,2471.40000,MedCost,Commercial,,3336.39,,,,,,,2636.16,3348.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,MedCost,Commercial,,2512.59,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,inpatient,,,4119.00000,2471.40000,MedCost,Commercial,,3336.39,,,,,,,2636.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,MedCost,Commercial,,2512.59,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,inpatient,,,3475.00000,2085.00000,MedCost,Commercial,,2814.75,,,,,,,2224.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,MedCost,Commercial,,2119.75,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,inpatient,,,3475.00000,2085.00000,MedCost,Commercial,,2814.75,,,,,,,2224.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,MedCost,Commercial,,2119.75,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,inpatient,,,512.00000,307.20000,MedCost,Commercial,,414.72,,,,,,,327.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,MedCost,Commercial,,312.32,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,inpatient,,,594.00000,356.40000,MedCost,Commercial,,481.14,,,,,,,380.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,MedCost,Commercial,,362.34,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,inpatient,,,1100.00000,660.00000,MedCost,Commercial,52,891.00,,,,,,,704.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,MedCost,Commercial,52,671.00,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,MedCost,Commercial,,614.79,,,,,,,485.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,MedCost,Commercial,,462.99,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,inpatient,,,711.00000,426.60000,MedCost,Commercial,,575.91,,,,,,,455.04,575.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,MedCost,Commercial,,433.71,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,inpatient,,,1461.00000,876.60000,MedCost,Commercial,,1183.41,,,,,,,935.04,1183.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,MedCost,Commercial,,891.21,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Commercial,,102.87,,,,,,,81.28,102.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Commercial,,77.47,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,inpatient,,,919.00000,551.40000,MedCost,Commercial,,744.39,,,,,,,588.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,MedCost,Commercial,,560.59,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,inpatient,,,919.00000,551.40000,MedCost,Commercial,,744.39,,,,,,,588.16,747.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,MedCost,Commercial,,560.59,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Commercial,,302.13,,,,,,,238.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Commercial,,227.53,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Commercial,,256.77,,,,,,,202.88,256.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Commercial,,193.37,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,inpatient,,,697.00000,418.20000,MedCost,Commercial,,564.57,,,,,,,446.08,564.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,MedCost,Commercial,,425.17,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,inpatient,,,1393.00000,835.80000,MedCost,Commercial,,1128.33,,,,,,,891.52,1128.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,MedCost,Commercial,,849.73,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,inpatient,,,2375.00000,1425.00000,MedCost,Commercial,,1923.75,,,,,,,1520.00,1923.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,MedCost,Commercial,,1448.75,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,inpatient,,,3167.00000,1900.20000,MedCost,Commercial,,2565.27,,,,,,,2026.88,2565.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,MedCost,Commercial,,1931.87,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,inpatient,,,4011.00000,2406.60000,MedCost,Commercial,,3248.91,,,,,,,2567.04,3248.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,MedCost,Commercial,,2446.71,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,inpatient,,,1324.00000,794.40000,MedCost,Commercial,,1072.44,,,,,,,847.36,1072.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,MedCost,Commercial,,807.64,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,inpatient,,,1207.00000,724.20000,MedCost,Commercial,,977.67,,,,,,,772.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,MedCost,Commercial,,736.27,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,inpatient,,,361.00000,216.60000,MedCost,Commercial,,292.41,,,,,,,231.04,293.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,MedCost,Commercial,,220.21,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,inpatient,,,296.00000,177.60000,MedCost,Commercial,,239.76,,,,,,,189.44,240.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,MedCost,Commercial,,180.56,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Commercial,,153.09,,,,,,,120.96,153.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Commercial,,115.29,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Commercial,,126.36,,,,,,,99.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Commercial,,95.16,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Commercial,,126.36,,,,,,,99.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Commercial,,95.16,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,inpatient,,,2736.00000,1641.60000,MedCost,Commercial,,2216.16,,,,,,,1751.04,2216.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,MedCost,Commercial,,1668.96,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Commercial,,162.81,,,,,,,128.64,162.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Commercial,,122.61,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,inpatient,,,249.00000,149.40000,MedCost,Commercial,,201.69,,,,,,,159.36,201.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,MedCost,Commercial,,151.89,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,inpatient,,,240.00000,144.00000,MedCost,Commercial,,194.40,,,,,,,153.60,194.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,MedCost,Commercial,,146.40,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Commercial,,256.77,,,,,,,202.88,256.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Commercial,,193.37,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Commercial,,323.19,,,,,,,255.36,323.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Commercial,,243.39,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Commercial,,300.51,,,,,,,237.44,300.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Commercial,,226.31,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Commercial,,384.75,,,,,,,304.00,384.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Commercial,,289.75,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,inpatient,,,181.00000,108.60000,MedCost,Commercial,,146.61,,,,,,,115.84,146.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,MedCost,Commercial,,110.41,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,inpatient,,,227.00000,136.20000,MedCost,Commercial,,183.87,,,,,,,145.28,183.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,MedCost,Commercial,,138.47,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,inpatient,,,267.00000,160.20000,MedCost,Commercial,,216.27,,,,,,,170.88,216.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,MedCost,Commercial,,162.87,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,inpatient,,,250.00000,150.00000,MedCost,Commercial,,202.50,,,,,,,160.00,202.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,MedCost,Commercial,,152.50,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,inpatient,,,406.00000,243.60000,MedCost,Commercial,,328.86,,,,,,,259.84,328.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,MedCost,Commercial,,247.66,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,inpatient,,,435.00000,261.00000,MedCost,Commercial,,352.35,,,,,,,278.40,352.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,MedCost,Commercial,,265.35,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Commercial,,353.97,,,,,,,279.68,353.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Commercial,,266.57,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,inpatient,,,397.00000,238.20000,MedCost,Commercial,,321.57,,,,,,,254.08,321.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,MedCost,Commercial,,242.17,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,inpatient,,,181.00000,108.60000,MedCost,Commercial,,146.61,,,,,,,115.84,146.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,MedCost,Commercial,,110.41,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,inpatient,,,254.00000,152.40000,MedCost,Commercial,,205.74,,,,,,,162.56,205.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,MedCost,Commercial,,154.94,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,inpatient,,,388.00000,232.80000,MedCost,Commercial,,314.28,,,,,,,248.32,314.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,MedCost,Commercial,,236.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,inpatient,,,489.00000,293.40000,MedCost,Commercial,,396.09,,,,,,,312.96,396.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,MedCost,Commercial,,298.29,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Commercial,,53.46,,,,,,,42.24,53.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Commercial,,40.26,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Commercial,,85.86,,,,,,,67.84,85.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Commercial,,64.66,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,inpatient,,,176.00000,105.60000,MedCost,Commercial,,142.56,,,,,,,112.64,142.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,MedCost,Commercial,,107.36,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,inpatient,,,260.00000,156.00000,MedCost,Commercial,,210.60,,,,,,,166.40,210.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,MedCost,Commercial,,158.60,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Commercial,,277.83,,,,,,,219.52,277.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Commercial,,209.23,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,inpatient,,,231.00000,138.60000,MedCost,Commercial,,187.11,,,,,,,147.84,187.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,MedCost,Commercial,,140.91,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Commercial,,256.77,,,,,,,202.88,256.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Commercial,,193.37,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Commercial,,384.75,,,,,,,304.00,384.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Commercial,,289.75,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,inpatient,,,576.00000,345.60000,MedCost,Commercial,,466.56,,,,,,,368.64,466.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,MedCost,Commercial,,351.36,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,inpatient,,,137.00000,82.20000,MedCost,Commercial,,110.97,,,,,,,87.68,110.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,MedCost,Commercial,,83.57,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,inpatient,,,112.00000,67.20000,MedCost,Commercial,,90.72,,,,,,,71.68,90.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,MedCost,Commercial,,68.32,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Commercial,,38.88,,,,,,,30.72,38.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Commercial,,29.28,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Commercial,,105.30,,,,,,,39.13,105.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Commercial,,79.30,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,25.00000,15.00000,MedCost,Commercial,,20.25,,,,,,,7.53,20.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,MedCost,Commercial,,15.25,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,28.59,77.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,16.25,43.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Commercial,JW,99.63,,,,,,,78.72,100.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Commercial,JW,75.03,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Commercial,,99.63,,,,,,,37.02,100.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Commercial,,75.03,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,JW,76.95,,,,,,,60.80,77.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,JW,57.95,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,inpatient,,,142.00000,85.20000,MedCost,Commercial,,115.02,,,,,,,42.74,115.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,MedCost,Commercial,,86.62,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Commercial,,228.25,,,,,,,47.30,228.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Commercial,,167.75,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Commercial,,162.00,,,,,,,60.20,162.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Commercial,,122.00,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Commercial,JW,162.00,,,,,,,128.00,162.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Commercial,JW,122.00,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Commercial,,368.55,,,,,,,136.96,369.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Commercial,,277.55,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Commercial,,737.91,,,,,,,274.21,740.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Commercial,,555.71,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Commercial,JW,737.91,,,,,,,583.04,740.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Commercial,JW,555.71,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Commercial,JW,368.55,,,,,,,291.20,369.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Commercial,JW,277.55,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Commercial,,800.28,,,,,,,297.39,803.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Commercial,,602.68,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,188.43,508.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,82.17,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Commercial,JW,800.28,,,,,,,632.32,803.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Commercial,JW,602.68,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Commercial,JW,221.13,,,,,,,174.72,221.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Commercial,JW,166.53,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Commercial,,462.51,,,,,,,171.87,464.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Commercial,,348.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,MedCost,Commercial,,212.22,,,,,,,78.86,213.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,MedCost,Commercial,,159.82,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Commercial,,2230.74,,,,,,,828.95,2239.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Commercial,,1679.94,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Commercial,,984.96,,,,,,,366.02,988.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Commercial,,741.76,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,MedCost,Commercial,,498.96,,,,,,,185.42,500.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,MedCost,Commercial,,375.76,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Commercial,JW,2230.74,,,,,,,1762.56,2239.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Commercial,JW,1679.94,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Commercial,JW,984.96,,,,,,,778.24,988.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Commercial,JW,741.76,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,MedCost,Commercial,JW,498.96,,,,,,,394.24,500.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,MedCost,Commercial,JW,375.76,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,2813.00000,1687.80000,MedCost,Commercial,,2278.53,,,,,,,846.71,2286.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,MedCost,Commercial,,1715.93,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Commercial,,99.63,,,,,,,37.02,100.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Commercial,,75.03,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,MedCost,Commercial,,277.02,,,,,,,102.94,278.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,MedCost,Commercial,,208.62,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,MedCost,Commercial,JW,277.02,,,,,,,218.88,278.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,MedCost,Commercial,JW,208.62,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Commercial,,1252.26,,,,,,,465.35,1256.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Commercial,,943.06,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,3094.00000,1856.40000,MedCost,Commercial,,2506.14,,,,,,,931.29,2515.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,MedCost,Commercial,,1887.34,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Commercial,JW,1252.26,,,,,,,989.44,1256.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Commercial,JW,943.06,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,MedCost,Commercial,,346.68,,,,,,,128.83,347.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,MedCost,Commercial,,261.08,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,MedCost,Commercial,JW,346.68,,,,,,,273.92,347.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,MedCost,Commercial,JW,261.08,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,145.38,392.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,MedCost,Commercial,JW,391.23,,,,,,,309.12,392.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,MedCost,Commercial,JW,294.63,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,10.00000,6.00000,MedCost,Commercial,,8.10,,,,,,,3.01,8.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,MedCost,Commercial,,6.10,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Commercial,,2023.38,,,,,,,751.90,2030.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Commercial,,1523.78,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Commercial,JW,2023.38,,,,,,,1598.72,2030.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Commercial,JW,1523.78,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Commercial,,1640.25,,,,,,,609.52,1646.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Commercial,,1235.25,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Commercial,JW,1640.25,,,,,,,1296.00,1646.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Commercial,JW,1235.25,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Commercial,,1383.48,,,,,,,514.11,1388.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Commercial,,1041.88,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Commercial,JW,1383.48,,,,,,,1093.12,1388.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Commercial,JW,1041.88,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,19.57,52.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,JW,52.65,,,,,,,41.60,52.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,JW,39.65,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,2469.00000,1481.40000,MedCost,Commercial,,1999.89,,,,,,,743.17,2007.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,MedCost,Commercial,,1506.09,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,MedCost,Commercial,,565.38,,,,,,,210.10,567.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,MedCost,Commercial,,425.78,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,MedCost,Commercial,,565.38,,,,,,,446.72,567.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,MedCost,Commercial,,425.78,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,188.43,508.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,400.64,508.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Commercial,,498.15,,,,,,,185.12,500.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Commercial,,375.15,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Commercial,,498.15,,,,,,,393.60,500.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Commercial,,375.15,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,132.14,356.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,280.96,356.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Commercial,,323.19,,,,,,,120.10,324.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Commercial,,243.39,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Commercial,,323.19,,,,,,,255.36,324.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Commercial,,243.39,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,2363.00000,1417.80000,MedCost,Commercial,JW,1914.03,,,,,,,1512.32,1921.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,MedCost,Commercial,JW,1441.43,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Commercial,JW,462.51,,,,,,,365.44,464.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Commercial,JW,348.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,MedCost,Commercial,JW,212.22,,,,,,,167.68,213.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,MedCost,Commercial,JW,159.82,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,MedCost,Commercial,,253.53,,,,,,,94.21,254.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,MedCost,Commercial,,190.93,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,MedCost,Commercial,JW,253.53,,,,,,,200.32,254.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,MedCost,Commercial,JW,190.93,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Commercial,,1275.75,,,,,,,474.07,1280.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Commercial,,960.75,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Commercial,JW,1275.75,,,,,,,1008.00,1280.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Commercial,JW,960.75,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Commercial,,1014.12,,,,,,,376.85,1017.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Commercial,,763.72,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Commercial,JW,1014.12,,,,,,,801.28,1017.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Commercial,JW,763.72,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,MedCost,Commercial,,519.21,,,,,,,192.94,521.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,MedCost,Commercial,,391.01,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,MedCost,Commercial,JW,519.21,,,,,,,410.24,521.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,MedCost,Commercial,JW,391.01,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,MedCost,Commercial,,275.40,,,,,,,102.34,276.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,MedCost,Commercial,,207.40,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,MedCost,Commercial,JW,275.40,,,,,,,217.60,276.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,MedCost,Commercial,JW,207.40,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,MedCost,Commercial,,220.32,,,,,,,81.87,221.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,MedCost,Commercial,,165.92,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,MedCost,Commercial,JW,220.32,,,,,,,174.08,221.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,MedCost,Commercial,JW,165.92,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2562.00000,1537.20000,MedCost,Commercial,,2075.22,,,,,,,771.16,2082.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,MedCost,Commercial,,1562.82,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,inpatient,,,295.00000,177.00000,MedCost,Commercial,,238.95,,,,,,,188.80,238.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,MedCost,Commercial,,179.95,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Commercial,,515.97,,,,,,,407.68,515.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Commercial,,388.57,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Commercial,,515.97,,,,,,,407.68,515.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Commercial,,388.57,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Commercial,,515.97,,,,,,,407.68,515.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Commercial,,388.57,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Commercial,,515.97,,,,,,,407.68,515.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Commercial,,388.57,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,inpatient,,,270.00000,162.00000,MedCost,Commercial,,218.70,,,,,,,172.80,219.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,MedCost,Commercial,,164.70,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,inpatient,,,4243.00000,2545.80000,MedCost,Commercial,,3436.83,,,,,,,2715.52,3449.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,MedCost,Commercial,,2588.23,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,inpatient,,,181.00000,108.60000,MedCost,Commercial,,146.61,,,,,,,115.84,146.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,MedCost,Commercial,,110.41,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,inpatient,,,246.00000,147.60000,MedCost,Commercial,,199.26,,,,,,,157.44,200.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,MedCost,Commercial,,150.06,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,inpatient,,,2577.00000,1546.20000,MedCost,Commercial,,2087.37,,,,,,,1649.28,2095.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,MedCost,Commercial,,1571.97,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,inpatient,,,209.00000,125.40000,MedCost,Commercial,,169.29,,,,,,,62.91,169.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,MedCost,Commercial,,127.49,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,inpatient,,,303.00000,181.80000,MedCost,Commercial,,245.43,,,,,,,193.92,246.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,MedCost,Commercial,,184.83,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,inpatient,,,1976.00000,1185.60000,MedCost,Commercial,,1600.56,,,,,,,1264.64,1606.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,MedCost,Commercial,,1205.36,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,inpatient,,,1976.00000,1185.60000,MedCost,Commercial,,1600.56,,,,,,,1264.64,1606.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,MedCost,Commercial,,1205.36,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,inpatient,,,432.00000,259.20000,MedCost,Commercial,,349.92,,,,,,,276.48,351.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,MedCost,Commercial,,263.52,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,inpatient,,,432.00000,259.20000,MedCost,Commercial,,349.92,,,,,,,276.48,351.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,MedCost,Commercial,,263.52,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,inpatient,,,337.00000,202.20000,MedCost,Commercial,,272.97,,,,,,,215.68,273.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,MedCost,Commercial,,205.57,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,inpatient,,,280.00000,168.00000,MedCost,Commercial,,226.80,,,,,,,179.20,227.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,MedCost,Commercial,,170.80,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Commercial,,217.89,,,,,,,172.16,218.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Commercial,,164.09,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,inpatient,,,9379.00000,5627.40000,MedCost,Commercial,,7596.99,,,,,,,6002.56,7596.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,MedCost,Commercial,,5721.19,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,inpatient,,,1113.00000,667.80000,MedCost,Commercial,,901.53,,,,,,,712.32,901.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,MedCost,Commercial,,678.93,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Commercial,,839.97,,,,,,,663.68,843.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Commercial,,632.57,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,inpatient,,,1197.00000,718.20000,MedCost,Commercial,,969.57,,,,,,,766.08,973.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,MedCost,Commercial,,730.17,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,inpatient,,,806.00000,483.60000,MedCost,Commercial,,652.86,,,,,,,515.84,655.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,MedCost,Commercial,,491.66,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,inpatient,,,1985.00000,1191.00000,MedCost,Commercial,,1607.85,,,,,,,1270.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,MedCost,Commercial,,1210.85,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,inpatient,,,1985.00000,1191.00000,MedCost,Commercial,,1607.85,,,,,,,1270.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,MedCost,Commercial,,1210.85,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,inpatient,,,11676.00000,7005.60000,MedCost,Commercial,,9457.56,,,,,,,7039.00,9457.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,MedCost,Commercial,,7122.36,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,inpatient,,,11676.00000,7005.60000,MedCost,Commercial,,9457.56,,,,,,,7039.00,9457.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,MedCost,Commercial,,7122.36,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,inpatient,,,20316.00000,12189.60000,MedCost,Commercial,,16455.96,,,,,,,7039.00,16455.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,MedCost,Commercial,,12392.76,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,inpatient,,,20316.00000,12189.60000,MedCost,Commercial,,16455.96,,,,,,,7039.00,16455.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,MedCost,Commercial,,12392.76,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,inpatient,,,8640.00000,5184.00000,MedCost,Commercial,,6998.40,,,,,,,5529.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,MedCost,Commercial,,5270.40,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,inpatient,,,8640.00000,5184.00000,MedCost,Commercial,,6998.40,,,,,,,5529.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,MedCost,Commercial,,5270.40,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,inpatient,,,18331.00000,10998.60000,MedCost,Commercial,,14848.11,,,,,,,7039.00,14848.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,MedCost,Commercial,,11181.91,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,inpatient,,,18331.00000,10998.60000,MedCost,Commercial,,14848.11,,,,,,,7039.00,14848.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,MedCost,Commercial,,11181.91,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,inpatient,,,29657.00000,17794.20000,MedCost,Commercial,,24022.17,,,,,,,7039.00,24022.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,MedCost,Commercial,,18090.77,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,inpatient,,,29657.00000,17794.20000,MedCost,Commercial,,24022.17,,,,,,,7039.00,24022.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,MedCost,Commercial,,18090.77,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Commercial,,217.89,,,,,,,172.16,218.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Commercial,,164.09,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,inpatient,,,410.00000,246.00000,MedCost,Commercial,,332.10,,,,,,,262.40,333.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,MedCost,Commercial,,250.10,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,inpatient,,,594.00000,356.40000,MedCost,Commercial,,481.14,,,,,,,380.16,482.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,MedCost,Commercial,,362.34,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,inpatient,,,512.00000,307.20000,MedCost,Commercial,,414.72,,,,,,,327.68,416.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,MedCost,Commercial,,312.32,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,inpatient,,,771.00000,462.60000,MedCost,Commercial,,624.51,,,,,,,493.44,626.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,MedCost,Commercial,,470.31,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,inpatient,,,681.00000,408.60000,MedCost,Commercial,,551.61,,,,,,,435.84,553.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,MedCost,Commercial,,415.41,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,inpatient,,,3875.00000,2325.00000,MedCost,Commercial,,3138.75,,,,,,,2480.00,3150.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,MedCost,Commercial,,2363.75,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Commercial,,115.83,,,,,,,91.52,116.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Commercial,,87.23,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Commercial,,255.15,,,,,,,201.60,256.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Commercial,,192.15,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Commercial,,157.95,,,,,,,124.80,158.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Commercial,,118.95,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Commercial,,255.15,,,,,,,201.60,256.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Commercial,,192.15,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Commercial,,157.95,,,,,,,124.80,158.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Commercial,,118.95,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Commercial,,255.15,,,,,,,201.60,256.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Commercial,,192.15,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Commercial,,157.95,,,,,,,124.80,158.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Commercial,,118.95,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Commercial,,417.15,,,,,,,329.60,418.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Commercial,,314.15,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,,100.65,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,inpatient,,,949.00000,569.40000,MedCost,Commercial,,768.69,,,,,,,607.36,768.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,MedCost,Commercial,,578.89,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,inpatient,,,484.00000,290.40000,MedCost,Commercial,,392.04,,,,,,,309.76,392.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,MedCost,Commercial,,295.24,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Commercial,,103.68,,,,,,,81.92,103.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Commercial,,78.08,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,inpatient,,,141.00000,84.60000,MedCost,Commercial,,114.21,,,,,,,90.24,114.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,MedCost,Commercial,,86.01,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Commercial,,127.98,,,,,,,101.12,127.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Commercial,,96.38,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Commercial,,74.52,,,,,,,58.88,74.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Commercial,,56.12,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Commercial,,74.52,,,,,,,58.88,74.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Commercial,,56.12,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Commercial,,171.72,,,,,,,135.68,171.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Commercial,,129.32,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,inpatient,,,410.00000,246.00000,MedCost,Commercial,,332.10,,,,,,,262.40,333.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,MedCost,Commercial,,250.10,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Commercial,,417.15,,,,,,,329.60,418.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Commercial,,314.15,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,inpatient,,,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,40.96,51.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,inpatient,,,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,40.96,51.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Commercial,,121.50,,,,,,,96.00,121.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Commercial,,91.50,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Commercial,,68.85,,,,,,,54.40,68.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Commercial,,51.85,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Commercial,,107.73,,,,,,,85.12,107.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Commercial,,81.13,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Commercial,,417.15,,,,,,,329.60,418.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Commercial,,314.15,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,40000.00000,24000.00000,MedCost,Commercial,,33200.00,,,,,,,6880.00,33200.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,MedCost,Commercial,,24400.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,inpatient,,,777.00000,466.20000,MedCost,Commercial,,629.37,,,,,,,497.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,MedCost,Commercial,,473.97,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,inpatient,,,8778.00000,5266.80000,MedCost,Commercial,,7110.18,,,,,,,5617.92,7110.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,MedCost,Commercial,,5354.58,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,inpatient,,,8778.00000,5266.80000,MedCost,Commercial,,7110.18,,,,,,,5617.92,7110.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,MedCost,Commercial,,5354.58,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,inpatient,,,4941.00000,2964.60000,MedCost,Commercial,,4002.21,,,,,,,3162.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,MedCost,Commercial,,3014.01,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Commercial,,236.52,,,,,,,186.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Commercial,,178.12,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,inpatient,,,884.00000,530.40000,MedCost,Commercial,,716.04,,,,,,,565.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,MedCost,Commercial,,539.24,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,inpatient,,,205.00000,123.00000,MedCost,Commercial,,166.05,,,,,,,131.20,166.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,MedCost,Commercial,,125.05,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,inpatient,,,205.00000,123.00000,MedCost,Commercial,,166.05,,,,,,,131.20,166.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,MedCost,Commercial,,125.05,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,inpatient,,,970.00000,582.00000,MedCost,Commercial,,785.70,,,,,,,620.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,MedCost,Commercial,,591.70,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,inpatient,,,1230.00000,738.00000,MedCost,Commercial,,996.30,,,,,,,787.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,MedCost,Commercial,,750.30,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Commercial,,262.44,,,,,,,207.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Commercial,,197.64,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,inpatient,,,6259.00000,3755.40000,MedCost,Commercial,,5069.79,,,,,,,4005.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,MedCost,Commercial,,3817.99,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Commercial,,2529.63,,,,,,,1998.72,2539.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Commercial,,1905.03,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,inpatient,,,486.00000,291.60000,MedCost,Commercial,,393.66,,,,,,,311.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,MedCost,Commercial,,296.46,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,inpatient,,,20624.00000,12374.40000,MedCost,Commercial,,16705.44,,,,,,,7039.00,16705.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,MedCost,Commercial,,12580.64,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Commercial,,2529.63,,,,,,,1998.72,2539.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Commercial,,1905.03,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,inpatient,,,842.00000,505.20000,MedCost,Commercial,,682.02,,,,,,,538.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,MedCost,Commercial,,513.62,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,inpatient,,,2336.00000,1401.60000,MedCost,Commercial,,1892.16,,,,,,,1495.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,MedCost,Commercial,,1424.96,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,inpatient,,,2317.00000,1390.20000,MedCost,Commercial,,1876.77,,,,,,,1482.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,MedCost,Commercial,,1413.37,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,inpatient,,,2322.00000,1393.20000,MedCost,Commercial,,1880.82,,,,,,,1486.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,MedCost,Commercial,,1416.42,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,inpatient,,,11929.00000,7157.40000,MedCost,Commercial,,9662.49,,,,,,,7039.00,9662.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,MedCost,Commercial,,7276.69,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,inpatient,,,524.00000,314.40000,MedCost,Commercial,,424.44,,,,,,,335.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,MedCost,Commercial,,319.64,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,inpatient,,,573.00000,343.80000,MedCost,Commercial,,464.13,,,,,,,366.72,464.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,MedCost,Commercial,,349.53,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,inpatient,,,1331.00000,798.60000,MedCost,Commercial,,1078.11,,,,,,,851.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,MedCost,Commercial,,811.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Commercial,,2074.41,,,,,,,1639.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Commercial,,1562.21,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Commercial,,2074.41,,,,,,,1639.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Commercial,,1562.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,inpatient,,,1895.00000,1137.00000,MedCost,Commercial,,1534.95,,,,,,,1212.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,MedCost,Commercial,,1155.95,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,inpatient,,,1895.00000,1137.00000,MedCost,Commercial,,1534.95,,,,,,,1212.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,MedCost,Commercial,,1155.95,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,inpatient,,,3456.00000,2073.60000,MedCost,Commercial,,2799.36,,,,,,,2211.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,MedCost,Commercial,,2108.16,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,inpatient,,,3456.00000,2073.60000,MedCost,Commercial,,2799.36,,,,,,,2211.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,MedCost,Commercial,,2108.16,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Commercial,,2074.41,,,,,,,1639.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Commercial,,1562.21,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Commercial,,2074.41,,,,,,,1639.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Commercial,,1562.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,inpatient,,,5187.00000,3112.20000,MedCost,Commercial,,4201.47,,,,,,,1561.29,4217.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,MedCost,Commercial,,3164.07,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Commercial,,1000.35,,,,,,,371.74,1004.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Commercial,,753.35,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Commercial,,848.88,,,,,,,315.45,852.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Commercial,,639.28,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,MedCost,Commercial,,572.67,,,,,,,212.81,574.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,MedCost,Commercial,,431.27,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Commercial,,445.50,,,,,,,165.55,447.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Commercial,,335.50,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Commercial,,358.02,,,,,,,133.04,359.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Commercial,,269.62,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,MedCost,Commercial,,377.46,,,,,,,140.27,378.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,MedCost,Commercial,,284.26,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Commercial,JW,1000.35,,,,,,,790.40,1004.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Commercial,JW,753.35,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Commercial,JW,848.88,,,,,,,670.72,852.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Commercial,JW,639.28,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,MedCost,Commercial,JW,572.67,,,,,,,452.48,574.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,MedCost,Commercial,JW,431.27,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Commercial,JW,445.50,,,,,,,352.00,447.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Commercial,JW,335.50,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Commercial,JW,358.02,,,,,,,282.88,359.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Commercial,JW,269.62,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,MedCost,Commercial,JW,377.46,,,,,,,298.24,378.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,MedCost,Commercial,JW,284.26,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,2078.00000,1246.80000,MedCost,Commercial,,1683.18,,,,,,,625.48,1689.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,MedCost,Commercial,,1267.58,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,inpatient,,,179.00000,107.40000,MedCost,Commercial,,144.99,,,,,,,114.56,145.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,MedCost,Commercial,,109.19,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,inpatient,,,797.00000,478.20000,MedCost,Commercial,,645.57,,,,,,,510.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,MedCost,Commercial,,486.17,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Commercial,,800.28,,,,,,,632.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Commercial,,602.68,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,inpatient,,,1432.00000,859.20000,MedCost,Commercial,,1159.92,,,,,,,916.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,MedCost,Commercial,,873.52,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,inpatient,,,886.00000,531.60000,MedCost,Commercial,,717.66,,,,,,,567.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,MedCost,Commercial,,540.46,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,inpatient,,,179.00000,107.40000,MedCost,Commercial,,144.99,,,,,,,114.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,MedCost,Commercial,,109.19,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,inpatient,,,1828.00000,1096.80000,MedCost,Commercial,,1480.68,,,,,,,1169.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,MedCost,Commercial,,1115.08,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,inpatient,,,2594.00000,1556.40000,MedCost,Commercial,,2101.14,,,,,,,1660.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,MedCost,Commercial,,1582.34,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,inpatient,,,945.00000,567.00000,MedCost,Commercial,,765.45,,,,,,,604.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,MedCost,Commercial,,576.45,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,inpatient,,,2883.00000,1729.80000,MedCost,Commercial,,2335.23,,,,,,,1845.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,MedCost,Commercial,,1758.63,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,inpatient,,,956.00000,573.60000,MedCost,Commercial,,774.36,,,,,,,611.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,MedCost,Commercial,,583.16,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,inpatient,,,886.00000,531.60000,MedCost,Commercial,,717.66,,,,,,,567.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,MedCost,Commercial,,540.46,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,inpatient,,,1402.00000,841.20000,MedCost,Commercial,,1135.62,,,,,,,897.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,MedCost,Commercial,,855.22,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,inpatient,,,2174.00000,1304.40000,MedCost,Commercial,,1760.94,,,,,,,1391.36,1767.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,MedCost,Commercial,,1326.14,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,inpatient,,,4232.00000,2539.20000,MedCost,Commercial,,3427.92,,,,,,,2708.48,3440.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,MedCost,Commercial,,2581.52,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,inpatient,,,19132.00000,11479.20000,MedCost,Commercial,,15496.92,,,,,,,12244.48,15554.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,MedCost,Commercial,,11670.52,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,inpatient,,,429.00000,257.40000,MedCost,Commercial,,347.49,,,,,,,274.56,347.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,MedCost,Commercial,,261.69,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,inpatient,,,452.00000,271.20000,MedCost,Commercial,,366.12,,,,,,,289.28,366.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,MedCost,Commercial,,275.72,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,inpatient,,,401.00000,240.60000,MedCost,Commercial,,324.81,,,,,,,256.64,324.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,MedCost,Commercial,,244.61,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,inpatient,,,665.00000,399.00000,MedCost,Commercial,,538.65,,,,,,,425.60,538.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,MedCost,Commercial,,405.65,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Commercial,,257.58,,,,,,,203.52,257.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Commercial,,193.98,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Commercial,,247.05,,,,,,,91.81,247.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Commercial,,186.05,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Commercial,,262.44,,,,,,,207.36,262.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Commercial,,197.64,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,inpatient,,,545.00000,327.00000,MedCost,Commercial,,441.45,,,,,,,348.80,441.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,MedCost,Commercial,,332.45,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,inpatient,,,352.00000,211.20000,MedCost,Commercial,,285.12,,,,,,,225.28,285.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,MedCost,Commercial,,214.72,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Commercial,,389.61,,,,,,,307.84,389.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Commercial,,293.41,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,inpatient,,,601.00000,360.60000,MedCost,Commercial,,486.81,,,,,,,384.64,486.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,MedCost,Commercial,,366.61,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,inpatient,,,394.00000,236.40000,MedCost,Commercial,,319.14,,,,,,,252.16,319.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,MedCost,Commercial,,240.34,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Commercial,,358.02,,,,,,,282.88,358.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Commercial,,269.62,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,inpatient,,,500.00000,300.00000,MedCost,Commercial,,405.00,,,,,,,320.00,405.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,MedCost,Commercial,,305.00,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Commercial,,123.12,,,,,,,97.28,123.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Commercial,,92.72,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,inpatient,,,270.00000,162.00000,MedCost,Commercial,,218.70,,,,,,,172.80,218.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,MedCost,Commercial,,164.70,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Commercial,,97.20,,,,,,,76.80,97.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Commercial,,73.20,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,inpatient,,,501.00000,300.60000,MedCost,Commercial,,405.81,,,,,,,320.64,405.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,MedCost,Commercial,,305.61,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,inpatient,,,671.00000,402.60000,MedCost,Commercial,,543.51,,,,,,,429.44,543.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,MedCost,Commercial,,409.31,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,inpatient,,,179.00000,107.40000,MedCost,Commercial,,144.99,,,,,,,114.56,144.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,MedCost,Commercial,,109.19,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,inpatient,,,302.00000,181.20000,MedCost,Commercial,,244.62,,,,,,,193.28,244.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,MedCost,Commercial,,184.22,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,inpatient,,,362.00000,217.20000,MedCost,Commercial,,293.22,,,,,,,231.68,293.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,MedCost,Commercial,,220.82,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,inpatient,,,483.00000,289.80000,MedCost,Commercial,,391.23,,,,,,,309.12,391.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,MedCost,Commercial,,294.63,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,inpatient,,,584.00000,350.40000,MedCost,Commercial,,473.04,,,,,,,373.76,473.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,MedCost,Commercial,,356.24,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,inpatient,,,1079.00000,647.40000,MedCost,Commercial,,873.99,,,,,,,690.56,873.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,MedCost,Commercial,,658.19,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,inpatient,,,585.00000,351.00000,MedCost,Commercial,,473.85,,,,,,,374.40,473.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,MedCost,Commercial,,356.85,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,246.40,311.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Commercial,,247.05,,,,,,,195.20,247.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Commercial,,186.05,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Commercial,,358.02,,,,,,,282.88,358.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Commercial,,269.62,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Commercial,,401.76,,,,,,,317.44,401.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Commercial,,302.56,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Commercial,,534.60,,,,,,,422.40,534.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Commercial,,402.60,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,inpatient,,,929.00000,557.40000,MedCost,Commercial,,752.49,,,,,,,594.56,752.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,MedCost,Commercial,,566.69,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Commercial,,353.97,,,,,,,279.68,353.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Commercial,,266.57,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,inpatient,,,327.00000,196.20000,MedCost,Commercial,,264.87,,,,,,,209.28,264.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,MedCost,Commercial,,199.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,inpatient,,,564.00000,338.40000,MedCost,Commercial,,456.84,,,,,,,360.96,456.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,MedCost,Commercial,,344.04,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,inpatient,,,492.00000,295.20000,MedCost,Commercial,,398.52,,,,,,,314.88,398.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,MedCost,Commercial,,300.12,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,inpatient,,,710.00000,426.00000,MedCost,Commercial,,575.10,,,,,,,454.40,575.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,MedCost,Commercial,,433.10,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,inpatient,,,875.00000,525.00000,MedCost,Commercial,,708.75,,,,,,,560.00,708.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,MedCost,Commercial,,533.75,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Commercial,,471.42,,,,,,,372.48,471.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Commercial,,355.02,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,inpatient,,,341.00000,204.60000,MedCost,Commercial,,276.21,,,,,,,218.24,276.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,MedCost,Commercial,,208.01,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,inpatient,,,541.00000,324.60000,MedCost,Commercial,,438.21,,,,,,,346.24,438.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,MedCost,Commercial,,330.01,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,inpatient,,,369.00000,221.40000,MedCost,Commercial,,298.89,,,,,,,236.16,298.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,MedCost,Commercial,,225.09,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,inpatient,,,368.00000,220.80000,MedCost,Commercial,,298.08,,,,,,,235.52,298.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,MedCost,Commercial,,224.48,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,inpatient,,,1211.00000,726.60000,MedCost,Commercial,,980.91,,,,,,,775.04,980.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,MedCost,Commercial,,738.71,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,inpatient,,,752.00000,451.20000,MedCost,Commercial,,609.12,,,,,,,481.28,609.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,MedCost,Commercial,,458.72,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,inpatient,,,1336.00000,801.60000,MedCost,Commercial,,1082.16,,,,,,,855.04,1082.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,MedCost,Commercial,,814.96,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,inpatient,,,1892.00000,1135.20000,MedCost,Commercial,,1532.52,,,,,,,1210.88,1532.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,MedCost,Commercial,,1154.12,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,inpatient,,,2081.00000,1248.60000,MedCost,Commercial,,1685.61,,,,,,,1331.84,1685.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,MedCost,Commercial,,1269.41,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,inpatient,,,425.00000,255.00000,MedCost,Commercial,,344.25,,,,,,,272.00,344.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,MedCost,Commercial,,259.25,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,inpatient,,,382.00000,229.20000,MedCost,Commercial,,309.42,,,,,,,244.48,309.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,MedCost,Commercial,,233.02,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,inpatient,,,459.00000,275.40000,MedCost,Commercial,,371.79,,,,,,,293.76,371.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,MedCost,Commercial,,279.99,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,inpatient,,,462.00000,277.20000,MedCost,Commercial,,374.22,,,,,,,295.68,374.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,MedCost,Commercial,,281.82,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Commercial,,1029.51,,,,,,,813.44,1029.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Commercial,,775.31,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,inpatient,,,522.00000,313.20000,MedCost,Commercial,,422.82,,,,,,,334.08,422.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,MedCost,Commercial,,318.42,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,inpatient,,,440.00000,264.00000,MedCost,Commercial,,356.40,,,,,,,281.60,356.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,MedCost,Commercial,,268.40,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,inpatient,,,406.00000,243.60000,MedCost,Commercial,,328.86,,,,,,,259.84,328.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,MedCost,Commercial,,247.66,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Commercial,,358.02,,,,,,,282.88,358.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Commercial,,269.62,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,inpatient,,,487.00000,292.20000,MedCost,Commercial,,394.47,,,,,,,311.68,394.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,MedCost,Commercial,,297.07,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,inpatient,,,379.00000,227.40000,MedCost,Commercial,,306.99,,,,,,,242.56,306.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,MedCost,Commercial,,231.19,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,inpatient,,,298.00000,178.80000,MedCost,Commercial,,241.38,,,,,,,190.72,241.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,MedCost,Commercial,,181.78,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,inpatient,,,375.00000,225.00000,MedCost,Commercial,,303.75,,,,,,,240.00,303.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,MedCost,Commercial,,228.75,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,inpatient,,,347.00000,208.20000,MedCost,Commercial,,281.07,,,,,,,222.08,281.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,MedCost,Commercial,,211.67,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,inpatient,,,653.00000,391.80000,MedCost,Commercial,,528.93,,,,,,,417.92,528.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,MedCost,Commercial,,398.33,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,inpatient,,,431.00000,258.60000,MedCost,Commercial,,349.11,,,,,,,275.84,349.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,MedCost,Commercial,,262.91,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,inpatient,,,394.00000,236.40000,MedCost,Commercial,,319.14,,,,,,,252.16,319.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,MedCost,Commercial,,240.34,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,inpatient,,,276.00000,165.60000,MedCost,Commercial,,223.56,,,,,,,176.64,223.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,MedCost,Commercial,,168.36,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,inpatient,,,841.00000,504.60000,MedCost,Commercial,,681.21,,,,,,,538.24,681.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,MedCost,Commercial,,513.01,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,inpatient,,,427.00000,256.20000,MedCost,Commercial,,345.87,,,,,,,273.28,345.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,MedCost,Commercial,,260.47,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Commercial,,300.51,,,,,,,237.44,300.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Commercial,,226.31,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,inpatient,,,482.00000,289.20000,MedCost,Commercial,,390.42,,,,,,,308.48,390.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,MedCost,Commercial,,294.02,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Commercial,,255.96,,,,,,,202.24,255.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Commercial,,192.76,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,MedCost,Commercial,,231.80,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,inpatient,,,354.00000,212.40000,MedCost,Commercial,,286.74,,,,,,,226.56,286.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,MedCost,Commercial,,215.94,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Commercial,,176.58,,,,,,,139.52,176.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Commercial,,132.98,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,inpatient,,,445.00000,267.00000,MedCost,Commercial,,360.45,,,,,,,284.80,360.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,MedCost,Commercial,,271.45,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Commercial,,375.03,,,,,,,296.32,375.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Commercial,,282.43,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,inpatient,,,380.00000,228.00000,MedCost,Commercial,,307.80,,,,,,,243.20,307.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,MedCost,Commercial,,231.80,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,inpatient,,,530.00000,318.00000,MedCost,Commercial,,429.30,,,,,,,339.20,429.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,MedCost,Commercial,,323.30,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Commercial,,375.03,,,,,,,296.32,375.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Commercial,,282.43,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,inpatient,,,401.00000,240.60000,MedCost,Commercial,,324.81,,,,,,,256.64,324.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,MedCost,Commercial,,244.61,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Commercial,,262.44,,,,,,,207.36,262.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Commercial,,197.64,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,inpatient,,,426.00000,255.60000,MedCost,Commercial,,345.06,,,,,,,272.64,345.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,MedCost,Commercial,,259.86,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,,400.95,,,,,,,316.80,400.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,,301.95,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,,400.95,,,,,,,316.80,400.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,,301.95,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,,400.95,,,,,,,316.80,400.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,,301.95,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,inpatient,,,782.00000,469.20000,MedCost,Commercial,,633.42,,,,,,,500.48,633.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,MedCost,Commercial,,477.02,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,inpatient,,,322.00000,193.20000,MedCost,Commercial,,260.82,,,,,,,206.08,260.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,MedCost,Commercial,,196.42,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,inpatient,,,247.00000,148.20000,MedCost,Commercial,,200.07,,,,,,,158.08,200.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,MedCost,Commercial,,150.67,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,inpatient,,,1055.00000,633.00000,MedCost,Commercial,,854.55,,,,,,,675.20,854.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,MedCost,Commercial,,643.55,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,inpatient,,,728.00000,436.80000,MedCost,Commercial,,589.68,,,,,,,465.92,589.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,MedCost,Commercial,,444.08,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,inpatient,,,888.00000,532.80000,MedCost,Commercial,,719.28,,,,,,,568.32,719.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,MedCost,Commercial,,541.68,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,inpatient,,,498.00000,298.80000,MedCost,Commercial,,403.38,,,,,,,318.72,403.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,MedCost,Commercial,,303.78,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,inpatient,,,529.00000,317.40000,MedCost,Commercial,,428.49,,,,,,,338.56,428.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,MedCost,Commercial,,322.69,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Commercial,,800.28,,,,,,,632.32,800.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Commercial,,602.68,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Commercial,,843.21,,,,,,,666.24,843.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Commercial,,635.01,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,inpatient,,,1074.00000,644.40000,MedCost,Commercial,,869.94,,,,,,,687.36,869.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,MedCost,Commercial,,655.14,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,inpatient,,,537.00000,322.20000,MedCost,Commercial,,434.97,,,,,,,343.68,434.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,MedCost,Commercial,,327.57,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,inpatient,,,98.00000,58.80000,MedCost,Commercial,,79.38,,,,,,,62.72,79.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,MedCost,Commercial,,59.78,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,inpatient,,,580.00000,348.00000,MedCost,Commercial,,469.80,,,,,,,371.20,469.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,MedCost,Commercial,,353.80,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,inpatient,,,643.00000,385.80000,MedCost,Commercial,,520.83,,,,,,,411.52,520.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,MedCost,Commercial,,392.23,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,inpatient,,,818.00000,490.80000,MedCost,Commercial,,662.58,,,,,,,523.52,662.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,MedCost,Commercial,,498.98,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,inpatient,,,666.00000,399.60000,MedCost,Commercial,,539.46,,,,,,,426.24,539.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,MedCost,Commercial,,406.26,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,inpatient,,,810.00000,486.00000,MedCost,Commercial,,656.10,,,,,,,518.40,656.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,MedCost,Commercial,,494.10,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,inpatient,,,2088.00000,1252.80000,MedCost,Commercial,,1691.28,,,,,,,1336.32,1691.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,MedCost,Commercial,,1273.68,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,inpatient,,,4645.00000,2787.00000,MedCost,Commercial,,3762.45,,,,,,,2972.80,3762.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,MedCost,Commercial,,2833.45,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,inpatient,,,3577.00000,2146.20000,MedCost,Commercial,,2897.37,,,,,,,2289.28,2897.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,MedCost,Commercial,,2181.97,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,inpatient,,,185.00000,111.00000,MedCost,Commercial,,149.85,,,,,,,118.40,149.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,MedCost,Commercial,,112.85,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,inpatient,,,1368.00000,820.80000,MedCost,Commercial,,1108.08,,,,,,,875.52,1108.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,MedCost,Commercial,,834.48,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,inpatient,,,1395.00000,837.00000,MedCost,Commercial,,1129.95,,,,,,,892.80,1129.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,MedCost,Commercial,,850.95,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,inpatient,,,4047.00000,2428.20000,MedCost,Commercial,,3278.07,,,,,,,2590.08,3278.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,MedCost,Commercial,,2468.67,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,inpatient,,,5746.00000,3447.60000,MedCost,Commercial,,4654.26,,,,,,,3677.44,4654.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,MedCost,Commercial,,3505.06,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,inpatient,,,1326.00000,795.60000,MedCost,Commercial,,1074.06,,,,,,,848.64,1074.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,MedCost,Commercial,,808.86,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,inpatient,,,2572.00000,1543.20000,MedCost,Commercial,,2083.32,,,,,,,1646.08,2083.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,MedCost,Commercial,,1568.92,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,inpatient,,,1031.00000,618.60000,MedCost,Commercial,,835.11,,,,,,,659.84,835.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,MedCost,Commercial,,628.91,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,inpatient,,,1202.00000,721.20000,MedCost,Commercial,,973.62,,,,,,,769.28,973.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,MedCost,Commercial,,733.22,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,inpatient,,,1608.00000,964.80000,MedCost,Commercial,,1302.48,,,,,,,1029.12,1302.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,MedCost,Commercial,,980.88,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Commercial,,651.24,,,,,,,514.56,651.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Commercial,,490.44,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,inpatient,,,1616.00000,969.60000,MedCost,Commercial,,1308.96,,,,,,,1034.24,1308.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,MedCost,Commercial,,985.76,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,inpatient,,,967.00000,580.20000,MedCost,Commercial,,783.27,,,,,,,618.88,783.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,MedCost,Commercial,,589.87,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,inpatient,,,799.00000,479.40000,MedCost,Commercial,,647.19,,,,,,,511.36,647.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,MedCost,Commercial,,487.39,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,inpatient,,,1106.00000,663.60000,MedCost,Commercial,,895.86,,,,,,,707.84,895.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,MedCost,Commercial,,674.66,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,inpatient,,,2333.00000,1399.80000,MedCost,Commercial,,1889.73,,,,,,,1493.12,1889.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,MedCost,Commercial,,1423.13,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,inpatient,,,1376.00000,825.60000,MedCost,Commercial,,1114.56,,,,,,,880.64,1114.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,MedCost,Commercial,,839.36,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Commercial,,165.24,,,,,,,130.56,165.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Commercial,,124.44,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,inpatient,,,175.00000,105.00000,MedCost,Commercial,,141.75,,,,,,,112.00,141.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,MedCost,Commercial,,106.75,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,inpatient,,,1204.00000,722.40000,MedCost,Commercial,,975.24,,,,,,,770.56,975.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,MedCost,Commercial,,734.44,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,inpatient,,,771.00000,462.60000,MedCost,Commercial,,624.51,,,,,,,493.44,624.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,MedCost,Commercial,,470.31,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,inpatient,,,1057.00000,634.20000,MedCost,Commercial,,856.17,,,,,,,676.48,856.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,MedCost,Commercial,,644.77,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,inpatient,,,358.00000,214.80000,MedCost,Commercial,,289.98,,,,,,,229.12,289.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,MedCost,Commercial,,218.38,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,inpatient,,,953.00000,571.80000,MedCost,Commercial,,771.93,,,,,,,609.92,771.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,MedCost,Commercial,,581.33,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,inpatient,,,169.00000,101.40000,MedCost,Commercial,,136.89,,,,,,,108.16,136.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,MedCost,Commercial,,103.09,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,inpatient,,,936.00000,561.60000,MedCost,Commercial,,758.16,,,,,,,599.04,758.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,MedCost,Commercial,,570.96,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,inpatient,,,306.00000,183.60000,MedCost,Commercial,,247.86,,,,,,,195.84,247.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,MedCost,Commercial,,186.66,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,inpatient,,,341.00000,204.60000,MedCost,Commercial,,276.21,,,,,,,218.24,276.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,MedCost,Commercial,,208.01,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Commercial,,115.83,,,,,,,91.52,115.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Commercial,,87.23,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,inpatient,,,744.00000,446.40000,MedCost,Commercial,,602.64,,,,,,,476.16,602.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,MedCost,Commercial,,453.84,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,inpatient,,,662.00000,397.20000,MedCost,Commercial,,536.22,,,,,,,423.68,536.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,MedCost,Commercial,,403.82,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,inpatient,,,657.00000,394.20000,MedCost,Commercial,,532.17,,,,,,,420.48,532.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,MedCost,Commercial,,400.77,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Commercial,,261.63,,,,,,,206.72,261.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Commercial,,197.03,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,inpatient,,,646.00000,387.60000,MedCost,Commercial,,523.26,,,,,,,413.44,523.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,MedCost,Commercial,,394.06,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,inpatient,,,346.00000,207.60000,MedCost,Commercial,,280.26,,,,,,,221.44,280.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,MedCost,Commercial,,211.06,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,inpatient,,,243.00000,145.80000,MedCost,Commercial,,196.83,,,,,,,155.52,196.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,MedCost,Commercial,,148.23,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,inpatient,,,268.00000,160.80000,MedCost,Commercial,,217.08,,,,,,,171.52,217.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,MedCost,Commercial,,163.48,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,inpatient,,,927.00000,556.20000,MedCost,Commercial,,750.87,,,,,,,593.28,750.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,MedCost,Commercial,,565.47,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,inpatient,,,306.00000,183.60000,MedCost,Commercial,,247.86,,,,,,,195.84,247.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,MedCost,Commercial,,186.66,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Commercial,,737.91,,,,,,,583.04,737.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Commercial,,555.71,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,inpatient,,,291.00000,174.60000,MedCost,Commercial,,235.71,,,,,,,186.24,235.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,MedCost,Commercial,,177.51,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,inpatient,,,788.00000,472.80000,MedCost,Commercial,,638.28,,,,,,,504.32,638.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,MedCost,Commercial,,480.68,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,inpatient,,,2343.00000,1405.80000,MedCost,Commercial,,1897.83,,,,,,,1499.52,1897.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,MedCost,Commercial,,1429.23,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,inpatient,,,4039.00000,2423.40000,MedCost,Commercial,,3271.59,,,,,,,2584.96,3271.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,MedCost,Commercial,,2463.79,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,inpatient,,,3338.00000,2002.80000,MedCost,Commercial,,2703.78,,,,,,,2136.32,2703.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,MedCost,Commercial,,2036.18,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,inpatient,,,3598.00000,2158.80000,MedCost,Commercial,,2914.38,,,,,,,2302.72,2914.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,MedCost,Commercial,,2194.78,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,inpatient,,,2035.00000,1221.00000,MedCost,Commercial,,1648.35,,,,,,,1302.40,1648.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,MedCost,Commercial,,1241.35,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,inpatient,,,4514.00000,2708.40000,MedCost,Commercial,,3656.34,,,,,,,2888.96,3656.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,MedCost,Commercial,,2753.54,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,inpatient,,,4514.00000,2708.40000,MedCost,Commercial,,3656.34,,,,,,,2888.96,3656.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,MedCost,Commercial,,2753.54,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,inpatient,,,4514.00000,2708.40000,MedCost,Commercial,,3656.34,,,,,,,2888.96,3656.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,MedCost,Commercial,,2753.54,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,inpatient,,,3053.00000,1831.80000,MedCost,Commercial,,2472.93,,,,,,,1953.92,2472.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,MedCost,Commercial,,1862.33,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,inpatient,,,1786.00000,1071.60000,MedCost,Commercial,,1446.66,,,,,,,1143.04,1446.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,MedCost,Commercial,,1089.46,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,inpatient,,,1404.00000,842.40000,MedCost,Commercial,,1137.24,,,,,,,898.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,MedCost,Commercial,,856.44,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,inpatient,,,268.00000,160.80000,MedCost,Commercial,,217.08,,,,,,,171.52,217.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,MedCost,Commercial,,163.48,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,inpatient,,,374.00000,224.40000,MedCost,Commercial,,302.94,,,,,,,239.36,302.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,MedCost,Commercial,,228.14,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,inpatient,,,332.00000,199.20000,MedCost,Commercial,,268.92,,,,,,,212.48,268.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,MedCost,Commercial,,202.52,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,inpatient,,,831.00000,498.60000,MedCost,Commercial,,673.11,,,,,,,531.84,673.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,MedCost,Commercial,,506.91,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Commercial,,132.03,,,,,,,49.06,132.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Commercial,,99.43,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,inpatient,,,501.00000,300.60000,MedCost,Commercial,,405.81,,,,,,,320.64,405.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,MedCost,Commercial,,305.61,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,inpatient,,,2081.00000,1248.60000,MedCost,Commercial,,1685.61,,,,,,,1331.84,1685.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,MedCost,Commercial,,1269.41,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,inpatient,,,617.00000,370.20000,MedCost,Commercial,,499.77,,,,,,,394.88,499.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,MedCost,Commercial,,376.37,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,inpatient,,,812.00000,487.20000,MedCost,Commercial,,657.72,,,,,,,519.68,657.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,MedCost,Commercial,,495.32,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,inpatient,,,861.00000,516.60000,MedCost,Commercial,,697.41,,,,,,,551.04,697.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,MedCost,Commercial,,525.21,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,inpatient,,,467.00000,280.20000,MedCost,Commercial,,378.27,,,,,,,298.88,378.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,MedCost,Commercial,,284.87,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,inpatient,,,494.00000,296.40000,MedCost,Commercial,,400.14,,,,,,,316.16,400.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,MedCost,Commercial,,301.34,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,inpatient,,,523.00000,313.80000,MedCost,Commercial,,423.63,,,,,,,334.72,423.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,MedCost,Commercial,,319.03,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,inpatient,,,758.00000,454.80000,MedCost,Commercial,,613.98,,,,,,,485.12,613.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,MedCost,Commercial,,462.38,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,inpatient,,,736.00000,441.60000,MedCost,Commercial,,596.16,,,,,,,471.04,596.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,MedCost,Commercial,,448.96,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,inpatient,,,1079.00000,647.40000,MedCost,Commercial,,873.99,,,,,,,690.56,873.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,MedCost,Commercial,,658.19,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,inpatient,,,229.00000,137.40000,MedCost,Commercial,,185.49,,,,,,,146.56,185.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,MedCost,Commercial,,139.69,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,inpatient,,,432.00000,259.20000,MedCost,Commercial,,349.92,,,,,,,276.48,349.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,MedCost,Commercial,,263.52,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,inpatient,,,1063.00000,637.80000,MedCost,Commercial,,861.03,,,,,,,680.32,861.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,MedCost,Commercial,,648.43,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Commercial,,498.15,,,,,,,393.60,498.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Commercial,,375.15,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,inpatient,,,785.00000,471.00000,MedCost,Commercial,,635.85,,,,,,,502.40,635.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,MedCost,Commercial,,478.85,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,37500.00000,22500.00000,MedCost,Commercial,,31125.00,,,,,,,6450.00,31125.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,MedCost,Commercial,,22875.00,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,inpatient,,,217.00000,130.20000,MedCost,Commercial,,175.77,,,,,,,138.88,175.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,MedCost,Commercial,,132.37,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,inpatient,,,1853.00000,1111.80000,MedCost,Commercial,,1500.93,,,,,,,1185.92,1500.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,MedCost,Commercial,,1130.33,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,inpatient,,,2253.00000,1351.80000,MedCost,Commercial,,1824.93,,,,,,,1441.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,MedCost,Commercial,,1374.33,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,inpatient,,,420.00000,252.00000,MedCost,Commercial,,340.20,,,,,,,268.80,340.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,MedCost,Commercial,,256.20,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Commercial,,445.50,,,,,,,352.00,445.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Commercial,,335.50,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,inpatient,,,540.00000,324.00000,MedCost,Commercial,,437.40,,,,,,,345.60,437.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,MedCost,Commercial,,329.40,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,inpatient,,,401.00000,240.60000,MedCost,Commercial,,324.81,,,,,,,256.64,324.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,MedCost,Commercial,,244.61,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,inpatient,,,596.00000,357.60000,MedCost,Commercial,,482.76,,,,,,,381.44,482.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,MedCost,Commercial,,363.56,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,inpatient,,,497.00000,298.20000,MedCost,Commercial,,402.57,,,,,,,318.08,402.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,MedCost,Commercial,,303.17,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,inpatient,,,752.00000,451.20000,MedCost,Commercial,,609.12,,,,,,,481.28,609.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,MedCost,Commercial,,458.72,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,inpatient,,,581.00000,348.60000,MedCost,Commercial,,470.61,,,,,,,371.84,470.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,MedCost,Commercial,,354.41,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,inpatient,,,928.00000,556.80000,MedCost,Commercial,,751.68,,,,,,,593.92,751.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,MedCost,Commercial,,566.08,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,inpatient,,,1382.00000,829.20000,MedCost,Commercial,,1119.42,,,,,,,884.48,1119.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,MedCost,Commercial,,843.02,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,inpatient,,,270.00000,162.00000,MedCost,Commercial,,218.70,,,,,,,172.80,218.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,MedCost,Commercial,,164.70,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,inpatient,,,829.00000,497.40000,MedCost,Commercial,,671.49,,,,,,,530.56,671.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,MedCost,Commercial,,505.69,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Commercial,,277.83,,,,,,,219.52,277.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Commercial,,209.23,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Commercial,,334.53,,,,,,,264.32,334.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Commercial,,251.93,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,inpatient,,,1357.00000,814.20000,MedCost,Commercial,,1099.17,,,,,,,868.48,1099.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,MedCost,Commercial,,827.77,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Commercial,,548.37,,,,,,,433.28,548.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Commercial,,412.97,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,inpatient,,,685.00000,411.00000,MedCost,Commercial,,554.85,,,,,,,438.40,554.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,MedCost,Commercial,,417.85,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,inpatient,,,1104.00000,662.40000,MedCost,Commercial,,894.24,,,,,,,706.56,894.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,MedCost,Commercial,,673.44,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,inpatient,,,583.00000,349.80000,MedCost,Commercial,,472.23,,,,,,,373.12,472.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,MedCost,Commercial,,355.63,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,inpatient,,,2917.00000,1750.20000,MedCost,Commercial,,2362.77,,,,,,,1866.88,2362.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,MedCost,Commercial,,1779.37,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,inpatient,,,1494.00000,896.40000,MedCost,Commercial,,1210.14,,,,,,,956.16,1210.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,MedCost,Commercial,,911.34,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,inpatient,,,1093.00000,655.80000,MedCost,Commercial,,885.33,,,,,,,699.52,885.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,MedCost,Commercial,,666.73,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,inpatient,,,976.00000,585.60000,MedCost,Commercial,,790.56,,,,,,,624.64,790.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,MedCost,Commercial,,595.36,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,inpatient,,,717.00000,430.20000,MedCost,Commercial,,580.77,,,,,,,458.88,580.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,MedCost,Commercial,,437.37,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,inpatient,,,1866.00000,1119.60000,MedCost,Commercial,,1511.46,,,,,,,1194.24,1511.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,MedCost,Commercial,,1138.26,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,inpatient,,,1014.00000,608.40000,MedCost,Commercial,,821.34,,,,,,,648.96,821.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,MedCost,Commercial,,618.54,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,inpatient,,,2079.00000,1247.40000,MedCost,Commercial,,1683.99,,,,,,,1330.56,1683.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,MedCost,Commercial,,1268.19,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,inpatient,,,1602.00000,961.20000,MedCost,Commercial,,1297.62,,,,,,,1025.28,1297.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,MedCost,Commercial,,977.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,inpatient,,,2290.00000,1374.00000,MedCost,Commercial,,1854.90,,,,,,,1465.60,1854.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,MedCost,Commercial,,1396.90,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,inpatient,,,1602.00000,961.20000,MedCost,Commercial,,1297.62,,,,,,,1025.28,1297.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,MedCost,Commercial,,977.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,inpatient,,,2378.00000,1426.80000,MedCost,Commercial,,1926.18,,,,,,,1521.92,1926.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,MedCost,Commercial,,1450.58,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,inpatient,,,2733.00000,1639.80000,MedCost,Commercial,,2213.73,,,,,,,1749.12,2213.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,MedCost,Commercial,,1667.13,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,inpatient,,,856.00000,513.60000,MedCost,Commercial,,693.36,,,,,,,547.84,693.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,MedCost,Commercial,,522.16,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,inpatient,,,1567.00000,940.20000,MedCost,Commercial,,1269.27,,,,,,,1002.88,1269.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,MedCost,Commercial,,955.87,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,inpatient,,,1230.00000,738.00000,MedCost,Commercial,,996.30,,,,,,,787.20,996.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,MedCost,Commercial,,750.30,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,inpatient,,,2245.00000,1347.00000,MedCost,Commercial,,1818.45,,,,,,,1436.80,1818.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,MedCost,Commercial,,1369.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,inpatient,,,1042.00000,625.20000,MedCost,Commercial,,844.02,,,,,,,666.88,844.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,MedCost,Commercial,,635.62,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,inpatient,,,1148.00000,688.80000,MedCost,Commercial,,929.88,,,,,,,734.72,929.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,MedCost,Commercial,,700.28,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,inpatient,,,1255.00000,753.00000,MedCost,Commercial,,1016.55,,,,,,,803.20,1016.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,MedCost,Commercial,,765.55,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,inpatient,,,1784.00000,1070.40000,MedCost,Commercial,,1445.04,,,,,,,1141.76,1445.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,MedCost,Commercial,,1088.24,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,inpatient,,,2636.00000,1581.60000,MedCost,Commercial,,2135.16,,,,,,,1687.04,2135.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,MedCost,Commercial,,1607.96,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,inpatient,,,2636.00000,1581.60000,MedCost,Commercial,,2135.16,,,,,,,1687.04,2135.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,MedCost,Commercial,,1607.96,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,inpatient,,,2497.00000,1498.20000,MedCost,Commercial,,2022.57,,,,,,,1598.08,2022.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,MedCost,Commercial,,1523.17,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,inpatient,,,3876.00000,2325.60000,MedCost,Commercial,,3139.56,,,,,,,2480.64,3139.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,MedCost,Commercial,,2364.36,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,inpatient,,,4844.00000,2906.40000,MedCost,Commercial,,3923.64,,,,,,,3100.16,3923.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,MedCost,Commercial,,2954.84,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,inpatient,,,831.00000,498.60000,MedCost,Commercial,,673.11,,,,,,,531.84,673.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,MedCost,Commercial,,506.91,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,inpatient,,,1439.00000,863.40000,MedCost,Commercial,,1165.59,,,,,,,920.96,1165.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,MedCost,Commercial,,877.79,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,inpatient,,,1294.00000,776.40000,MedCost,Commercial,,1048.14,,,,,,,828.16,1048.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,MedCost,Commercial,,789.34,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,inpatient,,,1592.00000,955.20000,MedCost,Commercial,,1289.52,,,,,,,1018.88,1289.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,MedCost,Commercial,,971.12,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,inpatient,,,2486.00000,1491.60000,MedCost,Commercial,,2013.66,,,,,,,1591.04,2013.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,MedCost,Commercial,,1516.46,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,inpatient,,,778.00000,466.80000,MedCost,Commercial,,630.18,,,,,,,497.92,630.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,MedCost,Commercial,,474.58,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,inpatient,,,1464.00000,878.40000,MedCost,Commercial,,1185.84,,,,,,,936.96,1185.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,MedCost,Commercial,,893.04,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,inpatient,,,864.00000,518.40000,MedCost,Commercial,,699.84,,,,,,,552.96,699.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,MedCost,Commercial,,527.04,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,inpatient,,,1090.00000,654.00000,MedCost,Commercial,,882.90,,,,,,,697.60,882.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,MedCost,Commercial,,664.90,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,inpatient,,,799.00000,479.40000,MedCost,Commercial,,647.19,,,,,,,511.36,647.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,MedCost,Commercial,,487.39,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Commercial,,939.60,,,,,,,742.40,939.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Commercial,,707.60,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,inpatient,,,1321.00000,792.60000,MedCost,Commercial,,1070.01,,,,,,,845.44,1070.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,MedCost,Commercial,,805.81,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Commercial,,939.60,,,,,,,742.40,939.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Commercial,,707.60,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,inpatient,,,1611.00000,966.60000,MedCost,Commercial,,1304.91,,,,,,,1031.04,1304.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,MedCost,Commercial,,982.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Commercial,,1029.51,,,,,,,813.44,1029.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Commercial,,775.31,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,inpatient,,,923.00000,553.80000,MedCost,Commercial,,747.63,,,,,,,590.72,747.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,MedCost,Commercial,,563.03,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,inpatient,,,2341.00000,1404.60000,MedCost,Commercial,,1896.21,,,,,,,1498.24,1896.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,MedCost,Commercial,,1428.01,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,inpatient,,,2943.00000,1765.80000,MedCost,Commercial,,2383.83,,,,,,,1883.52,2383.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,MedCost,Commercial,,1795.23,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,inpatient,,,277.00000,166.20000,MedCost,Commercial,,224.37,,,,,,,83.38,225.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,MedCost,Commercial,,168.97,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,15.35,41.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Commercial,,80.19,,,,,,,29.80,80.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Commercial,,60.39,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,inpatient,,,2030.00000,1218.00000,MedCost,Commercial,,1644.30,,,,,,,611.03,1650.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,MedCost,Commercial,,1238.30,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Commercial,,800.28,,,,,,,297.39,803.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Commercial,,602.68,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,32.21,86.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,inpatient,,,208.00000,124.80000,MedCost,Commercial,,168.48,,,,,,,62.61,169.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,MedCost,Commercial,,126.88,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,56.59,152.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,inpatient,,,2794.00000,1676.40000,MedCost,Commercial,,2263.14,,,,,,,840.99,2271.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,MedCost,Commercial,,1704.34,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,inpatient,,,12493.00000,7495.80000,MedCost,Commercial,,10119.33,,,,,,,3760.39,10156.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,MedCost,Commercial,,7620.73,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,inpatient,,,1643.00000,985.80000,MedCost,Commercial,,1330.83,,,,,,,1051.52,1330.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,MedCost,Commercial,,1002.23,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Commercial,,420.39,,,,,,,332.16,420.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Commercial,,316.59,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,inpatient,,,2033.00000,1219.80000,MedCost,Commercial,,1646.73,,,,,,,1301.12,1646.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,MedCost,Commercial,,1240.13,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,inpatient,,,470.00000,282.00000,MedCost,Commercial,,380.70,,,,,,,300.80,380.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,MedCost,Commercial,,286.70,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,inpatient,,,12371.00000,7422.60000,MedCost,Commercial,,10020.51,,,,,,,3723.67,10057.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,MedCost,Commercial,,7546.31,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Commercial,,548.37,,,,,,,433.28,548.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Commercial,,412.97,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Commercial,,0.81810,,,,,,,0.64640,0.81810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Commercial,,0.61610,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,inpatient,,,87.00000,52.20000,MedCost,Commercial,,70.47,,,,,,,26.19,70.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,MedCost,Commercial,,53.07,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,inpatient,,,878.00000,526.80000,MedCost,Commercial,,711.18,,,,,,,264.28,713.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,MedCost,Commercial,,535.58,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,inpatient,,,119.00000,71.40000,MedCost,Commercial,,96.39,,,,,,,35.82,96.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,MedCost,Commercial,,72.59,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,inpatient,,,584.00000,350.40000,MedCost,Commercial,,473.04,,,,,,,175.78,474.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,MedCost,Commercial,,356.24,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Commercial,,261.63,,,,,,,97.22,262.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Commercial,,197.03,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,inpatient,,,44.00000,26.40000,MedCost,Commercial,,35.64,,,,,,,13.24,35.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,MedCost,Commercial,,26.84,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,inpatient,,,5280.00000,3168.00000,MedCost,Commercial,,4276.80,,,,,,,1589.28,4292.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,MedCost,Commercial,,3220.80,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,inpatient,,,6.00000,3.60000,MedCost,Commercial,,4.86,,,,,,,1.81,4.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,MedCost,Commercial,,3.66,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,inpatient,,,649.00000,389.40000,MedCost,Commercial,,525.69,,,,,,,195.35,527.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,MedCost,Commercial,,395.89,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Commercial,,98.82,,,,,,,36.72,99.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Commercial,,74.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Commercial,,34.02,,,,,,,12.64,34.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Commercial,,25.62,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,inpatient,,,82.00000,49.20000,MedCost,Commercial,,66.42,,,,,,,24.68,66.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,MedCost,Commercial,,50.02,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,inpatient,,,254.00000,152.40000,MedCost,Commercial,,205.74,,,,,,,76.45,206.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,MedCost,Commercial,,154.94,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,23.18,62.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,inpatient,,,6058.00000,3634.80000,MedCost,Commercial,,4906.98,,,,,,,1823.46,4925.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,MedCost,Commercial,,3695.38,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,inpatient,,,183.00000,109.80000,MedCost,Commercial,,148.23,,,,,,,55.08,148.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,MedCost,Commercial,,111.63,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,inpatient,,,1075.00000,645.00000,MedCost,Commercial,,870.75,,,,,,,688.00,870.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,MedCost,Commercial,,655.75,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Commercial,,247.05,,,,,,,91.81,247.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Commercial,,186.05,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,inpatient,,,1428.00000,856.80000,MedCost,Commercial,,1156.68,,,,,,,913.92,1156.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,MedCost,Commercial,,871.08,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Commercial,,247.05,,,,,,,91.81,247.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Commercial,,186.05,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,inpatient,,,2016.00000,1209.60000,MedCost,Commercial,,1632.96,,,,,,,1290.24,1632.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,MedCost,Commercial,,1229.76,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,inpatient,,,2016.00000,1209.60000,MedCost,Commercial,,1632.96,,,,,,,1290.24,1632.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,MedCost,Commercial,,1229.76,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,inpatient,,,1343.00000,805.80000,MedCost,Commercial,,1087.83,,,,,,,404.24,1091.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,MedCost,Commercial,,819.23,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,inpatient,,,487.00000,292.20000,MedCost,Commercial,,394.47,,,,,,,146.59,395.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,MedCost,Commercial,,297.07,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,inpatient,,,435.00000,261.00000,MedCost,Commercial,,352.35,,,,,,,278.40,352.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,MedCost,Commercial,,265.35,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,inpatient,,,2240.00000,1344.00000,MedCost,Commercial,,1814.40,,,,,,,1433.60,1814.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,MedCost,Commercial,,1366.40,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,inpatient,,,1605.00000,963.00000,MedCost,Commercial,,1300.05,,,,,,,1027.20,1300.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,MedCost,Commercial,,979.05,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,inpatient,,,3344.00000,2006.40000,MedCost,Commercial,,2708.64,,,,,,,2140.16,2708.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,MedCost,Commercial,,2039.84,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,inpatient,,,3344.00000,2006.40000,MedCost,Commercial,,2708.64,,,,,,,2140.16,2708.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,MedCost,Commercial,,2039.84,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,inpatient,,,3344.00000,2006.40000,MedCost,Commercial,,2708.64,,,,,,,2140.16,2708.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,MedCost,Commercial,,2039.84,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,inpatient,,,1309.00000,785.40000,MedCost,Commercial,,1060.29,,,,,,,394.01,1064.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,MedCost,Commercial,,798.49,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,inpatient,,,1929.00000,1157.40000,MedCost,Commercial,,1562.49,,,,,,,580.63,1568.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,MedCost,Commercial,,1176.69,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,inpatient,,,1069.00000,641.40000,MedCost,Commercial,,865.89,,,,,,,321.77,869.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,MedCost,Commercial,,652.09,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,inpatient,,,1908.00000,1144.80000,MedCost,Commercial,,1545.48,,,,,,,574.31,1551.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,MedCost,Commercial,,1163.88,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,inpatient,,,1230.00000,738.00000,MedCost,Commercial,,996.30,,,,,,,370.23,999.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,MedCost,Commercial,,750.30,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,inpatient,,,4018.00000,2410.80000,MedCost,Commercial,,3254.58,,,,,,,2571.52,3254.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,MedCost,Commercial,,2450.98,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,inpatient,,,3310.00000,1986.00000,MedCost,Commercial,,2681.10,,,,,,,2118.40,2681.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,MedCost,Commercial,,2019.10,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,inpatient,,,4142.00000,2485.20000,MedCost,Commercial,,3355.02,,,,,,,2650.88,3355.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,MedCost,Commercial,,2526.62,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,inpatient,,,4142.00000,2485.20000,MedCost,Commercial,,3355.02,,,,,,,2650.88,3355.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,MedCost,Commercial,,2526.62,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,inpatient,,,4062.00000,2437.20000,MedCost,Commercial,,3290.22,,,,,,,2599.68,3290.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,MedCost,Commercial,,2477.82,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,inpatient,,,1033.00000,619.80000,MedCost,Commercial,,836.73,,,,,,,661.12,836.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,MedCost,Commercial,,630.13,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,inpatient,,,1126.00000,675.60000,MedCost,Commercial,,912.06,,,,,,,720.64,912.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,MedCost,Commercial,,686.86,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Commercial,,262.44,,,,,,,207.36,262.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Commercial,,197.64,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,inpatient,,,2537.00000,1522.20000,MedCost,Commercial,,2054.97,,,,,,,1623.68,2054.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,MedCost,Commercial,,1547.57,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,inpatient,,,1289.00000,773.40000,MedCost,Commercial,,1044.09,,,,,,,824.96,1044.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,MedCost,Commercial,,786.29,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,inpatient,,,1138.00000,682.80000,MedCost,Commercial,,921.78,,,,,,,728.32,921.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,MedCost,Commercial,,694.18,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,inpatient,,,1269.00000,761.40000,MedCost,Commercial,,1027.89,,,,,,,812.16,1027.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,MedCost,Commercial,,774.09,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,inpatient,,,2261.00000,1356.60000,MedCost,Commercial,,1831.41,,,,,,,1447.04,1831.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,MedCost,Commercial,,1379.21,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,inpatient,,,2668.00000,1600.80000,MedCost,Commercial,,2161.08,,,,,,,1707.52,2161.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,MedCost,Commercial,,1627.48,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,inpatient,,,3264.00000,1958.40000,MedCost,Commercial,,2643.84,,,,,,,2088.96,2643.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,MedCost,Commercial,,1991.04,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,inpatient,,,2450.00000,1470.00000,MedCost,Commercial,,1984.50,,,,,,,1568.00,1984.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,MedCost,Commercial,,1494.50,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,inpatient,,,2942.00000,1765.20000,MedCost,Commercial,,2383.02,,,,,,,1882.88,2383.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,MedCost,Commercial,,1794.62,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,inpatient,,,3282.00000,1969.20000,MedCost,Commercial,,2658.42,,,,,,,2100.48,2658.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,MedCost,Commercial,,2002.02,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,inpatient,,,2536.00000,1521.60000,MedCost,Commercial,,2054.16,,,,,,,1623.04,2054.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,MedCost,Commercial,,1546.96,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,inpatient,,,3096.00000,1857.60000,MedCost,Commercial,,2507.76,,,,,,,1981.44,2507.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,MedCost,Commercial,,1888.56,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,inpatient,,,3502.00000,2101.20000,MedCost,Commercial,,2836.62,,,,,,,2241.28,2836.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,MedCost,Commercial,,2136.22,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,inpatient,,,2584.00000,1550.40000,MedCost,Commercial,,2093.04,,,,,,,1653.76,2093.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,MedCost,Commercial,,1576.24,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,inpatient,,,3082.00000,1849.20000,MedCost,Commercial,,2496.42,,,,,,,1972.48,2496.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,MedCost,Commercial,,1880.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,inpatient,,,3512.00000,2107.20000,MedCost,Commercial,,2844.72,,,,,,,2247.68,2844.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,MedCost,Commercial,,2142.32,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,inpatient,,,4188.00000,2512.80000,MedCost,Commercial,,3392.28,,,,,,,2680.32,3392.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,MedCost,Commercial,,2554.68,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,inpatient,,,3971.00000,2382.60000,MedCost,Commercial,,3216.51,,,,,,,2541.44,3216.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,MedCost,Commercial,,2422.31,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,inpatient,,,2331.00000,1398.60000,MedCost,Commercial,,1888.11,,,,,,,1491.84,1888.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,MedCost,Commercial,,1421.91,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,inpatient,,,2925.00000,1755.00000,MedCost,Commercial,,2369.25,,,,,,,1872.00,2369.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,MedCost,Commercial,,1784.25,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,inpatient,,,3440.00000,2064.00000,MedCost,Commercial,,2786.40,,,,,,,2201.60,2786.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,MedCost,Commercial,,2098.40,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,inpatient,,,3874.00000,2324.40000,MedCost,Commercial,,3137.94,,,,,,,2479.36,3137.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,MedCost,Commercial,,2363.14,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,inpatient,,,2872.00000,1723.20000,MedCost,Commercial,,2326.32,,,,,,,1838.08,2326.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,MedCost,Commercial,,1751.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,inpatient,,,3618.00000,2170.80000,MedCost,Commercial,,2930.58,,,,,,,2315.52,2930.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,MedCost,Commercial,,2206.98,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,inpatient,,,3704.00000,2222.40000,MedCost,Commercial,,3000.24,,,,,,,2370.56,3000.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,MedCost,Commercial,,2259.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,inpatient,,,2242.00000,1345.20000,MedCost,Commercial,,1816.02,,,,,,,1434.88,1816.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,MedCost,Commercial,,1367.62,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,inpatient,,,2729.00000,1637.40000,MedCost,Commercial,,2210.49,,,,,,,1746.56,2210.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,MedCost,Commercial,,1664.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,inpatient,,,3184.00000,1910.40000,MedCost,Commercial,,2579.04,,,,,,,2037.76,2579.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,MedCost,Commercial,,1942.24,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,inpatient,,,2622.00000,1573.20000,MedCost,Commercial,,2123.82,,,,,,,1678.08,2123.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,MedCost,Commercial,,1599.42,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,inpatient,,,3189.00000,1913.40000,MedCost,Commercial,,2583.09,,,,,,,2040.96,2583.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,MedCost,Commercial,,1945.29,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,inpatient,,,3723.00000,2233.80000,MedCost,Commercial,,3015.63,,,,,,,2382.72,3015.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,MedCost,Commercial,,2271.03,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,inpatient,,,3018.00000,1810.80000,MedCost,Commercial,,2444.58,,,,,,,1931.52,2444.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,MedCost,Commercial,,1840.98,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,inpatient,,,2292.00000,1375.20000,MedCost,Commercial,,1856.52,,,,,,,1466.88,1856.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,MedCost,Commercial,,1398.12,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,inpatient,,,2865.00000,1719.00000,MedCost,Commercial,,2320.65,,,,,,,1833.60,2320.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,MedCost,Commercial,,1747.65,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,inpatient,,,3071.00000,1842.60000,MedCost,Commercial,,2487.51,,,,,,,1965.44,2487.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,MedCost,Commercial,,1873.31,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,inpatient,,,2934.00000,1760.40000,MedCost,Commercial,,2376.54,,,,,,,1877.76,2376.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,MedCost,Commercial,,1789.74,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,inpatient,,,4022.00000,2413.20000,MedCost,Commercial,,3257.82,,,,,,,2574.08,3257.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,MedCost,Commercial,,2453.42,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,inpatient,,,4343.00000,2605.80000,MedCost,Commercial,,3517.83,,,,,,,2779.52,3517.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,MedCost,Commercial,,2649.23,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,inpatient,,,3974.00000,2384.40000,MedCost,Commercial,,3218.94,,,,,,,2543.36,3218.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,MedCost,Commercial,,2424.14,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,inpatient,,,2511.00000,1506.60000,MedCost,Commercial,,2033.91,,,,,,,1607.04,2033.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,MedCost,Commercial,,1531.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,inpatient,,,3231.00000,1938.60000,MedCost,Commercial,,2617.11,,,,,,,2067.84,2617.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,MedCost,Commercial,,1970.91,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,inpatient,,,4235.00000,2541.00000,MedCost,Commercial,,3430.35,,,,,,,2710.40,3430.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,MedCost,Commercial,,2583.35,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,inpatient,,,4927.00000,2956.20000,MedCost,Commercial,,3990.87,,,,,,,3153.28,3990.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,MedCost,Commercial,,3005.47,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,inpatient,,,2494.00000,1496.40000,MedCost,Commercial,,2020.14,,,,,,,1596.16,2020.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,MedCost,Commercial,,1521.34,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,inpatient,,,3174.00000,1904.40000,MedCost,Commercial,,2570.94,,,,,,,2031.36,2570.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,MedCost,Commercial,,1936.14,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,inpatient,,,3758.00000,2254.80000,MedCost,Commercial,,3043.98,,,,,,,2405.12,3043.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,MedCost,Commercial,,2292.38,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,inpatient,,,7361.00000,4416.60000,MedCost,Commercial,,5962.41,,,,,,,4711.04,5962.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,MedCost,Commercial,,4490.21,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,inpatient,,,34463.00000,20677.80000,MedCost,Commercial,,27915.03,,,,,,,7039.00,27915.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,MedCost,Commercial,,21022.43,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,inpatient,,,5355.00000,3213.00000,MedCost,Commercial,,4337.55,,,,,,,3427.20,4337.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,MedCost,Commercial,,3266.55,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,inpatient,,,6379.00000,3827.40000,MedCost,Commercial,,5166.99,,,,,,,4082.56,5166.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,MedCost,Commercial,,3891.19,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,inpatient,,,7415.00000,4449.00000,MedCost,Commercial,,6006.15,,,,,,,4745.60,6006.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,MedCost,Commercial,,4523.15,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,inpatient,,,1309.00000,785.40000,MedCost,Commercial,,1060.29,,,,,,,837.76,1060.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,MedCost,Commercial,,798.49,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,inpatient,,,4059.00000,2435.40000,MedCost,Commercial,,3287.79,,,,,,,2597.76,3287.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,MedCost,Commercial,,2475.99,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,inpatient,,,3971.00000,2382.60000,MedCost,Commercial,,3216.51,,,,,,,2541.44,3216.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,MedCost,Commercial,,2422.31,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,inpatient,,,4188.00000,2512.80000,MedCost,Commercial,,3392.28,,,,,,,2680.32,3392.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,MedCost,Commercial,,2554.68,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,inpatient,,,2925.00000,1755.00000,MedCost,Commercial,,2369.25,,,,,,,1872.00,2369.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,MedCost,Commercial,,1784.25,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,inpatient,,,2800.00000,1680.00000,MedCost,Commercial,,2268.00,,,,,,,1792.00,2268.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,MedCost,Commercial,,1708.00,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,inpatient,,,477.00000,286.20000,MedCost,Commercial,,386.37,,,,,,,305.28,386.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,MedCost,Commercial,,290.97,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,inpatient,,,1173.00000,703.80000,MedCost,Commercial,,950.13,,,,,,,750.72,950.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,MedCost,Commercial,,715.53,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,inpatient,,,1332.00000,799.20000,MedCost,Commercial,,1078.92,,,,,,,852.48,1078.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,MedCost,Commercial,,812.52,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,inpatient,,,1332.00000,799.20000,MedCost,Commercial,,1078.92,,,,,,,852.48,1078.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,MedCost,Commercial,,812.52,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,inpatient,,,1450.00000,870.00000,MedCost,Commercial,,1174.50,,,,,,,928.00,1174.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,MedCost,Commercial,,884.50,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,inpatient,,,1764.00000,1058.40000,MedCost,Commercial,,1428.84,,,,,,,1128.96,1428.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,MedCost,Commercial,,1076.04,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,inpatient,,,1764.00000,1058.40000,MedCost,Commercial,,1428.84,,,,,,,1128.96,1428.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,MedCost,Commercial,,1076.04,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,inpatient,,,1901.00000,1140.60000,MedCost,Commercial,,1539.81,,,,,,,1216.64,1539.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,MedCost,Commercial,,1159.61,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Commercial,,384.75,,,,,,,304.00,384.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Commercial,,289.75,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,inpatient,,,337.00000,202.20000,MedCost,Commercial,,272.97,,,,,,,215.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,MedCost,Commercial,,205.57,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,inpatient,,,34463.00000,20677.80000,MedCost,Commercial,,27915.03,,,,,,,7039.00,27915.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,MedCost,Commercial,,21022.43,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,inpatient,,,34463.00000,20677.80000,MedCost,Commercial,,27915.03,,,,,,,7039.00,27915.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,MedCost,Commercial,,21022.43,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,inpatient,,,31466.00000,18879.60000,MedCost,Commercial,,25487.46,,,,,,,7039.00,25487.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,MedCost,Commercial,,19194.26,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Commercial,,217.89,,,,,,,172.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Commercial,,164.09,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,inpatient,,,728.00000,436.80000,MedCost,Commercial,,589.68,,,,,,,465.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,MedCost,Commercial,,444.08,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Commercial,,509.49,,,,,,,402.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Commercial,,383.69,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,inpatient,,,1993.00000,1195.80000,MedCost,Commercial,,1614.33,,,,,,,1275.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,MedCost,Commercial,,1215.73,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,inpatient,,,5105.00000,3063.00000,MedCost,Commercial,,4135.05,,,,,,,3267.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,MedCost,Commercial,,3114.05,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,inpatient,,,543.00000,325.80000,MedCost,Commercial,,439.83,,,,,,,347.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,MedCost,Commercial,,331.23,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,inpatient,,,1387.00000,832.20000,MedCost,Commercial,,1123.47,,,,,,,887.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,MedCost,Commercial,,846.07,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,inpatient,,,880.00000,528.00000,MedCost,Commercial,,712.80,,,,,,,563.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,MedCost,Commercial,,536.80,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,inpatient,,,57551.00000,34530.60000,MedCost,Commercial,,46616.31,,,,,,,7039.00,46616.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,MedCost,Commercial,,35106.11,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,inpatient,,,4857.00000,2914.20000,MedCost,Commercial,,3934.17,,,,,,,3108.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,MedCost,Commercial,,2962.77,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,inpatient,,,4857.00000,2914.20000,MedCost,Commercial,,3934.17,,,,,,,3108.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,MedCost,Commercial,,2962.77,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,inpatient,,,29535.00000,17721.00000,MedCost,Commercial,,23923.35,,,,,,,7039.00,23923.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,MedCost,Commercial,,18016.35,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,inpatient,,,1110.00000,666.00000,MedCost,Commercial,,899.10,,,,,,,710.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,MedCost,Commercial,,677.10,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,inpatient,,,2999.00000,1799.40000,MedCost,Commercial,,2429.19,,,,,,,1919.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,MedCost,Commercial,,1829.39,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,inpatient,,,155.00000,93.00000,MedCost,Commercial,,125.55,,,,,,,99.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,MedCost,Commercial,,94.55,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,inpatient,,,155.00000,93.00000,MedCost,Commercial,,125.55,,,,,,,99.20,126.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,MedCost,Commercial,,94.55,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,inpatient,,,421.00000,252.60000,MedCost,Commercial,,341.01,,,,,,,269.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,MedCost,Commercial,,256.81,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,inpatient,,,2921.00000,1752.60000,MedCost,Commercial,,2366.01,,,,,,,1869.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,MedCost,Commercial,,1781.81,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Commercial,,509.49,,,,,,,402.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Commercial,,383.69,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,inpatient,,,456.00000,273.60000,MedCost,Commercial,,369.36,,,,,,,291.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,MedCost,Commercial,,278.16,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,inpatient,,,232.00000,139.20000,MedCost,Commercial,,187.92,,,,,,,148.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,MedCost,Commercial,,141.52,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Commercial,,162.81,,,,,,,128.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Commercial,,122.61,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Commercial,,389.61,,,,,,,307.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Commercial,,293.41,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,inpatient,,,1109.00000,665.40000,MedCost,Commercial,,898.29,,,,,,,709.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,MedCost,Commercial,,676.49,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Commercial,,370.98,,,,,,,293.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Commercial,,279.38,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,inpatient,,,285.00000,171.00000,MedCost,Commercial,,230.85,,,,,,,182.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,MedCost,Commercial,,173.85,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,inpatient,,,1400.00000,840.00000,MedCost,Commercial,,1134.00,,,,,,,896.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,MedCost,Commercial,,854.00,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,inpatient,,,1582.00000,949.20000,MedCost,Commercial,,1281.42,,,,,,,1012.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,MedCost,Commercial,,965.02,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,inpatient,,,1582.00000,949.20000,MedCost,Commercial,,1281.42,,,,,,,1012.48,1286.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,MedCost,Commercial,,965.02,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,inpatient,,,2330.00000,1398.00000,MedCost,Commercial,,1887.30,,,,,,,1491.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,MedCost,Commercial,,1421.30,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,inpatient,,,2330.00000,1398.00000,MedCost,Commercial,,1887.30,,,,,,,1491.20,1894.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,MedCost,Commercial,,1421.30,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,inpatient,,,311.00000,186.60000,MedCost,Commercial,,251.91,,,,,,,199.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,MedCost,Commercial,,189.71,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,inpatient,,,311.00000,186.60000,MedCost,Commercial,,251.91,,,,,,,199.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,MedCost,Commercial,,189.71,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Commercial,,651.24,,,,,,,514.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Commercial,,490.44,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Commercial,,651.24,,,,,,,514.56,653.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Commercial,,490.44,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,inpatient,,,722.00000,433.20000,MedCost,Commercial,,584.82,,,,,,,462.08,586.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,MedCost,Commercial,,440.42,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,inpatient,,,577.00000,346.20000,MedCost,Commercial,,467.37,,,,,,,369.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,MedCost,Commercial,,351.97,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,inpatient,,,577.00000,346.20000,MedCost,Commercial,,467.37,,,,,,,369.28,469.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,MedCost,Commercial,,351.97,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,inpatient,,,4720.00000,2832.00000,MedCost,Commercial,,3823.20,,,,,,,3020.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,MedCost,Commercial,,2879.20,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,inpatient,,,3377.00000,2026.20000,MedCost,Commercial,,2735.37,,,,,,,2161.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,MedCost,Commercial,,2059.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,inpatient,,,712.00000,427.20000,MedCost,Commercial,,576.72,,,,,,,455.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,MedCost,Commercial,,434.32,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,inpatient,,,565.00000,339.00000,MedCost,Commercial,,457.65,,,,,,,361.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,MedCost,Commercial,,344.65,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,inpatient,,,1414.00000,848.40000,MedCost,Commercial,,1145.34,,,,,,,904.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,MedCost,Commercial,,862.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,inpatient,,,765.00000,459.00000,MedCost,Commercial,,619.65,,,,,,,489.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,MedCost,Commercial,,466.65,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,inpatient,,,1292.00000,775.20000,MedCost,Commercial,,1046.52,,,,,,,826.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,MedCost,Commercial,,788.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,inpatient,,,581.00000,348.60000,MedCost,Commercial,,470.61,,,,,,,371.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,MedCost,Commercial,,354.41,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,inpatient,,,1275.00000,765.00000,MedCost,Commercial,,1032.75,,,,,,,816.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,MedCost,Commercial,,777.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,inpatient,,,1275.00000,765.00000,MedCost,Commercial,,1032.75,,,,,,,816.00,1036.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,MedCost,Commercial,,777.75,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,inpatient,,,1168.00000,700.80000,MedCost,Commercial,,946.08,,,,,,,747.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,MedCost,Commercial,,712.48,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,inpatient,,,3019.00000,1811.40000,MedCost,Commercial,,2445.39,,,,,,,1932.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,MedCost,Commercial,,1841.59,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,inpatient,,,3019.00000,1811.40000,MedCost,Commercial,,2445.39,,,,,,,1932.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,MedCost,Commercial,,1841.59,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,inpatient,,,300.00000,180.00000,MedCost,Commercial,,243.00,,,,,,,192.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,MedCost,Commercial,,183.00,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,inpatient,,,1943.00000,1165.80000,MedCost,Commercial,,1573.83,,,,,,,1243.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,MedCost,Commercial,,1185.23,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,inpatient,,,1464.00000,878.40000,MedCost,Commercial,,1185.84,,,,,,,936.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,MedCost,Commercial,,893.04,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,inpatient,,,834.00000,500.40000,MedCost,Commercial,,675.54,,,,,,,533.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,MedCost,Commercial,,508.74,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,inpatient,,,1623.00000,973.80000,MedCost,Commercial,,1314.63,,,,,,,1038.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,MedCost,Commercial,,990.03,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,inpatient,,,1770.00000,1062.00000,MedCost,Commercial,,1433.70,,,,,,,1132.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,MedCost,Commercial,,1079.70,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,MedCost,Commercial,,1465.29,,,,,,,1157.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,MedCost,Commercial,,1103.49,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,MedCost,Commercial,,1465.29,,,,,,,1157.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,MedCost,Commercial,,1103.49,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,inpatient,,,2105.00000,1263.00000,MedCost,Commercial,,1705.05,,,,,,,1347.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,MedCost,Commercial,,1284.05,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,inpatient,,,2105.00000,1263.00000,MedCost,Commercial,,1705.05,,,,,,,1347.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,MedCost,Commercial,,1284.05,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Commercial,,548.37,,,,,,,433.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Commercial,,412.97,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Commercial,,548.37,,,,,,,433.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Commercial,,412.97,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Commercial,,420.39,,,,,,,332.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Commercial,,316.59,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,inpatient,,,684.00000,410.40000,MedCost,Commercial,,554.04,,,,,,,437.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,MedCost,Commercial,,417.24,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,inpatient,,,684.00000,410.40000,MedCost,Commercial,,554.04,,,,,,,437.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,MedCost,Commercial,,417.24,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,inpatient,,,2691.00000,1614.60000,MedCost,Commercial,,2179.71,,,,,,,1722.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,MedCost,Commercial,,1641.51,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,inpatient,,,2756.00000,1653.60000,MedCost,Commercial,,2232.36,,,,,,,1763.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,MedCost,Commercial,,1681.16,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,inpatient,,,2756.00000,1653.60000,MedCost,Commercial,,2232.36,,,,,,,1763.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,MedCost,Commercial,,1681.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,inpatient,,,1594.00000,956.40000,MedCost,Commercial,,1291.14,,,,,,,1020.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,MedCost,Commercial,,972.34,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,inpatient,,,1594.00000,956.40000,MedCost,Commercial,,1291.14,,,,,,,1020.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,MedCost,Commercial,,972.34,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,inpatient,,,916.00000,549.60000,MedCost,Commercial,,741.96,,,,,,,586.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,MedCost,Commercial,,558.76,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,inpatient,,,916.00000,549.60000,MedCost,Commercial,,741.96,,,,,,,586.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,MedCost,Commercial,,558.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,inpatient,,,1130.00000,678.00000,MedCost,Commercial,,915.30,,,,,,,723.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,MedCost,Commercial,,689.30,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,inpatient,,,1130.00000,678.00000,MedCost,Commercial,,915.30,,,,,,,723.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,MedCost,Commercial,,689.30,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,inpatient,,,1153.00000,691.80000,MedCost,Commercial,,933.93,,,,,,,737.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,MedCost,Commercial,,703.33,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,inpatient,,,1153.00000,691.80000,MedCost,Commercial,,933.93,,,,,,,737.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,MedCost,Commercial,,703.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,inpatient,,,5059.00000,3035.40000,MedCost,Commercial,,4097.79,,,,,,,3237.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,MedCost,Commercial,,3085.99,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,inpatient,,,4925.00000,2955.00000,MedCost,Commercial,,3989.25,,,,,,,3152.00,4004.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,MedCost,Commercial,,3004.25,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,inpatient,,,795.00000,477.00000,MedCost,Commercial,,643.95,,,,,,,508.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,MedCost,Commercial,,484.95,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,inpatient,,,725.00000,435.00000,MedCost,Commercial,,587.25,,,,,,,464.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,MedCost,Commercial,,442.25,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,inpatient,,,818.00000,490.80000,MedCost,Commercial,,662.58,,,,,,,523.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,MedCost,Commercial,,498.98,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,inpatient,,,742.00000,445.20000,MedCost,Commercial,,601.02,,,,,,,474.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,MedCost,Commercial,,452.62,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,inpatient,,,2247.00000,1348.20000,MedCost,Commercial,,1820.07,,,,,,,1438.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,MedCost,Commercial,,1370.67,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,inpatient,,,742.00000,445.20000,MedCost,Commercial,,601.02,,,,,,,474.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,MedCost,Commercial,,452.62,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,inpatient,,,3723.00000,2233.80000,MedCost,Commercial,,3015.63,,,,,,,2382.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,MedCost,Commercial,,2271.03,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,inpatient,,,886.00000,531.60000,MedCost,Commercial,,717.66,,,,,,,567.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,MedCost,Commercial,,540.46,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,inpatient,,,686.00000,411.60000,MedCost,Commercial,,555.66,,,,,,,439.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,MedCost,Commercial,,418.46,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Commercial,,157.95,,,,,,,124.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Commercial,,118.95,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,inpatient,,,533.00000,319.80000,MedCost,Commercial,,431.73,,,,,,,341.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,MedCost,Commercial,,325.13,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,inpatient,,,555.00000,333.00000,MedCost,Commercial,,449.55,,,,,,,355.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,MedCost,Commercial,,338.55,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,inpatient,,,590.00000,354.00000,MedCost,Commercial,,477.90,,,,,,,377.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,MedCost,Commercial,,359.90,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,inpatient,,,583.00000,349.80000,MedCost,Commercial,,472.23,,,,,,,373.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,MedCost,Commercial,,355.63,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,inpatient,,,665.00000,399.00000,MedCost,Commercial,,538.65,,,,,,,425.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,MedCost,Commercial,,405.65,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,inpatient,,,4163.00000,2497.80000,MedCost,Commercial,,3372.03,,,,,,,2664.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,MedCost,Commercial,,2539.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,inpatient,,,2128.00000,1276.80000,MedCost,Commercial,,1723.68,,,,,,,1361.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,MedCost,Commercial,,1298.08,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,inpatient,,,1343.00000,805.80000,MedCost,Commercial,,1087.83,,,,,,,859.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,MedCost,Commercial,,819.23,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,inpatient,,,1464.00000,878.40000,MedCost,Commercial,,1185.84,,,,,,,936.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,MedCost,Commercial,,893.04,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,inpatient,,,694.00000,416.40000,MedCost,Commercial,,562.14,,,,,,,444.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,MedCost,Commercial,,423.34,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,inpatient,,,587.00000,352.20000,MedCost,Commercial,,475.47,,,,,,,375.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,MedCost,Commercial,,358.07,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,inpatient,,,606.00000,363.60000,MedCost,Commercial,,490.86,,,,,,,387.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,MedCost,Commercial,,369.66,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,inpatient,,,884.00000,530.40000,MedCost,Commercial,,716.04,,,,,,,565.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,MedCost,Commercial,,539.24,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,inpatient,,,884.00000,530.40000,MedCost,Commercial,,716.04,,,,,,,565.76,718.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,MedCost,Commercial,,539.24,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,inpatient,,,14058.00000,8434.80000,MedCost,Commercial,,11386.98,,,,,,,7039.00,11386.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,MedCost,Commercial,,8575.38,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,inpatient,,,14058.00000,8434.80000,MedCost,Commercial,,11386.98,,,,,,,7039.00,11386.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,MedCost,Commercial,,8575.38,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,inpatient,,,14058.00000,8434.80000,MedCost,Commercial,,11386.98,,,,,,,7039.00,11386.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,MedCost,Commercial,,8575.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,inpatient,,,6186.00000,3711.60000,MedCost,Commercial,,5010.66,,,,,,,3959.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,MedCost,Commercial,,3773.46,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Commercial,,8516.34,,,,,,,6728.96,8516.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Commercial,,6413.54,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Commercial,,8516.34,,,,,,,6728.96,8516.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Commercial,,6413.54,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Commercial,,8516.34,,,,,,,6728.96,8516.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Commercial,,6413.54,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Commercial,,8516.34,,,,,,,6728.96,8516.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Commercial,,6413.54,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,inpatient,,,11452.00000,6871.20000,MedCost,Commercial,,9276.12,,,,,,,7039.00,9276.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,MedCost,Commercial,,6985.72,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,inpatient,,,11452.00000,6871.20000,MedCost,Commercial,,9276.12,,,,,,,7039.00,9276.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,MedCost,Commercial,,6985.72,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,inpatient,,,7673.00000,4603.80000,MedCost,Commercial,,6215.13,,,,,,,4910.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,MedCost,Commercial,,4680.53,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,inpatient,,,7902.00000,4741.20000,MedCost,Commercial,,6400.62,,,,,,,5057.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,MedCost,Commercial,,4820.22,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,inpatient,,,7902.00000,4741.20000,MedCost,Commercial,,6400.62,,,,,,,5057.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,MedCost,Commercial,,4820.22,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,inpatient,,,4800.00000,2880.00000,MedCost,Commercial,,3888.00,,,,,,,3072.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,MedCost,Commercial,,2928.00,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,inpatient,,,4471.00000,2682.60000,MedCost,Commercial,,3621.51,,,,,,,2861.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,MedCost,Commercial,,2727.31,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,inpatient,,,6062.00000,3637.20000,MedCost,Commercial,,4910.22,,,,,,,3879.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,MedCost,Commercial,,3697.82,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,inpatient,,,6062.00000,3637.20000,MedCost,Commercial,,4910.22,,,,,,,3879.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,MedCost,Commercial,,3697.82,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,inpatient,,,6062.00000,3637.20000,MedCost,Commercial,,4910.22,,,,,,,3879.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,MedCost,Commercial,,3697.82,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,inpatient,,,4394.00000,2636.40000,MedCost,Commercial,,3559.14,,,,,,,2812.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,MedCost,Commercial,,2680.34,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,inpatient,,,2417.00000,1450.20000,MedCost,Commercial,,1957.77,,,,,,,1546.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,MedCost,Commercial,,1474.37,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,inpatient,,,2475.00000,1485.00000,MedCost,Commercial,,2004.75,,,,,,,1584.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,MedCost,Commercial,,1509.75,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,inpatient,,,1613.00000,967.80000,MedCost,Commercial,,1306.53,,,,,,,1032.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,MedCost,Commercial,,983.93,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,inpatient,,,792.00000,475.20000,MedCost,Commercial,,641.52,,,,,,,506.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,MedCost,Commercial,,483.12,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Commercial,,2003.94,,,,,,,1583.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Commercial,,1509.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,inpatient,,,379.00000,227.40000,MedCost,Commercial,,306.99,,,,,,,242.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,MedCost,Commercial,,231.19,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,inpatient,,,482.00000,289.20000,MedCost,Commercial,,390.42,,,,,,,308.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,MedCost,Commercial,,294.02,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,inpatient,,,282.00000,169.20000,MedCost,Commercial,,228.42,,,,,,,180.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,MedCost,Commercial,,172.02,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,inpatient,,,542.00000,325.20000,MedCost,Commercial,,439.02,,,,,,,346.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,MedCost,Commercial,,330.62,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,inpatient,,,5294.00000,3176.40000,MedCost,Commercial,,4288.14,,,,,,,3388.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,MedCost,Commercial,,3229.34,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,inpatient,,,1277.00000,766.20000,MedCost,Commercial,,1034.37,,,,,,,817.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,MedCost,Commercial,,778.97,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,inpatient,,,7494.00000,4496.40000,MedCost,Commercial,,6070.14,,,,,,,4796.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,MedCost,Commercial,,4571.34,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,inpatient,,,395.00000,237.00000,MedCost,Commercial,,319.95,,,,,,,252.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,MedCost,Commercial,,240.95,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,inpatient,,,1640.00000,984.00000,MedCost,Commercial,,1328.40,,,,,,,1049.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,MedCost,Commercial,,1000.40,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,inpatient,,,1640.00000,984.00000,MedCost,Commercial,,1328.40,,,,,,,1049.60,1333.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,MedCost,Commercial,,1000.40,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,inpatient,,,2136.00000,1281.60000,MedCost,Commercial,,1730.16,,,,,,,1367.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,MedCost,Commercial,,1302.96,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Commercial,,737.91,,,,,,,583.04,740.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Commercial,,555.71,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,inpatient,,,3077.00000,1846.20000,MedCost,Commercial,,2492.37,,,,,,,1969.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,MedCost,Commercial,,1876.97,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,inpatient,,,2239.00000,1343.40000,MedCost,Commercial,,1813.59,,,,,,,1432.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,MedCost,Commercial,,1365.79,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Commercial,,433.35,,,,,,,342.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Commercial,,326.35,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,inpatient,,,1016.00000,609.60000,MedCost,Commercial,,822.96,,,,,,,650.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,MedCost,Commercial,,619.76,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,inpatient,,,3854.00000,2312.40000,MedCost,Commercial,,3121.74,,,,,,,2466.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,MedCost,Commercial,,2350.94,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,inpatient,,,642.00000,385.20000,MedCost,Commercial,,520.02,,,,,,,410.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,MedCost,Commercial,,391.62,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,inpatient,,,802.00000,481.20000,MedCost,Commercial,,649.62,,,,,,,513.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,MedCost,Commercial,,489.22,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,inpatient,,,642.00000,385.20000,MedCost,Commercial,,520.02,,,,,,,410.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,MedCost,Commercial,,391.62,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,inpatient,,,695.00000,417.00000,MedCost,Commercial,,562.95,,,,,,,444.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,MedCost,Commercial,,423.95,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,inpatient,,,5294.00000,3176.40000,MedCost,Commercial,,4288.14,,,,,,,3388.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,MedCost,Commercial,,3229.34,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,inpatient,,,2378.00000,1426.80000,MedCost,Commercial,,1926.18,,,,,,,1521.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,MedCost,Commercial,,1450.58,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,inpatient,,,2502.00000,1501.20000,MedCost,Commercial,,2026.62,,,,,,,1601.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,MedCost,Commercial,,1526.22,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,inpatient,,,2478.00000,1486.80000,MedCost,Commercial,,2007.18,,,,,,,1585.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,MedCost,Commercial,,1511.58,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,inpatient,,,636.00000,381.60000,MedCost,Commercial,,515.16,,,,,,,407.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,MedCost,Commercial,,387.96,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Commercial,,939.60,,,,,,,742.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Commercial,,707.60,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,inpatient,,,175.00000,105.00000,MedCost,Commercial,,141.75,,,,,,,112.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,MedCost,Commercial,,106.75,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,inpatient,,,6291.00000,3774.60000,MedCost,Commercial,,5095.71,,,,,,,4026.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,MedCost,Commercial,,3837.51,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,inpatient,,,7767.00000,4660.20000,MedCost,Commercial,,6291.27,,,,,,,4970.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,MedCost,Commercial,,4737.87,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,inpatient,,,2491.00000,1494.60000,MedCost,Commercial,,2017.71,,,,,,,1594.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,MedCost,Commercial,,1519.51,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Commercial,,238.14,,,,,,,188.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Commercial,,179.34,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,inpatient,,,231.00000,138.60000,MedCost,Commercial,,187.11,,,,,,,147.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,MedCost,Commercial,,140.91,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,inpatient,,,208.00000,124.80000,MedCost,Commercial,,168.48,,,,,,,133.12,169.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,MedCost,Commercial,,126.88,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,inpatient,,,404.00000,242.40000,MedCost,Commercial,,327.24,,,,,,,258.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,MedCost,Commercial,,246.44,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,inpatient,,,408.00000,244.80000,MedCost,Commercial,,330.48,,,,,,,261.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,MedCost,Commercial,,248.88,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Commercial,,2003.94,,,,,,,1583.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Commercial,,1509.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Commercial,,163.62,,,,,,,129.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Commercial,,123.22,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,inpatient,,,1592.00000,955.20000,MedCost,Commercial,,1289.52,,,,,,,1018.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,MedCost,Commercial,,971.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,inpatient,,,4497.00000,2698.20000,MedCost,Commercial,,3642.57,,,,,,,2878.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,MedCost,Commercial,,2743.17,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,inpatient,,,4234.00000,2540.40000,MedCost,Commercial,,3429.54,,,,,,,2709.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,MedCost,Commercial,,2582.74,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,inpatient,,,2921.00000,1752.60000,MedCost,Commercial,,2366.01,,,,,,,1869.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,MedCost,Commercial,,1781.81,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,inpatient,,,4574.00000,2744.40000,MedCost,Commercial,,3704.94,,,,,,,2927.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,MedCost,Commercial,,2790.14,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,inpatient,,,1055.00000,633.00000,MedCost,Commercial,,854.55,,,,,,,675.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,MedCost,Commercial,,643.55,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,inpatient,,,1055.00000,633.00000,MedCost,Commercial,,854.55,,,,,,,675.20,857.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,MedCost,Commercial,,643.55,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,inpatient,,,1471.00000,882.60000,MedCost,Commercial,,1191.51,,,,,,,941.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,MedCost,Commercial,,897.31,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Commercial,,233.28,,,,,,,184.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Commercial,,175.68,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Commercial,,233.28,,,,,,,184.32,234.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Commercial,,175.68,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,inpatient,,,1918.00000,1150.80000,MedCost,Commercial,,1553.58,,,,,,,1227.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,MedCost,Commercial,,1169.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,inpatient,,,1918.00000,1150.80000,MedCost,Commercial,,1553.58,,,,,,,1227.52,1559.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,MedCost,Commercial,,1169.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,inpatient,,,1173.00000,703.80000,MedCost,Commercial,,950.13,,,,,,,750.72,953.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,MedCost,Commercial,,715.53,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,inpatient,,,2511.00000,1506.60000,MedCost,Commercial,,2033.91,,,,,,,1607.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,MedCost,Commercial,,1531.71,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,inpatient,,,2511.00000,1506.60000,MedCost,Commercial,,2033.91,,,,,,,1607.04,2041.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,MedCost,Commercial,,1531.71,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,inpatient,,,2034.00000,1220.40000,MedCost,Commercial,,1647.54,,,,,,,1301.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,MedCost,Commercial,,1240.74,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,inpatient,,,2034.00000,1220.40000,MedCost,Commercial,,1647.54,,,,,,,1301.76,1653.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,MedCost,Commercial,,1240.74,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,inpatient,,,1738.00000,1042.80000,MedCost,Commercial,,1407.78,,,,,,,1112.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,MedCost,Commercial,,1060.18,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,inpatient,,,1738.00000,1042.80000,MedCost,Commercial,,1407.78,,,,,,,1112.32,1412.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,MedCost,Commercial,,1060.18,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,inpatient,,,1583.00000,949.80000,MedCost,Commercial,,1282.23,,,,,,,1013.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,MedCost,Commercial,,965.63,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,inpatient,,,1583.00000,949.80000,MedCost,Commercial,,1282.23,,,,,,,1013.12,1286.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,MedCost,Commercial,,965.63,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,inpatient,,,1646.00000,987.60000,MedCost,Commercial,,1333.26,,,,,,,1053.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,MedCost,Commercial,,1004.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,inpatient,,,1646.00000,987.60000,MedCost,Commercial,,1333.26,,,,,,,1053.44,1338.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,MedCost,Commercial,,1004.06,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,inpatient,,,1710.00000,1026.00000,MedCost,Commercial,,1385.10,,,,,,,1094.40,1390.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,MedCost,Commercial,,1043.10,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,inpatient,,,1515.00000,909.00000,MedCost,Commercial,,1227.15,,,,,,,969.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,MedCost,Commercial,,924.15,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,inpatient,,,1515.00000,909.00000,MedCost,Commercial,,1227.15,,,,,,,969.60,1231.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,MedCost,Commercial,,924.15,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,inpatient,,,1509.00000,905.40000,MedCost,Commercial,,1222.29,,,,,,,965.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,MedCost,Commercial,,920.49,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,inpatient,,,1509.00000,905.40000,MedCost,Commercial,,1222.29,,,,,,,965.76,1226.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,MedCost,Commercial,,920.49,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,inpatient,,,3322.00000,1993.20000,MedCost,Commercial,,2690.82,,,,,,,2126.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,MedCost,Commercial,,2026.42,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,inpatient,,,3322.00000,1993.20000,MedCost,Commercial,,2690.82,,,,,,,2126.08,2700.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,MedCost,Commercial,,2026.42,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,inpatient,,,1860.00000,1116.00000,MedCost,Commercial,,1506.60,,,,,,,1190.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,MedCost,Commercial,,1134.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,inpatient,,,1860.00000,1116.00000,MedCost,Commercial,,1506.60,,,,,,,1190.40,1512.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,MedCost,Commercial,,1134.60,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,inpatient,,,1818.00000,1090.80000,MedCost,Commercial,,1472.58,,,,,,,1163.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,MedCost,Commercial,,1108.98,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,inpatient,,,1818.00000,1090.80000,MedCost,Commercial,,1472.58,,,,,,,1163.52,1478.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,MedCost,Commercial,,1108.98,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,inpatient,,,2306.00000,1383.60000,MedCost,Commercial,,1867.86,,,,,,,1475.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,MedCost,Commercial,,1406.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,inpatient,,,368.00000,220.80000,MedCost,Commercial,,298.08,,,,,,,235.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,MedCost,Commercial,,224.48,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,inpatient,,,4857.00000,2914.20000,MedCost,Commercial,,3934.17,,,,,,,3108.48,3948.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,MedCost,Commercial,,2962.77,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,inpatient,,,220.00000,132.00000,MedCost,Commercial,,178.20,,,,,,,140.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,MedCost,Commercial,,134.20,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,inpatient,,,2841.00000,1704.60000,MedCost,Commercial,,2301.21,,,,,,,1818.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,MedCost,Commercial,,1733.01,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,inpatient,,,2990.00000,1794.00000,MedCost,Commercial,,2421.90,,,,,,,1913.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,MedCost,Commercial,,1823.90,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,inpatient,,,20137.00000,12082.20000,MedCost,Commercial,,16310.97,,,,,,,7039.00,16310.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,MedCost,Commercial,,12283.57,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,inpatient,,,10706.00000,6423.60000,MedCost,Commercial,,8671.86,,,,,,,6851.84,8671.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,MedCost,Commercial,,6530.66,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Commercial,,420.39,,,,,,,332.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Commercial,,316.59,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,inpatient,,,1168.00000,700.80000,MedCost,Commercial,,946.08,,,,,,,747.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,MedCost,Commercial,,712.48,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,inpatient,,,1074.00000,644.40000,MedCost,Commercial,,869.94,,,,,,,687.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,MedCost,Commercial,,655.14,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,inpatient,,,693.00000,415.80000,MedCost,Commercial,,561.33,,,,,,,443.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,MedCost,Commercial,,422.73,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,inpatient,,,776.00000,465.60000,MedCost,Commercial,,628.56,,,,,,,496.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,MedCost,Commercial,,473.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,inpatient,,,5458.00000,3274.80000,MedCost,Commercial,,4420.98,,,,,,,3493.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,MedCost,Commercial,,3329.38,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,inpatient,,,3712.00000,2227.20000,MedCost,Commercial,,3006.72,,,,,,,2375.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,MedCost,Commercial,,2264.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,inpatient,,,4719.00000,2831.40000,MedCost,Commercial,,3822.39,,,,,,,3020.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,MedCost,Commercial,,2878.59,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,inpatient,,,3869.00000,2321.40000,MedCost,Commercial,,3133.89,,,,,,,2476.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,MedCost,Commercial,,2360.09,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,inpatient,,,4864.00000,2918.40000,MedCost,Commercial,,3939.84,,,,,,,3112.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,MedCost,Commercial,,2967.04,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,inpatient,,,3988.00000,2392.80000,MedCost,Commercial,,3230.28,,,,,,,2552.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,MedCost,Commercial,,2432.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,inpatient,,,1688.00000,1012.80000,MedCost,Commercial,,1367.28,,,,,,,1080.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,MedCost,Commercial,,1029.68,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,inpatient,,,573.00000,343.80000,MedCost,Commercial,,464.13,,,,,,,366.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,MedCost,Commercial,,349.53,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,inpatient,,,7462.00000,4477.20000,MedCost,Commercial,,6044.22,,,,,,,4775.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,MedCost,Commercial,,4551.82,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,inpatient,,,1990.00000,1194.00000,MedCost,Commercial,,1611.90,,,,,,,1273.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,MedCost,Commercial,,1213.90,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,inpatient,,,1492.00000,895.20000,MedCost,Commercial,,1208.52,,,,,,,954.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,MedCost,Commercial,,910.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,inpatient,,,2653.00000,1591.80000,MedCost,Commercial,,2148.93,,,,,,,1697.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,MedCost,Commercial,,1618.33,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,inpatient,,,28766.00000,17259.60000,MedCost,Commercial,,23300.46,,,,,,,7039.00,23300.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,MedCost,Commercial,,17547.26,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,inpatient,,,4187.00000,2512.20000,MedCost,Commercial,,3391.47,,,,,,,2679.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,MedCost,Commercial,,2554.07,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,inpatient,,,13279.00000,7967.40000,MedCost,Commercial,,10755.99,,,,,,,7039.00,10755.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,MedCost,Commercial,,8100.19,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,inpatient,,,8848.00000,5308.80000,MedCost,Commercial,,7166.88,,,,,,,5662.72,7166.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,MedCost,Commercial,,5397.28,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,inpatient,,,3479.00000,2087.40000,MedCost,Commercial,,2817.99,,,,,,,2226.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,MedCost,Commercial,,2122.19,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,inpatient,,,1241.00000,744.60000,MedCost,Commercial,,1005.21,,,,,,,794.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,MedCost,Commercial,,757.01,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,inpatient,,,1696.00000,1017.60000,MedCost,Commercial,,1373.76,,,,,,,1085.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,MedCost,Commercial,,1034.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,inpatient,,,1696.00000,1017.60000,MedCost,Commercial,,1373.76,,,,,,,1085.44,1378.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,MedCost,Commercial,,1034.56,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,inpatient,,,1876.00000,1125.60000,MedCost,Commercial,,1519.56,,,,,,,1200.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,MedCost,Commercial,,1144.36,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,inpatient,,,1876.00000,1125.60000,MedCost,Commercial,,1519.56,,,,,,,1200.64,1525.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,MedCost,Commercial,,1144.36,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,inpatient,,,1732.00000,1039.20000,MedCost,Commercial,,1402.92,,,,,,,1108.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,MedCost,Commercial,,1056.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,inpatient,,,1732.00000,1039.20000,MedCost,Commercial,,1402.92,,,,,,,1108.48,1408.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,MedCost,Commercial,,1056.52,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,inpatient,,,1289.00000,773.40000,MedCost,Commercial,,1044.09,,,,,,,824.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,MedCost,Commercial,,786.29,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,inpatient,,,733.00000,439.80000,MedCost,Commercial,,593.73,,,,,,,469.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,MedCost,Commercial,,447.13,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,inpatient,,,1229.00000,737.40000,MedCost,Commercial,,995.49,,,,,,,786.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,MedCost,Commercial,,749.69,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,inpatient,,,7165.00000,4299.00000,MedCost,Commercial,,5803.65,,,,,,,4585.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,MedCost,Commercial,,4370.65,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,inpatient,,,1791.00000,1074.60000,MedCost,Commercial,,1450.71,,,,,,,1146.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,MedCost,Commercial,,1092.51,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,inpatient,,,1576.00000,945.60000,MedCost,Commercial,,1276.56,,,,,,,1008.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,MedCost,Commercial,,961.36,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,inpatient,,,1854.00000,1112.40000,MedCost,Commercial,,1501.74,,,,,,,1186.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,MedCost,Commercial,,1130.94,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,inpatient,,,1046.00000,627.60000,MedCost,Commercial,,847.26,,,,,,,669.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,MedCost,Commercial,,638.06,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,inpatient,,,3586.00000,2151.60000,MedCost,Commercial,,2904.66,,,,,,,2295.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,MedCost,Commercial,,2187.46,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,inpatient,,,3586.00000,2151.60000,MedCost,Commercial,,2904.66,,,,,,,2295.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,MedCost,Commercial,,2187.46,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Commercial,,2107.62,,,,,,,1665.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Commercial,,1587.22,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Commercial,,2107.62,,,,,,,1665.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Commercial,,1587.22,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Commercial,,2107.62,,,,,,,1665.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Commercial,,1587.22,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Commercial,,2107.62,,,,,,,1665.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Commercial,,1587.22,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,inpatient,,,3465.00000,2079.00000,MedCost,Commercial,,2806.65,,,,,,,2217.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,MedCost,Commercial,,2113.65,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,inpatient,,,2980.00000,1788.00000,MedCost,Commercial,,2413.80,,,,,,,1907.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,MedCost,Commercial,,1817.80,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,inpatient,,,6144.00000,3686.40000,MedCost,Commercial,,4976.64,,,,,,,3932.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,MedCost,Commercial,,3747.84,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,inpatient,,,7144.00000,4286.40000,MedCost,Commercial,,5786.64,,,,,,,4572.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,MedCost,Commercial,,4357.84,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,inpatient,,,5291.00000,3174.60000,MedCost,Commercial,,4285.71,,,,,,,3386.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,MedCost,Commercial,,3227.51,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,inpatient,,,4767.00000,2860.20000,MedCost,Commercial,,3861.27,,,,,,,3050.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,MedCost,Commercial,,2907.87,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,inpatient,,,1192.00000,715.20000,MedCost,Commercial,,965.52,,,,,,,762.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,MedCost,Commercial,,727.12,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,inpatient,,,8038.00000,4822.80000,MedCost,Commercial,,6510.78,,,,,,,5144.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,MedCost,Commercial,,4903.18,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,inpatient,,,8296.00000,4977.60000,MedCost,Commercial,,6719.76,,,,,,,5309.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,MedCost,Commercial,,5060.56,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,inpatient,,,12470.00000,7482.00000,MedCost,Commercial,,10100.70,,,,,,,7039.00,10100.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,MedCost,Commercial,,7606.70,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,inpatient,,,6955.00000,4173.00000,MedCost,Commercial,,5633.55,,,,,,,4451.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,MedCost,Commercial,,4242.55,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,inpatient,,,2658.00000,1594.80000,MedCost,Commercial,,2152.98,,,,,,,1701.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,MedCost,Commercial,,1621.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,inpatient,,,1848.00000,1108.80000,MedCost,Commercial,,1496.88,,,,,,,1182.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,MedCost,Commercial,,1127.28,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,inpatient,,,891.00000,534.60000,MedCost,Commercial,,721.71,,,,,,,570.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,MedCost,Commercial,,543.51,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,inpatient,,,1611.00000,966.60000,MedCost,Commercial,,1304.91,,,,,,,1031.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,MedCost,Commercial,,982.71,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,inpatient,,,1191.00000,714.60000,MedCost,Commercial,,964.71,,,,,,,762.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,MedCost,Commercial,,726.51,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,inpatient,,,3702.00000,2221.20000,MedCost,Commercial,,2998.62,,,,,,,2369.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,MedCost,Commercial,,2258.22,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,inpatient,,,3251.00000,1950.60000,MedCost,Commercial,,2633.31,,,,,,,2080.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,MedCost,Commercial,,1983.11,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,inpatient,,,3254.00000,1952.40000,MedCost,Commercial,,2635.74,,,,,,,2082.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,MedCost,Commercial,,1984.94,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,inpatient,,,2805.00000,1683.00000,MedCost,Commercial,,2272.05,,,,,,,1795.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,MedCost,Commercial,,1711.05,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,inpatient,,,2658.00000,1594.80000,MedCost,Commercial,,2152.98,,,,,,,1701.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,MedCost,Commercial,,1621.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,inpatient,,,4769.00000,2861.40000,MedCost,Commercial,,3862.89,,,,,,,3052.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,MedCost,Commercial,,2909.09,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,inpatient,,,5532.00000,3319.20000,MedCost,Commercial,,4480.92,,,,,,,3540.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,MedCost,Commercial,,3374.52,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,inpatient,,,8107.00000,4864.20000,MedCost,Commercial,,6566.67,,,,,,,5188.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,MedCost,Commercial,,4945.27,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,inpatient,,,751.00000,450.60000,MedCost,Commercial,,608.31,,,,,,,480.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,MedCost,Commercial,,458.11,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,inpatient,,,10877.00000,6526.20000,MedCost,Commercial,,8810.37,,,,,,,6961.28,8810.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,MedCost,Commercial,,6634.97,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,inpatient,,,7831.00000,4698.60000,MedCost,Commercial,,6343.11,,,,,,,5011.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,MedCost,Commercial,,4776.91,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,inpatient,,,3807.00000,2284.20000,MedCost,Commercial,,3083.67,,,,,,,2436.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,MedCost,Commercial,,2322.27,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,inpatient,,,17121.00000,10272.60000,MedCost,Commercial,,13868.01,,,,,,,7039.00,13868.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,MedCost,Commercial,,10443.81,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,inpatient,,,7327.00000,4396.20000,MedCost,Commercial,,5934.87,,,,,,,4689.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,MedCost,Commercial,,4469.47,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,inpatient,,,902.00000,541.20000,MedCost,Commercial,,730.62,,,,,,,577.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,MedCost,Commercial,,550.22,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,inpatient,,,3481.00000,2088.60000,MedCost,Commercial,,2819.61,,,,,,,2227.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,MedCost,Commercial,,2123.41,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,inpatient,,,3481.00000,2088.60000,MedCost,Commercial,,2819.61,,,,,,,2227.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,MedCost,Commercial,,2123.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,inpatient,,,17238.00000,10342.80000,MedCost,Commercial,,13962.78,,,,,,,7039.00,13962.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,MedCost,Commercial,,10515.18,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,inpatient,,,16182.00000,9709.20000,MedCost,Commercial,,13107.42,,,,,,,7039.00,13107.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,MedCost,Commercial,,9871.02,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,inpatient,,,16182.00000,9709.20000,MedCost,Commercial,,13107.42,,,,,,,7039.00,13107.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,MedCost,Commercial,,9871.02,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,inpatient,,,8795.00000,5277.00000,MedCost,Commercial,,7123.95,,,,,,,5628.80,7123.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,MedCost,Commercial,,5364.95,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,inpatient,,,8795.00000,5277.00000,MedCost,Commercial,,7123.95,,,,,,,5628.80,7123.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,MedCost,Commercial,,5364.95,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,inpatient,,,9322.00000,5593.20000,MedCost,Commercial,,7550.82,,,,,,,5966.08,7550.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,MedCost,Commercial,,5686.42,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,inpatient,,,9322.00000,5593.20000,MedCost,Commercial,,7550.82,,,,,,,5966.08,7550.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,MedCost,Commercial,,5686.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,inpatient,,,12428.00000,7456.80000,MedCost,Commercial,,10066.68,,,,,,,7039.00,10066.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,MedCost,Commercial,,7581.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,inpatient,,,9035.00000,5421.00000,MedCost,Commercial,,7318.35,,,,,,,5782.40,7318.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,MedCost,Commercial,,5511.35,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,inpatient,,,2910.00000,1746.00000,MedCost,Commercial,,2357.10,,,,,,,1862.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,MedCost,Commercial,,1775.10,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,inpatient,,,2368.00000,1420.80000,MedCost,Commercial,,1918.08,,,,,,,1515.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,MedCost,Commercial,,1444.48,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,inpatient,,,2368.00000,1420.80000,MedCost,Commercial,,1918.08,,,,,,,1515.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,MedCost,Commercial,,1444.48,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Commercial,,651.24,,,,,,,514.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Commercial,,490.44,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,inpatient,,,6560.00000,3936.00000,MedCost,Commercial,,5313.60,,,,,,,4198.40,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,MedCost,Commercial,,4001.60,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,inpatient,,,1686.00000,1011.60000,MedCost,Commercial,,1365.66,,,,,,,1079.04,1370.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,MedCost,Commercial,,1028.46,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,inpatient,,,2021.00000,1212.60000,MedCost,Commercial,,1637.01,,,,,,,1293.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,MedCost,Commercial,,1232.81,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,inpatient,,,3211.00000,1926.60000,MedCost,Commercial,,2600.91,,,,,,,2055.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,MedCost,Commercial,,1958.71,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,inpatient,,,487.00000,292.20000,MedCost,Commercial,,394.47,,,,,,,311.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,MedCost,Commercial,,297.07,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Commercial,,2315.79,,,,,,,1829.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Commercial,,1743.99,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Commercial,,2315.79,,,,,,,1829.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Commercial,,1743.99,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Commercial,,176.58,,,,,,,139.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Commercial,,132.98,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Commercial,,176.58,,,,,,,139.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Commercial,,132.98,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,inpatient,,,9944.00000,5966.40000,MedCost,Commercial,,8054.64,,,,,,,6364.16,8054.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,MedCost,Commercial,,6065.84,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,inpatient,,,9944.00000,5966.40000,MedCost,Commercial,,8054.64,,,,,,,6364.16,8054.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,MedCost,Commercial,,6065.84,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,inpatient,,,4014.00000,2408.40000,MedCost,Commercial,,3251.34,,,,,,,2568.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,MedCost,Commercial,,2448.54,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,inpatient,,,6092.00000,3655.20000,MedCost,Commercial,,4934.52,,,,,,,3898.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,MedCost,Commercial,,3716.12,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,inpatient,,,3452.00000,2071.20000,MedCost,Commercial,,2796.12,,,,,,,2209.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,MedCost,Commercial,,2105.72,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,MedCost,Commercial,,1465.29,,,,,,,1157.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,MedCost,Commercial,,1103.49,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Commercial,,509.49,,,,,,,402.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Commercial,,383.69,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Commercial,,2315.79,,,,,,,1829.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Commercial,,1743.99,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Commercial,,2315.79,,,,,,,1829.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Commercial,,1743.99,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,inpatient,,,4058.00000,2434.80000,MedCost,Commercial,,3286.98,,,,,,,2597.12,3286.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,MedCost,Commercial,,2475.38,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,inpatient,,,1959.00000,1175.40000,MedCost,Commercial,,1586.79,,,,,,,1253.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,MedCost,Commercial,,1194.99,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,inpatient,,,392.00000,235.20000,MedCost,Commercial,,317.52,,,,,,,250.88,317.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,MedCost,Commercial,,239.12,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,inpatient,,,459.00000,275.40000,MedCost,Commercial,,371.79,,,,,,,293.76,371.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,MedCost,Commercial,,279.99,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Commercial,,302.13,,,,,,,238.72,302.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Commercial,,227.53,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Commercial,,302.13,,,,,,,238.72,302.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Commercial,,227.53,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,inpatient,,,392.00000,235.20000,MedCost,Commercial,,317.52,,,,,,,250.88,317.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,MedCost,Commercial,,239.12,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,inpatient,,,320.00000,192.00000,MedCost,Commercial,,259.20,,,,,,,204.80,259.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,MedCost,Commercial,,195.20,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,inpatient,,,894.00000,536.40000,MedCost,Commercial,,724.14,,,,,,,572.16,724.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,MedCost,Commercial,,545.34,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,inpatient,,,574.00000,344.40000,MedCost,Commercial,,464.94,,,,,,,367.36,464.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,MedCost,Commercial,,350.14,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,inpatient,,,1142.00000,685.20000,MedCost,Commercial,,925.02,,,,,,,730.88,925.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,MedCost,Commercial,,696.62,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,inpatient,,,936.00000,561.60000,MedCost,Commercial,,758.16,,,,,,,599.04,758.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,MedCost,Commercial,,570.96,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,inpatient,,,1058.00000,634.80000,MedCost,Commercial,,856.98,,,,,,,677.12,856.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,MedCost,Commercial,,645.38,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,inpatient,,,771.00000,462.60000,MedCost,Commercial,,624.51,,,,,,,493.44,624.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,MedCost,Commercial,,470.31,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,inpatient,,,837.00000,502.20000,MedCost,Commercial,,677.97,,,,,,,535.68,677.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,MedCost,Commercial,,510.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Commercial,,255.15,,,,,,,201.60,255.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Commercial,,192.15,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,inpatient,,,758.00000,454.80000,MedCost,Commercial,,613.98,,,,,,,485.12,613.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,MedCost,Commercial,,462.38,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,inpatient,,,310.00000,186.00000,MedCost,Commercial,,251.10,,,,,,,198.40,251.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,MedCost,Commercial,,189.10,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,inpatient,,,825.00000,495.00000,MedCost,Commercial,,668.25,,,,,,,528.00,668.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,MedCost,Commercial,,503.25,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,inpatient,,,961.00000,576.60000,MedCost,Commercial,,778.41,,,,,,,615.04,778.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,MedCost,Commercial,,586.21,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Commercial,,420.39,,,,,,,332.16,420.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Commercial,,316.59,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Commercial,,515.97,,,,,,,407.68,515.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Commercial,,388.57,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,inpatient,,,427.00000,256.20000,MedCost,Commercial,,345.87,,,,,,,273.28,345.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,MedCost,Commercial,,260.47,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,inpatient,,,835.00000,501.00000,MedCost,Commercial,,676.35,,,,,,,534.40,676.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,MedCost,Commercial,,509.35,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,inpatient,,,668.00000,400.80000,MedCost,Commercial,,541.08,,,,,,,427.52,541.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,MedCost,Commercial,,407.48,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Commercial,,436.59,,,,,,,344.96,436.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Commercial,,328.79,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,inpatient,,,658.00000,394.80000,MedCost,Commercial,,532.98,,,,,,,421.12,532.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,MedCost,Commercial,,401.38,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Commercial,,839.97,,,,,,,663.68,839.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Commercial,,632.57,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,inpatient,,,823.00000,493.80000,MedCost,Commercial,,666.63,,,,,,,526.72,666.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,MedCost,Commercial,,502.03,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,inpatient,,,919.00000,551.40000,MedCost,Commercial,,744.39,,,,,,,588.16,744.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,MedCost,Commercial,,560.59,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,inpatient,,,301.00000,180.60000,MedCost,Commercial,,243.81,,,,,,,192.64,243.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,MedCost,Commercial,,183.61,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,inpatient,,,1178.00000,706.80000,MedCost,Commercial,,954.18,,,,,,,753.92,954.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,MedCost,Commercial,,718.58,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,inpatient,,,764.00000,458.40000,MedCost,Commercial,,618.84,,,,,,,488.96,618.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,MedCost,Commercial,,466.04,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,inpatient,,,250.00000,150.00000,MedCost,Commercial,,202.50,,,,,,,160.00,202.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,MedCost,Commercial,,152.50,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,inpatient,,,231.00000,138.60000,MedCost,Commercial,,187.11,,,,,,,147.84,187.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,MedCost,Commercial,,140.91,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Commercial,,150.66,,,,,,,119.04,150.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Commercial,,113.46,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,inpatient,,,1102.00000,661.20000,MedCost,Commercial,,892.62,,,,,,,705.28,892.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,MedCost,Commercial,,672.22,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,inpatient,,,825.00000,495.00000,MedCost,Commercial,,668.25,,,,,,,528.00,668.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,MedCost,Commercial,,503.25,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,inpatient,,,199.00000,119.40000,MedCost,Commercial,,161.19,,,,,,,127.36,161.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,MedCost,Commercial,,121.39,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,inpatient,,,684.00000,410.40000,MedCost,Commercial,,554.04,,,,,,,437.76,554.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,MedCost,Commercial,,417.24,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Commercial,,341.82,,,,,,,270.08,341.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Commercial,,257.42,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,inpatient,,,967.00000,580.20000,MedCost,Commercial,,783.27,,,,,,,618.88,783.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,MedCost,Commercial,,589.87,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,inpatient,,,724.00000,434.40000,MedCost,Commercial,,586.44,,,,,,,463.36,586.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,MedCost,Commercial,,441.64,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Commercial,,334.53,,,,,,,264.32,334.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Commercial,,251.93,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,inpatient,,,492.00000,295.20000,MedCost,Commercial,,398.52,,,,,,,314.88,398.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,MedCost,Commercial,,300.12,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,inpatient,,,459.00000,275.40000,MedCost,Commercial,,371.79,,,,,,,293.76,371.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,MedCost,Commercial,,279.99,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Commercial,,112.59,,,,,,,88.96,112.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Commercial,,84.79,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,inpatient,,,67.00000,40.20000,MedCost,Commercial,,54.27,,,,,,,42.88,54.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,MedCost,Commercial,,40.87,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,inpatient,,,109.00000,65.40000,MedCost,Commercial,,88.29,,,,,,,69.76,88.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,MedCost,Commercial,,66.49,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,inpatient,,,6386.00000,3831.60000,MedCost,Commercial,,5172.66,,,,,,,4087.04,5172.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,MedCost,Commercial,,3895.46,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,inpatient,,,4654.00000,2792.40000,MedCost,Commercial,,3769.74,,,,,,,2978.56,3769.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,MedCost,Commercial,,2838.94,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,inpatient,,,4182.00000,2509.20000,MedCost,Commercial,,3387.42,,,,,,,2676.48,3387.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,MedCost,Commercial,,2551.02,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,inpatient,,,6491.00000,3894.60000,MedCost,Commercial,,5257.71,,,,,,,4154.24,5257.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,MedCost,Commercial,,3959.51,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,inpatient,,,6150.00000,3690.00000,MedCost,Commercial,,4981.50,,,,,,,3936.00,4981.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,MedCost,Commercial,,3751.50,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,inpatient,,,2688.00000,1612.80000,MedCost,Commercial,,2177.28,,,,,,,1720.32,2177.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,MedCost,Commercial,,1639.68,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,inpatient,,,6150.00000,3690.00000,MedCost,Commercial,,4981.50,,,,,,,3936.00,4981.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,MedCost,Commercial,,3751.50,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,inpatient,,,6150.00000,3690.00000,MedCost,Commercial,,4981.50,,,,,,,3936.00,4981.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,MedCost,Commercial,,3751.50,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,inpatient,,,931.00000,558.60000,MedCost,Commercial,,754.11,,,,,,,595.84,754.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,MedCost,Commercial,,567.91,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,inpatient,,,1531.00000,918.60000,MedCost,Commercial,,1240.11,,,,,,,979.84,1240.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,MedCost,Commercial,,933.91,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,inpatient,,,3061.00000,1836.60000,MedCost,Commercial,,2479.41,,,,,,,1959.04,2479.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,MedCost,Commercial,,1867.21,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,inpatient,,,4660.00000,2796.00000,MedCost,Commercial,,3774.60,,,,,,,2982.40,3774.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,MedCost,Commercial,,2842.60,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,inpatient,,,4176.00000,2505.60000,MedCost,Commercial,,3382.56,,,,,,,2672.64,3382.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,MedCost,Commercial,,2547.36,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,inpatient,,,6052.00000,3631.20000,MedCost,Commercial,,4902.12,,,,,,,3873.28,4902.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,MedCost,Commercial,,3691.72,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,inpatient,,,8896.00000,5337.60000,MedCost,Commercial,,7205.76,,,,,,,5693.44,7205.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,MedCost,Commercial,,5426.56,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,inpatient,,,527.00000,316.20000,MedCost,Commercial,,426.87,,,,,,,337.28,426.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,MedCost,Commercial,,321.47,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,inpatient,,,899.00000,539.40000,MedCost,Commercial,,728.19,,,,,,,575.36,728.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,MedCost,Commercial,,548.39,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Commercial,,462.51,,,,,,,365.44,462.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Commercial,,348.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,inpatient,,,1012.00000,607.20000,MedCost,Commercial,,819.72,,,,,,,647.68,819.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,MedCost,Commercial,,617.32,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,inpatient,,,2736.00000,1641.60000,MedCost,Commercial,,2216.16,,,,,,,1751.04,2216.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,MedCost,Commercial,,1668.96,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,inpatient,,,2469.00000,1481.40000,MedCost,Commercial,,1999.89,,,,,,,1580.16,1999.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,MedCost,Commercial,,1506.09,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Commercial,,389.61,,,,,,,307.84,389.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Commercial,,293.41,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,inpatient,,,2813.00000,1687.80000,MedCost,Commercial,,2278.53,,,,,,,1800.32,2278.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,MedCost,Commercial,,1715.93,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,inpatient,,,3292.00000,1975.20000,MedCost,Commercial,,2666.52,,,,,,,2106.88,2666.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,MedCost,Commercial,,2008.12,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,inpatient,,,5069.00000,3041.40000,MedCost,Commercial,,4105.89,,,,,,,3244.16,4105.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,MedCost,Commercial,,3092.09,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,inpatient,,,6127.00000,3676.20000,MedCost,Commercial,,4962.87,,,,,,,3921.28,4962.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,MedCost,Commercial,,3737.47,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,inpatient,,,3459.00000,2075.40000,MedCost,Commercial,,2801.79,,,,,,,2213.76,2801.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,MedCost,Commercial,,2109.99,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,inpatient,,,5173.00000,3103.80000,MedCost,Commercial,,4190.13,,,,,,,3310.72,4190.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,MedCost,Commercial,,3155.53,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,inpatient,,,5388.00000,3232.80000,MedCost,Commercial,,4364.28,,,,,,,3448.32,4364.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,MedCost,Commercial,,3286.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,inpatient,,,3604.00000,2162.40000,MedCost,Commercial,,2919.24,,,,,,,2306.56,2919.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,MedCost,Commercial,,2198.44,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,inpatient,,,3765.00000,2259.00000,MedCost,Commercial,,3049.65,,,,,,,2409.60,3049.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,MedCost,Commercial,,2296.65,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,inpatient,,,5158.00000,3094.80000,MedCost,Commercial,,4177.98,,,,,,,3301.12,4177.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,MedCost,Commercial,,3146.38,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,inpatient,,,3472.00000,2083.20000,MedCost,Commercial,,2812.32,,,,,,,2222.08,2812.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,MedCost,Commercial,,2117.92,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,inpatient,,,4076.00000,2445.60000,MedCost,Commercial,,3301.56,,,,,,,2608.64,3301.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,MedCost,Commercial,,2486.36,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,inpatient,,,4699.00000,2819.40000,MedCost,Commercial,,3806.19,,,,,,,3007.36,3806.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,MedCost,Commercial,,2866.39,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,inpatient,,,3708.00000,2224.80000,MedCost,Commercial,,3003.48,,,,,,,2373.12,3003.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,MedCost,Commercial,,2261.88,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,inpatient,,,3892.00000,2335.20000,MedCost,Commercial,,3152.52,,,,,,,2490.88,3152.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,MedCost,Commercial,,2374.12,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,inpatient,,,5332.00000,3199.20000,MedCost,Commercial,,4318.92,,,,,,,3412.48,4318.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,MedCost,Commercial,,3252.52,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,inpatient,,,3675.00000,2205.00000,MedCost,Commercial,,2976.75,,,,,,,2352.00,2976.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,MedCost,Commercial,,2241.75,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,inpatient,,,3712.00000,2227.20000,MedCost,Commercial,,3006.72,,,,,,,2375.68,3006.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,MedCost,Commercial,,2264.32,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,inpatient,,,5158.00000,3094.80000,MedCost,Commercial,,4177.98,,,,,,,3301.12,4177.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,MedCost,Commercial,,3146.38,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,inpatient,,,4256.00000,2553.60000,MedCost,Commercial,,3447.36,,,,,,,2723.84,3447.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,MedCost,Commercial,,2596.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,inpatient,,,4501.00000,2700.60000,MedCost,Commercial,,3645.81,,,,,,,2880.64,3645.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,MedCost,Commercial,,2745.61,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,inpatient,,,5234.00000,3140.40000,MedCost,Commercial,,4239.54,,,,,,,3349.76,4239.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,MedCost,Commercial,,3192.74,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,inpatient,,,2919.00000,1751.40000,MedCost,Commercial,,2364.39,,,,,,,1868.16,2364.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,MedCost,Commercial,,1780.59,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,inpatient,,,4185.00000,2511.00000,MedCost,Commercial,,3389.85,,,,,,,2678.40,3389.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,MedCost,Commercial,,2552.85,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,inpatient,,,3172.00000,1903.20000,MedCost,Commercial,,2569.32,,,,,,,2030.08,2569.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,MedCost,Commercial,,1934.92,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Commercial,,204.93,,,,,,,161.92,204.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Commercial,,154.33,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,inpatient,,,3952.00000,2371.20000,MedCost,Commercial,52,3201.12,,,,,,,2529.28,3201.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,MedCost,Commercial,52,2410.72,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,inpatient,,,3933.00000,2359.80000,MedCost,Commercial,52,3185.73,,,,,,,2517.12,3185.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,MedCost,Commercial,52,2399.13,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,inpatient,,,3843.00000,2305.80000,MedCost,Commercial,,3112.83,,,,,,,2459.52,3112.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,MedCost,Commercial,,2344.23,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,inpatient,,,4405.00000,2643.00000,MedCost,Commercial,,3568.05,,,,,,,2819.20,3568.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,MedCost,Commercial,,2687.05,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,inpatient,,,5196.00000,3117.60000,MedCost,Commercial,,4208.76,,,,,,,3325.44,4208.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,MedCost,Commercial,,3169.56,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,inpatient,,,4024.00000,2414.40000,MedCost,Commercial,,3259.44,,,,,,,2575.36,3259.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,MedCost,Commercial,,2454.64,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,inpatient,,,4135.00000,2481.00000,MedCost,Commercial,,3349.35,,,,,,,2646.40,3349.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,MedCost,Commercial,,2522.35,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,inpatient,,,3516.00000,2109.60000,MedCost,Commercial,,2847.96,,,,,,,2250.24,2847.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,MedCost,Commercial,,2144.76,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,inpatient,,,4274.00000,2564.40000,MedCost,Commercial,,3461.94,,,,,,,2735.36,3461.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,MedCost,Commercial,,2607.14,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,inpatient,,,3523.00000,2113.80000,MedCost,Commercial,,2853.63,,,,,,,2254.72,2853.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,MedCost,Commercial,,2149.03,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,inpatient,,,4051.00000,2430.60000,MedCost,Commercial,,3281.31,,,,,,,2592.64,3281.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,MedCost,Commercial,,2471.11,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,inpatient,,,5104.00000,3062.40000,MedCost,Commercial,,4134.24,,,,,,,3266.56,4134.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,MedCost,Commercial,,3113.44,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,inpatient,,,4912.00000,2947.20000,MedCost,Commercial,,3978.72,,,,,,,3143.68,3978.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,MedCost,Commercial,,2996.32,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,inpatient,,,5454.00000,3272.40000,MedCost,Commercial,,4417.74,,,,,,,3490.56,4417.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,MedCost,Commercial,,3326.94,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,inpatient,,,4190.00000,2514.00000,MedCost,Commercial,,3393.90,,,,,,,2681.60,3393.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,MedCost,Commercial,,2555.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,inpatient,,,4637.00000,2782.20000,MedCost,Commercial,,3755.97,,,,,,,2967.68,3755.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,MedCost,Commercial,,2828.57,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,inpatient,,,5586.00000,3351.60000,MedCost,Commercial,,4524.66,,,,,,,3575.04,4524.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,MedCost,Commercial,,3407.46,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,inpatient,,,3468.00000,2080.80000,MedCost,Commercial,,2809.08,,,,,,,2219.52,2809.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,MedCost,Commercial,,2115.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,inpatient,,,3671.00000,2202.60000,MedCost,Commercial,,2973.51,,,,,,,2349.44,2973.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,MedCost,Commercial,,2239.31,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,inpatient,,,5340.00000,3204.00000,MedCost,Commercial,,4325.40,,,,,,,3417.60,4325.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,MedCost,Commercial,,3257.40,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,inpatient,,,3245.00000,1947.00000,MedCost,Commercial,,2628.45,,,,,,,2076.80,2628.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,MedCost,Commercial,,1979.45,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,inpatient,,,3599.00000,2159.40000,MedCost,Commercial,,2915.19,,,,,,,2303.36,2915.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,MedCost,Commercial,,2195.39,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,inpatient,,,4999.00000,2999.40000,MedCost,Commercial,,4049.19,,,,,,,3199.36,4049.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,MedCost,Commercial,,3049.39,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,inpatient,,,4225.00000,2535.00000,MedCost,Commercial,,3422.25,,,,,,,2704.00,3422.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,MedCost,Commercial,,2577.25,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,inpatient,,,3236.00000,1941.60000,MedCost,Commercial,,2621.16,,,,,,,2071.04,2621.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,MedCost,Commercial,,1973.96,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,inpatient,,,4472.00000,2683.20000,MedCost,Commercial,,3622.32,,,,,,,2862.08,3622.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,MedCost,Commercial,,2727.92,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,inpatient,,,4238.00000,2542.80000,MedCost,Commercial,,3432.78,,,,,,,2712.32,3432.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,MedCost,Commercial,,2585.18,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,inpatient,,,4238.00000,2542.80000,MedCost,Commercial,,3432.78,,,,,,,2712.32,3432.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,MedCost,Commercial,,2585.18,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,inpatient,,,4238.00000,2542.80000,MedCost,Commercial,,3432.78,,,,,,,2712.32,3432.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,MedCost,Commercial,,2585.18,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,inpatient,,,3535.00000,2121.00000,MedCost,Commercial,,2863.35,,,,,,,2262.40,2863.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,MedCost,Commercial,,2156.35,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,inpatient,,,4068.00000,2440.80000,MedCost,Commercial,,3295.08,,,,,,,2603.52,3295.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,MedCost,Commercial,,2481.48,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,inpatient,,,4068.00000,2440.80000,MedCost,Commercial,,3295.08,,,,,,,2603.52,3295.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,MedCost,Commercial,,2481.48,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,inpatient,,,4493.00000,2695.80000,MedCost,Commercial,,3639.33,,,,,,,2875.52,3639.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,MedCost,Commercial,,2740.73,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,inpatient,,,3250.00000,1950.00000,MedCost,Commercial,,2632.50,,,,,,,2080.00,2632.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,MedCost,Commercial,,1982.50,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,inpatient,,,4594.00000,2756.40000,MedCost,Commercial,,3721.14,,,,,,,2940.16,3721.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,MedCost,Commercial,,2802.34,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,inpatient,,,4466.00000,2679.60000,MedCost,Commercial,,3617.46,,,,,,,2858.24,3617.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,MedCost,Commercial,,2724.26,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,inpatient,,,4223.00000,2533.80000,MedCost,Commercial,,3420.63,,,,,,,2702.72,3420.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,MedCost,Commercial,,2576.03,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,inpatient,,,4223.00000,2533.80000,MedCost,Commercial,,3420.63,,,,,,,2702.72,3420.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,MedCost,Commercial,,2576.03,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,inpatient,,,4540.00000,2724.00000,MedCost,Commercial,,3677.40,,,,,,,2905.60,3677.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,MedCost,Commercial,,2769.40,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,inpatient,,,4540.00000,2724.00000,MedCost,Commercial,,3677.40,,,,,,,2905.60,3677.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,MedCost,Commercial,,2769.40,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,inpatient,,,4540.00000,2724.00000,MedCost,Commercial,,3677.40,,,,,,,2905.60,3677.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,MedCost,Commercial,,2769.40,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,inpatient,,,3523.00000,2113.80000,MedCost,Commercial,,2853.63,,,,,,,2254.72,2853.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,MedCost,Commercial,,2149.03,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,inpatient,,,1033.00000,619.80000,MedCost,Commercial,,836.73,,,,,,,661.12,836.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,MedCost,Commercial,,630.13,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,inpatient,,,2400.00000,1440.00000,MedCost,Commercial,,1944.00,,,,,,,1536.00,1944.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,MedCost,Commercial,,1464.00,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,inpatient,,,2385.00000,1431.00000,MedCost,Commercial,,1931.85,,,,,,,1526.40,1931.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,MedCost,Commercial,,1454.85,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,inpatient,,,3952.00000,2371.20000,MedCost,Commercial,,3201.12,,,,,,,2529.28,3201.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,MedCost,Commercial,,2410.72,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,inpatient,,,1875.00000,1125.00000,MedCost,Commercial,,1518.75,,,,,,,1200.00,1518.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,MedCost,Commercial,,1143.75,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,inpatient,,,426.00000,255.60000,MedCost,Commercial,,345.06,,,,,,,272.64,345.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,MedCost,Commercial,,259.86,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Commercial,,262.44,,,,,,,207.36,262.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Commercial,,197.64,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Commercial,,323.19,,,,,,,255.36,323.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Commercial,,243.39,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,inpatient,,,1745.00000,1047.00000,MedCost,Commercial,,1413.45,,,,,,,1116.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,MedCost,Commercial,,1064.45,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,inpatient,,,1745.00000,1047.00000,MedCost,Commercial,,1413.45,,,,,,,1116.80,1418.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,MedCost,Commercial,,1064.45,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Commercial,,127.98,,,,,,,101.12,128.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Commercial,,96.38,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,inpatient,,,1831.00000,1098.60000,MedCost,Commercial,,1483.11,,,,,,,1171.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,MedCost,Commercial,,1116.91,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,inpatient,,,1831.00000,1098.60000,MedCost,Commercial,,1483.11,,,,,,,1171.84,1488.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,MedCost,Commercial,,1116.91,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,inpatient,,,905.00000,543.00000,MedCost,Commercial,,733.05,,,,,,,579.20,733.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,MedCost,Commercial,,552.05,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,inpatient,,,540.00000,324.00000,MedCost,Commercial,,437.40,,,,,,,345.60,437.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,MedCost,Commercial,,329.40,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Commercial,,384.75,,,,,,,304.00,384.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Commercial,,289.75,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Commercial,,384.75,,,,,,,304.00,384.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Commercial,,289.75,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,inpatient,,,1299.00000,779.40000,MedCost,Commercial,,1052.19,,,,,,,831.36,1052.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,MedCost,Commercial,,792.39,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Commercial,,839.97,,,,,,,663.68,839.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Commercial,,632.57,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,inpatient,,,847.00000,508.20000,MedCost,Commercial,,686.07,,,,,,,542.08,686.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,MedCost,Commercial,,516.67,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,inpatient,,,616.00000,369.60000,MedCost,Commercial,,498.96,,,,,,,394.24,498.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,MedCost,Commercial,,375.76,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,inpatient,,,599.00000,359.40000,MedCost,Commercial,,485.19,,,,,,,383.36,485.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,MedCost,Commercial,,365.39,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Commercial,,236.52,,,,,,,186.88,236.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Commercial,,178.12,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,inpatient,,,431.00000,258.60000,MedCost,Commercial,,349.11,,,,,,,275.84,349.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,MedCost,Commercial,,262.91,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Commercial,,256.77,,,,,,,202.88,256.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Commercial,,193.37,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Commercial,,233.28,,,,,,,184.32,233.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Commercial,,175.68,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,inpatient,,,680.00000,408.00000,MedCost,Commercial,,550.80,,,,,,,435.20,550.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,MedCost,Commercial,,414.80,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,inpatient,,,281.00000,168.60000,MedCost,Commercial,,227.61,,,,,,,179.84,227.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,MedCost,Commercial,,171.41,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Commercial,,471.42,,,,,,,372.48,471.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Commercial,,355.02,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Commercial,,471.42,,,,,,,372.48,471.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Commercial,,355.02,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,inpatient,,,1436.00000,861.60000,MedCost,Commercial,,1163.16,,,,,,,919.04,1163.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,MedCost,Commercial,,875.96,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,inpatient,,,752.00000,451.20000,MedCost,Commercial,,609.12,,,,,,,481.28,609.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,MedCost,Commercial,,458.72,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,inpatient,,,1866.00000,1119.60000,MedCost,Commercial,,1511.46,,,,,,,1194.24,1511.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,MedCost,Commercial,,1138.26,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,inpatient,,,4350.00000,2610.00000,MedCost,Commercial,,3523.50,,,,,,,2784.00,3523.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,MedCost,Commercial,,2653.50,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,inpatient,,,252.00000,151.20000,MedCost,Commercial,,204.12,,,,,,,161.28,204.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,MedCost,Commercial,,153.72,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,inpatient,,,177.00000,106.20000,MedCost,Commercial,,143.37,,,,,,,113.28,143.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,MedCost,Commercial,,107.97,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,inpatient,,,369.00000,221.40000,MedCost,Commercial,,298.89,,,,,,,236.16,298.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,MedCost,Commercial,,225.09,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,inpatient,,,183.00000,109.80000,MedCost,Commercial,,148.23,,,,,,,117.12,148.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,MedCost,Commercial,,111.63,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,inpatient,,,427.00000,256.20000,MedCost,Commercial,,345.87,,,,,,,273.28,345.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,MedCost,Commercial,,260.47,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,inpatient,,,329.00000,197.40000,MedCost,Commercial,,266.49,,,,,,,210.56,266.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,MedCost,Commercial,,200.69,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Commercial,,222.75,,,,,,,176.00,222.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Commercial,,167.75,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Commercial,,323.19,,,,,,,255.36,323.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Commercial,,243.39,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,inpatient,,,631.00000,378.60000,MedCost,Commercial,,511.11,,,,,,,403.84,511.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,MedCost,Commercial,,384.91,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Commercial,,419.58,,,,,,,331.52,419.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Commercial,,315.98,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,inpatient,,,874.00000,524.40000,MedCost,Commercial,,707.94,,,,,,,559.36,707.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,MedCost,Commercial,,533.14,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,inpatient,,,562.00000,337.20000,MedCost,Commercial,,455.22,,,,,,,359.68,455.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,MedCost,Commercial,,342.82,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Commercial,,46.17,,,,,,,36.48,46.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Commercial,,34.77,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,inpatient,,,362.00000,217.20000,MedCost,Commercial,,293.22,,,,,,,231.68,293.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,MedCost,Commercial,,220.82,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,inpatient,,,756.00000,453.60000,MedCost,Commercial,,612.36,,,,,,,483.84,612.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,MedCost,Commercial,,461.16,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Commercial,,247.05,,,,,,,195.20,247.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Commercial,,186.05,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,inpatient,,,665.00000,399.00000,MedCost,Commercial,,538.65,,,,,,,425.60,538.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,MedCost,Commercial,,405.65,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Commercial,,341.82,,,,,,,270.08,341.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Commercial,,257.42,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,inpatient,,,956.00000,573.60000,MedCost,Commercial,,774.36,,,,,,,611.84,774.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,MedCost,Commercial,,583.16,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,inpatient,,,599.00000,359.40000,MedCost,Commercial,,485.19,,,,,,,383.36,485.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,MedCost,Commercial,,365.39,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Commercial,,341.82,,,,,,,270.08,341.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Commercial,,257.42,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Commercial,,370.98,,,,,,,293.12,370.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Commercial,,279.38,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,inpatient,,,364.00000,218.40000,MedCost,Commercial,,294.84,,,,,,,232.96,294.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,MedCost,Commercial,,222.04,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,inpatient,,,2524.00000,1514.40000,MedCost,Commercial,,2044.44,,,,,,,1615.36,2044.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,MedCost,Commercial,,1539.64,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,inpatient,,,2169.00000,1301.40000,MedCost,Commercial,,1756.89,,,,,,,1388.16,1756.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,MedCost,Commercial,,1323.09,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,inpatient,,,1106.00000,663.60000,MedCost,Commercial,,895.86,,,,,,,707.84,895.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,MedCost,Commercial,,674.66,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,inpatient,,,521.00000,312.60000,MedCost,Commercial,,422.01,,,,,,,333.44,422.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,MedCost,Commercial,,317.81,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,inpatient,,,553.00000,331.80000,MedCost,Commercial,,447.93,,,,,,,353.92,447.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,MedCost,Commercial,,337.33,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,inpatient,,,336.00000,201.60000,MedCost,Commercial,,272.16,,,,,,,215.04,272.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,MedCost,Commercial,,204.96,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Commercial,,103.68,,,,,,,81.92,103.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Commercial,,78.08,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,inpatient,,,512.00000,307.20000,MedCost,Commercial,,414.72,,,,,,,327.68,414.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,MedCost,Commercial,,312.32,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,inpatient,,,404.00000,242.40000,MedCost,Commercial,,327.24,,,,,,,258.56,327.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,MedCost,Commercial,,246.44,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,inpatient,,,404.00000,242.40000,MedCost,Commercial,,327.24,,,,,,,258.56,327.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,MedCost,Commercial,,246.44,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,inpatient,,,2404.00000,1442.40000,MedCost,Commercial,,1947.24,,,,,,,1538.56,1947.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,MedCost,Commercial,,1466.44,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Commercial,,38.07,,,,,,,30.08,38.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Commercial,,28.67,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,inpatient,,,14.00000,8.40000,MedCost,Commercial,,11.34,,,,,,,8.96,11.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,MedCost,Commercial,,8.54,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,inpatient,,,112.00000,67.20000,MedCost,Commercial,,90.72,,,,,,,71.68,90.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,MedCost,Commercial,,68.32,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Commercial,,132.03,,,,,,,104.32,132.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Commercial,,99.43,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Commercial,,106.92,,,,,,,84.48,106.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Commercial,,80.52,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Commercial,,21.06,,,,,,,16.64,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Commercial,,15.86,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,inpatient,,,44.00000,26.40000,MedCost,Commercial,,35.64,,,,,,,28.16,35.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,MedCost,Commercial,,26.84,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Commercial,,153.09,,,,,,,120.96,153.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Commercial,,115.29,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,inpatient,,,265.00000,159.00000,MedCost,Commercial,,214.65,,,,,,,169.60,214.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,MedCost,Commercial,,161.65,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00640,0.00810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,inpatient,,,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,56.32,71.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Commercial,,204.93,,,,,,,161.92,204.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Commercial,,154.33,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Commercial,,153.09,,,,,,,120.96,153.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Commercial,,115.29,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,inpatient,,,397.00000,238.20000,MedCost,Commercial,,321.57,,,,,,,254.08,321.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,MedCost,Commercial,,242.17,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,inpatient,,,155.00000,93.00000,MedCost,Commercial,,125.55,,,,,,,99.20,125.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,MedCost,Commercial,,94.55,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Commercial,,433.35,,,,,,,342.40,433.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Commercial,,326.35,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Commercial,,57.51,,,,,,,45.44,57.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Commercial,,43.31,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Commercial,,107.73,,,,,,,85.12,107.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Commercial,,81.13,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Commercial,,107.73,,,,,,,85.12,107.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Commercial,,81.13,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Commercial,,107.73,,,,,,,85.12,107.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Commercial,,81.13,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Commercial,,23.49,,,,,,,18.56,23.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Commercial,,17.69,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,inpatient,,,177.00000,106.20000,MedCost,Commercial,,143.37,,,,,,,113.28,143.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,MedCost,Commercial,,107.97,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,inpatient,,,124.00000,74.40000,MedCost,Commercial,,100.44,,,,,,,79.36,100.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,MedCost,Commercial,,75.64,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Commercial,,31.59,,,,,,,24.96,31.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Commercial,,23.79,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Commercial,,117.45,,,,,,,92.80,117.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Commercial,,88.45,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Commercial,,117.45,,,,,,,92.80,117.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Commercial,,88.45,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Commercial,,117.45,,,,,,,92.80,117.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Commercial,,88.45,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,72.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,72.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,72.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,inpatient,,,154.00000,92.40000,MedCost,Commercial,,124.74,,,,,,,98.56,124.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,MedCost,Commercial,,93.94,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Commercial,,23.49,,,,,,,18.56,23.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Commercial,,17.69,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Commercial,,34.83,,,,,,,27.52,34.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Commercial,,26.23,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Commercial,,34.02,,,,,,,26.88,34.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Commercial,,25.62,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Commercial,,38.88,,,,,,,30.72,38.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Commercial,,29.28,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Commercial,,131.22,,,,,,,103.68,131.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Commercial,,98.82,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Commercial,,93.15,,,,,,,73.60,93.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Commercial,,70.15,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Commercial,,93.15,,,,,,,73.60,93.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Commercial,,70.15,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Commercial,,93.15,,,,,,,73.60,93.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Commercial,,70.15,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Commercial,,34.02,,,,,,,26.88,34.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Commercial,,25.62,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,inpatient,,,60.00000,36.00000,MedCost,Commercial,,48.60,,,,,,,38.40,48.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,MedCost,Commercial,,36.60,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Commercial,,32.40,,,,,,,25.60,32.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Commercial,,24.40,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Commercial,,32.40,,,,,,,25.60,32.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Commercial,,24.40,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,inpatient,,,166.00000,99.60000,MedCost,Commercial,,134.46,,,,,,,106.24,134.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,MedCost,Commercial,,101.26,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,,54.29,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,,54.29,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Commercial,,53.46,,,,,,,42.24,53.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Commercial,,40.26,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,inpatient,,,53.00000,31.80000,MedCost,Commercial,,42.93,,,,,,,33.92,42.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,MedCost,Commercial,,32.33,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,inpatient,,,258.00000,154.80000,MedCost,Commercial,,208.98,,,,,,,165.12,208.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,MedCost,Commercial,,157.38,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Commercial,,53.46,,,,,,,42.24,53.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Commercial,,40.26,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,inpatient,,,243.00000,145.80000,MedCost,Commercial,,196.83,,,,,,,155.52,196.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,MedCost,Commercial,,148.23,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,72.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,72.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Commercial,,145.80,,,,,,,115.20,145.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Commercial,,109.80,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,inpatient,,,146.00000,87.60000,MedCost,Commercial,,118.26,,,,,,,93.44,118.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,MedCost,Commercial,,89.06,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Commercial,,63.99,,,,,,,50.56,63.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Commercial,,48.19,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Commercial,,31.59,,,,,,,24.96,31.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Commercial,,23.79,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,inpatient,,,299.00000,179.40000,MedCost,Commercial,,242.19,,,,,,,191.36,242.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,MedCost,Commercial,,182.39,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,inpatient,,,6.00000,3.60000,MedCost,Commercial,,4.86,,,,,,,3.84,4.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,MedCost,Commercial,,3.66,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Commercial,,162.81,,,,,,,128.64,162.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Commercial,,122.61,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,inpatient,,,579.00000,347.40000,MedCost,Commercial,,468.99,,,,,,,370.56,468.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,MedCost,Commercial,,353.19,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Commercial,,127.17,,,,,,,100.48,127.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Commercial,,95.77,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Commercial,,98.82,,,,,,,78.08,98.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Commercial,,74.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Commercial,,98.82,,,,,,,78.08,98.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Commercial,,74.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Commercial,,98.82,,,,,,,78.08,98.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Commercial,,74.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Commercial,,98.82,,,,,,,78.08,98.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Commercial,,74.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Commercial,,31.59,,,,,,,24.96,31.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Commercial,,23.79,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Commercial,,164.43,,,,,,,129.92,164.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Commercial,,123.83,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Commercial,,164.43,,,,,,,129.92,164.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Commercial,,123.83,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Commercial,,164.43,,,,,,,129.92,164.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Commercial,,123.83,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Commercial,,164.43,,,,,,,129.92,164.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Commercial,,123.83,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Commercial,,24.30,,,,,,,19.20,24.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Commercial,,18.30,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Commercial,,57.51,,,,,,,45.44,57.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Commercial,,43.31,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,inpatient,,,171.00000,102.60000,MedCost,Commercial,,138.51,,,,,,,109.44,138.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,MedCost,Commercial,,104.31,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Commercial,,131.22,,,,,,,103.68,131.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Commercial,,98.82,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,inpatient,,,78.00000,46.80000,MedCost,Commercial,,63.18,,,,,,,49.92,63.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,MedCost,Commercial,,47.58,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,inpatient,,,238.00000,142.80000,MedCost,Commercial,,192.78,,,,,,,152.32,192.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,MedCost,Commercial,,145.18,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Commercial,,126.36,,,,,,,99.84,126.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Commercial,,95.16,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,inpatient,,,221.00000,132.60000,MedCost,Commercial,,179.01,,,,,,,141.44,179.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,MedCost,Commercial,,134.81,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Commercial,,97.20,,,,,,,76.80,97.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Commercial,,73.20,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Commercial,,123.12,,,,,,,97.28,123.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Commercial,,92.72,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Commercial,,38.07,,,,,,,30.08,38.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Commercial,,28.67,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Commercial,,38.07,,,,,,,30.08,38.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Commercial,,28.67,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,inpatient,,,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,inpatient,,,197.00000,118.20000,MedCost,Commercial,,159.57,,,,,,,126.08,159.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,MedCost,Commercial,,120.17,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Commercial,,106.92,,,,,,,84.48,106.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Commercial,,80.52,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Commercial,,32.40,,,,,,,25.60,32.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Commercial,,24.40,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,53.76,68.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Commercial,,30.78,,,,,,,24.32,30.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Commercial,,23.18,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,51.20,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,51.20,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Commercial,,34.02,,,,,,,26.88,34.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Commercial,,25.62,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Commercial,,127.98,,,,,,,101.12,127.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Commercial,,96.38,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Commercial,,127.98,,,,,,,101.12,127.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Commercial,,96.38,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,inpatient,,,149.00000,89.40000,MedCost,Commercial,,120.69,,,,,,,95.36,120.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,MedCost,Commercial,,90.89,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Commercial,,30.78,,,,,,,24.32,30.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Commercial,,23.18,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Commercial,,115.83,,,,,,,91.52,115.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Commercial,,87.23,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,inpatient,,,83.00000,49.80000,MedCost,Commercial,,67.23,,,,,,,53.12,67.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,MedCost,Commercial,,50.63,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Commercial,,115.83,,,,,,,91.52,115.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Commercial,,87.23,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,inpatient,,,177.00000,106.20000,MedCost,Commercial,,143.37,,,,,,,113.28,143.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,MedCost,Commercial,,107.97,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Commercial,,21.06,,,,,,,16.64,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Commercial,,15.86,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Commercial,,21.06,,,,,,,16.64,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Commercial,,15.86,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Commercial,,21.06,,,,,,,16.64,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Commercial,,15.86,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,46.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,68.48,86.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,inpatient,,,2.00000,1.20000,MedCost,Commercial,,1.62,,,,,,,1.28,1.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,MedCost,Commercial,,1.22,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,inpatient,,,329.00000,197.40000,MedCost,Commercial,,266.49,,,,,,,210.56,266.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,MedCost,Commercial,,200.69,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Commercial,,44.55,,,,,,,35.20,44.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Commercial,,33.55,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,inpatient,,,146.00000,87.60000,MedCost,Commercial,,118.26,,,,,,,93.44,118.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,MedCost,Commercial,,89.06,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,inpatient,,,227.00000,136.20000,MedCost,Commercial,,183.87,,,,,,,145.28,183.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,MedCost,Commercial,,138.47,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Commercial,,174.15,,,,,,,137.60,174.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Commercial,,131.15,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Commercial,,174.15,,,,,,,137.60,174.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Commercial,,131.15,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Commercial,,36.45,,,,,,,28.80,36.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Commercial,,27.45,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,inpatient,,,53.00000,31.80000,MedCost,Commercial,,42.93,,,,,,,33.92,42.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,MedCost,Commercial,,32.33,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Commercial,,40.50,,,,,,,32.00,40.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Commercial,,30.50,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Commercial,,53.46,,,,,,,42.24,53.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Commercial,,40.26,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Commercial,,36.45,,,,,,,28.80,36.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Commercial,,27.45,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Commercial,,25.92,,,,,,,20.48,25.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Commercial,,19.52,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Commercial,,25.92,,,,,,,20.48,25.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Commercial,,19.52,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Commercial,,34.83,,,,,,,27.52,34.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Commercial,,26.23,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Commercial,,12.15,,,,,,,9.60,12.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Commercial,,9.15,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,inpatient,,,167.00000,100.20000,MedCost,Commercial,,135.27,,,,,,,106.88,135.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,MedCost,Commercial,,101.87,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Commercial,,36.45,,,,,,,28.80,36.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Commercial,,27.45,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,inpatient,,,160.00000,96.00000,MedCost,Commercial,,129.60,,,,,,,102.40,129.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,MedCost,Commercial,,97.60,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,inpatient,,,190.00000,114.00000,MedCost,Commercial,,153.90,,,,,,,121.60,153.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,MedCost,Commercial,,115.90,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,59.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Commercial,,53.46,,,,,,,42.24,53.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Commercial,,40.26,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Commercial,,108.54,,,,,,,85.76,108.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Commercial,,81.74,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Commercial,,105.30,,,,,,,83.20,105.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Commercial,,79.30,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,inpatient,,,108.00000,64.80000,MedCost,Commercial,,87.48,,,,,,,69.12,87.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,MedCost,Commercial,,65.88,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Commercial,,30.78,,,,,,,24.32,30.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Commercial,,23.18,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Commercial,,93.15,,,,,,,73.60,93.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Commercial,,70.15,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Commercial,,93.15,,,,,,,73.60,93.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Commercial,,70.15,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Commercial,,105.30,,,,,,,83.20,105.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Commercial,,79.30,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,inpatient,,,193.00000,115.80000,MedCost,Commercial,,156.33,,,,,,,123.52,156.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,MedCost,Commercial,,117.73,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Commercial,,63.99,,,,,,,50.56,63.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Commercial,,48.19,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Commercial,,9.72,,,,,,,7.68,9.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Commercial,,7.32,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Commercial,,300.51,,,,,,,237.44,300.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Commercial,,226.31,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Commercial,,300.51,,,,,,,237.44,300.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Commercial,,226.31,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,inpatient,,,225.00000,135.00000,MedCost,Commercial,,182.25,,,,,,,144.00,182.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,MedCost,Commercial,,137.25,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Commercial,,25.92,,,,,,,20.48,25.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Commercial,,19.52,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Commercial,,113.40,,,,,,,89.60,113.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Commercial,,85.40,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Commercial,,91.53,,,,,,,72.32,91.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Commercial,,68.93,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Commercial,,78.57,,,,,,,62.08,78.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Commercial,,59.17,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,inpatient,,,137.00000,82.20000,MedCost,Commercial,,110.97,,,,,,,87.68,110.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,MedCost,Commercial,,83.57,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Commercial,,97.20,,,,,,,76.80,97.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Commercial,,73.20,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,inpatient,,,8.00000,4.80000,MedCost,Commercial,,6.48,,,,,,,5.12,6.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,MedCost,Commercial,,4.88,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,inpatient,,,22.00000,13.20000,MedCost,Commercial,,17.82,,,,,,,14.08,17.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,MedCost,Commercial,,13.42,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Commercial,,85.86,,,,,,,67.84,85.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Commercial,,64.66,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,inpatient,,,174.00000,104.40000,MedCost,Commercial,,140.94,,,,,,,111.36,140.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,MedCost,Commercial,,106.14,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,29.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Commercial,,103.68,,,,,,,81.92,103.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Commercial,,78.08,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,inpatient,,,267.00000,160.20000,MedCost,Commercial,,216.27,,,,,,,170.88,216.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,MedCost,Commercial,,162.87,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,inpatient,,,147.00000,88.20000,MedCost,Commercial,,119.07,,,,,,,94.08,119.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,MedCost,Commercial,,89.67,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Commercial,,221.13,,,,,,,174.72,221.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Commercial,,166.53,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,inpatient,,,207.00000,124.20000,MedCost,Commercial,,167.67,,,,,,,132.48,167.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,MedCost,Commercial,,126.27,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Commercial,,40.50,,,,,,,32.00,40.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Commercial,,30.50,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,inpatient,,,237.00000,142.20000,MedCost,Commercial,,191.97,,,,,,,151.68,191.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,MedCost,Commercial,,144.57,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,inpatient,,,206.00000,123.60000,MedCost,Commercial,,166.86,,,,,,,131.84,166.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,MedCost,Commercial,,125.66,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,inpatient,,,41.00000,24.60000,MedCost,Commercial,,33.21,,,,,,,26.24,33.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,MedCost,Commercial,,25.01,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,inpatient,,,293.00000,175.80000,MedCost,Commercial,,237.33,,,,,,,187.52,237.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,MedCost,Commercial,,178.73,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Commercial,,162.81,,,,,,,128.64,162.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Commercial,,122.61,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Commercial,,37.26,,,,,,,29.44,37.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Commercial,,28.06,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Commercial,,91.53,,,,,,,72.32,91.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Commercial,,68.93,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Commercial,,91.53,,,,,,,72.32,91.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Commercial,,68.93,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Commercial,,40.50,,,,,,,32.00,40.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Commercial,,30.50,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Commercial,,109.35,,,,,,,86.40,109.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Commercial,,82.35,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,inpatient,,,223.00000,133.80000,MedCost,Commercial,,180.63,,,,,,,142.72,180.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,MedCost,Commercial,,136.03,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,inpatient,,,21.00000,12.60000,MedCost,Commercial,,17.01,,,,,,,13.44,17.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,MedCost,Commercial,,12.81,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Commercial,,46.17,,,,,,,36.48,46.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Commercial,,34.77,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Commercial,,117.45,,,,,,,92.80,117.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Commercial,,88.45,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,inpatient,,,68.00000,40.80000,MedCost,Commercial,,55.08,,,,,,,43.52,55.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,MedCost,Commercial,,41.48,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,,94.77,,,,,,,74.88,94.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,,71.37,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,inpatient,,,173.00000,103.80000,MedCost,Commercial,,140.13,,,,,,,110.72,140.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,MedCost,Commercial,,105.53,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Commercial,,78.57,,,,,,,62.08,78.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Commercial,,59.17,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Commercial,,93.96,,,,,,,74.24,93.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Commercial,,70.76,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Commercial,,93.96,,,,,,,74.24,93.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Commercial,,70.76,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Commercial,,12.15,,,,,,,9.60,12.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Commercial,,9.15,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,,54.29,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,,54.29,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Commercial,,28.35,,,,,,,22.40,28.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Commercial,,21.35,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Commercial,,36.45,,,,,,,28.80,36.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Commercial,,27.45,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,inpatient,,,69.00000,41.40000,MedCost,Commercial,,55.89,,,,,,,44.16,55.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,MedCost,Commercial,,42.09,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,inpatient,,,461.00000,276.60000,MedCost,Commercial,,373.41,,,,,,,295.04,373.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,MedCost,Commercial,,281.21,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Commercial,,98.82,,,,,,,78.08,98.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Commercial,,74.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Commercial,,157.95,,,,,,,124.80,157.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Commercial,,118.95,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,inpatient,,,83.00000,49.80000,MedCost,Commercial,,67.23,,,,,,,53.12,67.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,MedCost,Commercial,,50.63,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,inpatient,,,11.00000,6.60000,MedCost,Commercial,,8.91,,,,,,,7.04,8.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,MedCost,Commercial,,6.71,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Commercial,,28.35,,,,,,,22.40,28.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Commercial,,21.35,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Commercial,,109.35,,,,,,,86.40,109.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Commercial,,82.35,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,inpatient,,,108.00000,64.80000,MedCost,Commercial,,87.48,,,,,,,69.12,87.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,MedCost,Commercial,,65.88,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,inpatient,,,794.00000,476.40000,MedCost,Commercial,,643.14,,,,,,,508.16,643.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,MedCost,Commercial,,484.34,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,inpatient,,,447.00000,268.20000,MedCost,Commercial,,362.07,,,,,,,286.08,362.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,MedCost,Commercial,,272.67,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,inpatient,,,266.00000,159.60000,MedCost,Commercial,,215.46,,,,,,,170.24,215.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,MedCost,Commercial,,162.26,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,inpatient,,,570.00000,342.00000,MedCost,Commercial,,461.70,,,,,,,364.80,461.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,MedCost,Commercial,,347.70,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,inpatient,,,841.00000,504.60000,MedCost,Commercial,,681.21,,,,,,,538.24,681.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,MedCost,Commercial,,513.01,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,,100.65,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,inpatient,,,296.00000,177.60000,MedCost,Commercial,,239.76,,,,,,,189.44,239.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,MedCost,Commercial,,180.56,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,inpatient,,,361.00000,216.60000,MedCost,Commercial,,292.41,,,,,,,231.04,292.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,MedCost,Commercial,,220.21,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Commercial,,68.85,,,,,,,54.40,68.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Commercial,,51.85,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Commercial,,68.85,,,,,,,54.40,68.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Commercial,,51.85,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Commercial,,68.85,,,,,,,54.40,68.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Commercial,,51.85,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,inpatient,,,233.00000,139.80000,MedCost,Commercial,,188.73,,,,,,,149.12,188.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,MedCost,Commercial,,142.13,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Commercial,,117.45,,,,,,,92.80,117.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Commercial,,88.45,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Commercial,,99.63,,,,,,,78.72,99.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Commercial,,75.03,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Commercial,,108.54,,,,,,,85.76,108.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Commercial,,81.74,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,inpatient,,,196.00000,117.60000,MedCost,Commercial,,158.76,,,,,,,125.44,158.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,MedCost,Commercial,,119.56,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,inpatient,,,173.00000,103.80000,MedCost,Commercial,,140.13,,,,,,,110.72,140.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,MedCost,Commercial,,105.53,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,inpatient,,,501.00000,300.60000,MedCost,Commercial,,405.81,,,,,,,320.64,405.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,MedCost,Commercial,,305.61,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,inpatient,,,737.00000,442.20000,MedCost,Commercial,,596.97,,,,,,,471.68,596.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,MedCost,Commercial,,449.57,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,inpatient,,,126.00000,75.60000,MedCost,Commercial,,102.06,,,,,,,80.64,102.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,MedCost,Commercial,,76.86,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Commercial,,112.59,,,,,,,88.96,112.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Commercial,,84.79,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,29.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Commercial,,121.50,,,,,,,96.00,121.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Commercial,,91.50,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Commercial,,75.33,,,,,,,59.52,75.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Commercial,,56.73,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Commercial,,131.22,,,,,,,103.68,131.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Commercial,,98.82,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,inpatient,,,433.00000,259.80000,MedCost,Commercial,,350.73,,,,,,,277.12,350.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,MedCost,Commercial,,264.13,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,inpatient,,,433.00000,259.80000,MedCost,Commercial,,350.73,,,,,,,277.12,350.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,MedCost,Commercial,,264.13,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Commercial,,261.63,,,,,,,206.72,261.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Commercial,,197.03,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Commercial,,222.75,,,,,,,176.00,222.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Commercial,,167.75,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,inpatient,,,291.00000,174.60000,MedCost,Commercial,,235.71,,,,,,,186.24,235.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,MedCost,Commercial,,177.51,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,inpatient,,,264.00000,158.40000,MedCost,Commercial,,213.84,,,,,,,168.96,213.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,MedCost,Commercial,,161.04,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,inpatient,,,612.00000,367.20000,MedCost,Commercial,,495.72,,,,,,,391.68,495.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,MedCost,Commercial,,373.32,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Commercial,,130.41,,,,,,,103.04,130.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Commercial,,98.21,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,inpatient,,,237.00000,142.20000,MedCost,Commercial,,191.97,,,,,,,151.68,191.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,MedCost,Commercial,,144.57,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,inpatient,,,199.00000,119.40000,MedCost,Commercial,,161.19,,,,,,,127.36,161.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,MedCost,Commercial,,121.39,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Commercial,,80.19,,,,,,,63.36,80.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Commercial,,60.39,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,inpatient,,,325.00000,195.00000,MedCost,Commercial,,263.25,,,,,,,208.00,263.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,MedCost,Commercial,,198.25,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,inpatient,,,271.00000,162.60000,MedCost,Commercial,,219.51,,,,,,,173.44,219.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,MedCost,Commercial,,165.31,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Commercial,,261.63,,,,,,,206.72,261.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Commercial,,197.03,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,inpatient,,,251.00000,150.60000,MedCost,Commercial,,203.31,,,,,,,160.64,203.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,MedCost,Commercial,,153.11,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,inpatient,,,182.00000,109.20000,MedCost,Commercial,,147.42,,,,,,,116.48,147.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,MedCost,Commercial,,111.02,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Commercial,,150.66,,,,,,,119.04,150.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Commercial,,113.46,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Commercial,,150.66,,,,,,,119.04,150.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Commercial,,113.46,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,inpatient,,,247.00000,148.20000,MedCost,Commercial,,200.07,,,,,,,158.08,200.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,MedCost,Commercial,,150.67,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,inpatient,,,44.00000,26.40000,MedCost,Commercial,,35.64,,,,,,,28.16,35.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,MedCost,Commercial,,26.84,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Commercial,,121.50,,,,,,,96.00,121.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Commercial,,91.50,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,inpatient,,,196.00000,117.60000,MedCost,Commercial,,158.76,,,,,,,125.44,158.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,MedCost,Commercial,,119.56,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,inpatient,,,468.00000,280.80000,MedCost,Commercial,,379.08,,,,,,,299.52,379.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,MedCost,Commercial,,285.48,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,inpatient,,,283.00000,169.80000,MedCost,Commercial,,229.23,,,,,,,181.12,229.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,MedCost,Commercial,,172.63,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,59.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Commercial,,28.35,,,,,,,22.40,28.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Commercial,,21.35,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Commercial,,58.32,,,,,,,46.08,58.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Commercial,,43.92,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Commercial,,91.53,,,,,,,72.32,91.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Commercial,,68.93,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,inpatient,,,356.00000,213.60000,MedCost,Commercial,,288.36,,,,,,,227.84,288.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,MedCost,Commercial,,217.16,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,inpatient,,,146.00000,87.60000,MedCost,Commercial,,118.26,,,,,,,93.44,118.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,MedCost,Commercial,,89.06,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Commercial,,163.62,,,,,,,129.28,163.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Commercial,,123.22,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Commercial,,115.83,,,,,,,91.52,115.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Commercial,,87.23,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,,94.77,,,,,,,74.88,94.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,,71.37,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Commercial,,94.77,,,,,,,74.88,94.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Commercial,,71.37,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Commercial,,63.99,,,,,,,50.56,63.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Commercial,,48.19,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,inpatient,,,102.00000,61.20000,MedCost,Commercial,,82.62,,,,,,,65.28,82.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,MedCost,Commercial,,62.22,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Commercial,,68.85,,,,,,,54.40,68.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Commercial,,51.85,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,inpatient,,,98.00000,58.80000,MedCost,Commercial,,79.38,,,,,,,62.72,79.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,MedCost,Commercial,,59.78,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,inpatient,,,224.00000,134.40000,MedCost,Commercial,,181.44,,,,,,,143.36,181.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,MedCost,Commercial,,136.64,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,51.20,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Commercial,,31.59,,,,,,,24.96,31.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Commercial,,23.79,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,inpatient,,,19.00000,11.40000,MedCost,Commercial,,15.39,,,,,,,12.16,15.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,MedCost,Commercial,,11.59,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Commercial,,38.07,,,,,,,30.08,38.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Commercial,,28.67,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Commercial,,12.15,,,,,,,9.60,12.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Commercial,,9.15,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,inpatient,,,41.00000,24.60000,MedCost,Commercial,,33.21,,,,,,,26.24,33.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,MedCost,Commercial,,25.01,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Commercial,,152.28,,,,,,,120.32,152.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Commercial,,114.68,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Commercial,,98.82,,,,,,,78.08,98.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Commercial,,74.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Commercial,,105.30,,,,,,,83.20,105.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Commercial,,79.30,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Commercial,,57.51,,,,,,,45.44,57.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Commercial,,43.31,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Commercial,,127.17,,,,,,,100.48,127.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Commercial,,95.77,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,inpatient,,,27.00000,16.20000,MedCost,Commercial,,21.87,,,,,,,17.28,21.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,MedCost,Commercial,,16.47,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,inpatient,,,53.00000,31.80000,MedCost,Commercial,,42.93,,,,,,,33.92,42.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,MedCost,Commercial,,32.33,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,inpatient,,,187.00000,112.20000,MedCost,Commercial,,151.47,,,,,,,119.68,151.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,MedCost,Commercial,,114.07,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,inpatient,,,187.00000,112.20000,MedCost,Commercial,,151.47,,,,,,,119.68,151.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,MedCost,Commercial,,114.07,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Commercial,,78.57,,,,,,,62.08,78.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Commercial,,59.17,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Commercial,,172.53,,,,,,,136.32,172.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Commercial,,129.93,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Commercial,,165.24,,,,,,,130.56,165.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Commercial,,124.44,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,59.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Commercial,,25.92,,,,,,,20.48,25.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Commercial,,19.52,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Commercial,,165.24,,,,,,,130.56,165.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Commercial,,124.44,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Commercial,,25.11,,,,,,,19.84,25.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Commercial,,18.91,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Commercial,,56.70,,,,,,,44.80,56.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Commercial,,42.70,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Commercial,,117.45,,,,,,,92.80,117.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Commercial,,88.45,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Commercial,,74.52,,,,,,,58.88,74.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Commercial,,56.12,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Commercial,,31.59,,,,,,,24.96,31.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Commercial,,23.79,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Commercial,,24.30,,,,,,,19.20,24.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Commercial,,18.30,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Commercial,,24.30,,,,,,,19.20,24.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Commercial,,18.30,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Commercial,,21.06,,,,,,,16.64,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Commercial,,15.86,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,,104.49,,,,,,,82.56,104.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,,78.69,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Commercial,,93.96,,,,,,,74.24,93.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Commercial,,70.76,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Commercial,,63.99,,,,,,,50.56,63.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Commercial,,48.19,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,inpatient,,,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,59.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,59.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,59.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,59.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,inpatient,,,339.00000,203.40000,MedCost,Commercial,,274.59,,,,,,,216.96,274.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,MedCost,Commercial,,206.79,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,inpatient,,,68.00000,40.80000,MedCost,Commercial,,55.08,,,,,,,43.52,55.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,MedCost,Commercial,,41.48,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,53.76,68.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,,54.29,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,inpatient,,,16.00000,9.60000,MedCost,Commercial,,12.96,,,,,,,10.24,12.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,MedCost,Commercial,,9.76,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,inpatient,,,245.00000,147.00000,MedCost,Commercial,,198.45,,,,,,,156.80,198.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,MedCost,Commercial,,149.45,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,53.76,68.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,inpatient,,,154.00000,92.40000,MedCost,Commercial,,124.74,,,,,,,98.56,124.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,MedCost,Commercial,,93.94,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Commercial,,29.97,,,,,,,23.68,29.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Commercial,,22.57,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Commercial,,80.19,,,,,,,63.36,80.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Commercial,,60.39,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,inpatient,,,78.00000,46.80000,MedCost,Commercial,,63.18,,,,,,,49.92,63.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,MedCost,Commercial,,47.58,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Commercial,,32.40,,,,,,,25.60,32.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Commercial,,24.40,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Commercial,,46.17,,,,,,,36.48,46.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Commercial,,34.77,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Commercial,,30.78,,,,,,,24.32,30.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Commercial,,23.18,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Commercial,,51.03,,,,,,,40.32,51.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Commercial,,38.43,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Commercial,,145.80,,,,,,,115.20,145.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Commercial,,109.80,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,inpatient,,,33.00000,19.80000,MedCost,Commercial,,26.73,,,,,,,21.12,26.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,MedCost,Commercial,,20.13,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Commercial,,30.78,,,,,,,24.32,30.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Commercial,,23.18,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,inpatient,,,228.00000,136.80000,MedCost,Commercial,,184.68,,,,,,,145.92,184.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,MedCost,Commercial,,139.08,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,inpatient,,,169.00000,101.40000,MedCost,Commercial,,136.89,,,,,,,108.16,136.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,MedCost,Commercial,,103.09,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,inpatient,,,461.00000,276.60000,MedCost,Commercial,,373.41,,,,,,,295.04,373.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,MedCost,Commercial,,281.21,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Commercial,,172.53,,,,,,,136.32,172.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Commercial,,129.93,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Commercial,,172.53,,,,,,,136.32,172.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Commercial,,129.93,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Commercial,,509.49,,,,,,,402.56,509.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Commercial,,383.69,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,inpatient,,,581.00000,348.60000,MedCost,Commercial,,470.61,,,,,,,371.84,470.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,MedCost,Commercial,,354.41,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,inpatient,,,174.00000,104.40000,MedCost,Commercial,,140.94,,,,,,,111.36,140.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,MedCost,Commercial,,106.14,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Commercial,,130.41,,,,,,,103.04,130.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Commercial,,98.21,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Commercial,,283.50,,,,,,,224.00,283.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Commercial,,213.50,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Commercial,,171.72,,,,,,,135.68,171.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Commercial,,129.32,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Commercial,,132.84,,,,,,,104.96,132.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Commercial,,100.04,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Commercial,,132.84,,,,,,,104.96,132.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Commercial,,100.04,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Commercial,,222.75,,,,,,,176.00,222.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Commercial,,167.75,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,inpatient,,,257.00000,154.20000,MedCost,Commercial,,208.17,,,,,,,164.48,208.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,MedCost,Commercial,,156.77,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,inpatient,,,770.00000,462.00000,MedCost,Commercial,,623.70,,,,,,,492.80,623.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,MedCost,Commercial,,469.70,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,inpatient,,,87.00000,52.20000,MedCost,Commercial,,70.47,,,,,,,55.68,70.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,MedCost,Commercial,,53.07,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,inpatient,,,83.00000,49.80000,MedCost,Commercial,,67.23,,,,,,,53.12,67.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,MedCost,Commercial,,50.63,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Commercial,,38.88,,,,,,,30.72,38.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Commercial,,29.28,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,inpatient,,,112.00000,67.20000,MedCost,Commercial,,90.72,,,,,,,71.68,90.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,MedCost,Commercial,,68.32,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,inpatient,,,579.00000,347.40000,MedCost,Commercial,,468.99,,,,,,,370.56,468.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,MedCost,Commercial,,353.19,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,inpatient,,,279.00000,167.40000,MedCost,Commercial,,225.99,,,,,,,178.56,225.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,MedCost,Commercial,,170.19,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Commercial,,44.55,,,,,,,35.20,44.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Commercial,,33.55,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,inpatient,,,154.00000,92.40000,MedCost,Commercial,,124.74,,,,,,,98.56,124.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,MedCost,Commercial,,93.94,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,inpatient,,,96.00000,57.60000,MedCost,Commercial,,77.76,,,,,,,61.44,77.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,MedCost,Commercial,,58.56,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,inpatient,,,96.00000,57.60000,MedCost,Commercial,,77.76,,,,,,,61.44,77.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,MedCost,Commercial,,58.56,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,inpatient,,,96.00000,57.60000,MedCost,Commercial,,77.76,,,,,,,61.44,77.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,MedCost,Commercial,,58.56,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Commercial,,375.03,,,,,,,296.32,375.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Commercial,,282.43,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Commercial,,238.14,,,,,,,188.16,238.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Commercial,,179.34,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,inpatient,,,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,56.32,71.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,inpatient,,,88.00000,52.80000,MedCost,Commercial,,71.28,,,,,,,56.32,71.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,MedCost,Commercial,,53.68,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Commercial,,41.31,,,,,,,32.64,41.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Commercial,,31.11,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,inpatient,,,126.00000,75.60000,MedCost,Commercial,,102.06,,,,,,,80.64,102.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,MedCost,Commercial,,76.86,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Commercial,,9.72,,,,,,,7.68,9.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Commercial,,7.32,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Commercial,,121.50,,,,,,,96.00,121.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Commercial,,91.50,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Commercial,,97.20,,,,,,,76.80,97.20,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Commercial,,73.20,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,inpatient,,,548.00000,328.80000,MedCost,Commercial,,443.88,,,,,,,350.72,443.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,MedCost,Commercial,,334.28,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,inpatient,,,309.00000,185.40000,MedCost,Commercial,,250.29,,,,,,,197.76,250.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,MedCost,Commercial,,188.49,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Commercial,,102.87,,,,,,,81.28,102.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Commercial,,77.47,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Commercial,,29.16,,,,,,,23.04,29.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Commercial,,21.96,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,inpatient,,,22.00000,13.20000,MedCost,Commercial,,17.82,,,,,,,14.08,17.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,MedCost,Commercial,,13.42,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,inpatient,,,230.00000,138.00000,MedCost,Commercial,,186.30,,,,,,,147.20,186.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,MedCost,Commercial,,140.30,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Commercial,,23.49,,,,,,,18.56,23.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Commercial,,17.69,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,inpatient,,,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Commercial,,85.86,,,,,,,67.84,85.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Commercial,,64.66,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Commercial,,46.98,,,,,,,37.12,46.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Commercial,,35.38,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Commercial,,28.35,,,,,,,22.40,28.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Commercial,,21.35,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Commercial,,28.35,,,,,,,22.40,28.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Commercial,,21.35,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,inpatient,,,19.00000,11.40000,MedCost,Commercial,,15.39,,,,,,,12.16,15.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,MedCost,Commercial,,11.59,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Commercial,,49.41,,,,,,,39.04,49.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Commercial,,37.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,inpatient,,,64.00000,38.40000,MedCost,Commercial,,51.84,,,,,,,40.96,51.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,MedCost,Commercial,,39.04,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Commercial,,37.26,,,,,,,29.44,37.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Commercial,,28.06,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Commercial,,45.36,,,,,,,35.84,45.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Commercial,,34.16,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Commercial,,57.51,,,,,,,45.44,57.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Commercial,,43.31,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Commercial,,12.15,,,,,,,9.60,12.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Commercial,,9.15,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Commercial,,24.30,,,,,,,19.20,24.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Commercial,,18.30,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Commercial,,204.93,,,,,,,161.92,204.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Commercial,,154.33,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Commercial,,108.54,,,,,,,85.76,108.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Commercial,,81.74,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,inpatient,,,171.00000,102.60000,MedCost,Commercial,,138.51,,,,,,,109.44,138.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,MedCost,Commercial,,104.31,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Commercial,,21.06,,,,,,,16.64,21.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Commercial,,15.86,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Commercial,,131.22,,,,,,,103.68,131.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Commercial,,98.82,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Commercial,,63.99,,,,,,,50.56,63.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Commercial,,48.19,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Commercial,,23.49,,,,,,,18.56,23.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Commercial,,17.69,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00640,0.00810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,inpatient,,,414.00000,248.40000,MedCost,Commercial,,335.34,,,,,,,264.96,335.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,MedCost,Commercial,,252.54,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,inpatient,,,2.00000,1.20000,MedCost,Commercial,,1.62,,,,,,,1.28,1.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,MedCost,Commercial,,1.22,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Commercial,,419.58,,,,,,,331.52,419.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Commercial,,315.98,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Commercial,,65.61,,,,,,,51.84,65.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Commercial,,49.41,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Commercial,,23.49,,,,,,,18.56,23.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Commercial,,17.69,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Commercial,,130.41,,,,,,,103.04,130.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Commercial,,98.21,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,inpatient,,,1960.00000,1176.00000,MedCost,Commercial,,1587.60,,,,,,,1254.40,1587.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,MedCost,Commercial,,1195.60,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,inpatient,,,141.00000,84.60000,MedCost,Commercial,,114.21,,,,,,,90.24,114.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,MedCost,Commercial,,86.01,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,,54.29,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,inpatient,,,34.00000,20.40000,MedCost,Commercial,,27.54,,,,,,,21.76,27.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,MedCost,Commercial,,20.74,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Commercial,,30.78,,,,,,,24.32,30.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Commercial,,23.18,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Commercial,,56.70,,,,,,,44.80,56.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Commercial,,42.70,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Commercial,,56.70,,,,,,,44.80,56.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Commercial,,42.70,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Commercial,,12.15,,,,,,,9.60,12.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Commercial,,9.15,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Commercial,,28.35,,,,,,,22.40,28.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Commercial,,21.35,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Commercial,,60.75,,,,,,,48.00,60.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Commercial,,45.75,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Commercial,,39.69,,,,,,,31.36,39.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Commercial,,29.89,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,inpatient,,,529.00000,317.40000,MedCost,Commercial,,428.49,,,,,,,338.56,428.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,MedCost,Commercial,,322.69,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,inpatient,,,767.00000,460.20000,MedCost,Commercial,,621.27,,,,,,,490.88,621.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,MedCost,Commercial,,467.87,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Commercial,,108.54,,,,,,,85.76,108.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Commercial,,81.74,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,inpatient,,,1805.00000,1083.00000,MedCost,Commercial,,1462.05,,,,,,,1155.20,1462.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,MedCost,Commercial,,1101.05,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,inpatient,,,1258.00000,754.80000,MedCost,Commercial,,1018.98,,,,,,,805.12,1018.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,MedCost,Commercial,,767.38,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,inpatient,,,293.00000,175.80000,MedCost,Commercial,,237.33,,,,,,,187.52,237.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,MedCost,Commercial,,178.73,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Commercial,,93.96,,,,,,,74.24,93.96,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Commercial,,70.76,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,inpatient,,,1931.00000,1158.60000,MedCost,Commercial,,1564.11,,,,,,,1235.84,1564.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,MedCost,Commercial,,1177.91,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,inpatient,,,23.00000,13.80000,MedCost,Commercial,,18.63,,,,,,,14.72,18.63,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,MedCost,Commercial,,14.03,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,inpatient,,,259.00000,155.40000,MedCost,Commercial,,209.79,,,,,,,165.76,209.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,MedCost,Commercial,,157.99,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Commercial,,37.26,,,,,,,29.44,37.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Commercial,,28.06,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,inpatient,,,1808.00000,1084.80000,MedCost,Commercial,,1464.48,,,,,,,1157.12,1464.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,MedCost,Commercial,,1102.88,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,inpatient,,,707.00000,424.20000,MedCost,Commercial,,572.67,,,,,,,452.48,572.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,MedCost,Commercial,,431.27,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,68.48,86.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,inpatient,,,513.00000,307.80000,MedCost,Commercial,,415.53,,,,,,,328.32,415.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,MedCost,Commercial,,312.93,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Commercial,,153.09,,,,,,,120.96,153.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Commercial,,115.29,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,inpatient,,,1960.00000,1176.00000,MedCost,Commercial,,1587.60,,,,,,,1254.40,1587.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,MedCost,Commercial,,1195.60,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,inpatient,,,114.00000,68.40000,MedCost,Commercial,,92.34,,,,,,,72.96,92.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,MedCost,Commercial,,69.54,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Commercial,,262.44,,,,,,,207.36,262.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Commercial,,197.64,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,inpatient,,,194.00000,116.40000,MedCost,Commercial,,157.14,,,,,,,124.16,157.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,MedCost,Commercial,,118.34,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,inpatient,,,953.00000,571.80000,MedCost,Commercial,,771.93,,,,,,,609.92,771.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,MedCost,Commercial,,581.33,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,inpatient,,,639.00000,383.40000,MedCost,Commercial,,517.59,,,,,,,408.96,517.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,MedCost,Commercial,,389.79,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Commercial,,113.40,,,,,,,89.60,113.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Commercial,,85.40,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Commercial,QW,113.40,,,,,,,89.60,113.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Commercial,QW,85.40,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Commercial,,37.26,,,,,,,29.44,37.26,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Commercial,,28.06,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,inpatient,,,278.00000,166.80000,MedCost,Commercial,,225.18,,,,,,,177.92,225.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,MedCost,Commercial,,169.58,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,inpatient,,,1589.00000,953.40000,MedCost,Commercial,,1287.09,,,,,,,1016.96,1287.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,MedCost,Commercial,,969.29,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,inpatient,,,1187.00000,712.20000,MedCost,Commercial,,961.47,,,,,,,759.68,961.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,MedCost,Commercial,,724.07,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,inpatient,,,278.00000,166.80000,MedCost,Commercial,,225.18,,,,,,,177.92,225.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,MedCost,Commercial,,169.58,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,inpatient,,,609.00000,365.40000,MedCost,Commercial,,493.29,,,,,,,389.76,493.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,MedCost,Commercial,,371.49,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,inpatient,,,478.00000,286.80000,MedCost,Commercial,,387.18,,,,,,,305.92,387.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,MedCost,Commercial,,291.58,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Commercial,,165.24,,,,,,,130.56,165.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Commercial,,124.44,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,inpatient,,,426.00000,255.60000,MedCost,Commercial,,345.06,,,,,,,272.64,345.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,MedCost,Commercial,,259.86,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Commercial,,40.50,,,,,,,32.00,40.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Commercial,,30.50,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Commercial,QW,81.00,,,,,,,64.00,81.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Commercial,QW,61.00,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Commercial,,81.00,,,,,,,64.00,81.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Commercial,,61.00,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Commercial,,132.03,,,,,,,104.32,132.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Commercial,,99.43,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,inpatient,,,907.00000,544.20000,MedCost,Commercial,,734.67,,,,,,,580.48,734.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,MedCost,Commercial,,553.27,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Commercial,,222.75,,,,,,,176.00,222.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Commercial,,167.75,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Commercial,,106.92,,,,,,,84.48,106.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Commercial,,80.52,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,,100.65,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Commercial,,72.09,,,,,,,56.96,72.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Commercial,,54.29,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Commercial,,34.83,,,,,,,27.52,34.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Commercial,,26.23,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,inpatient,,,280.00000,168.00000,MedCost,Commercial,,226.80,,,,,,,179.20,226.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,MedCost,Commercial,,170.80,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Commercial,,63.99,,,,,,,50.56,63.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Commercial,,48.19,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,inpatient,,,194.00000,116.40000,MedCost,Commercial,,157.14,,,,,,,124.16,157.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,MedCost,Commercial,,118.34,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,inpatient,,,69.00000,41.40000,MedCost,Commercial,,55.89,,,,,,,44.16,55.89,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,MedCost,Commercial,,42.09,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Commercial,,53.46,,,,,,,42.24,53.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Commercial,,40.26,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Commercial,,283.50,,,,,,,224.00,283.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Commercial,,213.50,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Commercial,,109.35,,,,,,,86.40,109.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Commercial,,82.35,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Commercial,,172.53,,,,,,,136.32,172.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Commercial,,129.93,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,inpatient,,,219.00000,131.40000,MedCost,Commercial,,177.39,,,,,,,140.16,177.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,MedCost,Commercial,,133.59,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Commercial,,109.35,,,,,,,86.40,109.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Commercial,,82.35,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Commercial,,109.35,,,,,,,86.40,109.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Commercial,,82.35,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Commercial,,222.75,,,,,,,176.00,222.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Commercial,,167.75,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Commercial,,36.45,,,,,,,28.80,36.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Commercial,,27.45,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Commercial,,36.45,,,,,,,28.80,36.45,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Commercial,,27.45,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,inpatient,,,76.00000,45.60000,MedCost,Commercial,,61.56,,,,,,,48.64,61.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,MedCost,Commercial,,46.36,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Commercial,,34.83,,,,,,,27.52,34.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Commercial,,26.23,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Commercial,,68.04,,,,,,,53.76,68.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Commercial,,51.24,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Commercial,,81.81,,,,,,,64.64,81.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Commercial,,61.61,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,inpatient,,,149.00000,89.40000,MedCost,Commercial,,120.69,,,,,,,95.36,120.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,MedCost,Commercial,,90.89,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Commercial,,1075.68,,,,,,,849.92,1075.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,MedCost,Commercial,,810.08,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Commercial,,44.55,,,,,,,35.20,44.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Commercial,,33.55,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,inpatient,,,108.00000,64.80000,MedCost,Commercial,,87.48,,,,,,,69.12,87.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,MedCost,Commercial,,65.88,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Commercial,,95.58,,,,,,,75.52,95.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Commercial,,71.98,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Commercial,,52.65,,,,,,,41.60,52.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Commercial,,39.65,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Commercial,,46.17,,,,,,,36.48,46.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Commercial,,34.77,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,inpatient,,,271.00000,162.60000,MedCost,Commercial,,219.51,,,,,,,173.44,219.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,MedCost,Commercial,,165.31,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,inpatient,,,167.00000,100.20000,MedCost,Commercial,,135.27,,,,,,,106.88,135.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,MedCost,Commercial,,101.87,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,inpatient,,,271.00000,162.60000,MedCost,Commercial,,219.51,,,,,,,173.44,219.51,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,MedCost,Commercial,,165.31,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,inpatient,,,319.00000,191.40000,MedCost,Commercial,,258.39,,,,,,,204.16,258.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,MedCost,Commercial,,194.59,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Commercial,,417.15,,,,,,,329.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Commercial,,314.15,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,inpatient,,,526.00000,315.60000,MedCost,Commercial,,426.06,,,,,,,336.64,426.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,MedCost,Commercial,,320.86,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,inpatient,,,210.00000,126.00000,MedCost,Commercial,,170.10,,,,,,,134.40,170.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,MedCost,Commercial,,128.10,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00640,0.00810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,inpatient,,,27.00000,16.20000,MedCost,Commercial,,21.87,,,,,,,17.28,21.87,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,MedCost,Commercial,,16.47,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Commercial,,89.10,,,,,,,70.40,89.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Commercial,,67.10,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Commercial,,150.66,,,,,,,119.04,150.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Commercial,,113.46,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,inpatient,,,147.00000,88.20000,MedCost,Commercial,,119.07,,,,,,,94.08,119.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,MedCost,Commercial,,89.67,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,inpatient,,,147.00000,88.20000,MedCost,Commercial,,119.07,,,,,,,94.08,119.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,MedCost,Commercial,,89.67,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Commercial,,31.59,,,,,,,24.96,31.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Commercial,,23.79,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,inpatient,,,198.00000,118.80000,MedCost,Commercial,,160.38,,,,,,,126.72,160.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,MedCost,Commercial,,120.78,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,inpatient,,,119.00000,71.40000,MedCost,Commercial,,96.39,,,,,,,76.16,96.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,MedCost,Commercial,,72.59,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,inpatient,,,255.00000,153.00000,MedCost,Commercial,,206.55,,,,,,,163.20,206.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,MedCost,Commercial,,155.55,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,inpatient,,,261.00000,156.60000,MedCost,Commercial,,211.41,,,,,,,167.04,211.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,MedCost,Commercial,,159.21,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,inpatient,,,78.00000,46.80000,MedCost,Commercial,,63.18,,,,,,,49.92,63.18,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,MedCost,Commercial,,47.58,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Commercial,,110.16,,,,,,,87.04,110.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Commercial,,82.96,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,inpatient,,,209.00000,125.40000,MedCost,Commercial,,169.29,,,,,,,133.76,169.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,MedCost,Commercial,,127.49,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,inpatient,,,207.00000,124.20000,MedCost,Commercial,,167.67,,,,,,,132.48,167.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,MedCost,Commercial,,126.27,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Commercial,,419.58,,,,,,,331.52,419.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Commercial,,315.98,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,inpatient,,,148.00000,88.80000,MedCost,Commercial,,119.88,,,,,,,94.72,119.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,MedCost,Commercial,,90.28,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,inpatient,,,456.00000,273.60000,MedCost,Commercial,,369.36,,,,,,,291.84,369.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,MedCost,Commercial,,278.16,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,inpatient,,,597.00000,358.20000,MedCost,Commercial,,483.57,,,,,,,382.08,483.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,MedCost,Commercial,,364.17,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,inpatient,,,755.00000,453.00000,MedCost,Commercial,,611.55,,,,,,,483.20,611.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,MedCost,Commercial,,460.55,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,inpatient,,,561.00000,336.60000,MedCost,Commercial,,454.41,,,,,,,359.04,454.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,MedCost,Commercial,,342.21,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,inpatient,,,325.00000,195.00000,MedCost,Commercial,,263.25,,,,,,,208.00,263.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,MedCost,Commercial,,198.25,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,inpatient,,,225.00000,135.00000,MedCost,Commercial,,182.25,,,,,,,144.00,182.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,MedCost,Commercial,,137.25,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,inpatient,,,1019.00000,611.40000,MedCost,Commercial,,825.39,,,,,,,652.16,825.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,MedCost,Commercial,,621.59,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,inpatient,,,354.00000,212.40000,MedCost,Commercial,,286.74,,,,,,,226.56,286.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,MedCost,Commercial,,215.94,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,inpatient,,,609.00000,365.40000,MedCost,Commercial,,493.29,,,,,,,389.76,493.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,MedCost,Commercial,,371.49,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,inpatient,,,224.00000,134.40000,MedCost,Commercial,,181.44,,,,,,,143.36,181.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,MedCost,Commercial,,136.64,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,51.20,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Commercial,,106.92,,,,,,,84.48,106.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Commercial,,80.52,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Commercial,,109.35,,,,,,,86.40,109.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Commercial,,82.35,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,inpatient,,,548.00000,328.80000,MedCost,Commercial,,443.88,,,,,,,350.72,443.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,MedCost,Commercial,,334.28,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,inpatient,,,102.00000,61.20000,MedCost,Commercial,,82.62,,,,,,,65.28,82.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,MedCost,Commercial,,62.22,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,inpatient,,,175.00000,105.00000,MedCost,Commercial,,141.75,,,,,,,112.00,141.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,MedCost,Commercial,,106.75,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,inpatient,,,367.00000,220.20000,MedCost,Commercial,,297.27,,,,,,,234.88,297.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,MedCost,Commercial,,223.87,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Commercial,,534.60,,,,,,,422.40,534.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Commercial,,402.60,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00810,,,,,,,0.00640,0.00810,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Commercial,,0.00610,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,inpatient,,,124.00000,74.40000,MedCost,Commercial,,100.44,,,,,,,79.36,100.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,MedCost,Commercial,,75.64,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,inpatient,,,226.00000,135.60000,MedCost,Commercial,,183.06,,,,,,,144.64,183.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,MedCost,Commercial,,137.86,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,inpatient,,,370.00000,222.00000,MedCost,Commercial,,299.70,,,,,,,236.80,299.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,MedCost,Commercial,,225.70,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,inpatient,,,319.00000,191.40000,MedCost,Commercial,,258.39,,,,,,,204.16,258.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,MedCost,Commercial,,194.59,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,inpatient,,,319.00000,191.40000,MedCost,Commercial,,258.39,,,,,,,204.16,258.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,MedCost,Commercial,,194.59,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,inpatient,,,593.00000,355.80000,MedCost,Commercial,,480.33,,,,,,,379.52,480.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,MedCost,Commercial,,361.73,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,inpatient,,,548.00000,328.80000,MedCost,Commercial,,443.88,,,,,,,350.72,443.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,MedCost,Commercial,,334.28,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Commercial,,78.57,,,,,,,62.08,78.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Commercial,,59.17,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,,104.49,,,,,,,82.56,104.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,,78.69,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,inpatient,,,394.00000,236.40000,MedCost,Commercial,,319.14,,,,,,,252.16,319.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,MedCost,Commercial,,240.34,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,inpatient,,,313.00000,187.80000,MedCost,Commercial,,253.53,,,,,,,200.32,253.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,MedCost,Commercial,,190.93,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,inpatient,,,249.00000,149.40000,MedCost,Commercial,,201.69,,,,,,,159.36,201.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,MedCost,Commercial,,151.89,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Commercial,,62.37,,,,,,,49.28,62.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Commercial,,46.97,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,inpatient,,,384.00000,230.40000,MedCost,Commercial,,311.04,,,,,,,245.76,311.04,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,MedCost,Commercial,,234.24,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Commercial,,106.92,,,,,,,84.48,106.92,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Commercial,,80.52,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,inpatient,,,675.00000,405.00000,MedCost,Commercial,,546.75,,,,,,,432.00,546.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,MedCost,Commercial,,411.75,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Commercial,,153.09,,,,,,,120.96,153.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Commercial,,115.29,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,inpatient,,,414.00000,248.40000,MedCost,Commercial,,335.34,,,,,,,264.96,335.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,MedCost,Commercial,,252.54,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,inpatient,,,256.00000,153.60000,MedCost,Commercial,,207.36,,,,,,,163.84,207.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,MedCost,Commercial,,156.16,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,inpatient,,,261.00000,156.60000,MedCost,Commercial,,211.41,,,,,,,167.04,211.41,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,MedCost,Commercial,,159.21,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Commercial,,127.17,,,,,,,100.48,127.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Commercial,,95.77,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Commercial,,127.17,,,,,,,100.48,127.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Commercial,,95.77,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Commercial,,436.59,,,,,,,344.96,436.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Commercial,,328.79,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Commercial,,112.59,,,,,,,88.96,112.59,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Commercial,,84.79,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Commercial,,132.84,,,,,,,104.96,132.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Commercial,,100.04,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,inpatient,,,18.00000,10.80000,MedCost,Commercial,,14.58,,,,,,,11.52,14.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,MedCost,Commercial,,10.98,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,inpatient,,,414.00000,248.40000,MedCost,Commercial,,335.34,,,,,,,264.96,335.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,MedCost,Commercial,,252.54,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,inpatient,,,247.00000,148.20000,MedCost,Commercial,,200.07,,,,,,,158.08,200.07,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,MedCost,Commercial,,150.67,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,inpatient,,,2191.00000,1314.60000,MedCost,Commercial,,1774.71,,,,,,,1402.24,1774.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,MedCost,Commercial,,1336.51,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,inpatient,,,353.00000,211.80000,MedCost,Commercial,,285.93,,,,,,,225.92,285.93,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,MedCost,Commercial,,215.33,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,inpatient,,,192.00000,115.20000,MedCost,Commercial,,155.52,,,,,,,122.88,155.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,MedCost,Commercial,,117.12,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,inpatient,,,708.00000,424.80000,MedCost,Commercial,,573.48,,,,,,,453.12,573.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,MedCost,Commercial,,431.88,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Commercial,,419.58,,,,,,,331.52,419.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Commercial,,315.98,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,inpatient,,,354.00000,212.40000,MedCost,Commercial,,286.74,,,,,,,226.56,286.74,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,MedCost,Commercial,,215.94,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,246.40,311.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,inpatient,,,367.00000,220.20000,MedCost,Commercial,,297.27,,,,,,,234.88,297.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,MedCost,Commercial,,223.87,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,246.40,311.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Commercial,,420.39,,,,,,,332.16,420.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Commercial,,316.59,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,inpatient,,,1285.00000,771.00000,MedCost,Commercial,,1040.85,,,,,,,822.40,1040.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,MedCost,Commercial,,783.85,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,51.20,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,246.40,311.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,inpatient,,,367.00000,220.20000,MedCost,Commercial,,297.27,,,,,,,234.88,297.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,MedCost,Commercial,,223.87,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,inpatient,,,312.00000,187.20000,MedCost,Commercial,,252.72,,,,,,,199.68,252.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,MedCost,Commercial,,190.32,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Commercial,,104.49,,,,,,,82.56,104.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Commercial,,78.69,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,inpatient,,,1243.00000,745.80000,MedCost,Commercial,,1006.83,,,,,,,795.52,1006.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,MedCost,Commercial,,758.23,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Commercial,,19.44,,,,,,,15.36,19.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Commercial,,14.64,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,inpatient,,,192.00000,115.20000,MedCost,Commercial,,155.52,,,,,,,122.88,155.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,MedCost,Commercial,,117.12,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,51.20,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,inpatient,,,908.00000,544.80000,MedCost,Commercial,,735.48,,,,,,,581.12,735.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,MedCost,Commercial,,553.88,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Commercial,,534.60,,,,,,,422.40,534.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Commercial,,402.60,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,inpatient,,,474.00000,284.40000,MedCost,Commercial,,383.94,,,,,,,303.36,383.94,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,MedCost,Commercial,,289.14,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,inpatient,,,356.00000,213.60000,MedCost,Commercial,,288.36,,,,,,,227.84,288.36,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,MedCost,Commercial,,217.16,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,inpatient,,,125.00000,75.00000,MedCost,Commercial,,101.25,,,,,,,80.00,101.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,MedCost,Commercial,,76.25,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Commercial,,121.50,,,,,,,96.00,121.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Commercial,,91.50,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Commercial,,76.95,,,,,,,60.80,76.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Commercial,,57.95,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,inpatient,,,166.00000,99.60000,MedCost,Commercial,,134.46,,,,,,,106.24,134.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,MedCost,Commercial,,101.26,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Commercial,,64.80,,,,,,,51.20,64.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Commercial,,48.80,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,inpatient,,,159.00000,95.40000,MedCost,Commercial,,128.79,,,,,,,101.76,128.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,MedCost,Commercial,,96.99,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,inpatient,,,1589.00000,953.40000,MedCost,Commercial,,1287.09,,,,,,,1016.96,1287.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,MedCost,Commercial,,969.29,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,inpatient,,,798.00000,478.80000,MedCost,Commercial,,646.38,,,,,,,510.72,646.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,MedCost,Commercial,,486.78,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,inpatient,,,326.00000,195.60000,MedCost,Commercial,,264.06,,,,,,,208.64,264.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,MedCost,Commercial,,198.86,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Commercial,,53.46,,,,,,,42.24,53.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Commercial,,40.26,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Commercial,,34.02,,,,,,,26.88,34.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Commercial,,25.62,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,inpatient,,,105.00000,63.00000,MedCost,Commercial,,85.05,,,,,,,67.20,85.05,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,MedCost,Commercial,,64.05,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,inpatient,,,248.00000,148.80000,MedCost,Commercial,,200.88,,,,,,,158.72,200.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,MedCost,Commercial,,151.28,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,300.00000,180.00000,MedCost,Commercial,,243.00,,,,,,,192.00,243.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,MedCost,Commercial,,183.00,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,300.00000,180.00000,MedCost,Commercial,,243.00,,,,,,,192.00,243.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,MedCost,Commercial,,183.00,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,277.00000,166.20000,MedCost,Commercial,,224.37,,,,,,,177.28,224.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,MedCost,Commercial,,168.97,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,566.00000,339.60000,MedCost,Commercial,,458.46,,,,,,,362.24,458.46,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,MedCost,Commercial,,345.26,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Commercial,,46.17,,,,,,,36.48,46.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Commercial,,34.77,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,inpatient,,,679.00000,407.40000,MedCost,Commercial,,549.99,,,,,,,434.56,549.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,MedCost,Commercial,,414.19,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,inpatient,,,651.00000,390.60000,MedCost,Commercial,,527.31,,,,,,,416.64,527.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,MedCost,Commercial,,397.11,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Commercial,,843.21,,,,,,,666.24,843.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Commercial,,635.01,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,inpatient,,,1070.00000,642.00000,MedCost,Commercial,,866.70,,,,,,,684.80,866.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,MedCost,Commercial,,652.70,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Commercial,,174.15,,,,,,,137.60,174.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Commercial,,131.15,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,inpatient,,,419.00000,251.40000,MedCost,Commercial,,339.39,,,,,,,268.16,339.39,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,MedCost,Commercial,,255.59,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Commercial,,238.14,,,,,,,188.16,238.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Commercial,,179.34,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,inpatient,,,949.00000,569.40000,MedCost,Commercial,,768.69,,,,,,,607.36,768.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,MedCost,Commercial,,578.89,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,inpatient,,,1240.00000,744.00000,MedCost,Commercial,,1004.40,,,,,,,793.60,1004.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,MedCost,Commercial,,756.40,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,inpatient,,,600.00000,360.00000,MedCost,Commercial,,486.00,,,,,,,384.00,486.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,MedCost,Commercial,,366.00,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Commercial,,73.71,,,,,,,58.24,73.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Commercial,,55.51,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,inpatient,,,1528.00000,916.80000,MedCost,Commercial,,1237.68,,,,,,,977.92,1237.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,MedCost,Commercial,,932.08,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Commercial,,22.68,,,,,,,17.92,22.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Commercial,,17.08,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,,100.65,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,,100.65,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Commercial,,133.65,,,,,,,105.60,133.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Commercial,,100.65,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Commercial,,47.79,,,,,,,37.76,47.79,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Commercial,,35.99,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Commercial,,843.21,,,,,,,666.24,843.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Commercial,,635.01,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Commercial,,843.21,,,,,,,666.24,843.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Commercial,,635.01,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Commercial,,939.60,,,,,,,742.40,939.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Commercial,,707.60,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Commercial,,50.22,,,,,,,39.68,50.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Commercial,,37.82,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,inpatient,,,2616.00000,1569.60000,MedCost,Commercial,,2118.96,,,,,,,1674.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,MedCost,Commercial,,1595.76,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Commercial,,6941.70,,,,,,,5484.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Commercial,,5227.70,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Commercial,,6941.70,,,,,,,5484.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Commercial,,5227.70,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Commercial,,6941.70,,,,,,,5484.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Commercial,,5227.70,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Commercial,,6941.70,,,,,,,5484.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Commercial,,5227.70,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Commercial,,6941.70,,,,,,,5484.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Commercial,,5227.70,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,inpatient,,,35477.00000,21286.20000,MedCost,Commercial,,28736.37,,,,,,,7039.00,28736.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,MedCost,Commercial,,21640.97,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,inpatient,,,6012.00000,3607.20000,MedCost,Commercial,,4869.72,,,,,,,3847.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,MedCost,Commercial,,3667.32,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Commercial,,2003.94,,,,,,,1583.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Commercial,,1509.14,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Commercial,,2003.94,,,,,,,1583.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Commercial,,1509.14,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,inpatient,,,6715.00000,4029.00000,MedCost,Commercial,,5439.15,,,,,,,4297.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,MedCost,Commercial,,4096.15,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,inpatient,,,2043.00000,1225.80000,MedCost,Commercial,,1654.83,,,,,,,1307.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,MedCost,Commercial,,1246.23,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,inpatient,,,3368.00000,2020.80000,MedCost,Commercial,,2728.08,,,,,,,2155.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,MedCost,Commercial,,2054.48,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,inpatient,,,909.00000,545.40000,MedCost,Commercial,,736.29,,,,,,,581.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,MedCost,Commercial,,554.49,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,inpatient,,,909.00000,545.40000,MedCost,Commercial,,736.29,,,,,,,581.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,MedCost,Commercial,,554.49,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,inpatient,,,1981.00000,1188.60000,MedCost,Commercial,,1604.61,,,,,,,1267.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,MedCost,Commercial,,1208.41,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,inpatient,,,1981.00000,1188.60000,MedCost,Commercial,,1604.61,,,,,,,1267.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,MedCost,Commercial,,1208.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,inpatient,,,4166.00000,2499.60000,MedCost,Commercial,,3374.46,,,,,,,2666.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,MedCost,Commercial,,2541.26,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,inpatient,,,4166.00000,2499.60000,MedCost,Commercial,,3374.46,,,,,,,2666.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,MedCost,Commercial,,2541.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,inpatient,,,1896.00000,1137.60000,MedCost,Commercial,,1535.76,,,,,,,1213.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,MedCost,Commercial,,1156.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,inpatient,,,1896.00000,1137.60000,MedCost,Commercial,,1535.76,,,,,,,1213.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,MedCost,Commercial,,1156.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,inpatient,,,447.00000,268.20000,MedCost,Commercial,,362.07,,,,,,,286.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,MedCost,Commercial,,272.67,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,inpatient,,,823.00000,493.80000,MedCost,Commercial,,666.63,,,,,,,526.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,MedCost,Commercial,,502.03,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1453.14,,,,,,,1148.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1094.34,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1453.14,,,,,,,1148.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1094.34,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Commercial,,1146.96,,,,,,,906.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Commercial,,863.76,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Commercial,,1146.96,,,,,,,906.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Commercial,,863.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,inpatient,,,1586.00000,951.60000,MedCost,Commercial,,1284.66,,,,,,,1015.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,MedCost,Commercial,,967.46,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,inpatient,,,1586.00000,951.60000,MedCost,Commercial,,1284.66,,,,,,,1015.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,MedCost,Commercial,,967.46,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Commercial,,1146.96,,,,,,,906.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Commercial,,863.76,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Commercial,,1146.96,,,,,,,906.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Commercial,,863.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,inpatient,,,7717.00000,4630.20000,MedCost,Commercial,,6250.77,,,,,,,4938.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,MedCost,Commercial,,4707.37,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,inpatient,,,3858.00000,2314.80000,MedCost,Commercial,,3124.98,,,,,,,2469.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,MedCost,Commercial,,2353.38,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,inpatient,,,3858.00000,2314.80000,MedCost,Commercial,,3124.98,,,,,,,2469.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,MedCost,Commercial,,2353.38,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,inpatient,,,7166.00000,4299.60000,MedCost,Commercial,,5804.46,,,,,,,4586.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,MedCost,Commercial,,4371.26,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,inpatient,,,7166.00000,4299.60000,MedCost,Commercial,,5804.46,,,,,,,4586.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,MedCost,Commercial,,4371.26,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Commercial,,4464.72,,,,,,,3527.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Commercial,,3362.32,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Commercial,,4464.72,,,,,,,3527.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Commercial,,3362.32,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,inpatient,,,1378.00000,826.80000,MedCost,Commercial,,1116.18,,,,,,,881.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,MedCost,Commercial,,840.58,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,inpatient,,,1378.00000,826.80000,MedCost,Commercial,,1116.18,,,,,,,881.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,MedCost,Commercial,,840.58,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Commercial,,4464.72,,,,,,,3527.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Commercial,,3362.32,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Commercial,,4464.72,,,,,,,3527.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Commercial,,3362.32,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,inpatient,,,2659.00000,1595.40000,MedCost,Commercial,,2153.79,,,,,,,1701.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,MedCost,Commercial,,1621.99,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Commercial,,6941.70,,,,,,,5484.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Commercial,,5227.70,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Commercial,,6941.70,,,,,,,5484.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Commercial,,5227.70,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,inpatient,,,794.00000,476.40000,MedCost,Commercial,,643.14,,,,,,,508.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,MedCost,Commercial,,484.34,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,inpatient,,,29057.00000,17434.20000,MedCost,Commercial,,23536.17,,,,,,,7039.00,23536.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,MedCost,Commercial,,17724.77,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,inpatient,,,4394.00000,2636.40000,MedCost,Commercial,,3559.14,,,,,,,2812.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,MedCost,Commercial,,2680.34,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,inpatient,,,4394.00000,2636.40000,MedCost,Commercial,,3559.14,,,,,,,2812.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,MedCost,Commercial,,2680.34,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,280.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,280.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,280.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Commercial,,355.59,,,,,,,280.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Commercial,,267.79,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1828.17,,,,,,,1444.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1376.77,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1828.17,,,,,,,1444.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1376.77,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1828.17,,,,,,,1444.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1376.77,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1828.17,,,,,,,1444.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Commercial,,1376.77,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,inpatient,,,16729.00000,10037.40000,MedCost,Commercial,,13550.49,,,,,,,7039.00,13550.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,MedCost,Commercial,,10204.69,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,inpatient,,,16729.00000,10037.40000,MedCost,Commercial,,13550.49,,,,,,,7039.00,13550.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,MedCost,Commercial,,10204.69,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,inpatient,,,27882.00000,16729.20000,MedCost,Commercial,,22584.42,,,,,,,7039.00,22584.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,MedCost,Commercial,,17008.02,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,inpatient,,,27882.00000,16729.20000,MedCost,Commercial,,22584.42,,,,,,,7039.00,22584.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,MedCost,Commercial,,17008.02,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,inpatient,,,10037.00000,6022.20000,MedCost,Commercial,,8129.97,,,,,,,6423.68,8129.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,MedCost,Commercial,,6122.57,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,inpatient,,,10037.00000,6022.20000,MedCost,Commercial,,8129.97,,,,,,,6423.68,8129.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,MedCost,Commercial,,6122.57,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,inpatient,,,23142.00000,13885.20000,MedCost,Commercial,,18745.02,,,,,,,7039.00,18745.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,MedCost,Commercial,,14116.62,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,inpatient,,,23142.00000,13885.20000,MedCost,Commercial,,18745.02,,,,,,,7039.00,18745.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,MedCost,Commercial,,14116.62,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,inpatient,,,9307.00000,5584.20000,MedCost,Commercial,,7538.67,,,,,,,5956.48,7538.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,MedCost,Commercial,,5677.27,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,inpatient,,,9307.00000,5584.20000,MedCost,Commercial,,7538.67,,,,,,,5956.48,7538.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,MedCost,Commercial,,5677.27,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,inpatient,,,23479.00000,14087.40000,MedCost,Commercial,,19017.99,,,,,,,7039.00,19017.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,MedCost,Commercial,,14322.19,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,inpatient,,,23479.00000,14087.40000,MedCost,Commercial,,19017.99,,,,,,,7039.00,19017.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,MedCost,Commercial,,14322.19,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,inpatient,,,21152.00000,12691.20000,MedCost,Commercial,,17133.12,,,,,,,7039.00,17133.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,MedCost,Commercial,,12902.72,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,inpatient,,,21152.00000,12691.20000,MedCost,Commercial,,17133.12,,,,,,,7039.00,17133.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,MedCost,Commercial,,12902.72,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,inpatient,,,28133.00000,16879.80000,MedCost,Commercial,,22787.73,,,,,,,7039.00,22787.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,MedCost,Commercial,,17161.13,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,inpatient,,,28133.00000,16879.80000,MedCost,Commercial,,22787.73,,,,,,,7039.00,22787.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,MedCost,Commercial,,17161.13,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,inpatient,,,12328.00000,7396.80000,MedCost,Commercial,,9985.68,,,,,,,7039.00,9985.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,MedCost,Commercial,,7520.08,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,inpatient,,,23300.00000,13980.00000,MedCost,Commercial,,18873.00,,,,,,,7039.00,18873.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,MedCost,Commercial,,14213.00,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,inpatient,,,23300.00000,13980.00000,MedCost,Commercial,,18873.00,,,,,,,7039.00,18873.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,MedCost,Commercial,,14213.00,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,inpatient,,,21204.00000,12722.40000,MedCost,Commercial,,17175.24,,,,,,,7039.00,17175.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,MedCost,Commercial,,12934.44,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,inpatient,,,21204.00000,12722.40000,MedCost,Commercial,,17175.24,,,,,,,7039.00,17175.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,MedCost,Commercial,,12934.44,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,inpatient,,,24040.00000,14424.00000,MedCost,Commercial,,19472.40,,,,,,,7039.00,19472.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,MedCost,Commercial,,14664.40,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,inpatient,,,24040.00000,14424.00000,MedCost,Commercial,,19472.40,,,,,,,7039.00,19472.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,MedCost,Commercial,,14664.40,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,inpatient,,,9493.00000,5695.80000,MedCost,Commercial,,7689.33,,,,,,,6075.52,7689.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,MedCost,Commercial,,5790.73,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,inpatient,,,9493.00000,5695.80000,MedCost,Commercial,,7689.33,,,,,,,6075.52,7689.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,MedCost,Commercial,,5790.73,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,inpatient,,,20464.00000,12278.40000,MedCost,Commercial,,16575.84,,,,,,,7039.00,16575.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,MedCost,Commercial,,12483.04,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,inpatient,,,20464.00000,12278.40000,MedCost,Commercial,,16575.84,,,,,,,7039.00,16575.84,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,MedCost,Commercial,,12483.04,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,inpatient,,,17629.00000,10577.40000,MedCost,Commercial,,14279.49,,,,,,,7039.00,14279.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,MedCost,Commercial,,10753.69,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,inpatient,,,17629.00000,10577.40000,MedCost,Commercial,,14279.49,,,,,,,7039.00,14279.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,MedCost,Commercial,,10753.69,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,inpatient,,,20588.00000,12352.80000,MedCost,Commercial,,16676.28,,,,,,,7039.00,16676.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,MedCost,Commercial,,12558.68,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Commercial,LM,13121.19,,,,,,,7039.00,13121.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Commercial,LM,9881.39,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Commercial,RI,13121.19,,,,,,,7039.00,13121.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Commercial,RI,9881.39,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Commercial,RC,13121.19,,,,,,,7039.00,13121.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Commercial,RC,9881.39,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Commercial,LD,13121.19,,,,,,,7039.00,13121.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Commercial,LD,9881.39,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Commercial,LC,13121.19,,,,,,,7039.00,13121.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Commercial,LC,9881.39,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Commercial,LC,6769.17,,,,,,,5348.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Commercial,LC,5097.77,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Commercial,RI,6769.17,,,,,,,5348.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Commercial,RI,5097.77,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Commercial,RC,6769.17,,,,,,,5348.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Commercial,RC,5097.77,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Commercial,LD,6769.17,,,,,,,5348.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Commercial,LD,5097.77,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Commercial,LC,6769.17,,,,,,,5348.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Commercial,LC,5097.77,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,LM,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,LM,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,RI,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,RI,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,RC,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,RC,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,LD,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,LD,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,LC,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,LC,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,LM,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,LM,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,RI,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,RI,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,RC,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,RC,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,LD,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,LD,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Commercial,LC,11629.98,,,,,,,7039.00,11629.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Commercial,LC,8758.38,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,LM,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,LM,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,RI,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,RI,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,RC,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,RC,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,LD,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,LD,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,LC,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,LC,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,LM,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,LM,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,RI,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,RI,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,RC,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,RC,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,LD,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,LD,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Commercial,LC,17358.30,,,,,,,7039.00,17358.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Commercial,LC,13072.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,LM,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,LM,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,RI,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,RI,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,RC,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,RC,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,LD,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,LD,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,LC,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,LC,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,RC,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,RC,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,LD,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,LD,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Commercial,LC,18399.15,,,,,,,7039.00,18399.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Commercial,LC,13856.15,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LM,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LM,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,RI,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,RI,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LM,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LM,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,RI,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,RI,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,24706.22,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LM,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LM,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,RI,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,RI,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,RC,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LD,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,32806.62,,,,,,,7039.00,32806.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Commercial,LC,24706.22,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,inpatient,,,23143.00000,13885.80000,MedCost,Commercial,,18745.83,,,,,,,7039.00,18745.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,MedCost,Commercial,,14117.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,inpatient,,,23143.00000,13885.80000,MedCost,Commercial,,18745.83,,,,,,,7039.00,18745.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,MedCost,Commercial,,14117.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,inpatient,,,23787.00000,14272.20000,MedCost,Commercial,,19267.47,,,,,,,7039.00,19267.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,MedCost,Commercial,,14510.07,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,inpatient,,,23787.00000,14272.20000,MedCost,Commercial,,19267.47,,,,,,,7039.00,19267.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,MedCost,Commercial,,14510.07,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,LM,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,LM,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,RI,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,RI,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,RC,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,RC,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,LD,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,LD,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,LC,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,LC,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,LM,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,LM,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,RI,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,RI,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,RC,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,RC,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,LD,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,LD,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Commercial,LC,20134.98,,,,,,,7039.00,20134.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Commercial,LC,15163.38,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LM,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LM,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,RI,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,RI,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,RC,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,RC,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LD,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LD,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LC,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LC,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LM,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LM,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,RI,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,RI,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,RC,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,RC,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LD,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LD,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LC,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LC,15817.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LM,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LM,15817.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,RI,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,RI,15817.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,RC,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,RC,15817.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LD,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LD,15817.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Commercial,LC,21003.30,,,,,,,7039.00,21003.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Commercial,LC,15817.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,inpatient,,,393.00000,235.80000,MedCost,Commercial,,318.33,,,,,,,251.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,MedCost,Commercial,,239.73,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,inpatient,,,1664.00000,998.40000,MedCost,Commercial,,1347.84,,,,,,,1064.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,MedCost,Commercial,,1015.04,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1510.65,,,,,,,1193.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Commercial,,1137.65,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Commercial,,341.82,,,,,,,270.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Commercial,,257.42,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,inpatient,,,2527.00000,1516.20000,MedCost,Commercial,,2046.87,,,,,,,1617.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,MedCost,Commercial,,1541.47,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,inpatient,,,986.00000,591.60000,MedCost,Commercial,,798.66,,,,,,,631.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,MedCost,Commercial,,601.46,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,inpatient,,,11572.00000,6943.20000,MedCost,Commercial,,9373.32,,,,,,,7039.00,9373.32,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,MedCost,Commercial,,7058.92,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,inpatient,,,10706.00000,6423.60000,MedCost,Commercial,,8671.86,,,,,,,6851.84,8671.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,MedCost,Commercial,,6530.66,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,inpatient,,,10706.00000,6423.60000,MedCost,Commercial,,8671.86,,,,,,,6851.84,8671.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,MedCost,Commercial,,6530.66,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,inpatient,,,10210.00000,6126.00000,MedCost,Commercial,,8270.10,,,,,,,6534.40,8270.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,MedCost,Commercial,,6228.10,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,inpatient,,,4250.00000,2550.00000,MedCost,Commercial,,3442.50,,,,,,,2720.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,MedCost,Commercial,,2592.50,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,inpatient,,,7367.00000,4420.20000,MedCost,Commercial,,5967.27,,,,,,,4714.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,MedCost,Commercial,,4493.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,inpatient,,,10893.00000,6535.80000,MedCost,Commercial,,8823.33,,,,,,,6971.52,8823.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,MedCost,Commercial,,6644.73,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,inpatient,,,9673.00000,5803.80000,MedCost,Commercial,,7835.13,,,,,,,6190.72,7835.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,MedCost,Commercial,,5900.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,inpatient,,,10326.00000,6195.60000,MedCost,Commercial,,8364.06,,,,,,,6608.64,8364.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,MedCost,Commercial,,6298.86,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,inpatient,,,4543.00000,2725.80000,MedCost,Commercial,,3679.83,,,,,,,2907.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,MedCost,Commercial,,2771.23,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,inpatient,,,10624.00000,6374.40000,MedCost,Commercial,,8605.44,,,,,,,6799.36,8605.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,MedCost,Commercial,,6480.64,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,inpatient,,,13251.00000,7950.60000,MedCost,Commercial,,10733.31,,,,,,,7039.00,10733.31,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,MedCost,Commercial,,8083.11,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,inpatient,,,11937.00000,7162.20000,MedCost,Commercial,,9668.97,,,,,,,7039.00,9668.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,MedCost,Commercial,,7281.57,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,inpatient,,,12734.00000,7640.40000,MedCost,Commercial,,10314.54,,,,,,,7039.00,10314.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,MedCost,Commercial,,7767.74,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,inpatient,,,12950.00000,7770.00000,MedCost,Commercial,,10489.50,,,,,,,7039.00,10489.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,MedCost,Commercial,,7899.50,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,inpatient,,,15877.00000,9526.20000,MedCost,Commercial,,12860.37,,,,,,,7039.00,12860.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,MedCost,Commercial,,9684.97,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,inpatient,,,6778.00000,4066.80000,MedCost,Commercial,,5490.18,,,,,,,4337.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,MedCost,Commercial,,4134.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Commercial,,164.43,,,,,,,129.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Commercial,,123.83,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Commercial,,78.57,,,,,,,62.08,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Commercial,,59.17,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,inpatient,,,1503.00000,901.80000,MedCost,Commercial,,1217.43,,,,,,,961.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,MedCost,Commercial,,916.83,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,inpatient,,,4128.00000,2476.80000,MedCost,Commercial,,3343.68,,,,,,,2641.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,MedCost,Commercial,,2518.08,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,inpatient,,,8064.00000,4838.40000,MedCost,Commercial,,6531.84,,,,,,,5160.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,MedCost,Commercial,,4919.04,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,inpatient,,,484.00000,290.40000,MedCost,Commercial,,392.04,,,,,,,309.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,MedCost,Commercial,,295.24,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,400.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Commercial,,507.06,,,,,,,400.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Commercial,,381.86,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Commercial,,174.15,,,,,,,137.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Commercial,,131.15,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,inpatient,,,7671.00000,4602.60000,MedCost,Commercial,,6213.51,,,,,,,4909.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,MedCost,Commercial,,4679.31,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,inpatient,,,39133.00000,23479.80000,MedCost,Commercial,,31697.73,,,,,,,7039.00,31697.73,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,MedCost,Commercial,,23871.13,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,inpatient,,,12282.00000,7369.20000,MedCost,Commercial,,9948.42,,,,,,,7039.00,9948.42,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,MedCost,Commercial,,7492.02,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,inpatient,,,2525.00000,1515.00000,MedCost,Commercial,,2045.25,,,,,,,1616.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,MedCost,Commercial,,1540.25,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,inpatient,,,2824.00000,1694.40000,MedCost,Commercial,,2287.44,,,,,,,1807.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,MedCost,Commercial,,1722.64,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,inpatient,,,1266.00000,759.60000,MedCost,Commercial,,1025.46,,,,,,,810.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,MedCost,Commercial,,772.26,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,inpatient,,,528.00000,316.80000,MedCost,Commercial,,427.68,,,,,,,337.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,MedCost,Commercial,,322.08,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,inpatient,,,528.00000,316.80000,MedCost,Commercial,,427.68,,,,,,,337.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,MedCost,Commercial,,322.08,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,inpatient,,,528.00000,316.80000,MedCost,Commercial,,427.68,,,,,,,337.92,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,MedCost,Commercial,,322.08,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,inpatient,,,7882.00000,4729.20000,MedCost,Commercial,,6384.42,,,,,,,5044.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,MedCost,Commercial,,4808.02,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,inpatient,,,7882.00000,4729.20000,MedCost,Commercial,,6384.42,,,,,,,5044.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,MedCost,Commercial,,4808.02,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,inpatient,,,14979.00000,8987.40000,MedCost,Commercial,,12132.99,,,,,,,7039.00,12132.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,MedCost,Commercial,,9137.19,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,inpatient,,,14979.00000,8987.40000,MedCost,Commercial,,12132.99,,,,,,,7039.00,12132.99,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,MedCost,Commercial,,9137.19,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,inpatient,,,18267.00000,10960.20000,MedCost,Commercial,,14796.27,,,,,,,7039.00,14796.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,MedCost,Commercial,,11142.87,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,inpatient,,,13268.00000,7960.80000,MedCost,Commercial,,10747.08,,,,,,,7039.00,10747.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,MedCost,Commercial,,8093.48,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,inpatient,,,15077.00000,9046.20000,MedCost,Commercial,,12212.37,,,,,,,7039.00,12212.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,MedCost,Commercial,,9196.97,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,inpatient,,,18194.00000,10916.40000,MedCost,Commercial,,14737.14,,,,,,,7039.00,14737.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,MedCost,Commercial,,11098.34,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,inpatient,,,3193.00000,1915.80000,MedCost,Commercial,,2586.33,,,,,,,2043.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,MedCost,Commercial,,1947.73,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,inpatient,,,14089.00000,8453.40000,MedCost,Commercial,,11412.09,,,,,,,7039.00,11412.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,MedCost,Commercial,,8594.29,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,inpatient,,,14089.00000,8453.40000,MedCost,Commercial,,11412.09,,,,,,,7039.00,11412.09,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,MedCost,Commercial,,8594.29,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,inpatient,,,10215.00000,6129.00000,MedCost,Commercial,,8274.15,,,,,,,6537.60,8274.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,MedCost,Commercial,,6231.15,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,inpatient,,,2944.00000,1766.40000,MedCost,Commercial,,2384.64,,,,,,,1884.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,MedCost,Commercial,,1795.84,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,inpatient,,,2902.00000,1741.20000,MedCost,Commercial,,2350.62,,,,,,,1857.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,MedCost,Commercial,,1770.22,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,inpatient,,,2902.00000,1741.20000,MedCost,Commercial,,2350.62,,,,,,,1857.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,MedCost,Commercial,,1770.22,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,inpatient,,,20392.00000,12235.20000,MedCost,Commercial,,16517.52,,,,,,,7039.00,16517.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,MedCost,Commercial,,12439.12,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,inpatient,,,14925.00000,8955.00000,MedCost,Commercial,,12089.25,,,,,,,7039.00,12089.25,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,MedCost,Commercial,,9104.25,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,inpatient,,,2367.00000,1420.20000,MedCost,Commercial,,1917.27,,,,,,,1514.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,MedCost,Commercial,,1443.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,inpatient,,,23786.00000,14271.60000,MedCost,Commercial,,19266.66,,,,,,,7039.00,19266.66,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,MedCost,Commercial,,14509.46,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,inpatient,,,24521.00000,14712.60000,MedCost,Commercial,,19862.01,,,,,,,7039.00,19862.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,MedCost,Commercial,,14957.81,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,inpatient,,,26728.00000,16036.80000,MedCost,Commercial,,21649.68,,,,,,,7039.00,21649.68,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,MedCost,Commercial,,16304.08,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,inpatient,,,8508.00000,5104.80000,MedCost,Commercial,,6891.48,,,,,,,5445.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,MedCost,Commercial,,5189.88,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,inpatient,,,11401.00000,6840.60000,MedCost,Commercial,,9234.81,,,,,,,7039.00,9234.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,MedCost,Commercial,,6954.61,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,inpatient,,,11401.00000,6840.60000,MedCost,Commercial,,9234.81,,,,,,,7039.00,9234.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,MedCost,Commercial,,6954.61,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,inpatient,,,49887.00000,29932.20000,MedCost,Commercial,,40408.47,,,,,,,7039.00,40408.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,MedCost,Commercial,,30431.07,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,inpatient,,,5750.00000,3450.00000,MedCost,Commercial,,4657.50,,,,,,,3680.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,MedCost,Commercial,,3507.50,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,inpatient,,,3821.00000,2292.60000,MedCost,Commercial,,3095.01,,,,,,,2445.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,MedCost,Commercial,,2330.81,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,inpatient,,,57698.00000,34618.80000,MedCost,Commercial,,46735.38,,,,,,,7039.00,46735.38,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,MedCost,Commercial,,35195.78,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,inpatient,,,2639.00000,1583.40000,MedCost,Commercial,,2137.59,,,,,,,1688.96,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,MedCost,Commercial,,1609.79,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,inpatient,,,11667.00000,7000.20000,MedCost,Commercial,,9450.27,,,,,,,7466.88,9485.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,MedCost,Commercial,,7116.87,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,inpatient,,,2086.00000,1251.60000,MedCost,Commercial,,1689.66,,,,,,,1335.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,MedCost,Commercial,,1272.46,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,inpatient,,,4188.00000,2512.80000,MedCost,Commercial,,3392.28,,,,,,,2680.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,MedCost,Commercial,,2554.68,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,inpatient,,,6480.00000,3888.00000,MedCost,Commercial,,5248.80,,,,,,,4147.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,MedCost,Commercial,,3952.80,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,inpatient,,,6480.00000,3888.00000,MedCost,Commercial,,5248.80,,,,,,,4147.20,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,MedCost,Commercial,,3952.80,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,inpatient,,,3232.00000,1939.20000,MedCost,Commercial,,2617.92,,,,,,,2068.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,MedCost,Commercial,,1971.52,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,inpatient,,,2295.00000,1377.00000,MedCost,Commercial,,1858.95,,,,,,,1468.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,MedCost,Commercial,,1399.95,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,inpatient,,,3232.00000,1939.20000,MedCost,Commercial,,2617.92,,,,,,,2068.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,MedCost,Commercial,,1971.52,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,inpatient,,,3232.00000,1939.20000,MedCost,Commercial,,2617.92,,,,,,,2068.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,MedCost,Commercial,,1971.52,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,inpatient,,,3043.00000,1825.80000,MedCost,Commercial,,2464.83,,,,,,,1947.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,MedCost,Commercial,,1856.23,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,inpatient,,,2787.00000,1672.20000,MedCost,Commercial,,2257.47,,,,,,,1783.68,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,MedCost,Commercial,,1700.07,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,inpatient,,,9580.00000,5748.00000,MedCost,Commercial,,7759.80,,,,,,,6131.20,7759.80,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,MedCost,Commercial,,5843.80,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,inpatient,,,15230.00000,9138.00000,MedCost,Commercial,,12336.30,,,,,,,7039.00,12336.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,MedCost,Commercial,,9290.30,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,inpatient,,,15230.00000,9138.00000,MedCost,Commercial,,12336.30,,,,,,,7039.00,12336.30,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,MedCost,Commercial,,9290.30,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,inpatient,,,1624.00000,974.40000,MedCost,Commercial,,1315.44,,,,,,,1039.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,MedCost,Commercial,,990.64,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,inpatient,,,8084.00000,4850.40000,MedCost,Commercial,,6548.04,,,,,,,5173.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,MedCost,Commercial,,4931.24,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,inpatient,,,1658.00000,994.80000,MedCost,Commercial,,1342.98,,,,,,,1061.12,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,MedCost,Commercial,,1011.38,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,inpatient,,,3156.00000,1893.60000,MedCost,Commercial,,2556.36,,,,,,,2019.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,MedCost,Commercial,,1925.16,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,inpatient,,,25442.00000,15265.20000,MedCost,Commercial,,20608.02,,,,,,,7039.00,20608.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,MedCost,Commercial,,15519.62,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,inpatient,,,22534.00000,13520.40000,MedCost,Commercial,,18252.54,,,,,,,7039.00,18252.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,MedCost,Commercial,,13745.74,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,inpatient,,,22534.00000,13520.40000,MedCost,Commercial,,18252.54,,,,,,,7039.00,18252.54,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,MedCost,Commercial,,13745.74,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,inpatient,,,3025.00000,1815.00000,MedCost,Commercial,,2450.25,,,,,,,1936.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,MedCost,Commercial,,1845.25,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,MedCost,Commercial,,1148.58,,,,,,,907.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,MedCost,Commercial,,864.98,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,inpatient,,,20137.00000,12082.20000,MedCost,Commercial,,16310.97,,,,,,,7039.00,16310.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,MedCost,Commercial,,12283.57,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,inpatient,,,22381.00000,13428.60000,MedCost,Commercial,,18128.61,,,,,,,7039.00,18128.61,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,MedCost,Commercial,,13652.41,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,inpatient,,,2482.00000,1489.20000,MedCost,Commercial,,2010.42,,,,,,,1588.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,MedCost,Commercial,,1514.02,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,inpatient,,,1931.00000,1158.60000,MedCost,Commercial,,1564.11,,,,,,,1235.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,MedCost,Commercial,,1177.91,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,inpatient,,,5548.00000,3328.80000,MedCost,Commercial,,4493.88,,,,,,,3550.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,MedCost,Commercial,,3384.28,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,inpatient,,,5548.00000,3328.80000,MedCost,Commercial,,4493.88,,,,,,,3550.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,MedCost,Commercial,,3384.28,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,inpatient,,,6377.00000,3826.20000,MedCost,Commercial,,5165.37,,,,,,,4081.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,MedCost,Commercial,,3889.97,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,inpatient,,,2575.00000,1545.00000,MedCost,Commercial,,2085.75,,,,,,,1648.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,MedCost,Commercial,,1570.75,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,inpatient,,,13721.00000,8232.60000,MedCost,Commercial,,11114.01,,,,,,,7039.00,11114.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,MedCost,Commercial,,8369.81,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,inpatient,,,4800.00000,2880.00000,MedCost,Commercial,,3888.00,,,,,,,3072.00,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,MedCost,Commercial,,2928.00,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,MedCost,Commercial,,1148.58,,,,,,,907.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,MedCost,Commercial,,864.98,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,inpatient,,,2127.00000,1276.20000,MedCost,Commercial,,1722.87,,,,,,,1361.28,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,MedCost,Commercial,,1297.47,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,inpatient,,,2836.00000,1701.60000,MedCost,Commercial,,2297.16,,,,,,,1815.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,MedCost,Commercial,,1729.96,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,inpatient,,,7965.00000,4779.00000,MedCost,Commercial,,6451.65,,,,,,,5097.60,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,MedCost,Commercial,,4858.65,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,inpatient,,,18522.00000,11113.20000,MedCost,Commercial,,15002.82,,,,,,,7039.00,15002.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,MedCost,Commercial,,11298.42,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,inpatient,,,9224.00000,5534.40000,MedCost,Commercial,,7471.44,,,,,,,5903.36,7471.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,MedCost,Commercial,,5626.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,inpatient,,,6467.00000,3880.20000,MedCost,Commercial,,5238.27,,,,,,,4138.88,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,MedCost,Commercial,,3944.87,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,inpatient,,,7476.00000,4485.60000,MedCost,Commercial,,6055.56,,,,,,,4784.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,MedCost,Commercial,,4560.36,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Commercial,,233.28,,,,,,,184.32,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Commercial,,175.68,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,MedCost,Commercial,,1148.58,,,,,,,907.52,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,MedCost,Commercial,,864.98,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,inpatient,,,7970.00000,4782.00000,MedCost,Commercial,,6455.70,,,,,,,5100.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,MedCost,Commercial,,4861.70,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Commercial,,2463.21,,,,,,,1946.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Commercial,,1855.01,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Commercial,,2463.21,,,,,,,1946.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Commercial,,1855.01,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Commercial,,2463.21,,,,,,,1946.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Commercial,,1855.01,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Commercial,,2463.21,,,,,,,1946.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Commercial,,1855.01,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,inpatient,,,13301.00000,7980.60000,MedCost,Commercial,,10773.81,,,,,,,7039.00,10773.81,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,MedCost,Commercial,,8113.61,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,inpatient,,,26602.00000,15961.20000,MedCost,Commercial,,21547.62,,,,,,,7039.00,21547.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,MedCost,Commercial,,16227.22,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,inpatient,,,26602.00000,15961.20000,MedCost,Commercial,,21547.62,,,,,,,7039.00,21547.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,MedCost,Commercial,,16227.22,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,inpatient,,,42829.00000,25697.40000,MedCost,Commercial,,34691.49,,,,,,,7039.00,34691.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,MedCost,Commercial,,26125.69,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,inpatient,,,34962.00000,20977.20000,MedCost,Commercial,,28319.22,,,,,,,7039.00,28319.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,MedCost,Commercial,,21326.82,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,inpatient,,,9476.00000,5685.60000,MedCost,Commercial,,7675.56,,,,,,,6064.64,7675.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,MedCost,Commercial,,5780.36,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,inpatient,,,4345.00000,2607.00000,MedCost,Commercial,,3519.45,,,,,,,2780.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,MedCost,Commercial,,2650.45,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,inpatient,,,21406.00000,12843.60000,MedCost,Commercial,,17338.86,,,,,,,7039.00,17338.86,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,MedCost,Commercial,,13057.66,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,inpatient,,,34241.00000,20544.60000,MedCost,Commercial,,27735.21,,,,,,,7039.00,27735.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,MedCost,Commercial,,20887.01,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,inpatient,,,34241.00000,20544.60000,MedCost,Commercial,,27735.21,,,,,,,7039.00,27735.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,MedCost,Commercial,,20887.01,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,inpatient,,,34241.00000,20544.60000,MedCost,Commercial,,27735.21,,,,,,,7039.00,27735.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,MedCost,Commercial,,20887.01,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,inpatient,,,32373.00000,19423.80000,MedCost,Commercial,,26222.13,,,,,,,7039.00,26222.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,MedCost,Commercial,,19747.53,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,inpatient,,,6766.00000,4059.60000,MedCost,Commercial,,5480.46,,,,,,,4330.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,MedCost,Commercial,,4127.26,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,inpatient,,,6766.00000,4059.60000,MedCost,Commercial,,5480.46,,,,,,,4330.24,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,MedCost,Commercial,,4127.26,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Commercial,,86.67,,,,,,,68.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Commercial,,65.27,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,inpatient,,,39142.00000,23485.20000,MedCost,Commercial,,31705.02,,,,,,,7039.00,31705.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,MedCost,Commercial,,23876.62,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,inpatient,,,39142.00000,23485.20000,MedCost,Commercial,,31705.02,,,,,,,7039.00,31705.02,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,MedCost,Commercial,,23876.62,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,inpatient,,,47944.00000,28766.40000,MedCost,Commercial,,38834.64,,,,,,,7039.00,38834.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,MedCost,Commercial,,29245.84,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,inpatient,,,2399.00000,1439.40000,MedCost,Commercial,,1943.19,,,,,,,1535.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,MedCost,Commercial,,1463.39,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,inpatient,,,6494.00000,3896.40000,MedCost,Commercial,,5260.14,,,,,,,4156.16,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,MedCost,Commercial,,3961.34,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,inpatient,,,10837.00000,6502.20000,MedCost,Commercial,,8777.97,,,,,,,6935.68,8777.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,MedCost,Commercial,,6610.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Commercial,LD,2783.16,,,,,,,2199.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Commercial,LD,2095.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Commercial,RC,2783.16,,,,,,,2199.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Commercial,RC,2095.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Commercial,RI,2783.16,,,,,,,2199.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Commercial,RI,2095.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Commercial,LM,2783.16,,,,,,,2199.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Commercial,LM,2095.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Commercial,LD,2225.88,,,,,,,1758.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Commercial,LD,1676.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Commercial,RC,2225.88,,,,,,,1758.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Commercial,RC,1676.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Commercial,RI,2225.88,,,,,,,1758.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Commercial,RI,1676.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Commercial,LM,2225.88,,,,,,,1758.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Commercial,LM,1676.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Commercial,LD,1908.36,,,,,,,1507.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Commercial,LD,1437.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Commercial,RC,1908.36,,,,,,,1507.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Commercial,RC,1437.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Commercial,RI,1908.36,,,,,,,1507.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Commercial,RI,1437.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Commercial,LM,1908.36,,,,,,,1507.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Commercial,LM,1437.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,LD,400.95,,,,,,,316.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,LD,301.95,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,RC,400.95,,,,,,,316.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,RC,301.95,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,RI,400.95,,,,,,,316.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,RI,301.95,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,LM,400.95,,,,,,,316.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,LM,301.95,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Commercial,LC,2783.16,,,,,,,2199.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Commercial,LC,2095.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Commercial,LC,2225.88,,,,,,,1758.72,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Commercial,LC,1676.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Commercial,LC,1908.36,,,,,,,1507.84,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Commercial,LC,1437.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Commercial,LC,400.95,,,,,,,316.80,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Commercial,LC,301.95,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,inpatient,,,32611.00000,19566.60000,MedCost,Commercial,,26414.91,,,,,,,7039.00,26414.91,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,MedCost,Commercial,,19892.71,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,inpatient,,,61737.00000,37042.20000,MedCost,Commercial,,50006.97,,,,,,,7039.00,50006.97,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,MedCost,Commercial,,37659.57,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,inpatient,,,11403.00000,6841.80000,MedCost,Commercial,,9236.43,,,,,,,7039.00,9236.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,MedCost,Commercial,,6955.83,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,inpatient,,,2851.00000,1710.60000,MedCost,Commercial,,2309.31,,,,,,,1824.64,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,MedCost,Commercial,,1739.11,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,inpatient,,,575.00000,345.00000,MedCost,Commercial,,465.75,,,,,,,368.00,465.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,MedCost,Commercial,,350.75,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,inpatient,,,4021.00000,2412.60000,MedCost,Commercial,,3257.01,,,,,,,2573.44,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,MedCost,Commercial,,2452.81,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,inpatient,,,3304.00000,1982.40000,MedCost,Commercial,,2676.24,,,,,,,2114.56,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,MedCost,Commercial,,2015.44,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,inpatient,,,1290.00000,774.00000,MedCost,Commercial,,1044.90,,,,,,,825.60,1044.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,MedCost,Commercial,,786.90,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,inpatient,,,1563.00000,937.80000,MedCost,Commercial,,1266.03,,,,,,,1000.32,1266.03,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,MedCost,Commercial,,953.43,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,inpatient,,,1157.00000,694.20000,MedCost,Commercial,,937.17,,,,,,,740.48,937.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,MedCost,Commercial,,705.77,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,inpatient,,,2229.00000,1337.40000,MedCost,Commercial,,1805.49,,,,,,,1426.56,1805.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,MedCost,Commercial,,1359.69,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,inpatient,,,2229.00000,1337.40000,MedCost,Commercial,,1805.49,,,,,,,1426.56,1805.49,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,MedCost,Commercial,,1359.69,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,inpatient,,,899.00000,539.40000,MedCost,Commercial,,728.19,,,,,,,575.36,728.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,MedCost,Commercial,,548.39,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,inpatient,,,726.00000,435.60000,MedCost,Commercial,,588.06,,,,,,,464.64,588.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,MedCost,Commercial,,442.86,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,inpatient,,,726.00000,435.60000,MedCost,Commercial,,588.06,,,,,,,464.64,588.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,MedCost,Commercial,,442.86,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,inpatient,,,2558.00000,1534.80000,MedCost,Commercial,,2071.98,,,,,,,1637.12,2071.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,MedCost,Commercial,,1560.38,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,inpatient,,,2558.00000,1534.80000,MedCost,Commercial,,2071.98,,,,,,,1637.12,2071.98,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,MedCost,Commercial,,1560.38,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Commercial,,401.76,,,,,,,317.44,401.76,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Commercial,,302.56,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Commercial,,311.85,,,,,,,246.40,311.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Commercial,,234.85,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,inpatient,,,2736.00000,1641.60000,MedCost,Commercial,,2216.16,,,,,,,1751.04,2216.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,MedCost,Commercial,,1668.96,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Commercial,,44.55,,,,,,,35.20,44.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Commercial,,33.55,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,inpatient,,,1368.00000,820.80000,MedCost,Commercial,,1108.08,,,,,,,875.52,1108.08,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,MedCost,Commercial,,834.48,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,inpatient,,,243.00000,145.80000,MedCost,Commercial,,196.83,,,,,,,155.52,196.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,MedCost,Commercial,,148.23,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,inpatient,,,875.00000,525.00000,MedCost,Commercial,,708.75,,,,,,,560.00,708.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,MedCost,Commercial,,533.75,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,inpatient,,,622.00000,373.20000,MedCost,Commercial,,503.82,,,,,,,398.08,503.82,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,MedCost,Commercial,,379.42,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Commercial,,131.22,,,,,,,103.68,131.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Commercial,,98.82,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,inpatient,,,193.00000,115.80000,MedCost,Commercial,,156.33,,,,,,,123.52,156.33,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,MedCost,Commercial,,117.73,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,inpatient,,,1276.00000,765.60000,MedCost,Commercial,,1033.56,,,,,,,816.64,1033.56,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,MedCost,Commercial,,778.36,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,inpatient,,,285.00000,171.00000,MedCost,Commercial,,230.85,,,,,,,182.40,230.85,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,MedCost,Commercial,,173.85,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Commercial,,176.58,,,,,,,139.52,176.58,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Commercial,,132.98,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,inpatient,,,297.00000,178.20000,MedCost,Commercial,,240.57,,,,,,,190.08,240.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,MedCost,Commercial,,181.17,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,inpatient,,,109.00000,65.40000,MedCost,Commercial,,88.29,,,,,,,69.76,88.29,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,MedCost,Commercial,,66.49,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,inpatient,,,141.00000,84.60000,MedCost,Commercial,,114.21,,,,,,,90.24,114.21,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,MedCost,Commercial,,86.01,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Commercial,,34.83,,,,,,,27.52,34.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Commercial,,26.23,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,inpatient,,,6499.00000,3899.40000,MedCost,Commercial,,5264.19,,,,,,,4159.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,MedCost,Commercial,,3964.39,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,inpatient,,,3624.00000,2174.40000,MedCost,Commercial,,2935.44,,,,,,,2319.36,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,MedCost,Commercial,,2210.64,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,inpatient,,,7984.00000,4790.40000,MedCost,Commercial,,6467.04,,,,,,,5109.76,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,MedCost,Commercial,,4870.24,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,inpatient,,,2607.00000,1564.20000,MedCost,Commercial,,2111.67,,,,,,,1668.48,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,MedCost,Commercial,,1590.27,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,MedCost,Commercial,,1709.91,,,,,,,1351.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,MedCost,Commercial,,1287.71,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,MedCost,Commercial,,1709.91,,,,,,,1351.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,MedCost,Commercial,,1287.71,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,MedCost,Commercial,,1709.91,,,,,,,1351.04,7039.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,MedCost,Commercial,,1287.71,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX MED SURG SEMI PRIVATE ROOM,11200003,CDM,120,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Commercial,,1075.68,,,,,,,849.92,5693.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,inpatient,,,6375.00000,3825.00000,MedCost,Commercial,,5163.75,,,,,,,4080.00,5163.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,MedCost,Commercial,,3888.75,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,inpatient,,,8443.00000,5065.80000,MedCost,Commercial,,6838.83,,,,,,,5403.52,6838.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,MedCost,Commercial,,5150.23,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,inpatient,,,9477.00000,5686.20000,MedCost,Commercial,,7676.37,,,,,,,6065.28,7676.37,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,MedCost,Commercial,,5780.97,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX LEVEL 2 NURSERY ROOM,11720015,CDM,172,RC,,,,,facility,inpatient,,,3166.00000,1899.60000,MedCost,Commercial,,2564.46,,,,,,,2026.24,3569.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX LEVEL 4 INTENSIVE NURSERY ROOM,11740002,CDM,174,RC,,,,,facility,inpatient,,,6546.00000,3927.60000,MedCost,Commercial,,5302.26,,,,,,,4189.44,5695.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE SEMI PRIVATE ROOM,12000008,CDM,210,RC,,,,,facility,inpatient,,,3522.00000,2113.20000,MedCost,Commercial,,3200.00,,,,,,,1228.00,6258.00,per diem,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,inpatient,,,7831.00000,4698.60000,MedCost,Commercial,,6343.11,,,,,,,5011.84,6343.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,MedCost,Commercial,,4776.91,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,inpatient,,,10149.00000,6089.40000,MedCost,Commercial,,8220.69,,,,,,,6495.36,8220.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,MedCost,Commercial,,6190.89,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,inpatient,,,11308.00000,6784.80000,MedCost,Commercial,,9159.48,,,,,,,7237.12,9159.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,MedCost,Commercial,,6897.88,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,inpatient,,,480.00000,288.00000,MedCost,Commercial,,388.80,,,,,,,307.20,390.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,MedCost,Commercial,,292.80,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,inpatient,,,300.00000,180.00000,MedCost,Commercial,,243.00,,,,,,,192.00,243.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,MedCost,Commercial,,183.00,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,inpatient,,,480.00000,288.00000,MedCost,Commercial,,388.80,,,,,,,307.20,390.24,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,MedCost,Commercial,,292.80,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,inpatient,,,300.00000,180.00000,MedCost,Commercial,,243.00,,,,,,,192.00,243.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,MedCost,Commercial,,183.00,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,inpatient,,,34.00000,20.40000,MedCost,Commercial,,27.54,,,,,,,21.76,27.64,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,MedCost,Commercial,,20.74,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,73.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,inpatient,,,240.00000,144.00000,MedCost,Commercial,,194.40,,,,,,,153.60,195.12,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,MedCost,Commercial,,146.40,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,inpatient,,,374.00000,224.40000,MedCost,Commercial,,302.94,,,,,,,239.36,304.06,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,MedCost,Commercial,,228.14,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,inpatient,,,1320.00000,792.00000,MedCost,Commercial,,1069.20,,,,,,,844.80,1073.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,MedCost,Commercial,,805.20,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,inpatient,,,1425.00000,855.00000,MedCost,Commercial,,1154.25,,,,,,,912.00,1158.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,MedCost,Commercial,,869.25,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,inpatient,,,2232.00000,1339.20000,MedCost,Commercial,,1807.92,,,,,,,1428.48,1814.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,MedCost,Commercial,,1361.52,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,inpatient,,,293.00000,175.80000,MedCost,Commercial,,243.19,,,,,,,50.40,243.19,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,MedCost,Commercial,,178.73,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,inpatient,,,672.00000,403.20000,MedCost,Commercial,,544.32,,,,,,,430.08,546.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,MedCost,Commercial,,409.92,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,inpatient,,,104.00000,62.40000,MedCost,Commercial,,84.24,,,,,,,66.56,84.55,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,MedCost,Commercial,,63.44,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,inpatient,,,1016.00000,609.60000,MedCost,Commercial,,822.96,,,,,,,650.24,826.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,MedCost,Commercial,,619.76,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,inpatient,,,175.00000,105.00000,MedCost,Commercial,,141.75,,,,,,,112.00,142.28,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,MedCost,Commercial,,106.75,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,inpatient,,,258.00000,154.80000,MedCost,Commercial,,208.98,,,,,,,165.12,209.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,MedCost,Commercial,,157.38,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,inpatient,,,192.00000,115.20000,MedCost,Commercial,,155.52,,,,,,,122.88,156.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,MedCost,Commercial,,117.12,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,inpatient,,,3162.00000,1897.20000,MedCost,Commercial,,2561.22,,,,,,,2023.68,2570.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,MedCost,Commercial,,1928.82,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,inpatient,,,302.00000,181.20000,MedCost,Commercial,,244.62,,,,,,,193.28,245.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,MedCost,Commercial,,184.22,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,inpatient,,,296.00000,177.60000,MedCost,Commercial,,239.76,,,,,,,189.44,240.65,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,MedCost,Commercial,,180.56,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,inpatient,,,309.00000,185.40000,MedCost,Commercial,,250.29,,,,,,,197.76,251.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,MedCost,Commercial,,188.49,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,inpatient,,,285.00000,171.00000,MedCost,Commercial,,230.85,,,,,,,182.40,231.71,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,MedCost,Commercial,,173.85,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,inpatient,,,341.00000,204.60000,MedCost,Commercial,,276.21,,,,,,,218.24,277.23,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,MedCost,Commercial,,208.01,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,inpatient,,,432.00000,259.20000,MedCost,Commercial,,349.92,,,,,,,276.48,351.22,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,MedCost,Commercial,,263.52,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,inpatient,,,617.00000,370.20000,MedCost,Commercial,,499.77,,,,,,,394.88,501.62,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,MedCost,Commercial,,376.37,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,inpatient,,,44.00000,26.40000,MedCost,Commercial,,35.64,,,,,,,28.16,35.77,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,MedCost,Commercial,,26.84,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,inpatient,,,42.00000,25.20000,MedCost,Commercial,,34.02,,,,,,,26.88,34.15,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,MedCost,Commercial,,25.62,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,inpatient,,,71.00000,42.60000,MedCost,Commercial,,57.51,,,,,,,45.44,57.72,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,MedCost,Commercial,,43.31,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,inpatient,,,221.00000,132.60000,MedCost,Commercial,,179.01,,,,,,,141.44,179.67,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,MedCost,Commercial,,134.81,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,inpatient,,,402.00000,241.20000,MedCost,Commercial,,325.62,,,,,,,257.28,326.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,MedCost,Commercial,,245.22,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,inpatient,,,890.00000,534.00000,MedCost,Commercial,,720.90,,,,,,,569.60,723.57,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,MedCost,Commercial,,542.90,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,inpatient,,,74.00000,44.40000,MedCost,Commercial,,59.94,,,,,,,47.36,60.16,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,MedCost,Commercial,,45.14,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,inpatient,,,54.00000,32.40000,MedCost,Commercial,,43.74,,,,,,,34.56,43.90,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,MedCost,Commercial,,32.94,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,inpatient,,,265.00000,159.00000,MedCost,Commercial,,214.65,,,,,,,169.60,215.44,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,MedCost,Commercial,,161.65,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,inpatient,,,40.00000,24.00000,MedCost,Commercial,,32.40,,,,,,,25.60,32.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,MedCost,Commercial,,24.40,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,inpatient,,,750.00000,450.00000,MedCost,Commercial,,607.50,,,,,,,480.00,609.75,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,MedCost,Commercial,,457.50,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,inpatient,,,1175.00000,705.00000,MedCost,Commercial,,951.75,,,,,,,752.00,955.27,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,MedCost,Commercial,,716.75,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,inpatient,,,4010.00000,2406.00000,MedCost,Commercial,,3248.10,,,,,,,2566.40,3260.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,MedCost,Commercial,,2446.10,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,inpatient,,,1224.00000,734.40000,MedCost,Commercial,,991.44,,,,,,,783.36,995.11,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,MedCost,Commercial,,746.64,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1453.14,,,,,,,1148.16,1458.52,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Commercial,,1094.34,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,inpatient,,,2269.00000,1361.40000,MedCost,Commercial,,1837.89,,,,,,,1452.16,1844.70,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,MedCost,Commercial,,1384.09,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,inpatient,,,492.00000,295.20000,MedCost,Commercial,,398.52,,,,,,,314.88,400.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,MedCost,Commercial,,300.12,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,inpatient,,,4010.00000,2406.00000,MedCost,Commercial,,3248.10,,,,,,,2566.40,3260.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,MedCost,Commercial,,2446.10,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,inpatient,,,700.00000,420.00000,MedCost,Commercial,,567.00,,,,,,,448.00,569.10,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,MedCost,Commercial,,427.00,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,inpatient,,,780.00000,468.00000,MedCost,Commercial,,631.80,,,,,,,499.20,634.14,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,MedCost,Commercial,,475.80,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,inpatient,,,90.00000,54.00000,MedCost,Commercial,,72.90,,,,,,,57.60,73.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,MedCost,Commercial,,54.90,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,inpatient,,,1598.00000,958.80000,MedCost,Commercial,,1294.38,,,,,,,1022.72,1299.17,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,MedCost,Commercial,,974.78,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,inpatient,,,2569.00000,1541.40000,MedCost,Commercial,,2080.89,,,,,,,1644.16,2088.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,MedCost,Commercial,,1567.09,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,inpatient,,,500.00000,300.00000,MedCost,Commercial,,405.00,,,,,,,320.00,406.50,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,MedCost,Commercial,,305.00,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,inpatient,,,4000.00000,2400.00000,MedCost,Commercial,,3240.00,,,,,,,2560.00,3252.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,MedCost,Commercial,,2440.00,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,inpatient,,,2425.00000,1455.00000,MedCost,Commercial,,1964.25,,,,,,,1552.00,1971.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,MedCost,Commercial,,1479.25,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,inpatient,,,1800.00000,1080.00000,MedCost,Commercial,,1458.00,,,,,,,1152.00,1463.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,MedCost,Commercial,,1098.00,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,inpatient,,,2425.00000,1455.00000,MedCost,Commercial,,1964.25,,,,,,,1552.00,1971.53,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,MedCost,Commercial,,1479.25,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,inpatient,,,1800.00000,1080.00000,MedCost,Commercial,,1458.00,,,,,,,1152.00,1463.40,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,MedCost,Commercial,,1098.00,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,inpatient,,,1180.00000,708.00000,MedCost,Commercial,,955.80,,,,,,,755.20,959.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,MedCost,Commercial,,719.80,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,inpatient,,,1180.00000,708.00000,MedCost,Commercial,,955.80,,,,,,,755.20,959.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,MedCost,Commercial,,719.80,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,inpatient,,,1057.00000,634.20000,MedCost,Commercial,,856.17,,,,,,,676.48,859.34,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,MedCost,Commercial,,644.77,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,inpatient,,,238.00000,142.80000,MedCost,Commercial,GP,192.78,,,,,,,152.32,192.78,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,MedCost,Commercial,GP,145.18,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,inpatient,,,30903.00000,18541.80000,MedCost,Commercial,,25031.43,,,,,,,7039.00,25031.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,MedCost,Commercial,,18850.83,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,inpatient,,,14943.00000,8965.80000,MedCost,Commercial,,12103.83,,,,,,,7039.00,12103.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,MedCost,Commercial,,9115.23,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,inpatient,,,30903.00000,18541.80000,MedCost,Commercial,,25031.43,,,,,,,7039.00,25031.43,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,MedCost,Commercial,,18850.83,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,inpatient,,,14943.00000,8965.80000,MedCost,Commercial,,12103.83,,,,,,,7039.00,12103.83,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,MedCost,Commercial,,9115.23,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,inpatient,,,12987.00000,7792.20000,MedCost,Commercial,,10519.47,,,,,,,7039.00,10519.47,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,MedCost,Commercial,,7922.07,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,inpatient,,,13273.00000,7963.80000,MedCost,Commercial,,10751.13,,,,,,,7039.00,10751.13,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,MedCost,Commercial,,8096.53,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,inpatient,,,13560.00000,8136.00000,MedCost,Commercial,,10983.60,,,,,,,7039.00,10983.60,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,MedCost,Commercial,,8271.60,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,inpatient,,,13848.00000,8308.80000,MedCost,Commercial,,11216.88,,,,,,,7039.00,11216.88,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,MedCost,Commercial,,8447.28,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,inpatient,,,14135.00000,8481.00000,MedCost,Commercial,,11449.35,,,,,,,7039.00,11449.35,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,MedCost,Commercial,,8622.35,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,inpatient,,,14421.00000,8652.60000,MedCost,Commercial,,11681.01,,,,,,,7039.00,11681.01,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,MedCost,Commercial,,8796.81,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,inpatient,,,14708.00000,8824.80000,MedCost,Commercial,,11913.48,,,,,,,7039.00,11913.48,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,MedCost,Commercial,,8971.88,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,inpatient,,,14995.00000,8997.00000,MedCost,Commercial,,12145.95,,,,,,,7039.00,12145.95,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,MedCost,Commercial,,9146.95,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,inpatient,,,499.00000,299.40000,MedCost,Commercial,,404.19,,,,,,,319.36,405.69,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,MedCost,Commercial,,304.39,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,inpatient,,,246.00000,147.60000,MedCost,Commercial,,199.26,,,,,,,157.44,200.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,MedCost,Commercial,,150.06,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,inpatient,,,200.00000,120.00000,MedCost,Commercial,,162.00,,,,,,,128.00,162.00,percent of total billed charges,"If charges exceed the stop loss threshold of $58,728, the entire claim will be reimbursed at 80% of billed charges."
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,MedCost,Commercial,,122.00,,,,,,,34.82,150.00,percent of total billed charges,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,inpatient,,,0.14000,0.08000,MedCost,Ultra,,0.08960,,,,,,,0.04214,0.11382,percent of total billed charges,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,MedCost,Ultra,,0.07140,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,130.00000,78.00000,MedCost,Ultra,,83.20,,,,,,,39.13,105.69,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,MedCost,Ultra,,66.30,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,25.00000,15.00000,MedCost,Ultra,,16.00,,,,,,,7.53,20.32,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,MedCost,Ultra,,12.75,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,28.59,77.23,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,16.25,43.90,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,MedCost,Ultra,,78.72,,,,,,,78.72,100.00,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,MedCost,Ultra,,62.73,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,MedCost,Ultra,,78.72,,,,,,,37.02,100.00,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,MedCost,Ultra,,62.73,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,22.07000,13.24000,MedCost,Ultra,,14.12,,,,,,,6.64,17.94,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,MedCost,Ultra,,11.26,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,77.23,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,142.00000,85.20000,MedCost,Ultra,,90.88,,,,,,,42.74,115.45,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,MedCost,Ultra,,72.42,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,inpatient,,,39570.00000,23742.00000,MedCost,Ultra,,25324.80,,,,,,,11910.57,32170.41,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,MedCost,Ultra,,20180.70,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,17004.00000,10202.40000,MedCost,Ultra,,10882.56,,,,,,,5118.20,13824.25,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,MedCost,Ultra,,8672.04,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,inpatient,,,1.01000,0.61000,MedCost,Ultra,,0.64640,,,,,,,0.64640,0.81810,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,MedCost,Ultra,,0.51510,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,1919.00000,1151.40000,MedCost,Ultra,,1228.16,,,,,,,577.62,1560.15,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,MedCost,Ultra,,978.69,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,7252.00000,4351.20000,MedCost,Ultra,,4641.28,,,,,,,2182.85,5895.88,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,MedCost,Ultra,,3698.52,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,1734.00000,1040.40000,MedCost,Ultra,,1109.76,,,,,,,521.93,1409.74,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,MedCost,Ultra,,884.34,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,3295.00000,1977.00000,MedCost,Ultra,,2108.80,,,,,,,991.79,2678.84,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,MedCost,Ultra,,1680.45,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,40220.00000,24132.00000,MedCost,Ultra,,25740.80,,,,,,,12106.22,32698.86,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,MedCost,Ultra,,20512.20,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,12517.00000,7510.20000,MedCost,Ultra,,8010.88,,,,,,,3767.62,10176.32,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,MedCost,Ultra,,6383.67,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,11120.00000,6672.00000,MedCost,Ultra,,7116.80,,,,,,,3347.12,9040.56,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,MedCost,Ultra,,5671.20,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,15665.00000,9399.00000,MedCost,Ultra,,10025.60,,,,,,,4715.16,12735.65,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,MedCost,Ultra,,7989.15,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,31578.00000,18946.80000,MedCost,Ultra,,20209.92,,,,,,,9504.98,25672.91,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,MedCost,Ultra,,16104.78,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,2639.00000,1583.40000,MedCost,Ultra,,1688.96,,,,,,,794.34,2145.51,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,MedCost,Ultra,,1345.89,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,11117.00000,6670.20000,MedCost,Ultra,,7114.88,,,,,,,3346.22,9038.12,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,MedCost,Ultra,,5669.67,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,16042.00000,9625.20000,MedCost,Ultra,,10266.88,,,,,,,4828.64,13042.15,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,MedCost,Ultra,,8181.42,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,2696.00000,1617.60000,MedCost,Ultra,,1725.44,,,,,,,811.50,2191.85,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,MedCost,Ultra,,1374.96,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,8366.00000,5019.60000,MedCost,Ultra,,5354.24,,,,,,,2518.17,6801.56,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,MedCost,Ultra,,4266.66,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,8920.00000,5352.00000,MedCost,Ultra,,5708.80,,,,,,,2684.92,7251.96,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,MedCost,Ultra,,4549.20,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,11277.00000,6766.20000,MedCost,Ultra,,7217.28,,,,,,,3394.38,9168.20,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,MedCost,Ultra,,5751.27,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,inpatient,,,132.00000,79.20000,MedCost,Ultra,,84.48,,,,,,,84.48,107.32,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,MedCost,Ultra,,67.32,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,MedCost,Ultra,,291.20,,,,,,,136.96,369.92,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,MedCost,Ultra,,232.05,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,MedCost,Ultra,,583.04,,,,,,,274.21,740.64,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,MedCost,Ultra,,464.61,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,inpatient,,,31.28000,18.77000,MedCost,Ultra,,20.02,,,,,,,9.42,25.43,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,MedCost,Ultra,,15.95,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,inpatient,,,20.34000,12.20000,MedCost,Ultra,,13.02,,,,,,,6.12,16.54,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,MedCost,Ultra,,10.37,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,inpatient,,,278.96000,167.38000,MedCost,Ultra,,178.53,,,,,,,83.97,226.79,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,MedCost,Ultra,,142.27,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,inpatient,,,21.64000,12.98000,MedCost,Ultra,,13.85,,,,,,,6.51,17.59,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,MedCost,Ultra,,11.04,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,inpatient,,,0.03000,0.02000,MedCost,Ultra,,0.01920,,,,,,,0.00903,0.02439,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,MedCost,Ultra,,0.01530,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,inpatient,,,21.42000,12.85000,MedCost,Ultra,,13.71,,,,,,,6.45,17.41,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,MedCost,Ultra,,10.92,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,inpatient,,,40.61000,24.37000,MedCost,Ultra,,25.99,,,,,,,12.22,33.02,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,MedCost,Ultra,,20.71,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,inpatient,,,20.37000,12.22000,MedCost,Ultra,,13.04,,,,,,,6.13,16.56,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,MedCost,Ultra,,10.39,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,inpatient,,,19.90000,11.94000,MedCost,Ultra,,12.74,,,,,,,5.99,16.18,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,MedCost,Ultra,,10.15,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,MedCost,Ultra,,632.32,,,,,,,632.32,803.24,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,MedCost,Ultra,,503.88,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,174.72,221.95,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,inpatient,,,65.26000,39.16000,MedCost,Ultra,,41.77,,,,,,,19.64,53.06,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,MedCost,Ultra,,33.28,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,inpatient,,,178.21000,106.93000,MedCost,Ultra,,114.05,,,,,,,114.05,144.88,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,MedCost,Ultra,,90.89,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,inpatient,,,15495.00000,9297.00000,MedCost,Ultra,,9916.80,,,,,,,4663.99,12597.43,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,MedCost,Ultra,,7902.45,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,inpatient,,,6.33000,3.80000,MedCost,Ultra,,4.05,,,,,,,1.91,5.15,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,MedCost,Ultra,,3.23,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,,,182.00000,109.20000,MedCost,Ultra,,116.48,,,,,,,116.48,147.97,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,MedCost,Ultra,,92.82,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,MedCost,Ultra,,128.00,,,,,,,60.20,162.60,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,MedCost,Ultra,,102.00,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,MedCost,Ultra,,128.00,,,,,,,128.00,162.60,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,MedCost,Ultra,,102.00,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,inpatient,,,29.65000,17.79000,MedCost,Ultra,,18.98,,,,,,,8.92,24.11,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,MedCost,Ultra,,15.12,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Ultra,,790.40,,,,,,,371.74,1004.05,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Ultra,,629.85,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Ultra,,670.72,,,,,,,315.45,852.02,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Ultra,,534.48,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,MedCost,Ultra,,452.48,,,,,,,212.81,574.79,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,MedCost,Ultra,,360.57,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,MedCost,Ultra,,352.00,,,,,,,165.55,447.15,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,MedCost,Ultra,,280.50,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,MedCost,Ultra,,282.88,,,,,,,133.04,359.35,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,MedCost,Ultra,,225.42,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,MedCost,Ultra,,298.24,,,,,,,140.27,378.86,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,MedCost,Ultra,,237.66,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Ultra,,790.40,,,,,,,790.40,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Ultra,,629.85,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Ultra,,670.72,,,,,,,670.72,852.02,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Ultra,,534.48,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,MedCost,Ultra,,452.48,,,,,,,452.48,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,MedCost,Ultra,,360.57,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,MedCost,Ultra,,352.00,,,,,,,352.00,447.15,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,MedCost,Ultra,,280.50,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,MedCost,Ultra,,282.88,,,,,,,282.88,359.35,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,MedCost,Ultra,,225.42,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,MedCost,Ultra,,298.24,,,,,,,298.24,378.86,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,MedCost,Ultra,,237.66,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,inpatient,,,27.47000,16.48000,MedCost,Ultra,,17.58,,,,,,,8.27,22.33,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,MedCost,Ultra,,14.01,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,MedCost,Ultra,,365.44,,,,,,,171.87,464.22,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,MedCost,Ultra,,291.21,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,MedCost,Ultra,,167.68,,,,,,,78.86,213.01,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,MedCost,Ultra,,133.62,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,2469.00000,1481.40000,MedCost,Ultra,,1580.16,,,,,,,743.17,2007.30,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,MedCost,Ultra,,1259.19,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,MedCost,Ultra,,446.72,,,,,,,210.10,567.47,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,MedCost,Ultra,,355.98,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,MedCost,Ultra,,446.72,,,,,,,446.72,567.47,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,MedCost,Ultra,,355.98,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,188.43,508.94,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,400.64,508.94,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,MedCost,Ultra,,393.60,,,,,,,185.12,500.00,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,MedCost,Ultra,,313.65,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,MedCost,Ultra,,393.60,,,,,,,393.60,500.00,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,MedCost,Ultra,,313.65,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,132.14,356.91,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,280.96,356.91,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,MedCost,Ultra,,255.36,,,,,,,120.10,324.39,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,MedCost,Ultra,,203.49,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,MedCost,Ultra,,255.36,,,,,,,255.36,324.39,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,MedCost,Ultra,,203.49,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,2363.00000,1417.80000,MedCost,Ultra,,1512.32,,,,,,,1512.32,1921.12,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,MedCost,Ultra,,1205.13,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,MedCost,Ultra,,365.44,,,,,,,365.44,464.22,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,MedCost,Ultra,,291.21,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,MedCost,Ultra,,167.68,,,,,,,167.68,213.01,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,MedCost,Ultra,,133.62,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,MedCost,Ultra,,200.32,,,,,,,94.21,254.47,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,MedCost,Ultra,,159.63,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,MedCost,Ultra,,200.32,,,,,,,200.32,254.47,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,MedCost,Ultra,,159.63,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Ultra,,1008.00,,,,,,,474.07,1280.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Ultra,,803.25,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Ultra,,1008.00,,,,,,,1008.00,1280.47,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Ultra,,803.25,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Ultra,,801.28,,,,,,,376.85,1017.88,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Ultra,,638.52,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Ultra,,801.28,,,,,,,801.28,1017.88,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Ultra,,638.52,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,MedCost,Ultra,,410.24,,,,,,,192.94,521.13,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,MedCost,Ultra,,326.91,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,MedCost,Ultra,,410.24,,,,,,,410.24,521.13,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,MedCost,Ultra,,326.91,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,MedCost,Ultra,,217.60,,,,,,,102.34,276.42,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,MedCost,Ultra,,173.40,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,MedCost,Ultra,,217.60,,,,,,,217.60,276.42,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,MedCost,Ultra,,173.40,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,MedCost,Ultra,,174.08,,,,,,,81.87,221.14,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,MedCost,Ultra,,138.72,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,MedCost,Ultra,,174.08,,,,,,,174.08,221.14,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,MedCost,Ultra,,138.72,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,inpatient,,,216.17000,129.70000,MedCost,Ultra,,138.35,,,,,,,65.07,175.75,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,MedCost,Ultra,,110.25,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,MedCost,Ultra,,583.04,,,,,,,583.04,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,MedCost,Ultra,,464.61,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,MedCost,Ultra,,291.20,,,,,,,291.20,369.92,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,MedCost,Ultra,,232.05,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,5187.00000,3112.20000,MedCost,Ultra,,3319.68,,,,,,,1561.29,4217.03,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,MedCost,Ultra,,2645.37,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,inpatient,,,153.80000,92.28000,MedCost,Ultra,,98.43,,,,,,,46.29,125.04,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,MedCost,Ultra,,78.44,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2562.00000,1537.20000,MedCost,Ultra,,1639.68,,,,,,,771.16,2082.91,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,MedCost,Ultra,,1306.62,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,MedCost,Ultra,,632.32,,,,,,,297.39,803.24,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,MedCost,Ultra,,503.88,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,188.43,508.94,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,82.17,221.95,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,inpatient,,,872.14000,523.28000,MedCost,Ultra,,558.17,,,,,,,262.51,709.05,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,MedCost,Ultra,,444.79,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,inpatient,,,1070.23000,642.14000,MedCost,Ultra,,684.95,,,,,,,322.14,870.10,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,MedCost,Ultra,,545.82,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,inpatient,,,2.18000,1.31000,MedCost,Ultra,,1.40,,,,,,,0.65618,1.77,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,MedCost,Ultra,,1.11,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,2078.00000,1246.80000,MedCost,Ultra,,1329.92,,,,,,,625.48,1689.41,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,MedCost,Ultra,,1059.78,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Ultra,,1762.56,,,,,,,828.95,2239.00,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Ultra,,1404.54,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Ultra,,778.24,,,,,,,366.02,988.61,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Ultra,,620.16,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,MedCost,Ultra,,394.24,,,,,,,185.42,500.81,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,MedCost,Ultra,,314.16,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Ultra,,1762.56,,,,,,,1762.56,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Ultra,,1404.54,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Ultra,,778.24,,,,,,,778.24,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Ultra,,620.16,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,MedCost,Ultra,,394.24,,,,,,,394.24,500.81,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,MedCost,Ultra,,314.16,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,2813.00000,1687.80000,MedCost,Ultra,,1800.32,,,,,,,846.71,2286.97,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,MedCost,Ultra,,1434.63,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,inpatient,,,3.10000,1.86000,MedCost,Ultra,,1.98,,,,,,,0.93310,2.52,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,MedCost,Ultra,,1.58,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,9.84000,5.90000,MedCost,Ultra,,6.30,,,,,,,2.96,8.00,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,MedCost,Ultra,,5.02,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,inpatient,,,192.61000,115.57000,MedCost,Ultra,,123.27,,,,,,,123.27,156.59,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,MedCost,Ultra,,98.23,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,inpatient,,,66.43000,39.86000,MedCost,Ultra,,42.52,,,,,,,20.00,54.01,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,MedCost,Ultra,,33.88,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,MedCost,Ultra,,78.72,,,,,,,37.02,100.00,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,MedCost,Ultra,,62.73,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,inpatient,,,237.69000,142.61000,MedCost,Ultra,,152.12,,,,,,,71.54,193.24,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,MedCost,Ultra,,121.22,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,inpatient,,,273.90000,164.34000,MedCost,Ultra,,175.30,,,,,,,82.44,222.68,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,MedCost,Ultra,,139.69,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,inpatient,,,158.70000,95.22000,MedCost,Ultra,,101.57,,,,,,,47.77,129.02,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,MedCost,Ultra,,80.94,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,MedCost,Ultra,,218.88,,,,,,,102.94,278.05,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,MedCost,Ultra,,174.42,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,MedCost,Ultra,,218.88,,,,,,,218.88,278.05,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,MedCost,Ultra,,174.42,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Ultra,,989.44,,,,,,,465.35,1256.90,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Ultra,,788.46,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,3094.00000,1856.40000,MedCost,Ultra,,1980.16,,,,,,,931.29,2515.42,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,MedCost,Ultra,,1577.94,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Ultra,,989.44,,,,,,,989.44,1256.90,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Ultra,,788.46,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,inpatient,,,330.40000,198.24000,MedCost,Ultra,,211.46,,,,,,,99.45,268.62,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,MedCost,Ultra,,168.50,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,inpatient,,,329.28000,197.57000,MedCost,Ultra,,210.74,,,,,,,99.11,267.70,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,MedCost,Ultra,,167.93,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,inpatient,,,153.16000,91.90000,MedCost,Ultra,,98.02,,,,,,,46.10,124.52,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,MedCost,Ultra,,78.11,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,inpatient,,,158.82000,95.29000,MedCost,Ultra,,101.64,,,,,,,47.80,129.12,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,MedCost,Ultra,,81.00,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,MedCost,Ultra,,273.92,,,,,,,128.83,347.96,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,MedCost,Ultra,,218.28,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,MedCost,Ultra,,273.92,,,,,,,273.92,347.96,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,MedCost,Ultra,,218.28,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,145.38,392.68,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,309.12,392.68,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,10.00000,6.00000,MedCost,Ultra,,6.40,,,,,,,3.01,8.13,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,MedCost,Ultra,,5.10,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,inpatient,,,0.12000,0.07000,MedCost,Ultra,,0.07680,,,,,,,0.07680,0.09756,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,MedCost,Ultra,,0.06120,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,inpatient,,,0.27000,0.16000,MedCost,Ultra,,0.17280,,,,,,,0.17280,0.21951,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,MedCost,Ultra,,0.13770,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Ultra,,1598.72,,,,,,,751.90,2030.87,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Ultra,,1273.98,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Ultra,,1598.72,,,,,,,1598.72,2030.87,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Ultra,,1273.98,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Ultra,,1296.00,,,,,,,609.52,1646.33,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Ultra,,1032.75,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Ultra,,1296.00,,,,,,,1296.00,1646.33,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Ultra,,1032.75,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Ultra,,1093.12,,,,,,,514.11,1388.60,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Ultra,,871.08,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Ultra,,1093.12,,,,,,,1093.12,1388.60,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Ultra,,871.08,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00301,0.00813,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,inpatient,,,322.28000,193.37000,MedCost,Ultra,,206.26,,,,,,,97.01,262.01,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,MedCost,Ultra,,164.36,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,19.57,52.84,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.84,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,inpatient,,,81.13000,48.68000,MedCost,Ultra,,51.92,,,,,,,24.42,65.96,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,MedCost,Ultra,,41.38,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,inpatient,,,53.52000,32.11000,MedCost,Ultra,,34.25,,,,,,,16.11,43.51,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,MedCost,Ultra,,27.30,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,inpatient,,,126.03000,75.62000,MedCost,Ultra,,80.66,,,,,,,37.94,102.46,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,MedCost,Ultra,,64.28,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,inpatient,,,30.86000,18.52000,MedCost,Ultra,,19.75,,,,,,,9.29,25.09,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,MedCost,Ultra,,15.74,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,inpatient,,,16.63000,9.98000,MedCost,Ultra,,10.64,,,,,,,5.01,13.52,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,MedCost,Ultra,,8.48,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,inpatient,,,116.79000,70.07000,MedCost,Ultra,,74.75,,,,,,,35.15,94.95,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,MedCost,Ultra,,59.56,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,inpatient,,,33.65000,20.19000,MedCost,Ultra,,21.54,,,,,,,10.13,27.36,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,MedCost,Ultra,,17.16,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,inpatient,,,96.04000,57.62000,MedCost,Ultra,,61.47,,,,,,,28.91,78.08,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,MedCost,Ultra,,48.98,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,inpatient,,,275.02000,165.01000,MedCost,Ultra,,176.01,,,,,,,82.78,223.59,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,MedCost,Ultra,,140.26,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,inpatient,,,42.62000,25.57000,MedCost,Ultra,,27.28,,,,,,,12.83,34.65,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,MedCost,Ultra,,21.74,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,inpatient,,,51.42000,30.85000,MedCost,Ultra,,32.91,,,,,,,15.48,41.80,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,MedCost,Ultra,,26.22,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,inpatient,,,166.08000,99.65000,MedCost,Ultra,,106.29,,,,,,,49.99,135.02,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,MedCost,Ultra,,84.70,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,inpatient,,,128.79000,77.27000,MedCost,Ultra,,82.43,,,,,,,38.77,104.71,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,MedCost,Ultra,,65.68,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,inpatient,,,154.18000,92.51000,MedCost,Ultra,,98.68,,,,,,,46.41,125.35,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,MedCost,Ultra,,78.63,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,inpatient,,,146.33000,87.80000,MedCost,Ultra,,93.65,,,,,,,44.05,118.97,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,MedCost,Ultra,,74.63,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,inpatient,,,26.14000,15.68000,MedCost,Ultra,,16.73,,,,,,,7.87,21.25,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,MedCost,Ultra,,13.33,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,inpatient,,,28.56000,17.14000,MedCost,Ultra,,18.28,,,,,,,8.60,23.22,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,MedCost,Ultra,,14.57,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,inpatient,,,68.05000,40.83000,MedCost,Ultra,,43.55,,,,,,,20.48,55.32,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,MedCost,Ultra,,34.71,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,inpatient,,,140.75000,84.45000,MedCost,Ultra,,90.08,,,,,,,42.37,114.43,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,MedCost,Ultra,,71.78,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,0.51000,0.31000,MedCost,Ultra,,0.32640,,,,,,,0.15351,0.41463,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,MedCost,Ultra,,0.26010,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,inpatient,,,26.23000,15.74000,MedCost,Ultra,,16.79,,,,,,,7.90,21.32,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,MedCost,Ultra,,13.38,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,inpatient,,,5.92000,3.55000,MedCost,Ultra,,3.79,,,,,,,1.78,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,MedCost,Ultra,,3.02,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,inpatient,,,10.52000,6.31000,MedCost,Ultra,,6.73,,,,,,,6.73,8.55,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,MedCost,Ultra,,5.37,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,inpatient,,,0.11000,0.07000,MedCost,Ultra,,0.07040,,,,,,,0.03311,0.08943,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,MedCost,Ultra,,0.05610,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,inpatient,,,0.80000,0.48000,MedCost,Ultra,,0.51200,,,,,,,0.24080,0.65040,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,MedCost,Ultra,,0.40800,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,inpatient,,,7.76000,4.66000,MedCost,Ultra,,4.97,,,,,,,2.34,6.31,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,MedCost,Ultra,,3.96,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,inpatient,,,0.79000,0.47000,MedCost,Ultra,,0.50560,,,,,,,0.23779,0.64227,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,MedCost,Ultra,,0.40290,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,0.47000,0.28000,MedCost,Ultra,,0.30080,,,,,,,0.14147,0.38211,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,MedCost,Ultra,,0.23970,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,inpatient,,,0.64000,0.38000,MedCost,Ultra,,0.40960,,,,,,,0.19264,0.52032,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,MedCost,Ultra,,0.32640,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,inpatient,,,1666.78000,1000.07000,MedCost,Ultra,,1066.74,,,,,,,501.70,1355.09,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,MedCost,Ultra,,850.06,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,inpatient,,,0.02000,0.01000,MedCost,Ultra,,0.01280,,,,,,,0.00602,0.01626,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,MedCost,Ultra,,0.01020,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,inpatient,,,0.09000,0.05000,MedCost,Ultra,,0.05760,,,,,,,0.05760,0.07317,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,MedCost,Ultra,,0.04590,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,inpatient,,,2.57000,1.54000,MedCost,Ultra,,1.64,,,,,,,1.64,2.09,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,MedCost,Ultra,,1.31,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,inpatient,,,25.77000,15.46000,MedCost,Ultra,,16.49,,,,,,,7.76,20.95,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,MedCost,Ultra,,13.14,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,inpatient,,,81.46000,48.88000,MedCost,Ultra,,52.13,,,,,,,24.52,66.23,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,MedCost,Ultra,,41.54,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,0.07000,0.04000,MedCost,Ultra,,0.04480,,,,,,,0.02107,0.05691,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,MedCost,Ultra,,0.03570,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,inpatient,,,4.25000,2.55000,MedCost,Ultra,,2.72,,,,,,,1.28,3.46,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,MedCost,Ultra,,2.17,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,inpatient,,,6.12000,3.67000,MedCost,Ultra,,3.92,,,,,,,1.84,4.98,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,MedCost,Ultra,,3.12,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,inpatient,,,1.12000,0.67000,MedCost,Ultra,,0.71680,,,,,,,0.33712,0.91056,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,MedCost,Ultra,,0.57120,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,inpatient,,,1.61000,0.97000,MedCost,Ultra,,1.03,,,,,,,0.48461,1.31,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,MedCost,Ultra,,0.82110,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,inpatient,,,2.56000,1.54000,MedCost,Ultra,,1.64,,,,,,,0.77056,2.08,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,MedCost,Ultra,,1.31,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,inpatient,,,1.79000,1.07000,MedCost,Ultra,,1.15,,,,,,,0.53879,1.46,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,MedCost,Ultra,,0.91290,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,inpatient,,,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,inpatient,,,0.02000,0.01000,MedCost,Ultra,,0.01280,,,,,,,0.00602,0.01626,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,MedCost,Ultra,,0.01020,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,inpatient,,,22.10000,13.26000,MedCost,Ultra,,14.14,,,,,,,6.65,17.97,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,MedCost,Ultra,,11.27,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,inpatient,,,1100.73000,660.44000,MedCost,Ultra,,704.47,,,,,,,331.32,894.89,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,MedCost,Ultra,,561.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,inpatient,,,77.03000,46.22000,MedCost,Ultra,,49.30,,,,,,,23.19,62.63,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,MedCost,Ultra,,39.29,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,inpatient,,,134.92000,80.95000,MedCost,Ultra,,86.35,,,,,,,40.61,109.69,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,MedCost,Ultra,,68.81,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,inpatient,,,166.43000,99.86000,MedCost,Ultra,,106.52,,,,,,,50.10,135.31,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,MedCost,Ultra,,84.88,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,inpatient,,,17.28000,10.37000,MedCost,Ultra,,11.06,,,,,,,5.20,14.05,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,MedCost,Ultra,,8.81,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,inpatient,,,0.13000,0.08000,MedCost,Ultra,,0.08320,,,,,,,0.03913,0.10569,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,MedCost,Ultra,,0.06630,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,inpatient,,,36.34000,21.80000,MedCost,Ultra,,23.26,,,,,,,10.94,29.54,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,MedCost,Ultra,,18.53,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,inpatient,,,65.26000,39.16000,MedCost,Ultra,,41.77,,,,,,,19.64,53.06,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,MedCost,Ultra,,33.28,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,inpatient,,,143.90000,86.34000,MedCost,Ultra,,92.10,,,,,,,43.31,116.99,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,MedCost,Ultra,,73.39,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,inpatient,,,63.57000,38.14000,MedCost,Ultra,,40.68,,,,,,,19.13,51.68,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,MedCost,Ultra,,32.42,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,inpatient,,,249.07000,149.44000,MedCost,Ultra,,159.40,,,,,,,74.97,202.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,MedCost,Ultra,,127.03,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,inpatient,,,11.23000,6.74000,MedCost,Ultra,,7.19,,,,,,,3.38,9.13,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,MedCost,Ultra,,5.73,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,inpatient,,,25.48000,15.29000,MedCost,Ultra,,16.31,,,,,,,7.67,20.72,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,MedCost,Ultra,,12.99,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,inpatient,,,0.75000,0.45000,MedCost,Ultra,,0.48000,,,,,,,0.22575,0.60975,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,MedCost,Ultra,,0.38250,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,inpatient,,,0.04000,0.02000,MedCost,Ultra,,0.02560,,,,,,,0.01204,0.03252,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,MedCost,Ultra,,0.02040,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,inpatient,,,15.12000,9.07000,MedCost,Ultra,,9.68,,,,,,,9.68,12.29,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,MedCost,Ultra,,7.71,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,inpatient,,,13.35000,8.01000,MedCost,Ultra,,8.54,,,,,,,4.02,10.85,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,MedCost,Ultra,,6.81,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,inpatient,,,11.89000,7.13000,MedCost,Ultra,,7.61,,,,,,,3.58,9.67,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,MedCost,Ultra,,6.06,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,inpatient,,,17.69000,10.61000,MedCost,Ultra,,11.32,,,,,,,5.32,14.38,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,MedCost,Ultra,,9.02,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,inpatient,,,33.35000,20.01000,MedCost,Ultra,,21.34,,,,,,,10.04,27.11,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,MedCost,Ultra,,17.01,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,inpatient,,,54.96000,32.98000,MedCost,Ultra,,35.17,,,,,,,16.54,44.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,MedCost,Ultra,,28.03,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,inpatient,,,139.15000,83.49000,MedCost,Ultra,,89.06,,,,,,,41.88,113.13,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,MedCost,Ultra,,70.97,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,inpatient,25,ML,548.70000,329.22000,MedCost,Ultra,,351.17,,,,,,,165.16,446.09,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,MedCost,Ultra,,279.84,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,inpatient,5,ML,316.25000,189.75000,MedCost,Ultra,,202.40,,,,,,,95.19,257.11,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,MedCost,Ultra,,161.29,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,inpatient,1,UN,371.25000,222.75000,MedCost,Ultra,,237.60,,,,,,,111.75,301.83,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,MedCost,Ultra,,189.34,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,inpatient,1,UN,82.95000,49.77000,MedCost,Ultra,,53.09,,,,,,,24.97,67.44,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,MedCost,Ultra,,42.30,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,inpatient,1,ML,64.90000,38.94000,MedCost,Ultra,,41.54,,,,,,,19.53,52.76,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,MedCost,Ultra,,33.10,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,inpatient,1,ML,64.90000,38.94000,MedCost,Ultra,,41.54,,,,,,,19.53,52.76,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,MedCost,Ultra,,33.10,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,inpatient,50,ML,47.50000,28.50000,MedCost,Ultra,,30.40,,,,,,,30.40,38.62,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,MedCost,Ultra,,24.23,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,inpatient,1,UN,1.20000,0.72000,MedCost,Ultra,,0.76800,,,,,,,0.76800,0.97560,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,MedCost,Ultra,,0.61200,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,MedCost,Ultra,,1875.04,,,,,,,881.85,2381.89,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,MedCost,Ultra,,1494.17,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,MedCost,Ultra,,12449.18,,,,,,,5855.01,15814.35,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,MedCost,Ultra,,9920.44,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,10.59,,,,,,,10.59,13.46,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,8.44,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,12.67,,,,,,,12.67,16.10,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,10.10,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,11.71,,,,,,,11.71,14.88,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,9.33,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,12.80,,,,,,,12.80,16.26,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,10.20,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,inpatient,1,UN,21.35000,12.81000,MedCost,Ultra,,13.66,,,,,,,13.66,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,MedCost,Ultra,,10.89,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,inpatient,100,ML,128.45000,77.07000,MedCost,Ultra,,82.21,,,,,,,38.66,104.43,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,MedCost,Ultra,,65.51,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,inpatient,1,ML,84.10000,50.46000,MedCost,Ultra,,53.82,,,,,,,25.31,68.37,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,MedCost,Ultra,,42.89,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,inpatient,1,UN,350.70000,210.42000,MedCost,Ultra,,224.45,,,,,,,224.45,285.12,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,MedCost,Ultra,,178.86,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,inpatient,1,UN,385.55000,231.33000,MedCost,Ultra,,246.75,,,,,,,246.75,313.45,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,MedCost,Ultra,,196.63,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,inpatient,1,UN,19.40000,11.64000,MedCost,Ultra,,12.42,,,,,,,12.42,15.77,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,MedCost,Ultra,,9.89,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,inpatient,1,UN,3544.00000,2126.40000,MedCost,Ultra,,2268.16,,,,,,,1066.74,2881.27,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,MedCost,Ultra,,1807.44,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,inpatient,5,ML,304.25000,182.55000,MedCost,Ultra,,194.72,,,,,,,91.58,247.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,MedCost,Ultra,,155.17,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,inpatient,5,ML,43.45000,26.07000,MedCost,Ultra,,27.81,,,,,,,27.81,35.32,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,MedCost,Ultra,,22.16,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,10.40,,,,,,,10.40,13.21,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,8.29,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,10.37,,,,,,,10.37,13.17,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,8.26,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,inpatient,10,ML,2414.30000,1448.58000,MedCost,Ultra,,1545.15,,,,,,,726.70,1962.83,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,MedCost,Ultra,,1231.29,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,inpatient,1,UN,18.05000,10.83000,MedCost,Ultra,,11.55,,,,,,,11.55,14.67,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,MedCost,Ultra,,9.21,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,inpatient,1,UN,471.55000,282.93000,MedCost,Ultra,,301.79,,,,,,,141.94,383.37,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,MedCost,Ultra,,240.49,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,11.07,,,,,,,11.07,14.06,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,8.82,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,10.78,,,,,,,10.78,13.70,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,8.59,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,10.59,,,,,,,10.59,13.46,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,8.44,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,inpatient,1,UN,5220.40000,3132.24000,MedCost,Ultra,,3341.06,,,,,,,1571.34,4244.19,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,MedCost,Ultra,,2662.40,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,10.78,,,,,,,10.78,13.70,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,8.59,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,inpatient,0.5,ML,79.90000,47.94000,MedCost,Ultra,,51.14,,,,,,,24.05,64.96,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,MedCost,Ultra,,40.75,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,inpatient,1,ML,33.65000,20.19000,MedCost,Ultra,,21.54,,,,,,,10.13,27.36,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,MedCost,Ultra,,17.16,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,inpatient,10,ML,34.85000,20.91000,MedCost,Ultra,,22.30,,,,,,,10.49,28.33,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,MedCost,Ultra,,17.77,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,inpatient,30,ML,47.00000,28.20000,MedCost,Ultra,,30.08,,,,,,,14.15,38.21,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,MedCost,Ultra,,23.97,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,inpatient,1,ML,19.85000,11.91000,MedCost,Ultra,,12.70,,,,,,,5.97,16.14,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,MedCost,Ultra,,10.12,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,inpatient,1,ML,25.20000,15.12000,MedCost,Ultra,,16.13,,,,,,,7.59,20.49,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,MedCost,Ultra,,12.85,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,inpatient,60,ML,80.30000,48.18000,MedCost,Ultra,,51.39,,,,,,,51.39,65.28,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,MedCost,Ultra,,40.95,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,inpatient,4,ML,32.40000,19.44000,MedCost,Ultra,,20.74,,,,,,,20.74,26.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,MedCost,Ultra,,16.52,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,inpatient,1,UN,23.80000,14.28000,MedCost,Ultra,,15.23,,,,,,,15.23,19.35,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,MedCost,Ultra,,12.14,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,inpatient,1,UN,28.70000,17.22000,MedCost,Ultra,,18.37,,,,,,,18.37,23.33,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,MedCost,Ultra,,14.64,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,inpatient,5,ML,2.25000,1.35000,MedCost,Ultra,,1.44,,,,,,,1.44,1.83,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,MedCost,Ultra,,1.15,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,inpatient,1,UN,436.70000,262.02000,MedCost,Ultra,,279.49,,,,,,,131.45,355.04,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,MedCost,Ultra,,222.72,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,inpatient,1,UN,748.20000,448.92000,MedCost,Ultra,,478.85,,,,,,,225.21,608.29,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,MedCost,Ultra,,381.58,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,inpatient,1,UN,2284.55000,1370.73000,MedCost,Ultra,,1462.11,,,,,,,1462.11,1857.34,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,MedCost,Ultra,,1165.12,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,140.16,,,,,,,65.92,178.05,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,111.69,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,140.16,,,,,,,65.92,178.05,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,111.69,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,140.16,,,,,,,65.92,178.05,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,111.69,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,inpatient,1,UN,1.50000,0.90000,MedCost,Ultra,,0.96000,,,,,,,0.96000,1.22,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,MedCost,Ultra,,0.76500,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,inpatient,50,ML,49.45000,29.67000,MedCost,Ultra,,31.65,,,,,,,31.65,40.20,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,MedCost,Ultra,,25.22,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,inpatient,50,ML,57.55000,34.53000,MedCost,Ultra,,36.83,,,,,,,36.83,46.79,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,MedCost,Ultra,,29.35,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,inpatient,0.5,ML,568.50000,341.10000,MedCost,Ultra,,363.84,,,,,,,171.12,462.19,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,MedCost,Ultra,,289.94,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,inpatient,1,UN,21.80000,13.08000,MedCost,Ultra,,13.95,,,,,,,13.95,17.72,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,MedCost,Ultra,,11.12,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,inpatient,1,UN,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.76,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,inpatient,1,UN,24.65000,14.79000,MedCost,Ultra,,15.78,,,,,,,15.78,20.04,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,MedCost,Ultra,,12.57,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,11.42,14.51,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,inpatient,226,GR,7.00000,4.20000,MedCost,Ultra,,4.48,,,,,,,4.48,5.69,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,MedCost,Ultra,,3.57,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,11.71,,,,,,,11.71,14.88,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,9.33,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,inpatient,1,UN,2.60000,1.56000,MedCost,Ultra,,1.66,,,,,,,1.66,2.11,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,MedCost,Ultra,,1.33,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,inpatient,1,UN,18.05000,10.83000,MedCost,Ultra,,11.55,,,,,,,11.55,14.67,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,MedCost,Ultra,,9.21,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,inpatient,1,UN,18.40000,11.04000,MedCost,Ultra,,11.78,,,,,,,11.78,14.96,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,MedCost,Ultra,,9.38,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,inpatient,2,ML,26.75000,16.05000,MedCost,Ultra,,17.12,,,,,,,8.05,21.75,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,MedCost,Ultra,,13.64,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,inpatient,30,ML,30.90000,18.54000,MedCost,Ultra,,19.78,,,,,,,9.30,25.12,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,MedCost,Ultra,,15.76,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,inpatient,5,ML,23.80000,14.28000,MedCost,Ultra,,15.23,,,,,,,7.16,19.35,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,MedCost,Ultra,,12.14,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,inpatient,10,ML,47.55000,28.53000,MedCost,Ultra,,30.43,,,,,,,14.31,38.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,MedCost,Ultra,,24.25,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,inpatient,2,ML,29.35000,17.61000,MedCost,Ultra,,18.78,,,,,,,8.83,23.86,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,MedCost,Ultra,,14.97,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,MedCost,Ultra,,20.70,,,,,,,9.74,26.30,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,MedCost,Ultra,,16.50,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,inpatient,1,UN,2741.35000,1644.81000,MedCost,Ultra,,1754.46,,,,,,,825.15,2228.72,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,MedCost,Ultra,,1398.09,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,inpatient,1,ML,17.75000,10.65000,MedCost,Ultra,,11.36,,,,,,,5.34,14.43,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,MedCost,Ultra,,9.05,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,inpatient,1,ML,16.75000,10.05000,MedCost,Ultra,,10.72,,,,,,,5.04,13.62,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,MedCost,Ultra,,8.54,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,inpatient,1,ML,17.00000,10.20000,MedCost,Ultra,,10.88,,,,,,,5.12,13.82,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,MedCost,Ultra,,8.67,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,inpatient,1,ML,21.35000,12.81000,MedCost,Ultra,,13.66,,,,,,,6.43,17.36,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,MedCost,Ultra,,10.89,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,inpatient,5,GR,40.80000,24.48000,MedCost,Ultra,,26.11,,,,,,,26.11,33.17,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,MedCost,Ultra,,20.81,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,inpatient,1,ML,1839.60000,1103.76000,MedCost,Ultra,,1177.34,,,,,,,1177.34,1495.59,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,MedCost,Ultra,,938.20,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,inpatient,1,UN,16.15000,9.69000,MedCost,Ultra,,10.34,,,,,,,10.34,13.13,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,MedCost,Ultra,,8.24,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,inpatient,1,UN,17.35000,10.41000,MedCost,Ultra,,11.10,,,,,,,11.10,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,MedCost,Ultra,,8.85,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,inpatient,1,UN,17.75000,10.65000,MedCost,Ultra,,11.36,,,,,,,11.36,14.43,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,MedCost,Ultra,,9.05,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,inpatient,1,UN,32.75000,19.65000,MedCost,Ultra,,20.96,,,,,,,20.96,26.63,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,MedCost,Ultra,,16.70,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,inpatient,1,UN,246.90000,148.14000,MedCost,Ultra,,158.02,,,,,,,158.02,200.73,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,MedCost,Ultra,,125.92,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,inpatient,1,UN,1.65000,0.99000,MedCost,Ultra,,1.06,,,,,,,1.06,1.34,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,MedCost,Ultra,,0.84150,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,MedCost,Ultra,,14.85,,,,,,,6.98,18.86,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,MedCost,Ultra,,11.83,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,inpatient,0.25,ML,22.75000,13.65000,MedCost,Ultra,,14.56,,,,,,,6.85,18.50,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,MedCost,Ultra,,11.60,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,inpatient,5,ML,20322.25000,12193.35000,MedCost,Ultra,,13006.24,,,,,,,6117.00,16521.99,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,MedCost,Ultra,,10364.35,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,inpatient,1,UN,32.00000,19.20000,MedCost,Ultra,,20.48,,,,,,,20.48,26.02,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,MedCost,Ultra,,16.32,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.92800,,,,,,,0.92800,1.18,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.73950,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,inpatient,2.5,ML,157.85000,94.71000,MedCost,Ultra,,101.02,,,,,,,101.02,128.33,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,MedCost,Ultra,,80.50,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,inpatient,1,UN,300.90000,180.54000,MedCost,Ultra,,192.58,,,,,,,90.57,244.63,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,MedCost,Ultra,,153.46,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,MedCost,Ultra,,1584.00,,,,,,,744.98,2012.17,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,MedCost,Ultra,,1262.25,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,inpatient,1,UN,70.30000,42.18000,MedCost,Ultra,,44.99,,,,,,,21.16,57.15,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,MedCost,Ultra,,35.85,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,inpatient,30,ML,84.80000,50.88000,MedCost,Ultra,,54.27,,,,,,,25.52,68.94,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,MedCost,Ultra,,43.25,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,37.70000,22.62000,MedCost,Ultra,,24.13,,,,,,,24.13,30.65,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,MedCost,Ultra,,19.23,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,inpatient,60,ML,46.10000,27.66000,MedCost,Ultra,,29.50,,,,,,,29.50,37.48,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,MedCost,Ultra,,23.51,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,inpatient,10,ML,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,115.89,313.00,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,inpatient,1,UN,774.35000,464.61000,MedCost,Ultra,,495.58,,,,,,,233.08,629.55,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,MedCost,Ultra,,394.92,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,10.37,,,,,,,10.37,13.17,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,8.26,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,inpatient,10,ML,50.85000,30.51000,MedCost,Ultra,,32.54,,,,,,,32.54,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,MedCost,Ultra,,25.93,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,inpatient,30,ML,68.85000,41.31000,MedCost,Ultra,,44.06,,,,,,,44.06,55.98,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,MedCost,Ultra,,35.11,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,inpatient,30,ML,66.65000,39.99000,MedCost,Ultra,,42.66,,,,,,,20.06,54.19,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,MedCost,Ultra,,33.99,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,inpatient,20,ML,72.25000,43.35000,MedCost,Ultra,,46.24,,,,,,,21.75,58.74,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,MedCost,Ultra,,36.85,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,inpatient,10,ML,39.65000,23.79000,MedCost,Ultra,,25.38,,,,,,,11.93,32.24,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,MedCost,Ultra,,20.22,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,inpatient,30,ML,28.15000,16.89000,MedCost,Ultra,,18.02,,,,,,,8.47,22.89,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,MedCost,Ultra,,14.36,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,inpatient,6,ML,60837.10000,36502.26000,MedCost,Ultra,,38935.74,,,,,,,18311.97,49460.56,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,MedCost,Ultra,,31026.92,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,inpatient,1,UN,798.05000,478.83000,MedCost,Ultra,,510.75,,,,,,,510.75,648.81,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,MedCost,Ultra,,407.01,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,inpatient,1,ML,158.35000,95.01000,MedCost,Ultra,,101.34,,,,,,,47.66,128.74,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,MedCost,Ultra,,80.76,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,inpatient,1,UN,231.15000,138.69000,MedCost,Ultra,,147.94,,,,,,,147.94,187.92,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,MedCost,Ultra,,117.89,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,inpatient,1,UN,520.25000,312.15000,MedCost,Ultra,,332.96,,,,,,,156.60,422.96,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,MedCost,Ultra,,265.33,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,inpatient,1,UN,19.60000,11.76000,MedCost,Ultra,,12.54,,,,,,,12.54,15.93,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,MedCost,Ultra,,10.00,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,inpatient,1,UN,27.00000,16.20000,MedCost,Ultra,,17.28,,,,,,,17.28,21.95,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,MedCost,Ultra,,13.77,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,inpatient,1,UN,28.45000,17.07000,MedCost,Ultra,,18.21,,,,,,,18.21,23.13,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,MedCost,Ultra,,14.51,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,inpatient,0.3,ML,49.90000,29.94000,MedCost,Ultra,,31.94,,,,,,,15.02,40.57,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,MedCost,Ultra,,25.45,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,inpatient,0.4,ML,61.20000,36.72000,MedCost,Ultra,,39.17,,,,,,,18.42,49.76,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,MedCost,Ultra,,31.21,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,inpatient,0.6,ML,83.85000,50.31000,MedCost,Ultra,,53.66,,,,,,,25.24,68.17,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,MedCost,Ultra,,42.76,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,inpatient,0.8,ML,106.45000,63.87000,MedCost,Ultra,,68.13,,,,,,,32.04,86.54,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,MedCost,Ultra,,54.29,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,inpatient,1,ML,129.05000,77.43000,MedCost,Ultra,,82.59,,,,,,,38.84,104.92,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,MedCost,Ultra,,65.82,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,inpatient,0.8,ML,70.85000,42.51000,MedCost,Ultra,,45.34,,,,,,,21.33,57.60,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,MedCost,Ultra,,36.13,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,inpatient,70,GR,76.10000,45.66000,MedCost,Ultra,,48.70,,,,,,,48.70,61.87,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,MedCost,Ultra,,38.81,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,inpatient,1,UN,21.20000,12.72000,MedCost,Ultra,,13.57,,,,,,,13.57,17.24,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,MedCost,Ultra,,10.81,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,12.67,,,,,,,12.67,16.10,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,10.10,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,inpatient,1,UN,1235.40000,741.24000,MedCost,Ultra,,790.66,,,,,,,371.86,1004.38,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,MedCost,Ultra,,630.05,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,inpatient,1,UN,2341.05000,1404.63000,MedCost,Ultra,,1498.27,,,,,,,704.66,1903.27,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,MedCost,Ultra,,1193.94,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,inpatient,71,GR,8.50000,5.10000,MedCost,Ultra,,5.44,,,,,,,5.44,6.91,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,MedCost,Ultra,,4.33,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,inpatient,1,UN,171.00000,102.60000,MedCost,Ultra,,109.44,,,,,,,109.44,139.02,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,MedCost,Ultra,,87.21,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,MedCost,Ultra,,27.33,,,,,,,12.85,34.72,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,MedCost,Ultra,,21.78,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,10.88,,,,,,,10.88,13.82,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,8.67,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,inpatient,1,UN,20.60000,12.36000,MedCost,Ultra,,13.18,,,,,,,13.18,16.75,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,MedCost,Ultra,,10.51,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,inpatient,1,UN,37.05000,22.23000,MedCost,Ultra,,23.71,,,,,,,23.71,30.12,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,MedCost,Ultra,,18.90,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,inpatient,1,UN,37.25000,22.35000,MedCost,Ultra,,23.84,,,,,,,23.84,30.28,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,MedCost,Ultra,,19.00,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,inpatient,3.5,GR,70.05000,42.03000,MedCost,Ultra,,44.83,,,,,,,44.83,56.95,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,MedCost,Ultra,,35.73,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,inpatient,2,ML,123.00000,73.80000,MedCost,Ultra,,78.72,,,,,,,37.02,100.00,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,MedCost,Ultra,,62.73,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,inpatient,1,UN,3055.75000,1833.45000,MedCost,Ultra,,1955.68,,,,,,,919.78,2484.32,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,MedCost,Ultra,,1558.43,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,MedCost,Ultra,,3735.33,,,,,,,1756.77,4745.03,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,MedCost,Ultra,,2976.59,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,inpatient,1,UN,1345.40000,807.24000,MedCost,Ultra,,861.06,,,,,,,404.97,1093.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,MedCost,Ultra,,686.15,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,inpatient,2,ML,21.50000,12.90000,MedCost,Ultra,,13.76,,,,,,,6.47,17.48,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,MedCost,Ultra,,10.96,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,inpatient,1,ML,64.55000,38.73000,MedCost,Ultra,,41.31,,,,,,,19.43,52.48,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,MedCost,Ultra,,32.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,inpatient,50,ML,35.60000,21.36000,MedCost,Ultra,,22.78,,,,,,,10.72,28.94,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,MedCost,Ultra,,18.16,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,inpatient,10,ML,33.35000,20.01000,MedCost,Ultra,,21.34,,,,,,,21.34,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,MedCost,Ultra,,17.01,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,inpatient,30,ML,34.05000,20.43000,MedCost,Ultra,,21.79,,,,,,,21.79,27.68,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,MedCost,Ultra,,17.37,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,inpatient,1,UN,29.25000,17.55000,MedCost,Ultra,,18.72,,,,,,,18.72,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,MedCost,Ultra,,14.92,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,inpatient,1,UN,29.25000,17.55000,MedCost,Ultra,,18.72,,,,,,,18.72,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,MedCost,Ultra,,14.92,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,inpatient,1,UN,2420.70000,1452.42000,MedCost,Ultra,,1549.25,,,,,,,728.63,1968.03,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,MedCost,Ultra,,1234.56,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,inpatient,2,ML,6479.00000,3887.40000,MedCost,Ultra,,4146.56,,,,,,,1950.18,5267.43,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,MedCost,Ultra,,3304.29,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,inpatient,1,UN,168.00000,100.80000,MedCost,Ultra,,107.52,,,,,,,50.57,136.58,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,MedCost,Ultra,,85.68,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,inpatient,1,UN,27.55000,16.53000,MedCost,Ultra,,17.63,,,,,,,17.63,22.40,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,MedCost,Ultra,,14.05,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,inpatient,5,ML,63.70000,38.22000,MedCost,Ultra,,40.77,,,,,,,40.77,51.79,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,MedCost,Ultra,,32.49,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,inpatient,1,UN,1.50000,0.90000,MedCost,Ultra,,0.96000,,,,,,,0.96000,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,MedCost,Ultra,,0.76500,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.92800,,,,,,,0.92800,1.18,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.73950,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,inpatient,1,UN,27.50000,16.50000,MedCost,Ultra,,17.60,,,,,,,17.60,22.36,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,MedCost,Ultra,,14.03,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,inpatient,1,UN,31.45000,18.87000,MedCost,Ultra,,20.13,,,,,,,20.13,25.57,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,MedCost,Ultra,,16.04,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,inpatient,4,ML,157.40000,94.44000,MedCost,Ultra,,100.74,,,,,,,100.74,127.97,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,MedCost,Ultra,,80.27,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,inpatient,1,UN,23.45000,14.07000,MedCost,Ultra,,15.01,,,,,,,15.01,19.06,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,MedCost,Ultra,,11.96,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,inpatient,1,UN,102.95000,61.77000,MedCost,Ultra,,65.89,,,,,,,65.89,83.70,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,MedCost,Ultra,,52.50,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,inpatient,473,ML,585.05000,351.03000,MedCost,Ultra,,374.43,,,,,,,374.43,475.65,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,MedCost,Ultra,,298.38,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,inpatient,1,UN,180.90000,108.54000,MedCost,Ultra,,115.78,,,,,,,115.78,147.07,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,MedCost,Ultra,,92.26,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,inpatient,1,UN,260.30000,156.18000,MedCost,Ultra,,166.59,,,,,,,166.59,211.62,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,MedCost,Ultra,,132.75,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,inpatient,1,UN,205.20000,123.12000,MedCost,Ultra,,131.33,,,,,,,131.33,166.83,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,MedCost,Ultra,,104.65,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,732.38,,,,,,,344.45,930.36,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,583.62,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,inpatient,1,UN,18.20000,10.92000,MedCost,Ultra,,11.65,,,,,,,11.65,14.80,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,MedCost,Ultra,,9.28,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,inpatient,15,ML,100.95000,60.57000,MedCost,Ultra,,64.61,,,,,,,64.61,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,MedCost,Ultra,,51.48,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,inpatient,500,ML,178.50000,107.10000,MedCost,Ultra,,114.24,,,,,,,114.24,145.12,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,MedCost,Ultra,,91.03,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,inpatient,473,ML,525.45000,315.27000,MedCost,Ultra,,336.29,,,,,,,336.29,427.19,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,MedCost,Ultra,,267.98,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,inpatient,1,UN,1.55000,0.93000,MedCost,Ultra,,0.99200,,,,,,,0.99200,1.26,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,MedCost,Ultra,,0.79050,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,inpatient,100,ML,101.15000,60.69000,MedCost,Ultra,,64.74,,,,,,,30.45,82.23,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,MedCost,Ultra,,51.59,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,inpatient,0.6,ML,263.20000,157.92000,MedCost,Ultra,,168.45,,,,,,,79.22,213.98,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,MedCost,Ultra,,134.23,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,inpatient,0.8,ML,263.20000,157.92000,MedCost,Ultra,,168.45,,,,,,,79.22,213.98,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,MedCost,Ultra,,134.23,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,inpatient,0.6,ML,881.50000,528.90000,MedCost,Ultra,,564.16,,,,,,,265.33,716.66,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,MedCost,Ultra,,449.56,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,inpatient,0.025,GR,58.50000,35.10000,MedCost,Ultra,,37.44,,,,,,,37.44,47.56,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,MedCost,Ultra,,29.84,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,inpatient,0.42,ML,896.45000,537.87000,MedCost,Ultra,,573.73,,,,,,,269.83,728.81,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,MedCost,Ultra,,457.19,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,inpatient,0.4,ML,1424.70000,854.82000,MedCost,Ultra,,911.81,,,,,,,428.83,1158.28,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,MedCost,Ultra,,726.60,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,inpatient,0.3,ML,2129.05000,1277.43000,MedCost,Ultra,,1362.59,,,,,,,640.84,1730.92,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,MedCost,Ultra,,1085.82,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,inpatient,0.5,ML,3537.70000,2122.62000,MedCost,Ultra,,2264.13,,,,,,,1064.85,2876.15,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,MedCost,Ultra,,1804.23,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,inpatient,0.4,ML,7059.40000,4235.64000,MedCost,Ultra,,4518.02,,,,,,,2124.88,5739.29,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,MedCost,Ultra,,3600.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,inpatient,0.6,ML,10581.10000,6348.66000,MedCost,Ultra,,6771.90,,,,,,,3184.91,8602.43,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,MedCost,Ultra,,5396.36,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,inpatient,2,ML,1695.15000,1017.09000,MedCost,Ultra,,1084.90,,,,,,,510.24,1378.16,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,MedCost,Ultra,,864.53,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,inpatient,5,ML,8246.30000,4947.78000,MedCost,Ultra,,5277.63,,,,,,,2482.14,6704.24,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,MedCost,Ultra,,4205.61,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,inpatient,20,ML,32160.05000,19296.03000,MedCost,Ultra,,20582.43,,,,,,,9680.18,26146.12,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,MedCost,Ultra,,16401.63,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,MedCost,Ultra,,3609.76,,,,,,,1697.72,4585.52,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,MedCost,Ultra,,2876.53,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,MedCost,Ultra,,7179.17,,,,,,,3376.45,9119.79,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,MedCost,Ultra,,5720.90,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,MedCost,Ultra,,204.06,,,,,,,95.97,259.23,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,MedCost,Ultra,,162.61,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,MedCost,Ultra,,204.06,,,,,,,95.97,259.23,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,MedCost,Ultra,,162.61,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,inpatient,10,ML,8806.85000,5284.11000,MedCost,Ultra,,5636.38,,,,,,,2650.86,7159.97,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,MedCost,Ultra,,4491.49,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,inpatient,2.5,ML,16.30000,9.78000,MedCost,Ultra,,10.43,,,,,,,10.43,13.25,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,MedCost,Ultra,,8.31,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,inpatient,100,ML,83.30000,49.98000,MedCost,Ultra,,53.31,,,,,,,25.07,67.72,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,MedCost,Ultra,,42.48,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,inpatient,150,ML,101.35000,60.81000,MedCost,Ultra,,64.86,,,,,,,30.51,82.40,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,MedCost,Ultra,,51.69,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,inpatient,0.5,ML,153.95000,92.37000,MedCost,Ultra,,98.53,,,,,,,46.34,125.16,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,MedCost,Ultra,,78.51,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,inpatient,5,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.70,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,inpatient,1,UN,23.35000,14.01000,MedCost,Ultra,,14.94,,,,,,,14.94,18.98,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,MedCost,Ultra,,11.91,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,inpatient,0.05,ML,18.70000,11.22000,MedCost,Ultra,,11.97,,,,,,,5.63,15.20,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,MedCost,Ultra,,9.54,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,inpatient,1,UN,115.90000,69.54000,MedCost,Ultra,,74.18,,,,,,,74.18,94.23,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,MedCost,Ultra,,59.11,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,inpatient,1,UN,141.95000,85.17000,MedCost,Ultra,,90.85,,,,,,,42.73,115.41,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,MedCost,Ultra,,72.39,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,11.07,,,,,,,11.07,14.06,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,8.82,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,inpatient,4,ML,884.70000,530.82000,MedCost,Ultra,,566.21,,,,,,,266.29,719.26,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,MedCost,Ultra,,451.20,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.89600,,,,,,,0.89600,1.14,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.71400,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,MedCost,Ultra,,25674.18,,,,,,,12074.89,32614.23,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,MedCost,Ultra,,20459.11,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,MedCost,Ultra,,102168.38,,,,,,,48051.07,129785.78,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,MedCost,Ultra,,81415.43,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,inpatient,1,ML,985.50000,591.30000,MedCost,Ultra,,630.72,,,,,,,296.64,801.21,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,MedCost,Ultra,,502.61,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,inpatient,30,ML,2.00000,1.20000,MedCost,Ultra,,1.28,,,,,,,1.28,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,MedCost,Ultra,,1.02,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,inpatient,30,ML,1.75000,1.05000,MedCost,Ultra,,1.12,,,,,,,1.12,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,MedCost,Ultra,,0.89250,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,inpatient,30,ML,1.70000,1.02000,MedCost,Ultra,,1.09,,,,,,,1.09,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,MedCost,Ultra,,0.86700,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,inpatient,30,ML,1.60000,0.96000,MedCost,Ultra,,1.02,,,,,,,1.02,1.30,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,MedCost,Ultra,,0.81600,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,inpatient,50,ML,100.65000,60.39000,MedCost,Ultra,,64.42,,,,,,,30.30,81.83,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,MedCost,Ultra,,51.33,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,193.80000,116.28000,MedCost,Ultra,,124.03,,,,,,,58.33,157.56,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,MedCost,Ultra,,98.84,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,inpatient,1,UN,13260.65000,7956.39000,MedCost,Ultra,,8486.82,,,,,,,3991.46,10780.91,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,MedCost,Ultra,,6762.93,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,inpatient,60,GR,106.00000,63.60000,MedCost,Ultra,,67.84,,,,,,,67.84,86.18,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,MedCost,Ultra,,54.06,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,inpatient,59,ML,13.75000,8.25000,MedCost,Ultra,,8.80,,,,,,,8.80,11.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,MedCost,Ultra,,7.01,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,inpatient,1,UN,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.60,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,inpatient,1,UN,2245.35000,1347.21000,MedCost,Ultra,,1437.02,,,,,,,675.85,1825.47,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,MedCost,Ultra,,1145.13,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,inpatient,1,UN,86.05000,51.63000,MedCost,Ultra,,55.07,,,,,,,55.07,69.96,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,MedCost,Ultra,,43.89,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,inpatient,60,ML,709.90000,425.94000,MedCost,Ultra,,454.34,,,,,,,213.68,577.15,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,MedCost,Ultra,,362.05,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,inpatient,1,UN,213.80000,128.28000,MedCost,Ultra,,136.83,,,,,,,136.83,173.82,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,MedCost,Ultra,,109.04,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,inpatient,0.2,ML,60.60000,36.36000,MedCost,Ultra,,38.78,,,,,,,18.24,49.27,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,MedCost,Ultra,,30.91,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,inpatient,1,UN,95.75000,57.45000,MedCost,Ultra,,61.28,,,,,,,61.28,77.84,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,MedCost,Ultra,,48.83,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,inpatient,100,ML,184.45000,110.67000,MedCost,Ultra,,118.05,,,,,,,55.52,149.96,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,MedCost,Ultra,,94.07,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,inpatient,200,ML,224.70000,134.82000,MedCost,Ultra,,143.81,,,,,,,67.63,182.68,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,MedCost,Ultra,,114.60,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,inpatient,1,UN,60.25000,36.15000,MedCost,Ultra,,38.56,,,,,,,38.56,48.98,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,MedCost,Ultra,,30.73,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,inpatient,1,UN,1057.00000,634.20000,MedCost,Ultra,,676.48,,,,,,,676.48,859.34,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,MedCost,Ultra,,539.07,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.92800,,,,,,,0.92800,1.18,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.73950,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,inpatient,1,UN,47.00000,28.20000,MedCost,Ultra,,30.08,,,,,,,30.08,38.21,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,MedCost,Ultra,,23.97,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,inpatient,1,UN,1.20000,0.72000,MedCost,Ultra,,0.76800,,,,,,,0.76800,0.97560,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,MedCost,Ultra,,0.61200,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,inpatient,1,UN,3.10000,1.86000,MedCost,Ultra,,1.98,,,,,,,1.98,2.52,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,MedCost,Ultra,,1.58,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,inpatient,100,ML,80.15000,48.09000,MedCost,Ultra,,51.30,,,,,,,51.30,64.92,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,MedCost,Ultra,,40.88,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,inpatient,100,ML,77.35000,46.41000,MedCost,Ultra,,49.50,,,,,,,23.28,62.89,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,MedCost,Ultra,,39.45,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,inpatient,50,ML,76.30000,45.78000,MedCost,Ultra,,48.83,,,,,,,22.97,62.03,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,MedCost,Ultra,,38.91,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,inpatient,100,ML,77.35000,46.41000,MedCost,Ultra,,49.50,,,,,,,23.28,62.89,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,MedCost,Ultra,,39.45,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,MedCost,Ultra,,64.96,,,,,,,30.55,82.52,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,MedCost,Ultra,,51.77,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,inpatient,1000,ML,105.00000,63.00000,MedCost,Ultra,,67.20,,,,,,,31.61,85.36,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,MedCost,Ultra,,53.55,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,inpatient,60,ML,471.60000,282.96000,MedCost,Ultra,,301.82,,,,,,,301.82,383.41,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,MedCost,Ultra,,240.52,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,11.71,,,,,,,11.71,14.88,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,9.33,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,inpatient,1,UN,281.75000,169.05000,MedCost,Ultra,,180.32,,,,,,,180.32,229.06,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,MedCost,Ultra,,143.69,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,12.35,,,,,,,12.35,15.69,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,9.84,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,inpatient,1,UN,56048.55000,33629.13000,MedCost,Ultra,,35871.07,,,,,,,16870.61,45567.47,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,MedCost,Ultra,,28584.76,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,inpatient,1,UN,55.00000,33.00000,MedCost,Ultra,,35.20,,,,,,,35.20,44.72,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,MedCost,Ultra,,28.05,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,inpatient,1,UN,4464.60000,2678.76000,MedCost,Ultra,,2857.34,,,,,,,1343.84,3629.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,MedCost,Ultra,,2276.95,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,inpatient,1,UN,55.00000,33.00000,MedCost,Ultra,,35.20,,,,,,,35.20,44.72,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,MedCost,Ultra,,28.05,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,inpatient,100,ML,70.60000,42.36000,MedCost,Ultra,,45.18,,,,,,,21.25,57.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,MedCost,Ultra,,36.01,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,inpatient,20,ML,26.95000,16.17000,MedCost,Ultra,,17.25,,,,,,,8.11,21.91,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,MedCost,Ultra,,13.74,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,inpatient,1,UN,1.50000,0.90000,MedCost,Ultra,,0.96000,,,,,,,0.96000,1.22,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,MedCost,Ultra,,0.76500,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,inpatient,0.2,ML,31.40000,18.84000,MedCost,Ultra,,20.10,,,,,,,20.10,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,MedCost,Ultra,,16.01,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,12.35,,,,,,,12.35,15.69,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,9.84,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,inpatient,0.1,ML,67.75000,40.65000,MedCost,Ultra,,43.36,,,,,,,43.36,55.08,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,MedCost,Ultra,,34.55,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,inpatient,1,UN,29.80000,17.88000,MedCost,Ultra,,19.07,,,,,,,19.07,24.23,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,MedCost,Ultra,,15.20,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,inpatient,10,ML,1113.90000,668.34000,MedCost,Ultra,,712.90,,,,,,,335.28,905.60,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,MedCost,Ultra,,568.09,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,inpatient,20,ML,1830.00000,1098.00000,MedCost,Ultra,,1171.20,,,,,,,550.83,1487.79,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,MedCost,Ultra,,933.30,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,inpatient,5.26,ML,316.10000,189.66000,MedCost,Ultra,,202.30,,,,,,,95.15,256.99,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,MedCost,Ultra,,161.21,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,inpatient,26.3,ML,474.30000,284.58000,MedCost,Ultra,,303.55,,,,,,,142.76,385.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,MedCost,Ultra,,241.89,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,inpatient,1,UN,95.75000,57.45000,MedCost,Ultra,,61.28,,,,,,,61.28,77.84,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,MedCost,Ultra,,48.83,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,inpatient,1,UN,95.75000,57.45000,MedCost,Ultra,,61.28,,,,,,,61.28,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,MedCost,Ultra,,48.83,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,inpatient,1,UN,710.25000,426.15000,MedCost,Ultra,,454.56,,,,,,,213.79,577.43,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,MedCost,Ultra,,362.23,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,inpatient,1,UN,28.75000,17.25000,MedCost,Ultra,,18.40,,,,,,,18.40,23.37,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,MedCost,Ultra,,14.66,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,inpatient,1,UN,23.45000,14.07000,MedCost,Ultra,,15.01,,,,,,,15.01,19.06,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,MedCost,Ultra,,11.96,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,inpatient,1,UN,565.00000,339.00000,MedCost,Ultra,,361.60,,,,,,,361.60,459.35,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,MedCost,Ultra,,288.15,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,inpatient,1,UN,1198.35000,719.01000,MedCost,Ultra,,766.94,,,,,,,766.94,974.26,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,MedCost,Ultra,,611.16,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,inpatient,1000,ML,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,inpatient,1,UN,4.10000,2.46000,MedCost,Ultra,,2.62,,,,,,,2.62,3.33,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,MedCost,Ultra,,2.09,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,inpatient,1,UN,568.80000,341.28000,MedCost,Ultra,,364.03,,,,,,,171.21,462.43,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,MedCost,Ultra,,290.09,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,inpatient,100,ML,112.00000,67.20000,MedCost,Ultra,,71.68,,,,,,,33.71,91.06,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,MedCost,Ultra,,57.12,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,inpatient,100,ML,168.00000,100.80000,MedCost,Ultra,,107.52,,,,,,,50.57,136.58,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,MedCost,Ultra,,85.68,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,10.85,,,,,,,10.85,13.78,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,8.64,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,11.30,,,,,,,11.30,14.35,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,9.00,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,inpatient,1,UN,205.20000,123.12000,MedCost,Ultra,,131.33,,,,,,,131.33,166.83,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,MedCost,Ultra,,104.65,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,inpatient,1,UN,609.65000,365.79000,MedCost,Ultra,,390.18,,,,,,,183.50,495.65,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,MedCost,Ultra,,310.92,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,19.26,52.03,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,inpatient,1,UN,159.35000,95.61000,MedCost,Ultra,,101.98,,,,,,,47.96,129.55,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,MedCost,Ultra,,81.27,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,inpatient,1000,ML,87.00000,52.20000,MedCost,Ultra,,55.68,,,,,,,55.68,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,MedCost,Ultra,,44.37,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,inpatient,1000,ML,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,174.72,221.95,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,inpatient,0.05,ML,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,inpatient,425,GR,4.30000,2.58000,MedCost,Ultra,,2.75,,,,,,,2.75,3.50,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,MedCost,Ultra,,2.19,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,inpatient,1,UN,21.10000,12.66000,MedCost,Ultra,,13.50,,,,,,,13.50,17.15,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,MedCost,Ultra,,10.76,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,11.26,14.31,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,10.78,,,,,,,10.78,13.70,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,8.59,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,inpatient,5,ML,28.75000,17.25000,MedCost,Ultra,,18.40,,,,,,,18.40,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,MedCost,Ultra,,14.66,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,inpatient,5,ML,28.75000,17.25000,MedCost,Ultra,,18.40,,,,,,,18.40,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,MedCost,Ultra,,14.66,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,11.07,,,,,,,11.07,14.06,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,8.82,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,inpatient,1,UN,30.00000,18.00000,MedCost,Ultra,,19.20,,,,,,,19.20,24.39,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,MedCost,Ultra,,15.30,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,inpatient,1,ML,34.20000,20.52000,MedCost,Ultra,,21.89,,,,,,,10.29,27.80,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,MedCost,Ultra,,17.44,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,inpatient,45,GR,123.50000,74.10000,MedCost,Ultra,,79.04,,,,,,,79.04,100.41,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,MedCost,Ultra,,62.98,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,inpatient,1,UN,124.90000,74.94000,MedCost,Ultra,,79.94,,,,,,,79.94,101.54,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,MedCost,Ultra,,63.70,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,inpatient,10,ML,48.85000,29.31000,MedCost,Ultra,,31.26,,,,,,,31.26,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,MedCost,Ultra,,24.91,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,inpatient,15,ML,61.95000,37.17000,MedCost,Ultra,,39.65,,,,,,,39.65,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,MedCost,Ultra,,31.59,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,inpatient,5,ML,31.55000,18.93000,MedCost,Ultra,,20.19,,,,,,,20.19,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,MedCost,Ultra,,16.09,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,inpatient,15,ML,77.55000,46.53000,MedCost,Ultra,,49.63,,,,,,,49.63,63.05,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,MedCost,Ultra,,39.55,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,inpatient,1,UN,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,114.38,308.94,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,MedCost,Ultra,,193.80,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,inpatient,3.5,GR,910.30000,546.18000,MedCost,Ultra,,582.59,,,,,,,582.59,740.07,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,MedCost,Ultra,,464.25,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,inpatient,2.5,ML,167.75000,100.65000,MedCost,Ultra,,107.36,,,,,,,107.36,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,MedCost,Ultra,,85.55,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,inpatient,5,ML,320.20000,192.12000,MedCost,Ultra,,204.93,,,,,,,204.93,260.32,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,MedCost,Ultra,,163.30,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,inpatient,10,ML,88.20000,52.92000,MedCost,Ultra,,56.45,,,,,,,56.45,71.71,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,MedCost,Ultra,,44.98,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,inpatient,7.5,ML,604.05000,362.43000,MedCost,Ultra,,386.59,,,,,,,386.59,491.09,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,MedCost,Ultra,,308.07,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,25404.55000,15242.73000,MedCost,Ultra,,16258.91,,,,,,,7646.77,20653.90,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,MedCost,Ultra,,12956.32,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,inpatient,1,UN,1854.60000,1112.76000,MedCost,Ultra,,1186.94,,,,,,,558.23,1507.79,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,MedCost,Ultra,,945.85,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,inpatient,1,UN,21.00000,12.60000,MedCost,Ultra,,13.44,,,,,,,13.44,17.07,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,MedCost,Ultra,,10.71,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,inpatient,1,UN,961.85000,577.11000,MedCost,Ultra,,615.58,,,,,,,289.52,781.98,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,MedCost,Ultra,,490.54,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,inpatient,2.5,ML,24.95000,14.97000,MedCost,Ultra,,15.97,,,,,,,15.97,20.28,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,MedCost,Ultra,,12.72,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,inpatient,1,UN,84.65000,50.79000,MedCost,Ultra,,54.18,,,,,,,54.18,68.82,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,MedCost,Ultra,,43.17,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,inpatient,1,ML,36.05000,21.63000,MedCost,Ultra,,23.07,,,,,,,10.85,29.31,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,MedCost,Ultra,,18.39,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,11.07,,,,,,,11.07,14.06,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,8.82,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,inpatient,1,ML,1651.20000,990.72000,MedCost,Ultra,,1056.77,,,,,,,1056.77,1342.43,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,MedCost,Ultra,,842.11,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,14,ML,30285.20000,18171.12000,MedCost,Ultra,,19382.53,,,,,,,9115.85,24621.87,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,MedCost,Ultra,,15445.45,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,11.20,,,,,,,11.20,14.23,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,8.93,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,inpatient,10,ML,31.65000,18.99000,MedCost,Ultra,,20.26,,,,,,,20.26,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,MedCost,Ultra,,16.14,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,inpatient,100,ML,53.35000,32.01000,MedCost,Ultra,,34.14,,,,,,,34.14,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,MedCost,Ultra,,27.21,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,inpatient,20,ML,38.05000,22.83000,MedCost,Ultra,,24.35,,,,,,,24.35,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,MedCost,Ultra,,19.41,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,inpatient,40,ML,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,11.42,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,inpatient,50,ML,48.10000,28.86000,MedCost,Ultra,,30.78,,,,,,,30.78,39.11,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,MedCost,Ultra,,24.53,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,inpatient,5,ML,72.05000,43.23000,MedCost,Ultra,,46.11,,,,,,,21.69,58.58,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,MedCost,Ultra,,36.75,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,inpatient,1,UN,77.40000,46.44000,MedCost,Ultra,,49.54,,,,,,,49.54,62.93,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,MedCost,Ultra,,39.47,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,inpatient,20,ML,185.65000,111.39000,MedCost,Ultra,,118.82,,,,,,,55.88,150.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,MedCost,Ultra,,94.68,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,inpatient,10,ML,20.50000,12.30000,MedCost,Ultra,,13.12,,,,,,,13.12,16.67,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,MedCost,Ultra,,10.46,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,inpatient,1,UN,22.35000,13.41000,MedCost,Ultra,,14.30,,,,,,,14.30,18.17,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,MedCost,Ultra,,11.40,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,inpatient,1,UN,22.30000,13.38000,MedCost,Ultra,,14.27,,,,,,,14.27,18.13,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,MedCost,Ultra,,11.37,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,inpatient,2,ML,320.55000,192.33000,MedCost,Ultra,,205.15,,,,,,,96.49,260.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,MedCost,Ultra,,163.48,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,inpatient,40,ML,438.00000,262.80000,MedCost,Ultra,,280.32,,,,,,,131.84,356.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,MedCost,Ultra,,223.38,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,MedCost,Ultra,,10136.74,,,,,,,4767.43,12876.82,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,MedCost,Ultra,,8077.71,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,inpatient,1,UN,107.45000,64.47000,MedCost,Ultra,,68.77,,,,,,,68.77,87.36,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,MedCost,Ultra,,54.80,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,inpatient,1,ML,2063.50000,1238.10000,MedCost,Ultra,,1320.64,,,,,,,1320.64,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,MedCost,Ultra,,1052.38,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,inpatient,5,ML,2746.00000,1647.60000,MedCost,Ultra,,1757.44,,,,,,,1757.44,2232.50,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,MedCost,Ultra,,1400.46,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,16.86,,,,,,,7.93,21.42,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,13.44,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,inpatient,10,ML,196.20000,117.72000,MedCost,Ultra,,125.57,,,,,,,125.57,159.51,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,MedCost,Ultra,,100.06,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,inpatient,0.25,ML,18.10000,10.86000,MedCost,Ultra,,11.58,,,,,,,11.58,14.72,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,MedCost,Ultra,,9.23,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,inpatient,1,UN,2.70000,1.62000,MedCost,Ultra,,1.73,,,,,,,1.73,2.20,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,MedCost,Ultra,,1.38,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,inpatient,1,UN,60.00000,36.00000,MedCost,Ultra,,38.40,,,,,,,18.06,48.78,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,MedCost,Ultra,,30.60,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,inpatient,50,ML,32.20000,19.32000,MedCost,Ultra,,20.61,,,,,,,9.69,26.18,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,MedCost,Ultra,,16.42,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,inpatient,2.5,ML,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,inpatient,0.5,ML,22.30000,13.38000,MedCost,Ultra,,14.27,,,,,,,6.71,18.13,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,MedCost,Ultra,,11.37,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,inpatient,30,ML,87.55000,52.53000,MedCost,Ultra,,56.03,,,,,,,26.35,71.18,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,MedCost,Ultra,,44.65,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,inpatient,25,ML,115.20000,69.12000,MedCost,Ultra,,73.73,,,,,,,73.73,93.66,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,MedCost,Ultra,,58.75,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,inpatient,10,ML,1.30000,0.78000,MedCost,Ultra,,0.83200,,,,,,,0.83200,1.06,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,MedCost,Ultra,,0.66300,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,inpatient,10,ML,49.70000,29.82000,MedCost,Ultra,,31.81,,,,,,,31.81,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,MedCost,Ultra,,25.35,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,inpatient,5,ML,36.10000,21.66000,MedCost,Ultra,,23.10,,,,,,,23.10,29.35,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,MedCost,Ultra,,18.41,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,inpatient,10,ML,147.95000,88.77000,MedCost,Ultra,,94.69,,,,,,,44.53,120.28,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,MedCost,Ultra,,75.45,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,inpatient,5,ML,1.55000,0.93000,MedCost,Ultra,,0.99200,,,,,,,0.99200,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,MedCost,Ultra,,0.79050,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,inpatient,5,ML,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,inpatient,1,UN,1.75000,1.05000,MedCost,Ultra,,1.12,,,,,,,1.12,1.42,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,MedCost,Ultra,,0.89250,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,inpatient,1,ML,16.35000,9.81000,MedCost,Ultra,,10.46,,,,,,,10.46,13.29,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,MedCost,Ultra,,8.34,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,inpatient,1,UN,207.05000,124.23000,MedCost,Ultra,,132.51,,,,,,,132.51,168.33,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,MedCost,Ultra,,105.60,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,inpatient,5,ML,22.65000,13.59000,MedCost,Ultra,,14.50,,,,,,,14.50,18.41,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,MedCost,Ultra,,11.55,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,inpatient,1,UN,24.60000,14.76000,MedCost,Ultra,,15.74,,,,,,,15.74,20.00,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,MedCost,Ultra,,12.55,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,inpatient,1,ML,32.10000,19.26000,MedCost,Ultra,,20.54,,,,,,,9.66,26.10,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,MedCost,Ultra,,16.37,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,11.07,,,,,,,11.07,14.06,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,8.82,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,inpatient,2.5,ML,551.10000,330.66000,MedCost,Ultra,,352.70,,,,,,,352.70,448.04,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,MedCost,Ultra,,281.06,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,inpatient,10,ML,26.80000,16.08000,MedCost,Ultra,,17.15,,,,,,,8.07,21.79,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,MedCost,Ultra,,13.67,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,inpatient,30,ML,23.95000,14.37000,MedCost,Ultra,,15.33,,,,,,,7.21,19.47,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,MedCost,Ultra,,12.21,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,inpatient,50,ML,29.45000,17.67000,MedCost,Ultra,,18.85,,,,,,,8.86,23.94,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,MedCost,Ultra,,15.02,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,inpatient,10,ML,43.10000,25.86000,MedCost,Ultra,,27.58,,,,,,,12.97,35.04,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,MedCost,Ultra,,21.98,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,inpatient,30,ML,53.45000,32.07000,MedCost,Ultra,,34.21,,,,,,,16.09,43.45,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,MedCost,Ultra,,27.26,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,inpatient,25,ML,60.85000,36.51000,MedCost,Ultra,,38.94,,,,,,,38.94,49.47,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,MedCost,Ultra,,31.03,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,inpatient,300,ML,178.50000,107.10000,MedCost,Ultra,,114.24,,,,,,,53.73,145.12,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,MedCost,Ultra,,91.03,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,inpatient,4,ML,508.10000,304.86000,MedCost,Ultra,,325.18,,,,,,,325.18,413.09,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,MedCost,Ultra,,259.13,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,inpatient,2,ML,53.10000,31.86000,MedCost,Ultra,,33.98,,,,,,,15.98,43.17,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,MedCost,Ultra,,27.08,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,inpatient,0.25,ML,24.70000,14.82000,MedCost,Ultra,,15.81,,,,,,,7.43,20.08,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,MedCost,Ultra,,12.60,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,MedCost,Ultra,,19.07,,,,,,,8.97,24.23,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,MedCost,Ultra,,15.20,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,inpatient,3,ML,61.25000,36.75000,MedCost,Ultra,,39.20,,,,,,,39.20,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,MedCost,Ultra,,31.24,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,inpatient,3,ML,27.90000,16.74000,MedCost,Ultra,,17.86,,,,,,,17.86,22.68,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,MedCost,Ultra,,14.23,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,inpatient,10,ML,170.20000,102.12000,MedCost,Ultra,,108.93,,,,,,,51.23,138.37,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,MedCost,Ultra,,86.80,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,MedCost,Ultra,,228.64,,,,,,,107.53,290.44,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,MedCost,Ultra,,182.20,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,MedCost,Ultra,,739.87,,,,,,,347.97,939.87,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,MedCost,Ultra,,589.59,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,inpatient,50,GR,8.60000,5.16000,MedCost,Ultra,,5.50,,,,,,,5.50,6.99,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,MedCost,Ultra,,4.39,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,inpatient,114,GR,16.55000,9.93000,MedCost,Ultra,,10.59,,,,,,,10.59,13.46,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,MedCost,Ultra,,8.44,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,10.43,,,,,,,10.43,13.25,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,8.31,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,inpatient,5,ML,118261.70000,70957.02000,MedCost,Ultra,,75687.49,,,,,,,35596.77,96146.76,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,MedCost,Ultra,,60313.47,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,inpatient,5,ML,125.45000,75.27000,MedCost,Ultra,,80.29,,,,,,,80.29,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,MedCost,Ultra,,63.98,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,inpatient,50,ML,750.85000,450.51000,MedCost,Ultra,,480.54,,,,,,,480.54,610.44,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,MedCost,Ultra,,382.93,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,inpatient,118,ML,10.00000,6.00000,MedCost,Ultra,,6.40,,,,,,,6.40,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,MedCost,Ultra,,5.10,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,inpatient,236,ML,14.95000,8.97000,MedCost,Ultra,,9.57,,,,,,,9.57,12.15,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,MedCost,Ultra,,7.62,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,inpatient,100,ML,76.65000,45.99000,MedCost,Ultra,,49.06,,,,,,,23.07,62.32,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,MedCost,Ultra,,39.09,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,inpatient,500,ML,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,53.76,68.29,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,inpatient,14.1,GR,5.35000,3.21000,MedCost,Ultra,,3.42,,,,,,,3.42,4.35,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,MedCost,Ultra,,2.73,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,inpatient,2.5,ML,17.20000,10.32000,MedCost,Ultra,,11.01,,,,,,,11.01,13.98,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,MedCost,Ultra,,8.77,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,inpatient,1,ML,40.15000,24.09000,MedCost,Ultra,,25.70,,,,,,,12.09,32.64,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,MedCost,Ultra,,20.48,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,inpatient,1,ML,44.70000,26.82000,MedCost,Ultra,,28.61,,,,,,,13.45,36.34,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,MedCost,Ultra,,22.80,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,inpatient,0.75,ML,36.40000,21.84000,MedCost,Ultra,,23.30,,,,,,,10.96,29.59,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,MedCost,Ultra,,18.56,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,inpatient,100,ML,84.90000,50.94000,MedCost,Ultra,,54.34,,,,,,,54.34,68.77,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,MedCost,Ultra,,43.30,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,inpatient,50,ML,84.75000,50.85000,MedCost,Ultra,,54.24,,,,,,,54.24,68.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,MedCost,Ultra,,43.22,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,inpatient,100,ML,84.90000,50.94000,MedCost,Ultra,,54.34,,,,,,,54.34,68.77,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,MedCost,Ultra,,43.30,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,inpatient,50,ML,82.95000,49.77000,MedCost,Ultra,,53.09,,,,,,,53.09,67.19,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,MedCost,Ultra,,42.30,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,inpatient,1,UN,1052.35000,631.41000,MedCost,Ultra,,673.50,,,,,,,316.76,855.56,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,MedCost,Ultra,,536.70,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,inpatient,3,ML,5389.95000,3233.97000,MedCost,Ultra,,3449.57,,,,,,,3449.57,4382.03,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,MedCost,Ultra,,2748.87,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,inpatient,5,ML,3636.80000,2182.08000,MedCost,Ultra,,2327.55,,,,,,,1094.68,2956.72,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,MedCost,Ultra,,1854.77,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,inpatient,5,ML,33.10000,19.86000,MedCost,Ultra,,21.18,,,,,,,9.96,26.91,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,MedCost,Ultra,,16.88,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,inpatient,1,UN,15765.00000,9459.00000,MedCost,Ultra,,10089.60,,,,,,,4745.27,12816.94,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,MedCost,Ultra,,8040.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,inpatient,1,UN,2.90000,1.74000,MedCost,Ultra,,1.86,,,,,,,1.86,2.36,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,MedCost,Ultra,,1.48,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,inpatient,0.1,ML,21.05000,12.63000,MedCost,Ultra,,13.47,,,,,,,6.34,17.11,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,MedCost,Ultra,,10.74,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,inpatient,0.5,ML,430.80000,258.48000,MedCost,Ultra,,275.71,,,,,,,129.67,350.24,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,MedCost,Ultra,,219.71,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,inpatient,1,ML,236.50000,141.90000,MedCost,Ultra,,151.36,,,,,,,71.19,192.27,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,MedCost,Ultra,,120.61,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,inpatient,1,ML,64.90000,38.94000,MedCost,Ultra,,41.54,,,,,,,19.53,52.76,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,MedCost,Ultra,,33.10,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,inpatient,50,ML,108.00000,64.80000,MedCost,Ultra,,69.12,,,,,,,32.51,87.80,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,MedCost,Ultra,,55.08,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,inpatient,3.5,GR,12.40000,7.44000,MedCost,Ultra,,7.94,,,,,,,7.94,10.08,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,MedCost,Ultra,,6.32,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,inpatient,0.5,ML,144.25000,86.55000,MedCost,Ultra,,92.32,,,,,,,43.42,117.28,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,MedCost,Ultra,,73.57,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,inpatient,500,ML,289.80000,173.88000,MedCost,Ultra,,185.47,,,,,,,185.47,235.61,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,MedCost,Ultra,,147.80,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,inpatient,1,ML,2673.70000,1604.22000,MedCost,Ultra,,1711.17,,,,,,,804.78,2173.72,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,MedCost,Ultra,,1363.59,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,inpatient,1000,ML,87.50000,52.50000,MedCost,Ultra,,56.00,,,,,,,26.34,71.14,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,MedCost,Ultra,,44.62,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,inpatient,44.3,ML,9.75000,5.85000,MedCost,Ultra,,6.24,,,,,,,6.24,7.93,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,MedCost,Ultra,,4.97,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,inpatient,50,ML,3336.40000,2001.84000,MedCost,Ultra,,2135.30,,,,,,,1004.26,2712.49,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,MedCost,Ultra,,1701.56,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,inpatient,5,ML,23.65000,14.19000,MedCost,Ultra,,15.14,,,,,,,15.14,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,MedCost,Ultra,,12.06,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,inpatient,5,ML,30.90000,18.54000,MedCost,Ultra,,19.78,,,,,,,19.78,25.12,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,MedCost,Ultra,,15.76,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,MedCost,Ultra,,219.39,,,,,,,103.18,278.70,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,MedCost,Ultra,,174.83,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,inpatient,100,ML,818.20000,490.92000,MedCost,Ultra,,523.65,,,,,,,246.28,665.20,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,MedCost,Ultra,,417.28,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,inpatient,5,ML,319.70000,191.82000,MedCost,Ultra,,204.61,,,,,,,96.23,259.92,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,MedCost,Ultra,,163.05,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,inpatient,2,ML,984.90000,590.94000,MedCost,Ultra,,630.34,,,,,,,630.34,800.72,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,MedCost,Ultra,,502.30,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,16.06,,,,,,,16.06,20.41,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,12.80,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,inpatient,1,UN,1360.75000,816.45000,MedCost,Ultra,,870.88,,,,,,,409.59,1106.29,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,MedCost,Ultra,,693.98,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,inpatient,10,ML,87.50000,52.50000,MedCost,Ultra,,56.00,,,,,,,26.34,71.14,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,MedCost,Ultra,,44.62,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,inpatient,5,ML,217.35000,130.41000,MedCost,Ultra,,139.10,,,,,,,139.10,176.71,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,MedCost,Ultra,,110.85,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,inpatient,5,ML,38.40000,23.04000,MedCost,Ultra,,24.58,,,,,,,11.56,31.22,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,MedCost,Ultra,,19.58,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,inpatient,5,ML,39.20000,23.52000,MedCost,Ultra,,25.09,,,,,,,25.09,31.87,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,MedCost,Ultra,,19.99,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,inpatient,6,ML,6247.80000,3748.68000,MedCost,Ultra,,3998.59,,,,,,,1880.59,5079.46,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,MedCost,Ultra,,3186.38,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,inpatient,1,UN,18.80000,11.28000,MedCost,Ultra,,12.03,,,,,,,12.03,15.28,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,MedCost,Ultra,,9.59,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,inpatient,1,UN,20.80000,12.48000,MedCost,Ultra,,13.31,,,,,,,13.31,16.91,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,MedCost,Ultra,,10.61,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,inpatient,11.6,ML,9504.40000,5702.64000,MedCost,Ultra,,6082.82,,,,,,,6082.82,7727.08,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,MedCost,Ultra,,4847.24,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,inpatient,10.15,ML,3.85000,2.31000,MedCost,Ultra,,2.46,,,,,,,2.46,3.13,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,MedCost,Ultra,,1.96,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,inpatient,3,ML,57.75000,34.65000,MedCost,Ultra,,36.96,,,,,,,36.96,46.95,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,MedCost,Ultra,,29.45,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,MedCost,Ultra,,29.09,,,,,,,13.68,36.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,MedCost,Ultra,,23.18,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,MedCost,Ultra,,40.61,,,,,,,19.10,51.58,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,MedCost,Ultra,,32.36,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,inpatient,1,UN,262.00000,157.20000,MedCost,Ultra,,167.68,,,,,,,78.86,213.01,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,MedCost,Ultra,,133.62,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,inpatient,1,UN,352.50000,211.50000,MedCost,Ultra,,225.60,,,,,,,106.10,286.58,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,MedCost,Ultra,,179.78,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,inpatient,113,GR,10.85000,6.51000,MedCost,Ultra,,6.94,,,,,,,6.94,8.82,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,MedCost,Ultra,,5.53,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,inpatient,50,ML,298.60000,179.16000,MedCost,Ultra,,191.10,,,,,,,191.10,242.76,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,MedCost,Ultra,,152.29,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,inpatient,15,ML,1.65000,0.99000,MedCost,Ultra,,1.06,,,,,,,1.06,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,MedCost,Ultra,,0.84150,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,15,ML,1.40000,0.84000,MedCost,Ultra,,0.89600,,,,,,,0.89600,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,MedCost,Ultra,,0.71400,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,inpatient,15,ML,1.60000,0.96000,MedCost,Ultra,,1.02,,,,,,,1.02,1.30,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,MedCost,Ultra,,0.81600,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,inpatient,30,ML,46.30000,27.78000,MedCost,Ultra,,29.63,,,,,,,13.94,37.64,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,MedCost,Ultra,,23.61,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,inpatient,1,UN,218.65000,131.19000,MedCost,Ultra,,139.94,,,,,,,65.81,177.76,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,MedCost,Ultra,,111.51,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,inpatient,250,ML,179.40000,107.64000,MedCost,Ultra,,114.82,,,,,,,114.82,145.85,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,MedCost,Ultra,,91.49,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,99.80000,59.88000,MedCost,Ultra,,63.87,,,,,,,30.04,81.14,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,MedCost,Ultra,,50.90,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,inpatient,1,UN,1.30000,0.78000,MedCost,Ultra,,0.83200,,,,,,,0.83200,1.06,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,MedCost,Ultra,,0.66300,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,inpatient,50,ML,155.95000,93.57000,MedCost,Ultra,,99.81,,,,,,,46.94,126.79,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,MedCost,Ultra,,79.53,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,inpatient,5,ML,40.35000,24.21000,MedCost,Ultra,,25.82,,,,,,,25.82,32.80,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,MedCost,Ultra,,20.58,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,inpatient,1,UN,22.00000,13.20000,MedCost,Ultra,,14.08,,,,,,,6.62,17.89,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,MedCost,Ultra,,11.22,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,inpatient,1,ML,64.75000,38.85000,MedCost,Ultra,,41.44,,,,,,,19.49,52.64,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,MedCost,Ultra,,33.02,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,inpatient,200,ML,11976.20000,7185.72000,MedCost,Ultra,,7664.77,,,,,,,3604.84,9736.65,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,MedCost,Ultra,,6107.86,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,inpatient,4,ML,57.65000,34.59000,MedCost,Ultra,,36.90,,,,,,,36.90,46.87,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,MedCost,Ultra,,29.40,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,inpatient,0.5,ML,34.20000,20.52000,MedCost,Ultra,,21.89,,,,,,,10.29,27.80,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,MedCost,Ultra,,17.44,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,inpatient,250,ML,80.50000,48.30000,MedCost,Ultra,,51.52,,,,,,,24.23,65.45,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,MedCost,Ultra,,41.05,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,inpatient,0.25,ML,23.65000,14.19000,MedCost,Ultra,,15.14,,,,,,,7.12,19.23,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,MedCost,Ultra,,12.06,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,inpatient,1,UN,9718.80000,5831.28000,MedCost,Ultra,,6220.03,,,,,,,2925.36,7901.38,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,MedCost,Ultra,,4956.59,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,inpatient,1,UN,249.90000,149.94000,MedCost,Ultra,,159.94,,,,,,,75.22,203.17,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,MedCost,Ultra,,127.45,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,inpatient,8,ML,1.30000,0.78000,MedCost,Ultra,,0.83200,,,,,,,0.83200,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,MedCost,Ultra,,0.66300,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,inpatient,8,ML,7.35000,4.41000,MedCost,Ultra,,4.70,,,,,,,4.70,5.98,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,MedCost,Ultra,,3.75,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,inpatient,250,ML,137.85000,82.71000,MedCost,Ultra,,88.22,,,,,,,41.49,112.07,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,MedCost,Ultra,,70.30,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,inpatient,5,ML,18.50000,11.10000,MedCost,Ultra,,11.84,,,,,,,11.84,15.04,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,MedCost,Ultra,,9.44,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,inpatient,10,ML,80.75000,48.45000,MedCost,Ultra,,51.68,,,,,,,51.68,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,MedCost,Ultra,,41.18,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,inpatient,10,ML,86.00000,51.60000,MedCost,Ultra,,55.04,,,,,,,55.04,69.92,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,MedCost,Ultra,,43.86,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,inpatient,250,ML,180.00000,108.00000,MedCost,Ultra,,115.20,,,,,,,115.20,146.34,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,MedCost,Ultra,,91.80,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,inpatient,250,ML,97.15000,58.29000,MedCost,Ultra,,62.18,,,,,,,62.18,78.98,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,MedCost,Ultra,,49.55,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,MedCost,Ultra,,12449.18,,,,,,,5855.01,15814.35,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,MedCost,Ultra,,9920.44,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,inpatient,10,ML,159.05000,95.43000,MedCost,Ultra,,101.79,,,,,,,101.79,129.31,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,MedCost,Ultra,,81.12,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,inpatient,10,ML,93.85000,56.31000,MedCost,Ultra,,60.06,,,,,,,28.25,76.30,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,MedCost,Ultra,,47.86,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,inpatient,0.25,ML,70.45000,42.27000,MedCost,Ultra,,45.09,,,,,,,21.21,57.28,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,MedCost,Ultra,,35.93,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,5,ML,74.35000,44.61000,MedCost,Ultra,,47.58,,,,,,,22.38,60.45,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,MedCost,Ultra,,37.92,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,inpatient,5,ML,74.35000,44.61000,MedCost,Ultra,,47.58,,,,,,,22.38,60.45,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,MedCost,Ultra,,37.92,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,inpatient,5,ML,84.05000,50.43000,MedCost,Ultra,,53.79,,,,,,,25.30,68.33,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,MedCost,Ultra,,42.87,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,11.26,14.31,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,inpatient,60,GR,11.80000,7.08000,MedCost,Ultra,,7.55,,,,,,,7.55,9.59,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,MedCost,Ultra,,6.02,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,inpatient,1,UN,18.05000,10.83000,MedCost,Ultra,,11.55,,,,,,,11.55,14.67,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,MedCost,Ultra,,9.21,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,11.30,,,,,,,11.30,14.35,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,9.00,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,inpatient,1,UN,24.10000,14.46000,MedCost,Ultra,,15.42,,,,,,,15.42,19.59,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,MedCost,Ultra,,12.29,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,inpatient,15,ML,11.05000,6.63000,MedCost,Ultra,,7.07,,,,,,,7.07,8.98,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,MedCost,Ultra,,5.64,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,inpatient,1,UN,8199.90000,4919.94000,MedCost,Ultra,,5247.94,,,,,,,2468.17,6666.52,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,MedCost,Ultra,,4181.95,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,inpatient,1,UN,20.15000,12.09000,MedCost,Ultra,,12.90,,,,,,,12.90,16.38,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,MedCost,Ultra,,10.28,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,inpatient,1,UN,16.75000,10.05000,MedCost,Ultra,,10.72,,,,,,,10.72,13.62,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,MedCost,Ultra,,8.54,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,inpatient,1,UN,61.70000,37.02000,MedCost,Ultra,,39.49,,,,,,,39.49,50.16,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,MedCost,Ultra,,31.47,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,inpatient,500,ML,373.50000,224.10000,MedCost,Ultra,,239.04,,,,,,,239.04,303.66,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,MedCost,Ultra,,190.49,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,inpatient,1,ML,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,115.89,313.00,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,inpatient,35,ML,192.55000,115.53000,MedCost,Ultra,,123.23,,,,,,,123.23,156.54,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,MedCost,Ultra,,98.20,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,inpatient,1,UN,70.35000,42.21000,MedCost,Ultra,,45.02,,,,,,,21.18,57.19,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,MedCost,Ultra,,35.88,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,inpatient,1,UN,66.30000,39.78000,MedCost,Ultra,,42.43,,,,,,,19.96,53.90,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,MedCost,Ultra,,33.81,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,inpatient,10,ML,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.98,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,inpatient,1,UN,16.75000,10.05000,MedCost,Ultra,,10.72,,,,,,,10.72,13.62,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,MedCost,Ultra,,8.54,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,inpatient,1,UN,16.75000,10.05000,MedCost,Ultra,,10.72,,,,,,,10.72,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,MedCost,Ultra,,8.54,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,inpatient,1,UN,22.25000,13.35000,MedCost,Ultra,,14.24,,,,,,,14.24,18.09,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,MedCost,Ultra,,11.35,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,inpatient,1,UN,29.30000,17.58000,MedCost,Ultra,,18.75,,,,,,,8.82,23.82,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,MedCost,Ultra,,14.94,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,inpatient,1,UN,18.15000,10.89000,MedCost,Ultra,,11.62,,,,,,,11.62,14.76,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,MedCost,Ultra,,9.26,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,inpatient,1,UN,16.35000,9.81000,MedCost,Ultra,,10.46,,,,,,,10.46,13.29,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,MedCost,Ultra,,8.34,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,inpatient,250,ML,112.90000,67.74000,MedCost,Ultra,,72.26,,,,,,,33.98,91.79,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,MedCost,Ultra,,57.58,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,inpatient,250,ML,132.15000,79.29000,MedCost,Ultra,,84.58,,,,,,,39.78,107.44,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,MedCost,Ultra,,67.40,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.89600,,,,,,,0.89600,1.14,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.71400,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,inpatient,250,ML,90.15000,54.09000,MedCost,Ultra,,57.70,,,,,,,27.14,73.29,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,MedCost,Ultra,,45.98,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,inpatient,5,ML,148.65000,89.19000,MedCost,Ultra,,95.14,,,,,,,95.14,120.85,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,MedCost,Ultra,,75.81,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,inpatient,30,ML,44.55000,26.73000,MedCost,Ultra,,28.51,,,,,,,28.51,36.22,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,MedCost,Ultra,,22.72,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,inpatient,50,ML,104.30000,62.58000,MedCost,Ultra,,66.75,,,,,,,66.75,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,MedCost,Ultra,,53.19,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,inpatient,5,ML,20.25000,12.15000,MedCost,Ultra,,12.96,,,,,,,12.96,16.46,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,MedCost,Ultra,,10.33,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,5.37,14.51,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,inpatient,250,ML,346.00000,207.60000,MedCost,Ultra,,221.44,,,,,,,221.44,281.30,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,MedCost,Ultra,,176.46,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,inpatient,1,UN,1263.90000,758.34000,MedCost,Ultra,,808.90,,,,,,,380.43,1027.55,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,MedCost,Ultra,,644.59,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,inpatient,1,UN,23.05000,13.83000,MedCost,Ultra,,14.75,,,,,,,14.75,18.74,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,MedCost,Ultra,,11.76,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,inpatient,20,ML,452.80000,271.68000,MedCost,Ultra,,289.79,,,,,,,136.29,368.13,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,MedCost,Ultra,,230.93,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,inpatient,30,ML,907.80000,544.68000,MedCost,Ultra,,580.99,,,,,,,273.25,738.04,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,MedCost,Ultra,,462.98,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,15,ML,1.75000,1.05000,MedCost,Ultra,,1.12,,,,,,,1.12,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,MedCost,Ultra,,0.89250,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,inpatient,15,ML,1.70000,1.02000,MedCost,Ultra,,1.09,,,,,,,1.09,1.38,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,MedCost,Ultra,,0.86700,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,inpatient,30,ML,8.90000,5.34000,MedCost,Ultra,,5.70,,,,,,,5.70,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,MedCost,Ultra,,4.54,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.70,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,11.90,,,,,,,11.90,15.12,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,9.49,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,inpatient,3.7,ML,240.65000,144.39000,MedCost,Ultra,,154.02,,,,,,,154.02,195.65,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,MedCost,Ultra,,122.73,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,10.40,,,,,,,10.40,13.21,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,8.29,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,10.59,,,,,,,10.59,13.46,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,8.44,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,inpatient,22.5,ML,94.55000,56.73000,MedCost,Ultra,,60.51,,,,,,,60.51,76.87,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,MedCost,Ultra,,48.22,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,inpatient,1,ML,28.30000,16.98000,MedCost,Ultra,,18.11,,,,,,,8.52,23.01,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,MedCost,Ultra,,14.43,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,inpatient,250,ML,134.75000,80.85000,MedCost,Ultra,,86.24,,,,,,,40.56,109.55,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,MedCost,Ultra,,68.72,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,250,ML,141.75000,85.05000,MedCost,Ultra,,90.72,,,,,,,42.67,115.24,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,MedCost,Ultra,,72.29,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,inpatient,1,UN,43.75000,26.25000,MedCost,Ultra,,28.00,,,,,,,28.00,35.57,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,MedCost,Ultra,,22.31,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,inpatient,240,ML,348.65000,209.19000,MedCost,Ultra,,223.14,,,,,,,223.14,283.45,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,MedCost,Ultra,,177.81,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.70,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,inpatient,1,ML,20.95000,12.57000,MedCost,Ultra,,13.41,,,,,,,6.31,17.03,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,MedCost,Ultra,,10.68,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,inpatient,1,ML,18.75000,11.25000,MedCost,Ultra,,12.00,,,,,,,5.64,15.24,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,MedCost,Ultra,,9.56,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,inpatient,250,ML,141.75000,85.05000,MedCost,Ultra,,90.72,,,,,,,42.67,115.24,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,MedCost,Ultra,,72.29,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,inpatient,250,ML,164.50000,98.70000,MedCost,Ultra,,105.28,,,,,,,49.51,133.74,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,MedCost,Ultra,,83.89,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,inpatient,1000,ML,175.00000,105.00000,MedCost,Ultra,,112.00,,,,,,,112.00,142.28,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,MedCost,Ultra,,89.25,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,inpatient,473,ML,3.20000,1.92000,MedCost,Ultra,,2.05,,,,,,,2.05,2.60,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,MedCost,Ultra,,1.63,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,MedCost,Ultra,,64.96,,,,,,,30.55,82.52,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,MedCost,Ultra,,51.77,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,inpatient,30,ML,124.00000,74.40000,MedCost,Ultra,,79.36,,,,,,,79.36,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,MedCost,Ultra,,63.24,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,inpatient,15,ML,124.00000,74.40000,MedCost,Ultra,,79.36,,,,,,,79.36,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,MedCost,Ultra,,63.24,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,inpatient,100,ML,91.70000,55.02000,MedCost,Ultra,,58.69,,,,,,,27.60,74.55,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,MedCost,Ultra,,46.77,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,inpatient,5,ML,79.70000,47.82000,MedCost,Ultra,,51.01,,,,,,,51.01,64.80,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,MedCost,Ultra,,40.65,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,inpatient,20,ML,471.00000,282.60000,MedCost,Ultra,,301.44,,,,,,,301.44,382.92,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,MedCost,Ultra,,240.21,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,inpatient,1,UN,26.20000,15.72000,MedCost,Ultra,,16.77,,,,,,,16.77,21.30,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,MedCost,Ultra,,13.36,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,MedCost,Ultra,,14.85,,,,,,,14.85,18.86,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,MedCost,Ultra,,11.83,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,inpatient,1,UN,23.50000,14.10000,MedCost,Ultra,,15.04,,,,,,,15.04,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,MedCost,Ultra,,11.98,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,inpatient,1,UN,22.50000,13.50000,MedCost,Ultra,,14.40,,,,,,,14.40,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,MedCost,Ultra,,11.47,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,inpatient,1,UN,22.60000,13.56000,MedCost,Ultra,,14.46,,,,,,,14.46,18.37,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,MedCost,Ultra,,11.53,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,inpatient,1,UN,13881.15000,8328.69000,MedCost,Ultra,,8883.94,,,,,,,4178.23,11285.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,MedCost,Ultra,,7079.39,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,inpatient,1,UN,303.80000,182.28000,MedCost,Ultra,,194.43,,,,,,,194.43,246.99,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,MedCost,Ultra,,154.94,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,inpatient,28.4,GR,4.25000,2.55000,MedCost,Ultra,,2.72,,,,,,,2.72,3.46,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,MedCost,Ultra,,2.17,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,inpatient,1,UN,56.45000,33.87000,MedCost,Ultra,,36.13,,,,,,,36.13,45.89,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,MedCost,Ultra,,28.79,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,inpatient,1,UN,56.45000,33.87000,MedCost,Ultra,,36.13,,,,,,,36.13,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,MedCost,Ultra,,28.79,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,inpatient,1,UN,4065.55000,2439.33000,MedCost,Ultra,,2601.95,,,,,,,1223.73,3305.29,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,MedCost,Ultra,,2073.43,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,inpatient,20,ML,113.05000,67.83000,MedCost,Ultra,,72.35,,,,,,,34.03,91.91,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,MedCost,Ultra,,57.66,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,inpatient,20,ML,117.85000,70.71000,MedCost,Ultra,,75.42,,,,,,,35.47,95.81,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,MedCost,Ultra,,60.10,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,inpatient,1,UN,17829.40000,10697.64000,MedCost,Ultra,,11410.82,,,,,,,5366.65,14495.30,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,MedCost,Ultra,,9092.99,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,inpatient,1,UN,28362.00000,17017.20000,MedCost,Ultra,,18151.68,,,,,,,8536.96,23058.31,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,MedCost,Ultra,,14464.62,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,MedCost,Ultra,,41.82,,,,,,,19.67,53.13,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,MedCost,Ultra,,33.33,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,inpatient,118,ML,6.15000,3.69000,MedCost,Ultra,,3.94,,,,,,,3.94,5.00,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,MedCost,Ultra,,3.14,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,inpatient,1,ML,147.45000,88.47000,MedCost,Ultra,,94.37,,,,,,,44.38,119.88,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,MedCost,Ultra,,75.20,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,inpatient,1,UN,25.05000,15.03000,MedCost,Ultra,,16.03,,,,,,,16.03,20.37,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,MedCost,Ultra,,12.78,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,inpatient,1,UN,41.50000,24.90000,MedCost,Ultra,,26.56,,,,,,,26.56,33.74,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,MedCost,Ultra,,21.16,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,inpatient,1,UN,23.70000,14.22000,MedCost,Ultra,,15.17,,,,,,,15.17,19.27,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,MedCost,Ultra,,12.09,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,inpatient,1,UN,19.20000,11.52000,MedCost,Ultra,,12.29,,,,,,,12.29,15.61,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,MedCost,Ultra,,9.79,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,inpatient,0.5,ML,161.50000,96.90000,MedCost,Ultra,,103.36,,,,,,,48.61,131.30,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,MedCost,Ultra,,82.36,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,82.17,221.95,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,inpatient,1,UN,486.70000,292.02000,MedCost,Ultra,,311.49,,,,,,,311.49,395.69,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,MedCost,Ultra,,248.22,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,inpatient,10,ML,97.90000,58.74000,MedCost,Ultra,,62.66,,,,,,,29.47,79.59,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,MedCost,Ultra,,49.93,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,inpatient,3.75,ML,94.25000,56.55000,MedCost,Ultra,,60.32,,,,,,,60.32,76.63,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,MedCost,Ultra,,48.07,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,inpatient,1,UN,4576.00000,2745.60000,MedCost,Ultra,,2928.64,,,,,,,1377.38,3720.29,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,MedCost,Ultra,,2333.76,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,inpatient,3000,ML,153.00000,91.80000,MedCost,Ultra,,97.92,,,,,,,97.92,124.39,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,MedCost,Ultra,,78.03,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,inpatient,1,ML,24.05000,14.43000,MedCost,Ultra,,15.39,,,,,,,15.39,19.55,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,MedCost,Ultra,,12.27,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,inpatient,57,GR,4.80000,2.88000,MedCost,Ultra,,3.07,,,,,,,3.07,3.90,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,MedCost,Ultra,,2.45,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,inpatient,1,UN,326.05000,195.63000,MedCost,Ultra,,208.67,,,,,,,208.67,265.08,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,MedCost,Ultra,,166.29,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,inpatient,1,UN,84.60000,50.76000,MedCost,Ultra,,54.14,,,,,,,54.14,68.78,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,MedCost,Ultra,,43.15,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,inpatient,1,UN,84.60000,50.76000,MedCost,Ultra,,54.14,,,,,,,54.14,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,MedCost,Ultra,,43.15,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,inpatient,1,UN,643.15000,385.89000,MedCost,Ultra,,411.62,,,,,,,411.62,522.88,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,MedCost,Ultra,,328.01,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,inpatient,1,UN,643.15000,385.89000,MedCost,Ultra,,411.62,,,,,,,411.62,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,MedCost,Ultra,,328.01,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,11.01,,,,,,,11.01,13.98,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,8.77,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,inpatient,1,UN,549.95000,329.97000,MedCost,Ultra,,351.97,,,,,,,165.53,447.11,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,MedCost,Ultra,,280.47,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,MedCost,Ultra,,16.70,,,,,,,7.86,21.22,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,MedCost,Ultra,,13.31,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,inpatient,0.5,ML,22.35000,13.41000,MedCost,Ultra,,14.30,,,,,,,6.73,18.17,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,MedCost,Ultra,,11.40,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,inpatient,1,UN,1.85000,1.11000,MedCost,Ultra,,1.18,,,,,,,1.18,1.50,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,MedCost,Ultra,,0.94350,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,inpatient,1,UN,84.10000,50.46000,MedCost,Ultra,,53.82,,,,,,,53.82,68.37,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,MedCost,Ultra,,42.89,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,inpatient,1,UN,324.35000,194.61000,MedCost,Ultra,,207.58,,,,,,,97.63,263.70,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,MedCost,Ultra,,165.42,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,inpatient,1,UN,493.50000,296.10000,MedCost,Ultra,,315.84,,,,,,,148.54,401.22,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,MedCost,Ultra,,251.69,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,inpatient,1,UN,20.45000,12.27000,MedCost,Ultra,,13.09,,,,,,,13.09,16.63,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,MedCost,Ultra,,10.43,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,inpatient,1,UN,357.15000,214.29000,MedCost,Ultra,,228.58,,,,,,,228.58,290.36,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,MedCost,Ultra,,182.15,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,inpatient,1,UN,527.70000,316.62000,MedCost,Ultra,,337.73,,,,,,,337.73,429.02,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,MedCost,Ultra,,269.13,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,inpatient,1,UN,99.95000,59.97000,MedCost,Ultra,,63.97,,,,,,,63.97,81.26,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,MedCost,Ultra,,50.97,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,inpatient,1,UN,99.95000,59.97000,MedCost,Ultra,,63.97,,,,,,,63.97,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,MedCost,Ultra,,50.97,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,inpatient,1,UN,368.65000,221.19000,MedCost,Ultra,,235.94,,,,,,,235.94,299.71,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,MedCost,Ultra,,188.01,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,inpatient,5,ML,6392.40000,3835.44000,MedCost,Ultra,,4091.14,,,,,,,1924.11,5197.02,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,MedCost,Ultra,,3260.12,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,inpatient,1,ML,28.40000,17.04000,MedCost,Ultra,,18.18,,,,,,,8.55,23.09,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,MedCost,Ultra,,14.48,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,inpatient,10,ML,6878.50000,4127.10000,MedCost,Ultra,,4402.24,,,,,,,2070.43,5592.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,MedCost,Ultra,,3508.03,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,inpatient,50,ML,33292.40000,19975.44000,MedCost,Ultra,,21307.14,,,,,,,10021.01,27066.72,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,MedCost,Ultra,,16979.12,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,inpatient,1,UN,22.70000,13.62000,MedCost,Ultra,,14.53,,,,,,,14.53,18.46,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,MedCost,Ultra,,11.58,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,inpatient,1,UN,55.00000,33.00000,MedCost,Ultra,,35.20,,,,,,,16.55,44.72,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,MedCost,Ultra,,28.05,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,inpatient,1,UN,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,24.08,65.04,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,inpatient,1,UN,1.70000,1.02000,MedCost,Ultra,,1.09,,,,,,,1.09,1.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,MedCost,Ultra,,0.86700,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,MedCost,Ultra,,56.93,,,,,,,26.77,72.32,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,MedCost,Ultra,,45.36,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,inpatient,1,UN,39374.65000,23624.79000,MedCost,Ultra,,25199.78,,,,,,,11851.77,32011.59,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,MedCost,Ultra,,20081.07,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,inpatient,1,UN,8111.05000,4866.63000,MedCost,Ultra,,5191.07,,,,,,,2441.43,6594.28,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,MedCost,Ultra,,4136.64,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,inpatient,1,UN,88.95000,53.37000,MedCost,Ultra,,56.93,,,,,,,26.77,72.32,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,MedCost,Ultra,,45.36,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,inpatient,30,ML,381.35000,228.81000,MedCost,Ultra,,244.06,,,,,,,244.06,310.04,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,MedCost,Ultra,,194.49,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,inpatient,1,UN,75.60000,45.36000,MedCost,Ultra,,48.38,,,,,,,22.76,61.46,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,MedCost,Ultra,,38.56,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,MedCost,Ultra,,56.19,,,,,,,26.43,71.38,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,MedCost,Ultra,,44.78,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,inpatient,2,ML,2093.30000,1255.98000,MedCost,Ultra,,1339.71,,,,,,,630.08,1701.85,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,MedCost,Ultra,,1067.58,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,inpatient,1,UN,13983.35000,8390.01000,MedCost,Ultra,,8949.34,,,,,,,8949.34,11368.46,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,MedCost,Ultra,,7131.51,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,11.39,,,,,,,11.39,14.47,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,9.08,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,inpatient,10,ML,462.25000,277.35000,MedCost,Ultra,,295.84,,,,,,,139.14,375.81,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,MedCost,Ultra,,235.75,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,inpatient,1,ML,1095.00000,657.00000,MedCost,Ultra,,700.80,,,,,,,329.60,890.24,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,MedCost,Ultra,,558.45,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,inpatient,1,UN,247.50000,148.50000,MedCost,Ultra,,158.40,,,,,,,158.40,201.22,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,MedCost,Ultra,,126.22,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,10.50,,,,,,,10.50,13.33,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,8.36,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,inpatient,1,UN,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,47.15,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,MedCost,Ultra,,24.80,,,,,,,11.66,31.50,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,MedCost,Ultra,,19.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,MedCost,Ultra,,24.80,,,,,,,11.66,31.50,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,MedCost,Ultra,,19.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,inpatient,1,UN,241.15000,144.69000,MedCost,Ultra,,154.34,,,,,,,154.34,196.05,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,MedCost,Ultra,,122.99,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,inpatient,1,UN,307.90000,184.74000,MedCost,Ultra,,197.06,,,,,,,197.06,250.32,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,MedCost,Ultra,,157.03,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,inpatient,1,UN,406.80000,244.08000,MedCost,Ultra,,260.35,,,,,,,260.35,330.73,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,MedCost,Ultra,,207.47,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,15823.87,,,,,,,7442.16,20101.26,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,12609.65,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,inpatient,1,UN,809.35000,485.61000,MedCost,Ultra,,517.98,,,,,,,243.61,658.00,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,MedCost,Ultra,,412.77,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,inpatient,4,ML,6099.95000,3659.97000,MedCost,Ultra,,3903.97,,,,,,,1836.08,4959.26,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,MedCost,Ultra,,3110.97,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,inpatient,10,ML,14837.25000,8902.35000,MedCost,Ultra,,9495.84,,,,,,,4466.01,12062.68,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,MedCost,Ultra,,7567.00,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,10.37,,,,,,,10.37,13.17,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,8.26,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,10.40,,,,,,,10.40,13.21,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,8.29,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,inpatient,0.5,ML,731.15000,438.69000,MedCost,Ultra,,467.94,,,,,,,220.08,594.42,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,MedCost,Ultra,,372.89,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,inpatient,1,UN,39.50000,23.70000,MedCost,Ultra,,25.28,,,,,,,25.28,32.11,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,MedCost,Ultra,,20.14,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,inpatient,1,UN,47.70000,28.62000,MedCost,Ultra,,30.53,,,,,,,30.53,38.78,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,MedCost,Ultra,,24.33,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,inpatient,1,UN,54.55000,32.73000,MedCost,Ultra,,34.91,,,,,,,34.91,44.35,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,MedCost,Ultra,,27.82,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,inpatient,1,UN,77.70000,46.62000,MedCost,Ultra,,49.73,,,,,,,49.73,63.17,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,MedCost,Ultra,,39.63,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,MedCost,Ultra,,18699.46,,,,,,,8794.59,23754.15,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,MedCost,Ultra,,14901.13,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,4,ML,26225.00000,15735.00000,MedCost,Ultra,,16784.00,,,,,,,7893.73,21320.92,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,MedCost,Ultra,,13374.75,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,inpatient,1,UN,25.00000,15.00000,MedCost,Ultra,,16.00,,,,,,,16.00,20.32,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,MedCost,Ultra,,12.75,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,inpatient,1,UN,74.20000,44.52000,MedCost,Ultra,,47.49,,,,,,,47.49,60.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,MedCost,Ultra,,37.84,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,inpatient,1,UN,74.20000,44.52000,MedCost,Ultra,,47.49,,,,,,,47.49,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,MedCost,Ultra,,37.84,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,inpatient,20,ML,109.30000,65.58000,MedCost,Ultra,,69.95,,,,,,,69.95,88.86,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,MedCost,Ultra,,55.74,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,inpatient,250,ML,1780.00000,1068.00000,MedCost,Ultra,,1139.20,,,,,,,1139.20,1447.14,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,MedCost,Ultra,,907.80,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,inpatient,1,UN,57.75000,34.65000,MedCost,Ultra,,36.96,,,,,,,36.96,46.95,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,MedCost,Ultra,,29.45,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,inpatient,1,UN,57.75000,34.65000,MedCost,Ultra,,36.96,,,,,,,36.96,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,MedCost,Ultra,,29.45,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,inpatient,1,UN,21020.20000,12612.12000,MedCost,Ultra,,13452.93,,,,,,,6327.08,17089.42,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,MedCost,Ultra,,10720.30,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,inpatient,1,UN,31468.15000,18880.89000,MedCost,Ultra,,20139.62,,,,,,,9471.91,25583.61,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,MedCost,Ultra,,16048.76,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,inpatient,1,UN,16047.65000,9628.59000,MedCost,Ultra,,10270.50,,,,,,,4830.34,13046.74,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,MedCost,Ultra,,8184.30,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,inpatient,1,UN,1807.55000,1084.53000,MedCost,Ultra,,1156.83,,,,,,,544.07,1469.54,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,MedCost,Ultra,,921.85,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,inpatient,1,UN,3746.95000,2248.17000,MedCost,Ultra,,2398.05,,,,,,,1127.83,3046.27,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,MedCost,Ultra,,1910.94,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,inpatient,30,GR,8.10000,4.86000,MedCost,Ultra,,5.18,,,,,,,5.18,6.59,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,MedCost,Ultra,,4.13,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,inpatient,100,ML,94.50000,56.70000,MedCost,Ultra,,60.48,,,,,,,28.44,76.83,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,MedCost,Ultra,,48.20,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,inpatient,1,UN,486.70000,292.02000,MedCost,Ultra,,311.49,,,,,,,311.49,395.69,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,MedCost,Ultra,,248.22,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,inpatient,50,ML,3914.20000,2348.52000,MedCost,Ultra,,2505.09,,,,,,,1178.17,3182.24,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,MedCost,Ultra,,1996.24,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,inpatient,5,ML,84083.00000,50449.80000,MedCost,Ultra,,53813.12,,,,,,,25308.98,68359.48,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,MedCost,Ultra,,42882.33,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,inpatient,10,ML,1978.60000,1187.16000,MedCost,Ultra,,1266.30,,,,,,,595.56,1608.60,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,MedCost,Ultra,,1009.09,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,inpatient,2,ML,493.20000,295.92000,MedCost,Ultra,,315.65,,,,,,,148.45,400.97,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,MedCost,Ultra,,251.53,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,inpatient,1,UN,4629.40000,2777.64000,MedCost,Ultra,,2962.82,,,,,,,1393.45,3763.70,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,MedCost,Ultra,,2360.99,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,inpatient,1,UN,9181.80000,5509.08000,MedCost,Ultra,,5876.35,,,,,,,2763.72,7464.80,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,MedCost,Ultra,,4682.72,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,inpatient,1,UN,4571.50000,2742.90000,MedCost,Ultra,,2925.76,,,,,,,1376.02,3716.63,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,MedCost,Ultra,,2331.47,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,inpatient,1,UN,63.05000,37.83000,MedCost,Ultra,,40.35,,,,,,,40.35,51.26,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,MedCost,Ultra,,32.16,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,inpatient,1,UN,63.05000,37.83000,MedCost,Ultra,,40.35,,,,,,,40.35,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,MedCost,Ultra,,32.16,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,inpatient,1,UN,63.05000,37.83000,MedCost,Ultra,,40.35,,,,,,,40.35,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,MedCost,Ultra,,32.16,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,inpatient,0.8,ML,2013.40000,1208.04000,MedCost,Ultra,,1288.58,,,,,,,606.03,1636.89,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,MedCost,Ultra,,1026.83,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,inpatient,0.5,ML,1264.35000,758.61000,MedCost,Ultra,,809.18,,,,,,,380.57,1027.92,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,MedCost,Ultra,,644.82,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,inpatient,1,UN,44.30000,26.58000,MedCost,Ultra,,28.35,,,,,,,13.33,36.02,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,MedCost,Ultra,,22.59,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,inpatient,1,UN,129.20000,77.52000,MedCost,Ultra,,82.69,,,,,,,38.89,105.04,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,MedCost,Ultra,,65.89,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,inpatient,1,UN,47.00000,28.20000,MedCost,Ultra,,30.08,,,,,,,30.08,38.21,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,MedCost,Ultra,,23.97,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,inpatient,8,GR,84.20000,50.52000,MedCost,Ultra,,53.89,,,,,,,53.89,68.45,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,MedCost,Ultra,,42.94,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,MedCost,Ultra,,48.64,,,,,,,22.88,61.79,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,MedCost,Ultra,,38.76,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,inpatient,50,ML,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,26.49,71.54,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,inpatient,50,ML,10778.05000,6466.83000,MedCost,Ultra,,6897.95,,,,,,,3244.19,8762.55,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,MedCost,Ultra,,5496.81,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,inpatient,10,ML,13382.60000,8029.56000,MedCost,Ultra,,8564.86,,,,,,,4028.16,10880.05,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,MedCost,Ultra,,6825.13,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,inpatient,1,UN,44.60000,26.76000,MedCost,Ultra,,28.54,,,,,,,28.54,36.26,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,MedCost,Ultra,,22.75,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,inpatient,1,UN,44.60000,26.76000,MedCost,Ultra,,28.54,,,,,,,28.54,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,MedCost,Ultra,,22.75,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,inpatient,1,UN,57.50000,34.50000,MedCost,Ultra,,36.80,,,,,,,36.80,46.75,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,MedCost,Ultra,,29.32,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,inpatient,1,UN,16408.85000,9845.31000,MedCost,Ultra,,10501.66,,,,,,,4939.06,13340.40,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,MedCost,Ultra,,8368.51,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,inpatient,1,UN,578.15000,346.89000,MedCost,Ultra,,370.02,,,,,,,370.02,470.04,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,MedCost,Ultra,,294.86,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,inpatient,10,ML,97.75000,58.65000,MedCost,Ultra,,62.56,,,,,,,62.56,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,MedCost,Ultra,,49.85,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,inpatient,15,ML,147.30000,88.38000,MedCost,Ultra,,94.27,,,,,,,94.27,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,MedCost,Ultra,,75.12,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,inpatient,5,ML,59.50000,35.70000,MedCost,Ultra,,38.08,,,,,,,38.08,48.37,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,MedCost,Ultra,,30.34,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,inpatient,4,ML,11159.75000,6695.85000,MedCost,Ultra,,7142.24,,,,,,,3359.08,9072.88,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,MedCost,Ultra,,5691.47,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,inpatient,1,UN,1039.25000,623.55000,MedCost,Ultra,,665.12,,,,,,,665.12,844.91,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,MedCost,Ultra,,530.02,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,inpatient,2,ML,635.45000,381.27000,MedCost,Ultra,,406.69,,,,,,,406.69,516.62,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,MedCost,Ultra,,324.08,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,inpatient,120,ML,16.45000,9.87000,MedCost,Ultra,,10.53,,,,,,,10.53,13.37,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,MedCost,Ultra,,8.39,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,inpatient,1,UN,218.55000,131.13000,MedCost,Ultra,,139.87,,,,,,,139.87,177.68,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,MedCost,Ultra,,111.46,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,inpatient,1,UN,19.15000,11.49000,MedCost,Ultra,,12.26,,,,,,,12.26,15.57,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,MedCost,Ultra,,9.77,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,inpatient,3,ML,877.30000,526.38000,MedCost,Ultra,,561.47,,,,,,,264.07,713.24,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,MedCost,Ultra,,447.42,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,inpatient,1,UN,19.60000,11.76000,MedCost,Ultra,,12.54,,,,,,,12.54,15.93,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,MedCost,Ultra,,10.00,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,inpatient,1,UN,4037.40000,2422.44000,MedCost,Ultra,,2583.94,,,,,,,1215.26,3282.41,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,MedCost,Ultra,,2059.07,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,inpatient,2,ML,1656.85000,994.11000,MedCost,Ultra,,1060.38,,,,,,,498.71,1347.02,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,MedCost,Ultra,,844.99,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,inpatient,1,UN,309.65000,185.79000,MedCost,Ultra,,198.18,,,,,,,93.20,251.75,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,MedCost,Ultra,,157.92,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,inpatient,0.9996,UN,13510.90000,8106.54000,MedCost,Ultra,,8646.98,,,,,,,8646.98,10984.36,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,MedCost,Ultra,,6890.56,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,inpatient,1,UN,77.05000,46.23000,MedCost,Ultra,,49.31,,,,,,,49.31,62.64,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,MedCost,Ultra,,39.30,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,inpatient,1,UN,285.40000,171.24000,MedCost,Ultra,,182.66,,,,,,,182.66,232.03,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,MedCost,Ultra,,145.55,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,inpatient,1,UN,545.60000,327.36000,MedCost,Ultra,,349.18,,,,,,,349.18,443.57,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,MedCost,Ultra,,278.26,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,inpatient,1,UN,4647.20000,2788.32000,MedCost,Ultra,,2974.21,,,,,,,1398.81,3778.17,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,MedCost,Ultra,,2370.07,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,inpatient,5,ML,211.40000,126.84000,MedCost,Ultra,,135.30,,,,,,,135.30,171.87,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,MedCost,Ultra,,107.81,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,inpatient,1,UN,95.65000,57.39000,MedCost,Ultra,,61.22,,,,,,,61.22,77.76,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,MedCost,Ultra,,48.78,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,inpatient,1,ML,148.15000,88.89000,MedCost,Ultra,,94.82,,,,,,,94.82,120.45,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,MedCost,Ultra,,75.56,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,MedCost,Ultra,,32811.65,,,,,,,15431.73,41681.05,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,MedCost,Ultra,,26146.78,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,inpatient,1,UN,22.00000,13.20000,MedCost,Ultra,,14.08,,,,,,,14.08,17.89,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,MedCost,Ultra,,11.22,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,inpatient,10.7,GR,1350.15000,810.09000,MedCost,Ultra,,864.10,,,,,,,864.10,1097.67,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,MedCost,Ultra,,688.58,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,inpatient,1000,ML,122.50000,73.50000,MedCost,Ultra,,78.40,,,,,,,36.87,99.59,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,MedCost,Ultra,,62.48,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,inpatient,150,ML,2747.20000,1648.32000,MedCost,Ultra,,1758.21,,,,,,,1758.21,2233.47,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,MedCost,Ultra,,1401.07,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,inpatient,0.05,ML,61.35000,36.81000,MedCost,Ultra,,39.26,,,,,,,18.47,49.88,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,MedCost,Ultra,,31.29,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,inpatient,10,ML,1082.50000,649.50000,MedCost,Ultra,,692.80,,,,,,,325.83,880.07,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,MedCost,Ultra,,552.08,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,inpatient,2.5,ML,61.30000,36.78000,MedCost,Ultra,,39.23,,,,,,,39.23,49.84,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,MedCost,Ultra,,31.26,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,inpatient,40,ML,16023.00000,9613.80000,MedCost,Ultra,,10254.72,,,,,,,4822.92,13026.70,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,MedCost,Ultra,,8171.73,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,inpatient,10,ML,41.15000,24.69000,MedCost,Ultra,,26.34,,,,,,,12.39,33.45,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,MedCost,Ultra,,20.99,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,inpatient,100,ML,191.65000,114.99000,MedCost,Ultra,,122.66,,,,,,,57.69,155.81,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,MedCost,Ultra,,97.74,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,MedCost,Ultra,,42.40,,,,,,,19.94,53.86,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,MedCost,Ultra,,33.79,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,inpatient,200,ML,367.30000,220.38000,MedCost,Ultra,,235.07,,,,,,,110.56,298.61,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,MedCost,Ultra,,187.32,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,inpatient,15,ML,57.50000,34.50000,MedCost,Ultra,,36.80,,,,,,,17.31,46.75,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,MedCost,Ultra,,29.32,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,inpatient,15,ML,34.25000,20.55000,MedCost,Ultra,,21.92,,,,,,,10.31,27.85,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,MedCost,Ultra,,17.47,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,inpatient,15,ML,39.90000,23.94000,MedCost,Ultra,,25.54,,,,,,,12.01,32.44,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,MedCost,Ultra,,20.35,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,inpatient,1,ML,89877.30000,53926.38000,MedCost,Ultra,,57521.47,,,,,,,27053.07,73070.24,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,MedCost,Ultra,,45837.42,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,inpatient,10,ML,9488.70000,5693.22000,MedCost,Ultra,,6072.77,,,,,,,2856.10,7714.31,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,MedCost,Ultra,,4839.24,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,10,ML,86755.05000,52053.03000,MedCost,Ultra,,55523.23,,,,,,,26113.27,70531.86,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,MedCost,Ultra,,44245.08,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,inpatient,1,UN,44.80000,26.88000,MedCost,Ultra,,28.67,,,,,,,28.67,36.42,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,MedCost,Ultra,,22.85,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,inpatient,1,UN,7132.10000,4279.26000,MedCost,Ultra,,4564.54,,,,,,,2146.76,5798.40,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,MedCost,Ultra,,3637.37,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,inpatient,1,UN,896.70000,538.02000,MedCost,Ultra,,573.89,,,,,,,573.89,729.02,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,MedCost,Ultra,,457.32,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,10,ML,19171.55000,11502.93000,MedCost,Ultra,,12269.79,,,,,,,5770.64,15586.47,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,MedCost,Ultra,,9777.49,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,inpatient,2.4,ML,4810.20000,2886.12000,MedCost,Ultra,,3078.53,,,,,,,1447.87,3910.69,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,MedCost,Ultra,,2453.20,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,inpatient,11.7,ML,29212.00000,17527.20000,MedCost,Ultra,,18695.68,,,,,,,8792.81,23749.36,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,MedCost,Ultra,,14898.12,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,inpatient,1,UN,6.65000,3.99000,MedCost,Ultra,,4.26,,,,,,,4.26,5.41,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,MedCost,Ultra,,3.39,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,inpatient,1,ML,71.75000,43.05000,MedCost,Ultra,,45.92,,,,,,,45.92,58.33,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,MedCost,Ultra,,36.59,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,inpatient,13.4,ML,33345.80000,20007.48000,MedCost,Ultra,,21341.31,,,,,,,10037.09,27110.14,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,MedCost,Ultra,,17006.36,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,inpatient,3,ML,71.30000,42.78000,MedCost,Ultra,,45.63,,,,,,,45.63,57.97,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,MedCost,Ultra,,36.36,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,inpatient,2,ML,68.70000,41.22000,MedCost,Ultra,,43.97,,,,,,,43.97,55.85,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,MedCost,Ultra,,35.04,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,inpatient,118,ML,1312.75000,787.65000,MedCost,Ultra,,840.16,,,,,,,840.16,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,MedCost,Ultra,,669.50,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,inpatient,473,ML,4511.40000,2706.84000,MedCost,Ultra,,2887.30,,,,,,,2887.30,3667.77,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,MedCost,Ultra,,2300.81,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,inpatient,3,ML,47.80000,28.68000,MedCost,Ultra,,30.59,,,,,,,30.59,38.86,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,MedCost,Ultra,,24.38,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,inpatient,1,UN,48587.00000,29152.20000,MedCost,Ultra,,31095.68,,,,,,,14624.69,39501.23,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,MedCost,Ultra,,24779.37,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,inpatient,1,UN,105505.20000,63303.12000,MedCost,Ultra,,67523.33,,,,,,,31757.07,85775.73,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,MedCost,Ultra,,53807.65,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,inpatient,1,UN,17.45000,10.47000,MedCost,Ultra,,11.17,,,,,,,11.17,14.19,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,MedCost,Ultra,,8.90,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,inpatient,1,ML,131.60000,78.96000,MedCost,Ultra,,84.22,,,,,,,84.22,106.99,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,MedCost,Ultra,,67.12,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,inpatient,5,ML,95.30000,57.18000,MedCost,Ultra,,60.99,,,,,,,60.99,77.48,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,MedCost,Ultra,,48.60,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,inpatient,5,ML,95.30000,57.18000,MedCost,Ultra,,60.99,,,,,,,60.99,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,MedCost,Ultra,,48.60,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,MedCost,Ultra,,57.79,,,,,,,27.18,73.41,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,MedCost,Ultra,,46.05,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,10.78,,,,,,,10.78,13.70,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,8.59,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,10.69,13.58,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,inpatient,1,UN,27.85000,16.71000,MedCost,Ultra,,17.82,,,,,,,17.82,22.64,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,MedCost,Ultra,,14.20,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,11.33,,,,,,,11.33,14.39,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,9.03,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,inpatient,250,ML,199.50000,119.70000,MedCost,Ultra,,127.68,,,,,,,60.05,162.19,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,MedCost,Ultra,,101.75,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,inpatient,1,UN,997.50000,598.50000,MedCost,Ultra,,638.40,,,,,,,300.25,810.97,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,MedCost,Ultra,,508.73,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,inpatient,60,ML,66.10000,39.66000,MedCost,Ultra,,42.30,,,,,,,42.30,53.74,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,MedCost,Ultra,,33.71,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,inpatient,1,UN,668.55000,401.13000,MedCost,Ultra,,427.87,,,,,,,201.23,543.53,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,MedCost,Ultra,,340.96,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,inpatient,1,UN,4.70000,2.82000,MedCost,Ultra,,3.01,,,,,,,3.01,3.82,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,MedCost,Ultra,,2.40,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,inpatient,1,ML,18.40000,11.04000,MedCost,Ultra,,11.78,,,,,,,5.54,14.96,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,MedCost,Ultra,,9.38,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,inpatient,18,ML,1972.25000,1183.35000,MedCost,Ultra,,1262.24,,,,,,,593.65,1603.44,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,MedCost,Ultra,,1005.85,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,inpatient,1,ML,26620.10000,15972.06000,MedCost,Ultra,,17036.86,,,,,,,8012.65,21642.14,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,MedCost,Ultra,,13576.25,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,inpatient,6,ML,5890.65000,3534.39000,MedCost,Ultra,,3770.02,,,,,,,1773.09,4789.10,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,MedCost,Ultra,,3004.23,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,inpatient,1,UN,19.10000,11.46000,MedCost,Ultra,,12.22,,,,,,,12.22,15.53,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,MedCost,Ultra,,9.74,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,inpatient,24,ML,35224.60000,21134.76000,MedCost,Ultra,,22543.74,,,,,,,10602.60,28637.60,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,MedCost,Ultra,,17964.55,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,inpatient,50,ML,80.05000,48.03000,MedCost,Ultra,,51.23,,,,,,,24.10,65.08,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,MedCost,Ultra,,40.83,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,inpatient,1,UN,241.95000,145.17000,MedCost,Ultra,,154.85,,,,,,,154.85,196.71,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,MedCost,Ultra,,123.39,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,inpatient,1,UN,389.50000,233.70000,MedCost,Ultra,,249.28,,,,,,,249.28,316.66,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,MedCost,Ultra,,198.65,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,16.86,,,,,,,7.93,21.42,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,13.44,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,inpatient,0.5,ML,58.45000,35.07000,MedCost,Ultra,,37.41,,,,,,,17.59,47.52,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,MedCost,Ultra,,29.81,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,inpatient,1,UN,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,246.40,313.00,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,inpatient,1,ML,116.40000,69.84000,MedCost,Ultra,,74.50,,,,,,,74.50,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,MedCost,Ultra,,59.36,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,inpatient,1,ML,166.60000,99.96000,MedCost,Ultra,,106.62,,,,,,,106.62,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,MedCost,Ultra,,84.97,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,inpatient,1,ML,216.75000,130.05000,MedCost,Ultra,,138.72,,,,,,,138.72,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,MedCost,Ultra,,110.54,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,inpatient,1,ML,517.90000,310.74000,MedCost,Ultra,,331.46,,,,,,,331.46,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,MedCost,Ultra,,264.13,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,inpatient,1,ML,2023.50000,1214.10000,MedCost,Ultra,,1295.04,,,,,,,1295.04,1645.11,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,MedCost,Ultra,,1031.98,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,inpatient,0.6,ML,9514.15000,5708.49000,MedCost,Ultra,,6089.06,,,,,,,2863.76,7735.00,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,MedCost,Ultra,,4852.22,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,inpatient,2000,ML,525.00000,315.00000,MedCost,Ultra,,336.00,,,,,,,336.00,426.82,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,MedCost,Ultra,,267.75,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,inpatient,1,UN,130.90000,78.54000,MedCost,Ultra,,83.78,,,,,,,83.78,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,MedCost,Ultra,,66.76,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,inpatient,1,UN,130.90000,78.54000,MedCost,Ultra,,83.78,,,,,,,83.78,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,MedCost,Ultra,,66.76,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,inpatient,0.5,ML,489.25000,293.55000,MedCost,Ultra,,313.12,,,,,,,147.26,397.76,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,MedCost,Ultra,,249.52,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,inpatient,5,ML,21317.55000,12790.53000,MedCost,Ultra,,13643.23,,,,,,,6416.58,17331.17,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,MedCost,Ultra,,10871.95,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,inpatient,0.5,ML,1012.45000,607.47000,MedCost,Ultra,,647.97,,,,,,,304.75,823.12,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,MedCost,Ultra,,516.35,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,inpatient,0.8,ML,1610.35000,966.21000,MedCost,Ultra,,1030.62,,,,,,,484.72,1309.21,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,MedCost,Ultra,,821.28,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,inpatient,1,UN,344.75000,206.85000,MedCost,Ultra,,220.64,,,,,,,103.77,280.28,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,MedCost,Ultra,,175.82,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,10.59,,,,,,,10.59,13.46,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,8.44,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,inpatient,1,UN,55.90000,33.54000,MedCost,Ultra,,35.78,,,,,,,35.78,45.45,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,MedCost,Ultra,,28.51,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,inpatient,100,ML,5146.00000,3087.60000,MedCost,Ultra,,3293.44,,,,,,,3293.44,4183.70,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,MedCost,Ultra,,2624.46,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,inpatient,7,ML,48344.85000,29006.91000,MedCost,Ultra,,30940.70,,,,,,,14551.80,39304.36,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,MedCost,Ultra,,24655.87,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,MedCost,Ultra,,12167.84,,,,,,,5722.69,15456.96,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,MedCost,Ultra,,9696.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,inpatient,2.5,ML,48.10000,28.86000,MedCost,Ultra,,30.78,,,,,,,30.78,39.11,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,MedCost,Ultra,,24.53,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,inpatient,5,ML,4543.25000,2725.95000,MedCost,Ultra,,2907.68,,,,,,,2907.68,3693.66,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,MedCost,Ultra,,2317.06,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,MedCost,Ultra,,6449.28,,,,,,,3033.18,8192.60,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,MedCost,Ultra,,5139.27,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,MedCost,Ultra,,647.97,,,,,,,304.75,823.12,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,MedCost,Ultra,,516.35,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,inpatient,1,UN,36064.10000,21638.46000,MedCost,Ultra,,23081.02,,,,,,,10855.29,29320.11,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,MedCost,Ultra,,18392.69,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,inpatient,1,UN,2928.00000,1756.80000,MedCost,Ultra,,1873.92,,,,,,,881.33,2380.46,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,MedCost,Ultra,,1493.28,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,MedCost,Ultra,,23020.99,,,,,,,10827.06,29243.85,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,MedCost,Ultra,,18344.85,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,inpatient,5,ML,20846.10000,12507.66000,MedCost,Ultra,,13341.50,,,,,,,6274.68,16947.88,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,MedCost,Ultra,,10631.51,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,inpatient,1000,ML,203.00000,121.80000,MedCost,Ultra,,129.92,,,,,,,129.92,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,MedCost,Ultra,,103.53,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,inpatient,2000,ML,287.00000,172.20000,MedCost,Ultra,,183.68,,,,,,,183.68,233.33,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,MedCost,Ultra,,146.37,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,inpatient,5,ML,419.55000,251.73000,MedCost,Ultra,,268.51,,,,,,,126.28,341.09,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,MedCost,Ultra,,213.97,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,inpatient,10,ML,1781.00000,1068.60000,MedCost,Ultra,,1139.84,,,,,,,1139.84,1447.95,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,MedCost,Ultra,,908.31,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,inpatient,1,UN,82165.25000,49299.15000,MedCost,Ultra,,52585.76,,,,,,,24731.74,66800.35,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,MedCost,Ultra,,41904.28,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,inpatient,16,ML,12554.95000,7532.97000,MedCost,Ultra,,8035.17,,,,,,,3779.04,10207.17,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,MedCost,Ultra,,6403.02,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,inpatient,4,ML,3345.05000,2007.03000,MedCost,Ultra,,2140.83,,,,,,,1006.86,2719.53,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,MedCost,Ultra,,1705.98,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,inpatient,100,ML,201.25000,120.75000,MedCost,Ultra,,128.80,,,,,,,60.58,163.62,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,MedCost,Ultra,,102.64,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,inpatient,2.5,ML,48.00000,28.80000,MedCost,Ultra,,30.72,,,,,,,30.72,39.02,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,MedCost,Ultra,,24.48,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,inpatient,1.25,ML,23.85000,14.31000,MedCost,Ultra,,15.26,,,,,,,15.26,19.39,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,MedCost,Ultra,,12.16,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,11.39,,,,,,,11.39,14.47,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,9.08,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,inpatient,10,ML,3995.45000,2397.27000,MedCost,Ultra,,2557.09,,,,,,,1202.63,3248.30,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,MedCost,Ultra,,2037.68,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,inpatient,50,ML,18877.10000,11326.26000,MedCost,Ultra,,12081.34,,,,,,,5682.01,15347.08,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,MedCost,Ultra,,9627.32,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,inpatient,1,UN,17338.20000,10402.92000,MedCost,Ultra,,11096.45,,,,,,,5218.80,14095.96,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,MedCost,Ultra,,8842.48,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,inpatient,1,UN,51888.40000,31133.04000,MedCost,Ultra,,33208.58,,,,,,,15618.41,42185.27,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,MedCost,Ultra,,26463.08,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,inpatient,10,ML,10365.35000,6219.21000,MedCost,Ultra,,6633.82,,,,,,,3119.97,8427.03,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,MedCost,Ultra,,5286.33,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,inpatient,1,UN,6279.25000,3767.55000,MedCost,Ultra,,4018.72,,,,,,,1890.05,5105.03,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,MedCost,Ultra,,3202.42,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,inpatient,10,ML,107.15000,64.29000,MedCost,Ultra,,68.58,,,,,,,68.58,87.11,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,MedCost,Ultra,,54.65,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,inpatient,1,UN,12634.60000,7580.76000,MedCost,Ultra,,8086.14,,,,,,,3803.01,10271.93,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,MedCost,Ultra,,6443.65,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,12041.22,,,,,,,5663.13,15296.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,9595.34,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,inpatient,1,UN,13855.50000,8313.30000,MedCost,Ultra,,8867.52,,,,,,,4170.51,11264.52,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,MedCost,Ultra,,7066.31,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,inpatient,16,ML,11070.85000,6642.51000,MedCost,Ultra,,7085.34,,,,,,,3332.33,9000.60,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,MedCost,Ultra,,5646.13,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,inpatient,4,ML,2974.00000,1784.40000,MedCost,Ultra,,1903.36,,,,,,,895.17,2417.86,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,MedCost,Ultra,,1516.74,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,10,ML,3428.95000,2057.37000,MedCost,Ultra,,2194.53,,,,,,,1032.11,2787.74,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,MedCost,Ultra,,1748.76,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,50,ML,16044.60000,9626.76000,MedCost,Ultra,,10268.54,,,,,,,4829.42,13044.26,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,MedCost,Ultra,,8182.75,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,inpatient,1,UN,75742.60000,45445.56000,MedCost,Ultra,,48475.26,,,,,,,22798.52,61578.73,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,MedCost,Ultra,,38628.73,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,inpatient,1,UN,15195.80000,9117.48000,MedCost,Ultra,,9725.31,,,,,,,4573.94,12354.19,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,MedCost,Ultra,,7749.86,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,inpatient,1,UN,143.55000,86.13000,MedCost,Ultra,,91.87,,,,,,,91.87,116.71,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,MedCost,Ultra,,73.21,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,inpatient,1,UN,143.55000,86.13000,MedCost,Ultra,,91.87,,,,,,,91.87,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,MedCost,Ultra,,73.21,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,inpatient,2.5,ML,28.60000,17.16000,MedCost,Ultra,,18.30,,,,,,,18.30,23.25,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,MedCost,Ultra,,14.59,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,inpatient,1,ML,8211.30000,4926.78000,MedCost,Ultra,,5255.23,,,,,,,2471.60,6675.79,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,MedCost,Ultra,,4187.76,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,inpatient,25,ML,19413.25000,11647.95000,MedCost,Ultra,,12424.48,,,,,,,5843.39,15782.97,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,MedCost,Ultra,,9900.76,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,inpatient,5,ML,4102.65000,2461.59000,MedCost,Ultra,,2625.70,,,,,,,1234.90,3335.45,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,MedCost,Ultra,,2092.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,inpatient,2,ML,149.10000,89.46000,MedCost,Ultra,,95.42,,,,,,,95.42,121.22,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,MedCost,Ultra,,76.04,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,inpatient,1,UN,11554.40000,6932.64000,MedCost,Ultra,,7394.82,,,,,,,3477.87,9393.73,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,MedCost,Ultra,,5892.74,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,inpatient,1,UN,110033.00000,66019.80000,MedCost,Ultra,,70421.12,,,,,,,33119.93,89456.83,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,MedCost,Ultra,,56116.83,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,inpatient,1,UN,2163.00000,1297.80000,MedCost,Ultra,,1384.32,,,,,,,651.06,1758.52,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,MedCost,Ultra,,1103.13,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,10.88,,,,,,,10.88,13.82,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,8.67,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,inpatient,1,UN,42.75000,25.65000,MedCost,Ultra,,27.36,,,,,,,27.36,34.76,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,MedCost,Ultra,,21.80,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,inpatient,5,ML,176.25000,105.75000,MedCost,Ultra,,112.80,,,,,,,112.80,143.29,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,MedCost,Ultra,,89.89,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,inpatient,1,UN,17.90000,10.74000,MedCost,Ultra,,11.46,,,,,,,11.46,14.55,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,MedCost,Ultra,,9.13,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,inpatient,15,ML,61507.80000,36904.68000,MedCost,Ultra,,39364.99,,,,,,,18513.85,50005.84,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,MedCost,Ultra,,31368.98,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,inpatient,10,ML,41095.25000,24657.15000,MedCost,Ultra,,26300.96,,,,,,,12369.67,33410.44,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,MedCost,Ultra,,20958.58,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,inpatient,0.25,ML,65.65000,39.39000,MedCost,Ultra,,42.02,,,,,,,19.76,53.37,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,MedCost,Ultra,,33.48,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,inpatient,100,ML,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,26.49,71.54,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,inpatient,1,UN,6416.85000,3850.11000,MedCost,Ultra,,4106.78,,,,,,,1931.47,5216.90,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,MedCost,Ultra,,3272.59,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,inpatient,1,UN,17822.95000,10693.77000,MedCost,Ultra,,11406.69,,,,,,,5364.71,14490.06,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,MedCost,Ultra,,9089.70,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,inpatient,11,ML,100657.05000,60394.23000,MedCost,Ultra,,64420.51,,,,,,,30297.77,81834.18,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,MedCost,Ultra,,51335.10,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,inpatient,3,ML,27497.75000,16498.65000,MedCost,Ultra,,17598.56,,,,,,,8276.82,22355.67,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,MedCost,Ultra,,14023.85,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,inpatient,1,ML,1019.75000,611.85000,MedCost,Ultra,,652.64,,,,,,,652.64,829.06,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,MedCost,Ultra,,520.07,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,inpatient,1,UN,6743.50000,4046.10000,MedCost,Ultra,,4315.84,,,,,,,2029.79,5482.47,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,MedCost,Ultra,,3439.18,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,inpatient,1,UN,5603.90000,3362.34000,MedCost,Ultra,,3586.50,,,,,,,1686.77,4555.97,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,MedCost,Ultra,,2857.99,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,inpatient,1,UN,9216.70000,5530.02000,MedCost,Ultra,,5898.69,,,,,,,2774.23,7493.18,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,MedCost,Ultra,,4700.52,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,inpatient,1,UN,124890.65000,74934.39000,MedCost,Ultra,,79930.02,,,,,,,37592.09,101536.10,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,MedCost,Ultra,,63694.23,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,inpatient,10,ML,53208.20000,31924.92000,MedCost,Ultra,,34053.25,,,,,,,16015.67,43258.27,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,MedCost,Ultra,,27136.18,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,inpatient,20,ML,20471.00000,12282.60000,MedCost,Ultra,,13101.44,,,,,,,6161.77,16642.92,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,MedCost,Ultra,,10440.21,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,inpatient,7,ML,17024.40000,10214.64000,MedCost,Ultra,,10895.62,,,,,,,5124.34,13840.84,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,MedCost,Ultra,,8682.44,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,11.20,,,,,,,11.20,14.23,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,8.93,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,10.88,,,,,,,10.88,13.82,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,8.67,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,inpatient,30,ML,81.25000,48.75000,MedCost,Ultra,,52.00,,,,,,,52.00,66.06,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,MedCost,Ultra,,41.44,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,inpatient,0.5,ML,869.40000,521.64000,MedCost,Ultra,,556.42,,,,,,,261.69,706.82,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,MedCost,Ultra,,443.39,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,inpatient,1,UN,32838.55000,19703.13000,MedCost,Ultra,,21016.67,,,,,,,9884.40,26697.74,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,MedCost,Ultra,,16747.66,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,inpatient,100,ML,107.45000,64.47000,MedCost,Ultra,,68.77,,,,,,,32.34,87.36,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,MedCost,Ultra,,54.80,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,inpatient,1,UN,413.35000,248.01000,MedCost,Ultra,,264.54,,,,,,,264.54,336.05,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,MedCost,Ultra,,210.81,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,inpatient,1.5,ML,16340.20000,9804.12000,MedCost,Ultra,,10457.73,,,,,,,4918.40,13284.58,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,MedCost,Ultra,,8333.50,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,inpatient,1,UN,36433.75000,21860.25000,MedCost,Ultra,,23317.60,,,,,,,10966.56,29620.64,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,MedCost,Ultra,,18581.21,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,inpatient,1,ML,34.15000,20.49000,MedCost,Ultra,,21.86,,,,,,,21.86,27.76,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,MedCost,Ultra,,17.42,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,inpatient,100,ML,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,82.17,221.95,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,inpatient,1,UN,87.60000,52.56000,MedCost,Ultra,,56.06,,,,,,,26.37,71.22,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,MedCost,Ultra,,44.68,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,MedCost,Ultra,,52.96,,,,,,,24.91,67.28,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,MedCost,Ultra,,42.20,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,MedCost,Ultra,,52.96,,,,,,,24.91,67.28,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,MedCost,Ultra,,42.20,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,inpatient,0.5,ML,739.45000,443.67000,MedCost,Ultra,,473.25,,,,,,,222.57,601.17,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,MedCost,Ultra,,377.12,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,inpatient,0.8,ML,1173.55000,704.13000,MedCost,Ultra,,751.07,,,,,,,353.24,954.10,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,MedCost,Ultra,,598.51,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,inpatient,20,ML,68131.75000,40879.05000,MedCost,Ultra,,43604.32,,,,,,,20507.66,55391.11,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,MedCost,Ultra,,34747.19,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,inpatient,1,UN,76.00000,45.60000,MedCost,Ultra,,48.64,,,,,,,48.64,61.79,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,MedCost,Ultra,,38.76,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,inpatient,4,UN,2626.30000,1575.78000,MedCost,Ultra,,1680.83,,,,,,,1680.83,2135.18,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,MedCost,Ultra,,1339.41,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,inpatient,4,UN,1136.00000,681.60000,MedCost,Ultra,,727.04,,,,,,,727.04,923.57,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,MedCost,Ultra,,579.36,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,inpatient,4,UN,1136.00000,681.60000,MedCost,Ultra,,727.04,,,,,,,727.04,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,MedCost,Ultra,,579.36,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,inpatient,4,UN,2626.30000,1575.78000,MedCost,Ultra,,1680.83,,,,,,,1680.83,2135.18,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,MedCost,Ultra,,1339.41,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,11.26,14.31,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,inpatient,0.5,ML,104.05000,62.43000,MedCost,Ultra,,66.59,,,,,,,31.32,84.59,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,MedCost,Ultra,,53.07,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,inpatient,1.7,ML,46244.25000,27746.55000,MedCost,Ultra,,29596.32,,,,,,,13919.52,37596.58,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,MedCost,Ultra,,23584.57,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,inpatient,3,ML,9288.55000,5573.13000,MedCost,Ultra,,5944.67,,,,,,,2795.85,7551.59,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,MedCost,Ultra,,4737.16,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,inpatient,0.5,ML,520.00000,312.00000,MedCost,Ultra,,332.80,,,,,,,156.52,422.76,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,MedCost,Ultra,,265.20,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,inpatient,20,ML,30117.40000,18070.44000,MedCost,Ultra,,19275.14,,,,,,,9065.34,24485.45,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,MedCost,Ultra,,15359.87,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,inpatient,1,ML,3021.70000,1813.02000,MedCost,Ultra,,1933.89,,,,,,,909.53,2456.64,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,MedCost,Ultra,,1541.07,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,inpatient,30,ML,82676.70000,49606.02000,MedCost,Ultra,,52913.09,,,,,,,24885.69,67216.16,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,MedCost,Ultra,,42165.12,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,inpatient,20,ML,65144.20000,39086.52000,MedCost,Ultra,,41692.29,,,,,,,19608.40,52962.23,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,MedCost,Ultra,,33223.54,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,inpatient,0.28,ML,11967.50000,7180.50000,MedCost,Ultra,,7659.20,,,,,,,3602.22,9729.58,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,MedCost,Ultra,,6103.43,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,inpatient,0.56,ML,23918.10000,14350.86000,MedCost,Ultra,,15307.58,,,,,,,7199.35,19445.42,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,MedCost,Ultra,,12198.23,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,inpatient,0.7,ML,29894.05000,17936.43000,MedCost,Ultra,,19132.19,,,,,,,8998.11,24303.86,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,MedCost,Ultra,,15245.97,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,inpatient,1,UN,68158.20000,40894.92000,MedCost,Ultra,,43621.25,,,,,,,20515.62,55412.62,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,MedCost,Ultra,,34760.68,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,inpatient,1,UN,942.40000,565.44000,MedCost,Ultra,,603.14,,,,,,,283.66,766.17,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,MedCost,Ultra,,480.62,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,inpatient,0.5,ML,2546.40000,1527.84000,MedCost,Ultra,,1629.70,,,,,,,766.47,2070.22,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,MedCost,Ultra,,1298.66,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,inpatient,1,ML,2546.45000,1527.87000,MedCost,Ultra,,1629.73,,,,,,,766.48,2070.26,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,MedCost,Ultra,,1298.69,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,inpatient,0.5,ML,62.50000,37.50000,MedCost,Ultra,,40.00,,,,,,,40.00,50.81,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,MedCost,Ultra,,31.88,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,MedCost,Ultra,,32709.34,,,,,,,15383.61,41551.09,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,MedCost,Ultra,,26065.26,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,inpatient,1.5,ML,4087.55000,2452.53000,MedCost,Ultra,,2616.03,,,,,,,1230.35,3323.18,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,MedCost,Ultra,,2084.65,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,inpatient,30,ML,1475.80000,885.48000,MedCost,Ultra,,944.51,,,,,,,944.51,1199.83,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,MedCost,Ultra,,752.66,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,inpatient,10,ML,208.40000,125.04000,MedCost,Ultra,,133.38,,,,,,,133.38,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,MedCost,Ultra,,106.28,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,inpatient,5,ML,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.30,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,inpatient,1,ML,255.50000,153.30000,MedCost,Ultra,,163.52,,,,,,,76.91,207.72,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,MedCost,Ultra,,130.31,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,inpatient,1,UN,30.90000,18.54000,MedCost,Ultra,,19.78,,,,,,,19.78,25.12,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,MedCost,Ultra,,15.76,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,inpatient,10,ML,106.00000,63.60000,MedCost,Ultra,,67.84,,,,,,,67.84,86.18,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,MedCost,Ultra,,54.06,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,inpatient,30,ML,69.30000,41.58000,MedCost,Ultra,,44.35,,,,,,,44.35,56.34,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,MedCost,Ultra,,35.34,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,inpatient,1,UN,63488.50000,38093.10000,MedCost,Ultra,,40632.64,,,,,,,19110.04,51616.15,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,MedCost,Ultra,,32379.13,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,inpatient,2,ML,234.40000,140.64000,MedCost,Ultra,,150.02,,,,,,,70.55,190.57,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,MedCost,Ultra,,119.54,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,MedCost,Ultra,,12167.84,,,,,,,5722.69,15456.96,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,MedCost,Ultra,,9696.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,inpatient,0.11,ML,352.45000,211.47000,MedCost,Ultra,,225.57,,,,,,,106.09,286.54,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,MedCost,Ultra,,179.75,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,inpatient,36,ML,26733.05000,16039.83000,MedCost,Ultra,,17109.15,,,,,,,8046.65,21733.97,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,MedCost,Ultra,,13633.86,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,10.50,,,,,,,10.50,13.33,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,8.36,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,inpatient,1,UN,10993.10000,6595.86000,MedCost,Ultra,,7035.58,,,,,,,3308.92,8937.39,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,MedCost,Ultra,,5606.48,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,inpatient,1,UN,43783.25000,26269.95000,MedCost,Ultra,,28021.28,,,,,,,13178.76,35595.78,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,MedCost,Ultra,,22329.46,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,inpatient,0.5,ML,883.00000,529.80000,MedCost,Ultra,,565.12,,,,,,,265.78,717.88,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,MedCost,Ultra,,450.33,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,inpatient,20,ML,61242.05000,36745.23000,MedCost,Ultra,,39194.91,,,,,,,18433.86,49789.79,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,MedCost,Ultra,,31233.45,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,inpatient,1,UN,7315.00000,4389.00000,MedCost,Ultra,,4681.60,,,,,,,2201.82,5947.10,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,MedCost,Ultra,,3730.65,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,inpatient,0.5,ML,257.30000,154.38000,MedCost,Ultra,,164.67,,,,,,,77.45,209.18,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,MedCost,Ultra,,131.22,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,inpatient,0.5,ML,81.25000,48.75000,MedCost,Ultra,,52.00,,,,,,,24.46,66.06,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,MedCost,Ultra,,41.44,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,inpatient,0.1,ML,17.05000,10.23000,MedCost,Ultra,,10.91,,,,,,,5.13,13.86,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,MedCost,Ultra,,8.70,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,inpatient,0.1,ML,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,5.09,13.74,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,inpatient,0.1,ML,16.75000,10.05000,MedCost,Ultra,,10.72,,,,,,,5.04,13.62,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,MedCost,Ultra,,8.54,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,inpatient,5,ML,35224.60000,21134.76000,MedCost,Ultra,,22543.74,,,,,,,10602.60,28637.60,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,MedCost,Ultra,,17964.55,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,inpatient,1,UN,21795.75000,13077.45000,MedCost,Ultra,,13949.28,,,,,,,6560.52,17719.94,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,MedCost,Ultra,,11115.83,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,inpatient,1,UN,1.35000,0.81000,MedCost,Ultra,,0.86400,,,,,,,0.86400,1.10,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,MedCost,Ultra,,0.68850,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,inpatient,1,UN,1.30000,0.78000,MedCost,Ultra,,0.83200,,,,,,,0.83200,1.06,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,MedCost,Ultra,,0.66300,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,inpatient,20,ML,364.45000,218.67000,MedCost,Ultra,,233.25,,,,,,,109.70,296.30,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,MedCost,Ultra,,185.87,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,10.40,,,,,,,10.40,13.21,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,8.29,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,MedCost,Ultra,,24171.87,,,,,,,11368.33,30705.83,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,MedCost,Ultra,,19261.96,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,inpatient,0.3,ML,465.10000,279.06000,MedCost,Ultra,,297.66,,,,,,,140.00,378.13,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,MedCost,Ultra,,237.20,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,10.40,,,,,,,10.40,13.21,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,8.29,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,inpatient,1,UN,49.10000,29.46000,MedCost,Ultra,,31.42,,,,,,,31.42,39.92,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,MedCost,Ultra,,25.04,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,inpatient,10,ML,89.15000,53.49000,MedCost,Ultra,,57.06,,,,,,,57.06,72.48,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,MedCost,Ultra,,45.47,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,10.69,13.58,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,10.37,,,,,,,10.37,13.17,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,8.26,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,inpatient,5,ML,73.40000,44.04000,MedCost,Ultra,,46.98,,,,,,,46.98,59.67,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,MedCost,Ultra,,37.43,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,inpatient,1,UN,327.80000,196.68000,MedCost,Ultra,,209.79,,,,,,,98.67,266.50,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,MedCost,Ultra,,167.18,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,inpatient,1,UN,38.45000,23.07000,MedCost,Ultra,,24.61,,,,,,,24.61,31.26,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,MedCost,Ultra,,19.61,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,inpatient,1,UN,23.45000,14.07000,MedCost,Ultra,,15.01,,,,,,,15.01,19.06,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,MedCost,Ultra,,11.96,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,inpatient,1,UN,27.25000,16.35000,MedCost,Ultra,,17.44,,,,,,,17.44,22.15,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,MedCost,Ultra,,13.90,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,inpatient,1,UN,32.20000,19.32000,MedCost,Ultra,,20.61,,,,,,,20.61,26.18,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,MedCost,Ultra,,16.42,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,inpatient,1,UN,2.95000,1.77000,MedCost,Ultra,,1.89,,,,,,,1.89,2.40,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,MedCost,Ultra,,1.50,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,inpatient,5,ML,192.90000,115.74000,MedCost,Ultra,,123.46,,,,,,,58.06,156.83,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,MedCost,Ultra,,98.38,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,inpatient,10,GR,11.10000,6.66000,MedCost,Ultra,,7.10,,,,,,,7.10,9.02,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,MedCost,Ultra,,5.66,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,inpatient,1,UN,19.55000,11.73000,MedCost,Ultra,,12.51,,,,,,,12.51,15.89,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,MedCost,Ultra,,9.97,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,10.40,,,,,,,10.40,13.21,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,8.29,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,inpatient,1,UN,94.25000,56.55000,MedCost,Ultra,,60.32,,,,,,,28.37,76.63,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,MedCost,Ultra,,48.07,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.70,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,11.04,,,,,,,11.04,14.02,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,8.80,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,inpatient,1,UN,27.20000,16.32000,MedCost,Ultra,,17.41,,,,,,,17.41,22.11,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,MedCost,Ultra,,13.87,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,11.26,14.31,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,inpatient,1,UN,26.20000,15.72000,MedCost,Ultra,,16.77,,,,,,,16.77,21.30,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,MedCost,Ultra,,13.36,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,11.71,,,,,,,11.71,14.88,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,9.33,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,11.01,,,,,,,11.01,13.98,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,8.77,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,inpatient,1,UN,17.90000,10.74000,MedCost,Ultra,,11.46,,,,,,,11.46,14.55,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,MedCost,Ultra,,9.13,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,inpatient,0.5,ML,91.05000,54.63000,MedCost,Ultra,,58.27,,,,,,,27.41,74.02,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,MedCost,Ultra,,46.44,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,inpatient,1,UN,1399.95000,839.97000,MedCost,Ultra,,895.97,,,,,,,421.38,1138.16,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,MedCost,Ultra,,713.97,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,10.91,,,,,,,10.91,13.86,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,8.70,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,11.90,,,,,,,11.90,15.12,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,9.49,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,inpatient,10,ML,4408.90000,2645.34000,MedCost,Ultra,,2821.70,,,,,,,1327.08,3584.44,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,MedCost,Ultra,,2248.54,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,50,ML,20944.45000,12566.67000,MedCost,Ultra,,13404.45,,,,,,,6304.28,17027.84,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,MedCost,Ultra,,10681.67,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,inpatient,1,UN,67.95000,40.77000,MedCost,Ultra,,43.49,,,,,,,43.49,55.24,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,MedCost,Ultra,,34.65,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,inpatient,1.5,ML,6363.00000,3817.80000,MedCost,Ultra,,4072.32,,,,,,,1915.26,5173.12,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,MedCost,Ultra,,3245.13,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,inpatient,5,ML,83.90000,50.34000,MedCost,Ultra,,53.70,,,,,,,53.70,68.21,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,MedCost,Ultra,,42.79,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,inpatient,1,UN,18.70000,11.22000,MedCost,Ultra,,11.97,,,,,,,11.97,15.20,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,MedCost,Ultra,,9.54,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,inpatient,100,ML,197.80000,118.68000,MedCost,Ultra,,126.59,,,,,,,126.59,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,MedCost,Ultra,,100.88,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,inpatient,60,ML,46.10000,27.66000,MedCost,Ultra,,29.50,,,,,,,29.50,37.48,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,MedCost,Ultra,,23.51,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,MedCost,Ultra,,29.28,,,,,,,13.77,37.19,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,MedCost,Ultra,,23.33,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,inpatient,1,UN,17.35000,10.41000,MedCost,Ultra,,11.10,,,,,,,11.10,14.11,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,MedCost,Ultra,,8.85,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,12.67,,,,,,,12.67,16.10,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,10.10,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,inpatient,0.5,ML,4182.45000,2509.47000,MedCost,Ultra,,2676.77,,,,,,,1258.92,3400.33,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,MedCost,Ultra,,2133.05,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,inpatient,20,ML,81.55000,48.93000,MedCost,Ultra,,52.19,,,,,,,52.19,66.30,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,MedCost,Ultra,,41.59,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,inpatient,1,UN,18.80000,11.28000,MedCost,Ultra,,12.03,,,,,,,12.03,15.28,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,MedCost,Ultra,,9.59,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,inpatient,1,ML,126.65000,75.99000,MedCost,Ultra,,81.06,,,,,,,38.12,102.97,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,MedCost,Ultra,,64.59,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,inpatient,100,ML,472.90000,283.74000,MedCost,Ultra,,302.66,,,,,,,302.66,384.47,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,MedCost,Ultra,,241.18,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,inpatient,222,ML,9.65000,5.79000,MedCost,Ultra,,6.18,,,,,,,6.18,7.85,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,MedCost,Ultra,,4.92,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,13.06,,,,,,,13.06,16.59,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,10.40,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,inpatient,100,ML,1113.00000,667.80000,MedCost,Ultra,,712.32,,,,,,,335.01,904.87,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,MedCost,Ultra,,567.63,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,inpatient,500,ML,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,19.26,52.03,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,5.03,13.58,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,5.30,14.31,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,inpatient,1,UN,20.05000,12.03000,MedCost,Ultra,,12.83,,,,,,,6.04,16.30,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,MedCost,Ultra,,10.23,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,inpatient,5,ML,24.90000,14.94000,MedCost,Ultra,,15.94,,,,,,,7.49,20.24,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,MedCost,Ultra,,12.70,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,inpatient,5,ML,177.70000,106.62000,MedCost,Ultra,,113.73,,,,,,,113.73,144.47,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,MedCost,Ultra,,90.63,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,inpatient,5,GR,11.85000,7.11000,MedCost,Ultra,,7.58,,,,,,,7.58,9.63,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,MedCost,Ultra,,6.04,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,inpatient,1000,ML,87.00000,52.20000,MedCost,Ultra,,55.68,,,,,,,55.68,70.47,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,MedCost,Ultra,,44.37,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,inpatient,250,ML,81.75000,49.05000,MedCost,Ultra,,52.32,,,,,,,52.32,66.22,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,MedCost,Ultra,,41.69,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,inpatient,500,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,inpatient,500,ML,106.50000,63.90000,MedCost,Ultra,,68.16,,,,,,,68.16,86.27,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,MedCost,Ultra,,54.31,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,inpatient,10,ML,109.70000,65.82000,MedCost,Ultra,,70.21,,,,,,,70.21,89.19,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,MedCost,Ultra,,55.95,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,inpatient,1,UN,654.25000,392.55000,MedCost,Ultra,,418.72,,,,,,,196.93,531.91,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,MedCost,Ultra,,333.67,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,inpatient,100,ML,71.10000,42.66000,MedCost,Ultra,,45.50,,,,,,,45.50,57.59,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,MedCost,Ultra,,36.26,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,inpatient,25,ML,71.70000,43.02000,MedCost,Ultra,,45.89,,,,,,,45.89,58.08,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,MedCost,Ultra,,36.57,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,50.40,,,,,,,50.40,63.79,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,40.16,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,inpatient,50,ML,71.25000,42.75000,MedCost,Ultra,,45.60,,,,,,,45.60,57.71,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,MedCost,Ultra,,36.34,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,inpatient,500,ML,76.50000,45.90000,MedCost,Ultra,,48.96,,,,,,,48.96,61.97,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,MedCost,Ultra,,39.02,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,inpatient,50,ML,39.70000,23.82000,MedCost,Ultra,,25.41,,,,,,,25.41,32.16,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,MedCost,Ultra,,20.25,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,inpatient,500,ML,78.00000,46.80000,MedCost,Ultra,,49.92,,,,,,,49.92,63.18,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,MedCost,Ultra,,39.78,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,inpatient,1,UN,2058.00000,1234.80000,MedCost,Ultra,,1317.12,,,,,,,619.46,1673.15,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,MedCost,Ultra,,1049.58,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,13.06,,,,,,,13.06,16.59,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,10.40,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,13.06,,,,,,,13.06,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,10.40,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,inpatient,1,UN,516.55000,309.93000,MedCost,Ultra,,330.59,,,,,,,155.48,419.96,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,MedCost,Ultra,,263.44,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,inpatient,1,UN,22.25000,13.35000,MedCost,Ultra,,14.24,,,,,,,14.24,18.09,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,MedCost,Ultra,,11.35,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,inpatient,1,UN,22.25000,13.35000,MedCost,Ultra,,14.24,,,,,,,14.24,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,MedCost,Ultra,,11.35,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,inpatient,20,ML,53.90000,32.34000,MedCost,Ultra,,34.50,,,,,,,34.50,43.82,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,MedCost,Ultra,,27.49,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,inpatient,28,GR,8.60000,5.16000,MedCost,Ultra,,5.50,,,,,,,5.50,6.99,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,MedCost,Ultra,,4.39,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,inpatient,1,UN,18.75000,11.25000,MedCost,Ultra,,12.00,,,,,,,12.00,15.24,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,MedCost,Ultra,,9.56,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,inpatient,1,UN,142.10000,85.26000,MedCost,Ultra,,90.94,,,,,,,90.94,115.53,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,MedCost,Ultra,,72.47,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,inpatient,1,UN,16.65000,9.99000,MedCost,Ultra,,10.66,,,,,,,10.66,13.54,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,MedCost,Ultra,,8.49,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,inpatient,15,ML,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,inpatient,10,ML,422.40000,253.44000,MedCost,Ultra,,270.34,,,,,,,270.34,343.41,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,MedCost,Ultra,,215.42,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,10.69,13.58,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,inpatient,1,UN,50.70000,30.42000,MedCost,Ultra,,32.45,,,,,,,32.45,41.22,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,MedCost,Ultra,,25.86,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,inpatient,1,UN,88.65000,53.19000,MedCost,Ultra,,56.74,,,,,,,56.74,72.07,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,MedCost,Ultra,,45.21,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,inpatient,1,UN,21.40000,12.84000,MedCost,Ultra,,13.70,,,,,,,13.70,17.40,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,MedCost,Ultra,,10.91,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,11.20,,,,,,,11.20,14.23,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,8.93,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,inpatient,1,UN,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.51,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,inpatient,1,UN,17.55000,10.53000,MedCost,Ultra,,11.23,,,,,,,11.23,14.27,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,MedCost,Ultra,,8.95,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,inpatient,1,UN,90.95000,54.57000,MedCost,Ultra,,58.21,,,,,,,58.21,73.94,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,MedCost,Ultra,,46.38,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,inpatient,1,UN,21.25000,12.75000,MedCost,Ultra,,13.60,,,,,,,13.60,17.28,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,MedCost,Ultra,,10.84,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,11.20,,,,,,,11.20,14.23,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,8.93,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,inpatient,1,UN,1.90000,1.14000,MedCost,Ultra,,1.22,,,,,,,1.22,1.54,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,MedCost,Ultra,,0.96900,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,inpatient,1,UN,23.95000,14.37000,MedCost,Ultra,,15.33,,,,,,,7.21,19.47,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,MedCost,Ultra,,12.21,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,inpatient,3,ML,22.40000,13.44000,MedCost,Ultra,,14.34,,,,,,,14.34,18.21,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,MedCost,Ultra,,11.42,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,inpatient,5,ML,196.60000,117.96000,MedCost,Ultra,,125.82,,,,,,,59.18,159.84,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,MedCost,Ultra,,100.27,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,inpatient,3,ML,17.00000,10.20000,MedCost,Ultra,,10.88,,,,,,,10.88,13.82,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,MedCost,Ultra,,8.67,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,inpatient,1.25,ML,48.40000,29.04000,MedCost,Ultra,,30.98,,,,,,,14.57,39.35,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,MedCost,Ultra,,24.68,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,inpatient,1,ML,29.70000,17.82000,MedCost,Ultra,,19.01,,,,,,,8.94,24.15,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,MedCost,Ultra,,15.15,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,inpatient,5,ML,7.50000,4.50000,MedCost,Ultra,,4.80,,,,,,,4.80,6.10,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,MedCost,Ultra,,3.83,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,11.04,,,,,,,11.04,14.02,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,8.80,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,10.75,13.66,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,inpatient,1,UN,20.75000,12.45000,MedCost,Ultra,,13.28,,,,,,,13.28,16.87,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,MedCost,Ultra,,10.58,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,inpatient,50,ML,81.40000,48.84000,MedCost,Ultra,,52.10,,,,,,,24.50,66.18,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,MedCost,Ultra,,41.51,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,inpatient,1,UN,3.35000,2.01000,MedCost,Ultra,,2.14,,,,,,,2.14,2.72,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,MedCost,Ultra,,1.71,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,inpatient,10,ML,14.40000,8.64000,MedCost,Ultra,,9.22,,,,,,,9.22,11.71,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,MedCost,Ultra,,7.34,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,10.43,,,,,,,10.43,13.25,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,8.31,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,10.85,,,,,,,10.85,13.78,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,8.64,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,inpatient,1,UN,22.50000,13.50000,MedCost,Ultra,,14.40,,,,,,,14.40,18.29,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,MedCost,Ultra,,11.47,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,inpatient,1,UN,1.30000,0.78000,MedCost,Ultra,,0.83200,,,,,,,0.83200,1.06,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,MedCost,Ultra,,0.66300,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,inpatient,1,UN,32.60000,19.56000,MedCost,Ultra,,20.86,,,,,,,20.86,26.50,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,MedCost,Ultra,,16.63,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,inpatient,5,ML,79.85000,47.91000,MedCost,Ultra,,51.10,,,,,,,24.03,64.92,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,MedCost,Ultra,,40.72,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,inpatient,1,UN,22.90000,13.74000,MedCost,Ultra,,14.66,,,,,,,14.66,18.62,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,MedCost,Ultra,,11.68,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,inpatient,1,UN,18.15000,10.89000,MedCost,Ultra,,11.62,,,,,,,11.62,14.76,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,MedCost,Ultra,,9.26,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,inpatient,1,UN,18.85000,11.31000,MedCost,Ultra,,12.06,,,,,,,12.06,15.33,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,MedCost,Ultra,,9.61,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,inpatient,1,UN,19.90000,11.94000,MedCost,Ultra,,12.74,,,,,,,12.74,16.18,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,MedCost,Ultra,,10.15,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,inpatient,1,UN,164.50000,98.70000,MedCost,Ultra,,105.28,,,,,,,49.51,133.74,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,MedCost,Ultra,,83.89,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,inpatient,1,UN,16.45000,9.87000,MedCost,Ultra,,10.53,,,,,,,10.53,13.37,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,MedCost,Ultra,,8.39,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,11.01,,,,,,,11.01,13.98,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,8.77,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,inpatient,1,UN,84.35000,50.61000,MedCost,Ultra,,53.98,,,,,,,25.39,68.58,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,MedCost,Ultra,,43.02,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,inpatient,1,UN,31.35000,18.81000,MedCost,Ultra,,20.06,,,,,,,20.06,25.49,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,MedCost,Ultra,,15.99,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,inpatient,1,UN,7346.35000,4407.81000,MedCost,Ultra,,4701.66,,,,,,,2211.25,5972.58,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,MedCost,Ultra,,3746.64,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,inpatient,0.5,ML,28.10000,16.86000,MedCost,Ultra,,17.98,,,,,,,8.46,22.85,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,MedCost,Ultra,,14.33,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,inpatient,1,UN,76.80000,46.08000,MedCost,Ultra,,49.15,,,,,,,49.15,62.44,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,MedCost,Ultra,,39.17,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,inpatient,1,UN,31.70000,19.02000,MedCost,Ultra,,20.29,,,,,,,20.29,25.77,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,MedCost,Ultra,,16.17,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,10.88,,,,,,,10.88,13.82,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,8.67,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,10.78,,,,,,,10.78,13.70,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,8.59,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,inpatient,1.5,ML,2741.30000,1644.78000,MedCost,Ultra,,1754.43,,,,,,,1754.43,2228.68,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,MedCost,Ultra,,1398.06,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,inpatient,2,ML,88.20000,52.92000,MedCost,Ultra,,56.45,,,,,,,56.45,71.71,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,MedCost,Ultra,,44.98,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,inpatient,0.3,ML,39.90000,23.94000,MedCost,Ultra,,25.54,,,,,,,12.01,32.44,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,MedCost,Ultra,,20.35,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,inpatient,1,UN,26.35000,15.81000,MedCost,Ultra,,16.86,,,,,,,16.86,21.42,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,MedCost,Ultra,,13.44,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,inpatient,10,ML,97.15000,58.29000,MedCost,Ultra,,62.18,,,,,,,29.24,78.98,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,MedCost,Ultra,,49.55,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,inpatient,20,ML,101.60000,60.96000,MedCost,Ultra,,65.02,,,,,,,30.58,82.60,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,MedCost,Ultra,,51.82,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,inpatient,50,ML,147.00000,88.20000,MedCost,Ultra,,94.08,,,,,,,44.25,119.51,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,MedCost,Ultra,,74.97,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,inpatient,0.5,ML,25.85000,15.51000,MedCost,Ultra,,16.54,,,,,,,7.78,21.02,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,MedCost,Ultra,,13.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,inpatient,20,ML,1179.50000,707.70000,MedCost,Ultra,,754.88,,,,,,,355.03,958.93,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,MedCost,Ultra,,601.54,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,inpatient,10,ML,2255.00000,1353.00000,MedCost,Ultra,,1443.20,,,,,,,678.75,1833.32,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,MedCost,Ultra,,1150.05,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,inpatient,25,ML,5775.00000,3465.00000,MedCost,Ultra,,3696.00,,,,,,,1738.28,4695.07,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,MedCost,Ultra,,2945.25,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,inpatient,37.5,GR,5.90000,3.54000,MedCost,Ultra,,3.78,,,,,,,3.78,4.80,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,MedCost,Ultra,,3.01,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,inpatient,1,UN,2216.75000,1330.05000,MedCost,Ultra,,1418.72,,,,,,,1418.72,1802.22,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,MedCost,Ultra,,1130.54,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,inpatient,1,UN,18.85000,11.31000,MedCost,Ultra,,12.06,,,,,,,12.06,15.33,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,MedCost,Ultra,,9.61,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,inpatient,1,UN,228.00000,136.80000,MedCost,Ultra,,145.92,,,,,,,145.92,185.36,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,MedCost,Ultra,,116.28,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,12.35,,,,,,,12.35,15.69,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,9.84,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,inpatient,1,UN,20.15000,12.09000,MedCost,Ultra,,12.90,,,,,,,12.90,16.38,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,MedCost,Ultra,,10.28,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,inpatient,1,UN,263.60000,158.16000,MedCost,Ultra,,168.70,,,,,,,168.70,214.31,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,MedCost,Ultra,,134.44,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,inpatient,1,UN,21.20000,12.72000,MedCost,Ultra,,13.57,,,,,,,13.57,17.24,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,MedCost,Ultra,,10.81,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,inpatient,1,UN,19.40000,11.64000,MedCost,Ultra,,12.42,,,,,,,12.42,15.77,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,MedCost,Ultra,,9.89,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,inpatient,1,UN,23.10000,13.86000,MedCost,Ultra,,14.78,,,,,,,14.78,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,MedCost,Ultra,,11.78,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,inpatient,1,UN,22.65000,13.59000,MedCost,Ultra,,14.50,,,,,,,14.50,18.41,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,MedCost,Ultra,,11.55,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,12.80,,,,,,,12.80,16.26,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,10.20,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,inpatient,1,UN,25.90000,15.54000,MedCost,Ultra,,16.58,,,,,,,16.58,21.06,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,MedCost,Ultra,,13.21,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,inpatient,1,UN,101.20000,60.72000,MedCost,Ultra,,64.77,,,,,,,64.77,82.28,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,MedCost,Ultra,,51.61,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,inpatient,5,ML,607.05000,364.23000,MedCost,Ultra,,388.51,,,,,,,388.51,493.53,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,MedCost,Ultra,,309.60,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,inpatient,2000,ML,180.85000,108.51000,MedCost,Ultra,,115.74,,,,,,,54.44,147.03,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,MedCost,Ultra,,92.23,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,inpatient,2000,ML,180.85000,108.51000,MedCost,Ultra,,115.74,,,,,,,54.44,147.03,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,MedCost,Ultra,,92.23,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,inpatient,2000,ML,194.50000,116.70000,MedCost,Ultra,,124.48,,,,,,,58.54,158.13,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,MedCost,Ultra,,99.19,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,inpatient,2000,ML,195.65000,117.39000,MedCost,Ultra,,125.22,,,,,,,58.89,159.06,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,MedCost,Ultra,,99.78,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1000,ML,78.00000,46.80000,MedCost,Ultra,,49.92,,,,,,,49.92,63.18,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,MedCost,Ultra,,39.78,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,11.42,14.51,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,inpatient,1,UN,3.70000,2.22000,MedCost,Ultra,,2.37,,,,,,,2.37,3.01,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,MedCost,Ultra,,1.89,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,inpatient,1,UN,3.70000,2.22000,MedCost,Ultra,,2.37,,,,,,,2.37,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,MedCost,Ultra,,1.89,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,inpatient,1,UN,3.90000,2.34000,MedCost,Ultra,,2.50,,,,,,,2.50,3.17,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,MedCost,Ultra,,1.99,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,inpatient,1,UN,35.65000,21.39000,MedCost,Ultra,,22.82,,,,,,,22.82,28.98,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,MedCost,Ultra,,18.18,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,inpatient,1,UN,43.40000,26.04000,MedCost,Ultra,,27.78,,,,,,,27.78,35.28,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,MedCost,Ultra,,22.13,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,inpatient,1,UN,60.00000,36.00000,MedCost,Ultra,,38.40,,,,,,,38.40,48.78,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,MedCost,Ultra,,30.60,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,inpatient,1,UN,82.10000,49.26000,MedCost,Ultra,,52.54,,,,,,,52.54,66.75,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,MedCost,Ultra,,41.87,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,inpatient,1,UN,104.70000,62.82000,MedCost,Ultra,,67.01,,,,,,,67.01,85.12,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,MedCost,Ultra,,53.40,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,inpatient,1000,ML,220.75000,132.45000,MedCost,Ultra,,141.28,,,,,,,141.28,179.47,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,MedCost,Ultra,,112.58,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,inpatient,15,ML,13.40000,8.04000,MedCost,Ultra,,8.58,,,,,,,8.58,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,MedCost,Ultra,,6.83,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.92800,,,,,,,0.92800,1.18,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.73950,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,inpatient,1,UN,1011.80000,607.08000,MedCost,Ultra,,647.55,,,,,,,647.55,822.59,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,MedCost,Ultra,,516.02,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,inpatient,56,GR,8.05000,4.83000,MedCost,Ultra,,5.15,,,,,,,5.15,6.54,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,MedCost,Ultra,,4.11,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,inpatient,1000,ML,114.00000,68.40000,MedCost,Ultra,,72.96,,,,,,,72.96,92.68,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,MedCost,Ultra,,58.14,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,inpatient,1,UN,23.15000,13.89000,MedCost,Ultra,,14.82,,,,,,,14.82,18.82,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,MedCost,Ultra,,11.81,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,inpatient,1,UN,26.50000,15.90000,MedCost,Ultra,,16.96,,,,,,,16.96,21.54,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,MedCost,Ultra,,13.52,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,inpatient,1,UN,30.00000,18.00000,MedCost,Ultra,,19.20,,,,,,,19.20,24.39,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,MedCost,Ultra,,15.30,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,inpatient,150,ML,752.65000,451.59000,MedCost,Ultra,,481.70,,,,,,,481.70,611.90,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,MedCost,Ultra,,383.85,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,inpatient,1,UN,18.35000,11.01000,MedCost,Ultra,,11.74,,,,,,,11.74,14.92,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,MedCost,Ultra,,9.36,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,inpatient,10,ML,308.40000,185.04000,MedCost,Ultra,,197.38,,,,,,,92.83,250.73,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,MedCost,Ultra,,157.28,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,inpatient,1,UN,24.10000,14.46000,MedCost,Ultra,,15.42,,,,,,,15.42,19.59,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,MedCost,Ultra,,12.29,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,inpatient,1000,ML,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,inpatient,2000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.85,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,inpatient,1,UN,92.30000,55.38000,MedCost,Ultra,,59.07,,,,,,,59.07,75.04,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,MedCost,Ultra,,47.07,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,inpatient,1,UN,90.30000,54.18000,MedCost,Ultra,,57.79,,,,,,,57.79,73.41,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,MedCost,Ultra,,46.05,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,0.1,ML,22.85000,13.71000,MedCost,Ultra,,14.62,,,,,,,6.88,18.58,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,MedCost,Ultra,,11.65,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,inpatient,1,UN,20.30000,12.18000,MedCost,Ultra,,12.99,,,,,,,12.99,16.50,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,MedCost,Ultra,,10.35,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,inpatient,1,UN,18.10000,10.86000,MedCost,Ultra,,11.58,,,,,,,11.58,14.72,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,MedCost,Ultra,,9.23,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,inpatient,2,ML,46.15000,27.69000,MedCost,Ultra,,29.54,,,,,,,29.54,37.52,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,MedCost,Ultra,,23.54,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,inpatient,2,ML,51.50000,30.90000,MedCost,Ultra,,32.96,,,,,,,32.96,41.87,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,MedCost,Ultra,,26.27,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,inpatient,10,ML,267.70000,160.62000,MedCost,Ultra,,171.33,,,,,,,171.33,217.64,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,MedCost,Ultra,,136.53,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,inpatient,1,UN,27.90000,16.74000,MedCost,Ultra,,17.86,,,,,,,8.40,22.68,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,MedCost,Ultra,,14.23,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,inpatient,1,UN,63.15000,37.89000,MedCost,Ultra,,40.42,,,,,,,19.01,51.34,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,MedCost,Ultra,,32.21,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,inpatient,10,GR,599.15000,359.49000,MedCost,Ultra,,383.46,,,,,,,383.46,487.11,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,MedCost,Ultra,,305.57,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,inpatient,1,GR,37.75000,22.65000,MedCost,Ultra,,24.16,,,,,,,24.16,30.69,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,MedCost,Ultra,,19.25,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,inpatient,1,UN,62.45000,37.47000,MedCost,Ultra,,39.97,,,,,,,39.97,50.77,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,MedCost,Ultra,,31.85,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,inpatient,1,UN,3520.00000,2112.00000,MedCost,Ultra,,2252.80,,,,,,,1059.52,2861.76,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,MedCost,Ultra,,1795.20,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,inpatient,160,ML,1552.00000,931.20000,MedCost,Ultra,,993.28,,,,,,,993.28,1261.78,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,MedCost,Ultra,,791.52,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,inpatient,2.5,ML,1204.10000,722.46000,MedCost,Ultra,,770.62,,,,,,,362.43,978.93,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,MedCost,Ultra,,614.09,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,11.39,,,,,,,11.39,14.47,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,9.08,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,inpatient,1,UN,216.00000,129.60000,MedCost,Ultra,,138.24,,,,,,,138.24,175.61,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,MedCost,Ultra,,110.16,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,inpatient,5,ML,115.25000,69.15000,MedCost,Ultra,,73.76,,,,,,,73.76,93.70,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,MedCost,Ultra,,58.78,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,inpatient,1,UN,523.95000,314.37000,MedCost,Ultra,,335.33,,,,,,,157.71,425.97,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,MedCost,Ultra,,267.21,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,inpatient,1,UN,698.50000,419.10000,MedCost,Ultra,,447.04,,,,,,,210.25,567.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,MedCost,Ultra,,356.24,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,inpatient,10,ML,1199.00000,719.40000,MedCost,Ultra,,767.36,,,,,,,360.90,974.79,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,MedCost,Ultra,,611.49,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,inpatient,5,ML,335.80000,201.48000,MedCost,Ultra,,214.91,,,,,,,101.08,273.01,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,MedCost,Ultra,,171.26,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,inpatient,473,ML,349.50000,209.70000,MedCost,Ultra,,223.68,,,,,,,223.68,284.14,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,MedCost,Ultra,,178.25,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,inpatient,1,UN,19.10000,11.46000,MedCost,Ultra,,12.22,,,,,,,12.22,15.53,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,MedCost,Ultra,,9.74,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,inpatient,1,UN,19.25000,11.55000,MedCost,Ultra,,12.32,,,,,,,12.32,15.65,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,MedCost,Ultra,,9.82,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,inpatient,1,UN,21.35000,12.81000,MedCost,Ultra,,13.66,,,,,,,13.66,17.36,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,MedCost,Ultra,,10.89,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,inpatient,2,GR,28.45000,17.07000,MedCost,Ultra,,18.21,,,,,,,18.21,23.13,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,MedCost,Ultra,,14.51,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,inpatient,5,ML,19.30000,11.58000,MedCost,Ultra,,12.35,,,,,,,5.81,15.69,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,MedCost,Ultra,,9.84,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,inpatient,1,UN,12869.00000,7721.40000,MedCost,Ultra,,8236.16,,,,,,,3873.57,10462.50,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,MedCost,Ultra,,6563.19,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,inpatient,1,ML,52.40000,31.44000,MedCost,Ultra,,33.54,,,,,,,15.77,42.60,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,MedCost,Ultra,,26.72,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,inpatient,1,UN,357.25000,214.35000,MedCost,Ultra,,228.64,,,,,,,107.53,290.44,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,MedCost,Ultra,,182.20,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,inpatient,15,GR,66.60000,39.96000,MedCost,Ultra,,42.62,,,,,,,42.62,54.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,MedCost,Ultra,,33.97,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,inpatient,1,UN,17.75000,10.65000,MedCost,Ultra,,11.36,,,,,,,11.36,14.43,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,MedCost,Ultra,,9.05,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,inpatient,44,ML,2.45000,1.47000,MedCost,Ultra,,1.57,,,,,,,1.57,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,MedCost,Ultra,,1.25,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,inpatient,88,ML,4.45000,2.67000,MedCost,Ultra,,2.85,,,,,,,2.85,3.62,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,MedCost,Ultra,,2.27,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,inpatient,1,UN,21.35000,12.81000,MedCost,Ultra,,13.66,,,,,,,13.66,17.36,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,MedCost,Ultra,,10.89,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,inpatient,1,UN,27.10000,16.26000,MedCost,Ultra,,17.34,,,,,,,17.34,22.03,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,MedCost,Ultra,,13.82,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,inpatient,250,ML,693.00000,415.80000,MedCost,Ultra,,443.52,,,,,,,208.59,563.41,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,MedCost,Ultra,,353.43,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,inpatient,1,UN,19.50000,11.70000,MedCost,Ultra,,12.48,,,,,,,12.48,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,MedCost,Ultra,,9.95,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,10.91,,,,,,,10.91,13.86,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,8.70,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,inpatient,1,UN,19.50000,11.70000,MedCost,Ultra,,12.48,,,,,,,12.48,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,MedCost,Ultra,,9.95,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,inpatient,1,UN,21.60000,12.96000,MedCost,Ultra,,13.82,,,,,,,13.82,17.56,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,MedCost,Ultra,,11.02,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,inpatient,1,UN,83.10000,49.86000,MedCost,Ultra,,53.18,,,,,,,25.01,67.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,MedCost,Ultra,,42.38,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,inpatient,1,UN,369.65000,221.79000,MedCost,Ultra,,236.58,,,,,,,236.58,300.53,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,MedCost,Ultra,,188.52,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,inpatient,1000,ML,420.00000,252.00000,MedCost,Ultra,,268.80,,,,,,,268.80,341.46,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,MedCost,Ultra,,214.20,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,inpatient,1,ML,28.65000,17.19000,MedCost,Ultra,,18.34,,,,,,,8.62,23.29,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,MedCost,Ultra,,14.61,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,inpatient,10,ML,42.40000,25.44000,MedCost,Ultra,,27.14,,,,,,,12.76,34.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,MedCost,Ultra,,21.62,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,inpatient,2,ML,28.40000,17.04000,MedCost,Ultra,,18.18,,,,,,,8.55,23.09,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,MedCost,Ultra,,14.48,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,inpatient,20,ML,53.45000,32.07000,MedCost,Ultra,,34.21,,,,,,,16.09,43.45,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,MedCost,Ultra,,27.26,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,inpatient,5,ML,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,9.33,25.20,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,inpatient,5,ML,25.95000,15.57000,MedCost,Ultra,,16.61,,,,,,,16.61,21.10,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,MedCost,Ultra,,13.23,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,inpatient,1,UN,1.75000,1.05000,MedCost,Ultra,,1.12,,,,,,,1.12,1.42,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,MedCost,Ultra,,0.89250,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,inpatient,100,ML,119.90000,71.94000,MedCost,Ultra,,76.74,,,,,,,76.74,97.48,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,MedCost,Ultra,,61.15,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,inpatient,5,ML,6.30000,3.78000,MedCost,Ultra,,4.03,,,,,,,4.03,5.12,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,MedCost,Ultra,,3.21,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,inpatient,150,ML,94.00000,56.40000,MedCost,Ultra,,60.16,,,,,,,28.29,76.42,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,MedCost,Ultra,,47.94,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,inpatient,100,ML,86.50000,51.90000,MedCost,Ultra,,55.36,,,,,,,55.36,70.32,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,MedCost,Ultra,,44.12,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,11.07,,,,,,,11.07,14.06,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,8.82,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,inpatient,16.7,ML,465.05000,279.03000,MedCost,Ultra,,297.63,,,,,,,139.98,378.09,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,MedCost,Ultra,,237.18,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,inpatient,5,ML,319.00000,191.40000,MedCost,Ultra,,204.16,,,,,,,96.02,259.35,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,MedCost,Ultra,,162.69,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,inpatient,50,ML,843.95000,506.37000,MedCost,Ultra,,540.13,,,,,,,254.03,686.13,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,MedCost,Ultra,,430.41,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,inpatient,5,ML,20.50000,12.30000,MedCost,Ultra,,13.12,,,,,,,13.12,16.67,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,MedCost,Ultra,,10.46,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,11.14,,,,,,,11.14,14.15,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,8.87,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,11.42,14.51,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,inpatient,2,ML,265.05000,159.03000,MedCost,Ultra,,169.63,,,,,,,169.63,215.49,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,MedCost,Ultra,,135.18,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,inpatient,1,UN,858.55000,515.13000,MedCost,Ultra,,549.47,,,,,,,258.42,698.00,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,MedCost,Ultra,,437.86,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,inpatient,1,UN,19973.00000,11983.80000,MedCost,Ultra,,12782.72,,,,,,,6011.87,16238.05,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,MedCost,Ultra,,10186.23,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,inpatient,1,UN,33.80000,20.28000,MedCost,Ultra,,21.63,,,,,,,21.63,27.48,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,MedCost,Ultra,,17.24,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,inpatient,3,ML,21.35000,12.81000,MedCost,Ultra,,13.66,,,,,,,13.66,17.36,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,MedCost,Ultra,,10.89,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,inpatient,3,ML,21.35000,12.81000,MedCost,Ultra,,13.66,,,,,,,13.66,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,MedCost,Ultra,,10.89,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,inpatient,1,UN,183.15000,109.89000,MedCost,Ultra,,117.22,,,,,,,117.22,148.90,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,MedCost,Ultra,,93.41,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,inpatient,60,ML,116.30000,69.78000,MedCost,Ultra,,74.43,,,,,,,74.43,94.55,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,MedCost,Ultra,,59.31,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,inpatient,1,UN,29.90000,17.94000,MedCost,Ultra,,19.14,,,,,,,19.14,24.31,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,MedCost,Ultra,,15.25,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,inpatient,15,GR,125.35000,75.21000,MedCost,Ultra,,80.22,,,,,,,80.22,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,MedCost,Ultra,,63.93,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,inpatient,15,GR,71.50000,42.90000,MedCost,Ultra,,45.76,,,,,,,45.76,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,MedCost,Ultra,,36.47,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,inpatient,60,ML,190.10000,114.06000,MedCost,Ultra,,121.66,,,,,,,121.66,154.55,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,MedCost,Ultra,,96.95,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,inpatient,1,ML,84.55000,50.73000,MedCost,Ultra,,54.11,,,,,,,25.45,68.74,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,MedCost,Ultra,,43.12,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,inpatient,5,ML,521.30000,312.78000,MedCost,Ultra,,333.63,,,,,,,333.63,423.82,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,MedCost,Ultra,,265.86,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,inpatient,0.5,ML,59.70000,35.82000,MedCost,Ultra,,38.21,,,,,,,17.97,48.54,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,MedCost,Ultra,,30.45,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,inpatient,1,UN,22.00000,13.20000,MedCost,Ultra,,14.08,,,,,,,14.08,17.89,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,MedCost,Ultra,,11.22,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,inpatient,1,UN,28.60000,17.16000,MedCost,Ultra,,18.30,,,,,,,18.30,23.25,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,MedCost,Ultra,,14.59,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,inpatient,0.5,ML,121.05000,72.63000,MedCost,Ultra,,77.47,,,,,,,36.44,98.41,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,MedCost,Ultra,,61.74,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,MedCost,Ultra,,18699.46,,,,,,,8794.59,23754.15,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,MedCost,Ultra,,14901.13,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,inpatient,0.2,ML,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,5.55,15.00,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,inpatient,3,ML,36.65000,21.99000,MedCost,Ultra,,23.46,,,,,,,23.46,29.80,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,MedCost,Ultra,,18.69,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,10.75,13.66,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,inpatient,1,UN,22.15000,13.29000,MedCost,Ultra,,14.18,,,,,,,14.18,18.01,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,MedCost,Ultra,,11.30,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,inpatient,1,UN,22.35000,13.41000,MedCost,Ultra,,14.30,,,,,,,14.30,18.17,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,MedCost,Ultra,,11.40,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,inpatient,5,ML,93.35000,56.01000,MedCost,Ultra,,59.74,,,,,,,28.10,75.89,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,MedCost,Ultra,,47.61,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,inpatient,1,UN,2978.05000,1786.83000,MedCost,Ultra,,1905.95,,,,,,,896.39,2421.15,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,MedCost,Ultra,,1518.81,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,inpatient,1,UN,35.80000,21.48000,MedCost,Ultra,,22.91,,,,,,,22.91,29.11,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,MedCost,Ultra,,18.26,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,inpatient,1.6666666666666665,ML,128.65000,77.19000,MedCost,Ultra,,82.34,,,,,,,38.72,104.59,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,MedCost,Ultra,,65.61,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,inpatient,1,UN,2262.45000,1357.47000,MedCost,Ultra,,1447.97,,,,,,,681.00,1839.37,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,MedCost,Ultra,,1153.85,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,inpatient,10,ML,42.60000,25.56000,MedCost,Ultra,,27.26,,,,,,,12.82,34.63,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,MedCost,Ultra,,21.73,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,inpatient,2,ML,35.05000,21.03000,MedCost,Ultra,,22.43,,,,,,,10.55,28.50,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,MedCost,Ultra,,17.88,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,inpatient,4,ML,29.35000,17.61000,MedCost,Ultra,,18.78,,,,,,,8.83,23.86,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,MedCost,Ultra,,14.97,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,inpatient,120,ML,55.25000,33.15000,MedCost,Ultra,,35.36,,,,,,,35.36,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,MedCost,Ultra,,28.18,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,inpatient,60,ML,36.20000,21.72000,MedCost,Ultra,,23.17,,,,,,,23.17,29.43,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,MedCost,Ultra,,18.46,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,inpatient,20,ML,5230.30000,3138.18000,MedCost,Ultra,,3347.39,,,,,,,1574.32,4252.23,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,MedCost,Ultra,,2667.45,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,inpatient,20,ML,13051.70000,7831.02000,MedCost,Ultra,,8353.09,,,,,,,3928.56,10611.03,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,MedCost,Ultra,,6656.37,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,inpatient,20,ML,26087.25000,15652.35000,MedCost,Ultra,,16695.84,,,,,,,7852.26,21208.93,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,MedCost,Ultra,,13304.50,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,inpatient,20,ML,52158.50000,31295.10000,MedCost,Ultra,,33381.44,,,,,,,15699.71,42404.86,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,MedCost,Ultra,,26600.83,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,10.75,13.66,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,inpatient,100,ML,180.95000,108.57000,MedCost,Ultra,,115.81,,,,,,,54.47,147.11,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,MedCost,Ultra,,92.28,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,inpatient,1,UN,399.60000,239.76000,MedCost,Ultra,,255.74,,,,,,,255.74,324.87,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,MedCost,Ultra,,203.80,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,inpatient,1,UN,25.50000,15.30000,MedCost,Ultra,,16.32,,,,,,,16.32,20.73,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,MedCost,Ultra,,13.01,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,inpatient,1,UN,50.15000,30.09000,MedCost,Ultra,,32.10,,,,,,,32.10,40.77,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,MedCost,Ultra,,25.58,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,inpatient,1,UN,147.80000,88.68000,MedCost,Ultra,,94.59,,,,,,,94.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,MedCost,Ultra,,75.38,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,inpatient,1,UN,316.30000,189.78000,MedCost,Ultra,,202.43,,,,,,,95.21,257.15,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,MedCost,Ultra,,161.31,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,inpatient,1,UN,18.40000,11.04000,MedCost,Ultra,,11.78,,,,,,,11.78,14.96,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,MedCost,Ultra,,9.38,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,11.39,,,,,,,11.39,14.47,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,9.08,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,inpatient,50,ML,48.40000,29.04000,MedCost,Ultra,,30.98,,,,,,,30.98,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,MedCost,Ultra,,24.68,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,inpatient,75,ML,50.45000,30.27000,MedCost,Ultra,,32.29,,,,,,,32.29,41.02,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,MedCost,Ultra,,25.73,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,inpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,10.88,,,,,,,10.88,13.82,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,MedCost,Ultra,,8.67,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,inpatient,1,UN,17.95000,10.77000,MedCost,Ultra,,11.49,,,,,,,11.49,14.59,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,MedCost,Ultra,,9.15,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,inpatient,1,UN,4712.40000,2827.44000,MedCost,Ultra,,3015.94,,,,,,,1418.43,3831.18,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,MedCost,Ultra,,2403.32,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,10.91,,,,,,,10.91,13.86,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,8.70,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,inpatient,1,UN,57.35000,34.41000,MedCost,Ultra,,36.70,,,,,,,36.70,46.63,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,MedCost,Ultra,,29.25,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,inpatient,15,GR,134.50000,80.70000,MedCost,Ultra,,86.08,,,,,,,86.08,109.35,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,MedCost,Ultra,,68.59,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,inpatient,2,ML,37.15000,22.29000,MedCost,Ultra,,23.78,,,,,,,11.18,30.20,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,MedCost,Ultra,,18.95,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,MedCost,Ultra,,107.30,,,,,,,50.46,136.30,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,MedCost,Ultra,,85.50,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,inpatient,1,UN,48.90000,29.34000,MedCost,Ultra,,31.30,,,,,,,31.30,39.76,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,MedCost,Ultra,,24.94,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,inpatient,1,UN,21.90000,13.14000,MedCost,Ultra,,14.02,,,,,,,14.02,17.80,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,MedCost,Ultra,,11.17,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,inpatient,1,UN,22.50000,13.50000,MedCost,Ultra,,14.40,,,,,,,14.40,18.29,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,MedCost,Ultra,,11.47,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,inpatient,1,UN,22.90000,13.74000,MedCost,Ultra,,14.66,,,,,,,14.66,18.62,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,MedCost,Ultra,,11.68,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,inpatient,0.5,ML,321.65000,192.99000,MedCost,Ultra,,205.86,,,,,,,96.82,261.50,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,MedCost,Ultra,,164.04,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,inpatient,1,UN,21.50000,12.90000,MedCost,Ultra,,13.76,,,,,,,13.76,17.48,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,MedCost,Ultra,,10.96,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,inpatient,1,UN,26.25000,15.75000,MedCost,Ultra,,16.80,,,,,,,16.80,21.34,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,MedCost,Ultra,,13.39,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,inpatient,1,UN,37.10000,22.26000,MedCost,Ultra,,23.74,,,,,,,11.17,30.16,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,MedCost,Ultra,,18.92,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,inpatient,1,ML,27.85000,16.71000,MedCost,Ultra,,17.82,,,,,,,8.38,22.64,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,MedCost,Ultra,,14.20,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,inpatient,7.5,ML,465.05000,279.03000,MedCost,Ultra,,297.63,,,,,,,297.63,378.09,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,MedCost,Ultra,,237.18,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,inpatient,473,ML,11.30000,6.78000,MedCost,Ultra,,7.23,,,,,,,7.23,9.19,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,MedCost,Ultra,,5.76,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,inpatient,2.5,ML,1.65000,0.99000,MedCost,Ultra,,1.06,,,,,,,1.06,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,MedCost,Ultra,,0.84150,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,inpatient,2.5,ML,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,inpatient,1,UN,1034.85000,620.91000,MedCost,Ultra,,662.30,,,,,,,311.49,841.33,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,MedCost,Ultra,,527.77,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,inpatient,1,UN,24.85000,14.91000,MedCost,Ultra,,15.90,,,,,,,15.90,20.20,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,MedCost,Ultra,,12.67,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,inpatient,1,UN,24.80000,14.88000,MedCost,Ultra,,15.87,,,,,,,15.87,20.16,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,MedCost,Ultra,,12.65,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,inpatient,5,ML,252.00000,151.20000,MedCost,Ultra,,161.28,,,,,,,75.85,204.88,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,MedCost,Ultra,,128.52,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,inpatient,1,UN,30.00000,18.00000,MedCost,Ultra,,19.20,,,,,,,19.20,24.39,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,MedCost,Ultra,,15.30,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,inpatient,1,UN,32.35000,19.41000,MedCost,Ultra,,20.70,,,,,,,20.70,26.30,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,MedCost,Ultra,,16.50,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,11.33,,,,,,,11.33,14.39,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,9.03,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,11.30,,,,,,,11.30,14.35,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,9.00,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,inpatient,1,UN,18.25000,10.95000,MedCost,Ultra,,11.68,,,,,,,11.68,14.84,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,MedCost,Ultra,,9.31,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,inpatient,1,UN,19.65000,11.79000,MedCost,Ultra,,12.58,,,,,,,12.58,15.98,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,MedCost,Ultra,,10.02,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,MedCost,Ultra,,4690.05,,,,,,,2205.79,5957.83,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,MedCost,Ultra,,3737.38,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.4,ML,17.65000,10.59000,MedCost,Ultra,,11.30,,,,,,,5.31,14.35,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,MedCost,Ultra,,9.00,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,inpatient,1,ML,18.10000,10.86000,MedCost,Ultra,,11.58,,,,,,,11.58,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,MedCost,Ultra,,9.23,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,inpatient,1,ML,20.20000,12.12000,MedCost,Ultra,,12.93,,,,,,,12.93,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,MedCost,Ultra,,10.30,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,inpatient,1,ML,16.75000,10.05000,MedCost,Ultra,,10.72,,,,,,,10.72,13.62,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,MedCost,Ultra,,8.54,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,inpatient,1000,ML,87.50000,52.50000,MedCost,Ultra,,56.00,,,,,,,26.34,71.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,MedCost,Ultra,,44.62,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,inpatient,1,UN,6248.60000,3749.16000,MedCost,Ultra,,3999.10,,,,,,,1880.83,5080.11,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,MedCost,Ultra,,3186.79,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,inpatient,1,UN,87.55000,52.53000,MedCost,Ultra,,56.03,,,,,,,56.03,71.18,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,MedCost,Ultra,,44.65,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,inpatient,1,UN,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.51,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,inpatient,1,UN,48.90000,29.34000,MedCost,Ultra,,31.30,,,,,,,31.30,39.76,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,MedCost,Ultra,,24.94,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,inpatient,473,ML,96.90000,58.14000,MedCost,Ultra,,62.02,,,,,,,62.02,78.78,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,MedCost,Ultra,,49.42,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,inpatient,473,ML,105.40000,63.24000,MedCost,Ultra,,67.46,,,,,,,67.46,85.69,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,MedCost,Ultra,,53.75,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,inpatient,1,UN,21.25000,12.75000,MedCost,Ultra,,13.60,,,,,,,13.60,17.28,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,MedCost,Ultra,,10.84,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,10,ML,1.50000,0.90000,MedCost,Ultra,,0.96000,,,,,,,0.96000,1.22,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,MedCost,Ultra,,0.76500,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,inpatient,1,UN,18.70000,11.22000,MedCost,Ultra,,11.97,,,,,,,11.97,15.20,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,MedCost,Ultra,,9.54,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,inpatient,1,ML,70.60000,42.36000,MedCost,Ultra,,45.18,,,,,,,21.25,57.40,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,MedCost,Ultra,,36.01,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,inpatient,177,ML,4.85000,2.91000,MedCost,Ultra,,3.10,,,,,,,3.10,3.94,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,MedCost,Ultra,,2.47,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,10.85,,,,,,,10.85,13.78,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,8.64,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,inpatient,1,UN,28.40000,17.04000,MedCost,Ultra,,18.18,,,,,,,18.18,23.09,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,MedCost,Ultra,,14.48,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,inpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,10.78,,,,,,,10.78,13.70,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,MedCost,Ultra,,8.59,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,inpatient,1,UN,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,145.38,392.68,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,inpatient,1,UN,17.95000,10.77000,MedCost,Ultra,,11.49,,,,,,,11.49,14.59,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,MedCost,Ultra,,9.15,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,10.37,,,,,,,10.37,13.17,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,8.26,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,inpatient,5,ML,23.60000,14.16000,MedCost,Ultra,,15.10,,,,,,,15.10,19.19,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,MedCost,Ultra,,12.04,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,inpatient,28,GR,4.30000,2.58000,MedCost,Ultra,,2.75,,,,,,,2.75,3.50,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,MedCost,Ultra,,2.19,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,inpatient,28,GR,27.45000,16.47000,MedCost,Ultra,,17.57,,,,,,,17.57,22.32,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,MedCost,Ultra,,14.00,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,inpatient,28,GR,4.30000,2.58000,MedCost,Ultra,,2.75,,,,,,,2.75,3.50,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,MedCost,Ultra,,2.19,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,inpatient,28.35,GR,25.90000,15.54000,MedCost,Ultra,,16.58,,,,,,,16.58,21.06,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,MedCost,Ultra,,13.21,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,inpatient,1,UN,17.15000,10.29000,MedCost,Ultra,,10.98,,,,,,,10.98,13.94,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,MedCost,Ultra,,8.75,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,inpatient,1,UN,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.41,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,inpatient,473,ML,1.75000,1.05000,MedCost,Ultra,,1.12,,,,,,,1.12,1.42,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,MedCost,Ultra,,0.89250,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,inpatient,1,UN,22.55000,13.53000,MedCost,Ultra,,14.43,,,,,,,14.43,18.33,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,MedCost,Ultra,,11.50,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,inpatient,0.1,ML,23.30000,13.98000,MedCost,Ultra,,14.91,,,,,,,7.01,18.94,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,MedCost,Ultra,,11.88,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,inpatient,1,UN,22.55000,13.53000,MedCost,Ultra,,14.43,,,,,,,14.43,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,MedCost,Ultra,,11.50,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,inpatient,30,ML,8.35000,5.01000,MedCost,Ultra,,5.34,,,,,,,5.34,6.79,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,MedCost,Ultra,,4.26,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,inpatient,1,UN,22.70000,13.62000,MedCost,Ultra,,14.53,,,,,,,14.53,18.46,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,MedCost,Ultra,,11.58,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,inpatient,1,UN,16.10000,9.66000,MedCost,Ultra,,10.30,,,,,,,10.30,13.09,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,MedCost,Ultra,,8.21,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,inpatient,100,ML,113.50000,68.10000,MedCost,Ultra,,72.64,,,,,,,72.64,92.28,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,MedCost,Ultra,,57.88,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,inpatient,1,ML,169.40000,101.64000,MedCost,Ultra,,108.42,,,,,,,50.99,137.72,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,MedCost,Ultra,,86.39,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,inpatient,1,UN,27.85000,16.71000,MedCost,Ultra,,17.82,,,,,,,17.82,22.64,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,MedCost,Ultra,,14.20,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,inpatient,10,ML,31.35000,18.81000,MedCost,Ultra,,20.06,,,,,,,20.06,25.49,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,MedCost,Ultra,,15.99,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,inpatient,1,UN,18064.20000,10838.52000,MedCost,Ultra,,11561.09,,,,,,,5437.32,14686.19,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,MedCost,Ultra,,9212.74,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2531.58,,,,,,,1190.64,3215.90,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2017.36,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,inpatient,1,UN,30.90000,18.54000,MedCost,Ultra,,19.78,,,,,,,9.30,25.12,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,MedCost,Ultra,,15.76,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,inpatient,2,ML,757.60000,454.56000,MedCost,Ultra,,484.86,,,,,,,228.04,615.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,MedCost,Ultra,,386.38,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,inpatient,1,UN,231.15000,138.69000,MedCost,Ultra,,147.94,,,,,,,147.94,187.92,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,MedCost,Ultra,,117.89,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,inpatient,1,UN,143.75000,86.25000,MedCost,Ultra,,92.00,,,,,,,43.27,116.87,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,MedCost,Ultra,,73.31,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,MedCost,Ultra,,1753.98,,,,,,,824.92,2228.11,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,MedCost,Ultra,,1397.71,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,inpatient,1,UN,1507.85000,904.71000,MedCost,Ultra,,965.02,,,,,,,453.86,1225.88,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,MedCost,Ultra,,769.00,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,inpatient,15,ML,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,inpatient,15,ML,3.50000,2.10000,MedCost,Ultra,,2.24,,,,,,,2.24,2.85,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,MedCost,Ultra,,1.78,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,inpatient,3,ML,109.25000,65.55000,MedCost,Ultra,,69.92,,,,,,,32.88,88.82,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,MedCost,Ultra,,55.72,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,inpatient,1,UN,1.60000,0.96000,MedCost,Ultra,,1.02,,,,,,,1.02,1.30,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,MedCost,Ultra,,0.81600,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,10.43,,,,,,,10.43,13.25,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,8.31,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,inpatient,2.5,ML,27.40000,16.44000,MedCost,Ultra,,17.54,,,,,,,17.54,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,MedCost,Ultra,,13.97,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,inpatient,2.5,ML,20.20000,12.12000,MedCost,Ultra,,12.93,,,,,,,12.93,16.42,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,MedCost,Ultra,,10.30,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,inpatient,1,ML,40.95000,24.57000,MedCost,Ultra,,26.21,,,,,,,12.33,33.29,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,MedCost,Ultra,,20.88,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,inpatient,1,UN,1391.25000,834.75000,MedCost,Ultra,,890.40,,,,,,,890.40,1131.09,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,MedCost,Ultra,,709.54,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,inpatient,1,UN,60.95000,36.57000,MedCost,Ultra,,39.01,,,,,,,39.01,49.55,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,MedCost,Ultra,,31.08,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,inpatient,15,GR,37.05000,22.23000,MedCost,Ultra,,23.71,,,,,,,23.71,30.12,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,MedCost,Ultra,,18.90,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,inpatient,1,UN,23.80000,14.28000,MedCost,Ultra,,15.23,,,,,,,7.16,19.35,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,MedCost,Ultra,,12.14,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,inpatient,15,ML,377.25000,226.35000,MedCost,Ultra,,241.44,,,,,,,113.55,306.70,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,MedCost,Ultra,,192.40,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,inpatient,45,ML,482.55000,289.53000,MedCost,Ultra,,308.83,,,,,,,145.25,392.31,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,MedCost,Ultra,,246.10,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,inpatient,5,ML,334.00000,200.40000,MedCost,Ultra,,213.76,,,,,,,100.53,271.54,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,MedCost,Ultra,,170.34,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,inpatient,60,ML,535.35000,321.21000,MedCost,Ultra,,342.62,,,,,,,161.14,435.24,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,MedCost,Ultra,,273.03,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,inpatient,10,ML,117.60000,70.56000,MedCost,Ultra,,75.26,,,,,,,75.26,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,MedCost,Ultra,,59.98,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,inpatient,5,ML,90.30000,54.18000,MedCost,Ultra,,57.79,,,,,,,57.79,73.41,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,MedCost,Ultra,,46.05,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,inpatient,0.01,ML,16.05000,9.63000,MedCost,Ultra,,10.27,,,,,,,10.27,13.05,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,MedCost,Ultra,,8.19,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,inpatient,2,ML,25.05000,15.03000,MedCost,Ultra,,16.03,,,,,,,7.54,20.37,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,MedCost,Ultra,,12.78,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,inpatient,30,ML,116.10000,69.66000,MedCost,Ultra,,74.30,,,,,,,34.95,94.39,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,MedCost,Ultra,,59.21,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,inpatient,200,ML,686.20000,411.72000,MedCost,Ultra,,439.17,,,,,,,439.17,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,MedCost,Ultra,,349.96,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,inpatient,480,ML,1607.20000,964.32000,MedCost,Ultra,,1028.61,,,,,,,1028.61,1306.65,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,MedCost,Ultra,,819.67,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,inpatient,1,UN,17.45000,10.47000,MedCost,Ultra,,11.17,,,,,,,11.17,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,MedCost,Ultra,,8.90,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,inpatient,1,UN,18.65000,11.19000,MedCost,Ultra,,11.94,,,,,,,11.94,15.16,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,MedCost,Ultra,,9.51,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,250,ML,66.75000,40.05000,MedCost,Ultra,,42.72,,,,,,,42.72,54.07,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,MedCost,Ultra,,34.04,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,44.64,,,,,,,44.64,56.50,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,35.57,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,43.20,,,,,,,43.20,54.67,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,34.42,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,50.40,,,,,,,50.40,63.79,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,40.16,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,44.64,,,,,,,44.64,56.50,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,35.57,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,43.20,,,,,,,43.20,54.67,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,34.42,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,inpatient,250,ML,150.00000,90.00000,MedCost,Ultra,,96.00,,,,,,,96.00,121.50,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,MedCost,Ultra,,76.50,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,inpatient,250,ML,73.50000,44.10000,MedCost,Ultra,,47.04,,,,,,,47.04,59.53,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,MedCost,Ultra,,37.48,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,44.64,,,,,,,44.64,56.50,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,35.57,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,43.20,,,,,,,43.20,54.67,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,34.42,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,inpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,43.20,,,,,,,43.20,54.67,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,MedCost,Ultra,,34.42,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,inpatient,250,ML,66.75000,40.05000,MedCost,Ultra,,42.72,,,,,,,42.72,54.07,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,MedCost,Ultra,,34.04,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,inpatient,500,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,inpatient,500,ML,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,inpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,44.64,,,,,,,44.64,56.50,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,MedCost,Ultra,,35.57,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,50.40,,,,,,,50.40,63.79,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,40.16,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,inpatient,250,ML,66.75000,40.05000,MedCost,Ultra,,42.72,,,,,,,42.72,54.07,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,MedCost,Ultra,,34.04,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,inpatient,5,ML,16.15000,9.69000,MedCost,Ultra,,10.34,,,,,,,10.34,13.13,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,MedCost,Ultra,,8.24,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,inpatient,473,ML,1023.50000,614.10000,MedCost,Ultra,,655.04,,,,,,,655.04,832.11,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,MedCost,Ultra,,521.99,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,inpatient,4,ML,22.65000,13.59000,MedCost,Ultra,,14.50,,,,,,,6.82,18.41,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,MedCost,Ultra,,11.55,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,11.26,14.31,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,inpatient,1,UN,7227.30000,4336.38000,MedCost,Ultra,,4625.47,,,,,,,2175.42,5875.79,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,MedCost,Ultra,,3685.92,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,inpatient,20,ML,26468.35000,15881.01000,MedCost,Ultra,,16939.74,,,,,,,7966.97,21518.77,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,MedCost,Ultra,,13498.86,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,inpatient,1,ML,5590.45000,3354.27000,MedCost,Ultra,,3577.89,,,,,,,1682.73,4545.04,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,MedCost,Ultra,,2851.13,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,inpatient,5,ML,26468.35000,15881.01000,MedCost,Ultra,,16939.74,,,,,,,7966.97,21518.77,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,MedCost,Ultra,,13498.86,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,inpatient,1,UN,18.90000,11.34000,MedCost,Ultra,,12.10,,,,,,,12.10,15.37,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,MedCost,Ultra,,9.64,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,inpatient,1,UN,19.20000,11.52000,MedCost,Ultra,,12.29,,,,,,,12.29,15.61,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,MedCost,Ultra,,9.79,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,inpatient,10,ML,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,32.21,86.99,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,MedCost,Ultra,,4690.05,,,,,,,2205.79,5957.83,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,MedCost,Ultra,,3737.38,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,inpatient,1,ML,350.20000,210.12000,MedCost,Ultra,,224.13,,,,,,,105.41,284.71,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,MedCost,Ultra,,178.60,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,inpatient,1,UN,1243.00000,745.80000,MedCost,Ultra,,795.52,,,,,,,374.14,1010.56,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,MedCost,Ultra,,633.93,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,inpatient,2,ML,22.80000,13.68000,MedCost,Ultra,,14.59,,,,,,,14.59,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,MedCost,Ultra,,11.63,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,inpatient,2,ML,46.20000,27.72000,MedCost,Ultra,,29.57,,,,,,,29.57,37.56,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,MedCost,Ultra,,23.56,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,inpatient,1,ML,7030.60000,4218.36000,MedCost,Ultra,,4499.58,,,,,,,2116.21,5715.88,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,MedCost,Ultra,,3585.61,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,inpatient,26.3,ML,332.30000,199.38000,MedCost,Ultra,,212.67,,,,,,,100.02,270.16,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,MedCost,Ultra,,169.47,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,inpatient,5.26,ML,308.30000,184.98000,MedCost,Ultra,,197.31,,,,,,,92.80,250.65,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,MedCost,Ultra,,157.23,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,inpatient,52.6,ML,673.55000,404.13000,MedCost,Ultra,,431.07,,,,,,,202.74,547.60,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,MedCost,Ultra,,343.51,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,MedCost,Ultra,,25674.18,,,,,,,12074.89,32614.23,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,MedCost,Ultra,,20459.11,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,MedCost,Ultra,,102168.38,,,,,,,48051.07,129785.78,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,MedCost,Ultra,,81415.43,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,MedCost,Ultra,,941.63,,,,,,,442.86,1196.17,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,MedCost,Ultra,,750.36,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,MedCost,Ultra,,1875.04,,,,,,,881.85,2381.89,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,MedCost,Ultra,,1494.17,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,26823.30000,16093.98000,MedCost,Ultra,,17166.91,,,,,,,8073.81,21807.34,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,MedCost,Ultra,,13679.88,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,inpatient,1,ML,320.15000,192.09000,MedCost,Ultra,,204.90,,,,,,,96.37,260.28,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,MedCost,Ultra,,163.28,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,MedCost,Ultra,,185.63,,,,,,,87.31,235.81,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,MedCost,Ultra,,147.93,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,MedCost,Ultra,,201.44,,,,,,,94.74,255.89,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,MedCost,Ultra,,160.52,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,MedCost,Ultra,,185.47,,,,,,,87.23,235.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,MedCost,Ultra,,147.80,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,MedCost,Ultra,,269.63,,,,,,,126.81,342.52,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,MedCost,Ultra,,214.86,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,inpatient,16,ML,2035.00000,1221.00000,MedCost,Ultra,,1302.40,,,,,,,612.53,1654.45,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,MedCost,Ultra,,1037.85,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,inpatient,2,ML,495.00000,297.00000,MedCost,Ultra,,316.80,,,,,,,149.00,402.44,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,MedCost,Ultra,,252.45,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,inpatient,8,ML,996.60000,597.96000,MedCost,Ultra,,637.82,,,,,,,299.98,810.24,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,MedCost,Ultra,,508.27,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,inpatient,0.5,ML,22.90000,13.74000,MedCost,Ultra,,14.66,,,,,,,14.66,18.62,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,MedCost,Ultra,,11.68,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,inpatient,0.5,ML,77.55000,46.53000,MedCost,Ultra,,49.63,,,,,,,23.34,63.05,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,MedCost,Ultra,,39.55,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,inpatient,26.3,ML,337.40000,202.44000,MedCost,Ultra,,215.94,,,,,,,101.56,274.31,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,MedCost,Ultra,,172.07,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,MedCost,Ultra,,3609.76,,,,,,,1697.72,4585.52,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,MedCost,Ultra,,2876.53,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,MedCost,Ultra,,7179.17,,,,,,,3376.45,9119.79,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,MedCost,Ultra,,5720.90,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,inpatient,2,ML,105.35000,63.21000,MedCost,Ultra,,67.42,,,,,,,67.42,85.65,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,MedCost,Ultra,,53.73,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,MedCost,Ultra,,29.09,,,,,,,13.68,36.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,MedCost,Ultra,,23.18,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,MedCost,Ultra,,40.61,,,,,,,19.10,51.58,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,MedCost,Ultra,,32.36,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,1,ML,19.05000,11.43000,MedCost,Ultra,,12.19,,,,,,,5.73,15.49,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,MedCost,Ultra,,9.72,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,inpatient,1000,ML,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,25.28,68.29,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,inpatient,0.5,ML,26.65000,15.99000,MedCost,Ultra,,17.06,,,,,,,17.06,21.67,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,MedCost,Ultra,,13.59,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,MedCost,Ultra,,219.39,,,,,,,103.18,278.70,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,MedCost,Ultra,,174.83,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,inpatient,100,ML,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,18.36,49.59,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,MedCost,Ultra,,48.64,,,,,,,22.88,61.79,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,MedCost,Ultra,,38.76,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,inpatient,5,ML,292.85000,175.71000,MedCost,Ultra,,187.42,,,,,,,88.15,238.09,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,MedCost,Ultra,,149.35,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,inpatient,1,UN,20.80000,12.48000,MedCost,Ultra,,13.31,,,,,,,6.26,16.91,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,MedCost,Ultra,,10.61,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,MedCost,Ultra,,27.71,,,,,,,13.03,35.20,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,MedCost,Ultra,,22.08,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,16.06,,,,,,,7.56,20.41,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,12.80,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,MedCost,Ultra,,18.69,,,,,,,8.79,23.74,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,MedCost,Ultra,,14.89,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,inpatient,18,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,inpatient,1,UN,19.50000,11.70000,MedCost,Ultra,,12.48,,,,,,,5.87,15.85,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,MedCost,Ultra,,9.95,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,inpatient,1,UN,19.25000,11.55000,MedCost,Ultra,,12.32,,,,,,,5.79,15.65,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,MedCost,Ultra,,9.82,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,inpatient,50,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,10.69,13.58,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,10.75,13.66,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,inpatient,250,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,inpatient,100,ML,103.35000,62.01000,MedCost,Ultra,,66.14,,,,,,,31.11,84.02,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,MedCost,Ultra,,52.71,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,inpatient,12,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,inpatient,40,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,inpatient,100,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1000,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,inpatient,25,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,inpatient,250,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,inpatient,50,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,inpatient,500,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,inpatient,100,ML,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1000,ML,78.00000,46.80000,MedCost,Ultra,,49.92,,,,,,,49.92,63.18,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,MedCost,Ultra,,39.78,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,inpatient,25,ML,71.40000,42.84000,MedCost,Ultra,,45.70,,,,,,,45.70,57.83,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,MedCost,Ultra,,36.41,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,inpatient,250,ML,75.75000,45.45000,MedCost,Ultra,,48.48,,,,,,,48.48,61.36,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,MedCost,Ultra,,38.63,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,inpatient,50,ML,70.65000,42.39000,MedCost,Ultra,,45.22,,,,,,,45.22,57.23,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,MedCost,Ultra,,36.03,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,48.00,60.75,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,inpatient,48,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,inpatient,1,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,MedCost,Ultra,,183.36,,,,,,,86.24,232.92,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,MedCost,Ultra,,146.12,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,inpatient,0.3,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,inpatient,0.09999,ML,63.05000,37.83000,MedCost,Ultra,,40.35,,,,,,,18.98,51.26,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,MedCost,Ultra,,32.16,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,109.40000,65.64000,MedCost,Ultra,,70.02,,,,,,,70.02,88.94,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,MedCost,Ultra,,55.79,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,inpatient,480,ML,4.75000,2.85000,MedCost,Ultra,,3.04,,,,,,,3.04,3.86,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,MedCost,Ultra,,2.42,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,inpatient,50,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,140.16,,,,,,,65.92,178.05,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,111.69,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,732.38,,,,,,,344.45,930.36,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,583.62,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,inpatient,5,ML,1086.20000,651.72000,MedCost,Ultra,,695.17,,,,,,,695.17,883.08,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,MedCost,Ultra,,553.96,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,inpatient,5,ML,44.50000,26.70000,MedCost,Ultra,,28.48,,,,,,,28.48,36.18,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,MedCost,Ultra,,22.70,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,10,ML,46.50000,27.90000,MedCost,Ultra,,29.76,,,,,,,14.00,37.80,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,MedCost,Ultra,,23.71,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,inpatient,0.5,ML,31.55000,18.93000,MedCost,Ultra,,20.19,,,,,,,9.50,25.65,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,MedCost,Ultra,,16.09,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,inpatient,1,UN,2.80000,1.68000,MedCost,Ultra,,1.79,,,,,,,1.79,2.28,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,MedCost,Ultra,,1.43,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,inpatient,1,UN,36575.00000,21945.00000,MedCost,Ultra,,23408.00,,,,,,,11009.08,29735.47,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,MedCost,Ultra,,18653.25,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,inpatient,10,ML,318.15000,190.89000,MedCost,Ultra,,203.62,,,,,,,95.76,258.66,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,MedCost,Ultra,,162.26,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,140.16,,,,,,,65.92,178.05,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,MedCost,Ultra,,111.69,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,inpatient,8,ML,63.85000,38.31000,MedCost,Ultra,,40.86,,,,,,,19.22,51.91,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,MedCost,Ultra,,32.56,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,inpatient,500,ML,115.50000,69.30000,MedCost,Ultra,,73.92,,,,,,,34.77,93.90,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,MedCost,Ultra,,58.91,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,inpatient,1,ML,27.75000,16.65000,MedCost,Ultra,,17.76,,,,,,,8.35,22.56,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,MedCost,Ultra,,14.15,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,inpatient,30,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,7.52,,,,,,,7.52,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,5.99,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,7.52,,,,,,,7.52,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,5.99,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,7.52,,,,,,,7.52,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,5.99,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,inpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,7.52,,,,,,,7.52,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,MedCost,Ultra,,5.99,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,75.10000,45.06000,MedCost,Ultra,,48.06,,,,,,,22.61,61.06,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,MedCost,Ultra,,38.30,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,inpatient,20,ML,108.15000,64.89000,MedCost,Ultra,,69.22,,,,,,,32.55,87.93,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,MedCost,Ultra,,55.16,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,inpatient,40,ML,153.25000,91.95000,MedCost,Ultra,,98.08,,,,,,,46.13,124.59,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,MedCost,Ultra,,78.16,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,inpatient,2,ML,21.85000,13.11000,MedCost,Ultra,,13.98,,,,,,,6.58,17.76,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,MedCost,Ultra,,11.14,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,inpatient,2,ML,19.60000,11.76000,MedCost,Ultra,,12.54,,,,,,,5.90,15.93,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,MedCost,Ultra,,10.00,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,inpatient,25,ML,57.75000,34.65000,MedCost,Ultra,,36.96,,,,,,,36.96,46.95,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,MedCost,Ultra,,29.45,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,inpatient,60,ML,204.30000,122.58000,MedCost,Ultra,,130.75,,,,,,,130.75,166.10,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,MedCost,Ultra,,104.19,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,10.50,,,,,,,10.50,13.33,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,8.36,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,inpatient,1,UN,53.20000,31.92000,MedCost,Ultra,,34.05,,,,,,,34.05,43.25,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,MedCost,Ultra,,27.13,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,inpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,10.37,,,,,,,10.37,13.17,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,MedCost,Ultra,,8.26,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,inpatient,1,UN,23.95000,14.37000,MedCost,Ultra,,15.33,,,,,,,15.33,19.47,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,MedCost,Ultra,,12.21,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,inpatient,5,ML,13686.90000,8212.14000,MedCost,Ultra,,8759.62,,,,,,,4119.76,11127.45,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,MedCost,Ultra,,6980.32,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,inpatient,1,ML,2799.00000,1679.40000,MedCost,Ultra,,1791.36,,,,,,,842.50,2275.59,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,MedCost,Ultra,,1427.49,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,inpatient,20,ML,79.65000,47.79000,MedCost,Ultra,,50.98,,,,,,,23.97,64.76,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,MedCost,Ultra,,40.62,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,inpatient,1,UN,48.35000,29.01000,MedCost,Ultra,,30.94,,,,,,,14.55,39.31,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,MedCost,Ultra,,24.66,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,inpatient,1,UN,28.20000,16.92000,MedCost,Ultra,,18.05,,,,,,,8.49,22.93,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,MedCost,Ultra,,14.38,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,inpatient,100,ML,76.20000,45.72000,MedCost,Ultra,,48.77,,,,,,,48.77,61.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,MedCost,Ultra,,38.86,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,MedCost,Ultra,,29.28,,,,,,,13.77,37.19,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,MedCost,Ultra,,23.33,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,inpatient,25,ML,104.40000,62.64000,MedCost,Ultra,,66.82,,,,,,,66.82,84.88,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,MedCost,Ultra,,53.24,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,inpatient,5000,ML,243.00000,145.80000,MedCost,Ultra,,155.52,,,,,,,155.52,197.56,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,MedCost,Ultra,,123.93,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,inpatient,1,UN,63.60000,38.16000,MedCost,Ultra,,40.70,,,,,,,19.14,51.71,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,MedCost,Ultra,,32.44,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,inpatient,5000,ML,243.00000,145.80000,MedCost,Ultra,,155.52,,,,,,,155.52,197.56,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,MedCost,Ultra,,123.93,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,MedCost,Ultra,,19.07,,,,,,,8.97,24.23,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,MedCost,Ultra,,15.20,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,inpatient,1,UN,578.15000,346.89000,MedCost,Ultra,,370.02,,,,,,,370.02,470.04,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,MedCost,Ultra,,294.86,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,inpatient,5,ML,28.50000,17.10000,MedCost,Ultra,,18.24,,,,,,,8.58,23.17,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,MedCost,Ultra,,14.54,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,inpatient,5000,ML,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,174.72,221.95,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,inpatient,5000,ML,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,174.72,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,inpatient,2,ML,20.65000,12.39000,MedCost,Ultra,,13.22,,,,,,,6.22,16.79,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,MedCost,Ultra,,10.53,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,inpatient,2,ML,20.15000,12.09000,MedCost,Ultra,,12.90,,,,,,,6.07,16.38,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,MedCost,Ultra,,10.28,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,inpatient,2,ML,20.25000,12.15000,MedCost,Ultra,,12.96,,,,,,,6.10,16.46,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,MedCost,Ultra,,10.33,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,MedCost,Ultra,,16.86,,,,,,,7.93,21.42,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,MedCost,Ultra,,13.44,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,inpatient,14.2,GR,7.10000,4.26000,MedCost,Ultra,,4.54,,,,,,,4.54,5.77,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,MedCost,Ultra,,3.62,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,inpatient,100,ML,153.75000,92.25000,MedCost,Ultra,,98.40,,,,,,,46.28,125.00,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,MedCost,Ultra,,78.41,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,inpatient,100,ML,405.05000,243.03000,MedCost,Ultra,,259.23,,,,,,,121.92,329.31,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,MedCost,Ultra,,206.58,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,inpatient,120,ML,155.00000,93.00000,MedCost,Ultra,,99.20,,,,,,,99.20,126.02,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,MedCost,Ultra,,79.05,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,inpatient,100,ML,803.50000,482.10000,MedCost,Ultra,,514.24,,,,,,,514.24,653.25,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,MedCost,Ultra,,409.79,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,inpatient,4,ML,66.20000,39.72000,MedCost,Ultra,,42.37,,,,,,,19.93,53.82,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,MedCost,Ultra,,33.76,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,inpatient,100,ML,25.00000,15.00000,MedCost,Ultra,,16.00,,,,,,,16.00,20.32,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,MedCost,Ultra,,12.75,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,inpatient,100,ML,19.00000,11.40000,MedCost,Ultra,,12.16,,,,,,,12.16,15.45,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,MedCost,Ultra,,9.69,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,inpatient,100,ML,70.00000,42.00000,MedCost,Ultra,,44.80,,,,,,,44.80,56.91,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,MedCost,Ultra,,35.70,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,inpatient,200,ML,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,56.32,71.54,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,inpatient,120,ML,74.80000,44.88000,MedCost,Ultra,,47.87,,,,,,,47.87,60.81,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,MedCost,Ultra,,38.15,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,inpatient,15,ML,60.40000,36.24000,MedCost,Ultra,,38.66,,,,,,,38.66,49.11,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,MedCost,Ultra,,30.80,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,inpatient,100,ML,92.20000,55.32000,MedCost,Ultra,,59.01,,,,,,,59.01,74.96,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,MedCost,Ultra,,47.02,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,inpatient,240,ML,376.00000,225.60000,MedCost,Ultra,,240.64,,,,,,,240.64,305.69,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,MedCost,Ultra,,191.76,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,inpatient,200,ML,19.00000,11.40000,MedCost,Ultra,,12.16,,,,,,,12.16,15.45,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,MedCost,Ultra,,9.69,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,inpatient,1,UN,64.35000,38.61000,MedCost,Ultra,,41.18,,,,,,,41.18,52.32,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,MedCost,Ultra,,32.82,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,inpatient,20,ML,27.05000,16.23000,MedCost,Ultra,,17.31,,,,,,,17.31,21.99,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,MedCost,Ultra,,13.80,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,inpatient,5,ML,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.51,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,inpatient,1,ML,114.75000,68.85000,MedCost,Ultra,,73.44,,,,,,,34.54,93.29,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,MedCost,Ultra,,58.52,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,inpatient,5000,ML,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,174.72,221.95,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,inpatient,5000,ML,243.00000,145.80000,MedCost,Ultra,,155.52,,,,,,,155.52,197.56,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,MedCost,Ultra,,123.93,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,inpatient,30,GR,47.50000,28.50000,MedCost,Ultra,,30.40,,,,,,,30.40,38.62,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,MedCost,Ultra,,24.23,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,11.14,,,,,,,5.24,14.15,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,8.87,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,inpatient,0.4,ML,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,19.26,52.03,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,28.70000,17.22000,MedCost,Ultra,,18.37,,,,,,,18.37,23.33,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,MedCost,Ultra,,14.64,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,10.50,,,,,,,10.50,13.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,8.36,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,inpatient,0.25,ML,17.35000,10.41000,MedCost,Ultra,,11.10,,,,,,,5.22,14.11,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,MedCost,Ultra,,8.85,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,inpatient,500,ML,94.50000,56.70000,MedCost,Ultra,,60.48,,,,,,,28.44,76.83,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,MedCost,Ultra,,48.20,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,inpatient,300,ML,34.00000,20.40000,MedCost,Ultra,,21.76,,,,,,,21.76,27.64,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,MedCost,Ultra,,17.34,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,inpatient,50,ML,23.35000,14.01000,MedCost,Ultra,,14.94,,,,,,,14.94,18.98,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,MedCost,Ultra,,11.91,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,inpatient,50,ML,215.60000,129.36000,MedCost,Ultra,,137.98,,,,,,,64.90,175.28,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,MedCost,Ultra,,109.96,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,inpatient,40,ML,338.70000,203.22000,MedCost,Ultra,,216.77,,,,,,,216.77,275.36,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,MedCost,Ultra,,172.74,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,inpatient,10,ML,835.00000,501.00000,MedCost,Ultra,,534.40,,,,,,,251.34,678.86,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,MedCost,Ultra,,425.85,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,inpatient,0.5,UN,65.25000,39.15000,MedCost,Ultra,,41.76,,,,,,,19.64,53.05,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,MedCost,Ultra,,33.28,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,81.95000,49.17000,MedCost,Ultra,,52.45,,,,,,,24.67,66.63,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,MedCost,Ultra,,41.79,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,inpatient,300,ML,222.60000,133.56000,MedCost,Ultra,,142.46,,,,,,,67.00,180.97,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,MedCost,Ultra,,113.53,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,inpatient,25,ML,88.20000,52.92000,MedCost,Ultra,,56.45,,,,,,,56.45,71.71,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,MedCost,Ultra,,44.98,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,MedCost,Ultra,,56.35,,,,,,,26.50,71.58,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,MedCost,Ultra,,44.91,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.5,ML,128.55000,77.13000,MedCost,Ultra,,82.27,,,,,,,82.27,104.51,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,MedCost,Ultra,,65.56,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,inpatient,37.5,GR,5.90000,3.54000,MedCost,Ultra,,3.78,,,,,,,3.78,4.80,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,MedCost,Ultra,,3.01,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,MedCost,Ultra,,32.70,,,,,,,15.38,41.54,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,MedCost,Ultra,,26.06,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,inpatient,2,ML,28.40000,17.04000,MedCost,Ultra,,18.18,,,,,,,8.55,23.09,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,MedCost,Ultra,,14.48,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,MedCost,Ultra,,24171.87,,,,,,,11368.33,30705.83,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,MedCost,Ultra,,19261.96,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,inpatient,1,UN,319.00000,191.40000,MedCost,Ultra,,204.16,,,,,,,96.02,259.35,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,MedCost,Ultra,,162.69,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,inpatient,8,ML,168.40000,101.04000,MedCost,Ultra,,107.78,,,,,,,107.78,136.91,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,MedCost,Ultra,,85.88,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,inpatient,8,ML,64.55000,38.73000,MedCost,Ultra,,41.31,,,,,,,19.43,52.48,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,MedCost,Ultra,,32.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,inpatient,50,ML,72.70000,43.62000,MedCost,Ultra,,46.53,,,,,,,21.88,59.11,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,MedCost,Ultra,,37.08,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,inpatient,50,ML,64.90000,38.94000,MedCost,Ultra,,41.54,,,,,,,19.53,52.76,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,MedCost,Ultra,,33.10,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,inpatient,50,ML,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,22.57,60.98,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,inpatient,15,ML,60.40000,36.24000,MedCost,Ultra,,38.66,,,,,,,38.66,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,MedCost,Ultra,,30.80,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,inpatient,5,ML,87.95000,52.77000,MedCost,Ultra,,56.29,,,,,,,56.29,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,MedCost,Ultra,,44.85,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,inpatient,50,ML,372.10000,223.26000,MedCost,Ultra,,238.14,,,,,,,238.14,302.52,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,MedCost,Ultra,,189.77,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,inpatient,1,ML,19.25000,11.55000,MedCost,Ultra,,12.32,,,,,,,5.79,15.65,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,MedCost,Ultra,,9.82,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,inpatient,4,ML,67.40000,40.44000,MedCost,Ultra,,43.14,,,,,,,43.14,54.80,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,MedCost,Ultra,,34.37,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,inpatient,8,ML,68.40000,41.04000,MedCost,Ultra,,43.78,,,,,,,20.59,55.61,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,MedCost,Ultra,,34.88,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,inpatient,50,ML,96.60000,57.96000,MedCost,Ultra,,61.82,,,,,,,29.08,78.54,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,MedCost,Ultra,,49.27,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,inpatient,1,ML,30.70000,18.42000,MedCost,Ultra,,19.65,,,,,,,9.24,24.96,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,MedCost,Ultra,,15.66,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,inpatient,40,ML,106.55000,63.93000,MedCost,Ultra,,68.19,,,,,,,68.19,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,MedCost,Ultra,,54.34,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,inpatient,100,ML,171.80000,103.08000,MedCost,Ultra,,109.95,,,,,,,109.95,139.67,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,MedCost,Ultra,,87.62,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,inpatient,50,ML,103.95000,62.37000,MedCost,Ultra,,66.53,,,,,,,31.29,84.51,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,MedCost,Ultra,,53.01,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,250.40000,150.24000,MedCost,Ultra,,160.26,,,,,,,75.37,203.58,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,MedCost,Ultra,,127.70,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,inpatient,10,ML,170.95000,102.57000,MedCost,Ultra,,109.41,,,,,,,51.46,138.98,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,MedCost,Ultra,,87.18,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,inpatient,50,ML,80.65000,48.39000,MedCost,Ultra,,51.62,,,,,,,24.28,65.57,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,MedCost,Ultra,,41.13,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,inpatient,100,ML,70.35000,42.21000,MedCost,Ultra,,45.02,,,,,,,21.18,57.19,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,MedCost,Ultra,,35.88,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,inpatient,1,GR,103.95000,62.37000,MedCost,Ultra,,66.53,,,,,,,31.29,84.51,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,MedCost,Ultra,,53.01,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,inpatient,20,ML,81.90000,49.14000,MedCost,Ultra,,52.42,,,,,,,24.65,66.58,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,MedCost,Ultra,,41.77,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,inpatient,1,UN,96.60000,57.96000,MedCost,Ultra,,61.82,,,,,,,29.08,78.54,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,MedCost,Ultra,,49.27,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,109.20000,65.52000,MedCost,Ultra,,69.89,,,,,,,32.87,88.78,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,MedCost,Ultra,,55.69,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,inpatient,500,ML,478.80000,287.28000,MedCost,Ultra,,306.43,,,,,,,144.12,389.26,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,MedCost,Ultra,,244.19,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,inpatient,50,ML,117.85000,70.71000,MedCost,Ultra,,75.42,,,,,,,35.47,95.81,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,MedCost,Ultra,,60.10,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,300,ML,567.00000,340.20000,MedCost,Ultra,,362.88,,,,,,,170.67,460.97,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,MedCost,Ultra,,289.17,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,inpatient,1,UN,1165.70000,699.42000,MedCost,Ultra,,746.05,,,,,,,350.88,947.71,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,MedCost,Ultra,,594.51,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,inpatient,1,UN,1242.40000,745.44000,MedCost,Ultra,,795.14,,,,,,,373.96,1010.07,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,MedCost,Ultra,,633.62,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,MedCost,Ultra,,23.36,,,,,,,10.99,29.67,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,MedCost,Ultra,,18.61,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,inpatient,100,ML,83.60000,50.16000,MedCost,Ultra,,53.50,,,,,,,53.50,67.72,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,MedCost,Ultra,,42.64,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,inpatient,100,ML,74.35000,44.61000,MedCost,Ultra,,47.58,,,,,,,22.38,60.45,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,MedCost,Ultra,,37.92,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,inpatient,100,ML,153.30000,91.98000,MedCost,Ultra,,98.11,,,,,,,46.14,124.63,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,MedCost,Ultra,,78.18,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,250,ML,218.50000,131.10000,MedCost,Ultra,,139.84,,,,,,,65.77,177.64,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,MedCost,Ultra,,111.44,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,1000,ML,512.40000,307.44000,MedCost,Ultra,,327.94,,,,,,,154.23,416.58,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,MedCost,Ultra,,261.32,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,inpatient,1000,ML,961.80000,577.08000,MedCost,Ultra,,615.55,,,,,,,289.50,781.94,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,MedCost,Ultra,,490.52,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,MedCost,Ultra,,57.79,,,,,,,27.18,73.41,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,MedCost,Ultra,,46.05,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,inpatient,1,UN,103.15000,61.89000,MedCost,Ultra,,66.02,,,,,,,31.05,83.86,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,MedCost,Ultra,,52.61,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,inpatient,1,UN,247.75000,148.65000,MedCost,Ultra,,158.56,,,,,,,74.57,201.42,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,MedCost,Ultra,,126.35,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,inpatient,10,ML,66.80000,40.08000,MedCost,Ultra,,42.75,,,,,,,20.11,54.31,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,MedCost,Ultra,,34.07,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,inpatient,40,ML,78.15000,46.89000,MedCost,Ultra,,50.02,,,,,,,23.52,63.54,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,MedCost,Ultra,,39.86,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,inpatient,1,UN,735.15000,441.09000,MedCost,Ultra,,470.50,,,,,,,221.28,597.68,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,MedCost,Ultra,,374.93,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,inpatient,1,UN,17.55000,10.53000,MedCost,Ultra,,11.23,,,,,,,5.28,14.27,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,MedCost,Ultra,,8.95,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,0.1,ML,275.20000,165.12000,MedCost,Ultra,,176.13,,,,,,,82.84,223.74,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,MedCost,Ultra,,140.35,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,inpatient,0.2,ML,63.45000,38.07000,MedCost,Ultra,,40.61,,,,,,,19.10,51.58,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,MedCost,Ultra,,32.36,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,inpatient,10,ML,105.10000,63.06000,MedCost,Ultra,,67.26,,,,,,,31.64,85.45,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,MedCost,Ultra,,53.60,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,inpatient,100,ML,289.80000,173.88000,MedCost,Ultra,,185.47,,,,,,,87.23,235.61,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,MedCost,Ultra,,147.80,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,50,ML,176.40000,105.84000,MedCost,Ultra,,112.90,,,,,,,53.10,143.41,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,MedCost,Ultra,,89.96,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,inpatient,1,ML,24.20000,14.52000,MedCost,Ultra,,15.49,,,,,,,15.49,19.67,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,MedCost,Ultra,,12.34,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,inpatient,5,ML,120.55000,72.33000,MedCost,Ultra,,77.15,,,,,,,36.29,98.01,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,MedCost,Ultra,,61.48,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,inpatient,50,ML,71.40000,42.84000,MedCost,Ultra,,45.70,,,,,,,21.49,58.05,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,MedCost,Ultra,,36.41,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,inpatient,1,UN,78.35000,47.01000,MedCost,Ultra,,50.14,,,,,,,50.14,63.70,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,MedCost,Ultra,,39.96,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,inpatient,50,ML,180.60000,108.36000,MedCost,Ultra,,115.58,,,,,,,115.58,146.83,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,MedCost,Ultra,,92.11,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,inpatient,50,ML,171.80000,103.08000,MedCost,Ultra,,109.95,,,,,,,51.71,139.67,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,MedCost,Ultra,,87.62,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,inpatient,50,ML,75.60000,45.36000,MedCost,Ultra,,48.38,,,,,,,22.76,61.46,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,MedCost,Ultra,,38.56,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,inpatient,100,ML,29.20000,17.52000,MedCost,Ultra,,18.69,,,,,,,18.69,23.74,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,MedCost,Ultra,,14.89,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,inpatient,2,ML,34.75000,20.85000,MedCost,Ultra,,22.24,,,,,,,10.46,28.25,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,MedCost,Ultra,,17.72,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,inpatient,100,ML,71.40000,42.84000,MedCost,Ultra,,45.70,,,,,,,21.49,58.05,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,MedCost,Ultra,,36.41,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,inpatient,250,ML,1785.00000,1071.00000,MedCost,Ultra,,1142.40,,,,,,,537.28,1451.20,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,MedCost,Ultra,,910.35,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,inpatient,10,ML,99.55000,59.73000,MedCost,Ultra,,63.71,,,,,,,29.96,80.93,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,MedCost,Ultra,,50.77,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,inpatient,0.5,ML,25.15000,15.09000,MedCost,Ultra,,16.10,,,,,,,7.57,20.45,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,MedCost,Ultra,,12.83,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,inpatient,0.5,ML,34.85000,20.91000,MedCost,Ultra,,22.30,,,,,,,10.49,28.33,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,MedCost,Ultra,,17.77,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,inpatient,8,ML,71.75000,43.05000,MedCost,Ultra,,45.92,,,,,,,45.92,58.33,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,MedCost,Ultra,,36.59,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,inpatient,1,ML,27.75000,16.65000,MedCost,Ultra,,17.76,,,,,,,8.35,22.56,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,MedCost,Ultra,,14.15,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,MedCost,Ultra,,40.38,,,,,,,18.99,51.30,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,MedCost,Ultra,,32.18,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,inpatient,500,ML,174.00000,104.40000,MedCost,Ultra,,111.36,,,,,,,111.36,141.46,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,MedCost,Ultra,,88.74,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,inpatient,8,ML,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,40.96,52.03,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,inpatient,2,ML,88.20000,52.92000,MedCost,Ultra,,56.45,,,,,,,56.45,71.71,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,MedCost,Ultra,,44.98,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,0.5,ML,22.45000,13.47000,MedCost,Ultra,,14.37,,,,,,,6.76,18.25,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,MedCost,Ultra,,11.45,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,0.5,ML,22.50000,13.50000,MedCost,Ultra,,14.40,,,,,,,6.77,18.29,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,MedCost,Ultra,,11.47,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,inpatient,1,ML,25.60000,15.36000,MedCost,Ultra,,16.38,,,,,,,7.71,20.81,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,MedCost,Ultra,,13.06,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,MedCost,Ultra,,27.33,,,,,,,12.85,34.72,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,MedCost,Ultra,,21.78,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,MedCost,Ultra,,16.70,,,,,,,7.86,21.22,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,MedCost,Ultra,,13.31,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,82.17,221.95,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,inpatient,50,ML,131.05000,78.63000,MedCost,Ultra,,83.87,,,,,,,39.45,106.54,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,MedCost,Ultra,,66.84,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,inpatient,100,ML,94.50000,56.70000,MedCost,Ultra,,60.48,,,,,,,28.44,76.83,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,MedCost,Ultra,,48.20,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,inpatient,50,ML,139.65000,83.79000,MedCost,Ultra,,89.38,,,,,,,89.38,113.54,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,MedCost,Ultra,,71.22,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,29.15000,17.49000,MedCost,Ultra,,18.66,,,,,,,18.66,23.70,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,MedCost,Ultra,,14.87,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,inpatient,2.5,ML,104.30000,62.58000,MedCost,Ultra,,66.75,,,,,,,66.75,84.80,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,MedCost,Ultra,,53.19,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,inpatient,180,ML,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,68.48,86.99,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,inpatient,50,ML,81.90000,49.14000,MedCost,Ultra,,52.42,,,,,,,24.65,66.58,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,MedCost,Ultra,,41.77,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,inpatient,3,ML,17.75000,10.65000,MedCost,Ultra,,11.36,,,,,,,5.34,14.43,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,MedCost,Ultra,,9.05,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,inpatient,10,ML,68.30000,40.98000,MedCost,Ultra,,43.71,,,,,,,20.56,55.53,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,MedCost,Ultra,,34.83,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,inpatient,2.5,ML,17.25000,10.35000,MedCost,Ultra,,11.04,,,,,,,11.04,14.02,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,MedCost,Ultra,,8.80,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,55.90000,33.54000,MedCost,Ultra,,35.78,,,,,,,16.83,45.45,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,MedCost,Ultra,,28.51,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,inpatient,500,ML,82.25000,49.35000,MedCost,Ultra,,52.64,,,,,,,24.76,66.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,MedCost,Ultra,,41.95,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,inpatient,10,ML,106.35000,63.81000,MedCost,Ultra,,68.06,,,,,,,68.06,86.46,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,MedCost,Ultra,,54.24,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,333.3,ML,310.80000,186.48000,MedCost,Ultra,,198.91,,,,,,,93.55,252.68,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,MedCost,Ultra,,158.51,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,inpatient,10,ML,79.75000,47.85000,MedCost,Ultra,,51.04,,,,,,,24.00,64.84,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,MedCost,Ultra,,40.67,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,inpatient,20,ML,319.25000,191.55000,MedCost,Ultra,,204.32,,,,,,,96.09,259.55,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,MedCost,Ultra,,162.82,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,22.57,60.98,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,inpatient,4,ML,64.15000,38.49000,MedCost,Ultra,,41.06,,,,,,,19.31,52.15,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,MedCost,Ultra,,32.72,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,inpatient,50,ML,39.70000,23.82000,MedCost,Ultra,,25.41,,,,,,,25.41,32.16,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,MedCost,Ultra,,20.25,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,inpatient,100,ML,105.00000,63.00000,MedCost,Ultra,,67.20,,,,,,,31.61,85.36,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,MedCost,Ultra,,53.55,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,inpatient,10,ML,74.75000,44.85000,MedCost,Ultra,,47.84,,,,,,,47.84,60.77,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,MedCost,Ultra,,38.12,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,inpatient,50,ML,52.00000,31.20000,MedCost,Ultra,,33.28,,,,,,,15.65,42.28,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,MedCost,Ultra,,26.52,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,inpatient,400,ML,161.60000,96.96000,MedCost,Ultra,,103.42,,,,,,,48.64,131.38,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,MedCost,Ultra,,82.42,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,inpatient,0.5,ML,22.15000,13.29000,MedCost,Ultra,,14.18,,,,,,,14.18,18.01,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,MedCost,Ultra,,11.30,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,inpatient,15,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,MedCost,Ultra,,40.38,,,,,,,18.99,51.30,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,MedCost,Ultra,,32.18,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,inpatient,1,ML,451.85000,271.11000,MedCost,Ultra,,289.18,,,,,,,136.01,367.35,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,MedCost,Ultra,,230.44,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,MedCost,Ultra,,107.30,,,,,,,50.46,136.30,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,MedCost,Ultra,,85.50,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,inpatient,50,ML,276.60000,165.96000,MedCost,Ultra,,177.02,,,,,,,83.26,224.88,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,MedCost,Ultra,,141.07,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,inpatient,300,ML,239.40000,143.64000,MedCost,Ultra,,153.22,,,,,,,153.22,194.63,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,MedCost,Ultra,,122.09,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,inpatient,10,ML,73.90000,44.34000,MedCost,Ultra,,47.30,,,,,,,47.30,60.08,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,MedCost,Ultra,,37.69,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,inpatient,8,ML,65.70000,39.42000,MedCost,Ultra,,42.05,,,,,,,19.78,53.41,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,MedCost,Ultra,,33.51,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,inpatient,50,ML,79.60000,47.76000,MedCost,Ultra,,50.94,,,,,,,23.96,64.71,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,MedCost,Ultra,,40.60,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,inpatient,36,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,inpatient,6,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,inpatient,60,GR,59.80000,35.88000,MedCost,Ultra,,38.27,,,,,,,38.27,48.62,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,MedCost,Ultra,,30.50,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,inpatient,6.25,ME,16.05000,9.63000,MedCost,Ultra,,10.27,,,,,,,10.27,13.05,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,MedCost,Ultra,,8.19,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,inpatient,100,ML,247.60000,148.56000,MedCost,Ultra,,158.46,,,,,,,74.53,201.30,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,MedCost,Ultra,,126.28,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,MedCost,Ultra,,6449.28,,,,,,,3033.18,8192.60,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,MedCost,Ultra,,5139.27,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,inpatient,1,UN,87.60000,52.56000,MedCost,Ultra,,56.06,,,,,,,26.37,71.22,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,MedCost,Ultra,,44.68,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,inpatient,200,ML,150.40000,90.24000,MedCost,Ultra,,96.26,,,,,,,45.27,122.28,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,MedCost,Ultra,,76.70,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,inpatient,1150,ML,153.65000,92.19000,MedCost,Ultra,,98.34,,,,,,,98.34,124.92,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,MedCost,Ultra,,78.36,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,inpatient,1,ML,364.25000,218.55000,MedCost,Ultra,,233.12,,,,,,,109.64,296.14,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,MedCost,Ultra,,185.77,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,inpatient,96,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,inpatient,120,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,inpatient,120,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,inpatient,180,ME,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,inpatient,0.5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,MedCost,Ultra,,10136.74,,,,,,,4767.43,12876.82,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,MedCost,Ultra,,8077.71,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,inpatient,15,ML,394.60000,236.76000,MedCost,Ultra,,252.54,,,,,,,118.77,320.81,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,MedCost,Ultra,,201.25,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,MedCost,Ultra,,359.01,,,,,,,168.85,456.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,MedCost,Ultra,,286.08,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,MedCost,Ultra,,199.23,,,,,,,93.70,253.09,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,MedCost,Ultra,,158.76,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,MedCost,Ultra,,309.82,,,,,,,145.71,393.57,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,MedCost,Ultra,,246.89,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,MedCost,Ultra,,289.50,,,,,,,136.16,367.76,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,MedCost,Ultra,,230.70,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,MedCost,Ultra,,260.48,,,,,,,122.51,330.89,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,MedCost,Ultra,,207.57,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,inpatient,15,ML,367.40000,220.44000,MedCost,Ultra,,235.14,,,,,,,110.59,298.70,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,MedCost,Ultra,,187.37,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,MedCost,Ultra,,359.01,,,,,,,168.85,456.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,MedCost,Ultra,,286.08,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,MedCost,Ultra,,199.23,,,,,,,93.70,253.09,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,MedCost,Ultra,,158.76,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,MedCost,Ultra,,309.82,,,,,,,145.71,393.57,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,MedCost,Ultra,,246.89,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,MedCost,Ultra,,1753.98,,,,,,,824.92,2228.11,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,MedCost,Ultra,,1397.71,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,inpatient,4,ML,101.20000,60.72000,MedCost,Ultra,,64.77,,,,,,,30.46,82.28,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,MedCost,Ultra,,51.61,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,inpatient,60,ML,115.15000,69.09000,MedCost,Ultra,,73.70,,,,,,,73.70,93.62,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,MedCost,Ultra,,58.73,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,16.06,,,,,,,7.56,20.41,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,12.80,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,MedCost,Ultra,,18.98,,,,,,,8.92,24.11,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,MedCost,Ultra,,15.12,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,inpatient,10,ML,88.20000,52.92000,MedCost,Ultra,,56.45,,,,,,,56.45,71.71,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,MedCost,Ultra,,44.98,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,inpatient,1,UN,195.30000,117.18000,MedCost,Ultra,,124.99,,,,,,,58.79,158.78,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,MedCost,Ultra,,99.60,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,inpatient,0.25,ML,146.20000,87.72000,MedCost,Ultra,,93.57,,,,,,,93.57,118.86,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,MedCost,Ultra,,74.56,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,732.38,,,,,,,344.45,930.36,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,583.62,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,732.38,,,,,,,344.45,930.36,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,MedCost,Ultra,,583.62,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,inpatient,50,ML,73.60000,44.16000,MedCost,Ultra,,47.10,,,,,,,22.15,59.84,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,MedCost,Ultra,,37.54,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,inpatient,8,ML,64.45000,38.67000,MedCost,Ultra,,41.25,,,,,,,19.40,52.40,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,MedCost,Ultra,,32.87,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,inpatient,118,ML,412.15000,247.29000,MedCost,Ultra,,263.78,,,,,,,263.78,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,MedCost,Ultra,,210.20,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,inpatient,5,ML,40.35000,24.21000,MedCost,Ultra,,25.82,,,,,,,25.82,32.80,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,MedCost,Ultra,,20.58,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,inpatient,80,ML,173.25000,103.95000,MedCost,Ultra,,110.88,,,,,,,52.15,140.85,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,MedCost,Ultra,,88.36,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,0.5,ML,63.20000,37.92000,MedCost,Ultra,,40.45,,,,,,,19.02,51.38,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,MedCost,Ultra,,32.23,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,inpatient,100,ML,115.15000,69.09000,MedCost,Ultra,,73.70,,,,,,,73.70,93.62,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,MedCost,Ultra,,58.73,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,MedCost,Ultra,,31.30,,,,,,,31.30,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,MedCost,Ultra,,24.94,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,MedCost,Ultra,,16.48,,,,,,,16.48,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,MedCost,Ultra,,13.13,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,MedCost,Ultra,,20.70,,,,,,,20.70,26.30,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,MedCost,Ultra,,16.50,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,inpatient,50,ML,1584.85000,950.91000,MedCost,Ultra,,1014.30,,,,,,,1014.30,1288.48,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,MedCost,Ultra,,808.27,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,inpatient,10,ML,38.75000,23.25000,MedCost,Ultra,,24.80,,,,,,,11.66,31.50,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,MedCost,Ultra,,19.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,inpatient,100,ML,478.40000,287.04000,MedCost,Ultra,,306.18,,,,,,,306.18,388.94,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,MedCost,Ultra,,243.98,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,inpatient,50,ML,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,26.49,71.54,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,MedCost,Ultra,,1651.49,,,,,,,776.72,2097.91,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,MedCost,Ultra,,1316.03,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,inpatient,1,ML,17.20000,10.32000,MedCost,Ultra,,11.01,,,,,,,5.18,13.98,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,MedCost,Ultra,,8.77,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,inpatient,1,ML,144.30000,86.58000,MedCost,Ultra,,92.35,,,,,,,92.35,117.32,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,MedCost,Ultra,,73.59,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,inpatient,100,ML,1380.15000,828.09000,MedCost,Ultra,,883.30,,,,,,,883.30,1122.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,MedCost,Ultra,,703.88,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,inpatient,50,ML,73.80000,44.28000,MedCost,Ultra,,47.23,,,,,,,22.21,60.00,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,MedCost,Ultra,,37.64,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,inpatient,20,ML,215.00000,129.00000,MedCost,Ultra,,137.60,,,,,,,137.60,174.79,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,MedCost,Ultra,,109.65,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,inpatient,100,ML,597.25000,358.35000,MedCost,Ultra,,382.24,,,,,,,179.77,485.56,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,MedCost,Ultra,,304.60,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,inpatient,1,UN,109.20000,65.52000,MedCost,Ultra,,69.89,,,,,,,32.87,88.78,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,MedCost,Ultra,,55.69,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,inpatient,1,UN,115.50000,69.30000,MedCost,Ultra,,73.92,,,,,,,34.77,93.90,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,MedCost,Ultra,,58.91,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,MedCost,Ultra,,27.71,,,,,,,13.03,35.20,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,MedCost,Ultra,,22.08,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,MedCost,Ultra,,41.82,,,,,,,19.67,53.13,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,MedCost,Ultra,,33.33,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,inpatient,1,UN,47.45000,28.47000,MedCost,Ultra,,30.37,,,,,,,14.28,38.58,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,MedCost,Ultra,,24.20,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,inpatient,1,UN,66.05000,39.63000,MedCost,Ultra,,42.27,,,,,,,19.88,53.70,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,MedCost,Ultra,,33.69,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,inpatient,1,UN,36.50000,21.90000,MedCost,Ultra,,23.36,,,,,,,10.99,29.67,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,MedCost,Ultra,,18.61,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,66.05000,39.63000,MedCost,Ultra,,42.27,,,,,,,19.88,53.70,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,MedCost,Ultra,,33.69,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,inpatient,50,ML,48.45000,29.07000,MedCost,Ultra,,31.01,,,,,,,14.58,39.39,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,MedCost,Ultra,,24.71,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,inpatient,4,ML,88.80000,53.28000,MedCost,Ultra,,56.83,,,,,,,26.73,72.19,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,MedCost,Ultra,,45.29,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,inpatient,250,ML,260.40000,156.24000,MedCost,Ultra,,166.66,,,,,,,78.38,211.71,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,MedCost,Ultra,,132.80,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,inpatient,5,ML,119.70000,71.82000,MedCost,Ultra,,76.61,,,,,,,76.61,97.32,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,MedCost,Ultra,,61.05,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,inpatient,1,ML,118.25000,70.95000,MedCost,Ultra,,75.68,,,,,,,35.59,96.14,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,MedCost,Ultra,,60.31,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,MedCost,Ultra,,10.27,,,,,,,10.27,13.05,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,MedCost,Ultra,,8.19,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,MedCost,Ultra,,4347.52,,,,,,,2044.69,5522.71,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,MedCost,Ultra,,3464.43,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,inpatient,12,ML,30.95000,18.57000,MedCost,Ultra,,19.81,,,,,,,9.32,25.16,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,MedCost,Ultra,,15.78,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,inpatient,1,UN,83.25000,49.95000,MedCost,Ultra,,53.28,,,,,,,25.06,67.68,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,MedCost,Ultra,,42.46,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,inpatient,50,ML,65.10000,39.06000,MedCost,Ultra,,41.66,,,,,,,41.66,52.93,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,MedCost,Ultra,,33.20,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,inpatient,40,ML,178.35000,107.01000,MedCost,Ultra,,114.14,,,,,,,53.68,145.00,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,MedCost,Ultra,,90.96,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,inpatient,40,ML,50.60000,30.36000,MedCost,Ultra,,32.38,,,,,,,15.23,41.14,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,MedCost,Ultra,,25.81,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,inpatient,40,ML,231.70000,139.02000,MedCost,Ultra,,148.29,,,,,,,148.29,188.37,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,MedCost,Ultra,,118.17,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,inpatient,400,ML,237.75000,142.65000,MedCost,Ultra,,152.16,,,,,,,71.56,193.29,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,MedCost,Ultra,,121.25,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,inpatient,200,ML,150.40000,90.24000,MedCost,Ultra,,96.26,,,,,,,45.27,122.28,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,MedCost,Ultra,,76.70,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,145.38,392.68,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,inpatient,0.5,ML,68.25000,40.95000,MedCost,Ultra,,43.68,,,,,,,20.54,55.49,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,MedCost,Ultra,,34.81,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,inpatient,1,UN,22.10000,13.26000,MedCost,Ultra,,14.14,,,,,,,6.65,17.97,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,MedCost,Ultra,,11.27,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,inpatient,1,UN,22.80000,13.68000,MedCost,Ultra,,14.59,,,,,,,6.86,18.54,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,MedCost,Ultra,,11.63,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,inpatient,25,ML,458.95000,275.37000,MedCost,Ultra,,293.73,,,,,,,293.73,373.13,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,MedCost,Ultra,,234.06,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,inpatient,50,ML,26.05000,15.63000,MedCost,Ultra,,16.67,,,,,,,7.84,21.18,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,MedCost,Ultra,,13.29,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,MedCost,Ultra,,3735.33,,,,,,,1756.77,4745.03,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,MedCost,Ultra,,2976.59,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,inpatient,4,ML,63.05000,37.83000,MedCost,Ultra,,40.35,,,,,,,40.35,51.26,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,MedCost,Ultra,,32.16,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,inpatient,5,ML,63.15000,37.89000,MedCost,Ultra,,40.42,,,,,,,19.01,51.34,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,MedCost,Ultra,,32.21,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,inpatient,5,ML,63.25000,37.95000,MedCost,Ultra,,40.48,,,,,,,40.48,51.42,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,MedCost,Ultra,,32.26,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,inpatient,0.5,ML,63.30000,37.98000,MedCost,Ultra,,40.51,,,,,,,19.05,51.46,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,MedCost,Ultra,,32.28,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,inpatient,1,ML,63.05000,37.83000,MedCost,Ultra,,40.35,,,,,,,40.35,51.26,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,MedCost,Ultra,,32.16,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,inpatient,1,UN,144.90000,86.94000,MedCost,Ultra,,92.74,,,,,,,43.61,117.80,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,MedCost,Ultra,,73.90,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,inpatient,0.1,ML,19.35000,11.61000,MedCost,Ultra,,12.38,,,,,,,5.82,15.73,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,MedCost,Ultra,,9.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,MedCost,Ultra,,10.27,,,,,,,4.83,13.05,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,MedCost,Ultra,,8.19,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,inpatient,0.08,ML,66.20000,39.72000,MedCost,Ultra,,42.37,,,,,,,19.93,53.82,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,MedCost,Ultra,,33.76,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,inpatient,1,UN,50.05000,30.03000,MedCost,Ultra,,32.03,,,,,,,32.03,40.69,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,MedCost,Ultra,,25.53,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,10,ML,456.15000,273.69000,MedCost,Ultra,,291.94,,,,,,,137.30,370.85,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,MedCost,Ultra,,232.64,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,inpatient,10,ML,462.10000,277.26000,MedCost,Ultra,,295.74,,,,,,,139.09,375.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,MedCost,Ultra,,235.67,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,inpatient,10,ML,361.05000,216.63000,MedCost,Ultra,,231.07,,,,,,,108.68,293.53,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,MedCost,Ultra,,184.14,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,inpatient,0.5,ML,79.80000,47.88000,MedCost,Ultra,,51.07,,,,,,,51.07,64.88,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,MedCost,Ultra,,40.70,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,56.48,,,,,,,26.56,71.75,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,45.01,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,inpatient,5,ML,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,30.08,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,inpatient,100,ML,75.60000,45.36000,MedCost,Ultra,,48.38,,,,,,,48.38,61.24,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,MedCost,Ultra,,38.56,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,50.40,,,,,,,50.40,63.79,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,40.16,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,48.00,60.75,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,MedCost,Ultra,,10.27,,,,,,,4.83,13.05,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,MedCost,Ultra,,8.19,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,inpatient,1.25,ML,22.65000,13.59000,MedCost,Ultra,,14.50,,,,,,,14.50,18.41,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,MedCost,Ultra,,11.55,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,inpatient,5,ML,24.85000,14.91000,MedCost,Ultra,,15.90,,,,,,,7.48,20.20,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,MedCost,Ultra,,12.67,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,inpatient,2,ML,158.65000,95.19000,MedCost,Ultra,,101.54,,,,,,,47.75,128.98,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,MedCost,Ultra,,80.91,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,MedCost,Ultra,,56.93,,,,,,,26.77,72.32,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,MedCost,Ultra,,45.36,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,inpatient,1,UN,125.55000,75.33000,MedCost,Ultra,,80.35,,,,,,,37.79,102.07,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,MedCost,Ultra,,64.03,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,1,ML,84.10000,50.46000,MedCost,Ultra,,53.82,,,,,,,25.31,68.37,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,MedCost,Ultra,,42.89,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,MedCost,Ultra,,228.64,,,,,,,107.53,290.44,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,MedCost,Ultra,,182.20,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,MedCost,Ultra,,739.87,,,,,,,347.97,939.87,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,MedCost,Ultra,,589.59,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,16.86,,,,,,,7.93,21.42,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,13.44,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,inpatient,0.5,ML,24.95000,14.97000,MedCost,Ultra,,15.97,,,,,,,7.51,20.28,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,MedCost,Ultra,,12.72,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,inpatient,1,UN,730.25000,438.15000,MedCost,Ultra,,467.36,,,,,,,219.81,593.69,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,MedCost,Ultra,,372.43,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,inpatient,100,GR,101.70000,61.02000,MedCost,Ultra,,65.09,,,,,,,65.09,82.68,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,MedCost,Ultra,,51.87,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,19.26,52.03,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,inpatient,0.5,ML,103.50000,62.10000,MedCost,Ultra,,66.24,,,,,,,31.15,84.15,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,MedCost,Ultra,,52.78,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,inpatient,5,ML,62.05000,37.23000,MedCost,Ultra,,39.71,,,,,,,39.71,50.45,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,MedCost,Ultra,,31.65,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,MedCost,Ultra,,96.80,,,,,,,45.53,122.97,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,MedCost,Ultra,,77.14,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,MedCost,Ultra,,183.36,,,,,,,86.24,232.92,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,MedCost,Ultra,,146.12,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,inpatient,1,UN,39.00000,23.40000,MedCost,Ultra,,24.96,,,,,,,11.74,31.71,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,MedCost,Ultra,,19.89,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,inpatient,1,UN,61.50000,36.90000,MedCost,Ultra,,39.36,,,,,,,18.51,50.00,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,MedCost,Ultra,,31.36,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,inpatient,1,UN,26.40000,15.84000,MedCost,Ultra,,16.90,,,,,,,7.95,21.46,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,MedCost,Ultra,,13.46,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,MedCost,Ultra,,23.36,,,,,,,10.99,29.67,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,MedCost,Ultra,,18.61,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,inpatient,1,UN,210.00000,126.00000,MedCost,Ultra,,134.40,,,,,,,63.21,170.73,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,MedCost,Ultra,,107.10,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,inpatient,1,UN,75.60000,45.36000,MedCost,Ultra,,48.38,,,,,,,22.76,61.46,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,MedCost,Ultra,,38.56,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,MedCost,Ultra,,56.19,,,,,,,26.43,71.38,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,MedCost,Ultra,,44.78,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,inpatient,1,UN,82.30000,49.38000,MedCost,Ultra,,52.67,,,,,,,24.77,66.91,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,MedCost,Ultra,,41.97,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,16.06,,,,,,,7.56,20.41,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,MedCost,Ultra,,12.80,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,MedCost,Ultra,,18.98,,,,,,,8.92,24.11,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,MedCost,Ultra,,15.12,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,inpatient,8,ML,66.95000,40.17000,MedCost,Ultra,,42.85,,,,,,,20.15,54.43,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,MedCost,Ultra,,34.14,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,inpatient,50,ML,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,25.28,68.29,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,MedCost,Ultra,,14.85,,,,,,,6.98,18.86,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,MedCost,Ultra,,11.83,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,inpatient,120,ML,34.40000,20.64000,MedCost,Ultra,,22.02,,,,,,,22.02,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,MedCost,Ultra,,17.54,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,inpatient,50,ML,20.65000,12.39000,MedCost,Ultra,,13.22,,,,,,,13.22,16.79,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,MedCost,Ultra,,10.53,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,MedCost,Ultra,,27.33,,,,,,,12.85,34.72,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,MedCost,Ultra,,21.78,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,2,ML,23.95000,14.37000,MedCost,Ultra,,15.33,,,,,,,7.21,19.47,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,MedCost,Ultra,,12.21,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,5,ML,26.20000,15.72000,MedCost,Ultra,,16.77,,,,,,,7.89,21.30,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,MedCost,Ultra,,13.36,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,inpatient,5,ML,17.65000,10.59000,MedCost,Ultra,,11.30,,,,,,,11.30,14.35,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,MedCost,Ultra,,9.00,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,inpatient,1.25,ML,16.35000,9.81000,MedCost,Ultra,,10.46,,,,,,,10.46,13.29,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,MedCost,Ultra,,8.34,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,inpatient,500,ML,531.30000,318.78000,MedCost,Ultra,,340.03,,,,,,,159.92,431.95,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,MedCost,Ultra,,270.96,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,inpatient,120,ML,34.00000,20.40000,MedCost,Ultra,,21.76,,,,,,,21.76,27.64,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,MedCost,Ultra,,17.34,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,inpatient,120,ML,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,56.32,71.54,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,inpatient,4,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,MedCost,Ultra,,1651.49,,,,,,,776.72,2097.91,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,MedCost,Ultra,,1316.03,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,15823.87,,,,,,,7442.16,20101.26,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,12609.65,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,15823.87,,,,,,,7442.16,20101.26,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,12609.65,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,15823.87,,,,,,,7442.16,20101.26,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,12609.65,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,15823.87,,,,,,,7442.16,20101.26,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,12609.65,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,15823.87,,,,,,,7442.16,20101.26,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,MedCost,Ultra,,12609.65,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,MedCost,Ultra,,24171.87,,,,,,,11368.33,30705.83,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,MedCost,Ultra,,19261.96,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,inpatient,14,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,inpatient,150,ME,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,inpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,inpatient,15,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,inpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,inpatient,100,ML,403.95000,242.37000,MedCost,Ultra,,258.53,,,,,,,121.59,328.41,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,MedCost,Ultra,,206.01,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,inpatient,60,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,inpatient,100,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,inpatient,500,ME,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,inpatient,4,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,inpatient,4,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,inpatient,500,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,inpatient,16,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,inpatient,8,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,inpatient,100,ML,106.70000,64.02000,MedCost,Ultra,,68.29,,,,,,,32.12,86.75,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,MedCost,Ultra,,54.42,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,MedCost,Ultra,,18.98,,,,,,,8.92,24.11,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,MedCost,Ultra,,15.12,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,inpatient,0.1,ML,23.05000,13.83000,MedCost,Ultra,,14.75,,,,,,,6.94,18.74,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,MedCost,Ultra,,11.76,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,inpatient,1,ML,148.15000,88.89000,MedCost,Ultra,,94.82,,,,,,,94.82,120.45,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,MedCost,Ultra,,75.56,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,MedCost,Ultra,,19.17,,,,,,,9.01,24.35,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,MedCost,Ultra,,15.27,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,inpatient,113,GR,12.40000,7.44000,MedCost,Ultra,,7.94,,,,,,,7.94,10.08,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,MedCost,Ultra,,6.32,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,145.38,392.68,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,inpatient,4,ML,757.00000,454.20000,MedCost,Ultra,,484.48,,,,,,,227.86,615.44,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,MedCost,Ultra,,386.07,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,MedCost,Ultra,,31.30,,,,,,,14.72,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,MedCost,Ultra,,24.94,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,MedCost,Ultra,,16.48,,,,,,,7.75,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,MedCost,Ultra,,13.13,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,inpatient,5,ML,26.10000,15.66000,MedCost,Ultra,,16.70,,,,,,,7.86,21.22,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,MedCost,Ultra,,13.31,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,inpatient,1,ML,278.25000,166.95000,MedCost,Ultra,,178.08,,,,,,,83.75,226.22,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,MedCost,Ultra,,141.91,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,inpatient,10,ML,58.40000,35.04000,MedCost,Ultra,,37.38,,,,,,,37.38,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,MedCost,Ultra,,29.78,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,inpatient,15,ML,77.55000,46.53000,MedCost,Ultra,,49.63,,,,,,,49.63,63.05,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,MedCost,Ultra,,39.55,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.2,ML,16.85000,10.11000,MedCost,Ultra,,10.78,,,,,,,5.07,13.70,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,MedCost,Ultra,,8.59,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,inpatient,4000,ML,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,56.32,71.54,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,MedCost,Ultra,,345.47,,,,,,,162.48,438.86,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,MedCost,Ultra,,275.30,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,MedCost,Ultra,,197.38,,,,,,,92.83,250.73,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,MedCost,Ultra,,157.28,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,inpatient,20.3,ML,4.15000,2.49000,MedCost,Ultra,,2.66,,,,,,,2.66,3.37,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,MedCost,Ultra,,2.12,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,inpatient,5,ML,2.80000,1.68000,MedCost,Ultra,,1.79,,,,,,,1.79,2.28,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,MedCost,Ultra,,1.43,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,inpatient,287.5,ML,276.75000,166.05000,MedCost,Ultra,,177.12,,,,,,,83.30,225.00,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,MedCost,Ultra,,141.14,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,inpatient,555,ML,298.45000,179.07000,MedCost,Ultra,,191.01,,,,,,,89.83,242.64,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,MedCost,Ultra,,152.21,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,inpatient,557.5,ML,238.65000,143.19000,MedCost,Ultra,,152.74,,,,,,,71.83,194.02,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,MedCost,Ultra,,121.71,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,inpatient,560,ML,260.60000,156.36000,MedCost,Ultra,,166.78,,,,,,,78.44,211.87,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,MedCost,Ultra,,132.91,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,inpatient,30,ML,2.25000,1.35000,MedCost,Ultra,,1.44,,,,,,,1.44,1.83,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,MedCost,Ultra,,1.15,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,inpatient,0.09,ML,291.30000,174.78000,MedCost,Ultra,,186.43,,,,,,,87.68,236.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,MedCost,Ultra,,148.56,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,6.92,18.70,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,6.92,18.70,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,inpatient,10,ML,41.15000,24.69000,MedCost,Ultra,,26.34,,,,,,,12.39,33.45,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,MedCost,Ultra,,20.99,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,MedCost,Ultra,,42.40,,,,,,,19.94,53.86,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,MedCost,Ultra,,33.79,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,inpatient,50,ML,77.80000,46.68000,MedCost,Ultra,,49.79,,,,,,,49.79,63.25,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,MedCost,Ultra,,39.68,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,28.70000,17.22000,MedCost,Ultra,,18.37,,,,,,,18.37,23.33,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,MedCost,Ultra,,14.64,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,37.70000,22.62000,MedCost,Ultra,,24.13,,,,,,,24.13,30.65,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,MedCost,Ultra,,19.23,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,MedCost,Ultra,,23.81,,,,,,,11.20,30.24,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,MedCost,Ultra,,18.97,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,inpatient,1,UN,45136.00000,27081.60000,MedCost,Ultra,,28887.04,,,,,,,13585.94,36695.57,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,MedCost,Ultra,,23019.36,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,MedCost,Ultra,,23020.99,,,,,,,10827.06,29243.85,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,MedCost,Ultra,,18344.85,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,MedCost,Ultra,,32811.65,,,,,,,15431.73,41681.05,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,MedCost,Ultra,,26146.78,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,inpatient,1,UN,27.45000,16.47000,MedCost,Ultra,,17.57,,,,,,,17.57,22.32,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,MedCost,Ultra,,14.00,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,inpatient,1,UN,556.00000,333.60000,MedCost,Ultra,,355.84,,,,,,,355.84,452.03,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,MedCost,Ultra,,283.56,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,MedCost,Ultra,,201.44,,,,,,,94.74,255.89,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,MedCost,Ultra,,160.52,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,MedCost,Ultra,,185.47,,,,,,,87.23,235.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,MedCost,Ultra,,147.80,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,MedCost,Ultra,,269.63,,,,,,,126.81,342.52,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,MedCost,Ultra,,214.86,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,15,ML,46791.25000,28074.75000,MedCost,Ultra,,29946.40,,,,,,,14084.17,38041.29,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,MedCost,Ultra,,23863.54,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,MedCost,Ultra,,4887.17,,,,,,,2298.50,6208.23,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,MedCost,Ultra,,3894.46,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2531.58,,,,,,,1190.64,3215.90,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2017.36,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,MedCost,Ultra,,4887.17,,,,,,,2298.50,6208.23,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,MedCost,Ultra,,3894.46,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2531.58,,,,,,,1190.64,3215.90,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2017.36,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,MedCost,Ultra,,4887.17,,,,,,,2298.50,6208.23,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,MedCost,Ultra,,3894.46,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2531.58,,,,,,,1190.64,3215.90,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,MedCost,Ultra,,2017.36,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,MedCost,Ultra,,647.97,,,,,,,304.75,823.12,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,MedCost,Ultra,,516.35,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,12041.22,,,,,,,5663.13,15296.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,9595.34,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,12041.22,,,,,,,5663.13,15296.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,9595.34,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,12041.22,,,,,,,5663.13,15296.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,MedCost,Ultra,,9595.34,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,MedCost,Ultra,,32709.34,,,,,,,15383.61,41551.09,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,MedCost,Ultra,,26065.26,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,MedCost,Ultra,,1584.00,,,,,,,744.98,2012.17,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,MedCost,Ultra,,1262.25,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,MedCost,Ultra,,2672.42,,,,,,,1256.87,3394.80,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,MedCost,Ultra,,2129.58,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,MedCost,Ultra,,5304.51,,,,,,,2494.78,6738.39,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,MedCost,Ultra,,4227.03,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,MedCost,Ultra,,1093.18,,,,,,,514.14,1388.69,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,MedCost,Ultra,,871.13,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,MedCost,Ultra,,2672.42,,,,,,,1256.87,3394.80,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,MedCost,Ultra,,2129.58,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,MedCost,Ultra,,5304.51,,,,,,,2494.78,6738.39,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,MedCost,Ultra,,4227.03,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,MedCost,Ultra,,1093.18,,,,,,,514.14,1388.69,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,MedCost,Ultra,,871.13,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,inpatient,67,ML,278.85000,167.31000,MedCost,Ultra,,178.46,,,,,,,83.93,226.71,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,MedCost,Ultra,,142.21,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,inpatient,2,ML,44.10000,26.46000,MedCost,Ultra,,28.22,,,,,,,13.27,35.85,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,MedCost,Ultra,,22.49,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,inpatient,4,ML,29.75000,17.85000,MedCost,Ultra,,19.04,,,,,,,8.95,24.19,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,MedCost,Ultra,,15.17,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,inpatient,50,ML,191837.95000,115102.77000,MedCost,Ultra,,122776.29,,,,,,,122776.29,155964.25,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,MedCost,Ultra,,97837.35,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,inpatient,100,ML,128.90000,77.34000,MedCost,Ultra,,82.50,,,,,,,82.50,104.80,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,MedCost,Ultra,,65.74,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,inpatient,100,ML,70.50000,42.30000,MedCost,Ultra,,45.12,,,,,,,45.12,57.10,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,MedCost,Ultra,,35.95,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,inpatient,1000,ML,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,48.00,60.75,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,inpatient,250,ML,74.25000,44.55000,MedCost,Ultra,,47.52,,,,,,,47.52,60.14,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,MedCost,Ultra,,37.87,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,inpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,48.00,60.75,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,MedCost,Ultra,,941.63,,,,,,,442.86,1196.17,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,MedCost,Ultra,,750.36,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,inpatient,1,UN,70.75000,42.45000,MedCost,Ultra,,45.28,,,,,,,45.28,57.52,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,MedCost,Ultra,,36.08,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,inpatient,10,ML,20.30000,12.18000,MedCost,Ultra,,12.99,,,,,,,12.99,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,MedCost,Ultra,,10.35,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,inpatient,10,ML,21.50000,12.90000,MedCost,Ultra,,13.76,,,,,,,13.76,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,MedCost,Ultra,,10.96,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,inpatient,10,ML,19.25000,11.55000,MedCost,Ultra,,12.32,,,,,,,12.32,15.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,MedCost,Ultra,,9.82,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,inpatient,5,ML,671.00000,402.60000,MedCost,Ultra,,429.44,,,,,,,201.97,545.52,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,MedCost,Ultra,,342.21,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,inpatient,0.5,ML,145.05000,87.03000,MedCost,Ultra,,92.83,,,,,,,92.83,117.93,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,MedCost,Ultra,,73.98,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,inpatient,35.44,GR,736.00000,441.60000,MedCost,Ultra,,471.04,,,,,,,471.04,598.37,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,MedCost,Ultra,,375.36,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,inpatient,1,UN,263.45000,158.07000,MedCost,Ultra,,168.61,,,,,,,168.61,214.18,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,MedCost,Ultra,,134.36,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,inpatient,1,UN,55.40000,33.24000,MedCost,Ultra,,35.46,,,,,,,35.46,45.04,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,MedCost,Ultra,,28.25,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,inpatient,1,UN,55.40000,33.24000,MedCost,Ultra,,35.46,,,,,,,35.46,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,MedCost,Ultra,,28.25,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,inpatient,15,ML,5.10000,3.06000,MedCost,Ultra,,3.26,,,,,,,3.26,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,MedCost,Ultra,,2.60,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,inpatient,240,ML,12.95000,7.77000,MedCost,Ultra,,8.29,,,,,,,8.29,10.53,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,MedCost,Ultra,,6.60,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,inpatient,20,ML,79.90000,47.94000,MedCost,Ultra,,51.14,,,,,,,51.14,64.96,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,MedCost,Ultra,,40.75,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,inpatient,5,ML,60.25000,36.15000,MedCost,Ultra,,38.56,,,,,,,38.56,48.98,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,MedCost,Ultra,,30.73,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,inpatient,10,ML,460.75000,276.45000,MedCost,Ultra,,294.88,,,,,,,294.88,374.59,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,MedCost,Ultra,,234.98,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,inpatient,1000,ML,78.00000,46.80000,MedCost,Ultra,,49.92,,,,,,,49.92,63.18,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,MedCost,Ultra,,39.78,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,inpatient,1,UN,17.15000,10.29000,MedCost,Ultra,,10.98,,,,,,,10.98,13.94,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,MedCost,Ultra,,8.75,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,inpatient,1,UN,59.20000,35.52000,MedCost,Ultra,,37.89,,,,,,,37.89,48.13,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,MedCost,Ultra,,30.19,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,inpatient,1,UN,38.25000,22.95000,MedCost,Ultra,,24.48,,,,,,,24.48,31.10,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,MedCost,Ultra,,19.51,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,inpatient,60,ML,435.95000,261.57000,MedCost,Ultra,,279.01,,,,,,,279.01,354.43,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,MedCost,Ultra,,222.33,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,inpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,11.71,,,,,,,11.71,14.88,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,MedCost,Ultra,,9.33,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,inpatient,4,ML,106.60000,63.96000,MedCost,Ultra,,68.22,,,,,,,68.22,86.67,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,MedCost,Ultra,,54.37,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,inpatient,1,UN,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,32.21,86.99,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,inpatient,1,UN,583.00000,349.80000,MedCost,Ultra,,373.12,,,,,,,175.48,473.98,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,MedCost,Ultra,,297.33,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,inpatient,1,UN,313.75000,188.25000,MedCost,Ultra,,200.80,,,,,,,94.44,255.08,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,MedCost,Ultra,,160.01,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,inpatient,1,UN,51.80000,31.08000,MedCost,Ultra,,33.15,,,,,,,33.15,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,MedCost,Ultra,,26.42,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,inpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,13.06,,,,,,,13.06,16.59,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,MedCost,Ultra,,10.40,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,inpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,11.39,,,,,,,11.39,14.47,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,MedCost,Ultra,,9.08,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,inpatient,1,UN,18.20000,10.92000,MedCost,Ultra,,11.65,,,,,,,11.65,14.80,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,MedCost,Ultra,,9.28,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,11.33,,,,,,,11.33,14.39,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,9.03,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,inpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.63,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,inpatient,1,UN,22.65000,13.59000,MedCost,Ultra,,14.50,,,,,,,14.50,18.41,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,MedCost,Ultra,,11.55,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,inpatient,7.5,ML,34.00000,20.40000,MedCost,Ultra,,21.76,,,,,,,21.76,27.64,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,MedCost,Ultra,,17.34,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,inpatient,20,ML,30.50000,18.30000,MedCost,Ultra,,19.52,,,,,,,9.18,24.80,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,MedCost,Ultra,,15.55,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,inpatient,50,ML,30.60000,18.36000,MedCost,Ultra,,19.58,,,,,,,9.21,24.88,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,MedCost,Ultra,,15.61,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,inpatient,20,ML,34.15000,20.49000,MedCost,Ultra,,21.86,,,,,,,10.28,27.76,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,MedCost,Ultra,,17.42,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,inpatient,5,ML,38.00000,22.80000,MedCost,Ultra,,24.32,,,,,,,11.44,30.89,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,MedCost,Ultra,,19.38,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,inpatient,5,ML,115.10000,69.06000,MedCost,Ultra,,73.66,,,,,,,34.65,93.58,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,MedCost,Ultra,,58.70,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,inpatient,5,ML,49.10000,29.46000,MedCost,Ultra,,31.42,,,,,,,14.78,39.92,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,MedCost,Ultra,,25.04,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,inpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,10.40,,,,,,,10.40,13.21,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,MedCost,Ultra,,8.29,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,inpatient,1,UN,18.15000,10.89000,MedCost,Ultra,,11.62,,,,,,,11.62,14.76,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,MedCost,Ultra,,9.26,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,10.50,,,,,,,10.50,13.33,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,8.36,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,10.94,,,,,,,10.94,13.90,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,8.72,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,inpatient,5,ML,16.45000,9.87000,MedCost,Ultra,,10.53,,,,,,,10.53,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,MedCost,Ultra,,8.39,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,inpatient,5,ML,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,inpatient,1,UN,2.15000,1.29000,MedCost,Ultra,,1.38,,,,,,,1.38,1.75,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,MedCost,Ultra,,1.10,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,0.5,ML,23.80000,14.28000,MedCost,Ultra,,15.23,,,,,,,15.23,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,MedCost,Ultra,,12.14,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,inpatient,30,ML,116.70000,70.02000,MedCost,Ultra,,74.69,,,,,,,74.69,94.88,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,MedCost,Ultra,,59.52,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,inpatient,1,UN,234.40000,140.64000,MedCost,Ultra,,150.02,,,,,,,70.55,190.57,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,MedCost,Ultra,,119.54,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,inpatient,1,UN,47.45000,28.47000,MedCost,Ultra,,30.37,,,,,,,14.28,38.58,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,MedCost,Ultra,,24.20,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,inpatient,296,ML,4.25000,2.55000,MedCost,Ultra,,2.72,,,,,,,2.72,3.46,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,MedCost,Ultra,,2.17,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,inpatient,100,ML,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,27.39,73.98,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,inpatient,1,UN,48.35000,29.01000,MedCost,Ultra,,30.94,,,,,,,14.55,39.31,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,MedCost,Ultra,,24.66,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,MedCost,Ultra,,16.86,,,,,,,7.93,21.42,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,MedCost,Ultra,,13.44,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,inpatient,1,UN,31.25000,18.75000,MedCost,Ultra,,20.00,,,,,,,9.41,25.41,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,MedCost,Ultra,,15.94,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,inpatient,1,UN,29.65000,17.79000,MedCost,Ultra,,18.98,,,,,,,8.92,24.11,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,MedCost,Ultra,,15.12,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,inpatient,10,ML,185.65000,111.39000,MedCost,Ultra,,118.82,,,,,,,118.82,150.93,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,MedCost,Ultra,,94.68,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,inpatient,31.25,ML,77.15000,46.29000,MedCost,Ultra,,49.38,,,,,,,49.38,62.49,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,MedCost,Ultra,,39.35,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,inpatient,25,ML,29.90000,17.94000,MedCost,Ultra,,19.14,,,,,,,19.14,24.22,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,MedCost,Ultra,,15.25,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,10.94,,,,,,,10.94,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,8.72,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,MedCost,Ultra,,18.98,,,,,,,8.92,24.11,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,MedCost,Ultra,,15.12,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,MedCost,Ultra,,19.17,,,,,,,9.01,24.35,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,MedCost,Ultra,,15.27,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,inpatient,50,ML,87.25000,52.35000,MedCost,Ultra,,55.84,,,,,,,26.26,70.93,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,MedCost,Ultra,,44.50,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,inpatient,50,ML,89.05000,53.43000,MedCost,Ultra,,56.99,,,,,,,26.80,72.40,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,MedCost,Ultra,,45.42,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,inpatient,5,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,inpatient,500,ML,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.93,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,inpatient,1,UN,23.40000,14.04000,MedCost,Ultra,,14.98,,,,,,,14.98,19.02,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,MedCost,Ultra,,11.93,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,inpatient,5,ML,53.55000,32.13000,MedCost,Ultra,,34.27,,,,,,,16.12,43.54,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,MedCost,Ultra,,27.31,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,inpatient,1,UN,16.35000,9.81000,MedCost,Ultra,,10.46,,,,,,,10.46,13.29,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,MedCost,Ultra,,8.34,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,MedCost,Ultra,,23.81,,,,,,,11.20,30.24,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,MedCost,Ultra,,18.97,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,inpatient,2,ML,307.00000,184.20000,MedCost,Ultra,,196.48,,,,,,,92.41,249.59,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,MedCost,Ultra,,156.57,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,inpatient,1,UN,473.00000,283.80000,MedCost,Ultra,,302.72,,,,,,,142.37,384.55,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,MedCost,Ultra,,241.23,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,inpatient,1,UN,22.60000,13.56000,MedCost,Ultra,,14.46,,,,,,,14.46,18.37,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,MedCost,Ultra,,11.53,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,inpatient,0.25,ML,28.95000,17.37000,MedCost,Ultra,,18.53,,,,,,,8.71,23.54,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,MedCost,Ultra,,14.76,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,inpatient,1,ML,105.75000,63.45000,MedCost,Ultra,,67.68,,,,,,,31.83,85.97,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,MedCost,Ultra,,53.93,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,inpatient,1,UN,19.20000,11.52000,MedCost,Ultra,,12.29,,,,,,,12.29,15.61,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,MedCost,Ultra,,9.79,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,inpatient,1,UN,19.05000,11.43000,MedCost,Ultra,,12.19,,,,,,,12.19,15.49,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,MedCost,Ultra,,9.72,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,inpatient,5,ML,20.55000,12.33000,MedCost,Ultra,,13.15,,,,,,,6.19,16.71,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,MedCost,Ultra,,10.48,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,inpatient,1,UN,16.45000,9.87000,MedCost,Ultra,,10.53,,,,,,,10.53,13.37,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,MedCost,Ultra,,8.39,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,11.30,,,,,,,11.30,14.35,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,9.00,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,inpatient,1,UN,18.65000,11.19000,MedCost,Ultra,,11.94,,,,,,,11.94,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,MedCost,Ultra,,9.51,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,inpatient,100,ML,74.20000,44.52000,MedCost,Ultra,,47.49,,,,,,,22.33,60.32,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,MedCost,Ultra,,37.84,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,inpatient,45,GR,13.50000,8.10000,MedCost,Ultra,,8.64,,,,,,,8.64,10.98,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,MedCost,Ultra,,6.88,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,10.94,,,,,,,10.94,13.90,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,8.72,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,11.90,,,,,,,11.90,15.12,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,9.49,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,inpatient,1,UN,18.10000,10.86000,MedCost,Ultra,,11.58,,,,,,,11.58,14.72,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,MedCost,Ultra,,9.23,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,inpatient,0.5,ML,26.60000,15.96000,MedCost,Ultra,,17.02,,,,,,,8.01,21.63,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,MedCost,Ultra,,13.57,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,inpatient,1,ML,30.65000,18.39000,MedCost,Ultra,,19.62,,,,,,,9.23,24.92,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,MedCost,Ultra,,15.63,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,16.86,,,,,,,7.93,21.42,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,MedCost,Ultra,,13.44,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,inpatient,0.4,ML,22.10000,13.26000,MedCost,Ultra,,14.14,,,,,,,14.14,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,MedCost,Ultra,,11.27,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,inpatient,5,ML,26.10000,15.66000,MedCost,Ultra,,16.70,,,,,,,16.70,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,MedCost,Ultra,,13.31,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,inpatient,500,ML,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.98,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,inpatient,1,UN,23.30000,13.98000,MedCost,Ultra,,14.91,,,,,,,14.91,18.94,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,MedCost,Ultra,,11.88,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,inpatient,1,UN,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,30.08,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,inpatient,1,ML,32.30000,19.38000,MedCost,Ultra,,20.67,,,,,,,9.72,26.26,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,MedCost,Ultra,,16.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,MedCost,Ultra,,56.35,,,,,,,26.50,71.58,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,MedCost,Ultra,,44.91,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,inpatient,2,ML,166.15000,99.69000,MedCost,Ultra,,106.34,,,,,,,50.01,135.08,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,MedCost,Ultra,,84.74,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,10.91,,,,,,,10.91,13.86,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,8.70,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,inpatient,10,ML,128.35000,77.01000,MedCost,Ultra,,82.14,,,,,,,38.63,104.35,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,MedCost,Ultra,,65.46,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,inpatient,1,UN,53.70000,32.22000,MedCost,Ultra,,34.37,,,,,,,34.37,43.66,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,MedCost,Ultra,,27.39,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,inpatient,1,GR,25.70000,15.42000,MedCost,Ultra,,16.45,,,,,,,16.45,20.89,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,MedCost,Ultra,,13.11,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,10.75,13.66,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,10.94,,,,,,,10.94,13.90,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,8.72,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,inpatient,15,GR,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,inpatient,15,GR,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,inpatient,1,UN,18.40000,11.04000,MedCost,Ultra,,11.78,,,,,,,11.78,14.96,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,MedCost,Ultra,,9.38,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,inpatient,1,UN,23.25000,13.95000,MedCost,Ultra,,14.88,,,,,,,14.88,18.90,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,MedCost,Ultra,,11.86,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,inpatient,15,ML,10.50000,6.30000,MedCost,Ultra,,6.72,,,,,,,6.72,8.54,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,MedCost,Ultra,,5.36,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,inpatient,0.3,ML,20.95000,12.57000,MedCost,Ultra,,13.41,,,,,,,6.31,17.03,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,MedCost,Ultra,,10.68,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,inpatient,0.3,ML,17.95000,10.77000,MedCost,Ultra,,11.49,,,,,,,5.40,14.59,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,MedCost,Ultra,,9.15,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,inpatient,2,ML,204.45000,122.67000,MedCost,Ultra,,130.85,,,,,,,61.54,166.22,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,MedCost,Ultra,,104.27,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,inpatient,1,UN,247.55000,148.53000,MedCost,Ultra,,158.43,,,,,,,74.51,201.26,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,MedCost,Ultra,,126.25,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,inpatient,1,UN,73.90000,44.34000,MedCost,Ultra,,47.30,,,,,,,22.24,60.08,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,MedCost,Ultra,,37.69,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,inpatient,100,ML,42.70000,25.62000,MedCost,Ultra,,27.33,,,,,,,27.33,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,MedCost,Ultra,,21.78,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,10.75,13.66,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,MedCost,Ultra,,4347.52,,,,,,,2044.69,5522.71,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,MedCost,Ultra,,3464.43,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,11.42,14.51,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,inpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,11.07,,,,,,,11.07,14.06,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,MedCost,Ultra,,8.82,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,inpatient,5,ML,24.30000,14.58000,MedCost,Ultra,,15.55,,,,,,,15.55,19.76,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,MedCost,Ultra,,12.39,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,inpatient,1,UN,23.65000,14.19000,MedCost,Ultra,,15.14,,,,,,,15.14,19.23,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,MedCost,Ultra,,12.06,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,inpatient,1,ML,227.20000,136.32000,MedCost,Ultra,,145.41,,,,,,,68.39,184.71,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,MedCost,Ultra,,115.87,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,inpatient,1,ML,101.10000,60.66000,MedCost,Ultra,,64.70,,,,,,,30.43,82.19,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,MedCost,Ultra,,51.56,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,inpatient,1,ML,34.20000,20.52000,MedCost,Ultra,,21.89,,,,,,,10.29,27.80,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,MedCost,Ultra,,17.44,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,inpatient,10,ML,212.70000,127.62000,MedCost,Ultra,,136.13,,,,,,,64.02,172.93,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,MedCost,Ultra,,108.48,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,inpatient,5,ML,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,32.21,86.99,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,inpatient,15,ML,6.40000,3.84000,MedCost,Ultra,,4.10,,,,,,,4.10,5.20,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,MedCost,Ultra,,3.26,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,inpatient,15,ML,6.40000,3.84000,MedCost,Ultra,,4.10,,,,,,,4.10,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,MedCost,Ultra,,3.26,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,inpatient,2,ML,113.50000,68.10000,MedCost,Ultra,,72.64,,,,,,,72.64,92.28,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,MedCost,Ultra,,57.88,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,inpatient,2,ML,22.35000,13.41000,MedCost,Ultra,,14.30,,,,,,,6.73,18.17,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,MedCost,Ultra,,11.40,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,inpatient,1,UN,23.65000,14.19000,MedCost,Ultra,,15.14,,,,,,,15.14,19.23,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,MedCost,Ultra,,12.06,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.25,ML,72.30000,43.38000,MedCost,Ultra,,46.27,,,,,,,21.76,58.78,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,MedCost,Ultra,,36.87,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,inpatient,15,ML,252.60000,151.56000,MedCost,Ultra,,161.66,,,,,,,161.66,205.36,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,MedCost,Ultra,,128.83,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,inpatient,15,ML,258.00000,154.80000,MedCost,Ultra,,165.12,,,,,,,165.12,209.75,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,MedCost,Ultra,,131.58,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,inpatient,15,ML,269.70000,161.82000,MedCost,Ultra,,172.61,,,,,,,172.61,219.27,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,MedCost,Ultra,,137.55,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,inpatient,100,ML,155.40000,93.24000,MedCost,Ultra,,99.46,,,,,,,99.46,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,MedCost,Ultra,,79.25,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,inpatient,20,ML,85.70000,51.42000,MedCost,Ultra,,54.85,,,,,,,54.85,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,MedCost,Ultra,,43.71,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,inpatient,50,ML,110.05000,66.03000,MedCost,Ultra,,70.43,,,,,,,70.43,89.47,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,MedCost,Ultra,,56.13,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,inpatient,10,ML,72.65000,43.59000,MedCost,Ultra,,46.50,,,,,,,21.87,59.06,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,MedCost,Ultra,,37.05,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,inpatient,473,ML,189.15000,113.49000,MedCost,Ultra,,121.06,,,,,,,121.06,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,MedCost,Ultra,,96.47,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,inpatient,1,UN,44.85000,26.91000,MedCost,Ultra,,28.70,,,,,,,28.70,36.46,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,MedCost,Ultra,,22.87,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,inpatient,28.4,GR,3.85000,2.31000,MedCost,Ultra,,2.46,,,,,,,2.46,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,MedCost,Ultra,,1.96,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,inpatient,118,ML,3.05000,1.83000,MedCost,Ultra,,1.95,,,,,,,1.95,2.48,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,MedCost,Ultra,,1.56,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,inpatient,1,UN,410.50000,246.30000,MedCost,Ultra,,262.72,,,,,,,123.56,333.74,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,MedCost,Ultra,,209.35,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,inpatient,1,UN,22.05000,13.23000,MedCost,Ultra,,14.11,,,,,,,14.11,17.93,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,MedCost,Ultra,,11.25,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,inpatient,1,UN,24.45000,14.67000,MedCost,Ultra,,15.65,,,,,,,15.65,19.88,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,MedCost,Ultra,,12.47,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,inpatient,5,ML,148.75000,89.25000,MedCost,Ultra,,95.20,,,,,,,95.20,120.93,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,MedCost,Ultra,,75.86,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,inpatient,500,ML,1256.00000,753.60000,MedCost,Ultra,,803.84,,,,,,,378.06,1021.13,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,MedCost,Ultra,,640.56,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,5.09,13.74,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,5.09,13.74,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,10.85,,,,,,,5.10,13.78,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,8.64,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,5.06,13.66,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,inpatient,1,UN,21.30000,12.78000,MedCost,Ultra,,13.63,,,,,,,13.63,17.32,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,MedCost,Ultra,,10.86,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,inpatient,1,UN,17.45000,10.47000,MedCost,Ultra,,11.17,,,,,,,11.17,14.19,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,MedCost,Ultra,,8.90,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,inpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,inpatient,1,ML,202.50000,121.50000,MedCost,Ultra,,129.60,,,,,,,60.95,164.63,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,MedCost,Ultra,,103.28,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,inpatient,0.5,ML,22.20000,13.32000,MedCost,Ultra,,14.21,,,,,,,6.68,18.05,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,MedCost,Ultra,,11.32,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,11.14,,,,,,,11.14,14.15,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,8.87,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,inpatient,0.1,ML,17.55000,10.53000,MedCost,Ultra,,11.23,,,,,,,5.28,14.27,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,MedCost,Ultra,,8.95,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,inpatient,1,ML,24.45000,14.67000,MedCost,Ultra,,15.65,,,,,,,7.36,19.88,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,MedCost,Ultra,,12.47,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,inpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,11.33,,,,,,,11.33,14.39,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,MedCost,Ultra,,9.03,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,inpatient,15,ML,121.30000,72.78000,MedCost,Ultra,,77.63,,,,,,,77.63,98.62,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,MedCost,Ultra,,61.86,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,inpatient,500,ML,161.50000,96.90000,MedCost,Ultra,,103.36,,,,,,,103.36,131.30,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,MedCost,Ultra,,82.36,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,inpatient,1,UN,16.65000,9.99000,MedCost,Ultra,,10.66,,,,,,,10.66,13.54,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,MedCost,Ultra,,8.49,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,inpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,11.14,,,,,,,11.14,14.15,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,MedCost,Ultra,,8.87,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,10.91,,,,,,,10.91,13.86,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,8.70,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,inpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,11.81,,,,,,,11.81,15.00,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,MedCost,Ultra,,9.41,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,inpatient,25,ML,256.70000,154.02000,MedCost,Ultra,,164.29,,,,,,,77.27,208.70,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,MedCost,Ultra,,130.92,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,inpatient,5,ML,86.45000,51.87000,MedCost,Ultra,,55.33,,,,,,,26.02,70.28,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,MedCost,Ultra,,44.09,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,inpatient,1,UN,25.20000,15.12000,MedCost,Ultra,,16.13,,,,,,,16.13,20.49,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,MedCost,Ultra,,12.85,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,inpatient,0.5,ML,65.45000,39.27000,MedCost,Ultra,,41.89,,,,,,,19.70,53.21,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,MedCost,Ultra,,33.38,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.89600,,,,,,,0.89600,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.71400,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.89600,,,,,,,0.89600,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.71400,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,inpatient,1,UN,2.85000,1.71000,MedCost,Ultra,,1.82,,,,,,,1.82,2.32,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,MedCost,Ultra,,1.45,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,inpatient,15,ML,7.65000,4.59000,MedCost,Ultra,,4.90,,,,,,,4.90,6.22,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,MedCost,Ultra,,3.90,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,inpatient,1,UN,93.85000,56.31000,MedCost,Ultra,,60.06,,,,,,,60.06,76.30,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,MedCost,Ultra,,47.86,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,11.01,,,,,,,11.01,13.98,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,8.77,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,11.26,14.31,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,inpatient,1,UN,83.60000,50.16000,MedCost,Ultra,,53.50,,,,,,,25.16,67.97,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,MedCost,Ultra,,42.64,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,inpatient,1,UN,83.60000,50.16000,MedCost,Ultra,,53.50,,,,,,,25.16,67.97,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,MedCost,Ultra,,42.64,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,inpatient,1,UN,83.60000,50.16000,MedCost,Ultra,,53.50,,,,,,,25.16,67.97,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,MedCost,Ultra,,42.64,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,inpatient,1,UN,947.35000,568.41000,MedCost,Ultra,,606.30,,,,,,,606.30,770.20,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,MedCost,Ultra,,483.15,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,inpatient,16,GR,22.20000,13.32000,MedCost,Ultra,,14.21,,,,,,,14.21,18.05,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,MedCost,Ultra,,11.32,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,inpatient,1,UN,356.60000,213.96000,MedCost,Ultra,,228.22,,,,,,,228.22,289.92,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,MedCost,Ultra,,181.87,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,inpatient,10,ML,404.65000,242.79000,MedCost,Ultra,,258.98,,,,,,,121.80,328.98,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,MedCost,Ultra,,206.37,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,inpatient,2.5,ML,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,inpatient,2.5,ML,1.20000,0.72000,MedCost,Ultra,,0.76800,,,,,,,0.76800,0.97560,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,MedCost,Ultra,,0.61200,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,10.69,13.58,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,10.50,,,,,,,10.50,13.33,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,8.36,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,inpatient,50,GR,53.20000,31.92000,MedCost,Ultra,,34.05,,,,,,,34.05,43.25,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,MedCost,Ultra,,27.13,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,inpatient,0.3,ML,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,inpatient,10,ML,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,30.10,81.30,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,inpatient,5,ML,104.75000,62.85000,MedCost,Ultra,,67.04,,,,,,,31.53,85.16,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,MedCost,Ultra,,53.42,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,inpatient,20,ML,67.00000,40.20000,MedCost,Ultra,,42.88,,,,,,,42.88,54.47,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,MedCost,Ultra,,34.17,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,inpatient,100,ML,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.30,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,inpatient,10,ML,116.65000,69.99000,MedCost,Ultra,,74.66,,,,,,,74.66,94.84,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,MedCost,Ultra,,59.49,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,inpatient,50,ML,112.05000,67.23000,MedCost,Ultra,,71.71,,,,,,,71.71,91.10,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,MedCost,Ultra,,57.15,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,inpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,50.40,,,,,,,50.40,63.79,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,MedCost,Ultra,,40.16,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,inpatient,500,ML,76.50000,45.90000,MedCost,Ultra,,48.96,,,,,,,48.96,61.97,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,MedCost,Ultra,,39.02,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,500,ML,82.50000,49.50000,MedCost,Ultra,,52.80,,,,,,,24.83,67.07,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,MedCost,Ultra,,42.08,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,inpatient,30,ML,82.45000,49.47000,MedCost,Ultra,,52.77,,,,,,,24.82,67.03,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,MedCost,Ultra,,42.05,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,inpatient,30,ML,95.15000,57.09000,MedCost,Ultra,,60.90,,,,,,,28.64,77.36,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,MedCost,Ultra,,48.53,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,inpatient,4,ML,18.70000,11.22000,MedCost,Ultra,,11.97,,,,,,,11.97,15.20,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,MedCost,Ultra,,9.54,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,inpatient,15,ML,136.65000,81.99000,MedCost,Ultra,,87.46,,,,,,,87.46,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,MedCost,Ultra,,69.69,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,inpatient,5,ML,74.25000,44.55000,MedCost,Ultra,,47.52,,,,,,,47.52,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,MedCost,Ultra,,37.87,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,inpatient,50,ML,428.05000,256.83000,MedCost,Ultra,,273.95,,,,,,,273.95,348.00,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,MedCost,Ultra,,218.31,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,inpatient,50,ML,394.80000,236.88000,MedCost,Ultra,,252.67,,,,,,,118.83,320.97,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,MedCost,Ultra,,201.35,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,inpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,10.85,,,,,,,10.85,13.78,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,MedCost,Ultra,,8.64,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,inpatient,500,ML,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,inpatient,500,ML,69.00000,41.40000,MedCost,Ultra,,44.16,,,,,,,44.16,56.10,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,MedCost,Ultra,,35.19,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,inpatient,1,UN,80.15000,48.09000,MedCost,Ultra,,51.30,,,,,,,51.30,65.16,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,MedCost,Ultra,,40.88,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,inpatient,10,ML,115.70000,69.42000,MedCost,Ultra,,74.05,,,,,,,34.83,94.06,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,MedCost,Ultra,,59.01,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,inpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,10.75,,,,,,,10.75,13.66,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,MedCost,Ultra,,8.57,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,11.04,,,,,,,11.04,14.02,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,8.80,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,inpatient,0.3,ML,5298.55000,3179.13000,MedCost,Ultra,,3391.07,,,,,,,1594.86,4307.72,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,MedCost,Ultra,,2702.26,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,inpatient,1,ML,269.90000,161.94000,MedCost,Ultra,,172.74,,,,,,,81.24,219.43,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,MedCost,Ultra,,137.65,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,inpatient,1,UN,715.00000,429.00000,MedCost,Ultra,,457.60,,,,,,,215.22,581.29,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,MedCost,Ultra,,364.65,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,inpatient,1,UN,85.10000,51.06000,MedCost,Ultra,,54.46,,,,,,,25.62,69.19,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,MedCost,Ultra,,43.40,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,inpatient,1,UN,45.70000,27.42000,MedCost,Ultra,,29.25,,,,,,,29.25,37.15,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,MedCost,Ultra,,23.31,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,inpatient,1,UN,49.55000,29.73000,MedCost,Ultra,,31.71,,,,,,,31.71,40.28,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,MedCost,Ultra,,25.27,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,inpatient,5,ML,1.55000,0.93000,MedCost,Ultra,,0.99200,,,,,,,0.99200,1.26,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,MedCost,Ultra,,0.79050,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,inpatient,1,UN,407.75000,244.65000,MedCost,Ultra,,260.96,,,,,,,260.96,331.50,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,MedCost,Ultra,,207.95,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,inpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.70,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,inpatient,2,ML,1979.25000,1187.55000,MedCost,Ultra,,1266.72,,,,,,,1266.72,1609.13,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,MedCost,Ultra,,1009.42,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,inpatient,1,UN,367.80000,220.68000,MedCost,Ultra,,235.39,,,,,,,110.71,299.02,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,MedCost,Ultra,,187.58,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,inpatient,50,GR,6.90000,4.14000,MedCost,Ultra,,4.42,,,,,,,4.42,5.61,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,MedCost,Ultra,,3.52,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,inpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,inpatient,20,ML,646.00000,387.60000,MedCost,Ultra,,413.44,,,,,,,194.45,525.20,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,MedCost,Ultra,,329.46,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,inpatient,1,UN,26.55000,15.93000,MedCost,Ultra,,16.99,,,,,,,16.99,21.59,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,MedCost,Ultra,,13.54,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,inpatient,5,ML,79.80000,47.88000,MedCost,Ultra,,51.07,,,,,,,24.02,64.88,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,MedCost,Ultra,,40.70,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,inpatient,2.5,ML,118.85000,71.31000,MedCost,Ultra,,76.06,,,,,,,76.06,96.63,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,MedCost,Ultra,,60.61,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,inpatient,1,UN,22.30000,13.38000,MedCost,Ultra,,14.27,,,,,,,14.27,18.13,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,MedCost,Ultra,,11.37,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,inpatient,2,ML,94.80000,56.88000,MedCost,Ultra,,60.67,,,,,,,60.67,77.07,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,MedCost,Ultra,,48.35,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,inpatient,1,UN,848.40000,509.04000,MedCost,Ultra,,542.98,,,,,,,255.37,689.75,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,MedCost,Ultra,,432.68,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,inpatient,10,ML,32.20000,19.32000,MedCost,Ultra,,20.61,,,,,,,20.61,26.18,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,MedCost,Ultra,,16.42,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,inpatient,0.25,ML,27.95000,16.77000,MedCost,Ultra,,17.89,,,,,,,8.41,22.72,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,MedCost,Ultra,,14.25,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,inpatient,0.25,ML,28.70000,17.22000,MedCost,Ultra,,18.37,,,,,,,8.64,23.33,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,MedCost,Ultra,,14.64,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,inpatient,15,ML,286.00000,171.60000,MedCost,Ultra,,183.04,,,,,,,183.04,232.52,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,MedCost,Ultra,,145.86,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,inpatient,15,ML,6.25000,3.75000,MedCost,Ultra,,4.00,,,,,,,4.00,5.08,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,MedCost,Ultra,,3.19,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,inpatient,18.75,ML,25.05000,15.03000,MedCost,Ultra,,16.03,,,,,,,16.03,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,MedCost,Ultra,,12.78,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,18.75,ML,25.05000,15.03000,MedCost,Ultra,,16.03,,,,,,,16.03,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,MedCost,Ultra,,12.78,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,inpatient,1,UN,53.45000,32.07000,MedCost,Ultra,,34.21,,,,,,,34.21,43.45,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,MedCost,Ultra,,27.26,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,inpatient,1,UN,2850.10000,1710.06000,MedCost,Ultra,,1824.06,,,,,,,857.88,2317.13,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,MedCost,Ultra,,1453.55,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,inpatient,1,UN,62.05000,37.23000,MedCost,Ultra,,39.71,,,,,,,39.71,50.45,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,MedCost,Ultra,,31.65,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,inpatient,0.25,ML,22.80000,13.68000,MedCost,Ultra,,14.59,,,,,,,6.86,18.54,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,MedCost,Ultra,,11.63,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,12.67,,,,,,,12.67,16.10,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,10.10,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,inpatient,1,UN,23.65000,14.19000,MedCost,Ultra,,15.14,,,,,,,15.14,19.23,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,MedCost,Ultra,,12.06,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,inpatient,5,ML,62.50000,37.50000,MedCost,Ultra,,40.00,,,,,,,40.00,50.81,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,MedCost,Ultra,,31.88,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,inpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,10.56,,,,,,,10.56,13.41,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,MedCost,Ultra,,8.41,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,inpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,10.59,,,,,,,10.59,13.46,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,MedCost,Ultra,,8.44,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,inpatient,15,GR,25.00000,15.00000,MedCost,Ultra,,16.00,,,,,,,16.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,MedCost,Ultra,,12.75,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,inpatient,15,GR,40.60000,24.36000,MedCost,Ultra,,25.98,,,,,,,25.98,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,MedCost,Ultra,,20.71,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,inpatient,15,GR,29.95000,17.97000,MedCost,Ultra,,19.17,,,,,,,19.17,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,MedCost,Ultra,,15.27,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,1,ML,58.60000,35.16000,MedCost,Ultra,,37.50,,,,,,,17.64,47.64,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,MedCost,Ultra,,29.89,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,inpatient,1,ML,55.45000,33.27000,MedCost,Ultra,,35.49,,,,,,,16.69,45.08,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,MedCost,Ultra,,28.28,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,inpatient,1,ML,45.50000,27.30000,MedCost,Ultra,,29.12,,,,,,,13.70,36.99,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,MedCost,Ultra,,23.20,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,inpatient,5,GR,209.45000,125.67000,MedCost,Ultra,,134.05,,,,,,,134.05,170.28,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,MedCost,Ultra,,106.82,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,inpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,10.94,,,,,,,10.94,13.90,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,MedCost,Ultra,,8.72,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,inpatient,1,UN,25.95000,15.57000,MedCost,Ultra,,16.61,,,,,,,16.61,21.10,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,MedCost,Ultra,,13.23,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,inpatient,6.9,GR,431.25000,258.75000,MedCost,Ultra,,276.00,,,,,,,276.00,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,MedCost,Ultra,,219.94,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,inpatient,6,GR,493.60000,296.16000,MedCost,Ultra,,315.90,,,,,,,315.90,401.30,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,MedCost,Ultra,,251.74,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,inpatient,30,ML,27459.60000,16475.76000,MedCost,Ultra,,17574.14,,,,,,,8265.34,22324.65,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,MedCost,Ultra,,14004.40,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,inpatient,10,ML,92.40000,55.44000,MedCost,Ultra,,59.14,,,,,,,27.81,75.12,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,MedCost,Ultra,,47.12,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,inpatient,4,ML,18.70000,11.22000,MedCost,Ultra,,11.97,,,,,,,11.97,15.20,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,MedCost,Ultra,,9.54,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,MedCost,Ultra,,185.63,,,,,,,87.31,235.81,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,MedCost,Ultra,,147.93,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,inpatient,20,ML,305.10000,183.06000,MedCost,Ultra,,195.26,,,,,,,91.84,248.05,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,MedCost,Ultra,,155.60,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,inpatient,1,UN,9076.45000,5445.87000,MedCost,Ultra,,5808.93,,,,,,,2732.01,7379.15,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,MedCost,Ultra,,4628.99,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,inpatient,2,ML,27.35000,16.41000,MedCost,Ultra,,17.50,,,,,,,8.23,22.24,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,MedCost,Ultra,,13.95,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,inpatient,60,ML,120.60000,72.36000,MedCost,Ultra,,77.18,,,,,,,36.30,98.05,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,MedCost,Ultra,,61.51,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,inpatient,15,ML,106.00000,63.60000,MedCost,Ultra,,67.84,,,,,,,67.84,86.18,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,MedCost,Ultra,,54.06,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,inpatient,1,UN,107.50000,64.50000,MedCost,Ultra,,68.80,,,,,,,68.80,87.40,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,MedCost,Ultra,,54.83,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,inpatient,1,UN,107.45000,64.47000,MedCost,Ultra,,68.77,,,,,,,68.77,87.36,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,MedCost,Ultra,,54.80,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,inpatient,0.1,ML,56.75000,34.05000,MedCost,Ultra,,36.32,,,,,,,36.32,46.14,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,MedCost,Ultra,,28.94,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,inpatient,1,UN,131.40000,78.84000,MedCost,Ultra,,84.10,,,,,,,39.55,106.83,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,MedCost,Ultra,,67.01,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,inpatient,1,UN,97.30000,58.38000,MedCost,Ultra,,62.27,,,,,,,29.29,79.10,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,MedCost,Ultra,,49.62,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,inpatient,1,UN,442.10000,265.26000,MedCost,Ultra,,282.94,,,,,,,133.07,359.43,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,MedCost,Ultra,,225.47,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,inpatient,28.4,GR,4.45000,2.67000,MedCost,Ultra,,2.85,,,,,,,2.85,3.62,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,MedCost,Ultra,,2.27,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,inpatient,2,ML,61.50000,36.90000,MedCost,Ultra,,39.36,,,,,,,39.36,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,MedCost,Ultra,,31.36,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,inpatient,4,ML,45.20000,27.12000,MedCost,Ultra,,28.93,,,,,,,28.93,36.75,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,MedCost,Ultra,,23.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,inpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,10.50,,,,,,,10.50,13.33,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,MedCost,Ultra,,8.36,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,11.04,,,,,,,11.04,14.02,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,8.80,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,inpatient,28,GR,5.25000,3.15000,MedCost,Ultra,,3.36,,,,,,,3.36,4.27,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,MedCost,Ultra,,2.68,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,inpatient,10,ML,511.55000,306.93000,MedCost,Ultra,,327.39,,,,,,,153.98,415.89,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,MedCost,Ultra,,260.89,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,inpatient,1,ML,353.10000,211.86000,MedCost,Ultra,,225.98,,,,,,,106.28,287.07,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,MedCost,Ultra,,180.08,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,inpatient,1,UN,17.90000,10.74000,MedCost,Ultra,,11.46,,,,,,,11.46,14.55,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,MedCost,Ultra,,9.13,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,inpatient,1,UN,17.55000,10.53000,MedCost,Ultra,,11.23,,,,,,,11.23,14.27,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,MedCost,Ultra,,8.95,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,inpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,11.26,,,,,,,11.26,14.31,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,MedCost,Ultra,,8.98,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,inpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,11.30,,,,,,,11.30,14.35,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,MedCost,Ultra,,9.00,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,inpatient,1,UN,18.35000,11.01000,MedCost,Ultra,,11.74,,,,,,,11.74,14.92,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,MedCost,Ultra,,9.36,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,inpatient,1,UN,33.40000,20.04000,MedCost,Ultra,,21.38,,,,,,,21.38,27.15,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,MedCost,Ultra,,17.03,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,inpatient,0.5,ML,40477.65000,24286.59000,MedCost,Ultra,,25905.70,,,,,,,12183.77,32908.33,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,MedCost,Ultra,,20643.60,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,inpatient,10,ML,567.95000,340.77000,MedCost,Ultra,,363.49,,,,,,,170.95,461.74,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,MedCost,Ultra,,289.65,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,inpatient,2,ML,40.90000,24.54000,MedCost,Ultra,,26.18,,,,,,,12.31,33.25,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,MedCost,Ultra,,20.86,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,inpatient,2,ML,98.10000,58.86000,MedCost,Ultra,,62.78,,,,,,,62.78,79.76,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,MedCost,Ultra,,50.03,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,MedCost,Ultra,,289.50,,,,,,,136.16,367.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,MedCost,Ultra,,230.70,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,MedCost,Ultra,,260.48,,,,,,,122.51,330.89,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,MedCost,Ultra,,207.57,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,inpatient,1,UN,154.90000,92.94000,MedCost,Ultra,,99.14,,,,,,,99.14,125.93,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,MedCost,Ultra,,79.00,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,inpatient,4,ML,59.15000,35.49000,MedCost,Ultra,,37.86,,,,,,,37.86,48.09,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,MedCost,Ultra,,30.17,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,inpatient,1,UN,26867.20000,16120.32000,MedCost,Ultra,,17195.01,,,,,,,8087.03,21843.03,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,MedCost,Ultra,,13702.27,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,inpatient,1,UN,71.75000,43.05000,MedCost,Ultra,,45.92,,,,,,,45.92,58.33,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,MedCost,Ultra,,36.59,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,inpatient,1,UN,798.05000,478.83000,MedCost,Ultra,,510.75,,,,,,,510.75,648.81,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,MedCost,Ultra,,407.01,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,inpatient,28.4,GR,9.15000,5.49000,MedCost,Ultra,,5.86,,,,,,,5.86,7.44,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,MedCost,Ultra,,4.67,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,inpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.89600,,,,,,,0.89600,1.14,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,MedCost,Ultra,,0.71400,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,inpatient,1,UN,99.10000,59.46000,MedCost,Ultra,,63.42,,,,,,,63.42,80.57,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,MedCost,Ultra,,50.54,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,inpatient,1,UN,3832.85000,2299.71000,MedCost,Ultra,,2453.02,,,,,,,1153.69,3116.11,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,MedCost,Ultra,,1954.75,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,inpatient,113,GR,3.25000,1.95000,MedCost,Ultra,,2.08,,,,,,,2.08,2.64,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,MedCost,Ultra,,1.66,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,inpatient,1,UN,2.45000,1.47000,MedCost,Ultra,,1.57,,,,,,,1.57,1.99,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,MedCost,Ultra,,1.25,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,inpatient,1000,ML,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,73.17,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,inpatient,473,ML,1084.55000,650.73000,MedCost,Ultra,,694.11,,,,,,,694.11,881.74,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,MedCost,Ultra,,553.12,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,inpatient,1,UN,40.65000,24.39000,MedCost,Ultra,,26.02,,,,,,,26.02,33.05,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,MedCost,Ultra,,20.73,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,inpatient,1,UN,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.57,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,MedCost,Ultra,,345.47,,,,,,,162.48,438.86,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,MedCost,Ultra,,275.30,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,MedCost,Ultra,,197.38,,,,,,,92.83,250.73,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,MedCost,Ultra,,157.28,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,inpatient,250,ML,437.00000,262.20000,MedCost,Ultra,,279.68,,,,,,,131.54,355.28,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,MedCost,Ultra,,222.87,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,inpatient,250,ML,437.00000,262.20000,MedCost,Ultra,,279.68,,,,,,,131.54,355.28,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,MedCost,Ultra,,222.87,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,inpatient,1,ML,786.55000,471.93000,MedCost,Ultra,,503.39,,,,,,,236.75,639.47,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,MedCost,Ultra,,401.14,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,inpatient,1,UN,40057.65000,24034.59000,MedCost,Ultra,,25636.90,,,,,,,12057.35,32566.87,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,MedCost,Ultra,,20429.40,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,inpatient,1,UN,20036.85000,12022.11000,MedCost,Ultra,,12823.58,,,,,,,6031.09,16289.96,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,MedCost,Ultra,,10218.79,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,inpatient,15,ML,3.95000,2.37000,MedCost,Ultra,,2.53,,,,,,,2.53,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,MedCost,Ultra,,2.01,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,inpatient,15,ML,1.25000,0.75000,MedCost,Ultra,,0.80000,,,,,,,0.80000,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,MedCost,Ultra,,0.63750,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,inpatient,1,UN,2.00000,1.20000,MedCost,Ultra,,1.28,,,,,,,1.28,1.63,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,MedCost,Ultra,,1.02,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,inpatient,1,UN,101.95000,61.17000,MedCost,Ultra,,65.25,,,,,,,65.25,82.89,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,MedCost,Ultra,,51.99,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,11.20,,,,,,,11.20,14.23,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,8.93,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,inpatient,1,UN,16.45000,9.87000,MedCost,Ultra,,10.53,,,,,,,10.53,13.37,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,MedCost,Ultra,,8.39,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,inpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,10.62,,,,,,,10.62,13.50,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,MedCost,Ultra,,8.47,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,10.69,13.58,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,MedCost,Ultra,,32.70,,,,,,,15.38,41.54,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,MedCost,Ultra,,26.06,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,inpatient,1,UN,34.00000,20.40000,MedCost,Ultra,,21.76,,,,,,,10.23,27.64,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,MedCost,Ultra,,17.34,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,inpatient,250,ML,98.00000,58.80000,MedCost,Ultra,,62.72,,,,,,,62.72,79.67,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,MedCost,Ultra,,49.98,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,inpatient,1,UN,129.05000,77.43000,MedCost,Ultra,,82.59,,,,,,,38.84,104.92,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,MedCost,Ultra,,65.82,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,inpatient,5,ML,371.70000,223.02000,MedCost,Ultra,,237.89,,,,,,,111.88,302.19,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,MedCost,Ultra,,189.57,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,inpatient,1,UN,94.85000,56.91000,MedCost,Ultra,,60.70,,,,,,,28.55,77.11,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,MedCost,Ultra,,48.37,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,inpatient,300,ML,210.00000,126.00000,MedCost,Ultra,,134.40,,,,,,,134.40,170.73,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,MedCost,Ultra,,107.10,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,inpatient,0.5,ML,26.25000,15.75000,MedCost,Ultra,,16.80,,,,,,,7.90,21.34,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,MedCost,Ultra,,13.39,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,inpatient,0.75,ML,49.95000,29.97000,MedCost,Ultra,,31.97,,,,,,,15.03,40.61,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,MedCost,Ultra,,25.47,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,inpatient,1,ML,175.25000,105.15000,MedCost,Ultra,,112.16,,,,,,,52.75,142.48,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,MedCost,Ultra,,89.38,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,inpatient,2,ML,30.90000,18.54000,MedCost,Ultra,,19.78,,,,,,,9.30,25.12,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,MedCost,Ultra,,15.76,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,inpatient,5,ML,813.05000,487.83000,MedCost,Ultra,,520.35,,,,,,,244.73,661.01,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,MedCost,Ultra,,414.66,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,inpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.67200,,,,,,,0.67200,0.85365,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,MedCost,Ultra,,0.53550,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,12.80,,,,,,,12.80,16.26,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,10.20,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,inpatient,0.4,ML,531.50000,318.90000,MedCost,Ultra,,340.16,,,,,,,159.98,432.11,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,MedCost,Ultra,,271.06,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,inpatient,10,ML,80.05000,48.03000,MedCost,Ultra,,51.23,,,,,,,51.23,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,MedCost,Ultra,,40.83,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,inpatient,5,ML,37.55000,22.53000,MedCost,Ultra,,24.03,,,,,,,24.03,30.53,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,MedCost,Ultra,,19.15,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,inpatient,1,UN,18.75000,11.25000,MedCost,Ultra,,12.00,,,,,,,5.64,15.24,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,MedCost,Ultra,,9.56,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,MedCost,Ultra,,96.80,,,,,,,45.53,122.97,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,MedCost,Ultra,,77.14,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,inpatient,1,UN,276.30000,165.78000,MedCost,Ultra,,176.83,,,,,,,83.17,224.63,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,MedCost,Ultra,,140.91,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,inpatient,0.01,ML,48.35000,29.01000,MedCost,Ultra,,30.94,,,,,,,30.94,39.31,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,MedCost,Ultra,,24.66,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,inpatient,5,ML,266.40000,159.84000,MedCost,Ultra,,170.50,,,,,,,80.19,216.58,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,MedCost,Ultra,,135.86,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,inpatient,30,ML,4.05000,2.43000,MedCost,Ultra,,2.59,,,,,,,2.59,3.29,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,MedCost,Ultra,,2.07,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,inpatient,1,UN,159.90000,95.94000,MedCost,Ultra,,102.34,,,,,,,102.34,130.00,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,MedCost,Ultra,,81.55,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,56.48,,,,,,,26.56,71.75,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,45.01,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,56.48,,,,,,,26.56,71.75,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,45.01,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,inpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,56.48,,,,,,,26.56,71.75,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,MedCost,Ultra,,45.01,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,inpatient,1,UN,526.70000,316.02000,MedCost,Ultra,,337.09,,,,,,,158.54,428.21,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,MedCost,Ultra,,268.62,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,inpatient,1,UN,29.25000,17.55000,MedCost,Ultra,,18.72,,,,,,,18.72,23.78,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,MedCost,Ultra,,14.92,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,inpatient,1,UN,84.65000,50.79000,MedCost,Ultra,,54.18,,,,,,,25.48,68.82,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,MedCost,Ultra,,43.17,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,inpatient,1,UN,84.65000,50.79000,MedCost,Ultra,,54.18,,,,,,,25.48,68.82,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,MedCost,Ultra,,43.17,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,inpatient,118,ML,5.25000,3.15000,MedCost,Ultra,,3.36,,,,,,,3.36,4.27,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,MedCost,Ultra,,2.68,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,inpatient,4,ML,29.75000,17.85000,MedCost,Ultra,,19.04,,,,,,,8.95,24.19,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,MedCost,Ultra,,15.17,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,inpatient,3,ML,75.05000,45.03000,MedCost,Ultra,,48.03,,,,,,,22.59,61.02,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,MedCost,Ultra,,38.28,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,inpatient,3,ML,75.45000,45.27000,MedCost,Ultra,,48.29,,,,,,,22.71,61.34,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,MedCost,Ultra,,38.48,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,inpatient,3,ML,71.45000,42.87000,MedCost,Ultra,,45.73,,,,,,,21.51,58.09,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,MedCost,Ultra,,36.44,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,11.42,14.51,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,inpatient,2,ML,29.00000,17.40000,MedCost,Ultra,,18.56,,,,,,,8.73,23.58,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,MedCost,Ultra,,14.79,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,11.20,,,,,,,11.20,14.23,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,8.93,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,inpatient,1,UN,20.95000,12.57000,MedCost,Ultra,,13.41,,,,,,,13.41,17.03,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,MedCost,Ultra,,10.68,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,inpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,10.43,,,,,,,10.43,13.25,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,MedCost,Ultra,,8.31,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,inpatient,1,UN,16.15000,9.69000,MedCost,Ultra,,10.34,,,,,,,10.34,13.13,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,MedCost,Ultra,,8.24,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,inpatient,0.5,ML,39.05000,23.43000,MedCost,Ultra,,24.99,,,,,,,11.75,31.75,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,MedCost,Ultra,,19.92,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,inpatient,2,ML,3656.00000,2193.60000,MedCost,Ultra,,2339.84,,,,,,,1100.46,2972.33,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,MedCost,Ultra,,1864.56,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,inpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,12.67,,,,,,,12.67,16.10,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,MedCost,Ultra,,10.10,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,inpatient,1,UN,12542.25000,7525.35000,MedCost,Ultra,,8027.04,,,,,,,3775.22,10196.85,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,MedCost,Ultra,,6396.55,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,inpatient,1,UN,25068.40000,15041.04000,MedCost,Ultra,,16043.78,,,,,,,7545.59,20380.61,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,MedCost,Ultra,,12784.88,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,inpatient,10,ML,2068.75000,1241.25000,MedCost,Ultra,,1324.00,,,,,,,622.69,1681.89,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,MedCost,Ultra,,1055.06,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,inpatient,12.5,ML,2753.30000,1651.98000,MedCost,Ultra,,1762.11,,,,,,,828.74,2238.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,MedCost,Ultra,,1404.18,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,inpatient,15,ML,3080.00000,1848.00000,MedCost,Ultra,,1971.20,,,,,,,927.08,2504.04,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,MedCost,Ultra,,1570.80,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,inpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.70400,,,,,,,0.70400,0.89430,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,MedCost,Ultra,,0.56100,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,inpatient,3,ML,18.05000,10.83000,MedCost,Ultra,,11.55,,,,,,,11.55,14.67,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,MedCost,Ultra,,9.21,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,inpatient,50,ML,433.25000,259.95000,MedCost,Ultra,,277.28,,,,,,,130.41,352.23,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,MedCost,Ultra,,220.96,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,inpatient,1,UN,21.70000,13.02000,MedCost,Ultra,,13.89,,,,,,,13.89,17.64,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,MedCost,Ultra,,11.07,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,inpatient,1,UN,22.20000,13.32000,MedCost,Ultra,,14.21,,,,,,,14.21,18.05,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,MedCost,Ultra,,11.32,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,inpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,10.91,,,,,,,5.13,13.86,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,MedCost,Ultra,,8.70,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,inpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,11.20,,,,,,,5.27,14.23,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,MedCost,Ultra,,8.93,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,inpatient,1,ML,653.00000,391.80000,MedCost,Ultra,,417.92,,,,,,,196.55,530.89,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,MedCost,Ultra,,333.03,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,inpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.73600,,,,,,,0.73600,0.93495,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,MedCost,Ultra,,0.58650,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,inpatient,1,ML,86.10000,51.66000,MedCost,Ultra,,55.10,,,,,,,55.10,70.00,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,MedCost,Ultra,,43.91,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,inpatient,1,UN,60.60000,36.36000,MedCost,Ultra,,38.78,,,,,,,18.24,49.27,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,MedCost,Ultra,,30.91,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,inpatient,200,ML,745.95000,447.57000,MedCost,Ultra,,477.41,,,,,,,224.53,606.46,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,MedCost,Ultra,,380.43,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,inpatient,1,UN,105.00000,63.00000,MedCost,Ultra,,67.20,,,,,,,31.61,85.36,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,MedCost,Ultra,,53.55,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,inpatient,1,UN,39.70000,23.82000,MedCost,Ultra,,25.41,,,,,,,11.95,32.28,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,MedCost,Ultra,,20.25,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,inpatient,1,UN,61.50000,36.90000,MedCost,Ultra,,39.36,,,,,,,18.51,50.00,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,MedCost,Ultra,,31.36,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,MedCost,Ultra,,18.69,,,,,,,8.79,23.74,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,MedCost,Ultra,,14.89,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,inpatient,1,UN,21.70000,13.02000,MedCost,Ultra,,13.89,,,,,,,6.53,17.64,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,MedCost,Ultra,,11.07,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,inpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,10.69,,,,,,,10.69,13.58,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,MedCost,Ultra,,8.52,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,inpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,10.82,,,,,,,10.82,13.74,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,MedCost,Ultra,,8.62,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,inpatient,100,ML,85.00000,51.00000,MedCost,Ultra,,54.40,,,,,,,54.40,69.11,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,MedCost,Ultra,,43.35,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,inpatient,5,ML,18.55000,11.13000,MedCost,Ultra,,11.87,,,,,,,11.87,15.08,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,MedCost,Ultra,,9.46,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,inpatient,237,ML,222.95000,133.77000,MedCost,Ultra,,142.69,,,,,,,142.69,181.26,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,MedCost,Ultra,,113.70,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,inpatient,1,UN,315.00000,189.00000,MedCost,Ultra,,201.60,,,,,,,94.81,256.10,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,MedCost,Ultra,,160.65,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,inpatient,50,ML,14.80000,8.88000,MedCost,Ultra,,9.47,,,,,,,9.47,12.03,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,MedCost,Ultra,,7.55,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,inpatient,1,UN,1663.10000,997.86000,MedCost,Ultra,,1064.38,,,,,,,500.59,1352.10,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,MedCost,Ultra,,848.18,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,inpatient,5,ML,78.65000,47.19000,MedCost,Ultra,,50.34,,,,,,,50.34,63.94,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,MedCost,Ultra,,40.11,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,inpatient,1,UN,24.20000,14.52000,MedCost,Ultra,,15.49,,,,,,,15.49,19.67,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,MedCost,Ultra,,12.34,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,inpatient,10,ML,82.00000,49.20000,MedCost,Ultra,,52.48,,,,,,,52.48,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,MedCost,Ultra,,41.82,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,inpatient,2.5,ML,47.50000,28.50000,MedCost,Ultra,,30.40,,,,,,,30.40,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,MedCost,Ultra,,24.23,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,inpatient,5,ML,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,47.15,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,inpatient,10,ML,2189.00000,1313.40000,MedCost,Ultra,,1400.96,,,,,,,658.89,1779.66,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,MedCost,Ultra,,1116.39,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,inpatient,1,UN,35.95000,21.57000,MedCost,Ultra,,23.01,,,,,,,23.01,29.23,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,MedCost,Ultra,,18.33,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,inpatient,30,GR,264.80000,158.88000,MedCost,Ultra,,169.47,,,,,,,169.47,215.28,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,MedCost,Ultra,,135.05,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,inpatient,50,ML,104.50000,62.70000,MedCost,Ultra,,66.88,,,,,,,31.45,84.96,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,MedCost,Ultra,,53.30,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,inpatient,50,ML,113.75000,68.25000,MedCost,Ultra,,72.80,,,,,,,34.24,92.48,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,MedCost,Ultra,,58.01,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,inpatient,15,GR,46.05000,27.63000,MedCost,Ultra,,29.47,,,,,,,29.47,37.44,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,MedCost,Ultra,,23.49,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,inpatient,1,UN,22.10000,13.26000,MedCost,Ultra,,14.14,,,,,,,14.14,17.97,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,MedCost,Ultra,,11.27,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,inpatient,1,UN,22.35000,13.41000,MedCost,Ultra,,14.30,,,,,,,14.30,18.17,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,MedCost,Ultra,,11.40,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,inpatient,1,UN,27.00000,16.20000,MedCost,Ultra,,17.28,,,,,,,17.28,21.95,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,MedCost,Ultra,,13.77,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,inpatient,1,UN,22.70000,13.62000,MedCost,Ultra,,14.53,,,,,,,14.53,18.46,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,MedCost,Ultra,,11.58,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,inpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,11.90,,,,,,,11.90,15.12,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,MedCost,Ultra,,9.49,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,inpatient,1,UN,417.20000,250.32000,MedCost,Ultra,,267.01,,,,,,,125.58,339.18,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,MedCost,Ultra,,212.77,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,inpatient,60,GR,1533.80000,920.28000,MedCost,Ultra,,981.63,,,,,,,981.63,1246.98,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,MedCost,Ultra,,782.24,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,inpatient,1,UN,38.50000,23.10000,MedCost,Ultra,,24.64,,,,,,,24.64,31.30,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,MedCost,Ultra,,19.64,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,inpatient,1,UN,61.85000,37.11000,MedCost,Ultra,,39.58,,,,,,,39.58,50.28,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,MedCost,Ultra,,31.54,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,inpatient,1,UN,78.65000,47.19000,MedCost,Ultra,,50.34,,,,,,,50.34,63.94,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,MedCost,Ultra,,40.11,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,inpatient,5,ML,96.35000,57.81000,MedCost,Ultra,,61.66,,,,,,,29.00,78.33,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,MedCost,Ultra,,49.14,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,inpatient,5,ML,302.95000,181.77000,MedCost,Ultra,,193.89,,,,,,,91.19,246.30,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,MedCost,Ultra,,154.50,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,inpatient,1,UN,3628.20000,2176.92000,MedCost,Ultra,,2322.05,,,,,,,1092.09,2949.73,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,MedCost,Ultra,,1850.38,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,inpatient,2,ML,127.10000,76.26000,MedCost,Ultra,,81.34,,,,,,,81.34,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,MedCost,Ultra,,64.82,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,inpatient,5,ML,211.15000,126.69000,MedCost,Ultra,,135.14,,,,,,,135.14,171.66,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,MedCost,Ultra,,107.69,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,inpatient,1,UN,89.05000,53.43000,MedCost,Ultra,,56.99,,,,,,,26.80,72.40,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,MedCost,Ultra,,45.42,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,inpatient,1,UN,34.30000,20.58000,MedCost,Ultra,,21.95,,,,,,,10.32,27.89,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,MedCost,Ultra,,17.49,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,inpatient,1,UN,60.05000,36.03000,MedCost,Ultra,,38.43,,,,,,,38.43,48.82,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,MedCost,Ultra,,30.63,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,inpatient,1,UN,31.25000,18.75000,MedCost,Ultra,,20.00,,,,,,,20.00,25.41,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,MedCost,Ultra,,15.94,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,inpatient,1,UN,201.30000,120.78000,MedCost,Ultra,,128.83,,,,,,,60.59,163.66,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,MedCost,Ultra,,102.66,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,inpatient,1,UN,174.05000,104.43000,MedCost,Ultra,,111.39,,,,,,,52.39,141.50,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,MedCost,Ultra,,88.77,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,inpatient,1,ML,64.55000,38.73000,MedCost,Ultra,,41.31,,,,,,,19.43,52.48,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,MedCost,Ultra,,32.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,inpatient,1,ML,64.85000,38.91000,MedCost,Ultra,,41.50,,,,,,,19.52,52.72,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,MedCost,Ultra,,33.07,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,inpatient,1,ML,64.70000,38.82000,MedCost,Ultra,,41.41,,,,,,,19.47,52.60,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,MedCost,Ultra,,33.00,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,inpatient,0.5,ML,238.95000,143.37000,MedCost,Ultra,,152.93,,,,,,,71.92,194.27,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,MedCost,Ultra,,121.86,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,inpatient,1,UN,91.10000,54.66000,MedCost,Ultra,,58.30,,,,,,,27.42,74.06,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,MedCost,Ultra,,46.46,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,inpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.92800,,,,,,,0.92800,1.18,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,MedCost,Ultra,,0.73950,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,inpatient,240,ML,661.30000,396.78000,MedCost,Ultra,,423.23,,,,,,,423.23,537.64,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,MedCost,Ultra,,337.26,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,inpatient,1,ML,385.20000,231.12000,MedCost,Ultra,,246.53,,,,,,,115.95,313.17,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,MedCost,Ultra,,196.45,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,inpatient,10,ML,1813.25000,1087.95000,MedCost,Ultra,,1160.48,,,,,,,545.79,1474.17,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,MedCost,Ultra,,924.76,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,inpatient,1,UN,82.95000,49.77000,MedCost,Ultra,,53.09,,,,,,,24.97,67.44,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,MedCost,Ultra,,42.30,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,inpatient,10,ML,4.60000,2.76000,MedCost,Ultra,,2.94,,,,,,,2.94,3.74,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,MedCost,Ultra,,2.35,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,inpatient,500,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,inpatient,1,UN,2174.60000,1304.76000,MedCost,Ultra,,1391.74,,,,,,,1391.74,1767.95,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,MedCost,Ultra,,1109.05,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,inpatient,1000,ML,101.50000,60.90000,MedCost,Ultra,,64.96,,,,,,,30.55,82.52,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,MedCost,Ultra,,51.77,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,inpatient,1000,ML,98.00000,58.80000,MedCost,Ultra,,62.72,,,,,,,29.50,79.67,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,MedCost,Ultra,,49.98,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,inpatient,1000,ML,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,inpatient,1000,ML,94.50000,56.70000,MedCost,Ultra,,60.48,,,,,,,28.44,76.83,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,MedCost,Ultra,,48.20,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,inpatient,1000,ML,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,25.28,68.29,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,inpatient,1,UN,24.60000,14.76000,MedCost,Ultra,,15.74,,,,,,,15.74,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,MedCost,Ultra,,12.55,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,inpatient,1,UN,33.20000,19.92000,MedCost,Ultra,,21.25,,,,,,,21.25,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,MedCost,Ultra,,16.93,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,inpatient,1,UN,50.05000,30.03000,MedCost,Ultra,,32.03,,,,,,,32.03,40.69,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,MedCost,Ultra,,25.53,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,inpatient,1000,ML,98.00000,58.80000,MedCost,Ultra,,62.72,,,,,,,29.50,79.67,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,MedCost,Ultra,,49.98,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,inpatient,1000,ML,98.00000,58.80000,MedCost,Ultra,,62.72,,,,,,,29.50,79.67,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,MedCost,Ultra,,49.98,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,inpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,inpatient,500,ML,76.50000,45.90000,MedCost,Ultra,,48.96,,,,,,,48.96,61.97,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,MedCost,Ultra,,39.02,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,inpatient,100,ML,356.00000,213.60000,MedCost,Ultra,,227.84,,,,,,,107.16,289.43,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,MedCost,Ultra,,181.56,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,inpatient,1,UN,58.55000,35.13000,MedCost,Ultra,,37.47,,,,,,,37.47,47.60,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,MedCost,Ultra,,29.86,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,inpatient,1,UN,48.95000,29.37000,MedCost,Ultra,,31.33,,,,,,,31.33,39.80,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,MedCost,Ultra,,24.96,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,inpatient,17,ML,5076.25000,3045.75000,MedCost,Ultra,,3248.80,,,,,,,1527.95,4126.99,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,MedCost,Ultra,,2588.89,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,inpatient,1,UN,70.00000,42.00000,MedCost,Ultra,,44.80,,,,,,,44.80,56.91,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,MedCost,Ultra,,35.70,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,inpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,12.80,,,,,,,12.80,16.26,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,MedCost,Ultra,,10.20,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,inpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,12.35,,,,,,,12.35,15.69,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,MedCost,Ultra,,9.84,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,inpatient,1,ML,642.70000,385.62000,MedCost,Ultra,,411.33,,,,,,,193.45,522.52,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,MedCost,Ultra,,327.78,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,inpatient,0.5,ML,254.90000,152.94000,MedCost,Ultra,,163.14,,,,,,,76.72,207.23,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,MedCost,Ultra,,130.00,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,inpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,11.01,,,,,,,11.01,13.98,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,MedCost,Ultra,,8.77,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,inpatient,20,ML,95.55000,57.33000,MedCost,Ultra,,61.15,,,,,,,28.76,77.68,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,MedCost,Ultra,,48.73,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,inpatient,10,ML,25.15000,15.09000,MedCost,Ultra,,16.10,,,,,,,16.10,20.45,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,MedCost,Ultra,,12.83,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,inpatient,30,GR,166.25000,99.75000,MedCost,Ultra,,106.40,,,,,,,106.40,135.16,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,MedCost,Ultra,,84.79,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,inpatient,1,ML,85.30000,51.18000,MedCost,Ultra,,54.59,,,,,,,54.59,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,MedCost,Ultra,,43.50,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,inpatient,2,ML,102.85000,61.71000,MedCost,Ultra,,65.82,,,,,,,65.82,83.62,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,MedCost,Ultra,,52.45,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,inpatient,0.3,ML,25.45000,15.27000,MedCost,Ultra,,16.29,,,,,,,16.29,20.69,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,MedCost,Ultra,,12.98,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,inpatient,0.25,ML,1.40000,0.84000,MedCost,Ultra,,0.89600,,,,,,,0.89600,1.14,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,MedCost,Ultra,,0.71400,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,inpatient,88,ML,2416.85000,1450.11000,MedCost,Ultra,,1546.78,,,,,,,1546.78,1964.90,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,MedCost,Ultra,,1232.59,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,inpatient,1,UN,4022.30000,2413.38000,MedCost,Ultra,,2574.27,,,,,,,1210.71,3270.13,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,MedCost,Ultra,,2051.37,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,inpatient,10,ML,486.20000,291.72000,MedCost,Ultra,,311.17,,,,,,,146.35,395.28,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,MedCost,Ultra,,247.96,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,inpatient,20,ML,715.00000,429.00000,MedCost,Ultra,,457.60,,,,,,,215.22,581.29,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,MedCost,Ultra,,364.65,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,inpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,11.04,,,,,,,11.04,14.02,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,MedCost,Ultra,,8.80,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,inpatient,42.5,GR,1050.30000,630.18000,MedCost,Ultra,,672.19,,,,,,,672.19,853.89,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,MedCost,Ultra,,535.65,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,inpatient,1,UN,53.85000,32.31000,MedCost,Ultra,,34.46,,,,,,,34.46,43.78,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,MedCost,Ultra,,27.46,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,inpatient,1,UN,1730.85000,1038.51000,MedCost,Ultra,,1107.74,,,,,,,520.99,1407.18,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,MedCost,Ultra,,882.73,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,inpatient,1,UN,44.30000,26.58000,MedCost,Ultra,,28.35,,,,,,,28.35,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,MedCost,Ultra,,22.59,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,inpatient,1,UN,44.30000,26.58000,MedCost,Ultra,,28.35,,,,,,,28.35,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,MedCost,Ultra,,22.59,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,inpatient,1,UN,113.80000,68.28000,MedCost,Ultra,,72.83,,,,,,,72.83,92.52,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,MedCost,Ultra,,58.04,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,inpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,11.42,,,,,,,11.42,14.51,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,MedCost,Ultra,,9.10,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,inpatient,1.5,ML,1650.30000,990.18000,MedCost,Ultra,,1056.19,,,,,,,496.74,1341.69,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,MedCost,Ultra,,841.65,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,45414.56000,27248.74000,MedCost,Ultra,,29065.32,,,,,,,13669.78,36922.04,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,MedCost,Ultra,,23161.43,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,156212.38000,93727.43000,MedCost,Ultra,,99975.92,,,,,,,47019.93,127000.66,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,MedCost,Ultra,,79668.31,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,257500.00000,154500.00000,MedCost,Ultra,,164800.00,,,,,,,77507.50,209347.50,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,MedCost,Ultra,,131325.00,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,11159.74000,6695.84000,MedCost,Ultra,,7142.23,,,,,,,3359.08,9072.87,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,MedCost,Ultra,,5691.47,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,7390.20000,4434.12000,MedCost,Ultra,,4729.73,,,,,,,2224.45,6008.23,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,MedCost,Ultra,,3769.00,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,inpatient,2000,ML,259.00000,155.40000,MedCost,Ultra,,165.76,,,,,,,165.76,210.57,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,MedCost,Ultra,,132.09,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,inpatient,3.5,GR,13.65000,8.19000,MedCost,Ultra,,8.74,,,,,,,8.74,11.10,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,MedCost,Ultra,,6.96,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,inpatient,1,UN,1.20000,0.72000,MedCost,Ultra,,0.76800,,,,,,,0.76800,0.97560,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,MedCost,Ultra,,0.61200,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,inpatient,59,ML,9.15000,5.49000,MedCost,Ultra,,5.86,,,,,,,5.86,7.44,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,MedCost,Ultra,,4.67,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,inpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,inpatient,1000,ML,42.00000,25.20000,MedCost,Ultra,,26.88,,,,,,,12.64,34.15,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,MedCost,Ultra,,21.42,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,inpatient,24,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,inpatient,24,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,inpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.06020,0.16260,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,inpatient,200,ME,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,inpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,inpatient,25,UN,0.20000,0.12000,MedCost,Ultra,,0.12800,,,,,,,0.12800,0.16200,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,MedCost,Ultra,,0.10200,,,,,,,0.04004,0.15000,percent of total billed charges,
HC LTC LOA SHORT TERM PRIVATE ROOM LTP,11100030,CDM,180,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA LONG TERM CARE PRIVATE ROOM LTP,11100031,CDM,180,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,324.00,percent of total billed charges,
HC LTC LOA SHORT TERM SEMI PRIVATE ROOM LTP,11200016,CDM,180,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC LOA LONG TERM PASS SEMI PRIVATE ROOM,11200017,CDM,180,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC LOA MULTIDAY PASS SEMI PRIVATE ROOM,11850011,CDM,182,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC LOA MULTIDAY PASS SHORT TERM PRIVATE,11850023,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 1,11100016,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,5693.00,percent of total billed charges,
HC LTC LONG TERM PRIVATE ROOM LEVEL 1,11100017,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,5693.00,percent of total billed charges,
HC LTC LOA SHORT TERM PRIVATE ROOM,11100018,CDM,180,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA LONG TERM CARE PRIVATE ROOM,11100019,CDM,180,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,324.00,percent of total billed charges,
HC LTC BED HOLD  SHORT TERM PRIVATE ROOM,11100020,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,5693.00,percent of total billed charges,
HC LTC BED HOLD LONG TERM CARE PRIVATE ROOM,11100021,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,5693.00,percent of total billed charges,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 2,11100022,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,5693.00,percent of total billed charges,
HC LTC LONG TERM PRIVATE ROOM LEVEL 2,11100023,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,5693.00,percent of total billed charges,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 3,11100024,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,5693.00,percent of total billed charges,
HC LTC LONG TERM PRIVATE ROOM LEVEL 3,11100025,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,5693.00,percent of total billed charges,
HC LTC SHORT TERM PRIVATE ROOM LEVEL 4,11100026,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,5693.00,percent of total billed charges,
HC LTC LONG TERM PRIVATE ROOM LEVEL 4,11100027,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,5693.00,percent of total billed charges,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 1,11200004,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,5693.00,percent of total billed charges,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 1,11200005,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,5693.00,percent of total billed charges,
HC LTC LOA SHORT TERM SEMI PRIVATE ROOM,11200006,CDM,180,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC LOA LONG TERM CARE SEMI PRIVATE ROOM,11200007,CDM,180,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC BED HOLD SHORT TERM SEMI PRIVATE ROOM,11200008,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,5693.00,percent of total billed charges,
HC LTC BED HOLD LONG TERM CARE SEMI PRIVATE,11200009,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,5693.00,percent of total billed charges,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 2,11200010,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,5693.00,percent of total billed charges,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 2,11200011,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,5693.00,percent of total billed charges,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 3,11200012,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,5693.00,percent of total billed charges,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 3,11200013,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,5693.00,percent of total billed charges,
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 4,11200014,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,5693.00,percent of total billed charges,
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 4,11200015,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,5693.00,percent of total billed charges,
HC LTC LOA MULTIDAY PASS PRIVATE ROOM,11820001,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SINGLE DAY PASS PRIVATE ROOM,11820002,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA BED HOLD,11820003,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA LONG TERM PASS,11830003,CDM,183,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO ED PRIVATE ROOM,11850001,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO CLINIC APPOINTMENT PRIVATE ROOM,11850002,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO OR/CATH LAB/VIR/GI PRIVATE ROOM,11850003,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO IMAGING APPT PRIVATE ROOM,11850004,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO CLINIC APPT SEMI PRIVATE ROOM,11850012,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC LOA SEND TO ED SEMI PRIVATE ROOM,11850013,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC LOA SEND TO IMAGING APPT SEMI PRIVATE ROOM,11850014,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC LOA SEND TO OR/CATH/VIR/GI SEMI PRIVATE ROOM,11850015,CDM,185,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC LOA SINGLE DAY PASS SEMI PRIVATE ROOM,11850016,CDM,182,RC,,,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC LTC  LOA MULTIDAY PASS SHORT TERM SEMI PRIVATE,11850017,CDM,182,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC LOA SEND TO CLINIC APPT SHORT TERM SEMI PRIVATE,11850018,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC LOA SEND TO ED SHORT TERM ED SEMI PRIVATE,11850019,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC LOA SEND TO IMAGING APPT SHORT TERM SEMI PRIVATE,11850020,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC LOA SEND TO OR/CATH/VIR/GI SHORT TERM SEMI PRIVATE,11850021,CDM,185,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC LOA SINGLE DAY PASS SHORT TERM SEMI PRIVATE,11850022,CDM,182,RC,,,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC LTC  LOA SEND TO CLINIC APPT SHORT TERM PRIVATE,11850024,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO ED SHORT TERM PRIVATE,11850025,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO IMAGING APPT SHORT TERM PRIVATE,11850026,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SEND TO OR/CATH/VIR/GI SHORT TERM PRIVATE,11850027,CDM,185,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC LTC LOA SINGLE DAY PASS SHORT TERM PRIVATE,11850028,CDM,182,RC,,,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC REX PRIVATE ROOM,11100002,CDM,110,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Ultra,,849.92,,,,,,,849.92,5693.00,percent of total billed charges,
HC REX OB PRIVATE ROOM,11120001,CDM,112,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Ultra,,849.92,,,,,,,849.92,5693.00,percent of total billed charges,
HC REX HOSPICE PRIVATE ROOM,11150001,CDM,115,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Ultra,,849.92,,,,,,,849.92,2085.00,percent of total billed charges,
HC REX CONTINUED NEONATAL CARE PRIVATE ROOM,11710001,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,MedCost,Ultra,,1231.36,,,,,,,974.00,1558.44,percent of total billed charges,
HC REX LEVEL 1 NURSERY ROOM,11710002,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,MedCost,Ultra,,1231.36,,,,,,,974.00,1558.44,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,inpatient,,,519.00000,311.40000,MedCost,Ultra,,332.16,,,,,,,332.16,420.39,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,MedCost,Ultra,,264.69,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,inpatient,,,1287.00000,772.20000,MedCost,Ultra,,823.68,,,,,,,823.68,1042.47,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,MedCost,Ultra,,656.37,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,inpatient,,,1925.00000,1155.00000,MedCost,Ultra,,1232.00,,,,,,,1232.00,1559.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,MedCost,Ultra,,981.75,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,inpatient,,,2891.00000,1734.60000,MedCost,Ultra,,1850.24,,,,,,,1850.24,2341.71,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,MedCost,Ultra,,1474.41,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,inpatient,,,3469.00000,2081.40000,MedCost,Ultra,,2220.16,,,,,,,2220.16,2809.89,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,MedCost,Ultra,,1769.19,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,inpatient,,,4162.00000,2497.20000,MedCost,Ultra,,2663.68,,,,,,,2663.68,3371.22,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,MedCost,Ultra,,2122.62,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,inpatient,,,4996.00000,2997.60000,MedCost,Ultra,,3197.44,,,,,,,3197.44,4046.76,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,MedCost,Ultra,,2547.96,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX LEVEL 3 INTERMEDIATE NURSERY ROOM,11733001,CDM,173,RC,,,,,facility,inpatient,,,4517.00000,2710.20000,MedCost,Ultra,,2890.88,,,,,,,2890.88,5493.00,percent of total billed charges,
HC REX ICU ROOM,12000002,CDM,202,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,MedCost,Ultra,,2812.80,,,,,,,1228.00,6258.00,percent of total billed charges,
HC REX ICU ROOM,12000002,CDM,210,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,MedCost,Ultra,,2812.80,,,,,,,1228.00,6258.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,inpatient,,,2065.00000,1239.00000,MedCost,Ultra,,1321.60,,,,,,,1321.60,1672.65,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,MedCost,Ultra,,1053.15,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,inpatient,,,3033.00000,1819.80000,MedCost,Ultra,,1941.12,,,,,,,1941.12,2456.73,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,MedCost,Ultra,,1546.83,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,inpatient,,,5516.00000,3309.60000,MedCost,Ultra,,3530.24,,,,,,,3530.24,4467.96,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,MedCost,Ultra,,2813.16,,,,,,,615.00,4137.00,percent of total billed charges,
HC REX INTERMEDIATE CARE ROOM,12090002,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,MedCost,Ultra,,1333.76,,,,,,,1228.00,5197.00,percent of total billed charges,
HC REX INTERMEDIATE CARE SEMI PRIVATE ROOM,12090004,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,MedCost,Ultra,,1333.76,,,,,,,1228.00,5197.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,inpatient,,,160.00000,96.00000,MedCost,Ultra,,102.40,,,,,,,102.40,130.08,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,MedCost,Ultra,,81.60,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,inpatient,,,633.00000,379.80000,MedCost,Ultra,,405.12,,,,,,,405.12,514.63,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,MedCost,Ultra,,322.83,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,inpatient,,,173.00000,103.80000,MedCost,Ultra,,110.72,,,,,,,110.72,140.65,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,MedCost,Ultra,,88.23,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,,74.88,,,,,,,74.88,95.12,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,,59.67,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.41,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,inpatient,,,26.00000,15.60000,MedCost,Ultra,,16.64,,,,,,,16.64,21.14,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,MedCost,Ultra,,13.26,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,inpatient,,,143.00000,85.80000,MedCost,Ultra,,91.52,,,,,,,91.52,116.26,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,MedCost,Ultra,,72.93,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.22,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.85,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,inpatient,,,158.00000,94.80000,MedCost,Ultra,,101.12,,,,,,,101.12,128.45,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,MedCost,Ultra,,80.58,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,inpatient,,,524.00000,314.40000,MedCost,Ultra,,335.36,,,,,,,335.36,426.01,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,MedCost,Ultra,,267.24,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,inpatient,,,597.00000,358.20000,MedCost,Ultra,,382.08,,,,,,,382.08,485.36,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,MedCost,Ultra,,304.47,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,inpatient,,,508.00000,304.80000,MedCost,Ultra,,325.12,,,,,,,325.12,413.00,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,MedCost,Ultra,,259.08,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,inpatient,,,92.00000,55.20000,MedCost,Ultra,,58.88,,,,,,,58.88,74.80,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,MedCost,Ultra,,46.92,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,inpatient,,,73.00000,43.80000,MedCost,Ultra,,46.72,,,,,,,46.72,59.35,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,MedCost,Ultra,,37.23,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,inpatient,,,230.00000,138.00000,MedCost,Ultra,,147.20,,,,,,,147.20,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,MedCost,Ultra,,117.30,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,inpatient,,,211.00000,126.60000,MedCost,Ultra,,135.04,,,,,,,135.04,171.54,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,MedCost,Ultra,,107.61,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,inpatient,,,5233.00000,3139.80000,MedCost,Ultra,,3349.12,,,,,,,3349.12,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,MedCost,Ultra,,2668.83,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,inpatient,,,5233.00000,3139.80000,MedCost,Ultra,,3349.12,,,,,,,3349.12,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,MedCost,Ultra,,2668.83,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,inpatient,,,4982.00000,2989.20000,MedCost,Ultra,,3188.48,,,,,,,3188.48,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,MedCost,Ultra,,2540.82,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,inpatient,,,1786.00000,1071.60000,MedCost,Ultra,,1143.04,,,,,,,1143.04,1452.02,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,MedCost,Ultra,,910.86,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,47.15,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,inpatient,,,3005.00000,1803.00000,MedCost,Ultra,,1923.20,,,,,,,1923.20,2443.07,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,MedCost,Ultra,,1532.55,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,inpatient,,,1526.00000,915.60000,MedCost,Ultra,,976.64,,,,,,,976.64,1240.64,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,MedCost,Ultra,,778.26,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,inpatient,,,313.00000,187.80000,MedCost,Ultra,,200.32,,,,,,,200.32,254.47,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,MedCost,Ultra,,159.63,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.85,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.22,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,inpatient,,,1093.00000,655.80000,MedCost,Ultra,,699.52,,,,,,,699.52,888.61,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,MedCost,Ultra,,557.43,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,inpatient,,,342.00000,205.20000,MedCost,Ultra,,218.88,,,,,,,218.88,278.05,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,MedCost,Ultra,,174.42,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,inpatient,,,1236.00000,741.60000,MedCost,Ultra,,791.04,,,,,,,791.04,1004.87,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,MedCost,Ultra,,630.36,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,inpatient,,,909.00000,545.40000,MedCost,Ultra,,581.76,,,,,,,581.76,739.02,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,MedCost,Ultra,,463.59,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,inpatient,,,303.00000,181.80000,MedCost,Ultra,,193.92,,,,,,,193.92,246.34,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,MedCost,Ultra,,154.53,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,inpatient,,,500.00000,300.00000,MedCost,Ultra,,320.00,,,,,,,320.00,406.50,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,MedCost,Ultra,,255.00,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,inpatient,,,938.00000,562.80000,MedCost,Ultra,,600.32,,,,,,,600.32,762.59,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,MedCost,Ultra,,478.38,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,inpatient,,,266.00000,159.60000,MedCost,Ultra,,170.24,,,,,,,170.24,216.26,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,MedCost,Ultra,,135.66,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,inpatient,,,204.00000,122.40000,MedCost,Ultra,,130.56,,,,,,,130.56,165.85,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,MedCost,Ultra,,104.04,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,inpatient,,,1092.00000,655.20000,MedCost,Ultra,,698.88,,,,,,,698.88,887.80,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,MedCost,Ultra,,556.92,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,inpatient,,,948.00000,568.80000,MedCost,Ultra,,606.72,,,,,,,606.72,770.72,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,MedCost,Ultra,,483.48,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,inpatient,,,286.00000,171.60000,MedCost,Ultra,,183.04,,,,,,,183.04,232.52,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,MedCost,Ultra,,145.86,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,inpatient,,,43.00000,25.80000,MedCost,Ultra,,27.52,,,,,,,27.52,34.96,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,MedCost,Ultra,,21.93,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,inpatient,,,35.00000,21.00000,MedCost,Ultra,,22.40,,,,,,,22.40,28.45,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,MedCost,Ultra,,17.85,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,inpatient,,,140.00000,84.00000,MedCost,Ultra,,89.60,,,,,,,89.60,113.82,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,MedCost,Ultra,,71.40,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,inpatient,,,474.00000,284.40000,MedCost,Ultra,,303.36,,,,,,,303.36,385.36,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,MedCost,Ultra,,241.74,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,inpatient,,,126.00000,75.60000,MedCost,Ultra,,80.64,,,,,,,80.64,102.44,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,MedCost,Ultra,,64.26,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,inpatient,,,286.00000,171.60000,MedCost,Ultra,,183.04,,,,,,,183.04,232.52,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,MedCost,Ultra,,145.86,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,inpatient,,,134.00000,80.40000,MedCost,Ultra,,85.76,,,,,,,85.76,108.94,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,MedCost,Ultra,,68.34,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,inpatient,,,11.00000,6.60000,MedCost,Ultra,,7.04,,,,,,,7.04,8.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,MedCost,Ultra,,5.61,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,inpatient,,,4985.00000,2991.00000,MedCost,Ultra,,3190.40,,,,,,,857.42,4137.55,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,MedCost,Ultra,,2542.35,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,inpatient,,,20100.00000,12060.00000,MedCost,Ultra,,12864.00,,,,,,,3457.20,16683.00,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,MedCost,Ultra,,10251.00,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,inpatient,,,5074.00000,3044.40000,MedCost,Ultra,,3247.36,,,,,,,872.73,4211.42,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,MedCost,Ultra,,2587.74,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,inpatient,,,4240.00000,2544.00000,MedCost,Ultra,,2713.60,,,,,,,729.28,3519.20,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,MedCost,Ultra,,2162.40,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,inpatient,,,3478.00000,2086.80000,MedCost,Ultra,,2225.92,,,,,,,598.22,2886.74,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,MedCost,Ultra,,1773.78,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,inpatient,,,463.00000,277.80000,MedCost,Ultra,,296.32,,,,,,,296.32,376.42,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,MedCost,Ultra,,236.13,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2530.56,,,,,,,2530.56,7039.00,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2016.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,inpatient,,,4530.00000,2718.00000,MedCost,Ultra,,2899.20,,,,,,,2899.20,7039.00,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,MedCost,Ultra,,2310.30,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,inpatient,,,4461.00000,2676.60000,MedCost,Ultra,,2855.04,,,,,,,2855.04,7039.00,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,MedCost,Ultra,,2275.11,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,inpatient,,,3531.00000,2118.60000,MedCost,Ultra,,2259.84,,,,,,,2259.84,7039.00,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,MedCost,Ultra,,1800.81,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,inpatient,,,5835.00000,3501.00000,MedCost,Ultra,,3734.40,,,,,,,3734.40,7039.00,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,MedCost,Ultra,,2975.85,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,inpatient,,,4143.00000,2485.80000,MedCost,Ultra,,2651.52,,,,,,,2651.52,7039.00,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,MedCost,Ultra,,2112.93,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,inpatient,,,4143.00000,2485.80000,MedCost,Ultra,,2651.52,,,,,,,2651.52,7039.00,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,MedCost,Ultra,,2112.93,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,inpatient,,,4821.00000,2892.60000,MedCost,Ultra,,3085.44,,,,,,,3085.44,7039.00,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,MedCost,Ultra,,2458.71,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,inpatient,,,4821.00000,2892.60000,MedCost,Ultra,,3085.44,,,,,,,3085.44,7039.00,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,MedCost,Ultra,,2458.71,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,inpatient,,,5866.00000,3519.60000,MedCost,Ultra,,3754.24,,,,,,,3754.24,7039.00,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,MedCost,Ultra,,2991.66,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2530.56,,,,,,,2530.56,7039.00,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2016.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2530.56,,,,,,,2530.56,7039.00,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2016.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,inpatient,,,3531.00000,2118.60000,MedCost,Ultra,,2259.84,,,,,,,2259.84,7039.00,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,MedCost,Ultra,,1800.81,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,inpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2530.56,,,,,,,2530.56,7039.00,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,MedCost,Ultra,,2016.54,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,inpatient,,,1745.00000,1047.00000,MedCost,Ultra,,1116.80,,,,,,,1116.80,7039.00,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,MedCost,Ultra,,889.95,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,inpatient,,,4110.00000,2466.00000,MedCost,Ultra,,2630.40,,,,,,,2630.40,7039.00,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,MedCost,Ultra,,2096.10,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,inpatient,,,1691.00000,1014.60000,MedCost,Ultra,,1082.24,,,,,,,1082.24,7039.00,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,MedCost,Ultra,,862.41,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,inpatient,,,6499.00000,3899.40000,MedCost,Ultra,,4159.36,,,,,,,4159.36,7039.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,MedCost,Ultra,,3314.49,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,inpatient,,,1184.00000,710.40000,MedCost,Ultra,,757.76,,,,,,,757.76,962.59,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,MedCost,Ultra,,603.84,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,inpatient,,,2432.00000,1459.20000,MedCost,Ultra,,1556.48,,,,,,,1556.48,1977.22,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,MedCost,Ultra,,1240.32,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,inpatient,,,3684.00000,2210.40000,MedCost,Ultra,,2357.76,,,,,,,2357.76,2995.09,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,MedCost,Ultra,,1878.84,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,inpatient,,,4297.00000,2578.20000,MedCost,Ultra,,2750.08,,,,,,,2750.08,3493.46,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,MedCost,Ultra,,2191.47,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,inpatient,,,121.00000,72.60000,MedCost,Ultra,,77.44,,,,,,,77.44,98.37,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,MedCost,Ultra,,61.71,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,inpatient,,,1706.00000,1023.60000,MedCost,Ultra,,1091.84,,,,,,,1091.84,1381.86,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,MedCost,Ultra,,870.06,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,inpatient,,,3426.00000,2055.60000,MedCost,Ultra,,2192.64,,,,,,,2192.64,2775.06,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,MedCost,Ultra,,1747.26,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,inpatient,,,83.00000,49.80000,MedCost,Ultra,,53.12,,,,,,,53.12,67.23,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,MedCost,Ultra,,42.33,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,inpatient,,,467.00000,280.20000,MedCost,Ultra,,298.88,,,,,,,298.88,378.27,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,MedCost,Ultra,,238.17,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,inpatient,,,689.00000,413.40000,MedCost,Ultra,,440.96,,,,,,,440.96,560.16,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,MedCost,Ultra,,351.39,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,inpatient,,,1557.00000,934.20000,MedCost,Ultra,,996.48,,,,,,,996.48,1265.84,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,MedCost,Ultra,,794.07,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,inpatient,,,1179.00000,707.40000,MedCost,Ultra,,754.56,,,,,,,754.56,958.53,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,MedCost,Ultra,,601.29,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,inpatient,,,79.00000,47.40000,MedCost,Ultra,,50.56,,,,,,,50.56,64.23,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,MedCost,Ultra,,40.29,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,inpatient,,,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,56.32,71.28,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,inpatient,,,21.00000,12.60000,MedCost,Ultra,GP,13.44,,,,,,,13.44,17.01,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,MedCost,Ultra,GP,10.71,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,inpatient,,,333.00000,199.80000,MedCost,Ultra,,213.12,,,,,,,213.12,7039.00,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,MedCost,Ultra,,169.83,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,inpatient,,,1502.00000,901.20000,MedCost,Ultra,,961.28,,,,,,,961.28,1216.62,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,MedCost,Ultra,,766.02,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,inpatient,,,1422.00000,853.20000,MedCost,Ultra,,910.08,,,,,,,910.08,1151.82,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,MedCost,Ultra,,725.22,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,inpatient,,,1140.00000,684.00000,MedCost,Ultra,,729.60,,,,,,,729.60,923.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,MedCost,Ultra,,581.40,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,inpatient,,,858.00000,514.80000,MedCost,Ultra,,549.12,,,,,,,549.12,694.98,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,MedCost,Ultra,,437.58,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,inpatient,,,576.00000,345.60000,MedCost,Ultra,,368.64,,,,,,,368.64,466.56,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,MedCost,Ultra,,293.76,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,inpatient,,,294.00000,176.40000,MedCost,Ultra,,188.16,,,,,,,188.16,238.14,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,MedCost,Ultra,,149.94,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,inpatient,,,1638.00000,982.80000,MedCost,Ultra,,1048.32,,,,,,,1048.32,7039.00,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,MedCost,Ultra,,835.38,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,inpatient,,,4895.00000,2937.00000,MedCost,Ultra,,3132.80,,,,,,,3132.80,7039.00,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,MedCost,Ultra,,2496.45,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,inpatient,,,6492.00000,3895.20000,MedCost,Ultra,,4154.88,,,,,,,4154.88,7039.00,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,MedCost,Ultra,,3310.92,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,inpatient,,,3430.00000,2058.00000,MedCost,Ultra,,2195.20,,,,,,,2195.20,7039.00,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,MedCost,Ultra,,1749.30,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,inpatient,,,2604.00000,1562.40000,MedCost,Ultra,,1666.56,,,,,,,1666.56,7039.00,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,MedCost,Ultra,,1328.04,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,inpatient,,,26158.00000,15694.80000,MedCost,Ultra,,16741.12,,,,,,,7039.00,21187.98,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,MedCost,Ultra,,13340.58,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,inpatient,,,27399.00000,16439.40000,MedCost,Ultra,,17535.36,,,,,,,7039.00,22193.19,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,MedCost,Ultra,,13973.49,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,inpatient,,,28837.00000,17302.20000,MedCost,Ultra,,18455.68,,,,,,,7039.00,23357.97,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,MedCost,Ultra,,14706.87,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,inpatient,,,30074.00000,18044.40000,MedCost,Ultra,,19247.36,,,,,,,7039.00,24359.94,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,MedCost,Ultra,,15337.74,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,inpatient,,,31316.00000,18789.60000,MedCost,Ultra,,20042.24,,,,,,,7039.00,25365.96,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,MedCost,Ultra,,15971.16,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,inpatient,,,32554.00000,19532.40000,MedCost,Ultra,,20834.56,,,,,,,7039.00,26368.74,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,MedCost,Ultra,,16602.54,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,inpatient,,,33591.00000,20154.60000,MedCost,Ultra,,21498.24,,,,,,,7039.00,27208.71,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,MedCost,Ultra,,17131.41,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,inpatient,,,35029.00000,21017.40000,MedCost,Ultra,,22418.56,,,,,,,7039.00,28373.49,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,MedCost,Ultra,,17864.79,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,inpatient,,,36268.00000,21760.80000,MedCost,Ultra,,23211.52,,,,,,,7039.00,29377.08,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,MedCost,Ultra,,18496.68,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,inpatient,,,37507.00000,22504.20000,MedCost,Ultra,,24004.48,,,,,,,7039.00,30380.67,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,MedCost,Ultra,,19128.57,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,inpatient,,,38747.00000,23248.20000,MedCost,Ultra,,24798.08,,,,,,,7039.00,31385.07,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,MedCost,Ultra,,19760.97,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,inpatient,,,388.00000,232.80000,MedCost,Ultra,,248.32,,,,,,,248.32,7039.00,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,MedCost,Ultra,,197.88,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,inpatient,,,534.00000,320.40000,MedCost,Ultra,,341.76,,,,,,,341.76,7039.00,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,MedCost,Ultra,,272.34,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,inpatient,,,829.00000,497.40000,MedCost,Ultra,,530.56,,,,,,,530.56,7039.00,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,MedCost,Ultra,,422.79,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,inpatient,,,836.00000,501.60000,MedCost,Ultra,,535.04,,,,,,,535.04,7039.00,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,MedCost,Ultra,,426.36,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,inpatient,,,4035.00000,2421.00000,MedCost,Ultra,,2582.40,,,,,,,2582.40,7039.00,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,MedCost,Ultra,,2057.85,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,inpatient,,,9685.00000,5811.00000,MedCost,Ultra,,6198.40,,,,,,,6198.40,7844.85,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,MedCost,Ultra,,4939.35,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,inpatient,,,10407.00000,6244.20000,MedCost,Ultra,,6660.48,,,,,,,6660.48,8429.67,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,MedCost,Ultra,,5307.57,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,inpatient,,,11179.00000,6707.40000,MedCost,Ultra,,7154.56,,,,,,,7039.00,9054.99,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,MedCost,Ultra,,5701.29,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,inpatient,,,6094.00000,3656.40000,MedCost,Ultra,,3900.16,,,,,,,3900.16,7039.00,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,MedCost,Ultra,,3107.94,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,inpatient,,,7873.00000,4723.80000,MedCost,Ultra,,5038.72,,,,,,,5038.72,7039.00,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,MedCost,Ultra,,4015.23,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,inpatient,,,8955.00000,5373.00000,MedCost,Ultra,,5731.20,,,,,,,5731.20,7253.55,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,MedCost,Ultra,,4567.05,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,inpatient,,,11530.00000,6918.00000,MedCost,Ultra,,7379.20,,,,,,,7039.00,9339.30,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,MedCost,Ultra,,5880.30,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,inpatient,,,11836.00000,7101.60000,MedCost,Ultra,,7575.04,,,,,,,7039.00,9587.16,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,MedCost,Ultra,,6036.36,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,inpatient,,,12124.00000,7274.40000,MedCost,Ultra,,7759.36,,,,,,,7039.00,9820.44,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,MedCost,Ultra,,6183.24,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,inpatient,,,12413.00000,7447.80000,MedCost,Ultra,,7944.32,,,,,,,7039.00,10054.53,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,MedCost,Ultra,,6330.63,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,inpatient,,,12701.00000,7620.60000,MedCost,Ultra,,8128.64,,,,,,,7039.00,10287.81,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,MedCost,Ultra,,6477.51,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,inpatient,,,4946.00000,2967.60000,MedCost,Ultra,,3165.44,,,,,,,3165.44,7039.00,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,MedCost,Ultra,,2522.46,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,inpatient,,,668.00000,400.80000,MedCost,Ultra,,427.52,,,,,,,427.52,7039.00,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,MedCost,Ultra,,340.68,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,inpatient,,,4406.00000,2643.60000,MedCost,Ultra,,2819.84,,,,,,,2819.84,7039.00,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,MedCost,Ultra,,2247.06,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,inpatient,,,5949.00000,3569.40000,MedCost,Ultra,,3807.36,,,,,,,3807.36,7039.00,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,MedCost,Ultra,,3033.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,inpatient,,,8146.00000,4887.60000,MedCost,Ultra,,5213.44,,,,,,,5213.44,7039.00,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,MedCost,Ultra,,4154.46,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,inpatient,,,10324.00000,6194.40000,MedCost,Ultra,,6607.36,,,,,,,6607.36,8362.44,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,MedCost,Ultra,,5265.24,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,inpatient,,,11787.00000,7072.20000,MedCost,Ultra,,7543.68,,,,,,,7039.00,9547.47,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,MedCost,Ultra,,6011.37,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,inpatient,,,13350.00000,8010.00000,MedCost,Ultra,,8544.00,,,,,,,7039.00,10813.50,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,MedCost,Ultra,,6808.50,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,inpatient,,,15229.00000,9137.40000,MedCost,Ultra,,9746.56,,,,,,,7039.00,12335.49,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,MedCost,Ultra,,7766.79,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,inpatient,,,16324.00000,9794.40000,MedCost,Ultra,,10447.36,,,,,,,7039.00,13222.44,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,MedCost,Ultra,,8325.24,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,inpatient,,,17940.00000,10764.00000,MedCost,Ultra,,11481.60,,,,,,,7039.00,14531.40,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,MedCost,Ultra,,9149.40,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,inpatient,,,18819.00000,11291.40000,MedCost,Ultra,,12044.16,,,,,,,7039.00,15243.39,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,MedCost,Ultra,,9597.69,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,inpatient,,,19970.00000,11982.00000,MedCost,Ultra,,12780.80,,,,,,,7039.00,16175.70,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,MedCost,Ultra,,10184.70,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,inpatient,,,20711.00000,12426.60000,MedCost,Ultra,,13255.04,,,,,,,7039.00,16775.91,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,MedCost,Ultra,,10562.61,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,inpatient,,,20897.00000,12538.20000,MedCost,Ultra,,13374.08,,,,,,,7039.00,16926.57,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,MedCost,Ultra,,10657.47,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,inpatient,,,21207.00000,12724.20000,MedCost,Ultra,,13572.48,,,,,,,7039.00,17177.67,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,MedCost,Ultra,,10815.57,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,inpatient,,,21825.00000,13095.00000,MedCost,Ultra,,13968.00,,,,,,,7039.00,17678.25,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,MedCost,Ultra,,11130.75,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,inpatient,,,22444.00000,13466.40000,MedCost,Ultra,,14364.16,,,,,,,7039.00,18179.64,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,MedCost,Ultra,,11446.44,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,inpatient,,,23062.00000,13837.20000,MedCost,Ultra,,14759.68,,,,,,,7039.00,18680.22,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,MedCost,Ultra,,11761.62,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,inpatient,,,23685.00000,14211.00000,MedCost,Ultra,,15158.40,,,,,,,7039.00,19184.85,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,MedCost,Ultra,,12079.35,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,inpatient,,,24302.00000,14581.20000,MedCost,Ultra,,15553.28,,,,,,,7039.00,19684.62,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,MedCost,Ultra,,12394.02,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,inpatient,,,24922.00000,14953.20000,MedCost,Ultra,,15950.08,,,,,,,7039.00,20186.82,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,MedCost,Ultra,,12710.22,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,inpatient,,,13406.00000,8043.60000,MedCost,Ultra,,8579.84,,,,,,,7039.00,10858.86,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,MedCost,Ultra,,6837.06,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,inpatient,,,11362.00000,6817.20000,MedCost,Ultra,,7271.68,,,,,,,7039.00,9203.22,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,MedCost,Ultra,,5794.62,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,MedCost,Ultra,,4507.52,,,,,,,4507.52,7039.00,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,MedCost,Ultra,,3591.93,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,MedCost,Ultra,,4507.52,,,,,,,4507.52,7039.00,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,MedCost,Ultra,,3591.93,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,inpatient,,,7043.00000,4225.80000,MedCost,Ultra,,4507.52,,,,,,,4507.52,7039.00,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,MedCost,Ultra,,3591.93,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,inpatient,,,6480.00000,3888.00000,MedCost,Ultra,,4147.20,,,,,,,4147.20,7039.00,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,MedCost,Ultra,,3304.80,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,inpatient,,,13406.00000,8043.60000,MedCost,Ultra,,8579.84,,,,,,,7039.00,10858.86,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,MedCost,Ultra,,6837.06,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,inpatient,,,7562.00000,4537.20000,MedCost,Ultra,,4839.68,,,,,,,4839.68,7039.00,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,MedCost,Ultra,,3856.62,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,inpatient,,,8521.00000,5112.60000,MedCost,Ultra,,5453.44,,,,,,,5453.44,7039.00,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,MedCost,Ultra,,4345.71,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,inpatient,,,303.00000,181.80000,MedCost,Ultra,,193.92,,,,,,,193.92,7039.00,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,MedCost,Ultra,,154.53,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Ultra,,813.44,,,,,,,813.44,7039.00,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Ultra,,648.21,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,inpatient,,,508.00000,304.80000,MedCost,Ultra,,325.12,,,,,,,325.12,7039.00,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,MedCost,Ultra,,259.08,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,inpatient,,,508.00000,304.80000,MedCost,Ultra,,325.12,,,,,,,325.12,7039.00,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,MedCost,Ultra,,259.08,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,inpatient,,,808.00000,484.80000,MedCost,Ultra,,517.12,,,,,,,517.12,7039.00,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,MedCost,Ultra,,412.08,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,inpatient,,,10794.00000,6476.40000,MedCost,Ultra,,6908.16,,,,,,,6908.16,8743.14,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,MedCost,Ultra,,5504.94,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,inpatient,,,1890.00000,1134.00000,MedCost,Ultra,,1209.60,,,,,,,1209.60,7039.00,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,MedCost,Ultra,,963.90,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,inpatient,,,1225.00000,735.00000,MedCost,Ultra,,784.00,,,,,,,784.00,7039.00,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,MedCost,Ultra,,624.75,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,inpatient,,,7174.00000,4304.40000,MedCost,Ultra,,4591.36,,,,,,,4591.36,5832.46,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,MedCost,Ultra,,3658.74,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,inpatient,,,296.00000,177.60000,MedCost,Ultra,,189.44,,,,,,,189.44,7039.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,MedCost,Ultra,,150.96,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,inpatient,,,756.00000,453.60000,MedCost,Ultra,,483.84,,,,,,,483.84,614.63,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,MedCost,Ultra,,385.56,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,inpatient,,,3.00000,1.80000,MedCost,Ultra,,1.92,,,,,,,1.92,2.44,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,MedCost,Ultra,,1.53,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,inpatient,,,1649.00000,989.40000,MedCost,Ultra,,1055.36,,,,,,,1055.36,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,MedCost,Ultra,,840.99,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,inpatient,,,2127.00000,1276.20000,MedCost,Ultra,,1361.28,,,,,,,1361.28,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,MedCost,Ultra,,1084.77,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,inpatient,,,2607.00000,1564.20000,MedCost,Ultra,,1668.48,,,,,,,1668.48,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,MedCost,Ultra,,1329.57,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,inpatient,,,3085.00000,1851.00000,MedCost,Ultra,,1974.40,,,,,,,1974.40,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,MedCost,Ultra,,1573.35,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,inpatient,,,3564.00000,2138.40000,MedCost,Ultra,,2280.96,,,,,,,2280.96,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,MedCost,Ultra,,1817.64,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,inpatient,,,4043.00000,2425.80000,MedCost,Ultra,,2587.52,,,,,,,2587.52,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,MedCost,Ultra,,2061.93,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,inpatient,,,4521.00000,2712.60000,MedCost,Ultra,,2893.44,,,,,,,2893.44,3675.57,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,MedCost,Ultra,,2305.71,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,inpatient,,,661.00000,396.60000,MedCost,Ultra,,423.04,,,,,,,423.04,537.39,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,MedCost,Ultra,,337.11,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,inpatient,,,3280.00000,1968.00000,MedCost,Ultra,,2099.20,,,,,,,2099.20,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,MedCost,Ultra,,1672.80,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,inpatient,,,4322.00000,2593.20000,MedCost,Ultra,,2766.08,,,,,,,2766.08,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,MedCost,Ultra,,2204.22,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,inpatient,,,1294.00000,776.40000,MedCost,Ultra,,828.16,,,,,,,828.16,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,MedCost,Ultra,,659.94,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,inpatient,,,1763.00000,1057.80000,MedCost,Ultra,,1128.32,,,,,,,1128.32,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,MedCost,Ultra,,899.13,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,inpatient,,,1966.00000,1179.60000,MedCost,Ultra,,1258.24,,,,,,,1258.24,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,MedCost,Ultra,,1002.66,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,inpatient,,,2177.00000,1306.20000,MedCost,Ultra,,1393.28,,,,,,,1393.28,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,MedCost,Ultra,,1110.27,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,inpatient,,,2387.00000,1432.20000,MedCost,Ultra,,1527.68,,,,,,,1527.68,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,MedCost,Ultra,,1217.37,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,inpatient,,,2596.00000,1557.60000,MedCost,Ultra,,1661.44,,,,,,,1661.44,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,MedCost,Ultra,,1323.96,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,inpatient,,,2807.00000,1684.20000,MedCost,Ultra,,1796.48,,,,,,,1796.48,2282.09,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,MedCost,Ultra,,1431.57,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,inpatient,,,1649.00000,989.40000,MedCost,Ultra,,1055.36,,,,,,,1055.36,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,MedCost,Ultra,,840.99,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,inpatient,,,958.00000,574.80000,MedCost,Ultra,,613.12,,,,,,,613.12,778.85,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,MedCost,Ultra,,488.58,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,inpatient,,,2387.00000,1432.20000,MedCost,Ultra,,1527.68,,,,,,,1527.68,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,MedCost,Ultra,,1217.37,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,inpatient,,,1294.00000,776.40000,MedCost,Ultra,,828.16,,,,,,,828.16,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,MedCost,Ultra,,659.94,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,inpatient,,,1763.00000,1057.80000,MedCost,Ultra,,1128.32,,,,,,,1128.32,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,MedCost,Ultra,,899.13,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,inpatient,,,1966.00000,1179.60000,MedCost,Ultra,,1258.24,,,,,,,1258.24,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,MedCost,Ultra,,1002.66,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,inpatient,,,2177.00000,1306.20000,MedCost,Ultra,,1393.28,,,,,,,1393.28,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,MedCost,Ultra,,1110.27,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,inpatient,,,2596.00000,1557.60000,MedCost,Ultra,,1661.44,,,,,,,1661.44,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,MedCost,Ultra,,1323.96,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,inpatient,,,2807.00000,1684.20000,MedCost,Ultra,,1796.48,,,,,,,1796.48,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,MedCost,Ultra,,1431.57,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,inpatient,,,3280.00000,1968.00000,MedCost,Ultra,,2099.20,,,,,,,2099.20,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,MedCost,Ultra,,1672.80,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,inpatient,,,4322.00000,2593.20000,MedCost,Ultra,,2766.08,,,,,,,2766.08,3513.79,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,MedCost,Ultra,,2204.22,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,inpatient,,,499.00000,299.40000,MedCost,Ultra,,319.36,,,,,,,319.36,405.69,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,MedCost,Ultra,,254.49,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,inpatient,,,3430.00000,2058.00000,MedCost,Ultra,,2195.20,,,,,,,2195.20,7039.00,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,MedCost,Ultra,,1749.30,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,inpatient,,,285.00000,171.00000,MedCost,Ultra,,182.40,,,,,,,182.40,7039.00,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,MedCost,Ultra,,145.35,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,inpatient,,,1357.00000,814.20000,MedCost,Ultra,,868.48,,,,,,,868.48,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,MedCost,Ultra,,692.07,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,inpatient,,,1537.00000,922.20000,MedCost,Ultra,,983.68,,,,,,,983.68,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,MedCost,Ultra,,783.87,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,inpatient,,,1719.00000,1031.40000,MedCost,Ultra,,1100.16,,,,,,,1100.16,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,MedCost,Ultra,,876.69,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,inpatient,,,1901.00000,1140.60000,MedCost,Ultra,,1216.64,,,,,,,1216.64,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,MedCost,Ultra,,969.51,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,inpatient,,,2085.00000,1251.00000,MedCost,Ultra,,1334.40,,,,,,,1334.40,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,MedCost,Ultra,,1063.35,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,inpatient,,,2268.00000,1360.80000,MedCost,Ultra,,1451.52,,,,,,,1451.52,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,MedCost,Ultra,,1156.68,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,inpatient,,,2450.00000,1470.00000,MedCost,Ultra,,1568.00,,,,,,,1568.00,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,MedCost,Ultra,,1249.50,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,inpatient,,,2631.00000,1578.60000,MedCost,Ultra,,1683.84,,,,,,,1683.84,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,MedCost,Ultra,,1341.81,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,inpatient,,,2812.00000,1687.20000,MedCost,Ultra,,1799.68,,,,,,,1799.68,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,MedCost,Ultra,,1434.12,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,inpatient,,,2996.00000,1797.60000,MedCost,Ultra,,1917.44,,,,,,,1917.44,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,MedCost,Ultra,,1527.96,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,inpatient,,,3177.00000,1906.20000,MedCost,Ultra,,2033.28,,,,,,,2033.28,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,MedCost,Ultra,,1620.27,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,inpatient,,,3414.00000,2048.40000,MedCost,Ultra,,2184.96,,,,,,,2184.96,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,MedCost,Ultra,,1741.14,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,inpatient,,,3598.00000,2158.80000,MedCost,Ultra,,2302.72,,,,,,,2302.72,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,MedCost,Ultra,,1834.98,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,inpatient,,,4293.00000,2575.80000,MedCost,Ultra,,2747.52,,,,,,,2747.52,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,MedCost,Ultra,,2189.43,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,inpatient,,,4574.00000,2744.40000,MedCost,Ultra,,2927.36,,,,,,,2927.36,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,MedCost,Ultra,,2332.74,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,inpatient,,,4787.00000,2872.20000,MedCost,Ultra,,3063.68,,,,,,,3063.68,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,MedCost,Ultra,,2441.37,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,inpatient,,,4969.00000,2981.40000,MedCost,Ultra,,3180.16,,,,,,,3180.16,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,MedCost,Ultra,,2534.19,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,inpatient,,,5150.00000,3090.00000,MedCost,Ultra,,3296.00,,,,,,,3296.00,7039.00,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,MedCost,Ultra,,2626.50,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,inpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2796.16,,,,,,,2796.16,7039.00,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,MedCost,Ultra,,2228.19,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,inpatient,,,4636.00000,2781.60000,MedCost,Ultra,,2967.04,,,,,,,2967.04,7039.00,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,MedCost,Ultra,,2364.36,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,inpatient,,,4123.00000,2473.80000,MedCost,Ultra,,2638.72,,,,,,,2638.72,7039.00,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,MedCost,Ultra,,2102.73,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,inpatient,,,2613.00000,1567.80000,MedCost,Ultra,,1672.32,,,,,,,1672.32,7039.00,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,MedCost,Ultra,,1332.63,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,inpatient,,,2825.00000,1695.00000,MedCost,Ultra,,1808.00,,,,,,,1808.00,7039.00,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,MedCost,Ultra,,1440.75,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,inpatient,,,2486.00000,1491.60000,MedCost,Ultra,,1591.04,,,,,,,1591.04,7039.00,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,MedCost,Ultra,,1267.86,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,inpatient,,,3342.00000,2005.20000,MedCost,Ultra,,2138.88,,,,,,,2138.88,7039.00,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,MedCost,Ultra,,1704.42,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,inpatient,,,337.00000,202.20000,MedCost,Ultra,,215.68,,,,,,,215.68,7039.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,MedCost,Ultra,,171.87,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,MedCost,Ultra,,6452.48,,,,,,,6452.48,8166.42,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,MedCost,Ultra,,5141.82,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,MedCost,Ultra,,6452.48,,,,,,,6452.48,8166.42,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,MedCost,Ultra,,5141.82,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,inpatient,,,10082.00000,6049.20000,MedCost,Ultra,,6452.48,,,,,,,6452.48,8166.42,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,MedCost,Ultra,,5141.82,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,inpatient,,,1275.00000,765.00000,MedCost,Ultra,,816.00,,,,,,,816.00,7039.00,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,MedCost,Ultra,,650.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,inpatient,,,2096.00000,1257.60000,MedCost,Ultra,,1341.44,,,,,,,1341.44,7039.00,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,MedCost,Ultra,,1068.96,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,inpatient,,,2329.00000,1397.40000,MedCost,Ultra,,1490.56,,,,,,,1490.56,7039.00,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,MedCost,Ultra,,1187.79,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,inpatient,,,1264.00000,758.40000,MedCost,Ultra,,808.96,,,,,,,808.96,7039.00,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,MedCost,Ultra,,644.64,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,inpatient,,,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,309.12,7039.00,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,inpatient,,,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,309.12,7039.00,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,inpatient,,,7494.00000,4496.40000,MedCost,Ultra,,4796.16,,,,,,,4796.16,7039.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,MedCost,Ultra,,3821.94,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,inpatient,,,1016.00000,609.60000,MedCost,Ultra,,650.24,,,,,,,650.24,7039.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,MedCost,Ultra,,518.16,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,inpatient,,,404.00000,242.40000,MedCost,Ultra,,258.56,,,,,,,258.56,7039.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,MedCost,Ultra,,206.04,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,inpatient,,,4574.00000,2744.40000,MedCost,Ultra,,2927.36,,,,,,,2927.36,7039.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,MedCost,Ultra,,2332.74,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,inpatient,,,10837.00000,6502.20000,MedCost,Ultra,,6935.68,,,,,,,6935.68,8777.97,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,MedCost,Ultra,,5526.87,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,inpatient,,,5274.00000,3164.40000,MedCost,Ultra,,3375.36,,,,,,,3375.36,7039.00,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,MedCost,Ultra,,2689.74,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,inpatient,,,307.00000,184.20000,MedCost,Ultra,,196.48,,,,,,,196.48,248.67,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,MedCost,Ultra,,156.57,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00640,0.00810,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,inpatient,,,39984.00000,23990.40000,MedCost,Ultra,,25589.76,,,,,,,7039.00,32387.04,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,MedCost,Ultra,,20391.84,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,inpatient,,,41222.00000,24733.20000,MedCost,Ultra,,26382.08,,,,,,,7039.00,33389.82,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,MedCost,Ultra,,21023.22,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,inpatient,,,1885.00000,1131.00000,MedCost,Ultra,,1206.40,,,,,,,1206.40,7039.00,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,MedCost,Ultra,,961.35,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,inpatient,,,557.00000,334.20000,MedCost,Ultra,,356.48,,,,,,,356.48,7039.00,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,MedCost,Ultra,,284.07,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,inpatient,,,2915.00000,1749.00000,MedCost,Ultra,,1865.60,,,,,,,1865.60,7039.00,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,MedCost,Ultra,,1486.65,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,86.00000,51.60000,MedCost,Ultra,,55.04,,,,,,,55.04,69.66,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,MedCost,Ultra,,43.86,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,183.00000,109.80000,MedCost,Ultra,,117.12,,,,,,,117.12,148.23,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,MedCost,Ultra,,93.33,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Ultra,,63.36,,,,,,,63.36,80.19,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Ultra,,50.49,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Ultra,Q0,0.64640,,,,,,,0.64640,0.81810,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Ultra,Q0,0.51510,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Ultra,Q0,0.64640,,,,,,,0.64640,0.81810,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Ultra,Q0,0.51510,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,103.20,498.00,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,MedCost,Ultra,,306.00,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,MedCost,Ultra,,477.44,,,,,,,128.31,619.18,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,MedCost,Ultra,,380.46,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,1375.00000,825.00000,MedCost,Ultra,,880.00,,,,,,,236.50,1141.25,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,MedCost,Ultra,,701.25,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,19569.00000,11741.40000,MedCost,Ultra,,12524.16,,,,,,,3365.87,16242.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,MedCost,Ultra,,9980.19,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,9120.00000,5472.00000,MedCost,Ultra,,5836.80,,,,,,,1568.64,7569.60,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,MedCost,Ultra,,4651.20,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Ultra,,3276.80,,,,,,,880.64,4249.60,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Ultra,,2611.20,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,4954.00000,2972.40000,MedCost,Ultra,,3170.56,,,,,,,852.09,4111.82,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,MedCost,Ultra,,2526.54,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,7438.00000,4462.80000,MedCost,Ultra,,4760.32,,,,,,,1279.34,6173.54,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,MedCost,Ultra,,3793.38,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,8418.00000,5050.80000,MedCost,Ultra,,5387.52,,,,,,,1447.90,6986.94,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,MedCost,Ultra,,4293.18,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Ultra,,3276.80,,,,,,,880.64,4249.60,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Ultra,,2611.20,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,6348.00000,3808.80000,MedCost,Ultra,,4062.72,,,,,,,1091.86,5268.84,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,MedCost,Ultra,,3237.48,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Ultra,,203.52,,,,,,,54.70,263.94,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Ultra,,162.18,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,MedCost,Ultra,,65.92,,,,,,,17.72,85.49,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,MedCost,Ultra,,52.53,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,209.00000,125.40000,MedCost,Ultra,,133.76,,,,,,,35.95,173.47,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,MedCost,Ultra,,106.59,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.76,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Ultra,,92.80,,,,,,,24.94,120.35,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Ultra,,73.95,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Ultra,,203.52,,,,,,,54.70,263.94,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Ultra,,162.18,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,126.00000,75.60000,MedCost,Ultra,,80.64,,,,,,,21.67,104.58,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,MedCost,Ultra,,64.26,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,151.00000,90.60000,MedCost,Ultra,,96.64,,,,,,,25.97,125.33,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,MedCost,Ultra,,77.01,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,184.00000,110.40000,MedCost,Ultra,,117.76,,,,,,,31.65,152.72,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,MedCost,Ultra,,93.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,295.00000,177.00000,MedCost,Ultra,,188.80,,,,,,,50.74,244.85,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,MedCost,Ultra,,150.45,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,355.00000,213.00000,MedCost,Ultra,,227.20,,,,,,,61.06,294.65,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,MedCost,Ultra,,181.05,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Ultra,,670.72,,,,,,,180.26,869.84,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Ultra,,534.48,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,MedCost,Ultra,,65.92,,,,,,,17.72,85.49,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,MedCost,Ultra,,52.53,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,425.00000,255.00000,MedCost,Ultra,,272.00,,,,,,,73.10,352.75,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,MedCost,Ultra,,216.75,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,103.20,498.00,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,MedCost,Ultra,,306.00,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1073.00000,643.80000,MedCost,Ultra,,686.72,,,,,,,184.56,890.59,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,MedCost,Ultra,,547.23,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,948.00000,568.80000,MedCost,Ultra,,606.72,,,,,,,163.06,786.84,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,MedCost,Ultra,,483.48,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,MedCost,Ultra,,477.44,,,,,,,128.31,619.18,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,MedCost,Ultra,,380.46,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,MedCost,Ultra,,477.44,,,,,,,128.31,619.18,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,MedCost,Ultra,,380.46,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,46.96,226.59,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,774.00000,464.40000,MedCost,Ultra,,495.36,,,,,,,133.13,642.42,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,MedCost,Ultra,,394.74,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Ultra,,3276.80,,,,,,,3276.80,4162.56,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Ultra,,2611.20,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,503.00000,301.80000,MedCost,Ultra,,321.92,,,,,,,86.52,417.49,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,MedCost,Ultra,,256.53,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,inpatient,,,452.00000,271.20000,MedCost,Ultra,,289.28,,,,,,,289.28,367.48,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,MedCost,Ultra,,230.52,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,1349.00000,809.40000,MedCost,Ultra,,863.36,,,,,,,232.03,1119.67,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,MedCost,Ultra,,687.99,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,MedCost,Ultra,,3276.80,,,,,,,880.64,4249.60,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,MedCost,Ultra,,2611.20,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1484.00000,890.40000,MedCost,Ultra,,949.76,,,,,,,255.25,1231.72,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,MedCost,Ultra,,756.84,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1379.00000,827.40000,MedCost,Ultra,,882.56,,,,,,,237.19,1144.57,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,MedCost,Ultra,,703.29,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,9.98,48.14,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,9.98,48.14,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,9.98,48.14,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,9.98,48.14,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Ultra,,342.40,,,,,,,92.02,444.05,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Ultra,,272.85,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Ultra,,342.40,,,,,,,92.02,444.05,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Ultra,,272.85,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Ultra,,342.40,,,,,,,92.02,444.05,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Ultra,,272.85,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00640,0.00813,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,inpatient,,,6720.00000,4032.00000,MedCost,Ultra,,4300.80,,,,,,,4300.80,5463.36,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,MedCost,Ultra,,3427.20,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,MedCost,Ultra,,590.08,,,,,,,158.58,765.26,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,MedCost,Ultra,,470.22,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,MedCost,Ultra,,590.08,,,,,,,158.58,765.26,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,MedCost,Ultra,,470.22,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,MedCost,Ultra,,590.08,,,,,,,158.58,765.26,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,MedCost,Ultra,,470.22,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1215.00000,729.00000,MedCost,Ultra,,777.60,,,,,,,208.98,1008.45,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,MedCost,Ultra,,619.65,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1631.00000,978.60000,MedCost,Ultra,,1043.84,,,,,,,280.53,1353.73,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,MedCost,Ultra,,831.81,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,inpatient,,,2899.00000,1739.40000,MedCost,Ultra,,1855.36,,,,,,,1855.36,2356.89,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,MedCost,Ultra,,1478.49,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Ultra,,224.00,,,,,,,60.20,290.50,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Ultra,,178.50,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Ultra,,296.32,,,,,,,79.64,384.29,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Ultra,,236.13,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Ultra,,89.60,,,,,,,24.08,116.20,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Ultra,,71.40,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,16.34,78.85,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,inpatient,,,166.00000,99.60000,MedCost,Ultra,,106.24,,,,,,,28.55,137.78,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,MedCost,Ultra,,84.66,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Ultra,,224.00,,,,,,,60.20,290.50,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Ultra,,178.50,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,15.65,75.53,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,17.37,83.83,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5270.00000,3162.00000,MedCost,Ultra,,3372.80,,,,,,,906.44,4374.10,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,MedCost,Ultra,,2687.70,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,1024.00000,614.40000,MedCost,Ultra,,655.36,,,,,,,176.13,849.92,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,MedCost,Ultra,,522.24,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Ultra,,407.68,,,,,,,109.56,528.71,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Ultra,,324.87,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,inpatient,,,39570.00000,23742.00000,MedCost,Ultra,,25324.80,,,,,,,11910.57,32170.41,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,MedCost,Ultra,,20180.70,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,17004.00000,10202.40000,MedCost,Ultra,,10882.56,,,,,,,5118.20,13824.25,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,MedCost,Ultra,,8672.04,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,297.00000,178.20000,MedCost,Ultra,,190.08,,,,,,,51.08,246.51,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,MedCost,Ultra,,151.47,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,308.00000,184.80000,MedCost,Ultra,,197.12,,,,,,,52.98,255.64,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,MedCost,Ultra,,157.08,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,1919.00000,1151.40000,MedCost,Ultra,,1228.16,,,,,,,577.62,1560.15,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,MedCost,Ultra,,978.69,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,7252.00000,4351.20000,MedCost,Ultra,,4641.28,,,,,,,2182.85,5895.88,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,MedCost,Ultra,,3698.52,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,1734.00000,1040.40000,MedCost,Ultra,,1109.76,,,,,,,521.93,1409.74,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,MedCost,Ultra,,884.34,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,3295.00000,1977.00000,MedCost,Ultra,,2108.80,,,,,,,991.79,2678.84,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,MedCost,Ultra,,1680.45,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,40220.00000,24132.00000,MedCost,Ultra,,25740.80,,,,,,,12106.22,32698.86,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,MedCost,Ultra,,20512.20,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,12517.00000,7510.20000,MedCost,Ultra,,8010.88,,,,,,,3767.62,10176.32,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,MedCost,Ultra,,6383.67,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,11120.00000,6672.00000,MedCost,Ultra,,7116.80,,,,,,,3347.12,9040.56,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,MedCost,Ultra,,5671.20,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,15665.00000,9399.00000,MedCost,Ultra,,10025.60,,,,,,,4715.16,12735.65,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,MedCost,Ultra,,7989.15,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,31578.00000,18946.80000,MedCost,Ultra,,20209.92,,,,,,,9504.98,25672.91,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,MedCost,Ultra,,16104.78,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,2639.00000,1583.40000,MedCost,Ultra,,1688.96,,,,,,,794.34,2145.51,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,MedCost,Ultra,,1345.89,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,11117.00000,6670.20000,MedCost,Ultra,,7114.88,,,,,,,3346.22,9038.12,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,MedCost,Ultra,,5669.67,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,16042.00000,9625.20000,MedCost,Ultra,,10266.88,,,,,,,4828.64,13042.15,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,MedCost,Ultra,,8181.42,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,9476.00000,5685.60000,MedCost,Ultra,,6064.64,,,,,,,1629.87,7865.08,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,MedCost,Ultra,,4832.76,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,MedCost,Ultra,,1725.44,,,,,,,811.50,2191.85,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,MedCost,Ultra,,1374.96,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,MedCost,Ultra,,1725.44,,,,,,,463.71,2237.68,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,MedCost,Ultra,,1374.96,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,8366.00000,5019.60000,MedCost,Ultra,,5354.24,,,,,,,2518.17,6801.56,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,MedCost,Ultra,,4266.66,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Ultra,,0.64640,,,,,,,0.64640,0.81810,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Ultra,,0.51510,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,8920.00000,5352.00000,MedCost,Ultra,,5708.80,,,,,,,2684.92,7251.96,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,MedCost,Ultra,,4549.20,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,11277.00000,6766.20000,MedCost,Ultra,,7217.28,,,,,,,3394.38,9168.20,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,MedCost,Ultra,,5751.27,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6131.00000,3678.60000,MedCost,Ultra,,3923.84,,,,,,,1054.53,5088.73,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,MedCost,Ultra,,3126.81,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,inpatient,,,15495.00000,9297.00000,MedCost,Ultra,,9916.80,,,,,,,4663.99,12597.43,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,MedCost,Ultra,,7902.45,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,inpatient,,,1255.00000,753.00000,MedCost,Ultra,,803.20,,,,,,,215.86,1041.65,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,MedCost,Ultra,,640.05,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,inpatient,,,537.00000,322.20000,MedCost,Ultra,,343.68,,,,,,,92.36,445.71,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,MedCost,Ultra,,273.87,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6720.00000,4032.00000,MedCost,Ultra,,4300.80,,,,,,,1155.84,5577.60,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,MedCost,Ultra,,3427.20,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5270.00000,3162.00000,MedCost,Ultra,,3372.80,,,,,,,906.44,4374.10,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,MedCost,Ultra,,2687.70,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,940.00000,564.00000,MedCost,Ultra,,601.60,,,,,,,161.68,780.20,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,MedCost,Ultra,,479.40,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,inpatient,,,220.00000,132.00000,MedCost,Ultra,,140.80,,,,,,,37.84,182.60,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,MedCost,Ultra,,112.20,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,555.00000,333.00000,MedCost,Ultra,,355.20,,,,,,,95.46,460.65,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,MedCost,Ultra,,283.05,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5436.00000,3261.60000,MedCost,Ultra,,3479.04,,,,,,,934.99,4511.88,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,MedCost,Ultra,,2772.36,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,19845.00000,11907.00000,MedCost,Ultra,,12700.80,,,,,,,3413.34,16471.35,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,MedCost,Ultra,,10120.95,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,27390.00000,16434.00000,MedCost,Ultra,,17529.60,,,,,,,4711.08,22733.70,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,MedCost,Ultra,,13968.90,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,MedCost,Ultra,,179.84,,,,,,,48.33,233.23,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,MedCost,Ultra,,143.31,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,MedCost,Ultra,,179.84,,,,,,,48.33,233.23,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,MedCost,Ultra,,143.31,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,MedCost,Ultra,,168.32,,,,,,,45.24,218.29,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,MedCost,Ultra,,134.13,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,MedCost,Ultra,,168.32,,,,,,,45.24,218.29,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,MedCost,Ultra,,134.13,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,MedCost,Ultra,,168.32,,,,,,,45.24,218.29,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,MedCost,Ultra,,134.13,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00172,0.00830,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,3125.00000,1875.00000,MedCost,Ultra,,2000.00,,,,,,,537.50,2593.75,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,MedCost,Ultra,,1593.75,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1172.00000,703.20000,MedCost,Ultra,,750.08,,,,,,,750.08,952.84,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,MedCost,Ultra,,597.72,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1507.00000,904.20000,MedCost,Ultra,,964.48,,,,,,,964.48,1225.19,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,MedCost,Ultra,,768.57,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1415.00000,849.00000,MedCost,Ultra,,905.60,,,,,,,905.60,1150.39,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,MedCost,Ultra,,721.65,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1370.00000,822.00000,MedCost,Ultra,,876.80,,,,,,,876.80,1113.81,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,MedCost,Ultra,,698.70,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,inpatient,,,9964.00000,5978.40000,MedCost,Ultra,,6376.96,,,,,,,6376.96,8070.84,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,MedCost,Ultra,,5081.64,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,inpatient,,,6335.00000,3801.00000,MedCost,Ultra,Q1,4054.40,,,,,,,4054.40,5131.35,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,MedCost,Ultra,Q1,3230.85,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,inpatient,,,3795.00000,2277.00000,MedCost,Ultra,Q0,2428.80,,,,,,,2428.80,3073.95,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,MedCost,Ultra,Q0,1935.45,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,inpatient,,,182.00000,109.20000,MedCost,Ultra,,116.48,,,,,,,116.48,147.97,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,MedCost,Ultra,,92.82,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,inpatient,,,423.00000,253.80000,MedCost,Ultra,,270.72,,,,,,,270.72,342.63,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,MedCost,Ultra,,215.73,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Ultra,,351.36,,,,,,,351.36,444.69,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Ultra,,279.99,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Ultra,,241.28,,,,,,,241.28,305.37,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Ultra,,192.27,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,inpatient,,,585.00000,351.00000,MedCost,Ultra,,374.40,,,,,,,374.40,473.85,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,MedCost,Ultra,,298.35,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Ultra,,241.28,,,,,,,241.28,305.37,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Ultra,,192.27,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Ultra,,241.28,,,,,,,241.28,305.37,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Ultra,,192.27,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Ultra,,58.88,,,,,,,58.88,74.52,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Ultra,,46.92,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Ultra,,184.32,,,,,,,184.32,233.28,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Ultra,,146.88,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Ultra,,279.68,,,,,,,279.68,353.97,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Ultra,,222.87,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,inpatient,,,262.00000,157.20000,MedCost,Ultra,,167.68,,,,,,,167.68,212.22,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,MedCost,Ultra,,133.62,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,inpatient,,,234.00000,140.40000,MedCost,Ultra,,149.76,,,,,,,149.76,189.54,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,MedCost,Ultra,,119.34,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,inpatient,,,652.00000,391.20000,MedCost,Ultra,,417.28,,,,,,,417.28,528.12,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,MedCost,Ultra,,332.52,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,18.92,91.30,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,inpatient,,,33.00000,19.80000,MedCost,Ultra,,21.12,,,,,,,21.12,26.73,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,MedCost,Ultra,,16.83,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,inpatient,,,1899.00000,1139.40000,MedCost,Ultra,,1215.36,,,,,,,1215.36,1538.19,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,MedCost,Ultra,,968.49,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,,74.88,,,,,,,74.88,94.77,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,,59.67,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,,74.88,,,,,,,74.88,94.77,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,,59.67,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,inpatient,,,240.00000,144.00000,MedCost,Ultra,,153.60,,,,,,,153.60,194.40,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,MedCost,Ultra,,122.40,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,inpatient,,,360.00000,216.00000,MedCost,Ultra,,230.40,,,,,,,230.40,291.60,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,MedCost,Ultra,,183.60,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Ultra,,296.32,,,,,,,296.32,375.03,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Ultra,,236.13,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,inpatient,,,420.00000,252.00000,MedCost,Ultra,,268.80,,,,,,,268.80,340.20,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,MedCost,Ultra,,214.20,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,inpatient,,,1947.00000,1168.20000,MedCost,Ultra,,1246.08,,,,,,,1246.08,1577.07,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,MedCost,Ultra,,992.97,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,inpatient,,,1990.00000,1194.00000,MedCost,Ultra,,1273.60,,,,,,,1273.60,1611.90,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,MedCost,Ultra,,1014.90,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,inpatient,,,932.00000,559.20000,MedCost,Ultra,,596.48,,,,,,,596.48,754.92,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,MedCost,Ultra,,475.32,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,inpatient,,,1407.00000,844.20000,MedCost,Ultra,,900.48,,,,,,,900.48,1139.67,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,MedCost,Ultra,,717.57,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,inpatient,,,1460.00000,876.00000,MedCost,Ultra,,934.40,,,,,,,934.40,1182.60,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,MedCost,Ultra,,744.60,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,inpatient,,,1724.00000,1034.40000,MedCost,Ultra,,1103.36,,,,,,,1103.36,1396.44,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,MedCost,Ultra,,879.24,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,inpatient,,,2098.00000,1258.80000,MedCost,Ultra,,1342.72,,,,,,,1342.72,1699.38,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,MedCost,Ultra,,1069.98,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,inpatient,,,3519.00000,2111.40000,MedCost,Ultra,,2252.16,,,,,,,2252.16,2850.39,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,MedCost,Ultra,,1794.69,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,inpatient,,,6242.00000,3745.20000,MedCost,Ultra,,3994.88,,,,,,,3994.88,5056.02,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,MedCost,Ultra,,3183.42,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,inpatient,,,6731.00000,4038.60000,MedCost,Ultra,,4307.84,,,,,,,4307.84,5452.11,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,MedCost,Ultra,,3432.81,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,inpatient,,,635.00000,381.00000,MedCost,Ultra,,406.40,,,,,,,406.40,514.35,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,MedCost,Ultra,,323.85,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,inpatient,,,851.00000,510.60000,MedCost,Ultra,,544.64,,,,,,,544.64,689.31,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,MedCost,Ultra,,434.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,inpatient,,,6352.00000,3811.20000,MedCost,Ultra,,4065.28,,,,,,,4065.28,5145.12,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,MedCost,Ultra,,3239.52,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,inpatient,,,7135.00000,4281.00000,MedCost,Ultra,,4566.40,,,,,,,4566.40,5779.35,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,MedCost,Ultra,,3638.85,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,inpatient,,,7135.00000,4281.00000,MedCost,Ultra,,4566.40,,,,,,,4566.40,5779.35,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,MedCost,Ultra,,3638.85,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,inpatient,,,1698.00000,1018.80000,MedCost,Ultra,,1086.72,,,,,,,1086.72,1375.38,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,MedCost,Ultra,,865.98,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,inpatient,,,2769.00000,1661.40000,MedCost,Ultra,,1772.16,,,,,,,1772.16,2242.89,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,MedCost,Ultra,,1412.19,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,inpatient,,,734.00000,440.40000,MedCost,Ultra,,469.76,,,,,,,469.76,594.54,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,MedCost,Ultra,,374.34,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,inpatient,,,1096.00000,657.60000,MedCost,Ultra,,701.44,,,,,,,701.44,887.76,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,MedCost,Ultra,,558.96,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,inpatient,,,469.00000,281.40000,MedCost,Ultra,,300.16,,,,,,,300.16,379.89,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,MedCost,Ultra,,239.19,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,inpatient,,,968.00000,580.80000,MedCost,Ultra,,619.52,,,,,,,619.52,784.08,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,MedCost,Ultra,,493.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,inpatient,,,687.00000,412.20000,MedCost,Ultra,,439.68,,,,,,,439.68,556.47,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,MedCost,Ultra,,350.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,inpatient,,,1545.00000,927.00000,MedCost,Ultra,,988.80,,,,,,,988.80,1251.45,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,MedCost,Ultra,,787.95,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,inpatient,,,1071.00000,642.60000,MedCost,Ultra,,685.44,,,,,,,685.44,867.51,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,MedCost,Ultra,,546.21,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,inpatient,,,1862.00000,1117.20000,MedCost,Ultra,,1191.68,,,,,,,1191.68,1508.22,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,MedCost,Ultra,,949.62,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,inpatient,,,450.00000,270.00000,MedCost,Ultra,,288.00,,,,,,,288.00,364.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,MedCost,Ultra,,229.50,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,inpatient,,,1204.00000,722.40000,MedCost,Ultra,,770.56,,,,,,,770.56,975.24,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,MedCost,Ultra,,614.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,inpatient,,,7492.00000,4495.20000,MedCost,Ultra,,4794.88,,,,,,,4794.88,6068.52,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,MedCost,Ultra,,3820.92,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,inpatient,,,7454.00000,4472.40000,MedCost,Ultra,,4770.56,,,,,,,4770.56,6037.74,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,MedCost,Ultra,,3801.54,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,inpatient,,,2398.00000,1438.80000,MedCost,Ultra,,1534.72,,,,,,,1534.72,1942.38,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,MedCost,Ultra,,1222.98,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,inpatient,,,1746.00000,1047.60000,MedCost,Ultra,,1117.44,,,,,,,1117.44,1414.26,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,MedCost,Ultra,,890.46,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,inpatient,,,3100.00000,1860.00000,MedCost,Ultra,,1984.00,,,,,,,1984.00,2511.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,MedCost,Ultra,,1581.00,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,inpatient,,,8423.00000,5053.80000,MedCost,Ultra,,5390.72,,,,,,,5390.72,6822.63,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,MedCost,Ultra,,4295.73,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,inpatient,,,425.00000,255.00000,MedCost,Ultra,,272.00,,,,,,,272.00,344.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,MedCost,Ultra,,216.75,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,inpatient,,,567.00000,340.20000,MedCost,Ultra,,362.88,,,,,,,362.88,459.27,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,MedCost,Ultra,,289.17,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,inpatient,,,2178.00000,1306.80000,MedCost,Ultra,,1393.92,,,,,,,1393.92,1764.18,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,MedCost,Ultra,,1110.78,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,inpatient,,,2092.00000,1255.20000,MedCost,Ultra,,1338.88,,,,,,,1338.88,1694.52,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,MedCost,Ultra,,1066.92,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,inpatient,,,4635.00000,2781.00000,MedCost,Ultra,,2966.40,,,,,,,2966.40,3754.35,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,MedCost,Ultra,,2363.85,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,inpatient,,,2458.00000,1474.80000,MedCost,Ultra,,1573.12,,,,,,,1573.12,1990.98,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,MedCost,Ultra,,1253.58,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,inpatient,,,2999.00000,1799.40000,MedCost,Ultra,,1919.36,,,,,,,1919.36,2429.19,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,MedCost,Ultra,,1529.49,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Ultra,,202.24,,,,,,,202.24,255.96,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Ultra,,161.16,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,inpatient,,,321.00000,192.60000,MedCost,Ultra,,205.44,,,,,,,205.44,260.01,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,MedCost,Ultra,,163.71,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,inpatient,,,1076.00000,645.60000,MedCost,Ultra,,688.64,,,,,,,688.64,871.56,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,MedCost,Ultra,,548.76,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Ultra,,317.44,,,,,,,317.44,401.76,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Ultra,,252.96,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,inpatient,,,603.00000,361.80000,MedCost,Ultra,,385.92,,,,,,,385.92,488.43,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,MedCost,Ultra,,307.53,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Ultra,,317.44,,,,,,,317.44,401.76,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Ultra,,252.96,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,inpatient,,,1537.00000,922.20000,MedCost,Ultra,,983.68,,,,,,,983.68,1244.97,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,MedCost,Ultra,,783.87,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Ultra,,393.60,,,,,,,393.60,498.15,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Ultra,,313.65,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,inpatient,,,734.00000,440.40000,MedCost,Ultra,,469.76,,,,,,,469.76,594.54,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,MedCost,Ultra,,374.34,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,inpatient,,,457.00000,274.20000,MedCost,Ultra,,292.48,,,,,,,292.48,370.17,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,MedCost,Ultra,,233.07,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,inpatient,,,331.00000,198.60000,MedCost,Ultra,,211.84,,,,,,,211.84,268.11,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,MedCost,Ultra,,168.81,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,inpatient,,,523.00000,313.80000,MedCost,Ultra,,334.72,,,,,,,334.72,423.63,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,MedCost,Ultra,,266.73,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,inpatient,,,7135.00000,4281.00000,MedCost,Ultra,,4566.40,,,,,,,4566.40,5779.35,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,MedCost,Ultra,,3638.85,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,inpatient,,,1032.00000,619.20000,MedCost,Ultra,,660.48,,,,,,,660.48,835.92,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,MedCost,Ultra,,526.32,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,inpatient,,,889.00000,533.40000,MedCost,Ultra,,568.96,,,,,,,568.96,720.09,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,MedCost,Ultra,,453.39,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,inpatient,,,1163.00000,697.80000,MedCost,Ultra,,744.32,,,,,,,744.32,942.03,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,MedCost,Ultra,,593.13,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,inpatient,,,1051.00000,630.60000,MedCost,Ultra,,672.64,,,,,,,672.64,851.31,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,MedCost,Ultra,,536.01,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,inpatient,,,1406.00000,843.60000,MedCost,Ultra,,899.84,,,,,,,899.84,1138.86,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,MedCost,Ultra,,717.06,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,inpatient,,,1406.00000,843.60000,MedCost,Ultra,76,899.84,,,,,,,899.84,1138.86,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,MedCost,Ultra,76,717.06,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,,1193.60,,,,,,,1193.60,1510.65,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,,951.15,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,inpatient,,,3748.00000,2248.80000,MedCost,Ultra,,2398.72,,,,,,,2398.72,3035.88,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,MedCost,Ultra,,1911.48,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,inpatient,,,3748.00000,2248.80000,MedCost,Ultra,76,2398.72,,,,,,,2398.72,3035.88,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,MedCost,Ultra,76,1911.48,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,inpatient,,,3945.00000,2367.00000,MedCost,Ultra,,2524.80,,,,,,,2524.80,3195.45,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,MedCost,Ultra,,2011.95,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,inpatient,,,3945.00000,2367.00000,MedCost,Ultra,76,2524.80,,,,,,,2524.80,3195.45,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,MedCost,Ultra,76,2011.95,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,inpatient,,,2034.00000,1220.40000,MedCost,Ultra,,1301.76,,,,,,,1301.76,1647.54,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,MedCost,Ultra,,1037.34,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,inpatient,,,2261.00000,1356.60000,MedCost,Ultra,,1447.04,,,,,,,1447.04,1831.41,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,MedCost,Ultra,,1153.11,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,inpatient,,,2383.00000,1429.80000,MedCost,Ultra,,1525.12,,,,,,,1525.12,1930.23,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,MedCost,Ultra,,1215.33,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,inpatient,,,2629.00000,1577.40000,MedCost,Ultra,,1682.56,,,,,,,1682.56,2129.49,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,MedCost,Ultra,,1340.79,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,inpatient,,,1833.00000,1099.80000,MedCost,Ultra,,1173.12,,,,,,,1173.12,1484.73,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,MedCost,Ultra,,934.83,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,inpatient,,,2622.00000,1573.20000,MedCost,Ultra,,1678.08,,,,,,,1678.08,2123.82,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,MedCost,Ultra,,1337.22,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Ultra,,219.52,,,,,,,219.52,277.83,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Ultra,,174.93,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Ultra,,264.32,,,,,,,264.32,334.53,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Ultra,,210.63,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Ultra,,264.32,,,,,,,264.32,334.53,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Ultra,,210.63,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Ultra,,186.88,,,,,,,186.88,236.52,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Ultra,,148.92,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,inpatient,,,2842.00000,1705.20000,MedCost,Ultra,,1818.88,,,,,,,1818.88,2302.02,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,MedCost,Ultra,,1449.42,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,inpatient,,,27299.00000,16379.40000,MedCost,Ultra,,17471.36,,,,,,,17471.36,22112.19,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,MedCost,Ultra,,13922.49,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,inpatient,,,3753.00000,2251.80000,MedCost,Ultra,,2401.92,,,,,,,2401.92,3039.93,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,MedCost,Ultra,,1914.03,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,inpatient,,,4316.00000,2589.60000,MedCost,Ultra,,2762.24,,,,,,,2762.24,3495.96,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,MedCost,Ultra,,2201.16,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,inpatient,,,4316.00000,2589.60000,MedCost,Ultra,,2762.24,,,,,,,2762.24,3495.96,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,MedCost,Ultra,,2201.16,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,inpatient,,,648.00000,388.80000,MedCost,Ultra,,414.72,,,,,,,414.72,524.88,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,MedCost,Ultra,,330.48,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,inpatient,,,708.00000,424.80000,MedCost,Ultra,,453.12,,,,,,,453.12,573.48,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,MedCost,Ultra,,361.08,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,inpatient,,,1225.00000,735.00000,MedCost,Ultra,,784.00,,,,,,,784.00,992.25,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,MedCost,Ultra,,624.75,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,inpatient,,,860.00000,516.00000,MedCost,Ultra,,550.40,,,,,,,550.40,696.60,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,MedCost,Ultra,,438.60,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,inpatient,,,914.00000,548.40000,MedCost,Ultra,,584.96,,,,,,,584.96,740.34,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,MedCost,Ultra,,466.14,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,inpatient,,,938.00000,562.80000,MedCost,Ultra,,600.32,,,,,,,600.32,759.78,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,MedCost,Ultra,,478.38,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,inpatient,,,641.00000,384.60000,MedCost,Ultra,,410.24,,,,,,,410.24,519.21,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,MedCost,Ultra,,326.91,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,,1193.60,,,,,,,1193.60,1510.65,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,,951.15,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,76,1193.60,,,,,,,1193.60,1510.65,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,76,951.15,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,,1193.60,,,,,,,1193.60,1510.65,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,,951.15,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,76,1193.60,,,,,,,1193.60,1510.65,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,76,951.15,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Ultra,,219.52,,,,,,,219.52,277.83,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Ultra,,174.93,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,inpatient,,,650.00000,390.00000,MedCost,Ultra,,416.00,,,,,,,416.00,526.50,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,MedCost,Ultra,,331.50,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,inpatient,,,363.00000,217.80000,MedCost,Ultra,,232.32,,,,,,,232.32,294.03,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,MedCost,Ultra,,185.13,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,,1193.60,,,,,,,1193.60,1510.65,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,,951.15,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,76,1193.60,,,,,,,1193.60,1510.65,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,76,951.15,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Ultra,,291.20,,,,,,,291.20,368.55,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Ultra,,232.05,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,inpatient,,,860.00000,516.00000,MedCost,Ultra,76,550.40,,,,,,,550.40,696.60,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,MedCost,Ultra,76,438.60,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,inpatient,,,914.00000,548.40000,MedCost,Ultra,76,584.96,,,,,,,584.96,740.34,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,MedCost,Ultra,76,466.14,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,inpatient,,,499.00000,299.40000,MedCost,Ultra,,319.36,,,,,,,319.36,404.19,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,MedCost,Ultra,,254.49,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,inpatient,,,1044.00000,626.40000,MedCost,Ultra,,668.16,,,,,,,668.16,845.64,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,MedCost,Ultra,,532.44,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,inpatient,,,1629.00000,977.40000,MedCost,Ultra,,1042.56,,,,,,,1042.56,1319.49,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,MedCost,Ultra,,830.79,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,inpatient,,,2343.00000,1405.80000,MedCost,Ultra,,1499.52,,,,,,,1499.52,1897.83,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,MedCost,Ultra,,1194.93,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,inpatient,,,6914.00000,4148.40000,MedCost,Ultra,,4424.96,,,,,,,4424.96,5600.34,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,MedCost,Ultra,,3526.14,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,inpatient,,,733.00000,439.80000,MedCost,Ultra,,469.12,,,,,,,469.12,593.73,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,MedCost,Ultra,,373.83,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,inpatient,,,6067.00000,3640.20000,MedCost,Ultra,,3882.88,,,,,,,3882.88,4914.27,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,MedCost,Ultra,,3094.17,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,inpatient,,,2254.00000,1352.40000,MedCost,Ultra,,1442.56,,,,,,,1442.56,1825.74,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,MedCost,Ultra,,1149.54,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,inpatient,,,2837.00000,1702.20000,MedCost,Ultra,,1815.68,,,,,,,1815.68,2297.97,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,MedCost,Ultra,,1446.87,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,inpatient,,,1848.00000,1108.80000,MedCost,Ultra,,1182.72,,,,,,,1182.72,1496.88,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,MedCost,Ultra,,942.48,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,inpatient,,,871.00000,522.60000,MedCost,Ultra,,557.44,,,,,,,557.44,705.51,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,MedCost,Ultra,,444.21,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Ultra,,351.36,,,,,,,351.36,444.69,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Ultra,,279.99,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,inpatient,,,805.00000,483.00000,MedCost,Ultra,,515.20,,,,,,,515.20,652.05,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,MedCost,Ultra,,410.55,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Ultra,,801.28,,,,,,,801.28,1014.12,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Ultra,,638.52,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,inpatient,,,8164.00000,4898.40000,MedCost,Ultra,,5224.96,,,,,,,5224.96,6612.84,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,MedCost,Ultra,,4163.64,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,inpatient,,,2410.00000,1446.00000,MedCost,Ultra,,1542.40,,,,,,,1542.40,1952.10,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,MedCost,Ultra,,1229.10,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,inpatient,,,405.00000,243.00000,MedCost,Ultra,,259.20,,,,,,,259.20,328.05,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,MedCost,Ultra,,206.55,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,inpatient,,,560.00000,336.00000,MedCost,Ultra,,358.40,,,,,,,358.40,453.60,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,MedCost,Ultra,,285.60,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,inpatient,,,1662.00000,997.20000,MedCost,Ultra,,1063.68,,,,,,,1063.68,1346.22,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,MedCost,Ultra,,847.62,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,inpatient,,,1923.00000,1153.80000,MedCost,Ultra,,1230.72,,,,,,,1230.72,1557.63,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,MedCost,Ultra,,980.73,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,inpatient,,,1274.00000,764.40000,MedCost,Ultra,,815.36,,,,,,,815.36,1031.94,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,MedCost,Ultra,,649.74,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Ultra,,202.24,,,,,,,202.24,255.96,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Ultra,,161.16,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,inpatient,,,650.00000,390.00000,MedCost,Ultra,,416.00,,,,,,,416.00,526.50,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,MedCost,Ultra,,331.50,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,inpatient,,,2178.00000,1306.80000,MedCost,Ultra,,1393.92,,,,,,,1393.92,1764.18,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,MedCost,Ultra,,1110.78,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1998.72,,,,,,,1998.72,7039.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1592.73,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,inpatient,,,351.00000,210.60000,MedCost,Ultra,,224.64,,,,,,,224.64,284.31,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,MedCost,Ultra,,179.01,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,inpatient,,,1054.00000,632.40000,MedCost,Ultra,,674.56,,,,,,,674.56,7039.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,MedCost,Ultra,,537.54,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,inpatient,,,34.00000,20.40000,MedCost,Ultra,,21.76,,,,,,,21.76,27.64,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,MedCost,Ultra,,17.34,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,inpatient,,,465.00000,279.00000,MedCost,Ultra,,297.60,,,,,,,297.60,7039.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,MedCost,Ultra,,237.15,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,inpatient,,,1028.00000,616.80000,MedCost,Ultra,,657.92,,,,,,,657.92,835.76,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,MedCost,Ultra,,524.28,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,inpatient,,,1212.00000,727.20000,MedCost,Ultra,,775.68,,,,,,,775.68,985.36,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,MedCost,Ultra,,618.12,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,inpatient,,,322.00000,193.20000,MedCost,Ultra,,206.08,,,,,,,206.08,7039.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,MedCost,Ultra,,164.22,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,inpatient,,,757.00000,454.20000,MedCost,Ultra,,484.48,,,,,,,484.48,7039.00,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,MedCost,Ultra,,386.07,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Ultra,,103.68,,,,,,,103.68,7039.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Ultra,,82.62,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,inpatient,,,1170.00000,702.00000,MedCost,Ultra,,748.80,,,,,,,748.80,947.70,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,MedCost,Ultra,,596.70,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,inpatient,,,299.00000,179.40000,MedCost,Ultra,,191.36,,,,,,,191.36,242.19,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,MedCost,Ultra,,152.49,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,inpatient,,,595.00000,357.00000,MedCost,Ultra,,380.80,,,,,,,380.80,481.95,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,MedCost,Ultra,,303.45,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.03,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Ultra,,72.32,,,,,,,72.32,91.53,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Ultra,,57.63,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,inpatient,,,302.00000,181.20000,MedCost,Ultra,,193.28,,,,,,,193.28,244.62,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,MedCost,Ultra,,154.02,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,29.97,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,29.97,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,inpatient,,,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.63,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,46.98,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,inpatient,,,109.00000,65.40000,MedCost,Ultra,,69.76,,,,,,,69.76,88.29,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,MedCost,Ultra,,55.59,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Ultra,,128.00,,,,,,,128.00,162.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Ultra,,102.00,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Ultra,,103.04,,,,,,,103.04,130.41,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Ultra,,82.11,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Ultra,,72.32,,,,,,,72.32,91.53,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Ultra,,57.63,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Ultra,,85.12,,,,,,,85.12,107.73,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Ultra,,67.83,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Ultra,,72.32,,,,,,,72.32,91.53,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Ultra,,57.63,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,inpatient,,,438.00000,262.80000,MedCost,Ultra,,280.32,,,,,,,280.32,354.78,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,MedCost,Ultra,,223.38,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Ultra,,32.00,,,,,,,32.00,40.50,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Ultra,,25.50,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Ultra,,264.32,,,,,,,264.32,334.53,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Ultra,,210.63,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Ultra,,184.32,,,,,,,184.32,233.28,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Ultra,,146.88,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,29.97,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,inpatient,,,191.00000,114.60000,MedCost,Ultra,,122.24,,,,,,,122.24,154.71,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,MedCost,Ultra,,97.41,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Ultra,,172.16,,,,,,,172.16,217.89,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Ultra,,137.19,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,inpatient,,,67.00000,40.20000,MedCost,Ultra,GP,42.88,,,,,,,42.88,54.27,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,MedCost,Ultra,GP,34.17,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Ultra,GP,48.00,,,,,,,48.00,60.75,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Ultra,GP,38.25,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Ultra,GP,7.68,,,,,,,7.68,9.72,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Ultra,GP,6.12,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,inpatient,,,121.00000,72.60000,MedCost,Ultra,GP,77.44,,,,,,,77.44,98.01,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,MedCost,Ultra,GP,61.71,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,GP,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,GP,24.99,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,inpatient,,,16.00000,9.60000,MedCost,Ultra,GP,10.24,,,,,,,10.24,12.96,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,MedCost,Ultra,GP,8.16,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,inpatient,,,153.00000,91.80000,MedCost,Ultra,GP,97.92,,,,,,,97.92,123.93,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,MedCost,Ultra,GP,78.03,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Ultra,GP,104.32,,,,,,,104.32,132.03,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Ultra,GP,83.13,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Ultra,GP,81.92,,,,,,,81.92,103.68,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Ultra,GP,65.28,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,GP,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,GP,56.10,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,GP,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,GP,30.09,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Ultra,GP,104.96,,,,,,,104.96,132.84,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Ultra,GP,83.64,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,inpatient,,,160.00000,96.00000,MedCost,Ultra,GP,102.40,,,,,,,102.40,129.60,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,MedCost,Ultra,GP,81.60,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,inpatient,,,144.00000,86.40000,MedCost,Ultra,GP,92.16,,,,,,,92.16,116.64,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,MedCost,Ultra,GP,73.44,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,GP,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,GP,84.15,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Ultra,GP,88.96,,,,,,,88.96,112.59,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Ultra,GP,70.89,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Ultra,GP,129.28,,,,,,,129.28,163.62,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Ultra,GP,103.02,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,GP,74.88,,,,,,,74.88,94.77,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,GP,59.67,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,GP,82.56,,,,,,,82.56,104.49,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,GP,65.79,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,inpatient,,,151.00000,90.60000,MedCost,Ultra,GP,96.64,,,,,,,96.64,122.31,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,MedCost,Ultra,GP,77.01,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Ultra,GP,30.08,,,,,,,30.08,38.07,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Ultra,GP,23.97,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,GP,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,GP,60.18,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Ultra,GP,54.40,,,,,,,54.40,68.85,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Ultra,GP,43.35,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,GP,82.56,,,,,,,82.56,104.49,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,GP,65.79,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Ultra,GP,63.36,,,,,,,63.36,80.19,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Ultra,GP,50.49,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Ultra,GP,115.20,,,,,,,115.20,145.80,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Ultra,GP,91.80,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Ultra,GP,115.20,,,,,,,115.20,145.80,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Ultra,GP,91.80,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,GP,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,GP,46.41,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,GP,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,GP,46.41,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,GP,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,GP,45.39,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Ultra,GP,81.28,,,,,,,81.28,102.87,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Ultra,GP,64.77,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Ultra,GP,83.20,,,,,,,83.20,105.30,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Ultra,GP,66.30,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Ultra,GP,44.80,,,,,,,44.80,56.70,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Ultra,GP,35.70,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Ultra,GP,19.20,,,,,,,19.20,24.30,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Ultra,GP,15.30,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,inpatient,,,306.00000,183.60000,MedCost,Ultra,GP,195.84,,,,,,,195.84,247.86,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,MedCost,Ultra,GP,156.06,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,inpatient,,,423.00000,253.80000,MedCost,Ultra,GP,270.72,,,,,,,270.72,342.63,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,MedCost,Ultra,GP,215.73,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,inpatient,,,434.00000,260.40000,MedCost,Ultra,GP,277.76,,,,,,,277.76,351.54,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,MedCost,Ultra,GP,221.34,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Ultra,GP,184.32,,,,,,,184.32,233.28,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Ultra,GP,146.88,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,GO,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,GO,46.41,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,GO,74.88,,,,,,,74.88,94.77,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,GO,59.67,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,GO,82.56,,,,,,,82.56,104.49,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,GO,65.79,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,GO,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,GO,60.18,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Ultra,GO,44.80,,,,,,,44.80,56.70,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Ultra,GO,35.70,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,GO,82.56,,,,,,,82.56,104.49,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,GO,65.79,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Ultra,GO,63.36,,,,,,,63.36,80.19,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Ultra,GO,50.49,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Ultra,GO,7.68,,,,,,,7.68,9.72,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Ultra,GO,6.12,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Ultra,GO,104.32,,,,,,,104.32,132.03,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Ultra,GO,83.13,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Ultra,GO,81.92,,,,,,,81.92,103.68,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Ultra,GO,65.28,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,GO,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,GO,31.62,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Ultra,GO,104.96,,,,,,,104.96,132.84,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Ultra,GO,83.64,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,inpatient,,,160.00000,96.00000,MedCost,Ultra,GO,102.40,,,,,,,102.40,129.60,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,MedCost,Ultra,GO,81.60,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,inpatient,,,144.00000,86.40000,MedCost,Ultra,GO,92.16,,,,,,,92.16,116.64,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,MedCost,Ultra,GO,73.44,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,GO,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,GO,84.15,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,GO,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,GO,24.99,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,inpatient,,,224.00000,134.40000,MedCost,Ultra,GO,143.36,,,,,,,143.36,181.44,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,MedCost,Ultra,GO,114.24,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Ultra,GO,97.28,,,,,,,97.28,123.12,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Ultra,GO,77.52,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Ultra,GO,81.28,,,,,,,81.28,102.87,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Ultra,GO,64.77,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Ultra,GO,48.00,,,,,,,48.00,60.75,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Ultra,GO,38.25,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Ultra,GO,203.52,,,,,,,203.52,257.58,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Ultra,GO,162.18,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,inpatient,,,403.00000,241.80000,MedCost,Ultra,GO,257.92,,,,,,,257.92,326.43,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,MedCost,Ultra,GO,205.53,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,inpatient,,,415.00000,249.00000,MedCost,Ultra,GO,265.60,,,,,,,265.60,336.15,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,MedCost,Ultra,GO,211.65,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Ultra,GO,129.28,,,,,,,129.28,163.62,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Ultra,GO,103.02,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,inpatient,,,356.00000,213.60000,MedCost,Ultra,GN,227.84,,,,,,,227.84,288.36,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,MedCost,Ultra,GN,181.56,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,inpatient,,,336.00000,201.60000,MedCost,Ultra,GN,215.04,,,,,,,215.04,272.16,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,MedCost,Ultra,GN,171.36,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,inpatient,,,187.00000,112.20000,MedCost,Ultra,GN,119.68,,,,,,,119.68,151.47,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,MedCost,Ultra,GN,95.37,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Ultra,GN,172.16,,,,,,,172.16,217.89,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Ultra,GN,137.19,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Ultra,GN,128.00,,,,,,,128.00,162.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Ultra,GN,102.00,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Ultra,GN,201.60,,,,,,,201.60,255.15,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Ultra,GN,160.65,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Ultra,GN,81.92,,,,,,,81.92,103.68,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Ultra,GN,65.28,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Ultra,GN,44.80,,,,,,,44.80,56.70,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Ultra,GN,35.70,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Ultra,GN,54.40,,,,,,,54.40,68.85,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Ultra,GN,43.35,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Ultra,GN,63.36,,,,,,,63.36,80.19,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Ultra,GN,50.49,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,inpatient,,,229.00000,137.40000,MedCost,Ultra,GN,146.56,,,,,,,146.56,185.49,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,MedCost,Ultra,GN,116.79,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,GN,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,GN,69.36,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,inpatient,,,655.00000,393.00000,MedCost,Ultra,GN,419.20,,,,,,,419.20,530.55,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,MedCost,Ultra,GN,334.05,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,inpatient,,,259.00000,155.40000,MedCost,Ultra,GN,165.76,,,,,,,165.76,209.79,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,MedCost,Ultra,GN,132.09,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,inpatient,,,68.00000,40.80000,MedCost,Ultra,GN,43.52,,,,,,,43.52,55.08,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,MedCost,Ultra,GN,34.68,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Ultra,GN,83.20,,,,,,,83.20,105.30,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Ultra,GN,66.30,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Ultra,GN,44.80,,,,,,,44.80,56.70,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Ultra,GN,35.70,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Ultra,GN,19.20,,,,,,,19.20,24.30,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Ultra,GN,15.30,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,inpatient,,,214.00000,128.40000,MedCost,Ultra,GN,136.96,,,,,,,136.96,173.34,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,MedCost,Ultra,GN,109.14,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,inpatient,,,229.00000,137.40000,MedCost,Ultra,GN,146.56,,,,,,,146.56,185.49,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,MedCost,Ultra,GN,116.79,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Ultra,GN,68.48,,,,,,,68.48,86.67,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Ultra,GN,54.57,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,inpatient,,,353.00000,211.80000,MedCost,Ultra,GN,225.92,,,,,,,225.92,285.93,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,MedCost,Ultra,GN,180.03,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Ultra,GN,351.36,,,,,,,351.36,444.69,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Ultra,GN,279.99,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,inpatient,,,591.00000,354.60000,MedCost,Ultra,GN,378.24,,,,,,,378.24,478.71,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,MedCost,Ultra,GN,301.41,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,inpatient,,,864.00000,518.40000,MedCost,Ultra,,552.96,,,,,,,552.96,699.84,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,MedCost,Ultra,,440.64,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,inpatient,,,549.00000,329.40000,MedCost,Ultra,,351.36,,,,,,,351.36,444.69,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,MedCost,Ultra,,279.99,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,inpatient,,,885.00000,531.00000,MedCost,Ultra,,566.40,,,,,,,566.40,716.85,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,MedCost,Ultra,,451.35,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,inpatient,,,504.00000,302.40000,MedCost,Ultra,,322.56,,,,,,,322.56,408.24,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,MedCost,Ultra,,257.04,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,inpatient,,,745.00000,447.00000,MedCost,Ultra,,476.80,,,,,,,476.80,603.45,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,MedCost,Ultra,,379.95,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,inpatient,,,3756.00000,2253.60000,MedCost,Ultra,,2403.84,,,,,,,2403.84,3042.36,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,MedCost,Ultra,,1915.56,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Ultra,,27.52,,,,,,,27.52,34.83,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Ultra,,21.93,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,inpatient,,,148.00000,88.80000,MedCost,Ultra,,94.72,,,,,,,94.72,119.88,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,MedCost,Ultra,,75.48,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,inpatient,,,525.00000,315.00000,MedCost,Ultra,,336.00,,,,,,,336.00,425.25,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,MedCost,Ultra,,267.75,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,inpatient,,,523.00000,313.80000,MedCost,Ultra,,334.72,,,,,,,334.72,423.63,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,MedCost,Ultra,,266.73,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,inpatient,,,563.00000,337.80000,MedCost,Ultra,,360.32,,,,,,,360.32,456.03,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,MedCost,Ultra,,287.13,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Ultra,,241.28,,,,,,,241.28,305.37,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Ultra,,192.27,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,inpatient,,,377.00000,226.20000,MedCost,Ultra,,241.28,,,,,,,241.28,305.37,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,MedCost,Ultra,,192.27,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,inpatient,,,1357.00000,814.20000,MedCost,Ultra,,868.48,,,,,,,868.48,1099.17,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,MedCost,Ultra,,692.07,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,inpatient,,,418.00000,250.80000,MedCost,Ultra,,267.52,,,,,,,267.52,338.58,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,MedCost,Ultra,,213.18,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,inpatient,,,812.00000,487.20000,MedCost,Ultra,,519.68,,,,,,,519.68,657.72,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,MedCost,Ultra,,414.12,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,68.48,86.67,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,inpatient,,,567.00000,340.20000,MedCost,Ultra,,362.88,,,,,,,362.88,459.27,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,MedCost,Ultra,,289.17,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,inpatient,,,476.00000,285.60000,MedCost,Ultra,,304.64,,,,,,,304.64,385.56,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,MedCost,Ultra,,242.76,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,inpatient,,,652.00000,391.20000,MedCost,Ultra,,417.28,,,,,,,417.28,528.12,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,MedCost,Ultra,,332.52,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Ultra,,293.12,,,,,,,293.12,370.98,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Ultra,,233.58,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Ultra,,99.84,,,,,,,99.84,126.36,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Ultra,,79.56,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Ultra,,115.20,,,,,,,115.20,145.80,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Ultra,,91.80,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,inpatient,,,1170.00000,702.00000,MedCost,Ultra,,748.80,,,,,,,748.80,947.70,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,MedCost,Ultra,,596.70,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,inpatient,,,131.00000,78.60000,MedCost,Ultra,,83.84,,,,,,,83.84,106.11,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,MedCost,Ultra,,66.81,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,inpatient,,,1542.00000,925.20000,MedCost,Ultra,,986.88,,,,,,,986.88,1249.02,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,MedCost,Ultra,,786.42,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,inpatient,,,1542.00000,925.20000,MedCost,Ultra,,986.88,,,,,,,986.88,1249.02,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,MedCost,Ultra,,786.42,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,inpatient,,,264.00000,158.40000,MedCost,Ultra,,168.96,,,,,,,168.96,213.84,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,MedCost,Ultra,,134.64,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,inpatient,,,264.00000,158.40000,MedCost,Ultra,,168.96,,,,,,,168.96,213.84,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,MedCost,Ultra,,134.64,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,inpatient,,,2000.00000,1200.00000,MedCost,Ultra,,1280.00,,,,,,,1280.00,1626.00,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,MedCost,Ultra,,1020.00,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1998.72,,,,,,,1998.72,2529.63,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1592.73,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,inpatient,,,700.00000,420.00000,MedCost,Ultra,,448.00,,,,,,,448.00,569.10,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,MedCost,Ultra,,357.00,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,inpatient,,,2272.00000,1363.20000,MedCost,Ultra,,1454.08,,,,,,,1454.08,7039.00,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,MedCost,Ultra,,1158.72,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,inpatient,,,831.00000,498.60000,MedCost,Ultra,,531.84,,,,,,,531.84,675.60,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,MedCost,Ultra,,423.81,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,inpatient,,,505.00000,303.00000,MedCost,Ultra,,323.20,,,,,,,323.20,409.05,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,MedCost,Ultra,,257.55,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,inpatient,,,222.00000,133.20000,MedCost,Ultra,,142.08,,,,,,,142.08,179.82,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,MedCost,Ultra,,113.22,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,inpatient,,,333.00000,199.80000,MedCost,Ultra,,213.12,,,,,,,213.12,269.73,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,MedCost,Ultra,,169.83,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,inpatient,,,338.00000,202.80000,MedCost,Ultra,,216.32,,,,,,,216.32,273.78,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,MedCost,Ultra,,172.38,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,inpatient,,,185.00000,111.00000,MedCost,Ultra,,118.40,,,,,,,118.40,149.85,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,MedCost,Ultra,,94.35,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,inpatient,,,6043.00000,3625.80000,MedCost,Ultra,,3867.52,,,,,,,3867.52,4894.83,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,MedCost,Ultra,,3081.93,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,inpatient,,,6043.00000,3625.80000,MedCost,Ultra,,3867.52,,,,,,,3867.52,4894.83,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,MedCost,Ultra,,3081.93,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,inpatient,,,1017.00000,610.20000,MedCost,Ultra,,650.88,,,,,,,650.88,823.77,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,MedCost,Ultra,,518.67,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,inpatient,,,4200.00000,2520.00000,MedCost,Ultra,,2688.00,,,,,,,2688.00,3402.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,MedCost,Ultra,,2142.00,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,inpatient,,,4200.00000,2520.00000,MedCost,Ultra,,2688.00,,,,,,,2688.00,3402.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,MedCost,Ultra,,2142.00,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,inpatient,,,4266.00000,2559.60000,MedCost,Ultra,,2730.24,,,,,,,2730.24,3455.46,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,MedCost,Ultra,,2175.66,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,inpatient,,,1154.00000,692.40000,MedCost,Ultra,,738.56,,,,,,,738.56,934.74,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,MedCost,Ultra,,588.54,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,inpatient,,,552.00000,331.20000,MedCost,Ultra,,353.28,,,,,,,353.28,447.12,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,MedCost,Ultra,,281.52,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,inpatient,,,565.00000,339.00000,MedCost,Ultra,,361.60,,,,,,,361.60,457.65,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,MedCost,Ultra,,288.15,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,inpatient,,,1350.00000,810.00000,MedCost,Ultra,,864.00,,,,,,,864.00,1093.50,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,MedCost,Ultra,,688.50,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,inpatient,,,963.00000,577.80000,MedCost,Ultra,,616.32,,,,,,,616.32,780.03,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,MedCost,Ultra,,491.13,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Ultra,,352.00,,,,,,,352.00,445.50,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Ultra,,280.50,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,inpatient,,,963.00000,577.80000,MedCost,Ultra,,616.32,,,,,,,616.32,780.03,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,MedCost,Ultra,,491.13,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,inpatient,,,1051.00000,630.60000,MedCost,Ultra,,672.64,,,,,,,672.64,851.31,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,MedCost,Ultra,,536.01,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,inpatient,,,453.00000,271.80000,MedCost,Ultra,,289.92,,,,,,,289.92,366.93,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,MedCost,Ultra,,231.03,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Ultra,,813.44,,,,,,,813.44,1029.51,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Ultra,,648.21,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,inpatient,,,1159.00000,695.40000,MedCost,Ultra,,741.76,,,,,,,741.76,938.79,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,MedCost,Ultra,,591.09,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,inpatient,,,728.00000,436.80000,MedCost,Ultra,,465.92,,,,,,,465.92,589.68,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,MedCost,Ultra,,371.28,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Ultra,,307.84,,,,,,,307.84,389.61,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Ultra,,245.31,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,inpatient,,,1126.00000,675.60000,MedCost,Ultra,,720.64,,,,,,,720.64,912.06,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,MedCost,Ultra,,574.26,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Ultra,,202.24,,,,,,,202.24,255.96,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Ultra,,161.16,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,inpatient,,,758.00000,454.80000,MedCost,Ultra,,485.12,,,,,,,485.12,613.98,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,MedCost,Ultra,,386.58,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,inpatient,,,124.00000,74.40000,MedCost,Ultra,,79.36,,,,,,,79.36,100.44,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,MedCost,Ultra,,63.24,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,inpatient,,,958.00000,574.80000,MedCost,Ultra,,613.12,,,,,,,613.12,775.98,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,MedCost,Ultra,,488.58,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Ultra,,365.44,,,,,,,365.44,462.51,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Ultra,,291.21,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,inpatient,,,464.00000,278.40000,MedCost,Ultra,,296.96,,,,,,,296.96,375.84,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,MedCost,Ultra,,236.64,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Ultra,,344.96,,,,,,,344.96,436.59,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Ultra,,274.89,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,inpatient,,,503.00000,301.80000,MedCost,Ultra,,321.92,,,,,,,321.92,407.43,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,MedCost,Ultra,,256.53,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,inpatient,,,1572.00000,943.20000,MedCost,Ultra,,1006.08,,,,,,,1006.08,1273.32,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,MedCost,Ultra,,801.72,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,inpatient,,,405.00000,243.00000,MedCost,Ultra,,259.20,,,,,,,259.20,328.05,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,MedCost,Ultra,,206.55,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,inpatient,,,1572.00000,943.20000,MedCost,Ultra,,1006.08,,,,,,,1006.08,1273.32,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,MedCost,Ultra,,801.72,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,inpatient,,,405.00000,243.00000,MedCost,Ultra,,259.20,,,,,,,259.20,328.05,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,MedCost,Ultra,,206.55,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Ultra,,238.72,,,,,,,238.72,302.13,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Ultra,,190.23,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,inpatient,,,674.00000,404.40000,MedCost,Ultra,,431.36,,,,,,,431.36,545.94,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,MedCost,Ultra,,343.74,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,inpatient,,,822.00000,493.20000,MedCost,Ultra,,526.08,,,,,,,526.08,665.82,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,MedCost,Ultra,,419.22,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,inpatient,,,855.00000,513.00000,MedCost,Ultra,,547.20,,,,,,,547.20,692.55,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,MedCost,Ultra,,436.05,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,inpatient,,,888.00000,532.80000,MedCost,Ultra,,568.32,,,,,,,568.32,719.28,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,MedCost,Ultra,,452.88,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Ultra,,344.96,,,,,,,344.96,436.59,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Ultra,,274.89,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,inpatient,,,429.00000,257.40000,MedCost,Ultra,,274.56,,,,,,,274.56,347.49,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,MedCost,Ultra,,218.79,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,inpatient,,,295.00000,177.00000,MedCost,Ultra,,188.80,,,,,,,188.80,238.95,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,MedCost,Ultra,,150.45,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Ultra,,279.68,,,,,,,279.68,353.97,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Ultra,,222.87,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Ultra,,161.92,,,,,,,161.92,204.93,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Ultra,,129.03,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,inpatient,,,614.00000,368.40000,MedCost,Ultra,,392.96,,,,,,,392.96,497.34,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,MedCost,Ultra,,313.14,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,inpatient,,,614.00000,368.40000,MedCost,Ultra,,392.96,,,,,,,392.96,497.34,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,MedCost,Ultra,,313.14,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,inpatient,,,547.00000,328.20000,MedCost,Ultra,,350.08,,,,,,,350.08,443.07,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,MedCost,Ultra,,278.97,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Ultra,,135.68,,,,,,,135.68,171.72,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Ultra,,108.12,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Ultra,,135.68,,,,,,,135.68,171.72,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Ultra,,108.12,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Ultra,,135.68,,,,,,,135.68,171.72,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Ultra,,108.12,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Ultra,,135.68,,,,,,,135.68,171.72,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Ultra,,108.12,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,324.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,MedCost,Ultra,,204.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,324.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,MedCost,Ultra,,204.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,inpatient,,,400.00000,240.00000,MedCost,Ultra,,256.00,,,,,,,256.00,324.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,MedCost,Ultra,,204.00,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,inpatient,,,267.00000,160.20000,MedCost,Ultra,,170.88,,,,,,,170.88,216.27,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,MedCost,Ultra,,136.17,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,inpatient,,,366.00000,219.60000,MedCost,Ultra,,234.24,,,,,,,234.24,296.46,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,MedCost,Ultra,,186.66,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,inpatient,,,366.00000,219.60000,MedCost,Ultra,,234.24,,,,,,,234.24,296.46,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,MedCost,Ultra,,186.66,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,inpatient,,,1635.00000,981.00000,MedCost,Ultra,,1046.40,,,,,,,1046.40,1324.35,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,MedCost,Ultra,,833.85,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,inpatient,,,1635.00000,981.00000,MedCost,Ultra,,1046.40,,,,,,,1046.40,1324.35,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,MedCost,Ultra,,833.85,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,inpatient,,,457.00000,274.20000,MedCost,Ultra,,292.48,,,,,,,292.48,370.17,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,MedCost,Ultra,,233.07,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Ultra,,291.20,,,,,,,291.20,368.55,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Ultra,,232.05,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,inpatient,,,1491.00000,894.60000,MedCost,Ultra,,954.24,,,,,,,954.24,1207.71,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,MedCost,Ultra,,760.41,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,inpatient,,,1526.00000,915.60000,MedCost,Ultra,,976.64,,,,,,,976.64,1236.06,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,MedCost,Ultra,,778.26,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,inpatient,,,848.00000,508.80000,MedCost,Ultra,,542.72,,,,,,,542.72,686.88,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,MedCost,Ultra,,432.48,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,inpatient,,,1233.00000,739.80000,MedCost,Ultra,,789.12,,,,,,,789.12,998.73,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,MedCost,Ultra,,628.83,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,inpatient,,,423.00000,253.80000,MedCost,Ultra,,270.72,,,,,,,270.72,342.63,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,MedCost,Ultra,,215.73,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,inpatient,,,997.00000,598.20000,MedCost,Ultra,,638.08,,,,,,,638.08,807.57,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,MedCost,Ultra,,508.47,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Ultra,,296.32,,,,,,,296.32,375.03,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Ultra,,236.13,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,inpatient,,,544.00000,326.40000,MedCost,Ultra,,348.16,,,,,,,348.16,440.64,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,MedCost,Ultra,,277.44,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,inpatient,,,1315.00000,789.00000,MedCost,Ultra,,841.60,,,,,,,841.60,1065.15,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,MedCost,Ultra,,670.65,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,inpatient,,,1588.00000,952.80000,MedCost,Ultra,,1016.32,,,,,,,1016.32,1286.28,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,MedCost,Ultra,,809.88,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,inpatient,,,1950.00000,1170.00000,MedCost,Ultra,,1248.00,,,,,,,1248.00,1579.50,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,MedCost,Ultra,,994.50,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,inpatient,,,2767.00000,1660.20000,MedCost,Ultra,,1770.88,,,,,,,1770.88,2241.27,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,MedCost,Ultra,,1411.17,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,inpatient,,,3039.00000,1823.40000,MedCost,Ultra,,1944.96,,,,,,,1944.96,2461.59,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,MedCost,Ultra,,1549.89,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,inpatient,,,3856.00000,2313.60000,MedCost,Ultra,,2467.84,,,,,,,2467.84,3123.36,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,MedCost,Ultra,,1966.56,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,inpatient,,,2268.00000,1360.80000,MedCost,Ultra,,1451.52,,,,,,,1451.52,1837.08,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,MedCost,Ultra,,1156.68,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,inpatient,,,2540.00000,1524.00000,MedCost,Ultra,,1625.60,,,,,,,1625.60,2057.40,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,MedCost,Ultra,,1295.40,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,inpatient,,,2858.00000,1714.80000,MedCost,Ultra,,1829.12,,,,,,,1829.12,2314.98,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,MedCost,Ultra,,1457.58,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,inpatient,,,4536.00000,2721.60000,MedCost,Ultra,,2903.04,,,,,,,2903.04,3674.16,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,MedCost,Ultra,,2313.36,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,inpatient,,,5080.00000,3048.00000,MedCost,Ultra,,3251.20,,,,,,,3251.20,4114.80,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,MedCost,Ultra,,2590.80,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,inpatient,,,5670.00000,3402.00000,MedCost,Ultra,,3628.80,,,,,,,3628.80,4592.70,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,MedCost,Ultra,,2891.70,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,inpatient,,,1042.00000,625.20000,MedCost,Ultra,,666.88,,,,,,,666.88,844.02,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,MedCost,Ultra,,531.42,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.28,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.28,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.03,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,inpatient,,,225.00000,135.00000,MedCost,Ultra,,144.00,,,,,,,144.00,182.25,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,MedCost,Ultra,,114.75,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Ultra,,186.88,,,,,,,186.88,236.52,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Ultra,,148.92,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Ultra,,188.16,,,,,,,188.16,238.14,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Ultra,,149.94,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Ultra,,30.72,,,,,,,30.72,38.88,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Ultra,,24.48,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Ultra,,30.72,,,,,,,30.72,38.88,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Ultra,,24.48,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Ultra,,67.84,,,,,,,67.84,85.86,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Ultra,,54.06,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Ultra,,496.00,,,,,,,496.00,627.75,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Ultra,,395.25,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Ultra,,496.00,,,,,,,496.00,627.75,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Ultra,,395.25,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Ultra,,496.00,,,,,,,496.00,627.75,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Ultra,,395.25,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Ultra,,496.00,,,,,,,496.00,627.75,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Ultra,,395.25,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Ultra,,496.00,,,,,,,496.00,627.75,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Ultra,,395.25,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,inpatient,,,775.00000,465.00000,MedCost,Ultra,,496.00,,,,,,,496.00,627.75,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,MedCost,Ultra,,395.25,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,48.00,60.75,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,inpatient,,,66.67000,40.00000,MedCost,Ultra,GP,42.67,,,,,,,42.67,54.00,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,MedCost,Ultra,GP,34.00,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,inpatient,,,479.00000,287.40000,MedCost,Ultra,,306.56,,,,,,,306.56,389.43,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,MedCost,Ultra,,244.29,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,inpatient,,,2744.00000,1646.40000,MedCost,Ultra,,1756.16,,,,,,,1756.16,7039.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,MedCost,Ultra,,1399.44,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,inpatient,,,2744.00000,1646.40000,MedCost,Ultra,,1756.16,,,,,,,1756.16,2230.87,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,MedCost,Ultra,,1399.44,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,inpatient,,,3875.00000,2325.00000,MedCost,Ultra,,2480.00,,,,,,,2480.00,3150.38,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,MedCost,Ultra,,1976.25,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,inpatient,,,1085.00000,651.00000,MedCost,Ultra,,694.40,,,,,,,694.40,7039.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,MedCost,Ultra,,553.35,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,inpatient,,,1085.00000,651.00000,MedCost,Ultra,,694.40,,,,,,,694.40,882.11,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,MedCost,Ultra,,553.35,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,inpatient,,,2464.00000,1478.40000,MedCost,Ultra,,1576.96,,,,,,,1576.96,2003.23,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,MedCost,Ultra,,1256.64,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,inpatient,,,1039.00000,623.40000,MedCost,Ultra,,664.96,,,,,,,664.96,844.71,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,MedCost,Ultra,,529.89,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,inpatient,,,1039.00000,623.40000,MedCost,Ultra,,664.96,,,,,,,664.96,844.71,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,MedCost,Ultra,,529.89,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,inpatient,,,3190.00000,1914.00000,MedCost,Ultra,,2041.60,,,,,,,2041.60,2593.47,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,MedCost,Ultra,,1626.90,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,inpatient,,,430.00000,258.00000,MedCost,Ultra,,275.20,,,,,,,275.20,349.59,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,MedCost,Ultra,,219.30,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,inpatient,,,480.00000,288.00000,MedCost,Ultra,,307.20,,,,,,,307.20,390.24,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,MedCost,Ultra,,244.80,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,inpatient,,,536.00000,321.60000,MedCost,Ultra,,343.04,,,,,,,343.04,435.77,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,MedCost,Ultra,,273.36,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Ultra,,293.12,,,,,,,293.12,372.35,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Ultra,,233.58,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,inpatient,,,119.00000,71.40000,MedCost,Ultra,,76.16,,,,,,,76.16,96.75,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,MedCost,Ultra,,60.69,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,,82.56,,,,,,,82.56,104.88,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,,65.79,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,,82.56,,,,,,,82.56,104.88,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,,65.79,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,inpatient,,,208.00000,124.80000,MedCost,Ultra,,133.12,,,,,,,133.12,169.10,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,MedCost,Ultra,,106.08,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Ultra,,104.32,,,,,,,104.32,132.52,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Ultra,,83.13,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,inpatient,,,307.00000,184.20000,MedCost,Ultra,,196.48,,,,,,,196.48,249.59,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,MedCost,Ultra,,156.57,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,inpatient,,,520.00000,312.00000,MedCost,Ultra,,332.80,,,,,,,332.80,422.76,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,MedCost,Ultra,,265.20,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,inpatient,,,504.00000,302.40000,MedCost,Ultra,,322.56,,,,,,,322.56,409.75,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,MedCost,Ultra,,257.04,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,inpatient,,,618.00000,370.80000,MedCost,Ultra,,395.52,,,,,,,395.52,502.43,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,MedCost,Ultra,,315.18,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,inpatient,,,409.00000,245.40000,MedCost,Ultra,,261.76,,,,,,,261.76,332.52,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,MedCost,Ultra,,208.59,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,inpatient,,,770.00000,462.00000,MedCost,Ultra,,492.80,,,,,,,492.80,7039.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,MedCost,Ultra,,392.70,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,inpatient,,,770.00000,462.00000,MedCost,Ultra,,492.80,,,,,,,492.80,626.01,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,MedCost,Ultra,,392.70,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,inpatient,,,638.00000,382.80000,MedCost,Ultra,,408.32,,,,,,,408.32,7039.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,MedCost,Ultra,,325.38,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,inpatient,,,603.00000,361.80000,MedCost,Ultra,,385.92,,,,,,,385.92,490.24,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,MedCost,Ultra,,307.53,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,inpatient,,,902.00000,541.20000,MedCost,Ultra,,577.28,,,,,,,577.28,733.33,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,MedCost,Ultra,,460.02,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,inpatient,,,182.00000,109.20000,MedCost,Ultra,,116.48,,,,,,,116.48,7039.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,MedCost,Ultra,,92.82,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Ultra,,97.28,,,,,,,97.28,7039.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Ultra,,77.52,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,inpatient,,,280.00000,168.00000,MedCost,Ultra,,179.20,,,,,,,179.20,7039.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,MedCost,Ultra,,142.80,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,inpatient,,,388.00000,232.80000,MedCost,Ultra,,248.32,,,,,,,248.32,315.44,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,MedCost,Ultra,,197.88,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,MedCost,Ultra,,485.76,,,,,,,485.76,7039.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,MedCost,Ultra,,387.09,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,MedCost,Ultra,,485.76,,,,,,,485.76,617.07,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,MedCost,Ultra,,387.09,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,inpatient,,,2295.00000,1377.00000,MedCost,Ultra,,1468.80,,,,,,,1468.80,7039.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,MedCost,Ultra,,1170.45,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,inpatient,,,607.00000,364.20000,MedCost,Ultra,,388.48,,,,,,,388.48,493.49,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,MedCost,Ultra,,309.57,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,inpatient,,,1863.00000,1117.80000,MedCost,Ultra,,1192.32,,,,,,,1192.32,7039.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,MedCost,Ultra,,950.13,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,inpatient,,,1863.00000,1117.80000,MedCost,Ultra,,1192.32,,,,,,,1192.32,1514.62,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,MedCost,Ultra,,950.13,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,inpatient,,,2132.00000,1279.20000,MedCost,Ultra,,1364.48,,,,,,,1364.48,7039.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,MedCost,Ultra,,1087.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,inpatient,,,536.00000,321.60000,MedCost,Ultra,,343.04,,,,,,,343.04,435.77,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,MedCost,Ultra,,273.36,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Ultra,,663.68,,,,,,,663.68,843.08,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Ultra,,528.87,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,inpatient,,,12507.00000,7504.20000,MedCost,Ultra,,8004.48,,,,,,,8004.48,10168.19,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,MedCost,Ultra,,6378.57,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1520.00000,912.00000,MedCost,Ultra,,972.80,,,,,,,972.80,1235.76,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,MedCost,Ultra,,775.20,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,inpatient,,,1933.00000,1159.80000,MedCost,Ultra,,1237.12,,,,,,,1237.12,1571.53,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,MedCost,Ultra,,985.83,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,inpatient,,,834.00000,500.40000,MedCost,Ultra,,533.76,,,,,,,533.76,678.04,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,MedCost,Ultra,,425.34,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,inpatient,,,869.00000,521.40000,MedCost,Ultra,,556.16,,,,,,,556.16,706.50,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,MedCost,Ultra,,443.19,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,inpatient,,,925.00000,555.00000,MedCost,Ultra,,592.00,,,,,,,592.00,752.02,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,MedCost,Ultra,,471.75,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,inpatient,,,1538.00000,922.80000,MedCost,Ultra,,984.32,,,,,,,984.32,1250.39,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,MedCost,Ultra,,784.38,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,inpatient,,,1918.00000,1150.80000,MedCost,Ultra,,1227.52,,,,,,,1227.52,1559.33,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,MedCost,Ultra,,978.18,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,inpatient,,,9774.00000,5864.40000,MedCost,Ultra,,6255.36,,,,,,,6255.36,7946.26,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,MedCost,Ultra,,4984.74,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Ultra,,422.40,,,,,,,422.40,7039.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Ultra,,336.60,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Ultra,,422.40,,,,,,,422.40,536.58,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Ultra,,336.60,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,inpatient,,,3189.00000,1913.40000,MedCost,Ultra,,2040.96,,,,,,,2040.96,7039.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,MedCost,Ultra,,1626.39,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,inpatient,,,3189.00000,1913.40000,MedCost,Ultra,,2040.96,,,,,,,2040.96,2592.66,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,MedCost,Ultra,,1626.39,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,inpatient,,,1528.00000,916.80000,MedCost,Ultra,,977.92,,,,,,,977.92,7039.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,MedCost,Ultra,,779.28,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,inpatient,,,1528.00000,916.80000,MedCost,Ultra,,977.92,,,,,,,977.92,1242.26,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,MedCost,Ultra,,779.28,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,inpatient,,,1727.00000,1036.20000,MedCost,Ultra,,1105.28,,,,,,,1105.28,1404.05,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,MedCost,Ultra,,880.77,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,inpatient,,,2142.00000,1285.20000,MedCost,Ultra,,1370.88,,,,,,,1370.88,7039.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,MedCost,Ultra,,1092.42,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,inpatient,,,2142.00000,1285.20000,MedCost,Ultra,,1370.88,,,,,,,1370.88,1741.45,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,MedCost,Ultra,,1092.42,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,inpatient,,,1397.00000,838.20000,MedCost,Ultra,,894.08,,,,,,,894.08,7039.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,MedCost,Ultra,,712.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1397.00000,838.20000,MedCost,Ultra,,894.08,,,,,,,894.08,1135.76,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,MedCost,Ultra,,712.47,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,inpatient,,,621.00000,372.60000,MedCost,Ultra,,397.44,,,,,,,397.44,7039.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,MedCost,Ultra,,316.71,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,inpatient,,,621.00000,372.60000,MedCost,Ultra,,397.44,,,,,,,397.44,504.87,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,MedCost,Ultra,,316.71,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,inpatient,,,720.00000,432.00000,MedCost,Ultra,,460.80,,,,,,,460.80,7039.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,MedCost,Ultra,,367.20,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,inpatient,,,720.00000,432.00000,MedCost,Ultra,,460.80,,,,,,,460.80,585.36,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,MedCost,Ultra,,367.20,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,7039.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.59,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Ultra,,238.72,,,,,,,238.72,7039.00,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Ultra,,190.23,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,inpatient,,,2240.00000,1344.00000,MedCost,Ultra,,1433.60,,,,,,,1433.60,1821.12,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,MedCost,Ultra,,1142.40,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Ultra,JW,84.48,,,,,,,84.48,107.32,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Ultra,JW,67.32,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,inpatient,,,586.00000,351.60000,MedCost,Ultra,,375.04,,,,,,,375.04,476.42,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,MedCost,Ultra,,298.86,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,inpatient,,,499.00000,299.40000,MedCost,Ultra,,319.36,,,,,,,319.36,7039.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,MedCost,Ultra,,254.49,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,inpatient,,,604.00000,362.40000,MedCost,Ultra,,386.56,,,,,,,386.56,7039.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,MedCost,Ultra,,308.04,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,inpatient,,,499.00000,299.40000,MedCost,Ultra,,319.36,,,,,,,319.36,405.69,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,MedCost,Ultra,,254.49,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,inpatient,,,586.00000,351.60000,MedCost,Ultra,,375.04,,,,,,,375.04,7039.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,MedCost,Ultra,,298.86,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,inpatient,,,822.00000,493.20000,MedCost,Ultra,,526.08,,,,,,,526.08,668.29,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,MedCost,Ultra,,419.22,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,inpatient,,,1364.00000,818.40000,MedCost,Ultra,,872.96,,,,,,,872.96,1108.93,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,MedCost,Ultra,,695.64,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,inpatient,,,352.00000,211.20000,MedCost,Ultra,,225.28,,,,,,,225.28,286.18,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,MedCost,Ultra,,179.52,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2522.24,,,,,,,2522.24,7039.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2009.91,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2522.24,,,,,,,2522.24,3204.03,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2009.91,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2522.24,,,,,,,2522.24,7039.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2009.91,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,inpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2522.24,,,,,,,2522.24,3204.03,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,MedCost,Ultra,,2009.91,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,inpatient,,,1950.00000,1170.00000,MedCost,Ultra,,1248.00,,,,,,,1248.00,7039.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,MedCost,Ultra,,994.50,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,inpatient,,,1950.00000,1170.00000,MedCost,Ultra,,1248.00,,,,,,,1248.00,1585.35,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,MedCost,Ultra,,994.50,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,inpatient,,,3103.00000,1861.80000,MedCost,Ultra,,1985.92,,,,,,,1985.92,7039.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,MedCost,Ultra,,1582.53,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,inpatient,,,3103.00000,1861.80000,MedCost,Ultra,,1985.92,,,,,,,1985.92,2522.74,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,MedCost,Ultra,,1582.53,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,inpatient,,,1723.00000,1033.80000,MedCost,Ultra,,1102.72,,,,,,,1102.72,1400.80,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,MedCost,Ultra,,878.73,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,inpatient,,,2132.00000,1279.20000,MedCost,Ultra,,1364.48,,,,,,,1364.48,1733.32,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,MedCost,Ultra,,1087.32,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,inpatient,,,2800.00000,1680.00000,MedCost,Ultra,,1792.00,,,,,,,1792.00,2276.40,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,MedCost,Ultra,,1428.00,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,inpatient,,,543.00000,325.80000,MedCost,Ultra,,347.52,,,,,,,347.52,7039.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,MedCost,Ultra,,276.93,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,inpatient,,,4385.00000,2631.00000,MedCost,Ultra,,2806.40,,,,,,,2806.40,7039.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,MedCost,Ultra,,2236.35,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,inpatient,,,4850.00000,2910.00000,MedCost,Ultra,,3104.00,,,,,,,3104.00,7039.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,MedCost,Ultra,,2473.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,inpatient,,,5734.00000,3440.40000,MedCost,Ultra,,3669.76,,,,,,,3669.76,7039.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,MedCost,Ultra,,2924.34,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Ultra,,514.56,,,,,,,514.56,7039.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Ultra,,410.04,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,inpatient,,,1565.00000,939.00000,MedCost,Ultra,,1001.60,,,,,,,1001.60,1272.35,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,MedCost,Ultra,,798.15,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,inpatient,,,1565.00000,939.00000,MedCost,Ultra,,1001.60,,,,,,,1001.60,1272.35,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,MedCost,Ultra,,798.15,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1921.00000,1152.60000,MedCost,Ultra,,1229.44,,,,,,,1229.44,1561.77,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,MedCost,Ultra,,979.71,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,inpatient,,,1701.00000,1020.60000,MedCost,Ultra,,1088.64,,,,,,,1088.64,1382.91,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,MedCost,Ultra,,867.51,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Ultra,,372.48,,,,,,,372.48,473.17,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Ultra,,296.82,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,inpatient,,,2268.00000,1360.80000,MedCost,Ultra,,1451.52,,,,,,,1451.52,1843.88,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,MedCost,Ultra,,1156.68,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,inpatient,,,1265.00000,759.00000,MedCost,Ultra,,809.60,,,,,,,809.60,1028.44,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,MedCost,Ultra,,645.15,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,inpatient,,,2333.00000,1399.80000,MedCost,Ultra,,1493.12,,,,,,,1493.12,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,MedCost,Ultra,,1189.83,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,inpatient,,,2333.00000,1399.80000,MedCost,Ultra,,1493.12,,,,,,,1493.12,1896.73,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,MedCost,Ultra,,1189.83,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,inpatient,,,2047.00000,1228.20000,MedCost,Ultra,,1310.08,,,,,,,1310.08,1664.21,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,MedCost,Ultra,,1043.97,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,inpatient,,,1335.00000,801.00000,MedCost,Ultra,,854.40,,,,,,,854.40,1085.36,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,MedCost,Ultra,,680.85,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,inpatient,,,847.00000,508.20000,MedCost,Ultra,,542.08,,,,,,,542.08,688.61,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,MedCost,Ultra,,431.97,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,inpatient,,,1781.00000,1068.60000,MedCost,Ultra,,1139.84,,,,,,,1139.84,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,MedCost,Ultra,,908.31,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,inpatient,,,1781.00000,1068.60000,MedCost,Ultra,,1139.84,,,,,,,1139.84,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,MedCost,Ultra,,908.31,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,inpatient,,,1698.00000,1018.80000,MedCost,Ultra,,1086.72,,,,,,,1086.72,1380.47,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,MedCost,Ultra,,865.98,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,inpatient,,,1381.00000,828.60000,MedCost,Ultra,,883.84,,,,,,,883.84,1122.75,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,MedCost,Ultra,,704.31,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,inpatient,,,1381.00000,828.60000,MedCost,Ultra,,883.84,,,,,,,883.84,1122.75,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,MedCost,Ultra,,704.31,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Ultra,,1148.16,,,,,,,1148.16,1458.52,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Ultra,,914.94,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Ultra,,1148.16,,,,,,,1148.16,7039.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Ultra,,914.94,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,inpatient,,,4119.00000,2471.40000,MedCost,Ultra,,2636.16,,,,,,,2636.16,3348.75,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,MedCost,Ultra,,2100.69,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,inpatient,,,4119.00000,2471.40000,MedCost,Ultra,,2636.16,,,,,,,2636.16,7039.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,MedCost,Ultra,,2100.69,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,inpatient,,,3475.00000,2085.00000,MedCost,Ultra,,2224.00,,,,,,,2224.00,7039.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,MedCost,Ultra,,1772.25,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,inpatient,,,3475.00000,2085.00000,MedCost,Ultra,,2224.00,,,,,,,2224.00,7039.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,MedCost,Ultra,,1772.25,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,inpatient,,,512.00000,307.20000,MedCost,Ultra,,327.68,,,,,,,327.68,7039.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,MedCost,Ultra,,261.12,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,inpatient,,,594.00000,356.40000,MedCost,Ultra,,380.16,,,,,,,380.16,7039.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,MedCost,Ultra,,302.94,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,7039.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,inpatient,,,1100.00000,660.00000,MedCost,Ultra,52,704.00,,,,,,,704.00,7039.00,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,MedCost,Ultra,52,561.00,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,MedCost,Ultra,,485.76,,,,,,,485.76,7039.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,MedCost,Ultra,,387.09,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,inpatient,,,711.00000,426.60000,MedCost,Ultra,,455.04,,,,,,,455.04,575.91,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,MedCost,Ultra,,362.61,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,inpatient,,,1461.00000,876.60000,MedCost,Ultra,,935.04,,,,,,,935.04,1183.41,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,MedCost,Ultra,,745.11,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Ultra,,81.28,,,,,,,81.28,102.87,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Ultra,,64.77,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,inpatient,,,919.00000,551.40000,MedCost,Ultra,,588.16,,,,,,,588.16,7039.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,MedCost,Ultra,,468.69,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,inpatient,,,919.00000,551.40000,MedCost,Ultra,,588.16,,,,,,,588.16,747.15,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,MedCost,Ultra,,468.69,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Ultra,,238.72,,,,,,,238.72,7039.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Ultra,,190.23,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Ultra,,202.88,,,,,,,202.88,256.77,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Ultra,,161.67,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,inpatient,,,697.00000,418.20000,MedCost,Ultra,,446.08,,,,,,,446.08,564.57,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,MedCost,Ultra,,355.47,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,inpatient,,,1393.00000,835.80000,MedCost,Ultra,,891.52,,,,,,,891.52,1128.33,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,MedCost,Ultra,,710.43,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,inpatient,,,2375.00000,1425.00000,MedCost,Ultra,,1520.00,,,,,,,1520.00,1923.75,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,MedCost,Ultra,,1211.25,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,inpatient,,,3167.00000,1900.20000,MedCost,Ultra,,2026.88,,,,,,,2026.88,2565.27,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,MedCost,Ultra,,1615.17,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,inpatient,,,4011.00000,2406.60000,MedCost,Ultra,,2567.04,,,,,,,2567.04,3248.91,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,MedCost,Ultra,,2045.61,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,inpatient,,,1324.00000,794.40000,MedCost,Ultra,,847.36,,,,,,,847.36,1072.44,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,MedCost,Ultra,,675.24,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,inpatient,,,1207.00000,724.20000,MedCost,Ultra,,772.48,,,,,,,772.48,7039.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,MedCost,Ultra,,615.57,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,inpatient,,,361.00000,216.60000,MedCost,Ultra,,231.04,,,,,,,231.04,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,MedCost,Ultra,,184.11,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,inpatient,,,296.00000,177.60000,MedCost,Ultra,,189.44,,,,,,,189.44,240.65,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,MedCost,Ultra,,150.96,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Ultra,,120.96,,,,,,,120.96,153.66,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Ultra,,96.39,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Ultra,,99.84,,,,,,,99.84,7039.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Ultra,,79.56,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Ultra,,99.84,,,,,,,99.84,7039.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Ultra,,79.56,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,inpatient,,,2736.00000,1641.60000,MedCost,Ultra,,1751.04,,,,,,,1751.04,2216.16,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,MedCost,Ultra,,1395.36,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Ultra,,128.64,,,,,,,128.64,162.81,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Ultra,,102.51,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.28,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,inpatient,,,249.00000,149.40000,MedCost,Ultra,,159.36,,,,,,,159.36,201.69,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,MedCost,Ultra,,126.99,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,inpatient,,,240.00000,144.00000,MedCost,Ultra,,153.60,,,,,,,153.60,194.40,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,MedCost,Ultra,,122.40,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Ultra,,202.88,,,,,,,202.88,256.77,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Ultra,,161.67,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Ultra,,255.36,,,,,,,255.36,323.19,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Ultra,,203.49,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Ultra,,237.44,,,,,,,237.44,300.51,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Ultra,,189.21,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Ultra,,304.00,,,,,,,304.00,384.75,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Ultra,,242.25,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,inpatient,,,181.00000,108.60000,MedCost,Ultra,,115.84,,,,,,,115.84,146.61,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,MedCost,Ultra,,92.31,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,inpatient,,,227.00000,136.20000,MedCost,Ultra,,145.28,,,,,,,145.28,183.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,MedCost,Ultra,,115.77,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,inpatient,,,267.00000,160.20000,MedCost,Ultra,,170.88,,,,,,,170.88,216.27,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,MedCost,Ultra,,136.17,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,inpatient,,,250.00000,150.00000,MedCost,Ultra,,160.00,,,,,,,160.00,202.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,MedCost,Ultra,,127.50,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,inpatient,,,406.00000,243.60000,MedCost,Ultra,,259.84,,,,,,,259.84,328.86,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,MedCost,Ultra,,207.06,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,inpatient,,,435.00000,261.00000,MedCost,Ultra,,278.40,,,,,,,278.40,352.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,MedCost,Ultra,,221.85,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Ultra,,279.68,,,,,,,279.68,353.97,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Ultra,,222.87,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,inpatient,,,397.00000,238.20000,MedCost,Ultra,,254.08,,,,,,,254.08,321.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,MedCost,Ultra,,202.47,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,inpatient,,,181.00000,108.60000,MedCost,Ultra,,115.84,,,,,,,115.84,146.61,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,MedCost,Ultra,,92.31,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,inpatient,,,254.00000,152.40000,MedCost,Ultra,,162.56,,,,,,,162.56,205.74,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,MedCost,Ultra,,129.54,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,inpatient,,,388.00000,232.80000,MedCost,Ultra,,248.32,,,,,,,248.32,314.28,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,MedCost,Ultra,,197.88,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,inpatient,,,489.00000,293.40000,MedCost,Ultra,,312.96,,,,,,,312.96,396.09,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,MedCost,Ultra,,249.39,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Ultra,,42.24,,,,,,,42.24,53.46,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Ultra,,33.66,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Ultra,,67.84,,,,,,,67.84,85.86,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Ultra,,54.06,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,inpatient,,,176.00000,105.60000,MedCost,Ultra,,112.64,,,,,,,112.64,142.56,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,MedCost,Ultra,,89.76,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,inpatient,,,260.00000,156.00000,MedCost,Ultra,,166.40,,,,,,,166.40,210.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,MedCost,Ultra,,132.60,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Ultra,,219.52,,,,,,,219.52,277.83,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Ultra,,174.93,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,inpatient,,,231.00000,138.60000,MedCost,Ultra,,147.84,,,,,,,147.84,187.11,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,MedCost,Ultra,,117.81,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Ultra,,202.88,,,,,,,202.88,256.77,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Ultra,,161.67,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Ultra,,304.00,,,,,,,304.00,384.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Ultra,,242.25,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,inpatient,,,576.00000,345.60000,MedCost,Ultra,,368.64,,,,,,,368.64,466.56,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,MedCost,Ultra,,293.76,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,inpatient,,,137.00000,82.20000,MedCost,Ultra,,87.68,,,,,,,87.68,110.97,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,MedCost,Ultra,,69.87,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,inpatient,,,112.00000,67.20000,MedCost,Ultra,,71.68,,,,,,,71.68,90.72,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,MedCost,Ultra,,57.12,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Ultra,,30.72,,,,,,,30.72,38.88,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Ultra,,24.48,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Ultra,,83.20,,,,,,,39.13,105.69,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Ultra,,66.30,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,25.00000,15.00000,MedCost,Ultra,,16.00,,,,,,,7.53,20.32,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,MedCost,Ultra,,12.75,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,28.59,77.23,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,16.25,43.90,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Ultra,JW,78.72,,,,,,,78.72,100.00,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Ultra,JW,62.73,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Ultra,,78.72,,,,,,,37.02,100.00,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Ultra,,62.73,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,JW,60.80,,,,,,,60.80,77.23,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,JW,48.45,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,inpatient,,,142.00000,85.20000,MedCost,Ultra,,90.88,,,,,,,42.74,115.45,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,MedCost,Ultra,,72.42,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Ultra,,176.00,,,,,,,47.30,228.25,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Ultra,,140.25,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Ultra,,128.00,,,,,,,60.20,162.60,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Ultra,,102.00,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,MedCost,Ultra,JW,128.00,,,,,,,128.00,162.60,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,MedCost,Ultra,JW,102.00,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Ultra,,291.20,,,,,,,136.96,369.92,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Ultra,,232.05,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Ultra,,583.04,,,,,,,274.21,740.64,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Ultra,,464.61,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Ultra,JW,583.04,,,,,,,583.04,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Ultra,JW,464.61,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,MedCost,Ultra,JW,291.20,,,,,,,291.20,369.92,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,MedCost,Ultra,JW,232.05,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Ultra,,632.32,,,,,,,297.39,803.24,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Ultra,,503.88,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,188.43,508.94,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,82.17,221.95,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Ultra,JW,632.32,,,,,,,632.32,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Ultra,JW,503.88,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Ultra,JW,174.72,,,,,,,174.72,221.95,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Ultra,JW,139.23,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Ultra,,365.44,,,,,,,171.87,464.22,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Ultra,,291.21,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,MedCost,Ultra,,167.68,,,,,,,78.86,213.01,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,MedCost,Ultra,,133.62,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Ultra,,1762.56,,,,,,,828.95,2239.00,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Ultra,,1404.54,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Ultra,,778.24,,,,,,,366.02,988.61,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Ultra,,620.16,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,MedCost,Ultra,,394.24,,,,,,,185.42,500.81,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,MedCost,Ultra,,314.16,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,MedCost,Ultra,JW,1762.56,,,,,,,1762.56,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,MedCost,Ultra,JW,1404.54,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,MedCost,Ultra,JW,778.24,,,,,,,778.24,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,MedCost,Ultra,JW,620.16,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,MedCost,Ultra,JW,394.24,,,,,,,394.24,500.81,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,MedCost,Ultra,JW,314.16,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,2813.00000,1687.80000,MedCost,Ultra,,1800.32,,,,,,,846.71,2286.97,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,MedCost,Ultra,,1434.63,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Ultra,,78.72,,,,,,,37.02,100.00,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Ultra,,62.73,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,MedCost,Ultra,,218.88,,,,,,,102.94,278.05,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,MedCost,Ultra,,174.42,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,MedCost,Ultra,JW,218.88,,,,,,,218.88,278.05,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,MedCost,Ultra,JW,174.42,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Ultra,,989.44,,,,,,,465.35,1256.90,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Ultra,,788.46,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,3094.00000,1856.40000,MedCost,Ultra,,1980.16,,,,,,,931.29,2515.42,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,MedCost,Ultra,,1577.94,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,MedCost,Ultra,JW,989.44,,,,,,,989.44,1256.90,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,MedCost,Ultra,JW,788.46,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,MedCost,Ultra,,273.92,,,,,,,128.83,347.96,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,MedCost,Ultra,,218.28,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,MedCost,Ultra,JW,273.92,,,,,,,273.92,347.96,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,MedCost,Ultra,JW,218.28,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,145.38,392.68,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,MedCost,Ultra,JW,309.12,,,,,,,309.12,392.68,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,MedCost,Ultra,JW,246.33,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,10.00000,6.00000,MedCost,Ultra,,6.40,,,,,,,3.01,8.13,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,MedCost,Ultra,,5.10,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Ultra,,1598.72,,,,,,,751.90,2030.87,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Ultra,,1273.98,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,MedCost,Ultra,JW,1598.72,,,,,,,1598.72,2030.87,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,MedCost,Ultra,JW,1273.98,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Ultra,,1296.00,,,,,,,609.52,1646.33,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Ultra,,1032.75,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,MedCost,Ultra,JW,1296.00,,,,,,,1296.00,1646.33,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,MedCost,Ultra,JW,1032.75,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Ultra,,1093.12,,,,,,,514.11,1388.60,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Ultra,,871.08,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,MedCost,Ultra,JW,1093.12,,,,,,,1093.12,1388.60,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,MedCost,Ultra,JW,871.08,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,19.57,52.84,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,JW,41.60,,,,,,,41.60,52.84,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,JW,33.15,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,2469.00000,1481.40000,MedCost,Ultra,,1580.16,,,,,,,743.17,2007.30,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,MedCost,Ultra,,1259.19,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,MedCost,Ultra,,446.72,,,,,,,210.10,567.47,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,MedCost,Ultra,,355.98,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,MedCost,Ultra,,446.72,,,,,,,446.72,567.47,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,MedCost,Ultra,,355.98,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,188.43,508.94,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,400.64,508.94,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Ultra,,393.60,,,,,,,185.12,500.00,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Ultra,,313.65,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Ultra,,393.60,,,,,,,393.60,500.00,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Ultra,,313.65,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,132.14,356.91,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,280.96,356.91,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Ultra,,255.36,,,,,,,120.10,324.39,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Ultra,,203.49,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Ultra,,255.36,,,,,,,255.36,324.39,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Ultra,,203.49,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,2363.00000,1417.80000,MedCost,Ultra,JW,1512.32,,,,,,,1512.32,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,MedCost,Ultra,JW,1205.13,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Ultra,JW,365.44,,,,,,,365.44,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Ultra,JW,291.21,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,MedCost,Ultra,JW,167.68,,,,,,,167.68,213.01,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,MedCost,Ultra,JW,133.62,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,MedCost,Ultra,,200.32,,,,,,,94.21,254.47,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,MedCost,Ultra,,159.63,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,MedCost,Ultra,JW,200.32,,,,,,,200.32,254.47,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,MedCost,Ultra,JW,159.63,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Ultra,,1008.00,,,,,,,474.07,1280.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Ultra,,803.25,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,MedCost,Ultra,JW,1008.00,,,,,,,1008.00,1280.47,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,MedCost,Ultra,JW,803.25,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Ultra,,801.28,,,,,,,376.85,1017.88,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Ultra,,638.52,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,MedCost,Ultra,JW,801.28,,,,,,,801.28,1017.88,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,MedCost,Ultra,JW,638.52,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,MedCost,Ultra,,410.24,,,,,,,192.94,521.13,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,MedCost,Ultra,,326.91,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,MedCost,Ultra,JW,410.24,,,,,,,410.24,521.13,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,MedCost,Ultra,JW,326.91,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,MedCost,Ultra,,217.60,,,,,,,102.34,276.42,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,MedCost,Ultra,,173.40,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,MedCost,Ultra,JW,217.60,,,,,,,217.60,276.42,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,MedCost,Ultra,JW,173.40,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,MedCost,Ultra,,174.08,,,,,,,81.87,221.14,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,MedCost,Ultra,,138.72,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,MedCost,Ultra,JW,174.08,,,,,,,174.08,221.14,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,MedCost,Ultra,JW,138.72,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2562.00000,1537.20000,MedCost,Ultra,,1639.68,,,,,,,771.16,2082.91,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,MedCost,Ultra,,1306.62,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,inpatient,,,295.00000,177.00000,MedCost,Ultra,,188.80,,,,,,,188.80,238.95,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,MedCost,Ultra,,150.45,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Ultra,,407.68,,,,,,,407.68,515.97,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Ultra,,324.87,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Ultra,,407.68,,,,,,,407.68,515.97,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Ultra,,324.87,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Ultra,,407.68,,,,,,,407.68,515.97,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Ultra,,324.87,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Ultra,,407.68,,,,,,,407.68,515.97,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Ultra,,324.87,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,inpatient,,,270.00000,162.00000,MedCost,Ultra,,172.80,,,,,,,172.80,219.51,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,MedCost,Ultra,,137.70,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,inpatient,,,4243.00000,2545.80000,MedCost,Ultra,,2715.52,,,,,,,2715.52,3449.56,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,MedCost,Ultra,,2163.93,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,inpatient,,,181.00000,108.60000,MedCost,Ultra,,115.84,,,,,,,115.84,146.61,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,MedCost,Ultra,,92.31,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,inpatient,,,246.00000,147.60000,MedCost,Ultra,,157.44,,,,,,,157.44,200.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,MedCost,Ultra,,125.46,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,inpatient,,,2577.00000,1546.20000,MedCost,Ultra,,1649.28,,,,,,,1649.28,2095.10,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,MedCost,Ultra,,1314.27,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,inpatient,,,209.00000,125.40000,MedCost,Ultra,,133.76,,,,,,,62.91,169.92,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,MedCost,Ultra,,106.59,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,inpatient,,,303.00000,181.80000,MedCost,Ultra,,193.92,,,,,,,193.92,246.34,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,MedCost,Ultra,,154.53,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,inpatient,,,1976.00000,1185.60000,MedCost,Ultra,,1264.64,,,,,,,1264.64,1606.49,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,MedCost,Ultra,,1007.76,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,inpatient,,,1976.00000,1185.60000,MedCost,Ultra,,1264.64,,,,,,,1264.64,1606.49,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,MedCost,Ultra,,1007.76,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,inpatient,,,432.00000,259.20000,MedCost,Ultra,,276.48,,,,,,,276.48,351.22,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,MedCost,Ultra,,220.32,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,inpatient,,,432.00000,259.20000,MedCost,Ultra,,276.48,,,,,,,276.48,351.22,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,MedCost,Ultra,,220.32,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,inpatient,,,337.00000,202.20000,MedCost,Ultra,,215.68,,,,,,,215.68,273.98,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,MedCost,Ultra,,171.87,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,inpatient,,,280.00000,168.00000,MedCost,Ultra,,179.20,,,,,,,179.20,227.64,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,MedCost,Ultra,,142.80,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Ultra,,172.16,,,,,,,172.16,218.70,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Ultra,,137.19,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,inpatient,,,9379.00000,5627.40000,MedCost,Ultra,,6002.56,,,,,,,6002.56,7596.99,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,MedCost,Ultra,,4783.29,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,inpatient,,,1113.00000,667.80000,MedCost,Ultra,,712.32,,,,,,,712.32,901.53,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,MedCost,Ultra,,567.63,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Ultra,,663.68,,,,,,,663.68,843.08,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Ultra,,528.87,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,inpatient,,,1197.00000,718.20000,MedCost,Ultra,,766.08,,,,,,,766.08,973.16,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,MedCost,Ultra,,610.47,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,inpatient,,,806.00000,483.60000,MedCost,Ultra,,515.84,,,,,,,515.84,655.28,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,MedCost,Ultra,,411.06,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,inpatient,,,1985.00000,1191.00000,MedCost,Ultra,,1270.40,,,,,,,1270.40,7039.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,MedCost,Ultra,,1012.35,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,inpatient,,,1985.00000,1191.00000,MedCost,Ultra,,1270.40,,,,,,,1270.40,7039.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,MedCost,Ultra,,1012.35,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,inpatient,,,11676.00000,7005.60000,MedCost,Ultra,,7472.64,,,,,,,7039.00,9457.56,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,MedCost,Ultra,,5954.76,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,inpatient,,,11676.00000,7005.60000,MedCost,Ultra,,7472.64,,,,,,,7039.00,9457.56,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,MedCost,Ultra,,5954.76,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,inpatient,,,20316.00000,12189.60000,MedCost,Ultra,,13002.24,,,,,,,7039.00,16455.96,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,MedCost,Ultra,,10361.16,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,inpatient,,,20316.00000,12189.60000,MedCost,Ultra,,13002.24,,,,,,,7039.00,16455.96,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,MedCost,Ultra,,10361.16,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,inpatient,,,8640.00000,5184.00000,MedCost,Ultra,,5529.60,,,,,,,5529.60,7039.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,MedCost,Ultra,,4406.40,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,inpatient,,,8640.00000,5184.00000,MedCost,Ultra,,5529.60,,,,,,,5529.60,7039.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,MedCost,Ultra,,4406.40,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,inpatient,,,18331.00000,10998.60000,MedCost,Ultra,,11731.84,,,,,,,7039.00,14848.11,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,MedCost,Ultra,,9348.81,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,inpatient,,,18331.00000,10998.60000,MedCost,Ultra,,11731.84,,,,,,,7039.00,14848.11,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,MedCost,Ultra,,9348.81,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,inpatient,,,29657.00000,17794.20000,MedCost,Ultra,,18980.48,,,,,,,7039.00,24022.17,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,MedCost,Ultra,,15125.07,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,inpatient,,,29657.00000,17794.20000,MedCost,Ultra,,18980.48,,,,,,,7039.00,24022.17,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,MedCost,Ultra,,15125.07,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Ultra,,172.16,,,,,,,172.16,218.70,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Ultra,,137.19,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,inpatient,,,410.00000,246.00000,MedCost,Ultra,,262.40,,,,,,,262.40,333.33,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,MedCost,Ultra,,209.10,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,inpatient,,,594.00000,356.40000,MedCost,Ultra,,380.16,,,,,,,380.16,482.92,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,MedCost,Ultra,,302.94,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,inpatient,,,512.00000,307.20000,MedCost,Ultra,,327.68,,,,,,,327.68,416.26,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,MedCost,Ultra,,261.12,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,inpatient,,,771.00000,462.60000,MedCost,Ultra,,493.44,,,,,,,493.44,626.82,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,MedCost,Ultra,,393.21,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,inpatient,,,681.00000,408.60000,MedCost,Ultra,,435.84,,,,,,,435.84,553.65,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,MedCost,Ultra,,347.31,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,inpatient,,,3875.00000,2325.00000,MedCost,Ultra,,2480.00,,,,,,,2480.00,3150.38,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,MedCost,Ultra,,1976.25,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Ultra,,91.52,,,,,,,91.52,116.26,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Ultra,,72.93,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Ultra,,201.60,,,,,,,201.60,256.10,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Ultra,,160.65,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Ultra,,124.80,,,,,,,124.80,158.53,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Ultra,,99.45,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Ultra,,201.60,,,,,,,201.60,256.10,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Ultra,,160.65,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Ultra,,124.80,,,,,,,124.80,158.53,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Ultra,,99.45,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Ultra,,201.60,,,,,,,201.60,256.10,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Ultra,,160.65,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Ultra,,124.80,,,,,,,124.80,158.53,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Ultra,,99.45,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Ultra,,329.60,,,,,,,329.60,418.69,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Ultra,,262.65,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,,84.15,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,inpatient,,,949.00000,569.40000,MedCost,Ultra,,607.36,,,,,,,607.36,768.69,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,MedCost,Ultra,,483.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,inpatient,,,484.00000,290.40000,MedCost,Ultra,,309.76,,,,,,,309.76,392.04,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,MedCost,Ultra,,246.84,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Ultra,,81.92,,,,,,,81.92,103.68,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Ultra,,65.28,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,inpatient,,,141.00000,84.60000,MedCost,Ultra,,90.24,,,,,,,90.24,114.21,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,MedCost,Ultra,,71.91,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Ultra,,101.12,,,,,,,101.12,127.98,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Ultra,,80.58,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Ultra,,58.88,,,,,,,58.88,74.52,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Ultra,,46.92,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Ultra,,58.88,,,,,,,58.88,74.52,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Ultra,,46.92,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Ultra,,135.68,,,,,,,135.68,171.72,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Ultra,,108.12,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,inpatient,,,410.00000,246.00000,MedCost,Ultra,,262.40,,,,,,,262.40,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,MedCost,Ultra,,209.10,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Ultra,,329.60,,,,,,,329.60,418.69,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Ultra,,262.65,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,inpatient,,,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,40.96,51.84,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,inpatient,,,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,40.96,51.84,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Ultra,,96.00,,,,,,,96.00,121.50,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Ultra,,76.50,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Ultra,,54.40,,,,,,,54.40,68.85,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Ultra,,43.35,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Ultra,,85.12,,,,,,,85.12,107.73,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Ultra,,67.83,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Ultra,,329.60,,,,,,,329.60,418.69,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Ultra,,262.65,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,40000.00000,24000.00000,MedCost,Ultra,,25600.00,,,,,,,6880.00,33200.00,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,MedCost,Ultra,,20400.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,inpatient,,,777.00000,466.20000,MedCost,Ultra,,497.28,,,,,,,497.28,7039.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,MedCost,Ultra,,396.27,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,inpatient,,,8778.00000,5266.80000,MedCost,Ultra,,5617.92,,,,,,,5617.92,7110.18,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,MedCost,Ultra,,4476.78,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,inpatient,,,8778.00000,5266.80000,MedCost,Ultra,,5617.92,,,,,,,5617.92,7110.18,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,MedCost,Ultra,,4476.78,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,inpatient,,,4941.00000,2964.60000,MedCost,Ultra,,3162.24,,,,,,,3162.24,7039.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,MedCost,Ultra,,2519.91,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Ultra,,186.88,,,,,,,186.88,7039.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Ultra,,148.92,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,inpatient,,,884.00000,530.40000,MedCost,Ultra,,565.76,,,,,,,565.76,7039.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,MedCost,Ultra,,450.84,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,inpatient,,,205.00000,123.00000,MedCost,Ultra,,131.20,,,,,,,131.20,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,MedCost,Ultra,,104.55,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,inpatient,,,205.00000,123.00000,MedCost,Ultra,,131.20,,,,,,,131.20,166.05,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,MedCost,Ultra,,104.55,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,inpatient,,,970.00000,582.00000,MedCost,Ultra,,620.80,,,,,,,620.80,7039.00,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,MedCost,Ultra,,494.70,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,inpatient,,,1230.00000,738.00000,MedCost,Ultra,,787.20,,,,,,,787.20,7039.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,MedCost,Ultra,,627.30,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Ultra,,207.36,,,,,,,207.36,7039.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Ultra,,165.24,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,inpatient,,,6259.00000,3755.40000,MedCost,Ultra,,4005.76,,,,,,,4005.76,7039.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,MedCost,Ultra,,3192.09,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1998.72,,,,,,,1998.72,2539.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1592.73,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,inpatient,,,486.00000,291.60000,MedCost,Ultra,,311.04,,,,,,,311.04,7039.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,MedCost,Ultra,,247.86,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,inpatient,,,20624.00000,12374.40000,MedCost,Ultra,,13199.36,,,,,,,7039.00,16705.44,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,MedCost,Ultra,,10518.24,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,inpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1998.72,,,,,,,1998.72,2539.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,MedCost,Ultra,,1592.73,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,inpatient,,,842.00000,505.20000,MedCost,Ultra,,538.88,,,,,,,538.88,7039.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,MedCost,Ultra,,429.42,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,inpatient,,,2336.00000,1401.60000,MedCost,Ultra,,1495.04,,,,,,,1495.04,7039.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,MedCost,Ultra,,1191.36,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,inpatient,,,2317.00000,1390.20000,MedCost,Ultra,,1482.88,,,,,,,1482.88,7039.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,MedCost,Ultra,,1181.67,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,inpatient,,,2322.00000,1393.20000,MedCost,Ultra,,1486.08,,,,,,,1486.08,7039.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,MedCost,Ultra,,1184.22,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,inpatient,,,11929.00000,7157.40000,MedCost,Ultra,,7634.56,,,,,,,7039.00,9662.49,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,MedCost,Ultra,,6083.79,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,inpatient,,,524.00000,314.40000,MedCost,Ultra,,335.36,,,,,,,335.36,7039.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,MedCost,Ultra,,267.24,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,inpatient,,,573.00000,343.80000,MedCost,Ultra,,366.72,,,,,,,366.72,464.13,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,MedCost,Ultra,,292.23,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,inpatient,,,1331.00000,798.60000,MedCost,Ultra,,851.84,,,,,,,851.84,7039.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,MedCost,Ultra,,678.81,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1639.04,,,,,,,1639.04,7039.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1306.11,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1639.04,,,,,,,1639.04,7039.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1306.11,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,inpatient,,,1895.00000,1137.00000,MedCost,Ultra,,1212.80,,,,,,,1212.80,7039.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,MedCost,Ultra,,966.45,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,inpatient,,,1895.00000,1137.00000,MedCost,Ultra,,1212.80,,,,,,,1212.80,7039.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,MedCost,Ultra,,966.45,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,inpatient,,,3456.00000,2073.60000,MedCost,Ultra,,2211.84,,,,,,,2211.84,7039.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,MedCost,Ultra,,1762.56,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,inpatient,,,3456.00000,2073.60000,MedCost,Ultra,,2211.84,,,,,,,2211.84,7039.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,MedCost,Ultra,,1762.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1639.04,,,,,,,1639.04,7039.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1306.11,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,inpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1639.04,,,,,,,1639.04,7039.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,MedCost,Ultra,,1306.11,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,inpatient,,,5187.00000,3112.20000,MedCost,Ultra,,3319.68,,,,,,,1561.29,4217.03,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,MedCost,Ultra,,2645.37,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Ultra,,790.40,,,,,,,371.74,1004.05,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Ultra,,629.85,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Ultra,,670.72,,,,,,,315.45,852.02,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Ultra,,534.48,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,MedCost,Ultra,,452.48,,,,,,,212.81,574.79,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,MedCost,Ultra,,360.57,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Ultra,,352.00,,,,,,,165.55,447.15,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Ultra,,280.50,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Ultra,,282.88,,,,,,,133.04,359.35,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Ultra,,225.42,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,MedCost,Ultra,,298.24,,,,,,,140.27,378.86,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,MedCost,Ultra,,237.66,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,MedCost,Ultra,JW,790.40,,,,,,,790.40,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,MedCost,Ultra,JW,629.85,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,MedCost,Ultra,JW,670.72,,,,,,,670.72,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,MedCost,Ultra,JW,534.48,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,MedCost,Ultra,JW,452.48,,,,,,,452.48,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,MedCost,Ultra,JW,360.57,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Ultra,JW,352.00,,,,,,,352.00,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Ultra,JW,280.50,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Ultra,JW,282.88,,,,,,,282.88,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Ultra,JW,225.42,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,MedCost,Ultra,JW,298.24,,,,,,,298.24,378.86,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,MedCost,Ultra,JW,237.66,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,2078.00000,1246.80000,MedCost,Ultra,,1329.92,,,,,,,625.48,1689.41,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,MedCost,Ultra,,1059.78,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,inpatient,,,179.00000,107.40000,MedCost,Ultra,,114.56,,,,,,,114.56,145.53,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,MedCost,Ultra,,91.29,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.84,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,inpatient,,,797.00000,478.20000,MedCost,Ultra,,510.08,,,,,,,510.08,7039.00,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,MedCost,Ultra,,406.47,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Ultra,,632.32,,,,,,,632.32,7039.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Ultra,,503.88,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,inpatient,,,1432.00000,859.20000,MedCost,Ultra,,916.48,,,,,,,916.48,7039.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,MedCost,Ultra,,730.32,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,inpatient,,,886.00000,531.60000,MedCost,Ultra,,567.04,,,,,,,567.04,7039.00,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,MedCost,Ultra,,451.86,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,inpatient,,,179.00000,107.40000,MedCost,Ultra,,114.56,,,,,,,114.56,7039.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,MedCost,Ultra,,91.29,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,inpatient,,,1828.00000,1096.80000,MedCost,Ultra,,1169.92,,,,,,,1169.92,7039.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,MedCost,Ultra,,932.28,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,inpatient,,,2594.00000,1556.40000,MedCost,Ultra,,1660.16,,,,,,,1660.16,7039.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,MedCost,Ultra,,1322.94,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,inpatient,,,945.00000,567.00000,MedCost,Ultra,,604.80,,,,,,,604.80,7039.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,MedCost,Ultra,,481.95,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,inpatient,,,2883.00000,1729.80000,MedCost,Ultra,,1845.12,,,,,,,1845.12,7039.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,MedCost,Ultra,,1470.33,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,inpatient,,,956.00000,573.60000,MedCost,Ultra,,611.84,,,,,,,611.84,7039.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,MedCost,Ultra,,487.56,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,inpatient,,,886.00000,531.60000,MedCost,Ultra,,567.04,,,,,,,567.04,7039.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,MedCost,Ultra,,451.86,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,inpatient,,,1402.00000,841.20000,MedCost,Ultra,,897.28,,,,,,,897.28,7039.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,MedCost,Ultra,,715.02,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,inpatient,,,2174.00000,1304.40000,MedCost,Ultra,,1391.36,,,,,,,1391.36,1767.46,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,MedCost,Ultra,,1108.74,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,inpatient,,,4232.00000,2539.20000,MedCost,Ultra,,2708.48,,,,,,,2708.48,3440.62,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,MedCost,Ultra,,2158.32,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,inpatient,,,19132.00000,11479.20000,MedCost,Ultra,,12244.48,,,,,,,12244.48,15554.32,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,MedCost,Ultra,,9757.32,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,inpatient,,,429.00000,257.40000,MedCost,Ultra,,274.56,,,,,,,274.56,347.49,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,MedCost,Ultra,,218.79,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,inpatient,,,452.00000,271.20000,MedCost,Ultra,,289.28,,,,,,,289.28,366.12,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,MedCost,Ultra,,230.52,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,inpatient,,,401.00000,240.60000,MedCost,Ultra,,256.64,,,,,,,256.64,324.81,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,MedCost,Ultra,,204.51,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,inpatient,,,665.00000,399.00000,MedCost,Ultra,,425.60,,,,,,,425.60,538.65,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,MedCost,Ultra,,339.15,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,inpatient,,,318.00000,190.80000,MedCost,Ultra,,203.52,,,,,,,203.52,257.58,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,MedCost,Ultra,,162.18,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Ultra,,195.20,,,,,,,91.81,247.97,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Ultra,,155.55,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Ultra,,207.36,,,,,,,207.36,262.44,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Ultra,,165.24,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,inpatient,,,545.00000,327.00000,MedCost,Ultra,,348.80,,,,,,,348.80,441.45,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,MedCost,Ultra,,277.95,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,inpatient,,,352.00000,211.20000,MedCost,Ultra,,225.28,,,,,,,225.28,285.12,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,MedCost,Ultra,,179.52,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Ultra,,307.84,,,,,,,307.84,389.61,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Ultra,,245.31,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,inpatient,,,601.00000,360.60000,MedCost,Ultra,,384.64,,,,,,,384.64,486.81,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,MedCost,Ultra,,306.51,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,inpatient,,,394.00000,236.40000,MedCost,Ultra,,252.16,,,,,,,252.16,319.14,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,MedCost,Ultra,,200.94,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Ultra,,282.88,,,,,,,282.88,358.02,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Ultra,,225.42,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,inpatient,,,500.00000,300.00000,MedCost,Ultra,,320.00,,,,,,,320.00,405.00,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,MedCost,Ultra,,255.00,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Ultra,,97.28,,,,,,,97.28,123.12,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Ultra,,77.52,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,inpatient,,,270.00000,162.00000,MedCost,Ultra,,172.80,,,,,,,172.80,218.70,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,MedCost,Ultra,,137.70,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Ultra,,76.80,,,,,,,76.80,97.20,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Ultra,,61.20,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,inpatient,,,501.00000,300.60000,MedCost,Ultra,,320.64,,,,,,,320.64,405.81,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,MedCost,Ultra,,255.51,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,inpatient,,,671.00000,402.60000,MedCost,Ultra,,429.44,,,,,,,429.44,543.51,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,MedCost,Ultra,,342.21,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,inpatient,,,179.00000,107.40000,MedCost,Ultra,,114.56,,,,,,,114.56,144.99,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,MedCost,Ultra,,91.29,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,inpatient,,,302.00000,181.20000,MedCost,Ultra,,193.28,,,,,,,193.28,244.62,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,MedCost,Ultra,,154.02,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,inpatient,,,362.00000,217.20000,MedCost,Ultra,,231.68,,,,,,,231.68,293.22,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,MedCost,Ultra,,184.62,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,inpatient,,,483.00000,289.80000,MedCost,Ultra,,309.12,,,,,,,309.12,391.23,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,MedCost,Ultra,,246.33,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,inpatient,,,584.00000,350.40000,MedCost,Ultra,,373.76,,,,,,,373.76,473.04,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,MedCost,Ultra,,297.84,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,inpatient,,,1079.00000,647.40000,MedCost,Ultra,,690.56,,,,,,,690.56,873.99,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,MedCost,Ultra,,550.29,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,inpatient,,,585.00000,351.00000,MedCost,Ultra,,374.40,,,,,,,374.40,473.85,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,MedCost,Ultra,,298.35,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,246.40,311.85,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Ultra,,195.20,,,,,,,195.20,247.05,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Ultra,,155.55,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Ultra,,282.88,,,,,,,282.88,358.02,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Ultra,,225.42,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Ultra,,317.44,,,,,,,317.44,401.76,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Ultra,,252.96,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Ultra,,422.40,,,,,,,422.40,534.60,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Ultra,,336.60,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,inpatient,,,929.00000,557.40000,MedCost,Ultra,,594.56,,,,,,,594.56,752.49,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,MedCost,Ultra,,473.79,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,inpatient,,,437.00000,262.20000,MedCost,Ultra,,279.68,,,,,,,279.68,353.97,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,MedCost,Ultra,,222.87,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,inpatient,,,327.00000,196.20000,MedCost,Ultra,,209.28,,,,,,,209.28,264.87,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,MedCost,Ultra,,166.77,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,inpatient,,,564.00000,338.40000,MedCost,Ultra,,360.96,,,,,,,360.96,456.84,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,MedCost,Ultra,,287.64,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,inpatient,,,492.00000,295.20000,MedCost,Ultra,,314.88,,,,,,,314.88,398.52,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,MedCost,Ultra,,250.92,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,inpatient,,,710.00000,426.00000,MedCost,Ultra,,454.40,,,,,,,454.40,575.10,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,MedCost,Ultra,,362.10,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,inpatient,,,875.00000,525.00000,MedCost,Ultra,,560.00,,,,,,,560.00,708.75,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,MedCost,Ultra,,446.25,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Ultra,,372.48,,,,,,,372.48,471.42,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Ultra,,296.82,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,inpatient,,,341.00000,204.60000,MedCost,Ultra,,218.24,,,,,,,218.24,276.21,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,MedCost,Ultra,,173.91,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,inpatient,,,541.00000,324.60000,MedCost,Ultra,,346.24,,,,,,,346.24,438.21,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,MedCost,Ultra,,275.91,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,inpatient,,,369.00000,221.40000,MedCost,Ultra,,236.16,,,,,,,236.16,298.89,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,MedCost,Ultra,,188.19,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,inpatient,,,368.00000,220.80000,MedCost,Ultra,,235.52,,,,,,,235.52,298.08,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,MedCost,Ultra,,187.68,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,inpatient,,,1211.00000,726.60000,MedCost,Ultra,,775.04,,,,,,,775.04,980.91,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,MedCost,Ultra,,617.61,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,inpatient,,,752.00000,451.20000,MedCost,Ultra,,481.28,,,,,,,481.28,609.12,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,MedCost,Ultra,,383.52,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,inpatient,,,1336.00000,801.60000,MedCost,Ultra,,855.04,,,,,,,855.04,1082.16,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,MedCost,Ultra,,681.36,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,inpatient,,,1892.00000,1135.20000,MedCost,Ultra,,1210.88,,,,,,,1210.88,1532.52,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,MedCost,Ultra,,964.92,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,inpatient,,,2081.00000,1248.60000,MedCost,Ultra,,1331.84,,,,,,,1331.84,1685.61,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,MedCost,Ultra,,1061.31,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,inpatient,,,425.00000,255.00000,MedCost,Ultra,,272.00,,,,,,,272.00,344.25,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,MedCost,Ultra,,216.75,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,inpatient,,,382.00000,229.20000,MedCost,Ultra,,244.48,,,,,,,244.48,309.42,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,MedCost,Ultra,,194.82,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,inpatient,,,459.00000,275.40000,MedCost,Ultra,,293.76,,,,,,,293.76,371.79,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,MedCost,Ultra,,234.09,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,inpatient,,,462.00000,277.20000,MedCost,Ultra,,295.68,,,,,,,295.68,374.22,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,MedCost,Ultra,,235.62,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Ultra,,813.44,,,,,,,813.44,1029.51,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Ultra,,648.21,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,inpatient,,,522.00000,313.20000,MedCost,Ultra,,334.08,,,,,,,334.08,422.82,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,MedCost,Ultra,,266.22,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,inpatient,,,440.00000,264.00000,MedCost,Ultra,,281.60,,,,,,,281.60,356.40,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,MedCost,Ultra,,224.40,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,inpatient,,,406.00000,243.60000,MedCost,Ultra,,259.84,,,,,,,259.84,328.86,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,MedCost,Ultra,,207.06,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,inpatient,,,442.00000,265.20000,MedCost,Ultra,,282.88,,,,,,,282.88,358.02,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,MedCost,Ultra,,225.42,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,inpatient,,,487.00000,292.20000,MedCost,Ultra,,311.68,,,,,,,311.68,394.47,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,MedCost,Ultra,,248.37,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,inpatient,,,379.00000,227.40000,MedCost,Ultra,,242.56,,,,,,,242.56,306.99,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,MedCost,Ultra,,193.29,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,inpatient,,,298.00000,178.80000,MedCost,Ultra,,190.72,,,,,,,190.72,241.38,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,MedCost,Ultra,,151.98,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,inpatient,,,375.00000,225.00000,MedCost,Ultra,,240.00,,,,,,,240.00,303.75,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,MedCost,Ultra,,191.25,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,inpatient,,,347.00000,208.20000,MedCost,Ultra,,222.08,,,,,,,222.08,281.07,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,MedCost,Ultra,,176.97,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,inpatient,,,653.00000,391.80000,MedCost,Ultra,,417.92,,,,,,,417.92,528.93,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,MedCost,Ultra,,333.03,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,inpatient,,,431.00000,258.60000,MedCost,Ultra,,275.84,,,,,,,275.84,349.11,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,MedCost,Ultra,,219.81,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,inpatient,,,394.00000,236.40000,MedCost,Ultra,,252.16,,,,,,,252.16,319.14,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,MedCost,Ultra,,200.94,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,inpatient,,,276.00000,165.60000,MedCost,Ultra,,176.64,,,,,,,176.64,223.56,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,MedCost,Ultra,,140.76,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,inpatient,,,841.00000,504.60000,MedCost,Ultra,,538.24,,,,,,,538.24,681.21,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,MedCost,Ultra,,428.91,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,inpatient,,,427.00000,256.20000,MedCost,Ultra,,273.28,,,,,,,273.28,345.87,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,MedCost,Ultra,,217.77,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Ultra,,237.44,,,,,,,237.44,300.51,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Ultra,,189.21,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,inpatient,,,482.00000,289.20000,MedCost,Ultra,,308.48,,,,,,,308.48,390.42,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,MedCost,Ultra,,245.82,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,inpatient,,,316.00000,189.60000,MedCost,Ultra,,202.24,,,,,,,202.24,255.96,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,MedCost,Ultra,,161.16,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,MedCost,Ultra,,193.80,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,inpatient,,,354.00000,212.40000,MedCost,Ultra,,226.56,,,,,,,226.56,286.74,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,MedCost,Ultra,,180.54,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Ultra,,139.52,,,,,,,139.52,176.58,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Ultra,,111.18,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,inpatient,,,445.00000,267.00000,MedCost,Ultra,,284.80,,,,,,,284.80,360.45,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,MedCost,Ultra,,226.95,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Ultra,,296.32,,,,,,,296.32,375.03,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Ultra,,236.13,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,inpatient,,,380.00000,228.00000,MedCost,Ultra,,243.20,,,,,,,243.20,307.80,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,MedCost,Ultra,,193.80,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,inpatient,,,530.00000,318.00000,MedCost,Ultra,,339.20,,,,,,,339.20,429.30,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,MedCost,Ultra,,270.30,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Ultra,,296.32,,,,,,,296.32,375.03,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Ultra,,236.13,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,inpatient,,,401.00000,240.60000,MedCost,Ultra,,256.64,,,,,,,256.64,324.81,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,MedCost,Ultra,,204.51,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Ultra,,207.36,,,,,,,207.36,262.44,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Ultra,,165.24,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,inpatient,,,426.00000,255.60000,MedCost,Ultra,,272.64,,,,,,,272.64,345.06,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,MedCost,Ultra,,217.26,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,,316.80,,,,,,,316.80,400.95,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,,252.45,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,,316.80,,,,,,,316.80,400.95,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,,252.45,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,,316.80,,,,,,,316.80,400.95,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,,252.45,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,inpatient,,,782.00000,469.20000,MedCost,Ultra,,500.48,,,,,,,500.48,633.42,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,MedCost,Ultra,,398.82,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,inpatient,,,322.00000,193.20000,MedCost,Ultra,,206.08,,,,,,,206.08,260.82,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,MedCost,Ultra,,164.22,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,inpatient,,,247.00000,148.20000,MedCost,Ultra,,158.08,,,,,,,158.08,200.07,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,MedCost,Ultra,,125.97,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,inpatient,,,1055.00000,633.00000,MedCost,Ultra,,675.20,,,,,,,675.20,854.55,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,MedCost,Ultra,,538.05,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,inpatient,,,728.00000,436.80000,MedCost,Ultra,,465.92,,,,,,,465.92,589.68,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,MedCost,Ultra,,371.28,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,inpatient,,,888.00000,532.80000,MedCost,Ultra,,568.32,,,,,,,568.32,719.28,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,MedCost,Ultra,,452.88,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,inpatient,,,498.00000,298.80000,MedCost,Ultra,,318.72,,,,,,,318.72,403.38,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,MedCost,Ultra,,253.98,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,inpatient,,,529.00000,317.40000,MedCost,Ultra,,338.56,,,,,,,338.56,428.49,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,MedCost,Ultra,,269.79,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Ultra,,632.32,,,,,,,632.32,800.28,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Ultra,,503.88,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Ultra,,666.24,,,,,,,666.24,843.21,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Ultra,,530.91,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,inpatient,,,1074.00000,644.40000,MedCost,Ultra,,687.36,,,,,,,687.36,869.94,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,MedCost,Ultra,,547.74,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,inpatient,,,537.00000,322.20000,MedCost,Ultra,,343.68,,,,,,,343.68,434.97,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,MedCost,Ultra,,273.87,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,inpatient,,,98.00000,58.80000,MedCost,Ultra,,62.72,,,,,,,62.72,79.38,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,MedCost,Ultra,,49.98,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,inpatient,,,580.00000,348.00000,MedCost,Ultra,,371.20,,,,,,,371.20,469.80,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,MedCost,Ultra,,295.80,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,inpatient,,,643.00000,385.80000,MedCost,Ultra,,411.52,,,,,,,411.52,520.83,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,MedCost,Ultra,,327.93,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,inpatient,,,818.00000,490.80000,MedCost,Ultra,,523.52,,,,,,,523.52,662.58,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,MedCost,Ultra,,417.18,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,inpatient,,,666.00000,399.60000,MedCost,Ultra,,426.24,,,,,,,426.24,539.46,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,MedCost,Ultra,,339.66,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,inpatient,,,810.00000,486.00000,MedCost,Ultra,,518.40,,,,,,,518.40,656.10,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,MedCost,Ultra,,413.10,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,inpatient,,,2088.00000,1252.80000,MedCost,Ultra,,1336.32,,,,,,,1336.32,1691.28,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,MedCost,Ultra,,1064.88,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,inpatient,,,4645.00000,2787.00000,MedCost,Ultra,,2972.80,,,,,,,2972.80,3762.45,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,MedCost,Ultra,,2368.95,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,inpatient,,,3577.00000,2146.20000,MedCost,Ultra,,2289.28,,,,,,,2289.28,2897.37,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,MedCost,Ultra,,1824.27,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,inpatient,,,185.00000,111.00000,MedCost,Ultra,,118.40,,,,,,,118.40,149.85,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,MedCost,Ultra,,94.35,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,inpatient,,,1368.00000,820.80000,MedCost,Ultra,,875.52,,,,,,,875.52,1108.08,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,MedCost,Ultra,,697.68,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,inpatient,,,1395.00000,837.00000,MedCost,Ultra,,892.80,,,,,,,892.80,1129.95,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,MedCost,Ultra,,711.45,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,inpatient,,,4047.00000,2428.20000,MedCost,Ultra,,2590.08,,,,,,,2590.08,3278.07,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,MedCost,Ultra,,2063.97,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,inpatient,,,5746.00000,3447.60000,MedCost,Ultra,,3677.44,,,,,,,3677.44,4654.26,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,MedCost,Ultra,,2930.46,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,inpatient,,,1326.00000,795.60000,MedCost,Ultra,,848.64,,,,,,,848.64,1074.06,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,MedCost,Ultra,,676.26,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,inpatient,,,2572.00000,1543.20000,MedCost,Ultra,,1646.08,,,,,,,1646.08,2083.32,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,MedCost,Ultra,,1311.72,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,inpatient,,,1031.00000,618.60000,MedCost,Ultra,,659.84,,,,,,,659.84,835.11,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,MedCost,Ultra,,525.81,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,inpatient,,,1202.00000,721.20000,MedCost,Ultra,,769.28,,,,,,,769.28,973.62,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,MedCost,Ultra,,613.02,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,inpatient,,,1608.00000,964.80000,MedCost,Ultra,,1029.12,,,,,,,1029.12,1302.48,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,MedCost,Ultra,,820.08,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Ultra,,514.56,,,,,,,514.56,651.24,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Ultra,,410.04,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,inpatient,,,1616.00000,969.60000,MedCost,Ultra,,1034.24,,,,,,,1034.24,1308.96,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,MedCost,Ultra,,824.16,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,inpatient,,,967.00000,580.20000,MedCost,Ultra,,618.88,,,,,,,618.88,783.27,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,MedCost,Ultra,,493.17,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,inpatient,,,799.00000,479.40000,MedCost,Ultra,,511.36,,,,,,,511.36,647.19,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,MedCost,Ultra,,407.49,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,inpatient,,,1106.00000,663.60000,MedCost,Ultra,,707.84,,,,,,,707.84,895.86,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,MedCost,Ultra,,564.06,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,inpatient,,,2333.00000,1399.80000,MedCost,Ultra,,1493.12,,,,,,,1493.12,1889.73,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,MedCost,Ultra,,1189.83,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,inpatient,,,1376.00000,825.60000,MedCost,Ultra,,880.64,,,,,,,880.64,1114.56,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,MedCost,Ultra,,701.76,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Ultra,,130.56,,,,,,,130.56,165.24,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Ultra,,104.04,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,inpatient,,,175.00000,105.00000,MedCost,Ultra,,112.00,,,,,,,112.00,141.75,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,MedCost,Ultra,,89.25,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,inpatient,,,1204.00000,722.40000,MedCost,Ultra,,770.56,,,,,,,770.56,975.24,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,MedCost,Ultra,,614.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,inpatient,,,771.00000,462.60000,MedCost,Ultra,,493.44,,,,,,,493.44,624.51,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,MedCost,Ultra,,393.21,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,inpatient,,,1057.00000,634.20000,MedCost,Ultra,,676.48,,,,,,,676.48,856.17,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,MedCost,Ultra,,539.07,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,inpatient,,,358.00000,214.80000,MedCost,Ultra,,229.12,,,,,,,229.12,289.98,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,MedCost,Ultra,,182.58,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,inpatient,,,953.00000,571.80000,MedCost,Ultra,,609.92,,,,,,,609.92,771.93,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,MedCost,Ultra,,486.03,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,inpatient,,,169.00000,101.40000,MedCost,Ultra,,108.16,,,,,,,108.16,136.89,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,MedCost,Ultra,,86.19,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,inpatient,,,936.00000,561.60000,MedCost,Ultra,,599.04,,,,,,,599.04,758.16,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,MedCost,Ultra,,477.36,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,inpatient,,,306.00000,183.60000,MedCost,Ultra,,195.84,,,,,,,195.84,247.86,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,MedCost,Ultra,,156.06,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,inpatient,,,341.00000,204.60000,MedCost,Ultra,,218.24,,,,,,,218.24,276.21,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,MedCost,Ultra,,173.91,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Ultra,,91.52,,,,,,,91.52,115.83,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Ultra,,72.93,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,inpatient,,,744.00000,446.40000,MedCost,Ultra,,476.16,,,,,,,476.16,602.64,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,MedCost,Ultra,,379.44,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,inpatient,,,662.00000,397.20000,MedCost,Ultra,,423.68,,,,,,,423.68,536.22,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,MedCost,Ultra,,337.62,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,inpatient,,,657.00000,394.20000,MedCost,Ultra,,420.48,,,,,,,420.48,532.17,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,MedCost,Ultra,,335.07,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Ultra,,206.72,,,,,,,206.72,261.63,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Ultra,,164.73,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,inpatient,,,646.00000,387.60000,MedCost,Ultra,,413.44,,,,,,,413.44,523.26,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,MedCost,Ultra,,329.46,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,inpatient,,,346.00000,207.60000,MedCost,Ultra,,221.44,,,,,,,221.44,280.26,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,MedCost,Ultra,,176.46,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,inpatient,,,243.00000,145.80000,MedCost,Ultra,,155.52,,,,,,,155.52,196.83,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,MedCost,Ultra,,123.93,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,inpatient,,,268.00000,160.80000,MedCost,Ultra,,171.52,,,,,,,171.52,217.08,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,MedCost,Ultra,,136.68,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,inpatient,,,927.00000,556.20000,MedCost,Ultra,,593.28,,,,,,,593.28,750.87,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,MedCost,Ultra,,472.77,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,inpatient,,,306.00000,183.60000,MedCost,Ultra,,195.84,,,,,,,195.84,247.86,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,MedCost,Ultra,,156.06,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Ultra,,583.04,,,,,,,583.04,737.91,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Ultra,,464.61,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,inpatient,,,291.00000,174.60000,MedCost,Ultra,,186.24,,,,,,,186.24,235.71,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,MedCost,Ultra,,148.41,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,inpatient,,,788.00000,472.80000,MedCost,Ultra,,504.32,,,,,,,504.32,638.28,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,MedCost,Ultra,,401.88,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,inpatient,,,2343.00000,1405.80000,MedCost,Ultra,,1499.52,,,,,,,1499.52,1897.83,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,MedCost,Ultra,,1194.93,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,inpatient,,,4039.00000,2423.40000,MedCost,Ultra,,2584.96,,,,,,,2584.96,3271.59,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,MedCost,Ultra,,2059.89,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,inpatient,,,3338.00000,2002.80000,MedCost,Ultra,,2136.32,,,,,,,2136.32,2703.78,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,MedCost,Ultra,,1702.38,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,inpatient,,,3598.00000,2158.80000,MedCost,Ultra,,2302.72,,,,,,,2302.72,2914.38,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,MedCost,Ultra,,1834.98,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,inpatient,,,2035.00000,1221.00000,MedCost,Ultra,,1302.40,,,,,,,1302.40,1648.35,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,MedCost,Ultra,,1037.85,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,inpatient,,,4514.00000,2708.40000,MedCost,Ultra,,2888.96,,,,,,,2888.96,3656.34,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,MedCost,Ultra,,2302.14,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,inpatient,,,4514.00000,2708.40000,MedCost,Ultra,,2888.96,,,,,,,2888.96,3656.34,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,MedCost,Ultra,,2302.14,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,inpatient,,,4514.00000,2708.40000,MedCost,Ultra,,2888.96,,,,,,,2888.96,3656.34,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,MedCost,Ultra,,2302.14,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,inpatient,,,3053.00000,1831.80000,MedCost,Ultra,,1953.92,,,,,,,1953.92,2472.93,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,MedCost,Ultra,,1557.03,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,inpatient,,,1786.00000,1071.60000,MedCost,Ultra,,1143.04,,,,,,,1143.04,1446.66,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,MedCost,Ultra,,910.86,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,inpatient,,,1404.00000,842.40000,MedCost,Ultra,,898.56,,,,,,,898.56,7039.00,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,MedCost,Ultra,,716.04,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,inpatient,,,268.00000,160.80000,MedCost,Ultra,,171.52,,,,,,,171.52,217.08,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,MedCost,Ultra,,136.68,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,inpatient,,,374.00000,224.40000,MedCost,Ultra,,239.36,,,,,,,239.36,302.94,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,MedCost,Ultra,,190.74,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,inpatient,,,332.00000,199.20000,MedCost,Ultra,,212.48,,,,,,,212.48,268.92,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,MedCost,Ultra,,169.32,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,inpatient,,,831.00000,498.60000,MedCost,Ultra,,531.84,,,,,,,531.84,673.11,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,MedCost,Ultra,,423.81,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Ultra,,104.32,,,,,,,49.06,132.52,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Ultra,,83.13,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,inpatient,,,501.00000,300.60000,MedCost,Ultra,,320.64,,,,,,,320.64,405.81,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,MedCost,Ultra,,255.51,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,inpatient,,,2081.00000,1248.60000,MedCost,Ultra,,1331.84,,,,,,,1331.84,1685.61,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,MedCost,Ultra,,1061.31,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,inpatient,,,617.00000,370.20000,MedCost,Ultra,,394.88,,,,,,,394.88,499.77,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,MedCost,Ultra,,314.67,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,inpatient,,,812.00000,487.20000,MedCost,Ultra,,519.68,,,,,,,519.68,657.72,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,MedCost,Ultra,,414.12,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,inpatient,,,861.00000,516.60000,MedCost,Ultra,,551.04,,,,,,,551.04,697.41,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,MedCost,Ultra,,439.11,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,inpatient,,,467.00000,280.20000,MedCost,Ultra,,298.88,,,,,,,298.88,378.27,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,MedCost,Ultra,,238.17,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,inpatient,,,494.00000,296.40000,MedCost,Ultra,,316.16,,,,,,,316.16,400.14,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,MedCost,Ultra,,251.94,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,inpatient,,,523.00000,313.80000,MedCost,Ultra,,334.72,,,,,,,334.72,423.63,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,MedCost,Ultra,,266.73,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,inpatient,,,758.00000,454.80000,MedCost,Ultra,,485.12,,,,,,,485.12,613.98,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,MedCost,Ultra,,386.58,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,inpatient,,,736.00000,441.60000,MedCost,Ultra,,471.04,,,,,,,471.04,596.16,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,MedCost,Ultra,,375.36,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,inpatient,,,1079.00000,647.40000,MedCost,Ultra,,690.56,,,,,,,690.56,873.99,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,MedCost,Ultra,,550.29,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,inpatient,,,229.00000,137.40000,MedCost,Ultra,,146.56,,,,,,,146.56,185.49,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,MedCost,Ultra,,116.79,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,inpatient,,,432.00000,259.20000,MedCost,Ultra,,276.48,,,,,,,276.48,349.92,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,MedCost,Ultra,,220.32,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,inpatient,,,1063.00000,637.80000,MedCost,Ultra,,680.32,,,,,,,680.32,861.03,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,MedCost,Ultra,,542.13,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,inpatient,,,615.00000,369.00000,MedCost,Ultra,,393.60,,,,,,,393.60,498.15,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,MedCost,Ultra,,313.65,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,inpatient,,,785.00000,471.00000,MedCost,Ultra,,502.40,,,,,,,502.40,635.85,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,MedCost,Ultra,,400.35,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,37500.00000,22500.00000,MedCost,Ultra,,24000.00,,,,,,,6450.00,31125.00,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,MedCost,Ultra,,19125.00,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,inpatient,,,217.00000,130.20000,MedCost,Ultra,,138.88,,,,,,,138.88,175.77,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,MedCost,Ultra,,110.67,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,inpatient,,,1853.00000,1111.80000,MedCost,Ultra,,1185.92,,,,,,,1185.92,1500.93,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,MedCost,Ultra,,945.03,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,inpatient,,,2253.00000,1351.80000,MedCost,Ultra,,1441.92,,,,,,,1441.92,7039.00,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,MedCost,Ultra,,1149.03,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,inpatient,,,420.00000,252.00000,MedCost,Ultra,,268.80,,,,,,,268.80,340.20,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,MedCost,Ultra,,214.20,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,inpatient,,,550.00000,330.00000,MedCost,Ultra,,352.00,,,,,,,352.00,445.50,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,MedCost,Ultra,,280.50,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,inpatient,,,540.00000,324.00000,MedCost,Ultra,,345.60,,,,,,,345.60,437.40,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,MedCost,Ultra,,275.40,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,inpatient,,,401.00000,240.60000,MedCost,Ultra,,256.64,,,,,,,256.64,324.81,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,MedCost,Ultra,,204.51,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,inpatient,,,596.00000,357.60000,MedCost,Ultra,,381.44,,,,,,,381.44,482.76,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,MedCost,Ultra,,303.96,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,inpatient,,,497.00000,298.20000,MedCost,Ultra,,318.08,,,,,,,318.08,402.57,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,MedCost,Ultra,,253.47,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,inpatient,,,752.00000,451.20000,MedCost,Ultra,,481.28,,,,,,,481.28,609.12,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,MedCost,Ultra,,383.52,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,inpatient,,,581.00000,348.60000,MedCost,Ultra,,371.84,,,,,,,371.84,470.61,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,MedCost,Ultra,,296.31,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,inpatient,,,928.00000,556.80000,MedCost,Ultra,,593.92,,,,,,,593.92,751.68,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,MedCost,Ultra,,473.28,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,inpatient,,,1382.00000,829.20000,MedCost,Ultra,,884.48,,,,,,,884.48,1119.42,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,MedCost,Ultra,,704.82,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,inpatient,,,270.00000,162.00000,MedCost,Ultra,,172.80,,,,,,,172.80,218.70,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,MedCost,Ultra,,137.70,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,inpatient,,,829.00000,497.40000,MedCost,Ultra,,530.56,,,,,,,530.56,671.49,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,MedCost,Ultra,,422.79,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,inpatient,,,343.00000,205.80000,MedCost,Ultra,,219.52,,,,,,,219.52,277.83,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,MedCost,Ultra,,174.93,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Ultra,,264.32,,,,,,,264.32,334.53,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Ultra,,210.63,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,inpatient,,,1357.00000,814.20000,MedCost,Ultra,,868.48,,,,,,,868.48,1099.17,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,MedCost,Ultra,,692.07,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Ultra,,433.28,,,,,,,433.28,548.37,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Ultra,,345.27,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,inpatient,,,685.00000,411.00000,MedCost,Ultra,,438.40,,,,,,,438.40,554.85,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,MedCost,Ultra,,349.35,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,inpatient,,,1104.00000,662.40000,MedCost,Ultra,,706.56,,,,,,,706.56,894.24,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,MedCost,Ultra,,563.04,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,inpatient,,,583.00000,349.80000,MedCost,Ultra,,373.12,,,,,,,373.12,472.23,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,MedCost,Ultra,,297.33,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,inpatient,,,2917.00000,1750.20000,MedCost,Ultra,,1866.88,,,,,,,1866.88,2362.77,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,MedCost,Ultra,,1487.67,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,inpatient,,,1494.00000,896.40000,MedCost,Ultra,,956.16,,,,,,,956.16,1210.14,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,MedCost,Ultra,,761.94,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,inpatient,,,1093.00000,655.80000,MedCost,Ultra,,699.52,,,,,,,699.52,885.33,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,MedCost,Ultra,,557.43,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,inpatient,,,976.00000,585.60000,MedCost,Ultra,,624.64,,,,,,,624.64,790.56,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,MedCost,Ultra,,497.76,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,inpatient,,,717.00000,430.20000,MedCost,Ultra,,458.88,,,,,,,458.88,580.77,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,MedCost,Ultra,,365.67,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,inpatient,,,1866.00000,1119.60000,MedCost,Ultra,,1194.24,,,,,,,1194.24,1511.46,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,MedCost,Ultra,,951.66,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,inpatient,,,1014.00000,608.40000,MedCost,Ultra,,648.96,,,,,,,648.96,821.34,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,MedCost,Ultra,,517.14,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,inpatient,,,2079.00000,1247.40000,MedCost,Ultra,,1330.56,,,,,,,1330.56,1683.99,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,MedCost,Ultra,,1060.29,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,inpatient,,,1602.00000,961.20000,MedCost,Ultra,,1025.28,,,,,,,1025.28,1297.62,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,MedCost,Ultra,,817.02,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,inpatient,,,2290.00000,1374.00000,MedCost,Ultra,,1465.60,,,,,,,1465.60,1854.90,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,MedCost,Ultra,,1167.90,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,inpatient,,,1602.00000,961.20000,MedCost,Ultra,,1025.28,,,,,,,1025.28,1297.62,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,MedCost,Ultra,,817.02,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,inpatient,,,2378.00000,1426.80000,MedCost,Ultra,,1521.92,,,,,,,1521.92,1926.18,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,MedCost,Ultra,,1212.78,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,inpatient,,,2733.00000,1639.80000,MedCost,Ultra,,1749.12,,,,,,,1749.12,2213.73,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,MedCost,Ultra,,1393.83,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,inpatient,,,856.00000,513.60000,MedCost,Ultra,,547.84,,,,,,,547.84,693.36,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,MedCost,Ultra,,436.56,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,inpatient,,,1567.00000,940.20000,MedCost,Ultra,,1002.88,,,,,,,1002.88,1269.27,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,MedCost,Ultra,,799.17,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,inpatient,,,1230.00000,738.00000,MedCost,Ultra,,787.20,,,,,,,787.20,996.30,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,MedCost,Ultra,,627.30,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,inpatient,,,2245.00000,1347.00000,MedCost,Ultra,,1436.80,,,,,,,1436.80,1818.45,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,MedCost,Ultra,,1144.95,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,inpatient,,,1042.00000,625.20000,MedCost,Ultra,,666.88,,,,,,,666.88,844.02,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,MedCost,Ultra,,531.42,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,inpatient,,,1148.00000,688.80000,MedCost,Ultra,,734.72,,,,,,,734.72,929.88,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,MedCost,Ultra,,585.48,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,inpatient,,,1255.00000,753.00000,MedCost,Ultra,,803.20,,,,,,,803.20,1016.55,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,MedCost,Ultra,,640.05,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,inpatient,,,1784.00000,1070.40000,MedCost,Ultra,,1141.76,,,,,,,1141.76,1445.04,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,MedCost,Ultra,,909.84,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,inpatient,,,2636.00000,1581.60000,MedCost,Ultra,,1687.04,,,,,,,1687.04,2135.16,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,MedCost,Ultra,,1344.36,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,inpatient,,,2636.00000,1581.60000,MedCost,Ultra,,1687.04,,,,,,,1687.04,2135.16,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,MedCost,Ultra,,1344.36,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,inpatient,,,2497.00000,1498.20000,MedCost,Ultra,,1598.08,,,,,,,1598.08,2022.57,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,MedCost,Ultra,,1273.47,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,inpatient,,,3876.00000,2325.60000,MedCost,Ultra,,2480.64,,,,,,,2480.64,3139.56,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,MedCost,Ultra,,1976.76,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,inpatient,,,4844.00000,2906.40000,MedCost,Ultra,,3100.16,,,,,,,3100.16,3923.64,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,MedCost,Ultra,,2470.44,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,inpatient,,,831.00000,498.60000,MedCost,Ultra,,531.84,,,,,,,531.84,673.11,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,MedCost,Ultra,,423.81,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,inpatient,,,1439.00000,863.40000,MedCost,Ultra,,920.96,,,,,,,920.96,1165.59,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,MedCost,Ultra,,733.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,inpatient,,,1294.00000,776.40000,MedCost,Ultra,,828.16,,,,,,,828.16,1048.14,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,MedCost,Ultra,,659.94,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,inpatient,,,1592.00000,955.20000,MedCost,Ultra,,1018.88,,,,,,,1018.88,1289.52,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,MedCost,Ultra,,811.92,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,inpatient,,,2486.00000,1491.60000,MedCost,Ultra,,1591.04,,,,,,,1591.04,2013.66,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,MedCost,Ultra,,1267.86,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,inpatient,,,778.00000,466.80000,MedCost,Ultra,,497.92,,,,,,,497.92,630.18,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,MedCost,Ultra,,396.78,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,inpatient,,,1464.00000,878.40000,MedCost,Ultra,,936.96,,,,,,,936.96,1185.84,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,MedCost,Ultra,,746.64,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,inpatient,,,864.00000,518.40000,MedCost,Ultra,,552.96,,,,,,,552.96,699.84,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,MedCost,Ultra,,440.64,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,inpatient,,,1090.00000,654.00000,MedCost,Ultra,,697.60,,,,,,,697.60,882.90,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,MedCost,Ultra,,555.90,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,inpatient,,,799.00000,479.40000,MedCost,Ultra,,511.36,,,,,,,511.36,647.19,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,MedCost,Ultra,,407.49,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Ultra,,742.40,,,,,,,742.40,939.60,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Ultra,,591.60,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,inpatient,,,1321.00000,792.60000,MedCost,Ultra,,845.44,,,,,,,845.44,1070.01,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,MedCost,Ultra,,673.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Ultra,,742.40,,,,,,,742.40,939.60,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Ultra,,591.60,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,inpatient,,,1611.00000,966.60000,MedCost,Ultra,,1031.04,,,,,,,1031.04,1304.91,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,MedCost,Ultra,,821.61,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,inpatient,,,1271.00000,762.60000,MedCost,Ultra,,813.44,,,,,,,813.44,1029.51,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,MedCost,Ultra,,648.21,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,inpatient,,,923.00000,553.80000,MedCost,Ultra,,590.72,,,,,,,590.72,747.63,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,MedCost,Ultra,,470.73,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,inpatient,,,2341.00000,1404.60000,MedCost,Ultra,,1498.24,,,,,,,1498.24,1896.21,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,MedCost,Ultra,,1193.91,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,inpatient,,,2943.00000,1765.80000,MedCost,Ultra,,1883.52,,,,,,,1883.52,2383.83,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,MedCost,Ultra,,1500.93,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,inpatient,,,277.00000,166.20000,MedCost,Ultra,,177.28,,,,,,,83.38,225.20,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,MedCost,Ultra,,141.27,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,15.35,41.46,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Ultra,,63.36,,,,,,,29.80,80.49,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Ultra,,50.49,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,inpatient,,,2030.00000,1218.00000,MedCost,Ultra,,1299.20,,,,,,,611.03,1650.39,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,MedCost,Ultra,,1035.30,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,inpatient,,,988.00000,592.80000,MedCost,Ultra,,632.32,,,,,,,297.39,803.24,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,MedCost,Ultra,,503.88,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,32.21,86.99,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,inpatient,,,208.00000,124.80000,MedCost,Ultra,,133.12,,,,,,,62.61,169.10,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,MedCost,Ultra,,106.08,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,56.59,152.84,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,inpatient,,,2794.00000,1676.40000,MedCost,Ultra,,1788.16,,,,,,,840.99,2271.52,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,MedCost,Ultra,,1424.94,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,inpatient,,,12493.00000,7495.80000,MedCost,Ultra,,7995.52,,,,,,,3760.39,10156.81,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,MedCost,Ultra,,6371.43,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,inpatient,,,1643.00000,985.80000,MedCost,Ultra,,1051.52,,,,,,,1051.52,1330.83,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,MedCost,Ultra,,837.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Ultra,,332.16,,,,,,,332.16,420.39,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Ultra,,264.69,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,inpatient,,,2033.00000,1219.80000,MedCost,Ultra,,1301.12,,,,,,,1301.12,1646.73,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,MedCost,Ultra,,1036.83,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,inpatient,,,470.00000,282.00000,MedCost,Ultra,,300.80,,,,,,,300.80,380.70,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,MedCost,Ultra,,239.70,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,inpatient,,,12371.00000,7422.60000,MedCost,Ultra,,7917.44,,,,,,,3723.67,10057.62,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,MedCost,Ultra,,6309.21,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Ultra,,433.28,,,,,,,433.28,548.37,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Ultra,,345.27,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,inpatient,,,1.01000,0.61000,MedCost,Ultra,,0.64640,,,,,,,0.64640,0.81810,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,MedCost,Ultra,,0.51510,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,inpatient,,,87.00000,52.20000,MedCost,Ultra,,55.68,,,,,,,26.19,70.73,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,MedCost,Ultra,,44.37,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,inpatient,,,878.00000,526.80000,MedCost,Ultra,,561.92,,,,,,,264.28,713.81,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,MedCost,Ultra,,447.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,inpatient,,,119.00000,71.40000,MedCost,Ultra,,76.16,,,,,,,35.82,96.75,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,MedCost,Ultra,,60.69,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,inpatient,,,584.00000,350.40000,MedCost,Ultra,,373.76,,,,,,,175.78,474.79,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,MedCost,Ultra,,297.84,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Ultra,,206.72,,,,,,,97.22,262.60,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Ultra,,164.73,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,inpatient,,,44.00000,26.40000,MedCost,Ultra,,28.16,,,,,,,13.24,35.77,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,MedCost,Ultra,,22.44,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,inpatient,,,5280.00000,3168.00000,MedCost,Ultra,,3379.20,,,,,,,1589.28,4292.64,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,MedCost,Ultra,,2692.80,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,inpatient,,,6.00000,3.60000,MedCost,Ultra,,3.84,,,,,,,1.81,4.88,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,MedCost,Ultra,,3.06,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,inpatient,,,649.00000,389.40000,MedCost,Ultra,,415.36,,,,,,,195.35,527.64,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,MedCost,Ultra,,330.99,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Ultra,,78.08,,,,,,,36.72,99.19,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Ultra,,62.22,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Ultra,,26.88,,,,,,,12.64,34.15,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Ultra,,21.42,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,inpatient,,,82.00000,49.20000,MedCost,Ultra,,52.48,,,,,,,24.68,66.67,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,MedCost,Ultra,,41.82,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,inpatient,,,254.00000,152.40000,MedCost,Ultra,,162.56,,,,,,,76.45,206.50,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,MedCost,Ultra,,129.54,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,23.18,62.60,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,inpatient,,,6058.00000,3634.80000,MedCost,Ultra,,3877.12,,,,,,,1823.46,4925.15,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,MedCost,Ultra,,3089.58,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,inpatient,,,183.00000,109.80000,MedCost,Ultra,,117.12,,,,,,,55.08,148.78,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,MedCost,Ultra,,93.33,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,inpatient,,,1075.00000,645.00000,MedCost,Ultra,,688.00,,,,,,,688.00,870.75,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,MedCost,Ultra,,548.25,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Ultra,,195.20,,,,,,,91.81,247.97,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Ultra,,155.55,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,inpatient,,,1428.00000,856.80000,MedCost,Ultra,,913.92,,,,,,,913.92,1156.68,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,MedCost,Ultra,,728.28,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Ultra,,195.20,,,,,,,91.81,247.97,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Ultra,,155.55,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,inpatient,,,2016.00000,1209.60000,MedCost,Ultra,,1290.24,,,,,,,1290.24,1632.96,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,MedCost,Ultra,,1028.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,inpatient,,,2016.00000,1209.60000,MedCost,Ultra,,1290.24,,,,,,,1290.24,1632.96,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,MedCost,Ultra,,1028.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,inpatient,,,1343.00000,805.80000,MedCost,Ultra,,859.52,,,,,,,404.24,1091.86,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,MedCost,Ultra,,684.93,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,inpatient,,,487.00000,292.20000,MedCost,Ultra,,311.68,,,,,,,146.59,395.93,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,MedCost,Ultra,,248.37,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,inpatient,,,435.00000,261.00000,MedCost,Ultra,,278.40,,,,,,,278.40,352.35,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,MedCost,Ultra,,221.85,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,inpatient,,,2240.00000,1344.00000,MedCost,Ultra,,1433.60,,,,,,,1433.60,1814.40,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,MedCost,Ultra,,1142.40,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,inpatient,,,1605.00000,963.00000,MedCost,Ultra,,1027.20,,,,,,,1027.20,1300.05,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,MedCost,Ultra,,818.55,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,inpatient,,,3344.00000,2006.40000,MedCost,Ultra,,2140.16,,,,,,,2140.16,2708.64,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,MedCost,Ultra,,1705.44,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,inpatient,,,3344.00000,2006.40000,MedCost,Ultra,,2140.16,,,,,,,2140.16,2708.64,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,MedCost,Ultra,,1705.44,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,inpatient,,,3344.00000,2006.40000,MedCost,Ultra,,2140.16,,,,,,,2140.16,2708.64,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,MedCost,Ultra,,1705.44,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,inpatient,,,1309.00000,785.40000,MedCost,Ultra,,837.76,,,,,,,394.01,1064.22,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,MedCost,Ultra,,667.59,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,inpatient,,,1929.00000,1157.40000,MedCost,Ultra,,1234.56,,,,,,,580.63,1568.28,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,MedCost,Ultra,,983.79,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,inpatient,,,1069.00000,641.40000,MedCost,Ultra,,684.16,,,,,,,321.77,869.10,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,MedCost,Ultra,,545.19,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,inpatient,,,1908.00000,1144.80000,MedCost,Ultra,,1221.12,,,,,,,574.31,1551.20,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,MedCost,Ultra,,973.08,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,inpatient,,,1230.00000,738.00000,MedCost,Ultra,,787.20,,,,,,,370.23,999.99,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,MedCost,Ultra,,627.30,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,inpatient,,,4018.00000,2410.80000,MedCost,Ultra,,2571.52,,,,,,,2571.52,3254.58,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,MedCost,Ultra,,2049.18,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,inpatient,,,3310.00000,1986.00000,MedCost,Ultra,,2118.40,,,,,,,2118.40,2681.10,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,MedCost,Ultra,,1688.10,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,inpatient,,,4142.00000,2485.20000,MedCost,Ultra,,2650.88,,,,,,,2650.88,3355.02,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,MedCost,Ultra,,2112.42,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,inpatient,,,4142.00000,2485.20000,MedCost,Ultra,,2650.88,,,,,,,2650.88,3355.02,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,MedCost,Ultra,,2112.42,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,inpatient,,,4062.00000,2437.20000,MedCost,Ultra,,2599.68,,,,,,,2599.68,3290.22,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,MedCost,Ultra,,2071.62,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,inpatient,,,1033.00000,619.80000,MedCost,Ultra,,661.12,,,,,,,661.12,836.73,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,MedCost,Ultra,,526.83,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,inpatient,,,1126.00000,675.60000,MedCost,Ultra,,720.64,,,,,,,720.64,912.06,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,MedCost,Ultra,,574.26,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Ultra,,207.36,,,,,,,207.36,262.44,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Ultra,,165.24,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,inpatient,,,2537.00000,1522.20000,MedCost,Ultra,,1623.68,,,,,,,1623.68,2054.97,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,MedCost,Ultra,,1293.87,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,inpatient,,,1289.00000,773.40000,MedCost,Ultra,,824.96,,,,,,,824.96,1044.09,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,MedCost,Ultra,,657.39,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,inpatient,,,1138.00000,682.80000,MedCost,Ultra,,728.32,,,,,,,728.32,921.78,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,MedCost,Ultra,,580.38,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,inpatient,,,1269.00000,761.40000,MedCost,Ultra,,812.16,,,,,,,812.16,1027.89,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,MedCost,Ultra,,647.19,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,inpatient,,,2261.00000,1356.60000,MedCost,Ultra,,1447.04,,,,,,,1447.04,1831.41,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,MedCost,Ultra,,1153.11,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,inpatient,,,2668.00000,1600.80000,MedCost,Ultra,,1707.52,,,,,,,1707.52,2161.08,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,MedCost,Ultra,,1360.68,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,inpatient,,,3264.00000,1958.40000,MedCost,Ultra,,2088.96,,,,,,,2088.96,2643.84,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,MedCost,Ultra,,1664.64,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,inpatient,,,2450.00000,1470.00000,MedCost,Ultra,,1568.00,,,,,,,1568.00,1984.50,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,MedCost,Ultra,,1249.50,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,inpatient,,,2942.00000,1765.20000,MedCost,Ultra,,1882.88,,,,,,,1882.88,2383.02,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,MedCost,Ultra,,1500.42,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,inpatient,,,3282.00000,1969.20000,MedCost,Ultra,,2100.48,,,,,,,2100.48,2658.42,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,MedCost,Ultra,,1673.82,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,inpatient,,,2536.00000,1521.60000,MedCost,Ultra,,1623.04,,,,,,,1623.04,2054.16,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,MedCost,Ultra,,1293.36,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,inpatient,,,3096.00000,1857.60000,MedCost,Ultra,,1981.44,,,,,,,1981.44,2507.76,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,MedCost,Ultra,,1578.96,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,inpatient,,,3502.00000,2101.20000,MedCost,Ultra,,2241.28,,,,,,,2241.28,2836.62,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,MedCost,Ultra,,1786.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,inpatient,,,2584.00000,1550.40000,MedCost,Ultra,,1653.76,,,,,,,1653.76,2093.04,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,MedCost,Ultra,,1317.84,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,inpatient,,,3082.00000,1849.20000,MedCost,Ultra,,1972.48,,,,,,,1972.48,2496.42,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,MedCost,Ultra,,1571.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,inpatient,,,3512.00000,2107.20000,MedCost,Ultra,,2247.68,,,,,,,2247.68,2844.72,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,MedCost,Ultra,,1791.12,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,inpatient,,,4188.00000,2512.80000,MedCost,Ultra,,2680.32,,,,,,,2680.32,3392.28,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,MedCost,Ultra,,2135.88,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,inpatient,,,3971.00000,2382.60000,MedCost,Ultra,,2541.44,,,,,,,2541.44,3216.51,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,MedCost,Ultra,,2025.21,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,inpatient,,,2331.00000,1398.60000,MedCost,Ultra,,1491.84,,,,,,,1491.84,1888.11,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,MedCost,Ultra,,1188.81,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,inpatient,,,2925.00000,1755.00000,MedCost,Ultra,,1872.00,,,,,,,1872.00,2369.25,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,MedCost,Ultra,,1491.75,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,inpatient,,,3440.00000,2064.00000,MedCost,Ultra,,2201.60,,,,,,,2201.60,2786.40,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,MedCost,Ultra,,1754.40,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,inpatient,,,3874.00000,2324.40000,MedCost,Ultra,,2479.36,,,,,,,2479.36,3137.94,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,MedCost,Ultra,,1975.74,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,inpatient,,,2872.00000,1723.20000,MedCost,Ultra,,1838.08,,,,,,,1838.08,2326.32,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,MedCost,Ultra,,1464.72,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,inpatient,,,3618.00000,2170.80000,MedCost,Ultra,,2315.52,,,,,,,2315.52,2930.58,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,MedCost,Ultra,,1845.18,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,inpatient,,,3704.00000,2222.40000,MedCost,Ultra,,2370.56,,,,,,,2370.56,3000.24,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,MedCost,Ultra,,1889.04,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,inpatient,,,2242.00000,1345.20000,MedCost,Ultra,,1434.88,,,,,,,1434.88,1816.02,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,MedCost,Ultra,,1143.42,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,inpatient,,,2729.00000,1637.40000,MedCost,Ultra,,1746.56,,,,,,,1746.56,2210.49,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,MedCost,Ultra,,1391.79,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,inpatient,,,3184.00000,1910.40000,MedCost,Ultra,,2037.76,,,,,,,2037.76,2579.04,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,MedCost,Ultra,,1623.84,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,inpatient,,,2622.00000,1573.20000,MedCost,Ultra,,1678.08,,,,,,,1678.08,2123.82,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,MedCost,Ultra,,1337.22,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,inpatient,,,3189.00000,1913.40000,MedCost,Ultra,,2040.96,,,,,,,2040.96,2583.09,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,MedCost,Ultra,,1626.39,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,inpatient,,,3723.00000,2233.80000,MedCost,Ultra,,2382.72,,,,,,,2382.72,3015.63,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,MedCost,Ultra,,1898.73,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,inpatient,,,3018.00000,1810.80000,MedCost,Ultra,,1931.52,,,,,,,1931.52,2444.58,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,MedCost,Ultra,,1539.18,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,inpatient,,,2292.00000,1375.20000,MedCost,Ultra,,1466.88,,,,,,,1466.88,1856.52,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,MedCost,Ultra,,1168.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,inpatient,,,2865.00000,1719.00000,MedCost,Ultra,,1833.60,,,,,,,1833.60,2320.65,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,MedCost,Ultra,,1461.15,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,inpatient,,,3071.00000,1842.60000,MedCost,Ultra,,1965.44,,,,,,,1965.44,2487.51,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,MedCost,Ultra,,1566.21,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,inpatient,,,2934.00000,1760.40000,MedCost,Ultra,,1877.76,,,,,,,1877.76,2376.54,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,MedCost,Ultra,,1496.34,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,inpatient,,,4022.00000,2413.20000,MedCost,Ultra,,2574.08,,,,,,,2574.08,3257.82,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,MedCost,Ultra,,2051.22,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,inpatient,,,4343.00000,2605.80000,MedCost,Ultra,,2779.52,,,,,,,2779.52,3517.83,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,MedCost,Ultra,,2214.93,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,inpatient,,,3974.00000,2384.40000,MedCost,Ultra,,2543.36,,,,,,,2543.36,3218.94,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,MedCost,Ultra,,2026.74,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,inpatient,,,2511.00000,1506.60000,MedCost,Ultra,,1607.04,,,,,,,1607.04,2033.91,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,MedCost,Ultra,,1280.61,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,inpatient,,,3231.00000,1938.60000,MedCost,Ultra,,2067.84,,,,,,,2067.84,2617.11,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,MedCost,Ultra,,1647.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,inpatient,,,4235.00000,2541.00000,MedCost,Ultra,,2710.40,,,,,,,2710.40,3430.35,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,MedCost,Ultra,,2159.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,inpatient,,,4927.00000,2956.20000,MedCost,Ultra,,3153.28,,,,,,,3153.28,3990.87,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,MedCost,Ultra,,2512.77,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,inpatient,,,2494.00000,1496.40000,MedCost,Ultra,,1596.16,,,,,,,1596.16,2020.14,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,MedCost,Ultra,,1271.94,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,inpatient,,,3174.00000,1904.40000,MedCost,Ultra,,2031.36,,,,,,,2031.36,2570.94,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,MedCost,Ultra,,1618.74,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,inpatient,,,3758.00000,2254.80000,MedCost,Ultra,,2405.12,,,,,,,2405.12,3043.98,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,MedCost,Ultra,,1916.58,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,inpatient,,,7361.00000,4416.60000,MedCost,Ultra,,4711.04,,,,,,,4711.04,5962.41,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,MedCost,Ultra,,3754.11,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,inpatient,,,34463.00000,20677.80000,MedCost,Ultra,,22056.32,,,,,,,7039.00,27915.03,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,MedCost,Ultra,,17576.13,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,inpatient,,,5355.00000,3213.00000,MedCost,Ultra,,3427.20,,,,,,,3427.20,4337.55,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,MedCost,Ultra,,2731.05,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,inpatient,,,6379.00000,3827.40000,MedCost,Ultra,,4082.56,,,,,,,4082.56,5166.99,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,MedCost,Ultra,,3253.29,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,inpatient,,,7415.00000,4449.00000,MedCost,Ultra,,4745.60,,,,,,,4745.60,6006.15,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,MedCost,Ultra,,3781.65,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,inpatient,,,1309.00000,785.40000,MedCost,Ultra,,837.76,,,,,,,837.76,1060.29,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,MedCost,Ultra,,667.59,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,inpatient,,,4059.00000,2435.40000,MedCost,Ultra,,2597.76,,,,,,,2597.76,3287.79,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,MedCost,Ultra,,2070.09,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,inpatient,,,3971.00000,2382.60000,MedCost,Ultra,,2541.44,,,,,,,2541.44,3216.51,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,MedCost,Ultra,,2025.21,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,inpatient,,,4188.00000,2512.80000,MedCost,Ultra,,2680.32,,,,,,,2680.32,3392.28,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,MedCost,Ultra,,2135.88,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,inpatient,,,2925.00000,1755.00000,MedCost,Ultra,,1872.00,,,,,,,1872.00,2369.25,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,MedCost,Ultra,,1491.75,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,inpatient,,,2800.00000,1680.00000,MedCost,Ultra,,1792.00,,,,,,,1792.00,2268.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,MedCost,Ultra,,1428.00,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,inpatient,,,477.00000,286.20000,MedCost,Ultra,,305.28,,,,,,,305.28,386.37,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,MedCost,Ultra,,243.27,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,inpatient,,,1173.00000,703.80000,MedCost,Ultra,,750.72,,,,,,,750.72,950.13,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,MedCost,Ultra,,598.23,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,inpatient,,,1332.00000,799.20000,MedCost,Ultra,,852.48,,,,,,,852.48,1078.92,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,MedCost,Ultra,,679.32,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,inpatient,,,1332.00000,799.20000,MedCost,Ultra,,852.48,,,,,,,852.48,1078.92,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,MedCost,Ultra,,679.32,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,inpatient,,,1450.00000,870.00000,MedCost,Ultra,,928.00,,,,,,,928.00,1174.50,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,MedCost,Ultra,,739.50,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,inpatient,,,1764.00000,1058.40000,MedCost,Ultra,,1128.96,,,,,,,1128.96,1428.84,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,MedCost,Ultra,,899.64,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,inpatient,,,1764.00000,1058.40000,MedCost,Ultra,,1128.96,,,,,,,1128.96,1428.84,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,MedCost,Ultra,,899.64,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,inpatient,,,1901.00000,1140.60000,MedCost,Ultra,,1216.64,,,,,,,1216.64,1539.81,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,MedCost,Ultra,,969.51,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Ultra,,304.00,,,,,,,304.00,384.75,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Ultra,,242.25,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,inpatient,,,337.00000,202.20000,MedCost,Ultra,,215.68,,,,,,,215.68,7039.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,MedCost,Ultra,,171.87,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,inpatient,,,34463.00000,20677.80000,MedCost,Ultra,,22056.32,,,,,,,7039.00,27915.03,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,MedCost,Ultra,,17576.13,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,inpatient,,,34463.00000,20677.80000,MedCost,Ultra,,22056.32,,,,,,,7039.00,27915.03,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,MedCost,Ultra,,17576.13,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,inpatient,,,31466.00000,18879.60000,MedCost,Ultra,,20138.24,,,,,,,7039.00,25487.46,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,MedCost,Ultra,,16047.66,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,inpatient,,,269.00000,161.40000,MedCost,Ultra,,172.16,,,,,,,172.16,7039.00,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,MedCost,Ultra,,137.19,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,inpatient,,,728.00000,436.80000,MedCost,Ultra,,465.92,,,,,,,465.92,7039.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,MedCost,Ultra,,371.28,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Ultra,,402.56,,,,,,,402.56,7039.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Ultra,,320.79,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,inpatient,,,1993.00000,1195.80000,MedCost,Ultra,,1275.52,,,,,,,1275.52,7039.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,MedCost,Ultra,,1016.43,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,inpatient,,,5105.00000,3063.00000,MedCost,Ultra,,3267.20,,,,,,,3267.20,7039.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,MedCost,Ultra,,2603.55,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,inpatient,,,543.00000,325.80000,MedCost,Ultra,,347.52,,,,,,,347.52,7039.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,MedCost,Ultra,,276.93,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,inpatient,,,1387.00000,832.20000,MedCost,Ultra,,887.68,,,,,,,887.68,7039.00,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,MedCost,Ultra,,707.37,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,inpatient,,,880.00000,528.00000,MedCost,Ultra,,563.20,,,,,,,563.20,7039.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,MedCost,Ultra,,448.80,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,inpatient,,,57551.00000,34530.60000,MedCost,Ultra,,36832.64,,,,,,,7039.00,46616.31,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,MedCost,Ultra,,29351.01,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,inpatient,,,4857.00000,2914.20000,MedCost,Ultra,,3108.48,,,,,,,3108.48,7039.00,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,MedCost,Ultra,,2477.07,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,inpatient,,,4857.00000,2914.20000,MedCost,Ultra,,3108.48,,,,,,,3108.48,7039.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,MedCost,Ultra,,2477.07,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,inpatient,,,29535.00000,17721.00000,MedCost,Ultra,,18902.40,,,,,,,7039.00,23923.35,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,MedCost,Ultra,,15062.85,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,inpatient,,,1110.00000,666.00000,MedCost,Ultra,,710.40,,,,,,,710.40,7039.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,MedCost,Ultra,,566.10,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,inpatient,,,2999.00000,1799.40000,MedCost,Ultra,,1919.36,,,,,,,1919.36,7039.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,MedCost,Ultra,,1529.49,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,inpatient,,,155.00000,93.00000,MedCost,Ultra,,99.20,,,,,,,99.20,7039.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,MedCost,Ultra,,79.05,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,inpatient,,,155.00000,93.00000,MedCost,Ultra,,99.20,,,,,,,99.20,126.02,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,MedCost,Ultra,,79.05,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,inpatient,,,421.00000,252.60000,MedCost,Ultra,,269.44,,,,,,,269.44,7039.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,MedCost,Ultra,,214.71,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,inpatient,,,2921.00000,1752.60000,MedCost,Ultra,,1869.44,,,,,,,1869.44,7039.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,MedCost,Ultra,,1489.71,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Ultra,,402.56,,,,,,,402.56,7039.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Ultra,,320.79,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,inpatient,,,456.00000,273.60000,MedCost,Ultra,,291.84,,,,,,,291.84,7039.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,MedCost,Ultra,,232.56,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,inpatient,,,232.00000,139.20000,MedCost,Ultra,,148.48,,,,,,,148.48,7039.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,MedCost,Ultra,,118.32,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Ultra,,128.64,,,,,,,128.64,7039.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Ultra,,102.51,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Ultra,,307.84,,,,,,,307.84,7039.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Ultra,,245.31,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,inpatient,,,1109.00000,665.40000,MedCost,Ultra,,709.76,,,,,,,709.76,7039.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,MedCost,Ultra,,565.59,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Ultra,,293.12,,,,,,,293.12,7039.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Ultra,,233.58,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,inpatient,,,285.00000,171.00000,MedCost,Ultra,,182.40,,,,,,,182.40,7039.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,MedCost,Ultra,,145.35,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,7039.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,inpatient,,,1400.00000,840.00000,MedCost,Ultra,,896.00,,,,,,,896.00,7039.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,MedCost,Ultra,,714.00,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,inpatient,,,1582.00000,949.20000,MedCost,Ultra,,1012.48,,,,,,,1012.48,7039.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,MedCost,Ultra,,806.82,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,inpatient,,,1582.00000,949.20000,MedCost,Ultra,,1012.48,,,,,,,1012.48,1286.17,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,MedCost,Ultra,,806.82,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,inpatient,,,2330.00000,1398.00000,MedCost,Ultra,,1491.20,,,,,,,1491.20,7039.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,MedCost,Ultra,,1188.30,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,inpatient,,,2330.00000,1398.00000,MedCost,Ultra,,1491.20,,,,,,,1491.20,1894.29,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,MedCost,Ultra,,1188.30,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,inpatient,,,311.00000,186.60000,MedCost,Ultra,,199.04,,,,,,,199.04,7039.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,MedCost,Ultra,,158.61,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,inpatient,,,311.00000,186.60000,MedCost,Ultra,,199.04,,,,,,,199.04,7039.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,MedCost,Ultra,,158.61,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Ultra,,514.56,,,,,,,514.56,7039.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Ultra,,410.04,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Ultra,,514.56,,,,,,,514.56,653.65,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Ultra,,410.04,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,inpatient,,,722.00000,433.20000,MedCost,Ultra,,462.08,,,,,,,462.08,586.99,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,MedCost,Ultra,,368.22,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,inpatient,,,577.00000,346.20000,MedCost,Ultra,,369.28,,,,,,,369.28,7039.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,MedCost,Ultra,,294.27,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,inpatient,,,577.00000,346.20000,MedCost,Ultra,,369.28,,,,,,,369.28,469.10,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,MedCost,Ultra,,294.27,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,inpatient,,,4720.00000,2832.00000,MedCost,Ultra,,3020.80,,,,,,,3020.80,7039.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,MedCost,Ultra,,2407.20,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,inpatient,,,3377.00000,2026.20000,MedCost,Ultra,,2161.28,,,,,,,2161.28,7039.00,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,MedCost,Ultra,,1722.27,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,inpatient,,,712.00000,427.20000,MedCost,Ultra,,455.68,,,,,,,455.68,7039.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,MedCost,Ultra,,363.12,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,inpatient,,,565.00000,339.00000,MedCost,Ultra,,361.60,,,,,,,361.60,7039.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,MedCost,Ultra,,288.15,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,inpatient,,,1414.00000,848.40000,MedCost,Ultra,,904.96,,,,,,,904.96,7039.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,MedCost,Ultra,,721.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,inpatient,,,765.00000,459.00000,MedCost,Ultra,,489.60,,,,,,,489.60,7039.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,MedCost,Ultra,,390.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,inpatient,,,1292.00000,775.20000,MedCost,Ultra,,826.88,,,,,,,826.88,7039.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,MedCost,Ultra,,658.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,inpatient,,,581.00000,348.60000,MedCost,Ultra,,371.84,,,,,,,371.84,7039.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,MedCost,Ultra,,296.31,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,inpatient,,,1275.00000,765.00000,MedCost,Ultra,,816.00,,,,,,,816.00,7039.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,MedCost,Ultra,,650.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,inpatient,,,1275.00000,765.00000,MedCost,Ultra,,816.00,,,,,,,816.00,1036.58,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,MedCost,Ultra,,650.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,inpatient,,,1168.00000,700.80000,MedCost,Ultra,,747.52,,,,,,,747.52,7039.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,MedCost,Ultra,,595.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,inpatient,,,3019.00000,1811.40000,MedCost,Ultra,,1932.16,,,,,,,1932.16,7039.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,MedCost,Ultra,,1539.69,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,inpatient,,,3019.00000,1811.40000,MedCost,Ultra,,1932.16,,,,,,,1932.16,7039.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,MedCost,Ultra,,1539.69,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,inpatient,,,300.00000,180.00000,MedCost,Ultra,,192.00,,,,,,,192.00,7039.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,MedCost,Ultra,,153.00,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,inpatient,,,1943.00000,1165.80000,MedCost,Ultra,,1243.52,,,,,,,1243.52,7039.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,MedCost,Ultra,,990.93,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,inpatient,,,1464.00000,878.40000,MedCost,Ultra,,936.96,,,,,,,936.96,7039.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,MedCost,Ultra,,746.64,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,inpatient,,,834.00000,500.40000,MedCost,Ultra,,533.76,,,,,,,533.76,7039.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,MedCost,Ultra,,425.34,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,inpatient,,,1623.00000,973.80000,MedCost,Ultra,,1038.72,,,,,,,1038.72,7039.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,MedCost,Ultra,,827.73,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,inpatient,,,1770.00000,1062.00000,MedCost,Ultra,,1132.80,,,,,,,1132.80,7039.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,MedCost,Ultra,,902.70,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,MedCost,Ultra,,1157.76,,,,,,,1157.76,7039.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,MedCost,Ultra,,922.59,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,MedCost,Ultra,,1157.76,,,,,,,1157.76,7039.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,MedCost,Ultra,,922.59,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,inpatient,,,2105.00000,1263.00000,MedCost,Ultra,,1347.20,,,,,,,1347.20,7039.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,MedCost,Ultra,,1073.55,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,inpatient,,,2105.00000,1263.00000,MedCost,Ultra,,1347.20,,,,,,,1347.20,7039.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,MedCost,Ultra,,1073.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Ultra,,433.28,,,,,,,433.28,7039.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Ultra,,345.27,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,inpatient,,,677.00000,406.20000,MedCost,Ultra,,433.28,,,,,,,433.28,7039.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,MedCost,Ultra,,345.27,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Ultra,,332.16,,,,,,,332.16,7039.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Ultra,,264.69,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,inpatient,,,684.00000,410.40000,MedCost,Ultra,,437.76,,,,,,,437.76,7039.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,MedCost,Ultra,,348.84,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,inpatient,,,684.00000,410.40000,MedCost,Ultra,,437.76,,,,,,,437.76,7039.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,MedCost,Ultra,,348.84,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,inpatient,,,2691.00000,1614.60000,MedCost,Ultra,,1722.24,,,,,,,1722.24,7039.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,MedCost,Ultra,,1372.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,inpatient,,,2756.00000,1653.60000,MedCost,Ultra,,1763.84,,,,,,,1763.84,7039.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,MedCost,Ultra,,1405.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,inpatient,,,2756.00000,1653.60000,MedCost,Ultra,,1763.84,,,,,,,1763.84,7039.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,MedCost,Ultra,,1405.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,inpatient,,,1594.00000,956.40000,MedCost,Ultra,,1020.16,,,,,,,1020.16,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,MedCost,Ultra,,812.94,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,inpatient,,,1594.00000,956.40000,MedCost,Ultra,,1020.16,,,,,,,1020.16,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,MedCost,Ultra,,812.94,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,inpatient,,,916.00000,549.60000,MedCost,Ultra,,586.24,,,,,,,586.24,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,MedCost,Ultra,,467.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,inpatient,,,916.00000,549.60000,MedCost,Ultra,,586.24,,,,,,,586.24,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,MedCost,Ultra,,467.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,inpatient,,,1130.00000,678.00000,MedCost,Ultra,,723.20,,,,,,,723.20,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,MedCost,Ultra,,576.30,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,inpatient,,,1130.00000,678.00000,MedCost,Ultra,,723.20,,,,,,,723.20,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,MedCost,Ultra,,576.30,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,inpatient,,,1153.00000,691.80000,MedCost,Ultra,,737.92,,,,,,,737.92,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,MedCost,Ultra,,588.03,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,inpatient,,,1153.00000,691.80000,MedCost,Ultra,,737.92,,,,,,,737.92,7039.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,MedCost,Ultra,,588.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,inpatient,,,5059.00000,3035.40000,MedCost,Ultra,,3237.76,,,,,,,3237.76,7039.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,MedCost,Ultra,,2580.09,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,inpatient,,,4925.00000,2955.00000,MedCost,Ultra,,3152.00,,,,,,,3152.00,4004.03,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,MedCost,Ultra,,2511.75,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,inpatient,,,795.00000,477.00000,MedCost,Ultra,,508.80,,,,,,,508.80,7039.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,MedCost,Ultra,,405.45,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,inpatient,,,725.00000,435.00000,MedCost,Ultra,,464.00,,,,,,,464.00,7039.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,MedCost,Ultra,,369.75,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,inpatient,,,818.00000,490.80000,MedCost,Ultra,,523.52,,,,,,,523.52,7039.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,MedCost,Ultra,,417.18,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,inpatient,,,742.00000,445.20000,MedCost,Ultra,,474.88,,,,,,,474.88,7039.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,MedCost,Ultra,,378.42,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,inpatient,,,2247.00000,1348.20000,MedCost,Ultra,,1438.08,,,,,,,1438.08,7039.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,MedCost,Ultra,,1145.97,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,inpatient,,,742.00000,445.20000,MedCost,Ultra,,474.88,,,,,,,474.88,7039.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,MedCost,Ultra,,378.42,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,inpatient,,,3723.00000,2233.80000,MedCost,Ultra,,2382.72,,,,,,,2382.72,7039.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,MedCost,Ultra,,1898.73,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,inpatient,,,886.00000,531.60000,MedCost,Ultra,,567.04,,,,,,,567.04,7039.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,MedCost,Ultra,,451.86,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,inpatient,,,686.00000,411.60000,MedCost,Ultra,,439.04,,,,,,,439.04,7039.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,MedCost,Ultra,,349.86,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Ultra,,124.80,,,,,,,124.80,7039.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Ultra,,99.45,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,inpatient,,,533.00000,319.80000,MedCost,Ultra,,341.12,,,,,,,341.12,7039.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,MedCost,Ultra,,271.83,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,inpatient,,,555.00000,333.00000,MedCost,Ultra,,355.20,,,,,,,355.20,7039.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,MedCost,Ultra,,283.05,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,inpatient,,,590.00000,354.00000,MedCost,Ultra,,377.60,,,,,,,377.60,7039.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,MedCost,Ultra,,300.90,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,inpatient,,,583.00000,349.80000,MedCost,Ultra,,373.12,,,,,,,373.12,7039.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,MedCost,Ultra,,297.33,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,inpatient,,,665.00000,399.00000,MedCost,Ultra,,425.60,,,,,,,425.60,7039.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,MedCost,Ultra,,339.15,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,inpatient,,,4163.00000,2497.80000,MedCost,Ultra,,2664.32,,,,,,,2664.32,7039.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,MedCost,Ultra,,2123.13,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,inpatient,,,2128.00000,1276.80000,MedCost,Ultra,,1361.92,,,,,,,1361.92,7039.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,MedCost,Ultra,,1085.28,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,inpatient,,,1343.00000,805.80000,MedCost,Ultra,,859.52,,,,,,,859.52,7039.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,MedCost,Ultra,,684.93,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,inpatient,,,1464.00000,878.40000,MedCost,Ultra,,936.96,,,,,,,936.96,7039.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,MedCost,Ultra,,746.64,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,inpatient,,,694.00000,416.40000,MedCost,Ultra,,444.16,,,,,,,444.16,7039.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,MedCost,Ultra,,353.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,inpatient,,,587.00000,352.20000,MedCost,Ultra,,375.68,,,,,,,375.68,7039.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,MedCost,Ultra,,299.37,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,inpatient,,,606.00000,363.60000,MedCost,Ultra,,387.84,,,,,,,387.84,7039.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,MedCost,Ultra,,309.06,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,inpatient,,,884.00000,530.40000,MedCost,Ultra,,565.76,,,,,,,565.76,7039.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,MedCost,Ultra,,450.84,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,inpatient,,,884.00000,530.40000,MedCost,Ultra,,565.76,,,,,,,565.76,718.69,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,MedCost,Ultra,,450.84,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,inpatient,,,14058.00000,8434.80000,MedCost,Ultra,,8997.12,,,,,,,7039.00,11386.98,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,MedCost,Ultra,,7169.58,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,inpatient,,,14058.00000,8434.80000,MedCost,Ultra,,8997.12,,,,,,,7039.00,11386.98,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,MedCost,Ultra,,7169.58,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,inpatient,,,14058.00000,8434.80000,MedCost,Ultra,,8997.12,,,,,,,7039.00,11386.98,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,MedCost,Ultra,,7169.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,inpatient,,,6186.00000,3711.60000,MedCost,Ultra,,3959.04,,,,,,,3959.04,7039.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,MedCost,Ultra,,3154.86,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Ultra,,6728.96,,,,,,,6728.96,8516.34,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Ultra,,5362.14,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Ultra,,6728.96,,,,,,,6728.96,8516.34,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Ultra,,5362.14,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Ultra,,6728.96,,,,,,,6728.96,8516.34,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Ultra,,5362.14,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,inpatient,,,10514.00000,6308.40000,MedCost,Ultra,,6728.96,,,,,,,6728.96,8516.34,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,MedCost,Ultra,,5362.14,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,inpatient,,,11452.00000,6871.20000,MedCost,Ultra,,7329.28,,,,,,,7039.00,9276.12,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,MedCost,Ultra,,5840.52,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,inpatient,,,11452.00000,6871.20000,MedCost,Ultra,,7329.28,,,,,,,7039.00,9276.12,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,MedCost,Ultra,,5840.52,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,inpatient,,,7673.00000,4603.80000,MedCost,Ultra,,4910.72,,,,,,,4910.72,7039.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,MedCost,Ultra,,3913.23,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,inpatient,,,7902.00000,4741.20000,MedCost,Ultra,,5057.28,,,,,,,5057.28,7039.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,MedCost,Ultra,,4030.02,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,inpatient,,,7902.00000,4741.20000,MedCost,Ultra,,5057.28,,,,,,,5057.28,7039.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,MedCost,Ultra,,4030.02,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,inpatient,,,4800.00000,2880.00000,MedCost,Ultra,,3072.00,,,,,,,3072.00,7039.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,MedCost,Ultra,,2448.00,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,inpatient,,,4471.00000,2682.60000,MedCost,Ultra,,2861.44,,,,,,,2861.44,7039.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,MedCost,Ultra,,2280.21,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,inpatient,,,6062.00000,3637.20000,MedCost,Ultra,,3879.68,,,,,,,3879.68,7039.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,MedCost,Ultra,,3091.62,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,inpatient,,,6062.00000,3637.20000,MedCost,Ultra,,3879.68,,,,,,,3879.68,7039.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,MedCost,Ultra,,3091.62,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,inpatient,,,6062.00000,3637.20000,MedCost,Ultra,,3879.68,,,,,,,3879.68,7039.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,MedCost,Ultra,,3091.62,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,inpatient,,,4394.00000,2636.40000,MedCost,Ultra,,2812.16,,,,,,,2812.16,7039.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,MedCost,Ultra,,2240.94,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,inpatient,,,2417.00000,1450.20000,MedCost,Ultra,,1546.88,,,,,,,1546.88,7039.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,MedCost,Ultra,,1232.67,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,inpatient,,,2475.00000,1485.00000,MedCost,Ultra,,1584.00,,,,,,,1584.00,7039.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,MedCost,Ultra,,1262.25,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,inpatient,,,1613.00000,967.80000,MedCost,Ultra,,1032.32,,,,,,,1032.32,7039.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,MedCost,Ultra,,822.63,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,inpatient,,,792.00000,475.20000,MedCost,Ultra,,506.88,,,,,,,506.88,7039.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,MedCost,Ultra,,403.92,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1583.36,,,,,,,1583.36,7039.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1261.74,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,inpatient,,,379.00000,227.40000,MedCost,Ultra,,242.56,,,,,,,242.56,7039.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,MedCost,Ultra,,193.29,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,inpatient,,,482.00000,289.20000,MedCost,Ultra,,308.48,,,,,,,308.48,7039.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,MedCost,Ultra,,245.82,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,inpatient,,,282.00000,169.20000,MedCost,Ultra,,180.48,,,,,,,180.48,7039.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,MedCost,Ultra,,143.82,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,inpatient,,,542.00000,325.20000,MedCost,Ultra,,346.88,,,,,,,346.88,7039.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,MedCost,Ultra,,276.42,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,inpatient,,,5294.00000,3176.40000,MedCost,Ultra,,3388.16,,,,,,,3388.16,7039.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,MedCost,Ultra,,2699.94,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,inpatient,,,1277.00000,766.20000,MedCost,Ultra,,817.28,,,,,,,817.28,7039.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,MedCost,Ultra,,651.27,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,inpatient,,,7494.00000,4496.40000,MedCost,Ultra,,4796.16,,,,,,,4796.16,7039.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,MedCost,Ultra,,3821.94,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,inpatient,,,395.00000,237.00000,MedCost,Ultra,,252.80,,,,,,,252.80,7039.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,MedCost,Ultra,,201.45,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,inpatient,,,1640.00000,984.00000,MedCost,Ultra,,1049.60,,,,,,,1049.60,7039.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,MedCost,Ultra,,836.40,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,inpatient,,,1640.00000,984.00000,MedCost,Ultra,,1049.60,,,,,,,1049.60,1333.32,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,MedCost,Ultra,,836.40,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,inpatient,,,2136.00000,1281.60000,MedCost,Ultra,,1367.04,,,,,,,1367.04,7039.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,MedCost,Ultra,,1089.36,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,inpatient,,,911.00000,546.60000,MedCost,Ultra,,583.04,,,,,,,583.04,740.64,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,MedCost,Ultra,,464.61,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,inpatient,,,3077.00000,1846.20000,MedCost,Ultra,,1969.28,,,,,,,1969.28,7039.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,MedCost,Ultra,,1569.27,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,inpatient,,,2239.00000,1343.40000,MedCost,Ultra,,1432.96,,,,,,,1432.96,7039.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,MedCost,Ultra,,1141.89,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Ultra,,342.40,,,,,,,342.40,7039.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Ultra,,272.85,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,inpatient,,,1016.00000,609.60000,MedCost,Ultra,,650.24,,,,,,,650.24,7039.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,MedCost,Ultra,,518.16,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,inpatient,,,3854.00000,2312.40000,MedCost,Ultra,,2466.56,,,,,,,2466.56,7039.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,MedCost,Ultra,,1965.54,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,inpatient,,,642.00000,385.20000,MedCost,Ultra,,410.88,,,,,,,410.88,7039.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,MedCost,Ultra,,327.42,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,inpatient,,,802.00000,481.20000,MedCost,Ultra,,513.28,,,,,,,513.28,7039.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,MedCost,Ultra,,409.02,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,inpatient,,,642.00000,385.20000,MedCost,Ultra,,410.88,,,,,,,410.88,7039.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,MedCost,Ultra,,327.42,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,inpatient,,,695.00000,417.00000,MedCost,Ultra,,444.80,,,,,,,444.80,7039.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,MedCost,Ultra,,354.45,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,inpatient,,,5294.00000,3176.40000,MedCost,Ultra,,3388.16,,,,,,,3388.16,7039.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,MedCost,Ultra,,2699.94,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,inpatient,,,2378.00000,1426.80000,MedCost,Ultra,,1521.92,,,,,,,1521.92,7039.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,MedCost,Ultra,,1212.78,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,inpatient,,,2502.00000,1501.20000,MedCost,Ultra,,1601.28,,,,,,,1601.28,7039.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,MedCost,Ultra,,1276.02,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,inpatient,,,2478.00000,1486.80000,MedCost,Ultra,,1585.92,,,,,,,1585.92,7039.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,MedCost,Ultra,,1263.78,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,inpatient,,,636.00000,381.60000,MedCost,Ultra,,407.04,,,,,,,407.04,7039.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,MedCost,Ultra,,324.36,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Ultra,,742.40,,,,,,,742.40,7039.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Ultra,,591.60,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,inpatient,,,175.00000,105.00000,MedCost,Ultra,,112.00,,,,,,,112.00,7039.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,MedCost,Ultra,,89.25,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,inpatient,,,6291.00000,3774.60000,MedCost,Ultra,,4026.24,,,,,,,4026.24,7039.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,MedCost,Ultra,,3208.41,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,inpatient,,,7767.00000,4660.20000,MedCost,Ultra,,4970.88,,,,,,,4970.88,7039.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,MedCost,Ultra,,3961.17,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,7039.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,inpatient,,,2491.00000,1494.60000,MedCost,Ultra,,1594.24,,,,,,,1594.24,7039.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,MedCost,Ultra,,1270.41,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Ultra,,188.16,,,,,,,188.16,7039.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Ultra,,149.94,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,inpatient,,,231.00000,138.60000,MedCost,Ultra,,147.84,,,,,,,147.84,7039.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,MedCost,Ultra,,117.81,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,inpatient,,,208.00000,124.80000,MedCost,Ultra,,133.12,,,,,,,133.12,169.10,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,MedCost,Ultra,,106.08,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,inpatient,,,404.00000,242.40000,MedCost,Ultra,,258.56,,,,,,,258.56,7039.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,MedCost,Ultra,,206.04,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,inpatient,,,408.00000,244.80000,MedCost,Ultra,,261.12,,,,,,,261.12,7039.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,MedCost,Ultra,,208.08,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1583.36,,,,,,,1583.36,7039.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1261.74,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Ultra,,129.28,,,,,,,129.28,7039.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Ultra,,103.02,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,inpatient,,,1592.00000,955.20000,MedCost,Ultra,,1018.88,,,,,,,1018.88,7039.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,MedCost,Ultra,,811.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,inpatient,,,4497.00000,2698.20000,MedCost,Ultra,,2878.08,,,,,,,2878.08,7039.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,MedCost,Ultra,,2293.47,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,inpatient,,,4234.00000,2540.40000,MedCost,Ultra,,2709.76,,,,,,,2709.76,7039.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,MedCost,Ultra,,2159.34,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,inpatient,,,2921.00000,1752.60000,MedCost,Ultra,,1869.44,,,,,,,1869.44,7039.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,MedCost,Ultra,,1489.71,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,inpatient,,,4574.00000,2744.40000,MedCost,Ultra,,2927.36,,,,,,,2927.36,7039.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,MedCost,Ultra,,2332.74,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,inpatient,,,1055.00000,633.00000,MedCost,Ultra,,675.20,,,,,,,675.20,7039.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,MedCost,Ultra,,538.05,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,inpatient,,,1055.00000,633.00000,MedCost,Ultra,,675.20,,,,,,,675.20,857.72,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,MedCost,Ultra,,538.05,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,inpatient,,,1471.00000,882.60000,MedCost,Ultra,,941.44,,,,,,,941.44,7039.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,MedCost,Ultra,,750.21,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Ultra,,184.32,,,,,,,184.32,7039.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Ultra,,146.88,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Ultra,,184.32,,,,,,,184.32,234.14,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Ultra,,146.88,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,inpatient,,,1918.00000,1150.80000,MedCost,Ultra,,1227.52,,,,,,,1227.52,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,MedCost,Ultra,,978.18,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,inpatient,,,1918.00000,1150.80000,MedCost,Ultra,,1227.52,,,,,,,1227.52,1559.33,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,MedCost,Ultra,,978.18,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,inpatient,,,1173.00000,703.80000,MedCost,Ultra,,750.72,,,,,,,750.72,953.65,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,MedCost,Ultra,,598.23,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,inpatient,,,2511.00000,1506.60000,MedCost,Ultra,,1607.04,,,,,,,1607.04,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,MedCost,Ultra,,1280.61,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,inpatient,,,2511.00000,1506.60000,MedCost,Ultra,,1607.04,,,,,,,1607.04,2041.44,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,MedCost,Ultra,,1280.61,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,inpatient,,,2034.00000,1220.40000,MedCost,Ultra,,1301.76,,,,,,,1301.76,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,MedCost,Ultra,,1037.34,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,inpatient,,,2034.00000,1220.40000,MedCost,Ultra,,1301.76,,,,,,,1301.76,1653.64,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,MedCost,Ultra,,1037.34,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,inpatient,,,1738.00000,1042.80000,MedCost,Ultra,,1112.32,,,,,,,1112.32,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,MedCost,Ultra,,886.38,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,inpatient,,,1738.00000,1042.80000,MedCost,Ultra,,1112.32,,,,,,,1112.32,1412.99,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,MedCost,Ultra,,886.38,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,inpatient,,,1583.00000,949.80000,MedCost,Ultra,,1013.12,,,,,,,1013.12,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,MedCost,Ultra,,807.33,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,inpatient,,,1583.00000,949.80000,MedCost,Ultra,,1013.12,,,,,,,1013.12,1286.98,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,MedCost,Ultra,,807.33,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,inpatient,,,1646.00000,987.60000,MedCost,Ultra,,1053.44,,,,,,,1053.44,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,MedCost,Ultra,,839.46,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,inpatient,,,1646.00000,987.60000,MedCost,Ultra,,1053.44,,,,,,,1053.44,1338.20,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,MedCost,Ultra,,839.46,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,inpatient,,,1710.00000,1026.00000,MedCost,Ultra,,1094.40,,,,,,,1094.40,1390.23,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,MedCost,Ultra,,872.10,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,inpatient,,,1515.00000,909.00000,MedCost,Ultra,,969.60,,,,,,,969.60,7039.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,MedCost,Ultra,,772.65,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,inpatient,,,1515.00000,909.00000,MedCost,Ultra,,969.60,,,,,,,969.60,1231.69,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,MedCost,Ultra,,772.65,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,inpatient,,,1509.00000,905.40000,MedCost,Ultra,,965.76,,,,,,,965.76,7039.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,MedCost,Ultra,,769.59,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,inpatient,,,1509.00000,905.40000,MedCost,Ultra,,965.76,,,,,,,965.76,1226.82,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,MedCost,Ultra,,769.59,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,inpatient,,,3322.00000,1993.20000,MedCost,Ultra,,2126.08,,,,,,,2126.08,7039.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,MedCost,Ultra,,1694.22,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,inpatient,,,3322.00000,1993.20000,MedCost,Ultra,,2126.08,,,,,,,2126.08,2700.79,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,MedCost,Ultra,,1694.22,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,inpatient,,,1860.00000,1116.00000,MedCost,Ultra,,1190.40,,,,,,,1190.40,7039.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,MedCost,Ultra,,948.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,inpatient,,,1860.00000,1116.00000,MedCost,Ultra,,1190.40,,,,,,,1190.40,1512.18,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,MedCost,Ultra,,948.60,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,inpatient,,,1818.00000,1090.80000,MedCost,Ultra,,1163.52,,,,,,,1163.52,7039.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,MedCost,Ultra,,927.18,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,inpatient,,,1818.00000,1090.80000,MedCost,Ultra,,1163.52,,,,,,,1163.52,1478.03,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,MedCost,Ultra,,927.18,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,inpatient,,,2306.00000,1383.60000,MedCost,Ultra,,1475.84,,,,,,,1475.84,7039.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,MedCost,Ultra,,1176.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,inpatient,,,368.00000,220.80000,MedCost,Ultra,,235.52,,,,,,,235.52,7039.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,MedCost,Ultra,,187.68,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,inpatient,,,4857.00000,2914.20000,MedCost,Ultra,,3108.48,,,,,,,3108.48,3948.74,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,MedCost,Ultra,,2477.07,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,inpatient,,,220.00000,132.00000,MedCost,Ultra,,140.80,,,,,,,140.80,7039.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,MedCost,Ultra,,112.20,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,inpatient,,,2841.00000,1704.60000,MedCost,Ultra,,1818.24,,,,,,,1818.24,7039.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,MedCost,Ultra,,1448.91,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,inpatient,,,2990.00000,1794.00000,MedCost,Ultra,,1913.60,,,,,,,1913.60,7039.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,MedCost,Ultra,,1524.90,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,inpatient,,,20137.00000,12082.20000,MedCost,Ultra,,12887.68,,,,,,,7039.00,16310.97,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,MedCost,Ultra,,10269.87,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,inpatient,,,10706.00000,6423.60000,MedCost,Ultra,,6851.84,,,,,,,6851.84,8671.86,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,MedCost,Ultra,,5460.06,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Ultra,,332.16,,,,,,,332.16,7039.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Ultra,,264.69,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,inpatient,,,1168.00000,700.80000,MedCost,Ultra,,747.52,,,,,,,747.52,7039.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,MedCost,Ultra,,595.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,inpatient,,,1074.00000,644.40000,MedCost,Ultra,,687.36,,,,,,,687.36,7039.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,MedCost,Ultra,,547.74,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,inpatient,,,693.00000,415.80000,MedCost,Ultra,,443.52,,,,,,,443.52,7039.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,MedCost,Ultra,,353.43,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,inpatient,,,776.00000,465.60000,MedCost,Ultra,,496.64,,,,,,,496.64,7039.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,MedCost,Ultra,,395.76,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,inpatient,,,5458.00000,3274.80000,MedCost,Ultra,,3493.12,,,,,,,3493.12,7039.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,MedCost,Ultra,,2783.58,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,inpatient,,,3712.00000,2227.20000,MedCost,Ultra,,2375.68,,,,,,,2375.68,7039.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,MedCost,Ultra,,1893.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,inpatient,,,4719.00000,2831.40000,MedCost,Ultra,,3020.16,,,,,,,3020.16,7039.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,MedCost,Ultra,,2406.69,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,inpatient,,,3869.00000,2321.40000,MedCost,Ultra,,2476.16,,,,,,,2476.16,7039.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,MedCost,Ultra,,1973.19,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,inpatient,,,4864.00000,2918.40000,MedCost,Ultra,,3112.96,,,,,,,3112.96,7039.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,MedCost,Ultra,,2480.64,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,inpatient,,,3988.00000,2392.80000,MedCost,Ultra,,2552.32,,,,,,,2552.32,7039.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,MedCost,Ultra,,2033.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,inpatient,,,1688.00000,1012.80000,MedCost,Ultra,,1080.32,,,,,,,1080.32,7039.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,MedCost,Ultra,,860.88,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,inpatient,,,573.00000,343.80000,MedCost,Ultra,,366.72,,,,,,,366.72,7039.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,MedCost,Ultra,,292.23,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,inpatient,,,7462.00000,4477.20000,MedCost,Ultra,,4775.68,,,,,,,4775.68,7039.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,MedCost,Ultra,,3805.62,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,inpatient,,,1990.00000,1194.00000,MedCost,Ultra,,1273.60,,,,,,,1273.60,7039.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,MedCost,Ultra,,1014.90,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,inpatient,,,1492.00000,895.20000,MedCost,Ultra,,954.88,,,,,,,954.88,7039.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,MedCost,Ultra,,760.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,inpatient,,,2653.00000,1591.80000,MedCost,Ultra,,1697.92,,,,,,,1697.92,7039.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,MedCost,Ultra,,1353.03,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,inpatient,,,28766.00000,17259.60000,MedCost,Ultra,,18410.24,,,,,,,7039.00,23300.46,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,MedCost,Ultra,,14670.66,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,inpatient,,,4187.00000,2512.20000,MedCost,Ultra,,2679.68,,,,,,,2679.68,7039.00,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,MedCost,Ultra,,2135.37,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,inpatient,,,13279.00000,7967.40000,MedCost,Ultra,,8498.56,,,,,,,7039.00,10755.99,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,MedCost,Ultra,,6772.29,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,inpatient,,,8848.00000,5308.80000,MedCost,Ultra,,5662.72,,,,,,,5662.72,7166.88,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,MedCost,Ultra,,4512.48,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,inpatient,,,3479.00000,2087.40000,MedCost,Ultra,,2226.56,,,,,,,2226.56,7039.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,MedCost,Ultra,,1774.29,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,inpatient,,,1241.00000,744.60000,MedCost,Ultra,,794.24,,,,,,,794.24,7039.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,MedCost,Ultra,,632.91,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,inpatient,,,1696.00000,1017.60000,MedCost,Ultra,,1085.44,,,,,,,1085.44,7039.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,MedCost,Ultra,,864.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,inpatient,,,1696.00000,1017.60000,MedCost,Ultra,,1085.44,,,,,,,1085.44,1378.85,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,MedCost,Ultra,,864.96,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,inpatient,,,1876.00000,1125.60000,MedCost,Ultra,,1200.64,,,,,,,1200.64,7039.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,MedCost,Ultra,,956.76,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,inpatient,,,1876.00000,1125.60000,MedCost,Ultra,,1200.64,,,,,,,1200.64,1525.19,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,MedCost,Ultra,,956.76,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,inpatient,,,1732.00000,1039.20000,MedCost,Ultra,,1108.48,,,,,,,1108.48,7039.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,MedCost,Ultra,,883.32,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,inpatient,,,1732.00000,1039.20000,MedCost,Ultra,,1108.48,,,,,,,1108.48,1408.12,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,MedCost,Ultra,,883.32,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,inpatient,,,1289.00000,773.40000,MedCost,Ultra,,824.96,,,,,,,824.96,7039.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,MedCost,Ultra,,657.39,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,inpatient,,,733.00000,439.80000,MedCost,Ultra,,469.12,,,,,,,469.12,7039.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,MedCost,Ultra,,373.83,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,inpatient,,,1229.00000,737.40000,MedCost,Ultra,,786.56,,,,,,,786.56,7039.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,MedCost,Ultra,,626.79,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,inpatient,,,7165.00000,4299.00000,MedCost,Ultra,,4585.60,,,,,,,4585.60,7039.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,MedCost,Ultra,,3654.15,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,inpatient,,,1791.00000,1074.60000,MedCost,Ultra,,1146.24,,,,,,,1146.24,7039.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,MedCost,Ultra,,913.41,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,inpatient,,,1576.00000,945.60000,MedCost,Ultra,,1008.64,,,,,,,1008.64,7039.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,MedCost,Ultra,,803.76,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,inpatient,,,1854.00000,1112.40000,MedCost,Ultra,,1186.56,,,,,,,1186.56,7039.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,MedCost,Ultra,,945.54,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,inpatient,,,1046.00000,627.60000,MedCost,Ultra,,669.44,,,,,,,669.44,7039.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,MedCost,Ultra,,533.46,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,inpatient,,,3586.00000,2151.60000,MedCost,Ultra,,2295.04,,,,,,,2295.04,7039.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,MedCost,Ultra,,1828.86,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,inpatient,,,3586.00000,2151.60000,MedCost,Ultra,,2295.04,,,,,,,2295.04,7039.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,MedCost,Ultra,,1828.86,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1665.28,,,,,,,1665.28,7039.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1327.02,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1665.28,,,,,,,1665.28,7039.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1327.02,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1665.28,,,,,,,1665.28,7039.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1327.02,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,inpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1665.28,,,,,,,1665.28,7039.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,MedCost,Ultra,,1327.02,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,inpatient,,,3465.00000,2079.00000,MedCost,Ultra,,2217.60,,,,,,,2217.60,7039.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,MedCost,Ultra,,1767.15,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,inpatient,,,2980.00000,1788.00000,MedCost,Ultra,,1907.20,,,,,,,1907.20,7039.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,MedCost,Ultra,,1519.80,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,inpatient,,,6144.00000,3686.40000,MedCost,Ultra,,3932.16,,,,,,,3932.16,7039.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,MedCost,Ultra,,3133.44,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,inpatient,,,7144.00000,4286.40000,MedCost,Ultra,,4572.16,,,,,,,4572.16,7039.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,MedCost,Ultra,,3643.44,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,inpatient,,,5291.00000,3174.60000,MedCost,Ultra,,3386.24,,,,,,,3386.24,7039.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,MedCost,Ultra,,2698.41,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,inpatient,,,4767.00000,2860.20000,MedCost,Ultra,,3050.88,,,,,,,3050.88,7039.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,MedCost,Ultra,,2431.17,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,inpatient,,,1192.00000,715.20000,MedCost,Ultra,,762.88,,,,,,,762.88,7039.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,MedCost,Ultra,,607.92,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,inpatient,,,8038.00000,4822.80000,MedCost,Ultra,,5144.32,,,,,,,5144.32,7039.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,MedCost,Ultra,,4099.38,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,inpatient,,,8296.00000,4977.60000,MedCost,Ultra,,5309.44,,,,,,,5309.44,7039.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,MedCost,Ultra,,4230.96,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,inpatient,,,12470.00000,7482.00000,MedCost,Ultra,,7980.80,,,,,,,7039.00,10100.70,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,MedCost,Ultra,,6359.70,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,inpatient,,,6955.00000,4173.00000,MedCost,Ultra,,4451.20,,,,,,,4451.20,7039.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,MedCost,Ultra,,3547.05,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,inpatient,,,2658.00000,1594.80000,MedCost,Ultra,,1701.12,,,,,,,1701.12,7039.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,MedCost,Ultra,,1355.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,inpatient,,,1848.00000,1108.80000,MedCost,Ultra,,1182.72,,,,,,,1182.72,7039.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,MedCost,Ultra,,942.48,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,inpatient,,,891.00000,534.60000,MedCost,Ultra,,570.24,,,,,,,570.24,7039.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,MedCost,Ultra,,454.41,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,inpatient,,,1611.00000,966.60000,MedCost,Ultra,,1031.04,,,,,,,1031.04,7039.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,MedCost,Ultra,,821.61,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,inpatient,,,1191.00000,714.60000,MedCost,Ultra,,762.24,,,,,,,762.24,7039.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,MedCost,Ultra,,607.41,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,inpatient,,,3702.00000,2221.20000,MedCost,Ultra,,2369.28,,,,,,,2369.28,7039.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,MedCost,Ultra,,1888.02,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,inpatient,,,3251.00000,1950.60000,MedCost,Ultra,,2080.64,,,,,,,2080.64,7039.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,MedCost,Ultra,,1658.01,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,inpatient,,,3254.00000,1952.40000,MedCost,Ultra,,2082.56,,,,,,,2082.56,7039.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,MedCost,Ultra,,1659.54,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,inpatient,,,2805.00000,1683.00000,MedCost,Ultra,,1795.20,,,,,,,1795.20,7039.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,MedCost,Ultra,,1430.55,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,inpatient,,,2658.00000,1594.80000,MedCost,Ultra,,1701.12,,,,,,,1701.12,7039.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,MedCost,Ultra,,1355.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,inpatient,,,4769.00000,2861.40000,MedCost,Ultra,,3052.16,,,,,,,3052.16,7039.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,MedCost,Ultra,,2432.19,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,inpatient,,,5532.00000,3319.20000,MedCost,Ultra,,3540.48,,,,,,,3540.48,7039.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,MedCost,Ultra,,2821.32,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,inpatient,,,8107.00000,4864.20000,MedCost,Ultra,,5188.48,,,,,,,5188.48,7039.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,MedCost,Ultra,,4134.57,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,inpatient,,,751.00000,450.60000,MedCost,Ultra,,480.64,,,,,,,480.64,7039.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,MedCost,Ultra,,383.01,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,inpatient,,,10877.00000,6526.20000,MedCost,Ultra,,6961.28,,,,,,,6961.28,8810.37,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,MedCost,Ultra,,5547.27,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,inpatient,,,7831.00000,4698.60000,MedCost,Ultra,,5011.84,,,,,,,5011.84,7039.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,MedCost,Ultra,,3993.81,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,inpatient,,,3807.00000,2284.20000,MedCost,Ultra,,2436.48,,,,,,,2436.48,7039.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,MedCost,Ultra,,1941.57,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,inpatient,,,17121.00000,10272.60000,MedCost,Ultra,,10957.44,,,,,,,7039.00,13868.01,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,MedCost,Ultra,,8731.71,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,inpatient,,,7327.00000,4396.20000,MedCost,Ultra,,4689.28,,,,,,,4689.28,7039.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,MedCost,Ultra,,3736.77,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,inpatient,,,902.00000,541.20000,MedCost,Ultra,,577.28,,,,,,,577.28,7039.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,MedCost,Ultra,,460.02,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,inpatient,,,3481.00000,2088.60000,MedCost,Ultra,,2227.84,,,,,,,2227.84,7039.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,MedCost,Ultra,,1775.31,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,inpatient,,,3481.00000,2088.60000,MedCost,Ultra,,2227.84,,,,,,,2227.84,7039.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,MedCost,Ultra,,1775.31,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,inpatient,,,17238.00000,10342.80000,MedCost,Ultra,,11032.32,,,,,,,7039.00,13962.78,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,MedCost,Ultra,,8791.38,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,inpatient,,,16182.00000,9709.20000,MedCost,Ultra,,10356.48,,,,,,,7039.00,13107.42,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,MedCost,Ultra,,8252.82,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,inpatient,,,16182.00000,9709.20000,MedCost,Ultra,,10356.48,,,,,,,7039.00,13107.42,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,MedCost,Ultra,,8252.82,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,inpatient,,,8795.00000,5277.00000,MedCost,Ultra,,5628.80,,,,,,,5628.80,7123.95,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,MedCost,Ultra,,4485.45,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,inpatient,,,8795.00000,5277.00000,MedCost,Ultra,,5628.80,,,,,,,5628.80,7123.95,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,MedCost,Ultra,,4485.45,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,inpatient,,,9322.00000,5593.20000,MedCost,Ultra,,5966.08,,,,,,,5966.08,7550.82,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,MedCost,Ultra,,4754.22,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,inpatient,,,9322.00000,5593.20000,MedCost,Ultra,,5966.08,,,,,,,5966.08,7550.82,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,MedCost,Ultra,,4754.22,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,inpatient,,,12428.00000,7456.80000,MedCost,Ultra,,7953.92,,,,,,,7039.00,10066.68,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,MedCost,Ultra,,6338.28,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,inpatient,,,9035.00000,5421.00000,MedCost,Ultra,,5782.40,,,,,,,5782.40,7318.35,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,MedCost,Ultra,,4607.85,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,inpatient,,,2910.00000,1746.00000,MedCost,Ultra,,1862.40,,,,,,,1862.40,7039.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,MedCost,Ultra,,1484.10,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,inpatient,,,2368.00000,1420.80000,MedCost,Ultra,,1515.52,,,,,,,1515.52,7039.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,MedCost,Ultra,,1207.68,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,inpatient,,,2368.00000,1420.80000,MedCost,Ultra,,1515.52,,,,,,,1515.52,7039.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,MedCost,Ultra,,1207.68,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,inpatient,,,804.00000,482.40000,MedCost,Ultra,,514.56,,,,,,,514.56,7039.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,MedCost,Ultra,,410.04,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,inpatient,,,6560.00000,3936.00000,MedCost,Ultra,,4198.40,,,,,,,4198.40,7039.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,MedCost,Ultra,,3345.60,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,inpatient,,,1686.00000,1011.60000,MedCost,Ultra,,1079.04,,,,,,,1079.04,1370.72,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,MedCost,Ultra,,859.86,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,inpatient,,,2021.00000,1212.60000,MedCost,Ultra,,1293.44,,,,,,,1293.44,7039.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,MedCost,Ultra,,1030.71,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,inpatient,,,3211.00000,1926.60000,MedCost,Ultra,,2055.04,,,,,,,2055.04,7039.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,MedCost,Ultra,,1637.61,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,inpatient,,,487.00000,292.20000,MedCost,Ultra,,311.68,,,,,,,311.68,7039.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,MedCost,Ultra,,248.37,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1829.76,,,,,,,1829.76,7039.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1458.09,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1829.76,,,,,,,1829.76,7039.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1458.09,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Ultra,,139.52,,,,,,,139.52,7039.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Ultra,,111.18,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Ultra,,139.52,,,,,,,139.52,7039.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Ultra,,111.18,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,inpatient,,,9944.00000,5966.40000,MedCost,Ultra,,6364.16,,,,,,,6364.16,8054.64,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,MedCost,Ultra,,5071.44,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,inpatient,,,9944.00000,5966.40000,MedCost,Ultra,,6364.16,,,,,,,6364.16,8054.64,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,MedCost,Ultra,,5071.44,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,inpatient,,,4014.00000,2408.40000,MedCost,Ultra,,2568.96,,,,,,,2568.96,7039.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,MedCost,Ultra,,2047.14,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,inpatient,,,6092.00000,3655.20000,MedCost,Ultra,,3898.88,,,,,,,3898.88,7039.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,MedCost,Ultra,,3106.92,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,inpatient,,,3452.00000,2071.20000,MedCost,Ultra,,2209.28,,,,,,,2209.28,7039.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,MedCost,Ultra,,1760.52,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,inpatient,,,1809.00000,1085.40000,MedCost,Ultra,,1157.76,,,,,,,1157.76,7039.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,MedCost,Ultra,,922.59,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Ultra,,402.56,,,,,,,402.56,7039.00,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Ultra,,320.79,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1829.76,,,,,,,1829.76,7039.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1458.09,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,inpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1829.76,,,,,,,1829.76,7039.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,MedCost,Ultra,,1458.09,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,inpatient,,,4058.00000,2434.80000,MedCost,Ultra,,2597.12,,,,,,,2597.12,3286.98,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,MedCost,Ultra,,2069.58,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,inpatient,,,1959.00000,1175.40000,MedCost,Ultra,,1253.76,,,,,,,1253.76,7039.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,MedCost,Ultra,,999.09,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,inpatient,,,392.00000,235.20000,MedCost,Ultra,,250.88,,,,,,,250.88,317.52,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,MedCost,Ultra,,199.92,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,inpatient,,,459.00000,275.40000,MedCost,Ultra,,293.76,,,,,,,293.76,371.79,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,MedCost,Ultra,,234.09,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Ultra,,238.72,,,,,,,238.72,302.13,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Ultra,,190.23,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,inpatient,,,373.00000,223.80000,MedCost,Ultra,,238.72,,,,,,,238.72,302.13,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,MedCost,Ultra,,190.23,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,inpatient,,,392.00000,235.20000,MedCost,Ultra,,250.88,,,,,,,250.88,317.52,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,MedCost,Ultra,,199.92,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,inpatient,,,320.00000,192.00000,MedCost,Ultra,,204.80,,,,,,,204.80,259.20,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,MedCost,Ultra,,163.20,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,inpatient,,,894.00000,536.40000,MedCost,Ultra,,572.16,,,,,,,572.16,724.14,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,MedCost,Ultra,,455.94,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,inpatient,,,574.00000,344.40000,MedCost,Ultra,,367.36,,,,,,,367.36,464.94,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,MedCost,Ultra,,292.74,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,inpatient,,,1142.00000,685.20000,MedCost,Ultra,,730.88,,,,,,,730.88,925.02,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,MedCost,Ultra,,582.42,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,inpatient,,,936.00000,561.60000,MedCost,Ultra,,599.04,,,,,,,599.04,758.16,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,MedCost,Ultra,,477.36,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,inpatient,,,1058.00000,634.80000,MedCost,Ultra,,677.12,,,,,,,677.12,856.98,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,MedCost,Ultra,,539.58,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,inpatient,,,771.00000,462.60000,MedCost,Ultra,,493.44,,,,,,,493.44,624.51,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,MedCost,Ultra,,393.21,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,inpatient,,,837.00000,502.20000,MedCost,Ultra,,535.68,,,,,,,535.68,677.97,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,MedCost,Ultra,,426.87,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,inpatient,,,315.00000,189.00000,MedCost,Ultra,,201.60,,,,,,,201.60,255.15,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,MedCost,Ultra,,160.65,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,inpatient,,,758.00000,454.80000,MedCost,Ultra,,485.12,,,,,,,485.12,613.98,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,MedCost,Ultra,,386.58,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,inpatient,,,310.00000,186.00000,MedCost,Ultra,,198.40,,,,,,,198.40,251.10,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,MedCost,Ultra,,158.10,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,inpatient,,,825.00000,495.00000,MedCost,Ultra,,528.00,,,,,,,528.00,668.25,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,MedCost,Ultra,,420.75,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,inpatient,,,961.00000,576.60000,MedCost,Ultra,,615.04,,,,,,,615.04,778.41,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,MedCost,Ultra,,490.11,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Ultra,,332.16,,,,,,,332.16,420.39,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Ultra,,264.69,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,inpatient,,,637.00000,382.20000,MedCost,Ultra,,407.68,,,,,,,407.68,515.97,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,MedCost,Ultra,,324.87,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,inpatient,,,427.00000,256.20000,MedCost,Ultra,,273.28,,,,,,,273.28,345.87,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,MedCost,Ultra,,217.77,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,inpatient,,,835.00000,501.00000,MedCost,Ultra,,534.40,,,,,,,534.40,676.35,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,MedCost,Ultra,,425.85,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,inpatient,,,668.00000,400.80000,MedCost,Ultra,,427.52,,,,,,,427.52,541.08,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,MedCost,Ultra,,340.68,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Ultra,,344.96,,,,,,,344.96,436.59,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Ultra,,274.89,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,inpatient,,,658.00000,394.80000,MedCost,Ultra,,421.12,,,,,,,421.12,532.98,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,MedCost,Ultra,,335.58,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Ultra,,663.68,,,,,,,663.68,839.97,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Ultra,,528.87,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,inpatient,,,823.00000,493.80000,MedCost,Ultra,,526.72,,,,,,,526.72,666.63,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,MedCost,Ultra,,419.73,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,inpatient,,,919.00000,551.40000,MedCost,Ultra,,588.16,,,,,,,588.16,744.39,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,MedCost,Ultra,,468.69,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,inpatient,,,301.00000,180.60000,MedCost,Ultra,,192.64,,,,,,,192.64,243.81,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,MedCost,Ultra,,153.51,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,inpatient,,,1178.00000,706.80000,MedCost,Ultra,,753.92,,,,,,,753.92,954.18,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,MedCost,Ultra,,600.78,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,inpatient,,,764.00000,458.40000,MedCost,Ultra,,488.96,,,,,,,488.96,618.84,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,MedCost,Ultra,,389.64,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,inpatient,,,250.00000,150.00000,MedCost,Ultra,,160.00,,,,,,,160.00,202.50,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,MedCost,Ultra,,127.50,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,inpatient,,,231.00000,138.60000,MedCost,Ultra,,147.84,,,,,,,147.84,187.11,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,MedCost,Ultra,,117.81,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Ultra,,119.04,,,,,,,119.04,150.66,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Ultra,,94.86,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,inpatient,,,1102.00000,661.20000,MedCost,Ultra,,705.28,,,,,,,705.28,892.62,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,MedCost,Ultra,,562.02,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,inpatient,,,825.00000,495.00000,MedCost,Ultra,,528.00,,,,,,,528.00,668.25,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,MedCost,Ultra,,420.75,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,inpatient,,,199.00000,119.40000,MedCost,Ultra,,127.36,,,,,,,127.36,161.19,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,MedCost,Ultra,,101.49,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,inpatient,,,684.00000,410.40000,MedCost,Ultra,,437.76,,,,,,,437.76,554.04,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,MedCost,Ultra,,348.84,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Ultra,,270.08,,,,,,,270.08,341.82,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Ultra,,215.22,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,inpatient,,,967.00000,580.20000,MedCost,Ultra,,618.88,,,,,,,618.88,783.27,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,MedCost,Ultra,,493.17,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,inpatient,,,724.00000,434.40000,MedCost,Ultra,,463.36,,,,,,,463.36,586.44,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,MedCost,Ultra,,369.24,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,inpatient,,,413.00000,247.80000,MedCost,Ultra,,264.32,,,,,,,264.32,334.53,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,MedCost,Ultra,,210.63,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,inpatient,,,492.00000,295.20000,MedCost,Ultra,,314.88,,,,,,,314.88,398.52,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,MedCost,Ultra,,250.92,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,inpatient,,,459.00000,275.40000,MedCost,Ultra,,293.76,,,,,,,293.76,371.79,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,MedCost,Ultra,,234.09,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Ultra,,88.96,,,,,,,88.96,112.59,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Ultra,,70.89,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,inpatient,,,67.00000,40.20000,MedCost,Ultra,,42.88,,,,,,,42.88,54.27,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,MedCost,Ultra,,34.17,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,inpatient,,,109.00000,65.40000,MedCost,Ultra,,69.76,,,,,,,69.76,88.29,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,MedCost,Ultra,,55.59,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,inpatient,,,6386.00000,3831.60000,MedCost,Ultra,,4087.04,,,,,,,4087.04,5172.66,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,MedCost,Ultra,,3256.86,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,inpatient,,,4654.00000,2792.40000,MedCost,Ultra,,2978.56,,,,,,,2978.56,3769.74,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,MedCost,Ultra,,2373.54,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,inpatient,,,4182.00000,2509.20000,MedCost,Ultra,,2676.48,,,,,,,2676.48,3387.42,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,MedCost,Ultra,,2132.82,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,inpatient,,,6491.00000,3894.60000,MedCost,Ultra,,4154.24,,,,,,,4154.24,5257.71,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,MedCost,Ultra,,3310.41,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,inpatient,,,6150.00000,3690.00000,MedCost,Ultra,,3936.00,,,,,,,3936.00,4981.50,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,MedCost,Ultra,,3136.50,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,inpatient,,,2688.00000,1612.80000,MedCost,Ultra,,1720.32,,,,,,,1720.32,2177.28,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,MedCost,Ultra,,1370.88,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,inpatient,,,6150.00000,3690.00000,MedCost,Ultra,,3936.00,,,,,,,3936.00,4981.50,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,MedCost,Ultra,,3136.50,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,inpatient,,,6150.00000,3690.00000,MedCost,Ultra,,3936.00,,,,,,,3936.00,4981.50,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,MedCost,Ultra,,3136.50,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,inpatient,,,931.00000,558.60000,MedCost,Ultra,,595.84,,,,,,,595.84,754.11,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,MedCost,Ultra,,474.81,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,inpatient,,,1531.00000,918.60000,MedCost,Ultra,,979.84,,,,,,,979.84,1240.11,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,MedCost,Ultra,,780.81,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,inpatient,,,3061.00000,1836.60000,MedCost,Ultra,,1959.04,,,,,,,1959.04,2479.41,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,MedCost,Ultra,,1561.11,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,inpatient,,,4660.00000,2796.00000,MedCost,Ultra,,2982.40,,,,,,,2982.40,3774.60,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,MedCost,Ultra,,2376.60,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,inpatient,,,4176.00000,2505.60000,MedCost,Ultra,,2672.64,,,,,,,2672.64,3382.56,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,MedCost,Ultra,,2129.76,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,inpatient,,,6052.00000,3631.20000,MedCost,Ultra,,3873.28,,,,,,,3873.28,4902.12,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,MedCost,Ultra,,3086.52,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,inpatient,,,8896.00000,5337.60000,MedCost,Ultra,,5693.44,,,,,,,5693.44,7205.76,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,MedCost,Ultra,,4536.96,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,inpatient,,,527.00000,316.20000,MedCost,Ultra,,337.28,,,,,,,337.28,426.87,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,MedCost,Ultra,,268.77,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,inpatient,,,899.00000,539.40000,MedCost,Ultra,,575.36,,,,,,,575.36,728.19,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,MedCost,Ultra,,458.49,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,inpatient,,,571.00000,342.60000,MedCost,Ultra,,365.44,,,,,,,365.44,462.51,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,MedCost,Ultra,,291.21,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,inpatient,,,1012.00000,607.20000,MedCost,Ultra,,647.68,,,,,,,647.68,819.72,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,MedCost,Ultra,,516.12,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,inpatient,,,2736.00000,1641.60000,MedCost,Ultra,,1751.04,,,,,,,1751.04,2216.16,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,MedCost,Ultra,,1395.36,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,inpatient,,,2469.00000,1481.40000,MedCost,Ultra,,1580.16,,,,,,,1580.16,1999.89,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,MedCost,Ultra,,1259.19,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,inpatient,,,481.00000,288.60000,MedCost,Ultra,,307.84,,,,,,,307.84,389.61,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,MedCost,Ultra,,245.31,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,inpatient,,,2813.00000,1687.80000,MedCost,Ultra,,1800.32,,,,,,,1800.32,2278.53,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,MedCost,Ultra,,1434.63,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,inpatient,,,3292.00000,1975.20000,MedCost,Ultra,,2106.88,,,,,,,2106.88,2666.52,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,MedCost,Ultra,,1678.92,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,inpatient,,,5069.00000,3041.40000,MedCost,Ultra,,3244.16,,,,,,,3244.16,4105.89,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,MedCost,Ultra,,2585.19,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,inpatient,,,6127.00000,3676.20000,MedCost,Ultra,,3921.28,,,,,,,3921.28,4962.87,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,MedCost,Ultra,,3124.77,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,inpatient,,,3459.00000,2075.40000,MedCost,Ultra,,2213.76,,,,,,,2213.76,2801.79,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,MedCost,Ultra,,1764.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,inpatient,,,5173.00000,3103.80000,MedCost,Ultra,,3310.72,,,,,,,3310.72,4190.13,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,MedCost,Ultra,,2638.23,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,inpatient,,,5388.00000,3232.80000,MedCost,Ultra,,3448.32,,,,,,,3448.32,4364.28,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,MedCost,Ultra,,2747.88,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,inpatient,,,3604.00000,2162.40000,MedCost,Ultra,,2306.56,,,,,,,2306.56,2919.24,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,MedCost,Ultra,,1838.04,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,inpatient,,,3765.00000,2259.00000,MedCost,Ultra,,2409.60,,,,,,,2409.60,3049.65,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,MedCost,Ultra,,1920.15,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,inpatient,,,5158.00000,3094.80000,MedCost,Ultra,,3301.12,,,,,,,3301.12,4177.98,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,MedCost,Ultra,,2630.58,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,inpatient,,,3472.00000,2083.20000,MedCost,Ultra,,2222.08,,,,,,,2222.08,2812.32,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,MedCost,Ultra,,1770.72,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,inpatient,,,4076.00000,2445.60000,MedCost,Ultra,,2608.64,,,,,,,2608.64,3301.56,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,MedCost,Ultra,,2078.76,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,inpatient,,,4699.00000,2819.40000,MedCost,Ultra,,3007.36,,,,,,,3007.36,3806.19,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,MedCost,Ultra,,2396.49,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,inpatient,,,3708.00000,2224.80000,MedCost,Ultra,,2373.12,,,,,,,2373.12,3003.48,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,MedCost,Ultra,,1891.08,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,inpatient,,,3892.00000,2335.20000,MedCost,Ultra,,2490.88,,,,,,,2490.88,3152.52,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,MedCost,Ultra,,1984.92,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,inpatient,,,5332.00000,3199.20000,MedCost,Ultra,,3412.48,,,,,,,3412.48,4318.92,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,MedCost,Ultra,,2719.32,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,inpatient,,,3675.00000,2205.00000,MedCost,Ultra,,2352.00,,,,,,,2352.00,2976.75,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,MedCost,Ultra,,1874.25,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,inpatient,,,3712.00000,2227.20000,MedCost,Ultra,,2375.68,,,,,,,2375.68,3006.72,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,MedCost,Ultra,,1893.12,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,inpatient,,,5158.00000,3094.80000,MedCost,Ultra,,3301.12,,,,,,,3301.12,4177.98,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,MedCost,Ultra,,2630.58,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,inpatient,,,4256.00000,2553.60000,MedCost,Ultra,,2723.84,,,,,,,2723.84,3447.36,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,MedCost,Ultra,,2170.56,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,inpatient,,,4501.00000,2700.60000,MedCost,Ultra,,2880.64,,,,,,,2880.64,3645.81,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,MedCost,Ultra,,2295.51,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,inpatient,,,5234.00000,3140.40000,MedCost,Ultra,,3349.76,,,,,,,3349.76,4239.54,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,MedCost,Ultra,,2669.34,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,inpatient,,,2919.00000,1751.40000,MedCost,Ultra,,1868.16,,,,,,,1868.16,2364.39,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,MedCost,Ultra,,1488.69,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,inpatient,,,4185.00000,2511.00000,MedCost,Ultra,,2678.40,,,,,,,2678.40,3389.85,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,MedCost,Ultra,,2134.35,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,inpatient,,,3172.00000,1903.20000,MedCost,Ultra,,2030.08,,,,,,,2030.08,2569.32,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,MedCost,Ultra,,1617.72,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Ultra,,161.92,,,,,,,161.92,204.93,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Ultra,,129.03,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,inpatient,,,3952.00000,2371.20000,MedCost,Ultra,52,2529.28,,,,,,,2529.28,3201.12,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,MedCost,Ultra,52,2015.52,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,inpatient,,,3933.00000,2359.80000,MedCost,Ultra,52,2517.12,,,,,,,2517.12,3185.73,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,MedCost,Ultra,52,2005.83,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,inpatient,,,3843.00000,2305.80000,MedCost,Ultra,,2459.52,,,,,,,2459.52,3112.83,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,MedCost,Ultra,,1959.93,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,inpatient,,,4405.00000,2643.00000,MedCost,Ultra,,2819.20,,,,,,,2819.20,3568.05,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,MedCost,Ultra,,2246.55,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,inpatient,,,5196.00000,3117.60000,MedCost,Ultra,,3325.44,,,,,,,3325.44,4208.76,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,MedCost,Ultra,,2649.96,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,inpatient,,,4024.00000,2414.40000,MedCost,Ultra,,2575.36,,,,,,,2575.36,3259.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,MedCost,Ultra,,2052.24,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,inpatient,,,4135.00000,2481.00000,MedCost,Ultra,,2646.40,,,,,,,2646.40,3349.35,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,MedCost,Ultra,,2108.85,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,inpatient,,,3516.00000,2109.60000,MedCost,Ultra,,2250.24,,,,,,,2250.24,2847.96,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,MedCost,Ultra,,1793.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,inpatient,,,4274.00000,2564.40000,MedCost,Ultra,,2735.36,,,,,,,2735.36,3461.94,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,MedCost,Ultra,,2179.74,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,inpatient,,,3523.00000,2113.80000,MedCost,Ultra,,2254.72,,,,,,,2254.72,2853.63,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,MedCost,Ultra,,1796.73,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,inpatient,,,4051.00000,2430.60000,MedCost,Ultra,,2592.64,,,,,,,2592.64,3281.31,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,MedCost,Ultra,,2066.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,inpatient,,,5104.00000,3062.40000,MedCost,Ultra,,3266.56,,,,,,,3266.56,4134.24,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,MedCost,Ultra,,2603.04,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,inpatient,,,4912.00000,2947.20000,MedCost,Ultra,,3143.68,,,,,,,3143.68,3978.72,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,MedCost,Ultra,,2505.12,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,inpatient,,,5454.00000,3272.40000,MedCost,Ultra,,3490.56,,,,,,,3490.56,4417.74,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,MedCost,Ultra,,2781.54,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,inpatient,,,4190.00000,2514.00000,MedCost,Ultra,,2681.60,,,,,,,2681.60,3393.90,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,MedCost,Ultra,,2136.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,inpatient,,,4637.00000,2782.20000,MedCost,Ultra,,2967.68,,,,,,,2967.68,3755.97,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,MedCost,Ultra,,2364.87,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,inpatient,,,5586.00000,3351.60000,MedCost,Ultra,,3575.04,,,,,,,3575.04,4524.66,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,MedCost,Ultra,,2848.86,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,inpatient,,,3468.00000,2080.80000,MedCost,Ultra,,2219.52,,,,,,,2219.52,2809.08,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,MedCost,Ultra,,1768.68,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,inpatient,,,3671.00000,2202.60000,MedCost,Ultra,,2349.44,,,,,,,2349.44,2973.51,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,MedCost,Ultra,,1872.21,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,inpatient,,,5340.00000,3204.00000,MedCost,Ultra,,3417.60,,,,,,,3417.60,4325.40,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,MedCost,Ultra,,2723.40,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,inpatient,,,3245.00000,1947.00000,MedCost,Ultra,,2076.80,,,,,,,2076.80,2628.45,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,MedCost,Ultra,,1654.95,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,inpatient,,,3599.00000,2159.40000,MedCost,Ultra,,2303.36,,,,,,,2303.36,2915.19,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,MedCost,Ultra,,1835.49,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,inpatient,,,4999.00000,2999.40000,MedCost,Ultra,,3199.36,,,,,,,3199.36,4049.19,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,MedCost,Ultra,,2549.49,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,inpatient,,,4225.00000,2535.00000,MedCost,Ultra,,2704.00,,,,,,,2704.00,3422.25,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,MedCost,Ultra,,2154.75,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,inpatient,,,3236.00000,1941.60000,MedCost,Ultra,,2071.04,,,,,,,2071.04,2621.16,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,MedCost,Ultra,,1650.36,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,inpatient,,,4472.00000,2683.20000,MedCost,Ultra,,2862.08,,,,,,,2862.08,3622.32,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,MedCost,Ultra,,2280.72,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,inpatient,,,4238.00000,2542.80000,MedCost,Ultra,,2712.32,,,,,,,2712.32,3432.78,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,MedCost,Ultra,,2161.38,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,inpatient,,,4238.00000,2542.80000,MedCost,Ultra,,2712.32,,,,,,,2712.32,3432.78,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,MedCost,Ultra,,2161.38,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,inpatient,,,4238.00000,2542.80000,MedCost,Ultra,,2712.32,,,,,,,2712.32,3432.78,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,MedCost,Ultra,,2161.38,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,inpatient,,,3535.00000,2121.00000,MedCost,Ultra,,2262.40,,,,,,,2262.40,2863.35,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,MedCost,Ultra,,1802.85,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,inpatient,,,4068.00000,2440.80000,MedCost,Ultra,,2603.52,,,,,,,2603.52,3295.08,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,MedCost,Ultra,,2074.68,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,inpatient,,,4068.00000,2440.80000,MedCost,Ultra,,2603.52,,,,,,,2603.52,3295.08,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,MedCost,Ultra,,2074.68,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,inpatient,,,4493.00000,2695.80000,MedCost,Ultra,,2875.52,,,,,,,2875.52,3639.33,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,MedCost,Ultra,,2291.43,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,inpatient,,,3250.00000,1950.00000,MedCost,Ultra,,2080.00,,,,,,,2080.00,2632.50,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,MedCost,Ultra,,1657.50,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,inpatient,,,4594.00000,2756.40000,MedCost,Ultra,,2940.16,,,,,,,2940.16,3721.14,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,MedCost,Ultra,,2342.94,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,inpatient,,,4466.00000,2679.60000,MedCost,Ultra,,2858.24,,,,,,,2858.24,3617.46,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,MedCost,Ultra,,2277.66,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,inpatient,,,4223.00000,2533.80000,MedCost,Ultra,,2702.72,,,,,,,2702.72,3420.63,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,MedCost,Ultra,,2153.73,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,inpatient,,,4223.00000,2533.80000,MedCost,Ultra,,2702.72,,,,,,,2702.72,3420.63,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,MedCost,Ultra,,2153.73,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,inpatient,,,4540.00000,2724.00000,MedCost,Ultra,,2905.60,,,,,,,2905.60,3677.40,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,MedCost,Ultra,,2315.40,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,inpatient,,,4540.00000,2724.00000,MedCost,Ultra,,2905.60,,,,,,,2905.60,3677.40,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,MedCost,Ultra,,2315.40,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,inpatient,,,4540.00000,2724.00000,MedCost,Ultra,,2905.60,,,,,,,2905.60,3677.40,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,MedCost,Ultra,,2315.40,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,inpatient,,,3523.00000,2113.80000,MedCost,Ultra,,2254.72,,,,,,,2254.72,2853.63,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,MedCost,Ultra,,1796.73,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,inpatient,,,1033.00000,619.80000,MedCost,Ultra,,661.12,,,,,,,661.12,836.73,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,MedCost,Ultra,,526.83,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,inpatient,,,2400.00000,1440.00000,MedCost,Ultra,,1536.00,,,,,,,1536.00,1944.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,MedCost,Ultra,,1224.00,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,inpatient,,,2385.00000,1431.00000,MedCost,Ultra,,1526.40,,,,,,,1526.40,1931.85,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,MedCost,Ultra,,1216.35,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,inpatient,,,3952.00000,2371.20000,MedCost,Ultra,,2529.28,,,,,,,2529.28,3201.12,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,MedCost,Ultra,,2015.52,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,inpatient,,,1875.00000,1125.00000,MedCost,Ultra,,1200.00,,,,,,,1200.00,1518.75,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,MedCost,Ultra,,956.25,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,inpatient,,,426.00000,255.60000,MedCost,Ultra,,272.64,,,,,,,272.64,345.06,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,MedCost,Ultra,,217.26,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Ultra,,207.36,,,,,,,207.36,262.44,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Ultra,,165.24,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Ultra,,255.36,,,,,,,255.36,323.19,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Ultra,,203.49,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,inpatient,,,1745.00000,1047.00000,MedCost,Ultra,,1116.80,,,,,,,1116.80,7039.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,MedCost,Ultra,,889.95,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,inpatient,,,1745.00000,1047.00000,MedCost,Ultra,,1116.80,,,,,,,1116.80,1418.68,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,MedCost,Ultra,,889.95,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Ultra,,101.12,,,,,,,101.12,128.45,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Ultra,,80.58,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,inpatient,,,1831.00000,1098.60000,MedCost,Ultra,,1171.84,,,,,,,1171.84,7039.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,MedCost,Ultra,,933.81,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,inpatient,,,1831.00000,1098.60000,MedCost,Ultra,,1171.84,,,,,,,1171.84,1488.60,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,MedCost,Ultra,,933.81,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,inpatient,,,905.00000,543.00000,MedCost,Ultra,,579.20,,,,,,,579.20,733.05,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,MedCost,Ultra,,461.55,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,inpatient,,,540.00000,324.00000,MedCost,Ultra,,345.60,,,,,,,345.60,437.40,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,MedCost,Ultra,,275.40,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Ultra,,304.00,,,,,,,304.00,384.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Ultra,,242.25,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,inpatient,,,475.00000,285.00000,MedCost,Ultra,,304.00,,,,,,,304.00,384.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,MedCost,Ultra,,242.25,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,inpatient,,,1299.00000,779.40000,MedCost,Ultra,,831.36,,,,,,,831.36,1052.19,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,MedCost,Ultra,,662.49,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,inpatient,,,1037.00000,622.20000,MedCost,Ultra,,663.68,,,,,,,663.68,839.97,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,MedCost,Ultra,,528.87,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,inpatient,,,847.00000,508.20000,MedCost,Ultra,,542.08,,,,,,,542.08,686.07,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,MedCost,Ultra,,431.97,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,inpatient,,,616.00000,369.60000,MedCost,Ultra,,394.24,,,,,,,394.24,498.96,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,MedCost,Ultra,,314.16,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,inpatient,,,599.00000,359.40000,MedCost,Ultra,,383.36,,,,,,,383.36,485.19,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,MedCost,Ultra,,305.49,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,inpatient,,,292.00000,175.20000,MedCost,Ultra,,186.88,,,,,,,186.88,236.52,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,MedCost,Ultra,,148.92,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,inpatient,,,431.00000,258.60000,MedCost,Ultra,,275.84,,,,,,,275.84,349.11,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,MedCost,Ultra,,219.81,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,inpatient,,,317.00000,190.20000,MedCost,Ultra,,202.88,,,,,,,202.88,256.77,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,MedCost,Ultra,,161.67,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Ultra,,184.32,,,,,,,184.32,233.28,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Ultra,,146.88,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,inpatient,,,680.00000,408.00000,MedCost,Ultra,,435.20,,,,,,,435.20,550.80,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,MedCost,Ultra,,346.80,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,inpatient,,,281.00000,168.60000,MedCost,Ultra,,179.84,,,,,,,179.84,227.61,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,MedCost,Ultra,,143.31,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Ultra,,372.48,,,,,,,372.48,471.42,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Ultra,,296.82,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,inpatient,,,582.00000,349.20000,MedCost,Ultra,,372.48,,,,,,,372.48,471.42,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,MedCost,Ultra,,296.82,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,inpatient,,,1436.00000,861.60000,MedCost,Ultra,,919.04,,,,,,,919.04,1163.16,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,MedCost,Ultra,,732.36,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,inpatient,,,752.00000,451.20000,MedCost,Ultra,,481.28,,,,,,,481.28,609.12,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,MedCost,Ultra,,383.52,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,inpatient,,,1866.00000,1119.60000,MedCost,Ultra,,1194.24,,,,,,,1194.24,1511.46,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,MedCost,Ultra,,951.66,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,inpatient,,,4350.00000,2610.00000,MedCost,Ultra,,2784.00,,,,,,,2784.00,3523.50,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,MedCost,Ultra,,2218.50,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,inpatient,,,252.00000,151.20000,MedCost,Ultra,,161.28,,,,,,,161.28,204.12,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,MedCost,Ultra,,128.52,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,inpatient,,,177.00000,106.20000,MedCost,Ultra,,113.28,,,,,,,113.28,143.37,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,MedCost,Ultra,,90.27,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,inpatient,,,369.00000,221.40000,MedCost,Ultra,,236.16,,,,,,,236.16,298.89,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,MedCost,Ultra,,188.19,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,inpatient,,,183.00000,109.80000,MedCost,Ultra,,117.12,,,,,,,117.12,148.23,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,MedCost,Ultra,,93.33,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,inpatient,,,427.00000,256.20000,MedCost,Ultra,,273.28,,,,,,,273.28,345.87,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,MedCost,Ultra,,217.77,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,inpatient,,,329.00000,197.40000,MedCost,Ultra,,210.56,,,,,,,210.56,266.49,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,MedCost,Ultra,,167.79,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Ultra,,176.00,,,,,,,176.00,222.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Ultra,,140.25,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,inpatient,,,399.00000,239.40000,MedCost,Ultra,,255.36,,,,,,,255.36,323.19,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,MedCost,Ultra,,203.49,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,inpatient,,,631.00000,378.60000,MedCost,Ultra,,403.84,,,,,,,403.84,511.11,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,MedCost,Ultra,,321.81,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Ultra,,331.52,,,,,,,331.52,419.58,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Ultra,,264.18,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,inpatient,,,874.00000,524.40000,MedCost,Ultra,,559.36,,,,,,,559.36,707.94,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,MedCost,Ultra,,445.74,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,inpatient,,,562.00000,337.20000,MedCost,Ultra,,359.68,,,,,,,359.68,455.22,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,MedCost,Ultra,,286.62,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Ultra,,36.48,,,,,,,36.48,46.17,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Ultra,,29.07,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,inpatient,,,362.00000,217.20000,MedCost,Ultra,,231.68,,,,,,,231.68,293.22,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,MedCost,Ultra,,184.62,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,inpatient,,,756.00000,453.60000,MedCost,Ultra,,483.84,,,,,,,483.84,612.36,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,MedCost,Ultra,,385.56,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,inpatient,,,305.00000,183.00000,MedCost,Ultra,,195.20,,,,,,,195.20,247.05,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,MedCost,Ultra,,155.55,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,inpatient,,,665.00000,399.00000,MedCost,Ultra,,425.60,,,,,,,425.60,538.65,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,MedCost,Ultra,,339.15,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Ultra,,270.08,,,,,,,270.08,341.82,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Ultra,,215.22,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,inpatient,,,956.00000,573.60000,MedCost,Ultra,,611.84,,,,,,,611.84,774.36,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,MedCost,Ultra,,487.56,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,inpatient,,,599.00000,359.40000,MedCost,Ultra,,383.36,,,,,,,383.36,485.19,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,MedCost,Ultra,,305.49,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Ultra,,270.08,,,,,,,270.08,341.82,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Ultra,,215.22,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,inpatient,,,458.00000,274.80000,MedCost,Ultra,,293.12,,,,,,,293.12,370.98,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,MedCost,Ultra,,233.58,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,inpatient,,,364.00000,218.40000,MedCost,Ultra,,232.96,,,,,,,232.96,294.84,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,MedCost,Ultra,,185.64,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,inpatient,,,2524.00000,1514.40000,MedCost,Ultra,,1615.36,,,,,,,1615.36,2044.44,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,MedCost,Ultra,,1287.24,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,inpatient,,,2169.00000,1301.40000,MedCost,Ultra,,1388.16,,,,,,,1388.16,1756.89,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,MedCost,Ultra,,1106.19,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,inpatient,,,1106.00000,663.60000,MedCost,Ultra,,707.84,,,,,,,707.84,895.86,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,MedCost,Ultra,,564.06,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,inpatient,,,521.00000,312.60000,MedCost,Ultra,,333.44,,,,,,,333.44,422.01,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,MedCost,Ultra,,265.71,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,inpatient,,,553.00000,331.80000,MedCost,Ultra,,353.92,,,,,,,353.92,447.93,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,MedCost,Ultra,,282.03,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,inpatient,,,336.00000,201.60000,MedCost,Ultra,,215.04,,,,,,,215.04,272.16,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,MedCost,Ultra,,171.36,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Ultra,,81.92,,,,,,,81.92,103.68,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Ultra,,65.28,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,inpatient,,,512.00000,307.20000,MedCost,Ultra,,327.68,,,,,,,327.68,414.72,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,MedCost,Ultra,,261.12,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,inpatient,,,404.00000,242.40000,MedCost,Ultra,,258.56,,,,,,,258.56,327.24,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,MedCost,Ultra,,206.04,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,inpatient,,,404.00000,242.40000,MedCost,Ultra,,258.56,,,,,,,258.56,327.24,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,MedCost,Ultra,,206.04,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,inpatient,,,2404.00000,1442.40000,MedCost,Ultra,,1538.56,,,,,,,1538.56,1947.24,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,MedCost,Ultra,,1226.04,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Ultra,,30.08,,,,,,,30.08,38.07,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Ultra,,23.97,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,inpatient,,,14.00000,8.40000,MedCost,Ultra,,8.96,,,,,,,8.96,11.34,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,MedCost,Ultra,,7.14,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,inpatient,,,112.00000,67.20000,MedCost,Ultra,,71.68,,,,,,,71.68,90.72,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,MedCost,Ultra,,57.12,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Ultra,,104.32,,,,,,,104.32,132.03,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Ultra,,83.13,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Ultra,,84.48,,,,,,,84.48,106.92,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Ultra,,67.32,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Ultra,,16.64,,,,,,,16.64,21.06,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Ultra,,13.26,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,inpatient,,,44.00000,26.40000,MedCost,Ultra,,28.16,,,,,,,28.16,35.64,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,MedCost,Ultra,,22.44,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Ultra,,120.96,,,,,,,120.96,153.09,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Ultra,,96.39,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,inpatient,,,265.00000,159.00000,MedCost,Ultra,,169.60,,,,,,,169.60,214.65,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,MedCost,Ultra,,135.15,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00640,0.00810,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,inpatient,,,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,56.32,71.28,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Ultra,,161.92,,,,,,,161.92,204.93,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Ultra,,129.03,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Ultra,,120.96,,,,,,,120.96,153.09,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Ultra,,96.39,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,inpatient,,,397.00000,238.20000,MedCost,Ultra,,254.08,,,,,,,254.08,321.57,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,MedCost,Ultra,,202.47,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,inpatient,,,155.00000,93.00000,MedCost,Ultra,,99.20,,,,,,,99.20,125.55,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,MedCost,Ultra,,79.05,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,inpatient,,,535.00000,321.00000,MedCost,Ultra,,342.40,,,,,,,342.40,433.35,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,MedCost,Ultra,,272.85,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Ultra,,45.44,,,,,,,45.44,57.51,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Ultra,,36.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Ultra,,85.12,,,,,,,85.12,107.73,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Ultra,,67.83,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Ultra,,85.12,,,,,,,85.12,107.73,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Ultra,,67.83,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,inpatient,,,133.00000,79.80000,MedCost,Ultra,,85.12,,,,,,,85.12,107.73,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,MedCost,Ultra,,67.83,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.03,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Ultra,,18.56,,,,,,,18.56,23.49,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Ultra,,14.79,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,inpatient,,,177.00000,106.20000,MedCost,Ultra,,113.28,,,,,,,113.28,143.37,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,MedCost,Ultra,,90.27,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,inpatient,,,124.00000,74.40000,MedCost,Ultra,,79.36,,,,,,,79.36,100.44,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,MedCost,Ultra,,63.24,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Ultra,,24.96,,,,,,,24.96,31.59,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Ultra,,19.89,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Ultra,,92.80,,,,,,,92.80,117.45,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Ultra,,73.95,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Ultra,,92.80,,,,,,,92.80,117.45,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Ultra,,73.95,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Ultra,,92.80,,,,,,,92.80,117.45,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Ultra,,73.95,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,72.90,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,72.90,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,72.90,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,inpatient,,,154.00000,92.40000,MedCost,Ultra,,98.56,,,,,,,98.56,124.74,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,MedCost,Ultra,,78.54,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Ultra,,18.56,,,,,,,18.56,23.49,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Ultra,,14.79,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Ultra,,27.52,,,,,,,27.52,34.83,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Ultra,,21.93,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Ultra,,26.88,,,,,,,26.88,34.02,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Ultra,,21.42,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.28,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Ultra,,30.72,,,,,,,30.72,38.88,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Ultra,,24.48,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Ultra,,103.68,,,,,,,103.68,131.22,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Ultra,,82.62,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Ultra,,73.60,,,,,,,73.60,93.15,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Ultra,,58.65,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Ultra,,73.60,,,,,,,73.60,93.15,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Ultra,,58.65,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Ultra,,73.60,,,,,,,73.60,93.15,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Ultra,,58.65,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.00,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Ultra,,26.88,,,,,,,26.88,34.02,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Ultra,,21.42,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,inpatient,,,60.00000,36.00000,MedCost,Ultra,,38.40,,,,,,,38.40,48.60,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,MedCost,Ultra,,30.60,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Ultra,,25.60,,,,,,,25.60,32.40,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Ultra,,20.40,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Ultra,,25.60,,,,,,,25.60,32.40,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Ultra,,20.40,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,inpatient,,,166.00000,99.60000,MedCost,Ultra,,106.24,,,,,,,106.24,134.46,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,MedCost,Ultra,,84.66,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,,45.39,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,,45.39,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Ultra,,42.24,,,,,,,42.24,53.46,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Ultra,,33.66,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,inpatient,,,53.00000,31.80000,MedCost,Ultra,,33.92,,,,,,,33.92,42.93,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,MedCost,Ultra,,27.03,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,inpatient,,,258.00000,154.80000,MedCost,Ultra,,165.12,,,,,,,165.12,208.98,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,MedCost,Ultra,,131.58,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.03,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Ultra,,42.24,,,,,,,42.24,53.46,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Ultra,,33.66,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,inpatient,,,243.00000,145.80000,MedCost,Ultra,,155.52,,,,,,,155.52,196.83,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,MedCost,Ultra,,123.93,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,72.90,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,72.90,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Ultra,,115.20,,,,,,,115.20,145.80,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Ultra,,91.80,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,inpatient,,,146.00000,87.60000,MedCost,Ultra,,93.44,,,,,,,93.44,118.26,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,MedCost,Ultra,,74.46,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Ultra,,50.56,,,,,,,50.56,63.99,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Ultra,,40.29,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Ultra,,24.96,,,,,,,24.96,31.59,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Ultra,,19.89,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,inpatient,,,299.00000,179.40000,MedCost,Ultra,,191.36,,,,,,,191.36,242.19,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,MedCost,Ultra,,152.49,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,inpatient,,,6.00000,3.60000,MedCost,Ultra,,3.84,,,,,,,3.84,4.86,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,MedCost,Ultra,,3.06,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Ultra,,128.64,,,,,,,128.64,162.81,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Ultra,,102.51,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,inpatient,,,579.00000,347.40000,MedCost,Ultra,,370.56,,,,,,,370.56,468.99,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,MedCost,Ultra,,295.29,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Ultra,,100.48,,,,,,,100.48,127.17,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Ultra,,80.07,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Ultra,,78.08,,,,,,,78.08,98.82,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Ultra,,62.22,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Ultra,,78.08,,,,,,,78.08,98.82,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Ultra,,62.22,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Ultra,,78.08,,,,,,,78.08,98.82,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Ultra,,62.22,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Ultra,,78.08,,,,,,,78.08,98.82,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Ultra,,62.22,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Ultra,,24.96,,,,,,,24.96,31.59,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Ultra,,19.89,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.28,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Ultra,,129.92,,,,,,,129.92,164.43,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Ultra,,103.53,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Ultra,,129.92,,,,,,,129.92,164.43,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Ultra,,103.53,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Ultra,,129.92,,,,,,,129.92,164.43,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Ultra,,103.53,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Ultra,,129.92,,,,,,,129.92,164.43,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Ultra,,103.53,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Ultra,,19.20,,,,,,,19.20,24.30,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Ultra,,15.30,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Ultra,,45.44,,,,,,,45.44,57.51,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Ultra,,36.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,inpatient,,,171.00000,102.60000,MedCost,Ultra,,109.44,,,,,,,109.44,138.51,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,MedCost,Ultra,,87.21,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Ultra,,103.68,,,,,,,103.68,131.22,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Ultra,,82.62,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,inpatient,,,78.00000,46.80000,MedCost,Ultra,,49.92,,,,,,,49.92,63.18,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,MedCost,Ultra,,39.78,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,inpatient,,,238.00000,142.80000,MedCost,Ultra,,152.32,,,,,,,152.32,192.78,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,MedCost,Ultra,,121.38,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,inpatient,,,156.00000,93.60000,MedCost,Ultra,,99.84,,,,,,,99.84,126.36,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,MedCost,Ultra,,79.56,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,inpatient,,,221.00000,132.60000,MedCost,Ultra,,141.44,,,,,,,141.44,179.01,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,MedCost,Ultra,,112.71,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Ultra,,76.80,,,,,,,76.80,97.20,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Ultra,,61.20,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,inpatient,,,152.00000,91.20000,MedCost,Ultra,,97.28,,,,,,,97.28,123.12,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,MedCost,Ultra,,77.52,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Ultra,,30.08,,,,,,,30.08,38.07,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Ultra,,23.97,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Ultra,,30.08,,,,,,,30.08,38.07,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Ultra,,23.97,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,inpatient,,,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.63,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,inpatient,,,197.00000,118.20000,MedCost,Ultra,,126.08,,,,,,,126.08,159.57,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,MedCost,Ultra,,100.47,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Ultra,,84.48,,,,,,,84.48,106.92,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Ultra,,67.32,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Ultra,,25.60,,,,,,,25.60,32.40,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Ultra,,20.40,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,53.76,68.04,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Ultra,,24.32,,,,,,,24.32,30.78,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Ultra,,19.38,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,51.20,64.80,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,51.20,64.80,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Ultra,,26.88,,,,,,,26.88,34.02,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Ultra,,21.42,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Ultra,,101.12,,,,,,,101.12,127.98,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Ultra,,80.58,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,inpatient,,,158.00000,94.80000,MedCost,Ultra,,101.12,,,,,,,101.12,127.98,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,MedCost,Ultra,,80.58,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,inpatient,,,149.00000,89.40000,MedCost,Ultra,,95.36,,,,,,,95.36,120.69,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,MedCost,Ultra,,75.99,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Ultra,,24.32,,,,,,,24.32,30.78,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Ultra,,19.38,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.00,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Ultra,,91.52,,,,,,,91.52,115.83,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Ultra,,72.93,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,inpatient,,,83.00000,49.80000,MedCost,Ultra,,53.12,,,,,,,53.12,67.23,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,MedCost,Ultra,,42.33,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Ultra,,91.52,,,,,,,91.52,115.83,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Ultra,,72.93,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,inpatient,,,177.00000,106.20000,MedCost,Ultra,,113.28,,,,,,,113.28,143.37,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,MedCost,Ultra,,90.27,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Ultra,,16.64,,,,,,,16.64,21.06,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Ultra,,13.26,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Ultra,,16.64,,,,,,,16.64,21.06,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Ultra,,13.26,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Ultra,,16.64,,,,,,,16.64,21.06,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Ultra,,13.26,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,46.98,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,68.48,86.67,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,inpatient,,,2.00000,1.20000,MedCost,Ultra,,1.28,,,,,,,1.28,1.62,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,MedCost,Ultra,,1.02,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,inpatient,,,329.00000,197.40000,MedCost,Ultra,,210.56,,,,,,,210.56,266.49,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,MedCost,Ultra,,167.79,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Ultra,,35.20,,,,,,,35.20,44.55,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Ultra,,28.05,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,inpatient,,,146.00000,87.60000,MedCost,Ultra,,93.44,,,,,,,93.44,118.26,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,MedCost,Ultra,,74.46,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,inpatient,,,227.00000,136.20000,MedCost,Ultra,,145.28,,,,,,,145.28,183.87,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,MedCost,Ultra,,115.77,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Ultra,,137.60,,,,,,,137.60,174.15,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Ultra,,109.65,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Ultra,,137.60,,,,,,,137.60,174.15,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Ultra,,109.65,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Ultra,,28.80,,,,,,,28.80,36.45,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Ultra,,22.95,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.41,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.41,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,inpatient,,,53.00000,31.80000,MedCost,Ultra,,33.92,,,,,,,33.92,42.93,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,MedCost,Ultra,,27.03,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.00,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Ultra,,32.00,,,,,,,32.00,40.50,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Ultra,,25.50,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Ultra,,42.24,,,,,,,42.24,53.46,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Ultra,,33.66,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Ultra,,28.80,,,,,,,28.80,36.45,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Ultra,,22.95,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Ultra,,20.48,,,,,,,20.48,25.92,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Ultra,,16.32,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Ultra,,20.48,,,,,,,20.48,25.92,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Ultra,,16.32,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Ultra,,27.52,,,,,,,27.52,34.83,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Ultra,,21.93,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Ultra,,9.60,,,,,,,9.60,12.15,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Ultra,,7.65,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,inpatient,,,167.00000,100.20000,MedCost,Ultra,,106.88,,,,,,,106.88,135.27,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,MedCost,Ultra,,85.17,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Ultra,,28.80,,,,,,,28.80,36.45,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Ultra,,22.95,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,inpatient,,,160.00000,96.00000,MedCost,Ultra,,102.40,,,,,,,102.40,129.60,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,MedCost,Ultra,,81.60,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,inpatient,,,190.00000,114.00000,MedCost,Ultra,,121.60,,,,,,,121.60,153.90,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,MedCost,Ultra,,96.90,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.41,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,59.94,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Ultra,,42.24,,,,,,,42.24,53.46,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Ultra,,33.66,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Ultra,,85.76,,,,,,,85.76,108.54,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Ultra,,68.34,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Ultra,,83.20,,,,,,,83.20,105.30,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Ultra,,66.30,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,inpatient,,,108.00000,64.80000,MedCost,Ultra,,69.12,,,,,,,69.12,87.48,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,MedCost,Ultra,,55.08,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Ultra,,24.32,,,,,,,24.32,30.78,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Ultra,,19.38,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Ultra,,73.60,,,,,,,73.60,93.15,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Ultra,,58.65,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,inpatient,,,115.00000,69.00000,MedCost,Ultra,,73.60,,,,,,,73.60,93.15,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,MedCost,Ultra,,58.65,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Ultra,,83.20,,,,,,,83.20,105.30,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Ultra,,66.30,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,inpatient,,,193.00000,115.80000,MedCost,Ultra,,123.52,,,,,,,123.52,156.33,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,MedCost,Ultra,,98.43,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Ultra,,50.56,,,,,,,50.56,63.99,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Ultra,,40.29,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Ultra,,7.68,,,,,,,7.68,9.72,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Ultra,,6.12,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Ultra,,237.44,,,,,,,237.44,300.51,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Ultra,,189.21,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,inpatient,,,371.00000,222.60000,MedCost,Ultra,,237.44,,,,,,,237.44,300.51,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,MedCost,Ultra,,189.21,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,inpatient,,,225.00000,135.00000,MedCost,Ultra,,144.00,,,,,,,144.00,182.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,MedCost,Ultra,,114.75,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Ultra,,20.48,,,,,,,20.48,25.92,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Ultra,,16.32,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Ultra,,89.60,,,,,,,89.60,113.40,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Ultra,,71.40,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Ultra,,72.32,,,,,,,72.32,91.53,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Ultra,,57.63,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Ultra,,62.08,,,,,,,62.08,78.57,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Ultra,,49.47,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,inpatient,,,137.00000,82.20000,MedCost,Ultra,,87.68,,,,,,,87.68,110.97,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,MedCost,Ultra,,69.87,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Ultra,,76.80,,,,,,,76.80,97.20,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Ultra,,61.20,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,inpatient,,,8.00000,4.80000,MedCost,Ultra,,5.12,,,,,,,5.12,6.48,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,MedCost,Ultra,,4.08,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,inpatient,,,22.00000,13.20000,MedCost,Ultra,,14.08,,,,,,,14.08,17.82,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,MedCost,Ultra,,11.22,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Ultra,,67.84,,,,,,,67.84,85.86,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Ultra,,54.06,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,inpatient,,,174.00000,104.40000,MedCost,Ultra,,111.36,,,,,,,111.36,140.94,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,MedCost,Ultra,,88.74,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,29.97,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,inpatient,,,128.00000,76.80000,MedCost,Ultra,,81.92,,,,,,,81.92,103.68,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,MedCost,Ultra,,65.28,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,inpatient,,,267.00000,160.20000,MedCost,Ultra,,170.88,,,,,,,170.88,216.27,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,MedCost,Ultra,,136.17,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,inpatient,,,147.00000,88.20000,MedCost,Ultra,,94.08,,,,,,,94.08,119.07,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,MedCost,Ultra,,74.97,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,inpatient,,,273.00000,163.80000,MedCost,Ultra,,174.72,,,,,,,174.72,221.13,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,MedCost,Ultra,,139.23,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,inpatient,,,207.00000,124.20000,MedCost,Ultra,,132.48,,,,,,,132.48,167.67,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,MedCost,Ultra,,105.57,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Ultra,,32.00,,,,,,,32.00,40.50,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Ultra,,25.50,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,inpatient,,,237.00000,142.20000,MedCost,Ultra,,151.68,,,,,,,151.68,191.97,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,MedCost,Ultra,,120.87,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.28,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,inpatient,,,206.00000,123.60000,MedCost,Ultra,,131.84,,,,,,,131.84,166.86,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,MedCost,Ultra,,105.06,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,inpatient,,,41.00000,24.60000,MedCost,Ultra,,26.24,,,,,,,26.24,33.21,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,MedCost,Ultra,,20.91,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,inpatient,,,293.00000,175.80000,MedCost,Ultra,,187.52,,,,,,,187.52,237.33,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,MedCost,Ultra,,149.43,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,inpatient,,,201.00000,120.60000,MedCost,Ultra,,128.64,,,,,,,128.64,162.81,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,MedCost,Ultra,,102.51,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Ultra,,29.44,,,,,,,29.44,37.26,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Ultra,,23.46,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Ultra,,72.32,,,,,,,72.32,91.53,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Ultra,,57.63,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Ultra,,72.32,,,,,,,72.32,91.53,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Ultra,,57.63,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Ultra,,32.00,,,,,,,32.00,40.50,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Ultra,,25.50,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Ultra,,86.40,,,,,,,86.40,109.35,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Ultra,,68.85,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,inpatient,,,223.00000,133.80000,MedCost,Ultra,,142.72,,,,,,,142.72,180.63,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,MedCost,Ultra,,113.73,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,inpatient,,,21.00000,12.60000,MedCost,Ultra,,13.44,,,,,,,13.44,17.01,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,MedCost,Ultra,,10.71,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Ultra,,36.48,,,,,,,36.48,46.17,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Ultra,,29.07,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Ultra,,92.80,,,,,,,92.80,117.45,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Ultra,,73.95,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,inpatient,,,68.00000,40.80000,MedCost,Ultra,,43.52,,,,,,,43.52,55.08,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,MedCost,Ultra,,34.68,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,,74.88,,,,,,,74.88,94.77,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,,59.67,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,inpatient,,,173.00000,103.80000,MedCost,Ultra,,110.72,,,,,,,110.72,140.13,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,MedCost,Ultra,,88.23,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Ultra,,62.08,,,,,,,62.08,78.57,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Ultra,,49.47,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Ultra,,74.24,,,,,,,74.24,93.96,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Ultra,,59.16,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Ultra,,74.24,,,,,,,74.24,93.96,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Ultra,,59.16,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Ultra,,9.60,,,,,,,9.60,12.15,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Ultra,,7.65,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,,45.39,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,,45.39,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Ultra,,22.40,,,,,,,22.40,28.35,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Ultra,,17.85,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Ultra,,28.80,,,,,,,28.80,36.45,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Ultra,,22.95,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,inpatient,,,69.00000,41.40000,MedCost,Ultra,,44.16,,,,,,,44.16,55.89,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,MedCost,Ultra,,35.19,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,inpatient,,,461.00000,276.60000,MedCost,Ultra,,295.04,,,,,,,295.04,373.41,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,MedCost,Ultra,,235.11,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.03,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Ultra,,78.08,,,,,,,78.08,98.82,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Ultra,,62.22,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,inpatient,,,195.00000,117.00000,MedCost,Ultra,,124.80,,,,,,,124.80,157.95,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,MedCost,Ultra,,99.45,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,inpatient,,,83.00000,49.80000,MedCost,Ultra,,53.12,,,,,,,53.12,67.23,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,MedCost,Ultra,,42.33,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,inpatient,,,11.00000,6.60000,MedCost,Ultra,,7.04,,,,,,,7.04,8.91,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,MedCost,Ultra,,5.61,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Ultra,,22.40,,,,,,,22.40,28.35,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Ultra,,17.85,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Ultra,,86.40,,,,,,,86.40,109.35,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Ultra,,68.85,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,inpatient,,,108.00000,64.80000,MedCost,Ultra,,69.12,,,,,,,69.12,87.48,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,MedCost,Ultra,,55.08,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,inpatient,,,794.00000,476.40000,MedCost,Ultra,,508.16,,,,,,,508.16,643.14,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,MedCost,Ultra,,404.94,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,inpatient,,,447.00000,268.20000,MedCost,Ultra,,286.08,,,,,,,286.08,362.07,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,MedCost,Ultra,,227.97,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,inpatient,,,266.00000,159.60000,MedCost,Ultra,,170.24,,,,,,,170.24,215.46,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,MedCost,Ultra,,135.66,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,inpatient,,,570.00000,342.00000,MedCost,Ultra,,364.80,,,,,,,364.80,461.70,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,MedCost,Ultra,,290.70,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,inpatient,,,841.00000,504.60000,MedCost,Ultra,,538.24,,,,,,,538.24,681.21,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,MedCost,Ultra,,428.91,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,,84.15,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,inpatient,,,296.00000,177.60000,MedCost,Ultra,,189.44,,,,,,,189.44,239.76,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,MedCost,Ultra,,150.96,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,inpatient,,,361.00000,216.60000,MedCost,Ultra,,231.04,,,,,,,231.04,292.41,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,MedCost,Ultra,,184.11,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Ultra,,54.40,,,,,,,54.40,68.85,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Ultra,,43.35,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Ultra,,54.40,,,,,,,54.40,68.85,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Ultra,,43.35,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Ultra,,54.40,,,,,,,54.40,68.85,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Ultra,,43.35,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,inpatient,,,233.00000,139.80000,MedCost,Ultra,,149.12,,,,,,,149.12,188.73,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,MedCost,Ultra,,118.83,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Ultra,,92.80,,,,,,,92.80,117.45,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Ultra,,73.95,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,inpatient,,,123.00000,73.80000,MedCost,Ultra,,78.72,,,,,,,78.72,99.63,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,MedCost,Ultra,,62.73,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Ultra,,85.76,,,,,,,85.76,108.54,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Ultra,,68.34,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,inpatient,,,196.00000,117.60000,MedCost,Ultra,,125.44,,,,,,,125.44,158.76,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,MedCost,Ultra,,99.96,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,inpatient,,,173.00000,103.80000,MedCost,Ultra,,110.72,,,,,,,110.72,140.13,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,MedCost,Ultra,,88.23,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.41,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,inpatient,,,501.00000,300.60000,MedCost,Ultra,,320.64,,,,,,,320.64,405.81,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,MedCost,Ultra,,255.51,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,inpatient,,,737.00000,442.20000,MedCost,Ultra,,471.68,,,,,,,471.68,596.97,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,MedCost,Ultra,,375.87,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,inpatient,,,126.00000,75.60000,MedCost,Ultra,,80.64,,,,,,,80.64,102.06,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,MedCost,Ultra,,64.26,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Ultra,,88.96,,,,,,,88.96,112.59,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Ultra,,70.89,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,29.97,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Ultra,,96.00,,,,,,,96.00,121.50,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Ultra,,76.50,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,inpatient,,,93.00000,55.80000,MedCost,Ultra,,59.52,,,,,,,59.52,75.33,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,MedCost,Ultra,,47.43,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Ultra,,103.68,,,,,,,103.68,131.22,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Ultra,,82.62,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,inpatient,,,433.00000,259.80000,MedCost,Ultra,,277.12,,,,,,,277.12,350.73,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,MedCost,Ultra,,220.83,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,inpatient,,,433.00000,259.80000,MedCost,Ultra,,277.12,,,,,,,277.12,350.73,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,MedCost,Ultra,,220.83,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Ultra,,206.72,,,,,,,206.72,261.63,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Ultra,,164.73,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Ultra,,176.00,,,,,,,176.00,222.75,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Ultra,,140.25,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,inpatient,,,291.00000,174.60000,MedCost,Ultra,,186.24,,,,,,,186.24,235.71,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,MedCost,Ultra,,148.41,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,inpatient,,,264.00000,158.40000,MedCost,Ultra,,168.96,,,,,,,168.96,213.84,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,MedCost,Ultra,,134.64,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,inpatient,,,612.00000,367.20000,MedCost,Ultra,,391.68,,,,,,,391.68,495.72,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,MedCost,Ultra,,312.12,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Ultra,,103.04,,,,,,,103.04,130.41,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Ultra,,82.11,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,inpatient,,,237.00000,142.20000,MedCost,Ultra,,151.68,,,,,,,151.68,191.97,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,MedCost,Ultra,,120.87,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,inpatient,,,199.00000,119.40000,MedCost,Ultra,,127.36,,,,,,,127.36,161.19,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,MedCost,Ultra,,101.49,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Ultra,,63.36,,,,,,,63.36,80.19,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Ultra,,50.49,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,inpatient,,,325.00000,195.00000,MedCost,Ultra,,208.00,,,,,,,208.00,263.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,MedCost,Ultra,,165.75,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,inpatient,,,271.00000,162.60000,MedCost,Ultra,,173.44,,,,,,,173.44,219.51,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,MedCost,Ultra,,138.21,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,inpatient,,,323.00000,193.80000,MedCost,Ultra,,206.72,,,,,,,206.72,261.63,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,MedCost,Ultra,,164.73,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,inpatient,,,251.00000,150.60000,MedCost,Ultra,,160.64,,,,,,,160.64,203.31,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,MedCost,Ultra,,128.01,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,inpatient,,,182.00000,109.20000,MedCost,Ultra,,116.48,,,,,,,116.48,147.42,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,MedCost,Ultra,,92.82,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Ultra,,119.04,,,,,,,119.04,150.66,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Ultra,,94.86,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Ultra,,119.04,,,,,,,119.04,150.66,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Ultra,,94.86,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,inpatient,,,247.00000,148.20000,MedCost,Ultra,,158.08,,,,,,,158.08,200.07,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,MedCost,Ultra,,125.97,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,inpatient,,,44.00000,26.40000,MedCost,Ultra,,28.16,,,,,,,28.16,35.64,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,MedCost,Ultra,,22.44,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Ultra,,96.00,,,,,,,96.00,121.50,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Ultra,,76.50,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,inpatient,,,196.00000,117.60000,MedCost,Ultra,,125.44,,,,,,,125.44,158.76,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,MedCost,Ultra,,99.96,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,inpatient,,,468.00000,280.80000,MedCost,Ultra,,299.52,,,,,,,299.52,379.08,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,MedCost,Ultra,,238.68,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,inpatient,,,283.00000,169.80000,MedCost,Ultra,,181.12,,,,,,,181.12,229.23,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,MedCost,Ultra,,144.33,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,59.94,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Ultra,,22.40,,,,,,,22.40,28.35,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Ultra,,17.85,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,inpatient,,,72.00000,43.20000,MedCost,Ultra,,46.08,,,,,,,46.08,58.32,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,MedCost,Ultra,,36.72,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,inpatient,,,113.00000,67.80000,MedCost,Ultra,,72.32,,,,,,,72.32,91.53,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,MedCost,Ultra,,57.63,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,inpatient,,,356.00000,213.60000,MedCost,Ultra,,227.84,,,,,,,227.84,288.36,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,MedCost,Ultra,,181.56,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,inpatient,,,146.00000,87.60000,MedCost,Ultra,,93.44,,,,,,,93.44,118.26,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,MedCost,Ultra,,74.46,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.03,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,inpatient,,,202.00000,121.20000,MedCost,Ultra,,129.28,,,,,,,129.28,163.62,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,MedCost,Ultra,,103.02,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,inpatient,,,143.00000,85.80000,MedCost,Ultra,,91.52,,,,,,,91.52,115.83,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,MedCost,Ultra,,72.93,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,,74.88,,,,,,,74.88,94.77,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,,59.67,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,inpatient,,,117.00000,70.20000,MedCost,Ultra,,74.88,,,,,,,74.88,94.77,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,MedCost,Ultra,,59.67,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Ultra,,50.56,,,,,,,50.56,63.99,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Ultra,,40.29,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,inpatient,,,102.00000,61.20000,MedCost,Ultra,,65.28,,,,,,,65.28,82.62,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,MedCost,Ultra,,52.02,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,inpatient,,,85.00000,51.00000,MedCost,Ultra,,54.40,,,,,,,54.40,68.85,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,MedCost,Ultra,,43.35,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,inpatient,,,98.00000,58.80000,MedCost,Ultra,,62.72,,,,,,,62.72,79.38,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,MedCost,Ultra,,49.98,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,inpatient,,,224.00000,134.40000,MedCost,Ultra,,143.36,,,,,,,143.36,181.44,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,MedCost,Ultra,,114.24,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,51.20,64.80,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Ultra,,24.96,,,,,,,24.96,31.59,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Ultra,,19.89,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,inpatient,,,19.00000,11.40000,MedCost,Ultra,,12.16,,,,,,,12.16,15.39,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,MedCost,Ultra,,9.69,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,inpatient,,,47.00000,28.20000,MedCost,Ultra,,30.08,,,,,,,30.08,38.07,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,MedCost,Ultra,,23.97,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Ultra,,9.60,,,,,,,9.60,12.15,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Ultra,,7.65,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,inpatient,,,41.00000,24.60000,MedCost,Ultra,,26.24,,,,,,,26.24,33.21,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,MedCost,Ultra,,20.91,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.41,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,inpatient,,,188.00000,112.80000,MedCost,Ultra,,120.32,,,,,,,120.32,152.28,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,MedCost,Ultra,,95.88,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,inpatient,,,122.00000,73.20000,MedCost,Ultra,,78.08,,,,,,,78.08,98.82,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,MedCost,Ultra,,62.22,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,inpatient,,,130.00000,78.00000,MedCost,Ultra,,83.20,,,,,,,83.20,105.30,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,MedCost,Ultra,,66.30,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Ultra,,45.44,,,,,,,45.44,57.51,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Ultra,,36.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Ultra,,100.48,,,,,,,100.48,127.17,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Ultra,,80.07,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,inpatient,,,27.00000,16.20000,MedCost,Ultra,,17.28,,,,,,,17.28,21.87,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,MedCost,Ultra,,13.77,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,inpatient,,,53.00000,31.80000,MedCost,Ultra,,33.92,,,,,,,33.92,42.93,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,MedCost,Ultra,,27.03,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,inpatient,,,187.00000,112.20000,MedCost,Ultra,,119.68,,,,,,,119.68,151.47,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,MedCost,Ultra,,95.37,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,inpatient,,,187.00000,112.20000,MedCost,Ultra,,119.68,,,,,,,119.68,151.47,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,MedCost,Ultra,,95.37,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Ultra,,62.08,,,,,,,62.08,78.57,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Ultra,,49.47,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Ultra,,136.32,,,,,,,136.32,172.53,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Ultra,,108.63,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Ultra,,130.56,,,,,,,130.56,165.24,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Ultra,,104.04,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,59.94,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,inpatient,,,32.00000,19.20000,MedCost,Ultra,,20.48,,,,,,,20.48,25.92,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,MedCost,Ultra,,16.32,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Ultra,,130.56,,,,,,,130.56,165.24,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Ultra,,104.04,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,inpatient,,,31.00000,18.60000,MedCost,Ultra,,19.84,,,,,,,19.84,25.11,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,MedCost,Ultra,,15.81,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Ultra,,44.80,,,,,,,44.80,56.70,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Ultra,,35.70,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,inpatient,,,145.00000,87.00000,MedCost,Ultra,,92.80,,,,,,,92.80,117.45,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,MedCost,Ultra,,73.95,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,inpatient,,,92.00000,55.20000,MedCost,Ultra,,58.88,,,,,,,58.88,74.52,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,MedCost,Ultra,,46.92,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Ultra,,24.96,,,,,,,24.96,31.59,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Ultra,,19.89,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Ultra,,19.20,,,,,,,19.20,24.30,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Ultra,,15.30,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Ultra,,19.20,,,,,,,19.20,24.30,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Ultra,,15.30,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Ultra,,16.64,,,,,,,16.64,21.06,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Ultra,,13.26,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,,82.56,,,,,,,82.56,104.49,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,,65.79,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Ultra,,74.24,,,,,,,74.24,93.96,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Ultra,,59.16,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Ultra,,50.56,,,,,,,50.56,63.99,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Ultra,,40.29,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,inpatient,,,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.58,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,59.94,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,59.94,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,59.94,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,59.94,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,inpatient,,,339.00000,203.40000,MedCost,Ultra,,216.96,,,,,,,216.96,274.59,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,MedCost,Ultra,,172.89,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,inpatient,,,68.00000,40.80000,MedCost,Ultra,,43.52,,,,,,,43.52,55.08,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,MedCost,Ultra,,34.68,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,53.76,68.04,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,,45.39,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.41,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,inpatient,,,16.00000,9.60000,MedCost,Ultra,,10.24,,,,,,,10.24,12.96,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,MedCost,Ultra,,8.16,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,inpatient,,,245.00000,147.00000,MedCost,Ultra,,156.80,,,,,,,156.80,198.45,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,MedCost,Ultra,,124.95,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,53.76,68.04,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,inpatient,,,154.00000,92.40000,MedCost,Ultra,,98.56,,,,,,,98.56,124.74,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,MedCost,Ultra,,78.54,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,inpatient,,,37.00000,22.20000,MedCost,Ultra,,23.68,,,,,,,23.68,29.97,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,MedCost,Ultra,,18.87,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,inpatient,,,99.00000,59.40000,MedCost,Ultra,,63.36,,,,,,,63.36,80.19,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,MedCost,Ultra,,50.49,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,inpatient,,,78.00000,46.80000,MedCost,Ultra,,49.92,,,,,,,49.92,63.18,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,MedCost,Ultra,,39.78,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,inpatient,,,40.00000,24.00000,MedCost,Ultra,,25.60,,,,,,,25.60,32.40,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,MedCost,Ultra,,20.40,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Ultra,,36.48,,,,,,,36.48,46.17,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Ultra,,29.07,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Ultra,,24.32,,,,,,,24.32,30.78,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Ultra,,19.38,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,inpatient,,,63.00000,37.80000,MedCost,Ultra,,40.32,,,,,,,40.32,51.03,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,MedCost,Ultra,,32.13,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,inpatient,,,180.00000,108.00000,MedCost,Ultra,,115.20,,,,,,,115.20,145.80,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,MedCost,Ultra,,91.80,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,inpatient,,,33.00000,19.80000,MedCost,Ultra,,21.12,,,,,,,21.12,26.73,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,MedCost,Ultra,,16.83,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Ultra,,24.32,,,,,,,24.32,30.78,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Ultra,,19.38,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,inpatient,,,228.00000,136.80000,MedCost,Ultra,,145.92,,,,,,,145.92,184.68,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,MedCost,Ultra,,116.28,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,inpatient,,,169.00000,101.40000,MedCost,Ultra,,108.16,,,,,,,108.16,136.89,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,MedCost,Ultra,,86.19,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,inpatient,,,461.00000,276.60000,MedCost,Ultra,,295.04,,,,,,,295.04,373.41,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,MedCost,Ultra,,235.11,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Ultra,,136.32,,,,,,,136.32,172.53,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Ultra,,108.63,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Ultra,,136.32,,,,,,,136.32,172.53,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Ultra,,108.63,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,inpatient,,,629.00000,377.40000,MedCost,Ultra,,402.56,,,,,,,402.56,509.49,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,MedCost,Ultra,,320.79,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,inpatient,,,581.00000,348.60000,MedCost,Ultra,,371.84,,,,,,,371.84,470.61,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,MedCost,Ultra,,296.31,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,inpatient,,,174.00000,104.40000,MedCost,Ultra,,111.36,,,,,,,111.36,140.94,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,MedCost,Ultra,,88.74,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Ultra,,103.04,,,,,,,103.04,130.41,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Ultra,,82.11,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Ultra,,224.00,,,,,,,224.00,283.50,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Ultra,,178.50,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,inpatient,,,212.00000,127.20000,MedCost,Ultra,,135.68,,,,,,,135.68,171.72,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,MedCost,Ultra,,108.12,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Ultra,,104.96,,,,,,,104.96,132.84,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Ultra,,83.64,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Ultra,,104.96,,,,,,,104.96,132.84,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Ultra,,83.64,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Ultra,,176.00,,,,,,,176.00,222.75,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Ultra,,140.25,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,inpatient,,,257.00000,154.20000,MedCost,Ultra,,164.48,,,,,,,164.48,208.17,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,MedCost,Ultra,,131.07,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,inpatient,,,770.00000,462.00000,MedCost,Ultra,,492.80,,,,,,,492.80,623.70,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,MedCost,Ultra,,392.70,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,inpatient,,,87.00000,52.20000,MedCost,Ultra,,55.68,,,,,,,55.68,70.47,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,MedCost,Ultra,,44.37,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,inpatient,,,83.00000,49.80000,MedCost,Ultra,,53.12,,,,,,,53.12,67.23,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,MedCost,Ultra,,42.33,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,inpatient,,,48.00000,28.80000,MedCost,Ultra,,30.72,,,,,,,30.72,38.88,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,MedCost,Ultra,,24.48,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,inpatient,,,112.00000,67.20000,MedCost,Ultra,,71.68,,,,,,,71.68,90.72,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,MedCost,Ultra,,57.12,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,inpatient,,,579.00000,347.40000,MedCost,Ultra,,370.56,,,,,,,370.56,468.99,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,MedCost,Ultra,,295.29,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,inpatient,,,279.00000,167.40000,MedCost,Ultra,,178.56,,,,,,,178.56,225.99,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,MedCost,Ultra,,142.29,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Ultra,,35.20,,,,,,,35.20,44.55,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Ultra,,28.05,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,inpatient,,,154.00000,92.40000,MedCost,Ultra,,98.56,,,,,,,98.56,124.74,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,MedCost,Ultra,,78.54,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,inpatient,,,96.00000,57.60000,MedCost,Ultra,,61.44,,,,,,,61.44,77.76,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,MedCost,Ultra,,48.96,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,inpatient,,,96.00000,57.60000,MedCost,Ultra,,61.44,,,,,,,61.44,77.76,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,MedCost,Ultra,,48.96,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,inpatient,,,96.00000,57.60000,MedCost,Ultra,,61.44,,,,,,,61.44,77.76,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,MedCost,Ultra,,48.96,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,inpatient,,,463.00000,277.80000,MedCost,Ultra,,296.32,,,,,,,296.32,375.03,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,MedCost,Ultra,,236.13,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Ultra,,188.16,,,,,,,188.16,238.14,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Ultra,,149.94,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,inpatient,,,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,56.32,71.28,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,inpatient,,,88.00000,52.80000,MedCost,Ultra,,56.32,,,,,,,56.32,71.28,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,MedCost,Ultra,,44.88,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,inpatient,,,51.00000,30.60000,MedCost,Ultra,,32.64,,,,,,,32.64,41.31,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,MedCost,Ultra,,26.01,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,inpatient,,,126.00000,75.60000,MedCost,Ultra,,80.64,,,,,,,80.64,102.06,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,MedCost,Ultra,,64.26,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,inpatient,,,12.00000,7.20000,MedCost,Ultra,,7.68,,,,,,,7.68,9.72,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,MedCost,Ultra,,6.12,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Ultra,,96.00,,,,,,,96.00,121.50,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Ultra,,76.50,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,inpatient,,,120.00000,72.00000,MedCost,Ultra,,76.80,,,,,,,76.80,97.20,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,MedCost,Ultra,,61.20,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,inpatient,,,548.00000,328.80000,MedCost,Ultra,,350.72,,,,,,,350.72,443.88,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,MedCost,Ultra,,279.48,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,inpatient,,,309.00000,185.40000,MedCost,Ultra,,197.76,,,,,,,197.76,250.29,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,MedCost,Ultra,,157.59,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,inpatient,,,127.00000,76.20000,MedCost,Ultra,,81.28,,,,,,,81.28,102.87,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,MedCost,Ultra,,64.77,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,inpatient,,,36.00000,21.60000,MedCost,Ultra,,23.04,,,,,,,23.04,29.16,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,MedCost,Ultra,,18.36,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,inpatient,,,22.00000,13.20000,MedCost,Ultra,,14.08,,,,,,,14.08,17.82,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,MedCost,Ultra,,11.22,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,inpatient,,,230.00000,138.00000,MedCost,Ultra,,147.20,,,,,,,147.20,186.30,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,MedCost,Ultra,,117.30,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Ultra,,18.56,,,,,,,18.56,23.49,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Ultra,,14.79,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,inpatient,,,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.58,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,inpatient,,,106.00000,63.60000,MedCost,Ultra,,67.84,,,,,,,67.84,85.86,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,MedCost,Ultra,,54.06,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,inpatient,,,58.00000,34.80000,MedCost,Ultra,,37.12,,,,,,,37.12,46.98,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,MedCost,Ultra,,29.58,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Ultra,,22.40,,,,,,,22.40,28.35,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Ultra,,17.85,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Ultra,,22.40,,,,,,,22.40,28.35,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Ultra,,17.85,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,inpatient,,,19.00000,11.40000,MedCost,Ultra,,12.16,,,,,,,12.16,15.39,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,MedCost,Ultra,,9.69,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,inpatient,,,61.00000,36.60000,MedCost,Ultra,,39.04,,,,,,,39.04,49.41,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,MedCost,Ultra,,31.11,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,inpatient,,,64.00000,38.40000,MedCost,Ultra,,40.96,,,,,,,40.96,51.84,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,MedCost,Ultra,,32.64,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Ultra,,29.44,,,,,,,29.44,37.26,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Ultra,,23.46,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,inpatient,,,56.00000,33.60000,MedCost,Ultra,,35.84,,,,,,,35.84,45.36,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,MedCost,Ultra,,28.56,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,inpatient,,,71.00000,42.60000,MedCost,Ultra,,45.44,,,,,,,45.44,57.51,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,MedCost,Ultra,,36.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Ultra,,9.60,,,,,,,9.60,12.15,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Ultra,,7.65,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,inpatient,,,30.00000,18.00000,MedCost,Ultra,,19.20,,,,,,,19.20,24.30,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,MedCost,Ultra,,15.30,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,inpatient,,,253.00000,151.80000,MedCost,Ultra,,161.92,,,,,,,161.92,204.93,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,MedCost,Ultra,,129.03,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Ultra,,85.76,,,,,,,85.76,108.54,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Ultra,,68.34,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,inpatient,,,171.00000,102.60000,MedCost,Ultra,,109.44,,,,,,,109.44,138.51,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,MedCost,Ultra,,87.21,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,inpatient,,,26.00000,15.60000,MedCost,Ultra,,16.64,,,,,,,16.64,21.06,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,MedCost,Ultra,,13.26,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Ultra,,103.68,,,,,,,103.68,131.22,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Ultra,,82.62,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Ultra,,50.56,,,,,,,50.56,63.99,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Ultra,,40.29,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.74,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Ultra,,18.56,,,,,,,18.56,23.49,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Ultra,,14.79,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00640,0.00810,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,inpatient,,,414.00000,248.40000,MedCost,Ultra,,264.96,,,,,,,264.96,335.34,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,MedCost,Ultra,,211.14,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,inpatient,,,2.00000,1.20000,MedCost,Ultra,,1.28,,,,,,,1.28,1.62,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,MedCost,Ultra,,1.02,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Ultra,,331.52,,,,,,,331.52,419.58,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Ultra,,264.18,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,inpatient,,,81.00000,48.60000,MedCost,Ultra,,51.84,,,,,,,51.84,65.61,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,MedCost,Ultra,,41.31,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,inpatient,,,29.00000,17.40000,MedCost,Ultra,,18.56,,,,,,,18.56,23.49,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,MedCost,Ultra,,14.79,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,inpatient,,,161.00000,96.60000,MedCost,Ultra,,103.04,,,,,,,103.04,130.41,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,MedCost,Ultra,,82.11,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,inpatient,,,1960.00000,1176.00000,MedCost,Ultra,,1254.40,,,,,,,1254.40,1587.60,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,MedCost,Ultra,,999.60,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,inpatient,,,141.00000,84.60000,MedCost,Ultra,,90.24,,,,,,,90.24,114.21,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,MedCost,Ultra,,71.91,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,,45.39,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,inpatient,,,34.00000,20.40000,MedCost,Ultra,,21.76,,,,,,,21.76,27.54,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,MedCost,Ultra,,17.34,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,inpatient,,,38.00000,22.80000,MedCost,Ultra,,24.32,,,,,,,24.32,30.78,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,MedCost,Ultra,,19.38,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Ultra,,44.80,,,,,,,44.80,56.70,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Ultra,,35.70,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,inpatient,,,70.00000,42.00000,MedCost,Ultra,,44.80,,,,,,,44.80,56.70,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,MedCost,Ultra,,35.70,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,inpatient,,,15.00000,9.00000,MedCost,Ultra,,9.60,,,,,,,9.60,12.15,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,MedCost,Ultra,,7.65,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,inpatient,,,35.00000,21.00000,MedCost,Ultra,,22.40,,,,,,,22.40,28.35,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,MedCost,Ultra,,17.85,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,inpatient,,,75.00000,45.00000,MedCost,Ultra,,48.00,,,,,,,48.00,60.75,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,MedCost,Ultra,,38.25,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,inpatient,,,49.00000,29.40000,MedCost,Ultra,,31.36,,,,,,,31.36,39.69,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,MedCost,Ultra,,24.99,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,inpatient,,,529.00000,317.40000,MedCost,Ultra,,338.56,,,,,,,338.56,428.49,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,MedCost,Ultra,,269.79,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,inpatient,,,767.00000,460.20000,MedCost,Ultra,,490.88,,,,,,,490.88,621.27,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,MedCost,Ultra,,391.17,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,inpatient,,,134.00000,80.40000,MedCost,Ultra,,85.76,,,,,,,85.76,108.54,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,MedCost,Ultra,,68.34,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,inpatient,,,1805.00000,1083.00000,MedCost,Ultra,,1155.20,,,,,,,1155.20,1462.05,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,MedCost,Ultra,,920.55,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,inpatient,,,1258.00000,754.80000,MedCost,Ultra,,805.12,,,,,,,805.12,1018.98,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,MedCost,Ultra,,641.58,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,inpatient,,,293.00000,175.80000,MedCost,Ultra,,187.52,,,,,,,187.52,237.33,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,MedCost,Ultra,,149.43,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,inpatient,,,116.00000,69.60000,MedCost,Ultra,,74.24,,,,,,,74.24,93.96,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,MedCost,Ultra,,59.16,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,inpatient,,,1931.00000,1158.60000,MedCost,Ultra,,1235.84,,,,,,,1235.84,1564.11,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,MedCost,Ultra,,984.81,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,inpatient,,,23.00000,13.80000,MedCost,Ultra,,14.72,,,,,,,14.72,18.63,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,MedCost,Ultra,,11.73,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,inpatient,,,259.00000,155.40000,MedCost,Ultra,,165.76,,,,,,,165.76,209.79,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,MedCost,Ultra,,132.09,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Ultra,,29.44,,,,,,,29.44,37.26,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Ultra,,23.46,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,inpatient,,,1808.00000,1084.80000,MedCost,Ultra,,1157.12,,,,,,,1157.12,1464.48,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,MedCost,Ultra,,922.08,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,inpatient,,,707.00000,424.20000,MedCost,Ultra,,452.48,,,,,,,452.48,572.67,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,MedCost,Ultra,,360.57,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,68.48,86.67,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,inpatient,,,513.00000,307.80000,MedCost,Ultra,,328.32,,,,,,,328.32,415.53,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,MedCost,Ultra,,261.63,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Ultra,,120.96,,,,,,,120.96,153.09,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Ultra,,96.39,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,inpatient,,,1960.00000,1176.00000,MedCost,Ultra,,1254.40,,,,,,,1254.40,1587.60,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,MedCost,Ultra,,999.60,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,inpatient,,,114.00000,68.40000,MedCost,Ultra,,72.96,,,,,,,72.96,92.34,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,MedCost,Ultra,,58.14,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,inpatient,,,324.00000,194.40000,MedCost,Ultra,,207.36,,,,,,,207.36,262.44,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,MedCost,Ultra,,165.24,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,inpatient,,,194.00000,116.40000,MedCost,Ultra,,124.16,,,,,,,124.16,157.14,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,MedCost,Ultra,,98.94,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,inpatient,,,953.00000,571.80000,MedCost,Ultra,,609.92,,,,,,,609.92,771.93,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,MedCost,Ultra,,486.03,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,inpatient,,,639.00000,383.40000,MedCost,Ultra,,408.96,,,,,,,408.96,517.59,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,MedCost,Ultra,,325.89,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Ultra,,89.60,,,,,,,89.60,113.40,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Ultra,,71.40,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,inpatient,,,140.00000,84.00000,MedCost,Ultra,QW,89.60,,,,,,,89.60,113.40,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,MedCost,Ultra,QW,71.40,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,inpatient,,,46.00000,27.60000,MedCost,Ultra,,29.44,,,,,,,29.44,37.26,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,MedCost,Ultra,,23.46,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,inpatient,,,278.00000,166.80000,MedCost,Ultra,,177.92,,,,,,,177.92,225.18,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,MedCost,Ultra,,141.78,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,inpatient,,,1589.00000,953.40000,MedCost,Ultra,,1016.96,,,,,,,1016.96,1287.09,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,MedCost,Ultra,,810.39,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,inpatient,,,1187.00000,712.20000,MedCost,Ultra,,759.68,,,,,,,759.68,961.47,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,MedCost,Ultra,,605.37,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,inpatient,,,278.00000,166.80000,MedCost,Ultra,,177.92,,,,,,,177.92,225.18,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,MedCost,Ultra,,141.78,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,inpatient,,,609.00000,365.40000,MedCost,Ultra,,389.76,,,,,,,389.76,493.29,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,MedCost,Ultra,,310.59,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,inpatient,,,478.00000,286.80000,MedCost,Ultra,,305.92,,,,,,,305.92,387.18,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,MedCost,Ultra,,243.78,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,inpatient,,,204.00000,122.40000,MedCost,Ultra,,130.56,,,,,,,130.56,165.24,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,MedCost,Ultra,,104.04,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,inpatient,,,426.00000,255.60000,MedCost,Ultra,,272.64,,,,,,,272.64,345.06,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,MedCost,Ultra,,217.26,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,inpatient,,,50.00000,30.00000,MedCost,Ultra,,32.00,,,,,,,32.00,40.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,MedCost,Ultra,,25.50,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Ultra,QW,64.00,,,,,,,64.00,81.00,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Ultra,QW,51.00,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,inpatient,,,100.00000,60.00000,MedCost,Ultra,,64.00,,,,,,,64.00,81.00,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,MedCost,Ultra,,51.00,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,inpatient,,,163.00000,97.80000,MedCost,Ultra,,104.32,,,,,,,104.32,132.03,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,MedCost,Ultra,,83.13,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,inpatient,,,907.00000,544.20000,MedCost,Ultra,,580.48,,,,,,,580.48,734.67,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,MedCost,Ultra,,462.57,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Ultra,,176.00,,,,,,,176.00,222.75,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Ultra,,140.25,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Ultra,,84.48,,,,,,,84.48,106.92,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Ultra,,67.32,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,,84.15,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,inpatient,,,89.00000,53.40000,MedCost,Ultra,,56.96,,,,,,,56.96,72.09,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,MedCost,Ultra,,45.39,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Ultra,,27.52,,,,,,,27.52,34.83,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Ultra,,21.93,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,inpatient,,,280.00000,168.00000,MedCost,Ultra,,179.20,,,,,,,179.20,226.80,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,MedCost,Ultra,,142.80,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,inpatient,,,79.00000,47.40000,MedCost,Ultra,,50.56,,,,,,,50.56,63.99,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,MedCost,Ultra,,40.29,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,inpatient,,,194.00000,116.40000,MedCost,Ultra,,124.16,,,,,,,124.16,157.14,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,MedCost,Ultra,,98.94,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,inpatient,,,69.00000,41.40000,MedCost,Ultra,,44.16,,,,,,,44.16,55.89,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,MedCost,Ultra,,35.19,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Ultra,,42.24,,,,,,,42.24,53.46,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Ultra,,33.66,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,inpatient,,,350.00000,210.00000,MedCost,Ultra,,224.00,,,,,,,224.00,283.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,MedCost,Ultra,,178.50,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Ultra,,86.40,,,,,,,86.40,109.35,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Ultra,,68.85,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,inpatient,,,213.00000,127.80000,MedCost,Ultra,,136.32,,,,,,,136.32,172.53,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,MedCost,Ultra,,108.63,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,inpatient,,,219.00000,131.40000,MedCost,Ultra,,140.16,,,,,,,140.16,177.39,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,MedCost,Ultra,,111.69,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Ultra,,86.40,,,,,,,86.40,109.35,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Ultra,,68.85,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Ultra,,86.40,,,,,,,86.40,109.35,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Ultra,,68.85,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,inpatient,,,275.00000,165.00000,MedCost,Ultra,,176.00,,,,,,,176.00,222.75,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,MedCost,Ultra,,140.25,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Ultra,,28.80,,,,,,,28.80,36.45,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Ultra,,22.95,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,inpatient,,,45.00000,27.00000,MedCost,Ultra,,28.80,,,,,,,28.80,36.45,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,MedCost,Ultra,,22.95,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,inpatient,,,76.00000,45.60000,MedCost,Ultra,,48.64,,,,,,,48.64,61.56,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,MedCost,Ultra,,38.76,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Ultra,,27.52,,,,,,,27.52,34.83,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Ultra,,21.93,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,inpatient,,,84.00000,50.40000,MedCost,Ultra,,53.76,,,,,,,53.76,68.04,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,MedCost,Ultra,,42.84,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,inpatient,,,101.00000,60.60000,MedCost,Ultra,,64.64,,,,,,,64.64,81.81,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,MedCost,Ultra,,51.51,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,inpatient,,,149.00000,89.40000,MedCost,Ultra,,95.36,,,,,,,95.36,120.69,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,MedCost,Ultra,,75.99,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Ultra,,849.92,,,,,,,849.92,1075.68,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,MedCost,Ultra,,677.28,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Ultra,,35.20,,,,,,,35.20,44.55,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Ultra,,28.05,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,inpatient,,,108.00000,64.80000,MedCost,Ultra,,69.12,,,,,,,69.12,87.48,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,MedCost,Ultra,,55.08,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,inpatient,,,118.00000,70.80000,MedCost,Ultra,,75.52,,,,,,,75.52,95.58,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,MedCost,Ultra,,60.18,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,inpatient,,,65.00000,39.00000,MedCost,Ultra,,41.60,,,,,,,41.60,52.65,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,MedCost,Ultra,,33.15,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Ultra,,36.48,,,,,,,36.48,46.17,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Ultra,,29.07,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,inpatient,,,271.00000,162.60000,MedCost,Ultra,,173.44,,,,,,,173.44,219.51,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,MedCost,Ultra,,138.21,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,inpatient,,,167.00000,100.20000,MedCost,Ultra,,106.88,,,,,,,106.88,135.27,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,MedCost,Ultra,,85.17,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,inpatient,,,271.00000,162.60000,MedCost,Ultra,,173.44,,,,,,,173.44,219.51,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,MedCost,Ultra,,138.21,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,inpatient,,,319.00000,191.40000,MedCost,Ultra,,204.16,,,,,,,204.16,258.39,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,MedCost,Ultra,,162.69,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,inpatient,,,515.00000,309.00000,MedCost,Ultra,,329.60,,,,,,,329.60,7039.00,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,MedCost,Ultra,,262.65,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,inpatient,,,526.00000,315.60000,MedCost,Ultra,,336.64,,,,,,,336.64,426.06,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,MedCost,Ultra,,268.26,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,inpatient,,,210.00000,126.00000,MedCost,Ultra,,134.40,,,,,,,134.40,170.10,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,MedCost,Ultra,,107.10,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00640,0.00810,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,inpatient,,,27.00000,16.20000,MedCost,Ultra,,17.28,,,,,,,17.28,21.87,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,MedCost,Ultra,,13.77,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,inpatient,,,110.00000,66.00000,MedCost,Ultra,,70.40,,,,,,,70.40,89.10,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,MedCost,Ultra,,56.10,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,inpatient,,,186.00000,111.60000,MedCost,Ultra,,119.04,,,,,,,119.04,150.66,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,MedCost,Ultra,,94.86,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,inpatient,,,147.00000,88.20000,MedCost,Ultra,,94.08,,,,,,,94.08,119.07,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,MedCost,Ultra,,74.97,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,inpatient,,,147.00000,88.20000,MedCost,Ultra,,94.08,,,,,,,94.08,119.07,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,MedCost,Ultra,,74.97,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,inpatient,,,39.00000,23.40000,MedCost,Ultra,,24.96,,,,,,,24.96,31.59,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,MedCost,Ultra,,19.89,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,inpatient,,,198.00000,118.80000,MedCost,Ultra,,126.72,,,,,,,126.72,160.38,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,MedCost,Ultra,,100.98,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,inpatient,,,119.00000,71.40000,MedCost,Ultra,,76.16,,,,,,,76.16,96.39,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,MedCost,Ultra,,60.69,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,inpatient,,,255.00000,153.00000,MedCost,Ultra,,163.20,,,,,,,163.20,206.55,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,MedCost,Ultra,,130.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,inpatient,,,261.00000,156.60000,MedCost,Ultra,,167.04,,,,,,,167.04,211.41,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,MedCost,Ultra,,133.11,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,inpatient,,,78.00000,46.80000,MedCost,Ultra,,49.92,,,,,,,49.92,63.18,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,MedCost,Ultra,,39.78,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,inpatient,,,136.00000,81.60000,MedCost,Ultra,,87.04,,,,,,,87.04,110.16,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,MedCost,Ultra,,69.36,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,inpatient,,,209.00000,125.40000,MedCost,Ultra,,133.76,,,,,,,133.76,169.29,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,MedCost,Ultra,,106.59,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,inpatient,,,207.00000,124.20000,MedCost,Ultra,,132.48,,,,,,,132.48,167.67,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,MedCost,Ultra,,105.57,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Ultra,,331.52,,,,,,,331.52,419.58,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Ultra,,264.18,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,inpatient,,,148.00000,88.80000,MedCost,Ultra,,94.72,,,,,,,94.72,119.88,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,MedCost,Ultra,,75.48,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,inpatient,,,456.00000,273.60000,MedCost,Ultra,,291.84,,,,,,,291.84,369.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,MedCost,Ultra,,232.56,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,inpatient,,,597.00000,358.20000,MedCost,Ultra,,382.08,,,,,,,382.08,483.57,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,MedCost,Ultra,,304.47,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,inpatient,,,755.00000,453.00000,MedCost,Ultra,,483.20,,,,,,,483.20,611.55,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,MedCost,Ultra,,385.05,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,inpatient,,,561.00000,336.60000,MedCost,Ultra,,359.04,,,,,,,359.04,454.41,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,MedCost,Ultra,,286.11,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,inpatient,,,325.00000,195.00000,MedCost,Ultra,,208.00,,,,,,,208.00,263.25,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,MedCost,Ultra,,165.75,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,inpatient,,,225.00000,135.00000,MedCost,Ultra,,144.00,,,,,,,144.00,182.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,MedCost,Ultra,,114.75,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,inpatient,,,1019.00000,611.40000,MedCost,Ultra,,652.16,,,,,,,652.16,825.39,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,MedCost,Ultra,,519.69,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,inpatient,,,354.00000,212.40000,MedCost,Ultra,,226.56,,,,,,,226.56,286.74,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,MedCost,Ultra,,180.54,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,inpatient,,,609.00000,365.40000,MedCost,Ultra,,389.76,,,,,,,389.76,493.29,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,MedCost,Ultra,,310.59,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,inpatient,,,224.00000,134.40000,MedCost,Ultra,,143.36,,,,,,,143.36,181.44,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,MedCost,Ultra,,114.24,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,51.20,64.80,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Ultra,,84.48,,,,,,,84.48,106.92,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Ultra,,67.32,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,inpatient,,,135.00000,81.00000,MedCost,Ultra,,86.40,,,,,,,86.40,109.35,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,MedCost,Ultra,,68.85,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,inpatient,,,548.00000,328.80000,MedCost,Ultra,,350.72,,,,,,,350.72,443.88,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,MedCost,Ultra,,279.48,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,inpatient,,,102.00000,61.20000,MedCost,Ultra,,65.28,,,,,,,65.28,82.62,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,MedCost,Ultra,,52.02,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,inpatient,,,175.00000,105.00000,MedCost,Ultra,,112.00,,,,,,,112.00,141.75,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,MedCost,Ultra,,89.25,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,inpatient,,,367.00000,220.20000,MedCost,Ultra,,234.88,,,,,,,234.88,297.27,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,MedCost,Ultra,,187.17,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Ultra,,422.40,,,,,,,422.40,534.60,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Ultra,,336.60,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,inpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00640,,,,,,,0.00640,0.00810,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,MedCost,Ultra,,0.00510,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,inpatient,,,124.00000,74.40000,MedCost,Ultra,,79.36,,,,,,,79.36,100.44,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,MedCost,Ultra,,63.24,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,inpatient,,,226.00000,135.60000,MedCost,Ultra,,144.64,,,,,,,144.64,183.06,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,MedCost,Ultra,,115.26,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,inpatient,,,370.00000,222.00000,MedCost,Ultra,,236.80,,,,,,,236.80,299.70,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,MedCost,Ultra,,188.70,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,inpatient,,,319.00000,191.40000,MedCost,Ultra,,204.16,,,,,,,204.16,258.39,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,MedCost,Ultra,,162.69,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,inpatient,,,319.00000,191.40000,MedCost,Ultra,,204.16,,,,,,,204.16,258.39,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,MedCost,Ultra,,162.69,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,inpatient,,,593.00000,355.80000,MedCost,Ultra,,379.52,,,,,,,379.52,480.33,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,MedCost,Ultra,,302.43,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,inpatient,,,548.00000,328.80000,MedCost,Ultra,,350.72,,,,,,,350.72,443.88,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,MedCost,Ultra,,279.48,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Ultra,,62.08,,,,,,,62.08,78.57,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Ultra,,49.47,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,,82.56,,,,,,,82.56,104.49,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,,65.79,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,inpatient,,,394.00000,236.40000,MedCost,Ultra,,252.16,,,,,,,252.16,319.14,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,MedCost,Ultra,,200.94,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,inpatient,,,313.00000,187.80000,MedCost,Ultra,,200.32,,,,,,,200.32,253.53,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,MedCost,Ultra,,159.63,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,inpatient,,,249.00000,149.40000,MedCost,Ultra,,159.36,,,,,,,159.36,201.69,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,MedCost,Ultra,,126.99,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,inpatient,,,77.00000,46.20000,MedCost,Ultra,,49.28,,,,,,,49.28,62.37,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,MedCost,Ultra,,39.27,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,inpatient,,,384.00000,230.40000,MedCost,Ultra,,245.76,,,,,,,245.76,311.04,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,MedCost,Ultra,,195.84,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,inpatient,,,132.00000,79.20000,MedCost,Ultra,,84.48,,,,,,,84.48,106.92,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,MedCost,Ultra,,67.32,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,inpatient,,,675.00000,405.00000,MedCost,Ultra,,432.00,,,,,,,432.00,546.75,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,MedCost,Ultra,,344.25,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,inpatient,,,189.00000,113.40000,MedCost,Ultra,,120.96,,,,,,,120.96,153.09,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,MedCost,Ultra,,96.39,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,inpatient,,,414.00000,248.40000,MedCost,Ultra,,264.96,,,,,,,264.96,335.34,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,MedCost,Ultra,,211.14,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,inpatient,,,256.00000,153.60000,MedCost,Ultra,,163.84,,,,,,,163.84,207.36,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,MedCost,Ultra,,130.56,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,inpatient,,,261.00000,156.60000,MedCost,Ultra,,167.04,,,,,,,167.04,211.41,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,MedCost,Ultra,,133.11,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Ultra,,100.48,,,,,,,100.48,127.17,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Ultra,,80.07,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,inpatient,,,157.00000,94.20000,MedCost,Ultra,,100.48,,,,,,,100.48,127.17,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,MedCost,Ultra,,80.07,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,inpatient,,,539.00000,323.40000,MedCost,Ultra,,344.96,,,,,,,344.96,436.59,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,MedCost,Ultra,,274.89,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,inpatient,,,139.00000,83.40000,MedCost,Ultra,,88.96,,,,,,,88.96,112.59,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,MedCost,Ultra,,70.89,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,inpatient,,,164.00000,98.40000,MedCost,Ultra,,104.96,,,,,,,104.96,132.84,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,MedCost,Ultra,,83.64,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,inpatient,,,18.00000,10.80000,MedCost,Ultra,,11.52,,,,,,,11.52,14.58,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,MedCost,Ultra,,9.18,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,inpatient,,,414.00000,248.40000,MedCost,Ultra,,264.96,,,,,,,264.96,335.34,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,MedCost,Ultra,,211.14,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,inpatient,,,247.00000,148.20000,MedCost,Ultra,,158.08,,,,,,,158.08,200.07,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,MedCost,Ultra,,125.97,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,inpatient,,,2191.00000,1314.60000,MedCost,Ultra,,1402.24,,,,,,,1402.24,1774.71,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,MedCost,Ultra,,1117.41,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,inpatient,,,353.00000,211.80000,MedCost,Ultra,,225.92,,,,,,,225.92,285.93,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,MedCost,Ultra,,180.03,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,inpatient,,,192.00000,115.20000,MedCost,Ultra,,122.88,,,,,,,122.88,155.52,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,MedCost,Ultra,,97.92,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,inpatient,,,708.00000,424.80000,MedCost,Ultra,,453.12,,,,,,,453.12,573.48,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,MedCost,Ultra,,361.08,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,inpatient,,,518.00000,310.80000,MedCost,Ultra,,331.52,,,,,,,331.52,419.58,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,MedCost,Ultra,,264.18,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,inpatient,,,354.00000,212.40000,MedCost,Ultra,,226.56,,,,,,,226.56,286.74,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,MedCost,Ultra,,180.54,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,246.40,311.85,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,inpatient,,,367.00000,220.20000,MedCost,Ultra,,234.88,,,,,,,234.88,297.27,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,MedCost,Ultra,,187.17,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,246.40,311.85,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,inpatient,,,519.00000,311.40000,MedCost,Ultra,,332.16,,,,,,,332.16,420.39,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,MedCost,Ultra,,264.69,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,inpatient,,,1285.00000,771.00000,MedCost,Ultra,,822.40,,,,,,,822.40,1040.85,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,MedCost,Ultra,,655.35,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,51.20,64.80,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,246.40,311.85,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,inpatient,,,367.00000,220.20000,MedCost,Ultra,,234.88,,,,,,,234.88,297.27,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,MedCost,Ultra,,187.17,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,inpatient,,,312.00000,187.20000,MedCost,Ultra,,199.68,,,,,,,199.68,252.72,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,MedCost,Ultra,,159.12,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,inpatient,,,129.00000,77.40000,MedCost,Ultra,,82.56,,,,,,,82.56,104.49,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,MedCost,Ultra,,65.79,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,inpatient,,,1243.00000,745.80000,MedCost,Ultra,,795.52,,,,,,,795.52,1006.83,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,MedCost,Ultra,,633.93,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,inpatient,,,24.00000,14.40000,MedCost,Ultra,,15.36,,,,,,,15.36,19.44,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,MedCost,Ultra,,12.24,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,inpatient,,,192.00000,115.20000,MedCost,Ultra,,122.88,,,,,,,122.88,155.52,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,MedCost,Ultra,,97.92,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,51.20,64.80,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,inpatient,,,908.00000,544.80000,MedCost,Ultra,,581.12,,,,,,,581.12,735.48,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,MedCost,Ultra,,463.08,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,inpatient,,,660.00000,396.00000,MedCost,Ultra,,422.40,,,,,,,422.40,534.60,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,MedCost,Ultra,,336.60,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,inpatient,,,474.00000,284.40000,MedCost,Ultra,,303.36,,,,,,,303.36,383.94,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,MedCost,Ultra,,241.74,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,inpatient,,,356.00000,213.60000,MedCost,Ultra,,227.84,,,,,,,227.84,288.36,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,MedCost,Ultra,,181.56,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,inpatient,,,125.00000,75.00000,MedCost,Ultra,,80.00,,,,,,,80.00,101.25,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,MedCost,Ultra,,63.75,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,inpatient,,,150.00000,90.00000,MedCost,Ultra,,96.00,,,,,,,96.00,121.50,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,MedCost,Ultra,,76.50,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,inpatient,,,95.00000,57.00000,MedCost,Ultra,,60.80,,,,,,,60.80,76.95,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,MedCost,Ultra,,48.45,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,inpatient,,,166.00000,99.60000,MedCost,Ultra,,106.24,,,,,,,106.24,134.46,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,MedCost,Ultra,,84.66,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,inpatient,,,80.00000,48.00000,MedCost,Ultra,,51.20,,,,,,,51.20,64.80,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,MedCost,Ultra,,40.80,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,inpatient,,,159.00000,95.40000,MedCost,Ultra,,101.76,,,,,,,101.76,128.79,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,MedCost,Ultra,,81.09,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,inpatient,,,1589.00000,953.40000,MedCost,Ultra,,1016.96,,,,,,,1016.96,1287.09,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,MedCost,Ultra,,810.39,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,inpatient,,,798.00000,478.80000,MedCost,Ultra,,510.72,,,,,,,510.72,646.38,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,MedCost,Ultra,,406.98,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,inpatient,,,326.00000,195.60000,MedCost,Ultra,,208.64,,,,,,,208.64,264.06,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,MedCost,Ultra,,166.26,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,inpatient,,,66.00000,39.60000,MedCost,Ultra,,42.24,,,,,,,42.24,53.46,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,MedCost,Ultra,,33.66,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,inpatient,,,42.00000,25.20000,MedCost,Ultra,,26.88,,,,,,,26.88,34.02,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,MedCost,Ultra,,21.42,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,inpatient,,,105.00000,63.00000,MedCost,Ultra,,67.20,,,,,,,67.20,85.05,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,MedCost,Ultra,,53.55,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,inpatient,,,248.00000,148.80000,MedCost,Ultra,,158.72,,,,,,,158.72,200.88,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,MedCost,Ultra,,126.48,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,300.00000,180.00000,MedCost,Ultra,,192.00,,,,,,,192.00,243.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,MedCost,Ultra,,153.00,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,300.00000,180.00000,MedCost,Ultra,,192.00,,,,,,,192.00,243.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,MedCost,Ultra,,153.00,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,277.00000,166.20000,MedCost,Ultra,,177.28,,,,,,,177.28,224.37,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,MedCost,Ultra,,141.27,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,inpatient,,,566.00000,339.60000,MedCost,Ultra,,362.24,,,,,,,362.24,458.46,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,MedCost,Ultra,,288.66,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,inpatient,,,57.00000,34.20000,MedCost,Ultra,,36.48,,,,,,,36.48,46.17,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,MedCost,Ultra,,29.07,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,inpatient,,,679.00000,407.40000,MedCost,Ultra,,434.56,,,,,,,434.56,549.99,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,MedCost,Ultra,,346.29,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,inpatient,,,651.00000,390.60000,MedCost,Ultra,,416.64,,,,,,,416.64,527.31,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,MedCost,Ultra,,332.01,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Ultra,,666.24,,,,,,,666.24,843.21,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Ultra,,530.91,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,inpatient,,,1070.00000,642.00000,MedCost,Ultra,,684.80,,,,,,,684.80,866.70,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,MedCost,Ultra,,545.70,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Ultra,,137.60,,,,,,,137.60,174.15,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Ultra,,109.65,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,inpatient,,,419.00000,251.40000,MedCost,Ultra,,268.16,,,,,,,268.16,339.39,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,MedCost,Ultra,,213.69,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,inpatient,,,294.00000,176.40000,MedCost,Ultra,,188.16,,,,,,,188.16,238.14,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,MedCost,Ultra,,149.94,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,inpatient,,,949.00000,569.40000,MedCost,Ultra,,607.36,,,,,,,607.36,768.69,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,MedCost,Ultra,,483.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,inpatient,,,1240.00000,744.00000,MedCost,Ultra,,793.60,,,,,,,793.60,1004.40,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,MedCost,Ultra,,632.40,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,inpatient,,,600.00000,360.00000,MedCost,Ultra,,384.00,,,,,,,384.00,486.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,MedCost,Ultra,,306.00,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,inpatient,,,91.00000,54.60000,MedCost,Ultra,,58.24,,,,,,,58.24,73.71,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,MedCost,Ultra,,46.41,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,inpatient,,,1528.00000,916.80000,MedCost,Ultra,,977.92,,,,,,,977.92,1237.68,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,MedCost,Ultra,,779.28,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,inpatient,,,28.00000,16.80000,MedCost,Ultra,,17.92,,,,,,,17.92,22.68,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,MedCost,Ultra,,14.28,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,,84.15,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,,84.15,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,inpatient,,,165.00000,99.00000,MedCost,Ultra,,105.60,,,,,,,105.60,133.65,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,MedCost,Ultra,,84.15,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,inpatient,,,59.00000,35.40000,MedCost,Ultra,,37.76,,,,,,,37.76,47.79,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,MedCost,Ultra,,30.09,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Ultra,,666.24,,,,,,,666.24,843.21,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Ultra,,530.91,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,inpatient,,,1041.00000,624.60000,MedCost,Ultra,,666.24,,,,,,,666.24,843.21,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,MedCost,Ultra,,530.91,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,inpatient,,,1160.00000,696.00000,MedCost,Ultra,,742.40,,,,,,,742.40,939.60,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,MedCost,Ultra,,591.60,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,inpatient,,,62.00000,37.20000,MedCost,Ultra,,39.68,,,,,,,39.68,50.22,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,MedCost,Ultra,,31.62,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,inpatient,,,2616.00000,1569.60000,MedCost,Ultra,,1674.24,,,,,,,1674.24,7039.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,MedCost,Ultra,,1334.16,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Ultra,,5484.80,,,,,,,5484.80,7039.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Ultra,,4370.70,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Ultra,,5484.80,,,,,,,5484.80,7039.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Ultra,,4370.70,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Ultra,,5484.80,,,,,,,5484.80,7039.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Ultra,,4370.70,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Ultra,,5484.80,,,,,,,5484.80,7039.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Ultra,,4370.70,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Ultra,,5484.80,,,,,,,5484.80,7039.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Ultra,,4370.70,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,inpatient,,,35477.00000,21286.20000,MedCost,Ultra,,22705.28,,,,,,,7039.00,28736.37,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,MedCost,Ultra,,18093.27,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,inpatient,,,6012.00000,3607.20000,MedCost,Ultra,,3847.68,,,,,,,3847.68,7039.00,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,MedCost,Ultra,,3066.12,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1583.36,,,,,,,1583.36,7039.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1261.74,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,inpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1583.36,,,,,,,1583.36,7039.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,MedCost,Ultra,,1261.74,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,inpatient,,,6715.00000,4029.00000,MedCost,Ultra,,4297.60,,,,,,,4297.60,7039.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,MedCost,Ultra,,3424.65,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,inpatient,,,2043.00000,1225.80000,MedCost,Ultra,,1307.52,,,,,,,1307.52,7039.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,MedCost,Ultra,,1041.93,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,inpatient,,,3368.00000,2020.80000,MedCost,Ultra,,2155.52,,,,,,,2155.52,7039.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,MedCost,Ultra,,1717.68,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,inpatient,,,909.00000,545.40000,MedCost,Ultra,,581.76,,,,,,,581.76,7039.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,MedCost,Ultra,,463.59,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,inpatient,,,909.00000,545.40000,MedCost,Ultra,,581.76,,,,,,,581.76,7039.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,MedCost,Ultra,,463.59,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,inpatient,,,1981.00000,1188.60000,MedCost,Ultra,,1267.84,,,,,,,1267.84,7039.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,MedCost,Ultra,,1010.31,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,inpatient,,,1981.00000,1188.60000,MedCost,Ultra,,1267.84,,,,,,,1267.84,7039.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,MedCost,Ultra,,1010.31,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,inpatient,,,4166.00000,2499.60000,MedCost,Ultra,,2666.24,,,,,,,2666.24,7039.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,MedCost,Ultra,,2124.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,inpatient,,,4166.00000,2499.60000,MedCost,Ultra,,2666.24,,,,,,,2666.24,7039.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,MedCost,Ultra,,2124.66,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,inpatient,,,1896.00000,1137.60000,MedCost,Ultra,,1213.44,,,,,,,1213.44,7039.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,MedCost,Ultra,,966.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,inpatient,,,1896.00000,1137.60000,MedCost,Ultra,,1213.44,,,,,,,1213.44,7039.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,MedCost,Ultra,,966.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,inpatient,,,447.00000,268.20000,MedCost,Ultra,,286.08,,,,,,,286.08,7039.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,MedCost,Ultra,,227.97,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,inpatient,,,823.00000,493.80000,MedCost,Ultra,,526.72,,,,,,,526.72,7039.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,MedCost,Ultra,,419.73,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Ultra,,1148.16,,,,,,,1148.16,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Ultra,,914.94,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Ultra,,1148.16,,,,,,,1148.16,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Ultra,,914.94,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Ultra,,906.24,,,,,,,906.24,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Ultra,,722.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Ultra,,906.24,,,,,,,906.24,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Ultra,,722.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,inpatient,,,1586.00000,951.60000,MedCost,Ultra,,1015.04,,,,,,,1015.04,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,MedCost,Ultra,,808.86,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,inpatient,,,1586.00000,951.60000,MedCost,Ultra,,1015.04,,,,,,,1015.04,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,MedCost,Ultra,,808.86,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Ultra,,906.24,,,,,,,906.24,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Ultra,,722.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,inpatient,,,1416.00000,849.60000,MedCost,Ultra,,906.24,,,,,,,906.24,7039.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,MedCost,Ultra,,722.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,inpatient,,,7717.00000,4630.20000,MedCost,Ultra,,4938.88,,,,,,,4938.88,7039.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,MedCost,Ultra,,3935.67,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,inpatient,,,3858.00000,2314.80000,MedCost,Ultra,,2469.12,,,,,,,2469.12,7039.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,MedCost,Ultra,,1967.58,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,inpatient,,,3858.00000,2314.80000,MedCost,Ultra,,2469.12,,,,,,,2469.12,7039.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,MedCost,Ultra,,1967.58,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,inpatient,,,7166.00000,4299.60000,MedCost,Ultra,,4586.24,,,,,,,4586.24,7039.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,MedCost,Ultra,,3654.66,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,inpatient,,,7166.00000,4299.60000,MedCost,Ultra,,4586.24,,,,,,,4586.24,7039.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,MedCost,Ultra,,3654.66,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Ultra,,3527.68,,,,,,,3527.68,7039.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Ultra,,2811.12,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Ultra,,3527.68,,,,,,,3527.68,7039.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Ultra,,2811.12,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,inpatient,,,1378.00000,826.80000,MedCost,Ultra,,881.92,,,,,,,881.92,7039.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,MedCost,Ultra,,702.78,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,inpatient,,,1378.00000,826.80000,MedCost,Ultra,,881.92,,,,,,,881.92,7039.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,MedCost,Ultra,,702.78,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Ultra,,3527.68,,,,,,,3527.68,7039.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Ultra,,2811.12,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,inpatient,,,5512.00000,3307.20000,MedCost,Ultra,,3527.68,,,,,,,3527.68,7039.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,MedCost,Ultra,,2811.12,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,inpatient,,,2659.00000,1595.40000,MedCost,Ultra,,1701.76,,,,,,,1701.76,7039.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,MedCost,Ultra,,1356.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Ultra,,5484.80,,,,,,,5484.80,7039.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Ultra,,4370.70,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,inpatient,,,8570.00000,5142.00000,MedCost,Ultra,,5484.80,,,,,,,5484.80,7039.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,MedCost,Ultra,,4370.70,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,inpatient,,,794.00000,476.40000,MedCost,Ultra,,508.16,,,,,,,508.16,7039.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,MedCost,Ultra,,404.94,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,inpatient,,,29057.00000,17434.20000,MedCost,Ultra,,18596.48,,,,,,,7039.00,23536.17,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,MedCost,Ultra,,14819.07,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,inpatient,,,4394.00000,2636.40000,MedCost,Ultra,,2812.16,,,,,,,2812.16,7039.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,MedCost,Ultra,,2240.94,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,inpatient,,,4394.00000,2636.40000,MedCost,Ultra,,2812.16,,,,,,,2812.16,7039.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,MedCost,Ultra,,2240.94,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,280.96,7039.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,280.96,7039.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,280.96,7039.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,inpatient,,,439.00000,263.40000,MedCost,Ultra,,280.96,,,,,,,280.96,7039.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,MedCost,Ultra,,223.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1444.48,,,,,,,1444.48,7039.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1151.07,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1444.48,,,,,,,1444.48,7039.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1151.07,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1444.48,,,,,,,1444.48,7039.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1151.07,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,inpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1444.48,,,,,,,1444.48,7039.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,MedCost,Ultra,,1151.07,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,inpatient,,,16729.00000,10037.40000,MedCost,Ultra,,10706.56,,,,,,,7039.00,13550.49,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,MedCost,Ultra,,8531.79,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,inpatient,,,16729.00000,10037.40000,MedCost,Ultra,,10706.56,,,,,,,7039.00,13550.49,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,MedCost,Ultra,,8531.79,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,inpatient,,,27882.00000,16729.20000,MedCost,Ultra,,17844.48,,,,,,,7039.00,22584.42,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,MedCost,Ultra,,14219.82,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,inpatient,,,27882.00000,16729.20000,MedCost,Ultra,,17844.48,,,,,,,7039.00,22584.42,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,MedCost,Ultra,,14219.82,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,inpatient,,,10037.00000,6022.20000,MedCost,Ultra,,6423.68,,,,,,,6423.68,8129.97,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,MedCost,Ultra,,5118.87,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,inpatient,,,10037.00000,6022.20000,MedCost,Ultra,,6423.68,,,,,,,6423.68,8129.97,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,MedCost,Ultra,,5118.87,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,inpatient,,,23142.00000,13885.20000,MedCost,Ultra,,14810.88,,,,,,,7039.00,18745.02,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,MedCost,Ultra,,11802.42,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,inpatient,,,23142.00000,13885.20000,MedCost,Ultra,,14810.88,,,,,,,7039.00,18745.02,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,MedCost,Ultra,,11802.42,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,inpatient,,,9307.00000,5584.20000,MedCost,Ultra,,5956.48,,,,,,,5956.48,7538.67,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,MedCost,Ultra,,4746.57,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,inpatient,,,9307.00000,5584.20000,MedCost,Ultra,,5956.48,,,,,,,5956.48,7538.67,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,MedCost,Ultra,,4746.57,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,inpatient,,,23479.00000,14087.40000,MedCost,Ultra,,15026.56,,,,,,,7039.00,19017.99,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,MedCost,Ultra,,11974.29,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,inpatient,,,23479.00000,14087.40000,MedCost,Ultra,,15026.56,,,,,,,7039.00,19017.99,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,MedCost,Ultra,,11974.29,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,inpatient,,,21152.00000,12691.20000,MedCost,Ultra,,13537.28,,,,,,,7039.00,17133.12,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,MedCost,Ultra,,10787.52,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,inpatient,,,21152.00000,12691.20000,MedCost,Ultra,,13537.28,,,,,,,7039.00,17133.12,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,MedCost,Ultra,,10787.52,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,inpatient,,,28133.00000,16879.80000,MedCost,Ultra,,18005.12,,,,,,,7039.00,22787.73,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,MedCost,Ultra,,14347.83,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,inpatient,,,28133.00000,16879.80000,MedCost,Ultra,,18005.12,,,,,,,7039.00,22787.73,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,MedCost,Ultra,,14347.83,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,inpatient,,,12328.00000,7396.80000,MedCost,Ultra,,7889.92,,,,,,,7039.00,9985.68,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,MedCost,Ultra,,6287.28,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,inpatient,,,23300.00000,13980.00000,MedCost,Ultra,,14912.00,,,,,,,7039.00,18873.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,MedCost,Ultra,,11883.00,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,inpatient,,,23300.00000,13980.00000,MedCost,Ultra,,14912.00,,,,,,,7039.00,18873.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,MedCost,Ultra,,11883.00,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,inpatient,,,21204.00000,12722.40000,MedCost,Ultra,,13570.56,,,,,,,7039.00,17175.24,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,MedCost,Ultra,,10814.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,inpatient,,,21204.00000,12722.40000,MedCost,Ultra,,13570.56,,,,,,,7039.00,17175.24,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,MedCost,Ultra,,10814.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,inpatient,,,24040.00000,14424.00000,MedCost,Ultra,,15385.60,,,,,,,7039.00,19472.40,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,MedCost,Ultra,,12260.40,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,inpatient,,,24040.00000,14424.00000,MedCost,Ultra,,15385.60,,,,,,,7039.00,19472.40,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,MedCost,Ultra,,12260.40,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,inpatient,,,9493.00000,5695.80000,MedCost,Ultra,,6075.52,,,,,,,6075.52,7689.33,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,MedCost,Ultra,,4841.43,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,inpatient,,,9493.00000,5695.80000,MedCost,Ultra,,6075.52,,,,,,,6075.52,7689.33,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,MedCost,Ultra,,4841.43,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,inpatient,,,20464.00000,12278.40000,MedCost,Ultra,,13096.96,,,,,,,7039.00,16575.84,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,MedCost,Ultra,,10436.64,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,inpatient,,,20464.00000,12278.40000,MedCost,Ultra,,13096.96,,,,,,,7039.00,16575.84,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,MedCost,Ultra,,10436.64,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,inpatient,,,17629.00000,10577.40000,MedCost,Ultra,,11282.56,,,,,,,7039.00,14279.49,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,MedCost,Ultra,,8990.79,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,inpatient,,,17629.00000,10577.40000,MedCost,Ultra,,11282.56,,,,,,,7039.00,14279.49,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,MedCost,Ultra,,8990.79,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,inpatient,,,20588.00000,12352.80000,MedCost,Ultra,,13176.32,,,,,,,7039.00,16676.28,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,MedCost,Ultra,,10499.88,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Ultra,LM,10367.36,,,,,,,7039.00,13121.19,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Ultra,LM,8261.49,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Ultra,RI,10367.36,,,,,,,7039.00,13121.19,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Ultra,RI,8261.49,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Ultra,RC,10367.36,,,,,,,7039.00,13121.19,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Ultra,RC,8261.49,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Ultra,LD,10367.36,,,,,,,7039.00,13121.19,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Ultra,LD,8261.49,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,inpatient,,,16199.00000,9719.40000,MedCost,Ultra,LC,10367.36,,,,,,,7039.00,13121.19,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,MedCost,Ultra,LC,8261.49,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Ultra,LC,5348.48,,,,,,,5348.48,7039.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Ultra,LC,4262.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Ultra,RI,5348.48,,,,,,,5348.48,7039.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Ultra,RI,4262.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Ultra,RC,5348.48,,,,,,,5348.48,7039.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Ultra,RC,4262.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Ultra,LD,5348.48,,,,,,,5348.48,7039.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Ultra,LD,4262.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,inpatient,,,8357.00000,5014.20000,MedCost,Ultra,LC,5348.48,,,,,,,5348.48,7039.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,MedCost,Ultra,LC,4262.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,LM,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,LM,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,RI,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,RI,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,RC,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,RC,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,LD,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,LD,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,LC,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,LC,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,LM,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,LM,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,RI,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,RI,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,RC,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,RC,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,LD,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,LD,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,inpatient,,,14358.00000,8614.80000,MedCost,Ultra,LC,9189.12,,,,,,,7039.00,11629.98,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,MedCost,Ultra,LC,7322.58,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,LM,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,LM,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,RI,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,RI,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,RC,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,RC,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,LD,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,LD,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,LC,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,LC,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,LM,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,LM,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,RI,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,RI,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,RC,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,RC,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,LD,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,LD,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,inpatient,,,21430.00000,12858.00000,MedCost,Ultra,LC,13715.20,,,,,,,7039.00,17358.30,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,MedCost,Ultra,LC,10929.30,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,LM,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,LM,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,RI,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,RI,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,RC,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,RC,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,LD,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,LD,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,LC,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,LC,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,RC,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,RC,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,LD,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,LD,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,inpatient,,,22715.00000,13629.00000,MedCost,Ultra,LC,14537.60,,,,,,,7039.00,18399.15,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,MedCost,Ultra,LC,11584.65,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LM,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LM,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,RI,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,RI,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LM,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LM,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,RI,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,RI,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,20656.02,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LM,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LM,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,RI,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,RI,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,RC,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LD,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,inpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,25921.28,,,,,,,7039.00,32806.62,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,MedCost,Ultra,LC,20656.02,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,inpatient,,,23143.00000,13885.80000,MedCost,Ultra,,14811.52,,,,,,,7039.00,18745.83,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,MedCost,Ultra,,11802.93,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,inpatient,,,23143.00000,13885.80000,MedCost,Ultra,,14811.52,,,,,,,7039.00,18745.83,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,MedCost,Ultra,,11802.93,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,inpatient,,,23787.00000,14272.20000,MedCost,Ultra,,15223.68,,,,,,,7039.00,19267.47,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,MedCost,Ultra,,12131.37,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,inpatient,,,23787.00000,14272.20000,MedCost,Ultra,,15223.68,,,,,,,7039.00,19267.47,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,MedCost,Ultra,,12131.37,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,LM,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,LM,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,RI,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,RI,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,RC,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,RC,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,LD,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,LD,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,LC,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,LC,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,LM,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,LM,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,RI,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,RI,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,RC,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,RC,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,LD,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,LD,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,inpatient,,,24858.00000,14914.80000,MedCost,Ultra,LC,15909.12,,,,,,,7039.00,20134.98,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,MedCost,Ultra,LC,12677.58,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LM,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LM,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,RI,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,RI,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,RC,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,RC,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LD,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LD,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LC,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LC,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LM,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LM,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,RI,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,RI,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,RC,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,RC,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LD,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LD,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LC,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LC,13224.30,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LM,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LM,13224.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,RI,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,RI,13224.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,RC,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,RC,13224.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LD,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LD,13224.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,inpatient,,,25930.00000,15558.00000,MedCost,Ultra,LC,16595.20,,,,,,,7039.00,21003.30,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,MedCost,Ultra,LC,13224.30,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,inpatient,,,393.00000,235.80000,MedCost,Ultra,,251.52,,,,,,,251.52,7039.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,MedCost,Ultra,,200.43,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,inpatient,,,1664.00000,998.40000,MedCost,Ultra,,1064.96,,,,,,,1064.96,7039.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,MedCost,Ultra,,848.64,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,inpatient,,,1865.00000,1119.00000,MedCost,Ultra,,1193.60,,,,,,,1193.60,7039.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,MedCost,Ultra,,951.15,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,inpatient,,,422.00000,253.20000,MedCost,Ultra,,270.08,,,,,,,270.08,7039.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,MedCost,Ultra,,215.22,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,inpatient,,,2527.00000,1516.20000,MedCost,Ultra,,1617.28,,,,,,,1617.28,7039.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,MedCost,Ultra,,1288.77,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,inpatient,,,986.00000,591.60000,MedCost,Ultra,,631.04,,,,,,,631.04,7039.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,MedCost,Ultra,,502.86,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,inpatient,,,11572.00000,6943.20000,MedCost,Ultra,,7406.08,,,,,,,7039.00,9373.32,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,MedCost,Ultra,,5901.72,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,inpatient,,,10706.00000,6423.60000,MedCost,Ultra,,6851.84,,,,,,,6851.84,8671.86,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,MedCost,Ultra,,5460.06,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,inpatient,,,10706.00000,6423.60000,MedCost,Ultra,,6851.84,,,,,,,6851.84,8671.86,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,MedCost,Ultra,,5460.06,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,inpatient,,,10210.00000,6126.00000,MedCost,Ultra,,6534.40,,,,,,,6534.40,8270.10,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,MedCost,Ultra,,5207.10,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,inpatient,,,4250.00000,2550.00000,MedCost,Ultra,,2720.00,,,,,,,2720.00,7039.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,MedCost,Ultra,,2167.50,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,inpatient,,,7367.00000,4420.20000,MedCost,Ultra,,4714.88,,,,,,,4714.88,7039.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,MedCost,Ultra,,3757.17,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,inpatient,,,10893.00000,6535.80000,MedCost,Ultra,,6971.52,,,,,,,6971.52,8823.33,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,MedCost,Ultra,,5555.43,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,inpatient,,,9673.00000,5803.80000,MedCost,Ultra,,6190.72,,,,,,,6190.72,7835.13,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,MedCost,Ultra,,4933.23,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,inpatient,,,10326.00000,6195.60000,MedCost,Ultra,,6608.64,,,,,,,6608.64,8364.06,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,MedCost,Ultra,,5266.26,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,inpatient,,,4543.00000,2725.80000,MedCost,Ultra,,2907.52,,,,,,,2907.52,7039.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,MedCost,Ultra,,2316.93,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,inpatient,,,10624.00000,6374.40000,MedCost,Ultra,,6799.36,,,,,,,6799.36,8605.44,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,MedCost,Ultra,,5418.24,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,inpatient,,,13251.00000,7950.60000,MedCost,Ultra,,8480.64,,,,,,,7039.00,10733.31,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,MedCost,Ultra,,6758.01,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,inpatient,,,11937.00000,7162.20000,MedCost,Ultra,,7639.68,,,,,,,7039.00,9668.97,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,MedCost,Ultra,,6087.87,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,inpatient,,,12734.00000,7640.40000,MedCost,Ultra,,8149.76,,,,,,,7039.00,10314.54,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,MedCost,Ultra,,6494.34,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,inpatient,,,12950.00000,7770.00000,MedCost,Ultra,,8288.00,,,,,,,7039.00,10489.50,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,MedCost,Ultra,,6604.50,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,inpatient,,,15877.00000,9526.20000,MedCost,Ultra,,10161.28,,,,,,,7039.00,12860.37,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,MedCost,Ultra,,8097.27,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,inpatient,,,6778.00000,4066.80000,MedCost,Ultra,,4337.92,,,,,,,4337.92,7039.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,MedCost,Ultra,,3456.78,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,inpatient,,,203.00000,121.80000,MedCost,Ultra,,129.92,,,,,,,129.92,7039.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,MedCost,Ultra,,103.53,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,inpatient,,,97.00000,58.20000,MedCost,Ultra,,62.08,,,,,,,62.08,7039.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,MedCost,Ultra,,49.47,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,inpatient,,,1503.00000,901.80000,MedCost,Ultra,,961.92,,,,,,,961.92,7039.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,MedCost,Ultra,,766.53,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,inpatient,,,4128.00000,2476.80000,MedCost,Ultra,,2641.92,,,,,,,2641.92,7039.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,MedCost,Ultra,,2105.28,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,inpatient,,,8064.00000,4838.40000,MedCost,Ultra,,5160.96,,,,,,,5160.96,7039.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,MedCost,Ultra,,4112.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,inpatient,,,484.00000,290.40000,MedCost,Ultra,,309.76,,,,,,,309.76,7039.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,MedCost,Ultra,,246.84,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,400.64,7039.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,inpatient,,,626.00000,375.60000,MedCost,Ultra,,400.64,,,,,,,400.64,7039.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,MedCost,Ultra,,319.26,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,inpatient,,,215.00000,129.00000,MedCost,Ultra,,137.60,,,,,,,137.60,7039.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,MedCost,Ultra,,109.65,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,inpatient,,,7671.00000,4602.60000,MedCost,Ultra,,4909.44,,,,,,,4909.44,7039.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,MedCost,Ultra,,3912.21,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,inpatient,,,39133.00000,23479.80000,MedCost,Ultra,,25045.12,,,,,,,7039.00,31697.73,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,MedCost,Ultra,,19957.83,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,inpatient,,,12282.00000,7369.20000,MedCost,Ultra,,7860.48,,,,,,,7039.00,9948.42,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,MedCost,Ultra,,6263.82,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,inpatient,,,2525.00000,1515.00000,MedCost,Ultra,,1616.00,,,,,,,1616.00,7039.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,MedCost,Ultra,,1287.75,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,inpatient,,,2824.00000,1694.40000,MedCost,Ultra,,1807.36,,,,,,,1807.36,7039.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,MedCost,Ultra,,1440.24,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,inpatient,,,1266.00000,759.60000,MedCost,Ultra,,810.24,,,,,,,810.24,7039.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,MedCost,Ultra,,645.66,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,inpatient,,,528.00000,316.80000,MedCost,Ultra,,337.92,,,,,,,337.92,7039.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,MedCost,Ultra,,269.28,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,inpatient,,,528.00000,316.80000,MedCost,Ultra,,337.92,,,,,,,337.92,7039.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,MedCost,Ultra,,269.28,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,inpatient,,,528.00000,316.80000,MedCost,Ultra,,337.92,,,,,,,337.92,7039.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,MedCost,Ultra,,269.28,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,inpatient,,,7882.00000,4729.20000,MedCost,Ultra,,5044.48,,,,,,,5044.48,7039.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,MedCost,Ultra,,4019.82,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,inpatient,,,7882.00000,4729.20000,MedCost,Ultra,,5044.48,,,,,,,5044.48,7039.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,MedCost,Ultra,,4019.82,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,inpatient,,,14979.00000,8987.40000,MedCost,Ultra,,9586.56,,,,,,,7039.00,12132.99,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,MedCost,Ultra,,7639.29,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,inpatient,,,14979.00000,8987.40000,MedCost,Ultra,,9586.56,,,,,,,7039.00,12132.99,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,MedCost,Ultra,,7639.29,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,inpatient,,,18267.00000,10960.20000,MedCost,Ultra,,11690.88,,,,,,,7039.00,14796.27,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,MedCost,Ultra,,9316.17,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,inpatient,,,13268.00000,7960.80000,MedCost,Ultra,,8491.52,,,,,,,7039.00,10747.08,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,MedCost,Ultra,,6766.68,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,inpatient,,,15077.00000,9046.20000,MedCost,Ultra,,9649.28,,,,,,,7039.00,12212.37,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,MedCost,Ultra,,7689.27,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,inpatient,,,18194.00000,10916.40000,MedCost,Ultra,,11644.16,,,,,,,7039.00,14737.14,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,MedCost,Ultra,,9278.94,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,inpatient,,,3193.00000,1915.80000,MedCost,Ultra,,2043.52,,,,,,,2043.52,7039.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,MedCost,Ultra,,1628.43,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,inpatient,,,14089.00000,8453.40000,MedCost,Ultra,,9016.96,,,,,,,7039.00,11412.09,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,MedCost,Ultra,,7185.39,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,inpatient,,,14089.00000,8453.40000,MedCost,Ultra,,9016.96,,,,,,,7039.00,11412.09,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,MedCost,Ultra,,7185.39,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,inpatient,,,10215.00000,6129.00000,MedCost,Ultra,,6537.60,,,,,,,6537.60,8274.15,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,MedCost,Ultra,,5209.65,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,inpatient,,,2944.00000,1766.40000,MedCost,Ultra,,1884.16,,,,,,,1884.16,7039.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,MedCost,Ultra,,1501.44,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,inpatient,,,2902.00000,1741.20000,MedCost,Ultra,,1857.28,,,,,,,1857.28,7039.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,MedCost,Ultra,,1480.02,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,inpatient,,,2902.00000,1741.20000,MedCost,Ultra,,1857.28,,,,,,,1857.28,7039.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,MedCost,Ultra,,1480.02,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,inpatient,,,20392.00000,12235.20000,MedCost,Ultra,,13050.88,,,,,,,7039.00,16517.52,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,MedCost,Ultra,,10399.92,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,inpatient,,,14925.00000,8955.00000,MedCost,Ultra,,9552.00,,,,,,,7039.00,12089.25,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,MedCost,Ultra,,7611.75,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,inpatient,,,2367.00000,1420.20000,MedCost,Ultra,,1514.88,,,,,,,1514.88,7039.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,MedCost,Ultra,,1207.17,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,inpatient,,,23786.00000,14271.60000,MedCost,Ultra,,15223.04,,,,,,,7039.00,19266.66,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,MedCost,Ultra,,12130.86,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,inpatient,,,24521.00000,14712.60000,MedCost,Ultra,,15693.44,,,,,,,7039.00,19862.01,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,MedCost,Ultra,,12505.71,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,inpatient,,,26728.00000,16036.80000,MedCost,Ultra,,17105.92,,,,,,,7039.00,21649.68,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,MedCost,Ultra,,13631.28,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,inpatient,,,8508.00000,5104.80000,MedCost,Ultra,,5445.12,,,,,,,5445.12,7039.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,MedCost,Ultra,,4339.08,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,inpatient,,,11401.00000,6840.60000,MedCost,Ultra,,7296.64,,,,,,,7039.00,9234.81,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,MedCost,Ultra,,5814.51,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,inpatient,,,11401.00000,6840.60000,MedCost,Ultra,,7296.64,,,,,,,7039.00,9234.81,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,MedCost,Ultra,,5814.51,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,inpatient,,,49887.00000,29932.20000,MedCost,Ultra,,31927.68,,,,,,,7039.00,40408.47,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,MedCost,Ultra,,25442.37,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,inpatient,,,5750.00000,3450.00000,MedCost,Ultra,,3680.00,,,,,,,3680.00,7039.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,MedCost,Ultra,,2932.50,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,inpatient,,,3821.00000,2292.60000,MedCost,Ultra,,2445.44,,,,,,,2445.44,7039.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,MedCost,Ultra,,1948.71,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,inpatient,,,57698.00000,34618.80000,MedCost,Ultra,,36926.72,,,,,,,7039.00,46735.38,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,MedCost,Ultra,,29425.98,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,inpatient,,,2639.00000,1583.40000,MedCost,Ultra,,1688.96,,,,,,,1688.96,7039.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,MedCost,Ultra,,1345.89,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,inpatient,,,11667.00000,7000.20000,MedCost,Ultra,,7466.88,,,,,,,7466.88,9485.27,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,MedCost,Ultra,,5950.17,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,inpatient,,,2086.00000,1251.60000,MedCost,Ultra,,1335.04,,,,,,,1335.04,7039.00,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,MedCost,Ultra,,1063.86,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,inpatient,,,4188.00000,2512.80000,MedCost,Ultra,,2680.32,,,,,,,2680.32,7039.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,MedCost,Ultra,,2135.88,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,inpatient,,,6480.00000,3888.00000,MedCost,Ultra,,4147.20,,,,,,,4147.20,7039.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,MedCost,Ultra,,3304.80,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,inpatient,,,6480.00000,3888.00000,MedCost,Ultra,,4147.20,,,,,,,4147.20,7039.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,MedCost,Ultra,,3304.80,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,inpatient,,,3232.00000,1939.20000,MedCost,Ultra,,2068.48,,,,,,,2068.48,7039.00,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,MedCost,Ultra,,1648.32,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,inpatient,,,2295.00000,1377.00000,MedCost,Ultra,,1468.80,,,,,,,1468.80,7039.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,MedCost,Ultra,,1170.45,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,inpatient,,,3232.00000,1939.20000,MedCost,Ultra,,2068.48,,,,,,,2068.48,7039.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,MedCost,Ultra,,1648.32,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,inpatient,,,3232.00000,1939.20000,MedCost,Ultra,,2068.48,,,,,,,2068.48,7039.00,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,MedCost,Ultra,,1648.32,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,inpatient,,,3043.00000,1825.80000,MedCost,Ultra,,1947.52,,,,,,,1947.52,7039.00,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,MedCost,Ultra,,1551.93,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,inpatient,,,2787.00000,1672.20000,MedCost,Ultra,,1783.68,,,,,,,1783.68,7039.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,MedCost,Ultra,,1421.37,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,inpatient,,,9580.00000,5748.00000,MedCost,Ultra,,6131.20,,,,,,,6131.20,7759.80,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,MedCost,Ultra,,4885.80,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,inpatient,,,15230.00000,9138.00000,MedCost,Ultra,,9747.20,,,,,,,7039.00,12336.30,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,MedCost,Ultra,,7767.30,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,inpatient,,,15230.00000,9138.00000,MedCost,Ultra,,9747.20,,,,,,,7039.00,12336.30,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,MedCost,Ultra,,7767.30,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,inpatient,,,1624.00000,974.40000,MedCost,Ultra,,1039.36,,,,,,,1039.36,7039.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,MedCost,Ultra,,828.24,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,inpatient,,,8084.00000,4850.40000,MedCost,Ultra,,5173.76,,,,,,,5173.76,7039.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,MedCost,Ultra,,4122.84,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,inpatient,,,1658.00000,994.80000,MedCost,Ultra,,1061.12,,,,,,,1061.12,7039.00,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,MedCost,Ultra,,845.58,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,inpatient,,,3156.00000,1893.60000,MedCost,Ultra,,2019.84,,,,,,,2019.84,7039.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,MedCost,Ultra,,1609.56,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,inpatient,,,25442.00000,15265.20000,MedCost,Ultra,,16282.88,,,,,,,7039.00,20608.02,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,MedCost,Ultra,,12975.42,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,inpatient,,,22534.00000,13520.40000,MedCost,Ultra,,14421.76,,,,,,,7039.00,18252.54,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,MedCost,Ultra,,11492.34,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,inpatient,,,22534.00000,13520.40000,MedCost,Ultra,,14421.76,,,,,,,7039.00,18252.54,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,MedCost,Ultra,,11492.34,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,inpatient,,,3025.00000,1815.00000,MedCost,Ultra,,1936.00,,,,,,,1936.00,7039.00,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,MedCost,Ultra,,1542.75,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,MedCost,Ultra,,907.52,,,,,,,907.52,7039.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,MedCost,Ultra,,723.18,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,inpatient,,,20137.00000,12082.20000,MedCost,Ultra,,12887.68,,,,,,,7039.00,16310.97,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,MedCost,Ultra,,10269.87,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,inpatient,,,22381.00000,13428.60000,MedCost,Ultra,,14323.84,,,,,,,7039.00,18128.61,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,MedCost,Ultra,,11414.31,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,inpatient,,,2482.00000,1489.20000,MedCost,Ultra,,1588.48,,,,,,,1588.48,7039.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,MedCost,Ultra,,1265.82,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,inpatient,,,1931.00000,1158.60000,MedCost,Ultra,,1235.84,,,,,,,1235.84,7039.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,MedCost,Ultra,,984.81,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,inpatient,,,5548.00000,3328.80000,MedCost,Ultra,,3550.72,,,,,,,3550.72,7039.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,MedCost,Ultra,,2829.48,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,inpatient,,,5548.00000,3328.80000,MedCost,Ultra,,3550.72,,,,,,,3550.72,7039.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,MedCost,Ultra,,2829.48,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,inpatient,,,6377.00000,3826.20000,MedCost,Ultra,,4081.28,,,,,,,4081.28,7039.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,MedCost,Ultra,,3252.27,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,inpatient,,,2575.00000,1545.00000,MedCost,Ultra,,1648.00,,,,,,,1648.00,7039.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,MedCost,Ultra,,1313.25,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,inpatient,,,13721.00000,8232.60000,MedCost,Ultra,,8781.44,,,,,,,7039.00,11114.01,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,MedCost,Ultra,,6997.71,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,inpatient,,,4800.00000,2880.00000,MedCost,Ultra,,3072.00,,,,,,,3072.00,7039.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,MedCost,Ultra,,2448.00,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,MedCost,Ultra,,907.52,,,,,,,907.52,7039.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,MedCost,Ultra,,723.18,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,inpatient,,,2127.00000,1276.20000,MedCost,Ultra,,1361.28,,,,,,,1361.28,7039.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,MedCost,Ultra,,1084.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,inpatient,,,2836.00000,1701.60000,MedCost,Ultra,,1815.04,,,,,,,1815.04,7039.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,MedCost,Ultra,,1446.36,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,inpatient,,,7965.00000,4779.00000,MedCost,Ultra,,5097.60,,,,,,,5097.60,7039.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,MedCost,Ultra,,4062.15,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,inpatient,,,18522.00000,11113.20000,MedCost,Ultra,,11854.08,,,,,,,7039.00,15002.82,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,MedCost,Ultra,,9446.22,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,inpatient,,,9224.00000,5534.40000,MedCost,Ultra,,5903.36,,,,,,,5903.36,7471.44,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,MedCost,Ultra,,4704.24,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,inpatient,,,6467.00000,3880.20000,MedCost,Ultra,,4138.88,,,,,,,4138.88,7039.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,MedCost,Ultra,,3298.17,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,inpatient,,,7476.00000,4485.60000,MedCost,Ultra,,4784.64,,,,,,,4784.64,7039.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,MedCost,Ultra,,3812.76,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,inpatient,,,288.00000,172.80000,MedCost,Ultra,,184.32,,,,,,,184.32,7039.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,MedCost,Ultra,,146.88,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,inpatient,,,1418.00000,850.80000,MedCost,Ultra,,907.52,,,,,,,907.52,7039.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,MedCost,Ultra,,723.18,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,inpatient,,,7970.00000,4782.00000,MedCost,Ultra,,5100.80,,,,,,,5100.80,7039.00,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,MedCost,Ultra,,4064.70,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1946.24,,,,,,,1946.24,7039.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1550.91,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1946.24,,,,,,,1946.24,7039.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1550.91,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1946.24,,,,,,,1946.24,7039.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1550.91,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,inpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1946.24,,,,,,,1946.24,7039.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,MedCost,Ultra,,1550.91,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,inpatient,,,13301.00000,7980.60000,MedCost,Ultra,,8512.64,,,,,,,7039.00,10773.81,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,MedCost,Ultra,,6783.51,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,inpatient,,,26602.00000,15961.20000,MedCost,Ultra,,17025.28,,,,,,,7039.00,21547.62,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,MedCost,Ultra,,13567.02,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,inpatient,,,26602.00000,15961.20000,MedCost,Ultra,,17025.28,,,,,,,7039.00,21547.62,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,MedCost,Ultra,,13567.02,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,inpatient,,,42829.00000,25697.40000,MedCost,Ultra,,27410.56,,,,,,,7039.00,34691.49,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,MedCost,Ultra,,21842.79,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,inpatient,,,34962.00000,20977.20000,MedCost,Ultra,,22375.68,,,,,,,7039.00,28319.22,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,MedCost,Ultra,,17830.62,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,inpatient,,,9476.00000,5685.60000,MedCost,Ultra,,6064.64,,,,,,,6064.64,7675.56,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,MedCost,Ultra,,4832.76,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,inpatient,,,4345.00000,2607.00000,MedCost,Ultra,,2780.80,,,,,,,2780.80,7039.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,MedCost,Ultra,,2215.95,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,inpatient,,,21406.00000,12843.60000,MedCost,Ultra,,13699.84,,,,,,,7039.00,17338.86,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,MedCost,Ultra,,10917.06,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,inpatient,,,34241.00000,20544.60000,MedCost,Ultra,,21914.24,,,,,,,7039.00,27735.21,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,MedCost,Ultra,,17462.91,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,inpatient,,,34241.00000,20544.60000,MedCost,Ultra,,21914.24,,,,,,,7039.00,27735.21,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,MedCost,Ultra,,17462.91,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,inpatient,,,34241.00000,20544.60000,MedCost,Ultra,,21914.24,,,,,,,7039.00,27735.21,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,MedCost,Ultra,,17462.91,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,inpatient,,,32373.00000,19423.80000,MedCost,Ultra,,20718.72,,,,,,,7039.00,26222.13,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,MedCost,Ultra,,16510.23,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,inpatient,,,6766.00000,4059.60000,MedCost,Ultra,,4330.24,,,,,,,4330.24,7039.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,MedCost,Ultra,,3450.66,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,inpatient,,,6766.00000,4059.60000,MedCost,Ultra,,4330.24,,,,,,,4330.24,7039.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,MedCost,Ultra,,3450.66,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,inpatient,,,107.00000,64.20000,MedCost,Ultra,,68.48,,,,,,,68.48,7039.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,MedCost,Ultra,,54.57,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,inpatient,,,39142.00000,23485.20000,MedCost,Ultra,,25050.88,,,,,,,7039.00,31705.02,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,MedCost,Ultra,,19962.42,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,inpatient,,,39142.00000,23485.20000,MedCost,Ultra,,25050.88,,,,,,,7039.00,31705.02,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,MedCost,Ultra,,19962.42,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,inpatient,,,47944.00000,28766.40000,MedCost,Ultra,,30684.16,,,,,,,7039.00,38834.64,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,MedCost,Ultra,,24451.44,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,inpatient,,,2399.00000,1439.40000,MedCost,Ultra,,1535.36,,,,,,,1535.36,7039.00,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,MedCost,Ultra,,1223.49,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,inpatient,,,6494.00000,3896.40000,MedCost,Ultra,,4156.16,,,,,,,4156.16,7039.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,MedCost,Ultra,,3311.94,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,inpatient,,,10837.00000,6502.20000,MedCost,Ultra,,6935.68,,,,,,,6935.68,8777.97,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,MedCost,Ultra,,5526.87,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Ultra,LD,2199.04,,,,,,,2199.04,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Ultra,LD,1752.36,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Ultra,RC,2199.04,,,,,,,2199.04,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Ultra,RC,1752.36,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Ultra,RI,2199.04,,,,,,,2199.04,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Ultra,RI,1752.36,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Ultra,LM,2199.04,,,,,,,2199.04,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Ultra,LM,1752.36,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Ultra,LD,1758.72,,,,,,,1758.72,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Ultra,LD,1401.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Ultra,RC,1758.72,,,,,,,1758.72,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Ultra,RC,1401.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Ultra,RI,1758.72,,,,,,,1758.72,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Ultra,RI,1401.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Ultra,LM,1758.72,,,,,,,1758.72,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Ultra,LM,1401.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Ultra,LD,1507.84,,,,,,,1507.84,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Ultra,LD,1201.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Ultra,RC,1507.84,,,,,,,1507.84,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Ultra,RC,1201.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Ultra,RI,1507.84,,,,,,,1507.84,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Ultra,RI,1201.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Ultra,LM,1507.84,,,,,,,1507.84,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Ultra,LM,1201.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,LD,316.80,,,,,,,316.80,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,LD,252.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,RC,316.80,,,,,,,316.80,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,RC,252.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,RI,316.80,,,,,,,316.80,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,RI,252.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,LM,316.80,,,,,,,316.80,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,LM,252.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,inpatient,,,3436.00000,2061.60000,MedCost,Ultra,LC,2199.04,,,,,,,2199.04,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,MedCost,Ultra,LC,1752.36,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,inpatient,,,2748.00000,1648.80000,MedCost,Ultra,LC,1758.72,,,,,,,1758.72,7039.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,MedCost,Ultra,LC,1401.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,inpatient,,,2356.00000,1413.60000,MedCost,Ultra,LC,1507.84,,,,,,,1507.84,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,MedCost,Ultra,LC,1201.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,inpatient,,,495.00000,297.00000,MedCost,Ultra,LC,316.80,,,,,,,316.80,7039.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,MedCost,Ultra,LC,252.45,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,inpatient,,,32611.00000,19566.60000,MedCost,Ultra,,20871.04,,,,,,,7039.00,26414.91,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,MedCost,Ultra,,16631.61,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,inpatient,,,61737.00000,37042.20000,MedCost,Ultra,,39511.68,,,,,,,7039.00,50006.97,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,MedCost,Ultra,,31485.87,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,inpatient,,,11403.00000,6841.80000,MedCost,Ultra,,7297.92,,,,,,,7039.00,9236.43,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,MedCost,Ultra,,5815.53,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,inpatient,,,2851.00000,1710.60000,MedCost,Ultra,,1824.64,,,,,,,1824.64,7039.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,MedCost,Ultra,,1454.01,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,inpatient,,,575.00000,345.00000,MedCost,Ultra,,368.00,,,,,,,368.00,465.75,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,MedCost,Ultra,,293.25,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,inpatient,,,4021.00000,2412.60000,MedCost,Ultra,,2573.44,,,,,,,2573.44,7039.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,MedCost,Ultra,,2050.71,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,inpatient,,,3304.00000,1982.40000,MedCost,Ultra,,2114.56,,,,,,,2114.56,7039.00,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,MedCost,Ultra,,1685.04,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,inpatient,,,1290.00000,774.00000,MedCost,Ultra,,825.60,,,,,,,825.60,1044.90,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,MedCost,Ultra,,657.90,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,inpatient,,,1563.00000,937.80000,MedCost,Ultra,,1000.32,,,,,,,1000.32,1266.03,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,MedCost,Ultra,,797.13,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,inpatient,,,1157.00000,694.20000,MedCost,Ultra,,740.48,,,,,,,740.48,937.17,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,MedCost,Ultra,,590.07,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,inpatient,,,2229.00000,1337.40000,MedCost,Ultra,,1426.56,,,,,,,1426.56,1805.49,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,MedCost,Ultra,,1136.79,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,inpatient,,,2229.00000,1337.40000,MedCost,Ultra,,1426.56,,,,,,,1426.56,1805.49,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,MedCost,Ultra,,1136.79,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,inpatient,,,899.00000,539.40000,MedCost,Ultra,,575.36,,,,,,,575.36,728.19,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,MedCost,Ultra,,458.49,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,inpatient,,,726.00000,435.60000,MedCost,Ultra,,464.64,,,,,,,464.64,588.06,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,MedCost,Ultra,,370.26,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,inpatient,,,726.00000,435.60000,MedCost,Ultra,,464.64,,,,,,,464.64,588.06,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,MedCost,Ultra,,370.26,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,inpatient,,,2558.00000,1534.80000,MedCost,Ultra,,1637.12,,,,,,,1637.12,2071.98,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,MedCost,Ultra,,1304.58,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,inpatient,,,2558.00000,1534.80000,MedCost,Ultra,,1637.12,,,,,,,1637.12,2071.98,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,MedCost,Ultra,,1304.58,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,inpatient,,,496.00000,297.60000,MedCost,Ultra,,317.44,,,,,,,317.44,401.76,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,MedCost,Ultra,,252.96,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,inpatient,,,385.00000,231.00000,MedCost,Ultra,,246.40,,,,,,,246.40,311.85,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,MedCost,Ultra,,196.35,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,inpatient,,,2736.00000,1641.60000,MedCost,Ultra,,1751.04,,,,,,,1751.04,2216.16,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,MedCost,Ultra,,1395.36,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,inpatient,,,55.00000,33.00000,MedCost,Ultra,,35.20,,,,,,,35.20,44.55,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,MedCost,Ultra,,28.05,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,inpatient,,,1368.00000,820.80000,MedCost,Ultra,,875.52,,,,,,,875.52,1108.08,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,MedCost,Ultra,,697.68,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,inpatient,,,243.00000,145.80000,MedCost,Ultra,,155.52,,,,,,,155.52,196.83,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,MedCost,Ultra,,123.93,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,inpatient,,,875.00000,525.00000,MedCost,Ultra,,560.00,,,,,,,560.00,708.75,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,MedCost,Ultra,,446.25,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,inpatient,,,622.00000,373.20000,MedCost,Ultra,,398.08,,,,,,,398.08,503.82,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,MedCost,Ultra,,317.22,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,inpatient,,,162.00000,97.20000,MedCost,Ultra,,103.68,,,,,,,103.68,131.22,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,MedCost,Ultra,,82.62,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,inpatient,,,193.00000,115.80000,MedCost,Ultra,,123.52,,,,,,,123.52,156.33,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,MedCost,Ultra,,98.43,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,inpatient,,,1276.00000,765.60000,MedCost,Ultra,,816.64,,,,,,,816.64,1033.56,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,MedCost,Ultra,,650.76,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,inpatient,,,285.00000,171.00000,MedCost,Ultra,,182.40,,,,,,,182.40,230.85,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,MedCost,Ultra,,145.35,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,inpatient,,,218.00000,130.80000,MedCost,Ultra,,139.52,,,,,,,139.52,176.58,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,MedCost,Ultra,,111.18,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,inpatient,,,297.00000,178.20000,MedCost,Ultra,,190.08,,,,,,,190.08,240.57,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,MedCost,Ultra,,151.47,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,inpatient,,,109.00000,65.40000,MedCost,Ultra,,69.76,,,,,,,69.76,88.29,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,MedCost,Ultra,,55.59,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,inpatient,,,141.00000,84.60000,MedCost,Ultra,,90.24,,,,,,,90.24,114.21,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,MedCost,Ultra,,71.91,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,inpatient,,,43.00000,25.80000,MedCost,Ultra,,27.52,,,,,,,27.52,34.83,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,MedCost,Ultra,,21.93,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,inpatient,,,6499.00000,3899.40000,MedCost,Ultra,,4159.36,,,,,,,4159.36,7039.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,MedCost,Ultra,,3314.49,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,inpatient,,,3624.00000,2174.40000,MedCost,Ultra,,2319.36,,,,,,,2319.36,7039.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,MedCost,Ultra,,1848.24,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,inpatient,,,7984.00000,4790.40000,MedCost,Ultra,,5109.76,,,,,,,5109.76,7039.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,MedCost,Ultra,,4071.84,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,inpatient,,,2607.00000,1564.20000,MedCost,Ultra,,1668.48,,,,,,,1668.48,7039.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,MedCost,Ultra,,1329.57,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,MedCost,Ultra,,1351.04,,,,,,,1351.04,7039.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,MedCost,Ultra,,1076.61,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,MedCost,Ultra,,1351.04,,,,,,,1351.04,7039.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,MedCost,Ultra,,1076.61,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,inpatient,,,2111.00000,1266.60000,MedCost,Ultra,,1351.04,,,,,,,1351.04,7039.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,MedCost,Ultra,,1076.61,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX MED SURG SEMI PRIVATE ROOM,11200003,CDM,120,RC,,,,,facility,inpatient,,,1328.00000,796.80000,MedCost,Ultra,,849.92,,,,,,,849.92,5693.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,inpatient,,,6375.00000,3825.00000,MedCost,Ultra,,4080.00,,,,,,,4080.00,5163.75,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,MedCost,Ultra,,3251.25,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,inpatient,,,8443.00000,5065.80000,MedCost,Ultra,,5403.52,,,,,,,5403.52,6838.83,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,MedCost,Ultra,,4305.93,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,inpatient,,,9477.00000,5686.20000,MedCost,Ultra,,6065.28,,,,,,,6065.28,7676.37,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,MedCost,Ultra,,4833.27,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX LEVEL 2 NURSERY ROOM,11720015,CDM,172,RC,,,,,facility,inpatient,,,3166.00000,1899.60000,MedCost,Ultra,,2026.24,,,,,,,2026.24,3569.00,percent of total billed charges,
HC REX LEVEL 4 INTENSIVE NURSERY ROOM,11740002,CDM,174,RC,,,,,facility,inpatient,,,6546.00000,3927.60000,MedCost,Ultra,,4189.44,,,,,,,4189.44,5695.00,percent of total billed charges,
HC REX INTENSIVE CARE SEMI PRIVATE ROOM,12000008,CDM,210,RC,,,,,facility,inpatient,,,3522.00000,2113.20000,MedCost,Ultra,,2254.08,,,,,,,1228.00,6258.00,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,inpatient,,,7831.00000,4698.60000,MedCost,Ultra,,5011.84,,,,,,,5011.84,6343.11,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,MedCost,Ultra,,3993.81,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,inpatient,,,10149.00000,6089.40000,MedCost,Ultra,,6495.36,,,,,,,6495.36,8220.69,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,MedCost,Ultra,,5175.99,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,inpatient,,,11308.00000,6784.80000,MedCost,Ultra,,7237.12,,,,,,,7237.12,9159.48,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,MedCost,Ultra,,5767.08,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,inpatient,,,480.00000,288.00000,MedCost,Ultra,,307.20,,,,,,,307.20,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,MedCost,Ultra,,244.80,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,inpatient,,,300.00000,180.00000,MedCost,Ultra,,192.00,,,,,,,192.00,243.90,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,MedCost,Ultra,,153.00,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,inpatient,,,480.00000,288.00000,MedCost,Ultra,,307.20,,,,,,,307.20,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,MedCost,Ultra,,244.80,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,inpatient,,,300.00000,180.00000,MedCost,Ultra,,192.00,,,,,,,192.00,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,MedCost,Ultra,,153.00,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,inpatient,,,34.00000,20.40000,MedCost,Ultra,,21.76,,,,,,,21.76,27.64,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,MedCost,Ultra,,17.34,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,73.17,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,inpatient,,,240.00000,144.00000,MedCost,Ultra,,153.60,,,,,,,153.60,195.12,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,MedCost,Ultra,,122.40,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,inpatient,,,374.00000,224.40000,MedCost,Ultra,,239.36,,,,,,,239.36,304.06,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,MedCost,Ultra,,190.74,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,inpatient,,,1320.00000,792.00000,MedCost,Ultra,,844.80,,,,,,,844.80,1073.16,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,MedCost,Ultra,,673.20,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,inpatient,,,1425.00000,855.00000,MedCost,Ultra,,912.00,,,,,,,912.00,1158.53,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,MedCost,Ultra,,726.75,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,inpatient,,,2232.00000,1339.20000,MedCost,Ultra,,1428.48,,,,,,,1428.48,1814.62,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,MedCost,Ultra,,1138.32,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,inpatient,,,293.00000,175.80000,MedCost,Ultra,,187.52,,,,,,,50.40,243.19,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,MedCost,Ultra,,149.43,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,inpatient,,,672.00000,403.20000,MedCost,Ultra,,430.08,,,,,,,430.08,546.34,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,MedCost,Ultra,,342.72,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,inpatient,,,104.00000,62.40000,MedCost,Ultra,,66.56,,,,,,,66.56,84.55,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,MedCost,Ultra,,53.04,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,inpatient,,,1016.00000,609.60000,MedCost,Ultra,,650.24,,,,,,,650.24,826.01,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,MedCost,Ultra,,518.16,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,inpatient,,,175.00000,105.00000,MedCost,Ultra,,112.00,,,,,,,112.00,142.28,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,MedCost,Ultra,,89.25,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,inpatient,,,258.00000,154.80000,MedCost,Ultra,,165.12,,,,,,,165.12,209.75,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,MedCost,Ultra,,131.58,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,inpatient,,,192.00000,115.20000,MedCost,Ultra,,122.88,,,,,,,122.88,156.10,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,MedCost,Ultra,,97.92,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,inpatient,,,3162.00000,1897.20000,MedCost,Ultra,,2023.68,,,,,,,2023.68,2570.71,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,MedCost,Ultra,,1612.62,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,inpatient,,,302.00000,181.20000,MedCost,Ultra,,193.28,,,,,,,193.28,245.53,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,MedCost,Ultra,,154.02,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,inpatient,,,296.00000,177.60000,MedCost,Ultra,,189.44,,,,,,,189.44,240.65,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,MedCost,Ultra,,150.96,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,inpatient,,,309.00000,185.40000,MedCost,Ultra,,197.76,,,,,,,197.76,251.22,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,MedCost,Ultra,,157.59,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,inpatient,,,285.00000,171.00000,MedCost,Ultra,,182.40,,,,,,,182.40,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,MedCost,Ultra,,145.35,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,inpatient,,,341.00000,204.60000,MedCost,Ultra,,218.24,,,,,,,218.24,277.23,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,MedCost,Ultra,,173.91,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,inpatient,,,432.00000,259.20000,MedCost,Ultra,,276.48,,,,,,,276.48,351.22,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,MedCost,Ultra,,220.32,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,inpatient,,,617.00000,370.20000,MedCost,Ultra,,394.88,,,,,,,394.88,501.62,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,MedCost,Ultra,,314.67,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,inpatient,,,44.00000,26.40000,MedCost,Ultra,,28.16,,,,,,,28.16,35.77,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,MedCost,Ultra,,22.44,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,inpatient,,,42.00000,25.20000,MedCost,Ultra,,26.88,,,,,,,26.88,34.15,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,MedCost,Ultra,,21.42,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,inpatient,,,71.00000,42.60000,MedCost,Ultra,,45.44,,,,,,,45.44,57.72,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,MedCost,Ultra,,36.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,inpatient,,,221.00000,132.60000,MedCost,Ultra,,141.44,,,,,,,141.44,179.67,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,MedCost,Ultra,,112.71,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,inpatient,,,402.00000,241.20000,MedCost,Ultra,,257.28,,,,,,,257.28,326.83,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,MedCost,Ultra,,205.02,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,inpatient,,,890.00000,534.00000,MedCost,Ultra,,569.60,,,,,,,569.60,723.57,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,MedCost,Ultra,,453.90,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,inpatient,,,74.00000,44.40000,MedCost,Ultra,,47.36,,,,,,,47.36,60.16,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,MedCost,Ultra,,37.74,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,inpatient,,,54.00000,32.40000,MedCost,Ultra,,34.56,,,,,,,34.56,43.90,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,MedCost,Ultra,,27.54,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,inpatient,,,265.00000,159.00000,MedCost,Ultra,,169.60,,,,,,,169.60,215.44,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,MedCost,Ultra,,135.15,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,inpatient,,,40.00000,24.00000,MedCost,Ultra,,25.60,,,,,,,25.60,32.52,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,MedCost,Ultra,,20.40,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,inpatient,,,750.00000,450.00000,MedCost,Ultra,,480.00,,,,,,,480.00,609.75,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,MedCost,Ultra,,382.50,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,inpatient,,,1175.00000,705.00000,MedCost,Ultra,,752.00,,,,,,,752.00,955.27,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,MedCost,Ultra,,599.25,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,inpatient,,,4010.00000,2406.00000,MedCost,Ultra,,2566.40,,,,,,,2566.40,3260.13,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,MedCost,Ultra,,2045.10,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,inpatient,,,1224.00000,734.40000,MedCost,Ultra,,783.36,,,,,,,783.36,995.11,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,MedCost,Ultra,,624.24,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,inpatient,,,1794.00000,1076.40000,MedCost,Ultra,,1148.16,,,,,,,1148.16,1458.52,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,MedCost,Ultra,,914.94,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,inpatient,,,2269.00000,1361.40000,MedCost,Ultra,,1452.16,,,,,,,1452.16,1844.70,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,MedCost,Ultra,,1157.19,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,inpatient,,,492.00000,295.20000,MedCost,Ultra,,314.88,,,,,,,314.88,400.00,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,MedCost,Ultra,,250.92,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,inpatient,,,4010.00000,2406.00000,MedCost,Ultra,,2566.40,,,,,,,2566.40,3260.13,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,MedCost,Ultra,,2045.10,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,inpatient,,,700.00000,420.00000,MedCost,Ultra,,448.00,,,,,,,448.00,569.10,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,MedCost,Ultra,,357.00,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,inpatient,,,780.00000,468.00000,MedCost,Ultra,,499.20,,,,,,,499.20,634.14,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,MedCost,Ultra,,397.80,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,inpatient,,,90.00000,54.00000,MedCost,Ultra,,57.60,,,,,,,57.60,73.17,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,MedCost,Ultra,,45.90,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,inpatient,,,1598.00000,958.80000,MedCost,Ultra,,1022.72,,,,,,,1022.72,1299.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,MedCost,Ultra,,814.98,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,inpatient,,,2569.00000,1541.40000,MedCost,Ultra,,1644.16,,,,,,,1644.16,2088.60,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,MedCost,Ultra,,1310.19,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,inpatient,,,500.00000,300.00000,MedCost,Ultra,,320.00,,,,,,,320.00,406.50,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,MedCost,Ultra,,255.00,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,inpatient,,,4000.00000,2400.00000,MedCost,Ultra,,2560.00,,,,,,,2560.00,3252.00,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,MedCost,Ultra,,2040.00,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,inpatient,,,2425.00000,1455.00000,MedCost,Ultra,,1552.00,,,,,,,1552.00,1971.53,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,MedCost,Ultra,,1236.75,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,inpatient,,,1800.00000,1080.00000,MedCost,Ultra,,1152.00,,,,,,,1152.00,1463.40,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,MedCost,Ultra,,918.00,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,inpatient,,,2425.00000,1455.00000,MedCost,Ultra,,1552.00,,,,,,,1552.00,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,MedCost,Ultra,,1236.75,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,inpatient,,,1800.00000,1080.00000,MedCost,Ultra,,1152.00,,,,,,,1152.00,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,MedCost,Ultra,,918.00,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,inpatient,,,1180.00000,708.00000,MedCost,Ultra,,755.20,,,,,,,755.20,959.34,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,MedCost,Ultra,,601.80,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,inpatient,,,1180.00000,708.00000,MedCost,Ultra,,755.20,,,,,,,755.20,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,MedCost,Ultra,,601.80,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,inpatient,,,1057.00000,634.20000,MedCost,Ultra,,676.48,,,,,,,676.48,859.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,MedCost,Ultra,,539.07,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,inpatient,,,238.00000,142.80000,MedCost,Ultra,GP,152.32,,,,,,,152.32,192.78,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,MedCost,Ultra,GP,121.38,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,inpatient,,,30903.00000,18541.80000,MedCost,Ultra,,19777.92,,,,,,,7039.00,25031.43,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,MedCost,Ultra,,15760.53,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,inpatient,,,14943.00000,8965.80000,MedCost,Ultra,,9563.52,,,,,,,7039.00,12103.83,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,MedCost,Ultra,,7620.93,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,inpatient,,,30903.00000,18541.80000,MedCost,Ultra,,19777.92,,,,,,,7039.00,25031.43,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,MedCost,Ultra,,15760.53,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,inpatient,,,14943.00000,8965.80000,MedCost,Ultra,,9563.52,,,,,,,7039.00,12103.83,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,MedCost,Ultra,,7620.93,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,inpatient,,,12987.00000,7792.20000,MedCost,Ultra,,8311.68,,,,,,,7039.00,10519.47,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,MedCost,Ultra,,6623.37,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,inpatient,,,13273.00000,7963.80000,MedCost,Ultra,,8494.72,,,,,,,7039.00,10751.13,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,MedCost,Ultra,,6769.23,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,inpatient,,,13560.00000,8136.00000,MedCost,Ultra,,8678.40,,,,,,,7039.00,10983.60,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,MedCost,Ultra,,6915.60,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,inpatient,,,13848.00000,8308.80000,MedCost,Ultra,,8862.72,,,,,,,7039.00,11216.88,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,MedCost,Ultra,,7062.48,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,inpatient,,,14135.00000,8481.00000,MedCost,Ultra,,9046.40,,,,,,,7039.00,11449.35,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,MedCost,Ultra,,7208.85,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,inpatient,,,14421.00000,8652.60000,MedCost,Ultra,,9229.44,,,,,,,7039.00,11681.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,MedCost,Ultra,,7354.71,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,inpatient,,,14708.00000,8824.80000,MedCost,Ultra,,9413.12,,,,,,,7039.00,11913.48,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,MedCost,Ultra,,7501.08,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,inpatient,,,14995.00000,8997.00000,MedCost,Ultra,,9596.80,,,,,,,7039.00,12145.95,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,MedCost,Ultra,,7647.45,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,inpatient,,,499.00000,299.40000,MedCost,Ultra,,319.36,,,,,,,319.36,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,MedCost,Ultra,,254.49,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,inpatient,,,246.00000,147.60000,MedCost,Ultra,,157.44,,,,,,,157.44,200.00,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,MedCost,Ultra,,125.46,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,inpatient,,,200.00000,120.00000,MedCost,Ultra,,128.00,,,,,,,128.00,162.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,MedCost,Ultra,,102.00,,,,,,,34.82,150.00,percent of total billed charges,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,848.70,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,542.68,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Partners,Medicaid,,542.68,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Partners,Medicaid,,0.02803,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Partners,Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Partners,Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Partners,Medicaid,,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Partners,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Partners,Medicaid,,4.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Partners,Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Partners,Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Partners,Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Partners,Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Partners,Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Partners,Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Partners,Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Partners,Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Partners,Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Partners,Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Partners,Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Partners,Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Partners,Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Partners,Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Partners,Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Partners,Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Partners,Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Partners,Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Partners,Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Partners,Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Partners,Medicaid,,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Partners,Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Partners,Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Partners,Medicaid,,6.26,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Partners,Medicaid,,4.07,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Partners,Medicaid,,55.85,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Partners,Medicaid,,4.33,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Partners,Medicaid,,0.00601,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Partners,Medicaid,,4.29,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Partners,Medicaid,,8.13,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Partners,Medicaid,,4.08,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Partners,Medicaid,,3.98,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Partners,Medicaid,,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Partners,Medicaid,,13.07,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Partners,Medicaid,,35.68,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Partners,Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Partners,Medicaid,,1.27,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Partners,Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Partners,Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Partners,Medicaid,,40.04,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Partners,Medicaid,,5.94,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Partners,Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Partners,Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Partners,Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Partners,Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Partners,Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Partners,Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Partners,Medicaid,,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Partners,Medicaid,,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Partners,Medicaid,,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Partners,Medicaid,,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Partners,Medicaid,,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Partners,Medicaid,,93.29,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Partners,Medicaid,,5.50,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Partners,Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Partners,Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Partners,Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Partners,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Partners,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Partners,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Partners,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Partners,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Partners,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Partners,Medicaid,,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Partners,Medicaid,,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Partners,Medicaid,,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Partners,Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Partners,Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Partners,Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Partners,Medicaid,,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Partners,Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Partners,Medicaid,,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Partners,Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Partners,Medicaid,,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Partners,Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Partners,Medicaid,,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Partners,Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Partners,Medicaid,,54.45,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Partners,Medicaid,,43.28,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Partners,Medicaid,,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Partners,Medicaid,,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Partners,Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Partners,Medicaid,,30.79,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Partners,Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Partners,Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Partners,Medicaid,,174.60,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Partners,Medicaid,,214.26,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Partners,Medicaid,,0.43644,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Partners,Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Partners,Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Partners,Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Partners,Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Partners,Medicaid,,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Partners,Medicaid,,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Partners,Medicaid,,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Partners,Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Partners,Medicaid,,0.62062,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Partners,Medicaid,,1.97,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Partners,Medicaid,,38.56,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Partners,Medicaid,,13.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Partners,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Partners,Medicaid,,47.59,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Partners,Medicaid,,54.83,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Partners,Medicaid,,31.77,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Partners,Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Partners,Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Partners,Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Partners,Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Partners,Medicaid,,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Partners,Medicaid,,66.15,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Partners,Medicaid,,65.92,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Partners,Medicaid,,30.66,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Partners,Medicaid,,31.80,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Partners,Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Partners,Medicaid,,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Partners,Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Partners,Medicaid,,0.02402,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Partners,Medicaid,,0.05405,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Partners,Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Partners,Medicaid,,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Partners,Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Partners,Medicaid,,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Partners,Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Partners,Medicaid,,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Partners,Medicaid,,64.52,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Partners,Medicaid,,16.24,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Partners,Medicaid,,10.71,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Partners,Medicaid,,25.23,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Partners,Medicaid,,6.18,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Partners,Medicaid,,3.33,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Partners,Medicaid,,23.38,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Partners,Medicaid,,6.74,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Partners,Medicaid,,19.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Partners,Medicaid,,55.06,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Partners,Medicaid,,8.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Partners,Medicaid,,10.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Partners,Medicaid,,33.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Partners,Medicaid,,25.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Partners,Medicaid,,30.87,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Partners,Medicaid,,29.30,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Partners,Medicaid,,5.23,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Partners,Medicaid,,5.72,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Partners,Medicaid,,13.62,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Partners,Medicaid,,28.18,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Partners,Medicaid,,0.10210,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Partners,Medicaid,,5.25,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Partners,Medicaid,,1.19,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Partners,Medicaid,,2.11,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Partners,Medicaid,,0.02202,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Partners,Medicaid,,0.16016,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Partners,Medicaid,,1.55,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Partners,Medicaid,,0.15816,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Partners,Medicaid,,0.09409,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Partners,Medicaid,,0.12813,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Partners,Medicaid,,333.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Partners,Medicaid,,0.00400,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Partners,Medicaid,,0.01802,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Partners,Medicaid,,0.51451,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Partners,Medicaid,,5.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Partners,Medicaid,,16.31,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Partners,Medicaid,,0.01401,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Partners,Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Partners,Medicaid,,1.23,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Partners,Medicaid,,0.22422,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Partners,Medicaid,,0.32232,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Partners,Medicaid,,0.51251,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Partners,Medicaid,,0.35836,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Partners,Medicaid,,0.00400,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Partners,Medicaid,,4.42,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Partners,Medicaid,,220.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Partners,Medicaid,,15.42,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Partners,Medicaid,,27.01,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Partners,Medicaid,,33.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Partners,Medicaid,,3.46,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Partners,Medicaid,,0.02603,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Partners,Medicaid,,7.28,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Partners,Medicaid,,13.07,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Partners,Medicaid,,28.81,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Partners,Medicaid,,12.73,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Partners,Medicaid,,49.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Partners,Medicaid,,2.25,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Partners,Medicaid,,5.10,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Partners,Medicaid,,0.15015,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Partners,Medicaid,,0.00801,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Partners,Medicaid,,3.03,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Partners,Medicaid,,2.67,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Partners,Medicaid,,2.38,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Partners,Medicaid,,3.54,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Partners,Medicaid,,6.68,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Partners,Medicaid,,11.00,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Partners,Medicaid,,27.86,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Partners,Medicaid,,109.85,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Partners,Medicaid,,63.31,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Partners,Medicaid,,74.32,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Partners,Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Partners,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Partners,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Partners,Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Partners,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Partners,Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Partners,Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Partners,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Partners,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Partners,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Partners,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Partners,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Partners,Medicaid,,25.72,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Partners,Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Partners,Medicaid,,70.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Partners,Medicaid,,77.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Partners,Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Partners,Medicaid,,709.51,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Partners,Medicaid,,60.91,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Partners,Medicaid,,8.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Partners,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Partners,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Partners,Medicaid,,483.34,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Partners,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Partners,Medicaid,,94.40,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Partners,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Partners,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Partners,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Partners,Medicaid,,1045.12,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Partners,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Partners,Medicaid,,16.00,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Partners,Medicaid,,6.74,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Partners,Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Partners,Medicaid,,9.41,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Partners,Medicaid,,3.97,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Partners,Medicaid,,5.05,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Partners,Medicaid,,16.08,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Partners,Medicaid,,6.49,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Partners,Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Partners,Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Partners,Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Partners,Medicaid,,87.43,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Partners,Medicaid,,149.79,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Partners,Medicaid,,457.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Partners,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Partners,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Partners,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Partners,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Partners,Medicaid,,9.90,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Partners,Medicaid,,11.52,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Partners,Medicaid,,113.81,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Partners,Medicaid,,4.36,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Partners,Medicaid,,4.93,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Partners,Medicaid,,1.40,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Partners,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Partners,Medicaid,,0.52052,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Partners,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Partners,Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Partners,Medicaid,,5.36,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Partners,Medicaid,,6.19,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Partners,Medicaid,,4.76,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Partners,Medicaid,,9.52,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Partners,Medicaid,,5.88,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Partners,Medicaid,,6.48,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Partners,Medicaid,,548.82,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Partners,Medicaid,,3.55,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Partners,Medicaid,,3.35,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Partners,Medicaid,,3.40,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Partners,Medicaid,,4.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Partners,Medicaid,,8.17,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Partners,Medicaid,,368.29,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Partners,Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Partners,Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Partners,Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Partners,Medicaid,,6.56,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Partners,Medicaid,,49.43,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Partners,Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Partners,Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Partners,Medicaid,,4.55,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Partners,Medicaid,,4068.51,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Partners,Medicaid,,6.41,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Partners,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Partners,Medicaid,,31.60,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Partners,Medicaid,,60.24,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Partners,Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Partners,Medicaid,,14.07,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Partners,Medicaid,,16.98,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Partners,Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Partners,Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Partners,Medicaid,,155.02,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Partners,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Partners,Medicaid,,10.18,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Partners,Medicaid,,13.78,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Partners,Medicaid,,13.34,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Partners,Medicaid,,14.46,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Partners,Medicaid,,7.94,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Partners,Medicaid,,5.64,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Partners,Medicaid,,12179.59,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Partners,Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Partners,Medicaid,,31.70,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Partners,Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Partners,Medicaid,,104.15,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Partners,Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Partners,Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Partners,Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Partners,Medicaid,,9.99,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Partners,Medicaid,,12.25,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Partners,Medicaid,,16.79,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Partners,Medicaid,,21.31,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Partners,Medicaid,,25.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Partners,Medicaid,,14.18,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Partners,Medicaid,,15.24,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Partners,Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Partners,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Partners,Medicaid,,247.33,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Partners,Medicaid,,468.68,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Partners,Medicaid,,1.70,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Partners,Medicaid,,34.23,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Partners,Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Partners,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Partners,Medicaid,,4.12,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Partners,Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Partners,Medicaid,,7.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Partners,Medicaid,,14.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Partners,Medicaid,,24.62,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Partners,Medicaid,,611.76,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Partners,Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Partners,Medicaid,,269.35,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Partners,Medicaid,,4.30,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Partners,Medicaid,,12.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Partners,Medicaid,,7.13,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Partners,Medicaid,,6.68,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Partners,Medicaid,,6.82,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Partners,Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Partners,Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Partners,Medicaid,,484.62,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Partners,Medicaid,,1297.10,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Partners,Medicaid,,33.63,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Partners,Medicaid,,5.52,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Partners,Medicaid,,12.75,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Partners,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Partners,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Partners,Medicaid,,5.51,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Partners,Medicaid,,6.30,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Partners,Medicaid,,31.51,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Partners,Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Partners,Medicaid,,20.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Partners,Medicaid,,117.13,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Partners,Medicaid,,36.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Partners,Medicaid,,52.11,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Partners,Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Partners,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Partners,Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Partners,Medicaid,,20.21,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Partners,Medicaid,,35.74,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Partners,Medicaid,,105.20,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Partners,Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Partners,Medicaid,,20.25,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Partners,Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Partners,Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Partners,Medicaid,,176.48,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Partners,Medicaid,,11.71,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Partners,Medicaid,,179.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Partners,Medicaid,,285.22,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Partners,Medicaid,,426.24,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Partners,Medicaid,,708.25,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Partners,Medicaid,,1413.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Partners,Medicaid,,2118.34,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Partners,Medicaid,,339.37,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Partners,Medicaid,,1650.91,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Partners,Medicaid,,6438.44,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Partners,Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Partners,Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Partners,Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Partners,Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Partners,Medicaid,,1763.13,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Partners,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Partners,Medicaid,,16.68,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Partners,Medicaid,,20.29,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Partners,Medicaid,,30.82,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Partners,Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Partners,Medicaid,,3.74,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Partners,Medicaid,,23.20,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Partners,Medicaid,,28.42,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Partners,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Partners,Medicaid,,177.12,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Partners,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Partners,Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Partners,Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Partners,Medicaid,,197.30,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Partners,Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Partners,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Partners,Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Partners,Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Partners,Medicaid,,20.15,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Partners,Medicaid,,38.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Partners,Medicaid,,2654.78,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Partners,Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Partners,Medicaid,,2.75,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Partners,Medicaid,,449.52,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Partners,Medicaid,,17.23,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Partners,Medicaid,,142.12,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Partners,Medicaid,,42.80,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Partners,Medicaid,,12.13,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Partners,Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Partners,Medicaid,,36.93,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Partners,Medicaid,,44.98,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Partners,Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Partners,Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Partners,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Partners,Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Partners,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Partners,Medicaid,,0.62062,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Partners,Medicaid,,16.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Partners,Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Partners,Medicaid,,15.28,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Partners,Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Partners,Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Partners,Medicaid,,21.02,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Partners,Medicaid,,94.41,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Partners,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Partners,Medicaid,,56.41,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Partners,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Partners,Medicaid,,11220.92,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Partners,Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Partners,Medicaid,,893.81,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Partners,Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Partners,Medicaid,,14.13,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Partners,Medicaid,,5.40,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Partners,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Partners,Medicaid,,6.29,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Partners,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Partners,Medicaid,,13.56,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Partners,Medicaid,,5.97,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Partners,Medicaid,,223.00,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Partners,Medicaid,,366.37,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Partners,Medicaid,,63.28,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Partners,Medicaid,,94.95,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Partners,Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Partners,Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Partners,Medicaid,,142.19,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Partners,Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Partners,Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Partners,Medicaid,,113.11,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Partners,Medicaid,,239.91,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Partners,Medicaid,,0.82082,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Partners,Medicaid,,113.87,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Partners,Medicaid,,22.42,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Partners,Medicaid,,33.63,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Partners,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Partners,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Partners,Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Partners,Medicaid,,122.05,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Partners,Medicaid,,31.90,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Partners,Medicaid,,17.42,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Partners,Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Partners,Medicaid,,4.22,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Partners,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Partners,Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Partners,Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Partners,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Partners,Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Partners,Medicaid,,6.85,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Partners,Medicaid,,24.72,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Partners,Medicaid,,25.00,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Partners,Medicaid,,9.78,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Partners,Medicaid,,12.40,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Partners,Medicaid,,6.32,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Partners,Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Partners,Medicaid,,76.08,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Partners,Medicaid,,182.24,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Partners,Medicaid,,33.58,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Partners,Medicaid,,64.10,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Partners,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Partners,Medicaid,,120.93,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Partners,Medicaid,,5085.99,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Partners,Medicaid,,371.29,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Partners,Medicaid,,4.20,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Partners,Medicaid,,192.56,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Partners,Medicaid,,4.99,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Partners,Medicaid,,16.95,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Partners,Medicaid,,7.22,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Partners,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Partners,Medicaid,,330.57,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Partners,Medicaid,,6063.10,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Partners,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Partners,Medicaid,,6.34,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Partners,Medicaid,,10.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Partners,Medicaid,,7.62,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Partners,Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Partners,Medicaid,,14.42,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Partners,Medicaid,,15.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Partners,Medicaid,,37.17,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Partners,Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Partners,Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Partners,Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Partners,Medicaid,,64.17,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Partners,Medicaid,,87.69,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Partners,Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Partners,Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Partners,Medicaid,,413.11,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Partners,Medicaid,,549.75,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Partners,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Partners,Medicaid,,39.28,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Partners,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Partners,Medicaid,,0.54054,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Partners,Medicaid,,12.01,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Partners,Medicaid,,6.45,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Partners,Medicaid,,4.46,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Partners,Medicaid,,17.53,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Partners,Medicaid,,23.06,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Partners,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Partners,Medicaid,,9.95,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Partners,Medicaid,,7.23,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Partners,Medicaid,,29.62,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Partners,Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Partners,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Partners,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Partners,Medicaid,,41.45,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Partners,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Partners,Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Partners,Medicaid,,6.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Partners,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Partners,Medicaid,,110.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Partners,Medicaid,,5.37,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Partners,Medicaid,,4.79,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Partners,Medicaid,,5.90,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Partners,Medicaid,,8.63,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Partners,Medicaid,,10.70,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Partners,Medicaid,,12.18,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Partners,Medicaid,,35.74,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Partners,Medicaid,,101.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Partners,Medicaid,,10.63,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Partners,Medicaid,,4.94,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Partners,Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Partners,Medicaid,,12.26,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Partners,Medicaid,,5.59,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Partners,Medicaid,,34.07,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Partners,Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Partners,Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Partners,Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Partners,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Partners,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Partners,Medicaid,,23675.99,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Partners,Medicaid,,25.12,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Partners,Medicaid,,150.32,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Partners,Medicaid,,2.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Partners,Medicaid,,2.99,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Partners,Medicaid,,15.35,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Partners,Medicaid,,1.07,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Partners,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Partners,Medicaid,,8.04,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Partners,Medicaid,,8.95,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Partners,Medicaid,,7.29,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Partners,Medicaid,,17.00,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Partners,Medicaid,,16.97,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Partners,Medicaid,,17.00,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Partners,Medicaid,,16.61,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Partners,Medicaid,,210.68,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Partners,Medicaid,,1079.07,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Partners,Medicaid,,728.09,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Partners,Medicaid,,6.63,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Partners,Medicaid,,3156.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Partners,Medicaid,,0.58058,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Partners,Medicaid,,4.21,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Partners,Medicaid,,86.25,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Partners,Medicaid,,47.35,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Partners,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Partners,Medicaid,,21.62,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Partners,Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Partners,Medicaid,,28.88,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Partners,Medicaid,,58.02,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Partners,Medicaid,,535.27,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Partners,Medicaid,,17.52,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Partners,Medicaid,,1.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Partners,Medicaid,,667.95,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Partners,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Partners,Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Partners,Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Partners,Medicaid,,163.80,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Partners,Medicaid,,64.00,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Partners,Medicaid,,197.18,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Partners,Medicaid,,5.03,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Partners,Medicaid,,272.42,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Partners,Medicaid,,17.52,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Partners,Medicaid,,43.51,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Partners,Medicaid,,7.69,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Partners,Medicaid,,7.85,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Partners,Medicaid,,1250.81,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Partners,Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Partners,Medicaid,,4.16,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Partners,Medicaid,,1902.78,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Partners,Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Partners,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Partners,Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Partners,Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Partners,Medicaid,,52.45,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Partners,Medicaid,,70.57,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Partners,Medicaid,,2.17,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Partners,Medicaid,,59.78,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Partners,Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Partners,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Partners,Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Partners,Medicaid,,9.27,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Partners,Medicaid,,43.77,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Partners,Medicaid,,35.92,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Partners,Medicaid,,19.98,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Partners,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Partners,Medicaid,,31.22,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Partners,Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Partners,Medicaid,,4.40,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Partners,Medicaid,,12.96,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Partners,Medicaid,,2397.64,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Partners,Medicaid,,11.54,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Partners,Medicaid,,6.85,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Partners,Medicaid,,16.12,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Partners,Medicaid,,4.73,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Partners,Medicaid,,1945.70,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Partners,Medicaid,,50.03,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Partners,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Partners,Medicaid,,1.47,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Partners,Medicaid,,27.60,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Partners,Medicaid,,3.70,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Partners,Medicaid,,16.17,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Partners,Medicaid,,17.22,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Partners,Medicaid,,36.04,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Partners,Medicaid,,19.45,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Partners,Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Partners,Medicaid,,31.84,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Partners,Medicaid,,18.79,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Partners,Medicaid,,14.10,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Partners,Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Partners,Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Partners,Medicaid,,16.83,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Partners,Medicaid,,2.36,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Partners,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Partners,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Partners,Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Partners,Medicaid,,2.21,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Partners,Medicaid,,1641.62,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Partners,Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Partners,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Partners,Medicaid,,12.35,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Partners,Medicaid,,74.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Partners,Medicaid,,38.55,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Partners,Medicaid,,14.08,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Partners,Medicaid,,13.27,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Partners,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Partners,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Partners,Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Partners,Medicaid,,5.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Partners,Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Partners,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Partners,Medicaid,,22.60,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Partners,Medicaid,,26.46,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Partners,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Partners,Medicaid,,18.05,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Partners,Medicaid,,29.76,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Partners,Medicaid,,8.92,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Partners,Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Partners,Medicaid,,4.05,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Partners,Medicaid,,69.27,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Partners,Medicaid,,253.03,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Partners,Medicaid,,4.61,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Partners,Medicaid,,90.65,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Partners,Medicaid,,181.74,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Partners,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Partners,Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Partners,Medicaid,,1.78,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Partners,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Partners,Medicaid,,48.18,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Partners,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Partners,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Partners,Medicaid,,18.93,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Partners,Medicaid,,5.67,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Partners,Medicaid,,26.98,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Partners,Medicaid,,28.38,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Partners,Medicaid,,8.76,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Partners,Medicaid,,69.80,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Partners,Medicaid,,4.19,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Partners,Medicaid,,3.75,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Partners,Medicaid,,28.38,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Partners,Medicaid,,32.93,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Partners,Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Partners,Medicaid,,0.64064,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Partners,Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Partners,Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Partners,Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Partners,Medicaid,,18.36,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Partners,Medicaid,,15.96,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Partners,Medicaid,,94.29,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Partners,Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Partners,Medicaid,,4.64,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Partners,Medicaid,,4.70,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Partners,Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Partners,Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Partners,Medicaid,,2779.01,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Partners,Medicaid,,60.82,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Partners,Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Partners,Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Partners,Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Partners,Medicaid,,813.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Partners,Medicaid,,22.63,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Partners,Medicaid,,23.59,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Partners,Medicaid,,3569.45,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Partners,Medicaid,,5678.07,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Partners,Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Partners,Medicaid,,1.23,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Partners,Medicaid,,29.52,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Partners,Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Partners,Medicaid,,8.31,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Partners,Medicaid,,4.74,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Partners,Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Partners,Medicaid,,32.33,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Partners,Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Partners,Medicaid,,19.60,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Partners,Medicaid,,18.87,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Partners,Medicaid,,916.12,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Partners,Medicaid,,30.63,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Partners,Medicaid,,4.81,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Partners,Medicaid,,0.96096,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Partners,Medicaid,,65.28,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Partners,Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Partners,Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Partners,Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Partners,Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Partners,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Partners,Medicaid,,110.10,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Partners,Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Partners,Medicaid,,4.47,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Partners,Medicaid,,0.37037,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Partners,Medicaid,,16.84,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Partners,Medicaid,,64.93,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Partners,Medicaid,,98.80,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Partners,Medicaid,,4.09,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Partners,Medicaid,,71.50,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Partners,Medicaid,,105.65,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Partners,Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Partners,Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Partners,Medicaid,,73.80,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Partners,Medicaid,,1279.76,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Partners,Medicaid,,5.69,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Partners,Medicaid,,1377.08,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Partners,Medicaid,,6665.14,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Partners,Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Partners,Medicaid,,11.01,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Partners,Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Partners,Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Partners,Medicaid,,7882.80,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Partners,Medicaid,,1623.83,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Partners,Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Partners,Medicaid,,76.35,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Partners,Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Partners,Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Partners,Medicaid,,419.08,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Partners,Medicaid,,2799.47,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Partners,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Partners,Medicaid,,92.54,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Partners,Medicaid,,219.22,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Partners,Medicaid,,49.55,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Partners,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Partners,Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Partners,Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Partners,Medicaid,,48.28,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Partners,Medicaid,,61.64,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Partners,Medicaid,,81.44,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Partners,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Partners,Medicaid,,162.03,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Partners,Medicaid,,1221.21,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Partners,Medicaid,,2970.42,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Partners,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Partners,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Partners,Medicaid,,146.38,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Partners,Medicaid,,7.91,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Partners,Medicaid,,9.55,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Partners,Medicaid,,10.92,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Partners,Medicaid,,15.56,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Partners,Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Partners,Medicaid,,5250.24,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Partners,Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Partners,Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Partners,Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Partners,Medicaid,,21.88,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Partners,Medicaid,,356.36,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Partners,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Partners,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Partners,Medicaid,,4208.24,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Partners,Medicaid,,6299.92,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Partners,Medicaid,,3212.74,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Partners,Medicaid,,361.87,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Partners,Medicaid,,750.14,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Partners,Medicaid,,1.62,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Partners,Medicaid,,18.92,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Partners,Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Partners,Medicaid,,783.62,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Partners,Medicaid,,16833.42,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Partners,Medicaid,,396.12,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Partners,Medicaid,,98.74,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Partners,Medicaid,,926.81,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Partners,Medicaid,,1838.20,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Partners,Medicaid,,915.21,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Partners,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Partners,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Partners,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Partners,Medicaid,,403.08,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Partners,Medicaid,,253.12,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Partners,Medicaid,,8.87,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Partners,Medicaid,,25.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Partners,Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Partners,Medicaid,,16.86,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Partners,Medicaid,,15.22,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Partners,Medicaid,,2157.77,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Partners,Medicaid,,2679.20,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Partners,Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Partners,Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Partners,Medicaid,,11.51,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Partners,Medicaid,,3285.05,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Partners,Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Partners,Medicaid,,19.57,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Partners,Medicaid,,29.49,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Partners,Medicaid,,11.91,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Partners,Medicaid,,2234.18,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Partners,Medicaid,,208.06,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Partners,Medicaid,,127.22,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Partners,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Partners,Medicaid,,43.75,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Partners,Medicaid,,3.83,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Partners,Medicaid,,175.64,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Partners,Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Partners,Medicaid,,808.29,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Partners,Medicaid,,331.70,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Partners,Medicaid,,61.99,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Partners,Medicaid,,2704.88,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Partners,Medicaid,,15.43,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Partners,Medicaid,,57.14,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Partners,Medicaid,,109.23,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Partners,Medicaid,,930.37,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Partners,Medicaid,,42.32,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Partners,Medicaid,,19.15,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Partners,Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Partners,Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Partners,Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Partners,Medicaid,,270.30,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Partners,Medicaid,,24.52,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Partners,Medicaid,,549.99,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Partners,Medicaid,,12.28,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Partners,Medicaid,,216.72,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Partners,Medicaid,,12.27,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Partners,Medicaid,,3207.80,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Partners,Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Partners,Medicaid,,38.37,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Partners,Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Partners,Medicaid,,73.53,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Partners,Medicaid,,11.51,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Partners,Medicaid,,6.86,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Partners,Medicaid,,7.99,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Partners,Medicaid,,17993.44,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Partners,Medicaid,,1899.64,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Partners,Medicaid,,17368.36,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Partners,Medicaid,,8.97,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Partners,Medicaid,,1427.85,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Partners,Medicaid,,179.52,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Partners,Medicaid,,3838.14,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Partners,Medicaid,,963.00,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Partners,Medicaid,,5848.24,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Partners,Medicaid,,1.33,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Partners,Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Partners,Medicaid,,6675.83,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Partners,Medicaid,,14.27,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Partners,Medicaid,,13.75,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Partners,Medicaid,,262.81,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Partners,Medicaid,,903.18,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Partners,Medicaid,,9.57,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Partners,Medicaid,,9727.12,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Partners,Medicaid,,21122.14,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Partners,Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Partners,Medicaid,,26.35,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Partners,Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Partners,Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Partners,Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Partners,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Partners,Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Partners,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Partners,Medicaid,,39.94,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Partners,Medicaid,,199.70,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Partners,Medicaid,,13.23,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Partners,Medicaid,,133.84,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Partners,Medicaid,,0.94094,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Partners,Medicaid,,3.68,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Partners,Medicaid,,394.84,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Partners,Medicaid,,5329.34,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Partners,Medicaid,,1179.31,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Partners,Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Partners,Medicaid,,7051.96,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Partners,Medicaid,,16.03,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Partners,Medicaid,,48.44,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Partners,Medicaid,,77.98,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Partners,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Partners,Medicaid,,11.70,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Partners,Medicaid,,23.30,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Partners,Medicaid,,33.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Partners,Medicaid,,43.39,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Partners,Medicaid,,103.68,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Partners,Medicaid,,405.10,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Partners,Medicaid,,1904.73,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Partners,Medicaid,,105.11,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Partners,Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Partners,Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Partners,Medicaid,,97.95,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Partners,Medicaid,,4267.77,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Partners,Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Partners,Medicaid,,322.39,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Partners,Medicaid,,69.02,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Partners,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Partners,Medicaid,,11.19,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Partners,Medicaid,,1030.23,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Partners,Medicaid,,9678.64,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Partners,Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Partners,Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Partners,Medicaid,,909.56,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Partners,Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Partners,Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Partners,Medicaid,,7220.03,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Partners,Medicaid,,586.19,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Partners,Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Partners,Medicaid,,4173.39,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Partners,Medicaid,,40.64,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Partners,Medicaid,,57.46,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Partners,Medicaid,,83.99,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Partners,Medicaid,,356.56,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Partners,Medicaid,,16449.48,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Partners,Medicaid,,2513.50,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Partners,Medicaid,,669.68,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Partners,Medicaid,,40.29,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Partners,Medicaid,,9.61,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Partners,Medicaid,,4.77,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Partners,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Partners,Medicaid,,799.89,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Partners,Medicaid,,3779.20,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Partners,Medicaid,,3471.11,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Partners,Medicaid,,10388.06,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Partners,Medicaid,,2075.14,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Partners,Medicaid,,1257.11,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Partners,Medicaid,,21.45,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Partners,Medicaid,,2529.45,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Partners,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Partners,Medicaid,,2773.87,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Partners,Medicaid,,2216.38,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Partners,Medicaid,,595.39,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Partners,Medicaid,,686.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Partners,Medicaid,,3212.13,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Partners,Medicaid,,15163.67,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Partners,Medicaid,,3042.20,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Partners,Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Partners,Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Partners,Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Partners,Medicaid,,1643.90,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Partners,Medicaid,,3886.53,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Partners,Medicaid,,821.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Partners,Medicaid,,29.85,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Partners,Medicaid,,2313.19,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Partners,Medicaid,,22028.61,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Partners,Medicaid,,433.03,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Partners,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Partners,Medicaid,,8.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Partners,Medicaid,,35.29,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Partners,Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Partners,Medicaid,,12313.86,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Partners,Medicaid,,8227.27,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Partners,Medicaid,,13.14,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Partners,Medicaid,,1284.65,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Partners,Medicaid,,3568.15,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Partners,Medicaid,,20151.54,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Partners,Medicaid,,5505.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Partners,Medicaid,,204.15,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Partners,Medicaid,,1350.05,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Partners,Medicaid,,1121.90,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Partners,Medicaid,,1845.18,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Partners,Medicaid,,25003.11,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Partners,Medicaid,,10652.28,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Partners,Medicaid,,4098.29,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Partners,Medicaid,,3408.28,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Partners,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Partners,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Partners,Medicaid,,16.27,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Partners,Medicaid,,174.05,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Partners,Medicaid,,6574.28,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Partners,Medicaid,,21.51,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Partners,Medicaid,,82.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Partners,Medicaid,,3271.31,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Partners,Medicaid,,7294.04,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Partners,Medicaid,,6.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Partners,Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Partners,Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Partners,Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Partners,Medicaid,,148.04,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Partners,Medicaid,,234.94,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Partners,Medicaid,,13639.98,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Partners,Medicaid,,15.22,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Partners,Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Partners,Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Partners,Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Partners,Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Partners,Medicaid,,20.83,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Partners,Medicaid,,9258.10,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Partners,Medicaid,,1859.57,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Partners,Medicaid,,104.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Partners,Medicaid,,6029.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Partners,Medicaid,,604.94,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Partners,Medicaid,,16551.88,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Partners,Medicaid,,13041.87,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Partners,Medicaid,,2395.89,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Partners,Medicaid,,4788.40,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Partners,Medicaid,,5984.79,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Partners,Medicaid,,13645.27,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Partners,Medicaid,,188.67,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Partners,Medicaid,,509.79,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Partners,Medicaid,,509.80,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Partners,Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Partners,Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Partners,Medicaid,,818.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Partners,Medicaid,,295.46,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Partners,Medicaid,,41.72,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Partners,Medicaid,,51.15,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Partners,Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Partners,Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Partners,Medicaid,,13.87,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Partners,Medicaid,,12710.40,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Partners,Medicaid,,46.93,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Partners,Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Partners,Medicaid,,70.56,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Partners,Medicaid,,5351.96,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Partners,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Partners,Medicaid,,2200.82,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Partners,Medicaid,,8765.41,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Partners,Medicaid,,176.78,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Partners,Medicaid,,12260.66,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Partners,Medicaid,,1464.46,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Partners,Medicaid,,51.51,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Partners,Medicaid,,16.27,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Partners,Medicaid,,3.41,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Partners,Medicaid,,3.35,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Partners,Medicaid,,7051.96,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Partners,Medicaid,,4363.51,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Partners,Medicaid,,0.27027,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Partners,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Partners,Medicaid,,72.96,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Partners,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Partners,Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Partners,Medicaid,,93.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Partners,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Partners,Medicaid,,9.83,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Partners,Medicaid,,17.85,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Partners,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Partners,Medicaid,,14.69,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Partners,Medicaid,,65.63,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Partners,Medicaid,,7.70,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Partners,Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Partners,Medicaid,,5.46,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Partners,Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Partners,Medicaid,,0.59059,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Partners,Medicaid,,38.62,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Partners,Medicaid,,2.22,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Partners,Medicaid,,3.91,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Partners,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Partners,Medicaid,,18.87,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Partners,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Partners,Medicaid,,5.45,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Partners,Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Partners,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Partners,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Partners,Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Partners,Medicaid,,18.23,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Partners,Medicaid,,280.27,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Partners,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Partners,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Partners,Medicaid,,882.66,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Partners,Medicaid,,4193.08,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Partners,Medicaid,,13.60,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Partners,Medicaid,,1273.87,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Partners,Medicaid,,16.80,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Partners,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Partners,Medicaid,,39.60,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Partners,Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Partners,Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Partners,Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Partners,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Partners,Medicaid,,837.33,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Partners,Medicaid,,16.33,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Partners,Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Partners,Medicaid,,25.36,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Partners,Medicaid,,94.67,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Partners,Medicaid,,1.93,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Partners,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Partners,Medicaid,,222.82,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Partners,Medicaid,,4.01,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Partners,Medicaid,,4.98,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Partners,Medicaid,,35.58,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Partners,Medicaid,,2.37,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Partners,Medicaid,,17.42,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Partners,Medicaid,,16.37,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Partners,Medicaid,,21.32,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Partners,Medicaid,,21.96,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Partners,Medicaid,,130.98,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Partners,Medicaid,,14.23,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Partners,Medicaid,,14.35,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Partners,Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Partners,Medicaid,,14.26,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Partners,Medicaid,,15.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Partners,Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Partners,Medicaid,,15.62,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Partners,Medicaid,,412.01,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Partners,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Partners,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Partners,Medicaid,,103.41,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Partners,Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Partners,Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Partners,Medicaid,,10.79,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Partners,Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Partners,Medicaid,,3.75,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Partners,Medicaid,,28.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Partners,Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Partners,Medicaid,,84.56,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Partners,Medicaid,,10.15,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Partners,Medicaid,,17.75,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Partners,Medicaid,,4.28,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Partners,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Partners,Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Partners,Medicaid,,18.21,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Partners,Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Partners,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Partners,Medicaid,,0.38038,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Partners,Medicaid,,4.79,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Partners,Medicaid,,4.48,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Partners,Medicaid,,39.36,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Partners,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Partners,Medicaid,,9.69,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Partners,Medicaid,,5.95,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Partners,Medicaid,,1.50,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Partners,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Partners,Medicaid,,4.15,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Partners,Medicaid,,16.30,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Partners,Medicaid,,0.67067,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Partners,Medicaid,,2.88,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Partners,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Partners,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Partners,Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Partners,Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Partners,Medicaid,,6.53,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Partners,Medicaid,,15.99,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Partners,Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Partners,Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Partners,Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Partners,Medicaid,,3.98,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Partners,Medicaid,,32.93,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Partners,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Partners,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Partners,Medicaid,,16.89,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Partners,Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Partners,Medicaid,,1470.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Partners,Medicaid,,5.63,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Partners,Medicaid,,15.38,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Partners,Medicaid,,6.35,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Partners,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Partners,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Partners,Medicaid,,548.81,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Partners,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Partners,Medicaid,,7.99,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Partners,Medicaid,,5.28,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Partners,Medicaid,,19.45,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Partners,Medicaid,,20.34,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Partners,Medicaid,,29.43,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Partners,Medicaid,,5.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Partners,Medicaid,,236.14,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Partners,Medicaid,,451.45,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Partners,Medicaid,,1156.15,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Partners,Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Partners,Medicaid,,443.79,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Partners,Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Partners,Medicaid,,45.65,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Partners,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Partners,Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Partners,Medicaid,,52.77,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Partners,Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Partners,Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Partners,Medicaid,,4.62,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Partners,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Partners,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Partners,Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Partners,Medicaid,,20.26,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Partners,Medicaid,,121.53,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Partners,Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Partners,Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Partners,Medicaid,,38.94,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Partners,Medicaid,,39.17,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Partners,Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Partners,Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Partners,Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Partners,Medicaid,,0.78078,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Partners,Medicaid,,7.14,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Partners,Medicaid,,8.69,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Partners,Medicaid,,12.01,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Partners,Medicaid,,16.44,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Partners,Medicaid,,20.96,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Partners,Medicaid,,44.19,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Partners,Medicaid,,2.68,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Partners,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Partners,Medicaid,,202.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Partners,Medicaid,,1.61,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Partners,Medicaid,,22.82,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Partners,Medicaid,,4.63,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Partners,Medicaid,,5.31,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Partners,Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Partners,Medicaid,,150.68,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Partners,Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Partners,Medicaid,,61.74,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Partners,Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Partners,Medicaid,,18.48,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Partners,Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Partners,Medicaid,,4.57,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Partners,Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Partners,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Partners,Medicaid,,9.24,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Partners,Medicaid,,10.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Partners,Medicaid,,53.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Partners,Medicaid,,5.59,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Partners,Medicaid,,12.64,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Partners,Medicaid,,119.95,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Partners,Medicaid,,7.56,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Partners,Medicaid,,12.50,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Partners,Medicaid,,704.70,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Partners,Medicaid,,310.71,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Partners,Medicaid,,241.06,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Partners,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Partners,Medicaid,,43.24,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Partners,Medicaid,,23.07,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Partners,Medicaid,,104.89,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Partners,Medicaid,,139.84,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Partners,Medicaid,,240.04,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Partners,Medicaid,,67.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Partners,Medicaid,,69.97,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Partners,Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Partners,Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Partners,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Partners,Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Partners,Medicaid,,3.86,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Partners,Medicaid,,2576.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Partners,Medicaid,,10.49,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Partners,Medicaid,,71.52,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Partners,Medicaid,,13.33,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Partners,Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Partners,Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Partners,Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Partners,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Partners,Medicaid,,5.43,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Partners,Medicaid,,138.74,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Partners,Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Partners,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Partners,Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Partners,Medicaid,,4.32,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Partners,Medicaid,,16.64,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Partners,Medicaid,,74.00,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Partners,Medicaid,,84.08,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Partners,Medicaid,,5.74,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Partners,Medicaid,,8.49,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Partners,Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Partners,Medicaid,,10.70,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Partners,Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Partners,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Partners,Medicaid,,24.00,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Partners,Medicaid,,1.26,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Partners,Medicaid,,18.82,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Partners,Medicaid,,17.32,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Partners,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Partners,Medicaid,,93.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Partners,Medicaid,,63.86,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Partners,Medicaid,,168.96,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Partners,Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Partners,Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Partners,Medicaid,,53.06,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Partners,Medicaid,,171.88,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Partners,Medicaid,,3998.59,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Partners,Medicaid,,6.77,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Partners,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Partners,Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Partners,Medicaid,,36.67,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Partners,Medicaid,,23.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Partners,Medicaid,,5.99,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Partners,Medicaid,,25.10,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Partners,Medicaid,,14.31,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Partners,Medicaid,,38.06,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Partners,Medicaid,,16.93,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Partners,Medicaid,,104.36,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Partners,Medicaid,,11.95,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Partners,Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Partners,Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Partners,Medicaid,,24.23,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Partners,Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Partners,Medicaid,,7.34,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Partners,Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Partners,Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Partners,Medicaid,,18.69,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Partners,Medicaid,,596.21,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Partners,Medicaid,,7.17,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Partners,Medicaid,,25.76,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Partners,Medicaid,,452.94,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Partners,Medicaid,,8.53,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Partners,Medicaid,,7.02,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Partners,Medicaid,,5.88,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Partners,Medicaid,,11.06,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Partners,Medicaid,,7.25,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Partners,Medicaid,,1047.11,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Partners,Medicaid,,2612.95,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Partners,Medicaid,,5222.67,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Partners,Medicaid,,10442.13,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Partners,Medicaid,,36.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Partners,Medicaid,,80.00,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Partners,Medicaid,,5.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Partners,Medicaid,,10.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Partners,Medicaid,,29.59,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Partners,Medicaid,,63.32,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Partners,Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Partners,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Partners,Medicaid,,9.69,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Partners,Medicaid,,10.10,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Partners,Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Partners,Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Partners,Medicaid,,943.42,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Partners,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Partners,Medicaid,,11.48,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Partners,Medicaid,,26.93,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Partners,Medicaid,,7.44,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Partners,Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Partners,Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Partners,Medicaid,,4.38,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Partners,Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Partners,Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Partners,Medicaid,,64.39,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Partners,Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Partners,Medicaid,,5.26,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Partners,Medicaid,,7.43,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Partners,Medicaid,,5.58,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Partners,Medicaid,,93.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Partners,Medicaid,,2.26,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Partners,Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Partners,Medicaid,,207.18,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Partners,Medicaid,,4.97,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Partners,Medicaid,,4.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Partners,Medicaid,,50.45,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Partners,Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Partners,Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Partners,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Partners,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Partners,Medicaid,,3.65,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Partners,Medicaid,,3.93,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Partners,Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Partners,Medicaid,,3.53,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Partners,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Partners,Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Partners,Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Partners,Medicaid,,17.52,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Partners,Medicaid,,1250.97,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Partners,Medicaid,,17.53,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Partners,Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Partners,Medicaid,,19.40,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Partners,Medicaid,,21.10,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Partners,Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Partners,Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Partners,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Partners,Medicaid,,14.13,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Partners,Medicaid,,0.97097,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Partners,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Partners,Medicaid,,5.69,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Partners,Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Partners,Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Partners,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Partners,Medicaid,,4.72,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Partners,Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Partners,Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Partners,Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Partners,Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Partners,Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Partners,Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Partners,Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Partners,Medicaid,,4.66,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Partners,Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Partners,Medicaid,,1.67,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Partners,Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Partners,Medicaid,,3.22,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Partners,Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Partners,Medicaid,,33.91,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Partners,Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Partners,Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Partners,Medicaid,,3616.45,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Partners,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Partners,Medicaid,,6.19,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Partners,Medicaid,,151.67,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Partners,Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Partners,Medicaid,,28.78,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Partners,Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Partners,Medicaid,,301.87,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Partners,Medicaid,,0.70070,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Partners,Medicaid,,21.87,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Partners,Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Partners,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Partners,Medicaid,,5.49,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Partners,Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Partners,Medicaid,,8.20,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Partners,Medicaid,,278.53,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Partners,Medicaid,,12.20,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Partners,Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Partners,Medicaid,,4.76,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Partners,Medicaid,,75.53,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Partners,Medicaid,,96.61,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Partners,Medicaid,,66.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Partners,Medicaid,,107.18,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Partners,Medicaid,,23.54,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Partners,Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Partners,Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Partners,Medicaid,,5.02,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Partners,Medicaid,,23.24,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Partners,Medicaid,,137.38,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Partners,Medicaid,,321.76,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Partners,Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Partners,Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Partners,Medicaid,,13.36,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Partners,Medicaid,,13.96,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Partners,Medicaid,,13.51,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Partners,Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Partners,Medicaid,,13.96,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Partners,Medicaid,,13.51,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Partners,Medicaid,,30.03,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Partners,Medicaid,,14.71,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Partners,Medicaid,,13.96,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Partners,Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Partners,Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Partners,Medicaid,,13.36,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Partners,Medicaid,,13.96,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Partners,Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Partners,Medicaid,,13.36,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Partners,Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Partners,Medicaid,,204.90,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Partners,Medicaid,,4.53,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Partners,Medicaid,,1446.91,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Partners,Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Partners,Medicaid,,1119.21,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Partners,Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Partners,Medicaid,,3.78,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Partners,Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Partners,Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Partners,Medicaid,,70.11,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Partners,Medicaid,,248.85,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Partners,Medicaid,,4.56,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Partners,Medicaid,,9.25,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Partners,Medicaid,,1407.53,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Partners,Medicaid,,66.53,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Partners,Medicaid,,61.72,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Partners,Medicaid,,134.84,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Partners,Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Partners,Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Partners,Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Partners,Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Partners,Medicaid,,5370.02,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Partners,Medicaid,,64.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Partners,Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Partners,Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Partners,Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Partners,Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Partners,Medicaid,,407.41,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Partners,Medicaid,,99.10,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Partners,Medicaid,,199.52,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Partners,Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Partners,Medicaid,,15.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Partners,Medicaid,,67.55,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Partners,Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Partners,Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Partners,Medicaid,,21.09,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Partners,Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Partners,Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Partners,Medicaid,,3.81,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Partners,Medicaid,,5.34,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Partners,Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Partners,Medicaid,,15.22,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Partners,Medicaid,,58.63,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Partners,Medicaid,,4.16,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Partners,Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Partners,Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Partners,Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Partners,Medicaid,,3.90,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Partners,Medicaid,,3.85,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Partners,Medicaid,,20.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Partners,Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Partners,Medicaid,,14.29,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Partners,Medicaid,,15.17,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Partners,Medicaid,,14.14,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Partners,Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Partners,Medicaid,,12.62,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Partners,Medicaid,,21.90,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Partners,Medicaid,,0.95095,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Partners,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Partners,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Partners,Medicaid,,217.46,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Partners,Medicaid,,8.91,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Partners,Medicaid,,9.31,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Partners,Medicaid,,6.32,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Partners,Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Partners,Medicaid,,7322.31,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Partners,Medicaid,,63.69,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Partners,Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Partners,Medicaid,,12.78,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Partners,Medicaid,,23.12,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Partners,Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Partners,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Partners,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Partners,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Partners,Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Partners,Medicaid,,15.04,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Partners,Medicaid,,21.65,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Partners,Medicaid,,30.68,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Partners,Medicaid,,4.37,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Partners,Medicaid,,3.92,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Partners,Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Partners,Medicaid,,40.90,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Partners,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Partners,Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Partners,Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Partners,Medicaid,,4.79,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Partners,Medicaid,,2740.12,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Partners,Medicaid,,560.36,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Partners,Medicaid,,15.95,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Partners,Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Partners,Medicaid,,5.65,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Partners,Medicaid,,15.26,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Partners,Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Partners,Medicaid,,20.90,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Partners,Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Partners,Medicaid,,12.73,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Partners,Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Partners,Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Partners,Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Partners,Medicaid,,5.71,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Partners,Medicaid,,4.13,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Partners,Medicaid,,4.03,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Partners,Medicaid,,4.05,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Partners,Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Partners,Medicaid,,1.42,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Partners,Medicaid,,30.78,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Partners,Medicaid,,81.09,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Partners,Medicaid,,31.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Partners,Medicaid,,160.86,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Partners,Medicaid,,13.25,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Partners,Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Partners,Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Partners,Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Partners,Medicaid,,14.97,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Partners,Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Partners,Medicaid,,18.46,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Partners,Medicaid,,75.28,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Partners,Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Partners,Medicaid,,12.88,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Partners,Medicaid,,5.42,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Partners,Medicaid,,22.97,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Partners,Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Partners,Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Partners,Medicaid,,3.48,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Partners,Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Partners,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Partners,Medicaid,,3.47,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Partners,Medicaid,,18.92,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Partners,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Partners,Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Partners,Medicaid,,43.16,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Partners,Medicaid,,67.81,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Partners,Medicaid,,167.17,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Partners,Medicaid,,13.06,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Partners,Medicaid,,16.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Partners,Medicaid,,44.56,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Partners,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Partners,Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Partners,Medicaid,,25.74,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Partners,Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Partners,Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Partners,Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Partners,Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Partners,Medicaid,,63.86,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Partners,Medicaid,,33.71,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Partners,Medicaid,,12.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Partners,Medicaid,,14.55,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Partners,Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Partners,Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Partners,Medicaid,,17.61,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Partners,Medicaid,,74.49,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Partners,Medicaid,,3.85,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Partners,Medicaid,,13.49,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Partners,Medicaid,,13.69,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Partners,Medicaid,,19.34,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Partners,Medicaid,,6.15,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Partners,Medicaid,,21.33,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Partners,Medicaid,,34.39,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Partners,Medicaid,,20.81,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Partners,Medicaid,,50.13,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Partners,Medicaid,,34.22,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Partners,Medicaid,,16.15,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Partners,Medicaid,,14.08,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Partners,Medicaid,,20.81,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Partners,Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Partners,Medicaid,,19.34,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Partners,Medicaid,,21.86,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Partners,Medicaid,,95.86,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Partners,Medicaid,,23.59,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Partners,Medicaid,,113.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Partners,Medicaid,,233.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Partners,Medicaid,,248.73,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Partners,Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Partners,Medicaid,,16.74,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Partners,Medicaid,,14.88,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Partners,Medicaid,,30.69,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Partners,Medicaid,,43.74,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Partners,Medicaid,,102.58,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Partners,Medicaid,,192.55,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Partners,Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Partners,Medicaid,,20.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Partners,Medicaid,,49.60,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Partners,Medicaid,,13.37,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Partners,Medicaid,,15.65,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Partners,Medicaid,,147.18,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Partners,Medicaid,,3.51,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Partners,Medicaid,,55.10,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Partners,Medicaid,,12.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Partners,Medicaid,,21.04,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Partners,Medicaid,,58.02,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Partners,Medicaid,,35.32,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Partners,Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Partners,Medicaid,,24.13,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Partners,Medicaid,,14.29,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Partners,Medicaid,,15.69,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Partners,Medicaid,,36.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Partners,Medicaid,,34.39,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Partners,Medicaid,,15.14,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Partners,Medicaid,,5.85,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Partners,Medicaid,,6.96,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Partners,Medicaid,,14.29,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Partners,Medicaid,,357.36,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Partners,Medicaid,,19.93,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Partners,Medicaid,,5.04,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Partners,Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Partners,Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Partners,Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Partners,Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Partners,Medicaid,,34.83,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Partners,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Partners,Medicaid,,4.49,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Partners,Medicaid,,4.50,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Partners,Medicaid,,5.13,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Partners,Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Partners,Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Partners,Medicaid,,26.24,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Partners,Medicaid,,18.92,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Partners,Medicaid,,27.96,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Partners,Medicaid,,5.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Partners,Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Partners,Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Partners,Medicaid,,3.55,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Partners,Medicaid,,13.67,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Partners,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Partners,Medicaid,,11.19,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Partners,Medicaid,,16.47,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Partners,Medicaid,,21.29,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Partners,Medicaid,,62.22,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Partners,Medicaid,,15.97,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Partners,Medicaid,,63.91,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Partners,Medicaid,,12.84,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Partners,Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Partners,Medicaid,,21.02,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Partners,Medicaid,,14.96,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Partners,Medicaid,,10.41,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Partners,Medicaid,,32.35,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Partners,Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Partners,Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Partners,Medicaid,,90.46,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Partners,Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Partners,Medicaid,,55.38,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Partners,Medicaid,,47.93,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Partners,Medicaid,,14.79,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Partners,Medicaid,,13.15,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Partners,Medicaid,,15.94,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Partners,Medicaid,,11.97,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Partners,Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Partners,Medicaid,,49.57,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Partners,Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Partners,Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Partners,Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Partners,Medicaid,,30.76,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Partners,Medicaid,,72.92,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Partners,Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Partners,Medicaid,,79.00,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Partners,Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Partners,Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Partners,Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Partners,Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Partners,Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Partners,Medicaid,,73.55,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Partners,Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Partners,Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Partners,Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Partners,Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Partners,Medicaid,,20.26,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Partners,Medicaid,,23.05,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Partners,Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Partners,Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Partners,Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Partners,Medicaid,,39.10,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Partners,Medicaid,,29.27,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Partners,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Partners,Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Partners,Medicaid,,14.73,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Partners,Medicaid,,12.90,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Partners,Medicaid,,82.51,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Partners,Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Partners,Medicaid,,34.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Partners,Medicaid,,12.65,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Partners,Medicaid,,23.05,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Partners,Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Partners,Medicaid,,5.16,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Partners,Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Partners,Medicaid,,317.29,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Partners,Medicaid,,7.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Partners,Medicaid,,95.78,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Partners,Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Partners,Medicaid,,3.44,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Partners,Medicaid,,28.89,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Partners,Medicaid,,276.31,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Partners,Medicaid,,14.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Partners,Medicaid,,43.04,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Partners,Medicaid,,119.57,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Partners,Medicaid,,21.86,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Partners,Medicaid,,23.12,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Partners,Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Partners,Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Partners,Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Partners,Medicaid,,13.22,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Partners,Medicaid,,7.31,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Partners,Medicaid,,13.22,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Partners,Medicaid,,9.70,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Partners,Medicaid,,17.78,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Partners,Medicaid,,52.13,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Partners,Medicaid,,23.96,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Partners,Medicaid,,23.67,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Partners,Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Partners,Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Partners,Medicaid,,6.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Partners,Medicaid,,16.67,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Partners,Medicaid,,13.03,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Partners,Medicaid,,35.71,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Partners,Medicaid,,10.13,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Partners,Medicaid,,46.39,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Partners,Medicaid,,47.60,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Partners,Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Partners,Medicaid,,13.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Partners,Medicaid,,4.42,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Partners,Medicaid,,4.56,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Partners,Medicaid,,91.88,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Partners,Medicaid,,5.22,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Partners,Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Partners,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Partners,Medicaid,,12.64,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Partners,Medicaid,,12.66,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Partners,Medicaid,,12.67,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Partners,Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Partners,Medicaid,,29.01,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Partners,Medicaid,,3.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Partners,Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Partners,Medicaid,,13.25,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Partners,Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Partners,Medicaid,,91.32,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Partners,Medicaid,,92.51,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Partners,Medicaid,,72.28,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Partners,Medicaid,,15.98,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Partners,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Partners,Medicaid,,15.14,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Partners,Medicaid,,15.77,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Partners,Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Partners,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Partners,Medicaid,,4.97,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Partners,Medicaid,,31.76,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Partners,Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Partners,Medicaid,,25.14,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Partners,Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Partners,Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Partners,Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Partners,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Partners,Medicaid,,4.99,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Partners,Medicaid,,146.20,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Partners,Medicaid,,20.36,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Partners,Medicaid,,20.72,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Partners,Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Partners,Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Partners,Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Partners,Medicaid,,7.81,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Partners,Medicaid,,12.31,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Partners,Medicaid,,5.29,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Partners,Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Partners,Medicaid,,42.04,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Partners,Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Partners,Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Partners,Medicaid,,16.48,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Partners,Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Partners,Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Partners,Medicaid,,13.40,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Partners,Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Partners,Medicaid,,6.89,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Partners,Medicaid,,4.13,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Partners,Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Partners,Medicaid,,4.79,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Partners,Medicaid,,5.25,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Partners,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Partners,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Partners,Medicaid,,106.37,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Partners,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Partners,Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Partners,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Partners,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Partners,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Partners,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Partners,Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Partners,Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Partners,Medicaid,,80.87,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Partners,Medicaid,,21.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Partners,Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Partners,Medicaid,,4.61,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Partners,Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Partners,Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Partners,Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Partners,Medicaid,,151.55,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Partners,Medicaid,,9.79,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Partners,Medicaid,,5.16,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Partners,Medicaid,,5.23,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Partners,Medicaid,,55.71,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Partners,Medicaid,,11.69,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Partners,Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Partners,Medicaid,,3.37,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Partners,Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Partners,Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Partners,Medicaid,,0.83083,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Partners,Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Partners,Medicaid,,55.41,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Partners,Medicaid,,59.75,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Partners,Medicaid,,47.78,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Partners,Medicaid,,52.17,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Partners,Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Partners,Medicaid,,58.32,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Partners,Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Partners,Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Partners,Medicaid,,15.58,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Partners,Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Partners,Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Partners,Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Partners,Medicaid,,9036.23,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Partners,Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Partners,Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Partners,Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Partners,Medicaid,,111.31,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Partners,Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Partners,Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Partners,Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Partners,Medicaid,,9367.61,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Partners,Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Partners,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Partners,Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Partners,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Partners,Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Partners,Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Partners,Medicaid,,202.69,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Partners,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Partners,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Partners,Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Partners,Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Partners,Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Partners,Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Partners,Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Partners,Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Partners,Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Partners,Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Partners,Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Partners,Medicaid,,55.83,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Partners,Medicaid,,8.83,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Partners,Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Partners,Medicaid,,38405.96,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Partners,Medicaid,,25.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Partners,Medicaid,,14.11,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Partners,Medicaid,,14.86,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Partners,Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Partners,Medicaid,,14.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Partners,Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Partners,Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Partners,Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Partners,Medicaid,,134.33,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Partners,Medicaid,,29.04,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Partners,Medicaid,,147.35,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Partners,Medicaid,,52.74,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Partners,Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Partners,Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Partners,Medicaid,,1.02,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Partners,Medicaid,,2.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Partners,Medicaid,,16.00,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Partners,Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Partners,Medicaid,,92.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Partners,Medicaid,,15.62,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Partners,Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Partners,Medicaid,,11.85,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Partners,Medicaid,,7.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Partners,Medicaid,,87.28,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Partners,Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Partners,Medicaid,,21.34,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Partners,Medicaid,,116.72,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Partners,Medicaid,,62.81,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Partners,Medicaid,,10.37,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Partners,Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Partners,Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Partners,Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Partners,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Partners,Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Partners,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Partners,Medicaid,,6.11,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Partners,Medicaid,,6.13,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Partners,Medicaid,,6.84,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Partners,Medicaid,,7.61,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Partners,Medicaid,,23.04,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Partners,Medicaid,,9.83,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Partners,Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Partners,Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Partners,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Partners,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Partners,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Partners,Medicaid,,0.43043,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Partners,Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Partners,Medicaid,,23.36,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Partners,Medicaid,,46.93,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Partners,Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Partners,Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Partners,Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Partners,Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Partners,Medicaid,,6.26,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Partners,Medicaid,,5.94,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Partners,Medicaid,,37.17,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Partners,Medicaid,,15.45,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Partners,Medicaid,,5.99,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Partners,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Partners,Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Partners,Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Partners,Medicaid,,17.47,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Partners,Medicaid,,17.83,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Partners,Medicaid,,4.68,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Partners,Medicaid,,10.72,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Partners,Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Partners,Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Partners,Medicaid,,61.46,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Partners,Medicaid,,94.69,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Partners,Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Partners,Medicaid,,5.80,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Partners,Medicaid,,21.17,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Partners,Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Partners,Medicaid,,3.81,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Partners,Medicaid,,4.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Partners,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Partners,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Partners,Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Partners,Medicaid,,14.85,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Partners,Medicaid,,2.70,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Partners,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Partners,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Partners,Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Partners,Medicaid,,5.33,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Partners,Medicaid,,6.14,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Partners,Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Partners,Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Partners,Medicaid,,5.23,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Partners,Medicaid,,4.66,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Partners,Medicaid,,6.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Partners,Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Partners,Medicaid,,33.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Partners,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Partners,Medicaid,,25.70,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Partners,Medicaid,,10.75,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Partners,Medicaid,,5.15,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Partners,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Partners,Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Partners,Medicaid,,4.65,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Partners,Medicaid,,2.10,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Partners,Medicaid,,4.19,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Partners,Medicaid,,3.59,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Partners,Medicaid,,40.93,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Partners,Medicaid,,49.56,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Partners,Medicaid,,14.79,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Partners,Medicaid,,8.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Partners,Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Partners,Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Partners,Medicaid,,4.86,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Partners,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Partners,Medicaid,,45.49,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Partners,Medicaid,,20.24,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Partners,Medicaid,,6.85,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Partners,Medicaid,,42.58,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Partners,Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Partners,Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Partners,Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Partners,Medicaid,,4.47,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Partners,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Partners,Medicaid,,14.47,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Partners,Medicaid,,50.57,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Partners,Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Partners,Medicaid,,53.99,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Partners,Medicaid,,31.11,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Partners,Medicaid,,17.16,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Partners,Medicaid,,22.03,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Partners,Medicaid,,14.54,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Partners,Medicaid,,37.87,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Partners,Medicaid,,8.98,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Partners,Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Partners,Medicaid,,0.61061,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Partners,Medicaid,,82.18,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Partners,Medicaid,,4.41,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Partners,Medicaid,,4.89,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Partners,Medicaid,,29.78,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Partners,Medicaid,,251.45,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Partners,Medicaid,,3.39,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Partners,Medicaid,,4.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Partners,Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Partners,Medicaid,,40.54,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Partners,Medicaid,,4.44,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Partners,Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Partners,Medicaid,,3.51,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Partners,Medicaid,,4.89,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Partners,Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Partners,Medicaid,,24.28,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Partners,Medicaid,,32.33,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Partners,Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Partners,Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Partners,Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Partners,Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Partners,Medicaid,,51.39,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Partners,Medicaid,,17.31,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Partners,Medicaid,,5.05,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Partners,Medicaid,,13.10,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Partners,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Partners,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Partners,Medicaid,,0.57057,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Partners,Medicaid,,1.53,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Partners,Medicaid,,18.79,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Partners,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Partners,Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Partners,Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Partners,Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Partners,Medicaid,,189.66,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Partners,Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Partners,Medicaid,,71.39,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Partners,Medicaid,,81.01,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Partners,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Partners,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Partners,Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Partners,Medicaid,,20.97,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Partners,Medicaid,,13.41,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Partners,Medicaid,,23.35,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Partners,Medicaid,,22.43,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Partners,Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Partners,Medicaid,,15.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Partners,Medicaid,,16.52,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Partners,Medicaid,,16.51,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Partners,Medicaid,,19.05,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Partners,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Partners,Medicaid,,27.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Partners,Medicaid,,14.86,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Partners,Medicaid,,85.70,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Partners,Medicaid,,79.04,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Partners,Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Partners,Medicaid,,13.81,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Partners,Medicaid,,16.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Partners,Medicaid,,23.16,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Partners,Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Partners,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Partners,Medicaid,,1060.77,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Partners,Medicaid,,54.03,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Partners,Medicaid,,143.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Partners,Medicaid,,17.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Partners,Medicaid,,9.15,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Partners,Medicaid,,9.92,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Partners,Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Partners,Medicaid,,81.63,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Partners,Medicaid,,396.25,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Partners,Medicaid,,73.63,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Partners,Medicaid,,1.38,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Partners,Medicaid,,129.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Partners,Medicaid,,5.32,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Partners,Medicaid,,15.98,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Partners,Medicaid,,23.79,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Partners,Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Partners,Medicaid,,18.98,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Partners,Medicaid,,169.85,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Partners,Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Partners,Medicaid,,5.60,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Partners,Medicaid,,5.75,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Partners,Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Partners,Medicaid,,1.25,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Partners,Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Partners,Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Partners,Medicaid,,10.70,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Partners,Medicaid,,570.59,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Partners,Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Partners,Medicaid,,4.56,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Partners,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Partners,Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Partners,Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Partners,Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Partners,Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Partners,Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Partners,Medicaid,,8.13,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Partners,Medicaid,,6.00,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Partners,Medicaid,,11.73,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Partners,Medicaid,,11.10,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Partners,Medicaid,,9.11,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Partners,Medicaid,,41.93,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Partners,Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Partners,Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Partners,Medicaid,,86.34,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Partners,Medicaid,,98.82,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Partners,Medicaid,,5497.41,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Partners,Medicaid,,18.50,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Partners,Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Partners,Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Partners,Medicaid,,61.08,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Partners,Medicaid,,1817.11,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Partners,Medicaid,,5.48,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Partners,Medicaid,,24.14,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Partners,Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Partners,Medicaid,,21.52,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Partners,Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Partners,Medicaid,,11.36,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Partners,Medicaid,,26.31,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Partners,Medicaid,,19.48,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Partners,Medicaid,,88.51,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Partners,Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Partners,Medicaid,,12.31,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Partners,Medicaid,,9.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Partners,Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Partners,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Partners,Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Partners,Medicaid,,102.41,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Partners,Medicaid,,70.69,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Partners,Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Partners,Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Partners,Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Partners,Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Partners,Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Partners,Medicaid,,6.69,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Partners,Medicaid,,8103.63,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Partners,Medicaid,,113.70,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Partners,Medicaid,,8.19,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Partners,Medicaid,,19.64,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Partners,Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Partners,Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Partners,Medicaid,,31.01,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Partners,Medicaid,,11.84,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Partners,Medicaid,,5378.81,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Partners,Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Partners,Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Partners,Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Partners,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Partners,Medicaid,,19.84,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Partners,Medicaid,,767.34,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Partners,Medicaid,,0.65065,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Partners,Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Partners,Medicaid,,217.13,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Partners,Medicaid,,8.14,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Partners,Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Partners,Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Partners,Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Partners,Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Partners,Medicaid,,157.47,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Partners,Medicaid,,8019.54,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Partners,Medicaid,,4011.38,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Partners,Medicaid,,0.79079,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Partners,Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Partners,Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Partners,Medicaid,,20.41,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Partners,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Partners,Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Partners,Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Partners,Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Partners,Medicaid,,6.81,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Partners,Medicaid,,19.62,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Partners,Medicaid,,25.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Partners,Medicaid,,74.41,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Partners,Medicaid,,18.99,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Partners,Medicaid,,42.04,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Partners,Medicaid,,5.26,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Partners,Medicaid,,10.00,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Partners,Medicaid,,35.09,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Partners,Medicaid,,6.19,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Partners,Medicaid,,162.77,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Partners,Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Partners,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Partners,Medicaid,,106.41,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Partners,Medicaid,,16.03,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Partners,Medicaid,,7.52,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Partners,Medicaid,,3.75,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Partners,Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Partners,Medicaid,,55.32,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Partners,Medicaid,,9.68,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Partners,Medicaid,,53.33,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Partners,Medicaid,,0.81081,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Partners,Medicaid,,32.01,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Partners,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Partners,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Partners,Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Partners,Medicaid,,105.45,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Partners,Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Partners,Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Partners,Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Partners,Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Partners,Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Partners,Medicaid,,15.03,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Partners,Medicaid,,15.11,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Partners,Medicaid,,14.30,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Partners,Medicaid,,5.81,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Partners,Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Partners,Medicaid,,4.19,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Partners,Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Partners,Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Partners,Medicaid,,7.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Partners,Medicaid,,731.93,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Partners,Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Partners,Medicaid,,2510.96,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Partners,Medicaid,,5018.69,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Partners,Medicaid,,414.16,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Partners,Medicaid,,551.21,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Partners,Medicaid,,616.62,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Partners,Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Partners,Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Partners,Medicaid,,86.74,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Partners,Medicaid,,4.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Partners,Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Partners,Medicaid,,3.41,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Partners,Medicaid,,3.50,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Partners,Medicaid,,130.73,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Partners,Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Partners,Medicaid,,17.24,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Partners,Medicaid,,12.13,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Partners,Medicaid,,149.34,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Partners,Medicaid,,21.02,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Partners,Medicaid,,7.95,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Partners,Medicaid,,12.31,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Partners,Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Partners,Medicaid,,4.34,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Partners,Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Partners,Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Partners,Medicaid,,17.02,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Partners,Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Partners,Medicaid,,44.63,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Partners,Medicaid,,63.06,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Partners,Medicaid,,2.96,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Partners,Medicaid,,332.95,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Partners,Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Partners,Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Partners,Medicaid,,16.42,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Partners,Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Partners,Medicaid,,438.24,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Partners,Medicaid,,7.20,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Partners,Medicaid,,53.01,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Partners,Medicaid,,20.92,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Partners,Medicaid,,22.77,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Partners,Medicaid,,9.22,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Partners,Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Partners,Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Partners,Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Partners,Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Partners,Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Partners,Medicaid,,83.52,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Partners,Medicaid,,307.07,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Partners,Medicaid,,7.71,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Partners,Medicaid,,12.38,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Partners,Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Partners,Medicaid,,19.29,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Partners,Medicaid,,60.65,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Partners,Medicaid,,726.37,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Partners,Medicaid,,25.45,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Partners,Medicaid,,42.27,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Partners,Medicaid,,17.83,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Partners,Medicaid,,6.87,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Partners,Medicaid,,12.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Partners,Medicaid,,6.26,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Partners,Medicaid,,40.30,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Partners,Medicaid,,34.84,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Partners,Medicaid,,12.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Partners,Medicaid,,12.98,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Partners,Medicaid,,12.95,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Partners,Medicaid,,47.84,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Partners,Medicaid,,18.24,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Partners,Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Partners,Medicaid,,132.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Partners,Medicaid,,77.12,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Partners,Medicaid,,363.01,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Partners,Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Partners,Medicaid,,0.92092,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Partners,Medicaid,,435.35,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Partners,Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Partners,Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Partners,Medicaid,,18.92,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Partners,Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Partners,Medicaid,,6.65,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Partners,Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Partners,Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Partners,Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Partners,Medicaid,,15.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Partners,Medicaid,,71.27,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Partners,Medicaid,,11.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Partners,Medicaid,,9.80,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Partners,Medicaid,,1016.27,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Partners,Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Partners,Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Partners,Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Partners,Medicaid,,128.67,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Partners,Medicaid,,51.03,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Partners,Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Partners,Medicaid,,19.13,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Partners,Medicaid,,5.04,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Partners,Medicaid,,33.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Partners,Medicaid,,17.08,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Partners,Medicaid,,20.59,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Partners,Medicaid,,5.10,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Partners,Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Partners,Medicaid,,483.85,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Partners,Medicaid,,805.26,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Partners,Medicaid,,97.34,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Partners,Medicaid,,143.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Partners,Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Partners,Medicaid,,210.27,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Partners,Medicaid,,10.78,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Partners,Medicaid,,346.52,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Partners,Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Partners,Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Partners,Medicaid,,22.78,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Partners,Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Partners,Medicaid,,330.39,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Partners,Medicaid,,9091.99,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Partners,Medicaid,,31273.72,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Partners,Medicaid,,51551.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Partners,Medicaid,,2234.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Partners,Medicaid,,1479.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Partners,Medicaid,,51.85,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Partners,Medicaid,,2.73,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Partners,Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Partners,Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Partners,Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Partners,Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Partners,Medicaid,,103.90,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Partners,Medicaid,,257.66,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Partners,Medicaid,,385.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Partners,Medicaid,,578.78,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Partners,Medicaid,,694.49,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Partners,Medicaid,,833.23,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Partners,Medicaid,,1000.20,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Partners,Medicaid,,413.41,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Partners,Medicaid,,607.21,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Partners,Medicaid,,1104.30,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Partners,Medicaid,,32.03,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Partners,Medicaid,,126.73,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Partners,Medicaid,,34.63,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,,23.42,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Partners,Medicaid,,5.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Partners,Medicaid,,28.63,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Partners,Medicaid,,31.63,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Partners,Medicaid,,104.90,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Partners,Medicaid,,119.52,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Partners,Medicaid,,101.70,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Partners,Medicaid,,18.42,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Partners,Medicaid,,14.61,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Partners,Medicaid,,46.05,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Partners,Medicaid,,42.24,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Partners,Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Partners,Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Partners,Medicaid,,997.40,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Partners,Medicaid,,357.56,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Partners,Medicaid,,601.60,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Partners,Medicaid,,305.51,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Partners,Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Partners,Medicaid,,218.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Partners,Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Partners,Medicaid,,247.45,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Partners,Medicaid,,181.98,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Partners,Medicaid,,60.66,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Partners,Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Partners,Medicaid,,187.79,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Partners,Medicaid,,53.25,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Partners,Medicaid,,40.84,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Partners,Medicaid,,218.62,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Partners,Medicaid,,189.79,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Partners,Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Partners,Medicaid,,8.61,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Partners,Medicaid,,7.01,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Partners,Medicaid,,28.03,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Partners,Medicaid,,94.89,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Partners,Medicaid,,25.23,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Partners,Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Partners,Medicaid,,26.83,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Partners,Medicaid,,2.20,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Partners,Medicaid,,998.00,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Partners,Medicaid,,4024.02,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Partners,Medicaid,,1015.81,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Partners,Medicaid,,848.85,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Partners,Medicaid,,696.30,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Partners,Medicaid,,92.69,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Partners,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Partners,Medicaid,,906.91,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Partners,Medicaid,,893.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Partners,Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Partners,Medicaid,,1168.17,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Partners,Medicaid,,829.43,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Partners,Medicaid,,829.43,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Partners,Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Partners,Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Partners,Medicaid,,1174.37,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Partners,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Partners,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Partners,Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Partners,Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Partners,Medicaid,,349.35,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Partners,Medicaid,,822.82,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Partners,Medicaid,,338.54,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Partners,Medicaid,,1301.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Partners,Medicaid,,237.04,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Partners,Medicaid,,486.89,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Partners,Medicaid,,737.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Partners,Medicaid,,860.26,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Partners,Medicaid,,24.22,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Partners,Medicaid,,341.54,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Partners,Medicaid,,685.89,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Partners,Medicaid,,16.62,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Partners,Medicaid,,93.49,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Partners,Medicaid,,137.94,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Partners,Medicaid,,311.71,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Partners,Medicaid,,236.04,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Partners,Medicaid,,15.82,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Partners,Medicaid,GP,4.20,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Partners,Medicaid,,66.67,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Partners,Medicaid,,300.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Partners,Medicaid,,284.68,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Partners,Medicaid,,228.23,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Partners,Medicaid,,171.77,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Partners,Medicaid,,115.32,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Partners,Medicaid,,58.86,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Partners,Medicaid,,327.93,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Partners,Medicaid,,979.98,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Partners,Medicaid,,1299.70,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Partners,Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Partners,Medicaid,,521.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Partners,Medicaid,,5236.83,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Partners,Medicaid,,5485.28,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Partners,Medicaid,,5773.17,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Partners,Medicaid,,6020.81,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Partners,Medicaid,,6269.46,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Partners,Medicaid,,6517.31,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Partners,Medicaid,,6724.92,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Partners,Medicaid,,7012.81,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Partners,Medicaid,,7260.85,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Partners,Medicaid,,7508.90,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Partners,Medicaid,,7757.15,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Partners,Medicaid,,77.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Partners,Medicaid,,106.91,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Partners,Medicaid,,165.97,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Partners,Medicaid,,167.37,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Partners,Medicaid,,807.81,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Partners,Medicaid,,1938.94,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Partners,Medicaid,,2083.48,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Partners,Medicaid,,2238.04,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Partners,Medicaid,,1220.02,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Partners,Medicaid,,1576.17,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Partners,Medicaid,,1792.79,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Partners,Medicaid,,2308.31,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Partners,Medicaid,,2369.57,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Partners,Medicaid,,2427.22,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Partners,Medicaid,,2485.08,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Partners,Medicaid,,2542.74,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Partners,Medicaid,,990.19,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Partners,Medicaid,,133.73,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Partners,Medicaid,,882.08,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Partners,Medicaid,,1190.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Partners,Medicaid,,1630.83,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Partners,Medicaid,,2066.86,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Partners,Medicaid,,2359.76,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Partners,Medicaid,,2672.67,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Partners,Medicaid,,3048.85,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Partners,Medicaid,,3268.06,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Partners,Medicaid,,3591.59,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Partners,Medicaid,,3767.56,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Partners,Medicaid,,3997.99,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Partners,Medicaid,,4146.34,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Partners,Medicaid,,4183.58,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Partners,Medicaid,,4245.64,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Partners,Medicaid,,4369.36,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Partners,Medicaid,,4493.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Partners,Medicaid,,4617.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Partners,Medicaid,,4741.74,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Partners,Medicaid,,4865.26,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Partners,Medicaid,,4989.38,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Partners,Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Partners,Medicaid,,2274.67,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Partners,Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Partners,Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Partners,Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Partners,Medicaid,,1297.30,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Partners,Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Partners,Medicaid,,1513.91,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Partners,Medicaid,,1705.90,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Partners,Medicaid,,60.66,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Partners,Medicaid,,254.45,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Partners,Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Partners,Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Partners,Medicaid,,161.76,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Partners,Medicaid,,2160.96,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Partners,Medicaid,,378.38,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Partners,Medicaid,,245.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Partners,Medicaid,,1436.23,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Partners,Medicaid,,59.26,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Partners,Medicaid,,151.35,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Partners,Medicaid,,0.60060,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Partners,Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Partners,Medicaid,,425.83,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Partners,Medicaid,,521.92,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Partners,Medicaid,,617.62,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Partners,Medicaid,,713.51,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Partners,Medicaid,,809.41,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Partners,Medicaid,,905.10,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Partners,Medicaid,,132.33,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Partners,Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Partners,Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Partners,Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Partners,Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Partners,Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Partners,Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Partners,Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Partners,Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Partners,Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Partners,Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Partners,Medicaid,,191.79,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Partners,Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Partners,Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Partners,Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Partners,Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Partners,Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Partners,Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Partners,Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Partners,Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Partners,Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Partners,Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Partners,Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Partners,Medicaid,,57.06,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Partners,Medicaid,,271.67,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Partners,Medicaid,,307.71,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Partners,Medicaid,,344.14,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Partners,Medicaid,,380.58,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Partners,Medicaid,,417.42,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Partners,Medicaid,,454.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Partners,Medicaid,,490.49,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Partners,Medicaid,,526.73,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Partners,Medicaid,,562.96,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Partners,Medicaid,,599.80,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Partners,Medicaid,,636.04,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Partners,Medicaid,,683.48,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Partners,Medicaid,,720.32,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Partners,Medicaid,,859.46,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Partners,Medicaid,,915.71,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Partners,Medicaid,,958.36,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Partners,Medicaid,,994.79,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Partners,Medicaid,,1031.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Partners,Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Partners,Medicaid,,928.13,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Partners,Medicaid,,825.42,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Partners,Medicaid,,523.12,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Partners,Medicaid,,565.57,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Partners,Medicaid,,497.70,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Partners,Medicaid,,669.07,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Partners,Medicaid,,67.47,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Partners,Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Partners,Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Partners,Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Partners,Medicaid,,255.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Partners,Medicaid,,419.62,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Partners,Medicaid,,466.27,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Partners,Medicaid,,253.05,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Partners,Medicaid,,1500.30,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Partners,Medicaid,,203.40,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Partners,Medicaid,,80.88,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Partners,Medicaid,,915.71,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Partners,Medicaid,,2169.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Partners,Medicaid,,1055.85,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Partners,Medicaid,,61.46,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Partners,Medicaid,,8004.80,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Partners,Medicaid,,8252.64,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Partners,Medicaid,,377.38,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Partners,Medicaid,,111.51,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Partners,Medicaid,,583.58,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Partners,Medicaid,,17.22,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Partners,Medicaid,,36.64,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Partners,Medicaid,,19.82,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Partners,Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Partners,Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Partners,Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Partners,Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Partners,Medicaid,,275.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Partners,Medicaid,,3917.71,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Partners,Medicaid,,1825.82,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Partners,Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Partners,Medicaid,,991.79,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Partners,Medicaid,,1489.09,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Partners,Medicaid,,1685.28,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Partners,Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Partners,Medicaid,,1270.87,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Partners,Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Partners,Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Partners,Medicaid,,41.84,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Partners,Medicaid,,29.03,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Partners,Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Partners,Medicaid,,25.23,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Partners,Medicaid,,30.23,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Partners,Medicaid,,36.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Partners,Medicaid,,59.06,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Partners,Medicaid,,71.07,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Partners,Medicaid,,209.81,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Partners,Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Partners,Medicaid,,85.08,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Partners,Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Partners,Medicaid,,214.81,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Partners,Medicaid,,189.79,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Partners,Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Partners,Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Partners,Medicaid,,154.95,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Partners,Medicaid,,1025.02,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Partners,Medicaid,,100.70,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Partners,Medicaid,,90.49,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Partners,Medicaid,,270.07,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Partners,Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Partners,Medicaid,,297.10,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Partners,Medicaid,,276.08,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Partners,Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Partners,Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Partners,Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Partners,Medicaid,,1345.34,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Partners,Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Partners,Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Partners,Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Partners,Medicaid,,243.24,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Partners,Medicaid,,326.53,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Partners,Medicaid,,580.38,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Partners,Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Partners,Medicaid,,92.69,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Partners,Medicaid,,28.03,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Partners,Medicaid,,33.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Partners,Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Partners,Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Partners,Medicaid,,205.00,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Partners,Medicaid,,127.53,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Partners,Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Partners,Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Partners,Medicaid,,59.46,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Partners,Medicaid,,61.66,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Partners,Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Partners,Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Partners,Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Partners,Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Partners,Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Partners,Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Partners,Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Partners,Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Partners,Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Partners,Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Partners,Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Partners,Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Partners,Medicaid,,1897.10,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Partners,Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Partners,Medicaid,,539.74,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Partners,Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Partners,Medicaid,,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Partners,Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Partners,Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Partners,Medicaid,,1227.43,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Partners,Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Partners,Medicaid,,251.25,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Partners,Medicaid,,107.51,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Partners,Medicaid,,1345.34,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Partners,Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Partners,Medicaid,,188.19,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Partners,Medicaid,,44.04,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Partners,Medicaid,,111.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Partners,Medicaid,,1088.29,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Partners,Medicaid,,3972.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Partners,Medicaid,,5483.48,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Partners,Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Partners,Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Partners,Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Partners,Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Partners,Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Partners,Medicaid,,625.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Partners,Medicaid,,234.63,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Partners,Medicaid,,301.70,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Partners,Medicaid,,283.28,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Partners,Medicaid,,274.27,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Partners,Medicaid,,1994.79,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Partners,Medicaid,Q1,1268.27,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Partners,Medicaid,Q0,759.76,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Partners,Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Partners,Medicaid,,84.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Partners,Medicaid,,109.91,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Partners,Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Partners,Medicaid,,117.12,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Partners,Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Partners,Medicaid,,75.48,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Partners,Medicaid,,18.42,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Partners,Medicaid,,57.66,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Partners,Medicaid,,87.49,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Partners,Medicaid,,52.45,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Partners,Medicaid,,46.85,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Partners,Medicaid,,130.53,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Partners,Medicaid,,6.61,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Partners,Medicaid,,380.18,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Partners,Medicaid,,48.05,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Partners,Medicaid,,72.07,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Partners,Medicaid,,92.69,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Partners,Medicaid,,84.08,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Partners,Medicaid,,389.79,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Partners,Medicaid,,398.40,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Partners,Medicaid,,186.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Partners,Medicaid,,281.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Partners,Medicaid,,292.29,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Partners,Medicaid,,345.14,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Partners,Medicaid,,420.02,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Partners,Medicaid,,704.50,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Partners,Medicaid,,1249.65,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Partners,Medicaid,,1347.55,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Partners,Medicaid,,127.13,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Partners,Medicaid,,170.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Partners,Medicaid,,1271.67,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Partners,Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Partners,Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Partners,Medicaid,,339.94,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Partners,Medicaid,,554.35,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Partners,Medicaid,,146.95,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Partners,Medicaid,,219.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Partners,Medicaid,,93.89,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Partners,Medicaid,,193.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Partners,Medicaid,,137.54,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Partners,Medicaid,,309.31,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Partners,Medicaid,,214.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Partners,Medicaid,,372.77,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Partners,Medicaid,,90.09,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Partners,Medicaid,,241.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Partners,Medicaid,,1499.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Partners,Medicaid,,1492.29,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Partners,Medicaid,,480.08,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Partners,Medicaid,,349.55,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Partners,Medicaid,,620.62,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Partners,Medicaid,,1686.28,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Partners,Medicaid,,85.08,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Partners,Medicaid,,113.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Partners,Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Partners,Medicaid,,418.82,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Partners,Medicaid,,927.93,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Partners,Medicaid,,492.09,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Partners,Medicaid,,600.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Partners,Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Partners,Medicaid,,64.26,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Partners,Medicaid,,215.42,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Partners,Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Partners,Medicaid,,120.72,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Partners,Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Partners,Medicaid,,307.71,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Partners,Medicaid,,123.12,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Partners,Medicaid,,146.95,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Partners,Medicaid,,91.49,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Partners,Medicaid,,66.27,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Partners,Medicaid,,104.70,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Partners,Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Partners,Medicaid,,206.61,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Partners,Medicaid,,177.98,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Partners,Medicaid,,232.83,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Partners,Medicaid,,210.41,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Partners,Medicaid,,281.48,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Partners,Medicaid,76,281.48,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Partners,Medicaid,,750.35,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Partners,Medicaid,76,750.35,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Partners,Medicaid,,789.79,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Partners,Medicaid,76,789.79,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Partners,Medicaid,,407.21,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Partners,Medicaid,,452.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Partners,Medicaid,,477.08,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Partners,Medicaid,,526.33,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Partners,Medicaid,,366.97,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Partners,Medicaid,,524.92,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Partners,Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Partners,Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Partners,Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Partners,Medicaid,,58.46,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Partners,Medicaid,,568.97,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Partners,Medicaid,,5465.26,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Partners,Medicaid,,751.35,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Partners,Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Partners,Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Partners,Medicaid,,129.73,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Partners,Medicaid,,141.74,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Partners,Medicaid,,245.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Partners,Medicaid,,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Partners,Medicaid,,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Partners,Medicaid,,187.79,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Partners,Medicaid,,128.33,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Partners,Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Partners,Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Partners,Medicaid,,72.67,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Partners,Medicaid,,91.09,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Partners,Medicaid,76,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Partners,Medicaid,76,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Partners,Medicaid,,99.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Partners,Medicaid,,209.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Partners,Medicaid,,326.13,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Partners,Medicaid,,469.07,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Partners,Medicaid,,1384.18,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Partners,Medicaid,,146.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Partners,Medicaid,,1214.61,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Partners,Medicaid,,451.25,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Partners,Medicaid,,567.97,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Partners,Medicaid,,369.97,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Partners,Medicaid,,174.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Partners,Medicaid,,109.91,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Partners,Medicaid,,161.16,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Partners,Medicaid,,250.65,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Partners,Medicaid,,1634.43,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Partners,Medicaid,,482.48,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Partners,Medicaid,,81.08,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Partners,Medicaid,,112.11,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Partners,Medicaid,,332.73,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Partners,Medicaid,,384.98,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Partners,Medicaid,,255.05,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Partners,Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Partners,Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Partners,Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Partners,Medicaid,,625.22,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Partners,Medicaid,,70.27,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Partners,Medicaid,,211.01,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Partners,Medicaid,,6.81,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Partners,Medicaid,,93.09,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Partners,Medicaid,,205.81,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Partners,Medicaid,,242.64,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Partners,Medicaid,,64.46,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Partners,Medicaid,,151.55,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Partners,Medicaid,,32.43,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Partners,Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Partners,Medicaid,,59.86,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Partners,Medicaid,,119.12,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Partners,Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Partners,Medicaid,,60.46,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Partners,Medicaid,,21.82,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Partners,Medicaid,,40.04,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Partners,Medicaid,,32.23,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Partners,Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Partners,Medicaid,,26.63,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Partners,Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Partners,Medicaid,,87.69,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Partners,Medicaid,,10.01,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Partners,Medicaid,,82.68,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Partners,Medicaid,,57.66,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Partners,Medicaid,,38.24,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Partners,Medicaid,,53.85,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Partners,Medicaid,GP,13.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Partners,Medicaid,GP,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Partners,Medicaid,GP,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Partners,Medicaid,GP,24.22,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,GP,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Partners,Medicaid,GP,3.20,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Partners,Medicaid,GP,30.63,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Partners,Medicaid,GP,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Partners,Medicaid,GP,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,GP,22.02,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,GP,11.81,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Partners,Medicaid,GP,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Partners,Medicaid,GP,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Partners,Medicaid,GP,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,GP,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Partners,Medicaid,GP,27.83,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Partners,Medicaid,GP,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,GP,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Partners,Medicaid,GP,30.23,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Partners,Medicaid,GP,9.41,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,GP,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Partners,Medicaid,GP,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Partners,Medicaid,GP,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Partners,Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Partners,Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,GP,17.82,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Partners,Medicaid,GP,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Partners,Medicaid,GP,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Partners,Medicaid,GP,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Partners,Medicaid,GP,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Partners,Medicaid,GP,61.26,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Partners,Medicaid,GP,84.68,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Partners,Medicaid,GP,86.89,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Partners,Medicaid,GP,57.66,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,GO,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,GO,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,GO,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Partners,Medicaid,GO,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Partners,Medicaid,GO,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Partners,Medicaid,GO,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Partners,Medicaid,GO,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Partners,Medicaid,GO,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,GO,12.41,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Partners,Medicaid,GO,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Partners,Medicaid,GO,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Partners,Medicaid,GO,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,GO,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,GO,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Partners,Medicaid,GO,44.84,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Partners,Medicaid,GO,30.43,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Partners,Medicaid,GO,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Partners,Medicaid,GO,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Partners,Medicaid,GO,63.66,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Partners,Medicaid,GO,80.68,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Partners,Medicaid,GO,83.08,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Partners,Medicaid,GO,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Partners,Medicaid,GN,71.27,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Partners,Medicaid,GN,67.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Partners,Medicaid,GN,37.44,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Partners,Medicaid,GN,53.85,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Partners,Medicaid,GN,40.04,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Partners,Medicaid,GN,63.06,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Partners,Medicaid,GN,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Partners,Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Partners,Medicaid,GN,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Partners,Medicaid,GN,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Partners,Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,GN,27.23,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Partners,Medicaid,GN,131.13,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Partners,Medicaid,GN,51.85,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Partners,Medicaid,GN,13.61,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Partners,Medicaid,GN,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Partners,Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Partners,Medicaid,GN,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Partners,Medicaid,GN,42.84,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Partners,Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Partners,Medicaid,GN,21.42,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Partners,Medicaid,GN,70.67,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Partners,Medicaid,GN,109.91,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Partners,Medicaid,GN,118.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Partners,Medicaid,,172.97,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Partners,Medicaid,,109.91,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Partners,Medicaid,,177.18,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Partners,Medicaid,,100.90,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Partners,Medicaid,,149.15,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Partners,Medicaid,,751.95,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Partners,Medicaid,,8.61,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Partners,Medicaid,,29.63,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Partners,Medicaid,,105.11,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Partners,Medicaid,,104.70,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Partners,Medicaid,,112.71,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Partners,Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Partners,Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Partners,Medicaid,,271.67,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Partners,Medicaid,,83.68,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Partners,Medicaid,,162.56,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Partners,Medicaid,,113.51,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Partners,Medicaid,,95.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Partners,Medicaid,,130.53,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Partners,Medicaid,,91.69,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Partners,Medicaid,,31.23,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Partners,Medicaid,,36.04,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Partners,Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Partners,Medicaid,,26.23,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Partners,Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Partners,Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Partners,Medicaid,,52.85,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Partners,Medicaid,,52.85,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Partners,Medicaid,,400.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Partners,Medicaid,,625.22,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Partners,Medicaid,,140.14,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Partners,Medicaid,,454.85,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Partners,Medicaid,,166.37,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Partners,Medicaid,,101.10,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Partners,Medicaid,,44.44,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Partners,Medicaid,,66.67,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Partners,Medicaid,,67.67,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Partners,Medicaid,,37.04,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Partners,Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Partners,Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Partners,Medicaid,,203.60,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Partners,Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Partners,Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Partners,Medicaid,,854.05,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Partners,Medicaid,,231.03,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Partners,Medicaid,,110.51,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Partners,Medicaid,,113.11,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Partners,Medicaid,,270.27,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Partners,Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Partners,Medicaid,,110.11,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Partners,Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Partners,Medicaid,,210.41,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Partners,Medicaid,,90.69,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Partners,Medicaid,,254.45,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Partners,Medicaid,,232.03,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Partners,Medicaid,,145.75,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Partners,Medicaid,,96.30,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Partners,Medicaid,,225.43,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Partners,Medicaid,,63.26,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Partners,Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Partners,Medicaid,,24.82,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Partners,Medicaid,,191.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Partners,Medicaid,,114.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Partners,Medicaid,,92.89,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Partners,Medicaid,,107.91,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Partners,Medicaid,,100.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Partners,Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Partners,Medicaid,,81.08,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Partners,Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Partners,Medicaid,,81.08,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Partners,Medicaid,,74.67,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Partners,Medicaid,,134.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Partners,Medicaid,,164.56,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Partners,Medicaid,,171.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Partners,Medicaid,,177.78,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Partners,Medicaid,,107.91,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Partners,Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Partners,Medicaid,,59.06,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Partners,Medicaid,,87.49,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Partners,Medicaid,,50.65,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Partners,Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Partners,Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Partners,Medicaid,,109.51,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Partners,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Partners,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Partners,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Partners,Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Partners,Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Partners,Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Partners,Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Partners,Medicaid,,53.45,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Partners,Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Partners,Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Partners,Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Partners,Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Partners,Medicaid,,91.49,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Partners,Medicaid,,91.09,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Partners,Medicaid,,298.50,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Partners,Medicaid,,305.51,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Partners,Medicaid,,169.77,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Partners,Medicaid,,246.85,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Partners,Medicaid,,84.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Partners,Medicaid,,199.60,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Partners,Medicaid,,92.69,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Partners,Medicaid,,108.91,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Partners,Medicaid,,263.26,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Partners,Medicaid,,317.92,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Partners,Medicaid,,390.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Partners,Medicaid,,553.95,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Partners,Medicaid,,608.41,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Partners,Medicaid,,771.97,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Partners,Medicaid,,454.05,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Partners,Medicaid,,508.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Partners,Medicaid,,572.17,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Partners,Medicaid,,908.11,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Partners,Medicaid,,1017.02,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Partners,Medicaid,,1135.13,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Partners,Medicaid,,208.61,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Partners,Medicaid,,45.05,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Partners,Medicaid,,58.46,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Partners,Medicaid,,58.86,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Partners,Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Partners,Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Partners,Medicaid,,21.22,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Partners,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Partners,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Partners,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Partners,Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Partners,Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Partners,Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Partners,Medicaid,GP,13.35,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Partners,Medicaid,,95.90,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Partners,Medicaid,,549.35,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Partners,Medicaid,,549.35,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Partners,Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Partners,Medicaid,,217.22,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Partners,Medicaid,,217.22,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Partners,Medicaid,,493.29,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Partners,Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Partners,Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Partners,Medicaid,,638.64,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Partners,Medicaid,,86.09,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Partners,Medicaid,,96.10,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Partners,Medicaid,,107.31,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Partners,Medicaid,,91.69,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Partners,Medicaid,,23.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Partners,Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Partners,Medicaid,,32.63,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Partners,Medicaid,,61.46,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Partners,Medicaid,,104.10,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Partners,Medicaid,,100.90,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Partners,Medicaid,,123.72,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Partners,Medicaid,,81.88,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Partners,Medicaid,,154.15,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Partners,Medicaid,,154.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Partners,Medicaid,,127.73,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Partners,Medicaid,,120.72,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Partners,Medicaid,,180.58,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Partners,Medicaid,,36.44,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Partners,Medicaid,,30.43,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Partners,Medicaid,,56.06,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Partners,Medicaid,,77.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Partners,Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Partners,Medicaid,,151.95,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Partners,Medicaid,,459.46,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Partners,Medicaid,,121.52,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Partners,Medicaid,,372.97,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Partners,Medicaid,,372.97,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Partners,Medicaid,,426.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Partners,Medicaid,,107.31,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Partners,Medicaid,,207.61,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Partners,Medicaid,,2503.90,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Partners,Medicaid,,304.30,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Partners,Medicaid,,386.99,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Partners,Medicaid,,166.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Partners,Medicaid,,173.97,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Partners,Medicaid,,185.19,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Partners,Medicaid,,307.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Partners,Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Partners,Medicaid,,1956.75,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Partners,Medicaid,,132.13,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Partners,Medicaid,,132.13,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Partners,Medicaid,,638.44,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Partners,Medicaid,,638.44,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Partners,Medicaid,,305.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Partners,Medicaid,,305.91,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Partners,Medicaid,,345.75,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Partners,Medicaid,,428.83,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Partners,Medicaid,,428.83,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Partners,Medicaid,,279.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Partners,Medicaid,,279.68,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Partners,Medicaid,,124.32,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Partners,Medicaid,,124.32,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Partners,Medicaid,,144.14,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Partners,Medicaid,,144.14,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Partners,Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Partners,Medicaid,,448.45,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Partners,Medicaid,JW,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Partners,Medicaid,,117.32,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Partners,Medicaid,,99.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Partners,Medicaid,,120.92,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Partners,Medicaid,,99.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Partners,Medicaid,,117.32,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Partners,Medicaid,,164.56,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Partners,Medicaid,,273.07,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Partners,Medicaid,,70.47,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Partners,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Partners,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Partners,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Partners,Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Partners,Medicaid,,390.39,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Partners,Medicaid,,390.39,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Partners,Medicaid,,621.22,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Partners,Medicaid,,621.22,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Partners,Medicaid,,344.94,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Partners,Medicaid,,426.83,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Partners,Medicaid,,560.56,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Partners,Medicaid,,108.71,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Partners,Medicaid,,877.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Partners,Medicaid,,970.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Partners,Medicaid,,1147.95,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Partners,Medicaid,,160.96,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Partners,Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Partners,Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Partners,Medicaid,,384.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Partners,Medicaid,,340.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Partners,Medicaid,,116.52,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Partners,Medicaid,,454.05,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Partners,Medicaid,,253.25,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Partners,Medicaid,,467.07,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Partners,Medicaid,,467.07,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Partners,Medicaid,,409.81,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Partners,Medicaid,,267.27,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Partners,Medicaid,,169.57,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Partners,Medicaid,,356.56,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Partners,Medicaid,,356.56,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Partners,Medicaid,,339.94,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Partners,Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Partners,Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Partners,Medicaid,,359.16,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Partners,Medicaid,,359.16,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Partners,Medicaid,,824.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Partners,Medicaid,,824.62,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Partners,Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Partners,Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Partners,Medicaid,,102.50,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Partners,Medicaid,,118.92,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Partners,Medicaid,52,220.22,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Partners,Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Partners,Medicaid,,142.34,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Partners,Medicaid,,292.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Partners,Medicaid,,25.43,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Partners,Medicaid,,183.98,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Partners,Medicaid,,183.98,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Partners,Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Partners,Medicaid,,63.46,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Partners,Medicaid,,139.54,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Partners,Medicaid,,278.88,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Partners,Medicaid,,475.48,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Partners,Medicaid,,634.03,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Partners,Medicaid,,803.00,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Partners,Medicaid,,265.06,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Partners,Medicaid,,241.64,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Partners,Medicaid,,72.27,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Partners,Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Partners,Medicaid,,37.84,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Partners,Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Partners,Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Partners,Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Partners,Medicaid,,40.24,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Partners,Medicaid,,49.85,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Partners,Medicaid,,48.05,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Partners,Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Partners,Medicaid,,79.88,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Partners,Medicaid,,74.27,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Partners,Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Partners,Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Partners,Medicaid,,45.45,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Partners,Medicaid,,53.45,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Partners,Medicaid,,50.05,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Partners,Medicaid,,81.28,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Partners,Medicaid,,87.09,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Partners,Medicaid,,87.49,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Partners,Medicaid,,79.48,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Partners,Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Partners,Medicaid,,50.85,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Partners,Medicaid,,77.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Partners,Medicaid,,97.90,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Partners,Medicaid,,13.21,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Partners,Medicaid,,21.22,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Partners,Medicaid,,35.24,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Partners,Medicaid,,52.05,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Partners,Medicaid,,68.67,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Partners,Medicaid,,46.25,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Partners,Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Partners,Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Partners,Medicaid,,115.32,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Partners,Medicaid,,27.43,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Partners,Medicaid,,22.42,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Partners,Medicaid,,9.61,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Partners,Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Partners,Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Partners,Medicaid,JW,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Partners,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,JW,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Partners,Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Partners,Medicaid,,55.05,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Partners,Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Partners,Medicaid,JW,40.04,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Partners,Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Partners,Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Partners,Medicaid,JW,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Partners,Medicaid,JW,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Partners,Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Partners,Medicaid,JW,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Partners,Medicaid,JW,54.65,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Partners,Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Partners,Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Partners,Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Partners,Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Partners,Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Partners,Medicaid,JW,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Partners,Medicaid,JW,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Partners,Medicaid,JW,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Partners,Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Partners,Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Partners,Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Partners,Medicaid,JW,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Partners,Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Partners,Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Partners,Medicaid,JW,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Partners,Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Partners,Medicaid,JW,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Partners,Medicaid,JW,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Partners,Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Partners,Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Partners,Medicaid,JW,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Partners,Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Partners,Medicaid,JW,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Partners,Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Partners,Medicaid,JW,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,JW,13.01,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Partners,Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Partners,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Partners,Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Partners,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Partners,Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Partners,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Partners,Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Partners,Medicaid,JW,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Partners,Medicaid,JW,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Partners,Medicaid,JW,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Partners,Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Partners,Medicaid,JW,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Partners,Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Partners,Medicaid,JW,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Partners,Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Partners,Medicaid,JW,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Partners,Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Partners,Medicaid,JW,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Partners,Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Partners,Medicaid,JW,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Partners,Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Partners,Medicaid,JW,54.45,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Partners,Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Partners,Medicaid,,59.06,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Partners,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Partners,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Partners,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Partners,Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Partners,Medicaid,,54.05,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Partners,Medicaid,,849.45,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Partners,Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Partners,Medicaid,,49.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Partners,Medicaid,,515.92,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Partners,Medicaid,,41.84,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Partners,Medicaid,,60.66,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Partners,Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Partners,Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Partners,Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Partners,Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Partners,Medicaid,,67.47,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Partners,Medicaid,,56.06,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Partners,Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Partners,Medicaid,,1877.68,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Partners,Medicaid,,222.82,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Partners,Medicaid,,207.61,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Partners,Medicaid,,239.64,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Partners,Medicaid,,161.36,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Partners,Medicaid,,397.40,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Partners,Medicaid,,397.40,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Partners,Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Partners,Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Partners,Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Partners,Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Partners,Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Partners,Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Partners,Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Partners,Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Partners,Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Partners,Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Partners,Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Partners,Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Partners,Medicaid,,118.92,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Partners,Medicaid,,102.50,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Partners,Medicaid,,154.35,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Partners,Medicaid,,136.34,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Partners,Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Partners,Medicaid,,28.63,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Partners,Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Partners,Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Partners,Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Partners,Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Partners,Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Partners,Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Partners,Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,,33.03,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Partners,Medicaid,,189.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Partners,Medicaid,,96.90,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Partners,Medicaid,,25.63,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Partners,Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Partners,Medicaid,,31.63,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Partners,Medicaid,,18.42,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Partners,Medicaid,,18.42,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Partners,Medicaid,,42.44,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Partners,Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Partners,Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Partners,Medicaid,,30.03,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Partners,Medicaid,,17.02,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Partners,Medicaid,,26.63,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Partners,Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Partners,Medicaid,,8008.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Partners,Medicaid,,155.56,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Partners,Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Partners,Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Partners,Medicaid,,989.19,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Partners,Medicaid,,58.46,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Partners,Medicaid,,176.98,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Partners,Medicaid,,41.04,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Partners,Medicaid,,41.04,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Partners,Medicaid,,194.19,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Partners,Medicaid,,246.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Partners,Medicaid,,64.86,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Partners,Medicaid,,1253.05,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Partners,Medicaid,,625.22,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Partners,Medicaid,,97.30,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Partners,Medicaid,,4128.92,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Partners,Medicaid,,625.22,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Partners,Medicaid,,168.57,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Partners,Medicaid,,467.67,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Partners,Medicaid,,463.86,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Partners,Medicaid,,464.86,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Partners,Medicaid,,2388.19,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Partners,Medicaid,,104.90,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Partners,Medicaid,,114.71,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Partners,Medicaid,,266.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Partners,Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Partners,Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Partners,Medicaid,,379.38,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Partners,Medicaid,,379.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Partners,Medicaid,,691.89,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Partners,Medicaid,,691.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Partners,Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Partners,Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Partners,Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Partners,Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Partners,Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Partners,Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Partners,Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Partners,Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Partners,Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Partners,Medicaid,JW,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Partners,Medicaid,JW,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Partners,Medicaid,JW,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Partners,Medicaid,JW,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Partners,Medicaid,JW,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Partners,Medicaid,JW,93.29,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Partners,Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Partners,Medicaid,,35.84,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Partners,Medicaid,,159.56,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Partners,Medicaid,,197.80,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Partners,Medicaid,,286.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Partners,Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Partners,Medicaid,,35.84,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Partners,Medicaid,,365.97,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Partners,Medicaid,,519.32,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Partners,Medicaid,,189.19,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Partners,Medicaid,,577.18,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Partners,Medicaid,,191.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Partners,Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Partners,Medicaid,,280.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Partners,Medicaid,,435.23,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Partners,Medicaid,,847.25,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Partners,Medicaid,,3830.23,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Partners,Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Partners,Medicaid,,90.49,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Partners,Medicaid,,80.28,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Partners,Medicaid,,133.13,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Partners,Medicaid,,63.66,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Partners,Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Partners,Medicaid,,64.86,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Partners,Medicaid,,109.11,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Partners,Medicaid,,70.47,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Partners,Medicaid,,96.30,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Partners,Medicaid,,120.32,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Partners,Medicaid,,78.88,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Partners,Medicaid,,88.49,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Partners,Medicaid,,100.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Partners,Medicaid,,30.43,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Partners,Medicaid,,54.05,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Partners,Medicaid,,24.02,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Partners,Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Partners,Medicaid,,134.33,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Partners,Medicaid,,35.84,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Partners,Medicaid,,60.46,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Partners,Medicaid,,72.47,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Partners,Medicaid,,96.70,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Partners,Medicaid,,116.92,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Partners,Medicaid,,216.02,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Partners,Medicaid,,117.12,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Partners,Medicaid,,61.06,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Partners,Medicaid,,88.49,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Partners,Medicaid,,99.30,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Partners,Medicaid,,132.13,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Partners,Medicaid,,185.99,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Partners,Medicaid,,87.49,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Partners,Medicaid,,65.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Partners,Medicaid,,112.91,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Partners,Medicaid,,98.50,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Partners,Medicaid,,142.14,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Partners,Medicaid,,175.18,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Partners,Medicaid,,116.52,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Partners,Medicaid,,68.27,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Partners,Medicaid,,108.31,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Partners,Medicaid,,73.87,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Partners,Medicaid,,73.67,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Partners,Medicaid,,242.44,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Partners,Medicaid,,150.55,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Partners,Medicaid,,267.47,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Partners,Medicaid,,378.78,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Partners,Medicaid,,416.62,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Partners,Medicaid,,85.08,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Partners,Medicaid,,76.48,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Partners,Medicaid,,91.89,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Partners,Medicaid,,92.49,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Partners,Medicaid,,254.45,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Partners,Medicaid,,104.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Partners,Medicaid,,88.09,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Partners,Medicaid,,81.28,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Partners,Medicaid,,88.49,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Partners,Medicaid,,97.50,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Partners,Medicaid,,75.88,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Partners,Medicaid,,59.66,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Partners,Medicaid,,75.08,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Partners,Medicaid,,69.47,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Partners,Medicaid,,130.73,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Partners,Medicaid,,86.29,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Partners,Medicaid,,78.88,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Partners,Medicaid,,55.26,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Partners,Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Partners,Medicaid,,85.49,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Partners,Medicaid,,74.27,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Partners,Medicaid,,96.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Partners,Medicaid,,63.26,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Partners,Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Partners,Medicaid,,70.87,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Partners,Medicaid,,43.64,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Partners,Medicaid,,89.09,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Partners,Medicaid,,92.69,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Partners,Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Partners,Medicaid,,106.11,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Partners,Medicaid,,92.69,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Partners,Medicaid,,80.28,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Partners,Medicaid,,64.86,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Partners,Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Partners,Medicaid,,156.56,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Partners,Medicaid,,64.46,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Partners,Medicaid,,49.45,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Partners,Medicaid,,211.21,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Partners,Medicaid,,145.75,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Partners,Medicaid,,177.78,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Partners,Medicaid,,99.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Partners,Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Partners,Medicaid,,197.80,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Partners,Medicaid,,208.41,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Partners,Medicaid,,215.01,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Partners,Medicaid,,107.51,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Partners,Medicaid,,19.62,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Partners,Medicaid,,116.12,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Partners,Medicaid,,128.73,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Partners,Medicaid,,163.76,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Partners,Medicaid,,133.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Partners,Medicaid,,162.16,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Partners,Medicaid,,418.02,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Partners,Medicaid,,929.93,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Partners,Medicaid,,716.12,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Partners,Medicaid,,37.04,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Partners,Medicaid,,273.87,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Partners,Medicaid,,279.28,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Partners,Medicaid,,810.21,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Partners,Medicaid,,1150.35,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Partners,Medicaid,,265.47,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Partners,Medicaid,,514.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Partners,Medicaid,,206.41,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Partners,Medicaid,,240.64,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Partners,Medicaid,,321.92,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Partners,Medicaid,,160.96,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Partners,Medicaid,,323.52,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Partners,Medicaid,,193.59,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Partners,Medicaid,,159.96,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Partners,Medicaid,,221.42,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Partners,Medicaid,,467.07,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Partners,Medicaid,,275.48,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Partners,Medicaid,,40.84,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Partners,Medicaid,,35.03,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Partners,Medicaid,,241.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Partners,Medicaid,,154.35,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Partners,Medicaid,,211.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Partners,Medicaid,,71.67,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Partners,Medicaid,,190.79,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Partners,Medicaid,,33.83,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Partners,Medicaid,,187.39,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Partners,Medicaid,,61.26,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Partners,Medicaid,,68.27,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Partners,Medicaid,,28.63,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Partners,Medicaid,,148.95,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Partners,Medicaid,,132.53,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Partners,Medicaid,,131.53,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Partners,Medicaid,,64.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Partners,Medicaid,,129.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Partners,Medicaid,,69.27,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Partners,Medicaid,,48.65,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Partners,Medicaid,,53.65,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Partners,Medicaid,,185.59,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Partners,Medicaid,,61.26,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Partners,Medicaid,,182.38,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Partners,Medicaid,,58.26,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Partners,Medicaid,,157.76,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Partners,Medicaid,,469.07,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Partners,Medicaid,,808.61,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Partners,Medicaid,,668.27,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Partners,Medicaid,,720.32,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Partners,Medicaid,,407.41,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Partners,Medicaid,,903.70,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Partners,Medicaid,,903.70,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Partners,Medicaid,,903.70,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Partners,Medicaid,,611.21,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Partners,Medicaid,,357.56,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Partners,Medicaid,,281.08,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Partners,Medicaid,,53.65,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Partners,Medicaid,,74.87,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Partners,Medicaid,,66.47,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Partners,Medicaid,,166.37,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Partners,Medicaid,,32.63,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Partners,Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Partners,Medicaid,,416.62,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Partners,Medicaid,,123.52,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Partners,Medicaid,,162.56,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Partners,Medicaid,,172.37,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Partners,Medicaid,,93.49,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Partners,Medicaid,,98.90,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Partners,Medicaid,,104.70,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Partners,Medicaid,,151.75,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Partners,Medicaid,,147.35,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Partners,Medicaid,,216.02,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Partners,Medicaid,,45.85,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Partners,Medicaid,,86.49,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Partners,Medicaid,,212.81,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Partners,Medicaid,,123.12,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Partners,Medicaid,,157.16,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Partners,Medicaid,,7507.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Partners,Medicaid,,43.44,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Partners,Medicaid,,370.97,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Partners,Medicaid,,451.05,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Partners,Medicaid,,84.08,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Partners,Medicaid,,110.11,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Partners,Medicaid,,108.11,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Partners,Medicaid,,80.28,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Partners,Medicaid,,119.32,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Partners,Medicaid,,99.50,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Partners,Medicaid,,150.55,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Partners,Medicaid,,116.32,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Partners,Medicaid,,185.79,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Partners,Medicaid,,276.68,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Partners,Medicaid,,54.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Partners,Medicaid,,165.97,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Partners,Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Partners,Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Partners,Medicaid,,271.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Partners,Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Partners,Medicaid,,137.14,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Partners,Medicaid,,221.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Partners,Medicaid,,116.72,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Partners,Medicaid,,583.98,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Partners,Medicaid,,299.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Partners,Medicaid,,218.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Partners,Medicaid,,195.40,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Partners,Medicaid,,143.54,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Partners,Medicaid,,373.57,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Partners,Medicaid,,203.00,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Partners,Medicaid,,416.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Partners,Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Partners,Medicaid,,458.46,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Partners,Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Partners,Medicaid,,476.08,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Partners,Medicaid,,547.15,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Partners,Medicaid,,171.37,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Partners,Medicaid,,313.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Partners,Medicaid,,246.25,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Partners,Medicaid,,449.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Partners,Medicaid,,208.61,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Partners,Medicaid,,229.83,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Partners,Medicaid,,251.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Partners,Medicaid,,357.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Partners,Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Partners,Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Partners,Medicaid,,499.90,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Partners,Medicaid,,775.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Partners,Medicaid,,969.77,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Partners,Medicaid,,166.37,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Partners,Medicaid,,288.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Partners,Medicaid,,259.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Partners,Medicaid,,318.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Partners,Medicaid,,497.70,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Partners,Medicaid,,155.76,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Partners,Medicaid,,293.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Partners,Medicaid,,172.97,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Partners,Medicaid,,218.22,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Partners,Medicaid,,159.96,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Partners,Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Partners,Medicaid,,264.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Partners,Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Partners,Medicaid,,322.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Partners,Medicaid,,254.45,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Partners,Medicaid,,184.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Partners,Medicaid,,468.67,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Partners,Medicaid,,589.19,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Partners,Medicaid,,55.46,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Partners,Medicaid,,19.82,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Partners,Medicaid,,406.41,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Partners,Medicaid,,197.80,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Partners,Medicaid,,41.64,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Partners,Medicaid,,559.36,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Partners,Medicaid,,2501.10,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Partners,Medicaid,,328.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Partners,Medicaid,,103.90,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Partners,Medicaid,,407.01,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Partners,Medicaid,,94.09,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Partners,Medicaid,,2476.67,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Partners,Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Partners,Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Partners,Medicaid,,17.42,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Partners,Medicaid,,175.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Partners,Medicaid,,23.82,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Partners,Medicaid,,116.92,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Partners,Medicaid,,64.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Partners,Medicaid,,8.81,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Partners,Medicaid,,1057.06,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Partners,Medicaid,,1.20,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Partners,Medicaid,,129.93,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Partners,Medicaid,,24.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Partners,Medicaid,,8.41,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Partners,Medicaid,,16.42,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Partners,Medicaid,,50.85,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Partners,Medicaid,,1212.81,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Partners,Medicaid,,36.64,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Partners,Medicaid,,215.22,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Partners,Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Partners,Medicaid,,285.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Partners,Medicaid,,61.06,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Partners,Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Partners,Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Partners,Medicaid,,268.87,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Partners,Medicaid,,97.50,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Partners,Medicaid,,87.09,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Partners,Medicaid,,448.45,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Partners,Medicaid,,321.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Partners,Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Partners,Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Partners,Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Partners,Medicaid,,262.06,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Partners,Medicaid,,386.19,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Partners,Medicaid,,214.01,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Partners,Medicaid,,381.98,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Partners,Medicaid,,246.25,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Partners,Medicaid,,804.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Partners,Medicaid,,662.66,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Partners,Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Partners,Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Partners,Medicaid,,813.21,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Partners,Medicaid,,206.81,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Partners,Medicaid,,225.43,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Partners,Medicaid,,64.86,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Partners,Medicaid,,507.91,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Partners,Medicaid,,258.06,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Partners,Medicaid,,227.83,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Partners,Medicaid,,254.05,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Partners,Medicaid,,452.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Partners,Medicaid,,534.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Partners,Medicaid,,653.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Partners,Medicaid,,490.49,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Partners,Medicaid,,588.99,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Partners,Medicaid,,657.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Partners,Medicaid,,507.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Partners,Medicaid,,619.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Partners,Medicaid,,701.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Partners,Medicaid,,517.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Partners,Medicaid,,617.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Partners,Medicaid,,703.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Partners,Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Partners,Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Partners,Medicaid,,466.67,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Partners,Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Partners,Medicaid,,688.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Partners,Medicaid,,775.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Partners,Medicaid,,574.97,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Partners,Medicaid,,724.32,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Partners,Medicaid,,741.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Partners,Medicaid,,448.85,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Partners,Medicaid,,546.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Partners,Medicaid,,637.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Partners,Medicaid,,524.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Partners,Medicaid,,638.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Partners,Medicaid,,745.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Partners,Medicaid,,604.20,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Partners,Medicaid,,458.86,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Partners,Medicaid,,573.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Partners,Medicaid,,614.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Partners,Medicaid,,587.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Partners,Medicaid,,805.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Partners,Medicaid,,869.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Partners,Medicaid,,795.59,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Partners,Medicaid,,502.70,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Partners,Medicaid,,646.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Partners,Medicaid,,847.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Partners,Medicaid,,986.39,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Partners,Medicaid,,499.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Partners,Medicaid,,635.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Partners,Medicaid,,752.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Partners,Medicaid,,1473.67,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Partners,Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Partners,Medicaid,,1072.07,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Partners,Medicaid,,1277.08,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Partners,Medicaid,,1484.48,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Partners,Medicaid,,262.06,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Partners,Medicaid,,812.61,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Partners,Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Partners,Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Partners,Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Partners,Medicaid,,560.56,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Partners,Medicaid,,95.50,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Partners,Medicaid,,234.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Partners,Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Partners,Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Partners,Medicaid,,290.29,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Partners,Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Partners,Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Partners,Medicaid,,380.58,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Partners,Medicaid,,95.09,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Partners,Medicaid,,67.47,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Partners,Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Partners,Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Partners,Medicaid,,6299.49,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Partners,Medicaid,,53.85,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Partners,Medicaid,,145.75,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Partners,Medicaid,,125.93,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Partners,Medicaid,,399.00,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Partners,Medicaid,,1022.02,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Partners,Medicaid,,108.71,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Partners,Medicaid,,277.68,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Partners,Medicaid,,176.18,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Partners,Medicaid,,11521.71,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Partners,Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Partners,Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Partners,Medicaid,,5912.91,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Partners,Medicaid,,222.22,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Partners,Medicaid,,600.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Partners,Medicaid,,31.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Partners,Medicaid,,31.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Partners,Medicaid,,84.28,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Partners,Medicaid,,584.78,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Partners,Medicaid,,125.93,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Partners,Medicaid,,91.29,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Partners,Medicaid,,46.45,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Partners,Medicaid,,40.24,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Partners,Medicaid,,96.30,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Partners,Medicaid,,222.02,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Partners,Medicaid,,91.69,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Partners,Medicaid,,57.06,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Partners,Medicaid,,280.28,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Partners,Medicaid,,316.72,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Partners,Medicaid,,316.72,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Partners,Medicaid,,466.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Partners,Medicaid,,466.47,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Partners,Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Partners,Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Partners,Medicaid,,160.96,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Partners,Medicaid,,160.96,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Partners,Medicaid,,144.54,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Partners,Medicaid,,115.52,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Partners,Medicaid,,115.52,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Partners,Medicaid,,944.94,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Partners,Medicaid,,676.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Partners,Medicaid,,142.54,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Partners,Medicaid,,113.11,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Partners,Medicaid,,283.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Partners,Medicaid,,153.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Partners,Medicaid,,258.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Partners,Medicaid,,116.32,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Partners,Medicaid,,255.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Partners,Medicaid,,255.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Partners,Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Partners,Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Partners,Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Partners,Medicaid,,60.06,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Partners,Medicaid,,388.99,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Partners,Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Partners,Medicaid,,166.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Partners,Medicaid,,324.92,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Partners,Medicaid,,354.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Partners,Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Partners,Medicaid,,362.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Partners,Medicaid,,421.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Partners,Medicaid,,421.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Partners,Medicaid,,135.54,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Partners,Medicaid,,135.54,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Partners,Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Partners,Medicaid,,136.94,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Partners,Medicaid,,136.94,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Partners,Medicaid,,538.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Partners,Medicaid,,551.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Partners,Medicaid,,551.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Partners,Medicaid,,319.12,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Partners,Medicaid,,319.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Partners,Medicaid,,183.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Partners,Medicaid,,183.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Partners,Medicaid,,226.23,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Partners,Medicaid,,226.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Partners,Medicaid,,230.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Partners,Medicaid,,230.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Partners,Medicaid,,1012.81,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Partners,Medicaid,,985.99,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Partners,Medicaid,,159.16,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Partners,Medicaid,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Partners,Medicaid,,163.76,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Partners,Medicaid,,148.55,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Partners,Medicaid,,449.85,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Partners,Medicaid,,148.55,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Partners,Medicaid,,745.34,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Partners,Medicaid,,177.38,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Partners,Medicaid,,137.34,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Partners,Medicaid,,39.04,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Partners,Medicaid,,106.71,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Partners,Medicaid,,111.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Partners,Medicaid,,118.12,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Partners,Medicaid,,116.72,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Partners,Medicaid,,133.13,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Partners,Medicaid,,833.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Partners,Medicaid,,426.03,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Partners,Medicaid,,268.87,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Partners,Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Partners,Medicaid,,138.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Partners,Medicaid,,117.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Partners,Medicaid,,121.32,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Partners,Medicaid,,176.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Partners,Medicaid,,176.98,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Partners,Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Partners,Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Partners,Medicaid,,2814.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Partners,Medicaid,,1238.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Partners,Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Partners,Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Partners,Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Partners,Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Partners,Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Partners,Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Partners,Medicaid,,1536.13,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Partners,Medicaid,,1581.98,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Partners,Medicaid,,1581.98,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Partners,Medicaid,,960.96,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Partners,Medicaid,,895.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Partners,Medicaid,,1213.61,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Partners,Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Partners,Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Partners,Medicaid,,879.68,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Partners,Medicaid,,483.88,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Partners,Medicaid,,495.50,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Partners,Medicaid,,322.92,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Partners,Medicaid,,158.56,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Partners,Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Partners,Medicaid,,75.88,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Partners,Medicaid,,96.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Partners,Medicaid,,56.46,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Partners,Medicaid,,108.51,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Partners,Medicaid,,1059.86,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Partners,Medicaid,,255.66,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Partners,Medicaid,,1500.30,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Partners,Medicaid,,79.08,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Partners,Medicaid,,328.33,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Partners,Medicaid,,328.33,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Partners,Medicaid,,427.63,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Partners,Medicaid,,182.38,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Partners,Medicaid,,616.02,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Partners,Medicaid,,448.25,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Partners,Medicaid,,107.11,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Partners,Medicaid,,203.40,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Partners,Medicaid,,771.57,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Partners,Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Partners,Medicaid,,160.56,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Partners,Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Partners,Medicaid,,139.14,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Partners,Medicaid,,1059.86,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Partners,Medicaid,,476.08,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Partners,Medicaid,,500.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Partners,Medicaid,,496.10,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Partners,Medicaid,,127.33,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Partners,Medicaid,,232.23,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Partners,Medicaid,,35.03,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Partners,Medicaid,,1259.46,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Partners,Medicaid,,1554.95,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Partners,Medicaid,,498.70,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Partners,Medicaid,,58.86,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Partners,Medicaid,,46.25,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Partners,Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Partners,Medicaid,,80.88,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Partners,Medicaid,,81.68,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Partners,Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Partners,Medicaid,,40.44,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Partners,Medicaid,,318.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Partners,Medicaid,,900.30,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Partners,Medicaid,,847.65,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Partners,Medicaid,,584.78,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Partners,Medicaid,,915.71,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Partners,Medicaid,,211.21,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Partners,Medicaid,,211.21,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Partners,Medicaid,,294.49,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Partners,Medicaid,,57.66,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Partners,Medicaid,,57.66,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Partners,Medicaid,,383.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Partners,Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Partners,Medicaid,,234.83,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Partners,Medicaid,,502.70,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Partners,Medicaid,,502.70,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Partners,Medicaid,,407.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Partners,Medicaid,,407.21,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Partners,Medicaid,,347.95,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Partners,Medicaid,,347.95,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Partners,Medicaid,,316.92,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Partners,Medicaid,,316.92,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Partners,Medicaid,,329.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Partners,Medicaid,,329.53,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Partners,Medicaid,,342.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Partners,Medicaid,,303.30,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Partners,Medicaid,,303.30,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Partners,Medicaid,,302.10,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Partners,Medicaid,,302.10,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Partners,Medicaid,,665.06,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Partners,Medicaid,,665.06,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Partners,Medicaid,,372.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Partners,Medicaid,,372.37,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Partners,Medicaid,,363.96,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Partners,Medicaid,,363.96,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Partners,Medicaid,,461.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Partners,Medicaid,,73.67,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Partners,Medicaid,,972.37,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Partners,Medicaid,,44.04,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Partners,Medicaid,,568.77,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Partners,Medicaid,,598.60,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Partners,Medicaid,,4031.43,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Partners,Medicaid,,2143.34,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Partners,Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Partners,Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Partners,Medicaid,,215.01,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Partners,Medicaid,,138.74,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Partners,Medicaid,,155.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Partners,Medicaid,,1092.69,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Partners,Medicaid,,743.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Partners,Medicaid,,944.74,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Partners,Medicaid,,774.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Partners,Medicaid,,973.77,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Partners,Medicaid,,798.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Partners,Medicaid,,337.94,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Partners,Medicaid,,114.71,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Partners,Medicaid,,1493.89,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Partners,Medicaid,,398.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Partners,Medicaid,,298.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Partners,Medicaid,,531.13,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Partners,Medicaid,,5758.95,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Partners,Medicaid,,838.24,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Partners,Medicaid,,2658.46,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Partners,Medicaid,,1771.37,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Partners,Medicaid,,696.50,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Partners,Medicaid,,248.45,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Partners,Medicaid,,339.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Partners,Medicaid,,339.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Partners,Medicaid,,375.58,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Partners,Medicaid,,375.58,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Partners,Medicaid,,346.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Partners,Medicaid,,346.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Partners,Medicaid,,258.06,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Partners,Medicaid,,146.75,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Partners,Medicaid,,246.05,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Partners,Medicaid,,1434.43,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Partners,Medicaid,,358.56,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Partners,Medicaid,,315.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Partners,Medicaid,,371.17,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Partners,Medicaid,,209.41,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Partners,Medicaid,,717.92,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Partners,Medicaid,,717.92,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Partners,Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Partners,Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Partners,Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Partners,Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Partners,Medicaid,,693.69,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Partners,Medicaid,,596.60,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Partners,Medicaid,,1230.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Partners,Medicaid,,1430.23,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Partners,Medicaid,,1059.26,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Partners,Medicaid,,954.35,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Partners,Medicaid,,238.64,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Partners,Medicaid,,1609.21,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Partners,Medicaid,,1660.86,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Partners,Medicaid,,2496.49,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Partners,Medicaid,,1392.39,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Partners,Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Partners,Medicaid,,369.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Partners,Medicaid,,178.38,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Partners,Medicaid,,322.52,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Partners,Medicaid,,238.44,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Partners,Medicaid,,741.14,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Partners,Medicaid,,650.85,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Partners,Medicaid,,651.45,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Partners,Medicaid,,561.56,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Partners,Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Partners,Medicaid,,954.75,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Partners,Medicaid,,1107.51,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Partners,Medicaid,,1623.02,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Partners,Medicaid,,150.35,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Partners,Medicaid,,2177.58,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Partners,Medicaid,,1567.77,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Partners,Medicaid,,762.16,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Partners,Medicaid,,3427.62,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Partners,Medicaid,,1466.87,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Partners,Medicaid,,180.58,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Partners,Medicaid,,696.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Partners,Medicaid,,696.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Partners,Medicaid,,3451.05,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Partners,Medicaid,,3239.64,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Partners,Medicaid,,3239.64,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Partners,Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Partners,Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Partners,Medicaid,,1866.26,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Partners,Medicaid,,1866.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Partners,Medicaid,,2488.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Partners,Medicaid,,1808.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Partners,Medicaid,,582.58,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Partners,Medicaid,,474.07,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Partners,Medicaid,,474.07,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Partners,Medicaid,,160.96,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Partners,Medicaid,,1313.31,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Partners,Medicaid,,337.54,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Partners,Medicaid,,404.60,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Partners,Medicaid,,642.84,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Partners,Medicaid,,97.50,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Partners,Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Partners,Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Partners,Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Partners,Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Partners,Medicaid,,1990.79,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Partners,Medicaid,,1990.79,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Partners,Medicaid,,803.60,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Partners,Medicaid,,1219.62,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Partners,Medicaid,,691.09,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Partners,Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Partners,Medicaid,,125.93,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Partners,Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Partners,Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Partners,Medicaid,,812.41,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Partners,Medicaid,,392.19,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Partners,Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Partners,Medicaid,,91.89,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Partners,Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Partners,Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Partners,Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Partners,Medicaid,,64.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Partners,Medicaid,,178.98,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Partners,Medicaid,,114.91,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Partners,Medicaid,,228.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Partners,Medicaid,,187.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Partners,Medicaid,,211.81,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Partners,Medicaid,,154.35,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Partners,Medicaid,,167.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Partners,Medicaid,,63.06,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Partners,Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Partners,Medicaid,,62.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Partners,Medicaid,,165.16,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Partners,Medicaid,,192.39,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Partners,Medicaid,,103.90,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Partners,Medicaid,,127.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Partners,Medicaid,,85.49,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Partners,Medicaid,,167.17,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Partners,Medicaid,,133.73,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Partners,Medicaid,,107.91,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Partners,Medicaid,,131.73,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Partners,Medicaid,,207.61,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Partners,Medicaid,,164.76,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Partners,Medicaid,,183.98,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Partners,Medicaid,,60.26,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Partners,Medicaid,,235.84,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Partners,Medicaid,,152.95,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Partners,Medicaid,,50.05,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Partners,Medicaid,,46.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Partners,Medicaid,,37.24,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Partners,Medicaid,,220.62,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Partners,Medicaid,,165.16,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Partners,Medicaid,,39.84,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Partners,Medicaid,,136.94,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Partners,Medicaid,,84.48,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Partners,Medicaid,,193.59,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Partners,Medicaid,,144.94,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Partners,Medicaid,,82.68,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Partners,Medicaid,,98.50,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Partners,Medicaid,,91.89,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Partners,Medicaid,,27.83,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Partners,Medicaid,,13.41,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Partners,Medicaid,,21.82,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Partners,Medicaid,,1278.48,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Partners,Medicaid,,931.73,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Partners,Medicaid,,837.24,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Partners,Medicaid,,1299.50,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Partners,Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Partners,Medicaid,,538.14,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Partners,Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Partners,Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Partners,Medicaid,,186.39,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Partners,Medicaid,,306.51,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Partners,Medicaid,,612.81,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Partners,Medicaid,,932.93,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Partners,Medicaid,,836.04,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Partners,Medicaid,,1211.61,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Partners,Medicaid,,1780.98,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Partners,Medicaid,,105.51,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Partners,Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Partners,Medicaid,,114.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Partners,Medicaid,,202.60,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Partners,Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Partners,Medicaid,,494.29,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Partners,Medicaid,,96.30,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Partners,Medicaid,,563.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Partners,Medicaid,,659.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Partners,Medicaid,,1014.81,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Partners,Medicaid,,1226.63,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Partners,Medicaid,,692.49,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Partners,Medicaid,,1035.63,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Partners,Medicaid,,1078.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Partners,Medicaid,,721.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Partners,Medicaid,,753.75,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Partners,Medicaid,,1032.63,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Partners,Medicaid,,695.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Partners,Medicaid,,816.02,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Partners,Medicaid,,940.74,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Partners,Medicaid,,742.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Partners,Medicaid,,779.18,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Partners,Medicaid,,1067.47,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Partners,Medicaid,,735.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Partners,Medicaid,,743.14,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Partners,Medicaid,,1032.63,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Partners,Medicaid,,852.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Partners,Medicaid,,901.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Partners,Medicaid,,1047.85,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Partners,Medicaid,,584.38,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Partners,Medicaid,,837.84,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Partners,Medicaid,,635.03,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Partners,Medicaid,,50.65,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Partners,Medicaid,52,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Partners,Medicaid,52,787.39,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Partners,Medicaid,,769.37,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Partners,Medicaid,,881.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Partners,Medicaid,,1040.24,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Partners,Medicaid,,805.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Partners,Medicaid,,827.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Partners,Medicaid,,703.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Partners,Medicaid,,855.65,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Partners,Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Partners,Medicaid,,811.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Partners,Medicaid,,1021.82,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Partners,Medicaid,,983.38,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Partners,Medicaid,,1091.89,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Partners,Medicaid,,838.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Partners,Medicaid,,928.33,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Partners,Medicaid,,1118.32,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Partners,Medicaid,,694.29,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Partners,Medicaid,,734.93,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Partners,Medicaid,,1069.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Partners,Medicaid,,649.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Partners,Medicaid,,720.52,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Partners,Medicaid,,1000.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Partners,Medicaid,,845.85,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Partners,Medicaid,,647.85,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Partners,Medicaid,,895.29,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Partners,Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Partners,Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Partners,Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Partners,Medicaid,,707.71,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Partners,Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Partners,Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Partners,Medicaid,,899.50,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Partners,Medicaid,,650.65,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Partners,Medicaid,,919.72,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Partners,Medicaid,,894.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Partners,Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Partners,Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Partners,Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Partners,Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Partners,Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Partners,Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Partners,Medicaid,,206.81,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Partners,Medicaid,,480.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Partners,Medicaid,,477.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Partners,Medicaid,,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Partners,Medicaid,,375.38,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Partners,Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Partners,Medicaid,,64.86,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Partners,Medicaid,,79.88,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Partners,Medicaid,,349.35,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Partners,Medicaid,,349.35,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Partners,Medicaid,,31.63,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Partners,Medicaid,,366.57,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Partners,Medicaid,,366.57,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Partners,Medicaid,,181.18,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Partners,Medicaid,,108.11,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Partners,Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Partners,Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Partners,Medicaid,,260.06,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Partners,Medicaid,,207.61,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Partners,Medicaid,,169.57,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Partners,Medicaid,,123.32,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Partners,Medicaid,,119.92,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Partners,Medicaid,,58.46,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Partners,Medicaid,,86.29,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Partners,Medicaid,,63.46,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Partners,Medicaid,,57.66,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Partners,Medicaid,,136.14,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Partners,Medicaid,,56.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Partners,Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Partners,Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Partners,Medicaid,,287.49,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Partners,Medicaid,,150.55,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Partners,Medicaid,,373.57,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Partners,Medicaid,,870.87,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Partners,Medicaid,,50.45,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Partners,Medicaid,,35.44,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Partners,Medicaid,,73.87,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Partners,Medicaid,,36.64,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Partners,Medicaid,,85.49,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Partners,Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Partners,Medicaid,,55.05,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Partners,Medicaid,,79.88,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Partners,Medicaid,,126.33,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Partners,Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Partners,Medicaid,,174.97,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Partners,Medicaid,,112.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Partners,Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Partners,Medicaid,,72.47,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Partners,Medicaid,,151.35,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Partners,Medicaid,,61.06,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Partners,Medicaid,,133.13,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Partners,Medicaid,,84.48,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Partners,Medicaid,,191.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Partners,Medicaid,,119.92,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Partners,Medicaid,,84.48,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Partners,Medicaid,,91.69,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Partners,Medicaid,,72.87,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Partners,Medicaid,,505.30,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Partners,Medicaid,,434.23,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Partners,Medicaid,,221.42,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Partners,Medicaid,,104.30,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Partners,Medicaid,,110.71,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Partners,Medicaid,,67.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Partners,Medicaid,,25.63,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Partners,Medicaid,,102.50,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Partners,Medicaid,,80.88,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Partners,Medicaid,,80.88,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Partners,Medicaid,,481.28,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Partners,Medicaid,,9.41,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Partners,Medicaid,,2.80,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Partners,Medicaid,,22.42,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Partners,Medicaid,,32.63,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Partners,Medicaid,,26.43,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Partners,Medicaid,,5.21,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Partners,Medicaid,,8.81,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Partners,Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Partners,Medicaid,,53.05,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Partners,Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Partners,Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Partners,Medicaid,,79.48,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Partners,Medicaid,,31.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Partners,Medicaid,,107.11,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Partners,Medicaid,,14.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Partners,Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Partners,Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Partners,Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Partners,Medicaid,,5.81,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Partners,Medicaid,,35.44,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Partners,Medicaid,,24.82,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Partners,Medicaid,,7.81,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Partners,Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Partners,Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Partners,Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Partners,Medicaid,,30.83,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Partners,Medicaid,,5.81,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Partners,Medicaid,,8.61,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Partners,Medicaid,,8.41,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Partners,Medicaid,,9.61,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Partners,Medicaid,,32.43,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Partners,Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Partners,Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Partners,Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Partners,Medicaid,,8.41,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Partners,Medicaid,,12.01,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Partners,Medicaid,,8.01,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Partners,Medicaid,,8.01,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Partners,Medicaid,,33.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Partners,Medicaid,,13.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Partners,Medicaid,,10.61,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Partners,Medicaid,,51.65,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Partners,Medicaid,,13.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Partners,Medicaid,,48.65,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Partners,Medicaid,,36.04,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Partners,Medicaid,,29.23,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Partners,Medicaid,,15.82,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Partners,Medicaid,,7.81,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Partners,Medicaid,,59.86,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Partners,Medicaid,,1.20,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Partners,Medicaid,,40.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Partners,Medicaid,,115.92,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Partners,Medicaid,,31.43,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Partners,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Partners,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Partners,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Partners,Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Partners,Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Partners,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Partners,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Partners,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Partners,Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Partners,Medicaid,,6.01,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Partners,Medicaid,,14.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Partners,Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Partners,Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Partners,Medicaid,,15.62,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Partners,Medicaid,,47.65,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Partners,Medicaid,,31.23,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Partners,Medicaid,,44.24,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Partners,Medicaid,,24.02,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Partners,Medicaid,,30.43,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Partners,Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Partners,Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Partners,Medicaid,,39.44,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Partners,Medicaid,,26.43,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Partners,Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Partners,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Partners,Medicaid,,8.41,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Partners,Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Partners,Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Partners,Medicaid,,29.83,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Partners,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Partners,Medicaid,,28.63,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Partners,Medicaid,,16.62,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Partners,Medicaid,,28.63,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Partners,Medicaid,,35.44,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Partners,Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Partners,Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Partners,Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Partners,Medicaid,,0.40040,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Partners,Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Partners,Medicaid,,11.01,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Partners,Medicaid,,29.23,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Partners,Medicaid,,45.45,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Partners,Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Partners,Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Partners,Medicaid,,9.01,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Partners,Medicaid,,10.61,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Partners,Medicaid,,10.01,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Partners,Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Partners,Medicaid,,9.01,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Partners,Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Partners,Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Partners,Medicaid,,8.61,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Partners,Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Partners,Medicaid,,33.43,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Partners,Medicaid,,9.01,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Partners,Medicaid,,32.03,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Partners,Medicaid,,38.04,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Partners,Medicaid,,13.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Partners,Medicaid,,26.83,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Partners,Medicaid,,26.03,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Partners,Medicaid,,21.62,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Partners,Medicaid,,7.61,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Partners,Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Partners,Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Partners,Medicaid,,26.03,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Partners,Medicaid,,38.64,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Partners,Medicaid,,15.82,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Partners,Medicaid,,2.40,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Partners,Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Partners,Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Partners,Medicaid,,45.05,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Partners,Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Partners,Medicaid,,28.03,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Partners,Medicaid,,22.62,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Partners,Medicaid,,19.42,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Partners,Medicaid,,27.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Partners,Medicaid,,24.02,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Partners,Medicaid,,1.60,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Partners,Medicaid,,4.40,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Partners,Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Partners,Medicaid,,34.83,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Partners,Medicaid,,25.63,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Partners,Medicaid,,53.45,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Partners,Medicaid,,29.43,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Partners,Medicaid,,54.65,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Partners,Medicaid,,41.44,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Partners,Medicaid,,10.01,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Partners,Medicaid,,47.45,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Partners,Medicaid,,41.24,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Partners,Medicaid,,8.21,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Partners,Medicaid,,58.66,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Partners,Medicaid,,40.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Partners,Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Partners,Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Partners,Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Partners,Medicaid,,10.01,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Partners,Medicaid,,27.03,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Partners,Medicaid,,44.64,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Partners,Medicaid,,4.20,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Partners,Medicaid,,11.41,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Partners,Medicaid,,29.03,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Partners,Medicaid,,13.61,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,,23.42,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Partners,Medicaid,,34.63,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Partners,Medicaid,,19.42,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Partners,Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Partners,Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Partners,Medicaid,,3.00,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Partners,Medicaid,,7.01,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Partners,Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Partners,Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Partners,Medicaid,,92.29,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Partners,Medicaid,,24.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Partners,Medicaid,,39.04,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Partners,Medicaid,,16.62,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Partners,Medicaid,,2.20,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Partners,Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Partners,Medicaid,,27.03,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Partners,Medicaid,,21.62,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Partners,Medicaid,,158.96,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Partners,Medicaid,,89.49,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Partners,Medicaid,,53.25,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Partners,Medicaid,,114.11,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Partners,Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Partners,Medicaid,,59.26,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Partners,Medicaid,,72.27,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Partners,Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Partners,Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Partners,Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Partners,Medicaid,,46.65,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Partners,Medicaid,,29.03,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Partners,Medicaid,,24.62,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Partners,Medicaid,,26.83,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Partners,Medicaid,,39.24,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Partners,Medicaid,,34.63,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Partners,Medicaid,,100.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Partners,Medicaid,,147.55,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Partners,Medicaid,,25.23,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Partners,Medicaid,,27.83,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Partners,Medicaid,,30.03,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Partners,Medicaid,,18.62,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Partners,Medicaid,,32.43,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Partners,Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Partners,Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Partners,Medicaid,,64.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Partners,Medicaid,,55.05,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Partners,Medicaid,,58.26,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Partners,Medicaid,,52.85,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Partners,Medicaid,,122.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Partners,Medicaid,,32.23,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Partners,Medicaid,,47.45,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Partners,Medicaid,,39.84,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Partners,Medicaid,,19.82,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Partners,Medicaid,,65.06,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Partners,Medicaid,,54.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Partners,Medicaid,,64.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Partners,Medicaid,,50.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Partners,Medicaid,,36.44,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Partners,Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Partners,Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Partners,Medicaid,,49.45,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Partners,Medicaid,,8.81,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Partners,Medicaid,,30.03,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Partners,Medicaid,,39.24,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Partners,Medicaid,,93.69,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Partners,Medicaid,,56.66,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Partners,Medicaid,,7.01,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Partners,Medicaid,,14.41,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Partners,Medicaid,,22.62,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Partners,Medicaid,,71.27,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Partners,Medicaid,,29.23,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Partners,Medicaid,,40.44,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Partners,Medicaid,,28.63,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Partners,Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Partners,Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Partners,Medicaid,,20.42,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Partners,Medicaid,,17.02,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Partners,Medicaid,,19.62,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Partners,Medicaid,,44.84,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Partners,Medicaid,,7.81,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Partners,Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Partners,Medicaid,,9.41,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Partners,Medicaid,,3.00,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Partners,Medicaid,,8.21,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Partners,Medicaid,,37.64,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Partners,Medicaid,,24.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Partners,Medicaid,,26.03,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Partners,Medicaid,,14.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Partners,Medicaid,,31.43,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Partners,Medicaid,,5.41,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Partners,Medicaid,,10.61,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Partners,Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Partners,Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Partners,Medicaid,,19.42,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Partners,Medicaid,,42.64,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Partners,Medicaid,,40.84,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Partners,Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Partners,Medicaid,,40.84,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Partners,Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Partners,Medicaid,,14.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Partners,Medicaid,,29.03,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Partners,Medicaid,,18.42,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Partners,Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Partners,Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Partners,Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Partners,Medicaid,,5.21,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,,25.83,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Partners,Medicaid,,23.22,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Partners,Medicaid,,15.82,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Partners,Medicaid,,67.87,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Partners,Medicaid,,13.61,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,,17.82,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Partners,Medicaid,,3.20,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Partners,Medicaid,,49.05,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Partners,Medicaid,,30.83,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Partners,Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Partners,Medicaid,,19.82,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Partners,Medicaid,,15.62,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Partners,Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Partners,Medicaid,,11.41,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Partners,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Partners,Medicaid,,12.61,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Partners,Medicaid,,36.04,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Partners,Medicaid,,6.61,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Partners,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Partners,Medicaid,,45.65,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Partners,Medicaid,,33.83,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Partners,Medicaid,,92.29,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Partners,Medicaid,,42.64,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Partners,Medicaid,,42.64,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Partners,Medicaid,,125.93,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Partners,Medicaid,,116.32,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Partners,Medicaid,,34.83,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Partners,Medicaid,,32.23,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Partners,Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Partners,Medicaid,,42.44,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Partners,Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Partners,Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Partners,Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Partners,Medicaid,,51.45,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Partners,Medicaid,,154.15,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Partners,Medicaid,,17.42,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Partners,Medicaid,,16.62,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Partners,Medicaid,,9.61,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Partners,Medicaid,,22.42,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Partners,Medicaid,,115.92,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Partners,Medicaid,,55.86,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Partners,Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Partners,Medicaid,,30.83,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Partners,Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Partners,Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Partners,Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Partners,Medicaid,,92.69,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Partners,Medicaid,,58.86,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Partners,Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Partners,Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Partners,Medicaid,,25.23,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Partners,Medicaid,,2.40,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Partners,Medicaid,,30.03,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Partners,Medicaid,,24.02,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Partners,Medicaid,,109.71,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Partners,Medicaid,,61.86,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Partners,Medicaid,,25.43,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Partners,Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Partners,Medicaid,,4.40,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Partners,Medicaid,,46.05,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Partners,Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Partners,Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Partners,Medicaid,,11.61,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Partners,Medicaid,,7.01,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Partners,Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Partners,Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Partners,Medicaid,,12.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Partners,Medicaid,,12.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Partners,Medicaid,,9.21,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Partners,Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Partners,Medicaid,,14.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Partners,Medicaid,,3.00,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Partners,Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Partners,Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Partners,Medicaid,,26.83,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Partners,Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Partners,Medicaid,,5.21,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Partners,Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Partners,Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Partners,Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Partners,Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Partners,Medicaid,,0.40040,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Partners,Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Partners,Medicaid,,16.22,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Partners,Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Partners,Medicaid,,32.23,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Partners,Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Partners,Medicaid,,28.23,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Partners,Medicaid,,6.81,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Partners,Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Partners,Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Partners,Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Partners,Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Partners,Medicaid,,7.01,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Partners,Medicaid,,15.02,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Partners,Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Partners,Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Partners,Medicaid,,153.55,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Partners,Medicaid,,26.83,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Partners,Medicaid,,361.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Partners,Medicaid,,251.85,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Partners,Medicaid,,58.66,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Partners,Medicaid,,23.22,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Partners,Medicaid,,386.59,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Partners,Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Partners,Medicaid,,51.85,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Partners,Medicaid,,9.21,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Partners,Medicaid,,361.96,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Partners,Medicaid,,141.54,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Partners,Medicaid,,102.70,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Partners,Medicaid,,37.84,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Partners,Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Partners,Medicaid,,22.82,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Partners,Medicaid,,64.86,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Partners,Medicaid,,38.84,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Partners,Medicaid,,190.79,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Partners,Medicaid,,127.93,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Partners,Medicaid,,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Partners,Medicaid,QW,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Partners,Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Partners,Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Partners,Medicaid,,318.12,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Partners,Medicaid,,237.64,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Partners,Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Partners,Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Partners,Medicaid,,95.70,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Partners,Medicaid,,40.84,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Partners,Medicaid,,85.29,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Partners,Medicaid,,10.01,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Partners,Medicaid,QW,20.02,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Partners,Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Partners,Medicaid,,32.63,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Partners,Medicaid,,181.58,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Partners,Medicaid,,55.05,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Partners,Medicaid,,26.43,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,,33.03,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Partners,Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Partners,Medicaid,,8.61,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Partners,Medicaid,,56.06,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Partners,Medicaid,,15.82,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Partners,Medicaid,,38.84,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Partners,Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Partners,Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Partners,Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Partners,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Partners,Medicaid,,42.64,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Partners,Medicaid,,43.84,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Partners,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Partners,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Partners,Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Partners,Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Partners,Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Partners,Medicaid,,15.22,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Partners,Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Partners,Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Partners,Medicaid,,20.22,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Partners,Medicaid,,29.83,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Partners,Medicaid,,265.87,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Partners,Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Partners,Medicaid,,21.62,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Partners,Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Partners,Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Partners,Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Partners,Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Partners,Medicaid,,33.43,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Partners,Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Partners,Medicaid,,63.86,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Partners,Medicaid,,103.10,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Partners,Medicaid,,105.31,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Partners,Medicaid,,42.04,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Partners,Medicaid,,5.41,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Partners,Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Partners,Medicaid,,37.24,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Partners,Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Partners,Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Partners,Medicaid,,7.81,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Partners,Medicaid,,39.64,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Partners,Medicaid,,23.82,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Partners,Medicaid,,51.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Partners,Medicaid,,52.25,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Partners,Medicaid,,15.62,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Partners,Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Partners,Medicaid,,41.84,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Partners,Medicaid,,41.44,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Partners,Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Partners,Medicaid,,29.63,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Partners,Medicaid,,91.29,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Partners,Medicaid,,119.52,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Partners,Medicaid,,151.15,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Partners,Medicaid,,112.31,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Partners,Medicaid,,65.06,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Partners,Medicaid,,45.05,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Partners,Medicaid,,204.00,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Partners,Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Partners,Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Partners,Medicaid,,44.84,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Partners,Medicaid,,26.43,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Partners,Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Partners,Medicaid,,109.71,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Partners,Medicaid,,20.42,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Partners,Medicaid,,35.03,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Partners,Medicaid,,73.47,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Partners,Medicaid,,132.13,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Partners,Medicaid,,0.00200,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Partners,Medicaid,,24.82,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Partners,Medicaid,,45.25,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Partners,Medicaid,,74.07,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Partners,Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Partners,Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Partners,Medicaid,,118.72,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Partners,Medicaid,,109.71,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Partners,Medicaid,,19.42,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Partners,Medicaid,,78.88,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Partners,Medicaid,,62.66,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Partners,Medicaid,,49.85,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Partners,Medicaid,,15.42,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Partners,Medicaid,,76.88,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Partners,Medicaid,,26.43,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Partners,Medicaid,,135.13,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Partners,Medicaid,,37.84,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Partners,Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Partners,Medicaid,,51.25,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Partners,Medicaid,,52.25,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Partners,Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Partners,Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Partners,Medicaid,,107.91,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Partners,Medicaid,,27.83,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Partners,Medicaid,,32.83,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Partners,Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Partners,Medicaid,,82.88,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Partners,Medicaid,,49.45,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Partners,Medicaid,,438.64,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Partners,Medicaid,,70.67,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Partners,Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Partners,Medicaid,,141.74,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Partners,Medicaid,,103.70,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Partners,Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Partners,Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Partners,Medicaid,,103.90,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Partners,Medicaid,,257.26,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Partners,Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Partners,Medicaid,,62.46,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Partners,Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Partners,Medicaid,,248.85,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Partners,Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Partners,Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Partners,Medicaid,,181.78,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Partners,Medicaid,,132.13,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Partners,Medicaid,,94.89,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Partners,Medicaid,,71.27,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Partners,Medicaid,,25.02,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Partners,Medicaid,,30.03,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Partners,Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Partners,Medicaid,,33.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Partners,Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Partners,Medicaid,,31.83,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Partners,Medicaid,,318.12,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Partners,Medicaid,,159.76,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Partners,Medicaid,,65.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Partners,Medicaid,,13.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Partners,Medicaid,,8.41,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Partners,Medicaid,,21.02,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Partners,Medicaid,,49.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Partners,Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Partners,Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Partners,Medicaid,,55.46,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Partners,Medicaid,,113.31,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Partners,Medicaid,,11.41,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Partners,Medicaid,,135.94,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Partners,Medicaid,,130.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Partners,Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Partners,Medicaid,,214.21,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Partners,Medicaid,,43.04,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Partners,Medicaid,,83.88,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Partners,Medicaid,,58.86,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Partners,Medicaid,,189.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Partners,Medicaid,,248.25,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Partners,Medicaid,,120.12,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Partners,Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Partners,Medicaid,,305.91,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Partners,Medicaid,,5.61,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Partners,Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Partners,Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Partners,Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Partners,Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Partners,Medicaid,,232.23,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Partners,Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Partners,Medicaid,,523.72,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Partners,Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Partners,Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Partners,Medicaid,,1715.71,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Partners,Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Partners,Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Partners,Medicaid,,7102.50,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Partners,Medicaid,,1203.60,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Partners,Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Partners,Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Partners,Medicaid,,1344.34,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Partners,Medicaid,,409.01,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Partners,Medicaid,,674.27,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Partners,Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Partners,Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Partners,Medicaid,,396.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Partners,Medicaid,,396.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Partners,Medicaid,,834.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Partners,Medicaid,,834.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Partners,Medicaid,,379.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Partners,Medicaid,,379.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Partners,Medicaid,,89.49,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Partners,Medicaid,,164.76,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Partners,Medicaid,,359.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Partners,Medicaid,,359.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Partners,Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Partners,Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Partners,Medicaid,,317.52,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Partners,Medicaid,,317.52,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Partners,Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Partners,Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Partners,Medicaid,,1544.94,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Partners,Medicaid,,772.37,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Partners,Medicaid,,772.37,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Partners,Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Partners,Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Partners,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Partners,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Partners,Medicaid,,275.88,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Partners,Medicaid,,275.88,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Partners,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Partners,Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Partners,Medicaid,,532.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Partners,Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Partners,Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Partners,Medicaid,,158.96,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Partners,Medicaid,,5817.21,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Partners,Medicaid,,879.68,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Partners,Medicaid,,879.68,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Partners,Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Partners,Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Partners,Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Partners,Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Partners,Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Partners,Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Partners,Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Partners,Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Partners,Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Partners,Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Partners,Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Partners,Medicaid,,4633.03,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Partners,Medicaid,,4633.03,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Partners,Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Partners,Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Partners,Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Partners,Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Partners,Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Partners,Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Partners,Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Partners,Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Partners,Medicaid,,2468.07,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Partners,Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Partners,Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Partners,Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Partners,Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Partners,Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Partners,Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Partners,Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Partners,Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Partners,Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Partners,Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Partners,Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Partners,Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Partners,Medicaid,,4121.72,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Partners,Medicaid,LM,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Partners,Medicaid,RI,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Partners,Medicaid,RC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Partners,Medicaid,LD,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Partners,Medicaid,LC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Partners,Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Partners,Medicaid,RI,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Partners,Medicaid,RC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Partners,Medicaid,LD,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Partners,Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Partners,Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Partners,Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,LM,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,RI,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Partners,Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LM,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,RI,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Partners,Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Partners,Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Partners,Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Partners,Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Partners,Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Partners,Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LM,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,RI,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,RC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LD,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Partners,Medicaid,LC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Partners,Medicaid,,78.68,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Partners,Medicaid,,333.13,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Partners,Medicaid,,373.37,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Partners,Medicaid,,84.48,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Partners,Medicaid,,505.91,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Partners,Medicaid,,197.40,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Partners,Medicaid,,2316.71,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Partners,Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Partners,Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Partners,Medicaid,,2044.04,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Partners,Medicaid,,850.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Partners,Medicaid,,1474.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Partners,Medicaid,,2180.78,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Partners,Medicaid,,1936.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Partners,Medicaid,,2067.27,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Partners,Medicaid,,909.51,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Partners,Medicaid,,2126.92,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Partners,Medicaid,,2652.85,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Partners,Medicaid,,2389.79,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Partners,Medicaid,,2549.35,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Partners,Medicaid,,2592.59,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Partners,Medicaid,,3178.58,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Partners,Medicaid,,1356.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Partners,Medicaid,,40.64,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Partners,Medicaid,,19.42,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Partners,Medicaid,,300.90,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Partners,Medicaid,,826.43,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Partners,Medicaid,,1614.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Partners,Medicaid,,96.90,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Partners,Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Partners,Medicaid,,43.04,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Partners,Medicaid,,1535.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Partners,Medicaid,,7834.43,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Partners,Medicaid,,2458.86,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Partners,Medicaid,,505.50,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Partners,Medicaid,,565.36,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Partners,Medicaid,,253.45,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Partners,Medicaid,,105.71,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Partners,Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Partners,Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Partners,Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Partners,Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Partners,Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Partners,Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Partners,Medicaid,,3657.05,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Partners,Medicaid,,2656.25,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Partners,Medicaid,,3018.42,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Partners,Medicaid,,3642.44,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Partners,Medicaid,,639.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Partners,Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Partners,Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Partners,Medicaid,,2045.04,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Partners,Medicaid,,589.39,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Partners,Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Partners,Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Partners,Medicaid,,4082.48,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Partners,Medicaid,,2987.99,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Partners,Medicaid,,473.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Partners,Medicaid,,4761.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Partners,Medicaid,,4909.10,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Partners,Medicaid,,5350.95,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Partners,Medicaid,,1703.30,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Partners,Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Partners,Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Partners,Medicaid,,9987.38,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Partners,Medicaid,,1151.15,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Partners,Medicaid,,764.96,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Partners,Medicaid,,11551.14,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Partners,Medicaid,,528.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Partners,Medicaid,,2335.73,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Partners,Medicaid,,417.62,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Partners,Medicaid,,838.44,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Partners,Medicaid,,1297.30,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Partners,Medicaid,,1297.30,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Partners,Medicaid,,647.05,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Partners,Medicaid,,459.46,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Partners,Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Partners,Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Partners,Medicaid,,609.21,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Partners,Medicaid,,557.96,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Partners,Medicaid,,1917.92,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Partners,Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Partners,Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Partners,Medicaid,,325.12,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Partners,Medicaid,,1618.42,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Partners,Medicaid,,331.93,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Partners,Medicaid,,631.83,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Partners,Medicaid,,5093.49,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Partners,Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Partners,Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Partners,Medicaid,,605.61,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Partners,Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Partners,Medicaid,,4031.43,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Partners,Medicaid,,4480.68,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Partners,Medicaid,,496.90,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Partners,Medicaid,,386.59,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Partners,Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Partners,Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Partners,Medicaid,,1276.68,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Partners,Medicaid,,515.51,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Partners,Medicaid,,2746.94,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Partners,Medicaid,,960.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Partners,Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Partners,Medicaid,,425.83,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Partners,Medicaid,,567.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Partners,Medicaid,,1594.59,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Partners,Medicaid,,3708.10,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Partners,Medicaid,,1846.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Partners,Medicaid,,1294.69,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Partners,Medicaid,,1496.70,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Partners,Medicaid,,57.66,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Partners,Medicaid,,283.88,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Partners,Medicaid,,1595.59,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Partners,Medicaid,,608.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Partners,Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Partners,Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Partners,Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Partners,Medicaid,,2662.86,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Partners,Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Partners,Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Partners,Medicaid,,8574.37,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Partners,Medicaid,,6999.39,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Partners,Medicaid,,1897.10,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Partners,Medicaid,,869.87,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Partners,Medicaid,,4285.48,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Partners,Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Partners,Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Partners,Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Partners,Medicaid,,6481.07,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Partners,Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Partners,Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Partners,Medicaid,,21.42,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Partners,Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Partners,Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Partners,Medicaid,,9598.39,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Partners,Medicaid,,480.28,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Partners,Medicaid,,1300.10,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Partners,Medicaid,,2169.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Partners,Medicaid,LD,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Partners,Medicaid,RC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Partners,Medicaid,RI,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Partners,Medicaid,LM,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Partners,Medicaid,LD,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Partners,Medicaid,RC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Partners,Medicaid,RI,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Partners,Medicaid,LM,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Partners,Medicaid,LD,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Partners,Medicaid,RC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Partners,Medicaid,RI,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Partners,Medicaid,LM,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,LD,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,RC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,RI,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,LM,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Partners,Medicaid,LC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Partners,Medicaid,LC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Partners,Medicaid,LC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Partners,Medicaid,LC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Partners,Medicaid,,6528.72,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Partners,Medicaid,,12359.75,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Partners,Medicaid,,2282.88,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Partners,Medicaid,,570.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Partners,Medicaid,,115.11,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Partners,Medicaid,,805.00,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Partners,Medicaid,,661.46,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Partners,Medicaid,,258.26,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Partners,Medicaid,,312.91,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Partners,Medicaid,,231.63,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Partners,Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Partners,Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Partners,Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Partners,Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Partners,Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Partners,Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Partners,Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Partners,Medicaid,,99.30,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Partners,Medicaid,,77.08,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Partners,Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Partners,Medicaid,,11.01,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Partners,Medicaid,,273.87,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Partners,Medicaid,,48.65,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Partners,Medicaid,,175.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Partners,Medicaid,,124.52,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Partners,Medicaid,,32.43,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Partners,Medicaid,,38.64,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Partners,Medicaid,,255.46,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Partners,Medicaid,,57.06,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Partners,Medicaid,,43.64,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Partners,Medicaid,,59.46,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Partners,Medicaid,,21.82,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Partners,Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Partners,Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Partners,Medicaid,,1301.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Partners,Medicaid,,725.52,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Partners,Medicaid,,1598.40,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Partners,Medicaid,,521.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Partners,Medicaid,,422.62,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Partners,Medicaid,,422.62,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Partners,Medicaid,,422.62,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Partners,Medicaid,,1276.28,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Partners,Medicaid,,1690.29,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Partners,Medicaid,,1897.30,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Partners,Medicaid,,1567.77,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Partners,Medicaid,,2031.83,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Partners,Medicaid,,2263.86,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Partners,Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Partners,Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Partners,Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Partners,Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Partners,Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Partners,Medicaid,,48.05,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Partners,Medicaid,,74.87,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Partners,Medicaid,,264.26,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Partners,Medicaid,,285.29,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Partners,Medicaid,,446.85,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Partners,Medicaid,,58.66,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Partners,Medicaid,,134.53,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Partners,Medicaid,,20.82,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Partners,Medicaid,,203.40,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Partners,Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Partners,Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Partners,Medicaid,,38.44,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Partners,Medicaid,,633.03,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Partners,Medicaid,,60.46,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Partners,Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Partners,Medicaid,,61.86,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Partners,Medicaid,,57.06,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Partners,Medicaid,,68.27,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Partners,Medicaid,,86.49,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Partners,Medicaid,,123.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Partners,Medicaid,,8.81,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Partners,Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Partners,Medicaid,,14.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Partners,Medicaid,,44.24,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Partners,Medicaid,,80.48,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Partners,Medicaid,,178.18,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Partners,Medicaid,,14.81,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Partners,Medicaid,,10.81,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Partners,Medicaid,,53.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Partners,Medicaid,,8.01,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Partners,Medicaid,,150.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Partners,Medicaid,,235.24,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Partners,Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Partners,Medicaid,,245.04,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Partners,Medicaid,,359.16,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Partners,Medicaid,,454.25,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Partners,Medicaid,,98.50,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Partners,Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Partners,Medicaid,,140.14,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Partners,Medicaid,,156.16,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Partners,Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Partners,Medicaid,,319.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Partners,Medicaid,,514.31,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Partners,Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Partners,Medicaid,,800.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Partners,Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Partners,Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Partners,Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Partners,Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Partners,Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Partners,Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Partners,Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Partners,Medicaid,GP,47.65,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Partners,Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Partners,Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Partners,Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Partners,Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Partners,Medicaid,,2600.00,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Partners,Medicaid,,2657.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Partners,Medicaid,,2714.71,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Partners,Medicaid,,2772.37,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Partners,Medicaid,,2829.83,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Partners,Medicaid,,2887.08,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Partners,Medicaid,,2944.54,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Partners,Medicaid,,3002.00,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Partners,Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Partners,Medicaid,,49.25,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Partners,Medicaid,,40.04,,,,,,,34.82,150.00,percent of total billed charges,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,832.22,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,532.14,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Trillium,Medicaid,,532.14,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Trillium,Medicaid,,0.02831,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Trillium,Medicaid,,26.29,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Trillium,Medicaid,,5.05,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Trillium,Medicaid,,24.87,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Trillium,Medicaid,,24.87,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Trillium,Medicaid,,4.46,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Trillium,Medicaid,,28.71,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Trillium,Medicaid,,8001.05,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Trillium,Medicaid,,3438.21,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Trillium,Medicaid,,0.20422,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Trillium,Medicaid,,388.02,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Trillium,Medicaid,,1466.35,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Trillium,Medicaid,,350.61,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Trillium,Medicaid,,666.25,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Trillium,Medicaid,,8132.48,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Trillium,Medicaid,,2530.94,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Trillium,Medicaid,,2248.46,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Trillium,Medicaid,,3167.46,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Trillium,Medicaid,,6385.07,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Trillium,Medicaid,,533.61,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Trillium,Medicaid,,2247.86,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Trillium,Medicaid,,3243.69,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Trillium,Medicaid,,545.13,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Trillium,Medicaid,,1691.61,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Trillium,Medicaid,,1803.62,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Trillium,Medicaid,,2280.21,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Trillium,Medicaid,,26.69,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Trillium,Medicaid,,92.00,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Trillium,Medicaid,,184.20,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Trillium,Medicaid,,6.32,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Trillium,Medicaid,,4.11,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Trillium,Medicaid,,56.41,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Trillium,Medicaid,,4.38,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Trillium,Medicaid,,0.00607,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Trillium,Medicaid,,4.33,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Trillium,Medicaid,,8.21,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Trillium,Medicaid,,4.12,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Trillium,Medicaid,,4.02,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Trillium,Medicaid,,199.77,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Trillium,Medicaid,,13.20,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Trillium,Medicaid,,36.03,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Trillium,Medicaid,,3133.09,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Trillium,Medicaid,,1.28,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Trillium,Medicaid,,36.80,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Trillium,Medicaid,,40.44,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Trillium,Medicaid,,40.44,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Trillium,Medicaid,,6.00,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Trillium,Medicaid,,249.72,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Trillium,Medicaid,,211.91,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Trillium,Medicaid,,142.96,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Trillium,Medicaid,,111.21,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Trillium,Medicaid,,89.37,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Trillium,Medicaid,,94.23,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Trillium,Medicaid,,249.72,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Trillium,Medicaid,,211.91,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Trillium,Medicaid,,142.96,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Trillium,Medicaid,,111.21,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Trillium,Medicaid,,89.37,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Trillium,Medicaid,,94.23,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Trillium,Medicaid,,5.55,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Trillium,Medicaid,,115.46,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Trillium,Medicaid,,52.98,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Trillium,Medicaid,,499.23,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Trillium,Medicaid,,141.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Trillium,Medicaid,,141.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Trillium,Medicaid,,124.35,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Trillium,Medicaid,,124.35,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Trillium,Medicaid,,80.68,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Trillium,Medicaid,,80.68,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Trillium,Medicaid,,477.80,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Trillium,Medicaid,,115.46,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Trillium,Medicaid,,52.98,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Trillium,Medicaid,,63.29,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Trillium,Medicaid,,63.29,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Trillium,Medicaid,,318.46,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Trillium,Medicaid,,318.46,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Trillium,Medicaid,,253.15,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Trillium,Medicaid,,253.15,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Trillium,Medicaid,,129.61,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Trillium,Medicaid,,129.61,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Trillium,Medicaid,,68.75,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Trillium,Medicaid,,68.75,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Trillium,Medicaid,,55.00,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Trillium,Medicaid,,55.00,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Trillium,Medicaid,,43.71,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Trillium,Medicaid,,184.20,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Trillium,Medicaid,,92.00,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Trillium,Medicaid,,1048.81,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Trillium,Medicaid,,31.10,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Trillium,Medicaid,,518.04,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Trillium,Medicaid,,199.77,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Trillium,Medicaid,,176.35,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Trillium,Medicaid,,216.40,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Trillium,Medicaid,,0.44080,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Trillium,Medicaid,,420.17,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Trillium,Medicaid,,556.86,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Trillium,Medicaid,,245.88,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Trillium,Medicaid,,124.56,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Trillium,Medicaid,,556.86,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Trillium,Medicaid,,245.88,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Trillium,Medicaid,,124.56,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Trillium,Medicaid,,568.79,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Trillium,Medicaid,,0.62682,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Trillium,Medicaid,,1.99,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Trillium,Medicaid,,38.95,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Trillium,Medicaid,,13.43,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Trillium,Medicaid,,24.87,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Trillium,Medicaid,,48.06,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Trillium,Medicaid,,55.38,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Trillium,Medicaid,,32.09,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Trillium,Medicaid,,69.15,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Trillium,Medicaid,,69.15,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Trillium,Medicaid,,312.60,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Trillium,Medicaid,,625.61,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Trillium,Medicaid,,312.60,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Trillium,Medicaid,,66.81,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Trillium,Medicaid,,66.58,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Trillium,Medicaid,,30.97,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Trillium,Medicaid,,32.11,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Trillium,Medicaid,,86.54,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Trillium,Medicaid,,86.54,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Trillium,Medicaid,,2.02,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Trillium,Medicaid,,0.02426,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Trillium,Medicaid,,0.05459,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Trillium,Medicaid,,505.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Trillium,Medicaid,,505.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Trillium,Medicaid,,409.45,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Trillium,Medicaid,,409.45,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Trillium,Medicaid,,345.36,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Trillium,Medicaid,,345.36,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Trillium,Medicaid,,65.17,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Trillium,Medicaid,,16.40,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Trillium,Medicaid,,10.82,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Trillium,Medicaid,,25.48,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Trillium,Medicaid,,6.24,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Trillium,Medicaid,,3.36,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Trillium,Medicaid,,23.61,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Trillium,Medicaid,,6.80,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Trillium,Medicaid,,19.42,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Trillium,Medicaid,,55.61,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Trillium,Medicaid,,8.62,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Trillium,Medicaid,,10.40,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Trillium,Medicaid,,33.58,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Trillium,Medicaid,,26.04,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Trillium,Medicaid,,31.18,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Trillium,Medicaid,,29.59,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Trillium,Medicaid,,5.29,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Trillium,Medicaid,,5.77,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Trillium,Medicaid,,13.76,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Trillium,Medicaid,,28.46,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Trillium,Medicaid,,0.10312,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Trillium,Medicaid,,5.30,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Trillium,Medicaid,,1.20,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Trillium,Medicaid,,2.13,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Trillium,Medicaid,,0.02224,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Trillium,Medicaid,,0.16176,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Trillium,Medicaid,,1.57,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Trillium,Medicaid,,0.15974,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Trillium,Medicaid,,0.09503,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Trillium,Medicaid,,0.12941,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Trillium,Medicaid,,337.02,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Trillium,Medicaid,,0.00404,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Trillium,Medicaid,,0.01820,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Trillium,Medicaid,,0.51965,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Trillium,Medicaid,,5.21,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Trillium,Medicaid,,16.47,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Trillium,Medicaid,,0.01415,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Trillium,Medicaid,,0.85935,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Trillium,Medicaid,,1.24,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Trillium,Medicaid,,0.22646,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Trillium,Medicaid,,0.32554,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Trillium,Medicaid,,0.51763,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Trillium,Medicaid,,0.36194,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Trillium,Medicaid,,0.00404,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Trillium,Medicaid,,4.47,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Trillium,Medicaid,,222.57,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Trillium,Medicaid,,15.58,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Trillium,Medicaid,,27.28,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Trillium,Medicaid,,33.65,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Trillium,Medicaid,,3.49,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Trillium,Medicaid,,0.02629,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Trillium,Medicaid,,7.35,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Trillium,Medicaid,,13.20,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Trillium,Medicaid,,29.10,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Trillium,Medicaid,,12.85,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Trillium,Medicaid,,50.36,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Trillium,Medicaid,,2.27,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Trillium,Medicaid,,5.15,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Trillium,Medicaid,,0.15165,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Trillium,Medicaid,,0.00809,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Trillium,Medicaid,,3.06,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Trillium,Medicaid,,2.70,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Trillium,Medicaid,,2.40,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Trillium,Medicaid,,3.58,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Trillium,Medicaid,,6.74,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Trillium,Medicaid,,11.11,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Trillium,Medicaid,,28.14,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Trillium,Medicaid,,110.95,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Trillium,Medicaid,,63.95,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Trillium,Medicaid,,75.07,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Trillium,Medicaid,,16.77,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Trillium,Medicaid,,13.12,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Trillium,Medicaid,,13.12,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Trillium,Medicaid,,9.60,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Trillium,Medicaid,,0.24264,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Trillium,Medicaid,,592.40,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Trillium,Medicaid,,3933.16,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Trillium,Medicaid,,3.35,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Trillium,Medicaid,,4.00,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Trillium,Medicaid,,3.70,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Trillium,Medicaid,,4.04,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Trillium,Medicaid,,4.32,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Trillium,Medicaid,,25.97,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Trillium,Medicaid,,17.01,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Trillium,Medicaid,,70.91,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Trillium,Medicaid,,77.96,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Trillium,Medicaid,,3.92,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Trillium,Medicaid,,716.60,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Trillium,Medicaid,,61.52,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Trillium,Medicaid,,8.79,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Trillium,Medicaid,,3.29,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Trillium,Medicaid,,3.28,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Trillium,Medicaid,,488.17,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Trillium,Medicaid,,3.65,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Trillium,Medicaid,,95.35,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Trillium,Medicaid,,3.50,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Trillium,Medicaid,,3.41,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Trillium,Medicaid,,3.35,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Trillium,Medicaid,,1055.56,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Trillium,Medicaid,,3.41,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Trillium,Medicaid,,16.16,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Trillium,Medicaid,,6.80,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Trillium,Medicaid,,7.05,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Trillium,Medicaid,,9.50,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Trillium,Medicaid,,4.01,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Trillium,Medicaid,,5.10,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Trillium,Medicaid,,16.24,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Trillium,Medicaid,,6.55,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Trillium,Medicaid,,4.81,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Trillium,Medicaid,,5.80,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Trillium,Medicaid,,0.45495,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Trillium,Medicaid,,88.30,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Trillium,Medicaid,,151.29,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Trillium,Medicaid,,461.94,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Trillium,Medicaid,,44.28,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Trillium,Medicaid,,44.28,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Trillium,Medicaid,,44.28,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Trillium,Medicaid,,0.30330,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Trillium,Medicaid,,10.00,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Trillium,Medicaid,,11.64,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Trillium,Medicaid,,114.95,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Trillium,Medicaid,,4.41,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Trillium,Medicaid,,4.98,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Trillium,Medicaid,,1.42,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Trillium,Medicaid,,3.70,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Trillium,Medicaid,,0.52572,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Trillium,Medicaid,,3.65,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Trillium,Medicaid,,3.72,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Trillium,Medicaid,,5.41,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Trillium,Medicaid,,6.25,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Trillium,Medicaid,,4.81,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Trillium,Medicaid,,9.61,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Trillium,Medicaid,,5.93,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Trillium,Medicaid,,6.54,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Trillium,Medicaid,,554.30,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Trillium,Medicaid,,3.59,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Trillium,Medicaid,,3.39,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Trillium,Medicaid,,3.44,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Trillium,Medicaid,,4.32,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Trillium,Medicaid,,8.25,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Trillium,Medicaid,,371.97,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Trillium,Medicaid,,3.27,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Trillium,Medicaid,,3.51,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Trillium,Medicaid,,3.59,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Trillium,Medicaid,,6.62,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Trillium,Medicaid,,49.92,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Trillium,Medicaid,,0.33363,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Trillium,Medicaid,,4.69,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Trillium,Medicaid,,4.60,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Trillium,Medicaid,,4109.16,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Trillium,Medicaid,,6.47,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Trillium,Medicaid,,0.29319,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Trillium,Medicaid,,31.92,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Trillium,Medicaid,,60.84,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Trillium,Medicaid,,500.44,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Trillium,Medicaid,,14.21,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Trillium,Medicaid,,17.15,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Trillium,Medicaid,,7.62,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Trillium,Medicaid,,9.32,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Trillium,Medicaid,,156.57,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Trillium,Medicaid,,3.28,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Trillium,Medicaid,,10.28,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Trillium,Medicaid,,13.92,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Trillium,Medicaid,,13.48,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Trillium,Medicaid,,14.61,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Trillium,Medicaid,,8.02,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Trillium,Medicaid,,5.69,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Trillium,Medicaid,,12301.26,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Trillium,Medicaid,,161.37,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Trillium,Medicaid,,32.02,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Trillium,Medicaid,,46.74,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Trillium,Medicaid,,105.19,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Trillium,Medicaid,,3.96,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Trillium,Medicaid,,5.46,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Trillium,Medicaid,,5.75,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Trillium,Medicaid,,10.09,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Trillium,Medicaid,,12.37,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Trillium,Medicaid,,16.95,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Trillium,Medicaid,,21.52,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Trillium,Medicaid,,26.09,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Trillium,Medicaid,,14.33,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Trillium,Medicaid,,15.39,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Trillium,Medicaid,,4.29,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Trillium,Medicaid,,4.00,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Trillium,Medicaid,,249.80,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Trillium,Medicaid,,473.36,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Trillium,Medicaid,,1.72,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Trillium,Medicaid,,34.58,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Trillium,Medicaid,,8.63,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Trillium,Medicaid,,3.44,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Trillium,Medicaid,,4.17,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Trillium,Medicaid,,7.49,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Trillium,Medicaid,,7.53,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Trillium,Medicaid,,14.16,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Trillium,Medicaid,,24.87,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Trillium,Medicaid,,617.87,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Trillium,Medicaid,,1180.13,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Trillium,Medicaid,,272.04,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Trillium,Medicaid,,4.35,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Trillium,Medicaid,,13.05,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Trillium,Medicaid,,7.20,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Trillium,Medicaid,,6.74,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Trillium,Medicaid,,6.88,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Trillium,Medicaid,,5.91,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Trillium,Medicaid,,5.91,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Trillium,Medicaid,,489.47,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Trillium,Medicaid,,1310.05,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Trillium,Medicaid,,33.97,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Trillium,Medicaid,,5.57,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Trillium,Medicaid,,12.88,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Trillium,Medicaid,,0.30330,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Trillium,Medicaid,,0.29319,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Trillium,Medicaid,,5.56,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Trillium,Medicaid,,6.36,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Trillium,Medicaid,,31.83,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Trillium,Medicaid,,4.74,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Trillium,Medicaid,,20.82,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Trillium,Medicaid,,118.30,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Trillium,Medicaid,,36.58,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Trillium,Medicaid,,52.63,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Trillium,Medicaid,,41.49,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Trillium,Medicaid,,231.39,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Trillium,Medicaid,,3.68,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Trillium,Medicaid,,20.41,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Trillium,Medicaid,,36.09,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Trillium,Medicaid,,106.25,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Trillium,Medicaid,,0.31341,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Trillium,Medicaid,,20.45,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Trillium,Medicaid,,53.22,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Trillium,Medicaid,,53.22,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Trillium,Medicaid,,178.24,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Trillium,Medicaid,,11.83,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Trillium,Medicaid,,181.26,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Trillium,Medicaid,,288.07,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Trillium,Medicaid,,430.49,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Trillium,Medicaid,,715.32,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Trillium,Medicaid,,1427.41,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Trillium,Medicaid,,2139.50,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Trillium,Medicaid,,342.76,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Trillium,Medicaid,,1667.40,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Trillium,Medicaid,,6502.76,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Trillium,Medicaid,,1140.46,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Trillium,Medicaid,,2268.17,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Trillium,Medicaid,,64.47,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Trillium,Medicaid,,64.47,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Trillium,Medicaid,,1780.75,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Trillium,Medicaid,,3.30,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Trillium,Medicaid,,16.84,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Trillium,Medicaid,,20.49,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Trillium,Medicaid,,31.13,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Trillium,Medicaid,,4.72,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Trillium,Medicaid,,3.78,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Trillium,Medicaid,,23.43,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Trillium,Medicaid,,28.70,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Trillium,Medicaid,,3.50,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Trillium,Medicaid,,178.89,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Trillium,Medicaid,,0.28308,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Trillium,Medicaid,,8111.43,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Trillium,Medicaid,,32278.82,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Trillium,Medicaid,,199.27,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Trillium,Medicaid,,0.40440,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Trillium,Medicaid,,0.35385,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Trillium,Medicaid,,0.34374,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Trillium,Medicaid,,0.32352,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Trillium,Medicaid,,20.35,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Trillium,Medicaid,,39.19,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Trillium,Medicaid,,2681.30,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Trillium,Medicaid,,21.43,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Trillium,Medicaid,,2.78,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Trillium,Medicaid,,454.01,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Trillium,Medicaid,,17.40,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Trillium,Medicaid,,143.54,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Trillium,Medicaid,,43.23,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Trillium,Medicaid,,12.25,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Trillium,Medicaid,,19.36,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Trillium,Medicaid,,37.30,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Trillium,Medicaid,,45.43,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Trillium,Medicaid,,12.18,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Trillium,Medicaid,,213.73,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Trillium,Medicaid,,0.29319,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Trillium,Medicaid,,9.50,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Trillium,Medicaid,,0.24264,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Trillium,Medicaid,,0.62682,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Trillium,Medicaid,,16.21,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Trillium,Medicaid,,15.64,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Trillium,Medicaid,,15.43,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Trillium,Medicaid,,15.64,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Trillium,Medicaid,,20.52,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Trillium,Medicaid,,21.23,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Trillium,Medicaid,,95.36,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Trillium,Medicaid,,3.70,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Trillium,Medicaid,,56.97,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Trillium,Medicaid,,3.90,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Trillium,Medicaid,,11333.02,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Trillium,Medicaid,,11.12,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Trillium,Medicaid,,902.74,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Trillium,Medicaid,,11.12,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Trillium,Medicaid,,14.28,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Trillium,Medicaid,,5.45,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Trillium,Medicaid,,0.30330,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Trillium,Medicaid,,6.35,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Trillium,Medicaid,,3.90,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Trillium,Medicaid,,13.70,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Trillium,Medicaid,,6.03,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Trillium,Medicaid,,225.23,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Trillium,Medicaid,,370.03,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Trillium,Medicaid,,63.92,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Trillium,Medicaid,,95.90,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Trillium,Medicaid,,19.36,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Trillium,Medicaid,,19.36,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Trillium,Medicaid,,143.61,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Trillium,Medicaid,,5.81,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Trillium,Medicaid,,4.74,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Trillium,Medicaid,,114.24,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Trillium,Medicaid,,242.31,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Trillium,Medicaid,,0.82902,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Trillium,Medicaid,,115.01,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Trillium,Medicaid,,22.65,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Trillium,Medicaid,,33.97,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Trillium,Medicaid,,3.43,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Trillium,Medicaid,,3.57,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Trillium,Medicaid,,41.49,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Trillium,Medicaid,,123.27,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Trillium,Medicaid,,32.22,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Trillium,Medicaid,,17.59,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Trillium,Medicaid,,0.86946,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Trillium,Medicaid,,4.27,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Trillium,Medicaid,,3.41,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Trillium,Medicaid,,5.81,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Trillium,Medicaid,,5.81,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Trillium,Medicaid,,3.50,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Trillium,Medicaid,,6.07,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Trillium,Medicaid,,6.92,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Trillium,Medicaid,,24.97,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Trillium,Medicaid,,25.25,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Trillium,Medicaid,,9.88,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Trillium,Medicaid,,12.53,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Trillium,Medicaid,,6.38,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Trillium,Medicaid,,15.68,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Trillium,Medicaid,,76.84,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Trillium,Medicaid,,184.06,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Trillium,Medicaid,,33.92,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Trillium,Medicaid,,64.74,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Trillium,Medicaid,,17.83,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Trillium,Medicaid,,122.14,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Trillium,Medicaid,,5136.80,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Trillium,Medicaid,,375.00,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Trillium,Medicaid,,4.25,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Trillium,Medicaid,,194.49,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Trillium,Medicaid,,5.04,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Trillium,Medicaid,,17.12,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Trillium,Medicaid,,7.29,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Trillium,Medicaid,,3.50,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Trillium,Medicaid,,333.87,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Trillium,Medicaid,,6123.67,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Trillium,Medicaid,,3.54,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Trillium,Medicaid,,6.40,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Trillium,Medicaid,,10.79,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Trillium,Medicaid,,7.69,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Trillium,Medicaid,,9.73,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Trillium,Medicaid,,14.57,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Trillium,Medicaid,,15.65,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Trillium,Medicaid,,37.54,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Trillium,Medicaid,,4.15,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Trillium,Medicaid,,4.52,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Trillium,Medicaid,,4.51,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Trillium,Medicaid,,64.82,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Trillium,Medicaid,,88.56,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Trillium,Medicaid,,3202.58,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Trillium,Medicaid,,21.73,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Trillium,Medicaid,,417.24,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Trillium,Medicaid,,555.24,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Trillium,Medicaid,,5.33,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Trillium,Medicaid,,39.67,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Trillium,Medicaid,,3.66,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Trillium,Medicaid,,0.54594,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Trillium,Medicaid,,12.13,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Trillium,Medicaid,,6.51,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Trillium,Medicaid,,4.51,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Trillium,Medicaid,,17.70,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Trillium,Medicaid,,23.29,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Trillium,Medicaid,,0.26286,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Trillium,Medicaid,,10.05,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Trillium,Medicaid,,7.30,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Trillium,Medicaid,,29.92,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Trillium,Medicaid,,0.31341,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Trillium,Medicaid,,0.35385,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Trillium,Medicaid,,3.31,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Trillium,Medicaid,,41.87,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Trillium,Medicaid,,4.58,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Trillium,Medicaid,,4.97,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Trillium,Medicaid,,6.49,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Trillium,Medicaid,,3.50,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Trillium,Medicaid,,111.43,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Trillium,Medicaid,,5.42,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Trillium,Medicaid,,4.84,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Trillium,Medicaid,,5.95,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Trillium,Medicaid,,8.71,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Trillium,Medicaid,,10.81,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Trillium,Medicaid,,12.30,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Trillium,Medicaid,,36.09,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Trillium,Medicaid,,102.74,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Trillium,Medicaid,,10.74,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Trillium,Medicaid,,4.99,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Trillium,Medicaid,,6.03,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Trillium,Medicaid,,12.38,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Trillium,Medicaid,,5.64,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Trillium,Medicaid,,34.41,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Trillium,Medicaid,,72.24,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Trillium,Medicaid,,233.75,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Trillium,Medicaid,,1.74,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Trillium,Medicaid,,3.35,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Trillium,Medicaid,,3.30,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Trillium,Medicaid,,23912.52,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Trillium,Medicaid,,25.37,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Trillium,Medicaid,,151.82,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Trillium,Medicaid,,2.02,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Trillium,Medicaid,,3.02,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Trillium,Medicaid,,15.50,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Trillium,Medicaid,,1.08,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Trillium,Medicaid,,3.48,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Trillium,Medicaid,,8.12,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Trillium,Medicaid,,9.04,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Trillium,Medicaid,,7.36,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Trillium,Medicaid,,17.17,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Trillium,Medicaid,,17.14,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Trillium,Medicaid,,17.17,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Trillium,Medicaid,,16.77,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Trillium,Medicaid,,212.79,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Trillium,Medicaid,,1089.85,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Trillium,Medicaid,,735.36,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Trillium,Medicaid,,6.69,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Trillium,Medicaid,,3187.68,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Trillium,Medicaid,,0.58638,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Trillium,Medicaid,,4.26,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Trillium,Medicaid,,87.11,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Trillium,Medicaid,,47.82,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Trillium,Medicaid,,13.12,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Trillium,Medicaid,,21.84,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Trillium,Medicaid,,2.51,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Trillium,Medicaid,,29.17,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Trillium,Medicaid,,58.60,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Trillium,Medicaid,,540.62,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Trillium,Medicaid,,17.69,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Trillium,Medicaid,,1.97,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Trillium,Medicaid,,674.62,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Trillium,Medicaid,,4.78,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Trillium,Medicaid,,6.25,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Trillium,Medicaid,,69.31,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Trillium,Medicaid,,165.44,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Trillium,Medicaid,,64.64,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Trillium,Medicaid,,199.15,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Trillium,Medicaid,,5.08,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Trillium,Medicaid,,275.14,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Trillium,Medicaid,,17.69,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Trillium,Medicaid,,43.95,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Trillium,Medicaid,,7.76,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Trillium,Medicaid,,7.93,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Trillium,Medicaid,,1263.31,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Trillium,Medicaid,,3.80,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Trillium,Medicaid,,4.21,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Trillium,Medicaid,,1921.79,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Trillium,Medicaid,,0.77847,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Trillium,Medicaid,,11.68,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Trillium,Medicaid,,9.19,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Trillium,Medicaid,,12.83,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Trillium,Medicaid,,52.98,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Trillium,Medicaid,,71.28,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Trillium,Medicaid,,2.19,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Trillium,Medicaid,,60.38,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Trillium,Medicaid,,0.33363,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Trillium,Medicaid,,0.28308,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Trillium,Medicaid,,0.32352,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Trillium,Medicaid,,9.36,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Trillium,Medicaid,,44.21,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Trillium,Medicaid,,36.27,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Trillium,Medicaid,,20.18,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Trillium,Medicaid,,0.26286,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Trillium,Medicaid,,31.53,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Trillium,Medicaid,,8.16,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Trillium,Medicaid,,4.45,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Trillium,Medicaid,,13.09,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Trillium,Medicaid,,2421.59,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Trillium,Medicaid,,11.66,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Trillium,Medicaid,,6.92,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Trillium,Medicaid,,16.28,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Trillium,Medicaid,,4.78,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Trillium,Medicaid,,1965.14,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Trillium,Medicaid,,50.53,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Trillium,Medicaid,,0.26286,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Trillium,Medicaid,,1.49,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Trillium,Medicaid,,27.87,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Trillium,Medicaid,,3.74,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Trillium,Medicaid,,16.33,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Trillium,Medicaid,,17.39,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Trillium,Medicaid,,36.40,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Trillium,Medicaid,,19.64,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Trillium,Medicaid,,3933.16,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Trillium,Medicaid,,32.16,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Trillium,Medicaid,,18.98,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Trillium,Medicaid,,14.24,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Trillium,Medicaid,,15.03,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Trillium,Medicaid,,15.03,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Trillium,Medicaid,,16.99,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Trillium,Medicaid,,2.39,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Trillium,Medicaid,,3.65,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Trillium,Medicaid,,3.57,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Trillium,Medicaid,,4.87,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Trillium,Medicaid,,2.23,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Trillium,Medicaid,,1658.02,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Trillium,Medicaid,,4.07,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Trillium,Medicaid,,3.39,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Trillium,Medicaid,,12.48,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Trillium,Medicaid,,75.52,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Trillium,Medicaid,,38.93,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Trillium,Medicaid,,14.22,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Trillium,Medicaid,,13.41,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Trillium,Medicaid,,3.39,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Trillium,Medicaid,,3.39,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Trillium,Medicaid,,4.50,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Trillium,Medicaid,,5.92,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Trillium,Medicaid,,3.67,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Trillium,Medicaid,,3.31,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Trillium,Medicaid,,22.83,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Trillium,Medicaid,,26.72,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Trillium,Medicaid,,0.28308,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Trillium,Medicaid,,18.23,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Trillium,Medicaid,,30.06,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Trillium,Medicaid,,9.01,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Trillium,Medicaid,,21.09,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Trillium,Medicaid,,4.09,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Trillium,Medicaid,,69.96,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Trillium,Medicaid,,255.56,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Trillium,Medicaid,,4.66,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Trillium,Medicaid,,91.56,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Trillium,Medicaid,,183.56,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Trillium,Medicaid,,0.35385,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Trillium,Medicaid,,0.34374,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Trillium,Medicaid,,1.80,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Trillium,Medicaid,,3.76,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Trillium,Medicaid,,48.66,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Trillium,Medicaid,,3.29,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Trillium,Medicaid,,3.35,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Trillium,Medicaid,,19.12,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Trillium,Medicaid,,5.72,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Trillium,Medicaid,,27.25,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Trillium,Medicaid,,28.66,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Trillium,Medicaid,,8.85,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Trillium,Medicaid,,70.50,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Trillium,Medicaid,,4.24,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Trillium,Medicaid,,3.79,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Trillium,Medicaid,,28.66,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Trillium,Medicaid,,33.26,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Trillium,Medicaid,,35.38,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Trillium,Medicaid,,0.64704,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Trillium,Medicaid,,20.52,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Trillium,Medicaid,,25.07,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Trillium,Medicaid,,25.07,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Trillium,Medicaid,,18.54,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Trillium,Medicaid,,16.12,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Trillium,Medicaid,,95.24,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Trillium,Medicaid,,5.30,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Trillium,Medicaid,,4.69,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Trillium,Medicaid,,4.75,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Trillium,Medicaid,,4.55,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Trillium,Medicaid,,4.57,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Trillium,Medicaid,,2806.77,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Trillium,Medicaid,,61.43,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Trillium,Medicaid,,0.85935,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Trillium,Medicaid,,11.41,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Trillium,Medicaid,,11.41,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Trillium,Medicaid,,822.05,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Trillium,Medicaid,,22.86,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Trillium,Medicaid,,23.83,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Trillium,Medicaid,,3605.10,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Trillium,Medicaid,,5734.80,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Trillium,Medicaid,,13.21,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Trillium,Medicaid,,1.24,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Trillium,Medicaid,,29.81,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Trillium,Medicaid,,5.07,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Trillium,Medicaid,,8.39,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Trillium,Medicaid,,4.79,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Trillium,Medicaid,,3.88,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Trillium,Medicaid,,32.66,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Trillium,Medicaid,,98.41,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Trillium,Medicaid,,19.80,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Trillium,Medicaid,,19.06,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Trillium,Medicaid,,925.27,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Trillium,Medicaid,,30.94,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Trillium,Medicaid,,4.86,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Trillium,Medicaid,,0.97056,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Trillium,Medicaid,,65.93,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Trillium,Medicaid,,17.11,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Trillium,Medicaid,,17.11,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Trillium,Medicaid,,130.04,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Trillium,Medicaid,,130.04,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Trillium,Medicaid,,3.48,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Trillium,Medicaid,,111.20,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Trillium,Medicaid,,5.28,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Trillium,Medicaid,,4.52,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Trillium,Medicaid,,0.37407,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Trillium,Medicaid,,17.01,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Trillium,Medicaid,,65.58,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Trillium,Medicaid,,99.79,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Trillium,Medicaid,,4.13,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Trillium,Medicaid,,72.22,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Trillium,Medicaid,,106.70,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Trillium,Medicaid,,20.21,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Trillium,Medicaid,,20.21,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Trillium,Medicaid,,74.54,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Trillium,Medicaid,,1292.54,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Trillium,Medicaid,,5.74,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Trillium,Medicaid,,1390.83,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Trillium,Medicaid,,6731.72,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Trillium,Medicaid,,4.59,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Trillium,Medicaid,,11.12,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Trillium,Medicaid,,0.34374,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Trillium,Medicaid,,17.99,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Trillium,Medicaid,,7961.55,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Trillium,Medicaid,,1640.05,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Trillium,Medicaid,,17.99,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Trillium,Medicaid,,77.11,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Trillium,Medicaid,,15.29,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Trillium,Medicaid,,17.75,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Trillium,Medicaid,,423.27,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Trillium,Medicaid,,2827.43,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Trillium,Medicaid,,3.60,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Trillium,Medicaid,,93.47,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Trillium,Medicaid,,221.41,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Trillium,Medicaid,,50.04,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Trillium,Medicaid,,3.32,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Trillium,Medicaid,,7.84,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Trillium,Medicaid,,7.84,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Trillium,Medicaid,,48.76,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Trillium,Medicaid,,62.26,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Trillium,Medicaid,,82.25,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Trillium,Medicaid,,4999.35,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Trillium,Medicaid,,163.65,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Trillium,Medicaid,,1233.41,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Trillium,Medicaid,,3000.09,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Trillium,Medicaid,,3.28,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Trillium,Medicaid,,3.29,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Trillium,Medicaid,,147.84,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Trillium,Medicaid,,7.99,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Trillium,Medicaid,,9.64,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Trillium,Medicaid,,11.03,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Trillium,Medicaid,,15.71,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Trillium,Medicaid,,5907.86,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Trillium,Medicaid,,5302.69,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Trillium,Medicaid,,5.05,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Trillium,Medicaid,,15.00,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Trillium,Medicaid,,15.00,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Trillium,Medicaid,,22.10,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Trillium,Medicaid,,359.92,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Trillium,Medicaid,,11.68,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Trillium,Medicaid,,11.68,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Trillium,Medicaid,,4250.28,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Trillium,Medicaid,,6362.86,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Trillium,Medicaid,,3244.83,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Trillium,Medicaid,,365.49,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Trillium,Medicaid,,757.63,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Trillium,Medicaid,,1.64,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Trillium,Medicaid,,19.11,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Trillium,Medicaid,,98.41,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Trillium,Medicaid,,791.45,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Trillium,Medicaid,,17001.58,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Trillium,Medicaid,,400.07,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Trillium,Medicaid,,99.73,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Trillium,Medicaid,,936.06,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Trillium,Medicaid,,1856.56,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Trillium,Medicaid,,924.36,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Trillium,Medicaid,,12.75,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Trillium,Medicaid,,12.75,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Trillium,Medicaid,,12.75,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Trillium,Medicaid,,407.11,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Trillium,Medicaid,,255.65,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Trillium,Medicaid,,8.96,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Trillium,Medicaid,,26.12,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Trillium,Medicaid,,9.50,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Trillium,Medicaid,,17.03,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Trillium,Medicaid,,15.37,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Trillium,Medicaid,,2179.32,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Trillium,Medicaid,,2705.96,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Trillium,Medicaid,,9.02,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Trillium,Medicaid,,9.02,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Trillium,Medicaid,,11.63,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Trillium,Medicaid,,3317.87,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Trillium,Medicaid,,116.90,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Trillium,Medicaid,,19.77,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Trillium,Medicaid,,29.78,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Trillium,Medicaid,,12.03,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Trillium,Medicaid,,2256.50,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Trillium,Medicaid,,210.14,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Trillium,Medicaid,,128.49,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Trillium,Medicaid,,3.33,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Trillium,Medicaid,,44.19,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Trillium,Medicaid,,3.87,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Trillium,Medicaid,,177.39,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Trillium,Medicaid,,3.96,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Trillium,Medicaid,,816.36,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Trillium,Medicaid,,335.02,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Trillium,Medicaid,,62.61,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Trillium,Medicaid,,2731.90,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Trillium,Medicaid,,15.58,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Trillium,Medicaid,,57.71,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Trillium,Medicaid,,110.32,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Trillium,Medicaid,,939.66,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Trillium,Medicaid,,42.75,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Trillium,Medicaid,,19.34,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Trillium,Medicaid,,29.96,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Trillium,Medicaid,,10366.43,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Trillium,Medicaid,,4.45,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Trillium,Medicaid,,273.00,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Trillium,Medicaid,,24.77,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Trillium,Medicaid,,555.48,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Trillium,Medicaid,,12.40,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Trillium,Medicaid,,218.88,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Trillium,Medicaid,,12.39,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Trillium,Medicaid,,3239.85,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Trillium,Medicaid,,8.32,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Trillium,Medicaid,,38.75,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Trillium,Medicaid,,13.40,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Trillium,Medicaid,,74.27,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Trillium,Medicaid,,11.63,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Trillium,Medicaid,,6.93,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Trillium,Medicaid,,8.07,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Trillium,Medicaid,,18173.19,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Trillium,Medicaid,,1918.62,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Trillium,Medicaid,,17541.87,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Trillium,Medicaid,,9.06,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Trillium,Medicaid,,1442.11,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Trillium,Medicaid,,181.31,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Trillium,Medicaid,,3876.49,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Trillium,Medicaid,,972.62,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Trillium,Medicaid,,5906.67,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Trillium,Medicaid,,1.34,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Trillium,Medicaid,,14.51,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Trillium,Medicaid,,6742.52,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Trillium,Medicaid,,14.42,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Trillium,Medicaid,,13.89,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Trillium,Medicaid,,265.44,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Trillium,Medicaid,,912.21,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Trillium,Medicaid,,9.67,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Trillium,Medicaid,,9824.29,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Trillium,Medicaid,,21333.15,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Trillium,Medicaid,,3.53,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Trillium,Medicaid,,26.61,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Trillium,Medicaid,,19.27,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Trillium,Medicaid,,19.27,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Trillium,Medicaid,,18.26,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Trillium,Medicaid,,3.41,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Trillium,Medicaid,,5.63,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Trillium,Medicaid,,3.58,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Trillium,Medicaid,,40.34,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Trillium,Medicaid,,201.69,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Trillium,Medicaid,,13.37,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Trillium,Medicaid,,135.18,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Trillium,Medicaid,,0.95034,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Trillium,Medicaid,,3.72,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Trillium,Medicaid,,398.79,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Trillium,Medicaid,,5382.58,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Trillium,Medicaid,,1191.09,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Trillium,Medicaid,,3.86,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Trillium,Medicaid,,7122.41,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Trillium,Medicaid,,16.19,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Trillium,Medicaid,,48.92,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Trillium,Medicaid,,78.76,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Trillium,Medicaid,,5.33,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Trillium,Medicaid,,11.82,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Trillium,Medicaid,,23.54,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Trillium,Medicaid,,33.69,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Trillium,Medicaid,,43.83,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Trillium,Medicaid,,104.72,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Trillium,Medicaid,,409.15,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Trillium,Medicaid,,1923.76,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Trillium,Medicaid,,106.16,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Trillium,Medicaid,,26.47,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Trillium,Medicaid,,26.47,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Trillium,Medicaid,,98.93,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Trillium,Medicaid,,4310.41,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Trillium,Medicaid,,204.72,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Trillium,Medicaid,,325.61,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Trillium,Medicaid,,69.71,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Trillium,Medicaid,,3.35,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Trillium,Medicaid,,11.30,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Trillium,Medicaid,,1040.52,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Trillium,Medicaid,,9775.33,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Trillium,Medicaid,,3844.28,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Trillium,Medicaid,,9.73,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Trillium,Medicaid,,918.65,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Trillium,Medicaid,,2037.57,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Trillium,Medicaid,,204.72,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Trillium,Medicaid,,7292.16,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Trillium,Medicaid,,592.04,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Trillium,Medicaid,,7273.19,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Trillium,Medicaid,,4215.08,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Trillium,Medicaid,,41.05,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Trillium,Medicaid,,58.03,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Trillium,Medicaid,,84.83,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Trillium,Medicaid,,360.12,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Trillium,Medicaid,,16613.81,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Trillium,Medicaid,,2538.61,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Trillium,Medicaid,,676.37,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Trillium,Medicaid,,40.69,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Trillium,Medicaid,,9.71,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Trillium,Medicaid,,4.82,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Trillium,Medicaid,,3.60,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Trillium,Medicaid,,807.88,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Trillium,Medicaid,,3816.95,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Trillium,Medicaid,,3505.78,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Trillium,Medicaid,,10491.83,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Trillium,Medicaid,,2095.87,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Trillium,Medicaid,,1269.66,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Trillium,Medicaid,,21.67,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Trillium,Medicaid,,2554.72,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Trillium,Medicaid,,3804.27,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Trillium,Medicaid,,2801.58,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Trillium,Medicaid,,2238.53,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Trillium,Medicaid,,601.34,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Trillium,Medicaid,,693.33,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Trillium,Medicaid,,3244.22,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Trillium,Medicaid,,15315.15,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Trillium,Medicaid,,3072.59,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Trillium,Medicaid,,29.03,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Trillium,Medicaid,,29.03,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Trillium,Medicaid,,5.78,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Trillium,Medicaid,,1660.32,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Trillium,Medicaid,,3925.36,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Trillium,Medicaid,,829.56,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Trillium,Medicaid,,30.15,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Trillium,Medicaid,,2336.30,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Trillium,Medicaid,,22248.67,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Trillium,Medicaid,,437.36,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Trillium,Medicaid,,3.44,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Trillium,Medicaid,,8.64,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Trillium,Medicaid,,35.64,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Trillium,Medicaid,,3.62,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Trillium,Medicaid,,12436.88,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Trillium,Medicaid,,8309.46,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Trillium,Medicaid,,13.27,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Trillium,Medicaid,,1297.49,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Trillium,Medicaid,,3603.80,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Trillium,Medicaid,,20352.86,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Trillium,Medicaid,,5560.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Trillium,Medicaid,,206.19,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Trillium,Medicaid,,1363.54,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Trillium,Medicaid,,1133.11,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Trillium,Medicaid,,1863.62,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Trillium,Medicaid,,25252.89,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Trillium,Medicaid,,10758.70,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Trillium,Medicaid,,4139.24,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Trillium,Medicaid,,3442.33,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Trillium,Medicaid,,3.54,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Trillium,Medicaid,,3.44,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Trillium,Medicaid,,16.43,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Trillium,Medicaid,,175.79,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Trillium,Medicaid,,6639.95,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Trillium,Medicaid,,21.73,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Trillium,Medicaid,,83.58,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Trillium,Medicaid,,3303.99,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Trillium,Medicaid,,7366.90,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Trillium,Medicaid,,6.91,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Trillium,Medicaid,,17.71,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Trillium,Medicaid,,16.73,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Trillium,Medicaid,,16.73,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Trillium,Medicaid,,149.52,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Trillium,Medicaid,,237.29,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Trillium,Medicaid,,13776.24,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Trillium,Medicaid,,15.37,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Trillium,Medicaid,,531.04,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Trillium,Medicaid,,229.70,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Trillium,Medicaid,,229.70,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Trillium,Medicaid,,531.04,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Trillium,Medicaid,,21.04,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Trillium,Medicaid,,9350.59,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Trillium,Medicaid,,1878.14,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Trillium,Medicaid,,105.14,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Trillium,Medicaid,,6089.74,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Trillium,Medicaid,,610.99,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Trillium,Medicaid,,16717.23,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Trillium,Medicaid,,13172.16,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Trillium,Medicaid,,2419.83,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Trillium,Medicaid,,4836.24,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Trillium,Medicaid,,6044.58,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Trillium,Medicaid,,13781.59,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Trillium,Medicaid,,190.55,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Trillium,Medicaid,,514.88,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Trillium,Medicaid,,514.89,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Trillium,Medicaid,,12.64,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Trillium,Medicaid,,10334.11,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Trillium,Medicaid,,826.50,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Trillium,Medicaid,,298.41,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Trillium,Medicaid,,42.14,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Trillium,Medicaid,,51.66,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Trillium,Medicaid,,6.25,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Trillium,Medicaid,,21.43,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Trillium,Medicaid,,14.01,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Trillium,Medicaid,,12837.37,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Trillium,Medicaid,,47.40,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Trillium,Medicaid,,3844.28,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Trillium,Medicaid,,71.27,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Trillium,Medicaid,,5405.42,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Trillium,Medicaid,,3.32,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Trillium,Medicaid,,2222.80,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Trillium,Medicaid,,8852.97,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Trillium,Medicaid,,178.54,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Trillium,Medicaid,,12383.14,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Trillium,Medicaid,,1479.09,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Trillium,Medicaid,,52.03,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Trillium,Medicaid,,16.43,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Trillium,Medicaid,,3.45,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Trillium,Medicaid,,3.39,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Trillium,Medicaid,,7122.41,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Trillium,Medicaid,,4407.10,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Trillium,Medicaid,,0.27297,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Trillium,Medicaid,,0.26286,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Trillium,Medicaid,,73.69,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Trillium,Medicaid,,3.29,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Trillium,Medicaid,,7636.80,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Trillium,Medicaid,,94.04,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Trillium,Medicaid,,3.29,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Trillium,Medicaid,,9.93,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Trillium,Medicaid,,18.03,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Trillium,Medicaid,,3.28,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Trillium,Medicaid,,14.84,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Trillium,Medicaid,,66.28,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Trillium,Medicaid,,7.77,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Trillium,Medicaid,,4.74,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Trillium,Medicaid,,5.51,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Trillium,Medicaid,,6.51,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Trillium,Medicaid,,0.59649,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Trillium,Medicaid,,39.00,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Trillium,Medicaid,,2.24,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Trillium,Medicaid,,3.95,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Trillium,Medicaid,,3.29,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Trillium,Medicaid,,19.06,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Trillium,Medicaid,,3.49,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Trillium,Medicaid,,5.50,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Trillium,Medicaid,,5.30,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Trillium,Medicaid,,3.70,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Trillium,Medicaid,,3.48,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Trillium,Medicaid,,3.62,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Trillium,Medicaid,,18.41,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Trillium,Medicaid,,283.07,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Trillium,Medicaid,,3.45,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Trillium,Medicaid,,3.76,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Trillium,Medicaid,,891.48,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Trillium,Medicaid,,4234.97,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Trillium,Medicaid,,13.74,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Trillium,Medicaid,,1286.60,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Trillium,Medicaid,,16.96,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Trillium,Medicaid,,3.78,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Trillium,Medicaid,,40.00,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Trillium,Medicaid,,9.32,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Trillium,Medicaid,,9.25,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Trillium,Medicaid,,3.51,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Trillium,Medicaid,,4.00,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Trillium,Medicaid,,845.69,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Trillium,Medicaid,,16.49,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Trillium,Medicaid,,3.80,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Trillium,Medicaid,,25.61,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Trillium,Medicaid,,95.62,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Trillium,Medicaid,,1.95,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Trillium,Medicaid,,4.12,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Trillium,Medicaid,,225.05,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Trillium,Medicaid,,4.05,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Trillium,Medicaid,,5.03,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Trillium,Medicaid,,35.93,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Trillium,Medicaid,,2.40,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Trillium,Medicaid,,17.59,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Trillium,Medicaid,,16.53,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Trillium,Medicaid,,21.53,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Trillium,Medicaid,,22.18,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Trillium,Medicaid,,132.29,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Trillium,Medicaid,,14.38,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Trillium,Medicaid,,14.50,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Trillium,Medicaid,,15.92,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Trillium,Medicaid,,14.41,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Trillium,Medicaid,,15.47,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Trillium,Medicaid,,8.03,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Trillium,Medicaid,,15.77,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Trillium,Medicaid,,416.13,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Trillium,Medicaid,,4.12,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Trillium,Medicaid,,4.12,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Trillium,Medicaid,,104.45,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Trillium,Medicaid,,4.50,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Trillium,Medicaid,,4.50,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Trillium,Medicaid,,10.90,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Trillium,Medicaid,,1.74,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Trillium,Medicaid,,3.79,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Trillium,Medicaid,,28.73,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Trillium,Medicaid,,3.37,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Trillium,Medicaid,,85.41,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Trillium,Medicaid,,10.25,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Trillium,Medicaid,,17.93,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Trillium,Medicaid,,4.33,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Trillium,Medicaid,,3.54,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Trillium,Medicaid,,3.55,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Trillium,Medicaid,,18.39,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Trillium,Medicaid,,4.30,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Trillium,Medicaid,,3.54,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Trillium,Medicaid,,0.38418,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Trillium,Medicaid,,4.84,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Trillium,Medicaid,,4.53,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Trillium,Medicaid,,39.75,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Trillium,Medicaid,,3.44,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Trillium,Medicaid,,9.79,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Trillium,Medicaid,,6.01,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Trillium,Medicaid,,1.52,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Trillium,Medicaid,,3.49,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Trillium,Medicaid,,4.20,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Trillium,Medicaid,,16.46,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Trillium,Medicaid,,0.67737,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Trillium,Medicaid,,2.91,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Trillium,Medicaid,,3.30,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Trillium,Medicaid,,3.43,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Trillium,Medicaid,,4.55,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Trillium,Medicaid,,0.26286,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Trillium,Medicaid,,6.59,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Trillium,Medicaid,,16.15,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Trillium,Medicaid,,4.63,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Trillium,Medicaid,,3.67,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Trillium,Medicaid,,3.81,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Trillium,Medicaid,,4.02,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Trillium,Medicaid,,33.26,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Trillium,Medicaid,,3.33,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Trillium,Medicaid,,3.48,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Trillium,Medicaid,,17.06,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Trillium,Medicaid,,6.34,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Trillium,Medicaid,,1485.43,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Trillium,Medicaid,,5.68,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Trillium,Medicaid,,15.53,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Trillium,Medicaid,,6.41,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Trillium,Medicaid,,3.44,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Trillium,Medicaid,,3.41,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Trillium,Medicaid,,554.29,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Trillium,Medicaid,,17.83,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Trillium,Medicaid,,8.07,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Trillium,Medicaid,,5.33,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Trillium,Medicaid,,19.64,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Trillium,Medicaid,,20.54,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Trillium,Medicaid,,29.72,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Trillium,Medicaid,,5.23,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Trillium,Medicaid,,238.49,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Trillium,Medicaid,,455.96,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Trillium,Medicaid,,1167.70,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Trillium,Medicaid,,1.19,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Trillium,Medicaid,,448.23,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Trillium,Medicaid,,3.81,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Trillium,Medicaid,,46.10,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Trillium,Medicaid,,3.90,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Trillium,Medicaid,,4.07,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Trillium,Medicaid,,53.30,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Trillium,Medicaid,,4.29,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Trillium,Medicaid,,3.92,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Trillium,Medicaid,,4.67,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Trillium,Medicaid,,4.58,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Trillium,Medicaid,,4.04,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Trillium,Medicaid,,5.24,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Trillium,Medicaid,,20.46,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Trillium,Medicaid,,122.75,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Trillium,Medicaid,,36.57,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Trillium,Medicaid,,36.57,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Trillium,Medicaid,,39.33,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Trillium,Medicaid,,39.56,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Trillium,Medicaid,,15.77,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Trillium,Medicaid,,0.74814,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Trillium,Medicaid,,0.74814,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Trillium,Medicaid,,0.78858,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Trillium,Medicaid,,7.21,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Trillium,Medicaid,,8.78,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Trillium,Medicaid,,12.13,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Trillium,Medicaid,,16.60,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Trillium,Medicaid,,21.17,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Trillium,Medicaid,,44.64,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Trillium,Medicaid,,2.71,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Trillium,Medicaid,,0.29319,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Trillium,Medicaid,,204.59,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Trillium,Medicaid,,1.63,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Trillium,Medicaid,,23.05,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Trillium,Medicaid,,4.68,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Trillium,Medicaid,,5.36,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Trillium,Medicaid,,6.07,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Trillium,Medicaid,,152.19,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Trillium,Medicaid,,3.71,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Trillium,Medicaid,,62.36,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Trillium,Medicaid,,4.87,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Trillium,Medicaid,,18.66,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Trillium,Medicaid,,18.26,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Trillium,Medicaid,,4.62,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Trillium,Medicaid,,4.10,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Trillium,Medicaid,,3.66,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Trillium,Medicaid,,9.33,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Trillium,Medicaid,,10.41,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Trillium,Medicaid,,54.13,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Trillium,Medicaid,,5.64,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Trillium,Medicaid,,12.77,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Trillium,Medicaid,,121.15,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Trillium,Medicaid,,7.63,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Trillium,Medicaid,,12.63,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Trillium,Medicaid,,711.74,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Trillium,Medicaid,,313.81,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Trillium,Medicaid,,243.47,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Trillium,Medicaid,,3.60,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Trillium,Medicaid,,43.68,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Trillium,Medicaid,,23.30,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Trillium,Medicaid,,105.94,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Trillium,Medicaid,,141.24,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Trillium,Medicaid,,242.44,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Trillium,Medicaid,,67.90,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Trillium,Medicaid,,70.67,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Trillium,Medicaid,,3.86,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Trillium,Medicaid,,3.89,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Trillium,Medicaid,,4.32,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Trillium,Medicaid,,5.75,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Trillium,Medicaid,,3.90,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Trillium,Medicaid,,2602.11,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Trillium,Medicaid,,10.60,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Trillium,Medicaid,,72.24,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Trillium,Medicaid,,13.47,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Trillium,Medicaid,,3.59,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Trillium,Medicaid,,0.49539,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Trillium,Medicaid,,0.89979,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Trillium,Medicaid,,4.32,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Trillium,Medicaid,,5.48,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Trillium,Medicaid,,140.12,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Trillium,Medicaid,,3.94,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Trillium,Medicaid,,3.45,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Trillium,Medicaid,,3.94,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Trillium,Medicaid,,4.37,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Trillium,Medicaid,,16.80,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Trillium,Medicaid,,74.74,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Trillium,Medicaid,,84.92,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Trillium,Medicaid,,5.79,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Trillium,Medicaid,,8.57,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Trillium,Medicaid,,5.74,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Trillium,Medicaid,,10.81,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Trillium,Medicaid,,5.25,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Trillium,Medicaid,,0.35385,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Trillium,Medicaid,,24.24,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Trillium,Medicaid,,1.27,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Trillium,Medicaid,,19.01,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Trillium,Medicaid,,17.49,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Trillium,Medicaid,,3.50,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Trillium,Medicaid,,94.03,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Trillium,Medicaid,,64.50,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Trillium,Medicaid,,170.65,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Trillium,Medicaid,,4.15,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Trillium,Medicaid,,3.52,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Trillium,Medicaid,,53.59,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Trillium,Medicaid,,173.60,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Trillium,Medicaid,,4038.54,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Trillium,Medicaid,,6.83,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Trillium,Medicaid,,4.32,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Trillium,Medicaid,,4.32,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Trillium,Medicaid,,37.03,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Trillium,Medicaid,,23.52,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Trillium,Medicaid,,6.05,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Trillium,Medicaid,,25.35,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Trillium,Medicaid,,14.46,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Trillium,Medicaid,,38.44,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Trillium,Medicaid,,17.10,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Trillium,Medicaid,,105.41,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Trillium,Medicaid,,12.07,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Trillium,Medicaid,,4.45,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Trillium,Medicaid,,5.78,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Trillium,Medicaid,,24.48,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Trillium,Medicaid,,5907.86,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Trillium,Medicaid,,7.41,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Trillium,Medicaid,,4.48,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Trillium,Medicaid,,4.52,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Trillium,Medicaid,,18.88,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Trillium,Medicaid,,602.16,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Trillium,Medicaid,,7.24,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Trillium,Medicaid,,26.01,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Trillium,Medicaid,,457.47,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Trillium,Medicaid,,8.61,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Trillium,Medicaid,,7.09,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Trillium,Medicaid,,5.93,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Trillium,Medicaid,,11.17,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Trillium,Medicaid,,7.32,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Trillium,Medicaid,,1057.57,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Trillium,Medicaid,,2639.05,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Trillium,Medicaid,,5274.84,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Trillium,Medicaid,,10546.45,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Trillium,Medicaid,,36.59,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Trillium,Medicaid,,80.80,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Trillium,Medicaid,,5.16,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Trillium,Medicaid,,10.14,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Trillium,Medicaid,,29.89,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Trillium,Medicaid,,63.96,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Trillium,Medicaid,,3.72,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Trillium,Medicaid,,3.60,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Trillium,Medicaid,,9.79,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Trillium,Medicaid,,10.20,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Trillium,Medicaid,,3.44,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Trillium,Medicaid,,3.63,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Trillium,Medicaid,,952.85,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Trillium,Medicaid,,3.45,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Trillium,Medicaid,,11.60,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Trillium,Medicaid,,27.20,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Trillium,Medicaid,,7.51,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Trillium,Medicaid,,33.90,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Trillium,Medicaid,,9.89,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Trillium,Medicaid,,4.43,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Trillium,Medicaid,,4.55,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Trillium,Medicaid,,4.63,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Trillium,Medicaid,,65.04,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Trillium,Medicaid,,4.35,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Trillium,Medicaid,,5.31,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Trillium,Medicaid,,7.50,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Trillium,Medicaid,,5.63,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Trillium,Medicaid,,94.03,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Trillium,Medicaid,,2.28,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Trillium,Medicaid,,0.33363,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Trillium,Medicaid,,209.25,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Trillium,Medicaid,,5.02,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Trillium,Medicaid,,5.01,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Trillium,Medicaid,,50.95,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Trillium,Medicaid,,6.07,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Trillium,Medicaid,,6.54,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Trillium,Medicaid,,3.58,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Trillium,Medicaid,,3.57,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Trillium,Medicaid,,3.69,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Trillium,Medicaid,,3.97,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Trillium,Medicaid,,1481.76,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Trillium,Medicaid,,3.57,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Trillium,Medicaid,,3.66,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Trillium,Medicaid,,4.08,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Trillium,Medicaid,,3.39,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Trillium,Medicaid,,17.69,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Trillium,Medicaid,,1263.47,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Trillium,Medicaid,,17.70,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Trillium,Medicaid,,9.89,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Trillium,Medicaid,,19.59,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Trillium,Medicaid,,21.31,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Trillium,Medicaid,,4.30,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Trillium,Medicaid,,0.30330,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Trillium,Medicaid,,3.78,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Trillium,Medicaid,,14.28,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Trillium,Medicaid,,0.98067,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Trillium,Medicaid,,3.43,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Trillium,Medicaid,,5.74,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Trillium,Medicaid,,3.41,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Trillium,Medicaid,,3.63,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Trillium,Medicaid,,3.28,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Trillium,Medicaid,,4.77,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Trillium,Medicaid,,0.86946,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Trillium,Medicaid,,5.55,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Trillium,Medicaid,,0.86946,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Trillium,Medicaid,,5.24,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Trillium,Medicaid,,3.47,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Trillium,Medicaid,,0.35385,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Trillium,Medicaid,,4.56,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Trillium,Medicaid,,4.71,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Trillium,Medicaid,,4.56,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Trillium,Medicaid,,1.69,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Trillium,Medicaid,,4.59,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Trillium,Medicaid,,3.26,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Trillium,Medicaid,,22.95,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Trillium,Medicaid,,34.25,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Trillium,Medicaid,,5.63,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Trillium,Medicaid,,6.34,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Trillium,Medicaid,,3652.58,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Trillium,Medicaid,,799.82,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Trillium,Medicaid,,6.25,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Trillium,Medicaid,,153.19,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Trillium,Medicaid,,46.74,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Trillium,Medicaid,,29.07,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Trillium,Medicaid,,554.15,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Trillium,Medicaid,,304.89,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Trillium,Medicaid,,0.70770,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Trillium,Medicaid,,22.09,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Trillium,Medicaid,,0.32352,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Trillium,Medicaid,,3.30,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Trillium,Medicaid,,5.54,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Trillium,Medicaid,,4.08,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Trillium,Medicaid,,8.28,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Trillium,Medicaid,,281.31,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Trillium,Medicaid,,12.32,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Trillium,Medicaid,,7.49,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Trillium,Medicaid,,4.81,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Trillium,Medicaid,,76.28,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Trillium,Medicaid,,97.57,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Trillium,Medicaid,,67.53,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Trillium,Medicaid,,108.25,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Trillium,Medicaid,,23.78,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Trillium,Medicaid,,18.26,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Trillium,Medicaid,,3.25,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Trillium,Medicaid,,5.07,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Trillium,Medicaid,,23.48,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Trillium,Medicaid,,138.75,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Trillium,Medicaid,,324.98,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Trillium,Medicaid,,3.53,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Trillium,Medicaid,,3.77,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Trillium,Medicaid,,13.50,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Trillium,Medicaid,,14.10,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Trillium,Medicaid,,13.65,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Trillium,Medicaid,,15.92,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Trillium,Medicaid,,14.10,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Trillium,Medicaid,,13.65,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Trillium,Medicaid,,30.33,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Trillium,Medicaid,,14.86,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Trillium,Medicaid,,14.10,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Trillium,Medicaid,,13.65,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Trillium,Medicaid,,13.65,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Trillium,Medicaid,,13.50,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Trillium,Medicaid,,14.10,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Trillium,Medicaid,,15.92,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Trillium,Medicaid,,13.50,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Trillium,Medicaid,,3.27,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Trillium,Medicaid,,206.95,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Trillium,Medicaid,,4.58,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Trillium,Medicaid,,1461.36,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Trillium,Medicaid,,5351.90,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Trillium,Medicaid,,1130.39,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Trillium,Medicaid,,5351.90,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Trillium,Medicaid,,3.82,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Trillium,Medicaid,,3.88,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Trillium,Medicaid,,1481.76,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Trillium,Medicaid,,70.81,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Trillium,Medicaid,,251.33,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Trillium,Medicaid,,4.61,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Trillium,Medicaid,,9.34,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Trillium,Medicaid,,1421.59,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Trillium,Medicaid,,67.19,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Trillium,Medicaid,,62.34,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Trillium,Medicaid,,136.19,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Trillium,Medicaid,,8111.43,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Trillium,Medicaid,,32278.82,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Trillium,Medicaid,,297.50,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Trillium,Medicaid,,592.40,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Trillium,Medicaid,,5423.67,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Trillium,Medicaid,,64.73,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Trillium,Medicaid,,58.65,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Trillium,Medicaid,,63.64,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Trillium,Medicaid,,58.60,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Trillium,Medicaid,,85.19,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Trillium,Medicaid,,411.48,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Trillium,Medicaid,,100.09,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Trillium,Medicaid,,201.51,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Trillium,Medicaid,,4.63,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Trillium,Medicaid,,15.68,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Trillium,Medicaid,,68.22,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Trillium,Medicaid,,1140.46,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Trillium,Medicaid,,2268.17,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Trillium,Medicaid,,21.30,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Trillium,Medicaid,,9.19,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Trillium,Medicaid,,12.83,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Trillium,Medicaid,,3.85,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Trillium,Medicaid,,5.39,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Trillium,Medicaid,,69.31,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Trillium,Medicaid,,15.37,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Trillium,Medicaid,,59.21,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Trillium,Medicaid,,4.21,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Trillium,Medicaid,,8.76,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Trillium,Medicaid,,5.08,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Trillium,Medicaid,,5.90,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Trillium,Medicaid,,3.94,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Trillium,Medicaid,,3.89,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Trillium,Medicaid,,20.90,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Trillium,Medicaid,,15.77,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Trillium,Medicaid,,14.44,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Trillium,Medicaid,,15.32,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Trillium,Medicaid,,14.29,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Trillium,Medicaid,,57.93,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Trillium,Medicaid,,12.75,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Trillium,Medicaid,,22.12,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Trillium,Medicaid,,0.96045,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Trillium,Medicaid,,44.28,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Trillium,Medicaid,,231.39,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Trillium,Medicaid,,219.63,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Trillium,Medicaid,,9.00,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Trillium,Medicaid,,9.40,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Trillium,Medicaid,,6.38,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Trillium,Medicaid,,0.56616,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Trillium,Medicaid,,7395.47,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Trillium,Medicaid,,64.33,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Trillium,Medicaid,,44.28,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Trillium,Medicaid,,12.91,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Trillium,Medicaid,,23.35,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Trillium,Medicaid,,5.61,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Trillium,Medicaid,,2.38,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Trillium,Medicaid,,2.38,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Trillium,Medicaid,,2.38,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Trillium,Medicaid,,2.38,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Trillium,Medicaid,,15.19,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Trillium,Medicaid,,21.87,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Trillium,Medicaid,,30.99,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Trillium,Medicaid,,4.42,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Trillium,Medicaid,,3.96,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Trillium,Medicaid,,11.68,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Trillium,Medicaid,,41.31,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Trillium,Medicaid,,3.32,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Trillium,Medicaid,,10.76,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Trillium,Medicaid,,3.28,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Trillium,Medicaid,,4.84,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Trillium,Medicaid,,2767.49,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Trillium,Medicaid,,565.96,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Trillium,Medicaid,,16.11,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Trillium,Medicaid,,9.78,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Trillium,Medicaid,,5.70,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Trillium,Medicaid,,15.41,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Trillium,Medicaid,,9.25,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Trillium,Medicaid,,21.11,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Trillium,Medicaid,,49.13,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Trillium,Medicaid,,12.86,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Trillium,Medicaid,,49.13,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Trillium,Medicaid,,6.03,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Trillium,Medicaid,,116.90,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Trillium,Medicaid,,5.76,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Trillium,Medicaid,,4.18,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Trillium,Medicaid,,4.07,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Trillium,Medicaid,,4.09,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Trillium,Medicaid,,5.33,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Trillium,Medicaid,,1.44,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Trillium,Medicaid,,31.09,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Trillium,Medicaid,,81.90,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Trillium,Medicaid,,31.34,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Trillium,Medicaid,,162.47,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Trillium,Medicaid,,13.39,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Trillium,Medicaid,,5.05,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Trillium,Medicaid,,3.84,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Trillium,Medicaid,,14.15,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Trillium,Medicaid,,15.12,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Trillium,Medicaid,,12.21,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Trillium,Medicaid,,18.64,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Trillium,Medicaid,,76.03,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Trillium,Medicaid,,3.84,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Trillium,Medicaid,,13.01,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Trillium,Medicaid,,5.47,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Trillium,Medicaid,,23.20,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Trillium,Medicaid,,49.13,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Trillium,Medicaid,,9.60,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Trillium,Medicaid,,3.52,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Trillium,Medicaid,,5.80,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Trillium,Medicaid,,3.32,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Trillium,Medicaid,,3.51,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Trillium,Medicaid,,19.11,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Trillium,Medicaid,,6.87,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Trillium,Medicaid,,4.72,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Trillium,Medicaid,,43.59,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Trillium,Medicaid,,68.49,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Trillium,Medicaid,,168.84,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Trillium,Medicaid,,13.19,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Trillium,Medicaid,,16.57,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Trillium,Medicaid,,45.01,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Trillium,Medicaid,,17.83,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Trillium,Medicaid,,17.80,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Trillium,Medicaid,,25.99,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Trillium,Medicaid,,1.19,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Trillium,Medicaid,,10.33,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Trillium,Medicaid,,5.74,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Trillium,Medicaid,,7636.80,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Trillium,Medicaid,,64.50,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Trillium,Medicaid,,34.05,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Trillium,Medicaid,,13.05,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Trillium,Medicaid,,14.70,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Trillium,Medicaid,,13.12,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Trillium,Medicaid,,12.21,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Trillium,Medicaid,,17.78,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Trillium,Medicaid,,75.24,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Trillium,Medicaid,,3.89,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Trillium,Medicaid,,13.63,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Trillium,Medicaid,,13.83,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Trillium,Medicaid,,19.53,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Trillium,Medicaid,,6.21,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Trillium,Medicaid,,21.54,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Trillium,Medicaid,,34.74,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Trillium,Medicaid,,21.02,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Trillium,Medicaid,,50.63,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Trillium,Medicaid,,34.57,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Trillium,Medicaid,,16.31,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Trillium,Medicaid,,14.22,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Trillium,Medicaid,,21.02,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Trillium,Medicaid,,16.56,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Trillium,Medicaid,,19.53,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Trillium,Medicaid,,22.08,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Trillium,Medicaid,,96.81,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Trillium,Medicaid,,23.83,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Trillium,Medicaid,,114.65,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Trillium,Medicaid,,235.70,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Trillium,Medicaid,,251.21,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Trillium,Medicaid,,7.38,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Trillium,Medicaid,,16.90,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Trillium,Medicaid,,15.03,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Trillium,Medicaid,,31.00,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Trillium,Medicaid,,44.18,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Trillium,Medicaid,,103.61,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Trillium,Medicaid,,194.48,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Trillium,Medicaid,,18.26,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Trillium,Medicaid,,20.86,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Trillium,Medicaid,,50.10,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Trillium,Medicaid,,13.51,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Trillium,Medicaid,,15.80,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Trillium,Medicaid,,148.65,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Trillium,Medicaid,,3.55,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Trillium,Medicaid,,55.65,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Trillium,Medicaid,,12.83,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Trillium,Medicaid,,21.25,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Trillium,Medicaid,,58.60,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Trillium,Medicaid,,35.67,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Trillium,Medicaid,,4.89,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Trillium,Medicaid,,24.38,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Trillium,Medicaid,,14.44,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Trillium,Medicaid,,15.84,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Trillium,Medicaid,,36.52,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Trillium,Medicaid,,34.74,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Trillium,Medicaid,,15.29,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Trillium,Medicaid,,5.90,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Trillium,Medicaid,,7.03,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Trillium,Medicaid,,14.44,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Trillium,Medicaid,,360.93,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Trillium,Medicaid,,20.13,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Trillium,Medicaid,,5.09,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Trillium,Medicaid,,7.05,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Trillium,Medicaid,,14.51,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Trillium,Medicaid,,5.61,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Trillium,Medicaid,,12.76,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Trillium,Medicaid,,35.18,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Trillium,Medicaid,,17.83,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Trillium,Medicaid,,4.54,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Trillium,Medicaid,,4.55,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Trillium,Medicaid,,5.18,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Trillium,Medicaid,,8.63,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Trillium,Medicaid,,5.28,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Trillium,Medicaid,,26.50,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Trillium,Medicaid,,19.11,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Trillium,Medicaid,,28.24,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Trillium,Medicaid,,5.89,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Trillium,Medicaid,,21.09,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Trillium,Medicaid,,16.56,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Trillium,Medicaid,,3.59,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Trillium,Medicaid,,13.81,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Trillium,Medicaid,,3.49,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Trillium,Medicaid,,11.30,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Trillium,Medicaid,,16.63,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Trillium,Medicaid,,21.50,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Trillium,Medicaid,,62.84,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Trillium,Medicaid,,16.13,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Trillium,Medicaid,,64.55,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Trillium,Medicaid,,12.97,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Trillium,Medicaid,,8.03,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Trillium,Medicaid,,21.23,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Trillium,Medicaid,,15.11,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Trillium,Medicaid,,10.51,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Trillium,Medicaid,,32.68,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Trillium,Medicaid,,4.48,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Trillium,Medicaid,,12.76,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Trillium,Medicaid,,91.36,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Trillium,Medicaid,,33.90,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Trillium,Medicaid,,55.93,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Trillium,Medicaid,,48.41,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Trillium,Medicaid,,14.94,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Trillium,Medicaid,,13.28,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Trillium,Medicaid,,16.10,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Trillium,Medicaid,,12.09,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Trillium,Medicaid,,3.25,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Trillium,Medicaid,,50.06,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Trillium,Medicaid,,2037.57,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Trillium,Medicaid,,17.71,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Trillium,Medicaid,,30.41,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Trillium,Medicaid,,31.07,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Trillium,Medicaid,,73.65,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Trillium,Medicaid,,3202.58,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Trillium,Medicaid,,79.79,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Trillium,Medicaid,,113.42,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Trillium,Medicaid,,62.94,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Trillium,Medicaid,,97.89,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Trillium,Medicaid,,91.47,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Trillium,Medicaid,,82.30,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Trillium,Medicaid,,74.29,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Trillium,Medicaid,,113.42,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Trillium,Medicaid,,62.94,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Trillium,Medicaid,,97.89,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Trillium,Medicaid,,554.15,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Trillium,Medicaid,,20.46,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Trillium,Medicaid,,23.28,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Trillium,Medicaid,,5.08,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Trillium,Medicaid,,6.00,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Trillium,Medicaid,,17.83,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Trillium,Medicaid,,39.49,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Trillium,Medicaid,,29.56,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Trillium,Medicaid,,231.39,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Trillium,Medicaid,,231.39,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Trillium,Medicaid,,14.88,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Trillium,Medicaid,,13.03,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Trillium,Medicaid,,83.34,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Trillium,Medicaid,,8.16,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Trillium,Medicaid,,35.03,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Trillium,Medicaid,,12.78,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Trillium,Medicaid,,23.28,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Trillium,Medicaid,,9.89,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Trillium,Medicaid,,5.21,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Trillium,Medicaid,,6.54,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Trillium,Medicaid,,320.46,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Trillium,Medicaid,,7.84,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Trillium,Medicaid,,96.73,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Trillium,Medicaid,,521.77,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Trillium,Medicaid,,3.48,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Trillium,Medicaid,,29.18,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Trillium,Medicaid,,279.07,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Trillium,Medicaid,,14.92,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Trillium,Medicaid,,43.47,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Trillium,Medicaid,,120.76,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Trillium,Medicaid,,22.08,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Trillium,Medicaid,,23.35,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Trillium,Medicaid,,8.76,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Trillium,Medicaid,,13.21,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Trillium,Medicaid,,9.59,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Trillium,Medicaid,,13.36,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Trillium,Medicaid,,7.38,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Trillium,Medicaid,,13.36,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Trillium,Medicaid,,9.80,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Trillium,Medicaid,,17.96,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Trillium,Medicaid,,52.65,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Trillium,Medicaid,,24.20,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Trillium,Medicaid,,23.91,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Trillium,Medicaid,,3.25,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Trillium,Medicaid,,1373.54,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Trillium,Medicaid,,6.26,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Trillium,Medicaid,,16.83,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Trillium,Medicaid,,13.16,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Trillium,Medicaid,,36.06,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Trillium,Medicaid,,10.23,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Trillium,Medicaid,,46.85,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Trillium,Medicaid,,48.07,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Trillium,Medicaid,,30.41,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Trillium,Medicaid,,13.80,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Trillium,Medicaid,,4.47,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Trillium,Medicaid,,4.61,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Trillium,Medicaid,,92.80,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Trillium,Medicaid,,5.27,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Trillium,Medicaid,,1180.13,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Trillium,Medicaid,,12.75,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Trillium,Medicaid,,12.77,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Trillium,Medicaid,,12.79,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Trillium,Medicaid,,12.80,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Trillium,Medicaid,,12.75,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Trillium,Medicaid,,29.30,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Trillium,Medicaid,,3.91,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Trillium,Medicaid,,3.25,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Trillium,Medicaid,,13.39,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Trillium,Medicaid,,10.12,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Trillium,Medicaid,,92.23,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Trillium,Medicaid,,93.44,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Trillium,Medicaid,,73.00,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Trillium,Medicaid,,16.14,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Trillium,Medicaid,,17.84,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Trillium,Medicaid,,15.29,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Trillium,Medicaid,,15.92,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Trillium,Medicaid,,3.25,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Trillium,Medicaid,,4.58,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Trillium,Medicaid,,5.02,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Trillium,Medicaid,,32.08,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Trillium,Medicaid,,17.99,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Trillium,Medicaid,,25.39,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Trillium,Medicaid,,17.01,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Trillium,Medicaid,,72.24,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Trillium,Medicaid,,233.75,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Trillium,Medicaid,,5.33,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Trillium,Medicaid,,5.04,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Trillium,Medicaid,,147.66,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Trillium,Medicaid,,20.56,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Trillium,Medicaid,,20.93,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Trillium,Medicaid,,12.55,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Trillium,Medicaid,,30.58,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Trillium,Medicaid,,57.93,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Trillium,Medicaid,,7.89,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Trillium,Medicaid,,12.44,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Trillium,Medicaid,,5.34,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Trillium,Medicaid,,7.38,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Trillium,Medicaid,,42.46,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Trillium,Medicaid,,15.29,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Trillium,Medicaid,,17.75,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Trillium,Medicaid,,16.64,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Trillium,Medicaid,,5.08,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Trillium,Medicaid,,6.00,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Trillium,Medicaid,,13.54,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Trillium,Medicaid,,4.69,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Trillium,Medicaid,,6.96,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Trillium,Medicaid,,4.18,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Trillium,Medicaid,,8.63,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Trillium,Medicaid,,4.84,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Trillium,Medicaid,,5.30,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Trillium,Medicaid,,3.57,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Trillium,Medicaid,,3.31,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Trillium,Medicaid,,107.43,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Trillium,Medicaid,,6.87,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Trillium,Medicaid,,521.77,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Trillium,Medicaid,,4999.35,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Trillium,Medicaid,,4999.35,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Trillium,Medicaid,,4999.35,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Trillium,Medicaid,,4999.35,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Trillium,Medicaid,,4999.35,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Trillium,Medicaid,,7636.80,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Trillium,Medicaid,,81.68,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Trillium,Medicaid,,21.57,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Trillium,Medicaid,,6.00,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Trillium,Medicaid,,4.66,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Trillium,Medicaid,,29.96,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Trillium,Medicaid,,6.06,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Trillium,Medicaid,,2.51,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Trillium,Medicaid,,153.07,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Trillium,Medicaid,,9.89,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Trillium,Medicaid,,5.21,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Trillium,Medicaid,,5.28,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Trillium,Medicaid,,56.26,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Trillium,Medicaid,,11.81,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Trillium,Medicaid,,15.68,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Trillium,Medicaid,,3.41,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Trillium,Medicaid,,109.15,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Trillium,Medicaid,,62.36,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Trillium,Medicaid,,0.83913,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Trillium,Medicaid,,0.56616,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Trillium,Medicaid,,55.96,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Trillium,Medicaid,,60.35,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Trillium,Medicaid,,48.26,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Trillium,Medicaid,,52.69,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Trillium,Medicaid,,0.45495,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Trillium,Medicaid,,58.90,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Trillium,Medicaid,,8.32,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Trillium,Medicaid,,13.40,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Trillium,Medicaid,,15.73,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Trillium,Medicaid,,5.80,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Trillium,Medicaid,,7.62,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Trillium,Medicaid,,7.52,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Trillium,Medicaid,,9126.50,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Trillium,Medicaid,,7273.19,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Trillium,Medicaid,,10366.43,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Trillium,Medicaid,,5.55,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Trillium,Medicaid,,112.42,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Trillium,Medicaid,,63.64,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Trillium,Medicaid,,58.60,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Trillium,Medicaid,,85.19,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Trillium,Medicaid,,9461.19,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Trillium,Medicaid,,1544.04,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Trillium,Medicaid,,799.82,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Trillium,Medicaid,,1544.04,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Trillium,Medicaid,,799.82,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Trillium,Medicaid,,1544.04,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Trillium,Medicaid,,799.82,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Trillium,Medicaid,,204.72,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Trillium,Medicaid,,3804.27,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Trillium,Medicaid,,3804.27,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Trillium,Medicaid,,3804.27,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Trillium,Medicaid,,10334.11,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Trillium,Medicaid,,500.44,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Trillium,Medicaid,,844.32,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Trillium,Medicaid,,1675.89,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Trillium,Medicaid,,345.38,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Trillium,Medicaid,,844.32,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Trillium,Medicaid,,1675.89,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Trillium,Medicaid,,345.38,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Trillium,Medicaid,,56.38,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Trillium,Medicaid,,8.92,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Trillium,Medicaid,,6.02,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Trillium,Medicaid,,38789.63,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Trillium,Medicaid,,26.06,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Trillium,Medicaid,,14.26,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Trillium,Medicaid,,15.01,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Trillium,Medicaid,,297.50,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Trillium,Medicaid,,14.31,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Trillium,Medicaid,,4.10,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Trillium,Medicaid,,4.35,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Trillium,Medicaid,,3.89,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Trillium,Medicaid,,135.68,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Trillium,Medicaid,,29.33,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Trillium,Medicaid,,148.82,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Trillium,Medicaid,,53.27,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Trillium,Medicaid,,11.20,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Trillium,Medicaid,,11.20,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Trillium,Medicaid,,1.03,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Trillium,Medicaid,,2.62,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Trillium,Medicaid,,16.16,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Trillium,Medicaid,,12.18,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Trillium,Medicaid,,93.16,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Trillium,Medicaid,,15.77,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Trillium,Medicaid,,3.47,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Trillium,Medicaid,,11.97,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Trillium,Medicaid,,7.73,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Trillium,Medicaid,,88.15,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Trillium,Medicaid,,3.70,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Trillium,Medicaid,,21.55,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Trillium,Medicaid,,117.88,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Trillium,Medicaid,,63.44,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Trillium,Medicaid,,10.47,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Trillium,Medicaid,,4.12,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Trillium,Medicaid,,3.60,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Trillium,Medicaid,,3.68,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Trillium,Medicaid,,3.58,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Trillium,Medicaid,,4.58,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Trillium,Medicaid,,6.87,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Trillium,Medicaid,,6.17,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Trillium,Medicaid,,6.19,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Trillium,Medicaid,,6.91,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Trillium,Medicaid,,7.68,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Trillium,Medicaid,,23.27,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Trillium,Medicaid,,9.93,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Trillium,Medicaid,,3.29,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Trillium,Medicaid,,3.67,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Trillium,Medicaid,,3.32,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Trillium,Medicaid,,3.46,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Trillium,Medicaid,,3.33,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Trillium,Medicaid,,0.43473,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Trillium,Medicaid,,4.81,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Trillium,Medicaid,,23.60,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Trillium,Medicaid,,47.40,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Trillium,Medicaid,,9.59,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Trillium,Medicaid,,0.85935,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Trillium,Medicaid,,9.78,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Trillium,Medicaid,,5.33,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Trillium,Medicaid,,6.32,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Trillium,Medicaid,,6.00,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Trillium,Medicaid,,37.54,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Trillium,Medicaid,,15.60,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Trillium,Medicaid,,6.05,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Trillium,Medicaid,,3.46,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Trillium,Medicaid,,6.00,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Trillium,Medicaid,,6.06,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Trillium,Medicaid,,17.64,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Trillium,Medicaid,,18.01,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Trillium,Medicaid,,4.73,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Trillium,Medicaid,,10.83,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Trillium,Medicaid,,3.31,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Trillium,Medicaid,,7.52,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Trillium,Medicaid,,62.08,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Trillium,Medicaid,,95.64,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Trillium,Medicaid,,4.57,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Trillium,Medicaid,,5.85,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Trillium,Medicaid,,21.38,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Trillium,Medicaid,,3.88,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Trillium,Medicaid,,3.85,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Trillium,Medicaid,,4.16,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Trillium,Medicaid,,3.33,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Trillium,Medicaid,,3.57,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Trillium,Medicaid,,3.77,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Trillium,Medicaid,,15.00,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Trillium,Medicaid,,2.73,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Trillium,Medicaid,,3.46,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Trillium,Medicaid,,3.76,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Trillium,Medicaid,,3.66,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Trillium,Medicaid,,5.38,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Trillium,Medicaid,,6.20,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Trillium,Medicaid,,5.33,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Trillium,Medicaid,,4.47,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Trillium,Medicaid,,5.28,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Trillium,Medicaid,,4.71,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Trillium,Medicaid,,6.53,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Trillium,Medicaid,,17.80,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Trillium,Medicaid,,33.60,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Trillium,Medicaid,,3.45,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Trillium,Medicaid,,25.95,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Trillium,Medicaid,,10.86,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Trillium,Medicaid,,5.20,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Trillium,Medicaid,,3.46,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Trillium,Medicaid,,3.72,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Trillium,Medicaid,,4.70,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Trillium,Medicaid,,2.12,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Trillium,Medicaid,,4.24,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Trillium,Medicaid,,3.63,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Trillium,Medicaid,,41.34,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Trillium,Medicaid,,50.05,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Trillium,Medicaid,,14.94,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Trillium,Medicaid,,8.63,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Trillium,Medicaid,,1373.54,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Trillium,Medicaid,,3.50,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Trillium,Medicaid,,4.91,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Trillium,Medicaid,,4.78,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Trillium,Medicaid,,45.94,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Trillium,Medicaid,,20.44,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Trillium,Medicaid,,6.92,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Trillium,Medicaid,,43.01,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Trillium,Medicaid,,1.29,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Trillium,Medicaid,,1.29,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Trillium,Medicaid,,22.95,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Trillium,Medicaid,,4.52,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Trillium,Medicaid,,4.78,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Trillium,Medicaid,,14.62,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Trillium,Medicaid,,51.08,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Trillium,Medicaid,,52.17,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Trillium,Medicaid,,54.53,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Trillium,Medicaid,,31.42,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Trillium,Medicaid,,17.33,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Trillium,Medicaid,,22.25,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Trillium,Medicaid,,14.69,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Trillium,Medicaid,,38.25,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Trillium,Medicaid,,9.07,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Trillium,Medicaid,,0.77847,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Trillium,Medicaid,,0.61671,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Trillium,Medicaid,,83.00,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Trillium,Medicaid,,4.46,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Trillium,Medicaid,,4.94,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Trillium,Medicaid,,30.08,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Trillium,Medicaid,,253.96,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Trillium,Medicaid,,3.43,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Trillium,Medicaid,,4.31,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Trillium,Medicaid,,3.53,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Trillium,Medicaid,,40.95,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Trillium,Medicaid,,4.49,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Trillium,Medicaid,,3.52,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Trillium,Medicaid,,3.55,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Trillium,Medicaid,,4.94,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Trillium,Medicaid,,3.58,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Trillium,Medicaid,,24.53,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Trillium,Medicaid,,32.66,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Trillium,Medicaid,,3.37,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Trillium,Medicaid,,3.52,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Trillium,Medicaid,,3.45,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Trillium,Medicaid,,3.73,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Trillium,Medicaid,,51.90,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Trillium,Medicaid,,17.48,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Trillium,Medicaid,,5.10,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Trillium,Medicaid,,13.23,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Trillium,Medicaid,,0.28308,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Trillium,Medicaid,,0.28308,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Trillium,Medicaid,,0.57627,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Trillium,Medicaid,,1.55,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Trillium,Medicaid,,18.98,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Trillium,Medicaid,,3.48,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Trillium,Medicaid,,16.90,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Trillium,Medicaid,,16.90,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Trillium,Medicaid,,16.90,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Trillium,Medicaid,,191.55,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Trillium,Medicaid,,4.49,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Trillium,Medicaid,,72.10,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Trillium,Medicaid,,81.82,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Trillium,Medicaid,,0.24264,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Trillium,Medicaid,,3.32,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Trillium,Medicaid,,10.76,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Trillium,Medicaid,,21.18,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Trillium,Medicaid,,13.55,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Trillium,Medicaid,,23.59,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Trillium,Medicaid,,22.66,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Trillium,Medicaid,,15.92,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Trillium,Medicaid,,15.47,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Trillium,Medicaid,,16.68,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Trillium,Medicaid,,16.67,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Trillium,Medicaid,,19.24,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Trillium,Medicaid,,3.78,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Trillium,Medicaid,,27.63,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Trillium,Medicaid,,15.01,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Trillium,Medicaid,,86.55,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Trillium,Medicaid,,79.83,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Trillium,Medicaid,,3.43,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Trillium,Medicaid,,13.95,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Trillium,Medicaid,,16.21,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Trillium,Medicaid,,23.39,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Trillium,Medicaid,,3.40,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Trillium,Medicaid,,3.49,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Trillium,Medicaid,,1071.37,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Trillium,Medicaid,,54.57,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Trillium,Medicaid,,144.57,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Trillium,Medicaid,,17.21,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Trillium,Medicaid,,9.24,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Trillium,Medicaid,,10.02,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Trillium,Medicaid,,0.31341,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Trillium,Medicaid,,82.45,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Trillium,Medicaid,,400.20,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Trillium,Medicaid,,74.37,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Trillium,Medicaid,,1.40,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Trillium,Medicaid,,130.62,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Trillium,Medicaid,,5.37,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Trillium,Medicaid,,16.14,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Trillium,Medicaid,,24.03,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Trillium,Medicaid,,4.51,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Trillium,Medicaid,,19.17,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Trillium,Medicaid,,171.55,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Trillium,Medicaid,,6.51,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Trillium,Medicaid,,5.65,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Trillium,Medicaid,,5.80,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Trillium,Medicaid,,57.83,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Trillium,Medicaid,,1.26,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Trillium,Medicaid,,5.07,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Trillium,Medicaid,,5.07,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Trillium,Medicaid,,10.81,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Trillium,Medicaid,,576.29,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Trillium,Medicaid,,12.55,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Trillium,Medicaid,,4.61,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Trillium,Medicaid,,4.00,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Trillium,Medicaid,,4.78,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Trillium,Medicaid,,12.64,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Trillium,Medicaid,,3.34,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Trillium,Medicaid,,3.35,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Trillium,Medicaid,,5.05,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Trillium,Medicaid,,8.21,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Trillium,Medicaid,,6.06,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Trillium,Medicaid,,11.85,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Trillium,Medicaid,,11.21,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Trillium,Medicaid,,9.20,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Trillium,Medicaid,,42.35,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Trillium,Medicaid,,3.46,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Trillium,Medicaid,,5.25,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Trillium,Medicaid,,87.20,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Trillium,Medicaid,,99.81,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Trillium,Medicaid,,5552.33,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Trillium,Medicaid,,18.68,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Trillium,Medicaid,,3.78,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Trillium,Medicaid,,58.65,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Trillium,Medicaid,,61.69,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Trillium,Medicaid,,1835.26,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Trillium,Medicaid,,5.53,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Trillium,Medicaid,,24.39,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Trillium,Medicaid,,21.43,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Trillium,Medicaid,,21.74,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Trillium,Medicaid,,21.73,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Trillium,Medicaid,,11.47,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Trillium,Medicaid,,26.57,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Trillium,Medicaid,,19.67,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Trillium,Medicaid,,89.39,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Trillium,Medicaid,,0.89979,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Trillium,Medicaid,,12.44,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Trillium,Medicaid,,9.14,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Trillium,Medicaid,,3.32,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Trillium,Medicaid,,3.49,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Trillium,Medicaid,,1.06,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Trillium,Medicaid,,103.44,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Trillium,Medicaid,,71.40,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Trillium,Medicaid,,3.62,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Trillium,Medicaid,,3.55,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Trillium,Medicaid,,3.56,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Trillium,Medicaid,,3.57,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Trillium,Medicaid,,3.71,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Trillium,Medicaid,,6.75,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Trillium,Medicaid,,8184.58,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Trillium,Medicaid,,114.84,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Trillium,Medicaid,,8.27,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Trillium,Medicaid,,19.84,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Trillium,Medicaid,,91.47,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Trillium,Medicaid,,82.30,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Trillium,Medicaid,,31.32,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Trillium,Medicaid,,11.96,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Trillium,Medicaid,,5432.55,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Trillium,Medicaid,,14.51,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Trillium,Medicaid,,161.37,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Trillium,Medicaid,,1.85,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Trillium,Medicaid,,0.28308,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Trillium,Medicaid,,20.04,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Trillium,Medicaid,,775.00,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Trillium,Medicaid,,0.65715,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Trillium,Medicaid,,0.49539,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Trillium,Medicaid,,219.30,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Trillium,Medicaid,,8.22,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Trillium,Medicaid,,109.15,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Trillium,Medicaid,,62.36,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Trillium,Medicaid,,88.36,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Trillium,Medicaid,,88.36,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Trillium,Medicaid,,159.04,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Trillium,Medicaid,,8099.66,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Trillium,Medicaid,,4051.45,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Trillium,Medicaid,,0.79869,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Trillium,Medicaid,,0.25275,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Trillium,Medicaid,,0.40440,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Trillium,Medicaid,,20.61,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Trillium,Medicaid,,3.54,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Trillium,Medicaid,,3.33,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Trillium,Medicaid,,3.36,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Trillium,Medicaid,,10.33,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Trillium,Medicaid,,6.87,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Trillium,Medicaid,,19.82,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Trillium,Medicaid,,26.09,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Trillium,Medicaid,,75.16,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Trillium,Medicaid,,19.18,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Trillium,Medicaid,,42.46,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Trillium,Medicaid,,5.31,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Trillium,Medicaid,,10.10,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Trillium,Medicaid,,35.44,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Trillium,Medicaid,,6.25,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Trillium,Medicaid,,164.40,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Trillium,Medicaid,,0.21231,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Trillium,Medicaid,,4.04,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Trillium,Medicaid,,107.47,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Trillium,Medicaid,,16.19,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Trillium,Medicaid,,7.59,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Trillium,Medicaid,,3.79,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Trillium,Medicaid,,30.58,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Trillium,Medicaid,,55.87,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Trillium,Medicaid,,9.78,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Trillium,Medicaid,,53.87,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Trillium,Medicaid,,0.81891,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Trillium,Medicaid,,32.33,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Trillium,Medicaid,,17.84,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Trillium,Medicaid,,17.84,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Trillium,Medicaid,,17.84,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Trillium,Medicaid,,106.50,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Trillium,Medicaid,,5.91,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Trillium,Medicaid,,17.12,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Trillium,Medicaid,,17.12,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Trillium,Medicaid,,1.06,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Trillium,Medicaid,,6.02,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Trillium,Medicaid,,15.18,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Trillium,Medicaid,,15.26,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Trillium,Medicaid,,14.45,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Trillium,Medicaid,,5.86,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Trillium,Medicaid,,3.54,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Trillium,Medicaid,,4.24,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Trillium,Medicaid,,3.30,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Trillium,Medicaid,,3.27,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Trillium,Medicaid,,7.90,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Trillium,Medicaid,,739.24,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Trillium,Medicaid,,4.00,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Trillium,Medicaid,,2536.04,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Trillium,Medicaid,,5068.83,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Trillium,Medicaid,,418.30,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Trillium,Medicaid,,556.72,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Trillium,Medicaid,,622.78,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Trillium,Medicaid,,0.22242,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Trillium,Medicaid,,3.65,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Trillium,Medicaid,,87.60,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Trillium,Medicaid,,4.39,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Trillium,Medicaid,,4.49,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Trillium,Medicaid,,3.45,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Trillium,Medicaid,,3.54,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Trillium,Medicaid,,132.04,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Trillium,Medicaid,,0.23253,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Trillium,Medicaid,,17.41,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Trillium,Medicaid,,12.25,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Trillium,Medicaid,,150.83,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Trillium,Medicaid,,21.23,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Trillium,Medicaid,,8.03,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Trillium,Medicaid,,12.44,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Trillium,Medicaid,,5.90,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Trillium,Medicaid,,4.39,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Trillium,Medicaid,,3.38,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Trillium,Medicaid,,3.42,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Trillium,Medicaid,,17.19,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Trillium,Medicaid,,3.75,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Trillium,Medicaid,,45.08,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Trillium,Medicaid,,63.69,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Trillium,Medicaid,,2.99,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Trillium,Medicaid,,336.28,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Trillium,Medicaid,,15.90,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Trillium,Medicaid,,4.89,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Trillium,Medicaid,,16.58,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Trillium,Medicaid,,9.60,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Trillium,Medicaid,,442.62,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Trillium,Medicaid,,7.27,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Trillium,Medicaid,,53.54,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Trillium,Medicaid,,21.13,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Trillium,Medicaid,,23.00,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Trillium,Medicaid,,9.31,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Trillium,Medicaid,,4.47,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Trillium,Medicaid,,4.52,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Trillium,Medicaid,,5.46,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Trillium,Medicaid,,4.59,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Trillium,Medicaid,,3.76,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Trillium,Medicaid,,84.36,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Trillium,Medicaid,,310.13,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Trillium,Medicaid,,7.78,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Trillium,Medicaid,,12.51,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Trillium,Medicaid,,15.90,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Trillium,Medicaid,,19.48,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Trillium,Medicaid,,61.26,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Trillium,Medicaid,,733.62,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Trillium,Medicaid,,25.70,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Trillium,Medicaid,,42.69,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Trillium,Medicaid,,18.01,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Trillium,Medicaid,,6.94,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Trillium,Medicaid,,12.14,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Trillium,Medicaid,,6.32,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Trillium,Medicaid,,40.70,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Trillium,Medicaid,,35.19,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Trillium,Medicaid,,13.05,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Trillium,Medicaid,,13.11,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Trillium,Medicaid,,13.08,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Trillium,Medicaid,,48.32,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Trillium,Medicaid,,18.42,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Trillium,Medicaid,,0.29319,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Trillium,Medicaid,,133.71,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Trillium,Medicaid,,77.89,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Trillium,Medicaid,,366.64,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Trillium,Medicaid,,16.77,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Trillium,Medicaid,,0.93012,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Trillium,Medicaid,,439.70,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Trillium,Medicaid,,20.52,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Trillium,Medicaid,,19.82,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Trillium,Medicaid,,19.11,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Trillium,Medicaid,,4.97,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Trillium,Medicaid,,6.71,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Trillium,Medicaid,,10.12,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Trillium,Medicaid,,19.82,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Trillium,Medicaid,,19.82,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Trillium,Medicaid,,15.47,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Trillium,Medicaid,,71.98,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Trillium,Medicaid,,11.84,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Trillium,Medicaid,,9.90,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Trillium,Medicaid,,1026.42,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Trillium,Medicaid,,14.15,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Trillium,Medicaid,,4.04,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Trillium,Medicaid,,3.90,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Trillium,Medicaid,,129.95,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Trillium,Medicaid,,51.54,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Trillium,Medicaid,,3.48,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Trillium,Medicaid,,19.32,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Trillium,Medicaid,,5.09,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Trillium,Medicaid,,33.62,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Trillium,Medicaid,,17.25,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Trillium,Medicaid,,20.80,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Trillium,Medicaid,,5.15,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Trillium,Medicaid,,0.28308,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Trillium,Medicaid,,488.69,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Trillium,Medicaid,,813.31,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Trillium,Medicaid,,98.31,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Trillium,Medicaid,,144.57,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Trillium,Medicaid,,3.49,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Trillium,Medicaid,,212.37,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Trillium,Medicaid,,10.89,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Trillium,Medicaid,,349.98,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Trillium,Medicaid,,8.96,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Trillium,Medicaid,,8.96,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Trillium,Medicaid,,23.01,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Trillium,Medicaid,,3.61,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Trillium,Medicaid,,333.69,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Trillium,Medicaid,,9182.82,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Trillium,Medicaid,,31586.14,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Trillium,Medicaid,,52066.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Trillium,Medicaid,,2256.50,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Trillium,Medicaid,,1494.30,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Trillium,Medicaid,,52.37,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Trillium,Medicaid,,2.76,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Trillium,Medicaid,,0.24264,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Trillium,Medicaid,,1.85,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Trillium,Medicaid,,8.49,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Trillium,Medicaid,,0.04044,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Trillium,Medicaid,,104.94,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Trillium,Medicaid,,260.23,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Trillium,Medicaid,,389.24,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Trillium,Medicaid,,584.56,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Trillium,Medicaid,,701.43,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Trillium,Medicaid,,841.56,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Trillium,Medicaid,,1010.19,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Trillium,Medicaid,,417.54,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Trillium,Medicaid,,613.27,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Trillium,Medicaid,,1115.34,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Trillium,Medicaid,,32.35,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Trillium,Medicaid,,127.99,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Trillium,Medicaid,,34.98,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,,23.66,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Trillium,Medicaid,,5.26,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Trillium,Medicaid,,28.91,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Trillium,Medicaid,,31.95,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Trillium,Medicaid,,105.95,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Trillium,Medicaid,,120.71,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Trillium,Medicaid,,102.72,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Trillium,Medicaid,,18.60,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Trillium,Medicaid,,14.76,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Trillium,Medicaid,,46.51,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Trillium,Medicaid,,42.66,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Trillium,Medicaid,,1058.11,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Trillium,Medicaid,,1058.11,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Trillium,Medicaid,,1007.36,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Trillium,Medicaid,,361.13,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Trillium,Medicaid,,607.61,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Trillium,Medicaid,,308.56,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Trillium,Medicaid,,63.29,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Trillium,Medicaid,,221.00,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Trillium,Medicaid,,69.15,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Trillium,Medicaid,,249.92,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Trillium,Medicaid,,183.80,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Trillium,Medicaid,,61.27,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Trillium,Medicaid,,101.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Trillium,Medicaid,,189.66,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Trillium,Medicaid,,53.79,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Trillium,Medicaid,,41.25,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Trillium,Medicaid,,220.80,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Trillium,Medicaid,,191.69,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Trillium,Medicaid,,57.83,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Trillium,Medicaid,,8.69,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Trillium,Medicaid,,7.08,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Trillium,Medicaid,,28.31,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Trillium,Medicaid,,95.84,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Trillium,Medicaid,,25.48,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Trillium,Medicaid,,57.83,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Trillium,Medicaid,,27.09,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Trillium,Medicaid,,2.22,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Trillium,Medicaid,,1007.97,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Trillium,Medicaid,,4064.22,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Trillium,Medicaid,,1025.96,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Trillium,Medicaid,,857.33,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Trillium,Medicaid,,703.25,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Trillium,Medicaid,,93.62,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Trillium,Medicaid,,799.50,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Trillium,Medicaid,,915.97,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Trillium,Medicaid,,902.01,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Trillium,Medicaid,,713.97,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Trillium,Medicaid,,1179.84,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Trillium,Medicaid,,837.71,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Trillium,Medicaid,,837.71,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Trillium,Medicaid,,974.81,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Trillium,Medicaid,,974.81,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Trillium,Medicaid,,1186.11,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Trillium,Medicaid,,799.50,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Trillium,Medicaid,,799.50,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Trillium,Medicaid,,713.97,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Trillium,Medicaid,,799.50,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Trillium,Medicaid,,352.84,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Trillium,Medicaid,,831.04,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Trillium,Medicaid,,341.92,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Trillium,Medicaid,,1314.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Trillium,Medicaid,,239.40,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Trillium,Medicaid,,491.75,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Trillium,Medicaid,,744.90,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Trillium,Medicaid,,868.85,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Trillium,Medicaid,,24.47,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Trillium,Medicaid,,344.95,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Trillium,Medicaid,,692.74,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Trillium,Medicaid,,16.78,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Trillium,Medicaid,,94.43,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Trillium,Medicaid,,139.32,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Trillium,Medicaid,,314.83,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Trillium,Medicaid,,238.39,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Trillium,Medicaid,,15.97,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Trillium,Medicaid,GP,4.25,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Trillium,Medicaid,,67.33,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Trillium,Medicaid,,303.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Trillium,Medicaid,,287.53,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Trillium,Medicaid,,230.51,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Trillium,Medicaid,,173.49,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Trillium,Medicaid,,116.47,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Trillium,Medicaid,,59.45,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Trillium,Medicaid,,331.20,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Trillium,Medicaid,,989.77,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Trillium,Medicaid,,1312.68,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Trillium,Medicaid,,693.55,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Trillium,Medicaid,,526.53,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Trillium,Medicaid,,5289.15,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Trillium,Medicaid,,5540.08,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Trillium,Medicaid,,5830.84,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Trillium,Medicaid,,6080.96,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Trillium,Medicaid,,6332.10,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Trillium,Medicaid,,6582.42,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Trillium,Medicaid,,6792.10,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Trillium,Medicaid,,7082.86,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Trillium,Medicaid,,7333.39,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Trillium,Medicaid,,7583.92,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Trillium,Medicaid,,7834.64,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Trillium,Medicaid,,78.45,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Trillium,Medicaid,,107.97,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Trillium,Medicaid,,167.62,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Trillium,Medicaid,,169.04,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Trillium,Medicaid,,815.88,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Trillium,Medicaid,,1958.31,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Trillium,Medicaid,,2104.30,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Trillium,Medicaid,,2260.39,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Trillium,Medicaid,,1232.21,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Trillium,Medicaid,,1591.92,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Trillium,Medicaid,,1810.70,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Trillium,Medicaid,,2331.37,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Trillium,Medicaid,,2393.24,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Trillium,Medicaid,,2451.47,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Trillium,Medicaid,,2509.91,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Trillium,Medicaid,,2568.14,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Trillium,Medicaid,,1000.08,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Trillium,Medicaid,,135.07,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Trillium,Medicaid,,890.89,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Trillium,Medicaid,,1202.89,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Trillium,Medicaid,,1647.12,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Trillium,Medicaid,,2087.51,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Trillium,Medicaid,,2383.33,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Trillium,Medicaid,,2699.37,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Trillium,Medicaid,,3079.30,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Trillium,Medicaid,,3300.71,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Trillium,Medicaid,,3627.47,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Trillium,Medicaid,,3805.20,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Trillium,Medicaid,,4037.93,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Trillium,Medicaid,,4187.76,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Trillium,Medicaid,,4225.37,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Trillium,Medicaid,,4288.06,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Trillium,Medicaid,,4413.02,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Trillium,Medicaid,,4538.18,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Trillium,Medicaid,,4663.14,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Trillium,Medicaid,,4789.11,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Trillium,Medicaid,,4913.86,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Trillium,Medicaid,,5039.23,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Trillium,Medicaid,,2710.69,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Trillium,Medicaid,,2297.40,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Trillium,Medicaid,,1424.09,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Trillium,Medicaid,,1424.09,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Trillium,Medicaid,,1424.09,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Trillium,Medicaid,,1310.26,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Trillium,Medicaid,,2710.69,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Trillium,Medicaid,,1529.04,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Trillium,Medicaid,,1722.95,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Trillium,Medicaid,,61.27,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Trillium,Medicaid,,257.00,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Trillium,Medicaid,,102.72,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Trillium,Medicaid,,102.72,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Trillium,Medicaid,,163.38,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Trillium,Medicaid,,2182.55,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Trillium,Medicaid,,382.16,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Trillium,Medicaid,,247.69,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Trillium,Medicaid,,1450.58,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Trillium,Medicaid,,59.85,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Trillium,Medicaid,,152.86,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Trillium,Medicaid,,0.60660,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Trillium,Medicaid,,333.43,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Trillium,Medicaid,,430.08,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Trillium,Medicaid,,527.14,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Trillium,Medicaid,,623.79,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Trillium,Medicaid,,720.64,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Trillium,Medicaid,,817.49,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Trillium,Medicaid,,914.15,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Trillium,Medicaid,,133.65,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Trillium,Medicaid,,663.22,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Trillium,Medicaid,,873.91,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Trillium,Medicaid,,261.65,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Trillium,Medicaid,,356.48,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Trillium,Medicaid,,397.53,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Trillium,Medicaid,,440.19,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Trillium,Medicaid,,482.65,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Trillium,Medicaid,,524.91,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Trillium,Medicaid,,567.58,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Trillium,Medicaid,,333.43,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Trillium,Medicaid,,193.71,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Trillium,Medicaid,,482.65,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Trillium,Medicaid,,261.65,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Trillium,Medicaid,,356.48,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Trillium,Medicaid,,397.53,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Trillium,Medicaid,,440.19,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Trillium,Medicaid,,524.91,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Trillium,Medicaid,,567.58,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Trillium,Medicaid,,663.22,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Trillium,Medicaid,,873.91,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Trillium,Medicaid,,100.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Trillium,Medicaid,,693.55,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Trillium,Medicaid,,57.63,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Trillium,Medicaid,,274.39,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Trillium,Medicaid,,310.78,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Trillium,Medicaid,,347.58,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Trillium,Medicaid,,384.38,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Trillium,Medicaid,,421.59,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Trillium,Medicaid,,458.59,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Trillium,Medicaid,,495.39,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Trillium,Medicaid,,531.99,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Trillium,Medicaid,,568.59,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Trillium,Medicaid,,605.79,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Trillium,Medicaid,,642.39,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Trillium,Medicaid,,690.31,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Trillium,Medicaid,,727.52,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Trillium,Medicaid,,868.04,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Trillium,Medicaid,,924.86,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Trillium,Medicaid,,967.93,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Trillium,Medicaid,,1004.73,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Trillium,Medicaid,,1041.33,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Trillium,Medicaid,,883.41,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Trillium,Medicaid,,937.40,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Trillium,Medicaid,,833.67,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Trillium,Medicaid,,528.35,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Trillium,Medicaid,,571.22,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Trillium,Medicaid,,502.67,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Trillium,Medicaid,,675.75,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Trillium,Medicaid,,68.14,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Trillium,Medicaid,,2038.58,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Trillium,Medicaid,,2038.58,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Trillium,Medicaid,,2038.58,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Trillium,Medicaid,,257.81,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Trillium,Medicaid,,423.81,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Trillium,Medicaid,,470.92,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Trillium,Medicaid,,255.58,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Trillium,Medicaid,,1515.29,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Trillium,Medicaid,,205.44,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Trillium,Medicaid,,81.69,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Trillium,Medicaid,,924.86,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Trillium,Medicaid,,2191.24,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Trillium,Medicaid,,1066.40,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Trillium,Medicaid,,62.08,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Trillium,Medicaid,,8084.76,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Trillium,Medicaid,,8335.09,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Trillium,Medicaid,,381.15,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Trillium,Medicaid,,112.63,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Trillium,Medicaid,,589.41,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Trillium,Medicaid,,17.39,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Trillium,Medicaid,,37.00,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Trillium,Medicaid,,20.02,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Trillium,Medicaid,Q0,0.20422,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Trillium,Medicaid,Q0,0.20422,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Trillium,Medicaid,,121.32,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Trillium,Medicaid,,150.84,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Trillium,Medicaid,,278.02,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Trillium,Medicaid,,3956.85,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Trillium,Medicaid,,1844.06,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Trillium,Medicaid,,1035.26,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Trillium,Medicaid,,1001.70,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Trillium,Medicaid,,1503.96,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Trillium,Medicaid,,1702.12,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Trillium,Medicaid,,1035.26,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Trillium,Medicaid,,1283.57,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Trillium,Medicaid,,64.30,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Trillium,Medicaid,,20.83,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Trillium,Medicaid,,42.26,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Trillium,Medicaid,,29.32,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Trillium,Medicaid,,64.30,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Trillium,Medicaid,,25.48,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Trillium,Medicaid,,30.53,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Trillium,Medicaid,,37.20,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Trillium,Medicaid,,59.65,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Trillium,Medicaid,,71.78,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Trillium,Medicaid,,211.91,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Trillium,Medicaid,,20.83,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Trillium,Medicaid,,85.94,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Trillium,Medicaid,,121.32,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Trillium,Medicaid,,216.96,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Trillium,Medicaid,,191.69,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Trillium,Medicaid,,150.84,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Trillium,Medicaid,,150.84,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Trillium,Medicaid,,156.50,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Trillium,Medicaid,,1035.26,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Trillium,Medicaid,,101.71,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Trillium,Medicaid,,91.39,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Trillium,Medicaid,,272.77,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Trillium,Medicaid,,1035.26,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Trillium,Medicaid,,300.06,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Trillium,Medicaid,,278.83,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Trillium,Medicaid,,108.18,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Trillium,Medicaid,,108.18,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Trillium,Medicaid,,108.18,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Trillium,Medicaid,,1358.78,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Trillium,Medicaid,,186.43,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Trillium,Medicaid,,186.43,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Trillium,Medicaid,,186.43,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Trillium,Medicaid,,245.67,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Trillium,Medicaid,,329.79,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Trillium,Medicaid,,586.18,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Trillium,Medicaid,,70.77,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Trillium,Medicaid,,93.62,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Trillium,Medicaid,,28.31,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Trillium,Medicaid,,33.57,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Trillium,Medicaid,,70.77,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Trillium,Medicaid,,1065.59,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Trillium,Medicaid,,207.05,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Trillium,Medicaid,,128.80,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Trillium,Medicaid,,8001.05,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Trillium,Medicaid,,3438.21,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Trillium,Medicaid,,60.05,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Trillium,Medicaid,,62.28,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Trillium,Medicaid,,388.02,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Trillium,Medicaid,,1466.35,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Trillium,Medicaid,,350.61,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Trillium,Medicaid,,666.25,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Trillium,Medicaid,,8132.48,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Trillium,Medicaid,,2530.94,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Trillium,Medicaid,,2248.46,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Trillium,Medicaid,,3167.46,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Trillium,Medicaid,,6385.07,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Trillium,Medicaid,,533.61,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Trillium,Medicaid,,2247.86,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Trillium,Medicaid,,3243.69,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Trillium,Medicaid,,1916.05,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Trillium,Medicaid,,545.13,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Trillium,Medicaid,,545.13,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Trillium,Medicaid,,1691.61,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Trillium,Medicaid,,0.20422,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Trillium,Medicaid,,1803.62,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Trillium,Medicaid,,2280.21,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Trillium,Medicaid,,1239.69,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Trillium,Medicaid,,3133.09,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Trillium,Medicaid,,253.76,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Trillium,Medicaid,,108.58,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Trillium,Medicaid,,1358.78,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Trillium,Medicaid,,1065.59,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Trillium,Medicaid,,190.07,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Trillium,Medicaid,,44.48,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Trillium,Medicaid,,112.22,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Trillium,Medicaid,,1099.16,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Trillium,Medicaid,,4012.66,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Trillium,Medicaid,,5538.26,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Trillium,Medicaid,,56.82,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Trillium,Medicaid,,56.82,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Trillium,Medicaid,,53.18,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Trillium,Medicaid,,53.18,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Trillium,Medicaid,,53.18,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Trillium,Medicaid,,631.88,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Trillium,Medicaid,,236.98,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Trillium,Medicaid,,304.72,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Trillium,Medicaid,,286.11,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Trillium,Medicaid,,277.01,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Trillium,Medicaid,,2014.72,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Trillium,Medicaid,Q1,1280.94,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Trillium,Medicaid,Q0,767.35,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Trillium,Medicaid,,36.80,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Trillium,Medicaid,,85.53,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Trillium,Medicaid,,111.01,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Trillium,Medicaid,,76.23,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Trillium,Medicaid,,118.29,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Trillium,Medicaid,,76.23,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Trillium,Medicaid,,76.23,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Trillium,Medicaid,,18.60,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Trillium,Medicaid,,58.23,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Trillium,Medicaid,,88.36,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Trillium,Medicaid,,52.98,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Trillium,Medicaid,,47.31,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Trillium,Medicaid,,131.83,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Trillium,Medicaid,,6.67,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Trillium,Medicaid,,383.98,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,,23.66,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,,23.66,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Trillium,Medicaid,,48.53,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Trillium,Medicaid,,72.79,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Trillium,Medicaid,,93.62,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Trillium,Medicaid,,84.92,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Trillium,Medicaid,,393.68,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Trillium,Medicaid,,402.38,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Trillium,Medicaid,,188.45,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Trillium,Medicaid,,284.50,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Trillium,Medicaid,,295.21,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Trillium,Medicaid,,348.59,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Trillium,Medicaid,,424.22,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Trillium,Medicaid,,711.54,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Trillium,Medicaid,,1262.13,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Trillium,Medicaid,,1361.01,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Trillium,Medicaid,,128.40,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Trillium,Medicaid,,172.07,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Trillium,Medicaid,,1284.37,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Trillium,Medicaid,,1442.70,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Trillium,Medicaid,,1442.70,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Trillium,Medicaid,,343.34,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Trillium,Medicaid,,559.89,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Trillium,Medicaid,,148.41,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Trillium,Medicaid,,221.61,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Trillium,Medicaid,,94.83,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Trillium,Medicaid,,195.73,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Trillium,Medicaid,,138.91,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Trillium,Medicaid,,312.40,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Trillium,Medicaid,,216.56,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Trillium,Medicaid,,376.50,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Trillium,Medicaid,,90.99,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Trillium,Medicaid,,243.45,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Trillium,Medicaid,,1514.88,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Trillium,Medicaid,,1507.20,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Trillium,Medicaid,,484.88,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Trillium,Medicaid,,353.04,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Trillium,Medicaid,,626.82,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Trillium,Medicaid,,1703.13,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Trillium,Medicaid,,85.94,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Trillium,Medicaid,,114.65,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Trillium,Medicaid,,440.39,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Trillium,Medicaid,,423.00,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Trillium,Medicaid,,937.20,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Trillium,Medicaid,,497.01,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Trillium,Medicaid,,606.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Trillium,Medicaid,,63.90,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Trillium,Medicaid,,64.91,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Trillium,Medicaid,,217.57,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Trillium,Medicaid,,100.29,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Trillium,Medicaid,,121.93,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Trillium,Medicaid,,100.29,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Trillium,Medicaid,,310.78,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Trillium,Medicaid,,124.35,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Trillium,Medicaid,,148.41,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Trillium,Medicaid,,92.41,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Trillium,Medicaid,,66.93,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Trillium,Medicaid,,105.75,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Trillium,Medicaid,,1442.70,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Trillium,Medicaid,,208.67,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Trillium,Medicaid,,179.76,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Trillium,Medicaid,,235.16,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Trillium,Medicaid,,212.51,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Trillium,Medicaid,,284.29,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Trillium,Medicaid,76,284.29,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,,377.10,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Trillium,Medicaid,,757.85,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Trillium,Medicaid,76,757.85,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Trillium,Medicaid,,797.68,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Trillium,Medicaid,76,797.68,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Trillium,Medicaid,,411.27,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Trillium,Medicaid,,457.17,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Trillium,Medicaid,,481.84,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Trillium,Medicaid,,531.58,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Trillium,Medicaid,,370.63,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Trillium,Medicaid,,530.17,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Trillium,Medicaid,,69.35,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Trillium,Medicaid,,83.51,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Trillium,Medicaid,,83.51,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Trillium,Medicaid,,59.04,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Trillium,Medicaid,,574.65,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Trillium,Medicaid,,5519.86,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Trillium,Medicaid,,758.86,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Trillium,Medicaid,,872.70,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Trillium,Medicaid,,872.70,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Trillium,Medicaid,,131.03,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Trillium,Medicaid,,143.16,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Trillium,Medicaid,,247.69,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Trillium,Medicaid,,173.89,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Trillium,Medicaid,,184.81,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Trillium,Medicaid,,189.66,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Trillium,Medicaid,,129.61,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,,377.10,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,76,377.10,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,,377.10,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,76,377.10,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Trillium,Medicaid,,69.35,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Trillium,Medicaid,,131.43,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Trillium,Medicaid,,73.40,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,,377.10,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,76,377.10,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Trillium,Medicaid,,92.00,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Trillium,Medicaid,76,173.89,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Trillium,Medicaid,76,184.81,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Trillium,Medicaid,,100.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Trillium,Medicaid,,211.10,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Trillium,Medicaid,,329.38,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Trillium,Medicaid,,473.75,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Trillium,Medicaid,,1398.01,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Trillium,Medicaid,,148.21,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Trillium,Medicaid,,1226.75,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Trillium,Medicaid,,455.76,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Trillium,Medicaid,,573.64,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Trillium,Medicaid,,373.67,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Trillium,Medicaid,,176.12,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Trillium,Medicaid,,111.01,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Trillium,Medicaid,,162.77,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Trillium,Medicaid,,253.15,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Trillium,Medicaid,,1650.76,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Trillium,Medicaid,,487.30,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Trillium,Medicaid,,81.89,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Trillium,Medicaid,,113.23,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Trillium,Medicaid,,336.06,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Trillium,Medicaid,,388.83,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Trillium,Medicaid,,257.60,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Trillium,Medicaid,,63.90,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Trillium,Medicaid,,131.43,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Trillium,Medicaid,,440.39,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Trillium,Medicaid,,631.47,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Trillium,Medicaid,,70.97,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Trillium,Medicaid,,213.12,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Trillium,Medicaid,,6.87,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Trillium,Medicaid,,94.02,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Trillium,Medicaid,,207.86,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Trillium,Medicaid,,245.07,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Trillium,Medicaid,,65.11,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Trillium,Medicaid,,153.07,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Trillium,Medicaid,,32.76,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Trillium,Medicaid,,236.57,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Trillium,Medicaid,,60.46,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Trillium,Medicaid,,120.31,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Trillium,Medicaid,,22.85,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Trillium,Medicaid,,61.06,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Trillium,Medicaid,,22.04,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Trillium,Medicaid,,40.44,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Trillium,Medicaid,,32.55,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Trillium,Medicaid,,22.85,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Trillium,Medicaid,,26.89,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Trillium,Medicaid,,22.85,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Trillium,Medicaid,,88.56,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Trillium,Medicaid,,10.11,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Trillium,Medicaid,,83.51,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Trillium,Medicaid,,58.23,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Trillium,Medicaid,,38.62,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Trillium,Medicaid,,54.39,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Trillium,Medicaid,GP,13.55,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Trillium,Medicaid,GP,15.16,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Trillium,Medicaid,GP,2.43,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Trillium,Medicaid,GP,24.47,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,GP,9.91,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Trillium,Medicaid,GP,3.24,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Trillium,Medicaid,GP,30.94,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Trillium,Medicaid,GP,32.96,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Trillium,Medicaid,GP,25.88,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,GP,22.24,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,GP,11.93,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Trillium,Medicaid,GP,33.16,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Trillium,Medicaid,GP,32.35,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Trillium,Medicaid,GP,29.12,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,GP,33.36,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Trillium,Medicaid,GP,28.11,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Trillium,Medicaid,GP,40.84,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,GP,23.66,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,GP,26.08,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Trillium,Medicaid,GP,30.53,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Trillium,Medicaid,GP,9.50,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,GP,23.86,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Trillium,Medicaid,GP,17.19,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,GP,26.08,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Trillium,Medicaid,GP,20.02,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Trillium,Medicaid,GP,36.40,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Trillium,Medicaid,GP,36.40,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,GP,18.40,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,GP,18.40,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,GP,18.00,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Trillium,Medicaid,GP,25.68,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Trillium,Medicaid,GP,26.29,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Trillium,Medicaid,GP,14.15,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Trillium,Medicaid,GP,6.07,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Trillium,Medicaid,GP,61.87,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Trillium,Medicaid,GP,85.53,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Trillium,Medicaid,GP,87.75,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Trillium,Medicaid,GP,58.23,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,GO,18.40,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,GO,23.66,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,GO,26.08,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,GO,23.86,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Trillium,Medicaid,GO,14.15,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,GO,26.08,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Trillium,Medicaid,GO,20.02,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Trillium,Medicaid,GO,2.43,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Trillium,Medicaid,GO,32.96,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Trillium,Medicaid,GO,25.88,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,GO,12.54,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Trillium,Medicaid,GO,33.16,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Trillium,Medicaid,GO,32.35,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Trillium,Medicaid,GO,29.12,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,GO,33.36,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,GO,9.91,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Trillium,Medicaid,GO,45.29,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Trillium,Medicaid,GO,30.73,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Trillium,Medicaid,GO,25.68,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Trillium,Medicaid,GO,15.16,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Trillium,Medicaid,GO,64.30,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Trillium,Medicaid,GO,81.49,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Trillium,Medicaid,GO,83.91,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Trillium,Medicaid,GO,40.84,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Trillium,Medicaid,GN,71.98,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Trillium,Medicaid,GN,67.94,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Trillium,Medicaid,GN,37.81,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Trillium,Medicaid,GN,54.39,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Trillium,Medicaid,GN,40.44,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Trillium,Medicaid,GN,63.69,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Trillium,Medicaid,GN,25.88,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Trillium,Medicaid,GN,14.15,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Trillium,Medicaid,GN,17.19,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Trillium,Medicaid,GN,20.02,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Trillium,Medicaid,GN,46.30,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,GN,27.50,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Trillium,Medicaid,GN,132.44,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Trillium,Medicaid,GN,52.37,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Trillium,Medicaid,GN,13.75,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Trillium,Medicaid,GN,26.29,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Trillium,Medicaid,GN,14.15,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Trillium,Medicaid,GN,6.07,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Trillium,Medicaid,GN,43.27,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Trillium,Medicaid,GN,46.30,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Trillium,Medicaid,GN,21.64,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Trillium,Medicaid,GN,71.38,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Trillium,Medicaid,GN,111.01,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Trillium,Medicaid,GN,119.50,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Trillium,Medicaid,,174.70,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Trillium,Medicaid,,111.01,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Trillium,Medicaid,,178.95,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Trillium,Medicaid,,101.91,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Trillium,Medicaid,,150.64,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Trillium,Medicaid,,759.46,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Trillium,Medicaid,,8.69,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Trillium,Medicaid,,29.93,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Trillium,Medicaid,,106.16,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Trillium,Medicaid,,105.75,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Trillium,Medicaid,,113.84,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Trillium,Medicaid,,76.23,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Trillium,Medicaid,,76.23,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Trillium,Medicaid,,274.39,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Trillium,Medicaid,,84.52,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Trillium,Medicaid,,164.19,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Trillium,Medicaid,,114.65,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Trillium,Medicaid,,96.25,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Trillium,Medicaid,,131.83,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Trillium,Medicaid,,92.61,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Trillium,Medicaid,,31.54,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Trillium,Medicaid,,36.40,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Trillium,Medicaid,,236.57,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Trillium,Medicaid,,26.49,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Trillium,Medicaid,,311.79,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Trillium,Medicaid,,311.79,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Trillium,Medicaid,,53.38,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Trillium,Medicaid,,53.38,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Trillium,Medicaid,,404.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Trillium,Medicaid,,631.47,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Trillium,Medicaid,,141.54,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Trillium,Medicaid,,459.40,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Trillium,Medicaid,,168.03,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Trillium,Medicaid,,102.11,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Trillium,Medicaid,,44.89,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Trillium,Medicaid,,67.33,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Trillium,Medicaid,,68.34,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Trillium,Medicaid,,37.41,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Trillium,Medicaid,,1221.89,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Trillium,Medicaid,,1221.89,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Trillium,Medicaid,,205.64,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Trillium,Medicaid,,849.24,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Trillium,Medicaid,,849.24,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Trillium,Medicaid,,862.59,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Trillium,Medicaid,,233.34,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Trillium,Medicaid,,111.61,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Trillium,Medicaid,,114.24,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Trillium,Medicaid,,272.97,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Trillium,Medicaid,,194.72,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Trillium,Medicaid,,111.21,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Trillium,Medicaid,,194.72,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Trillium,Medicaid,,212.51,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Trillium,Medicaid,,91.60,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Trillium,Medicaid,,257.00,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Trillium,Medicaid,,234.35,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Trillium,Medicaid,,147.20,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Trillium,Medicaid,,97.26,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Trillium,Medicaid,,227.68,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Trillium,Medicaid,,63.90,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Trillium,Medicaid,,153.27,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Trillium,Medicaid,,25.07,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Trillium,Medicaid,,193.71,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Trillium,Medicaid,,115.46,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Trillium,Medicaid,,93.82,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Trillium,Medicaid,,108.99,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Trillium,Medicaid,,101.71,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Trillium,Medicaid,,317.86,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Trillium,Medicaid,,81.89,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Trillium,Medicaid,,317.86,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Trillium,Medicaid,,81.89,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Trillium,Medicaid,,75.42,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Trillium,Medicaid,,136.28,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Trillium,Medicaid,,166.21,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Trillium,Medicaid,,172.88,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Trillium,Medicaid,,179.55,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Trillium,Medicaid,,108.99,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Trillium,Medicaid,,86.74,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Trillium,Medicaid,,59.65,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Trillium,Medicaid,,88.36,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Trillium,Medicaid,,51.16,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Trillium,Medicaid,,124.15,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Trillium,Medicaid,,124.15,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Trillium,Medicaid,,110.60,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Trillium,Medicaid,,42.87,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Trillium,Medicaid,,42.87,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Trillium,Medicaid,,42.87,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Trillium,Medicaid,,42.87,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Trillium,Medicaid,,80.88,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Trillium,Medicaid,,80.88,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Trillium,Medicaid,,80.88,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Trillium,Medicaid,,53.99,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Trillium,Medicaid,,74.01,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Trillium,Medicaid,,74.01,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Trillium,Medicaid,,330.60,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Trillium,Medicaid,,330.60,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Trillium,Medicaid,,92.41,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Trillium,Medicaid,,92.00,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Trillium,Medicaid,,301.48,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Trillium,Medicaid,,308.56,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Trillium,Medicaid,,171.47,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Trillium,Medicaid,,249.31,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Trillium,Medicaid,,85.53,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Trillium,Medicaid,,201.59,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Trillium,Medicaid,,93.62,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Trillium,Medicaid,,110.00,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Trillium,Medicaid,,265.89,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Trillium,Medicaid,,321.09,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Trillium,Medicaid,,394.29,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Trillium,Medicaid,,559.49,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Trillium,Medicaid,,614.49,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Trillium,Medicaid,,779.68,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Trillium,Medicaid,,458.59,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Trillium,Medicaid,,513.59,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Trillium,Medicaid,,577.89,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Trillium,Medicaid,,917.18,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Trillium,Medicaid,,1027.18,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Trillium,Medicaid,,1146.47,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Trillium,Medicaid,,210.69,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Trillium,Medicaid,,45.49,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Trillium,Medicaid,,59.04,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Trillium,Medicaid,,59.45,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Trillium,Medicaid,,9.71,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Trillium,Medicaid,,9.71,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Trillium,Medicaid,,21.43,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Trillium,Medicaid,,156.71,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Trillium,Medicaid,,156.71,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Trillium,Medicaid,,156.71,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Trillium,Medicaid,,156.71,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Trillium,Medicaid,,156.71,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Trillium,Medicaid,,156.71,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Trillium,Medicaid,GP,13.48,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Trillium,Medicaid,,96.85,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Trillium,Medicaid,,554.84,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Trillium,Medicaid,,554.84,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Trillium,Medicaid,,783.52,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Trillium,Medicaid,,219.39,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Trillium,Medicaid,,219.39,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Trillium,Medicaid,,498.22,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Trillium,Medicaid,,210.09,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Trillium,Medicaid,,210.09,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Trillium,Medicaid,,645.02,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Trillium,Medicaid,,86.95,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Trillium,Medicaid,,97.06,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Trillium,Medicaid,,108.38,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Trillium,Medicaid,,92.61,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Trillium,Medicaid,,24.06,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,,26.08,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,,26.08,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Trillium,Medicaid,,42.06,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Trillium,Medicaid,,32.96,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Trillium,Medicaid,,62.08,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Trillium,Medicaid,,105.14,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Trillium,Medicaid,,101.91,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Trillium,Medicaid,,124.96,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Trillium,Medicaid,,82.70,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Trillium,Medicaid,,155.69,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Trillium,Medicaid,,155.69,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Trillium,Medicaid,,129.00,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Trillium,Medicaid,,121.93,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Trillium,Medicaid,,182.38,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Trillium,Medicaid,,36.80,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Trillium,Medicaid,,30.73,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Trillium,Medicaid,,56.62,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Trillium,Medicaid,,78.45,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Trillium,Medicaid,,153.47,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Trillium,Medicaid,,153.47,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Trillium,Medicaid,,464.05,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Trillium,Medicaid,,122.74,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Trillium,Medicaid,,376.70,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Trillium,Medicaid,,376.70,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Trillium,Medicaid,,431.09,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Trillium,Medicaid,,108.38,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Trillium,Medicaid,,209.68,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Trillium,Medicaid,,2528.92,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Trillium,Medicaid,,307.34,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Trillium,Medicaid,,390.85,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Trillium,Medicaid,,168.63,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Trillium,Medicaid,,175.71,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Trillium,Medicaid,,187.03,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Trillium,Medicaid,,310.98,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Trillium,Medicaid,,387.82,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Trillium,Medicaid,,1976.30,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Trillium,Medicaid,,133.45,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Trillium,Medicaid,,133.45,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Trillium,Medicaid,,644.82,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Trillium,Medicaid,,644.82,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Trillium,Medicaid,,308.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Trillium,Medicaid,,308.96,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Trillium,Medicaid,,349.20,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Trillium,Medicaid,,433.11,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Trillium,Medicaid,,433.11,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Trillium,Medicaid,,282.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Trillium,Medicaid,,282.47,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Trillium,Medicaid,,125.57,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Trillium,Medicaid,,125.57,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Trillium,Medicaid,,145.58,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Trillium,Medicaid,,145.58,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Trillium,Medicaid,,75.42,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Trillium,Medicaid,,452.93,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Trillium,Medicaid,JW,26.69,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Trillium,Medicaid,,118.49,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Trillium,Medicaid,,100.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Trillium,Medicaid,,122.13,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Trillium,Medicaid,,100.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Trillium,Medicaid,,118.49,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Trillium,Medicaid,,166.21,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Trillium,Medicaid,,275.80,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Trillium,Medicaid,,71.17,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Trillium,Medicaid,,796.87,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Trillium,Medicaid,,796.87,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Trillium,Medicaid,,796.87,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Trillium,Medicaid,,796.87,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Trillium,Medicaid,,394.29,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Trillium,Medicaid,,394.29,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Trillium,Medicaid,,627.43,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Trillium,Medicaid,,627.43,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Trillium,Medicaid,,348.39,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Trillium,Medicaid,,431.09,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Trillium,Medicaid,,566.16,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Trillium,Medicaid,,109.79,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Trillium,Medicaid,,886.65,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Trillium,Medicaid,,980.67,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Trillium,Medicaid,,1159.41,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Trillium,Medicaid,,162.57,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Trillium,Medicaid,,316.44,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Trillium,Medicaid,,316.44,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Trillium,Medicaid,,388.43,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Trillium,Medicaid,,343.94,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Trillium,Medicaid,,117.68,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Trillium,Medicaid,,458.59,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Trillium,Medicaid,,255.78,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Trillium,Medicaid,,471.73,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Trillium,Medicaid,,471.73,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Trillium,Medicaid,,413.90,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Trillium,Medicaid,,269.94,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Trillium,Medicaid,,171.26,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Trillium,Medicaid,,360.12,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Trillium,Medicaid,,360.12,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Trillium,Medicaid,,343.34,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Trillium,Medicaid,,279.24,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Trillium,Medicaid,,279.24,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Trillium,Medicaid,,362.75,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Trillium,Medicaid,,362.75,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Trillium,Medicaid,,832.86,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Trillium,Medicaid,,832.86,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Trillium,Medicaid,,702.64,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Trillium,Medicaid,,702.64,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Trillium,Medicaid,,103.53,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Trillium,Medicaid,,120.11,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Trillium,Medicaid,52,222.42,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Trillium,Medicaid,,153.47,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Trillium,Medicaid,,143.76,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Trillium,Medicaid,,295.41,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Trillium,Medicaid,,25.68,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Trillium,Medicaid,,185.82,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Trillium,Medicaid,,185.82,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Trillium,Medicaid,,75.42,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Trillium,Medicaid,,64.10,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Trillium,Medicaid,,140.93,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Trillium,Medicaid,,281.66,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Trillium,Medicaid,,480.23,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Trillium,Medicaid,,640.37,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Trillium,Medicaid,,811.02,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Trillium,Medicaid,,267.71,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Trillium,Medicaid,,244.06,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Trillium,Medicaid,,72.99,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Trillium,Medicaid,,59.85,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Trillium,Medicaid,,38.22,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Trillium,Medicaid,,31.54,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Trillium,Medicaid,,31.54,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Trillium,Medicaid,,553.22,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Trillium,Medicaid,,40.64,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Trillium,Medicaid,,50.35,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Trillium,Medicaid,,48.53,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Trillium,Medicaid,,64.10,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Trillium,Medicaid,,80.68,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Trillium,Medicaid,,75.02,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Trillium,Medicaid,,96.05,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Trillium,Medicaid,,36.60,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Trillium,Medicaid,,45.90,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Trillium,Medicaid,,53.99,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Trillium,Medicaid,,50.55,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Trillium,Medicaid,,82.09,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Trillium,Medicaid,,87.96,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Trillium,Medicaid,,88.36,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Trillium,Medicaid,,80.27,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Trillium,Medicaid,,36.60,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Trillium,Medicaid,,51.36,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Trillium,Medicaid,,78.45,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Trillium,Medicaid,,98.88,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Trillium,Medicaid,,13.35,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Trillium,Medicaid,,21.43,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Trillium,Medicaid,,35.59,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Trillium,Medicaid,,52.57,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Trillium,Medicaid,,69.35,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Trillium,Medicaid,,46.71,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Trillium,Medicaid,,64.10,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Trillium,Medicaid,,96.05,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Trillium,Medicaid,,116.47,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Trillium,Medicaid,,27.70,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Trillium,Medicaid,,22.65,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Trillium,Medicaid,,9.71,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Trillium,Medicaid,,26.29,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Trillium,Medicaid,,5.05,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Trillium,Medicaid,JW,24.87,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Trillium,Medicaid,,24.87,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,JW,19.21,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Trillium,Medicaid,,28.71,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Trillium,Medicaid,,55.60,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Trillium,Medicaid,,40.44,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Trillium,Medicaid,JW,40.44,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Trillium,Medicaid,,92.00,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Trillium,Medicaid,,184.20,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Trillium,Medicaid,JW,184.20,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Trillium,Medicaid,JW,92.00,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Trillium,Medicaid,,199.77,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Trillium,Medicaid,JW,199.77,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Trillium,Medicaid,JW,55.20,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Trillium,Medicaid,,115.46,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Trillium,Medicaid,,52.98,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Trillium,Medicaid,,556.86,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Trillium,Medicaid,,245.88,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Trillium,Medicaid,,124.56,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Trillium,Medicaid,JW,556.86,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Trillium,Medicaid,JW,245.88,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Trillium,Medicaid,JW,124.56,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Trillium,Medicaid,,568.79,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Trillium,Medicaid,,24.87,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Trillium,Medicaid,,69.15,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Trillium,Medicaid,JW,69.15,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Trillium,Medicaid,,312.60,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Trillium,Medicaid,,625.61,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Trillium,Medicaid,JW,312.60,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Trillium,Medicaid,,86.54,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Trillium,Medicaid,JW,86.54,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Trillium,Medicaid,JW,97.66,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Trillium,Medicaid,,2.02,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Trillium,Medicaid,,505.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Trillium,Medicaid,JW,505.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Trillium,Medicaid,,409.45,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Trillium,Medicaid,JW,409.45,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Trillium,Medicaid,,345.36,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Trillium,Medicaid,JW,345.36,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,JW,13.14,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Trillium,Medicaid,,499.23,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Trillium,Medicaid,,141.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Trillium,Medicaid,,141.14,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Trillium,Medicaid,,124.35,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Trillium,Medicaid,,124.35,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Trillium,Medicaid,,80.68,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Trillium,Medicaid,,80.68,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Trillium,Medicaid,JW,477.80,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Trillium,Medicaid,JW,115.46,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Trillium,Medicaid,JW,52.98,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Trillium,Medicaid,,63.29,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Trillium,Medicaid,JW,63.29,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Trillium,Medicaid,,318.46,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Trillium,Medicaid,JW,318.46,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Trillium,Medicaid,,253.15,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Trillium,Medicaid,JW,253.15,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Trillium,Medicaid,,129.61,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Trillium,Medicaid,JW,129.61,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Trillium,Medicaid,,68.75,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Trillium,Medicaid,JW,68.75,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Trillium,Medicaid,,55.00,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Trillium,Medicaid,JW,55.00,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Trillium,Medicaid,,518.04,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Trillium,Medicaid,,59.65,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Trillium,Medicaid,,128.80,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Trillium,Medicaid,,128.80,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Trillium,Medicaid,,128.80,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Trillium,Medicaid,,128.80,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Trillium,Medicaid,,54.59,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Trillium,Medicaid,,857.93,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Trillium,Medicaid,,36.60,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Trillium,Medicaid,,49.74,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Trillium,Medicaid,,521.07,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Trillium,Medicaid,,42.26,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Trillium,Medicaid,,61.27,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Trillium,Medicaid,,399.55,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Trillium,Medicaid,,399.55,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Trillium,Medicaid,,87.35,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Trillium,Medicaid,,87.35,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Trillium,Medicaid,,68.14,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Trillium,Medicaid,,56.62,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Trillium,Medicaid,,54.39,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Trillium,Medicaid,,1896.43,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Trillium,Medicaid,,225.05,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Trillium,Medicaid,,209.68,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Trillium,Medicaid,,242.03,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Trillium,Medicaid,,162.97,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Trillium,Medicaid,,401.37,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Trillium,Medicaid,,401.37,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Trillium,Medicaid,,2360.89,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Trillium,Medicaid,,2360.89,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Trillium,Medicaid,,4107.90,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Trillium,Medicaid,,4107.90,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Trillium,Medicaid,,1747.01,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Trillium,Medicaid,,1747.01,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Trillium,Medicaid,,3706.53,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Trillium,Medicaid,,3706.53,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Trillium,Medicaid,,5996.65,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Trillium,Medicaid,,5996.65,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Trillium,Medicaid,,54.39,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Trillium,Medicaid,,82.90,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Trillium,Medicaid,,120.11,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Trillium,Medicaid,,103.53,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Trillium,Medicaid,,155.90,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Trillium,Medicaid,,137.70,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Trillium,Medicaid,,783.52,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Trillium,Medicaid,,28.91,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Trillium,Medicaid,,63.69,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Trillium,Medicaid,,39.43,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Trillium,Medicaid,,63.69,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Trillium,Medicaid,,39.43,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Trillium,Medicaid,,63.69,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Trillium,Medicaid,,39.43,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Trillium,Medicaid,,104.13,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,,33.36,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Trillium,Medicaid,,191.89,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Trillium,Medicaid,,97.86,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Trillium,Medicaid,,25.88,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Trillium,Medicaid,,28.51,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Trillium,Medicaid,,31.95,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Trillium,Medicaid,,18.60,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Trillium,Medicaid,,18.60,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Trillium,Medicaid,,42.87,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Trillium,Medicaid,,82.90,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Trillium,Medicaid,,104.13,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Trillium,Medicaid,,30.33,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Trillium,Medicaid,,17.19,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Trillium,Medicaid,,26.89,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Trillium,Medicaid,,104.13,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Trillium,Medicaid,,8088.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Trillium,Medicaid,,157.11,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Trillium,Medicaid,,1774.91,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Trillium,Medicaid,,1774.91,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Trillium,Medicaid,,999.07,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Trillium,Medicaid,,59.04,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Trillium,Medicaid,,178.74,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Trillium,Medicaid,,41.45,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Trillium,Medicaid,,41.45,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Trillium,Medicaid,,196.13,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Trillium,Medicaid,,248.71,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Trillium,Medicaid,,65.51,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Trillium,Medicaid,,1265.57,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Trillium,Medicaid,,631.47,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Trillium,Medicaid,,98.27,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Trillium,Medicaid,,4170.17,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Trillium,Medicaid,,631.47,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Trillium,Medicaid,,170.25,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Trillium,Medicaid,,472.34,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Trillium,Medicaid,,468.50,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Trillium,Medicaid,,469.51,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Trillium,Medicaid,,2412.04,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Trillium,Medicaid,,105.95,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Trillium,Medicaid,,115.86,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Trillium,Medicaid,,269.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Trillium,Medicaid,,517.83,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Trillium,Medicaid,,517.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Trillium,Medicaid,,383.17,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Trillium,Medicaid,,383.17,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Trillium,Medicaid,,698.80,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Trillium,Medicaid,,698.80,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Trillium,Medicaid,,517.83,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Trillium,Medicaid,,517.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Trillium,Medicaid,,1048.81,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Trillium,Medicaid,,249.72,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Trillium,Medicaid,,211.91,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Trillium,Medicaid,,142.96,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Trillium,Medicaid,,111.21,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Trillium,Medicaid,,89.37,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Trillium,Medicaid,,94.23,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Trillium,Medicaid,JW,249.72,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Trillium,Medicaid,JW,211.91,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Trillium,Medicaid,JW,142.96,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Trillium,Medicaid,JW,111.21,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Trillium,Medicaid,JW,89.37,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Trillium,Medicaid,JW,94.23,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Trillium,Medicaid,,420.17,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Trillium,Medicaid,,36.19,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Trillium,Medicaid,,161.15,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Trillium,Medicaid,,199.77,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Trillium,Medicaid,,289.55,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Trillium,Medicaid,,179.15,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Trillium,Medicaid,,36.19,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Trillium,Medicaid,,369.62,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Trillium,Medicaid,,524.51,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Trillium,Medicaid,,191.08,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Trillium,Medicaid,,582.94,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Trillium,Medicaid,,193.30,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Trillium,Medicaid,,179.15,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Trillium,Medicaid,,283.48,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Trillium,Medicaid,,439.58,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Trillium,Medicaid,,855.71,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Trillium,Medicaid,,3868.49,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Trillium,Medicaid,,86.74,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Trillium,Medicaid,,91.39,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Trillium,Medicaid,,81.08,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Trillium,Medicaid,,134.46,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Trillium,Medicaid,,64.30,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Trillium,Medicaid,,61.67,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Trillium,Medicaid,,65.51,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Trillium,Medicaid,,110.20,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Trillium,Medicaid,,71.17,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Trillium,Medicaid,,97.26,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Trillium,Medicaid,,121.52,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Trillium,Medicaid,,79.67,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Trillium,Medicaid,,89.37,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Trillium,Medicaid,,101.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Trillium,Medicaid,,30.73,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Trillium,Medicaid,,54.59,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Trillium,Medicaid,,24.26,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Trillium,Medicaid,,101.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Trillium,Medicaid,,135.68,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Trillium,Medicaid,,36.19,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Trillium,Medicaid,,61.06,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Trillium,Medicaid,,73.20,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Trillium,Medicaid,,97.66,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Trillium,Medicaid,,118.08,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Trillium,Medicaid,,218.17,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Trillium,Medicaid,,118.29,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Trillium,Medicaid,,61.67,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Trillium,Medicaid,,89.37,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Trillium,Medicaid,,100.29,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Trillium,Medicaid,,133.45,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Trillium,Medicaid,,187.84,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Trillium,Medicaid,,88.36,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Trillium,Medicaid,,66.12,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Trillium,Medicaid,,114.04,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Trillium,Medicaid,,99.48,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Trillium,Medicaid,,143.56,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Trillium,Medicaid,,176.93,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Trillium,Medicaid,,117.68,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Trillium,Medicaid,,68.95,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Trillium,Medicaid,,109.39,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Trillium,Medicaid,,74.61,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Trillium,Medicaid,,74.41,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Trillium,Medicaid,,244.86,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Trillium,Medicaid,,152.05,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Trillium,Medicaid,,270.14,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Trillium,Medicaid,,382.56,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Trillium,Medicaid,,420.78,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Trillium,Medicaid,,85.94,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Trillium,Medicaid,,77.24,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Trillium,Medicaid,,92.81,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Trillium,Medicaid,,93.42,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Trillium,Medicaid,,257.00,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Trillium,Medicaid,,105.55,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Trillium,Medicaid,,88.97,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Trillium,Medicaid,,82.09,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Trillium,Medicaid,,89.37,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Trillium,Medicaid,,98.47,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Trillium,Medicaid,,76.63,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Trillium,Medicaid,,60.26,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Trillium,Medicaid,,75.83,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Trillium,Medicaid,,70.16,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Trillium,Medicaid,,132.04,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Trillium,Medicaid,,87.15,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Trillium,Medicaid,,79.67,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Trillium,Medicaid,,55.81,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Trillium,Medicaid,,170.05,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Trillium,Medicaid,,86.34,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Trillium,Medicaid,,75.02,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Trillium,Medicaid,,97.46,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Trillium,Medicaid,,63.90,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Trillium,Medicaid,,76.84,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Trillium,Medicaid,,71.58,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Trillium,Medicaid,,44.08,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Trillium,Medicaid,,89.98,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Trillium,Medicaid,,93.62,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Trillium,Medicaid,,76.84,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Trillium,Medicaid,,107.17,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Trillium,Medicaid,,93.62,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Trillium,Medicaid,,81.08,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Trillium,Medicaid,,65.51,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Trillium,Medicaid,,86.14,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,,100.09,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,,100.09,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,,100.09,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Trillium,Medicaid,,158.12,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Trillium,Medicaid,,65.11,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Trillium,Medicaid,,49.94,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Trillium,Medicaid,,213.32,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Trillium,Medicaid,,147.20,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Trillium,Medicaid,,179.55,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Trillium,Medicaid,,100.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Trillium,Medicaid,,106.96,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Trillium,Medicaid,,199.77,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Trillium,Medicaid,,210.49,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Trillium,Medicaid,,217.16,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Trillium,Medicaid,,108.58,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Trillium,Medicaid,,19.82,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Trillium,Medicaid,,117.28,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Trillium,Medicaid,,130.01,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Trillium,Medicaid,,165.40,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Trillium,Medicaid,,134.67,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Trillium,Medicaid,,163.78,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Trillium,Medicaid,,422.19,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Trillium,Medicaid,,939.22,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Trillium,Medicaid,,723.27,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Trillium,Medicaid,,37.41,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Trillium,Medicaid,,276.61,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Trillium,Medicaid,,282.07,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Trillium,Medicaid,,818.30,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Trillium,Medicaid,,1161.84,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Trillium,Medicaid,,268.12,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Trillium,Medicaid,,520.06,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Trillium,Medicaid,,208.47,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Trillium,Medicaid,,243.04,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Trillium,Medicaid,,325.14,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Trillium,Medicaid,,162.57,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Trillium,Medicaid,,326.76,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Trillium,Medicaid,,195.53,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Trillium,Medicaid,,161.56,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Trillium,Medicaid,,223.63,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Trillium,Medicaid,,471.73,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Trillium,Medicaid,,278.23,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Trillium,Medicaid,,41.25,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Trillium,Medicaid,,35.38,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Trillium,Medicaid,,243.45,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Trillium,Medicaid,,155.90,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Trillium,Medicaid,,213.73,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Trillium,Medicaid,,72.39,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Trillium,Medicaid,,192.70,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Trillium,Medicaid,,34.17,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Trillium,Medicaid,,189.26,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Trillium,Medicaid,,61.87,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Trillium,Medicaid,,68.95,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Trillium,Medicaid,,28.91,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Trillium,Medicaid,,150.44,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Trillium,Medicaid,,133.86,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Trillium,Medicaid,,132.85,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Trillium,Medicaid,,65.31,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Trillium,Medicaid,,130.62,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Trillium,Medicaid,,69.96,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Trillium,Medicaid,,49.13,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Trillium,Medicaid,,54.19,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Trillium,Medicaid,,187.44,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Trillium,Medicaid,,61.87,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Trillium,Medicaid,,184.20,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Trillium,Medicaid,,58.84,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Trillium,Medicaid,,159.33,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Trillium,Medicaid,,473.75,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Trillium,Medicaid,,816.69,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Trillium,Medicaid,,674.94,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Trillium,Medicaid,,727.52,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Trillium,Medicaid,,411.48,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Trillium,Medicaid,,912.73,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Trillium,Medicaid,,912.73,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Trillium,Medicaid,,912.73,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Trillium,Medicaid,,617.32,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Trillium,Medicaid,,361.13,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Trillium,Medicaid,,283.89,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Trillium,Medicaid,,54.19,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Trillium,Medicaid,,75.62,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Trillium,Medicaid,,67.13,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Trillium,Medicaid,,168.03,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Trillium,Medicaid,,32.96,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Trillium,Medicaid,,101.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Trillium,Medicaid,,420.78,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Trillium,Medicaid,,124.76,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Trillium,Medicaid,,164.19,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Trillium,Medicaid,,174.09,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Trillium,Medicaid,,94.43,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Trillium,Medicaid,,99.89,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Trillium,Medicaid,,105.75,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Trillium,Medicaid,,153.27,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Trillium,Medicaid,,148.82,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Trillium,Medicaid,,218.17,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Trillium,Medicaid,,46.30,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Trillium,Medicaid,,87.35,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Trillium,Medicaid,,214.94,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Trillium,Medicaid,,124.35,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Trillium,Medicaid,,158.73,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Trillium,Medicaid,,7582.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Trillium,Medicaid,,43.88,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Trillium,Medicaid,,374.68,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Trillium,Medicaid,,455.56,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Trillium,Medicaid,,84.92,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Trillium,Medicaid,,111.21,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Trillium,Medicaid,,109.19,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Trillium,Medicaid,,81.08,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Trillium,Medicaid,,120.51,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Trillium,Medicaid,,100.49,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Trillium,Medicaid,,152.05,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Trillium,Medicaid,,117.48,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Trillium,Medicaid,,187.64,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Trillium,Medicaid,,279.44,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Trillium,Medicaid,,54.59,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Trillium,Medicaid,,167.62,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Trillium,Medicaid,,69.35,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Trillium,Medicaid,,83.51,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Trillium,Medicaid,,274.39,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Trillium,Medicaid,,136.89,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Trillium,Medicaid,,138.51,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Trillium,Medicaid,,223.23,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Trillium,Medicaid,,117.88,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Trillium,Medicaid,,589.82,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Trillium,Medicaid,,302.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Trillium,Medicaid,,221.00,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Trillium,Medicaid,,197.35,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Trillium,Medicaid,,144.98,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Trillium,Medicaid,,377.31,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Trillium,Medicaid,,205.03,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Trillium,Medicaid,,420.37,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Trillium,Medicaid,,323.92,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Trillium,Medicaid,,463.04,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Trillium,Medicaid,,323.92,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Trillium,Medicaid,,480.83,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Trillium,Medicaid,,552.61,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Trillium,Medicaid,,173.08,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Trillium,Medicaid,,316.85,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Trillium,Medicaid,,248.71,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Trillium,Medicaid,,453.94,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Trillium,Medicaid,,210.69,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Trillium,Medicaid,,232.13,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Trillium,Medicaid,,253.76,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Trillium,Medicaid,,360.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Trillium,Medicaid,,533.00,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Trillium,Medicaid,,533.00,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Trillium,Medicaid,,504.89,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Trillium,Medicaid,,783.73,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Trillium,Medicaid,,979.46,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Trillium,Medicaid,,168.03,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Trillium,Medicaid,,290.97,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Trillium,Medicaid,,261.65,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Trillium,Medicaid,,321.90,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Trillium,Medicaid,,502.67,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Trillium,Medicaid,,157.31,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Trillium,Medicaid,,296.02,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Trillium,Medicaid,,174.70,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Trillium,Medicaid,,220.40,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Trillium,Medicaid,,161.56,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Trillium,Medicaid,,234.55,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Trillium,Medicaid,,267.11,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Trillium,Medicaid,,234.55,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Trillium,Medicaid,,325.74,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Trillium,Medicaid,,257.00,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Trillium,Medicaid,,186.63,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Trillium,Medicaid,,473.35,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Trillium,Medicaid,,595.07,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Trillium,Medicaid,,56.01,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Trillium,Medicaid,,20.02,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Trillium,Medicaid,,410.47,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Trillium,Medicaid,,199.77,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Trillium,Medicaid,,42.06,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Trillium,Medicaid,,564.95,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Trillium,Medicaid,,2526.08,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Trillium,Medicaid,,332.21,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Trillium,Medicaid,,104.94,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Trillium,Medicaid,,411.07,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Trillium,Medicaid,,95.03,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Trillium,Medicaid,,2501.42,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Trillium,Medicaid,,136.89,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Trillium,Medicaid,,0.20422,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Trillium,Medicaid,,17.59,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Trillium,Medicaid,,177.53,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Trillium,Medicaid,,24.06,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Trillium,Medicaid,,118.08,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Trillium,Medicaid,,65.31,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Trillium,Medicaid,,8.90,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Trillium,Medicaid,,1067.62,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Trillium,Medicaid,,1.21,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Trillium,Medicaid,,131.23,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Trillium,Medicaid,,24.67,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Trillium,Medicaid,,8.49,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Trillium,Medicaid,,16.58,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Trillium,Medicaid,,51.36,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Trillium,Medicaid,,1224.93,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Trillium,Medicaid,,37.00,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Trillium,Medicaid,,217.37,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Trillium,Medicaid,,61.67,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Trillium,Medicaid,,288.74,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Trillium,Medicaid,,61.67,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Trillium,Medicaid,,407.64,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Trillium,Medicaid,,407.64,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Trillium,Medicaid,,271.55,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Trillium,Medicaid,,98.47,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Trillium,Medicaid,,87.96,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Trillium,Medicaid,,452.93,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Trillium,Medicaid,,324.53,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Trillium,Medicaid,,676.16,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Trillium,Medicaid,,676.16,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Trillium,Medicaid,,676.16,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Trillium,Medicaid,,264.68,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Trillium,Medicaid,,390.04,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Trillium,Medicaid,,216.15,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Trillium,Medicaid,,385.80,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Trillium,Medicaid,,248.71,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Trillium,Medicaid,,812.44,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Trillium,Medicaid,,669.28,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Trillium,Medicaid,,837.51,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Trillium,Medicaid,,837.51,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Trillium,Medicaid,,821.34,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Trillium,Medicaid,,208.87,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Trillium,Medicaid,,227.68,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Trillium,Medicaid,,65.51,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Trillium,Medicaid,,512.98,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Trillium,Medicaid,,260.64,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Trillium,Medicaid,,230.10,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Trillium,Medicaid,,256.59,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Trillium,Medicaid,,457.17,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Trillium,Medicaid,,539.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Trillium,Medicaid,,659.98,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Trillium,Medicaid,,495.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Trillium,Medicaid,,594.87,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Trillium,Medicaid,,663.62,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Trillium,Medicaid,,512.78,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Trillium,Medicaid,,626.01,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Trillium,Medicaid,,708.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Trillium,Medicaid,,522.48,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Trillium,Medicaid,,623.18,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Trillium,Medicaid,,710.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Trillium,Medicaid,,846.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Trillium,Medicaid,,802.94,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Trillium,Medicaid,,471.33,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Trillium,Medicaid,,591.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Trillium,Medicaid,,695.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Trillium,Medicaid,,783.32,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Trillium,Medicaid,,580.72,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Trillium,Medicaid,,731.56,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Trillium,Medicaid,,748.95,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Trillium,Medicaid,,453.33,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Trillium,Medicaid,,551.80,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Trillium,Medicaid,,643.80,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Trillium,Medicaid,,530.17,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Trillium,Medicaid,,644.82,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Trillium,Medicaid,,752.79,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Trillium,Medicaid,,610.24,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Trillium,Medicaid,,463.44,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Trillium,Medicaid,,579.30,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Trillium,Medicaid,,620.96,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Trillium,Medicaid,,593.25,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Trillium,Medicaid,,813.25,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Trillium,Medicaid,,878.15,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Trillium,Medicaid,,803.54,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Trillium,Medicaid,,507.72,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Trillium,Medicaid,,653.31,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Trillium,Medicaid,,856.32,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Trillium,Medicaid,,996.24,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Trillium,Medicaid,,504.29,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Trillium,Medicaid,,641.78,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Trillium,Medicaid,,759.87,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Trillium,Medicaid,,1488.39,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Trillium,Medicaid,,6968.42,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Trillium,Medicaid,,1082.78,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Trillium,Medicaid,,1289.83,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Trillium,Medicaid,,1499.31,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Trillium,Medicaid,,264.68,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Trillium,Medicaid,,820.73,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Trillium,Medicaid,,802.94,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Trillium,Medicaid,,846.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Trillium,Medicaid,,591.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Trillium,Medicaid,,566.16,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Trillium,Medicaid,,96.45,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Trillium,Medicaid,,237.18,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Trillium,Medicaid,,269.33,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Trillium,Medicaid,,269.33,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Trillium,Medicaid,,293.19,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Trillium,Medicaid,,356.68,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Trillium,Medicaid,,356.68,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Trillium,Medicaid,,384.38,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Trillium,Medicaid,,96.05,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Trillium,Medicaid,,68.14,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Trillium,Medicaid,,6968.42,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Trillium,Medicaid,,6968.42,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Trillium,Medicaid,,6362.43,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Trillium,Medicaid,,54.39,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Trillium,Medicaid,,147.20,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Trillium,Medicaid,,127.18,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Trillium,Medicaid,,402.98,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Trillium,Medicaid,,1032.23,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Trillium,Medicaid,,109.79,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Trillium,Medicaid,,280.45,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Trillium,Medicaid,,177.94,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Trillium,Medicaid,,11636.81,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Trillium,Medicaid,,982.09,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Trillium,Medicaid,,982.09,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Trillium,Medicaid,,5971.98,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Trillium,Medicaid,,224.44,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Trillium,Medicaid,,606.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Trillium,Medicaid,,31.34,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Trillium,Medicaid,,31.34,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Trillium,Medicaid,,85.13,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Trillium,Medicaid,,590.63,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Trillium,Medicaid,,127.18,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Trillium,Medicaid,,92.20,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Trillium,Medicaid,,46.91,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Trillium,Medicaid,,40.64,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Trillium,Medicaid,,97.26,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Trillium,Medicaid,,224.24,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Trillium,Medicaid,,92.61,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Trillium,Medicaid,,57.63,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Trillium,Medicaid,,283.08,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Trillium,Medicaid,,319.88,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Trillium,Medicaid,,319.88,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Trillium,Medicaid,,471.13,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Trillium,Medicaid,,471.13,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Trillium,Medicaid,,62.88,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Trillium,Medicaid,,62.88,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Trillium,Medicaid,,162.57,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Trillium,Medicaid,,162.57,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Trillium,Medicaid,,145.99,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Trillium,Medicaid,,116.67,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Trillium,Medicaid,,116.67,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Trillium,Medicaid,,954.38,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Trillium,Medicaid,,682.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Trillium,Medicaid,,143.97,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Trillium,Medicaid,,114.24,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Trillium,Medicaid,,285.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Trillium,Medicaid,,154.68,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Trillium,Medicaid,,261.24,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Trillium,Medicaid,,117.48,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Trillium,Medicaid,,257.81,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Trillium,Medicaid,,257.81,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Trillium,Medicaid,,236.17,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Trillium,Medicaid,,610.44,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Trillium,Medicaid,,610.44,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Trillium,Medicaid,,60.66,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Trillium,Medicaid,,392.87,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Trillium,Medicaid,,296.02,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Trillium,Medicaid,,168.63,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Trillium,Medicaid,,328.17,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Trillium,Medicaid,,357.89,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Trillium,Medicaid,,365.78,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Trillium,Medicaid,,365.78,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Trillium,Medicaid,,425.63,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Trillium,Medicaid,,425.63,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Trillium,Medicaid,,136.89,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Trillium,Medicaid,,136.89,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Trillium,Medicaid,,104.94,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Trillium,Medicaid,,138.30,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Trillium,Medicaid,,138.30,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Trillium,Medicaid,,544.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Trillium,Medicaid,,557.26,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Trillium,Medicaid,,557.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Trillium,Medicaid,,322.31,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Trillium,Medicaid,,322.31,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Trillium,Medicaid,,185.22,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Trillium,Medicaid,,185.22,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Trillium,Medicaid,,228.49,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Trillium,Medicaid,,228.49,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Trillium,Medicaid,,233.14,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Trillium,Medicaid,,233.14,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Trillium,Medicaid,,1022.93,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Trillium,Medicaid,,995.84,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Trillium,Medicaid,,160.75,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Trillium,Medicaid,,146.59,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Trillium,Medicaid,,165.40,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Trillium,Medicaid,,150.03,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Trillium,Medicaid,,454.34,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Trillium,Medicaid,,150.03,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Trillium,Medicaid,,752.79,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Trillium,Medicaid,,179.15,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Trillium,Medicaid,,138.71,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Trillium,Medicaid,,39.43,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Trillium,Medicaid,,107.77,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Trillium,Medicaid,,112.22,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Trillium,Medicaid,,119.30,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Trillium,Medicaid,,117.88,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Trillium,Medicaid,,134.46,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Trillium,Medicaid,,841.76,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Trillium,Medicaid,,430.28,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Trillium,Medicaid,,271.55,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Trillium,Medicaid,,296.02,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Trillium,Medicaid,,140.33,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Trillium,Medicaid,,118.69,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Trillium,Medicaid,,122.53,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Trillium,Medicaid,,178.74,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Trillium,Medicaid,,178.74,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Trillium,Medicaid,,2842.53,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Trillium,Medicaid,,2842.53,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Trillium,Medicaid,,2842.53,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Trillium,Medicaid,,1250.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Trillium,Medicaid,,2125.93,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Trillium,Medicaid,,2125.93,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Trillium,Medicaid,,2125.93,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Trillium,Medicaid,,2125.93,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Trillium,Medicaid,,2315.59,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Trillium,Medicaid,,2315.59,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Trillium,Medicaid,,1551.48,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Trillium,Medicaid,,1597.78,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Trillium,Medicaid,,1597.78,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Trillium,Medicaid,,970.56,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Trillium,Medicaid,,904.04,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Trillium,Medicaid,,1225.74,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Trillium,Medicaid,,1225.74,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Trillium,Medicaid,,1225.74,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Trillium,Medicaid,,888.47,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Trillium,Medicaid,,488.72,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Trillium,Medicaid,,500.44,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Trillium,Medicaid,,326.15,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Trillium,Medicaid,,160.14,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Trillium,Medicaid,,500.24,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Trillium,Medicaid,,76.63,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Trillium,Medicaid,,97.46,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Trillium,Medicaid,,57.02,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Trillium,Medicaid,,109.59,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Trillium,Medicaid,,1070.45,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Trillium,Medicaid,,258.21,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Trillium,Medicaid,,1515.29,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Trillium,Medicaid,,79.87,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Trillium,Medicaid,,331.61,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Trillium,Medicaid,,331.61,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Trillium,Medicaid,,431.90,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Trillium,Medicaid,,184.20,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Trillium,Medicaid,,622.17,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Trillium,Medicaid,,452.73,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Trillium,Medicaid,,108.18,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Trillium,Medicaid,,205.44,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Trillium,Medicaid,,779.28,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Trillium,Medicaid,,129.81,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Trillium,Medicaid,,162.16,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Trillium,Medicaid,,129.81,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Trillium,Medicaid,,140.53,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Trillium,Medicaid,,1070.45,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Trillium,Medicaid,,480.83,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Trillium,Medicaid,,505.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Trillium,Medicaid,,501.05,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Trillium,Medicaid,,128.60,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Trillium,Medicaid,,234.55,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Trillium,Medicaid,,35.38,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Trillium,Medicaid,,1272.04,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Trillium,Medicaid,,1570.49,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Trillium,Medicaid,,503.68,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Trillium,Medicaid,,59.45,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Trillium,Medicaid,,46.71,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Trillium,Medicaid,,42.06,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Trillium,Medicaid,,81.69,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Trillium,Medicaid,,82.50,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Trillium,Medicaid,,500.24,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Trillium,Medicaid,,40.84,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Trillium,Medicaid,,321.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Trillium,Medicaid,,909.29,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Trillium,Medicaid,,856.11,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Trillium,Medicaid,,590.63,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Trillium,Medicaid,,924.86,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Trillium,Medicaid,,213.32,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Trillium,Medicaid,,213.32,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Trillium,Medicaid,,297.44,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Trillium,Medicaid,,58.23,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Trillium,Medicaid,,58.23,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Trillium,Medicaid,,387.82,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Trillium,Medicaid,,387.82,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Trillium,Medicaid,,237.18,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Trillium,Medicaid,,507.72,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Trillium,Medicaid,,507.72,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Trillium,Medicaid,,411.27,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Trillium,Medicaid,,411.27,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Trillium,Medicaid,,351.42,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Trillium,Medicaid,,351.42,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Trillium,Medicaid,,320.08,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Trillium,Medicaid,,320.08,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Trillium,Medicaid,,332.82,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Trillium,Medicaid,,332.82,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Trillium,Medicaid,,345.76,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Trillium,Medicaid,,306.33,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Trillium,Medicaid,,306.33,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Trillium,Medicaid,,305.12,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Trillium,Medicaid,,305.12,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Trillium,Medicaid,,671.71,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Trillium,Medicaid,,671.71,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Trillium,Medicaid,,376.09,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Trillium,Medicaid,,376.09,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Trillium,Medicaid,,367.60,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Trillium,Medicaid,,367.60,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Trillium,Medicaid,,466.27,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Trillium,Medicaid,,74.41,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Trillium,Medicaid,,982.09,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Trillium,Medicaid,,44.48,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Trillium,Medicaid,,574.45,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Trillium,Medicaid,,604.58,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Trillium,Medicaid,,4071.70,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Trillium,Medicaid,,2164.75,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Trillium,Medicaid,,104.94,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Trillium,Medicaid,,236.17,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Trillium,Medicaid,,217.16,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Trillium,Medicaid,,140.12,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Trillium,Medicaid,,156.91,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Trillium,Medicaid,,1103.61,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Trillium,Medicaid,,750.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Trillium,Medicaid,,954.18,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Trillium,Medicaid,,782.31,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Trillium,Medicaid,,983.50,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Trillium,Medicaid,,806.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Trillium,Medicaid,,341.31,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Trillium,Medicaid,,115.86,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Trillium,Medicaid,,1508.82,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Trillium,Medicaid,,402.38,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Trillium,Medicaid,,301.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Trillium,Medicaid,,536.44,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Trillium,Medicaid,,5816.49,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Trillium,Medicaid,,846.61,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Trillium,Medicaid,,2685.01,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Trillium,Medicaid,,1789.07,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Trillium,Medicaid,,703.45,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Trillium,Medicaid,,250.93,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Trillium,Medicaid,,342.93,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Trillium,Medicaid,,342.93,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Trillium,Medicaid,,379.33,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Trillium,Medicaid,,379.33,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Trillium,Medicaid,,350.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Trillium,Medicaid,,350.21,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Trillium,Medicaid,,260.64,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Trillium,Medicaid,,148.21,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Trillium,Medicaid,,248.50,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Trillium,Medicaid,,1448.76,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Trillium,Medicaid,,362.14,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Trillium,Medicaid,,318.67,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Trillium,Medicaid,,374.88,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Trillium,Medicaid,,211.50,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Trillium,Medicaid,,725.09,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Trillium,Medicaid,,725.09,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Trillium,Medicaid,,526.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Trillium,Medicaid,,526.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Trillium,Medicaid,,526.12,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Trillium,Medicaid,,526.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Trillium,Medicaid,,700.62,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Trillium,Medicaid,,602.56,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Trillium,Medicaid,,1242.32,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Trillium,Medicaid,,1444.52,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Trillium,Medicaid,,1069.84,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Trillium,Medicaid,,963.89,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Trillium,Medicaid,,241.02,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Trillium,Medicaid,,1625.28,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Trillium,Medicaid,,1677.45,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Trillium,Medicaid,,2521.43,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Trillium,Medicaid,,1406.30,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Trillium,Medicaid,,537.45,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Trillium,Medicaid,,373.67,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Trillium,Medicaid,,180.16,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Trillium,Medicaid,,325.74,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Trillium,Medicaid,,240.82,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Trillium,Medicaid,,748.54,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Trillium,Medicaid,,657.35,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Trillium,Medicaid,,657.96,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Trillium,Medicaid,,567.17,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Trillium,Medicaid,,537.45,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Trillium,Medicaid,,964.29,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Trillium,Medicaid,,1118.57,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Trillium,Medicaid,,1639.24,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Trillium,Medicaid,,151.85,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Trillium,Medicaid,,2199.33,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Trillium,Medicaid,,1583.43,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Trillium,Medicaid,,769.78,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Trillium,Medicaid,,3461.87,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Trillium,Medicaid,,1481.52,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Trillium,Medicaid,,182.38,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Trillium,Medicaid,,703.86,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Trillium,Medicaid,,703.86,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Trillium,Medicaid,,3485.52,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Trillium,Medicaid,,3272.00,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Trillium,Medicaid,,3272.00,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Trillium,Medicaid,,1778.35,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Trillium,Medicaid,,1778.35,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Trillium,Medicaid,,1884.91,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Trillium,Medicaid,,1884.91,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Trillium,Medicaid,,2512.94,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Trillium,Medicaid,,1826.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Trillium,Medicaid,,588.40,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Trillium,Medicaid,,478.81,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Trillium,Medicaid,,478.81,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Trillium,Medicaid,,162.57,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Trillium,Medicaid,,1326.43,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Trillium,Medicaid,,340.91,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Trillium,Medicaid,,408.65,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Trillium,Medicaid,,649.26,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Trillium,Medicaid,,98.47,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Trillium,Medicaid,,578.09,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Trillium,Medicaid,,578.09,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Trillium,Medicaid,,44.08,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Trillium,Medicaid,,44.08,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Trillium,Medicaid,,2010.68,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Trillium,Medicaid,,2010.68,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Trillium,Medicaid,,811.63,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Trillium,Medicaid,,1231.80,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Trillium,Medicaid,,697.99,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Trillium,Medicaid,,365.78,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Trillium,Medicaid,,127.18,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Trillium,Medicaid,,578.09,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Trillium,Medicaid,,578.09,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Trillium,Medicaid,,820.53,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Trillium,Medicaid,,396.11,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Trillium,Medicaid,,79.26,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Trillium,Medicaid,,92.81,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Trillium,Medicaid,,75.42,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Trillium,Medicaid,,75.42,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Trillium,Medicaid,,79.26,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Trillium,Medicaid,,64.70,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Trillium,Medicaid,,180.77,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Trillium,Medicaid,,116.06,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Trillium,Medicaid,,230.91,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Trillium,Medicaid,,189.26,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Trillium,Medicaid,,213.93,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Trillium,Medicaid,,155.90,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Trillium,Medicaid,,169.24,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Trillium,Medicaid,,63.69,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Trillium,Medicaid,,153.27,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Trillium,Medicaid,,62.68,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Trillium,Medicaid,,166.81,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Trillium,Medicaid,,194.31,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Trillium,Medicaid,,104.94,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Trillium,Medicaid,,128.80,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Trillium,Medicaid,,86.34,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Trillium,Medicaid,,168.84,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Trillium,Medicaid,,135.07,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Trillium,Medicaid,,108.99,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Trillium,Medicaid,,133.05,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Trillium,Medicaid,,209.68,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Trillium,Medicaid,,166.41,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Trillium,Medicaid,,185.82,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Trillium,Medicaid,,60.86,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Trillium,Medicaid,,238.19,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Trillium,Medicaid,,154.48,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Trillium,Medicaid,,50.55,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Trillium,Medicaid,,46.71,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Trillium,Medicaid,,37.61,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Trillium,Medicaid,,222.82,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Trillium,Medicaid,,166.81,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Trillium,Medicaid,,40.24,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Trillium,Medicaid,,138.30,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Trillium,Medicaid,,85.33,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Trillium,Medicaid,,195.53,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Trillium,Medicaid,,146.39,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Trillium,Medicaid,,83.51,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Trillium,Medicaid,,99.48,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Trillium,Medicaid,,92.81,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Trillium,Medicaid,,28.11,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Trillium,Medicaid,,13.55,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Trillium,Medicaid,,22.04,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Trillium,Medicaid,,1291.25,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Trillium,Medicaid,,941.04,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Trillium,Medicaid,,845.60,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Trillium,Medicaid,,1312.48,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Trillium,Medicaid,,1243.53,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Trillium,Medicaid,,543.51,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Trillium,Medicaid,,1243.53,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Trillium,Medicaid,,1243.53,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Trillium,Medicaid,,188.25,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Trillium,Medicaid,,309.57,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Trillium,Medicaid,,618.93,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Trillium,Medicaid,,942.25,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Trillium,Medicaid,,844.39,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Trillium,Medicaid,,1223.71,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Trillium,Medicaid,,1798.77,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Trillium,Medicaid,,106.56,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Trillium,Medicaid,,181.78,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Trillium,Medicaid,,115.46,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Trillium,Medicaid,,204.63,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Trillium,Medicaid,,553.22,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Trillium,Medicaid,,499.23,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Trillium,Medicaid,,97.26,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Trillium,Medicaid,,568.79,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Trillium,Medicaid,,665.64,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Trillium,Medicaid,,1024.95,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Trillium,Medicaid,,1238.88,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Trillium,Medicaid,,699.41,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Trillium,Medicaid,,1045.98,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Trillium,Medicaid,,1089.45,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Trillium,Medicaid,,728.73,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Trillium,Medicaid,,761.28,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Trillium,Medicaid,,1042.95,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Trillium,Medicaid,,702.04,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Trillium,Medicaid,,824.17,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Trillium,Medicaid,,950.14,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Trillium,Medicaid,,749.76,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Trillium,Medicaid,,786.96,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Trillium,Medicaid,,1078.13,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Trillium,Medicaid,,743.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Trillium,Medicaid,,750.57,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Trillium,Medicaid,,1042.95,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Trillium,Medicaid,,860.56,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Trillium,Medicaid,,910.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Trillium,Medicaid,,1058.31,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Trillium,Medicaid,,590.22,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Trillium,Medicaid,,846.21,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Trillium,Medicaid,,641.38,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Trillium,Medicaid,,51.16,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Trillium,Medicaid,52,799.09,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Trillium,Medicaid,52,795.25,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Trillium,Medicaid,,777.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Trillium,Medicaid,,890.69,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Trillium,Medicaid,,1050.63,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Trillium,Medicaid,,813.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Trillium,Medicaid,,836.10,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Trillium,Medicaid,,710.94,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Trillium,Medicaid,,864.20,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Trillium,Medicaid,,712.35,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Trillium,Medicaid,,819.11,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Trillium,Medicaid,,1032.03,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Trillium,Medicaid,,993.21,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Trillium,Medicaid,,1102.80,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Trillium,Medicaid,,847.22,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Trillium,Medicaid,,937.60,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Trillium,Medicaid,,1129.49,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Trillium,Medicaid,,701.23,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Trillium,Medicaid,,742.28,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Trillium,Medicaid,,1079.75,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Trillium,Medicaid,,656.14,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Trillium,Medicaid,,727.72,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Trillium,Medicaid,,1010.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Trillium,Medicaid,,854.29,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Trillium,Medicaid,,654.32,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Trillium,Medicaid,,904.24,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Trillium,Medicaid,,856.92,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Trillium,Medicaid,,856.92,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Trillium,Medicaid,,856.92,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Trillium,Medicaid,,714.78,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Trillium,Medicaid,,822.55,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Trillium,Medicaid,,822.55,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Trillium,Medicaid,,908.48,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Trillium,Medicaid,,657.15,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Trillium,Medicaid,,928.91,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Trillium,Medicaid,,903.03,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Trillium,Medicaid,,853.89,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Trillium,Medicaid,,853.89,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Trillium,Medicaid,,917.99,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Trillium,Medicaid,,917.99,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Trillium,Medicaid,,917.99,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Trillium,Medicaid,,712.35,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Trillium,Medicaid,,208.87,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Trillium,Medicaid,,485.28,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Trillium,Medicaid,,482.25,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Trillium,Medicaid,,799.09,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Trillium,Medicaid,,379.12,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Trillium,Medicaid,,86.14,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Trillium,Medicaid,,65.51,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Trillium,Medicaid,,80.68,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Trillium,Medicaid,,352.84,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Trillium,Medicaid,,352.84,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Trillium,Medicaid,,31.95,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Trillium,Medicaid,,370.23,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Trillium,Medicaid,,370.23,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Trillium,Medicaid,,182.99,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Trillium,Medicaid,,109.19,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Trillium,Medicaid,,96.05,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Trillium,Medicaid,,96.05,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Trillium,Medicaid,,262.66,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Trillium,Medicaid,,209.68,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Trillium,Medicaid,,171.26,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Trillium,Medicaid,,124.56,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Trillium,Medicaid,,121.12,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Trillium,Medicaid,,59.04,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Trillium,Medicaid,,87.15,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Trillium,Medicaid,,64.10,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Trillium,Medicaid,,58.23,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Trillium,Medicaid,,137.50,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Trillium,Medicaid,,56.82,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Trillium,Medicaid,,117.68,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Trillium,Medicaid,,117.68,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Trillium,Medicaid,,290.36,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Trillium,Medicaid,,152.05,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Trillium,Medicaid,,377.31,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Trillium,Medicaid,,879.57,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Trillium,Medicaid,,50.95,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Trillium,Medicaid,,35.79,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Trillium,Medicaid,,74.61,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Trillium,Medicaid,,37.00,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Trillium,Medicaid,,86.34,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Trillium,Medicaid,,66.52,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Trillium,Medicaid,,55.60,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Trillium,Medicaid,,80.68,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Trillium,Medicaid,,127.59,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Trillium,Medicaid,,104.74,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Trillium,Medicaid,,176.72,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Trillium,Medicaid,,113.64,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Trillium,Medicaid,,11.53,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Trillium,Medicaid,,73.20,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Trillium,Medicaid,,152.86,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Trillium,Medicaid,,61.67,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Trillium,Medicaid,,134.46,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Trillium,Medicaid,,85.33,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Trillium,Medicaid,,193.30,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Trillium,Medicaid,,121.12,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Trillium,Medicaid,,85.33,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Trillium,Medicaid,,92.61,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Trillium,Medicaid,,73.60,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Trillium,Medicaid,,510.35,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Trillium,Medicaid,,438.57,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Trillium,Medicaid,,223.63,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Trillium,Medicaid,,105.35,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Trillium,Medicaid,,111.82,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Trillium,Medicaid,,67.94,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Trillium,Medicaid,,25.88,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Trillium,Medicaid,,103.53,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Trillium,Medicaid,,81.69,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Trillium,Medicaid,,81.69,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Trillium,Medicaid,,486.09,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Trillium,Medicaid,,9.50,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Trillium,Medicaid,,2.83,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Trillium,Medicaid,,22.65,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Trillium,Medicaid,,32.96,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Trillium,Medicaid,,26.69,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Trillium,Medicaid,,5.26,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Trillium,Medicaid,,8.90,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Trillium,Medicaid,,38.22,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Trillium,Medicaid,,53.58,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Trillium,Medicaid,,51.16,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Trillium,Medicaid,,38.22,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Trillium,Medicaid,,80.27,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Trillium,Medicaid,,31.34,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Trillium,Medicaid,,108.18,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Trillium,Medicaid,,14.36,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Trillium,Medicaid,,26.89,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Trillium,Medicaid,,26.89,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Trillium,Medicaid,,26.89,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Trillium,Medicaid,,5.86,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Trillium,Medicaid,,35.79,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Trillium,Medicaid,,25.07,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Trillium,Medicaid,,7.89,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Trillium,Medicaid,,29.32,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Trillium,Medicaid,,29.32,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Trillium,Medicaid,,29.32,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Trillium,Medicaid,,31.14,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Trillium,Medicaid,,5.86,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Trillium,Medicaid,,8.69,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Trillium,Medicaid,,8.49,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Trillium,Medicaid,,9.71,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Trillium,Medicaid,,32.76,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Trillium,Medicaid,,23.25,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Trillium,Medicaid,,23.25,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Trillium,Medicaid,,23.25,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Trillium,Medicaid,,8.49,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Trillium,Medicaid,,12.13,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Trillium,Medicaid,,8.09,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Trillium,Medicaid,,8.09,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Trillium,Medicaid,,33.57,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,,18.00,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,,18.00,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Trillium,Medicaid,,13.35,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Trillium,Medicaid,,10.72,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Trillium,Medicaid,,52.17,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Trillium,Medicaid,,13.35,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Trillium,Medicaid,,49.13,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Trillium,Medicaid,,36.40,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Trillium,Medicaid,,29.52,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Trillium,Medicaid,,15.97,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Trillium,Medicaid,,7.89,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Trillium,Medicaid,,60.46,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Trillium,Medicaid,,1.21,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Trillium,Medicaid,,40.64,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Trillium,Medicaid,,117.07,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Trillium,Medicaid,,31.75,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Trillium,Medicaid,,24.67,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Trillium,Medicaid,,24.67,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Trillium,Medicaid,,24.67,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Trillium,Medicaid,,24.67,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Trillium,Medicaid,,7.89,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Trillium,Medicaid,,41.05,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Trillium,Medicaid,,41.05,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Trillium,Medicaid,,41.05,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Trillium,Medicaid,,41.05,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Trillium,Medicaid,,6.07,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Trillium,Medicaid,,14.36,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Trillium,Medicaid,,34.58,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Trillium,Medicaid,,32.76,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Trillium,Medicaid,,15.77,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Trillium,Medicaid,,48.12,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Trillium,Medicaid,,31.54,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Trillium,Medicaid,,44.69,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Trillium,Medicaid,,24.26,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Trillium,Medicaid,,30.73,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Trillium,Medicaid,,9.50,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Trillium,Medicaid,,9.50,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Trillium,Medicaid,,39.83,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Trillium,Medicaid,,26.69,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Trillium,Medicaid,,8.09,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Trillium,Medicaid,,7.68,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Trillium,Medicaid,,8.49,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Trillium,Medicaid,,31.95,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Trillium,Medicaid,,31.95,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Trillium,Medicaid,,30.13,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Trillium,Medicaid,,7.68,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Trillium,Medicaid,,28.91,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Trillium,Medicaid,,16.78,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Trillium,Medicaid,,28.91,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Trillium,Medicaid,,35.79,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Trillium,Medicaid,,5.26,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Trillium,Medicaid,,5.26,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Trillium,Medicaid,,5.26,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Trillium,Medicaid,,0.40440,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Trillium,Medicaid,,66.52,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Trillium,Medicaid,,11.12,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Trillium,Medicaid,,29.52,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Trillium,Medicaid,,45.90,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Trillium,Medicaid,,43.47,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Trillium,Medicaid,,43.47,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Trillium,Medicaid,,9.10,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Trillium,Medicaid,,10.72,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Trillium,Medicaid,,10.11,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Trillium,Medicaid,,13.35,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Trillium,Medicaid,,9.10,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Trillium,Medicaid,,6.47,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Trillium,Medicaid,,6.47,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Trillium,Medicaid,,8.69,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Trillium,Medicaid,,3.03,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Trillium,Medicaid,,33.77,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Trillium,Medicaid,,9.10,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Trillium,Medicaid,,32.35,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Trillium,Medicaid,,38.42,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Trillium,Medicaid,,13.35,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Trillium,Medicaid,,27.09,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Trillium,Medicaid,,26.29,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Trillium,Medicaid,,21.84,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Trillium,Medicaid,,7.68,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Trillium,Medicaid,,23.25,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Trillium,Medicaid,,23.25,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Trillium,Medicaid,,26.29,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Trillium,Medicaid,,39.02,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Trillium,Medicaid,,15.97,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Trillium,Medicaid,,2.43,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Trillium,Medicaid,,75.02,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Trillium,Medicaid,,75.02,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Trillium,Medicaid,,45.49,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Trillium,Medicaid,,6.47,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Trillium,Medicaid,,28.31,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Trillium,Medicaid,,22.85,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Trillium,Medicaid,,19.61,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Trillium,Medicaid,,27.70,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Trillium,Medicaid,,24.26,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Trillium,Medicaid,,1.62,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Trillium,Medicaid,,4.45,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Trillium,Medicaid,,21.43,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Trillium,Medicaid,,35.18,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Trillium,Medicaid,,25.88,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Trillium,Medicaid,,53.99,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Trillium,Medicaid,,29.72,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Trillium,Medicaid,,55.20,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Trillium,Medicaid,,41.86,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Trillium,Medicaid,,10.11,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Trillium,Medicaid,,47.92,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Trillium,Medicaid,,41.65,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Trillium,Medicaid,,8.29,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Trillium,Medicaid,,59.24,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Trillium,Medicaid,,40.64,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Trillium,Medicaid,,9.30,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Trillium,Medicaid,,22.85,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Trillium,Medicaid,,22.85,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Trillium,Medicaid,,10.11,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Trillium,Medicaid,,27.30,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Trillium,Medicaid,,45.09,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Trillium,Medicaid,,4.25,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Trillium,Medicaid,,11.53,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Trillium,Medicaid,,29.32,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Trillium,Medicaid,,13.75,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,,23.66,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Trillium,Medicaid,,34.98,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Trillium,Medicaid,,19.61,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Trillium,Medicaid,,23.46,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Trillium,Medicaid,,23.46,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Trillium,Medicaid,,3.03,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,,18.00,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,,18.00,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Trillium,Medicaid,,7.08,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Trillium,Medicaid,,9.10,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Trillium,Medicaid,,13.95,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Trillium,Medicaid,,93.21,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Trillium,Medicaid,,24.67,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Trillium,Medicaid,,39.43,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Trillium,Medicaid,,16.78,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Trillium,Medicaid,,2.22,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Trillium,Medicaid,,7.08,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Trillium,Medicaid,,27.30,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Trillium,Medicaid,,21.84,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Trillium,Medicaid,,160.55,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Trillium,Medicaid,,90.38,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Trillium,Medicaid,,53.79,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Trillium,Medicaid,,115.25,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Trillium,Medicaid,,170.05,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,,33.36,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Trillium,Medicaid,,59.85,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Trillium,Medicaid,,72.99,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Trillium,Medicaid,,17.19,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Trillium,Medicaid,,17.19,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Trillium,Medicaid,,17.19,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Trillium,Medicaid,,47.11,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Trillium,Medicaid,,29.32,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Trillium,Medicaid,,24.87,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Trillium,Medicaid,,27.09,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Trillium,Medicaid,,39.63,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Trillium,Medicaid,,34.98,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Trillium,Medicaid,,101.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Trillium,Medicaid,,149.02,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Trillium,Medicaid,,25.48,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Trillium,Medicaid,,28.11,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Trillium,Medicaid,,30.33,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Trillium,Medicaid,,18.80,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Trillium,Medicaid,,32.76,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Trillium,Medicaid,,87.55,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Trillium,Medicaid,,87.55,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Trillium,Medicaid,,65.31,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Trillium,Medicaid,,55.60,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Trillium,Medicaid,,58.84,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Trillium,Medicaid,,53.38,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Trillium,Medicaid,,123.75,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Trillium,Medicaid,,32.55,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Trillium,Medicaid,,47.92,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Trillium,Medicaid,,40.24,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Trillium,Medicaid,,20.02,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Trillium,Medicaid,,65.72,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Trillium,Medicaid,,54.80,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Trillium,Medicaid,,65.31,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Trillium,Medicaid,,50.75,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Trillium,Medicaid,,36.80,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Trillium,Medicaid,,37.61,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Trillium,Medicaid,,37.61,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Trillium,Medicaid,,49.94,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Trillium,Medicaid,,8.90,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Trillium,Medicaid,,30.33,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Trillium,Medicaid,,39.63,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Trillium,Medicaid,,94.63,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Trillium,Medicaid,,57.22,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Trillium,Medicaid,,7.08,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Trillium,Medicaid,,14.56,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Trillium,Medicaid,,22.85,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Trillium,Medicaid,,71.98,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Trillium,Medicaid,,29.52,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Trillium,Medicaid,,40.84,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Trillium,Medicaid,,28.91,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,,23.66,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Trillium,Medicaid,,23.66,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Trillium,Medicaid,,15.97,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Trillium,Medicaid,,20.62,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Trillium,Medicaid,,17.19,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Trillium,Medicaid,,19.82,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Trillium,Medicaid,,45.29,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Trillium,Medicaid,,7.89,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Trillium,Medicaid,,3.84,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Trillium,Medicaid,,9.50,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Trillium,Medicaid,,3.03,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Trillium,Medicaid,,8.29,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Trillium,Medicaid,,38.01,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Trillium,Medicaid,,24.67,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Trillium,Medicaid,,26.29,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Trillium,Medicaid,,14.36,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Trillium,Medicaid,,31.75,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Trillium,Medicaid,,5.46,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Trillium,Medicaid,,10.72,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Trillium,Medicaid,,37.81,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Trillium,Medicaid,,37.81,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Trillium,Medicaid,,19.61,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Trillium,Medicaid,,43.07,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Trillium,Medicaid,,41.25,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Trillium,Medicaid,,6.47,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Trillium,Medicaid,,41.25,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Trillium,Medicaid,,6.27,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Trillium,Medicaid,,14.15,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Trillium,Medicaid,,29.32,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Trillium,Medicaid,,18.60,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Trillium,Medicaid,,7.89,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Trillium,Medicaid,,6.07,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Trillium,Medicaid,,6.07,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Trillium,Medicaid,,5.26,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,,26.08,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Trillium,Medicaid,,23.46,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Trillium,Medicaid,,15.97,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Trillium,Medicaid,,68.55,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Trillium,Medicaid,,13.75,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,,18.00,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Trillium,Medicaid,,3.24,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Trillium,Medicaid,,49.54,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Trillium,Medicaid,,31.14,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Trillium,Medicaid,,7.48,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Trillium,Medicaid,,20.02,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Trillium,Medicaid,,15.77,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Trillium,Medicaid,,8.09,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Trillium,Medicaid,,11.53,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Trillium,Medicaid,,7.68,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Trillium,Medicaid,,12.74,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Trillium,Medicaid,,36.40,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Trillium,Medicaid,,6.67,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Trillium,Medicaid,,7.68,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Trillium,Medicaid,,46.10,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Trillium,Medicaid,,34.17,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Trillium,Medicaid,,93.21,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Trillium,Medicaid,,43.07,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Trillium,Medicaid,,43.07,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Trillium,Medicaid,,127.18,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Trillium,Medicaid,,117.48,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Trillium,Medicaid,,35.18,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Trillium,Medicaid,,32.55,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Trillium,Medicaid,,70.77,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Trillium,Medicaid,,42.87,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Trillium,Medicaid,,33.16,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Trillium,Medicaid,,33.16,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Trillium,Medicaid,,55.60,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Trillium,Medicaid,,51.97,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Trillium,Medicaid,,155.69,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Trillium,Medicaid,,17.59,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Trillium,Medicaid,,16.78,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Trillium,Medicaid,,9.71,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Trillium,Medicaid,,22.65,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Trillium,Medicaid,,117.07,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Trillium,Medicaid,,56.41,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Trillium,Medicaid,,11.12,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Trillium,Medicaid,,31.14,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Trillium,Medicaid,,19.41,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Trillium,Medicaid,,19.41,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Trillium,Medicaid,,19.41,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Trillium,Medicaid,,93.62,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Trillium,Medicaid,,59.45,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Trillium,Medicaid,,17.79,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Trillium,Medicaid,,10.31,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Trillium,Medicaid,,25.48,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Trillium,Medicaid,,2.43,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Trillium,Medicaid,,30.33,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Trillium,Medicaid,,24.26,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Trillium,Medicaid,,110.81,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Trillium,Medicaid,,62.48,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Trillium,Medicaid,,25.68,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Trillium,Medicaid,,7.28,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Trillium,Medicaid,,4.45,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Trillium,Medicaid,,46.51,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Trillium,Medicaid,,5.86,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Trillium,Medicaid,,21.43,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Trillium,Medicaid,,11.73,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Trillium,Medicaid,,7.08,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Trillium,Medicaid,,7.08,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Trillium,Medicaid,,3.84,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Trillium,Medicaid,,12.33,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Trillium,Medicaid,,12.94,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Trillium,Medicaid,,9.30,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Trillium,Medicaid,,11.32,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Trillium,Medicaid,,14.36,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Trillium,Medicaid,,3.03,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Trillium,Medicaid,,6.07,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Trillium,Medicaid,,51.16,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Trillium,Medicaid,,27.09,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Trillium,Medicaid,,34.58,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Trillium,Medicaid,,5.26,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Trillium,Medicaid,,32.76,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Trillium,Medicaid,,15.97,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Trillium,Medicaid,,5.86,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Trillium,Medicaid,,83.71,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Trillium,Medicaid,,0.40440,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Trillium,Medicaid,,104.74,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Trillium,Medicaid,,16.38,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Trillium,Medicaid,,5.86,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Trillium,Medicaid,,32.55,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Trillium,Medicaid,,396.31,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Trillium,Medicaid,,28.51,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,,18.00,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Trillium,Medicaid,,6.87,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Trillium,Medicaid,,7.68,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Trillium,Medicaid,,14.15,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Trillium,Medicaid,,14.15,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Trillium,Medicaid,,3.03,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Trillium,Medicaid,,7.08,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Trillium,Medicaid,,15.16,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Trillium,Medicaid,,9.91,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Trillium,Medicaid,,106.96,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Trillium,Medicaid,,155.09,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Trillium,Medicaid,,27.09,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Trillium,Medicaid,,364.97,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Trillium,Medicaid,,254.37,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Trillium,Medicaid,,59.24,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Trillium,Medicaid,,23.46,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Trillium,Medicaid,,390.45,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Trillium,Medicaid,,4.65,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Trillium,Medicaid,,52.37,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Trillium,Medicaid,,9.30,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Trillium,Medicaid,,365.58,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Trillium,Medicaid,,142.96,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Trillium,Medicaid,,103.73,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Trillium,Medicaid,,38.22,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Trillium,Medicaid,,396.31,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Trillium,Medicaid,,23.05,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Trillium,Medicaid,,65.51,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Trillium,Medicaid,,39.23,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Trillium,Medicaid,,192.70,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Trillium,Medicaid,,129.21,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Trillium,Medicaid,,28.31,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Trillium,Medicaid,QW,28.31,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Trillium,Medicaid,,9.30,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Trillium,Medicaid,,56.21,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Trillium,Medicaid,,321.30,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Trillium,Medicaid,,240.01,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Trillium,Medicaid,,56.21,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Trillium,Medicaid,,123.14,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Trillium,Medicaid,,96.65,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Trillium,Medicaid,,41.25,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Trillium,Medicaid,,86.14,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Trillium,Medicaid,,10.11,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Trillium,Medicaid,QW,20.22,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Trillium,Medicaid,,20.22,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Trillium,Medicaid,,32.96,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Trillium,Medicaid,,183.40,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Trillium,Medicaid,,55.60,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Trillium,Medicaid,,26.69,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,,33.36,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Trillium,Medicaid,,18.00,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Trillium,Medicaid,,8.69,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Trillium,Medicaid,,56.62,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Trillium,Medicaid,,15.97,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Trillium,Medicaid,,39.23,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Trillium,Medicaid,,13.95,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Trillium,Medicaid,,13.35,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Trillium,Medicaid,,70.77,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Trillium,Medicaid,,27.30,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Trillium,Medicaid,,43.07,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Trillium,Medicaid,,44.28,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Trillium,Medicaid,,27.30,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Trillium,Medicaid,,27.30,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Trillium,Medicaid,,55.60,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Trillium,Medicaid,,9.10,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Trillium,Medicaid,,9.10,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Trillium,Medicaid,,15.37,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Trillium,Medicaid,,8.69,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Trillium,Medicaid,,16.98,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Trillium,Medicaid,,20.42,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Trillium,Medicaid,,30.13,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Trillium,Medicaid,,268.52,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Trillium,Medicaid,,11.12,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Trillium,Medicaid,,21.84,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Trillium,Medicaid,,23.86,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Trillium,Medicaid,,13.14,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Trillium,Medicaid,,11.53,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Trillium,Medicaid,,54.80,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Trillium,Medicaid,,33.77,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Trillium,Medicaid,,54.80,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Trillium,Medicaid,,64.50,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Trillium,Medicaid,,104.13,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Trillium,Medicaid,,106.36,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Trillium,Medicaid,,42.46,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Trillium,Medicaid,,5.46,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Trillium,Medicaid,,22.24,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Trillium,Medicaid,,37.61,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Trillium,Medicaid,,29.72,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Trillium,Medicaid,,29.72,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Trillium,Medicaid,,7.89,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Trillium,Medicaid,,40.04,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Trillium,Medicaid,,24.06,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Trillium,Medicaid,,51.56,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Trillium,Medicaid,,52.77,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Trillium,Medicaid,,15.77,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Trillium,Medicaid,,27.50,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Trillium,Medicaid,,42.26,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Trillium,Medicaid,,41.86,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Trillium,Medicaid,,104.74,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Trillium,Medicaid,,29.93,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Trillium,Medicaid,,92.20,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Trillium,Medicaid,,120.71,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Trillium,Medicaid,,152.66,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Trillium,Medicaid,,113.43,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Trillium,Medicaid,,65.72,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Trillium,Medicaid,,45.49,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Trillium,Medicaid,,206.04,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Trillium,Medicaid,,71.58,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Trillium,Medicaid,,123.14,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Trillium,Medicaid,,45.29,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Trillium,Medicaid,,26.69,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Trillium,Medicaid,,27.30,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Trillium,Medicaid,,110.81,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Trillium,Medicaid,,20.62,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Trillium,Medicaid,,35.38,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Trillium,Medicaid,,74.21,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Trillium,Medicaid,,133.45,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Trillium,Medicaid,,0.00202,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Trillium,Medicaid,,25.07,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Trillium,Medicaid,,45.70,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Trillium,Medicaid,,74.81,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Trillium,Medicaid,,64.50,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Trillium,Medicaid,,64.50,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Trillium,Medicaid,,119.90,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Trillium,Medicaid,,110.81,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Trillium,Medicaid,,19.61,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,,26.08,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Trillium,Medicaid,,79.67,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Trillium,Medicaid,,63.29,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Trillium,Medicaid,,50.35,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Trillium,Medicaid,,15.57,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Trillium,Medicaid,,77.64,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Trillium,Medicaid,,26.69,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Trillium,Medicaid,,136.49,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Trillium,Medicaid,,38.22,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Trillium,Medicaid,,83.71,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Trillium,Medicaid,,51.76,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Trillium,Medicaid,,52.77,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Trillium,Medicaid,,31.75,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Trillium,Medicaid,,31.75,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Trillium,Medicaid,,108.99,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Trillium,Medicaid,,28.11,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Trillium,Medicaid,,33.16,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Trillium,Medicaid,,3.64,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Trillium,Medicaid,,83.71,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Trillium,Medicaid,,49.94,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Trillium,Medicaid,,443.02,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Trillium,Medicaid,,71.38,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Trillium,Medicaid,,38.82,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Trillium,Medicaid,,143.16,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Trillium,Medicaid,,104.74,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Trillium,Medicaid,,71.58,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Trillium,Medicaid,,74.21,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Trillium,Medicaid,,104.94,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Trillium,Medicaid,,259.83,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Trillium,Medicaid,,74.21,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Trillium,Medicaid,,63.09,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Trillium,Medicaid,,26.08,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Trillium,Medicaid,,251.33,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Trillium,Medicaid,,4.85,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Trillium,Medicaid,,38.82,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Trillium,Medicaid,,183.60,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Trillium,Medicaid,,133.45,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Trillium,Medicaid,,95.84,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Trillium,Medicaid,,71.98,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Trillium,Medicaid,,25.27,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Trillium,Medicaid,,30.33,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Trillium,Medicaid,,19.21,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Trillium,Medicaid,,33.57,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Trillium,Medicaid,,16.18,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Trillium,Medicaid,,32.15,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Trillium,Medicaid,,321.30,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Trillium,Medicaid,,161.36,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Trillium,Medicaid,,65.92,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Trillium,Medicaid,,13.35,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Trillium,Medicaid,,8.49,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Trillium,Medicaid,,21.23,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Trillium,Medicaid,,50.15,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Trillium,Medicaid,,60.66,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Trillium,Medicaid,,60.66,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Trillium,Medicaid,,56.01,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Trillium,Medicaid,,114.45,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Trillium,Medicaid,,11.53,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Trillium,Medicaid,,137.29,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Trillium,Medicaid,,131.63,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Trillium,Medicaid,,210.49,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Trillium,Medicaid,,216.35,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Trillium,Medicaid,,43.47,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Trillium,Medicaid,,84.72,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Trillium,Medicaid,,59.45,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Trillium,Medicaid,,191.89,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Trillium,Medicaid,,250.73,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Trillium,Medicaid,,121.32,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Trillium,Medicaid,,18.40,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Trillium,Medicaid,,308.96,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Trillium,Medicaid,,5.66,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,,33.36,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,,33.36,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Trillium,Medicaid,,33.36,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Trillium,Medicaid,,11.93,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Trillium,Medicaid,,210.49,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Trillium,Medicaid,,210.49,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Trillium,Medicaid,,234.55,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Trillium,Medicaid,,12.54,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Trillium,Medicaid,,528.96,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Trillium,Medicaid,,1732.85,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Trillium,Medicaid,,1732.85,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Trillium,Medicaid,,1732.85,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Trillium,Medicaid,,1732.85,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Trillium,Medicaid,,1732.85,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Trillium,Medicaid,,7173.45,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Trillium,Medicaid,,1215.63,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Trillium,Medicaid,,500.24,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Trillium,Medicaid,,500.24,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Trillium,Medicaid,,1357.77,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Trillium,Medicaid,,413.09,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Trillium,Medicaid,,681.01,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Trillium,Medicaid,,183.80,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Trillium,Medicaid,,183.80,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Trillium,Medicaid,,400.56,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Trillium,Medicaid,,400.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Trillium,Medicaid,,842.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Trillium,Medicaid,,842.37,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Trillium,Medicaid,,383.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Trillium,Medicaid,,383.37,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Trillium,Medicaid,,90.38,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Trillium,Medicaid,,166.41,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Trillium,Medicaid,,362.75,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Trillium,Medicaid,,362.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Trillium,Medicaid,,286.32,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Trillium,Medicaid,,286.32,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Trillium,Medicaid,,320.69,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Trillium,Medicaid,,320.69,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Trillium,Medicaid,,286.32,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Trillium,Medicaid,,286.32,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Trillium,Medicaid,,1560.38,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Trillium,Medicaid,,780.09,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Trillium,Medicaid,,780.09,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Trillium,Medicaid,,1448.97,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Trillium,Medicaid,,1448.97,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Trillium,Medicaid,,1114.53,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Trillium,Medicaid,,1114.53,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Trillium,Medicaid,,278.63,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Trillium,Medicaid,,278.63,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Trillium,Medicaid,,1114.53,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Trillium,Medicaid,,1114.53,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Trillium,Medicaid,,537.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Trillium,Medicaid,,1732.85,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Trillium,Medicaid,,1732.85,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Trillium,Medicaid,,160.55,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Trillium,Medicaid,,5875.33,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Trillium,Medicaid,,888.47,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Trillium,Medicaid,,888.47,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Trillium,Medicaid,,88.77,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Trillium,Medicaid,,456.37,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Trillium,Medicaid,,456.37,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Trillium,Medicaid,,456.37,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Trillium,Medicaid,,456.37,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Trillium,Medicaid,,3382.60,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Trillium,Medicaid,,3382.60,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Trillium,Medicaid,,5637.74,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Trillium,Medicaid,,5637.74,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Trillium,Medicaid,,2029.48,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Trillium,Medicaid,,2029.48,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Trillium,Medicaid,,4679.31,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Trillium,Medicaid,,4679.31,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Trillium,Medicaid,,1881.88,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Trillium,Medicaid,,1881.88,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Trillium,Medicaid,,4747.45,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Trillium,Medicaid,,4747.45,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Trillium,Medicaid,,4276.93,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Trillium,Medicaid,,4276.93,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Trillium,Medicaid,,5688.49,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Trillium,Medicaid,,5688.49,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Trillium,Medicaid,,2492.72,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Trillium,Medicaid,,4711.26,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Trillium,Medicaid,,4711.26,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Trillium,Medicaid,,4287.45,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Trillium,Medicaid,,4287.45,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Trillium,Medicaid,,4860.89,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Trillium,Medicaid,,4860.89,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Trillium,Medicaid,,1919.48,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Trillium,Medicaid,,1919.48,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Trillium,Medicaid,,4137.82,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Trillium,Medicaid,,4137.82,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Trillium,Medicaid,,3564.58,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Trillium,Medicaid,,3564.58,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Trillium,Medicaid,,4162.89,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Trillium,Medicaid,LM,3275.44,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Trillium,Medicaid,RI,3275.44,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Trillium,Medicaid,RC,3275.44,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Trillium,Medicaid,LD,3275.44,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Trillium,Medicaid,LC,3275.44,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Trillium,Medicaid,LC,1689.79,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Trillium,Medicaid,RI,1689.79,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Trillium,Medicaid,RC,1689.79,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Trillium,Medicaid,LD,1689.79,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Trillium,Medicaid,LC,1689.79,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,LM,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,RI,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,RC,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,LD,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,LC,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,LM,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,RI,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,RC,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,LD,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Trillium,Medicaid,LC,2903.19,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,LM,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,RI,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,RC,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,LD,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,LC,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,LM,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,RI,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,RC,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,LD,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Trillium,Medicaid,LC,4333.15,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,LM,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,RI,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,RC,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,LD,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,LC,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,RC,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,LD,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Trillium,Medicaid,LC,4592.97,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LM,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,RI,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,RC,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LD,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LC,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LM,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,RI,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,RC,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LD,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LC,8189.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LM,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,RI,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,RC,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LD,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LC,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,RC,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LD,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Trillium,Medicaid,LC,8189.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Trillium,Medicaid,,4679.51,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Trillium,Medicaid,,4679.51,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Trillium,Medicaid,,4809.73,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Trillium,Medicaid,,4809.73,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,LM,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,RI,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,RC,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,LD,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,LC,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,LM,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,RI,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,RC,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,LD,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Trillium,Medicaid,LC,5026.29,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LM,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,RI,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,RC,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LD,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LC,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LM,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,RI,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,RC,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LD,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LC,5243.05,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LM,5243.05,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,RI,5243.05,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,RC,5243.05,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LD,5243.05,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Trillium,Medicaid,LC,5243.05,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Trillium,Medicaid,,79.46,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Trillium,Medicaid,,336.46,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Trillium,Medicaid,,377.10,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Trillium,Medicaid,,85.33,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Trillium,Medicaid,,510.96,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Trillium,Medicaid,,199.37,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Trillium,Medicaid,,2339.86,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Trillium,Medicaid,,2164.75,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Trillium,Medicaid,,2164.75,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Trillium,Medicaid,,2064.46,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Trillium,Medicaid,,859.35,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Trillium,Medicaid,,1489.61,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Trillium,Medicaid,,2202.56,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Trillium,Medicaid,,1955.88,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Trillium,Medicaid,,2087.92,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Trillium,Medicaid,,918.59,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Trillium,Medicaid,,2148.17,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Trillium,Medicaid,,2679.35,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Trillium,Medicaid,,2413.66,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Trillium,Medicaid,,2574.81,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Trillium,Medicaid,,2618.49,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Trillium,Medicaid,,3210.33,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Trillium,Medicaid,,1370.51,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Trillium,Medicaid,,41.05,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Trillium,Medicaid,,19.61,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Trillium,Medicaid,,303.91,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Trillium,Medicaid,,834.68,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Trillium,Medicaid,,1630.54,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Trillium,Medicaid,,97.86,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Trillium,Medicaid,,126.58,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Trillium,Medicaid,,43.47,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Trillium,Medicaid,,1551.08,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Trillium,Medicaid,,7912.69,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Trillium,Medicaid,,2483.42,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Trillium,Medicaid,,510.56,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Trillium,Medicaid,,571.01,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Trillium,Medicaid,,255.99,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Trillium,Medicaid,,106.76,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Trillium,Medicaid,,106.76,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Trillium,Medicaid,,106.76,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Trillium,Medicaid,,1593.74,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Trillium,Medicaid,,1593.74,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Trillium,Medicaid,,3028.75,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Trillium,Medicaid,,3028.75,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Trillium,Medicaid,,3693.59,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Trillium,Medicaid,,2682.79,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Trillium,Medicaid,,3048.57,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Trillium,Medicaid,,3678.83,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Trillium,Medicaid,,645.62,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Trillium,Medicaid,,2848.80,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Trillium,Medicaid,,2848.80,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Trillium,Medicaid,,2065.47,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Trillium,Medicaid,,595.28,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Trillium,Medicaid,,586.78,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Trillium,Medicaid,,586.78,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Trillium,Medicaid,,4123.26,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Trillium,Medicaid,,3017.84,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Trillium,Medicaid,,478.61,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Trillium,Medicaid,,4809.53,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Trillium,Medicaid,,4958.15,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Trillium,Medicaid,,5404.40,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Trillium,Medicaid,,1720.32,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Trillium,Medicaid,,2305.28,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Trillium,Medicaid,,2305.28,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Trillium,Medicaid,,10087.15,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Trillium,Medicaid,,1162.65,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Trillium,Medicaid,,772.61,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Trillium,Medicaid,,11666.54,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Trillium,Medicaid,,533.61,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Trillium,Medicaid,,2359.07,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Trillium,Medicaid,,421.79,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Trillium,Medicaid,,846.81,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Trillium,Medicaid,,1310.26,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Trillium,Medicaid,,1310.26,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Trillium,Medicaid,,653.51,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Trillium,Medicaid,,464.05,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Trillium,Medicaid,,653.51,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Trillium,Medicaid,,653.51,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Trillium,Medicaid,,615.29,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Trillium,Medicaid,,563.53,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Trillium,Medicaid,,1937.08,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Trillium,Medicaid,,3079.51,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Trillium,Medicaid,,3079.51,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Trillium,Medicaid,,328.37,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Trillium,Medicaid,,1634.58,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Trillium,Medicaid,,335.25,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Trillium,Medicaid,,638.14,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Trillium,Medicaid,,5144.37,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Trillium,Medicaid,,4556.37,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Trillium,Medicaid,,4556.37,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Trillium,Medicaid,,611.65,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Trillium,Medicaid,,286.72,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Trillium,Medicaid,,4071.70,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Trillium,Medicaid,,4525.44,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Trillium,Medicaid,,501.86,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Trillium,Medicaid,,390.45,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Trillium,Medicaid,,1121.81,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Trillium,Medicaid,,1121.81,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Trillium,Medicaid,,1289.43,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Trillium,Medicaid,,520.66,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Trillium,Medicaid,,2774.39,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Trillium,Medicaid,,970.56,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Trillium,Medicaid,,286.72,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Trillium,Medicaid,,430.08,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Trillium,Medicaid,,573.44,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Trillium,Medicaid,,1610.52,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Trillium,Medicaid,,3745.15,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Trillium,Medicaid,,1865.09,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Trillium,Medicaid,,1307.63,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Trillium,Medicaid,,1511.65,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Trillium,Medicaid,,58.23,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Trillium,Medicaid,,286.72,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Trillium,Medicaid,,1611.53,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Trillium,Medicaid,,614.89,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Trillium,Medicaid,,614.89,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Trillium,Medicaid,,614.89,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Trillium,Medicaid,,614.89,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Trillium,Medicaid,,2689.46,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Trillium,Medicaid,,5378.92,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Trillium,Medicaid,,5378.92,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Trillium,Medicaid,,8660.02,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Trillium,Medicaid,,7069.32,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Trillium,Medicaid,,1916.05,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Trillium,Medicaid,,878.56,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Trillium,Medicaid,,4328.29,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Trillium,Medicaid,,6923.53,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Trillium,Medicaid,,6923.53,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Trillium,Medicaid,,6923.53,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Trillium,Medicaid,,6545.82,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Trillium,Medicaid,,1368.09,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Trillium,Medicaid,,1368.09,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Trillium,Medicaid,,21.64,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Trillium,Medicaid,,7914.51,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Trillium,Medicaid,,7914.51,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Trillium,Medicaid,,9694.28,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Trillium,Medicaid,,485.08,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Trillium,Medicaid,,1313.09,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Trillium,Medicaid,,2191.24,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Trillium,Medicaid,LD,694.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Trillium,Medicaid,RC,694.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Trillium,Medicaid,RI,694.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Trillium,Medicaid,LM,694.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Trillium,Medicaid,LD,555.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Trillium,Medicaid,RC,555.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Trillium,Medicaid,RI,555.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Trillium,Medicaid,LM,555.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Trillium,Medicaid,LD,476.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Trillium,Medicaid,RC,476.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Trillium,Medicaid,RI,476.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Trillium,Medicaid,LM,476.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,LD,100.09,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,RC,100.09,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,RI,100.09,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,LM,100.09,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Trillium,Medicaid,LC,694.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Trillium,Medicaid,LC,555.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Trillium,Medicaid,LC,476.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Trillium,Medicaid,LC,100.09,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Trillium,Medicaid,,6593.94,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Trillium,Medicaid,,12483.22,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Trillium,Medicaid,,2305.69,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Trillium,Medicaid,,576.47,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Trillium,Medicaid,,116.27,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Trillium,Medicaid,,813.05,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Trillium,Medicaid,,668.07,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Trillium,Medicaid,,260.84,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Trillium,Medicaid,,316.04,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Trillium,Medicaid,,233.95,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Trillium,Medicaid,,450.70,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Trillium,Medicaid,,450.70,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Trillium,Medicaid,,181.78,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Trillium,Medicaid,,146.80,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Trillium,Medicaid,,146.80,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Trillium,Medicaid,,517.23,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Trillium,Medicaid,,517.23,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Trillium,Medicaid,,100.29,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Trillium,Medicaid,,77.85,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Trillium,Medicaid,,553.22,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Trillium,Medicaid,,11.12,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Trillium,Medicaid,,276.61,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Trillium,Medicaid,,49.13,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Trillium,Medicaid,,176.93,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Trillium,Medicaid,,125.77,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Trillium,Medicaid,,32.76,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Trillium,Medicaid,,39.02,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Trillium,Medicaid,,258.01,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Trillium,Medicaid,,57.63,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Trillium,Medicaid,,44.08,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Trillium,Medicaid,,60.05,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Trillium,Medicaid,,22.04,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Trillium,Medicaid,,28.51,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Trillium,Medicaid,,8.69,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Trillium,Medicaid,,1314.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Trillium,Medicaid,,732.77,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Trillium,Medicaid,,1614.36,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Trillium,Medicaid,,527.14,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Trillium,Medicaid,,426.84,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Trillium,Medicaid,,426.84,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Trillium,Medicaid,,426.84,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Trillium,Medicaid,,1289.03,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Trillium,Medicaid,,1707.17,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Trillium,Medicaid,,1916.25,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Trillium,Medicaid,,1583.43,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Trillium,Medicaid,,2052.13,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Trillium,Medicaid,,2286.48,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Trillium,Medicaid,,97.06,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Trillium,Medicaid,,60.66,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Trillium,Medicaid,,97.06,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Trillium,Medicaid,,60.66,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Trillium,Medicaid,,6.87,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Trillium,Medicaid,,48.53,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Trillium,Medicaid,,75.62,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Trillium,Medicaid,,266.90,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Trillium,Medicaid,,288.13,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Trillium,Medicaid,,451.31,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Trillium,Medicaid,,59.24,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Trillium,Medicaid,,135.88,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Trillium,Medicaid,,21.03,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Trillium,Medicaid,,205.44,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Trillium,Medicaid,,35.38,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Trillium,Medicaid,,52.17,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Trillium,Medicaid,,38.82,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Trillium,Medicaid,,639.36,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Trillium,Medicaid,,61.06,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Trillium,Medicaid,,59.85,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Trillium,Medicaid,,62.48,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Trillium,Medicaid,,57.63,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Trillium,Medicaid,,68.95,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Trillium,Medicaid,,87.35,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Trillium,Medicaid,,124.76,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Trillium,Medicaid,,8.90,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Trillium,Medicaid,,8.49,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Trillium,Medicaid,,14.36,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Trillium,Medicaid,,44.69,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Trillium,Medicaid,,81.28,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Trillium,Medicaid,,179.96,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Trillium,Medicaid,,14.96,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Trillium,Medicaid,,10.92,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Trillium,Medicaid,,53.58,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Trillium,Medicaid,,8.09,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Trillium,Medicaid,,151.65,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Trillium,Medicaid,,237.59,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Trillium,Medicaid,,810.82,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Trillium,Medicaid,,247.49,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Trillium,Medicaid,,362.75,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Trillium,Medicaid,,458.79,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Trillium,Medicaid,,99.48,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Trillium,Medicaid,,810.82,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Trillium,Medicaid,,141.54,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Trillium,Medicaid,,157.72,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Trillium,Medicaid,,18.20,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Trillium,Medicaid,,323.12,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Trillium,Medicaid,,519.45,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Trillium,Medicaid,,101.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Trillium,Medicaid,,808.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Trillium,Medicaid,,490.33,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Trillium,Medicaid,,363.96,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Trillium,Medicaid,,490.33,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Trillium,Medicaid,,363.96,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Trillium,Medicaid,,238.60,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Trillium,Medicaid,,238.60,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Trillium,Medicaid,,213.73,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Trillium,Medicaid,GP,48.12,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Trillium,Medicaid,,6248.59,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Trillium,Medicaid,,3021.47,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Trillium,Medicaid,,6248.59,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Trillium,Medicaid,,3021.47,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Trillium,Medicaid,,2625.97,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Trillium,Medicaid,,2683.80,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Trillium,Medicaid,,2741.83,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Trillium,Medicaid,,2800.07,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Trillium,Medicaid,,2858.10,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Trillium,Medicaid,,2915.93,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Trillium,Medicaid,,2973.96,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Trillium,Medicaid,,3031.99,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Trillium,Medicaid,,100.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Trillium,Medicaid,,49.74,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Trillium,Medicaid,,40.44,,,,,,,34.82,150.00,percent of total billed charges,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,823.98,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,526.87,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,CHIP/Medicaid,,526.87,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,United Healthcare,CHIP/Medicaid,,0.02803,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,CHIP/Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,United Healthcare,CHIP/Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,CHIP/Medicaid,,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,CHIP/Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,United Healthcare,CHIP/Medicaid,,4.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,United Healthcare,CHIP/Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,United Healthcare,CHIP/Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,United Healthcare,CHIP/Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,United Healthcare,CHIP/Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,United Healthcare,CHIP/Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,United Healthcare,CHIP/Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,United Healthcare,CHIP/Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,United Healthcare,CHIP/Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,United Healthcare,CHIP/Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,United Healthcare,CHIP/Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,United Healthcare,CHIP/Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,United Healthcare,CHIP/Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,United Healthcare,CHIP/Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,United Healthcare,CHIP/Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,United Healthcare,CHIP/Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,United Healthcare,CHIP/Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,United Healthcare,CHIP/Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,United Healthcare,CHIP/Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,United Healthcare,CHIP/Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,United Healthcare,CHIP/Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,CHIP/Medicaid,,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,CHIP/Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,CHIP/Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,United Healthcare,CHIP/Medicaid,,6.26,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,United Healthcare,CHIP/Medicaid,,4.07,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,United Healthcare,CHIP/Medicaid,,55.85,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,United Healthcare,CHIP/Medicaid,,4.33,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,United Healthcare,CHIP/Medicaid,,0.00601,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,United Healthcare,CHIP/Medicaid,,4.29,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,United Healthcare,CHIP/Medicaid,,8.13,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,United Healthcare,CHIP/Medicaid,,4.08,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,United Healthcare,CHIP/Medicaid,,3.98,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,CHIP/Medicaid,,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,United Healthcare,CHIP/Medicaid,,13.07,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,United Healthcare,CHIP/Medicaid,,35.68,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,United Healthcare,CHIP/Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,United Healthcare,CHIP/Medicaid,,1.27,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,CHIP/Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,CHIP/Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,CHIP/Medicaid,,40.04,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,United Healthcare,CHIP/Medicaid,,5.94,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,CHIP/Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,CHIP/Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,CHIP/Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,CHIP/Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,CHIP/Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,CHIP/Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,CHIP/Medicaid,,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,CHIP/Medicaid,,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,CHIP/Medicaid,,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,CHIP/Medicaid,,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,CHIP/Medicaid,,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,CHIP/Medicaid,,93.29,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,United Healthcare,CHIP/Medicaid,,5.50,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,CHIP/Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,CHIP/Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,CHIP/Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,CHIP/Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,CHIP/Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,CHIP/Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,CHIP/Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,CHIP/Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,CHIP/Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,United Healthcare,CHIP/Medicaid,,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,CHIP/Medicaid,,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,CHIP/Medicaid,,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,CHIP/Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,CHIP/Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,CHIP/Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,CHIP/Medicaid,,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,CHIP/Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,CHIP/Medicaid,,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,CHIP/Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,CHIP/Medicaid,,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,CHIP/Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,CHIP/Medicaid,,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,CHIP/Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,CHIP/Medicaid,,54.45,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,United Healthcare,CHIP/Medicaid,,43.28,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,CHIP/Medicaid,,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,CHIP/Medicaid,,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,United Healthcare,CHIP/Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,United Healthcare,CHIP/Medicaid,,30.79,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,United Healthcare,CHIP/Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,CHIP/Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,United Healthcare,CHIP/Medicaid,,174.60,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,United Healthcare,CHIP/Medicaid,,214.26,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,United Healthcare,CHIP/Medicaid,,0.43644,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,United Healthcare,CHIP/Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,CHIP/Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,CHIP/Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,CHIP/Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,CHIP/Medicaid,,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,CHIP/Medicaid,,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,CHIP/Medicaid,,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,CHIP/Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,United Healthcare,CHIP/Medicaid,,0.62062,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,United Healthcare,CHIP/Medicaid,,1.97,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,United Healthcare,CHIP/Medicaid,,38.56,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,United Healthcare,CHIP/Medicaid,,13.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,CHIP/Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,United Healthcare,CHIP/Medicaid,,47.59,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,United Healthcare,CHIP/Medicaid,,54.83,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,United Healthcare,CHIP/Medicaid,,31.77,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,CHIP/Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,CHIP/Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,CHIP/Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,United Healthcare,CHIP/Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,CHIP/Medicaid,,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,United Healthcare,CHIP/Medicaid,,66.15,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,United Healthcare,CHIP/Medicaid,,65.92,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,United Healthcare,CHIP/Medicaid,,30.66,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,United Healthcare,CHIP/Medicaid,,31.80,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,CHIP/Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,CHIP/Medicaid,,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,United Healthcare,CHIP/Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,United Healthcare,CHIP/Medicaid,,0.02402,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,United Healthcare,CHIP/Medicaid,,0.05405,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,CHIP/Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,CHIP/Medicaid,,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,CHIP/Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,CHIP/Medicaid,,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,CHIP/Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,CHIP/Medicaid,,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,United Healthcare,CHIP/Medicaid,,64.52,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,United Healthcare,CHIP/Medicaid,,16.24,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,United Healthcare,CHIP/Medicaid,,10.71,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,United Healthcare,CHIP/Medicaid,,25.23,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,United Healthcare,CHIP/Medicaid,,6.18,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,United Healthcare,CHIP/Medicaid,,3.33,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,United Healthcare,CHIP/Medicaid,,23.38,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,United Healthcare,CHIP/Medicaid,,6.74,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,United Healthcare,CHIP/Medicaid,,19.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,United Healthcare,CHIP/Medicaid,,55.06,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,United Healthcare,CHIP/Medicaid,,8.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,United Healthcare,CHIP/Medicaid,,10.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,United Healthcare,CHIP/Medicaid,,33.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,United Healthcare,CHIP/Medicaid,,25.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,United Healthcare,CHIP/Medicaid,,30.87,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,United Healthcare,CHIP/Medicaid,,29.30,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,United Healthcare,CHIP/Medicaid,,5.23,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,United Healthcare,CHIP/Medicaid,,5.72,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,United Healthcare,CHIP/Medicaid,,13.62,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,United Healthcare,CHIP/Medicaid,,28.18,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,United Healthcare,CHIP/Medicaid,,0.10210,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,United Healthcare,CHIP/Medicaid,,5.25,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,United Healthcare,CHIP/Medicaid,,1.19,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,United Healthcare,CHIP/Medicaid,,2.11,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,United Healthcare,CHIP/Medicaid,,0.02202,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,United Healthcare,CHIP/Medicaid,,0.16016,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,United Healthcare,CHIP/Medicaid,,1.55,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,United Healthcare,CHIP/Medicaid,,0.15816,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,United Healthcare,CHIP/Medicaid,,0.09409,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,United Healthcare,CHIP/Medicaid,,0.12813,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,United Healthcare,CHIP/Medicaid,,333.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,United Healthcare,CHIP/Medicaid,,0.00400,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,United Healthcare,CHIP/Medicaid,,0.01802,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,United Healthcare,CHIP/Medicaid,,0.51451,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,United Healthcare,CHIP/Medicaid,,5.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,United Healthcare,CHIP/Medicaid,,16.31,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,United Healthcare,CHIP/Medicaid,,0.01401,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,United Healthcare,CHIP/Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,United Healthcare,CHIP/Medicaid,,1.23,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,United Healthcare,CHIP/Medicaid,,0.22422,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,United Healthcare,CHIP/Medicaid,,0.32232,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,United Healthcare,CHIP/Medicaid,,0.51251,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,United Healthcare,CHIP/Medicaid,,0.35836,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,United Healthcare,CHIP/Medicaid,,0.00400,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,United Healthcare,CHIP/Medicaid,,4.42,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,United Healthcare,CHIP/Medicaid,,220.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,United Healthcare,CHIP/Medicaid,,27.01,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,United Healthcare,CHIP/Medicaid,,33.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,United Healthcare,CHIP/Medicaid,,0.02603,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,United Healthcare,CHIP/Medicaid,,7.28,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,United Healthcare,CHIP/Medicaid,,13.07,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,United Healthcare,CHIP/Medicaid,,28.81,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,United Healthcare,CHIP/Medicaid,,12.73,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,United Healthcare,CHIP/Medicaid,,49.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,United Healthcare,CHIP/Medicaid,,2.25,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,United Healthcare,CHIP/Medicaid,,5.10,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,United Healthcare,CHIP/Medicaid,,0.15015,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,United Healthcare,CHIP/Medicaid,,0.00801,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,United Healthcare,CHIP/Medicaid,,3.03,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,United Healthcare,CHIP/Medicaid,,2.67,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,United Healthcare,CHIP/Medicaid,,2.38,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,United Healthcare,CHIP/Medicaid,,3.54,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,United Healthcare,CHIP/Medicaid,,6.68,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,United Healthcare,CHIP/Medicaid,,11.00,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,United Healthcare,CHIP/Medicaid,,27.86,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,United Healthcare,CHIP/Medicaid,,109.85,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,United Healthcare,CHIP/Medicaid,,63.31,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,United Healthcare,CHIP/Medicaid,,74.32,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,CHIP/Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,United Healthcare,CHIP/Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,United Healthcare,CHIP/Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,United Healthcare,CHIP/Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,CHIP/Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,CHIP/Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,CHIP/Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,CHIP/Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,CHIP/Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,CHIP/Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,CHIP/Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,CHIP/Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,United Healthcare,CHIP/Medicaid,,25.72,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,United Healthcare,CHIP/Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,United Healthcare,CHIP/Medicaid,,70.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,United Healthcare,CHIP/Medicaid,,77.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,United Healthcare,CHIP/Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,United Healthcare,CHIP/Medicaid,,709.51,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,United Healthcare,CHIP/Medicaid,,60.91,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,United Healthcare,CHIP/Medicaid,,8.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,CHIP/Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,CHIP/Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,United Healthcare,CHIP/Medicaid,,483.34,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,CHIP/Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,United Healthcare,CHIP/Medicaid,,94.40,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,CHIP/Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,CHIP/Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,United Healthcare,CHIP/Medicaid,,1045.12,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,CHIP/Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,United Healthcare,CHIP/Medicaid,,16.00,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,United Healthcare,CHIP/Medicaid,,6.74,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,United Healthcare,CHIP/Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,United Healthcare,CHIP/Medicaid,,9.41,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,United Healthcare,CHIP/Medicaid,,3.97,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,United Healthcare,CHIP/Medicaid,,5.05,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,United Healthcare,CHIP/Medicaid,,16.08,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,United Healthcare,CHIP/Medicaid,,6.49,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,United Healthcare,CHIP/Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,CHIP/Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,United Healthcare,CHIP/Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,United Healthcare,CHIP/Medicaid,,87.43,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,United Healthcare,CHIP/Medicaid,,149.79,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,United Healthcare,CHIP/Medicaid,,457.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,CHIP/Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,CHIP/Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,CHIP/Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,CHIP/Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,United Healthcare,CHIP/Medicaid,,9.90,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,United Healthcare,CHIP/Medicaid,,11.52,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,United Healthcare,CHIP/Medicaid,,113.81,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,United Healthcare,CHIP/Medicaid,,4.36,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,United Healthcare,CHIP/Medicaid,,4.93,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,United Healthcare,CHIP/Medicaid,,1.40,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,CHIP/Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,United Healthcare,CHIP/Medicaid,,0.52052,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,CHIP/Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,CHIP/Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,United Healthcare,CHIP/Medicaid,,5.36,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,United Healthcare,CHIP/Medicaid,,6.19,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,United Healthcare,CHIP/Medicaid,,4.76,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,United Healthcare,CHIP/Medicaid,,9.52,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,United Healthcare,CHIP/Medicaid,,5.88,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,United Healthcare,CHIP/Medicaid,,6.48,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,United Healthcare,CHIP/Medicaid,,548.82,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,United Healthcare,CHIP/Medicaid,,3.55,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,United Healthcare,CHIP/Medicaid,,3.35,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,United Healthcare,CHIP/Medicaid,,3.40,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,United Healthcare,CHIP/Medicaid,,4.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,United Healthcare,CHIP/Medicaid,,8.17,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,United Healthcare,CHIP/Medicaid,,368.29,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,United Healthcare,CHIP/Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,United Healthcare,CHIP/Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,United Healthcare,CHIP/Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,United Healthcare,CHIP/Medicaid,,6.56,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,United Healthcare,CHIP/Medicaid,,49.43,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,United Healthcare,CHIP/Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,United Healthcare,CHIP/Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,United Healthcare,CHIP/Medicaid,,4.55,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,United Healthcare,CHIP/Medicaid,,4068.51,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,United Healthcare,CHIP/Medicaid,,6.41,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,CHIP/Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,United Healthcare,CHIP/Medicaid,,31.60,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,United Healthcare,CHIP/Medicaid,,60.24,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,CHIP/Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,United Healthcare,CHIP/Medicaid,,14.07,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,United Healthcare,CHIP/Medicaid,,16.98,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,United Healthcare,CHIP/Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,United Healthcare,CHIP/Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,United Healthcare,CHIP/Medicaid,,155.02,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,CHIP/Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,United Healthcare,CHIP/Medicaid,,10.18,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,United Healthcare,CHIP/Medicaid,,13.78,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,United Healthcare,CHIP/Medicaid,,13.34,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,United Healthcare,CHIP/Medicaid,,14.46,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,United Healthcare,CHIP/Medicaid,,7.94,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,United Healthcare,CHIP/Medicaid,,5.64,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,United Healthcare,CHIP/Medicaid,,12179.59,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,United Healthcare,CHIP/Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,United Healthcare,CHIP/Medicaid,,31.70,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,United Healthcare,CHIP/Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,United Healthcare,CHIP/Medicaid,,104.15,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,United Healthcare,CHIP/Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,United Healthcare,CHIP/Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,United Healthcare,CHIP/Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,United Healthcare,CHIP/Medicaid,,9.99,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,United Healthcare,CHIP/Medicaid,,12.25,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,United Healthcare,CHIP/Medicaid,,16.79,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,United Healthcare,CHIP/Medicaid,,21.31,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,United Healthcare,CHIP/Medicaid,,25.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,United Healthcare,CHIP/Medicaid,,14.18,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,United Healthcare,CHIP/Medicaid,,15.24,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,United Healthcare,CHIP/Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,CHIP/Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,United Healthcare,CHIP/Medicaid,,247.33,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,United Healthcare,CHIP/Medicaid,,468.68,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,United Healthcare,CHIP/Medicaid,,1.70,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,United Healthcare,CHIP/Medicaid,,34.23,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,United Healthcare,CHIP/Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,CHIP/Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,United Healthcare,CHIP/Medicaid,,4.12,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,United Healthcare,CHIP/Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,United Healthcare,CHIP/Medicaid,,7.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,United Healthcare,CHIP/Medicaid,,14.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,United Healthcare,CHIP/Medicaid,,24.62,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,United Healthcare,CHIP/Medicaid,,611.76,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,CHIP/Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,United Healthcare,CHIP/Medicaid,,269.35,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,United Healthcare,CHIP/Medicaid,,4.30,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,United Healthcare,CHIP/Medicaid,,12.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,United Healthcare,CHIP/Medicaid,,7.13,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,United Healthcare,CHIP/Medicaid,,6.68,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,United Healthcare,CHIP/Medicaid,,6.82,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,CHIP/Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,CHIP/Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,United Healthcare,CHIP/Medicaid,,484.62,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,United Healthcare,CHIP/Medicaid,,1297.10,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,United Healthcare,CHIP/Medicaid,,33.63,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,United Healthcare,CHIP/Medicaid,,5.52,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,United Healthcare,CHIP/Medicaid,,12.75,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,CHIP/Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,CHIP/Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,United Healthcare,CHIP/Medicaid,,5.51,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,United Healthcare,CHIP/Medicaid,,6.30,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,United Healthcare,CHIP/Medicaid,,31.51,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,CHIP/Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,United Healthcare,CHIP/Medicaid,,20.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,United Healthcare,CHIP/Medicaid,,117.13,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,United Healthcare,CHIP/Medicaid,,36.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,United Healthcare,CHIP/Medicaid,,52.11,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,United Healthcare,CHIP/Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,CHIP/Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,United Healthcare,CHIP/Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,United Healthcare,CHIP/Medicaid,,20.21,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,United Healthcare,CHIP/Medicaid,,35.74,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,United Healthcare,CHIP/Medicaid,,105.20,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,United Healthcare,CHIP/Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,United Healthcare,CHIP/Medicaid,,20.25,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,United Healthcare,CHIP/Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,United Healthcare,CHIP/Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,United Healthcare,CHIP/Medicaid,,176.48,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,United Healthcare,CHIP/Medicaid,,11.71,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,United Healthcare,CHIP/Medicaid,,179.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,United Healthcare,CHIP/Medicaid,,285.22,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,United Healthcare,CHIP/Medicaid,,426.24,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,United Healthcare,CHIP/Medicaid,,708.25,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,United Healthcare,CHIP/Medicaid,,1413.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,United Healthcare,CHIP/Medicaid,,2118.34,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,United Healthcare,CHIP/Medicaid,,339.37,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,United Healthcare,CHIP/Medicaid,,1650.91,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,United Healthcare,CHIP/Medicaid,,6438.44,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,CHIP/Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,CHIP/Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,CHIP/Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,CHIP/Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,United Healthcare,CHIP/Medicaid,,1763.13,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,United Healthcare,CHIP/Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,United Healthcare,CHIP/Medicaid,,16.68,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,United Healthcare,CHIP/Medicaid,,20.29,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,United Healthcare,CHIP/Medicaid,,30.82,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,United Healthcare,CHIP/Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,United Healthcare,CHIP/Medicaid,,3.74,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,United Healthcare,CHIP/Medicaid,,23.20,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,United Healthcare,CHIP/Medicaid,,28.42,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,United Healthcare,CHIP/Medicaid,,177.12,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,CHIP/Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,CHIP/Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,CHIP/Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,United Healthcare,CHIP/Medicaid,,197.30,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,United Healthcare,CHIP/Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,United Healthcare,CHIP/Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,United Healthcare,CHIP/Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,United Healthcare,CHIP/Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,United Healthcare,CHIP/Medicaid,,20.15,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,United Healthcare,CHIP/Medicaid,,38.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,United Healthcare,CHIP/Medicaid,,2654.78,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,United Healthcare,CHIP/Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,United Healthcare,CHIP/Medicaid,,2.75,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,United Healthcare,CHIP/Medicaid,,449.52,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,United Healthcare,CHIP/Medicaid,,17.23,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,United Healthcare,CHIP/Medicaid,,142.12,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,United Healthcare,CHIP/Medicaid,,42.80,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,United Healthcare,CHIP/Medicaid,,12.13,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,CHIP/Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,United Healthcare,CHIP/Medicaid,,36.93,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,United Healthcare,CHIP/Medicaid,,44.98,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,United Healthcare,CHIP/Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,United Healthcare,CHIP/Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,CHIP/Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,United Healthcare,CHIP/Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,CHIP/Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,United Healthcare,CHIP/Medicaid,,0.62062,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,United Healthcare,CHIP/Medicaid,,16.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,United Healthcare,CHIP/Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,United Healthcare,CHIP/Medicaid,,15.28,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,United Healthcare,CHIP/Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,United Healthcare,CHIP/Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,United Healthcare,CHIP/Medicaid,,21.02,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,United Healthcare,CHIP/Medicaid,,94.41,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,CHIP/Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,United Healthcare,CHIP/Medicaid,,56.41,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,CHIP/Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,United Healthcare,CHIP/Medicaid,,11220.92,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,CHIP/Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,United Healthcare,CHIP/Medicaid,,893.81,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,CHIP/Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,United Healthcare,CHIP/Medicaid,,14.13,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,United Healthcare,CHIP/Medicaid,,5.40,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,CHIP/Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,United Healthcare,CHIP/Medicaid,,6.29,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,CHIP/Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,United Healthcare,CHIP/Medicaid,,13.56,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,United Healthcare,CHIP/Medicaid,,5.97,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,United Healthcare,CHIP/Medicaid,,223.00,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,United Healthcare,CHIP/Medicaid,,366.37,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,United Healthcare,CHIP/Medicaid,,63.28,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,United Healthcare,CHIP/Medicaid,,94.95,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,CHIP/Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,CHIP/Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,United Healthcare,CHIP/Medicaid,,142.19,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,United Healthcare,CHIP/Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,CHIP/Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,United Healthcare,CHIP/Medicaid,,113.11,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,United Healthcare,CHIP/Medicaid,,239.91,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,United Healthcare,CHIP/Medicaid,,0.82082,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,United Healthcare,CHIP/Medicaid,,113.87,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,United Healthcare,CHIP/Medicaid,,22.42,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,United Healthcare,CHIP/Medicaid,,33.63,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,CHIP/Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,CHIP/Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,United Healthcare,CHIP/Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,United Healthcare,CHIP/Medicaid,,122.05,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,United Healthcare,CHIP/Medicaid,,31.90,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,United Healthcare,CHIP/Medicaid,,17.42,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,United Healthcare,CHIP/Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,United Healthcare,CHIP/Medicaid,,4.22,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,CHIP/Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,United Healthcare,CHIP/Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,United Healthcare,CHIP/Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,CHIP/Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,United Healthcare,CHIP/Medicaid,,6.85,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,United Healthcare,CHIP/Medicaid,,24.72,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,United Healthcare,CHIP/Medicaid,,25.00,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,United Healthcare,CHIP/Medicaid,,9.78,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,United Healthcare,CHIP/Medicaid,,12.40,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,United Healthcare,CHIP/Medicaid,,6.32,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,United Healthcare,CHIP/Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,United Healthcare,CHIP/Medicaid,,76.08,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,United Healthcare,CHIP/Medicaid,,182.24,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,United Healthcare,CHIP/Medicaid,,33.58,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,United Healthcare,CHIP/Medicaid,,64.10,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,United Healthcare,CHIP/Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,United Healthcare,CHIP/Medicaid,,120.93,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,United Healthcare,CHIP/Medicaid,,5085.99,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,United Healthcare,CHIP/Medicaid,,371.29,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,United Healthcare,CHIP/Medicaid,,4.20,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,United Healthcare,CHIP/Medicaid,,192.56,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,United Healthcare,CHIP/Medicaid,,4.99,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,CHIP/Medicaid,,16.95,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,United Healthcare,CHIP/Medicaid,,7.22,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,United Healthcare,CHIP/Medicaid,,330.57,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,United Healthcare,CHIP/Medicaid,,6063.10,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,CHIP/Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,United Healthcare,CHIP/Medicaid,,6.34,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,United Healthcare,CHIP/Medicaid,,10.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,United Healthcare,CHIP/Medicaid,,7.62,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,United Healthcare,CHIP/Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,United Healthcare,CHIP/Medicaid,,14.42,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,United Healthcare,CHIP/Medicaid,,15.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,United Healthcare,CHIP/Medicaid,,37.17,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,United Healthcare,CHIP/Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,CHIP/Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,United Healthcare,CHIP/Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,United Healthcare,CHIP/Medicaid,,64.17,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,United Healthcare,CHIP/Medicaid,,87.69,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,CHIP/Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,United Healthcare,CHIP/Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,United Healthcare,CHIP/Medicaid,,413.11,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,United Healthcare,CHIP/Medicaid,,549.75,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,CHIP/Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,United Healthcare,CHIP/Medicaid,,39.28,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,United Healthcare,CHIP/Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,United Healthcare,CHIP/Medicaid,,0.54054,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,United Healthcare,CHIP/Medicaid,,12.01,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,United Healthcare,CHIP/Medicaid,,6.45,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,United Healthcare,CHIP/Medicaid,,4.46,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,United Healthcare,CHIP/Medicaid,,17.53,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,United Healthcare,CHIP/Medicaid,,23.06,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,United Healthcare,CHIP/Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,United Healthcare,CHIP/Medicaid,,9.95,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,United Healthcare,CHIP/Medicaid,,7.23,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,United Healthcare,CHIP/Medicaid,,29.62,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,United Healthcare,CHIP/Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,United Healthcare,CHIP/Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,United Healthcare,CHIP/Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,United Healthcare,CHIP/Medicaid,,41.45,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,United Healthcare,CHIP/Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,United Healthcare,CHIP/Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,United Healthcare,CHIP/Medicaid,,6.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,United Healthcare,CHIP/Medicaid,,110.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,United Healthcare,CHIP/Medicaid,,5.37,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,United Healthcare,CHIP/Medicaid,,4.79,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,United Healthcare,CHIP/Medicaid,,5.90,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,United Healthcare,CHIP/Medicaid,,8.63,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,United Healthcare,CHIP/Medicaid,,10.70,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,United Healthcare,CHIP/Medicaid,,12.18,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,United Healthcare,CHIP/Medicaid,,35.74,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,United Healthcare,CHIP/Medicaid,,101.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,United Healthcare,CHIP/Medicaid,,10.63,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,United Healthcare,CHIP/Medicaid,,4.94,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,United Healthcare,CHIP/Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,United Healthcare,CHIP/Medicaid,,12.26,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,United Healthcare,CHIP/Medicaid,,5.59,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,United Healthcare,CHIP/Medicaid,,34.07,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,United Healthcare,CHIP/Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,United Healthcare,CHIP/Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,United Healthcare,CHIP/Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,United Healthcare,CHIP/Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,CHIP/Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,United Healthcare,CHIP/Medicaid,,23675.99,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,United Healthcare,CHIP/Medicaid,,25.12,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,United Healthcare,CHIP/Medicaid,,150.32,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,United Healthcare,CHIP/Medicaid,,2.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,United Healthcare,CHIP/Medicaid,,2.99,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,United Healthcare,CHIP/Medicaid,,15.35,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,United Healthcare,CHIP/Medicaid,,1.07,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,United Healthcare,CHIP/Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,United Healthcare,CHIP/Medicaid,,8.04,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,United Healthcare,CHIP/Medicaid,,8.95,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,United Healthcare,CHIP/Medicaid,,7.29,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,United Healthcare,CHIP/Medicaid,,17.00,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,United Healthcare,CHIP/Medicaid,,16.97,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,United Healthcare,CHIP/Medicaid,,17.00,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,United Healthcare,CHIP/Medicaid,,16.61,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,United Healthcare,CHIP/Medicaid,,210.68,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,United Healthcare,CHIP/Medicaid,,1079.07,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,United Healthcare,CHIP/Medicaid,,728.09,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,United Healthcare,CHIP/Medicaid,,6.63,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,United Healthcare,CHIP/Medicaid,,3156.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,United Healthcare,CHIP/Medicaid,,0.58058,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,United Healthcare,CHIP/Medicaid,,4.21,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,United Healthcare,CHIP/Medicaid,,86.25,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,United Healthcare,CHIP/Medicaid,,47.35,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,United Healthcare,CHIP/Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,United Healthcare,CHIP/Medicaid,,21.62,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,United Healthcare,CHIP/Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,United Healthcare,CHIP/Medicaid,,28.88,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,United Healthcare,CHIP/Medicaid,,58.02,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,United Healthcare,CHIP/Medicaid,,535.27,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,United Healthcare,CHIP/Medicaid,,17.52,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,United Healthcare,CHIP/Medicaid,,1.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,United Healthcare,CHIP/Medicaid,,667.95,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,United Healthcare,CHIP/Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,United Healthcare,CHIP/Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,United Healthcare,CHIP/Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,United Healthcare,CHIP/Medicaid,,163.80,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,United Healthcare,CHIP/Medicaid,,64.00,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,United Healthcare,CHIP/Medicaid,,197.18,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,CHIP/Medicaid,,5.03,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,United Healthcare,CHIP/Medicaid,,272.42,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,United Healthcare,CHIP/Medicaid,,17.52,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,United Healthcare,CHIP/Medicaid,,43.51,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,United Healthcare,CHIP/Medicaid,,7.69,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,United Healthcare,CHIP/Medicaid,,7.85,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,United Healthcare,CHIP/Medicaid,,1250.81,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,United Healthcare,CHIP/Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,United Healthcare,CHIP/Medicaid,,4.16,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,United Healthcare,CHIP/Medicaid,,1902.78,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,United Healthcare,CHIP/Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,United Healthcare,CHIP/Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,CHIP/Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,CHIP/Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,United Healthcare,CHIP/Medicaid,,52.45,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,United Healthcare,CHIP/Medicaid,,70.57,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,United Healthcare,CHIP/Medicaid,,2.17,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,United Healthcare,CHIP/Medicaid,,59.78,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,United Healthcare,CHIP/Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,United Healthcare,CHIP/Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,United Healthcare,CHIP/Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,United Healthcare,CHIP/Medicaid,,9.27,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,United Healthcare,CHIP/Medicaid,,43.77,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,United Healthcare,CHIP/Medicaid,,35.92,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,United Healthcare,CHIP/Medicaid,,19.98,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,CHIP/Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,United Healthcare,CHIP/Medicaid,,31.22,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,United Healthcare,CHIP/Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,CHIP/Medicaid,,4.40,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,United Healthcare,CHIP/Medicaid,,12.96,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,United Healthcare,CHIP/Medicaid,,2397.64,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,United Healthcare,CHIP/Medicaid,,11.54,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,United Healthcare,CHIP/Medicaid,,6.85,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,United Healthcare,CHIP/Medicaid,,16.12,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,United Healthcare,CHIP/Medicaid,,4.73,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,United Healthcare,CHIP/Medicaid,,1945.70,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,United Healthcare,CHIP/Medicaid,,50.03,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,United Healthcare,CHIP/Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,United Healthcare,CHIP/Medicaid,,1.47,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,United Healthcare,CHIP/Medicaid,,27.60,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,United Healthcare,CHIP/Medicaid,,3.70,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,United Healthcare,CHIP/Medicaid,,16.17,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,United Healthcare,CHIP/Medicaid,,17.22,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,United Healthcare,CHIP/Medicaid,,36.04,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,United Healthcare,CHIP/Medicaid,,19.45,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,CHIP/Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,United Healthcare,CHIP/Medicaid,,31.84,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,United Healthcare,CHIP/Medicaid,,18.79,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,United Healthcare,CHIP/Medicaid,,14.10,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,United Healthcare,CHIP/Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,United Healthcare,CHIP/Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,United Healthcare,CHIP/Medicaid,,16.83,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,United Healthcare,CHIP/Medicaid,,2.36,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,CHIP/Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,CHIP/Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,United Healthcare,CHIP/Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,United Healthcare,CHIP/Medicaid,,2.21,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,United Healthcare,CHIP/Medicaid,,1641.62,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,United Healthcare,CHIP/Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,CHIP/Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,United Healthcare,CHIP/Medicaid,,12.35,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,United Healthcare,CHIP/Medicaid,,74.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,United Healthcare,CHIP/Medicaid,,38.55,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,United Healthcare,CHIP/Medicaid,,14.08,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,United Healthcare,CHIP/Medicaid,,13.27,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,CHIP/Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,CHIP/Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,CHIP/Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,United Healthcare,CHIP/Medicaid,,5.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,CHIP/Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,United Healthcare,CHIP/Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,United Healthcare,CHIP/Medicaid,,22.60,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,United Healthcare,CHIP/Medicaid,,26.46,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,CHIP/Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,United Healthcare,CHIP/Medicaid,,18.05,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,United Healthcare,CHIP/Medicaid,,29.76,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,United Healthcare,CHIP/Medicaid,,8.92,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,United Healthcare,CHIP/Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,United Healthcare,CHIP/Medicaid,,4.05,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,United Healthcare,CHIP/Medicaid,,69.27,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,United Healthcare,CHIP/Medicaid,,253.03,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,United Healthcare,CHIP/Medicaid,,4.61,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,United Healthcare,CHIP/Medicaid,,90.65,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,United Healthcare,CHIP/Medicaid,,181.74,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,United Healthcare,CHIP/Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,United Healthcare,CHIP/Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,United Healthcare,CHIP/Medicaid,,1.78,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,CHIP/Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,United Healthcare,CHIP/Medicaid,,48.18,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,CHIP/Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,CHIP/Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,United Healthcare,CHIP/Medicaid,,18.93,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,United Healthcare,CHIP/Medicaid,,5.67,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,United Healthcare,CHIP/Medicaid,,26.98,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,United Healthcare,CHIP/Medicaid,,28.38,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,United Healthcare,CHIP/Medicaid,,8.76,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,United Healthcare,CHIP/Medicaid,,69.80,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,United Healthcare,CHIP/Medicaid,,4.19,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,United Healthcare,CHIP/Medicaid,,3.75,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,United Healthcare,CHIP/Medicaid,,28.38,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,United Healthcare,CHIP/Medicaid,,32.93,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,United Healthcare,CHIP/Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,United Healthcare,CHIP/Medicaid,,0.64064,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,United Healthcare,CHIP/Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,United Healthcare,CHIP/Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,United Healthcare,CHIP/Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,United Healthcare,CHIP/Medicaid,,18.36,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,United Healthcare,CHIP/Medicaid,,15.96,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,United Healthcare,CHIP/Medicaid,,94.29,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,United Healthcare,CHIP/Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,United Healthcare,CHIP/Medicaid,,4.64,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,United Healthcare,CHIP/Medicaid,,4.70,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,CHIP/Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,United Healthcare,CHIP/Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,United Healthcare,CHIP/Medicaid,,2779.01,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,United Healthcare,CHIP/Medicaid,,60.82,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,United Healthcare,CHIP/Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,United Healthcare,CHIP/Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,United Healthcare,CHIP/Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,United Healthcare,CHIP/Medicaid,,813.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,United Healthcare,CHIP/Medicaid,,22.63,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,United Healthcare,CHIP/Medicaid,,23.59,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,United Healthcare,CHIP/Medicaid,,3569.45,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,United Healthcare,CHIP/Medicaid,,5678.07,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,United Healthcare,CHIP/Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,United Healthcare,CHIP/Medicaid,,1.23,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,United Healthcare,CHIP/Medicaid,,29.52,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,United Healthcare,CHIP/Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,United Healthcare,CHIP/Medicaid,,8.31,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,United Healthcare,CHIP/Medicaid,,4.74,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,CHIP/Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,United Healthcare,CHIP/Medicaid,,32.33,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,United Healthcare,CHIP/Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,United Healthcare,CHIP/Medicaid,,19.60,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,United Healthcare,CHIP/Medicaid,,18.87,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,United Healthcare,CHIP/Medicaid,,916.12,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,United Healthcare,CHIP/Medicaid,,30.63,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,United Healthcare,CHIP/Medicaid,,4.81,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,United Healthcare,CHIP/Medicaid,,0.96096,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,United Healthcare,CHIP/Medicaid,,65.28,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,United Healthcare,CHIP/Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,United Healthcare,CHIP/Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,United Healthcare,CHIP/Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,United Healthcare,CHIP/Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,CHIP/Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,United Healthcare,CHIP/Medicaid,,110.10,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,United Healthcare,CHIP/Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,United Healthcare,CHIP/Medicaid,,4.47,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,United Healthcare,CHIP/Medicaid,,0.37037,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,United Healthcare,CHIP/Medicaid,,16.84,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,United Healthcare,CHIP/Medicaid,,64.93,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,United Healthcare,CHIP/Medicaid,,98.80,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,United Healthcare,CHIP/Medicaid,,4.09,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,United Healthcare,CHIP/Medicaid,,71.50,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,United Healthcare,CHIP/Medicaid,,105.65,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,United Healthcare,CHIP/Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,United Healthcare,CHIP/Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,United Healthcare,CHIP/Medicaid,,73.80,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,United Healthcare,CHIP/Medicaid,,1279.76,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,United Healthcare,CHIP/Medicaid,,5.69,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,United Healthcare,CHIP/Medicaid,,1377.08,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,United Healthcare,CHIP/Medicaid,,6665.14,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,CHIP/Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,CHIP/Medicaid,,11.01,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,United Healthcare,CHIP/Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,CHIP/Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,United Healthcare,CHIP/Medicaid,,7882.80,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,United Healthcare,CHIP/Medicaid,,1623.83,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,CHIP/Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,United Healthcare,CHIP/Medicaid,,76.35,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,United Healthcare,CHIP/Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,United Healthcare,CHIP/Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,United Healthcare,CHIP/Medicaid,,419.08,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,United Healthcare,CHIP/Medicaid,,2799.47,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,CHIP/Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,United Healthcare,CHIP/Medicaid,,92.54,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,United Healthcare,CHIP/Medicaid,,219.22,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,United Healthcare,CHIP/Medicaid,,49.55,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,CHIP/Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,United Healthcare,CHIP/Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,United Healthcare,CHIP/Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,United Healthcare,CHIP/Medicaid,,48.28,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,United Healthcare,CHIP/Medicaid,,61.64,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,United Healthcare,CHIP/Medicaid,,81.44,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,CHIP/Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,United Healthcare,CHIP/Medicaid,,162.03,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,United Healthcare,CHIP/Medicaid,,1221.21,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,United Healthcare,CHIP/Medicaid,,2970.42,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,CHIP/Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,CHIP/Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,United Healthcare,CHIP/Medicaid,,146.38,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,United Healthcare,CHIP/Medicaid,,7.91,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,United Healthcare,CHIP/Medicaid,,9.55,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,United Healthcare,CHIP/Medicaid,,10.92,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,United Healthcare,CHIP/Medicaid,,15.56,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,CHIP/Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,United Healthcare,CHIP/Medicaid,,5250.24,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,United Healthcare,CHIP/Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,United Healthcare,CHIP/Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,United Healthcare,CHIP/Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,United Healthcare,CHIP/Medicaid,,21.88,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,United Healthcare,CHIP/Medicaid,,356.36,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,United Healthcare,CHIP/Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,United Healthcare,CHIP/Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,United Healthcare,CHIP/Medicaid,,4208.24,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,United Healthcare,CHIP/Medicaid,,6299.92,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,United Healthcare,CHIP/Medicaid,,3212.74,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,United Healthcare,CHIP/Medicaid,,361.87,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,United Healthcare,CHIP/Medicaid,,750.14,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,United Healthcare,CHIP/Medicaid,,1.62,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,United Healthcare,CHIP/Medicaid,,18.92,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,United Healthcare,CHIP/Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,United Healthcare,CHIP/Medicaid,,783.62,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,United Healthcare,CHIP/Medicaid,,16833.42,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,United Healthcare,CHIP/Medicaid,,396.12,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,United Healthcare,CHIP/Medicaid,,98.74,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,United Healthcare,CHIP/Medicaid,,926.81,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,United Healthcare,CHIP/Medicaid,,1838.20,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,United Healthcare,CHIP/Medicaid,,915.21,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,CHIP/Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,CHIP/Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,CHIP/Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,United Healthcare,CHIP/Medicaid,,403.08,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,United Healthcare,CHIP/Medicaid,,253.12,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,CHIP/Medicaid,,8.87,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,United Healthcare,CHIP/Medicaid,,25.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,United Healthcare,CHIP/Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,United Healthcare,CHIP/Medicaid,,16.86,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,United Healthcare,CHIP/Medicaid,,15.22,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,United Healthcare,CHIP/Medicaid,,2157.77,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,United Healthcare,CHIP/Medicaid,,2679.20,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,United Healthcare,CHIP/Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,United Healthcare,CHIP/Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,United Healthcare,CHIP/Medicaid,,11.51,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,United Healthcare,CHIP/Medicaid,,3285.05,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,United Healthcare,CHIP/Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,United Healthcare,CHIP/Medicaid,,19.57,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,United Healthcare,CHIP/Medicaid,,29.49,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,United Healthcare,CHIP/Medicaid,,11.91,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,United Healthcare,CHIP/Medicaid,,2234.18,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,United Healthcare,CHIP/Medicaid,,208.06,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,United Healthcare,CHIP/Medicaid,,127.22,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,United Healthcare,CHIP/Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,United Healthcare,CHIP/Medicaid,,43.75,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,United Healthcare,CHIP/Medicaid,,3.83,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,United Healthcare,CHIP/Medicaid,,175.64,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,United Healthcare,CHIP/Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,United Healthcare,CHIP/Medicaid,,808.29,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,United Healthcare,CHIP/Medicaid,,331.70,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,United Healthcare,CHIP/Medicaid,,61.99,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,United Healthcare,CHIP/Medicaid,,2704.88,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,United Healthcare,CHIP/Medicaid,,15.43,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,United Healthcare,CHIP/Medicaid,,57.14,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,United Healthcare,CHIP/Medicaid,,109.23,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,United Healthcare,CHIP/Medicaid,,930.37,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,United Healthcare,CHIP/Medicaid,,42.32,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,United Healthcare,CHIP/Medicaid,,19.15,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,United Healthcare,CHIP/Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,CHIP/Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,CHIP/Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,United Healthcare,CHIP/Medicaid,,270.30,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,United Healthcare,CHIP/Medicaid,,24.52,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,United Healthcare,CHIP/Medicaid,,549.99,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,United Healthcare,CHIP/Medicaid,,12.28,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,United Healthcare,CHIP/Medicaid,,216.72,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,United Healthcare,CHIP/Medicaid,,12.27,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,United Healthcare,CHIP/Medicaid,,3207.80,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,United Healthcare,CHIP/Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,United Healthcare,CHIP/Medicaid,,38.37,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,United Healthcare,CHIP/Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,United Healthcare,CHIP/Medicaid,,73.53,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,United Healthcare,CHIP/Medicaid,,11.51,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,United Healthcare,CHIP/Medicaid,,6.86,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,United Healthcare,CHIP/Medicaid,,7.99,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,United Healthcare,CHIP/Medicaid,,17993.44,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,United Healthcare,CHIP/Medicaid,,1899.64,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,United Healthcare,CHIP/Medicaid,,17368.36,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,United Healthcare,CHIP/Medicaid,,8.97,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,United Healthcare,CHIP/Medicaid,,1427.85,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,United Healthcare,CHIP/Medicaid,,179.52,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,United Healthcare,CHIP/Medicaid,,3838.14,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,United Healthcare,CHIP/Medicaid,,963.00,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,United Healthcare,CHIP/Medicaid,,5848.24,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,United Healthcare,CHIP/Medicaid,,1.33,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,United Healthcare,CHIP/Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,United Healthcare,CHIP/Medicaid,,6675.83,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,United Healthcare,CHIP/Medicaid,,14.27,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,United Healthcare,CHIP/Medicaid,,13.75,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,United Healthcare,CHIP/Medicaid,,262.81,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,United Healthcare,CHIP/Medicaid,,903.18,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,United Healthcare,CHIP/Medicaid,,9.57,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,United Healthcare,CHIP/Medicaid,,9727.12,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,United Healthcare,CHIP/Medicaid,,21122.14,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,CHIP/Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,United Healthcare,CHIP/Medicaid,,26.35,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,United Healthcare,CHIP/Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,United Healthcare,CHIP/Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,United Healthcare,CHIP/Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,CHIP/Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,United Healthcare,CHIP/Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,CHIP/Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,United Healthcare,CHIP/Medicaid,,39.94,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,United Healthcare,CHIP/Medicaid,,199.70,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,United Healthcare,CHIP/Medicaid,,13.23,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,United Healthcare,CHIP/Medicaid,,133.84,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,United Healthcare,CHIP/Medicaid,,0.94094,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,United Healthcare,CHIP/Medicaid,,3.68,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,United Healthcare,CHIP/Medicaid,,394.84,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,United Healthcare,CHIP/Medicaid,,5329.34,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,United Healthcare,CHIP/Medicaid,,1179.31,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,United Healthcare,CHIP/Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,United Healthcare,CHIP/Medicaid,,7051.96,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,United Healthcare,CHIP/Medicaid,,16.03,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,United Healthcare,CHIP/Medicaid,,48.44,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,United Healthcare,CHIP/Medicaid,,77.98,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,CHIP/Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,United Healthcare,CHIP/Medicaid,,11.70,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,United Healthcare,CHIP/Medicaid,,23.30,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,United Healthcare,CHIP/Medicaid,,33.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,United Healthcare,CHIP/Medicaid,,43.39,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,United Healthcare,CHIP/Medicaid,,103.68,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,United Healthcare,CHIP/Medicaid,,405.10,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,United Healthcare,CHIP/Medicaid,,1904.73,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,United Healthcare,CHIP/Medicaid,,105.11,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,United Healthcare,CHIP/Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,United Healthcare,CHIP/Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,United Healthcare,CHIP/Medicaid,,97.95,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,United Healthcare,CHIP/Medicaid,,4267.77,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,United Healthcare,CHIP/Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,United Healthcare,CHIP/Medicaid,,322.39,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,United Healthcare,CHIP/Medicaid,,69.02,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,CHIP/Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,United Healthcare,CHIP/Medicaid,,11.19,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,United Healthcare,CHIP/Medicaid,,1030.23,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,United Healthcare,CHIP/Medicaid,,9678.64,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,CHIP/Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,United Healthcare,CHIP/Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,United Healthcare,CHIP/Medicaid,,909.56,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,CHIP/Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,CHIP/Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,United Healthcare,CHIP/Medicaid,,7220.03,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,United Healthcare,CHIP/Medicaid,,586.19,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,CHIP/Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,United Healthcare,CHIP/Medicaid,,4173.39,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,United Healthcare,CHIP/Medicaid,,40.64,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,United Healthcare,CHIP/Medicaid,,57.46,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,United Healthcare,CHIP/Medicaid,,83.99,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,United Healthcare,CHIP/Medicaid,,356.56,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,United Healthcare,CHIP/Medicaid,,16449.48,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,United Healthcare,CHIP/Medicaid,,2513.50,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,United Healthcare,CHIP/Medicaid,,669.68,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,United Healthcare,CHIP/Medicaid,,40.29,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,United Healthcare,CHIP/Medicaid,,9.61,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,United Healthcare,CHIP/Medicaid,,4.77,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,CHIP/Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,United Healthcare,CHIP/Medicaid,,799.89,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,United Healthcare,CHIP/Medicaid,,3779.20,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,United Healthcare,CHIP/Medicaid,,3471.11,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,United Healthcare,CHIP/Medicaid,,10388.06,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,United Healthcare,CHIP/Medicaid,,2075.14,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,United Healthcare,CHIP/Medicaid,,1257.11,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,United Healthcare,CHIP/Medicaid,,21.45,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,United Healthcare,CHIP/Medicaid,,2529.45,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,CHIP/Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,United Healthcare,CHIP/Medicaid,,2773.87,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,United Healthcare,CHIP/Medicaid,,2216.38,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,United Healthcare,CHIP/Medicaid,,595.39,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,United Healthcare,CHIP/Medicaid,,686.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,United Healthcare,CHIP/Medicaid,,3212.13,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,United Healthcare,CHIP/Medicaid,,15163.67,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,United Healthcare,CHIP/Medicaid,,3042.20,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,United Healthcare,CHIP/Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,United Healthcare,CHIP/Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,United Healthcare,CHIP/Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,United Healthcare,CHIP/Medicaid,,1643.90,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,United Healthcare,CHIP/Medicaid,,3886.53,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,United Healthcare,CHIP/Medicaid,,821.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,United Healthcare,CHIP/Medicaid,,29.85,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,United Healthcare,CHIP/Medicaid,,2313.19,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,United Healthcare,CHIP/Medicaid,,22028.61,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,United Healthcare,CHIP/Medicaid,,433.03,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,CHIP/Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,United Healthcare,CHIP/Medicaid,,8.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,United Healthcare,CHIP/Medicaid,,35.29,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,CHIP/Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,United Healthcare,CHIP/Medicaid,,12313.86,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,United Healthcare,CHIP/Medicaid,,8227.27,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,United Healthcare,CHIP/Medicaid,,13.14,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,United Healthcare,CHIP/Medicaid,,1284.65,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,United Healthcare,CHIP/Medicaid,,3568.15,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,United Healthcare,CHIP/Medicaid,,20151.54,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,United Healthcare,CHIP/Medicaid,,5505.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,United Healthcare,CHIP/Medicaid,,204.15,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,United Healthcare,CHIP/Medicaid,,1350.05,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,United Healthcare,CHIP/Medicaid,,1121.90,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,United Healthcare,CHIP/Medicaid,,1845.18,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,United Healthcare,CHIP/Medicaid,,25003.11,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,United Healthcare,CHIP/Medicaid,,10652.28,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,United Healthcare,CHIP/Medicaid,,4098.29,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,United Healthcare,CHIP/Medicaid,,3408.28,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,CHIP/Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,CHIP/Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,United Healthcare,CHIP/Medicaid,,16.27,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,United Healthcare,CHIP/Medicaid,,174.05,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,United Healthcare,CHIP/Medicaid,,6574.28,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,United Healthcare,CHIP/Medicaid,,21.51,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,United Healthcare,CHIP/Medicaid,,82.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,United Healthcare,CHIP/Medicaid,,3271.31,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,United Healthcare,CHIP/Medicaid,,7294.04,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,United Healthcare,CHIP/Medicaid,,6.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,United Healthcare,CHIP/Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,United Healthcare,CHIP/Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,United Healthcare,CHIP/Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,United Healthcare,CHIP/Medicaid,,148.04,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,United Healthcare,CHIP/Medicaid,,234.94,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,United Healthcare,CHIP/Medicaid,,13639.98,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,United Healthcare,CHIP/Medicaid,,15.22,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,United Healthcare,CHIP/Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,United Healthcare,CHIP/Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,United Healthcare,CHIP/Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,United Healthcare,CHIP/Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,United Healthcare,CHIP/Medicaid,,20.83,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,United Healthcare,CHIP/Medicaid,,9258.10,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,United Healthcare,CHIP/Medicaid,,1859.57,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,United Healthcare,CHIP/Medicaid,,104.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,United Healthcare,CHIP/Medicaid,,6029.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,United Healthcare,CHIP/Medicaid,,604.94,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,United Healthcare,CHIP/Medicaid,,16551.88,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,United Healthcare,CHIP/Medicaid,,13041.87,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,United Healthcare,CHIP/Medicaid,,2395.89,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,United Healthcare,CHIP/Medicaid,,4788.40,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,United Healthcare,CHIP/Medicaid,,5984.79,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,United Healthcare,CHIP/Medicaid,,13645.27,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,United Healthcare,CHIP/Medicaid,,188.67,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,United Healthcare,CHIP/Medicaid,,509.79,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,United Healthcare,CHIP/Medicaid,,509.80,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,United Healthcare,CHIP/Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,CHIP/Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,United Healthcare,CHIP/Medicaid,,818.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,United Healthcare,CHIP/Medicaid,,295.46,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,United Healthcare,CHIP/Medicaid,,41.72,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,United Healthcare,CHIP/Medicaid,,51.15,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,United Healthcare,CHIP/Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,United Healthcare,CHIP/Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,United Healthcare,CHIP/Medicaid,,13.87,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,United Healthcare,CHIP/Medicaid,,12710.40,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,United Healthcare,CHIP/Medicaid,,46.93,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,CHIP/Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,United Healthcare,CHIP/Medicaid,,70.56,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,United Healthcare,CHIP/Medicaid,,5351.96,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,CHIP/Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,United Healthcare,CHIP/Medicaid,,2200.82,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,United Healthcare,CHIP/Medicaid,,8765.41,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,United Healthcare,CHIP/Medicaid,,176.78,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,United Healthcare,CHIP/Medicaid,,12260.66,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,United Healthcare,CHIP/Medicaid,,1464.46,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,United Healthcare,CHIP/Medicaid,,51.51,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,United Healthcare,CHIP/Medicaid,,16.27,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,United Healthcare,CHIP/Medicaid,,3.41,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,United Healthcare,CHIP/Medicaid,,3.35,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,United Healthcare,CHIP/Medicaid,,7051.96,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,United Healthcare,CHIP/Medicaid,,4363.51,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,United Healthcare,CHIP/Medicaid,,0.27027,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,CHIP/Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,United Healthcare,CHIP/Medicaid,,72.96,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,CHIP/Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,CHIP/Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,United Healthcare,CHIP/Medicaid,,93.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,CHIP/Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,United Healthcare,CHIP/Medicaid,,9.83,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,United Healthcare,CHIP/Medicaid,,17.85,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,CHIP/Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,United Healthcare,CHIP/Medicaid,,14.69,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,United Healthcare,CHIP/Medicaid,,65.63,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,United Healthcare,CHIP/Medicaid,,7.70,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,CHIP/Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,United Healthcare,CHIP/Medicaid,,5.46,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,United Healthcare,CHIP/Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,United Healthcare,CHIP/Medicaid,,0.59059,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,United Healthcare,CHIP/Medicaid,,38.62,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,United Healthcare,CHIP/Medicaid,,2.22,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,United Healthcare,CHIP/Medicaid,,3.91,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,CHIP/Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,United Healthcare,CHIP/Medicaid,,18.87,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,CHIP/Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,United Healthcare,CHIP/Medicaid,,5.45,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,United Healthcare,CHIP/Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,CHIP/Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,CHIP/Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,CHIP/Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,United Healthcare,CHIP/Medicaid,,18.23,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,United Healthcare,CHIP/Medicaid,,280.27,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,CHIP/Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,CHIP/Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,United Healthcare,CHIP/Medicaid,,882.66,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,United Healthcare,CHIP/Medicaid,,4193.08,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,United Healthcare,CHIP/Medicaid,,13.60,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,United Healthcare,CHIP/Medicaid,,1273.87,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,United Healthcare,CHIP/Medicaid,,16.80,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,United Healthcare,CHIP/Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,United Healthcare,CHIP/Medicaid,,39.60,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,United Healthcare,CHIP/Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,United Healthcare,CHIP/Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,United Healthcare,CHIP/Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,CHIP/Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,United Healthcare,CHIP/Medicaid,,837.33,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,United Healthcare,CHIP/Medicaid,,16.33,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,United Healthcare,CHIP/Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,United Healthcare,CHIP/Medicaid,,25.36,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,United Healthcare,CHIP/Medicaid,,94.67,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,United Healthcare,CHIP/Medicaid,,1.93,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,CHIP/Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,United Healthcare,CHIP/Medicaid,,222.82,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,United Healthcare,CHIP/Medicaid,,4.01,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,United Healthcare,CHIP/Medicaid,,4.98,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,United Healthcare,CHIP/Medicaid,,35.58,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,United Healthcare,CHIP/Medicaid,,2.37,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,United Healthcare,CHIP/Medicaid,,17.42,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,United Healthcare,CHIP/Medicaid,,16.37,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,United Healthcare,CHIP/Medicaid,,21.32,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,United Healthcare,CHIP/Medicaid,,21.96,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,United Healthcare,CHIP/Medicaid,,130.98,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,United Healthcare,CHIP/Medicaid,,14.23,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,United Healthcare,CHIP/Medicaid,,14.35,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,United Healthcare,CHIP/Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,United Healthcare,CHIP/Medicaid,,14.26,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,United Healthcare,CHIP/Medicaid,,15.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,United Healthcare,CHIP/Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,United Healthcare,CHIP/Medicaid,,15.62,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,United Healthcare,CHIP/Medicaid,,412.01,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,CHIP/Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,CHIP/Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,United Healthcare,CHIP/Medicaid,,103.41,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,CHIP/Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,CHIP/Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,United Healthcare,CHIP/Medicaid,,10.79,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,United Healthcare,CHIP/Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,United Healthcare,CHIP/Medicaid,,3.75,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,United Healthcare,CHIP/Medicaid,,28.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,United Healthcare,CHIP/Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,United Healthcare,CHIP/Medicaid,,84.56,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,United Healthcare,CHIP/Medicaid,,10.15,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,United Healthcare,CHIP/Medicaid,,17.75,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,United Healthcare,CHIP/Medicaid,,4.28,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,CHIP/Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,CHIP/Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,United Healthcare,CHIP/Medicaid,,18.21,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,United Healthcare,CHIP/Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,CHIP/Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,United Healthcare,CHIP/Medicaid,,0.38038,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,United Healthcare,CHIP/Medicaid,,4.79,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,United Healthcare,CHIP/Medicaid,,4.48,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,United Healthcare,CHIP/Medicaid,,39.36,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,United Healthcare,CHIP/Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,United Healthcare,CHIP/Medicaid,,9.69,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,United Healthcare,CHIP/Medicaid,,5.95,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,United Healthcare,CHIP/Medicaid,,1.50,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,CHIP/Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,United Healthcare,CHIP/Medicaid,,4.15,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,United Healthcare,CHIP/Medicaid,,16.30,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,United Healthcare,CHIP/Medicaid,,0.67067,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,United Healthcare,CHIP/Medicaid,,2.88,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,CHIP/Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,CHIP/Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,CHIP/Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,CHIP/Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,United Healthcare,CHIP/Medicaid,,6.53,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,United Healthcare,CHIP/Medicaid,,15.99,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,United Healthcare,CHIP/Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,CHIP/Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,United Healthcare,CHIP/Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,United Healthcare,CHIP/Medicaid,,3.98,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,United Healthcare,CHIP/Medicaid,,32.93,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,CHIP/Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,CHIP/Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,United Healthcare,CHIP/Medicaid,,16.89,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,United Healthcare,CHIP/Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,United Healthcare,CHIP/Medicaid,,1470.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,United Healthcare,CHIP/Medicaid,,5.63,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,United Healthcare,CHIP/Medicaid,,15.38,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,United Healthcare,CHIP/Medicaid,,6.35,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,CHIP/Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,CHIP/Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,United Healthcare,CHIP/Medicaid,,548.81,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,United Healthcare,CHIP/Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,United Healthcare,CHIP/Medicaid,,7.99,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,United Healthcare,CHIP/Medicaid,,5.28,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,United Healthcare,CHIP/Medicaid,,19.45,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,United Healthcare,CHIP/Medicaid,,20.34,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,United Healthcare,CHIP/Medicaid,,29.43,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,United Healthcare,CHIP/Medicaid,,5.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,United Healthcare,CHIP/Medicaid,,236.14,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,United Healthcare,CHIP/Medicaid,,451.45,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,United Healthcare,CHIP/Medicaid,,1156.15,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,United Healthcare,CHIP/Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,United Healthcare,CHIP/Medicaid,,443.79,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,United Healthcare,CHIP/Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,United Healthcare,CHIP/Medicaid,,45.65,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,CHIP/Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,United Healthcare,CHIP/Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,United Healthcare,CHIP/Medicaid,,52.77,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,United Healthcare,CHIP/Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,United Healthcare,CHIP/Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,United Healthcare,CHIP/Medicaid,,4.62,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,United Healthcare,CHIP/Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,CHIP/Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,United Healthcare,CHIP/Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,United Healthcare,CHIP/Medicaid,,20.26,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,United Healthcare,CHIP/Medicaid,,121.53,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,United Healthcare,CHIP/Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,United Healthcare,CHIP/Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,United Healthcare,CHIP/Medicaid,,38.94,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,United Healthcare,CHIP/Medicaid,,39.17,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,United Healthcare,CHIP/Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,United Healthcare,CHIP/Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,United Healthcare,CHIP/Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,United Healthcare,CHIP/Medicaid,,0.78078,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,United Healthcare,CHIP/Medicaid,,7.14,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,United Healthcare,CHIP/Medicaid,,8.69,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,United Healthcare,CHIP/Medicaid,,12.01,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,United Healthcare,CHIP/Medicaid,,16.44,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,United Healthcare,CHIP/Medicaid,,20.96,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,United Healthcare,CHIP/Medicaid,,44.19,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,United Healthcare,CHIP/Medicaid,,2.68,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,CHIP/Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,United Healthcare,CHIP/Medicaid,,202.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,United Healthcare,CHIP/Medicaid,,1.61,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,United Healthcare,CHIP/Medicaid,,22.82,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,United Healthcare,CHIP/Medicaid,,4.63,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,United Healthcare,CHIP/Medicaid,,5.31,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,CHIP/Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,United Healthcare,CHIP/Medicaid,,150.68,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,United Healthcare,CHIP/Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,United Healthcare,CHIP/Medicaid,,61.74,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,United Healthcare,CHIP/Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,United Healthcare,CHIP/Medicaid,,18.48,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,United Healthcare,CHIP/Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,United Healthcare,CHIP/Medicaid,,4.57,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,United Healthcare,CHIP/Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,United Healthcare,CHIP/Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,United Healthcare,CHIP/Medicaid,,9.24,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,United Healthcare,CHIP/Medicaid,,10.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,United Healthcare,CHIP/Medicaid,,53.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,United Healthcare,CHIP/Medicaid,,5.59,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,United Healthcare,CHIP/Medicaid,,12.64,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,United Healthcare,CHIP/Medicaid,,119.95,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,United Healthcare,CHIP/Medicaid,,7.56,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,United Healthcare,CHIP/Medicaid,,12.50,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,United Healthcare,CHIP/Medicaid,,704.70,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,United Healthcare,CHIP/Medicaid,,310.71,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,United Healthcare,CHIP/Medicaid,,241.06,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,CHIP/Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,United Healthcare,CHIP/Medicaid,,43.24,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,United Healthcare,CHIP/Medicaid,,23.07,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,United Healthcare,CHIP/Medicaid,,104.89,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,United Healthcare,CHIP/Medicaid,,139.84,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,United Healthcare,CHIP/Medicaid,,240.04,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,United Healthcare,CHIP/Medicaid,,67.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,United Healthcare,CHIP/Medicaid,,69.97,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,United Healthcare,CHIP/Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,United Healthcare,CHIP/Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,CHIP/Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,United Healthcare,CHIP/Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,United Healthcare,CHIP/Medicaid,,3.86,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,United Healthcare,CHIP/Medicaid,,2576.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,United Healthcare,CHIP/Medicaid,,10.49,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,United Healthcare,CHIP/Medicaid,,71.52,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,United Healthcare,CHIP/Medicaid,,13.33,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,United Healthcare,CHIP/Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,United Healthcare,CHIP/Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,United Healthcare,CHIP/Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,CHIP/Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,United Healthcare,CHIP/Medicaid,,5.43,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,United Healthcare,CHIP/Medicaid,,138.74,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,CHIP/Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,CHIP/Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,CHIP/Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,United Healthcare,CHIP/Medicaid,,4.32,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,United Healthcare,CHIP/Medicaid,,16.64,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,United Healthcare,CHIP/Medicaid,,74.00,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,United Healthcare,CHIP/Medicaid,,84.08,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,United Healthcare,CHIP/Medicaid,,5.74,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,United Healthcare,CHIP/Medicaid,,8.49,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,United Healthcare,CHIP/Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,United Healthcare,CHIP/Medicaid,,10.70,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,United Healthcare,CHIP/Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,United Healthcare,CHIP/Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,United Healthcare,CHIP/Medicaid,,24.00,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,United Healthcare,CHIP/Medicaid,,1.26,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,United Healthcare,CHIP/Medicaid,,18.82,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,United Healthcare,CHIP/Medicaid,,17.32,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,United Healthcare,CHIP/Medicaid,,93.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,United Healthcare,CHIP/Medicaid,,63.86,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,United Healthcare,CHIP/Medicaid,,168.96,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,United Healthcare,CHIP/Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,CHIP/Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,United Healthcare,CHIP/Medicaid,,53.06,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,United Healthcare,CHIP/Medicaid,,171.88,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,United Healthcare,CHIP/Medicaid,,3998.59,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,United Healthcare,CHIP/Medicaid,,6.77,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,United Healthcare,CHIP/Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,United Healthcare,CHIP/Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,United Healthcare,CHIP/Medicaid,,36.67,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,United Healthcare,CHIP/Medicaid,,23.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,United Healthcare,CHIP/Medicaid,,5.99,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,United Healthcare,CHIP/Medicaid,,25.10,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,United Healthcare,CHIP/Medicaid,,14.31,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,United Healthcare,CHIP/Medicaid,,38.06,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,United Healthcare,CHIP/Medicaid,,16.93,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,United Healthcare,CHIP/Medicaid,,104.36,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,United Healthcare,CHIP/Medicaid,,11.95,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,CHIP/Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,United Healthcare,CHIP/Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,United Healthcare,CHIP/Medicaid,,24.23,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,CHIP/Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,United Healthcare,CHIP/Medicaid,,7.34,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,United Healthcare,CHIP/Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,CHIP/Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,United Healthcare,CHIP/Medicaid,,18.69,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,United Healthcare,CHIP/Medicaid,,596.21,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,United Healthcare,CHIP/Medicaid,,7.17,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,United Healthcare,CHIP/Medicaid,,25.76,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,United Healthcare,CHIP/Medicaid,,452.94,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,United Healthcare,CHIP/Medicaid,,8.53,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,United Healthcare,CHIP/Medicaid,,7.02,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,United Healthcare,CHIP/Medicaid,,5.88,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,United Healthcare,CHIP/Medicaid,,11.06,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,United Healthcare,CHIP/Medicaid,,7.25,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,United Healthcare,CHIP/Medicaid,,1047.11,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,United Healthcare,CHIP/Medicaid,,2612.95,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,United Healthcare,CHIP/Medicaid,,5222.67,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,United Healthcare,CHIP/Medicaid,,10442.13,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,United Healthcare,CHIP/Medicaid,,36.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,United Healthcare,CHIP/Medicaid,,80.00,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,United Healthcare,CHIP/Medicaid,,5.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,United Healthcare,CHIP/Medicaid,,10.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,United Healthcare,CHIP/Medicaid,,29.59,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,United Healthcare,CHIP/Medicaid,,63.32,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,CHIP/Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,CHIP/Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,United Healthcare,CHIP/Medicaid,,9.69,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,United Healthcare,CHIP/Medicaid,,10.10,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,CHIP/Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,United Healthcare,CHIP/Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,United Healthcare,CHIP/Medicaid,,943.42,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,CHIP/Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,United Healthcare,CHIP/Medicaid,,11.48,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,United Healthcare,CHIP/Medicaid,,26.93,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,United Healthcare,CHIP/Medicaid,,7.44,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,United Healthcare,CHIP/Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,United Healthcare,CHIP/Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,United Healthcare,CHIP/Medicaid,,4.38,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,CHIP/Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,United Healthcare,CHIP/Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,United Healthcare,CHIP/Medicaid,,64.39,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,United Healthcare,CHIP/Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,United Healthcare,CHIP/Medicaid,,5.26,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,United Healthcare,CHIP/Medicaid,,7.43,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,United Healthcare,CHIP/Medicaid,,5.58,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,United Healthcare,CHIP/Medicaid,,93.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,United Healthcare,CHIP/Medicaid,,2.26,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,United Healthcare,CHIP/Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,United Healthcare,CHIP/Medicaid,,207.18,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,United Healthcare,CHIP/Medicaid,,4.97,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,United Healthcare,CHIP/Medicaid,,4.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,United Healthcare,CHIP/Medicaid,,50.45,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,CHIP/Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,United Healthcare,CHIP/Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,CHIP/Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,CHIP/Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,United Healthcare,CHIP/Medicaid,,3.65,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,United Healthcare,CHIP/Medicaid,,3.93,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,United Healthcare,CHIP/Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,United Healthcare,CHIP/Medicaid,,3.53,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,United Healthcare,CHIP/Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,United Healthcare,CHIP/Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,United Healthcare,CHIP/Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,United Healthcare,CHIP/Medicaid,,17.52,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,United Healthcare,CHIP/Medicaid,,1250.97,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,United Healthcare,CHIP/Medicaid,,17.53,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,United Healthcare,CHIP/Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,United Healthcare,CHIP/Medicaid,,19.40,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,United Healthcare,CHIP/Medicaid,,21.10,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,United Healthcare,CHIP/Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,United Healthcare,CHIP/Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,United Healthcare,CHIP/Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,United Healthcare,CHIP/Medicaid,,14.13,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,United Healthcare,CHIP/Medicaid,,0.97097,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,CHIP/Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,United Healthcare,CHIP/Medicaid,,5.69,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,CHIP/Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,United Healthcare,CHIP/Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,CHIP/Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,United Healthcare,CHIP/Medicaid,,4.72,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,United Healthcare,CHIP/Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,United Healthcare,CHIP/Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,United Healthcare,CHIP/Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,United Healthcare,CHIP/Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,United Healthcare,CHIP/Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,United Healthcare,CHIP/Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,United Healthcare,CHIP/Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,United Healthcare,CHIP/Medicaid,,4.66,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,United Healthcare,CHIP/Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,United Healthcare,CHIP/Medicaid,,1.67,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,CHIP/Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,United Healthcare,CHIP/Medicaid,,3.22,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,United Healthcare,CHIP/Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,United Healthcare,CHIP/Medicaid,,33.91,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,United Healthcare,CHIP/Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,United Healthcare,CHIP/Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,United Healthcare,CHIP/Medicaid,,3616.45,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,CHIP/Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,United Healthcare,CHIP/Medicaid,,6.19,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,United Healthcare,CHIP/Medicaid,,151.67,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,United Healthcare,CHIP/Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,United Healthcare,CHIP/Medicaid,,28.78,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,CHIP/Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,United Healthcare,CHIP/Medicaid,,301.87,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,United Healthcare,CHIP/Medicaid,,0.70070,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,United Healthcare,CHIP/Medicaid,,21.87,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,United Healthcare,CHIP/Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,CHIP/Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,United Healthcare,CHIP/Medicaid,,5.49,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,United Healthcare,CHIP/Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,United Healthcare,CHIP/Medicaid,,8.20,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,United Healthcare,CHIP/Medicaid,,278.53,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,United Healthcare,CHIP/Medicaid,,12.20,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,United Healthcare,CHIP/Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,United Healthcare,CHIP/Medicaid,,4.76,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,United Healthcare,CHIP/Medicaid,,75.53,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,United Healthcare,CHIP/Medicaid,,96.61,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,United Healthcare,CHIP/Medicaid,,66.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,United Healthcare,CHIP/Medicaid,,107.18,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,United Healthcare,CHIP/Medicaid,,23.54,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,United Healthcare,CHIP/Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,United Healthcare,CHIP/Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,United Healthcare,CHIP/Medicaid,,5.02,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,United Healthcare,CHIP/Medicaid,,23.24,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,United Healthcare,CHIP/Medicaid,,137.38,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,United Healthcare,CHIP/Medicaid,,321.76,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,CHIP/Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,United Healthcare,CHIP/Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,United Healthcare,CHIP/Medicaid,,13.36,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,United Healthcare,CHIP/Medicaid,,13.96,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,United Healthcare,CHIP/Medicaid,,13.51,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,United Healthcare,CHIP/Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,United Healthcare,CHIP/Medicaid,,13.96,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,United Healthcare,CHIP/Medicaid,,13.51,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,United Healthcare,CHIP/Medicaid,,30.03,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,United Healthcare,CHIP/Medicaid,,14.71,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,United Healthcare,CHIP/Medicaid,,13.96,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,United Healthcare,CHIP/Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,United Healthcare,CHIP/Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,United Healthcare,CHIP/Medicaid,,13.36,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,United Healthcare,CHIP/Medicaid,,13.96,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,United Healthcare,CHIP/Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,United Healthcare,CHIP/Medicaid,,13.36,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,United Healthcare,CHIP/Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,United Healthcare,CHIP/Medicaid,,204.90,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,United Healthcare,CHIP/Medicaid,,4.53,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,United Healthcare,CHIP/Medicaid,,1446.91,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,United Healthcare,CHIP/Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,United Healthcare,CHIP/Medicaid,,1119.21,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,United Healthcare,CHIP/Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,United Healthcare,CHIP/Medicaid,,3.78,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,CHIP/Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,United Healthcare,CHIP/Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,United Healthcare,CHIP/Medicaid,,70.11,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,United Healthcare,CHIP/Medicaid,,248.85,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,United Healthcare,CHIP/Medicaid,,4.56,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,United Healthcare,CHIP/Medicaid,,9.25,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,United Healthcare,CHIP/Medicaid,,1407.53,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,United Healthcare,CHIP/Medicaid,,66.53,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,United Healthcare,CHIP/Medicaid,,61.72,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,United Healthcare,CHIP/Medicaid,,134.84,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,CHIP/Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,CHIP/Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,CHIP/Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,CHIP/Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,United Healthcare,CHIP/Medicaid,,5370.02,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,United Healthcare,CHIP/Medicaid,,64.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,United Healthcare,CHIP/Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,United Healthcare,CHIP/Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,United Healthcare,CHIP/Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,United Healthcare,CHIP/Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,United Healthcare,CHIP/Medicaid,,407.41,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,United Healthcare,CHIP/Medicaid,,99.10,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,United Healthcare,CHIP/Medicaid,,199.52,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,United Healthcare,CHIP/Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,United Healthcare,CHIP/Medicaid,,15.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,United Healthcare,CHIP/Medicaid,,67.55,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,CHIP/Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,CHIP/Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,United Healthcare,CHIP/Medicaid,,21.09,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,CHIP/Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,CHIP/Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,United Healthcare,CHIP/Medicaid,,3.81,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,United Healthcare,CHIP/Medicaid,,5.34,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,United Healthcare,CHIP/Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,United Healthcare,CHIP/Medicaid,,15.22,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,United Healthcare,CHIP/Medicaid,,58.63,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,United Healthcare,CHIP/Medicaid,,4.16,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,United Healthcare,CHIP/Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,CHIP/Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,United Healthcare,CHIP/Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,CHIP/Medicaid,,3.90,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,United Healthcare,CHIP/Medicaid,,3.85,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,United Healthcare,CHIP/Medicaid,,20.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,United Healthcare,CHIP/Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,United Healthcare,CHIP/Medicaid,,14.29,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,United Healthcare,CHIP/Medicaid,,15.17,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,United Healthcare,CHIP/Medicaid,,14.14,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,United Healthcare,CHIP/Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,United Healthcare,CHIP/Medicaid,,12.62,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,United Healthcare,CHIP/Medicaid,,21.90,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,United Healthcare,CHIP/Medicaid,,0.95095,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,CHIP/Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,CHIP/Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,United Healthcare,CHIP/Medicaid,,217.46,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,United Healthcare,CHIP/Medicaid,,8.91,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,United Healthcare,CHIP/Medicaid,,9.31,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,United Healthcare,CHIP/Medicaid,,6.32,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,United Healthcare,CHIP/Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,United Healthcare,CHIP/Medicaid,,7322.31,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,United Healthcare,CHIP/Medicaid,,63.69,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,CHIP/Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,United Healthcare,CHIP/Medicaid,,12.78,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,United Healthcare,CHIP/Medicaid,,23.12,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,United Healthcare,CHIP/Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,CHIP/Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,CHIP/Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,CHIP/Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,CHIP/Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,United Healthcare,CHIP/Medicaid,,15.04,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,United Healthcare,CHIP/Medicaid,,21.65,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,United Healthcare,CHIP/Medicaid,,30.68,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,United Healthcare,CHIP/Medicaid,,4.37,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,United Healthcare,CHIP/Medicaid,,3.92,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,United Healthcare,CHIP/Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,United Healthcare,CHIP/Medicaid,,40.90,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,CHIP/Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,United Healthcare,CHIP/Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,CHIP/Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,United Healthcare,CHIP/Medicaid,,4.79,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,United Healthcare,CHIP/Medicaid,,2740.12,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,United Healthcare,CHIP/Medicaid,,560.36,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,United Healthcare,CHIP/Medicaid,,15.95,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,United Healthcare,CHIP/Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,United Healthcare,CHIP/Medicaid,,5.65,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,United Healthcare,CHIP/Medicaid,,15.26,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,United Healthcare,CHIP/Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,United Healthcare,CHIP/Medicaid,,20.90,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,CHIP/Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,United Healthcare,CHIP/Medicaid,,12.73,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,CHIP/Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,United Healthcare,CHIP/Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,United Healthcare,CHIP/Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,United Healthcare,CHIP/Medicaid,,5.71,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,United Healthcare,CHIP/Medicaid,,4.13,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,United Healthcare,CHIP/Medicaid,,4.03,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,United Healthcare,CHIP/Medicaid,,4.05,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,United Healthcare,CHIP/Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,United Healthcare,CHIP/Medicaid,,1.42,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,United Healthcare,CHIP/Medicaid,,30.78,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,United Healthcare,CHIP/Medicaid,,81.09,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,United Healthcare,CHIP/Medicaid,,31.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,United Healthcare,CHIP/Medicaid,,160.86,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,United Healthcare,CHIP/Medicaid,,13.25,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,United Healthcare,CHIP/Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,United Healthcare,CHIP/Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,United Healthcare,CHIP/Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,United Healthcare,CHIP/Medicaid,,14.97,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,United Healthcare,CHIP/Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,United Healthcare,CHIP/Medicaid,,18.46,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,United Healthcare,CHIP/Medicaid,,75.28,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,United Healthcare,CHIP/Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,United Healthcare,CHIP/Medicaid,,12.88,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,United Healthcare,CHIP/Medicaid,,5.42,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,United Healthcare,CHIP/Medicaid,,22.97,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,CHIP/Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,United Healthcare,CHIP/Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,CHIP/Medicaid,,3.48,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,CHIP/Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,CHIP/Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,United Healthcare,CHIP/Medicaid,,3.47,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,United Healthcare,CHIP/Medicaid,,18.92,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,United Healthcare,CHIP/Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,United Healthcare,CHIP/Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,United Healthcare,CHIP/Medicaid,,43.16,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,United Healthcare,CHIP/Medicaid,,67.81,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,United Healthcare,CHIP/Medicaid,,167.17,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,United Healthcare,CHIP/Medicaid,,13.06,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,United Healthcare,CHIP/Medicaid,,16.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,United Healthcare,CHIP/Medicaid,,44.56,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,United Healthcare,CHIP/Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,United Healthcare,CHIP/Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,United Healthcare,CHIP/Medicaid,,25.74,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,United Healthcare,CHIP/Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,United Healthcare,CHIP/Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,United Healthcare,CHIP/Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,CHIP/Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,United Healthcare,CHIP/Medicaid,,63.86,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,United Healthcare,CHIP/Medicaid,,33.71,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,United Healthcare,CHIP/Medicaid,,12.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,United Healthcare,CHIP/Medicaid,,14.55,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,United Healthcare,CHIP/Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,United Healthcare,CHIP/Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,United Healthcare,CHIP/Medicaid,,17.61,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,United Healthcare,CHIP/Medicaid,,74.49,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,United Healthcare,CHIP/Medicaid,,3.85,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,United Healthcare,CHIP/Medicaid,,13.49,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,United Healthcare,CHIP/Medicaid,,13.69,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,United Healthcare,CHIP/Medicaid,,19.34,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,United Healthcare,CHIP/Medicaid,,6.15,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,United Healthcare,CHIP/Medicaid,,21.33,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,United Healthcare,CHIP/Medicaid,,34.39,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,United Healthcare,CHIP/Medicaid,,20.81,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,United Healthcare,CHIP/Medicaid,,50.13,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,United Healthcare,CHIP/Medicaid,,34.22,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,United Healthcare,CHIP/Medicaid,,16.15,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,United Healthcare,CHIP/Medicaid,,14.08,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,United Healthcare,CHIP/Medicaid,,20.81,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,United Healthcare,CHIP/Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,United Healthcare,CHIP/Medicaid,,19.34,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,United Healthcare,CHIP/Medicaid,,21.86,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,United Healthcare,CHIP/Medicaid,,95.86,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,United Healthcare,CHIP/Medicaid,,23.59,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,United Healthcare,CHIP/Medicaid,,113.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,United Healthcare,CHIP/Medicaid,,233.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,United Healthcare,CHIP/Medicaid,,248.73,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,United Healthcare,CHIP/Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,United Healthcare,CHIP/Medicaid,,16.74,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,United Healthcare,CHIP/Medicaid,,14.88,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,United Healthcare,CHIP/Medicaid,,30.69,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,United Healthcare,CHIP/Medicaid,,43.74,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,United Healthcare,CHIP/Medicaid,,102.58,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,United Healthcare,CHIP/Medicaid,,192.55,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,United Healthcare,CHIP/Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,United Healthcare,CHIP/Medicaid,,20.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,United Healthcare,CHIP/Medicaid,,49.60,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,United Healthcare,CHIP/Medicaid,,13.37,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,United Healthcare,CHIP/Medicaid,,15.65,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,United Healthcare,CHIP/Medicaid,,147.18,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,CHIP/Medicaid,,3.51,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,United Healthcare,CHIP/Medicaid,,55.10,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,United Healthcare,CHIP/Medicaid,,12.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,United Healthcare,CHIP/Medicaid,,21.04,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,United Healthcare,CHIP/Medicaid,,58.02,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,United Healthcare,CHIP/Medicaid,,35.32,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,United Healthcare,CHIP/Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,United Healthcare,CHIP/Medicaid,,24.13,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,United Healthcare,CHIP/Medicaid,,14.29,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,United Healthcare,CHIP/Medicaid,,15.69,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,United Healthcare,CHIP/Medicaid,,36.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,United Healthcare,CHIP/Medicaid,,34.39,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,United Healthcare,CHIP/Medicaid,,15.14,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,United Healthcare,CHIP/Medicaid,,5.85,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,United Healthcare,CHIP/Medicaid,,6.96,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,United Healthcare,CHIP/Medicaid,,14.29,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,United Healthcare,CHIP/Medicaid,,357.36,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,United Healthcare,CHIP/Medicaid,,19.93,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,United Healthcare,CHIP/Medicaid,,5.04,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,United Healthcare,CHIP/Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,United Healthcare,CHIP/Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,United Healthcare,CHIP/Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,United Healthcare,CHIP/Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,United Healthcare,CHIP/Medicaid,,34.83,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,United Healthcare,CHIP/Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,United Healthcare,CHIP/Medicaid,,4.49,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,United Healthcare,CHIP/Medicaid,,4.50,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,United Healthcare,CHIP/Medicaid,,5.13,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,United Healthcare,CHIP/Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,United Healthcare,CHIP/Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,United Healthcare,CHIP/Medicaid,,26.24,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,United Healthcare,CHIP/Medicaid,,18.92,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,United Healthcare,CHIP/Medicaid,,27.96,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,United Healthcare,CHIP/Medicaid,,5.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,United Healthcare,CHIP/Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,United Healthcare,CHIP/Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,United Healthcare,CHIP/Medicaid,,3.55,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,United Healthcare,CHIP/Medicaid,,13.67,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,United Healthcare,CHIP/Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,United Healthcare,CHIP/Medicaid,,11.19,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,United Healthcare,CHIP/Medicaid,,16.47,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,United Healthcare,CHIP/Medicaid,,21.29,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,United Healthcare,CHIP/Medicaid,,62.22,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,United Healthcare,CHIP/Medicaid,,15.97,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,United Healthcare,CHIP/Medicaid,,63.91,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,United Healthcare,CHIP/Medicaid,,12.84,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,United Healthcare,CHIP/Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,United Healthcare,CHIP/Medicaid,,21.02,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,United Healthcare,CHIP/Medicaid,,14.96,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,United Healthcare,CHIP/Medicaid,,10.41,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,United Healthcare,CHIP/Medicaid,,32.35,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,United Healthcare,CHIP/Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,United Healthcare,CHIP/Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,United Healthcare,CHIP/Medicaid,,90.46,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,United Healthcare,CHIP/Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,United Healthcare,CHIP/Medicaid,,55.38,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,United Healthcare,CHIP/Medicaid,,47.93,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,United Healthcare,CHIP/Medicaid,,14.79,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,United Healthcare,CHIP/Medicaid,,13.15,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,United Healthcare,CHIP/Medicaid,,15.94,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,United Healthcare,CHIP/Medicaid,,11.97,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,United Healthcare,CHIP/Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,United Healthcare,CHIP/Medicaid,,49.57,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,CHIP/Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,United Healthcare,CHIP/Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,United Healthcare,CHIP/Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,United Healthcare,CHIP/Medicaid,,30.76,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,United Healthcare,CHIP/Medicaid,,72.92,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,CHIP/Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,United Healthcare,CHIP/Medicaid,,79.00,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,United Healthcare,CHIP/Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,United Healthcare,CHIP/Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,United Healthcare,CHIP/Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,United Healthcare,CHIP/Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,United Healthcare,CHIP/Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,United Healthcare,CHIP/Medicaid,,73.55,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,United Healthcare,CHIP/Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,United Healthcare,CHIP/Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,United Healthcare,CHIP/Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,CHIP/Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,United Healthcare,CHIP/Medicaid,,20.26,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,United Healthcare,CHIP/Medicaid,,23.05,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,CHIP/Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,United Healthcare,CHIP/Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,United Healthcare,CHIP/Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,United Healthcare,CHIP/Medicaid,,39.10,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,United Healthcare,CHIP/Medicaid,,29.27,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,CHIP/Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,CHIP/Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,United Healthcare,CHIP/Medicaid,,14.73,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,United Healthcare,CHIP/Medicaid,,12.90,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,United Healthcare,CHIP/Medicaid,,82.51,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,United Healthcare,CHIP/Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,United Healthcare,CHIP/Medicaid,,34.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,United Healthcare,CHIP/Medicaid,,12.65,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,United Healthcare,CHIP/Medicaid,,23.05,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,United Healthcare,CHIP/Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,United Healthcare,CHIP/Medicaid,,5.16,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,United Healthcare,CHIP/Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,United Healthcare,CHIP/Medicaid,,317.29,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,United Healthcare,CHIP/Medicaid,,7.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,United Healthcare,CHIP/Medicaid,,95.78,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,CHIP/Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,United Healthcare,CHIP/Medicaid,,3.44,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,United Healthcare,CHIP/Medicaid,,28.89,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,United Healthcare,CHIP/Medicaid,,276.31,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,United Healthcare,CHIP/Medicaid,,14.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,United Healthcare,CHIP/Medicaid,,43.04,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,United Healthcare,CHIP/Medicaid,,119.57,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,United Healthcare,CHIP/Medicaid,,21.86,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,United Healthcare,CHIP/Medicaid,,23.12,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,United Healthcare,CHIP/Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,United Healthcare,CHIP/Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,United Healthcare,CHIP/Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,United Healthcare,CHIP/Medicaid,,13.22,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,United Healthcare,CHIP/Medicaid,,7.31,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,United Healthcare,CHIP/Medicaid,,13.22,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,United Healthcare,CHIP/Medicaid,,9.70,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,United Healthcare,CHIP/Medicaid,,17.78,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,United Healthcare,CHIP/Medicaid,,52.13,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,United Healthcare,CHIP/Medicaid,,23.96,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,United Healthcare,CHIP/Medicaid,,23.67,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,United Healthcare,CHIP/Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,United Healthcare,CHIP/Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,United Healthcare,CHIP/Medicaid,,6.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,United Healthcare,CHIP/Medicaid,,16.67,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,United Healthcare,CHIP/Medicaid,,13.03,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,United Healthcare,CHIP/Medicaid,,35.71,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,United Healthcare,CHIP/Medicaid,,10.13,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,United Healthcare,CHIP/Medicaid,,46.39,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,United Healthcare,CHIP/Medicaid,,47.60,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,United Healthcare,CHIP/Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,United Healthcare,CHIP/Medicaid,,13.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,United Healthcare,CHIP/Medicaid,,4.42,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,United Healthcare,CHIP/Medicaid,,4.56,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,United Healthcare,CHIP/Medicaid,,91.88,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,United Healthcare,CHIP/Medicaid,,5.22,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,CHIP/Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,United Healthcare,CHIP/Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,United Healthcare,CHIP/Medicaid,,12.64,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,United Healthcare,CHIP/Medicaid,,12.66,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,United Healthcare,CHIP/Medicaid,,12.67,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,United Healthcare,CHIP/Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,United Healthcare,CHIP/Medicaid,,29.01,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,United Healthcare,CHIP/Medicaid,,3.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,United Healthcare,CHIP/Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,United Healthcare,CHIP/Medicaid,,13.25,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,United Healthcare,CHIP/Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,United Healthcare,CHIP/Medicaid,,91.32,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,United Healthcare,CHIP/Medicaid,,92.51,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,United Healthcare,CHIP/Medicaid,,72.28,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,United Healthcare,CHIP/Medicaid,,15.98,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,CHIP/Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,United Healthcare,CHIP/Medicaid,,15.14,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,United Healthcare,CHIP/Medicaid,,15.77,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,United Healthcare,CHIP/Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,United Healthcare,CHIP/Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,United Healthcare,CHIP/Medicaid,,4.97,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,United Healthcare,CHIP/Medicaid,,31.76,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,CHIP/Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,United Healthcare,CHIP/Medicaid,,25.14,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,United Healthcare,CHIP/Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,United Healthcare,CHIP/Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,United Healthcare,CHIP/Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,CHIP/Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,United Healthcare,CHIP/Medicaid,,4.99,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,United Healthcare,CHIP/Medicaid,,146.20,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,United Healthcare,CHIP/Medicaid,,20.36,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,United Healthcare,CHIP/Medicaid,,20.72,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,United Healthcare,CHIP/Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,United Healthcare,CHIP/Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,United Healthcare,CHIP/Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,United Healthcare,CHIP/Medicaid,,7.81,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,United Healthcare,CHIP/Medicaid,,12.31,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,United Healthcare,CHIP/Medicaid,,5.29,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,United Healthcare,CHIP/Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,United Healthcare,CHIP/Medicaid,,42.04,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,United Healthcare,CHIP/Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,United Healthcare,CHIP/Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,United Healthcare,CHIP/Medicaid,,16.48,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,CHIP/Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,United Healthcare,CHIP/Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,United Healthcare,CHIP/Medicaid,,13.40,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,United Healthcare,CHIP/Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,United Healthcare,CHIP/Medicaid,,6.89,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,United Healthcare,CHIP/Medicaid,,4.13,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,United Healthcare,CHIP/Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,United Healthcare,CHIP/Medicaid,,4.79,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,United Healthcare,CHIP/Medicaid,,5.25,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,United Healthcare,CHIP/Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,United Healthcare,CHIP/Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,United Healthcare,CHIP/Medicaid,,106.37,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,United Healthcare,CHIP/Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,CHIP/Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,CHIP/Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,CHIP/Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,CHIP/Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,CHIP/Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,CHIP/Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,CHIP/Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,United Healthcare,CHIP/Medicaid,,80.87,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,United Healthcare,CHIP/Medicaid,,21.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,United Healthcare,CHIP/Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,United Healthcare,CHIP/Medicaid,,4.61,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,United Healthcare,CHIP/Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,United Healthcare,CHIP/Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,United Healthcare,CHIP/Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,United Healthcare,CHIP/Medicaid,,151.55,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,United Healthcare,CHIP/Medicaid,,9.79,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,United Healthcare,CHIP/Medicaid,,5.16,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,United Healthcare,CHIP/Medicaid,,5.23,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,United Healthcare,CHIP/Medicaid,,55.71,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,United Healthcare,CHIP/Medicaid,,11.69,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,United Healthcare,CHIP/Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,United Healthcare,CHIP/Medicaid,,3.37,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,United Healthcare,CHIP/Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,United Healthcare,CHIP/Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,United Healthcare,CHIP/Medicaid,,0.83083,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,United Healthcare,CHIP/Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,United Healthcare,CHIP/Medicaid,,55.41,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,United Healthcare,CHIP/Medicaid,,59.75,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,United Healthcare,CHIP/Medicaid,,47.78,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,United Healthcare,CHIP/Medicaid,,52.17,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,United Healthcare,CHIP/Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,United Healthcare,CHIP/Medicaid,,58.32,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,United Healthcare,CHIP/Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,United Healthcare,CHIP/Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,United Healthcare,CHIP/Medicaid,,15.58,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,CHIP/Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,United Healthcare,CHIP/Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,United Healthcare,CHIP/Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,United Healthcare,CHIP/Medicaid,,9036.23,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,CHIP/Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,CHIP/Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,United Healthcare,CHIP/Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,United Healthcare,CHIP/Medicaid,,111.31,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,United Healthcare,CHIP/Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,United Healthcare,CHIP/Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,United Healthcare,CHIP/Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,United Healthcare,CHIP/Medicaid,,9367.61,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,CHIP/Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,CHIP/Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,CHIP/Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,CHIP/Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,CHIP/Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,CHIP/Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,CHIP/Medicaid,,202.69,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,CHIP/Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,CHIP/Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,CHIP/Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,CHIP/Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,CHIP/Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,CHIP/Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,CHIP/Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,CHIP/Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,CHIP/Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,CHIP/Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,CHIP/Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,United Healthcare,CHIP/Medicaid,,55.83,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,United Healthcare,CHIP/Medicaid,,8.83,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,CHIP/Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,United Healthcare,CHIP/Medicaid,,38405.96,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,United Healthcare,CHIP/Medicaid,,25.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,United Healthcare,CHIP/Medicaid,,14.11,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,United Healthcare,CHIP/Medicaid,,14.86,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,CHIP/Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,United Healthcare,CHIP/Medicaid,,14.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,United Healthcare,CHIP/Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,United Healthcare,CHIP/Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,United Healthcare,CHIP/Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,United Healthcare,CHIP/Medicaid,,134.33,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,United Healthcare,CHIP/Medicaid,,29.04,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,United Healthcare,CHIP/Medicaid,,147.35,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,United Healthcare,CHIP/Medicaid,,52.74,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,United Healthcare,CHIP/Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,United Healthcare,CHIP/Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,United Healthcare,CHIP/Medicaid,,1.02,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,United Healthcare,CHIP/Medicaid,,2.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,United Healthcare,CHIP/Medicaid,,16.00,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,United Healthcare,CHIP/Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,United Healthcare,CHIP/Medicaid,,92.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,United Healthcare,CHIP/Medicaid,,15.62,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,United Healthcare,CHIP/Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,United Healthcare,CHIP/Medicaid,,11.85,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,United Healthcare,CHIP/Medicaid,,7.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,United Healthcare,CHIP/Medicaid,,87.28,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,CHIP/Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,United Healthcare,CHIP/Medicaid,,21.34,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,United Healthcare,CHIP/Medicaid,,116.72,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,United Healthcare,CHIP/Medicaid,,62.81,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,United Healthcare,CHIP/Medicaid,,10.37,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,CHIP/Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,CHIP/Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,United Healthcare,CHIP/Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,CHIP/Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,United Healthcare,CHIP/Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,United Healthcare,CHIP/Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,United Healthcare,CHIP/Medicaid,,6.11,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,United Healthcare,CHIP/Medicaid,,6.13,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,United Healthcare,CHIP/Medicaid,,6.84,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,United Healthcare,CHIP/Medicaid,,7.61,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,United Healthcare,CHIP/Medicaid,,23.04,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,United Healthcare,CHIP/Medicaid,,9.83,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,CHIP/Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,CHIP/Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,CHIP/Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,CHIP/Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,United Healthcare,CHIP/Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,United Healthcare,CHIP/Medicaid,,0.43043,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,United Healthcare,CHIP/Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,United Healthcare,CHIP/Medicaid,,23.36,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,United Healthcare,CHIP/Medicaid,,46.93,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,United Healthcare,CHIP/Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,United Healthcare,CHIP/Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,United Healthcare,CHIP/Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,United Healthcare,CHIP/Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,United Healthcare,CHIP/Medicaid,,6.26,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,United Healthcare,CHIP/Medicaid,,5.94,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,United Healthcare,CHIP/Medicaid,,37.17,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,United Healthcare,CHIP/Medicaid,,15.45,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,United Healthcare,CHIP/Medicaid,,5.99,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,CHIP/Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,United Healthcare,CHIP/Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,United Healthcare,CHIP/Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,United Healthcare,CHIP/Medicaid,,17.47,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,United Healthcare,CHIP/Medicaid,,17.83,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,United Healthcare,CHIP/Medicaid,,4.68,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,United Healthcare,CHIP/Medicaid,,10.72,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,United Healthcare,CHIP/Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,United Healthcare,CHIP/Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,United Healthcare,CHIP/Medicaid,,61.46,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,United Healthcare,CHIP/Medicaid,,94.69,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,United Healthcare,CHIP/Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,United Healthcare,CHIP/Medicaid,,5.80,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,United Healthcare,CHIP/Medicaid,,21.17,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,CHIP/Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,United Healthcare,CHIP/Medicaid,,3.81,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,United Healthcare,CHIP/Medicaid,,4.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,CHIP/Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,CHIP/Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,United Healthcare,CHIP/Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,United Healthcare,CHIP/Medicaid,,14.85,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,United Healthcare,CHIP/Medicaid,,2.70,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,CHIP/Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,CHIP/Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,United Healthcare,CHIP/Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,United Healthcare,CHIP/Medicaid,,5.33,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,United Healthcare,CHIP/Medicaid,,6.14,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,CHIP/Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,United Healthcare,CHIP/Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,United Healthcare,CHIP/Medicaid,,5.23,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,United Healthcare,CHIP/Medicaid,,4.66,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,United Healthcare,CHIP/Medicaid,,6.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,United Healthcare,CHIP/Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,United Healthcare,CHIP/Medicaid,,33.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,CHIP/Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,United Healthcare,CHIP/Medicaid,,25.70,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,United Healthcare,CHIP/Medicaid,,10.75,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,United Healthcare,CHIP/Medicaid,,5.15,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,CHIP/Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,CHIP/Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,United Healthcare,CHIP/Medicaid,,4.65,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,United Healthcare,CHIP/Medicaid,,2.10,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,United Healthcare,CHIP/Medicaid,,4.19,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,United Healthcare,CHIP/Medicaid,,3.59,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,United Healthcare,CHIP/Medicaid,,40.93,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,United Healthcare,CHIP/Medicaid,,49.56,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,United Healthcare,CHIP/Medicaid,,14.79,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,United Healthcare,CHIP/Medicaid,,8.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,United Healthcare,CHIP/Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,CHIP/Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,United Healthcare,CHIP/Medicaid,,4.86,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,CHIP/Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,United Healthcare,CHIP/Medicaid,,45.49,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,United Healthcare,CHIP/Medicaid,,20.24,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,United Healthcare,CHIP/Medicaid,,6.85,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,United Healthcare,CHIP/Medicaid,,42.58,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,United Healthcare,CHIP/Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,United Healthcare,CHIP/Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,United Healthcare,CHIP/Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,United Healthcare,CHIP/Medicaid,,4.47,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,CHIP/Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,United Healthcare,CHIP/Medicaid,,14.47,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,United Healthcare,CHIP/Medicaid,,50.57,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,United Healthcare,CHIP/Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,United Healthcare,CHIP/Medicaid,,53.99,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,United Healthcare,CHIP/Medicaid,,31.11,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,United Healthcare,CHIP/Medicaid,,17.16,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,United Healthcare,CHIP/Medicaid,,22.03,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,United Healthcare,CHIP/Medicaid,,14.54,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,United Healthcare,CHIP/Medicaid,,37.87,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,United Healthcare,CHIP/Medicaid,,8.98,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,United Healthcare,CHIP/Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,United Healthcare,CHIP/Medicaid,,0.61061,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,United Healthcare,CHIP/Medicaid,,82.18,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,United Healthcare,CHIP/Medicaid,,4.41,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,United Healthcare,CHIP/Medicaid,,4.89,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,United Healthcare,CHIP/Medicaid,,29.78,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,United Healthcare,CHIP/Medicaid,,251.45,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,CHIP/Medicaid,,3.39,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,United Healthcare,CHIP/Medicaid,,4.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,CHIP/Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,United Healthcare,CHIP/Medicaid,,40.54,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,United Healthcare,CHIP/Medicaid,,4.44,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,CHIP/Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,United Healthcare,CHIP/Medicaid,,3.51,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,United Healthcare,CHIP/Medicaid,,4.89,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,CHIP/Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,United Healthcare,CHIP/Medicaid,,24.28,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,United Healthcare,CHIP/Medicaid,,32.33,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,United Healthcare,CHIP/Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,CHIP/Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,CHIP/Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,CHIP/Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,United Healthcare,CHIP/Medicaid,,51.39,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,United Healthcare,CHIP/Medicaid,,17.31,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,United Healthcare,CHIP/Medicaid,,5.05,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,United Healthcare,CHIP/Medicaid,,13.10,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,CHIP/Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,CHIP/Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,United Healthcare,CHIP/Medicaid,,0.57057,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,United Healthcare,CHIP/Medicaid,,1.53,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,United Healthcare,CHIP/Medicaid,,18.79,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,CHIP/Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,CHIP/Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,CHIP/Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,CHIP/Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,United Healthcare,CHIP/Medicaid,,189.66,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,United Healthcare,CHIP/Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,United Healthcare,CHIP/Medicaid,,71.39,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,United Healthcare,CHIP/Medicaid,,81.01,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,United Healthcare,CHIP/Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,CHIP/Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,United Healthcare,CHIP/Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,United Healthcare,CHIP/Medicaid,,20.97,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,United Healthcare,CHIP/Medicaid,,13.41,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,United Healthcare,CHIP/Medicaid,,23.35,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,United Healthcare,CHIP/Medicaid,,22.43,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,United Healthcare,CHIP/Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,United Healthcare,CHIP/Medicaid,,15.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,United Healthcare,CHIP/Medicaid,,16.52,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,United Healthcare,CHIP/Medicaid,,16.51,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,United Healthcare,CHIP/Medicaid,,19.05,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,United Healthcare,CHIP/Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,United Healthcare,CHIP/Medicaid,,27.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,United Healthcare,CHIP/Medicaid,,14.86,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,United Healthcare,CHIP/Medicaid,,85.70,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,United Healthcare,CHIP/Medicaid,,79.04,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,CHIP/Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,United Healthcare,CHIP/Medicaid,,13.81,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,United Healthcare,CHIP/Medicaid,,16.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,United Healthcare,CHIP/Medicaid,,23.16,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,CHIP/Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,CHIP/Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,United Healthcare,CHIP/Medicaid,,1060.77,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,United Healthcare,CHIP/Medicaid,,54.03,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,United Healthcare,CHIP/Medicaid,,143.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,United Healthcare,CHIP/Medicaid,,17.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,United Healthcare,CHIP/Medicaid,,9.15,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,United Healthcare,CHIP/Medicaid,,9.92,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,United Healthcare,CHIP/Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,United Healthcare,CHIP/Medicaid,,81.63,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,United Healthcare,CHIP/Medicaid,,396.25,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,United Healthcare,CHIP/Medicaid,,73.63,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,United Healthcare,CHIP/Medicaid,,1.38,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,United Healthcare,CHIP/Medicaid,,129.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,United Healthcare,CHIP/Medicaid,,5.32,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,United Healthcare,CHIP/Medicaid,,15.98,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,United Healthcare,CHIP/Medicaid,,23.79,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,United Healthcare,CHIP/Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,United Healthcare,CHIP/Medicaid,,18.98,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,United Healthcare,CHIP/Medicaid,,169.85,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,United Healthcare,CHIP/Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,United Healthcare,CHIP/Medicaid,,5.60,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,United Healthcare,CHIP/Medicaid,,5.75,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,United Healthcare,CHIP/Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,United Healthcare,CHIP/Medicaid,,1.25,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,United Healthcare,CHIP/Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,United Healthcare,CHIP/Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,United Healthcare,CHIP/Medicaid,,10.70,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,United Healthcare,CHIP/Medicaid,,570.59,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,United Healthcare,CHIP/Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,United Healthcare,CHIP/Medicaid,,4.56,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,CHIP/Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,CHIP/Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,United Healthcare,CHIP/Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,CHIP/Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,CHIP/Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,United Healthcare,CHIP/Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,United Healthcare,CHIP/Medicaid,,8.13,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,United Healthcare,CHIP/Medicaid,,6.00,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,United Healthcare,CHIP/Medicaid,,11.73,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,United Healthcare,CHIP/Medicaid,,11.10,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,United Healthcare,CHIP/Medicaid,,9.11,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,United Healthcare,CHIP/Medicaid,,41.93,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,CHIP/Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,United Healthcare,CHIP/Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,United Healthcare,CHIP/Medicaid,,86.34,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,United Healthcare,CHIP/Medicaid,,98.82,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,United Healthcare,CHIP/Medicaid,,5497.41,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,United Healthcare,CHIP/Medicaid,,18.50,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,United Healthcare,CHIP/Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,United Healthcare,CHIP/Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,United Healthcare,CHIP/Medicaid,,61.08,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,United Healthcare,CHIP/Medicaid,,1817.11,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,United Healthcare,CHIP/Medicaid,,5.48,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,United Healthcare,CHIP/Medicaid,,24.14,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,United Healthcare,CHIP/Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,United Healthcare,CHIP/Medicaid,,21.52,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,United Healthcare,CHIP/Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,United Healthcare,CHIP/Medicaid,,11.36,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,United Healthcare,CHIP/Medicaid,,26.31,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,United Healthcare,CHIP/Medicaid,,19.48,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,United Healthcare,CHIP/Medicaid,,88.51,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,United Healthcare,CHIP/Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,United Healthcare,CHIP/Medicaid,,12.31,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,United Healthcare,CHIP/Medicaid,,9.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,CHIP/Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,CHIP/Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,United Healthcare,CHIP/Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,United Healthcare,CHIP/Medicaid,,102.41,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,United Healthcare,CHIP/Medicaid,,70.69,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,CHIP/Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,CHIP/Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,CHIP/Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,CHIP/Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,United Healthcare,CHIP/Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,United Healthcare,CHIP/Medicaid,,6.69,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,United Healthcare,CHIP/Medicaid,,8103.63,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,United Healthcare,CHIP/Medicaid,,113.70,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,United Healthcare,CHIP/Medicaid,,8.19,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,United Healthcare,CHIP/Medicaid,,19.64,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,United Healthcare,CHIP/Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,United Healthcare,CHIP/Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,United Healthcare,CHIP/Medicaid,,31.01,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,United Healthcare,CHIP/Medicaid,,11.84,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,United Healthcare,CHIP/Medicaid,,5378.81,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,United Healthcare,CHIP/Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,United Healthcare,CHIP/Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,United Healthcare,CHIP/Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,CHIP/Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,United Healthcare,CHIP/Medicaid,,19.84,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,United Healthcare,CHIP/Medicaid,,767.34,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,United Healthcare,CHIP/Medicaid,,0.65065,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,United Healthcare,CHIP/Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,United Healthcare,CHIP/Medicaid,,217.13,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,United Healthcare,CHIP/Medicaid,,8.14,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,United Healthcare,CHIP/Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,United Healthcare,CHIP/Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,CHIP/Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,CHIP/Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,United Healthcare,CHIP/Medicaid,,157.47,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,United Healthcare,CHIP/Medicaid,,8019.54,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,United Healthcare,CHIP/Medicaid,,4011.38,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,United Healthcare,CHIP/Medicaid,,0.79079,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,CHIP/Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,United Healthcare,CHIP/Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,United Healthcare,CHIP/Medicaid,,20.41,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,CHIP/Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,CHIP/Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,CHIP/Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,United Healthcare,CHIP/Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,United Healthcare,CHIP/Medicaid,,6.81,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,United Healthcare,CHIP/Medicaid,,19.62,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,United Healthcare,CHIP/Medicaid,,25.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,United Healthcare,CHIP/Medicaid,,74.41,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,United Healthcare,CHIP/Medicaid,,18.99,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,United Healthcare,CHIP/Medicaid,,42.04,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,United Healthcare,CHIP/Medicaid,,5.26,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,United Healthcare,CHIP/Medicaid,,10.00,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,United Healthcare,CHIP/Medicaid,,35.09,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,United Healthcare,CHIP/Medicaid,,6.19,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,United Healthcare,CHIP/Medicaid,,162.77,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,CHIP/Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,CHIP/Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,United Healthcare,CHIP/Medicaid,,106.41,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,United Healthcare,CHIP/Medicaid,,16.03,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,United Healthcare,CHIP/Medicaid,,7.52,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,United Healthcare,CHIP/Medicaid,,3.75,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,United Healthcare,CHIP/Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,United Healthcare,CHIP/Medicaid,,55.32,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,United Healthcare,CHIP/Medicaid,,9.68,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,United Healthcare,CHIP/Medicaid,,53.33,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,United Healthcare,CHIP/Medicaid,,0.81081,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,United Healthcare,CHIP/Medicaid,,32.01,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,CHIP/Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,CHIP/Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,CHIP/Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,United Healthcare,CHIP/Medicaid,,105.45,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,CHIP/Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,CHIP/Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,CHIP/Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,United Healthcare,CHIP/Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,CHIP/Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,United Healthcare,CHIP/Medicaid,,15.03,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,United Healthcare,CHIP/Medicaid,,15.11,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,United Healthcare,CHIP/Medicaid,,14.30,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,United Healthcare,CHIP/Medicaid,,5.81,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,CHIP/Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,United Healthcare,CHIP/Medicaid,,4.19,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,CHIP/Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,United Healthcare,CHIP/Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,United Healthcare,CHIP/Medicaid,,7.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,United Healthcare,CHIP/Medicaid,,731.93,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,CHIP/Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,United Healthcare,CHIP/Medicaid,,2510.96,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,United Healthcare,CHIP/Medicaid,,5018.69,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,United Healthcare,CHIP/Medicaid,,414.16,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,United Healthcare,CHIP/Medicaid,,551.21,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,United Healthcare,CHIP/Medicaid,,616.62,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,CHIP/Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,United Healthcare,CHIP/Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,United Healthcare,CHIP/Medicaid,,86.74,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,United Healthcare,CHIP/Medicaid,,4.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,United Healthcare,CHIP/Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,CHIP/Medicaid,,3.41,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,CHIP/Medicaid,,3.50,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,United Healthcare,CHIP/Medicaid,,130.73,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,CHIP/Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,United Healthcare,CHIP/Medicaid,,17.24,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,United Healthcare,CHIP/Medicaid,,12.13,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,United Healthcare,CHIP/Medicaid,,149.34,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,United Healthcare,CHIP/Medicaid,,21.02,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,United Healthcare,CHIP/Medicaid,,7.95,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,United Healthcare,CHIP/Medicaid,,12.31,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,United Healthcare,CHIP/Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,United Healthcare,CHIP/Medicaid,,4.34,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,CHIP/Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,CHIP/Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,United Healthcare,CHIP/Medicaid,,17.02,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,United Healthcare,CHIP/Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,United Healthcare,CHIP/Medicaid,,44.63,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,United Healthcare,CHIP/Medicaid,,63.06,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,United Healthcare,CHIP/Medicaid,,2.96,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,United Healthcare,CHIP/Medicaid,,332.95,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,United Healthcare,CHIP/Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,United Healthcare,CHIP/Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,United Healthcare,CHIP/Medicaid,,16.42,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,United Healthcare,CHIP/Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,United Healthcare,CHIP/Medicaid,,438.24,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,United Healthcare,CHIP/Medicaid,,7.20,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,United Healthcare,CHIP/Medicaid,,53.01,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,United Healthcare,CHIP/Medicaid,,20.92,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,United Healthcare,CHIP/Medicaid,,22.77,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,United Healthcare,CHIP/Medicaid,,9.22,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,United Healthcare,CHIP/Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,CHIP/Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,United Healthcare,CHIP/Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,CHIP/Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,CHIP/Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,United Healthcare,CHIP/Medicaid,,83.52,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,United Healthcare,CHIP/Medicaid,,307.07,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,United Healthcare,CHIP/Medicaid,,7.71,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,United Healthcare,CHIP/Medicaid,,12.38,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,United Healthcare,CHIP/Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,United Healthcare,CHIP/Medicaid,,19.29,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,United Healthcare,CHIP/Medicaid,,60.65,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,United Healthcare,CHIP/Medicaid,,726.37,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,United Healthcare,CHIP/Medicaid,,25.45,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,United Healthcare,CHIP/Medicaid,,42.27,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,United Healthcare,CHIP/Medicaid,,17.83,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,United Healthcare,CHIP/Medicaid,,6.87,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,United Healthcare,CHIP/Medicaid,,12.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,United Healthcare,CHIP/Medicaid,,6.26,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,United Healthcare,CHIP/Medicaid,,40.30,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,United Healthcare,CHIP/Medicaid,,34.84,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,United Healthcare,CHIP/Medicaid,,12.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,United Healthcare,CHIP/Medicaid,,12.98,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,United Healthcare,CHIP/Medicaid,,12.95,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,United Healthcare,CHIP/Medicaid,,47.84,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,United Healthcare,CHIP/Medicaid,,18.24,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,CHIP/Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,United Healthcare,CHIP/Medicaid,,132.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,United Healthcare,CHIP/Medicaid,,77.12,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,United Healthcare,CHIP/Medicaid,,363.01,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,CHIP/Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,United Healthcare,CHIP/Medicaid,,0.92092,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,United Healthcare,CHIP/Medicaid,,435.35,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,United Healthcare,CHIP/Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,United Healthcare,CHIP/Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,United Healthcare,CHIP/Medicaid,,18.92,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,United Healthcare,CHIP/Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,United Healthcare,CHIP/Medicaid,,6.65,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,United Healthcare,CHIP/Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,United Healthcare,CHIP/Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,United Healthcare,CHIP/Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,United Healthcare,CHIP/Medicaid,,15.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,United Healthcare,CHIP/Medicaid,,71.27,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,United Healthcare,CHIP/Medicaid,,11.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,United Healthcare,CHIP/Medicaid,,9.80,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,United Healthcare,CHIP/Medicaid,,1016.27,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,United Healthcare,CHIP/Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,CHIP/Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,CHIP/Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,United Healthcare,CHIP/Medicaid,,128.67,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,United Healthcare,CHIP/Medicaid,,51.03,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,CHIP/Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,United Healthcare,CHIP/Medicaid,,19.13,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,United Healthcare,CHIP/Medicaid,,5.04,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,United Healthcare,CHIP/Medicaid,,33.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,United Healthcare,CHIP/Medicaid,,17.08,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,United Healthcare,CHIP/Medicaid,,20.59,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,United Healthcare,CHIP/Medicaid,,5.10,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,United Healthcare,CHIP/Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,United Healthcare,CHIP/Medicaid,,483.85,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,United Healthcare,CHIP/Medicaid,,805.26,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,United Healthcare,CHIP/Medicaid,,97.34,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,United Healthcare,CHIP/Medicaid,,143.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,CHIP/Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,United Healthcare,CHIP/Medicaid,,210.27,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,United Healthcare,CHIP/Medicaid,,10.78,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,United Healthcare,CHIP/Medicaid,,346.52,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,CHIP/Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,CHIP/Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,United Healthcare,CHIP/Medicaid,,22.78,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,CHIP/Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,United Healthcare,CHIP/Medicaid,,330.39,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,United Healthcare,CHIP/Medicaid,,9091.99,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,United Healthcare,CHIP/Medicaid,,31273.72,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,United Healthcare,CHIP/Medicaid,,51551.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,United Healthcare,CHIP/Medicaid,,2234.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,United Healthcare,CHIP/Medicaid,,1479.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,United Healthcare,CHIP/Medicaid,,51.85,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,United Healthcare,CHIP/Medicaid,,2.73,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,CHIP/Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,United Healthcare,CHIP/Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,United Healthcare,CHIP/Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,United Healthcare,CHIP/Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,CHIP/Medicaid,,103.90,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,United Healthcare,CHIP/Medicaid,,257.66,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,United Healthcare,CHIP/Medicaid,,385.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,United Healthcare,CHIP/Medicaid,,578.78,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,United Healthcare,CHIP/Medicaid,,694.49,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,United Healthcare,CHIP/Medicaid,,833.23,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,United Healthcare,CHIP/Medicaid,,1000.20,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,United Healthcare,CHIP/Medicaid,,413.41,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,United Healthcare,CHIP/Medicaid,,607.21,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,United Healthcare,CHIP/Medicaid,,1104.30,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,CHIP/Medicaid,,32.03,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,United Healthcare,CHIP/Medicaid,,126.73,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,CHIP/Medicaid,,34.63,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,,23.42,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,CHIP/Medicaid,,5.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,CHIP/Medicaid,,28.63,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,CHIP/Medicaid,,31.63,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,United Healthcare,CHIP/Medicaid,,104.90,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,United Healthcare,CHIP/Medicaid,,119.52,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,United Healthcare,CHIP/Medicaid,,101.70,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,CHIP/Medicaid,,18.42,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,United Healthcare,CHIP/Medicaid,,14.61,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,United Healthcare,CHIP/Medicaid,,46.05,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,United Healthcare,CHIP/Medicaid,,42.24,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,United Healthcare,CHIP/Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,United Healthcare,CHIP/Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,United Healthcare,CHIP/Medicaid,,997.40,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,United Healthcare,CHIP/Medicaid,,357.56,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,United Healthcare,CHIP/Medicaid,,601.60,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,United Healthcare,CHIP/Medicaid,,305.51,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,CHIP/Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,United Healthcare,CHIP/Medicaid,,218.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,CHIP/Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,United Healthcare,CHIP/Medicaid,,247.45,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,CHIP/Medicaid,,181.98,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,CHIP/Medicaid,,60.66,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,CHIP/Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,United Healthcare,CHIP/Medicaid,,187.79,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,United Healthcare,CHIP/Medicaid,,53.25,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,CHIP/Medicaid,,40.84,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,United Healthcare,CHIP/Medicaid,,218.62,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,United Healthcare,CHIP/Medicaid,,189.79,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,United Healthcare,CHIP/Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,CHIP/Medicaid,,8.61,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,CHIP/Medicaid,,7.01,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,CHIP/Medicaid,,28.03,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,United Healthcare,CHIP/Medicaid,,94.89,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,CHIP/Medicaid,,25.23,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,United Healthcare,CHIP/Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,CHIP/Medicaid,,26.83,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,United Healthcare,CHIP/Medicaid,,2.20,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,United Healthcare,CHIP/Medicaid,,998.00,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,United Healthcare,CHIP/Medicaid,,4024.02,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,United Healthcare,CHIP/Medicaid,,1015.81,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,United Healthcare,CHIP/Medicaid,,848.85,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,United Healthcare,CHIP/Medicaid,,696.30,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,CHIP/Medicaid,,92.69,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,United Healthcare,CHIP/Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,United Healthcare,CHIP/Medicaid,,906.91,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,United Healthcare,CHIP/Medicaid,,893.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,United Healthcare,CHIP/Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,United Healthcare,CHIP/Medicaid,,1168.17,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,United Healthcare,CHIP/Medicaid,,829.43,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,United Healthcare,CHIP/Medicaid,,829.43,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,United Healthcare,CHIP/Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,United Healthcare,CHIP/Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,United Healthcare,CHIP/Medicaid,,1174.37,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,United Healthcare,CHIP/Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,United Healthcare,CHIP/Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,United Healthcare,CHIP/Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,United Healthcare,CHIP/Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,CHIP/Medicaid,,349.35,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,United Healthcare,CHIP/Medicaid,,822.82,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,United Healthcare,CHIP/Medicaid,,338.54,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,United Healthcare,CHIP/Medicaid,,1301.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,United Healthcare,CHIP/Medicaid,,237.04,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,United Healthcare,CHIP/Medicaid,,486.89,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,United Healthcare,CHIP/Medicaid,,737.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,United Healthcare,CHIP/Medicaid,,860.26,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,United Healthcare,CHIP/Medicaid,,24.22,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,United Healthcare,CHIP/Medicaid,,341.54,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,United Healthcare,CHIP/Medicaid,,685.89,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,CHIP/Medicaid,,16.62,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,United Healthcare,CHIP/Medicaid,,93.49,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,United Healthcare,CHIP/Medicaid,,137.94,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,United Healthcare,CHIP/Medicaid,,311.71,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,United Healthcare,CHIP/Medicaid,,236.04,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,CHIP/Medicaid,,15.82,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,United Healthcare,CHIP/Medicaid,GP,4.20,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,United Healthcare,CHIP/Medicaid,,66.67,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,United Healthcare,CHIP/Medicaid,,300.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,United Healthcare,CHIP/Medicaid,,284.68,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,United Healthcare,CHIP/Medicaid,,228.23,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,United Healthcare,CHIP/Medicaid,,171.77,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,United Healthcare,CHIP/Medicaid,,115.32,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,CHIP/Medicaid,,58.86,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,United Healthcare,CHIP/Medicaid,,327.93,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,United Healthcare,CHIP/Medicaid,,979.98,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,United Healthcare,CHIP/Medicaid,,1299.70,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,United Healthcare,CHIP/Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,United Healthcare,CHIP/Medicaid,,521.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,United Healthcare,CHIP/Medicaid,,5236.83,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,United Healthcare,CHIP/Medicaid,,5485.28,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,United Healthcare,CHIP/Medicaid,,5773.17,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,United Healthcare,CHIP/Medicaid,,6020.81,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,United Healthcare,CHIP/Medicaid,,6269.46,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,United Healthcare,CHIP/Medicaid,,6517.31,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,United Healthcare,CHIP/Medicaid,,6724.92,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,United Healthcare,CHIP/Medicaid,,7012.81,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,United Healthcare,CHIP/Medicaid,,7260.85,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,United Healthcare,CHIP/Medicaid,,7508.90,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,United Healthcare,CHIP/Medicaid,,7757.15,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,CHIP/Medicaid,,77.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,United Healthcare,CHIP/Medicaid,,106.91,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,United Healthcare,CHIP/Medicaid,,165.97,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,United Healthcare,CHIP/Medicaid,,167.37,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,United Healthcare,CHIP/Medicaid,,807.81,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,United Healthcare,CHIP/Medicaid,,1938.94,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,United Healthcare,CHIP/Medicaid,,2083.48,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,United Healthcare,CHIP/Medicaid,,2238.04,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,United Healthcare,CHIP/Medicaid,,1220.02,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,United Healthcare,CHIP/Medicaid,,1576.17,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,United Healthcare,CHIP/Medicaid,,1792.79,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,United Healthcare,CHIP/Medicaid,,2308.31,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,United Healthcare,CHIP/Medicaid,,2369.57,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,United Healthcare,CHIP/Medicaid,,2427.22,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,United Healthcare,CHIP/Medicaid,,2485.08,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,United Healthcare,CHIP/Medicaid,,2542.74,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,United Healthcare,CHIP/Medicaid,,990.19,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,United Healthcare,CHIP/Medicaid,,133.73,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,United Healthcare,CHIP/Medicaid,,882.08,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,United Healthcare,CHIP/Medicaid,,1190.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,United Healthcare,CHIP/Medicaid,,1630.83,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,United Healthcare,CHIP/Medicaid,,2066.86,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,United Healthcare,CHIP/Medicaid,,2359.76,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,United Healthcare,CHIP/Medicaid,,2672.67,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,United Healthcare,CHIP/Medicaid,,3048.85,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,United Healthcare,CHIP/Medicaid,,3268.06,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,United Healthcare,CHIP/Medicaid,,3591.59,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,United Healthcare,CHIP/Medicaid,,3767.56,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,United Healthcare,CHIP/Medicaid,,3997.99,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,United Healthcare,CHIP/Medicaid,,4146.34,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,United Healthcare,CHIP/Medicaid,,4183.58,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,United Healthcare,CHIP/Medicaid,,4245.64,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,United Healthcare,CHIP/Medicaid,,4369.36,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,United Healthcare,CHIP/Medicaid,,4493.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,United Healthcare,CHIP/Medicaid,,4617.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,United Healthcare,CHIP/Medicaid,,4741.74,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,United Healthcare,CHIP/Medicaid,,4865.26,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,United Healthcare,CHIP/Medicaid,,4989.38,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,United Healthcare,CHIP/Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,United Healthcare,CHIP/Medicaid,,2274.67,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,United Healthcare,CHIP/Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,United Healthcare,CHIP/Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,United Healthcare,CHIP/Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,CHIP/Medicaid,,1297.30,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,United Healthcare,CHIP/Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,United Healthcare,CHIP/Medicaid,,1513.91,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,United Healthcare,CHIP/Medicaid,,1705.90,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,CHIP/Medicaid,,60.66,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,CHIP/Medicaid,,254.45,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,United Healthcare,CHIP/Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,United Healthcare,CHIP/Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,United Healthcare,CHIP/Medicaid,,161.76,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,United Healthcare,CHIP/Medicaid,,2160.96,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,United Healthcare,CHIP/Medicaid,,378.38,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,United Healthcare,CHIP/Medicaid,,245.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,United Healthcare,CHIP/Medicaid,,1436.23,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,CHIP/Medicaid,,59.26,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,United Healthcare,CHIP/Medicaid,,151.35,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,United Healthcare,CHIP/Medicaid,,0.60060,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,United Healthcare,CHIP/Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,United Healthcare,CHIP/Medicaid,,425.83,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,United Healthcare,CHIP/Medicaid,,521.92,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,United Healthcare,CHIP/Medicaid,,617.62,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,United Healthcare,CHIP/Medicaid,,713.51,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,United Healthcare,CHIP/Medicaid,,809.41,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,United Healthcare,CHIP/Medicaid,,905.10,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,United Healthcare,CHIP/Medicaid,,132.33,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,United Healthcare,CHIP/Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,United Healthcare,CHIP/Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,CHIP/Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,United Healthcare,CHIP/Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,United Healthcare,CHIP/Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,United Healthcare,CHIP/Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,United Healthcare,CHIP/Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,United Healthcare,CHIP/Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,United Healthcare,CHIP/Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,United Healthcare,CHIP/Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,United Healthcare,CHIP/Medicaid,,191.79,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,United Healthcare,CHIP/Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,CHIP/Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,United Healthcare,CHIP/Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,United Healthcare,CHIP/Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,United Healthcare,CHIP/Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,United Healthcare,CHIP/Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,United Healthcare,CHIP/Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,United Healthcare,CHIP/Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,United Healthcare,CHIP/Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,CHIP/Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,United Healthcare,CHIP/Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,CHIP/Medicaid,,57.06,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,CHIP/Medicaid,,271.67,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,United Healthcare,CHIP/Medicaid,,307.71,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,United Healthcare,CHIP/Medicaid,,344.14,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,United Healthcare,CHIP/Medicaid,,380.58,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,United Healthcare,CHIP/Medicaid,,417.42,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,CHIP/Medicaid,,454.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,United Healthcare,CHIP/Medicaid,,490.49,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,United Healthcare,CHIP/Medicaid,,526.73,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,United Healthcare,CHIP/Medicaid,,562.96,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,United Healthcare,CHIP/Medicaid,,599.80,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,United Healthcare,CHIP/Medicaid,,636.04,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,United Healthcare,CHIP/Medicaid,,683.48,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,United Healthcare,CHIP/Medicaid,,720.32,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,United Healthcare,CHIP/Medicaid,,859.46,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,United Healthcare,CHIP/Medicaid,,915.71,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,United Healthcare,CHIP/Medicaid,,958.36,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,United Healthcare,CHIP/Medicaid,,994.79,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,United Healthcare,CHIP/Medicaid,,1031.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,United Healthcare,CHIP/Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,United Healthcare,CHIP/Medicaid,,928.13,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,United Healthcare,CHIP/Medicaid,,825.42,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,United Healthcare,CHIP/Medicaid,,523.12,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,United Healthcare,CHIP/Medicaid,,565.57,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,United Healthcare,CHIP/Medicaid,,497.70,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,United Healthcare,CHIP/Medicaid,,669.07,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,CHIP/Medicaid,,67.47,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,United Healthcare,CHIP/Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,United Healthcare,CHIP/Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,United Healthcare,CHIP/Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,United Healthcare,CHIP/Medicaid,,255.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,United Healthcare,CHIP/Medicaid,,419.62,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,United Healthcare,CHIP/Medicaid,,466.27,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,United Healthcare,CHIP/Medicaid,,253.05,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,United Healthcare,CHIP/Medicaid,,1500.30,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,CHIP/Medicaid,,203.40,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,CHIP/Medicaid,,80.88,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,United Healthcare,CHIP/Medicaid,,915.71,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,United Healthcare,CHIP/Medicaid,,2169.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,United Healthcare,CHIP/Medicaid,,1055.85,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,United Healthcare,CHIP/Medicaid,,61.46,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,United Healthcare,CHIP/Medicaid,,8004.80,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,United Healthcare,CHIP/Medicaid,,8252.64,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,United Healthcare,CHIP/Medicaid,,377.38,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,United Healthcare,CHIP/Medicaid,,111.51,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,United Healthcare,CHIP/Medicaid,,583.58,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,United Healthcare,CHIP/Medicaid,,17.22,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,CHIP/Medicaid,,36.64,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,CHIP/Medicaid,,19.82,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,United Healthcare,CHIP/Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,United Healthcare,CHIP/Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,CHIP/Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,CHIP/Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,United Healthcare,CHIP/Medicaid,,275.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,United Healthcare,CHIP/Medicaid,,3917.71,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,United Healthcare,CHIP/Medicaid,,1825.82,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,CHIP/Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,United Healthcare,CHIP/Medicaid,,991.79,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,United Healthcare,CHIP/Medicaid,,1489.09,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,United Healthcare,CHIP/Medicaid,,1685.28,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,CHIP/Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,United Healthcare,CHIP/Medicaid,,1270.87,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,CHIP/Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,United Healthcare,CHIP/Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,CHIP/Medicaid,,41.84,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,CHIP/Medicaid,,29.03,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,CHIP/Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,CHIP/Medicaid,,25.23,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,United Healthcare,CHIP/Medicaid,,30.23,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,United Healthcare,CHIP/Medicaid,,36.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,CHIP/Medicaid,,59.06,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,United Healthcare,CHIP/Medicaid,,71.07,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,CHIP/Medicaid,,209.81,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,United Healthcare,CHIP/Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,CHIP/Medicaid,,85.08,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,CHIP/Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,United Healthcare,CHIP/Medicaid,,214.81,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,United Healthcare,CHIP/Medicaid,,189.79,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,CHIP/Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,CHIP/Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,United Healthcare,CHIP/Medicaid,,154.95,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,CHIP/Medicaid,,1025.02,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,United Healthcare,CHIP/Medicaid,,100.70,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,United Healthcare,CHIP/Medicaid,,90.49,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,United Healthcare,CHIP/Medicaid,,270.07,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,CHIP/Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,United Healthcare,CHIP/Medicaid,,297.10,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,United Healthcare,CHIP/Medicaid,,276.08,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,CHIP/Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,CHIP/Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,CHIP/Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,United Healthcare,CHIP/Medicaid,,1345.34,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,CHIP/Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,CHIP/Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,CHIP/Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,United Healthcare,CHIP/Medicaid,,243.24,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,United Healthcare,CHIP/Medicaid,,326.53,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,United Healthcare,CHIP/Medicaid,,580.38,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,CHIP/Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,CHIP/Medicaid,,92.69,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,CHIP/Medicaid,,28.03,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,CHIP/Medicaid,,33.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,CHIP/Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,United Healthcare,CHIP/Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,United Healthcare,CHIP/Medicaid,,205.00,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,CHIP/Medicaid,,127.53,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,United Healthcare,CHIP/Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,United Healthcare,CHIP/Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,CHIP/Medicaid,,59.46,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,United Healthcare,CHIP/Medicaid,,61.66,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,United Healthcare,CHIP/Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,United Healthcare,CHIP/Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,United Healthcare,CHIP/Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,United Healthcare,CHIP/Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,United Healthcare,CHIP/Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,United Healthcare,CHIP/Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,United Healthcare,CHIP/Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,United Healthcare,CHIP/Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,United Healthcare,CHIP/Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,United Healthcare,CHIP/Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,United Healthcare,CHIP/Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,United Healthcare,CHIP/Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,United Healthcare,CHIP/Medicaid,,1897.10,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,United Healthcare,CHIP/Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,United Healthcare,CHIP/Medicaid,,539.74,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,United Healthcare,CHIP/Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,United Healthcare,CHIP/Medicaid,,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,United Healthcare,CHIP/Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,United Healthcare,CHIP/Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,United Healthcare,CHIP/Medicaid,,1227.43,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,United Healthcare,CHIP/Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,CHIP/Medicaid,,251.25,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,United Healthcare,CHIP/Medicaid,,107.51,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,United Healthcare,CHIP/Medicaid,,1345.34,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,United Healthcare,CHIP/Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,United Healthcare,CHIP/Medicaid,,188.19,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,United Healthcare,CHIP/Medicaid,,44.04,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,United Healthcare,CHIP/Medicaid,,111.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,United Healthcare,CHIP/Medicaid,,1088.29,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,United Healthcare,CHIP/Medicaid,,3972.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,United Healthcare,CHIP/Medicaid,,5483.48,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,CHIP/Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,CHIP/Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,CHIP/Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,CHIP/Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,CHIP/Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,United Healthcare,CHIP/Medicaid,,625.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,United Healthcare,CHIP/Medicaid,,234.63,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,United Healthcare,CHIP/Medicaid,,301.70,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,United Healthcare,CHIP/Medicaid,,283.28,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,United Healthcare,CHIP/Medicaid,,274.27,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,United Healthcare,CHIP/Medicaid,,1994.79,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,United Healthcare,CHIP/Medicaid,Q1,1268.27,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,United Healthcare,CHIP/Medicaid,Q0,759.76,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,CHIP/Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,CHIP/Medicaid,,84.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,CHIP/Medicaid,,109.91,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,CHIP/Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,CHIP/Medicaid,,117.12,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,CHIP/Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,CHIP/Medicaid,,75.48,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,CHIP/Medicaid,,18.42,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,CHIP/Medicaid,,57.66,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,CHIP/Medicaid,,87.49,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,CHIP/Medicaid,,52.45,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,United Healthcare,CHIP/Medicaid,,46.85,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,CHIP/Medicaid,,130.53,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,CHIP/Medicaid,,6.61,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,United Healthcare,CHIP/Medicaid,,380.18,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,CHIP/Medicaid,,48.05,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,United Healthcare,CHIP/Medicaid,,72.07,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,CHIP/Medicaid,,92.69,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,CHIP/Medicaid,,84.08,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,United Healthcare,CHIP/Medicaid,,389.79,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,CHIP/Medicaid,,398.40,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,United Healthcare,CHIP/Medicaid,,186.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,United Healthcare,CHIP/Medicaid,,281.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,United Healthcare,CHIP/Medicaid,,292.29,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,United Healthcare,CHIP/Medicaid,,345.14,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,United Healthcare,CHIP/Medicaid,,420.02,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,United Healthcare,CHIP/Medicaid,,704.50,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,United Healthcare,CHIP/Medicaid,,1249.65,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,United Healthcare,CHIP/Medicaid,,1347.55,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,United Healthcare,CHIP/Medicaid,,127.13,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,United Healthcare,CHIP/Medicaid,,170.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,United Healthcare,CHIP/Medicaid,,1271.67,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,CHIP/Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,CHIP/Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,CHIP/Medicaid,,339.94,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,United Healthcare,CHIP/Medicaid,,554.35,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,CHIP/Medicaid,,146.95,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,United Healthcare,CHIP/Medicaid,,219.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,United Healthcare,CHIP/Medicaid,,93.89,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,United Healthcare,CHIP/Medicaid,,193.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,United Healthcare,CHIP/Medicaid,,137.54,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,United Healthcare,CHIP/Medicaid,,309.31,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,United Healthcare,CHIP/Medicaid,,214.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,United Healthcare,CHIP/Medicaid,,372.77,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,United Healthcare,CHIP/Medicaid,,90.09,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,United Healthcare,CHIP/Medicaid,,241.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,United Healthcare,CHIP/Medicaid,,1499.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,United Healthcare,CHIP/Medicaid,,1492.29,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,United Healthcare,CHIP/Medicaid,,480.08,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,United Healthcare,CHIP/Medicaid,,349.55,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,United Healthcare,CHIP/Medicaid,,620.62,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,United Healthcare,CHIP/Medicaid,,1686.28,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,CHIP/Medicaid,,85.08,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,United Healthcare,CHIP/Medicaid,,113.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,United Healthcare,CHIP/Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,United Healthcare,CHIP/Medicaid,,418.82,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,United Healthcare,CHIP/Medicaid,,927.93,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,United Healthcare,CHIP/Medicaid,,492.09,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,CHIP/Medicaid,,600.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,CHIP/Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,United Healthcare,CHIP/Medicaid,,64.26,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,United Healthcare,CHIP/Medicaid,,215.42,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,CHIP/Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,CHIP/Medicaid,,120.72,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,CHIP/Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,United Healthcare,CHIP/Medicaid,,307.71,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,CHIP/Medicaid,,123.12,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,CHIP/Medicaid,,146.95,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,CHIP/Medicaid,,91.49,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,United Healthcare,CHIP/Medicaid,,66.27,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,CHIP/Medicaid,,104.70,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,CHIP/Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,United Healthcare,CHIP/Medicaid,,206.61,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,United Healthcare,CHIP/Medicaid,,177.98,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,United Healthcare,CHIP/Medicaid,,232.83,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,CHIP/Medicaid,,210.41,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,United Healthcare,CHIP/Medicaid,,281.48,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,United Healthcare,CHIP/Medicaid,76,281.48,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,United Healthcare,CHIP/Medicaid,,750.35,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,United Healthcare,CHIP/Medicaid,76,750.35,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,United Healthcare,CHIP/Medicaid,,789.79,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,United Healthcare,CHIP/Medicaid,76,789.79,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,CHIP/Medicaid,,407.21,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,CHIP/Medicaid,,452.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,United Healthcare,CHIP/Medicaid,,477.08,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,United Healthcare,CHIP/Medicaid,,526.33,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,United Healthcare,CHIP/Medicaid,,366.97,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,CHIP/Medicaid,,524.92,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,CHIP/Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,CHIP/Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,CHIP/Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,CHIP/Medicaid,,58.46,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,United Healthcare,CHIP/Medicaid,,568.97,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,United Healthcare,CHIP/Medicaid,,5465.26,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,United Healthcare,CHIP/Medicaid,,751.35,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,CHIP/Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,CHIP/Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,United Healthcare,CHIP/Medicaid,,129.73,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,United Healthcare,CHIP/Medicaid,,141.74,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,United Healthcare,CHIP/Medicaid,,245.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,United Healthcare,CHIP/Medicaid,,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,United Healthcare,CHIP/Medicaid,,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,United Healthcare,CHIP/Medicaid,,187.79,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,CHIP/Medicaid,,128.33,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,CHIP/Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,United Healthcare,CHIP/Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,United Healthcare,CHIP/Medicaid,,72.67,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,CHIP/Medicaid,,91.09,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,United Healthcare,CHIP/Medicaid,76,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,United Healthcare,CHIP/Medicaid,76,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,CHIP/Medicaid,,99.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,United Healthcare,CHIP/Medicaid,,209.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,United Healthcare,CHIP/Medicaid,,326.13,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,CHIP/Medicaid,,469.07,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,United Healthcare,CHIP/Medicaid,,1384.18,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,CHIP/Medicaid,,146.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,United Healthcare,CHIP/Medicaid,,1214.61,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,United Healthcare,CHIP/Medicaid,,451.25,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,United Healthcare,CHIP/Medicaid,,567.97,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,United Healthcare,CHIP/Medicaid,,369.97,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,United Healthcare,CHIP/Medicaid,,174.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,CHIP/Medicaid,,109.91,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,United Healthcare,CHIP/Medicaid,,161.16,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,CHIP/Medicaid,,250.65,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,United Healthcare,CHIP/Medicaid,,1634.43,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,United Healthcare,CHIP/Medicaid,,482.48,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,CHIP/Medicaid,,81.08,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,United Healthcare,CHIP/Medicaid,,112.11,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,United Healthcare,CHIP/Medicaid,,332.73,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,United Healthcare,CHIP/Medicaid,,384.98,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,United Healthcare,CHIP/Medicaid,,255.05,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,CHIP/Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,United Healthcare,CHIP/Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,United Healthcare,CHIP/Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,CHIP/Medicaid,,625.22,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,United Healthcare,CHIP/Medicaid,,70.27,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,United Healthcare,CHIP/Medicaid,,211.01,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,CHIP/Medicaid,,6.81,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,United Healthcare,CHIP/Medicaid,,93.09,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,United Healthcare,CHIP/Medicaid,,205.81,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,United Healthcare,CHIP/Medicaid,,242.64,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,United Healthcare,CHIP/Medicaid,,64.46,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,United Healthcare,CHIP/Medicaid,,151.55,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,CHIP/Medicaid,,32.43,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,CHIP/Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,United Healthcare,CHIP/Medicaid,,59.86,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,United Healthcare,CHIP/Medicaid,,119.12,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,CHIP/Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,CHIP/Medicaid,,60.46,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,CHIP/Medicaid,,21.82,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,CHIP/Medicaid,,40.04,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,CHIP/Medicaid,,32.23,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,CHIP/Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,CHIP/Medicaid,,26.63,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,CHIP/Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,United Healthcare,CHIP/Medicaid,,87.69,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,CHIP/Medicaid,,10.01,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,CHIP/Medicaid,,82.68,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,CHIP/Medicaid,,57.66,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,United Healthcare,CHIP/Medicaid,,38.24,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,CHIP/Medicaid,,53.85,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,United Healthcare,CHIP/Medicaid,GP,13.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,CHIP/Medicaid,GP,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,CHIP/Medicaid,GP,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,United Healthcare,CHIP/Medicaid,GP,24.22,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,GP,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,United Healthcare,CHIP/Medicaid,GP,3.20,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,United Healthcare,CHIP/Medicaid,GP,30.63,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,CHIP/Medicaid,GP,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,CHIP/Medicaid,GP,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,GP,22.02,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,GP,11.81,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,CHIP/Medicaid,GP,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,CHIP/Medicaid,GP,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,United Healthcare,CHIP/Medicaid,GP,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,GP,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,CHIP/Medicaid,GP,27.83,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,CHIP/Medicaid,GP,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,GP,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,United Healthcare,CHIP/Medicaid,GP,30.23,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,CHIP/Medicaid,GP,9.41,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,GP,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,CHIP/Medicaid,GP,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,CHIP/Medicaid,GP,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,CHIP/Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,CHIP/Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,GP,17.82,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,CHIP/Medicaid,GP,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,CHIP/Medicaid,GP,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,CHIP/Medicaid,GP,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,CHIP/Medicaid,GP,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,CHIP/Medicaid,GP,61.26,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,CHIP/Medicaid,GP,84.68,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,United Healthcare,CHIP/Medicaid,GP,86.89,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,CHIP/Medicaid,GP,57.66,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,GO,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,GO,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,GO,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,CHIP/Medicaid,GO,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,CHIP/Medicaid,GO,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,CHIP/Medicaid,GO,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,CHIP/Medicaid,GO,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,CHIP/Medicaid,GO,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,GO,12.41,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,CHIP/Medicaid,GO,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,CHIP/Medicaid,GO,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,United Healthcare,CHIP/Medicaid,GO,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,GO,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,GO,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,CHIP/Medicaid,GO,44.84,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,CHIP/Medicaid,GO,30.43,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,CHIP/Medicaid,GO,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,CHIP/Medicaid,GO,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,CHIP/Medicaid,GO,63.66,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,United Healthcare,CHIP/Medicaid,GO,80.68,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,United Healthcare,CHIP/Medicaid,GO,83.08,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,CHIP/Medicaid,GO,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,CHIP/Medicaid,GN,71.27,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,United Healthcare,CHIP/Medicaid,GN,67.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,CHIP/Medicaid,GN,37.44,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,CHIP/Medicaid,GN,53.85,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,CHIP/Medicaid,GN,40.04,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,CHIP/Medicaid,GN,63.06,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,CHIP/Medicaid,GN,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,CHIP/Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,CHIP/Medicaid,GN,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,CHIP/Medicaid,GN,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,CHIP/Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,GN,27.23,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,United Healthcare,CHIP/Medicaid,GN,131.13,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,United Healthcare,CHIP/Medicaid,GN,51.85,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,CHIP/Medicaid,GN,13.61,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,CHIP/Medicaid,GN,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,CHIP/Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,CHIP/Medicaid,GN,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,United Healthcare,CHIP/Medicaid,GN,42.84,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,CHIP/Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,CHIP/Medicaid,GN,21.42,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,United Healthcare,CHIP/Medicaid,GN,70.67,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,CHIP/Medicaid,GN,109.91,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,United Healthcare,CHIP/Medicaid,GN,118.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,CHIP/Medicaid,,172.97,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,CHIP/Medicaid,,109.91,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,United Healthcare,CHIP/Medicaid,,177.18,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,CHIP/Medicaid,,100.90,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,United Healthcare,CHIP/Medicaid,,149.15,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,United Healthcare,CHIP/Medicaid,,751.95,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,CHIP/Medicaid,,8.61,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,CHIP/Medicaid,,29.63,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,United Healthcare,CHIP/Medicaid,,105.11,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,CHIP/Medicaid,,104.70,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,United Healthcare,CHIP/Medicaid,,112.71,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,CHIP/Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,CHIP/Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,CHIP/Medicaid,,271.67,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,United Healthcare,CHIP/Medicaid,,83.68,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,CHIP/Medicaid,,162.56,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,United Healthcare,CHIP/Medicaid,,113.51,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,United Healthcare,CHIP/Medicaid,,95.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,CHIP/Medicaid,,130.53,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,CHIP/Medicaid,,91.69,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,CHIP/Medicaid,,31.23,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,CHIP/Medicaid,,36.04,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,CHIP/Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,United Healthcare,CHIP/Medicaid,,26.23,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,CHIP/Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,CHIP/Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,CHIP/Medicaid,,52.85,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,CHIP/Medicaid,,52.85,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,United Healthcare,CHIP/Medicaid,,400.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,CHIP/Medicaid,,625.22,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,United Healthcare,CHIP/Medicaid,,140.14,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,United Healthcare,CHIP/Medicaid,,454.85,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,CHIP/Medicaid,,166.37,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,United Healthcare,CHIP/Medicaid,,101.10,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,United Healthcare,CHIP/Medicaid,,44.44,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,United Healthcare,CHIP/Medicaid,,66.67,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,United Healthcare,CHIP/Medicaid,,67.67,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,CHIP/Medicaid,,37.04,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,CHIP/Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,CHIP/Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,United Healthcare,CHIP/Medicaid,,203.60,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,CHIP/Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,CHIP/Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,United Healthcare,CHIP/Medicaid,,854.05,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,United Healthcare,CHIP/Medicaid,,231.03,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,United Healthcare,CHIP/Medicaid,,110.51,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,United Healthcare,CHIP/Medicaid,,113.11,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,United Healthcare,CHIP/Medicaid,,270.27,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,CHIP/Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,CHIP/Medicaid,,110.11,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,CHIP/Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,CHIP/Medicaid,,210.41,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,United Healthcare,CHIP/Medicaid,,90.69,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,CHIP/Medicaid,,254.45,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,United Healthcare,CHIP/Medicaid,,232.03,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,CHIP/Medicaid,,145.75,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,CHIP/Medicaid,,96.30,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,United Healthcare,CHIP/Medicaid,,225.43,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,CHIP/Medicaid,,63.26,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,CHIP/Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,CHIP/Medicaid,,24.82,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,United Healthcare,CHIP/Medicaid,,191.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,CHIP/Medicaid,,114.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,United Healthcare,CHIP/Medicaid,,92.89,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,CHIP/Medicaid,,107.91,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,United Healthcare,CHIP/Medicaid,,100.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,CHIP/Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,CHIP/Medicaid,,81.08,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,CHIP/Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,CHIP/Medicaid,,81.08,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,CHIP/Medicaid,,74.67,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,United Healthcare,CHIP/Medicaid,,134.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,CHIP/Medicaid,,164.56,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,United Healthcare,CHIP/Medicaid,,171.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,United Healthcare,CHIP/Medicaid,,177.78,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,CHIP/Medicaid,,107.91,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,CHIP/Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,CHIP/Medicaid,,59.06,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,CHIP/Medicaid,,87.49,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,CHIP/Medicaid,,50.65,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,United Healthcare,CHIP/Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,United Healthcare,CHIP/Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,United Healthcare,CHIP/Medicaid,,109.51,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,CHIP/Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,CHIP/Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,CHIP/Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,CHIP/Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,CHIP/Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,CHIP/Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,CHIP/Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,CHIP/Medicaid,,53.45,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,CHIP/Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,CHIP/Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,CHIP/Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,CHIP/Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,CHIP/Medicaid,,91.49,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,CHIP/Medicaid,,91.09,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,United Healthcare,CHIP/Medicaid,,298.50,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,United Healthcare,CHIP/Medicaid,,305.51,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,United Healthcare,CHIP/Medicaid,,169.77,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,United Healthcare,CHIP/Medicaid,,246.85,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,CHIP/Medicaid,,84.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,United Healthcare,CHIP/Medicaid,,199.60,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,CHIP/Medicaid,,92.69,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,United Healthcare,CHIP/Medicaid,,108.91,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,United Healthcare,CHIP/Medicaid,,263.26,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,United Healthcare,CHIP/Medicaid,,317.92,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,CHIP/Medicaid,,390.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,United Healthcare,CHIP/Medicaid,,553.95,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,United Healthcare,CHIP/Medicaid,,608.41,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,United Healthcare,CHIP/Medicaid,,771.97,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,CHIP/Medicaid,,454.05,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,United Healthcare,CHIP/Medicaid,,508.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,United Healthcare,CHIP/Medicaid,,572.17,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,United Healthcare,CHIP/Medicaid,,908.11,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,United Healthcare,CHIP/Medicaid,,1017.02,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,United Healthcare,CHIP/Medicaid,,1135.13,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,CHIP/Medicaid,,208.61,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,CHIP/Medicaid,,45.05,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,CHIP/Medicaid,,58.46,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,CHIP/Medicaid,,58.86,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,CHIP/Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,CHIP/Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,CHIP/Medicaid,,21.22,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,CHIP/Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,CHIP/Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,CHIP/Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,CHIP/Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,CHIP/Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,CHIP/Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,United Healthcare,CHIP/Medicaid,GP,13.35,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,United Healthcare,CHIP/Medicaid,,95.90,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,CHIP/Medicaid,,549.35,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,CHIP/Medicaid,,549.35,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,CHIP/Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,CHIP/Medicaid,,217.22,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,CHIP/Medicaid,,217.22,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,United Healthcare,CHIP/Medicaid,,493.29,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,United Healthcare,CHIP/Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,United Healthcare,CHIP/Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,United Healthcare,CHIP/Medicaid,,638.64,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,United Healthcare,CHIP/Medicaid,,86.09,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,CHIP/Medicaid,,96.10,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,CHIP/Medicaid,,107.31,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,CHIP/Medicaid,,91.69,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,CHIP/Medicaid,,23.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,CHIP/Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,CHIP/Medicaid,,32.63,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,United Healthcare,CHIP/Medicaid,,61.46,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,United Healthcare,CHIP/Medicaid,,104.10,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,CHIP/Medicaid,,100.90,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,United Healthcare,CHIP/Medicaid,,123.72,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,United Healthcare,CHIP/Medicaid,,81.88,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,CHIP/Medicaid,,154.15,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,CHIP/Medicaid,,154.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,United Healthcare,CHIP/Medicaid,,127.73,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,CHIP/Medicaid,,120.72,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,CHIP/Medicaid,,180.58,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,CHIP/Medicaid,,36.44,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,CHIP/Medicaid,,30.43,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,CHIP/Medicaid,,56.06,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,CHIP/Medicaid,,77.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,CHIP/Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,CHIP/Medicaid,,151.95,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,United Healthcare,CHIP/Medicaid,,459.46,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,United Healthcare,CHIP/Medicaid,,121.52,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,CHIP/Medicaid,,372.97,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,CHIP/Medicaid,,372.97,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,United Healthcare,CHIP/Medicaid,,426.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,CHIP/Medicaid,,107.31,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,CHIP/Medicaid,,207.61,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,United Healthcare,CHIP/Medicaid,,2503.90,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,United Healthcare,CHIP/Medicaid,,304.30,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,United Healthcare,CHIP/Medicaid,,386.99,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,United Healthcare,CHIP/Medicaid,,166.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,United Healthcare,CHIP/Medicaid,,173.97,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,United Healthcare,CHIP/Medicaid,,185.19,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,United Healthcare,CHIP/Medicaid,,307.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,CHIP/Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,United Healthcare,CHIP/Medicaid,,1956.75,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,CHIP/Medicaid,,132.13,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,CHIP/Medicaid,,132.13,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,CHIP/Medicaid,,638.44,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,CHIP/Medicaid,,638.44,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,CHIP/Medicaid,,305.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,CHIP/Medicaid,,305.91,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,United Healthcare,CHIP/Medicaid,,345.75,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,CHIP/Medicaid,,428.83,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,CHIP/Medicaid,,428.83,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,CHIP/Medicaid,,279.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,CHIP/Medicaid,,279.68,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,CHIP/Medicaid,,124.32,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,CHIP/Medicaid,,124.32,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,United Healthcare,CHIP/Medicaid,,144.14,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,United Healthcare,CHIP/Medicaid,,144.14,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,CHIP/Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,CHIP/Medicaid,,448.45,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,CHIP/Medicaid,JW,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,CHIP/Medicaid,,117.32,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,CHIP/Medicaid,,99.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,United Healthcare,CHIP/Medicaid,,120.92,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,CHIP/Medicaid,,99.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,CHIP/Medicaid,,117.32,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,CHIP/Medicaid,,164.56,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,United Healthcare,CHIP/Medicaid,,273.07,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,CHIP/Medicaid,,70.47,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,CHIP/Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,CHIP/Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,CHIP/Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,CHIP/Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,CHIP/Medicaid,,390.39,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,CHIP/Medicaid,,390.39,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,CHIP/Medicaid,,621.22,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,CHIP/Medicaid,,621.22,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,United Healthcare,CHIP/Medicaid,,344.94,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,United Healthcare,CHIP/Medicaid,,426.83,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,United Healthcare,CHIP/Medicaid,,560.56,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,United Healthcare,CHIP/Medicaid,,108.71,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,United Healthcare,CHIP/Medicaid,,877.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,United Healthcare,CHIP/Medicaid,,970.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,United Healthcare,CHIP/Medicaid,,1147.95,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,CHIP/Medicaid,,160.96,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,United Healthcare,CHIP/Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,United Healthcare,CHIP/Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,United Healthcare,CHIP/Medicaid,,384.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,United Healthcare,CHIP/Medicaid,,340.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,CHIP/Medicaid,,116.52,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,CHIP/Medicaid,,454.05,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,United Healthcare,CHIP/Medicaid,,253.25,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,CHIP/Medicaid,,467.07,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,CHIP/Medicaid,,467.07,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,United Healthcare,CHIP/Medicaid,,409.81,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,United Healthcare,CHIP/Medicaid,,267.27,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,CHIP/Medicaid,,169.57,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,CHIP/Medicaid,,356.56,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,CHIP/Medicaid,,356.56,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,CHIP/Medicaid,,339.94,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,CHIP/Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,CHIP/Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,CHIP/Medicaid,,359.16,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,CHIP/Medicaid,,359.16,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,CHIP/Medicaid,,824.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,CHIP/Medicaid,,824.62,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,CHIP/Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,CHIP/Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,CHIP/Medicaid,,102.50,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,United Healthcare,CHIP/Medicaid,,118.92,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,United Healthcare,CHIP/Medicaid,52,220.22,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,CHIP/Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,United Healthcare,CHIP/Medicaid,,142.34,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,United Healthcare,CHIP/Medicaid,,292.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,CHIP/Medicaid,,25.43,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,CHIP/Medicaid,,183.98,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,CHIP/Medicaid,,183.98,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,CHIP/Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,CHIP/Medicaid,,63.46,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,United Healthcare,CHIP/Medicaid,,139.54,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,United Healthcare,CHIP/Medicaid,,278.88,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,United Healthcare,CHIP/Medicaid,,475.48,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,United Healthcare,CHIP/Medicaid,,634.03,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,United Healthcare,CHIP/Medicaid,,803.00,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,United Healthcare,CHIP/Medicaid,,265.06,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,United Healthcare,CHIP/Medicaid,,241.64,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,United Healthcare,CHIP/Medicaid,,72.27,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,CHIP/Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,CHIP/Medicaid,,37.84,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,CHIP/Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,CHIP/Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,CHIP/Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,CHIP/Medicaid,,40.24,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,United Healthcare,CHIP/Medicaid,,49.85,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,CHIP/Medicaid,,48.05,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,CHIP/Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,CHIP/Medicaid,,79.88,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,CHIP/Medicaid,,74.27,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,CHIP/Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,CHIP/Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,United Healthcare,CHIP/Medicaid,,45.45,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,CHIP/Medicaid,,53.45,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,United Healthcare,CHIP/Medicaid,,50.05,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,United Healthcare,CHIP/Medicaid,,81.28,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,United Healthcare,CHIP/Medicaid,,87.09,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,CHIP/Medicaid,,87.49,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,United Healthcare,CHIP/Medicaid,,79.48,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,CHIP/Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,United Healthcare,CHIP/Medicaid,,50.85,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,CHIP/Medicaid,,77.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,United Healthcare,CHIP/Medicaid,,97.90,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,CHIP/Medicaid,,13.21,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,CHIP/Medicaid,,21.22,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,United Healthcare,CHIP/Medicaid,,35.24,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,United Healthcare,CHIP/Medicaid,,52.05,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,CHIP/Medicaid,,68.67,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,CHIP/Medicaid,,46.25,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,CHIP/Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,CHIP/Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,United Healthcare,CHIP/Medicaid,,115.32,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,United Healthcare,CHIP/Medicaid,,27.43,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,CHIP/Medicaid,,22.42,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,CHIP/Medicaid,,9.61,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,CHIP/Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,United Healthcare,CHIP/Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,CHIP/Medicaid,JW,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,CHIP/Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,JW,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,United Healthcare,CHIP/Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,CHIP/Medicaid,,55.05,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,CHIP/Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,CHIP/Medicaid,JW,40.04,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,CHIP/Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,CHIP/Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,CHIP/Medicaid,JW,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,CHIP/Medicaid,JW,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,CHIP/Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,CHIP/Medicaid,JW,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,CHIP/Medicaid,JW,54.65,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,CHIP/Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,CHIP/Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,CHIP/Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,CHIP/Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,CHIP/Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,CHIP/Medicaid,JW,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,CHIP/Medicaid,JW,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,CHIP/Medicaid,JW,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,CHIP/Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,CHIP/Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,CHIP/Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,CHIP/Medicaid,JW,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,CHIP/Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,United Healthcare,CHIP/Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,CHIP/Medicaid,JW,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,CHIP/Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,CHIP/Medicaid,JW,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,CHIP/Medicaid,JW,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,United Healthcare,CHIP/Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,CHIP/Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,CHIP/Medicaid,JW,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,CHIP/Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,CHIP/Medicaid,JW,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,CHIP/Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,CHIP/Medicaid,JW,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,JW,13.01,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,CHIP/Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,CHIP/Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,CHIP/Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,CHIP/Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,CHIP/Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,CHIP/Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,CHIP/Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,United Healthcare,CHIP/Medicaid,JW,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,CHIP/Medicaid,JW,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,CHIP/Medicaid,JW,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,CHIP/Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,CHIP/Medicaid,JW,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,CHIP/Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,CHIP/Medicaid,JW,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,CHIP/Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,CHIP/Medicaid,JW,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,CHIP/Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,CHIP/Medicaid,JW,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,CHIP/Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,CHIP/Medicaid,JW,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,CHIP/Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,CHIP/Medicaid,JW,54.45,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,United Healthcare,CHIP/Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,CHIP/Medicaid,,59.06,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,CHIP/Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,CHIP/Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,CHIP/Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,CHIP/Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,CHIP/Medicaid,,54.05,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,United Healthcare,CHIP/Medicaid,,849.45,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,CHIP/Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,United Healthcare,CHIP/Medicaid,,49.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,United Healthcare,CHIP/Medicaid,,515.92,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,CHIP/Medicaid,,41.84,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,CHIP/Medicaid,,60.66,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,CHIP/Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,CHIP/Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,CHIP/Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,CHIP/Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,CHIP/Medicaid,,67.47,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,CHIP/Medicaid,,56.06,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,CHIP/Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,United Healthcare,CHIP/Medicaid,,1877.68,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,United Healthcare,CHIP/Medicaid,,222.82,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,CHIP/Medicaid,,207.61,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,United Healthcare,CHIP/Medicaid,,239.64,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,United Healthcare,CHIP/Medicaid,,161.36,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,CHIP/Medicaid,,397.40,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,CHIP/Medicaid,,397.40,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,CHIP/Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,CHIP/Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,CHIP/Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,CHIP/Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,CHIP/Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,CHIP/Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,CHIP/Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,CHIP/Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,CHIP/Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,CHIP/Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,CHIP/Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,CHIP/Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,United Healthcare,CHIP/Medicaid,,118.92,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,CHIP/Medicaid,,102.50,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,CHIP/Medicaid,,154.35,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,United Healthcare,CHIP/Medicaid,,136.34,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,CHIP/Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,CHIP/Medicaid,,28.63,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,CHIP/Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,CHIP/Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,CHIP/Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,CHIP/Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,CHIP/Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,CHIP/Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,CHIP/Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,,33.03,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,United Healthcare,CHIP/Medicaid,,189.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,United Healthcare,CHIP/Medicaid,,96.90,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,CHIP/Medicaid,,25.63,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,CHIP/Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,CHIP/Medicaid,,31.63,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,CHIP/Medicaid,,18.42,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,CHIP/Medicaid,,18.42,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,CHIP/Medicaid,,42.44,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,CHIP/Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,CHIP/Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,CHIP/Medicaid,,30.03,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,CHIP/Medicaid,,17.02,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,CHIP/Medicaid,,26.63,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,CHIP/Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,United Healthcare,CHIP/Medicaid,,8008.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,United Healthcare,CHIP/Medicaid,,155.56,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,United Healthcare,CHIP/Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,United Healthcare,CHIP/Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,United Healthcare,CHIP/Medicaid,,989.19,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,CHIP/Medicaid,,58.46,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,CHIP/Medicaid,,176.98,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,United Healthcare,CHIP/Medicaid,,41.04,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,United Healthcare,CHIP/Medicaid,,41.04,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,United Healthcare,CHIP/Medicaid,,194.19,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,CHIP/Medicaid,,246.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,CHIP/Medicaid,,64.86,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,United Healthcare,CHIP/Medicaid,,1253.05,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,CHIP/Medicaid,,625.22,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,United Healthcare,CHIP/Medicaid,,97.30,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,United Healthcare,CHIP/Medicaid,,4128.92,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,CHIP/Medicaid,,625.22,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,United Healthcare,CHIP/Medicaid,,168.57,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,United Healthcare,CHIP/Medicaid,,467.67,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,United Healthcare,CHIP/Medicaid,,463.86,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,United Healthcare,CHIP/Medicaid,,464.86,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,United Healthcare,CHIP/Medicaid,,2388.19,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,United Healthcare,CHIP/Medicaid,,104.90,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,United Healthcare,CHIP/Medicaid,,114.71,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,United Healthcare,CHIP/Medicaid,,266.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,CHIP/Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,CHIP/Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,United Healthcare,CHIP/Medicaid,,379.38,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,United Healthcare,CHIP/Medicaid,,379.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,United Healthcare,CHIP/Medicaid,,691.89,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,United Healthcare,CHIP/Medicaid,,691.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,CHIP/Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,CHIP/Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,United Healthcare,CHIP/Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,CHIP/Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,CHIP/Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,CHIP/Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,CHIP/Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,CHIP/Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,CHIP/Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,CHIP/Medicaid,JW,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,CHIP/Medicaid,JW,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,CHIP/Medicaid,JW,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,CHIP/Medicaid,JW,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,CHIP/Medicaid,JW,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,CHIP/Medicaid,JW,93.29,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,United Healthcare,CHIP/Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,CHIP/Medicaid,,35.84,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,United Healthcare,CHIP/Medicaid,,159.56,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,CHIP/Medicaid,,197.80,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,United Healthcare,CHIP/Medicaid,,286.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,CHIP/Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,CHIP/Medicaid,,35.84,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,United Healthcare,CHIP/Medicaid,,365.97,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,United Healthcare,CHIP/Medicaid,,519.32,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,United Healthcare,CHIP/Medicaid,,189.19,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,United Healthcare,CHIP/Medicaid,,577.18,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,CHIP/Medicaid,,191.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,CHIP/Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,United Healthcare,CHIP/Medicaid,,280.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,United Healthcare,CHIP/Medicaid,,435.23,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,United Healthcare,CHIP/Medicaid,,847.25,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,United Healthcare,CHIP/Medicaid,,3830.23,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,CHIP/Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,United Healthcare,CHIP/Medicaid,,90.49,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,CHIP/Medicaid,,80.28,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,CHIP/Medicaid,,133.13,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,CHIP/Medicaid,,63.66,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,CHIP/Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,CHIP/Medicaid,,64.86,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,United Healthcare,CHIP/Medicaid,,109.11,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,CHIP/Medicaid,,70.47,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,CHIP/Medicaid,,96.30,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,United Healthcare,CHIP/Medicaid,,120.32,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,CHIP/Medicaid,,78.88,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,CHIP/Medicaid,,88.49,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,CHIP/Medicaid,,100.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,CHIP/Medicaid,,30.43,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,CHIP/Medicaid,,54.05,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,CHIP/Medicaid,,24.02,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,CHIP/Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,United Healthcare,CHIP/Medicaid,,134.33,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,CHIP/Medicaid,,35.84,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,CHIP/Medicaid,,60.46,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,CHIP/Medicaid,,72.47,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,CHIP/Medicaid,,96.70,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,United Healthcare,CHIP/Medicaid,,116.92,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,CHIP/Medicaid,,216.02,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,CHIP/Medicaid,,117.12,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,CHIP/Medicaid,,61.06,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,CHIP/Medicaid,,88.49,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,CHIP/Medicaid,,99.30,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,CHIP/Medicaid,,132.13,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,United Healthcare,CHIP/Medicaid,,185.99,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,CHIP/Medicaid,,87.49,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,United Healthcare,CHIP/Medicaid,,65.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,United Healthcare,CHIP/Medicaid,,112.91,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,CHIP/Medicaid,,98.50,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,United Healthcare,CHIP/Medicaid,,142.14,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,CHIP/Medicaid,,175.18,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,CHIP/Medicaid,,116.52,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,CHIP/Medicaid,,68.27,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,United Healthcare,CHIP/Medicaid,,108.31,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,CHIP/Medicaid,,73.87,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,United Healthcare,CHIP/Medicaid,,73.67,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,United Healthcare,CHIP/Medicaid,,242.44,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,CHIP/Medicaid,,150.55,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,United Healthcare,CHIP/Medicaid,,267.47,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,United Healthcare,CHIP/Medicaid,,378.78,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,CHIP/Medicaid,,416.62,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,CHIP/Medicaid,,85.08,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,United Healthcare,CHIP/Medicaid,,76.48,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,CHIP/Medicaid,,91.89,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,United Healthcare,CHIP/Medicaid,,92.49,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,CHIP/Medicaid,,254.45,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,United Healthcare,CHIP/Medicaid,,104.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,United Healthcare,CHIP/Medicaid,,88.09,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,United Healthcare,CHIP/Medicaid,,81.28,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,CHIP/Medicaid,,88.49,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,CHIP/Medicaid,,97.50,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,United Healthcare,CHIP/Medicaid,,75.88,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,United Healthcare,CHIP/Medicaid,,59.66,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,United Healthcare,CHIP/Medicaid,,75.08,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,United Healthcare,CHIP/Medicaid,,69.47,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,United Healthcare,CHIP/Medicaid,,130.73,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,CHIP/Medicaid,,86.29,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,CHIP/Medicaid,,78.88,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,United Healthcare,CHIP/Medicaid,,55.26,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,CHIP/Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,CHIP/Medicaid,,85.49,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,CHIP/Medicaid,,74.27,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,CHIP/Medicaid,,96.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,CHIP/Medicaid,,63.26,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,CHIP/Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,CHIP/Medicaid,,70.87,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,CHIP/Medicaid,,43.64,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,United Healthcare,CHIP/Medicaid,,89.09,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,CHIP/Medicaid,,92.69,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,CHIP/Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,United Healthcare,CHIP/Medicaid,,106.11,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,CHIP/Medicaid,,92.69,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,CHIP/Medicaid,,80.28,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,CHIP/Medicaid,,64.86,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,CHIP/Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,United Healthcare,CHIP/Medicaid,,156.56,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,United Healthcare,CHIP/Medicaid,,64.46,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,CHIP/Medicaid,,49.45,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,CHIP/Medicaid,,211.21,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,CHIP/Medicaid,,145.75,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,United Healthcare,CHIP/Medicaid,,177.78,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,United Healthcare,CHIP/Medicaid,,99.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,United Healthcare,CHIP/Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,CHIP/Medicaid,,197.80,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,CHIP/Medicaid,,208.41,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,CHIP/Medicaid,,215.01,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,United Healthcare,CHIP/Medicaid,,107.51,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,CHIP/Medicaid,,19.62,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,United Healthcare,CHIP/Medicaid,,116.12,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,United Healthcare,CHIP/Medicaid,,128.73,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,CHIP/Medicaid,,163.76,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,United Healthcare,CHIP/Medicaid,,133.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,United Healthcare,CHIP/Medicaid,,162.16,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,United Healthcare,CHIP/Medicaid,,418.02,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,United Healthcare,CHIP/Medicaid,,929.93,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,United Healthcare,CHIP/Medicaid,,716.12,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,CHIP/Medicaid,,37.04,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,United Healthcare,CHIP/Medicaid,,273.87,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,United Healthcare,CHIP/Medicaid,,279.28,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,United Healthcare,CHIP/Medicaid,,810.21,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,United Healthcare,CHIP/Medicaid,,1150.35,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,United Healthcare,CHIP/Medicaid,,265.47,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,United Healthcare,CHIP/Medicaid,,514.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,United Healthcare,CHIP/Medicaid,,206.41,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,United Healthcare,CHIP/Medicaid,,240.64,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,United Healthcare,CHIP/Medicaid,,321.92,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,CHIP/Medicaid,,160.96,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,United Healthcare,CHIP/Medicaid,,323.52,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,CHIP/Medicaid,,193.59,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,CHIP/Medicaid,,159.96,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,CHIP/Medicaid,,221.42,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,CHIP/Medicaid,,467.07,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,United Healthcare,CHIP/Medicaid,,275.48,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,CHIP/Medicaid,,40.84,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,CHIP/Medicaid,,35.03,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,United Healthcare,CHIP/Medicaid,,241.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,CHIP/Medicaid,,154.35,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,United Healthcare,CHIP/Medicaid,,211.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,United Healthcare,CHIP/Medicaid,,71.67,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,CHIP/Medicaid,,190.79,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,CHIP/Medicaid,,33.83,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,CHIP/Medicaid,,187.39,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,CHIP/Medicaid,,61.26,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,CHIP/Medicaid,,68.27,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,CHIP/Medicaid,,28.63,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,United Healthcare,CHIP/Medicaid,,148.95,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,United Healthcare,CHIP/Medicaid,,132.53,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,United Healthcare,CHIP/Medicaid,,131.53,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,CHIP/Medicaid,,64.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,United Healthcare,CHIP/Medicaid,,129.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,United Healthcare,CHIP/Medicaid,,69.27,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,CHIP/Medicaid,,48.65,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,CHIP/Medicaid,,53.65,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,United Healthcare,CHIP/Medicaid,,185.59,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,CHIP/Medicaid,,61.26,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,CHIP/Medicaid,,182.38,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,CHIP/Medicaid,,58.26,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,United Healthcare,CHIP/Medicaid,,157.76,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,CHIP/Medicaid,,469.07,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,United Healthcare,CHIP/Medicaid,,808.61,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,United Healthcare,CHIP/Medicaid,,668.27,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,United Healthcare,CHIP/Medicaid,,720.32,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,United Healthcare,CHIP/Medicaid,,407.41,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,CHIP/Medicaid,,903.70,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,CHIP/Medicaid,,903.70,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,CHIP/Medicaid,,903.70,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,United Healthcare,CHIP/Medicaid,,611.21,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,United Healthcare,CHIP/Medicaid,,357.56,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,United Healthcare,CHIP/Medicaid,,281.08,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,CHIP/Medicaid,,53.65,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,United Healthcare,CHIP/Medicaid,,74.87,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,United Healthcare,CHIP/Medicaid,,66.47,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,CHIP/Medicaid,,166.37,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,CHIP/Medicaid,,32.63,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,CHIP/Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,CHIP/Medicaid,,416.62,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,United Healthcare,CHIP/Medicaid,,123.52,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,CHIP/Medicaid,,162.56,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,United Healthcare,CHIP/Medicaid,,172.37,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,United Healthcare,CHIP/Medicaid,,93.49,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,United Healthcare,CHIP/Medicaid,,98.90,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,CHIP/Medicaid,,104.70,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,CHIP/Medicaid,,151.75,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,United Healthcare,CHIP/Medicaid,,147.35,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,CHIP/Medicaid,,216.02,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,CHIP/Medicaid,,45.85,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,CHIP/Medicaid,,86.49,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,United Healthcare,CHIP/Medicaid,,212.81,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,CHIP/Medicaid,,123.12,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,United Healthcare,CHIP/Medicaid,,157.16,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,United Healthcare,CHIP/Medicaid,,7507.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,United Healthcare,CHIP/Medicaid,,43.44,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,United Healthcare,CHIP/Medicaid,,370.97,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,United Healthcare,CHIP/Medicaid,,451.05,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,CHIP/Medicaid,,84.08,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,CHIP/Medicaid,,110.11,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,United Healthcare,CHIP/Medicaid,,108.11,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,CHIP/Medicaid,,80.28,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,United Healthcare,CHIP/Medicaid,,119.32,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,United Healthcare,CHIP/Medicaid,,99.50,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,CHIP/Medicaid,,150.55,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,CHIP/Medicaid,,116.32,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,United Healthcare,CHIP/Medicaid,,185.79,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,United Healthcare,CHIP/Medicaid,,276.68,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,CHIP/Medicaid,,54.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,United Healthcare,CHIP/Medicaid,,165.97,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,CHIP/Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,CHIP/Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,CHIP/Medicaid,,271.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,CHIP/Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,United Healthcare,CHIP/Medicaid,,137.14,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,United Healthcare,CHIP/Medicaid,,221.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,CHIP/Medicaid,,116.72,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,United Healthcare,CHIP/Medicaid,,583.98,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,United Healthcare,CHIP/Medicaid,,299.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,United Healthcare,CHIP/Medicaid,,218.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,United Healthcare,CHIP/Medicaid,,195.40,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,United Healthcare,CHIP/Medicaid,,143.54,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,CHIP/Medicaid,,373.57,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,United Healthcare,CHIP/Medicaid,,203.00,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,United Healthcare,CHIP/Medicaid,,416.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,CHIP/Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,United Healthcare,CHIP/Medicaid,,458.46,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,CHIP/Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,CHIP/Medicaid,,476.08,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,United Healthcare,CHIP/Medicaid,,547.15,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,United Healthcare,CHIP/Medicaid,,171.37,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,United Healthcare,CHIP/Medicaid,,313.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,CHIP/Medicaid,,246.25,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,United Healthcare,CHIP/Medicaid,,449.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,CHIP/Medicaid,,208.61,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,United Healthcare,CHIP/Medicaid,,229.83,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,CHIP/Medicaid,,251.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,United Healthcare,CHIP/Medicaid,,357.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,CHIP/Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,CHIP/Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,United Healthcare,CHIP/Medicaid,,499.90,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,United Healthcare,CHIP/Medicaid,,775.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,United Healthcare,CHIP/Medicaid,,969.77,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,CHIP/Medicaid,,166.37,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,United Healthcare,CHIP/Medicaid,,288.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,CHIP/Medicaid,,259.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,CHIP/Medicaid,,318.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,United Healthcare,CHIP/Medicaid,,497.70,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,United Healthcare,CHIP/Medicaid,,155.76,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,CHIP/Medicaid,,293.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,CHIP/Medicaid,,172.97,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,United Healthcare,CHIP/Medicaid,,218.22,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,CHIP/Medicaid,,159.96,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,CHIP/Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,United Healthcare,CHIP/Medicaid,,264.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,CHIP/Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,CHIP/Medicaid,,322.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,CHIP/Medicaid,,254.45,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,United Healthcare,CHIP/Medicaid,,184.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,United Healthcare,CHIP/Medicaid,,468.67,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,United Healthcare,CHIP/Medicaid,,589.19,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,United Healthcare,CHIP/Medicaid,,55.46,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,CHIP/Medicaid,,19.82,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,United Healthcare,CHIP/Medicaid,,406.41,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,CHIP/Medicaid,,197.80,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,CHIP/Medicaid,,41.64,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,United Healthcare,CHIP/Medicaid,,559.36,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,United Healthcare,CHIP/Medicaid,,2501.10,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,United Healthcare,CHIP/Medicaid,,328.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,CHIP/Medicaid,,103.90,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,United Healthcare,CHIP/Medicaid,,407.01,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,United Healthcare,CHIP/Medicaid,,94.09,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,United Healthcare,CHIP/Medicaid,,2476.67,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,CHIP/Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,United Healthcare,CHIP/Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,United Healthcare,CHIP/Medicaid,,17.42,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,United Healthcare,CHIP/Medicaid,,175.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,CHIP/Medicaid,,23.82,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,United Healthcare,CHIP/Medicaid,,116.92,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,CHIP/Medicaid,,64.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,CHIP/Medicaid,,8.81,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,United Healthcare,CHIP/Medicaid,,1057.06,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,United Healthcare,CHIP/Medicaid,,1.20,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,United Healthcare,CHIP/Medicaid,,129.93,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,CHIP/Medicaid,,24.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,CHIP/Medicaid,,8.41,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,United Healthcare,CHIP/Medicaid,,16.42,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,United Healthcare,CHIP/Medicaid,,50.85,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,United Healthcare,CHIP/Medicaid,,1212.81,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,CHIP/Medicaid,,36.64,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,United Healthcare,CHIP/Medicaid,,215.22,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,CHIP/Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,United Healthcare,CHIP/Medicaid,,285.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,CHIP/Medicaid,,61.06,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,CHIP/Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,CHIP/Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,United Healthcare,CHIP/Medicaid,,268.87,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,CHIP/Medicaid,,97.50,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,United Healthcare,CHIP/Medicaid,,87.09,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,CHIP/Medicaid,,448.45,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,United Healthcare,CHIP/Medicaid,,321.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,CHIP/Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,CHIP/Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,CHIP/Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,CHIP/Medicaid,,262.06,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,United Healthcare,CHIP/Medicaid,,386.19,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,United Healthcare,CHIP/Medicaid,,214.01,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,United Healthcare,CHIP/Medicaid,,381.98,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,CHIP/Medicaid,,246.25,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,United Healthcare,CHIP/Medicaid,,804.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,United Healthcare,CHIP/Medicaid,,662.66,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,CHIP/Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,CHIP/Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,United Healthcare,CHIP/Medicaid,,813.21,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,United Healthcare,CHIP/Medicaid,,206.81,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,United Healthcare,CHIP/Medicaid,,225.43,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,CHIP/Medicaid,,64.86,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,United Healthcare,CHIP/Medicaid,,507.91,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,United Healthcare,CHIP/Medicaid,,258.06,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,United Healthcare,CHIP/Medicaid,,227.83,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,United Healthcare,CHIP/Medicaid,,254.05,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,CHIP/Medicaid,,452.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,United Healthcare,CHIP/Medicaid,,534.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,United Healthcare,CHIP/Medicaid,,653.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,United Healthcare,CHIP/Medicaid,,490.49,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,United Healthcare,CHIP/Medicaid,,588.99,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,United Healthcare,CHIP/Medicaid,,657.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,United Healthcare,CHIP/Medicaid,,507.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,United Healthcare,CHIP/Medicaid,,619.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,United Healthcare,CHIP/Medicaid,,701.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,United Healthcare,CHIP/Medicaid,,517.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,United Healthcare,CHIP/Medicaid,,617.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,United Healthcare,CHIP/Medicaid,,703.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,CHIP/Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,CHIP/Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,United Healthcare,CHIP/Medicaid,,466.67,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,CHIP/Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,United Healthcare,CHIP/Medicaid,,688.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,United Healthcare,CHIP/Medicaid,,775.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,United Healthcare,CHIP/Medicaid,,574.97,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,United Healthcare,CHIP/Medicaid,,724.32,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,United Healthcare,CHIP/Medicaid,,741.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,United Healthcare,CHIP/Medicaid,,448.85,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,United Healthcare,CHIP/Medicaid,,546.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,United Healthcare,CHIP/Medicaid,,637.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,CHIP/Medicaid,,524.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,CHIP/Medicaid,,638.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,CHIP/Medicaid,,745.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,United Healthcare,CHIP/Medicaid,,604.20,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,United Healthcare,CHIP/Medicaid,,458.86,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,United Healthcare,CHIP/Medicaid,,573.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,United Healthcare,CHIP/Medicaid,,614.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,United Healthcare,CHIP/Medicaid,,587.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,United Healthcare,CHIP/Medicaid,,805.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,United Healthcare,CHIP/Medicaid,,869.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,United Healthcare,CHIP/Medicaid,,795.59,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,CHIP/Medicaid,,502.70,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,United Healthcare,CHIP/Medicaid,,646.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,United Healthcare,CHIP/Medicaid,,847.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,United Healthcare,CHIP/Medicaid,,986.39,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,United Healthcare,CHIP/Medicaid,,499.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,United Healthcare,CHIP/Medicaid,,635.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,United Healthcare,CHIP/Medicaid,,752.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,United Healthcare,CHIP/Medicaid,,1473.67,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,CHIP/Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,United Healthcare,CHIP/Medicaid,,1072.07,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,United Healthcare,CHIP/Medicaid,,1277.08,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,United Healthcare,CHIP/Medicaid,,1484.48,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,CHIP/Medicaid,,262.06,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,United Healthcare,CHIP/Medicaid,,812.61,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,CHIP/Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,CHIP/Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,CHIP/Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,United Healthcare,CHIP/Medicaid,,560.56,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,United Healthcare,CHIP/Medicaid,,95.50,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,United Healthcare,CHIP/Medicaid,,234.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,CHIP/Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,CHIP/Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,United Healthcare,CHIP/Medicaid,,290.29,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,CHIP/Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,CHIP/Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,United Healthcare,CHIP/Medicaid,,380.58,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,CHIP/Medicaid,,95.09,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,CHIP/Medicaid,,67.47,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,CHIP/Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,CHIP/Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,United Healthcare,CHIP/Medicaid,,6299.49,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,CHIP/Medicaid,,53.85,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,CHIP/Medicaid,,145.75,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,CHIP/Medicaid,,125.93,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,United Healthcare,CHIP/Medicaid,,399.00,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,United Healthcare,CHIP/Medicaid,,1022.02,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,United Healthcare,CHIP/Medicaid,,108.71,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,United Healthcare,CHIP/Medicaid,,277.68,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,United Healthcare,CHIP/Medicaid,,176.18,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,United Healthcare,CHIP/Medicaid,,11521.71,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,CHIP/Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,CHIP/Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,United Healthcare,CHIP/Medicaid,,5912.91,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,United Healthcare,CHIP/Medicaid,,222.22,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,CHIP/Medicaid,,600.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,CHIP/Medicaid,,31.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,CHIP/Medicaid,,31.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,United Healthcare,CHIP/Medicaid,,84.28,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,CHIP/Medicaid,,584.78,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,CHIP/Medicaid,,125.93,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,United Healthcare,CHIP/Medicaid,,91.29,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,United Healthcare,CHIP/Medicaid,,46.45,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,CHIP/Medicaid,,40.24,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,CHIP/Medicaid,,96.30,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,United Healthcare,CHIP/Medicaid,,222.02,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,CHIP/Medicaid,,91.69,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,CHIP/Medicaid,,57.06,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,United Healthcare,CHIP/Medicaid,,280.28,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,CHIP/Medicaid,,316.72,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,CHIP/Medicaid,,316.72,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,CHIP/Medicaid,,466.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,CHIP/Medicaid,,466.47,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,United Healthcare,CHIP/Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,United Healthcare,CHIP/Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,CHIP/Medicaid,,160.96,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,CHIP/Medicaid,,160.96,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,United Healthcare,CHIP/Medicaid,,144.54,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,CHIP/Medicaid,,115.52,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,CHIP/Medicaid,,115.52,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,United Healthcare,CHIP/Medicaid,,944.94,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,United Healthcare,CHIP/Medicaid,,676.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,United Healthcare,CHIP/Medicaid,,142.54,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,United Healthcare,CHIP/Medicaid,,113.11,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,United Healthcare,CHIP/Medicaid,,283.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,United Healthcare,CHIP/Medicaid,,153.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,United Healthcare,CHIP/Medicaid,,258.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,CHIP/Medicaid,,116.32,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,United Healthcare,CHIP/Medicaid,,255.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,United Healthcare,CHIP/Medicaid,,255.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,United Healthcare,CHIP/Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,CHIP/Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,CHIP/Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,CHIP/Medicaid,,60.06,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,United Healthcare,CHIP/Medicaid,,388.99,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,CHIP/Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,United Healthcare,CHIP/Medicaid,,166.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,United Healthcare,CHIP/Medicaid,,324.92,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,United Healthcare,CHIP/Medicaid,,354.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,CHIP/Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,CHIP/Medicaid,,362.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,United Healthcare,CHIP/Medicaid,,421.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,United Healthcare,CHIP/Medicaid,,421.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,CHIP/Medicaid,,135.54,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,CHIP/Medicaid,,135.54,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,CHIP/Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,CHIP/Medicaid,,136.94,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,CHIP/Medicaid,,136.94,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,United Healthcare,CHIP/Medicaid,,538.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,United Healthcare,CHIP/Medicaid,,551.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,United Healthcare,CHIP/Medicaid,,551.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,United Healthcare,CHIP/Medicaid,,319.12,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,United Healthcare,CHIP/Medicaid,,319.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,United Healthcare,CHIP/Medicaid,,183.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,United Healthcare,CHIP/Medicaid,,183.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,United Healthcare,CHIP/Medicaid,,226.23,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,United Healthcare,CHIP/Medicaid,,226.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,United Healthcare,CHIP/Medicaid,,230.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,United Healthcare,CHIP/Medicaid,,230.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,United Healthcare,CHIP/Medicaid,,1012.81,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,United Healthcare,CHIP/Medicaid,,985.99,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,United Healthcare,CHIP/Medicaid,,159.16,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,United Healthcare,CHIP/Medicaid,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,CHIP/Medicaid,,163.76,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,CHIP/Medicaid,,148.55,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,United Healthcare,CHIP/Medicaid,,449.85,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,CHIP/Medicaid,,148.55,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,CHIP/Medicaid,,745.34,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,CHIP/Medicaid,,177.38,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,United Healthcare,CHIP/Medicaid,,137.34,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,CHIP/Medicaid,,39.04,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,United Healthcare,CHIP/Medicaid,,106.71,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,United Healthcare,CHIP/Medicaid,,111.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,United Healthcare,CHIP/Medicaid,,118.12,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,CHIP/Medicaid,,116.72,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,CHIP/Medicaid,,133.13,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,United Healthcare,CHIP/Medicaid,,833.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,United Healthcare,CHIP/Medicaid,,426.03,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,United Healthcare,CHIP/Medicaid,,268.87,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,CHIP/Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,United Healthcare,CHIP/Medicaid,,138.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,United Healthcare,CHIP/Medicaid,,117.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,United Healthcare,CHIP/Medicaid,,121.32,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,CHIP/Medicaid,,176.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,CHIP/Medicaid,,176.98,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,CHIP/Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,CHIP/Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,CHIP/Medicaid,,2814.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,United Healthcare,CHIP/Medicaid,,1238.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,CHIP/Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,CHIP/Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,CHIP/Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,CHIP/Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,CHIP/Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,CHIP/Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,United Healthcare,CHIP/Medicaid,,1536.13,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,CHIP/Medicaid,,1581.98,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,CHIP/Medicaid,,1581.98,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,United Healthcare,CHIP/Medicaid,,960.96,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,United Healthcare,CHIP/Medicaid,,895.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,CHIP/Medicaid,,1213.61,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,CHIP/Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,CHIP/Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,CHIP/Medicaid,,879.68,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,United Healthcare,CHIP/Medicaid,,483.88,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,United Healthcare,CHIP/Medicaid,,495.50,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,United Healthcare,CHIP/Medicaid,,322.92,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,United Healthcare,CHIP/Medicaid,,158.56,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,CHIP/Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,United Healthcare,CHIP/Medicaid,,75.88,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,CHIP/Medicaid,,96.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,United Healthcare,CHIP/Medicaid,,56.46,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,United Healthcare,CHIP/Medicaid,,108.51,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,CHIP/Medicaid,,1059.86,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,United Healthcare,CHIP/Medicaid,,255.66,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,United Healthcare,CHIP/Medicaid,,1500.30,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,United Healthcare,CHIP/Medicaid,,79.08,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,CHIP/Medicaid,,328.33,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,CHIP/Medicaid,,328.33,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,United Healthcare,CHIP/Medicaid,,427.63,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,CHIP/Medicaid,,182.38,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,United Healthcare,CHIP/Medicaid,,616.02,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,United Healthcare,CHIP/Medicaid,,448.25,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,CHIP/Medicaid,,107.11,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,CHIP/Medicaid,,203.40,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,United Healthcare,CHIP/Medicaid,,771.57,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,CHIP/Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,United Healthcare,CHIP/Medicaid,,160.56,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,CHIP/Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,United Healthcare,CHIP/Medicaid,,139.14,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,CHIP/Medicaid,,1059.86,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,CHIP/Medicaid,,476.08,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,United Healthcare,CHIP/Medicaid,,500.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,United Healthcare,CHIP/Medicaid,,496.10,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,United Healthcare,CHIP/Medicaid,,127.33,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,CHIP/Medicaid,,232.23,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,CHIP/Medicaid,,35.03,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,United Healthcare,CHIP/Medicaid,,1259.46,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,United Healthcare,CHIP/Medicaid,,1554.95,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,United Healthcare,CHIP/Medicaid,,498.70,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,CHIP/Medicaid,,58.86,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,CHIP/Medicaid,,46.25,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,CHIP/Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,CHIP/Medicaid,,80.88,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,United Healthcare,CHIP/Medicaid,,81.68,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,CHIP/Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,CHIP/Medicaid,,40.44,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,CHIP/Medicaid,,318.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,United Healthcare,CHIP/Medicaid,,900.30,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,United Healthcare,CHIP/Medicaid,,847.65,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,CHIP/Medicaid,,584.78,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,United Healthcare,CHIP/Medicaid,,915.71,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,CHIP/Medicaid,,211.21,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,CHIP/Medicaid,,211.21,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,United Healthcare,CHIP/Medicaid,,294.49,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,CHIP/Medicaid,,57.66,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,CHIP/Medicaid,,57.66,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,CHIP/Medicaid,,383.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,CHIP/Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,United Healthcare,CHIP/Medicaid,,234.83,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,CHIP/Medicaid,,502.70,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,CHIP/Medicaid,,502.70,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,CHIP/Medicaid,,407.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,CHIP/Medicaid,,407.21,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,CHIP/Medicaid,,347.95,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,CHIP/Medicaid,,347.95,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,CHIP/Medicaid,,316.92,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,CHIP/Medicaid,,316.92,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,United Healthcare,CHIP/Medicaid,,329.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,United Healthcare,CHIP/Medicaid,,329.53,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,United Healthcare,CHIP/Medicaid,,342.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,CHIP/Medicaid,,303.30,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,CHIP/Medicaid,,303.30,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,CHIP/Medicaid,,302.10,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,CHIP/Medicaid,,302.10,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,CHIP/Medicaid,,665.06,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,CHIP/Medicaid,,665.06,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,United Healthcare,CHIP/Medicaid,,372.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,United Healthcare,CHIP/Medicaid,,372.37,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,CHIP/Medicaid,,363.96,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,CHIP/Medicaid,,363.96,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,United Healthcare,CHIP/Medicaid,,461.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,United Healthcare,CHIP/Medicaid,,73.67,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,CHIP/Medicaid,,972.37,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,United Healthcare,CHIP/Medicaid,,44.04,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,United Healthcare,CHIP/Medicaid,,568.77,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,United Healthcare,CHIP/Medicaid,,598.60,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,United Healthcare,CHIP/Medicaid,,4031.43,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,CHIP/Medicaid,,2143.34,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,CHIP/Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,United Healthcare,CHIP/Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,CHIP/Medicaid,,215.01,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,United Healthcare,CHIP/Medicaid,,138.74,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,United Healthcare,CHIP/Medicaid,,155.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,United Healthcare,CHIP/Medicaid,,1092.69,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,United Healthcare,CHIP/Medicaid,,743.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,United Healthcare,CHIP/Medicaid,,944.74,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,United Healthcare,CHIP/Medicaid,,774.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,United Healthcare,CHIP/Medicaid,,973.77,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,United Healthcare,CHIP/Medicaid,,798.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,United Healthcare,CHIP/Medicaid,,337.94,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,United Healthcare,CHIP/Medicaid,,114.71,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,United Healthcare,CHIP/Medicaid,,1493.89,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,CHIP/Medicaid,,398.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,United Healthcare,CHIP/Medicaid,,298.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,United Healthcare,CHIP/Medicaid,,531.13,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,United Healthcare,CHIP/Medicaid,,5758.95,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,United Healthcare,CHIP/Medicaid,,838.24,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,United Healthcare,CHIP/Medicaid,,2658.46,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,United Healthcare,CHIP/Medicaid,,1771.37,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,United Healthcare,CHIP/Medicaid,,696.50,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,United Healthcare,CHIP/Medicaid,,248.45,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,CHIP/Medicaid,,339.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,CHIP/Medicaid,,339.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,CHIP/Medicaid,,375.58,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,CHIP/Medicaid,,375.58,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,CHIP/Medicaid,,346.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,CHIP/Medicaid,,346.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,United Healthcare,CHIP/Medicaid,,258.06,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,CHIP/Medicaid,,146.75,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,United Healthcare,CHIP/Medicaid,,246.05,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,United Healthcare,CHIP/Medicaid,,1434.43,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,United Healthcare,CHIP/Medicaid,,358.56,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,United Healthcare,CHIP/Medicaid,,315.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,United Healthcare,CHIP/Medicaid,,371.17,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,United Healthcare,CHIP/Medicaid,,209.41,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,United Healthcare,CHIP/Medicaid,,717.92,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,United Healthcare,CHIP/Medicaid,,717.92,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,CHIP/Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,CHIP/Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,CHIP/Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,CHIP/Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,United Healthcare,CHIP/Medicaid,,693.69,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,United Healthcare,CHIP/Medicaid,,596.60,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,United Healthcare,CHIP/Medicaid,,1230.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,United Healthcare,CHIP/Medicaid,,1430.23,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,United Healthcare,CHIP/Medicaid,,1059.26,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,United Healthcare,CHIP/Medicaid,,954.35,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,United Healthcare,CHIP/Medicaid,,238.64,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,United Healthcare,CHIP/Medicaid,,1609.21,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,United Healthcare,CHIP/Medicaid,,1660.86,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,United Healthcare,CHIP/Medicaid,,2496.49,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,United Healthcare,CHIP/Medicaid,,1392.39,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,United Healthcare,CHIP/Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,United Healthcare,CHIP/Medicaid,,369.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,United Healthcare,CHIP/Medicaid,,178.38,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,CHIP/Medicaid,,322.52,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,United Healthcare,CHIP/Medicaid,,238.44,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,United Healthcare,CHIP/Medicaid,,741.14,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,United Healthcare,CHIP/Medicaid,,650.85,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,United Healthcare,CHIP/Medicaid,,651.45,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,United Healthcare,CHIP/Medicaid,,561.56,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,United Healthcare,CHIP/Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,United Healthcare,CHIP/Medicaid,,954.75,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,United Healthcare,CHIP/Medicaid,,1107.51,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,United Healthcare,CHIP/Medicaid,,1623.02,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,United Healthcare,CHIP/Medicaid,,150.35,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,United Healthcare,CHIP/Medicaid,,2177.58,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,United Healthcare,CHIP/Medicaid,,1567.77,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,United Healthcare,CHIP/Medicaid,,762.16,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,United Healthcare,CHIP/Medicaid,,3427.62,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,United Healthcare,CHIP/Medicaid,,1466.87,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,CHIP/Medicaid,,180.58,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,United Healthcare,CHIP/Medicaid,,696.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,United Healthcare,CHIP/Medicaid,,696.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,United Healthcare,CHIP/Medicaid,,3451.05,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,United Healthcare,CHIP/Medicaid,,3239.64,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,United Healthcare,CHIP/Medicaid,,3239.64,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,CHIP/Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,CHIP/Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,United Healthcare,CHIP/Medicaid,,1866.26,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,United Healthcare,CHIP/Medicaid,,1866.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,United Healthcare,CHIP/Medicaid,,2488.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,United Healthcare,CHIP/Medicaid,,1808.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,United Healthcare,CHIP/Medicaid,,582.58,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,United Healthcare,CHIP/Medicaid,,474.07,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,United Healthcare,CHIP/Medicaid,,474.07,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,CHIP/Medicaid,,160.96,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,United Healthcare,CHIP/Medicaid,,1313.31,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,United Healthcare,CHIP/Medicaid,,337.54,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,United Healthcare,CHIP/Medicaid,,404.60,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,United Healthcare,CHIP/Medicaid,,642.84,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,CHIP/Medicaid,,97.50,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,CHIP/Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,CHIP/Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,CHIP/Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,CHIP/Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,CHIP/Medicaid,,1990.79,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,CHIP/Medicaid,,1990.79,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,United Healthcare,CHIP/Medicaid,,803.60,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,United Healthcare,CHIP/Medicaid,,1219.62,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,United Healthcare,CHIP/Medicaid,,691.09,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,CHIP/Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,CHIP/Medicaid,,125.93,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,CHIP/Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,CHIP/Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,United Healthcare,CHIP/Medicaid,,812.41,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,United Healthcare,CHIP/Medicaid,,392.19,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,United Healthcare,CHIP/Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,CHIP/Medicaid,,91.89,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,CHIP/Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,CHIP/Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,United Healthcare,CHIP/Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,United Healthcare,CHIP/Medicaid,,64.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,United Healthcare,CHIP/Medicaid,,178.98,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,United Healthcare,CHIP/Medicaid,,114.91,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,United Healthcare,CHIP/Medicaid,,228.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,CHIP/Medicaid,,187.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,United Healthcare,CHIP/Medicaid,,211.81,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,CHIP/Medicaid,,154.35,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,United Healthcare,CHIP/Medicaid,,167.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,CHIP/Medicaid,,63.06,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,CHIP/Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,United Healthcare,CHIP/Medicaid,,62.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,United Healthcare,CHIP/Medicaid,,165.16,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,United Healthcare,CHIP/Medicaid,,192.39,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,CHIP/Medicaid,,103.90,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,CHIP/Medicaid,,127.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,CHIP/Medicaid,,85.49,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,United Healthcare,CHIP/Medicaid,,167.17,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,United Healthcare,CHIP/Medicaid,,133.73,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,CHIP/Medicaid,,107.91,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,United Healthcare,CHIP/Medicaid,,131.73,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,CHIP/Medicaid,,207.61,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,United Healthcare,CHIP/Medicaid,,164.76,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,CHIP/Medicaid,,183.98,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,United Healthcare,CHIP/Medicaid,,60.26,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,United Healthcare,CHIP/Medicaid,,235.84,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,United Healthcare,CHIP/Medicaid,,152.95,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,United Healthcare,CHIP/Medicaid,,50.05,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,CHIP/Medicaid,,46.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,CHIP/Medicaid,,37.24,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,United Healthcare,CHIP/Medicaid,,220.62,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,United Healthcare,CHIP/Medicaid,,165.16,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,United Healthcare,CHIP/Medicaid,,39.84,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,CHIP/Medicaid,,136.94,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,CHIP/Medicaid,,84.48,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,CHIP/Medicaid,,193.59,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,United Healthcare,CHIP/Medicaid,,144.94,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,CHIP/Medicaid,,82.68,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,CHIP/Medicaid,,98.50,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,CHIP/Medicaid,,91.89,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,CHIP/Medicaid,,27.83,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,United Healthcare,CHIP/Medicaid,,13.41,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,CHIP/Medicaid,,21.82,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,United Healthcare,CHIP/Medicaid,,1278.48,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,United Healthcare,CHIP/Medicaid,,931.73,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,United Healthcare,CHIP/Medicaid,,837.24,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,United Healthcare,CHIP/Medicaid,,1299.50,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,CHIP/Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,United Healthcare,CHIP/Medicaid,,538.14,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,CHIP/Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,CHIP/Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,United Healthcare,CHIP/Medicaid,,186.39,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,United Healthcare,CHIP/Medicaid,,306.51,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,United Healthcare,CHIP/Medicaid,,612.81,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,United Healthcare,CHIP/Medicaid,,932.93,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,United Healthcare,CHIP/Medicaid,,836.04,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,United Healthcare,CHIP/Medicaid,,1211.61,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,United Healthcare,CHIP/Medicaid,,1780.98,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,United Healthcare,CHIP/Medicaid,,105.51,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,CHIP/Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,CHIP/Medicaid,,114.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,United Healthcare,CHIP/Medicaid,,202.60,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,CHIP/Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,CHIP/Medicaid,,494.29,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,CHIP/Medicaid,,96.30,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,CHIP/Medicaid,,563.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,United Healthcare,CHIP/Medicaid,,659.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,United Healthcare,CHIP/Medicaid,,1014.81,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,United Healthcare,CHIP/Medicaid,,1226.63,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,United Healthcare,CHIP/Medicaid,,692.49,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,United Healthcare,CHIP/Medicaid,,1035.63,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,United Healthcare,CHIP/Medicaid,,1078.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,United Healthcare,CHIP/Medicaid,,721.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,United Healthcare,CHIP/Medicaid,,753.75,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,CHIP/Medicaid,,1032.63,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,United Healthcare,CHIP/Medicaid,,695.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,United Healthcare,CHIP/Medicaid,,816.02,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,United Healthcare,CHIP/Medicaid,,940.74,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,United Healthcare,CHIP/Medicaid,,742.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,United Healthcare,CHIP/Medicaid,,779.18,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,United Healthcare,CHIP/Medicaid,,1067.47,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,United Healthcare,CHIP/Medicaid,,735.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,United Healthcare,CHIP/Medicaid,,743.14,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,CHIP/Medicaid,,1032.63,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,United Healthcare,CHIP/Medicaid,,852.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,United Healthcare,CHIP/Medicaid,,901.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,United Healthcare,CHIP/Medicaid,,1047.85,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,United Healthcare,CHIP/Medicaid,,584.38,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,United Healthcare,CHIP/Medicaid,,837.84,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,United Healthcare,CHIP/Medicaid,,635.03,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,CHIP/Medicaid,,50.65,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,United Healthcare,CHIP/Medicaid,52,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,United Healthcare,CHIP/Medicaid,52,787.39,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,United Healthcare,CHIP/Medicaid,,769.37,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,United Healthcare,CHIP/Medicaid,,881.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,United Healthcare,CHIP/Medicaid,,1040.24,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,United Healthcare,CHIP/Medicaid,,805.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,United Healthcare,CHIP/Medicaid,,827.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,United Healthcare,CHIP/Medicaid,,703.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,United Healthcare,CHIP/Medicaid,,855.65,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,CHIP/Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,United Healthcare,CHIP/Medicaid,,811.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,United Healthcare,CHIP/Medicaid,,1021.82,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,United Healthcare,CHIP/Medicaid,,983.38,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,United Healthcare,CHIP/Medicaid,,1091.89,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,United Healthcare,CHIP/Medicaid,,838.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,United Healthcare,CHIP/Medicaid,,928.33,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,United Healthcare,CHIP/Medicaid,,1118.32,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,United Healthcare,CHIP/Medicaid,,694.29,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,United Healthcare,CHIP/Medicaid,,734.93,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,United Healthcare,CHIP/Medicaid,,1069.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,United Healthcare,CHIP/Medicaid,,649.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,United Healthcare,CHIP/Medicaid,,720.52,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,United Healthcare,CHIP/Medicaid,,1000.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,United Healthcare,CHIP/Medicaid,,845.85,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,United Healthcare,CHIP/Medicaid,,647.85,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,United Healthcare,CHIP/Medicaid,,895.29,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,CHIP/Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,CHIP/Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,CHIP/Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,United Healthcare,CHIP/Medicaid,,707.71,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,United Healthcare,CHIP/Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,United Healthcare,CHIP/Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,United Healthcare,CHIP/Medicaid,,899.50,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,United Healthcare,CHIP/Medicaid,,650.65,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,United Healthcare,CHIP/Medicaid,,919.72,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,United Healthcare,CHIP/Medicaid,,894.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,United Healthcare,CHIP/Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,United Healthcare,CHIP/Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,CHIP/Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,CHIP/Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,CHIP/Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,CHIP/Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,United Healthcare,CHIP/Medicaid,,206.81,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,United Healthcare,CHIP/Medicaid,,480.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,United Healthcare,CHIP/Medicaid,,477.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,United Healthcare,CHIP/Medicaid,,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,United Healthcare,CHIP/Medicaid,,375.38,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,CHIP/Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,CHIP/Medicaid,,64.86,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,CHIP/Medicaid,,79.88,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,CHIP/Medicaid,,349.35,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,CHIP/Medicaid,,349.35,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,CHIP/Medicaid,,31.63,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,CHIP/Medicaid,,366.57,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,CHIP/Medicaid,,366.57,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,United Healthcare,CHIP/Medicaid,,181.18,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,United Healthcare,CHIP/Medicaid,,108.11,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,CHIP/Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,CHIP/Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,United Healthcare,CHIP/Medicaid,,260.06,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,CHIP/Medicaid,,207.61,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,CHIP/Medicaid,,169.57,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,CHIP/Medicaid,,123.32,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,CHIP/Medicaid,,119.92,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,CHIP/Medicaid,,58.46,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,CHIP/Medicaid,,86.29,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,CHIP/Medicaid,,63.46,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,CHIP/Medicaid,,57.66,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,United Healthcare,CHIP/Medicaid,,136.14,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,CHIP/Medicaid,,56.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,CHIP/Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,CHIP/Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,United Healthcare,CHIP/Medicaid,,287.49,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,CHIP/Medicaid,,150.55,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,CHIP/Medicaid,,373.57,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,United Healthcare,CHIP/Medicaid,,870.87,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,United Healthcare,CHIP/Medicaid,,50.45,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,CHIP/Medicaid,,35.44,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,CHIP/Medicaid,,73.87,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,CHIP/Medicaid,,36.64,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,CHIP/Medicaid,,85.49,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,CHIP/Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,CHIP/Medicaid,,55.05,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,CHIP/Medicaid,,79.88,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,United Healthcare,CHIP/Medicaid,,126.33,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,CHIP/Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,United Healthcare,CHIP/Medicaid,,174.97,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,United Healthcare,CHIP/Medicaid,,112.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,CHIP/Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,CHIP/Medicaid,,72.47,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,United Healthcare,CHIP/Medicaid,,151.35,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,CHIP/Medicaid,,61.06,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,CHIP/Medicaid,,133.13,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,CHIP/Medicaid,,84.48,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,CHIP/Medicaid,,191.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,CHIP/Medicaid,,119.92,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,CHIP/Medicaid,,84.48,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,CHIP/Medicaid,,91.69,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,United Healthcare,CHIP/Medicaid,,72.87,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,United Healthcare,CHIP/Medicaid,,505.30,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,United Healthcare,CHIP/Medicaid,,434.23,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,CHIP/Medicaid,,221.42,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,United Healthcare,CHIP/Medicaid,,104.30,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,United Healthcare,CHIP/Medicaid,,110.71,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,United Healthcare,CHIP/Medicaid,,67.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,CHIP/Medicaid,,25.63,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,CHIP/Medicaid,,102.50,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,CHIP/Medicaid,,80.88,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,CHIP/Medicaid,,80.88,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,United Healthcare,CHIP/Medicaid,,481.28,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,CHIP/Medicaid,,9.41,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,United Healthcare,CHIP/Medicaid,,2.80,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,CHIP/Medicaid,,22.42,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,CHIP/Medicaid,,32.63,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,CHIP/Medicaid,,26.43,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,CHIP/Medicaid,,5.21,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,CHIP/Medicaid,,8.81,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,CHIP/Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,United Healthcare,CHIP/Medicaid,,53.05,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,CHIP/Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,CHIP/Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,United Healthcare,CHIP/Medicaid,,79.48,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,CHIP/Medicaid,,31.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,CHIP/Medicaid,,107.11,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,CHIP/Medicaid,,14.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,CHIP/Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,CHIP/Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,CHIP/Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,CHIP/Medicaid,,5.81,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,CHIP/Medicaid,,35.44,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,CHIP/Medicaid,,24.82,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,CHIP/Medicaid,,7.81,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,CHIP/Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,CHIP/Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,CHIP/Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,CHIP/Medicaid,,30.83,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,CHIP/Medicaid,,5.81,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,CHIP/Medicaid,,8.61,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,CHIP/Medicaid,,8.41,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,CHIP/Medicaid,,9.61,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,CHIP/Medicaid,,32.43,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,CHIP/Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,CHIP/Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,CHIP/Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,CHIP/Medicaid,,8.41,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,United Healthcare,CHIP/Medicaid,,12.01,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,CHIP/Medicaid,,8.01,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,CHIP/Medicaid,,8.01,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,CHIP/Medicaid,,33.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,CHIP/Medicaid,,13.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,CHIP/Medicaid,,10.61,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,United Healthcare,CHIP/Medicaid,,51.65,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,CHIP/Medicaid,,13.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,CHIP/Medicaid,,48.65,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,CHIP/Medicaid,,36.04,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,CHIP/Medicaid,,29.23,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,CHIP/Medicaid,,15.82,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,CHIP/Medicaid,,7.81,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,United Healthcare,CHIP/Medicaid,,59.86,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,United Healthcare,CHIP/Medicaid,,1.20,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,CHIP/Medicaid,,40.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,CHIP/Medicaid,,115.92,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,CHIP/Medicaid,,31.43,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,CHIP/Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,CHIP/Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,CHIP/Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,CHIP/Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,CHIP/Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,CHIP/Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,CHIP/Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,CHIP/Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,CHIP/Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,CHIP/Medicaid,,6.01,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,CHIP/Medicaid,,14.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,CHIP/Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,CHIP/Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,CHIP/Medicaid,,15.62,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,United Healthcare,CHIP/Medicaid,,47.65,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,CHIP/Medicaid,,31.23,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,United Healthcare,CHIP/Medicaid,,44.24,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,CHIP/Medicaid,,24.02,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,CHIP/Medicaid,,30.43,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,CHIP/Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,CHIP/Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,United Healthcare,CHIP/Medicaid,,39.44,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,CHIP/Medicaid,,26.43,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,CHIP/Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,CHIP/Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,CHIP/Medicaid,,8.41,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,CHIP/Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,CHIP/Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,CHIP/Medicaid,,29.83,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,CHIP/Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,CHIP/Medicaid,,28.63,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,CHIP/Medicaid,,16.62,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,CHIP/Medicaid,,28.63,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,CHIP/Medicaid,,35.44,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,CHIP/Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,CHIP/Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,CHIP/Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,United Healthcare,CHIP/Medicaid,,0.40040,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,CHIP/Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,CHIP/Medicaid,,11.01,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,CHIP/Medicaid,,29.23,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,United Healthcare,CHIP/Medicaid,,45.45,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,CHIP/Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,CHIP/Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,CHIP/Medicaid,,9.01,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,CHIP/Medicaid,,10.61,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,CHIP/Medicaid,,10.01,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,CHIP/Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,CHIP/Medicaid,,9.01,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,CHIP/Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,CHIP/Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,CHIP/Medicaid,,8.61,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,CHIP/Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,CHIP/Medicaid,,33.43,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,CHIP/Medicaid,,9.01,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,CHIP/Medicaid,,32.03,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,United Healthcare,CHIP/Medicaid,,38.04,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,CHIP/Medicaid,,13.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,CHIP/Medicaid,,26.83,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,CHIP/Medicaid,,26.03,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,CHIP/Medicaid,,21.62,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,CHIP/Medicaid,,7.61,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,CHIP/Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,CHIP/Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,CHIP/Medicaid,,26.03,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,United Healthcare,CHIP/Medicaid,,38.64,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,CHIP/Medicaid,,15.82,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,CHIP/Medicaid,,2.40,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,CHIP/Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,CHIP/Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,CHIP/Medicaid,,45.05,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,CHIP/Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,CHIP/Medicaid,,28.03,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,CHIP/Medicaid,,22.62,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,CHIP/Medicaid,,19.42,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,United Healthcare,CHIP/Medicaid,,27.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,CHIP/Medicaid,,24.02,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,United Healthcare,CHIP/Medicaid,,1.60,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,CHIP/Medicaid,,4.40,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,CHIP/Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,CHIP/Medicaid,,34.83,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,CHIP/Medicaid,,25.63,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,CHIP/Medicaid,,53.45,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,CHIP/Medicaid,,29.43,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,CHIP/Medicaid,,54.65,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,CHIP/Medicaid,,41.44,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,CHIP/Medicaid,,10.01,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,CHIP/Medicaid,,47.45,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,United Healthcare,CHIP/Medicaid,,41.24,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,CHIP/Medicaid,,8.21,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,CHIP/Medicaid,,58.66,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,CHIP/Medicaid,,40.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,CHIP/Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,CHIP/Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,CHIP/Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,CHIP/Medicaid,,10.01,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,CHIP/Medicaid,,27.03,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,United Healthcare,CHIP/Medicaid,,44.64,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,United Healthcare,CHIP/Medicaid,,4.20,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,CHIP/Medicaid,,11.41,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,CHIP/Medicaid,,29.03,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,CHIP/Medicaid,,13.61,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,,23.42,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,CHIP/Medicaid,,34.63,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,CHIP/Medicaid,,19.42,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,CHIP/Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,CHIP/Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,CHIP/Medicaid,,3.00,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,CHIP/Medicaid,,7.01,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,CHIP/Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,CHIP/Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,CHIP/Medicaid,,92.29,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,CHIP/Medicaid,,24.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,CHIP/Medicaid,,39.04,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,CHIP/Medicaid,,16.62,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,United Healthcare,CHIP/Medicaid,,2.20,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,CHIP/Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,CHIP/Medicaid,,27.03,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,CHIP/Medicaid,,21.62,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,CHIP/Medicaid,,158.96,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,United Healthcare,CHIP/Medicaid,,89.49,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,United Healthcare,CHIP/Medicaid,,53.25,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,United Healthcare,CHIP/Medicaid,,114.11,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,CHIP/Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,CHIP/Medicaid,,59.26,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,United Healthcare,CHIP/Medicaid,,72.27,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,CHIP/Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,CHIP/Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,CHIP/Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,United Healthcare,CHIP/Medicaid,,46.65,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,CHIP/Medicaid,,29.03,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,CHIP/Medicaid,,24.62,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,CHIP/Medicaid,,26.83,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,CHIP/Medicaid,,39.24,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,CHIP/Medicaid,,34.63,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,CHIP/Medicaid,,100.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,United Healthcare,CHIP/Medicaid,,147.55,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,CHIP/Medicaid,,25.23,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,CHIP/Medicaid,,27.83,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,CHIP/Medicaid,,30.03,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,CHIP/Medicaid,,18.62,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,CHIP/Medicaid,,32.43,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,CHIP/Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,CHIP/Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,CHIP/Medicaid,,64.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,CHIP/Medicaid,,55.05,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,CHIP/Medicaid,,58.26,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,CHIP/Medicaid,,52.85,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,United Healthcare,CHIP/Medicaid,,122.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,CHIP/Medicaid,,32.23,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,CHIP/Medicaid,,47.45,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,United Healthcare,CHIP/Medicaid,,39.84,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,CHIP/Medicaid,,19.82,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,CHIP/Medicaid,,65.06,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,CHIP/Medicaid,,54.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,CHIP/Medicaid,,64.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,United Healthcare,CHIP/Medicaid,,50.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,CHIP/Medicaid,,36.44,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,CHIP/Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,CHIP/Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,CHIP/Medicaid,,49.45,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,CHIP/Medicaid,,8.81,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,CHIP/Medicaid,,30.03,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,CHIP/Medicaid,,39.24,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,United Healthcare,CHIP/Medicaid,,93.69,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,United Healthcare,CHIP/Medicaid,,56.66,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,CHIP/Medicaid,,7.01,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,CHIP/Medicaid,,14.41,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,CHIP/Medicaid,,22.62,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,CHIP/Medicaid,,71.27,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,CHIP/Medicaid,,29.23,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,CHIP/Medicaid,,40.44,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,CHIP/Medicaid,,28.63,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,CHIP/Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,CHIP/Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,CHIP/Medicaid,,20.42,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,CHIP/Medicaid,,17.02,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,CHIP/Medicaid,,19.62,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,CHIP/Medicaid,,44.84,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,CHIP/Medicaid,,7.81,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,CHIP/Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,CHIP/Medicaid,,9.41,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,CHIP/Medicaid,,3.00,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,CHIP/Medicaid,,8.21,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,CHIP/Medicaid,,37.64,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,CHIP/Medicaid,,24.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,CHIP/Medicaid,,26.03,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,CHIP/Medicaid,,14.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,CHIP/Medicaid,,31.43,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,CHIP/Medicaid,,5.41,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,CHIP/Medicaid,,10.61,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,CHIP/Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,CHIP/Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,CHIP/Medicaid,,19.42,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,CHIP/Medicaid,,42.64,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,CHIP/Medicaid,,40.84,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,CHIP/Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,CHIP/Medicaid,,40.84,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,CHIP/Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,CHIP/Medicaid,,14.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,CHIP/Medicaid,,29.03,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,CHIP/Medicaid,,18.42,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,CHIP/Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,CHIP/Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,CHIP/Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,CHIP/Medicaid,,5.21,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,,25.83,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,CHIP/Medicaid,,23.22,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,CHIP/Medicaid,,15.82,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,United Healthcare,CHIP/Medicaid,,67.87,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,CHIP/Medicaid,,13.61,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,,17.82,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,United Healthcare,CHIP/Medicaid,,3.20,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,United Healthcare,CHIP/Medicaid,,49.05,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,CHIP/Medicaid,,30.83,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,CHIP/Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,CHIP/Medicaid,,19.82,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,CHIP/Medicaid,,15.62,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,CHIP/Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,CHIP/Medicaid,,11.41,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,CHIP/Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,CHIP/Medicaid,,12.61,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,CHIP/Medicaid,,36.04,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,CHIP/Medicaid,,6.61,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,CHIP/Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,United Healthcare,CHIP/Medicaid,,45.65,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,CHIP/Medicaid,,33.83,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,CHIP/Medicaid,,92.29,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,CHIP/Medicaid,,42.64,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,CHIP/Medicaid,,42.64,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,CHIP/Medicaid,,125.93,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,CHIP/Medicaid,,116.32,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,CHIP/Medicaid,,34.83,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,CHIP/Medicaid,,32.23,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,CHIP/Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,CHIP/Medicaid,,42.44,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,CHIP/Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,CHIP/Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,CHIP/Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,United Healthcare,CHIP/Medicaid,,51.45,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,CHIP/Medicaid,,154.15,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,United Healthcare,CHIP/Medicaid,,17.42,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,CHIP/Medicaid,,16.62,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,CHIP/Medicaid,,9.61,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,CHIP/Medicaid,,22.42,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,CHIP/Medicaid,,115.92,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,United Healthcare,CHIP/Medicaid,,55.86,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,CHIP/Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,CHIP/Medicaid,,30.83,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,CHIP/Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,CHIP/Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,CHIP/Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,CHIP/Medicaid,,92.69,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,CHIP/Medicaid,,58.86,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,CHIP/Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,CHIP/Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,CHIP/Medicaid,,25.23,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,CHIP/Medicaid,,2.40,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,CHIP/Medicaid,,30.03,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,CHIP/Medicaid,,24.02,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,CHIP/Medicaid,,109.71,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,United Healthcare,CHIP/Medicaid,,61.86,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,CHIP/Medicaid,,25.43,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,CHIP/Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,CHIP/Medicaid,,4.40,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,United Healthcare,CHIP/Medicaid,,46.05,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,CHIP/Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,CHIP/Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,CHIP/Medicaid,,11.61,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,CHIP/Medicaid,,7.01,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,CHIP/Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,CHIP/Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,CHIP/Medicaid,,12.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,CHIP/Medicaid,,12.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,CHIP/Medicaid,,9.21,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,CHIP/Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,CHIP/Medicaid,,14.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,CHIP/Medicaid,,3.00,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,CHIP/Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,CHIP/Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,CHIP/Medicaid,,26.83,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,CHIP/Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,CHIP/Medicaid,,5.21,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,CHIP/Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,CHIP/Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,CHIP/Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,CHIP/Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,United Healthcare,CHIP/Medicaid,,0.40040,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,CHIP/Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,CHIP/Medicaid,,16.22,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,CHIP/Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,CHIP/Medicaid,,32.23,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,CHIP/Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,CHIP/Medicaid,,28.23,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,CHIP/Medicaid,,6.81,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,CHIP/Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,CHIP/Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,CHIP/Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,CHIP/Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,CHIP/Medicaid,,7.01,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,CHIP/Medicaid,,15.02,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,CHIP/Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,United Healthcare,CHIP/Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,United Healthcare,CHIP/Medicaid,,153.55,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,CHIP/Medicaid,,26.83,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,United Healthcare,CHIP/Medicaid,,361.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,United Healthcare,CHIP/Medicaid,,251.85,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,CHIP/Medicaid,,58.66,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,CHIP/Medicaid,,23.22,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,United Healthcare,CHIP/Medicaid,,386.59,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,CHIP/Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,United Healthcare,CHIP/Medicaid,,51.85,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,CHIP/Medicaid,,9.21,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,United Healthcare,CHIP/Medicaid,,361.96,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,CHIP/Medicaid,,141.54,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,United Healthcare,CHIP/Medicaid,,102.70,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,CHIP/Medicaid,,37.84,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,CHIP/Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,United Healthcare,CHIP/Medicaid,,22.82,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,CHIP/Medicaid,,64.86,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,CHIP/Medicaid,,38.84,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,CHIP/Medicaid,,190.79,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,United Healthcare,CHIP/Medicaid,,127.93,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,CHIP/Medicaid,,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,CHIP/Medicaid,QW,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,CHIP/Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,CHIP/Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,United Healthcare,CHIP/Medicaid,,318.12,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,United Healthcare,CHIP/Medicaid,,237.64,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,CHIP/Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,CHIP/Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,United Healthcare,CHIP/Medicaid,,95.70,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,CHIP/Medicaid,,40.84,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,CHIP/Medicaid,,85.29,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,CHIP/Medicaid,,10.01,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,CHIP/Medicaid,QW,20.02,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,CHIP/Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,CHIP/Medicaid,,32.63,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,United Healthcare,CHIP/Medicaid,,181.58,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,CHIP/Medicaid,,55.05,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,CHIP/Medicaid,,26.43,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,,33.03,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,CHIP/Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,CHIP/Medicaid,,8.61,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,CHIP/Medicaid,,56.06,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,CHIP/Medicaid,,15.82,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,CHIP/Medicaid,,38.84,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,CHIP/Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,CHIP/Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,CHIP/Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,CHIP/Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,CHIP/Medicaid,,42.64,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,United Healthcare,CHIP/Medicaid,,43.84,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,CHIP/Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,CHIP/Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,CHIP/Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,CHIP/Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,CHIP/Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,United Healthcare,CHIP/Medicaid,,15.22,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,CHIP/Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,CHIP/Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,CHIP/Medicaid,,20.22,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,CHIP/Medicaid,,29.83,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,United Healthcare,CHIP/Medicaid,,265.87,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,CHIP/Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,CHIP/Medicaid,,21.62,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,CHIP/Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,CHIP/Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,CHIP/Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,CHIP/Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,CHIP/Medicaid,,33.43,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,CHIP/Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,CHIP/Medicaid,,63.86,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,CHIP/Medicaid,,103.10,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,United Healthcare,CHIP/Medicaid,,105.31,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,United Healthcare,CHIP/Medicaid,,42.04,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,CHIP/Medicaid,,5.41,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,CHIP/Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,CHIP/Medicaid,,37.24,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,CHIP/Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,CHIP/Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,CHIP/Medicaid,,7.81,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,United Healthcare,CHIP/Medicaid,,39.64,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,CHIP/Medicaid,,23.82,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,United Healthcare,CHIP/Medicaid,,51.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,CHIP/Medicaid,,52.25,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,CHIP/Medicaid,,15.62,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,CHIP/Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,CHIP/Medicaid,,41.84,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,CHIP/Medicaid,,41.44,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,CHIP/Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,CHIP/Medicaid,,29.63,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,United Healthcare,CHIP/Medicaid,,91.29,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,United Healthcare,CHIP/Medicaid,,119.52,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,United Healthcare,CHIP/Medicaid,,151.15,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,United Healthcare,CHIP/Medicaid,,112.31,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,CHIP/Medicaid,,65.06,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,CHIP/Medicaid,,45.05,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,United Healthcare,CHIP/Medicaid,,204.00,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,CHIP/Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,CHIP/Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,CHIP/Medicaid,,44.84,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,CHIP/Medicaid,,26.43,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,CHIP/Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,CHIP/Medicaid,,109.71,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,CHIP/Medicaid,,20.42,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,CHIP/Medicaid,,35.03,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,CHIP/Medicaid,,73.47,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,CHIP/Medicaid,,132.13,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,CHIP/Medicaid,,0.00200,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,CHIP/Medicaid,,24.82,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,United Healthcare,CHIP/Medicaid,,45.25,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,United Healthcare,CHIP/Medicaid,,74.07,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,CHIP/Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,CHIP/Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,United Healthcare,CHIP/Medicaid,,118.72,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,CHIP/Medicaid,,109.71,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,CHIP/Medicaid,,19.42,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,CHIP/Medicaid,,78.88,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,CHIP/Medicaid,,62.66,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,United Healthcare,CHIP/Medicaid,,49.85,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,CHIP/Medicaid,,15.42,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,United Healthcare,CHIP/Medicaid,,76.88,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,CHIP/Medicaid,,26.43,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,United Healthcare,CHIP/Medicaid,,135.13,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,CHIP/Medicaid,,37.84,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,CHIP/Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,United Healthcare,CHIP/Medicaid,,51.25,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,CHIP/Medicaid,,52.25,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,CHIP/Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,CHIP/Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,CHIP/Medicaid,,107.91,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,CHIP/Medicaid,,27.83,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,CHIP/Medicaid,,32.83,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,CHIP/Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,CHIP/Medicaid,,82.88,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,CHIP/Medicaid,,49.45,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,United Healthcare,CHIP/Medicaid,,438.64,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,United Healthcare,CHIP/Medicaid,,70.67,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,CHIP/Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,United Healthcare,CHIP/Medicaid,,141.74,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,CHIP/Medicaid,,103.70,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,CHIP/Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,CHIP/Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,CHIP/Medicaid,,103.90,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,United Healthcare,CHIP/Medicaid,,257.26,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,CHIP/Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,United Healthcare,CHIP/Medicaid,,62.46,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,CHIP/Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,United Healthcare,CHIP/Medicaid,,248.85,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,CHIP/Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,CHIP/Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,United Healthcare,CHIP/Medicaid,,181.78,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,CHIP/Medicaid,,132.13,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,United Healthcare,CHIP/Medicaid,,94.89,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,CHIP/Medicaid,,71.27,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,United Healthcare,CHIP/Medicaid,,25.02,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,CHIP/Medicaid,,30.03,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,CHIP/Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,CHIP/Medicaid,,33.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,CHIP/Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,United Healthcare,CHIP/Medicaid,,31.83,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,United Healthcare,CHIP/Medicaid,,318.12,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,United Healthcare,CHIP/Medicaid,,159.76,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,United Healthcare,CHIP/Medicaid,,65.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,CHIP/Medicaid,,13.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,CHIP/Medicaid,,8.41,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,United Healthcare,CHIP/Medicaid,,21.02,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,United Healthcare,CHIP/Medicaid,,49.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,CHIP/Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,CHIP/Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,United Healthcare,CHIP/Medicaid,,55.46,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,United Healthcare,CHIP/Medicaid,,113.31,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,CHIP/Medicaid,,11.41,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,United Healthcare,CHIP/Medicaid,,135.94,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,United Healthcare,CHIP/Medicaid,,130.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,CHIP/Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,United Healthcare,CHIP/Medicaid,,214.21,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,CHIP/Medicaid,,43.04,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,United Healthcare,CHIP/Medicaid,,83.88,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,CHIP/Medicaid,,58.86,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,United Healthcare,CHIP/Medicaid,,189.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,United Healthcare,CHIP/Medicaid,,248.25,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,CHIP/Medicaid,,120.12,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,CHIP/Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,CHIP/Medicaid,,305.91,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,CHIP/Medicaid,,5.61,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,CHIP/Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,CHIP/Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,CHIP/Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,CHIP/Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,CHIP/Medicaid,,232.23,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,CHIP/Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,United Healthcare,CHIP/Medicaid,,523.72,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,CHIP/Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,CHIP/Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,CHIP/Medicaid,,1715.71,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,CHIP/Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,CHIP/Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,United Healthcare,CHIP/Medicaid,,7102.50,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,United Healthcare,CHIP/Medicaid,,1203.60,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,CHIP/Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,CHIP/Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,United Healthcare,CHIP/Medicaid,,1344.34,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,United Healthcare,CHIP/Medicaid,,409.01,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,United Healthcare,CHIP/Medicaid,,674.27,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,CHIP/Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,CHIP/Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,United Healthcare,CHIP/Medicaid,,396.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,United Healthcare,CHIP/Medicaid,,396.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,United Healthcare,CHIP/Medicaid,,834.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,United Healthcare,CHIP/Medicaid,,834.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,United Healthcare,CHIP/Medicaid,,379.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,United Healthcare,CHIP/Medicaid,,379.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,United Healthcare,CHIP/Medicaid,,89.49,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,United Healthcare,CHIP/Medicaid,,164.76,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,CHIP/Medicaid,,359.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,CHIP/Medicaid,,359.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,CHIP/Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,CHIP/Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,United Healthcare,CHIP/Medicaid,,317.52,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,United Healthcare,CHIP/Medicaid,,317.52,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,CHIP/Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,CHIP/Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,United Healthcare,CHIP/Medicaid,,1544.94,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,CHIP/Medicaid,,772.37,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,CHIP/Medicaid,,772.37,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,CHIP/Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,CHIP/Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,CHIP/Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,CHIP/Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,CHIP/Medicaid,,275.88,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,CHIP/Medicaid,,275.88,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,CHIP/Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,CHIP/Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,United Healthcare,CHIP/Medicaid,,532.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,CHIP/Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,CHIP/Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,CHIP/Medicaid,,158.96,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,United Healthcare,CHIP/Medicaid,,5817.21,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,CHIP/Medicaid,,879.68,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,CHIP/Medicaid,,879.68,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,CHIP/Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,CHIP/Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,CHIP/Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,CHIP/Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,CHIP/Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,CHIP/Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,CHIP/Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,CHIP/Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,CHIP/Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,United Healthcare,CHIP/Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,United Healthcare,CHIP/Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,United Healthcare,CHIP/Medicaid,,4633.03,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,United Healthcare,CHIP/Medicaid,,4633.03,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,CHIP/Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,CHIP/Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,CHIP/Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,CHIP/Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,CHIP/Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,CHIP/Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,CHIP/Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,CHIP/Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,United Healthcare,CHIP/Medicaid,,2468.07,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,CHIP/Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,CHIP/Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,CHIP/Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,CHIP/Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,CHIP/Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,CHIP/Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,United Healthcare,CHIP/Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,United Healthcare,CHIP/Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,United Healthcare,CHIP/Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,United Healthcare,CHIP/Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,United Healthcare,CHIP/Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,United Healthcare,CHIP/Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,United Healthcare,CHIP/Medicaid,,4121.72,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,CHIP/Medicaid,LM,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,CHIP/Medicaid,RI,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,CHIP/Medicaid,RC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,CHIP/Medicaid,LD,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,CHIP/Medicaid,LC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,CHIP/Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,CHIP/Medicaid,RI,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,CHIP/Medicaid,RC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,CHIP/Medicaid,LD,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,CHIP/Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,CHIP/Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,CHIP/Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,LM,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,RI,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,CHIP/Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LM,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,RI,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,CHIP/Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,CHIP/Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,CHIP/Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,United Healthcare,CHIP/Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,United Healthcare,CHIP/Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,CHIP/Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LM,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,RI,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,RC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LD,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,CHIP/Medicaid,LC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,United Healthcare,CHIP/Medicaid,,78.68,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,United Healthcare,CHIP/Medicaid,,333.13,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,CHIP/Medicaid,,373.37,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,CHIP/Medicaid,,84.48,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,United Healthcare,CHIP/Medicaid,,505.91,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,United Healthcare,CHIP/Medicaid,,197.40,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,United Healthcare,CHIP/Medicaid,,2316.71,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,CHIP/Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,CHIP/Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,United Healthcare,CHIP/Medicaid,,2044.04,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,United Healthcare,CHIP/Medicaid,,850.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,United Healthcare,CHIP/Medicaid,,1474.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,United Healthcare,CHIP/Medicaid,,2180.78,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,United Healthcare,CHIP/Medicaid,,1936.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,United Healthcare,CHIP/Medicaid,,2067.27,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,United Healthcare,CHIP/Medicaid,,909.51,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,United Healthcare,CHIP/Medicaid,,2126.92,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,United Healthcare,CHIP/Medicaid,,2652.85,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,United Healthcare,CHIP/Medicaid,,2389.79,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,United Healthcare,CHIP/Medicaid,,2549.35,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,United Healthcare,CHIP/Medicaid,,2592.59,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,United Healthcare,CHIP/Medicaid,,3178.58,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,United Healthcare,CHIP/Medicaid,,1356.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,CHIP/Medicaid,,40.64,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,CHIP/Medicaid,,19.42,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,United Healthcare,CHIP/Medicaid,,300.90,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,United Healthcare,CHIP/Medicaid,,826.43,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,United Healthcare,CHIP/Medicaid,,1614.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,United Healthcare,CHIP/Medicaid,,96.90,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,CHIP/Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,CHIP/Medicaid,,43.04,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,United Healthcare,CHIP/Medicaid,,1535.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,United Healthcare,CHIP/Medicaid,,7834.43,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,United Healthcare,CHIP/Medicaid,,2458.86,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,United Healthcare,CHIP/Medicaid,,505.50,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,United Healthcare,CHIP/Medicaid,,565.36,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,United Healthcare,CHIP/Medicaid,,253.45,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,CHIP/Medicaid,,105.71,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,CHIP/Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,CHIP/Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,CHIP/Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,CHIP/Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,CHIP/Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,CHIP/Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,United Healthcare,CHIP/Medicaid,,3657.05,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,United Healthcare,CHIP/Medicaid,,2656.25,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,United Healthcare,CHIP/Medicaid,,3018.42,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,United Healthcare,CHIP/Medicaid,,3642.44,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,United Healthcare,CHIP/Medicaid,,639.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,CHIP/Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,CHIP/Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,United Healthcare,CHIP/Medicaid,,2045.04,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,United Healthcare,CHIP/Medicaid,,589.39,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,CHIP/Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,CHIP/Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,United Healthcare,CHIP/Medicaid,,4082.48,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,United Healthcare,CHIP/Medicaid,,2987.99,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,United Healthcare,CHIP/Medicaid,,473.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,United Healthcare,CHIP/Medicaid,,4761.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,United Healthcare,CHIP/Medicaid,,4909.10,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,United Healthcare,CHIP/Medicaid,,5350.95,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,United Healthcare,CHIP/Medicaid,,1703.30,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,CHIP/Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,CHIP/Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,United Healthcare,CHIP/Medicaid,,9987.38,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,United Healthcare,CHIP/Medicaid,,1151.15,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,United Healthcare,CHIP/Medicaid,,764.96,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,United Healthcare,CHIP/Medicaid,,11551.14,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,United Healthcare,CHIP/Medicaid,,528.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,United Healthcare,CHIP/Medicaid,,2335.73,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,United Healthcare,CHIP/Medicaid,,417.62,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,CHIP/Medicaid,,838.44,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,CHIP/Medicaid,,1297.30,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,CHIP/Medicaid,,1297.30,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,CHIP/Medicaid,,647.05,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,United Healthcare,CHIP/Medicaid,,459.46,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,CHIP/Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,CHIP/Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,United Healthcare,CHIP/Medicaid,,609.21,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,United Healthcare,CHIP/Medicaid,,557.96,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,United Healthcare,CHIP/Medicaid,,1917.92,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,United Healthcare,CHIP/Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,United Healthcare,CHIP/Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,United Healthcare,CHIP/Medicaid,,325.12,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,United Healthcare,CHIP/Medicaid,,1618.42,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,United Healthcare,CHIP/Medicaid,,331.93,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,United Healthcare,CHIP/Medicaid,,631.83,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,United Healthcare,CHIP/Medicaid,,5093.49,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,United Healthcare,CHIP/Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,United Healthcare,CHIP/Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,United Healthcare,CHIP/Medicaid,,605.61,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,CHIP/Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,United Healthcare,CHIP/Medicaid,,4031.43,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,United Healthcare,CHIP/Medicaid,,4480.68,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,United Healthcare,CHIP/Medicaid,,496.90,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,United Healthcare,CHIP/Medicaid,,386.59,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,CHIP/Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,CHIP/Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,United Healthcare,CHIP/Medicaid,,1276.68,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,United Healthcare,CHIP/Medicaid,,515.51,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,United Healthcare,CHIP/Medicaid,,2746.94,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,United Healthcare,CHIP/Medicaid,,960.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,CHIP/Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,United Healthcare,CHIP/Medicaid,,425.83,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,United Healthcare,CHIP/Medicaid,,567.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,United Healthcare,CHIP/Medicaid,,1594.59,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,United Healthcare,CHIP/Medicaid,,3708.10,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,United Healthcare,CHIP/Medicaid,,1846.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,United Healthcare,CHIP/Medicaid,,1294.69,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,United Healthcare,CHIP/Medicaid,,1496.70,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,CHIP/Medicaid,,57.66,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,CHIP/Medicaid,,283.88,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,United Healthcare,CHIP/Medicaid,,1595.59,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,CHIP/Medicaid,,608.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,CHIP/Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,CHIP/Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,CHIP/Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,United Healthcare,CHIP/Medicaid,,2662.86,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,CHIP/Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,CHIP/Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,United Healthcare,CHIP/Medicaid,,8574.37,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,United Healthcare,CHIP/Medicaid,,6999.39,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,United Healthcare,CHIP/Medicaid,,1897.10,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,United Healthcare,CHIP/Medicaid,,869.87,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,United Healthcare,CHIP/Medicaid,,4285.48,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,CHIP/Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,CHIP/Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,CHIP/Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,United Healthcare,CHIP/Medicaid,,6481.07,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,CHIP/Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,CHIP/Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,CHIP/Medicaid,,21.42,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,CHIP/Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,CHIP/Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,United Healthcare,CHIP/Medicaid,,9598.39,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,United Healthcare,CHIP/Medicaid,,480.28,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,United Healthcare,CHIP/Medicaid,,1300.10,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,United Healthcare,CHIP/Medicaid,,2169.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,CHIP/Medicaid,LD,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,CHIP/Medicaid,RC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,CHIP/Medicaid,RI,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,CHIP/Medicaid,LM,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,CHIP/Medicaid,LD,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,CHIP/Medicaid,RC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,CHIP/Medicaid,RI,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,CHIP/Medicaid,LM,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,CHIP/Medicaid,LD,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,CHIP/Medicaid,RC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,CHIP/Medicaid,RI,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,CHIP/Medicaid,LM,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,LD,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,RC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,RI,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,LM,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,CHIP/Medicaid,LC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,CHIP/Medicaid,LC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,CHIP/Medicaid,LC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,CHIP/Medicaid,LC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,United Healthcare,CHIP/Medicaid,,6528.72,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,United Healthcare,CHIP/Medicaid,,12359.75,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,United Healthcare,CHIP/Medicaid,,2282.88,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,United Healthcare,CHIP/Medicaid,,570.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,United Healthcare,CHIP/Medicaid,,115.11,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,United Healthcare,CHIP/Medicaid,,805.00,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,United Healthcare,CHIP/Medicaid,,661.46,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,United Healthcare,CHIP/Medicaid,,258.26,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,United Healthcare,CHIP/Medicaid,,312.91,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,United Healthcare,CHIP/Medicaid,,231.63,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,CHIP/Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,CHIP/Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,CHIP/Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,CHIP/Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,CHIP/Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,CHIP/Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,CHIP/Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,CHIP/Medicaid,,99.30,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,CHIP/Medicaid,,77.08,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,CHIP/Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,CHIP/Medicaid,,11.01,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,United Healthcare,CHIP/Medicaid,,273.87,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,CHIP/Medicaid,,48.65,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,CHIP/Medicaid,,175.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,United Healthcare,CHIP/Medicaid,,124.52,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,CHIP/Medicaid,,32.43,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,United Healthcare,CHIP/Medicaid,,38.64,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,United Healthcare,CHIP/Medicaid,,255.46,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,CHIP/Medicaid,,57.06,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,CHIP/Medicaid,,43.64,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,CHIP/Medicaid,,59.46,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,CHIP/Medicaid,,21.82,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,CHIP/Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,CHIP/Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,United Healthcare,CHIP/Medicaid,,1301.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,United Healthcare,CHIP/Medicaid,,725.52,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,United Healthcare,CHIP/Medicaid,,1598.40,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,United Healthcare,CHIP/Medicaid,,521.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,CHIP/Medicaid,,422.62,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,CHIP/Medicaid,,422.62,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,CHIP/Medicaid,,422.62,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,United Healthcare,CHIP/Medicaid,,1276.28,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,United Healthcare,CHIP/Medicaid,,1690.29,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,United Healthcare,CHIP/Medicaid,,1897.30,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,United Healthcare,CHIP/Medicaid,,1567.77,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,United Healthcare,CHIP/Medicaid,,2031.83,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,United Healthcare,CHIP/Medicaid,,2263.86,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,CHIP/Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,CHIP/Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,CHIP/Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,CHIP/Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,CHIP/Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,CHIP/Medicaid,,48.05,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,United Healthcare,CHIP/Medicaid,,74.87,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,United Healthcare,CHIP/Medicaid,,264.26,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,United Healthcare,CHIP/Medicaid,,285.29,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,United Healthcare,CHIP/Medicaid,,446.85,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,CHIP/Medicaid,,58.66,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,United Healthcare,CHIP/Medicaid,,134.53,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,United Healthcare,CHIP/Medicaid,,20.82,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,CHIP/Medicaid,,203.40,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,CHIP/Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,United Healthcare,CHIP/Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,CHIP/Medicaid,,38.44,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,United Healthcare,CHIP/Medicaid,,633.03,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,CHIP/Medicaid,,60.46,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,CHIP/Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,United Healthcare,CHIP/Medicaid,,61.86,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,CHIP/Medicaid,,57.06,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,CHIP/Medicaid,,68.27,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,CHIP/Medicaid,,86.49,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,United Healthcare,CHIP/Medicaid,,123.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,CHIP/Medicaid,,8.81,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,CHIP/Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,CHIP/Medicaid,,14.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,United Healthcare,CHIP/Medicaid,,44.24,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,United Healthcare,CHIP/Medicaid,,80.48,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,United Healthcare,CHIP/Medicaid,,178.18,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,CHIP/Medicaid,,14.81,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,CHIP/Medicaid,,10.81,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,United Healthcare,CHIP/Medicaid,,53.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,CHIP/Medicaid,,8.01,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,United Healthcare,CHIP/Medicaid,,150.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,United Healthcare,CHIP/Medicaid,,235.24,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,United Healthcare,CHIP/Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,United Healthcare,CHIP/Medicaid,,245.04,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,CHIP/Medicaid,,359.16,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,United Healthcare,CHIP/Medicaid,,454.25,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,CHIP/Medicaid,,98.50,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,United Healthcare,CHIP/Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,United Healthcare,CHIP/Medicaid,,140.14,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,United Healthcare,CHIP/Medicaid,,156.16,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,CHIP/Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,United Healthcare,CHIP/Medicaid,,319.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,United Healthcare,CHIP/Medicaid,,514.31,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,CHIP/Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,United Healthcare,CHIP/Medicaid,,800.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,United Healthcare,CHIP/Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,United Healthcare,CHIP/Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,United Healthcare,CHIP/Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,United Healthcare,CHIP/Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,United Healthcare,CHIP/Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,United Healthcare,CHIP/Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,United Healthcare,CHIP/Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,United Healthcare,CHIP/Medicaid,GP,47.65,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,United Healthcare,CHIP/Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,United Healthcare,CHIP/Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,United Healthcare,CHIP/Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,United Healthcare,CHIP/Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,United Healthcare,CHIP/Medicaid,,2600.00,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,United Healthcare,CHIP/Medicaid,,2657.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,United Healthcare,CHIP/Medicaid,,2714.71,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,United Healthcare,CHIP/Medicaid,,2772.37,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,United Healthcare,CHIP/Medicaid,,2829.83,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,United Healthcare,CHIP/Medicaid,,2887.08,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,United Healthcare,CHIP/Medicaid,,2944.54,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,United Healthcare,CHIP/Medicaid,,3002.00,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,CHIP/Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,United Healthcare,CHIP/Medicaid,,49.25,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,CHIP/Medicaid,,40.04,,,,,,,34.82,150.00,percent of total billed charges,
SNF Bill Type,211,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,212,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,213,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,214,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,215,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,216,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,217,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,218,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,219,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,2012.00,,,,,,,1336.00,2012.00,per diem,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,397739.02,,,,,,,150928.76,397739.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,259561.38,,,,,,,98790.80,259561.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,102204.38,,,,,,,39415.99,102204.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,79003.62,,,,,,,30661.75,79003.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,54002.05,,,,,,,21228.00,54002.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,147453.44,,,,,,,56489.61,147453.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,99200.52,,,,,,,38282.54,99200.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,57624.30,,,,,,,22718.84,57624.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,107380.09,,,,,,,41368.91,107380.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,73305.09,,,,,,,28511.54,73305.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,85200.61,,,,,,,33000.02,85200.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,58263.30,,,,,,,22835.89,58263.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,47276.62,,,,,,,18639.19,47276.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,112589.53,,,,,,,43334.56,112589.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,63929.97,,,,,,,24974.06,63929.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41135.85,,,,,,,16218.14,41135.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,83960.09,,,,,,,32531.94,83960.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39932.81,,,,,,,15743.83,39932.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31161.08,,,,,,,12285.51,31161.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,72533.05,,,,,,,28220.24,72533.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,44795.58,,,,,,,17661.01,44795.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36406.13,,,,,,,14353.41,36406.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,61690.66,,,,,,,24129.11,61690.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30405.90,,,,,,,11987.77,30405.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22027.69,,,,,,,8684.59,22027.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,72355.03,,,,,,,28153.06,72355.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41201.44,,,,,,,16244.00,41201.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32375.37,,,,,,,12764.25,32375.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33370.41,,,,,,,13156.55,33370.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18349.23,,,,,,,7234.33,18349.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28612.58,,,,,,,11280.74,28612.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19106.28,,,,,,,7532.80,19106.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43532.57,,,,,,,17163.06,43532.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24278.25,,,,,,,9571.89,24278.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32034.32,,,,,,,12629.79,32034.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23253.23,,,,,,,9167.77,23253.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17236.13,,,,,,,6795.48,17236.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,51665.30,,,,,,,20346.30,51665.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32928.17,,,,,,,12982.19,32928.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26305.81,,,,,,,10371.27,26305.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37684.13,,,,,,,14857.27,37684.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18932.01,,,,,,,7464.10,18932.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12824.97,,,,,,,5056.35,12824.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27521.97,,,,,,,10850.76,27521.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16197.99,,,,,,,6386.19,16197.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14968.71,,,,,,,5901.53,14968.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31196.69,,,,,,,12299.54,31196.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19226.21,,,,,,,7580.09,19226.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14170.43,,,,,,,5586.81,14170.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30062.98,,,,,,,11852.57,30062.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19316.16,,,,,,,7615.55,19316.16,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35932.03,,,,,,,14166.49,35932.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14031.76,,,,,,,5532.13,14031.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33917.59,,,,,,,13372.28,33917.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16782.65,,,,,,,6616.69,16782.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,42829.86,,,,,,,16886.01,42829.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26155.90,,,,,,,10312.17,26155.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17910.74,,,,,,,7061.45,17910.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,42573.13,,,,,,,16784.80,42573.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24411.30,,,,,,,9624.35,24411.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17140.56,,,,,,,6757.80,17140.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25331.38,,,,,,,9987.10,25331.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20586.67,,,,,,,8116.46,20586.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15425.94,,,,,,,6081.80,15425.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32909.43,,,,,,,12974.81,32909.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19170.00,,,,,,,7557.92,19170.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14921.87,,,,,,,5883.06,14921.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,65950.04,,,,,,,25736.28,65950.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,48331.63,,,,,,,19055.13,48331.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,48331.63,,,,,,,19055.13,48331.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,67681.52,,,,,,,26389.63,67681.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43004.13,,,,,,,16954.72,43004.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25530.01,,,,,,,10065.41,25530.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36293.70,,,,,,,14309.08,36293.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16913.82,,,,,,,6668.41,16913.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21004.55,,,,,,,8281.21,21004.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15671.43,,,,,,,6178.58,15671.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,44057.26,,,,,,,17369.93,44057.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25353.87,,,,,,,9995.96,25353.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28762.49,,,,,,,11339.84,28762.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33881.99,,,,,,,13358.24,33881.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20329.94,,,,,,,8015.24,20329.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21799.08,,,,,,,8594.46,21799.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14725.11,,,,,,,5805.49,14725.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14964.97,,,,,,,5900.06,14964.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24793.57,,,,,,,9775.06,24793.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14387.80,,,,,,,5672.51,14387.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39636.73,,,,,,,15627.10,39636.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19025.71,,,,,,,7501.04,19025.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27981.07,,,,,,,11031.76,27981.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16606.50,,,,,,,6547.25,16606.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22647.96,,,,,,,8929.14,22647.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,79927.46,,,,,,,31010.33,79927.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40871.63,,,,,,,16113.97,40871.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29914.94,,,,,,,11794.20,29914.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,70207.54,,,,,,,27342.76,70207.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32472.81,,,,,,,12802.67,32472.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22529.90,,,,,,,8882.59,22529.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39677.96,,,,,,,15643.35,39677.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23826.64,,,,,,,9393.84,23826.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14936.86,,,,,,,5888.97,14936.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14084.23,,,,,,,5552.82,14084.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24950.98,,,,,,,9837.12,24950.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13754.43,,,,,,,5422.79,13754.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22153.25,,,,,,,8734.09,22153.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13833.13,,,,,,,5453.82,13833.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29298.43,,,,,,,11551.14,29298.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17174.29,,,,,,,6771.10,17174.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12950.52,,,,,,,5105.85,12950.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32171.12,,,,,,,12683.72,32171.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17048.74,,,,,,,6721.60,17048.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13276.58,,,,,,,5234.40,13276.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,83984.45,,,,,,,32541.14,83984.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,47297.24,,,,,,,18647.31,47297.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35870.19,,,,,,,14142.11,35870.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,70040.76,,,,,,,27279.81,70040.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33793.91,,,,,,,13323.52,33793.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25604.97,,,,,,,10094.96,25604.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,55774.76,,,,,,,21896.90,55774.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25739.89,,,,,,,10148.16,25739.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15084.90,,,,,,,5947.34,15084.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29283.44,,,,,,,11545.23,29283.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18289.26,,,,,,,7210.69,18289.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14147.94,,,,,,,5577.94,14147.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33093.07,,,,,,,13047.21,33093.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20069.47,,,,,,,7912.55,20069.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13941.82,,,,,,,5496.67,13941.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28668.80,,,,,,,11302.90,28668.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19940.17,,,,,,,7861.57,19940.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14738.22,,,,,,,5810.66,14738.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29204.73,,,,,,,11514.20,29204.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18534.74,,,,,,,7307.47,18534.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13439.61,,,,,,,5298.67,13439.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23150.16,,,,,,,9127.14,23150.16,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20757.19,,,,,,,8183.69,20757.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15796.98,,,,,,,6228.08,15796.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12030.44,,,,,,,4743.10,12030.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24630.54,,,,,,,9710.79,24630.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15101.76,,,,,,,5953.99,15101.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11777.46,,,,,,,4643.36,11777.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35364.24,,,,,,,13942.63,35364.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17785.18,,,,,,,7011.95,17785.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13420.87,,,,,,,5291.29,13420.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33057.47,,,,,,,13033.17,33057.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20599.78,,,,,,,8121.63,20599.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13400.26,,,,,,,5283.16,13400.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18199.32,,,,,,,7175.23,18199.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12555.13,,,,,,,4949.96,12555.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15129.87,,,,,,,5965.07,15129.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34311.11,,,,,,,13527.43,34311.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17635.27,,,,,,,6952.85,17635.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,120579.84,,,,,,,46349.51,120579.84,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,51507.89,,,,,,,20286.88,51507.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,212102.99,,,,,,,80883.55,212102.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,203769.76,,,,,,,77739.20,203769.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,106941.60,,,,,,,41203.47,106941.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,186584.22,,,,,,,71254.67,186584.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,183319.89,,,,,,,70022.93,183319.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,123214.55,,,,,,,47343.65,123214.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,123214.55,,,,,,,47343.65,123214.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,143883.66,,,,,,,55142.64,143883.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,99931.34,,,,,,,38558.31,99931.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,94448.31,,,,,,,36489.42,94448.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,92709.33,,,,,,,35833.26,92709.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,59018.48,,,,,,,23120.82,59018.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,157967.90,,,,,,,60456.99,157967.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,113607.06,,,,,,,43718.51,113607.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,143263.40,,,,,,,54908.59,143263.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,102365.54,,,,,,,39476.79,102365.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,109971.70,,,,,,,42346.80,109971.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,78493.92,,,,,,,30469.42,78493.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,92227.74,,,,,,,35651.54,92227.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,53415.52,,,,,,,21006.71,53415.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25942.27,,,,,,,10227.95,25942.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,59829.88,,,,,,,23426.99,59829.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39930.94,,,,,,,15743.09,44147.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33870.74,,,,,,,13353.81,33870.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,85494.81,,,,,,,33111.02,85494.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40897.87,,,,,,,16124.31,40897.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28005.44,,,,,,,11041.37,28005.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,65367.25,,,,,,,25516.39,65367.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,48638.95,,,,,,,19176.29,48638.95,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33387.28,,,,,,,13163.20,33387.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,50546.58,,,,,,,19924.18,50546.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31816.95,,,,,,,12544.09,31816.95,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20466.74,,,,,,,8069.17,20466.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,58879.81,,,,,,,23068.51,58879.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37892.13,,,,,,,14939.27,37892.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,60954.22,,,,,,,22172.00,60954.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35426.08,,,,,,,13967.01,35426.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30542.70,,,,,,,12041.70,30542.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,57292.62,,,,,,,22469.61,57292.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,62599.50,,,,,,,24472.05,62599.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,67801.45,,,,,,,26434.87,67801.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,114840.09,,,,,,,44183.77,114840.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,89212.63,,,,,,,34513.86,89212.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,128884.97,,,,,,,49483.25,128884.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,79138.54,,,,,,,30712.64,79138.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,98872.59,,,,,,,38158.82,98872.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66641.51,,,,,,,25997.21,66641.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,47840.67,,,,,,,18861.56,47840.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,77307.74,,,,,,,30021.84,77307.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,61683.17,,,,,,,24126.28,61683.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,133616.57,,,,,,,51268.60,133616.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,112557.68,,,,,,,43322.54,112557.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,86546.07,,,,,,,33507.69,86546.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,104305.02,,,,,,,40208.61,104305.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,67580.33,,,,,,,26351.43,67580.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30059.23,,,,,,,11851.09,30059.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17223.01,,,,,,,6790.31,17223.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13550.17,,,,,,,5342.26,13550.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37118.21,,,,,,,14634.15,37118.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12971.14,,,,,,,5113.97,12971.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11222.79,,,,,,,4424.67,11222.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41465.66,,,,,,,16348.17,41465.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20052.60,,,,,,,7905.90,20052.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,50711.48,,,,,,,19986.40,50711.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31985.60,,,,,,,12610.58,31985.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17421.65,,,,,,,6868.62,17421.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24057.13,,,,,,,9484.71,24057.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15909.41,,,,,,,6272.41,15909.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,10606.27,,,,,,,4181.61,10606.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29268.44,,,,,,,11539.32,29268.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11683.77,,,,,,,4606.42,11683.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,8528.12,,,,,,,3362.28,8528.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30595.17,,,,,,,12062.39,30595.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20003.88,,,,,,,7886.69,20003.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13486.46,,,,,,,5317.14,13486.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22423.09,,,,,,,8840.48,22423.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12615.09,,,,,,,4973.60,12615.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22299.41,,,,,,,8791.72,22299.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14149.82,,,,,,,5578.68,14149.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29528.92,,,,,,,11642.01,29528.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17112.45,,,,,,,6746.72,17112.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22561.76,,,,,,,8895.15,22561.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13786.28,,,,,,,5435.35,13786.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,10608.15,,,,,,,4182.35,10608.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13152.90,,,,,,,5185.64,13152.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16332.91,,,,,,,6439.38,16332.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13492.08,,,,,,,5319.36,13492.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39074.56,,,,,,,15405.46,39074.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18051.28,,,,,,,7116.86,18051.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12781.87,,,,,,,5039.35,12781.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,125298.32,,,,,,,48129.92,125298.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,45389.61,,,,,,,17895.21,45389.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,83630.28,,,,,,,32407.49,83630.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,45072.92,,,,,,,17770.36,45072.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,50985.07,,,,,,,20089.63,50985.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33036.86,,,,,,,13025.04,33036.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,81091.15,,,,,,,31449.41,81091.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,59046.59,,,,,,,23131.43,59046.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,60159.69,,,,,,,23551.45,60159.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,93458.89,,,,,,,36116.09,93458.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,45801.86,,,,,,,18057.75,45801.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30025.50,,,,,,,11837.79,30025.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,86133.81,,,,,,,33352.15,86133.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,44921.13,,,,,,,17710.51,44921.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31535.86,,,,,,,12433.27,31535.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,67848.30,,,,,,,26452.56,67848.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43890.49,,,,,,,17304.17,43890.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30692.61,,,,,,,12100.81,30692.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66915.10,,,,,,,26100.45,66915.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39514.93,,,,,,,15579.08,39514.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28764.37,,,,,,,11340.58,28764.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,48399.09,,,,,,,19081.73,48399.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28196.57,,,,,,,11116.72,28196.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22228.20,,,,,,,8763.65,22228.20,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43017.25,,,,,,,16959.89,43017.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24525.60,,,,,,,9669.41,24525.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16314.17,,,,,,,6431.99,16314.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,46695.71,,,,,,,18410.16,46695.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28567.61,,,,,,,11263.01,28567.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21883.40,,,,,,,8627.71,21883.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,54380.58,,,,,,,21370.84,54380.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31526.49,,,,,,,12429.57,31526.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25203.96,,,,,,,9936.86,25203.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,82316.68,,,,,,,31911.85,82316.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43577.54,,,,,,,17180.79,43577.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26195.25,,,,,,,10327.69,26195.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,64435.93,,,,,,,25164.98,64435.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,45241.57,,,,,,,17836.85,45241.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29830.61,,,,,,,11760.96,29830.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18742.75,,,,,,,7389.48,18742.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13132.29,,,,,,,5177.51,13132.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33226.12,,,,,,,13099.66,33226.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19132.52,,,,,,,7543.15,19132.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13630.75,,,,,,,5374.03,13630.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40077.10,,,,,,,15800.72,40077.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22666.69,,,,,,,8936.52,22666.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17320.46,,,,,,,6828.73,17320.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34254.89,,,,,,,13505.26,34254.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18377.34,,,,,,,7245.41,18377.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11813.07,,,,,,,4657.40,11813.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36769.67,,,,,,,14496.73,36769.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20303.71,,,,,,,8004.90,20303.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15002.44,,,,,,,5914.83,15002.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25872.94,,,,,,,10200.61,25872.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16018.10,,,,,,,6315.26,16018.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29650.72,,,,,,,11690.03,29650.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18294.89,,,,,,,7212.90,18294.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12766.88,,,,,,,5033.44,12766.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27673.76,,,,,,,10910.60,27673.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14800.06,,,,,,,5835.04,14800.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,10194.02,,,,,,,4019.07,10194.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23766.67,,,,,,,9370.20,23766.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14608.92,,,,,,,5759.68,14608.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29969.28,,,,,,,11815.63,29969.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17534.08,,,,,,,6912.95,17534.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12161.61,,,,,,,4794.81,12161.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,44878.03,,,,,,,17693.52,44878.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28363.35,,,,,,,11182.48,28363.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21450.53,,,,,,,8457.04,21450.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,75340.15,,,,,,,29279.42,75340.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,102511.70,,,,,,,39531.94,102511.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,54346.85,,,,,,,21358.11,54346.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41593.08,,,,,,,16398.40,41593.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66815.78,,,,,,,26062.95,66815.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40800.42,,,,,,,16085.89,40800.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29751.91,,,,,,,11729.93,29751.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,61900.54,,,,,,,24208.31,61900.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39398.75,,,,,,,15533.27,39398.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31116.11,,,,,,,12267.77,31116.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66759.56,,,,,,,26041.75,66759.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,38727.89,,,,,,,15268.78,38727.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25546.88,,,,,,,10072.06,25546.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,44718.75,,,,,,,17630.72,44718.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31698.89,,,,,,,12497.54,31698.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25593.73,,,,,,,10090.53,25593.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,63845.65,,,,,,,24942.24,63845.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32559.01,,,,,,,12836.65,32559.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26225.23,,,,,,,10339.51,26225.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,77823.07,,,,,,,30216.30,77823.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40999.06,,,,,,,16164.21,40999.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28114.12,,,,,,,11084.22,28114.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,206526.27,,,,,,,78779.31,206526.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,135269.35,,,,,,,51892.24,135269.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,105350.66,,,,,,,40603.15,105350.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,168830.89,,,,,,,64555.88,168830.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,108069.69,,,,,,,41629.10,108069.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36882.10,,,,,,,14541.06,36882.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19792.13,,,,,,,7803.21,19792.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13351.54,,,,,,,5263.95,13351.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34417.92,,,,,,,13569.54,34417.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21195.68,,,,,,,8356.57,21195.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15989.99,,,,,,,6304.18,15989.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30548.32,,,,,,,12043.92,30548.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15763.25,,,,,,,6214.79,15763.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11644.41,,,,,,,4590.90,11644.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33630.88,,,,,,,13259.24,33630.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18088.76,,,,,,,7131.64,18088.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13111.68,,,,,,,5169.38,13111.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31311.00,,,,,,,12344.61,31311.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20507.96,,,,,,,8085.43,20507.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15502.77,,,,,,,6112.09,15502.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,125206.50,,,,,,,48095.26,125206.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,79468.35,,,,,,,30837.10,79468.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,99871.37,,,,,,,38535.67,99871.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,60534.47,,,,,,,23692.85,60534.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,157471.31,,,,,,,60269.61,157471.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,111742.53,,,,,,,43014.97,111742.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,78190.35,,,,,,,30354.87,78190.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,100452.28,,,,,,,39604.11,100452.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,49845.74,,,,,,,19652.08,49845.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,106802.93,,,,,,,41151.13,106802.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,58366.36,,,,,,,22874.77,58366.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34174.31,,,,,,,13473.50,34174.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,97543.99,,,,,,,32841.00,97543.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66084.96,,,,,,,25787.19,66084.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,51494.77,,,,,,,20281.95,51494.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,56839.13,,,,,,,22298.52,56839.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36145.66,,,,,,,14490.34,36145.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,90485.01,,,,,,,34993.95,90485.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,55206.97,,,,,,,21682.65,55206.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,45747.52,,,,,,,18036.32,45747.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,80444.65,,,,,,,31205.47,80444.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,42644.34,,,,,,,16812.87,42644.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22115.77,,,,,,,8719.32,22115.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,64735.75,,,,,,,25278.10,64735.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,46082.95,,,,,,,18168.57,46082.95,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34833.93,,,,,,,13733.55,34833.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,54573.59,,,,,,,21443.67,54573.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39248.84,,,,,,,15474.17,39248.84,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30563.31,,,,,,,12049.83,30563.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,51942.63,,,,,,,20450.94,51942.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,60472.63,,,,,,,23669.52,60472.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39185.12,,,,,,,15449.05,39185.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29349.02,,,,,,,11571.09,29349.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28550.74,,,,,,,11256.36,28550.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20927.72,,,,,,,8250.92,20927.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,68802.11,,,,,,,26812.44,68802.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,47523.98,,,,,,,18736.71,47523.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37599.80,,,,,,,14824.02,37599.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,67941.99,,,,,,,26487.90,67941.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33803.28,,,,,,,13327.21,33803.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21581.71,,,,,,,8508.76,21581.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,56531.82,,,,,,,22182.53,56531.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37755.34,,,,,,,14885.34,37755.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,59305.19,,,,,,,23229.03,59305.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32757.65,,,,,,,12914.96,32757.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25220.82,,,,,,,9943.51,25220.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,52302.42,,,,,,,20586.69,52302.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35026.94,,,,,,,13809.65,35026.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33595.28,,,,,,,13245.21,33595.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22479.30,,,,,,,8862.64,22479.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33850.13,,,,,,,13345.68,33850.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28378.34,,,,,,,11188.39,28378.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,56601.15,,,,,,,22208.72,56601.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,38965.88,,,,,,,15362.61,38965.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31020.54,,,,,,,12230.10,31020.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29500.81,,,,,,,11630.93,29500.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19156.88,,,,,,,7552.75,19156.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,59719.32,,,,,,,23385.28,59719.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,38941.52,,,,,,,15353.00,38941.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28796.22,,,,,,,11353.14,28796.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,70033.26,,,,,,,27276.98,70033.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37481.75,,,,,,,14777.48,37481.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27994.19,,,,,,,11036.93,27994.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,53784.68,,,,,,,21145.99,53784.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39683.58,,,,,,,15645.57,39683.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29377.13,,,,,,,11582.17,29377.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15105.51,,,,,,,5955.47,15105.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24023.40,,,,,,,9471.42,24023.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15133.62,,,,,,,5966.55,15133.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17882.63,,,,,,,7050.37,17882.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13497.70,,,,,,,5321.58,13497.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36910.21,,,,,,,14552.14,36910.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24291.37,,,,,,,9577.06,24291.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14457.14,,,,,,,5699.84,14457.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33102.44,,,,,,,13050.90,33102.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19263.69,,,,,,,7594.86,19263.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14140.45,,,,,,,5574.98,14140.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,46504.58,,,,,,,18334.80,46504.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21613.56,,,,,,,8521.32,21613.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15669.55,,,,,,,6177.85,15669.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36183.14,,,,,,,14265.49,36183.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22621.72,,,,,,,8918.79,22621.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16379.76,,,,,,,6457.85,16379.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31408.44,,,,,,,12383.03,31408.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18013.80,,,,,,,7102.08,18013.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24291.37,,,,,,,9577.06,24291.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15555.24,,,,,,,6132.78,15555.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24769.21,,,,,,,9765.46,24769.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15564.61,,,,,,,6136.47,15564.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27863.02,,,,,,,10985.22,27863.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16737.67,,,,,,,6598.96,16737.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34946.36,,,,,,,13777.88,34946.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21101.99,,,,,,,8319.63,21101.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15064.28,,,,,,,5939.21,15064.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26699.33,,,,,,,10526.42,26699.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16780.77,,,,,,,6615.95,16780.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28925.52,,,,,,,11404.12,28925.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18259.28,,,,,,,7198.87,18259.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14041.13,,,,,,,5535.83,14041.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,55113.27,,,,,,,21647.31,55113.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31659.54,,,,,,,12482.03,31659.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21480.52,,,,,,,8468.86,21480.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,122766.68,,,,,,,47174.67,122766.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,65050.56,,,,,,,25396.90,65050.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30612.03,,,,,,,12069.04,30612.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,91843.59,,,,,,,35506.60,91843.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,49671.47,,,,,,,19583.37,49671.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30102.33,,,,,,,11868.08,30102.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,60686.25,,,,,,,23750.13,60686.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32380.99,,,,,,,12766.46,32380.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27042.25,,,,,,,10661.62,27042.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36102.56,,,,,,,14233.72,36102.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32313.53,,,,,,,12739.87,32313.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40114.58,,,,,,,15815.49,40114.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36149.40,,,,,,,14252.19,36149.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36265.59,,,,,,,14298.00,36265.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22230.08,,,,,,,8764.38,22230.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16242.97,,,,,,,6403.92,16242.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39739.80,,,,,,,15667.73,39739.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20284.97,,,,,,,7997.51,20284.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31239.79,,,,,,,12316.53,31239.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21199.43,,,,,,,8358.04,21199.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13739.43,,,,,,,5416.88,13739.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19518.54,,,,,,,7695.34,19518.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11337.09,,,,,,,4469.74,11337.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26633.74,,,,,,,10500.56,26633.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16319.80,,,,,,,6434.21,16319.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27585.68,,,,,,,10875.87,27585.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17164.92,,,,,,,6767.41,17164.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28355.85,,,,,,,11179.52,28355.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16985.03,,,,,,,6696.48,16985.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41072.14,,,,,,,16193.02,41072.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26221.48,,,,,,,10338.03,26221.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,65350.39,,,,,,,25510.02,65350.39,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35047.55,,,,,,,13817.78,35047.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26577.52,,,,,,,10478.40,26577.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,54106.99,,,,,,,16490.00,54106.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29988.02,,,,,,,11823.02,35030.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28265.91,,,,,,,11144.06,35030.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66695.85,,,,,,,26017.71,66695.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33615.89,,,,,,,13253.33,33615.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23459.35,,,,,,,9249.04,23459.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,56593.65,,,,,,,22205.88,56593.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28097.26,,,,,,,11077.57,28097.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24891.01,,,,,,,9813.48,24891.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,69836.51,,,,,,,27202.76,69836.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40828.53,,,,,,,16096.97,40828.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27349.57,,,,,,,10782.79,27349.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26922.32,,,,,,,10614.34,26922.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16793.89,,,,,,,6621.13,16793.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11640.67,,,,,,,4589.43,11640.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25027.81,,,,,,,9867.41,25027.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14582.69,,,,,,,5749.34,14582.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26648.73,,,,,,,10506.47,26648.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30846.27,,,,,,,12161.39,30846.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19207.47,,,,,,,7572.70,19207.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14397.17,,,,,,,5676.20,14397.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,97375.34,,,,,,,37593.86,97375.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,52456.08,,,,,,,20644.67,52456.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39662.97,,,,,,,15637.44,39662.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,59661.23,,,,,,,23363.36,59661.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34292.37,,,,,,,13520.04,34292.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29079.18,,,,,,,11464.70,29079.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,47613.93,,,,,,,18772.17,47613.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24767.34,,,,,,,9764.72,24767.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19402.36,,,,,,,7649.54,19402.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,57369.45,,,,,,,22498.61,57369.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28487.03,,,,,,,11231.24,28487.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19617.86,,,,,,,7734.50,19617.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,58488.17,,,,,,,22920.74,58488.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32780.13,,,,,,,12923.83,32780.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20729.08,,,,,,,8172.61,20729.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,54717.88,,,,,,,21498.11,54717.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29082.93,,,,,,,11466.18,29082.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18313.62,,,,,,,7220.29,18313.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33636.50,,,,,,,13261.46,33636.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20228.75,,,,,,,7975.35,20228.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,78733.78,,,,,,,30559.94,78733.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43823.03,,,,,,,17277.58,43823.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30758.19,,,,,,,12126.66,30758.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27752.46,,,,,,,10941.63,27752.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16411.62,,,,,,,6470.41,16411.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11249.02,,,,,,,4435.02,11249.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33799.53,,,,,,,13325.74,33799.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19634.72,,,,,,,7741.15,19634.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14809.43,,,,,,,5838.74,14809.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21742.86,,,,,,,8572.30,21742.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15169.22,,,,,,,5980.59,15169.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25194.59,,,,,,,9933.17,25194.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,14648.28,,,,,,,5775.20,14648.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21433.67,,,,,,,8450.39,21433.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12911.17,,,,,,,5090.33,12911.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20196.89,,,,,,,7962.79,20196.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31001.80,,,,,,,12222.71,31001.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19020.08,,,,,,,7498.82,19020.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12928.04,,,,,,,5096.98,12928.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37483.62,,,,,,,14778.22,37483.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28749.37,,,,,,,11334.67,28749.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43607.53,,,,,,,17192.61,43607.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26257.09,,,,,,,10352.07,26257.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39048.33,,,,,,,15395.11,39048.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20607.28,,,,,,,8124.58,20607.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28172.21,,,,,,,11107.12,28172.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19814.62,,,,,,,7812.07,19814.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41924.76,,,,,,,16529.17,41924.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27565.07,,,,,,,10867.75,27565.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35426.08,,,,,,,13967.01,35426.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25168.35,,,,,,,9922.82,25168.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33911.97,,,,,,,13370.06,33911.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21413.06,,,,,,,8442.27,21413.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11462.65,,,,,,,4519.24,11462.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21928.38,,,,,,,8645.44,21928.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13529.56,,,,,,,5334.14,13529.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27788.06,,,,,,,10955.67,27788.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15201.08,,,,,,,5993.15,15201.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19838.98,,,,,,,7821.68,19838.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12592.61,,,,,,,4964.74,12592.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39914.07,,,,,,,15736.44,39914.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25213.32,,,,,,,9940.55,25213.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66982.56,,,,,,,26125.88,66982.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,38613.58,,,,,,,15223.71,38613.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27518.22,,,,,,,10849.28,27518.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,66079.34,,,,,,,26052.30,66079.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33910.09,,,,,,,13369.32,33910.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26723.69,,,,,,,10536.03,26723.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34382.32,,,,,,,13555.50,34382.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23249.48,,,,,,,9166.29,23249.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,38398.08,,,,,,,15138.75,38398.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21315.61,,,,,,,8403.85,21315.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32551.52,,,,,,,12833.69,32551.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15731.39,,,,,,,6202.23,15731.39,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25996.61,,,,,,,10249.37,25996.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,48114.26,,,,,,,18969.43,48114.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27655.02,,,,,,,10903.21,27655.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34511.62,,,,,,,13606.48,34511.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20384.28,,,,,,,8036.67,20384.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17998.81,,,,,,,7096.17,17998.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26832.37,,,,,,,10578.88,26832.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18345.48,,,,,,,7232.85,18345.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12435.20,,,,,,,4902.68,12435.20,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18879.54,,,,,,,7443.41,18879.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,10673.73,,,,,,,4208.20,10673.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9518.00,,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.",9518.0,9152.0,11740.0,26,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate."
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31665.16,,,,,,,12484.24,31665.16,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18789.60,,,,,,,7407.95,18789.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12268.42,,,,,,,4836.92,12268.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13362.78,,,,,,,5268.38,13362.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15908.00,,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate.",,,,0,5414.00,31619.23,case rate,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15908.00,,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate.",15908.0,15296.0,31816.0,1 through 10,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate."
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15908.00,,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate.",15908.0,15296.0,16022.0,20,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate."
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15908.00,,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate.",15908.0,15296.0,17374.13,16,5414.00,21243.91,case rate,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate."
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15908.00,,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate.",15908.0,15296.0,16022.0,54,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate."
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15908.00,,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate.",15908.0,15296.0,16022.0,111,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $2,222.00 Per Diem rate."
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33771.43,,,,,,,1810.00,33771.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,111375.25,,,,,,,1810.00,111375.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,76061.60,,,,,,,1810.00,76061.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,45895.56,,,,,,,1810.00,45895.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,78134.13,,,,,,,1810.00,78134.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27656.89,,,,,,,375.00,27656.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,3744.05,,,,,,,314.00,3744.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9518.00,,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.",,,,0,4210.00,9947.78,case rate,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9518.00,,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.",9518.0,9518.0,9518.0,1 through 10,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9518.00,,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.",9152.0,9152.0,9152.0,1 through 10,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate."
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,84867.06,,,,,,,32874.17,84867.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,52645.35,,,,,,,20716.09,52645.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35770.88,,,,,,,14102.95,35770.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,74658.05,,,,,,,29022.04,74658.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34833.93,,,,,,,13733.55,34833.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25410.08,,,,,,,10018.13,25410.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9518.00,,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.",9518.0,9152.0,19036.0,18,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9518.00,,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.",9518.0,9152.0,9586.0,96,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9518.00,,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate.",9518.0,9152.0,9586.0,319,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $2,222.00 Per Diem rate."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41373.84,,,,,,,16311.97,41373.84,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23721.70,,,,,,,9352.47,23721.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19612.24,,,,,,,7732.28,19612.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26315.18,,,,,,,10374.97,26315.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17206.15,,,,,,,6783.66,17206.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28582.60,,,,,,,11268.92,28582.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39852.23,,,,,,,15712.06,39852.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19001.35,,,,,,,7491.43,19001.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11843.05,,,,,,,4669.22,11843.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31631.43,,,,,,,12470.94,31631.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19754.65,,,,,,,7788.43,19754.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16113.67,,,,,,,6352.94,16113.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,109900.49,,,,,,,42319.93,109900.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41949.13,,,,,,,16538.78,41949.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22561.76,,,,,,,8895.15,22561.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,85914.57,,,,,,,33269.41,85914.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,42455.08,,,,,,,16738.25,42455.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,25286.41,,,,,,,9969.37,25286.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,87657.29,,,,,,,33926.98,87657.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43309.58,,,,,,,17075.15,43309.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31927.51,,,,,,,12587.67,31927.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,59215.24,,,,,,,23195.07,59215.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28202.19,,,,,,,11118.94,28202.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22533.65,,,,,,,8884.07,22533.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13522.06,,,,,,,5331.18,13522.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,9798.62,,,,,,,3863.19,9798.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,102875.24,,,,,,,39669.12,102875.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39085.81,,,,,,,15409.89,39085.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22852.21,,,,,,,9009.67,22852.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,90027.78,,,,,,,34821.45,90027.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39115.79,,,,,,,15421.71,39115.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,27057.24,,,,,,,10667.53,27057.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,60618.79,,,,,,,23724.68,60618.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30570.80,,,,,,,12052.78,30570.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18933.89,,,,,,,7464.84,18933.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37380.56,,,,,,,14737.58,37380.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22812.86,,,,,,,8994.15,22812.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15958.13,,,,,,,6291.62,15958.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,48580.86,,,,,,,19153.39,48580.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24514.36,,,,,,,9664.98,24514.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15916.91,,,,,,,6275.37,15916.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,50773.32,,,,,,,20009.72,50773.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,162270.37,,,,,,,62080.42,162270.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,92544.43,,,,,,,35771.03,92544.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37442.40,,,,,,,14761.96,37442.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28056.03,,,,,,,11061.31,28056.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,85238.09,,,,,,,33014.15,85238.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,40129.57,,,,,,,15821.40,40129.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26101.55,,,,,,,10290.75,26101.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34174.31,,,,,,,13473.50,34174.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18699.65,,,,,,,7372.49,18699.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16634.61,,,,,,,6558.33,16634.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28076.64,,,,,,,11069.44,28076.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16295.43,,,,,,,6424.60,16295.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,39224.47,,,,,,,15464.56,39224.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19321.78,,,,,,,7617.77,19321.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,13673.85,,,,,,,5391.02,13673.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,129520.22,,,,,,,49722.96,129520.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36400.51,,,,,,,14351.19,36400.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19175.62,,,,,,,7560.14,19175.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,72424.36,,,,,,,823.98,72424.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17993.19,,,,,,,823.98,17993.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17631.53,,,,,,,823.98,17631.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20121.94,,,,,,,823.98,20121.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,36846.50,,,,,,,823.98,36846.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30149.18,,,,,,,823.98,30149.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26174.64,,,,,,,823.98,26174.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,38889.05,,,,,,,823.98,38889.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,20067.60,,,,,,,823.98,20067.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11560.09,,,,,,,823.98,11560.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26526.93,,,,,,,823.98,26526.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32701.43,,,,,,,823.98,32701.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16542.79,,,,,,,823.98,16542.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,78640.09,,,,,,,30524.57,78640.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,35875.82,,,,,,,14144.33,35875.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21917.13,,,,,,,8641.00,21917.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,68830.22,,,,,,,26823.05,68830.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,26830.50,,,,,,,10578.14,26830.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,33025.61,,,,,,,13020.61,33025.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,71944.64,,,,,,,27998.19,71944.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37388.05,,,,,,,14740.54,37388.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24598.69,,,,,,,9698.23,24598.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30630.77,,,,,,,12076.42,30630.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16593.38,,,,,,,6542.07,16593.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,31511.50,,,,,,,12423.66,31511.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12485.80,,,,,,,4922.62,12485.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29390.25,,,,,,,11587.34,29390.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16061.20,,,,,,,6332.25,16061.20,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,34307.36,,,,,,,13525.95,34307.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,18782.10,,,,,,,7404.99,18782.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,12899.93,,,,,,,5085.90,12899.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32782.01,,,,,,,12924.57,32782.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,19070.68,,,,,,,7518.77,19070.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,345363.52,,,,,,,136162.32,345363.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,134409.23,,,,,,,51567.69,134409.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,60354.57,,,,,,,23624.98,60354.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,71521.14,,,,,,,28197.78,71521.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,41424.43,,,,,,,16331.91,41424.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,38602.34,,,,,,,15219.28,38602.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,67994.46,,,,,,,26507.70,67994.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,43791.17,,,,,,,17265.02,43791.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,37997.07,,,,,,,14980.65,37997.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,29019.22,,,,,,,526.87,29019.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,21489.89,,,,,,,526.87,21489.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23787.29,,,,,,,9378.33,23787.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,15000.57,,,,,,,5914.09,15000.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22293.79,,,,,,,8789.50,22293.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,11762.47,,,,,,,4637.45,11762.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,10418.88,,,,,,,4107.73,10418.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,126134.08,,,,,,,48445.28,126134.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,70514.86,,,,,,,27458.71,70514.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,142789.31,,,,,,,54729.71,142789.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,78964.27,,,,,,,30646.88,78964.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,55169.49,,,,,,,21668.51,55169.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,51228.68,,,,,,,20181.55,51228.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,28719.39,,,,,,,11322.85,28719.39,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,17624.03,,,,,,,6948.41,17624.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,114707.04,,,,,,,44133.55,114707.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,49422.24,,,,,,,19485.11,49422.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,54080.75,,,,,,,21257.70,54080.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,24267.01,,,,,,,9567.46,24267.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,16762.04,,,,,,,6608.57,16762.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,23753.56,,,,,,,9365.03,23753.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,87919.64,,,,,,,34025.97,87919.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,46069.83,,,,,,,18163.40,46069.83,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,32118.65,,,,,,,12663.03,32118.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,64244.79,,,,,,,25092.85,64244.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,30799.42,,,,,,,12142.92,30799.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Commercial,,22471.81,,,,,,,8859.69,22471.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,38900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",361,RC,31627,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15777,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,18291.76,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)",360,RC,43775,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64488,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10016.47,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,60512,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22853,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",361,RC,31654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22845,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4964.08,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6274.19,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,52940.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6274.19,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF INTRAUTERINE DEVICE (IUD),360,RC,58300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20936,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4311.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4311.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20931,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4964.08,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,11124.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1494.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,52940.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6314.07,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,9423.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,29826,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64468,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)",360,RC,43845,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6314.07,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4964.08,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)",360,RC,43644,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,20937,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4311.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,6649.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4311.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20985,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64466,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31632,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,52940.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT",360,RC,27487,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,52940.00,,,,,,,34125.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,3660.29,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63052,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6274.19,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1970.84,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64486,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OMENTAL FLAP, INTRA-ABDOMINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL",360,RC,60650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; PERINEAL APPROACH",360,RC,45130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93657,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61782,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,9423.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,4121.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC/DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49596,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,61783,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,14302,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,7277.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT",360,RC,27486,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22842,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27132,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G, ABDOMINAL APPROACH",360,RC,58146,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION),360,RC,38724,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6274.19,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT",360,RC,23474,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22634,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF TOTAL OR NEAR TOTAL NON-INFECTED MESH OR OTHER PROSTHESIS AT THE TIME OF INITIAL OR RECURRENT ANTERIOR ABDOMINAL HERNIA REPAIR OR PARASTOMAL HERNIA REPAIR, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4749.28,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);",360,RC,58150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,9423.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3308.62,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63053,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,10006,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2194.26,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL;",360,RC,57110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64473,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S)",360,RC,58180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19126,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6274.19,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL OF GEROTA'S FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES, AND ADRENALECTOMY)",360,RC,50545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,82346.00,,,,,,,6735.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27134,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,6649.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE RESECTION AND ANASTOMOSIS",360,RC,44202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, TOTAL HYSTERECTOMY FOR RESECTION OF MALIGNANCY (TUMOR DEBULKING), WITH OMENTECTOMY INCLUDING SALPINGO-OOPHORECTOMY, UNILATERAL OR BILATERAL, WHEN PERFORMED",360,RC,58575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR",360,RC,22558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49618,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1558.81,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,82346.00,,,,,,,6735.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1494.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,52940.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITHOUT VAGOTOMY",360,RC,43860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES)",360,RC,21147,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6258.49,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22632,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,57.15,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; CERVICAL BELOW C2 SEGMENT",360,RC,22600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8700.96,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, WITH PERINEAL BODY RECONSTRUCTION, WITH OR WITHOUT LEVATOR PLICATION",360,RC,57308,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,4311.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; SINGLE IMPLANT",360,RC,52441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,57.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,1539.73,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM (SEPARATE PROCEDURE)",360,RC,49255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PYLOROPLASTY,360,RC,43800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,4376.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,12247.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64467,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10910.59,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,39682.00,,,,,,,4121.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36907,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,594.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,82346.00,,,,,,,6735.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),750,RC,43273,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS",360,RC,44204,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE)",360,RC,45400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6258.49,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG-ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,7300.39,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY LYMPH NODES",360,RC,19305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)",360,RC,21145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION",360,RC,43645,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,66990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4311.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF PARASTOMAL HERNIA, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL OR RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS, WHEN PERFORMED; REDUCIBLE",360,RC,49621,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH RADICAL NECK DISSECTION",360,RC,60254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL;",360,RC,58940,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,58720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITH FIXATION",360,RC,27450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4311.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BICORTICAL OR TRICORTICAL (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20938,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4311.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,26125,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; EACH ADDITIONAL SEGMENT, THORACIC OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63057,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL CAROTID ARTERY, OPEN OR PERCUTANEOUS, INCLUDING ANGIOPLASTY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION; WITH DISTAL EMBOLIC PROTECTION",360,RC,37215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, HIP OR THIGH, ANY TYPE",360,RC,27025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,56606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,642.16,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; EACH ADDITIONAL PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,52442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BALLOON DILATION, URETERAL STRICTURE, INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,50706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1659.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; ABDOMINAL APPROACH",360,RC,58140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BACKBENCH PREPARATION OF CORNEAL ENDOTHELIAL ALLOGRAFT PRIOR TO TRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,65757,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,931.82,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4964.08,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,64636,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SECOND LEVEL, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22858,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF ANTERIOR INSTRUMENTATION,360,RC,22855,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF ADJUSTABLE SUTURE(S) DURING STRABISMUS SURGERY, INCLUDING POSTOPERATIVE ADJUSTMENT(S) OF SUTURE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR SPECIFIC STRABISMUS SURGERY)",360,RC,67335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS)",360,RC,44207,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE",360,RC,44187,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH THORACIC SYMPATHECTOMY",360,RC,32664,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; COMMON FEMORAL",360,RC,35371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4507.53,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY",360,RC,43846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4121.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1558.81,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (OMENTAL TACKING PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49326,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY",360,RC,50546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY",360,RC,50548,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETEROLYSIS, WITH OR WITHOUT REPOSITIONING OF URETER FOR RETROPERITONEAL FIBROSIS",360,RC,50715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,9721.99,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF MESH OR OTHER PROSTHESIS FOR REPAIR OF PELVIC FLOOR DEFECT, EACH SITE (ANTERIOR, POSTERIOR COMPARTMENT), VAGINAL APPROACH (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,57267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGECTOMY AND/OR OOPHORECTOMY, ABDOMINAL OR VAGINAL APPROACH",360,RC,59120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4121.00,13110.66,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,1878.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,527.80,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH, METHYLMETHACRYLATE) TO INTERVERTEBRAL DISC SPACE OR VERTEBRAL BODY DEFECT WITHOUT INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22859,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REINSERTION OF SPINAL FIXATION DEVICE,360,RC,22849,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS",360,RC,22548,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3120.11,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR VERTEBRAL JOINT(S) ARTHROPLASTY (EG, FACET JOINT[S] REPLACEMENT), INCLUDING FACETECTOMY, LAMINECTOMY, FORAMINOTOMY, AND VERTEBRAL COLUMN FIXATION, INJECTION OF BONE CEMENT, WHEN PERFORMED, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE",360,RC,0202T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,4311.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,7300.39,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,7300.39,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; WITH REPAIR OF ENTEROCELE",360,RC,58280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4749.28,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS (NONOBSTETRICAL)",360,RC,58520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH RADICAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY), WITH REMOVAL OF TUBE(S) AND OVARY(S), IF PERFORMED",360,RC,58548,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,360,RC,51600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID BLADDER, INCLUDING INTESTINE ANASTOMOSIS;",360,RC,51590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,12247.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE);",360,RC,60540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF SKULL,360,RC,61500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, INTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61781,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; RE-AMPUTATION",360,RC,27886,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ACETABULOPLASTY; RESECTION, FEMORAL HEAD (EG, GIRDLESTONE PROCEDURE)",360,RC,27122,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27137,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE",360,RC,63077,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL (IE, PERITONEAL, MESENTERIC, RETROPERITONEAL), PRIMARY OR SECONDARY TUMOR(S) OR CYST(S), SUM OF THE MAXIMUM LENGTH OF TUMOR(S) OR CYST(S); 5 CM OR LESS",360,RC,49186,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR WITHOUT BIOPSY(S) (SEPARATE PROCEDURE)",360,RC,49000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64474,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY CONTINUOUS INFUSION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64487,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE), WITH SIGMOID RESECTION",360,RC,45402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,527.80,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND ANASTOMOSIS OTHER THAN COLORECTAL",360,RC,44625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE PROCEDURE),360,RC,44346,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; THORACIC (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,931.82,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44206,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44143,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE),360,RC,44139,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENTEROENTEROSTOMY, ANASTOMOSIS OF INTESTINE, WITH OR WITHOUT CUTANEOUS ENTEROSTOMY (SEPARATE PROCEDURE)",360,RC,44130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF MALROTATION BY LYSIS OF DUODENAL BANDS AND/OR REDUCTION OF MIDGUT VOLVULUS (EG, LADD PROCEDURE)",360,RC,44055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,C5276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE),360,RC,44005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITH VAGOTOMY",360,RC,43865,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY OF STERNUM, PARTIAL",360,RC,21620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION FIRST AND/OR CERVICAL RIB;,360,RC,21615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,7277.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR OSTEOTOMY (INCLUDES CORRECTION OF GENU VARUS [BOWLEG] OR GENU VALGUS [KNOCK-KNEE]); BEFORE EPIPHYSEAL CLOSURE",360,RC,27455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27514,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE PROCEDURE)",360,RC,38770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19084,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15847,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36909,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,10910.59,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS",360,RC,36620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36217,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATION NOT FOLLOWED BY SURGICAL REPAIR, ARTERY; LOWER EXTREMITY (EG, COMMON FEMORAL, DEEP FEMORAL, SUPERFICIAL FEMORAL, POPLITEAL, TIBIAL, PERONEAL)",360,RC,35703,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3501.31,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH MEDIASTINAL AND REGIONAL LYMPHADENECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,32674,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13122,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE",360,RC,27703,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VULVECTOMY, RADICAL, PARTIAL;",360,RC,56630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4121.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLECTOMY, PARTIAL; WITH ANASTOMOSIS",360,RC,44140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6649.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,7962.20,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH REMOVAL OF A SINGLE LUNG SEGMENT (SEGMENTECTOMY)",360,RC,32669,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND ANASTOMOSIS",360,RC,44120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH THERAPEUTIC WEDGE RESECTION (EG, MASS, NODULE), INITIAL UNILATERAL",360,RC,32666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMBAR, SACRAL, OR LUMBOSACRAL",360,RC,22015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; CERVICAL, THORACIC, OR CERVICOTHORACIC",360,RC,22010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REDUCTION OF VOLVULUS, INTUSSUSCEPTION, INTERNAL HERNIA, BY LAPAROTOMY",360,RC,44050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL",360,RC,44020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4311.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,12378.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,69990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,629.57,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4121.00,9721.99,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR COMPLETE WITH PARATHYROID AUTOTRANSPLANTATION",360,RC,C7555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER THAN ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE)",360,RC,43848,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3660.29,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL POUCH",360,RC,43634,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PARAESOPHAGEAL HIATAL HERNIA (INCLUDING FUNDOPLICATION), VIA LAPAROTOMY, EXCEPT NEONATAL; WITHOUT IMPLANTATION OF MESH OR OTHER PROSTHESIS",360,RC,43332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1659.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING, OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, FEMUR",360,RC,27495,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL SHAFT FRACTURE, WITH OR WITHOUT EXTERNAL FIXATION, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,27506,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE WITHOUT INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27511,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE MARROW ASPIRATION FOR BONE GRAFTING, SPINE SURGERY ONLY, THROUGH SEPARATE SKIN OR FASCIAL INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20939,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)/EXTRACORPOREAL LIFE SUPPORT (ECLS) PROVIDED BY PHYSICIAN; INITIATION, VENO-ARTERIAL",361,RC,33947,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ALLOGRAFT, INCLUDES TEMPLATING, CUTTING, PLACEMENT AND INTERNAL FIXATION, WHEN PERFORMED; OSTEOARTICULAR, INCLUDING ARTICULAR SURFACE AND CONTIGUOUS BONE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20932,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MANUAL PREPARATION AND INSERTION OF DRUG-DELIVERY DEVICE(S), INTRAMEDULLARY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, EACH INTRACRANIAL BRANCH OF THE INTERNAL CAROTID OR VERTEBRAL ARTERIES, UNILATERAL, WITH ANGIOGRAPHY OF THE SELECTED VESSEL CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (EG, MIDDLE CEREBRAL ARTERY, POSTERIOR INFERIOR CEREBELLAR ARTERY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,36228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANTATION OR REPLACEMENT; WITH TESTING OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR",481,RC,93641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; EACH ADDITIONAL BRANCH SUBTENDED BY THE BYPASS GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37253,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,52940.00,,,,,,,8442.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY;",360,RC,58275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37223,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,360,RC,58340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE",360,RC,11005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE STENTING, AND ALL ANGIOPLASTY IN THE CENTRAL DIALYSIS SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36908,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,150.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS)",360,RC,58740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPEXY, ABDOMINAL APPROACH",360,RC,57280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CESAREAN DELIVERY ONLY;,360,RC,59514,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6649.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY",360,RC,59830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10945.84,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,642.16,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF CAROTID BODY TUMOR; WITHOUT EXCISION OF CAROTID ARTERY,360,RC,60600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TWIST DRILL HOLE(S) FOR SUBDURAL, INTRACEREBRAL, OR VENTRICULAR PUNCTURE; FOR EVACUATION AND/OR DRAINAGE OF SUBDURAL HEMATOMA",360,RC,61108,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,64466,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,12247.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8213.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, BIPOLAR ARTHROPLASTY)",360,RC,27125,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64491,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64492,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT",360,RC,27138,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE POSTERIOR BONY ELEMENTS (INCLUDING THE APPLICATION OF BRIDGING BONE GRAFT AND NON-SEGMENTAL FIXATION DEVICES [EG, WIRE, SUTURE, MINI-PLATES], WHEN PERFORMED)",360,RC,63051,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3395.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, FEMORAL NECK AND PROXIMAL FEMUR",360,RC,27187,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63078,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT",360,RC,63081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT",360,RC,27236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK OR PSEUDOMENINGOCELE, WITH LAMINECTOMY",360,RC,63709,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DURAL GRAFT, SPINAL",360,RC,63710,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEPATECTOMY, RESECTION OF LIVER; PARTIAL LOBECTOMY",360,RC,47120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,47001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,990.00,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64469,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)",360,RC,36248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,92978,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY CONTINUOUS INFUSIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64489,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND URETHROPLASTY, SACROPERINEAL APPROACH",360,RC,46744,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR VAGINAL), POUCH ADVANCEMENT; COMBINED TRANSPERINEAL AND TRANSABDOMINAL APPROACH",360,RC,46712,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,588.93,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF CATHETER, AORTA",360,RC,36200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; ABDOMEN",360,RC,35840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,124.01,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,4964.08,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11047,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-FEMORAL",360,RC,35661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ANGIOSCOPY (NONCORONARY VESSELS OR GRAFTS) DURING THERAPEUTIC INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,35400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROCTOPEXY (EG, FOR PROLAPSE); ABDOMINAL APPROACH",360,RC,45540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; DEEP (PROFUNDA) FEMORAL",360,RC,35372,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE SPARING; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES",360,RC,55845,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; CAROTID, VERTEBRAL, SUBCLAVIAN, BY NECK INCISION",360,RC,35301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMPLETE, COMBINED ABDOMINOPERINEAL, WITH COLOSTOMY",360,RC,45395,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,2912.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; ABDOMINAL AND PERINEAL APPROACH",360,RC,45135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SINGLE INTERSPACE, LUMBAR",360,RC,22857,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, MECKEL'S DIVERTICULUM AND THE MESENTERY",360,RC,44899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA AND PERINEUM",360,RC,11004,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1316.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF MESENTERY (SEPARATE PROCEDURE),360,RC,44820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 7 TO 12 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22843,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, POPLITEAL ARTERY",360,RC,35151,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF INTESTINAL CUTANEOUS FISTULA,360,RC,44640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)/EXTRACORPOREAL LIFE SUPPORT (ECLS) PROVIDED BY PHYSICIAN; INITIATION, VENO-ARTERIAL",360,RC,33947,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); 4 OR MORE CORONARY ARTERIAL GRAFTS",360,RC,33536,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3501.31,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3501.31,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF COLOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) (SEPARATE PROCEDURE),360,RC,44345,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1558.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE",360,RC,44310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,150.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE, WITH RESECTION AND ANASTOMOSIS",360,RC,44227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,24600.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,8045.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)",360,RC,44213,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,3142.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,13852.00,,,,,,,7962.20,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; EACH ADDITIONAL SMALL INTESTINE RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,44203,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN LEVEL CECOSTOMY",360,RC,44188,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,10022.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,United Healthcare,Commercial,,5754.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,inpatient,,,0.14000,0.08000,United Healthcare,Commercial,,0.11382,,,,,,,0.04214,0.11382,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,United Healthcare,Commercial,,1.47,,,,,,,0.02803,1.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,130.00000,78.00000,United Healthcare,Commercial,,105.69,,,,,,,39.13,105.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Commercial,,82.50,,,,,,,26.03,96.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,7.53,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,United Healthcare,Commercial,,31.86,,,,,,,5.00,31.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Commercial,,77.23,,,,,,,28.59,77.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,138.68,,,,,,,19.02,138.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,54.00000,32.40000,United Healthcare,Commercial,,43.90,,,,,,,16.25,43.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,6.96,,,,,,,5.99,40.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Commercial,,100.00,,,,,,,78.72,100.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Commercial,,100.00,,,,,,,24.62,124.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Commercial,,100.00,,,,,,,37.02,100.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Commercial,,132.99,,,,,,,24.62,132.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,22.07000,13.24000,United Healthcare,Commercial,,17.94,,,,,,,6.64,17.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,United Healthcare,Commercial,,79.61,,,,,,,4.42,81.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.03300,,,,,,,0.00200,0.03300,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Commercial,,77.23,,,,,,,60.80,77.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,77.23,,,,,,,19.02,106.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,142.00000,85.20000,United Healthcare,Commercial,,115.45,,,,,,,42.74,115.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,United Healthcare,Commercial,,371.55,,,,,,,28.43,371.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,inpatient,,,39570.00000,23742.00000,United Healthcare,Commercial,,32170.41,,,,,,,11910.57,32170.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,17004.00000,10202.40000,United Healthcare,Commercial,,13824.25,,,,,,,5118.20,13824.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,1919.00000,1151.40000,United Healthcare,Commercial,,1560.15,,,,,,,577.62,1560.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,7252.00000,4351.20000,United Healthcare,Commercial,,5895.88,,,,,,,2182.85,5895.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,1734.00000,1040.40000,United Healthcare,Commercial,,1409.74,,,,,,,521.93,1409.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,3295.00000,1977.00000,United Healthcare,Commercial,,2678.84,,,,,,,991.79,2678.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,40220.00000,24132.00000,United Healthcare,Commercial,,32698.86,,,,,,,12106.22,32698.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,12517.00000,7510.20000,United Healthcare,Commercial,,10176.32,,,,,,,3767.62,10176.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,11120.00000,6672.00000,United Healthcare,Commercial,,9040.56,,,,,,,3347.12,9040.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,15665.00000,9399.00000,United Healthcare,Commercial,,12735.65,,,,,,,4715.16,12735.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,31578.00000,18946.80000,United Healthcare,Commercial,,25672.91,,,,,,,9504.98,25672.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,2639.00000,1583.40000,United Healthcare,Commercial,,2145.51,,,,,,,794.34,2145.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,11117.00000,6670.20000,United Healthcare,Commercial,,9038.12,,,,,,,3346.22,9038.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,16042.00000,9625.20000,United Healthcare,Commercial,,13042.15,,,,,,,4828.64,13042.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,2696.00000,1617.60000,United Healthcare,Commercial,,2191.85,,,,,,,811.50,2191.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,8366.00000,5019.60000,United Healthcare,Commercial,,6801.56,,,,,,,2518.17,6801.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,8920.00000,5352.00000,United Healthcare,Commercial,,7251.96,,,,,,,2684.92,7251.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,11277.00000,6766.20000,United Healthcare,Commercial,,9168.20,,,,,,,3394.38,9168.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,inpatient,,,132.00000,79.20000,United Healthcare,Commercial,,107.32,,,,,,,84.48,107.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Commercial,,107.32,,,,,,,26.43,107.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,United Healthcare,Commercial,,369.92,,,,,,,136.96,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Commercial,,6.75,,,,,,,5.88,337.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,United Healthcare,Commercial,,740.64,,,,,,,274.21,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Commercial,,6.75,,,,,,,5.88,676.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,inpatient,,,31.28000,18.77000,United Healthcare,Commercial,,25.43,,,,,,,9.42,25.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,United Healthcare,Commercial,,25.43,,,,,,,6.26,79.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,inpatient,,,20.34000,12.20000,United Healthcare,Commercial,,16.54,,,,,,,6.12,16.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,United Healthcare,Commercial,,16.54,,,,,,,4.07,16.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,inpatient,,,278.96000,167.38000,United Healthcare,Commercial,,226.79,,,,,,,83.97,226.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,United Healthcare,Commercial,,1004.55,,,,,,,55.85,1004.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,inpatient,,,21.64000,12.98000,United Healthcare,Commercial,,17.59,,,,,,,6.51,17.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,United Healthcare,Commercial,,17.59,,,,,,,4.33,50.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,inpatient,,,0.03000,0.02000,United Healthcare,Commercial,,0.02439,,,,,,,0.00903,0.02439,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,United Healthcare,Commercial,,0.08250,,,,,,,0.00601,0.08250,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,inpatient,,,21.42000,12.85000,United Healthcare,Commercial,,17.41,,,,,,,6.45,17.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,United Healthcare,Commercial,,17.41,,,,,,,4.29,52.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,inpatient,,,40.61000,24.37000,United Healthcare,Commercial,,33.02,,,,,,,12.22,33.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,United Healthcare,Commercial,,227.30,,,,,,,8.13,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,inpatient,,,20.37000,12.22000,United Healthcare,Commercial,,16.56,,,,,,,6.13,16.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,United Healthcare,Commercial,,16.56,,,,,,,4.08,24.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,inpatient,,,19.90000,11.94000,United Healthcare,Commercial,,16.18,,,,,,,5.99,16.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,United Healthcare,Commercial,,16.18,,,,,,,3.98,48.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Commercial,,803.24,,,,,,,632.32,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Commercial,,803.24,,,,,,,197.80,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,174.72,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,54.65,238.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,inpatient,,,65.26000,39.16000,United Healthcare,Commercial,,53.06,,,,,,,19.64,53.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,United Healthcare,Commercial,,53.06,,,,,,,13.07,170.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,inpatient,,,178.21000,106.93000,United Healthcare,Commercial,,144.88,,,,,,,114.05,144.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,United Healthcare,Commercial,,144.88,,,,,,,35.68,569.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,inpatient,,,15495.00000,9297.00000,United Healthcare,Commercial,,12597.43,,,,,,,4663.99,12597.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,inpatient,,,6.33000,3.80000,United Healthcare,Commercial,,5.15,,,,,,,1.91,5.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,United Healthcare,Commercial,,19.72,,,,,,,1.27,20.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,,,182.00000,109.20000,United Healthcare,Commercial,,147.97,,,,,,,116.48,147.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Commercial,,147.97,,,,,,,36.44,147.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,United Healthcare,Commercial,,162.60,,,,,,,60.20,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Commercial,,186.47,,,,,,,40.04,186.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,United Healthcare,Commercial,,162.60,,,,,,,128.00,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Commercial,,162.60,,,,,,,40.04,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,inpatient,,,29.65000,17.79000,United Healthcare,Commercial,,24.11,,,,,,,8.92,24.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,United Healthcare,Commercial,,24.11,,,,,,,5.94,75.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,United Healthcare,Commercial,,1004.05,,,,,,,371.74,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,Commercial,,343.20,,,,,,,247.25,916.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,852.02,,,,,,,315.45,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,343.20,,,,,,,209.81,777.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,United Healthcare,Commercial,,574.79,,,,,,,212.81,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Commercial,,343.20,,,,,,,141.54,524.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,United Healthcare,Commercial,,447.15,,,,,,,165.55,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Commercial,,343.20,,,,,,,110.11,408.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,United Healthcare,Commercial,,359.35,,,,,,,133.04,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Commercial,,343.20,,,,,,,88.49,343.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,United Healthcare,Commercial,,378.86,,,,,,,140.27,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,Commercial,,343.20,,,,,,,93.29,345.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,United Healthcare,Commercial,,1004.05,,,,,,,790.40,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,Commercial,,1004.05,,,,,,,247.25,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,852.02,,,,,,,670.72,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,852.02,,,,,,,209.81,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,United Healthcare,Commercial,,574.79,,,,,,,452.48,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Commercial,,574.79,,,,,,,141.54,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,United Healthcare,Commercial,,447.15,,,,,,,352.00,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Commercial,,447.15,,,,,,,110.11,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,United Healthcare,Commercial,,359.35,,,,,,,282.88,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Commercial,,359.35,,,,,,,88.49,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,United Healthcare,Commercial,,378.86,,,,,,,298.24,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,Commercial,,378.86,,,,,,,93.29,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,inpatient,,,27.47000,16.48000,United Healthcare,Commercial,,22.33,,,,,,,8.27,22.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,United Healthcare,Commercial,,79.91,,,,,,,5.50,79.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,United Healthcare,Commercial,,464.22,,,,,,,171.87,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Commercial,,178.08,,,,,,,114.31,423.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,United Healthcare,Commercial,,213.01,,,,,,,78.86,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Commercial,,178.08,,,,,,,52.45,194.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,2469.00000,1481.40000,United Healthcare,Commercial,,2007.30,,,,,,,743.17,2007.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,Commercial,,1442.92,,,,,,,494.29,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,United Healthcare,Commercial,,567.47,,,,,,,210.10,567.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,Commercial,,1442.92,,,,,,,139.74,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,United Healthcare,Commercial,,567.47,,,,,,,446.72,567.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,Commercial,,567.47,,,,,,,139.74,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,188.43,508.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,1442.92,,,,,,,125.33,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,400.64,508.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,125.33,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,United Healthcare,Commercial,,500.00,,,,,,,185.12,500.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Commercial,,1442.92,,,,,,,123.12,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,United Healthcare,Commercial,,500.00,,,,,,,393.60,500.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Commercial,,500.00,,,,,,,123.12,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,United Healthcare,Commercial,,356.91,,,,,,,132.14,356.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,1442.92,,,,,,,87.89,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,United Healthcare,Commercial,,356.91,,,,,,,280.96,356.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,356.91,,,,,,,87.89,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,United Healthcare,Commercial,,324.39,,,,,,,120.10,324.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Commercial,,1442.92,,,,,,,79.88,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,United Healthcare,Commercial,,324.39,,,,,,,255.36,324.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Commercial,,324.39,,,,,,,79.88,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,2363.00000,1417.80000,United Healthcare,Commercial,,1921.12,,,,,,,1512.32,1921.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,United Healthcare,Commercial,,1921.12,,,,,,,154.34,1921.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,United Healthcare,Commercial,,464.22,,,,,,,365.44,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Commercial,,464.22,,,,,,,114.31,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,United Healthcare,Commercial,,213.01,,,,,,,167.68,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Commercial,,213.01,,,,,,,52.45,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,United Healthcare,Commercial,,254.47,,,,,,,94.21,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Commercial,,178.08,,,,,,,62.66,232.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,United Healthcare,Commercial,,254.47,,,,,,,200.32,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Commercial,,254.47,,,,,,,62.66,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,United Healthcare,Commercial,,1280.47,,,,,,,474.07,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,Commercial,,274.21,,,,,,,240.06,1168.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,United Healthcare,Commercial,,1280.47,,,,,,,1008.00,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,Commercial,,1280.47,,,,,,,240.06,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,United Healthcare,Commercial,,1017.88,,,,,,,376.85,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Commercial,,274.21,,,,,,,240.06,929.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,United Healthcare,Commercial,,1017.88,,,,,,,801.28,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Commercial,,1017.88,,,,,,,240.06,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,United Healthcare,Commercial,,521.13,,,,,,,192.94,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Commercial,,274.21,,,,,,,128.33,475.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,United Healthcare,Commercial,,521.13,,,,,,,410.24,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Commercial,,521.13,,,,,,,128.33,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,United Healthcare,Commercial,,276.42,,,,,,,102.34,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,Commercial,,274.21,,,,,,,68.07,274.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,United Healthcare,Commercial,,276.42,,,,,,,217.60,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,Commercial,,276.42,,,,,,,68.07,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,United Healthcare,Commercial,,221.14,,,,,,,81.87,221.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,Commercial,,274.21,,,,,,,54.45,274.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,United Healthcare,Commercial,,221.14,,,,,,,174.08,221.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,Commercial,,221.14,,,,,,,54.45,240.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,inpatient,,,216.17000,129.70000,United Healthcare,Commercial,,175.75,,,,,,,65.07,175.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,United Healthcare,Commercial,,774.28,,,,,,,43.28,774.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,United Healthcare,Commercial,,740.64,,,,,,,583.04,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Commercial,,740.64,,,,,,,5.88,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,United Healthcare,Commercial,,369.92,,,,,,,291.20,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Commercial,,369.92,,,,,,,5.88,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,5187.00000,3112.20000,United Healthcare,Commercial,,4217.03,,,,,,,1561.29,4217.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,United Healthcare,Commercial,,146.35,,,,,,,120.36,3849.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,inpatient,,,153.80000,92.28000,United Healthcare,Commercial,,125.04,,,,,,,46.29,125.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,United Healthcare,Commercial,,509.36,,,,,,,30.79,509.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2562.00000,1537.20000,United Healthcare,Commercial,,2082.91,,,,,,,771.16,2082.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,United Healthcare,Commercial,,274.21,,,,,,,240.06,1901.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Commercial,,803.24,,,,,,,297.39,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Commercial,,268.27,,,,,,,197.80,733.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,188.43,508.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,268.27,,,,,,,125.33,464.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,82.17,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Commercial,,268.27,,,,,,,54.65,268.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,inpatient,,,872.14000,523.28000,United Healthcare,Commercial,,709.05,,,,,,,262.51,709.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,United Healthcare,Commercial,,3043.97,,,,,,,174.60,3043.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,inpatient,,,1070.23000,642.14000,United Healthcare,Commercial,,870.10,,,,,,,322.14,870.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,United Healthcare,Commercial,,3968.20,,,,,,,214.26,3968.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,inpatient,,,2.18000,1.31000,United Healthcare,Commercial,,1.77,,,,,,,0.65618,1.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,United Healthcare,Commercial,,1.77,,,,,,,0.43644,1.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,2078.00000,1246.80000,United Healthcare,Commercial,,1689.41,,,,,,,625.48,1689.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,,2239.00,,,,,,,828.95,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,,274.21,,,,,,,240.06,2044.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,United Healthcare,Commercial,,988.61,,,,,,,366.02,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,Commercial,,274.21,,,,,,,240.06,902.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,United Healthcare,Commercial,,500.81,,,,,,,185.42,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Commercial,,274.21,,,,,,,123.32,457.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,,2239.00,,,,,,,1762.56,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,,2239.00,,,,,,,240.06,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,United Healthcare,Commercial,,988.61,,,,,,,778.24,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,Commercial,,988.61,,,,,,,240.06,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,United Healthcare,Commercial,,500.81,,,,,,,394.24,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Commercial,,500.81,,,,,,,123.32,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,2813.00000,1687.80000,United Healthcare,Commercial,,2286.97,,,,,,,846.71,2286.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,Commercial,,268.27,,,,,,,238.43,2087.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,inpatient,,,3.10000,1.86000,United Healthcare,Commercial,,2.52,,,,,,,0.93310,2.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,United Healthcare,Commercial,,9.06,,,,,,,0.62062,9.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,9.84000,5.90000,United Healthcare,Commercial,,8.00,,,,,,,2.96,8.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,United Healthcare,Commercial,,32.67,,,,,,,1.97,33.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,inpatient,,,192.61000,115.57000,United Healthcare,Commercial,,156.59,,,,,,,123.27,156.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,United Healthcare,Commercial,,156.59,,,,,,,38.56,454.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,inpatient,,,66.43000,39.86000,United Healthcare,Commercial,,54.01,,,,,,,20.00,54.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,United Healthcare,Commercial,,54.01,,,,,,,13.30,179.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Commercial,,100.00,,,,,,,37.02,100.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Commercial,,132.99,,,,,,,24.62,132.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,inpatient,,,237.69000,142.61000,United Healthcare,Commercial,,193.24,,,,,,,71.54,193.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,United Healthcare,Commercial,,710.99,,,,,,,47.59,728.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,inpatient,,,273.90000,164.34000,United Healthcare,Commercial,,222.68,,,,,,,82.44,222.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,United Healthcare,Commercial,,851.88,,,,,,,54.83,872.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,inpatient,,,158.70000,95.22000,United Healthcare,Commercial,,129.02,,,,,,,47.77,129.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,United Healthcare,Commercial,,439.79,,,,,,,31.77,450.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,United Healthcare,Commercial,,278.05,,,,,,,102.94,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Commercial,,83.59,,,,,,,68.47,253.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,United Healthcare,Commercial,,278.05,,,,,,,218.88,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Commercial,,278.05,,,,,,,68.47,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,United Healthcare,Commercial,,1256.90,,,,,,,465.35,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,Commercial,,370.75,,,,,,,309.51,1147.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,3094.00000,1856.40000,United Healthcare,Commercial,,2515.42,,,,,,,931.29,2515.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,United Healthcare,Commercial,,370.75,,,,,,,327.43,2296.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,United Healthcare,Commercial,,1256.90,,,,,,,989.44,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,Commercial,,1256.90,,,,,,,309.51,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,inpatient,,,330.40000,198.24000,United Healthcare,Commercial,,268.62,,,,,,,99.45,268.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,United Healthcare,Commercial,,1002.31,,,,,,,66.15,1002.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.03300,,,,,,,0.00200,0.03300,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,inpatient,,,329.28000,197.57000,United Healthcare,Commercial,,267.70,,,,,,,99.11,267.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,United Healthcare,Commercial,,1000.84,,,,,,,65.92,1000.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,inpatient,,,153.16000,91.90000,United Healthcare,Commercial,,124.52,,,,,,,46.10,124.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,United Healthcare,Commercial,,424.45,,,,,,,30.66,434.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,inpatient,,,158.82000,95.29000,United Healthcare,Commercial,,129.12,,,,,,,47.80,129.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,United Healthcare,Commercial,,440.09,,,,,,,31.80,450.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,United Healthcare,Commercial,,347.96,,,,,,,128.83,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,Commercial,,83.59,,,,,,,70.59,317.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,United Healthcare,Commercial,,347.96,,,,,,,273.92,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,Commercial,,347.96,,,,,,,70.59,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,United Healthcare,Commercial,,392.68,,,,,,,145.38,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Commercial,,83.59,,,,,,,70.59,358.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,United Healthcare,Commercial,,392.68,,,,,,,309.12,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Commercial,,392.68,,,,,,,70.59,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,10.00000,6.00000,United Healthcare,Commercial,,8.13,,,,,,,3.01,8.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,United Healthcare,Commercial,,6.96,,,,,,,2.00,7.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,inpatient,,,0.12000,0.07000,United Healthcare,Commercial,,0.09756,,,,,,,0.07680,0.09756,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,United Healthcare,Commercial,,0.09756,,,,,,,0.02402,0.28320,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,inpatient,,,0.27000,0.16000,United Healthcare,Commercial,,0.21951,,,,,,,0.17280,0.21951,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,United Healthcare,Commercial,,0.21951,,,,,,,0.05405,0.49560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,,2030.87,,,,,,,751.90,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,,916.82,,,,,,,500.10,1854.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,,2030.87,,,,,,,1598.72,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,,2030.87,,,,,,,500.10,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,,1646.33,,,,,,,609.52,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,,916.82,,,,,,,405.40,1502.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,,1646.33,,,,,,,1296.00,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,,1646.33,,,,,,,405.40,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,,1388.60,,,,,,,514.11,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,,916.82,,,,,,,341.94,1267.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,,1388.60,,,,,,,1093.12,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,,1388.60,,,,,,,341.94,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00301,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.16500,,,,,,,0.00200,0.16500,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,inpatient,,,322.28000,193.37000,United Healthcare,Commercial,,262.01,,,,,,,97.01,262.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,United Healthcare,Commercial,,892.68,,,,,,,64.52,914.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,United Healthcare,Commercial,,52.84,,,,,,,19.57,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,31.86,,,,,,,13.01,48.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,United Healthcare,Commercial,,52.84,,,,,,,41.60,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,52.84,,,,,,,13.01,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,inpatient,,,81.13000,48.68000,United Healthcare,Commercial,,65.96,,,,,,,24.42,65.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,United Healthcare,Commercial,,197.87,,,,,,,16.24,221.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,inpatient,,,53.52000,32.11000,United Healthcare,Commercial,,43.51,,,,,,,16.11,43.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,United Healthcare,Commercial,,115.22,,,,,,,10.71,115.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,inpatient,,,126.03000,75.62000,United Healthcare,Commercial,,102.46,,,,,,,37.94,102.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,United Healthcare,Commercial,,431.84,,,,,,,25.23,431.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,inpatient,,,30.86000,18.52000,United Healthcare,Commercial,,25.09,,,,,,,9.29,25.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,United Healthcare,Commercial,,99.48,,,,,,,6.18,99.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,inpatient,,,16.63000,9.98000,United Healthcare,Commercial,,13.52,,,,,,,5.01,13.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,United Healthcare,Commercial,,42.98,,,,,,,3.33,42.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,inpatient,,,116.79000,70.07000,United Healthcare,Commercial,,94.95,,,,,,,35.15,94.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,United Healthcare,Commercial,,367.50,,,,,,,23.38,367.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,inpatient,,,33.65000,20.19000,United Healthcare,Commercial,,27.36,,,,,,,10.13,27.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,United Healthcare,Commercial,,97.20,,,,,,,6.74,97.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,inpatient,,,96.04000,57.62000,United Healthcare,Commercial,,78.08,,,,,,,28.91,78.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,United Healthcare,Commercial,,309.79,,,,,,,19.23,309.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,inpatient,,,275.02000,165.01000,United Healthcare,Commercial,,223.59,,,,,,,82.78,223.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,United Healthcare,Commercial,,907.10,,,,,,,55.06,907.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,inpatient,,,42.62000,25.57000,United Healthcare,Commercial,,34.65,,,,,,,12.83,34.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,United Healthcare,Commercial,,145.73,,,,,,,8.53,145.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,inpatient,,,51.42000,30.85000,United Healthcare,Commercial,,41.80,,,,,,,15.48,41.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,United Healthcare,Commercial,,108.11,,,,,,,10.29,128.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,inpatient,,,166.08000,99.65000,United Healthcare,Commercial,,135.02,,,,,,,49.99,135.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,United Healthcare,Commercial,,597.45,,,,,,,33.25,597.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,inpatient,,,128.79000,77.27000,United Healthcare,Commercial,,104.71,,,,,,,38.77,104.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,United Healthcare,Commercial,,363.38,,,,,,,25.78,372.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,inpatient,,,154.18000,92.51000,United Healthcare,Commercial,,125.35,,,,,,,46.41,125.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,United Healthcare,Commercial,,544.37,,,,,,,30.87,544.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,inpatient,,,146.33000,87.80000,United Healthcare,Commercial,,118.97,,,,,,,44.05,118.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,United Healthcare,Commercial,,447.63,,,,,,,29.30,518.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,inpatient,,,26.14000,15.68000,United Healthcare,Commercial,,21.25,,,,,,,7.87,21.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,United Healthcare,Commercial,,204.60,,,,,,,5.23,209.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,inpatient,,,28.56000,17.14000,United Healthcare,Commercial,,23.22,,,,,,,8.60,23.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,United Healthcare,Commercial,,86.23,,,,,,,5.72,88.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,inpatient,,,68.05000,40.83000,United Healthcare,Commercial,,55.32,,,,,,,20.48,55.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,United Healthcare,Commercial,,191.61,,,,,,,13.62,196.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,inpatient,,,140.75000,84.45000,United Healthcare,Commercial,,114.43,,,,,,,42.37,114.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,United Healthcare,Commercial,,383.20,,,,,,,28.18,392.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,0.51000,0.31000,United Healthcare,Commercial,,0.41463,,,,,,,0.15351,0.41463,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,United Healthcare,Commercial,,1.30,,,,,,,0.10210,1.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,inpatient,,,26.23000,15.74000,United Healthcare,Commercial,,21.32,,,,,,,7.90,21.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,United Healthcare,Commercial,,48.11,,,,,,,5.25,48.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,inpatient,,,5.92000,3.55000,United Healthcare,Commercial,,4.81,,,,,,,1.78,4.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,United Healthcare,Commercial,,4.81,,,,,,,1.19,4.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,inpatient,,,10.52000,6.31000,United Healthcare,Commercial,,8.55,,,,,,,6.73,8.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,United Healthcare,Commercial,,8.55,,,,,,,2.11,8.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,inpatient,,,0.11000,0.07000,United Healthcare,Commercial,,0.08943,,,,,,,0.03311,0.08943,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,United Healthcare,Commercial,,0.33000,,,,,,,0.02202,0.33000,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,inpatient,,,0.80000,0.48000,United Healthcare,Commercial,,0.65040,,,,,,,0.24080,0.65040,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,United Healthcare,Commercial,,2.46,,,,,,,0.16016,2.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,inpatient,,,7.76000,4.66000,United Healthcare,Commercial,,6.31,,,,,,,2.34,6.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,United Healthcare,Commercial,,12.74,,,,,,,1.55,12.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,inpatient,,,0.79000,0.47000,United Healthcare,Commercial,,0.64227,,,,,,,0.23779,0.64227,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,United Healthcare,Commercial,,1.55,,,,,,,0.15816,1.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,0.47000,0.28000,United Healthcare,Commercial,,0.38211,,,,,,,0.14147,0.38211,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,United Healthcare,Commercial,,0.95700,,,,,,,0.09409,0.95700,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,inpatient,,,0.64000,0.38000,United Healthcare,Commercial,,0.52032,,,,,,,0.19264,0.52032,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,United Healthcare,Commercial,,0.52032,,,,,,,0.12813,0.52032,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,inpatient,,,1666.78000,1000.07000,United Healthcare,Commercial,,1355.09,,,,,,,501.70,1355.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,United Healthcare,Commercial,,4729.26,,,,,,,333.69,4844.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,inpatient,,,0.02000,0.01000,United Healthcare,Commercial,,0.01626,,,,,,,0.00602,0.01626,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,United Healthcare,Commercial,,0.01626,,,,,,,0.00400,0.01626,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,inpatient,,,0.09000,0.05000,United Healthcare,Commercial,,0.07317,,,,,,,0.05760,0.07317,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,United Healthcare,Commercial,,0.07317,,,,,,,0.01802,1.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,inpatient,,,2.57000,1.54000,United Healthcare,Commercial,,2.09,,,,,,,1.64,2.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,United Healthcare,Commercial,,2.09,,,,,,,0.51451,6.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,inpatient,,,25.77000,15.46000,United Healthcare,Commercial,,20.95,,,,,,,7.76,20.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,United Healthcare,Commercial,,75.85,,,,,,,5.16,75.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,inpatient,,,81.46000,48.88000,United Healthcare,Commercial,,66.23,,,,,,,24.52,66.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,United Healthcare,Commercial,,224.38,,,,,,,16.31,224.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,0.07000,0.04000,United Healthcare,Commercial,,0.05691,,,,,,,0.02107,0.05691,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,United Healthcare,Commercial,,0.16500,,,,,,,0.01401,0.16500,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,inpatient,,,4.25000,2.55000,United Healthcare,Commercial,,3.46,,,,,,,1.28,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,United Healthcare,Commercial,,3.46,,,,,,,0.85085,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,inpatient,,,6.12000,3.67000,United Healthcare,Commercial,,4.98,,,,,,,1.84,4.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,United Healthcare,Commercial,,4.98,,,,,,,1.23,4.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,inpatient,,,1.12000,0.67000,United Healthcare,Commercial,,0.91056,,,,,,,0.33712,0.91056,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,United Healthcare,Commercial,,2.34,,,,,,,0.22422,2.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,inpatient,,,1.61000,0.97000,United Healthcare,Commercial,,1.31,,,,,,,0.48461,1.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,United Healthcare,Commercial,,2.59,,,,,,,0.32232,2.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,inpatient,,,2.56000,1.54000,United Healthcare,Commercial,,2.08,,,,,,,0.77056,2.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,United Healthcare,Commercial,,6.20,,,,,,,0.51251,6.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,inpatient,,,1.79000,1.07000,United Healthcare,Commercial,,1.46,,,,,,,0.53879,1.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,United Healthcare,Commercial,,5.53,,,,,,,0.35836,5.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,inpatient,,,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,United Healthcare,Commercial,,1.06,,,,,,,0.04004,1.06,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,inpatient,,,0.02000,0.01000,United Healthcare,Commercial,,0.01626,,,,,,,0.00602,0.01626,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,United Healthcare,Commercial,,3.60,,,,,,,0.00400,3.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,inpatient,,,22.10000,13.26000,United Healthcare,Commercial,,17.97,,,,,,,6.65,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,United Healthcare,Commercial,,60.85,,,,,,,4.42,62.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,inpatient,,,1100.73000,660.44000,United Healthcare,Commercial,,894.89,,,,,,,331.32,894.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,United Healthcare,Commercial,,3968.20,,,,,,,220.37,3968.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,inpatient,,,77.03000,46.22000,United Healthcare,Commercial,,62.63,,,,,,,23.19,62.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,United Healthcare,Commercial,,199.80,,,,,,,15.42,199.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,inpatient,,,134.92000,80.95000,United Healthcare,Commercial,,109.69,,,,,,,40.61,109.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,United Healthcare,Commercial,,311.67,,,,,,,27.01,319.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,inpatient,,,166.43000,99.86000,United Healthcare,Commercial,,135.31,,,,,,,50.10,135.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,United Healthcare,Commercial,,266.00,,,,,,,33.32,272.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,inpatient,,,17.28000,10.37000,United Healthcare,Commercial,,14.05,,,,,,,5.20,14.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,United Healthcare,Commercial,,18.18,,,,,,,3.46,18.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,inpatient,,,0.13000,0.08000,United Healthcare,Commercial,,0.10569,,,,,,,0.03913,0.10569,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,United Healthcare,Commercial,,0.54450,,,,,,,0.02603,0.54450,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,inpatient,,,36.34000,21.80000,United Healthcare,Commercial,,29.54,,,,,,,10.94,29.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,United Healthcare,Commercial,,100.32,,,,,,,7.28,115.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,inpatient,,,65.26000,39.16000,United Healthcare,Commercial,,53.06,,,,,,,19.64,53.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,United Healthcare,Commercial,,227.30,,,,,,,13.07,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,inpatient,,,143.90000,86.34000,United Healthcare,Commercial,,116.99,,,,,,,43.31,116.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,United Healthcare,Commercial,,479.90,,,,,,,28.81,479.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,inpatient,,,63.57000,38.14000,United Healthcare,Commercial,,51.68,,,,,,,19.13,51.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,United Healthcare,Commercial,,208.49,,,,,,,12.73,208.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,inpatient,,,249.07000,149.44000,United Healthcare,Commercial,,202.49,,,,,,,74.97,202.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,United Healthcare,Commercial,,702.37,,,,,,,49.86,719.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,inpatient,,,11.23000,6.74000,United Healthcare,Commercial,,9.13,,,,,,,3.38,9.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,United Healthcare,Commercial,,24.75,,,,,,,2.25,25.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,inpatient,,,25.48000,15.29000,United Healthcare,Commercial,,20.72,,,,,,,7.67,20.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,United Healthcare,Commercial,,34.35,,,,,,,5.10,53.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,inpatient,,,0.75000,0.45000,United Healthcare,Commercial,,0.60975,,,,,,,0.22575,0.60975,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,United Healthcare,Commercial,,0.42900,,,,,,,0.15015,0.55665,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,inpatient,,,0.04000,0.02000,United Healthcare,Commercial,,0.03252,,,,,,,0.01204,0.03252,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,United Healthcare,Commercial,,0.21450,,,,,,,0.00801,0.21450,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,inpatient,,,15.12000,9.07000,United Healthcare,Commercial,,12.29,,,,,,,9.68,12.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,United Healthcare,Commercial,,12.29,,,,,,,3.03,70.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,inpatient,,,13.35000,8.01000,United Healthcare,Commercial,,10.85,,,,,,,4.02,10.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,United Healthcare,Commercial,,41.05,,,,,,,2.67,42.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,inpatient,,,11.89000,7.13000,United Healthcare,Commercial,,9.67,,,,,,,3.58,9.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,United Healthcare,Commercial,,70.08,,,,,,,2.38,71.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,inpatient,,,17.69000,10.61000,United Healthcare,Commercial,,14.38,,,,,,,5.32,14.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,United Healthcare,Commercial,,32.59,,,,,,,3.54,41.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,inpatient,,,33.35000,20.01000,United Healthcare,Commercial,,27.11,,,,,,,10.04,27.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,United Healthcare,Commercial,,99.02,,,,,,,6.68,111.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,inpatient,,,54.96000,32.98000,United Healthcare,Commercial,,44.68,,,,,,,16.54,44.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,United Healthcare,Commercial,,227.30,,,,,,,11.00,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,inpatient,,,139.15000,83.49000,United Healthcare,Commercial,,113.13,,,,,,,41.88,113.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,United Healthcare,Commercial,,483.40,,,,,,,27.86,495.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,inpatient,25,ML,548.70000,329.22000,United Healthcare,Commercial,,446.09,,,,,,,165.16,446.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,United Healthcare,Commercial,,3.55,,,,,,,2.22,407.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,inpatient,5,ML,316.25000,189.75000,United Healthcare,Commercial,,257.11,,,,,,,95.19,257.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,United Healthcare,Commercial,,3.55,,,,,,,2.22,234.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,inpatient,1,UN,371.25000,222.75000,United Healthcare,Commercial,,301.83,,,,,,,111.75,301.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,United Healthcare,Commercial,,206.25,,,,,,,74.32,275.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,inpatient,1,UN,82.95000,49.77000,United Healthcare,Commercial,,67.44,,,,,,,24.97,67.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,Commercial,,4.64,,,,,,,1.65,61.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,inpatient,1,ML,64.90000,38.94000,United Healthcare,Commercial,,52.76,,,,,,,19.53,52.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,48.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,inpatient,1,ML,64.90000,38.94000,United Healthcare,Commercial,,52.76,,,,,,,19.53,52.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,48.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,inpatient,50,ML,47.50000,28.50000,United Healthcare,Commercial,,38.62,,,,,,,30.40,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,United Healthcare,Commercial,,38.62,,,,,,,9.51,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,inpatient,1,UN,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.76800,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,United Healthcare,Commercial,,2381.89,,,,,,,881.85,2381.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,Commercial,,169.42,,,,,,,60.36,2174.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,United Healthcare,Commercial,,15814.35,,,,,,,5855.01,15814.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,Commercial,,206.53,,,,,,,73.58,14437.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,inpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,10.59,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,inpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,12.67,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,inpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,11.71,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,inpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,12.80,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,inpatient,1,UN,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,13.66,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,inpatient,100,ML,128.45000,77.07000,United Healthcare,Commercial,,104.43,,,,,,,38.66,104.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,United Healthcare,Commercial,,6.15,,,,,,,5.33,95.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,inpatient,1,ML,84.10000,50.46000,United Healthcare,Commercial,,68.37,,,,,,,25.31,68.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,United Healthcare,Commercial,,1.58,,,,,,,1.13,62.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,inpatient,1,UN,350.70000,210.42000,United Healthcare,Commercial,,285.12,,,,,,,224.45,285.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,United Healthcare,Commercial,,285.12,,,,,,,70.21,285.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,inpatient,1,UN,385.55000,231.33000,United Healthcare,Commercial,,313.45,,,,,,,246.75,313.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,United Healthcare,Commercial,,313.45,,,,,,,77.19,313.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,inpatient,1,UN,19.40000,11.64000,United Healthcare,Commercial,,15.77,,,,,,,12.42,15.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,United Healthcare,Commercial,,15.77,,,,,,,3.88,15.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,inpatient,1,UN,3544.00000,2126.40000,United Healthcare,Commercial,,2881.27,,,,,,,1066.74,2881.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,United Healthcare,Commercial,,5.03,,,,,,,1.82,2630.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,inpatient,5,ML,304.25000,182.55000,United Healthcare,Commercial,,247.36,,,,,,,91.58,247.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,United Healthcare,Commercial,,247.36,,,,,,,0.89680,247.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,inpatient,5,ML,43.45000,26.07000,United Healthcare,Commercial,,35.32,,,,,,,27.81,35.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,United Healthcare,Commercial,,35.32,,,,,,,8.70,35.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,inpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,10.40,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,inpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,10.37,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,inpatient,10,ML,2414.30000,1448.58000,United Healthcare,Commercial,,1962.83,,,,,,,726.70,1962.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,United Healthcare,Commercial,,596.39,,,,,,,167.14,1791.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,inpatient,1,UN,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,11.55,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,inpatient,1,UN,471.55000,282.93000,United Healthcare,Commercial,,383.37,,,,,,,141.94,383.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,United Healthcare,Commercial,,107.86,,,,,,,93.31,349.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,inpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,inpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,11.07,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,inpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,10.78,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,inpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,10.59,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,inpatient,1,UN,5220.40000,3132.24000,United Healthcare,Commercial,,4244.19,,,,,,,1571.34,4244.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,United Healthcare,Commercial,,1998.73,,,,,,,711.66,3874.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,inpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,10.78,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,inpatient,0.5,ML,79.90000,47.94000,United Healthcare,Commercial,,64.96,,,,,,,24.05,64.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,United Healthcare,Commercial,,12.74,,,,,,,10.38,59.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,inpatient,1,ML,33.65000,20.19000,United Healthcare,Commercial,,27.36,,,,,,,10.13,27.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,24.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,inpatient,10,ML,34.85000,20.91000,United Healthcare,Commercial,,28.33,,,,,,,10.49,28.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,25.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,inpatient,30,ML,47.00000,28.20000,United Healthcare,Commercial,,38.21,,,,,,,14.15,38.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,34.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,inpatient,1,ML,19.85000,11.91000,United Healthcare,Commercial,,16.14,,,,,,,5.97,16.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,14.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,inpatient,1,ML,25.20000,15.12000,United Healthcare,Commercial,,20.49,,,,,,,7.59,20.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,18.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,inpatient,60,ML,80.30000,48.18000,United Healthcare,Commercial,,65.28,,,,,,,51.39,65.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,United Healthcare,Commercial,,65.28,,,,,,,16.08,65.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,inpatient,4,ML,32.40000,19.44000,United Healthcare,Commercial,,26.34,,,,,,,20.74,26.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,United Healthcare,Commercial,,26.34,,,,,,,6.49,26.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,inpatient,1,UN,23.80000,14.28000,United Healthcare,Commercial,,19.35,,,,,,,15.23,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,United Healthcare,Commercial,,19.35,,,,,,,4.76,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,inpatient,1,UN,28.70000,17.22000,United Healthcare,Commercial,,23.33,,,,,,,18.37,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,Commercial,,23.33,,,,,,,5.75,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,inpatient,5,ML,2.25000,1.35000,United Healthcare,Commercial,,1.83,,,,,,,1.44,1.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,United Healthcare,Commercial,,1.83,,,,,,,0.45045,1.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,inpatient,1,UN,436.70000,262.02000,United Healthcare,Commercial,,355.04,,,,,,,131.45,355.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,United Healthcare,Commercial,,63.99,,,,,,,59.47,324.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,inpatient,1,UN,748.20000,448.92000,United Healthcare,Commercial,,608.29,,,,,,,225.21,608.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,United Healthcare,Commercial,,63.99,,,,,,,59.47,555.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,inpatient,1,UN,2284.55000,1370.73000,United Healthcare,Commercial,,1857.34,,,,,,,1462.11,1857.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,United Healthcare,Commercial,,1857.34,,,,,,,457.37,1857.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,178.05,,,,,,,65.92,178.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,162.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,178.05,,,,,,,65.92,178.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,162.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,178.05,,,,,,,65.92,178.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,162.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,inpatient,1,UN,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,inpatient,50,ML,49.45000,29.67000,United Healthcare,Commercial,,40.20,,,,,,,31.65,40.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,United Healthcare,Commercial,,40.20,,,,,,,1.06,40.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,inpatient,50,ML,57.55000,34.53000,United Healthcare,Commercial,,46.79,,,,,,,36.83,46.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,United Healthcare,Commercial,,46.79,,,,,,,0.35400,46.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,inpatient,0.5,ML,568.50000,341.10000,United Healthcare,Commercial,,462.19,,,,,,,171.12,462.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,United Healthcare,Commercial,,21.40,,,,,,,6.49,421.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,inpatient,1,UN,21.80000,13.08000,United Healthcare,Commercial,,17.72,,,,,,,13.95,17.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,United Healthcare,Commercial,,17.72,,,,,,,4.36,17.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,inpatient,1,UN,28.00000,16.80000,United Healthcare,Commercial,,22.76,,,,,,,17.92,22.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,United Healthcare,Commercial,,22.76,,,,,,,5.61,22.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,inpatient,1,UN,24.65000,14.79000,United Healthcare,Commercial,,20.04,,,,,,,15.78,20.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,United Healthcare,Commercial,,20.04,,,,,,,4.93,20.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,11.42,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,inpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,inpatient,226,GR,7.00000,4.20000,United Healthcare,Commercial,,5.69,,,,,,,4.48,5.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,United Healthcare,Commercial,,5.69,,,,,,,1.40,5.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,inpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,11.71,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,inpatient,1,UN,2.60000,1.56000,United Healthcare,Commercial,,2.11,,,,,,,1.66,2.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,United Healthcare,Commercial,,2.11,,,,,,,0.52052,2.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,inpatient,1,UN,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,11.55,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,inpatient,1,UN,18.40000,11.04000,United Healthcare,Commercial,,14.96,,,,,,,11.78,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,Commercial,,14.96,,,,,,,3.68,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,inpatient,2,ML,26.75000,16.05000,United Healthcare,Commercial,,21.75,,,,,,,8.05,21.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,19.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,inpatient,30,ML,30.90000,18.54000,United Healthcare,Commercial,,25.12,,,,,,,9.30,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,22.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,inpatient,5,ML,23.80000,14.28000,United Healthcare,Commercial,,19.35,,,,,,,7.16,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,17.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,inpatient,10,ML,47.55000,28.53000,United Healthcare,Commercial,,38.66,,,,,,,14.31,38.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,35.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,inpatient,2,ML,29.35000,17.61000,United Healthcare,Commercial,,23.86,,,,,,,8.83,23.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,21.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,United Healthcare,Commercial,,26.30,,,,,,,9.74,26.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,24.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,inpatient,1,UN,2741.35000,1644.81000,United Healthcare,Commercial,,2228.72,,,,,,,825.15,2228.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,United Healthcare,Commercial,,9.21,,,,,,,3.32,2034.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,inpatient,1,ML,17.75000,10.65000,United Healthcare,Commercial,,14.43,,,,,,,5.34,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,United Healthcare,Commercial,,0.11550,,,,,,,0.02360,13.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,inpatient,1,ML,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,5.04,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,United Healthcare,Commercial,,0.11550,,,,,,,0.02360,12.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,inpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,inpatient,1,ML,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,5.12,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,United Healthcare,Commercial,,0.11550,,,,,,,0.02360,12.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,inpatient,1,ML,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,6.43,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,United Healthcare,Commercial,,0.11550,,,,,,,0.02360,15.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,inpatient,5,GR,40.80000,24.48000,United Healthcare,Commercial,,33.17,,,,,,,26.11,33.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,United Healthcare,Commercial,,33.17,,,,,,,8.17,33.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,inpatient,1,ML,1839.60000,1103.76000,United Healthcare,Commercial,,1495.59,,,,,,,1177.34,1495.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,United Healthcare,Commercial,,1495.59,,,,,,,368.29,1495.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,inpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,inpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,inpatient,1,UN,16.15000,9.69000,United Healthcare,Commercial,,13.13,,,,,,,10.34,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,United Healthcare,Commercial,,13.13,,,,,,,3.23,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,inpatient,1,UN,17.35000,10.41000,United Healthcare,Commercial,,14.11,,,,,,,11.10,14.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,United Healthcare,Commercial,,14.11,,,,,,,3.47,14.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,inpatient,1,UN,17.75000,10.65000,United Healthcare,Commercial,,14.43,,,,,,,11.36,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,United Healthcare,Commercial,,14.43,,,,,,,3.55,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,inpatient,1,UN,32.75000,19.65000,United Healthcare,Commercial,,26.63,,,,,,,20.96,26.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,United Healthcare,Commercial,,26.63,,,,,,,6.56,26.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,inpatient,1,UN,246.90000,148.14000,United Healthcare,Commercial,,200.73,,,,,,,158.02,200.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,United Healthcare,Commercial,,200.73,,,,,,,49.43,200.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,inpatient,1,UN,1.65000,0.99000,United Healthcare,Commercial,,1.34,,,,,,,1.06,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,United Healthcare,Commercial,,1.34,,,,,,,0.33033,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,United Healthcare,Commercial,,18.86,,,,,,,6.98,18.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,United Healthcare,Commercial,,3.60,,,,,,,3.26,17.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,inpatient,0.25,ML,22.75000,13.65000,United Healthcare,Commercial,,18.50,,,,,,,6.85,18.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,United Healthcare,Commercial,,3.60,,,,,,,3.26,16.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,inpatient,5,ML,20322.25000,12193.35000,United Healthcare,Commercial,,16521.99,,,,,,,6117.00,16521.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,United Healthcare,Commercial,,13648.19,,,,,,,4068.51,15083.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,inpatient,1,UN,32.00000,19.20000,United Healthcare,Commercial,,26.02,,,,,,,20.48,26.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,United Healthcare,Commercial,,26.02,,,,,,,2.05,26.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,inpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.92800,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,inpatient,2.5,ML,157.85000,94.71000,United Healthcare,Commercial,,128.33,,,,,,,101.02,128.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,United Healthcare,Commercial,,128.33,,,,,,,31.60,128.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,inpatient,1,UN,300.90000,180.54000,United Healthcare,Commercial,,244.63,,,,,,,90.57,244.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,United Healthcare,Commercial,,309.79,,,,,,,60.24,309.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,United Healthcare,Commercial,,2012.17,,,,,,,744.98,2012.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,Commercial,,294.11,,,,,,,93.02,1836.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,inpatient,1,UN,70.30000,42.18000,United Healthcare,Commercial,,57.15,,,,,,,21.16,57.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,United Healthcare,Commercial,,35.13,,,,,,,14.07,52.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,inpatient,30,ML,84.80000,50.88000,United Healthcare,Commercial,,68.94,,,,,,,25.52,68.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,United Healthcare,Commercial,,10.39,,,,,,,9.32,62.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,37.70000,22.62000,United Healthcare,Commercial,,30.65,,,,,,,24.13,30.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,United Healthcare,Commercial,,30.65,,,,,,,7.55,30.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,inpatient,60,ML,46.10000,27.66000,United Healthcare,Commercial,,37.48,,,,,,,29.50,37.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,United Healthcare,Commercial,,37.48,,,,,,,9.23,37.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,inpatient,10,ML,385.00000,231.00000,United Healthcare,Commercial,,313.00,,,,,,,115.89,313.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,United Healthcare,Commercial,,3.61,,,,,,,3.61,285.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,inpatient,1,UN,774.35000,464.61000,United Healthcare,Commercial,,629.55,,,,,,,233.08,629.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,United Healthcare,Commercial,,8.05,,,,,,,7.39,574.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,inpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,10.37,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,inpatient,10,ML,50.85000,30.51000,United Healthcare,Commercial,,41.34,,,,,,,32.54,41.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,United Healthcare,Commercial,,41.34,,,,,,,10.18,41.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,inpatient,30,ML,68.85000,41.31000,United Healthcare,Commercial,,55.98,,,,,,,44.06,55.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,United Healthcare,Commercial,,55.98,,,,,,,13.78,55.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,inpatient,30,ML,66.65000,39.99000,United Healthcare,Commercial,,54.19,,,,,,,20.06,54.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,United Healthcare,Commercial,,10.39,,,,,,,9.32,49.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,inpatient,20,ML,72.25000,43.35000,United Healthcare,Commercial,,58.74,,,,,,,21.75,58.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,United Healthcare,Commercial,,10.39,,,,,,,9.32,53.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,inpatient,10,ML,39.65000,23.79000,United Healthcare,Commercial,,32.24,,,,,,,11.93,32.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,29.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,inpatient,30,ML,28.15000,16.89000,United Healthcare,Commercial,,22.89,,,,,,,8.47,22.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,20.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,inpatient,6,ML,60837.10000,36502.26000,United Healthcare,Commercial,,49460.56,,,,,,,18311.97,49460.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,United Healthcare,Commercial,,618.29,,,,,,,220.46,45153.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,inpatient,1,UN,798.05000,478.83000,United Healthcare,Commercial,,648.81,,,,,,,510.75,648.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,United Healthcare,Commercial,,648.81,,,,,,,159.77,648.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,inpatient,1,ML,158.35000,95.01000,United Healthcare,Commercial,,128.74,,,,,,,47.66,128.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,United Healthcare,Commercial,,60.06,,,,,,,31.70,117.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,inpatient,1,UN,231.15000,138.69000,United Healthcare,Commercial,,187.92,,,,,,,147.94,187.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,United Healthcare,Commercial,,187.92,,,,,,,46.28,187.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,inpatient,1,UN,520.25000,312.15000,United Healthcare,Commercial,,422.96,,,,,,,156.60,422.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,386.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,inpatient,1,UN,19.60000,11.76000,United Healthcare,Commercial,,15.93,,,,,,,12.54,15.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,United Healthcare,Commercial,,15.93,,,,,,,3.92,15.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,inpatient,1,UN,27.00000,16.20000,United Healthcare,Commercial,,21.95,,,,,,,17.28,21.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,United Healthcare,Commercial,,21.95,,,,,,,5.41,21.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,inpatient,1,UN,28.45000,17.07000,United Healthcare,Commercial,,23.13,,,,,,,18.21,23.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,United Healthcare,Commercial,,23.13,,,,,,,5.70,23.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,inpatient,0.3,ML,49.90000,29.94000,United Healthcare,Commercial,,40.57,,,,,,,15.02,40.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,United Healthcare,Commercial,,1.55,,,,,,,1.39,37.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,inpatient,0.4,ML,61.20000,36.72000,United Healthcare,Commercial,,49.76,,,,,,,18.42,49.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,United Healthcare,Commercial,,1.55,,,,,,,1.39,45.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,inpatient,0.6,ML,83.85000,50.31000,United Healthcare,Commercial,,68.17,,,,,,,25.24,68.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,United Healthcare,Commercial,,1.55,,,,,,,1.39,62.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,inpatient,0.8,ML,106.45000,63.87000,United Healthcare,Commercial,,86.54,,,,,,,32.04,86.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,United Healthcare,Commercial,,1.55,,,,,,,1.39,79.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,inpatient,1,ML,129.05000,77.43000,United Healthcare,Commercial,,104.92,,,,,,,38.84,104.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,United Healthcare,Commercial,,1.55,,,,,,,1.39,95.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,inpatient,0.8,ML,70.85000,42.51000,United Healthcare,Commercial,,57.60,,,,,,,21.33,57.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,United Healthcare,Commercial,,1.55,,,,,,,1.39,52.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,inpatient,70,GR,76.10000,45.66000,United Healthcare,Commercial,,61.87,,,,,,,48.70,61.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,United Healthcare,Commercial,,61.87,,,,,,,15.24,61.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,inpatient,1,UN,21.20000,12.72000,United Healthcare,Commercial,,17.24,,,,,,,13.57,17.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,United Healthcare,Commercial,,17.24,,,,,,,4.24,17.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,inpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,12.67,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,inpatient,1,UN,1235.40000,741.24000,United Healthcare,Commercial,,1004.38,,,,,,,371.86,1004.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,United Healthcare,Commercial,,9.64,,,,,,,5.40,916.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,inpatient,1,UN,2341.05000,1404.63000,United Healthcare,Commercial,,1903.27,,,,,,,704.66,1903.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,United Healthcare,Commercial,,9.64,,,,,,,5.40,1737.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,inpatient,71,GR,8.50000,5.10000,United Healthcare,Commercial,,6.91,,,,,,,5.44,6.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,United Healthcare,Commercial,,6.91,,,,,,,1.70,6.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,inpatient,1,UN,171.00000,102.60000,United Healthcare,Commercial,,139.02,,,,,,,109.44,139.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,United Healthcare,Commercial,,139.02,,,,,,,34.23,139.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,United Healthcare,Commercial,,34.72,,,,,,,12.85,34.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,31.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,inpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,10.88,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,inpatient,1,UN,20.60000,12.36000,United Healthcare,Commercial,,16.75,,,,,,,13.18,16.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,United Healthcare,Commercial,,16.75,,,,,,,4.12,16.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,inpatient,1,UN,37.05000,22.23000,United Healthcare,Commercial,,30.12,,,,,,,23.71,30.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,United Healthcare,Commercial,,30.12,,,,,,,7.42,30.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,inpatient,1,UN,37.25000,22.35000,United Healthcare,Commercial,,30.28,,,,,,,23.84,30.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,United Healthcare,Commercial,,30.28,,,,,,,7.46,30.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,inpatient,3.5,GR,70.05000,42.03000,United Healthcare,Commercial,,56.95,,,,,,,44.83,56.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,United Healthcare,Commercial,,56.95,,,,,,,14.02,56.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,inpatient,2,ML,123.00000,73.80000,United Healthcare,Commercial,,100.00,,,,,,,37.02,100.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,United Healthcare,Commercial,,16.80,,,,,,,16.80,91.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,inpatient,1,UN,3055.75000,1833.45000,United Healthcare,Commercial,,2484.32,,,,,,,919.78,2484.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,United Healthcare,Commercial,,76.97,,,,,,,19.74,2267.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,United Healthcare,Commercial,,4745.03,,,,,,,1756.77,4745.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,Commercial,,76.97,,,,,,,19.74,4331.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,inpatient,1,UN,1345.40000,807.24000,United Healthcare,Commercial,,1093.81,,,,,,,404.97,1093.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,United Healthcare,Commercial,,76.97,,,,,,,19.74,998.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,inpatient,2,ML,21.50000,12.90000,United Healthcare,Commercial,,17.48,,,,,,,6.47,17.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,United Healthcare,Commercial,,0.24750,,,,,,,0.24750,15.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,inpatient,1,ML,64.55000,38.73000,United Healthcare,Commercial,,52.48,,,,,,,19.43,52.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,United Healthcare,Commercial,,0.24750,,,,,,,0.24750,47.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,inpatient,50,ML,35.60000,21.36000,United Healthcare,Commercial,,28.94,,,,,,,10.72,28.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,26.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,inpatient,10,ML,33.35000,20.01000,United Healthcare,Commercial,,27.11,,,,,,,21.34,27.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,United Healthcare,Commercial,,27.11,,,,,,,6.68,27.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,inpatient,30,ML,34.05000,20.43000,United Healthcare,Commercial,,27.68,,,,,,,21.79,27.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,United Healthcare,Commercial,,27.68,,,,,,,6.82,27.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,inpatient,1,UN,29.25000,17.55000,United Healthcare,Commercial,,23.78,,,,,,,18.72,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,Commercial,,23.78,,,,,,,5.86,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,inpatient,1,UN,29.25000,17.55000,United Healthcare,Commercial,,23.78,,,,,,,18.72,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,Commercial,,23.78,,,,,,,5.86,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,inpatient,1,UN,2420.70000,1452.42000,United Healthcare,Commercial,,1968.03,,,,,,,728.63,1968.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,United Healthcare,Commercial,,16.65,,,,,,,8.49,1796.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,inpatient,2,ML,6479.00000,3887.40000,United Healthcare,Commercial,,5267.43,,,,,,,1950.18,5267.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,United Healthcare,Commercial,,284.72,,,,,,,86.66,4808.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,inpatient,1,UN,168.00000,100.80000,United Healthcare,Commercial,,136.58,,,,,,,50.57,136.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,United Healthcare,Commercial,,0.29700,,,,,,,0.23600,124.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,inpatient,1,UN,27.55000,16.53000,United Healthcare,Commercial,,22.40,,,,,,,17.63,22.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,United Healthcare,Commercial,,22.40,,,,,,,5.52,22.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,inpatient,5,ML,63.70000,38.22000,United Healthcare,Commercial,,51.79,,,,,,,40.77,51.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,United Healthcare,Commercial,,51.79,,,,,,,12.75,51.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,inpatient,1,UN,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,inpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.92800,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,inpatient,1,UN,27.50000,16.50000,United Healthcare,Commercial,,22.36,,,,,,,17.60,22.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,United Healthcare,Commercial,,22.36,,,,,,,5.51,22.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,inpatient,1,UN,31.45000,18.87000,United Healthcare,Commercial,,25.57,,,,,,,20.13,25.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,United Healthcare,Commercial,,25.57,,,,,,,6.30,25.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,inpatient,4,ML,157.40000,94.44000,United Healthcare,Commercial,,127.97,,,,,,,100.74,127.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,United Healthcare,Commercial,,127.97,,,,,,,31.51,127.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,inpatient,1,UN,23.45000,14.07000,United Healthcare,Commercial,,19.06,,,,,,,15.01,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,Commercial,,19.06,,,,,,,4.69,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,inpatient,1,UN,102.95000,61.77000,United Healthcare,Commercial,,83.70,,,,,,,65.89,83.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,United Healthcare,Commercial,,83.70,,,,,,,20.61,83.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,inpatient,473,ML,585.05000,351.03000,United Healthcare,Commercial,,475.65,,,,,,,374.43,475.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,United Healthcare,Commercial,,475.65,,,,,,,117.13,475.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,inpatient,1,UN,180.90000,108.54000,United Healthcare,Commercial,,147.07,,,,,,,115.78,147.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,United Healthcare,Commercial,,147.07,,,,,,,36.22,147.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,inpatient,1,UN,260.30000,156.18000,United Healthcare,Commercial,,211.62,,,,,,,166.59,211.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,United Healthcare,Commercial,,211.62,,,,,,,52.11,211.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,inpatient,1,UN,205.20000,123.12000,United Healthcare,Commercial,,166.83,,,,,,,131.33,166.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,United Healthcare,Commercial,,166.83,,,,,,,41.08,166.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,930.36,,,,,,,344.45,930.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,11.55,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,inpatient,1,UN,18.20000,10.92000,United Healthcare,Commercial,,14.80,,,,,,,11.65,14.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,United Healthcare,Commercial,,14.80,,,,,,,3.64,14.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,inpatient,15,ML,100.95000,60.57000,United Healthcare,Commercial,,82.07,,,,,,,64.61,82.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,United Healthcare,Commercial,,82.07,,,,,,,20.21,82.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,inpatient,500,ML,178.50000,107.10000,United Healthcare,Commercial,,145.12,,,,,,,114.24,145.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,United Healthcare,Commercial,,145.12,,,,,,,35.74,145.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,inpatient,473,ML,525.45000,315.27000,United Healthcare,Commercial,,427.19,,,,,,,336.29,427.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,United Healthcare,Commercial,,427.19,,,,,,,105.20,427.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,inpatient,1,UN,1.55000,0.93000,United Healthcare,Commercial,,1.26,,,,,,,0.99200,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,United Healthcare,Commercial,,1.26,,,,,,,0.31031,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,inpatient,100,ML,101.15000,60.69000,United Healthcare,Commercial,,82.23,,,,,,,30.45,82.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,United Healthcare,Commercial,,0.13200,,,,,,,0.13200,75.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,inpatient,0.6,ML,263.20000,157.92000,United Healthcare,Commercial,,213.98,,,,,,,79.22,213.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,United Healthcare,Commercial,,1.96,,,,,,,1.70,195.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,inpatient,0.8,ML,263.20000,157.92000,United Healthcare,Commercial,,213.98,,,,,,,79.22,213.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,United Healthcare,Commercial,,1.96,,,,,,,1.70,195.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,inpatient,0.6,ML,881.50000,528.90000,United Healthcare,Commercial,,716.66,,,,,,,265.33,716.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,United Healthcare,Commercial,,49.12,,,,,,,39.03,654.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,inpatient,0.025,GR,58.50000,35.10000,United Healthcare,Commercial,,47.56,,,,,,,37.44,47.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,United Healthcare,Commercial,,47.56,,,,,,,11.71,47.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,inpatient,0.42,ML,896.45000,537.87000,United Healthcare,Commercial,,728.81,,,,,,,269.83,728.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,United Healthcare,Commercial,,8.17,,,,,,,2.84,665.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,inpatient,0.4,ML,1424.70000,854.82000,United Healthcare,Commercial,,1158.28,,,,,,,428.83,1158.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,United Healthcare,Commercial,,8.17,,,,,,,2.84,1057.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,inpatient,0.3,ML,2129.05000,1277.43000,United Healthcare,Commercial,,1730.92,,,,,,,640.84,1730.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,United Healthcare,Commercial,,8.17,,,,,,,2.84,1580.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,inpatient,0.5,ML,3537.70000,2122.62000,United Healthcare,Commercial,,2876.15,,,,,,,1064.85,2876.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,United Healthcare,Commercial,,8.17,,,,,,,2.84,2625.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,inpatient,0.4,ML,7059.40000,4235.64000,United Healthcare,Commercial,,5739.29,,,,,,,2124.88,5739.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,United Healthcare,Commercial,,8.17,,,,,,,2.84,5239.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,inpatient,0.6,ML,10581.10000,6348.66000,United Healthcare,Commercial,,8602.43,,,,,,,3184.91,8602.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,United Healthcare,Commercial,,8.17,,,,,,,2.84,7853.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,inpatient,2,ML,1695.15000,1017.09000,United Healthcare,Commercial,,1378.16,,,,,,,510.24,1378.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,United Healthcare,Commercial,,79.78,,,,,,,29.11,1258.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,inpatient,5,ML,8246.30000,4947.78000,United Healthcare,Commercial,,6704.24,,,,,,,2482.14,6704.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,United Healthcare,Commercial,,469.77,,,,,,,167.84,6120.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,inpatient,20,ML,32160.05000,19296.03000,United Healthcare,Commercial,,26146.12,,,,,,,9680.18,26146.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,United Healthcare,Commercial,,469.77,,,,,,,167.84,23869.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,United Healthcare,Commercial,,4585.52,,,,,,,1697.72,4585.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,Commercial,,15.76,,,,,,,5.54,4186.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,United Healthcare,Commercial,,9119.79,,,,,,,3376.45,9119.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,Commercial,,15.76,,,,,,,5.54,8325.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,United Healthcare,Commercial,,259.23,,,,,,,95.97,259.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,Commercial,,198.87,,,,,,,63.83,236.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,United Healthcare,Commercial,,259.23,,,,,,,95.97,259.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,Commercial,,198.87,,,,,,,63.83,236.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,inpatient,10,ML,8806.85000,5284.11000,United Healthcare,Commercial,,7159.97,,,,,,,2650.86,7159.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,United Healthcare,Commercial,,19.01,,,,,,,6.53,6536.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,inpatient,2.5,ML,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,10.43,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,inpatient,100,ML,83.30000,49.98000,United Healthcare,Commercial,,67.72,,,,,,,25.07,67.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,United Healthcare,Commercial,,5.33,,,,,,,5.33,61.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,inpatient,150,ML,101.35000,60.81000,United Healthcare,Commercial,,82.40,,,,,,,30.51,82.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,United Healthcare,Commercial,,5.33,,,,,,,5.33,75.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,inpatient,0.5,ML,153.95000,92.37000,United Healthcare,Commercial,,125.16,,,,,,,46.34,125.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,United Healthcare,Commercial,,145.73,,,,,,,30.82,145.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,inpatient,5,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,14.72,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,inpatient,1,UN,23.35000,14.01000,United Healthcare,Commercial,,18.98,,,,,,,14.94,18.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,United Healthcare,Commercial,,18.98,,,,,,,4.67,18.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,inpatient,0.05,ML,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,5.63,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,United Healthcare,Commercial,,478.67,,,,,,,3.74,490.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,inpatient,1,UN,115.90000,69.54000,United Healthcare,Commercial,,94.23,,,,,,,74.18,94.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,United Healthcare,Commercial,,94.23,,,,,,,23.20,94.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,inpatient,1,UN,141.95000,85.17000,United Healthcare,Commercial,,115.41,,,,,,,42.73,115.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,United Healthcare,Commercial,,30.38,,,,,,,22.75,105.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,inpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,11.07,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,inpatient,4,ML,884.70000,530.82000,United Healthcare,Commercial,,719.26,,,,,,,266.29,719.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,United Healthcare,Commercial,,3.65,,,,,,,3.65,656.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,inpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.89600,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,United Healthcare,Commercial,,32614.23,,,,,,,12074.89,32614.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,Commercial,,499.34,,,,,,,177.98,29774.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,United Healthcare,Commercial,,129785.78,,,,,,,48051.07,129785.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,Commercial,,499.34,,,,,,,177.98,118483.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,inpatient,1,ML,985.50000,591.30000,United Healthcare,Commercial,,801.21,,,,,,,296.64,801.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,United Healthcare,Commercial,,79.78,,,,,,,29.11,731.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,inpatient,30,ML,2.00000,1.20000,United Healthcare,Commercial,,1.63,,,,,,,1.28,1.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,United Healthcare,Commercial,,1.63,,,,,,,0.40040,1.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,inpatient,30,ML,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,inpatient,30,ML,1.70000,1.02000,United Healthcare,Commercial,,1.38,,,,,,,1.09,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,United Healthcare,Commercial,,1.38,,,,,,,0.34034,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,inpatient,30,ML,1.60000,0.96000,United Healthcare,Commercial,,1.30,,,,,,,1.02,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,United Healthcare,Commercial,,1.30,,,,,,,0.32032,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,inpatient,50,ML,100.65000,60.39000,United Healthcare,Commercial,,81.83,,,,,,,30.30,81.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,United Healthcare,Commercial,,2.39,,,,,,,1.86,74.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,193.80000,116.28000,United Healthcare,Commercial,,157.56,,,,,,,58.33,157.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,United Healthcare,Commercial,,5.53,,,,,,,2.90,143.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,inpatient,1,UN,13260.65000,7956.39000,United Healthcare,Commercial,,10780.91,,,,,,,3991.46,10780.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,United Healthcare,Commercial,,6925.74,,,,,,,2529.92,9842.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,inpatient,60,GR,106.00000,63.60000,United Healthcare,Commercial,,86.18,,,,,,,67.84,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,United Healthcare,Commercial,,86.18,,,,,,,21.22,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,inpatient,59,ML,13.75000,8.25000,United Healthcare,Commercial,,11.18,,,,,,,8.80,11.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,United Healthcare,Commercial,,11.18,,,,,,,2.75,11.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,inpatient,1,UN,77.00000,46.20000,United Healthcare,Commercial,,62.60,,,,,,,49.28,62.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,United Healthcare,Commercial,,62.60,,,,,,,15.42,62.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,inpatient,1,UN,2245.35000,1347.21000,United Healthcare,Commercial,,1825.47,,,,,,,675.85,1825.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,United Healthcare,Commercial,,1188.40,,,,,,,419.06,1666.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,inpatient,1,UN,86.05000,51.63000,United Healthcare,Commercial,,69.96,,,,,,,55.07,69.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,United Healthcare,Commercial,,69.96,,,,,,,17.23,69.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,inpatient,60,ML,709.90000,425.94000,United Healthcare,Commercial,,577.15,,,,,,,213.68,577.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,United Healthcare,Commercial,,5.91,,,,,,,2.16,526.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,inpatient,1,UN,213.80000,128.28000,United Healthcare,Commercial,,173.82,,,,,,,136.83,173.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,United Healthcare,Commercial,,173.82,,,,,,,42.80,173.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,inpatient,0.2,ML,60.60000,36.36000,United Healthcare,Commercial,,49.27,,,,,,,18.24,49.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,United Healthcare,Commercial,,7.74,,,,,,,6.44,44.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,inpatient,1,UN,95.75000,57.45000,United Healthcare,Commercial,,77.84,,,,,,,61.28,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,Commercial,,77.84,,,,,,,19.17,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,inpatient,100,ML,184.45000,110.67000,United Healthcare,Commercial,,149.96,,,,,,,55.52,149.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,United Healthcare,Commercial,,7.11,,,,,,,6.16,136.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,inpatient,200,ML,224.70000,134.82000,United Healthcare,Commercial,,182.68,,,,,,,67.63,182.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,United Healthcare,Commercial,,7.11,,,,,,,6.16,166.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,inpatient,1,UN,60.25000,36.15000,United Healthcare,Commercial,,48.98,,,,,,,38.56,48.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,United Healthcare,Commercial,,48.98,,,,,,,12.06,48.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,inpatient,1,UN,1057.00000,634.20000,United Healthcare,Commercial,,859.34,,,,,,,676.48,859.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,United Healthcare,Commercial,,859.34,,,,,,,211.61,859.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,inpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.92800,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,inpatient,1,UN,47.00000,28.20000,United Healthcare,Commercial,,38.21,,,,,,,30.08,38.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,United Healthcare,Commercial,,38.21,,,,,,,9.41,38.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,inpatient,1,UN,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.76800,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,inpatient,1,UN,3.10000,1.86000,United Healthcare,Commercial,,2.52,,,,,,,1.98,2.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,United Healthcare,Commercial,,2.52,,,,,,,0.62062,2.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,inpatient,100,ML,77.35000,46.41000,United Healthcare,Commercial,,62.89,,,,,,,23.28,62.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,57.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,inpatient,50,ML,76.30000,45.78000,United Healthcare,Commercial,,62.03,,,,,,,22.97,62.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,56.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,inpatient,100,ML,77.35000,46.41000,United Healthcare,Commercial,,62.89,,,,,,,23.28,62.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,57.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,United Healthcare,Commercial,,82.52,,,,,,,30.55,82.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,75.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,inpatient,1000,ML,105.00000,63.00000,United Healthcare,Commercial,,85.36,,,,,,,31.61,85.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,77.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,inpatient,60,ML,471.60000,282.96000,United Healthcare,Commercial,,383.41,,,,,,,301.82,383.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,United Healthcare,Commercial,,383.41,,,,,,,94.41,383.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,inpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,11.71,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,inpatient,1,UN,281.75000,169.05000,United Healthcare,Commercial,,229.06,,,,,,,180.32,229.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,United Healthcare,Commercial,,229.06,,,,,,,56.41,229.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,inpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,12.35,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,inpatient,1,UN,56048.55000,33629.13000,United Healthcare,Commercial,,45567.47,,,,,,,16870.61,45567.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,United Healthcare,Commercial,,703.82,,,,,,,250.88,41599.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,inpatient,1,UN,55.00000,33.00000,United Healthcare,Commercial,,44.72,,,,,,,35.20,44.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,Commercial,,44.72,,,,,,,11.01,44.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,inpatient,1,UN,4464.60000,2678.76000,United Healthcare,Commercial,,3629.72,,,,,,,1343.84,3629.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,United Healthcare,Commercial,,14.11,,,,,,,5.03,3313.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,inpatient,1,UN,55.00000,33.00000,United Healthcare,Commercial,,44.72,,,,,,,35.20,44.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,Commercial,,44.72,,,,,,,11.01,44.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,inpatient,100,ML,70.60000,42.36000,United Healthcare,Commercial,,57.40,,,,,,,21.25,57.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,52.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,inpatient,20,ML,26.95000,16.17000,United Healthcare,Commercial,,21.91,,,,,,,8.11,21.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,20.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,inpatient,1,UN,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,inpatient,0.2,ML,31.40000,18.84000,United Healthcare,Commercial,,25.53,,,,,,,20.10,25.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,United Healthcare,Commercial,,25.53,,,,,,,6.29,25.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,inpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,12.35,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,inpatient,0.1,ML,67.75000,40.65000,United Healthcare,Commercial,,55.08,,,,,,,43.36,55.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,United Healthcare,Commercial,,55.08,,,,,,,13.56,55.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,inpatient,1,UN,29.80000,17.88000,United Healthcare,Commercial,,24.23,,,,,,,19.07,24.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,United Healthcare,Commercial,,24.23,,,,,,,5.97,24.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,inpatient,10,ML,1113.90000,668.34000,United Healthcare,Commercial,,905.60,,,,,,,335.28,905.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,United Healthcare,Commercial,,4.06,,,,,,,1.42,826.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,inpatient,20,ML,1830.00000,1098.00000,United Healthcare,Commercial,,1487.79,,,,,,,550.83,1487.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,United Healthcare,Commercial,,4.06,,,,,,,1.42,1358.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,inpatient,5.26,ML,316.10000,189.66000,United Healthcare,Commercial,,256.99,,,,,,,95.15,256.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,United Healthcare,Commercial,,8.05,,,,,,,7.39,234.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,inpatient,26.3,ML,474.30000,284.58000,United Healthcare,Commercial,,385.61,,,,,,,142.76,385.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,United Healthcare,Commercial,,8.05,,,,,,,7.39,352.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,inpatient,1,UN,95.75000,57.45000,United Healthcare,Commercial,,77.84,,,,,,,61.28,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,Commercial,,77.84,,,,,,,19.17,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,inpatient,1,UN,95.75000,57.45000,United Healthcare,Commercial,,77.84,,,,,,,61.28,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,Commercial,,77.84,,,,,,,19.17,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,inpatient,1,UN,710.25000,426.15000,United Healthcare,Commercial,,577.43,,,,,,,213.79,577.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,United Healthcare,Commercial,,0.42900,,,,,,,0.33040,527.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,inpatient,1,UN,28.75000,17.25000,United Healthcare,Commercial,,23.37,,,,,,,18.40,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,United Healthcare,Commercial,,23.37,,,,,,,5.76,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,inpatient,1,UN,23.45000,14.07000,United Healthcare,Commercial,,19.06,,,,,,,15.01,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,Commercial,,19.06,,,,,,,4.69,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,inpatient,1,UN,565.00000,339.00000,United Healthcare,Commercial,,459.35,,,,,,,361.60,459.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,United Healthcare,Commercial,,459.35,,,,,,,113.11,459.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,inpatient,1,UN,1198.35000,719.01000,United Healthcare,Commercial,,974.26,,,,,,,766.94,974.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,United Healthcare,Commercial,,974.26,,,,,,,239.91,974.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,inpatient,1,UN,4.10000,2.46000,United Healthcare,Commercial,,3.33,,,,,,,2.62,3.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,United Healthcare,Commercial,,3.33,,,,,,,0.82082,3.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,inpatient,1,UN,568.80000,341.28000,United Healthcare,Commercial,,462.43,,,,,,,171.21,462.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,United Healthcare,Commercial,,597.45,,,,,,,113.87,597.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,inpatient,100,ML,112.00000,67.20000,United Healthcare,Commercial,,91.06,,,,,,,33.71,91.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,United Healthcare,Commercial,,0.13200,,,,,,,0.09440,83.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,inpatient,100,ML,168.00000,100.80000,United Healthcare,Commercial,,136.58,,,,,,,50.57,136.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,United Healthcare,Commercial,,0.13200,,,,,,,0.09440,124.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,inpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,10.85,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,inpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,11.30,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,inpatient,1,UN,205.20000,123.12000,United Healthcare,Commercial,,166.83,,,,,,,131.33,166.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,United Healthcare,Commercial,,166.83,,,,,,,41.08,166.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,inpatient,1,UN,609.65000,365.79000,United Healthcare,Commercial,,495.65,,,,,,,183.50,495.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,United Healthcare,Commercial,,370.18,,,,,,,122.05,452.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,United Healthcare,Commercial,,52.03,,,,,,,19.26,52.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,United Healthcare,Commercial,,2.29,,,,,,,1.89,47.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,inpatient,1,UN,159.35000,95.61000,United Healthcare,Commercial,,129.55,,,,,,,47.96,129.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,United Healthcare,Commercial,,46.91,,,,,,,31.90,118.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,inpatient,1000,ML,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,51.84,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,inpatient,1000,ML,87.00000,52.20000,United Healthcare,Commercial,,70.73,,,,,,,55.68,70.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,United Healthcare,Commercial,,70.73,,,,,,,17.42,70.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,inpatient,1000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,174.72,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,inpatient,0.05,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,inpatient,425,GR,4.30000,2.58000,United Healthcare,Commercial,,3.50,,,,,,,2.75,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,United Healthcare,Commercial,,3.50,,,,,,,0.86086,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,inpatient,1,UN,21.10000,12.66000,United Healthcare,Commercial,,17.15,,,,,,,13.50,17.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,United Healthcare,Commercial,,17.15,,,,,,,4.22,17.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,11.26,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,inpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,10.78,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,inpatient,5,ML,28.75000,17.25000,United Healthcare,Commercial,,23.37,,,,,,,18.40,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,United Healthcare,Commercial,,23.37,,,,,,,5.76,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,inpatient,5,ML,28.75000,17.25000,United Healthcare,Commercial,,23.37,,,,,,,18.40,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,United Healthcare,Commercial,,23.37,,,,,,,5.76,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,inpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,11.07,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,inpatient,1,UN,30.00000,18.00000,United Healthcare,Commercial,,24.39,,,,,,,19.20,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,Commercial,,24.39,,,,,,,6.01,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,inpatient,1,ML,34.20000,20.52000,United Healthcare,Commercial,,27.80,,,,,,,10.29,27.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,United Healthcare,Commercial,,7.46,,,,,,,6.85,25.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,inpatient,45,GR,123.50000,74.10000,United Healthcare,Commercial,,100.41,,,,,,,79.04,100.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,United Healthcare,Commercial,,100.41,,,,,,,24.72,100.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,inpatient,1,UN,124.90000,74.94000,United Healthcare,Commercial,,101.54,,,,,,,79.94,101.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,United Healthcare,Commercial,,101.54,,,,,,,25.00,101.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,inpatient,10,ML,48.85000,29.31000,United Healthcare,Commercial,,39.72,,,,,,,31.26,39.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,United Healthcare,Commercial,,39.72,,,,,,,9.78,39.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,inpatient,15,ML,61.95000,37.17000,United Healthcare,Commercial,,50.37,,,,,,,39.65,50.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,United Healthcare,Commercial,,50.37,,,,,,,12.40,50.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,inpatient,5,ML,31.55000,18.93000,United Healthcare,Commercial,,25.65,,,,,,,20.19,25.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,United Healthcare,Commercial,,25.65,,,,,,,6.32,25.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,inpatient,15,ML,77.55000,46.53000,United Healthcare,Commercial,,63.05,,,,,,,49.63,63.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,United Healthcare,Commercial,,63.05,,,,,,,15.53,63.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,inpatient,1,UN,380.00000,228.00000,United Healthcare,Commercial,,308.94,,,,,,,114.38,308.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,United Healthcare,Commercial,,6.70,,,,,,,5.59,282.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,inpatient,3.5,GR,910.30000,546.18000,United Healthcare,Commercial,,740.07,,,,,,,582.59,740.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,United Healthcare,Commercial,,740.07,,,,,,,182.24,740.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,inpatient,2.5,ML,167.75000,100.65000,United Healthcare,Commercial,,136.38,,,,,,,107.36,136.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,United Healthcare,Commercial,,136.38,,,,,,,33.58,136.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,inpatient,5,ML,320.20000,192.12000,United Healthcare,Commercial,,260.32,,,,,,,204.93,260.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,United Healthcare,Commercial,,260.32,,,,,,,64.10,260.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,inpatient,10,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,56.45,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,inpatient,7.5,ML,604.05000,362.43000,United Healthcare,Commercial,,491.09,,,,,,,386.59,491.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,United Healthcare,Commercial,,491.09,,,,,,,120.93,491.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,25404.55000,15242.73000,United Healthcare,Commercial,,20653.90,,,,,,,7646.77,20653.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,United Healthcare,Commercial,,169.42,,,,,,,60.36,18855.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,inpatient,1,UN,1854.60000,1112.76000,United Healthcare,Commercial,,1507.79,,,,,,,558.23,1507.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,inpatient,1,UN,21.00000,12.60000,United Healthcare,Commercial,,17.07,,,,,,,13.44,17.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,United Healthcare,Commercial,,17.07,,,,,,,4.20,17.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,inpatient,1,UN,961.85000,577.11000,United Healthcare,Commercial,,781.98,,,,,,,289.52,781.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,713.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,inpatient,2.5,ML,24.95000,14.97000,United Healthcare,Commercial,,20.28,,,,,,,15.97,20.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,United Healthcare,Commercial,,20.28,,,,,,,4.99,20.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,inpatient,1,UN,84.65000,50.79000,United Healthcare,Commercial,,68.82,,,,,,,54.18,68.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Commercial,,68.82,,,,,,,16.95,68.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,inpatient,1,ML,36.05000,21.63000,United Healthcare,Commercial,,29.31,,,,,,,10.85,29.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,United Healthcare,Commercial,,0.33000,,,,,,,0.21240,26.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,inpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,11.07,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,inpatient,1,ML,1651.20000,990.72000,United Healthcare,Commercial,,1342.43,,,,,,,1056.77,1342.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,United Healthcare,Commercial,,1342.43,,,,,,,330.57,1342.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,14,ML,30285.20000,18171.12000,United Healthcare,Commercial,,24621.87,,,,,,,9115.85,24621.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,United Healthcare,Commercial,,45.99,,,,,,,16.51,22477.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,11.20,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,inpatient,10,ML,31.65000,18.99000,United Healthcare,Commercial,,25.73,,,,,,,20.26,25.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,United Healthcare,Commercial,,25.73,,,,,,,6.34,25.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,inpatient,100,ML,53.35000,32.01000,United Healthcare,Commercial,,43.37,,,,,,,34.14,43.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,United Healthcare,Commercial,,43.37,,,,,,,10.68,43.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,inpatient,20,ML,38.05000,22.83000,United Healthcare,Commercial,,30.93,,,,,,,24.35,30.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,United Healthcare,Commercial,,30.93,,,,,,,7.62,30.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,inpatient,40,ML,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,11.42,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,inpatient,50,ML,48.10000,28.86000,United Healthcare,Commercial,,39.11,,,,,,,30.78,39.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,United Healthcare,Commercial,,39.11,,,,,,,9.63,39.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,inpatient,5,ML,72.05000,43.23000,United Healthcare,Commercial,,58.58,,,,,,,21.69,58.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,53.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,inpatient,1,UN,77.40000,46.44000,United Healthcare,Commercial,,62.93,,,,,,,49.54,62.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,United Healthcare,Commercial,,62.93,,,,,,,15.50,62.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,inpatient,20,ML,185.65000,111.39000,United Healthcare,Commercial,,150.93,,,,,,,55.88,150.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,United Healthcare,Commercial,,4.11,,,,,,,3.56,137.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,inpatient,10,ML,20.50000,12.30000,United Healthcare,Commercial,,16.67,,,,,,,13.12,16.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,United Healthcare,Commercial,,16.67,,,,,,,4.10,16.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,inpatient,1,UN,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,14.30,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,4.47,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,inpatient,1,UN,22.30000,13.38000,United Healthcare,Commercial,,18.13,,,,,,,14.27,18.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,United Healthcare,Commercial,,18.13,,,,,,,4.46,18.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,inpatient,2,ML,320.55000,192.33000,United Healthcare,Commercial,,260.61,,,,,,,96.49,260.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,United Healthcare,Commercial,,6.15,,,,,,,6.15,237.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,inpatient,40,ML,438.00000,262.80000,United Healthcare,Commercial,,356.09,,,,,,,131.84,356.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,United Healthcare,Commercial,,6.15,,,,,,,6.15,325.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,United Healthcare,Commercial,,12876.82,,,,,,,4767.43,12876.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,Commercial,,149.99,,,,,,,53.98,11755.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,inpatient,1,UN,107.45000,64.47000,United Healthcare,Commercial,,87.36,,,,,,,68.77,87.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,United Healthcare,Commercial,,87.36,,,,,,,21.51,87.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,inpatient,1,ML,2063.50000,1238.10000,United Healthcare,Commercial,,1677.63,,,,,,,1320.64,1677.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,United Healthcare,Commercial,,1677.63,,,,,,,413.11,1677.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,inpatient,5,ML,2746.00000,1647.60000,United Healthcare,Commercial,,2232.50,,,,,,,1757.44,2232.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,United Healthcare,Commercial,,2232.50,,,,,,,549.75,2232.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,7.93,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,22.13,,,,,,,5.28,22.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,inpatient,10,ML,196.20000,117.72000,United Healthcare,Commercial,,159.51,,,,,,,125.57,159.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,United Healthcare,Commercial,,159.51,,,,,,,39.28,159.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,inpatient,0.25,ML,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,11.58,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,inpatient,1,UN,2.70000,1.62000,United Healthcare,Commercial,,2.20,,,,,,,1.73,2.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,United Healthcare,Commercial,,2.20,,,,,,,0.54054,2.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,inpatient,1,UN,60.00000,36.00000,United Healthcare,Commercial,,48.78,,,,,,,18.06,48.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,United Healthcare,Commercial,,42.98,,,,,,,12.01,44.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,inpatient,50,ML,32.20000,19.32000,United Healthcare,Commercial,,26.18,,,,,,,9.69,26.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,23.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,inpatient,2.5,ML,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,inpatient,0.5,ML,22.30000,13.38000,United Healthcare,Commercial,,18.13,,,,,,,6.71,18.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,United Healthcare,Commercial,,10.89,,,,,,,4.46,21.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,inpatient,30,ML,87.55000,52.53000,United Healthcare,Commercial,,71.18,,,,,,,26.35,71.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,64.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,inpatient,25,ML,115.20000,69.12000,United Healthcare,Commercial,,93.66,,,,,,,73.73,93.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,United Healthcare,Commercial,,93.66,,,,,,,23.06,93.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,inpatient,10,ML,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.83200,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,inpatient,10,ML,49.70000,29.82000,United Healthcare,Commercial,,40.41,,,,,,,31.81,40.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,United Healthcare,Commercial,,40.41,,,,,,,9.95,40.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,inpatient,5,ML,36.10000,21.66000,United Healthcare,Commercial,,29.35,,,,,,,23.10,29.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,United Healthcare,Commercial,,29.35,,,,,,,7.23,29.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,inpatient,10,ML,147.95000,88.77000,United Healthcare,Commercial,,120.28,,,,,,,44.53,120.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,United Healthcare,Commercial,,0.11550,,,,,,,0.07080,109.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,inpatient,5,ML,1.55000,0.93000,United Healthcare,Commercial,,1.26,,,,,,,0.99200,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,United Healthcare,Commercial,,1.26,,,,,,,0.31031,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,inpatient,5,ML,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,inpatient,1,UN,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,inpatient,1,ML,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,10.46,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,inpatient,1,UN,207.05000,124.23000,United Healthcare,Commercial,,168.33,,,,,,,132.51,168.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,United Healthcare,Commercial,,168.33,,,,,,,41.45,168.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,inpatient,5,ML,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,14.50,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,inpatient,1,UN,24.60000,14.76000,United Healthcare,Commercial,,20.00,,,,,,,15.74,20.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,United Healthcare,Commercial,,20.00,,,,,,,4.92,20.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,inpatient,1,ML,32.10000,19.26000,United Healthcare,Commercial,,26.10,,,,,,,9.66,26.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,23.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,inpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,11.07,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,inpatient,2.5,ML,551.10000,330.66000,United Healthcare,Commercial,,448.04,,,,,,,352.70,448.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,United Healthcare,Commercial,,448.04,,,,,,,110.33,448.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,inpatient,10,ML,26.80000,16.08000,United Healthcare,Commercial,,21.79,,,,,,,8.07,21.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,19.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,inpatient,30,ML,23.95000,14.37000,United Healthcare,Commercial,,19.47,,,,,,,7.21,19.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,17.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,inpatient,50,ML,29.45000,17.67000,United Healthcare,Commercial,,23.94,,,,,,,8.86,23.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,21.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,inpatient,10,ML,43.10000,25.86000,United Healthcare,Commercial,,35.04,,,,,,,12.97,35.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,31.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,inpatient,30,ML,53.45000,32.07000,United Healthcare,Commercial,,43.45,,,,,,,16.09,43.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,39.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,inpatient,25,ML,60.85000,36.51000,United Healthcare,Commercial,,49.47,,,,,,,38.94,49.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,United Healthcare,Commercial,,49.47,,,,,,,12.18,49.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,inpatient,300,ML,178.50000,107.10000,United Healthcare,Commercial,,145.12,,,,,,,53.73,145.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,United Healthcare,Commercial,,9.45,,,,,,,8.43,132.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,inpatient,4,ML,508.10000,304.86000,United Healthcare,Commercial,,413.09,,,,,,,325.18,413.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,United Healthcare,Commercial,,413.09,,,,,,,101.72,413.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,inpatient,2,ML,53.10000,31.86000,United Healthcare,Commercial,,43.17,,,,,,,15.98,43.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,United Healthcare,Commercial,,1.37,,,,,,,1.13,39.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,inpatient,0.25,ML,24.70000,14.82000,United Healthcare,Commercial,,20.08,,,,,,,7.43,20.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,United Healthcare,Commercial,,3.60,,,,,,,3.26,18.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,United Healthcare,Commercial,,24.23,,,,,,,8.97,24.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,22.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,inpatient,3,ML,61.25000,36.75000,United Healthcare,Commercial,,49.80,,,,,,,39.20,49.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,United Healthcare,Commercial,,49.80,,,,,,,12.26,49.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,inpatient,3,ML,27.90000,16.74000,United Healthcare,Commercial,,22.68,,,,,,,17.86,22.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,United Healthcare,Commercial,,22.68,,,,,,,5.59,22.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,inpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,inpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,inpatient,10,ML,170.20000,102.12000,United Healthcare,Commercial,,138.37,,,,,,,51.23,138.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,United Healthcare,Commercial,,0.24750,,,,,,,0.16520,126.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,United Healthcare,Commercial,,290.44,,,,,,,107.53,290.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,United Healthcare,Commercial,,6.20,,,,,,,2.50,265.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,United Healthcare,Commercial,,939.87,,,,,,,347.97,939.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,United Healthcare,Commercial,,1.58,,,,,,,1.13,858.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,inpatient,50,GR,8.60000,5.16000,United Healthcare,Commercial,,6.99,,,,,,,5.50,6.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,United Healthcare,Commercial,,6.99,,,,,,,1.72,6.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,inpatient,114,GR,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,10.59,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,inpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,10.43,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,inpatient,5,ML,118261.70000,70957.02000,United Healthcare,Commercial,,96146.76,,,,,,,35596.77,96146.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,United Healthcare,Commercial,,77384.51,,,,,,,23675.99,87773.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,inpatient,5,ML,125.45000,75.27000,United Healthcare,Commercial,,101.99,,,,,,,80.29,101.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,United Healthcare,Commercial,,101.99,,,,,,,25.12,101.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,inpatient,50,ML,750.85000,450.51000,United Healthcare,Commercial,,610.44,,,,,,,480.54,610.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,United Healthcare,Commercial,,610.44,,,,,,,150.32,610.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,inpatient,118,ML,10.00000,6.00000,United Healthcare,Commercial,,8.13,,,,,,,6.40,8.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,United Healthcare,Commercial,,8.13,,,,,,,2.00,8.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,inpatient,236,ML,14.95000,8.97000,United Healthcare,Commercial,,12.15,,,,,,,9.57,12.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,United Healthcare,Commercial,,12.15,,,,,,,2.99,12.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,inpatient,100,ML,76.65000,45.99000,United Healthcare,Commercial,,62.32,,,,,,,23.07,62.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,United Healthcare,Commercial,,2.29,,,,,,,1.89,56.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,inpatient,500,ML,84.00000,50.40000,United Healthcare,Commercial,,68.29,,,,,,,53.76,68.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,United Healthcare,Commercial,,68.29,,,,,,,3.37,68.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,inpatient,14.1,GR,5.35000,3.21000,United Healthcare,Commercial,,4.35,,,,,,,3.42,4.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,United Healthcare,Commercial,,4.35,,,,,,,1.07,4.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,inpatient,2.5,ML,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,11.01,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,inpatient,1,ML,40.15000,24.09000,United Healthcare,Commercial,,32.64,,,,,,,12.09,32.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,United Healthcare,Commercial,,42.72,,,,,,,8.04,42.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,inpatient,1,ML,44.70000,26.82000,United Healthcare,Commercial,,36.34,,,,,,,13.45,36.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,United Healthcare,Commercial,,42.72,,,,,,,8.95,42.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,inpatient,0.75,ML,36.40000,21.84000,United Healthcare,Commercial,,29.59,,,,,,,10.96,29.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,United Healthcare,Commercial,,42.72,,,,,,,7.29,42.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,inpatient,1,UN,1052.35000,631.41000,United Healthcare,Commercial,,855.56,,,,,,,316.76,855.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,United Healthcare,Commercial,,8.50,,,,,,,7.69,781.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,inpatient,3,ML,5389.95000,3233.97000,United Healthcare,Commercial,,4382.03,,,,,,,3449.57,4382.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,United Healthcare,Commercial,,4382.03,,,,,,,1079.07,4382.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,inpatient,5,ML,3636.80000,2182.08000,United Healthcare,Commercial,,2956.72,,,,,,,1094.68,2956.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,United Healthcare,Commercial,,195.10,,,,,,,64.64,2699.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,inpatient,5,ML,33.10000,19.86000,United Healthcare,Commercial,,26.91,,,,,,,9.96,26.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,24.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,inpatient,1,UN,15765.00000,9459.00000,United Healthcare,Commercial,,12816.94,,,,,,,4745.27,12816.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,United Healthcare,Commercial,,249.73,,,,,,,88.98,11700.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,inpatient,1,UN,2.90000,1.74000,United Healthcare,Commercial,,2.36,,,,,,,1.86,2.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,United Healthcare,Commercial,,2.36,,,,,,,0.58058,2.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,inpatient,0.1,ML,21.05000,12.63000,United Healthcare,Commercial,,17.11,,,,,,,6.34,17.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,United Healthcare,Commercial,,6.20,,,,,,,2.50,15.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,inpatient,0.5,ML,430.80000,258.48000,United Healthcare,Commercial,,350.24,,,,,,,129.67,350.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,United Healthcare,Commercial,,355.72,,,,,,,86.25,417.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,inpatient,1,ML,236.50000,141.90000,United Healthcare,Commercial,,192.27,,,,,,,71.19,192.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,United Healthcare,Commercial,,191.61,,,,,,,47.35,196.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,inpatient,1,ML,64.90000,38.94000,United Healthcare,Commercial,,52.76,,,,,,,19.53,52.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,48.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,inpatient,50,ML,108.00000,64.80000,United Healthcare,Commercial,,87.80,,,,,,,32.51,87.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,United Healthcare,Commercial,,1.37,,,,,,,1.13,80.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,inpatient,3.5,GR,12.40000,7.44000,United Healthcare,Commercial,,10.08,,,,,,,7.94,10.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,United Healthcare,Commercial,,10.08,,,,,,,2.48,10.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,inpatient,0.5,ML,144.25000,86.55000,United Healthcare,Commercial,,117.28,,,,,,,43.42,117.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,United Healthcare,Commercial,,99.02,,,,,,,28.88,111.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,inpatient,500,ML,289.80000,173.88000,United Healthcare,Commercial,,235.61,,,,,,,185.47,235.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,United Healthcare,Commercial,,235.61,,,,,,,58.02,235.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,inpatient,1,ML,2673.70000,1604.22000,United Healthcare,Commercial,,2173.72,,,,,,,804.78,2173.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,United Healthcare,Commercial,,1571.01,,,,,,,535.27,1984.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,inpatient,1000,ML,87.50000,52.50000,United Healthcare,Commercial,,71.14,,,,,,,26.34,71.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,64.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,inpatient,44.3,ML,9.75000,5.85000,United Healthcare,Commercial,,7.93,,,,,,,6.24,7.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,United Healthcare,Commercial,,7.93,,,,,,,1.95,7.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,inpatient,50,ML,3336.40000,2001.84000,United Healthcare,Commercial,,2712.49,,,,,,,1004.26,2712.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,United Healthcare,Commercial,,2022.55,,,,,,,667.95,2476.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,inpatient,5,ML,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,15.14,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,inpatient,5,ML,30.90000,18.54000,United Healthcare,Commercial,,25.12,,,,,,,19.78,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,United Healthcare,Commercial,,25.12,,,,,,,6.19,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,United Healthcare,Commercial,,278.70,,,,,,,103.18,278.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,United Healthcare,Commercial,,21.40,,,,,,,19.40,254.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,inpatient,100,ML,818.20000,490.92000,United Healthcare,Commercial,,665.20,,,,,,,246.28,665.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,United Healthcare,Commercial,,665.20,,,,,,,2.76,665.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,inpatient,5,ML,319.70000,191.82000,United Healthcare,Commercial,,259.92,,,,,,,96.23,259.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,United Healthcare,Commercial,,7.41,,,,,,,7.13,237.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,inpatient,2,ML,984.90000,590.94000,United Healthcare,Commercial,,800.72,,,,,,,630.34,800.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,United Healthcare,Commercial,,800.72,,,,,,,137.63,800.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,inpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,20.41,,,,,,,16.06,20.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,20.41,,,,,,,5.03,20.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,inpatient,1,UN,1360.75000,816.45000,United Healthcare,Commercial,,1106.29,,,,,,,409.59,1106.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,United Healthcare,Commercial,,1341.05,,,,,,,272.42,1710.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,inpatient,10,ML,87.50000,52.50000,United Healthcare,Commercial,,71.14,,,,,,,26.34,71.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,United Healthcare,Commercial,,1.80,,,,,,,1.80,64.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,inpatient,5,ML,217.35000,130.41000,United Healthcare,Commercial,,176.71,,,,,,,139.10,176.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,United Healthcare,Commercial,,176.71,,,,,,,43.51,176.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,inpatient,5,ML,38.40000,23.04000,United Healthcare,Commercial,,31.22,,,,,,,11.56,31.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,United Healthcare,Commercial,,2.61,,,,,,,2.60,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,inpatient,5,ML,39.20000,23.52000,United Healthcare,Commercial,,31.87,,,,,,,25.09,31.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,United Healthcare,Commercial,,31.87,,,,,,,7.85,31.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,inpatient,6,ML,6247.80000,3748.68000,United Healthcare,Commercial,,5079.46,,,,,,,1880.59,5079.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,United Healthcare,Commercial,,24.75,,,,,,,7.71,4637.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,inpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,inpatient,1,UN,18.80000,11.28000,United Healthcare,Commercial,,15.28,,,,,,,12.03,15.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,United Healthcare,Commercial,,15.28,,,,,,,3.76,15.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,inpatient,1,UN,20.80000,12.48000,United Healthcare,Commercial,,16.91,,,,,,,13.31,16.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,United Healthcare,Commercial,,16.91,,,,,,,4.16,16.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,inpatient,11.6,ML,9504.40000,5702.64000,United Healthcare,Commercial,,7727.08,,,,,,,6082.82,7727.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,United Healthcare,Commercial,,7727.08,,,,,,,1878.77,7727.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,inpatient,10.15,ML,3.85000,2.31000,United Healthcare,Commercial,,3.13,,,,,,,2.46,3.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,United Healthcare,Commercial,,3.13,,,,,,,0.77077,3.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,inpatient,3,ML,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,36.96,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,United Healthcare,Commercial,,36.95,,,,,,,13.68,36.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,33.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,United Healthcare,Commercial,,51.58,,,,,,,19.10,51.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,47.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,inpatient,1,UN,262.00000,157.20000,United Healthcare,Commercial,,213.01,,,,,,,78.86,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,194.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,inpatient,1,UN,352.50000,211.50000,United Healthcare,Commercial,,286.58,,,,,,,106.10,286.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,261.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,inpatient,113,GR,10.85000,6.51000,United Healthcare,Commercial,,8.82,,,,,,,6.94,8.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,United Healthcare,Commercial,,8.82,,,,,,,2.17,8.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,inpatient,50,ML,298.60000,179.16000,United Healthcare,Commercial,,242.76,,,,,,,191.10,242.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,United Healthcare,Commercial,,242.76,,,,,,,59.78,242.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,inpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,inpatient,15,ML,1.65000,0.99000,United Healthcare,Commercial,,1.34,,,,,,,1.06,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,United Healthcare,Commercial,,1.34,,,,,,,0.33033,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,15,ML,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.89600,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,inpatient,15,ML,1.60000,0.96000,United Healthcare,Commercial,,1.30,,,,,,,1.02,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,United Healthcare,Commercial,,1.30,,,,,,,0.32032,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,inpatient,30,ML,46.30000,27.78000,United Healthcare,Commercial,,37.64,,,,,,,13.94,37.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,United Healthcare,Commercial,,12.39,,,,,,,5.14,34.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,inpatient,1,UN,218.65000,131.19000,United Healthcare,Commercial,,177.76,,,,,,,65.81,177.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,United Healthcare,Commercial,,57.72,,,,,,,43.77,162.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,inpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,inpatient,250,ML,179.40000,107.64000,United Healthcare,Commercial,,145.85,,,,,,,114.82,145.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,United Healthcare,Commercial,,145.85,,,,,,,35.92,145.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,99.80000,59.88000,United Healthcare,Commercial,,81.14,,,,,,,30.04,81.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,United Healthcare,Commercial,,4.24,,,,,,,2.17,74.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,inpatient,1,UN,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.83200,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,inpatient,50,ML,155.95000,93.57000,United Healthcare,Commercial,,126.79,,,,,,,46.94,126.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,United Healthcare,Commercial,,2.61,,,,,,,2.60,115.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,inpatient,5,ML,40.35000,24.21000,United Healthcare,Commercial,,32.80,,,,,,,25.82,32.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,United Healthcare,Commercial,,32.80,,,,,,,8.08,32.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,inpatient,1,UN,22.00000,13.20000,United Healthcare,Commercial,,17.89,,,,,,,6.62,17.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,Commercial,,0.41250,,,,,,,0.40120,16.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,inpatient,1,ML,64.75000,38.85000,United Healthcare,Commercial,,52.64,,,,,,,19.49,52.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,United Healthcare,Commercial,,713.92,,,,,,,12.96,731.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,inpatient,200,ML,11976.20000,7185.72000,United Healthcare,Commercial,,9736.65,,,,,,,3604.84,9736.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,United Healthcare,Commercial,,130.76,,,,,,,47.49,8888.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,inpatient,4,ML,57.65000,34.59000,United Healthcare,Commercial,,46.87,,,,,,,36.90,46.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,United Healthcare,Commercial,,46.87,,,,,,,11.54,46.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,inpatient,0.5,ML,34.20000,20.52000,United Healthcare,Commercial,,27.80,,,,,,,10.29,27.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,25.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,inpatient,250,ML,80.50000,48.30000,United Healthcare,Commercial,,65.45,,,,,,,24.23,65.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,United Healthcare,Commercial,,1.39,,,,,,,1.01,59.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,inpatient,0.25,ML,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,7.12,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,United Healthcare,Commercial,,1.67,,,,,,,1.44,17.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,inpatient,1,UN,9718.80000,5831.28000,United Healthcare,Commercial,,7901.38,,,,,,,2925.36,7901.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,United Healthcare,Commercial,,423.13,,,,,,,171.16,7213.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,inpatient,1,UN,249.90000,149.94000,United Healthcare,Commercial,,203.17,,,,,,,75.22,203.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,United Healthcare,Commercial,,44.10,,,,,,,38.23,185.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,inpatient,8,ML,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.83200,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,inpatient,8,ML,7.35000,4.41000,United Healthcare,Commercial,,5.98,,,,,,,4.70,5.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,United Healthcare,Commercial,,5.98,,,,,,,1.47,5.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,inpatient,250,ML,137.85000,82.71000,United Healthcare,Commercial,,112.07,,,,,,,41.49,112.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,102.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,inpatient,5,ML,18.50000,11.10000,United Healthcare,Commercial,,15.04,,,,,,,11.84,15.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,United Healthcare,Commercial,,15.04,,,,,,,3.70,15.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,inpatient,10,ML,80.75000,48.45000,United Healthcare,Commercial,,65.65,,,,,,,51.68,65.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,United Healthcare,Commercial,,65.65,,,,,,,16.17,65.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,inpatient,10,ML,86.00000,51.60000,United Healthcare,Commercial,,69.92,,,,,,,55.04,69.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,United Healthcare,Commercial,,69.92,,,,,,,17.22,69.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,inpatient,250,ML,180.00000,108.00000,United Healthcare,Commercial,,146.34,,,,,,,115.20,146.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,United Healthcare,Commercial,,146.34,,,,,,,36.04,146.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,inpatient,250,ML,97.15000,58.29000,United Healthcare,Commercial,,78.98,,,,,,,62.18,78.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,United Healthcare,Commercial,,78.98,,,,,,,19.45,78.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,United Healthcare,Commercial,,15814.35,,,,,,,5855.01,15814.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,Commercial,,206.53,,,,,,,73.58,14437.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,inpatient,10,ML,159.05000,95.43000,United Healthcare,Commercial,,129.31,,,,,,,101.79,129.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,United Healthcare,Commercial,,129.31,,,,,,,31.84,129.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,inpatient,10,ML,93.85000,56.31000,United Healthcare,Commercial,,76.30,,,,,,,28.25,76.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,United Healthcare,Commercial,,0.11550,,,,,,,0.07080,69.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,inpatient,0.25,ML,70.45000,42.27000,United Healthcare,Commercial,,57.28,,,,,,,21.21,57.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,United Healthcare,Commercial,,0.19800,,,,,,,0.19800,52.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,5,ML,74.35000,44.61000,United Healthcare,Commercial,,60.45,,,,,,,22.38,60.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,55.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,inpatient,5,ML,74.35000,44.61000,United Healthcare,Commercial,,60.45,,,,,,,22.38,60.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,55.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,inpatient,5,ML,84.05000,50.43000,United Healthcare,Commercial,,68.33,,,,,,,25.30,68.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,62.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,11.26,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,inpatient,60,GR,11.80000,7.08000,United Healthcare,Commercial,,9.59,,,,,,,7.55,9.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,United Healthcare,Commercial,,9.59,,,,,,,2.36,9.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,inpatient,1,UN,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,11.55,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,inpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,11.30,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,inpatient,1,UN,24.10000,14.46000,United Healthcare,Commercial,,19.59,,,,,,,15.42,19.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,United Healthcare,Commercial,,19.59,,,,,,,4.82,19.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,inpatient,15,ML,11.05000,6.63000,United Healthcare,Commercial,,8.98,,,,,,,7.07,8.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,United Healthcare,Commercial,,8.98,,,,,,,2.21,8.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,inpatient,1,UN,8199.90000,4919.94000,United Healthcare,Commercial,,6666.52,,,,,,,2468.17,6666.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,United Healthcare,Commercial,,4729.26,,,,,,,1641.62,6085.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,inpatient,1,UN,20.15000,12.09000,United Healthcare,Commercial,,16.38,,,,,,,12.90,16.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,United Healthcare,Commercial,,16.38,,,,,,,4.03,16.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,inpatient,1,UN,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,10.72,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,inpatient,1,UN,61.70000,37.02000,United Healthcare,Commercial,,50.16,,,,,,,39.49,50.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,United Healthcare,Commercial,,50.16,,,,,,,12.35,50.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,inpatient,500,ML,373.50000,224.10000,United Healthcare,Commercial,,303.66,,,,,,,239.04,303.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,United Healthcare,Commercial,,303.66,,,,,,,74.77,303.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,inpatient,1,ML,385.00000,231.00000,United Healthcare,Commercial,,313.00,,,,,,,115.89,313.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,United Healthcare,Commercial,,5.33,,,,,,,5.33,285.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,inpatient,35,ML,192.55000,115.53000,United Healthcare,Commercial,,156.54,,,,,,,123.23,156.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,United Healthcare,Commercial,,156.54,,,,,,,38.55,156.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,inpatient,1,UN,70.35000,42.21000,United Healthcare,Commercial,,57.19,,,,,,,21.18,57.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,United Healthcare,Commercial,,2.29,,,,,,,1.89,52.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,inpatient,1,UN,66.30000,39.78000,United Healthcare,Commercial,,53.90,,,,,,,19.96,53.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,United Healthcare,Commercial,,2.29,,,,,,,1.89,49.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,inpatient,10,ML,91.00000,54.60000,United Healthcare,Commercial,,73.98,,,,,,,58.24,73.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,United Healthcare,Commercial,,73.98,,,,,,,18.22,73.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,inpatient,1,UN,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,10.72,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,inpatient,1,UN,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,10.72,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,inpatient,1,UN,22.25000,13.35000,United Healthcare,Commercial,,18.09,,,,,,,14.24,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,Commercial,,18.09,,,,,,,4.45,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,inpatient,1,UN,29.30000,17.58000,United Healthcare,Commercial,,23.82,,,,,,,8.82,23.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,United Healthcare,Commercial,,6.24,,,,,,,4.37,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,inpatient,1,UN,18.15000,10.89000,United Healthcare,Commercial,,14.76,,,,,,,11.62,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,Commercial,,14.76,,,,,,,3.63,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,inpatient,1,UN,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,10.46,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,inpatient,250,ML,112.90000,67.74000,United Healthcare,Commercial,,91.79,,,,,,,33.98,91.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,United Healthcare,Commercial,,1.80,,,,,,,1.80,83.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,inpatient,250,ML,132.15000,79.29000,United Healthcare,Commercial,,107.44,,,,,,,39.78,107.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,United Healthcare,Commercial,,1.80,,,,,,,1.80,98.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,inpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.89600,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,inpatient,250,ML,90.15000,54.09000,United Healthcare,Commercial,,73.29,,,,,,,27.14,73.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,66.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,inpatient,5,ML,148.65000,89.19000,United Healthcare,Commercial,,120.85,,,,,,,95.14,120.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,United Healthcare,Commercial,,120.85,,,,,,,29.76,120.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,inpatient,30,ML,44.55000,26.73000,United Healthcare,Commercial,,36.22,,,,,,,28.51,36.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,United Healthcare,Commercial,,36.22,,,,,,,8.92,36.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,inpatient,50,ML,104.30000,62.58000,United Healthcare,Commercial,,84.80,,,,,,,66.75,84.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,United Healthcare,Commercial,,84.80,,,,,,,20.88,84.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,inpatient,5,ML,20.25000,12.15000,United Healthcare,Commercial,,16.46,,,,,,,12.96,16.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,United Healthcare,Commercial,,16.46,,,,,,,4.05,16.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,5.37,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,0.42900,,,,,,,0.37760,13.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,inpatient,250,ML,346.00000,207.60000,United Healthcare,Commercial,,281.30,,,,,,,221.44,281.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,United Healthcare,Commercial,,281.30,,,,,,,69.27,281.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,inpatient,1,UN,1263.90000,758.34000,United Healthcare,Commercial,,1027.55,,,,,,,380.43,1027.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,United Healthcare,Commercial,,87.37,,,,,,,61.17,938.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,inpatient,1,UN,23.05000,13.83000,United Healthcare,Commercial,,18.74,,,,,,,14.75,18.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,United Healthcare,Commercial,,18.74,,,,,,,4.61,18.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,inpatient,20,ML,452.80000,271.68000,United Healthcare,Commercial,,368.13,,,,,,,136.29,368.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,United Healthcare,Commercial,,1.25,,,,,,,1.25,336.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,inpatient,30,ML,907.80000,544.68000,United Healthcare,Commercial,,738.04,,,,,,,273.25,738.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,United Healthcare,Commercial,,1.25,,,,,,,1.25,673.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,15,ML,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,inpatient,15,ML,1.70000,1.02000,United Healthcare,Commercial,,1.38,,,,,,,1.09,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,United Healthcare,Commercial,,1.38,,,,,,,0.34034,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,inpatient,30,ML,8.90000,5.34000,United Healthcare,Commercial,,7.24,,,,,,,5.70,7.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,United Healthcare,Commercial,,7.24,,,,,,,1.78,7.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,inpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,14.72,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,inpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,11.90,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,inpatient,3.7,ML,240.65000,144.39000,United Healthcare,Commercial,,195.65,,,,,,,154.02,195.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,United Healthcare,Commercial,,195.65,,,,,,,48.18,195.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,inpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,10.40,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,inpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,10.59,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,inpatient,22.5,ML,94.55000,56.73000,United Healthcare,Commercial,,76.87,,,,,,,60.51,76.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,United Healthcare,Commercial,,76.87,,,,,,,18.93,76.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,inpatient,1,ML,28.30000,16.98000,United Healthcare,Commercial,,23.01,,,,,,,8.52,23.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,United Healthcare,Commercial,,29.37,,,,,,,5.67,29.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,inpatient,250,ML,134.75000,80.85000,United Healthcare,Commercial,,109.55,,,,,,,40.56,109.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,United Healthcare,Commercial,,3.86,,,,,,,3.52,100.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,250,ML,141.75000,85.05000,United Healthcare,Commercial,,115.24,,,,,,,42.67,115.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,United Healthcare,Commercial,,3.86,,,,,,,3.52,105.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,inpatient,1,UN,43.75000,26.25000,United Healthcare,Commercial,,35.57,,,,,,,28.00,35.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,United Healthcare,Commercial,,35.57,,,,,,,8.76,35.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,inpatient,240,ML,348.65000,209.19000,United Healthcare,Commercial,,283.45,,,,,,,223.14,283.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,United Healthcare,Commercial,,283.45,,,,,,,69.80,283.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,inpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,14.72,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,inpatient,1,ML,20.95000,12.57000,United Healthcare,Commercial,,17.03,,,,,,,6.31,17.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,United Healthcare,Commercial,,0.11550,,,,,,,0.02360,15.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,inpatient,1,ML,18.75000,11.25000,United Healthcare,Commercial,,15.24,,,,,,,5.64,15.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,United Healthcare,Commercial,,0.11550,,,,,,,0.02360,13.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,inpatient,250,ML,141.75000,85.05000,United Healthcare,Commercial,,115.24,,,,,,,42.67,115.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,United Healthcare,Commercial,,21.73,,,,,,,16.71,105.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,inpatient,250,ML,164.50000,98.70000,United Healthcare,Commercial,,133.74,,,,,,,49.51,133.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,United Healthcare,Commercial,,21.73,,,,,,,16.71,122.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,inpatient,1000,ML,175.00000,105.00000,United Healthcare,Commercial,,142.28,,,,,,,112.00,142.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,United Healthcare,Commercial,,142.28,,,,,,,35.03,142.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,inpatient,473,ML,3.20000,1.92000,United Healthcare,Commercial,,2.60,,,,,,,2.05,2.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,United Healthcare,Commercial,,2.60,,,,,,,0.64064,2.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,United Healthcare,Commercial,,82.52,,,,,,,30.55,82.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,75.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,inpatient,30,ML,124.00000,74.40000,United Healthcare,Commercial,,100.81,,,,,,,79.36,100.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,United Healthcare,Commercial,,100.81,,,,,,,24.82,100.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,inpatient,15,ML,124.00000,74.40000,United Healthcare,Commercial,,100.81,,,,,,,79.36,100.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,United Healthcare,Commercial,,100.81,,,,,,,24.82,100.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,inpatient,100,ML,91.70000,55.02000,United Healthcare,Commercial,,74.55,,,,,,,27.60,74.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,United Healthcare,Commercial,,1.37,,,,,,,1.13,68.06,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,inpatient,5,ML,79.70000,47.82000,United Healthcare,Commercial,,64.80,,,,,,,51.01,64.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,United Healthcare,Commercial,,64.80,,,,,,,15.96,64.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,inpatient,20,ML,471.00000,282.60000,United Healthcare,Commercial,,382.92,,,,,,,301.44,382.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,United Healthcare,Commercial,,382.92,,,,,,,94.29,382.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,inpatient,1,UN,26.20000,15.72000,United Healthcare,Commercial,,21.30,,,,,,,16.77,21.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,United Healthcare,Commercial,,21.30,,,,,,,5.25,21.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,United Healthcare,Commercial,,18.86,,,,,,,14.85,18.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,United Healthcare,Commercial,,18.86,,,,,,,4.64,18.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,inpatient,1,UN,23.50000,14.10000,United Healthcare,Commercial,,19.11,,,,,,,15.04,19.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,United Healthcare,Commercial,,19.11,,,,,,,4.70,19.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,inpatient,1,UN,22.50000,13.50000,United Healthcare,Commercial,,18.29,,,,,,,14.40,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,Commercial,,18.29,,,,,,,4.50,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,inpatient,1,UN,22.60000,13.56000,United Healthcare,Commercial,,18.37,,,,,,,14.46,18.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,United Healthcare,Commercial,,18.37,,,,,,,4.52,18.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,inpatient,1,UN,13881.15000,8328.69000,United Healthcare,Commercial,,11285.37,,,,,,,4178.23,11285.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,United Healthcare,Commercial,,1998.73,,,,,,,711.66,10302.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,inpatient,1,UN,303.80000,182.28000,United Healthcare,Commercial,,246.99,,,,,,,194.43,246.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,United Healthcare,Commercial,,246.99,,,,,,,60.82,246.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,inpatient,28.4,GR,4.25000,2.55000,United Healthcare,Commercial,,3.46,,,,,,,2.72,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,United Healthcare,Commercial,,3.46,,,,,,,0.85085,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,inpatient,1,UN,56.45000,33.87000,United Healthcare,Commercial,,45.89,,,,,,,36.13,45.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,United Healthcare,Commercial,,45.89,,,,,,,11.30,45.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,inpatient,1,UN,56.45000,33.87000,United Healthcare,Commercial,,45.89,,,,,,,36.13,45.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,United Healthcare,Commercial,,45.89,,,,,,,11.30,45.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,inpatient,1,UN,4065.55000,2439.33000,United Healthcare,Commercial,,3305.29,,,,,,,1223.73,3305.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,United Healthcare,Commercial,,3304.19,,,,,,,813.92,3304.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,inpatient,20,ML,113.05000,67.83000,United Healthcare,Commercial,,91.91,,,,,,,34.03,91.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,83.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,inpatient,20,ML,117.85000,70.71000,United Healthcare,Commercial,,95.81,,,,,,,35.47,95.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,87.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,inpatient,1,UN,17829.40000,10697.64000,United Healthcare,Commercial,,14495.30,,,,,,,5366.65,14495.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,United Healthcare,Commercial,,113.93,,,,,,,40.90,13232.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,inpatient,1,UN,28362.00000,17017.20000,United Healthcare,Commercial,,23058.31,,,,,,,8536.96,23058.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,United Healthcare,Commercial,,113.93,,,,,,,40.90,21050.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,United Healthcare,Commercial,,53.13,,,,,,,19.67,53.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,United Healthcare,Commercial,,3.35,,,,,,,2.88,48.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,inpatient,118,ML,6.15000,3.69000,United Healthcare,Commercial,,5.00,,,,,,,3.94,5.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,United Healthcare,Commercial,,5.00,,,,,,,1.23,5.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,inpatient,1,ML,147.45000,88.47000,United Healthcare,Commercial,,119.88,,,,,,,44.38,119.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,United Healthcare,Commercial,,73.71,,,,,,,29.52,109.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,inpatient,1,UN,25.05000,15.03000,United Healthcare,Commercial,,20.37,,,,,,,16.03,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,United Healthcare,Commercial,,20.37,,,,,,,5.02,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,inpatient,1,UN,41.50000,24.90000,United Healthcare,Commercial,,33.74,,,,,,,26.56,33.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,United Healthcare,Commercial,,33.74,,,,,,,8.31,33.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,inpatient,1,UN,23.70000,14.22000,United Healthcare,Commercial,,19.27,,,,,,,15.17,19.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,United Healthcare,Commercial,,19.27,,,,,,,4.74,19.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,inpatient,1,UN,19.20000,11.52000,United Healthcare,Commercial,,15.61,,,,,,,12.29,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,Commercial,,15.61,,,,,,,3.84,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,inpatient,0.5,ML,161.50000,96.90000,United Healthcare,Commercial,,131.30,,,,,,,48.61,131.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,United Healthcare,Commercial,,108.11,,,,,,,32.33,128.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,82.17,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,United Healthcare,Commercial,,14.16,,,,,,,11.94,202.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,inpatient,1,UN,486.70000,292.02000,United Healthcare,Commercial,,395.69,,,,,,,311.49,395.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,United Healthcare,Commercial,,395.69,,,,,,,97.44,395.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,inpatient,10,ML,97.90000,58.74000,United Healthcare,Commercial,,79.59,,,,,,,29.47,79.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,United Healthcare,Commercial,,4.32,,,,,,,1.82,72.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,inpatient,3.75,ML,94.25000,56.55000,United Healthcare,Commercial,,76.63,,,,,,,60.32,76.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,United Healthcare,Commercial,,76.63,,,,,,,18.87,76.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,inpatient,1,UN,4576.00000,2745.60000,United Healthcare,Commercial,,3720.29,,,,,,,1377.38,3720.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,United Healthcare,Commercial,,3718.93,,,,,,,916.12,3718.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,inpatient,3000,ML,153.00000,91.80000,United Healthcare,Commercial,,124.39,,,,,,,97.92,124.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,United Healthcare,Commercial,,124.39,,,,,,,30.63,124.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,inpatient,1,ML,24.05000,14.43000,United Healthcare,Commercial,,19.55,,,,,,,15.39,19.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,United Healthcare,Commercial,,19.55,,,,,,,4.81,19.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,inpatient,57,GR,4.80000,2.88000,United Healthcare,Commercial,,3.90,,,,,,,3.07,3.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,United Healthcare,Commercial,,3.90,,,,,,,0.96096,3.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,inpatient,1,UN,326.05000,195.63000,United Healthcare,Commercial,,265.08,,,,,,,208.67,265.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,United Healthcare,Commercial,,265.08,,,,,,,65.28,265.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,inpatient,1,UN,84.60000,50.76000,United Healthcare,Commercial,,68.78,,,,,,,54.14,68.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,United Healthcare,Commercial,,68.78,,,,,,,16.94,68.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,inpatient,1,UN,84.60000,50.76000,United Healthcare,Commercial,,68.78,,,,,,,54.14,68.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,United Healthcare,Commercial,,68.78,,,,,,,16.94,68.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,inpatient,1,UN,643.15000,385.89000,United Healthcare,Commercial,,522.88,,,,,,,411.62,522.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,United Healthcare,Commercial,,522.88,,,,,,,128.76,522.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,inpatient,1,UN,643.15000,385.89000,United Healthcare,Commercial,,522.88,,,,,,,411.62,522.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,United Healthcare,Commercial,,522.88,,,,,,,128.76,522.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,inpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,11.01,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,inpatient,1,UN,549.95000,329.97000,United Healthcare,Commercial,,447.11,,,,,,,165.53,447.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,United Healthcare,Commercial,,56.91,,,,,,,50.79,408.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,United Healthcare,Commercial,,21.22,,,,,,,7.86,21.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,19.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,inpatient,0.5,ML,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,6.73,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,16.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,inpatient,1,UN,1.85000,1.11000,United Healthcare,Commercial,,1.50,,,,,,,1.18,1.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,United Healthcare,Commercial,,1.50,,,,,,,0.37037,1.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,inpatient,1,UN,84.10000,50.46000,United Healthcare,Commercial,,68.37,,,,,,,53.82,68.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,United Healthcare,Commercial,,68.37,,,,,,,16.84,68.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,inpatient,1,UN,324.35000,194.61000,United Healthcare,Commercial,,263.70,,,,,,,97.63,263.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,United Healthcare,Commercial,,8.05,,,,,,,7.39,240.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,inpatient,1,UN,493.50000,296.10000,United Healthcare,Commercial,,401.22,,,,,,,148.54,401.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,United Healthcare,Commercial,,8.05,,,,,,,7.39,366.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,inpatient,1,UN,20.45000,12.27000,United Healthcare,Commercial,,16.63,,,,,,,13.09,16.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,United Healthcare,Commercial,,16.63,,,,,,,4.09,16.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,inpatient,1,UN,357.15000,214.29000,United Healthcare,Commercial,,290.36,,,,,,,228.58,290.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,United Healthcare,Commercial,,290.36,,,,,,,71.50,290.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,inpatient,1,UN,527.70000,316.62000,United Healthcare,Commercial,,429.02,,,,,,,337.73,429.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,United Healthcare,Commercial,,429.02,,,,,,,105.65,429.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,inpatient,1,UN,99.95000,59.97000,United Healthcare,Commercial,,81.26,,,,,,,63.97,81.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,United Healthcare,Commercial,,81.26,,,,,,,20.01,81.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,inpatient,1,UN,99.95000,59.97000,United Healthcare,Commercial,,81.26,,,,,,,63.97,81.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,United Healthcare,Commercial,,81.26,,,,,,,20.01,81.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,inpatient,1,UN,368.65000,221.19000,United Healthcare,Commercial,,299.71,,,,,,,235.94,299.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,United Healthcare,Commercial,,299.71,,,,,,,73.80,299.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,inpatient,5,ML,6392.40000,3835.44000,United Healthcare,Commercial,,5197.02,,,,,,,1924.11,5197.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,United Healthcare,Commercial,,835.26,,,,,,,299.42,4744.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,inpatient,1,ML,28.40000,17.04000,United Healthcare,Commercial,,23.09,,,,,,,8.55,23.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,United Healthcare,Commercial,,12.39,,,,,,,5.14,21.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,inpatient,10,ML,6878.50000,4127.10000,United Healthcare,Commercial,,5592.22,,,,,,,2070.43,5592.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,United Healthcare,Commercial,,202.69,,,,,,,72.13,5105.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,inpatient,50,ML,33292.40000,19975.44000,United Healthcare,Commercial,,27066.72,,,,,,,10021.01,27066.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,United Healthcare,Commercial,,202.69,,,,,,,72.13,24709.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,inpatient,1,UN,22.70000,13.62000,United Healthcare,Commercial,,18.46,,,,,,,14.53,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,Commercial,,18.46,,,,,,,4.54,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,inpatient,1,UN,55.00000,33.00000,United Healthcare,Commercial,,44.72,,,,,,,16.55,44.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,Commercial,,5.40,,,,,,,2.60,40.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,inpatient,1,UN,80.00000,48.00000,United Healthcare,Commercial,,65.04,,,,,,,24.08,65.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,United Healthcare,Commercial,,5.40,,,,,,,2.60,59.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,inpatient,1,UN,1.70000,1.02000,United Healthcare,Commercial,,1.38,,,,,,,1.09,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,United Healthcare,Commercial,,1.38,,,,,,,0.34034,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,United Healthcare,Commercial,,72.32,,,,,,,26.77,72.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Commercial,,5.82,,,,,,,2.08,66.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,inpatient,1,UN,39374.65000,23624.79000,United Healthcare,Commercial,,32011.59,,,,,,,11851.77,32011.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,United Healthcare,Commercial,,60.06,,,,,,,20.67,29223.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,inpatient,1,UN,8111.05000,4866.63000,United Healthcare,Commercial,,6594.28,,,,,,,2441.43,6594.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,United Healthcare,Commercial,,42.34,,,,,,,15.14,6020.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,inpatient,1,UN,88.95000,53.37000,United Healthcare,Commercial,,72.32,,,,,,,26.77,72.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Commercial,,5.82,,,,,,,2.08,66.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,inpatient,30,ML,381.35000,228.81000,United Healthcare,Commercial,,310.04,,,,,,,244.06,310.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,United Healthcare,Commercial,,310.04,,,,,,,76.35,310.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,inpatient,1,UN,75.60000,45.36000,United Healthcare,Commercial,,61.46,,,,,,,22.76,61.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,United Healthcare,Commercial,,1.20,,,,,,,0.99120,56.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,United Healthcare,Commercial,,71.38,,,,,,,26.43,71.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,United Healthcare,Commercial,,1.20,,,,,,,0.99120,65.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,inpatient,2,ML,2093.30000,1255.98000,United Healthcare,Commercial,,1701.85,,,,,,,630.08,1701.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,United Healthcare,Commercial,,24.75,,,,,,,7.71,1553.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,inpatient,1,UN,13983.35000,8390.01000,United Healthcare,Commercial,,11368.46,,,,,,,8949.34,11368.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,United Healthcare,Commercial,,11368.46,,,,,,,2799.47,11368.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,inpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,11.39,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,inpatient,10,ML,462.25000,277.35000,United Healthcare,Commercial,,375.81,,,,,,,139.14,375.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,343.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,inpatient,1,ML,1095.00000,657.00000,United Healthcare,Commercial,,890.24,,,,,,,329.60,890.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,United Healthcare,Commercial,,436.66,,,,,,,150.45,812.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,inpatient,1,UN,247.50000,148.50000,United Healthcare,Commercial,,201.22,,,,,,,158.40,201.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,United Healthcare,Commercial,,201.22,,,,,,,49.55,201.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,inpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,10.50,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,inpatient,1,UN,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,37.12,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,United Healthcare,Commercial,,31.50,,,,,,,11.66,31.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,United Healthcare,Commercial,,3.43,,,,,,,2.19,28.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,United Healthcare,Commercial,,31.50,,,,,,,11.66,31.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,United Healthcare,Commercial,,3.43,,,,,,,2.19,28.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,inpatient,1,UN,241.15000,144.69000,United Healthcare,Commercial,,196.05,,,,,,,154.34,196.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,United Healthcare,Commercial,,196.05,,,,,,,48.28,196.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,inpatient,1,UN,307.90000,184.74000,United Healthcare,Commercial,,250.32,,,,,,,197.06,250.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,United Healthcare,Commercial,,250.32,,,,,,,61.64,250.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,inpatient,1,UN,406.80000,244.08000,United Healthcare,Commercial,,330.73,,,,,,,260.35,330.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,United Healthcare,Commercial,,330.73,,,,,,,81.44,330.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,20101.26,,,,,,,7442.16,20101.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,444.35,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,inpatient,1,UN,809.35000,485.61000,United Healthcare,Commercial,,658.00,,,,,,,243.61,658.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,United Healthcare,Commercial,,24.85,,,,,,,8.80,600.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,inpatient,4,ML,6099.95000,3659.97000,United Healthcare,Commercial,,4959.26,,,,,,,1836.08,4959.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,United Healthcare,Commercial,,89.84,,,,,,,31.97,4527.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,inpatient,10,ML,14837.25000,8902.35000,United Healthcare,Commercial,,12062.68,,,,,,,4466.01,12062.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,United Healthcare,Commercial,,89.84,,,,,,,31.97,11012.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,inpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,10.37,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,inpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,10.40,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,inpatient,0.5,ML,731.15000,438.69000,United Healthcare,Commercial,,594.42,,,,,,,220.08,594.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,United Healthcare,Commercial,,774.28,,,,,,,146.38,774.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,inpatient,1,UN,39.50000,23.70000,United Healthcare,Commercial,,32.11,,,,,,,25.28,32.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,United Healthcare,Commercial,,32.11,,,,,,,7.91,32.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,inpatient,1,UN,47.70000,28.62000,United Healthcare,Commercial,,38.78,,,,,,,30.53,38.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,United Healthcare,Commercial,,38.78,,,,,,,9.55,38.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,inpatient,1,UN,54.55000,32.73000,United Healthcare,Commercial,,44.35,,,,,,,34.91,44.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,United Healthcare,Commercial,,44.35,,,,,,,10.92,44.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,inpatient,1,UN,77.70000,46.62000,United Healthcare,Commercial,,63.17,,,,,,,49.73,63.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,United Healthcare,Commercial,,63.17,,,,,,,15.56,63.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Commercial,,23754.15,,,,,,,8794.59,23754.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Commercial,,158.99,,,,,,,86.66,21685.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,4,ML,26225.00000,15735.00000,United Healthcare,Commercial,,21320.92,,,,,,,7893.73,21320.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,United Healthcare,Commercial,,159.42,,,,,,,58.48,19464.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,inpatient,1,UN,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,16.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,5.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,inpatient,1,UN,74.20000,44.52000,United Healthcare,Commercial,,60.32,,,,,,,47.49,60.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,United Healthcare,Commercial,,60.32,,,,,,,14.85,60.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,inpatient,1,UN,74.20000,44.52000,United Healthcare,Commercial,,60.32,,,,,,,47.49,60.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,United Healthcare,Commercial,,60.32,,,,,,,14.85,60.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,inpatient,20,ML,109.30000,65.58000,United Healthcare,Commercial,,88.86,,,,,,,69.95,88.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,United Healthcare,Commercial,,88.86,,,,,,,21.88,88.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,inpatient,250,ML,1780.00000,1068.00000,United Healthcare,Commercial,,1447.14,,,,,,,1139.20,1447.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,United Healthcare,Commercial,,1447.14,,,,,,,356.36,1447.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,inpatient,1,UN,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,36.96,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,inpatient,1,UN,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,36.96,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,inpatient,1,UN,21020.20000,12612.12000,United Healthcare,Commercial,,17089.42,,,,,,,6327.08,17089.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,United Healthcare,Commercial,,577.71,,,,,,,197.47,15601.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,inpatient,1,UN,31468.15000,18880.89000,United Healthcare,Commercial,,25583.61,,,,,,,9471.91,25583.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,United Healthcare,Commercial,,577.71,,,,,,,197.47,23355.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,inpatient,1,UN,16047.65000,9628.59000,United Healthcare,Commercial,,13046.74,,,,,,,4830.34,13046.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,United Healthcare,Commercial,,577.71,,,,,,,197.47,11910.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,inpatient,1,UN,1807.55000,1084.53000,United Healthcare,Commercial,,1469.54,,,,,,,544.07,1469.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,United Healthcare,Commercial,,285.73,,,,,,,101.59,1341.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,inpatient,1,UN,3746.95000,2248.17000,United Healthcare,Commercial,,3046.27,,,,,,,1127.83,3046.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,United Healthcare,Commercial,,3043.97,,,,,,,750.14,3043.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,inpatient,30,GR,8.10000,4.86000,United Healthcare,Commercial,,6.59,,,,,,,5.18,6.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,United Healthcare,Commercial,,6.59,,,,,,,1.62,6.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,inpatient,100,ML,94.50000,56.70000,United Healthcare,Commercial,,76.83,,,,,,,28.44,76.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,United Healthcare,Commercial,,2.29,,,,,,,1.89,70.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,inpatient,1,UN,486.70000,292.02000,United Healthcare,Commercial,,395.69,,,,,,,311.49,395.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,United Healthcare,Commercial,,395.69,,,,,,,97.44,395.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,inpatient,50,ML,3914.20000,2348.52000,United Healthcare,Commercial,,3182.24,,,,,,,1178.17,3182.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,United Healthcare,Commercial,,137.30,,,,,,,49.22,2905.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,inpatient,5,ML,84083.00000,50449.80000,United Healthcare,Commercial,,68359.48,,,,,,,25308.98,68359.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,United Healthcare,Commercial,,68359.48,,,,,,,16833.42,68359.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,inpatient,10,ML,1978.60000,1187.16000,United Healthcare,Commercial,,1608.60,,,,,,,595.56,1608.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,United Healthcare,Commercial,,131.82,,,,,,,47.56,1468.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,inpatient,2,ML,493.20000,295.92000,United Healthcare,Commercial,,400.97,,,,,,,148.45,400.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,United Healthcare,Commercial,,131.82,,,,,,,47.56,366.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,inpatient,1,UN,4629.40000,2777.64000,United Healthcare,Commercial,,3763.70,,,,,,,1393.45,3763.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,United Healthcare,Commercial,,222.44,,,,,,,76.44,3435.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,inpatient,1,UN,9181.80000,5509.08000,United Healthcare,Commercial,,7464.80,,,,,,,2763.72,7464.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,United Healthcare,Commercial,,222.44,,,,,,,76.44,6814.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,inpatient,1,UN,4571.50000,2742.90000,United Healthcare,Commercial,,3716.63,,,,,,,1376.02,3716.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,United Healthcare,Commercial,,53.94,,,,,,,19.38,3392.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,inpatient,1,UN,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,40.35,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,inpatient,1,UN,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,40.35,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,inpatient,1,UN,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,40.35,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,inpatient,0.8,ML,2013.40000,1208.04000,United Healthcare,Commercial,,1636.89,,,,,,,606.03,1636.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,United Healthcare,Commercial,,1.01,,,,,,,0.44620,1494.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,inpatient,0.5,ML,1264.35000,758.61000,United Healthcare,Commercial,,1027.92,,,,,,,380.57,1027.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,United Healthcare,Commercial,,1.01,,,,,,,0.44620,938.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,inpatient,1,UN,44.30000,26.58000,United Healthcare,Commercial,,36.02,,,,,,,13.33,36.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,Commercial,,4.98,,,,,,,4.32,32.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,inpatient,1,UN,129.20000,77.52000,United Healthcare,Commercial,,105.04,,,,,,,38.89,105.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,United Healthcare,Commercial,,4.98,,,,,,,4.32,95.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,inpatient,1,UN,47.00000,28.20000,United Healthcare,Commercial,,38.21,,,,,,,30.08,38.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,United Healthcare,Commercial,,38.21,,,,,,,9.41,38.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,inpatient,8,GR,84.20000,50.52000,United Healthcare,Commercial,,68.45,,,,,,,53.89,68.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,United Healthcare,Commercial,,68.45,,,,,,,16.86,68.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,United Healthcare,Commercial,,61.79,,,,,,,22.88,61.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,United Healthcare,Commercial,,0.46200,,,,,,,0.46200,56.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,inpatient,50,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,26.49,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,United Healthcare,Commercial,,0.46200,,,,,,,0.46200,65.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,inpatient,50,ML,10778.05000,6466.83000,United Healthcare,Commercial,,8762.55,,,,,,,3244.19,8762.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,inpatient,10,ML,13382.60000,8029.56000,United Healthcare,Commercial,,10880.05,,,,,,,4028.16,10880.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,United Healthcare,Commercial,,177.67,,,,,,,64.02,9932.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,inpatient,1,UN,44.60000,26.76000,United Healthcare,Commercial,,36.26,,,,,,,28.54,36.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,United Healthcare,Commercial,,36.26,,,,,,,8.93,36.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,inpatient,1,UN,44.60000,26.76000,United Healthcare,Commercial,,36.26,,,,,,,28.54,36.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,United Healthcare,Commercial,,36.26,,,,,,,8.93,36.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,inpatient,1,UN,57.50000,34.50000,United Healthcare,Commercial,,46.75,,,,,,,36.80,46.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,United Healthcare,Commercial,,46.75,,,,,,,11.51,46.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,inpatient,1,UN,16408.85000,9845.31000,United Healthcare,Commercial,,13340.40,,,,,,,4939.06,13340.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,United Healthcare,Commercial,,85.29,,,,,,,30.33,12178.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,inpatient,1,UN,578.15000,346.89000,United Healthcare,Commercial,,470.04,,,,,,,370.02,470.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,United Healthcare,Commercial,,470.04,,,,,,,115.75,470.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,inpatient,10,ML,97.75000,58.65000,United Healthcare,Commercial,,79.47,,,,,,,62.56,79.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,United Healthcare,Commercial,,79.47,,,,,,,19.57,79.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,inpatient,15,ML,147.30000,88.38000,United Healthcare,Commercial,,119.75,,,,,,,94.27,119.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,United Healthcare,Commercial,,119.75,,,,,,,29.49,119.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,inpatient,5,ML,59.50000,35.70000,United Healthcare,Commercial,,48.37,,,,,,,38.08,48.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,United Healthcare,Commercial,,48.37,,,,,,,11.91,48.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,inpatient,4,ML,11159.75000,6695.85000,United Healthcare,Commercial,,9072.88,,,,,,,3359.08,9072.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,United Healthcare,Commercial,,35.72,,,,,,,13.09,8282.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,inpatient,1,UN,1039.25000,623.55000,United Healthcare,Commercial,,844.91,,,,,,,665.12,844.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,United Healthcare,Commercial,,844.91,,,,,,,208.06,844.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,inpatient,2,ML,635.45000,381.27000,United Healthcare,Commercial,,516.62,,,,,,,406.69,516.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,United Healthcare,Commercial,,516.62,,,,,,,127.22,516.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,inpatient,120,ML,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,10.53,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,inpatient,1,UN,218.55000,131.13000,United Healthcare,Commercial,,177.68,,,,,,,139.87,177.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,United Healthcare,Commercial,,177.68,,,,,,,43.75,177.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,inpatient,1,UN,19.15000,11.49000,United Healthcare,Commercial,,15.57,,,,,,,12.26,15.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,United Healthcare,Commercial,,15.57,,,,,,,3.83,15.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,inpatient,3,ML,877.30000,526.38000,United Healthcare,Commercial,,713.24,,,,,,,264.07,713.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,651.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,inpatient,1,UN,19.60000,11.76000,United Healthcare,Commercial,,15.93,,,,,,,12.54,15.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,United Healthcare,Commercial,,15.93,,,,,,,3.92,15.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,inpatient,1,UN,4037.40000,2422.44000,United Healthcare,Commercial,,3282.41,,,,,,,1215.26,3282.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,United Healthcare,Commercial,,53.58,,,,,,,19.39,2996.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,inpatient,2,ML,1656.85000,994.11000,United Healthcare,Commercial,,1347.02,,,,,,,498.71,1347.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,United Healthcare,Commercial,,311.67,,,,,,,109.08,1229.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,inpatient,1,UN,309.65000,185.79000,United Healthcare,Commercial,,251.75,,,,,,,93.20,251.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,United Healthcare,Commercial,,194.04,,,,,,,61.99,229.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,inpatient,0.9996,UN,13510.90000,8106.54000,United Healthcare,Commercial,,10984.36,,,,,,,8646.98,10984.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,United Healthcare,Commercial,,10984.36,,,,,,,2704.88,10984.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,inpatient,1,UN,77.05000,46.23000,United Healthcare,Commercial,,62.64,,,,,,,49.31,62.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,United Healthcare,Commercial,,62.64,,,,,,,15.43,62.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,inpatient,1,UN,285.40000,171.24000,United Healthcare,Commercial,,232.03,,,,,,,182.66,232.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,United Healthcare,Commercial,,232.03,,,,,,,57.14,232.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,inpatient,1,UN,545.60000,327.36000,United Healthcare,Commercial,,443.57,,,,,,,349.18,443.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,United Healthcare,Commercial,,443.57,,,,,,,109.23,443.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,inpatient,1,UN,4647.20000,2788.32000,United Healthcare,Commercial,,3778.17,,,,,,,1398.81,3778.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,United Healthcare,Commercial,,3968.20,,,,,,,930.37,3968.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,inpatient,5,ML,211.40000,126.84000,United Healthcare,Commercial,,171.87,,,,,,,135.30,171.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,United Healthcare,Commercial,,171.87,,,,,,,42.32,171.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,inpatient,1,UN,95.65000,57.39000,United Healthcare,Commercial,,77.76,,,,,,,61.22,77.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,United Healthcare,Commercial,,77.76,,,,,,,19.15,77.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,inpatient,1,ML,148.15000,88.89000,United Healthcare,Commercial,,120.45,,,,,,,94.82,120.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,United Healthcare,Commercial,,120.45,,,,,,,29.66,120.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,United Healthcare,Commercial,,41681.05,,,,,,,15431.73,41681.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,Commercial,,247.80,,,,,,,88.60,38051.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,inpatient,1,UN,22.00000,13.20000,United Healthcare,Commercial,,17.89,,,,,,,14.08,17.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,Commercial,,17.89,,,,,,,4.40,17.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,inpatient,10.7,GR,1350.15000,810.09000,United Healthcare,Commercial,,1097.67,,,,,,,864.10,1097.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,United Healthcare,Commercial,,1097.67,,,,,,,270.30,1097.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,inpatient,1000,ML,122.50000,73.50000,United Healthcare,Commercial,,99.59,,,,,,,36.87,99.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,90.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,inpatient,150,ML,2747.20000,1648.32000,United Healthcare,Commercial,,2233.47,,,,,,,1758.21,2233.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,United Healthcare,Commercial,,2233.47,,,,,,,549.99,2233.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,inpatient,0.05,ML,61.35000,36.81000,United Healthcare,Commercial,,49.88,,,,,,,18.47,49.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,United Healthcare,Commercial,,4.98,,,,,,,1.78,45.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,inpatient,10,ML,1082.50000,649.50000,United Healthcare,Commercial,,880.07,,,,,,,325.83,880.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,United Healthcare,Commercial,,21.40,,,,,,,6.49,803.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,inpatient,2.5,ML,61.30000,36.78000,United Healthcare,Commercial,,49.84,,,,,,,39.23,49.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,United Healthcare,Commercial,,49.84,,,,,,,12.27,49.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,inpatient,40,ML,16023.00000,9613.80000,United Healthcare,Commercial,,13026.70,,,,,,,4822.92,13026.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,United Healthcare,Commercial,,108.44,,,,,,,38.64,11892.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,inpatient,10,ML,41.15000,24.69000,United Healthcare,Commercial,,33.45,,,,,,,12.39,33.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,30.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,inpatient,100,ML,191.65000,114.99000,United Healthcare,Commercial,,155.81,,,,,,,57.69,155.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,142.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,United Healthcare,Commercial,,53.86,,,,,,,19.94,53.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,49.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,inpatient,200,ML,367.30000,220.38000,United Healthcare,Commercial,,298.61,,,,,,,110.56,298.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,272.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,inpatient,15,ML,57.50000,34.50000,United Healthcare,Commercial,,46.75,,,,,,,17.31,46.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,42.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,inpatient,15,ML,34.25000,20.55000,United Healthcare,Commercial,,27.85,,,,,,,10.31,27.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,25.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,inpatient,15,ML,39.90000,23.94000,United Healthcare,Commercial,,32.44,,,,,,,12.01,32.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,29.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,inpatient,1,ML,89877.30000,53926.38000,United Healthcare,Commercial,,73070.24,,,,,,,27053.07,73070.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,United Healthcare,Commercial,,383.87,,,,,,,137.35,66706.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,inpatient,10,ML,9488.70000,5693.22000,United Healthcare,Commercial,,7714.31,,,,,,,2856.10,7714.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,United Healthcare,Commercial,,273.07,,,,,,,97.09,7042.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,10,ML,86755.05000,52053.03000,United Healthcare,Commercial,,70531.86,,,,,,,26113.27,70531.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,United Healthcare,Commercial,,162.54,,,,,,,57.63,64389.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,inpatient,1,UN,44.80000,26.88000,United Healthcare,Commercial,,36.42,,,,,,,28.67,36.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,United Healthcare,Commercial,,36.42,,,,,,,8.97,36.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,inpatient,1,UN,7132.10000,4279.26000,United Healthcare,Commercial,,5798.40,,,,,,,2146.76,5798.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,United Healthcare,Commercial,,207.41,,,,,,,72.78,5293.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,inpatient,1,UN,896.70000,538.02000,United Healthcare,Commercial,,729.02,,,,,,,573.89,729.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,United Healthcare,Commercial,,729.02,,,,,,,179.52,729.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,10,ML,19171.55000,11502.93000,United Healthcare,Commercial,,15586.47,,,,,,,5770.64,15586.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,United Healthcare,Commercial,,232.09,,,,,,,82.57,14229.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,inpatient,2.4,ML,4810.20000,2886.12000,United Healthcare,Commercial,,3910.69,,,,,,,1447.87,3910.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,United Healthcare,Commercial,,232.09,,,,,,,82.57,3570.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,inpatient,11.7,ML,29212.00000,17527.20000,United Healthcare,Commercial,,23749.36,,,,,,,8792.81,23749.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,United Healthcare,Commercial,,100.62,,,,,,,35.59,21681.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,inpatient,1,UN,6.65000,3.99000,United Healthcare,Commercial,,5.41,,,,,,,4.26,5.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,United Healthcare,Commercial,,5.41,,,,,,,1.33,5.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,inpatient,1,ML,71.75000,43.05000,United Healthcare,Commercial,,58.33,,,,,,,45.92,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,United Healthcare,Commercial,,58.33,,,,,,,14.36,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,inpatient,13.4,ML,33345.80000,20007.48000,United Healthcare,Commercial,,27110.14,,,,,,,10037.09,27110.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,United Healthcare,Commercial,,100.62,,,,,,,35.59,24749.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,inpatient,3,ML,71.30000,42.78000,United Healthcare,Commercial,,57.97,,,,,,,45.63,57.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,United Healthcare,Commercial,,57.97,,,,,,,14.27,57.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,inpatient,2,ML,68.70000,41.22000,United Healthcare,Commercial,,55.85,,,,,,,43.97,55.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,United Healthcare,Commercial,,55.85,,,,,,,13.75,55.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,inpatient,118,ML,1312.75000,787.65000,United Healthcare,Commercial,,1067.27,,,,,,,840.16,1067.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,United Healthcare,Commercial,,1067.27,,,,,,,262.81,1067.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,inpatient,473,ML,4511.40000,2706.84000,United Healthcare,Commercial,,3667.77,,,,,,,2887.30,3667.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,United Healthcare,Commercial,,3667.77,,,,,,,903.18,3667.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,inpatient,3,ML,47.80000,28.68000,United Healthcare,Commercial,,38.86,,,,,,,30.59,38.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,United Healthcare,Commercial,,38.86,,,,,,,9.57,38.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,inpatient,1,UN,48587.00000,29152.20000,United Healthcare,Commercial,,39501.23,,,,,,,14624.69,39501.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,United Healthcare,Commercial,,694.49,,,,,,,248.41,36061.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,inpatient,1,UN,105505.20000,63303.12000,United Healthcare,Commercial,,85775.73,,,,,,,31757.07,85775.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,United Healthcare,Commercial,,7345.44,,,,,,,2617.11,78305.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,inpatient,1,UN,17.45000,10.47000,United Healthcare,Commercial,,14.19,,,,,,,11.17,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,Commercial,,14.19,,,,,,,3.49,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,inpatient,1,ML,131.60000,78.96000,United Healthcare,Commercial,,106.99,,,,,,,84.22,106.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,United Healthcare,Commercial,,106.99,,,,,,,26.35,106.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,inpatient,5,ML,95.30000,57.18000,United Healthcare,Commercial,,77.48,,,,,,,60.99,77.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,United Healthcare,Commercial,,77.48,,,,,,,19.08,77.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,inpatient,5,ML,95.30000,57.18000,United Healthcare,Commercial,,77.48,,,,,,,60.99,77.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,United Healthcare,Commercial,,77.48,,,,,,,19.08,77.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,United Healthcare,Commercial,,73.41,,,,,,,27.18,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,United Healthcare,Commercial,,3.02,,,,,,,2.53,67.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,inpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,10.78,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,10.69,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,inpatient,1,UN,27.85000,16.71000,United Healthcare,Commercial,,22.64,,,,,,,17.82,22.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,United Healthcare,Commercial,,22.64,,,,,,,5.58,22.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,inpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,11.33,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,inpatient,250,ML,199.50000,119.70000,United Healthcare,Commercial,,162.19,,,,,,,60.05,162.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,United Healthcare,Commercial,,21.73,,,,,,,16.71,148.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,inpatient,1,UN,997.50000,598.50000,United Healthcare,Commercial,,810.97,,,,,,,300.25,810.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,United Healthcare,Commercial,,5.94,,,,,,,2.11,740.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,inpatient,60,ML,66.10000,39.66000,United Healthcare,Commercial,,53.74,,,,,,,42.30,53.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,United Healthcare,Commercial,,53.74,,,,,,,13.23,53.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,inpatient,1,UN,668.55000,401.13000,United Healthcare,Commercial,,543.53,,,,,,,201.23,543.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,inpatient,1,UN,4.70000,2.82000,United Healthcare,Commercial,,3.82,,,,,,,3.01,3.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,United Healthcare,Commercial,,3.82,,,,,,,0.94094,3.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,inpatient,1,ML,18.40000,11.04000,United Healthcare,Commercial,,14.96,,,,,,,5.54,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,United Healthcare,Commercial,,1.58,,,,,,,1.13,13.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,inpatient,18,ML,1972.25000,1183.35000,United Healthcare,Commercial,,1603.44,,,,,,,593.65,1603.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,United Healthcare,Commercial,,4.82,,,,,,,1.59,1463.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,inpatient,1,ML,26620.10000,15972.06000,United Healthcare,Commercial,,21642.14,,,,,,,8012.65,21642.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,United Healthcare,Commercial,,457.73,,,,,,,159.65,19757.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,inpatient,6,ML,5890.65000,3534.39000,United Healthcare,Commercial,,4789.10,,,,,,,1773.09,4789.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,United Healthcare,Commercial,,15.96,,,,,,,7.91,4372.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,inpatient,1,UN,19.10000,11.46000,United Healthcare,Commercial,,15.53,,,,,,,12.22,15.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,United Healthcare,Commercial,,15.53,,,,,,,3.82,15.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,inpatient,24,ML,35224.60000,21134.76000,United Healthcare,Commercial,,28637.60,,,,,,,10602.60,28637.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,United Healthcare,Commercial,,89.84,,,,,,,31.97,26143.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,inpatient,50,ML,80.05000,48.03000,United Healthcare,Commercial,,65.08,,,,,,,24.10,65.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,59.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,inpatient,1,UN,241.95000,145.17000,United Healthcare,Commercial,,196.71,,,,,,,154.85,196.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,United Healthcare,Commercial,,196.71,,,,,,,48.44,196.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,inpatient,1,UN,389.50000,233.70000,United Healthcare,Commercial,,316.66,,,,,,,249.28,316.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,United Healthcare,Commercial,,316.66,,,,,,,77.98,316.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,7.93,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,22.13,,,,,,,5.28,22.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,inpatient,0.5,ML,58.45000,35.07000,United Healthcare,Commercial,,47.52,,,,,,,17.59,47.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,United Healthcare,Commercial,,49.09,,,,,,,11.70,50.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,inpatient,1,UN,385.00000,231.00000,United Healthcare,Commercial,,313.00,,,,,,,246.40,313.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,United Healthcare,Commercial,,313.00,,,,,,,77.08,313.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,inpatient,1,ML,116.40000,69.84000,United Healthcare,Commercial,,94.63,,,,,,,74.50,94.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,United Healthcare,Commercial,,94.63,,,,,,,7.61,94.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,inpatient,1,ML,166.60000,99.96000,United Healthcare,Commercial,,135.45,,,,,,,106.62,135.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,United Healthcare,Commercial,,135.45,,,,,,,7.61,135.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,inpatient,1,ML,216.75000,130.05000,United Healthcare,Commercial,,176.22,,,,,,,138.72,176.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,United Healthcare,Commercial,,176.22,,,,,,,7.61,176.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,inpatient,1,ML,517.90000,310.74000,United Healthcare,Commercial,,421.05,,,,,,,331.46,421.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,United Healthcare,Commercial,,421.05,,,,,,,7.61,421.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,inpatient,1,ML,2023.50000,1214.10000,United Healthcare,Commercial,,1645.11,,,,,,,1295.04,1645.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,United Healthcare,Commercial,,1645.11,,,,,,,7.61,1645.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,inpatient,0.6,ML,9514.15000,5708.49000,United Healthcare,Commercial,,7735.00,,,,,,,2863.76,7735.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,United Healthcare,Commercial,,282.35,,,,,,,96.16,7061.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,inpatient,2000,ML,525.00000,315.00000,United Healthcare,Commercial,,426.82,,,,,,,336.00,426.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,United Healthcare,Commercial,,426.82,,,,,,,105.11,426.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,inpatient,1,UN,130.90000,78.54000,United Healthcare,Commercial,,106.42,,,,,,,83.78,106.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,United Healthcare,Commercial,,106.42,,,,,,,26.21,106.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,inpatient,1,UN,130.90000,78.54000,United Healthcare,Commercial,,106.42,,,,,,,83.78,106.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,United Healthcare,Commercial,,106.42,,,,,,,26.21,106.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,inpatient,0.5,ML,489.25000,293.55000,United Healthcare,Commercial,,397.76,,,,,,,147.26,397.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,United Healthcare,Commercial,,483.40,,,,,,,97.95,495.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,inpatient,5,ML,21317.55000,12790.53000,United Healthcare,Commercial,,17331.17,,,,,,,6416.58,17331.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,United Healthcare,Commercial,,676.55,,,,,,,241.04,15821.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,inpatient,0.5,ML,1012.45000,607.47000,United Healthcare,Commercial,,823.12,,,,,,,304.75,823.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,United Healthcare,Commercial,,0.79200,,,,,,,0.29100,751.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,inpatient,0.8,ML,1610.35000,966.21000,United Healthcare,Commercial,,1309.21,,,,,,,484.72,1309.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,United Healthcare,Commercial,,0.79200,,,,,,,0.29100,1195.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,inpatient,1,UN,344.75000,206.85000,United Healthcare,Commercial,,280.28,,,,,,,103.77,280.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,United Healthcare,Commercial,,3.51,,,,,,,3.14,255.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,inpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,10.59,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,inpatient,1,UN,55.90000,33.54000,United Healthcare,Commercial,,45.45,,,,,,,35.78,45.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,United Healthcare,Commercial,,45.45,,,,,,,11.19,45.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,inpatient,100,ML,5146.00000,3087.60000,United Healthcare,Commercial,,4183.70,,,,,,,3293.44,4183.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,United Healthcare,Commercial,,4183.70,,,,,,,1030.23,4183.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,inpatient,7,ML,48344.85000,29006.91000,United Healthcare,Commercial,,39304.36,,,,,,,14551.80,39304.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,United Healthcare,Commercial,,78.14,,,,,,,28.41,35881.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Commercial,,15456.96,,,,,,,5722.69,15456.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Commercial,,370.38,,,,,,,103.14,14110.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,inpatient,2.5,ML,48.10000,28.86000,United Healthcare,Commercial,,39.11,,,,,,,30.78,39.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,United Healthcare,Commercial,,39.11,,,,,,,9.63,39.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,inpatient,5,ML,4543.25000,2725.95000,United Healthcare,Commercial,,3693.66,,,,,,,2907.68,3693.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,United Healthcare,Commercial,,3693.66,,,,,,,909.56,3693.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,United Healthcare,Commercial,,8192.60,,,,,,,3033.18,8192.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,Commercial,,358.17,,,,,,,127.44,7479.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,United Healthcare,Commercial,,823.12,,,,,,,304.75,823.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,Commercial,,0.79200,,,,,,,0.29100,751.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,inpatient,1,UN,36064.10000,21638.46000,United Healthcare,Commercial,,29320.11,,,,,,,10855.29,29320.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,inpatient,1,UN,2928.00000,1756.80000,United Healthcare,Commercial,,2380.46,,,,,,,881.33,2380.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,United Healthcare,Commercial,,276.31,,,,,,,99.04,2173.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,United Healthcare,Commercial,,29243.85,,,,,,,10827.06,29243.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,Commercial,,247.80,,,,,,,88.60,26697.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,inpatient,5,ML,20846.10000,12507.66000,United Healthcare,Commercial,,16947.88,,,,,,,6274.68,16947.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,United Healthcare,Commercial,,171.44,,,,,,,59.60,15471.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,inpatient,1000,ML,203.00000,121.80000,United Healthcare,Commercial,,165.04,,,,,,,129.92,165.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,United Healthcare,Commercial,,165.04,,,,,,,40.64,165.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,inpatient,2000,ML,287.00000,172.20000,United Healthcare,Commercial,,233.33,,,,,,,183.68,233.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,United Healthcare,Commercial,,233.33,,,,,,,57.46,233.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,inpatient,5,ML,419.55000,251.73000,United Healthcare,Commercial,,341.09,,,,,,,126.28,341.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,United Healthcare,Commercial,,19.34,,,,,,,6.63,311.39,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,inpatient,10,ML,1781.00000,1068.60000,United Healthcare,Commercial,,1447.95,,,,,,,1139.84,1447.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,United Healthcare,Commercial,,1447.95,,,,,,,356.56,1447.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,inpatient,1,UN,82165.25000,49299.15000,United Healthcare,Commercial,,66800.35,,,,,,,24731.74,66800.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,United Healthcare,Commercial,,370.89,,,,,,,132.57,60983.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,inpatient,16,ML,12554.95000,7532.97000,United Healthcare,Commercial,,10207.17,,,,,,,3779.04,10207.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,United Healthcare,Commercial,,78.54,,,,,,,27.02,9318.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,inpatient,4,ML,3345.05000,2007.03000,United Healthcare,Commercial,,2719.53,,,,,,,1006.86,2719.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,United Healthcare,Commercial,,78.54,,,,,,,27.02,2482.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,inpatient,100,ML,201.25000,120.75000,United Healthcare,Commercial,,163.62,,,,,,,60.58,163.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,United Healthcare,Commercial,,0.21450,,,,,,,0.21240,149.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,inpatient,2.5,ML,48.00000,28.80000,United Healthcare,Commercial,,39.02,,,,,,,30.72,39.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,United Healthcare,Commercial,,39.02,,,,,,,9.61,39.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,inpatient,1.25,ML,23.85000,14.31000,United Healthcare,Commercial,,19.39,,,,,,,15.26,19.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,United Healthcare,Commercial,,19.39,,,,,,,4.77,19.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,inpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,11.39,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,inpatient,10,ML,3995.45000,2397.27000,United Healthcare,Commercial,,3248.30,,,,,,,1202.63,3248.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,United Healthcare,Commercial,,84.89,,,,,,,28.50,2965.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,inpatient,50,ML,18877.10000,11326.26000,United Healthcare,Commercial,,15347.08,,,,,,,5682.01,15347.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,United Healthcare,Commercial,,84.89,,,,,,,28.50,14010.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,inpatient,1,UN,17338.20000,10402.92000,United Healthcare,Commercial,,14095.96,,,,,,,5218.80,14095.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,United Healthcare,Commercial,,114.23,,,,,,,40.72,12868.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,inpatient,1,UN,51888.40000,31133.04000,United Healthcare,Commercial,,42185.27,,,,,,,15618.41,42185.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,United Healthcare,Commercial,,114.23,,,,,,,40.72,38511.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,inpatient,10,ML,10365.35000,6219.21000,United Healthcare,Commercial,,8427.03,,,,,,,3119.97,8427.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,United Healthcare,Commercial,,352.79,,,,,,,125.60,7693.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,inpatient,1,UN,6279.25000,3767.55000,United Healthcare,Commercial,,5105.03,,,,,,,1890.05,5105.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,United Healthcare,Commercial,,29.95,,,,,,,10.68,4660.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,inpatient,10,ML,107.15000,64.29000,United Healthcare,Commercial,,87.11,,,,,,,68.58,87.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,United Healthcare,Commercial,,87.11,,,,,,,21.45,87.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,inpatient,1,UN,12634.60000,7580.76000,United Healthcare,Commercial,,10271.93,,,,,,,3803.01,10271.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,United Healthcare,Commercial,,99.81,,,,,,,35.64,9377.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,15296.11,,,,,,,5663.13,15296.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,99.81,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,inpatient,1,UN,13855.50000,8313.30000,United Healthcare,Commercial,,11264.52,,,,,,,4170.51,11264.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,United Healthcare,Commercial,,81.67,,,,,,,29.08,10283.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,inpatient,16,ML,11070.85000,6642.51000,United Healthcare,Commercial,,9000.60,,,,,,,3332.33,9000.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,United Healthcare,Commercial,,65.14,,,,,,,25.00,8216.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,inpatient,4,ML,2974.00000,1784.40000,United Healthcare,Commercial,,2417.86,,,,,,,895.17,2417.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,United Healthcare,Commercial,,65.14,,,,,,,25.00,2207.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,10,ML,3428.95000,2057.37000,United Healthcare,Commercial,,2787.74,,,,,,,1032.11,2787.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,United Healthcare,Commercial,,72.15,,,,,,,27.01,2544.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,50,ML,16044.60000,9626.76000,United Healthcare,Commercial,,13044.26,,,,,,,4829.42,13044.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,United Healthcare,Commercial,,72.15,,,,,,,27.01,11908.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,inpatient,1,UN,75742.60000,45445.56000,United Healthcare,Commercial,,61578.73,,,,,,,22798.52,61578.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,United Healthcare,Commercial,,977.62,,,,,,,348.41,56216.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,inpatient,1,UN,15195.80000,9117.48000,United Healthcare,Commercial,,12354.19,,,,,,,4573.94,12354.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,United Healthcare,Commercial,,77.91,,,,,,,27.15,11278.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,inpatient,1,UN,143.55000,86.13000,United Healthcare,Commercial,,116.71,,,,,,,91.87,116.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,United Healthcare,Commercial,,116.71,,,,,,,28.74,116.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,inpatient,1,UN,143.55000,86.13000,United Healthcare,Commercial,,116.71,,,,,,,91.87,116.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,United Healthcare,Commercial,,116.71,,,,,,,28.74,116.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,inpatient,2.5,ML,28.60000,17.16000,United Healthcare,Commercial,,23.25,,,,,,,18.30,23.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,United Healthcare,Commercial,,23.25,,,,,,,5.73,23.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,inpatient,1,ML,8211.30000,4926.78000,United Healthcare,Commercial,,6675.79,,,,,,,2471.60,6675.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,United Healthcare,Commercial,,54.04,,,,,,,19.37,6094.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,inpatient,25,ML,19413.25000,11647.95000,United Healthcare,Commercial,,15782.97,,,,,,,5843.39,15782.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,United Healthcare,Commercial,,225.59,,,,,,,79.44,14408.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,inpatient,5,ML,4102.65000,2461.59000,United Healthcare,Commercial,,3335.45,,,,,,,1234.90,3335.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,United Healthcare,Commercial,,225.59,,,,,,,79.44,3044.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,inpatient,2,ML,149.10000,89.46000,United Healthcare,Commercial,,121.22,,,,,,,95.42,121.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,United Healthcare,Commercial,,121.22,,,,,,,29.85,121.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,inpatient,1,UN,11554.40000,6932.64000,United Healthcare,Commercial,,9393.73,,,,,,,3477.87,9393.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,United Healthcare,Commercial,,98.72,,,,,,,35.19,8575.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,inpatient,1,UN,110033.00000,66019.80000,United Healthcare,Commercial,,89456.83,,,,,,,33119.93,89456.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,United Healthcare,Commercial,,864.17,,,,,,,308.97,81666.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,inpatient,1,UN,2163.00000,1297.80000,United Healthcare,Commercial,,1758.52,,,,,,,651.06,1758.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,United Healthcare,Commercial,,56.88,,,,,,,19.80,1605.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,inpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,10.88,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,inpatient,1,UN,42.75000,25.65000,United Healthcare,Commercial,,34.76,,,,,,,27.36,34.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,United Healthcare,Commercial,,34.76,,,,,,,8.56,34.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,inpatient,5,ML,176.25000,105.75000,United Healthcare,Commercial,,143.29,,,,,,,112.80,143.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,United Healthcare,Commercial,,143.29,,,,,,,35.29,143.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,inpatient,1,UN,17.90000,10.74000,United Healthcare,Commercial,,14.55,,,,,,,11.46,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,Commercial,,14.55,,,,,,,3.58,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,inpatient,20,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,inpatient,15,ML,61507.80000,36904.68000,United Healthcare,Commercial,,50005.84,,,,,,,18513.85,50005.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,United Healthcare,Commercial,,172.57,,,,,,,60.24,45651.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,inpatient,10,ML,41095.25000,24657.15000,United Healthcare,Commercial,,33410.44,,,,,,,12369.67,33410.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,United Healthcare,Commercial,,172.57,,,,,,,60.24,30500.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,inpatient,0.25,ML,65.65000,39.39000,United Healthcare,Commercial,,53.37,,,,,,,19.76,53.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,United Healthcare,Commercial,,0.19800,,,,,,,0.19800,48.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,inpatient,100,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,26.49,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,65.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,inpatient,1,UN,6416.85000,3850.11000,United Healthcare,Commercial,,5216.90,,,,,,,1931.47,5216.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,United Healthcare,Commercial,,38.33,,,,,,,13.88,4762.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,inpatient,1,UN,17822.95000,10693.77000,United Healthcare,Commercial,,14490.06,,,,,,,5364.71,14490.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,United Healthcare,Commercial,,370.89,,,,,,,132.57,13228.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,inpatient,11,ML,100657.05000,60394.23000,United Healthcare,Commercial,,81834.18,,,,,,,30297.77,81834.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,United Healthcare,Commercial,,613.07,,,,,,,218.36,74707.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,inpatient,3,ML,27497.75000,16498.65000,United Healthcare,Commercial,,22355.67,,,,,,,8276.82,22355.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,United Healthcare,Commercial,,613.07,,,,,,,218.36,20408.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,inpatient,1,ML,1019.75000,611.85000,United Healthcare,Commercial,,829.06,,,,,,,652.64,829.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,United Healthcare,Commercial,,829.06,,,,,,,7.61,829.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,inpatient,1,UN,6743.50000,4046.10000,United Healthcare,Commercial,,5482.47,,,,,,,2029.79,5482.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,United Healthcare,Commercial,,14.67,,,,,,,5.30,5005.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,inpatient,1,UN,5603.90000,3362.34000,United Healthcare,Commercial,,4555.97,,,,,,,1686.77,4555.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,United Healthcare,Commercial,,77.91,,,,,,,27.15,4159.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,inpatient,1,UN,9216.70000,5530.02000,United Healthcare,Commercial,,7493.18,,,,,,,2774.23,7493.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,United Healthcare,Commercial,,5753.30,,,,,,,1845.18,6840.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,inpatient,1,UN,124890.65000,74934.39000,United Healthcare,Commercial,,101536.10,,,,,,,37592.09,101536.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,United Healthcare,Commercial,,590.07,,,,,,,210.39,92693.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,inpatient,10,ML,53208.20000,31924.92000,United Healthcare,Commercial,,43258.27,,,,,,,16015.67,43258.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,United Healthcare,Commercial,,663.79,,,,,,,236.40,39491.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,inpatient,20,ML,20471.00000,12282.60000,United Healthcare,Commercial,,16642.92,,,,,,,6161.77,16642.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,inpatient,7,ML,17024.40000,10214.64000,United Healthcare,Commercial,,13840.84,,,,,,,5124.34,13840.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,United Healthcare,Commercial,,60.47,,,,,,,21.86,12635.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,11.20,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,inpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,10.88,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,inpatient,30,ML,81.25000,48.75000,United Healthcare,Commercial,,66.06,,,,,,,52.00,66.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,United Healthcare,Commercial,,66.06,,,,,,,16.27,66.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,inpatient,0.5,ML,869.40000,521.64000,United Healthcare,Commercial,,706.82,,,,,,,261.69,706.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,United Healthcare,Commercial,,851.88,,,,,,,174.05,872.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,inpatient,1,UN,32838.55000,19703.13000,United Healthcare,Commercial,,26697.74,,,,,,,9884.40,26697.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,United Healthcare,Commercial,,513.60,,,,,,,183.10,24372.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,inpatient,100,ML,107.45000,64.47000,United Healthcare,Commercial,,87.36,,,,,,,32.34,87.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,United Healthcare,Commercial,,0.21450,,,,,,,0.21240,79.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,inpatient,1,UN,413.35000,248.01000,United Healthcare,Commercial,,336.05,,,,,,,264.54,336.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,United Healthcare,Commercial,,336.05,,,,,,,82.75,336.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,inpatient,1.5,ML,16340.20000,9804.12000,United Healthcare,Commercial,,13284.58,,,,,,,4918.40,13284.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,United Healthcare,Commercial,,33.63,,,,,,,11.95,12127.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,inpatient,1,UN,36433.75000,21860.25000,United Healthcare,Commercial,,29620.64,,,,,,,10966.56,29620.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,United Healthcare,Commercial,,230.13,,,,,,,82.03,27041.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,inpatient,1,ML,34.15000,20.49000,United Healthcare,Commercial,,27.76,,,,,,,21.86,27.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,United Healthcare,Commercial,,27.76,,,,,,,6.84,27.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,inpatient,100,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,82.17,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,United Healthcare,Commercial,,3.43,,,,,,,2.19,202.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,inpatient,1,UN,87.60000,52.56000,United Healthcare,Commercial,,71.22,,,,,,,26.37,71.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,United Healthcare,Commercial,,2.29,,,,,,,1.89,65.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,United Healthcare,Commercial,,67.28,,,,,,,24.91,67.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,United Healthcare,Commercial,,48.11,,,,,,,16.57,61.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,United Healthcare,Commercial,,67.28,,,,,,,24.91,67.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,United Healthcare,Commercial,,48.11,,,,,,,16.57,61.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,inpatient,0.5,ML,739.45000,443.67000,United Healthcare,Commercial,,601.17,,,,,,,222.57,601.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,United Healthcare,Commercial,,1.12,,,,,,,0.36860,548.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,inpatient,0.8,ML,1173.55000,704.13000,United Healthcare,Commercial,,954.10,,,,,,,353.24,954.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,United Healthcare,Commercial,,1.12,,,,,,,0.36860,871.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,inpatient,20,ML,68131.75000,40879.05000,United Healthcare,Commercial,,55391.11,,,,,,,20507.66,55391.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,United Healthcare,Commercial,,538.10,,,,,,,191.90,50567.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,inpatient,1,UN,76.00000,45.60000,United Healthcare,Commercial,,61.79,,,,,,,48.64,61.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,United Healthcare,Commercial,,61.79,,,,,,,15.22,61.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,inpatient,4,UN,2626.30000,1575.78000,United Healthcare,Commercial,,2135.18,,,,,,,1680.83,2135.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,United Healthcare,Commercial,,2135.18,,,,,,,525.79,2135.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,inpatient,4,UN,1136.00000,681.60000,United Healthcare,Commercial,,923.57,,,,,,,727.04,923.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,United Healthcare,Commercial,,923.57,,,,,,,227.43,923.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,inpatient,4,UN,1136.00000,681.60000,United Healthcare,Commercial,,923.57,,,,,,,727.04,923.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,United Healthcare,Commercial,,923.57,,,,,,,227.43,923.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,inpatient,4,UN,2626.30000,1575.78000,United Healthcare,Commercial,,2135.18,,,,,,,1680.83,2135.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,United Healthcare,Commercial,,2135.18,,,,,,,525.79,2135.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,11.26,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,inpatient,0.5,ML,104.05000,62.43000,United Healthcare,Commercial,,84.59,,,,,,,31.32,84.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,United Healthcare,Commercial,,97.20,,,,,,,20.83,97.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,inpatient,1.7,ML,46244.25000,27746.55000,United Healthcare,Commercial,,37596.58,,,,,,,13919.52,37596.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,United Healthcare,Commercial,,90.58,,,,,,,32.57,34322.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,inpatient,3,ML,9288.55000,5573.13000,United Healthcare,Commercial,,7551.59,,,,,,,2795.85,7551.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,United Healthcare,Commercial,,90.58,,,,,,,32.57,6893.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,inpatient,0.5,ML,520.00000,312.00000,United Healthcare,Commercial,,422.76,,,,,,,156.52,422.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,United Healthcare,Commercial,,544.37,,,,,,,104.10,544.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,inpatient,20,ML,30117.40000,18070.44000,United Healthcare,Commercial,,24485.45,,,,,,,9065.34,24485.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,United Healthcare,Commercial,,189.27,,,,,,,67.41,22353.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,inpatient,1,ML,3021.70000,1813.02000,United Healthcare,Commercial,,2456.64,,,,,,,909.53,2456.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,United Healthcare,Commercial,,1777.12,,,,,,,604.94,2242.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,inpatient,30,ML,82676.70000,49606.02000,United Healthcare,Commercial,,67216.16,,,,,,,24885.69,67216.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,United Healthcare,Commercial,,1777.12,,,,,,,634.99,61362.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,inpatient,20,ML,65144.20000,39086.52000,United Healthcare,Commercial,,52962.23,,,,,,,19608.40,52962.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,United Healthcare,Commercial,,81.63,,,,,,,29.64,48350.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,inpatient,0.28,ML,11967.50000,7180.50000,United Healthcare,Commercial,,9729.58,,,,,,,3602.22,9729.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,United Healthcare,Commercial,,68.28,,,,,,,24.29,8882.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,inpatient,0.56,ML,23918.10000,14350.86000,United Healthcare,Commercial,,19445.42,,,,,,,7199.35,19445.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,United Healthcare,Commercial,,68.28,,,,,,,24.29,17752.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,inpatient,0.7,ML,29894.05000,17936.43000,United Healthcare,Commercial,,24303.86,,,,,,,8998.11,24303.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,United Healthcare,Commercial,,68.28,,,,,,,24.29,22187.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,inpatient,1,UN,68158.20000,40894.92000,United Healthcare,Commercial,,55412.62,,,,,,,20515.62,55412.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,United Healthcare,Commercial,,172691.03,,,,,,,13645.27,176902.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,inpatient,1,UN,942.40000,565.44000,United Healthcare,Commercial,,766.17,,,,,,,283.66,766.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,United Healthcare,Commercial,,1002.31,,,,,,,188.67,1002.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,inpatient,0.5,ML,2546.40000,1527.84000,United Healthcare,Commercial,,2070.22,,,,,,,766.47,2070.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,United Healthcare,Commercial,,1816.88,,,,,,,509.79,1889.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,inpatient,1,ML,2546.45000,1527.87000,United Healthcare,Commercial,,2070.26,,,,,,,766.48,2070.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,United Healthcare,Commercial,,1816.88,,,,,,,509.80,1889.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,inpatient,0.5,ML,62.50000,37.50000,United Healthcare,Commercial,,50.81,,,,,,,40.00,50.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,United Healthcare,Commercial,,50.81,,,,,,,12.51,50.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,United Healthcare,Commercial,,41551.09,,,,,,,15383.61,41551.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,Commercial,,197.11,,,,,,,70.44,37932.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,inpatient,1.5,ML,4087.55000,2452.53000,United Healthcare,Commercial,,3323.18,,,,,,,1230.35,3323.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,United Healthcare,Commercial,,197.11,,,,,,,70.44,3033.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,inpatient,30,ML,1475.80000,885.48000,United Healthcare,Commercial,,1199.83,,,,,,,944.51,1199.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,United Healthcare,Commercial,,1199.83,,,,,,,295.46,1199.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,inpatient,10,ML,208.40000,125.04000,United Healthcare,Commercial,,169.43,,,,,,,133.38,169.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,United Healthcare,Commercial,,169.43,,,,,,,41.72,169.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,inpatient,5,ML,100.00000,60.00000,United Healthcare,Commercial,,81.30,,,,,,,64.00,81.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,United Healthcare,Commercial,,81.30,,,,,,,20.02,81.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,inpatient,1,ML,255.50000,153.30000,United Healthcare,Commercial,,207.72,,,,,,,76.91,207.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,United Healthcare,Commercial,,1.47,,,,,,,1.35,189.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,inpatient,1,UN,30.90000,18.54000,United Healthcare,Commercial,,25.12,,,,,,,19.78,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,United Healthcare,Commercial,,25.12,,,,,,,6.19,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,inpatient,10,ML,106.00000,63.60000,United Healthcare,Commercial,,86.18,,,,,,,67.84,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,United Healthcare,Commercial,,86.18,,,,,,,21.22,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,inpatient,30,ML,69.30000,41.58000,United Healthcare,Commercial,,56.34,,,,,,,44.35,56.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,United Healthcare,Commercial,,56.34,,,,,,,13.87,56.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,inpatient,1,UN,63488.50000,38093.10000,United Healthcare,Commercial,,51616.15,,,,,,,19110.04,51616.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,United Healthcare,Commercial,,531.56,,,,,,,189.85,47121.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,inpatient,2,ML,234.40000,140.64000,United Healthcare,Commercial,,190.57,,,,,,,70.55,190.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,United Healthcare,Commercial,,21.40,,,,,,,6.49,173.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Commercial,,15456.96,,,,,,,5722.69,15456.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Commercial,,370.38,,,,,,,103.14,14110.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,inpatient,0.11,ML,352.45000,211.47000,United Healthcare,Commercial,,286.54,,,,,,,106.09,286.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,United Healthcare,Commercial,,4.98,,,,,,,1.78,261.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,inpatient,36,ML,26733.05000,16039.83000,United Healthcare,Commercial,,21733.97,,,,,,,8046.65,21733.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,United Healthcare,Commercial,,19708.18,,,,,,,5351.96,20188.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,inpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,10.50,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,inpatient,1,UN,10993.10000,6595.86000,United Healthcare,Commercial,,8937.39,,,,,,,3308.92,8937.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,United Healthcare,Commercial,,155.23,,,,,,,55.32,8159.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,inpatient,1,UN,43783.25000,26269.95000,United Healthcare,Commercial,,35595.78,,,,,,,13178.76,35595.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,United Healthcare,Commercial,,155.23,,,,,,,55.32,32495.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,inpatient,0.5,ML,883.00000,529.80000,United Healthcare,Commercial,,717.88,,,,,,,265.78,717.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,United Healthcare,Commercial,,892.68,,,,,,,176.78,914.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,inpatient,20,ML,61242.05000,36745.23000,United Healthcare,Commercial,,49789.79,,,,,,,18433.86,49789.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,United Healthcare,Commercial,,203.81,,,,,,,73.69,45453.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,inpatient,1,UN,7315.00000,4389.00000,United Healthcare,Commercial,,5947.10,,,,,,,2201.82,5947.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,United Healthcare,Commercial,,91.36,,,,,,,32.43,5429.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,inpatient,0.5,ML,257.30000,154.38000,United Healthcare,Commercial,,209.18,,,,,,,77.45,209.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,United Healthcare,Commercial,,227.30,,,,,,,51.51,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,inpatient,0.5,ML,81.25000,48.75000,United Healthcare,Commercial,,66.06,,,,,,,24.46,66.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,United Healthcare,Commercial,,60.85,,,,,,,16.27,62.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,inpatient,0.1,ML,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,5.13,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,United Healthcare,Commercial,,2.59,,,,,,,2.36,12.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,inpatient,0.1,ML,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,5.09,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,United Healthcare,Commercial,,2.59,,,,,,,2.36,12.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,inpatient,0.1,ML,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,5.04,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,United Healthcare,Commercial,,2.59,,,,,,,2.36,12.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,inpatient,5,ML,35224.60000,21134.76000,United Healthcare,Commercial,,28637.60,,,,,,,10602.60,28637.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,United Healthcare,Commercial,,72.80,,,,,,,26.54,26143.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,inpatient,1,UN,21795.75000,13077.45000,United Healthcare,Commercial,,17719.94,,,,,,,6560.52,17719.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,United Healthcare,Commercial,,17719.94,,,,,,,50.01,17719.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,inpatient,1,UN,1.35000,0.81000,United Healthcare,Commercial,,1.10,,,,,,,0.86400,1.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,United Healthcare,Commercial,,1.10,,,,,,,0.27027,1.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,inpatient,1,UN,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.83200,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,inpatient,20,ML,364.45000,218.67000,United Healthcare,Commercial,,296.30,,,,,,,109.70,296.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,United Healthcare,Commercial,,2.21,,,,,,,1.96,270.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,inpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,10.40,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,United Healthcare,Commercial,,30705.83,,,,,,,11368.33,30705.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Commercial,,468.11,,,,,,,167.05,28031.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,inpatient,0.3,ML,465.10000,279.06000,United Healthcare,Commercial,,378.13,,,,,,,140.00,378.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,United Healthcare,Commercial,,424.45,,,,,,,93.11,434.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,inpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,10.40,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,inpatient,1,UN,49.10000,29.46000,United Healthcare,Commercial,,39.92,,,,,,,31.42,39.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,United Healthcare,Commercial,,39.92,,,,,,,9.83,39.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,inpatient,10,ML,89.15000,53.49000,United Healthcare,Commercial,,72.48,,,,,,,57.06,72.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,United Healthcare,Commercial,,72.48,,,,,,,17.85,72.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,10.69,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,inpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,10.37,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,inpatient,5,ML,73.40000,44.04000,United Healthcare,Commercial,,59.67,,,,,,,46.98,59.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,United Healthcare,Commercial,,59.67,,,,,,,14.69,59.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,inpatient,1,UN,327.80000,196.68000,United Healthcare,Commercial,,266.50,,,,,,,98.67,266.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,United Healthcare,Commercial,,10.39,,,,,,,8.14,243.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,inpatient,1,UN,38.45000,23.07000,United Healthcare,Commercial,,31.26,,,,,,,24.61,31.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,United Healthcare,Commercial,,31.26,,,,,,,7.70,31.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,inpatient,1,UN,23.45000,14.07000,United Healthcare,Commercial,,19.06,,,,,,,15.01,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,Commercial,,19.06,,,,,,,4.69,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,inpatient,1,UN,27.25000,16.35000,United Healthcare,Commercial,,22.15,,,,,,,17.44,22.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,United Healthcare,Commercial,,22.15,,,,,,,5.46,22.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,inpatient,1,UN,32.20000,19.32000,United Healthcare,Commercial,,26.18,,,,,,,20.61,26.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,United Healthcare,Commercial,,26.18,,,,,,,6.45,26.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,inpatient,1,UN,2.95000,1.77000,United Healthcare,Commercial,,2.40,,,,,,,1.89,2.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,United Healthcare,Commercial,,2.40,,,,,,,0.59059,2.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,inpatient,5,ML,192.90000,115.74000,United Healthcare,Commercial,,156.83,,,,,,,58.06,156.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,United Healthcare,Commercial,,66.13,,,,,,,38.62,143.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,inpatient,10,GR,11.10000,6.66000,United Healthcare,Commercial,,9.02,,,,,,,7.10,9.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,United Healthcare,Commercial,,9.02,,,,,,,2.22,9.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,inpatient,1,UN,19.55000,11.73000,United Healthcare,Commercial,,15.89,,,,,,,12.51,15.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,United Healthcare,Commercial,,15.89,,,,,,,3.91,15.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,inpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,10.40,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,inpatient,1,UN,94.25000,56.55000,United Healthcare,Commercial,,76.63,,,,,,,28.37,76.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,United Healthcare,Commercial,,7.11,,,,,,,4.81,69.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,inpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,14.72,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,inpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,11.04,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,inpatient,1,UN,27.20000,16.32000,United Healthcare,Commercial,,22.11,,,,,,,17.41,22.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,United Healthcare,Commercial,,22.11,,,,,,,5.45,22.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,11.26,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,inpatient,1,UN,26.20000,15.72000,United Healthcare,Commercial,,21.30,,,,,,,16.77,21.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,United Healthcare,Commercial,,21.30,,,,,,,5.25,21.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,inpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,inpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,11.71,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,inpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,11.01,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,inpatient,1,UN,17.90000,10.74000,United Healthcare,Commercial,,14.55,,,,,,,11.46,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,Commercial,,14.55,,,,,,,3.58,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,inpatient,0.5,ML,91.05000,54.63000,United Healthcare,Commercial,,74.02,,,,,,,27.41,74.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,United Healthcare,Commercial,,182.95,,,,,,,18.23,182.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,inpatient,1,UN,1399.95000,839.97000,United Healthcare,Commercial,,1138.16,,,,,,,421.38,1138.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,United Healthcare,Commercial,,61.58,,,,,,,20.84,1039.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,inpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,10.91,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,inpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,11.90,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,inpatient,10,ML,4408.90000,2645.34000,United Healthcare,Commercial,,3584.44,,,,,,,1327.08,3584.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,United Healthcare,Commercial,,206.71,,,,,,,72.96,3272.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,50,ML,20944.45000,12566.67000,United Healthcare,Commercial,,17027.84,,,,,,,6304.28,17027.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,United Healthcare,Commercial,,206.71,,,,,,,72.96,15544.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,inpatient,1,UN,67.95000,40.77000,United Healthcare,Commercial,,55.24,,,,,,,43.49,55.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,United Healthcare,Commercial,,55.24,,,,,,,13.60,55.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,inpatient,1.5,ML,6363.00000,3817.80000,United Healthcare,Commercial,,5173.12,,,,,,,1915.26,5173.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,United Healthcare,Commercial,,16.42,,,,,,,6.09,4722.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,inpatient,5,ML,83.90000,50.34000,United Healthcare,Commercial,,68.21,,,,,,,53.70,68.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,United Healthcare,Commercial,,68.21,,,,,,,16.80,68.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,inpatient,1,UN,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,11.97,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,inpatient,100,ML,197.80000,118.68000,United Healthcare,Commercial,,160.81,,,,,,,126.59,160.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,United Healthcare,Commercial,,160.81,,,,,,,39.60,160.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,inpatient,60,ML,46.10000,27.66000,United Healthcare,Commercial,,37.48,,,,,,,29.50,37.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,United Healthcare,Commercial,,37.48,,,,,,,9.23,37.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,inpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,United Healthcare,Commercial,,37.19,,,,,,,13.77,37.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,United Healthcare,Commercial,,0.95700,,,,,,,0.29100,33.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,inpatient,1,UN,17.35000,10.41000,United Healthcare,Commercial,,14.11,,,,,,,11.10,14.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,United Healthcare,Commercial,,14.11,,,,,,,3.47,14.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,inpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,12.67,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,inpatient,0.5,ML,4182.45000,2509.47000,United Healthcare,Commercial,,3400.33,,,,,,,1258.92,3400.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,United Healthcare,Commercial,,127.58,,,,,,,100.21,3104.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,inpatient,20,ML,81.55000,48.93000,United Healthcare,Commercial,,66.30,,,,,,,52.19,66.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,United Healthcare,Commercial,,66.30,,,,,,,16.33,66.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,inpatient,1,UN,18.80000,11.28000,United Healthcare,Commercial,,15.28,,,,,,,12.03,15.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,United Healthcare,Commercial,,15.28,,,,,,,3.76,15.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,inpatient,1,ML,126.65000,75.99000,United Healthcare,Commercial,,102.97,,,,,,,38.12,102.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,United Healthcare,Commercial,,1.83,,,,,,,1.83,94.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,inpatient,100,ML,472.90000,283.74000,United Healthcare,Commercial,,384.47,,,,,,,302.66,384.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,United Healthcare,Commercial,,384.47,,,,,,,94.67,384.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,inpatient,222,ML,9.65000,5.79000,United Healthcare,Commercial,,7.85,,,,,,,6.18,7.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,United Healthcare,Commercial,,7.85,,,,,,,1.93,7.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,inpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,13.06,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,inpatient,100,ML,1113.00000,667.80000,United Healthcare,Commercial,,904.87,,,,,,,335.01,904.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,United Healthcare,Commercial,,62.11,,,,,,,24.07,826.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,inpatient,500,ML,64.00000,38.40000,United Healthcare,Commercial,,52.03,,,,,,,19.26,52.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,47.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,5.03,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,12.39,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,5.30,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,13.06,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,inpatient,1,UN,20.05000,12.03000,United Healthcare,Commercial,,16.30,,,,,,,6.04,16.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,14.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,inpatient,5,ML,24.90000,14.94000,United Healthcare,Commercial,,20.24,,,,,,,7.49,20.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,United Healthcare,Commercial,,0.33000,,,,,,,0.21240,18.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,inpatient,5,ML,177.70000,106.62000,United Healthcare,Commercial,,144.47,,,,,,,113.73,144.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,United Healthcare,Commercial,,144.47,,,,,,,35.58,144.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,inpatient,5,GR,11.85000,7.11000,United Healthcare,Commercial,,9.63,,,,,,,7.58,9.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,United Healthcare,Commercial,,9.63,,,,,,,2.37,9.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,inpatient,10,ML,109.70000,65.82000,United Healthcare,Commercial,,89.19,,,,,,,70.21,89.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,United Healthcare,Commercial,,89.19,,,,,,,21.96,89.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,inpatient,1,UN,654.25000,392.55000,United Healthcare,Commercial,,531.91,,,,,,,196.93,531.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,United Healthcare,Commercial,,10.76,,,,,,,7.60,485.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,inpatient,1,UN,2058.00000,1234.80000,United Healthcare,Commercial,,1673.15,,,,,,,619.46,1673.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,United Healthcare,Commercial,,84.89,,,,,,,30.16,1527.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,inpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,13.06,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,inpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,13.06,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,inpatient,1,UN,516.55000,309.93000,United Healthcare,Commercial,,419.96,,,,,,,155.48,419.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,United Healthcare,Commercial,,1.12,,,,,,,0.84960,383.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,inpatient,1,UN,22.25000,13.35000,United Healthcare,Commercial,,18.09,,,,,,,14.24,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,Commercial,,18.09,,,,,,,4.45,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,inpatient,1,UN,22.25000,13.35000,United Healthcare,Commercial,,18.09,,,,,,,14.24,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,Commercial,,18.09,,,,,,,4.45,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,inpatient,20,ML,53.90000,32.34000,United Healthcare,Commercial,,43.82,,,,,,,34.50,43.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,United Healthcare,Commercial,,43.82,,,,,,,10.79,43.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,inpatient,28,GR,8.60000,5.16000,United Healthcare,Commercial,,6.99,,,,,,,5.50,6.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,United Healthcare,Commercial,,6.99,,,,,,,1.72,6.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,inpatient,1,UN,18.75000,11.25000,United Healthcare,Commercial,,15.24,,,,,,,12.00,15.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,United Healthcare,Commercial,,15.24,,,,,,,3.75,15.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,inpatient,1,UN,142.10000,85.26000,United Healthcare,Commercial,,115.53,,,,,,,90.94,115.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,United Healthcare,Commercial,,115.53,,,,,,,28.45,115.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,inpatient,1,UN,16.65000,9.99000,United Healthcare,Commercial,,13.54,,,,,,,10.66,13.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,United Healthcare,Commercial,,13.54,,,,,,,3.33,13.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,inpatient,15,ML,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,inpatient,10,ML,422.40000,253.44000,United Healthcare,Commercial,,343.41,,,,,,,270.34,343.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,United Healthcare,Commercial,,343.41,,,,,,,84.56,343.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,10.69,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,inpatient,1,UN,50.70000,30.42000,United Healthcare,Commercial,,41.22,,,,,,,32.45,41.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,United Healthcare,Commercial,,41.22,,,,,,,10.15,41.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,inpatient,1,UN,88.65000,53.19000,United Healthcare,Commercial,,72.07,,,,,,,56.74,72.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,United Healthcare,Commercial,,72.07,,,,,,,17.75,72.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,inpatient,1,UN,21.40000,12.84000,United Healthcare,Commercial,,17.40,,,,,,,13.70,17.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,United Healthcare,Commercial,,17.40,,,,,,,4.28,17.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,11.20,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,inpatient,1,UN,24.00000,14.40000,United Healthcare,Commercial,,19.51,,,,,,,15.36,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,United Healthcare,Commercial,,19.51,,,,,,,4.80,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,inpatient,1,UN,17.55000,10.53000,United Healthcare,Commercial,,14.27,,,,,,,11.23,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,Commercial,,14.27,,,,,,,3.51,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,inpatient,1,UN,90.95000,54.57000,United Healthcare,Commercial,,73.94,,,,,,,58.21,73.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,United Healthcare,Commercial,,73.94,,,,,,,18.21,73.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,inpatient,1,UN,21.25000,12.75000,United Healthcare,Commercial,,17.28,,,,,,,13.60,17.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,United Healthcare,Commercial,,17.28,,,,,,,4.25,17.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,11.20,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,inpatient,1,UN,1.90000,1.14000,United Healthcare,Commercial,,1.54,,,,,,,1.22,1.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,United Healthcare,Commercial,,1.54,,,,,,,0.38038,1.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,inpatient,1,UN,23.95000,14.37000,United Healthcare,Commercial,,19.47,,,,,,,7.21,19.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,United Healthcare,Commercial,,0.41250,,,,,,,0.40120,17.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,inpatient,3,ML,22.40000,13.44000,United Healthcare,Commercial,,18.21,,,,,,,14.34,18.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,United Healthcare,Commercial,,18.21,,,,,,,4.48,18.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,inpatient,5,ML,196.60000,117.96000,United Healthcare,Commercial,,159.84,,,,,,,59.18,159.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,United Healthcare,Commercial,,5.94,,,,,,,4.77,145.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,inpatient,3,ML,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,10.88,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,inpatient,1.25,ML,48.40000,29.04000,United Healthcare,Commercial,,39.35,,,,,,,14.57,39.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,United Healthcare,Commercial,,0.42900,,,,,,,0.37760,35.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,inpatient,1,ML,29.70000,17.82000,United Healthcare,Commercial,,24.15,,,,,,,8.94,24.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,United Healthcare,Commercial,,2.46,,,,,,,1.79,22.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,inpatient,5,ML,7.50000,4.50000,United Healthcare,Commercial,,6.10,,,,,,,4.80,6.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,United Healthcare,Commercial,,6.10,,,,,,,1.50,6.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,inpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,11.04,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,10.75,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,inpatient,1,UN,20.75000,12.45000,United Healthcare,Commercial,,16.87,,,,,,,13.28,16.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,United Healthcare,Commercial,,16.87,,,,,,,4.15,16.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,inpatient,50,ML,81.40000,48.84000,United Healthcare,Commercial,,66.18,,,,,,,24.50,66.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,United Healthcare,Commercial,,3.61,,,,,,,3.07,60.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,inpatient,1,UN,3.35000,2.01000,United Healthcare,Commercial,,2.72,,,,,,,2.14,2.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,United Healthcare,Commercial,,2.72,,,,,,,0.67067,2.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,inpatient,10,ML,14.40000,8.64000,United Healthcare,Commercial,,11.71,,,,,,,9.22,11.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,United Healthcare,Commercial,,11.71,,,,,,,2.88,11.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,inpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,10.43,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,inpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,10.85,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,inpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,inpatient,1,UN,22.50000,13.50000,United Healthcare,Commercial,,18.29,,,,,,,14.40,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,Commercial,,18.29,,,,,,,4.50,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,inpatient,1,UN,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.83200,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,Commercial,,1.06,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,inpatient,1,UN,32.60000,19.56000,United Healthcare,Commercial,,26.50,,,,,,,20.86,26.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,United Healthcare,Commercial,,26.50,,,,,,,6.53,26.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,inpatient,5,ML,79.85000,47.91000,United Healthcare,Commercial,,64.92,,,,,,,24.03,64.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,United Healthcare,Commercial,,1.80,,,,,,,1.80,59.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,inpatient,1,UN,22.90000,13.74000,United Healthcare,Commercial,,18.62,,,,,,,14.66,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,United Healthcare,Commercial,,18.62,,,,,,,4.58,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,inpatient,1,UN,18.15000,10.89000,United Healthcare,Commercial,,14.76,,,,,,,11.62,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,Commercial,,14.76,,,,,,,3.63,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,inpatient,1,UN,18.85000,11.31000,United Healthcare,Commercial,,15.33,,,,,,,12.06,15.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,United Healthcare,Commercial,,15.33,,,,,,,3.77,15.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,inpatient,1,UN,19.90000,11.94000,United Healthcare,Commercial,,16.18,,,,,,,12.74,16.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,United Healthcare,Commercial,,16.18,,,,,,,3.98,16.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,inpatient,1,UN,164.50000,98.70000,United Healthcare,Commercial,,133.74,,,,,,,49.51,133.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,United Healthcare,Commercial,,0.33000,,,,,,,0.25960,122.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,inpatient,1,UN,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,10.53,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,inpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,11.01,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,inpatient,1,UN,84.35000,50.61000,United Healthcare,Commercial,,68.58,,,,,,,25.39,68.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,United Healthcare,Commercial,,25.97,,,,,,,4.55,62.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,inpatient,1,UN,31.35000,18.81000,United Healthcare,Commercial,,25.49,,,,,,,20.06,25.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,United Healthcare,Commercial,,25.49,,,,,,,6.28,25.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,inpatient,1,UN,7346.35000,4407.81000,United Healthcare,Commercial,,5972.58,,,,,,,2211.25,5972.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,United Healthcare,Commercial,,117.86,,,,,,,41.89,5452.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,inpatient,0.5,ML,28.10000,16.86000,United Healthcare,Commercial,,22.85,,,,,,,8.46,22.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,United Healthcare,Commercial,,14.59,,,,,,,5.63,20.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,inpatient,1,UN,76.80000,46.08000,United Healthcare,Commercial,,62.44,,,,,,,49.15,62.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,United Healthcare,Commercial,,62.44,,,,,,,15.38,62.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,inpatient,1,UN,31.70000,19.02000,United Healthcare,Commercial,,25.77,,,,,,,20.29,25.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,United Healthcare,Commercial,,25.77,,,,,,,6.35,25.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,inpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,10.88,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,inpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,10.78,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,inpatient,1.5,ML,2741.30000,1644.78000,United Healthcare,Commercial,,2228.68,,,,,,,1754.43,2228.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,United Healthcare,Commercial,,2228.68,,,,,,,548.81,2228.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,inpatient,2,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,56.45,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,inpatient,0.3,ML,39.90000,23.94000,United Healthcare,Commercial,,32.44,,,,,,,12.01,32.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,United Healthcare,Commercial,,48.11,,,,,,,7.99,48.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,inpatient,1,UN,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,16.86,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,5.28,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,inpatient,10,ML,97.15000,58.29000,United Healthcare,Commercial,,78.98,,,,,,,29.24,78.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,United Healthcare,Commercial,,3.81,,,,,,,3.42,72.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,inpatient,20,ML,101.60000,60.96000,United Healthcare,Commercial,,82.60,,,,,,,30.58,82.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,United Healthcare,Commercial,,3.81,,,,,,,3.42,75.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,inpatient,50,ML,147.00000,88.20000,United Healthcare,Commercial,,119.51,,,,,,,44.25,119.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,United Healthcare,Commercial,,3.81,,,,,,,3.42,109.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,inpatient,0.5,ML,25.85000,15.51000,United Healthcare,Commercial,,21.02,,,,,,,7.78,21.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,United Healthcare,Commercial,,12.39,,,,,,,5.14,19.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,inpatient,20,ML,1179.50000,707.70000,United Healthcare,Commercial,,958.93,,,,,,,355.03,958.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,United Healthcare,Commercial,,29.37,,,,,,,28.44,875.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,inpatient,10,ML,2255.00000,1353.00000,United Healthcare,Commercial,,1833.32,,,,,,,678.75,1833.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,United Healthcare,Commercial,,297.51,,,,,,,105.22,1673.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,inpatient,25,ML,5775.00000,3465.00000,United Healthcare,Commercial,,4695.07,,,,,,,1738.28,4695.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,United Healthcare,Commercial,,297.51,,,,,,,105.22,4286.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,inpatient,37.5,GR,5.90000,3.54000,United Healthcare,Commercial,,4.80,,,,,,,3.78,4.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,United Healthcare,Commercial,,4.80,,,,,,,1.18,4.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,inpatient,1,UN,2216.75000,1330.05000,United Healthcare,Commercial,,1802.22,,,,,,,1418.72,1802.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,United Healthcare,Commercial,,1802.22,,,,,,,443.79,1802.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,inpatient,1,UN,18.85000,11.31000,United Healthcare,Commercial,,15.33,,,,,,,12.06,15.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,United Healthcare,Commercial,,15.33,,,,,,,3.77,15.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,inpatient,1,UN,228.00000,136.80000,United Healthcare,Commercial,,185.36,,,,,,,145.92,185.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,United Healthcare,Commercial,,185.36,,,,,,,45.65,185.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,inpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,12.35,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,inpatient,1,UN,20.15000,12.09000,United Healthcare,Commercial,,16.38,,,,,,,12.90,16.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,United Healthcare,Commercial,,16.38,,,,,,,4.03,16.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,inpatient,1,UN,263.60000,158.16000,United Healthcare,Commercial,,214.31,,,,,,,168.70,214.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,United Healthcare,Commercial,,214.31,,,,,,,52.77,214.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,inpatient,1,UN,21.20000,12.72000,United Healthcare,Commercial,,17.24,,,,,,,13.57,17.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,United Healthcare,Commercial,,17.24,,,,,,,4.24,17.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,inpatient,1,UN,19.40000,11.64000,United Healthcare,Commercial,,15.77,,,,,,,12.42,15.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,United Healthcare,Commercial,,15.77,,,,,,,3.88,15.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,inpatient,1,UN,23.10000,13.86000,United Healthcare,Commercial,,18.78,,,,,,,14.78,18.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,United Healthcare,Commercial,,18.78,,,,,,,4.62,18.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,inpatient,1,UN,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,14.50,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,inpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,12.80,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,inpatient,1,UN,25.90000,15.54000,United Healthcare,Commercial,,21.06,,,,,,,16.58,21.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,United Healthcare,Commercial,,21.06,,,,,,,5.19,21.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,inpatient,1,UN,101.20000,60.72000,United Healthcare,Commercial,,82.28,,,,,,,64.77,82.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,United Healthcare,Commercial,,82.28,,,,,,,20.26,82.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,inpatient,5,ML,607.05000,364.23000,United Healthcare,Commercial,,493.53,,,,,,,388.51,493.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,United Healthcare,Commercial,,493.53,,,,,,,121.53,493.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,inpatient,2000,ML,180.85000,108.51000,United Healthcare,Commercial,,147.03,,,,,,,54.44,147.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,inpatient,2000,ML,180.85000,108.51000,United Healthcare,Commercial,,147.03,,,,,,,54.44,147.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,inpatient,2000,ML,194.50000,116.70000,United Healthcare,Commercial,,158.13,,,,,,,58.54,158.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,inpatient,2000,ML,195.65000,117.39000,United Healthcare,Commercial,,159.06,,,,,,,58.89,159.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,11.42,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,inpatient,1,UN,3.70000,2.22000,United Healthcare,Commercial,,3.01,,,,,,,2.37,3.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,United Healthcare,Commercial,,3.01,,,,,,,0.74074,3.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,inpatient,1,UN,3.70000,2.22000,United Healthcare,Commercial,,3.01,,,,,,,2.37,3.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,United Healthcare,Commercial,,3.01,,,,,,,0.74074,3.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,inpatient,1,UN,3.90000,2.34000,United Healthcare,Commercial,,3.17,,,,,,,2.50,3.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,United Healthcare,Commercial,,3.17,,,,,,,0.78078,3.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,inpatient,1,UN,35.65000,21.39000,United Healthcare,Commercial,,28.98,,,,,,,22.82,28.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,United Healthcare,Commercial,,28.98,,,,,,,7.14,28.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,inpatient,1,UN,43.40000,26.04000,United Healthcare,Commercial,,35.28,,,,,,,27.78,35.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,United Healthcare,Commercial,,35.28,,,,,,,8.69,35.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,inpatient,1,UN,60.00000,36.00000,United Healthcare,Commercial,,48.78,,,,,,,38.40,48.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,United Healthcare,Commercial,,48.78,,,,,,,12.01,48.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,inpatient,1,UN,82.10000,49.26000,United Healthcare,Commercial,,66.75,,,,,,,52.54,66.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,United Healthcare,Commercial,,66.75,,,,,,,16.44,66.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,inpatient,1,UN,104.70000,62.82000,United Healthcare,Commercial,,85.12,,,,,,,67.01,85.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,United Healthcare,Commercial,,85.12,,,,,,,20.96,85.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,inpatient,1000,ML,220.75000,132.45000,United Healthcare,Commercial,,179.47,,,,,,,141.28,179.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,United Healthcare,Commercial,,179.47,,,,,,,44.19,179.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,inpatient,15,ML,13.40000,8.04000,United Healthcare,Commercial,,10.89,,,,,,,8.58,10.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,United Healthcare,Commercial,,10.89,,,,,,,2.68,10.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,inpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.92800,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,inpatient,1,UN,1011.80000,607.08000,United Healthcare,Commercial,,822.59,,,,,,,647.55,822.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,United Healthcare,Commercial,,822.59,,,,,,,202.56,822.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,inpatient,56,GR,8.05000,4.83000,United Healthcare,Commercial,,6.54,,,,,,,5.15,6.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,United Healthcare,Commercial,,6.54,,,,,,,1.61,6.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,inpatient,1000,ML,114.00000,68.40000,United Healthcare,Commercial,,92.68,,,,,,,72.96,92.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,United Healthcare,Commercial,,92.68,,,,,,,22.82,92.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,inpatient,1,UN,23.15000,13.89000,United Healthcare,Commercial,,18.82,,,,,,,14.82,18.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,United Healthcare,Commercial,,18.82,,,,,,,4.63,18.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,inpatient,1,UN,26.50000,15.90000,United Healthcare,Commercial,,21.54,,,,,,,16.96,21.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,United Healthcare,Commercial,,21.54,,,,,,,5.31,21.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,inpatient,1,UN,30.00000,18.00000,United Healthcare,Commercial,,24.39,,,,,,,19.20,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,Commercial,,24.39,,,,,,,6.01,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,inpatient,150,ML,752.65000,451.59000,United Healthcare,Commercial,,611.90,,,,,,,481.70,611.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,United Healthcare,Commercial,,611.90,,,,,,,150.68,611.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,inpatient,1,UN,18.35000,11.01000,United Healthcare,Commercial,,14.92,,,,,,,11.74,14.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,United Healthcare,Commercial,,14.92,,,,,,,3.67,14.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,inpatient,10,ML,308.40000,185.04000,United Healthcare,Commercial,,250.73,,,,,,,92.83,250.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,228.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,inpatient,1,UN,24.10000,14.46000,United Healthcare,Commercial,,19.59,,,,,,,15.42,19.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,United Healthcare,Commercial,,19.59,,,,,,,4.82,19.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,inpatient,1000,ML,93.00000,55.80000,United Healthcare,Commercial,,75.61,,,,,,,59.52,75.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,United Healthcare,Commercial,,75.61,,,,,,,18.62,75.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,inpatient,2000,ML,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,51.84,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,inpatient,1,UN,92.30000,55.38000,United Healthcare,Commercial,,75.04,,,,,,,59.07,75.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,United Healthcare,Commercial,,75.04,,,,,,,18.48,75.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,inpatient,1,UN,90.30000,54.18000,United Healthcare,Commercial,,73.41,,,,,,,57.79,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,United Healthcare,Commercial,,73.41,,,,,,,18.08,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,0.1,ML,22.85000,13.71000,United Healthcare,Commercial,,18.58,,,,,,,6.88,18.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,United Healthcare,Commercial,,1.58,,,,,,,1.13,16.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,inpatient,1,UN,20.30000,12.18000,United Healthcare,Commercial,,16.50,,,,,,,12.99,16.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,United Healthcare,Commercial,,16.50,,,,,,,4.06,16.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,inpatient,1,UN,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,11.58,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,inpatient,2,ML,46.15000,27.69000,United Healthcare,Commercial,,37.52,,,,,,,29.54,37.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,United Healthcare,Commercial,,37.52,,,,,,,9.24,37.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,inpatient,2,ML,51.50000,30.90000,United Healthcare,Commercial,,41.87,,,,,,,32.96,41.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,United Healthcare,Commercial,,41.87,,,,,,,10.31,41.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,inpatient,10,ML,267.70000,160.62000,United Healthcare,Commercial,,217.64,,,,,,,171.33,217.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,United Healthcare,Commercial,,217.64,,,,,,,53.59,217.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,inpatient,1,UN,27.90000,16.74000,United Healthcare,Commercial,,22.68,,,,,,,8.40,22.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,United Healthcare,Commercial,,2.10,,,,,,,1.89,20.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,inpatient,1,UN,63.15000,37.89000,United Healthcare,Commercial,,51.34,,,,,,,19.01,51.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,United Healthcare,Commercial,,5.64,,,,,,,4.81,46.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,inpatient,10,GR,599.15000,359.49000,United Healthcare,Commercial,,487.11,,,,,,,383.46,487.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,United Healthcare,Commercial,,487.11,,,,,,,119.95,487.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,inpatient,1,GR,37.75000,22.65000,United Healthcare,Commercial,,30.69,,,,,,,24.16,30.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,United Healthcare,Commercial,,30.69,,,,,,,7.56,30.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,inpatient,1,UN,62.45000,37.47000,United Healthcare,Commercial,,50.77,,,,,,,39.97,50.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,United Healthcare,Commercial,,50.77,,,,,,,12.50,50.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,inpatient,1,UN,3520.00000,2112.00000,United Healthcare,Commercial,,2861.76,,,,,,,1059.52,2861.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,United Healthcare,Commercial,,824.70,,,,,,,318.49,2612.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,inpatient,160,ML,1552.00000,931.20000,United Healthcare,Commercial,,1261.78,,,,,,,993.28,1261.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,United Healthcare,Commercial,,1261.78,,,,,,,310.71,1261.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,inpatient,2.5,ML,1204.10000,722.46000,United Healthcare,Commercial,,978.93,,,,,,,362.43,978.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,United Healthcare,Commercial,,2.01,,,,,,,0.77600,893.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,inpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,11.39,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,inpatient,1,UN,216.00000,129.60000,United Healthcare,Commercial,,175.61,,,,,,,138.24,175.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,United Healthcare,Commercial,,175.61,,,,,,,43.24,175.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,inpatient,5,ML,115.25000,69.15000,United Healthcare,Commercial,,93.70,,,,,,,73.76,93.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,United Healthcare,Commercial,,93.70,,,,,,,23.07,93.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,inpatient,1,UN,523.95000,314.37000,United Healthcare,Commercial,,425.97,,,,,,,157.71,425.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,United Healthcare,Commercial,,204.32,,,,,,,104.89,388.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,inpatient,1,UN,698.50000,419.10000,United Healthcare,Commercial,,567.88,,,,,,,210.25,567.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,United Healthcare,Commercial,,1.58,,,,,,,1.13,518.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,inpatient,10,ML,1199.00000,719.40000,United Healthcare,Commercial,,974.79,,,,,,,360.90,974.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,United Healthcare,Commercial,,15.96,,,,,,,7.91,889.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,inpatient,5,ML,335.80000,201.48000,United Healthcare,Commercial,,273.01,,,,,,,101.08,273.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,United Healthcare,Commercial,,0.59400,,,,,,,0.54280,249.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,inpatient,473,ML,349.50000,209.70000,United Healthcare,Commercial,,284.14,,,,,,,223.68,284.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,United Healthcare,Commercial,,284.14,,,,,,,69.97,284.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,inpatient,1,UN,19.10000,11.46000,United Healthcare,Commercial,,15.53,,,,,,,12.22,15.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,United Healthcare,Commercial,,15.53,,,,,,,3.82,15.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,inpatient,1,UN,19.25000,11.55000,United Healthcare,Commercial,,15.65,,,,,,,12.32,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,United Healthcare,Commercial,,15.65,,,,,,,3.85,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,inpatient,1,UN,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,13.66,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,inpatient,2,GR,28.45000,17.07000,United Healthcare,Commercial,,23.13,,,,,,,18.21,23.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,United Healthcare,Commercial,,23.13,,,,,,,5.70,23.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,inpatient,5,ML,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,5.81,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,United Healthcare,Commercial,,0.74250,,,,,,,0.54280,14.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,inpatient,1,UN,12869.00000,7721.40000,United Healthcare,Commercial,,10462.50,,,,,,,3873.57,10462.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,United Healthcare,Commercial,,5066.92,,,,,,,1773.86,9551.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,inpatient,1,ML,52.40000,31.44000,United Healthcare,Commercial,,42.60,,,,,,,15.77,42.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,United Healthcare,Commercial,,27.51,,,,,,,10.49,38.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,inpatient,1,UN,357.25000,214.35000,United Healthcare,Commercial,,290.44,,,,,,,107.53,290.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,United Healthcare,Commercial,,0.46200,,,,,,,0.40120,265.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,inpatient,15,GR,66.60000,39.96000,United Healthcare,Commercial,,54.15,,,,,,,42.62,54.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,United Healthcare,Commercial,,54.15,,,,,,,13.33,54.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,inpatient,1,UN,17.75000,10.65000,United Healthcare,Commercial,,14.43,,,,,,,11.36,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,United Healthcare,Commercial,,14.43,,,,,,,3.55,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,inpatient,44,ML,2.45000,1.47000,United Healthcare,Commercial,,1.99,,,,,,,1.57,1.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,United Healthcare,Commercial,,1.99,,,,,,,0.49049,1.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,inpatient,88,ML,4.45000,2.67000,United Healthcare,Commercial,,3.62,,,,,,,2.85,3.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,United Healthcare,Commercial,,3.62,,,,,,,0.89089,3.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,inpatient,1,UN,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,13.66,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,inpatient,1,UN,27.10000,16.26000,United Healthcare,Commercial,,22.03,,,,,,,17.34,22.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,United Healthcare,Commercial,,22.03,,,,,,,5.43,22.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,inpatient,250,ML,693.00000,415.80000,United Healthcare,Commercial,,563.41,,,,,,,208.59,563.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,United Healthcare,Commercial,,0.75900,,,,,,,0.51920,514.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,inpatient,1,UN,19.50000,11.70000,United Healthcare,Commercial,,15.85,,,,,,,12.48,15.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,Commercial,,15.85,,,,,,,3.90,15.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,inpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,10.91,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,inpatient,1,UN,19.50000,11.70000,United Healthcare,Commercial,,15.85,,,,,,,12.48,15.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,Commercial,,15.85,,,,,,,3.90,15.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,inpatient,1,UN,21.60000,12.96000,United Healthcare,Commercial,,17.56,,,,,,,13.82,17.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,United Healthcare,Commercial,,17.56,,,,,,,4.32,17.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,inpatient,1,UN,83.10000,49.86000,United Healthcare,Commercial,,67.56,,,,,,,25.01,67.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,United Healthcare,Commercial,,4.64,,,,,,,1.65,61.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,inpatient,1,UN,369.65000,221.79000,United Healthcare,Commercial,,300.53,,,,,,,236.58,300.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,United Healthcare,Commercial,,300.53,,,,,,,74.00,300.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,inpatient,1000,ML,420.00000,252.00000,United Healthcare,Commercial,,341.46,,,,,,,268.80,341.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,United Healthcare,Commercial,,341.46,,,,,,,84.08,341.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,inpatient,1,ML,28.65000,17.19000,United Healthcare,Commercial,,23.29,,,,,,,8.62,23.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,United Healthcare,Commercial,,2.61,,,,,,,2.60,21.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,inpatient,10,ML,42.40000,25.44000,United Healthcare,Commercial,,34.47,,,,,,,12.76,34.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,United Healthcare,Commercial,,2.61,,,,,,,2.60,31.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,inpatient,2,ML,28.40000,17.04000,United Healthcare,Commercial,,23.09,,,,,,,8.55,23.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,United Healthcare,Commercial,,2.61,,,,,,,2.60,21.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,inpatient,20,ML,53.45000,32.07000,United Healthcare,Commercial,,43.45,,,,,,,16.09,43.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,United Healthcare,Commercial,,2.61,,,,,,,2.60,39.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,inpatient,5,ML,31.00000,18.60000,United Healthcare,Commercial,,25.20,,,,,,,9.33,25.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,United Healthcare,Commercial,,2.61,,,,,,,2.60,23.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,inpatient,5,ML,25.95000,15.57000,United Healthcare,Commercial,,21.10,,,,,,,16.61,21.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,United Healthcare,Commercial,,21.10,,,,,,,5.20,21.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,inpatient,1,UN,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,inpatient,100,ML,119.90000,71.94000,United Healthcare,Commercial,,97.48,,,,,,,76.74,97.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,United Healthcare,Commercial,,97.48,,,,,,,24.00,97.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,inpatient,5,ML,6.30000,3.78000,United Healthcare,Commercial,,5.12,,,,,,,4.03,5.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,United Healthcare,Commercial,,5.12,,,,,,,1.26,5.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,inpatient,150,ML,94.00000,56.40000,United Healthcare,Commercial,,76.42,,,,,,,28.29,76.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,United Healthcare,Commercial,,2.61,,,,,,,2.60,69.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,inpatient,100,ML,86.50000,51.90000,United Healthcare,Commercial,,70.32,,,,,,,55.36,70.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,United Healthcare,Commercial,,70.32,,,,,,,17.32,70.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,inpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,inpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,11.07,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,inpatient,16.7,ML,465.05000,279.03000,United Healthcare,Commercial,,378.09,,,,,,,139.98,378.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,United Healthcare,Commercial,,0.29700,,,,,,,0.29700,345.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,inpatient,5,ML,319.00000,191.40000,United Healthcare,Commercial,,259.35,,,,,,,96.02,259.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,United Healthcare,Commercial,,0.29700,,,,,,,0.29700,236.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,inpatient,50,ML,843.95000,506.37000,United Healthcare,Commercial,,686.13,,,,,,,254.03,686.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,United Healthcare,Commercial,,0.29700,,,,,,,0.29700,626.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,inpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,inpatient,5,ML,20.50000,12.30000,United Healthcare,Commercial,,16.67,,,,,,,13.12,16.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,United Healthcare,Commercial,,16.67,,,,,,,4.10,16.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,inpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,14.15,,,,,,,11.14,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,14.15,,,,,,,3.48,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,11.42,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,inpatient,2,ML,265.05000,159.03000,United Healthcare,Commercial,,215.49,,,,,,,169.63,215.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,United Healthcare,Commercial,,215.49,,,,,,,53.06,215.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,inpatient,1,UN,858.55000,515.13000,United Healthcare,Commercial,,698.00,,,,,,,258.42,698.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,United Healthcare,Commercial,,256.33,,,,,,,91.62,637.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,inpatient,1,UN,19973.00000,11983.80000,United Healthcare,Commercial,,16238.05,,,,,,,6011.87,16238.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,United Healthcare,Commercial,,13526.96,,,,,,,3998.59,14823.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,inpatient,1,UN,33.80000,20.28000,United Healthcare,Commercial,,27.48,,,,,,,21.63,27.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,United Healthcare,Commercial,,27.48,,,,,,,6.77,27.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,inpatient,3,ML,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,13.66,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,inpatient,3,ML,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,13.66,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,United Healthcare,Commercial,,17.36,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,inpatient,1,UN,183.15000,109.89000,United Healthcare,Commercial,,148.90,,,,,,,117.22,148.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,United Healthcare,Commercial,,148.90,,,,,,,36.67,148.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,inpatient,60,ML,116.30000,69.78000,United Healthcare,Commercial,,94.55,,,,,,,74.43,94.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,United Healthcare,Commercial,,94.55,,,,,,,23.28,94.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,inpatient,1,UN,29.90000,17.94000,United Healthcare,Commercial,,24.31,,,,,,,19.14,24.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,United Healthcare,Commercial,,24.31,,,,,,,5.99,24.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,inpatient,15,GR,125.35000,75.21000,United Healthcare,Commercial,,101.91,,,,,,,80.22,101.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,United Healthcare,Commercial,,101.91,,,,,,,25.10,101.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,inpatient,15,GR,71.50000,42.90000,United Healthcare,Commercial,,58.13,,,,,,,45.76,58.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,United Healthcare,Commercial,,58.13,,,,,,,14.31,58.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,inpatient,60,ML,190.10000,114.06000,United Healthcare,Commercial,,154.55,,,,,,,121.66,154.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,United Healthcare,Commercial,,154.55,,,,,,,38.06,154.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,inpatient,1,ML,84.55000,50.73000,United Healthcare,Commercial,,68.74,,,,,,,25.45,68.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,United Healthcare,Commercial,,1.55,,,,,,,1.39,62.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,inpatient,5,ML,521.30000,312.78000,United Healthcare,Commercial,,423.82,,,,,,,333.63,423.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,United Healthcare,Commercial,,423.82,,,,,,,104.36,423.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,inpatient,0.5,ML,59.70000,35.82000,United Healthcare,Commercial,,48.54,,,,,,,17.97,48.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,United Healthcare,Commercial,,20.23,,,,,,,7.12,44.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,inpatient,1,UN,22.00000,13.20000,United Healthcare,Commercial,,17.89,,,,,,,14.08,17.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,Commercial,,17.89,,,,,,,4.40,17.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,inpatient,1,UN,28.60000,17.16000,United Healthcare,Commercial,,23.25,,,,,,,18.30,23.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,United Healthcare,Commercial,,23.25,,,,,,,5.73,23.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,inpatient,0.5,ML,121.05000,72.63000,United Healthcare,Commercial,,98.41,,,,,,,36.44,98.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,United Healthcare,Commercial,,1.96,,,,,,,1.70,89.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Commercial,,23754.15,,,,,,,8794.59,23754.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Commercial,,158.99,,,,,,,86.66,21685.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,inpatient,0.2,ML,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,5.55,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,United Healthcare,Commercial,,0.16500,,,,,,,0.14160,13.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,inpatient,3,ML,36.65000,21.99000,United Healthcare,Commercial,,29.80,,,,,,,23.46,29.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,United Healthcare,Commercial,,29.80,,,,,,,7.34,29.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,10.75,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,inpatient,1,UN,22.15000,13.29000,United Healthcare,Commercial,,18.01,,,,,,,14.18,18.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,United Healthcare,Commercial,,18.01,,,,,,,4.43,18.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,inpatient,1,UN,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,14.30,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,4.47,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,inpatient,5,ML,93.35000,56.01000,United Healthcare,Commercial,,75.89,,,,,,,28.10,75.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,United Healthcare,Commercial,,30.38,,,,,,,18.69,69.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,inpatient,1,UN,2978.05000,1786.83000,United Healthcare,Commercial,,2421.15,,,,,,,896.39,2421.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,United Healthcare,Commercial,,11.80,,,,,,,6.30,2210.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,inpatient,1,UN,35.80000,21.48000,United Healthcare,Commercial,,29.11,,,,,,,22.91,29.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,United Healthcare,Commercial,,29.11,,,,,,,7.17,29.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,inpatient,1.6666666666666665,ML,128.65000,77.19000,United Healthcare,Commercial,,104.59,,,,,,,38.72,104.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,United Healthcare,Commercial,,30.38,,,,,,,22.75,95.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,inpatient,1,UN,2262.45000,1357.47000,United Healthcare,Commercial,,1839.37,,,,,,,681.00,1839.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,United Healthcare,Commercial,,423.13,,,,,,,171.16,1679.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,inpatient,10,ML,42.60000,25.56000,United Healthcare,Commercial,,34.63,,,,,,,12.82,34.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,31.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,inpatient,2,ML,35.05000,21.03000,United Healthcare,Commercial,,28.50,,,,,,,10.55,28.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,26.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,inpatient,4,ML,29.35000,17.61000,United Healthcare,Commercial,,23.86,,,,,,,8.83,23.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,21.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,inpatient,120,ML,55.25000,33.15000,United Healthcare,Commercial,,44.92,,,,,,,35.36,44.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,United Healthcare,Commercial,,44.92,,,,,,,11.06,44.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,inpatient,60,ML,36.20000,21.72000,United Healthcare,Commercial,,29.43,,,,,,,23.17,29.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,United Healthcare,Commercial,,29.43,,,,,,,7.25,29.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,inpatient,20,ML,5230.30000,3138.18000,United Healthcare,Commercial,,4252.23,,,,,,,1574.32,4252.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,United Healthcare,Commercial,,151.04,,,,,,,53.07,3881.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,inpatient,20,ML,13051.70000,7831.02000,United Healthcare,Commercial,,10611.03,,,,,,,3928.56,10611.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,United Healthcare,Commercial,,151.04,,,,,,,53.07,9686.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,inpatient,20,ML,26087.25000,15652.35000,United Healthcare,Commercial,,21208.93,,,,,,,7852.26,21208.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,United Healthcare,Commercial,,151.04,,,,,,,53.07,19361.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,inpatient,20,ML,52158.50000,31295.10000,United Healthcare,Commercial,,42404.86,,,,,,,15699.71,42404.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,United Healthcare,Commercial,,151.04,,,,,,,53.07,38712.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,10.75,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,inpatient,100,ML,180.95000,108.57000,United Healthcare,Commercial,,147.11,,,,,,,54.47,147.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,United Healthcare,Commercial,,3.81,,,,,,,3.42,134.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,inpatient,1,UN,399.60000,239.76000,United Healthcare,Commercial,,324.87,,,,,,,255.74,324.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,United Healthcare,Commercial,,324.87,,,,,,,80.00,324.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,inpatient,1,UN,25.50000,15.30000,United Healthcare,Commercial,,20.73,,,,,,,16.32,20.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,United Healthcare,Commercial,,20.73,,,,,,,5.11,20.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,inpatient,1,UN,50.15000,30.09000,United Healthcare,Commercial,,40.77,,,,,,,32.10,40.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,United Healthcare,Commercial,,40.77,,,,,,,10.04,40.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,inpatient,1,UN,147.80000,88.68000,United Healthcare,Commercial,,120.16,,,,,,,94.59,120.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,United Healthcare,Commercial,,120.16,,,,,,,29.59,120.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,inpatient,1,UN,316.30000,189.78000,United Healthcare,Commercial,,257.15,,,,,,,95.21,257.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,United Healthcare,Commercial,,2.13,,,,,,,1.82,234.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,inpatient,1,UN,18.40000,11.04000,United Healthcare,Commercial,,14.96,,,,,,,11.78,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,Commercial,,14.96,,,,,,,3.68,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,inpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,11.39,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,inpatient,50,ML,48.40000,29.04000,United Healthcare,Commercial,,39.35,,,,,,,30.98,39.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,United Healthcare,Commercial,,39.35,,,,,,,9.69,39.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,inpatient,75,ML,50.45000,30.27000,United Healthcare,Commercial,,41.02,,,,,,,32.29,41.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,United Healthcare,Commercial,,41.02,,,,,,,10.10,41.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,inpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,10.88,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Commercial,,13.82,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,inpatient,1,UN,17.95000,10.77000,United Healthcare,Commercial,,14.59,,,,,,,11.49,14.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,United Healthcare,Commercial,,14.59,,,,,,,3.59,14.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,inpatient,1,UN,4712.40000,2827.44000,United Healthcare,Commercial,,3831.18,,,,,,,1418.43,3831.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,United Healthcare,Commercial,,1024.96,,,,,,,366.19,3497.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,inpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,10.91,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,inpatient,1,UN,57.35000,34.41000,United Healthcare,Commercial,,46.63,,,,,,,36.70,46.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,United Healthcare,Commercial,,46.63,,,,,,,11.48,46.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,inpatient,15,GR,134.50000,80.70000,United Healthcare,Commercial,,109.35,,,,,,,86.08,109.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,United Healthcare,Commercial,,109.35,,,,,,,26.93,109.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,inpatient,2,ML,37.15000,22.29000,United Healthcare,Commercial,,30.20,,,,,,,11.18,30.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,United Healthcare,Commercial,,7.13,,,,,,,5.22,27.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,United Healthcare,Commercial,,136.30,,,,,,,50.46,136.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,United Healthcare,Commercial,,7.13,,,,,,,5.22,124.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,inpatient,1,UN,48.90000,29.34000,United Healthcare,Commercial,,39.76,,,,,,,31.30,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,United Healthcare,Commercial,,39.76,,,,,,,9.79,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,inpatient,1,UN,21.90000,13.14000,United Healthcare,Commercial,,17.80,,,,,,,14.02,17.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,United Healthcare,Commercial,,17.80,,,,,,,4.38,17.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,inpatient,1,UN,22.50000,13.50000,United Healthcare,Commercial,,18.29,,,,,,,14.40,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,Commercial,,18.29,,,,,,,4.50,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,inpatient,1,UN,22.90000,13.74000,United Healthcare,Commercial,,18.62,,,,,,,14.66,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,United Healthcare,Commercial,,18.62,,,,,,,4.58,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,inpatient,0.5,ML,321.65000,192.99000,United Healthcare,Commercial,,261.50,,,,,,,96.82,261.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,United Healthcare,Commercial,,336.47,,,,,,,64.39,336.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,inpatient,1,UN,21.50000,12.90000,United Healthcare,Commercial,,17.48,,,,,,,13.76,17.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,United Healthcare,Commercial,,17.48,,,,,,,4.30,17.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,inpatient,1,UN,26.25000,15.75000,United Healthcare,Commercial,,21.34,,,,,,,16.80,21.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,United Healthcare,Commercial,,21.34,,,,,,,5.26,21.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,inpatient,1,UN,37.10000,22.26000,United Healthcare,Commercial,,30.16,,,,,,,11.17,30.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,United Healthcare,Commercial,,27.06,,,,,,,7.43,27.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,inpatient,1,ML,27.85000,16.71000,United Healthcare,Commercial,,22.64,,,,,,,8.38,22.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,United Healthcare,Commercial,,1.17,,,,,,,0.44620,20.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,inpatient,7.5,ML,465.05000,279.03000,United Healthcare,Commercial,,378.09,,,,,,,297.63,378.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,United Healthcare,Commercial,,378.09,,,,,,,93.10,378.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,inpatient,473,ML,11.30000,6.78000,United Healthcare,Commercial,,9.19,,,,,,,7.23,9.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,United Healthcare,Commercial,,9.19,,,,,,,2.26,9.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,inpatient,2.5,ML,1.65000,0.99000,United Healthcare,Commercial,,1.34,,,,,,,1.06,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,United Healthcare,Commercial,,1.34,,,,,,,0.33033,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,inpatient,2.5,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,inpatient,1,UN,1034.85000,620.91000,United Healthcare,Commercial,,841.33,,,,,,,311.49,841.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,United Healthcare,Commercial,,7.41,,,,,,,6.44,768.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,inpatient,1,UN,24.85000,14.91000,United Healthcare,Commercial,,20.20,,,,,,,15.90,20.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,United Healthcare,Commercial,,20.20,,,,,,,4.97,20.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,inpatient,1,UN,24.80000,14.88000,United Healthcare,Commercial,,20.16,,,,,,,15.87,20.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,United Healthcare,Commercial,,20.16,,,,,,,4.96,20.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,inpatient,5,ML,252.00000,151.20000,United Healthcare,Commercial,,204.88,,,,,,,75.85,204.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,United Healthcare,Commercial,,14.16,,,,,,,11.94,187.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,inpatient,1,UN,30.00000,18.00000,United Healthcare,Commercial,,24.39,,,,,,,19.20,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,Commercial,,24.39,,,,,,,6.01,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,inpatient,1,UN,32.35000,19.41000,United Healthcare,Commercial,,26.30,,,,,,,20.70,26.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,United Healthcare,Commercial,,26.30,,,,,,,6.48,26.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,inpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,11.33,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,inpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,11.30,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,inpatient,1,UN,18.25000,10.95000,United Healthcare,Commercial,,14.84,,,,,,,11.68,14.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,United Healthcare,Commercial,,14.84,,,,,,,3.65,14.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,inpatient,1,UN,19.65000,11.79000,United Healthcare,Commercial,,15.98,,,,,,,12.58,15.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,United Healthcare,Commercial,,15.98,,,,,,,3.93,15.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,United Healthcare,Commercial,,5957.83,,,,,,,2205.79,5957.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,United Healthcare,Commercial,,4.32,,,,,,,4.32,5438.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.4,ML,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,5.31,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,United Healthcare,Commercial,,2.29,,,,,,,1.89,13.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,inpatient,1,ML,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,11.58,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,inpatient,1,ML,20.20000,12.12000,United Healthcare,Commercial,,16.42,,,,,,,12.93,16.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,United Healthcare,Commercial,,16.42,,,,,,,4.04,16.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,inpatient,1,ML,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,10.72,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,United Healthcare,Commercial,,13.62,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,inpatient,1000,ML,87.50000,52.50000,United Healthcare,Commercial,,71.14,,,,,,,26.34,71.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,64.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,inpatient,1,UN,6248.60000,3749.16000,United Healthcare,Commercial,,5080.11,,,,,,,1880.83,5080.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,United Healthcare,Commercial,,110.42,,,,,,,43.26,4637.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,inpatient,1,UN,87.55000,52.53000,United Healthcare,Commercial,,71.18,,,,,,,56.03,71.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,United Healthcare,Commercial,,71.18,,,,,,,17.53,71.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,inpatient,1,UN,24.00000,14.40000,United Healthcare,Commercial,,19.51,,,,,,,15.36,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,United Healthcare,Commercial,,19.51,,,,,,,4.80,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,inpatient,1,UN,48.90000,29.34000,United Healthcare,Commercial,,39.76,,,,,,,31.30,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,United Healthcare,Commercial,,39.76,,,,,,,9.79,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,inpatient,473,ML,96.90000,58.14000,United Healthcare,Commercial,,78.78,,,,,,,62.02,78.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,United Healthcare,Commercial,,78.78,,,,,,,19.40,78.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,inpatient,473,ML,105.40000,63.24000,United Healthcare,Commercial,,85.69,,,,,,,67.46,85.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,United Healthcare,Commercial,,85.69,,,,,,,21.10,85.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,inpatient,1,UN,21.25000,12.75000,United Healthcare,Commercial,,17.28,,,,,,,13.60,17.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,United Healthcare,Commercial,,17.28,,,,,,,4.25,17.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,10,ML,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.96000,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,United Healthcare,Commercial,,1.22,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,inpatient,1,UN,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,11.97,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,inpatient,1,ML,70.60000,42.36000,United Healthcare,Commercial,,57.40,,,,,,,21.25,57.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,United Healthcare,Commercial,,14.12,,,,,,,13.22,52.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,inpatient,177,ML,4.85000,2.91000,United Healthcare,Commercial,,3.94,,,,,,,3.10,3.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,United Healthcare,Commercial,,3.94,,,,,,,0.97097,3.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,inpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,10.85,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,inpatient,1,UN,28.40000,17.04000,United Healthcare,Commercial,,23.09,,,,,,,18.18,23.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,United Healthcare,Commercial,,23.09,,,,,,,5.69,23.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,inpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,10.78,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,inpatient,1,UN,483.00000,289.80000,United Healthcare,Commercial,,392.68,,,,,,,145.38,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,358.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,inpatient,1,UN,17.95000,10.77000,United Healthcare,Commercial,,14.59,,,,,,,11.49,14.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,United Healthcare,Commercial,,14.59,,,,,,,3.59,14.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,inpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,10.37,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,inpatient,5,ML,23.60000,14.16000,United Healthcare,Commercial,,19.19,,,,,,,15.10,19.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,United Healthcare,Commercial,,19.19,,,,,,,4.72,19.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,inpatient,28,GR,4.30000,2.58000,United Healthcare,Commercial,,3.50,,,,,,,2.75,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,United Healthcare,Commercial,,3.50,,,,,,,0.86086,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,inpatient,28,GR,27.45000,16.47000,United Healthcare,Commercial,,22.32,,,,,,,17.57,22.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,United Healthcare,Commercial,,22.32,,,,,,,5.50,22.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,inpatient,28,GR,4.30000,2.58000,United Healthcare,Commercial,,3.50,,,,,,,2.75,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,United Healthcare,Commercial,,3.50,,,,,,,0.86086,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,inpatient,28.35,GR,25.90000,15.54000,United Healthcare,Commercial,,21.06,,,,,,,16.58,21.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,United Healthcare,Commercial,,21.06,,,,,,,5.19,21.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,inpatient,1,UN,17.15000,10.29000,United Healthcare,Commercial,,13.94,,,,,,,10.98,13.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,United Healthcare,Commercial,,13.94,,,,,,,3.43,13.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,inpatient,1,UN,62.00000,37.20000,United Healthcare,Commercial,,50.41,,,,,,,39.68,50.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,United Healthcare,Commercial,,50.41,,,,,,,12.41,50.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,inpatient,473,ML,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,1.12,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,United Healthcare,Commercial,,1.42,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,inpatient,1,UN,22.55000,13.53000,United Healthcare,Commercial,,18.33,,,,,,,14.43,18.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,United Healthcare,Commercial,,18.33,,,,,,,4.51,18.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,inpatient,0.1,ML,23.30000,13.98000,United Healthcare,Commercial,,18.94,,,,,,,7.01,18.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,17.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,inpatient,1,UN,22.55000,13.53000,United Healthcare,Commercial,,18.33,,,,,,,14.43,18.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,United Healthcare,Commercial,,18.33,,,,,,,4.51,18.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,inpatient,30,ML,8.35000,5.01000,United Healthcare,Commercial,,6.79,,,,,,,5.34,6.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,United Healthcare,Commercial,,6.79,,,,,,,1.67,6.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,inpatient,1,UN,22.70000,13.62000,United Healthcare,Commercial,,18.46,,,,,,,14.53,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,Commercial,,18.46,,,,,,,4.54,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,inpatient,1,UN,16.10000,9.66000,United Healthcare,Commercial,,13.09,,,,,,,10.30,13.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,United Healthcare,Commercial,,13.09,,,,,,,3.22,13.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,inpatient,100,ML,113.50000,68.10000,United Healthcare,Commercial,,92.28,,,,,,,72.64,92.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,United Healthcare,Commercial,,92.28,,,,,,,22.72,92.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,inpatient,1,ML,169.40000,101.64000,United Healthcare,Commercial,,137.72,,,,,,,50.99,137.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,United Healthcare,Commercial,,46.08,,,,,,,33.91,125.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,inpatient,1,UN,27.85000,16.71000,United Healthcare,Commercial,,22.64,,,,,,,17.82,22.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,United Healthcare,Commercial,,22.64,,,,,,,5.58,22.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,inpatient,10,ML,31.35000,18.81000,United Healthcare,Commercial,,25.49,,,,,,,20.06,25.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,United Healthcare,Commercial,,25.49,,,,,,,6.28,25.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,inpatient,1,UN,18064.20000,10838.52000,United Healthcare,Commercial,,14686.19,,,,,,,5437.32,14686.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,United Healthcare,Commercial,,10.15,,,,,,,4.23,13407.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,3215.90,,,,,,,1190.64,3215.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,213.64,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,inpatient,1,UN,30.90000,18.54000,United Healthcare,Commercial,,25.12,,,,,,,9.30,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,United Healthcare,Commercial,,1.01,,,,,,,0.80240,22.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,inpatient,2,ML,757.60000,454.56000,United Healthcare,Commercial,,615.93,,,,,,,228.04,615.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,United Healthcare,Commercial,,13.53,,,,,,,11.47,562.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,inpatient,1,UN,231.15000,138.69000,United Healthcare,Commercial,,187.92,,,,,,,147.94,187.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,United Healthcare,Commercial,,187.92,,,,,,,46.28,187.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,inpatient,1,UN,143.75000,86.25000,United Healthcare,Commercial,,116.87,,,,,,,43.27,116.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,United Healthcare,Commercial,,2.48,,,,,,,2.05,106.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,United Healthcare,Commercial,,2228.11,,,,,,,824.92,2228.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,Commercial,,1.68,,,,,,,0.46560,2034.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,inpatient,1,UN,1507.85000,904.71000,United Healthcare,Commercial,,1225.88,,,,,,,453.86,1225.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,United Healthcare,Commercial,,1.68,,,,,,,0.46560,1119.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,inpatient,15,ML,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,inpatient,15,ML,3.50000,2.10000,United Healthcare,Commercial,,2.85,,,,,,,2.24,2.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,United Healthcare,Commercial,,2.85,,,,,,,0.70070,2.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,inpatient,3,ML,109.25000,65.55000,United Healthcare,Commercial,,88.82,,,,,,,32.88,88.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,United Healthcare,Commercial,,1.01,,,,,,,0.89680,81.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,inpatient,1,UN,1.60000,0.96000,United Healthcare,Commercial,,1.30,,,,,,,1.02,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,United Healthcare,Commercial,,1.30,,,,,,,0.32032,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,inpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,inpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,10.43,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,inpatient,2.5,ML,27.40000,16.44000,United Healthcare,Commercial,,22.28,,,,,,,17.54,22.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,United Healthcare,Commercial,,22.28,,,,,,,5.49,22.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,inpatient,2.5,ML,20.20000,12.12000,United Healthcare,Commercial,,16.42,,,,,,,12.93,16.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,United Healthcare,Commercial,,16.42,,,,,,,4.04,16.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,inpatient,1,ML,40.95000,24.57000,United Healthcare,Commercial,,33.29,,,,,,,12.33,33.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,United Healthcare,Commercial,,1.25,,,,,,,1.25,30.39,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,inpatient,1,UN,1391.25000,834.75000,United Healthcare,Commercial,,1131.09,,,,,,,890.40,1131.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,United Healthcare,Commercial,,1131.09,,,,,,,278.53,1131.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,inpatient,1,UN,60.95000,36.57000,United Healthcare,Commercial,,49.55,,,,,,,39.01,49.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,United Healthcare,Commercial,,49.55,,,,,,,12.20,49.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,inpatient,15,GR,37.05000,22.23000,United Healthcare,Commercial,,30.12,,,,,,,23.71,30.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,United Healthcare,Commercial,,30.12,,,,,,,7.42,30.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,inpatient,1,UN,23.80000,14.28000,United Healthcare,Commercial,,19.35,,,,,,,7.16,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,United Healthcare,Commercial,,4.74,,,,,,,1.68,17.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,inpatient,15,ML,377.25000,226.35000,United Healthcare,Commercial,,306.70,,,,,,,113.55,306.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,United Healthcare,Commercial,,5.74,,,,,,,5.74,279.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,inpatient,45,ML,482.55000,289.53000,United Healthcare,Commercial,,392.31,,,,,,,145.25,392.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,United Healthcare,Commercial,,5.74,,,,,,,5.74,358.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,inpatient,5,ML,334.00000,200.40000,United Healthcare,Commercial,,271.54,,,,,,,100.53,271.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,United Healthcare,Commercial,,5.74,,,,,,,5.74,247.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,inpatient,60,ML,535.35000,321.21000,United Healthcare,Commercial,,435.24,,,,,,,161.14,435.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,United Healthcare,Commercial,,5.74,,,,,,,5.74,397.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,inpatient,10,ML,117.60000,70.56000,United Healthcare,Commercial,,95.61,,,,,,,75.26,95.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,United Healthcare,Commercial,,95.61,,,,,,,23.54,95.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,inpatient,5,ML,90.30000,54.18000,United Healthcare,Commercial,,73.41,,,,,,,57.79,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,United Healthcare,Commercial,,73.41,,,,,,,18.08,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,inpatient,0.01,ML,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,10.27,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,3.21,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,inpatient,2,ML,25.05000,15.03000,United Healthcare,Commercial,,20.37,,,,,,,7.54,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,United Healthcare,Commercial,,6.70,,,,,,,5.02,18.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,inpatient,30,ML,116.10000,69.66000,United Healthcare,Commercial,,94.39,,,,,,,34.95,94.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,United Healthcare,Commercial,,6.70,,,,,,,5.59,86.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,inpatient,200,ML,686.20000,411.72000,United Healthcare,Commercial,,557.88,,,,,,,439.17,557.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,United Healthcare,Commercial,,557.88,,,,,,,137.38,557.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,inpatient,480,ML,1607.20000,964.32000,United Healthcare,Commercial,,1306.65,,,,,,,1028.61,1306.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,United Healthcare,Commercial,,1306.65,,,,,,,321.76,1306.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,inpatient,1,UN,17.45000,10.47000,United Healthcare,Commercial,,14.19,,,,,,,11.17,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,Commercial,,14.19,,,,,,,3.49,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,inpatient,1,UN,18.65000,11.19000,United Healthcare,Commercial,,15.16,,,,,,,11.94,15.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,United Healthcare,Commercial,,15.16,,,,,,,3.73,15.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,inpatient,5,ML,16.15000,9.69000,United Healthcare,Commercial,,13.13,,,,,,,10.34,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,United Healthcare,Commercial,,13.13,,,,,,,3.23,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,inpatient,473,ML,1023.50000,614.10000,United Healthcare,Commercial,,832.11,,,,,,,655.04,832.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,United Healthcare,Commercial,,832.11,,,,,,,204.90,832.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,inpatient,4,ML,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,6.82,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,United Healthcare,Commercial,,4.09,,,,,,,4.04,16.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,11.26,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,inpatient,1,UN,7227.30000,4336.38000,United Healthcare,Commercial,,5875.79,,,,,,,2175.42,5875.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,United Healthcare,Commercial,,33.00,,,,,,,10.22,5364.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,inpatient,20,ML,26468.35000,15881.01000,United Healthcare,Commercial,,21518.77,,,,,,,7966.97,21518.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,United Healthcare,Commercial,,27.57,,,,,,,9.84,19644.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,inpatient,1,ML,5590.45000,3354.27000,United Healthcare,Commercial,,4545.04,,,,,,,1682.73,4545.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,United Healthcare,Commercial,,27.57,,,,,,,9.84,4149.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,inpatient,5,ML,26468.35000,15881.01000,United Healthcare,Commercial,,21518.77,,,,,,,7966.97,21518.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,United Healthcare,Commercial,,27.57,,,,,,,9.84,19644.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,inpatient,1,UN,18.90000,11.34000,United Healthcare,Commercial,,15.37,,,,,,,12.10,15.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,United Healthcare,Commercial,,15.37,,,,,,,3.78,15.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,Commercial,,6644.81,,,,,,,0.04004,6806.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,inpatient,1,UN,19.20000,11.52000,United Healthcare,Commercial,,15.61,,,,,,,12.29,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,Commercial,,15.61,,,,,,,3.84,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,inpatient,10,ML,107.00000,64.20000,United Healthcare,Commercial,,86.99,,,,,,,32.21,86.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,United Healthcare,Commercial,,22.61,,,,,,,21.42,79.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,United Healthcare,Commercial,,5957.83,,,,,,,2205.79,5957.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,United Healthcare,Commercial,,4.32,,,,,,,4.32,5438.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,inpatient,1,ML,350.20000,210.12000,United Healthcare,Commercial,,284.71,,,,,,,105.41,284.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,United Healthcare,Commercial,,56.91,,,,,,,50.79,259.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,inpatient,1,UN,1243.00000,745.80000,United Healthcare,Commercial,,1010.56,,,,,,,374.14,1010.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,United Healthcare,Commercial,,76.97,,,,,,,19.74,922.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,inpatient,2,ML,22.80000,13.68000,United Healthcare,Commercial,,18.54,,,,,,,14.59,18.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,United Healthcare,Commercial,,18.54,,,,,,,4.56,18.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,inpatient,2,ML,46.20000,27.72000,United Healthcare,Commercial,,37.56,,,,,,,29.57,37.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,United Healthcare,Commercial,,37.56,,,,,,,9.25,37.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,inpatient,1,ML,7030.60000,4218.36000,United Healthcare,Commercial,,5715.88,,,,,,,2116.21,5715.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,United Healthcare,Commercial,,4.32,,,,,,,2.88,5218.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,inpatient,26.3,ML,332.30000,199.38000,United Healthcare,Commercial,,270.16,,,,,,,100.02,270.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,United Healthcare,Commercial,,8.05,,,,,,,7.39,246.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,inpatient,5.26,ML,308.30000,184.98000,United Healthcare,Commercial,,250.65,,,,,,,92.80,250.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,United Healthcare,Commercial,,8.05,,,,,,,7.39,228.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,inpatient,52.6,ML,673.55000,404.13000,United Healthcare,Commercial,,547.60,,,,,,,202.74,547.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,United Healthcare,Commercial,,8.05,,,,,,,7.39,499.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,United Healthcare,Commercial,,32614.23,,,,,,,12074.89,32614.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,Commercial,,499.34,,,,,,,177.98,29774.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,United Healthcare,Commercial,,129785.78,,,,,,,48051.07,129785.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,Commercial,,499.34,,,,,,,177.98,118483.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,United Healthcare,Commercial,,1196.17,,,,,,,442.86,1196.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,Commercial,,195.06,,,,,,,66.15,1092.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,United Healthcare,Commercial,,2381.89,,,,,,,881.85,2381.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,Commercial,,169.42,,,,,,,60.36,2174.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,26823.30000,16093.98000,United Healthcare,Commercial,,21807.34,,,,,,,8073.81,21807.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,United Healthcare,Commercial,,169.42,,,,,,,60.36,19908.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,inpatient,1,ML,320.15000,192.09000,United Healthcare,Commercial,,260.28,,,,,,,96.37,260.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,United Healthcare,Commercial,,7.41,,,,,,,7.13,237.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,United Healthcare,Commercial,,235.81,,,,,,,87.31,235.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,United Healthcare,Commercial,,4.69,,,,,,,4.69,215.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,United Healthcare,Commercial,,255.89,,,,,,,94.74,255.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,United Healthcare,Commercial,,6.15,,,,,,,6.15,233.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,United Healthcare,Commercial,,235.61,,,,,,,87.23,235.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,United Healthcare,Commercial,,6.15,,,,,,,6.15,215.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,United Healthcare,Commercial,,342.52,,,,,,,126.81,342.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,United Healthcare,Commercial,,6.15,,,,,,,6.15,312.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,inpatient,16,ML,2035.00000,1221.00000,United Healthcare,Commercial,,1654.45,,,,,,,612.53,1654.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,United Healthcare,Commercial,,1.04,,,,,,,1.04,1510.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,inpatient,2,ML,495.00000,297.00000,United Healthcare,Commercial,,402.44,,,,,,,149.00,402.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,United Healthcare,Commercial,,1.04,,,,,,,1.04,367.39,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,inpatient,8,ML,996.60000,597.96000,United Healthcare,Commercial,,810.24,,,,,,,299.98,810.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,United Healthcare,Commercial,,1.04,,,,,,,1.04,739.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,inpatient,0.5,ML,22.90000,13.74000,United Healthcare,Commercial,,18.62,,,,,,,14.66,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,United Healthcare,Commercial,,18.62,,,,,,,4.58,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,inpatient,0.5,ML,77.55000,46.53000,United Healthcare,Commercial,,63.05,,,,,,,23.34,63.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,United Healthcare,Commercial,,107.86,,,,,,,15.53,107.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,inpatient,26.3,ML,337.40000,202.44000,United Healthcare,Commercial,,274.31,,,,,,,101.56,274.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,United Healthcare,Commercial,,8.05,,,,,,,7.39,250.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,United Healthcare,Commercial,,4585.52,,,,,,,1697.72,4585.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,Commercial,,15.76,,,,,,,5.54,4186.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,United Healthcare,Commercial,,9119.79,,,,,,,3376.45,9119.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,Commercial,,15.76,,,,,,,5.54,8325.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,inpatient,2,ML,105.35000,63.21000,United Healthcare,Commercial,,85.65,,,,,,,67.42,85.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,United Healthcare,Commercial,,85.65,,,,,,,21.09,85.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,United Healthcare,Commercial,,36.95,,,,,,,13.68,36.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,33.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,United Healthcare,Commercial,,51.58,,,,,,,19.10,51.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,47.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,1,ML,19.05000,11.43000,United Healthcare,Commercial,,15.49,,,,,,,5.73,15.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,14.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,inpatient,1000,ML,84.00000,50.40000,United Healthcare,Commercial,,68.29,,,,,,,25.28,68.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,62.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,inpatient,0.5,ML,26.65000,15.99000,United Healthcare,Commercial,,21.67,,,,,,,17.06,21.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,United Healthcare,Commercial,,21.67,,,,,,,5.34,21.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,United Healthcare,Commercial,,278.70,,,,,,,103.18,278.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,United Healthcare,Commercial,,21.40,,,,,,,19.40,254.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,inpatient,100,ML,61.00000,36.60000,United Healthcare,Commercial,,49.59,,,,,,,18.36,49.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,United Healthcare,Commercial,,12.39,,,,,,,5.14,45.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,United Healthcare,Commercial,,61.79,,,,,,,22.88,61.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,56.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,inpatient,5,ML,292.85000,175.71000,United Healthcare,Commercial,,238.09,,,,,,,88.15,238.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,United Healthcare,Commercial,,10.76,,,,,,,7.60,217.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,inpatient,1,UN,20.80000,12.48000,United Healthcare,Commercial,,16.91,,,,,,,6.26,16.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,United Healthcare,Commercial,,2.29,,,,,,,1.89,15.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,United Healthcare,Commercial,,35.20,,,,,,,13.03,35.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,United Healthcare,Commercial,,3.35,,,,,,,2.88,32.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,inpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,20.41,,,,,,,7.56,20.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,1.30,,,,,,,1.01,18.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,United Healthcare,Commercial,,23.74,,,,,,,8.79,23.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,United Healthcare,Commercial,,1.30,,,,,,,1.01,21.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,inpatient,1,UN,19.50000,11.70000,United Healthcare,Commercial,,15.85,,,,,,,5.87,15.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,Commercial,,1.30,,,,,,,1.01,14.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,inpatient,1,UN,19.25000,11.55000,United Healthcare,Commercial,,15.65,,,,,,,5.79,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,United Healthcare,Commercial,,1.30,,,,,,,1.01,14.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,10.69,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,10.75,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,inpatient,250,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,United Healthcare,Commercial,,3.86,,,,,,,0.04004,3.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.59400,,,,,,,0.04004,0.59400,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,inpatient,100,ML,103.35000,62.01000,United Healthcare,Commercial,,84.02,,,,,,,31.11,84.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,United Healthcare,Commercial,,0.13200,,,,,,,0.13200,76.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,inpatient,12,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,United Healthcare,Commercial,,0.33000,,,,,,,0.04004,0.33000,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,inpatient,40,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,inpatient,30,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,inpatient,30,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.04950,,,,,,,0.04004,0.14844,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.04950,,,,,,,0.04004,0.14844,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,inpatient,1,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,0.14844,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.33000,,,,,,,0.04004,0.33000,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,United Healthcare,Commercial,,232.92,,,,,,,86.24,232.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,United Healthcare,Commercial,,7.28,,,,,,,5.97,212.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,inpatient,0.3,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,2.46,,,,,,,0.04004,2.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.70950,,,,,,,0.04004,0.71810,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,inpatient,0.09999,ML,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,18.98,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,United Healthcare,Commercial,,4.47,,,,,,,3.71,46.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,109.40000,65.64000,United Healthcare,Commercial,,88.94,,,,,,,70.02,88.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,United Healthcare,Commercial,,88.94,,,,,,,2.90,88.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,703.82,,,,,,,0.04004,720.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,inpatient,480,ML,4.75000,2.85000,United Healthcare,Commercial,,3.86,,,,,,,3.04,3.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,United Healthcare,Commercial,,3.86,,,,,,,0.95095,3.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,inpatient,50,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,178.05,,,,,,,65.92,178.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,162.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,930.36,,,,,,,344.45,930.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,11.55,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,inpatient,5,ML,1086.20000,651.72000,United Healthcare,Commercial,,883.08,,,,,,,695.17,883.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,United Healthcare,Commercial,,883.08,,,,,,,217.46,883.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,inpatient,5,ML,44.50000,26.70000,United Healthcare,Commercial,,36.18,,,,,,,28.48,36.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,United Healthcare,Commercial,,36.18,,,,,,,8.91,36.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,10,ML,46.50000,27.90000,United Healthcare,Commercial,,37.80,,,,,,,14.00,37.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,34.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,inpatient,0.5,ML,31.55000,18.93000,United Healthcare,Commercial,,25.65,,,,,,,9.50,25.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,23.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,inpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,inpatient,1,UN,2.80000,1.68000,United Healthcare,Commercial,,2.28,,,,,,,1.79,2.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,United Healthcare,Commercial,,2.28,,,,,,,0.56056,2.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,inpatient,1,UN,36575.00000,21945.00000,United Healthcare,Commercial,,29735.47,,,,,,,11009.08,29735.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,United Healthcare,Commercial,,561.18,,,,,,,200.92,27145.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,inpatient,10,ML,318.15000,190.89000,United Healthcare,Commercial,,258.66,,,,,,,95.76,258.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,236.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,178.05,,,,,,,65.92,178.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,162.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,inpatient,8,ML,63.85000,38.31000,United Healthcare,Commercial,,51.91,,,,,,,19.22,51.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,47.39,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,inpatient,500,ML,115.50000,69.30000,United Healthcare,Commercial,,93.90,,,,,,,34.77,93.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,85.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,inpatient,1,ML,27.75000,16.65000,United Healthcare,Commercial,,22.56,,,,,,,8.35,22.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,United Healthcare,Commercial,,2.61,,,,,,,2.60,20.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,inpatient,30,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,inpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,7.52,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,inpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,7.52,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,inpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,7.52,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,inpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,7.52,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Commercial,,9.55,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.29700,,,,,,,0.04004,0.33040,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,75.10000,45.06000,United Healthcare,Commercial,,61.06,,,,,,,22.61,61.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,United Healthcare,Commercial,,0.33000,,,,,,,0.21240,55.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,inpatient,20,ML,108.15000,64.89000,United Healthcare,Commercial,,87.93,,,,,,,32.55,87.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,United Healthcare,Commercial,,27.51,,,,,,,21.65,80.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,inpatient,40,ML,153.25000,91.95000,United Healthcare,Commercial,,124.59,,,,,,,46.13,124.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,United Healthcare,Commercial,,27.51,,,,,,,23.46,113.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,inpatient,2,ML,21.85000,13.11000,United Healthcare,Commercial,,17.76,,,,,,,6.58,17.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,United Healthcare,Commercial,,0.24750,,,,,,,0.24750,16.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,inpatient,2,ML,19.60000,11.76000,United Healthcare,Commercial,,15.93,,,,,,,5.90,15.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,United Healthcare,Commercial,,0.24750,,,,,,,0.24750,14.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,inpatient,25,ML,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,36.96,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,United Healthcare,Commercial,,46.95,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,inpatient,60,ML,204.30000,122.58000,United Healthcare,Commercial,,166.10,,,,,,,130.75,166.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,United Healthcare,Commercial,,166.10,,,,,,,40.90,166.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,inpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,10.50,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,inpatient,1,UN,53.20000,31.92000,United Healthcare,Commercial,,43.25,,,,,,,34.05,43.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,United Healthcare,Commercial,,43.25,,,,,,,10.65,43.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,inpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,10.37,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Commercial,,13.17,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,inpatient,1,UN,23.95000,14.37000,United Healthcare,Commercial,,19.47,,,,,,,15.33,19.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,United Healthcare,Commercial,,19.47,,,,,,,4.79,19.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,inpatient,5,ML,13686.90000,8212.14000,United Healthcare,Commercial,,11127.45,,,,,,,4119.76,11127.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,United Healthcare,Commercial,,725.39,,,,,,,271.45,10158.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,inpatient,1,ML,2799.00000,1679.40000,United Healthcare,Commercial,,2275.59,,,,,,,842.50,2275.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,United Healthcare,Commercial,,725.39,,,,,,,271.45,2077.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,inpatient,20,ML,79.65000,47.79000,United Healthcare,Commercial,,64.76,,,,,,,23.97,64.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,United Healthcare,Commercial,,1.06,,,,,,,0.80240,59.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,inpatient,1,UN,48.35000,29.01000,United Healthcare,Commercial,,39.31,,,,,,,14.55,39.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,United Healthcare,Commercial,,1.34,,,,,,,1.30,35.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,inpatient,1,UN,28.20000,16.92000,United Healthcare,Commercial,,22.93,,,,,,,8.49,22.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,United Healthcare,Commercial,,1.34,,,,,,,1.30,20.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,United Healthcare,Commercial,,37.19,,,,,,,13.77,37.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,United Healthcare,Commercial,,0.95700,,,,,,,0.29100,33.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,inpatient,25,ML,104.40000,62.64000,United Healthcare,Commercial,,84.88,,,,,,,66.82,84.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,United Healthcare,Commercial,,84.88,,,,,,,20.90,84.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,inpatient,5000,ML,243.00000,145.80000,United Healthcare,Commercial,,197.56,,,,,,,155.52,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,Commercial,,197.56,,,,,,,48.65,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,inpatient,1,UN,63.60000,38.16000,United Healthcare,Commercial,,51.71,,,,,,,19.14,51.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,United Healthcare,Commercial,,3.02,,,,,,,2.53,47.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,inpatient,5000,ML,243.00000,145.80000,United Healthcare,Commercial,,197.56,,,,,,,155.52,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,Commercial,,197.56,,,,,,,48.65,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,United Healthcare,Commercial,,24.23,,,,,,,8.97,24.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,22.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,inpatient,1,UN,578.15000,346.89000,United Healthcare,Commercial,,470.04,,,,,,,370.02,470.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,United Healthcare,Commercial,,470.04,,,,,,,115.75,470.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,inpatient,5,ML,28.50000,17.10000,United Healthcare,Commercial,,23.17,,,,,,,8.58,23.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,United Healthcare,Commercial,,3.81,,,,,,,3.42,21.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,inpatient,5000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,174.72,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,inpatient,5000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,174.72,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,inpatient,2,ML,20.65000,12.39000,United Healthcare,Commercial,,16.79,,,,,,,6.22,16.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,United Healthcare,Commercial,,6.70,,,,,,,4.13,15.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,inpatient,2,ML,20.15000,12.09000,United Healthcare,Commercial,,16.38,,,,,,,6.07,16.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,United Healthcare,Commercial,,1.37,,,,,,,1.13,14.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,inpatient,2,ML,20.25000,12.15000,United Healthcare,Commercial,,16.46,,,,,,,6.10,16.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,United Healthcare,Commercial,,1.37,,,,,,,1.13,15.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,7.93,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,United Healthcare,Commercial,,1.37,,,,,,,1.13,19.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,inpatient,14.2,GR,7.10000,4.26000,United Healthcare,Commercial,,5.77,,,,,,,4.54,5.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,United Healthcare,Commercial,,5.77,,,,,,,1.42,5.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,inpatient,100,ML,153.75000,92.25000,United Healthcare,Commercial,,125.00,,,,,,,46.28,125.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,114.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,inpatient,100,ML,405.05000,243.03000,United Healthcare,Commercial,,329.31,,,,,,,121.92,329.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,United Healthcare,Commercial,,0.41250,,,,,,,0.40120,300.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,inpatient,120,ML,155.00000,93.00000,United Healthcare,Commercial,,126.02,,,,,,,99.20,126.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,United Healthcare,Commercial,,126.02,,,,,,,31.03,126.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,inpatient,100,ML,803.50000,482.10000,United Healthcare,Commercial,,653.25,,,,,,,514.24,653.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,United Healthcare,Commercial,,653.25,,,,,,,160.86,653.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,inpatient,4,ML,66.20000,39.72000,United Healthcare,Commercial,,53.82,,,,,,,19.93,53.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,United Healthcare,Commercial,,10.89,,,,,,,10.89,49.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,inpatient,100,ML,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,16.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,5.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,inpatient,100,ML,19.00000,11.40000,United Healthcare,Commercial,,15.45,,,,,,,12.16,15.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,United Healthcare,Commercial,,15.45,,,,,,,3.80,15.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,inpatient,100,ML,70.00000,42.00000,United Healthcare,Commercial,,56.91,,,,,,,44.80,56.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,United Healthcare,Commercial,,56.91,,,,,,,14.01,56.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,inpatient,200,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,56.32,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,17.62,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,inpatient,120,ML,74.80000,44.88000,United Healthcare,Commercial,,60.81,,,,,,,47.87,60.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,United Healthcare,Commercial,,60.81,,,,,,,14.97,60.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,inpatient,15,ML,60.40000,36.24000,United Healthcare,Commercial,,49.11,,,,,,,38.66,49.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,United Healthcare,Commercial,,49.11,,,,,,,12.09,49.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,inpatient,100,ML,92.20000,55.32000,United Healthcare,Commercial,,74.96,,,,,,,59.01,74.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,United Healthcare,Commercial,,74.96,,,,,,,18.46,74.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,inpatient,240,ML,376.00000,225.60000,United Healthcare,Commercial,,305.69,,,,,,,240.64,305.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,United Healthcare,Commercial,,305.69,,,,,,,75.28,305.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,inpatient,200,ML,19.00000,11.40000,United Healthcare,Commercial,,15.45,,,,,,,12.16,15.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,United Healthcare,Commercial,,15.45,,,,,,,3.80,15.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,inpatient,1,UN,64.35000,38.61000,United Healthcare,Commercial,,52.32,,,,,,,41.18,52.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,United Healthcare,Commercial,,52.32,,,,,,,12.88,52.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,inpatient,20,ML,27.05000,16.23000,United Healthcare,Commercial,,21.99,,,,,,,17.31,21.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,United Healthcare,Commercial,,21.99,,,,,,,5.42,21.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,inpatient,5,ML,24.00000,14.40000,United Healthcare,Commercial,,19.51,,,,,,,15.36,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,United Healthcare,Commercial,,19.51,,,,,,,4.80,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,inpatient,1,ML,114.75000,68.85000,United Healthcare,Commercial,,93.29,,,,,,,34.54,93.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,United Healthcare,Commercial,,0.33000,,,,,,,0.21240,85.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,inpatient,5000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,174.72,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,inpatient,5000,ML,243.00000,145.80000,United Healthcare,Commercial,,197.56,,,,,,,155.52,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,Commercial,,197.56,,,,,,,48.65,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,inpatient,30,GR,47.50000,28.50000,United Healthcare,Commercial,,38.62,,,,,,,30.40,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,United Healthcare,Commercial,,38.62,,,,,,,9.51,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,inpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,14.15,,,,,,,5.24,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,5.82,,,,,,,0.14160,12.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,inpatient,0.4,ML,64.00000,38.40000,United Healthcare,Commercial,,52.03,,,,,,,19.26,52.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,United Healthcare,Commercial,,76.28,,,,,,,12.81,76.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,28.70000,17.22000,United Healthcare,Commercial,,23.33,,,,,,,18.37,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,Commercial,,23.33,,,,,,,5.75,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,inpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,10.50,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,inpatient,0.25,ML,17.35000,10.41000,United Healthcare,Commercial,,14.11,,,,,,,5.22,14.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,United Healthcare,Commercial,,2.46,,,,,,,1.79,12.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,inpatient,500,ML,94.50000,56.70000,United Healthcare,Commercial,,76.83,,,,,,,28.44,76.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,70.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,inpatient,300,ML,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,21.76,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,inpatient,50,ML,23.35000,14.01000,United Healthcare,Commercial,,18.98,,,,,,,14.94,18.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,United Healthcare,Commercial,,18.98,,,,,,,4.67,18.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,inpatient,50,ML,215.60000,129.36000,United Healthcare,Commercial,,175.28,,,,,,,64.90,175.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,inpatient,40,ML,338.70000,203.22000,United Healthcare,Commercial,,275.36,,,,,,,216.77,275.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,United Healthcare,Commercial,,275.36,,,,,,,67.81,275.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,inpatient,10,ML,835.00000,501.00000,United Healthcare,Commercial,,678.86,,,,,,,251.34,678.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,United Healthcare,Commercial,,49.09,,,,,,,17.57,619.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,inpatient,0.5,UN,65.25000,39.15000,United Healthcare,Commercial,,53.05,,,,,,,19.64,53.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,United Healthcare,Commercial,,2.29,,,,,,,1.89,48.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,81.95000,49.17000,United Healthcare,Commercial,,66.63,,,,,,,24.67,66.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,United Healthcare,Commercial,,6.24,,,,,,,4.37,60.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,inpatient,300,ML,222.60000,133.56000,United Healthcare,Commercial,,180.97,,,,,,,67.00,180.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,United Healthcare,Commercial,,9.45,,,,,,,8.43,165.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,inpatient,25,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,56.45,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,United Healthcare,Commercial,,71.58,,,,,,,26.50,71.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,United Healthcare,Commercial,,0.19800,,,,,,,0.18880,65.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.5,ML,128.55000,77.13000,United Healthcare,Commercial,,104.51,,,,,,,82.27,104.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,United Healthcare,Commercial,,104.51,,,,,,,6.44,104.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,inpatient,37.5,GR,5.90000,3.54000,United Healthcare,Commercial,,4.80,,,,,,,3.78,4.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,United Healthcare,Commercial,,4.80,,,,,,,1.18,4.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,United Healthcare,Commercial,,41.54,,,,,,,15.38,41.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,United Healthcare,Commercial,,4.06,,,,,,,3.28,37.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,inpatient,2,ML,28.40000,17.04000,United Healthcare,Commercial,,23.09,,,,,,,8.55,23.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,United Healthcare,Commercial,,2.61,,,,,,,2.60,21.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,United Healthcare,Commercial,,30705.83,,,,,,,11368.33,30705.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Commercial,,468.11,,,,,,,167.05,28031.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,inpatient,1,UN,319.00000,191.40000,United Healthcare,Commercial,,259.35,,,,,,,96.02,259.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,United Healthcare,Commercial,,10.76,,,,,,,7.60,236.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,inpatient,8,ML,168.40000,101.04000,United Healthcare,Commercial,,136.91,,,,,,,107.78,136.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,United Healthcare,Commercial,,136.91,,,,,,,33.71,136.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,inpatient,8,ML,64.55000,38.73000,United Healthcare,Commercial,,52.48,,,,,,,19.43,52.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,United Healthcare,Commercial,,1.80,,,,,,,1.80,47.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,inpatient,50,ML,72.70000,43.62000,United Healthcare,Commercial,,59.11,,,,,,,21.88,59.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,United Healthcare,Commercial,,1.80,,,,,,,1.80,53.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,inpatient,50,ML,64.90000,38.94000,United Healthcare,Commercial,,52.76,,,,,,,19.53,52.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,48.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,inpatient,50,ML,75.00000,45.00000,United Healthcare,Commercial,,60.98,,,,,,,22.57,60.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,55.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,inpatient,15,ML,60.40000,36.24000,United Healthcare,Commercial,,49.11,,,,,,,38.66,49.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,United Healthcare,Commercial,,49.11,,,,,,,12.09,49.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,inpatient,5,ML,87.95000,52.77000,United Healthcare,Commercial,,71.50,,,,,,,56.29,71.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,United Healthcare,Commercial,,71.50,,,,,,,17.61,71.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,inpatient,50,ML,372.10000,223.26000,United Healthcare,Commercial,,302.52,,,,,,,238.14,302.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,United Healthcare,Commercial,,302.52,,,,,,,74.49,302.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,inpatient,1,ML,19.25000,11.55000,United Healthcare,Commercial,,15.65,,,,,,,5.79,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,United Healthcare,Commercial,,0.95700,,,,,,,0.29100,14.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,inpatient,4,ML,67.40000,40.44000,United Healthcare,Commercial,,54.80,,,,,,,43.14,54.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,United Healthcare,Commercial,,54.80,,,,,,,13.49,54.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,inpatient,8,ML,68.40000,41.04000,United Healthcare,Commercial,,55.61,,,,,,,20.59,55.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,United Healthcare,Commercial,,3.81,,,,,,,3.42,50.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,inpatient,50,ML,96.60000,57.96000,United Healthcare,Commercial,,78.54,,,,,,,29.08,78.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,United Healthcare,Commercial,,3.81,,,,,,,3.42,71.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,inpatient,1,ML,30.70000,18.42000,United Healthcare,Commercial,,24.96,,,,,,,9.24,24.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,United Healthcare,Commercial,,29.37,,,,,,,6.15,29.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,inpatient,40,ML,106.55000,63.93000,United Healthcare,Commercial,,86.63,,,,,,,68.19,86.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,United Healthcare,Commercial,,86.63,,,,,,,21.33,86.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,inpatient,100,ML,171.80000,103.08000,United Healthcare,Commercial,,139.67,,,,,,,109.95,139.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,United Healthcare,Commercial,,139.67,,,,,,,34.39,139.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,inpatient,50,ML,103.95000,62.37000,United Healthcare,Commercial,,84.51,,,,,,,31.29,84.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,250.40000,150.24000,United Healthcare,Commercial,,203.58,,,,,,,75.37,203.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,185.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,inpatient,10,ML,170.95000,102.57000,United Healthcare,Commercial,,138.98,,,,,,,51.46,138.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,126.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,inpatient,50,ML,80.65000,48.39000,United Healthcare,Commercial,,65.57,,,,,,,24.28,65.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,United Healthcare,Commercial,,5.33,,,,,,,5.33,59.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,inpatient,100,ML,70.35000,42.21000,United Healthcare,Commercial,,57.19,,,,,,,21.18,57.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,52.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,inpatient,1,GR,103.95000,62.37000,United Healthcare,Commercial,,84.51,,,,,,,31.29,84.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,United Healthcare,Commercial,,19.39,,,,,,,19.39,77.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,inpatient,20,ML,81.90000,49.14000,United Healthcare,Commercial,,66.58,,,,,,,24.65,66.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,United Healthcare,Commercial,,19.39,,,,,,,16.40,60.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,inpatient,1,UN,96.60000,57.96000,United Healthcare,Commercial,,78.54,,,,,,,29.08,78.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,United Healthcare,Commercial,,13.96,,,,,,,11.28,71.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,109.20000,65.52000,United Healthcare,Commercial,,88.78,,,,,,,32.87,88.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,United Healthcare,Commercial,,4.47,,,,,,,3.71,81.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,inpatient,500,ML,478.80000,287.28000,United Healthcare,Commercial,,389.26,,,,,,,144.12,389.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,United Healthcare,Commercial,,3.35,,,,,,,2.88,355.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,inpatient,50,ML,117.85000,70.71000,United Healthcare,Commercial,,95.81,,,,,,,35.47,95.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,United Healthcare,Commercial,,4.55,,,,,,,4.32,87.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,300,ML,567.00000,340.20000,United Healthcare,Commercial,,460.97,,,,,,,170.67,460.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,United Healthcare,Commercial,,1.20,,,,,,,0.99120,420.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,inpatient,1,UN,1165.70000,699.42000,United Healthcare,Commercial,,947.71,,,,,,,350.88,947.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,United Healthcare,Commercial,,394.43,,,,,,,144.52,865.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,inpatient,1,UN,1242.40000,745.44000,United Healthcare,Commercial,,1010.07,,,,,,,373.96,1010.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,United Healthcare,Commercial,,533.03,,,,,,,176.98,922.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,United Healthcare,Commercial,,29.67,,,,,,,10.99,29.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,United Healthcare,Commercial,,6.24,,,,,,,4.37,27.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,inpatient,100,ML,74.35000,44.61000,United Healthcare,Commercial,,60.45,,,,,,,22.38,60.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,55.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,inpatient,100,ML,153.30000,91.98000,United Healthcare,Commercial,,124.63,,,,,,,46.14,124.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,United Healthcare,Commercial,,0.13200,,,,,,,0.09440,113.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,250,ML,218.50000,131.10000,United Healthcare,Commercial,,177.64,,,,,,,65.77,177.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,United Healthcare,Commercial,,1.30,,,,,,,1.01,162.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,1000,ML,512.40000,307.44000,United Healthcare,Commercial,,416.58,,,,,,,154.23,416.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,380.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,inpatient,1000,ML,961.80000,577.08000,United Healthcare,Commercial,,781.94,,,,,,,289.50,781.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,713.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,United Healthcare,Commercial,,73.41,,,,,,,27.18,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,United Healthcare,Commercial,,3.02,,,,,,,2.53,67.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,inpatient,1,UN,103.15000,61.89000,United Healthcare,Commercial,,83.86,,,,,,,31.05,83.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,United Healthcare,Commercial,,57.72,,,,,,,20.65,76.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,inpatient,1,UN,247.75000,148.65000,United Healthcare,Commercial,,201.42,,,,,,,74.57,201.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,183.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,inpatient,10,ML,66.80000,40.08000,United Healthcare,Commercial,,54.31,,,,,,,20.11,54.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,United Healthcare,Commercial,,14.12,,,,,,,13.22,49.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,inpatient,40,ML,78.15000,46.89000,United Healthcare,Commercial,,63.54,,,,,,,23.52,63.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,United Healthcare,Commercial,,14.12,,,,,,,13.22,58.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,inpatient,1,UN,735.15000,441.09000,United Healthcare,Commercial,,597.68,,,,,,,221.28,597.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,United Healthcare,Commercial,,109.94,,,,,,,93.10,545.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,inpatient,1,UN,17.55000,10.53000,United Healthcare,Commercial,,14.27,,,,,,,5.28,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,Commercial,,1.58,,,,,,,1.13,13.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,0.1,ML,275.20000,165.12000,United Healthcare,Commercial,,223.74,,,,,,,82.84,223.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,United Healthcare,Commercial,,4.69,,,,,,,4.69,204.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,inpatient,0.2,ML,63.45000,38.07000,United Healthcare,Commercial,,51.58,,,,,,,19.10,51.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,47.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,inpatient,10,ML,105.10000,63.06000,United Healthcare,Commercial,,85.45,,,,,,,31.64,85.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,78.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,inpatient,100,ML,289.80000,173.88000,United Healthcare,Commercial,,235.61,,,,,,,87.23,235.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,215.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,50,ML,176.40000,105.84000,United Healthcare,Commercial,,143.41,,,,,,,53.10,143.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,United Healthcare,Commercial,,0.11550,,,,,,,0.09440,130.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,inpatient,1,ML,24.20000,14.52000,United Healthcare,Commercial,,19.67,,,,,,,15.49,19.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,United Healthcare,Commercial,,19.67,,,,,,,4.84,19.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,inpatient,5,ML,120.55000,72.33000,United Healthcare,Commercial,,98.01,,,,,,,36.29,98.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,United Healthcare,Commercial,,1.55,,,,,,,1.39,89.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,inpatient,50,ML,71.40000,42.84000,United Healthcare,Commercial,,58.05,,,,,,,21.49,58.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,52.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,inpatient,1,UN,78.35000,47.01000,United Healthcare,Commercial,,63.70,,,,,,,50.14,63.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,United Healthcare,Commercial,,63.70,,,,,,,15.69,63.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,inpatient,50,ML,180.60000,108.36000,United Healthcare,Commercial,,146.83,,,,,,,115.58,146.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,United Healthcare,Commercial,,146.83,,,,,,,36.16,146.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,inpatient,50,ML,171.80000,103.08000,United Healthcare,Commercial,,139.67,,,,,,,51.71,139.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,United Healthcare,Commercial,,0.75900,,,,,,,0.51920,127.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,2.61,,,,,,,0.04004,2.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,2.61,,,,,,,0.04004,2.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,173.61,,,,,,,0.04004,173.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,inpatient,50,ML,75.60000,45.36000,United Healthcare,Commercial,,61.46,,,,,,,22.76,61.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,56.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,inpatient,100,ML,29.20000,17.52000,United Healthcare,Commercial,,23.74,,,,,,,18.69,23.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,United Healthcare,Commercial,,23.74,,,,,,,5.85,23.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,inpatient,2,ML,34.75000,20.85000,United Healthcare,Commercial,,28.25,,,,,,,10.46,28.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,25.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,inpatient,100,ML,71.40000,42.84000,United Healthcare,Commercial,,58.05,,,,,,,21.49,58.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,United Healthcare,Commercial,,57.72,,,,,,,14.29,57.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,inpatient,250,ML,1785.00000,1071.00000,United Healthcare,Commercial,,1451.20,,,,,,,537.28,1451.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,United Healthcare,Commercial,,0.70950,,,,,,,0.20370,1324.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,inpatient,10,ML,99.55000,59.73000,United Healthcare,Commercial,,80.93,,,,,,,29.96,80.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,United Healthcare,Commercial,,0.33000,,,,,,,0.21240,73.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,inpatient,0.5,ML,25.15000,15.09000,United Healthcare,Commercial,,20.45,,,,,,,7.57,20.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,United Healthcare,Commercial,,29.37,,,,,,,5.04,29.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,inpatient,0.5,ML,34.85000,20.91000,United Healthcare,Commercial,,28.33,,,,,,,10.49,28.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,25.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,inpatient,8,ML,71.75000,43.05000,United Healthcare,Commercial,,58.33,,,,,,,45.92,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,United Healthcare,Commercial,,58.33,,,,,,,14.36,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,inpatient,1,ML,27.75000,16.65000,United Healthcare,Commercial,,22.56,,,,,,,8.35,22.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,United Healthcare,Commercial,,2.61,,,,,,,2.60,20.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,United Healthcare,Commercial,,51.30,,,,,,,18.99,51.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,United Healthcare,Commercial,,3.86,,,,,,,3.52,46.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,inpatient,500,ML,174.00000,104.40000,United Healthcare,Commercial,,141.46,,,,,,,111.36,141.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,United Healthcare,Commercial,,141.46,,,,,,,34.83,141.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,inpatient,8,ML,64.00000,38.40000,United Healthcare,Commercial,,52.03,,,,,,,40.96,52.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,United Healthcare,Commercial,,52.03,,,,,,,12.81,52.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,inpatient,2,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,56.45,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,0.5,ML,22.45000,13.47000,United Healthcare,Commercial,,18.25,,,,,,,6.76,18.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,16.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,0.5,ML,22.50000,13.50000,United Healthcare,Commercial,,18.29,,,,,,,6.77,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,16.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,inpatient,1,ML,25.60000,15.36000,United Healthcare,Commercial,,20.81,,,,,,,7.71,20.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,19.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,United Healthcare,Commercial,,34.72,,,,,,,12.85,34.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,31.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,United Healthcare,Commercial,,21.22,,,,,,,7.86,21.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,19.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,82.17,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,United Healthcare,Commercial,,14.16,,,,,,,11.94,202.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,inpatient,50,ML,131.05000,78.63000,United Healthcare,Commercial,,106.54,,,,,,,39.45,106.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,United Healthcare,Commercial,,1.37,,,,,,,1.13,97.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,inpatient,100,ML,94.50000,56.70000,United Healthcare,Commercial,,76.83,,,,,,,28.44,76.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,United Healthcare,Commercial,,1.37,,,,,,,1.13,70.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,inpatient,50,ML,139.65000,83.79000,United Healthcare,Commercial,,113.54,,,,,,,89.38,113.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,United Healthcare,Commercial,,113.54,,,,,,,27.96,113.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,29.15000,17.49000,United Healthcare,Commercial,,23.70,,,,,,,18.66,23.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,United Healthcare,Commercial,,23.70,,,,,,,0.21240,23.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,inpatient,2.5,ML,104.30000,62.58000,United Healthcare,Commercial,,84.80,,,,,,,66.75,84.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,United Healthcare,Commercial,,84.80,,,,,,,20.88,84.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,inpatient,180,ML,107.00000,64.20000,United Healthcare,Commercial,,86.99,,,,,,,68.48,86.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,United Healthcare,Commercial,,86.99,,,,,,,21.42,86.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,inpatient,50,ML,81.90000,49.14000,United Healthcare,Commercial,,66.58,,,,,,,24.65,66.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,United Healthcare,Commercial,,21.73,,,,,,,16.40,60.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,inpatient,3,ML,17.75000,10.65000,United Healthcare,Commercial,,14.43,,,,,,,5.34,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,13.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,inpatient,10,ML,68.30000,40.98000,United Healthcare,Commercial,,55.53,,,,,,,20.56,55.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,United Healthcare,Commercial,,0.04950,,,,,,,0.04720,50.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,inpatient,2.5,ML,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,11.04,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,55.90000,33.54000,United Healthcare,Commercial,,45.45,,,,,,,16.83,45.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,United Healthcare,Commercial,,4.24,,,,,,,2.17,41.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,inpatient,500,ML,82.25000,49.35000,United Healthcare,Commercial,,66.87,,,,,,,24.76,66.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,United Healthcare,Commercial,,0.59400,,,,,,,0.49560,61.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,inpatient,10,ML,106.35000,63.81000,United Healthcare,Commercial,,86.46,,,,,,,68.06,86.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,United Healthcare,Commercial,,86.46,,,,,,,21.29,86.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,333.3,ML,310.80000,186.48000,United Healthcare,Commercial,,252.68,,,,,,,93.55,252.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,United Healthcare,Commercial,,1.34,,,,,,,1.30,230.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,inpatient,10,ML,79.75000,47.85000,United Healthcare,Commercial,,64.84,,,,,,,24.00,64.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,United Healthcare,Commercial,,1.25,,,,,,,1.25,59.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,inpatient,20,ML,319.25000,191.55000,United Healthcare,Commercial,,259.55,,,,,,,96.09,259.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,inpatient,500,ML,75.00000,45.00000,United Healthcare,Commercial,,60.98,,,,,,,22.57,60.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,United Healthcare,Commercial,,0.28050,,,,,,,0.28050,55.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,inpatient,4,ML,64.15000,38.49000,United Healthcare,Commercial,,52.15,,,,,,,19.31,52.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,47.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,inpatient,100,ML,105.00000,63.00000,United Healthcare,Commercial,,85.36,,,,,,,31.61,85.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,United Healthcare,Commercial,,2.72,,,,,,,2.57,77.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,inpatient,10,ML,74.75000,44.85000,United Healthcare,Commercial,,60.77,,,,,,,47.84,60.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,United Healthcare,Commercial,,60.77,,,,,,,14.96,60.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,inpatient,50,ML,52.00000,31.20000,United Healthcare,Commercial,,42.28,,,,,,,15.65,42.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,United Healthcare,Commercial,,42.28,,,,,,,10.41,42.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,inpatient,400,ML,161.60000,96.96000,United Healthcare,Commercial,,131.38,,,,,,,48.64,131.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,United Healthcare,Commercial,,4.06,,,,,,,3.28,119.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,inpatient,0.5,ML,22.15000,13.29000,United Healthcare,Commercial,,18.01,,,,,,,14.18,18.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,United Healthcare,Commercial,,18.01,,,,,,,4.43,18.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,inpatient,15,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,Commercial,,195.76,,,,,,,0.04004,200.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,United Healthcare,Commercial,,51.30,,,,,,,18.99,51.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,United Healthcare,Commercial,,3.86,,,,,,,3.52,46.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,inpatient,1,ML,451.85000,271.11000,United Healthcare,Commercial,,367.35,,,,,,,136.01,367.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,United Healthcare,Commercial,,256.33,,,,,,,90.46,335.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,United Healthcare,Commercial,,136.30,,,,,,,50.46,136.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,United Healthcare,Commercial,,7.13,,,,,,,5.22,124.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,inpatient,50,ML,276.60000,165.96000,United Healthcare,Commercial,,224.88,,,,,,,83.26,224.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,United Healthcare,Commercial,,0.24750,,,,,,,0.16520,205.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,inpatient,300,ML,239.40000,143.64000,United Healthcare,Commercial,,194.63,,,,,,,153.22,194.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,United Healthcare,Commercial,,194.63,,,,,,,47.93,194.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,inpatient,10,ML,73.90000,44.34000,United Healthcare,Commercial,,60.08,,,,,,,47.30,60.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,United Healthcare,Commercial,,60.08,,,,,,,14.79,60.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,inpatient,8,ML,65.70000,39.42000,United Healthcare,Commercial,,53.41,,,,,,,19.78,53.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,United Healthcare,Commercial,,1.80,,,,,,,1.80,48.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,inpatient,50,ML,79.60000,47.76000,United Healthcare,Commercial,,64.71,,,,,,,23.96,64.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,United Healthcare,Commercial,,1.80,,,,,,,1.80,59.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,inpatient,36,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,United Healthcare,Commercial,,195.76,,,,,,,0.04004,200.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,inpatient,6,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,United Healthcare,Commercial,,195.76,,,,,,,0.04004,200.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,inpatient,60,GR,59.80000,35.88000,United Healthcare,Commercial,,48.62,,,,,,,38.27,48.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,United Healthcare,Commercial,,48.62,,,,,,,11.97,48.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,inpatient,6.25,ME,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,10.27,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,3.21,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,inpatient,100,ML,247.60000,148.56000,United Healthcare,Commercial,,201.30,,,,,,,74.53,201.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,183.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,United Healthcare,Commercial,,8192.60,,,,,,,3033.18,8192.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,Commercial,,358.17,,,,,,,127.44,7479.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,inpatient,1,UN,87.60000,52.56000,United Healthcare,Commercial,,71.22,,,,,,,26.37,71.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,United Healthcare,Commercial,,2.29,,,,,,,1.89,65.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,inpatient,200,ML,150.40000,90.24000,United Healthcare,Commercial,,122.28,,,,,,,45.27,122.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,United Healthcare,Commercial,,6.15,,,,,,,5.33,111.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,inpatient,1150,ML,153.65000,92.19000,United Healthcare,Commercial,,124.92,,,,,,,98.34,124.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,United Healthcare,Commercial,,124.92,,,,,,,30.76,124.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,inpatient,1,ML,364.25000,218.55000,United Healthcare,Commercial,,296.14,,,,,,,109.64,296.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,United Healthcare,Commercial,,256.33,,,,,,,72.92,270.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,inpatient,20,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,Commercial,,0.33000,,,,,,,0.04004,0.33000,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,4729.26,,,,,,,0.04004,4844.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,4729.26,,,,,,,0.04004,4844.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,inpatient,120,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,inpatient,120,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.12800,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,inpatient,180,ME,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,United Healthcare,Commercial,,98.72,,,,,,,0.04004,101.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,232.09,,,,,,,0.04004,237.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,United Healthcare,Commercial,,12876.82,,,,,,,4767.43,12876.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,Commercial,,149.99,,,,,,,53.98,11755.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,inpatient,15,ML,394.60000,236.76000,United Healthcare,Commercial,,320.81,,,,,,,118.77,320.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,United Healthcare,Commercial,,5.74,,,,,,,5.74,292.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,United Healthcare,Commercial,,456.05,,,,,,,168.85,456.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,United Healthcare,Commercial,,5.74,,,,,,,5.74,416.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,United Healthcare,Commercial,,253.09,,,,,,,93.70,253.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,United Healthcare,Commercial,,5.74,,,,,,,5.74,231.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,United Healthcare,Commercial,,393.57,,,,,,,145.71,393.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,United Healthcare,Commercial,,5.74,,,,,,,5.74,359.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,United Healthcare,Commercial,,367.76,,,,,,,136.16,367.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,United Healthcare,Commercial,,5.31,,,,,,,5.31,335.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,United Healthcare,Commercial,,330.89,,,,,,,122.51,330.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,United Healthcare,Commercial,,5.31,,,,,,,5.31,302.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,inpatient,15,ML,367.40000,220.44000,United Healthcare,Commercial,,298.70,,,,,,,110.59,298.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,United Healthcare,Commercial,,5.74,,,,,,,5.74,272.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,United Healthcare,Commercial,,456.05,,,,,,,168.85,456.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,United Healthcare,Commercial,,5.74,,,,,,,5.74,416.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,United Healthcare,Commercial,,253.09,,,,,,,93.70,253.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,United Healthcare,Commercial,,5.74,,,,,,,5.74,231.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,United Healthcare,Commercial,,393.57,,,,,,,145.71,393.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,United Healthcare,Commercial,,5.74,,,,,,,5.74,359.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,United Healthcare,Commercial,,2228.11,,,,,,,824.92,2228.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,Commercial,,1.68,,,,,,,0.46560,2034.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,inpatient,4,ML,101.20000,60.72000,United Healthcare,Commercial,,82.28,,,,,,,30.46,82.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,United Healthcare,Commercial,,1.06,,,,,,,0.80240,75.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,inpatient,60,ML,115.15000,69.09000,United Healthcare,Commercial,,93.62,,,,,,,73.70,93.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,United Healthcare,Commercial,,93.62,,,,,,,23.05,93.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,20.41,,,,,,,7.56,20.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,1.30,,,,,,,1.01,18.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,United Healthcare,Commercial,,24.11,,,,,,,8.92,24.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,United Healthcare,Commercial,,1.30,,,,,,,1.01,22.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,inpatient,10,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,56.45,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,United Healthcare,Commercial,,71.71,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,inpatient,1,UN,195.30000,117.18000,United Healthcare,Commercial,,158.78,,,,,,,58.79,158.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,United Healthcare,Commercial,,46.91,,,,,,,39.10,144.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,inpatient,0.25,ML,146.20000,87.72000,United Healthcare,Commercial,,118.86,,,,,,,93.57,118.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,United Healthcare,Commercial,,118.86,,,,,,,29.27,118.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,930.36,,,,,,,344.45,930.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,11.55,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,930.36,,,,,,,344.45,930.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Commercial,,11.55,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,inpatient,50,ML,73.60000,44.16000,United Healthcare,Commercial,,59.84,,,,,,,22.15,59.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,54.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,inpatient,8,ML,64.45000,38.67000,United Healthcare,Commercial,,52.40,,,,,,,19.40,52.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,United Healthcare,Commercial,,3.86,,,,,,,3.52,47.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,inpatient,118,ML,412.15000,247.29000,United Healthcare,Commercial,,335.08,,,,,,,263.78,335.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,United Healthcare,Commercial,,335.08,,,,,,,82.51,335.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,inpatient,5,ML,40.35000,24.21000,United Healthcare,Commercial,,32.80,,,,,,,25.82,32.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,United Healthcare,Commercial,,32.80,,,,,,,8.08,32.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,inpatient,80,ML,173.25000,103.95000,United Healthcare,Commercial,,140.85,,,,,,,52.15,140.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,United Healthcare,Commercial,,1.67,,,,,,,0.35890,128.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,0.5,ML,63.20000,37.92000,United Healthcare,Commercial,,51.38,,,,,,,19.02,51.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,United Healthcare,Commercial,,3.86,,,,,,,3.52,46.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,inpatient,100,ML,115.15000,69.09000,United Healthcare,Commercial,,93.62,,,,,,,73.70,93.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,United Healthcare,Commercial,,93.62,,,,,,,0.54280,93.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,United Healthcare,Commercial,,39.76,,,,,,,31.30,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,United Healthcare,Commercial,,39.76,,,,,,,9.79,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,United Healthcare,Commercial,,20.93,,,,,,,16.48,20.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,United Healthcare,Commercial,,20.93,,,,,,,5.16,20.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,United Healthcare,Commercial,,26.30,,,,,,,20.70,26.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,United Healthcare,Commercial,,26.30,,,,,,,6.48,26.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,inpatient,50,ML,1584.85000,950.91000,United Healthcare,Commercial,,1288.48,,,,,,,1014.30,1288.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,United Healthcare,Commercial,,1288.48,,,,,,,317.29,1288.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,inpatient,10,ML,38.75000,23.25000,United Healthcare,Commercial,,31.50,,,,,,,11.66,31.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,United Healthcare,Commercial,,1.58,,,,,,,1.13,28.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,inpatient,100,ML,478.40000,287.04000,United Healthcare,Commercial,,388.94,,,,,,,306.18,388.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,United Healthcare,Commercial,,388.94,,,,,,,95.78,388.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,inpatient,50,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,26.49,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,United Healthcare,Commercial,,2.61,,,,,,,2.60,65.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,United Healthcare,Commercial,,2097.91,,,,,,,776.72,2097.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,Commercial,,18.32,,,,,,,6.53,1915.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,inpatient,1,ML,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,5.18,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,United Healthcare,Commercial,,2.39,,,,,,,1.86,12.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,inpatient,1,ML,144.30000,86.58000,United Healthcare,Commercial,,117.32,,,,,,,92.35,117.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,United Healthcare,Commercial,,117.32,,,,,,,28.89,117.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,inpatient,100,ML,1380.15000,828.09000,United Healthcare,Commercial,,1122.06,,,,,,,883.30,1122.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,United Healthcare,Commercial,,1122.06,,,,,,,276.31,1122.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,inpatient,50,ML,73.80000,44.28000,United Healthcare,Commercial,,60.00,,,,,,,22.21,60.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,United Healthcare,Commercial,,2.39,,,,,,,1.86,54.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,inpatient,20,ML,215.00000,129.00000,United Healthcare,Commercial,,174.79,,,,,,,137.60,174.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,United Healthcare,Commercial,,174.79,,,,,,,43.04,174.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,inpatient,100,ML,597.25000,358.35000,United Healthcare,Commercial,,485.56,,,,,,,179.77,485.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,United Healthcare,Commercial,,5.94,,,,,,,4.77,443.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,inpatient,1,UN,109.20000,65.52000,United Healthcare,Commercial,,88.78,,,,,,,32.87,88.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,81.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,inpatient,1,UN,115.50000,69.30000,United Healthcare,Commercial,,93.90,,,,,,,34.77,93.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,85.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,United Healthcare,Commercial,,35.20,,,,,,,13.03,35.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,United Healthcare,Commercial,,3.35,,,,,,,2.88,32.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,United Healthcare,Commercial,,53.13,,,,,,,19.67,53.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,United Healthcare,Commercial,,3.35,,,,,,,2.88,48.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,inpatient,1,UN,47.45000,28.47000,United Healthcare,Commercial,,38.58,,,,,,,14.28,38.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,United Healthcare,Commercial,,1.34,,,,,,,1.30,35.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,inpatient,1,UN,66.05000,39.63000,United Healthcare,Commercial,,53.70,,,,,,,19.88,53.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,United Healthcare,Commercial,,1.34,,,,,,,1.30,49.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,inpatient,1,UN,36.50000,21.90000,United Healthcare,Commercial,,29.67,,,,,,,10.99,29.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,United Healthcare,Commercial,,4.47,,,,,,,3.71,27.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,66.05000,39.63000,United Healthcare,Commercial,,53.70,,,,,,,19.88,53.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,United Healthcare,Commercial,,4.47,,,,,,,3.71,49.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,inpatient,50,ML,48.45000,29.07000,United Healthcare,Commercial,,39.39,,,,,,,14.58,39.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,35.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,inpatient,4,ML,88.80000,53.28000,United Healthcare,Commercial,,72.19,,,,,,,26.73,72.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,United Healthcare,Commercial,,1.68,,,,,,,1.49,65.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,inpatient,250,ML,260.40000,156.24000,United Healthcare,Commercial,,211.71,,,,,,,78.38,211.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,193.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,inpatient,5,ML,119.70000,71.82000,United Healthcare,Commercial,,97.32,,,,,,,76.61,97.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,United Healthcare,Commercial,,97.32,,,,,,,23.96,97.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,inpatient,1,ML,118.25000,70.95000,United Healthcare,Commercial,,96.14,,,,,,,35.59,96.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,United Healthcare,Commercial,,1.58,,,,,,,1.13,87.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,10.27,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,3.21,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,United Healthcare,Commercial,,5522.71,,,,,,,2044.69,5522.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,United Healthcare,Commercial,,173.61,,,,,,,127.13,5041.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,inpatient,12,ML,30.95000,18.57000,United Healthcare,Commercial,,25.16,,,,,,,9.32,25.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,22.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,inpatient,1,UN,83.25000,49.95000,United Healthcare,Commercial,,67.68,,,,,,,25.06,67.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,United Healthcare,Commercial,,24.55,,,,,,,16.67,61.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,inpatient,50,ML,65.10000,39.06000,United Healthcare,Commercial,,52.93,,,,,,,41.66,52.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,United Healthcare,Commercial,,52.93,,,,,,,13.03,52.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,inpatient,40,ML,178.35000,107.01000,United Healthcare,Commercial,,145.00,,,,,,,53.68,145.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,United Healthcare,Commercial,,66.13,,,,,,,35.71,132.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,inpatient,40,ML,50.60000,30.36000,United Healthcare,Commercial,,41.14,,,,,,,15.23,41.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,United Healthcare,Commercial,,1.37,,,,,,,1.13,37.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,inpatient,40,ML,231.70000,139.02000,United Healthcare,Commercial,,188.37,,,,,,,148.29,188.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,United Healthcare,Commercial,,188.37,,,,,,,46.39,188.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,inpatient,400,ML,237.75000,142.65000,United Healthcare,Commercial,,193.29,,,,,,,71.56,193.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,United Healthcare,Commercial,,6.15,,,,,,,5.33,176.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,inpatient,200,ML,150.40000,90.24000,United Healthcare,Commercial,,122.28,,,,,,,45.27,122.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,United Healthcare,Commercial,,6.15,,,,,,,5.33,111.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,United Healthcare,Commercial,,392.68,,,,,,,145.38,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,Commercial,,2.01,,,,,,,0.77600,358.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,inpatient,0.5,ML,68.25000,40.95000,United Healthcare,Commercial,,55.49,,,,,,,20.54,55.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,United Healthcare,Commercial,,2.29,,,,,,,1.89,50.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,inpatient,1,UN,22.10000,13.26000,United Healthcare,Commercial,,17.97,,,,,,,6.65,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,United Healthcare,Commercial,,6.24,,,,,,,4.37,16.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,inpatient,1,UN,22.80000,13.68000,United Healthcare,Commercial,,18.54,,,,,,,6.86,18.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,16.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,inpatient,25,ML,458.95000,275.37000,United Healthcare,Commercial,,373.13,,,,,,,293.73,373.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,United Healthcare,Commercial,,373.13,,,,,,,91.88,373.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,inpatient,50,ML,26.05000,15.63000,United Healthcare,Commercial,,21.18,,,,,,,7.84,21.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,United Healthcare,Commercial,,2.61,,,,,,,2.60,19.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,United Healthcare,Commercial,,4745.03,,,,,,,1756.77,4745.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,Commercial,,76.97,,,,,,,19.74,4331.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,inpatient,4,ML,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,40.35,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,inpatient,5,ML,63.15000,37.89000,United Healthcare,Commercial,,51.34,,,,,,,19.01,51.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,United Healthcare,Commercial,,0.24750,,,,,,,0.16520,46.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,inpatient,5,ML,63.25000,37.95000,United Healthcare,Commercial,,51.42,,,,,,,40.48,51.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,United Healthcare,Commercial,,51.42,,,,,,,12.66,51.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,inpatient,0.5,ML,63.30000,37.98000,United Healthcare,Commercial,,51.46,,,,,,,19.05,51.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,United Healthcare,Commercial,,3.86,,,,,,,3.52,46.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,inpatient,1,ML,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,40.35,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,United Healthcare,Commercial,,51.26,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,inpatient,1,UN,144.90000,86.94000,United Healthcare,Commercial,,117.80,,,,,,,43.61,117.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,United Healthcare,Commercial,,0.46200,,,,,,,0.40120,107.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,inpatient,0.1,ML,19.35000,11.61000,United Healthcare,Commercial,,15.73,,,,,,,5.82,15.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,United Healthcare,Commercial,,256.33,,,,,,,3.87,262.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,4.83,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,United Healthcare,Commercial,,92.89,,,,,,,3.21,102.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,inpatient,0.08,ML,66.20000,39.72000,United Healthcare,Commercial,,53.82,,,,,,,19.93,53.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,49.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,inpatient,1,UN,50.05000,30.03000,United Healthcare,Commercial,,40.69,,,,,,,32.03,40.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,United Healthcare,Commercial,,40.69,,,,,,,10.02,40.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,10,ML,456.15000,273.69000,United Healthcare,Commercial,,370.85,,,,,,,137.30,370.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,United Healthcare,Commercial,,2.34,,,,,,,1.98,338.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,inpatient,10,ML,462.10000,277.26000,United Healthcare,Commercial,,375.69,,,,,,,139.09,375.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,United Healthcare,Commercial,,2.34,,,,,,,1.98,342.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,inpatient,10,ML,361.05000,216.63000,United Healthcare,Commercial,,293.53,,,,,,,108.68,293.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,United Healthcare,Commercial,,2.34,,,,,,,1.98,267.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,inpatient,0.5,ML,79.80000,47.88000,United Healthcare,Commercial,,64.88,,,,,,,51.07,64.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,United Healthcare,Commercial,,64.88,,,,,,,15.98,64.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,71.75,,,,,,,26.56,71.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,7.21,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,inpatient,5,ML,37.00000,22.20000,United Healthcare,Commercial,,30.08,,,,,,,23.68,30.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,United Healthcare,Commercial,,30.08,,,,,,,7.41,30.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,United Healthcare,Commercial,,13.05,,,,,,,4.83,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,United Healthcare,Commercial,,92.89,,,,,,,3.21,102.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,inpatient,1.25,ML,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,14.50,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,inpatient,5,ML,24.85000,14.91000,United Healthcare,Commercial,,20.20,,,,,,,7.48,20.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,United Healthcare,Commercial,,2.61,,,,,,,2.60,18.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,inpatient,2,ML,158.65000,95.19000,United Healthcare,Commercial,,128.98,,,,,,,47.75,128.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,United Healthcare,Commercial,,0.19800,,,,,,,0.18880,117.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,United Healthcare,Commercial,,72.32,,,,,,,26.77,72.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Commercial,,5.82,,,,,,,2.08,66.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,inpatient,1,UN,125.55000,75.33000,United Healthcare,Commercial,,102.07,,,,,,,37.79,102.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,United Healthcare,Commercial,,57.72,,,,,,,25.14,93.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,1,ML,84.10000,50.46000,United Healthcare,Commercial,,68.37,,,,,,,25.31,68.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,United Healthcare,Commercial,,1.58,,,,,,,1.13,62.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,United Healthcare,Commercial,,290.44,,,,,,,107.53,290.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,United Healthcare,Commercial,,6.20,,,,,,,2.50,265.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,United Healthcare,Commercial,,939.87,,,,,,,347.97,939.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,United Healthcare,Commercial,,1.58,,,,,,,1.13,858.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,7.93,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,22.13,,,,,,,5.28,22.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,inpatient,0.5,ML,24.95000,14.97000,United Healthcare,Commercial,,20.28,,,,,,,7.51,20.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,United Healthcare,Commercial,,12.39,,,,,,,4.99,18.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,inpatient,1,UN,730.25000,438.15000,United Healthcare,Commercial,,593.69,,,,,,,219.81,593.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,United Healthcare,Commercial,,0.42900,,,,,,,0.33040,541.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,inpatient,100,GR,101.70000,61.02000,United Healthcare,Commercial,,82.68,,,,,,,65.09,82.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,United Healthcare,Commercial,,82.68,,,,,,,20.36,82.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,United Healthcare,Commercial,,52.03,,,,,,,19.26,52.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,United Healthcare,Commercial,,2.29,,,,,,,1.89,47.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,inpatient,0.5,ML,103.50000,62.10000,United Healthcare,Commercial,,84.15,,,,,,,31.15,84.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,United Healthcare,Commercial,,86.23,,,,,,,20.72,88.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,inpatient,5,ML,62.05000,37.23000,United Healthcare,Commercial,,50.45,,,,,,,39.71,50.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,United Healthcare,Commercial,,50.45,,,,,,,12.42,50.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,United Healthcare,Commercial,,122.97,,,,,,,45.53,122.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,United Healthcare,Commercial,,7.28,,,,,,,5.97,112.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,United Healthcare,Commercial,,232.92,,,,,,,86.24,232.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,United Healthcare,Commercial,,7.28,,,,,,,5.97,212.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,inpatient,1,UN,39.00000,23.40000,United Healthcare,Commercial,,31.71,,,,,,,11.74,31.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,United Healthcare,Commercial,,3.35,,,,,,,2.88,28.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,inpatient,1,UN,61.50000,36.90000,United Healthcare,Commercial,,50.00,,,,,,,18.51,50.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,United Healthcare,Commercial,,3.35,,,,,,,2.88,45.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,inpatient,1,UN,26.40000,15.84000,United Healthcare,Commercial,,21.46,,,,,,,7.95,21.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,United Healthcare,Commercial,,6.24,,,,,,,4.37,19.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,United Healthcare,Commercial,,29.67,,,,,,,10.99,29.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,United Healthcare,Commercial,,6.24,,,,,,,4.37,27.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,inpatient,1,UN,210.00000,126.00000,United Healthcare,Commercial,,170.73,,,,,,,63.21,170.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,155.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,inpatient,1,UN,75.60000,45.36000,United Healthcare,Commercial,,61.46,,,,,,,22.76,61.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,United Healthcare,Commercial,,1.20,,,,,,,0.99120,56.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,United Healthcare,Commercial,,71.38,,,,,,,26.43,71.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,United Healthcare,Commercial,,1.20,,,,,,,0.99120,65.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,inpatient,1,UN,82.30000,49.38000,United Healthcare,Commercial,,66.91,,,,,,,24.77,66.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,United Healthcare,Commercial,,4.06,,,,,,,3.28,61.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,20.41,,,,,,,7.56,20.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,Commercial,,1.30,,,,,,,1.01,18.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,United Healthcare,Commercial,,24.11,,,,,,,8.92,24.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,United Healthcare,Commercial,,1.30,,,,,,,1.01,22.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,inpatient,8,ML,66.95000,40.17000,United Healthcare,Commercial,,54.43,,,,,,,20.15,54.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,United Healthcare,Commercial,,21.73,,,,,,,13.40,49.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,inpatient,50,ML,84.00000,50.40000,United Healthcare,Commercial,,68.29,,,,,,,25.28,68.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,United Healthcare,Commercial,,21.73,,,,,,,16.71,62.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,United Healthcare,Commercial,,18.86,,,,,,,6.98,18.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,United Healthcare,Commercial,,3.60,,,,,,,3.26,17.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,inpatient,120,ML,34.40000,20.64000,United Healthcare,Commercial,,27.97,,,,,,,22.02,27.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,United Healthcare,Commercial,,27.97,,,,,,,6.89,27.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,inpatient,50,ML,20.65000,12.39000,United Healthcare,Commercial,,16.79,,,,,,,13.22,16.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,United Healthcare,Commercial,,16.79,,,,,,,4.13,16.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,United Healthcare,Commercial,,34.72,,,,,,,12.85,34.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,31.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,2,ML,23.95000,14.37000,United Healthcare,Commercial,,19.47,,,,,,,7.21,19.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,17.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,5,ML,26.20000,15.72000,United Healthcare,Commercial,,21.30,,,,,,,7.89,21.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,19.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,inpatient,5,ML,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,11.30,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,inpatient,1.25,ML,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,10.46,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,inpatient,500,ML,531.30000,318.78000,United Healthcare,Commercial,,431.95,,,,,,,159.92,431.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,394.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,inpatient,120,ML,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,21.76,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,inpatient,120,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,56.32,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,17.62,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,inpatient,4,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Commercial,,159.42,,,,,,,0.04004,163.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,United Healthcare,Commercial,,2097.91,,,,,,,776.72,2097.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,Commercial,,18.32,,,,,,,6.53,1915.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,20101.26,,,,,,,7442.16,20101.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,444.35,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,20101.26,,,,,,,7442.16,20101.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,444.35,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,20101.26,,,,,,,7442.16,20101.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,444.35,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,20101.26,,,,,,,7442.16,20101.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,444.35,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,20101.26,,,,,,,7442.16,20101.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Commercial,,444.35,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,United Healthcare,Commercial,,30705.83,,,,,,,11368.33,30705.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Commercial,,468.11,,,,,,,167.05,28031.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,inpatient,14,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,inpatient,150,ME,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,United Healthcare,Commercial,,207.41,,,,,,,0.04004,212.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Commercial,,171.44,,,,,,,0.04004,175.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,inpatient,15,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,Commercial,,172.57,,,,,,,0.04004,176.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Commercial,,172.57,,,,,,,0.04004,176.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,inpatient,100,ML,403.95000,242.37000,United Healthcare,Commercial,,328.41,,,,,,,121.59,328.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,United Healthcare,Commercial,,4.69,,,,,,,4.69,299.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,inpatient,60,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,United Healthcare,Commercial,,5.74,,,,,,,0.04004,5.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,inpatient,100,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,United Healthcare,Commercial,,5.31,,,,,,,0.04004,5.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,inpatient,500,ME,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,United Healthcare,Commercial,,10.15,,,,,,,0.04004,10.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,inpatient,4,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Commercial,,159.42,,,,,,,0.04004,163.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,inpatient,4,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Commercial,,159.42,,,,,,,0.04004,163.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,inpatient,500,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,United Healthcare,Commercial,,0.04950,,,,,,,0.04004,0.14844,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,inpatient,16,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,United Healthcare,Commercial,,1.04,,,,,,,0.04004,1.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,inpatient,8,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,United Healthcare,Commercial,,1.04,,,,,,,0.04004,1.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,inpatient,100,ML,106.70000,64.02000,United Healthcare,Commercial,,86.75,,,,,,,32.12,86.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,United Healthcare,Commercial,,6.15,,,,,,,5.33,79.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,United Healthcare,Commercial,,24.11,,,,,,,8.92,24.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,United Healthcare,Commercial,,42.72,,,,,,,5.94,42.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,inpatient,0.1,ML,23.05000,13.83000,United Healthcare,Commercial,,18.74,,,,,,,6.94,18.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,United Healthcare,Commercial,,0.24750,,,,,,,0.21240,17.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,inpatient,1,ML,148.15000,88.89000,United Healthcare,Commercial,,120.45,,,,,,,94.82,120.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,United Healthcare,Commercial,,120.45,,,,,,,29.66,120.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,United Healthcare,Commercial,,24.35,,,,,,,9.01,24.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,United Healthcare,Commercial,,42.72,,,,,,,6.00,42.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,inpatient,113,GR,12.40000,7.44000,United Healthcare,Commercial,,10.08,,,,,,,7.94,10.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,United Healthcare,Commercial,,10.08,,,,,,,2.48,10.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,United Healthcare,Commercial,,392.68,,,,,,,145.38,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,Commercial,,2.01,,,,,,,0.77600,358.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,inpatient,4,ML,757.00000,454.20000,United Healthcare,Commercial,,615.44,,,,,,,227.86,615.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,United Healthcare,Commercial,,39.76,,,,,,,14.72,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,36.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,United Healthcare,Commercial,,20.93,,,,,,,7.75,20.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,19.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,inpatient,5,ML,26.10000,15.66000,United Healthcare,Commercial,,21.22,,,,,,,7.86,21.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,19.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,inpatient,1,ML,278.25000,166.95000,United Healthcare,Commercial,,226.22,,,,,,,83.75,226.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,United Healthcare,Commercial,,197.87,,,,,,,55.71,221.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,inpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,inpatient,10,ML,58.40000,35.04000,United Healthcare,Commercial,,47.48,,,,,,,37.38,47.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,United Healthcare,Commercial,,47.48,,,,,,,11.69,47.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,inpatient,15,ML,77.55000,46.53000,United Healthcare,Commercial,,63.05,,,,,,,49.63,63.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,United Healthcare,Commercial,,63.05,,,,,,,15.53,63.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.2,ML,16.85000,10.11000,United Healthcare,Commercial,,13.70,,,,,,,5.07,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,United Healthcare,Commercial,,2.29,,,,,,,1.89,12.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,inpatient,4000,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,56.32,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,United Healthcare,Commercial,,71.54,,,,,,,17.62,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,United Healthcare,Commercial,,438.86,,,,,,,162.48,438.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,United Healthcare,Commercial,,144.51,,,,,,,108.07,400.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,United Healthcare,Commercial,,250.73,,,,,,,92.83,250.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,United Healthcare,Commercial,,144.51,,,,,,,61.74,228.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,inpatient,20.3,ML,4.15000,2.49000,United Healthcare,Commercial,,3.37,,,,,,,2.66,3.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,United Healthcare,Commercial,,3.37,,,,,,,0.83083,3.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,inpatient,5,ML,2.80000,1.68000,United Healthcare,Commercial,,2.28,,,,,,,1.79,2.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,United Healthcare,Commercial,,2.28,,,,,,,0.56056,2.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,inpatient,287.5,ML,276.75000,166.05000,United Healthcare,Commercial,,225.00,,,,,,,83.30,225.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,205.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,inpatient,555,ML,298.45000,179.07000,United Healthcare,Commercial,,242.64,,,,,,,89.83,242.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,221.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,inpatient,557.5,ML,238.65000,143.19000,United Healthcare,Commercial,,194.02,,,,,,,71.83,194.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,177.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,inpatient,560,ML,260.60000,156.36000,United Healthcare,Commercial,,211.87,,,,,,,78.44,211.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,193.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,inpatient,30,ML,2.25000,1.35000,United Healthcare,Commercial,,1.83,,,,,,,1.44,1.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,United Healthcare,Commercial,,1.83,,,,,,,0.45045,1.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,inpatient,0.09,ML,291.30000,174.78000,United Healthcare,Commercial,,236.83,,,,,,,87.68,236.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,United Healthcare,Commercial,,4.98,,,,,,,1.78,216.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,6.92,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,17.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,6.92,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,United Healthcare,Commercial,,0.42900,,,,,,,0.35400,17.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,inpatient,10,ML,41.15000,24.69000,United Healthcare,Commercial,,33.45,,,,,,,12.39,33.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,30.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,United Healthcare,Commercial,,53.86,,,,,,,19.94,53.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,United Healthcare,Commercial,,0.16500,,,,,,,0.11800,49.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,inpatient,50,ML,77.80000,46.68000,United Healthcare,Commercial,,63.25,,,,,,,49.79,63.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,United Healthcare,Commercial,,63.25,,,,,,,15.58,63.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,28.70000,17.22000,United Healthcare,Commercial,,23.33,,,,,,,18.37,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,Commercial,,23.33,,,,,,,5.75,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,inpatient,1,UN,37.70000,22.62000,United Healthcare,Commercial,,30.65,,,,,,,24.13,30.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,United Healthcare,Commercial,,30.65,,,,,,,7.55,30.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,United Healthcare,Commercial,,30.24,,,,,,,11.20,30.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,United Healthcare,Commercial,,0.54450,,,,,,,0.44840,27.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,inpatient,1,UN,45136.00000,27081.60000,United Healthcare,Commercial,,36695.57,,,,,,,13585.94,36695.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,United Healthcare,Commercial,,644.19,,,,,,,229.52,33499.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,United Healthcare,Commercial,,29243.85,,,,,,,10827.06,29243.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,Commercial,,247.80,,,,,,,88.60,26697.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,United Healthcare,Commercial,,41681.05,,,,,,,15431.73,41681.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,Commercial,,247.80,,,,,,,88.60,38051.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,inpatient,1,UN,27.45000,16.47000,United Healthcare,Commercial,,22.32,,,,,,,17.57,22.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,United Healthcare,Commercial,,22.32,,,,,,,5.50,22.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,inpatient,1,UN,556.00000,333.60000,United Healthcare,Commercial,,452.03,,,,,,,355.84,452.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,United Healthcare,Commercial,,452.03,,,,,,,111.31,452.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,United Healthcare,Commercial,,255.89,,,,,,,94.74,255.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,United Healthcare,Commercial,,6.15,,,,,,,6.15,233.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,United Healthcare,Commercial,,235.61,,,,,,,87.23,235.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,United Healthcare,Commercial,,6.15,,,,,,,6.15,215.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,United Healthcare,Commercial,,342.52,,,,,,,126.81,342.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,United Healthcare,Commercial,,6.15,,,,,,,6.15,312.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,15,ML,46791.25000,28074.75000,United Healthcare,Commercial,,38041.29,,,,,,,14084.17,38041.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,United Healthcare,Commercial,,148.85,,,,,,,53.90,34728.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,United Healthcare,Commercial,,6208.23,,,,,,,2298.50,6208.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Commercial,,213.64,,,,,,,76.02,5667.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,3215.90,,,,,,,1190.64,3215.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,213.64,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,United Healthcare,Commercial,,6208.23,,,,,,,2298.50,6208.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Commercial,,213.64,,,,,,,76.02,5667.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,3215.90,,,,,,,1190.64,3215.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,213.64,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,United Healthcare,Commercial,,6208.23,,,,,,,2298.50,6208.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Commercial,,213.64,,,,,,,76.02,5667.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,3215.90,,,,,,,1190.64,3215.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Commercial,,213.64,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,Commercial,,6644.81,,,,,,,0.04004,6806.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,United Healthcare,Commercial,,823.12,,,,,,,304.75,823.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,Commercial,,0.82500,,,,,,,0.27160,751.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,15296.11,,,,,,,5663.13,15296.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,99.81,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,15296.11,,,,,,,5663.13,15296.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,99.81,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,15296.11,,,,,,,5663.13,15296.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Commercial,,99.81,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,United Healthcare,Commercial,,41551.09,,,,,,,15383.61,41551.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,Commercial,,197.11,,,,,,,70.44,37932.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,United Healthcare,Commercial,,2012.17,,,,,,,744.98,2012.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,Commercial,,294.11,,,,,,,93.02,1836.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,United Healthcare,Commercial,,3394.80,,,,,,,1256.87,3394.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,Commercial,,12.77,,,,,,,4.29,3099.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,United Healthcare,Commercial,,6738.39,,,,,,,2494.78,6738.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,Commercial,,12.77,,,,,,,4.29,6151.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,United Healthcare,Commercial,,1388.69,,,,,,,514.14,1388.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,Commercial,,12.77,,,,,,,4.29,1267.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,United Healthcare,Commercial,,3394.80,,,,,,,1256.87,3394.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,Commercial,,12.77,,,,,,,4.29,3099.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,United Healthcare,Commercial,,6738.39,,,,,,,2494.78,6738.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,Commercial,,12.77,,,,,,,4.29,6151.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,United Healthcare,Commercial,,1388.69,,,,,,,514.14,1388.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,Commercial,,12.77,,,,,,,4.29,1267.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,inpatient,67,ML,278.85000,167.31000,United Healthcare,Commercial,,226.71,,,,,,,83.93,226.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,United Healthcare,Commercial,,19.90,,,,,,,6.18,206.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,inpatient,2,ML,44.10000,26.46000,United Healthcare,Commercial,,35.85,,,,,,,13.27,35.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,United Healthcare,Commercial,,7.13,,,,,,,5.22,32.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,inpatient,4,ML,29.75000,17.85000,United Healthcare,Commercial,,24.19,,,,,,,8.95,24.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,Commercial,,1.67,,,,,,,0.35890,22.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,inpatient,50,ML,191837.95000,115102.77000,United Healthcare,Commercial,,155964.25,,,,,,,122776.29,155964.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,United Healthcare,Commercial,,155964.25,,,,,,,38405.96,155964.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,inpatient,100,ML,128.90000,77.34000,United Healthcare,Commercial,,104.80,,,,,,,82.50,104.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,United Healthcare,Commercial,,104.80,,,,,,,25.81,104.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,United Healthcare,Commercial,,1196.17,,,,,,,442.86,1196.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,Commercial,,195.06,,,,,,,66.15,1092.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,inpatient,1,UN,70.75000,42.45000,United Healthcare,Commercial,,57.52,,,,,,,45.28,57.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,United Healthcare,Commercial,,57.52,,,,,,,14.16,57.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,inpatient,10,ML,20.30000,12.18000,United Healthcare,Commercial,,16.50,,,,,,,12.99,16.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,United Healthcare,Commercial,,16.50,,,,,,,4.06,16.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,inpatient,10,ML,21.50000,12.90000,United Healthcare,Commercial,,17.48,,,,,,,13.76,17.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,United Healthcare,Commercial,,17.48,,,,,,,4.30,17.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,inpatient,10,ML,19.25000,11.55000,United Healthcare,Commercial,,15.65,,,,,,,12.32,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,United Healthcare,Commercial,,15.65,,,,,,,3.85,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,inpatient,5,ML,671.00000,402.60000,United Healthcare,Commercial,,545.52,,,,,,,201.97,545.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,United Healthcare,Commercial,,5.33,,,,,,,5.33,498.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,inpatient,0.5,ML,145.05000,87.03000,United Healthcare,Commercial,,117.93,,,,,,,92.83,117.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,United Healthcare,Commercial,,117.93,,,,,,,29.04,117.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,inpatient,35.44,GR,736.00000,441.60000,United Healthcare,Commercial,,598.37,,,,,,,471.04,598.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,United Healthcare,Commercial,,598.37,,,,,,,147.35,598.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,inpatient,1,UN,263.45000,158.07000,United Healthcare,Commercial,,214.18,,,,,,,168.61,214.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,United Healthcare,Commercial,,214.18,,,,,,,52.74,214.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,inpatient,1,UN,55.40000,33.24000,United Healthcare,Commercial,,45.04,,,,,,,35.46,45.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,United Healthcare,Commercial,,45.04,,,,,,,11.09,45.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,inpatient,1,UN,55.40000,33.24000,United Healthcare,Commercial,,45.04,,,,,,,35.46,45.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,United Healthcare,Commercial,,45.04,,,,,,,11.09,45.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,inpatient,15,ML,5.10000,3.06000,United Healthcare,Commercial,,4.15,,,,,,,3.26,4.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,United Healthcare,Commercial,,4.15,,,,,,,1.02,4.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,inpatient,240,ML,12.95000,7.77000,United Healthcare,Commercial,,10.53,,,,,,,8.29,10.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,United Healthcare,Commercial,,10.53,,,,,,,2.59,10.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,inpatient,20,ML,79.90000,47.94000,United Healthcare,Commercial,,64.96,,,,,,,51.14,64.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,United Healthcare,Commercial,,64.96,,,,,,,16.00,64.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,inpatient,5,ML,60.25000,36.15000,United Healthcare,Commercial,,48.98,,,,,,,38.56,48.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,United Healthcare,Commercial,,48.98,,,,,,,12.06,48.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,inpatient,10,ML,460.75000,276.45000,United Healthcare,Commercial,,374.59,,,,,,,294.88,374.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,United Healthcare,Commercial,,374.59,,,,,,,92.24,374.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,inpatient,1,UN,17.15000,10.29000,United Healthcare,Commercial,,13.94,,,,,,,10.98,13.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,United Healthcare,Commercial,,13.94,,,,,,,3.43,13.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,inpatient,1,UN,59.20000,35.52000,United Healthcare,Commercial,,48.13,,,,,,,37.89,48.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,United Healthcare,Commercial,,48.13,,,,,,,11.85,48.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,inpatient,1,UN,38.25000,22.95000,United Healthcare,Commercial,,31.10,,,,,,,24.48,31.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,United Healthcare,Commercial,,31.10,,,,,,,7.66,31.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,inpatient,60,ML,435.95000,261.57000,United Healthcare,Commercial,,354.43,,,,,,,279.01,354.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,United Healthcare,Commercial,,354.43,,,,,,,87.28,354.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,inpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,11.71,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Commercial,,14.88,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,inpatient,4,ML,106.60000,63.96000,United Healthcare,Commercial,,86.67,,,,,,,68.22,86.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,United Healthcare,Commercial,,86.67,,,,,,,21.34,86.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,inpatient,1,UN,107.00000,64.20000,United Healthcare,Commercial,,86.99,,,,,,,32.21,86.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,United Healthcare,Commercial,,10.76,,,,,,,7.60,79.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,inpatient,1,UN,583.00000,349.80000,United Healthcare,Commercial,,473.98,,,,,,,175.48,473.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,United Healthcare,Commercial,,10.76,,,,,,,7.60,432.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,inpatient,1,UN,313.75000,188.25000,United Healthcare,Commercial,,255.08,,,,,,,94.44,255.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,United Healthcare,Commercial,,10.76,,,,,,,7.60,232.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,inpatient,1,UN,51.80000,31.08000,United Healthcare,Commercial,,42.11,,,,,,,33.15,42.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,United Healthcare,Commercial,,42.11,,,,,,,10.37,42.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,inpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,13.06,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Commercial,,16.59,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,inpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,11.39,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Commercial,,14.47,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,inpatient,1,UN,18.20000,10.92000,United Healthcare,Commercial,,14.80,,,,,,,11.65,14.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,United Healthcare,Commercial,,14.80,,,,,,,3.64,14.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,inpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,11.33,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,inpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,11.52,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Commercial,,14.63,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,inpatient,1,UN,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,14.50,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,United Healthcare,Commercial,,18.41,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,inpatient,7.5,ML,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,21.76,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,inpatient,20,ML,30.50000,18.30000,United Healthcare,Commercial,,24.80,,,,,,,9.18,24.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,22.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,inpatient,50,ML,30.60000,18.36000,United Healthcare,Commercial,,24.88,,,,,,,9.21,24.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,22.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,inpatient,20,ML,34.15000,20.49000,United Healthcare,Commercial,,27.76,,,,,,,10.28,27.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,25.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,inpatient,5,ML,38.00000,22.80000,United Healthcare,Commercial,,30.89,,,,,,,11.44,30.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,28.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,inpatient,5,ML,115.10000,69.06000,United Healthcare,Commercial,,93.58,,,,,,,34.65,93.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,85.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,inpatient,5,ML,49.10000,29.46000,United Healthcare,Commercial,,39.92,,,,,,,14.78,39.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,United Healthcare,Commercial,,0.16500,,,,,,,0.02360,36.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,inpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,10.40,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Commercial,,13.21,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,inpatient,1,UN,18.15000,10.89000,United Healthcare,Commercial,,14.76,,,,,,,11.62,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,Commercial,,14.76,,,,,,,3.63,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,inpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,10.50,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,inpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,inpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,10.94,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,inpatient,5,ML,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,10.53,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,inpatient,5,ML,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,inpatient,1,UN,2.15000,1.29000,United Healthcare,Commercial,,1.75,,,,,,,1.38,1.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,United Healthcare,Commercial,,1.75,,,,,,,0.43043,1.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,0.5,ML,23.80000,14.28000,United Healthcare,Commercial,,19.35,,,,,,,15.23,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,United Healthcare,Commercial,,19.35,,,,,,,4.76,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,inpatient,30,ML,116.70000,70.02000,United Healthcare,Commercial,,94.88,,,,,,,74.69,94.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,United Healthcare,Commercial,,94.88,,,,,,,23.36,94.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,inpatient,1,UN,234.40000,140.64000,United Healthcare,Commercial,,190.57,,,,,,,70.55,190.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,United Healthcare,Commercial,,92.89,,,,,,,46.93,173.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,inpatient,1,UN,47.45000,28.47000,United Healthcare,Commercial,,38.58,,,,,,,14.28,38.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,United Healthcare,Commercial,,1.34,,,,,,,1.30,35.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,inpatient,296,ML,4.25000,2.55000,United Healthcare,Commercial,,3.46,,,,,,,2.72,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,United Healthcare,Commercial,,3.46,,,,,,,0.85085,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,inpatient,100,ML,91.00000,54.60000,United Healthcare,Commercial,,73.98,,,,,,,27.39,73.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,United Healthcare,Commercial,,1.37,,,,,,,1.13,67.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,inpatient,1,UN,48.35000,29.01000,United Healthcare,Commercial,,39.31,,,,,,,14.55,39.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,United Healthcare,Commercial,,1.34,,,,,,,1.30,35.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,7.93,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,United Healthcare,Commercial,,1.37,,,,,,,1.13,19.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,inpatient,1,UN,31.25000,18.75000,United Healthcare,Commercial,,25.41,,,,,,,9.41,25.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,United Healthcare,Commercial,,1.34,,,,,,,1.30,23.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,inpatient,1,UN,29.65000,17.79000,United Healthcare,Commercial,,24.11,,,,,,,8.92,24.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,United Healthcare,Commercial,,1.34,,,,,,,1.30,22.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,inpatient,10,ML,185.65000,111.39000,United Healthcare,Commercial,,150.93,,,,,,,118.82,150.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,United Healthcare,Commercial,,150.93,,,,,,,37.17,150.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,inpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,10.94,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,United Healthcare,Commercial,,24.11,,,,,,,8.92,24.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,United Healthcare,Commercial,,42.72,,,,,,,5.94,42.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,United Healthcare,Commercial,,24.35,,,,,,,9.01,24.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,United Healthcare,Commercial,,42.72,,,,,,,6.00,42.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,inpatient,50,ML,87.25000,52.35000,United Healthcare,Commercial,,70.93,,,,,,,26.26,70.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,United Healthcare,Commercial,,10.39,,,,,,,9.32,64.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,inpatient,50,ML,89.05000,53.43000,United Healthcare,Commercial,,72.40,,,,,,,26.80,72.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,United Healthcare,Commercial,,10.39,,,,,,,9.32,66.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,inpatient,5,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,14.72,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,inpatient,500,ML,118.00000,70.80000,United Healthcare,Commercial,,95.93,,,,,,,75.52,95.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,United Healthcare,Commercial,,95.93,,,,,,,23.62,95.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,inpatient,1,UN,23.40000,14.04000,United Healthcare,Commercial,,19.02,,,,,,,14.98,19.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,United Healthcare,Commercial,,19.02,,,,,,,4.68,19.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,inpatient,5,ML,53.55000,32.13000,United Healthcare,Commercial,,43.54,,,,,,,16.12,43.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,United Healthcare,Commercial,,13.04,,,,,,,10.72,39.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,inpatient,1,UN,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,10.46,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,United Healthcare,Commercial,,13.29,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,United Healthcare,Commercial,,30.24,,,,,,,11.20,30.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,United Healthcare,Commercial,,0.54450,,,,,,,0.44840,27.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,inpatient,2,ML,307.00000,184.20000,United Healthcare,Commercial,,249.59,,,,,,,92.41,249.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,United Healthcare,Commercial,,6.15,,,,,,,6.15,227.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,inpatient,1,UN,473.00000,283.80000,United Healthcare,Commercial,,384.55,,,,,,,142.37,384.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,United Healthcare,Commercial,,6.15,,,,,,,6.15,351.06,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,inpatient,1,UN,22.60000,13.56000,United Healthcare,Commercial,,18.37,,,,,,,14.46,18.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,United Healthcare,Commercial,,18.37,,,,,,,4.52,18.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,inpatient,0.25,ML,28.95000,17.37000,United Healthcare,Commercial,,23.54,,,,,,,8.71,23.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,United Healthcare,Commercial,,0.33000,,,,,,,0.11640,21.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,inpatient,1,ML,105.75000,63.45000,United Healthcare,Commercial,,85.97,,,,,,,31.83,85.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,United Healthcare,Commercial,,0.33000,,,,,,,0.11640,78.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,inpatient,1,UN,19.20000,11.52000,United Healthcare,Commercial,,15.61,,,,,,,12.29,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,Commercial,,15.61,,,,,,,3.84,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,inpatient,1,UN,19.05000,11.43000,United Healthcare,Commercial,,15.49,,,,,,,12.19,15.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,United Healthcare,Commercial,,15.49,,,,,,,3.81,15.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,inpatient,5,ML,20.55000,12.33000,United Healthcare,Commercial,,16.71,,,,,,,6.19,16.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,United Healthcare,Commercial,,0.34650,,,,,,,0.28320,15.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,inpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,inpatient,1,UN,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,10.53,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,inpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,11.30,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,inpatient,1,UN,18.65000,11.19000,United Healthcare,Commercial,,15.16,,,,,,,11.94,15.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,United Healthcare,Commercial,,15.16,,,,,,,3.73,15.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,inpatient,100,ML,74.20000,44.52000,United Healthcare,Commercial,,60.32,,,,,,,22.33,60.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,55.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,inpatient,45,GR,13.50000,8.10000,United Healthcare,Commercial,,10.98,,,,,,,8.64,10.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,United Healthcare,Commercial,,10.98,,,,,,,2.70,10.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,inpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,10.94,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,inpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,11.90,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,inpatient,1,UN,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,11.58,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,United Healthcare,Commercial,,14.72,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,inpatient,0.5,ML,26.60000,15.96000,United Healthcare,Commercial,,21.63,,,,,,,8.01,21.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,United Healthcare,Commercial,,22.13,,,,,,,5.33,22.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,inpatient,1,ML,30.65000,18.39000,United Healthcare,Commercial,,24.92,,,,,,,9.23,24.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,United Healthcare,Commercial,,22.13,,,,,,,6.14,22.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,21.42,,,,,,,7.93,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,United Healthcare,Commercial,,22.13,,,,,,,5.28,22.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,inpatient,0.4,ML,22.10000,13.26000,United Healthcare,Commercial,,17.97,,,,,,,14.14,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,United Healthcare,Commercial,,17.97,,,,,,,4.42,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,inpatient,5,ML,26.10000,15.66000,United Healthcare,Commercial,,21.22,,,,,,,16.70,21.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,United Healthcare,Commercial,,21.22,,,,,,,5.23,21.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,inpatient,500,ML,91.00000,54.60000,United Healthcare,Commercial,,73.98,,,,,,,58.24,73.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,United Healthcare,Commercial,,73.98,,,,,,,18.22,73.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,inpatient,1,UN,23.30000,13.98000,United Healthcare,Commercial,,18.94,,,,,,,14.91,18.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,United Healthcare,Commercial,,18.94,,,,,,,4.66,18.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,inpatient,1,UN,37.00000,22.20000,United Healthcare,Commercial,,30.08,,,,,,,23.68,30.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,United Healthcare,Commercial,,30.08,,,,,,,7.41,30.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,inpatient,1,ML,32.30000,19.38000,United Healthcare,Commercial,,26.26,,,,,,,9.72,26.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,United Healthcare,Commercial,,9.55,,,,,,,6.47,23.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,United Healthcare,Commercial,,71.58,,,,,,,26.50,71.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,United Healthcare,Commercial,,0.19800,,,,,,,0.18880,65.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,inpatient,2,ML,166.15000,99.69000,United Healthcare,Commercial,,135.08,,,,,,,50.01,135.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,United Healthcare,Commercial,,0.19800,,,,,,,0.18880,123.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,inpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,10.91,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,inpatient,10,ML,128.35000,77.01000,United Healthcare,Commercial,,104.35,,,,,,,38.63,104.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,United Healthcare,Commercial,,3.86,,,,,,,3.52,95.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,inpatient,1,UN,53.70000,32.22000,United Healthcare,Commercial,,43.66,,,,,,,34.37,43.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,United Healthcare,Commercial,,43.66,,,,,,,10.75,43.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,inpatient,1,GR,25.70000,15.42000,United Healthcare,Commercial,,20.89,,,,,,,16.45,20.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,United Healthcare,Commercial,,20.89,,,,,,,5.15,20.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,10.75,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,inpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,10.94,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,inpatient,15,GR,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,37.12,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,inpatient,15,GR,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,37.12,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,inpatient,1,UN,18.40000,11.04000,United Healthcare,Commercial,,14.96,,,,,,,11.78,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,Commercial,,14.96,,,,,,,3.68,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,inpatient,1,UN,23.25000,13.95000,United Healthcare,Commercial,,18.90,,,,,,,14.88,18.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,United Healthcare,Commercial,,18.90,,,,,,,4.65,18.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,inpatient,15,ML,10.50000,6.30000,United Healthcare,Commercial,,8.54,,,,,,,6.72,8.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,United Healthcare,Commercial,,8.54,,,,,,,2.10,8.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,inpatient,0.3,ML,20.95000,12.57000,United Healthcare,Commercial,,17.03,,,,,,,6.31,17.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,United Healthcare,Commercial,,5.48,,,,,,,3.37,15.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,inpatient,0.3,ML,17.95000,10.77000,United Healthcare,Commercial,,14.59,,,,,,,5.40,14.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,United Healthcare,Commercial,,5.48,,,,,,,3.37,13.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,inpatient,2,ML,204.45000,122.67000,United Healthcare,Commercial,,166.22,,,,,,,61.54,166.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,United Healthcare,Commercial,,125.07,,,,,,,40.93,151.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,inpatient,1,UN,247.55000,148.53000,United Healthcare,Commercial,,201.26,,,,,,,74.51,201.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,United Healthcare,Commercial,,2.39,,,,,,,1.86,183.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,inpatient,1,UN,73.90000,44.34000,United Healthcare,Commercial,,60.08,,,,,,,22.24,60.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,United Healthcare,Commercial,,2.39,,,,,,,1.86,54.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,inpatient,100,ML,42.70000,25.62000,United Healthcare,Commercial,,34.72,,,,,,,27.33,34.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,United Healthcare,Commercial,,34.72,,,,,,,8.55,34.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,10.75,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,United Healthcare,Commercial,,5522.71,,,,,,,2044.69,5522.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,United Healthcare,Commercial,,173.61,,,,,,,127.13,5041.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,11.42,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,inpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,11.07,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Commercial,,14.06,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,inpatient,5,ML,24.30000,14.58000,United Healthcare,Commercial,,19.76,,,,,,,15.55,19.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,United Healthcare,Commercial,,19.76,,,,,,,4.86,19.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,inpatient,1,UN,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,15.14,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,inpatient,1,ML,227.20000,136.32000,United Healthcare,Commercial,,184.71,,,,,,,68.39,184.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,United Healthcare,Commercial,,74.48,,,,,,,45.49,168.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,inpatient,1,ML,101.10000,60.66000,United Healthcare,Commercial,,82.19,,,,,,,30.43,82.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,United Healthcare,Commercial,,74.48,,,,,,,20.24,75.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,inpatient,1,ML,34.20000,20.52000,United Healthcare,Commercial,,27.80,,,,,,,10.29,27.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,25.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,inpatient,10,ML,212.70000,127.62000,United Healthcare,Commercial,,172.93,,,,,,,64.02,172.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,157.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,inpatient,5,ML,107.00000,64.20000,United Healthcare,Commercial,,86.99,,,,,,,32.21,86.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,79.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,inpatient,15,ML,6.40000,3.84000,United Healthcare,Commercial,,5.20,,,,,,,4.10,5.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,United Healthcare,Commercial,,5.20,,,,,,,1.28,5.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,inpatient,15,ML,6.40000,3.84000,United Healthcare,Commercial,,5.20,,,,,,,4.10,5.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,United Healthcare,Commercial,,5.20,,,,,,,1.28,5.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,inpatient,2,ML,113.50000,68.10000,United Healthcare,Commercial,,92.28,,,,,,,72.64,92.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,United Healthcare,Commercial,,92.28,,,,,,,22.72,92.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,inpatient,2,ML,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,6.73,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,United Healthcare,Commercial,,1.80,,,,,,,1.06,16.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,inpatient,1,UN,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,15.14,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.25,ML,72.30000,43.38000,United Healthcare,Commercial,,58.78,,,,,,,21.76,58.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,United Healthcare,Commercial,,7.74,,,,,,,6.44,53.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,inpatient,15,ML,252.60000,151.56000,United Healthcare,Commercial,,205.36,,,,,,,161.66,205.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,United Healthcare,Commercial,,205.36,,,,,,,50.57,205.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,inpatient,15,ML,258.00000,154.80000,United Healthcare,Commercial,,209.75,,,,,,,165.12,209.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,United Healthcare,Commercial,,209.75,,,,,,,51.65,209.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,inpatient,15,ML,269.70000,161.82000,United Healthcare,Commercial,,219.27,,,,,,,172.61,219.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,United Healthcare,Commercial,,219.27,,,,,,,53.99,219.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,inpatient,100,ML,155.40000,93.24000,United Healthcare,Commercial,,126.34,,,,,,,99.46,126.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,United Healthcare,Commercial,,126.34,,,,,,,31.11,126.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,inpatient,20,ML,85.70000,51.42000,United Healthcare,Commercial,,69.67,,,,,,,54.85,69.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,United Healthcare,Commercial,,69.67,,,,,,,17.16,69.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,inpatient,50,ML,110.05000,66.03000,United Healthcare,Commercial,,89.47,,,,,,,70.43,89.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,United Healthcare,Commercial,,89.47,,,,,,,22.03,89.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,inpatient,10,ML,72.65000,43.59000,United Healthcare,Commercial,,59.06,,,,,,,21.87,59.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,53.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,inpatient,473,ML,189.15000,113.49000,United Healthcare,Commercial,,153.78,,,,,,,121.06,153.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,United Healthcare,Commercial,,153.78,,,,,,,37.87,153.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,inpatient,1,UN,44.85000,26.91000,United Healthcare,Commercial,,36.46,,,,,,,28.70,36.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,United Healthcare,Commercial,,36.46,,,,,,,8.98,36.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,inpatient,28.4,GR,3.85000,2.31000,United Healthcare,Commercial,,3.13,,,,,,,2.46,3.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,United Healthcare,Commercial,,3.13,,,,,,,0.77077,3.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,inpatient,118,ML,3.05000,1.83000,United Healthcare,Commercial,,2.48,,,,,,,1.95,2.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,United Healthcare,Commercial,,2.48,,,,,,,0.61061,2.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,inpatient,1,UN,410.50000,246.30000,United Healthcare,Commercial,,333.74,,,,,,,123.56,333.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,United Healthcare,Commercial,,283.26,,,,,,,82.18,304.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,inpatient,1,UN,22.05000,13.23000,United Healthcare,Commercial,,17.93,,,,,,,14.11,17.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,United Healthcare,Commercial,,17.93,,,,,,,4.41,17.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,inpatient,1,UN,24.45000,14.67000,United Healthcare,Commercial,,19.88,,,,,,,15.65,19.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,United Healthcare,Commercial,,19.88,,,,,,,4.89,19.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,inpatient,5,ML,148.75000,89.25000,United Healthcare,Commercial,,120.93,,,,,,,95.20,120.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,United Healthcare,Commercial,,120.93,,,,,,,29.78,120.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,inpatient,500,ML,1256.00000,753.60000,United Healthcare,Commercial,,1021.13,,,,,,,378.06,1021.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,United Healthcare,Commercial,,3.84,,,,,,,0.02360,932.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,5.09,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,3.84,,,,,,,0.02360,12.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,5.09,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,3.84,,,,,,,0.02360,12.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,inpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,5.10,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,3.84,,,,,,,0.02360,12.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,5.06,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,3.84,,,,,,,0.02360,12.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,inpatient,1,UN,21.30000,12.78000,United Healthcare,Commercial,,17.32,,,,,,,13.63,17.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,United Healthcare,Commercial,,17.32,,,,,,,4.26,17.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,inpatient,1,UN,17.45000,10.47000,United Healthcare,Commercial,,14.19,,,,,,,11.17,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,Commercial,,14.19,,,,,,,3.49,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,inpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,inpatient,1,ML,202.50000,121.50000,United Healthcare,Commercial,,164.63,,,,,,,60.95,164.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,United Healthcare,Commercial,,529.04,,,,,,,40.54,695.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,inpatient,0.5,ML,22.20000,13.32000,United Healthcare,Commercial,,18.05,,,,,,,6.68,18.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,United Healthcare,Commercial,,6.86,,,,,,,4.27,16.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,inpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,14.15,,,,,,,11.14,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,14.15,,,,,,,3.48,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,inpatient,0.1,ML,17.55000,10.53000,United Healthcare,Commercial,,14.27,,,,,,,5.28,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,United Healthcare,Commercial,,1.72,,,,,,,1.65,13.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,inpatient,1,ML,24.45000,14.67000,United Healthcare,Commercial,,19.88,,,,,,,7.36,19.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,United Healthcare,Commercial,,7.82,,,,,,,4.89,18.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,inpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,inpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,11.33,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Commercial,,14.39,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,inpatient,15,ML,121.30000,72.78000,United Healthcare,Commercial,,98.62,,,,,,,77.63,98.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,United Healthcare,Commercial,,98.62,,,,,,,24.28,98.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,inpatient,500,ML,161.50000,96.90000,United Healthcare,Commercial,,131.30,,,,,,,103.36,131.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,United Healthcare,Commercial,,131.30,,,,,,,32.33,131.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,inpatient,1,UN,16.65000,9.99000,United Healthcare,Commercial,,13.54,,,,,,,10.66,13.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,United Healthcare,Commercial,,13.54,,,,,,,3.33,13.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,inpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,14.15,,,,,,,11.14,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,Commercial,,14.15,,,,,,,3.48,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,inpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,10.91,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,inpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,11.81,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Commercial,,15.00,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,inpatient,25,ML,256.70000,154.02000,United Healthcare,Commercial,,208.70,,,,,,,77.27,208.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,United Healthcare,Commercial,,4.47,,,,,,,4.11,190.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,inpatient,5,ML,86.45000,51.87000,United Healthcare,Commercial,,70.28,,,,,,,26.02,70.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,United Healthcare,Commercial,,4.47,,,,,,,4.11,64.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,inpatient,1,UN,25.20000,15.12000,United Healthcare,Commercial,,20.49,,,,,,,16.13,20.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,United Healthcare,Commercial,,20.49,,,,,,,5.05,20.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,inpatient,0.5,ML,65.45000,39.27000,United Healthcare,Commercial,,53.21,,,,,,,19.70,53.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,United Healthcare,Commercial,,34.85,,,,,,,13.10,48.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,inpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.89600,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,inpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.89600,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,inpatient,1,UN,2.85000,1.71000,United Healthcare,Commercial,,2.32,,,,,,,1.82,2.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,United Healthcare,Commercial,,2.32,,,,,,,0.57057,2.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,inpatient,15,ML,7.65000,4.59000,United Healthcare,Commercial,,6.22,,,,,,,4.90,6.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,United Healthcare,Commercial,,6.22,,,,,,,1.53,6.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,inpatient,1,UN,93.85000,56.31000,United Healthcare,Commercial,,76.30,,,,,,,60.06,76.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,United Healthcare,Commercial,,76.30,,,,,,,18.79,76.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,inpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,11.01,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,11.26,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,inpatient,1,UN,83.60000,50.16000,United Healthcare,Commercial,,67.97,,,,,,,25.16,67.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Commercial,,4.06,,,,,,,1.45,62.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,inpatient,1,UN,83.60000,50.16000,United Healthcare,Commercial,,67.97,,,,,,,25.16,67.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Commercial,,4.06,,,,,,,1.45,62.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,inpatient,1,UN,83.60000,50.16000,United Healthcare,Commercial,,67.97,,,,,,,25.16,67.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Commercial,,4.06,,,,,,,1.45,62.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,inpatient,1,UN,947.35000,568.41000,United Healthcare,Commercial,,770.20,,,,,,,606.30,770.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,United Healthcare,Commercial,,770.20,,,,,,,189.66,770.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,inpatient,16,GR,22.20000,13.32000,United Healthcare,Commercial,,18.05,,,,,,,14.21,18.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,United Healthcare,Commercial,,18.05,,,,,,,4.44,18.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,inpatient,1,UN,356.60000,213.96000,United Healthcare,Commercial,,289.92,,,,,,,228.22,289.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,United Healthcare,Commercial,,289.92,,,,,,,71.39,289.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,inpatient,10,ML,404.65000,242.79000,United Healthcare,Commercial,,328.98,,,,,,,121.80,328.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,United Healthcare,Commercial,,1.52,,,,,,,0.54280,300.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,inpatient,2.5,ML,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,inpatient,2.5,ML,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.76800,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,10.69,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,inpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,10.50,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,inpatient,50,GR,53.20000,31.92000,United Healthcare,Commercial,,43.25,,,,,,,34.05,43.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,United Healthcare,Commercial,,43.25,,,,,,,10.65,43.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,inpatient,0.3,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,inpatient,10,ML,100.00000,60.00000,United Healthcare,Commercial,,81.30,,,,,,,30.10,81.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,United Healthcare,Commercial,,0.19800,,,,,,,0.19800,74.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,inpatient,5,ML,104.75000,62.85000,United Healthcare,Commercial,,85.16,,,,,,,31.53,85.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,United Healthcare,Commercial,,0.19800,,,,,,,0.19800,77.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,inpatient,20,ML,67.00000,40.20000,United Healthcare,Commercial,,54.47,,,,,,,42.88,54.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,United Healthcare,Commercial,,54.47,,,,,,,13.41,54.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,inpatient,100,ML,100.00000,60.00000,United Healthcare,Commercial,,81.30,,,,,,,64.00,81.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,United Healthcare,Commercial,,81.30,,,,,,,20.02,81.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,inpatient,10,ML,116.65000,69.99000,United Healthcare,Commercial,,94.84,,,,,,,74.66,94.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,United Healthcare,Commercial,,94.84,,,,,,,23.35,94.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,inpatient,50,ML,112.05000,67.23000,United Healthcare,Commercial,,91.10,,,,,,,71.71,91.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,United Healthcare,Commercial,,91.10,,,,,,,22.43,91.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,500,ML,82.50000,49.50000,United Healthcare,Commercial,,67.07,,,,,,,24.83,67.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,United Healthcare,Commercial,,0.28050,,,,,,,0.28050,61.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,inpatient,30,ML,82.45000,49.47000,United Healthcare,Commercial,,67.03,,,,,,,24.82,67.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,United Healthcare,Commercial,,0.28050,,,,,,,0.28050,61.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,inpatient,30,ML,95.15000,57.09000,United Healthcare,Commercial,,77.36,,,,,,,28.64,77.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,United Healthcare,Commercial,,0.28050,,,,,,,0.28050,70.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,inpatient,4,ML,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,11.97,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,inpatient,15,ML,136.65000,81.99000,United Healthcare,Commercial,,111.10,,,,,,,87.46,111.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,United Healthcare,Commercial,,111.10,,,,,,,27.36,111.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,inpatient,5,ML,74.25000,44.55000,United Healthcare,Commercial,,60.37,,,,,,,47.52,60.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,United Healthcare,Commercial,,60.37,,,,,,,14.86,60.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,inpatient,50,ML,428.05000,256.83000,United Healthcare,Commercial,,348.00,,,,,,,273.95,348.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,United Healthcare,Commercial,,348.00,,,,,,,85.70,348.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,inpatient,50,ML,394.80000,236.88000,United Healthcare,Commercial,,320.97,,,,,,,118.83,320.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,United Healthcare,Commercial,,2.52,,,,,,,1.94,293.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,inpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,10.85,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Commercial,,13.78,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,inpatient,500,ML,72.00000,43.20000,United Healthcare,Commercial,,58.54,,,,,,,46.08,58.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,United Healthcare,Commercial,,58.54,,,,,,,14.41,58.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,inpatient,500,ML,69.00000,41.40000,United Healthcare,Commercial,,56.10,,,,,,,44.16,56.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,United Healthcare,Commercial,,56.10,,,,,,,13.81,56.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,inpatient,1,UN,80.15000,48.09000,United Healthcare,Commercial,,65.16,,,,,,,51.30,65.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,United Healthcare,Commercial,,65.16,,,,,,,16.05,65.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,inpatient,10,ML,115.70000,69.42000,United Healthcare,Commercial,,94.06,,,,,,,34.83,94.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,United Healthcare,Commercial,,0.13200,,,,,,,0.11800,85.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,10.75,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Commercial,,13.66,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,inpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,11.04,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,inpatient,0.3,ML,5298.55000,3179.13000,United Healthcare,Commercial,,4307.72,,,,,,,1594.86,4307.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,United Healthcare,Commercial,,8.17,,,,,,,2.84,3932.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,inpatient,1,ML,269.90000,161.94000,United Healthcare,Commercial,,219.43,,,,,,,81.24,219.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,United Healthcare,Commercial,,0.97350,,,,,,,0.84960,200.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,inpatient,1,UN,715.00000,429.00000,United Healthcare,Commercial,,581.29,,,,,,,215.22,581.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,United Healthcare,Commercial,,2.13,,,,,,,1.84,530.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,inpatient,1,UN,85.10000,51.06000,United Healthcare,Commercial,,69.19,,,,,,,25.62,69.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,United Healthcare,Commercial,,4.19,,,,,,,1.56,63.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,inpatient,1,UN,45.70000,27.42000,United Healthcare,Commercial,,37.15,,,,,,,29.25,37.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,United Healthcare,Commercial,,37.15,,,,,,,9.15,37.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,inpatient,1,UN,49.55000,29.73000,United Healthcare,Commercial,,40.28,,,,,,,31.71,40.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,United Healthcare,Commercial,,40.28,,,,,,,9.92,40.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,inpatient,5,ML,1.55000,0.93000,United Healthcare,Commercial,,1.26,,,,,,,0.99200,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,United Healthcare,Commercial,,1.26,,,,,,,0.31031,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,inpatient,1,UN,407.75000,244.65000,United Healthcare,Commercial,,331.50,,,,,,,260.96,331.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,United Healthcare,Commercial,,331.50,,,,,,,81.63,331.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,inpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,14.72,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Commercial,,18.70,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,inpatient,2,ML,1979.25000,1187.55000,United Healthcare,Commercial,,1609.13,,,,,,,1266.72,1609.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,United Healthcare,Commercial,,1609.13,,,,,,,396.25,1609.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,inpatient,1,UN,367.80000,220.68000,United Healthcare,Commercial,,299.02,,,,,,,110.71,299.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,United Healthcare,Commercial,,7.41,,,,,,,6.44,272.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,inpatient,50,GR,6.90000,4.14000,United Healthcare,Commercial,,5.61,,,,,,,4.42,5.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,United Healthcare,Commercial,,5.61,,,,,,,1.38,5.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,inpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,inpatient,20,ML,646.00000,387.60000,United Healthcare,Commercial,,525.20,,,,,,,194.45,525.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,United Healthcare,Commercial,,29.37,,,,,,,28.44,479.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,inpatient,1,UN,26.55000,15.93000,United Healthcare,Commercial,,21.59,,,,,,,16.99,21.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,United Healthcare,Commercial,,21.59,,,,,,,5.32,21.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,inpatient,5,ML,79.80000,47.88000,United Healthcare,Commercial,,64.88,,,,,,,24.02,64.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,United Healthcare,Commercial,,0.13200,,,,,,,0.09440,59.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,inpatient,2.5,ML,118.85000,71.31000,United Healthcare,Commercial,,96.63,,,,,,,76.06,96.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,United Healthcare,Commercial,,96.63,,,,,,,23.79,96.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,inpatient,1,UN,22.30000,13.38000,United Healthcare,Commercial,,18.13,,,,,,,14.27,18.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,United Healthcare,Commercial,,18.13,,,,,,,4.46,18.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,inpatient,2,ML,94.80000,56.88000,United Healthcare,Commercial,,77.07,,,,,,,60.67,77.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,United Healthcare,Commercial,,77.07,,,,,,,18.98,77.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,inpatient,1,UN,848.40000,509.04000,United Healthcare,Commercial,,689.75,,,,,,,255.37,689.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,United Healthcare,Commercial,,0.84150,,,,,,,0.61360,629.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,inpatient,10,ML,32.20000,19.32000,United Healthcare,Commercial,,26.18,,,,,,,20.61,26.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,United Healthcare,Commercial,,26.18,,,,,,,6.45,26.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,inpatient,0.25,ML,27.95000,16.77000,United Healthcare,Commercial,,22.72,,,,,,,8.41,22.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,20.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,inpatient,0.25,ML,28.70000,17.22000,United Healthcare,Commercial,,23.33,,,,,,,8.64,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,21.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,inpatient,15,ML,286.00000,171.60000,United Healthcare,Commercial,,232.52,,,,,,,183.04,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,United Healthcare,Commercial,,232.52,,,,,,,57.26,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,inpatient,15,ML,6.25000,3.75000,United Healthcare,Commercial,,5.08,,,,,,,4.00,5.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,United Healthcare,Commercial,,5.08,,,,,,,1.25,5.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,inpatient,18.75,ML,25.05000,15.03000,United Healthcare,Commercial,,20.37,,,,,,,16.03,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,United Healthcare,Commercial,,20.37,,,,,,,5.02,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,inpatient,18.75,ML,25.05000,15.03000,United Healthcare,Commercial,,20.37,,,,,,,16.03,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,United Healthcare,Commercial,,20.37,,,,,,,5.02,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,inpatient,1,UN,53.45000,32.07000,United Healthcare,Commercial,,43.45,,,,,,,34.21,43.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,United Healthcare,Commercial,,43.45,,,,,,,10.70,43.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,inpatient,1,UN,2850.10000,1710.06000,United Healthcare,Commercial,,2317.13,,,,,,,857.88,2317.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,United Healthcare,Commercial,,0.57750,,,,,,,0.57750,2115.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,inpatient,1,UN,62.05000,37.23000,United Healthcare,Commercial,,50.45,,,,,,,39.71,50.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,United Healthcare,Commercial,,50.45,,,,,,,12.42,50.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,inpatient,0.25,ML,22.80000,13.68000,United Healthcare,Commercial,,18.54,,,,,,,6.86,18.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,United Healthcare,Commercial,,4.87,,,,,,,4.30,16.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,inpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,12.67,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,inpatient,1,UN,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,15.14,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,Commercial,,19.23,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,inpatient,5,ML,62.50000,37.50000,United Healthcare,Commercial,,50.81,,,,,,,40.00,50.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,United Healthcare,Commercial,,50.81,,,,,,,12.51,50.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,inpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,10.56,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Commercial,,13.41,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,inpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,10.59,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Commercial,,13.46,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,inpatient,15,GR,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,16.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,5.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,inpatient,15,GR,40.60000,24.36000,United Healthcare,Commercial,,33.01,,,,,,,25.98,33.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,United Healthcare,Commercial,,33.01,,,,,,,8.13,33.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,inpatient,15,GR,29.95000,17.97000,United Healthcare,Commercial,,24.35,,,,,,,19.17,24.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,United Healthcare,Commercial,,24.35,,,,,,,6.00,24.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,1,ML,58.60000,35.16000,United Healthcare,Commercial,,47.64,,,,,,,17.64,47.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,United Healthcare,Commercial,,2.34,,,,,,,1.98,43.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,inpatient,1,ML,55.45000,33.27000,United Healthcare,Commercial,,45.08,,,,,,,16.69,45.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,United Healthcare,Commercial,,2.34,,,,,,,1.98,41.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,inpatient,1,ML,45.50000,27.30000,United Healthcare,Commercial,,36.99,,,,,,,13.70,36.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,United Healthcare,Commercial,,2.34,,,,,,,1.98,33.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,inpatient,5,GR,209.45000,125.67000,United Healthcare,Commercial,,170.28,,,,,,,134.05,170.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,United Healthcare,Commercial,,170.28,,,,,,,41.93,170.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,inpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,10.94,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Commercial,,13.90,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,inpatient,1,UN,25.95000,15.57000,United Healthcare,Commercial,,21.10,,,,,,,16.61,21.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,United Healthcare,Commercial,,21.10,,,,,,,5.20,21.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,inpatient,6.9,GR,431.25000,258.75000,United Healthcare,Commercial,,350.61,,,,,,,276.00,350.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,United Healthcare,Commercial,,350.61,,,,,,,86.34,350.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,inpatient,6,GR,493.60000,296.16000,United Healthcare,Commercial,,401.30,,,,,,,315.90,401.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,United Healthcare,Commercial,,401.30,,,,,,,98.82,401.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,inpatient,30,ML,27459.60000,16475.76000,United Healthcare,Commercial,,22324.65,,,,,,,8265.34,22324.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,United Healthcare,Commercial,,121.89,,,,,,,43.48,20380.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,inpatient,10,ML,92.40000,55.44000,United Healthcare,Commercial,,75.12,,,,,,,27.81,75.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,United Healthcare,Commercial,,0.75900,,,,,,,0.51920,68.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,inpatient,4,ML,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,11.97,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,United Healthcare,Commercial,,15.20,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,United Healthcare,Commercial,,235.81,,,,,,,87.31,235.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,United Healthcare,Commercial,,4.69,,,,,,,4.69,215.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,inpatient,20,ML,305.10000,183.06000,United Healthcare,Commercial,,248.05,,,,,,,91.84,248.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,United Healthcare,Commercial,,4.69,,,,,,,4.69,226.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,inpatient,1,UN,9076.45000,5445.87000,United Healthcare,Commercial,,7379.15,,,,,,,2732.01,7379.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,United Healthcare,Commercial,,87.91,,,,,,,25.91,6736.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,inpatient,2,ML,27.35000,16.41000,United Healthcare,Commercial,,22.24,,,,,,,8.23,22.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,United Healthcare,Commercial,,4.55,,,,,,,4.32,20.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,inpatient,60,ML,120.60000,72.36000,United Healthcare,Commercial,,98.05,,,,,,,36.30,98.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,United Healthcare,Commercial,,4.55,,,,,,,4.32,89.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,inpatient,15,ML,106.00000,63.60000,United Healthcare,Commercial,,86.18,,,,,,,67.84,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,United Healthcare,Commercial,,86.18,,,,,,,21.22,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,inpatient,1,UN,107.50000,64.50000,United Healthcare,Commercial,,87.40,,,,,,,68.80,87.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,United Healthcare,Commercial,,87.40,,,,,,,21.52,87.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,inpatient,1,UN,107.45000,64.47000,United Healthcare,Commercial,,87.36,,,,,,,68.77,87.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,United Healthcare,Commercial,,87.36,,,,,,,21.51,87.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,inpatient,0.1,ML,56.75000,34.05000,United Healthcare,Commercial,,46.14,,,,,,,36.32,46.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,United Healthcare,Commercial,,46.14,,,,,,,11.36,46.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,inpatient,1,UN,131.40000,78.84000,United Healthcare,Commercial,,106.83,,,,,,,39.55,106.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,97.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,inpatient,1,UN,97.30000,58.38000,United Healthcare,Commercial,,79.10,,,,,,,29.29,79.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,72.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,inpatient,1,UN,442.10000,265.26000,United Healthcare,Commercial,,359.43,,,,,,,133.07,359.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,328.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,inpatient,28.4,GR,4.45000,2.67000,United Healthcare,Commercial,,3.62,,,,,,,2.85,3.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,United Healthcare,Commercial,,3.62,,,,,,,0.89089,3.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,inpatient,2,ML,61.50000,36.90000,United Healthcare,Commercial,,50.00,,,,,,,39.36,50.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,United Healthcare,Commercial,,50.00,,,,,,,12.31,50.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,inpatient,4,ML,45.20000,27.12000,United Healthcare,Commercial,,36.75,,,,,,,28.93,36.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,United Healthcare,Commercial,,36.75,,,,,,,9.05,36.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,inpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,10.50,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Commercial,,13.33,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,inpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,11.04,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,inpatient,28,GR,5.25000,3.15000,United Healthcare,Commercial,,4.27,,,,,,,3.36,4.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,United Healthcare,Commercial,,4.27,,,,,,,1.05,4.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,inpatient,10,ML,511.55000,306.93000,United Healthcare,Commercial,,415.89,,,,,,,153.98,415.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,United Healthcare,Commercial,,14.40,,,,,,,12.51,379.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,inpatient,1,ML,353.10000,211.86000,United Healthcare,Commercial,,287.07,,,,,,,106.28,287.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,United Healthcare,Commercial,,21.40,,,,,,,19.40,262.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,inpatient,1,UN,17.90000,10.74000,United Healthcare,Commercial,,14.55,,,,,,,11.46,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,Commercial,,14.55,,,,,,,3.58,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,inpatient,1,UN,17.55000,10.53000,United Healthcare,Commercial,,14.27,,,,,,,11.23,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,Commercial,,14.27,,,,,,,3.51,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,11.26,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Commercial,,14.31,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,inpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,11.30,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Commercial,,14.35,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,inpatient,1,UN,18.35000,11.01000,United Healthcare,Commercial,,14.92,,,,,,,11.74,14.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,United Healthcare,Commercial,,14.92,,,,,,,3.67,14.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,inpatient,1,UN,33.40000,20.04000,United Healthcare,Commercial,,27.15,,,,,,,21.38,27.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,United Healthcare,Commercial,,27.15,,,,,,,6.69,27.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,inpatient,0.5,ML,40477.65000,24286.59000,United Healthcare,Commercial,,32908.33,,,,,,,12183.77,32908.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,United Healthcare,Commercial,,66.56,,,,,,,28.94,30042.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,inpatient,10,ML,567.95000,340.77000,United Healthcare,Commercial,,461.74,,,,,,,170.95,461.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,United Healthcare,Commercial,,19.90,,,,,,,6.18,421.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,inpatient,2,ML,40.90000,24.54000,United Healthcare,Commercial,,33.25,,,,,,,12.31,33.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,United Healthcare,Commercial,,19.90,,,,,,,6.18,30.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,inpatient,2,ML,98.10000,58.86000,United Healthcare,Commercial,,79.76,,,,,,,62.78,79.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,United Healthcare,Commercial,,79.76,,,,,,,19.64,79.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,United Healthcare,Commercial,,367.76,,,,,,,136.16,367.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,United Healthcare,Commercial,,5.31,,,,,,,5.31,335.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,United Healthcare,Commercial,,330.89,,,,,,,122.51,330.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,United Healthcare,Commercial,,5.31,,,,,,,5.31,302.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,inpatient,1,UN,154.90000,92.94000,United Healthcare,Commercial,,125.93,,,,,,,99.14,125.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,United Healthcare,Commercial,,125.93,,,,,,,31.01,125.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,inpatient,4,ML,59.15000,35.49000,United Healthcare,Commercial,,48.09,,,,,,,37.86,48.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,United Healthcare,Commercial,,48.09,,,,,,,11.84,48.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,inpatient,1,UN,26867.20000,16120.32000,United Healthcare,Commercial,,21843.03,,,,,,,8087.03,21843.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,United Healthcare,Commercial,,377.54,,,,,,,135.03,19940.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,inpatient,1,UN,71.75000,43.05000,United Healthcare,Commercial,,58.33,,,,,,,45.92,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,United Healthcare,Commercial,,58.33,,,,,,,14.36,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,inpatient,1,UN,798.05000,478.83000,United Healthcare,Commercial,,648.81,,,,,,,510.75,648.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,United Healthcare,Commercial,,648.81,,,,,,,159.77,648.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,inpatient,28.4,GR,9.15000,5.49000,United Healthcare,Commercial,,7.44,,,,,,,5.86,7.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,United Healthcare,Commercial,,7.44,,,,,,,1.83,7.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,inpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.89600,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,inpatient,1,UN,99.10000,59.46000,United Healthcare,Commercial,,80.57,,,,,,,63.42,80.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,United Healthcare,Commercial,,80.57,,,,,,,19.84,80.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,inpatient,1,UN,3832.85000,2299.71000,United Healthcare,Commercial,,3116.11,,,,,,,1153.69,3116.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,United Healthcare,Commercial,,10.15,,,,,,,4.23,2844.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,inpatient,113,GR,3.25000,1.95000,United Healthcare,Commercial,,2.64,,,,,,,2.08,2.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,United Healthcare,Commercial,,2.64,,,,,,,0.65065,2.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,inpatient,1,UN,2.45000,1.47000,United Healthcare,Commercial,,1.99,,,,,,,1.57,1.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,United Healthcare,Commercial,,1.99,,,,,,,0.49049,1.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,inpatient,1000,ML,90.00000,54.00000,United Healthcare,Commercial,,73.17,,,,,,,57.60,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,United Healthcare,Commercial,,73.17,,,,,,,18.02,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,inpatient,473,ML,1084.55000,650.73000,United Healthcare,Commercial,,881.74,,,,,,,694.11,881.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,United Healthcare,Commercial,,881.74,,,,,,,217.13,881.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,inpatient,1,UN,40.65000,24.39000,United Healthcare,Commercial,,33.05,,,,,,,26.02,33.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,United Healthcare,Commercial,,33.05,,,,,,,8.14,33.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,inpatient,1,UN,136.00000,81.60000,United Healthcare,Commercial,,110.57,,,,,,,87.04,110.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,United Healthcare,Commercial,,110.57,,,,,,,27.23,110.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,United Healthcare,Commercial,,438.86,,,,,,,162.48,438.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,United Healthcare,Commercial,,144.51,,,,,,,108.07,400.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,United Healthcare,Commercial,,250.73,,,,,,,92.83,250.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,United Healthcare,Commercial,,144.51,,,,,,,61.74,228.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,inpatient,250,ML,437.00000,262.20000,United Healthcare,Commercial,,355.28,,,,,,,131.54,355.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,Commercial,,144.51,,,,,,,51.49,324.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,inpatient,250,ML,437.00000,262.20000,United Healthcare,Commercial,,355.28,,,,,,,131.54,355.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,Commercial,,144.51,,,,,,,51.49,324.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,inpatient,1,ML,786.55000,471.93000,United Healthcare,Commercial,,639.47,,,,,,,236.75,639.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,United Healthcare,Commercial,,1.30,,,,,,,1.30,583.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,inpatient,1,UN,40057.65000,24034.59000,United Healthcare,Commercial,,32566.87,,,,,,,12057.35,32566.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,United Healthcare,Commercial,,256.33,,,,,,,91.62,29730.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,inpatient,1,UN,20036.85000,12022.11000,United Healthcare,Commercial,,16289.96,,,,,,,6031.09,16289.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,United Healthcare,Commercial,,256.33,,,,,,,91.62,14871.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,inpatient,15,ML,3.95000,2.37000,United Healthcare,Commercial,,3.21,,,,,,,2.53,3.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,United Healthcare,Commercial,,3.21,,,,,,,0.79079,3.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,inpatient,15,ML,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.80000,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,Commercial,,1.02,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,inpatient,1,UN,2.00000,1.20000,United Healthcare,Commercial,,1.63,,,,,,,1.28,1.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,United Healthcare,Commercial,,1.63,,,,,,,0.40040,1.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,inpatient,1,UN,101.95000,61.17000,United Healthcare,Commercial,,82.89,,,,,,,65.25,82.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,United Healthcare,Commercial,,82.89,,,,,,,20.41,82.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,11.20,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,inpatient,1,UN,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,10.53,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,Commercial,,13.37,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,inpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,10.62,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Commercial,,13.50,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,10.69,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,United Healthcare,Commercial,,41.54,,,,,,,15.38,41.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,United Healthcare,Commercial,,4.06,,,,,,,3.28,37.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,inpatient,1,UN,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,10.23,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,United Healthcare,Commercial,,4.06,,,,,,,3.28,25.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,inpatient,250,ML,98.00000,58.80000,United Healthcare,Commercial,,79.67,,,,,,,62.72,79.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,United Healthcare,Commercial,,79.67,,,,,,,19.62,79.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,inpatient,1,UN,129.05000,77.43000,United Healthcare,Commercial,,104.92,,,,,,,38.84,104.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,United Healthcare,Commercial,,13.96,,,,,,,11.28,95.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,inpatient,5,ML,371.70000,223.02000,United Healthcare,Commercial,,302.19,,,,,,,111.88,302.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,United Healthcare,Commercial,,3.81,,,,,,,3.81,275.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,inpatient,1,UN,94.85000,56.91000,United Healthcare,Commercial,,77.11,,,,,,,28.55,77.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,United Healthcare,Commercial,,11.14,,,,,,,3.98,70.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,inpatient,300,ML,210.00000,126.00000,United Healthcare,Commercial,,170.73,,,,,,,134.40,170.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,United Healthcare,Commercial,,170.73,,,,,,,42.04,170.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,inpatient,0.5,ML,26.25000,15.75000,United Healthcare,Commercial,,21.34,,,,,,,7.90,21.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,United Healthcare,Commercial,,1.67,,,,,,,1.44,19.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,inpatient,0.75,ML,49.95000,29.97000,United Healthcare,Commercial,,40.61,,,,,,,15.03,40.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,United Healthcare,Commercial,,1.67,,,,,,,1.44,37.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,inpatient,1,ML,175.25000,105.15000,United Healthcare,Commercial,,142.48,,,,,,,52.75,142.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,United Healthcare,Commercial,,1.67,,,,,,,1.44,130.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,inpatient,2,ML,30.90000,18.54000,United Healthcare,Commercial,,25.12,,,,,,,9.30,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,United Healthcare,Commercial,,0.95700,,,,,,,0.29100,22.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,inpatient,5,ML,813.05000,487.83000,United Healthcare,Commercial,,661.01,,,,,,,244.73,661.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,United Healthcare,Commercial,,7.87,,,,,,,7.13,603.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,inpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.67200,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Commercial,,0.85365,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,inpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,12.80,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,inpatient,0.4,ML,531.50000,318.90000,United Healthcare,Commercial,,432.11,,,,,,,159.98,432.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,United Healthcare,Commercial,,5.20,,,,,,,3.42,394.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,inpatient,10,ML,80.05000,48.03000,United Healthcare,Commercial,,65.08,,,,,,,51.23,65.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,United Healthcare,Commercial,,65.08,,,,,,,16.03,65.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,inpatient,5,ML,37.55000,22.53000,United Healthcare,Commercial,,30.53,,,,,,,24.03,30.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,United Healthcare,Commercial,,30.53,,,,,,,7.52,30.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,inpatient,1,UN,18.75000,11.25000,United Healthcare,Commercial,,15.24,,,,,,,5.64,15.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,United Healthcare,Commercial,,5.82,,,,,,,0.14160,13.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,United Healthcare,Commercial,,122.97,,,,,,,45.53,122.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,United Healthcare,Commercial,,7.28,,,,,,,5.97,112.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,inpatient,1,UN,276.30000,165.78000,United Healthcare,Commercial,,224.63,,,,,,,83.17,224.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,United Healthcare,Commercial,,7.28,,,,,,,5.97,205.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,inpatient,0.01,ML,48.35000,29.01000,United Healthcare,Commercial,,39.31,,,,,,,30.94,39.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,United Healthcare,Commercial,,39.31,,,,,,,9.68,39.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,inpatient,5,ML,266.40000,159.84000,United Healthcare,Commercial,,216.58,,,,,,,80.19,216.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,United Healthcare,Commercial,,18.76,,,,,,,16.43,197.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,inpatient,30,ML,4.05000,2.43000,United Healthcare,Commercial,,3.29,,,,,,,2.59,3.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,United Healthcare,Commercial,,3.29,,,,,,,0.81081,3.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,inpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,inpatient,1,UN,159.90000,95.94000,United Healthcare,Commercial,,130.00,,,,,,,102.34,130.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,United Healthcare,Commercial,,130.00,,,,,,,32.01,130.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,71.75,,,,,,,26.56,71.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,7.21,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,71.75,,,,,,,26.56,71.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,7.21,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,71.75,,,,,,,26.56,71.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Commercial,,7.21,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,inpatient,1,UN,526.70000,316.02000,United Healthcare,Commercial,,428.21,,,,,,,158.54,428.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,United Healthcare,Commercial,,56.91,,,,,,,50.79,390.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,inpatient,1,UN,29.25000,17.55000,United Healthcare,Commercial,,23.78,,,,,,,18.72,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,Commercial,,23.78,,,,,,,5.86,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,inpatient,1,UN,84.65000,50.79000,United Healthcare,Commercial,,68.82,,,,,,,25.48,68.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Commercial,,4.19,,,,,,,1.62,62.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,inpatient,1,UN,84.65000,50.79000,United Healthcare,Commercial,,68.82,,,,,,,25.48,68.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Commercial,,4.19,,,,,,,1.62,62.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,inpatient,118,ML,5.25000,3.15000,United Healthcare,Commercial,,4.27,,,,,,,3.36,4.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,United Healthcare,Commercial,,4.27,,,,,,,1.05,4.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,inpatient,4,ML,29.75000,17.85000,United Healthcare,Commercial,,24.19,,,,,,,8.95,24.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,Commercial,,1.67,,,,,,,0.35890,22.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,inpatient,3,ML,75.05000,45.03000,United Healthcare,Commercial,,61.02,,,,,,,22.59,61.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,United Healthcare,Commercial,,1.39,,,,,,,1.01,55.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,inpatient,3,ML,75.45000,45.27000,United Healthcare,Commercial,,61.34,,,,,,,22.71,61.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,United Healthcare,Commercial,,1.39,,,,,,,1.01,56.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,inpatient,3,ML,71.45000,42.87000,United Healthcare,Commercial,,58.09,,,,,,,21.51,58.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,United Healthcare,Commercial,,1.39,,,,,,,1.01,53.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,11.42,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,inpatient,2,ML,29.00000,17.40000,United Healthcare,Commercial,,23.58,,,,,,,8.73,23.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,United Healthcare,Commercial,,0.03300,,,,,,,0.02360,21.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,11.20,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,inpatient,1,UN,20.95000,12.57000,United Healthcare,Commercial,,17.03,,,,,,,13.41,17.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,United Healthcare,Commercial,,17.03,,,,,,,4.19,17.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,inpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,10.43,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Commercial,,13.25,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,inpatient,1,UN,16.15000,9.69000,United Healthcare,Commercial,,13.13,,,,,,,10.34,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,United Healthcare,Commercial,,13.13,,,,,,,3.23,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,inpatient,0.5,ML,39.05000,23.43000,United Healthcare,Commercial,,31.75,,,,,,,11.75,31.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,United Healthcare,Commercial,,13.74,,,,,,,7.82,28.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,inpatient,2,ML,3656.00000,2193.60000,United Healthcare,Commercial,,2972.33,,,,,,,1100.46,2972.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,United Healthcare,Commercial,,2275.47,,,,,,,470.42,2713.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,inpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,12.67,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Commercial,,16.10,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,inpatient,1,UN,12542.25000,7525.35000,United Healthcare,Commercial,,10196.85,,,,,,,3775.22,10196.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,United Healthcare,Commercial,,29.95,,,,,,,10.68,9308.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,inpatient,1,UN,25068.40000,15041.04000,United Healthcare,Commercial,,20380.61,,,,,,,7545.59,20380.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,United Healthcare,Commercial,,29.95,,,,,,,10.68,18605.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,inpatient,10,ML,2068.75000,1241.25000,United Healthcare,Commercial,,1681.89,,,,,,,622.69,1681.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,United Healthcare,Commercial,,80.59,,,,,,,23.16,1535.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,inpatient,12.5,ML,2753.30000,1651.98000,United Healthcare,Commercial,,2238.43,,,,,,,828.74,2238.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,United Healthcare,Commercial,,80.59,,,,,,,23.16,2043.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,inpatient,15,ML,3080.00000,1848.00000,United Healthcare,Commercial,,2504.04,,,,,,,927.08,2504.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,United Healthcare,Commercial,,80.59,,,,,,,23.16,2285.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,inpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.70400,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Commercial,,0.89430,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,inpatient,3,ML,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,11.55,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,United Healthcare,Commercial,,14.67,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,inpatient,50,ML,433.25000,259.95000,United Healthcare,Commercial,,352.23,,,,,,,130.41,352.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,United Healthcare,Commercial,,352.23,,,,,,,2.76,352.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,inpatient,1,UN,21.70000,13.02000,United Healthcare,Commercial,,17.64,,,,,,,13.89,17.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,United Healthcare,Commercial,,17.64,,,,,,,4.34,17.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,inpatient,1,UN,22.20000,13.32000,United Healthcare,Commercial,,18.05,,,,,,,14.21,18.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,United Healthcare,Commercial,,18.05,,,,,,,4.44,18.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,inpatient,1,UN,17.05000,10.23000,United Healthcare,Commercial,,13.86,,,,,,,5.13,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Commercial,,14.23,,,,,,,5.27,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,inpatient,1,ML,653.00000,391.80000,United Healthcare,Commercial,,530.89,,,,,,,196.55,530.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,United Healthcare,Commercial,,530.89,,,,,,,49.52,530.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,inpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.73600,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Commercial,,0.93495,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,inpatient,1,ML,86.10000,51.66000,United Healthcare,Commercial,,70.00,,,,,,,55.10,70.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,United Healthcare,Commercial,,70.00,,,,,,,17.24,70.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,inpatient,1,UN,60.60000,36.36000,United Healthcare,Commercial,,49.27,,,,,,,18.24,49.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,United Healthcare,Commercial,,19.39,,,,,,,12.13,44.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,inpatient,200,ML,745.95000,447.57000,United Healthcare,Commercial,,606.46,,,,,,,224.53,606.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,United Healthcare,Commercial,,0.24750,,,,,,,0.16520,553.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,inpatient,1,UN,105.00000,63.00000,United Healthcare,Commercial,,85.36,,,,,,,31.61,85.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,United Healthcare,Commercial,,13.96,,,,,,,11.28,77.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,inpatient,1,UN,39.70000,23.82000,United Healthcare,Commercial,,32.28,,,,,,,11.95,32.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,United Healthcare,Commercial,,4.47,,,,,,,3.71,29.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,inpatient,1,UN,61.50000,36.90000,United Healthcare,Commercial,,50.00,,,,,,,18.51,50.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,United Healthcare,Commercial,,4.47,,,,,,,3.71,45.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,United Healthcare,Commercial,,23.74,,,,,,,8.79,23.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,United Healthcare,Commercial,,1.30,,,,,,,1.01,21.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,inpatient,1,UN,21.70000,13.02000,United Healthcare,Commercial,,17.64,,,,,,,6.53,17.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,United Healthcare,Commercial,,1.30,,,,,,,1.01,16.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,10.69,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Commercial,,13.58,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,10.82,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Commercial,,13.74,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,inpatient,100,ML,85.00000,51.00000,United Healthcare,Commercial,,69.11,,,,,,,54.40,69.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,United Healthcare,Commercial,,69.11,,,,,,,17.02,69.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,inpatient,5,ML,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,11.87,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,United Healthcare,Commercial,,15.08,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,inpatient,237,ML,222.95000,133.77000,United Healthcare,Commercial,,181.26,,,,,,,142.69,181.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,United Healthcare,Commercial,,181.26,,,,,,,44.63,181.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,inpatient,1,UN,315.00000,189.00000,United Healthcare,Commercial,,256.10,,,,,,,94.81,256.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,United Healthcare,Commercial,,109.94,,,,,,,63.06,233.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,inpatient,50,ML,14.80000,8.88000,United Healthcare,Commercial,,12.03,,,,,,,9.47,12.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,United Healthcare,Commercial,,12.03,,,,,,,2.96,12.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,inpatient,1,UN,1663.10000,997.86000,United Healthcare,Commercial,,1352.10,,,,,,,500.59,1352.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,United Healthcare,Commercial,,11.80,,,,,,,6.30,1234.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,inpatient,5,ML,78.65000,47.19000,United Healthcare,Commercial,,63.94,,,,,,,50.34,63.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,United Healthcare,Commercial,,63.94,,,,,,,15.75,63.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,inpatient,1,UN,24.20000,14.52000,United Healthcare,Commercial,,19.67,,,,,,,15.49,19.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,United Healthcare,Commercial,,19.67,,,,,,,4.84,19.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,inpatient,10,ML,82.00000,49.20000,United Healthcare,Commercial,,66.67,,,,,,,52.48,66.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,United Healthcare,Commercial,,66.67,,,,,,,16.42,66.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,inpatient,2.5,ML,47.50000,28.50000,United Healthcare,Commercial,,38.62,,,,,,,30.40,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,United Healthcare,Commercial,,38.62,,,,,,,9.51,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,inpatient,5,ML,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,37.12,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,inpatient,10,ML,2189.00000,1313.40000,United Healthcare,Commercial,,1779.66,,,,,,,658.89,1779.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,United Healthcare,Commercial,,26.48,,,,,,,10.36,1624.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,inpatient,1,UN,35.95000,21.57000,United Healthcare,Commercial,,29.23,,,,,,,23.01,29.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,United Healthcare,Commercial,,29.23,,,,,,,7.20,29.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,inpatient,30,GR,264.80000,158.88000,United Healthcare,Commercial,,215.28,,,,,,,169.47,215.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,United Healthcare,Commercial,,215.28,,,,,,,53.01,215.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,inpatient,50,ML,104.50000,62.70000,United Healthcare,Commercial,,84.96,,,,,,,31.45,84.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,United Healthcare,Commercial,,4.55,,,,,,,4.32,77.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,inpatient,50,ML,113.75000,68.25000,United Healthcare,Commercial,,92.48,,,,,,,34.24,92.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,United Healthcare,Commercial,,4.55,,,,,,,4.32,84.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,inpatient,15,GR,46.05000,27.63000,United Healthcare,Commercial,,37.44,,,,,,,29.47,37.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,United Healthcare,Commercial,,37.44,,,,,,,9.22,37.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,inpatient,1,UN,22.10000,13.26000,United Healthcare,Commercial,,17.97,,,,,,,14.14,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,United Healthcare,Commercial,,17.97,,,,,,,4.42,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,inpatient,1,UN,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,14.30,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,Commercial,,18.17,,,,,,,4.47,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,inpatient,1,UN,27.00000,16.20000,United Healthcare,Commercial,,21.95,,,,,,,17.28,21.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,United Healthcare,Commercial,,21.95,,,,,,,5.41,21.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,inpatient,1,UN,22.70000,13.62000,United Healthcare,Commercial,,18.46,,,,,,,14.53,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,Commercial,,18.46,,,,,,,4.54,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,inpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,11.90,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Commercial,,15.12,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,inpatient,1,UN,417.20000,250.32000,United Healthcare,Commercial,,339.18,,,,,,,125.58,339.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,United Healthcare,Commercial,,76.28,,,,,,,59.87,309.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,inpatient,60,GR,1533.80000,920.28000,United Healthcare,Commercial,,1246.98,,,,,,,981.63,1246.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,United Healthcare,Commercial,,1246.98,,,,,,,307.07,1246.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,inpatient,1,UN,38.50000,23.10000,United Healthcare,Commercial,,31.30,,,,,,,24.64,31.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,United Healthcare,Commercial,,31.30,,,,,,,7.71,31.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,inpatient,1,UN,61.85000,37.11000,United Healthcare,Commercial,,50.28,,,,,,,39.58,50.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,United Healthcare,Commercial,,50.28,,,,,,,12.38,50.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,inpatient,1,UN,78.65000,47.19000,United Healthcare,Commercial,,63.94,,,,,,,50.34,63.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,United Healthcare,Commercial,,63.94,,,,,,,15.75,63.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,inpatient,5,ML,96.35000,57.81000,United Healthcare,Commercial,,78.33,,,,,,,29.00,78.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,inpatient,5,ML,302.95000,181.77000,United Healthcare,Commercial,,246.30,,,,,,,91.19,246.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,United Healthcare,Commercial,,2.21,,,,,,,1.96,224.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,inpatient,1,UN,3628.20000,2176.92000,United Healthcare,Commercial,,2949.73,,,,,,,1092.09,2949.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,United Healthcare,Commercial,,11.86,,,,,,,4.32,2692.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,inpatient,2,ML,127.10000,76.26000,United Healthcare,Commercial,,103.33,,,,,,,81.34,103.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,United Healthcare,Commercial,,103.33,,,,,,,25.45,103.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,inpatient,5,ML,211.15000,126.69000,United Healthcare,Commercial,,171.66,,,,,,,135.14,171.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,United Healthcare,Commercial,,171.66,,,,,,,42.27,171.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,inpatient,1,UN,89.05000,53.43000,United Healthcare,Commercial,,72.40,,,,,,,26.80,72.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,United Healthcare,Commercial,,5.64,,,,,,,4.81,66.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,inpatient,1,UN,34.30000,20.58000,United Healthcare,Commercial,,27.89,,,,,,,10.32,27.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,United Healthcare,Commercial,,2.10,,,,,,,1.89,25.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,inpatient,1,UN,60.05000,36.03000,United Healthcare,Commercial,,48.82,,,,,,,38.43,48.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,United Healthcare,Commercial,,48.82,,,,,,,12.02,48.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,inpatient,1,UN,31.25000,18.75000,United Healthcare,Commercial,,25.41,,,,,,,20.00,25.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,United Healthcare,Commercial,,25.41,,,,,,,6.26,25.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,inpatient,1,UN,201.30000,120.78000,United Healthcare,Commercial,,163.66,,,,,,,60.59,163.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,United Healthcare,Commercial,,24.55,,,,,,,21.26,149.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,inpatient,1,UN,174.05000,104.43000,United Healthcare,Commercial,,141.50,,,,,,,52.39,141.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,United Healthcare,Commercial,,24.55,,,,,,,21.26,129.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,inpatient,1,ML,64.55000,38.73000,United Healthcare,Commercial,,52.48,,,,,,,19.43,52.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,United Healthcare,Commercial,,0.11550,,,,,,,0.07080,47.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,inpatient,1,ML,64.85000,38.91000,United Healthcare,Commercial,,52.72,,,,,,,19.52,52.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,United Healthcare,Commercial,,0.11550,,,,,,,0.07080,48.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,inpatient,1,ML,64.70000,38.82000,United Healthcare,Commercial,,52.60,,,,,,,19.47,52.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,United Healthcare,Commercial,,0.11550,,,,,,,0.07080,48.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,inpatient,0.5,ML,238.95000,143.37000,United Healthcare,Commercial,,194.27,,,,,,,71.92,194.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,United Healthcare,Commercial,,445.83,,,,,,,47.84,445.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,inpatient,1,UN,91.10000,54.66000,United Healthcare,Commercial,,74.06,,,,,,,27.42,74.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,United Healthcare,Commercial,,0.08250,,,,,,,0.07080,67.61,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,inpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.92800,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Commercial,,1.18,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,inpatient,240,ML,661.30000,396.78000,United Healthcare,Commercial,,537.64,,,,,,,423.23,537.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,United Healthcare,Commercial,,537.64,,,,,,,132.39,537.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,inpatient,1,ML,385.20000,231.12000,United Healthcare,Commercial,,313.17,,,,,,,115.95,313.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,United Healthcare,Commercial,,10.59,,,,,,,3.41,285.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,inpatient,10,ML,1813.25000,1087.95000,United Healthcare,Commercial,,1474.17,,,,,,,545.79,1474.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,United Healthcare,Commercial,,10.59,,,,,,,3.41,1345.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,inpatient,1,UN,82.95000,49.77000,United Healthcare,Commercial,,67.44,,,,,,,24.97,67.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,Commercial,,4.64,,,,,,,1.65,61.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,inpatient,10,ML,4.60000,2.76000,United Healthcare,Commercial,,3.74,,,,,,,2.94,3.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,United Healthcare,Commercial,,3.74,,,,,,,0.92092,3.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,inpatient,1,UN,2174.60000,1304.76000,United Healthcare,Commercial,,1767.95,,,,,,,1391.74,1767.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,United Healthcare,Commercial,,1767.95,,,,,,,435.35,1767.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,inpatient,1000,ML,101.50000,60.90000,United Healthcare,Commercial,,82.52,,,,,,,30.55,82.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,75.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,inpatient,1000,ML,98.00000,58.80000,United Healthcare,Commercial,,79.67,,,,,,,29.50,79.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,72.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,inpatient,1000,ML,94.50000,56.70000,United Healthcare,Commercial,,76.83,,,,,,,28.44,76.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,70.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,inpatient,1000,ML,84.00000,50.40000,United Healthcare,Commercial,,68.29,,,,,,,25.28,68.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,62.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,inpatient,1,UN,24.60000,14.76000,United Healthcare,Commercial,,20.00,,,,,,,15.74,20.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,United Healthcare,Commercial,,20.00,,,,,,,4.92,20.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,inpatient,1,UN,33.20000,19.92000,United Healthcare,Commercial,,26.99,,,,,,,21.25,26.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,United Healthcare,Commercial,,26.99,,,,,,,6.65,26.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,inpatient,1,UN,50.05000,30.03000,United Healthcare,Commercial,,40.69,,,,,,,32.03,40.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,United Healthcare,Commercial,,40.69,,,,,,,10.02,40.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,inpatient,1000,ML,98.00000,58.80000,United Healthcare,Commercial,,79.67,,,,,,,29.50,79.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,72.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,inpatient,1000,ML,98.00000,58.80000,United Healthcare,Commercial,,79.67,,,,,,,29.50,79.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,United Healthcare,Commercial,,0.46200,,,,,,,0.25960,72.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,inpatient,100,ML,356.00000,213.60000,United Healthcare,Commercial,,289.43,,,,,,,107.16,289.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,United Healthcare,Commercial,,4.69,,,,,,,4.69,264.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,inpatient,1,UN,58.55000,35.13000,United Healthcare,Commercial,,47.60,,,,,,,37.47,47.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,United Healthcare,Commercial,,47.60,,,,,,,11.72,47.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,inpatient,1,UN,48.95000,29.37000,United Healthcare,Commercial,,39.80,,,,,,,31.33,39.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,United Healthcare,Commercial,,39.80,,,,,,,9.80,39.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,inpatient,17,ML,5076.25000,3045.75000,United Healthcare,Commercial,,4126.99,,,,,,,1527.95,4126.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,United Healthcare,Commercial,,0.84150,,,,,,,0.31040,3767.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,inpatient,1,UN,70.00000,42.00000,United Healthcare,Commercial,,56.91,,,,,,,44.80,56.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,United Healthcare,Commercial,,56.91,,,,,,,14.01,56.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,inpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,12.80,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Commercial,,16.26,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,inpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,12.35,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Commercial,,15.69,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,inpatient,1,ML,642.70000,385.62000,United Healthcare,Commercial,,522.52,,,,,,,193.45,522.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,United Healthcare,Commercial,,10.89,,,,,,,10.89,477.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,inpatient,0.5,ML,254.90000,152.94000,United Healthcare,Commercial,,207.23,,,,,,,76.72,207.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,United Healthcare,Commercial,,264.28,,,,,,,51.03,264.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,inpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,11.01,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Commercial,,13.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,inpatient,20,ML,95.55000,57.33000,United Healthcare,Commercial,,77.68,,,,,,,28.76,77.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,United Healthcare,Commercial,,21.73,,,,,,,16.71,70.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,inpatient,10,ML,25.15000,15.09000,United Healthcare,Commercial,,20.45,,,,,,,16.10,20.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,United Healthcare,Commercial,,20.45,,,,,,,5.04,20.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,inpatient,30,GR,166.25000,99.75000,United Healthcare,Commercial,,135.16,,,,,,,106.40,135.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,United Healthcare,Commercial,,135.16,,,,,,,33.28,135.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,inpatient,1,ML,85.30000,51.18000,United Healthcare,Commercial,,69.35,,,,,,,54.59,69.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,United Healthcare,Commercial,,69.35,,,,,,,17.08,69.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,inpatient,2,ML,102.85000,61.71000,United Healthcare,Commercial,,83.62,,,,,,,65.82,83.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,United Healthcare,Commercial,,83.62,,,,,,,20.59,83.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,inpatient,0.3,ML,25.45000,15.27000,United Healthcare,Commercial,,20.69,,,,,,,16.29,20.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,United Healthcare,Commercial,,20.69,,,,,,,5.10,20.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,inpatient,0.25,ML,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.89600,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,United Healthcare,Commercial,,1.14,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,inpatient,88,ML,2416.85000,1450.11000,United Healthcare,Commercial,,1964.90,,,,,,,1546.78,1964.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,United Healthcare,Commercial,,1964.90,,,,,,,483.85,1964.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,inpatient,1,UN,4022.30000,2413.38000,United Healthcare,Commercial,,3270.13,,,,,,,1210.71,3270.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,United Healthcare,Commercial,,16.65,,,,,,,8.49,2985.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,inpatient,10,ML,486.20000,291.72000,United Healthcare,Commercial,,395.28,,,,,,,146.35,395.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,United Healthcare,Commercial,,0.24750,,,,,,,0.18880,360.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,inpatient,20,ML,715.00000,429.00000,United Healthcare,Commercial,,581.29,,,,,,,215.22,581.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,United Healthcare,Commercial,,0.24750,,,,,,,0.18880,530.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,inpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,11.04,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Commercial,,14.02,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,inpatient,42.5,GR,1050.30000,630.18000,United Healthcare,Commercial,,853.89,,,,,,,672.19,853.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,United Healthcare,Commercial,,853.89,,,,,,,210.27,853.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,inpatient,1,UN,53.85000,32.31000,United Healthcare,Commercial,,43.78,,,,,,,34.46,43.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,United Healthcare,Commercial,,43.78,,,,,,,10.78,43.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,inpatient,1,UN,1730.85000,1038.51000,United Healthcare,Commercial,,1407.18,,,,,,,520.99,1407.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,United Healthcare,Commercial,,1063.79,,,,,,,346.52,1284.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,inpatient,1,UN,44.30000,26.58000,United Healthcare,Commercial,,36.02,,,,,,,28.35,36.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,Commercial,,36.02,,,,,,,8.87,36.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,inpatient,1,UN,44.30000,26.58000,United Healthcare,Commercial,,36.02,,,,,,,28.35,36.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,Commercial,,36.02,,,,,,,8.87,36.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,inpatient,1,UN,113.80000,68.28000,United Healthcare,Commercial,,92.52,,,,,,,72.83,92.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,United Healthcare,Commercial,,92.52,,,,,,,22.78,92.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,11.42,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Commercial,,14.51,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,inpatient,1.5,ML,1650.30000,990.18000,United Healthcare,Commercial,,1341.69,,,,,,,496.74,1341.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,United Healthcare,Commercial,,1414.40,,,,,,,330.39,1448.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,45414.56000,27248.74000,United Healthcare,Commercial,,36922.04,,,,,,,13669.78,36922.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,156212.38000,93727.43000,United Healthcare,Commercial,,127000.66,,,,,,,47019.93,127000.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,United Healthcare,Commercial,,215040.47,,,,,,,31273.72,215040.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,257500.00000,154500.00000,United Healthcare,Commercial,,209347.50,,,,,,,77507.50,209347.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,United Healthcare,Commercial,,215040.47,,,,,,,51551.50,215040.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,11159.74000,6695.84000,United Healthcare,Commercial,,9072.87,,,,,,,3359.08,9072.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,United Healthcare,Commercial,,370.75,,,,,,,327.43,8282.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,7390.20000,4434.12000,United Healthcare,Commercial,,6008.23,,,,,,,2224.45,6008.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,United Healthcare,Commercial,,370.75,,,,,,,327.43,5485.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,inpatient,2000,ML,259.00000,155.40000,United Healthcare,Commercial,,210.57,,,,,,,165.76,210.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,United Healthcare,Commercial,,210.57,,,,,,,51.85,210.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,inpatient,3.5,GR,13.65000,8.19000,United Healthcare,Commercial,,11.10,,,,,,,8.74,11.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,United Healthcare,Commercial,,11.10,,,,,,,2.73,11.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,inpatient,1,UN,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.76800,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,Commercial,,0.97560,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,inpatient,59,ML,9.15000,5.49000,United Healthcare,Commercial,,7.44,,,,,,,5.86,7.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,United Healthcare,Commercial,,7.44,,,,,,,1.83,7.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,inpatient,1000,ML,42.00000,25.20000,United Healthcare,Commercial,,34.15,,,,,,,12.64,34.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,United Healthcare,Commercial,,34.15,,,,,,,8.41,34.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,inpatient,20,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.06020,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,Commercial,,0.16260,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 1,11100016,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Commercial,,1228.00,,,,,,,384.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM PRIVATE ROOM LEVEL 1,11100017,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1228.00,,,,,,,256.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC BED HOLD  SHORT TERM PRIVATE ROOM,11100020,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Commercial,,1228.00,,,,,,,384.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC BED HOLD LONG TERM CARE PRIVATE ROOM,11100021,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1228.00,,,,,,,256.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 2,11100022,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Commercial,,1228.00,,,,,,,384.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM PRIVATE ROOM LEVEL 2,11100023,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1228.00,,,,,,,256.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 3,11100024,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Commercial,,1228.00,,,,,,,384.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM PRIVATE ROOM LEVEL 3,11100025,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1228.00,,,,,,,256.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC SHORT TERM PRIVATE ROOM LEVEL 4,11100026,CDM,110,RC,,,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Commercial,,1228.00,,,,,,,384.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM PRIVATE ROOM LEVEL 4,11100027,CDM,110,RC,,,,,facility,inpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1228.00,,,,,,,256.00,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 1,11200004,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,United Healthcare,Commercial,,1228.00,,,,,,,371.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 1,11200005,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,United Healthcare,Commercial,,1228.00,,,,,,,243.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC BED HOLD SHORT TERM SEMI PRIVATE ROOM,11200008,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,United Healthcare,Commercial,,1228.00,,,,,,,371.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC BED HOLD LONG TERM CARE SEMI PRIVATE,11200009,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,United Healthcare,Commercial,,1228.00,,,,,,,243.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 2,11200010,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,United Healthcare,Commercial,,1228.00,,,,,,,371.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 2,11200011,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,United Healthcare,Commercial,,1228.00,,,,,,,243.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 3,11200012,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,United Healthcare,Commercial,,1228.00,,,,,,,371.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 3,11200013,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,United Healthcare,Commercial,,1228.00,,,,,,,243.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC SHORT TERM SEMI PRIVATE ROOM LEVEL 4,11200014,CDM,120,RC,,,,,facility,inpatient,,,580.00000,348.00000,United Healthcare,Commercial,,1228.00,,,,,,,371.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC LTC LONG TERM SEMI PRIVATE ROOM LEVEL 4,11200015,CDM,120,RC,,,,,facility,inpatient,,,380.00000,228.00000,United Healthcare,Commercial,,1228.00,,,,,,,243.20,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX PRIVATE ROOM,11100002,CDM,110,RC,,,,,facility,inpatient,,,1328.00000,796.80000,United Healthcare,Commercial,,1228.00,,,,,,,849.92,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX OB PRIVATE ROOM,11120001,CDM,112,RC,,,,,facility,inpatient,,,1328.00000,796.80000,United Healthcare,Commercial,,1228.00,,,,,,,849.92,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX HOSPICE PRIVATE ROOM,11150001,CDM,115,RC,,,,,facility,inpatient,,,1328.00000,796.80000,United Healthcare,Commercial,,1315.00,,,,,,,849.92,2085.00,per diem,
HC REX CONTINUED NEONATAL CARE PRIVATE ROOM,11710001,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,United Healthcare,Commercial,,1248.00,,,,,,,974.00,1558.44,per diem,
HC REX LEVEL 1 NURSERY ROOM,11710002,CDM,171,RC,,,,,facility,inpatient,,,1924.00000,1154.40000,United Healthcare,Commercial,,1248.00,,,,,,,974.00,1558.44,per diem,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Commercial,,954.00,,,,,,,103.90,954.00,per diem,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,United Healthcare,Commercial,,954.00,,,,,,,257.66,965.25,per diem,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,United Healthcare,Commercial,,954.00,,,,,,,385.38,1443.75,per diem,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,United Healthcare,Commercial,,954.00,,,,,,,578.78,2168.25,per diem,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,United Healthcare,Commercial,,954.00,,,,,,,615.00,2601.75,per diem,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,United Healthcare,Commercial,,954.00,,,,,,,615.00,3121.50,per diem,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,United Healthcare,Commercial,,954.00,,,,,,,615.00,3747.00,per diem,
HC REX LEVEL 3 INTERMEDIATE NURSERY ROOM,11733001,CDM,173,RC,,,,,facility,inpatient,,,4517.00000,2710.20000,United Healthcare,Commercial,,5493.00,,,,,,,2890.88,5493.00,per diem,
HC REX ICU ROOM,12000002,CDM,202,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,United Healthcare,Commercial,,1228.00,,,,,,,1228.00,6258.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX ICU ROOM,12000002,CDM,210,RC,,,,,facility,inpatient,,,4395.00000,2637.00000,United Healthcare,Commercial,,1228.00,,,,,,,1228.00,6258.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,United Healthcare,Commercial,,954.00,,,,,,,413.41,1548.75,per diem,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,United Healthcare,Commercial,,954.00,,,,,,,607.21,2274.75,per diem,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,United Healthcare,Commercial,,954.00,,,,,,,615.00,4137.00,per diem,
HC REX INTERMEDIATE CARE ROOM,12090002,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,United Healthcare,Commercial,,1228.00,,,,,,,1228.00,5197.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX INTERMEDIATE CARE SEMI PRIVATE ROOM,12090004,CDM,206,RC,,,,,facility,inpatient,,,2084.00000,1250.40000,United Healthcare,Commercial,,1228.00,,,,,,,1228.00,5197.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,inpatient,,,160.00000,96.00000,United Healthcare,Commercial,,130.08,,,,,,,102.40,130.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Commercial,,130.08,,,,,,,32.03,130.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,inpatient,,,633.00000,379.80000,United Healthcare,Commercial,,514.63,,,,,,,405.12,514.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,United Healthcare,Commercial,,514.63,,,,,,,126.73,514.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,inpatient,,,173.00000,103.80000,United Healthcare,Commercial,,140.65,,,,,,,110.72,140.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Commercial,,140.65,,,,,,,34.63,140.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,inpatient,,,117.00000,70.20000,United Healthcare,Commercial,,95.12,,,,,,,74.88,95.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,,95.12,,,,,,,23.42,95.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,inpatient,,,62.00000,37.20000,United Healthcare,Commercial,,50.41,,,,,,,39.68,50.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,50.41,,,,,,,12.41,50.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,inpatient,,,26.00000,15.60000,United Healthcare,Commercial,,21.14,,,,,,,16.64,21.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Commercial,,21.14,,,,,,,5.21,21.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,inpatient,,,143.00000,85.80000,United Healthcare,Commercial,,116.26,,,,,,,91.52,116.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Commercial,,116.26,,,,,,,28.63,116.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,inpatient,,,63.00000,37.80000,United Healthcare,Commercial,,51.22,,,,,,,40.32,51.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,51.22,,,,,,,12.61,51.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,inpatient,,,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,51.84,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,inpatient,,,158.00000,94.80000,United Healthcare,Commercial,,128.45,,,,,,,101.12,128.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Commercial,,128.45,,,,,,,31.63,128.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,inpatient,,,524.00000,314.40000,United Healthcare,Commercial,,426.01,,,,,,,335.36,426.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,United Healthcare,Commercial,,426.01,,,,,,,104.90,426.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,inpatient,,,597.00000,358.20000,United Healthcare,Commercial,,485.36,,,,,,,382.08,485.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,United Healthcare,Commercial,,485.36,,,,,,,119.52,485.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,inpatient,,,508.00000,304.80000,United Healthcare,Commercial,,413.00,,,,,,,325.12,413.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,United Healthcare,Commercial,,413.00,,,,,,,101.70,413.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,inpatient,,,92.00000,55.20000,United Healthcare,Commercial,,74.80,,,,,,,58.88,74.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Commercial,,74.80,,,,,,,18.42,74.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,inpatient,,,73.00000,43.80000,United Healthcare,Commercial,,59.35,,,,,,,46.72,59.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,United Healthcare,Commercial,,59.35,,,,,,,14.61,59.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,inpatient,,,230.00000,138.00000,United Healthcare,Commercial,,186.99,,,,,,,147.20,186.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,United Healthcare,Commercial,,186.99,,,,,,,46.05,186.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,inpatient,,,211.00000,126.60000,United Healthcare,Commercial,,171.54,,,,,,,135.04,171.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,United Healthcare,Commercial,,171.54,,,,,,,42.24,171.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,inpatient,,,5233.00000,3139.80000,United Healthcare,Commercial,,4254.43,,,,,,,3349.12,4254.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,United Healthcare,Commercial,,4254.43,,,,,,,1047.65,4254.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,inpatient,,,5233.00000,3139.80000,United Healthcare,Commercial,,4254.43,,,,,,,3349.12,4254.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,United Healthcare,Commercial,,4254.43,,,,,,,1047.65,4254.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,inpatient,,,4982.00000,2989.20000,United Healthcare,Commercial,,4050.37,,,,,,,3188.48,4050.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,United Healthcare,Commercial,,4050.37,,,,,,,997.40,4050.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,inpatient,,,1786.00000,1071.60000,United Healthcare,Commercial,,1452.02,,,,,,,1143.04,1452.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,United Healthcare,Commercial,,1452.02,,,,,,,357.56,1452.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,37.12,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,inpatient,,,3005.00000,1803.00000,United Healthcare,Commercial,,2443.07,,,,,,,1923.20,2443.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,United Healthcare,Commercial,,2443.07,,,,,,,601.60,2443.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,inpatient,,,1526.00000,915.60000,United Healthcare,Commercial,,1240.64,,,,,,,976.64,1240.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,United Healthcare,Commercial,,1240.64,,,,,,,305.51,1240.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,inpatient,,,313.00000,187.80000,United Healthcare,Commercial,,254.47,,,,,,,200.32,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Commercial,,254.47,,,,,,,62.66,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,inpatient,,,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,51.84,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,65.85,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,inpatient,,,63.00000,37.80000,United Healthcare,Commercial,,51.22,,,,,,,40.32,51.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,51.22,,,,,,,12.61,51.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,inpatient,,,1093.00000,655.80000,United Healthcare,Commercial,,888.61,,,,,,,699.52,888.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,United Healthcare,Commercial,,888.61,,,,,,,218.82,888.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,inpatient,,,342.00000,205.20000,United Healthcare,Commercial,,278.05,,,,,,,218.88,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Commercial,,278.05,,,,,,,68.47,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,inpatient,,,1236.00000,741.60000,United Healthcare,Commercial,,1004.87,,,,,,,791.04,1004.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,United Healthcare,Commercial,,1004.87,,,,,,,247.45,1004.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,inpatient,,,909.00000,545.40000,United Healthcare,Commercial,,739.02,,,,,,,581.76,739.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,Commercial,,739.02,,,,,,,181.98,739.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,inpatient,,,303.00000,181.80000,United Healthcare,Commercial,,246.34,,,,,,,193.92,246.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,Commercial,,246.34,,,,,,,60.66,246.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,inpatient,,,500.00000,300.00000,United Healthcare,Commercial,,406.50,,,,,,,320.00,406.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,Commercial,,406.50,,,,,,,100.10,406.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,inpatient,,,938.00000,562.80000,United Healthcare,Commercial,,762.59,,,,,,,600.32,762.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,United Healthcare,Commercial,,762.59,,,,,,,187.79,762.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,inpatient,,,266.00000,159.60000,United Healthcare,Commercial,,216.26,,,,,,,170.24,216.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,United Healthcare,Commercial,,216.26,,,,,,,53.25,216.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,inpatient,,,204.00000,122.40000,United Healthcare,Commercial,,165.85,,,,,,,130.56,165.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Commercial,,165.85,,,,,,,40.84,165.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,inpatient,,,1092.00000,655.20000,United Healthcare,Commercial,,887.80,,,,,,,698.88,887.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,United Healthcare,Commercial,,887.80,,,,,,,218.62,887.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,inpatient,,,948.00000,568.80000,United Healthcare,Commercial,,770.72,,,,,,,606.72,770.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,United Healthcare,Commercial,,770.72,,,,,,,189.79,770.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,inpatient,,,286.00000,171.60000,United Healthcare,Commercial,,232.52,,,,,,,183.04,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,United Healthcare,Commercial,,232.52,,,,,,,57.26,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,inpatient,,,43.00000,25.80000,United Healthcare,Commercial,,34.96,,,,,,,27.52,34.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Commercial,,34.96,,,,,,,8.61,34.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,inpatient,,,35.00000,21.00000,United Healthcare,Commercial,,28.45,,,,,,,22.40,28.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Commercial,,28.45,,,,,,,7.01,28.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,inpatient,,,140.00000,84.00000,United Healthcare,Commercial,,113.82,,,,,,,89.60,113.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Commercial,,113.82,,,,,,,28.03,113.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,inpatient,,,474.00000,284.40000,United Healthcare,Commercial,,385.36,,,,,,,303.36,385.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,United Healthcare,Commercial,,385.36,,,,,,,94.89,385.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,inpatient,,,126.00000,75.60000,United Healthcare,Commercial,,102.44,,,,,,,80.64,102.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Commercial,,102.44,,,,,,,25.23,102.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,inpatient,,,286.00000,171.60000,United Healthcare,Commercial,,232.52,,,,,,,183.04,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,United Healthcare,Commercial,,232.52,,,,,,,57.26,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,inpatient,,,134.00000,80.40000,United Healthcare,Commercial,,108.94,,,,,,,85.76,108.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Commercial,,108.94,,,,,,,26.83,108.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,inpatient,,,11.00000,6.60000,United Healthcare,Commercial,,8.94,,,,,,,7.04,8.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,United Healthcare,Commercial,,8.94,,,,,,,2.20,8.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,inpatient,,,4985.00000,2991.00000,United Healthcare,Commercial,,4052.80,,,,,,,857.42,4137.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,United Healthcare,Commercial,,1116.64,,,,,,,633.10,3669.96,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,inpatient,,,20100.00000,12060.00000,United Healthcare,Commercial,,16341.30,,,,,,,3457.20,16683.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,United Healthcare,Commercial,,4502.40,,,,,,,2552.70,14797.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,inpatient,,,5074.00000,3044.40000,United Healthcare,Commercial,,4125.16,,,,,,,872.73,4211.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,United Healthcare,Commercial,,1136.58,,,,,,,644.40,3735.48,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,inpatient,,,4240.00000,2544.00000,United Healthcare,Commercial,,3447.12,,,,,,,729.28,3519.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,United Healthcare,Commercial,,949.76,,,,,,,538.48,3121.49,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,inpatient,,,3478.00000,2086.80000,United Healthcare,Commercial,,2827.61,,,,,,,598.22,2886.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,United Healthcare,Commercial,,779.07,,,,,,,441.71,2560.50,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,inpatient,,,463.00000,277.80000,United Healthcare,Commercial,,376.42,,,,,,,296.32,376.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Commercial,,376.42,,,,,,,92.69,376.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,inpatient,,,1184.00000,710.40000,United Healthcare,Commercial,,962.59,,,,,,,757.76,962.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,United Healthcare,Commercial,,962.59,,,,,,,237.04,962.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,inpatient,,,2432.00000,1459.20000,United Healthcare,Commercial,,1977.22,,,,,,,1556.48,1977.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,United Healthcare,Commercial,,1977.22,,,,,,,486.89,1977.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,inpatient,,,3684.00000,2210.40000,United Healthcare,Commercial,,2995.09,,,,,,,2357.76,2995.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,United Healthcare,Commercial,,2995.09,,,,,,,737.54,2995.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,inpatient,,,4297.00000,2578.20000,United Healthcare,Commercial,,3493.46,,,,,,,2750.08,3493.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,United Healthcare,Commercial,,3493.46,,,,,,,860.26,3493.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,inpatient,,,121.00000,72.60000,United Healthcare,Commercial,,98.37,,,,,,,77.44,98.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,United Healthcare,Commercial,,98.37,,,,,,,24.22,98.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,United Healthcare,Commercial,,954.00,,,,,,,341.54,1279.50,per diem,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,United Healthcare,Commercial,,954.00,,,,,,,615.00,2569.50,per diem,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Commercial,,954.00,,,,,,,16.62,954.00,per diem,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,United Healthcare,Commercial,,954.00,,,,,,,93.49,954.00,per diem,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,inpatient,,,689.00000,413.40000,United Healthcare,Commercial,,560.16,,,,,,,440.96,560.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,United Healthcare,Commercial,,560.16,,,,,,,119.95,560.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,inpatient,,,1557.00000,934.20000,United Healthcare,Commercial,,1265.84,,,,,,,996.48,1265.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,United Healthcare,Commercial,,1265.84,,,,,,,271.07,1265.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,inpatient,,,1179.00000,707.40000,United Healthcare,Commercial,,958.53,,,,,,,754.56,958.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,United Healthcare,Commercial,,958.53,,,,,,,205.26,958.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,inpatient,,,79.00000,47.40000,United Healthcare,Commercial,,64.23,,,,,,,50.56,64.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Commercial,,64.23,,,,,,,13.75,64.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Commercial,,1090.00,,,,,,,15.32,1090.00,per diem,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,inpatient,,,7174.00000,4304.40000,United Healthcare,Commercial,,5832.46,,,,,,,4591.36,5832.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,United Healthcare,Commercial,,5832.46,,,,,,,1436.23,5832.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,inpatient,,,756.00000,453.60000,United Healthcare,Commercial,,614.63,,,,,,,483.84,614.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,United Healthcare,Commercial,,614.63,,,,,,,151.35,614.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,inpatient,,,3.00000,1.80000,United Healthcare,Commercial,,2.44,,,,,,,1.92,2.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,United Healthcare,Commercial,,2.44,,,,,,,0.60060,2.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,inpatient,,,1649.00000,989.40000,United Healthcare,Commercial,,1340.64,,,,,,,1055.36,1340.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,United Healthcare,Commercial,,1340.64,,,,,,,330.13,1340.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,inpatient,,,2127.00000,1276.20000,United Healthcare,Commercial,,1729.25,,,,,,,1361.28,1729.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,United Healthcare,Commercial,,1729.25,,,,,,,425.83,1729.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,inpatient,,,2607.00000,1564.20000,United Healthcare,Commercial,,2119.49,,,,,,,1668.48,2119.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,United Healthcare,Commercial,,2119.49,,,,,,,521.92,2119.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,inpatient,,,3085.00000,1851.00000,United Healthcare,Commercial,,2508.11,,,,,,,1974.40,2508.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,United Healthcare,Commercial,,2508.11,,,,,,,617.62,2508.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,inpatient,,,3564.00000,2138.40000,United Healthcare,Commercial,,2897.53,,,,,,,2280.96,2897.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,United Healthcare,Commercial,,2897.53,,,,,,,713.51,2897.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,inpatient,,,4043.00000,2425.80000,United Healthcare,Commercial,,3286.96,,,,,,,2587.52,3286.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,United Healthcare,Commercial,,3286.96,,,,,,,809.41,3286.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,inpatient,,,4521.00000,2712.60000,United Healthcare,Commercial,,3675.57,,,,,,,2893.44,3675.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,United Healthcare,Commercial,,3675.57,,,,,,,905.10,3675.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,inpatient,,,661.00000,396.60000,United Healthcare,Commercial,,537.39,,,,,,,423.04,537.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,United Healthcare,Commercial,,537.39,,,,,,,132.33,537.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,inpatient,,,3280.00000,1968.00000,United Healthcare,Commercial,,2666.64,,,,,,,2099.20,2666.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,United Healthcare,Commercial,,2666.64,,,,,,,656.66,2666.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,inpatient,,,4322.00000,2593.20000,United Healthcare,Commercial,,3513.79,,,,,,,2766.08,3513.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,United Healthcare,Commercial,,3513.79,,,,,,,865.26,3513.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,inpatient,,,1294.00000,776.40000,United Healthcare,Commercial,,1052.02,,,,,,,828.16,1052.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,Commercial,,1052.02,,,,,,,259.06,1052.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,inpatient,,,1763.00000,1057.80000,United Healthcare,Commercial,,1433.32,,,,,,,1128.32,1433.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,United Healthcare,Commercial,,1433.32,,,,,,,352.95,1433.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,inpatient,,,1966.00000,1179.60000,United Healthcare,Commercial,,1598.36,,,,,,,1258.24,1598.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,United Healthcare,Commercial,,1598.36,,,,,,,393.59,1598.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,inpatient,,,2177.00000,1306.20000,United Healthcare,Commercial,,1769.90,,,,,,,1393.28,1769.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,United Healthcare,Commercial,,1769.90,,,,,,,435.84,1769.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,inpatient,,,2387.00000,1432.20000,United Healthcare,Commercial,,1940.63,,,,,,,1527.68,1940.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,United Healthcare,Commercial,,1940.63,,,,,,,477.88,1940.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,inpatient,,,2596.00000,1557.60000,United Healthcare,Commercial,,2110.55,,,,,,,1661.44,2110.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,United Healthcare,Commercial,,2110.55,,,,,,,519.72,2110.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,inpatient,,,2807.00000,1684.20000,United Healthcare,Commercial,,2282.09,,,,,,,1796.48,2282.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,United Healthcare,Commercial,,2282.09,,,,,,,561.96,2282.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,inpatient,,,1649.00000,989.40000,United Healthcare,Commercial,,1340.64,,,,,,,1055.36,1340.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,United Healthcare,Commercial,,1340.64,,,,,,,330.13,1340.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,inpatient,,,958.00000,574.80000,United Healthcare,Commercial,,778.85,,,,,,,613.12,778.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,United Healthcare,Commercial,,778.85,,,,,,,191.79,778.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,inpatient,,,2387.00000,1432.20000,United Healthcare,Commercial,,1940.63,,,,,,,1527.68,1940.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,United Healthcare,Commercial,,1940.63,,,,,,,477.88,1940.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,inpatient,,,1294.00000,776.40000,United Healthcare,Commercial,,1052.02,,,,,,,828.16,1052.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,Commercial,,1052.02,,,,,,,259.06,1052.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,inpatient,,,1763.00000,1057.80000,United Healthcare,Commercial,,1433.32,,,,,,,1128.32,1433.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,United Healthcare,Commercial,,1433.32,,,,,,,352.95,1433.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,inpatient,,,1966.00000,1179.60000,United Healthcare,Commercial,,1598.36,,,,,,,1258.24,1598.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,United Healthcare,Commercial,,1598.36,,,,,,,393.59,1598.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,inpatient,,,2177.00000,1306.20000,United Healthcare,Commercial,,1769.90,,,,,,,1393.28,1769.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,United Healthcare,Commercial,,1769.90,,,,,,,435.84,1769.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,inpatient,,,2596.00000,1557.60000,United Healthcare,Commercial,,2110.55,,,,,,,1661.44,2110.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,United Healthcare,Commercial,,2110.55,,,,,,,519.72,2110.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,inpatient,,,2807.00000,1684.20000,United Healthcare,Commercial,,2282.09,,,,,,,1796.48,2282.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,United Healthcare,Commercial,,2282.09,,,,,,,561.96,2282.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,inpatient,,,3280.00000,1968.00000,United Healthcare,Commercial,,2666.64,,,,,,,2099.20,2666.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,United Healthcare,Commercial,,2666.64,,,,,,,656.66,2666.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,inpatient,,,4322.00000,2593.20000,United Healthcare,Commercial,,3513.79,,,,,,,2766.08,3513.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,United Healthcare,Commercial,,3513.79,,,,,,,865.26,3513.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,inpatient,,,499.00000,299.40000,United Healthcare,Commercial,,405.69,,,,,,,319.36,405.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Commercial,,405.69,,,,,,,99.90,405.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,134.00,,,,,,,15.42,134.00,per diem,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,7281.00,,,,,,,10.56,7281.00,case rate,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,United Healthcare,Commercial,,7281.00,,,,,,,16.21,7281.00,case rate,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,Commercial,,7281.00,,,,,,,34.50,7281.00,case rate,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Commercial,,7281.00,,,,,,,18.85,7281.00,case rate,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Commercial,,7281.00,,,,,,,18.66,7281.00,case rate,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Commercial,,487.80,,,,,,,103.20,498.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,Commercial,,134.40,,,,,,,76.20,441.72,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,United Healthcare,Commercial,,606.50,,,,,,,128.31,619.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,Commercial,,167.10,,,,,,,94.74,549.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,1375.00000,825.00000,United Healthcare,Commercial,,1117.88,,,,,,,236.50,1141.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,United Healthcare,Commercial,,308.00,,,,,,,174.62,1012.27,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,19569.00000,11741.40000,United Healthcare,Commercial,,15909.60,,,,,,,3365.87,16242.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,United Healthcare,Commercial,,4383.46,,,,,,,2485.26,14406.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,9120.00000,5472.00000,United Healthcare,Commercial,,7414.56,,,,,,,1568.64,7569.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,United Healthcare,Commercial,,2042.88,,,,,,,1158.24,6714.14,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,4162.56,,,,,,,880.64,4249.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,1146.88,,,,,,,650.24,3769.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,4954.00000,2972.40000,United Healthcare,Commercial,,4027.60,,,,,,,852.09,4111.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,United Healthcare,Commercial,,1109.70,,,,,,,629.16,3647.13,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,7438.00000,4462.80000,United Healthcare,Commercial,,6047.09,,,,,,,1279.34,6173.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,United Healthcare,Commercial,,1666.11,,,,,,,944.63,5475.86,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,8418.00000,5050.80000,United Healthcare,Commercial,,6843.83,,,,,,,1447.90,6986.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,United Healthcare,Commercial,,1885.63,,,,,,,1069.09,6197.33,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,4162.56,,,,,,,880.64,4249.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,1146.88,,,,,,,650.24,3769.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,6348.00000,3808.80000,United Healthcare,Commercial,,5160.92,,,,,,,1091.86,5268.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,United Healthcare,Commercial,,1421.95,,,,,,,806.20,4673.40,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,United Healthcare,Commercial,,258.53,,,,,,,54.70,263.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Commercial,,71.23,,,,,,,40.39,234.11,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,United Healthcare,Commercial,,83.74,,,,,,,17.72,85.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,United Healthcare,Commercial,,23.07,,,,,,,13.08,75.83,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,209.00000,125.40000,United Healthcare,Commercial,,169.92,,,,,,,35.95,173.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Commercial,,46.82,,,,,,,26.54,153.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,inpatient,,,28.00000,16.80000,United Healthcare,Commercial,,22.76,,,,,,,17.92,22.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,22.76,,,,,,,5.61,22.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,145.00000,87.00000,United Healthcare,Commercial,,117.89,,,,,,,24.94,120.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Commercial,,32.48,,,,,,,18.41,106.75,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,United Healthcare,Commercial,,258.53,,,,,,,54.70,263.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Commercial,,71.23,,,,,,,40.39,234.11,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,126.00000,75.60000,United Healthcare,Commercial,,102.44,,,,,,,21.67,104.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Commercial,,28.22,,,,,,,16.00,92.76,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,151.00000,90.60000,United Healthcare,Commercial,,122.76,,,,,,,25.97,125.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,United Healthcare,Commercial,,33.82,,,,,,,19.18,111.17,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,184.00000,110.40000,United Healthcare,Commercial,,149.59,,,,,,,31.65,152.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,United Healthcare,Commercial,,41.22,,,,,,,23.37,135.46,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,295.00000,177.00000,United Healthcare,Commercial,,239.84,,,,,,,50.74,244.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Commercial,,66.08,,,,,,,37.47,217.18,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,355.00000,213.00000,United Healthcare,Commercial,,288.62,,,,,,,61.06,294.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,United Healthcare,Commercial,,79.52,,,,,,,45.09,261.35,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,852.02,,,,,,,180.26,869.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,234.75,,,,,,,133.10,771.54,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,United Healthcare,Commercial,,83.74,,,,,,,17.72,85.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,United Healthcare,Commercial,,23.07,,,,,,,13.08,75.83,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,425.00000,255.00000,United Healthcare,Commercial,,345.52,,,,,,,73.10,352.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,Commercial,,95.20,,,,,,,53.98,312.88,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Commercial,,487.80,,,,,,,103.20,498.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,Commercial,,134.40,,,,,,,76.20,441.72,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1073.00000,643.80000,United Healthcare,Commercial,,872.35,,,,,,,184.56,890.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,United Healthcare,Commercial,,240.35,,,,,,,136.27,789.94,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,948.00000,568.80000,United Healthcare,Commercial,,770.72,,,,,,,163.06,786.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,United Healthcare,Commercial,,212.35,,,,,,,120.40,697.92,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,United Healthcare,Commercial,,606.50,,,,,,,128.31,619.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,Commercial,,167.10,,,,,,,94.74,549.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,United Healthcare,Commercial,,606.50,,,,,,,128.31,619.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,Commercial,,167.10,,,,,,,94.74,549.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,46.96,226.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Commercial,,61.15,,,,,,,34.67,200.98,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,774.00000,464.40000,United Healthcare,Commercial,,629.26,,,,,,,133.13,642.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,United Healthcare,Commercial,,173.38,,,,,,,98.30,569.82,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,inpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,4162.56,,,,,,,3276.80,4162.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,4162.56,,,,,,,1025.02,4162.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,503.00000,301.80000,United Healthcare,Commercial,,408.94,,,,,,,86.52,417.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,United Healthcare,Commercial,,112.67,,,,,,,63.88,370.31,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,inpatient,,,452.00000,271.20000,United Healthcare,Commercial,,367.48,,,,,,,289.28,367.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,United Healthcare,Commercial,,367.48,,,,,,,90.49,367.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,1349.00000,809.40000,United Healthcare,Commercial,,1096.74,,,,,,,232.03,1119.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,United Healthcare,Commercial,,302.18,,,,,,,171.32,993.13,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,4162.56,,,,,,,880.64,4249.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Commercial,,1146.88,,,,,,,650.24,3769.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1484.00000,890.40000,United Healthcare,Commercial,,1206.49,,,,,,,255.25,1231.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,United Healthcare,Commercial,,332.42,,,,,,,188.47,1092.52,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1379.00000,827.40000,United Healthcare,Commercial,,1121.13,,,,,,,237.19,1144.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,United Healthcare,Commercial,,308.90,,,,,,,175.13,1015.22,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,9.98,48.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,12.99,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,9.98,48.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,12.99,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,9.98,48.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,12.99,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Commercial,,47.15,,,,,,,9.98,48.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,12.99,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,United Healthcare,Commercial,,434.95,,,,,,,92.02,444.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Commercial,,119.84,,,,,,,67.94,393.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,United Healthcare,Commercial,,434.95,,,,,,,92.02,444.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Commercial,,119.84,,,,,,,67.94,393.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,United Healthcare,Commercial,,434.95,,,,,,,92.02,444.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Commercial,,119.84,,,,,,,67.94,393.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00640,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,inpatient,,,6720.00000,4032.00000,United Healthcare,Commercial,,5463.36,,,,,,,4300.80,5463.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,United Healthcare,Commercial,,5463.36,,,,,,,1345.34,5463.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,United Healthcare,Commercial,,749.59,,,,,,,158.58,765.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,Commercial,,206.53,,,,,,,117.09,678.78,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,United Healthcare,Commercial,,749.59,,,,,,,158.58,765.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,Commercial,,206.53,,,,,,,117.09,678.78,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,United Healthcare,Commercial,,749.59,,,,,,,158.58,765.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,Commercial,,206.53,,,,,,,117.09,678.78,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1215.00000,729.00000,United Healthcare,Commercial,,987.79,,,,,,,208.98,1008.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,United Healthcare,Commercial,,272.16,,,,,,,154.31,894.48,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1631.00000,978.60000,United Healthcare,Commercial,,1326.00,,,,,,,280.53,1353.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,United Healthcare,Commercial,,365.34,,,,,,,207.14,1200.74,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,inpatient,,,2899.00000,1739.40000,United Healthcare,Commercial,,2356.89,,,,,,,1855.36,2356.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,United Healthcare,Commercial,,2356.89,,,,,,,580.38,2356.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,inpatient,,,350.00000,210.00000,United Healthcare,Commercial,,284.55,,,,,,,60.20,290.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Commercial,,78.40,,,,,,,44.45,257.67,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,inpatient,,,463.00000,277.80000,United Healthcare,Commercial,,376.42,,,,,,,79.64,384.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Commercial,,103.71,,,,,,,58.80,340.86,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,inpatient,,,140.00000,84.00000,United Healthcare,Commercial,,113.82,,,,,,,24.08,116.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Commercial,,31.36,,,,,,,17.78,103.07,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Commercial,,77.23,,,,,,,16.34,78.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,21.28,,,,,,,12.06,69.94,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,inpatient,,,166.00000,99.60000,United Healthcare,Commercial,,134.96,,,,,,,28.55,137.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Commercial,,37.18,,,,,,,21.08,122.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,inpatient,,,350.00000,210.00000,United Healthcare,Commercial,,284.55,,,,,,,60.20,290.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Commercial,,78.40,,,,,,,44.45,257.67,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,inpatient,,,91.00000,54.60000,United Healthcare,Commercial,,73.98,,,,,,,15.65,75.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,20.38,,,,,,,11.56,66.99,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,inpatient,,,101.00000,60.60000,United Healthcare,Commercial,,82.11,,,,,,,17.37,83.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,22.62,,,,,,,12.83,74.36,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5270.00000,3162.00000,United Healthcare,Commercial,,4284.51,,,,,,,906.44,4374.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,United Healthcare,Commercial,,1180.48,,,,,,,669.29,3879.77,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,1024.00000,614.40000,United Healthcare,Commercial,,832.51,,,,,,,176.13,849.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,United Healthcare,Commercial,,229.38,,,,,,,130.05,753.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,inpatient,,,637.00000,382.20000,United Healthcare,Commercial,,517.88,,,,,,,109.56,528.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Commercial,,142.69,,,,,,,80.90,468.96,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,inpatient,,,39570.00000,23742.00000,United Healthcare,Commercial,,32170.41,,,,,,,11910.57,32170.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,17004.00000,10202.40000,United Healthcare,Commercial,,13824.25,,,,,,,5118.20,13824.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,297.00000,178.20000,United Healthcare,Commercial,,241.46,,,,,,,51.08,246.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,Commercial,,66.53,,,,,,,33.78,218.65,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,308.00000,184.80000,United Healthcare,Commercial,,250.40,,,,,,,52.98,255.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,United Healthcare,Commercial,,68.99,,,,,,,33.78,226.75,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,1919.00000,1151.40000,United Healthcare,Commercial,,1560.15,,,,,,,577.62,1560.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,7252.00000,4351.20000,United Healthcare,Commercial,,5895.88,,,,,,,2182.85,5895.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,1734.00000,1040.40000,United Healthcare,Commercial,,1409.74,,,,,,,521.93,1409.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,3295.00000,1977.00000,United Healthcare,Commercial,,2678.84,,,,,,,991.79,2678.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,40220.00000,24132.00000,United Healthcare,Commercial,,32698.86,,,,,,,12106.22,32698.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,12517.00000,7510.20000,United Healthcare,Commercial,,10176.32,,,,,,,3767.62,10176.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,11120.00000,6672.00000,United Healthcare,Commercial,,9040.56,,,,,,,3347.12,9040.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,15665.00000,9399.00000,United Healthcare,Commercial,,12735.65,,,,,,,4715.16,12735.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,31578.00000,18946.80000,United Healthcare,Commercial,,25672.91,,,,,,,9504.98,25672.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,2639.00000,1583.40000,United Healthcare,Commercial,,2145.51,,,,,,,794.34,2145.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,11117.00000,6670.20000,United Healthcare,Commercial,,9038.12,,,,,,,3346.22,9038.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,16042.00000,9625.20000,United Healthcare,Commercial,,13042.15,,,,,,,4828.64,13042.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,9476.00000,5685.60000,United Healthcare,Commercial,,7703.99,,,,,,,1629.87,7865.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,United Healthcare,Commercial,,2122.62,,,,,,,1203.45,6976.23,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,United Healthcare,Commercial,,2191.85,,,,,,,811.50,2191.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,United Healthcare,Commercial,,2191.85,,,,,,,463.71,2237.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,United Healthcare,Commercial,,603.90,,,,,,,342.39,1984.80,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,8366.00000,5019.60000,United Healthcare,Commercial,,6801.56,,,,,,,2518.17,6801.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,8920.00000,5352.00000,United Healthcare,Commercial,,7251.96,,,,,,,2684.92,7251.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,11277.00000,6766.20000,United Healthcare,Commercial,,9168.20,,,,,,,3394.38,9168.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6131.00000,3678.60000,United Healthcare,Commercial,,4984.50,,,,,,,1054.53,5088.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,United Healthcare,Commercial,,1373.34,,,,,,,778.64,4513.64,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,inpatient,,,15495.00000,9297.00000,United Healthcare,Commercial,,12597.43,,,,,,,4663.99,12597.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,inpatient,,,1255.00000,753.00000,United Healthcare,Commercial,,1020.32,,,,,,,215.86,1041.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,Commercial,,281.12,,,,,,,35.64,923.93,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,inpatient,,,537.00000,322.20000,United Healthcare,Commercial,,436.58,,,,,,,92.36,445.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,United Healthcare,Commercial,,120.29,,,,,,,68.20,395.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6720.00000,4032.00000,United Healthcare,Commercial,,5463.36,,,,,,,1155.84,5577.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,United Healthcare,Commercial,,1505.28,,,,,,,853.44,4947.26,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5270.00000,3162.00000,United Healthcare,Commercial,,4284.51,,,,,,,906.44,4374.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,United Healthcare,Commercial,,1180.48,,,,,,,669.29,3879.77,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,940.00000,564.00000,United Healthcare,Commercial,,764.22,,,,,,,161.68,780.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,United Healthcare,Commercial,,210.56,,,,,,,119.38,692.03,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,inpatient,,,220.00000,132.00000,United Healthcare,Commercial,,178.86,,,,,,,37.84,182.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,United Healthcare,Commercial,,49.28,,,,,,,27.94,161.96,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,555.00000,333.00000,United Healthcare,Commercial,,451.21,,,,,,,95.46,460.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,United Healthcare,Commercial,,124.32,,,,,,,70.48,408.59,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5436.00000,3261.60000,United Healthcare,Commercial,,4419.47,,,,,,,934.99,4511.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,United Healthcare,Commercial,,1217.66,,,,,,,690.37,4001.98,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,19845.00000,11907.00000,United Healthcare,Commercial,,16133.99,,,,,,,3413.34,16471.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,United Healthcare,Commercial,,4445.28,,,,,,,2520.32,14609.89,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,27390.00000,16434.00000,United Healthcare,Commercial,,22268.07,,,,,,,4711.08,22733.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,United Healthcare,Commercial,,6135.36,,,,,,,3478.53,20164.52,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,United Healthcare,Commercial,,228.45,,,,,,,48.33,233.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,Commercial,,62.94,,,,,,,35.69,206.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,United Healthcare,Commercial,,228.45,,,,,,,48.33,233.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,Commercial,,62.94,,,,,,,35.69,206.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,United Healthcare,Commercial,,213.82,,,,,,,45.24,218.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,Commercial,,58.91,,,,,,,33.40,193.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,United Healthcare,Commercial,,213.82,,,,,,,45.24,218.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,Commercial,,58.91,,,,,,,33.40,193.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,United Healthcare,Commercial,,213.82,,,,,,,45.24,218.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,Commercial,,58.91,,,,,,,33.40,193.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00813,,,,,,,0.00172,0.00830,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,0.00224,,,,,,,0.00127,0.00736,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,3125.00000,1875.00000,United Healthcare,Commercial,,2540.62,,,,,,,537.50,2593.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,United Healthcare,Commercial,,700.00,,,,,,,396.88,2300.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1172.00000,703.20000,United Healthcare,Commercial,,952.84,,,,,,,750.08,952.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,United Healthcare,Commercial,,952.84,,,,,,,234.63,952.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1507.00000,904.20000,United Healthcare,Commercial,,1225.19,,,,,,,964.48,1225.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,United Healthcare,Commercial,,1225.19,,,,,,,301.70,1225.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1415.00000,849.00000,United Healthcare,Commercial,,1150.39,,,,,,,905.60,1150.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,United Healthcare,Commercial,,1150.39,,,,,,,283.28,1150.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,inpatient,,,1370.00000,822.00000,United Healthcare,Commercial,,1113.81,,,,,,,876.80,1113.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,United Healthcare,Commercial,,1113.81,,,,,,,274.27,1113.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,inpatient,,,182.00000,109.20000,United Healthcare,Commercial,,147.97,,,,,,,116.48,147.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Commercial,,147.97,,,,,,,36.44,147.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Commercial,,767.00,,,,,,,84.68,767.00,per diem,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Commercial,,759.00,,,,,,,95.58,759.00,per diem,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Commercial,,759.00,,,,,,,44.39,759.00,per diem,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,Commercial,,759.00,,,,,,,101.85,759.00,per diem,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Commercial,,759.00,,,,,,,44.39,759.00,per diem,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Commercial,,759.00,,,,,,,65.64,759.00,per diem,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Commercial,,759.00,,,,,,,16.02,759.00,per diem,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Commercial,,759.00,,,,,,,50.14,759.00,per diem,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Commercial,,759.00,,,,,,,76.08,759.00,per diem,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Commercial,,759.00,,,,,,,44.39,759.00,per diem,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,United Healthcare,Commercial,,759.00,,,,,,,40.74,759.00,per diem,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,Commercial,,759.00,,,,,,,113.51,759.00,per diem,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,inpatient,,,110.00000,66.00000,United Healthcare,Commercial,,89.43,,,,,,,18.92,91.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,24.64,,,,,,,13.97,80.98,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,Commercial,,4.18,,,,,,,3.90,24.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,United Healthcare,Commercial,,3466.00,,,,,,,319.11,3466.00,per diem,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,,3466.00,,,,,,,23.42,3466.00,per diem,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,,3466.00,,,,,,,23.42,3466.00,per diem,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,Commercial,,3466.00,,,,,,,48.05,3466.00,per diem,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,United Healthcare,Commercial,,3466.00,,,,,,,72.07,3466.00,per diem,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Commercial,,3466.00,,,,,,,92.69,3466.00,per diem,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,Commercial,,3466.00,,,,,,,68.47,3466.00,per diem,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,United Healthcare,Commercial,,3466.00,,,,,,,319.11,3466.00,per diem,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,Commercial,,3466.00,,,,,,,319.11,3466.00,per diem,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,United Healthcare,Commercial,,1067.00,,,,,,,292.29,1095.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,United Healthcare,Commercial,,1067.00,,,,,,,345.14,1293.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1573.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,2639.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,4681.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,5048.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,United Healthcare,Commercial,,1067.00,,,,,,,127.13,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,4764.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,5351.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,5351.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,Commercial,,1067.00,,,,,,,339.94,1273.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,2076.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,United Healthcare,Commercial,,1067.00,,,,,,,93.89,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1158.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,United Healthcare,Commercial,,1067.00,,,,,,,214.41,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1396.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,United Healthcare,Commercial,,1067.00,,,,,,,90.09,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,5619.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,5590.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1798.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1309.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,United Healthcare,Commercial,,3185.00,,,,,,,620.62,3185.00,per diem,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,United Healthcare,Commercial,,3185.00,,,,,,,1686.28,6317.25,per diem,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,Commercial,,1067.00,,,,,,,85.08,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,United Healthcare,Commercial,,1067.00,,,,,,,113.51,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,United Healthcare,Commercial,,1067.00,,,,,,,436.04,1633.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,United Healthcare,Commercial,,1067.00,,,,,,,418.82,1569.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,United Healthcare,Commercial,,1067.00,,,,,,,556.54,3476.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,United Healthcare,Commercial,,1067.00,,,,,,,492.09,1843.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,Commercial,,1067.00,,,,,,,600.40,2249.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Commercial,,1067.00,,,,,,,63.26,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,United Healthcare,Commercial,,1067.00,,,,,,,64.26,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,United Healthcare,Commercial,,3466.00,,,,,,,215.42,3466.00,per diem,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Commercial,,3466.00,,,,,,,68.47,3466.00,per diem,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,Commercial,,3466.00,,,,,,,120.72,3466.00,per diem,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Commercial,,3466.00,,,,,,,68.47,3466.00,per diem,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,United Healthcare,Commercial,,3466.00,,,,,,,307.71,3466.00,per diem,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Commercial,,3466.00,,,,,,,44.39,3466.00,per diem,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,Commercial,,3466.00,,,,,,,146.95,3466.00,per diem,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,Commercial,,767.00,,,,,,,91.49,767.00,per diem,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,United Healthcare,Commercial,,767.00,,,,,,,66.27,767.00,per diem,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Commercial,,3466.00,,,,,,,104.70,3466.00,per diem,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,5351.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,United Healthcare,Commercial,,1067.00,,,,,,,206.61,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,United Healthcare,Commercial,,1067.00,,,,,,,105.35,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,United Healthcare,Commercial,,1067.00,,,,,,,232.83,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,Commercial,,1067.00,,,,,,,210.41,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,United Healthcare,Commercial,,1067.00,,,,,,,253.01,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,United Healthcare,Commercial,76,1067.00,,,,,,,281.48,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,,1067.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,United Healthcare,Commercial,,1067.00,,,,,,,556.54,2811.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,United Healthcare,Commercial,76,1067.00,,,,,,,688.00,2811.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,United Healthcare,Commercial,,1067.00,,,,,,,556.54,2958.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,United Healthcare,Commercial,76,1067.00,,,,,,,688.00,2958.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1525.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1695.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1787.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1971.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1374.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1966.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Commercial,,1067.00,,,,,,,68.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Commercial,,1067.00,,,,,,,82.68,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Commercial,,1067.00,,,,,,,82.68,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Commercial,,3466.00,,,,,,,58.46,3466.00,per diem,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,United Healthcare,Commercial,,26864.00,,,,,,,568.97,26864.00,case rate,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,United Healthcare,Commercial,,26864.00,,,,,,,5465.26,26864.00,case rate,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,United Healthcare,Commercial,,1067.00,,,,,,,667.51,2814.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,Commercial,,1067.00,,,,,,,667.51,3237.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,Commercial,,1067.00,,,,,,,667.51,3237.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,United Healthcare,Commercial,,1067.00,,,,,,,129.73,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,United Healthcare,Commercial,,1067.00,,,,,,,141.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,United Healthcare,Commercial,,1067.00,,,,,,,245.25,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,United Healthcare,Commercial,,1067.00,,,,,,,172.17,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,United Healthcare,Commercial,,1067.00,,,,,,,182.98,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,United Healthcare,Commercial,,1067.00,,,,,,,187.79,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Commercial,,1067.00,,,,,,,128.33,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,,1067.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,76,1067.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,,1067.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,76,1067.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Commercial,,1067.00,,,,,,,68.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,United Healthcare,Commercial,,1067.00,,,,,,,130.13,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,United Healthcare,Commercial,,1067.00,,,,,,,72.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,,1067.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,76,1067.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Commercial,,3466.00,,,,,,,91.09,3466.00,per diem,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,United Healthcare,Commercial,76,1067.00,,,,,,,172.17,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,United Healthcare,Commercial,76,1067.00,,,,,,,182.98,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Commercial,,1067.00,,,,,,,99.90,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,United Healthcare,Commercial,,1067.00,,,,,,,326.13,1221.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1757.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,5185.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,United Healthcare,Commercial,,1067.00,,,,,,,688.00,4550.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1690.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,2127.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,1386.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Commercial,,1067.00,,,,,,,109.91,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,United Healthcare,Commercial,,1067.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Commercial,,1067.00,,,,,,,250.65,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,United Healthcare,Commercial,,1067.00,,,,,,,352.19,6123.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,United Healthcare,Commercial,,1067.00,,,,,,,482.48,1807.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,Commercial,,1067.00,,,,,,,81.08,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,United Healthcare,Commercial,,1067.00,,,,,,,112.11,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,United Healthcare,Commercial,,1067.00,,,,,,,332.73,1246.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,United Healthcare,Commercial,,1067.00,,,,,,,384.98,1442.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,United Healthcare,Commercial,,1067.00,,,,,,,255.05,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Commercial,,1067.00,,,,,,,63.26,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,United Healthcare,Commercial,,1067.00,,,,,,,130.13,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,United Healthcare,Commercial,,1067.00,,,,,,,436.04,1633.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Commercial,,3142.00,,,,,,,625.22,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,United Healthcare,Commercial,,767.00,,,,,,,61.11,767.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,United Healthcare,Commercial,,5754.00,,,,,,,211.01,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,inpatient,,,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,21.76,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,6.41,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,United Healthcare,Commercial,,832.00,,,,,,,93.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,inpatient,,,1028.00000,616.80000,United Healthcare,Commercial,,835.76,,,,,,,657.92,835.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,United Healthcare,Commercial,,835.76,,,,,,,186.78,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,inpatient,,,1212.00000,727.20000,United Healthcare,Commercial,,985.36,,,,,,,775.68,985.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,United Healthcare,Commercial,,985.36,,,,,,,186.78,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,United Healthcare,Commercial,,2912.00,,,,,,,64.46,5189.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,United Healthcare,Commercial,,832.00,,,,,,,151.55,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Commercial,,832.00,,,,,,,32.43,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,Commercial,,2907.00,,,,,,,203.70,4311.00,per diem,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,United Healthcare,Commercial,,467.00,,,,,,,59.86,467.00,per diem,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,United Healthcare,Commercial,,440.00,,,,,,,103.59,4311.00,per diem,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,440.00,,,,,,,10.97,440.00,per diem,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Commercial,,440.00,,,,,,,19.67,440.00,per diem,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,440.00,,,,,,,4.87,440.00,per diem,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,440.00,,,,,,,4.87,440.00,per diem,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Commercial,,440.00,,,,,,,52.58,440.00,per diem,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Commercial,,440.00,,,,,,,6.44,440.00,per diem,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Commercial,,440.00,,,,,,,6.44,440.00,per diem,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Commercial,,440.00,,,,,,,4.00,440.00,per diem,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,440.00,,,,,,,10.10,440.00,per diem,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,440.00,,,,,,,9.75,440.00,per diem,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Commercial,,440.00,,,,,,,18.98,440.00,per diem,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Commercial,,440.00,,,,,,,34.82,440.00,per diem,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Commercial,,440.00,,,,,,,28.03,440.00,per diem,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Commercial,,440.00,,,,,,,19.67,440.00,per diem,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Commercial,,440.00,,,,,,,23.16,440.00,per diem,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Commercial,,440.00,,,,,,,19.67,440.00,per diem,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,United Healthcare,Commercial,,440.00,,,,,,,76.26,440.00,per diem,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Commercial,,440.00,,,,,,,8.71,440.00,per diem,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Commercial,,440.00,,,,,,,71.90,440.00,per diem,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Commercial,,440.00,,,,,,,50.14,440.00,per diem,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,440.00,,,,,,,9.40,440.00,per diem,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Commercial,,440.00,,,,,,,6.44,440.00,per diem,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,United Healthcare,Commercial,,440.00,,,,,,,33.25,440.00,per diem,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Commercial,,440.00,,,,,,,35.88,440.00,per diem,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,United Healthcare,Commercial,GP,276.00,,,,,,,10.44,276.00,per diem,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Commercial,GP,276.00,,,,,,,11.69,276.00,per diem,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Commercial,GP,276.00,,,,,,,1.87,276.00,per diem,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,United Healthcare,Commercial,GP,276.00,,,,,,,18.85,276.00,per diem,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,GP,276.00,,,,,,,7.63,276.00,per diem,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,United Healthcare,Commercial,GP,276.00,,,,,,,2.49,276.00,per diem,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,United Healthcare,Commercial,GP,276.00,,,,,,,23.84,276.00,per diem,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Commercial,GP,276.00,,,,,,,25.40,276.00,per diem,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Commercial,GP,276.00,,,,,,,19.94,276.00,per diem,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,GP,276.00,,,,,,,17.14,276.00,per diem,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,GP,276.00,,,,,,,9.19,276.00,per diem,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Commercial,GP,276.00,,,,,,,25.55,276.00,per diem,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Commercial,GP,276.00,,,,,,,24.93,276.00,per diem,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,United Healthcare,Commercial,GP,276.00,,,,,,,22.44,276.00,per diem,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,GP,276.00,,,,,,,25.71,276.00,per diem,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Commercial,GP,276.00,,,,,,,21.66,276.00,per diem,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Commercial,GP,276.00,,,,,,,31.47,276.00,per diem,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,GP,276.00,,,,,,,18.23,276.00,per diem,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,GP,276.00,,,,,,,20.10,276.00,per diem,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,United Healthcare,Commercial,GP,276.00,,,,,,,23.53,276.00,per diem,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Commercial,GP,276.00,,,,,,,7.32,276.00,per diem,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,GP,276.00,,,,,,,18.38,276.00,per diem,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Commercial,GP,276.00,,,,,,,13.24,276.00,per diem,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,GP,276.00,,,,,,,20.10,276.00,per diem,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Commercial,GP,276.00,,,,,,,15.42,276.00,per diem,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Commercial,GP,276.00,,,,,,,28.04,4311.00,per diem,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Commercial,GP,276.00,,,,,,,28.04,4311.00,per diem,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,GP,276.00,,,,,,,14.18,276.00,per diem,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,GP,276.00,,,,,,,14.18,276.00,per diem,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,GP,276.00,,,,,,,13.87,276.00,per diem,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Commercial,GP,276.00,,,,,,,19.79,276.00,per diem,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Commercial,GP,276.00,,,,,,,20.25,276.00,per diem,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Commercial,GP,276.00,,,,,,,10.91,276.00,per diem,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Commercial,GP,276.00,,,,,,,4.67,276.00,per diem,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Commercial,GP,276.00,,,,,,,47.67,276.00,per diem,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Commercial,GP,276.00,,,,,,,65.90,276.00,per diem,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,United Healthcare,Commercial,GP,276.00,,,,,,,67.62,276.00,per diem,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Commercial,GP,276.00,,,,,,,44.87,276.00,per diem,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,GO,276.00,,,,,,,14.18,276.00,per diem,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,GO,276.00,,,,,,,18.23,276.00,per diem,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,GO,276.00,,,,,,,20.10,276.00,per diem,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,GO,276.00,,,,,,,18.38,276.00,per diem,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Commercial,GO,276.00,,,,,,,10.91,276.00,per diem,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,GO,276.00,,,,,,,20.10,276.00,per diem,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Commercial,GO,276.00,,,,,,,15.42,276.00,per diem,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Commercial,GO,276.00,,,,,,,1.87,276.00,per diem,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Commercial,GO,276.00,,,,,,,25.40,276.00,per diem,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Commercial,GO,276.00,,,,,,,19.94,276.00,per diem,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,GO,276.00,,,,,,,9.66,276.00,per diem,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Commercial,GO,276.00,,,,,,,25.55,276.00,per diem,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Commercial,GO,276.00,,,,,,,24.93,276.00,per diem,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,United Healthcare,Commercial,GO,276.00,,,,,,,22.44,276.00,per diem,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,GO,276.00,,,,,,,25.71,276.00,per diem,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,GO,276.00,,,,,,,7.63,276.00,per diem,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Commercial,GO,276.00,,,,,,,34.90,276.00,per diem,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Commercial,GO,276.00,,,,,,,23.68,276.00,per diem,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Commercial,GO,276.00,,,,,,,19.79,276.00,per diem,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Commercial,GO,276.00,,,,,,,11.69,276.00,per diem,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Commercial,GO,276.00,,,,,,,49.54,276.00,per diem,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,United Healthcare,Commercial,GO,276.00,,,,,,,62.79,276.00,per diem,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,United Healthcare,Commercial,GO,276.00,,,,,,,64.66,276.00,per diem,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Commercial,GO,276.00,,,,,,,31.47,276.00,per diem,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Commercial,GN,276.00,,,,,,,55.46,276.00,per diem,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,United Healthcare,Commercial,GN,276.00,,,,,,,52.35,276.00,per diem,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Commercial,GN,276.00,,,,,,,29.13,276.00,per diem,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Commercial,GN,276.00,,,,,,,41.91,276.00,per diem,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Commercial,GN,276.00,,,,,,,31.16,276.00,per diem,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Commercial,GN,276.00,,,,,,,49.08,276.00,per diem,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Commercial,GN,276.00,,,,,,,19.94,276.00,per diem,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Commercial,GN,276.00,,,,,,,10.91,276.00,per diem,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Commercial,GN,276.00,,,,,,,13.24,276.00,per diem,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Commercial,GN,276.00,,,,,,,15.42,276.00,per diem,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,Commercial,GN,276.00,,,,,,,35.68,276.00,per diem,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,GN,276.00,,,,,,,21.19,276.00,per diem,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,United Healthcare,Commercial,GN,276.00,,,,,,,102.05,399.55,per diem,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,United Healthcare,Commercial,GN,276.00,,,,,,,40.35,276.00,per diem,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Commercial,GN,276.00,,,,,,,10.59,276.00,per diem,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Commercial,GN,276.00,,,,,,,20.25,276.00,per diem,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Commercial,GN,276.00,,,,,,,10.91,276.00,per diem,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Commercial,GN,276.00,,,,,,,4.67,276.00,per diem,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,United Healthcare,Commercial,GN,276.00,,,,,,,33.34,276.00,per diem,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,Commercial,GN,276.00,,,,,,,35.68,276.00,per diem,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Commercial,GN,276.00,,,,,,,16.67,276.00,per diem,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,United Healthcare,Commercial,GN,276.00,,,,,,,55.00,276.00,per diem,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Commercial,GN,276.00,,,,,,,85.53,411.75,per diem,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,United Healthcare,Commercial,GN,276.00,,,,,,,92.08,443.25,per diem,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,Commercial,,374.00,,,,,,,150.42,648.00,per diem,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Commercial,,374.00,,,,,,,95.58,411.75,per diem,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,United Healthcare,Commercial,,374.00,,,,,,,154.08,663.75,per diem,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,Commercial,,374.00,,,,,,,87.75,557.85,per diem,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,United Healthcare,Commercial,,374.00,,,,,,,129.70,558.75,per diem,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,United Healthcare,Commercial,,374.00,,,,,,,243.00,2817.00,per diem,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Commercial,,374.00,,,,,,,7.49,374.00,per diem,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,Commercial,,374.00,,,,,,,25.77,374.00,per diem,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,United Healthcare,Commercial,,374.00,,,,,,,91.40,393.75,per diem,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Commercial,,374.00,,,,,,,91.05,392.25,per diem,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,United Healthcare,Commercial,,374.00,,,,,,,98.02,422.25,per diem,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Commercial,,374.00,,,,,,,65.64,374.00,per diem,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Commercial,,374.00,,,,,,,65.64,374.00,per diem,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,Commercial,,374.00,,,,,,,236.25,1017.75,per diem,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,United Healthcare,Commercial,,374.00,,,,,,,72.77,374.00,per diem,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,Commercial,,374.00,,,,,,,141.37,609.00,per diem,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Commercial,,374.00,,,,,,,18.63,374.00,per diem,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,United Healthcare,Commercial,,374.00,,,,,,,98.71,425.25,per diem,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,United Healthcare,Commercial,,374.00,,,,,,,82.87,374.00,per diem,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,Commercial,,374.00,,,,,,,113.51,489.00,per diem,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Commercial,,374.00,,,,,,,79.74,374.00,per diem,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Commercial,,374.00,,,,,,,27.16,374.00,per diem,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Commercial,,192.00,,,,,,,31.34,327.39,per diem,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,Commercial,,2907.00,,,,,,,203.70,4311.00,per diem,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,United Healthcare,Commercial,,192.00,,,,,,,22.81,192.00,per diem,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,Commercial,,192.00,,,,,,,124.00,1156.50,per diem,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,Commercial,,192.00,,,,,,,124.00,1156.50,per diem,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Commercial,,192.00,,,,,,,45.96,198.00,per diem,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Commercial,,192.00,,,,,,,45.96,327.39,per diem,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,inpatient,,,2000.00000,1200.00000,United Healthcare,Commercial,,1626.00,,,,,,,1280.00,1626.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,United Healthcare,Commercial,,1626.00,,,,,,,186.78,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Commercial,,767.00,,,,,,,494.00,4376.00,per diem,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,inpatient,,,700.00000,420.00000,United Healthcare,Commercial,,569.10,,,,,,,448.00,569.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,United Healthcare,Commercial,,569.10,,,,,,,121.87,735.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,United Healthcare,Commercial,,3641.00,,,,,,,303.99,12247.00,per diem,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,inpatient,,,831.00000,498.60000,United Healthcare,Commercial,,675.60,,,,,,,531.84,675.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Commercial,,675.60,,,,,,,144.68,675.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,United Healthcare,Commercial,,528.00,,,,,,,87.92,557.85,per diem,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,United Healthcare,Commercial,,528.00,,,,,,,38.65,528.00,per diem,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,United Healthcare,Commercial,,528.00,,,,,,,57.98,528.00,per diem,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,United Healthcare,Commercial,,528.00,,,,,,,58.85,528.00,per diem,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,Commercial,,767.00,,,,,,,32.21,767.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,Commercial,,954.00,,,,,,,510.48,4532.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,Commercial,,954.00,,,,,,,510.48,4532.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,United Healthcare,Commercial,,954.00,,,,,,,150.52,1990.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,Commercial,,954.00,,,,,,,840.84,3150.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,Commercial,,954.00,,,,,,,840.84,3150.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,United Healthcare,Commercial,,954.00,,,,,,,854.05,3199.50,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,United Healthcare,Commercial,,269.00,,,,,,,175.00,865.50,per diem,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,United Healthcare,Commercial,,954.00,,,,,,,110.51,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,United Healthcare,Commercial,,269.00,,,,,,,98.37,423.75,per diem,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,United Healthcare,Commercial,,269.00,,,,,,,175.00,1012.50,per diem,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,Commercial,,954.00,,,,,,,192.79,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Commercial,,269.00,,,,,,,95.75,412.50,per diem,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,Commercial,,954.00,,,,,,,192.79,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,Commercial,,269.00,,,,,,,150.52,788.25,per diem,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,United Healthcare,Commercial,,954.00,,,,,,,90.69,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Commercial,,269.00,,,,,,,175.00,953.25,per diem,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,United Healthcare,Commercial,,954.00,,,,,,,232.03,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Commercial,,269.00,,,,,,,102.31,546.00,per diem,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Commercial,,954.00,,,,,,,96.30,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,United Healthcare,Commercial,,269.00,,,,,,,175.00,844.50,per diem,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Commercial,,954.00,,,,,,,63.26,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Commercial,,269.00,,,,,,,102.31,568.50,per diem,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Commercial,,954.00,,,,,,,24.82,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,United Healthcare,Commercial,,269.00,,,,,,,102.31,718.50,per diem,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Commercial,,269.00,,,,,,,99.41,428.25,per diem,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,United Healthcare,Commercial,,269.00,,,,,,,80.78,348.00,per diem,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Commercial,,269.00,,,,,,,93.70,404.25,per diem,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,United Healthcare,Commercial,,269.00,,,,,,,87.57,377.25,per diem,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,Commercial,,767.00,,,,,,,273.69,1990.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,Commercial,,954.00,,,,,,,81.08,1069.64,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,Commercial,,767.00,,,,,,,273.69,1990.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,Commercial,,954.00,,,,,,,81.08,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Commercial,,954.00,,,,,,,74.67,1990.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,United Healthcare,Commercial,,1831.00,,,,,,,117.34,1831.00,per diem,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,Commercial,,1831.00,,,,,,,124.01,1831.00,per diem,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,United Healthcare,Commercial,,1831.00,,,,,,,148.86,1831.00,per diem,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,United Healthcare,Commercial,,1831.00,,,,,,,150.52,1831.00,per diem,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Commercial,,1831.00,,,,,,,93.84,1831.00,per diem,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,Commercial,,1831.00,,,,,,,74.69,1831.00,per diem,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Commercial,,1831.00,,,,,,,51.36,1831.00,per diem,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Commercial,,1831.00,,,,,,,76.08,1831.00,per diem,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Commercial,,1831.00,,,,,,,44.05,1831.00,per diem,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,United Healthcare,Commercial,,1831.00,,,,,,,106.90,1831.00,per diem,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,United Healthcare,Commercial,,1831.00,,,,,,,106.90,1831.00,per diem,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,United Healthcare,Commercial,,1831.00,,,,,,,95.23,1831.00,per diem,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Commercial,,1831.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Commercial,,1831.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Commercial,,1831.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Commercial,,1831.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1831.00,,,,,,,69.64,1831.00,per diem,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1831.00,,,,,,,69.64,1831.00,per diem,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Commercial,,1831.00,,,,,,,69.64,1831.00,per diem,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Commercial,,1831.00,,,,,,,46.48,1831.00,per diem,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,Commercial,,1831.00,,,,,,,63.72,1831.00,per diem,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,Commercial,,1831.00,,,,,,,63.72,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,Commercial,,1831.00,,,,,,,284.65,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,Commercial,,1831.00,,,,,,,284.65,1831.00,per diem,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,Commercial,,1831.00,,,,,,,79.56,1831.00,per diem,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Commercial,,1831.00,,,,,,,79.22,1831.00,per diem,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,United Healthcare,Commercial,,1831.00,,,,,,,259.58,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,United Healthcare,Commercial,,1831.00,,,,,,,265.68,1831.00,per diem,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,United Healthcare,Commercial,,1831.00,,,,,,,147.64,1831.00,per diem,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,United Healthcare,Commercial,,1831.00,,,,,,,214.67,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Commercial,,1831.00,,,,,,,73.64,1831.00,per diem,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,United Healthcare,Commercial,,954.00,,,,,,,199.60,1990.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Commercial,,467.00,,,,,,,92.69,467.00,per diem,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,United Healthcare,Commercial,,954.00,,,,,,,108.91,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,United Healthcare,Commercial,,954.00,,,,,,,263.26,986.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,United Healthcare,Commercial,,954.00,,,,,,,299.59,1191.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Commercial,,954.00,,,,,,,299.59,1462.50,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,United Healthcare,Commercial,,954.00,,,,,,,510.48,2075.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,United Healthcare,Commercial,,954.00,,,,,,,510.48,2279.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,United Healthcare,Commercial,,954.00,,,,,,,510.48,2892.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,Commercial,,954.00,,,,,,,299.59,1701.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,United Healthcare,Commercial,,954.00,,,,,,,299.59,1905.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,United Healthcare,Commercial,,954.00,,,,,,,510.48,2143.50,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,United Healthcare,Commercial,,954.00,,,,,,,510.48,3402.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,United Healthcare,Commercial,,954.00,,,,,,,510.48,3810.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,United Healthcare,Commercial,,954.00,,,,,,,615.00,4252.50,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,Commercial,,954.00,,,,,,,208.61,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,767.00,,,,,,,37.64,767.00,per diem,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,767.00,,,,,,,37.64,767.00,per diem,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,1090.00,,,,,,,10.97,1090.00,per diem,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Commercial,,767.00,,,,,,,44.39,4311.00,per diem,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Commercial,,1090.00,,,,,,,50.84,1090.00,per diem,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Commercial,,1090.00,,,,,,,51.19,1090.00,per diem,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Commercial,,42.00,,,,,,,8.36,42.00,per diem,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Commercial,,42.00,,,,,,,8.36,42.00,per diem,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,42.00,,,,,,,20.54,88.50,per diem,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,42.00,,,,,,,20.54,88.50,per diem,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,42.00,,,,,,,20.54,88.50,per diem,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,42.00,,,,,,,20.54,88.50,per diem,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Commercial,,42.00,,,,,,,18.45,79.50,per diem,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,42.00,,,,,,,20.54,88.50,per diem,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Commercial,,759.00,,,,,,,134.93,759.00,per diem,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Commercial,,759.00,,,,,,,134.93,759.00,per diem,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Commercial,,759.00,,,,,,,134.93,759.00,per diem,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Commercial,,759.00,,,,,,,134.93,759.00,per diem,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Commercial,,42.00,,,,,,,26.00,581.25,per diem,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Commercial,,42.00,,,,,,,26.00,581.25,per diem,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Commercial,,42.00,,,,,,,13.06,56.25,per diem,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,United Healthcare,Commercial,GP,276.00,,,,,,,10.39,4311.00,per diem,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,inpatient,,,479.00000,287.40000,United Healthcare,Commercial,,389.43,,,,,,,306.56,389.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,United Healthcare,Commercial,,389.43,,,,,,,90.29,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,Commercial,,3142.00,,,,,,,549.35,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,inpatient,,,2744.00000,1646.40000,United Healthcare,Commercial,,2230.87,,,,,,,1756.16,2230.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,Commercial,,2230.87,,,,,,,517.24,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,inpatient,,,3875.00000,2325.00000,United Healthcare,Commercial,,3150.38,,,,,,,2480.00,3150.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,Commercial,,3150.38,,,,,,,730.44,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,inpatient,,,1085.00000,651.00000,United Healthcare,Commercial,,882.11,,,,,,,694.40,882.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,Commercial,,882.11,,,,,,,204.52,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,inpatient,,,2464.00000,1478.40000,United Healthcare,Commercial,,2003.23,,,,,,,1576.96,2003.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,United Healthcare,Commercial,,2003.23,,,,,,,464.46,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,inpatient,,,1039.00000,623.40000,United Healthcare,Commercial,,844.71,,,,,,,664.96,844.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,United Healthcare,Commercial,,844.71,,,,,,,195.85,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,inpatient,,,1039.00000,623.40000,United Healthcare,Commercial,,844.71,,,,,,,664.96,844.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,United Healthcare,Commercial,,844.71,,,,,,,195.85,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,inpatient,,,3190.00000,1914.00000,United Healthcare,Commercial,,2593.47,,,,,,,2041.60,2593.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,United Healthcare,Commercial,,2593.47,,,,,,,601.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,inpatient,,,430.00000,258.00000,United Healthcare,Commercial,,349.59,,,,,,,275.20,349.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,United Healthcare,Commercial,,349.59,,,,,,,81.06,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,inpatient,,,480.00000,288.00000,United Healthcare,Commercial,,390.24,,,,,,,307.20,390.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,Commercial,,390.24,,,,,,,90.48,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,inpatient,,,536.00000,321.60000,United Healthcare,Commercial,,435.77,,,,,,,343.04,435.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,Commercial,,435.77,,,,,,,101.04,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,inpatient,,,458.00000,274.80000,United Healthcare,Commercial,,372.35,,,,,,,293.12,372.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Commercial,,372.35,,,,,,,86.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,inpatient,,,119.00000,71.40000,United Healthcare,Commercial,,96.75,,,,,,,76.16,96.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,Commercial,,96.75,,,,,,,22.43,96.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,inpatient,,,129.00000,77.40000,United Healthcare,Commercial,,104.88,,,,,,,82.56,104.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,,104.88,,,,,,,24.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,inpatient,,,129.00000,77.40000,United Healthcare,Commercial,,104.88,,,,,,,82.56,104.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,,104.88,,,,,,,24.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,inpatient,,,208.00000,124.80000,United Healthcare,Commercial,,169.10,,,,,,,133.12,169.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,Commercial,,169.10,,,,,,,39.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,inpatient,,,163.00000,97.80000,United Healthcare,Commercial,,132.52,,,,,,,104.32,132.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Commercial,,132.52,,,,,,,30.73,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,inpatient,,,307.00000,184.20000,United Healthcare,Commercial,,249.59,,,,,,,196.48,249.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,United Healthcare,Commercial,,249.59,,,,,,,57.87,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,inpatient,,,520.00000,312.00000,United Healthcare,Commercial,,422.76,,,,,,,332.80,422.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,United Healthcare,Commercial,,422.76,,,,,,,98.02,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,inpatient,,,504.00000,302.40000,United Healthcare,Commercial,,409.75,,,,,,,322.56,409.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,Commercial,,409.75,,,,,,,95.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,inpatient,,,618.00000,370.80000,United Healthcare,Commercial,,502.43,,,,,,,395.52,502.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,United Healthcare,Commercial,,502.43,,,,,,,116.49,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,inpatient,,,409.00000,245.40000,United Healthcare,Commercial,,332.52,,,,,,,261.76,332.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,United Healthcare,Commercial,,332.52,,,,,,,77.10,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Commercial,,832.00,,,,,,,154.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,inpatient,,,770.00000,462.00000,United Healthcare,Commercial,,626.01,,,,,,,492.80,626.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Commercial,,626.01,,,,,,,145.15,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,United Healthcare,Commercial,,832.00,,,,,,,127.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,inpatient,,,603.00000,361.80000,United Healthcare,Commercial,,490.24,,,,,,,385.92,490.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,Commercial,,490.24,,,,,,,113.67,490.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,inpatient,,,902.00000,541.20000,United Healthcare,Commercial,,733.33,,,,,,,577.28,733.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,Commercial,,733.33,,,,,,,170.03,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Commercial,,832.00,,,,,,,36.44,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Commercial,,832.00,,,,,,,30.43,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Commercial,,832.00,,,,,,,56.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,inpatient,,,388.00000,232.80000,United Healthcare,Commercial,,315.44,,,,,,,248.32,315.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,Commercial,,315.44,,,,,,,73.14,315.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Commercial,,832.00,,,,,,,151.95,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,inpatient,,,759.00000,455.40000,United Healthcare,Commercial,,617.07,,,,,,,485.76,617.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Commercial,,617.07,,,,,,,143.07,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,United Healthcare,Commercial,,3142.00,,,,,,,459.46,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,inpatient,,,607.00000,364.20000,United Healthcare,Commercial,,493.49,,,,,,,388.48,493.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,United Healthcare,Commercial,,493.49,,,,,,,114.42,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,Commercial,,2912.00,,,,,,,372.97,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,inpatient,,,1863.00000,1117.80000,United Healthcare,Commercial,,1514.62,,,,,,,1192.32,1514.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,Commercial,,1514.62,,,,,,,351.18,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,inpatient,,,536.00000,321.60000,United Healthcare,Commercial,,435.77,,,,,,,343.04,435.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,Commercial,,435.77,,,,,,,101.04,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,inpatient,,,1037.00000,622.20000,United Healthcare,Commercial,,843.08,,,,,,,663.68,843.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Commercial,,843.08,,,,,,,195.47,843.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,inpatient,,,12507.00000,7504.20000,United Healthcare,Commercial,,10168.19,,,,,,,8004.48,10168.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,United Healthcare,Commercial,,10168.19,,,,,,,2357.57,10168.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1520.00000,912.00000,United Healthcare,Commercial,,1235.76,,,,,,,972.80,1235.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,United Healthcare,Commercial,,1235.76,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,inpatient,,,1933.00000,1159.80000,United Healthcare,Commercial,,1571.53,,,,,,,1237.12,1571.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,United Healthcare,Commercial,,1571.53,,,,,,,364.37,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,inpatient,,,834.00000,500.40000,United Healthcare,Commercial,,678.04,,,,,,,533.76,678.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,United Healthcare,Commercial,,678.04,,,,,,,157.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,inpatient,,,869.00000,521.40000,United Healthcare,Commercial,,706.50,,,,,,,556.16,706.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,United Healthcare,Commercial,,706.50,,,,,,,163.81,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,inpatient,,,925.00000,555.00000,United Healthcare,Commercial,,752.02,,,,,,,592.00,752.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,United Healthcare,Commercial,,752.02,,,,,,,174.36,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,inpatient,,,1538.00000,922.80000,United Healthcare,Commercial,,1250.39,,,,,,,984.32,1250.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,United Healthcare,Commercial,,1250.39,,,,,,,289.91,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,inpatient,,,1918.00000,1150.80000,United Healthcare,Commercial,,1559.33,,,,,,,1227.52,1559.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Commercial,,1559.33,,,,,,,361.54,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,inpatient,,,9774.00000,5864.40000,United Healthcare,Commercial,,7946.26,,,,,,,6255.36,7946.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,United Healthcare,Commercial,,7946.26,,,,,,,1842.40,7946.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Commercial,,832.00,,,,,,,132.13,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,inpatient,,,660.00000,396.00000,United Healthcare,Commercial,,536.58,,,,,,,422.40,536.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Commercial,,536.58,,,,,,,124.41,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Commercial,,5754.00,,,,,,,638.44,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,inpatient,,,3189.00000,1913.40000,United Healthcare,Commercial,,2592.66,,,,,,,2040.96,2592.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Commercial,,2592.66,,,,,,,601.13,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,inpatient,,,1528.00000,916.80000,United Healthcare,Commercial,,1242.26,,,,,,,977.92,1242.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,Commercial,,1242.26,,,,,,,288.03,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,inpatient,,,1727.00000,1036.20000,United Healthcare,Commercial,,1404.05,,,,,,,1105.28,1404.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,United Healthcare,Commercial,,1404.05,,,,,,,325.54,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,Commercial,,2912.00,,,,,,,428.83,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,inpatient,,,2142.00000,1285.20000,United Healthcare,Commercial,,1741.45,,,,,,,1370.88,1741.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,Commercial,,1741.45,,,,,,,403.77,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1397.00000,838.20000,United Healthcare,Commercial,,1135.76,,,,,,,894.08,1135.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,Commercial,,1135.76,,,,,,,263.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,Commercial,,832.00,,,,,,,124.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,inpatient,,,621.00000,372.60000,United Healthcare,Commercial,,504.87,,,,,,,397.44,504.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,Commercial,,504.87,,,,,,,117.06,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,United Healthcare,Commercial,,832.00,,,,,,,144.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,inpatient,,,720.00000,432.00000,United Healthcare,Commercial,,585.36,,,,,,,460.80,585.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,United Healthcare,Commercial,,585.36,,,,,,,135.72,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,inpatient,,,61.00000,36.60000,United Healthcare,Commercial,,49.59,,,,,,,39.04,49.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,49.59,,,,,,,11.50,208.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Commercial,,2912.00,,,,,,,74.67,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,inpatient,,,2240.00000,1344.00000,United Healthcare,Commercial,,1821.12,,,,,,,1433.60,1821.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,Commercial,,1821.12,,,,,,,422.24,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,inpatient,,,132.00000,79.20000,United Healthcare,Commercial,JW,107.32,,,,,,,84.48,107.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Commercial,JW,107.32,,,,,,,26.43,107.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,inpatient,,,586.00000,351.60000,United Healthcare,Commercial,,476.42,,,,,,,375.04,476.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,Commercial,,476.42,,,,,,,110.46,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Commercial,,2912.00,,,,,,,99.90,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,United Healthcare,Commercial,,832.00,,,,,,,120.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,inpatient,,,499.00000,299.40000,United Healthcare,Commercial,,405.69,,,,,,,319.36,405.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Commercial,,405.69,,,,,,,94.06,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,Commercial,,2912.00,,,,,,,117.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,inpatient,,,822.00000,493.20000,United Healthcare,Commercial,,668.29,,,,,,,526.08,668.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,Commercial,,668.29,,,,,,,154.95,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,inpatient,,,1364.00000,818.40000,United Healthcare,Commercial,,1108.93,,,,,,,872.96,1108.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,United Healthcare,Commercial,,1108.93,,,,,,,257.11,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,inpatient,,,352.00000,211.20000,United Healthcare,Commercial,,286.18,,,,,,,225.28,286.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,Commercial,,286.18,,,,,,,66.35,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,inpatient,,,3941.00000,2364.60000,United Healthcare,Commercial,,3204.03,,,,,,,2522.24,3204.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Commercial,,3204.03,,,,,,,666.26,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Commercial,,2912.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,inpatient,,,3941.00000,2364.60000,United Healthcare,Commercial,,3204.03,,,,,,,2522.24,3204.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Commercial,,3204.03,,,,,,,666.26,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Commercial,,2912.00,,,,,,,390.39,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,inpatient,,,1950.00000,1170.00000,United Healthcare,Commercial,,1585.35,,,,,,,1248.00,1585.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Commercial,,1585.35,,,,,,,367.57,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,Commercial,,2912.00,,,,,,,621.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,inpatient,,,3103.00000,1861.80000,United Healthcare,Commercial,,2522.74,,,,,,,1985.92,2522.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,Commercial,,2522.74,,,,,,,584.92,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,inpatient,,,1723.00000,1033.80000,United Healthcare,Commercial,,1400.80,,,,,,,1102.72,1400.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,United Healthcare,Commercial,,1400.80,,,,,,,324.79,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,inpatient,,,2132.00000,1279.20000,United Healthcare,Commercial,,1733.32,,,,,,,1364.48,1733.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,United Healthcare,Commercial,,1733.32,,,,,,,401.88,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,inpatient,,,2800.00000,1680.00000,United Healthcare,Commercial,,2276.40,,,,,,,1792.00,2276.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,United Healthcare,Commercial,,2276.40,,,,,,,527.80,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,United Healthcare,Commercial,,832.00,,,,,,,108.71,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,United Healthcare,Commercial,,2912.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Commercial,,832.00,,,,,,,160.96,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,inpatient,,,1565.00000,939.00000,United Healthcare,Commercial,,1272.35,,,,,,,1001.60,1272.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,United Healthcare,Commercial,,1272.35,,,,,,,295.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,inpatient,,,1565.00000,939.00000,United Healthcare,Commercial,,1272.35,,,,,,,1001.60,1272.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,United Healthcare,Commercial,,1272.35,,,,,,,295.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,inpatient,,,1921.00000,1152.60000,United Healthcare,Commercial,,1561.77,,,,,,,1229.44,1561.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,United Healthcare,Commercial,,1561.77,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,inpatient,,,1701.00000,1020.60000,United Healthcare,Commercial,,1382.91,,,,,,,1088.64,1382.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,United Healthcare,Commercial,,1382.91,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,inpatient,,,582.00000,349.20000,United Healthcare,Commercial,,473.17,,,,,,,372.48,473.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Commercial,,473.17,,,,,,,109.71,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,inpatient,,,2268.00000,1360.80000,United Healthcare,Commercial,,1843.88,,,,,,,1451.52,1843.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,Commercial,,1843.88,,,,,,,427.52,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,inpatient,,,1265.00000,759.00000,United Healthcare,Commercial,,1028.44,,,,,,,809.60,1028.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,United Healthcare,Commercial,,1028.44,,,,,,,238.45,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Commercial,,2912.00,,,,,,,467.07,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,inpatient,,,2333.00000,1399.80000,United Healthcare,Commercial,,1896.73,,,,,,,1493.12,1896.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Commercial,,1896.73,,,,,,,439.77,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,inpatient,,,2047.00000,1228.20000,United Healthcare,Commercial,,1664.21,,,,,,,1310.08,1664.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,United Healthcare,Commercial,,1664.21,,,,,,,385.86,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,inpatient,,,1335.00000,801.00000,United Healthcare,Commercial,,1085.36,,,,,,,854.40,1085.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,United Healthcare,Commercial,,1085.36,,,,,,,251.65,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,inpatient,,,847.00000,508.20000,United Healthcare,Commercial,,688.61,,,,,,,542.08,688.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,Commercial,,688.61,,,,,,,159.66,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,Commercial,,2912.00,,,,,,,356.56,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,inpatient,,,1781.00000,1068.60000,United Healthcare,Commercial,,1447.95,,,,,,,1139.84,1447.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,Commercial,,1447.95,,,,,,,335.72,1447.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,inpatient,,,1698.00000,1018.80000,United Healthcare,Commercial,,1380.47,,,,,,,1086.72,1380.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,Commercial,,1380.47,,,,,,,320.07,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,inpatient,,,1381.00000,828.60000,United Healthcare,Commercial,,1122.75,,,,,,,883.84,1122.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,Commercial,,1122.75,,,,,,,260.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,inpatient,,,1381.00000,828.60000,United Healthcare,Commercial,,1122.75,,,,,,,883.84,1122.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,Commercial,,1122.75,,,,,,,260.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,inpatient,,,1794.00000,1076.40000,United Healthcare,Commercial,,1458.52,,,,,,,1148.16,1458.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Commercial,,1458.52,,,,,,,338.17,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Commercial,,5754.00,,,,,,,359.16,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,inpatient,,,4119.00000,2471.40000,United Healthcare,Commercial,,3348.75,,,,,,,2636.16,3348.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,Commercial,,3348.75,,,,,,,776.43,8442.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,Commercial,,5754.00,,,,,,,824.62,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,Commercial,,3142.00,,,,,,,695.70,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,Commercial,,3142.00,,,,,,,695.70,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Commercial,,832.00,,,,,,,102.50,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,United Healthcare,Commercial,,832.00,,,,,,,118.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,United Healthcare,Commercial,52,5754.00,,,,,,,220.22,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Commercial,,832.00,,,,,,,151.95,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,United Healthcare,Commercial,,1912.00,,,,,,,123.79,1912.00,per diem,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,United Healthcare,Commercial,,1912.00,,,,,,,254.36,1912.00,per diem,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Commercial,,767.00,,,,,,,22.11,767.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,inpatient,,,919.00000,551.40000,United Healthcare,Commercial,,747.15,,,,,,,588.16,747.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Commercial,,747.15,,,,,,,173.23,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Commercial,,365.00,,,,,,,59.12,365.00,case rate,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,United Healthcare,Commercial,,624.00,,,,,,,129.99,624.00,case rate,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,United Healthcare,Commercial,,1295.00,,,,,,,259.79,1295.00,case rate,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,United Healthcare,Commercial,,1773.00,,,,,,,409.68,3235.00,case rate,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,United Healthcare,Commercial,,1958.00,,,,,,,589.86,3709.00,case rate,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,United Healthcare,Commercial,,2247.00,,,,,,,748.05,5152.00,case rate,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,United Healthcare,Commercial,,3641.00,,,,,,,161.50,3641.00,per diem,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,inpatient,,,361.00000,216.60000,United Healthcare,Commercial,,293.49,,,,,,,231.04,293.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,United Healthcare,Commercial,,293.49,,,,,,,72.27,293.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,inpatient,,,296.00000,177.60000,United Healthcare,Commercial,,240.65,,,,,,,189.44,240.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,Commercial,,240.65,,,,,,,59.26,240.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,inpatient,,,189.00000,113.40000,United Healthcare,Commercial,,153.66,,,,,,,120.96,153.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Commercial,,153.66,,,,,,,37.84,153.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Commercial,,3641.00,,,,,,,20.87,3641.00,per diem,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Commercial,,3641.00,,,,,,,20.87,3641.00,per diem,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Commercial,,968.00,,,,,,,266.00,2052.00,per diem,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Commercial,,105.00,,,,,,,34.99,134.00,per diem,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,105.00,,,,,,,32.73,134.00,per diem,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,United Healthcare,Commercial,,105.00,,,,,,,43.35,151.89,per diem,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,Commercial,,105.00,,,,,,,41.78,146.40,per diem,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Commercial,,105.00,,,,,,,55.19,193.37,per diem,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Commercial,,105.00,,,,,,,69.47,243.39,per diem,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Commercial,,105.00,,,,,,,64.59,226.31,per diem,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Commercial,,105.00,,,,,,,82.70,289.75,per diem,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,Commercial,,105.00,,,,,,,31.51,134.00,per diem,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Commercial,,105.00,,,,,,,12.54,134.00,per diem,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,United Healthcare,Commercial,,105.00,,,,,,,39.52,138.47,per diem,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Commercial,,105.00,,,,,,,17.41,134.00,per diem,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Commercial,,105.00,,,,,,,46.48,162.87,per diem,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,United Healthcare,Commercial,,105.00,,,,,,,43.52,152.50,per diem,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,United Healthcare,Commercial,,105.00,,,,,,,70.68,247.66,per diem,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,United Healthcare,Commercial,,105.00,,,,,,,75.73,265.35,per diem,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Commercial,,105.00,,,,,,,76.08,266.57,per diem,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,United Healthcare,Commercial,,105.00,,,,,,,69.12,242.17,per diem,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,Commercial,,105.00,,,,,,,31.51,134.00,per diem,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,United Healthcare,Commercial,,105.00,,,,,,,44.22,154.94,per diem,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,Commercial,,105.00,,,,,,,67.55,236.68,per diem,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,United Healthcare,Commercial,,105.00,,,,,,,85.13,298.29,per diem,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Commercial,,105.00,,,,,,,11.49,134.00,per diem,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Commercial,,105.00,,,,,,,18.45,134.00,per diem,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,United Healthcare,Commercial,,105.00,,,,,,,30.64,134.00,per diem,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,United Healthcare,Commercial,,105.00,,,,,,,45.27,158.60,per diem,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Commercial,,105.00,,,,,,,59.72,209.23,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,Commercial,,105.00,,,,,,,40.22,140.91,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Commercial,,105.00,,,,,,,55.19,193.37,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Commercial,,105.00,,,,,,,82.70,289.75,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,United Healthcare,Commercial,,105.00,,,,,,,100.28,351.36,per diem,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,105.00,,,,,,,8.53,134.00,per diem,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Commercial,,105.00,,,,,,,16.19,134.00,per diem,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,United Healthcare,Commercial,,105.00,,,,,,,23.85,134.00,per diem,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Commercial,,105.00,,,,,,,19.50,134.00,per diem,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Commercial,,105.00,,,,,,,8.36,134.00,per diem,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,inpatient,,,130.00000,78.00000,United Healthcare,Commercial,,105.69,,,,,,,39.13,105.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Commercial,,82.50,,,,,,,26.03,96.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,25.00000,15.00000,United Healthcare,Commercial,,20.32,,,,,,,7.53,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,United Healthcare,Commercial,,31.86,,,,,,,5.00,31.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Commercial,,77.23,,,,,,,28.59,77.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,138.68,,,,,,,19.02,138.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,54.00000,32.40000,United Healthcare,Commercial,,43.90,,,,,,,16.25,43.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,6.96,,,,,,,5.99,40.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Commercial,JW,100.00,,,,,,,78.72,100.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Commercial,JW,100.00,,,,,,,24.62,124.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Commercial,,100.00,,,,,,,37.02,100.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Commercial,,132.99,,,,,,,24.62,132.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Commercial,JW,77.23,,,,,,,60.80,77.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,JW,77.23,,,,,,,19.02,106.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,inpatient,,,142.00000,85.20000,United Healthcare,Commercial,,115.45,,,,,,,42.74,115.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,United Healthcare,Commercial,,371.55,,,,,,,28.43,371.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,inpatient,,,275.00000,165.00000,United Healthcare,Commercial,,223.57,,,,,,,47.30,228.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Commercial,,61.60,,,,,,,34.92,202.46,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,United Healthcare,Commercial,,162.60,,,,,,,60.20,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Commercial,,186.47,,,,,,,40.04,186.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,United Healthcare,Commercial,JW,162.60,,,,,,,128.00,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Commercial,JW,162.60,,,,,,,40.04,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,United Healthcare,Commercial,,369.92,,,,,,,136.96,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Commercial,,6.75,,,,,,,5.88,337.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,United Healthcare,Commercial,,740.64,,,,,,,274.21,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Commercial,,6.75,,,,,,,5.88,676.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,United Healthcare,Commercial,JW,740.64,,,,,,,583.04,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Commercial,JW,740.64,,,,,,,5.88,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,United Healthcare,Commercial,JW,369.92,,,,,,,291.20,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Commercial,JW,369.92,,,,,,,5.88,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Commercial,,803.24,,,,,,,297.39,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Commercial,,268.27,,,,,,,197.80,733.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,188.43,508.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,268.27,,,,,,,125.33,464.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Commercial,,221.95,,,,,,,82.17,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Commercial,,268.27,,,,,,,54.65,268.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Commercial,JW,803.24,,,,,,,632.32,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Commercial,JW,803.24,,,,,,,197.80,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Commercial,JW,221.95,,,,,,,174.72,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Commercial,JW,221.95,,,,,,,54.65,238.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,United Healthcare,Commercial,,464.22,,,,,,,171.87,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Commercial,,178.08,,,,,,,114.31,423.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,United Healthcare,Commercial,,213.01,,,,,,,78.86,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Commercial,,178.08,,,,,,,52.45,194.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,,2239.00,,,,,,,828.95,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,,274.21,,,,,,,240.06,2044.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,United Healthcare,Commercial,,988.61,,,,,,,366.02,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,Commercial,,274.21,,,,,,,240.06,902.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,United Healthcare,Commercial,,500.81,,,,,,,185.42,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Commercial,,274.21,,,,,,,123.32,457.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,JW,2239.00,,,,,,,1762.56,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,Commercial,JW,2239.00,,,,,,,240.06,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,United Healthcare,Commercial,JW,988.61,,,,,,,778.24,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,Commercial,JW,988.61,,,,,,,240.06,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,United Healthcare,Commercial,JW,500.81,,,,,,,394.24,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Commercial,JW,500.81,,,,,,,123.32,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,2813.00000,1687.80000,United Healthcare,Commercial,,2286.97,,,,,,,846.71,2286.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,Commercial,,268.27,,,,,,,238.43,2087.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Commercial,,100.00,,,,,,,37.02,100.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Commercial,,132.99,,,,,,,24.62,132.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,United Healthcare,Commercial,,278.05,,,,,,,102.94,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Commercial,,83.59,,,,,,,68.47,253.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,United Healthcare,Commercial,JW,278.05,,,,,,,218.88,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Commercial,JW,278.05,,,,,,,68.47,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,United Healthcare,Commercial,,1256.90,,,,,,,465.35,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,Commercial,,370.75,,,,,,,309.51,1147.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,3094.00000,1856.40000,United Healthcare,Commercial,,2515.42,,,,,,,931.29,2515.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,United Healthcare,Commercial,,370.75,,,,,,,327.43,2296.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,United Healthcare,Commercial,JW,1256.90,,,,,,,989.44,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,Commercial,JW,1256.90,,,,,,,309.51,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,United Healthcare,Commercial,,347.96,,,,,,,128.83,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,Commercial,,83.59,,,,,,,70.59,317.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,United Healthcare,Commercial,JW,347.96,,,,,,,273.92,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,Commercial,JW,347.96,,,,,,,70.59,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,United Healthcare,Commercial,,392.68,,,,,,,145.38,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Commercial,,83.59,,,,,,,70.59,358.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,United Healthcare,Commercial,JW,392.68,,,,,,,309.12,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Commercial,JW,392.68,,,,,,,70.59,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,10.00000,6.00000,United Healthcare,Commercial,,8.13,,,,,,,3.01,8.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,United Healthcare,Commercial,,6.96,,,,,,,2.00,7.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,,2030.87,,,,,,,751.90,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,,916.82,,,,,,,500.10,1854.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,JW,2030.87,,,,,,,1598.72,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,Commercial,JW,2030.87,,,,,,,500.10,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,,1646.33,,,,,,,609.52,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,,916.82,,,,,,,405.40,1502.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,JW,1646.33,,,,,,,1296.00,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,Commercial,JW,1646.33,,,,,,,405.40,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,,1388.60,,,,,,,514.11,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,,916.82,,,,,,,341.94,1267.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,JW,1388.60,,,,,,,1093.12,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,Commercial,JW,1388.60,,,,,,,341.94,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,United Healthcare,Commercial,,52.84,,,,,,,19.57,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,31.86,,,,,,,13.01,48.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,United Healthcare,Commercial,JW,52.84,,,,,,,41.60,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,JW,52.84,,,,,,,13.01,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,2469.00000,1481.40000,United Healthcare,Commercial,,2007.30,,,,,,,743.17,2007.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,Commercial,,1442.92,,,,,,,494.29,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,United Healthcare,Commercial,,567.47,,,,,,,210.10,567.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,Commercial,,1442.92,,,,,,,139.74,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,United Healthcare,Commercial,,567.47,,,,,,,446.72,567.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,Commercial,,567.47,,,,,,,139.74,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,188.43,508.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,1442.92,,,,,,,125.33,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,400.64,508.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,508.94,,,,,,,125.33,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,United Healthcare,Commercial,,500.00,,,,,,,185.12,500.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Commercial,,1442.92,,,,,,,123.12,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,United Healthcare,Commercial,,500.00,,,,,,,393.60,500.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Commercial,,500.00,,,,,,,123.12,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,United Healthcare,Commercial,,356.91,,,,,,,132.14,356.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,1442.92,,,,,,,87.89,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,United Healthcare,Commercial,,356.91,,,,,,,280.96,356.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,356.91,,,,,,,87.89,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,United Healthcare,Commercial,,324.39,,,,,,,120.10,324.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Commercial,,1442.92,,,,,,,79.88,6571.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,United Healthcare,Commercial,,324.39,,,,,,,255.36,324.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Commercial,,324.39,,,,,,,79.88,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,2363.00000,1417.80000,United Healthcare,Commercial,JW,1921.12,,,,,,,1512.32,1921.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,United Healthcare,Commercial,JW,1921.12,,,,,,,154.34,1921.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,United Healthcare,Commercial,JW,464.22,,,,,,,365.44,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Commercial,JW,464.22,,,,,,,114.31,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,United Healthcare,Commercial,JW,213.01,,,,,,,167.68,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Commercial,JW,213.01,,,,,,,52.45,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,United Healthcare,Commercial,,254.47,,,,,,,94.21,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Commercial,,178.08,,,,,,,62.66,232.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,United Healthcare,Commercial,JW,254.47,,,,,,,200.32,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Commercial,JW,254.47,,,,,,,62.66,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,United Healthcare,Commercial,,1280.47,,,,,,,474.07,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,Commercial,,274.21,,,,,,,240.06,1168.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,United Healthcare,Commercial,JW,1280.47,,,,,,,1008.00,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,Commercial,JW,1280.47,,,,,,,240.06,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,United Healthcare,Commercial,,1017.88,,,,,,,376.85,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Commercial,,274.21,,,,,,,240.06,929.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,United Healthcare,Commercial,JW,1017.88,,,,,,,801.28,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Commercial,JW,1017.88,,,,,,,240.06,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,United Healthcare,Commercial,,521.13,,,,,,,192.94,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Commercial,,274.21,,,,,,,128.33,475.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,United Healthcare,Commercial,JW,521.13,,,,,,,410.24,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Commercial,JW,521.13,,,,,,,128.33,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,United Healthcare,Commercial,,276.42,,,,,,,102.34,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,Commercial,,274.21,,,,,,,68.07,274.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,United Healthcare,Commercial,JW,276.42,,,,,,,217.60,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,Commercial,JW,276.42,,,,,,,68.07,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,United Healthcare,Commercial,,221.14,,,,,,,81.87,221.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,Commercial,,274.21,,,,,,,54.45,274.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,United Healthcare,Commercial,JW,221.14,,,,,,,174.08,221.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,Commercial,JW,221.14,,,,,,,54.45,240.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2562.00000,1537.20000,United Healthcare,Commercial,,2082.91,,,,,,,771.16,2082.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,United Healthcare,Commercial,,274.21,,,,,,,240.06,1901.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Commercial,,134.00,,,,,,,57.15,221.25,per diem,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Commercial,,134.00,,,,,,,37.76,477.75,per diem,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Commercial,,134.00,,,,,,,37.76,477.75,per diem,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Commercial,,134.00,,,,,,,37.76,477.75,per diem,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Commercial,,134.00,,,,,,,37.76,477.75,per diem,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,inpatient,,,270.00000,162.00000,United Healthcare,Commercial,,219.51,,,,,,,172.80,219.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Commercial,,219.51,,,,,,,50.90,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,inpatient,,,4243.00000,2545.80000,United Healthcare,Commercial,,3449.56,,,,,,,2715.52,3449.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,United Healthcare,Commercial,,3449.56,,,,,,,799.81,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,Commercial,,105.00,,,,,,,31.51,134.00,per diem,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,inpatient,,,246.00000,147.60000,United Healthcare,Commercial,,200.00,,,,,,,157.44,200.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,United Healthcare,Commercial,,200.00,,,,,,,46.37,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,inpatient,,,2577.00000,1546.20000,United Healthcare,Commercial,,2095.10,,,,,,,1649.28,2095.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,United Healthcare,Commercial,,2095.10,,,,,,,485.76,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,inpatient,,,209.00000,125.40000,United Healthcare,Commercial,,169.92,,,,,,,62.91,169.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Commercial,,139.09,,,,,,,41.84,142.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,inpatient,,,303.00000,181.80000,United Healthcare,Commercial,,246.34,,,,,,,193.92,246.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,Commercial,,246.34,,,,,,,57.12,246.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,inpatient,,,1976.00000,1185.60000,United Healthcare,Commercial,,1606.49,,,,,,,1264.64,1606.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,Commercial,,1606.49,,,,,,,372.48,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,inpatient,,,1976.00000,1185.60000,United Healthcare,Commercial,,1606.49,,,,,,,1264.64,1606.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,Commercial,,1606.49,,,,,,,372.48,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,inpatient,,,432.00000,259.20000,United Healthcare,Commercial,,351.22,,,,,,,276.48,351.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Commercial,,351.22,,,,,,,81.43,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,inpatient,,,432.00000,259.20000,United Healthcare,Commercial,,351.22,,,,,,,276.48,351.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Commercial,,351.22,,,,,,,81.43,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,inpatient,,,337.00000,202.20000,United Healthcare,Commercial,,273.98,,,,,,,215.68,273.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,Commercial,,273.98,,,,,,,63.52,273.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,inpatient,,,280.00000,168.00000,United Healthcare,Commercial,,227.64,,,,,,,179.20,227.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Commercial,,227.64,,,,,,,52.78,227.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,inpatient,,,269.00000,161.40000,United Healthcare,Commercial,,218.70,,,,,,,172.16,218.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Commercial,,218.70,,,,,,,50.71,218.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,United Healthcare,Commercial,,8045.00,,,,,,,1877.68,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,United Healthcare,Commercial,,954.00,,,,,,,222.82,3342.81,per diem,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,inpatient,,,1037.00000,622.20000,United Healthcare,Commercial,,843.08,,,,,,,663.68,843.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Commercial,,843.08,,,,,,,195.47,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,inpatient,,,1197.00000,718.20000,United Healthcare,Commercial,,973.16,,,,,,,766.08,973.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,United Healthcare,Commercial,,973.16,,,,,,,225.63,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,inpatient,,,806.00000,483.60000,United Healthcare,Commercial,,655.28,,,,,,,515.84,655.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,United Healthcare,Commercial,,655.28,,,,,,,151.93,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,Commercial,,3142.00,,,,,,,397.40,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,Commercial,,3142.00,,,,,,,397.40,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,Commercial,,13852.00,,,,,,,2337.54,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,Commercial,,13852.00,,,,,,,2337.54,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,Commercial,,24600.00,,,,,,,4067.26,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,Commercial,,24600.00,,,,,,,4067.26,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,Commercial,,13852.00,,,,,,,1729.73,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,Commercial,,13852.00,,,,,,,1729.73,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,Commercial,,24600.00,,,,,,,3669.87,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,Commercial,,24600.00,,,,,,,3669.87,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,Commercial,,52940.00,,,,,,,5937.33,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,Commercial,,52940.00,,,,,,,5937.33,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,inpatient,,,269.00000,161.40000,United Healthcare,Commercial,,218.70,,,,,,,172.16,218.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Commercial,,218.70,,,,,,,50.71,218.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,inpatient,,,410.00000,246.00000,United Healthcare,Commercial,,333.33,,,,,,,262.40,333.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,Commercial,,333.33,,,,,,,77.28,333.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,inpatient,,,594.00000,356.40000,United Healthcare,Commercial,,482.92,,,,,,,380.16,482.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,United Healthcare,Commercial,,482.92,,,,,,,111.97,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,inpatient,,,512.00000,307.20000,United Healthcare,Commercial,,416.26,,,,,,,327.68,416.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Commercial,,416.26,,,,,,,96.51,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,inpatient,,,771.00000,462.60000,United Healthcare,Commercial,,626.82,,,,,,,493.44,626.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,Commercial,,626.82,,,,,,,145.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,inpatient,,,681.00000,408.60000,United Healthcare,Commercial,,553.65,,,,,,,435.84,553.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,United Healthcare,Commercial,,553.65,,,,,,,128.37,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,inpatient,,,3875.00000,2325.00000,United Healthcare,Commercial,,3150.38,,,,,,,2480.00,3150.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,Commercial,,3150.38,,,,,,,730.44,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,inpatient,,,143.00000,85.80000,United Healthcare,Commercial,,116.26,,,,,,,91.52,116.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Commercial,,116.26,,,,,,,26.96,116.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,inpatient,,,315.00000,189.00000,United Healthcare,Commercial,,256.10,,,,,,,201.60,256.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Commercial,,256.10,,,,,,,59.38,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,inpatient,,,195.00000,117.00000,United Healthcare,Commercial,,158.53,,,,,,,124.80,158.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Commercial,,158.53,,,,,,,36.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,inpatient,,,315.00000,189.00000,United Healthcare,Commercial,,256.10,,,,,,,201.60,256.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Commercial,,256.10,,,,,,,59.38,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,inpatient,,,195.00000,117.00000,United Healthcare,Commercial,,158.53,,,,,,,124.80,158.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Commercial,,158.53,,,,,,,36.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,inpatient,,,315.00000,189.00000,United Healthcare,Commercial,,256.10,,,,,,,201.60,256.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Commercial,,256.10,,,,,,,59.38,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,inpatient,,,195.00000,117.00000,United Healthcare,Commercial,,158.53,,,,,,,124.80,158.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Commercial,,158.53,,,,,,,36.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,United Healthcare,Commercial,,418.69,,,,,,,329.60,418.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Commercial,,418.69,,,,,,,97.08,420.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,,767.00,,,,,,,28.73,767.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,United Healthcare,Commercial,,767.00,,,,,,,88.31,767.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,United Healthcare,Commercial,,767.00,,,,,,,84.26,767.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Commercial,,269.00,,,,,,,22.28,269.00,per diem,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Commercial,,269.00,,,,,,,24.55,269.00,per diem,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Commercial,,269.00,,,,,,,27.51,269.00,per diem,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Commercial,,767.00,,,,,,,16.02,767.00,per diem,"Must be billed without CPT Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Commercial,,269.00,,,,,,,16.02,269.00,per diem,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Commercial,,269.00,,,,,,,23.56,269.00,per diem,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,inpatient,,,410.00000,246.00000,United Healthcare,Commercial,,333.33,,,,,,,262.40,333.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,Commercial,,333.33,,,,,,,77.28,333.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,United Healthcare,Commercial,,418.69,,,,,,,329.60,418.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Commercial,,418.69,,,,,,,97.08,420.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,Commercial,,1090.00,,,,,,,11.14,1090.00,per diem,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,Commercial,,1090.00,,,,,,,11.14,1090.00,per diem,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,1090.00,,,,,,,4.87,1090.00,per diem,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Commercial,,1090.00,,,,,,,26.11,1090.00,per diem,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Commercial,,1090.00,,,,,,,14.80,1090.00,per diem,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Commercial,,767.00,,,,,,,26.63,767.00,per diem,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,inpatient,,,515.00000,309.00000,United Healthcare,Commercial,,418.69,,,,,,,329.60,418.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Commercial,,418.69,,,,,,,97.08,420.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,40000.00000,24000.00000,United Healthcare,Commercial,,32520.00,,,,,,,6880.00,33200.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,United Healthcare,Commercial,,8960.00,,,,,,,5080.00,29448.00,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,United Healthcare,Commercial,,8045.00,,,,,,,155.56,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,United Healthcare,Commercial,,4681.00,,,,,,,1757.36,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,United Healthcare,Commercial,,4681.00,,,,,,,1757.36,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,United Healthcare,Commercial,,3641.00,,,,,,,661.11,3641.00,per diem,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Commercial,,832.00,,,,,,,58.46,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Commercial,,3142.00,,,,,,,176.98,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,inpatient,,,205.00000,123.00000,United Healthcare,Commercial,,166.66,,,,,,,131.20,166.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,United Healthcare,Commercial,,166.66,,,,,,,38.64,166.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,United Healthcare,Commercial,,2912.00,,,,,,,194.19,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Commercial,,3142.00,,,,,,,246.25,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Commercial,,832.00,,,,,,,64.86,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,United Healthcare,Commercial,,3142.00,,,,,,,1253.05,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,inpatient,,,3123.00000,1873.80000,United Healthcare,Commercial,,2539.00,,,,,,,1998.72,2539.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Commercial,,2539.00,,,,,,,420.60,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,United Healthcare,Commercial,,5754.00,,,,,,,97.30,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,United Healthcare,Commercial,,13852.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,inpatient,,,3123.00000,1873.80000,United Healthcare,Commercial,,2539.00,,,,,,,1998.72,2539.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Commercial,,2539.00,,,,,,,588.69,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,United Healthcare,Commercial,,2912.00,,,,,,,168.57,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,United Healthcare,Commercial,,3142.00,,,,,,,467.67,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,United Healthcare,Commercial,,3142.00,,,,,,,463.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,United Healthcare,Commercial,,3142.00,,,,,,,464.86,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,United Healthcare,Commercial,,24600.00,,,,,,,2388.19,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,United Healthcare,Commercial,,2912.00,,,,,,,104.90,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,United Healthcare,Commercial,,467.00,,,,,,,114.71,467.00,per diem,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Commercial,,2912.00,,,,,,,512.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,United Healthcare,Commercial,,2912.00,,,,,,,379.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Commercial,,2912.00,,,,,,,512.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,inpatient,,,5187.00000,3112.20000,United Healthcare,Commercial,,4217.03,,,,,,,1561.29,4217.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,United Healthcare,Commercial,,146.35,,,,,,,120.36,3849.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,United Healthcare,Commercial,,1004.05,,,,,,,371.74,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,Commercial,,343.20,,,,,,,247.25,916.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,852.02,,,,,,,315.45,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Commercial,,343.20,,,,,,,209.81,777.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,United Healthcare,Commercial,,574.79,,,,,,,212.81,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Commercial,,343.20,,,,,,,141.54,524.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,United Healthcare,Commercial,,447.15,,,,,,,165.55,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Commercial,,343.20,,,,,,,110.11,408.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,United Healthcare,Commercial,,359.35,,,,,,,133.04,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Commercial,,343.20,,,,,,,88.49,343.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,United Healthcare,Commercial,,378.86,,,,,,,140.27,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,Commercial,,343.20,,,,,,,93.29,345.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,United Healthcare,Commercial,JW,1004.05,,,,,,,790.40,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,Commercial,JW,1004.05,,,,,,,247.25,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Commercial,JW,852.02,,,,,,,670.72,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Commercial,JW,852.02,,,,,,,209.81,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,United Healthcare,Commercial,JW,574.79,,,,,,,452.48,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Commercial,JW,574.79,,,,,,,141.54,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,United Healthcare,Commercial,JW,447.15,,,,,,,352.00,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Commercial,JW,447.15,,,,,,,110.11,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,United Healthcare,Commercial,JW,359.35,,,,,,,282.88,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Commercial,JW,359.35,,,,,,,88.49,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,United Healthcare,Commercial,JW,378.86,,,,,,,298.24,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,Commercial,JW,378.86,,,,,,,93.29,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,2078.00000,1246.80000,United Healthcare,Commercial,,1689.41,,,,,,,625.48,1689.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,inpatient,,,179.00000,107.40000,United Healthcare,Commercial,,145.53,,,,,,,114.56,145.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Commercial,,145.53,,,,,,,33.74,145.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,inpatient,,,188.00000,112.80000,United Healthcare,Commercial,,152.84,,,,,,,120.32,152.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,152.84,,,,,,,35.44,152.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,United Healthcare,Commercial,,832.00,,,,,,,159.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,1064.69,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Commercial,,832.00,,,,,,,35.84,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,United Healthcare,Commercial,,3142.00,,,,,,,365.97,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,United Healthcare,Commercial,,3142.00,,,,,,,519.32,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,United Healthcare,Commercial,,3142.00,,,,,,,577.18,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,inpatient,,,2174.00000,1304.40000,United Healthcare,Commercial,,1767.46,,,,,,,1391.36,1767.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,United Healthcare,Commercial,,1767.46,,,,,,,409.80,2452.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,inpatient,,,4232.00000,2539.20000,United Healthcare,Commercial,,3440.62,,,,,,,2708.48,3440.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,United Healthcare,Commercial,,3440.62,,,,,,,736.79,3440.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,inpatient,,,19132.00000,11479.20000,United Healthcare,Commercial,,15554.32,,,,,,,12244.48,15554.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,United Healthcare,Commercial,,15554.32,,,,,,,3330.88,15554.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,Commercial,,1831.00,,,,,,,74.69,1831.00,per diem,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,United Healthcare,Commercial,,1831.00,,,,,,,78.69,1831.00,per diem,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Commercial,,1831.00,,,,,,,69.81,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Commercial,,1831.00,,,,,,,115.78,1831.00,per diem,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Commercial,,1831.00,,,,,,,55.36,1831.00,per diem,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,United Healthcare,Commercial,,247.97,,,,,,,91.81,247.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Commercial,,713.33,,,,,,,61.06,722.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Commercial,,268.00,,,,,,,45.52,268.00,per diem,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,United Healthcare,Commercial,,268.00,,,,,,,61.58,408.75,per diem,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,Commercial,,268.00,,,,,,,70.47,268.00,per diem,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Commercial,,268.00,,,,,,,42.96,360.75,per diem,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,United Healthcare,Commercial,,268.00,,,,,,,67.36,450.75,per diem,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Commercial,,268.00,,,,,,,57.08,295.50,per diem,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Commercial,,268.00,,,,,,,65.78,331.50,per diem,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,Commercial,,268.00,,,,,,,67.36,375.00,per diem,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Commercial,,268.00,,,,,,,30.43,268.00,per diem,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Commercial,,268.00,,,,,,,52.60,268.00,per diem,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Commercial,,268.00,,,,,,,24.02,268.00,per diem,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Commercial,,268.00,,,,,,,51.96,375.75,per diem,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,United Healthcare,Commercial,,268.00,,,,,,,60.30,503.25,per diem,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Commercial,,268.00,,,,,,,35.84,268.00,per diem,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Commercial,,268.00,,,,,,,15.34,268.00,per diem,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,Commercial,,268.00,,,,,,,43.60,271.50,per diem,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Commercial,,268.00,,,,,,,50.02,362.25,per diem,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,United Healthcare,Commercial,,268.00,,,,,,,56.44,438.00,per diem,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,Commercial,,268.00,,,,,,,57.74,809.25,per diem,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,Commercial,,268.00,,,,,,,71.86,438.75,per diem,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Commercial,,268.00,,,,,,,46.82,288.75,per diem,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Commercial,,268.00,,,,,,,59.66,268.00,per diem,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Commercial,,268.00,,,,,,,32.04,331.50,per diem,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Commercial,,268.00,,,,,,,55.16,372.00,per diem,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Commercial,,268.00,,,,,,,77.00,495.00,per diem,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,United Healthcare,Commercial,,268.00,,,,,,,91.78,696.75,per diem,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Commercial,,268.00,,,,,,,44.24,327.75,per diem,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,United Healthcare,Commercial,,268.00,,,,,,,54.52,268.00,per diem,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,United Healthcare,Commercial,,268.00,,,,,,,47.46,423.00,per diem,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Commercial,,268.00,,,,,,,55.80,369.00,per diem,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,United Healthcare,Commercial,,268.00,,,,,,,74.44,532.50,per diem,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,Commercial,,268.00,,,,,,,91.12,656.25,per diem,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Commercial,,268.00,,,,,,,57.74,436.50,per diem,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Commercial,,268.00,,,,,,,37.18,268.00,per diem,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,United Healthcare,Commercial,,268.00,,,,,,,57.74,405.75,per diem,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,Commercial,,268.00,,,,,,,54.52,276.75,per diem,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,United Healthcare,Commercial,,268.00,,,,,,,46.16,276.00,per diem,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,United Healthcare,Commercial,,268.00,,,,,,,138.66,908.25,per diem,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Commercial,,268.00,,,,,,,141.22,830.63,per diem,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,United Healthcare,Commercial,,268.00,,,,,,,135.44,1002.00,per diem,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,United Healthcare,Commercial,,268.00,,,,,,,195.18,1419.00,per diem,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,Commercial,,268.00,,,,,,,139.30,2053.05,per diem,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,Commercial,,268.00,,,,,,,46.16,318.75,per diem,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,United Healthcare,Commercial,,268.00,,,,,,,28.82,286.50,per diem,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Commercial,,268.00,,,,,,,26.90,344.25,per diem,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,United Healthcare,Commercial,,268.00,,,,,,,48.74,346.50,per diem,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Commercial,,268.00,,,,,,,204.18,953.25,per diem,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,United Healthcare,Commercial,,268.00,,,,,,,37.18,391.50,per diem,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,United Healthcare,Commercial,,268.00,,,,,,,46.16,330.00,per diem,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,United Healthcare,Commercial,,268.00,,,,,,,40.38,304.50,per diem,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Commercial,,268.00,,,,,,,46.16,331.50,per diem,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Commercial,,268.00,,,,,,,97.50,375.47,per diem,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,United Healthcare,Commercial,,268.00,,,,,,,41.04,284.25,per diem,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,United Healthcare,Commercial,,268.00,,,,,,,46.16,268.00,per diem,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,United Healthcare,Commercial,,268.00,,,,,,,49.38,281.25,per diem,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,United Healthcare,Commercial,,268.00,,,,,,,62.22,268.00,per diem,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,United Healthcare,Commercial,,268.00,,,,,,,130.73,489.75,per diem,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,Commercial,,268.00,,,,,,,44.24,323.25,per diem,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Commercial,,268.00,,,,,,,53.88,295.50,per diem,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,United Healthcare,Commercial,,268.00,,,,,,,55.26,268.00,per diem,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,Commercial,,268.00,,,,,,,168.37,630.75,per diem,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Commercial,,268.00,,,,,,,50.02,320.25,per diem,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Commercial,,268.00,,,,,,,60.94,278.25,per diem,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,Commercial,,268.00,,,,,,,68.00,361.50,per diem,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Commercial,,268.00,,,,,,,61.58,268.00,per diem,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,Commercial,,268.00,,,,,,,76.08,375.47,per diem,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Commercial,,268.00,,,,,,,45.52,268.00,per diem,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Commercial,,268.00,,,,,,,43.64,268.00,per diem,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,United Healthcare,Commercial,,268.00,,,,,,,46.82,333.75,per diem,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Commercial,,268.00,,,,,,,54.52,347.25,per diem,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,Commercial,,268.00,,,,,,,76.08,375.47,per diem,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,United Healthcare,Commercial,,268.00,,,,,,,39.74,397.50,per diem,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Commercial,,268.00,,,,,,,50.66,347.25,per diem,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Commercial,,268.00,,,,,,,40.38,300.75,per diem,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Commercial,,268.00,,,,,,,43.60,268.00,per diem,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Commercial,,268.00,,,,,,,41.04,319.50,per diem,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,,268.00,,,,,,,63.20,576.46,per diem,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,,268.00,,,,,,,63.20,576.46,per diem,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,,268.00,,,,,,,63.20,576.46,per diem,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,United Healthcare,Commercial,,268.00,,,,,,,138.66,586.50,per diem,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,United Healthcare,Commercial,,268.00,,,,,,,64.46,268.00,per diem,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Commercial,,268.00,,,,,,,49.45,311.44,per diem,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Commercial,,268.00,,,,,,,211.21,791.25,per diem,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Commercial,,268.00,,,,,,,145.75,546.00,per diem,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,United Healthcare,Commercial,,268.00,,,,,,,177.78,666.00,per diem,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,United Healthcare,Commercial,,268.00,,,,,,,99.70,373.50,per diem,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,United Healthcare,Commercial,,268.00,,,,,,,105.91,396.75,per diem,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Commercial,,268.00,,,,,,,171.27,741.00,per diem,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Commercial,,268.00,,,,,,,171.27,780.75,per diem,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,Commercial,,268.00,,,,,,,100.76,805.50,per diem,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,United Healthcare,Commercial,,268.00,,,,,,,107.51,402.75,per diem,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,Commercial,,268.00,,,,,,,19.62,375.47,per diem,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,United Healthcare,Commercial,,268.00,,,,,,,116.12,435.00,per diem,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,United Healthcare,Commercial,,268.00,,,,,,,98.30,482.25,per diem,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,Commercial,,268.00,,,,,,,163.76,613.50,per diem,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,United Healthcare,Commercial,,268.00,,,,,,,133.33,2153.70,per diem,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,United Healthcare,Commercial,,268.00,,,,,,,154.08,607.50,per diem,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,United Healthcare,Commercial,,268.00,,,,,,,130.88,5683.29,per diem,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,United Healthcare,Commercial,,268.00,,,,,,,116.82,3483.75,per diem,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,United Healthcare,Commercial,,268.00,,,,,,,125.18,3309.13,per diem,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,Commercial,,268.00,,,,,,,37.04,268.00,per diem,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,United Healthcare,Commercial,,268.00,,,,,,,117.46,1633.21,per diem,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,United Healthcare,Commercial,,268.00,,,,,,,126.46,1633.21,per diem,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,United Healthcare,Commercial,,268.00,,,,,,,118.74,3309.13,per diem,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,United Healthcare,Commercial,,268.00,,,,,,,129.02,4309.50,per diem,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,United Healthcare,Commercial,,268.00,,,,,,,130.96,3309.13,per diem,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,United Healthcare,Commercial,,268.00,,,,,,,150.14,3309.13,per diem,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,United Healthcare,Commercial,,268.00,,,,,,,143.80,3309.13,per diem,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,United Healthcare,Commercial,,268.00,,,,,,,167.48,5683.29,per diem,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,United Healthcare,Commercial,,268.00,,,,,,,139.94,3309.13,per diem,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Commercial,,268.00,,,,,,,160.96,3309.13,per diem,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,United Healthcare,Commercial,,268.00,,,,,,,139.94,3309.13,per diem,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,Commercial,,268.00,,,,,,,138.66,3309.13,per diem,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,Commercial,,268.00,,,,,,,139.30,3309.13,per diem,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,Commercial,,268.00,,,,,,,150.22,5683.29,per diem,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Commercial,,268.00,,,,,,,232.00,1749.75,per diem,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,United Healthcare,Commercial,,268.00,,,,,,,82.40,3309.13,per diem,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Commercial,,268.00,,,,,,,40.84,268.00,per diem,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Commercial,,268.00,,,,,,,35.03,268.00,per diem,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,United Healthcare,Commercial,,268.00,,,,,,,232.00,903.00,per diem,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,Commercial,,268.00,,,,,,,154.35,578.25,per diem,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,United Healthcare,Commercial,,268.00,,,,,,,211.61,792.75,per diem,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,United Healthcare,Commercial,,268.00,,,,,,,71.67,268.50,per diem,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,Commercial,,268.00,,,,,,,53.24,714.75,per diem,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,Commercial,,268.00,,,,,,,33.83,268.00,per diem,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,Commercial,,268.00,,,,,,,68.64,702.00,per diem,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Commercial,,268.00,,,,,,,48.74,576.46,per diem,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Commercial,,268.00,,,,,,,68.27,268.00,per diem,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Commercial,,268.00,,,,,,,28.63,268.00,per diem,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,United Healthcare,Commercial,,268.00,,,,,,,148.95,558.00,per diem,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,United Healthcare,Commercial,,268.00,,,,,,,132.53,496.50,per diem,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,United Healthcare,Commercial,,268.00,,,,,,,131.53,492.75,per diem,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Commercial,,268.00,,,,,,,64.66,268.00,per diem,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,United Healthcare,Commercial,,268.00,,,,,,,91.12,484.50,per diem,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,United Healthcare,Commercial,,268.00,,,,,,,32.68,268.00,per diem,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Commercial,,268.00,,,,,,,48.65,268.00,per diem,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,Commercial,,268.00,,,,,,,53.65,268.00,per diem,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,United Healthcare,Commercial,,268.00,,,,,,,102.31,695.25,per diem,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Commercial,,268.00,,,,,,,61.26,268.00,per diem,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Commercial,,268.00,,,,,,,52.60,683.25,per diem,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,Commercial,,268.00,,,,,,,40.38,268.00,per diem,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,United Healthcare,Commercial,,268.00,,,,,,,157.76,5683.29,per diem,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,Commercial,,268.00,,,,,,,133.52,3309.13,per diem,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,United Healthcare,Commercial,,268.00,,,,,,,137.94,3309.13,per diem,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,United Healthcare,Commercial,,268.00,,,,,,,148.86,5683.29,per diem,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,United Healthcare,Commercial,,268.00,,,,,,,186.12,3309.13,per diem,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,United Healthcare,Commercial,,268.00,,,,,,,170.70,5683.29,per diem,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Commercial,,268.00,,,,,,,136.10,3385.50,per diem,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Commercial,,268.00,,,,,,,138.58,3385.50,per diem,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Commercial,,268.00,,,,,,,155.28,3385.50,per diem,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,United Healthcare,Commercial,,268.00,,,,,,,198.96,3309.13,per diem,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,United Healthcare,Commercial,,268.00,,,,,,,232.00,1339.50,per diem,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,Commercial,,268.00,,,,,,,32.68,268.00,per diem,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,United Healthcare,Commercial,,268.00,,,,,,,44.24,280.50,per diem,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,United Healthcare,Commercial,,268.00,,,,,,,60.30,268.00,per diem,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Commercial,,268.00,,,,,,,166.37,623.25,per diem,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,inpatient,,,163.00000,97.80000,United Healthcare,Commercial,,132.52,,,,,,,49.06,132.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Commercial,,75.73,,,,,,,32.63,104.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Commercial,,268.00,,,,,,,51.96,375.75,per diem,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,Commercial,,268.00,,,,,,,137.38,2053.05,per diem,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,United Healthcare,Commercial,,268.00,,,,,,,57.74,462.75,per diem,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,Commercial,,268.00,,,,,,,102.31,609.00,per diem,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,United Healthcare,Commercial,,268.00,,,,,,,102.31,645.75,per diem,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,United Healthcare,Commercial,,268.00,,,,,,,44.88,350.25,per diem,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,United Healthcare,Commercial,,268.00,,,,,,,69.30,370.50,per diem,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Commercial,,268.00,,,,,,,87.92,392.25,per diem,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Commercial,,268.00,,,,,,,58.38,568.50,per diem,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,United Healthcare,Commercial,,268.00,,,,,,,75.72,552.00,per diem,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,Commercial,,268.00,,,,,,,89.20,809.25,per diem,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,Commercial,,268.00,,,,,,,40.38,268.00,per diem,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Commercial,,268.00,,,,,,,50.66,324.00,per diem,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,United Healthcare,Commercial,,268.00,,,,,,,212.81,797.25,per diem,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Commercial,,268.00,,,,,,,123.12,461.25,per diem,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,United Healthcare,Commercial,,268.00,,,,,,,154.08,588.75,per diem,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,37500.00000,22500.00000,United Healthcare,Commercial,,30487.50,,,,,,,6450.00,31125.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,United Healthcare,Commercial,,8400.00,,,,,,,4762.50,27607.50,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,United Healthcare,Commercial,,467.00,,,,,,,43.44,467.00,per diem,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,United Healthcare,Commercial,,268.00,,,,,,,170.70,5683.29,per diem,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,United Healthcare,Commercial,,2912.00,,,,,,,451.05,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,Commercial,,268.00,,,,,,,56.44,315.00,per diem,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Commercial,,268.00,,,,,,,49.38,412.50,per diem,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,United Healthcare,Commercial,,268.00,,,,,,,58.38,405.00,per diem,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Commercial,,268.00,,,,,,,80.28,300.75,per diem,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,United Healthcare,Commercial,,268.00,,,,,,,119.32,447.00,per diem,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,United Healthcare,Commercial,,268.00,,,,,,,99.50,372.75,per diem,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Commercial,,268.00,,,,,,,66.72,564.00,per diem,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Commercial,,268.00,,,,,,,116.32,633.86,per diem,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,United Healthcare,Commercial,,268.00,,,,,,,171.27,696.00,per diem,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,United Healthcare,Commercial,,268.00,,,,,,,171.27,1036.50,per diem,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Commercial,,1197.00,,,,,,,54.05,2905.00,per diem,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,United Healthcare,Commercial,,3466.00,,,,,,,165.97,3466.00,per diem,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Commercial,,1067.00,,,,,,,68.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Commercial,,1067.00,,,,,,,82.68,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Commercial,,1560.00,,,,,,,135.54,1560.00,per diem,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,United Healthcare,Commercial,,1560.00,,,,,,,137.14,1560.00,per diem,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,United Healthcare,Commercial,,1560.00,,,,,,,221.02,1560.00,per diem,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,Commercial,,1560.00,,,,,,,116.72,1560.00,per diem,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2187.75,per diem,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,United Healthcare,Commercial,,1560.00,,,,,,,218.82,1560.00,per diem,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,United Healthcare,Commercial,,1560.00,,,,,,,195.40,1560.00,per diem,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,United Healthcare,Commercial,,1560.00,,,,,,,143.54,1560.00,per diem,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,United Healthcare,Commercial,,1560.00,,,,,,,203.00,1560.00,per diem,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1717.50,per diem,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1783.50,per diem,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2049.75,per diem,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,United Healthcare,Commercial,,1560.00,,,,,,,171.37,1560.00,per diem,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Commercial,,1560.00,,,,,,,246.25,1560.00,per diem,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1683.75,per diem,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,Commercial,,1560.00,,,,,,,208.61,1560.00,per diem,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,United Healthcare,Commercial,,1560.00,,,,,,,229.83,1560.00,per diem,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,Commercial,,1560.00,,,,,,,251.25,1560.00,per diem,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1977.00,per diem,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1977.00,per diem,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1872.75,per diem,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2907.00,per diem,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,3633.00,per diem,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Commercial,,1560.00,,,,,,,166.37,1560.00,per diem,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1864.50,per diem,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,United Healthcare,Commercial,,1560.00,,,,,,,155.76,1560.00,per diem,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,Commercial,,1560.00,,,,,,,172.97,1560.00,per diem,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,United Healthcare,Commercial,,1560.00,,,,,,,218.22,1560.00,per diem,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,Commercial,,1560.00,,,,,,,159.96,1560.00,per diem,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Commercial,,1560.00,,,,,,,232.23,1560.00,per diem,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Commercial,,1560.00,,,,,,,232.23,1560.00,per diem,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Commercial,,1560.00,,,,,,,254.45,1560.00,per diem,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,United Healthcare,Commercial,,1560.00,,,,,,,184.78,1560.00,per diem,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1755.75,per diem,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2207.25,per diem,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,inpatient,,,277.00000,166.20000,United Healthcare,Commercial,,225.20,,,,,,,83.38,225.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,United Healthcare,Commercial,,80.16,,,,,,,55.46,178.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,inpatient,,,51.00000,30.60000,United Healthcare,Commercial,,41.46,,,,,,,15.35,41.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,62.96,,,,,,,10.21,208.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,inpatient,,,99.00000,59.40000,United Healthcare,Commercial,,80.49,,,,,,,29.80,80.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Commercial,,110.96,,,,,,,19.82,154.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,inpatient,,,2030.00000,1218.00000,United Healthcare,Commercial,,1650.39,,,,,,,611.03,1650.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,United Healthcare,Commercial,,1947.38,,,,,,,406.41,2131.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Commercial,,803.24,,,,,,,297.39,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Commercial,,1410.77,,,,,,,197.80,1410.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,inpatient,,,107.00000,64.20000,United Healthcare,Commercial,,86.99,,,,,,,32.21,86.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Commercial,,59.90,,,,,,,21.42,325.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,inpatient,,,208.00000,124.80000,United Healthcare,Commercial,,169.10,,,,,,,62.61,169.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,Commercial,,807.54,,,,,,,41.64,807.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,inpatient,,,188.00000,112.80000,United Healthcare,Commercial,,152.84,,,,,,,56.59,152.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,55.49,,,,,,,37.64,120.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,inpatient,,,2794.00000,1676.40000,United Healthcare,Commercial,,2271.52,,,,,,,840.99,2271.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,United Healthcare,Commercial,,5212.53,,,,,,,559.36,9315.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,inpatient,,,12493.00000,7495.80000,United Healthcare,Commercial,,10156.81,,,,,,,3760.39,10156.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,United Healthcare,Commercial,,5648.68,,,,,,,2012.57,12296.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,United Healthcare,Commercial,,1560.00,,,,,,,215.63,1560.00,per diem,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Commercial,,1560.00,,,,,,,103.90,1560.00,per diem,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,United Healthcare,Commercial,,1560.00,,,,,,,215.63,1560.00,per diem,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,United Healthcare,Commercial,,1560.00,,,,,,,94.09,1560.00,per diem,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,inpatient,,,12371.00000,7422.60000,United Healthcare,Commercial,,10057.62,,,,,,,3723.67,10057.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,United Healthcare,Commercial,,11747.34,,,,,,,2476.67,39196.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Commercial,,1560.00,,,,,,,135.54,1560.00,per diem,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,inpatient,,,87.00000,52.20000,United Healthcare,Commercial,,70.73,,,,,,,26.19,70.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,United Healthcare,Commercial,,2045.69,,,,,,,17.42,2045.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,inpatient,,,878.00000,526.80000,United Healthcare,Commercial,,713.81,,,,,,,264.28,713.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,United Healthcare,Commercial,,1136.88,,,,,,,175.78,1136.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,inpatient,,,119.00000,71.40000,United Healthcare,Commercial,,96.75,,,,,,,35.82,96.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,Commercial,,318.78,,,,,,,23.82,318.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,inpatient,,,584.00000,350.40000,United Healthcare,Commercial,,474.79,,,,,,,175.78,474.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,United Healthcare,Commercial,,458.82,,,,,,,116.92,458.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,inpatient,,,323.00000,193.80000,United Healthcare,Commercial,,262.60,,,,,,,97.22,262.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Commercial,,257.14,,,,,,,64.66,257.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,inpatient,,,44.00000,26.40000,United Healthcare,Commercial,,35.77,,,,,,,13.24,35.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Commercial,,11.47,,,,,,,8.43,28.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,inpatient,,,5280.00000,3168.00000,United Healthcare,Commercial,,4292.64,,,,,,,1589.28,4292.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,United Healthcare,Commercial,,2807.95,,,,,,,1000.45,10134.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,inpatient,,,6.00000,3.60000,United Healthcare,Commercial,,4.88,,,,,,,1.81,4.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,United Healthcare,Commercial,,29.06,,,,,,,1.20,29.06,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,inpatient,,,649.00000,389.40000,United Healthcare,Commercial,,527.64,,,,,,,195.35,527.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,United Healthcare,Commercial,,2091.51,,,,,,,129.93,2091.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,inpatient,,,122.00000,73.20000,United Healthcare,Commercial,,99.19,,,,,,,36.72,99.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Commercial,,132.97,,,,,,,24.42,132.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,inpatient,,,42.00000,25.20000,United Healthcare,Commercial,,34.15,,,,,,,12.64,34.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Commercial,,161.14,,,,,,,8.41,161.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,inpatient,,,82.00000,49.20000,United Healthcare,Commercial,,66.67,,,,,,,24.68,66.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,United Healthcare,Commercial,,1226.71,,,,,,,16.42,1226.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,inpatient,,,254.00000,152.40000,United Healthcare,Commercial,,206.50,,,,,,,76.45,206.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,United Healthcare,Commercial,,287.08,,,,,,,50.85,287.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,inpatient,,,77.00000,46.20000,United Healthcare,Commercial,,62.60,,,,,,,23.18,62.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,308.90,,,,,,,15.42,308.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,inpatient,,,6058.00000,3634.80000,United Healthcare,Commercial,,4925.15,,,,,,,1823.46,4925.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,United Healthcare,Commercial,,5974.85,,,,,,,1212.81,6878.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,inpatient,,,183.00000,109.80000,United Healthcare,Commercial,,148.78,,,,,,,55.08,148.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,Commercial,,137.38,,,,,,,36.64,137.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,United Healthcare,Commercial,,1560.00,,,,,,,215.22,1560.00,per diem,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,United Healthcare,Commercial,,247.97,,,,,,,91.81,247.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Commercial,,713.33,,,,,,,61.06,722.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,inpatient,,,305.00000,183.00000,United Healthcare,Commercial,,247.97,,,,,,,91.81,247.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Commercial,,467.68,,,,,,,61.06,479.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,inpatient,,,1343.00000,805.80000,United Healthcare,Commercial,,1091.86,,,,,,,404.24,1091.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,inpatient,,,487.00000,292.20000,United Healthcare,Commercial,,395.93,,,,,,,146.59,395.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Commercial,,730.77,,,,,,,97.50,1243.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,United Healthcare,Commercial,,1560.00,,,,,,,87.09,1560.00,per diem,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1680.00,per diem,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,1560.00,per diem,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2508.00,per diem,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2508.00,per diem,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2508.00,per diem,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,inpatient,,,1309.00000,785.40000,United Healthcare,Commercial,,1064.22,,,,,,,394.01,1064.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,Commercial,,1357.64,,,,,,,262.06,1851.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,inpatient,,,1929.00000,1157.40000,United Healthcare,Commercial,,1568.28,,,,,,,580.63,1568.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,United Healthcare,Commercial,,1620.17,,,,,,,386.19,2316.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,inpatient,,,1069.00000,641.40000,United Healthcare,Commercial,,869.10,,,,,,,321.77,869.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,United Healthcare,Commercial,,905.07,,,,,,,214.01,1480.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,inpatient,,,1908.00000,1144.80000,United Healthcare,Commercial,,1551.20,,,,,,,574.31,1551.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,United Healthcare,Commercial,,2377.95,,,,,,,369.58,2435.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,inpatient,,,1230.00000,738.00000,United Healthcare,Commercial,,999.99,,,,,,,370.23,999.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Commercial,,1827.39,,,,,,,246.25,1871.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,United Healthcare,Commercial,,1197.00,,,,,,,84.71,2905.00,per diem,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2905.00,per diem,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2942.87,per diem,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2942.87,per diem,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,3501.50,per diem,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,United Healthcare,Commercial,,1197.00,,,,,,,206.81,2905.00,per diem,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,United Healthcare,Commercial,,1197.00,,,,,,,225.43,2905.00,per diem,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Commercial,,1197.00,,,,,,,64.86,2905.00,per diem,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,United Healthcare,Commercial,,1197.00,,,,,,,507.91,2905.00,per diem,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,United Healthcare,Commercial,,1197.00,,,,,,,258.06,2905.00,per diem,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,United Healthcare,Commercial,,1197.00,,,,,,,227.83,2905.00,per diem,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,United Healthcare,Commercial,,1197.00,,,,,,,254.05,2905.00,per diem,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2908.74,per diem,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,3211.99,per diem,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2942.40,per diem,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2905.00,per diem,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2905.00,per diem,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,3037.26,per diem,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2905.00,per diem,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,3356.74,per diem,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,3008.52,per diem,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,3500.13,per diem,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,4490.21,per diem,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,21022.43,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,United Healthcare,Commercial,,1197.00,,,,,,,232.56,3266.55,per diem,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,3891.19,per diem,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,4523.15,per diem,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,Commercial,,1197.00,,,,,,,84.71,2905.00,per diem,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,3052.31,per diem,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,United Healthcare,Commercial,,1197.00,,,,,,,560.56,2905.00,per diem,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,United Healthcare,Commercial,,1067.00,,,,,,,95.50,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,United Healthcare,Commercial,,1197.00,,,,,,,102.31,2905.00,per diem,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,Commercial,,1197.00,,,,,,,171.27,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,United Healthcare,Commercial,,1197.00,,,,,,,232.56,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,Commercial,,1197.00,,,,,,,343.59,2905.00,per diem,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,United Healthcare,Commercial,,1197.00,,,,,,,380.58,2905.00,per diem,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Commercial,,1197.00,,,,,,,95.09,2905.00,per diem,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,Commercial,,2912.00,,,,,,,67.47,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,21022.43,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,21022.43,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,19194.26,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Commercial,,3142.00,,,,,,,53.85,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Commercial,,3142.00,,,,,,,145.75,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Commercial,,8045.00,,,,,,,125.93,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,United Healthcare,Commercial,,8045.00,,,,,,,399.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,United Healthcare,Commercial,,8045.00,,,,,,,1022.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,United Healthcare,Commercial,,2912.00,,,,,,,277.68,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,United Healthcare,Commercial,,3142.00,,,,,,,176.18,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,35106.11,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Commercial,,13852.00,,,,,,,972.37,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Commercial,,13852.00,,,,,,,972.37,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,18016.35,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,United Healthcare,Commercial,,2912.00,,,,,,,222.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,Commercial,,5754.00,,,,,,,600.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Commercial,,832.00,,,,,,,31.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,inpatient,,,155.00000,93.00000,United Healthcare,Commercial,,126.02,,,,,,,99.20,126.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Commercial,,126.02,,,,,,,29.22,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,United Healthcare,Commercial,,2912.00,,,,,,,84.28,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,Commercial,,13852.00,,,,,,,584.78,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Commercial,,13852.00,,,,,,,125.93,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,United Healthcare,Commercial,,832.00,,,,,,,91.29,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,United Healthcare,Commercial,,3142.00,,,,,,,46.45,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Commercial,,832.00,,,,,,,40.24,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Commercial,,3142.00,,,,,,,96.30,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,United Healthcare,Commercial,,3142.00,,,,,,,222.02,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Commercial,,832.00,,,,,,,91.69,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,Commercial,,832.00,,,,,,,57.06,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,832.00,,,,,,,20.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,United Healthcare,Commercial,,3142.00,,,,,,,280.28,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,Commercial,,2912.00,,,,,,,316.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,inpatient,,,1582.00000,949.20000,United Healthcare,Commercial,,1286.17,,,,,,,1012.48,1286.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,Commercial,,1286.17,,,,,,,298.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,Commercial,,3142.00,,,,,,,466.47,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,inpatient,,,2330.00000,1398.00000,United Healthcare,Commercial,,1894.29,,,,,,,1491.20,1894.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,Commercial,,1894.29,,,,,,,439.20,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,United Healthcare,Commercial,,3142.00,,,,,,,62.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,United Healthcare,Commercial,,832.00,,,,,,,62.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Commercial,,832.00,,,,,,,160.96,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,inpatient,,,804.00000,482.40000,United Healthcare,Commercial,,653.65,,,,,,,514.56,653.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Commercial,,653.65,,,,,,,151.55,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,inpatient,,,722.00000,433.20000,United Healthcare,Commercial,,586.99,,,,,,,462.08,586.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,United Healthcare,Commercial,,586.99,,,,,,,136.10,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,Commercial,,832.00,,,,,,,115.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,inpatient,,,577.00000,346.20000,United Healthcare,Commercial,,469.10,,,,,,,369.28,469.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,Commercial,,469.10,,,,,,,108.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,United Healthcare,Commercial,,10022.00,,,,,,,944.94,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,United Healthcare,Commercial,,3142.00,,,,,,,142.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,United Healthcare,Commercial,,832.00,,,,,,,113.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,United Healthcare,Commercial,,832.00,,,,,,,153.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Commercial,,832.00,,,,,,,116.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,inpatient,,,1275.00000,765.00000,United Healthcare,Commercial,,1036.58,,,,,,,816.00,1036.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,United Healthcare,Commercial,,1036.58,,,,,,,240.34,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,Commercial,,5754.00,,,,,,,604.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,Commercial,,5754.00,,,,,,,604.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Commercial,,3142.00,,,,,,,60.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,United Healthcare,Commercial,,8045.00,,,,,,,388.99,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Commercial,,2912.00,,,,,,,293.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,United Healthcare,Commercial,,3142.00,,,,,,,166.97,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,United Healthcare,Commercial,,2912.00,,,,,,,324.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,United Healthcare,Commercial,,2912.00,,,,,,,354.35,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,1251.65,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Commercial,,832.00,,,,,,,135.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Commercial,,832.00,,,,,,,135.54,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Commercial,,832.00,,,,,,,103.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,Commercial,,832.00,,,,,,,136.94,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,Commercial,,832.00,,,,,,,136.94,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,United Healthcare,Commercial,,8045.00,,,,,,,1012.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,inpatient,,,4925.00000,2955.00000,United Healthcare,Commercial,,4004.03,,,,,,,3152.00,4004.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,United Healthcare,Commercial,,4004.03,,,,,,,928.36,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,United Healthcare,Commercial,,832.00,,,,,,,159.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,United Healthcare,Commercial,,832.00,,,,,,,145.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,Commercial,,2912.00,,,,,,,163.76,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,Commercial,,13852.00,,,,,,,148.55,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,United Healthcare,Commercial,,8045.00,,,,,,,449.85,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,Commercial,,8045.00,,,,,,,148.55,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,Commercial,,8045.00,,,,,,,745.34,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Commercial,,2912.00,,,,,,,177.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,United Healthcare,Commercial,,2912.00,,,,,,,137.34,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Commercial,,2912.00,,,,,,,39.04,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,United Healthcare,Commercial,,2912.00,,,,,,,106.71,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,United Healthcare,Commercial,,8045.00,,,,,,,111.11,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,United Healthcare,Commercial,,2912.00,,,,,,,118.12,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,Commercial,,8045.00,,,,,,,116.72,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Commercial,,13852.00,,,,,,,133.13,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,United Healthcare,Commercial,,8045.00,,,,,,,833.43,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,United Healthcare,Commercial,,2912.00,,,,,,,426.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,United Healthcare,Commercial,,2912.00,,,,,,,268.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Commercial,,3142.00,,,,,,,293.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,United Healthcare,Commercial,,8045.00,,,,,,,138.94,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,United Healthcare,Commercial,,2912.00,,,,,,,117.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,United Healthcare,Commercial,,2912.00,,,,,,,121.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,inpatient,,,884.00000,530.40000,United Healthcare,Commercial,,718.69,,,,,,,565.76,718.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Commercial,,718.69,,,,,,,166.63,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Commercial,,13852.00,,,,,,,2814.41,18878.80,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Commercial,,13852.00,,,,,,,2814.41,18878.80,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Commercial,,13852.00,,,,,,,2104.90,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Commercial,,13852.00,,,,,,,2104.90,15260.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Commercial,,8045.00,,,,,,,2104.90,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Commercial,,8045.00,,,,,,,2104.90,15260.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,Commercial,,13852.00,,,,,,,2292.69,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,Commercial,,13852.00,,,,,,,2292.69,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,United Healthcare,Commercial,,8045.00,,,,,,,1536.13,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,Commercial,,8045.00,,,,,,,1581.98,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,Commercial,,8045.00,,,,,,,1581.98,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,United Healthcare,Commercial,,8045.00,,,,,,,960.96,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,United Healthcare,Commercial,,13852.00,,,,,,,895.09,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,Commercial,,24600.00,,,,,,,1213.61,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,Commercial,,13852.00,,,,,,,1213.61,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,Commercial,,13852.00,,,,,,,1213.61,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Commercial,,13852.00,,,,,,,879.68,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,United Healthcare,Commercial,,2912.00,,,,,,,483.88,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,United Healthcare,Commercial,,2912.00,,,,,,,495.50,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,United Healthcare,Commercial,,3142.00,,,,,,,322.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,United Healthcare,Commercial,,832.00,,,,,,,158.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,United Healthcare,Commercial,,832.00,,,,,,,75.88,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,Commercial,,832.00,,,,,,,96.50,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,United Healthcare,Commercial,,3142.00,,,,,,,56.46,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,United Healthcare,Commercial,,832.00,,,,,,,108.51,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,Commercial,,13852.00,,,,,,,1059.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,United Healthcare,Commercial,,8045.00,,,,,,,255.66,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,United Healthcare,Commercial,,13852.00,,,,,,,1500.30,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,United Healthcare,Commercial,,3142.00,,,,,,,79.08,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,Commercial,,3142.00,,,,,,,328.33,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,inpatient,,,1640.00000,984.00000,United Healthcare,Commercial,,1333.32,,,,,,,1049.60,1333.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,Commercial,,1333.32,,,,,,,309.14,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,United Healthcare,Commercial,,3142.00,,,,,,,427.63,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,inpatient,,,911.00000,546.60000,United Healthcare,Commercial,,740.64,,,,,,,583.04,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Commercial,,740.64,,,,,,,171.72,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,United Healthcare,Commercial,,8045.00,,,,,,,616.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,United Healthcare,Commercial,,8045.00,,,,,,,448.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Commercial,,3142.00,,,,,,,107.11,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,Commercial,,3142.00,,,,,,,203.40,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,United Healthcare,Commercial,,3142.00,,,,,,,771.57,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,Commercial,,3142.00,,,,,,,128.53,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,United Healthcare,Commercial,,3142.00,,,,,,,160.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,Commercial,,3142.00,,,,,,,128.53,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,United Healthcare,Commercial,,832.00,,,,,,,139.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,Commercial,,3142.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,Commercial,,3142.00,,,,,,,476.08,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,United Healthcare,Commercial,,5754.00,,,,,,,500.90,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,United Healthcare,Commercial,,5754.00,,,,,,,496.10,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,United Healthcare,Commercial,,3142.00,,,,,,,127.33,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Commercial,,2912.00,,,,,,,232.23,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Commercial,,2912.00,,,,,,,35.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,United Healthcare,Commercial,,13852.00,,,,,,,1259.46,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,United Healthcare,Commercial,,13852.00,,,,,,,1554.95,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,832.00,,,,,,,18.02,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,United Healthcare,Commercial,,5754.00,,,,,,,498.70,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Commercial,,832.00,,,,,,,58.86,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,Commercial,,832.00,,,,,,,46.25,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,inpatient,,,208.00000,124.80000,United Healthcare,Commercial,,169.10,,,,,,,133.12,169.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,Commercial,,169.10,,,,,,,39.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Commercial,,832.00,,,,,,,80.88,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,United Healthcare,Commercial,,832.00,,,,,,,81.68,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Commercial,,2912.00,,,,,,,40.44,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,United Healthcare,Commercial,,24600.00,,,,,,,900.30,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,United Healthcare,Commercial,,24600.00,,,,,,,847.65,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,Commercial,,24600.00,,,,,,,584.78,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,United Healthcare,Commercial,,4681.00,,,,,,,915.71,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Commercial,,2912.00,,,,,,,211.21,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,inpatient,,,1055.00000,633.00000,United Healthcare,Commercial,,857.72,,,,,,,675.20,857.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Commercial,,857.72,,,,,,,198.87,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,United Healthcare,Commercial,,2912.00,,,,,,,294.49,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Commercial,,832.00,,,,,,,57.66,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,inpatient,,,288.00000,172.80000,United Healthcare,Commercial,,234.14,,,,,,,184.32,234.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Commercial,,234.14,,,,,,,54.29,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Commercial,,2912.00,,,,,,,383.98,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,inpatient,,,1918.00000,1150.80000,United Healthcare,Commercial,,1559.33,,,,,,,1227.52,1559.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Commercial,,1559.33,,,,,,,361.54,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,inpatient,,,1173.00000,703.80000,United Healthcare,Commercial,,953.65,,,,,,,750.72,953.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,United Healthcare,Commercial,,953.65,,,,,,,221.11,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Commercial,,2912.00,,,,,,,502.70,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,inpatient,,,2511.00000,1506.60000,United Healthcare,Commercial,,2041.44,,,,,,,1607.04,2041.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Commercial,,2041.44,,,,,,,473.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,inpatient,,,2034.00000,1220.40000,United Healthcare,Commercial,,1653.64,,,,,,,1301.76,1653.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,Commercial,,1653.64,,,,,,,383.41,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,Commercial,,2912.00,,,,,,,347.95,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,inpatient,,,1738.00000,1042.80000,United Healthcare,Commercial,,1412.99,,,,,,,1112.32,1412.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,Commercial,,1412.99,,,,,,,327.61,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,Commercial,,2912.00,,,,,,,316.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,inpatient,,,1583.00000,949.80000,United Healthcare,Commercial,,1286.98,,,,,,,1013.12,1286.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,Commercial,,1286.98,,,,,,,298.40,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,inpatient,,,1646.00000,987.60000,United Healthcare,Commercial,,1338.20,,,,,,,1053.44,1338.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,United Healthcare,Commercial,,1338.20,,,,,,,310.27,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,inpatient,,,1710.00000,1026.00000,United Healthcare,Commercial,,1390.23,,,,,,,1094.40,1390.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,United Healthcare,Commercial,,1390.23,,,,,,,322.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,Commercial,,2912.00,,,,,,,303.30,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,inpatient,,,1515.00000,909.00000,United Healthcare,Commercial,,1231.69,,,,,,,969.60,1231.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,Commercial,,1231.69,,,,,,,285.58,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,Commercial,,2912.00,,,,,,,302.10,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,inpatient,,,1509.00000,905.40000,United Healthcare,Commercial,,1226.82,,,,,,,965.76,1226.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,Commercial,,1226.82,,,,,,,284.45,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,Commercial,,5754.00,,,,,,,665.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,inpatient,,,3322.00000,1993.20000,United Healthcare,Commercial,,2700.79,,,,,,,2126.08,2700.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,Commercial,,2700.79,,,,,,,626.20,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,inpatient,,,1860.00000,1116.00000,United Healthcare,Commercial,,1512.18,,,,,,,1190.40,1512.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,United Healthcare,Commercial,,1512.18,,,,,,,350.61,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,Commercial,,2912.00,,,,,,,363.96,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,inpatient,,,1818.00000,1090.80000,United Healthcare,Commercial,,1478.03,,,,,,,1163.52,1478.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,Commercial,,1478.03,,,,,,,342.69,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,United Healthcare,Commercial,,832.00,,,,,,,73.67,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,inpatient,,,4857.00000,2914.20000,United Healthcare,Commercial,,3948.74,,,,,,,3108.48,3948.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Commercial,,3948.74,,,,,,,915.54,6735.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,United Healthcare,Commercial,,8045.00,,,,,,,568.77,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,United Healthcare,Commercial,,8045.00,,,,,,,598.60,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,United Healthcare,Commercial,,24600.00,,,,,,,4031.43,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Commercial,,24600.00,,,,,,,2143.34,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Commercial,,832.00,,,,,,,103.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,Commercial,,2912.00,,,,,,,215.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,United Healthcare,Commercial,,832.00,,,,,,,138.74,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,United Healthcare,Commercial,,2912.00,,,,,,,155.36,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,United Healthcare,Commercial,,3142.00,,,,,,,1092.69,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,United Healthcare,Commercial,,3142.00,,,,,,,944.74,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,United Healthcare,Commercial,,3142.00,,,,,,,973.77,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,United Healthcare,Commercial,,3142.00,,,,,,,337.94,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,United Healthcare,Commercial,,832.00,,,,,,,114.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,United Healthcare,Commercial,,13852.00,,,,,,,1493.89,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,Commercial,,2912.00,,,,,,,398.40,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,United Healthcare,Commercial,,2912.00,,,,,,,531.13,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,17547.26,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,United Healthcare,Commercial,,24600.00,,,,,,,838.24,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,United Healthcare,Commercial,,24600.00,,,,,,,2658.46,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,United Healthcare,Commercial,,24600.00,,,,,,,1771.37,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,United Healthcare,Commercial,,2912.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,United Healthcare,Commercial,,8045.00,,,,,,,248.45,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,inpatient,,,1696.00000,1017.60000,United Healthcare,Commercial,,1378.85,,,,,,,1085.44,1378.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,Commercial,,1378.85,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,Commercial,,2912.00,,,,,,,375.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,inpatient,,,1876.00000,1125.60000,United Healthcare,Commercial,,1525.19,,,,,,,1200.64,1525.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,Commercial,,1525.19,,,,,,,353.63,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,inpatient,,,1732.00000,1039.20000,United Healthcare,Commercial,,1408.12,,,,,,,1108.48,1408.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,Commercial,,1408.12,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,United Healthcare,Commercial,,8045.00,,,,,,,258.06,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,Commercial,,8045.00,,,,,,,146.75,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,United Healthcare,Commercial,,13852.00,,,,,,,1434.43,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,United Healthcare,Commercial,,13852.00,,,,,,,358.56,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,United Healthcare,Commercial,,2912.00,,,,,,,371.17,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,United Healthcare,Commercial,,2912.00,,,,,,,209.41,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,United Healthcare,Commercial,,4681.00,,,,,,,717.92,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,United Healthcare,Commercial,,4681.00,,,,,,,717.92,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,United Healthcare,Commercial,,8045.00,,,,,,,693.69,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,United Healthcare,Commercial,,8045.00,,,,,,,596.60,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,United Healthcare,Commercial,,8045.00,,,,,,,1230.03,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,United Healthcare,Commercial,,8045.00,,,,,,,1430.23,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,United Healthcare,Commercial,,8045.00,,,,,,,1059.26,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,United Healthcare,Commercial,,8045.00,,,,,,,954.35,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,United Healthcare,Commercial,,3142.00,,,,,,,238.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,United Healthcare,Commercial,,13852.00,,,,,,,1609.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,United Healthcare,Commercial,,13852.00,,,,,,,1660.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,United Healthcare,Commercial,,13852.00,,,,,,,2496.49,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,United Healthcare,Commercial,,8045.00,,,,,,,1392.39,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,United Healthcare,Commercial,,2912.00,,,,,,,178.38,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,Commercial,,2912.00,,,,,,,322.52,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,United Healthcare,Commercial,,2912.00,,,,,,,238.44,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,United Healthcare,Commercial,,5754.00,,,,,,,741.14,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,United Healthcare,Commercial,,5754.00,,,,,,,650.85,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,United Healthcare,Commercial,,2912.00,,,,,,,651.45,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,United Healthcare,Commercial,,2912.00,,,,,,,561.56,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,United Healthcare,Commercial,,8045.00,,,,,,,954.75,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,United Healthcare,Commercial,,8045.00,,,,,,,1107.51,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,United Healthcare,Commercial,,8045.00,,,,,,,1623.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,United Healthcare,Commercial,,832.00,,,,,,,150.35,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,United Healthcare,Commercial,,4681.00,,,,,,,1567.77,5418.27,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,United Healthcare,Commercial,,4681.00,,,,,,,762.16,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,United Healthcare,Commercial,,52940.00,,,,,,,3427.62,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,United Healthcare,Commercial,,13852.00,,,,,,,1466.87,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,Commercial,,2912.00,,,,,,,180.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,United Healthcare,Commercial,,13852.00,,,,,,,3451.05,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,11196.33,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9871.02,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,Commercial,,13852.00,,,,,,,1760.76,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,Commercial,,13852.00,,,,,,,1760.76,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,6449.89,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,United Healthcare,Commercial,,3142.00,,,,,,,582.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,United Healthcare,Commercial,,4681.00,,,,,,,474.07,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,United Healthcare,Commercial,,4681.00,,,,,,,474.07,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Commercial,,4681.00,,,,,,,160.96,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,United Healthcare,Commercial,,2912.00,,,,,,,990.00,4538.86,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,inpatient,,,1686.00000,1011.60000,United Healthcare,Commercial,,1370.72,,,,,,,1079.04,1370.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,United Healthcare,Commercial,,1370.72,,,,,,,317.81,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,United Healthcare,Commercial,,2912.00,,,,,,,404.60,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,United Healthcare,Commercial,,2912.00,,,,,,,594.81,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Commercial,,832.00,,,,,,,97.50,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Commercial,,2912.00,,,,,,,572.37,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Commercial,,3142.00,,,,,,,572.37,10768.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Commercial,,832.00,,,,,,,43.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Commercial,,832.00,,,,,,,43.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,Commercial,,5754.00,,,,,,,1990.79,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,Commercial,,8045.00,,,,,,,1990.79,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,United Healthcare,Commercial,,3142.00,,,,,,,803.60,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,United Healthcare,Commercial,,10022.00,,,,,,,1219.62,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,United Healthcare,Commercial,,2912.00,,,,,,,594.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,1251.65,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Commercial,,2912.00,,,,,,,125.93,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Commercial,,2912.00,,,,,,,572.37,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Commercial,,3142.00,,,,,,,572.37,10768.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,United Healthcare,Commercial,,1197.00,,,,,,,651.00,2905.00,per diem,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,United Healthcare,Commercial,,2912.00,,,,,,,392.19,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,United Healthcare,Commercial,,246.00,,,,,,,78.48,294.00,per diem,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Commercial,,246.00,,,,,,,91.89,344.25,per diem,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Commercial,,246.00,,,,,,,74.67,279.75,per diem,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Commercial,,246.00,,,,,,,74.67,279.75,per diem,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,United Healthcare,Commercial,,246.00,,,,,,,78.48,294.00,per diem,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,United Healthcare,Commercial,,467.00,,,,,,,64.06,467.00,per diem,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,United Healthcare,Commercial,,467.00,,,,,,,102.31,670.50,per diem,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,United Healthcare,Commercial,,467.00,,,,,,,59.02,467.00,per diem,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,United Healthcare,Commercial,,467.00,,,,,,,102.31,856.50,per diem,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,Commercial,,467.00,,,,,,,102.31,702.00,per diem,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,United Healthcare,Commercial,,467.00,,,,,,,102.31,793.50,per diem,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,Commercial,,467.00,,,,,,,58.38,578.25,per diem,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,United Healthcare,Commercial,,467.00,,,,,,,102.31,627.75,per diem,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Commercial,,467.00,,,,,,,63.06,467.00,per diem,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Commercial,,467.00,,,,,,,102.31,568.50,per diem,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,United Healthcare,Commercial,,467.00,,,,,,,62.06,467.00,per diem,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,United Healthcare,Commercial,,467.00,,,,,,,102.31,618.75,per diem,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,United Healthcare,Commercial,,467.00,,,,,,,160.28,720.75,per diem,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Commercial,,467.00,,,,,,,103.90,467.00,per diem,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Commercial,,467.00,,,,,,,97.56,477.75,per diem,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Commercial,,467.00,,,,,,,85.49,467.00,per diem,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,United Healthcare,Commercial,,467.00,,,,,,,102.31,626.25,per diem,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,United Healthcare,Commercial,,467.00,,,,,,,102.31,501.00,per diem,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Commercial,,467.00,,,,,,,89.84,467.00,per diem,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,United Healthcare,Commercial,,467.00,,,,,,,131.73,493.50,per diem,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Commercial,,467.00,,,,,,,102.31,777.75,per diem,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,United Healthcare,Commercial,,467.00,,,,,,,46.82,617.25,per diem,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Commercial,,467.00,,,,,,,102.31,689.25,per diem,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,United Healthcare,Commercial,,467.00,,,,,,,60.26,467.00,per diem,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,United Healthcare,Commercial,,467.00,,,,,,,54.52,883.50,per diem,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,United Healthcare,Commercial,,467.00,,,,,,,63.52,573.00,per diem,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,United Healthcare,Commercial,,467.00,,,,,,,50.05,467.00,per diem,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,Commercial,,467.00,,,,,,,46.25,467.00,per diem,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Commercial,,467.00,,,,,,,37.24,467.00,per diem,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,United Healthcare,Commercial,,467.00,,,,,,,220.62,826.50,per diem,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,United Healthcare,Commercial,,467.00,,,,,,,165.16,618.75,per diem,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,United Healthcare,Commercial,,467.00,,,,,,,39.84,467.00,per diem,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,467.00,,,,,,,8.28,467.00,per diem,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,Commercial,,467.00,,,,,,,136.94,513.00,per diem,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Commercial,,467.00,,,,,,,84.48,467.00,per diem,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,Commercial,,467.00,,,,,,,102.31,725.25,per diem,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,United Healthcare,Commercial,,467.00,,,,,,,144.94,543.00,per diem,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Commercial,,467.00,,,,,,,82.68,467.00,per diem,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Commercial,,467.00,,,,,,,84.71,467.00,per diem,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Commercial,,467.00,,,,,,,91.89,467.00,per diem,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,467.00,,,,,,,22.02,467.00,per diem,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Commercial,,246.00,,,,,,,27.83,246.00,per diem,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,United Healthcare,Commercial,,246.00,,,,,,,13.41,246.00,per diem,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Commercial,,246.00,,,,,,,21.82,246.00,per diem,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,United Healthcare,Commercial,,3257.00,,,,,,,1113.08,5598.00,per diem,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,United Healthcare,Commercial,,3257.00,,,,,,,811.19,5598.00,per diem,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,United Healthcare,Commercial,,3257.00,,,,,,,728.92,5598.00,per diem,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,United Healthcare,Commercial,,3257.00,,,,,,,1131.38,5598.00,per diem,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Commercial,,3257.00,,,,,,,1071.94,5598.00,per diem,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,United Healthcare,Commercial,,1560.00,,,,,,,257.00,2016.00,per diem,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Commercial,,3257.00,,,,,,,1071.94,5598.00,per diem,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Commercial,,3257.00,,,,,,,1071.94,5598.00,per diem,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,United Healthcare,Commercial,,3257.00,,,,,,,162.27,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,United Healthcare,Commercial,,3257.00,,,,,,,266.85,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,United Healthcare,Commercial,,3257.00,,,,,,,533.53,5598.00,per diem,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,United Healthcare,Commercial,,3257.00,,,,,,,812.24,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,United Healthcare,Commercial,,3257.00,,,,,,,727.88,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,United Healthcare,Commercial,,3257.00,,,,,,,1054.86,5598.00,per diem,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,United Healthcare,Commercial,,3257.00,,,,,,,1550.57,5598.00,per diem,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,United Healthcare,Commercial,,968.00,,,,,,,73.94,968.00,per diem,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,Commercial,,968.00,,,,,,,126.13,968.00,per diem,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Commercial,,968.00,,,,,,,80.11,968.00,per diem,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,United Healthcare,Commercial,,968.00,,,,,,,141.98,968.00,per diem,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Commercial,,968.00,,,,,,,266.00,2052.00,per diem,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,Commercial,,968.00,,,,,,,266.00,1851.75,per diem,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Commercial,,968.00,,,,,,,67.48,968.00,per diem,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,United Healthcare,Commercial,,1005.00,,,,,,,760.10,3601.53,per diem,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,4352.85,per diem,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3155.53,per diem,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3286.68,per diem,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3127.52,per diem,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3810.99,per diem,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,United Healthcare,Commercial,,1005.00,,,,,,,760.10,2893.96,per diem,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3525.98,per diem,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2825.00,per diem,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3252.52,per diem,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,United Healthcare,Commercial,,1005.00,,,,,,,743.14,2917.94,per diem,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3522.51,per diem,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2876.72,per diem,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3192.74,per diem,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2972.99,per diem,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,United Healthcare,Commercial,,1005.00,,,,,,,84.71,2825.00,per diem,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Commercial,,1005.00,,,,,,,50.65,2825.00,per diem,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,United Healthcare,Commercial,52,1005.00,,,,,,,791.19,2825.00,per diem,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,United Healthcare,Commercial,52,1005.00,,,,,,,787.39,2825.00,per diem,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2825.00,per diem,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3169.56,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3113.44,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2996.32,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3326.94,per diem,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2828.57,per diem,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3407.46,per diem,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2825.00,per diem,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,3981.96,per diem,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,2825.00,per diem,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,United Healthcare,Commercial,,1005.00,,,,,,,343.59,4009.45,per diem,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,United Healthcare,Commercial,,1005.00,,,,,,,845.85,3021.02,per diem,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,United Healthcare,Commercial,,1005.00,,,,,,,647.85,3021.02,per diem,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,United Healthcare,Commercial,,1005.00,,,,,,,895.29,3021.02,per diem,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,Commercial,,1005.00,,,,,,,848.45,3010.70,per diem,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,Commercial,,1005.00,,,,,,,848.45,3010.70,per diem,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,Commercial,,1005.00,,,,,,,848.45,3010.70,per diem,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,United Healthcare,Commercial,,1005.00,,,,,,,707.71,2825.00,per diem,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,United Healthcare,Commercial,,1005.00,,,,,,,814.41,2825.00,per diem,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,United Healthcare,Commercial,,1005.00,,,,,,,814.41,2825.00,per diem,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,United Healthcare,Commercial,,1005.00,,,,,,,899.50,3027.91,per diem,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,United Healthcare,Commercial,,1005.00,,,,,,,650.65,3027.91,per diem,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,United Healthcare,Commercial,,1005.00,,,,,,,919.72,3027.91,per diem,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,United Healthcare,Commercial,,1005.00,,,,,,,894.09,2825.00,per diem,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,United Healthcare,Commercial,,1005.00,,,,,,,845.44,2825.00,per diem,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,United Healthcare,Commercial,,1005.00,,,,,,,845.44,2825.00,per diem,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,Commercial,,1005.00,,,,,,,908.91,3048.50,per diem,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,Commercial,,1005.00,,,,,,,908.91,3048.50,per diem,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,Commercial,,1005.00,,,,,,,908.91,3048.50,per diem,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,United Healthcare,Commercial,,1005.00,,,,,,,206.81,2825.00,per diem,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,United Healthcare,Commercial,,1005.00,,,,,,,232.56,2825.00,per diem,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,United Healthcare,Commercial,,1005.00,,,,,,,791.19,2825.00,per diem,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,United Healthcare,Commercial,,1005.00,,,,,,,375.38,2825.00,per diem,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Commercial,,268.00,,,,,,,41.04,319.50,per diem,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Commercial,,134.00,,,,,,,64.86,243.00,per diem,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Commercial,,134.00,,,,,,,57.15,299.25,per diem,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,Commercial,,2912.00,,,,,,,349.35,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,inpatient,,,1745.00000,1047.00000,United Healthcare,Commercial,,1418.68,,,,,,,1116.80,1418.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,Commercial,,1418.68,,,,,,,328.93,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,inpatient,,,158.00000,94.80000,United Healthcare,Commercial,,128.45,,,,,,,101.12,128.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Commercial,,128.45,,,,,,,29.78,128.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,Commercial,,2912.00,,,,,,,366.57,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,inpatient,,,1831.00000,1098.60000,United Healthcare,Commercial,,1488.60,,,,,,,1171.84,1488.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,Commercial,,1488.60,,,,,,,345.14,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,United Healthcare,Commercial,,269.00,,,,,,,102.31,678.75,per diem,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,United Healthcare,Commercial,,269.00,,,,,,,94.01,405.00,per diem,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Commercial,,269.00,,,,,,,82.70,356.25,per diem,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Commercial,,269.00,,,,,,,82.70,356.25,per diem,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,United Healthcare,Commercial,,269.00,,,,,,,150.52,974.25,per diem,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Commercial,,269.00,,,,,,,175.00,777.75,per diem,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,Commercial,,269.00,,,,,,,102.31,635.25,per diem,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Commercial,,269.00,,,,,,,102.31,462.00,per diem,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,Commercial,,269.00,,,,,,,104.29,449.25,per diem,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Commercial,,269.00,,,,,,,50.84,269.00,per diem,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,4.01,,,,,,,4.01,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,Commercial,,16.34,,,,,,,10.24,323.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Commercial,,73.96,,,,,,,46.38,237.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Commercial,,13.44,,,,,,,8.42,216.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,United Healthcare,Commercial,,73.70,,,,,,,46.20,510.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,Commercial,,12.64,,,,,,,7.92,210.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Commercial,,253.66,,,,,,,116.52,436.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Commercial,,224.08,,,,,,,116.52,436.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,United Healthcare,Commercial,,775.01,,,,,,,287.49,1077.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Commercial,,405.68,,,,,,,150.55,564.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,Commercial,,1615.18,,,,,,,373.57,2152.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,United Healthcare,Commercial,,1615.18,,,,,,,870.87,3262.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,United Healthcare,Commercial,,91.46,,,,,,,50.45,189.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Commercial,,102.16,,,,,,,35.44,136.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,Commercial,,79.43,,,,,,,55.33,276.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,Commercial,,62.50,,,,,,,36.64,137.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Commercial,,230.45,,,,,,,85.49,320.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,Commercial,,140.80,,,,,,,65.87,246.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Commercial,,48.73,,,,,,,33.95,206.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Commercial,,101.11,,,,,,,63.40,299.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,United Healthcare,Commercial,,306.32,,,,,,,126.33,473.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Commercial,,240.51,,,,,,,103.70,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,United Healthcare,Commercial,,332.70,,,,,,,174.97,655.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,United Healthcare,Commercial,,332.70,,,,,,,112.51,436.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Commercial,,3.47,,,,,,,2.18,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,Commercial,,485.33,,,,,,,72.47,646.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,United Healthcare,Commercial,,71.11,,,,,,,49.54,567.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Commercial,,67.53,,,,,,,42.34,228.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Commercial,,311.73,,,,,,,133.13,498.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Commercial,,325.82,,,,,,,84.48,434.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,Commercial,,622.12,,,,,,,191.39,816.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,Commercial,,561.96,,,,,,,119.92,748.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Commercial,,177.44,,,,,,,84.48,316.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Commercial,,112.55,,,,,,,72.10,343.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,United Healthcare,Commercial,,142.04,,,,,,,72.87,273.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,United Healthcare,Commercial,,534.62,,,,,,,335.20,1893.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,United Healthcare,Commercial,,518.88,,,,,,,325.32,1626.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,Commercial,,274.22,,,,,,,171.93,829.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,United Healthcare,Commercial,,236.57,,,,,,,104.30,390.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,United Healthcare,Commercial,,191.35,,,,,,,110.71,414.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,United Healthcare,Commercial,,343.25,,,,,,,67.27,457.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Commercial,,173.55,,,,,,,25.63,173.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Commercial,,417.72,,,,,,,102.50,556.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Commercial,,269.09,,,,,,,80.88,358.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Commercial,,411.86,,,,,,,80.88,549.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Commercial,,25.96,,,,,,,9.41,35.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,United Healthcare,Commercial,,7.02,,,,,,,2.80,10.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Commercial,,13.52,,,,,,,8.48,84.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Commercial,,14.94,,,,,,,9.37,122.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Commercial,,11.63,,,,,,,7.29,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Commercial,,6.67,,,,,,,4.18,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Commercial,,6.62,,,,,,,4.14,33.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Commercial,,90.02,,,,,,,37.84,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,United Healthcare,Commercial,,13.09,,,,,,,8.21,198.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,65.74,,,,,,,0.00200,76.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Commercial,,10.84,,,,,,,6.80,66.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Commercial,,20.72,,,,,,,12.99,189.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Commercial,,90.02,,,,,,,37.84,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,United Healthcare,Commercial,,90.02,,,,,,,60.28,297.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Commercial,,90.02,,,,,,,31.03,118.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Commercial,,90.02,,,,,,,18.62,118.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Commercial,,90.02,,,,,,,60.28,401.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,23.33,,,,,,,14.63,68.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,23.33,,,,,,,14.63,68.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,23.33,,,,,,,14.63,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,22.53,,,,,,,14.13,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,20.54,,,,,,,10.21,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,20.96,,,,,,,13.13,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Commercial,,25.35,,,,,,,15.89,99.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Commercial,,25.35,,,,,,,15.89,99.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Commercial,,25.35,,,,,,,15.89,99.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,22.73,,,,,,,12.61,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.23,,,,,,,6.41,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Commercial,,21.30,,,,,,,5.81,28.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,20.51,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Commercial,,21.29,,,,,,,13.35,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Commercial,,21.25,,,,,,,13.32,132.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Commercial,,21.25,,,,,,,13.32,93.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Commercial,,21.88,,,,,,,7.81,30.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Commercial,,24.96,,,,,,,15.65,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Commercial,,24.96,,,,,,,15.65,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Commercial,,24.96,,,,,,,15.65,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,20.96,,,,,,,13.13,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,20.96,,,,,,,13.13,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,20.96,,,,,,,13.13,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Commercial,,50.46,,,,,,,30.83,115.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Commercial,,6.99,,,,,,,4.38,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Commercial,,12.64,,,,,,,7.92,32.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,12.64,,,,,,,7.92,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,7.66,,,,,,,4.80,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Commercial,,10.83,,,,,,,7.55,31.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,8.94,,,,,,,5.61,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,8.94,,,,,,,5.61,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,24.05,,,,,,,16.75,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Commercial,,20.79,,,,,,,9.61,36.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Commercial,,25.96,,,,,,,16.27,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,22.54,,,,,,,14.13,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Commercial,,10.03,,,,,,,6.29,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Commercial,,10.03,,,,,,,6.29,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Commercial,,10.03,,,,,,,6.29,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Commercial,,25.02,,,,,,,15.69,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Commercial,,7.75,,,,,,,4.87,31.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Commercial,,7.75,,,,,,,4.87,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,7.75,,,,,,,4.87,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,United Healthcare,Commercial,,6.10,,,,,,,4.25,45.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Commercial,,7.41,,,,,,,5.16,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Commercial,,5.89,,,,,,,4.10,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Commercial,,45.80,,,,,,,28.71,124.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,,7.98,,,,,,,5.01,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,,7.98,,,,,,,5.01,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Commercial,,9.33,,,,,,,5.85,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Commercial,,7.56,,,,,,,4.73,39.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,19.06,,,,,,,11.95,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,19.06,,,,,,,11.95,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,United Healthcare,Commercial,,29.33,,,,,,,18.39,193.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,16.61,,,,,,,10.42,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,21.84,,,,,,,13.70,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,21.84,,,,,,,13.70,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,7.12,,,,,,,4.46,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,8.01,,,,,,,5.58,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,8.01,,,,,,,5.58,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,7.56,,,,,,,4.80,18.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Commercial,,6.74,,,,,,,4.22,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Commercial,,53.70,,,,,,,28.73,182.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,37.75,,,,,,,18.02,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,37.75,,,,,,,18.02,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Commercial,,25.96,,,,,,,18.08,135.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Commercial,,25.22,,,,,,,15.81,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Commercial,,21.25,,,,,,,13.32,109.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,10.07,,,,,,,6.31,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Commercial,,17.87,,,,,,,11.20,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Commercial,,7.92,,,,,,,4.97,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,8.01,,,,,,,5.02,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,8.01,,,,,,,5.02,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,United Healthcare,Commercial,,43.22,,,,,,,27.10,224.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,United Healthcare,Commercial,,23.06,,,,,,,1.20,31.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Commercial,,7.88,,,,,,,4.95,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Commercial,,21.10,,,,,,,13.22,150.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,Commercial,,99.65,,,,,,,62.48,434.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Commercial,,22.75,,,,,,,14.26,117.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Commercial,,14.40,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Commercial,,14.40,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Commercial,,14.40,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Commercial,,14.40,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Commercial,,15.32,,,,,,,7.81,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,36.30,,,,,,,25.29,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Commercial,,109.68,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Commercial,,109.68,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Commercial,,109.68,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Commercial,,109.68,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,13.61,,,,,,,9.48,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Commercial,,6.09,,,,,,,3.81,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,6.09,,,,,,,3.81,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,6.09,,,,,,,3.81,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,6.09,,,,,,,3.81,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Commercial,,6.09,,,,,,,3.81,53.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,Commercial,,7.34,,,,,,,4.61,128.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Commercial,,19.91,,,,,,,12.48,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,6.07,,,,,,,3.80,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,6.07,,,,,,,3.80,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Commercial,,11.14,,,,,,,6.98,58.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,United Healthcare,Commercial,,28.76,,,,,,,18.02,178.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Commercial,,28.64,,,,,,,17.96,117.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Commercial,,19.45,,,,,,,12.20,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,United Healthcare,Commercial,,19.91,,,,,,,12.48,165.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Commercial,,27.93,,,,,,,17.52,90.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Commercial,,11.14,,,,,,,7.76,114.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,15.02,,,,,,,9.42,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Commercial,,11.42,,,,,,,7.95,35.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Commercial,,11.42,,,,,,,7.95,35.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Commercial,,7.34,,,,,,,4.60,17.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,United Healthcare,Commercial,,26.09,,,,,,,17.38,147.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Commercial,,35.44,,,,,,,23.38,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Commercial,,17.84,,,,,,,8.01,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Commercial,,17.84,,,,,,,11.18,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Commercial,,17.69,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.01,,,,,,,6.28,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,16.53,,,,,,,11.22,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Commercial,,9.35,,,,,,,5.86,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Commercial,,9.35,,,,,,,5.86,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,30.37,,,,,,,10.81,41.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Commercial,,29.25,,,,,,,8.41,40.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Commercial,,10.66,,,,,,,6.68,118.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Commercial,,10.66,,,,,,,6.68,118.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,Commercial,,12.67,,,,,,,7.94,111.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Commercial,,14.76,,,,,,,10.19,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,10.36,,,,,,,6.50,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,10.36,,,,,,,6.50,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,10.36,,,,,,,6.21,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Commercial,,19.98,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Commercial,,54.67,,,,,,,20.02,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Commercial,,24.05,,,,,,,16.75,107.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,24.05,,,,,,,16.22,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Commercial,,10.23,,,,,,,6.41,62.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,10.54,,,,,,,6.62,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Commercial,,63.85,,,,,,,28.63,107.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Commercial,,63.85,,,,,,,35.44,132.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Commercial,,5.55,,,,,,,3.47,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Commercial,,5.55,,,,,,,3.47,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Commercial,,5.55,,,,,,,3.47,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,8.01,,,,,,,5.02,43.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,7.34,,,,,,,4.60,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Commercial,,8.05,,,,,,,5.61,80.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,United Healthcare,Commercial,,8.05,,,,,,,0.40040,11.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,Commercial,,136.61,,,,,,,65.87,246.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Commercial,,7.12,,,,,,,4.62,41.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,6.67,,,,,,,4.59,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,6.67,,,,,,,4.59,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,6.67,,,,,,,4.59,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,22.57,,,,,,,14.15,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Commercial,,32.27,,,,,,,20.23,109.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,United Healthcare,Commercial,,29.98,,,,,,,18.80,170.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Commercial,,28.46,,,,,,,17.84,161.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Commercial,,28.46,,,,,,,17.84,161.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Commercial,,5.66,,,,,,,3.56,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,5.66,,,,,,,3.56,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,5.66,,,,,,,3.56,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Commercial,,5.66,,,,,,,3.88,39.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Commercial,,16.61,,,,,,,10.42,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Commercial,,27.59,,,,,,,10.01,38.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Commercial,,27.59,,,,,,,13.21,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Commercial,,7.45,,,,,,,4.67,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Commercial,,7.52,,,,,,,4.91,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Commercial,,7.52,,,,,,,4.91,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Commercial,,7.52,,,,,,,4.71,32.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Commercial,,4.57,,,,,,,3.00,11.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,Commercial,,39.93,,,,,,,25.04,125.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Commercial,,10.62,,,,,,,6.66,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Commercial,,13.95,,,,,,,8.75,120.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,United Healthcare,Commercial,,26.00,,,,,,,16.30,142.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,8.01,,,,,,,5.02,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Commercial,,8.20,,,,,,,5.14,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,19.74,,,,,,,12.38,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Commercial,,8.89,,,,,,,5.57,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Commercial,,21.94,,,,,,,13.75,100.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Commercial,,26.21,,,,,,,16.43,97.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Commercial,,17.36,,,,,,,12.10,81.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,6.11,,,,,,,3.83,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Commercial,,7.74,,,,,,,5.39,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,6.99,,,,,,,4.38,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Commercial,,7.34,,,,,,,4.93,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Commercial,,7.34,,,,,,,4.93,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Commercial,,90.02,,,,,,,26.03,118.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,United Healthcare,Commercial,,90.02,,,,,,,38.64,144.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,23.29,,,,,,,10.81,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Commercial,,12.19,,,,,,,7.63,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Commercial,,8.07,,,,,,,2.40,11.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Commercial,,23.29,,,,,,,14.60,278.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Commercial,,23.29,,,,,,,14.60,278.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Commercial,,28.41,,,,,,,17.82,168.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Commercial,,17.26,,,,,,,6.41,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Commercial,,8.01,,,,,,,5.02,105.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Commercial,,20.04,,,,,,,12.56,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Commercial,,39.38,,,,,,,19.42,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,39.38,,,,,,,16.22,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,39.38,,,,,,,16.22,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,United Healthcare,Commercial,,18.56,,,,,,,11.64,102.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Commercial,,21.26,,,,,,,13.33,90.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,United Healthcare,Commercial,,21.26,,,,,,,1.60,29.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,Commercial,,27.75,,,,,,,4.40,38.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Commercial,,27.75,,,,,,,17.39,79.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,Commercial,,18.64,,,,,,,11.69,130.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Commercial,,18.64,,,,,,,7.41,27.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Commercial,,32.20,,,,,,,20.19,96.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Commercial,,32.20,,,,,,,20.19,200.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Commercial,,8.01,,,,,,,5.02,110.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Commercial,,41.67,,,,,,,29.02,204.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,Commercial,,34.57,,,,,,,21.67,155.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Commercial,,45.41,,,,,,,10.01,62.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,Commercial,,58.37,,,,,,,36.60,177.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,41.43,,,,,,,25.98,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,41.43,,,,,,,23.62,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,381.82,,,,,,,16.22,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,34.63,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,United Healthcare,Commercial,,58.37,,,,,,,36.60,154.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,Commercial,,58.37,,,,,,,8.21,80.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Commercial,,72.69,,,,,,,45.57,219.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Commercial,,108.30,,,,,,,40.24,150.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Commercial,,22.51,,,,,,,9.21,34.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Commercial,,16.07,,,,,,,11.19,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Commercial,,16.07,,,,,,,11.19,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Commercial,,16.46,,,,,,,10.01,37.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Commercial,,8.77,,,,,,,5.50,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,United Healthcare,Commercial,,95.90,,,,,,,44.64,167.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,United Healthcare,Commercial,,23.91,,,,,,,4.20,25.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,6.62,,,,,,,4.14,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Commercial,,6.81,,,,,,,4.27,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Commercial,,6.81,,,,,,,4.27,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Commercial,,26.35,,,,,,,13.61,51.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,,22.27,,,,,,,13.96,87.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Commercial,,26.07,,,,,,,16.34,129.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Commercial,,23.66,,,,,,,14.83,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Commercial,,28.07,,,,,,,17.60,87.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Commercial,,28.07,,,,,,,17.60,87.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,15.75,,,,,,,9.87,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Commercial,,15.75,,,,,,,3.00,21.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,,23.46,,,,,,,16.34,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,,23.46,,,,,,,16.34,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Commercial,,12.98,,,,,,,7.01,26.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Commercial,,20.40,,,,,,,9.01,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,Commercial,,29.95,,,,,,,13.81,51.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,Commercial,,13.75,,,,,,,8.62,345.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,21.20,,,,,,,12.61,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Commercial,,18.21,,,,,,,11.42,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Commercial,,16.61,,,,,,,10.42,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,19.16,,,,,,,7.21,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Commercial,,17.42,,,,,,,10.92,146.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Commercial,,19.16,,,,,,,12.02,62.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,United Healthcare,Commercial,,29.95,,,,,,,2.20,41.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,29.95,,,,,,,5.61,41.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Commercial,,19.93,,,,,,,7.01,27.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Commercial,,22.27,,,,,,,13.96,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Commercial,,22.29,,,,,,,13.98,81.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,20.48,,,,,,,10.81,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,19.93,,,,,,,11.21,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,22.07,,,,,,,13.84,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,Commercial,,152.46,,,,,,,106.21,595.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,United Healthcare,Commercial,,89.37,,,,,,,62.26,335.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,United Healthcare,Commercial,,89.37,,,,,,,53.25,199.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,United Healthcare,Commercial,,450.80,,,,,,,114.11,601.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,Commercial,,453.64,,,,,,,168.37,630.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,,13.61,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,Commercial,,201.52,,,,,,,37.47,222.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,United Healthcare,Commercial,,381.82,,,,,,,37.47,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Commercial,,8.34,,,,,,,5.23,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Commercial,,8.34,,,,,,,5.23,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Commercial,,8.34,,,,,,,5.23,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,United Healthcare,Commercial,,8.01,,,,,,,5.02,174.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Commercial,,4.63,,,,,,,2.90,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,4.63,,,,,,,2.90,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Commercial,,8.84,,,,,,,6.16,92.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Commercial,,8.84,,,,,,,6.16,100.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,Commercial,,5.92,,,,,,,3.72,147.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Commercial,,201.52,,,,,,,22.03,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,201.52,,,,,,,12.21,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Commercial,,44.72,,,,,,,37.47,375.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,United Healthcare,Commercial,,44.72,,,,,,,37.47,552.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Commercial,,23.91,,,,,,,22.03,94.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Commercial,,19.36,,,,,,,13.49,104.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Commercial,,5.32,,,,,,,3.69,27.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,3.66,,,,,,,2.30,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,3.66,,,,,,,2.30,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Commercial,,12.01,,,,,,,7.54,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,9.99,,,,,,,6.28,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,6.18,,,,,,,3.87,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Commercial,,8.61,,,,,,,5.40,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Commercial,,3.93,,,,,,,2.46,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,6.91,,,,,,,4.35,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,Commercial,,777.12,,,,,,,53.18,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,Commercial,,777.12,,,,,,,53.18,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Commercial,,20.10,,,,,,,12.59,242.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Commercial,,27.31,,,,,,,17.12,206.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,Commercial,,27.69,,,,,,,17.36,218.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Commercial,,27.69,,,,,,,17.36,198.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,United Healthcare,Commercial,,18.40,,,,,,,11.53,459.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Commercial,,35.49,,,,,,,22.25,120.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,35.49,,,,,,,15.42,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,Commercial,,35.49,,,,,,,22.25,177.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,United Healthcare,Commercial,,42.96,,,,,,,29.93,149.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Commercial,,35.49,,,,,,,19.82,74.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,Commercial,,29.46,,,,,,,18.47,243.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Commercial,,27.69,,,,,,,17.36,203.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Commercial,,27.69,,,,,,,17.36,242.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,United Healthcare,Commercial,,29.94,,,,,,,18.77,188.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Commercial,,13.76,,,,,,,8.84,136.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Commercial,,29.30,,,,,,,18.36,139.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Commercial,,29.30,,,,,,,18.36,139.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Commercial,,18.34,,,,,,,11.49,185.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Commercial,,21.41,,,,,,,13.42,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Commercial,,23.72,,,,,,,8.81,33.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Commercial,,42.96,,,,,,,29.93,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,Commercial,,23.72,,,,,,,14.86,147.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,United Healthcare,Commercial,,19.91,,,,,,,12.48,351.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,United Healthcare,Commercial,,19.91,,,,,,,12.48,212.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,19.91,,,,,,,12.48,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Commercial,,6.58,,,,,,,4.15,26.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,10.66,,,,,,,6.68,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Commercial,,15.75,,,,,,,9.87,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Commercial,,13.53,,,,,,,9.43,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Commercial,,26.60,,,,,,,16.67,267.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,13.03,,,,,,,9.08,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Commercial,,20.26,,,,,,,12.70,109.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,20.26,,,,,,,12.61,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Commercial,,34.68,,,,,,,24.16,151.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Commercial,,34.68,,,,,,,24.16,107.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,,27.80,,,,,,,17.44,87.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Commercial,,27.80,,,,,,,17.44,87.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Commercial,,6.09,,,,,,,4.16,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,Commercial,,6.10,,,,,,,3.82,76.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,14.82,,,,,,,9.29,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Commercial,,14.82,,,,,,,9.29,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,Commercial,,27.80,,,,,,,17.44,73.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,15.23,,,,,,,9.55,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Commercial,,25.96,,,,,,,18.08,168.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Commercial,,5.95,,,,,,,4.14,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,8.52,,,,,,,5.34,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Commercial,,8.92,,,,,,,5.60,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,Commercial,,8.92,,,,,,,3.80,14.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,9.29,,,,,,,5.83,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,9.29,,,,,,,5.83,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Commercial,,9.99,,,,,,,6.28,35.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Commercial,,9.99,,,,,,,3.00,13.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,Commercial,,18.05,,,,,,,8.21,30.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,10.34,,,,,,,6.48,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Commercial,,15.97,,,,,,,10.01,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Commercial,,15.97,,,,,,,10.01,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Commercial,,14.61,,,,,,,9.16,97.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,14.61,,,,,,,9.16,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Commercial,,14.61,,,,,,,9.16,53.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Commercial,,13.32,,,,,,,8.36,117.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,Commercial,,13.32,,,,,,,5.41,20.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Commercial,,14.61,,,,,,,9.59,39.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Commercial,,14.64,,,,,,,9.19,140.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Commercial,,14.64,,,,,,,9.19,140.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Commercial,,14.64,,,,,,,9.19,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Commercial,,12.48,,,,,,,7.84,159.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Commercial,,12.48,,,,,,,7.84,153.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,12.48,,,,,,,7.84,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,12.48,,,,,,,7.84,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.24,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.24,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Commercial,,10.24,,,,,,,6.41,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.24,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.24,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Commercial,,10.24,,,,,,,6.43,153.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,10.24,,,,,,,6.21,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Commercial,,10.24,,,,,,,6.21,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.24,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,10.24,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Commercial,,10.24,,,,,,,6.43,52.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Commercial,,12.48,,,,,,,7.83,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Commercial,,11.92,,,,,,,7.48,69.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.00,,,,,,,8.16,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Commercial,,15.97,,,,,,,7.81,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,15.97,,,,,,,10.01,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Commercial,,8.01,,,,,,,5.02,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Commercial,,8.01,,,,,,,5.02,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Commercial,,178.46,,,,,,,5.21,245.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,6.62,,,,,,,4.18,18.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,,6.62,,,,,,,4.14,96.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,9.11,,,,,,,5.70,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Commercial,,13.77,,,,,,,8.63,87.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Commercial,,7.34,,,,,,,4.61,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,10.67,,,,,,,7.26,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Commercial,,7.34,,,,,,,3.60,13.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,13.38,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,13.38,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,13.38,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,13.38,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,United Healthcare,Commercial,,13.38,,,,,,,8.39,254.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Commercial,,6.62,,,,,,,4.14,51.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Commercial,,6.62,,,,,,,4.14,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,,6.62,,,,,,,4.14,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,8.34,,,,,,,5.23,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,United Healthcare,Commercial,,8.34,,,,,,,3.20,12.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,8.34,,,,,,,5.23,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,United Healthcare,Commercial,,9.27,,,,,,,5.81,183.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Commercial,,27.80,,,,,,,16.82,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Commercial,,8.11,,,,,,,5.65,115.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,8.11,,,,,,,5.65,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Commercial,,18.55,,,,,,,7.41,27.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Commercial,,18.55,,,,,,,11.62,74.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,18.55,,,,,,,11.62,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Commercial,,18.55,,,,,,,11.62,58.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Commercial,,19.25,,,,,,,8.01,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Commercial,,15.99,,,,,,,10.02,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Commercial,,15.99,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,37.25,,,,,,,19.02,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Commercial,,37.25,,,,,,,12.61,50.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Commercial,,18.55,,,,,,,11.62,135.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,Commercial,,18.55,,,,,,,6.61,25.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Commercial,,18.55,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,United Healthcare,Commercial,,54.29,,,,,,,34.04,171.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,Commercial,,54.29,,,,,,,33.83,126.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,Commercial,,54.29,,,,,,,34.04,345.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Commercial,,66.28,,,,,,,41.55,159.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Commercial,,54.29,,,,,,,34.04,159.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Commercial,,66.28,,,,,,,41.55,471.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Commercial,,66.28,,,,,,,41.55,435.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,Commercial,,54.29,,,,,,,34.04,130.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Commercial,,54.29,,,,,,,32.23,120.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Commercial,,131.65,,,,,,,70.07,262.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Commercial,,54.29,,,,,,,34.04,159.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Commercial,,54.29,,,,,,,32.83,123.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Commercial,,54.29,,,,,,,32.83,123.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Commercial,,133.39,,,,,,,55.05,206.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,United Healthcare,Commercial,,198.59,,,,,,,51.45,264.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Commercial,,644.81,,,,,,,154.15,852.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,United Healthcare,Commercial,,54.29,,,,,,,17.42,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Commercial,,54.29,,,,,,,16.62,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Commercial,,54.29,,,,,,,9.61,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,54.29,,,,,,,16.22,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Commercial,,54.29,,,,,,,22.42,84.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,Commercial,,66.28,,,,,,,41.55,434.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,United Healthcare,Commercial,,366.19,,,,,,,55.86,488.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Commercial,,21.29,,,,,,,11.01,41.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Commercial,,23.02,,,,,,,16.03,115.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Commercial,,22.37,,,,,,,15.59,72.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Commercial,,22.37,,,,,,,15.59,72.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Commercial,,22.37,,,,,,,15.59,72.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Commercial,,398.30,,,,,,,92.69,548.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Commercial,,398.30,,,,,,,58.86,548.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Commercial,,4.90,,,,,,,3.07,66.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Commercial,,4.90,,,,,,,3.07,66.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,4.85,,,,,,,3.38,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,4.85,,,,,,,3.38,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Commercial,,4.85,,,,,,,3.38,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Commercial,,11.99,,,,,,,8.35,94.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Commercial,,201.52,,,,,,,2.40,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Commercial,,8.52,,,,,,,5.43,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,11.07,,,,,,,7.11,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Commercial,,8.06,,,,,,,5.62,90.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Commercial,,141.81,,,,,,,88.91,411.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,United Healthcare,Commercial,,27.93,,,,,,,17.51,231.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Commercial,,37.42,,,,,,,23.45,95.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Commercial,,19.16,,,,,,,7.21,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,Commercial,,7.32,,,,,,,4.40,16.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,United Healthcare,Commercial,,20.51,,,,,,,12.85,172.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,25.46,,,,,,,15.42,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Commercial,,16.06,,,,,,,5.81,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Commercial,,8.07,,,,,,,3.60,13.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Commercial,,27.75,,,,,,,17.39,79.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Commercial,,6.62,,,,,,,4.14,43.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Commercial,,20.19,,,,,,,7.01,27.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Commercial,,19.93,,,,,,,7.01,27.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,Commercial,,8.01,,,,,,,3.80,14.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Commercial,,22.25,,,,,,,12.21,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,Commercial,,12.48,,,,,,,7.84,48.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Commercial,,12.48,,,,,,,7.84,34.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Commercial,,18.95,,,,,,,11.21,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Commercial,,13.32,,,,,,,8.35,53.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Commercial,,20.40,,,,,,,3.00,28.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,10.34,,,,,,,6.48,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Commercial,,8.01,,,,,,,5.02,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Commercial,,20.72,,,,,,,12.99,189.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,Commercial,,7.34,,,,,,,4.61,128.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Commercial,,7.34,,,,,,,4.61,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Commercial,,19.91,,,,,,,12.48,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Commercial,,6.09,,,,,,,4.16,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,8.77,,,,,,,5.61,21.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,20.48,,,,,,,10.81,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Commercial,,10.24,,,,,,,5.81,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,381.82,,,,,,,0.00200,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Commercial,,381.82,,,,,,,53.18,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Commercial,,191.35,,,,,,,103.70,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Commercial,,20.34,,,,,,,14.17,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,23.29,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Commercial,,11.30,,,,,,,5.81,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Commercial,,39.92,,,,,,,25.04,120.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,Commercial,,1057.58,,,,,,,133.70,1470.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,54.29,,,,,,,9.81,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,24.60,,,,,,,15.44,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Commercial,,8.51,,,,,,,5.33,105.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,,41.45,,,,,,,17.82,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Commercial,,4.18,,,,,,,2.62,25.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,13.32,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Commercial,,18.55,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Commercial,,23.05,,,,,,,14.01,52.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Commercial,,23.05,,,,,,,14.01,52.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Commercial,,4.18,,,,,,,3.00,11.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Commercial,,4.18,,,,,,,3.90,26.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Commercial,,4.18,,,,,,,3.90,56.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Commercial,,54.29,,,,,,,9.81,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,United Healthcare,Commercial,,188.17,,,,,,,105.91,396.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,United Healthcare,Commercial,,257.88,,,,,,,153.55,575.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Commercial,,115.57,,,,,,,26.83,154.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,United Healthcare,Commercial,,893.71,,,,,,,361.36,1353.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,United Healthcare,Commercial,,2823.29,,,,,,,251.85,3699.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Commercial,,522.50,,,,,,,58.66,696.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Commercial,,4.18,,,,,,,4.18,4311.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,United Healthcare,Commercial,,17.25,,,,,,,10.82,1448.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Commercial,,9.99,,,,,,,4.60,17.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,United Healthcare,Commercial,,8.52,,,,,,,5.34,194.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Commercial,,25.78,,,,,,,9.21,34.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,41.43,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,41.43,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,41.43,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,41.43,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,41.43,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Commercial,,257.88,,,,,,,141.54,530.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,31.02,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Commercial,,54.29,,,,,,,21.42,80.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,United Healthcare,Commercial,,190.76,,,,,,,102.70,384.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Commercial,,54.29,,,,,,,34.04,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,Commercial,,1057.58,,,,,,,133.70,1470.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,United Healthcare,Commercial,,303.63,,,,,,,22.82,324.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Commercial,,54.29,,,,,,,34.04,243.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,54.29,,,,,,,27.23,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,Commercial,,108.60,,,,,,,38.84,145.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,Commercial,,188.17,,,,,,,117.98,714.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,United Healthcare,Commercial,,257.88,,,,,,,127.93,479.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Commercial,,34.68,,,,,,,24.16,105.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Commercial,QW,34.68,,,,,,,24.16,105.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Commercial,,22.25,,,,,,,9.21,34.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,Commercial,,90.02,,,,,,,55.66,208.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,United Healthcare,Commercial,,1615.18,,,,,,,318.12,2152.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,United Healthcare,Commercial,,644.81,,,,,,,237.64,890.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,Commercial,,141.81,,,,,,,55.66,208.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,32.20,,,,,,,20.19,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,Commercial,,332.70,,,,,,,121.92,456.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,United Healthcare,Commercial,,64.61,,,,,,,40.51,358.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Commercial,,66.28,,,,,,,40.84,153.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Commercial,,22.37,,,,,,,15.59,319.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Commercial,,8.07,,,,,,,5.06,37.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,40.67,,,,,,,22.02,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Commercial,QW,71.45,,,,,,,20.02,76.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Commercial,,58.66,,,,,,,20.02,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Commercial,,24.05,,,,,,,16.75,122.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,United Healthcare,Commercial,,580.32,,,,,,,181.58,680.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Commercial,,198.56,,,,,,,55.05,212.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Commercial,,15.97,,,,,,,10.01,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,,25.96,,,,,,,18.08,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Commercial,,25.96,,,,,,,17.82,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Commercial,,37.75,,,,,,,8.61,50.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Commercial,,53.70,,,,,,,37.41,210.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Commercial,,13.38,,,,,,,8.39,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,Commercial,,198.59,,,,,,,38.84,264.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,54.67,,,,,,,18.22,72.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,Commercial,,33.63,,,,,,,13.81,51.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Commercial,,32.20,,,,,,,13.21,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Commercial,,190.76,,,,,,,70.07,262.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Commercial,,18.56,,,,,,,9.01,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Commercial,,18.56,,,,,,,9.01,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,United Healthcare,Commercial,,31.44,,,,,,,15.22,57.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Commercial,,17.84,,,,,,,8.61,32.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,24.05,,,,,,,13.01,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Commercial,,34.57,,,,,,,16.82,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Commercial,,45.41,,,,,,,20.22,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,Commercial,,38.14,,,,,,,26.57,111.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,United Healthcare,Commercial,,198.48,,,,,,,124.44,996.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Commercial,,17.84,,,,,,,11.01,41.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Commercial,,71.25,,,,,,,21.62,81.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,54.29,,,,,,,23.62,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Commercial,,54.29,,,,,,,23.62,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,15.02,,,,,,,9.42,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Commercial,,16.53,,,,,,,11.22,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Commercial,,3.47,,,,,,,2.18,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Commercial,,54.29,,,,,,,34.04,203.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,Commercial,,48.86,,,,,,,33.43,125.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Commercial,,48.86,,,,,,,34.04,203.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Commercial,,190.76,,,,,,,63.86,254.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,United Healthcare,Commercial,,366.19,,,,,,,105.31,394.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,United Healthcare,Commercial,,97.75,,,,,,,42.04,157.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,70.99,,,,,,,0.00200,70.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,Commercial,,3.66,,,,,,,2.30,20.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Commercial,,44.72,,,,,,,22.02,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Commercial,,44.72,,,,,,,24.90,139.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Commercial,,70.99,,,,,,,29.43,110.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Commercial,,70.99,,,,,,,29.43,110.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Commercial,,45.17,,,,,,,7.81,47.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,United Healthcare,Commercial,,31.34,,,,,,,19.65,148.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,Commercial,,23.91,,,,,,,23.56,89.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,United Healthcare,Commercial,,201.52,,,,,,,36.54,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,Commercial,,70.99,,,,,,,51.40,195.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,40.99,,,,,,,25.81,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Commercial,,40.99,,,,,,,15.62,58.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Commercial,,40.99,,,,,,,25.81,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Commercial,,381.82,,,,,,,24.90,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,Commercial,,381.82,,,,,,,24.90,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Commercial,,180.23,,,,,,,103.70,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,Commercial,,180.23,,,,,,,29.63,248.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,United Healthcare,Commercial,,217.71,,,,,,,91.29,342.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,United Healthcare,Commercial,,227.83,,,,,,,119.52,447.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,United Healthcare,Commercial,,227.83,,,,,,,145.79,566.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,United Healthcare,Commercial,,200.16,,,,,,,112.31,420.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,Commercial,,18.20,,,,,,,12.68,243.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Commercial,,368.07,,,,,,,45.05,490.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,United Healthcare,Commercial,,192.84,,,,,,,121.73,764.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Commercial,,201.36,,,,,,,70.87,268.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,Commercial,,278.14,,,,,,,121.92,456.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Commercial,,33.13,,,,,,,20.78,168.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Commercial,,33.13,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Commercial,,49.71,,,,,,,26.43,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Commercial,,59.01,,,,,,,27.03,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Commercial,,71.27,,,,,,,49.65,411.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,Commercial,,46.60,,,,,,,20.42,76.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Commercial,,106.13,,,,,,,35.03,146.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,Commercial,,37.47,,,,,,,26.10,275.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Commercial,,70.99,,,,,,,15.51,495.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Commercial,,44.72,,,,,,,0.00200,109.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Commercial,,23.91,,,,,,,20.48,93.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,United Healthcare,Commercial,,44.72,,,,,,,24.90,169.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,United Healthcare,Commercial,,70.99,,,,,,,51.40,277.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Commercial,,70.99,,,,,,,51.40,239.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Commercial,,70.99,,,,,,,51.40,239.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,United Healthcare,Commercial,,381.82,,,,,,,80.53,444.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Commercial,,777.12,,,,,,,80.53,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Commercial,,12.54,,,,,,,12.54,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,,44.72,,,,,,,24.90,135.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Commercial,,97.86,,,,,,,24.90,295.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Commercial,,97.86,,,,,,,24.90,234.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,United Healthcare,Commercial,,777.12,,,,,,,49.85,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Commercial,,70.99,,,,,,,15.42,70.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,United Healthcare,Commercial,,201.52,,,,,,,53.18,288.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Commercial,,30.61,,,,,,,24.90,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,United Healthcare,Commercial,,777.12,,,,,,,24.90,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Commercial,,23.59,,,,,,,23.59,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Commercial,,381.82,,,,,,,53.18,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,United Healthcare,Commercial,,16.78,,,,,,,11.69,192.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,Commercial,,201.52,,,,,,,52.25,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Commercial,,201.52,,,,,,,31.43,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Commercial,,201.52,,,,,,,31.43,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Commercial,,201.52,,,,,,,80.53,404.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Commercial,,47.18,,,,,,,27.83,104.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Commercial,,142.39,,,,,,,32.83,189.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Commercial,,7.75,,,,,,,3.60,13.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Commercial,,201.52,,,,,,,53.18,310.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,34.63,,,,,,,18.22,68.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Commercial,,200.16,,,,,,,49.45,269.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,United Healthcare,Commercial,,217.71,,,,,,,136.51,1643.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,United Healthcare,Commercial,,200.16,,,,,,,70.67,269.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Commercial,,71.27,,,,,,,38.44,144.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,United Healthcare,Commercial,,91.83,,,,,,,53.18,531.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Commercial,,122.94,,,,,,,53.18,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Commercial,,201.36,,,,,,,70.87,268.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Commercial,,381.82,,,,,,,77.08,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,Commercial,,89.82,,,,,,,67.67,275.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Commercial,,201.52,,,,,,,53.18,288.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Commercial,,137.00,,,,,,,103.90,389.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,United Healthcare,Commercial,,71.27,,,,,,,49.65,963.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Commercial,,33.13,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Commercial,,201.52,,,,,,,53.18,288.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,Commercial,,89.82,,,,,,,67.67,275.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,United Healthcare,Commercial,,70.99,,,,,,,24.90,234.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Commercial,,44.72,,,,,,,24.90,135.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,United Healthcare,Commercial,,381.82,,,,,,,24.90,932.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,34.63,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,34.63,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,34.63,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,34.63,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,34.63,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Commercial,,34.63,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Commercial,,71.27,,,,,,,38.44,144.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Commercial,,33.13,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,United Healthcare,Commercial,,201.52,,,,,,,164.86,681.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Commercial,,201.52,,,,,,,132.13,646.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Commercial,,70.99,,,,,,,70.99,267.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,United Healthcare,Commercial,,33.13,,,,,,,20.78,93.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Commercial,,33.13,,,,,,,20.78,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Commercial,,33.13,,,,,,,19.02,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Commercial,,71.27,,,,,,,33.23,124.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Commercial,,33.13,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,United Healthcare,Commercial,,59.01,,,,,,,31.83,119.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Commercial,,201.52,,,,,,,13.21,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Commercial,,201.52,,,,,,,8.41,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,381.82,,,,,,,5.61,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,United Healthcare,Commercial,,44.72,,,,,,,21.02,78.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,United Healthcare,Commercial,,201.52,,,,,,,37.47,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,2907.00,,,,,,,10.79,2907.00,per diem,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Commercial,,2907.00,,,,,,,52.23,2907.00,per diem,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Commercial,,2907.00,,,,,,,52.23,2907.00,per diem,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,United Healthcare,Commercial,,2907.00,,,,,,,48.23,2907.00,per diem,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,United Healthcare,Commercial,,2907.00,,,,,,,98.54,2907.00,per diem,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,2907.00,,,,,,,15.84,2907.00,per diem,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,2907.00,,,,,,,15.84,2907.00,per diem,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Commercial,,2907.00,,,,,,,9.92,2907.00,per diem,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,United Healthcare,Commercial,,2907.00,,,,,,,118.21,2907.00,per diem,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,United Healthcare,Commercial,,2907.00,,,,,,,113.34,2907.00,per diem,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Commercial,,2907.00,,,,,,,181.24,2907.00,per diem,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,United Healthcare,Commercial,,2907.00,,,,,,,186.29,2907.00,per diem,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Commercial,,2907.00,,,,,,,37.43,2907.00,per diem,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,United Healthcare,Commercial,,2907.00,,,,,,,72.95,2907.00,per diem,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Commercial,,2907.00,,,,,,,51.19,2907.00,per diem,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,United Healthcare,Commercial,,2907.00,,,,,,,165.22,2907.00,per diem,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,United Healthcare,Commercial,,2907.00,,,,,,,215.88,2907.00,per diem,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,Commercial,,2907.00,,,,,,,104.46,2907.00,per diem,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Commercial,,2907.00,,,,,,,15.84,2907.00,per diem,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,Commercial,,2907.00,,,,,,,266.02,2907.00,per diem,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Commercial,,4.63,,,,,,,2.90,21.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,,13.61,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,,13.61,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Commercial,,13.61,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Commercial,,8.85,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Commercial,,2907.00,,,,,,,181.24,2907.00,per diem,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Commercial,,2907.00,,,,,,,181.24,2907.00,per diem,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Commercial,,2907.00,,,,,,,201.96,2907.00,per diem,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,2907.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,2907.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,2907.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,2907.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Commercial,,2907.00,,,,,,,10.79,2907.00,per diem,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,United Healthcare,Commercial,,4681.00,,,,,,,523.72,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Commercial,,8045.00,,,,,,,1715.71,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Commercial,,8045.00,,,,,,,1715.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Commercial,,13852.00,,,,,,,1715.71,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Commercial,,8045.00,,,,,,,1715.71,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Commercial,,8045.00,,,,,,,1715.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,United Healthcare,Commercial,,832.00,,,,,,,150.52,21640.97,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,United Healthcare,Commercial,,832.00,,,,,,,150.52,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Commercial,,13852.00,,,,,,,495.29,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Commercial,,13852.00,,,,,,,495.29,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,United Healthcare,Commercial,,52940.00,,,,,,,1344.34,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,United Healthcare,Commercial,,52940.00,,,,,,,409.01,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,United Healthcare,Commercial,,4681.00,,,,,,,674.27,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,Commercial,,4681.00,,,,,,,181.98,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,Commercial,,4681.00,,,,,,,181.98,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,United Healthcare,Commercial,,832.00,,,,,,,89.49,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,United Healthcare,Commercial,,832.00,,,,,,,164.76,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,United Healthcare,Commercial,,8045.00,,,,,,,1544.94,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,Commercial,,8045.00,,,,,,,772.37,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,Commercial,,8045.00,,,,,,,772.37,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,Commercial,,13852.00,,,,,,,1434.63,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,Commercial,,13852.00,,,,,,,1434.63,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Commercial,,13852.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Commercial,,13852.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,Commercial,,8045.00,,,,,,,275.88,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,Commercial,,8045.00,,,,,,,275.88,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Commercial,,13852.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Commercial,,13852.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Commercial,,8045.00,,,,,,,1715.71,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Commercial,,8045.00,,,,,,,1715.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,Commercial,,2912.00,,,,,,,158.96,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,United Healthcare,Commercial,,24600.00,,,,,,,5817.21,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Commercial,,8045.00,,,,,,,879.68,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Commercial,,8045.00,,,,,,,879.68,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,2912.00,,,,,,,87.89,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,2912.00,,,,,,,87.89,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,2912.00,,,,,,,87.89,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Commercial,,2912.00,,,,,,,87.89,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Commercial,,4681.00,,,,,,,451.85,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Commercial,,4681.00,,,,,,,451.85,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Commercial,,4681.00,,,,,,,451.85,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Commercial,,4681.00,,,,,,,451.85,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,Commercial,,13852.00,,,,,,,3349.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,Commercial,,13852.00,,,,,,,3349.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,Commercial,,24600.00,,,,,,,5581.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,Commercial,,24600.00,,,,,,,5581.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,United Healthcare,Commercial,,13852.00,,,,,,,2009.41,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,United Healthcare,Commercial,,13852.00,,,,,,,2009.41,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,16011.95,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,14116.62,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,Commercial,,13852.00,,,,,,,1863.26,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,Commercial,,13852.00,,,,,,,1863.26,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,Commercial,,24600.00,,,,,,,4700.50,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,Commercial,,24600.00,,,,,,,4700.50,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,Commercial,,24600.00,,,,,,,4234.63,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,Commercial,,24600.00,,,,,,,4234.63,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,Commercial,,52940.00,,,,,,,5632.23,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,Commercial,,52940.00,,,,,,,5632.23,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,United Healthcare,Commercial,,13852.00,,,,,,,2468.07,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,Commercial,,24600.00,,,,,,,4664.66,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,Commercial,,24600.00,,,,,,,4664.66,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,Commercial,,24600.00,,,,,,,4245.04,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,Commercial,,24600.00,,,,,,,4245.04,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,Commercial,,52940.00,,,,,,,4812.81,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,Commercial,,52940.00,,,,,,,4812.81,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,United Healthcare,Commercial,,13852.00,,,,,,,1900.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,United Healthcare,Commercial,,13852.00,,,,,,,1900.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,United Healthcare,Commercial,,24600.00,,,,,,,4096.89,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,United Healthcare,Commercial,,24600.00,,,,,,,4096.89,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,United Healthcare,Commercial,,13852.00,,,,,,,3529.33,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,United Healthcare,Commercial,,13852.00,,,,,,,3529.33,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,United Healthcare,Commercial,,13852.00,,,,,,,4121.72,14244.84,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Commercial,LM,13852.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Commercial,RI,13852.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Commercial,RC,13852.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Commercial,LD,13852.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Commercial,LC,13852.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Commercial,LC,13852.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Commercial,RI,13852.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Commercial,RC,13852.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Commercial,LD,13852.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Commercial,LC,13852.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,LM,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,RI,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,RC,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,LD,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,LC,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,LM,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,RI,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,RC,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,LD,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Commercial,LC,24600.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,LM,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,RI,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,RC,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,LD,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,LC,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,LM,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,RI,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,RC,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,LD,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Commercial,LC,13852.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,LM,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,RI,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,RC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,LD,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,LC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,RC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,LD,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Commercial,LC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LM,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,RI,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,RC,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LD,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LC,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LM,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,RI,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,RC,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LD,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LC,13852.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LM,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,RI,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,RC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LD,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,RC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LD,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Commercial,LC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,Commercial,,13852.00,,,,,,,4633.23,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,Commercial,,13852.00,,,,,,,4633.23,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,United Healthcare,Commercial,,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,LM,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,RI,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,RC,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,LD,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,LC,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,LM,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,RI,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,RC,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,LD,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Commercial,LC,13852.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LM,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,RI,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,RC,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LD,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LC,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LM,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,RI,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,RC,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LD,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LC,13852.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LM,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,RI,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,RC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LD,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Commercial,LC,13852.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,United Healthcare,Commercial,,2912.00,,,,,,,78.68,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,United Healthcare,Commercial,,3641.00,,,,,,,222.64,3641.00,per diem,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Commercial,,4681.00,,,,,,,373.37,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Commercial,,832.00,,,,,,,84.48,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,United Healthcare,Commercial,,4681.00,,,,,,,505.91,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,United Healthcare,Commercial,,13852.00,,,,,,,2316.71,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Commercial,,13852.00,,,,,,,2143.34,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Commercial,,13852.00,,,,,,,2143.34,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,United Healthcare,Commercial,,13852.00,,,,,,,2044.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,United Healthcare,Commercial,,13852.00,,,,,,,850.85,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,United Healthcare,Commercial,,10022.00,,,,,,,1474.87,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,United Healthcare,Commercial,,10022.00,,,,,,,2180.78,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,United Healthcare,Commercial,,10022.00,,,,,,,1936.53,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,United Healthcare,Commercial,,10022.00,,,,,,,2067.27,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,United Healthcare,Commercial,,10022.00,,,,,,,909.51,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,United Healthcare,Commercial,,10022.00,,,,,,,2126.92,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,United Healthcare,Commercial,,10022.00,,,,,,,2652.85,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,United Healthcare,Commercial,,10022.00,,,,,,,2389.79,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,United Healthcare,Commercial,,10022.00,,,,,,,2549.35,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,United Healthcare,Commercial,,10022.00,,,,,,,2592.59,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,United Healthcare,Commercial,,10022.00,,,,,,,3094.46,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Commercial,,832.00,,,,,,,40.64,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Commercial,,832.00,,,,,,,19.42,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,United Healthcare,Commercial,,2912.00,,,,,,,300.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,United Healthcare,Commercial,,8045.00,,,,,,,826.43,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,United Healthcare,Commercial,,832.00,,,,,,,96.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,832.00,,,,,,,125.33,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Commercial,,832.00,,,,,,,125.33,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Commercial,,832.00,,,,,,,43.04,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,United Healthcare,Commercial,,39682.00,,,,,,,7834.43,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,12247.00,per diem,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,United Healthcare,Commercial,,3641.00,,,,,,,337.85,12247.00,per diem,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,United Healthcare,Commercial,,3641.00,,,,,,,377.85,3641.00,per diem,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,United Healthcare,Commercial,,4681.00,,,,,,,253.45,9503.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,Commercial,,4681.00,,,,,,,105.71,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,Commercial,,4681.00,,,,,,,105.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,Commercial,,4681.00,,,,,,,105.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,Commercial,,24600.00,,,,,,,1577.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,Commercial,,24600.00,,,,,,,1577.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,Commercial,,24600.00,,,,,,,2998.80,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,Commercial,,24600.00,,,,,,,2998.80,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,United Healthcare,Commercial,,39682.00,,,,,,,3657.05,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,United Healthcare,Commercial,,24600.00,,,,,,,2656.25,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,United Healthcare,Commercial,,24600.00,,,,,,,3018.42,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,United Healthcare,Commercial,,39682.00,,,,,,,3642.44,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,United Healthcare,Commercial,,8045.00,,,,,,,639.24,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,Commercial,,13852.00,,,,,,,2820.62,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,Commercial,,13852.00,,,,,,,2820.62,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,United Healthcare,Commercial,,8045.00,,,,,,,2045.04,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,United Healthcare,Commercial,,8045.00,,,,,,,589.39,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,Commercial,,3142.00,,,,,,,580.98,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,Commercial,,3142.00,,,,,,,580.98,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,United Healthcare,Commercial,,39682.00,,,,,,,4082.48,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,United Healthcare,Commercial,,39682.00,,,,,,,2987.99,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,United Healthcare,Commercial,,8045.00,,,,,,,473.87,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,United Healthcare,Commercial,,24600.00,,,,,,,4761.96,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,United Healthcare,Commercial,,24600.00,,,,,,,4909.10,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,United Healthcare,Commercial,,24600.00,,,,,,,5350.95,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,United Healthcare,Commercial,,8045.00,,,,,,,1703.30,8700.96,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,Commercial,,8045.00,,,,,,,2282.48,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,Commercial,,8045.00,,,,,,,2282.48,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,United Healthcare,Commercial,,82346.00,,,,,,,9987.38,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,United Healthcare,Commercial,,8045.00,,,,,,,1151.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,United Healthcare,Commercial,,8045.00,,,,,,,764.96,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,United Healthcare,Commercial,,82346.00,,,,,,,11551.14,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,United Healthcare,Commercial,,4681.00,,,,,,,528.33,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,inpatient,,,11667.00000,7000.20000,United Healthcare,Commercial,,9485.27,,,,,,,7466.88,9485.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,United Healthcare,Commercial,,9485.27,,,,,,,2199.23,9485.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,United Healthcare,Commercial,,2912.00,,,,,,,417.62,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Commercial,,2912.00,,,,,,,594.81,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,Commercial,,3641.00,,,,,,,867.02,12247.00,per diem,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,Commercial,,3641.00,,,,,,,867.02,7977.75,per diem,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Commercial,,3641.00,,,,,,,432.44,3641.00,per diem,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,United Healthcare,Commercial,,3641.00,,,,,,,307.07,12247.00,per diem,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Commercial,,3641.00,,,,,,,432.44,7977.75,per diem,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Commercial,,3641.00,,,,,,,432.44,7977.75,per diem,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,United Healthcare,Commercial,,3641.00,,,,,,,407.15,3641.00,per diem,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,United Healthcare,Commercial,,3641.00,,,,,,,372.90,12247.00,per diem,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,United Healthcare,Commercial,,3641.00,,,,,,,1281.80,12247.00,per diem,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,12247.00,per diem,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,12247.00,per diem,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,United Healthcare,Commercial,,3641.00,,,,,,,217.29,3641.00,per diem,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,United Healthcare,Commercial,,3641.00,,,,,,,1081.64,7977.75,per diem,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,United Healthcare,Commercial,,3641.00,,,,,,,221.84,3641.00,per diem,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,United Healthcare,Commercial,,3641.00,,,,,,,422.27,12247.00,per diem,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,16639.07,per diem,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,14737.24,per diem,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,14737.24,per diem,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,United Healthcare,Commercial,,3641.00,,,,,,,404.75,3641.00,per diem,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Commercial,,3641.00,,,,,,,150.52,3641.00,per diem,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,12283.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,United Healthcare,Commercial,,24600.00,,,,,,,4480.68,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,United Healthcare,Commercial,,82346.00,,,,,,,496.90,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,United Healthcare,Commercial,,4681.00,,,,,,,386.59,9503.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,Commercial,,82346.00,,,,,,,1110.71,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,Commercial,,82346.00,,,,,,,1110.71,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,United Healthcare,Commercial,,82346.00,,,,,,,1276.68,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,United Healthcare,Commercial,,82346.00,,,,,,,515.51,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Commercial,,3641.00,,,,,,,150.52,3641.00,per diem,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,United Healthcare,Commercial,,832.00,,,,,,,150.52,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,United Healthcare,Commercial,,832.00,,,,,,,150.52,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,United Healthcare,Commercial,,4681.00,,,,,,,1594.59,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,11298.42,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,United Healthcare,Commercial,,4681.00,,,,,,,1846.64,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,United Healthcare,Commercial,,4681.00,,,,,,,1294.69,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,United Healthcare,Commercial,,10022.00,,,,,,,1496.70,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Commercial,,832.00,,,,,,,150.52,981.11,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,United Healthcare,Commercial,,8045.00,,,,,,,1595.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Commercial,,3641.00,,,,,,,406.89,4376.00,per diem,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Commercial,,3641.00,,,,,,,406.89,3641.00,per diem,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Commercial,,3641.00,,,,,,,406.89,3641.00,per diem,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Commercial,,3641.00,,,,,,,406.89,3641.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,United Healthcare,Commercial,,13852.00,,,,,,,2662.86,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,Commercial,,24600.00,,,,,,,5325.72,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,Commercial,,24600.00,,,,,,,5325.72,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,United Healthcare,Commercial,,24600.00,,,,,,,8574.37,26125.69,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,United Healthcare,Commercial,,2912.00,,,,,,,594.81,21326.82,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,United Healthcare,Commercial,,82346.00,,,,,,,1897.10,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,United Healthcare,Commercial,,4681.00,,,,,,,869.87,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,United Healthcare,Commercial,,24600.00,,,,,,,4285.48,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Commercial,,24600.00,,,,,,,6855.05,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Commercial,,24600.00,,,,,,,6855.05,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Commercial,,24600.00,,,,,,,6855.05,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,United Healthcare,Commercial,,4681.00,,,,,,,2025.00,22398.88,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,Commercial,,10022.00,,,,,,,1354.55,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,Commercial,,10022.00,,,,,,,1354.55,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Commercial,,832.00,,,,,,,21.42,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,25792.05,per diem,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,25792.05,per diem,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,United Healthcare,Commercial,,3641.00,,,,,,,1411.00,31355.38,per diem,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,United Healthcare,Commercial,,4681.00,,,,,,,480.28,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,United Healthcare,Commercial,,8045.00,,,,,,,2169.57,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Commercial,LD,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Commercial,RC,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Commercial,RI,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Commercial,LM,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Commercial,LD,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Commercial,RC,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Commercial,RI,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Commercial,LM,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Commercial,LD,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Commercial,RC,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Commercial,RI,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Commercial,LM,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,LD,832.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,RC,832.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,RI,832.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,LM,832.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Commercial,LC,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Commercial,LC,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Commercial,LC,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Commercial,LC,832.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,United Healthcare,Commercial,,2912.00,,,,,,,594.81,19892.71,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,United Healthcare,Commercial,,82346.00,,,,,,,9423.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,United Healthcare,Commercial,,13852.00,,,,,,,2282.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,United Healthcare,Commercial,,832.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,United Healthcare,Commercial,,467.00,,,,,,,41.04,467.00,per diem,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,United Healthcare,Commercial,,3641.00,,,,,,,538.01,20050.47,per diem,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,United Healthcare,Commercial,,3641.00,,,,,,,442.08,3641.00,per diem,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,United Healthcare,Commercial,,833.00,,,,,,,198.53,967.50,per diem,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,United Healthcare,Commercial,,968.00,,,,,,,219.29,1172.25,per diem,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,United Healthcare,Commercial,,968.00,,,,,,,162.33,968.00,per diem,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,Commercial,,968.00,,,,,,,266.00,1671.75,per diem,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,Commercial,,968.00,,,,,,,266.00,1671.75,per diem,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,Commercial,,968.00,,,,,,,126.13,968.00,per diem,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,Commercial,,968.00,,,,,,,101.86,968.00,per diem,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,Commercial,,968.00,,,,,,,101.86,968.00,per diem,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,Commercial,,968.00,,,,,,,266.00,1918.50,per diem,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,Commercial,,968.00,,,,,,,266.00,1918.50,per diem,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Commercial,,968.00,,,,,,,69.59,968.00,per diem,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Commercial,,968.00,,,,,,,54.02,968.00,per diem,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Commercial,,968.00,,,,,,,266.00,2052.00,per diem,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Commercial,,968.00,,,,,,,7.72,968.00,per diem,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,United Healthcare,Commercial,,968.00,,,,,,,191.93,1026.00,per diem,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Commercial,,134.00,,,,,,,35.88,182.25,per diem,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,Commercial,,134.00,,,,,,,87.00,656.25,per diem,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,United Healthcare,Commercial,,134.00,,,,,,,57.15,466.50,per diem,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Commercial,,134.00,,,,,,,32.43,134.00,per diem,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,United Healthcare,Commercial,,269.00,,,,,,,33.60,269.00,per diem,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,United Healthcare,Commercial,,269.00,,,,,,,175.00,957.00,per diem,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,Commercial,,269.00,,,,,,,49.62,269.00,per diem,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Commercial,,269.00,,,,,,,37.95,269.00,per diem,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,Commercial,,269.00,,,,,,,51.71,269.00,per diem,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Commercial,,269.00,,,,,,,18.98,269.00,per diem,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Commercial,,269.00,,,,,,,24.55,269.00,per diem,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,United Healthcare,Commercial,,5754.00,,,,,,,1301.10,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,United Healthcare,Commercial,,8045.00,,,,,,,725.52,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,United Healthcare,Commercial,,13852.00,,,,,,,1598.40,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,United Healthcare,Commercial,,2912.00,,,,,,,521.92,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Commercial,,24600.00,,,,,,,422.62,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Commercial,,8045.00,,,,,,,422.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Commercial,,8045.00,,,,,,,422.62,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REX MED SURG SEMI PRIVATE ROOM,11200003,CDM,120,RC,,,,,facility,inpatient,,,1328.00000,796.80000,United Healthcare,Commercial,,1228.00,,,,,,,849.92,5693.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,United Healthcare,Commercial,,954.00,,,,,,,615.00,4781.25,per diem,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,United Healthcare,Commercial,,954.00,,,,,,,615.00,6332.25,per diem,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,United Healthcare,Commercial,,954.00,,,,,,,615.00,7107.75,per diem,
HC REX LEVEL 2 NURSERY ROOM,11720015,CDM,172,RC,,,,,facility,inpatient,,,3166.00000,1899.60000,United Healthcare,Commercial,,3488.00,,,,,,,2026.24,3569.00,per diem,
HC REX LEVEL 4 INTENSIVE NURSERY ROOM,11740002,CDM,174,RC,,,,,facility,inpatient,,,6546.00000,3927.60000,United Healthcare,Commercial,,5499.00,,,,,,,4189.44,5695.00,per diem,
HC REX INTENSIVE CARE SEMI PRIVATE ROOM,12000008,CDM,210,RC,,,,,facility,inpatient,,,3522.00000,2113.20000,United Healthcare,Commercial,,1228.00,,,,,,,1228.00,6258.00,per diem,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,United Healthcare,Commercial,,954.00,,,,,,,615.00,5873.25,per diem,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,United Healthcare,Commercial,,954.00,,,,,,,615.00,7611.75,per diem,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,United Healthcare,Commercial,,954.00,,,,,,,615.00,8481.00,per diem,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,inpatient,,,480.00000,288.00000,United Healthcare,Commercial,,390.24,,,,,,,307.20,390.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,Commercial,,390.24,,,,,,,96.10,390.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,inpatient,,,300.00000,180.00000,United Healthcare,Commercial,,243.90,,,,,,,192.00,243.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Commercial,,243.90,,,,,,,60.06,243.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,inpatient,,,480.00000,288.00000,United Healthcare,Commercial,,390.24,,,,,,,307.20,390.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,Commercial,,390.24,,,,,,,96.10,390.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,inpatient,,,300.00000,180.00000,United Healthcare,Commercial,,243.90,,,,,,,192.00,243.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Commercial,,243.90,,,,,,,60.06,243.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,inpatient,,,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,21.76,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Commercial,,27.64,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,inpatient,,,90.00000,54.00000,United Healthcare,Commercial,,73.17,,,,,,,57.60,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,73.17,,,,,,,18.02,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,inpatient,,,240.00000,144.00000,United Healthcare,Commercial,,195.12,,,,,,,153.60,195.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,Commercial,,195.12,,,,,,,48.05,195.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,inpatient,,,374.00000,224.40000,United Healthcare,Commercial,,304.06,,,,,,,239.36,304.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,United Healthcare,Commercial,,304.06,,,,,,,74.87,304.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,inpatient,,,1320.00000,792.00000,United Healthcare,Commercial,,1073.16,,,,,,,844.80,1073.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,United Healthcare,Commercial,,1073.16,,,,,,,264.26,1073.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,inpatient,,,1425.00000,855.00000,United Healthcare,Commercial,,1158.53,,,,,,,912.00,1158.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,United Healthcare,Commercial,,1158.53,,,,,,,285.29,1158.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,inpatient,,,2232.00000,1339.20000,United Healthcare,Commercial,,1814.62,,,,,,,1428.48,1814.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,United Healthcare,Commercial,,1814.62,,,,,,,446.85,1814.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,inpatient,,,293.00000,175.80000,United Healthcare,Commercial,,238.21,,,,,,,50.40,243.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Commercial,,65.63,,,,,,,37.21,215.71,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,inpatient,,,672.00000,403.20000,United Healthcare,Commercial,,546.34,,,,,,,430.08,546.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,United Healthcare,Commercial,,546.34,,,,,,,134.53,546.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,inpatient,,,104.00000,62.40000,United Healthcare,Commercial,,84.55,,,,,,,66.56,84.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,United Healthcare,Commercial,,84.55,,,,,,,20.82,84.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,inpatient,,,1016.00000,609.60000,United Healthcare,Commercial,,826.01,,,,,,,650.24,826.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,Commercial,,826.01,,,,,,,203.40,826.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,inpatient,,,175.00000,105.00000,United Healthcare,Commercial,,142.28,,,,,,,112.00,142.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Commercial,,142.28,,,,,,,35.03,142.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,inpatient,,,258.00000,154.80000,United Healthcare,Commercial,,209.75,,,,,,,165.12,209.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,United Healthcare,Commercial,,209.75,,,,,,,51.65,209.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,inpatient,,,192.00000,115.20000,United Healthcare,Commercial,,156.10,,,,,,,122.88,156.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Commercial,,156.10,,,,,,,38.44,156.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,inpatient,,,3162.00000,1897.20000,United Healthcare,Commercial,,2570.71,,,,,,,2023.68,2570.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,United Healthcare,Commercial,,2570.71,,,,,,,633.03,2570.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,inpatient,,,302.00000,181.20000,United Healthcare,Commercial,,245.53,,,,,,,193.28,245.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Commercial,,245.53,,,,,,,60.46,245.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,inpatient,,,296.00000,177.60000,United Healthcare,Commercial,,240.65,,,,,,,189.44,240.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,Commercial,,240.65,,,,,,,59.26,240.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,inpatient,,,309.00000,185.40000,United Healthcare,Commercial,,251.22,,,,,,,197.76,251.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,United Healthcare,Commercial,,251.22,,,,,,,61.86,251.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,inpatient,,,285.00000,171.00000,United Healthcare,Commercial,,231.71,,,,,,,182.40,231.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,Commercial,,231.71,,,,,,,57.06,231.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,inpatient,,,341.00000,204.60000,United Healthcare,Commercial,,277.23,,,,,,,218.24,277.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Commercial,,277.23,,,,,,,68.27,277.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,inpatient,,,432.00000,259.20000,United Healthcare,Commercial,,351.22,,,,,,,276.48,351.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Commercial,,351.22,,,,,,,86.49,351.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,inpatient,,,617.00000,370.20000,United Healthcare,Commercial,,501.62,,,,,,,394.88,501.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,United Healthcare,Commercial,,501.62,,,,,,,123.52,501.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,inpatient,,,44.00000,26.40000,United Healthcare,Commercial,,35.77,,,,,,,28.16,35.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Commercial,,35.77,,,,,,,8.81,35.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,inpatient,,,42.00000,25.20000,United Healthcare,Commercial,,34.15,,,,,,,26.88,34.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Commercial,,34.15,,,,,,,8.41,34.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,inpatient,,,71.00000,42.60000,United Healthcare,Commercial,,57.72,,,,,,,45.44,57.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Commercial,,57.72,,,,,,,14.21,57.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,inpatient,,,221.00000,132.60000,United Healthcare,Commercial,,179.67,,,,,,,141.44,179.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,United Healthcare,Commercial,,179.67,,,,,,,44.24,179.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,inpatient,,,402.00000,241.20000,United Healthcare,Commercial,,326.83,,,,,,,257.28,326.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,United Healthcare,Commercial,,326.83,,,,,,,80.48,326.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,inpatient,,,890.00000,534.00000,United Healthcare,Commercial,,723.57,,,,,,,569.60,723.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,United Healthcare,Commercial,,723.57,,,,,,,178.18,723.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,inpatient,,,74.00000,44.40000,United Healthcare,Commercial,,60.16,,,,,,,47.36,60.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Commercial,,60.16,,,,,,,14.81,60.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,inpatient,,,54.00000,32.40000,United Healthcare,Commercial,,43.90,,,,,,,34.56,43.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Commercial,,43.90,,,,,,,10.81,43.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,inpatient,,,265.00000,159.00000,United Healthcare,Commercial,,215.44,,,,,,,169.60,215.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,United Healthcare,Commercial,,215.44,,,,,,,53.05,215.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,inpatient,,,40.00000,24.00000,United Healthcare,Commercial,,32.52,,,,,,,25.60,32.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Commercial,,32.52,,,,,,,8.01,32.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,inpatient,,,750.00000,450.00000,United Healthcare,Commercial,,609.75,,,,,,,480.00,609.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,United Healthcare,Commercial,,609.75,,,,,,,150.15,609.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,inpatient,,,1175.00000,705.00000,United Healthcare,Commercial,,955.27,,,,,,,752.00,955.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,United Healthcare,Commercial,,955.27,,,,,,,235.24,955.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,inpatient,,,4010.00000,2406.00000,United Healthcare,Commercial,,3260.13,,,,,,,2566.40,3260.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,United Healthcare,Commercial,,3260.13,,,,,,,802.80,3260.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,inpatient,,,1224.00000,734.40000,United Healthcare,Commercial,,995.11,,,,,,,783.36,995.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,United Healthcare,Commercial,,995.11,,,,,,,245.04,995.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,inpatient,,,1794.00000,1076.40000,United Healthcare,Commercial,,1458.52,,,,,,,1148.16,1458.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Commercial,,1458.52,,,,,,,359.16,1458.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,inpatient,,,2269.00000,1361.40000,United Healthcare,Commercial,,1844.70,,,,,,,1452.16,1844.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,United Healthcare,Commercial,,1844.70,,,,,,,454.25,1844.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,inpatient,,,492.00000,295.20000,United Healthcare,Commercial,,400.00,,,,,,,314.88,400.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Commercial,,400.00,,,,,,,98.50,400.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,inpatient,,,4010.00000,2406.00000,United Healthcare,Commercial,,3260.13,,,,,,,2566.40,3260.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,United Healthcare,Commercial,,3260.13,,,,,,,802.80,3260.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,inpatient,,,700.00000,420.00000,United Healthcare,Commercial,,569.10,,,,,,,448.00,569.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,United Healthcare,Commercial,,569.10,,,,,,,140.14,569.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,inpatient,,,780.00000,468.00000,United Healthcare,Commercial,,634.14,,,,,,,499.20,634.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,United Healthcare,Commercial,,634.14,,,,,,,156.16,634.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,inpatient,,,90.00000,54.00000,United Healthcare,Commercial,,73.17,,,,,,,57.60,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Commercial,,73.17,,,,,,,18.02,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,inpatient,,,1598.00000,958.80000,United Healthcare,Commercial,,1299.17,,,,,,,1022.72,1299.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,United Healthcare,Commercial,,1299.17,,,,,,,319.92,1299.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,inpatient,,,2569.00000,1541.40000,United Healthcare,Commercial,,2088.60,,,,,,,1644.16,2088.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,United Healthcare,Commercial,,2088.60,,,,,,,514.31,2088.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,inpatient,,,500.00000,300.00000,United Healthcare,Commercial,,406.50,,,,,,,320.00,406.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,Commercial,,406.50,,,,,,,100.10,406.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,inpatient,,,4000.00000,2400.00000,United Healthcare,Commercial,,3252.00,,,,,,,2560.00,3252.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,United Healthcare,Commercial,,3252.00,,,,,,,800.80,3252.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,inpatient,,,2425.00000,1455.00000,United Healthcare,Commercial,,1971.53,,,,,,,1552.00,1971.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,United Healthcare,Commercial,,1971.53,,,,,,,485.49,1971.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,inpatient,,,1800.00000,1080.00000,United Healthcare,Commercial,,1463.40,,,,,,,1152.00,1463.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,United Healthcare,Commercial,,1463.40,,,,,,,360.36,1463.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,inpatient,,,2425.00000,1455.00000,United Healthcare,Commercial,,1971.53,,,,,,,1552.00,1971.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,United Healthcare,Commercial,,1971.53,,,,,,,485.49,1971.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,inpatient,,,1800.00000,1080.00000,United Healthcare,Commercial,,1463.40,,,,,,,1152.00,1463.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,United Healthcare,Commercial,,1463.40,,,,,,,360.36,1463.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,inpatient,,,1180.00000,708.00000,United Healthcare,Commercial,,959.34,,,,,,,755.20,959.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,United Healthcare,Commercial,,959.34,,,,,,,236.24,959.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,inpatient,,,1180.00000,708.00000,United Healthcare,Commercial,,959.34,,,,,,,755.20,959.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,United Healthcare,Commercial,,959.34,,,,,,,236.24,959.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,inpatient,,,1057.00000,634.20000,United Healthcare,Commercial,,859.34,,,,,,,676.48,859.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,United Healthcare,Commercial,,859.34,,,,,,,211.61,859.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,United Healthcare,Commercial,GP,276.00,,,,,,,37.08,276.00,per diem,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,inpatient,,,499.00000,299.40000,United Healthcare,Commercial,,405.69,,,,,,,319.36,405.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Commercial,,405.69,,,,,,,99.90,405.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,inpatient,,,246.00000,147.60000,United Healthcare,Commercial,,200.00,,,,,,,157.44,200.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,United Healthcare,Commercial,,200.00,,,,,,,49.25,200.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed. If Separately Reimbursable Drug Covered Service is billed with a Covered Service listed in Table 5 the contract rate for the separately reimbursable drug will apply but no additional contract rate will be given."
SNF Bill Type,211,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,212,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,213,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,214,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,215,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,216,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,217,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,218,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
SNF Bill Type,219,LOCAL,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,1336.00,,,,,,,1336.00,2012.00,per diem,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,238040.62,,,,,,,150928.76,397739.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,155343.45,,,,,,,98790.80,259561.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,61167.73,,,,,,,39415.99,102204.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,47282.44,,,,,,,30661.75,79003.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32319.39,,,,,,,21228.00,54002.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,88248.59,,,,,,,56489.61,147453.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,59369.97,,,,,,,38282.54,99200.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,34487.25,,,,,,,22718.84,57624.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,64265.31,,,,,,,41368.91,107380.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,43871.96,,,,,,,28511.54,73305.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,50991.24,,,,,,,33000.02,85200.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,34869.68,,,,,,,22835.89,58263.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28294.32,,,,,,,18639.19,47276.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,67383.08,,,,,,,43334.56,112589.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,38261.09,,,,,,,24974.06,63929.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24619.17,,,,,,,16218.14,41135.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,50248.81,,,,,,,32531.94,83960.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23899.17,,,,,,,15743.83,39932.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18649.42,,,,,,,12285.51,31161.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,43409.90,,,,,,,28220.24,72533.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26809.46,,,,,,,17661.01,44795.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21788.50,,,,,,,14353.41,36406.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36920.90,,,,,,,24129.11,61690.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18197.46,,,,,,,11987.77,30405.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13183.23,,,,,,,8684.59,22027.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,43303.36,,,,,,,28153.06,72355.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24658.42,,,,,,,16244.00,41201.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19376.16,,,,,,,12764.25,32375.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19971.67,,,,,,,13156.55,33370.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10981.73,,,,,,,7234.33,18349.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17124.18,,,,,,,11280.74,28612.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11434.81,,,,,,,7532.80,19106.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26053.57,,,,,,,17163.06,43532.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14530.15,,,,,,,9571.89,24278.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19172.04,,,,,,,12629.79,32034.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13916.69,,,,,,,9167.77,23253.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10315.56,,,,,,,6795.48,17236.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30920.88,,,,,,,20346.30,51665.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19707.00,,,,,,,12982.19,32928.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15743.62,,,,,,,10371.27,26305.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22553.37,,,,,,,14857.27,37684.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11330.51,,,,,,,7464.10,18932.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7675.55,,,,,,,5056.35,12824.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16471.47,,,,,,,10850.76,27521.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9694.25,,,,,,,6386.19,16197.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8958.54,,,,,,,5901.53,14968.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18670.73,,,,,,,12299.54,31196.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11506.59,,,,,,,7580.09,19226.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8480.78,,,,,,,5586.81,14170.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17992.22,,,,,,,11852.57,30062.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11560.42,,,,,,,7615.55,19316.16,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21504.76,,,,,,,14166.49,35932.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8397.79,,,,,,,5532.13,14031.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20299.15,,,,,,,13372.28,33917.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10044.15,,,,,,,6616.69,16782.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25633.00,,,,,,,16886.01,42829.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15653.90,,,,,,,10312.17,26155.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10719.30,,,,,,,7061.45,17910.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25479.36,,,,,,,16784.80,42573.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14609.78,,,,,,,9624.35,24411.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10258.36,,,,,,,6757.80,17140.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15160.44,,,,,,,9987.10,25331.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12320.80,,,,,,,8116.46,20586.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9232.19,,,,,,,6081.80,15425.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19695.78,,,,,,,12974.81,32909.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11472.94,,,,,,,7557.92,19170.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8930.50,,,,,,,5883.06,14921.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39470.07,,,,,,,25736.28,65950.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28925.73,,,,,,,19055.13,48331.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28925.73,,,,,,,19055.13,48331.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40506.34,,,,,,,26389.63,67681.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25737.30,,,,,,,16954.72,43004.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15279.32,,,,,,,10065.41,25530.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21721.21,,,,,,,14309.08,36293.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10122.66,,,,,,,6668.41,16913.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12570.89,,,,,,,8281.21,21004.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9379.10,,,,,,,6178.58,15671.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26367.59,,,,,,,17369.93,44057.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15173.90,,,,,,,9995.96,25353.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17213.90,,,,,,,11339.84,28762.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20277.84,,,,,,,13358.24,33881.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12167.15,,,,,,,8015.24,20329.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13046.41,,,,,,,8594.46,21799.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8812.75,,,,,,,5805.49,14725.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8956.30,,,,,,,5900.06,14964.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14838.57,,,,,,,9775.06,24793.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8610.88,,,,,,,5672.51,14387.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23721.97,,,,,,,15627.10,39636.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11386.59,,,,,,,7501.04,19025.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16746.24,,,,,,,11031.76,27981.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9938.73,,,,,,,6547.25,16606.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13554.45,,,,,,,8929.14,22647.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,47835.34,,,,,,,31010.33,79927.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24461.04,,,,,,,16113.97,40871.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17903.63,,,,,,,11794.20,29914.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,42018.12,,,,,,,27342.76,70207.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19434.47,,,,,,,12802.67,32472.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13483.79,,,,,,,8882.59,22529.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23746.64,,,,,,,15643.35,39677.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14259.87,,,,,,,9393.84,23826.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8939.48,,,,,,,5888.97,14936.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8429.19,,,,,,,5552.82,14084.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14932.77,,,,,,,9837.12,24950.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8231.81,,,,,,,5422.79,13754.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13258.37,,,,,,,8734.09,22153.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8278.91,,,,,,,5453.82,13833.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17534.65,,,,,,,11551.14,29298.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10278.55,,,,,,,6771.10,17174.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7750.69,,,,,,,5105.85,12950.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19253.91,,,,,,,12683.72,32171.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10203.41,,,,,,,6721.60,17048.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7945.83,,,,,,,5234.40,13276.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,50263.39,,,,,,,32541.14,83984.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28306.66,,,,,,,18647.31,47297.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21467.75,,,,,,,14142.11,35870.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,41918.31,,,,,,,27279.81,70040.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20225.13,,,,,,,13323.52,33793.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15324.18,,,,,,,10094.96,25604.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,33380.33,,,,,,,21896.90,55774.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15404.92,,,,,,,10148.16,25739.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9028.08,,,,,,,5947.34,15084.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17525.68,,,,,,,11545.23,29283.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10945.84,,,,,,,7210.69,18289.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8467.33,,,,,,,5577.94,14147.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19805.69,,,,,,,13047.21,33093.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12011.26,,,,,,,7912.55,20069.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8343.96,,,,,,,5496.67,13941.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17157.83,,,,,,,11302.90,28668.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11933.88,,,,,,,7861.57,19940.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8820.60,,,,,,,5810.66,14738.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17478.58,,,,,,,11514.20,29204.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11092.76,,,,,,,7307.47,18534.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8043.40,,,,,,,5298.67,13439.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13855.01,,,,,,,9127.14,23150.16,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12422.86,,,,,,,8183.69,20757.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9454.25,,,,,,,6228.08,15796.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7200.03,,,,,,,4743.10,12030.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14741.00,,,,,,,9710.79,24630.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9038.17,,,,,,,5953.99,15101.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7048.63,,,,,,,4643.36,11777.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21164.95,,,,,,,13942.63,35364.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10644.16,,,,,,,7011.95,17785.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8032.18,,,,,,,5291.29,13420.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19784.38,,,,,,,13033.17,33057.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12328.65,,,,,,,8121.63,20599.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8019.85,,,,,,,5283.16,13400.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10892.01,,,,,,,7175.23,18199.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7514.05,,,,,,,4949.96,12555.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9054.99,,,,,,,5965.07,15129.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20534.67,,,,,,,13527.43,34311.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10554.44,,,,,,,6952.85,17635.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,72165.16,,,,,,,46349.51,120579.84,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30826.67,,,,,,,20286.88,51507.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,126940.34,,,,,,,80883.55,212102.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,121953.03,,,,,,,77739.20,203769.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,64002.88,,,,,,,41203.47,106941.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,111667.76,,,,,,,71254.67,186584.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,109714.10,,,,,,,70022.93,183319.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,73741.99,,,,,,,47343.65,123214.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,73741.99,,,,,,,47343.65,123214.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,86112.13,,,,,,,55142.64,143883.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,59807.35,,,,,,,38558.31,99931.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,56525.84,,,,,,,36489.42,94448.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,55485.09,,,,,,,35833.26,92709.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35321.64,,,,,,,23120.82,59018.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,94541.33,,,,,,,60456.99,157967.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,67992.06,,,,,,,43718.51,113607.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,85740.92,,,,,,,54908.59,143263.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,61264.18,,,,,,,39476.79,102365.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,65816.35,,,,,,,42346.80,109971.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,46977.39,,,,,,,30469.42,78493.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,55196.87,,,,,,,35651.54,92227.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,31968.36,,,,,,,21006.71,53415.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15526.05,,,,,,,10227.95,25942.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35807.25,,,,,,,23426.99,59829.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23898.04,,,,,,,15743.09,44147.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20271.11,,,,,,,13353.81,33870.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,51167.32,,,,,,,33111.02,85494.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24476.74,,,,,,,16124.31,40897.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16760.82,,,,,,,11041.37,28005.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39121.28,,,,,,,25516.39,65367.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,29109.65,,,,,,,19176.29,48638.95,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19981.77,,,,,,,13163.20,33387.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30251.34,,,,,,,19924.18,50546.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19041.95,,,,,,,12544.09,31816.95,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12249.02,,,,,,,8069.17,20466.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35238.65,,,,,,,23068.51,58879.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22677.85,,,,,,,14939.27,37892.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36480.15,,,,,,,22172.00,60954.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21201.96,,,,,,,13967.01,35426.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18279.33,,,,,,,12041.70,30542.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,34288.74,,,,,,,22469.61,57292.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,37464.83,,,,,,,24472.05,62599.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40578.11,,,,,,,26434.87,67801.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,68730.01,,,,,,,44183.77,114840.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,53392.37,,,,,,,34513.86,89212.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,77135.65,,,,,,,49483.25,128884.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,47363.19,,,,,,,30712.64,79138.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,59173.70,,,,,,,38158.82,98872.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39883.90,,,,,,,25997.21,66641.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28631.90,,,,,,,18861.56,47840.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,46267.48,,,,,,,30021.84,77307.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36916.42,,,,,,,24126.28,61683.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,79967.44,,,,,,,51268.60,133616.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,67364.02,,,,,,,43322.54,112557.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,51796.48,,,,,,,33507.69,86546.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,62424.93,,,,,,,40208.61,104305.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40445.78,,,,,,,26351.43,67580.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17989.98,,,,,,,11851.09,30059.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10307.71,,,,,,,6790.31,17223.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8109.57,,,,,,,5342.26,13550.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22214.67,,,,,,,14634.15,37118.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7763.02,,,,,,,5113.97,12971.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6716.66,,,,,,,4424.67,11222.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24816.55,,,,,,,16348.17,41465.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12001.17,,,,,,,7905.90,20052.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30350.03,,,,,,,19986.40,50711.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19142.88,,,,,,,12610.58,31985.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10426.59,,,,,,,6868.62,17421.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14397.82,,,,,,,9484.71,24057.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9521.53,,,,,,,6272.41,15909.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6347.69,,,,,,,4181.61,10606.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17516.71,,,,,,,11539.32,29268.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6992.55,,,,,,,4606.42,11683.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,5103.95,,,,,,,3362.28,8528.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18310.73,,,,,,,12062.39,30595.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11972.01,,,,,,,7886.69,20003.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8071.44,,,,,,,5317.14,13486.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13419.87,,,,,,,8840.48,22423.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7549.94,,,,,,,4973.60,12615.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13345.85,,,,,,,8791.72,22299.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8468.45,,,,,,,5578.68,14149.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17672.60,,,,,,,11642.01,29528.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10241.54,,,,,,,6746.72,17112.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13502.86,,,,,,,8895.15,22561.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8250.88,,,,,,,5435.35,13786.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6348.81,,,,,,,4182.35,10608.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7871.81,,,,,,,5185.64,13152.90,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9774.99,,,,,,,6439.38,16332.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8074.80,,,,,,,5319.36,13492.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23385.52,,,,,,,15405.46,39074.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10803.41,,,,,,,7116.86,18051.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7649.75,,,,,,,5039.35,12781.87,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,74989.10,,,,,,,48129.92,125298.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27164.97,,,,,,,17895.21,45389.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,50051.42,,,,,,,32407.49,83630.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26975.44,,,,,,,17770.36,45072.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30513.77,,,,,,,20089.63,50985.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19772.04,,,,,,,13025.04,33036.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,48531.79,,,,,,,31449.41,81091.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35338.46,,,,,,,23131.43,59046.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36004.64,,,,,,,23551.45,60159.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,55933.69,,,,,,,36116.09,93458.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27411.70,,,,,,,18057.75,45801.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17969.79,,,,,,,11837.79,30025.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,51549.75,,,,,,,33352.15,86133.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26884.60,,,,,,,17710.51,44921.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18873.72,,,,,,,12433.27,31535.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40606.15,,,,,,,26452.56,67848.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26267.77,,,,,,,17304.17,43890.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18369.05,,,,,,,12100.81,30692.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40047.64,,,,,,,26100.45,66915.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23649.07,,,,,,,15579.08,39514.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17215.03,,,,,,,11340.58,28764.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28966.10,,,,,,,19081.73,48399.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16875.21,,,,,,,11116.72,28196.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13303.23,,,,,,,8763.65,22228.20,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25745.15,,,,,,,16959.89,43017.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14678.19,,,,,,,9669.41,24525.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9763.78,,,,,,,6431.99,16314.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27946.66,,,,,,,18410.16,46695.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17097.27,,,,,,,11263.01,28567.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13096.88,,,,,,,8627.71,21883.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32545.93,,,,,,,21370.84,54380.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18868.12,,,,,,,12429.57,31526.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15084.17,,,,,,,9936.86,25203.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,49265.25,,,,,,,31911.85,82316.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26080.48,,,,,,,17180.79,43577.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15677.45,,,,,,,10327.69,26195.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,38563.90,,,,,,,25164.98,64435.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27076.37,,,,,,,17836.85,45241.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17853.16,,,,,,,11760.96,29830.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11217.24,,,,,,,7389.48,18742.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7859.47,,,,,,,5177.51,13132.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19885.32,,,,,,,13099.66,33226.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11450.51,,,,,,,7543.15,19132.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8157.79,,,,,,,5374.03,13630.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23985.52,,,,,,,15800.72,40077.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13565.66,,,,,,,8936.52,22666.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10366.02,,,,,,,6828.73,17320.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20501.02,,,,,,,13505.26,34254.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10998.55,,,,,,,7245.41,18377.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7069.94,,,,,,,4657.40,11813.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22006.07,,,,,,,14496.73,36769.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12151.45,,,,,,,8004.90,20303.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8978.73,,,,,,,5914.83,15002.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15484.55,,,,,,,10200.61,25872.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9586.58,,,,,,,6315.26,16018.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17745.49,,,,,,,11690.03,29650.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10949.20,,,,,,,7212.90,18294.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7640.78,,,,,,,5033.44,12766.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16562.31,,,,,,,10910.60,27673.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8857.61,,,,,,,5835.04,14800.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6100.96,,,,,,,4019.07,10194.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14223.98,,,,,,,9370.20,23766.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8743.21,,,,,,,5759.68,14608.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17936.15,,,,,,,11815.63,29969.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10493.88,,,,,,,6912.95,17534.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7278.53,,,,,,,4794.81,12161.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26858.80,,,,,,,17693.52,44878.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16975.02,,,,,,,11182.48,28363.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12837.81,,,,,,,8457.04,21450.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,45089.91,,,,,,,29279.42,75340.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,61351.66,,,,,,,39531.94,102511.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32525.74,,,,,,,21358.11,54346.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24892.81,,,,,,,16398.40,41593.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39988.20,,,,,,,26062.95,66815.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24418.42,,,,,,,16085.89,40800.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17806.06,,,,,,,11729.93,29751.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,37046.51,,,,,,,24208.31,61900.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23579.54,,,,,,,15533.27,39398.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18622.51,,,,,,,12267.77,31116.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39954.56,,,,,,,26041.75,66759.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23178.04,,,,,,,15268.78,38727.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15289.41,,,,,,,10072.06,25546.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26763.48,,,,,,,17630.72,44718.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18971.29,,,,,,,12497.54,31698.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15317.45,,,,,,,10090.53,25593.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,38210.63,,,,,,,24942.24,63845.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19486.06,,,,,,,12836.65,32559.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15695.39,,,,,,,10339.51,26225.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,46575.89,,,,,,,30216.30,77823.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24537.30,,,,,,,16164.21,40999.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16825.86,,,,,,,11084.22,28114.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,123602.76,,,,,,,78779.31,206526.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,80956.60,,,,,,,51892.24,135269.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,63050.73,,,,,,,40603.15,105350.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,101042.66,,,,,,,64555.88,168830.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,64678.03,,,,,,,41629.10,108069.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22073.36,,,,,,,14541.06,36882.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11845.28,,,,,,,7803.21,19792.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7990.69,,,,,,,5263.95,13351.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20598.59,,,,,,,13569.54,34417.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12685.29,,,,,,,8356.57,21195.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9569.76,,,,,,,6304.18,15989.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18282.69,,,,,,,12043.92,30548.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9434.06,,,,,,,6214.79,15763.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6969.00,,,,,,,4590.90,11644.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20127.56,,,,,,,13259.24,33630.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10825.84,,,,,,,7131.64,18088.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7847.14,,,,,,,5169.38,13111.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18739.14,,,,,,,12344.61,31311.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12273.70,,,,,,,8085.43,20507.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9278.17,,,,,,,6112.09,15502.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,74934.14,,,,,,,48095.26,125206.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,47560.57,,,,,,,30837.10,79468.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,59771.46,,,,,,,38535.67,99871.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36228.94,,,,,,,23692.85,60534.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,94244.13,,,,,,,60269.61,157471.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,66876.17,,,,,,,43014.97,111742.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,46795.71,,,,,,,30354.87,78190.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,60119.13,,,,,,,39604.11,100452.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,29831.90,,,,,,,19652.08,49845.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,63919.89,,,,,,,41151.13,106802.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,34931.36,,,,,,,22874.77,58366.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20452.80,,,,,,,13473.50,34174.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,58378.56,,,,,,,32841.00,97543.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39550.82,,,,,,,25787.19,66084.96,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30818.82,,,,,,,20281.95,51494.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,34017.34,,,,,,,22298.52,56839.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21632.61,,,,,,,14490.34,36145.66,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,54153.87,,,,,,,34993.95,90485.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,33040.51,,,,,,,21682.65,55206.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27379.18,,,,,,,18036.32,45747.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,48144.87,,,,,,,31205.47,80444.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25521.98,,,,,,,16812.87,42644.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13235.94,,,,,,,8719.32,22115.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,38743.34,,,,,,,25278.10,64735.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27579.93,,,,,,,18168.57,46082.95,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20847.56,,,,,,,13733.55,34833.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32661.44,,,,,,,21443.67,54573.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23489.82,,,,,,,15474.17,39248.84,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18291.67,,,,,,,12049.83,30563.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,31086.86,,,,,,,20450.94,51942.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36191.93,,,,,,,23669.52,60472.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23451.69,,,,,,,15449.05,39185.12,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17564.93,,,,,,,11571.09,29349.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17087.17,,,,,,,11256.36,28550.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12524.91,,,,,,,8250.92,20927.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,41176.99,,,,,,,26812.44,68802.11,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28442.36,,,,,,,18736.71,47523.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22502.90,,,,,,,14824.02,37599.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40662.23,,,,,,,26487.90,67941.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20230.74,,,,,,,13327.21,33803.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12916.32,,,,,,,8508.76,21581.71,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,33833.41,,,,,,,22182.53,56531.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22595.98,,,,,,,14885.34,37755.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35493.23,,,,,,,23229.03,59305.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19604.94,,,,,,,12914.96,32757.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15094.27,,,,,,,9943.51,25220.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,31302.19,,,,,,,20586.69,52302.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20963.08,,,,,,,13809.65,35026.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20106.25,,,,,,,13245.21,33595.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13453.51,,,,,,,8862.64,22479.30,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20258.78,,,,,,,13345.68,33850.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16984.00,,,,,,,11188.39,28378.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,33874.91,,,,,,,22208.72,56601.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23320.47,,,,,,,15362.61,38965.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18565.31,,,,,,,12230.10,31020.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17655.77,,,,,,,11630.93,29500.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11465.09,,,,,,,7552.75,19156.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35741.08,,,,,,,23385.28,59719.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23305.89,,,,,,,15353.00,38941.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17234.09,,,,,,,11353.14,28796.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,41913.82,,,,,,,27276.98,70033.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22432.24,,,,,,,14777.48,37481.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16754.09,,,,,,,11036.93,27994.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32189.29,,,,,,,21145.99,53784.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23750.01,,,,,,,15645.57,39683.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17581.76,,,,,,,11582.17,29377.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9040.41,,,,,,,5955.47,15105.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14377.63,,,,,,,9471.42,24023.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9057.23,,,,,,,5966.55,15133.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10702.47,,,,,,,7050.37,17882.63,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8078.16,,,,,,,5321.58,13497.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22090.19,,,,,,,14552.14,36910.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14538.00,,,,,,,9577.06,24291.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8652.37,,,,,,,5699.84,14457.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19811.30,,,,,,,13050.90,33102.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11529.02,,,,,,,7594.86,19263.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8462.84,,,,,,,5574.98,14140.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27832.27,,,,,,,18334.80,46504.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12935.38,,,,,,,8521.32,21613.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9377.98,,,,,,,6177.85,15669.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21655.04,,,,,,,14265.49,36183.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13538.75,,,,,,,8918.79,22621.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9803.03,,,,,,,6457.85,16379.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18797.46,,,,,,,12383.03,31408.44,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10780.98,,,,,,,7102.08,18013.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14538.00,,,,,,,9577.06,24291.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9309.57,,,,,,,6132.78,15555.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14823.99,,,,,,,9765.46,24769.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9315.18,,,,,,,6136.47,15564.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16675.58,,,,,,,10985.22,27863.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10017.24,,,,,,,6598.96,16737.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20914.85,,,,,,,13777.88,34946.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12629.21,,,,,,,8319.63,21101.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9015.74,,,,,,,5939.21,15064.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15979.13,,,,,,,10526.42,26699.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10043.03,,,,,,,6615.95,16780.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17311.47,,,,,,,11404.12,28925.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10927.90,,,,,,,7198.87,18259.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8403.40,,,,,,,5535.83,14041.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32984.44,,,,,,,21647.31,55113.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18947.74,,,,,,,12482.03,31659.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12855.75,,,,,,,8468.86,21480.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,73473.95,,,,,,,47174.67,122766.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,38931.75,,,,,,,25396.90,65050.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18320.82,,,,,,,12069.04,30612.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,54966.96,,,,,,,35506.60,91843.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,29727.60,,,,,,,19583.37,49671.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18015.78,,,,,,,11868.08,30102.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36319.78,,,,,,,23750.13,60686.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19379.52,,,,,,,12766.46,32380.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16184.37,,,,,,,10661.62,27042.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21606.82,,,,,,,14233.72,36102.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19339.15,,,,,,,12739.87,32313.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24007.95,,,,,,,15815.49,40114.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21634.86,,,,,,,14252.19,36149.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21704.39,,,,,,,14298.00,36265.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13304.35,,,,,,,8764.38,22230.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9721.16,,,,,,,6403.92,16242.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23783.65,,,,,,,15667.73,39739.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12140.24,,,,,,,7997.51,20284.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18696.53,,,,,,,12316.53,31239.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12687.53,,,,,,,8358.04,21199.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8222.84,,,,,,,5416.88,13739.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11681.54,,,,,,,7695.34,19518.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6785.07,,,,,,,4469.74,11337.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15939.88,,,,,,,10500.56,26633.74,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9767.14,,,,,,,6434.21,16319.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16509.60,,,,,,,10875.87,27585.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10272.94,,,,,,,6767.41,17164.92,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16970.54,,,,,,,11179.52,28355.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10165.28,,,,,,,6696.48,16985.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24581.04,,,,,,,16193.02,41072.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15693.15,,,,,,,10338.03,26221.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39111.19,,,,,,,25510.02,65350.39,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20975.41,,,,,,,13817.78,35047.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15906.23,,,,,,,10478.40,26577.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32382.19,,,,,,,16490.00,54106.99,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17947.36,,,,,,,11823.02,35030.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16916.71,,,,,,,11144.06,35030.00,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39916.43,,,,,,,26017.71,66695.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20118.59,,,,,,,13253.33,33615.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14040.06,,,,,,,9249.04,23459.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,33870.42,,,,,,,22205.88,56593.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16815.77,,,,,,,11077.57,28097.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14896.88,,,,,,,9813.48,24891.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,41796.06,,,,,,,27202.76,69836.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24435.24,,,,,,,16096.97,40828.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16368.29,,,,,,,10782.79,27349.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16112.59,,,,,,,10614.34,26922.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10050.88,,,,,,,6621.13,16793.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6966.76,,,,,,,4589.43,11640.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14978.75,,,,,,,9867.41,25027.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8727.51,,,,,,,5749.34,14582.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15948.85,,,,,,,10506.47,26648.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18461.01,,,,,,,12161.39,30846.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11495.38,,,,,,,7572.70,19207.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8616.48,,,,,,,5676.20,14397.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,58277.63,,,,,,,37593.86,97375.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,31394.15,,,,,,,20644.67,52456.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23737.67,,,,,,,15637.44,39662.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35706.32,,,,,,,23363.36,59661.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20523.45,,,,,,,13520.04,34292.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17403.44,,,,,,,11464.70,29079.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28496.19,,,,,,,18772.17,47613.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14822.87,,,,,,,9764.72,24767.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11612.01,,,,,,,7649.54,19402.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,34334.72,,,,,,,22498.61,57369.45,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17049.04,,,,,,,11231.24,28487.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11740.98,,,,,,,7734.50,19617.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35004.26,,,,,,,22920.74,58488.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19618.40,,,,,,,12923.83,32780.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12406.03,,,,,,,8172.61,20729.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32747.80,,,,,,,21498.11,54717.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17405.68,,,,,,,11466.18,29082.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10960.42,,,,,,,7220.29,18313.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20130.92,,,,,,,13261.46,33636.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12106.59,,,,,,,7975.35,20228.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,47120.94,,,,,,,30559.94,78733.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26227.40,,,,,,,17277.58,43823.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18408.30,,,,,,,12126.66,30758.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16609.42,,,,,,,10941.63,27752.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9822.10,,,,,,,6470.41,16411.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6732.36,,,,,,,4435.02,11249.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20228.50,,,,,,,13325.74,33799.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11751.08,,,,,,,7741.15,19634.72,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8863.21,,,,,,,5838.74,14809.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13012.76,,,,,,,8572.30,21742.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9078.54,,,,,,,5980.59,15169.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15078.57,,,,,,,9933.17,25194.59,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8766.77,,,,,,,5775.20,14648.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12827.72,,,,,,,8450.39,21433.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7727.14,,,,,,,5090.33,12911.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12087.53,,,,,,,7962.79,20196.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18554.10,,,,,,,12222.71,31001.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11383.23,,,,,,,7498.82,19020.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7737.23,,,,,,,5096.98,12928.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22433.36,,,,,,,14778.22,37483.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17206.05,,,,,,,11334.67,28749.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26098.43,,,,,,,17192.61,43607.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15714.46,,,,,,,10352.07,26257.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23369.82,,,,,,,15395.11,39048.33,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12333.14,,,,,,,8124.58,20607.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16860.63,,,,,,,11107.12,28172.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11858.74,,,,,,,7812.07,19814.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25091.32,,,,,,,16529.17,41924.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16497.26,,,,,,,10867.75,27565.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21201.96,,,,,,,13967.01,35426.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15062.87,,,,,,,9922.82,25168.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20295.79,,,,,,,13370.06,33911.97,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12815.38,,,,,,,8442.27,21413.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6860.22,,,,,,,4519.24,11462.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13123.79,,,,,,,8645.44,21928.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8097.23,,,,,,,5334.14,13529.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16630.72,,,,,,,10955.67,27788.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9097.61,,,,,,,5993.15,15201.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11873.32,,,,,,,7821.68,19838.98,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7536.48,,,,,,,4964.74,12592.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23887.95,,,,,,,15736.44,39914.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15089.78,,,,,,,9940.55,25213.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40088.02,,,,,,,26125.88,66982.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23109.63,,,,,,,15223.71,38613.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16469.23,,,,,,,10849.28,27518.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,39547.45,,,,,,,26052.30,66079.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20294.66,,,,,,,13369.32,33910.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15993.71,,,,,,,10536.03,26723.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20577.28,,,,,,,13555.50,34382.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13914.45,,,,,,,9166.29,23249.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22980.66,,,,,,,15138.75,38398.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12757.06,,,,,,,8403.85,21315.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19481.58,,,,,,,12833.69,32551.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9414.99,,,,,,,6202.23,15731.39,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15558.57,,,,,,,10249.37,25996.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,28795.63,,,,,,,18969.43,48114.26,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16551.10,,,,,,,10903.21,27655.02,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20654.67,,,,,,,13606.48,34511.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12199.68,,,,,,,8036.67,20384.28,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10772.01,,,,,,,7096.17,17998.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16058.76,,,,,,,10578.88,26832.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10979.49,,,,,,,7232.85,18345.48,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7442.27,,,,,,,4902.68,12435.20,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11299.11,,,,,,,7443.41,18879.54,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6388.06,,,,,,,4208.20,10673.73,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6322.00,,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18951.11,,,,,,,12484.24,31665.16,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11245.28,,,,,,,7407.95,18789.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7342.46,,,,,,,4836.92,12268.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7997.42,,,,,,,5268.38,13362.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10566.00,,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,5414.00,31619.23,case rate,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10566.00,,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10566.00,,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10566.00,,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,5414.00,21243.91,case rate,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10566.00,,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10566.00,,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,5414.00,15908.00,case rate,"Case rate up to day 4. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,2318.00,,,,,,,1810.00,33771.43,per diem,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,4197.00,,,,,,,1810.00,111375.25,per diem,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,3386.00,,,,,,,1810.00,76061.60,per diem,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,2318.00,,,,,,,1810.00,45895.56,per diem,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,3386.00,,,,,,,1810.00,78134.13,per diem,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,2318.00,,,,,,,375.00,27656.89,per diem,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,740.00,,,,,,,314.00,3744.05,per diem,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6322.00,,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,4210.00,9947.78,case rate,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6322.00,,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6322.00,,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,50791.61,,,,,,,32874.17,84867.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,31507.42,,,,,,,20716.09,52645.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21408.31,,,,,,,14102.95,35770.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,44681.68,,,,,,,29022.04,74658.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20847.56,,,,,,,13733.55,34833.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15207.54,,,,,,,10018.13,25410.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6322.00,,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6322.00,,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6322.00,,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.",,,,0,4210.00,9518.00,case rate,"Case rate up to day 2. Additional days reimbursed at $1,477.00 Per Diem rate.; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24761.60,,,,,,,16311.97,41373.84,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14197.07,,,,,,,9352.47,23721.70,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11737.62,,,,,,,7732.28,19612.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15749.22,,,,,,,10374.97,26315.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10297.61,,,,,,,6783.66,17206.15,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17106.24,,,,,,,11268.92,28582.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23850.94,,,,,,,15712.06,39852.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11372.01,,,,,,,7491.43,19001.35,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7087.88,,,,,,,4669.22,11843.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18930.92,,,,,,,12470.94,31631.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11822.85,,,,,,,7788.43,19754.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9643.78,,,,,,,6352.94,16113.67,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,65773.73,,,,,,,42319.93,109900.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25105.90,,,,,,,16538.78,41949.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13502.86,,,,,,,8895.15,22561.76,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,51418.53,,,,,,,33269.41,85914.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25408.70,,,,,,,16738.25,42455.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15133.52,,,,,,,9969.37,25286.41,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,52461.53,,,,,,,33926.98,87657.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,25920.11,,,,,,,17075.15,43309.58,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19108.12,,,,,,,12587.67,31927.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,35439.40,,,,,,,23195.07,59215.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16878.58,,,,,,,11118.94,28202.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13486.04,,,,,,,8884.07,22533.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8092.74,,,,,,,5331.18,13522.06,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,5864.32,,,,,,,3863.19,9798.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,61569.23,,,,,,,39669.12,102875.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23392.25,,,,,,,15409.89,39085.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13676.69,,,,,,,9009.67,22852.21,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,53880.22,,,,,,,34821.45,90027.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23410.19,,,,,,,15421.71,39115.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16193.34,,,,,,,10667.53,27057.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36279.40,,,,,,,23724.68,60618.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18296.15,,,,,,,12052.78,30570.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11331.64,,,,,,,7464.84,18933.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22371.68,,,,,,,14737.58,37380.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13653.14,,,,,,,8994.15,22812.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9550.69,,,,,,,6291.62,15958.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,29074.89,,,,,,,19153.39,48580.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14671.46,,,,,,,9664.98,24514.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9526.02,,,,,,,6275.37,15916.91,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30387.04,,,,,,,20009.72,50773.32,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,97116.29,,,,,,,62080.42,162270.37,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,55386.40,,,,,,,35771.03,92544.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22408.69,,,,,,,14761.96,37442.40,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16791.10,,,,,,,11061.31,28056.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,51013.67,,,,,,,33014.15,85238.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24016.92,,,,,,,15821.40,40129.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15621.37,,,,,,,10290.75,26101.55,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20452.80,,,,,,,13473.50,34174.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11191.45,,,,,,,7372.49,18699.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9955.56,,,,,,,6558.33,16634.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16803.43,,,,,,,11069.44,28076.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9752.56,,,,,,,6424.60,16295.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23475.24,,,,,,,15464.56,39224.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11563.79,,,,,,,7617.77,19321.78,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8183.59,,,,,,,5391.02,13673.85,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,77515.84,,,,,,,49722.96,129520.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21785.14,,,,,,,14351.19,36400.51,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11476.31,,,,,,,7560.14,19175.62,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,43344.85,,,,,,,823.98,72424.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10768.64,,,,,,,823.98,17993.19,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10552.19,,,,,,,823.98,17631.53,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12042.67,,,,,,,823.98,20121.94,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22052.05,,,,,,,823.98,36846.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18043.81,,,,,,,823.98,30149.18,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15665.11,,,,,,,823.98,26174.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23274.49,,,,,,,823.98,38889.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12010.14,,,,,,,823.98,20067.60,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6918.53,,,,,,,823.98,11560.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,15875.95,,,,,,,823.98,26526.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19571.30,,,,,,,823.98,32701.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9900.60,,,,,,,823.98,16542.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,47064.87,,,,,,,30524.57,78640.09,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,21471.12,,,,,,,14144.33,35875.82,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13117.06,,,,,,,8641.00,21917.13,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,41193.82,,,,,,,26823.05,68830.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,16057.64,,,,,,,10578.14,26830.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19765.32,,,,,,,13020.61,33025.61,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,43057.75,,,,,,,27998.19,71944.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22376.17,,,,,,,14740.54,37388.05,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14721.93,,,,,,,9698.23,24598.69,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18332.04,,,,,,,12076.42,30630.77,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9930.88,,,,,,,6542.07,16593.38,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18859.14,,,,,,,12423.66,31511.50,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7472.55,,,,,,,4922.62,12485.80,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17589.61,,,,,,,11587.34,29390.25,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,9612.38,,,,,,,6332.25,16061.20,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,20532.42,,,,,,,13525.95,34307.36,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11240.79,,,,,,,7404.99,18782.10,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7720.41,,,,,,,5085.90,12899.93,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19619.52,,,,,,,12924.57,32782.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,11413.51,,,,,,,7518.77,19070.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,206694.69,,,,,,,136162.32,345363.52,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,80441.83,,,,,,,51567.69,134409.23,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,36121.27,,,,,,,23624.98,60354.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,42804.29,,,,,,,28197.78,71521.14,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,24791.88,,,,,,,16331.91,41424.43,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,23102.90,,,,,,,15219.28,38602.34,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,40693.63,,,,,,,26507.70,67994.46,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,26208.33,,,,,,,17265.02,43791.17,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,22740.66,,,,,,,14980.65,37997.07,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17367.55,,,,,,,526.87,29019.22,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,12861.36,,,,,,,526.87,21489.89,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14236.32,,,,,,,9378.33,23787.29,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,8977.61,,,,,,,5914.09,15000.57,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13342.49,,,,,,,8789.50,22293.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,7039.66,,,,,,,4637.45,11762.47,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,6235.54,,,,,,,4107.73,10418.88,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,75489.29,,,,,,,48445.28,126134.08,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,42202.04,,,,,,,27458.71,70514.86,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,85457.18,,,,,,,54729.71,142789.31,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,47258.89,,,,,,,30646.88,78964.27,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,33018.08,,,,,,,21668.51,55169.49,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,30659.57,,,,,,,20181.55,51228.68,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,17188.11,,,,,,,11322.85,28719.39,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10547.71,,,,,,,6948.41,17624.03,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,68650.38,,,,,,,44133.55,114707.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,29578.44,,,,,,,19485.11,49422.24,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,32366.49,,,,,,,21257.70,54080.75,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14523.42,,,,,,,9567.46,24267.01,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,10031.82,,,,,,,6608.57,16762.04,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,14216.13,,,,,,,9365.03,23753.56,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,52618.54,,,,,,,34025.97,87919.64,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,27572.08,,,,,,,18163.40,46069.83,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,19222.51,,,,,,,12663.03,32118.65,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,38449.51,,,,,,,25092.85,64244.79,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,18432.97,,,,,,,12142.92,30799.42,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Individual Exchange,,13449.03,,,,,,,8859.69,22471.81,case rate,"When length of stay exceeds the MS-DRG specific CMS Arithmetic Mean Length of Stay rounded to the nearest whole day plus 6 days during a single Admission, the contract rate will be $8,112.00 Per Diem for each day in excess of the Inpatient Outlier Threshold in addition to the applicable contract rate."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,38900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",361,RC,31627,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15777,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,18291.76,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)",360,RC,43775,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64488,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10016.47,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,60512,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22853,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",361,RC,31654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22845,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4964.08,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6274.19,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,34125.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6274.19,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF INTRAUTERINE DEVICE (IUD),360,RC,58300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20936,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4311.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4311.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20931,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4964.08,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,11124.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1494.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,34125.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6314.07,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,9423.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,29826,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64468,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)",360,RC,43845,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6314.07,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4964.08,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)",360,RC,43644,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,20937,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4311.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,6649.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4311.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20985,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64466,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,31632,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,34125.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT",360,RC,27487,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,34125.00,,,,,,,34125.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,3660.29,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63052,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6274.19,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1970.84,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64486,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OMENTAL FLAP, INTRA-ABDOMINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL",360,RC,60650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; PERINEAL APPROACH",360,RC,45130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93657,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61782,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,9423.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,4121.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC/DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49596,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3308.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,61783,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,14302,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,7277.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT",360,RC,27486,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22842,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27132,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G, ABDOMINAL APPROACH",360,RC,58146,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION),360,RC,38724,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6274.19,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT",360,RC,23474,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22634,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF TOTAL OR NEAR TOTAL NON-INFECTED MESH OR OTHER PROSTHESIS AT THE TIME OF INITIAL OR RECURRENT ANTERIOR ABDOMINAL HERNIA REPAIR OR PARASTOMAL HERNIA REPAIR, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4749.28,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);",360,RC,58150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,9423.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3308.62,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63053,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,10006,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2194.26,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL;",360,RC,57110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64473,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S)",360,RC,58180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19126,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6274.19,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL OF GEROTA'S FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES, AND ADRENALECTOMY)",360,RC,50545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,53081.00,,,,,,,6735.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27134,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,6649.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE RESECTION AND ANASTOMOSIS",360,RC,44202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, TOTAL HYSTERECTOMY FOR RESECTION OF MALIGNANCY (TUMOR DEBULKING), WITH OMENTECTOMY INCLUDING SALPINGO-OOPHORECTOMY, UNILATERAL OR BILATERAL, WHEN PERFORMED",360,RC,58575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1970.84,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR",360,RC,22558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49618,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1558.81,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,53081.00,,,,,,,6735.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1494.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,34125.00,,,,,,,4376.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITHOUT VAGOTOMY",360,RC,43860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES)",360,RC,21147,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6258.49,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22632,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,57.15,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; CERVICAL BELOW C2 SEGMENT",360,RC,22600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8700.96,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, WITH PERINEAL BODY RECONSTRUCTION, WITH OR WITHOUT LEVATOR PLICATION",360,RC,57308,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,4311.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; SINGLE IMPLANT",360,RC,52441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,57.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,1539.73,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM (SEPARATE PROCEDURE)",360,RC,49255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PYLOROPLASTY,360,RC,43800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,4376.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,12247.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64467,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10910.59,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,25579.00,,,,,,,4121.00,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36907,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,53081.00,,,,,,,6735.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),750,RC,43273,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS",360,RC,44204,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE)",360,RC,45400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6258.49,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG-ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,7300.39,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY LYMPH NODES",360,RC,19305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)",360,RC,21145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION",360,RC,43645,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,66990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4311.00,13652.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF PARASTOMAL HERNIA, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL OR RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS, WHEN PERFORMED; REDUCIBLE",360,RC,49621,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH RADICAL NECK DISSECTION",360,RC,60254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL;",360,RC,58940,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,58720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITH FIXATION",360,RC,27450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4311.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BICORTICAL OR TRICORTICAL (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20938,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4311.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,26125,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; EACH ADDITIONAL SEGMENT, THORACIC OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63057,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL CAROTID ARTERY, OPEN OR PERCUTANEOUS, INCLUDING ANGIOPLASTY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION; WITH DISTAL EMBOLIC PROTECTION",360,RC,37215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, HIP OR THIGH, ANY TYPE",360,RC,27025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,56606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,642.16,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; EACH ADDITIONAL PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,52442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BALLOON DILATION, URETERAL STRICTURE, INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,50706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1659.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; ABDOMINAL APPROACH",360,RC,58140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BACKBENCH PREPARATION OF CORNEAL ENDOTHELIAL ALLOGRAFT PRIOR TO TRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,65757,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,931.82,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4964.08,12686.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,64636,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SECOND LEVEL, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22858,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF ANTERIOR INSTRUMENTATION,360,RC,22855,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10087.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF ADJUSTABLE SUTURE(S) DURING STRABISMUS SURGERY, INCLUDING POSTOPERATIVE ADJUSTMENT(S) OF SUTURE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR SPECIFIC STRABISMUS SURGERY)",360,RC,67335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS)",360,RC,44207,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE",360,RC,44187,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH THORACIC SYMPATHECTOMY",360,RC,32664,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; COMMON FEMORAL",360,RC,35371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4507.53,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY",360,RC,43846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4121.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1558.81,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (OMENTAL TACKING PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49326,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY",360,RC,50546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY",360,RC,50548,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETEROLYSIS, WITH OR WITHOUT REPOSITIONING OF URETER FOR RETROPERITONEAL FIBROSIS",360,RC,50715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,9721.99,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF MESH OR OTHER PROSTHESIS FOR REPAIR OF PELVIC FLOOR DEFECT, EACH SITE (ANTERIOR, POSTERIOR COMPARTMENT), VAGINAL APPROACH (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,57267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3121.59,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGECTOMY AND/OR OOPHORECTOMY, ABDOMINAL OR VAGINAL APPROACH",360,RC,59120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4121.00,13110.66,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,1878.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,527.80,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH, METHYLMETHACRYLATE) TO INTERVERTEBRAL DISC SPACE OR VERTEBRAL BODY DEFECT WITHOUT INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22859,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REINSERTION OF SPINAL FIXATION DEVICE,360,RC,22849,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS",360,RC,22548,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3120.11,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR VERTEBRAL JOINT(S) ARTHROPLASTY (EG, FACET JOINT[S] REPLACEMENT), INCLUDING FACETECTOMY, LAMINECTOMY, FORAMINOTOMY, AND VERTEBRAL COLUMN FIXATION, INJECTION OF BONE CEMENT, WHEN PERFORMED, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE",360,RC,0202T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,4311.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,7300.39,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,7300.39,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; WITH REPAIR OF ENTEROCELE",360,RC,58280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4749.28,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4749.28,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS (NONOBSTETRICAL)",360,RC,58520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH RADICAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY), WITH REMOVAL OF TUBE(S) AND OVARY(S), IF PERFORMED",360,RC,58548,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,3121.59,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1558.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,360,RC,51600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID BLADDER, INCLUDING INTESTINE ANASTOMOSIS;",360,RC,51590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,12247.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE);",360,RC,60540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF SKULL,360,RC,61500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, INTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61781,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; RE-AMPUTATION",360,RC,27886,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ACETABULOPLASTY; RESECTION, FEMORAL HEAD (EG, GIRDLESTONE PROCEDURE)",360,RC,27122,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27137,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE",360,RC,63077,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL (IE, PERITONEAL, MESENTERIC, RETROPERITONEAL), PRIMARY OR SECONDARY TUMOR(S) OR CYST(S), SUM OF THE MAXIMUM LENGTH OF TUMOR(S) OR CYST(S); 5 CM OR LESS",360,RC,49186,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR WITHOUT BIOPSY(S) (SEPARATE PROCEDURE)",360,RC,49000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64474,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY CONTINUOUS INFUSION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64487,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE), WITH SIGMOID RESECTION",360,RC,45402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3870.33,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,527.80,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND ANASTOMOSIS OTHER THAN COLORECTAL",360,RC,44625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE PROCEDURE),360,RC,44346,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; THORACIC (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,931.82,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44206,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44143,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE),360,RC,44139,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENTEROENTEROSTOMY, ANASTOMOSIS OF INTESTINE, WITH OR WITHOUT CUTANEOUS ENTEROSTOMY (SEPARATE PROCEDURE)",360,RC,44130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION OF MALROTATION BY LYSIS OF DUODENAL BANDS AND/OR REDUCTION OF MIDGUT VOLVULUS (EG, LADD PROCEDURE)",360,RC,44055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,C5276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE),360,RC,44005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITH VAGOTOMY",360,RC,43865,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY OF STERNUM, PARTIAL",360,RC,21620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION FIRST AND/OR CERVICAL RIB;,360,RC,21615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,7277.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR OSTEOTOMY (INCLUDES CORRECTION OF GENU VARUS [BOWLEG] OR GENU VALGUS [KNOCK-KNEE]); BEFORE EPIPHYSEAL CLOSURE",360,RC,27455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27514,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE PROCEDURE)",360,RC,38770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19084,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15847,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36909,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,10910.59,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS",360,RC,36620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36217,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATION NOT FOLLOWED BY SURGICAL REPAIR, ARTERY; LOWER EXTREMITY (EG, COMMON FEMORAL, DEEP FEMORAL, SUPERFICIAL FEMORAL, POPLITEAL, TIBIAL, PERONEAL)",360,RC,35703,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3501.31,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH MEDIASTINAL AND REGIONAL LYMPHADENECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,32674,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13122,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE",360,RC,27703,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,9503.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VULVECTOMY, RADICAL, PARTIAL;",360,RC,56630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4121.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,837.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLECTOMY, PARTIAL; WITH ANASTOMOSIS",360,RC,44140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6649.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,7962.20,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH REMOVAL OF A SINGLE LUNG SEGMENT (SEGMENTECTOMY)",360,RC,32669,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND ANASTOMOSIS",360,RC,44120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, SURGICAL; WITH THERAPEUTIC WEDGE RESECTION (EG, MASS, NODULE), INITIAL UNILATERAL",360,RC,32666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMBAR, SACRAL, OR LUMBOSACRAL",360,RC,22015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; CERVICAL, THORACIC, OR CERVICOTHORACIC",360,RC,22010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REDUCTION OF VOLVULUS, INTUSSUSCEPTION, INTERNAL HERNIA, BY LAPAROTOMY",360,RC,44050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL",360,RC,44020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4311.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,12378.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,69990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,629.57,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4121.00,9721.99,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THYROIDECTOMY, TOTAL OR COMPLETE WITH PARATHYROID AUTOTRANSPLANTATION",360,RC,C7555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER THAN ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE)",360,RC,43848,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3660.29,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL POUCH",360,RC,43634,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PARAESOPHAGEAL HIATAL HERNIA (INCLUDING FUNDOPLICATION), VIA LAPAROTOMY, EXCEPT NEONATAL; WITHOUT IMPLANTATION OF MESH OR OTHER PROSTHESIS",360,RC,43332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1659.09,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3547.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3660.29,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1970.84,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3547.15,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING, OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, FEMUR",360,RC,27495,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL SHAFT FRACTURE, WITH OR WITHOUT EXTERNAL FIXATION, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,27506,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE WITHOUT INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27511,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5691.37,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BONE MARROW ASPIRATION FOR BONE GRAFTING, SPINE SURGERY ONLY, THROUGH SEPARATE SKIN OR FASCIAL INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20939,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1425.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)/EXTRACORPOREAL LIFE SUPPORT (ECLS) PROVIDED BY PHYSICIAN; INITIATION, VENO-ARTERIAL",361,RC,33947,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4376.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3120.11,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ALLOGRAFT, INCLUDES TEMPLATING, CUTTING, PLACEMENT AND INTERNAL FIXATION, WHEN PERFORMED; OSTEOARTICULAR, INCLUDING ARTICULAR SURFACE AND CONTIGUOUS BONE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20932,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MANUAL PREPARATION AND INSERTION OF DRUG-DELIVERY DEVICE(S), INTRAMEDULLARY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, EACH INTRACRANIAL BRANCH OF THE INTERNAL CAROTID OR VERTEBRAL ARTERIES, UNILATERAL, WITH ANGIOGRAPHY OF THE SELECTED VESSEL CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (EG, MIDDLE CEREBRAL ARTERY, POSTERIOR INFERIOR CEREBELLAR ARTERY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,36228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4376.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANTATION OR REPLACEMENT; WITH TESTING OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR",481,RC,93641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3684.09,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6735.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; EACH ADDITIONAL BRANCH SUBTENDED BY THE BYPASS GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3684.09,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37253,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,34125.00,,,,,,,8442.00,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY;",360,RC,58275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,8442.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37223,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,360,RC,58340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE",360,RC,11005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,642.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE STENTING, AND ALL ANGIOPLASTY IN THE CENTRAL DIALYSIS SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36908,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,150.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS)",360,RC,58740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3058.98,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLPOPEXY, ABDOMINAL APPROACH",360,RC,57280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4890.88,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CESAREAN DELIVERY ONLY;,360,RC,59514,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6649.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY",360,RC,59830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10945.84,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,642.16,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5485.35,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5613.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF CAROTID BODY TUMOR; WITHOUT EXCISION OF CAROTID ARTERY,360,RC,60600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TWIST DRILL HOLE(S) FOR SUBDURAL, INTRACEREBRAL, OR VENTRICULAR PUNCTURE; FOR EVACUATION AND/OR DRAINAGE OF SUBDURAL HEMATOMA",360,RC,61108,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,64466,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,12247.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3318.21,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8213.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, BIPOLAR ARTHROPLASTY)",360,RC,27125,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64491,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,4376.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64492,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT",360,RC,27138,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE POSTERIOR BONY ELEMENTS (INCLUDING THE APPLICATION OF BRIDGING BONE GRAFT AND NON-SEGMENTAL FIXATION DEVICES [EG, WIRE, SUTURE, MINI-PLATES], WHEN PERFORMED)",360,RC,63051,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3395.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, FEMORAL NECK AND PROXIMAL FEMUR",360,RC,27187,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8442.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63078,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT",360,RC,63081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1659.09,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT",360,RC,27236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,3318.21,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,5613.15,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK OR PSEUDOMENINGOCELE, WITH LAMINECTOMY",360,RC,63709,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DURAL GRAFT, SPINAL",360,RC,63710,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEPATECTOMY, RESECTION OF LIVER; PARTIAL LOBECTOMY",360,RC,47120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,47001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64469,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)",360,RC,36248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,92978,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1539.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY CONTINUOUS INFUSIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64489,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND URETHROPLASTY, SACROPERINEAL APPROACH",360,RC,46744,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR VAGINAL), POUCH ADVANCEMENT; COMBINED TRANSPERINEAL AND TRANSABDOMINAL APPROACH",360,RC,46712,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3028.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3318.21,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,588.93,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,7510.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6872.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,124.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INTRODUCTION OF CATHETER, AORTA",360,RC,36200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; ABDOMEN",360,RC,35840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,1878.73,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2638.41,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,124.01,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1759.87,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,4964.08,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11047,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-FEMORAL",360,RC,35661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ANGIOSCOPY (NONCORONARY VESSELS OR GRAFTS) DURING THERAPEUTIC INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,35400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROCTOPEXY (EG, FOR PROLAPSE); ABDOMINAL APPROACH",360,RC,45540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; DEEP (PROFUNDA) FEMORAL",360,RC,35372,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,2638.41,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE SPARING; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES",360,RC,55845,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,6649.00,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,5200.74,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,527.80,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; CAROTID, VERTEBRAL, SUBCLAVIAN, BY NECK INCISION",360,RC,35301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMPLETE, COMBINED ABDOMINOPERINEAL, WITH COLOSTOMY",360,RC,45395,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2753.54,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1134.38,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,990.00,,,,,,,877.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,8612.00,19334.39,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2194.26,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; ABDOMINAL AND PERINEAL APPROACH",360,RC,45135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SINGLE INTERSPACE, LUMBAR",360,RC,22857,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,11124.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, MECKEL'S DIVERTICULUM AND THE MESENTERY",360,RC,44899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA AND PERINEUM",360,RC,11004,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1316.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
EXCISION OF LESION OF MESENTERY (SEPARATE PROCEDURE),360,RC,44820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 7 TO 12 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22843,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, POPLITEAL ARTERY",360,RC,35151,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CLOSURE OF INTESTINAL CUTANEOUS FISTULA,360,RC,44640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)/EXTRACORPOREAL LIFE SUPPORT (ECLS) PROVIDED BY PHYSICIAN; INITIATION, VENO-ARTERIAL",360,RC,33947,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); 4 OR MORE CORONARY ARTERIAL GRAFTS",360,RC,33536,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3501.31,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3501.31,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF COLOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) (SEPARATE PROCEDURE),360,RC,44345,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,5219.00,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1558.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3121.59,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1539.73,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,931.82,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3522.17,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE",360,RC,44310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,150.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE, WITH RESECTION AND ANASTOMOSIS",360,RC,44227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,15486.00,,,,,,,6735.00,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,5219.00,,,,,,,3628.02,10087.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)",360,RC,44213,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,1825.06,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,8612.00,,,,,,,7962.20,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL; EACH ADDITIONAL SMALL INTESTINE RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,44203,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN LEVEL CECOSTOMY",360,RC,44188,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,2244.50,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,6636.00,,,,,,,6636.00,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3788.00,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,,3788.00,,,,,,,3121.59,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,inpatient,,,0.14000,0.08000,United Healthcare,Individual Exchange,,0.04214,,,,,,,0.04214,0.11382,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,130.00000,78.00000,United Healthcare,Individual Exchange,,39.13,,,,,,,39.13,105.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,25.00000,15.00000,United Healthcare,Individual Exchange,,7.53,,,,,,,7.53,20.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,28.59,,,,,,,28.59,77.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,16.25,,,,,,,16.25,43.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Individual Exchange,,64.21,,,,,,,24.62,124.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Individual Exchange,,37.02,,,,,,,37.02,100.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,22.07000,13.24000,United Healthcare,Individual Exchange,,6.64,,,,,,,6.64,17.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,United Healthcare,Individual Exchange,,81.55,,,,,,,4.42,81.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,49.59,,,,,,,19.02,106.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,142.00000,85.20000,United Healthcare,Individual Exchange,,42.74,,,,,,,42.74,115.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,inpatient,,,39570.00000,23742.00000,United Healthcare,Individual Exchange,,11910.57,,,,,,,11910.57,32170.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,17004.00000,10202.40000,United Healthcare,Individual Exchange,,5118.20,,,,,,,5118.20,13824.25,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,1919.00000,1151.40000,United Healthcare,Individual Exchange,,577.62,,,,,,,577.62,1560.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,7252.00000,4351.20000,United Healthcare,Individual Exchange,,2182.85,,,,,,,2182.85,5895.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,1734.00000,1040.40000,United Healthcare,Individual Exchange,,521.93,,,,,,,521.93,1409.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,3295.00000,1977.00000,United Healthcare,Individual Exchange,,991.79,,,,,,,991.79,2678.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,40220.00000,24132.00000,United Healthcare,Individual Exchange,,12106.22,,,,,,,12106.22,32698.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,12517.00000,7510.20000,United Healthcare,Individual Exchange,,3767.62,,,,,,,3767.62,10176.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,11120.00000,6672.00000,United Healthcare,Individual Exchange,,3347.12,,,,,,,3347.12,9040.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,15665.00000,9399.00000,United Healthcare,Individual Exchange,,4715.16,,,,,,,4715.16,12735.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,31578.00000,18946.80000,United Healthcare,Individual Exchange,,9504.98,,,,,,,9504.98,25672.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,2639.00000,1583.40000,United Healthcare,Individual Exchange,,794.34,,,,,,,794.34,2145.51,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,11117.00000,6670.20000,United Healthcare,Individual Exchange,,3346.22,,,,,,,3346.22,9038.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,16042.00000,9625.20000,United Healthcare,Individual Exchange,,4828.64,,,,,,,4828.64,13042.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,2696.00000,1617.60000,United Healthcare,Individual Exchange,,811.50,,,,,,,811.50,2191.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,inpatient,,,8366.00000,5019.60000,United Healthcare,Individual Exchange,,2518.17,,,,,,,2518.17,6801.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,8920.00000,5352.00000,United Healthcare,Individual Exchange,,2684.92,,,,,,,2684.92,7251.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,inpatient,,,11277.00000,6766.20000,United Healthcare,Individual Exchange,,3394.38,,,,,,,3394.38,9168.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Individual Exchange,,68.90,,,,,,,26.43,107.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,455.00000,273.00000,United Healthcare,Individual Exchange,,136.96,,,,,,,136.96,369.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,inpatient,,,911.00000,546.60000,United Healthcare,Individual Exchange,,274.21,,,,,,,274.21,740.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,inpatient,,,31.28000,18.77000,United Healthcare,Individual Exchange,,9.42,,,,,,,9.42,25.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,United Healthcare,Individual Exchange,,16.33,,,,,,,6.26,79.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,inpatient,,,20.34000,12.20000,United Healthcare,Individual Exchange,,6.12,,,,,,,6.12,16.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,United Healthcare,Individual Exchange,,10.62,,,,,,,4.07,16.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,inpatient,,,278.96000,167.38000,United Healthcare,Individual Exchange,,83.97,,,,,,,83.97,226.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,inpatient,,,21.64000,12.98000,United Healthcare,Individual Exchange,,6.51,,,,,,,6.51,17.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,United Healthcare,Individual Exchange,,11.30,,,,,,,4.33,50.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,inpatient,,,0.03000,0.02000,United Healthcare,Individual Exchange,,0.00903,,,,,,,0.00903,0.02439,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,inpatient,,,21.42000,12.85000,United Healthcare,Individual Exchange,,6.45,,,,,,,6.45,17.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,United Healthcare,Individual Exchange,,11.18,,,,,,,4.29,52.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,inpatient,,,40.61000,24.37000,United Healthcare,Individual Exchange,,12.22,,,,,,,12.22,33.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,United Healthcare,Individual Exchange,,232.85,,,,,,,8.13,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,inpatient,,,20.37000,12.22000,United Healthcare,Individual Exchange,,6.13,,,,,,,6.13,16.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,United Healthcare,Individual Exchange,,10.63,,,,,,,4.08,24.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,inpatient,,,19.90000,11.94000,United Healthcare,Individual Exchange,,5.99,,,,,,,5.99,16.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,United Healthcare,Individual Exchange,,10.39,,,,,,,3.98,48.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Individual Exchange,,515.74,,,,,,,197.80,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Individual Exchange,,142.51,,,,,,,54.65,238.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,inpatient,,,65.26000,39.16000,United Healthcare,Individual Exchange,,19.64,,,,,,,19.64,53.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,United Healthcare,Individual Exchange,,34.07,,,,,,,13.07,170.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,United Healthcare,Individual Exchange,,93.03,,,,,,,35.68,569.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,inpatient,,,15495.00000,9297.00000,United Healthcare,Individual Exchange,,4663.99,,,,,,,4663.99,12597.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,inpatient,,,6.33000,3.80000,United Healthcare,Individual Exchange,,1.91,,,,,,,1.91,5.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,United Healthcare,Individual Exchange,,20.19,,,,,,,1.27,20.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Individual Exchange,,95.00,,,,,,,36.44,147.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,inpatient,,,200.00000,120.00000,United Healthcare,Individual Exchange,,60.20,,,,,,,60.20,162.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Individual Exchange,,104.40,,,,,,,40.04,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,inpatient,,,29.65000,17.79000,United Healthcare,Individual Exchange,,8.92,,,,,,,8.92,24.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,United Healthcare,Individual Exchange,,15.48,,,,,,,5.94,75.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1235.00000,741.00000,United Healthcare,Individual Exchange,,371.74,,,,,,,371.74,1004.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Individual Exchange,,315.45,,,,,,,315.45,852.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,707.00000,424.20000,United Healthcare,Individual Exchange,,212.81,,,,,,,212.81,574.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,550.00000,330.00000,United Healthcare,Individual Exchange,,165.55,,,,,,,165.55,447.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,442.00000,265.20000,United Healthcare,Individual Exchange,,133.04,,,,,,,133.04,359.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,inpatient,,,466.00000,279.60000,United Healthcare,Individual Exchange,,140.27,,,,,,,140.27,378.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,Individual Exchange,,644.67,,,,,,,247.25,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Individual Exchange,,547.06,,,,,,,209.81,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Individual Exchange,,369.05,,,,,,,141.54,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Individual Exchange,,287.10,,,,,,,110.11,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Individual Exchange,,230.72,,,,,,,88.49,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,Individual Exchange,,243.25,,,,,,,93.29,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,inpatient,,,27.47000,16.48000,United Healthcare,Individual Exchange,,8.27,,,,,,,8.27,22.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,571.00000,342.60000,United Healthcare,Individual Exchange,,171.87,,,,,,,171.87,464.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,262.00000,157.20000,United Healthcare,Individual Exchange,,78.86,,,,,,,78.86,213.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,2469.00000,1481.40000,United Healthcare,Individual Exchange,,743.17,,,,,,,743.17,2007.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,698.00000,418.80000,United Healthcare,Individual Exchange,,210.10,,,,,,,210.10,567.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,Individual Exchange,,364.36,,,,,,,139.74,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,188.43,,,,,,,188.43,508.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,326.77,,,,,,,125.33,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,615.00000,369.00000,United Healthcare,Individual Exchange,,185.12,,,,,,,185.12,500.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Individual Exchange,,321.03,,,,,,,123.12,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,132.14,,,,,,,132.14,356.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,229.16,,,,,,,87.89,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,inpatient,,,399.00000,239.40000,United Healthcare,Individual Exchange,,120.10,,,,,,,120.10,324.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Individual Exchange,,208.28,,,,,,,79.88,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,United Healthcare,Individual Exchange,,1233.49,,,,,,,154.34,1921.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Individual Exchange,,298.06,,,,,,,114.31,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Individual Exchange,,136.76,,,,,,,52.45,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,313.00000,187.80000,United Healthcare,Individual Exchange,,94.21,,,,,,,94.21,254.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Individual Exchange,,163.39,,,,,,,62.66,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1575.00000,945.00000,United Healthcare,Individual Exchange,,474.07,,,,,,,474.07,1280.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,Individual Exchange,,822.15,,,,,,,240.06,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1252.00000,751.20000,United Healthcare,Individual Exchange,,376.85,,,,,,,376.85,1017.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Individual Exchange,,653.54,,,,,,,240.06,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,641.00000,384.60000,United Healthcare,Individual Exchange,,192.94,,,,,,,192.94,521.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Individual Exchange,,334.60,,,,,,,128.33,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,340.00000,204.00000,United Healthcare,Individual Exchange,,102.34,,,,,,,102.34,276.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,Individual Exchange,,177.48,,,,,,,68.07,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,272.00000,163.20000,United Healthcare,Individual Exchange,,81.87,,,,,,,81.87,221.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,Individual Exchange,,141.98,,,,,,,54.45,240.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,inpatient,,,216.17000,129.70000,United Healthcare,Individual Exchange,,65.07,,,,,,,65.07,175.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Individual Exchange,,475.54,,,,,,,5.88,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Individual Exchange,,237.51,,,,,,,5.88,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,5187.00000,3112.20000,United Healthcare,Individual Exchange,,1561.29,,,,,,,1561.29,4217.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,inpatient,,,153.80000,92.28000,United Healthcare,Individual Exchange,,46.29,,,,,,,46.29,125.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2562.00000,1537.20000,United Healthcare,Individual Exchange,,771.16,,,,,,,771.16,2082.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Individual Exchange,,297.39,,,,,,,297.39,803.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,188.43,,,,,,,188.43,508.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Individual Exchange,,82.17,,,,,,,82.17,221.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,inpatient,,,872.14000,523.28000,United Healthcare,Individual Exchange,,262.51,,,,,,,262.51,709.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,inpatient,,,1070.23000,642.14000,United Healthcare,Individual Exchange,,322.14,,,,,,,322.14,870.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,inpatient,,,2.18000,1.31000,United Healthcare,Individual Exchange,,0.65618,,,,,,,0.65618,1.77,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,2078.00000,1246.80000,United Healthcare,Individual Exchange,,625.48,,,,,,,625.48,1689.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,2754.00000,1652.40000,United Healthcare,Individual Exchange,,828.95,,,,,,,828.95,2239.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,1216.00000,729.60000,United Healthcare,Individual Exchange,,366.02,,,,,,,366.02,988.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,inpatient,,,616.00000,369.60000,United Healthcare,Individual Exchange,,185.42,,,,,,,185.42,500.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,Individual Exchange,,1437.59,,,,,,,240.06,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,Individual Exchange,,634.75,,,,,,,240.06,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Individual Exchange,,321.55,,,,,,,123.32,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,inpatient,,,2813.00000,1687.80000,United Healthcare,Individual Exchange,,846.71,,,,,,,846.71,2286.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,inpatient,,,3.10000,1.86000,United Healthcare,Individual Exchange,,0.93310,,,,,,,0.93310,2.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,United Healthcare,Individual Exchange,,9.29,,,,,,,0.62062,9.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,9.84000,5.90000,United Healthcare,Individual Exchange,,2.96,,,,,,,2.96,8.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,United Healthcare,Individual Exchange,,33.47,,,,,,,1.97,33.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,United Healthcare,Individual Exchange,,100.54,,,,,,,38.56,454.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,inpatient,,,66.43000,39.86000,United Healthcare,Individual Exchange,,20.00,,,,,,,20.00,54.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,United Healthcare,Individual Exchange,,34.68,,,,,,,13.30,179.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Individual Exchange,,37.02,,,,,,,37.02,100.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,inpatient,,,237.69000,142.61000,United Healthcare,Individual Exchange,,71.54,,,,,,,71.54,193.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,United Healthcare,Individual Exchange,,728.32,,,,,,,47.59,728.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,inpatient,,,273.90000,164.34000,United Healthcare,Individual Exchange,,82.44,,,,,,,82.44,222.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,United Healthcare,Individual Exchange,,872.64,,,,,,,54.83,872.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,inpatient,,,158.70000,95.22000,United Healthcare,Individual Exchange,,47.77,,,,,,,47.77,129.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,United Healthcare,Individual Exchange,,450.52,,,,,,,31.77,450.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,342.00000,205.20000,United Healthcare,Individual Exchange,,102.94,,,,,,,102.94,278.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Individual Exchange,,178.52,,,,,,,68.47,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,1546.00000,927.60000,United Healthcare,Individual Exchange,,465.35,,,,,,,465.35,1256.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,3094.00000,1856.40000,United Healthcare,Individual Exchange,,931.29,,,,,,,931.29,2515.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,Individual Exchange,,807.01,,,,,,,309.51,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,inpatient,,,330.40000,198.24000,United Healthcare,Individual Exchange,,99.45,,,,,,,99.45,268.62,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,inpatient,,,329.28000,197.57000,United Healthcare,Individual Exchange,,99.11,,,,,,,99.11,267.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,inpatient,,,153.16000,91.90000,United Healthcare,Individual Exchange,,46.10,,,,,,,46.10,124.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,United Healthcare,Individual Exchange,,434.78,,,,,,,30.66,434.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,inpatient,,,158.82000,95.29000,United Healthcare,Individual Exchange,,47.80,,,,,,,47.80,129.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,United Healthcare,Individual Exchange,,450.83,,,,,,,31.80,450.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,428.00000,256.80000,United Healthcare,Individual Exchange,,128.83,,,,,,,128.83,347.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,Individual Exchange,,223.42,,,,,,,70.59,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,483.00000,289.80000,United Healthcare,Individual Exchange,,145.38,,,,,,,145.38,392.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Individual Exchange,,252.13,,,,,,,70.59,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,inpatient,,,10.00000,6.00000,United Healthcare,Individual Exchange,,3.01,,,,,,,3.01,8.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,United Healthcare,Individual Exchange,,0.06264,,,,,,,0.02402,0.28320,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,United Healthcare,Individual Exchange,,0.14094,,,,,,,0.05405,0.49560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2498.00000,1498.80000,United Healthcare,Individual Exchange,,751.90,,,,,,,751.90,2030.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,Individual Exchange,,1303.96,,,,,,,500.10,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,2025.00000,1215.00000,United Healthcare,Individual Exchange,,609.52,,,,,,,609.52,1646.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,Individual Exchange,,1057.05,,,,,,,405.40,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,inpatient,,,1708.00000,1024.80000,United Healthcare,Individual Exchange,,514.11,,,,,,,514.11,1388.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,Individual Exchange,,891.58,,,,,,,341.94,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00301,,,,,,,0.00301,0.00813,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,inpatient,,,322.28000,193.37000,United Healthcare,Individual Exchange,,97.01,,,,,,,97.01,262.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,United Healthcare,Individual Exchange,,914.46,,,,,,,64.52,914.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,inpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,19.57,,,,,,,19.57,52.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,33.93,,,,,,,13.01,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,inpatient,,,81.13000,48.68000,United Healthcare,Individual Exchange,,24.42,,,,,,,24.42,65.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,inpatient,,,53.52000,32.11000,United Healthcare,Individual Exchange,,16.11,,,,,,,16.11,43.51,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,inpatient,,,126.03000,75.62000,United Healthcare,Individual Exchange,,37.94,,,,,,,37.94,102.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,inpatient,,,30.86000,18.52000,United Healthcare,Individual Exchange,,9.29,,,,,,,9.29,25.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,inpatient,,,16.63000,9.98000,United Healthcare,Individual Exchange,,5.01,,,,,,,5.01,13.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,inpatient,,,116.79000,70.07000,United Healthcare,Individual Exchange,,35.15,,,,,,,35.15,94.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,inpatient,,,33.65000,20.19000,United Healthcare,Individual Exchange,,10.13,,,,,,,10.13,27.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,inpatient,,,96.04000,57.62000,United Healthcare,Individual Exchange,,28.91,,,,,,,28.91,78.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,inpatient,,,275.02000,165.01000,United Healthcare,Individual Exchange,,82.78,,,,,,,82.78,223.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,inpatient,,,42.62000,25.57000,United Healthcare,Individual Exchange,,12.83,,,,,,,12.83,34.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,inpatient,,,51.42000,30.85000,United Healthcare,Individual Exchange,,15.48,,,,,,,15.48,41.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,inpatient,,,166.08000,99.65000,United Healthcare,Individual Exchange,,49.99,,,,,,,49.99,135.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,inpatient,,,128.79000,77.27000,United Healthcare,Individual Exchange,,38.77,,,,,,,38.77,104.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,United Healthcare,Individual Exchange,,372.23,,,,,,,25.78,372.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,inpatient,,,154.18000,92.51000,United Healthcare,Individual Exchange,,46.41,,,,,,,46.41,125.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,inpatient,,,146.33000,87.80000,United Healthcare,Individual Exchange,,44.05,,,,,,,44.05,118.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,United Healthcare,Individual Exchange,,458.55,,,,,,,29.30,518.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,inpatient,,,26.14000,15.68000,United Healthcare,Individual Exchange,,7.87,,,,,,,7.87,21.25,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,United Healthcare,Individual Exchange,,209.59,,,,,,,5.23,209.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,inpatient,,,28.56000,17.14000,United Healthcare,Individual Exchange,,8.60,,,,,,,8.60,23.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,United Healthcare,Individual Exchange,,88.33,,,,,,,5.72,88.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,inpatient,,,68.05000,40.83000,United Healthcare,Individual Exchange,,20.48,,,,,,,20.48,55.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,United Healthcare,Individual Exchange,,196.28,,,,,,,13.62,196.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,inpatient,,,140.75000,84.45000,United Healthcare,Individual Exchange,,42.37,,,,,,,42.37,114.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,United Healthcare,Individual Exchange,,392.53,,,,,,,28.18,392.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,0.51000,0.31000,United Healthcare,Individual Exchange,,0.15351,,,,,,,0.15351,0.41463,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,inpatient,,,26.23000,15.74000,United Healthcare,Individual Exchange,,7.90,,,,,,,7.90,21.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,inpatient,,,5.92000,3.55000,United Healthcare,Individual Exchange,,1.78,,,,,,,1.78,4.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,United Healthcare,Individual Exchange,,3.09,,,,,,,1.19,4.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,United Healthcare,Individual Exchange,,5.49,,,,,,,2.11,8.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,inpatient,,,0.11000,0.07000,United Healthcare,Individual Exchange,,0.03311,,,,,,,0.03311,0.08943,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,inpatient,,,0.80000,0.48000,United Healthcare,Individual Exchange,,0.24080,,,,,,,0.24080,0.65040,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,inpatient,,,7.76000,4.66000,United Healthcare,Individual Exchange,,2.34,,,,,,,2.34,6.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,inpatient,,,0.79000,0.47000,United Healthcare,Individual Exchange,,0.23779,,,,,,,0.23779,0.64227,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,0.47000,0.28000,United Healthcare,Individual Exchange,,0.14147,,,,,,,0.14147,0.38211,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,inpatient,,,0.64000,0.38000,United Healthcare,Individual Exchange,,0.19264,,,,,,,0.19264,0.52032,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,United Healthcare,Individual Exchange,,0.33408,,,,,,,0.12813,0.52032,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,inpatient,,,1666.78000,1000.07000,United Healthcare,Individual Exchange,,501.70,,,,,,,501.70,1355.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,United Healthcare,Individual Exchange,,4844.60,,,,,,,333.69,4844.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,inpatient,,,0.02000,0.01000,United Healthcare,Individual Exchange,,0.00602,,,,,,,0.00602,0.01626,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,United Healthcare,Individual Exchange,,0.01044,,,,,,,0.00400,0.01626,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,United Healthcare,Individual Exchange,,0.04698,,,,,,,0.01802,1.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,United Healthcare,Individual Exchange,,1.34,,,,,,,0.51451,6.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,inpatient,,,25.77000,15.46000,United Healthcare,Individual Exchange,,7.76,,,,,,,7.76,20.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,inpatient,,,81.46000,48.88000,United Healthcare,Individual Exchange,,24.52,,,,,,,24.52,66.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,0.07000,0.04000,United Healthcare,Individual Exchange,,0.02107,,,,,,,0.02107,0.05691,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,inpatient,,,4.25000,2.55000,United Healthcare,Individual Exchange,,1.28,,,,,,,1.28,3.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,United Healthcare,Individual Exchange,,2.22,,,,,,,0.85085,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,inpatient,,,6.12000,3.67000,United Healthcare,Individual Exchange,,1.84,,,,,,,1.84,4.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,United Healthcare,Individual Exchange,,3.19,,,,,,,1.23,4.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,inpatient,,,1.12000,0.67000,United Healthcare,Individual Exchange,,0.33712,,,,,,,0.33712,0.91056,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,inpatient,,,1.61000,0.97000,United Healthcare,Individual Exchange,,0.48461,,,,,,,0.48461,1.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,inpatient,,,2.56000,1.54000,United Healthcare,Individual Exchange,,0.77056,,,,,,,0.77056,2.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,inpatient,,,1.79000,1.07000,United Healthcare,Individual Exchange,,0.53879,,,,,,,0.53879,1.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,inpatient,,,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,inpatient,,,0.02000,0.01000,United Healthcare,Individual Exchange,,0.00602,,,,,,,0.00602,0.01626,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,inpatient,,,22.10000,13.26000,United Healthcare,Individual Exchange,,6.65,,,,,,,6.65,17.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,United Healthcare,Individual Exchange,,62.32,,,,,,,4.42,62.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,inpatient,,,1100.73000,660.44000,United Healthcare,Individual Exchange,,331.32,,,,,,,331.32,894.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,inpatient,,,77.03000,46.22000,United Healthcare,Individual Exchange,,23.19,,,,,,,23.19,62.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,inpatient,,,134.92000,80.95000,United Healthcare,Individual Exchange,,40.61,,,,,,,40.61,109.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,United Healthcare,Individual Exchange,,319.27,,,,,,,27.01,319.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,inpatient,,,166.43000,99.86000,United Healthcare,Individual Exchange,,50.10,,,,,,,50.10,135.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,United Healthcare,Individual Exchange,,272.48,,,,,,,33.32,272.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,inpatient,,,17.28000,10.37000,United Healthcare,Individual Exchange,,5.20,,,,,,,5.20,14.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,United Healthcare,Individual Exchange,,18.64,,,,,,,3.46,18.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,inpatient,,,0.13000,0.08000,United Healthcare,Individual Exchange,,0.03913,,,,,,,0.03913,0.10569,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,inpatient,,,36.34000,21.80000,United Healthcare,Individual Exchange,,10.94,,,,,,,10.94,29.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,United Healthcare,Individual Exchange,,102.77,,,,,,,7.28,115.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,inpatient,,,65.26000,39.16000,United Healthcare,Individual Exchange,,19.64,,,,,,,19.64,53.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,United Healthcare,Individual Exchange,,232.85,,,,,,,13.07,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,inpatient,,,143.90000,86.34000,United Healthcare,Individual Exchange,,43.31,,,,,,,43.31,116.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,inpatient,,,63.57000,38.14000,United Healthcare,Individual Exchange,,19.13,,,,,,,19.13,51.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,inpatient,,,249.07000,149.44000,United Healthcare,Individual Exchange,,74.97,,,,,,,74.97,202.49,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,United Healthcare,Individual Exchange,,719.50,,,,,,,49.86,719.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,inpatient,,,11.23000,6.74000,United Healthcare,Individual Exchange,,3.38,,,,,,,3.38,9.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,United Healthcare,Individual Exchange,,25.35,,,,,,,2.25,25.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,inpatient,,,25.48000,15.29000,United Healthcare,Individual Exchange,,7.67,,,,,,,7.67,20.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,inpatient,,,0.75000,0.45000,United Healthcare,Individual Exchange,,0.22575,,,,,,,0.22575,0.60975,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,inpatient,,,0.04000,0.02000,United Healthcare,Individual Exchange,,0.01204,,,,,,,0.01204,0.03252,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,United Healthcare,Individual Exchange,,7.89,,,,,,,3.03,70.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,inpatient,,,13.35000,8.01000,United Healthcare,Individual Exchange,,4.02,,,,,,,4.02,10.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,United Healthcare,Individual Exchange,,42.05,,,,,,,2.67,42.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,inpatient,,,11.89000,7.13000,United Healthcare,Individual Exchange,,3.58,,,,,,,3.58,9.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,United Healthcare,Individual Exchange,,71.79,,,,,,,2.38,71.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,inpatient,,,17.69000,10.61000,United Healthcare,Individual Exchange,,5.32,,,,,,,5.32,14.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,United Healthcare,Individual Exchange,,33.38,,,,,,,3.54,41.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,inpatient,,,33.35000,20.01000,United Healthcare,Individual Exchange,,10.04,,,,,,,10.04,27.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,inpatient,,,54.96000,32.98000,United Healthcare,Individual Exchange,,16.54,,,,,,,16.54,44.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,United Healthcare,Individual Exchange,,232.85,,,,,,,11.00,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,inpatient,,,139.15000,83.49000,United Healthcare,Individual Exchange,,41.88,,,,,,,41.88,113.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,United Healthcare,Individual Exchange,,495.21,,,,,,,27.86,495.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,inpatient,25,ML,548.70000,329.22000,United Healthcare,Individual Exchange,,165.16,,,,,,,165.16,446.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,inpatient,5,ML,316.25000,189.75000,United Healthcare,Individual Exchange,,95.19,,,,,,,95.19,257.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,inpatient,1,UN,371.25000,222.75000,United Healthcare,Individual Exchange,,111.75,,,,,,,111.75,301.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,inpatient,1,UN,82.95000,49.77000,United Healthcare,Individual Exchange,,24.97,,,,,,,24.97,67.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,Individual Exchange,,4.74,,,,,,,1.65,61.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,inpatient,1,ML,64.90000,38.94000,United Healthcare,Individual Exchange,,19.53,,,,,,,19.53,52.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,inpatient,1,ML,64.90000,38.94000,United Healthcare,Individual Exchange,,19.53,,,,,,,19.53,52.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,United Healthcare,Individual Exchange,,24.80,,,,,,,9.51,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,Individual Exchange,,0.62640,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,United Healthcare,Individual Exchange,,881.85,,,,,,,881.85,2381.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,Individual Exchange,,173.55,,,,,,,60.36,2174.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,United Healthcare,Individual Exchange,,5855.01,,,,,,,5855.01,15814.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,Individual Exchange,,211.57,,,,,,,73.58,14437.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Individual Exchange,,8.64,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Individual Exchange,,10.34,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Individual Exchange,,9.55,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Individual Exchange,,10.44,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,Individual Exchange,,11.14,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,inpatient,100,ML,128.45000,77.07000,United Healthcare,Individual Exchange,,38.66,,,,,,,38.66,104.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,inpatient,1,ML,84.10000,50.46000,United Healthcare,Individual Exchange,,25.31,,,,,,,25.31,68.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,United Healthcare,Individual Exchange,,183.07,,,,,,,70.21,285.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,United Healthcare,Individual Exchange,,201.26,,,,,,,77.19,313.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,United Healthcare,Individual Exchange,,10.13,,,,,,,3.88,15.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,inpatient,1,UN,3544.00000,2126.40000,United Healthcare,Individual Exchange,,1066.74,,,,,,,1066.74,2881.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,United Healthcare,Individual Exchange,,5.16,,,,,,,1.82,2630.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,inpatient,5,ML,304.25000,182.55000,United Healthcare,Individual Exchange,,91.58,,,,,,,91.58,247.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,United Healthcare,Individual Exchange,,158.82,,,,,,,0.89680,247.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,United Healthcare,Individual Exchange,,22.68,,,,,,,8.70,35.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Individual Exchange,,8.48,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Individual Exchange,,8.46,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,inpatient,10,ML,2414.30000,1448.58000,United Healthcare,Individual Exchange,,726.70,,,,,,,726.70,1962.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,United Healthcare,Individual Exchange,,610.94,,,,,,,167.14,1791.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,Individual Exchange,,9.42,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,inpatient,1,UN,471.55000,282.93000,United Healthcare,Individual Exchange,,141.94,,,,,,,141.94,383.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Individual Exchange,,9.03,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Individual Exchange,,8.80,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Individual Exchange,,8.64,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,inpatient,1,UN,5220.40000,3132.24000,United Healthcare,Individual Exchange,,1571.34,,,,,,,1571.34,4244.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,United Healthcare,Individual Exchange,,2047.47,,,,,,,711.66,3874.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Individual Exchange,,8.80,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,inpatient,0.5,ML,79.90000,47.94000,United Healthcare,Individual Exchange,,24.05,,,,,,,24.05,64.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,inpatient,1,ML,33.65000,20.19000,United Healthcare,Individual Exchange,,10.13,,,,,,,10.13,27.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,inpatient,10,ML,34.85000,20.91000,United Healthcare,Individual Exchange,,10.49,,,,,,,10.49,28.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,inpatient,30,ML,47.00000,28.20000,United Healthcare,Individual Exchange,,14.15,,,,,,,14.15,38.21,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,inpatient,1,ML,19.85000,11.91000,United Healthcare,Individual Exchange,,5.97,,,,,,,5.97,16.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,inpatient,1,ML,25.20000,15.12000,United Healthcare,Individual Exchange,,7.59,,,,,,,7.59,20.49,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,United Healthcare,Individual Exchange,,41.92,,,,,,,16.08,65.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,United Healthcare,Individual Exchange,,16.91,,,,,,,6.49,26.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,United Healthcare,Individual Exchange,,12.42,,,,,,,4.76,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,Individual Exchange,,14.98,,,,,,,5.75,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,United Healthcare,Individual Exchange,,1.17,,,,,,,0.45045,1.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,inpatient,1,UN,436.70000,262.02000,United Healthcare,Individual Exchange,,131.45,,,,,,,131.45,355.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,inpatient,1,UN,748.20000,448.92000,United Healthcare,Individual Exchange,,225.21,,,,,,,225.21,608.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,United Healthcare,Individual Exchange,,1192.54,,,,,,,457.37,1857.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Individual Exchange,,65.92,,,,,,,65.92,178.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Individual Exchange,,65.92,,,,,,,65.92,178.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Individual Exchange,,65.92,,,,,,,65.92,178.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,Individual Exchange,,0.78300,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,United Healthcare,Individual Exchange,,25.81,,,,,,,1.06,40.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,United Healthcare,Individual Exchange,,30.04,,,,,,,0.35400,46.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,inpatient,0.5,ML,568.50000,341.10000,United Healthcare,Individual Exchange,,171.12,,,,,,,171.12,462.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,United Healthcare,Individual Exchange,,21.93,,,,,,,6.49,421.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,United Healthcare,Individual Exchange,,11.38,,,,,,,4.36,17.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,United Healthcare,Individual Exchange,,14.62,,,,,,,5.61,22.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,United Healthcare,Individual Exchange,,12.87,,,,,,,4.93,20.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Individual Exchange,,9.32,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,United Healthcare,Individual Exchange,,3.65,,,,,,,1.40,5.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Individual Exchange,,9.55,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,United Healthcare,Individual Exchange,,1.36,,,,,,,0.52052,2.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,Individual Exchange,,9.42,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,Individual Exchange,,9.60,,,,,,,3.68,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,inpatient,2,ML,26.75000,16.05000,United Healthcare,Individual Exchange,,8.05,,,,,,,8.05,21.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,inpatient,30,ML,30.90000,18.54000,United Healthcare,Individual Exchange,,9.30,,,,,,,9.30,25.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,inpatient,5,ML,23.80000,14.28000,United Healthcare,Individual Exchange,,7.16,,,,,,,7.16,19.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,inpatient,10,ML,47.55000,28.53000,United Healthcare,Individual Exchange,,14.31,,,,,,,14.31,38.66,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,inpatient,2,ML,29.35000,17.61000,United Healthcare,Individual Exchange,,8.83,,,,,,,8.83,23.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,inpatient,5,ML,32.35000,19.41000,United Healthcare,Individual Exchange,,9.74,,,,,,,9.74,26.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,inpatient,1,UN,2741.35000,1644.81000,United Healthcare,Individual Exchange,,825.15,,,,,,,825.15,2228.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,United Healthcare,Individual Exchange,,9.42,,,,,,,3.32,2034.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,inpatient,1,ML,17.75000,10.65000,United Healthcare,Individual Exchange,,5.34,,,,,,,5.34,14.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,inpatient,1,ML,16.75000,10.05000,United Healthcare,Individual Exchange,,5.04,,,,,,,5.04,13.62,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,inpatient,1,ML,17.00000,10.20000,United Healthcare,Individual Exchange,,5.12,,,,,,,5.12,13.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,inpatient,1,ML,21.35000,12.81000,United Healthcare,Individual Exchange,,6.43,,,,,,,6.43,17.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,United Healthcare,Individual Exchange,,21.30,,,,,,,8.17,33.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,United Healthcare,Individual Exchange,,960.27,,,,,,,368.29,1495.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,United Healthcare,Individual Exchange,,8.43,,,,,,,3.23,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,United Healthcare,Individual Exchange,,9.06,,,,,,,3.47,14.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,United Healthcare,Individual Exchange,,9.27,,,,,,,3.55,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,United Healthcare,Individual Exchange,,17.10,,,,,,,6.56,26.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,United Healthcare,Individual Exchange,,128.88,,,,,,,49.43,200.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,United Healthcare,Individual Exchange,,0.86130,,,,,,,0.33033,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,United Healthcare,Individual Exchange,,6.98,,,,,,,6.98,18.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,inpatient,0.25,ML,22.75000,13.65000,United Healthcare,Individual Exchange,,6.85,,,,,,,6.85,18.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,inpatient,5,ML,20322.25000,12193.35000,United Healthcare,Individual Exchange,,6117.00,,,,,,,6117.00,16521.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,United Healthcare,Individual Exchange,,13981.06,,,,,,,4068.51,15083.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,United Healthcare,Individual Exchange,,16.70,,,,,,,2.05,26.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Individual Exchange,,0.75690,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,United Healthcare,Individual Exchange,,82.40,,,,,,,31.60,128.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,inpatient,1,UN,300.90000,180.54000,United Healthcare,Individual Exchange,,90.57,,,,,,,90.57,244.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,United Healthcare,Individual Exchange,,744.98,,,,,,,744.98,2012.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,Individual Exchange,,301.28,,,,,,,93.02,1836.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,inpatient,1,UN,70.30000,42.18000,United Healthcare,Individual Exchange,,21.16,,,,,,,21.16,57.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,inpatient,30,ML,84.80000,50.88000,United Healthcare,Individual Exchange,,25.52,,,,,,,25.52,68.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,United Healthcare,Individual Exchange,,19.68,,,,,,,7.55,30.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,United Healthcare,Individual Exchange,,24.06,,,,,,,9.23,37.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,inpatient,10,ML,385.00000,231.00000,United Healthcare,Individual Exchange,,115.89,,,,,,,115.89,313.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,inpatient,1,UN,774.35000,464.61000,United Healthcare,Individual Exchange,,233.08,,,,,,,233.08,629.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Individual Exchange,,8.46,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,United Healthcare,Individual Exchange,,26.54,,,,,,,10.18,41.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,United Healthcare,Individual Exchange,,35.94,,,,,,,13.78,55.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,inpatient,30,ML,66.65000,39.99000,United Healthcare,Individual Exchange,,20.06,,,,,,,20.06,54.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,inpatient,20,ML,72.25000,43.35000,United Healthcare,Individual Exchange,,21.75,,,,,,,21.75,58.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,inpatient,10,ML,39.65000,23.79000,United Healthcare,Individual Exchange,,11.93,,,,,,,11.93,32.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,inpatient,30,ML,28.15000,16.89000,United Healthcare,Individual Exchange,,8.47,,,,,,,8.47,22.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,inpatient,6,ML,60837.10000,36502.26000,United Healthcare,Individual Exchange,,18311.97,,,,,,,18311.97,49460.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,United Healthcare,Individual Exchange,,633.36,,,,,,,220.46,45153.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,United Healthcare,Individual Exchange,,416.58,,,,,,,159.77,648.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,inpatient,1,ML,158.35000,95.01000,United Healthcare,Individual Exchange,,47.66,,,,,,,47.66,128.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,United Healthcare,Individual Exchange,,120.66,,,,,,,46.28,187.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,inpatient,1,UN,520.25000,312.15000,United Healthcare,Individual Exchange,,156.60,,,,,,,156.60,422.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,386.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,United Healthcare,Individual Exchange,,10.23,,,,,,,3.92,15.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,United Healthcare,Individual Exchange,,14.09,,,,,,,5.41,21.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,United Healthcare,Individual Exchange,,14.85,,,,,,,5.70,23.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,inpatient,0.3,ML,49.90000,29.94000,United Healthcare,Individual Exchange,,15.02,,,,,,,15.02,40.57,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,inpatient,0.4,ML,61.20000,36.72000,United Healthcare,Individual Exchange,,18.42,,,,,,,18.42,49.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,inpatient,0.6,ML,83.85000,50.31000,United Healthcare,Individual Exchange,,25.24,,,,,,,25.24,68.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,inpatient,0.8,ML,106.45000,63.87000,United Healthcare,Individual Exchange,,32.04,,,,,,,32.04,86.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,inpatient,1,ML,129.05000,77.43000,United Healthcare,Individual Exchange,,38.84,,,,,,,38.84,104.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,inpatient,0.8,ML,70.85000,42.51000,United Healthcare,Individual Exchange,,21.33,,,,,,,21.33,57.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,United Healthcare,Individual Exchange,,39.72,,,,,,,15.24,61.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,United Healthcare,Individual Exchange,,11.07,,,,,,,4.24,17.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Individual Exchange,,10.34,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,inpatient,1,UN,1235.40000,741.24000,United Healthcare,Individual Exchange,,371.86,,,,,,,371.86,1004.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,United Healthcare,Individual Exchange,,14.81,,,,,,,5.40,916.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,inpatient,1,UN,2341.05000,1404.63000,United Healthcare,Individual Exchange,,704.66,,,,,,,704.66,1903.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,United Healthcare,Individual Exchange,,14.81,,,,,,,5.40,1737.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,United Healthcare,Individual Exchange,,4.44,,,,,,,1.70,6.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,United Healthcare,Individual Exchange,,89.26,,,,,,,34.23,139.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,United Healthcare,Individual Exchange,,12.85,,,,,,,12.85,34.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Individual Exchange,,8.87,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,United Healthcare,Individual Exchange,,10.75,,,,,,,4.12,16.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,United Healthcare,Individual Exchange,,19.34,,,,,,,7.42,30.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,United Healthcare,Individual Exchange,,19.44,,,,,,,7.46,30.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,United Healthcare,Individual Exchange,,36.57,,,,,,,14.02,56.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,inpatient,2,ML,123.00000,73.80000,United Healthcare,Individual Exchange,,37.02,,,,,,,37.02,100.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,inpatient,1,UN,3055.75000,1833.45000,United Healthcare,Individual Exchange,,919.78,,,,,,,919.78,2484.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,United Healthcare,Individual Exchange,,78.84,,,,,,,19.74,2267.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,United Healthcare,Individual Exchange,,1756.77,,,,,,,1756.77,4745.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,Individual Exchange,,78.84,,,,,,,19.74,4331.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,inpatient,1,UN,1345.40000,807.24000,United Healthcare,Individual Exchange,,404.97,,,,,,,404.97,1093.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,United Healthcare,Individual Exchange,,78.84,,,,,,,19.74,998.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,inpatient,2,ML,21.50000,12.90000,United Healthcare,Individual Exchange,,6.47,,,,,,,6.47,17.48,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,inpatient,1,ML,64.55000,38.73000,United Healthcare,Individual Exchange,,19.43,,,,,,,19.43,52.48,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,inpatient,50,ML,35.60000,21.36000,United Healthcare,Individual Exchange,,10.72,,,,,,,10.72,28.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,United Healthcare,Individual Exchange,,17.41,,,,,,,6.68,27.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,United Healthcare,Individual Exchange,,17.77,,,,,,,6.82,27.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,Individual Exchange,,15.27,,,,,,,5.86,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,Individual Exchange,,15.27,,,,,,,5.86,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,inpatient,1,UN,2420.70000,1452.42000,United Healthcare,Individual Exchange,,728.63,,,,,,,728.63,1968.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,United Healthcare,Individual Exchange,,25.57,,,,,,,8.49,1796.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,inpatient,2,ML,6479.00000,3887.40000,United Healthcare,Individual Exchange,,1950.18,,,,,,,1950.18,5267.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,United Healthcare,Individual Exchange,,291.67,,,,,,,86.66,4808.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,inpatient,1,UN,168.00000,100.80000,United Healthcare,Individual Exchange,,50.57,,,,,,,50.57,136.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,United Healthcare,Individual Exchange,,14.38,,,,,,,5.52,22.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,United Healthcare,Individual Exchange,,33.25,,,,,,,12.75,51.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,Individual Exchange,,0.78300,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Individual Exchange,,0.75690,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,United Healthcare,Individual Exchange,,14.36,,,,,,,5.51,22.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,United Healthcare,Individual Exchange,,16.42,,,,,,,6.30,25.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,United Healthcare,Individual Exchange,,82.16,,,,,,,31.51,127.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,Individual Exchange,,12.24,,,,,,,4.69,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,United Healthcare,Individual Exchange,,53.74,,,,,,,20.61,83.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,United Healthcare,Individual Exchange,,305.40,,,,,,,117.13,475.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,United Healthcare,Individual Exchange,,94.43,,,,,,,36.22,147.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,United Healthcare,Individual Exchange,,135.88,,,,,,,52.11,211.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,United Healthcare,Individual Exchange,,107.11,,,,,,,41.08,166.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,344.45,,,,,,,344.45,930.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,United Healthcare,Individual Exchange,,9.50,,,,,,,3.64,14.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,United Healthcare,Individual Exchange,,52.70,,,,,,,20.21,82.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,United Healthcare,Individual Exchange,,93.18,,,,,,,35.74,145.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,United Healthcare,Individual Exchange,,274.28,,,,,,,105.20,427.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,United Healthcare,Individual Exchange,,0.80910,,,,,,,0.31031,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,inpatient,100,ML,101.15000,60.69000,United Healthcare,Individual Exchange,,30.45,,,,,,,30.45,82.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,inpatient,0.6,ML,263.20000,157.92000,United Healthcare,Individual Exchange,,79.22,,,,,,,79.22,213.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,inpatient,0.8,ML,263.20000,157.92000,United Healthcare,Individual Exchange,,79.22,,,,,,,79.22,213.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,inpatient,0.6,ML,881.50000,528.90000,United Healthcare,Individual Exchange,,265.33,,,,,,,265.33,716.66,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,United Healthcare,Individual Exchange,,30.54,,,,,,,11.71,47.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,inpatient,0.42,ML,896.45000,537.87000,United Healthcare,Individual Exchange,,269.83,,,,,,,269.83,728.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,United Healthcare,Individual Exchange,,8.37,,,,,,,2.84,665.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,inpatient,0.4,ML,1424.70000,854.82000,United Healthcare,Individual Exchange,,428.83,,,,,,,428.83,1158.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,United Healthcare,Individual Exchange,,8.37,,,,,,,2.84,1057.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,inpatient,0.3,ML,2129.05000,1277.43000,United Healthcare,Individual Exchange,,640.84,,,,,,,640.84,1730.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,United Healthcare,Individual Exchange,,8.37,,,,,,,2.84,1580.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,inpatient,0.5,ML,3537.70000,2122.62000,United Healthcare,Individual Exchange,,1064.85,,,,,,,1064.85,2876.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,United Healthcare,Individual Exchange,,8.37,,,,,,,2.84,2625.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,inpatient,0.4,ML,7059.40000,4235.64000,United Healthcare,Individual Exchange,,2124.88,,,,,,,2124.88,5739.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,United Healthcare,Individual Exchange,,8.37,,,,,,,2.84,5239.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,inpatient,0.6,ML,10581.10000,6348.66000,United Healthcare,Individual Exchange,,3184.91,,,,,,,3184.91,8602.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,United Healthcare,Individual Exchange,,8.37,,,,,,,2.84,7853.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,inpatient,2,ML,1695.15000,1017.09000,United Healthcare,Individual Exchange,,510.24,,,,,,,510.24,1378.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,United Healthcare,Individual Exchange,,81.71,,,,,,,29.11,1258.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,inpatient,5,ML,8246.30000,4947.78000,United Healthcare,Individual Exchange,,2482.14,,,,,,,2482.14,6704.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,United Healthcare,Individual Exchange,,481.23,,,,,,,167.84,6120.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,inpatient,20,ML,32160.05000,19296.03000,United Healthcare,Individual Exchange,,9680.18,,,,,,,9680.18,26146.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,United Healthcare,Individual Exchange,,481.23,,,,,,,167.84,23869.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,United Healthcare,Individual Exchange,,1697.72,,,,,,,1697.72,4585.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,Individual Exchange,,16.15,,,,,,,5.54,4186.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,United Healthcare,Individual Exchange,,3376.45,,,,,,,3376.45,9119.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,Individual Exchange,,16.15,,,,,,,5.54,8325.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,United Healthcare,Individual Exchange,,95.97,,,,,,,95.97,259.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,Individual Exchange,,203.72,,,,,,,63.83,236.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,inpatient,0.05,ML,318.85000,191.31000,United Healthcare,Individual Exchange,,95.97,,,,,,,95.97,259.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,Individual Exchange,,203.72,,,,,,,63.83,236.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,inpatient,10,ML,8806.85000,5284.11000,United Healthcare,Individual Exchange,,2650.86,,,,,,,2650.86,7159.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,United Healthcare,Individual Exchange,,19.47,,,,,,,6.53,6536.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,United Healthcare,Individual Exchange,,8.51,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,inpatient,100,ML,83.30000,49.98000,United Healthcare,Individual Exchange,,25.07,,,,,,,25.07,67.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,inpatient,150,ML,101.35000,60.81000,United Healthcare,Individual Exchange,,30.51,,,,,,,30.51,82.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,inpatient,0.5,ML,153.95000,92.37000,United Healthcare,Individual Exchange,,46.34,,,,,,,46.34,125.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,12.01,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,United Healthcare,Individual Exchange,,12.19,,,,,,,4.67,18.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,inpatient,0.05,ML,18.70000,11.22000,United Healthcare,Individual Exchange,,5.63,,,,,,,5.63,15.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,United Healthcare,Individual Exchange,,490.35,,,,,,,3.74,490.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,United Healthcare,Individual Exchange,,60.50,,,,,,,23.20,94.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,inpatient,1,UN,141.95000,85.17000,United Healthcare,Individual Exchange,,42.73,,,,,,,42.73,115.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Individual Exchange,,9.03,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,inpatient,4,ML,884.70000,530.82000,United Healthcare,Individual Exchange,,266.29,,,,,,,266.29,719.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Individual Exchange,,0.73080,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,United Healthcare,Individual Exchange,,12074.89,,,,,,,12074.89,32614.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,Individual Exchange,,511.50,,,,,,,177.98,29774.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,United Healthcare,Individual Exchange,,48051.07,,,,,,,48051.07,129785.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,Individual Exchange,,511.50,,,,,,,177.98,118483.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,inpatient,1,ML,985.50000,591.30000,United Healthcare,Individual Exchange,,296.64,,,,,,,296.64,801.21,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,United Healthcare,Individual Exchange,,81.71,,,,,,,29.11,731.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,United Healthcare,Individual Exchange,,1.04,,,,,,,0.40040,1.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,United Healthcare,Individual Exchange,,0.91350,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,United Healthcare,Individual Exchange,,0.88740,,,,,,,0.34034,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,United Healthcare,Individual Exchange,,0.83520,,,,,,,0.32032,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,inpatient,50,ML,100.65000,60.39000,United Healthcare,Individual Exchange,,30.30,,,,,,,30.30,81.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,3,ML,193.80000,116.28000,United Healthcare,Individual Exchange,,58.33,,,,,,,58.33,157.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,inpatient,1,UN,13260.65000,7956.39000,United Healthcare,Individual Exchange,,3991.46,,,,,,,3991.46,10780.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,United Healthcare,Individual Exchange,,7094.66,,,,,,,2529.92,9842.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,United Healthcare,Individual Exchange,,55.33,,,,,,,21.22,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,United Healthcare,Individual Exchange,,7.18,,,,,,,2.75,11.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,United Healthcare,Individual Exchange,,40.19,,,,,,,15.42,62.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,inpatient,1,UN,2245.35000,1347.21000,United Healthcare,Individual Exchange,,675.85,,,,,,,675.85,1825.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,United Healthcare,Individual Exchange,,1217.38,,,,,,,419.06,1666.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,United Healthcare,Individual Exchange,,44.92,,,,,,,17.23,69.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,inpatient,60,ML,709.90000,425.94000,United Healthcare,Individual Exchange,,213.68,,,,,,,213.68,577.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,United Healthcare,Individual Exchange,,6.05,,,,,,,2.16,526.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,United Healthcare,Individual Exchange,,111.60,,,,,,,42.80,173.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,inpatient,0.2,ML,60.60000,36.36000,United Healthcare,Individual Exchange,,18.24,,,,,,,18.24,49.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,Individual Exchange,,49.98,,,,,,,19.17,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,inpatient,100,ML,184.45000,110.67000,United Healthcare,Individual Exchange,,55.52,,,,,,,55.52,149.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,inpatient,200,ML,224.70000,134.82000,United Healthcare,Individual Exchange,,67.63,,,,,,,67.63,182.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,United Healthcare,Individual Exchange,,31.45,,,,,,,12.06,48.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,United Healthcare,Individual Exchange,,551.75,,,,,,,211.61,859.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Individual Exchange,,0.75690,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,United Healthcare,Individual Exchange,,24.53,,,,,,,9.41,38.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,Individual Exchange,,0.62640,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,United Healthcare,Individual Exchange,,1.62,,,,,,,0.62062,2.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,inpatient,100,ML,77.35000,46.41000,United Healthcare,Individual Exchange,,23.28,,,,,,,23.28,62.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,inpatient,50,ML,76.30000,45.78000,United Healthcare,Individual Exchange,,22.97,,,,,,,22.97,62.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,inpatient,100,ML,77.35000,46.41000,United Healthcare,Individual Exchange,,23.28,,,,,,,23.28,62.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,United Healthcare,Individual Exchange,,30.55,,,,,,,30.55,82.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,inpatient,1000,ML,105.00000,63.00000,United Healthcare,Individual Exchange,,31.61,,,,,,,31.61,85.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,United Healthcare,Individual Exchange,,246.18,,,,,,,94.41,383.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Individual Exchange,,9.55,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,United Healthcare,Individual Exchange,,147.07,,,,,,,56.41,229.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Individual Exchange,,10.07,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,inpatient,1,UN,56048.55000,33629.13000,United Healthcare,Individual Exchange,,16870.61,,,,,,,16870.61,45567.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,United Healthcare,Individual Exchange,,720.99,,,,,,,250.88,41599.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,Individual Exchange,,28.71,,,,,,,11.01,44.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,inpatient,1,UN,4464.60000,2678.76000,United Healthcare,Individual Exchange,,1343.84,,,,,,,1343.84,3629.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,United Healthcare,Individual Exchange,,14.45,,,,,,,5.03,3313.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,United Healthcare,Individual Exchange,,28.71,,,,,,,11.01,44.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,inpatient,100,ML,70.60000,42.36000,United Healthcare,Individual Exchange,,21.25,,,,,,,21.25,57.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,inpatient,20,ML,26.95000,16.17000,United Healthcare,Individual Exchange,,8.11,,,,,,,8.11,21.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,United Healthcare,Individual Exchange,,0.78300,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,United Healthcare,Individual Exchange,,16.39,,,,,,,6.29,25.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Individual Exchange,,10.07,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,United Healthcare,Individual Exchange,,35.37,,,,,,,13.56,55.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,United Healthcare,Individual Exchange,,15.56,,,,,,,5.97,24.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,inpatient,10,ML,1113.90000,668.34000,United Healthcare,Individual Exchange,,335.28,,,,,,,335.28,905.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,inpatient,20,ML,1830.00000,1098.00000,United Healthcare,Individual Exchange,,550.83,,,,,,,550.83,1487.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,inpatient,5.26,ML,316.10000,189.66000,United Healthcare,Individual Exchange,,95.15,,,,,,,95.15,256.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,inpatient,26.3,ML,474.30000,284.58000,United Healthcare,Individual Exchange,,142.76,,,,,,,142.76,385.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,Individual Exchange,,49.98,,,,,,,19.17,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,United Healthcare,Individual Exchange,,49.98,,,,,,,19.17,77.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,inpatient,1,UN,710.25000,426.15000,United Healthcare,Individual Exchange,,213.79,,,,,,,213.79,577.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,United Healthcare,Individual Exchange,,15.01,,,,,,,5.76,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,Individual Exchange,,12.24,,,,,,,4.69,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,United Healthcare,Individual Exchange,,294.93,,,,,,,113.11,459.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,United Healthcare,Individual Exchange,,625.54,,,,,,,239.91,974.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,United Healthcare,Individual Exchange,,2.14,,,,,,,0.82082,3.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,inpatient,1,UN,568.80000,341.28000,United Healthcare,Individual Exchange,,171.21,,,,,,,171.21,462.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,inpatient,100,ML,112.00000,67.20000,United Healthcare,Individual Exchange,,33.71,,,,,,,33.71,91.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,inpatient,100,ML,168.00000,100.80000,United Healthcare,Individual Exchange,,50.57,,,,,,,50.57,136.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Individual Exchange,,8.85,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Individual Exchange,,9.21,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,United Healthcare,Individual Exchange,,107.11,,,,,,,41.08,166.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,inpatient,1,UN,609.65000,365.79000,United Healthcare,Individual Exchange,,183.50,,,,,,,183.50,495.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,United Healthcare,Individual Exchange,,19.26,,,,,,,19.26,52.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,inpatient,1,UN,159.35000,95.61000,United Healthcare,Individual Exchange,,47.96,,,,,,,47.96,129.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,United Healthcare,Individual Exchange,,42.28,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,United Healthcare,Individual Exchange,,45.41,,,,,,,17.42,70.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,United Healthcare,Individual Exchange,,142.51,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,United Healthcare,Individual Exchange,,2.24,,,,,,,0.86086,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,United Healthcare,Individual Exchange,,11.01,,,,,,,4.22,17.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,9.19,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Individual Exchange,,8.80,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,United Healthcare,Individual Exchange,,15.01,,,,,,,5.76,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,United Healthcare,Individual Exchange,,15.01,,,,,,,5.76,23.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Individual Exchange,,9.03,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,Individual Exchange,,15.66,,,,,,,6.01,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,inpatient,1,ML,34.20000,20.52000,United Healthcare,Individual Exchange,,10.29,,,,,,,10.29,27.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,United Healthcare,Individual Exchange,,64.47,,,,,,,24.72,100.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,United Healthcare,Individual Exchange,,65.20,,,,,,,25.00,101.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,United Healthcare,Individual Exchange,,25.50,,,,,,,9.78,39.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,United Healthcare,Individual Exchange,,32.34,,,,,,,12.40,50.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,United Healthcare,Individual Exchange,,16.47,,,,,,,6.32,25.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,United Healthcare,Individual Exchange,,40.48,,,,,,,15.53,63.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,inpatient,1,UN,380.00000,228.00000,United Healthcare,Individual Exchange,,114.38,,,,,,,114.38,308.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,United Healthcare,Individual Exchange,,475.18,,,,,,,182.24,740.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,United Healthcare,Individual Exchange,,87.57,,,,,,,33.58,136.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,United Healthcare,Individual Exchange,,167.14,,,,,,,64.10,260.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,United Healthcare,Individual Exchange,,46.04,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,United Healthcare,Individual Exchange,,315.31,,,,,,,120.93,491.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,25404.55000,15242.73000,United Healthcare,Individual Exchange,,7646.77,,,,,,,7646.77,20653.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,United Healthcare,Individual Exchange,,173.55,,,,,,,60.36,18855.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,inpatient,1,UN,1854.60000,1112.76000,United Healthcare,Individual Exchange,,558.23,,,,,,,558.23,1507.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,United Healthcare,Individual Exchange,,10.96,,,,,,,4.20,17.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,inpatient,1,UN,961.85000,577.11000,United Healthcare,Individual Exchange,,289.52,,,,,,,289.52,781.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,United Healthcare,Individual Exchange,,13.02,,,,,,,4.99,20.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Individual Exchange,,44.19,,,,,,,16.95,68.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,inpatient,1,ML,36.05000,21.63000,United Healthcare,Individual Exchange,,10.85,,,,,,,10.85,29.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Individual Exchange,,9.03,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,United Healthcare,Individual Exchange,,861.93,,,,,,,330.57,1342.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,14,ML,30285.20000,18171.12000,United Healthcare,Individual Exchange,,9115.85,,,,,,,9115.85,24621.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,United Healthcare,Individual Exchange,,47.11,,,,,,,16.51,22477.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Individual Exchange,,9.13,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,United Healthcare,Individual Exchange,,16.52,,,,,,,6.34,25.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,United Healthcare,Individual Exchange,,27.85,,,,,,,10.68,43.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,United Healthcare,Individual Exchange,,19.86,,,,,,,7.62,30.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,United Healthcare,Individual Exchange,,9.32,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,United Healthcare,Individual Exchange,,25.11,,,,,,,9.63,39.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,inpatient,5,ML,72.05000,43.23000,United Healthcare,Individual Exchange,,21.69,,,,,,,21.69,58.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,United Healthcare,Individual Exchange,,40.40,,,,,,,15.50,62.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,inpatient,20,ML,185.65000,111.39000,United Healthcare,Individual Exchange,,55.88,,,,,,,55.88,150.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,United Healthcare,Individual Exchange,,10.70,,,,,,,4.10,16.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,Individual Exchange,,11.67,,,,,,,4.47,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,United Healthcare,Individual Exchange,,11.64,,,,,,,4.46,18.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,inpatient,2,ML,320.55000,192.33000,United Healthcare,Individual Exchange,,96.49,,,,,,,96.49,260.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,inpatient,40,ML,438.00000,262.80000,United Healthcare,Individual Exchange,,131.84,,,,,,,131.84,356.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,United Healthcare,Individual Exchange,,4767.43,,,,,,,4767.43,12876.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,Individual Exchange,,153.64,,,,,,,53.98,11755.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,United Healthcare,Individual Exchange,,56.09,,,,,,,21.51,87.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,United Healthcare,Individual Exchange,,1077.15,,,,,,,413.11,1677.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,United Healthcare,Individual Exchange,,1433.41,,,,,,,549.75,2232.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Individual Exchange,,7.93,,,,,,,7.93,21.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,United Healthcare,Individual Exchange,,102.42,,,,,,,39.28,159.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,United Healthcare,Individual Exchange,,9.45,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,United Healthcare,Individual Exchange,,1.41,,,,,,,0.54054,2.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,inpatient,1,UN,60.00000,36.00000,United Healthcare,Individual Exchange,,18.06,,,,,,,18.06,48.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,inpatient,50,ML,32.20000,19.32000,United Healthcare,Individual Exchange,,9.69,,,,,,,9.69,26.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,inpatient,0.5,ML,22.30000,13.38000,United Healthcare,Individual Exchange,,6.71,,,,,,,6.71,18.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,inpatient,30,ML,87.55000,52.53000,United Healthcare,Individual Exchange,,26.35,,,,,,,26.35,71.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,United Healthcare,Individual Exchange,,60.13,,,,,,,23.06,93.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,United Healthcare,Individual Exchange,,0.67860,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,United Healthcare,Individual Exchange,,25.94,,,,,,,9.95,40.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,United Healthcare,Individual Exchange,,18.84,,,,,,,7.23,29.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,inpatient,10,ML,147.95000,88.77000,United Healthcare,Individual Exchange,,44.53,,,,,,,44.53,120.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,United Healthcare,Individual Exchange,,0.80910,,,,,,,0.31031,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,United Healthcare,Individual Exchange,,0.91350,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,United Healthcare,Individual Exchange,,8.53,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,United Healthcare,Individual Exchange,,108.08,,,,,,,41.45,168.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,United Healthcare,Individual Exchange,,12.84,,,,,,,4.92,20.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,inpatient,1,ML,32.10000,19.26000,United Healthcare,Individual Exchange,,9.66,,,,,,,9.66,26.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Individual Exchange,,9.03,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,United Healthcare,Individual Exchange,,287.67,,,,,,,110.33,448.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,inpatient,10,ML,26.80000,16.08000,United Healthcare,Individual Exchange,,8.07,,,,,,,8.07,21.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,inpatient,30,ML,23.95000,14.37000,United Healthcare,Individual Exchange,,7.21,,,,,,,7.21,19.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,inpatient,50,ML,29.45000,17.67000,United Healthcare,Individual Exchange,,8.86,,,,,,,8.86,23.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,inpatient,10,ML,43.10000,25.86000,United Healthcare,Individual Exchange,,12.97,,,,,,,12.97,35.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,inpatient,30,ML,53.45000,32.07000,United Healthcare,Individual Exchange,,16.09,,,,,,,16.09,43.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,United Healthcare,Individual Exchange,,31.76,,,,,,,12.18,49.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,inpatient,300,ML,178.50000,107.10000,United Healthcare,Individual Exchange,,53.73,,,,,,,53.73,145.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,United Healthcare,Individual Exchange,,265.23,,,,,,,101.72,413.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,inpatient,2,ML,53.10000,31.86000,United Healthcare,Individual Exchange,,15.98,,,,,,,15.98,43.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,inpatient,0.25,ML,24.70000,14.82000,United Healthcare,Individual Exchange,,7.43,,,,,,,7.43,20.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,United Healthcare,Individual Exchange,,8.97,,,,,,,8.97,24.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,United Healthcare,Individual Exchange,,31.97,,,,,,,12.26,49.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,United Healthcare,Individual Exchange,,14.56,,,,,,,5.59,22.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,inpatient,10,ML,170.20000,102.12000,United Healthcare,Individual Exchange,,51.23,,,,,,,51.23,138.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,United Healthcare,Individual Exchange,,107.53,,,,,,,107.53,290.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,United Healthcare,Individual Exchange,,347.97,,,,,,,347.97,939.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,United Healthcare,Individual Exchange,,4.49,,,,,,,1.72,6.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,United Healthcare,Individual Exchange,,8.64,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Individual Exchange,,8.51,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,inpatient,5,ML,118261.70000,70957.02000,United Healthcare,Individual Exchange,,35596.77,,,,,,,35596.77,96146.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,United Healthcare,Individual Exchange,,79271.86,,,,,,,23675.99,87773.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,United Healthcare,Individual Exchange,,65.48,,,,,,,25.12,101.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,United Healthcare,Individual Exchange,,391.94,,,,,,,150.32,610.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,United Healthcare,Individual Exchange,,5.22,,,,,,,2.00,8.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,United Healthcare,Individual Exchange,,7.80,,,,,,,2.99,12.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,inpatient,100,ML,76.65000,45.99000,United Healthcare,Individual Exchange,,23.07,,,,,,,23.07,62.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,United Healthcare,Individual Exchange,,43.85,,,,,,,3.37,68.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,United Healthcare,Individual Exchange,,2.79,,,,,,,1.07,4.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,United Healthcare,Individual Exchange,,8.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,inpatient,1,ML,40.15000,24.09000,United Healthcare,Individual Exchange,,12.09,,,,,,,12.09,32.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,inpatient,1,ML,44.70000,26.82000,United Healthcare,Individual Exchange,,13.45,,,,,,,13.45,36.34,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,inpatient,0.75,ML,36.40000,21.84000,United Healthcare,Individual Exchange,,10.96,,,,,,,10.96,29.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,inpatient,1,UN,1052.35000,631.41000,United Healthcare,Individual Exchange,,316.76,,,,,,,316.76,855.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,United Healthcare,Individual Exchange,,2813.55,,,,,,,1079.07,4382.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,inpatient,5,ML,3636.80000,2182.08000,United Healthcare,Individual Exchange,,1094.68,,,,,,,1094.68,2956.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,United Healthcare,Individual Exchange,,199.85,,,,,,,64.64,2699.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,inpatient,5,ML,33.10000,19.86000,United Healthcare,Individual Exchange,,9.96,,,,,,,9.96,26.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,inpatient,1,UN,15765.00000,9459.00000,United Healthcare,Individual Exchange,,4745.27,,,,,,,4745.27,12816.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,United Healthcare,Individual Exchange,,255.83,,,,,,,88.98,11700.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,United Healthcare,Individual Exchange,,1.51,,,,,,,0.58058,2.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,inpatient,0.1,ML,21.05000,12.63000,United Healthcare,Individual Exchange,,6.34,,,,,,,6.34,17.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,inpatient,0.5,ML,430.80000,258.48000,United Healthcare,Individual Exchange,,129.67,,,,,,,129.67,350.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,United Healthcare,Individual Exchange,,364.39,,,,,,,86.25,417.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,inpatient,1,ML,236.50000,141.90000,United Healthcare,Individual Exchange,,71.19,,,,,,,71.19,192.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,United Healthcare,Individual Exchange,,196.28,,,,,,,47.35,196.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,inpatient,1,ML,64.90000,38.94000,United Healthcare,Individual Exchange,,19.53,,,,,,,19.53,52.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,inpatient,50,ML,108.00000,64.80000,United Healthcare,Individual Exchange,,32.51,,,,,,,32.51,87.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,United Healthcare,Individual Exchange,,6.47,,,,,,,2.48,10.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,inpatient,0.5,ML,144.25000,86.55000,United Healthcare,Individual Exchange,,43.42,,,,,,,43.42,117.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,United Healthcare,Individual Exchange,,151.28,,,,,,,58.02,235.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,inpatient,1,ML,2673.70000,1604.22000,United Healthcare,Individual Exchange,,804.78,,,,,,,804.78,2173.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,United Healthcare,Individual Exchange,,1609.33,,,,,,,535.27,1984.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,inpatient,1000,ML,87.50000,52.50000,United Healthcare,Individual Exchange,,26.34,,,,,,,26.34,71.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,United Healthcare,Individual Exchange,,5.09,,,,,,,1.95,7.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,inpatient,50,ML,3336.40000,2001.84000,United Healthcare,Individual Exchange,,1004.26,,,,,,,1004.26,2712.49,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,United Healthcare,Individual Exchange,,2071.87,,,,,,,667.95,2476.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,United Healthcare,Individual Exchange,,12.35,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,United Healthcare,Individual Exchange,,16.13,,,,,,,6.19,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,United Healthcare,Individual Exchange,,103.18,,,,,,,103.18,278.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,inpatient,100,ML,818.20000,490.92000,United Healthcare,Individual Exchange,,246.28,,,,,,,246.28,665.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,United Healthcare,Individual Exchange,,427.10,,,,,,,2.76,665.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,inpatient,5,ML,319.70000,191.82000,United Healthcare,Individual Exchange,,96.23,,,,,,,96.23,259.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,United Healthcare,Individual Exchange,,514.12,,,,,,,137.63,800.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,United Healthcare,Individual Exchange,,13.10,,,,,,,5.03,20.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,inpatient,1,UN,1360.75000,816.45000,United Healthcare,Individual Exchange,,409.59,,,,,,,409.59,1106.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,inpatient,10,ML,87.50000,52.50000,United Healthcare,Individual Exchange,,26.34,,,,,,,26.34,71.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,United Healthcare,Individual Exchange,,113.46,,,,,,,43.51,176.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,inpatient,5,ML,38.40000,23.04000,United Healthcare,Individual Exchange,,11.56,,,,,,,11.56,31.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,United Healthcare,Individual Exchange,,20.46,,,,,,,7.85,31.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,inpatient,6,ML,6247.80000,3748.68000,United Healthcare,Individual Exchange,,1880.59,,,,,,,1880.59,5079.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,United Healthcare,Individual Exchange,,25.35,,,,,,,7.71,4637.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,United Healthcare,Individual Exchange,,9.81,,,,,,,3.76,15.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,United Healthcare,Individual Exchange,,10.86,,,,,,,4.16,16.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,United Healthcare,Individual Exchange,,4961.30,,,,,,,1878.77,7727.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,United Healthcare,Individual Exchange,,2.01,,,,,,,0.77077,3.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,United Healthcare,Individual Exchange,,30.15,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,United Healthcare,Individual Exchange,,13.68,,,,,,,13.68,36.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,33.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,United Healthcare,Individual Exchange,,19.10,,,,,,,19.10,51.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,47.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,inpatient,1,UN,262.00000,157.20000,United Healthcare,Individual Exchange,,78.86,,,,,,,78.86,213.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,194.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,inpatient,1,UN,352.50000,211.50000,United Healthcare,Individual Exchange,,106.10,,,,,,,106.10,286.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,261.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,United Healthcare,Individual Exchange,,5.66,,,,,,,2.17,8.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,United Healthcare,Individual Exchange,,155.87,,,,,,,59.78,242.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,United Healthcare,Individual Exchange,,0.86130,,,,,,,0.33033,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,United Healthcare,Individual Exchange,,0.73080,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,United Healthcare,Individual Exchange,,0.83520,,,,,,,0.32032,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,inpatient,30,ML,46.30000,27.78000,United Healthcare,Individual Exchange,,13.94,,,,,,,13.94,37.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,inpatient,1,UN,218.65000,131.19000,United Healthcare,Individual Exchange,,65.81,,,,,,,65.81,177.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,United Healthcare,Individual Exchange,,93.65,,,,,,,35.92,145.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,99.80000,59.88000,United Healthcare,Individual Exchange,,30.04,,,,,,,30.04,81.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,Individual Exchange,,0.67860,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,inpatient,50,ML,155.95000,93.57000,United Healthcare,Individual Exchange,,46.94,,,,,,,46.94,126.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,United Healthcare,Individual Exchange,,21.06,,,,,,,8.08,32.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,inpatient,1,UN,22.00000,13.20000,United Healthcare,Individual Exchange,,6.62,,,,,,,6.62,17.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,inpatient,1,ML,64.75000,38.85000,United Healthcare,Individual Exchange,,19.49,,,,,,,19.49,52.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,United Healthcare,Individual Exchange,,731.33,,,,,,,12.96,731.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,inpatient,200,ML,11976.20000,7185.72000,United Healthcare,Individual Exchange,,3604.84,,,,,,,3604.84,9736.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,United Healthcare,Individual Exchange,,133.95,,,,,,,47.49,8888.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,United Healthcare,Individual Exchange,,30.09,,,,,,,11.54,46.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,inpatient,0.5,ML,34.20000,20.52000,United Healthcare,Individual Exchange,,10.29,,,,,,,10.29,27.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,inpatient,250,ML,80.50000,48.30000,United Healthcare,Individual Exchange,,24.23,,,,,,,24.23,65.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,inpatient,0.25,ML,23.65000,14.19000,United Healthcare,Individual Exchange,,7.12,,,,,,,7.12,19.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,inpatient,1,UN,9718.80000,5831.28000,United Healthcare,Individual Exchange,,2925.36,,,,,,,2925.36,7901.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,United Healthcare,Individual Exchange,,433.45,,,,,,,171.16,7213.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,inpatient,1,UN,249.90000,149.94000,United Healthcare,Individual Exchange,,75.22,,,,,,,75.22,203.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,United Healthcare,Individual Exchange,,0.67860,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,United Healthcare,Individual Exchange,,3.84,,,,,,,1.47,5.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,inpatient,250,ML,137.85000,82.71000,United Healthcare,Individual Exchange,,41.49,,,,,,,41.49,112.07,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,United Healthcare,Individual Exchange,,9.66,,,,,,,3.70,15.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,United Healthcare,Individual Exchange,,42.15,,,,,,,16.17,65.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,United Healthcare,Individual Exchange,,44.89,,,,,,,17.22,69.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,United Healthcare,Individual Exchange,,93.96,,,,,,,36.04,146.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,United Healthcare,Individual Exchange,,50.71,,,,,,,19.45,78.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,inpatient,1,UN,19451.85000,11671.11000,United Healthcare,Individual Exchange,,5855.01,,,,,,,5855.01,15814.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,Individual Exchange,,211.57,,,,,,,73.58,14437.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,United Healthcare,Individual Exchange,,83.02,,,,,,,31.84,129.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,inpatient,10,ML,93.85000,56.31000,United Healthcare,Individual Exchange,,28.25,,,,,,,28.25,76.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,inpatient,0.25,ML,70.45000,42.27000,United Healthcare,Individual Exchange,,21.21,,,,,,,21.21,57.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,5,ML,74.35000,44.61000,United Healthcare,Individual Exchange,,22.38,,,,,,,22.38,60.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,inpatient,5,ML,74.35000,44.61000,United Healthcare,Individual Exchange,,22.38,,,,,,,22.38,60.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,inpatient,5,ML,84.05000,50.43000,United Healthcare,Individual Exchange,,25.30,,,,,,,25.30,68.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,9.19,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,United Healthcare,Individual Exchange,,6.16,,,,,,,2.36,9.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,United Healthcare,Individual Exchange,,9.42,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Individual Exchange,,9.21,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,United Healthcare,Individual Exchange,,12.58,,,,,,,4.82,19.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,United Healthcare,Individual Exchange,,5.77,,,,,,,2.21,8.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,inpatient,1,UN,8199.90000,4919.94000,United Healthcare,Individual Exchange,,2468.17,,,,,,,2468.17,6666.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,United Healthcare,Individual Exchange,,4844.60,,,,,,,1641.62,6085.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,United Healthcare,Individual Exchange,,10.52,,,,,,,4.03,16.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,Individual Exchange,,8.74,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,United Healthcare,Individual Exchange,,32.21,,,,,,,12.35,50.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,United Healthcare,Individual Exchange,,194.97,,,,,,,74.77,303.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,inpatient,1,ML,385.00000,231.00000,United Healthcare,Individual Exchange,,115.89,,,,,,,115.89,313.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,United Healthcare,Individual Exchange,,100.51,,,,,,,38.55,156.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,inpatient,1,UN,70.35000,42.21000,United Healthcare,Individual Exchange,,21.18,,,,,,,21.18,57.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,inpatient,1,UN,66.30000,39.78000,United Healthcare,Individual Exchange,,19.96,,,,,,,19.96,53.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,United Healthcare,Individual Exchange,,47.50,,,,,,,18.22,73.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,Individual Exchange,,8.74,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,United Healthcare,Individual Exchange,,8.74,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,Individual Exchange,,11.61,,,,,,,4.45,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,inpatient,1,UN,29.30000,17.58000,United Healthcare,Individual Exchange,,8.82,,,,,,,8.82,23.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,Individual Exchange,,9.47,,,,,,,3.63,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,United Healthcare,Individual Exchange,,8.53,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,inpatient,250,ML,112.90000,67.74000,United Healthcare,Individual Exchange,,33.98,,,,,,,33.98,91.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,inpatient,250,ML,132.15000,79.29000,United Healthcare,Individual Exchange,,39.78,,,,,,,39.78,107.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Individual Exchange,,0.73080,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,inpatient,250,ML,90.15000,54.09000,United Healthcare,Individual Exchange,,27.14,,,,,,,27.14,73.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,United Healthcare,Individual Exchange,,0.03340,,,,,,,0.02360,66.91,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,United Healthcare,Individual Exchange,,77.60,,,,,,,29.76,120.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,United Healthcare,Individual Exchange,,23.26,,,,,,,8.92,36.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,United Healthcare,Individual Exchange,,54.44,,,,,,,20.88,84.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,United Healthcare,Individual Exchange,,10.57,,,,,,,4.05,16.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,inpatient,1,UN,17.85000,10.71000,United Healthcare,Individual Exchange,,5.37,,,,,,,5.37,14.51,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,United Healthcare,Individual Exchange,,180.61,,,,,,,69.27,281.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,inpatient,1,UN,1263.90000,758.34000,United Healthcare,Individual Exchange,,380.43,,,,,,,380.43,1027.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,United Healthcare,Individual Exchange,,89.50,,,,,,,61.17,938.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,United Healthcare,Individual Exchange,,12.03,,,,,,,4.61,18.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,inpatient,20,ML,452.80000,271.68000,United Healthcare,Individual Exchange,,136.29,,,,,,,136.29,368.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,inpatient,30,ML,907.80000,544.68000,United Healthcare,Individual Exchange,,273.25,,,,,,,273.25,738.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,United Healthcare,Individual Exchange,,0.91350,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,United Healthcare,Individual Exchange,,0.88740,,,,,,,0.34034,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,United Healthcare,Individual Exchange,,4.65,,,,,,,1.78,7.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,12.01,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Individual Exchange,,9.71,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,United Healthcare,Individual Exchange,,125.62,,,,,,,48.18,195.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Individual Exchange,,8.48,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Individual Exchange,,8.64,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,United Healthcare,Individual Exchange,,49.36,,,,,,,18.93,76.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,inpatient,1,ML,28.30000,16.98000,United Healthcare,Individual Exchange,,8.52,,,,,,,8.52,23.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,inpatient,250,ML,134.75000,80.85000,United Healthcare,Individual Exchange,,40.56,,,,,,,40.56,109.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,250,ML,141.75000,85.05000,United Healthcare,Individual Exchange,,42.67,,,,,,,42.67,115.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,United Healthcare,Individual Exchange,,22.84,,,,,,,8.76,35.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,United Healthcare,Individual Exchange,,182.00,,,,,,,69.80,283.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,12.01,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,inpatient,1,ML,20.95000,12.57000,United Healthcare,Individual Exchange,,6.31,,,,,,,6.31,17.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,inpatient,1,ML,18.75000,11.25000,United Healthcare,Individual Exchange,,5.64,,,,,,,5.64,15.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,inpatient,250,ML,141.75000,85.05000,United Healthcare,Individual Exchange,,42.67,,,,,,,42.67,115.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,inpatient,250,ML,164.50000,98.70000,United Healthcare,Individual Exchange,,49.51,,,,,,,49.51,133.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,United Healthcare,Individual Exchange,,91.35,,,,,,,35.03,142.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,United Healthcare,Individual Exchange,,1.67,,,,,,,0.64064,2.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,inpatient,1000,ML,101.50000,60.90000,United Healthcare,Individual Exchange,,30.55,,,,,,,30.55,82.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,United Healthcare,Individual Exchange,,64.73,,,,,,,24.82,100.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,United Healthcare,Individual Exchange,,64.73,,,,,,,24.82,100.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,inpatient,100,ML,91.70000,55.02000,United Healthcare,Individual Exchange,,27.60,,,,,,,27.60,74.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,United Healthcare,Individual Exchange,,41.60,,,,,,,15.96,64.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,United Healthcare,Individual Exchange,,245.86,,,,,,,94.29,382.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,United Healthcare,Individual Exchange,,13.68,,,,,,,5.25,21.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,United Healthcare,Individual Exchange,,12.11,,,,,,,4.64,18.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,United Healthcare,Individual Exchange,,12.27,,,,,,,4.70,19.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,Individual Exchange,,11.74,,,,,,,4.50,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,United Healthcare,Individual Exchange,,11.80,,,,,,,4.52,18.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,inpatient,1,UN,13881.15000,8328.69000,United Healthcare,Individual Exchange,,4178.23,,,,,,,4178.23,11285.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,United Healthcare,Individual Exchange,,2047.47,,,,,,,711.66,10302.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,United Healthcare,Individual Exchange,,158.58,,,,,,,60.82,246.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,United Healthcare,Individual Exchange,,2.22,,,,,,,0.85085,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,United Healthcare,Individual Exchange,,29.47,,,,,,,11.30,45.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,United Healthcare,Individual Exchange,,29.47,,,,,,,11.30,45.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,inpatient,1,UN,4065.55000,2439.33000,United Healthcare,Individual Exchange,,1223.73,,,,,,,1223.73,3305.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,inpatient,20,ML,113.05000,67.83000,United Healthcare,Individual Exchange,,34.03,,,,,,,34.03,91.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,inpatient,20,ML,117.85000,70.71000,United Healthcare,Individual Exchange,,35.47,,,,,,,35.47,95.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,inpatient,1,UN,17829.40000,10697.64000,United Healthcare,Individual Exchange,,5366.65,,,,,,,5366.65,14495.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,United Healthcare,Individual Exchange,,116.72,,,,,,,40.90,13232.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,inpatient,1,UN,28362.00000,17017.20000,United Healthcare,Individual Exchange,,8536.96,,,,,,,8536.96,23058.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,United Healthcare,Individual Exchange,,116.72,,,,,,,40.90,21050.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,United Healthcare,Individual Exchange,,19.67,,,,,,,19.67,53.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,United Healthcare,Individual Exchange,,3.21,,,,,,,1.23,5.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,inpatient,1,ML,147.45000,88.47000,United Healthcare,Individual Exchange,,44.38,,,,,,,44.38,119.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,United Healthcare,Individual Exchange,,13.08,,,,,,,5.02,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,United Healthcare,Individual Exchange,,21.66,,,,,,,8.31,33.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,United Healthcare,Individual Exchange,,12.37,,,,,,,4.74,19.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,Individual Exchange,,10.02,,,,,,,3.84,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,inpatient,0.5,ML,161.50000,96.90000,United Healthcare,Individual Exchange,,48.61,,,,,,,48.61,131.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,United Healthcare,Individual Exchange,,82.17,,,,,,,82.17,221.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,United Healthcare,Individual Exchange,,254.06,,,,,,,97.44,395.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,inpatient,10,ML,97.90000,58.74000,United Healthcare,Individual Exchange,,29.47,,,,,,,29.47,79.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,United Healthcare,Individual Exchange,,49.20,,,,,,,18.87,76.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,inpatient,1,UN,4576.00000,2745.60000,United Healthcare,Individual Exchange,,1377.38,,,,,,,1377.38,3720.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,United Healthcare,Individual Exchange,,79.87,,,,,,,30.63,124.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,United Healthcare,Individual Exchange,,12.55,,,,,,,4.81,19.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,United Healthcare,Individual Exchange,,2.51,,,,,,,0.96096,3.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,United Healthcare,Individual Exchange,,170.20,,,,,,,65.28,265.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,United Healthcare,Individual Exchange,,44.16,,,,,,,16.94,68.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,United Healthcare,Individual Exchange,,44.16,,,,,,,16.94,68.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,United Healthcare,Individual Exchange,,335.72,,,,,,,128.76,522.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,United Healthcare,Individual Exchange,,335.72,,,,,,,128.76,522.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Individual Exchange,,8.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,inpatient,1,UN,549.95000,329.97000,United Healthcare,Individual Exchange,,165.53,,,,,,,165.53,447.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,United Healthcare,Individual Exchange,,7.86,,,,,,,7.86,21.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,inpatient,0.5,ML,22.35000,13.41000,United Healthcare,Individual Exchange,,6.73,,,,,,,6.73,18.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,United Healthcare,Individual Exchange,,0.96570,,,,,,,0.37037,1.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,United Healthcare,Individual Exchange,,43.90,,,,,,,16.84,68.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,inpatient,1,UN,324.35000,194.61000,United Healthcare,Individual Exchange,,97.63,,,,,,,97.63,263.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,inpatient,1,UN,493.50000,296.10000,United Healthcare,Individual Exchange,,148.54,,,,,,,148.54,401.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,United Healthcare,Individual Exchange,,10.67,,,,,,,4.09,16.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,United Healthcare,Individual Exchange,,186.43,,,,,,,71.50,290.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,United Healthcare,Individual Exchange,,275.46,,,,,,,105.65,429.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,United Healthcare,Individual Exchange,,52.17,,,,,,,20.01,81.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,United Healthcare,Individual Exchange,,52.17,,,,,,,20.01,81.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,United Healthcare,Individual Exchange,,192.44,,,,,,,73.80,299.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,inpatient,5,ML,6392.40000,3835.44000,United Healthcare,Individual Exchange,,1924.11,,,,,,,1924.11,5197.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,United Healthcare,Individual Exchange,,855.64,,,,,,,299.42,4744.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,inpatient,1,ML,28.40000,17.04000,United Healthcare,Individual Exchange,,8.55,,,,,,,8.55,23.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,inpatient,10,ML,6878.50000,4127.10000,United Healthcare,Individual Exchange,,2070.43,,,,,,,2070.43,5592.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,United Healthcare,Individual Exchange,,207.63,,,,,,,72.13,5105.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,inpatient,50,ML,33292.40000,19975.44000,United Healthcare,Individual Exchange,,10021.01,,,,,,,10021.01,27066.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,United Healthcare,Individual Exchange,,207.63,,,,,,,72.13,24709.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,Individual Exchange,,11.85,,,,,,,4.54,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,inpatient,1,UN,55.00000,33.00000,United Healthcare,Individual Exchange,,16.55,,,,,,,16.55,44.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,inpatient,1,UN,80.00000,48.00000,United Healthcare,Individual Exchange,,24.08,,,,,,,24.08,65.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,United Healthcare,Individual Exchange,,0.88740,,,,,,,0.34034,1.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,United Healthcare,Individual Exchange,,26.77,,,,,,,26.77,72.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Individual Exchange,,5.96,,,,,,,2.08,66.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,inpatient,1,UN,39374.65000,23624.79000,United Healthcare,Individual Exchange,,11851.77,,,,,,,11851.77,32011.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,United Healthcare,Individual Exchange,,61.52,,,,,,,20.67,29223.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,inpatient,1,UN,8111.05000,4866.63000,United Healthcare,Individual Exchange,,2441.43,,,,,,,2441.43,6594.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,United Healthcare,Individual Exchange,,43.37,,,,,,,15.14,6020.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,inpatient,1,UN,88.95000,53.37000,United Healthcare,Individual Exchange,,26.77,,,,,,,26.77,72.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Individual Exchange,,5.96,,,,,,,2.08,66.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,United Healthcare,Individual Exchange,,199.06,,,,,,,76.35,310.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,inpatient,1,UN,75.60000,45.36000,United Healthcare,Individual Exchange,,22.76,,,,,,,22.76,61.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,United Healthcare,Individual Exchange,,26.43,,,,,,,26.43,71.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,inpatient,2,ML,2093.30000,1255.98000,United Healthcare,Individual Exchange,,630.08,,,,,,,630.08,1701.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,United Healthcare,Individual Exchange,,25.35,,,,,,,7.71,1553.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,United Healthcare,Individual Exchange,,7299.31,,,,,,,2799.47,11368.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Individual Exchange,,9.29,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,inpatient,10,ML,462.25000,277.35000,United Healthcare,Individual Exchange,,139.14,,,,,,,139.14,375.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,inpatient,1,ML,1095.00000,657.00000,United Healthcare,Individual Exchange,,329.60,,,,,,,329.60,890.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,United Healthcare,Individual Exchange,,447.31,,,,,,,150.45,812.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,United Healthcare,Individual Exchange,,129.19,,,,,,,49.55,201.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Individual Exchange,,8.56,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,United Healthcare,Individual Exchange,,30.28,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,United Healthcare,Individual Exchange,,11.66,,,,,,,11.66,31.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,inpatient,0.25,ML,38.75000,23.25000,United Healthcare,Individual Exchange,,11.66,,,,,,,11.66,31.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,United Healthcare,Individual Exchange,,125.88,,,,,,,48.28,196.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,United Healthcare,Individual Exchange,,160.72,,,,,,,61.64,250.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,United Healthcare,Individual Exchange,,212.35,,,,,,,81.44,330.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,7442.16,,,,,,,7442.16,20101.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,455.18,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,inpatient,1,UN,809.35000,485.61000,United Healthcare,Individual Exchange,,243.61,,,,,,,243.61,658.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,United Healthcare,Individual Exchange,,25.47,,,,,,,8.80,600.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,inpatient,4,ML,6099.95000,3659.97000,United Healthcare,Individual Exchange,,1836.08,,,,,,,1836.08,4959.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,United Healthcare,Individual Exchange,,92.03,,,,,,,31.97,4527.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,inpatient,10,ML,14837.25000,8902.35000,United Healthcare,Individual Exchange,,4466.01,,,,,,,4466.01,12062.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,United Healthcare,Individual Exchange,,92.03,,,,,,,31.97,11012.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Individual Exchange,,8.46,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Individual Exchange,,8.48,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,inpatient,0.5,ML,731.15000,438.69000,United Healthcare,Individual Exchange,,220.08,,,,,,,220.08,594.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,United Healthcare,Individual Exchange,,20.62,,,,,,,7.91,32.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,United Healthcare,Individual Exchange,,24.90,,,,,,,9.55,38.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,United Healthcare,Individual Exchange,,28.48,,,,,,,10.92,44.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,United Healthcare,Individual Exchange,,40.56,,,,,,,15.56,63.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Individual Exchange,,8794.59,,,,,,,8794.59,23754.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Individual Exchange,,162.88,,,,,,,86.66,21685.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,4,ML,26225.00000,15735.00000,United Healthcare,Individual Exchange,,7893.73,,,,,,,7893.73,21320.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,United Healthcare,Individual Exchange,,163.33,,,,,,,58.48,19464.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,United Healthcare,Individual Exchange,,13.05,,,,,,,5.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,United Healthcare,Individual Exchange,,38.73,,,,,,,14.85,60.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,United Healthcare,Individual Exchange,,38.73,,,,,,,14.85,60.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,United Healthcare,Individual Exchange,,57.05,,,,,,,21.88,88.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,United Healthcare,Individual Exchange,,929.16,,,,,,,356.36,1447.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,United Healthcare,Individual Exchange,,30.15,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,United Healthcare,Individual Exchange,,30.15,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,inpatient,1,UN,21020.20000,12612.12000,United Healthcare,Individual Exchange,,6327.08,,,,,,,6327.08,17089.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,United Healthcare,Individual Exchange,,591.80,,,,,,,197.47,15601.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,inpatient,1,UN,31468.15000,18880.89000,United Healthcare,Individual Exchange,,9471.91,,,,,,,9471.91,25583.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,United Healthcare,Individual Exchange,,591.80,,,,,,,197.47,23355.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,inpatient,1,UN,16047.65000,9628.59000,United Healthcare,Individual Exchange,,4830.34,,,,,,,4830.34,13046.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,United Healthcare,Individual Exchange,,591.80,,,,,,,197.47,11910.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,inpatient,1,UN,1807.55000,1084.53000,United Healthcare,Individual Exchange,,544.07,,,,,,,544.07,1469.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,United Healthcare,Individual Exchange,,292.70,,,,,,,101.59,1341.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,inpatient,1,UN,3746.95000,2248.17000,United Healthcare,Individual Exchange,,1127.83,,,,,,,1127.83,3046.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,United Healthcare,Individual Exchange,,4.23,,,,,,,1.62,6.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,inpatient,100,ML,94.50000,56.70000,United Healthcare,Individual Exchange,,28.44,,,,,,,28.44,76.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,United Healthcare,Individual Exchange,,254.06,,,,,,,97.44,395.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,inpatient,50,ML,3914.20000,2348.52000,United Healthcare,Individual Exchange,,1178.17,,,,,,,1178.17,3182.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,United Healthcare,Individual Exchange,,140.65,,,,,,,49.22,2905.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,inpatient,5,ML,84083.00000,50449.80000,United Healthcare,Individual Exchange,,25308.98,,,,,,,25308.98,68359.48,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,United Healthcare,Individual Exchange,,43891.33,,,,,,,16833.42,68359.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,inpatient,10,ML,1978.60000,1187.16000,United Healthcare,Individual Exchange,,595.56,,,,,,,595.56,1608.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,United Healthcare,Individual Exchange,,135.04,,,,,,,47.56,1468.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,inpatient,2,ML,493.20000,295.92000,United Healthcare,Individual Exchange,,148.45,,,,,,,148.45,400.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,United Healthcare,Individual Exchange,,135.04,,,,,,,47.56,366.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,inpatient,1,UN,4629.40000,2777.64000,United Healthcare,Individual Exchange,,1393.45,,,,,,,1393.45,3763.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,United Healthcare,Individual Exchange,,227.85,,,,,,,76.44,3435.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,inpatient,1,UN,9181.80000,5509.08000,United Healthcare,Individual Exchange,,2763.72,,,,,,,2763.72,7464.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,United Healthcare,Individual Exchange,,227.85,,,,,,,76.44,6814.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,inpatient,1,UN,4571.50000,2742.90000,United Healthcare,Individual Exchange,,1376.02,,,,,,,1376.02,3716.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,United Healthcare,Individual Exchange,,55.24,,,,,,,19.38,3392.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,Individual Exchange,,32.91,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,Individual Exchange,,32.91,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,United Healthcare,Individual Exchange,,32.91,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,inpatient,0.8,ML,2013.40000,1208.04000,United Healthcare,Individual Exchange,,606.03,,,,,,,606.03,1636.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,United Healthcare,Individual Exchange,,1.04,,,,,,,0.44620,1494.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,inpatient,0.5,ML,1264.35000,758.61000,United Healthcare,Individual Exchange,,380.57,,,,,,,380.57,1027.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,United Healthcare,Individual Exchange,,1.04,,,,,,,0.44620,938.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,inpatient,1,UN,44.30000,26.58000,United Healthcare,Individual Exchange,,13.33,,,,,,,13.33,36.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,inpatient,1,UN,129.20000,77.52000,United Healthcare,Individual Exchange,,38.89,,,,,,,38.89,105.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,United Healthcare,Individual Exchange,,24.53,,,,,,,9.41,38.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,United Healthcare,Individual Exchange,,43.95,,,,,,,16.86,68.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,United Healthcare,Individual Exchange,,22.88,,,,,,,22.88,61.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,inpatient,50,ML,88.00000,52.80000,United Healthcare,Individual Exchange,,26.49,,,,,,,26.49,71.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,inpatient,50,ML,10778.05000,6466.83000,United Healthcare,Individual Exchange,,3244.19,,,,,,,3244.19,8762.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,inpatient,10,ML,13382.60000,8029.56000,United Healthcare,Individual Exchange,,4028.16,,,,,,,4028.16,10880.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,United Healthcare,Individual Exchange,,182.00,,,,,,,64.02,9932.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,United Healthcare,Individual Exchange,,23.28,,,,,,,8.93,36.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,United Healthcare,Individual Exchange,,23.28,,,,,,,8.93,36.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,United Healthcare,Individual Exchange,,30.02,,,,,,,11.51,46.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,inpatient,1,UN,16408.85000,9845.31000,United Healthcare,Individual Exchange,,4939.06,,,,,,,4939.06,13340.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,United Healthcare,Individual Exchange,,87.37,,,,,,,30.33,12178.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,United Healthcare,Individual Exchange,,301.79,,,,,,,115.75,470.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,United Healthcare,Individual Exchange,,51.03,,,,,,,19.57,79.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,United Healthcare,Individual Exchange,,76.89,,,,,,,29.49,119.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,United Healthcare,Individual Exchange,,31.06,,,,,,,11.91,48.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,inpatient,4,ML,11159.75000,6695.85000,United Healthcare,Individual Exchange,,3359.08,,,,,,,3359.08,9072.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,United Healthcare,Individual Exchange,,36.59,,,,,,,13.09,8282.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,United Healthcare,Individual Exchange,,542.49,,,,,,,208.06,844.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,United Healthcare,Individual Exchange,,331.70,,,,,,,127.22,516.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,United Healthcare,Individual Exchange,,8.59,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,United Healthcare,Individual Exchange,,114.08,,,,,,,43.75,177.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,United Healthcare,Individual Exchange,,10.00,,,,,,,3.83,15.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,inpatient,3,ML,877.30000,526.38000,United Healthcare,Individual Exchange,,264.07,,,,,,,264.07,713.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,United Healthcare,Individual Exchange,,10.23,,,,,,,3.92,15.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,inpatient,1,UN,4037.40000,2422.44000,United Healthcare,Individual Exchange,,1215.26,,,,,,,1215.26,3282.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,United Healthcare,Individual Exchange,,54.89,,,,,,,19.39,2996.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,inpatient,2,ML,1656.85000,994.11000,United Healthcare,Individual Exchange,,498.71,,,,,,,498.71,1347.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,United Healthcare,Individual Exchange,,319.27,,,,,,,109.08,1229.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,inpatient,1,UN,309.65000,185.79000,United Healthcare,Individual Exchange,,93.20,,,,,,,93.20,251.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,United Healthcare,Individual Exchange,,198.76,,,,,,,61.99,229.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,United Healthcare,Individual Exchange,,7052.69,,,,,,,2704.88,10984.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,United Healthcare,Individual Exchange,,40.22,,,,,,,15.43,62.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,United Healthcare,Individual Exchange,,148.98,,,,,,,57.14,232.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,United Healthcare,Individual Exchange,,284.80,,,,,,,109.23,443.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,inpatient,1,UN,4647.20000,2788.32000,United Healthcare,Individual Exchange,,1398.81,,,,,,,1398.81,3778.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,United Healthcare,Individual Exchange,,110.35,,,,,,,42.32,171.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,United Healthcare,Individual Exchange,,49.93,,,,,,,19.15,77.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,United Healthcare,Individual Exchange,,77.33,,,,,,,29.66,120.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,United Healthcare,Individual Exchange,,15431.73,,,,,,,15431.73,41681.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,Individual Exchange,,253.84,,,,,,,88.60,38051.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,Individual Exchange,,11.48,,,,,,,4.40,17.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,United Healthcare,Individual Exchange,,704.78,,,,,,,270.30,1097.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,inpatient,1000,ML,122.50000,73.50000,United Healthcare,Individual Exchange,,36.87,,,,,,,36.87,99.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,United Healthcare,Individual Exchange,,1434.04,,,,,,,549.99,2233.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,inpatient,0.05,ML,61.35000,36.81000,United Healthcare,Individual Exchange,,18.47,,,,,,,18.47,49.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,United Healthcare,Individual Exchange,,5.11,,,,,,,1.78,45.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,inpatient,10,ML,1082.50000,649.50000,United Healthcare,Individual Exchange,,325.83,,,,,,,325.83,880.07,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,United Healthcare,Individual Exchange,,21.93,,,,,,,6.49,803.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,United Healthcare,Individual Exchange,,32.00,,,,,,,12.27,49.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,inpatient,40,ML,16023.00000,9613.80000,United Healthcare,Individual Exchange,,4822.92,,,,,,,4822.92,13026.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,United Healthcare,Individual Exchange,,111.09,,,,,,,38.64,11892.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,inpatient,10,ML,41.15000,24.69000,United Healthcare,Individual Exchange,,12.39,,,,,,,12.39,33.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,inpatient,100,ML,191.65000,114.99000,United Healthcare,Individual Exchange,,57.69,,,,,,,57.69,155.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,United Healthcare,Individual Exchange,,19.94,,,,,,,19.94,53.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,inpatient,200,ML,367.30000,220.38000,United Healthcare,Individual Exchange,,110.56,,,,,,,110.56,298.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,inpatient,15,ML,57.50000,34.50000,United Healthcare,Individual Exchange,,17.31,,,,,,,17.31,46.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,inpatient,15,ML,34.25000,20.55000,United Healthcare,Individual Exchange,,10.31,,,,,,,10.31,27.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,inpatient,15,ML,39.90000,23.94000,United Healthcare,Individual Exchange,,12.01,,,,,,,12.01,32.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,inpatient,1,ML,89877.30000,53926.38000,United Healthcare,Individual Exchange,,27053.07,,,,,,,27053.07,73070.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,United Healthcare,Individual Exchange,,393.23,,,,,,,137.35,66706.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,inpatient,10,ML,9488.70000,5693.22000,United Healthcare,Individual Exchange,,2856.10,,,,,,,2856.10,7714.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,United Healthcare,Individual Exchange,,279.73,,,,,,,97.09,7042.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,10,ML,86755.05000,52053.03000,United Healthcare,Individual Exchange,,26113.27,,,,,,,26113.27,70531.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,United Healthcare,Individual Exchange,,166.50,,,,,,,57.63,64389.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,United Healthcare,Individual Exchange,,23.39,,,,,,,8.97,36.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,inpatient,1,UN,7132.10000,4279.26000,United Healthcare,Individual Exchange,,2146.76,,,,,,,2146.76,5798.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,United Healthcare,Individual Exchange,,212.46,,,,,,,72.78,5293.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,United Healthcare,Individual Exchange,,468.08,,,,,,,179.52,729.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,10,ML,19171.55000,11502.93000,United Healthcare,Individual Exchange,,5770.64,,,,,,,5770.64,15586.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,United Healthcare,Individual Exchange,,237.76,,,,,,,82.57,14229.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,inpatient,2.4,ML,4810.20000,2886.12000,United Healthcare,Individual Exchange,,1447.87,,,,,,,1447.87,3910.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,United Healthcare,Individual Exchange,,237.76,,,,,,,82.57,3570.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,inpatient,11.7,ML,29212.00000,17527.20000,United Healthcare,Individual Exchange,,8792.81,,,,,,,8792.81,23749.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,United Healthcare,Individual Exchange,,103.07,,,,,,,35.59,21681.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,United Healthcare,Individual Exchange,,3.47,,,,,,,1.33,5.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,United Healthcare,Individual Exchange,,37.45,,,,,,,14.36,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,inpatient,13.4,ML,33345.80000,20007.48000,United Healthcare,Individual Exchange,,10037.09,,,,,,,10037.09,27110.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,United Healthcare,Individual Exchange,,103.07,,,,,,,35.59,24749.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,United Healthcare,Individual Exchange,,37.22,,,,,,,14.27,57.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,United Healthcare,Individual Exchange,,35.86,,,,,,,13.75,55.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,United Healthcare,Individual Exchange,,685.26,,,,,,,262.81,1067.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,United Healthcare,Individual Exchange,,2354.95,,,,,,,903.18,3667.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,United Healthcare,Individual Exchange,,24.95,,,,,,,9.57,38.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,inpatient,1,UN,48587.00000,29152.20000,United Healthcare,Individual Exchange,,14624.69,,,,,,,14624.69,39501.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,United Healthcare,Individual Exchange,,711.42,,,,,,,248.41,36061.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,inpatient,1,UN,105505.20000,63303.12000,United Healthcare,Individual Exchange,,31757.07,,,,,,,31757.07,85775.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,United Healthcare,Individual Exchange,,7524.59,,,,,,,2617.11,78305.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,Individual Exchange,,9.11,,,,,,,3.49,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,United Healthcare,Individual Exchange,,68.70,,,,,,,26.35,106.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,United Healthcare,Individual Exchange,,49.75,,,,,,,19.08,77.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,United Healthcare,Individual Exchange,,49.75,,,,,,,19.08,77.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,United Healthcare,Individual Exchange,,27.18,,,,,,,27.18,73.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Individual Exchange,,8.80,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,8.72,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,United Healthcare,Individual Exchange,,14.54,,,,,,,5.58,22.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Individual Exchange,,9.24,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,inpatient,250,ML,199.50000,119.70000,United Healthcare,Individual Exchange,,60.05,,,,,,,60.05,162.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,inpatient,1,UN,997.50000,598.50000,United Healthcare,Individual Exchange,,300.25,,,,,,,300.25,810.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,United Healthcare,Individual Exchange,,6.08,,,,,,,2.11,740.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,United Healthcare,Individual Exchange,,34.50,,,,,,,13.23,53.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,inpatient,1,UN,668.55000,401.13000,United Healthcare,Individual Exchange,,201.23,,,,,,,201.23,543.53,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,United Healthcare,Individual Exchange,,2.45,,,,,,,0.94094,3.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,inpatient,1,ML,18.40000,11.04000,United Healthcare,Individual Exchange,,5.54,,,,,,,5.54,14.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,inpatient,18,ML,1972.25000,1183.35000,United Healthcare,Individual Exchange,,593.65,,,,,,,593.65,1603.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,United Healthcare,Individual Exchange,,4.94,,,,,,,1.59,1463.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,inpatient,1,ML,26620.10000,15972.06000,United Healthcare,Individual Exchange,,8012.65,,,,,,,8012.65,21642.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,United Healthcare,Individual Exchange,,468.90,,,,,,,159.65,19757.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,inpatient,6,ML,5890.65000,3534.39000,United Healthcare,Individual Exchange,,1773.09,,,,,,,1773.09,4789.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,United Healthcare,Individual Exchange,,16.35,,,,,,,7.91,4372.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,United Healthcare,Individual Exchange,,9.97,,,,,,,3.82,15.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,inpatient,24,ML,35224.60000,21134.76000,United Healthcare,Individual Exchange,,10602.60,,,,,,,10602.60,28637.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,United Healthcare,Individual Exchange,,92.03,,,,,,,31.97,26143.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,inpatient,50,ML,80.05000,48.03000,United Healthcare,Individual Exchange,,24.10,,,,,,,24.10,65.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,United Healthcare,Individual Exchange,,126.30,,,,,,,48.44,196.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,United Healthcare,Individual Exchange,,203.32,,,,,,,77.98,316.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Individual Exchange,,7.93,,,,,,,7.93,21.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,inpatient,0.5,ML,58.45000,35.07000,United Healthcare,Individual Exchange,,17.59,,,,,,,17.59,47.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,United Healthcare,Individual Exchange,,50.28,,,,,,,11.70,50.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,United Healthcare,Individual Exchange,,200.97,,,,,,,77.08,313.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,United Healthcare,Individual Exchange,,60.76,,,,,,,7.61,94.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,United Healthcare,Individual Exchange,,86.97,,,,,,,7.61,135.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,United Healthcare,Individual Exchange,,113.14,,,,,,,7.61,176.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,United Healthcare,Individual Exchange,,270.34,,,,,,,7.61,421.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,United Healthcare,Individual Exchange,,1056.27,,,,,,,7.61,1645.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,inpatient,0.6,ML,9514.15000,5708.49000,United Healthcare,Individual Exchange,,2863.76,,,,,,,2863.76,7735.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,United Healthcare,Individual Exchange,,289.24,,,,,,,96.16,7061.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,United Healthcare,Individual Exchange,,274.05,,,,,,,105.11,426.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,United Healthcare,Individual Exchange,,68.33,,,,,,,26.21,106.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,United Healthcare,Individual Exchange,,68.33,,,,,,,26.21,106.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,inpatient,0.5,ML,489.25000,293.55000,United Healthcare,Individual Exchange,,147.26,,,,,,,147.26,397.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,United Healthcare,Individual Exchange,,495.21,,,,,,,97.95,495.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,inpatient,5,ML,21317.55000,12790.53000,United Healthcare,Individual Exchange,,6416.58,,,,,,,6416.58,17331.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,United Healthcare,Individual Exchange,,693.05,,,,,,,241.04,15821.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,inpatient,0.5,ML,1012.45000,607.47000,United Healthcare,Individual Exchange,,304.75,,,,,,,304.75,823.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,United Healthcare,Individual Exchange,,0.80160,,,,,,,0.29100,751.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,inpatient,0.8,ML,1610.35000,966.21000,United Healthcare,Individual Exchange,,484.72,,,,,,,484.72,1309.21,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,United Healthcare,Individual Exchange,,0.80160,,,,,,,0.29100,1195.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,inpatient,1,UN,344.75000,206.85000,United Healthcare,Individual Exchange,,103.77,,,,,,,103.77,280.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Individual Exchange,,8.64,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,United Healthcare,Individual Exchange,,29.18,,,,,,,11.19,45.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,United Healthcare,Individual Exchange,,2686.21,,,,,,,1030.23,4183.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,inpatient,7,ML,48344.85000,29006.91000,United Healthcare,Individual Exchange,,14551.80,,,,,,,14551.80,39304.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,United Healthcare,Individual Exchange,,80.04,,,,,,,28.41,35881.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Individual Exchange,,5722.69,,,,,,,5722.69,15456.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Individual Exchange,,379.41,,,,,,,103.14,14110.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,United Healthcare,Individual Exchange,,25.11,,,,,,,9.63,39.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,United Healthcare,Individual Exchange,,2371.58,,,,,,,909.56,3693.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,United Healthcare,Individual Exchange,,3033.18,,,,,,,3033.18,8192.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,Individual Exchange,,366.92,,,,,,,127.44,7479.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,United Healthcare,Individual Exchange,,304.75,,,,,,,304.75,823.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,Individual Exchange,,0.80160,,,,,,,0.29100,751.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,inpatient,1,UN,36064.10000,21638.46000,United Healthcare,Individual Exchange,,10855.29,,,,,,,10855.29,29320.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,inpatient,1,UN,2928.00000,1756.80000,United Healthcare,Individual Exchange,,881.33,,,,,,,881.33,2380.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,United Healthcare,Individual Exchange,,10827.06,,,,,,,10827.06,29243.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,Individual Exchange,,253.84,,,,,,,88.60,26697.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,inpatient,5,ML,20846.10000,12507.66000,United Healthcare,Individual Exchange,,6274.68,,,,,,,6274.68,16947.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,United Healthcare,Individual Exchange,,175.62,,,,,,,59.60,15471.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,United Healthcare,Individual Exchange,,105.97,,,,,,,40.64,165.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,United Healthcare,Individual Exchange,,149.81,,,,,,,57.46,233.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,inpatient,5,ML,419.55000,251.73000,United Healthcare,Individual Exchange,,126.28,,,,,,,126.28,341.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,United Healthcare,Individual Exchange,,19.81,,,,,,,6.63,311.39,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,United Healthcare,Individual Exchange,,929.68,,,,,,,356.56,1447.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,inpatient,1,UN,82165.25000,49299.15000,United Healthcare,Individual Exchange,,24731.74,,,,,,,24731.74,66800.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,United Healthcare,Individual Exchange,,379.93,,,,,,,132.57,60983.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,inpatient,16,ML,12554.95000,7532.97000,United Healthcare,Individual Exchange,,3779.04,,,,,,,3779.04,10207.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,United Healthcare,Individual Exchange,,80.46,,,,,,,27.02,9318.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,inpatient,4,ML,3345.05000,2007.03000,United Healthcare,Individual Exchange,,1006.86,,,,,,,1006.86,2719.53,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,United Healthcare,Individual Exchange,,80.46,,,,,,,27.02,2482.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,inpatient,100,ML,201.25000,120.75000,United Healthcare,Individual Exchange,,60.58,,,,,,,60.58,163.62,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,United Healthcare,Individual Exchange,,25.06,,,,,,,9.61,39.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,United Healthcare,Individual Exchange,,12.45,,,,,,,4.77,19.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Individual Exchange,,9.29,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,inpatient,10,ML,3995.45000,2397.27000,United Healthcare,Individual Exchange,,1202.63,,,,,,,1202.63,3248.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,United Healthcare,Individual Exchange,,86.96,,,,,,,28.50,2965.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,inpatient,50,ML,18877.10000,11326.26000,United Healthcare,Individual Exchange,,5682.01,,,,,,,5682.01,15347.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,United Healthcare,Individual Exchange,,86.96,,,,,,,28.50,14010.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,inpatient,1,UN,17338.20000,10402.92000,United Healthcare,Individual Exchange,,5218.80,,,,,,,5218.80,14095.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,United Healthcare,Individual Exchange,,117.02,,,,,,,40.72,12868.41,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,inpatient,1,UN,51888.40000,31133.04000,United Healthcare,Individual Exchange,,15618.41,,,,,,,15618.41,42185.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,United Healthcare,Individual Exchange,,117.02,,,,,,,40.72,38511.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,inpatient,10,ML,10365.35000,6219.21000,United Healthcare,Individual Exchange,,3119.97,,,,,,,3119.97,8427.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,United Healthcare,Individual Exchange,,361.39,,,,,,,125.60,7693.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,inpatient,1,UN,6279.25000,3767.55000,United Healthcare,Individual Exchange,,1890.05,,,,,,,1890.05,5105.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,United Healthcare,Individual Exchange,,30.68,,,,,,,10.68,4660.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,United Healthcare,Individual Exchange,,55.93,,,,,,,21.45,87.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,inpatient,1,UN,12634.60000,7580.76000,United Healthcare,Individual Exchange,,3803.01,,,,,,,3803.01,10271.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,United Healthcare,Individual Exchange,,102.24,,,,,,,35.64,9377.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,5663.13,,,,,,,5663.13,15296.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,102.24,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,inpatient,1,UN,13855.50000,8313.30000,United Healthcare,Individual Exchange,,4170.51,,,,,,,4170.51,11264.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,United Healthcare,Individual Exchange,,83.67,,,,,,,29.08,10283.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,inpatient,16,ML,11070.85000,6642.51000,United Healthcare,Individual Exchange,,3332.33,,,,,,,3332.33,9000.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,United Healthcare,Individual Exchange,,66.73,,,,,,,25.00,8216.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,inpatient,4,ML,2974.00000,1784.40000,United Healthcare,Individual Exchange,,895.17,,,,,,,895.17,2417.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,United Healthcare,Individual Exchange,,66.73,,,,,,,25.00,2207.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,10,ML,3428.95000,2057.37000,United Healthcare,Individual Exchange,,1032.11,,,,,,,1032.11,2787.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,United Healthcare,Individual Exchange,,73.91,,,,,,,27.01,2544.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,50,ML,16044.60000,9626.76000,United Healthcare,Individual Exchange,,4829.42,,,,,,,4829.42,13044.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,United Healthcare,Individual Exchange,,73.91,,,,,,,27.01,11908.30,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,inpatient,1,UN,75742.60000,45445.56000,United Healthcare,Individual Exchange,,22798.52,,,,,,,22798.52,61578.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,United Healthcare,Individual Exchange,,1001.47,,,,,,,348.41,56216.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,inpatient,1,UN,15195.80000,9117.48000,United Healthcare,Individual Exchange,,4573.94,,,,,,,4573.94,12354.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,United Healthcare,Individual Exchange,,79.83,,,,,,,27.15,11278.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,United Healthcare,Individual Exchange,,74.93,,,,,,,28.74,116.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,United Healthcare,Individual Exchange,,74.93,,,,,,,28.74,116.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,United Healthcare,Individual Exchange,,14.93,,,,,,,5.73,23.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,inpatient,1,ML,8211.30000,4926.78000,United Healthcare,Individual Exchange,,2471.60,,,,,,,2471.60,6675.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,United Healthcare,Individual Exchange,,55.36,,,,,,,19.37,6094.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,inpatient,25,ML,19413.25000,11647.95000,United Healthcare,Individual Exchange,,5843.39,,,,,,,5843.39,15782.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,United Healthcare,Individual Exchange,,231.09,,,,,,,79.44,14408.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,inpatient,5,ML,4102.65000,2461.59000,United Healthcare,Individual Exchange,,1234.90,,,,,,,1234.90,3335.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,United Healthcare,Individual Exchange,,231.09,,,,,,,79.44,3044.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,United Healthcare,Individual Exchange,,77.83,,,,,,,29.85,121.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,inpatient,1,UN,11554.40000,6932.64000,United Healthcare,Individual Exchange,,3477.87,,,,,,,3477.87,9393.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,United Healthcare,Individual Exchange,,101.12,,,,,,,35.19,8575.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,inpatient,1,UN,110033.00000,66019.80000,United Healthcare,Individual Exchange,,33119.93,,,,,,,33119.93,89456.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,United Healthcare,Individual Exchange,,885.25,,,,,,,308.97,81666.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,inpatient,1,UN,2163.00000,1297.80000,United Healthcare,Individual Exchange,,651.06,,,,,,,651.06,1758.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,United Healthcare,Individual Exchange,,58.27,,,,,,,19.80,1605.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Individual Exchange,,8.87,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,United Healthcare,Individual Exchange,,22.32,,,,,,,8.56,34.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,United Healthcare,Individual Exchange,,92.00,,,,,,,35.29,143.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,Individual Exchange,,9.34,,,,,,,3.58,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,inpatient,15,ML,61507.80000,36904.68000,United Healthcare,Individual Exchange,,18513.85,,,,,,,18513.85,50005.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,United Healthcare,Individual Exchange,,176.79,,,,,,,60.24,45651.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,inpatient,10,ML,41095.25000,24657.15000,United Healthcare,Individual Exchange,,12369.67,,,,,,,12369.67,33410.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,United Healthcare,Individual Exchange,,176.79,,,,,,,60.24,30500.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,inpatient,0.25,ML,65.65000,39.39000,United Healthcare,Individual Exchange,,19.76,,,,,,,19.76,53.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,inpatient,100,ML,88.00000,52.80000,United Healthcare,Individual Exchange,,26.49,,,,,,,26.49,71.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,inpatient,1,UN,6416.85000,3850.11000,United Healthcare,Individual Exchange,,1931.47,,,,,,,1931.47,5216.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,United Healthcare,Individual Exchange,,39.26,,,,,,,13.88,4762.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,inpatient,1,UN,17822.95000,10693.77000,United Healthcare,Individual Exchange,,5364.71,,,,,,,5364.71,14490.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,United Healthcare,Individual Exchange,,379.93,,,,,,,132.57,13228.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,inpatient,11,ML,100657.05000,60394.23000,United Healthcare,Individual Exchange,,30297.77,,,,,,,30297.77,81834.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,United Healthcare,Individual Exchange,,628.04,,,,,,,218.36,74707.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,inpatient,3,ML,27497.75000,16498.65000,United Healthcare,Individual Exchange,,8276.82,,,,,,,8276.82,22355.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,United Healthcare,Individual Exchange,,628.04,,,,,,,218.36,20408.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,United Healthcare,Individual Exchange,,532.31,,,,,,,7.61,829.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,inpatient,1,UN,6743.50000,4046.10000,United Healthcare,Individual Exchange,,2029.79,,,,,,,2029.79,5482.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,United Healthcare,Individual Exchange,,15.03,,,,,,,5.30,5005.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,inpatient,1,UN,5603.90000,3362.34000,United Healthcare,Individual Exchange,,1686.77,,,,,,,1686.77,4555.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,United Healthcare,Individual Exchange,,79.83,,,,,,,27.15,4159.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,inpatient,1,UN,9216.70000,5530.02000,United Healthcare,Individual Exchange,,2774.23,,,,,,,2774.23,7493.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,United Healthcare,Individual Exchange,,5893.61,,,,,,,1845.18,6840.63,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,inpatient,1,UN,124890.65000,74934.39000,United Healthcare,Individual Exchange,,37592.09,,,,,,,37592.09,101536.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,United Healthcare,Individual Exchange,,604.47,,,,,,,210.39,92693.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,inpatient,10,ML,53208.20000,31924.92000,United Healthcare,Individual Exchange,,16015.67,,,,,,,16015.67,43258.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,United Healthcare,Individual Exchange,,679.99,,,,,,,236.40,39491.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,inpatient,20,ML,20471.00000,12282.60000,United Healthcare,Individual Exchange,,6161.77,,,,,,,6161.77,16642.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,inpatient,7,ML,17024.40000,10214.64000,United Healthcare,Individual Exchange,,5124.34,,,,,,,5124.34,13840.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,United Healthcare,Individual Exchange,,61.94,,,,,,,21.86,12635.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Individual Exchange,,9.13,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Individual Exchange,,8.87,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,United Healthcare,Individual Exchange,,42.41,,,,,,,16.27,66.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,inpatient,0.5,ML,869.40000,521.64000,United Healthcare,Individual Exchange,,261.69,,,,,,,261.69,706.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,United Healthcare,Individual Exchange,,872.64,,,,,,,174.05,872.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,inpatient,1,UN,32838.55000,19703.13000,United Healthcare,Individual Exchange,,9884.40,,,,,,,9884.40,26697.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,United Healthcare,Individual Exchange,,526.13,,,,,,,183.10,24372.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,inpatient,100,ML,107.45000,64.47000,United Healthcare,Individual Exchange,,32.34,,,,,,,32.34,87.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,United Healthcare,Individual Exchange,,215.77,,,,,,,82.75,336.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,inpatient,1.5,ML,16340.20000,9804.12000,United Healthcare,Individual Exchange,,4918.40,,,,,,,4918.40,13284.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,United Healthcare,Individual Exchange,,34.44,,,,,,,11.95,12127.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,inpatient,1,UN,36433.75000,21860.25000,United Healthcare,Individual Exchange,,10966.56,,,,,,,10966.56,29620.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,United Healthcare,Individual Exchange,,235.75,,,,,,,82.03,27041.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,United Healthcare,Individual Exchange,,17.83,,,,,,,6.84,27.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,inpatient,100,ML,273.00000,163.80000,United Healthcare,Individual Exchange,,82.17,,,,,,,82.17,221.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,inpatient,1,UN,87.60000,52.56000,United Healthcare,Individual Exchange,,26.37,,,,,,,26.37,71.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,United Healthcare,Individual Exchange,,24.91,,,,,,,24.91,67.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,inpatient,1.5,ML,82.75000,49.65000,United Healthcare,Individual Exchange,,24.91,,,,,,,24.91,67.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,inpatient,0.5,ML,739.45000,443.67000,United Healthcare,Individual Exchange,,222.57,,,,,,,222.57,601.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,United Healthcare,Individual Exchange,,1.14,,,,,,,0.36860,548.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,inpatient,0.8,ML,1173.55000,704.13000,United Healthcare,Individual Exchange,,353.24,,,,,,,353.24,954.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,United Healthcare,Individual Exchange,,1.14,,,,,,,0.36860,871.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,inpatient,20,ML,68131.75000,40879.05000,United Healthcare,Individual Exchange,,20507.66,,,,,,,20507.66,55391.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,United Healthcare,Individual Exchange,,551.23,,,,,,,191.90,50567.38,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,United Healthcare,Individual Exchange,,39.67,,,,,,,15.22,61.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,United Healthcare,Individual Exchange,,1370.93,,,,,,,525.79,2135.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,United Healthcare,Individual Exchange,,592.99,,,,,,,227.43,923.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,United Healthcare,Individual Exchange,,592.99,,,,,,,227.43,923.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,United Healthcare,Individual Exchange,,1370.93,,,,,,,525.79,2135.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,9.19,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,inpatient,0.5,ML,104.05000,62.43000,United Healthcare,Individual Exchange,,31.32,,,,,,,31.32,84.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,inpatient,1.7,ML,46244.25000,27746.55000,United Healthcare,Individual Exchange,,13919.52,,,,,,,13919.52,37596.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,United Healthcare,Individual Exchange,,92.79,,,,,,,32.57,34322.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,inpatient,3,ML,9288.55000,5573.13000,United Healthcare,Individual Exchange,,2795.85,,,,,,,2795.85,7551.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,United Healthcare,Individual Exchange,,92.79,,,,,,,32.57,6893.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,inpatient,0.5,ML,520.00000,312.00000,United Healthcare,Individual Exchange,,156.52,,,,,,,156.52,422.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,inpatient,20,ML,30117.40000,18070.44000,United Healthcare,Individual Exchange,,9065.34,,,,,,,9065.34,24485.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,United Healthcare,Individual Exchange,,193.89,,,,,,,67.41,22353.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,inpatient,1,ML,3021.70000,1813.02000,United Healthcare,Individual Exchange,,909.53,,,,,,,909.53,2456.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,United Healthcare,Individual Exchange,,1820.45,,,,,,,604.94,2242.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,inpatient,30,ML,82676.70000,49606.02000,United Healthcare,Individual Exchange,,24885.69,,,,,,,24885.69,67216.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,United Healthcare,Individual Exchange,,1820.45,,,,,,,634.99,61362.65,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,inpatient,20,ML,65144.20000,39086.52000,United Healthcare,Individual Exchange,,19608.40,,,,,,,19608.40,52962.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,United Healthcare,Individual Exchange,,83.62,,,,,,,29.64,48350.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,inpatient,0.28,ML,11967.50000,7180.50000,United Healthcare,Individual Exchange,,3602.22,,,,,,,3602.22,9729.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,United Healthcare,Individual Exchange,,69.94,,,,,,,24.29,8882.28,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,inpatient,0.56,ML,23918.10000,14350.86000,United Healthcare,Individual Exchange,,7199.35,,,,,,,7199.35,19445.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,United Healthcare,Individual Exchange,,69.94,,,,,,,24.29,17752.01,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,inpatient,0.7,ML,29894.05000,17936.43000,United Healthcare,Individual Exchange,,8998.11,,,,,,,8998.11,24303.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,United Healthcare,Individual Exchange,,69.94,,,,,,,24.29,22187.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,inpatient,1,UN,68158.20000,40894.92000,United Healthcare,Individual Exchange,,20515.62,,,,,,,20515.62,55412.62,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,United Healthcare,Individual Exchange,,176902.85,,,,,,,13645.27,176902.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,inpatient,1,UN,942.40000,565.44000,United Healthcare,Individual Exchange,,283.66,,,,,,,283.66,766.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,inpatient,0.5,ML,2546.40000,1527.84000,United Healthcare,Individual Exchange,,766.47,,,,,,,766.47,2070.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,inpatient,1,ML,2546.45000,1527.87000,United Healthcare,Individual Exchange,,766.48,,,,,,,766.48,2070.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,United Healthcare,Individual Exchange,,32.62,,,,,,,12.51,50.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,United Healthcare,Individual Exchange,,15383.61,,,,,,,15383.61,41551.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,Individual Exchange,,201.92,,,,,,,70.44,37932.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,inpatient,1.5,ML,4087.55000,2452.53000,United Healthcare,Individual Exchange,,1230.35,,,,,,,1230.35,3323.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,United Healthcare,Individual Exchange,,201.92,,,,,,,70.44,3033.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,United Healthcare,Individual Exchange,,770.37,,,,,,,295.46,1199.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,United Healthcare,Individual Exchange,,108.78,,,,,,,41.72,169.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,United Healthcare,Individual Exchange,,52.20,,,,,,,20.02,81.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,inpatient,1,ML,255.50000,153.30000,United Healthcare,Individual Exchange,,76.91,,,,,,,76.91,207.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,United Healthcare,Individual Exchange,,16.13,,,,,,,6.19,25.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,United Healthcare,Individual Exchange,,55.33,,,,,,,21.22,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,United Healthcare,Individual Exchange,,36.17,,,,,,,13.87,56.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,inpatient,1,UN,63488.50000,38093.10000,United Healthcare,Individual Exchange,,19110.04,,,,,,,19110.04,51616.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,United Healthcare,Individual Exchange,,544.54,,,,,,,189.85,47121.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,inpatient,2,ML,234.40000,140.64000,United Healthcare,Individual Exchange,,70.55,,,,,,,70.55,190.57,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,United Healthcare,Individual Exchange,,21.93,,,,,,,6.49,173.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,inpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Individual Exchange,,5722.69,,,,,,,5722.69,15456.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Individual Exchange,,379.41,,,,,,,103.14,14110.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,inpatient,0.11,ML,352.45000,211.47000,United Healthcare,Individual Exchange,,106.09,,,,,,,106.09,286.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,United Healthcare,Individual Exchange,,5.11,,,,,,,1.78,261.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,inpatient,36,ML,26733.05000,16039.83000,United Healthcare,Individual Exchange,,8046.65,,,,,,,8046.65,21733.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,United Healthcare,Individual Exchange,,20188.85,,,,,,,5351.96,20188.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Individual Exchange,,8.56,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,inpatient,1,UN,10993.10000,6595.86000,United Healthcare,Individual Exchange,,3308.92,,,,,,,3308.92,8937.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,United Healthcare,Individual Exchange,,159.02,,,,,,,55.32,8159.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,inpatient,1,UN,43783.25000,26269.95000,United Healthcare,Individual Exchange,,13178.76,,,,,,,13178.76,35595.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,United Healthcare,Individual Exchange,,159.02,,,,,,,55.32,32495.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,inpatient,0.5,ML,883.00000,529.80000,United Healthcare,Individual Exchange,,265.78,,,,,,,265.78,717.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,United Healthcare,Individual Exchange,,914.46,,,,,,,176.78,914.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,inpatient,20,ML,61242.05000,36745.23000,United Healthcare,Individual Exchange,,18433.86,,,,,,,18433.86,49789.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,United Healthcare,Individual Exchange,,208.78,,,,,,,73.69,45453.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,inpatient,1,UN,7315.00000,4389.00000,United Healthcare,Individual Exchange,,2201.82,,,,,,,2201.82,5947.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,United Healthcare,Individual Exchange,,93.60,,,,,,,32.43,5429.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,inpatient,0.5,ML,257.30000,154.38000,United Healthcare,Individual Exchange,,77.45,,,,,,,77.45,209.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,United Healthcare,Individual Exchange,,232.85,,,,,,,51.51,232.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,inpatient,0.5,ML,81.25000,48.75000,United Healthcare,Individual Exchange,,24.46,,,,,,,24.46,66.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,United Healthcare,Individual Exchange,,62.32,,,,,,,16.27,62.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,inpatient,0.1,ML,17.05000,10.23000,United Healthcare,Individual Exchange,,5.13,,,,,,,5.13,13.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,inpatient,0.1,ML,16.90000,10.14000,United Healthcare,Individual Exchange,,5.09,,,,,,,5.09,13.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,inpatient,0.1,ML,16.75000,10.05000,United Healthcare,Individual Exchange,,5.04,,,,,,,5.04,13.62,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,inpatient,5,ML,35224.60000,21134.76000,United Healthcare,Individual Exchange,,10602.60,,,,,,,10602.60,28637.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,United Healthcare,Individual Exchange,,74.58,,,,,,,26.54,26143.70,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,inpatient,1,UN,21795.75000,13077.45000,United Healthcare,Individual Exchange,,6560.52,,,,,,,6560.52,17719.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,United Healthcare,Individual Exchange,,11377.38,,,,,,,50.01,17719.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,United Healthcare,Individual Exchange,,0.70470,,,,,,,0.27027,1.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,Individual Exchange,,0.67860,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,inpatient,20,ML,364.45000,218.67000,United Healthcare,Individual Exchange,,109.70,,,,,,,109.70,296.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Individual Exchange,,8.48,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,United Healthcare,Individual Exchange,,11368.33,,,,,,,11368.33,30705.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Individual Exchange,,479.52,,,,,,,167.05,28031.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,inpatient,0.3,ML,465.10000,279.06000,United Healthcare,Individual Exchange,,140.00,,,,,,,140.00,378.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,United Healthcare,Individual Exchange,,434.78,,,,,,,93.11,434.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Individual Exchange,,8.48,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,United Healthcare,Individual Exchange,,25.63,,,,,,,9.83,39.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,United Healthcare,Individual Exchange,,46.54,,,,,,,17.85,72.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,8.72,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Individual Exchange,,8.46,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,United Healthcare,Individual Exchange,,38.31,,,,,,,14.69,59.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,inpatient,1,UN,327.80000,196.68000,United Healthcare,Individual Exchange,,98.67,,,,,,,98.67,266.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,United Healthcare,Individual Exchange,,20.07,,,,,,,7.70,31.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,United Healthcare,Individual Exchange,,12.24,,,,,,,4.69,19.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,United Healthcare,Individual Exchange,,14.22,,,,,,,5.46,22.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,United Healthcare,Individual Exchange,,16.81,,,,,,,6.45,26.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,United Healthcare,Individual Exchange,,1.54,,,,,,,0.59059,2.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,inpatient,5,ML,192.90000,115.74000,United Healthcare,Individual Exchange,,58.06,,,,,,,58.06,156.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,United Healthcare,Individual Exchange,,5.79,,,,,,,2.22,9.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,United Healthcare,Individual Exchange,,10.21,,,,,,,3.91,15.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Individual Exchange,,8.48,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,inpatient,1,UN,94.25000,56.55000,United Healthcare,Individual Exchange,,28.37,,,,,,,28.37,76.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,12.01,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Individual Exchange,,9.00,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,United Healthcare,Individual Exchange,,14.20,,,,,,,5.45,22.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,9.19,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,United Healthcare,Individual Exchange,,13.68,,,,,,,5.25,21.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Individual Exchange,,9.55,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Individual Exchange,,8.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,Individual Exchange,,9.34,,,,,,,3.58,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,inpatient,0.5,ML,91.05000,54.63000,United Healthcare,Individual Exchange,,27.41,,,,,,,27.41,74.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,inpatient,1,UN,1399.95000,839.97000,United Healthcare,Individual Exchange,,421.38,,,,,,,421.38,1138.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,United Healthcare,Individual Exchange,,63.09,,,,,,,20.84,1039.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Individual Exchange,,8.90,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Individual Exchange,,9.71,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,inpatient,10,ML,4408.90000,2645.34000,United Healthcare,Individual Exchange,,1327.08,,,,,,,1327.08,3584.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,United Healthcare,Individual Exchange,,211.76,,,,,,,72.96,3272.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,50,ML,20944.45000,12566.67000,United Healthcare,Individual Exchange,,6304.28,,,,,,,6304.28,17027.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,United Healthcare,Individual Exchange,,211.76,,,,,,,72.96,15544.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,United Healthcare,Individual Exchange,,35.47,,,,,,,13.60,55.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,inpatient,1.5,ML,6363.00000,3817.80000,United Healthcare,Individual Exchange,,1915.26,,,,,,,1915.26,5173.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,United Healthcare,Individual Exchange,,16.82,,,,,,,6.09,4722.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,United Healthcare,Individual Exchange,,43.80,,,,,,,16.80,68.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,United Healthcare,Individual Exchange,,9.76,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,United Healthcare,Individual Exchange,,103.25,,,,,,,39.60,160.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,United Healthcare,Individual Exchange,,24.06,,,,,,,9.23,37.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,United Healthcare,Individual Exchange,,13.77,,,,,,,13.77,37.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,United Healthcare,Individual Exchange,,9.06,,,,,,,3.47,14.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Individual Exchange,,10.34,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,inpatient,0.5,ML,4182.45000,2509.47000,United Healthcare,Individual Exchange,,1258.92,,,,,,,1258.92,3400.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,United Healthcare,Individual Exchange,,42.57,,,,,,,16.33,66.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,United Healthcare,Individual Exchange,,9.81,,,,,,,3.76,15.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,inpatient,1,ML,126.65000,75.99000,United Healthcare,Individual Exchange,,38.12,,,,,,,38.12,102.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,United Healthcare,Individual Exchange,,246.85,,,,,,,94.67,384.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,United Healthcare,Individual Exchange,,5.04,,,,,,,1.93,7.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Individual Exchange,,10.65,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,inpatient,100,ML,1113.00000,667.80000,United Healthcare,Individual Exchange,,335.01,,,,,,,335.01,904.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,inpatient,500,ML,64.00000,38.40000,United Healthcare,Individual Exchange,,19.26,,,,,,,19.26,52.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,inpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,5.03,,,,,,,5.03,13.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,inpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,5.30,,,,,,,5.30,14.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,inpatient,1,UN,20.05000,12.03000,United Healthcare,Individual Exchange,,6.04,,,,,,,6.04,16.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,inpatient,5,ML,24.90000,14.94000,United Healthcare,Individual Exchange,,7.49,,,,,,,7.49,20.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,United Healthcare,Individual Exchange,,92.76,,,,,,,35.58,144.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,United Healthcare,Individual Exchange,,6.19,,,,,,,2.37,9.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,United Healthcare,Individual Exchange,,57.26,,,,,,,21.96,89.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,inpatient,1,UN,654.25000,392.55000,United Healthcare,Individual Exchange,,196.93,,,,,,,196.93,531.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,inpatient,1,UN,2058.00000,1234.80000,United Healthcare,Individual Exchange,,619.46,,,,,,,619.46,1673.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,United Healthcare,Individual Exchange,,86.96,,,,,,,30.16,1527.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Individual Exchange,,10.65,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Individual Exchange,,10.65,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,inpatient,1,UN,516.55000,309.93000,United Healthcare,Individual Exchange,,155.48,,,,,,,155.48,419.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,Individual Exchange,,11.61,,,,,,,4.45,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,United Healthcare,Individual Exchange,,11.61,,,,,,,4.45,18.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,United Healthcare,Individual Exchange,,28.14,,,,,,,10.79,43.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,United Healthcare,Individual Exchange,,4.49,,,,,,,1.72,6.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,United Healthcare,Individual Exchange,,9.79,,,,,,,3.75,15.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,United Healthcare,Individual Exchange,,74.18,,,,,,,28.45,115.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,United Healthcare,Individual Exchange,,8.69,,,,,,,3.33,13.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,United Healthcare,Individual Exchange,,220.49,,,,,,,84.56,343.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,8.72,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,United Healthcare,Individual Exchange,,26.47,,,,,,,10.15,41.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,United Healthcare,Individual Exchange,,46.28,,,,,,,17.75,72.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,United Healthcare,Individual Exchange,,11.17,,,,,,,4.28,17.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Individual Exchange,,9.13,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,United Healthcare,Individual Exchange,,12.53,,,,,,,4.80,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,Individual Exchange,,9.16,,,,,,,3.51,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,United Healthcare,Individual Exchange,,47.48,,,,,,,18.21,73.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,United Healthcare,Individual Exchange,,11.09,,,,,,,4.25,17.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Individual Exchange,,9.13,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,United Healthcare,Individual Exchange,,0.99180,,,,,,,0.38038,1.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,inpatient,1,UN,23.95000,14.37000,United Healthcare,Individual Exchange,,7.21,,,,,,,7.21,19.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,United Healthcare,Individual Exchange,,11.69,,,,,,,4.48,18.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,inpatient,5,ML,196.60000,117.96000,United Healthcare,Individual Exchange,,59.18,,,,,,,59.18,159.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,United Healthcare,Individual Exchange,,8.87,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,inpatient,1.25,ML,48.40000,29.04000,United Healthcare,Individual Exchange,,14.57,,,,,,,14.57,39.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,inpatient,1,ML,29.70000,17.82000,United Healthcare,Individual Exchange,,8.94,,,,,,,8.94,24.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,United Healthcare,Individual Exchange,,3.92,,,,,,,1.50,6.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Individual Exchange,,9.00,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,8.77,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,United Healthcare,Individual Exchange,,10.83,,,,,,,4.15,16.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,inpatient,50,ML,81.40000,48.84000,United Healthcare,Individual Exchange,,24.50,,,,,,,24.50,66.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,United Healthcare,Individual Exchange,,1.75,,,,,,,0.67067,2.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,United Healthcare,Individual Exchange,,7.52,,,,,,,2.88,11.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Individual Exchange,,8.51,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Individual Exchange,,8.85,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,Individual Exchange,,11.74,,,,,,,4.50,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,United Healthcare,Individual Exchange,,0.67860,,,,,,,0.26026,1.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,United Healthcare,Individual Exchange,,17.02,,,,,,,6.53,26.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,inpatient,5,ML,79.85000,47.91000,United Healthcare,Individual Exchange,,24.03,,,,,,,24.03,64.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,United Healthcare,Individual Exchange,,11.95,,,,,,,4.58,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,Individual Exchange,,9.47,,,,,,,3.63,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,United Healthcare,Individual Exchange,,9.84,,,,,,,3.77,15.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,United Healthcare,Individual Exchange,,10.39,,,,,,,3.98,16.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,inpatient,1,UN,164.50000,98.70000,United Healthcare,Individual Exchange,,49.51,,,,,,,49.51,133.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,Individual Exchange,,8.59,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Individual Exchange,,8.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,inpatient,1,UN,84.35000,50.61000,United Healthcare,Individual Exchange,,25.39,,,,,,,25.39,68.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,United Healthcare,Individual Exchange,,16.36,,,,,,,6.28,25.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,inpatient,1,UN,7346.35000,4407.81000,United Healthcare,Individual Exchange,,2211.25,,,,,,,2211.25,5972.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,United Healthcare,Individual Exchange,,120.72,,,,,,,41.89,5452.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,inpatient,0.5,ML,28.10000,16.86000,United Healthcare,Individual Exchange,,8.46,,,,,,,8.46,22.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,United Healthcare,Individual Exchange,,40.09,,,,,,,15.38,62.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,United Healthcare,Individual Exchange,,16.55,,,,,,,6.35,25.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Individual Exchange,,8.87,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Individual Exchange,,8.80,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,United Healthcare,Individual Exchange,,1430.96,,,,,,,548.81,2228.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,United Healthcare,Individual Exchange,,46.04,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,inpatient,0.3,ML,39.90000,23.94000,United Healthcare,Individual Exchange,,12.01,,,,,,,12.01,32.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,United Healthcare,Individual Exchange,,13.75,,,,,,,5.28,21.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,inpatient,10,ML,97.15000,58.29000,United Healthcare,Individual Exchange,,29.24,,,,,,,29.24,78.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,inpatient,20,ML,101.60000,60.96000,United Healthcare,Individual Exchange,,30.58,,,,,,,30.58,82.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,inpatient,50,ML,147.00000,88.20000,United Healthcare,Individual Exchange,,44.25,,,,,,,44.25,119.51,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,inpatient,0.5,ML,25.85000,15.51000,United Healthcare,Individual Exchange,,7.78,,,,,,,7.78,21.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,inpatient,20,ML,1179.50000,707.70000,United Healthcare,Individual Exchange,,355.03,,,,,,,355.03,958.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,inpatient,10,ML,2255.00000,1353.00000,United Healthcare,Individual Exchange,,678.75,,,,,,,678.75,1833.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,United Healthcare,Individual Exchange,,304.77,,,,,,,105.22,1673.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,inpatient,25,ML,5775.00000,3465.00000,United Healthcare,Individual Exchange,,1738.28,,,,,,,1738.28,4695.07,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,United Healthcare,Individual Exchange,,304.77,,,,,,,105.22,4286.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,United Healthcare,Individual Exchange,,3.08,,,,,,,1.18,4.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,United Healthcare,Individual Exchange,,1157.14,,,,,,,443.79,1802.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,United Healthcare,Individual Exchange,,9.84,,,,,,,3.77,15.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,United Healthcare,Individual Exchange,,119.02,,,,,,,45.65,185.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Individual Exchange,,10.07,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,United Healthcare,Individual Exchange,,10.52,,,,,,,4.03,16.38,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,United Healthcare,Individual Exchange,,137.60,,,,,,,52.77,214.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,United Healthcare,Individual Exchange,,11.07,,,,,,,4.24,17.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,United Healthcare,Individual Exchange,,10.13,,,,,,,3.88,15.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,United Healthcare,Individual Exchange,,12.06,,,,,,,4.62,18.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Individual Exchange,,10.44,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,United Healthcare,Individual Exchange,,13.52,,,,,,,5.19,21.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,United Healthcare,Individual Exchange,,52.83,,,,,,,20.26,82.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,United Healthcare,Individual Exchange,,316.88,,,,,,,121.53,493.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,inpatient,2000,ML,180.85000,108.51000,United Healthcare,Individual Exchange,,54.44,,,,,,,54.44,147.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,inpatient,2000,ML,180.85000,108.51000,United Healthcare,Individual Exchange,,54.44,,,,,,,54.44,147.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,inpatient,2000,ML,194.50000,116.70000,United Healthcare,Individual Exchange,,58.54,,,,,,,58.54,158.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,inpatient,2000,ML,195.65000,117.39000,United Healthcare,Individual Exchange,,58.89,,,,,,,58.89,159.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Individual Exchange,,9.32,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,United Healthcare,Individual Exchange,,1.93,,,,,,,0.74074,3.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,United Healthcare,Individual Exchange,,1.93,,,,,,,0.74074,3.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,United Healthcare,Individual Exchange,,2.04,,,,,,,0.78078,3.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,United Healthcare,Individual Exchange,,18.61,,,,,,,7.14,28.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,United Healthcare,Individual Exchange,,22.65,,,,,,,8.69,35.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,United Healthcare,Individual Exchange,,31.32,,,,,,,12.01,48.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,United Healthcare,Individual Exchange,,42.86,,,,,,,16.44,66.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,United Healthcare,Individual Exchange,,54.65,,,,,,,20.96,85.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,United Healthcare,Individual Exchange,,115.23,,,,,,,44.19,179.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,United Healthcare,Individual Exchange,,6.99,,,,,,,2.68,10.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Individual Exchange,,0.75690,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,United Healthcare,Individual Exchange,,528.16,,,,,,,202.56,822.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,United Healthcare,Individual Exchange,,4.20,,,,,,,1.61,6.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,United Healthcare,Individual Exchange,,59.51,,,,,,,22.82,92.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,United Healthcare,Individual Exchange,,12.08,,,,,,,4.63,18.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,United Healthcare,Individual Exchange,,13.83,,,,,,,5.31,21.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,Individual Exchange,,15.66,,,,,,,6.01,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,United Healthcare,Individual Exchange,,392.88,,,,,,,150.68,611.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,United Healthcare,Individual Exchange,,9.58,,,,,,,3.67,14.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,inpatient,10,ML,308.40000,185.04000,United Healthcare,Individual Exchange,,92.83,,,,,,,92.83,250.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,United Healthcare,Individual Exchange,,12.58,,,,,,,4.82,19.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,United Healthcare,Individual Exchange,,48.55,,,,,,,18.62,75.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,United Healthcare,Individual Exchange,,42.28,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,United Healthcare,Individual Exchange,,48.18,,,,,,,18.48,75.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,United Healthcare,Individual Exchange,,47.14,,,,,,,18.08,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,0.1,ML,22.85000,13.71000,United Healthcare,Individual Exchange,,6.88,,,,,,,6.88,18.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,United Healthcare,Individual Exchange,,10.60,,,,,,,4.06,16.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,United Healthcare,Individual Exchange,,9.45,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,United Healthcare,Individual Exchange,,24.09,,,,,,,9.24,37.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,United Healthcare,Individual Exchange,,26.88,,,,,,,10.31,41.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,United Healthcare,Individual Exchange,,139.74,,,,,,,53.59,217.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,inpatient,1,UN,27.90000,16.74000,United Healthcare,Individual Exchange,,8.40,,,,,,,8.40,22.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,inpatient,1,UN,63.15000,37.89000,United Healthcare,Individual Exchange,,19.01,,,,,,,19.01,51.34,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,United Healthcare,Individual Exchange,,312.76,,,,,,,119.95,487.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,United Healthcare,Individual Exchange,,19.71,,,,,,,7.56,30.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,United Healthcare,Individual Exchange,,32.60,,,,,,,12.50,50.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,inpatient,1,UN,3520.00000,2112.00000,United Healthcare,Individual Exchange,,1059.52,,,,,,,1059.52,2861.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,United Healthcare,Individual Exchange,,844.82,,,,,,,318.49,2612.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,United Healthcare,Individual Exchange,,810.14,,,,,,,310.71,1261.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,inpatient,2.5,ML,1204.10000,722.46000,United Healthcare,Individual Exchange,,362.43,,,,,,,362.43,978.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,United Healthcare,Individual Exchange,,2.07,,,,,,,0.77600,893.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Individual Exchange,,9.29,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,United Healthcare,Individual Exchange,,112.75,,,,,,,43.24,175.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,United Healthcare,Individual Exchange,,60.16,,,,,,,23.07,93.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,inpatient,1,UN,523.95000,314.37000,United Healthcare,Individual Exchange,,157.71,,,,,,,157.71,425.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,inpatient,1,UN,698.50000,419.10000,United Healthcare,Individual Exchange,,210.25,,,,,,,210.25,567.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,inpatient,10,ML,1199.00000,719.40000,United Healthcare,Individual Exchange,,360.90,,,,,,,360.90,974.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,United Healthcare,Individual Exchange,,16.35,,,,,,,7.91,889.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,inpatient,5,ML,335.80000,201.48000,United Healthcare,Individual Exchange,,101.08,,,,,,,101.08,273.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,United Healthcare,Individual Exchange,,182.44,,,,,,,69.97,284.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,United Healthcare,Individual Exchange,,9.97,,,,,,,3.82,15.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,United Healthcare,Individual Exchange,,10.05,,,,,,,3.85,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,Individual Exchange,,11.14,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,United Healthcare,Individual Exchange,,14.85,,,,,,,5.70,23.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,inpatient,5,ML,19.30000,11.58000,United Healthcare,Individual Exchange,,5.81,,,,,,,5.81,15.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,inpatient,1,UN,12869.00000,7721.40000,United Healthcare,Individual Exchange,,3873.57,,,,,,,3873.57,10462.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,United Healthcare,Individual Exchange,,5190.51,,,,,,,1773.86,9551.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,inpatient,1,ML,52.40000,31.44000,United Healthcare,Individual Exchange,,15.77,,,,,,,15.77,42.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,inpatient,1,UN,357.25000,214.35000,United Healthcare,Individual Exchange,,107.53,,,,,,,107.53,290.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,United Healthcare,Individual Exchange,,34.77,,,,,,,13.33,54.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,United Healthcare,Individual Exchange,,9.27,,,,,,,3.55,14.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,United Healthcare,Individual Exchange,,1.28,,,,,,,0.49049,1.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,United Healthcare,Individual Exchange,,2.32,,,,,,,0.89089,3.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,United Healthcare,Individual Exchange,,11.14,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,United Healthcare,Individual Exchange,,14.15,,,,,,,5.43,22.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,inpatient,250,ML,693.00000,415.80000,United Healthcare,Individual Exchange,,208.59,,,,,,,208.59,563.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,Individual Exchange,,10.18,,,,,,,3.90,15.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Individual Exchange,,8.90,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,United Healthcare,Individual Exchange,,10.18,,,,,,,3.90,15.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,United Healthcare,Individual Exchange,,11.28,,,,,,,4.32,17.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,inpatient,1,UN,83.10000,49.86000,United Healthcare,Individual Exchange,,25.01,,,,,,,25.01,67.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,United Healthcare,Individual Exchange,,4.74,,,,,,,1.65,61.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,United Healthcare,Individual Exchange,,192.96,,,,,,,74.00,300.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,United Healthcare,Individual Exchange,,219.24,,,,,,,84.08,341.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,inpatient,1,ML,28.65000,17.19000,United Healthcare,Individual Exchange,,8.62,,,,,,,8.62,23.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,inpatient,10,ML,42.40000,25.44000,United Healthcare,Individual Exchange,,12.76,,,,,,,12.76,34.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,inpatient,2,ML,28.40000,17.04000,United Healthcare,Individual Exchange,,8.55,,,,,,,8.55,23.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,inpatient,20,ML,53.45000,32.07000,United Healthcare,Individual Exchange,,16.09,,,,,,,16.09,43.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,inpatient,5,ML,31.00000,18.60000,United Healthcare,Individual Exchange,,9.33,,,,,,,9.33,25.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,United Healthcare,Individual Exchange,,13.55,,,,,,,5.20,21.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,United Healthcare,Individual Exchange,,0.91350,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,United Healthcare,Individual Exchange,,62.59,,,,,,,24.00,97.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,United Healthcare,Individual Exchange,,3.29,,,,,,,1.26,5.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,inpatient,150,ML,94.00000,56.40000,United Healthcare,Individual Exchange,,28.29,,,,,,,28.29,76.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,United Healthcare,Individual Exchange,,45.15,,,,,,,17.32,70.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Individual Exchange,,9.03,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,inpatient,16.7,ML,465.05000,279.03000,United Healthcare,Individual Exchange,,139.98,,,,,,,139.98,378.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,inpatient,5,ML,319.00000,191.40000,United Healthcare,Individual Exchange,,96.02,,,,,,,96.02,259.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,inpatient,50,ML,843.95000,506.37000,United Healthcare,Individual Exchange,,254.03,,,,,,,254.03,686.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,United Healthcare,Individual Exchange,,10.70,,,,,,,4.10,16.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,Individual Exchange,,9.08,,,,,,,3.48,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Individual Exchange,,9.32,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,United Healthcare,Individual Exchange,,138.36,,,,,,,53.06,215.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,inpatient,1,UN,858.55000,515.13000,United Healthcare,Individual Exchange,,258.42,,,,,,,258.42,698.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,United Healthcare,Individual Exchange,,262.57,,,,,,,91.62,637.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,inpatient,1,UN,19973.00000,11983.80000,United Healthcare,Individual Exchange,,6011.87,,,,,,,6011.87,16238.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,United Healthcare,Individual Exchange,,13856.88,,,,,,,3998.59,14823.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,United Healthcare,Individual Exchange,,17.64,,,,,,,6.77,27.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,United Healthcare,Individual Exchange,,11.14,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,United Healthcare,Individual Exchange,,11.14,,,,,,,4.27,17.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,United Healthcare,Individual Exchange,,95.60,,,,,,,36.67,148.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,United Healthcare,Individual Exchange,,60.71,,,,,,,23.28,94.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,United Healthcare,Individual Exchange,,15.61,,,,,,,5.99,24.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,United Healthcare,Individual Exchange,,65.43,,,,,,,25.10,101.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,United Healthcare,Individual Exchange,,37.32,,,,,,,14.31,58.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,United Healthcare,Individual Exchange,,99.23,,,,,,,38.06,154.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,inpatient,1,ML,84.55000,50.73000,United Healthcare,Individual Exchange,,25.45,,,,,,,25.45,68.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,United Healthcare,Individual Exchange,,272.12,,,,,,,104.36,423.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,inpatient,0.5,ML,59.70000,35.82000,United Healthcare,Individual Exchange,,17.97,,,,,,,17.97,48.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,United Healthcare,Individual Exchange,,20.72,,,,,,,7.12,44.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,United Healthcare,Individual Exchange,,11.48,,,,,,,4.40,17.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,United Healthcare,Individual Exchange,,14.93,,,,,,,5.73,23.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,inpatient,0.5,ML,121.05000,72.63000,United Healthcare,Individual Exchange,,36.44,,,,,,,36.44,98.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,inpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Individual Exchange,,8794.59,,,,,,,8794.59,23754.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Individual Exchange,,162.88,,,,,,,86.66,21685.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,inpatient,0.2,ML,18.45000,11.07000,United Healthcare,Individual Exchange,,5.55,,,,,,,5.55,15.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,United Healthcare,Individual Exchange,,19.13,,,,,,,7.34,29.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,8.77,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,United Healthcare,Individual Exchange,,11.56,,,,,,,4.43,18.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,Individual Exchange,,11.67,,,,,,,4.47,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,inpatient,5,ML,93.35000,56.01000,United Healthcare,Individual Exchange,,28.10,,,,,,,28.10,75.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,inpatient,1,UN,2978.05000,1786.83000,United Healthcare,Individual Exchange,,896.39,,,,,,,896.39,2421.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,United Healthcare,Individual Exchange,,18.14,,,,,,,6.30,2210.31,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,United Healthcare,Individual Exchange,,18.69,,,,,,,7.17,29.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,inpatient,1.6666666666666665,ML,128.65000,77.19000,United Healthcare,Individual Exchange,,38.72,,,,,,,38.72,104.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,inpatient,1,UN,2262.45000,1357.47000,United Healthcare,Individual Exchange,,681.00,,,,,,,681.00,1839.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,United Healthcare,Individual Exchange,,433.45,,,,,,,171.16,1679.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,inpatient,10,ML,42.60000,25.56000,United Healthcare,Individual Exchange,,12.82,,,,,,,12.82,34.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,inpatient,2,ML,35.05000,21.03000,United Healthcare,Individual Exchange,,10.55,,,,,,,10.55,28.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,inpatient,4,ML,29.35000,17.61000,United Healthcare,Individual Exchange,,8.83,,,,,,,8.83,23.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,United Healthcare,Individual Exchange,,28.84,,,,,,,11.06,44.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,United Healthcare,Individual Exchange,,18.90,,,,,,,7.25,29.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,inpatient,20,ML,5230.30000,3138.18000,United Healthcare,Individual Exchange,,1574.32,,,,,,,1574.32,4252.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,United Healthcare,Individual Exchange,,154.73,,,,,,,53.07,3881.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,inpatient,20,ML,13051.70000,7831.02000,United Healthcare,Individual Exchange,,3928.56,,,,,,,3928.56,10611.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,United Healthcare,Individual Exchange,,154.73,,,,,,,53.07,9686.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,inpatient,20,ML,26087.25000,15652.35000,United Healthcare,Individual Exchange,,7852.26,,,,,,,7852.26,21208.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,United Healthcare,Individual Exchange,,154.73,,,,,,,53.07,19361.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,inpatient,20,ML,52158.50000,31295.10000,United Healthcare,Individual Exchange,,15699.71,,,,,,,15699.71,42404.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,United Healthcare,Individual Exchange,,154.73,,,,,,,53.07,38712.04,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,8.77,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,inpatient,100,ML,180.95000,108.57000,United Healthcare,Individual Exchange,,54.47,,,,,,,54.47,147.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,United Healthcare,Individual Exchange,,208.59,,,,,,,80.00,324.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,United Healthcare,Individual Exchange,,13.31,,,,,,,5.11,20.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,United Healthcare,Individual Exchange,,26.18,,,,,,,10.04,40.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,United Healthcare,Individual Exchange,,77.15,,,,,,,29.59,120.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,inpatient,1,UN,316.30000,189.78000,United Healthcare,Individual Exchange,,95.21,,,,,,,95.21,257.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,Individual Exchange,,9.60,,,,,,,3.68,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Individual Exchange,,9.29,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,United Healthcare,Individual Exchange,,25.26,,,,,,,9.69,39.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,United Healthcare,Individual Exchange,,26.33,,,,,,,10.10,41.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,United Healthcare,Individual Exchange,,8.87,,,,,,,3.40,13.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,United Healthcare,Individual Exchange,,9.37,,,,,,,3.59,14.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,inpatient,1,UN,4712.40000,2827.44000,United Healthcare,Individual Exchange,,1418.43,,,,,,,1418.43,3831.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,United Healthcare,Individual Exchange,,1049.96,,,,,,,366.19,3497.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Individual Exchange,,8.90,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,United Healthcare,Individual Exchange,,29.94,,,,,,,11.48,46.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,United Healthcare,Individual Exchange,,70.21,,,,,,,26.93,109.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,inpatient,2,ML,37.15000,22.29000,United Healthcare,Individual Exchange,,11.18,,,,,,,11.18,30.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,United Healthcare,Individual Exchange,,50.46,,,,,,,50.46,136.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,United Healthcare,Individual Exchange,,25.53,,,,,,,9.79,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,United Healthcare,Individual Exchange,,11.43,,,,,,,4.38,17.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,United Healthcare,Individual Exchange,,11.74,,,,,,,4.50,18.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,United Healthcare,Individual Exchange,,11.95,,,,,,,4.58,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,inpatient,0.5,ML,321.65000,192.99000,United Healthcare,Individual Exchange,,96.82,,,,,,,96.82,261.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,United Healthcare,Individual Exchange,,11.22,,,,,,,4.30,17.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,United Healthcare,Individual Exchange,,13.70,,,,,,,5.26,21.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,inpatient,1,UN,37.10000,22.26000,United Healthcare,Individual Exchange,,11.17,,,,,,,11.17,30.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,inpatient,1,ML,27.85000,16.71000,United Healthcare,Individual Exchange,,8.38,,,,,,,8.38,22.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,United Healthcare,Individual Exchange,,1.20,,,,,,,0.44620,20.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,United Healthcare,Individual Exchange,,242.76,,,,,,,93.10,378.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,United Healthcare,Individual Exchange,,5.90,,,,,,,2.26,9.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,United Healthcare,Individual Exchange,,0.86130,,,,,,,0.33033,1.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,inpatient,1,UN,1034.85000,620.91000,United Healthcare,Individual Exchange,,311.49,,,,,,,311.49,841.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,United Healthcare,Individual Exchange,,12.97,,,,,,,4.97,20.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,United Healthcare,Individual Exchange,,12.95,,,,,,,4.96,20.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,inpatient,5,ML,252.00000,151.20000,United Healthcare,Individual Exchange,,75.85,,,,,,,75.85,204.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,United Healthcare,Individual Exchange,,15.66,,,,,,,6.01,24.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,United Healthcare,Individual Exchange,,16.89,,,,,,,6.48,26.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Individual Exchange,,9.24,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Individual Exchange,,9.21,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,United Healthcare,Individual Exchange,,9.53,,,,,,,3.65,14.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,United Healthcare,Individual Exchange,,10.26,,,,,,,3.93,15.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,United Healthcare,Individual Exchange,,2205.79,,,,,,,2205.79,5957.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.4,ML,17.65000,10.59000,United Healthcare,Individual Exchange,,5.31,,,,,,,5.31,14.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,United Healthcare,Individual Exchange,,9.45,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,United Healthcare,Individual Exchange,,10.54,,,,,,,4.04,16.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,United Healthcare,Individual Exchange,,8.74,,,,,,,3.35,13.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,inpatient,1000,ML,87.50000,52.50000,United Healthcare,Individual Exchange,,26.34,,,,,,,26.34,71.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,inpatient,1,UN,6248.60000,3749.16000,United Healthcare,Individual Exchange,,1880.83,,,,,,,1880.83,5080.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,United Healthcare,Individual Exchange,,113.13,,,,,,,43.26,4637.71,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,United Healthcare,Individual Exchange,,45.70,,,,,,,17.53,71.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,United Healthcare,Individual Exchange,,12.53,,,,,,,4.80,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,United Healthcare,Individual Exchange,,25.53,,,,,,,9.79,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,United Healthcare,Individual Exchange,,50.58,,,,,,,19.40,78.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,United Healthcare,Individual Exchange,,55.02,,,,,,,21.10,85.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,United Healthcare,Individual Exchange,,11.09,,,,,,,4.25,17.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,United Healthcare,Individual Exchange,,0.78300,,,,,,,0.30030,1.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,United Healthcare,Individual Exchange,,9.76,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,inpatient,1,ML,70.60000,42.36000,United Healthcare,Individual Exchange,,21.25,,,,,,,21.25,57.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,United Healthcare,Individual Exchange,,2.53,,,,,,,0.97097,3.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Individual Exchange,,8.85,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,United Healthcare,Individual Exchange,,14.82,,,,,,,5.69,23.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,United Healthcare,Individual Exchange,,8.80,,,,,,,3.37,13.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,inpatient,1,UN,483.00000,289.80000,United Healthcare,Individual Exchange,,145.38,,,,,,,145.38,392.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,United Healthcare,Individual Exchange,,9.37,,,,,,,3.59,14.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Individual Exchange,,8.46,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,United Healthcare,Individual Exchange,,12.32,,,,,,,4.72,19.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,United Healthcare,Individual Exchange,,2.24,,,,,,,0.86086,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,United Healthcare,Individual Exchange,,14.33,,,,,,,5.50,22.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,United Healthcare,Individual Exchange,,2.24,,,,,,,0.86086,3.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,United Healthcare,Individual Exchange,,13.52,,,,,,,5.19,21.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,United Healthcare,Individual Exchange,,8.95,,,,,,,3.43,13.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,United Healthcare,Individual Exchange,,32.36,,,,,,,12.41,50.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,United Healthcare,Individual Exchange,,0.91350,,,,,,,0.35035,1.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,United Healthcare,Individual Exchange,,11.77,,,,,,,4.51,18.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,inpatient,0.1,ML,23.30000,13.98000,United Healthcare,Individual Exchange,,7.01,,,,,,,7.01,18.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,United Healthcare,Individual Exchange,,11.77,,,,,,,4.51,18.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,United Healthcare,Individual Exchange,,4.36,,,,,,,1.67,6.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,Individual Exchange,,11.85,,,,,,,4.54,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,United Healthcare,Individual Exchange,,8.40,,,,,,,3.22,13.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,United Healthcare,Individual Exchange,,59.25,,,,,,,22.72,92.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,inpatient,1,ML,169.40000,101.64000,United Healthcare,Individual Exchange,,50.99,,,,,,,50.99,137.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,United Healthcare,Individual Exchange,,14.54,,,,,,,5.58,22.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,United Healthcare,Individual Exchange,,16.36,,,,,,,6.28,25.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,inpatient,1,UN,18064.20000,10838.52000,United Healthcare,Individual Exchange,,5437.32,,,,,,,5437.32,14686.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,United Healthcare,Individual Exchange,,10.40,,,,,,,4.23,13407.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,1190.64,,,,,,,1190.64,3215.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,218.84,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,inpatient,1,UN,30.90000,18.54000,United Healthcare,Individual Exchange,,9.30,,,,,,,9.30,25.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,inpatient,2,ML,757.60000,454.56000,United Healthcare,Individual Exchange,,228.04,,,,,,,228.04,615.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,United Healthcare,Individual Exchange,,120.66,,,,,,,46.28,187.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,inpatient,1,UN,143.75000,86.25000,United Healthcare,Individual Exchange,,43.27,,,,,,,43.27,116.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,United Healthcare,Individual Exchange,,824.92,,,,,,,824.92,2228.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,Individual Exchange,,1.74,,,,,,,0.46560,2034.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,inpatient,1,UN,1507.85000,904.71000,United Healthcare,Individual Exchange,,453.86,,,,,,,453.86,1225.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,United Healthcare,Individual Exchange,,1.74,,,,,,,0.46560,1119.13,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,United Healthcare,Individual Exchange,,1.83,,,,,,,0.70070,2.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,inpatient,3,ML,109.25000,65.55000,United Healthcare,Individual Exchange,,32.88,,,,,,,32.88,88.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,United Healthcare,Individual Exchange,,0.83520,,,,,,,0.32032,1.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Individual Exchange,,8.51,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,United Healthcare,Individual Exchange,,14.30,,,,,,,5.49,22.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,United Healthcare,Individual Exchange,,10.54,,,,,,,4.04,16.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,inpatient,1,ML,40.95000,24.57000,United Healthcare,Individual Exchange,,12.33,,,,,,,12.33,33.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,United Healthcare,Individual Exchange,,726.23,,,,,,,278.53,1131.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,United Healthcare,Individual Exchange,,31.82,,,,,,,12.20,49.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,United Healthcare,Individual Exchange,,19.34,,,,,,,7.42,30.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,inpatient,1,UN,23.80000,14.28000,United Healthcare,Individual Exchange,,7.16,,,,,,,7.16,19.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,United Healthcare,Individual Exchange,,4.86,,,,,,,1.68,17.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,inpatient,15,ML,377.25000,226.35000,United Healthcare,Individual Exchange,,113.55,,,,,,,113.55,306.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,inpatient,45,ML,482.55000,289.53000,United Healthcare,Individual Exchange,,145.25,,,,,,,145.25,392.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,inpatient,5,ML,334.00000,200.40000,United Healthcare,Individual Exchange,,100.53,,,,,,,100.53,271.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,inpatient,60,ML,535.35000,321.21000,United Healthcare,Individual Exchange,,161.14,,,,,,,161.14,435.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,United Healthcare,Individual Exchange,,61.39,,,,,,,23.54,95.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,United Healthcare,Individual Exchange,,47.14,,,,,,,18.08,73.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,United Healthcare,Individual Exchange,,8.38,,,,,,,3.21,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,inpatient,2,ML,25.05000,15.03000,United Healthcare,Individual Exchange,,7.54,,,,,,,7.54,20.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,inpatient,30,ML,116.10000,69.66000,United Healthcare,Individual Exchange,,34.95,,,,,,,34.95,94.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,United Healthcare,Individual Exchange,,358.20,,,,,,,137.38,557.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,United Healthcare,Individual Exchange,,838.96,,,,,,,321.76,1306.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,Individual Exchange,,9.11,,,,,,,3.49,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,United Healthcare,Individual Exchange,,9.74,,,,,,,3.73,15.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,United Healthcare,Individual Exchange,,8.43,,,,,,,3.23,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,United Healthcare,Individual Exchange,,534.27,,,,,,,204.90,832.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,inpatient,4,ML,22.65000,13.59000,United Healthcare,Individual Exchange,,6.82,,,,,,,6.82,18.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,9.19,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,inpatient,1,UN,7227.30000,4336.38000,United Healthcare,Individual Exchange,,2175.42,,,,,,,2175.42,5875.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,United Healthcare,Individual Exchange,,33.80,,,,,,,10.22,5364.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,inpatient,20,ML,26468.35000,15881.01000,United Healthcare,Individual Exchange,,7966.97,,,,,,,7966.97,21518.77,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,United Healthcare,Individual Exchange,,28.26,,,,,,,9.84,19644.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,inpatient,1,ML,5590.45000,3354.27000,United Healthcare,Individual Exchange,,1682.73,,,,,,,1682.73,4545.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,United Healthcare,Individual Exchange,,28.26,,,,,,,9.84,4149.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,inpatient,5,ML,26468.35000,15881.01000,United Healthcare,Individual Exchange,,7966.97,,,,,,,7966.97,21518.77,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,United Healthcare,Individual Exchange,,28.26,,,,,,,9.84,19644.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,United Healthcare,Individual Exchange,,9.87,,,,,,,3.78,15.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,6806.87,,,,,,,0.04004,6806.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,Individual Exchange,,10.02,,,,,,,3.84,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,inpatient,10,ML,107.00000,64.20000,United Healthcare,Individual Exchange,,32.21,,,,,,,32.21,86.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,1,UN,7328.20000,4396.92000,United Healthcare,Individual Exchange,,2205.79,,,,,,,2205.79,5957.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,inpatient,1,ML,350.20000,210.12000,United Healthcare,Individual Exchange,,105.41,,,,,,,105.41,284.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,inpatient,1,UN,1243.00000,745.80000,United Healthcare,Individual Exchange,,374.14,,,,,,,374.14,1010.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,United Healthcare,Individual Exchange,,78.84,,,,,,,19.74,922.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,United Healthcare,Individual Exchange,,11.90,,,,,,,4.56,18.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,United Healthcare,Individual Exchange,,24.12,,,,,,,9.25,37.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,inpatient,1,ML,7030.60000,4218.36000,United Healthcare,Individual Exchange,,2116.21,,,,,,,2116.21,5715.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,inpatient,26.3,ML,332.30000,199.38000,United Healthcare,Individual Exchange,,100.02,,,,,,,100.02,270.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,inpatient,5.26,ML,308.30000,184.98000,United Healthcare,Individual Exchange,,92.80,,,,,,,92.80,250.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,inpatient,52.6,ML,673.55000,404.13000,United Healthcare,Individual Exchange,,202.74,,,,,,,202.74,547.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,10,ML,40115.90000,24069.54000,United Healthcare,Individual Exchange,,12074.89,,,,,,,12074.89,32614.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,Individual Exchange,,511.50,,,,,,,177.98,29774.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,inpatient,40,ML,159638.10000,95782.86000,United Healthcare,Individual Exchange,,48051.07,,,,,,,48051.07,129785.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,Individual Exchange,,511.50,,,,,,,177.98,118483.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,United Healthcare,Individual Exchange,,442.86,,,,,,,442.86,1196.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,Individual Exchange,,199.83,,,,,,,66.15,1092.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,inpatient,5,ML,2929.75000,1757.85000,United Healthcare,Individual Exchange,,881.85,,,,,,,881.85,2381.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,Individual Exchange,,173.55,,,,,,,60.36,2174.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,inpatient,50,ML,26823.30000,16093.98000,United Healthcare,Individual Exchange,,8073.81,,,,,,,8073.81,21807.34,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,United Healthcare,Individual Exchange,,173.55,,,,,,,60.36,19908.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,inpatient,1,ML,320.15000,192.09000,United Healthcare,Individual Exchange,,96.37,,,,,,,96.37,260.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,United Healthcare,Individual Exchange,,87.31,,,,,,,87.31,235.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,United Healthcare,Individual Exchange,,94.74,,,,,,,94.74,255.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,United Healthcare,Individual Exchange,,87.23,,,,,,,87.23,235.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,United Healthcare,Individual Exchange,,126.81,,,,,,,126.81,342.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,inpatient,16,ML,2035.00000,1221.00000,United Healthcare,Individual Exchange,,612.53,,,,,,,612.53,1654.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,inpatient,2,ML,495.00000,297.00000,United Healthcare,Individual Exchange,,149.00,,,,,,,149.00,402.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,inpatient,8,ML,996.60000,597.96000,United Healthcare,Individual Exchange,,299.98,,,,,,,299.98,810.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,United Healthcare,Individual Exchange,,11.95,,,,,,,4.58,18.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,inpatient,0.5,ML,77.55000,46.53000,United Healthcare,Individual Exchange,,23.34,,,,,,,23.34,63.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,inpatient,26.3,ML,337.40000,202.44000,United Healthcare,Individual Exchange,,101.56,,,,,,,101.56,274.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,inpatient,10,ML,5640.25000,3384.15000,United Healthcare,Individual Exchange,,1697.72,,,,,,,1697.72,4585.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,Individual Exchange,,16.15,,,,,,,5.54,4186.19,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,inpatient,20,ML,11217.45000,6730.47000,United Healthcare,Individual Exchange,,3376.45,,,,,,,3376.45,9119.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,Individual Exchange,,16.15,,,,,,,5.54,8325.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,United Healthcare,Individual Exchange,,54.99,,,,,,,21.09,85.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,1,UN,45.45000,27.27000,United Healthcare,Individual Exchange,,13.68,,,,,,,13.68,36.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,33.73,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,63.45000,38.07000,United Healthcare,Individual Exchange,,19.10,,,,,,,19.10,51.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,47.09,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,1,ML,19.05000,11.43000,United Healthcare,Individual Exchange,,5.73,,,,,,,5.73,15.49,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,inpatient,1000,ML,84.00000,50.40000,United Healthcare,Individual Exchange,,25.28,,,,,,,25.28,68.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,United Healthcare,Individual Exchange,,13.91,,,,,,,5.34,21.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ML,342.80000,205.68000,United Healthcare,Individual Exchange,,103.18,,,,,,,103.18,278.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,inpatient,100,ML,61.00000,36.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,18.36,49.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,inpatient,100,ML,76.00000,45.60000,United Healthcare,Individual Exchange,,22.88,,,,,,,22.88,61.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,inpatient,5,ML,292.85000,175.71000,United Healthcare,Individual Exchange,,88.15,,,,,,,88.15,238.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,inpatient,1,UN,20.80000,12.48000,United Healthcare,Individual Exchange,,6.26,,,,,,,6.26,16.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,United Healthcare,Individual Exchange,,13.03,,,,,,,13.03,35.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,inpatient,1,UN,25.10000,15.06000,United Healthcare,Individual Exchange,,7.56,,,,,,,7.56,20.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,United Healthcare,Individual Exchange,,8.79,,,,,,,8.79,23.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,inpatient,1,UN,19.50000,11.70000,United Healthcare,Individual Exchange,,5.87,,,,,,,5.87,15.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,inpatient,1,UN,19.25000,11.55000,United Healthcare,Individual Exchange,,5.79,,,,,,,5.79,15.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,8.72,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,8.77,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,inpatient,250,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,inpatient,100,ML,103.35000,62.01000,United Healthcare,Individual Exchange,,31.11,,,,,,,31.11,84.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,inpatient,12,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,inpatient,1,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,United Healthcare,Individual Exchange,,86.24,,,,,,,86.24,232.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.04004,0.71810,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,inpatient,0.09999,ML,63.05000,37.83000,United Healthcare,Individual Exchange,,18.98,,,,,,,18.98,51.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,United Healthcare,Individual Exchange,,57.11,,,,,,,2.90,88.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,720.99,,,,,,,0.04004,720.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,United Healthcare,Individual Exchange,,2.48,,,,,,,0.95095,3.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,inpatient,50,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Individual Exchange,,65.92,,,,,,,65.92,178.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,344.45,,,,,,,344.45,930.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,United Healthcare,Individual Exchange,,567.00,,,,,,,217.46,883.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,United Healthcare,Individual Exchange,,23.23,,,,,,,8.91,36.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,inpatient,10,ML,46.50000,27.90000,United Healthcare,Individual Exchange,,14.00,,,,,,,14.00,37.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,inpatient,0.5,ML,31.55000,18.93000,United Healthcare,Individual Exchange,,9.50,,,,,,,9.50,25.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,United Healthcare,Individual Exchange,,1.46,,,,,,,0.56056,2.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,inpatient,1,UN,36575.00000,21945.00000,United Healthcare,Individual Exchange,,11009.08,,,,,,,11009.08,29735.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,United Healthcare,Individual Exchange,,574.88,,,,,,,200.92,27145.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,inpatient,10,ML,318.15000,190.89000,United Healthcare,Individual Exchange,,95.76,,,,,,,95.76,258.66,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,219.00000,131.40000,United Healthcare,Individual Exchange,,65.92,,,,,,,65.92,178.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,inpatient,8,ML,63.85000,38.31000,United Healthcare,Individual Exchange,,19.22,,,,,,,19.22,51.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,United Healthcare,Individual Exchange,,0.03340,,,,,,,0.02360,47.39,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,inpatient,500,ML,115.50000,69.30000,United Healthcare,Individual Exchange,,34.77,,,,,,,34.77,93.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,United Healthcare,Individual Exchange,,0.03340,,,,,,,0.02360,85.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,inpatient,1,ML,27.75000,16.65000,United Healthcare,Individual Exchange,,8.35,,,,,,,8.35,22.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Individual Exchange,,6.13,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Individual Exchange,,6.13,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Individual Exchange,,6.13,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,United Healthcare,Individual Exchange,,6.13,,,,,,,0.63720,9.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,1,ML,75.10000,45.06000,United Healthcare,Individual Exchange,,22.61,,,,,,,22.61,61.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,inpatient,20,ML,108.15000,64.89000,United Healthcare,Individual Exchange,,32.55,,,,,,,32.55,87.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,inpatient,40,ML,153.25000,91.95000,United Healthcare,Individual Exchange,,46.13,,,,,,,46.13,124.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,inpatient,2,ML,21.85000,13.11000,United Healthcare,Individual Exchange,,6.58,,,,,,,6.58,17.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,inpatient,2,ML,19.60000,11.76000,United Healthcare,Individual Exchange,,5.90,,,,,,,5.90,15.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,United Healthcare,Individual Exchange,,30.15,,,,,,,11.56,46.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,United Healthcare,Individual Exchange,,106.64,,,,,,,40.90,166.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Individual Exchange,,8.56,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,United Healthcare,Individual Exchange,,27.77,,,,,,,10.65,43.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,United Healthcare,Individual Exchange,,8.46,,,,,,,3.24,13.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,United Healthcare,Individual Exchange,,12.50,,,,,,,4.79,19.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,inpatient,5,ML,13686.90000,8212.14000,United Healthcare,Individual Exchange,,4119.76,,,,,,,4119.76,11127.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,United Healthcare,Individual Exchange,,743.07,,,,,,,271.45,10158.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,inpatient,1,ML,2799.00000,1679.40000,United Healthcare,Individual Exchange,,842.50,,,,,,,842.50,2275.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,United Healthcare,Individual Exchange,,743.07,,,,,,,271.45,2077.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,inpatient,20,ML,79.65000,47.79000,United Healthcare,Individual Exchange,,23.97,,,,,,,23.97,64.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,inpatient,1,UN,48.35000,29.01000,United Healthcare,Individual Exchange,,14.55,,,,,,,14.55,39.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,inpatient,1,UN,28.20000,16.92000,United Healthcare,Individual Exchange,,8.49,,,,,,,8.49,22.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,1,ML,45.75000,27.45000,United Healthcare,Individual Exchange,,13.77,,,,,,,13.77,37.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,United Healthcare,Individual Exchange,,54.50,,,,,,,20.90,84.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,Individual Exchange,,126.85,,,,,,,48.65,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,inpatient,1,UN,63.60000,38.16000,United Healthcare,Individual Exchange,,19.14,,,,,,,19.14,51.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,Individual Exchange,,126.85,,,,,,,48.65,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,inpatient,1,ML,29.80000,17.88000,United Healthcare,Individual Exchange,,8.97,,,,,,,8.97,24.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,United Healthcare,Individual Exchange,,301.79,,,,,,,115.75,470.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,inpatient,5,ML,28.50000,17.10000,United Healthcare,Individual Exchange,,8.58,,,,,,,8.58,23.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,Individual Exchange,,142.51,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,Individual Exchange,,142.51,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,inpatient,2,ML,20.65000,12.39000,United Healthcare,Individual Exchange,,6.22,,,,,,,6.22,16.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,inpatient,2,ML,20.15000,12.09000,United Healthcare,Individual Exchange,,6.07,,,,,,,6.07,16.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,inpatient,2,ML,20.25000,12.15000,United Healthcare,Individual Exchange,,6.10,,,,,,,6.10,16.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,United Healthcare,Individual Exchange,,7.93,,,,,,,7.93,21.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,United Healthcare,Individual Exchange,,3.71,,,,,,,1.42,5.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,inpatient,100,ML,153.75000,92.25000,United Healthcare,Individual Exchange,,46.28,,,,,,,46.28,125.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,inpatient,100,ML,405.05000,243.03000,United Healthcare,Individual Exchange,,121.92,,,,,,,121.92,329.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,United Healthcare,Individual Exchange,,80.91,,,,,,,31.03,126.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,United Healthcare,Individual Exchange,,419.43,,,,,,,160.86,653.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,inpatient,4,ML,66.20000,39.72000,United Healthcare,Individual Exchange,,19.93,,,,,,,19.93,53.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,United Healthcare,Individual Exchange,,13.05,,,,,,,5.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,United Healthcare,Individual Exchange,,9.92,,,,,,,3.80,15.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,United Healthcare,Individual Exchange,,36.54,,,,,,,14.01,56.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,United Healthcare,Individual Exchange,,45.94,,,,,,,17.62,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,United Healthcare,Individual Exchange,,39.05,,,,,,,14.97,60.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,United Healthcare,Individual Exchange,,31.53,,,,,,,12.09,49.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,United Healthcare,Individual Exchange,,48.13,,,,,,,18.46,74.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,United Healthcare,Individual Exchange,,196.27,,,,,,,75.28,305.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,United Healthcare,Individual Exchange,,9.92,,,,,,,3.80,15.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,United Healthcare,Individual Exchange,,33.59,,,,,,,12.88,52.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,United Healthcare,Individual Exchange,,14.12,,,,,,,5.42,21.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,United Healthcare,Individual Exchange,,12.53,,,,,,,4.80,19.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,inpatient,1,ML,114.75000,68.85000,United Healthcare,Individual Exchange,,34.54,,,,,,,34.54,93.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,United Healthcare,Individual Exchange,,142.51,,,,,,,54.65,221.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,United Healthcare,Individual Exchange,,126.85,,,,,,,48.65,197.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,United Healthcare,Individual Exchange,,24.80,,,,,,,9.51,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,inpatient,1,UN,17.40000,10.44000,United Healthcare,Individual Exchange,,5.24,,,,,,,5.24,14.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,inpatient,0.4,ML,64.00000,38.40000,United Healthcare,Individual Exchange,,19.26,,,,,,,19.26,52.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,Individual Exchange,,14.98,,,,,,,5.75,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Individual Exchange,,8.56,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,inpatient,0.25,ML,17.35000,10.41000,United Healthcare,Individual Exchange,,5.22,,,,,,,5.22,14.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,inpatient,500,ML,94.50000,56.70000,United Healthcare,Individual Exchange,,28.44,,,,,,,28.44,76.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,United Healthcare,Individual Exchange,,17.75,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,United Healthcare,Individual Exchange,,12.19,,,,,,,4.67,18.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,inpatient,50,ML,215.60000,129.36000,United Healthcare,Individual Exchange,,64.90,,,,,,,64.90,175.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,United Healthcare,Individual Exchange,,176.80,,,,,,,67.81,275.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,inpatient,10,ML,835.00000,501.00000,United Healthcare,Individual Exchange,,251.34,,,,,,,251.34,678.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,United Healthcare,Individual Exchange,,50.28,,,,,,,17.57,619.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,inpatient,0.5,UN,65.25000,39.15000,United Healthcare,Individual Exchange,,19.64,,,,,,,19.64,53.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,81.95000,49.17000,United Healthcare,Individual Exchange,,24.67,,,,,,,24.67,66.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,inpatient,300,ML,222.60000,133.56000,United Healthcare,Individual Exchange,,67.00,,,,,,,67.00,180.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,United Healthcare,Individual Exchange,,46.04,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,United Healthcare,Individual Exchange,,26.50,,,,,,,26.50,71.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,United Healthcare,Individual Exchange,,67.10,,,,,,,6.44,104.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,United Healthcare,Individual Exchange,,3.08,,,,,,,1.18,4.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,United Healthcare,Individual Exchange,,15.38,,,,,,,15.38,41.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,inpatient,2,ML,28.40000,17.04000,United Healthcare,Individual Exchange,,8.55,,,,,,,8.55,23.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,United Healthcare,Individual Exchange,,11368.33,,,,,,,11368.33,30705.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Individual Exchange,,479.52,,,,,,,167.05,28031.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,inpatient,1,UN,319.00000,191.40000,United Healthcare,Individual Exchange,,96.02,,,,,,,96.02,259.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,United Healthcare,Individual Exchange,,87.90,,,,,,,33.71,136.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,inpatient,8,ML,64.55000,38.73000,United Healthcare,Individual Exchange,,19.43,,,,,,,19.43,52.48,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,inpatient,50,ML,72.70000,43.62000,United Healthcare,Individual Exchange,,21.88,,,,,,,21.88,59.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,inpatient,50,ML,64.90000,38.94000,United Healthcare,Individual Exchange,,19.53,,,,,,,19.53,52.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,United Healthcare,Individual Exchange,,0.03340,,,,,,,0.02360,48.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,inpatient,50,ML,75.00000,45.00000,United Healthcare,Individual Exchange,,22.57,,,,,,,22.57,60.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,United Healthcare,Individual Exchange,,31.53,,,,,,,12.09,49.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,United Healthcare,Individual Exchange,,45.91,,,,,,,17.61,71.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,United Healthcare,Individual Exchange,,194.24,,,,,,,74.49,302.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,inpatient,1,ML,19.25000,11.55000,United Healthcare,Individual Exchange,,5.79,,,,,,,5.79,15.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,United Healthcare,Individual Exchange,,35.18,,,,,,,13.49,54.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,inpatient,8,ML,68.40000,41.04000,United Healthcare,Individual Exchange,,20.59,,,,,,,20.59,55.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,inpatient,50,ML,96.60000,57.96000,United Healthcare,Individual Exchange,,29.08,,,,,,,29.08,78.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,inpatient,1,ML,30.70000,18.42000,United Healthcare,Individual Exchange,,9.24,,,,,,,9.24,24.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,United Healthcare,Individual Exchange,,55.62,,,,,,,21.33,86.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,United Healthcare,Individual Exchange,,89.68,,,,,,,34.39,139.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,inpatient,50,ML,103.95000,62.37000,United Healthcare,Individual Exchange,,31.29,,,,,,,31.29,84.51,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,inpatient,10,ML,250.40000,150.24000,United Healthcare,Individual Exchange,,75.37,,,,,,,75.37,203.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,inpatient,10,ML,170.95000,102.57000,United Healthcare,Individual Exchange,,51.46,,,,,,,51.46,138.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,inpatient,50,ML,80.65000,48.39000,United Healthcare,Individual Exchange,,24.28,,,,,,,24.28,65.57,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,inpatient,100,ML,70.35000,42.21000,United Healthcare,Individual Exchange,,21.18,,,,,,,21.18,57.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,inpatient,1,GR,103.95000,62.37000,United Healthcare,Individual Exchange,,31.29,,,,,,,31.29,84.51,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,inpatient,20,ML,81.90000,49.14000,United Healthcare,Individual Exchange,,24.65,,,,,,,24.65,66.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,inpatient,1,UN,96.60000,57.96000,United Healthcare,Individual Exchange,,29.08,,,,,,,29.08,78.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,109.20000,65.52000,United Healthcare,Individual Exchange,,32.87,,,,,,,32.87,88.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,inpatient,500,ML,478.80000,287.28000,United Healthcare,Individual Exchange,,144.12,,,,,,,144.12,389.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,inpatient,50,ML,117.85000,70.71000,United Healthcare,Individual Exchange,,35.47,,,,,,,35.47,95.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,300,ML,567.00000,340.20000,United Healthcare,Individual Exchange,,170.67,,,,,,,170.67,460.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,inpatient,1,UN,1165.70000,699.42000,United Healthcare,Individual Exchange,,350.88,,,,,,,350.88,947.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,United Healthcare,Individual Exchange,,404.06,,,,,,,144.52,865.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,inpatient,1,UN,1242.40000,745.44000,United Healthcare,Individual Exchange,,373.96,,,,,,,373.96,1010.07,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,United Healthcare,Individual Exchange,,546.04,,,,,,,176.98,922.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,United Healthcare,Individual Exchange,,10.99,,,,,,,10.99,29.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,inpatient,100,ML,74.35000,44.61000,United Healthcare,Individual Exchange,,22.38,,,,,,,22.38,60.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,inpatient,100,ML,153.30000,91.98000,United Healthcare,Individual Exchange,,46.14,,,,,,,46.14,124.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,250,ML,218.50000,131.10000,United Healthcare,Individual Exchange,,65.77,,,,,,,65.77,177.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,1000,ML,512.40000,307.44000,United Healthcare,Individual Exchange,,154.23,,,,,,,154.23,416.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,inpatient,1000,ML,961.80000,577.08000,United Healthcare,Individual Exchange,,289.50,,,,,,,289.50,781.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,1,UN,90.30000,54.18000,United Healthcare,Individual Exchange,,27.18,,,,,,,27.18,73.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,inpatient,1,UN,103.15000,61.89000,United Healthcare,Individual Exchange,,31.05,,,,,,,31.05,83.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,inpatient,1,UN,247.75000,148.65000,United Healthcare,Individual Exchange,,74.57,,,,,,,74.57,201.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,183.88,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,inpatient,10,ML,66.80000,40.08000,United Healthcare,Individual Exchange,,20.11,,,,,,,20.11,54.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,inpatient,40,ML,78.15000,46.89000,United Healthcare,Individual Exchange,,23.52,,,,,,,23.52,63.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,inpatient,1,UN,735.15000,441.09000,United Healthcare,Individual Exchange,,221.28,,,,,,,221.28,597.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,inpatient,1,UN,17.55000,10.53000,United Healthcare,Individual Exchange,,5.28,,,,,,,5.28,14.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,0.1,ML,275.20000,165.12000,United Healthcare,Individual Exchange,,82.84,,,,,,,82.84,223.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,inpatient,0.2,ML,63.45000,38.07000,United Healthcare,Individual Exchange,,19.10,,,,,,,19.10,51.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,inpatient,10,ML,105.10000,63.06000,United Healthcare,Individual Exchange,,31.64,,,,,,,31.64,85.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,inpatient,100,ML,289.80000,173.88000,United Healthcare,Individual Exchange,,87.23,,,,,,,87.23,235.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,inpatient,50,ML,176.40000,105.84000,United Healthcare,Individual Exchange,,53.10,,,,,,,53.10,143.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,United Healthcare,Individual Exchange,,12.63,,,,,,,4.84,19.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,inpatient,5,ML,120.55000,72.33000,United Healthcare,Individual Exchange,,36.29,,,,,,,36.29,98.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,inpatient,50,ML,71.40000,42.84000,United Healthcare,Individual Exchange,,21.49,,,,,,,21.49,58.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,United Healthcare,Individual Exchange,,40.90,,,,,,,15.69,63.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,United Healthcare,Individual Exchange,,94.27,,,,,,,36.16,146.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,inpatient,50,ML,171.80000,103.08000,United Healthcare,Individual Exchange,,51.71,,,,,,,51.71,139.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,inpatient,50,ML,75.60000,45.36000,United Healthcare,Individual Exchange,,22.76,,,,,,,22.76,61.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,United Healthcare,Individual Exchange,,15.24,,,,,,,5.85,23.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,inpatient,2,ML,34.75000,20.85000,United Healthcare,Individual Exchange,,10.46,,,,,,,10.46,28.25,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,inpatient,100,ML,71.40000,42.84000,United Healthcare,Individual Exchange,,21.49,,,,,,,21.49,58.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,inpatient,250,ML,1785.00000,1071.00000,United Healthcare,Individual Exchange,,537.28,,,,,,,537.28,1451.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,United Healthcare,Individual Exchange,,0.71810,,,,,,,0.20370,1324.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,inpatient,10,ML,99.55000,59.73000,United Healthcare,Individual Exchange,,29.96,,,,,,,29.96,80.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,inpatient,0.5,ML,25.15000,15.09000,United Healthcare,Individual Exchange,,7.57,,,,,,,7.57,20.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,inpatient,0.5,ML,34.85000,20.91000,United Healthcare,Individual Exchange,,10.49,,,,,,,10.49,28.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,United Healthcare,Individual Exchange,,37.45,,,,,,,14.36,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,inpatient,1,ML,27.75000,16.65000,United Healthcare,Individual Exchange,,8.35,,,,,,,8.35,22.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,United Healthcare,Individual Exchange,,18.99,,,,,,,18.99,51.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,United Healthcare,Individual Exchange,,90.83,,,,,,,34.83,141.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,United Healthcare,Individual Exchange,,33.41,,,,,,,12.81,52.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,United Healthcare,Individual Exchange,,46.04,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,0.5,ML,22.45000,13.47000,United Healthcare,Individual Exchange,,6.76,,,,,,,6.76,18.25,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,0.5,ML,22.50000,13.50000,United Healthcare,Individual Exchange,,6.77,,,,,,,6.77,18.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,inpatient,1,ML,25.60000,15.36000,United Healthcare,Individual Exchange,,7.71,,,,,,,7.71,20.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,United Healthcare,Individual Exchange,,12.85,,,,,,,12.85,34.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,inpatient,2,ML,26.10000,15.66000,United Healthcare,Individual Exchange,,7.86,,,,,,,7.86,21.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,inpatient,100,ML,273.00000,163.80000,United Healthcare,Individual Exchange,,82.17,,,,,,,82.17,221.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,inpatient,50,ML,131.05000,78.63000,United Healthcare,Individual Exchange,,39.45,,,,,,,39.45,106.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,inpatient,100,ML,94.50000,56.70000,United Healthcare,Individual Exchange,,28.44,,,,,,,28.44,76.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,United Healthcare,Individual Exchange,,72.90,,,,,,,27.96,113.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,United Healthcare,Individual Exchange,,15.22,,,,,,,0.21240,23.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,United Healthcare,Individual Exchange,,54.44,,,,,,,20.88,84.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,United Healthcare,Individual Exchange,,55.85,,,,,,,21.42,86.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,inpatient,50,ML,81.90000,49.14000,United Healthcare,Individual Exchange,,24.65,,,,,,,24.65,66.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,inpatient,3,ML,17.75000,10.65000,United Healthcare,Individual Exchange,,5.34,,,,,,,5.34,14.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,inpatient,10,ML,68.30000,40.98000,United Healthcare,Individual Exchange,,20.56,,,,,,,20.56,55.53,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,United Healthcare,Individual Exchange,,9.00,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,inpatient,5,ML,55.90000,33.54000,United Healthcare,Individual Exchange,,16.83,,,,,,,16.83,45.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,inpatient,500,ML,82.25000,49.35000,United Healthcare,Individual Exchange,,24.76,,,,,,,24.76,66.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,United Healthcare,Individual Exchange,,55.51,,,,,,,21.29,86.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,333.3,ML,310.80000,186.48000,United Healthcare,Individual Exchange,,93.55,,,,,,,93.55,252.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,inpatient,10,ML,79.75000,47.85000,United Healthcare,Individual Exchange,,24.00,,,,,,,24.00,64.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,inpatient,20,ML,319.25000,191.55000,United Healthcare,Individual Exchange,,96.09,,,,,,,96.09,259.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,inpatient,500,ML,75.00000,45.00000,United Healthcare,Individual Exchange,,22.57,,,,,,,22.57,60.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,inpatient,4,ML,64.15000,38.49000,United Healthcare,Individual Exchange,,19.31,,,,,,,19.31,52.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,inpatient,100,ML,105.00000,63.00000,United Healthcare,Individual Exchange,,31.61,,,,,,,31.61,85.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,United Healthcare,Individual Exchange,,39.02,,,,,,,14.96,60.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,inpatient,50,ML,52.00000,31.20000,United Healthcare,Individual Exchange,,15.65,,,,,,,15.65,42.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,United Healthcare,Individual Exchange,,27.14,,,,,,,10.41,42.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,inpatient,400,ML,161.60000,96.96000,United Healthcare,Individual Exchange,,48.64,,,,,,,48.64,131.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,United Healthcare,Individual Exchange,,11.56,,,,,,,4.43,18.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,inpatient,15,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,200.52,,,,,,,0.04004,200.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,inpatient,0.5,ML,63.10000,37.86000,United Healthcare,Individual Exchange,,18.99,,,,,,,18.99,51.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,inpatient,1,ML,451.85000,271.11000,United Healthcare,Individual Exchange,,136.01,,,,,,,136.01,367.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,United Healthcare,Individual Exchange,,262.57,,,,,,,90.46,335.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,20,ML,167.65000,100.59000,United Healthcare,Individual Exchange,,50.46,,,,,,,50.46,136.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,inpatient,50,ML,276.60000,165.96000,United Healthcare,Individual Exchange,,83.26,,,,,,,83.26,224.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,United Healthcare,Individual Exchange,,124.97,,,,,,,47.93,194.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,United Healthcare,Individual Exchange,,38.58,,,,,,,14.79,60.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,inpatient,8,ML,65.70000,39.42000,United Healthcare,Individual Exchange,,19.78,,,,,,,19.78,53.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,inpatient,50,ML,79.60000,47.76000,United Healthcare,Individual Exchange,,23.96,,,,,,,23.96,64.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,inpatient,36,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,200.52,,,,,,,0.04004,200.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,inpatient,6,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,200.52,,,,,,,0.04004,200.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,United Healthcare,Individual Exchange,,31.22,,,,,,,11.97,48.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,United Healthcare,Individual Exchange,,8.38,,,,,,,3.21,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,inpatient,100,ML,247.60000,148.56000,United Healthcare,Individual Exchange,,74.53,,,,,,,74.53,201.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,inpatient,1,UN,10077.00000,6046.20000,United Healthcare,Individual Exchange,,3033.18,,,,,,,3033.18,8192.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,Individual Exchange,,366.92,,,,,,,127.44,7479.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,inpatient,1,UN,87.60000,52.56000,United Healthcare,Individual Exchange,,26.37,,,,,,,26.37,71.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,inpatient,200,ML,150.40000,90.24000,United Healthcare,Individual Exchange,,45.27,,,,,,,45.27,122.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,United Healthcare,Individual Exchange,,80.21,,,,,,,30.76,124.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,inpatient,1,ML,364.25000,218.55000,United Healthcare,Individual Exchange,,109.64,,,,,,,109.64,296.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,United Healthcare,Individual Exchange,,262.57,,,,,,,72.92,270.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,inpatient,20,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,4844.60,,,,,,,0.04004,4844.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,4844.60,,,,,,,0.04004,4844.60,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,inpatient,180,ME,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,United Healthcare,Individual Exchange,,101.12,,,,,,,0.04004,101.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,237.76,,,,,,,0.04004,237.76,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,inpatient,1,UN,15838.65000,9503.19000,United Healthcare,Individual Exchange,,4767.43,,,,,,,4767.43,12876.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,Individual Exchange,,153.64,,,,,,,53.98,11755.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,inpatient,15,ML,394.60000,236.76000,United Healthcare,Individual Exchange,,118.77,,,,,,,118.77,320.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,United Healthcare,Individual Exchange,,168.85,,,,,,,168.85,456.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,United Healthcare,Individual Exchange,,93.70,,,,,,,93.70,253.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,United Healthcare,Individual Exchange,,145.71,,,,,,,145.71,393.57,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,United Healthcare,Individual Exchange,,136.16,,,,,,,136.16,367.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,United Healthcare,Individual Exchange,,122.51,,,,,,,122.51,330.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,inpatient,15,ML,367.40000,220.44000,United Healthcare,Individual Exchange,,110.59,,,,,,,110.59,298.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,inpatient,45,ML,560.95000,336.57000,United Healthcare,Individual Exchange,,168.85,,,,,,,168.85,456.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,inpatient,5,ML,311.30000,186.78000,United Healthcare,Individual Exchange,,93.70,,,,,,,93.70,253.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,inpatient,60,ML,484.10000,290.46000,United Healthcare,Individual Exchange,,145.71,,,,,,,145.71,393.57,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,inpatient,1,UN,2740.60000,1644.36000,United Healthcare,Individual Exchange,,824.92,,,,,,,824.92,2228.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,Individual Exchange,,1.74,,,,,,,0.46560,2034.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,inpatient,4,ML,101.20000,60.72000,United Healthcare,Individual Exchange,,30.46,,,,,,,30.46,82.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,United Healthcare,Individual Exchange,,60.11,,,,,,,23.05,93.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,United Healthcare,Individual Exchange,,7.56,,,,,,,7.56,20.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,United Healthcare,Individual Exchange,,8.92,,,,,,,8.92,24.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,United Healthcare,Individual Exchange,,46.04,,,,,,,17.66,71.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,inpatient,1,UN,195.30000,117.18000,United Healthcare,Individual Exchange,,58.79,,,,,,,58.79,158.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,United Healthcare,Individual Exchange,,76.32,,,,,,,29.27,118.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,344.45,,,,,,,344.45,930.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,inpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,344.45,,,,,,,344.45,930.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.10,849.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,inpatient,50,ML,73.60000,44.16000,United Healthcare,Individual Exchange,,22.15,,,,,,,22.15,59.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,inpatient,8,ML,64.45000,38.67000,United Healthcare,Individual Exchange,,19.40,,,,,,,19.40,52.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,United Healthcare,Individual Exchange,,215.14,,,,,,,82.51,335.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,United Healthcare,Individual Exchange,,21.06,,,,,,,8.08,32.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,inpatient,80,ML,173.25000,103.95000,United Healthcare,Individual Exchange,,52.15,,,,,,,52.15,140.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,United Healthcare,Individual Exchange,,1.70,,,,,,,0.35890,128.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,inpatient,0.5,ML,63.20000,37.92000,United Healthcare,Individual Exchange,,19.02,,,,,,,19.02,51.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,United Healthcare,Individual Exchange,,60.11,,,,,,,0.54280,93.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,United Healthcare,Individual Exchange,,25.53,,,,,,,9.79,39.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,United Healthcare,Individual Exchange,,13.44,,,,,,,5.16,20.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,United Healthcare,Individual Exchange,,16.89,,,,,,,6.48,26.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,United Healthcare,Individual Exchange,,827.29,,,,,,,317.29,1288.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,inpatient,10,ML,38.75000,23.25000,United Healthcare,Individual Exchange,,11.66,,,,,,,11.66,31.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,United Healthcare,Individual Exchange,,249.72,,,,,,,95.78,388.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,inpatient,50,ML,88.00000,52.80000,United Healthcare,Individual Exchange,,26.49,,,,,,,26.49,71.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,United Healthcare,Individual Exchange,,776.72,,,,,,,776.72,2097.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,Individual Exchange,,18.77,,,,,,,6.53,1915.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,inpatient,1,ML,17.20000,10.32000,United Healthcare,Individual Exchange,,5.18,,,,,,,5.18,13.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,United Healthcare,Individual Exchange,,75.32,,,,,,,28.89,117.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,United Healthcare,Individual Exchange,,720.44,,,,,,,276.31,1122.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,inpatient,50,ML,73.80000,44.28000,United Healthcare,Individual Exchange,,22.21,,,,,,,22.21,60.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,United Healthcare,Individual Exchange,,112.23,,,,,,,43.04,174.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,inpatient,100,ML,597.25000,358.35000,United Healthcare,Individual Exchange,,179.77,,,,,,,179.77,485.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,inpatient,1,UN,109.20000,65.52000,United Healthcare,Individual Exchange,,32.87,,,,,,,32.87,88.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,inpatient,1,UN,115.50000,69.30000,United Healthcare,Individual Exchange,,34.77,,,,,,,34.77,93.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,UN,43.30000,25.98000,United Healthcare,Individual Exchange,,13.03,,,,,,,13.03,35.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,1,UN,65.35000,39.21000,United Healthcare,Individual Exchange,,19.67,,,,,,,19.67,53.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,inpatient,1,UN,47.45000,28.47000,United Healthcare,Individual Exchange,,14.28,,,,,,,14.28,38.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,inpatient,1,UN,66.05000,39.63000,United Healthcare,Individual Exchange,,19.88,,,,,,,19.88,53.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,inpatient,1,UN,36.50000,21.90000,United Healthcare,Individual Exchange,,10.99,,,,,,,10.99,29.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,inpatient,1,UN,66.05000,39.63000,United Healthcare,Individual Exchange,,19.88,,,,,,,19.88,53.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,inpatient,50,ML,48.45000,29.07000,United Healthcare,Individual Exchange,,14.58,,,,,,,14.58,39.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,inpatient,4,ML,88.80000,53.28000,United Healthcare,Individual Exchange,,26.73,,,,,,,26.73,72.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,inpatient,250,ML,260.40000,156.24000,United Healthcare,Individual Exchange,,78.38,,,,,,,78.38,211.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,United Healthcare,Individual Exchange,,62.48,,,,,,,23.96,97.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,inpatient,1,ML,118.25000,70.95000,United Healthcare,Individual Exchange,,35.59,,,,,,,35.59,96.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,United Healthcare,Individual Exchange,,8.38,,,,,,,3.21,13.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,United Healthcare,Individual Exchange,,2044.69,,,,,,,2044.69,5522.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,inpatient,12,ML,30.95000,18.57000,United Healthcare,Individual Exchange,,9.32,,,,,,,9.32,25.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,inpatient,1,UN,83.25000,49.95000,United Healthcare,Individual Exchange,,25.06,,,,,,,25.06,67.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,United Healthcare,Individual Exchange,,33.98,,,,,,,13.03,52.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,inpatient,40,ML,178.35000,107.01000,United Healthcare,Individual Exchange,,53.68,,,,,,,53.68,145.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,inpatient,40,ML,50.60000,30.36000,United Healthcare,Individual Exchange,,15.23,,,,,,,15.23,41.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,United Healthcare,Individual Exchange,,120.95,,,,,,,46.39,188.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,inpatient,400,ML,237.75000,142.65000,United Healthcare,Individual Exchange,,71.56,,,,,,,71.56,193.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,inpatient,200,ML,150.40000,90.24000,United Healthcare,Individual Exchange,,45.27,,,,,,,45.27,122.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,United Healthcare,Individual Exchange,,145.38,,,,,,,145.38,392.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,Individual Exchange,,2.07,,,,,,,0.77600,358.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,inpatient,0.5,ML,68.25000,40.95000,United Healthcare,Individual Exchange,,20.54,,,,,,,20.54,55.49,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,inpatient,1,UN,22.10000,13.26000,United Healthcare,Individual Exchange,,6.65,,,,,,,6.65,17.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,inpatient,1,UN,22.80000,13.68000,United Healthcare,Individual Exchange,,6.86,,,,,,,6.86,18.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,United Healthcare,Individual Exchange,,239.57,,,,,,,91.88,373.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,inpatient,50,ML,26.05000,15.63000,United Healthcare,Individual Exchange,,7.84,,,,,,,7.84,21.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,inpatient,1,UN,5836.45000,3501.87000,United Healthcare,Individual Exchange,,1756.77,,,,,,,1756.77,4745.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,Individual Exchange,,78.84,,,,,,,19.74,4331.81,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,United Healthcare,Individual Exchange,,32.91,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,inpatient,5,ML,63.15000,37.89000,United Healthcare,Individual Exchange,,19.01,,,,,,,19.01,51.34,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,United Healthcare,Individual Exchange,,33.02,,,,,,,12.66,51.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,inpatient,0.5,ML,63.30000,37.98000,United Healthcare,Individual Exchange,,19.05,,,,,,,19.05,51.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,United Healthcare,Individual Exchange,,32.91,,,,,,,12.62,51.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,inpatient,1,UN,144.90000,86.94000,United Healthcare,Individual Exchange,,43.61,,,,,,,43.61,117.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,inpatient,0.1,ML,19.35000,11.61000,United Healthcare,Individual Exchange,,5.82,,,,,,,5.82,15.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,United Healthcare,Individual Exchange,,262.57,,,,,,,3.87,262.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,United Healthcare,Individual Exchange,,4.83,,,,,,,4.83,13.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,inpatient,0.08,ML,66.20000,39.72000,United Healthcare,Individual Exchange,,19.93,,,,,,,19.93,53.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,United Healthcare,Individual Exchange,,26.13,,,,,,,10.02,40.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,10,ML,456.15000,273.69000,United Healthcare,Individual Exchange,,137.30,,,,,,,137.30,370.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,inpatient,10,ML,462.10000,277.26000,United Healthcare,Individual Exchange,,139.09,,,,,,,139.09,375.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,inpatient,10,ML,361.05000,216.63000,United Healthcare,Individual Exchange,,108.68,,,,,,,108.68,293.53,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,United Healthcare,Individual Exchange,,41.66,,,,,,,15.98,64.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,26.56,,,,,,,26.56,71.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,7.40,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,United Healthcare,Individual Exchange,,19.31,,,,,,,7.41,30.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,inpatient,0.1,ML,16.05000,9.63000,United Healthcare,Individual Exchange,,4.83,,,,,,,4.83,13.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,inpatient,5,ML,24.85000,14.91000,United Healthcare,Individual Exchange,,7.48,,,,,,,7.48,20.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,inpatient,2,ML,158.65000,95.19000,United Healthcare,Individual Exchange,,47.75,,,,,,,47.75,128.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,88.95000,53.37000,United Healthcare,Individual Exchange,,26.77,,,,,,,26.77,72.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Individual Exchange,,5.96,,,,,,,2.08,66.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,inpatient,1,UN,125.55000,75.33000,United Healthcare,Individual Exchange,,37.79,,,,,,,37.79,102.07,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,1,ML,84.10000,50.46000,United Healthcare,Individual Exchange,,25.31,,,,,,,25.31,68.37,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,inpatient,10,ML,357.25000,214.35000,United Healthcare,Individual Exchange,,107.53,,,,,,,107.53,290.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,30,ML,1156.05000,693.63000,United Healthcare,Individual Exchange,,347.97,,,,,,,347.97,939.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Individual Exchange,,7.93,,,,,,,7.93,21.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,inpatient,0.5,ML,24.95000,14.97000,United Healthcare,Individual Exchange,,7.51,,,,,,,7.51,20.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,inpatient,1,UN,730.25000,438.15000,United Healthcare,Individual Exchange,,219.81,,,,,,,219.81,593.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,United Healthcare,Individual Exchange,,53.09,,,,,,,20.36,82.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,inpatient,50,ML,64.00000,38.40000,United Healthcare,Individual Exchange,,19.26,,,,,,,19.26,52.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,inpatient,0.5,ML,103.50000,62.10000,United Healthcare,Individual Exchange,,31.15,,,,,,,31.15,84.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,United Healthcare,Individual Exchange,,88.33,,,,,,,20.72,88.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,United Healthcare,Individual Exchange,,32.39,,,,,,,12.42,50.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,United Healthcare,Individual Exchange,,45.53,,,,,,,45.53,122.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,1,UN,286.50000,171.90000,United Healthcare,Individual Exchange,,86.24,,,,,,,86.24,232.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,inpatient,1,UN,39.00000,23.40000,United Healthcare,Individual Exchange,,11.74,,,,,,,11.74,31.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,inpatient,1,UN,61.50000,36.90000,United Healthcare,Individual Exchange,,18.51,,,,,,,18.51,50.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,inpatient,1,UN,26.40000,15.84000,United Healthcare,Individual Exchange,,7.95,,,,,,,7.95,21.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,inpatient,1,UN,36.50000,21.90000,United Healthcare,Individual Exchange,,10.99,,,,,,,10.99,29.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,inpatient,1,UN,210.00000,126.00000,United Healthcare,Individual Exchange,,63.21,,,,,,,63.21,170.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,inpatient,1,UN,75.60000,45.36000,United Healthcare,Individual Exchange,,22.76,,,,,,,22.76,61.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,UN,87.80000,52.68000,United Healthcare,Individual Exchange,,26.43,,,,,,,26.43,71.38,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,inpatient,1,UN,82.30000,49.38000,United Healthcare,Individual Exchange,,24.77,,,,,,,24.77,66.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,inpatient,1,UN,25.10000,15.06000,United Healthcare,Individual Exchange,,7.56,,,,,,,7.56,20.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,1,UN,29.65000,17.79000,United Healthcare,Individual Exchange,,8.92,,,,,,,8.92,24.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,inpatient,8,ML,66.95000,40.17000,United Healthcare,Individual Exchange,,20.15,,,,,,,20.15,54.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,inpatient,50,ML,84.00000,50.40000,United Healthcare,Individual Exchange,,25.28,,,,,,,25.28,68.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,inpatient,0.25,ML,23.20000,13.92000,United Healthcare,Individual Exchange,,6.98,,,,,,,6.98,18.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,United Healthcare,Individual Exchange,,17.96,,,,,,,6.89,27.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,United Healthcare,Individual Exchange,,10.78,,,,,,,4.13,16.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,inpatient,10,ML,42.70000,25.62000,United Healthcare,Individual Exchange,,12.85,,,,,,,12.85,34.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,inpatient,2,ML,23.95000,14.37000,United Healthcare,Individual Exchange,,7.21,,,,,,,7.21,19.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,inpatient,5,ML,26.20000,15.72000,United Healthcare,Individual Exchange,,7.89,,,,,,,7.89,21.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,United Healthcare,Individual Exchange,,9.21,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,United Healthcare,Individual Exchange,,8.53,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,inpatient,500,ML,531.30000,318.78000,United Healthcare,Individual Exchange,,159.92,,,,,,,159.92,431.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,United Healthcare,Individual Exchange,,17.75,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,United Healthcare,Individual Exchange,,45.94,,,,,,,17.62,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,inpatient,4,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,163.33,,,,,,,0.04004,163.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,1,UN,2580.45000,1548.27000,United Healthcare,Individual Exchange,,776.72,,,,,,,776.72,2097.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,Individual Exchange,,18.77,,,,,,,6.53,1915.21,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,7442.16,,,,,,,7442.16,20101.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,455.18,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,7442.16,,,,,,,7442.16,20101.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,455.18,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,7442.16,,,,,,,7442.16,20101.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,455.18,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,7442.16,,,,,,,7442.16,20101.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,455.18,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,inpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,7442.16,,,,,,,7442.16,20101.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Individual Exchange,,455.18,,,,,,,159.32,18350.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,inpatient,1,UN,37768.55000,22661.13000,United Healthcare,Individual Exchange,,11368.33,,,,,,,11368.33,30705.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Individual Exchange,,479.52,,,,,,,167.05,28031.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,inpatient,14,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,inpatient,150,ME,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,United Healthcare,Individual Exchange,,212.46,,,,,,,0.04004,212.46,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,inpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,175.62,,,,,,,0.04004,175.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,inpatient,15,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,176.79,,,,,,,0.04004,176.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,inpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,176.79,,,,,,,0.04004,176.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,inpatient,100,ML,403.95000,242.37000,United Healthcare,Individual Exchange,,121.59,,,,,,,121.59,328.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,inpatient,60,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,inpatient,100,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,inpatient,500,ME,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,United Healthcare,Individual Exchange,,10.40,,,,,,,0.04004,10.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,inpatient,4,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,163.33,,,,,,,0.04004,163.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,inpatient,4,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,163.33,,,,,,,0.04004,163.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,inpatient,500,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,inpatient,16,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,inpatient,8,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,inpatient,100,ML,106.70000,64.02000,United Healthcare,Individual Exchange,,32.12,,,,,,,32.12,86.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,United Healthcare,Individual Exchange,,8.92,,,,,,,8.92,24.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,inpatient,0.1,ML,23.05000,13.83000,United Healthcare,Individual Exchange,,6.94,,,,,,,6.94,18.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,United Healthcare,Individual Exchange,,77.33,,,,,,,29.66,120.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,United Healthcare,Individual Exchange,,9.01,,,,,,,9.01,24.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,United Healthcare,Individual Exchange,,6.47,,,,,,,2.48,10.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ML,483.00000,289.80000,United Healthcare,Individual Exchange,,145.38,,,,,,,145.38,392.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,Individual Exchange,,2.07,,,,,,,0.77600,358.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,inpatient,4,ML,757.00000,454.20000,United Healthcare,Individual Exchange,,227.86,,,,,,,227.86,615.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,inpatient,10,ML,48.90000,29.34000,United Healthcare,Individual Exchange,,14.72,,,,,,,14.72,39.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,inpatient,2,ML,25.75000,15.45000,United Healthcare,Individual Exchange,,7.75,,,,,,,7.75,20.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,inpatient,5,ML,26.10000,15.66000,United Healthcare,Individual Exchange,,7.86,,,,,,,7.86,21.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,inpatient,1,ML,278.25000,166.95000,United Healthcare,Individual Exchange,,83.75,,,,,,,83.75,226.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,United Healthcare,Individual Exchange,,30.48,,,,,,,11.69,47.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,United Healthcare,Individual Exchange,,40.48,,,,,,,15.53,63.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,inpatient,0.2,ML,16.85000,10.11000,United Healthcare,Individual Exchange,,5.07,,,,,,,5.07,13.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,United Healthcare,Individual Exchange,,45.94,,,,,,,17.62,71.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,United Healthcare,Individual Exchange,,162.48,,,,,,,162.48,438.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,United Healthcare,Individual Exchange,,92.83,,,,,,,92.83,250.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,United Healthcare,Individual Exchange,,2.17,,,,,,,0.83083,3.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,United Healthcare,Individual Exchange,,1.46,,,,,,,0.56056,2.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,inpatient,287.5,ML,276.75000,166.05000,United Healthcare,Individual Exchange,,83.30,,,,,,,83.30,225.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,inpatient,555,ML,298.45000,179.07000,United Healthcare,Individual Exchange,,89.83,,,,,,,89.83,242.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,inpatient,557.5,ML,238.65000,143.19000,United Healthcare,Individual Exchange,,71.83,,,,,,,71.83,194.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,inpatient,560,ML,260.60000,156.36000,United Healthcare,Individual Exchange,,78.44,,,,,,,78.44,211.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,United Healthcare,Individual Exchange,,1.17,,,,,,,0.45045,1.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,inpatient,0.09,ML,291.30000,174.78000,United Healthcare,Individual Exchange,,87.68,,,,,,,87.68,236.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,United Healthcare,Individual Exchange,,5.11,,,,,,,1.78,216.20,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,6.92,,,,,,,6.92,18.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,inpatient,0.5,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,6.92,,,,,,,6.92,18.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,inpatient,10,ML,41.15000,24.69000,United Healthcare,Individual Exchange,,12.39,,,,,,,12.39,33.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,inpatient,20,ML,66.25000,39.75000,United Healthcare,Individual Exchange,,19.94,,,,,,,19.94,53.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,United Healthcare,Individual Exchange,,40.61,,,,,,,15.58,63.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,United Healthcare,Individual Exchange,,14.98,,,,,,,5.75,23.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,United Healthcare,Individual Exchange,,19.68,,,,,,,7.55,30.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,United Healthcare,Individual Exchange,,11.20,,,,,,,11.20,30.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,inpatient,1,UN,45136.00000,27081.60000,United Healthcare,Individual Exchange,,13585.94,,,,,,,13585.94,36695.57,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,United Healthcare,Individual Exchange,,659.92,,,,,,,229.52,33499.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,14,ML,35970.30000,21582.18000,United Healthcare,Individual Exchange,,10827.06,,,,,,,10827.06,29243.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,Individual Exchange,,253.84,,,,,,,88.60,26697.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,20,ML,51268.20000,30760.92000,United Healthcare,Individual Exchange,,15431.73,,,,,,,15431.73,41681.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,Individual Exchange,,253.84,,,,,,,88.60,38051.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,United Healthcare,Individual Exchange,,14.33,,,,,,,5.50,22.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,United Healthcare,Individual Exchange,,290.23,,,,,,,111.31,452.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,inpatient,10,ML,314.75000,188.85000,United Healthcare,Individual Exchange,,94.74,,,,,,,94.74,255.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,inpatient,2,ML,289.80000,173.88000,United Healthcare,Individual Exchange,,87.23,,,,,,,87.23,235.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,40,ML,421.30000,252.78000,United Healthcare,Individual Exchange,,126.81,,,,,,,126.81,342.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,15,ML,46791.25000,28074.75000,United Healthcare,Individual Exchange,,14084.17,,,,,,,14084.17,38041.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,United Healthcare,Individual Exchange,,152.47,,,,,,,53.90,34728.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,United Healthcare,Individual Exchange,,2298.50,,,,,,,2298.50,6208.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Individual Exchange,,218.84,,,,,,,76.02,5667.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,1190.64,,,,,,,1190.64,3215.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,218.84,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,United Healthcare,Individual Exchange,,2298.50,,,,,,,2298.50,6208.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Individual Exchange,,218.84,,,,,,,76.02,5667.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,1190.64,,,,,,,1190.64,3215.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,218.84,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,inpatient,100,ML,7636.20000,4581.72000,United Healthcare,Individual Exchange,,2298.50,,,,,,,2298.50,6208.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Individual Exchange,,218.84,,,,,,,76.02,5667.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,inpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,1190.64,,,,,,,1190.64,3215.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Individual Exchange,,218.84,,,,,,,76.02,2935.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,inpatient,1,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,6806.87,,,,,,,0.04004,6806.87,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,inpatient,1,ML,1012.45000,607.47000,United Healthcare,Individual Exchange,,304.75,,,,,,,304.75,823.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,Individual Exchange,,0.83500,,,,,,,0.27160,751.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,5663.13,,,,,,,5663.13,15296.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,102.24,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,5663.13,,,,,,,5663.13,15296.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,102.24,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,5663.13,,,,,,,5663.13,15296.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Individual Exchange,,102.24,,,,,,,35.64,13964.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,inpatient,1,ML,51108.35000,30665.01000,United Healthcare,Individual Exchange,,15383.61,,,,,,,15383.61,41551.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,Individual Exchange,,201.92,,,,,,,70.44,37932.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,inpatient,1,UN,2475.00000,1485.00000,United Healthcare,Individual Exchange,,744.98,,,,,,,744.98,2012.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,Individual Exchange,,301.28,,,,,,,93.02,1836.94,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,United Healthcare,Individual Exchange,,1256.87,,,,,,,1256.87,3394.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,Individual Exchange,,13.08,,,,,,,4.29,3099.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,United Healthcare,Individual Exchange,,2494.78,,,,,,,2494.78,6738.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,Individual Exchange,,13.08,,,,,,,4.29,6151.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,United Healthcare,Individual Exchange,,514.14,,,,,,,514.14,1388.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,Individual Exchange,,13.08,,,,,,,4.29,1267.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,inpatient,10,ML,4175.65000,2505.39000,United Healthcare,Individual Exchange,,1256.87,,,,,,,1256.87,3394.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,Individual Exchange,,13.08,,,,,,,4.29,3099.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,inpatient,20,ML,8288.30000,4972.98000,United Healthcare,Individual Exchange,,2494.78,,,,,,,2494.78,6738.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,Individual Exchange,,13.08,,,,,,,4.29,6151.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,inpatient,4,ML,1708.10000,1024.86000,United Healthcare,Individual Exchange,,514.14,,,,,,,514.14,1388.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,Individual Exchange,,13.08,,,,,,,4.29,1267.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,inpatient,67,ML,278.85000,167.31000,United Healthcare,Individual Exchange,,83.93,,,,,,,83.93,226.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,inpatient,2,ML,44.10000,26.46000,United Healthcare,Individual Exchange,,13.27,,,,,,,13.27,35.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,inpatient,4,ML,29.75000,17.85000,United Healthcare,Individual Exchange,,8.95,,,,,,,8.95,24.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,Individual Exchange,,1.70,,,,,,,0.35890,22.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,United Healthcare,Individual Exchange,,100139.41,,,,,,,38405.96,155964.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,United Healthcare,Individual Exchange,,67.29,,,,,,,25.81,104.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,inpatient,2,ML,1471.30000,882.78000,United Healthcare,Individual Exchange,,442.86,,,,,,,442.86,1196.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,Individual Exchange,,199.83,,,,,,,66.15,1092.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,United Healthcare,Individual Exchange,,36.93,,,,,,,14.16,57.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,United Healthcare,Individual Exchange,,10.60,,,,,,,4.06,16.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,United Healthcare,Individual Exchange,,11.22,,,,,,,4.30,17.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,United Healthcare,Individual Exchange,,10.05,,,,,,,3.85,15.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,inpatient,5,ML,671.00000,402.60000,United Healthcare,Individual Exchange,,201.97,,,,,,,201.97,545.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,United Healthcare,Individual Exchange,,75.72,,,,,,,29.04,117.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,United Healthcare,Individual Exchange,,384.19,,,,,,,147.35,598.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,United Healthcare,Individual Exchange,,137.52,,,,,,,52.74,214.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,United Healthcare,Individual Exchange,,28.92,,,,,,,11.09,45.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,United Healthcare,Individual Exchange,,28.92,,,,,,,11.09,45.04,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,United Healthcare,Individual Exchange,,2.66,,,,,,,1.02,4.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,United Healthcare,Individual Exchange,,6.76,,,,,,,2.59,10.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,United Healthcare,Individual Exchange,,41.71,,,,,,,16.00,64.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,United Healthcare,Individual Exchange,,31.45,,,,,,,12.06,48.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,United Healthcare,Individual Exchange,,240.51,,,,,,,92.24,374.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,United Healthcare,Individual Exchange,,8.95,,,,,,,3.43,13.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,United Healthcare,Individual Exchange,,30.90,,,,,,,11.85,48.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,United Healthcare,Individual Exchange,,19.97,,,,,,,7.66,31.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,United Healthcare,Individual Exchange,,227.57,,,,,,,87.28,354.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,United Healthcare,Individual Exchange,,9.55,,,,,,,3.66,14.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,United Healthcare,Individual Exchange,,55.65,,,,,,,21.34,86.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,inpatient,1,UN,107.00000,64.20000,United Healthcare,Individual Exchange,,32.21,,,,,,,32.21,86.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,inpatient,1,UN,583.00000,349.80000,United Healthcare,Individual Exchange,,175.48,,,,,,,175.48,473.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,inpatient,1,UN,313.75000,188.25000,United Healthcare,Individual Exchange,,94.44,,,,,,,94.44,255.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,United Healthcare,Individual Exchange,,27.04,,,,,,,10.37,42.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,United Healthcare,Individual Exchange,,10.65,,,,,,,4.08,16.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,United Healthcare,Individual Exchange,,9.29,,,,,,,3.56,14.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,United Healthcare,Individual Exchange,,9.50,,,,,,,3.64,14.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Individual Exchange,,9.24,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,United Healthcare,Individual Exchange,,9.40,,,,,,,3.60,14.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,United Healthcare,Individual Exchange,,11.82,,,,,,,4.53,18.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,United Healthcare,Individual Exchange,,17.75,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,inpatient,20,ML,30.50000,18.30000,United Healthcare,Individual Exchange,,9.18,,,,,,,9.18,24.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,inpatient,50,ML,30.60000,18.36000,United Healthcare,Individual Exchange,,9.21,,,,,,,9.21,24.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,inpatient,20,ML,34.15000,20.49000,United Healthcare,Individual Exchange,,10.28,,,,,,,10.28,27.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,inpatient,5,ML,38.00000,22.80000,United Healthcare,Individual Exchange,,11.44,,,,,,,11.44,30.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,inpatient,5,ML,115.10000,69.06000,United Healthcare,Individual Exchange,,34.65,,,,,,,34.65,93.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,inpatient,5,ML,49.10000,29.46000,United Healthcare,Individual Exchange,,14.78,,,,,,,14.78,39.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,United Healthcare,Individual Exchange,,8.48,,,,,,,3.25,13.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,United Healthcare,Individual Exchange,,9.47,,,,,,,3.63,14.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Individual Exchange,,8.56,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Individual Exchange,,8.93,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,United Healthcare,Individual Exchange,,8.59,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,United Healthcare,Individual Exchange,,1.12,,,,,,,0.43043,1.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,United Healthcare,Individual Exchange,,12.42,,,,,,,4.76,19.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,United Healthcare,Individual Exchange,,60.92,,,,,,,23.36,94.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,inpatient,1,UN,234.40000,140.64000,United Healthcare,Individual Exchange,,70.55,,,,,,,70.55,190.57,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,inpatient,1,UN,47.45000,28.47000,United Healthcare,Individual Exchange,,14.28,,,,,,,14.28,38.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,United Healthcare,Individual Exchange,,2.22,,,,,,,0.85085,3.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,inpatient,100,ML,91.00000,54.60000,United Healthcare,Individual Exchange,,27.39,,,,,,,27.39,73.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,inpatient,1,UN,48.35000,29.01000,United Healthcare,Individual Exchange,,14.55,,,,,,,14.55,39.31,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,inpatient,2,ML,26.35000,15.81000,United Healthcare,Individual Exchange,,7.93,,,,,,,7.93,21.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,inpatient,1,UN,31.25000,18.75000,United Healthcare,Individual Exchange,,9.41,,,,,,,9.41,25.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,inpatient,1,UN,29.65000,17.79000,United Healthcare,Individual Exchange,,8.92,,,,,,,8.92,24.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,United Healthcare,Individual Exchange,,96.91,,,,,,,37.17,150.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Individual Exchange,,8.93,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,inpatient,1,ML,29.65000,17.79000,United Healthcare,Individual Exchange,,8.92,,,,,,,8.92,24.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,inpatient,1,ML,29.95000,17.97000,United Healthcare,Individual Exchange,,9.01,,,,,,,9.01,24.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,inpatient,50,ML,87.25000,52.35000,United Healthcare,Individual Exchange,,26.26,,,,,,,26.26,70.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,inpatient,50,ML,89.05000,53.43000,United Healthcare,Individual Exchange,,26.80,,,,,,,26.80,72.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,12.01,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,United Healthcare,Individual Exchange,,61.60,,,,,,,23.62,95.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,United Healthcare,Individual Exchange,,12.21,,,,,,,4.68,19.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,inpatient,5,ML,53.55000,32.13000,United Healthcare,Individual Exchange,,16.12,,,,,,,16.12,43.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,United Healthcare,Individual Exchange,,8.53,,,,,,,3.27,13.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,1,UN,37.20000,22.32000,United Healthcare,Individual Exchange,,11.20,,,,,,,11.20,30.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,inpatient,2,ML,307.00000,184.20000,United Healthcare,Individual Exchange,,92.41,,,,,,,92.41,249.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,inpatient,1,UN,473.00000,283.80000,United Healthcare,Individual Exchange,,142.37,,,,,,,142.37,384.55,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,United Healthcare,Individual Exchange,,11.80,,,,,,,4.52,18.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,inpatient,0.25,ML,28.95000,17.37000,United Healthcare,Individual Exchange,,8.71,,,,,,,8.71,23.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,United Healthcare,Individual Exchange,,0.33400,,,,,,,0.11640,21.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,inpatient,1,ML,105.75000,63.45000,United Healthcare,Individual Exchange,,31.83,,,,,,,31.83,85.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,United Healthcare,Individual Exchange,,0.33400,,,,,,,0.11640,78.49,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,United Healthcare,Individual Exchange,,10.02,,,,,,,3.84,15.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,United Healthcare,Individual Exchange,,9.94,,,,,,,3.81,15.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,inpatient,5,ML,20.55000,12.33000,United Healthcare,Individual Exchange,,6.19,,,,,,,6.19,16.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,Individual Exchange,,8.59,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Individual Exchange,,9.21,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,United Healthcare,Individual Exchange,,9.74,,,,,,,3.73,15.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,inpatient,100,ML,74.20000,44.52000,United Healthcare,Individual Exchange,,22.33,,,,,,,22.33,60.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,United Healthcare,Individual Exchange,,7.05,,,,,,,2.70,10.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Individual Exchange,,8.93,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Individual Exchange,,9.71,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,United Healthcare,Individual Exchange,,9.45,,,,,,,3.62,14.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,inpatient,0.5,ML,26.60000,15.96000,United Healthcare,Individual Exchange,,8.01,,,,,,,8.01,21.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,inpatient,1,ML,30.65000,18.39000,United Healthcare,Individual Exchange,,9.23,,,,,,,9.23,24.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,inpatient,0.5,ML,26.35000,15.81000,United Healthcare,Individual Exchange,,7.93,,,,,,,7.93,21.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,United Healthcare,Individual Exchange,,11.54,,,,,,,4.42,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,United Healthcare,Individual Exchange,,13.62,,,,,,,5.23,21.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,United Healthcare,Individual Exchange,,47.50,,,,,,,18.22,73.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,United Healthcare,Individual Exchange,,12.16,,,,,,,4.66,18.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,United Healthcare,Individual Exchange,,19.31,,,,,,,7.41,30.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,inpatient,1,ML,32.30000,19.38000,United Healthcare,Individual Exchange,,9.72,,,,,,,9.72,26.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,1,ML,88.05000,52.83000,United Healthcare,Individual Exchange,,26.50,,,,,,,26.50,71.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,inpatient,2,ML,166.15000,99.69000,United Healthcare,Individual Exchange,,50.01,,,,,,,50.01,135.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Individual Exchange,,8.90,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,inpatient,10,ML,128.35000,77.01000,United Healthcare,Individual Exchange,,38.63,,,,,,,38.63,104.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,United Healthcare,Individual Exchange,,28.03,,,,,,,10.75,43.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,United Healthcare,Individual Exchange,,13.42,,,,,,,5.15,20.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,8.77,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Individual Exchange,,8.93,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,United Healthcare,Individual Exchange,,30.28,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,United Healthcare,Individual Exchange,,30.28,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,United Healthcare,Individual Exchange,,9.60,,,,,,,3.68,14.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,United Healthcare,Individual Exchange,,12.14,,,,,,,4.65,18.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,United Healthcare,Individual Exchange,,5.48,,,,,,,2.10,8.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,inpatient,0.3,ML,20.95000,12.57000,United Healthcare,Individual Exchange,,6.31,,,,,,,6.31,17.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,inpatient,0.3,ML,17.95000,10.77000,United Healthcare,Individual Exchange,,5.40,,,,,,,5.40,14.59,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,inpatient,2,ML,204.45000,122.67000,United Healthcare,Individual Exchange,,61.54,,,,,,,61.54,166.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,inpatient,1,UN,247.55000,148.53000,United Healthcare,Individual Exchange,,74.51,,,,,,,74.51,201.26,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,inpatient,1,UN,73.90000,44.34000,United Healthcare,Individual Exchange,,22.24,,,,,,,22.24,60.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,United Healthcare,Individual Exchange,,22.29,,,,,,,8.55,34.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,8.77,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,inpatient,50,ML,6793.00000,4075.80000,United Healthcare,Individual Exchange,,2044.69,,,,,,,2044.69,5522.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Individual Exchange,,9.32,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,United Healthcare,Individual Exchange,,9.03,,,,,,,3.46,14.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,United Healthcare,Individual Exchange,,12.68,,,,,,,4.86,19.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,Individual Exchange,,12.35,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,inpatient,1,ML,227.20000,136.32000,United Healthcare,Individual Exchange,,68.39,,,,,,,68.39,184.71,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,inpatient,1,ML,101.10000,60.66000,United Healthcare,Individual Exchange,,30.43,,,,,,,30.43,82.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,inpatient,1,ML,34.20000,20.52000,United Healthcare,Individual Exchange,,10.29,,,,,,,10.29,27.80,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,inpatient,10,ML,212.70000,127.62000,United Healthcare,Individual Exchange,,64.02,,,,,,,64.02,172.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,inpatient,5,ML,107.00000,64.20000,United Healthcare,Individual Exchange,,32.21,,,,,,,32.21,86.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,United Healthcare,Individual Exchange,,3.34,,,,,,,1.28,5.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,United Healthcare,Individual Exchange,,3.34,,,,,,,1.28,5.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,United Healthcare,Individual Exchange,,59.25,,,,,,,22.72,92.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,inpatient,2,ML,22.35000,13.41000,United Healthcare,Individual Exchange,,6.73,,,,,,,6.73,18.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,Individual Exchange,,12.35,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,0.25,ML,72.30000,43.38000,United Healthcare,Individual Exchange,,21.76,,,,,,,21.76,58.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,United Healthcare,Individual Exchange,,131.86,,,,,,,50.57,205.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,United Healthcare,Individual Exchange,,134.68,,,,,,,51.65,209.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,United Healthcare,Individual Exchange,,140.78,,,,,,,53.99,219.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,United Healthcare,Individual Exchange,,81.12,,,,,,,31.11,126.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,United Healthcare,Individual Exchange,,44.74,,,,,,,17.16,69.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,United Healthcare,Individual Exchange,,57.45,,,,,,,22.03,89.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,inpatient,10,ML,72.65000,43.59000,United Healthcare,Individual Exchange,,21.87,,,,,,,21.87,59.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,United Healthcare,Individual Exchange,,98.74,,,,,,,37.87,153.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,United Healthcare,Individual Exchange,,23.41,,,,,,,8.98,36.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,United Healthcare,Individual Exchange,,2.01,,,,,,,0.77077,3.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,United Healthcare,Individual Exchange,,1.59,,,,,,,0.61061,2.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,inpatient,1,UN,410.50000,246.30000,United Healthcare,Individual Exchange,,123.56,,,,,,,123.56,333.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,United Healthcare,Individual Exchange,,11.51,,,,,,,4.41,17.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,United Healthcare,Individual Exchange,,12.76,,,,,,,4.89,19.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,United Healthcare,Individual Exchange,,77.65,,,,,,,29.78,120.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,inpatient,500,ML,1256.00000,753.60000,United Healthcare,Individual Exchange,,378.06,,,,,,,378.06,1021.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,5.09,,,,,,,5.09,13.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,inpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,5.09,,,,,,,5.09,13.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,inpatient,1,UN,16.95000,10.17000,United Healthcare,Individual Exchange,,5.10,,,,,,,5.10,13.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,inpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,5.06,,,,,,,5.06,13.66,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,United Healthcare,Individual Exchange,,11.12,,,,,,,4.26,17.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,United Healthcare,Individual Exchange,,9.11,,,,,,,3.49,14.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,inpatient,1,ML,202.50000,121.50000,United Healthcare,Individual Exchange,,60.95,,,,,,,60.95,164.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,United Healthcare,Individual Exchange,,541.93,,,,,,,40.54,695.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,inpatient,0.5,ML,22.20000,13.32000,United Healthcare,Individual Exchange,,6.68,,,,,,,6.68,18.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,Individual Exchange,,9.08,,,,,,,3.48,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,inpatient,0.1,ML,17.55000,10.53000,United Healthcare,Individual Exchange,,5.28,,,,,,,5.28,14.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,inpatient,1,ML,24.45000,14.67000,United Healthcare,Individual Exchange,,7.36,,,,,,,7.36,19.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,United Healthcare,Individual Exchange,,9.24,,,,,,,3.54,14.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,United Healthcare,Individual Exchange,,63.32,,,,,,,24.28,98.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,United Healthcare,Individual Exchange,,84.30,,,,,,,32.33,131.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,United Healthcare,Individual Exchange,,8.69,,,,,,,3.33,13.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,United Healthcare,Individual Exchange,,9.08,,,,,,,3.48,14.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,United Healthcare,Individual Exchange,,8.90,,,,,,,3.41,13.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,United Healthcare,Individual Exchange,,9.63,,,,,,,3.69,15.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,inpatient,25,ML,256.70000,154.02000,United Healthcare,Individual Exchange,,77.27,,,,,,,77.27,208.70,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,inpatient,5,ML,86.45000,51.87000,United Healthcare,Individual Exchange,,26.02,,,,,,,26.02,70.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,United Healthcare,Individual Exchange,,13.15,,,,,,,5.05,20.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,inpatient,0.5,ML,65.45000,39.27000,United Healthcare,Individual Exchange,,19.70,,,,,,,19.70,53.21,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Individual Exchange,,0.73080,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Individual Exchange,,0.73080,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,United Healthcare,Individual Exchange,,1.49,,,,,,,0.57057,2.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,United Healthcare,Individual Exchange,,3.99,,,,,,,1.53,6.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,United Healthcare,Individual Exchange,,48.99,,,,,,,18.79,76.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Individual Exchange,,8.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,9.19,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,inpatient,1,UN,83.60000,50.16000,United Healthcare,Individual Exchange,,25.16,,,,,,,25.16,67.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Individual Exchange,,4.16,,,,,,,1.45,62.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,inpatient,1,UN,83.60000,50.16000,United Healthcare,Individual Exchange,,25.16,,,,,,,25.16,67.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Individual Exchange,,4.16,,,,,,,1.45,62.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,inpatient,1,UN,83.60000,50.16000,United Healthcare,Individual Exchange,,25.16,,,,,,,25.16,67.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Individual Exchange,,4.16,,,,,,,1.45,62.05,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,United Healthcare,Individual Exchange,,494.52,,,,,,,189.66,770.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,United Healthcare,Individual Exchange,,11.59,,,,,,,4.44,18.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,United Healthcare,Individual Exchange,,186.15,,,,,,,71.39,289.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,inpatient,10,ML,404.65000,242.79000,United Healthcare,Individual Exchange,,121.80,,,,,,,121.80,328.98,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,United Healthcare,Individual Exchange,,0.62640,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,8.72,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Individual Exchange,,8.56,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,United Healthcare,Individual Exchange,,27.77,,,,,,,10.65,43.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,inpatient,10,ML,100.00000,60.00000,United Healthcare,Individual Exchange,,30.10,,,,,,,30.10,81.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,inpatient,5,ML,104.75000,62.85000,United Healthcare,Individual Exchange,,31.53,,,,,,,31.53,85.16,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,United Healthcare,Individual Exchange,,34.97,,,,,,,13.41,54.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,United Healthcare,Individual Exchange,,52.20,,,,,,,20.02,81.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,United Healthcare,Individual Exchange,,60.89,,,,,,,23.35,94.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,United Healthcare,Individual Exchange,,58.49,,,,,,,22.43,91.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,500,ML,82.50000,49.50000,United Healthcare,Individual Exchange,,24.83,,,,,,,24.83,67.07,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,inpatient,30,ML,82.45000,49.47000,United Healthcare,Individual Exchange,,24.82,,,,,,,24.82,67.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,inpatient,30,ML,95.15000,57.09000,United Healthcare,Individual Exchange,,28.64,,,,,,,28.64,77.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,United Healthcare,Individual Exchange,,9.76,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,United Healthcare,Individual Exchange,,71.33,,,,,,,27.36,111.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,United Healthcare,Individual Exchange,,38.76,,,,,,,14.86,60.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,United Healthcare,Individual Exchange,,223.44,,,,,,,85.70,348.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,inpatient,50,ML,394.80000,236.88000,United Healthcare,Individual Exchange,,118.83,,,,,,,118.83,320.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,United Healthcare,Individual Exchange,,8.85,,,,,,,3.39,13.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,United Healthcare,Individual Exchange,,37.58,,,,,,,14.41,58.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,United Healthcare,Individual Exchange,,36.02,,,,,,,13.81,56.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,United Healthcare,Individual Exchange,,41.84,,,,,,,16.05,65.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,inpatient,10,ML,115.70000,69.42000,United Healthcare,Individual Exchange,,34.83,,,,,,,34.83,94.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,United Healthcare,Individual Exchange,,8.77,,,,,,,3.36,13.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Individual Exchange,,9.00,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,inpatient,0.3,ML,5298.55000,3179.13000,United Healthcare,Individual Exchange,,1594.86,,,,,,,1594.86,4307.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,United Healthcare,Individual Exchange,,8.37,,,,,,,2.84,3932.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,inpatient,1,ML,269.90000,161.94000,United Healthcare,Individual Exchange,,81.24,,,,,,,81.24,219.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,inpatient,1,UN,715.00000,429.00000,United Healthcare,Individual Exchange,,215.22,,,,,,,215.22,581.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,inpatient,1,UN,85.10000,51.06000,United Healthcare,Individual Exchange,,25.62,,,,,,,25.62,69.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,United Healthcare,Individual Exchange,,4.29,,,,,,,1.56,63.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,United Healthcare,Individual Exchange,,23.86,,,,,,,9.15,37.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,United Healthcare,Individual Exchange,,25.87,,,,,,,9.92,40.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,United Healthcare,Individual Exchange,,0.80910,,,,,,,0.31031,1.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,United Healthcare,Individual Exchange,,212.85,,,,,,,81.63,331.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,United Healthcare,Individual Exchange,,12.01,,,,,,,4.60,18.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,United Healthcare,Individual Exchange,,1033.17,,,,,,,396.25,1609.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,inpatient,1,UN,367.80000,220.68000,United Healthcare,Individual Exchange,,110.71,,,,,,,110.71,299.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,United Healthcare,Individual Exchange,,3.60,,,,,,,1.38,5.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,inpatient,20,ML,646.00000,387.60000,United Healthcare,Individual Exchange,,194.45,,,,,,,194.45,525.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,United Healthcare,Individual Exchange,,13.86,,,,,,,5.32,21.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,inpatient,5,ML,79.80000,47.88000,United Healthcare,Individual Exchange,,24.02,,,,,,,24.02,64.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,United Healthcare,Individual Exchange,,62.04,,,,,,,23.79,96.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,United Healthcare,Individual Exchange,,11.64,,,,,,,4.46,18.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,United Healthcare,Individual Exchange,,49.49,,,,,,,18.98,77.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,inpatient,1,UN,848.40000,509.04000,United Healthcare,Individual Exchange,,255.37,,,,,,,255.37,689.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,United Healthcare,Individual Exchange,,16.81,,,,,,,6.45,26.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,inpatient,0.25,ML,27.95000,16.77000,United Healthcare,Individual Exchange,,8.41,,,,,,,8.41,22.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,inpatient,0.25,ML,28.70000,17.22000,United Healthcare,Individual Exchange,,8.64,,,,,,,8.64,23.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,United Healthcare,Individual Exchange,,149.29,,,,,,,57.26,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,United Healthcare,Individual Exchange,,3.26,,,,,,,1.25,5.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,United Healthcare,Individual Exchange,,13.08,,,,,,,5.02,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,United Healthcare,Individual Exchange,,13.08,,,,,,,5.02,20.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,United Healthcare,Individual Exchange,,27.90,,,,,,,10.70,43.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,inpatient,1,UN,2850.10000,1710.06000,United Healthcare,Individual Exchange,,857.88,,,,,,,857.88,2317.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,United Healthcare,Individual Exchange,,32.39,,,,,,,12.42,50.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,inpatient,0.25,ML,22.80000,13.68000,United Healthcare,Individual Exchange,,6.86,,,,,,,6.86,18.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Individual Exchange,,10.34,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,United Healthcare,Individual Exchange,,12.35,,,,,,,4.73,19.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,United Healthcare,Individual Exchange,,32.62,,,,,,,12.51,50.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,United Healthcare,Individual Exchange,,8.61,,,,,,,3.30,13.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,United Healthcare,Individual Exchange,,8.64,,,,,,,3.31,13.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,United Healthcare,Individual Exchange,,13.05,,,,,,,5.00,20.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,United Healthcare,Individual Exchange,,21.19,,,,,,,8.13,33.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,United Healthcare,Individual Exchange,,15.63,,,,,,,6.00,24.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,1,ML,58.60000,35.16000,United Healthcare,Individual Exchange,,17.64,,,,,,,17.64,47.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,inpatient,1,ML,55.45000,33.27000,United Healthcare,Individual Exchange,,16.69,,,,,,,16.69,45.08,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,inpatient,1,ML,45.50000,27.30000,United Healthcare,Individual Exchange,,13.70,,,,,,,13.70,36.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,United Healthcare,Individual Exchange,,109.33,,,,,,,41.93,170.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,United Healthcare,Individual Exchange,,8.93,,,,,,,3.42,13.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,United Healthcare,Individual Exchange,,13.55,,,,,,,5.20,21.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,United Healthcare,Individual Exchange,,225.11,,,,,,,86.34,350.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,United Healthcare,Individual Exchange,,257.66,,,,,,,98.82,401.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,inpatient,30,ML,27459.60000,16475.76000,United Healthcare,Individual Exchange,,8265.34,,,,,,,8265.34,22324.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,United Healthcare,Individual Exchange,,124.87,,,,,,,43.48,20380.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,inpatient,10,ML,92.40000,55.44000,United Healthcare,Individual Exchange,,27.81,,,,,,,27.81,75.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,United Healthcare,Individual Exchange,,9.76,,,,,,,3.74,15.20,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,10,ML,290.05000,174.03000,United Healthcare,Individual Exchange,,87.31,,,,,,,87.31,235.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,inpatient,20,ML,305.10000,183.06000,United Healthcare,Individual Exchange,,91.84,,,,,,,91.84,248.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,inpatient,1,UN,9076.45000,5445.87000,United Healthcare,Individual Exchange,,2732.01,,,,,,,2732.01,7379.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,United Healthcare,Individual Exchange,,90.05,,,,,,,25.91,6736.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,inpatient,2,ML,27.35000,16.41000,United Healthcare,Individual Exchange,,8.23,,,,,,,8.23,22.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,inpatient,60,ML,120.60000,72.36000,United Healthcare,Individual Exchange,,36.30,,,,,,,36.30,98.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,United Healthcare,Individual Exchange,,55.33,,,,,,,21.22,86.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,United Healthcare,Individual Exchange,,56.12,,,,,,,21.52,87.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,United Healthcare,Individual Exchange,,56.09,,,,,,,21.51,87.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,United Healthcare,Individual Exchange,,29.62,,,,,,,11.36,46.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,inpatient,1,UN,131.40000,78.84000,United Healthcare,Individual Exchange,,39.55,,,,,,,39.55,106.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,inpatient,1,UN,97.30000,58.38000,United Healthcare,Individual Exchange,,29.29,,,,,,,29.29,79.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,inpatient,1,UN,442.10000,265.26000,United Healthcare,Individual Exchange,,133.07,,,,,,,133.07,359.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,United Healthcare,Individual Exchange,,2.32,,,,,,,0.89089,3.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,United Healthcare,Individual Exchange,,32.10,,,,,,,12.31,50.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,United Healthcare,Individual Exchange,,23.59,,,,,,,9.05,36.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,United Healthcare,Individual Exchange,,8.56,,,,,,,3.28,13.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Individual Exchange,,9.00,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,United Healthcare,Individual Exchange,,2.74,,,,,,,1.05,4.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,inpatient,10,ML,511.55000,306.93000,United Healthcare,Individual Exchange,,153.98,,,,,,,153.98,415.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,inpatient,1,ML,353.10000,211.86000,United Healthcare,Individual Exchange,,106.28,,,,,,,106.28,287.07,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,United Healthcare,Individual Exchange,,9.34,,,,,,,3.58,14.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,United Healthcare,Individual Exchange,,9.16,,,,,,,3.51,14.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,United Healthcare,Individual Exchange,,9.19,,,,,,,3.52,14.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,United Healthcare,Individual Exchange,,9.21,,,,,,,3.53,14.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,United Healthcare,Individual Exchange,,9.58,,,,,,,3.67,14.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,United Healthcare,Individual Exchange,,17.43,,,,,,,6.69,27.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,inpatient,0.5,ML,40477.65000,24286.59000,United Healthcare,Individual Exchange,,12183.77,,,,,,,12183.77,32908.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,United Healthcare,Individual Exchange,,68.19,,,,,,,28.94,30042.51,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,inpatient,10,ML,567.95000,340.77000,United Healthcare,Individual Exchange,,170.95,,,,,,,170.95,461.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,inpatient,2,ML,40.90000,24.54000,United Healthcare,Individual Exchange,,12.31,,,,,,,12.31,33.25,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,United Healthcare,Individual Exchange,,51.21,,,,,,,19.64,79.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,inpatient,100,ML,452.35000,271.41000,United Healthcare,Individual Exchange,,136.16,,,,,,,136.16,367.76,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,inpatient,50,ML,407.00000,244.20000,United Healthcare,Individual Exchange,,122.51,,,,,,,122.51,330.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,United Healthcare,Individual Exchange,,80.86,,,,,,,31.01,125.93,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,United Healthcare,Individual Exchange,,30.88,,,,,,,11.84,48.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,inpatient,1,UN,26867.20000,16120.32000,United Healthcare,Individual Exchange,,8087.03,,,,,,,8087.03,21843.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,United Healthcare,Individual Exchange,,386.74,,,,,,,135.03,19940.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,United Healthcare,Individual Exchange,,37.45,,,,,,,14.36,58.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,United Healthcare,Individual Exchange,,416.58,,,,,,,159.77,648.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,United Healthcare,Individual Exchange,,4.78,,,,,,,1.83,7.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,United Healthcare,Individual Exchange,,0.73080,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,United Healthcare,Individual Exchange,,51.73,,,,,,,19.84,80.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,inpatient,1,UN,3832.85000,2299.71000,United Healthcare,Individual Exchange,,1153.69,,,,,,,1153.69,3116.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,United Healthcare,Individual Exchange,,10.40,,,,,,,4.23,2844.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,United Healthcare,Individual Exchange,,1.70,,,,,,,0.65065,2.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,United Healthcare,Individual Exchange,,1.28,,,,,,,0.49049,1.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,United Healthcare,Individual Exchange,,46.98,,,,,,,18.02,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,United Healthcare,Individual Exchange,,566.14,,,,,,,217.13,881.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,United Healthcare,Individual Exchange,,21.22,,,,,,,8.14,33.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,United Healthcare,Individual Exchange,,70.99,,,,,,,27.23,110.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,inpatient,100,ML,539.80000,323.88000,United Healthcare,Individual Exchange,,162.48,,,,,,,162.48,438.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,50,ML,308.40000,185.04000,United Healthcare,Individual Exchange,,92.83,,,,,,,92.83,250.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,inpatient,250,ML,437.00000,262.20000,United Healthcare,Individual Exchange,,131.54,,,,,,,131.54,355.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,Individual Exchange,,148.03,,,,,,,51.49,324.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,inpatient,250,ML,437.00000,262.20000,United Healthcare,Individual Exchange,,131.54,,,,,,,131.54,355.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,Individual Exchange,,148.03,,,,,,,51.49,324.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,inpatient,1,ML,786.55000,471.93000,United Healthcare,Individual Exchange,,236.75,,,,,,,236.75,639.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,inpatient,1,UN,40057.65000,24034.59000,United Healthcare,Individual Exchange,,12057.35,,,,,,,12057.35,32566.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,United Healthcare,Individual Exchange,,262.57,,,,,,,91.62,29730.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,inpatient,1,UN,20036.85000,12022.11000,United Healthcare,Individual Exchange,,6031.09,,,,,,,6031.09,16289.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,United Healthcare,Individual Exchange,,262.57,,,,,,,91.62,14871.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,United Healthcare,Individual Exchange,,2.06,,,,,,,0.79079,3.21,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,United Healthcare,Individual Exchange,,0.65250,,,,,,,0.25025,1.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,United Healthcare,Individual Exchange,,1.04,,,,,,,0.40040,1.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,United Healthcare,Individual Exchange,,53.22,,,,,,,20.41,82.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Individual Exchange,,9.13,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,United Healthcare,Individual Exchange,,8.59,,,,,,,3.29,13.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,United Healthcare,Individual Exchange,,8.67,,,,,,,3.32,13.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,8.72,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1,UN,51.10000,30.66000,United Healthcare,Individual Exchange,,15.38,,,,,,,15.38,41.54,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,inpatient,1,UN,34.00000,20.40000,United Healthcare,Individual Exchange,,10.23,,,,,,,10.23,27.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,United Healthcare,Individual Exchange,,51.16,,,,,,,19.62,79.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,inpatient,1,UN,129.05000,77.43000,United Healthcare,Individual Exchange,,38.84,,,,,,,38.84,104.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,inpatient,5,ML,371.70000,223.02000,United Healthcare,Individual Exchange,,111.88,,,,,,,111.88,302.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,inpatient,1,UN,94.85000,56.91000,United Healthcare,Individual Exchange,,28.55,,,,,,,28.55,77.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,United Healthcare,Individual Exchange,,11.41,,,,,,,3.98,70.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,United Healthcare,Individual Exchange,,109.62,,,,,,,42.04,170.73,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,inpatient,0.5,ML,26.25000,15.75000,United Healthcare,Individual Exchange,,7.90,,,,,,,7.90,21.34,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,inpatient,0.75,ML,49.95000,29.97000,United Healthcare,Individual Exchange,,15.03,,,,,,,15.03,40.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,inpatient,1,ML,175.25000,105.15000,United Healthcare,Individual Exchange,,52.75,,,,,,,52.75,142.48,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,inpatient,2,ML,30.90000,18.54000,United Healthcare,Individual Exchange,,9.30,,,,,,,9.30,25.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,inpatient,5,ML,813.05000,487.83000,United Healthcare,Individual Exchange,,244.73,,,,,,,244.73,661.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,United Healthcare,Individual Exchange,,0.54810,,,,,,,0.21021,0.85365,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Individual Exchange,,10.44,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,inpatient,0.4,ML,531.50000,318.90000,United Healthcare,Individual Exchange,,159.98,,,,,,,159.98,432.11,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,United Healthcare,Individual Exchange,,41.79,,,,,,,16.03,65.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,United Healthcare,Individual Exchange,,19.60,,,,,,,7.52,30.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,inpatient,1,UN,18.75000,11.25000,United Healthcare,Individual Exchange,,5.64,,,,,,,5.64,15.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,UN,151.25000,90.75000,United Healthcare,Individual Exchange,,45.53,,,,,,,45.53,122.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,inpatient,1,UN,276.30000,165.78000,United Healthcare,Individual Exchange,,83.17,,,,,,,83.17,224.63,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,United Healthcare,Individual Exchange,,25.24,,,,,,,9.68,39.31,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,inpatient,5,ML,266.40000,159.84000,United Healthcare,Individual Exchange,,80.19,,,,,,,80.19,216.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,United Healthcare,Individual Exchange,,2.11,,,,,,,0.81081,3.29,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,United Healthcare,Individual Exchange,,83.47,,,,,,,32.01,130.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,26.56,,,,,,,26.56,71.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,7.40,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,26.56,,,,,,,26.56,71.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,7.40,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,inpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,26.56,,,,,,,26.56,71.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Individual Exchange,,7.40,,,,,,,2.58,65.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,inpatient,1,UN,526.70000,316.02000,United Healthcare,Individual Exchange,,158.54,,,,,,,158.54,428.21,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,United Healthcare,Individual Exchange,,15.27,,,,,,,5.86,23.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,inpatient,1,UN,84.65000,50.79000,United Healthcare,Individual Exchange,,25.48,,,,,,,25.48,68.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Individual Exchange,,4.29,,,,,,,1.62,62.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,inpatient,1,UN,84.65000,50.79000,United Healthcare,Individual Exchange,,25.48,,,,,,,25.48,68.82,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Individual Exchange,,4.29,,,,,,,1.62,62.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,United Healthcare,Individual Exchange,,2.74,,,,,,,1.05,4.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,inpatient,4,ML,29.75000,17.85000,United Healthcare,Individual Exchange,,8.95,,,,,,,8.95,24.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,Individual Exchange,,1.70,,,,,,,0.35890,22.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,inpatient,3,ML,75.05000,45.03000,United Healthcare,Individual Exchange,,22.59,,,,,,,22.59,61.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,inpatient,3,ML,75.45000,45.27000,United Healthcare,Individual Exchange,,22.71,,,,,,,22.71,61.34,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,inpatient,3,ML,71.45000,42.87000,United Healthcare,Individual Exchange,,21.51,,,,,,,21.51,58.09,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Individual Exchange,,9.32,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,inpatient,2,ML,29.00000,17.40000,United Healthcare,Individual Exchange,,8.73,,,,,,,8.73,23.58,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,United Healthcare,Individual Exchange,,9.13,,,,,,,3.50,14.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,United Healthcare,Individual Exchange,,10.94,,,,,,,4.19,17.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,United Healthcare,Individual Exchange,,8.51,,,,,,,3.26,13.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,United Healthcare,Individual Exchange,,8.43,,,,,,,3.23,13.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,inpatient,0.5,ML,39.05000,23.43000,United Healthcare,Individual Exchange,,11.75,,,,,,,11.75,31.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,inpatient,2,ML,3656.00000,2193.60000,United Healthcare,Individual Exchange,,1100.46,,,,,,,1100.46,2972.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,United Healthcare,Individual Exchange,,2330.97,,,,,,,470.42,2713.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,United Healthcare,Individual Exchange,,10.34,,,,,,,3.96,16.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,inpatient,1,UN,12542.25000,7525.35000,United Healthcare,Individual Exchange,,3775.22,,,,,,,3775.22,10196.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,United Healthcare,Individual Exchange,,30.68,,,,,,,10.68,9308.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,inpatient,1,UN,25068.40000,15041.04000,United Healthcare,Individual Exchange,,7545.59,,,,,,,7545.59,20380.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,United Healthcare,Individual Exchange,,30.68,,,,,,,10.68,18605.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,inpatient,10,ML,2068.75000,1241.25000,United Healthcare,Individual Exchange,,622.69,,,,,,,622.69,1681.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,United Healthcare,Individual Exchange,,82.55,,,,,,,23.16,1535.43,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,inpatient,12.5,ML,2753.30000,1651.98000,United Healthcare,Individual Exchange,,828.74,,,,,,,828.74,2238.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,United Healthcare,Individual Exchange,,82.55,,,,,,,23.16,2043.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,inpatient,15,ML,3080.00000,1848.00000,United Healthcare,Individual Exchange,,927.08,,,,,,,927.08,2504.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,United Healthcare,Individual Exchange,,82.55,,,,,,,23.16,2285.98,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,United Healthcare,Individual Exchange,,0.57420,,,,,,,0.22022,0.89430,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,United Healthcare,Individual Exchange,,9.42,,,,,,,3.61,14.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,inpatient,50,ML,433.25000,259.95000,United Healthcare,Individual Exchange,,130.41,,,,,,,130.41,352.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,United Healthcare,Individual Exchange,,226.16,,,,,,,2.76,352.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,United Healthcare,Individual Exchange,,11.33,,,,,,,4.34,17.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,United Healthcare,Individual Exchange,,11.59,,,,,,,4.44,18.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,inpatient,1,UN,17.05000,10.23000,United Healthcare,Individual Exchange,,5.13,,,,,,,5.13,13.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,inpatient,1,UN,17.50000,10.50000,United Healthcare,Individual Exchange,,5.27,,,,,,,5.27,14.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,inpatient,1,ML,653.00000,391.80000,United Healthcare,Individual Exchange,,196.55,,,,,,,196.55,530.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,United Healthcare,Individual Exchange,,340.87,,,,,,,49.52,530.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,United Healthcare,Individual Exchange,,0.60030,,,,,,,0.23023,0.93495,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,United Healthcare,Individual Exchange,,44.94,,,,,,,17.24,70.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,inpatient,1,UN,60.60000,36.36000,United Healthcare,Individual Exchange,,18.24,,,,,,,18.24,49.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,inpatient,200,ML,745.95000,447.57000,United Healthcare,Individual Exchange,,224.53,,,,,,,224.53,606.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,inpatient,1,UN,105.00000,63.00000,United Healthcare,Individual Exchange,,31.61,,,,,,,31.61,85.36,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,inpatient,1,UN,39.70000,23.82000,United Healthcare,Individual Exchange,,11.95,,,,,,,11.95,32.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,inpatient,1,UN,61.50000,36.90000,United Healthcare,Individual Exchange,,18.51,,,,,,,18.51,50.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,1,UN,29.20000,17.52000,United Healthcare,Individual Exchange,,8.79,,,,,,,8.79,23.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,inpatient,1,UN,21.70000,13.02000,United Healthcare,Individual Exchange,,6.53,,,,,,,6.53,17.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,United Healthcare,Individual Exchange,,8.72,,,,,,,3.34,13.58,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,United Healthcare,Individual Exchange,,8.82,,,,,,,3.38,13.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,United Healthcare,Individual Exchange,,44.37,,,,,,,17.02,69.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,United Healthcare,Individual Exchange,,9.68,,,,,,,3.71,15.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,United Healthcare,Individual Exchange,,116.38,,,,,,,44.63,181.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,inpatient,1,UN,315.00000,189.00000,United Healthcare,Individual Exchange,,94.81,,,,,,,94.81,256.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,United Healthcare,Individual Exchange,,7.73,,,,,,,2.96,12.03,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,inpatient,1,UN,1663.10000,997.86000,United Healthcare,Individual Exchange,,500.59,,,,,,,500.59,1352.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,United Healthcare,Individual Exchange,,18.14,,,,,,,6.30,1234.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,United Healthcare,Individual Exchange,,41.06,,,,,,,15.75,63.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,United Healthcare,Individual Exchange,,12.63,,,,,,,4.84,19.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,United Healthcare,Individual Exchange,,42.80,,,,,,,16.42,66.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,United Healthcare,Individual Exchange,,24.80,,,,,,,9.51,38.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,United Healthcare,Individual Exchange,,30.28,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,inpatient,10,ML,2189.00000,1313.40000,United Healthcare,Individual Exchange,,658.89,,,,,,,658.89,1779.66,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,United Healthcare,Individual Exchange,,27.14,,,,,,,10.36,1624.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,United Healthcare,Individual Exchange,,18.77,,,,,,,7.20,29.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,United Healthcare,Individual Exchange,,138.23,,,,,,,53.01,215.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,inpatient,50,ML,104.50000,62.70000,United Healthcare,Individual Exchange,,31.45,,,,,,,31.45,84.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,inpatient,50,ML,113.75000,68.25000,United Healthcare,Individual Exchange,,34.24,,,,,,,34.24,92.48,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,United Healthcare,Individual Exchange,,24.04,,,,,,,9.22,37.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,United Healthcare,Individual Exchange,,11.54,,,,,,,4.42,17.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,United Healthcare,Individual Exchange,,11.67,,,,,,,4.47,18.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,United Healthcare,Individual Exchange,,14.09,,,,,,,5.41,21.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,United Healthcare,Individual Exchange,,11.85,,,,,,,4.54,18.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,United Healthcare,Individual Exchange,,9.71,,,,,,,3.72,15.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,inpatient,1,UN,417.20000,250.32000,United Healthcare,Individual Exchange,,125.58,,,,,,,125.58,339.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,United Healthcare,Individual Exchange,,800.64,,,,,,,307.07,1246.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,United Healthcare,Individual Exchange,,20.10,,,,,,,7.71,31.30,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,United Healthcare,Individual Exchange,,32.29,,,,,,,12.38,50.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,United Healthcare,Individual Exchange,,41.06,,,,,,,15.75,63.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,inpatient,5,ML,96.35000,57.81000,United Healthcare,Individual Exchange,,29.00,,,,,,,29.00,78.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,inpatient,5,ML,302.95000,181.77000,United Healthcare,Individual Exchange,,91.19,,,,,,,91.19,246.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,inpatient,1,UN,3628.20000,2176.92000,United Healthcare,Individual Exchange,,1092.09,,,,,,,1092.09,2949.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,United Healthcare,Individual Exchange,,12.16,,,,,,,4.32,2692.85,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,United Healthcare,Individual Exchange,,66.35,,,,,,,25.45,103.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,United Healthcare,Individual Exchange,,110.22,,,,,,,42.27,171.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,inpatient,1,UN,89.05000,53.43000,United Healthcare,Individual Exchange,,26.80,,,,,,,26.80,72.40,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,inpatient,1,UN,34.30000,20.58000,United Healthcare,Individual Exchange,,10.32,,,,,,,10.32,27.89,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,United Healthcare,Individual Exchange,,31.35,,,,,,,12.02,48.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,United Healthcare,Individual Exchange,,16.31,,,,,,,6.26,25.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,inpatient,1,UN,201.30000,120.78000,United Healthcare,Individual Exchange,,60.59,,,,,,,60.59,163.66,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,inpatient,1,UN,174.05000,104.43000,United Healthcare,Individual Exchange,,52.39,,,,,,,52.39,141.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,inpatient,1,ML,64.55000,38.73000,United Healthcare,Individual Exchange,,19.43,,,,,,,19.43,52.48,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,inpatient,1,ML,64.85000,38.91000,United Healthcare,Individual Exchange,,19.52,,,,,,,19.52,52.72,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,inpatient,1,ML,64.70000,38.82000,United Healthcare,Individual Exchange,,19.47,,,,,,,19.47,52.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,inpatient,0.5,ML,238.95000,143.37000,United Healthcare,Individual Exchange,,71.92,,,,,,,71.92,194.27,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,inpatient,1,UN,91.10000,54.66000,United Healthcare,Individual Exchange,,27.42,,,,,,,27.42,74.06,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,United Healthcare,Individual Exchange,,0.75690,,,,,,,0.29029,1.18,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,United Healthcare,Individual Exchange,,345.20,,,,,,,132.39,537.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,inpatient,1,ML,385.20000,231.12000,United Healthcare,Individual Exchange,,115.95,,,,,,,115.95,313.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,United Healthcare,Individual Exchange,,10.86,,,,,,,3.41,285.90,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,inpatient,10,ML,1813.25000,1087.95000,United Healthcare,Individual Exchange,,545.79,,,,,,,545.79,1474.17,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,United Healthcare,Individual Exchange,,10.86,,,,,,,3.41,1345.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,inpatient,1,UN,82.95000,49.77000,United Healthcare,Individual Exchange,,24.97,,,,,,,24.97,67.44,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,Individual Exchange,,4.74,,,,,,,1.65,61.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,United Healthcare,Individual Exchange,,2.40,,,,,,,0.92092,3.74,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,United Healthcare,Individual Exchange,,1135.14,,,,,,,435.35,1767.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,inpatient,1000,ML,101.50000,60.90000,United Healthcare,Individual Exchange,,30.55,,,,,,,30.55,82.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,inpatient,1000,ML,98.00000,58.80000,United Healthcare,Individual Exchange,,29.50,,,,,,,29.50,79.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,inpatient,1000,ML,94.50000,56.70000,United Healthcare,Individual Exchange,,28.44,,,,,,,28.44,76.83,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,inpatient,1000,ML,84.00000,50.40000,United Healthcare,Individual Exchange,,25.28,,,,,,,25.28,68.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,United Healthcare,Individual Exchange,,12.84,,,,,,,4.92,20.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,United Healthcare,Individual Exchange,,17.33,,,,,,,6.65,26.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,United Healthcare,Individual Exchange,,26.13,,,,,,,10.02,40.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,inpatient,1000,ML,98.00000,58.80000,United Healthcare,Individual Exchange,,29.50,,,,,,,29.50,79.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,inpatient,1000,ML,98.00000,58.80000,United Healthcare,Individual Exchange,,29.50,,,,,,,29.50,79.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,inpatient,100,ML,356.00000,213.60000,United Healthcare,Individual Exchange,,107.16,,,,,,,107.16,289.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,United Healthcare,Individual Exchange,,30.56,,,,,,,11.72,47.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,United Healthcare,Individual Exchange,,25.55,,,,,,,9.80,39.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,inpatient,17,ML,5076.25000,3045.75000,United Healthcare,Individual Exchange,,1527.95,,,,,,,1527.95,4126.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,United Healthcare,Individual Exchange,,0.86840,,,,,,,0.31040,3767.59,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,United Healthcare,Individual Exchange,,36.54,,,,,,,14.01,56.91,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,United Healthcare,Individual Exchange,,10.44,,,,,,,4.00,16.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,United Healthcare,Individual Exchange,,10.07,,,,,,,3.86,15.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,inpatient,1,ML,642.70000,385.62000,United Healthcare,Individual Exchange,,193.45,,,,,,,193.45,522.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,inpatient,0.5,ML,254.90000,152.94000,United Healthcare,Individual Exchange,,76.72,,,,,,,76.72,207.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,United Healthcare,Individual Exchange,,8.98,,,,,,,3.44,13.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,inpatient,20,ML,95.55000,57.33000,United Healthcare,Individual Exchange,,28.76,,,,,,,28.76,77.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,United Healthcare,Individual Exchange,,13.13,,,,,,,5.04,20.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,United Healthcare,Individual Exchange,,86.78,,,,,,,33.28,135.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,United Healthcare,Individual Exchange,,44.53,,,,,,,17.08,69.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,United Healthcare,Individual Exchange,,53.69,,,,,,,20.59,83.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,United Healthcare,Individual Exchange,,13.28,,,,,,,5.10,20.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,United Healthcare,Individual Exchange,,0.73080,,,,,,,0.28028,1.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,United Healthcare,Individual Exchange,,1261.60,,,,,,,483.85,1964.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,inpatient,1,UN,4022.30000,2413.38000,United Healthcare,Individual Exchange,,1210.71,,,,,,,1210.71,3270.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,United Healthcare,Individual Exchange,,25.57,,,,,,,8.49,2985.35,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,inpatient,10,ML,486.20000,291.72000,United Healthcare,Individual Exchange,,146.35,,,,,,,146.35,395.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,inpatient,20,ML,715.00000,429.00000,United Healthcare,Individual Exchange,,215.22,,,,,,,215.22,581.29,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,United Healthcare,Individual Exchange,,9.00,,,,,,,3.45,14.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,United Healthcare,Individual Exchange,,548.26,,,,,,,210.27,853.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,United Healthcare,Individual Exchange,,28.11,,,,,,,10.78,43.78,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,inpatient,1,UN,1730.85000,1038.51000,United Healthcare,Individual Exchange,,520.99,,,,,,,520.99,1407.18,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,United Healthcare,Individual Exchange,,1089.74,,,,,,,346.52,1284.64,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,Individual Exchange,,23.12,,,,,,,8.87,36.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,United Healthcare,Individual Exchange,,23.12,,,,,,,8.87,36.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,United Healthcare,Individual Exchange,,59.40,,,,,,,22.78,92.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,United Healthcare,Individual Exchange,,9.32,,,,,,,3.57,14.51,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,inpatient,1.5,ML,1650.30000,990.18000,United Healthcare,Individual Exchange,,496.74,,,,,,,496.74,1341.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,United Healthcare,Individual Exchange,,1448.89,,,,,,,330.39,1448.89,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,inpatient,,,45414.56000,27248.74000,United Healthcare,Individual Exchange,,13669.78,,,,,,,13669.78,36922.04,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,156212.38000,93727.43000,United Healthcare,Individual Exchange,,47019.93,,,,,,,47019.93,127000.66,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,inpatient,,,257500.00000,154500.00000,United Healthcare,Individual Exchange,,77507.50,,,,,,,77507.50,209347.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,11159.74000,6695.84000,United Healthcare,Individual Exchange,,3359.08,,,,,,,3359.08,9072.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,inpatient,,,7390.20000,4434.12000,United Healthcare,Individual Exchange,,2224.45,,,,,,,2224.45,6008.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,United Healthcare,Individual Exchange,,135.20,,,,,,,51.85,210.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,United Healthcare,Individual Exchange,,7.13,,,,,,,2.73,11.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,United Healthcare,Individual Exchange,,0.62640,,,,,,,0.24024,0.97560,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,United Healthcare,Individual Exchange,,4.78,,,,,,,1.83,7.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,inpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,inpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,inpatient,1000,ML,42.00000,25.20000,United Healthcare,Individual Exchange,,12.64,,,,,,,12.64,34.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,United Healthcare,Individual Exchange,,21.92,,,,,,,8.41,34.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,inpatient,20,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.06020,,,,,,,0.06020,0.16260,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,Individual Exchange,,0.10440,,,,,,,0.04004,0.16260,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX HOSPICE PRIVATE ROOM,11150001,CDM,115,RC,,,,,facility,inpatient,,,1328.00000,796.80000,United Healthcare,Individual Exchange,,874.00,,,,,,,849.92,2085.00,per diem,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Individual Exchange,,615.00,,,,,,,103.90,954.00,per diem,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,United Healthcare,Individual Exchange,,615.00,,,,,,,257.66,965.25,per diem,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,385.38,1443.75,per diem,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,578.78,2168.25,per diem,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,2601.75,per diem,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,3121.50,per diem,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,3747.00,per diem,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,413.41,1548.75,per diem,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,607.21,2274.75,per diem,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,4137.00,per diem,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Individual Exchange,,83.52,,,,,,,32.03,130.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,United Healthcare,Individual Exchange,,330.43,,,,,,,126.73,514.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Individual Exchange,,90.31,,,,,,,34.63,140.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,,61.07,,,,,,,23.42,95.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,32.36,,,,,,,12.41,50.41,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Individual Exchange,,13.57,,,,,,,5.21,21.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Individual Exchange,,74.65,,,,,,,28.63,116.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,32.89,,,,,,,12.61,51.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,42.28,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Individual Exchange,,82.48,,,,,,,31.63,128.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,United Healthcare,Individual Exchange,,273.53,,,,,,,104.90,426.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,United Healthcare,Individual Exchange,,311.63,,,,,,,119.52,485.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,United Healthcare,Individual Exchange,,265.18,,,,,,,101.70,413.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Individual Exchange,,48.02,,,,,,,18.42,74.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,United Healthcare,Individual Exchange,,38.11,,,,,,,14.61,59.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,United Healthcare,Individual Exchange,,120.06,,,,,,,46.05,186.99,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,United Healthcare,Individual Exchange,,110.14,,,,,,,42.24,171.54,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,United Healthcare,Individual Exchange,,2731.63,,,,,,,1047.65,4254.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,United Healthcare,Individual Exchange,,2731.63,,,,,,,1047.65,4254.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,United Healthcare,Individual Exchange,,2600.60,,,,,,,997.40,4050.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,United Healthcare,Individual Exchange,,932.29,,,,,,,357.56,1452.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,30.28,,,,,,,11.61,47.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,United Healthcare,Individual Exchange,,1568.61,,,,,,,601.60,2443.07,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,United Healthcare,Individual Exchange,,796.57,,,,,,,305.51,1240.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Individual Exchange,,163.39,,,,,,,62.66,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,42.28,,,,,,,16.22,65.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,32.89,,,,,,,12.61,51.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,United Healthcare,Individual Exchange,,570.55,,,,,,,218.82,888.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Individual Exchange,,178.52,,,,,,,68.47,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,United Healthcare,Individual Exchange,,645.19,,,,,,,247.45,1004.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,Individual Exchange,,474.50,,,,,,,181.98,739.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,Individual Exchange,,158.17,,,,,,,60.66,246.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,Individual Exchange,,261.00,,,,,,,100.10,406.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,United Healthcare,Individual Exchange,,489.64,,,,,,,187.79,762.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,United Healthcare,Individual Exchange,,138.85,,,,,,,53.25,216.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Individual Exchange,,106.49,,,,,,,40.84,165.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,United Healthcare,Individual Exchange,,570.02,,,,,,,218.62,887.80,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,United Healthcare,Individual Exchange,,494.86,,,,,,,189.79,770.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,United Healthcare,Individual Exchange,,149.29,,,,,,,57.26,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Individual Exchange,,22.45,,,,,,,8.61,34.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Individual Exchange,,18.27,,,,,,,7.01,28.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Individual Exchange,,73.08,,,,,,,28.03,113.82,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,United Healthcare,Individual Exchange,,247.43,,,,,,,94.89,385.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Individual Exchange,,65.77,,,,,,,25.23,102.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,United Healthcare,Individual Exchange,,149.29,,,,,,,57.26,232.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Individual Exchange,,69.95,,,,,,,26.83,108.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,United Healthcare,Individual Exchange,,5.74,,,,,,,2.20,8.94,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,inpatient,,,4985.00000,2991.00000,United Healthcare,Individual Exchange,,857.42,,,,,,,857.42,4137.55,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,United Healthcare,Individual Exchange,,633.10,,,,,,,633.10,3669.96,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,inpatient,,,20100.00000,12060.00000,United Healthcare,Individual Exchange,,3457.20,,,,,,,3457.20,16683.00,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,United Healthcare,Individual Exchange,,2552.70,,,,,,,2552.70,14797.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,inpatient,,,5074.00000,3044.40000,United Healthcare,Individual Exchange,,872.73,,,,,,,872.73,4211.42,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,United Healthcare,Individual Exchange,,644.40,,,,,,,644.40,3735.48,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,inpatient,,,4240.00000,2544.00000,United Healthcare,Individual Exchange,,729.28,,,,,,,729.28,3519.20,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,United Healthcare,Individual Exchange,,538.48,,,,,,,538.48,3121.49,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,inpatient,,,3478.00000,2086.80000,United Healthcare,Individual Exchange,,598.22,,,,,,,598.22,2886.74,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,United Healthcare,Individual Exchange,,441.71,,,,,,,441.71,2560.50,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,241.69,,,,,,,92.69,376.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,United Healthcare,Individual Exchange,,618.05,,,,,,,237.04,962.59,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,United Healthcare,Individual Exchange,,1269.50,,,,,,,486.89,1977.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,United Healthcare,Individual Exchange,,1923.05,,,,,,,737.54,2995.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,United Healthcare,Individual Exchange,,2243.03,,,,,,,860.26,3493.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,United Healthcare,Individual Exchange,,63.16,,,,,,,24.22,98.37,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,341.54,1279.50,per diem,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,2569.50,per diem,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,16.62,954.00,per diem,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,United Healthcare,Individual Exchange,,615.00,,,,,,,93.49,954.00,per diem,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,United Healthcare,Individual Exchange,,359.66,,,,,,,119.95,560.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,United Healthcare,Individual Exchange,,812.75,,,,,,,271.07,1265.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,United Healthcare,Individual Exchange,,615.44,,,,,,,205.26,958.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Individual Exchange,,41.24,,,,,,,13.75,64.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Individual Exchange,,703.00,,,,,,,15.32,1090.00,per diem,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,United Healthcare,Individual Exchange,,3744.83,,,,,,,1436.23,5832.46,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,United Healthcare,Individual Exchange,,394.63,,,,,,,151.35,614.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,United Healthcare,Individual Exchange,,1.57,,,,,,,0.60060,2.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,United Healthcare,Individual Exchange,,860.78,,,,,,,330.13,1340.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,United Healthcare,Individual Exchange,,1110.29,,,,,,,425.83,1729.25,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,United Healthcare,Individual Exchange,,1360.85,,,,,,,521.92,2119.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,United Healthcare,Individual Exchange,,1610.37,,,,,,,617.62,2508.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,United Healthcare,Individual Exchange,,1860.41,,,,,,,713.51,2897.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,United Healthcare,Individual Exchange,,2110.45,,,,,,,809.41,3286.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,United Healthcare,Individual Exchange,,2359.96,,,,,,,905.10,3675.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,United Healthcare,Individual Exchange,,345.04,,,,,,,132.33,537.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,United Healthcare,Individual Exchange,,1712.16,,,,,,,656.66,2666.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,United Healthcare,Individual Exchange,,2256.08,,,,,,,865.26,3513.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,Individual Exchange,,675.47,,,,,,,259.06,1052.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,United Healthcare,Individual Exchange,,920.29,,,,,,,352.95,1433.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,United Healthcare,Individual Exchange,,1026.25,,,,,,,393.59,1598.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,United Healthcare,Individual Exchange,,1136.39,,,,,,,435.84,1769.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,United Healthcare,Individual Exchange,,1246.01,,,,,,,477.88,1940.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,United Healthcare,Individual Exchange,,1355.11,,,,,,,519.72,2110.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,United Healthcare,Individual Exchange,,1465.25,,,,,,,561.96,2282.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,United Healthcare,Individual Exchange,,860.78,,,,,,,330.13,1340.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,United Healthcare,Individual Exchange,,500.08,,,,,,,191.79,778.85,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,United Healthcare,Individual Exchange,,1246.01,,,,,,,477.88,1940.63,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,Individual Exchange,,675.47,,,,,,,259.06,1052.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,United Healthcare,Individual Exchange,,920.29,,,,,,,352.95,1433.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,United Healthcare,Individual Exchange,,1026.25,,,,,,,393.59,1598.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,United Healthcare,Individual Exchange,,1136.39,,,,,,,435.84,1769.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,United Healthcare,Individual Exchange,,1355.11,,,,,,,519.72,2110.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,United Healthcare,Individual Exchange,,1465.25,,,,,,,561.96,2282.09,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,United Healthcare,Individual Exchange,,1712.16,,,,,,,656.66,2666.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,United Healthcare,Individual Exchange,,2256.08,,,,,,,865.26,3513.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Individual Exchange,,260.48,,,,,,,99.90,405.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,87.00,,,,,,,15.42,134.00,per diem,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,4076.00,,,,,,,10.56,7281.00,case rate,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,United Healthcare,Individual Exchange,,4076.00,,,,,,,16.21,7281.00,case rate,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,Individual Exchange,,4076.00,,,,,,,34.50,7281.00,case rate,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Individual Exchange,,4076.00,,,,,,,18.85,7281.00,case rate,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Individual Exchange,,4076.00,,,,,,,18.66,7281.00,case rate,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Individual Exchange,,103.20,,,,,,,103.20,498.00,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,Individual Exchange,,76.20,,,,,,,76.20,441.72,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,United Healthcare,Individual Exchange,,128.31,,,,,,,128.31,619.18,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,Individual Exchange,,94.74,,,,,,,94.74,549.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,1375.00000,825.00000,United Healthcare,Individual Exchange,,236.50,,,,,,,236.50,1141.25,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,United Healthcare,Individual Exchange,,174.62,,,,,,,174.62,1012.27,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,19569.00000,11741.40000,United Healthcare,Individual Exchange,,3365.87,,,,,,,3365.87,16242.27,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,United Healthcare,Individual Exchange,,2485.26,,,,,,,2485.26,14406.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,9120.00000,5472.00000,United Healthcare,Individual Exchange,,1568.64,,,,,,,1568.64,7569.60,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,United Healthcare,Individual Exchange,,1158.24,,,,,,,1158.24,6714.14,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,United Healthcare,Individual Exchange,,880.64,,,,,,,880.64,4249.60,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Individual Exchange,,650.24,,,,,,,650.24,3769.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,4954.00000,2972.40000,United Healthcare,Individual Exchange,,852.09,,,,,,,852.09,4111.82,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,United Healthcare,Individual Exchange,,629.16,,,,,,,629.16,3647.13,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,7438.00000,4462.80000,United Healthcare,Individual Exchange,,1279.34,,,,,,,1279.34,6173.54,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,United Healthcare,Individual Exchange,,944.63,,,,,,,944.63,5475.86,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,8418.00000,5050.80000,United Healthcare,Individual Exchange,,1447.90,,,,,,,1447.90,6986.94,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,United Healthcare,Individual Exchange,,1069.09,,,,,,,1069.09,6197.33,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5120.00000,3072.00000,United Healthcare,Individual Exchange,,880.64,,,,,,,880.64,4249.60,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Individual Exchange,,650.24,,,,,,,650.24,3769.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,6348.00000,3808.80000,United Healthcare,Individual Exchange,,1091.86,,,,,,,1091.86,5268.84,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,United Healthcare,Individual Exchange,,806.20,,,,,,,806.20,4673.40,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,United Healthcare,Individual Exchange,,54.70,,,,,,,54.70,263.94,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Individual Exchange,,40.39,,,,,,,40.39,234.11,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,United Healthcare,Individual Exchange,,17.72,,,,,,,17.72,85.49,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,United Healthcare,Individual Exchange,,13.08,,,,,,,13.08,75.83,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,209.00000,125.40000,United Healthcare,Individual Exchange,,35.95,,,,,,,35.95,173.47,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Individual Exchange,,26.54,,,,,,,26.54,153.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,14.62,,,,,,,5.61,22.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,24.94,,,,,,,24.94,120.35,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,18.41,,,,,,,18.41,106.75,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,318.00000,190.80000,United Healthcare,Individual Exchange,,54.70,,,,,,,54.70,263.94,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Individual Exchange,,40.39,,,,,,,40.39,234.11,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,126.00000,75.60000,United Healthcare,Individual Exchange,,21.67,,,,,,,21.67,104.58,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Individual Exchange,,16.00,,,,,,,16.00,92.76,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,151.00000,90.60000,United Healthcare,Individual Exchange,,25.97,,,,,,,25.97,125.33,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,United Healthcare,Individual Exchange,,19.18,,,,,,,19.18,111.17,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,184.00000,110.40000,United Healthcare,Individual Exchange,,31.65,,,,,,,31.65,152.72,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,United Healthcare,Individual Exchange,,23.37,,,,,,,23.37,135.46,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,295.00000,177.00000,United Healthcare,Individual Exchange,,50.74,,,,,,,50.74,244.85,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Individual Exchange,,37.47,,,,,,,37.47,217.18,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,355.00000,213.00000,United Healthcare,Individual Exchange,,61.06,,,,,,,61.06,294.65,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,United Healthcare,Individual Exchange,,45.09,,,,,,,45.09,261.35,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Individual Exchange,,180.26,,,,,,,180.26,869.84,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Individual Exchange,,133.10,,,,,,,133.10,771.54,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,103.00000,61.80000,United Healthcare,Individual Exchange,,17.72,,,,,,,17.72,85.49,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,United Healthcare,Individual Exchange,,13.08,,,,,,,13.08,75.83,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,425.00000,255.00000,United Healthcare,Individual Exchange,,73.10,,,,,,,73.10,352.75,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,Individual Exchange,,53.98,,,,,,,53.98,312.88,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,600.00000,360.00000,United Healthcare,Individual Exchange,,103.20,,,,,,,103.20,498.00,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,Individual Exchange,,76.20,,,,,,,76.20,441.72,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1073.00000,643.80000,United Healthcare,Individual Exchange,,184.56,,,,,,,184.56,890.59,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,United Healthcare,Individual Exchange,,136.27,,,,,,,136.27,789.94,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,948.00000,568.80000,United Healthcare,Individual Exchange,,163.06,,,,,,,163.06,786.84,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,United Healthcare,Individual Exchange,,120.40,,,,,,,120.40,697.92,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,United Healthcare,Individual Exchange,,128.31,,,,,,,128.31,619.18,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,Individual Exchange,,94.74,,,,,,,94.74,549.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,746.00000,447.60000,United Healthcare,Individual Exchange,,128.31,,,,,,,128.31,619.18,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,United Healthcare,Individual Exchange,,94.74,,,,,,,94.74,549.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Individual Exchange,,46.96,,,,,,,46.96,226.59,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Individual Exchange,,34.67,,,,,,,34.67,200.98,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,774.00000,464.40000,United Healthcare,Individual Exchange,,133.13,,,,,,,133.13,642.42,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,United Healthcare,Individual Exchange,,98.30,,,,,,,98.30,569.82,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Individual Exchange,,2672.64,,,,,,,1025.02,4162.56,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,503.00000,301.80000,United Healthcare,Individual Exchange,,86.52,,,,,,,86.52,417.49,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,United Healthcare,Individual Exchange,,63.88,,,,,,,63.88,370.31,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,United Healthcare,Individual Exchange,,235.94,,,,,,,90.49,367.48,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,inpatient,,,1349.00000,809.40000,United Healthcare,Individual Exchange,,232.03,,,,,,,232.03,1119.67,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,United Healthcare,Individual Exchange,,171.32,,,,,,,171.32,993.13,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5120.00000,3072.00000,United Healthcare,Individual Exchange,,880.64,,,,,,,880.64,4249.60,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,United Healthcare,Individual Exchange,,650.24,,,,,,,650.24,3769.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1484.00000,890.40000,United Healthcare,Individual Exchange,,255.25,,,,,,,255.25,1231.72,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,United Healthcare,Individual Exchange,,188.47,,,,,,,188.47,1092.52,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1379.00000,827.40000,United Healthcare,Individual Exchange,,237.19,,,,,,,237.19,1144.57,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,United Healthcare,Individual Exchange,,175.13,,,,,,,175.13,1015.22,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,9.98,,,,,,,9.98,48.14,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,7.37,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,9.98,,,,,,,9.98,48.14,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,7.37,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,9.98,,,,,,,9.98,48.14,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,7.37,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,9.98,,,,,,,9.98,48.14,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,7.37,,,,,,,7.37,42.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,92.02,,,,,,,92.02,444.05,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,67.94,,,,,,,67.94,393.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,92.02,,,,,,,92.02,444.05,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,67.94,,,,,,,67.94,393.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,92.02,,,,,,,92.02,444.05,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,67.94,,,,,,,67.94,393.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00522,,,,,,,0.00200,0.00813,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,United Healthcare,Individual Exchange,,3507.84,,,,,,,1345.34,5463.36,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,United Healthcare,Individual Exchange,,158.58,,,,,,,158.58,765.26,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,Individual Exchange,,117.09,,,,,,,117.09,678.78,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,United Healthcare,Individual Exchange,,158.58,,,,,,,158.58,765.26,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,Individual Exchange,,117.09,,,,,,,117.09,678.78,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,922.00000,553.20000,United Healthcare,Individual Exchange,,158.58,,,,,,,158.58,765.26,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,United Healthcare,Individual Exchange,,117.09,,,,,,,117.09,678.78,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1215.00000,729.00000,United Healthcare,Individual Exchange,,208.98,,,,,,,208.98,1008.45,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,United Healthcare,Individual Exchange,,154.31,,,,,,,154.31,894.48,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,1631.00000,978.60000,United Healthcare,Individual Exchange,,280.53,,,,,,,280.53,1353.73,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,United Healthcare,Individual Exchange,,207.14,,,,,,,207.14,1200.74,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,United Healthcare,Individual Exchange,,1513.28,,,,,,,580.38,2356.89,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,inpatient,,,350.00000,210.00000,United Healthcare,Individual Exchange,,60.20,,,,,,,60.20,290.50,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Individual Exchange,,44.45,,,,,,,44.45,257.67,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,inpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,79.64,,,,,,,79.64,384.29,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,58.80,,,,,,,58.80,340.86,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,inpatient,,,140.00000,84.00000,United Healthcare,Individual Exchange,,24.08,,,,,,,24.08,116.20,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Individual Exchange,,17.78,,,,,,,17.78,103.07,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,16.34,,,,,,,16.34,78.85,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,12.06,,,,,,,12.06,69.94,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,inpatient,,,166.00000,99.60000,United Healthcare,Individual Exchange,,28.55,,,,,,,28.55,137.78,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Individual Exchange,,21.08,,,,,,,21.08,122.21,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,inpatient,,,350.00000,210.00000,United Healthcare,Individual Exchange,,60.20,,,,,,,60.20,290.50,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Individual Exchange,,44.45,,,,,,,44.45,257.67,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,inpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,15.65,,,,,,,15.65,75.53,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,11.56,,,,,,,11.56,66.99,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,inpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,17.37,,,,,,,17.37,83.83,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,12.83,,,,,,,12.83,74.36,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5270.00000,3162.00000,United Healthcare,Individual Exchange,,906.44,,,,,,,906.44,4374.10,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,United Healthcare,Individual Exchange,,669.29,,,,,,,669.29,3879.77,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,inpatient,,,1024.00000,614.40000,United Healthcare,Individual Exchange,,176.13,,,,,,,176.13,849.92,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,United Healthcare,Individual Exchange,,130.05,,,,,,,130.05,753.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,inpatient,,,637.00000,382.20000,United Healthcare,Individual Exchange,,109.56,,,,,,,109.56,528.71,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Individual Exchange,,80.90,,,,,,,80.90,468.96,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,inpatient,,,39570.00000,23742.00000,United Healthcare,Individual Exchange,,11910.57,,,,,,,11910.57,32170.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,17004.00000,10202.40000,United Healthcare,Individual Exchange,,5118.20,,,,,,,5118.20,13824.25,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,297.00000,178.20000,United Healthcare,Individual Exchange,,51.08,,,,,,,51.08,246.51,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,Individual Exchange,,37.72,,,,,,,33.78,218.65,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,inpatient,,,308.00000,184.80000,United Healthcare,Individual Exchange,,52.98,,,,,,,52.98,255.64,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,United Healthcare,Individual Exchange,,39.12,,,,,,,33.78,226.75,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,1919.00000,1151.40000,United Healthcare,Individual Exchange,,577.62,,,,,,,577.62,1560.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,7252.00000,4351.20000,United Healthcare,Individual Exchange,,2182.85,,,,,,,2182.85,5895.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,1734.00000,1040.40000,United Healthcare,Individual Exchange,,521.93,,,,,,,521.93,1409.74,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,3295.00000,1977.00000,United Healthcare,Individual Exchange,,991.79,,,,,,,991.79,2678.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,40220.00000,24132.00000,United Healthcare,Individual Exchange,,12106.22,,,,,,,12106.22,32698.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,12517.00000,7510.20000,United Healthcare,Individual Exchange,,3767.62,,,,,,,3767.62,10176.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,11120.00000,6672.00000,United Healthcare,Individual Exchange,,3347.12,,,,,,,3347.12,9040.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,15665.00000,9399.00000,United Healthcare,Individual Exchange,,4715.16,,,,,,,4715.16,12735.65,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,31578.00000,18946.80000,United Healthcare,Individual Exchange,,9504.98,,,,,,,9504.98,25672.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,2639.00000,1583.40000,United Healthcare,Individual Exchange,,794.34,,,,,,,794.34,2145.51,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,11117.00000,6670.20000,United Healthcare,Individual Exchange,,3346.22,,,,,,,3346.22,9038.12,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,inpatient,,,16042.00000,9625.20000,United Healthcare,Individual Exchange,,4828.64,,,,,,,4828.64,13042.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,9476.00000,5685.60000,United Healthcare,Individual Exchange,,1629.87,,,,,,,1629.87,7865.08,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,United Healthcare,Individual Exchange,,1203.45,,,,,,,1203.45,6976.23,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,United Healthcare,Individual Exchange,,811.50,,,,,,,811.50,2191.85,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,inpatient,,,2696.00000,1617.60000,United Healthcare,Individual Exchange,,463.71,,,,,,,463.71,2237.68,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,United Healthcare,Individual Exchange,,342.39,,,,,,,342.39,1984.80,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,inpatient,,,8366.00000,5019.60000,United Healthcare,Individual Exchange,,2518.17,,,,,,,2518.17,6801.56,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,8920.00000,5352.00000,United Healthcare,Individual Exchange,,2684.92,,,,,,,2684.92,7251.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,inpatient,,,11277.00000,6766.20000,United Healthcare,Individual Exchange,,3394.38,,,,,,,3394.38,9168.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6131.00000,3678.60000,United Healthcare,Individual Exchange,,1054.53,,,,,,,1054.53,5088.73,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,United Healthcare,Individual Exchange,,778.64,,,,,,,778.64,4513.64,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,inpatient,,,15495.00000,9297.00000,United Healthcare,Individual Exchange,,4663.99,,,,,,,4663.99,12597.43,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,inpatient,,,1255.00000,753.00000,United Healthcare,Individual Exchange,,215.86,,,,,,,215.86,1041.65,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,Individual Exchange,,159.38,,,,,,,35.64,923.93,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,inpatient,,,537.00000,322.20000,United Healthcare,Individual Exchange,,92.36,,,,,,,92.36,445.71,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,United Healthcare,Individual Exchange,,68.20,,,,,,,68.20,395.34,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,inpatient,,,6720.00000,4032.00000,United Healthcare,Individual Exchange,,1155.84,,,,,,,1155.84,5577.60,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,United Healthcare,Individual Exchange,,853.44,,,,,,,853.44,4947.26,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,5270.00000,3162.00000,United Healthcare,Individual Exchange,,906.44,,,,,,,906.44,4374.10,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,United Healthcare,Individual Exchange,,669.29,,,,,,,669.29,3879.77,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,940.00000,564.00000,United Healthcare,Individual Exchange,,161.68,,,,,,,161.68,780.20,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,United Healthcare,Individual Exchange,,119.38,,,,,,,119.38,692.03,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,inpatient,,,220.00000,132.00000,United Healthcare,Individual Exchange,,37.84,,,,,,,37.84,182.60,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,United Healthcare,Individual Exchange,,27.94,,,,,,,27.94,161.96,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,555.00000,333.00000,United Healthcare,Individual Exchange,,95.46,,,,,,,95.46,460.65,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,United Healthcare,Individual Exchange,,70.48,,,,,,,70.48,408.59,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,inpatient,,,5436.00000,3261.60000,United Healthcare,Individual Exchange,,934.99,,,,,,,934.99,4511.88,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,United Healthcare,Individual Exchange,,690.37,,,,,,,690.37,4001.98,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,19845.00000,11907.00000,United Healthcare,Individual Exchange,,3413.34,,,,,,,3413.34,16471.35,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,United Healthcare,Individual Exchange,,2520.32,,,,,,,2520.32,14609.89,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,inpatient,,,27390.00000,16434.00000,United Healthcare,Individual Exchange,,4711.08,,,,,,,4711.08,22733.70,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,United Healthcare,Individual Exchange,,3478.53,,,,,,,3478.53,20164.52,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,United Healthcare,Individual Exchange,,48.33,,,,,,,48.33,233.23,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,Individual Exchange,,35.69,,,,,,,35.69,206.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,281.00000,168.60000,United Healthcare,Individual Exchange,,48.33,,,,,,,48.33,233.23,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,Individual Exchange,,35.69,,,,,,,35.69,206.87,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,United Healthcare,Individual Exchange,,45.24,,,,,,,45.24,218.29,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,Individual Exchange,,33.40,,,,,,,33.40,193.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,United Healthcare,Individual Exchange,,45.24,,,,,,,45.24,218.29,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,Individual Exchange,,33.40,,,,,,,33.40,193.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,inpatient,,,263.00000,157.80000,United Healthcare,Individual Exchange,,45.24,,,,,,,45.24,218.29,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,United Healthcare,Individual Exchange,,33.40,,,,,,,33.40,193.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,inpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00172,,,,,,,0.00172,0.00830,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,0.00127,,,,,,,0.00127,0.00736,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,inpatient,,,3125.00000,1875.00000,United Healthcare,Individual Exchange,,537.50,,,,,,,537.50,2593.75,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,United Healthcare,Individual Exchange,,396.88,,,,,,,396.88,2300.62,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,United Healthcare,Individual Exchange,,611.78,,,,,,,234.63,952.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,United Healthcare,Individual Exchange,,786.65,,,,,,,301.70,1225.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,United Healthcare,Individual Exchange,,738.63,,,,,,,283.28,1150.39,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,United Healthcare,Individual Exchange,,715.14,,,,,,,274.27,1113.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Individual Exchange,,95.00,,,,,,,36.44,147.97,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Individual Exchange,,494.00,,,,,,,84.68,767.00,per diem,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Individual Exchange,,488.00,,,,,,,95.58,759.00,per diem,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Individual Exchange,,488.00,,,,,,,44.39,759.00,per diem,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,Individual Exchange,,488.00,,,,,,,101.85,759.00,per diem,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Individual Exchange,,488.00,,,,,,,44.39,759.00,per diem,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Individual Exchange,,488.00,,,,,,,65.64,759.00,per diem,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Individual Exchange,,488.00,,,,,,,16.02,759.00,per diem,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Individual Exchange,,488.00,,,,,,,50.14,759.00,per diem,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Individual Exchange,,488.00,,,,,,,76.08,759.00,per diem,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Individual Exchange,,488.00,,,,,,,44.39,759.00,per diem,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,United Healthcare,Individual Exchange,,488.00,,,,,,,40.74,759.00,per diem,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,Individual Exchange,,488.00,,,,,,,113.51,759.00,per diem,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,inpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,18.92,,,,,,,18.92,91.30,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,13.97,,,,,,,13.97,80.98,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,Individual Exchange,,4.47,,,,,,,3.90,24.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,United Healthcare,Individual Exchange,,2310.00,,,,,,,319.11,3466.00,per diem,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,,2310.00,,,,,,,23.42,3466.00,per diem,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,,2310.00,,,,,,,23.42,3466.00,per diem,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,Individual Exchange,,2310.00,,,,,,,48.05,3466.00,per diem,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,United Healthcare,Individual Exchange,,2310.00,,,,,,,72.07,3466.00,per diem,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,2310.00,,,,,,,92.69,3466.00,per diem,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,Individual Exchange,,2310.00,,,,,,,68.47,3466.00,per diem,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,United Healthcare,Individual Exchange,,2310.00,,,,,,,319.11,3466.00,per diem,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,Individual Exchange,,2310.00,,,,,,,319.11,3466.00,per diem,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,292.29,1095.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,345.14,1293.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1573.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,2639.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,4681.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,5048.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.13,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,4764.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,5351.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,5351.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,339.94,1273.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,2076.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,93.89,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1158.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,214.41,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1396.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,90.09,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,5619.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,5590.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1798.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1309.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,United Healthcare,Individual Exchange,,2053.00,,,,,,,620.62,3185.00,per diem,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,United Healthcare,Individual Exchange,,2053.00,,,,,,,1686.28,6317.25,per diem,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,85.08,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,113.51,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,436.04,1633.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,418.82,1569.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,556.54,3476.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,492.09,1843.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,600.40,2249.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,63.26,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,64.26,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,United Healthcare,Individual Exchange,,2310.00,,,,,,,215.42,3466.00,per diem,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Individual Exchange,,2310.00,,,,,,,68.47,3466.00,per diem,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,Individual Exchange,,2310.00,,,,,,,120.72,3466.00,per diem,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Individual Exchange,,2310.00,,,,,,,68.47,3466.00,per diem,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,United Healthcare,Individual Exchange,,2310.00,,,,,,,307.71,3466.00,per diem,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Individual Exchange,,2310.00,,,,,,,44.39,3466.00,per diem,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,Individual Exchange,,2310.00,,,,,,,146.95,3466.00,per diem,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,Individual Exchange,,494.00,,,,,,,91.49,767.00,per diem,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,United Healthcare,Individual Exchange,,494.00,,,,,,,66.27,767.00,per diem,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Individual Exchange,,2310.00,,,,,,,104.70,3466.00,per diem,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,5351.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,206.61,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,105.35,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,232.83,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,210.41,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,253.01,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,United Healthcare,Individual Exchange,76,688.00,,,,,,,281.48,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,556.54,2811.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,United Healthcare,Individual Exchange,76,688.00,,,,,,,688.00,2811.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,556.54,2958.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,United Healthcare,Individual Exchange,76,688.00,,,,,,,688.00,2958.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1525.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1695.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1787.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1971.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1374.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1966.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,68.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,82.68,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,82.68,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Individual Exchange,,2310.00,,,,,,,58.46,3466.00,per diem,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,United Healthcare,Individual Exchange,,17317.00,,,,,,,568.97,26864.00,case rate,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,United Healthcare,Individual Exchange,,17317.00,,,,,,,5465.26,26864.00,case rate,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,667.51,2814.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,667.51,3237.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,667.51,3237.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,129.73,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,141.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,245.25,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,172.17,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,182.98,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,187.79,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,128.33,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,76,688.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,76,688.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,68.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,130.13,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,72.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,76,688.00,,,,,,,373.37,1398.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Individual Exchange,,2310.00,,,,,,,91.09,3466.00,per diem,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,United Healthcare,Individual Exchange,76,688.00,,,,,,,172.17,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,United Healthcare,Individual Exchange,76,688.00,,,,,,,182.98,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,99.90,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,326.13,1221.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1757.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,5185.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,688.00,4550.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1690.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,2127.75,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,1386.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,109.91,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,127.74,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,250.65,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,352.19,6123.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,482.48,1807.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,81.08,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,112.11,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,332.73,1246.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,384.98,1442.25,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,United Healthcare,Individual Exchange,,688.00,,,,,,,255.05,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Individual Exchange,,688.00,,,,,,,63.26,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,United Healthcare,Individual Exchange,,688.00,,,,,,,130.13,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,436.04,1633.50,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,625.22,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,United Healthcare,Individual Exchange,,494.00,,,,,,,61.11,767.00,per diem,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,211.01,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Individual Exchange,,17.75,,,,,,,6.41,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,93.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,United Healthcare,Individual Exchange,,536.62,,,,,,,186.78,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,United Healthcare,Individual Exchange,,632.66,,,,,,,186.78,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,64.46,5189.94,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,151.55,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,32.43,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,203.70,4311.00,per diem,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,59.86,467.00,per diem,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,United Healthcare,Individual Exchange,,282.00,,,,,,,103.59,4311.00,per diem,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,10.97,440.00,per diem,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,19.67,440.00,per diem,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,4.87,440.00,per diem,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,4.87,440.00,per diem,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Individual Exchange,,282.00,,,,,,,52.58,440.00,per diem,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Individual Exchange,,282.00,,,,,,,6.44,440.00,per diem,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Individual Exchange,,282.00,,,,,,,6.44,440.00,per diem,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,4.00,440.00,per diem,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,10.10,440.00,per diem,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,282.00,,,,,,,9.75,440.00,per diem,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Individual Exchange,,282.00,,,,,,,18.98,440.00,per diem,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Individual Exchange,,282.00,,,,,,,34.82,440.00,per diem,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Individual Exchange,,282.00,,,,,,,28.03,440.00,per diem,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,19.67,440.00,per diem,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,23.16,440.00,per diem,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,19.67,440.00,per diem,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,76.26,440.00,per diem,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Individual Exchange,,282.00,,,,,,,8.71,440.00,per diem,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,71.90,440.00,per diem,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Individual Exchange,,282.00,,,,,,,50.14,440.00,per diem,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,282.00,,,,,,,9.40,440.00,per diem,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Individual Exchange,,282.00,,,,,,,6.44,440.00,per diem,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,United Healthcare,Individual Exchange,,282.00,,,,,,,33.25,440.00,per diem,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Individual Exchange,,282.00,,,,,,,35.88,440.00,per diem,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,10.44,276.00,per diem,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,11.69,276.00,per diem,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,1.87,276.00,per diem,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,18.85,276.00,per diem,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,7.63,276.00,per diem,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,2.49,276.00,per diem,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,23.84,276.00,per diem,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,25.40,276.00,per diem,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,19.94,276.00,per diem,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,17.14,276.00,per diem,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,9.19,276.00,per diem,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,25.55,276.00,per diem,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,24.93,276.00,per diem,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,22.44,276.00,per diem,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,25.71,276.00,per diem,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,21.66,276.00,per diem,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,31.47,276.00,per diem,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,18.23,276.00,per diem,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,20.10,276.00,per diem,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,23.53,276.00,per diem,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,7.32,276.00,per diem,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,18.38,276.00,per diem,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,13.24,276.00,per diem,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,20.10,276.00,per diem,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,15.42,276.00,per diem,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,28.04,4311.00,per diem,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,28.04,4311.00,per diem,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,14.18,276.00,per diem,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,14.18,276.00,per diem,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,13.87,276.00,per diem,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,19.79,276.00,per diem,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,20.25,276.00,per diem,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,10.91,276.00,per diem,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,4.67,276.00,per diem,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,47.67,276.00,per diem,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,65.90,276.00,per diem,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,67.62,276.00,per diem,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,44.87,276.00,per diem,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,14.18,276.00,per diem,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,18.23,276.00,per diem,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,20.10,276.00,per diem,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,18.38,276.00,per diem,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,10.91,276.00,per diem,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,20.10,276.00,per diem,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,15.42,276.00,per diem,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,1.87,276.00,per diem,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,25.40,276.00,per diem,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,19.94,276.00,per diem,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,9.66,276.00,per diem,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,25.55,276.00,per diem,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,24.93,276.00,per diem,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,22.44,276.00,per diem,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,25.71,276.00,per diem,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,7.63,276.00,per diem,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,34.90,276.00,per diem,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,23.68,276.00,per diem,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,19.79,276.00,per diem,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,11.69,276.00,per diem,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,49.54,276.00,per diem,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,62.79,276.00,per diem,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,64.66,276.00,per diem,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Individual Exchange,GO,165.00,,,,,,,31.47,276.00,per diem,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,55.46,276.00,per diem,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,52.35,276.00,per diem,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,29.13,276.00,per diem,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,41.91,276.00,per diem,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,31.16,276.00,per diem,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,49.08,276.00,per diem,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,19.94,276.00,per diem,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,10.91,276.00,per diem,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,13.24,276.00,per diem,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,15.42,276.00,per diem,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,35.68,276.00,per diem,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,21.19,276.00,per diem,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,102.05,399.55,per diem,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,40.35,276.00,per diem,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,10.59,276.00,per diem,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,20.25,276.00,per diem,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,10.91,276.00,per diem,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,4.67,276.00,per diem,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,33.34,276.00,per diem,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,35.68,276.00,per diem,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,16.67,276.00,per diem,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,55.00,276.00,per diem,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,85.53,411.75,per diem,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,United Healthcare,Individual Exchange,GN,165.00,,,,,,,92.08,443.25,per diem,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,Individual Exchange,,243.00,,,,,,,150.42,648.00,per diem,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Individual Exchange,,243.00,,,,,,,95.58,411.75,per diem,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,United Healthcare,Individual Exchange,,243.00,,,,,,,154.08,663.75,per diem,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,Individual Exchange,,243.00,,,,,,,87.75,557.85,per diem,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,United Healthcare,Individual Exchange,,243.00,,,,,,,129.70,558.75,per diem,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,United Healthcare,Individual Exchange,,243.00,,,,,,,243.00,2817.00,per diem,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Individual Exchange,,243.00,,,,,,,7.49,374.00,per diem,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,Individual Exchange,,243.00,,,,,,,25.77,374.00,per diem,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,United Healthcare,Individual Exchange,,243.00,,,,,,,91.40,393.75,per diem,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Individual Exchange,,243.00,,,,,,,91.05,392.25,per diem,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,United Healthcare,Individual Exchange,,243.00,,,,,,,98.02,422.25,per diem,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Individual Exchange,,243.00,,,,,,,65.64,374.00,per diem,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Individual Exchange,,243.00,,,,,,,65.64,374.00,per diem,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,Individual Exchange,,243.00,,,,,,,236.25,1017.75,per diem,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,United Healthcare,Individual Exchange,,243.00,,,,,,,72.77,374.00,per diem,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,Individual Exchange,,243.00,,,,,,,141.37,609.00,per diem,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Individual Exchange,,243.00,,,,,,,18.63,374.00,per diem,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,United Healthcare,Individual Exchange,,243.00,,,,,,,98.71,425.25,per diem,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,United Healthcare,Individual Exchange,,243.00,,,,,,,82.87,374.00,per diem,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,Individual Exchange,,243.00,,,,,,,113.51,489.00,per diem,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Individual Exchange,,243.00,,,,,,,79.74,374.00,per diem,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Individual Exchange,,243.00,,,,,,,27.16,374.00,per diem,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Individual Exchange,,124.00,,,,,,,31.34,327.39,per diem,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,203.70,4311.00,per diem,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,United Healthcare,Individual Exchange,,124.00,,,,,,,22.81,192.00,per diem,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,Individual Exchange,,124.00,,,,,,,124.00,1156.50,per diem,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,Individual Exchange,,124.00,,,,,,,124.00,1156.50,per diem,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Individual Exchange,,124.00,,,,,,,45.96,198.00,per diem,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Individual Exchange,,124.00,,,,,,,45.96,327.39,per diem,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,United Healthcare,Individual Exchange,,1044.00,,,,,,,186.78,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Individual Exchange,,494.00,,,,,,,494.00,4376.00,per diem,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,United Healthcare,Individual Exchange,,365.40,,,,,,,121.87,735.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,303.99,12247.00,per diem,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Individual Exchange,,433.78,,,,,,,144.68,675.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,United Healthcare,Individual Exchange,,339.00,,,,,,,87.92,557.85,per diem,For non-psychiatric disorders only.
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,United Healthcare,Individual Exchange,,339.00,,,,,,,38.65,528.00,per diem,For non-psychiatric disorders only.
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,United Healthcare,Individual Exchange,,339.00,,,,,,,57.98,528.00,per diem,For non-psychiatric disorders only.
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,United Healthcare,Individual Exchange,,339.00,,,,,,,58.85,528.00,per diem,For non-psychiatric disorders only.
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,Individual Exchange,,494.00,,,,,,,32.21,767.00,per diem,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,Individual Exchange,,1990.00,,,,,,,510.48,4532.25,per diem,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,Individual Exchange,,1990.00,,,,,,,510.48,4532.25,per diem,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,United Healthcare,Individual Exchange,,1990.00,,,,,,,150.52,1990.00,per diem,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,Individual Exchange,,1990.00,,,,,,,840.84,3150.00,per diem,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,Individual Exchange,,1990.00,,,,,,,840.84,3150.00,per diem,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,United Healthcare,Individual Exchange,,1990.00,,,,,,,854.05,3199.50,per diem,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,United Healthcare,Individual Exchange,,175.00,,,,,,,175.00,865.50,per diem,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,United Healthcare,Individual Exchange,,615.00,,,,,,,110.51,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,98.37,423.75,per diem,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,175.00,1012.50,per diem,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,192.79,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,95.75,412.50,per diem,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,192.79,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,150.52,788.25,per diem,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,90.69,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,175.00,953.25,per diem,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,United Healthcare,Individual Exchange,,615.00,,,,,,,232.03,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,102.31,546.00,per diem,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,96.30,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,175.00,844.50,per diem,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,63.26,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,102.31,568.50,per diem,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Individual Exchange,,615.00,,,,,,,24.82,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,102.31,718.50,per diem,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,99.41,428.25,per diem,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,United Healthcare,Individual Exchange,,175.00,,,,,,,80.78,348.00,per diem,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Individual Exchange,,175.00,,,,,,,93.70,404.25,per diem,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,87.57,377.25,per diem,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,Individual Exchange,,1990.00,,,,,,,273.69,1990.00,per diem,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,81.08,1069.64,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,Individual Exchange,,1990.00,,,,,,,273.69,1990.00,per diem,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,81.08,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Individual Exchange,,1990.00,,,,,,,74.67,1990.00,per diem,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,117.34,1831.00,per diem,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,124.01,1831.00,per diem,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,148.86,1831.00,per diem,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,150.52,1831.00,per diem,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,93.84,1831.00,per diem,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,74.69,1831.00,per diem,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,51.36,1831.00,per diem,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,76.08,1831.00,per diem,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,44.05,1831.00,per diem,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,106.90,1831.00,per diem,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,106.90,1831.00,per diem,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,95.23,1831.00,per diem,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,36.91,1831.00,per diem,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,69.64,1831.00,per diem,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,69.64,1831.00,per diem,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,69.64,1831.00,per diem,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,46.48,1831.00,per diem,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,63.72,1831.00,per diem,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,63.72,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,284.65,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,284.65,1831.00,per diem,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,79.56,1831.00,per diem,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,79.22,1831.00,per diem,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,259.58,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,265.68,1831.00,per diem,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,147.64,1831.00,per diem,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,214.67,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,73.64,1831.00,per diem,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,United Healthcare,Individual Exchange,,1990.00,,,,,,,199.60,1990.00,per diem,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,92.69,467.00,per diem,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,United Healthcare,Individual Exchange,,615.00,,,,,,,108.91,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,263.26,986.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,299.59,1191.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,299.59,1462.50,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,United Healthcare,Individual Exchange,,615.00,,,,,,,510.48,2075.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,United Healthcare,Individual Exchange,,615.00,,,,,,,510.48,2279.25,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,510.48,2892.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,299.59,1701.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,299.59,1905.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,510.48,2143.50,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,510.48,3402.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,510.48,3810.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,4252.50,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,Individual Exchange,,615.00,,,,,,,208.61,954.00,per diem,"Must be billed without CPT/HCPCS Codes 95782-95783, 95800-95801, 95805-95811, G0398-G0400"
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,494.00,,,,,,,37.64,767.00,per diem,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,494.00,,,,,,,37.64,767.00,per diem,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,703.00,,,,,,,10.97,1090.00,per diem,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Individual Exchange,,494.00,,,,,,,44.39,4311.00,per diem,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Individual Exchange,,703.00,,,,,,,50.84,1090.00,per diem,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Individual Exchange,,703.00,,,,,,,51.19,1090.00,per diem,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Individual Exchange,,26.00,,,,,,,8.36,42.00,per diem,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Individual Exchange,,26.00,,,,,,,8.36,42.00,per diem,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,26.00,,,,,,,20.54,88.50,per diem,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,26.00,,,,,,,20.54,88.50,per diem,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,26.00,,,,,,,20.54,88.50,per diem,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,26.00,,,,,,,20.54,88.50,per diem,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Individual Exchange,,26.00,,,,,,,18.45,79.50,per diem,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,26.00,,,,,,,20.54,88.50,per diem,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Individual Exchange,,488.00,,,,,,,134.93,759.00,per diem,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Individual Exchange,,488.00,,,,,,,134.93,759.00,per diem,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Individual Exchange,,488.00,,,,,,,134.93,759.00,per diem,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Individual Exchange,,488.00,,,,,,,134.93,759.00,per diem,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Individual Exchange,,26.00,,,,,,,26.00,581.25,per diem,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,United Healthcare,Individual Exchange,,26.00,,,,,,,26.00,581.25,per diem,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Individual Exchange,,26.00,,,,,,,13.06,56.25,per diem,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,10.39,4311.00,per diem,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,United Healthcare,Individual Exchange,,250.04,,,,,,,90.29,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,549.35,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,Individual Exchange,,1432.37,,,,,,,517.24,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,Individual Exchange,,2022.75,,,,,,,730.44,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,Individual Exchange,,566.37,,,,,,,204.52,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,United Healthcare,Individual Exchange,,1286.21,,,,,,,464.46,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,United Healthcare,Individual Exchange,,542.36,,,,,,,195.85,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,United Healthcare,Individual Exchange,,542.36,,,,,,,195.85,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,United Healthcare,Individual Exchange,,1665.18,,,,,,,601.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,United Healthcare,Individual Exchange,,224.46,,,,,,,81.06,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,Individual Exchange,,250.56,,,,,,,90.48,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,Individual Exchange,,279.79,,,,,,,101.04,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Individual Exchange,,239.08,,,,,,,86.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,Individual Exchange,,62.12,,,,,,,22.43,96.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,,67.34,,,,,,,24.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,,67.34,,,,,,,24.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,Individual Exchange,,108.58,,,,,,,39.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Individual Exchange,,85.09,,,,,,,30.73,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,United Healthcare,Individual Exchange,,160.25,,,,,,,57.87,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,United Healthcare,Individual Exchange,,271.44,,,,,,,98.02,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,Individual Exchange,,263.09,,,,,,,95.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,United Healthcare,Individual Exchange,,322.60,,,,,,,116.49,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,United Healthcare,Individual Exchange,,213.50,,,,,,,77.10,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,154.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Individual Exchange,,401.94,,,,,,,145.15,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,127.73,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,Individual Exchange,,314.77,,,,,,,113.67,490.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,Individual Exchange,,470.84,,,,,,,170.03,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,36.44,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,30.43,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,56.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,Individual Exchange,,202.54,,,,,,,73.14,315.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,151.95,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Individual Exchange,,396.20,,,,,,,143.07,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,459.46,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,United Healthcare,Individual Exchange,,316.85,,,,,,,114.42,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,372.97,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,Individual Exchange,,972.49,,,,,,,351.18,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,Individual Exchange,,279.79,,,,,,,101.04,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Individual Exchange,,541.31,,,,,,,195.47,843.08,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,United Healthcare,Individual Exchange,,6528.65,,,,,,,2357.57,10168.19,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,United Healthcare,Individual Exchange,,793.44,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,United Healthcare,Individual Exchange,,1009.03,,,,,,,364.37,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,United Healthcare,Individual Exchange,,435.35,,,,,,,157.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,United Healthcare,Individual Exchange,,453.62,,,,,,,163.81,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,United Healthcare,Individual Exchange,,482.85,,,,,,,174.36,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,United Healthcare,Individual Exchange,,802.84,,,,,,,289.91,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Individual Exchange,,1001.20,,,,,,,361.54,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,United Healthcare,Individual Exchange,,5102.03,,,,,,,1842.40,7946.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,132.13,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Individual Exchange,,344.52,,,,,,,124.41,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,638.44,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Individual Exchange,,1664.66,,,,,,,601.13,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,Individual Exchange,,797.62,,,,,,,288.03,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,United Healthcare,Individual Exchange,,901.49,,,,,,,325.54,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,428.83,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,Individual Exchange,,1118.12,,,,,,,403.77,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,Individual Exchange,,729.23,,,,,,,263.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,124.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,Individual Exchange,,324.16,,,,,,,117.06,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,144.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,United Healthcare,Individual Exchange,,375.84,,,,,,,135.72,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,31.84,,,,,,,11.50,208.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,74.67,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,Individual Exchange,,1169.28,,,,,,,422.24,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Individual Exchange,JW,68.90,,,,,,,26.43,107.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,Individual Exchange,,305.89,,,,,,,110.46,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,99.90,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,120.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Individual Exchange,,260.48,,,,,,,94.06,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,117.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,Individual Exchange,,429.08,,,,,,,154.95,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,United Healthcare,Individual Exchange,,712.01,,,,,,,257.11,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,Individual Exchange,,183.74,,,,,,,66.35,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Individual Exchange,,2057.20,,,,,,,666.26,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,666.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Individual Exchange,,2057.20,,,,,,,666.26,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,390.39,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Individual Exchange,,1017.90,,,,,,,367.57,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,621.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,Individual Exchange,,1619.77,,,,,,,584.92,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,United Healthcare,Individual Exchange,,899.41,,,,,,,324.79,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,United Healthcare,Individual Exchange,,1112.90,,,,,,,401.88,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,United Healthcare,Individual Exchange,,1461.60,,,,,,,527.80,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,108.71,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,856.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,160.96,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,United Healthcare,Individual Exchange,,816.93,,,,,,,295.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,United Healthcare,Individual Exchange,,816.93,,,,,,,295.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,United Healthcare,Individual Exchange,,1002.76,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,United Healthcare,Individual Exchange,,887.92,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Individual Exchange,,303.80,,,,,,,109.71,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,Individual Exchange,,1183.90,,,,,,,427.52,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,United Healthcare,Individual Exchange,,660.33,,,,,,,238.45,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,467.07,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Individual Exchange,,1217.83,,,,,,,439.77,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,United Healthcare,Individual Exchange,,1068.53,,,,,,,385.86,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,United Healthcare,Individual Exchange,,696.87,,,,,,,251.65,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,Individual Exchange,,442.13,,,,,,,159.66,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,356.56,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,Individual Exchange,,929.68,,,,,,,335.72,1447.95,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,Individual Exchange,,886.36,,,,,,,320.07,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,Individual Exchange,,720.88,,,,,,,260.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,Individual Exchange,,720.88,,,,,,,260.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Individual Exchange,,936.47,,,,,,,338.17,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,359.16,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,Individual Exchange,,2150.12,,,,,,,776.43,8442.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,824.62,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,695.70,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,695.70,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,102.50,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,118.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,United Healthcare,Individual Exchange,52,3788.00,,,,,,,220.22,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,151.95,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,United Healthcare,Individual Exchange,,1233.00,,,,,,,123.79,1912.00,per diem,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,United Healthcare,Individual Exchange,,1233.00,,,,,,,254.36,1912.00,per diem,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Individual Exchange,,494.00,,,,,,,22.11,767.00,per diem,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Individual Exchange,,479.72,,,,,,,173.23,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Individual Exchange,,145.00,,,,,,,59.12,365.00,case rate,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,United Healthcare,Individual Exchange,,236.00,,,,,,,129.99,624.00,case rate,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,United Healthcare,Individual Exchange,,780.00,,,,,,,259.79,1295.00,case rate,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,United Healthcare,Individual Exchange,,1068.00,,,,,,,409.68,3235.00,case rate,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,589.86,3709.00,case rate,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,United Healthcare,Individual Exchange,,1422.00,,,,,,,748.05,5152.00,case rate,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,161.50,3641.00,per diem,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,United Healthcare,Individual Exchange,,188.44,,,,,,,72.27,293.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,Individual Exchange,,154.51,,,,,,,59.26,240.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Individual Exchange,,98.66,,,,,,,37.84,153.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,20.87,3641.00,per diem,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,20.87,3641.00,per diem,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,2052.00,per diem,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,34.99,134.00,per diem,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,134.00,,,,,,,32.73,134.00,per diem,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,United Healthcare,Individual Exchange,,134.00,,,,,,,43.35,151.89,per diem,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,Individual Exchange,,134.00,,,,,,,41.78,146.40,per diem,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,55.19,193.37,per diem,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Individual Exchange,,134.00,,,,,,,69.47,243.39,per diem,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,64.59,226.31,per diem,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Individual Exchange,,134.00,,,,,,,82.70,289.75,per diem,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,31.51,134.00,per diem,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,12.54,134.00,per diem,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,39.52,138.47,per diem,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Individual Exchange,,134.00,,,,,,,17.41,134.00,per diem,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,46.48,162.87,per diem,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,United Healthcare,Individual Exchange,,134.00,,,,,,,43.52,152.50,per diem,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,70.68,247.66,per diem,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,United Healthcare,Individual Exchange,,134.00,,,,,,,75.73,265.35,per diem,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,76.08,266.57,per diem,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,69.12,242.17,per diem,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,31.51,134.00,per diem,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,United Healthcare,Individual Exchange,,134.00,,,,,,,44.22,154.94,per diem,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,Individual Exchange,,134.00,,,,,,,67.55,236.68,per diem,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,United Healthcare,Individual Exchange,,134.00,,,,,,,85.13,298.29,per diem,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,11.49,134.00,per diem,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,18.45,134.00,per diem,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,30.64,134.00,per diem,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,United Healthcare,Individual Exchange,,134.00,,,,,,,45.27,158.60,per diem,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Individual Exchange,,134.00,,,,,,,59.72,209.23,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,40.22,140.91,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,55.19,193.37,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Individual Exchange,,134.00,,,,,,,82.70,289.75,per diem,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,100.28,351.36,per diem,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,134.00,,,,,,,8.53,134.00,per diem,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Individual Exchange,,134.00,,,,,,,16.19,134.00,per diem,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,23.85,134.00,per diem,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Individual Exchange,,134.00,,,,,,,19.50,134.00,per diem,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Individual Exchange,,134.00,,,,,,,8.36,134.00,per diem,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,inpatient,,,130.00000,78.00000,United Healthcare,Individual Exchange,,39.13,,,,,,,39.13,105.69,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,25.00000,15.00000,United Healthcare,Individual Exchange,,7.53,,,,,,,7.53,20.32,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,inpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,28.59,,,,,,,28.59,77.23,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,16.25,,,,,,,16.25,43.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Individual Exchange,JW,64.21,,,,,,,24.62,124.49,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Individual Exchange,,37.02,,,,,,,37.02,100.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,JW,49.59,,,,,,,19.02,106.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,inpatient,,,142.00000,85.20000,United Healthcare,Individual Exchange,,42.74,,,,,,,42.74,115.45,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,inpatient,,,275.00000,165.00000,United Healthcare,Individual Exchange,,47.30,,,,,,,47.30,228.25,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Individual Exchange,,34.92,,,,,,,34.92,202.46,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,inpatient,,,200.00000,120.00000,United Healthcare,Individual Exchange,,60.20,,,,,,,60.20,162.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Individual Exchange,JW,104.40,,,,,,,40.04,162.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,455.00000,273.00000,United Healthcare,Individual Exchange,,136.96,,,,,,,136.96,369.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,inpatient,,,911.00000,546.60000,United Healthcare,Individual Exchange,,274.21,,,,,,,274.21,740.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Individual Exchange,JW,475.54,,,,,,,5.88,740.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Individual Exchange,JW,237.51,,,,,,,5.88,369.92,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Individual Exchange,,297.39,,,,,,,297.39,803.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,188.43,,,,,,,188.43,508.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,273.00000,163.80000,United Healthcare,Individual Exchange,,82.17,,,,,,,82.17,221.95,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Individual Exchange,JW,515.74,,,,,,,197.80,803.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Individual Exchange,JW,142.51,,,,,,,54.65,238.43,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,571.00000,342.60000,United Healthcare,Individual Exchange,,171.87,,,,,,,171.87,464.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,262.00000,157.20000,United Healthcare,Individual Exchange,,78.86,,,,,,,78.86,213.01,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2754.00000,1652.40000,United Healthcare,Individual Exchange,,828.95,,,,,,,828.95,2239.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1216.00000,729.60000,United Healthcare,Individual Exchange,,366.02,,,,,,,366.02,988.61,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,616.00000,369.60000,United Healthcare,Individual Exchange,,185.42,,,,,,,185.42,500.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,United Healthcare,Individual Exchange,JW,1437.59,,,,,,,240.06,2239.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,United Healthcare,Individual Exchange,JW,634.75,,,,,,,240.06,988.61,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Individual Exchange,JW,321.55,,,,,,,123.32,500.81,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,inpatient,,,2813.00000,1687.80000,United Healthcare,Individual Exchange,,846.71,,,,,,,846.71,2286.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,inpatient,,,123.00000,73.80000,United Healthcare,Individual Exchange,,37.02,,,,,,,37.02,100.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,342.00000,205.20000,United Healthcare,Individual Exchange,,102.94,,,,,,,102.94,278.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,United Healthcare,Individual Exchange,JW,178.52,,,,,,,68.47,278.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,1546.00000,927.60000,United Healthcare,Individual Exchange,,465.35,,,,,,,465.35,1256.90,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,inpatient,,,3094.00000,1856.40000,United Healthcare,Individual Exchange,,931.29,,,,,,,931.29,2515.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,United Healthcare,Individual Exchange,JW,807.01,,,,,,,309.51,1256.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,428.00000,256.80000,United Healthcare,Individual Exchange,,128.83,,,,,,,128.83,347.96,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,United Healthcare,Individual Exchange,JW,223.42,,,,,,,70.59,347.96,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,inpatient,,,483.00000,289.80000,United Healthcare,Individual Exchange,,145.38,,,,,,,145.38,392.68,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Individual Exchange,JW,252.13,,,,,,,70.59,392.68,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,inpatient,,,10.00000,6.00000,United Healthcare,Individual Exchange,,3.01,,,,,,,3.01,8.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2498.00000,1498.80000,United Healthcare,Individual Exchange,,751.90,,,,,,,751.90,2030.87,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,United Healthcare,Individual Exchange,JW,1303.96,,,,,,,500.10,2030.87,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,2025.00000,1215.00000,United Healthcare,Individual Exchange,,609.52,,,,,,,609.52,1646.33,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,United Healthcare,Individual Exchange,JW,1057.05,,,,,,,405.40,1646.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,inpatient,,,1708.00000,1024.80000,United Healthcare,Individual Exchange,,514.11,,,,,,,514.11,1388.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,United Healthcare,Individual Exchange,JW,891.58,,,,,,,341.94,1388.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,inpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,19.57,,,,,,,19.57,52.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,JW,33.93,,,,,,,13.01,52.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,2469.00000,1481.40000,United Healthcare,Individual Exchange,,743.17,,,,,,,743.17,2007.30,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,698.00000,418.80000,United Healthcare,Individual Exchange,,210.10,,,,,,,210.10,567.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,United Healthcare,Individual Exchange,,364.36,,,,,,,139.74,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,188.43,,,,,,,188.43,508.94,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,326.77,,,,,,,125.33,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,615.00000,369.00000,United Healthcare,Individual Exchange,,185.12,,,,,,,185.12,500.00,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Individual Exchange,,321.03,,,,,,,123.12,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,132.14,,,,,,,132.14,356.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,229.16,,,,,,,87.89,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,inpatient,,,399.00000,239.40000,United Healthcare,Individual Exchange,,120.10,,,,,,,120.10,324.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Individual Exchange,,208.28,,,,,,,79.88,6571.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,United Healthcare,Individual Exchange,JW,1233.49,,,,,,,154.34,1921.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Individual Exchange,JW,298.06,,,,,,,114.31,464.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Individual Exchange,JW,136.76,,,,,,,52.45,213.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,inpatient,,,313.00000,187.80000,United Healthcare,Individual Exchange,,94.21,,,,,,,94.21,254.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Individual Exchange,JW,163.39,,,,,,,62.66,254.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1575.00000,945.00000,United Healthcare,Individual Exchange,,474.07,,,,,,,474.07,1280.47,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,United Healthcare,Individual Exchange,JW,822.15,,,,,,,240.06,1280.47,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,1252.00000,751.20000,United Healthcare,Individual Exchange,,376.85,,,,,,,376.85,1017.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Individual Exchange,JW,653.54,,,,,,,240.06,1017.88,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,641.00000,384.60000,United Healthcare,Individual Exchange,,192.94,,,,,,,192.94,521.13,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,United Healthcare,Individual Exchange,JW,334.60,,,,,,,128.33,521.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,340.00000,204.00000,United Healthcare,Individual Exchange,,102.34,,,,,,,102.34,276.42,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,United Healthcare,Individual Exchange,JW,177.48,,,,,,,68.07,276.42,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,272.00000,163.20000,United Healthcare,Individual Exchange,,81.87,,,,,,,81.87,221.14,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,United Healthcare,Individual Exchange,JW,141.98,,,,,,,54.45,240.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,inpatient,,,2562.00000,1537.20000,United Healthcare,Individual Exchange,,771.16,,,,,,,771.16,2082.91,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Individual Exchange,,87.00,,,,,,,57.15,221.25,per diem,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Individual Exchange,,87.00,,,,,,,37.76,477.75,per diem,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Individual Exchange,,87.00,,,,,,,37.76,477.75,per diem,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Individual Exchange,,87.00,,,,,,,37.76,477.75,per diem,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Individual Exchange,,87.00,,,,,,,37.76,477.75,per diem,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Individual Exchange,,140.94,,,,,,,50.90,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,United Healthcare,Individual Exchange,,2214.85,,,,,,,799.81,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,United Healthcare,Individual Exchange,,134.00,,,,,,,31.51,134.00,per diem,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,United Healthcare,Individual Exchange,,128.41,,,,,,,46.37,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,United Healthcare,Individual Exchange,,1345.19,,,,,,,485.76,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,inpatient,,,209.00000,125.40000,United Healthcare,Individual Exchange,,62.91,,,,,,,62.91,169.92,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Individual Exchange,,142.48,,,,,,,41.84,142.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,Individual Exchange,,158.17,,,,,,,57.12,246.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,Individual Exchange,,1031.47,,,,,,,372.48,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,Individual Exchange,,1031.47,,,,,,,372.48,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Individual Exchange,,225.50,,,,,,,81.43,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Individual Exchange,,225.50,,,,,,,81.43,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,Individual Exchange,,175.91,,,,,,,63.52,273.98,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Individual Exchange,,146.16,,,,,,,52.78,227.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Individual Exchange,,140.42,,,,,,,50.71,218.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1877.68,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,222.82,3342.81,per diem,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Individual Exchange,,541.31,,,,,,,195.47,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,United Healthcare,Individual Exchange,,624.83,,,,,,,225.63,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,United Healthcare,Individual Exchange,,420.73,,,,,,,151.93,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,397.40,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,397.40,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2337.54,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2337.54,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4067.26,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4067.26,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1729.73,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1729.73,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,3669.87,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,3669.87,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,Individual Exchange,,34125.00,,,,,,,5937.33,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,Individual Exchange,,34125.00,,,,,,,5937.33,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Individual Exchange,,140.42,,,,,,,50.71,218.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,Individual Exchange,,214.02,,,,,,,77.28,333.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,United Healthcare,Individual Exchange,,310.07,,,,,,,111.97,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Individual Exchange,,267.26,,,,,,,96.51,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,Individual Exchange,,402.46,,,,,,,145.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,United Healthcare,Individual Exchange,,355.48,,,,,,,128.37,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,Individual Exchange,,2022.75,,,,,,,730.44,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Individual Exchange,,74.65,,,,,,,26.96,116.26,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Individual Exchange,,164.43,,,,,,,59.38,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Individual Exchange,,101.79,,,,,,,36.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Individual Exchange,,164.43,,,,,,,59.38,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Individual Exchange,,101.79,,,,,,,36.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Individual Exchange,,164.43,,,,,,,59.38,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Individual Exchange,,101.79,,,,,,,36.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Individual Exchange,,268.83,,,,,,,97.08,420.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,,494.00,,,,,,,28.73,767.00,per diem,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,United Healthcare,Individual Exchange,,494.00,,,,,,,88.31,767.00,per diem,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,United Healthcare,Individual Exchange,,494.00,,,,,,,84.26,767.00,per diem,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,22.28,269.00,per diem,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,24.55,269.00,per diem,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,27.51,269.00,per diem,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Individual Exchange,,494.00,,,,,,,16.02,767.00,per diem,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Individual Exchange,,175.00,,,,,,,16.02,269.00,per diem,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Individual Exchange,,175.00,,,,,,,23.56,269.00,per diem,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,Individual Exchange,,214.02,,,,,,,77.28,333.33,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Individual Exchange,,268.83,,,,,,,97.08,420.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,Individual Exchange,,703.00,,,,,,,11.14,1090.00,per diem,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,Individual Exchange,,703.00,,,,,,,11.14,1090.00,per diem,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,703.00,,,,,,,4.87,1090.00,per diem,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Individual Exchange,,703.00,,,,,,,26.11,1090.00,per diem,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Individual Exchange,,703.00,,,,,,,14.80,1090.00,per diem,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Individual Exchange,,494.00,,,,,,,26.63,767.00,per diem,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Individual Exchange,,268.83,,,,,,,97.08,420.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,40000.00000,24000.00000,United Healthcare,Individual Exchange,,6880.00,,,,,,,6880.00,33200.00,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,United Healthcare,Individual Exchange,,5080.00,,,,,,,5080.00,29448.00,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,155.56,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1757.36,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1757.36,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,661.11,3641.00,per diem,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,58.46,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,176.98,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,United Healthcare,Individual Exchange,,107.01,,,,,,,38.64,166.66,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,194.19,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,246.25,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,64.86,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1253.05,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Individual Exchange,,1630.21,,,,,,,420.60,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,United Healthcare,Individual Exchange,,3788.00,,,,,,,97.30,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,3318.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Individual Exchange,,1630.21,,,,,,,588.69,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,168.57,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,467.67,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,463.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,464.86,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,2388.19,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,104.90,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,114.71,467.00,per diem,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,512.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,379.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,512.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,inpatient,,,5187.00000,3112.20000,United Healthcare,Individual Exchange,,1561.29,,,,,,,1561.29,4217.03,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1235.00000,741.00000,United Healthcare,Individual Exchange,,371.74,,,,,,,371.74,1004.05,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,1048.00000,628.80000,United Healthcare,Individual Exchange,,315.45,,,,,,,315.45,852.02,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,707.00000,424.20000,United Healthcare,Individual Exchange,,212.81,,,,,,,212.81,574.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,550.00000,330.00000,United Healthcare,Individual Exchange,,165.55,,,,,,,165.55,447.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,442.00000,265.20000,United Healthcare,Individual Exchange,,133.04,,,,,,,133.04,359.35,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,inpatient,,,466.00000,279.60000,United Healthcare,Individual Exchange,,140.27,,,,,,,140.27,378.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,United Healthcare,Individual Exchange,JW,644.67,,,,,,,247.25,1004.05,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,United Healthcare,Individual Exchange,JW,547.06,,,,,,,209.81,852.02,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Individual Exchange,JW,369.05,,,,,,,141.54,574.79,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Individual Exchange,JW,287.10,,,,,,,110.11,447.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Individual Exchange,JW,230.72,,,,,,,88.49,359.35,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,United Healthcare,Individual Exchange,JW,243.25,,,,,,,93.29,378.86,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,inpatient,,,2078.00000,1246.80000,United Healthcare,Individual Exchange,,625.48,,,,,,,625.48,1689.41,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Individual Exchange,,93.44,,,,,,,33.74,145.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,98.14,,,,,,,35.44,152.84,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,159.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,1064.69,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,35.84,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,365.97,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,519.32,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,577.18,3142.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,United Healthcare,Individual Exchange,,1134.83,,,,,,,409.80,2452.76,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,United Healthcare,Individual Exchange,,2209.10,,,,,,,736.79,3440.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,United Healthcare,Individual Exchange,,9986.90,,,,,,,3330.88,15554.32,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,74.69,1831.00,per diem,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,78.69,1831.00,per diem,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,69.81,1831.00,per diem,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,115.78,1831.00,per diem,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,55.36,1831.00,per diem,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,United Healthcare,Individual Exchange,,91.81,,,,,,,91.81,247.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,45.52,268.00,per diem,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,61.58,408.75,per diem,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,70.47,268.00,per diem,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,42.96,360.75,per diem,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,67.36,450.75,per diem,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,57.08,295.50,per diem,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,65.78,331.50,per diem,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,67.36,375.00,per diem,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,30.43,268.00,per diem,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,52.60,268.00,per diem,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,24.02,268.00,per diem,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,51.96,375.75,per diem,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,60.30,503.25,per diem,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,35.84,268.00,per diem,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,15.34,268.00,per diem,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,43.60,271.50,per diem,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,50.02,362.25,per diem,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,56.44,438.00,per diem,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,57.74,809.25,per diem,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,71.86,438.75,per diem,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,46.82,288.75,per diem,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,59.66,268.00,per diem,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,32.04,331.50,per diem,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,55.16,372.00,per diem,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,77.00,495.00,per diem,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,91.78,696.75,per diem,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,44.24,327.75,per diem,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,54.52,268.00,per diem,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,47.46,423.00,per diem,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,55.80,369.00,per diem,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,74.44,532.50,per diem,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,91.12,656.25,per diem,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,57.74,436.50,per diem,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,37.18,268.00,per diem,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,57.74,405.75,per diem,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,54.52,276.75,per diem,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,46.16,276.00,per diem,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,138.66,908.25,per diem,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,141.22,830.63,per diem,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,135.44,1002.00,per diem,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,195.18,1419.00,per diem,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,139.30,2053.05,per diem,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,46.16,318.75,per diem,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,28.82,286.50,per diem,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,26.90,344.25,per diem,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,48.74,346.50,per diem,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,204.18,953.25,per diem,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,37.18,391.50,per diem,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,46.16,330.00,per diem,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,40.38,304.50,per diem,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,46.16,331.50,per diem,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,97.50,375.47,per diem,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,41.04,284.25,per diem,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,46.16,268.00,per diem,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,49.38,281.25,per diem,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,62.22,268.00,per diem,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,130.73,489.75,per diem,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,44.24,323.25,per diem,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,53.88,295.50,per diem,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,55.26,268.00,per diem,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,168.37,630.75,per diem,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,50.02,320.25,per diem,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,60.94,278.25,per diem,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,68.00,361.50,per diem,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,61.58,268.00,per diem,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,76.08,375.47,per diem,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,45.52,268.00,per diem,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,43.64,268.00,per diem,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,46.82,333.75,per diem,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,54.52,347.25,per diem,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,76.08,375.47,per diem,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,39.74,397.50,per diem,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,50.66,347.25,per diem,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,40.38,300.75,per diem,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,43.60,268.00,per diem,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,41.04,319.50,per diem,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,63.20,576.46,per diem,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,63.20,576.46,per diem,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,63.20,576.46,per diem,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,138.66,586.50,per diem,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,64.46,268.00,per diem,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,49.45,311.44,per diem,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,211.21,791.25,per diem,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,145.75,546.00,per diem,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,177.78,666.00,per diem,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,99.70,373.50,per diem,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,105.91,396.75,per diem,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,171.27,741.00,per diem,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,171.27,780.75,per diem,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,100.76,805.50,per diem,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,107.51,402.75,per diem,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,19.62,375.47,per diem,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,116.12,435.00,per diem,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,98.30,482.25,per diem,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,163.76,613.50,per diem,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,133.33,2153.70,per diem,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,154.08,607.50,per diem,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,130.88,5683.29,per diem,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,116.82,3483.75,per diem,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,125.18,3309.13,per diem,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,37.04,268.00,per diem,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,117.46,1633.21,per diem,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,126.46,1633.21,per diem,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,118.74,3309.13,per diem,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,129.02,4309.50,per diem,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,130.96,3309.13,per diem,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,150.14,3309.13,per diem,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,143.80,3309.13,per diem,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,167.48,5683.29,per diem,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,139.94,3309.13,per diem,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,160.96,3309.13,per diem,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,139.94,3309.13,per diem,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,138.66,3309.13,per diem,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,139.30,3309.13,per diem,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,150.22,5683.29,per diem,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,232.00,1749.75,per diem,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,82.40,3309.13,per diem,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,40.84,268.00,per diem,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,35.03,268.00,per diem,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,232.00,903.00,per diem,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,154.35,578.25,per diem,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,211.61,792.75,per diem,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,71.67,268.50,per diem,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,53.24,714.75,per diem,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,33.83,268.00,per diem,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,68.64,702.00,per diem,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,48.74,576.46,per diem,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,68.27,268.00,per diem,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,28.63,268.00,per diem,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,148.95,558.00,per diem,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,132.53,496.50,per diem,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,131.53,492.75,per diem,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,64.66,268.00,per diem,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,91.12,484.50,per diem,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,32.68,268.00,per diem,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,48.65,268.00,per diem,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,53.65,268.00,per diem,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,102.31,695.25,per diem,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,61.26,268.00,per diem,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,52.60,683.25,per diem,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,40.38,268.00,per diem,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,157.76,5683.29,per diem,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,133.52,3309.13,per diem,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,137.94,3309.13,per diem,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,148.86,5683.29,per diem,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,186.12,3309.13,per diem,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,170.70,5683.29,per diem,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,136.10,3385.50,per diem,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,138.58,3385.50,per diem,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,155.28,3385.50,per diem,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,198.96,3309.13,per diem,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,232.00,1339.50,per diem,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,32.68,268.00,per diem,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,44.24,280.50,per diem,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,60.30,268.00,per diem,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,166.37,623.25,per diem,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,inpatient,,,163.00000,97.80000,United Healthcare,Individual Exchange,,49.06,,,,,,,49.06,132.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,51.96,375.75,per diem,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,137.38,2053.05,per diem,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,57.74,462.75,per diem,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,102.31,609.00,per diem,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,102.31,645.75,per diem,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,44.88,350.25,per diem,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,69.30,370.50,per diem,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,87.92,392.25,per diem,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,58.38,568.50,per diem,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,75.72,552.00,per diem,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,89.20,809.25,per diem,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,Individual Exchange,,232.00,,,,,,,40.38,268.00,per diem,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,50.66,324.00,per diem,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,212.81,797.25,per diem,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,123.12,461.25,per diem,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,154.08,588.75,per diem,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,inpatient,,,37500.00000,22500.00000,United Healthcare,Individual Exchange,,6450.00,,,,,,,6450.00,31125.00,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,United Healthcare,Individual Exchange,,4762.50,,,,,,,4762.50,27607.50,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,43.44,467.00,per diem,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,170.70,5683.29,per diem,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,451.05,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,56.44,315.00,per diem,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,49.38,412.50,per diem,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,United Healthcare,Individual Exchange,,232.00,,,,,,,58.38,405.00,per diem,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,80.28,300.75,per diem,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,119.32,447.00,per diem,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,99.50,372.75,per diem,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,66.72,564.00,per diem,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,116.32,633.86,per diem,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,United Healthcare,Individual Exchange,,232.00,,,,,,,171.27,696.00,per diem,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,United Healthcare,Individual Exchange,,232.00,,,,,,,171.27,1036.50,per diem,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,54.05,2905.00,per diem,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,United Healthcare,Individual Exchange,,2310.00,,,,,,,165.97,3466.00,per diem,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,68.67,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Individual Exchange,,688.00,,,,,,,82.68,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,135.54,1560.00,per diem,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,137.14,1560.00,per diem,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,221.02,1560.00,per diem,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,116.72,1560.00,per diem,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2187.75,per diem,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,218.82,1560.00,per diem,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,195.40,1560.00,per diem,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,143.54,1560.00,per diem,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,203.00,1560.00,per diem,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1717.50,per diem,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1783.50,per diem,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2049.75,per diem,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,171.37,1560.00,per diem,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,246.25,1560.00,per diem,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1683.75,per diem,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,208.61,1560.00,per diem,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,229.83,1560.00,per diem,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,251.25,1560.00,per diem,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1977.00,per diem,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1977.00,per diem,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1872.75,per diem,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2907.00,per diem,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,3633.00,per diem,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,166.37,1560.00,per diem,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1864.50,per diem,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,155.76,1560.00,per diem,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,172.97,1560.00,per diem,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,218.22,1560.00,per diem,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,159.96,1560.00,per diem,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,232.23,1560.00,per diem,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,232.23,1560.00,per diem,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,254.45,1560.00,per diem,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,184.78,1560.00,per diem,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1755.75,per diem,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2207.25,per diem,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,inpatient,,,277.00000,166.20000,United Healthcare,Individual Exchange,,83.38,,,,,,,83.38,225.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,inpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,15.35,,,,,,,15.35,41.46,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,64.51,,,,,,,10.21,208.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,inpatient,,,99.00000,59.40000,United Healthcare,Individual Exchange,,29.80,,,,,,,29.80,80.49,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,inpatient,,,2030.00000,1218.00000,United Healthcare,Individual Exchange,,611.03,,,,,,,611.03,1650.39,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,United Healthcare,Individual Exchange,,1994.87,,,,,,,406.41,2131.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,inpatient,,,988.00000,592.80000,United Healthcare,Individual Exchange,,297.39,,,,,,,297.39,803.24,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,inpatient,,,107.00000,64.20000,United Healthcare,Individual Exchange,,32.21,,,,,,,32.21,86.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,inpatient,,,208.00000,124.80000,United Healthcare,Individual Exchange,,62.61,,,,,,,62.61,169.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,inpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,56.59,,,,,,,56.59,152.84,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,inpatient,,,2794.00000,1676.40000,United Healthcare,Individual Exchange,,840.99,,,,,,,840.99,2271.52,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,United Healthcare,Individual Exchange,,5339.66,,,,,,,559.36,9315.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,inpatient,,,12493.00000,7495.80000,United Healthcare,Individual Exchange,,3760.39,,,,,,,3760.39,10156.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,United Healthcare,Individual Exchange,,5786.43,,,,,,,2012.57,12296.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,215.63,1560.00,per diem,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,103.90,1560.00,per diem,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,215.63,1560.00,per diem,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,94.09,1560.00,per diem,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,inpatient,,,12371.00000,7422.60000,United Healthcare,Individual Exchange,,3723.67,,,,,,,3723.67,10057.62,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,United Healthcare,Individual Exchange,,12033.85,,,,,,,2476.67,39196.15,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Individual Exchange,,257.00,,,,,,,135.54,1560.00,per diem,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,inpatient,,,87.00000,52.20000,United Healthcare,Individual Exchange,,26.19,,,,,,,26.19,70.73,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,inpatient,,,878.00000,526.80000,United Healthcare,Individual Exchange,,264.28,,,,,,,264.28,713.81,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,inpatient,,,119.00000,71.40000,United Healthcare,Individual Exchange,,35.82,,,,,,,35.82,96.75,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,inpatient,,,584.00000,350.40000,United Healthcare,Individual Exchange,,175.78,,,,,,,175.78,474.79,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,inpatient,,,323.00000,193.80000,United Healthcare,Individual Exchange,,97.22,,,,,,,97.22,262.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,inpatient,,,44.00000,26.40000,United Healthcare,Individual Exchange,,13.24,,,,,,,13.24,35.77,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,inpatient,,,5280.00000,3168.00000,United Healthcare,Individual Exchange,,1589.28,,,,,,,1589.28,4292.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,United Healthcare,Individual Exchange,,2876.44,,,,,,,1000.45,10134.22,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,inpatient,,,6.00000,3.60000,United Healthcare,Individual Exchange,,1.81,,,,,,,1.81,4.88,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,inpatient,,,649.00000,389.40000,United Healthcare,Individual Exchange,,195.35,,,,,,,195.35,527.64,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,inpatient,,,122.00000,73.20000,United Healthcare,Individual Exchange,,36.72,,,,,,,36.72,99.19,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,inpatient,,,42.00000,25.20000,United Healthcare,Individual Exchange,,12.64,,,,,,,12.64,34.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,inpatient,,,82.00000,49.20000,United Healthcare,Individual Exchange,,24.68,,,,,,,24.68,66.67,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,inpatient,,,254.00000,152.40000,United Healthcare,Individual Exchange,,76.45,,,,,,,76.45,206.50,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,inpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,23.18,,,,,,,23.18,62.60,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,inpatient,,,6058.00000,3634.80000,United Healthcare,Individual Exchange,,1823.46,,,,,,,1823.46,4925.15,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,United Healthcare,Individual Exchange,,6120.58,,,,,,,1212.81,6878.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,inpatient,,,183.00000,109.80000,United Healthcare,Individual Exchange,,55.08,,,,,,,55.08,148.78,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,215.22,1560.00,per diem,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,inpatient,,,305.00000,183.00000,United Healthcare,Individual Exchange,,91.81,,,,,,,91.81,247.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,inpatient,,,305.00000,183.00000,United Healthcare,Individual Exchange,,91.81,,,,,,,91.81,247.97,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Individual Exchange,,479.07,,,,,,,61.06,479.07,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,inpatient,,,1343.00000,805.80000,United Healthcare,Individual Exchange,,404.24,,,,,,,404.24,1091.86,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,inpatient,,,487.00000,292.20000,United Healthcare,Individual Exchange,,146.59,,,,,,,146.59,395.93,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Individual Exchange,,748.59,,,,,,,97.50,1243.67,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,87.09,1560.00,per diem,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1680.00,per diem,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,1560.00,per diem,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2508.00,per diem,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2508.00,per diem,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2508.00,per diem,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,inpatient,,,1309.00000,785.40000,United Healthcare,Individual Exchange,,394.01,,,,,,,394.01,1064.22,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,Individual Exchange,,1390.74,,,,,,,262.06,1851.54,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,inpatient,,,1929.00000,1157.40000,United Healthcare,Individual Exchange,,580.63,,,,,,,580.63,1568.28,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,United Healthcare,Individual Exchange,,1659.68,,,,,,,386.19,2316.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,inpatient,,,1069.00000,641.40000,United Healthcare,Individual Exchange,,321.77,,,,,,,321.77,869.10,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,United Healthcare,Individual Exchange,,927.13,,,,,,,214.01,1480.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,inpatient,,,1908.00000,1144.80000,United Healthcare,Individual Exchange,,574.31,,,,,,,574.31,1551.20,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,United Healthcare,Individual Exchange,,2435.93,,,,,,,369.58,2435.93,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,inpatient,,,1230.00000,738.00000,United Healthcare,Individual Exchange,,370.23,,,,,,,370.23,999.99,percent of total billed charges,"Contract rate for High Cost Drugs that have eligible charges greater than $3,377.00."
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Individual Exchange,,1871.97,,,,,,,246.25,1871.97,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, codes for a Separately Reimbursable Drug not yet listed on the fee schedule or listed on the fee schedule will default to a contract rate of 50% PPR."
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,84.71,2905.00,per diem,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2905.00,per diem,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2942.87,per diem,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2942.87,per diem,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,3501.50,per diem,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,206.81,2905.00,per diem,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,225.43,2905.00,per diem,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,64.86,2905.00,per diem,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,507.91,2905.00,per diem,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,258.06,2905.00,per diem,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,227.83,2905.00,per diem,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,254.05,2905.00,per diem,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2908.74,per diem,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,3211.99,per diem,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2942.40,per diem,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2905.00,per diem,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2905.00,per diem,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,3037.26,per diem,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2905.00,per diem,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,3356.74,per diem,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,3008.52,per diem,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,3500.13,per diem,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,4490.21,per diem,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,21022.43,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,232.56,3266.55,per diem,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,3891.19,per diem,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,4523.15,per diem,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,84.71,2905.00,per diem,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,3052.31,per diem,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,560.56,2905.00,per diem,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,United Healthcare,Individual Exchange,,688.00,,,,,,,95.50,1067.00,per diem,"Must be billed without CPT Codes 61796-61800, 63620-63621, 77371, 77372, 77373"
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,102.31,2905.00,per diem,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,Individual Exchange,,734.00,,,,,,,171.27,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,232.56,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2905.00,per diem,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,Individual Exchange,,734.00,,,,,,,343.59,2905.00,per diem,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,United Healthcare,Individual Exchange,,734.00,,,,,,,380.58,2905.00,per diem,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Individual Exchange,,734.00,,,,,,,95.09,2905.00,per diem,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,67.47,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,21022.43,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,21022.43,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,19194.26,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,53.85,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,145.75,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,125.93,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,399.00,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1022.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,277.68,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,176.18,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,35106.11,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,972.37,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,972.37,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,18016.35,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,222.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,600.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,31.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Individual Exchange,,80.91,,,,,,,29.22,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,84.28,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,584.78,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,125.93,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,91.29,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,46.45,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,40.24,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,96.30,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,222.02,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,91.69,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,57.06,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,20.22,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,280.28,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,316.72,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,Individual Exchange,,825.80,,,,,,,298.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,466.47,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,Individual Exchange,,1216.26,,,,,,,439.20,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,62.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,62.26,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,160.96,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Individual Exchange,,419.69,,,,,,,151.55,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,United Healthcare,Individual Exchange,,376.88,,,,,,,136.10,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,115.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,Individual Exchange,,301.19,,,,,,,108.76,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,United Healthcare,Individual Exchange,,6636.00,,,,,,,944.94,13527.54,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,142.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,113.11,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,153.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,116.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,United Healthcare,Individual Exchange,,665.55,,,,,,,240.34,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,604.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,604.40,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,60.06,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,388.99,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,293.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,166.97,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,324.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,354.35,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,1251.65,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,135.54,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,135.54,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,103.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,136.94,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,136.94,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1012.81,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,United Healthcare,Individual Exchange,,2570.85,,,,,,,928.36,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,159.16,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,145.15,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,163.76,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,148.55,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,449.85,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,148.55,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,745.34,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,177.38,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,137.34,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,39.04,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,106.71,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,111.11,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,118.12,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,116.72,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,133.13,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,833.43,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,426.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,268.87,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,293.09,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,138.94,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,117.52,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,121.32,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Individual Exchange,,461.45,,,,,,,166.63,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2814.41,18878.80,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2814.41,18878.80,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2104.90,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2104.90,15260.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,2104.90,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,2104.90,15260.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2292.69,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2292.69,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1536.13,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1581.98,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1581.98,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,960.96,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,895.09,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,1213.61,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1213.61,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1213.61,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,879.68,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,483.88,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,495.50,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,322.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,158.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,75.88,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,96.50,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,56.46,4121.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,108.51,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1059.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,255.66,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1500.30,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,79.08,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,328.33,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,Individual Exchange,,856.08,,,,,,,309.14,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,427.63,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Individual Exchange,,475.54,,,,,,,171.72,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,616.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,448.25,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,107.11,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,203.40,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,771.57,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,128.53,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,160.56,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,128.53,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,139.14,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,902.01,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,476.08,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,United Healthcare,Individual Exchange,,3788.00,,,,,,,500.90,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,United Healthcare,Individual Exchange,,3788.00,,,,,,,496.10,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,127.33,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,232.23,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,35.03,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1259.46,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1554.95,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,18.02,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,United Healthcare,Individual Exchange,,3788.00,,,,,,,498.70,5754.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,58.86,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,46.25,832.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,Individual Exchange,,108.58,,,,,,,39.21,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,80.88,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,81.68,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,40.44,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,900.30,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,847.65,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,584.78,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,915.71,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,211.21,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Individual Exchange,,550.71,,,,,,,198.87,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,294.49,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,57.66,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Individual Exchange,,150.34,,,,,,,54.29,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,383.98,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Individual Exchange,,1001.20,,,,,,,361.54,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,United Healthcare,Individual Exchange,,612.31,,,,,,,221.11,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,502.70,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Individual Exchange,,1310.74,,,,,,,473.32,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,Individual Exchange,,1061.75,,,,,,,383.41,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,347.95,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,Individual Exchange,,907.24,,,,,,,327.61,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,316.92,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,Individual Exchange,,826.33,,,,,,,298.40,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,United Healthcare,Individual Exchange,,859.21,,,,,,,310.27,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,United Healthcare,Individual Exchange,,892.62,,,,,,,322.33,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,303.30,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,Individual Exchange,,790.83,,,,,,,285.58,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,302.10,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,Individual Exchange,,787.70,,,,,,,284.45,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,Individual Exchange,,3788.00,,,,,,,665.06,9350.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,Individual Exchange,,1734.08,,,,,,,626.20,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,United Healthcare,Individual Exchange,,970.92,,,,,,,350.61,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,363.96,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,Individual Exchange,,949.00,,,,,,,342.69,4376.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,73.67,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Individual Exchange,,2535.35,,,,,,,915.54,6735.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,568.77,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,598.60,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4031.43,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,2143.34,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,103.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,215.01,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,138.74,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,155.36,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1092.69,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,944.74,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,973.77,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,337.94,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,114.71,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1493.89,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,398.40,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,531.13,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,17547.26,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,838.24,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,2658.46,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,United Healthcare,Individual Exchange,,15486.00,,,,,,,1771.37,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,676.91,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,248.45,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,Individual Exchange,,885.31,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,375.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,Individual Exchange,,979.27,,,,,,,353.63,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,Individual Exchange,,904.10,,,,,,,284.00,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,258.06,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,146.75,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1434.43,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,358.56,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,371.17,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,209.41,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,717.92,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,717.92,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,693.69,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,596.60,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1230.03,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1430.23,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1059.26,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,954.35,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,238.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1609.21,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1660.86,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2496.49,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1392.39,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,178.38,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,322.52,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,238.44,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,United Healthcare,Individual Exchange,,3788.00,,,,,,,741.14,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,United Healthcare,Individual Exchange,,3788.00,,,,,,,650.85,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,651.45,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,561.56,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,954.75,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1107.51,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1623.02,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,150.35,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,11124.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1567.77,5418.27,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,762.16,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,United Healthcare,Individual Exchange,,34125.00,,,,,,,3427.62,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1466.87,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,180.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,3451.05,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,11196.33,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9871.02,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1760.76,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1760.76,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,6449.89,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,582.58,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,474.07,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,474.07,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,160.96,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,990.00,4538.86,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,United Healthcare,Individual Exchange,,880.09,,,,,,,317.81,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,404.60,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,97.50,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,572.37,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,572.37,10768.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,43.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,43.64,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,1990.79,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1990.79,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,803.60,12408.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,United Healthcare,Individual Exchange,,6636.00,,,,,,,1219.62,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,1251.65,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,125.93,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,572.37,6649.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,572.37,10768.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,United Healthcare,Individual Exchange,,734.00,,,,,,,651.00,2905.00,per diem,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,392.19,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,United Healthcare,Individual Exchange,,159.00,,,,,,,78.48,294.00,per diem,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Individual Exchange,,159.00,,,,,,,91.89,344.25,per diem,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Individual Exchange,,159.00,,,,,,,74.67,279.75,per diem,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Individual Exchange,,159.00,,,,,,,74.67,279.75,per diem,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,United Healthcare,Individual Exchange,,159.00,,,,,,,78.48,294.00,per diem,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,64.06,467.00,per diem,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,670.50,per diem,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,59.02,467.00,per diem,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,856.50,per diem,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,702.00,per diem,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,793.50,per diem,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,Individual Exchange,,222.00,,,,,,,58.38,578.25,per diem,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,627.75,per diem,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,63.06,467.00,per diem,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,568.50,per diem,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,62.06,467.00,per diem,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,618.75,per diem,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,United Healthcare,Individual Exchange,,222.00,,,,,,,160.28,720.75,per diem,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,103.90,467.00,per diem,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,97.56,477.75,per diem,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,85.49,467.00,per diem,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,626.25,per diem,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,501.00,per diem,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,89.84,467.00,per diem,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,131.73,493.50,per diem,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,777.75,per diem,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,46.82,617.25,per diem,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,689.25,per diem,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,United Healthcare,Individual Exchange,,222.00,,,,,,,60.26,467.00,per diem,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,54.52,883.50,per diem,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,63.52,573.00,per diem,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,50.05,467.00,per diem,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,Individual Exchange,,222.00,,,,,,,46.25,467.00,per diem,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Individual Exchange,,222.00,,,,,,,37.24,467.00,per diem,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,220.62,826.50,per diem,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,165.16,618.75,per diem,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,39.84,467.00,per diem,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,222.00,,,,,,,8.28,467.00,per diem,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,136.94,513.00,per diem,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,84.48,467.00,per diem,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,102.31,725.25,per diem,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,144.94,543.00,per diem,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Individual Exchange,,222.00,,,,,,,82.68,467.00,per diem,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Individual Exchange,,222.00,,,,,,,84.71,467.00,per diem,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Individual Exchange,,222.00,,,,,,,91.89,467.00,per diem,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,22.02,467.00,per diem,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Individual Exchange,,159.00,,,,,,,27.83,246.00,per diem,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,United Healthcare,Individual Exchange,,159.00,,,,,,,13.41,246.00,per diem,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Individual Exchange,,159.00,,,,,,,21.82,246.00,per diem,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,United Healthcare,Individual Exchange,,2100.00,,,,,,,1113.08,5598.00,per diem,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,United Healthcare,Individual Exchange,,2100.00,,,,,,,811.19,5598.00,per diem,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,United Healthcare,Individual Exchange,,2100.00,,,,,,,728.92,5598.00,per diem,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,United Healthcare,Individual Exchange,,2100.00,,,,,,,1131.38,5598.00,per diem,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Individual Exchange,,2100.00,,,,,,,1071.94,5598.00,per diem,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,United Healthcare,Individual Exchange,,257.00,,,,,,,257.00,2016.00,per diem,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Individual Exchange,,2100.00,,,,,,,1071.94,5598.00,per diem,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Individual Exchange,,2100.00,,,,,,,1071.94,5598.00,per diem,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,United Healthcare,Individual Exchange,,2100.00,,,,,,,162.27,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,United Healthcare,Individual Exchange,,2100.00,,,,,,,266.85,5598.00,per diem,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,United Healthcare,Individual Exchange,,2100.00,,,,,,,533.53,5598.00,per diem,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,United Healthcare,Individual Exchange,,2100.00,,,,,,,812.24,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,United Healthcare,Individual Exchange,,2100.00,,,,,,,727.88,5598.00,per diem,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,United Healthcare,Individual Exchange,,2100.00,,,,,,,1054.86,5598.00,per diem,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,United Healthcare,Individual Exchange,,2100.00,,,,,,,1550.57,5598.00,per diem,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,United Healthcare,Individual Exchange,,266.00,,,,,,,73.94,968.00,per diem,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,Individual Exchange,,266.00,,,,,,,126.13,968.00,per diem,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,80.11,968.00,per diem,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,United Healthcare,Individual Exchange,,266.00,,,,,,,141.98,968.00,per diem,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,2052.00,per diem,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,1851.75,per diem,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,67.48,968.00,per diem,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,760.10,3601.53,per diem,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,4352.85,per diem,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3155.53,per diem,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3286.68,per diem,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3127.52,per diem,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3810.99,per diem,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,760.10,2893.96,per diem,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3525.98,per diem,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2825.00,per diem,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3252.52,per diem,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,743.14,2917.94,per diem,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3522.51,per diem,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2876.72,per diem,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3192.74,per diem,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2972.99,per diem,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,84.71,2825.00,per diem,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,50.65,2825.00,per diem,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,United Healthcare,Individual Exchange,52,1181.00,,,,,,,791.19,2825.00,per diem,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,United Healthcare,Individual Exchange,52,1181.00,,,,,,,787.39,2825.00,per diem,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2825.00,per diem,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3169.56,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2825.00,per diem,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3113.44,per diem,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2996.32,per diem,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3326.94,per diem,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2828.57,per diem,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3407.46,per diem,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2825.00,per diem,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,3981.96,per diem,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,2825.00,per diem,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,343.59,4009.45,per diem,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,845.85,3021.02,per diem,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,647.85,3021.02,per diem,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,895.29,3021.02,per diem,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,848.45,3010.70,per diem,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,848.45,3010.70,per diem,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,848.45,3010.70,per diem,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,707.71,2825.00,per diem,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,814.41,2825.00,per diem,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,814.41,2825.00,per diem,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,899.50,3027.91,per diem,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,650.65,3027.91,per diem,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,United Healthcare,Individual Exchange,,1181.00,,,,,,,919.72,3027.91,per diem,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,United Healthcare,Individual Exchange,,1181.00,,,,,,,894.09,2825.00,per diem,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,845.44,2825.00,per diem,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,845.44,2825.00,per diem,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,908.91,3048.50,per diem,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,908.91,3048.50,per diem,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,908.91,3048.50,per diem,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,United Healthcare,Individual Exchange,,1181.00,,,,,,,206.81,2825.00,per diem,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,232.56,2825.00,per diem,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,United Healthcare,Individual Exchange,,1181.00,,,,,,,791.19,2825.00,per diem,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,United Healthcare,Individual Exchange,,1181.00,,,,,,,375.38,2825.00,per diem,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Individual Exchange,,232.00,,,,,,,41.04,319.50,per diem,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Individual Exchange,,87.00,,,,,,,64.86,243.00,per diem,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Individual Exchange,,87.00,,,,,,,57.15,299.25,per diem,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,Individual Exchange,,990.00,,,,,,,349.35,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,Individual Exchange,,910.89,,,,,,,328.93,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Individual Exchange,,82.48,,,,,,,29.78,128.45,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,366.57,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,Individual Exchange,,955.78,,,,,,,345.14,4311.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,102.31,678.75,per diem,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,94.01,405.00,per diem,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,82.70,356.25,per diem,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,82.70,356.25,per diem,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,United Healthcare,Individual Exchange,,175.00,,,,,,,150.52,974.25,per diem,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Individual Exchange,,175.00,,,,,,,175.00,777.75,per diem,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,Individual Exchange,,175.00,,,,,,,102.31,635.25,per diem,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,102.31,462.00,per diem,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,Individual Exchange,,175.00,,,,,,,104.29,449.25,per diem,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Individual Exchange,,175.00,,,,,,,50.84,269.00,per diem,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,4.27,,,,,,,4.01,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,Individual Exchange,,22.53,,,,,,,10.24,323.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Individual Exchange,,89.16,,,,,,,46.38,237.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Individual Exchange,,18.50,,,,,,,8.42,216.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,United Healthcare,Individual Exchange,,101.53,,,,,,,46.20,510.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,Individual Exchange,,17.41,,,,,,,7.92,210.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Individual Exchange,,332.94,,,,,,,116.52,436.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Individual Exchange,,294.09,,,,,,,116.52,436.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,United Healthcare,Individual Exchange,,828.44,,,,,,,287.49,1077.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Individual Exchange,,434.32,,,,,,,150.55,564.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,Individual Exchange,,1726.54,,,,,,,373.57,2152.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,United Healthcare,Individual Exchange,,1726.54,,,,,,,870.87,3262.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,United Healthcare,Individual Exchange,,99.92,,,,,,,50.45,189.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Individual Exchange,,124.09,,,,,,,35.44,136.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,Individual Exchange,,84.90,,,,,,,55.33,276.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,Individual Exchange,,66.82,,,,,,,36.64,137.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Individual Exchange,,246.95,,,,,,,85.49,320.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,Individual Exchange,,150.51,,,,,,,65.87,246.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Individual Exchange,,52.09,,,,,,,33.95,206.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Individual Exchange,,132.72,,,,,,,63.40,299.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,United Healthcare,Individual Exchange,,402.03,,,,,,,126.33,473.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Individual Exchange,,303.22,,,,,,,103.70,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,United Healthcare,Individual Exchange,,436.66,,,,,,,174.97,655.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,United Healthcare,Individual Exchange,,436.66,,,,,,,112.51,436.66,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Individual Exchange,,4.79,,,,,,,2.18,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,Individual Exchange,,587.98,,,,,,,72.47,646.78,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,United Healthcare,Individual Exchange,,76.02,,,,,,,49.54,567.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Individual Exchange,,88.63,,,,,,,42.34,228.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Individual Exchange,,409.16,,,,,,,133.13,498.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Individual Exchange,,348.29,,,,,,,84.48,434.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,Individual Exchange,,816.53,,,,,,,191.39,816.53,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,Individual Exchange,,448.55,,,,,,,119.92,748.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Individual Exchange,,226.13,,,,,,,84.48,316.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Individual Exchange,,147.73,,,,,,,72.10,343.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,United Healthcare,Individual Exchange,,186.43,,,,,,,72.87,273.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,United Healthcare,Individual Exchange,,701.70,,,,,,,335.20,1893.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,United Healthcare,Individual Exchange,,681.00,,,,,,,325.32,1626.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,Individual Exchange,,359.91,,,,,,,171.93,829.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,United Healthcare,Individual Exchange,,192.05,,,,,,,104.30,390.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,United Healthcare,Individual Exchange,,251.14,,,,,,,110.71,414.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,United Healthcare,Individual Exchange,,367.84,,,,,,,67.27,457.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Individual Exchange,,123.55,,,,,,,25.63,173.55,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Individual Exchange,,490.44,,,,,,,102.50,556.86,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Individual Exchange,,287.64,,,,,,,80.88,358.40,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Individual Exchange,,440.25,,,,,,,80.88,549.16,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Individual Exchange,,35.77,,,,,,,9.41,35.77,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,United Healthcare,Individual Exchange,,6.76,,,,,,,2.80,10.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Individual Exchange,,18.63,,,,,,,8.48,84.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Individual Exchange,,20.59,,,,,,,9.37,122.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Individual Exchange,,16.02,,,,,,,7.29,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Individual Exchange,,9.17,,,,,,,4.18,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.14,33.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Individual Exchange,,118.79,,,,,,,37.84,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,United Healthcare,Individual Exchange,,18.04,,,,,,,8.21,198.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,61.23,,,,,,,0.00200,76.44,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Individual Exchange,,14.96,,,,,,,6.80,66.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Individual Exchange,,28.56,,,,,,,12.99,189.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Individual Exchange,,118.79,,,,,,,37.84,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,United Healthcare,Individual Exchange,,118.79,,,,,,,60.28,297.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Individual Exchange,,118.79,,,,,,,31.03,118.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Individual Exchange,,118.79,,,,,,,18.62,118.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Individual Exchange,,118.79,,,,,,,60.28,401.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,32.13,,,,,,,14.63,68.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,32.13,,,,,,,14.63,68.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,32.13,,,,,,,14.63,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Individual Exchange,,40.10,,,,,,,14.21,53.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,31.04,,,,,,,14.13,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,28.30,,,,,,,10.21,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,28.88,,,,,,,13.13,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Individual Exchange,,34.95,,,,,,,15.89,99.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Individual Exchange,,34.95,,,,,,,15.89,99.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Individual Exchange,,34.95,,,,,,,15.89,99.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,31.32,,,,,,,12.61,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,14.08,,,,,,,6.41,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Individual Exchange,,24.42,,,,,,,5.81,28.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,28.27,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Individual Exchange,,29.34,,,,,,,13.35,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Individual Exchange,,29.27,,,,,,,13.32,132.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Individual Exchange,,29.27,,,,,,,13.32,93.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Individual Exchange,,30.17,,,,,,,7.81,30.17,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,34.37,,,,,,,15.65,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,34.37,,,,,,,15.65,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,34.37,,,,,,,15.65,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,28.88,,,,,,,13.13,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,28.88,,,,,,,13.13,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,28.88,,,,,,,13.13,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Individual Exchange,,69.50,,,,,,,30.83,115.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Individual Exchange,,9.63,,,,,,,4.38,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Individual Exchange,,17.43,,,,,,,7.92,32.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,17.43,,,,,,,7.92,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,10.55,,,,,,,4.80,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Individual Exchange,,11.03,,,,,,,7.55,31.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,12.33,,,,,,,5.61,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,12.33,,,,,,,5.61,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,25.71,,,,,,,16.75,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Individual Exchange,,28.63,,,,,,,9.61,36.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Individual Exchange,,35.77,,,,,,,16.27,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,31.06,,,,,,,14.13,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Individual Exchange,,13.82,,,,,,,6.29,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Individual Exchange,,13.82,,,,,,,6.29,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Individual Exchange,,13.82,,,,,,,6.29,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Individual Exchange,,34.49,,,,,,,15.69,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Individual Exchange,,10.70,,,,,,,4.87,31.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Individual Exchange,,10.70,,,,,,,4.87,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,10.70,,,,,,,4.87,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,United Healthcare,Individual Exchange,,6.94,,,,,,,4.25,45.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Individual Exchange,,6.94,,,,,,,5.16,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Individual Exchange,,6.94,,,,,,,4.10,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Individual Exchange,,63.11,,,,,,,28.71,124.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,,11.00,,,,,,,5.01,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,,11.00,,,,,,,5.01,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Individual Exchange,,12.86,,,,,,,5.85,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Individual Exchange,,10.42,,,,,,,4.73,39.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,26.29,,,,,,,11.95,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,26.29,,,,,,,11.95,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,United Healthcare,Individual Exchange,,40.44,,,,,,,18.39,193.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,22.89,,,,,,,10.42,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,30.12,,,,,,,13.70,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,30.12,,,,,,,13.70,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,9.80,,,,,,,4.46,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,10.71,,,,,,,5.58,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,10.71,,,,,,,5.58,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,10.43,,,,,,,4.80,18.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Individual Exchange,,9.28,,,,,,,4.22,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Individual Exchange,,28.73,,,,,,,28.73,182.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,40.35,,,,,,,18.02,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,40.35,,,,,,,18.02,67.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Individual Exchange,,29.18,,,,,,,18.08,135.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Individual Exchange,,34.76,,,,,,,15.81,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Individual Exchange,,27.88,,,,,,,13.32,109.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,13.88,,,,,,,6.31,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Individual Exchange,,24.62,,,,,,,11.20,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Individual Exchange,,10.92,,,,,,,4.97,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,United Healthcare,Individual Exchange,,59.56,,,,,,,27.10,224.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,United Healthcare,Individual Exchange,,31.74,,,,,,,1.20,31.74,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Individual Exchange,,10.85,,,,,,,4.95,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Individual Exchange,,29.04,,,,,,,13.22,150.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,Individual Exchange,,137.32,,,,,,,62.48,434.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Individual Exchange,,31.34,,,,,,,14.26,117.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Individual Exchange,,19.82,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Individual Exchange,,19.82,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Individual Exchange,,19.82,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Individual Exchange,,19.82,,,,,,,9.02,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Individual Exchange,,18.06,,,,,,,7.81,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,41.25,,,,,,,25.29,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Individual Exchange,,60.50,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Individual Exchange,,60.50,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Individual Exchange,,60.50,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Individual Exchange,,60.50,,,,,,,40.64,152.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,18.61,,,,,,,9.48,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Individual Exchange,,8.37,,,,,,,3.81,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,8.37,,,,,,,3.81,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,8.37,,,,,,,3.81,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,8.37,,,,,,,3.81,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Individual Exchange,,8.37,,,,,,,3.81,53.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,Individual Exchange,,10.13,,,,,,,4.61,128.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Individual Exchange,,27.45,,,,,,,12.48,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,8.34,,,,,,,3.80,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,8.34,,,,,,,3.80,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Individual Exchange,,15.35,,,,,,,6.98,58.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,United Healthcare,Individual Exchange,,39.63,,,,,,,18.02,178.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Individual Exchange,,39.49,,,,,,,17.96,117.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Individual Exchange,,26.82,,,,,,,12.20,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,United Healthcare,Individual Exchange,,27.45,,,,,,,12.48,165.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Individual Exchange,,38.49,,,,,,,17.52,90.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Individual Exchange,,12.71,,,,,,,7.76,114.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,20.69,,,,,,,9.42,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Individual Exchange,,15.62,,,,,,,7.95,35.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Individual Exchange,,15.62,,,,,,,7.95,35.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Individual Exchange,,10.13,,,,,,,4.60,17.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,United Healthcare,Individual Exchange,,35.97,,,,,,,17.38,147.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Individual Exchange,,37.88,,,,,,,23.38,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Individual Exchange,,24.58,,,,,,,8.01,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Individual Exchange,,24.58,,,,,,,11.18,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Individual Exchange,,24.38,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,13.81,,,,,,,6.28,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,22.78,,,,,,,11.22,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Individual Exchange,,12.86,,,,,,,5.86,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Individual Exchange,,12.86,,,,,,,5.86,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,41.83,,,,,,,10.81,41.83,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Individual Exchange,,40.33,,,,,,,8.41,40.33,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Individual Exchange,,14.68,,,,,,,6.68,118.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Individual Exchange,,14.68,,,,,,,6.68,118.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,Individual Exchange,,17.46,,,,,,,7.94,111.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Individual Exchange,,20.34,,,,,,,10.19,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,14.29,,,,,,,6.50,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,14.29,,,,,,,6.50,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,14.29,,,,,,,6.21,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Individual Exchange,,27.54,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Individual Exchange,,72.37,,,,,,,20.02,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Individual Exchange,,25.71,,,,,,,16.75,107.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,25.71,,,,,,,16.22,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Individual Exchange,,14.08,,,,,,,6.41,62.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,14.53,,,,,,,6.62,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Individual Exchange,,88.00,,,,,,,28.63,107.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Individual Exchange,,88.00,,,,,,,35.44,132.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Individual Exchange,,7.64,,,,,,,3.47,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Individual Exchange,,7.64,,,,,,,3.47,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Individual Exchange,,7.64,,,,,,,3.47,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,43.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,10.10,,,,,,,4.60,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.61,80.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,United Healthcare,Individual Exchange,,11.03,,,,,,,0.40040,11.03,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,Individual Exchange,,134.91,,,,,,,65.87,246.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Individual Exchange,,9.80,,,,,,,4.62,41.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,9.17,,,,,,,4.59,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,9.17,,,,,,,4.59,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,9.17,,,,,,,4.59,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,31.10,,,,,,,14.15,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Individual Exchange,,44.47,,,,,,,20.23,109.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,United Healthcare,Individual Exchange,,41.32,,,,,,,18.80,170.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Individual Exchange,,39.20,,,,,,,17.84,161.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Individual Exchange,,39.20,,,,,,,17.84,161.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Individual Exchange,,7.82,,,,,,,3.56,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,7.82,,,,,,,3.56,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,7.82,,,,,,,3.56,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Individual Exchange,,7.82,,,,,,,3.88,39.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Individual Exchange,,22.89,,,,,,,10.42,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Individual Exchange,,38.02,,,,,,,10.01,38.02,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Individual Exchange,,38.02,,,,,,,13.21,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Individual Exchange,,10.26,,,,,,,4.67,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Individual Exchange,,10.36,,,,,,,4.91,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Individual Exchange,,10.36,,,,,,,4.91,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Individual Exchange,,10.36,,,,,,,4.71,32.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Individual Exchange,,5.34,,,,,,,3.00,11.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,Individual Exchange,,55.05,,,,,,,25.04,125.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Individual Exchange,,14.64,,,,,,,6.66,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Individual Exchange,,19.23,,,,,,,8.75,120.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,United Healthcare,Individual Exchange,,35.81,,,,,,,16.30,142.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Individual Exchange,,11.29,,,,,,,5.14,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,27.22,,,,,,,12.38,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Individual Exchange,,12.26,,,,,,,5.57,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Individual Exchange,,30.23,,,,,,,13.75,100.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Individual Exchange,,36.11,,,,,,,16.43,97.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Individual Exchange,,20.98,,,,,,,12.10,81.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,8.41,,,,,,,3.83,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Individual Exchange,,10.13,,,,,,,5.39,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,9.63,,,,,,,4.38,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Individual Exchange,,10.13,,,,,,,4.93,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Individual Exchange,,10.13,,,,,,,4.93,86.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Individual Exchange,,118.79,,,,,,,26.03,118.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,United Healthcare,Individual Exchange,,118.79,,,,,,,38.64,144.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,32.09,,,,,,,10.81,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Individual Exchange,,16.80,,,,,,,7.63,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Individual Exchange,,11.11,,,,,,,2.40,11.11,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Individual Exchange,,32.09,,,,,,,14.60,278.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Individual Exchange,,32.09,,,,,,,14.60,278.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Individual Exchange,,39.16,,,,,,,17.82,168.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Individual Exchange,,23.80,,,,,,,6.41,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,105.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Individual Exchange,,27.60,,,,,,,12.56,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Individual Exchange,,54.24,,,,,,,19.42,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,54.24,,,,,,,16.22,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,54.24,,,,,,,16.22,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,United Healthcare,Individual Exchange,,25.60,,,,,,,11.64,102.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Individual Exchange,,29.29,,,,,,,13.33,90.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,United Healthcare,Individual Exchange,,29.29,,,,,,,1.60,29.29,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,Individual Exchange,,38.23,,,,,,,4.40,38.23,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Individual Exchange,,38.23,,,,,,,17.39,79.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,Individual Exchange,,25.69,,,,,,,11.69,130.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Individual Exchange,,25.69,,,,,,,7.41,27.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Individual Exchange,,44.37,,,,,,,20.19,96.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Individual Exchange,,44.37,,,,,,,20.19,200.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,110.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Individual Exchange,,47.78,,,,,,,29.02,204.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,Individual Exchange,,47.63,,,,,,,21.67,155.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Individual Exchange,,62.57,,,,,,,10.01,62.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,Individual Exchange,,80.42,,,,,,,36.60,177.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,57.08,,,,,,,25.98,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,57.08,,,,,,,23.62,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,24.90,,,,,,,16.22,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,United Healthcare,Individual Exchange,,80.42,,,,,,,36.60,154.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,Individual Exchange,,80.42,,,,,,,8.21,80.42,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Individual Exchange,,100.17,,,,,,,45.57,219.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Individual Exchange,,80.42,,,,,,,40.24,150.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Individual Exchange,,31.01,,,,,,,9.21,34.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Individual Exchange,,21.73,,,,,,,11.19,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Individual Exchange,,21.73,,,,,,,11.19,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Individual Exchange,,22.68,,,,,,,10.01,37.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Individual Exchange,,12.10,,,,,,,5.50,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,United Healthcare,Individual Exchange,,132.13,,,,,,,44.64,167.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,United Healthcare,Individual Exchange,,8.03,,,,,,,4.20,25.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.14,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Individual Exchange,,9.38,,,,,,,4.27,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,9.38,,,,,,,4.27,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Individual Exchange,,36.32,,,,,,,13.61,51.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,,30.70,,,,,,,13.96,87.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Individual Exchange,,35.90,,,,,,,16.34,129.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Individual Exchange,,32.61,,,,,,,14.83,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Individual Exchange,,38.67,,,,,,,17.60,87.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Individual Exchange,,38.67,,,,,,,17.60,87.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,21.69,,,,,,,9.87,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Individual Exchange,,21.69,,,,,,,3.00,21.69,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,,30.94,,,,,,,16.34,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,,30.94,,,,,,,16.34,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Individual Exchange,,17.89,,,,,,,7.01,26.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Individual Exchange,,28.12,,,,,,,9.01,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,Individual Exchange,,41.26,,,,,,,13.81,51.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,Individual Exchange,,18.93,,,,,,,8.62,345.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,29.24,,,,,,,12.61,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Individual Exchange,,25.10,,,,,,,11.42,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Individual Exchange,,22.89,,,,,,,10.42,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,26.43,,,,,,,7.21,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Individual Exchange,,24.00,,,,,,,10.92,146.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Individual Exchange,,26.43,,,,,,,12.02,62.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,United Healthcare,Individual Exchange,,41.26,,,,,,,2.20,41.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,41.26,,,,,,,5.61,41.26,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Individual Exchange,,27.47,,,,,,,7.01,27.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Individual Exchange,,30.70,,,,,,,13.96,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Individual Exchange,,30.71,,,,,,,13.98,81.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,28.23,,,,,,,10.81,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,27.47,,,,,,,11.21,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,30.43,,,,,,,13.84,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,Individual Exchange,,171.23,,,,,,,106.21,595.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,United Healthcare,Individual Exchange,,80.97,,,,,,,62.26,335.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,United Healthcare,Individual Exchange,,60.73,,,,,,,53.25,199.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,United Healthcare,Individual Exchange,,259.58,,,,,,,114.11,601.18,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,Individual Exchange,,235.98,,,,,,,168.37,630.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,,22.03,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,Individual Exchange,,37.47,,,,,,,37.47,222.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,United Healthcare,Individual Exchange,,37.47,,,,,,,37.47,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Individual Exchange,,11.46,,,,,,,5.23,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Individual Exchange,,11.46,,,,,,,5.23,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Individual Exchange,,11.46,,,,,,,5.23,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,174.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,6.36,,,,,,,2.90,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,6.36,,,,,,,2.90,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Individual Exchange,,8.00,,,,,,,6.16,92.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Individual Exchange,,8.00,,,,,,,6.16,100.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,Individual Exchange,,8.16,,,,,,,3.72,147.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Individual Exchange,,22.03,,,,,,,22.03,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,22.03,,,,,,,12.21,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Individual Exchange,,37.47,,,,,,,37.47,375.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,United Healthcare,Individual Exchange,,37.47,,,,,,,37.47,552.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Individual Exchange,,22.03,,,,,,,22.03,94.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Individual Exchange,,25.57,,,,,,,13.49,104.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Individual Exchange,,7.33,,,,,,,3.69,27.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,5.05,,,,,,,2.30,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,5.05,,,,,,,2.30,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Individual Exchange,,16.58,,,,,,,7.54,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,13.80,,,,,,,6.28,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,8.54,,,,,,,3.87,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Individual Exchange,,11.89,,,,,,,5.40,69.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Individual Exchange,,5.42,,,,,,,2.46,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,9.53,,,,,,,4.35,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Individual Exchange,,27.68,,,,,,,12.59,242.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Individual Exchange,,37.62,,,,,,,17.12,206.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,Individual Exchange,,38.17,,,,,,,17.36,218.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Individual Exchange,,38.17,,,,,,,17.36,198.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,United Healthcare,Individual Exchange,,25.35,,,,,,,11.53,459.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Individual Exchange,,48.92,,,,,,,22.25,120.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,48.92,,,,,,,15.42,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,Individual Exchange,,48.92,,,,,,,22.25,177.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,United Healthcare,Individual Exchange,,48.92,,,,,,,29.93,149.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Individual Exchange,,48.92,,,,,,,19.82,74.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,Individual Exchange,,40.59,,,,,,,18.47,243.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Individual Exchange,,38.17,,,,,,,17.36,203.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Individual Exchange,,38.17,,,,,,,17.36,242.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,United Healthcare,Individual Exchange,,41.25,,,,,,,18.77,188.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Individual Exchange,,18.96,,,,,,,8.84,136.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Individual Exchange,,40.38,,,,,,,18.36,139.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Individual Exchange,,40.38,,,,,,,18.36,139.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Individual Exchange,,25.28,,,,,,,11.49,185.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Individual Exchange,,29.49,,,,,,,13.42,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Individual Exchange,,32.67,,,,,,,8.81,33.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Individual Exchange,,48.92,,,,,,,29.93,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,Individual Exchange,,32.67,,,,,,,14.86,147.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,United Healthcare,Individual Exchange,,27.45,,,,,,,12.48,351.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,United Healthcare,Individual Exchange,,27.45,,,,,,,12.48,212.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,27.45,,,,,,,12.48,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Individual Exchange,,9.08,,,,,,,4.15,26.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,14.68,,,,,,,6.68,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Individual Exchange,,21.69,,,,,,,9.87,54.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Individual Exchange,,18.12,,,,,,,9.43,84.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Individual Exchange,,36.66,,,,,,,16.67,267.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,14.14,,,,,,,9.08,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Individual Exchange,,27.91,,,,,,,12.70,109.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,27.91,,,,,,,12.61,47.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Individual Exchange,,45.80,,,,,,,24.16,151.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Individual Exchange,,45.80,,,,,,,24.16,107.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,,37.66,,,,,,,17.44,87.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Individual Exchange,,37.66,,,,,,,17.44,87.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Individual Exchange,,8.37,,,,,,,4.16,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,Individual Exchange,,8.39,,,,,,,3.82,76.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,20.39,,,,,,,9.29,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Individual Exchange,,20.39,,,,,,,9.29,63.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,Individual Exchange,,38.33,,,,,,,17.44,73.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,20.98,,,,,,,9.55,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Individual Exchange,,29.18,,,,,,,18.08,168.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Individual Exchange,,7.56,,,,,,,4.14,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,11.76,,,,,,,5.34,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Individual Exchange,,12.31,,,,,,,5.60,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,Individual Exchange,,12.31,,,,,,,3.80,14.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,12.80,,,,,,,5.83,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,12.80,,,,,,,5.83,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Individual Exchange,,13.80,,,,,,,6.28,35.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Individual Exchange,,13.80,,,,,,,3.00,13.80,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,Individual Exchange,,24.89,,,,,,,8.21,30.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,14.25,,,,,,,6.48,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Individual Exchange,,22.01,,,,,,,10.01,141.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Individual Exchange,,22.01,,,,,,,10.01,91.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Individual Exchange,,20.11,,,,,,,9.16,97.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,20.11,,,,,,,9.16,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Individual Exchange,,20.11,,,,,,,9.16,53.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,117.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,Individual Exchange,,18.36,,,,,,,5.41,20.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Individual Exchange,,20.11,,,,,,,9.59,39.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Individual Exchange,,20.17,,,,,,,9.19,140.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Individual Exchange,,20.17,,,,,,,9.19,140.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Individual Exchange,,20.17,,,,,,,9.19,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Individual Exchange,,17.23,,,,,,,7.84,159.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Individual Exchange,,17.23,,,,,,,7.84,153.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,17.23,,,,,,,7.84,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,17.23,,,,,,,7.84,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.41,24.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,153.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.21,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.21,23.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Individual Exchange,,14.14,,,,,,,6.43,52.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Individual Exchange,,17.23,,,,,,,7.83,108.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Individual Exchange,,16.45,,,,,,,7.48,69.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,17.91,,,,,,,8.16,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Individual Exchange,,22.01,,,,,,,7.81,29.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,22.01,,,,,,,10.01,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Individual Exchange,,245.92,,,,,,,5.21,245.92,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.18,18.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.14,96.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,12.54,,,,,,,5.70,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Individual Exchange,,18.96,,,,,,,8.63,87.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Individual Exchange,,10.13,,,,,,,4.61,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,14.70,,,,,,,7.26,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Individual Exchange,,10.13,,,,,,,3.60,13.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,18.42,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,18.42,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,18.42,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,18.42,,,,,,,8.39,55.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,United Healthcare,Individual Exchange,,18.42,,,,,,,8.39,254.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.14,51.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.14,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.14,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,11.46,,,,,,,5.23,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,United Healthcare,Individual Exchange,,11.46,,,,,,,3.20,12.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,11.46,,,,,,,5.23,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,United Healthcare,Individual Exchange,,12.77,,,,,,,5.81,183.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Individual Exchange,,38.31,,,,,,,16.82,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Individual Exchange,,9.09,,,,,,,5.65,115.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,9.09,,,,,,,5.65,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Individual Exchange,,25.57,,,,,,,7.41,27.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Individual Exchange,,25.57,,,,,,,11.62,74.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,25.57,,,,,,,11.62,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Individual Exchange,,25.57,,,,,,,11.62,58.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Individual Exchange,,25.57,,,,,,,8.01,30.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Individual Exchange,,22.01,,,,,,,10.02,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Individual Exchange,,22.01,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,50.79,,,,,,,19.02,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Individual Exchange,,50.79,,,,,,,12.61,50.79,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Individual Exchange,,25.57,,,,,,,11.62,135.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,Individual Exchange,,25.57,,,,,,,6.61,25.57,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Individual Exchange,,25.57,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,171.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,Individual Exchange,,74.82,,,,,,,33.83,126.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,345.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Individual Exchange,,91.32,,,,,,,41.55,159.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,159.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Individual Exchange,,91.32,,,,,,,41.55,471.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Individual Exchange,,91.32,,,,,,,41.55,435.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,130.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Individual Exchange,,74.82,,,,,,,32.23,120.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Individual Exchange,,181.40,,,,,,,70.07,262.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,159.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Individual Exchange,,71.09,,,,,,,32.83,123.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Individual Exchange,,71.09,,,,,,,32.83,123.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Individual Exchange,,178.24,,,,,,,55.05,206.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,United Healthcare,Individual Exchange,,262.46,,,,,,,51.45,264.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Individual Exchange,,852.72,,,,,,,154.15,852.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,United Healthcare,Individual Exchange,,74.82,,,,,,,17.42,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Individual Exchange,,74.82,,,,,,,16.62,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Individual Exchange,,74.82,,,,,,,9.61,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,74.82,,,,,,,16.22,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Individual Exchange,,71.25,,,,,,,22.42,84.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,Individual Exchange,,91.32,,,,,,,41.55,434.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,United Healthcare,Individual Exchange,,432.31,,,,,,,55.86,488.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Individual Exchange,,25.57,,,,,,,11.01,41.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Individual Exchange,,25.57,,,,,,,16.03,115.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Individual Exchange,,25.57,,,,,,,15.59,72.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Individual Exchange,,25.57,,,,,,,15.59,72.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Individual Exchange,,25.57,,,,,,,15.59,72.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Individual Exchange,,548.82,,,,,,,92.69,548.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Individual Exchange,,548.82,,,,,,,58.86,548.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Individual Exchange,,6.76,,,,,,,3.07,66.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Individual Exchange,,6.76,,,,,,,3.07,66.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,5.45,,,,,,,3.38,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,5.45,,,,,,,3.38,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Individual Exchange,,5.45,,,,,,,3.38,38.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Individual Exchange,,13.48,,,,,,,8.35,94.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Individual Exchange,,37.47,,,,,,,2.40,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Individual Exchange,,11.75,,,,,,,5.43,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,15.24,,,,,,,7.11,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Individual Exchange,,10.13,,,,,,,5.62,90.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Individual Exchange,,186.14,,,,,,,88.91,411.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,United Healthcare,Individual Exchange,,38.49,,,,,,,17.51,231.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Individual Exchange,,51.56,,,,,,,23.45,95.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Individual Exchange,,26.43,,,,,,,7.21,27.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,Individual Exchange,,10.08,,,,,,,4.40,16.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,United Healthcare,Individual Exchange,,26.93,,,,,,,12.85,172.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,35.11,,,,,,,15.42,57.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Individual Exchange,,17.17,,,,,,,5.81,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Individual Exchange,,11.11,,,,,,,3.60,13.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Individual Exchange,,38.23,,,,,,,17.39,79.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Individual Exchange,,9.09,,,,,,,4.14,43.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Individual Exchange,,27.82,,,,,,,7.01,27.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Individual Exchange,,27.47,,,,,,,7.01,27.47,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,Individual Exchange,,11.03,,,,,,,3.80,14.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Individual Exchange,,30.66,,,,,,,12.21,45.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,Individual Exchange,,17.23,,,,,,,7.84,48.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Individual Exchange,,17.23,,,,,,,7.84,34.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Individual Exchange,,25.57,,,,,,,11.21,42.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Individual Exchange,,18.35,,,,,,,8.35,53.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Individual Exchange,,28.12,,,,,,,3.00,28.12,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,14.25,,,,,,,6.48,36.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Individual Exchange,,11.03,,,,,,,5.02,22.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Individual Exchange,,28.56,,,,,,,12.99,189.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Individual Exchange,,35.00,,,,,,,26.83,100.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,Individual Exchange,,10.13,,,,,,,4.61,128.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Individual Exchange,,10.13,,,,,,,4.61,19.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Individual Exchange,,27.45,,,,,,,12.48,121.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Individual Exchange,,8.37,,,,,,,4.16,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,12.10,,,,,,,5.61,21.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,28.23,,,,,,,10.81,40.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Individual Exchange,,14.14,,,,,,,5.81,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,53.18,,,,,,,0.00200,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Individual Exchange,,251.14,,,,,,,103.70,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Individual Exchange,,23.33,,,,,,,14.17,60.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,32.09,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Individual Exchange,,15.58,,,,,,,5.81,21.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Individual Exchange,,55.01,,,,,,,25.04,120.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,Individual Exchange,,133.70,,,,,,,133.70,1470.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,74.82,,,,,,,9.81,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,33.90,,,,,,,15.44,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Individual Exchange,,11.72,,,,,,,5.33,105.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,,41.32,,,,,,,17.82,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Individual Exchange,,5.76,,,,,,,2.62,25.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,18.36,,,,,,,8.36,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Individual Exchange,,25.57,,,,,,,7.61,28.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Individual Exchange,,25.57,,,,,,,14.01,52.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Individual Exchange,,25.57,,,,,,,14.01,52.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Individual Exchange,,4.47,,,,,,,3.00,11.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Individual Exchange,,4.47,,,,,,,3.90,26.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Individual Exchange,,4.47,,,,,,,3.90,56.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Individual Exchange,,74.82,,,,,,,9.81,74.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,United Healthcare,Individual Exchange,,246.60,,,,,,,105.91,396.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,United Healthcare,Individual Exchange,,275.65,,,,,,,153.55,575.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Individual Exchange,,123.55,,,,,,,26.83,154.14,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,United Healthcare,Individual Exchange,,955.33,,,,,,,361.36,1353.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,United Healthcare,Individual Exchange,,3699.95,,,,,,,251.85,3699.95,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Individual Exchange,,138.78,,,,,,,58.66,696.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Individual Exchange,,4.47,,,,,,,4.18,4311.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,United Healthcare,Individual Exchange,,23.79,,,,,,,10.82,1448.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Individual Exchange,,13.80,,,,,,,4.60,17.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,United Healthcare,Individual Exchange,,11.76,,,,,,,5.34,194.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Individual Exchange,,28.98,,,,,,,9.21,34.68,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,57.08,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,57.08,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,57.08,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,57.08,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,57.08,,,,,,,5.61,57.08,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Individual Exchange,,275.65,,,,,,,141.54,530.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,42.75,,,,,,,12.41,46.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Individual Exchange,,74.82,,,,,,,21.42,80.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,United Healthcare,Individual Exchange,,203.91,,,,,,,102.70,384.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,Individual Exchange,,133.70,,,,,,,133.70,1470.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,United Healthcare,Individual Exchange,,324.56,,,,,,,22.82,324.56,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,243.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,74.82,,,,,,,27.23,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,Individual Exchange,,128.99,,,,,,,38.84,145.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,Individual Exchange,,246.60,,,,,,,117.98,714.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,United Healthcare,Individual Exchange,,275.65,,,,,,,127.93,479.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Individual Exchange,,45.80,,,,,,,24.16,105.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Individual Exchange,QW,45.80,,,,,,,24.16,105.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Individual Exchange,,30.66,,,,,,,9.21,34.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,Individual Exchange,,118.79,,,,,,,55.66,208.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,United Healthcare,Individual Exchange,,1726.54,,,,,,,318.12,2152.96,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,United Healthcare,Individual Exchange,,850.95,,,,,,,237.64,890.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,Individual Exchange,,186.14,,,,,,,55.66,208.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,44.37,,,,,,,20.19,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,Individual Exchange,,436.66,,,,,,,121.92,456.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,United Healthcare,Individual Exchange,,88.99,,,,,,,40.51,358.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Individual Exchange,,91.32,,,,,,,40.84,153.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Individual Exchange,,25.57,,,,,,,15.59,319.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Individual Exchange,,11.11,,,,,,,5.06,37.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,38.37,,,,,,,22.02,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Individual Exchange,QW,76.37,,,,,,,20.02,76.37,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Individual Exchange,,62.71,,,,,,,20.02,75.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Individual Exchange,,25.71,,,,,,,16.75,122.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,United Healthcare,Individual Exchange,,620.33,,,,,,,181.58,680.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Individual Exchange,,212.24,,,,,,,55.05,212.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Individual Exchange,,22.01,,,,,,,10.01,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,,27.74,,,,,,,18.08,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Individual Exchange,,27.74,,,,,,,17.82,66.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Individual Exchange,,40.35,,,,,,,8.61,50.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Individual Exchange,,57.41,,,,,,,37.41,210.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Individual Exchange,,18.42,,,,,,,8.39,59.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,Individual Exchange,,212.29,,,,,,,38.84,264.62,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,72.37,,,,,,,18.22,72.58,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,Individual Exchange,,46.34,,,,,,,13.81,51.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Individual Exchange,,44.36,,,,,,,13.21,49.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Individual Exchange,,203.91,,,,,,,70.07,262.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Individual Exchange,,39.58,,,,,,,27.03,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Individual Exchange,,24.11,,,,,,,24.11,159.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,United Healthcare,Individual Exchange,,52.07,,,,,,,43.84,164.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Individual Exchange,,36.36,,,,,,,27.03,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Individual Exchange,,39.58,,,,,,,27.03,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Individual Exchange,,25.60,,,,,,,9.01,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Individual Exchange,,25.60,,,,,,,9.01,33.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,United Healthcare,Individual Exchange,,43.31,,,,,,,15.22,57.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Individual Exchange,,24.58,,,,,,,8.61,32.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,27.60,,,,,,,13.01,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Individual Exchange,,47.63,,,,,,,16.82,63.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Individual Exchange,,62.57,,,,,,,20.22,75.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,Individual Exchange,,42.87,,,,,,,26.57,111.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,United Healthcare,Individual Exchange,,259.85,,,,,,,124.44,996.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Individual Exchange,,24.58,,,,,,,11.01,41.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Individual Exchange,,76.16,,,,,,,21.62,81.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,74.82,,,,,,,23.62,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Individual Exchange,,74.82,,,,,,,23.62,88.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,20.69,,,,,,,9.42,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Individual Exchange,,22.78,,,,,,,11.22,48.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Individual Exchange,,4.79,,,,,,,2.18,42.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Individual Exchange,,74.82,,,,,,,34.04,203.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,Individual Exchange,,52.23,,,,,,,33.43,125.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Individual Exchange,,52.23,,,,,,,34.04,203.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Individual Exchange,,203.91,,,,,,,63.86,254.34,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,United Healthcare,Individual Exchange,,391.44,,,,,,,105.31,394.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,United Healthcare,Individual Exchange,,104.48,,,,,,,42.04,157.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,15.51,,,,,,,0.00200,70.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,Individual Exchange,,5.05,,,,,,,2.30,20.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Individual Exchange,,24.90,,,,,,,22.02,82.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,139.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Individual Exchange,,53.18,,,,,,,29.43,110.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Individual Exchange,,53.18,,,,,,,29.43,110.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Individual Exchange,,47.45,,,,,,,7.81,47.45,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,United Healthcare,Individual Exchange,,43.19,,,,,,,19.65,148.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,23.56,89.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,United Healthcare,Individual Exchange,,53.18,,,,,,,36.54,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,Individual Exchange,,53.18,,,,,,,51.40,195.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,56.47,,,,,,,25.81,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Individual Exchange,,56.47,,,,,,,15.62,58.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Individual Exchange,,56.47,,,,,,,25.81,102.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Individual Exchange,,248.36,,,,,,,103.70,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,Individual Exchange,,248.36,,,,,,,29.63,248.36,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,United Healthcare,Individual Exchange,,300.02,,,,,,,91.29,342.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,United Healthcare,Individual Exchange,,313.92,,,,,,,119.52,447.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,United Healthcare,Individual Exchange,,313.92,,,,,,,145.79,566.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,United Healthcare,Individual Exchange,,269.27,,,,,,,112.31,420.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,Individual Exchange,,21.53,,,,,,,12.68,243.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Individual Exchange,,376.77,,,,,,,45.05,490.72,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,United Healthcare,Individual Exchange,,265.73,,,,,,,121.73,764.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Individual Exchange,,265.73,,,,,,,70.87,268.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,Individual Exchange,,383.24,,,,,,,121.92,456.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Individual Exchange,,45.66,,,,,,,20.78,168.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Individual Exchange,,45.66,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Individual Exchange,,68.49,,,,,,,26.43,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Individual Exchange,,74.21,,,,,,,27.03,101.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Individual Exchange,,85.61,,,,,,,49.65,411.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,Individual Exchange,,53.51,,,,,,,20.42,76.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Individual Exchange,,146.24,,,,,,,35.03,146.24,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,Individual Exchange,,40.50,,,,,,,26.10,275.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Individual Exchange,,15.51,,,,,,,15.51,495.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Individual Exchange,,24.90,,,,,,,0.00200,109.32,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,20.48,93.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,169.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,United Healthcare,Individual Exchange,,53.18,,,,,,,51.40,277.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Individual Exchange,,53.18,,,,,,,51.40,239.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Individual Exchange,,53.18,,,,,,,51.40,239.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,United Healthcare,Individual Exchange,,80.53,,,,,,,80.53,444.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Individual Exchange,,80.53,,,,,,,80.53,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Individual Exchange,,15.51,,,,,,,12.54,72.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,135.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,295.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,234.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,United Healthcare,Individual Exchange,,80.53,,,,,,,49.85,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Individual Exchange,,53.18,,,,,,,15.42,70.99,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,288.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,99.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,858.84,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,23.59,141.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,United Healthcare,Individual Exchange,,17.93,,,,,,,11.69,192.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,Individual Exchange,,53.18,,,,,,,52.25,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Individual Exchange,,53.18,,,,,,,31.43,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Individual Exchange,,53.18,,,,,,,31.43,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Individual Exchange,,80.53,,,,,,,80.53,404.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Individual Exchange,,42.43,,,,,,,27.83,104.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Individual Exchange,,152.21,,,,,,,32.83,189.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Individual Exchange,,10.70,,,,,,,3.60,13.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,310.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,24.90,,,,,,,18.22,68.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Individual Exchange,,269.27,,,,,,,49.45,269.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,United Healthcare,Individual Exchange,,300.02,,,,,,,136.51,1643.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,United Healthcare,Individual Exchange,,269.27,,,,,,,70.67,269.27,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Individual Exchange,,85.61,,,,,,,38.44,144.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,531.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,388.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Individual Exchange,,265.73,,,,,,,70.87,268.48,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Individual Exchange,,114.56,,,,,,,77.08,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,Individual Exchange,,67.67,,,,,,,67.67,275.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,288.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Individual Exchange,,104.44,,,,,,,103.90,389.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,United Healthcare,Individual Exchange,,85.61,,,,,,,49.65,963.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Individual Exchange,,45.66,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Individual Exchange,,53.18,,,,,,,53.18,288.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,Individual Exchange,,67.67,,,,,,,67.67,275.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,234.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,135.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,United Healthcare,Individual Exchange,,24.90,,,,,,,24.90,932.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Individual Exchange,,24.90,,,,,,,4.80,41.10,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Individual Exchange,,85.61,,,,,,,38.44,144.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Individual Exchange,,45.66,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,United Healthcare,Individual Exchange,,273.30,,,,,,,164.86,681.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Individual Exchange,,273.30,,,,,,,132.13,646.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Individual Exchange,,80.53,,,,,,,70.99,267.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,United Healthcare,Individual Exchange,,45.66,,,,,,,20.78,93.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Individual Exchange,,45.66,,,,,,,20.78,112.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Individual Exchange,,45.66,,,,,,,19.02,71.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Individual Exchange,,85.61,,,,,,,33.23,124.50,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Individual Exchange,,45.66,,,,,,,16.02,60.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,United Healthcare,Individual Exchange,,74.21,,,,,,,31.83,119.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Individual Exchange,,53.18,,,,,,,13.21,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Individual Exchange,,22.03,,,,,,,8.41,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,74.08,,,,,,,5.61,381.82,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,United Healthcare,Individual Exchange,,22.03,,,,,,,21.02,78.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,United Healthcare,Individual Exchange,,37.47,,,,,,,37.47,201.52,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,10.79,2907.00,per diem,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,52.23,2907.00,per diem,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,52.23,2907.00,per diem,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,48.23,2907.00,per diem,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,98.54,2907.00,per diem,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,15.84,2907.00,per diem,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,15.84,2907.00,per diem,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,9.92,2907.00,per diem,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,United Healthcare,Individual Exchange,,1874.00,,,,,,,118.21,2907.00,per diem,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,113.34,2907.00,per diem,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,181.24,2907.00,per diem,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,186.29,2907.00,per diem,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,37.43,2907.00,per diem,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,United Healthcare,Individual Exchange,,1874.00,,,,,,,72.95,2907.00,per diem,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Individual Exchange,,1874.00,,,,,,,51.19,2907.00,per diem,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,United Healthcare,Individual Exchange,,1874.00,,,,,,,165.22,2907.00,per diem,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,215.88,2907.00,per diem,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,104.46,2907.00,per diem,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,15.84,2907.00,per diem,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,Individual Exchange,,1874.00,,,,,,,266.02,2907.00,per diem,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Individual Exchange,,6.36,,,,,,,2.90,21.00,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,,22.03,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,,22.03,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Individual Exchange,,22.03,,,,,,,9.48,123.75,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Individual Exchange,,12.20,,,,,,,5.55,44.25,fee schedule,"Unless otherwise indicated in the Facility Fee Schedule Specifications, Laboratory/Pathology Codes not yet listed on the fee schedule or listed on the fee schedule that do not have a Primary or Gap Fill Source Fee will default to a contract rate of 50% PPR."
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,181.24,2907.00,per diem,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Individual Exchange,,1874.00,,,,,,,181.24,2907.00,per diem,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Individual Exchange,,1874.00,,,,,,,201.96,2907.00,per diem,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,10.79,2907.00,per diem,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Individual Exchange,,1874.00,,,,,,,10.79,2907.00,per diem,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,523.72,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1715.71,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1715.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1715.71,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1715.71,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1715.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,150.52,21640.97,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,150.52,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,495.29,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,495.29,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,United Healthcare,Individual Exchange,,34125.00,,,,,,,1344.34,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,United Healthcare,Individual Exchange,,34125.00,,,,,,,409.01,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,674.27,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,181.98,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,181.98,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,89.49,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,164.76,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,4376.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1544.94,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,772.37,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,772.37,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1434.63,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1434.63,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,275.88,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,275.88,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1103.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1715.71,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1715.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,158.96,4311.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,5817.21,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,879.68,8213.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,879.68,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,87.89,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,87.89,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,87.89,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Individual Exchange,,990.00,,,,,,,87.89,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,451.85,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,451.85,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,451.85,6735.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,451.85,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,3349.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,3349.15,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,5581.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,5581.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2009.41,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2009.41,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,16011.95,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,14116.62,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1863.26,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1863.26,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4700.50,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4700.50,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4234.63,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4234.63,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,Individual Exchange,,34125.00,,,,,,,5632.23,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,Individual Exchange,,34125.00,,,,,,,5632.23,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2468.07,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4664.66,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4664.66,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4245.04,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4245.04,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,Individual Exchange,,34125.00,,,,,,,4812.81,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,Individual Exchange,,34125.00,,,,,,,4812.81,52940.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1900.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1900.50,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4096.89,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4096.89,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,3529.33,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,3529.33,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4121.72,14244.84,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,3243.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,1673.07,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,LM,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,RI,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,RC,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,LD,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,LC,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,LM,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,RI,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,RC,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,LD,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,United Healthcare,Individual Exchange,LC,15486.00,,,,,,,2874.47,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4290.29,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,8108.50,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4633.23,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4633.23,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4976.57,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,5191.19,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LM,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,RI,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,RC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LD,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,United Healthcare,Individual Exchange,LC,8612.00,,,,,,,4311.00,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,78.68,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,222.64,3641.00,per diem,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,373.37,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,84.48,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,505.91,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2316.71,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2143.34,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2143.34,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2044.04,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,United Healthcare,Individual Exchange,,8612.00,,,,,,,850.85,27871.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,United Healthcare,Individual Exchange,,6636.00,,,,,,,1474.87,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,United Healthcare,Individual Exchange,,6636.00,,,,,,,2180.78,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,United Healthcare,Individual Exchange,,6636.00,,,,,,,1936.53,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,United Healthcare,Individual Exchange,,6636.00,,,,,,,2067.27,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,United Healthcare,Individual Exchange,,6636.00,,,,,,,909.51,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,United Healthcare,Individual Exchange,,6636.00,,,,,,,2126.92,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,United Healthcare,Individual Exchange,,6636.00,,,,,,,2652.85,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,United Healthcare,Individual Exchange,,6636.00,,,,,,,2389.79,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,United Healthcare,Individual Exchange,,6636.00,,,,,,,2549.35,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,United Healthcare,Individual Exchange,,6636.00,,,,,,,2592.59,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,United Healthcare,Individual Exchange,,6636.00,,,,,,,3094.46,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,40.64,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,19.42,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,300.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,826.43,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,United Healthcare,Individual Exchange,,173.00,,,,,,,96.90,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,125.33,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,125.33,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,43.04,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,United Healthcare,Individual Exchange,,25579.00,,,,,,,7834.43,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,12247.00,per diem,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,337.85,12247.00,per diem,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,377.85,3641.00,per diem,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,253.45,9503.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,105.71,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,105.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,105.71,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,1577.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,1577.98,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,2998.80,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,2998.80,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,United Healthcare,Individual Exchange,,25579.00,,,,,,,3657.05,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,United Healthcare,Individual Exchange,,15486.00,,,,,,,2656.25,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,3018.42,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,United Healthcare,Individual Exchange,,25579.00,,,,,,,3642.44,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,639.24,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2820.62,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2820.62,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,2045.04,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,589.39,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,580.98,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,580.98,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,United Healthcare,Individual Exchange,,25579.00,,,,,,,4082.48,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,United Healthcare,Individual Exchange,,25579.00,,,,,,,2987.99,39682.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,473.87,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4761.96,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4909.10,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,United Healthcare,Individual Exchange,,15486.00,,,,,,,5350.95,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1703.30,8700.96,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,2282.48,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,2282.48,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,United Healthcare,Individual Exchange,,53081.00,,,,,,,9987.38,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1151.15,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,764.96,8442.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,United Healthcare,Individual Exchange,,53081.00,,,,,,,11551.14,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,528.33,4681.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,United Healthcare,Individual Exchange,,6090.17,,,,,,,2199.23,9485.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,417.62,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,2912.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,867.02,12247.00,per diem,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,867.02,7977.75,per diem,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,432.44,3641.00,per diem,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,307.07,12247.00,per diem,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,432.44,7977.75,per diem,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,432.44,7977.75,per diem,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,United Healthcare,Individual Exchange,,1411.00,,,,,,,407.15,3641.00,per diem,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,372.90,12247.00,per diem,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1281.80,12247.00,per diem,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,12247.00,per diem,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,12247.00,per diem,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,217.29,3641.00,per diem,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1081.64,7977.75,per diem,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,United Healthcare,Individual Exchange,,1411.00,,,,,,,221.84,3641.00,per diem,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,422.27,12247.00,per diem,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,16639.07,per diem,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,14737.24,per diem,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,14737.24,per diem,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,United Healthcare,Individual Exchange,,1411.00,,,,,,,404.75,3641.00,per diem,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Individual Exchange,,1411.00,,,,,,,150.52,3641.00,per diem,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,12283.57,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4480.68,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,United Healthcare,Individual Exchange,,53081.00,,,,,,,496.90,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,386.59,9503.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,Individual Exchange,,53081.00,,,,,,,1110.71,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,Individual Exchange,,53081.00,,,,,,,1110.71,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,United Healthcare,Individual Exchange,,53081.00,,,,,,,1276.68,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,United Healthcare,Individual Exchange,,53081.00,,,,,,,515.51,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Individual Exchange,,1411.00,,,,,,,150.52,3641.00,per diem,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,150.52,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,150.52,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1594.59,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,11298.42,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1846.64,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,United Healthcare,Individual Exchange,,2025.00,,,,,,,1294.69,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,United Healthcare,Individual Exchange,,6636.00,,,,,,,1496.70,10022.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Individual Exchange,,173.00,,,,,,,150.52,981.11,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,United Healthcare,Individual Exchange,,5219.00,,,,,,,1595.59,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,406.89,4376.00,per diem,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,406.89,3641.00,per diem,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,406.89,3641.00,per diem,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,406.89,3641.00,per diem,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2662.86,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,5325.72,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,Individual Exchange,,15486.00,,,,,,,5325.72,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,United Healthcare,Individual Exchange,,15486.00,,,,,,,8574.37,26125.69,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,21326.82,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,United Healthcare,Individual Exchange,,53081.00,,,,,,,1897.10,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,United Healthcare,Individual Exchange,,2025.00,,,,,,,869.87,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,4285.48,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,6855.05,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,6855.05,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,6855.05,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,United Healthcare,Individual Exchange,,2025.00,,,,,,,2025.00,22398.88,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,Individual Exchange,,6636.00,,,,,,,1354.55,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,Individual Exchange,,6636.00,,,,,,,1354.55,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Individual Exchange,,173.00,,,,,,,21.42,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,25792.05,per diem,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,25792.05,per diem,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,1411.00,31355.38,per diem,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,United Healthcare,Individual Exchange,,2025.00,,,,,,,480.28,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,United Healthcare,Individual Exchange,,5219.00,,,,,,,2169.57,12247.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Individual Exchange,LD,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Individual Exchange,RC,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Individual Exchange,RI,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Individual Exchange,LM,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Individual Exchange,LD,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Individual Exchange,RC,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Individual Exchange,RI,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Individual Exchange,LM,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Individual Exchange,LD,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Individual Exchange,RC,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Individual Exchange,RI,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Individual Exchange,LM,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,LD,173.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,RC,173.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,RI,173.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,LM,173.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,United Healthcare,Individual Exchange,LC,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,United Healthcare,Individual Exchange,LC,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,United Healthcare,Individual Exchange,LC,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Individual Exchange,LC,173.00,,,,,,,99.10,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,United Healthcare,Individual Exchange,,990.00,,,,,,,594.81,19892.71,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,United Healthcare,Individual Exchange,,53081.00,,,,,,,9423.00,82346.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,United Healthcare,Individual Exchange,,8612.00,,,,,,,2282.88,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,United Healthcare,Individual Exchange,,173.00,,,,,,,173.00,9423.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,United Healthcare,Individual Exchange,,222.00,,,,,,,41.04,467.00,per diem,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,United Healthcare,Individual Exchange,,1411.00,,,,,,,538.01,20050.47,per diem,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,United Healthcare,Individual Exchange,,1411.00,,,,,,,442.08,3641.00,per diem,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,United Healthcare,Individual Exchange,,200.00,,,,,,,198.53,967.50,per diem,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,United Healthcare,Individual Exchange,,266.00,,,,,,,219.29,1172.25,per diem,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,United Healthcare,Individual Exchange,,266.00,,,,,,,162.33,968.00,per diem,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,1671.75,per diem,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,1671.75,per diem,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,Individual Exchange,,266.00,,,,,,,126.13,968.00,per diem,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,101.86,968.00,per diem,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,101.86,968.00,per diem,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,1918.50,per diem,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,1918.50,per diem,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,69.59,968.00,per diem,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Individual Exchange,,266.00,,,,,,,54.02,968.00,per diem,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Individual Exchange,,266.00,,,,,,,266.00,2052.00,per diem,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Individual Exchange,,266.00,,,,,,,7.72,968.00,per diem,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,United Healthcare,Individual Exchange,,266.00,,,,,,,191.93,1026.00,per diem,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Individual Exchange,,87.00,,,,,,,35.88,182.25,per diem,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,Individual Exchange,,87.00,,,,,,,87.00,656.25,per diem,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,United Healthcare,Individual Exchange,,87.00,,,,,,,57.15,466.50,per diem,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Individual Exchange,,87.00,,,,,,,32.43,134.00,per diem,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,33.60,269.00,per diem,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,175.00,957.00,per diem,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,Individual Exchange,,175.00,,,,,,,49.62,269.00,per diem,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Individual Exchange,,175.00,,,,,,,37.95,269.00,per diem,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,Individual Exchange,,175.00,,,,,,,51.71,269.00,per diem,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Individual Exchange,,175.00,,,,,,,18.98,269.00,per diem,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Individual Exchange,,175.00,,,,,,,24.55,269.00,per diem,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,United Healthcare,Individual Exchange,,3788.00,,,,,,,1301.10,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,United Healthcare,Individual Exchange,,5219.00,,,,,,,725.52,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,United Healthcare,Individual Exchange,,8612.00,,,,,,,1598.40,13852.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,United Healthcare,Individual Exchange,,990.00,,,,,,,521.92,5152.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Individual Exchange,,15486.00,,,,,,,422.62,24600.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,422.62,8045.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Individual Exchange,,5219.00,,,,,,,422.62,17457.00,case rate,"Multiple Outpatient Procedures will be reimbursed at 100% for the highest allowable procedure, 50% for the second highest allowable procedure, and 25% for the third highest allowable procedure. Any additional procedures will not be reimbursed."
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,4781.25,per diem,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,6332.25,per diem,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,7107.75,per diem,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,5873.25,per diem,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,7611.75,per diem,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,United Healthcare,Individual Exchange,,615.00,,,,,,,615.00,8481.00,per diem,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,Individual Exchange,,250.56,,,,,,,96.10,390.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Individual Exchange,,156.60,,,,,,,60.06,243.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,Individual Exchange,,250.56,,,,,,,96.10,390.24,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Individual Exchange,,156.60,,,,,,,60.06,243.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Individual Exchange,,17.75,,,,,,,6.81,27.64,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,46.98,,,,,,,18.02,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,Individual Exchange,,125.28,,,,,,,48.05,195.12,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,United Healthcare,Individual Exchange,,195.23,,,,,,,74.87,304.06,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,United Healthcare,Individual Exchange,,689.04,,,,,,,264.26,1073.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,United Healthcare,Individual Exchange,,743.85,,,,,,,285.29,1158.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,United Healthcare,Individual Exchange,,1165.10,,,,,,,446.85,1814.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,inpatient,,,293.00000,175.80000,United Healthcare,Individual Exchange,,50.40,,,,,,,50.40,243.19,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $3,377.00."
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Individual Exchange,,37.21,,,,,,,37.21,215.71,percent of total billed charges,"Contract rate for High Cost Implants that have eligible charges greater than $6,362.00."
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,United Healthcare,Individual Exchange,,350.78,,,,,,,134.53,546.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,United Healthcare,Individual Exchange,,54.29,,,,,,,20.82,84.55,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,Individual Exchange,,530.35,,,,,,,203.40,826.01,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Individual Exchange,,91.35,,,,,,,35.03,142.28,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,United Healthcare,Individual Exchange,,134.68,,,,,,,51.65,209.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Individual Exchange,,100.22,,,,,,,38.44,156.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,United Healthcare,Individual Exchange,,1650.56,,,,,,,633.03,2570.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Individual Exchange,,157.64,,,,,,,60.46,245.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,Individual Exchange,,154.51,,,,,,,59.26,240.65,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,United Healthcare,Individual Exchange,,161.30,,,,,,,61.86,251.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,United Healthcare,Individual Exchange,,148.77,,,,,,,57.06,231.71,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Individual Exchange,,178.00,,,,,,,68.27,277.23,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Individual Exchange,,225.50,,,,,,,86.49,351.22,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,United Healthcare,Individual Exchange,,322.07,,,,,,,123.52,501.62,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Individual Exchange,,22.97,,,,,,,8.81,35.77,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Individual Exchange,,21.92,,,,,,,8.41,34.15,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Individual Exchange,,37.06,,,,,,,14.21,57.72,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,United Healthcare,Individual Exchange,,115.36,,,,,,,44.24,179.67,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,United Healthcare,Individual Exchange,,209.84,,,,,,,80.48,326.83,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,United Healthcare,Individual Exchange,,464.58,,,,,,,178.18,723.57,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Individual Exchange,,38.63,,,,,,,14.81,60.16,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Individual Exchange,,28.19,,,,,,,10.81,43.90,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,United Healthcare,Individual Exchange,,138.33,,,,,,,53.05,215.44,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Individual Exchange,,20.88,,,,,,,8.01,32.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,United Healthcare,Individual Exchange,,391.50,,,,,,,150.15,609.75,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,United Healthcare,Individual Exchange,,613.35,,,,,,,235.24,955.27,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,United Healthcare,Individual Exchange,,2093.22,,,,,,,802.80,3260.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,United Healthcare,Individual Exchange,,638.93,,,,,,,245.04,995.11,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Individual Exchange,,936.47,,,,,,,359.16,1458.52,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,United Healthcare,Individual Exchange,,1184.42,,,,,,,454.25,1844.70,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Individual Exchange,,256.82,,,,,,,98.50,400.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,United Healthcare,Individual Exchange,,2093.22,,,,,,,802.80,3260.13,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,United Healthcare,Individual Exchange,,365.40,,,,,,,140.14,569.10,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,United Healthcare,Individual Exchange,,407.16,,,,,,,156.16,634.14,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Individual Exchange,,46.98,,,,,,,18.02,73.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,United Healthcare,Individual Exchange,,834.16,,,,,,,319.92,1299.17,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,United Healthcare,Individual Exchange,,1341.02,,,,,,,514.31,2088.60,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,Individual Exchange,,261.00,,,,,,,100.10,406.50,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,United Healthcare,Individual Exchange,,2088.00,,,,,,,800.80,3252.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,United Healthcare,Individual Exchange,,1265.85,,,,,,,485.49,1971.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,United Healthcare,Individual Exchange,,939.60,,,,,,,360.36,1463.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,United Healthcare,Individual Exchange,,1265.85,,,,,,,485.49,1971.53,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,United Healthcare,Individual Exchange,,939.60,,,,,,,360.36,1463.40,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,United Healthcare,Individual Exchange,,615.96,,,,,,,236.24,959.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,United Healthcare,Individual Exchange,,615.96,,,,,,,236.24,959.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,United Healthcare,Individual Exchange,,551.75,,,,,,,211.61,859.34,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,United Healthcare,Individual Exchange,GP,165.00,,,,,,,37.08,276.00,per diem,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Individual Exchange,,260.48,,,,,,,99.90,405.69,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,United Healthcare,Individual Exchange,,128.41,,,,,,,49.25,200.00,percent of total billed charges,"When billed with a Covered Service subject to a Per Case, Per Visit, or Per Unit via Facility Fee Schedule Payment Method, these services are always considered included in other services and not reimbursed."
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,215412.76,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,87653.85,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,163376.49,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,106938.50,,,,,,,98790.80,259561.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,42666.79,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33190.55,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22978.77,,,,,,,21228.00,54002.05,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,61148.55,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,41439.87,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25241.25,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,44780.78,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,30863.01,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,35721.67,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24719.26,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20231.80,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,46908.54,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27033.77,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17723.63,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,35214.98,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17232.26,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13649.49,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,30547.68,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19218.43,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15791.80,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,26119.14,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13341.04,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9918.99,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,30474.96,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17750.42,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14145.45,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14785.32,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8416.54,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12608.57,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8725.76,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18702.56,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10838.23,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14006.15,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10419.55,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7961.91,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22024.35,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14371.25,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11666.37,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16313.80,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8654.58,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6160.19,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12163.11,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7537.89,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7035.79,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13664.02,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8774.75,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6709.73,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13200.97,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8811.48,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15598.15,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7237.86,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14775.38,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7776.68,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18415.54,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11605.15,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8237.46,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18310.69,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10892.56,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7922.88,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11268.38,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9330.42,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7222.55,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14363.60,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8751.77,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7016.65,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27858.86,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28566.09,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18486.74,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11349.49,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15745.88,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7830.26,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9501.09,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7322.81,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18916.86,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11277.56,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12669.80,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14760.82,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9225.55,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9825.63,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6936.29,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7034.25,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11048.71,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6798.52,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17530.75,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8692.84,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12350.62,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7704.74,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10379.75,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33567.88,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17615.72,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13140.51,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,29597.83,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14185.27,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10124.13,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17128.17,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10653.76,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7022.79,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6674.53,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11113.00,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6539.82,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9970.26,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6571.97,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12888.69,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7936.65,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6211.46,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14062.03,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7885.36,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6344.65,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,35224.95,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20240.22,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15572.92,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,29529.70,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14724.84,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11380.10,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23702.83,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11435.22,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7083.25,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12882.57,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8392.06,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6700.55,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14438.60,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9119.17,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6691.37,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12631.53,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9066.35,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6941.65,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12850.44,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8492.31,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6411.24,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10377.45,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9400.07,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7374.09,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5835.67,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10982.12,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7090.12,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5732.34,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15366.26,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8186.17,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6403.58,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14424.06,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9335.77,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6395.17,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8355.32,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6049.98,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7101.62,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14936.10,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8124.94,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,50172.15,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21960.03,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,87554.35,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,84150.68,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,44601.69,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,77131.34,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,75798.02,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,59690.48,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,41738.37,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,39498.86,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,38788.59,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25027.69,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,65443.13,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,47324.16,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,59437.13,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,42732.61,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,45839.31,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,32982.36,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,38591.88,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22739.22,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11517.89,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25359.12,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17231.49,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14756.23,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,35841.82,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17626.41,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12360.57,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27620.84,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20788.24,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14558.76,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21567.41,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13917.37,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9281.42,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24971.07,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16398.75,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25818.35,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13396.91,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24322.78,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,26490.37,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28615.06,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,47827.79,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,37360.36,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,53564.34,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33245.65,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,41305.94,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28141.31,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20462.18,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,32497.87,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,26116.07,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,55496.94,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,46895.53,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,36271.21,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,43524.79,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28524.74,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13199.44,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7956.55,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6456.39,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16082.64,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6219.89,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5505.79,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17858.34,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9112.27,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21634.77,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13986.26,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8037.68,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10747.91,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7420.02,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5253.97,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12876.45,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5774.43,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,4405.15,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13418.34,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9092.37,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6430.38,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10080.51,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6074.47,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10029.98,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6701.31,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12982.83,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7911.39,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6552.83,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5254.73,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6294.12,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7593.00,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6432.66,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16881.72,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8294.85,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6142.58,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,52099.39,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19461.06,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,35080.27,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19331.71,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21746.51,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14415.63,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,34043.17,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25039.17,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25493.84,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,39094.73,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19629.42,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13185.67,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,36102.84,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19269.71,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13802.57,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28634.21,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18848.74,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13458.14,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28253.06,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17061.59,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12670.56,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20690.27,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12438.65,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10000.89,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18492.09,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10939.25,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7585.34,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19994.53,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12590.19,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9860.08,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23133.38,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13798.74,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11216.32,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,34543.75,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18720.94,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11621.20,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27240.44,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19400.60,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13106.07,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8577.27,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6285.71,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14492.95,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8736.47,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6489.29,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17291.19,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10179.99,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7996.35,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14913.13,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8428.02,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5746.87,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15940.27,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9214.84,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7049.57,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11489.57,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7464.40,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13032.60,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8394.36,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6136.47,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12225.09,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6966.90,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5085.59,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10629.27,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6888.84,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13162.69,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8083.60,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5889.25,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19252.10,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12506.75,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9683.26,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,31694.22,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,42792.31,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23119.60,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17910.39,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28212.47,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17586.64,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13073.91,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,26204.87,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17014.13,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13631.12,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28189.53,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16740.12,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11356.39,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19187.05,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13869.16,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11375.53,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,26999.33,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14220.47,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11633.46,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,32708.36,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17667.76,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12404.98,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,85276.57,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,56172.01,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,43951.87,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,69880.07,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,45062.43,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15986.21,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9005.88,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6375.27,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14979.72,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9579.16,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7452.92,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13399.20,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7360.31,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5678.00,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14658.27,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8310.15,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6277.29,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13710.70,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9298.26,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7253.93,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,52061.88,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33380.36,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,41713.86,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25646.90,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,65240.30,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,46562.60,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,32858.36,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,43194.12,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21281.15,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,44545.04,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24761.35,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,40763.27,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27913.97,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21954.69,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24137.57,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15685.42,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,37880.05,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23470.91,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19607.24,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33779.12,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18339.78,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9954.97,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27362.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19744.25,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23212.22,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16952.88,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13405.34,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22137.61,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25621.65,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16926.87,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12909.36,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14460.79,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9469.72,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,29023.77,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20332.84,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16279.37,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28672.47,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14728.68,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10170.04,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24012.02,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16342.87,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25144.82,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14301.58,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11223.21,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22284.56,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15228.48,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14643.73,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11248.47,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14747.82,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12512.90,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24040.37,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16837.31,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13592.09,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12971.36,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8746.44,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25313.97,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16827.37,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12683.56,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,29526.63,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16231.12,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12355.99,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22889.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17130.46,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12920.83,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7091.66,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10734.13,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7103.15,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8225.97,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6434.97,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15997.69,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6948.53,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14442.42,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8790.05,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6697.49,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19916.46,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9749.85,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7322.04,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15700.72,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10161.62,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7612.12,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13750.53,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8279.54,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7275.36,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11038.75,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7279.18,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12302.40,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7758.30,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15195.59,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9540.90,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7074.82,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11827.11,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7775.91,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12736.38,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8379.80,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6656.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23432.65,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13853.08,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9695.51,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,51065.36,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27491.49,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14675.87,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,38434.98,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21209.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13217.04,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25708.90,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14147.76,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11967.17,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15667.80,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14120.20,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17306.50,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15686.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15734.39,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10001.65,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7556.25,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17153.42,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9207.19,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13681.63,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9580.68,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6810.76,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8894.14,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5552.46,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11800.31,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7587.64,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12189.12,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7932.82,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12503.69,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7859.34,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17697.61,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11631.94,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27613.94,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15236.90,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11777.35,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23021.63,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13170.34,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12466.97,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28163.50,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14652.15,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10503.75,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24037.29,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12398.07,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11088.51,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,29446.28,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17598.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12092.68,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11918.19,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7781.28,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5676.47,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11144.39,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6878.11,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11806.44,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13520.90,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8767.08,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6802.33,,,,,,,5676.20,14397.17,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,40694.39,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22347.32,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17122.05,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25290.24,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14928.45,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12799.14,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20369.56,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11037.99,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8846.69,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24354.16,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12557.29,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8934.71,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,24811.11,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14310.76,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9388.58,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23271.15,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12800.68,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8402.00,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14660.56,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9184.23,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33080.34,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18821.20,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13484.93,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12257.25,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7625.13,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5516.50,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14727.15,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8941.60,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6970.73,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9802.66,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7117.70,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11212.51,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6904.90,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9676.36,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6195.39,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9171.21,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13584.44,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8690.56,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6202.28,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16231.91,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12664.44,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18733.19,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11646.48,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16871.00,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9338.83,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12428.70,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9015.07,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18045.87,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12180.70,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11201.78,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14773.07,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9667.94,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5940.52,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9878.43,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6447.99,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12271.80,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7130.69,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9025.02,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6065.28,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17224.61,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11220.15,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28280.60,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16693.42,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12161.57,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28344.13,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14772.31,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11837.06,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14965.18,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10418.04,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16605.42,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9628.15,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14217.40,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7501.91,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11540.09,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20573.93,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12217.45,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15018.00,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9247.76,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8273.41,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11881.44,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8415.00,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6000.99,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8633.14,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5288.42,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9123.75,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13855.37,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8596.40,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5932.88,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7361.08,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19712.87,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9035.74,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8252.75,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13546.92,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9469.72,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8260.41,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14715.68,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,46412.59,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,31988.89,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19667.71,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,32835.41,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12218.22,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,2451.13,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9853.93,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8578.80,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8247.39,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,35585.44,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,22424.63,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15532.33,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,31415.61,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11300.51,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9181.93,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6692.90,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6082.11,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17820.82,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10610.90,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8932.41,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11670.19,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7949.65,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12596.31,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17199.35,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8682.89,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5759.11,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18384.93,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9794.24,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7503.45,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,45810.23,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18055.80,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,36013.28,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18262.46,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11249.99,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,36725.08,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18611.49,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13962.53,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25108.06,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12440.96,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10125.65,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6444.91,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,4924.09,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,42940.80,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16886.29,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10255.76,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,37693.32,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16898.56,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11973.30,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25681.35,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13408.38,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8655.36,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16189.80,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10239.68,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7439.92,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,20764.51,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10934.67,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7423.08,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21660.01,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,67200.45,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,38721.22,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16215.06,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12381.24,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,35736.97,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17312.62,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11582.94,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8559.68,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7716.22,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12389.66,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7577.68,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16942.94,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8813.78,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6506.90,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,53823.82,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15789.50,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8754.09,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,30503.29,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8271.10,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8123.40,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9140.60,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15971.67,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13236.18,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11612.79,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16805.94,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9118.42,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5643.55,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,11756.68,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14278.65,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7678.71,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33042.06,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15575.19,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9873.84,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,29035.26,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12275.62,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,15956.36,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,30307.32,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16192.86,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10969.12,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13432.90,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7699.38,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13792.61,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6021.67,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12926.20,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7482.00,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14934.57,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8593.35,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,6190.80,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14311.54,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8711.22,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,164335.51,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,55820.70,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,25573.43,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,30727.54,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,17841.49,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16688.83,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,28693.91,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,18808.19,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,16441.60,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12774.66,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,9699.34,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10637.70,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7048.81,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10027.67,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5726.21,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,5177.42,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,52440.77,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,29723.35,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,59243.50,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,33174.46,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23455.60,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21846.01,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,12652.20,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,8120.32,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,47773.44,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,21108.17,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,23010.91,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10833.63,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,7831.04,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10854.29,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,36832.24,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,19738.90,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,14040.60,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,27162.37,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,13501.77,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,United Healthcare,Medicare Advantage,,10100.38,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18119.20,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5373.49,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,22332.87,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5373.49,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9965.52,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6834.82,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,22332.87,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,695.12,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6834.82,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,46864.96,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,552.58,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,418.48,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18700.70,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9965.52,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6199.45,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3581.50,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6834.82,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,23376.18,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18406.40,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,61.87,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,8618.87,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,316.80,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,202.19,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,61.87,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6791.65,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13530.72,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10898.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,415.57,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,12986.98,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6834.82,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,241.85,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,316.80,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,91.70,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,695.12,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1008.67,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1617.80,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4879.29,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,12986.98,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,571.33,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18700.70,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6669.40,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6498.27,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,571.33,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1008.67,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13530.72,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10898.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,241.85,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,681.49,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,95.59,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,9630.27,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7701.19,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,202.19,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,530.34,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,241.85,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,455.29,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,209.51,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18700.70,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,11810.43,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2133.38,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,209.51,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,209.51,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13530.72,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,10842.57,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,695.12,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,637.50,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,134.24,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,415.57,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5373.49,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1424.94,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3790.08,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,8618.87,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,United Healthcare,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,United Healthcare,Medicare Advantage,,30.85,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,United Healthcare,Medicare Advantage,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,United Healthcare,Medicare Advantage,,7.64,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,United Healthcare,Medicare Advantage,,3.52,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,United Healthcare,Medicare Advantage,,12.67,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,United Healthcare,Medicare Advantage,,0.12600,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,United Healthcare,Medicare Advantage,,1816.84,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,United Healthcare,Medicare Advantage,,118.07,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,United Healthcare,Medicare Advantage,,120.27,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,United Healthcare,Medicare Advantage,,7.11,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,United Healthcare,Medicare Advantage,,8.35,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,United Healthcare,Medicare Advantage,,31.51,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,United Healthcare,Medicare Advantage,,15.87,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,Medicare Advantage,,1.78,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,Medicare Advantage,,65.34,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,Medicare Advantage,,79.65,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,United Healthcare,Medicare Advantage,,1.97,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,United Healthcare,Medicare Advantage,,180.93,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,United Healthcare,Medicare Advantage,,770.35,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,United Healthcare,Medicare Advantage,,9.17,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,United Healthcare,Medicare Advantage,,3.59,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,United Healthcare,Medicare Advantage,,5391.84,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,Medicare Advantage,,100.69,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,United Healthcare,Medicare Advantage,,238.64,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,United Healthcare,Medicare Advantage,,5.85,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,United Healthcare,Medicare Advantage,,5.85,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,United Healthcare,Medicare Advantage,,21.37,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,Medicare Advantage,,21.37,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,United Healthcare,Medicare Advantage,,21.37,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,United Healthcare,Medicare Advantage,,9.19,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,United Healthcare,Medicare Advantage,,93.81,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,United Healthcare,Medicare Advantage,,3.08,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,United Healthcare,Medicare Advantage,,3.08,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,United Healthcare,Medicare Advantage,,3.08,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,United Healthcare,Medicare Advantage,,3.08,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,United Healthcare,Medicare Advantage,,3.08,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,United Healthcare,Medicare Advantage,,3.08,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,United Healthcare,Medicare Advantage,,31.51,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,United Healthcare,Medicare Advantage,,181.68,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,United Healthcare,Medicare Advantage,,181.68,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,Medicare Advantage,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,Medicare Advantage,,6.00,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,Medicare Advantage,,76.86,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,United Healthcare,Medicare Advantage,,76.86,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,United Healthcare,Medicare Advantage,,7.07,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,United Healthcare,Medicare Advantage,,190.28,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,Medicare Advantage,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,Medicare Advantage,,192.65,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,United Healthcare,Medicare Advantage,,31.51,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,United Healthcare,Medicare Advantage,,2738.57,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,United Healthcare,Medicare Advantage,,453.62,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,United Healthcare,Medicare Advantage,,2.34,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,United Healthcare,Medicare Advantage,,271.57,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,United Healthcare,Medicare Advantage,,5.45,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,United Healthcare,Medicare Advantage,,1.53,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,United Healthcare,Medicare Advantage,,1.53,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,United Healthcare,Medicare Advantage,,65.34,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,United Healthcare,Medicare Advantage,,17.87,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,Medicare Advantage,,58.43,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,United Healthcare,Medicare Advantage,,29845.26,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,United Healthcare,Medicare Advantage,,69.97,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,United Healthcare,Medicare Advantage,,96.32,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,United Healthcare,Medicare Advantage,,140.90,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,United Healthcare,Medicare Advantage,,622.65,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,United Healthcare,Medicare Advantage,,786.29,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,United Healthcare,Medicare Advantage,,2.99,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,United Healthcare,Medicare Advantage,,148.98,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,United Healthcare,Medicare Advantage,,8.35,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,United Healthcare,Medicare Advantage,,276.31,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,United Healthcare,Medicare Advantage,,51.41,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,United Healthcare,Medicare Advantage,,185.27,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,United Healthcare,Medicare Advantage,,79.65,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,United Healthcare,Medicare Advantage,,1816.84,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,United Healthcare,Medicare Advantage,,66.21,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,United Healthcare,Medicare Advantage,,770.35,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,United Healthcare,Medicare Advantage,,44.27,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,United Healthcare,Medicare Advantage,,44.27,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,United Healthcare,Medicare Advantage,,324.11,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,United Healthcare,Medicare Advantage,,78.08,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,United Healthcare,Medicare Advantage,,78.08,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,United Healthcare,Medicare Advantage,,22.38,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,United Healthcare,Medicare Advantage,,16.39,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,United Healthcare,Medicare Advantage,,8.35,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,United Healthcare,Medicare Advantage,,175.68,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,United Healthcare,Medicare Advantage,,9.52,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,United Healthcare,Medicare Advantage,,34.61,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,United Healthcare,Medicare Advantage,,34.61,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Medicare Advantage,,93.81,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,United Healthcare,Medicare Advantage,,63.30,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,United Healthcare,Medicare Advantage,,213.76,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,United Healthcare,Medicare Advantage,,213.76,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,United Healthcare,Medicare Advantage,,213.76,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,United Healthcare,Medicare Advantage,,109.97,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,United Healthcare,Medicare Advantage,,53.28,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,United Healthcare,Medicare Advantage,,51.48,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,United Healthcare,Medicare Advantage,,51.48,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,United Healthcare,Medicare Advantage,,82.74,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,United Healthcare,Medicare Advantage,,82.74,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,United Healthcare,Medicare Advantage,,20.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,United Healthcare,Medicare Advantage,,0.48300,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,United Healthcare,Medicare Advantage,,0.48300,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,United Healthcare,Medicare Advantage,,69.30,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,United Healthcare,Medicare Advantage,,32.83,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,United Healthcare,Medicare Advantage,,14.16,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,United Healthcare,Medicare Advantage,,20.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,United Healthcare,Medicare Advantage,,118.07,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,United Healthcare,Medicare Advantage,,74.89,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,Medicare Advantage,,95.91,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,United Healthcare,Medicare Advantage,,1.92,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,United Healthcare,Medicare Advantage,,9.17,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,United Healthcare,Medicare Advantage,,41.82,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,United Healthcare,Medicare Advantage,,148.68,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,United Healthcare,Medicare Advantage,,105.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,United Healthcare,Medicare Advantage,,62.38,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,United Healthcare,Medicare Advantage,,78.78,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,United Healthcare,Medicare Advantage,,89.38,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,United Healthcare,Medicare Advantage,,89.38,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,United Healthcare,Medicare Advantage,,38.52,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,United Healthcare,Medicare Advantage,,38.52,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,United Healthcare,Medicare Advantage,,268.89,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,United Healthcare,Medicare Advantage,,2832.95,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,United Healthcare,Medicare Advantage,,2.29,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,United Healthcare,Medicare Advantage,,1.72,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,United Healthcare,Medicare Advantage,,172.82,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,United Healthcare,Medicare Advantage,,8.56,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,United Healthcare,Medicare Advantage,,34.61,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,United Healthcare,Medicare Advantage,,19.02,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,United Healthcare,Medicare Advantage,,8.24,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,United Healthcare,Medicare Advantage,,8.24,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,United Healthcare,Medicare Advantage,,8.24,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,United Healthcare,Medicare Advantage,,8.24,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,United Healthcare,Medicare Advantage,,8.24,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,United Healthcare,Medicare Advantage,,104.09,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,United Healthcare,Medicare Advantage,,260.93,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,United Healthcare,Medicare Advantage,,30.75,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Medicare Advantage,,111.65,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,Medicare Advantage,,137.95,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,United Healthcare,Medicare Advantage,,107.20,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,Medicare Advantage,,95.91,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,United Healthcare,Medicare Advantage,,64.51,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,United Healthcare,Medicare Advantage,,7.17,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,United Healthcare,Medicare Advantage,,143.50,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,United Healthcare,Medicare Advantage,,29.25,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,United Healthcare,Medicare Advantage,,29.25,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,United Healthcare,Medicare Advantage,,30.85,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,United Healthcare,Medicare Advantage,,30.85,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,United Healthcare,Medicare Advantage,,44.08,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,United Healthcare,Medicare Advantage,,44.08,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,United Healthcare,Medicare Advantage,,135.95,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,United Healthcare,Medicare Advantage,,11.56,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,United Healthcare,Medicare Advantage,,38.58,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,United Healthcare,Medicare Advantage,,31.48,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,United Healthcare,Medicare Advantage,,27.06,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,United Healthcare,Medicare Advantage,,27.06,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,United Healthcare,Medicare Advantage,,29.24,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,United Healthcare,Medicare Advantage,,29.24,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,United Healthcare,Medicare Advantage,,377.15,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,United Healthcare,Medicare Advantage,,29.39,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,United Healthcare,Medicare Advantage,,20.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,United Healthcare,Medicare Advantage,,86.00,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,United Healthcare,Medicare Advantage,,86.00,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,United Healthcare,Medicare Advantage,,38.09,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,United Healthcare,Medicare Advantage,,334.46,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,United Healthcare,Medicare Advantage,,21.43,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,United Healthcare,Medicare Advantage,,65.20,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,United Healthcare,Medicare Advantage,,65.20,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,United Healthcare,Medicare Advantage,,15.03,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,United Healthcare,Medicare Advantage,,143.50,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,United Healthcare,Medicare Advantage,,236.37,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,United Healthcare,Medicare Advantage,,236.37,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,United Healthcare,Medicare Advantage,,8.24,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,United Healthcare,Medicare Advantage,,5.73,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,United Healthcare,Medicare Advantage,,29.39,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,United Healthcare,Medicare Advantage,,2222.14,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,United Healthcare,Medicare Advantage,,227.75,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,United Healthcare,Medicare Advantage,,255.90,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,United Healthcare,Medicare Advantage,,23.67,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,United Healthcare,Medicare Advantage,,198.20,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,United Healthcare,Medicare Advantage,,12.94,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,United Healthcare,Medicare Advantage,,88.80,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,United Healthcare,Medicare Advantage,,0.39900,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,United Healthcare,Medicare Advantage,,0.39900,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,United Healthcare,Medicare Advantage,,207.72,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,United Healthcare,Medicare Advantage,,35.26,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,United Healthcare,Medicare Advantage,,35.26,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,United Healthcare,Medicare Advantage,,72.96,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,United Healthcare,Medicare Advantage,,687.36,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,United Healthcare,Medicare Advantage,,687.36,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,United Healthcare,Medicare Advantage,,32.09,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,United Healthcare,Medicare Advantage,,26.29,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,United Healthcare,Medicare Advantage,,26.29,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,United Healthcare,Medicare Advantage,,26.29,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,United Healthcare,Medicare Advantage,,66509.39,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,Medicare Advantage,,76.25,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,United Healthcare,Medicare Advantage,,76.25,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,United Healthcare,Medicare Advantage,,205.51,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,United Healthcare,Medicare Advantage,,9.17,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,United Healthcare,Medicare Advantage,,111.65,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,United Healthcare,Medicare Advantage,,1.92,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,United Healthcare,Medicare Advantage,,59.88,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,United Healthcare,Medicare Advantage,,59.88,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,United Healthcare,Medicare Advantage,,79.77,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,United Healthcare,Medicare Advantage,,35.10,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,United Healthcare,Medicare Advantage,,28.73,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,United Healthcare,Medicare Advantage,,54.14,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,United Healthcare,Medicare Advantage,,22.55,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,United Healthcare,Medicare Advantage,,78.98,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,United Healthcare,Medicare Advantage,,78.98,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,United Healthcare,Medicare Advantage,,6.59,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,United Healthcare,Medicare Advantage,,32.64,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,United Healthcare,Medicare Advantage,,45.35,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,United Healthcare,Medicare Advantage,,113.89,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,United Healthcare,Medicare Advantage,,113.89,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,United Healthcare,Medicare Advantage,,344.76,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,United Healthcare,Medicare Advantage,,0.84000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,United Healthcare,Medicare Advantage,,8.56,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,United Healthcare,Medicare Advantage,,1920.16,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,United Healthcare,Medicare Advantage,,1.78,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,United Healthcare,Medicare Advantage,,99.17,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,United Healthcare,Medicare Advantage,,5426.64,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,United Healthcare,Medicare Advantage,,7.71,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,United Healthcare,Medicare Advantage,,93.81,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,United Healthcare,Medicare Advantage,,6.83,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,United Healthcare,Medicare Advantage,,185.27,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,United Healthcare,Medicare Advantage,,57.45,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,United Healthcare,Medicare Advantage,,57.45,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,United Healthcare,Medicare Advantage,,57.45,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,United Healthcare,Medicare Advantage,,57.45,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,United Healthcare,Medicare Advantage,,396.40,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,United Healthcare,Medicare Advantage,,0.48300,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,United Healthcare,Medicare Advantage,,46.83,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,United Healthcare,Medicare Advantage,,4.58,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,Medicare Advantage,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,United Healthcare,Medicare Advantage,,0.50400,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,United Healthcare,Medicare Advantage,,1.82,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,United Healthcare,Medicare Advantage,,11.07,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,United Healthcare,Medicare Advantage,,10.65,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,United Healthcare,Medicare Advantage,,10.65,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,United Healthcare,Medicare Advantage,,10.65,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,United Healthcare,Medicare Advantage,,21.37,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,United Healthcare,Medicare Advantage,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,United Healthcare,Medicare Advantage,,192.65,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,Medicare Advantage,,71.61,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,United Healthcare,Medicare Advantage,,65.34,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,United Healthcare,Medicare Advantage,,65.34,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,United Healthcare,Medicare Advantage,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,United Healthcare,Medicare Advantage,,6.00,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,271.57,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,United Healthcare,Medicare Advantage,,217.49,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,United Healthcare,Medicare Advantage,,293.84,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,United Healthcare,Medicare Advantage,,293.84,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,United Healthcare,Medicare Advantage,,19.02,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,United Healthcare,Medicare Advantage,,156.44,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,United Healthcare,Medicare Advantage,,191.57,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,United Healthcare,Medicare Advantage,,0.22050,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,United Healthcare,Medicare Advantage,,99.17,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,United Healthcare,Medicare Advantage,,137.95,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,United Healthcare,Medicare Advantage,,99.17,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,95.91,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Medicare Advantage,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,United Healthcare,Medicare Advantage,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,United Healthcare,Medicare Advantage,,38.09,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,89.38,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,United Healthcare,Medicare Advantage,,58.43,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,United Healthcare,Medicare Advantage,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,United Healthcare,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,United Healthcare,Medicare Advantage,,0.38850,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,Medicare Advantage,,7.07,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,Medicare Advantage,,0.84000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,United Healthcare,Medicare Advantage,,21.37,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,United Healthcare,Medicare Advantage,,99.17,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,United Healthcare,Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,United Healthcare,Medicare Advantage,,7.07,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,United Healthcare,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,United Healthcare,Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,United Healthcare,Medicare Advantage,,78.78,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,64.51,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,65.20,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,65.20,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,United Healthcare,Medicare Advantage,,4.58,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,United Healthcare,Medicare Advantage,,0.84000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,United Healthcare,Medicare Advantage,,1.92,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,United Healthcare,Medicare Advantage,,248.45,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,United Healthcare,Medicare Advantage,,95.91,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,United Healthcare,Medicare Advantage,,95.91,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,United Healthcare,Medicare Advantage,,58.35,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,United Healthcare,Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,United Healthcare,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,United Healthcare,Medicare Advantage,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,United Healthcare,Medicare Advantage,,0.29400,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,United Healthcare,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,United Healthcare,Medicare Advantage,,76.25,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,United Healthcare,Medicare Advantage,,100.69,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,Medicare Advantage,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,Medicare Advantage,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,Medicare Advantage,,4.64,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,United Healthcare,Medicare Advantage,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,United Healthcare,Medicare Advantage,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,United Healthcare,Medicare Advantage,,4.64,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,Medicare Advantage,,0.38850,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,United Healthcare,Medicare Advantage,,71.61,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,United Healthcare,Medicare Advantage,,0.12600,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,United Healthcare,Medicare Advantage,,0.12600,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,United Healthcare,Medicare Advantage,,309.42,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,United Healthcare,Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,United Healthcare,Medicare Advantage,,3.08,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,United Healthcare,Medicare Advantage,,1.69,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,United Healthcare,Medicare Advantage,,47.06,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,United Healthcare,Medicare Advantage,,28.05,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,United Healthcare,Medicare Advantage,,31.33,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,United Healthcare,Medicare Advantage,,146.17,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,United Healthcare,Medicare Advantage,,4.58,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,Medicare Advantage,,55.73,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,United Healthcare,Medicare Advantage,,55.73,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,United Healthcare,Medicare Advantage,,99.17,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,United Healthcare,Medicare Advantage,,99.17,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,United Healthcare,Medicare Advantage,,4.30,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,United Healthcare,Medicare Advantage,,0.31500,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,United Healthcare,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Medicare Advantage,,1.75,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,United Healthcare,Medicare Advantage,,1.75,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,United Healthcare,Medicare Advantage,,0.38850,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,United Healthcare,Medicare Advantage,,509.22,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,United Healthcare,Medicare Advantage,,11.56,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,United Healthcare,Medicare Advantage,,11.56,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,United Healthcare,Medicare Advantage,,25.07,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,United Healthcare,Medicare Advantage,,25.07,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,United Healthcare,Medicare Advantage,,25.07,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,United Healthcare,Medicare Advantage,,2.99,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,United Healthcare,Medicare Advantage,,53.60,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,United Healthcare,Medicare Advantage,,6.83,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,United Healthcare,Medicare Advantage,,11.21,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,United Healthcare,Medicare Advantage,,4.67,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,United Healthcare,Medicare Advantage,,3.70,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,United Healthcare,Medicare Advantage,,3.70,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,United Healthcare,Medicare Advantage,,1.78,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,United Healthcare,Medicare Advantage,,0.33600,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,United Healthcare,Medicare Advantage,,9.19,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,United Healthcare,Medicare Advantage,,411.66,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,United Healthcare,Medicare Advantage,,534.41,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Medicare Advantage,,638.50,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Medicare Advantage,,356.58,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,Medicare Advantage,,36.56,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,United Healthcare,Medicare Advantage,,36.56,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,Medicare Advantage,,38.58,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Medicare Advantage,,134.24,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Medicare Advantage,,219.42,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,Medicare Advantage,,219.42,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Medicare Advantage,,74.12,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Medicare Advantage,,219.42,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Medicare Advantage,,219.42,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,United Healthcare,Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,Medicare Advantage,,345.43,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,Medicare Advantage,,9.54,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,United Healthcare,Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Medicare Advantage,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Medicare Advantage,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,United Healthcare,Medicare Advantage,,74.12,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,United Healthcare,Medicare Advantage,,219.42,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Medicare Advantage,,345.43,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,United Healthcare,Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,United Healthcare,Medicare Advantage,,381.23,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,Medicare Advantage,,381.23,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,United Healthcare,Medicare Advantage,,138.27,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,United Healthcare,Medicare Advantage,,381.23,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,United Healthcare,Medicare Advantage,,138.27,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,United Healthcare,Medicare Advantage,,1828.66,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,United Healthcare,Medicare Advantage,,1828.66,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,United Healthcare,Medicare Advantage,,602.44,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,United Healthcare,Medicare Advantage,,602.44,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,United Healthcare,Medicare Advantage,,602.44,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,Medicare Advantage,,722.56,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Medicare Advantage,,114.04,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,United Healthcare,Medicare Advantage,,345.43,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,Medicare Advantage,,345.43,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,United Healthcare,Medicare Advantage,,345.43,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Medicare Advantage,,48.05,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,United Healthcare,Medicare Advantage,,345.43,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,Medicare Advantage,,219.42,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,United Healthcare,Medicare Advantage,,219.42,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Medicare Advantage,,345.43,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,United Healthcare,Medicare Advantage,,114.04,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,United Healthcare,Medicare Advantage,,273.87,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,Medicare Advantage,,273.87,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,United Healthcare,Medicare Advantage,,273.87,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,United Healthcare,Medicare Advantage,,602.44,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,United Healthcare,Medicare Advantage,,602.44,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,United Healthcare,Medicare Advantage,,602.44,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Medicare Advantage,,345.43,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,United Healthcare,Medicare Advantage,,7961.22,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,United Healthcare,Medicare Advantage,,7961.22,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,United Healthcare,Medicare Advantage,,722.56,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,Medicare Advantage,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,United Healthcare,Medicare Advantage,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Medicare Advantage,,345.43,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Medicare Advantage,,138.27,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,United Healthcare,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,United Healthcare,Medicare Advantage,,381.23,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,United Healthcare,Medicare Advantage,,381.23,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,United Healthcare,Medicare Advantage,,602.44,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Medicare Advantage,,1707.19,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,United Healthcare,Medicare Advantage,,209.51,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,United Healthcare,Medicare Advantage,,3311.27,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Medicare Advantage,,211.82,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,United Healthcare,Medicare Advantage,,241.85,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,United Healthcare,Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,United Healthcare,Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,United Healthcare,Medicare Advantage,,5140.98,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,United Healthcare,Medicare Advantage,,316.80,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,Medicare Advantage,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,United Healthcare,Medicare Advantage,,241.85,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,134.24,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,134.24,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Medicare Advantage,,211.82,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Medicare Advantage,,134.24,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Medicare Advantage,,134.24,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Medicare Advantage,,25.50,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Medicare Advantage,,25.50,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Medicare Advantage,,40.88,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,United Healthcare,Medicare Advantage,,134.24,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Medicare Advantage,,211.82,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Medicare Advantage,,211.82,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,211.82,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Medicare Advantage,,211.82,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,United Healthcare,Medicare Advantage,,38.84,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Medicare Advantage,,38.84,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,United Healthcare,Medicare Advantage,,162.94,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,Medicare Advantage,,552.58,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,United Healthcare,Medicare Advantage,,324.30,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Medicare Advantage,,162.94,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,Medicare Advantage,,61.87,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Medicare Advantage,,134.24,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,United Healthcare,Medicare Advantage,,134.24,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Medicare Advantage,,134.24,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,United Healthcare,Medicare Advantage,,134.24,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,United Healthcare,Medicare Advantage,,162.94,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Medicare Advantage,,61.87,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,United Healthcare,Medicare Advantage,,162.94,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,United Healthcare,Medicare Advantage,,162.94,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Medicare Advantage,,162.94,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,United Healthcare,Medicare Advantage,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Medicare Advantage,,324.30,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,United Healthcare,Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Medicare Advantage,,1707.19,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,United Healthcare,Medicare Advantage,,728.71,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Medicare Advantage,,443.47,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,United Healthcare,Medicare Advantage,,552.58,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,United Healthcare,Medicare Advantage,,415.57,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,Medicare Advantage,,162.94,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,Medicare Advantage,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Medicare Advantage,,134.24,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,United Healthcare,Medicare Advantage,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,United Healthcare,Medicare Advantage,,324.30,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,United Healthcare,Medicare Advantage,,552.58,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Medicare Advantage,,324.30,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Medicare Advantage,,61.87,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Medicare Advantage,,162.94,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,United Healthcare,Medicare Advantage,,134.24,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,Medicare Advantage,,134.24,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,United Healthcare,Medicare Advantage,,162.94,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Medicare Advantage,,134.24,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,Medicare Advantage,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Medicare Advantage,,134.24,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Medicare Advantage,,162.94,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,United Healthcare,Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Medicare Advantage,,162.94,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,Medicare Advantage,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,United Healthcare,Medicare Advantage,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,United Healthcare,Medicare Advantage,,552.58,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,United Healthcare,Medicare Advantage,,324.30,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,United Healthcare,Medicare Advantage,,552.58,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,United Healthcare,Medicare Advantage,,324.30,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,United Healthcare,Medicare Advantage,,552.58,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,United Healthcare,Medicare Advantage,,162.94,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,United Healthcare,Medicare Advantage,,324.30,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,Medicare Advantage,,324.30,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,United Healthcare,Medicare Advantage,,552.58,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Medicare Advantage,,31.03,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Medicare Advantage,,48.05,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Medicare Advantage,,43.24,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,United Healthcare,Medicare Advantage,,206.93,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,Medicare Advantage,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,United Healthcare,Medicare Advantage,,637.50,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,United Healthcare,Medicare Advantage,,206.93,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,United Healthcare,Medicare Advantage,,206.93,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,Medicare Advantage,,206.93,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Medicare Advantage,,416.08,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,Medicare Advantage,,61.87,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Medicare Advantage,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Medicare Advantage,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,Medicare Advantage,,206.93,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,United Healthcare,Medicare Advantage,,206.93,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,United Healthcare,Medicare Advantage,,206.93,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,United Healthcare,Medicare Advantage,,732.74,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,United Healthcare,Medicare Advantage,,307.42,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,United Healthcare,Medicare Advantage,,307.42,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Medicare Advantage,,307.42,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Medicare Advantage,,307.42,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,United Healthcare,Medicare Advantage,,307.42,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,United Healthcare,Medicare Advantage,,276.58,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,Medicare Advantage,,241.85,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Medicare Advantage,,416.08,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Medicare Advantage,,416.08,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Medicare Advantage,,416.08,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,United Healthcare,Medicare Advantage,,134.24,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Medicare Advantage,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Medicare Advantage,,345.43,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,United Healthcare,Medicare Advantage,,721.21,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,United Healthcare,Medicare Advantage,,312.33,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Medicare Advantage,,312.33,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,United Healthcare,Medicare Advantage,,6834.82,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,United Healthcare,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,United Healthcare,Medicare Advantage,,307.42,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,United Healthcare,Medicare Advantage,,6834.82,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Medicare Advantage,,307.42,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Medicare Advantage,,307.42,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,United Healthcare,Medicare Advantage,,927.18,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,Medicare Advantage,,927.18,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,United Healthcare,Medicare Advantage,,927.18,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,Medicare Advantage,,206.93,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,United Healthcare,Medicare Advantage,,206.93,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,206.93,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,206.93,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Medicare Advantage,,732.74,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,Medicare Advantage,,927.18,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,United Healthcare,Medicare Advantage,,721.21,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,United Healthcare,Medicare Advantage,,927.18,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,Medicare Advantage,,416.08,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Medicare Advantage,,927.18,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,United Healthcare,Medicare Advantage,,927.18,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,United Healthcare,Medicare Advantage,,927.18,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,United Healthcare,Medicare Advantage,,927.18,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,United Healthcare,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,United Healthcare,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,United Healthcare,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,United Healthcare,Medicare Advantage,,721.21,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,United Healthcare,Medicare Advantage,,927.18,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,United Healthcare,Medicare Advantage,,721.21,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,Medicare Advantage,,927.18,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,United Healthcare,Medicare Advantage,,721.21,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Medicare Advantage,,206.93,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,206.93,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,United Healthcare,Medicare Advantage,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,United Healthcare,Medicare Advantage,,143.61,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Medicare Advantage,,134.24,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Medicare Advantage,,416.08,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,United Healthcare,Medicare Advantage,,202.19,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,United Healthcare,Medicare Advantage,,164.92,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,United Healthcare,Medicare Advantage,,288.36,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,United Healthcare,Medicare Advantage,,443.47,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,United Healthcare,Medicare Advantage,,638.50,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,United Healthcare,Medicare Advantage,,877.52,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Medicare Advantage,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Medicare Advantage,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,United Healthcare,Medicare Advantage,,61.87,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Medicare Advantage,,206.93,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,United Healthcare,Medicare Advantage,,1227.93,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,United Healthcare,Medicare Advantage,,416.08,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Medicare Advantage,,53.64,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,United Healthcare,Medicare Advantage,,206.93,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,Medicare Advantage,,164.32,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Medicare Advantage,,164.32,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Medicare Advantage,,164.32,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,United Healthcare,Medicare Advantage,,3311.27,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Medicare Advantage,,312.33,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,United Healthcare,Medicare Advantage,,637.50,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Medicare Advantage,,164.32,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,Medicare Advantage,,206.93,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Medicare Advantage,,206.93,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,United Healthcare,Medicare Advantage,,416.08,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,United Healthcare,Medicare Advantage,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Medicare Advantage,,40.88,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Medicare Advantage,,206.93,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Medicare Advantage,,416.08,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Medicare Advantage,,637.50,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Medicare Advantage,,134.24,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,United Healthcare,Medicare Advantage,,95.59,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,United Healthcare,Medicare Advantage,,95.59,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Medicare Advantage,,38.84,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Medicare Advantage,,38.84,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Medicare Advantage,,38.84,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Medicare Advantage,,38.84,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Medicare Advantage,,38.84,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Medicare Advantage,,25.50,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,United Healthcare,Medicare Advantage,,206.93,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Medicare Advantage,,61.87,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,United Healthcare,Medicare Advantage,,18209.54,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,United Healthcare,Medicare Advantage,,7439.71,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,United Healthcare,Medicare Advantage,,134.24,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,United Healthcare,Medicare Advantage,,134.24,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Medicare Advantage,,976.41,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Medicare Advantage,,253.29,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Medicare Advantage,,455.29,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,United Healthcare,Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,United Healthcare,Medicare Advantage,,1707.19,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,United Healthcare,Medicare Advantage,,732.74,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,United Healthcare,Medicare Advantage,,643.87,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Medicare Advantage,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,United Healthcare,Medicare Advantage,,732.74,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,United Healthcare,Medicare Advantage,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Medicare Advantage,,61.87,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Medicare Advantage,,74.12,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,United Healthcare,Medicare Advantage,,552.58,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Medicare Advantage,,552.58,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,United Healthcare,Medicare Advantage,,552.58,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Medicare Advantage,,162.94,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,United Healthcare,Medicare Advantage,,976.41,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,United Healthcare,Medicare Advantage,,976.41,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,United Healthcare,Medicare Advantage,,976.41,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Medicare Advantage,,552.58,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,United Healthcare,Medicare Advantage,,552.58,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,United Healthcare,Medicare Advantage,,2429.62,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,United Healthcare,Medicare Advantage,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,United Healthcare,Medicare Advantage,,324.30,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Medicare Advantage,,162.94,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,United Healthcare,Medicare Advantage,,324.30,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Medicare Advantage,,251.74,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,United Healthcare,Medicare Advantage,,822.79,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Medicare Advantage,,822.79,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,United Healthcare,Medicare Advantage,,822.79,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,United Healthcare,Medicare Advantage,,822.79,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,United Healthcare,Medicare Advantage,,371.93,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,United Healthcare,Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,Medicare Advantage,,371.93,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,Medicare Advantage,,571.02,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Medicare Advantage,,571.02,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,United Healthcare,Medicare Advantage,,185.40,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,United Healthcare,Medicare Advantage,,185.40,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,United Healthcare,Medicare Advantage,,18209.54,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,United Healthcare,Medicare Advantage,,822.79,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,United Healthcare,Medicare Advantage,,345.43,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,United Healthcare,Medicare Advantage,,418.48,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,United Healthcare,Medicare Advantage,,560.57,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,United Healthcare,Medicare Advantage,,418.48,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,United Healthcare,Medicare Advantage,,560.57,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,United Healthcare,Medicare Advantage,,560.57,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Medicare Advantage,,560.57,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,24.29,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,United Healthcare,Medicare Advantage,,751.05,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,United Healthcare,Medicare Advantage,,2010.34,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,United Healthcare,Medicare Advantage,,2178.55,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,United Healthcare,Medicare Advantage,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,United Healthcare,Medicare Advantage,,233.41,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,United Healthcare,Medicare Advantage,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,United Healthcare,Medicare Advantage,,233.41,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,United Healthcare,Medicare Advantage,,4530.66,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,United Healthcare,Medicare Advantage,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,United Healthcare,Medicare Advantage,,1082.96,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,United Healthcare,Medicare Advantage,,2304.35,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Medicare Advantage,,180.83,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,United Healthcare,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,United Healthcare,Medicare Advantage,,281.84,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,Medicare Advantage,,523.60,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,United Healthcare,Medicare Advantage,,624.86,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,United Healthcare,Medicare Advantage,,349.06,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,United Healthcare,Medicare Advantage,,400.06,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,United Healthcare,Medicare Advantage,,704.78,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,United Healthcare,Medicare Advantage,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,United Healthcare,Medicare Advantage,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,United Healthcare,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Medicare Advantage,,989.88,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,United Healthcare,Medicare Advantage,,1975.59,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,United Healthcare,Medicare Advantage,,1975.59,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Medicare Advantage,,6498.27,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,United Healthcare,Medicare Advantage,,906.81,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Medicare Advantage,,416.08,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Medicare Advantage,,416.08,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,United Healthcare,Medicare Advantage,,643.87,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,Medicare Advantage,,6076.09,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Medicare Advantage,,6498.27,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,United Healthcare,Medicare Advantage,,1975.59,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,United Healthcare,Medicare Advantage,,976.41,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,United Healthcare,Medicare Advantage,,1542.65,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Medicare Advantage,,307.42,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,United Healthcare,Medicare Advantage,,307.42,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,United Healthcare,Medicare Advantage,,13399.92,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,United Healthcare,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,Medicare Advantage,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,United Healthcare,Medicare Advantage,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Medicare Advantage,,643.87,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,United Healthcare,Medicare Advantage,,643.87,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Medicare Advantage,,643.87,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,United Healthcare,Medicare Advantage,,643.87,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Medicare Advantage,,219.42,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,United Healthcare,Medicare Advantage,,219.42,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,United Healthcare,Medicare Advantage,,643.87,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,United Healthcare,Medicare Advantage,,418.48,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Medicare Advantage,,455.29,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,United Healthcare,Medicare Advantage,,415.57,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,United Healthcare,Medicare Advantage,,976.41,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,Medicare Advantage,,10842.57,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,United Healthcare,Medicare Advantage,,10842.57,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,Medicare Advantage,,976.41,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,United Healthcare,Medicare Advantage,,976.41,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,United Healthcare,Medicare Advantage,,1424.94,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Medicare Advantage,,1975.59,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,United Healthcare,Medicare Advantage,,1975.59,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,United Healthcare,Medicare Advantage,,1975.59,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,Medicare Advantage,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,United Healthcare,Medicare Advantage,,976.41,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,United Healthcare,Medicare Advantage,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,United Healthcare,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Medicare Advantage,,695.12,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Medicare Advantage,,732.74,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,United Healthcare,Medicare Advantage,,6076.09,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,United Healthcare,Medicare Advantage,,10842.57,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,United Healthcare,Medicare Advantage,,134.24,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Medicare Advantage,,253.29,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Medicare Advantage,,732.74,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Medicare Advantage,,732.74,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,United Healthcare,Medicare Advantage,,732.74,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Medicare Advantage,,927.18,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,United Healthcare,Medicare Advantage,,927.18,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,Medicare Advantage,,927.18,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,United Healthcare,Medicare Advantage,,927.18,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,Medicare Advantage,,927.18,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,United Healthcare,Medicare Advantage,,927.18,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,United Healthcare,Medicare Advantage,,2033.68,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,United Healthcare,Medicare Advantage,,927.18,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,United Healthcare,Medicare Advantage,,1227.93,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,United Healthcare,Medicare Advantage,,7439.71,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,United Healthcare,Medicare Advantage,,7439.71,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,United Healthcare,Medicare Advantage,,732.74,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,United Healthcare,Medicare Advantage,,455.29,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,United Healthcare,Medicare Advantage,,732.74,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,United Healthcare,Medicare Advantage,,10842.57,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,United Healthcare,Medicare Advantage,,732.74,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,United Healthcare,Medicare Advantage,,732.74,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,United Healthcare,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,United Healthcare,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,United Healthcare,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,United Healthcare,Medicare Advantage,,3379.04,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,United Healthcare,Medicare Advantage,,3379.04,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,United Healthcare,Medicare Advantage,,7439.71,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,United Healthcare,Medicare Advantage,,7439.71,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,United Healthcare,Medicare Advantage,,822.79,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,United Healthcare,Medicare Advantage,,822.79,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,United Healthcare,Medicare Advantage,,3675.27,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,United Healthcare,Medicare Advantage,,976.41,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,United Healthcare,Medicare Advantage,,6076.09,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,United Healthcare,Medicare Advantage,,6076.09,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,United Healthcare,Medicare Advantage,,6076.09,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,United Healthcare,Medicare Advantage,,6498.27,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,United Healthcare,Medicare Advantage,,695.12,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,United Healthcare,Medicare Advantage,,695.12,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,United Healthcare,Medicare Advantage,,3591.87,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,United Healthcare,Medicare Advantage,,2133.38,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,United Healthcare,Medicare Advantage,,3591.87,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,United Healthcare,Medicare Advantage,,3591.87,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,United Healthcare,Medicare Advantage,,3591.87,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,United Healthcare,Medicare Advantage,,732.74,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,United Healthcare,Medicare Advantage,,2980.64,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Medicare Advantage,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Medicare Advantage,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Medicare Advantage,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,Medicare Advantage,,3591.87,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,United Healthcare,Medicare Advantage,,3591.87,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,United Healthcare,Medicare Advantage,,1687.37,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,United Healthcare,Medicare Advantage,,6669.40,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Medicare Advantage,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,United Healthcare,Medicare Advantage,,1059.54,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,United Healthcare,Medicare Advantage,,822.79,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,United Healthcare,Medicare Advantage,,110.74,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,United Healthcare,Medicare Advantage,,91.70,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,United Healthcare,Medicare Advantage,,110.74,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,United Healthcare,Medicare Advantage,,1359.57,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,United Healthcare,Medicare Advantage,,418.48,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,United Healthcare,Medicare Advantage,,1519.02,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,United Healthcare,Medicare Advantage,,2343.75,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,United Healthcare,Medicare Advantage,,2031.31,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,United Healthcare,Medicare Advantage,,571.02,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,United Healthcare,Medicare Advantage,,571.02,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,United Healthcare,Medicare Advantage,,822.79,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,United Healthcare,Medicare Advantage,,822.79,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,United Healthcare,Medicare Advantage,,822.79,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,United Healthcare,Medicare Advantage,,91.70,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,United Healthcare,Medicare Advantage,,371.93,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,United Healthcare,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Medicare Advantage,,91.70,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Medicare Advantage,,61.87,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,Medicare Advantage,,721.21,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,United Healthcare,Medicare Advantage,,721.21,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,United Healthcare,Medicare Advantage,,721.21,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,United Healthcare,Medicare Advantage,,251.74,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,United Healthcare,Medicare Advantage,,110.74,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,United Healthcare,Medicare Advantage,,110.74,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,United Healthcare,Medicare Advantage,,11.09,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,United Healthcare,Medicare Advantage,,50.20,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Medicare Advantage,,9.11,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,United Healthcare,Medicare Advantage,,50.01,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,United Healthcare,Medicare Advantage,,8.58,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Medicare Advantage,,172.16,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,United Healthcare,Medicare Advantage,,152.08,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,United Healthcare,Medicare Advantage,,584.43,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,United Healthcare,Medicare Advantage,,305.93,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,United Healthcare,Medicare Advantage,,1218.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,United Healthcare,Medicare Advantage,,1218.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,United Healthcare,Medicare Advantage,,68.97,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Medicare Advantage,,77.04,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,United Healthcare,Medicare Advantage,,59.89,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,United Healthcare,Medicare Advantage,,47.13,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,United Healthcare,Medicare Advantage,,173.79,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,Medicare Advantage,,106.18,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Medicare Advantage,,36.75,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,United Healthcare,Medicare Advantage,,68.63,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,United Healthcare,Medicare Advantage,,207.89,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Medicare Advantage,,181.37,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,United Healthcare,Medicare Advantage,,244.72,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,United Healthcare,Medicare Advantage,,244.72,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Medicare Advantage,,2.36,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,United Healthcare,Medicare Advantage,,365.99,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,United Healthcare,Medicare Advantage,,53.62,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,United Healthcare,Medicare Advantage,,45.83,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,United Healthcare,Medicare Advantage,,211.57,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Medicare Advantage,,245.70,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,United Healthcare,Medicare Advantage,,422.23,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,United Healthcare,Medicare Advantage,,423.77,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,United Healthcare,Medicare Advantage,,133.80,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,United Healthcare,Medicare Advantage,,78.05,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,United Healthcare,Medicare Advantage,,99.48,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,United Healthcare,Medicare Advantage,,362.85,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,United Healthcare,Medicare Advantage,,352.15,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,United Healthcare,Medicare Advantage,,186.11,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,United Healthcare,Medicare Advantage,,178.40,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,United Healthcare,Medicare Advantage,,129.86,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,United Healthcare,Medicare Advantage,,258.85,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Medicare Advantage,,130.87,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,United Healthcare,Medicare Advantage,,315.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Medicare Advantage,,202.91,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,United Healthcare,Medicare Advantage,,310.58,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Medicare Advantage,,17.61,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,United Healthcare,Medicare Advantage,,5.29,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Medicare Advantage,,9.18,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Medicare Advantage,,10.14,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Medicare Advantage,,7.90,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Medicare Advantage,,4.53,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Medicare Advantage,,65.25,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,United Healthcare,Medicare Advantage,,8.88,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Medicare Advantage,,7.36,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Medicare Advantage,,14.06,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Medicare Advantage,,65.25,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,United Healthcare,Medicare Advantage,,65.25,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,United Healthcare,Medicare Advantage,,65.25,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Medicare Advantage,,65.25,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,United Healthcare,Medicare Advantage,,65.25,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Medicare Advantage,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Medicare Advantage,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,15.83,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,15.30,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,13.94,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,14.22,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,United Healthcare,Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Medicare Advantage,,15.42,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.94,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Medicare Advantage,,16.07,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,13.91,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Medicare Advantage,,14.45,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Medicare Advantage,,14.42,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Medicare Advantage,,14.42,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Medicare Advantage,,14.85,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Medicare Advantage,,34.25,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Medicare Advantage,,4.75,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Medicare Advantage,,8.58,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,8.58,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,5.20,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Medicare Advantage,,8.17,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Medicare Advantage,,6.07,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Medicare Advantage,,6.07,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Medicare Advantage,,18.13,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Medicare Advantage,,14.11,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Medicare Advantage,,17.61,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,15.30,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Medicare Advantage,,16.99,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Medicare Advantage,,5.27,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Medicare Advantage,,5.27,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,5.27,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,United Healthcare,Medicare Advantage,,4.60,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Medicare Advantage,,5.59,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Medicare Advantage,,4.44,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Medicare Advantage,,31.08,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Medicare Advantage,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Medicare Advantage,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Medicare Advantage,,6.33,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Medicare Advantage,,5.12,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,United Healthcare,Medicare Advantage,,19.91,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Medicare Advantage,,11.28,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,14.83,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,14.83,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,4.83,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Medicare Advantage,,5.25,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Medicare Advantage,,4.57,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Medicare Advantage,,40.50,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Medicare Advantage,,28.47,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,United Healthcare,Medicare Advantage,,28.47,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Medicare Advantage,,19.57,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Medicare Advantage,,17.11,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Medicare Advantage,,14.42,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,6.84,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Medicare Advantage,,12.13,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Medicare Advantage,,5.38,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,United Healthcare,Medicare Advantage,,29.34,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,United Healthcare,Medicare Advantage,,15.64,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Medicare Advantage,,5.36,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Medicare Advantage,,14.31,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,Medicare Advantage,,67.63,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Medicare Advantage,,15.44,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Medicare Advantage,,11.55,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Medicare Advantage,,27.37,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,United Healthcare,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,10.26,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Medicare Advantage,,4.13,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Medicare Advantage,,4.13,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,Medicare Advantage,,4.99,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Medicare Advantage,,13.51,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Medicare Advantage,,4.12,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Medicare Advantage,,4.12,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Medicare Advantage,,7.56,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,United Healthcare,Medicare Advantage,,19.51,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,United Healthcare,Medicare Advantage,,19.45,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Medicare Advantage,,13.21,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,United Healthcare,Medicare Advantage,,13.51,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Medicare Advantage,,18.96,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,United Healthcare,Medicare Advantage,,8.40,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,10.20,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Medicare Advantage,,8.61,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Medicare Advantage,,8.61,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Medicare Advantage,,4.99,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,United Healthcare,Medicare Advantage,,18.82,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Medicare Advantage,,26.72,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Medicare Advantage,,12.11,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Medicare Advantage,,12.11,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Medicare Advantage,,12.00,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.79,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,12.15,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Medicare Advantage,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Medicare Advantage,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,20.68,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Medicare Advantage,,20.29,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Medicare Advantage,,7.23,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,United Healthcare,Medicare Advantage,,7.23,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,Medicare Advantage,,8.60,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Medicare Advantage,,11.03,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Medicare Advantage,,7.04,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Medicare Advantage,,13.57,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Medicare Advantage,,41.22,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Medicare Advantage,,18.13,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,18.13,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Medicare Advantage,,6.94,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,7.16,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Medicare Advantage,,43.34,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,United Healthcare,Medicare Advantage,,43.34,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,4.98,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Medicare Advantage,,6.07,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,United Healthcare,Medicare Advantage,,6.07,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,United Healthcare,Medicare Advantage,,103.02,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Medicare Advantage,,5.00,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,15.32,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Medicare Advantage,,21.90,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,United Healthcare,Medicare Advantage,,20.35,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Medicare Advantage,,19.31,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Medicare Advantage,,19.31,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Medicare Advantage,,3.85,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Medicare Advantage,,4.20,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Medicare Advantage,,11.28,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Medicare Advantage,,18.72,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Medicare Advantage,,18.72,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Medicare Advantage,,5.05,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Medicare Advantage,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Medicare Advantage,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Medicare Advantage,,5.10,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Medicare Advantage,,3.44,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,Medicare Advantage,,27.10,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Medicare Advantage,,7.21,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,United Healthcare,Medicare Advantage,,9.47,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,United Healthcare,Medicare Advantage,,17.64,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Medicare Advantage,,5.57,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Medicare Advantage,,13.40,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Medicare Advantage,,6.03,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Medicare Advantage,,14.89,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Medicare Advantage,,17.79,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Medicare Advantage,,13.09,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,4.15,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Medicare Advantage,,5.84,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,4.75,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Medicare Advantage,,5.33,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,United Healthcare,Medicare Advantage,,5.33,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Medicare Advantage,,65.25,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,United Healthcare,Medicare Advantage,,65.25,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,15.80,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Medicare Advantage,,8.26,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Medicare Advantage,,5.48,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Medicare Advantage,,15.80,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,United Healthcare,Medicare Advantage,,15.80,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Medicare Advantage,,19.29,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Medicare Advantage,,11.72,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Medicare Advantage,,13.60,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Medicare Advantage,,26.72,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,26.72,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,26.72,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,United Healthcare,Medicare Advantage,,12.60,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Medicare Advantage,,14.43,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,United Healthcare,Medicare Advantage,,14.43,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,Medicare Advantage,,18.83,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Medicare Advantage,,18.83,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,Medicare Advantage,,12.65,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Medicare Advantage,,12.65,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,United Healthcare,Medicare Advantage,,21.85,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,United Healthcare,Medicare Advantage,,21.85,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,United Healthcare,Medicare Advantage,,31.42,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,Medicare Advantage,,23.46,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Medicare Advantage,,30.82,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,Medicare Advantage,,39.62,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Medicare Advantage,,28.12,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,28.12,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,374.62,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,United Healthcare,Medicare Advantage,,39.62,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,Medicare Advantage,,39.62,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Medicare Advantage,,49.33,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,United Healthcare,Medicare Advantage,,81.67,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Medicare Advantage,,15.28,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Medicare Advantage,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Medicare Advantage,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Medicare Advantage,,11.17,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Medicare Advantage,,5.95,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,United Healthcare,Medicare Advantage,,65.08,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,United Healthcare,Medicare Advantage,,25.50,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Medicare Advantage,,4.62,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Medicare Advantage,,4.62,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Medicare Advantage,,17.88,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Medicare Advantage,,15.11,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Medicare Advantage,,17.69,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Medicare Advantage,,16.05,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Medicare Advantage,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Medicare Advantage,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,10.69,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Medicare Advantage,,10.69,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Medicare Advantage,,17.69,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Medicare Advantage,,17.69,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Medicare Advantage,,9.54,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Medicare Advantage,,13.85,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,Medicare Advantage,,20.32,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,Medicare Advantage,,9.33,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Medicare Advantage,,14.40,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Medicare Advantage,,12.36,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Medicare Advantage,,11.28,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,13.01,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,United Healthcare,Medicare Advantage,,11.82,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Medicare Advantage,,13.01,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,United Healthcare,Medicare Advantage,,20.32,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,20.32,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Medicare Advantage,,13.52,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Medicare Advantage,,15.11,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Medicare Advantage,,15.13,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,13.90,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Medicare Advantage,,13.52,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,14.98,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,Medicare Advantage,,114.96,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,United Healthcare,Medicare Advantage,,67.40,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,United Healthcare,Medicare Advantage,,67.40,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,United Healthcare,Medicare Advantage,,339.94,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,United Healthcare,Medicare Advantage,,342.09,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,United Healthcare,Medicare Advantage,,178.46,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,United Healthcare,Medicare Advantage,,374.62,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Medicare Advantage,,3.14,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,3.14,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,United Healthcare,Medicare Advantage,,6.67,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Medicare Advantage,,6.67,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,Medicare Advantage,,4.02,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,United Healthcare,Medicare Advantage,,178.46,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,178.46,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,United Healthcare,Medicare Advantage,,61.87,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,United Healthcare,Medicare Advantage,,61.87,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Medicare Advantage,,25.50,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,United Healthcare,Medicare Advantage,,14.61,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Medicare Advantage,,3.99,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,2.49,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,2.49,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Medicare Advantage,,8.16,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,6.79,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,4.19,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,United Healthcare,Medicare Advantage,,5.85,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Medicare Advantage,,2.67,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,4.70,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,Medicare Advantage,,850.74,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,United Healthcare,Medicare Advantage,,850.74,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Medicare Advantage,,13.63,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Medicare Advantage,,18.53,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,United Healthcare,Medicare Advantage,,18.80,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,United Healthcare,Medicare Advantage,,18.80,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,United Healthcare,Medicare Advantage,,12.48,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Medicare Advantage,,24.09,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,24.09,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,United Healthcare,Medicare Advantage,,24.09,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,United Healthcare,Medicare Advantage,,32.40,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Medicare Advantage,,24.09,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,Medicare Advantage,,19.99,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Medicare Advantage,,18.80,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,United Healthcare,Medicare Advantage,,18.80,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,United Healthcare,Medicare Advantage,,20.32,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,United Healthcare,Medicare Advantage,,9.57,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Medicare Advantage,,19.88,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Medicare Advantage,,19.88,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Medicare Advantage,,12.44,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Medicare Advantage,,14.53,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,United Healthcare,Medicare Advantage,,16.09,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Medicare Advantage,,32.40,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,United Healthcare,Medicare Advantage,,16.09,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,United Healthcare,Medicare Advantage,,13.51,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,United Healthcare,Medicare Advantage,,13.51,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Medicare Advantage,,13.51,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Medicare Advantage,,4.49,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Medicare Advantage,,7.23,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,United Healthcare,Medicare Advantage,,10.69,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,United Healthcare,Medicare Advantage,,10.21,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Medicare Advantage,,18.05,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,9.83,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,United Healthcare,Medicare Advantage,,13.74,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Medicare Advantage,,13.74,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,United Healthcare,Medicare Advantage,,26.16,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,United Healthcare,Medicare Advantage,,26.16,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Medicare Advantage,,18.88,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,United Healthcare,Medicare Advantage,,18.88,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Medicare Advantage,,4.50,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,Medicare Advantage,,4.14,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Medicare Advantage,,10.06,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,United Healthcare,Medicare Advantage,,10.06,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,United Healthcare,Medicare Advantage,,18.88,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Medicare Advantage,,10.34,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Medicare Advantage,,19.57,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,5.79,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Medicare Advantage,,6.06,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,Medicare Advantage,,6.06,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,6.31,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,6.31,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,United Healthcare,Medicare Advantage,,6.79,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Medicare Advantage,,6.79,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,United Healthcare,Medicare Advantage,,12.25,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,7.01,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,United Healthcare,Medicare Advantage,,10.84,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,United Healthcare,Medicare Advantage,,10.84,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,United Healthcare,Medicare Advantage,,9.91,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,9.91,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Medicare Advantage,,9.91,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,Medicare Advantage,,9.05,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,United Healthcare,Medicare Advantage,,10.38,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Medicare Advantage,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,United Healthcare,Medicare Advantage,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,United Healthcare,Medicare Advantage,,9.94,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Medicare Advantage,,8.48,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Medicare Advantage,,8.48,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Medicare Advantage,,8.48,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,8.48,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Medicare Advantage,,6.96,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,United Healthcare,Medicare Advantage,,8.47,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,United Healthcare,Medicare Advantage,,8.10,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,8.83,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,United Healthcare,Medicare Advantage,,10.84,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,10.84,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Medicare Advantage,,121.13,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,United Healthcare,Medicare Advantage,,4.53,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,6.17,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Medicare Advantage,,9.35,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Medicare Advantage,,4.99,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Medicare Advantage,,7.85,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Medicare Advantage,,4.99,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,United Healthcare,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,United Healthcare,Medicare Advantage,,9.08,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,5.66,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,United Healthcare,Medicare Advantage,,5.66,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,5.66,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,United Healthcare,Medicare Advantage,,6.29,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Medicare Advantage,,18.88,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Medicare Advantage,,6.11,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,6.11,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,United Healthcare,Medicare Advantage,,12.58,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,United Healthcare,Medicare Advantage,,12.58,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,12.58,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Medicare Advantage,,12.58,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,United Healthcare,Medicare Advantage,,14.51,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Medicare Advantage,,10.85,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Medicare Advantage,,10.85,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,25.28,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,United Healthcare,Medicare Advantage,,25.28,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,United Healthcare,Medicare Advantage,,12.58,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,United Healthcare,Medicare Advantage,,12.58,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Medicare Advantage,,12.58,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,United Healthcare,Medicare Advantage,,39.13,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Medicare Advantage,,44.98,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,United Healthcare,Medicare Advantage,,44.98,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,United Healthcare,Medicare Advantage,,44.98,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Medicare Advantage,,36.84,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Medicare Advantage,,89.36,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Medicare Advantage,,36.84,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Medicare Advantage,,36.84,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Medicare Advantage,,100.59,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,United Healthcare,Medicare Advantage,,149.76,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,United Healthcare,Medicare Advantage,,437.62,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,United Healthcare,Medicare Advantage,,36.84,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,United Healthcare,Medicare Advantage,,36.84,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,United Healthcare,Medicare Advantage,,36.84,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,36.84,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,United Healthcare,Medicare Advantage,,36.84,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,United Healthcare,Medicare Advantage,,44.98,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,United Healthcare,Medicare Advantage,,276.14,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Medicare Advantage,,16.05,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,United Healthcare,Medicare Advantage,,17.36,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,United Healthcare,Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,United Healthcare,Medicare Advantage,,270.32,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Medicare Advantage,,270.32,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Medicare Advantage,,3.33,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,United Healthcare,Medicare Advantage,,3.33,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,United Healthcare,Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,United Healthcare,Medicare Advantage,,9.04,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,United Healthcare,Medicare Advantage,,178.46,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Medicare Advantage,,5.88,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,7.70,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,United Healthcare,Medicare Advantage,,6.08,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Medicare Advantage,,96.24,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,United Healthcare,Medicare Advantage,,18.95,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,United Healthcare,Medicare Advantage,,25.39,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,United Healthcare,Medicare Advantage,,13.01,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,United Healthcare,Medicare Advantage,,4.96,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,United Healthcare,Medicare Advantage,,13.91,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,17.28,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Medicare Advantage,,12.11,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Medicare Advantage,,5.48,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,United Healthcare,Medicare Advantage,,18.83,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,United Healthcare,Medicare Advantage,,4.48,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Medicare Advantage,,13.70,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Medicare Advantage,,13.52,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,United Healthcare,Medicare Advantage,,5.44,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,United Healthcare,Medicare Advantage,,15.10,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,United Healthcare,Medicare Advantage,,8.48,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Medicare Advantage,,8.48,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,United Healthcare,Medicare Advantage,,14.29,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,United Healthcare,Medicare Advantage,,9.04,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Medicare Advantage,,13.85,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,7.01,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,United Healthcare,Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,United Healthcare,Medicare Advantage,,14.06,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,United Healthcare,Medicare Advantage,,4.99,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,United Healthcare,Medicare Advantage,,4.99,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Medicare Advantage,,13.51,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Medicare Advantage,,4.50,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,6.45,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,United Healthcare,Medicare Advantage,,13.90,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Medicare Advantage,,6.96,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Medicare Advantage,,178.46,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Medicare Advantage,,178.46,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Medicare Advantage,,129.86,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,United Healthcare,Medicare Advantage,,15.34,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,15.80,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,United Healthcare,Medicare Advantage,,7.68,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,United Healthcare,Medicare Advantage,,27.10,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,Medicare Advantage,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,36.84,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,16.72,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Medicare Advantage,,5.78,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Medicare Advantage,,28.58,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,United Healthcare,Medicare Advantage,,2.83,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,United Healthcare,Medicare Advantage,,12.58,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Medicare Advantage,,17.38,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,United Healthcare,Medicare Advantage,,17.38,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,United Healthcare,Medicare Advantage,,9.54,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,United Healthcare,Medicare Advantage,,9.54,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,United Healthcare,Medicare Advantage,,9.54,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,United Healthcare,Medicare Advantage,,36.84,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,United Healthcare,Medicare Advantage,,127.71,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,United Healthcare,Medicare Advantage,,194.46,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,United Healthcare,Medicare Advantage,,87.15,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,United Healthcare,Medicare Advantage,,673.94,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,United Healthcare,Medicare Advantage,,1916.12,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,United Healthcare,Medicare Advantage,,394.01,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,United Healthcare,Medicare Advantage,,9.54,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,United Healthcare,Medicare Advantage,,11.71,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,United Healthcare,Medicare Advantage,,6.79,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,United Healthcare,Medicare Advantage,,5.79,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Medicare Advantage,,19.45,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,United Healthcare,Medicare Advantage,,194.46,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,United Healthcare,Medicare Advantage,,36.84,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,United Healthcare,Medicare Advantage,,143.85,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,United Healthcare,Medicare Advantage,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,United Healthcare,Medicare Advantage,,228.96,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,36.84,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,Medicare Advantage,,73.71,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,United Healthcare,Medicare Advantage,,127.71,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,United Healthcare,Medicare Advantage,,194.46,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Medicare Advantage,,26.16,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,United Healthcare,Medicare Advantage,QW,26.16,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,United Healthcare,Medicare Advantage,,15.10,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,Medicare Advantage,,65.25,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,United Healthcare,Medicare Advantage,,1218.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,United Healthcare,Medicare Advantage,,437.62,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,United Healthcare,Medicare Advantage,,96.24,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,21.85,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,Medicare Advantage,,244.72,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,United Healthcare,Medicare Advantage,,43.85,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,United Healthcare,Medicare Advantage,,44.98,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,United Healthcare,Medicare Advantage,,16.87,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,United Healthcare,Medicare Advantage,,5.48,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Medicare Advantage,,30.67,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Medicare Advantage,QW,53.88,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,United Healthcare,Medicare Advantage,,44.24,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,United Healthcare,Medicare Advantage,,18.13,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,United Healthcare,Medicare Advantage,,437.62,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,United Healthcare,Medicare Advantage,,149.76,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Medicare Advantage,,10.84,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Medicare Advantage,,19.57,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,United Healthcare,Medicare Advantage,,19.57,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Medicare Advantage,,28.47,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,United Healthcare,Medicare Advantage,,40.50,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,United Healthcare,Medicare Advantage,,9.08,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,United Healthcare,Medicare Advantage,,149.76,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Medicare Advantage,,41.22,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,United Healthcare,Medicare Advantage,,22.82,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Medicare Advantage,,21.85,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,United Healthcare,Medicare Advantage,,143.85,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Medicare Advantage,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,United Healthcare,Medicare Advantage,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,United Healthcare,Medicare Advantage,,21.34,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,United Healthcare,Medicare Advantage,,12.11,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,18.13,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,United Healthcare,Medicare Advantage,,23.46,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,United Healthcare,Medicare Advantage,,30.82,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,United Healthcare,Medicare Advantage,,28.76,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,United Healthcare,Medicare Advantage,,134.70,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,United Healthcare,Medicare Advantage,,12.11,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,United Healthcare,Medicare Advantage,,53.88,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,36.84,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,United Healthcare,Medicare Advantage,,36.84,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,10.20,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,United Healthcare,Medicare Advantage,,12.15,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Medicare Advantage,,2.36,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,United Healthcare,Medicare Advantage,,36.84,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,United Healthcare,Medicare Advantage,,36.84,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Medicare Advantage,,143.85,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,United Healthcare,Medicare Advantage,,9.05,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,United Healthcare,Medicare Advantage,,276.14,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,United Healthcare,Medicare Advantage,,73.71,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Medicare Advantage,,55.64,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,United Healthcare,Medicare Advantage,,2.49,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,United Healthcare,Medicare Advantage,,40.88,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,United Healthcare,Medicare Advantage,,40.88,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Medicare Advantage,,55.64,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,United Healthcare,Medicare Advantage,,55.64,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,United Healthcare,Medicare Advantage,,21.27,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,United Healthcare,Medicare Advantage,,25.50,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,United Healthcare,Medicare Advantage,,178.46,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,Medicare Advantage,,55.64,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,27.94,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,United Healthcare,Medicare Advantage,,27.94,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,United Healthcare,Medicare Advantage,,27.94,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,United Healthcare,Medicare Advantage,,374.62,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,United Healthcare,Medicare Advantage,,374.62,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,United Healthcare,Medicare Advantage,,122.31,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,United Healthcare,Medicare Advantage,,122.31,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,United Healthcare,Medicare Advantage,,147.77,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,United Healthcare,Medicare Advantage,,157.81,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,United Healthcare,Medicare Advantage,,157.81,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,United Healthcare,Medicare Advantage,,150.94,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,United Healthcare,Medicare Advantage,,13.72,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,United Healthcare,Medicare Advantage,,277.56,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,United Healthcare,Medicare Advantage,,131.76,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Medicare Advantage,,151.84,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,United Healthcare,Medicare Advantage,,198.00,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,United Healthcare,Medicare Advantage,,22.49,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,United Healthcare,Medicare Advantage,,36.55,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,United Healthcare,Medicare Advantage,,44.50,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Medicare Advantage,,53.75,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,United Healthcare,Medicare Advantage,,35.14,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,United Healthcare,Medicare Advantage,,72.03,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,United Healthcare,Medicare Advantage,,28.26,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Medicare Advantage,,55.64,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,United Healthcare,Medicare Advantage,,40.88,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,United Healthcare,Medicare Advantage,,25.50,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,United Healthcare,Medicare Advantage,,40.88,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,United Healthcare,Medicare Advantage,,55.64,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Medicare Advantage,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,United Healthcare,Medicare Advantage,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,United Healthcare,Medicare Advantage,,374.62,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,United Healthcare,Medicare Advantage,,850.74,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Medicare Advantage,,134.24,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,United Healthcare,Medicare Advantage,,850.74,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,United Healthcare,Medicare Advantage,,55.64,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,United Healthcare,Medicare Advantage,,178.46,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,United Healthcare,Medicare Advantage,,850.74,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Medicare Advantage,,178.46,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,United Healthcare,Medicare Advantage,,12.65,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,United Healthcare,Medicare Advantage,,178.46,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Medicare Advantage,,178.46,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,United Healthcare,Medicare Advantage,,178.46,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,United Healthcare,Medicare Advantage,,178.46,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,United Healthcare,Medicare Advantage,,107.37,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,United Healthcare,Medicare Advantage,,5.27,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,United Healthcare,Medicare Advantage,,178.46,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,United Healthcare,Medicare Advantage,,150.94,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,United Healthcare,Medicare Advantage,,147.77,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,United Healthcare,Medicare Advantage,,150.94,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Medicare Advantage,,53.75,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,United Healthcare,Medicare Advantage,,151.84,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Medicare Advantage,,374.62,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Medicare Advantage,,178.46,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,United Healthcare,Medicare Advantage,,53.75,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,United Healthcare,Medicare Advantage,,178.46,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,United Healthcare,Medicare Advantage,,55.64,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,United Healthcare,Medicare Advantage,,134.24,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,United Healthcare,Medicare Advantage,,374.62,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,United Healthcare,Medicare Advantage,,53.75,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,United Healthcare,Medicare Advantage,,178.46,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,United Healthcare,Medicare Advantage,,178.46,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,United Healthcare,Medicare Advantage,,178.46,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,United Healthcare,Medicare Advantage,,22.49,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,United Healthcare,Medicare Advantage,,22.49,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,United Healthcare,Medicare Advantage,,22.49,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,United Healthcare,Medicare Advantage,,53.75,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,United Healthcare,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,United Healthcare,Medicare Advantage,,44.50,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,United Healthcare,Medicare Advantage,,178.46,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,United Healthcare,Medicare Advantage,,178.46,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,178.46,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,United Healthcare,Medicare Advantage,,40.88,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,United Healthcare,Medicare Advantage,,178.46,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Medicare Advantage,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,United Healthcare,Medicare Advantage,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,United Healthcare,Medicare Advantage,,189.54,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,United Healthcare,Medicare Advantage,,189.54,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Medicare Advantage,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Medicare Advantage,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,United Healthcare,Medicare Advantage,,87.78,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,United Healthcare,Medicare Advantage,,150.30,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,United Healthcare,Medicare Advantage,,413.31,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,United Healthcare,Medicare Advantage,,703.66,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,United Healthcare,Medicare Advantage,,680.83,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,United Healthcare,Medicare Advantage,,266.40,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,United Healthcare,Medicare Advantage,,153.41,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,United Healthcare,Medicare Advantage,,809.71,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,United Healthcare,Medicare Advantage,,252.48,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,United Healthcare,Medicare Advantage,,74.04,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,United Healthcare,Medicare Advantage,,611.61,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,United Healthcare,Medicare Advantage,,3.14,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,United Healthcare,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,United Healthcare,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,United Healthcare,Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,United Healthcare,Medicare Advantage,,703.66,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,United Healthcare,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,United Healthcare,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,United Healthcare,Medicare Advantage,,681.49,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,United Healthcare,Medicare Advantage,,681.49,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,United Healthcare,Medicare Advantage,,345.43,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,Medicare Advantage,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,United Healthcare,Medicare Advantage,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,United Healthcare,Medicare Advantage,,10898.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,United Healthcare,Medicare Advantage,,10898.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,United Healthcare,Medicare Advantage,,10898.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,United Healthcare,Medicare Advantage,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,United Healthcare,Medicare Advantage,,10898.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,United Healthcare,Medicare Advantage,,10898.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,United Healthcare,Medicare Advantage,,19861.32,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,United Healthcare,Medicare Advantage,,23376.18,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,United Healthcare,Medicare Advantage,,33389.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,United Healthcare,Medicare Advantage,,732.74,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Medicare Advantage,,1264.28,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,United Healthcare,Medicare Advantage,,1264.28,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,United Healthcare,Medicare Advantage,,1264.28,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,United Healthcare,Medicare Advantage,,7902.49,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,United Healthcare,Medicare Advantage,,552.58,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,United Healthcare,Medicare Advantage,,19861.32,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,United Healthcare,Medicare Advantage,,33389.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,Medicare Advantage,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,United Healthcare,Medicare Advantage,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,United Healthcare,Medicare Advantage,,33389.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,United Healthcare,Medicare Advantage,,29606.17,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,United Healthcare,Medicare Advantage,,415.57,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,United Healthcare,Medicare Advantage,,162.94,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,United Healthcare,Medicare Advantage,,1617.80,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,United Healthcare,Medicare Advantage,,33389.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,United Healthcare,Medicare Advantage,,11810.43,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,United Healthcare,Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,United Healthcare,Medicare Advantage,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,Medicare Advantage,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,United Healthcare,Medicare Advantage,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,United Healthcare,Medicare Advantage,,25548.73,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,United Healthcare,Medicare Advantage,,643.87,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,United Healthcare,Medicare Advantage,,33389.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,United Healthcare,Medicare Advantage,,5937.75,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,United Healthcare,Medicare Advantage,,110.74,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,United Healthcare,Medicare Advantage,,19861.32,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,United Healthcare,Medicare Advantage,,324.30,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,United Healthcare,Medicare Advantage,,571.02,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,United Healthcare,Medicare Advantage,,571.02,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,United Healthcare,Medicare Advantage,,251.74,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,United Healthcare,Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,United Healthcare,Medicare Advantage,,38.84,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,United Healthcare,Medicare Advantage,,134.24,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,United Healthcare,Medicare Advantage,,61.87,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,United Healthcare,Medicare Advantage,,95.59,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,United Healthcare,Medicare Advantage,,251.74,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,United Healthcare,Medicare Advantage,,131.12,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,United Healthcare,Medicare Advantage,,131.12,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,United Healthcare,Medicare Advantage,,61.87,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,United Healthcare,Medicare Advantage,,61.87,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,United Healthcare,Medicare Advantage,,3839.70,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,United Healthcare,Medicare Advantage,,3277.91,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,United Healthcare,Medicare Advantage,,7439.71,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,United Healthcare,Medicare Advantage,,732.74,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Medicare Advantage,,8618.87,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,United Healthcare,Medicare Advantage,,3790.08,,,,,,,422.62,17457.00,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,205155.01,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,83479.86,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,155596.66,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,101846.19,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,76035.22,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34678.87,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,95277.00,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,41732.08,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,53184.42,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,40635.04,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31610.05,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21884.54,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,88481.10,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,44101.86,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,40476.11,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,315654.06,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,52884.84,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,58236.71,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,39466.54,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24039.29,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,42648.36,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,29393.34,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34020.64,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23542.15,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19268.38,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,44674.80,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,25746.45,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16879.65,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,33538.08,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16411.68,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12999.51,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,29093.03,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18303.27,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15039.81,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24875.37,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12705.75,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9446.66,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,29023.77,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16905.16,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13471.86,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14081.26,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8015.75,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12008.16,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8310.25,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17811.96,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10322.12,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13339.19,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9923.38,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7582.77,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20975.57,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13686.90,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11110.83,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15536.95,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8242.46,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5866.85,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11583.91,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7178.94,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6700.75,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13013.35,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8356.90,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6390.22,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12572.35,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8391.89,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14855.38,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6893.20,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14071.79,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7406.36,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17538.61,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11052.52,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7845.20,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17438.75,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10373.87,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7545.60,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10731.79,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8886.11,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6878.62,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13679.62,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8335.02,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6682.52,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26532.25,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19678.79,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19678.79,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27205.80,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17606.42,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10809.04,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14996.08,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7457.39,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9048.66,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6974.10,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18016.06,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10740.53,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12066.48,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14057.92,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8786.24,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9357.74,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6605.99,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6699.29,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10522.58,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6474.78,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16695.95,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8278.90,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11762.50,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7337.85,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9885.48,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31969.41,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16776.88,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12514.77,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,28188.41,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13509.78,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9642.03,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16312.54,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10146.44,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6688.37,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6356.70,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10583.81,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6228.40,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9495.49,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6259.02,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12274.94,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7558.71,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5915.68,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13392.41,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7509.87,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6042.52,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,33547.57,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19276.40,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14831.35,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,28123.52,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14023.66,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10838.19,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22574.12,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10890.69,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6745.95,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12269.11,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7992.44,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6381.48,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13751.05,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8684.92,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6372.73,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12030.03,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8634.62,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6611.10,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12238.51,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8087.91,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6105.94,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9883.29,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8952.45,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7022.94,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5557.78,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10459.16,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6752.50,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5459.37,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14634.53,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7796.35,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6098.65,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13737.20,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8891.21,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6090.64,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7957.45,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5761.89,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6763.45,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14224.86,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7738.04,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,47783.00,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20914.31,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,83385.10,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,80143.50,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,42477.80,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,73458.42,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,72188.59,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,48807.89,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,48807.89,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,56848.08,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,39750.83,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,37617.96,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,36941.51,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23835.90,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,62326.79,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,45070.63,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,56606.79,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,40697.72,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,43656.49,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31411.77,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,36754.17,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21656.40,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10969.42,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24151.54,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16410.94,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14053.55,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34135.07,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16787.06,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11771.97,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26305.56,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19798.32,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13865.49,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20540.39,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13254.64,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8839.45,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23781.97,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15617.86,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24588.90,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14658.57,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12758.96,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23164.55,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,25228.92,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27252.44,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,45550.28,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,35581.30,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,51013.66,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31662.52,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,39338.99,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26801.25,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19487.79,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,30950.35,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24872.45,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,52854.23,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,44662.41,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34544.01,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,41452.18,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27166.42,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12570.90,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7577.67,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6148.94,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15316.80,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5923.70,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5243.61,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17007.94,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8678.35,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20604.54,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13320.25,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7654.93,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10236.10,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7066.69,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5003.78,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12263.29,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5499.46,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,4195.38,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12779.37,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8659.40,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6124.17,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9600.49,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5785.21,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9552.36,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6382.20,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12364.60,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7534.66,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9654.42,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6240.79,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5004.50,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5994.40,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7231.43,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6126.34,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16077.83,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7899.86,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5850.08,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,49618.47,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18534.34,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,33409.78,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18411.15,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20710.96,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13729.17,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,32422.07,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23846.83,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24279.85,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,37233.08,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18694.69,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12557.78,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34383.66,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18352.10,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13145.30,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27270.68,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17951.18,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12817.28,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26907.68,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16249.13,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12067.20,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19705.02,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11846.33,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9524.66,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17611.51,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10418.33,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7224.13,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19042.41,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11990.66,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9390.55,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22031.79,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13141.66,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10682.21,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,32898.81,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17829.47,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11067.81,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,25943.28,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18476.76,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12481.97,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8168.83,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5986.39,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13802.81,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8320.45,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6180.28,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16467.80,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9695.23,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7615.57,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14202.98,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8026.69,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5473.21,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15181.21,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8776.04,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6713.88,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10942.45,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7108.95,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12412.00,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7994.63,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5844.26,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11642.94,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6635.14,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,4843.42,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10123.11,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6560.80,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12535.90,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7698.67,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5608.81,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18335.33,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11911.19,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9222.15,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,30184.97,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,40754.58,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22018.67,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17057.51,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26869.02,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16749.18,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12451.34,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24957.02,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16203.93,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12982.02,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26847.17,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15942.97,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10815.61,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18273.38,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13208.72,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10833.84,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,25713.65,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13543.30,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11079.49,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31150.82,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16826.44,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11814.27,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,81215.78,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,53497.15,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,41858.92,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,66552.45,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,42916.60,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15224.96,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8577.03,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6071.69,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14266.40,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9123.01,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7098.02,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12761.14,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7009.82,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5407.62,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13960.26,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7914.43,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5978.37,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13057.81,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8855.49,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6908.50,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,49582.74,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31790.82,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,39727.49,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24425.62,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,62133.62,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,44345.33,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31293.68,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,41137.26,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20267.76,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,42423.85,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23582.24,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14171.65,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,38822.16,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26584.73,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20909.23,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22988.16,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14938.50,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,36076.24,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22353.25,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18673.56,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,32170.59,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17466.46,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9480.92,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26059.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18804.05,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14428.23,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22106.88,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16145.60,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12766.99,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21083.44,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24401.57,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16120.83,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12294.63,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13772.18,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9018.78,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27641.69,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19364.61,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15504.16,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27307.11,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14027.31,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9685.75,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22868.59,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15564.64,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23947.45,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13620.55,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10688.77,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21223.39,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14503.31,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13946.41,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10712.83,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14045.54,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11917.05,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22895.59,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16035.53,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12944.85,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12353.68,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8329.94,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24108.54,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16026.07,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12079.58,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,28120.60,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15458.21,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11767.61,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21799.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16314.72,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12305.55,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6753.96,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10222.98,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6764.90,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7834.26,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6128.54,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15235.90,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10327.21,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6617.65,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13754.69,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8371.48,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6378.56,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18968.06,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9285.57,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6973.37,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14953.07,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9677.73,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7249.64,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13095.74,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7885.28,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10327.21,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6928.91,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10513.10,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6932.55,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11716.57,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7388.86,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14471.99,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9086.57,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6737.92,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11263.91,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7405.63,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12129.89,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7980.76,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6339.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22316.81,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13193.41,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9233.82,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,48633.68,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26182.37,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13977.02,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,36604.74,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20199.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12587.66,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24484.67,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13474.06,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11397.30,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14921.71,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13447.81,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16482.38,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14939.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14985.13,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9525.38,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7196.43,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16336.59,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8768.75,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13030.12,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9124.46,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6486.44,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8470.61,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5288.06,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11238.39,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7226.32,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11608.69,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7555.07,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11908.28,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7485.09,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16854.87,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11078.04,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26298.99,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14511.33,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11216.52,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21925.36,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12543.18,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11873.30,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26822.38,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13954.43,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10003.57,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22892.66,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11807.69,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10560.49,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,28044.08,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16760.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11516.84,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11350.66,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7410.74,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5406.16,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10613.70,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6550.58,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11244.23,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12877.05,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8349.60,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6478.41,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,35148.31,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27890.99,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24419.06,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,38756.56,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21283.16,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16306.71,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24085.94,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14217.57,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12189.66,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19399.58,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10512.37,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8425.42,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23194.44,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11959.32,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8509.25,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23629.63,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13629.30,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8941.50,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22163.00,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12191.12,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8001.90,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13962.44,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8746.89,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31505.09,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17924.95,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12842.79,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11673.57,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7262.03,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5253.81,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14025.86,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8515.81,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6638.79,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9335.87,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6778.76,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10678.58,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6576.10,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9215.58,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5900.37,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8734.49,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12937.56,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8276.72,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5906.93,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15458.96,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12061.37,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17841.13,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11091.89,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16067.62,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8894.12,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11836.86,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8585.78,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17186.54,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11600.67,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14658.57,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10668.36,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14069.59,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9207.56,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5657.64,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9408.03,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6140.94,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11687.43,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6791.13,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8595.26,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5776.46,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16404.39,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10685.86,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26933.90,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15898.50,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11582.45,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,26994.41,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14068.87,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11273.39,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14252.55,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9921.94,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15814.69,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9169.67,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13540.38,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7144.68,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10990.56,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19594.22,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11635.67,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14302.86,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8807.39,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7879.44,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11315.66,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8014.29,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5715.23,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8222.04,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5036.59,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8689.29,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13195.59,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8187.05,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5650.36,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7010.55,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18774.16,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8605.47,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7859.76,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12901.83,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9018.78,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7867.06,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14014.93,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,44202.47,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,30465.61,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18731.15,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31271.82,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11636.40,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,2334.41,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9384.70,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8170.29,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7854.66,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,33890.90,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21356.79,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14792.70,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,29919.63,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14428.23,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10762.39,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8744.70,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6374.19,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5792.49,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16972.21,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10105.62,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8507.06,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11114.47,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7571.10,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11996.49,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16380.33,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8269.42,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5484.87,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17509.46,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9327.85,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7146.14,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,43628.79,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17196.00,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9654.42,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34298.36,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17392.82,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10714.28,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34976.27,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17725.23,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13297.65,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,23912.44,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11848.53,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9643.48,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6138.01,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,4689.61,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,40896.00,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16082.18,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9767.39,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,35898.40,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16093.87,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11403.14,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24458.43,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12769.89,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8243.20,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15418.86,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9752.08,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7085.64,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,19775.72,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10413.97,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7069.60,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20628.58,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,64000.43,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,36877.35,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15442.91,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11791.66,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,34035.21,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16488.21,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11031.37,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14171.65,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8152.08,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7348.78,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11799.68,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7216.84,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16136.13,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8394.08,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6197.05,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,51260.78,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15037.62,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8337.23,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,29050.75,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7877.24,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7736.57,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8705.33,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15211.11,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12605.89,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11059.80,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16005.66,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8684.21,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5374.81,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11196.84,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13598.71,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7313.06,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31468.63,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14833.51,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9403.66,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27652.63,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,11691.07,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15196.53,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,28864.11,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15421.77,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10446.78,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12793.24,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7332.74,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13135.82,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5734.92,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12310.67,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7125.71,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,14223.40,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8184.14,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5896.00,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13630.04,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,8296.40,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,156510.01,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,53162.57,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,24355.65,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,29264.32,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,16991.90,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15894.12,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,27327.53,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,17912.56,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,15658.67,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12166.34,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9237.47,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10131.14,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,6713.15,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9550.16,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,5453.53,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,4930.88,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,49943.59,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,28307.95,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,56422.38,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,31594.72,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,22338.67,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20805.72,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12049.71,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7733.64,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,45498.51,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,20103.02,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,21915.15,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10317.74,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,7458.13,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,10337.42,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,35078.32,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,18798.95,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,13372.00,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,25868.92,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,12858.83,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN Behavioral Health,,9619.41,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17256.38,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5117.61,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,21269.40,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7334.47,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5117.61,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9490.97,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1540.76,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,30224.93,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6509.35,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,21269.40,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7334.47,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,662.02,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,662.02,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6509.35,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5117.61,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5904.24,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,301.71,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5904.24,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,19964.31,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,30224.93,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,44633.30,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,230.33,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,526.27,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,398.55,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,19964.31,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17810.19,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,863.63,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9490.97,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5904.24,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,505.09,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5904.24,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3410.95,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,960.64,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6509.35,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,22263.03,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,19964.31,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17810.19,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,863.63,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,199.53,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,31799.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1540.76,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17529.90,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,544.12,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5904.24,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,58.92,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,8208.45,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,960.64,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,199.53,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,662.02,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,863.63,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,301.71,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,8208.45,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,192.56,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,395.78,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,127.85,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,58.92,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6468.24,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12886.40,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,19964.31,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,31799.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10379.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,395.78,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5904.24,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,544.12,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12368.55,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6509.35,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,230.33,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6351.81,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,301.71,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,87.33,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,199.53,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,662.02,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,960.64,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,960.64,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5117.61,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1540.76,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4646.94,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12368.55,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6351.81,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,544.12,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,8208.45,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17810.19,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6351.81,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6188.83,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,544.12,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,960.64,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,230.33,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,505.09,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,395.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3609.60,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,127.85,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,127.85,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17810.19,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12886.40,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,301.71,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,863.63,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10379.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,8208.45,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,230.33,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,649.04,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,91.04,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,9171.69,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7334.47,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,230.33,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5904.24,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,192.56,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,301.71,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,230.33,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,505.09,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,127.85,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,505.09,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,230.33,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,433.61,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,395.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,199.53,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17810.19,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17810.19,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,395.78,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,17810.19,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,11248.03,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2031.79,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,662.02,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,199.53,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,199.53,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12886.40,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,10326.26,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,662.02,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3500.26,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,301.71,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,607.14,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,395.78,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,127.85,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3420.83,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,197.08,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,127.85,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,395.78,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5117.61,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,544.12,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2838.70,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,904.27,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1357.09,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3609.60,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3609.60,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,296.49,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,960.64,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,8208.45,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,8208.45,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,241.23,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Optum,VACCN Behavioral Health,,29.38,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Optum,VACCN Behavioral Health,,56824.55,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Optum,VACCN Behavioral Health,,7.28,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Optum,VACCN Behavioral Health,,3.35,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Optum,VACCN Behavioral Health,,12.07,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Optum,VACCN Behavioral Health,,0.12000,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Optum,VACCN Behavioral Health,,1730.32,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Optum,VACCN Behavioral Health,,112.45,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Optum,VACCN Behavioral Health,,114.54,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Optum,VACCN Behavioral Health,,6.77,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Optum,VACCN Behavioral Health,,7.95,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Optum,VACCN Behavioral Health,,30.01,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Optum,VACCN Behavioral Health,,15.11,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Optum,VACCN Behavioral Health,,1.70,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Optum,VACCN Behavioral Health,,62.23,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Optum,VACCN Behavioral Health,,75.86,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Optum,VACCN Behavioral Health,,1.88,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Optum,VACCN Behavioral Health,,172.31,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Optum,VACCN Behavioral Health,,733.67,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Optum,VACCN Behavioral Health,,8.73,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Optum,VACCN Behavioral Health,,3.42,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Optum,VACCN Behavioral Health,,5135.09,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Optum,VACCN Behavioral Health,,95.90,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Optum,VACCN Behavioral Health,,227.28,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Optum,VACCN Behavioral Health,,5.57,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Optum,VACCN Behavioral Health,,5.57,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Optum,VACCN Behavioral Health,,20.35,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Optum,VACCN Behavioral Health,,20.35,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Optum,VACCN Behavioral Health,,20.35,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Optum,VACCN Behavioral Health,,8.75,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Optum,VACCN Behavioral Health,,89.34,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN Behavioral Health,,4.23,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Optum,VACCN Behavioral Health,,2.93,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Optum,VACCN Behavioral Health,,2.93,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Optum,VACCN Behavioral Health,,2.93,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Optum,VACCN Behavioral Health,,2.93,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Optum,VACCN Behavioral Health,,2.93,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Optum,VACCN Behavioral Health,,2.93,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Optum,VACCN Behavioral Health,,30.01,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Optum,VACCN Behavioral Health,,173.03,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Optum,VACCN Behavioral Health,,173.03,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Optum,VACCN Behavioral Health,,5.71,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Optum,VACCN Behavioral Health,,5.71,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Optum,VACCN Behavioral Health,,73.20,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Optum,VACCN Behavioral Health,,73.20,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Optum,VACCN Behavioral Health,,6.73,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Optum,VACCN Behavioral Health,,181.22,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Optum,VACCN Behavioral Health,,183.48,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Optum,VACCN Behavioral Health,,183.48,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Optum,VACCN Behavioral Health,,30.01,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Optum,VACCN Behavioral Health,,2608.16,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Optum,VACCN Behavioral Health,,432.02,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Optum,VACCN Behavioral Health,,2.23,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Optum,VACCN Behavioral Health,,258.64,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Optum,VACCN Behavioral Health,,5.19,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Optum,VACCN Behavioral Health,,1.46,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Optum,VACCN Behavioral Health,,1.46,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Optum,VACCN Behavioral Health,,62.23,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Optum,VACCN Behavioral Health,,17.02,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Optum,VACCN Behavioral Health,,55.65,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Optum,VACCN Behavioral Health,,28424.06,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Optum,VACCN Behavioral Health,,66.64,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Optum,VACCN Behavioral Health,,91.73,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Optum,VACCN Behavioral Health,,134.19,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Optum,VACCN Behavioral Health,,593.00,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Optum,VACCN Behavioral Health,,748.85,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Optum,VACCN Behavioral Health,,2.85,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Optum,VACCN Behavioral Health,,141.89,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Optum,VACCN Behavioral Health,,7.95,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Optum,VACCN Behavioral Health,,263.15,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Optum,VACCN Behavioral Health,,48.96,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Optum,VACCN Behavioral Health,,176.45,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Optum,VACCN Behavioral Health,,75.86,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Optum,VACCN Behavioral Health,,1730.32,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Optum,VACCN Behavioral Health,,63.06,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Optum,VACCN Behavioral Health,,733.67,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Optum,VACCN Behavioral Health,,42.16,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Optum,VACCN Behavioral Health,,42.16,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Optum,VACCN Behavioral Health,,308.68,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Optum,VACCN Behavioral Health,,74.36,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Optum,VACCN Behavioral Health,,74.36,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Optum,VACCN Behavioral Health,,2.14,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Optum,VACCN Behavioral Health,,21.31,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Optum,VACCN Behavioral Health,,15.61,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Optum,VACCN Behavioral Health,,2.14,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Optum,VACCN Behavioral Health,,7.95,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Optum,VACCN Behavioral Health,,167.31,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN Behavioral Health,,164.25,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Optum,VACCN Behavioral Health,,9.07,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Optum,VACCN Behavioral Health,,32.96,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Optum,VACCN Behavioral Health,,32.96,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Optum,VACCN Behavioral Health,,89.34,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Optum,VACCN Behavioral Health,,60.29,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Optum,VACCN Behavioral Health,,203.58,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Optum,VACCN Behavioral Health,,203.58,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Optum,VACCN Behavioral Health,,203.58,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Optum,VACCN Behavioral Health,,104.73,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Optum,VACCN Behavioral Health,,50.74,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Optum,VACCN Behavioral Health,,49.03,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Optum,VACCN Behavioral Health,,49.03,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Optum,VACCN Behavioral Health,,78.80,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Optum,VACCN Behavioral Health,,78.80,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Optum,VACCN Behavioral Health,,19.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Optum,VACCN Behavioral Health,,0.46000,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Optum,VACCN Behavioral Health,,0.46000,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Optum,VACCN Behavioral Health,,66.00,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Optum,VACCN Behavioral Health,,31.27,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Optum,VACCN Behavioral Health,,13.49,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Optum,VACCN Behavioral Health,,19.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Optum,VACCN Behavioral Health,,112.45,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Optum,VACCN Behavioral Health,,71.32,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Optum,VACCN Behavioral Health,,91.34,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Optum,VACCN Behavioral Health,,1.83,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Optum,VACCN Behavioral Health,,8.73,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Optum,VACCN Behavioral Health,,39.83,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Optum,VACCN Behavioral Health,,141.60,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Optum,VACCN Behavioral Health,,100.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Optum,VACCN Behavioral Health,,59.41,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Optum,VACCN Behavioral Health,,75.03,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Optum,VACCN Behavioral Health,,85.12,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Optum,VACCN Behavioral Health,,85.12,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Optum,VACCN Behavioral Health,,36.69,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Optum,VACCN Behavioral Health,,36.69,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Optum,VACCN Behavioral Health,,256.09,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Optum,VACCN Behavioral Health,,2698.05,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Optum,VACCN Behavioral Health,,2.18,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Optum,VACCN Behavioral Health,,1.64,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Optum,VACCN Behavioral Health,,164.59,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Optum,VACCN Behavioral Health,,8.15,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Optum,VACCN Behavioral Health,,32.96,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Optum,VACCN Behavioral Health,,18.11,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Optum,VACCN Behavioral Health,,7.85,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Optum,VACCN Behavioral Health,,7.85,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Optum,VACCN Behavioral Health,,7.85,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Optum,VACCN Behavioral Health,,7.85,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Optum,VACCN Behavioral Health,,7.85,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Optum,VACCN Behavioral Health,,99.13,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Optum,VACCN Behavioral Health,,248.50,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Optum,VACCN Behavioral Health,,29.29,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Optum,VACCN Behavioral Health,,106.33,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Optum,VACCN Behavioral Health,,131.38,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Optum,VACCN Behavioral Health,,102.10,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Optum,VACCN Behavioral Health,,91.34,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Optum,VACCN Behavioral Health,,61.44,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Optum,VACCN Behavioral Health,,6.83,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Optum,VACCN Behavioral Health,,136.67,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Optum,VACCN Behavioral Health,,27.86,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Optum,VACCN Behavioral Health,,27.86,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Optum,VACCN Behavioral Health,,29.38,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Optum,VACCN Behavioral Health,,29.38,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Optum,VACCN Behavioral Health,,41.98,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Optum,VACCN Behavioral Health,,41.98,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Optum,VACCN Behavioral Health,,129.48,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Optum,VACCN Behavioral Health,,11.01,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Optum,VACCN Behavioral Health,,36.74,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN Behavioral Health,,36.74,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Optum,VACCN Behavioral Health,,29.98,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Optum,VACCN Behavioral Health,,25.77,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Optum,VACCN Behavioral Health,,25.77,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Optum,VACCN Behavioral Health,,27.85,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Optum,VACCN Behavioral Health,,27.85,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Optum,VACCN Behavioral Health,,359.19,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Optum,VACCN Behavioral Health,,27.99,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Optum,VACCN Behavioral Health,,19.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Optum,VACCN Behavioral Health,,81.90,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Optum,VACCN Behavioral Health,,81.90,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Optum,VACCN Behavioral Health,,36.28,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Optum,VACCN Behavioral Health,,318.53,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Optum,VACCN Behavioral Health,,20.41,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Optum,VACCN Behavioral Health,,62.10,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Optum,VACCN Behavioral Health,,62.10,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Optum,VACCN Behavioral Health,,14.31,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Optum,VACCN Behavioral Health,,136.67,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Optum,VACCN Behavioral Health,,225.11,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Optum,VACCN Behavioral Health,,225.11,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Optum,VACCN Behavioral Health,,7.85,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Optum,VACCN Behavioral Health,,5.46,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Optum,VACCN Behavioral Health,,27.99,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Optum,VACCN Behavioral Health,,2116.32,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Optum,VACCN Behavioral Health,,216.90,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Optum,VACCN Behavioral Health,,243.71,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Optum,VACCN Behavioral Health,,22.54,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Optum,VACCN Behavioral Health,,188.76,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Optum,VACCN Behavioral Health,,12.32,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Optum,VACCN Behavioral Health,,84.57,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Optum,VACCN Behavioral Health,,0.38000,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Optum,VACCN Behavioral Health,,0.38000,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Optum,VACCN Behavioral Health,,197.83,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Optum,VACCN Behavioral Health,,33.58,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Optum,VACCN Behavioral Health,,33.58,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Optum,VACCN Behavioral Health,,69.49,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Optum,VACCN Behavioral Health,,654.63,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Optum,VACCN Behavioral Health,,654.63,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Optum,VACCN Behavioral Health,,30.56,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Optum,VACCN Behavioral Health,,25.04,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Optum,VACCN Behavioral Health,,25.04,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Optum,VACCN Behavioral Health,,25.04,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Optum,VACCN Behavioral Health,,63342.28,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Optum,VACCN Behavioral Health,,72.62,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Optum,VACCN Behavioral Health,,72.62,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Optum,VACCN Behavioral Health,,195.72,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Optum,VACCN Behavioral Health,,8.73,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Optum,VACCN Behavioral Health,,106.33,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Optum,VACCN Behavioral Health,,1.83,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Optum,VACCN Behavioral Health,,57.03,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Optum,VACCN Behavioral Health,,57.03,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Optum,VACCN Behavioral Health,,75.97,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Optum,VACCN Behavioral Health,,33.43,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Optum,VACCN Behavioral Health,,27.36,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Optum,VACCN Behavioral Health,,51.56,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Optum,VACCN Behavioral Health,,172.22,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Optum,VACCN Behavioral Health,,21.48,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Optum,VACCN Behavioral Health,,75.22,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Optum,VACCN Behavioral Health,,75.22,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Optum,VACCN Behavioral Health,,6.28,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Optum,VACCN Behavioral Health,,31.09,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Optum,VACCN Behavioral Health,,43.19,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Optum,VACCN Behavioral Health,,108.47,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Optum,VACCN Behavioral Health,,108.47,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Optum,VACCN Behavioral Health,,328.34,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Optum,VACCN Behavioral Health,,0.80000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Optum,VACCN Behavioral Health,,8.15,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Optum,VACCN Behavioral Health,,1828.72,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Optum,VACCN Behavioral Health,,1.70,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Optum,VACCN Behavioral Health,,94.45,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Optum,VACCN Behavioral Health,,5168.23,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Optum,VACCN Behavioral Health,,7.34,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Optum,VACCN Behavioral Health,,89.34,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Optum,VACCN Behavioral Health,,6.50,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Optum,VACCN Behavioral Health,,176.45,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Optum,VACCN Behavioral Health,,54.71,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Optum,VACCN Behavioral Health,,54.71,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Optum,VACCN Behavioral Health,,54.71,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Optum,VACCN Behavioral Health,,54.71,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Optum,VACCN Behavioral Health,,377.52,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Optum,VACCN Behavioral Health,,0.46000,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Optum,VACCN Behavioral Health,,44.60,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Optum,VACCN Behavioral Health,,4.36,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN Behavioral Health,,78.37,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Optum,VACCN Behavioral Health,,0.48000,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Optum,VACCN Behavioral Health,,0.48000,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Optum,VACCN Behavioral Health,,1.73,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Optum,VACCN Behavioral Health,,10.54,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Optum,VACCN Behavioral Health,,10.14,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Optum,VACCN Behavioral Health,,10.14,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Optum,VACCN Behavioral Health,,10.14,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,2429.89,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Optum,VACCN Behavioral Health,,20.35,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Optum,VACCN Behavioral Health,,183.48,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Optum,VACCN Behavioral Health,,183.48,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Optum,VACCN Behavioral Health,,68.20,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Optum,VACCN Behavioral Health,,62.23,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Optum,VACCN Behavioral Health,,62.23,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Optum,VACCN Behavioral Health,,5.71,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Optum,VACCN Behavioral Health,,5.71,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,258.64,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN Behavioral Health,,4.23,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Optum,VACCN Behavioral Health,,207.13,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Optum,VACCN Behavioral Health,,279.85,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Optum,VACCN Behavioral Health,,279.85,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Optum,VACCN Behavioral Health,,18.11,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Optum,VACCN Behavioral Health,,172.22,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Optum,VACCN Behavioral Health,,148.99,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Optum,VACCN Behavioral Health,,182.45,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Optum,VACCN Behavioral Health,,0.21000,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,70.75,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Optum,VACCN Behavioral Health,,94.45,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,70.75,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,70.75,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Optum,VACCN Behavioral Health,,131.38,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Optum,VACCN Behavioral Health,,94.45,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,91.34,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Optum,VACCN Behavioral Health,,1730.32,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Optum,VACCN Behavioral Health,,1730.32,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Optum,VACCN Behavioral Health,,36.28,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,85.12,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Optum,VACCN Behavioral Health,,55.65,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Optum,VACCN Behavioral Health,,0.48000,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN Behavioral Health,,4.23,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN Behavioral Health,,4.23,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Optum,VACCN Behavioral Health,,0.37000,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Optum,VACCN Behavioral Health,,6.73,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Optum,VACCN Behavioral Health,,0.80000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Optum,VACCN Behavioral Health,,20.35,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Optum,VACCN Behavioral Health,,94.45,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN Behavioral Health,,2.66,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Optum,VACCN Behavioral Health,,2.14,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,60.29,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Optum,VACCN Behavioral Health,,6.73,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN Behavioral Health,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN Behavioral Health,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN Behavioral Health,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN Behavioral Health,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN Behavioral Health,,164.25,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Optum,VACCN Behavioral Health,,172.22,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Optum,VACCN Behavioral Health,,75.03,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,61.44,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,62.10,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,62.10,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Optum,VACCN Behavioral Health,,4.36,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,60.29,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,60.29,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Optum,VACCN Behavioral Health,,0.80000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Optum,VACCN Behavioral Health,,1.83,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Optum,VACCN Behavioral Health,,236.62,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Optum,VACCN Behavioral Health,,91.34,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Optum,VACCN Behavioral Health,,91.34,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Optum,VACCN Behavioral Health,,55.57,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Optum,VACCN Behavioral Health,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN Behavioral Health,,78.37,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Optum,VACCN Behavioral Health,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN Behavioral Health,,78.37,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Optum,VACCN Behavioral Health,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN Behavioral Health,,78.37,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Optum,VACCN Behavioral Health,,2429.89,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Optum,VACCN Behavioral Health,,0.28000,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN Behavioral Health,,36.74,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN Behavioral Health,,36.74,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN Behavioral Health,,36.74,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Optum,VACCN Behavioral Health,,72.62,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Optum,VACCN Behavioral Health,,95.90,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Optum,VACCN Behavioral Health,,4.42,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Optum,VACCN Behavioral Health,,4.42,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Optum,VACCN Behavioral Health,,4.42,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Optum,VACCN Behavioral Health,,4.42,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Optum,VACCN Behavioral Health,,4.42,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Optum,VACCN Behavioral Health,,4.42,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Optum,VACCN Behavioral Health,,0.37000,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Optum,VACCN Behavioral Health,,68.20,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Optum,VACCN Behavioral Health,,0.12000,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Optum,VACCN Behavioral Health,,0.12000,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Optum,VACCN Behavioral Health,,294.69,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Optum,VACCN Behavioral Health,,1.49,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Optum,VACCN Behavioral Health,,1.49,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Optum,VACCN Behavioral Health,,1.49,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Optum,VACCN Behavioral Health,,2.93,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Optum,VACCN Behavioral Health,,1.61,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Optum,VACCN Behavioral Health,,44.82,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Optum,VACCN Behavioral Health,,26.71,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Optum,VACCN Behavioral Health,,29.84,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Optum,VACCN Behavioral Health,,139.21,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Optum,VACCN Behavioral Health,,4.36,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Optum,VACCN Behavioral Health,,53.08,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Optum,VACCN Behavioral Health,,53.08,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Optum,VACCN Behavioral Health,,94.45,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Optum,VACCN Behavioral Health,,94.45,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Optum,VACCN Behavioral Health,,4.10,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Optum,VACCN Behavioral Health,,0.30000,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN Behavioral Health,,2.66,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN Behavioral Health,,2.66,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN Behavioral Health,,2.66,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Optum,VACCN Behavioral Health,,1.67,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Optum,VACCN Behavioral Health,,1.67,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Optum,VACCN Behavioral Health,,0.37000,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Optum,VACCN Behavioral Health,,484.97,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Optum,VACCN Behavioral Health,,11.01,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Optum,VACCN Behavioral Health,,11.01,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Optum,VACCN Behavioral Health,,23.88,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Optum,VACCN Behavioral Health,,23.88,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Optum,VACCN Behavioral Health,,23.88,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Optum,VACCN Behavioral Health,,2.85,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Optum,VACCN Behavioral Health,,51.05,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Optum,VACCN Behavioral Health,,6.50,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Optum,VACCN Behavioral Health,,10.68,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Optum,VACCN Behavioral Health,,4.45,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Optum,VACCN Behavioral Health,,3.52,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Optum,VACCN Behavioral Health,,3.52,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Optum,VACCN Behavioral Health,,1.70,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Optum,VACCN Behavioral Health,,0.32000,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Optum,VACCN Behavioral Health,,8.75,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Optum,VACCN Behavioral Health,,392.06,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Optum,VACCN Behavioral Health,,508.96,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Optum,VACCN Behavioral Health,,608.10,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN Behavioral Health,,339.60,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Optum,VACCN Behavioral Health,,34.82,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Optum,VACCN Behavioral Health,,34.82,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Optum,VACCN Behavioral Health,,36.74,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Optum,VACCN Behavioral Health,,127.85,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Optum,VACCN Behavioral Health,,208.97,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN Behavioral Health,,45.76,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Optum,VACCN Behavioral Health,,208.97,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN Behavioral Health,,45.76,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN Behavioral Health,,70.59,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN Behavioral Health,,208.97,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Optum,VACCN Behavioral Health,,208.97,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Optum,VACCN Behavioral Health,,45.76,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Optum,VACCN Behavioral Health,,328.98,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Optum,VACCN Behavioral Health,,9.09,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Optum,VACCN Behavioral Health,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN Behavioral Health,,70.59,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN Behavioral Health,,70.59,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Optum,VACCN Behavioral Health,,70.59,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Optum,VACCN Behavioral Health,,208.97,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN Behavioral Health,,328.98,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Optum,VACCN Behavioral Health,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Optum,VACCN Behavioral Health,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Optum,VACCN Behavioral Health,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Optum,VACCN Behavioral Health,,363.08,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Optum,VACCN Behavioral Health,,363.08,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Optum,VACCN Behavioral Health,,131.69,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Optum,VACCN Behavioral Health,,363.08,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Optum,VACCN Behavioral Health,,131.69,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Optum,VACCN Behavioral Health,,1741.58,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Optum,VACCN Behavioral Health,,1741.58,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Optum,VACCN Behavioral Health,,573.75,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Optum,VACCN Behavioral Health,,573.75,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Optum,VACCN Behavioral Health,,573.75,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Optum,VACCN Behavioral Health,,688.15,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Optum,VACCN Behavioral Health,,108.61,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Optum,VACCN Behavioral Health,,328.98,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Optum,VACCN Behavioral Health,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Optum,VACCN Behavioral Health,,328.98,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Optum,VACCN Behavioral Health,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Optum,VACCN Behavioral Health,,328.98,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Optum,VACCN Behavioral Health,,45.76,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Optum,VACCN Behavioral Health,,328.98,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Optum,VACCN Behavioral Health,,208.97,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Optum,VACCN Behavioral Health,,208.97,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Optum,VACCN Behavioral Health,,328.98,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Optum,VACCN Behavioral Health,,108.61,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Optum,VACCN Behavioral Health,,260.83,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Optum,VACCN Behavioral Health,,260.83,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Optum,VACCN Behavioral Health,,260.83,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Optum,VACCN Behavioral Health,,573.75,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Optum,VACCN Behavioral Health,,573.75,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Optum,VACCN Behavioral Health,,573.75,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Optum,VACCN Behavioral Health,,328.98,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Optum,VACCN Behavioral Health,,7582.11,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Optum,VACCN Behavioral Health,,7582.11,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Optum,VACCN Behavioral Health,,688.15,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Optum,VACCN Behavioral Health,,688.15,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Optum,VACCN Behavioral Health,,688.15,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Optum,VACCN Behavioral Health,,328.98,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Optum,VACCN Behavioral Health,,131.69,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Optum,VACCN Behavioral Health,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Optum,VACCN Behavioral Health,,363.08,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Optum,VACCN Behavioral Health,,363.08,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Optum,VACCN Behavioral Health,,573.75,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN Behavioral Health,,1625.90,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Optum,VACCN Behavioral Health,,199.53,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Optum,VACCN Behavioral Health,,3153.59,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Optum,VACCN Behavioral Health,,201.73,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Optum,VACCN Behavioral Health,,230.33,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Optum,VACCN Behavioral Health,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Optum,VACCN Behavioral Health,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Optum,VACCN Behavioral Health,,4896.17,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Optum,VACCN Behavioral Health,,301.71,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Optum,VACCN Behavioral Health,,433.61,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Optum,VACCN Behavioral Health,,230.33,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,127.85,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,127.85,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Optum,VACCN Behavioral Health,,201.73,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN Behavioral Health,,127.85,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN Behavioral Health,,127.85,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Optum,VACCN Behavioral Health,,24.29,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN Behavioral Health,,24.29,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Optum,VACCN Behavioral Health,,38.93,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Optum,VACCN Behavioral Health,,127.85,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN Behavioral Health,,201.73,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN Behavioral Health,,201.73,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,201.73,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN Behavioral Health,,201.73,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Optum,VACCN Behavioral Health,,36.99,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN Behavioral Health,,36.99,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Optum,VACCN Behavioral Health,,155.18,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Optum,VACCN Behavioral Health,,526.27,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Optum,VACCN Behavioral Health,,308.86,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN Behavioral Health,,155.18,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Optum,VACCN Behavioral Health,,58.92,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Optum,VACCN Behavioral Health,,127.85,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Optum,VACCN Behavioral Health,,127.85,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN Behavioral Health,,127.85,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN Behavioral Health,,127.85,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Optum,VACCN Behavioral Health,,155.18,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Optum,VACCN Behavioral Health,,58.92,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Optum,VACCN Behavioral Health,,155.18,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Optum,VACCN Behavioral Health,,155.18,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN Behavioral Health,,155.18,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Optum,VACCN Behavioral Health,,433.61,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Optum,VACCN Behavioral Health,,308.86,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Optum,VACCN Behavioral Health,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN Behavioral Health,,1625.90,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Optum,VACCN Behavioral Health,,694.01,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Optum,VACCN Behavioral Health,,422.35,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Optum,VACCN Behavioral Health,,526.27,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Optum,VACCN Behavioral Health,,395.78,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Optum,VACCN Behavioral Health,,155.18,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Optum,VACCN Behavioral Health,,308.86,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Optum,VACCN Behavioral Health,,127.85,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Optum,VACCN Behavioral Health,,308.86,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Optum,VACCN Behavioral Health,,308.86,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Optum,VACCN Behavioral Health,,526.27,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Optum,VACCN Behavioral Health,,308.86,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Optum,VACCN Behavioral Health,,58.92,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Optum,VACCN Behavioral Health,,155.18,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Optum,VACCN Behavioral Health,,127.85,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Optum,VACCN Behavioral Health,,127.85,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Optum,VACCN Behavioral Health,,155.18,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN Behavioral Health,,127.85,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Optum,VACCN Behavioral Health,,308.86,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Optum,VACCN Behavioral Health,,127.85,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN Behavioral Health,,155.18,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Optum,VACCN Behavioral Health,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Optum,VACCN Behavioral Health,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Optum,VACCN Behavioral Health,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Optum,VACCN Behavioral Health,,155.18,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Optum,VACCN Behavioral Health,,127.85,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Optum,VACCN Behavioral Health,,127.85,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Optum,VACCN Behavioral Health,,526.27,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Optum,VACCN Behavioral Health,,308.86,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Optum,VACCN Behavioral Health,,526.27,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Optum,VACCN Behavioral Health,,308.86,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Optum,VACCN Behavioral Health,,526.27,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Optum,VACCN Behavioral Health,,155.18,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Optum,VACCN Behavioral Health,,308.86,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Optum,VACCN Behavioral Health,,308.86,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Optum,VACCN Behavioral Health,,526.27,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN Behavioral Health,,29.55,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Optum,VACCN Behavioral Health,,45.76,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Optum,VACCN Behavioral Health,,41.18,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Optum,VACCN Behavioral Health,,197.08,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Optum,VACCN Behavioral Health,,2838.70,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Optum,VACCN Behavioral Health,,607.14,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Optum,VACCN Behavioral Health,,607.14,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Optum,VACCN Behavioral Health,,197.08,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Optum,VACCN Behavioral Health,,197.08,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Optum,VACCN Behavioral Health,,197.08,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Optum,VACCN Behavioral Health,,396.27,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Optum,VACCN Behavioral Health,,58.92,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN Behavioral Health,,58.92,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN Behavioral Health,,58.92,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Optum,VACCN Behavioral Health,,197.08,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Optum,VACCN Behavioral Health,,197.08,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Optum,VACCN Behavioral Health,,197.08,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Optum,VACCN Behavioral Health,,697.85,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Optum,VACCN Behavioral Health,,292.78,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Optum,VACCN Behavioral Health,,292.78,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Optum,VACCN Behavioral Health,,292.78,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Optum,VACCN Behavioral Health,,292.78,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Optum,VACCN Behavioral Health,,292.78,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Optum,VACCN Behavioral Health,,263.41,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Optum,VACCN Behavioral Health,,230.33,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Optum,VACCN Behavioral Health,,396.27,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Optum,VACCN Behavioral Health,,396.27,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Optum,VACCN Behavioral Health,,396.27,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Optum,VACCN Behavioral Health,,127.85,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Optum,VACCN Behavioral Health,,328.98,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Optum,VACCN Behavioral Health,,328.98,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Optum,VACCN Behavioral Health,,686.87,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Optum,VACCN Behavioral Health,,297.46,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN Behavioral Health,,297.46,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Optum,VACCN Behavioral Health,,6509.35,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Optum,VACCN Behavioral Health,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Optum,VACCN Behavioral Health,,292.78,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Optum,VACCN Behavioral Health,,6509.35,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN Behavioral Health,,292.78,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN Behavioral Health,,292.78,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Optum,VACCN Behavioral Health,,883.03,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Optum,VACCN Behavioral Health,,883.03,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Optum,VACCN Behavioral Health,,883.03,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Optum,VACCN Behavioral Health,,197.08,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Optum,VACCN Behavioral Health,,197.08,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,197.08,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,197.08,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Optum,VACCN Behavioral Health,,697.85,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Optum,VACCN Behavioral Health,,883.03,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Optum,VACCN Behavioral Health,,686.87,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Optum,VACCN Behavioral Health,,883.03,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Optum,VACCN Behavioral Health,,396.27,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Optum,VACCN Behavioral Health,,883.03,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Optum,VACCN Behavioral Health,,883.03,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Optum,VACCN Behavioral Health,,883.03,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Optum,VACCN Behavioral Health,,883.03,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Optum,VACCN Behavioral Health,,883.03,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Optum,VACCN Behavioral Health,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Optum,VACCN Behavioral Health,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Optum,VACCN Behavioral Health,,686.87,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Optum,VACCN Behavioral Health,,883.03,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Optum,VACCN Behavioral Health,,686.87,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Optum,VACCN Behavioral Health,,883.03,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Optum,VACCN Behavioral Health,,686.87,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Optum,VACCN Behavioral Health,,197.08,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,197.08,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Optum,VACCN Behavioral Health,,328.98,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Optum,VACCN Behavioral Health,,136.77,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Optum,VACCN Behavioral Health,,127.85,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Optum,VACCN Behavioral Health,,396.27,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Optum,VACCN Behavioral Health,,192.56,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Optum,VACCN Behavioral Health,,157.07,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Optum,VACCN Behavioral Health,,274.63,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Optum,VACCN Behavioral Health,,422.35,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Optum,VACCN Behavioral Health,,608.10,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Optum,VACCN Behavioral Health,,835.73,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN Behavioral Health,,127.85,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN Behavioral Health,,127.85,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Optum,VACCN Behavioral Health,,58.92,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN Behavioral Health,,38.93,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN Behavioral Health,,38.93,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN Behavioral Health,,38.93,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN Behavioral Health,,38.93,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Optum,VACCN Behavioral Health,,197.08,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Optum,VACCN Behavioral Health,,1169.46,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Optum,VACCN Behavioral Health,,396.27,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Optum,VACCN Behavioral Health,,51.09,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Optum,VACCN Behavioral Health,,197.08,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Optum,VACCN Behavioral Health,,156.50,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Optum,VACCN Behavioral Health,,156.50,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN Behavioral Health,,156.50,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Optum,VACCN Behavioral Health,,3153.59,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN Behavioral Health,,297.46,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Optum,VACCN Behavioral Health,,607.14,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN Behavioral Health,,156.50,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Optum,VACCN Behavioral Health,,197.08,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Optum,VACCN Behavioral Health,,197.08,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Optum,VACCN Behavioral Health,,396.27,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Optum,VACCN Behavioral Health,,2838.70,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN Behavioral Health,,38.93,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN Behavioral Health,,197.08,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN Behavioral Health,,396.27,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN Behavioral Health,,607.14,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN Behavioral Health,,396.27,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN Behavioral Health,,127.85,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Optum,VACCN Behavioral Health,,91.04,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Optum,VACCN Behavioral Health,,91.04,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Optum,VACCN Behavioral Health,,36.99,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Optum,VACCN Behavioral Health,,36.99,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Optum,VACCN Behavioral Health,,36.99,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Optum,VACCN Behavioral Health,,36.99,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Optum,VACCN Behavioral Health,,36.99,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN Behavioral Health,,24.29,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Optum,VACCN Behavioral Health,,197.08,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN Behavioral Health,,396.27,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN Behavioral Health,,58.92,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN Behavioral Health,,396.27,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Optum,VACCN Behavioral Health,,17342.42,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Optum,VACCN Behavioral Health,,7085.44,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Optum,VACCN Behavioral Health,,127.85,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Optum,VACCN Behavioral Health,,127.85,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Optum,VACCN Behavioral Health,,929.91,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN Behavioral Health,,241.23,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN Behavioral Health,,433.61,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Optum,VACCN Behavioral Health,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN Behavioral Health,,1625.90,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Optum,VACCN Behavioral Health,,697.85,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Optum,VACCN Behavioral Health,,613.21,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Optum,VACCN Behavioral Health,,697.85,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Optum,VACCN Behavioral Health,,697.85,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Optum,VACCN Behavioral Health,,697.85,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Optum,VACCN Behavioral Health,,58.92,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN Behavioral Health,,70.59,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Optum,VACCN Behavioral Health,,526.27,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Optum,VACCN Behavioral Health,,526.27,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Optum,VACCN Behavioral Health,,526.27,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Optum,VACCN Behavioral Health,,308.86,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Optum,VACCN Behavioral Health,,155.18,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Optum,VACCN Behavioral Health,,929.91,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Optum,VACCN Behavioral Health,,929.91,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Optum,VACCN Behavioral Health,,929.91,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Optum,VACCN Behavioral Health,,308.86,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Optum,VACCN Behavioral Health,,526.27,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Optum,VACCN Behavioral Health,,526.27,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Optum,VACCN Behavioral Health,,2313.92,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Optum,VACCN Behavioral Health,,308.86,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Optum,VACCN Behavioral Health,,308.86,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Optum,VACCN Behavioral Health,,155.18,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Optum,VACCN Behavioral Health,,308.86,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Optum,VACCN Behavioral Health,,239.75,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Optum,VACCN Behavioral Health,,783.61,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Optum,VACCN Behavioral Health,,783.61,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Optum,VACCN Behavioral Health,,783.61,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Optum,VACCN Behavioral Health,,783.61,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Optum,VACCN Behavioral Health,,354.22,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Optum,VACCN Behavioral Health,,543.83,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Optum,VACCN Behavioral Health,,543.83,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Optum,VACCN Behavioral Health,,543.83,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Optum,VACCN Behavioral Health,,354.22,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Optum,VACCN Behavioral Health,,543.83,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Optum,VACCN Behavioral Health,,543.83,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Optum,VACCN Behavioral Health,,176.57,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Optum,VACCN Behavioral Health,,176.57,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Optum,VACCN Behavioral Health,,17342.42,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Optum,VACCN Behavioral Health,,783.61,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Optum,VACCN Behavioral Health,,328.98,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Optum,VACCN Behavioral Health,,398.55,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Optum,VACCN Behavioral Health,,533.88,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Optum,VACCN Behavioral Health,,398.55,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Optum,VACCN Behavioral Health,,533.88,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Optum,VACCN Behavioral Health,,533.88,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN Behavioral Health,,533.88,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,23.13,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Optum,VACCN Behavioral Health,,715.29,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Optum,VACCN Behavioral Health,,1914.61,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Optum,VACCN Behavioral Health,,2074.81,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Optum,VACCN Behavioral Health,,222.30,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Optum,VACCN Behavioral Health,,222.30,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Optum,VACCN Behavioral Health,,222.30,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Optum,VACCN Behavioral Health,,222.30,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Optum,VACCN Behavioral Health,,4314.91,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Optum,VACCN Behavioral Health,,56824.55,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Optum,VACCN Behavioral Health,,1031.39,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Optum,VACCN Behavioral Health,,2194.62,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Optum,VACCN Behavioral Health,,172.22,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Optum,VACCN Behavioral Health,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Optum,VACCN Behavioral Health,,268.42,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Optum,VACCN Behavioral Health,,498.67,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Optum,VACCN Behavioral Health,,595.10,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Optum,VACCN Behavioral Health,,332.44,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Optum,VACCN Behavioral Health,,381.01,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Optum,VACCN Behavioral Health,,671.22,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Optum,VACCN Behavioral Health,,87.33,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Optum,VACCN Behavioral Health,,87.33,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Optum,VACCN Behavioral Health,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Optum,VACCN Behavioral Health,,942.74,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN Behavioral Health,,1881.51,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Optum,VACCN Behavioral Health,,1881.51,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN Behavioral Health,,6188.83,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Optum,VACCN Behavioral Health,,863.63,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Optum,VACCN Behavioral Health,,396.27,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Optum,VACCN Behavioral Health,,396.27,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Optum,VACCN Behavioral Health,,613.21,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Optum,VACCN Behavioral Health,,5786.75,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN Behavioral Health,,6188.83,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Optum,VACCN Behavioral Health,,1881.51,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Optum,VACCN Behavioral Health,,929.91,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Optum,VACCN Behavioral Health,,1469.19,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Optum,VACCN Behavioral Health,,292.78,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Optum,VACCN Behavioral Health,,292.78,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Optum,VACCN Behavioral Health,,12761.83,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Optum,VACCN Behavioral Health,,237.92,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Optum,VACCN Behavioral Health,,3218.13,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Optum,VACCN Behavioral Health,,3218.13,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Optum,VACCN Behavioral Health,,613.21,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Optum,VACCN Behavioral Health,,613.21,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Optum,VACCN Behavioral Health,,613.21,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Optum,VACCN Behavioral Health,,613.21,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Optum,VACCN Behavioral Health,,208.97,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Optum,VACCN Behavioral Health,,208.97,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Optum,VACCN Behavioral Health,,613.21,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Optum,VACCN Behavioral Health,,398.55,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN Behavioral Health,,433.61,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Optum,VACCN Behavioral Health,,395.78,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Optum,VACCN Behavioral Health,,929.91,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Optum,VACCN Behavioral Health,,10326.26,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Optum,VACCN Behavioral Health,,10326.26,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Optum,VACCN Behavioral Health,,929.91,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Optum,VACCN Behavioral Health,,929.91,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Optum,VACCN Behavioral Health,,1357.09,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Optum,VACCN Behavioral Health,,1881.51,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Optum,VACCN Behavioral Health,,1881.51,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Optum,VACCN Behavioral Health,,1881.51,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Optum,VACCN Behavioral Health,,929.91,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Optum,VACCN Behavioral Health,,929.91,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Optum,VACCN Behavioral Health,,929.91,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Optum,VACCN Behavioral Health,,929.91,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN Behavioral Health,,662.02,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Optum,VACCN Behavioral Health,,697.85,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Optum,VACCN Behavioral Health,,5786.75,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Optum,VACCN Behavioral Health,,10326.26,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Optum,VACCN Behavioral Health,,127.85,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Optum,VACCN Behavioral Health,,241.23,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN Behavioral Health,,199.53,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Optum,VACCN Behavioral Health,,697.85,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Optum,VACCN Behavioral Health,,697.85,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Optum,VACCN Behavioral Health,,697.85,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Optum,VACCN Behavioral Health,,883.03,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Optum,VACCN Behavioral Health,,883.03,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Optum,VACCN Behavioral Health,,883.03,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Optum,VACCN Behavioral Health,,883.03,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Optum,VACCN Behavioral Health,,883.03,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Optum,VACCN Behavioral Health,,883.03,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Optum,VACCN Behavioral Health,,1936.84,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Optum,VACCN Behavioral Health,,883.03,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Optum,VACCN Behavioral Health,,1169.46,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Optum,VACCN Behavioral Health,,7085.44,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Optum,VACCN Behavioral Health,,7085.44,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Optum,VACCN Behavioral Health,,697.85,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Optum,VACCN Behavioral Health,,433.61,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Optum,VACCN Behavioral Health,,697.85,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Optum,VACCN Behavioral Health,,10326.26,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Optum,VACCN Behavioral Health,,697.85,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Optum,VACCN Behavioral Health,,697.85,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Optum,VACCN Behavioral Health,,697.85,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Optum,VACCN Behavioral Health,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Optum,VACCN Behavioral Health,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Optum,VACCN Behavioral Health,,3218.13,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Optum,VACCN Behavioral Health,,3218.13,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Optum,VACCN Behavioral Health,,7085.44,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Optum,VACCN Behavioral Health,,7085.44,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Optum,VACCN Behavioral Health,,783.61,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Optum,VACCN Behavioral Health,,783.61,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Optum,VACCN Behavioral Health,,3500.26,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Optum,VACCN Behavioral Health,,929.91,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Optum,VACCN Behavioral Health,,5786.75,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Optum,VACCN Behavioral Health,,5786.75,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Optum,VACCN Behavioral Health,,5786.75,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Optum,VACCN Behavioral Health,,6188.83,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Optum,VACCN Behavioral Health,,662.02,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Optum,VACCN Behavioral Health,,662.02,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Optum,VACCN Behavioral Health,,3420.83,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Optum,VACCN Behavioral Health,,2031.79,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Optum,VACCN Behavioral Health,,3420.83,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Optum,VACCN Behavioral Health,,3420.83,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Optum,VACCN Behavioral Health,,3420.83,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Optum,VACCN Behavioral Health,,697.85,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Optum,VACCN Behavioral Health,,2838.70,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN Behavioral Health,,613.21,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN Behavioral Health,,241.23,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN Behavioral Health,,241.23,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Optum,VACCN Behavioral Health,,3420.83,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Optum,VACCN Behavioral Health,,3420.83,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Optum,VACCN Behavioral Health,,1607.02,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Optum,VACCN Behavioral Health,,6351.81,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN Behavioral Health,,613.21,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Optum,VACCN Behavioral Health,,1009.09,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Optum,VACCN Behavioral Health,,783.61,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Optum,VACCN Behavioral Health,,105.47,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Optum,VACCN Behavioral Health,,87.33,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Optum,VACCN Behavioral Health,,105.47,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Optum,VACCN Behavioral Health,,1294.83,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Optum,VACCN Behavioral Health,,398.55,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Optum,VACCN Behavioral Health,,1446.69,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Optum,VACCN Behavioral Health,,2232.14,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Optum,VACCN Behavioral Health,,1934.58,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Optum,VACCN Behavioral Health,,543.83,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Optum,VACCN Behavioral Health,,543.83,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Optum,VACCN Behavioral Health,,783.61,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Optum,VACCN Behavioral Health,,783.61,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Optum,VACCN Behavioral Health,,783.61,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Optum,VACCN Behavioral Health,,87.33,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Optum,VACCN Behavioral Health,,354.22,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Optum,VACCN Behavioral Health,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Optum,VACCN Behavioral Health,,87.33,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Optum,VACCN Behavioral Health,,58.92,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Optum,VACCN Behavioral Health,,686.87,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Optum,VACCN Behavioral Health,,686.87,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Optum,VACCN Behavioral Health,,686.87,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN Behavioral Health,,239.75,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Optum,VACCN Behavioral Health,,105.47,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Optum,VACCN Behavioral Health,,105.47,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Optum,VACCN Behavioral Health,,10.56,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Optum,VACCN Behavioral Health,,47.81,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN Behavioral Health,,8.68,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Optum,VACCN Behavioral Health,,47.63,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Optum,VACCN Behavioral Health,,8.17,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN Behavioral Health,,163.96,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN Behavioral Health,,144.84,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Optum,VACCN Behavioral Health,,556.60,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Optum,VACCN Behavioral Health,,291.36,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Optum,VACCN Behavioral Health,,1160.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Optum,VACCN Behavioral Health,,1160.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Optum,VACCN Behavioral Health,,65.69,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Optum,VACCN Behavioral Health,,73.37,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Optum,VACCN Behavioral Health,,57.04,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Optum,VACCN Behavioral Health,,44.89,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Optum,VACCN Behavioral Health,,165.51,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Optum,VACCN Behavioral Health,,101.12,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN Behavioral Health,,35.00,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Optum,VACCN Behavioral Health,,65.36,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Optum,VACCN Behavioral Health,,197.99,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Optum,VACCN Behavioral Health,,172.73,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Optum,VACCN Behavioral Health,,233.07,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Optum,VACCN Behavioral Health,,233.07,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN Behavioral Health,,2.25,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Optum,VACCN Behavioral Health,,348.56,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Optum,VACCN Behavioral Health,,51.07,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Optum,VACCN Behavioral Health,,43.65,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Optum,VACCN Behavioral Health,,201.50,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Optum,VACCN Behavioral Health,,234.00,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Optum,VACCN Behavioral Health,,402.12,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Optum,VACCN Behavioral Health,,403.59,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Optum,VACCN Behavioral Health,,127.43,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Optum,VACCN Behavioral Health,,74.33,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Optum,VACCN Behavioral Health,,94.74,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Optum,VACCN Behavioral Health,,345.57,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Optum,VACCN Behavioral Health,,335.38,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Optum,VACCN Behavioral Health,,177.25,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Optum,VACCN Behavioral Health,,169.90,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Optum,VACCN Behavioral Health,,123.68,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Optum,VACCN Behavioral Health,,246.52,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Optum,VACCN Behavioral Health,,124.64,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Optum,VACCN Behavioral Health,,300.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Optum,VACCN Behavioral Health,,193.25,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Optum,VACCN Behavioral Health,,295.79,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN Behavioral Health,,16.77,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Optum,VACCN Behavioral Health,,5.04,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Optum,VACCN Behavioral Health,,8.74,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Optum,VACCN Behavioral Health,,9.66,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN Behavioral Health,,7.52,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN Behavioral Health,,4.31,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Optum,VACCN Behavioral Health,,62.14,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Optum,VACCN Behavioral Health,,8.46,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Optum,VACCN Behavioral Health,,7.01,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Optum,VACCN Behavioral Health,,13.39,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Optum,VACCN Behavioral Health,,62.14,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Optum,VACCN Behavioral Health,,62.14,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Optum,VACCN Behavioral Health,,62.14,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN Behavioral Health,,62.14,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Optum,VACCN Behavioral Health,,62.14,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN Behavioral Health,,15.08,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN Behavioral Health,,15.08,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,15.08,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,14.57,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,13.28,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,13.54,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN Behavioral Health,,16.38,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN Behavioral Health,,16.38,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN Behavioral Health,,16.38,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN Behavioral Health,,14.69,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.61,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN Behavioral Health,,15.30,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,13.25,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN Behavioral Health,,13.76,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Optum,VACCN Behavioral Health,,13.73,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Optum,VACCN Behavioral Health,,13.73,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN Behavioral Health,,14.14,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN Behavioral Health,,16.13,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN Behavioral Health,,16.13,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN Behavioral Health,,16.13,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN Behavioral Health,,13.54,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN Behavioral Health,,13.54,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN Behavioral Health,,13.54,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Optum,VACCN Behavioral Health,,32.62,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN Behavioral Health,,4.52,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN Behavioral Health,,8.17,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,8.17,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,4.95,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN Behavioral Health,,7.78,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN Behavioral Health,,5.78,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN Behavioral Health,,5.78,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN Behavioral Health,,17.27,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Optum,VACCN Behavioral Health,,13.44,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN Behavioral Health,,16.77,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,14.57,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN Behavioral Health,,6.48,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN Behavioral Health,,6.48,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN Behavioral Health,,6.48,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN Behavioral Health,,16.18,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN Behavioral Health,,5.02,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN Behavioral Health,,5.02,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,5.02,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Optum,VACCN Behavioral Health,,4.38,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN Behavioral Health,,5.32,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN Behavioral Health,,4.23,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Optum,VACCN Behavioral Health,,29.60,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN Behavioral Health,,5.16,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN Behavioral Health,,5.16,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN Behavioral Health,,6.03,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Optum,VACCN Behavioral Health,,4.88,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,12.32,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,12.32,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Optum,VACCN Behavioral Health,,18.96,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN Behavioral Health,,10.74,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,14.12,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,14.12,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,4.60,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,5.75,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,5.75,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Optum,VACCN Behavioral Health,,5.00,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN Behavioral Health,,4.35,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Optum,VACCN Behavioral Health,,38.57,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN Behavioral Health,,27.11,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN Behavioral Health,,27.11,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Optum,VACCN Behavioral Health,,18.64,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN Behavioral Health,,16.30,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Optum,VACCN Behavioral Health,,13.73,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,6.51,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN Behavioral Health,,11.55,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN Behavioral Health,,5.12,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Optum,VACCN Behavioral Health,,27.94,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Optum,VACCN Behavioral Health,,14.90,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN Behavioral Health,,5.10,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Optum,VACCN Behavioral Health,,13.63,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Optum,VACCN Behavioral Health,,64.41,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN Behavioral Health,,14.70,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN Behavioral Health,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN Behavioral Health,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN Behavioral Health,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN Behavioral Health,,9.30,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN Behavioral Health,,11.00,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN Behavioral Health,,26.07,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN Behavioral Health,,78.77,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN Behavioral Health,,78.77,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN Behavioral Health,,78.77,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN Behavioral Health,,78.77,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,9.77,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN Behavioral Health,,3.93,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN Behavioral Health,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN Behavioral Health,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN Behavioral Health,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Optum,VACCN Behavioral Health,,3.93,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Optum,VACCN Behavioral Health,,4.75,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN Behavioral Health,,12.87,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN Behavioral Health,,3.92,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN Behavioral Health,,3.92,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Optum,VACCN Behavioral Health,,7.20,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Optum,VACCN Behavioral Health,,18.58,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN Behavioral Health,,18.52,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN Behavioral Health,,12.58,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Optum,VACCN Behavioral Health,,12.87,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN Behavioral Health,,18.06,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Optum,VACCN Behavioral Health,,8.00,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,9.71,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN Behavioral Health,,8.20,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN Behavioral Health,,8.20,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Optum,VACCN Behavioral Health,,4.75,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Optum,VACCN Behavioral Health,,17.92,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN Behavioral Health,,25.45,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN Behavioral Health,,11.53,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN Behavioral Health,,11.53,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN Behavioral Health,,11.43,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.47,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,11.57,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN Behavioral Health,,6.04,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN Behavioral Health,,6.04,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,19.70,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN Behavioral Health,,19.32,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Optum,VACCN Behavioral Health,,6.89,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Optum,VACCN Behavioral Health,,6.89,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Optum,VACCN Behavioral Health,,8.19,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN Behavioral Health,,10.50,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,6.70,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,6.70,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN Behavioral Health,,6.70,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN Behavioral Health,,12.92,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN Behavioral Health,,39.26,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN Behavioral Health,,17.27,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,17.27,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Optum,VACCN Behavioral Health,,6.61,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,6.82,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN Behavioral Health,,41.28,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Optum,VACCN Behavioral Health,,41.28,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN Behavioral Health,,3.58,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN Behavioral Health,,3.58,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN Behavioral Health,,3.58,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,4.74,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Optum,VACCN Behavioral Health,,5.78,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Optum,VACCN Behavioral Health,,5.78,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Optum,VACCN Behavioral Health,,98.11,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Optum,VACCN Behavioral Health,,4.76,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,4.73,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,4.73,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,4.73,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,14.59,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Optum,VACCN Behavioral Health,,20.86,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Optum,VACCN Behavioral Health,,19.38,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Optum,VACCN Behavioral Health,,18.39,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Optum,VACCN Behavioral Health,,18.39,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN Behavioral Health,,3.67,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,3.67,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,3.67,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Optum,VACCN Behavioral Health,,4.00,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN Behavioral Health,,10.74,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN Behavioral Health,,17.83,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN Behavioral Health,,17.83,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN Behavioral Health,,4.81,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN Behavioral Health,,5.06,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN Behavioral Health,,5.06,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN Behavioral Health,,4.86,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN Behavioral Health,,3.28,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Optum,VACCN Behavioral Health,,25.81,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN Behavioral Health,,6.87,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Optum,VACCN Behavioral Health,,9.02,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Optum,VACCN Behavioral Health,,16.80,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN Behavioral Health,,5.30,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN Behavioral Health,,12.76,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN Behavioral Health,,5.74,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Optum,VACCN Behavioral Health,,14.18,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Optum,VACCN Behavioral Health,,16.94,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Optum,VACCN Behavioral Health,,12.47,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,3.95,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN Behavioral Health,,5.56,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,4.52,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN Behavioral Health,,5.08,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN Behavioral Health,,5.08,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Optum,VACCN Behavioral Health,,62.14,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Optum,VACCN Behavioral Health,,62.14,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,15.05,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN Behavioral Health,,7.87,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Optum,VACCN Behavioral Health,,5.22,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Optum,VACCN Behavioral Health,,15.05,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Optum,VACCN Behavioral Health,,15.05,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Optum,VACCN Behavioral Health,,18.37,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN Behavioral Health,,11.16,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN Behavioral Health,,12.95,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Optum,VACCN Behavioral Health,,25.45,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,25.45,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,25.45,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Optum,VACCN Behavioral Health,,12.00,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN Behavioral Health,,13.74,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Optum,VACCN Behavioral Health,,13.74,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Optum,VACCN Behavioral Health,,17.93,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Optum,VACCN Behavioral Health,,17.93,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Optum,VACCN Behavioral Health,,12.05,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN Behavioral Health,,12.05,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Optum,VACCN Behavioral Health,,20.81,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Optum,VACCN Behavioral Health,,20.81,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Optum,VACCN Behavioral Health,,29.92,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Optum,VACCN Behavioral Health,,22.34,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN Behavioral Health,,29.35,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Optum,VACCN Behavioral Health,,37.73,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN Behavioral Health,,26.78,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,26.78,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,356.78,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Optum,VACCN Behavioral Health,,37.73,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Optum,VACCN Behavioral Health,,37.73,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Optum,VACCN Behavioral Health,,46.98,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Optum,VACCN Behavioral Health,,77.78,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN Behavioral Health,,14.55,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN Behavioral Health,,11.54,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN Behavioral Health,,11.54,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN Behavioral Health,,10.64,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Optum,VACCN Behavioral Health,,5.67,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Optum,VACCN Behavioral Health,,61.98,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Optum,VACCN Behavioral Health,,24.29,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN Behavioral Health,,4.40,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN Behavioral Health,,4.40,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Optum,VACCN Behavioral Health,,17.03,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN Behavioral Health,,14.39,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Optum,VACCN Behavioral Health,,16.85,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Optum,VACCN Behavioral Health,,15.29,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN Behavioral Health,,18.14,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN Behavioral Health,,18.14,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,10.18,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN Behavioral Health,,10.18,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN Behavioral Health,,16.85,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN Behavioral Health,,16.85,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN Behavioral Health,,9.09,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN Behavioral Health,,13.19,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Optum,VACCN Behavioral Health,,19.35,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Optum,VACCN Behavioral Health,,8.89,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN Behavioral Health,,13.71,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN Behavioral Health,,11.77,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN Behavioral Health,,10.74,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,12.39,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Optum,VACCN Behavioral Health,,11.26,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Optum,VACCN Behavioral Health,,12.39,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Optum,VACCN Behavioral Health,,19.35,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,19.35,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN Behavioral Health,,12.88,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Optum,VACCN Behavioral Health,,14.39,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Optum,VACCN Behavioral Health,,14.41,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,13.24,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN Behavioral Health,,12.88,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,14.27,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Optum,VACCN Behavioral Health,,109.49,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Optum,VACCN Behavioral Health,,64.19,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Optum,VACCN Behavioral Health,,64.19,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Optum,VACCN Behavioral Health,,323.75,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Optum,VACCN Behavioral Health,,325.80,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN Behavioral Health,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Optum,VACCN Behavioral Health,,169.96,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Optum,VACCN Behavioral Health,,356.78,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN Behavioral Health,,5.39,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN Behavioral Health,,5.39,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN Behavioral Health,,5.39,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN Behavioral Health,,2.99,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,2.99,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Optum,VACCN Behavioral Health,,6.35,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Optum,VACCN Behavioral Health,,6.35,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Optum,VACCN Behavioral Health,,3.83,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Optum,VACCN Behavioral Health,,169.96,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,169.96,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Optum,VACCN Behavioral Health,,58.92,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Optum,VACCN Behavioral Health,,58.92,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Optum,VACCN Behavioral Health,,24.29,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Optum,VACCN Behavioral Health,,13.91,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN Behavioral Health,,3.80,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,2.37,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,2.37,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN Behavioral Health,,7.77,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,6.47,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,3.99,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN Behavioral Health,,5.57,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN Behavioral Health,,2.54,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,4.48,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Optum,VACCN Behavioral Health,,810.23,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Optum,VACCN Behavioral Health,,810.23,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Optum,VACCN Behavioral Health,,12.98,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN Behavioral Health,,17.65,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Optum,VACCN Behavioral Health,,17.90,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Optum,VACCN Behavioral Health,,17.90,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Optum,VACCN Behavioral Health,,11.89,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Optum,VACCN Behavioral Health,,22.94,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,22.94,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Optum,VACCN Behavioral Health,,22.94,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Optum,VACCN Behavioral Health,,30.86,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Optum,VACCN Behavioral Health,,22.94,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Optum,VACCN Behavioral Health,,19.04,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Optum,VACCN Behavioral Health,,17.90,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Optum,VACCN Behavioral Health,,17.90,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Optum,VACCN Behavioral Health,,19.35,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Optum,VACCN Behavioral Health,,9.11,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Optum,VACCN Behavioral Health,,18.93,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Optum,VACCN Behavioral Health,,18.93,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Optum,VACCN Behavioral Health,,11.85,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN Behavioral Health,,13.84,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Optum,VACCN Behavioral Health,,15.32,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN Behavioral Health,,30.86,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Optum,VACCN Behavioral Health,,15.32,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Optum,VACCN Behavioral Health,,12.87,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Optum,VACCN Behavioral Health,,12.87,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN Behavioral Health,,12.87,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN Behavioral Health,,4.28,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN Behavioral Health,,6.89,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN Behavioral Health,,10.18,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN Behavioral Health,,9.72,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Optum,VACCN Behavioral Health,,17.19,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,9.36,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Optum,VACCN Behavioral Health,,13.09,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN Behavioral Health,,13.09,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Optum,VACCN Behavioral Health,,24.91,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN Behavioral Health,,24.91,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN Behavioral Health,,17.98,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN Behavioral Health,,17.98,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN Behavioral Health,,4.29,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Optum,VACCN Behavioral Health,,3.94,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN Behavioral Health,,9.58,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN Behavioral Health,,9.58,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Optum,VACCN Behavioral Health,,17.98,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN Behavioral Health,,9.85,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Optum,VACCN Behavioral Health,,18.64,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,5.51,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN Behavioral Health,,5.77,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Optum,VACCN Behavioral Health,,5.77,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,6.01,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,6.01,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN Behavioral Health,,6.47,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN Behavioral Health,,6.47,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Optum,VACCN Behavioral Health,,11.67,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,6.68,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN Behavioral Health,,10.32,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN Behavioral Health,,10.32,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Optum,VACCN Behavioral Health,,9.44,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,9.44,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Optum,VACCN Behavioral Health,,9.44,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Optum,VACCN Behavioral Health,,8.62,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Optum,VACCN Behavioral Health,,9.89,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Optum,VACCN Behavioral Health,,9.47,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Optum,VACCN Behavioral Health,,9.47,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Optum,VACCN Behavioral Health,,9.47,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Optum,VACCN Behavioral Health,,8.08,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Optum,VACCN Behavioral Health,,8.08,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN Behavioral Health,,8.08,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,8.08,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Optum,VACCN Behavioral Health,,6.63,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN Behavioral Health,,8.07,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Optum,VACCN Behavioral Health,,7.71,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.41,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN Behavioral Health,,10.32,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,10.32,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN Behavioral Health,,115.36,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Optum,VACCN Behavioral Health,,4.31,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,5.88,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN Behavioral Health,,8.90,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN Behavioral Health,,4.75,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN Behavioral Health,,7.48,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Optum,VACCN Behavioral Health,,4.75,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN Behavioral Health,,8.65,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN Behavioral Health,,8.65,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN Behavioral Health,,8.65,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN Behavioral Health,,8.65,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Optum,VACCN Behavioral Health,,8.65,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,5.39,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Optum,VACCN Behavioral Health,,5.39,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,5.39,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Optum,VACCN Behavioral Health,,5.99,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN Behavioral Health,,17.98,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Optum,VACCN Behavioral Health,,5.82,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,5.82,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN Behavioral Health,,11.98,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Optum,VACCN Behavioral Health,,11.98,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,11.98,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Optum,VACCN Behavioral Health,,11.98,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN Behavioral Health,,13.82,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN Behavioral Health,,10.33,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN Behavioral Health,,10.33,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,24.08,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN Behavioral Health,,24.08,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Optum,VACCN Behavioral Health,,11.98,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Optum,VACCN Behavioral Health,,11.98,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN Behavioral Health,,11.98,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Optum,VACCN Behavioral Health,,37.27,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Optum,VACCN Behavioral Health,,42.84,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN Behavioral Health,,42.84,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Optum,VACCN Behavioral Health,,42.84,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Optum,VACCN Behavioral Health,,35.09,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Optum,VACCN Behavioral Health,,85.10,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Optum,VACCN Behavioral Health,,35.09,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Optum,VACCN Behavioral Health,,35.09,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN Behavioral Health,,95.80,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Optum,VACCN Behavioral Health,,142.63,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Optum,VACCN Behavioral Health,,416.78,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Optum,VACCN Behavioral Health,,35.09,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Optum,VACCN Behavioral Health,,35.09,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Optum,VACCN Behavioral Health,,35.09,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,35.09,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Optum,VACCN Behavioral Health,,35.09,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Optum,VACCN Behavioral Health,,42.84,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Optum,VACCN Behavioral Health,,262.99,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Optum,VACCN Behavioral Health,,15.29,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Optum,VACCN Behavioral Health,,16.53,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Optum,VACCN Behavioral Health,,16.07,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Optum,VACCN Behavioral Health,,16.07,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Optum,VACCN Behavioral Health,,16.07,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN Behavioral Health,,257.45,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Optum,VACCN Behavioral Health,,257.45,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Optum,VACCN Behavioral Health,,3.17,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Optum,VACCN Behavioral Health,,3.17,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,3.48,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,3.48,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN Behavioral Health,,3.48,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Optum,VACCN Behavioral Health,,8.61,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Optum,VACCN Behavioral Health,,169.96,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN Behavioral Health,,5.60,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,7.33,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN Behavioral Health,,5.79,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Optum,VACCN Behavioral Health,,91.66,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Optum,VACCN Behavioral Health,,18.05,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Optum,VACCN Behavioral Health,,24.18,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN Behavioral Health,,12.39,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Optum,VACCN Behavioral Health,,4.72,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Optum,VACCN Behavioral Health,,13.25,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,16.46,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN Behavioral Health,,11.53,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Optum,VACCN Behavioral Health,,5.22,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Optum,VACCN Behavioral Health,,17.93,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Optum,VACCN Behavioral Health,,4.27,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN Behavioral Health,,13.05,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN Behavioral Health,,12.88,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Optum,VACCN Behavioral Health,,5.18,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN Behavioral Health,,14.38,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Optum,VACCN Behavioral Health,,8.08,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN Behavioral Health,,8.08,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN Behavioral Health,,13.61,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Optum,VACCN Behavioral Health,,8.61,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN Behavioral Health,,13.19,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,6.68,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN Behavioral Health,,5.18,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Optum,VACCN Behavioral Health,,13.39,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Optum,VACCN Behavioral Health,,4.75,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN Behavioral Health,,4.75,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN Behavioral Health,,12.87,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN Behavioral Health,,4.29,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,6.14,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN Behavioral Health,,13.24,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN Behavioral Health,,6.63,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Optum,VACCN Behavioral Health,,169.96,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Optum,VACCN Behavioral Health,,169.96,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Optum,VACCN Behavioral Health,,123.68,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN Behavioral Health,,14.61,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,15.05,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN Behavioral Health,,7.31,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Optum,VACCN Behavioral Health,,25.81,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Optum,VACCN Behavioral Health,,759.53,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,35.09,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,15.92,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Optum,VACCN Behavioral Health,,5.50,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN Behavioral Health,,27.22,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Optum,VACCN Behavioral Health,,2.70,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN Behavioral Health,,11.98,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Optum,VACCN Behavioral Health,,16.55,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Optum,VACCN Behavioral Health,,16.55,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN Behavioral Health,,9.09,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN Behavioral Health,,9.09,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Optum,VACCN Behavioral Health,,9.09,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN Behavioral Health,,35.09,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Optum,VACCN Behavioral Health,,121.63,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Optum,VACCN Behavioral Health,,185.20,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Optum,VACCN Behavioral Health,,83.00,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Optum,VACCN Behavioral Health,,641.85,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Optum,VACCN Behavioral Health,,1824.88,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Optum,VACCN Behavioral Health,,375.25,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN Behavioral Health,,9.09,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Optum,VACCN Behavioral Health,,11.15,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Optum,VACCN Behavioral Health,,6.47,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Optum,VACCN Behavioral Health,,5.51,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN Behavioral Health,,18.52,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,26.78,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Optum,VACCN Behavioral Health,,185.20,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,20.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Optum,VACCN Behavioral Health,,35.09,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Optum,VACCN Behavioral Health,,137.00,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Optum,VACCN Behavioral Health,,759.53,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Optum,VACCN Behavioral Health,,218.06,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,35.09,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Optum,VACCN Behavioral Health,,70.20,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Optum,VACCN Behavioral Health,,121.63,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Optum,VACCN Behavioral Health,,185.20,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Optum,VACCN Behavioral Health,,24.91,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Optum,VACCN Behavioral Health,QW,24.91,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN Behavioral Health,,14.38,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Optum,VACCN Behavioral Health,,62.14,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Optum,VACCN Behavioral Health,,1160.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Optum,VACCN Behavioral Health,,416.78,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Optum,VACCN Behavioral Health,,91.66,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,20.81,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Optum,VACCN Behavioral Health,,233.07,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Optum,VACCN Behavioral Health,,41.76,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Optum,VACCN Behavioral Health,,42.84,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Optum,VACCN Behavioral Health,,16.07,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN Behavioral Health,,5.22,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN Behavioral Health,,29.21,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN Behavioral Health,QW,51.31,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN Behavioral Health,,42.13,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Optum,VACCN Behavioral Health,,17.27,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Optum,VACCN Behavioral Health,,416.78,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN Behavioral Health,,142.63,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN Behavioral Health,,10.32,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN Behavioral Health,,18.64,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN Behavioral Health,,18.64,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN Behavioral Health,,27.11,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Optum,VACCN Behavioral Health,,38.57,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN Behavioral Health,,8.65,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Optum,VACCN Behavioral Health,,142.63,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN Behavioral Health,,39.26,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Optum,VACCN Behavioral Health,,21.73,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN Behavioral Health,,20.81,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Optum,VACCN Behavioral Health,,137.00,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN Behavioral Health,,12.00,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN Behavioral Health,,12.00,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Optum,VACCN Behavioral Health,,20.32,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN Behavioral Health,,11.53,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,17.27,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN Behavioral Health,,22.34,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN Behavioral Health,,29.35,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Optum,VACCN Behavioral Health,,27.39,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Optum,VACCN Behavioral Health,,128.29,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Optum,VACCN Behavioral Health,,11.53,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Optum,VACCN Behavioral Health,,51.31,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,35.09,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN Behavioral Health,,35.09,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,9.71,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN Behavioral Health,,11.57,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN Behavioral Health,,2.25,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Optum,VACCN Behavioral Health,,35.09,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Optum,VACCN Behavioral Health,,35.09,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Optum,VACCN Behavioral Health,,137.00,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN Behavioral Health,,8.62,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Optum,VACCN Behavioral Health,,262.99,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Optum,VACCN Behavioral Health,,70.20,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Optum,VACCN Behavioral Health,,52.99,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Optum,VACCN Behavioral Health,,2.37,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN Behavioral Health,,38.93,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Optum,VACCN Behavioral Health,,38.93,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Optum,VACCN Behavioral Health,,52.99,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Optum,VACCN Behavioral Health,,52.99,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Optum,VACCN Behavioral Health,,20.26,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Optum,VACCN Behavioral Health,,24.29,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Optum,VACCN Behavioral Health,,169.96,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Optum,VACCN Behavioral Health,,52.99,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,26.61,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Optum,VACCN Behavioral Health,,26.61,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN Behavioral Health,,26.61,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Optum,VACCN Behavioral Health,,356.78,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Optum,VACCN Behavioral Health,,356.78,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Optum,VACCN Behavioral Health,,116.49,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Optum,VACCN Behavioral Health,,116.49,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Optum,VACCN Behavioral Health,,140.73,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Optum,VACCN Behavioral Health,,150.30,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Optum,VACCN Behavioral Health,,150.30,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Optum,VACCN Behavioral Health,,143.75,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Optum,VACCN Behavioral Health,,13.07,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Optum,VACCN Behavioral Health,,264.34,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Optum,VACCN Behavioral Health,,125.49,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Optum,VACCN Behavioral Health,,144.61,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Optum,VACCN Behavioral Health,,188.57,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Optum,VACCN Behavioral Health,,21.42,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN Behavioral Health,,21.42,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN Behavioral Health,,34.81,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Optum,VACCN Behavioral Health,,42.38,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Optum,VACCN Behavioral Health,,51.19,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Optum,VACCN Behavioral Health,,33.47,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Optum,VACCN Behavioral Health,,68.60,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Optum,VACCN Behavioral Health,,26.91,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN Behavioral Health,,52.99,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Optum,VACCN Behavioral Health,,38.93,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Optum,VACCN Behavioral Health,,24.29,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Optum,VACCN Behavioral Health,,38.93,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Optum,VACCN Behavioral Health,,52.99,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Optum,VACCN Behavioral Health,,52.99,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Optum,VACCN Behavioral Health,,52.99,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Optum,VACCN Behavioral Health,,356.78,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Optum,VACCN Behavioral Health,,810.23,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN Behavioral Health,,127.85,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Optum,VACCN Behavioral Health,,810.23,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN Behavioral Health,,52.99,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Optum,VACCN Behavioral Health,,169.96,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Optum,VACCN Behavioral Health,,810.23,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Optum,VACCN Behavioral Health,,169.96,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Optum,VACCN Behavioral Health,,12.05,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Optum,VACCN Behavioral Health,,169.96,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN Behavioral Health,,169.96,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN Behavioral Health,,169.96,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN Behavioral Health,,169.96,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Optum,VACCN Behavioral Health,,102.26,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Optum,VACCN Behavioral Health,,5.02,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Optum,VACCN Behavioral Health,,169.96,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Optum,VACCN Behavioral Health,,143.75,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Optum,VACCN Behavioral Health,,140.73,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Optum,VACCN Behavioral Health,,143.75,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Optum,VACCN Behavioral Health,,51.19,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Optum,VACCN Behavioral Health,,144.61,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN Behavioral Health,,356.78,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN Behavioral Health,,169.96,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Optum,VACCN Behavioral Health,,51.19,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN Behavioral Health,,21.42,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN Behavioral Health,,169.96,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Optum,VACCN Behavioral Health,,52.99,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN Behavioral Health,,127.85,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Optum,VACCN Behavioral Health,,356.78,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Optum,VACCN Behavioral Health,,51.19,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN Behavioral Health,,21.42,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Optum,VACCN Behavioral Health,,169.96,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN Behavioral Health,,169.96,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Optum,VACCN Behavioral Health,,169.96,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Optum,VACCN Behavioral Health,,21.42,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN Behavioral Health,,21.42,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN Behavioral Health,,21.42,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Optum,VACCN Behavioral Health,,51.19,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN Behavioral Health,,21.42,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Optum,VACCN Behavioral Health,,42.38,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN Behavioral Health,,169.96,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN Behavioral Health,,169.96,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,169.96,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Optum,VACCN Behavioral Health,,38.93,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Optum,VACCN Behavioral Health,,169.96,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Optum,VACCN Behavioral Health,,180.51,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Optum,VACCN Behavioral Health,,180.51,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Optum,VACCN Behavioral Health,,180.51,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Optum,VACCN Behavioral Health,,180.51,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN Behavioral Health,,83.60,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN Behavioral Health,,83.60,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN Behavioral Health,,83.60,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Optum,VACCN Behavioral Health,,143.14,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Optum,VACCN Behavioral Health,,393.63,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN Behavioral Health,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Optum,VACCN Behavioral Health,,670.15,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Optum,VACCN Behavioral Health,,648.41,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Optum,VACCN Behavioral Health,,253.71,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Optum,VACCN Behavioral Health,,146.10,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Optum,VACCN Behavioral Health,,771.15,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Optum,VACCN Behavioral Health,,240.46,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN Behavioral Health,,70.51,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Optum,VACCN Behavioral Health,,582.49,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN Behavioral Health,,2.99,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN Behavioral Health,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN Behavioral Health,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN Behavioral Health,,9.77,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN Behavioral Health,,5.72,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN Behavioral Health,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN Behavioral Health,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN Behavioral Health,,670.15,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN Behavioral Health,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN Behavioral Health,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Optum,VACCN Behavioral Health,,649.04,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Optum,VACCN Behavioral Health,,649.04,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Optum,VACCN Behavioral Health,,328.98,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Optum,VACCN Behavioral Health,,10379.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Optum,VACCN Behavioral Health,,10379.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Optum,VACCN Behavioral Health,,10379.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Optum,VACCN Behavioral Health,,10379.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Optum,VACCN Behavioral Health,,10379.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Optum,VACCN Behavioral Health,,1814.30,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Optum,VACCN Behavioral Health,,10379.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Optum,VACCN Behavioral Health,,10379.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Optum,VACCN Behavioral Health,,18915.54,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Optum,VACCN Behavioral Health,,22263.03,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Optum,VACCN Behavioral Health,,31799.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Optum,VACCN Behavioral Health,,697.85,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Optum,VACCN Behavioral Health,,1204.08,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Optum,VACCN Behavioral Health,,1204.08,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Optum,VACCN Behavioral Health,,1204.08,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Optum,VACCN Behavioral Health,,7526.18,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Optum,VACCN Behavioral Health,,526.27,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Optum,VACCN Behavioral Health,,18915.54,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Optum,VACCN Behavioral Health,,31799.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Optum,VACCN Behavioral Health,,22263.03,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Optum,VACCN Behavioral Health,,22263.03,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Optum,VACCN Behavioral Health,,31799.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Optum,VACCN Behavioral Health,,28196.35,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN Behavioral Health,,395.78,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Optum,VACCN Behavioral Health,,155.18,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Optum,VACCN Behavioral Health,,1540.76,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Optum,VACCN Behavioral Health,,31799.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Optum,VACCN Behavioral Health,,11248.03,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Optum,VACCN Behavioral Health,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Optum,VACCN Behavioral Health,,3190.16,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Optum,VACCN Behavioral Health,,24332.12,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Optum,VACCN Behavioral Health,,24332.12,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Optum,VACCN Behavioral Health,,24332.12,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Optum,VACCN Behavioral Health,,613.21,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Optum,VACCN Behavioral Health,,31799.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Optum,VACCN Behavioral Health,,5655.00,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Optum,VACCN Behavioral Health,,105.47,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Optum,VACCN Behavioral Health,,18915.54,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Optum,VACCN Behavioral Health,,308.86,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Optum,VACCN Behavioral Health,,543.83,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Optum,VACCN Behavioral Health,,543.83,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Optum,VACCN Behavioral Health,,239.75,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Optum,VACCN Behavioral Health,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Optum,VACCN Behavioral Health,,36.99,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Optum,VACCN Behavioral Health,,127.85,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Optum,VACCN Behavioral Health,,58.92,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN Behavioral Health,,91.04,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Optum,VACCN Behavioral Health,,239.75,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN Behavioral Health,,124.88,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Optum,VACCN Behavioral Health,,124.88,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Optum,VACCN Behavioral Health,,58.92,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Optum,VACCN Behavioral Health,,58.92,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Optum,VACCN Behavioral Health,,3656.86,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Optum,VACCN Behavioral Health,,3121.82,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Optum,VACCN Behavioral Health,,7085.44,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Optum,VACCN Behavioral Health,,697.85,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Optum,VACCN Behavioral Health,,8208.45,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Optum,VACCN Behavioral Health,,3609.60,,,,,,,422.62,17457.00,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,205155.01,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,83479.86,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,155596.66,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,101846.19,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,76035.22,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34678.87,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,95277.00,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,41732.08,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,53184.42,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,40635.04,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31610.05,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21884.54,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,88481.10,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,44101.86,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,40476.11,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,315654.06,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,52884.84,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,58236.71,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,39466.54,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24039.29,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,42648.36,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,29393.34,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34020.64,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23542.15,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19268.38,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,44674.80,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,25746.45,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16879.65,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,33538.08,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16411.68,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12999.51,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,29093.03,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18303.27,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15039.81,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24875.37,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12705.75,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9446.66,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,29023.77,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16905.16,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13471.86,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14081.26,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8015.75,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12008.16,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8310.25,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17811.96,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10322.12,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13339.19,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9923.38,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7582.77,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20975.57,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13686.90,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11110.83,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15536.95,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8242.46,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5866.85,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11583.91,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7178.94,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6700.75,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13013.35,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8356.90,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6390.22,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12572.35,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8391.89,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14855.38,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6893.20,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14071.79,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7406.36,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17538.61,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11052.52,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7845.20,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17438.75,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10373.87,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7545.60,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10731.79,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8886.11,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6878.62,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13679.62,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8335.02,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6682.52,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26532.25,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19678.79,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19678.79,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27205.80,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17606.42,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10809.04,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14996.08,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7457.39,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9048.66,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6974.10,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18016.06,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10740.53,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12066.48,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14057.92,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8786.24,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9357.74,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6605.99,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6699.29,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10522.58,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6474.78,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16695.95,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8278.90,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11762.50,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7337.85,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9885.48,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31969.41,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16776.88,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12514.77,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,28188.41,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13509.78,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9642.03,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16312.54,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10146.44,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6688.37,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6356.70,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10583.81,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6228.40,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9495.49,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6259.02,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12274.94,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7558.71,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5915.68,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13392.41,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7509.87,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6042.52,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,33547.57,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19276.40,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14831.35,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,28123.52,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14023.66,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10838.19,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22574.12,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10890.69,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6745.95,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12269.11,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7992.44,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6381.48,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13751.05,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8684.92,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6372.73,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12030.03,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8634.62,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6611.10,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12238.51,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8087.91,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6105.94,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9883.29,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8952.45,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7022.94,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5557.78,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10459.16,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6752.50,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5459.37,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14634.53,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7796.35,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6098.65,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13737.20,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8891.21,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6090.64,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7957.45,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5761.89,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6763.45,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14224.86,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7738.04,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,47783.00,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20914.31,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,83385.10,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,80143.50,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,42477.80,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,73458.42,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,72188.59,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,48807.89,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,48807.89,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,56848.08,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,39750.83,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,37617.96,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,36941.51,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23835.90,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,62326.79,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,45070.63,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,56606.79,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,40697.72,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,43656.49,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31411.77,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,36754.17,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21656.40,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10969.42,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24151.54,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16410.94,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14053.55,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34135.07,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16787.06,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11771.97,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26305.56,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19798.32,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13865.49,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20540.39,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13254.64,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8839.45,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23781.97,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15617.86,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24588.90,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14658.57,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12758.96,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23164.55,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,25228.92,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27252.44,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,45550.28,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,35581.30,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,51013.66,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31662.52,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,39338.99,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26801.25,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19487.79,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,30950.35,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24872.45,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,52854.23,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,44662.41,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34544.01,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,41452.18,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27166.42,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12570.90,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7577.67,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6148.94,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15316.80,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5923.70,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5243.61,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17007.94,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8678.35,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20604.54,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13320.25,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7654.93,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10236.10,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7066.69,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5003.78,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12263.29,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5499.46,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,4195.38,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12779.37,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8659.40,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6124.17,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9600.49,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5785.21,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9552.36,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6382.20,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12364.60,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7534.66,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9654.42,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6240.79,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5004.50,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5994.40,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7231.43,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6126.34,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16077.83,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7899.86,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5850.08,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,49618.47,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18534.34,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,33409.78,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18411.15,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20710.96,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13729.17,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,32422.07,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23846.83,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24279.85,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,37233.08,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18694.69,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12557.78,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34383.66,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18352.10,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13145.30,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27270.68,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17951.18,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12817.28,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26907.68,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16249.13,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12067.20,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19705.02,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11846.33,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9524.66,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17611.51,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10418.33,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7224.13,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19042.41,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11990.66,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9390.55,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22031.79,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13141.66,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10682.21,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,32898.81,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17829.47,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11067.81,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,25943.28,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18476.76,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12481.97,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8168.83,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5986.39,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13802.81,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8320.45,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6180.28,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16467.80,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9695.23,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7615.57,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14202.98,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8026.69,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5473.21,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15181.21,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8776.04,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6713.88,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10942.45,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7108.95,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12412.00,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7994.63,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5844.26,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11642.94,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6635.14,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,4843.42,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10123.11,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6560.80,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12535.90,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7698.67,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5608.81,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18335.33,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11911.19,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9222.15,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,30184.97,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,40754.58,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22018.67,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17057.51,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26869.02,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16749.18,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12451.34,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24957.02,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16203.93,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12982.02,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26847.17,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15942.97,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10815.61,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18273.38,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13208.72,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10833.84,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,25713.65,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13543.30,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11079.49,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31150.82,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16826.44,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11814.27,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,81215.78,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,53497.15,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,41858.92,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,66552.45,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,42916.60,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15224.96,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8577.03,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6071.69,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14266.40,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9123.01,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7098.02,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12761.14,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7009.82,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5407.62,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13960.26,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7914.43,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5978.37,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13057.81,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8855.49,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6908.50,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,49582.74,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31790.82,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,39727.49,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24425.62,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,62133.62,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,44345.33,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31293.68,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,41137.26,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20267.76,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,42423.85,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23582.24,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14171.65,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,38822.16,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26584.73,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20909.23,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22988.16,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14938.50,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,36076.24,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22353.25,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18673.56,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,32170.59,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17466.46,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9480.92,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26059.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18804.05,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14428.23,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22106.88,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16145.60,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12766.99,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21083.44,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24401.57,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16120.83,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12294.63,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13772.18,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9018.78,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27641.69,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19364.61,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15504.16,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27307.11,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14027.31,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9685.75,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22868.59,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15564.64,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23947.45,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13620.55,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10688.77,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21223.39,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14503.31,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13946.41,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10712.83,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14045.54,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11917.05,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22895.59,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16035.53,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12944.85,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12353.68,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8329.94,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24108.54,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16026.07,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12079.58,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,28120.60,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15458.21,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11767.61,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21799.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16314.72,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12305.55,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6753.96,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10222.98,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6764.90,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7834.26,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6128.54,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15235.90,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10327.21,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6617.65,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13754.69,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8371.48,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6378.56,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18968.06,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9285.57,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6973.37,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14953.07,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9677.73,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7249.64,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13095.74,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7885.28,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10327.21,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6928.91,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10513.10,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6932.55,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11716.57,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7388.86,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14471.99,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9086.57,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6737.92,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11263.91,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7405.63,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12129.89,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7980.76,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6339.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22316.81,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13193.41,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9233.82,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,48633.68,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26182.37,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13977.02,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,36604.74,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20199.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12587.66,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24484.67,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13474.06,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11397.30,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14921.71,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13447.81,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16482.38,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14939.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14985.13,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9525.38,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7196.43,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16336.59,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8768.75,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13030.12,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9124.46,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6486.44,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8470.61,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5288.06,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11238.39,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7226.32,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11608.69,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7555.07,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11908.28,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7485.09,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16854.87,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11078.04,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26298.99,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14511.33,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11216.52,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21925.36,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12543.18,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11873.30,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26822.38,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13954.43,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10003.57,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22892.66,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11807.69,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10560.49,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,28044.08,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16760.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11516.84,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11350.66,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7410.74,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5406.16,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10613.70,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6550.58,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11244.23,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12877.05,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8349.60,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6478.41,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,35148.31,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27890.99,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24419.06,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,38756.56,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21283.16,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16306.71,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24085.94,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14217.57,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12189.66,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19399.58,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10512.37,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8425.42,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23194.44,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11959.32,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8509.25,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23629.63,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13629.30,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8941.50,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22163.00,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12191.12,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8001.90,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13962.44,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8746.89,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31505.09,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17924.95,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12842.79,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11673.57,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7262.03,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5253.81,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14025.86,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8515.81,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6638.79,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9335.87,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6778.76,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10678.58,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6576.10,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9215.58,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5900.37,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8734.49,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12937.56,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8276.72,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5906.93,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15458.96,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12061.37,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17841.13,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11091.89,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16067.62,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8894.12,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11836.86,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8585.78,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17186.54,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11600.67,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14658.57,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10668.36,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14069.59,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9207.56,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5657.64,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9408.03,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6140.94,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11687.43,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6791.13,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8595.26,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5776.46,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16404.39,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10685.86,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26933.90,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15898.50,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11582.45,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,26994.41,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14068.87,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11273.39,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14252.55,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9921.94,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15814.69,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9169.67,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13540.38,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7144.68,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10990.56,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19594.22,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11635.67,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14302.86,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8807.39,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7879.44,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11315.66,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8014.29,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5715.23,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8222.04,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5036.59,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8689.29,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13195.59,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8187.05,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5650.36,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7010.55,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18774.16,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8605.47,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7859.76,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12901.83,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9018.78,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7867.06,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14014.93,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,44202.47,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,30465.61,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18731.15,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31271.82,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11636.40,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,2334.41,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9384.70,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8170.29,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7854.66,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,33890.90,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21356.79,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14792.70,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,29919.63,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14428.23,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10762.39,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8744.70,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6374.19,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5792.49,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16972.21,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10105.62,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8507.06,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11114.47,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7571.10,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11996.49,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16380.33,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8269.42,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5484.87,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17509.46,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9327.85,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7146.14,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,43628.79,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17196.00,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9654.42,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34298.36,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17392.82,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10714.28,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34976.27,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17725.23,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13297.65,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,23912.44,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11848.53,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9643.48,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6138.01,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,4689.61,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,40896.00,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16082.18,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9767.39,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,35898.40,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16093.87,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11403.14,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24458.43,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12769.89,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8243.20,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15418.86,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9752.08,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7085.64,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,19775.72,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10413.97,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7069.60,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20628.58,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,64000.43,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,36877.35,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15442.91,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11791.66,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,34035.21,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16488.21,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11031.37,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14171.65,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8152.08,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7348.78,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11799.68,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7216.84,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16136.13,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8394.08,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6197.05,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,51260.78,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15037.62,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8337.23,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,29050.75,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7877.24,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7736.57,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8705.33,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15211.11,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12605.89,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11059.80,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16005.66,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8684.21,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5374.81,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11196.84,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13598.71,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7313.06,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31468.63,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14833.51,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9403.66,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27652.63,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,11691.07,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15196.53,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,28864.11,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15421.77,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10446.78,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12793.24,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7332.74,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13135.82,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5734.92,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12310.67,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7125.71,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,14223.40,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8184.14,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5896.00,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13630.04,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,8296.40,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,156510.01,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,53162.57,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,24355.65,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,29264.32,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,16991.90,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15894.12,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,27327.53,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,17912.56,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,15658.67,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12166.34,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9237.47,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10131.14,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,6713.15,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9550.16,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,5453.53,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,4930.88,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,49943.59,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,28307.95,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,56422.38,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,31594.72,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,22338.67,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20805.72,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12049.71,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7733.64,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,45498.51,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,20103.02,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,21915.15,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10317.74,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,7458.13,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,10337.42,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,35078.32,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,18798.95,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,13372.00,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,25868.92,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,12858.83,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,VACCN,,9619.41,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17256.38,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5117.61,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,21269.40,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7334.47,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5117.61,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9490.97,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1540.76,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,30224.93,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6509.35,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,21269.40,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7334.47,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,662.02,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,662.02,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6509.35,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5117.61,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5904.24,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,301.71,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5904.24,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,19964.31,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,30224.93,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,44633.30,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,230.33,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,526.27,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,398.55,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,19964.31,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17810.19,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3410.95,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,863.63,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9490.97,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5904.24,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,505.09,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5904.24,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6188.83,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,24332.12,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3410.95,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,960.64,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6509.35,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,22263.03,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,19964.31,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17810.19,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,863.63,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,199.53,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,31799.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1540.76,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17529.90,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,544.12,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5904.24,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,58.92,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,8208.45,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,960.64,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,199.53,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,662.02,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,863.63,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,301.71,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,8208.45,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,192.56,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,395.78,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,127.85,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,58.92,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6468.24,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12886.40,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,19964.31,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,613.21,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,31799.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10379.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,395.78,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5904.24,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,544.12,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12368.55,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6509.35,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,230.33,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6351.81,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,301.71,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,87.33,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,199.53,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,662.02,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,960.64,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,960.64,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5117.61,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1540.76,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4646.94,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12368.55,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6351.81,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,544.12,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,8208.45,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7526.18,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17810.19,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6351.81,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6188.83,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3990.03,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,544.12,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,960.64,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,230.33,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,505.09,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,395.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3609.60,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,613.21,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,127.85,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,127.85,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17810.19,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12886.40,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,301.71,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,863.63,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10379.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,8208.45,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,613.21,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,230.33,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,649.04,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,91.04,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,9171.69,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7334.47,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,230.33,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,6865.98,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5904.24,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,192.56,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3773.49,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,301.71,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3656.86,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,613.21,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,230.33,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,505.09,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5867.39,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,127.85,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1469.19,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3216.61,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,505.09,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,230.33,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,433.61,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,4896.17,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,395.78,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,199.53,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3798.03,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17810.19,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17810.19,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,395.78,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,17810.19,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,11248.03,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2031.79,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,662.02,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,199.53,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,155.18,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3153.59,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,199.53,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12886.40,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,10326.26,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,662.02,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5655.00,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,12761.83,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3500.26,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,301.71,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1710.40,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,396.27,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5786.75,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,883.03,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,697.85,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3121.82,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,607.14,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,395.78,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,127.85,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3420.83,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1936.84,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,197.08,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,127.85,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1814.30,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,395.78,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5117.61,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2720.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5361.59,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,544.12,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2838.70,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1169.46,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,904.27,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,18239.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2262.12,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1357.09,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3609.60,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3609.60,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1607.02,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1587.35,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,296.49,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,960.64,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3631.10,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,155.18,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,8208.45,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3740.23,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,1881.51,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,8208.45,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,2313.92,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,7085.44,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,241.23,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,5042.14,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,Optum,VACCN,,3218.13,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Optum,VACCN,,29.38,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Optum,VACCN,,56824.55,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Optum,VACCN,,7.28,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Optum,VACCN,,3.35,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Optum,VACCN,,12.07,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Optum,VACCN,,0.12000,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Optum,VACCN,,0.21000,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Optum,VACCN,,0.30000,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Optum,VACCN,,1730.32,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Optum,VACCN,,112.45,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Optum,VACCN,,114.54,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Optum,VACCN,,6.77,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Optum,VACCN,,7.95,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Optum,VACCN,,30.01,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Optum,VACCN,,15.11,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Optum,VACCN,,1.70,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Optum,VACCN,,62.23,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Optum,VACCN,,75.86,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Optum,VACCN,,1.88,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Optum,VACCN,,172.31,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Optum,VACCN,,733.67,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Optum,VACCN,,8.73,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Optum,VACCN,,3.42,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Optum,VACCN,,5135.09,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Optum,VACCN,,95.90,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Optum,VACCN,,227.28,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Optum,VACCN,,0.21000,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Optum,VACCN,,5.57,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Optum,VACCN,,5.57,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Optum,VACCN,,20.35,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Optum,VACCN,,20.35,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Optum,VACCN,,20.35,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Optum,VACCN,,8.75,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Optum,VACCN,,89.34,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN,,4.23,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Optum,VACCN,,2.93,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Optum,VACCN,,2.93,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Optum,VACCN,,2.93,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Optum,VACCN,,2.93,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Optum,VACCN,,2.93,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Optum,VACCN,,2.93,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Optum,VACCN,,30.01,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Optum,VACCN,,173.03,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Optum,VACCN,,173.03,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Optum,VACCN,,5.71,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Optum,VACCN,,5.71,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Optum,VACCN,,73.20,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Optum,VACCN,,73.20,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Optum,VACCN,,6.73,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Optum,VACCN,,181.22,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Optum,VACCN,,183.48,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Optum,VACCN,,183.48,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Optum,VACCN,,30.01,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Optum,VACCN,,2608.16,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Optum,VACCN,,432.02,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Optum,VACCN,,2.23,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Optum,VACCN,,258.64,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Optum,VACCN,,5.19,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Optum,VACCN,,1.46,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Optum,VACCN,,1.46,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Optum,VACCN,,62.23,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Optum,VACCN,,17.02,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Optum,VACCN,,55.65,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Optum,VACCN,,28424.06,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Optum,VACCN,,66.64,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Optum,VACCN,,91.73,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Optum,VACCN,,134.19,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Optum,VACCN,,593.00,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Optum,VACCN,,748.85,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Optum,VACCN,,2.85,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Optum,VACCN,,141.89,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Optum,VACCN,,7.95,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Optum,VACCN,,0.21000,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Optum,VACCN,,0.21000,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Optum,VACCN,,0.21000,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Optum,VACCN,,0.21000,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Optum,VACCN,,263.15,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Optum,VACCN,,48.96,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Optum,VACCN,,176.45,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Optum,VACCN,,75.86,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Optum,VACCN,,1730.32,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Optum,VACCN,,63.06,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Optum,VACCN,,733.67,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Optum,VACCN,,42.16,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Optum,VACCN,,42.16,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Optum,VACCN,,308.68,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Optum,VACCN,,74.36,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Optum,VACCN,,74.36,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Optum,VACCN,,2.14,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Optum,VACCN,,21.31,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Optum,VACCN,,15.61,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Optum,VACCN,,2.14,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Optum,VACCN,,7.95,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Optum,VACCN,,167.31,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN,,164.25,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Optum,VACCN,,9.07,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Optum,VACCN,,32.96,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Optum,VACCN,,32.96,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Optum,VACCN,,89.34,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Optum,VACCN,,60.29,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Optum,VACCN,,203.58,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Optum,VACCN,,203.58,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Optum,VACCN,,203.58,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Optum,VACCN,,104.73,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Optum,VACCN,,50.74,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Optum,VACCN,,49.03,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Optum,VACCN,,49.03,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Optum,VACCN,,78.80,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Optum,VACCN,,78.80,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Optum,VACCN,,19.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Optum,VACCN,,0.46000,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Optum,VACCN,,0.46000,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Optum,VACCN,,66.00,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Optum,VACCN,,31.27,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Optum,VACCN,,13.49,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Optum,VACCN,,19.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Optum,VACCN,,112.45,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Optum,VACCN,,71.32,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Optum,VACCN,,91.34,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Optum,VACCN,,1.83,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Optum,VACCN,,8.73,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Optum,VACCN,,39.83,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Optum,VACCN,,141.60,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Optum,VACCN,,100.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Optum,VACCN,,59.41,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Optum,VACCN,,75.03,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Optum,VACCN,,85.12,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Optum,VACCN,,85.12,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Optum,VACCN,,36.69,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Optum,VACCN,,36.69,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Optum,VACCN,,256.09,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Optum,VACCN,,2698.05,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Optum,VACCN,,2.18,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Optum,VACCN,,1.64,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Optum,VACCN,,164.59,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Optum,VACCN,,8.15,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Optum,VACCN,,32.96,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Optum,VACCN,,18.11,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Optum,VACCN,,7.85,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Optum,VACCN,,7.85,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Optum,VACCN,,7.85,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Optum,VACCN,,7.85,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Optum,VACCN,,7.85,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Optum,VACCN,,99.13,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Optum,VACCN,,248.50,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Optum,VACCN,,0.30000,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Optum,VACCN,,0.30000,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Optum,VACCN,,29.29,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Optum,VACCN,,106.33,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Optum,VACCN,,131.38,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Optum,VACCN,,0.30000,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Optum,VACCN,,102.10,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Optum,VACCN,,91.34,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Optum,VACCN,,61.44,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Optum,VACCN,,6.83,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Optum,VACCN,,136.67,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Optum,VACCN,,27.86,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Optum,VACCN,,27.86,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Optum,VACCN,,29.38,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Optum,VACCN,,29.38,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Optum,VACCN,,41.98,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Optum,VACCN,,41.98,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Optum,VACCN,,129.48,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Optum,VACCN,,11.01,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Optum,VACCN,,36.74,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN,,36.74,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Optum,VACCN,,29.98,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Optum,VACCN,,25.77,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Optum,VACCN,,25.77,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Optum,VACCN,,27.85,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Optum,VACCN,,27.85,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Optum,VACCN,,359.19,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Optum,VACCN,,27.99,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Optum,VACCN,,19.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Optum,VACCN,,81.90,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Optum,VACCN,,81.90,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Optum,VACCN,,36.28,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Optum,VACCN,,318.53,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Optum,VACCN,,20.41,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Optum,VACCN,,62.10,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Optum,VACCN,,62.10,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Optum,VACCN,,14.31,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Optum,VACCN,,136.67,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Optum,VACCN,,225.11,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Optum,VACCN,,225.11,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Optum,VACCN,,7.85,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Optum,VACCN,,5.46,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Optum,VACCN,,27.99,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Optum,VACCN,,2116.32,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Optum,VACCN,,216.90,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Optum,VACCN,,243.71,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Optum,VACCN,,22.54,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Optum,VACCN,,188.76,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Optum,VACCN,,12.32,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Optum,VACCN,,84.57,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Optum,VACCN,,0.38000,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Optum,VACCN,,0.38000,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Optum,VACCN,,197.83,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Optum,VACCN,,33.58,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Optum,VACCN,,33.58,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Optum,VACCN,,69.49,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Optum,VACCN,,654.63,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Optum,VACCN,,654.63,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Optum,VACCN,,30.56,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Optum,VACCN,,25.04,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Optum,VACCN,,25.04,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Optum,VACCN,,25.04,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Optum,VACCN,,63342.28,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Optum,VACCN,,72.62,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Optum,VACCN,,72.62,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Optum,VACCN,,195.72,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Optum,VACCN,,8.73,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Optum,VACCN,,106.33,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Optum,VACCN,,1.83,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Optum,VACCN,,57.03,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Optum,VACCN,,57.03,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Optum,VACCN,,75.97,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Optum,VACCN,,33.43,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Optum,VACCN,,27.36,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Optum,VACCN,,51.56,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Optum,VACCN,,172.22,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Optum,VACCN,,21.48,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Optum,VACCN,,75.22,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Optum,VACCN,,75.22,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Optum,VACCN,,6.28,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Optum,VACCN,,0.30000,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Optum,VACCN,,31.09,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Optum,VACCN,,43.19,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Optum,VACCN,,108.47,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Optum,VACCN,,108.47,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Optum,VACCN,,328.34,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Optum,VACCN,,0.80000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Optum,VACCN,,8.15,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Optum,VACCN,,1828.72,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Optum,VACCN,,1.70,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Optum,VACCN,,94.45,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Optum,VACCN,,5168.23,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Optum,VACCN,,7.34,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Optum,VACCN,,89.34,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Optum,VACCN,,6.50,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Optum,VACCN,,176.45,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Optum,VACCN,,54.71,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Optum,VACCN,,54.71,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Optum,VACCN,,54.71,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Optum,VACCN,,54.71,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Optum,VACCN,,377.52,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Optum,VACCN,,0.46000,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Optum,VACCN,,44.60,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Optum,VACCN,,4.36,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN,,78.37,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Optum,VACCN,,0.48000,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Optum,VACCN,,0.48000,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Optum,VACCN,,1.73,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Optum,VACCN,,10.54,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Optum,VACCN,,10.14,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Optum,VACCN,,10.14,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Optum,VACCN,,10.14,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Optum,VACCN,,2429.89,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Optum,VACCN,,20.35,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Optum,VACCN,,183.48,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Optum,VACCN,,183.48,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Optum,VACCN,,68.20,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Optum,VACCN,,62.23,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Optum,VACCN,,62.23,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Optum,VACCN,,5.71,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Optum,VACCN,,5.71,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Optum,VACCN,,0.21000,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Optum,VACCN,,0.21000,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Optum,VACCN,,0.21000,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Optum,VACCN,,258.64,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN,,4.23,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Optum,VACCN,,207.13,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Optum,VACCN,,279.85,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Optum,VACCN,,279.85,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Optum,VACCN,,0.30000,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Optum,VACCN,,18.11,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Optum,VACCN,,172.22,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Optum,VACCN,,0.30000,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Optum,VACCN,,148.99,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Optum,VACCN,,182.45,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Optum,VACCN,,0.21000,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Optum,VACCN,,0.21000,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Optum,VACCN,,70.75,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Optum,VACCN,,94.45,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Optum,VACCN,,70.75,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Optum,VACCN,,70.75,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Optum,VACCN,,131.38,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Optum,VACCN,,94.45,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Optum,VACCN,,91.34,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Optum,VACCN,,1730.32,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Optum,VACCN,,1730.32,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Optum,VACCN,,36.28,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Optum,VACCN,,85.12,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Optum,VACCN,,55.65,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Optum,VACCN,,0.48000,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN,,4.23,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Optum,VACCN,,4.23,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Optum,VACCN,,0.37000,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Optum,VACCN,,6.73,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Optum,VACCN,,0.80000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Optum,VACCN,,20.35,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Optum,VACCN,,94.45,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN,,2.66,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Optum,VACCN,,2.14,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Optum,VACCN,,60.29,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Optum,VACCN,,6.73,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN,,164.25,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Optum,VACCN,,164.25,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Optum,VACCN,,172.22,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Optum,VACCN,,75.03,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Optum,VACCN,,61.44,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Optum,VACCN,,62.10,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Optum,VACCN,,62.10,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Optum,VACCN,,4.36,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Optum,VACCN,,60.29,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Optum,VACCN,,60.29,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Optum,VACCN,,0.80000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Optum,VACCN,,1.83,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Optum,VACCN,,236.62,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Optum,VACCN,,91.34,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Optum,VACCN,,91.34,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Optum,VACCN,,55.57,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Optum,VACCN,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN,,78.37,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Optum,VACCN,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN,,78.37,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Optum,VACCN,,78.37,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Optum,VACCN,,78.37,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Optum,VACCN,,2429.89,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Optum,VACCN,,0.28000,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN,,36.74,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN,,36.74,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Optum,VACCN,,36.74,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Optum,VACCN,,72.62,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Optum,VACCN,,95.90,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Optum,VACCN,,4.42,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Optum,VACCN,,4.42,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Optum,VACCN,,4.42,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Optum,VACCN,,4.42,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Optum,VACCN,,4.42,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Optum,VACCN,,4.42,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Optum,VACCN,,0.37000,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Optum,VACCN,,68.20,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Optum,VACCN,,0.12000,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Optum,VACCN,,0.12000,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Optum,VACCN,,294.69,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Optum,VACCN,,1.49,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Optum,VACCN,,1.49,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Optum,VACCN,,1.49,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Optum,VACCN,,2.93,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Optum,VACCN,,1.61,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Optum,VACCN,,44.82,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Optum,VACCN,,26.71,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Optum,VACCN,,29.84,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Optum,VACCN,,139.21,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Optum,VACCN,,4.36,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Optum,VACCN,,53.08,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Optum,VACCN,,53.08,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Optum,VACCN,,94.45,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Optum,VACCN,,94.45,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Optum,VACCN,,4.10,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Optum,VACCN,,0.30000,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN,,2.66,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN,,2.66,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Optum,VACCN,,2.66,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Optum,VACCN,,1.67,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Optum,VACCN,,1.67,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Optum,VACCN,,0.37000,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Optum,VACCN,,484.97,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Optum,VACCN,,11.01,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Optum,VACCN,,11.01,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Optum,VACCN,,23.88,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Optum,VACCN,,23.88,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Optum,VACCN,,23.88,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Optum,VACCN,,2.85,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Optum,VACCN,,51.05,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Optum,VACCN,,6.50,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Optum,VACCN,,10.68,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Optum,VACCN,,4.45,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Optum,VACCN,,3.52,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Optum,VACCN,,3.52,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Optum,VACCN,,1.70,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Optum,VACCN,,0.32000,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Optum,VACCN,,8.75,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Optum,VACCN,,392.06,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Optum,VACCN,,508.96,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Optum,VACCN,,608.10,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN,,339.60,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Optum,VACCN,,34.82,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Optum,VACCN,,34.82,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Optum,VACCN,,36.74,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Optum,VACCN,,127.85,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Optum,VACCN,,208.97,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN,,45.76,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Optum,VACCN,,208.97,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN,,45.76,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN,,70.59,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN,,208.97,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Optum,VACCN,,208.97,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Optum,VACCN,,45.76,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Optum,VACCN,,328.98,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Optum,VACCN,,9.09,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Optum,VACCN,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN,,70.59,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN,,70.59,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Optum,VACCN,,70.59,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Optum,VACCN,,208.97,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN,,328.98,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Optum,VACCN,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Optum,VACCN,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Optum,VACCN,,328.98,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Optum,VACCN,,363.08,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Optum,VACCN,,363.08,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Optum,VACCN,,363.08,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Optum,VACCN,,363.08,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Optum,VACCN,,1357.09,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Optum,VACCN,,1357.09,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Optum,VACCN,,131.69,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Optum,VACCN,,1357.09,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Optum,VACCN,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Optum,VACCN,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Optum,VACCN,,363.08,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Optum,VACCN,,363.08,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Optum,VACCN,,131.69,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Optum,VACCN,,131.69,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Optum,VACCN,,363.08,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Optum,VACCN,,363.08,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Optum,VACCN,,131.69,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Optum,VACCN,,363.08,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Optum,VACCN,,363.08,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Optum,VACCN,,131.69,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Optum,VACCN,,131.69,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Optum,VACCN,,1741.58,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Optum,VACCN,,1741.58,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Optum,VACCN,,573.75,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Optum,VACCN,,573.75,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Optum,VACCN,,573.75,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Optum,VACCN,,688.15,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Optum,VACCN,,108.61,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Optum,VACCN,,328.98,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Optum,VACCN,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Optum,VACCN,,328.98,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Optum,VACCN,,70.59,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Optum,VACCN,,328.98,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Optum,VACCN,,45.76,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Optum,VACCN,,328.98,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Optum,VACCN,,208.97,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Optum,VACCN,,208.97,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Optum,VACCN,,328.98,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Optum,VACCN,,1357.09,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Optum,VACCN,,108.61,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Optum,VACCN,,260.83,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Optum,VACCN,,260.83,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Optum,VACCN,,260.83,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Optum,VACCN,,573.75,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Optum,VACCN,,573.75,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Optum,VACCN,,573.75,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Optum,VACCN,,363.08,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Optum,VACCN,,363.08,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Optum,VACCN,,363.08,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Optum,VACCN,,363.08,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Optum,VACCN,,363.08,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Optum,VACCN,,363.08,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Optum,VACCN,,328.98,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Optum,VACCN,,7582.11,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Optum,VACCN,,7582.11,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Optum,VACCN,,688.15,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Optum,VACCN,,688.15,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Optum,VACCN,,688.15,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Optum,VACCN,,328.98,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Optum,VACCN,,363.08,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Optum,VACCN,,363.08,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Optum,VACCN,,1357.09,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Optum,VACCN,,1357.09,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Optum,VACCN,,363.08,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Optum,VACCN,,363.08,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Optum,VACCN,,363.08,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Optum,VACCN,,131.69,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Optum,VACCN,,131.69,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Optum,VACCN,,363.08,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Optum,VACCN,,363.08,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Optum,VACCN,,573.75,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN,,1625.90,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Optum,VACCN,,199.53,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Optum,VACCN,,3153.59,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Optum,VACCN,,201.73,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Optum,VACCN,,230.33,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Optum,VACCN,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Optum,VACCN,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Optum,VACCN,,4896.17,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Optum,VACCN,,301.71,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Optum,VACCN,,433.61,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Optum,VACCN,,230.33,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN,,201.73,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN,,201.73,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,127.85,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,127.85,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Optum,VACCN,,201.73,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN,,127.85,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN,,127.85,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Optum,VACCN,,201.73,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Optum,VACCN,,24.29,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN,,24.29,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Optum,VACCN,,38.93,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Optum,VACCN,,127.85,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN,,201.73,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN,,201.73,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN,,201.73,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Optum,VACCN,,201.73,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN,,201.73,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Optum,VACCN,,201.73,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN,,201.73,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,201.73,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN,,201.73,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Optum,VACCN,,36.99,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN,,36.99,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Optum,VACCN,,155.18,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Optum,VACCN,,155.18,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Optum,VACCN,,308.86,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Optum,VACCN,,526.27,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Optum,VACCN,,308.86,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Optum,VACCN,,308.86,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN,,155.18,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Optum,VACCN,,58.92,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Optum,VACCN,,308.86,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Optum,VACCN,,127.85,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Optum,VACCN,,127.85,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN,,127.85,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Optum,VACCN,,127.85,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Optum,VACCN,,308.86,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Optum,VACCN,,155.18,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Optum,VACCN,,308.86,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Optum,VACCN,,58.92,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Optum,VACCN,,308.86,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Optum,VACCN,,155.18,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Optum,VACCN,,155.18,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN,,155.18,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Optum,VACCN,,308.86,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Optum,VACCN,,433.61,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Optum,VACCN,,308.86,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Optum,VACCN,,308.86,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Optum,VACCN,,308.86,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Optum,VACCN,,192.56,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN,,1625.90,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Optum,VACCN,,694.01,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Optum,VACCN,,422.35,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Optum,VACCN,,526.27,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Optum,VACCN,,395.78,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Optum,VACCN,,155.18,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Optum,VACCN,,526.27,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Optum,VACCN,,526.27,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Optum,VACCN,,155.18,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Optum,VACCN,,1009.09,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Optum,VACCN,,1009.09,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Optum,VACCN,,1009.09,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Optum,VACCN,,239.75,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Optum,VACCN,,308.86,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Optum,VACCN,,105.47,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Optum,VACCN,,239.75,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Optum,VACCN,,308.86,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Optum,VACCN,,127.85,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Optum,VACCN,,308.86,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Optum,VACCN,,155.18,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Optum,VACCN,,308.86,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Optum,VACCN,,239.75,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Optum,VACCN,,526.27,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Optum,VACCN,,105.47,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Optum,VACCN,,239.75,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Optum,VACCN,,308.86,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Optum,VACCN,,105.47,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Optum,VACCN,,58.92,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Optum,VACCN,,105.47,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Optum,VACCN,,239.75,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Optum,VACCN,,105.47,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN,,105.47,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Optum,VACCN,,105.47,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Optum,VACCN,,1009.09,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Optum,VACCN,,1009.09,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Optum,VACCN,,1009.09,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Optum,VACCN,,155.18,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Optum,VACCN,,127.85,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Optum,VACCN,,127.85,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Optum,VACCN,,155.18,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Optum,VACCN,,155.18,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN,,127.85,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Optum,VACCN,,308.86,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Optum,VACCN,,308.86,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Optum,VACCN,,127.85,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN,,155.18,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN,,308.86,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Optum,VACCN,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Optum,VACCN,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Optum,VACCN,,526.27,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Optum,VACCN,,155.18,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Optum,VACCN,,127.85,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Optum,VACCN,,127.85,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Optum,VACCN,,308.86,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Optum,VACCN,,308.86,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Optum,VACCN,,1009.09,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Optum,VACCN,,526.27,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Optum,VACCN,,308.86,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Optum,VACCN,,526.27,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Optum,VACCN,,1009.09,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Optum,VACCN,,308.86,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Optum,VACCN,,526.27,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN,,105.47,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Optum,VACCN,,155.18,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Optum,VACCN,,308.86,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Optum,VACCN,,308.86,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Optum,VACCN,,308.86,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Optum,VACCN,,526.27,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Optum,VACCN,,526.27,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Optum,VACCN,,526.27,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Optum,VACCN,,308.86,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Optum,VACCN,,308.86,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Optum,VACCN,,526.27,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Optum,VACCN,,526.27,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Optum,VACCN,,526.27,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Optum,VACCN,,1009.09,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Optum,VACCN,,308.86,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN,,70.59,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN,,70.59,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN,,29.55,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Optum,VACCN,,45.76,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,70.59,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,70.59,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,70.59,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,70.59,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,70.59,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Optum,VACCN,,41.18,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Optum,VACCN,,197.08,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Optum,VACCN,,1607.02,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Optum,VACCN,,1607.02,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Optum,VACCN,,2838.70,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Optum,VACCN,,607.14,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Optum,VACCN,,607.14,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Optum,VACCN,,1607.02,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Optum,VACCN,,197.08,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Optum,VACCN,,197.08,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Optum,VACCN,,197.08,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Optum,VACCN,,396.27,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Optum,VACCN,,58.92,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN,,58.92,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN,,58.92,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Optum,VACCN,,197.08,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Optum,VACCN,,197.08,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Optum,VACCN,,197.08,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Optum,VACCN,,697.85,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Optum,VACCN,,292.78,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Optum,VACCN,,292.78,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Optum,VACCN,,292.78,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Optum,VACCN,,292.78,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Optum,VACCN,,292.78,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Optum,VACCN,,263.41,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Optum,VACCN,,230.33,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Optum,VACCN,,396.27,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Optum,VACCN,,396.27,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Optum,VACCN,,396.27,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Optum,VACCN,,127.85,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Optum,VACCN,,328.98,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Optum,VACCN,,328.98,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Optum,VACCN,,1607.02,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Optum,VACCN,,686.87,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Optum,VACCN,,686.87,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Optum,VACCN,,686.87,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Optum,VACCN,,297.46,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN,,297.46,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Optum,VACCN,,6509.35,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Optum,VACCN,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Optum,VACCN,,686.87,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Optum,VACCN,,292.78,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Optum,VACCN,,883.03,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Optum,VACCN,,883.03,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Optum,VACCN,,6509.35,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN,,292.78,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN,,292.78,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Optum,VACCN,,1936.84,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Optum,VACCN,,1936.84,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Optum,VACCN,,883.03,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Optum,VACCN,,883.03,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Optum,VACCN,,883.03,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Optum,VACCN,,292.78,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Optum,VACCN,,197.08,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Optum,VACCN,,197.08,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,197.08,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,197.08,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Optum,VACCN,,697.85,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Optum,VACCN,,883.03,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Optum,VACCN,,686.87,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Optum,VACCN,,686.87,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Optum,VACCN,,686.87,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Optum,VACCN,,292.78,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Optum,VACCN,,883.03,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Optum,VACCN,,396.27,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Optum,VACCN,,686.87,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Optum,VACCN,,883.03,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Optum,VACCN,,883.03,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Optum,VACCN,,686.87,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Optum,VACCN,,686.87,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Optum,VACCN,,883.03,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Optum,VACCN,,883.03,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Optum,VACCN,,883.03,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Optum,VACCN,,883.03,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Optum,VACCN,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Optum,VACCN,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN,,292.78,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Optum,VACCN,,883.03,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Optum,VACCN,,686.87,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Optum,VACCN,,686.87,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Optum,VACCN,,686.87,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Optum,VACCN,,883.03,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Optum,VACCN,,686.87,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Optum,VACCN,,883.03,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Optum,VACCN,,686.87,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Optum,VACCN,,686.87,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Optum,VACCN,,686.87,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Optum,VACCN,,686.87,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Optum,VACCN,,686.87,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Optum,VACCN,,1936.84,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Optum,VACCN,,1936.84,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Optum,VACCN,,1936.84,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Optum,VACCN,,1936.84,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Optum,VACCN,,1814.30,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Optum,VACCN,,1814.30,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Optum,VACCN,,197.08,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,197.08,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Optum,VACCN,,328.98,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Optum,VACCN,,136.77,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Optum,VACCN,,127.85,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Optum,VACCN,,396.27,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Optum,VACCN,,396.27,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Optum,VACCN,,192.56,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Optum,VACCN,,87.33,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Optum,VACCN,,157.07,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Optum,VACCN,,274.63,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Optum,VACCN,,422.35,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Optum,VACCN,,608.10,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Optum,VACCN,,835.73,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Optum,VACCN,,308.86,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN,,127.85,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN,,127.85,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Optum,VACCN,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Optum,VACCN,,58.92,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN,,38.93,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN,,38.93,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN,,38.93,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN,,38.93,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Optum,VACCN,,197.08,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Optum,VACCN,,1169.46,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Optum,VACCN,,396.27,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Optum,VACCN,,1607.02,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Optum,VACCN,,51.09,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Optum,VACCN,,197.08,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Optum,VACCN,,1814.30,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Optum,VACCN,,1814.30,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Optum,VACCN,,1814.30,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Optum,VACCN,,1814.30,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Optum,VACCN,,156.50,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Optum,VACCN,,156.50,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN,,156.50,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Optum,VACCN,,3121.82,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Optum,VACCN,,3153.59,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN,,297.46,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Optum,VACCN,,607.14,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Optum,VACCN,,686.87,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Optum,VACCN,,1540.76,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Optum,VACCN,,1540.76,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Optum,VACCN,,5655.00,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Optum,VACCN,,5655.00,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Optum,VACCN,,11248.03,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Optum,VACCN,,11248.03,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Optum,VACCN,,5655.00,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Optum,VACCN,,5655.00,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Optum,VACCN,,11248.03,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Optum,VACCN,,11248.03,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Optum,VACCN,,17810.19,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Optum,VACCN,,17810.19,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN,,156.50,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Optum,VACCN,,197.08,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Optum,VACCN,,197.08,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Optum,VACCN,,396.27,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Optum,VACCN,,2838.70,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN,,38.93,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN,,197.08,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN,,396.27,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN,,607.14,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN,,396.27,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN,,127.85,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Optum,VACCN,,91.04,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Optum,VACCN,,91.04,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Optum,VACCN,,36.99,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Optum,VACCN,,36.99,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Optum,VACCN,,36.99,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Optum,VACCN,,36.99,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Optum,VACCN,,36.99,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN,,24.29,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Optum,VACCN,,197.08,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN,,396.27,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN,,58.92,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN,,396.27,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Optum,VACCN,,17342.42,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Optum,VACCN,,7085.44,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Optum,VACCN,,1607.02,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Optum,VACCN,,127.85,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Optum,VACCN,,127.85,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Optum,VACCN,,1607.02,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Optum,VACCN,,929.91,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN,,241.23,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Optum,VACCN,,2031.79,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN,,433.61,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Optum,VACCN,,2031.79,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Optum,VACCN,,3420.83,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Optum,VACCN,,1625.90,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Optum,VACCN,,697.85,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Optum,VACCN,,1607.02,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Optum,VACCN,,1607.02,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Optum,VACCN,,1607.02,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Optum,VACCN,,11248.03,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Optum,VACCN,,613.21,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Optum,VACCN,,697.85,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Optum,VACCN,,697.85,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Optum,VACCN,,697.85,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Optum,VACCN,,697.85,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Optum,VACCN,,58.92,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN,,70.59,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Optum,VACCN,,526.27,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Optum,VACCN,,526.27,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Optum,VACCN,,526.27,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Optum,VACCN,,308.86,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Optum,VACCN,,155.18,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Optum,VACCN,,929.91,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Optum,VACCN,,929.91,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Optum,VACCN,,308.86,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Optum,VACCN,,929.91,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Optum,VACCN,,308.86,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Optum,VACCN,,526.27,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Optum,VACCN,,526.27,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Optum,VACCN,,2313.92,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Optum,VACCN,,308.86,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Optum,VACCN,,308.86,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Optum,VACCN,,155.18,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Optum,VACCN,,308.86,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Optum,VACCN,,308.86,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN,,87.33,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Optum,VACCN,,105.47,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Optum,VACCN,,105.47,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Optum,VACCN,,87.33,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Optum,VACCN,,105.47,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Optum,VACCN,,87.33,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Optum,VACCN,,239.75,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Optum,VACCN,,105.47,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Optum,VACCN,,87.33,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Optum,VACCN,,87.33,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN,,87.33,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Optum,VACCN,,105.47,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Optum,VACCN,,105.47,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Optum,VACCN,,87.33,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Optum,VACCN,,87.33,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Optum,VACCN,,87.33,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Optum,VACCN,,87.33,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Optum,VACCN,,105.47,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Optum,VACCN,,105.47,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Optum,VACCN,,105.47,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN,,87.33,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Optum,VACCN,,87.33,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Optum,VACCN,,87.33,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Optum,VACCN,,87.33,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN,,105.47,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Optum,VACCN,,105.47,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Optum,VACCN,,105.47,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Optum,VACCN,,105.47,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Optum,VACCN,,87.33,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Optum,VACCN,,105.47,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Optum,VACCN,,105.47,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Optum,VACCN,,105.47,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN,,105.47,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Optum,VACCN,,105.47,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Optum,VACCN,,105.47,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Optum,VACCN,,105.47,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Optum,VACCN,,87.33,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Optum,VACCN,,783.61,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Optum,VACCN,,783.61,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Optum,VACCN,,783.61,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Optum,VACCN,,783.61,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Optum,VACCN,,1936.84,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Optum,VACCN,,87.33,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Optum,VACCN,,105.47,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Optum,VACCN,,87.33,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Optum,VACCN,,87.33,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Optum,VACCN,,354.22,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Optum,VACCN,,87.33,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Optum,VACCN,,87.33,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Optum,VACCN,,87.33,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Optum,VACCN,,87.33,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Optum,VACCN,,354.22,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Optum,VACCN,,87.33,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Optum,VACCN,,105.47,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Optum,VACCN,,87.33,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Optum,VACCN,,87.33,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Optum,VACCN,,354.22,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Optum,VACCN,,105.47,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Optum,VACCN,,87.33,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Optum,VACCN,,87.33,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Optum,VACCN,,354.22,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Optum,VACCN,,87.33,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Optum,VACCN,,87.33,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Optum,VACCN,,105.47,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Optum,VACCN,,87.33,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Optum,VACCN,,354.22,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Optum,VACCN,,87.33,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN,,87.33,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Optum,VACCN,,87.33,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN,,87.33,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Optum,VACCN,,354.22,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Optum,VACCN,,87.33,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN,,87.33,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Optum,VACCN,,87.33,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN,,87.33,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Optum,VACCN,,87.33,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Optum,VACCN,,543.83,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Optum,VACCN,,543.83,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Optum,VACCN,,543.83,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Optum,VACCN,,176.57,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Optum,VACCN,,176.57,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Optum,VACCN,,176.57,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN,,176.57,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Optum,VACCN,,354.22,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Optum,VACCN,,354.22,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Optum,VACCN,,354.22,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Optum,VACCN,,239.75,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Optum,VACCN,,239.75,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Optum,VACCN,,239.75,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Optum,VACCN,,2031.79,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Optum,VACCN,,239.75,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Optum,VACCN,,5361.59,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Optum,VACCN,,3121.82,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Optum,VACCN,,3121.82,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Optum,VACCN,,105.47,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Optum,VACCN,,1540.76,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Optum,VACCN,,1540.76,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Optum,VACCN,,3121.82,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Optum,VACCN,,1540.76,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Optum,VACCN,,3121.82,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Optum,VACCN,,3121.82,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Optum,VACCN,,3121.82,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Optum,VACCN,,5361.59,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Optum,VACCN,,3121.82,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Optum,VACCN,,3121.82,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Optum,VACCN,,3121.82,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Optum,VACCN,,3121.82,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Optum,VACCN,,3121.82,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Optum,VACCN,,5361.59,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Optum,VACCN,,3121.82,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Optum,VACCN,,239.75,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Optum,VACCN,,87.33,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Optum,VACCN,,543.83,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Optum,VACCN,,543.83,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Optum,VACCN,,105.47,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN,,87.33,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Optum,VACCN,,239.75,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Optum,VACCN,,239.75,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Optum,VACCN,,105.47,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Optum,VACCN,,105.47,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Optum,VACCN,,105.47,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Optum,VACCN,,105.47,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Optum,VACCN,,105.47,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Optum,VACCN,,105.47,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Optum,VACCN,,87.33,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Optum,VACCN,,5361.59,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Optum,VACCN,,3121.82,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Optum,VACCN,,3121.82,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Optum,VACCN,,5361.59,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Optum,VACCN,,3121.82,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Optum,VACCN,,5361.59,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Optum,VACCN,,3121.82,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Optum,VACCN,,3121.82,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Optum,VACCN,,3121.82,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Optum,VACCN,,3121.82,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Optum,VACCN,,87.33,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Optum,VACCN,,87.33,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Optum,VACCN,,105.47,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Optum,VACCN,,239.75,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Optum,VACCN,,105.47,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Optum,VACCN,,1936.84,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Optum,VACCN,,87.33,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Optum,VACCN,,105.47,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Optum,VACCN,,105.47,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Optum,VACCN,,87.33,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Optum,VACCN,,87.33,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Optum,VACCN,,105.47,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Optum,VACCN,,105.47,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Optum,VACCN,,105.47,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Optum,VACCN,,105.47,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Optum,VACCN,,87.33,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Optum,VACCN,,87.33,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Optum,VACCN,,176.57,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Optum,VACCN,,176.57,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Optum,VACCN,,17342.42,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Optum,VACCN,,5361.59,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Optum,VACCN,,783.61,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Optum,VACCN,,87.33,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Optum,VACCN,,105.47,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Optum,VACCN,,105.47,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Optum,VACCN,,176.57,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Optum,VACCN,,176.57,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Optum,VACCN,,176.57,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Optum,VACCN,,105.47,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Optum,VACCN,,176.57,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Optum,VACCN,,176.57,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Optum,VACCN,,176.57,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Optum,VACCN,,105.47,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Optum,VACCN,,328.98,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Optum,VACCN,,398.55,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Optum,VACCN,,398.55,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Optum,VACCN,,398.55,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Optum,VACCN,,398.55,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Optum,VACCN,,533.88,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Optum,VACCN,,398.55,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Optum,VACCN,,533.88,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Optum,VACCN,,398.55,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Optum,VACCN,,398.55,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Optum,VACCN,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Optum,VACCN,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Optum,VACCN,,533.88,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Optum,VACCN,,398.55,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Optum,VACCN,,533.88,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Optum,VACCN,,398.55,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Optum,VACCN,,398.55,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Optum,VACCN,,398.55,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Optum,VACCN,,398.55,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Optum,VACCN,,398.55,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Optum,VACCN,,398.55,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Optum,VACCN,,398.55,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Optum,VACCN,,398.55,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Optum,VACCN,,398.55,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Optum,VACCN,,1294.83,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Optum,VACCN,,1294.83,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Optum,VACCN,,398.55,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Optum,VACCN,,533.88,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Optum,VACCN,,398.55,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Optum,VACCN,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Optum,VACCN,,533.88,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Optum,VACCN,,533.88,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Optum,VACCN,,1294.83,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN,,398.55,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN,,533.88,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Optum,VACCN,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Optum,VACCN,,398.55,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Optum,VACCN,,398.55,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Optum,VACCN,,1294.83,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Optum,VACCN,,1294.83,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,23.13,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Optum,VACCN,,715.29,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Optum,VACCN,,1914.61,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Optum,VACCN,,2074.81,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Optum,VACCN,,222.30,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Optum,VACCN,,222.30,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Optum,VACCN,,222.30,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Optum,VACCN,,222.30,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Optum,VACCN,,4314.91,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Optum,VACCN,,398.55,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Optum,VACCN,,56824.55,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Optum,VACCN,,1031.39,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Optum,VACCN,,2194.62,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Optum,VACCN,,398.55,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Optum,VACCN,,172.22,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Optum,VACCN,,398.55,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Optum,VACCN,,533.88,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Optum,VACCN,,268.42,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Optum,VACCN,,398.55,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Optum,VACCN,,398.55,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Optum,VACCN,,1294.83,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Optum,VACCN,,1294.83,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Optum,VACCN,,1294.83,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Optum,VACCN,,1446.69,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Optum,VACCN,,498.67,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Optum,VACCN,,595.10,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Optum,VACCN,,332.44,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Optum,VACCN,,381.01,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Optum,VACCN,,671.22,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Optum,VACCN,,87.33,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Optum,VACCN,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Optum,VACCN,,354.22,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Optum,VACCN,,354.22,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Optum,VACCN,,176.57,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN,,87.33,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Optum,VACCN,,176.57,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Optum,VACCN,,176.57,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Optum,VACCN,,176.57,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Optum,VACCN,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Optum,VACCN,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Optum,VACCN,,176.57,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Optum,VACCN,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Optum,VACCN,,176.57,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Optum,VACCN,,176.57,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Optum,VACCN,,176.57,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Optum,VACCN,,354.22,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Optum,VACCN,,239.75,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Optum,VACCN,,354.22,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Optum,VACCN,,354.22,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Optum,VACCN,,87.33,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Optum,VACCN,,176.57,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Optum,VACCN,,105.47,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Optum,VACCN,,176.57,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Optum,VACCN,,239.75,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Optum,VACCN,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Optum,VACCN,,354.22,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Optum,VACCN,,942.74,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Optum,VACCN,,1540.76,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Optum,VACCN,,1881.51,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Optum,VACCN,,1881.51,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN,,6188.83,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Optum,VACCN,,3500.26,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Optum,VACCN,,1936.84,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Optum,VACCN,,863.63,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Optum,VACCN,,1607.02,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Optum,VACCN,,5361.59,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Optum,VACCN,,5361.59,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Optum,VACCN,,1607.02,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Optum,VACCN,,1607.02,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Optum,VACCN,,396.27,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Optum,VACCN,,396.27,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Optum,VACCN,,613.21,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Optum,VACCN,,5786.75,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN,,6188.83,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Optum,VACCN,,1881.51,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Optum,VACCN,,929.91,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Optum,VACCN,,2031.79,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Optum,VACCN,,1607.02,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Optum,VACCN,,1607.02,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Optum,VACCN,,1607.02,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Optum,VACCN,,1607.02,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Optum,VACCN,,1607.02,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Optum,VACCN,,1469.19,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Optum,VACCN,,292.78,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Optum,VACCN,,292.78,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Optum,VACCN,,292.78,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Optum,VACCN,,292.78,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Optum,VACCN,,292.78,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Optum,VACCN,,12761.83,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Optum,VACCN,,237.92,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Optum,VACCN,,1607.02,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Optum,VACCN,,3218.13,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Optum,VACCN,,3218.13,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Optum,VACCN,,1607.02,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Optum,VACCN,,3500.26,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Optum,VACCN,,613.21,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Optum,VACCN,,1357.09,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Optum,VACCN,,613.21,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Optum,VACCN,,1540.76,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Optum,VACCN,,3121.82,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Optum,VACCN,,3121.82,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Optum,VACCN,,5361.59,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Optum,VACCN,,3121.82,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Optum,VACCN,,3121.82,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Optum,VACCN,,3121.82,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Optum,VACCN,,1540.76,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Optum,VACCN,,1540.76,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Optum,VACCN,,613.21,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Optum,VACCN,,1540.76,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Optum,VACCN,,3121.82,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Optum,VACCN,,1540.76,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Optum,VACCN,,3121.82,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Optum,VACCN,,5361.59,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Optum,VACCN,,3121.82,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Optum,VACCN,,1540.76,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Optum,VACCN,,613.21,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Optum,VACCN,,1540.76,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Optum,VACCN,,3121.82,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Optum,VACCN,,1540.76,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Optum,VACCN,,1540.76,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Optum,VACCN,,208.97,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Optum,VACCN,,208.97,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Optum,VACCN,,17810.19,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Optum,VACCN,,17810.19,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN,,11248.03,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN,,11248.03,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN,,3121.82,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Optum,VACCN,,3121.82,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Optum,VACCN,,5361.59,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Optum,VACCN,,5361.59,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Optum,VACCN,,3121.82,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Optum,VACCN,,3121.82,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Optum,VACCN,,3121.82,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Optum,VACCN,,3121.82,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Optum,VACCN,,5361.59,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Optum,VACCN,,11248.03,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Optum,VACCN,,5361.59,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Optum,VACCN,,613.21,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Optum,VACCN,,1607.02,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Optum,VACCN,,1607.02,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Optum,VACCN,,398.55,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN,,433.61,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Optum,VACCN,,395.78,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Optum,VACCN,,929.91,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Optum,VACCN,,10326.26,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Optum,VACCN,,3500.26,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Optum,VACCN,,10326.26,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Optum,VACCN,,1607.02,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Optum,VACCN,,929.91,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Optum,VACCN,,929.91,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Optum,VACCN,,1607.02,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Optum,VACCN,,1357.09,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Optum,VACCN,,3500.26,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Optum,VACCN,,3121.82,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Optum,VACCN,,1881.51,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Optum,VACCN,,1881.51,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Optum,VACCN,,1881.51,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Optum,VACCN,,929.91,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Optum,VACCN,,929.91,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Optum,VACCN,,929.91,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Optum,VACCN,,239.75,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Optum,VACCN,,929.91,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Optum,VACCN,,1607.02,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Optum,VACCN,,2031.79,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Optum,VACCN,,2031.79,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Optum,VACCN,,2031.79,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN,,662.02,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Optum,VACCN,,697.85,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Optum,VACCN,,5786.75,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Optum,VACCN,,10326.26,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Optum,VACCN,,2031.79,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Optum,VACCN,,127.85,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Optum,VACCN,,241.23,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN,,199.53,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Optum,VACCN,,697.85,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Optum,VACCN,,11248.03,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Optum,VACCN,,11248.03,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Optum,VACCN,,697.85,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Optum,VACCN,,697.85,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Optum,VACCN,,686.87,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Optum,VACCN,,883.03,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Optum,VACCN,,883.03,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Optum,VACCN,,883.03,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Optum,VACCN,,883.03,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Optum,VACCN,,883.03,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Optum,VACCN,,883.03,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Optum,VACCN,,883.03,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Optum,VACCN,,883.03,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Optum,VACCN,,883.03,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Optum,VACCN,,883.03,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Optum,VACCN,,883.03,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Optum,VACCN,,883.03,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Optum,VACCN,,1936.84,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Optum,VACCN,,1936.84,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Optum,VACCN,,883.03,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Optum,VACCN,,883.03,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Optum,VACCN,,1169.46,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Optum,VACCN,,7085.44,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Optum,VACCN,,7085.44,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Optum,VACCN,,11248.03,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Optum,VACCN,,11248.03,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Optum,VACCN,,697.85,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Optum,VACCN,,433.61,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Optum,VACCN,,697.85,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Optum,VACCN,,1607.02,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Optum,VACCN,,1607.02,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Optum,VACCN,,1607.02,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Optum,VACCN,,1607.02,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Optum,VACCN,,10326.26,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Optum,VACCN,,697.85,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Optum,VACCN,,697.85,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Optum,VACCN,,11248.03,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Optum,VACCN,,17810.19,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Optum,VACCN,,11248.03,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Optum,VACCN,,697.85,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Optum,VACCN,,3500.26,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Optum,VACCN,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Optum,VACCN,,686.87,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Optum,VACCN,,686.87,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Optum,VACCN,,292.78,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Optum,VACCN,,292.78,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Optum,VACCN,,3218.13,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Optum,VACCN,,3218.13,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Optum,VACCN,,7085.44,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Optum,VACCN,,7085.44,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Optum,VACCN,,783.61,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Optum,VACCN,,783.61,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Optum,VACCN,,3500.26,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Optum,VACCN,,3500.26,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Optum,VACCN,,3500.26,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Optum,VACCN,,3500.26,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Optum,VACCN,,3500.26,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Optum,VACCN,,3500.26,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Optum,VACCN,,929.91,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Optum,VACCN,,5786.75,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Optum,VACCN,,5786.75,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Optum,VACCN,,5786.75,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Optum,VACCN,,6188.83,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Optum,VACCN,,1607.02,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Optum,VACCN,,662.02,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Optum,VACCN,,662.02,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Optum,VACCN,,2031.79,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Optum,VACCN,,3420.83,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Optum,VACCN,,2031.79,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Optum,VACCN,,2031.79,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Optum,VACCN,,3420.83,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Optum,VACCN,,3420.83,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Optum,VACCN,,3420.83,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Optum,VACCN,,17810.19,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Optum,VACCN,,5361.59,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Optum,VACCN,,697.85,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Optum,VACCN,,5655.00,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Optum,VACCN,,5655.00,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Optum,VACCN,,5655.00,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Optum,VACCN,,2838.70,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Optum,VACCN,,1540.76,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Optum,VACCN,,1540.76,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Optum,VACCN,,1540.76,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Optum,VACCN,,613.21,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN,,613.21,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN,,1540.76,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN,,241.23,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN,,241.23,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Optum,VACCN,,3420.83,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Optum,VACCN,,3420.83,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Optum,VACCN,,1607.02,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Optum,VACCN,,6351.81,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Optum,VACCN,,613.21,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN,,1540.76,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN,,613.21,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Optum,VACCN,,1540.76,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Optum,VACCN,,1009.09,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Optum,VACCN,,783.61,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Optum,VACCN,,105.47,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Optum,VACCN,,105.47,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Optum,VACCN,,105.47,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Optum,VACCN,,105.47,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Optum,VACCN,,105.47,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Optum,VACCN,,105.47,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Optum,VACCN,,105.47,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Optum,VACCN,,105.47,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Optum,VACCN,,105.47,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Optum,VACCN,,105.47,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Optum,VACCN,,105.47,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Optum,VACCN,,239.75,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Optum,VACCN,,105.47,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Optum,VACCN,,105.47,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Optum,VACCN,,105.47,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Optum,VACCN,,105.47,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN,,105.47,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Optum,VACCN,,239.75,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN,,105.47,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Optum,VACCN,,105.47,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Optum,VACCN,,105.47,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Optum,VACCN,,105.47,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Optum,VACCN,,105.47,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Optum,VACCN,,105.47,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Optum,VACCN,,87.33,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Optum,VACCN,,87.33,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,105.47,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Optum,VACCN,,87.33,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Optum,VACCN,,105.47,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Optum,VACCN,,87.33,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Optum,VACCN,,105.47,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Optum,VACCN,,1294.83,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Optum,VACCN,,1446.69,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Optum,VACCN,,1446.69,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Optum,VACCN,,1446.69,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Optum,VACCN,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Optum,VACCN,,398.55,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Optum,VACCN,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Optum,VACCN,,1446.69,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Optum,VACCN,,1446.69,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Optum,VACCN,,1446.69,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Optum,VACCN,,1446.69,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Optum,VACCN,,1446.69,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Optum,VACCN,,1446.69,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Optum,VACCN,,2232.14,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Optum,VACCN,,1934.58,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Optum,VACCN,,239.75,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Optum,VACCN,,543.83,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Optum,VACCN,,543.83,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Optum,VACCN,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Optum,VACCN,,543.83,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Optum,VACCN,,783.61,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Optum,VACCN,,354.22,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Optum,VACCN,,354.22,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Optum,VACCN,,354.22,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Optum,VACCN,,354.22,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Optum,VACCN,,354.22,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Optum,VACCN,,783.61,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Optum,VACCN,,354.22,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Optum,VACCN,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Optum,VACCN,,354.22,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Optum,VACCN,,783.61,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Optum,VACCN,,354.22,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Optum,VACCN,,354.22,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Optum,VACCN,,354.22,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Optum,VACCN,,354.22,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Optum,VACCN,,87.33,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Optum,VACCN,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Optum,VACCN,,354.22,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Optum,VACCN,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Optum,VACCN,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Optum,VACCN,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Optum,VACCN,,354.22,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Optum,VACCN,,354.22,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Optum,VACCN,,354.22,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Optum,VACCN,,354.22,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Optum,VACCN,,354.22,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Optum,VACCN,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Optum,VACCN,,354.22,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Optum,VACCN,,354.22,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Optum,VACCN,,354.22,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Optum,VACCN,,239.75,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Optum,VACCN,,87.33,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Optum,VACCN,,58.92,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Optum,VACCN,,686.87,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Optum,VACCN,,686.87,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Optum,VACCN,,686.87,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Optum,VACCN,,686.87,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Optum,VACCN,,105.47,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Optum,VACCN,,105.47,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Optum,VACCN,,105.47,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Optum,VACCN,,155.18,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Optum,VACCN,,239.75,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Optum,VACCN,,105.47,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Optum,VACCN,,105.47,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Optum,VACCN,,239.75,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Optum,VACCN,,105.47,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Optum,VACCN,,10.56,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Optum,VACCN,,47.81,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN,,8.68,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Optum,VACCN,,47.63,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Optum,VACCN,,8.17,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN,,163.96,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Optum,VACCN,,144.84,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Optum,VACCN,,556.60,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Optum,VACCN,,291.36,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Optum,VACCN,,1160.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Optum,VACCN,,1160.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Optum,VACCN,,65.69,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Optum,VACCN,,73.37,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Optum,VACCN,,57.04,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Optum,VACCN,,44.89,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Optum,VACCN,,165.51,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Optum,VACCN,,101.12,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN,,35.00,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Optum,VACCN,,65.36,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Optum,VACCN,,197.99,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Optum,VACCN,,172.73,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Optum,VACCN,,233.07,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Optum,VACCN,,233.07,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN,,2.25,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Optum,VACCN,,348.56,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Optum,VACCN,,51.07,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Optum,VACCN,,43.65,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Optum,VACCN,,201.50,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Optum,VACCN,,234.00,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Optum,VACCN,,402.12,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Optum,VACCN,,403.59,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Optum,VACCN,,127.43,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Optum,VACCN,,74.33,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Optum,VACCN,,94.74,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Optum,VACCN,,345.57,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Optum,VACCN,,335.38,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Optum,VACCN,,177.25,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Optum,VACCN,,169.90,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Optum,VACCN,,123.68,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Optum,VACCN,,246.52,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Optum,VACCN,,124.64,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Optum,VACCN,,300.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Optum,VACCN,,193.25,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Optum,VACCN,,295.79,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN,,16.77,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Optum,VACCN,,5.04,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Optum,VACCN,,8.74,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Optum,VACCN,,9.66,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN,,7.52,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN,,4.31,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Optum,VACCN,,4.27,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Optum,VACCN,,62.14,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Optum,VACCN,,8.46,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Optum,VACCN,,7.01,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Optum,VACCN,,13.39,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Optum,VACCN,,62.14,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Optum,VACCN,,62.14,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Optum,VACCN,,62.14,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN,,62.14,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Optum,VACCN,,62.14,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN,,15.08,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN,,15.08,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,15.08,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,14.57,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,13.28,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,13.54,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN,,16.38,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN,,16.38,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Optum,VACCN,,16.38,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN,,14.69,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.61,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN,,15.30,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,13.25,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN,,13.76,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Optum,VACCN,,13.73,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Optum,VACCN,,13.73,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN,,14.14,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN,,16.13,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN,,16.13,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN,,16.13,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN,,13.54,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN,,13.54,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN,,13.54,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Optum,VACCN,,32.62,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN,,4.52,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN,,8.17,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,8.17,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,4.95,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN,,7.78,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN,,5.78,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN,,5.78,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN,,17.27,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Optum,VACCN,,13.44,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN,,16.77,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,14.57,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN,,6.48,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN,,6.48,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN,,6.48,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN,,16.18,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN,,5.02,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN,,5.02,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,5.02,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Optum,VACCN,,4.38,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN,,5.32,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN,,4.23,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Optum,VACCN,,29.60,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN,,5.16,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN,,5.16,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN,,6.03,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Optum,VACCN,,4.88,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,12.32,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,12.32,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Optum,VACCN,,18.96,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN,,10.74,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,14.12,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,14.12,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,4.60,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,5.75,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,5.75,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Optum,VACCN,,5.00,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN,,4.35,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Optum,VACCN,,38.57,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN,,27.11,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Optum,VACCN,,27.11,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Optum,VACCN,,18.64,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN,,16.30,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Optum,VACCN,,13.73,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,6.51,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN,,11.55,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN,,5.12,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,5.18,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,5.18,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Optum,VACCN,,27.94,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Optum,VACCN,,14.90,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN,,5.10,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Optum,VACCN,,13.63,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Optum,VACCN,,64.41,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN,,14.70,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN,,9.30,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN,,9.30,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN,,11.00,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN,,26.07,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN,,78.77,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN,,78.77,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN,,78.77,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Optum,VACCN,,78.77,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,9.77,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN,,3.93,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN,,3.93,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Optum,VACCN,,3.93,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Optum,VACCN,,4.75,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN,,12.87,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN,,3.92,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN,,3.92,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Optum,VACCN,,7.20,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Optum,VACCN,,18.58,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Optum,VACCN,,18.52,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN,,12.58,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Optum,VACCN,,12.87,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN,,18.06,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Optum,VACCN,,8.00,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,9.71,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN,,8.20,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN,,8.20,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Optum,VACCN,,4.75,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Optum,VACCN,,17.92,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN,,25.45,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN,,11.53,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN,,11.53,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN,,11.43,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.47,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,11.57,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN,,6.04,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN,,6.04,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,19.70,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN,,19.32,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Optum,VACCN,,6.89,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Optum,VACCN,,6.89,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Optum,VACCN,,8.19,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN,,10.50,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,6.70,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,6.70,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN,,6.70,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN,,12.92,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN,,39.26,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN,,17.27,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,17.27,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Optum,VACCN,,6.61,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,6.82,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN,,41.28,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Optum,VACCN,,41.28,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN,,3.58,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN,,3.58,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN,,3.58,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Optum,VACCN,,5.18,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,4.74,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Optum,VACCN,,5.78,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Optum,VACCN,,5.78,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Optum,VACCN,,98.11,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Optum,VACCN,,4.76,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,4.73,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,4.73,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,4.73,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,14.59,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Optum,VACCN,,20.86,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Optum,VACCN,,19.38,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Optum,VACCN,,18.39,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Optum,VACCN,,18.39,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN,,3.67,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,3.67,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,3.67,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Optum,VACCN,,4.00,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN,,10.74,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN,,17.83,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN,,17.83,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN,,4.81,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN,,5.06,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN,,5.06,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN,,4.86,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN,,3.28,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Optum,VACCN,,25.81,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN,,6.87,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Optum,VACCN,,9.02,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Optum,VACCN,,16.80,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,5.18,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN,,5.30,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN,,12.76,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN,,5.74,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Optum,VACCN,,14.18,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Optum,VACCN,,16.94,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Optum,VACCN,,12.47,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,3.95,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN,,5.56,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,4.52,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN,,5.08,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Optum,VACCN,,5.08,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Optum,VACCN,,62.14,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Optum,VACCN,,62.14,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,15.05,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN,,7.87,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Optum,VACCN,,5.22,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Optum,VACCN,,15.05,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Optum,VACCN,,15.05,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Optum,VACCN,,18.37,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN,,11.16,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Optum,VACCN,,5.18,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN,,12.95,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Optum,VACCN,,25.45,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,25.45,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,25.45,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Optum,VACCN,,12.00,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN,,13.74,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Optum,VACCN,,13.74,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Optum,VACCN,,17.93,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Optum,VACCN,,17.93,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Optum,VACCN,,12.05,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN,,12.05,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Optum,VACCN,,20.81,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Optum,VACCN,,20.81,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Optum,VACCN,,5.18,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Optum,VACCN,,29.92,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Optum,VACCN,,22.34,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN,,29.35,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Optum,VACCN,,37.73,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN,,26.78,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,26.78,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,356.78,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Optum,VACCN,,37.73,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Optum,VACCN,,37.73,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Optum,VACCN,,46.98,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Optum,VACCN,,77.78,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN,,14.55,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN,,11.54,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN,,11.54,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN,,10.64,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Optum,VACCN,,5.67,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Optum,VACCN,,61.98,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Optum,VACCN,,24.29,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN,,4.27,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN,,4.40,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN,,4.40,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Optum,VACCN,,17.03,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN,,14.39,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Optum,VACCN,,16.85,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Optum,VACCN,,15.29,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN,,18.14,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN,,18.14,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,10.18,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN,,10.18,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN,,16.85,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN,,16.85,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN,,9.09,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN,,13.19,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Optum,VACCN,,19.35,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Optum,VACCN,,8.89,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN,,13.71,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN,,11.77,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN,,10.74,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,12.39,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Optum,VACCN,,11.26,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Optum,VACCN,,12.39,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Optum,VACCN,,19.35,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,19.35,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN,,12.88,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Optum,VACCN,,14.39,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Optum,VACCN,,14.41,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,13.24,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN,,12.88,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,14.27,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Optum,VACCN,,109.49,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Optum,VACCN,,64.19,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Optum,VACCN,,64.19,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Optum,VACCN,,323.75,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Optum,VACCN,,325.80,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Optum,VACCN,,169.96,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Optum,VACCN,,356.78,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN,,5.39,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN,,5.39,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN,,5.39,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Optum,VACCN,,5.18,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN,,2.99,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,2.99,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Optum,VACCN,,6.35,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Optum,VACCN,,6.35,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Optum,VACCN,,3.83,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Optum,VACCN,,169.96,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,169.96,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Optum,VACCN,,58.92,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Optum,VACCN,,58.92,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Optum,VACCN,,24.29,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Optum,VACCN,,13.91,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN,,3.80,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,2.37,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,2.37,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN,,7.77,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,6.47,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,3.99,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Optum,VACCN,,5.57,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN,,2.54,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,4.48,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Optum,VACCN,,810.23,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Optum,VACCN,,810.23,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Optum,VACCN,,12.98,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN,,17.65,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Optum,VACCN,,17.90,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Optum,VACCN,,17.90,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Optum,VACCN,,11.89,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Optum,VACCN,,22.94,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,22.94,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Optum,VACCN,,22.94,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Optum,VACCN,,30.86,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Optum,VACCN,,22.94,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Optum,VACCN,,19.04,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Optum,VACCN,,17.90,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Optum,VACCN,,17.90,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Optum,VACCN,,19.35,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Optum,VACCN,,9.11,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Optum,VACCN,,18.93,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Optum,VACCN,,18.93,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Optum,VACCN,,11.85,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN,,13.84,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Optum,VACCN,,15.32,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN,,30.86,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Optum,VACCN,,15.32,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Optum,VACCN,,12.87,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Optum,VACCN,,12.87,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN,,12.87,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN,,4.28,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN,,6.89,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Optum,VACCN,,10.18,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Optum,VACCN,,9.72,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Optum,VACCN,,17.19,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,9.36,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Optum,VACCN,,13.09,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN,,13.09,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Optum,VACCN,,24.91,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Optum,VACCN,,24.91,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN,,17.98,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Optum,VACCN,,17.98,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN,,4.29,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Optum,VACCN,,3.94,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN,,9.58,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Optum,VACCN,,9.58,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Optum,VACCN,,17.98,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN,,9.85,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Optum,VACCN,,18.64,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN,,4.27,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,5.51,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN,,5.77,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Optum,VACCN,,5.77,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,6.01,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,6.01,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Optum,VACCN,,6.47,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN,,6.47,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Optum,VACCN,,11.67,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,6.68,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Optum,VACCN,,10.32,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Optum,VACCN,,10.32,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Optum,VACCN,,9.44,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,9.44,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Optum,VACCN,,9.44,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN,,8.62,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Optum,VACCN,,8.62,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Optum,VACCN,,9.89,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Optum,VACCN,,9.47,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Optum,VACCN,,9.47,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Optum,VACCN,,9.47,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Optum,VACCN,,8.08,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Optum,VACCN,,8.08,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN,,8.08,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,8.08,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.63,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.63,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Optum,VACCN,,6.63,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.63,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.63,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Optum,VACCN,,6.63,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN,,6.63,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Optum,VACCN,,6.63,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.63,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,6.63,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Optum,VACCN,,6.63,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Optum,VACCN,,8.07,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Optum,VACCN,,7.71,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.41,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Optum,VACCN,,10.32,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,10.32,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN,,5.18,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN,,5.18,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN,,115.36,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Optum,VACCN,,4.31,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN,,4.27,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,5.88,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN,,8.90,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN,,4.75,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN,,7.48,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Optum,VACCN,,4.75,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN,,8.65,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN,,8.65,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN,,8.65,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Optum,VACCN,,8.65,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Optum,VACCN,,8.65,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Optum,VACCN,,4.27,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN,,4.27,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN,,4.27,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,5.39,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Optum,VACCN,,5.39,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,5.39,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Optum,VACCN,,5.99,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN,,17.98,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Optum,VACCN,,5.82,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,5.82,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Optum,VACCN,,11.98,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Optum,VACCN,,11.98,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,11.98,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Optum,VACCN,,11.98,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Optum,VACCN,,13.82,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN,,10.33,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN,,10.33,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,24.08,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Optum,VACCN,,24.08,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Optum,VACCN,,11.98,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Optum,VACCN,,11.98,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN,,11.98,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Optum,VACCN,,35.09,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Optum,VACCN,,37.27,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Optum,VACCN,,35.09,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Optum,VACCN,,42.84,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Optum,VACCN,,35.09,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Optum,VACCN,,42.84,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Optum,VACCN,,42.84,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Optum,VACCN,,35.09,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Optum,VACCN,,35.09,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Optum,VACCN,,85.10,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Optum,VACCN,,35.09,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Optum,VACCN,,35.09,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Optum,VACCN,,35.09,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN,,95.80,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Optum,VACCN,,142.63,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Optum,VACCN,,416.78,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Optum,VACCN,,35.09,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Optum,VACCN,,35.09,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Optum,VACCN,,35.09,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,35.09,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Optum,VACCN,,35.09,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Optum,VACCN,,42.84,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Optum,VACCN,,262.99,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Optum,VACCN,,15.29,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Optum,VACCN,,16.53,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Optum,VACCN,,16.07,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Optum,VACCN,,16.07,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Optum,VACCN,,16.07,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Optum,VACCN,,257.45,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Optum,VACCN,,257.45,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Optum,VACCN,,3.17,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Optum,VACCN,,3.17,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,3.48,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,3.48,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Optum,VACCN,,3.48,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Optum,VACCN,,8.61,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Optum,VACCN,,169.96,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN,,5.60,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,7.33,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Optum,VACCN,,5.79,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Optum,VACCN,,91.66,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Optum,VACCN,,18.05,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Optum,VACCN,,24.18,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Optum,VACCN,,12.39,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Optum,VACCN,,4.72,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Optum,VACCN,,13.25,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,16.46,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN,,11.53,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Optum,VACCN,,5.22,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Optum,VACCN,,17.93,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Optum,VACCN,,4.27,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN,,13.05,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN,,12.88,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Optum,VACCN,,5.18,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Optum,VACCN,,14.38,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Optum,VACCN,,8.08,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN,,8.08,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Optum,VACCN,,13.61,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Optum,VACCN,,8.61,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN,,13.19,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,6.68,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Optum,VACCN,,5.18,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Optum,VACCN,,13.39,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Optum,VACCN,,4.75,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Optum,VACCN,,4.75,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN,,12.87,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN,,4.29,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,6.14,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Optum,VACCN,,13.24,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN,,6.63,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Optum,VACCN,,169.96,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Optum,VACCN,,169.96,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Optum,VACCN,,123.68,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Optum,VACCN,,14.61,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,15.05,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Optum,VACCN,,7.31,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Optum,VACCN,,25.81,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Optum,VACCN,,759.53,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,35.09,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,15.92,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Optum,VACCN,,5.50,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN,,27.22,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Optum,VACCN,,2.70,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,8.62,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Optum,VACCN,,11.98,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Optum,VACCN,,16.55,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Optum,VACCN,,16.55,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Optum,VACCN,,9.09,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Optum,VACCN,,9.09,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Optum,VACCN,,9.09,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Optum,VACCN,,35.09,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Optum,VACCN,,121.63,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Optum,VACCN,,185.20,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Optum,VACCN,,83.00,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Optum,VACCN,,641.85,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Optum,VACCN,,1824.88,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Optum,VACCN,,375.25,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Optum,VACCN,,9.09,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Optum,VACCN,,11.15,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Optum,VACCN,,6.47,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Optum,VACCN,,5.51,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN,,18.52,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,26.78,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,26.78,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Optum,VACCN,,185.20,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,20.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Optum,VACCN,,35.09,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Optum,VACCN,,137.00,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Optum,VACCN,,35.09,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Optum,VACCN,,759.53,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Optum,VACCN,,218.06,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Optum,VACCN,,35.09,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,35.09,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Optum,VACCN,,70.20,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Optum,VACCN,,121.63,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Optum,VACCN,,185.20,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Optum,VACCN,,24.91,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Optum,VACCN,QW,24.91,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Optum,VACCN,,14.38,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Optum,VACCN,,62.14,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Optum,VACCN,,1160.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Optum,VACCN,,416.78,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Optum,VACCN,,91.66,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,20.81,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Optum,VACCN,,233.07,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Optum,VACCN,,41.76,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Optum,VACCN,,42.84,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Optum,VACCN,,16.07,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Optum,VACCN,,5.22,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN,,29.21,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN,QW,51.31,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Optum,VACCN,,42.13,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Optum,VACCN,,17.27,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Optum,VACCN,,416.78,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Optum,VACCN,,142.63,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN,,10.32,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN,,18.64,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Optum,VACCN,,18.64,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN,,27.11,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Optum,VACCN,,38.57,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Optum,VACCN,,8.65,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Optum,VACCN,,142.63,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN,,39.26,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Optum,VACCN,,21.73,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN,,20.81,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Optum,VACCN,,137.00,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN,,12.00,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Optum,VACCN,,12.00,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Optum,VACCN,,20.32,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Optum,VACCN,,11.53,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,17.27,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Optum,VACCN,,22.34,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Optum,VACCN,,29.35,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Optum,VACCN,,27.39,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Optum,VACCN,,128.29,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Optum,VACCN,,11.53,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Optum,VACCN,,51.31,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,35.09,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Optum,VACCN,,35.09,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,9.71,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Optum,VACCN,,11.57,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN,,2.25,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Optum,VACCN,,35.09,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Optum,VACCN,,35.09,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Optum,VACCN,,35.09,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Optum,VACCN,,137.00,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Optum,VACCN,,8.62,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Optum,VACCN,,262.99,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Optum,VACCN,,70.20,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Optum,VACCN,,52.99,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Optum,VACCN,,2.37,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Optum,VACCN,,38.93,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Optum,VACCN,,38.93,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Optum,VACCN,,52.99,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Optum,VACCN,,52.99,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Optum,VACCN,,20.26,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Optum,VACCN,,24.29,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Optum,VACCN,,169.96,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Optum,VACCN,,52.99,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,26.61,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Optum,VACCN,,26.61,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Optum,VACCN,,26.61,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Optum,VACCN,,356.78,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Optum,VACCN,,356.78,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Optum,VACCN,,116.49,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Optum,VACCN,,116.49,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Optum,VACCN,,140.73,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Optum,VACCN,,150.30,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Optum,VACCN,,150.30,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Optum,VACCN,,143.75,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Optum,VACCN,,13.07,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Optum,VACCN,,264.34,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Optum,VACCN,,125.49,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Optum,VACCN,,144.61,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Optum,VACCN,,188.57,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Optum,VACCN,,21.42,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN,,21.42,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Optum,VACCN,,34.81,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Optum,VACCN,,42.38,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Optum,VACCN,,51.19,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Optum,VACCN,,33.47,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Optum,VACCN,,68.60,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Optum,VACCN,,26.91,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN,,52.99,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Optum,VACCN,,38.93,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Optum,VACCN,,24.29,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Optum,VACCN,,38.93,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Optum,VACCN,,52.99,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Optum,VACCN,,52.99,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Optum,VACCN,,52.99,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Optum,VACCN,,356.78,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Optum,VACCN,,810.23,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN,,127.85,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Optum,VACCN,,810.23,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Optum,VACCN,,52.99,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Optum,VACCN,,169.96,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Optum,VACCN,,810.23,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Optum,VACCN,,169.96,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Optum,VACCN,,12.05,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Optum,VACCN,,169.96,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN,,169.96,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Optum,VACCN,,169.96,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Optum,VACCN,,169.96,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Optum,VACCN,,102.26,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Optum,VACCN,,5.02,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Optum,VACCN,,169.96,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Optum,VACCN,,143.75,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Optum,VACCN,,140.73,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Optum,VACCN,,143.75,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Optum,VACCN,,51.19,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Optum,VACCN,,144.61,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN,,356.78,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN,,169.96,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Optum,VACCN,,51.19,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN,,21.42,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Optum,VACCN,,169.96,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Optum,VACCN,,52.99,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Optum,VACCN,,127.85,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Optum,VACCN,,356.78,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Optum,VACCN,,51.19,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN,,21.42,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Optum,VACCN,,169.96,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Optum,VACCN,,169.96,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Optum,VACCN,,169.96,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Optum,VACCN,,21.42,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Optum,VACCN,,21.42,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Optum,VACCN,,21.42,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Optum,VACCN,,51.19,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Optum,VACCN,,21.42,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Optum,VACCN,,42.38,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Optum,VACCN,,169.96,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Optum,VACCN,,169.96,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,169.96,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Optum,VACCN,,38.93,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Optum,VACCN,,169.96,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Optum,VACCN,,180.51,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Optum,VACCN,,180.51,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Optum,VACCN,,180.51,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Optum,VACCN,,180.51,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN,,83.60,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN,,83.60,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Optum,VACCN,,83.60,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Optum,VACCN,,143.14,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Optum,VACCN,,393.63,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Optum,VACCN,,670.15,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Optum,VACCN,,648.41,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Optum,VACCN,,253.71,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Optum,VACCN,,146.10,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Optum,VACCN,,771.15,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Optum,VACCN,,240.46,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Optum,VACCN,,70.51,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Optum,VACCN,,582.49,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Optum,VACCN,,2.99,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN,,9.77,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Optum,VACCN,,9.77,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Optum,VACCN,,5.72,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Optum,VACCN,,483.13,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Optum,VACCN,,670.15,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Optum,VACCN,,63.05,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN,,5361.59,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Optum,VACCN,,155.18,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Optum,VACCN,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN,,8208.45,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Optum,VACCN,,8208.45,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Optum,VACCN,,3121.82,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Optum,VACCN,,3121.82,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Optum,VACCN,,3121.82,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Optum,VACCN,,5361.59,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Optum,VACCN,,5361.59,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Optum,VACCN,,3121.82,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Optum,VACCN,,3121.82,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Optum,VACCN,,5361.59,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN,,3121.82,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Optum,VACCN,,3121.82,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Optum,VACCN,,3121.82,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Optum,VACCN,,11248.03,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Optum,VACCN,,3121.82,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Optum,VACCN,,3121.82,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN,,3121.82,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN,,3121.82,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN,,3121.82,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Optum,VACCN,,3121.82,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Optum,VACCN,,5655.00,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Optum,VACCN,,5655.00,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Optum,VACCN,,11248.03,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Optum,VACCN,,11248.03,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Optum,VACCN,,5655.00,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Optum,VACCN,,5655.00,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Optum,VACCN,,17810.19,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Optum,VACCN,,17810.19,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Optum,VACCN,,11248.03,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Optum,VACCN,,11248.03,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Optum,VACCN,,17810.19,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Optum,VACCN,,17810.19,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Optum,VACCN,,11248.03,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Optum,VACCN,,17810.19,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Optum,VACCN,,17810.19,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Optum,VACCN,,17810.19,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Optum,VACCN,,17810.19,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Optum,VACCN,,17810.19,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Optum,VACCN,,17810.19,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Optum,VACCN,,11248.03,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Optum,VACCN,,11248.03,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Optum,VACCN,,649.04,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Optum,VACCN,,649.04,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Optum,VACCN,,328.98,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Optum,VACCN,,5655.00,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Optum,VACCN,,11248.03,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Optum,VACCN,,11248.03,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Optum,VACCN,,11248.03,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Optum,VACCN,,3190.16,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Optum,VACCN,,3190.16,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Optum,VACCN,,3190.16,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Optum,VACCN,,3190.16,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Optum,VACCN,,3190.16,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Optum,VACCN,,3190.16,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Optum,VACCN,,3190.16,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Optum,VACCN,,3190.16,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Optum,VACCN,,3190.16,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Optum,VACCN,,3190.16,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Optum,VACCN,,3190.16,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Optum,VACCN,,1540.76,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Optum,VACCN,,3121.82,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Optum,VACCN,,17810.19,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Optum,VACCN,,7526.18,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Optum,VACCN,,17810.19,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Optum,VACCN,,17810.19,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Optum,VACCN,,10379.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Optum,VACCN,,10379.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Optum,VACCN,,10379.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Optum,VACCN,,8208.45,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Optum,VACCN,,10379.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Optum,VACCN,,10379.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Optum,VACCN,,3121.82,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Optum,VACCN,,8208.45,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Optum,VACCN,,8208.45,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Optum,VACCN,,3609.60,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Optum,VACCN,,3609.60,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Optum,VACCN,,1814.30,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Optum,VACCN,,1814.30,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Optum,VACCN,,10379.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Optum,VACCN,,3121.82,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Optum,VACCN,,8208.45,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Optum,VACCN,,10379.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Optum,VACCN,,18915.54,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Optum,VACCN,,8208.45,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Optum,VACCN,,3609.60,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Optum,VACCN,,3609.60,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Optum,VACCN,,22263.03,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Optum,VACCN,,3609.60,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Optum,VACCN,,3609.60,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Optum,VACCN,,31799.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Optum,VACCN,,8208.45,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Optum,VACCN,,697.85,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Optum,VACCN,,613.21,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Optum,VACCN,,7526.18,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Optum,VACCN,,7526.18,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Optum,VACCN,,1204.08,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Optum,VACCN,,7526.18,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Optum,VACCN,,7526.18,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Optum,VACCN,,1204.08,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Optum,VACCN,,7526.18,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Optum,VACCN,,7526.18,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Optum,VACCN,,1204.08,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Optum,VACCN,,7526.18,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Optum,VACCN,,526.27,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Optum,VACCN,,155.18,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Optum,VACCN,,18915.54,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Optum,VACCN,,31799.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Optum,VACCN,,22263.03,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Optum,VACCN,,22263.03,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Optum,VACCN,,31799.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Optum,VACCN,,28196.35,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Optum,VACCN,,155.18,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Optum,VACCN,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Optum,VACCN,,155.18,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Optum,VACCN,,395.78,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Optum,VACCN,,155.18,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Optum,VACCN,,3121.82,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Optum,VACCN,,1540.76,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Optum,VACCN,,11248.03,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Optum,VACCN,,17810.19,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Optum,VACCN,,17810.19,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Optum,VACCN,,17810.19,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Optum,VACCN,,613.21,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Optum,VACCN,,31799.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Optum,VACCN,,11248.03,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Optum,VACCN,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Optum,VACCN,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Optum,VACCN,,17810.19,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Optum,VACCN,,3190.16,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Optum,VACCN,,3190.16,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Optum,VACCN,,24332.12,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Optum,VACCN,,24332.12,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Optum,VACCN,,24332.12,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Optum,VACCN,,5655.00,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Optum,VACCN,,613.21,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Optum,VACCN,,31799.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Optum,VACCN,,5655.00,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Optum,VACCN,,105.47,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Optum,VACCN,,18915.54,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Optum,VACCN,,308.86,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Optum,VACCN,,543.83,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Optum,VACCN,,543.83,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Optum,VACCN,,543.83,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Optum,VACCN,,543.83,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Optum,VACCN,,239.75,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Optum,VACCN,,239.75,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Optum,VACCN,,239.75,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Optum,VACCN,,543.83,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Optum,VACCN,,543.83,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Optum,VACCN,,543.83,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Optum,VACCN,,36.99,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Optum,VACCN,,127.85,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Optum,VACCN,,58.92,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Optum,VACCN,,91.04,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Optum,VACCN,,239.75,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Optum,VACCN,,124.88,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Optum,VACCN,,124.88,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Optum,VACCN,,58.92,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Optum,VACCN,,58.92,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Optum,VACCN,,3656.86,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Optum,VACCN,,3121.82,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Optum,VACCN,,7085.44,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Optum,VACCN,,697.85,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Optum,VACCN,,8208.45,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Optum,VACCN,,3609.60,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Optum,VACCN,,3609.60,,,,,,,422.62,17457.00,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,205155.01,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,83479.86,,,,,,,80975.46,145942.25,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,95277.00,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,41732.08,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,53184.42,,,,,,,22680.42,56375.49,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,88481.10,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,44101.86,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,40476.11,,,,,,,35745.36,62312.47,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,52884.84,,,,,,,48961.75,85351.71,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,35148.31,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,27890.99,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Optum,Transplant,,24419.06,,,,,,,23686.49,41592.73,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,Optum,Transplant,,697.85,,,,,,,676.91,2912.00,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,848.70,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,542.68,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Vaya,Medicaid,,542.68,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,Vaya,Medicaid,,0.02887,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,Vaya,Medicaid,,26.81,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,Vaya,Medicaid,,5.16,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Vaya,Medicaid,,25.36,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Vaya,Medicaid,,25.36,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,Vaya,Medicaid,,4.55,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,Vaya,Medicaid,,29.28,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,Vaya,Medicaid,,8159.33,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,Vaya,Medicaid,,3506.22,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,Vaya,Medicaid,,0.20826,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,Vaya,Medicaid,,395.70,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,Vaya,Medicaid,,1495.36,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,Vaya,Medicaid,,357.55,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,Vaya,Medicaid,,679.43,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,Vaya,Medicaid,,8293.36,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,Vaya,Medicaid,,2581.01,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,Vaya,Medicaid,,2292.94,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,Vaya,Medicaid,,3230.12,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,Vaya,Medicaid,,6511.38,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,Vaya,Medicaid,,544.16,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,Vaya,Medicaid,,2292.33,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,Vaya,Medicaid,,3307.86,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,Vaya,Medicaid,,555.92,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,Vaya,Medicaid,,1725.07,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,Vaya,Medicaid,,1839.30,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,Vaya,Medicaid,,2325.32,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,Vaya,Medicaid,,27.22,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Vaya,Medicaid,,93.82,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Vaya,Medicaid,,187.85,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,Vaya,Medicaid,,6.45,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,Vaya,Medicaid,,4.19,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,Vaya,Medicaid,,57.52,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,Vaya,Medicaid,,4.46,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,Vaya,Medicaid,,0.00619,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,Vaya,Medicaid,,4.42,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,Vaya,Medicaid,,8.37,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,Vaya,Medicaid,,4.20,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,Vaya,Medicaid,,4.10,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Vaya,Medicaid,,203.73,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Vaya,Medicaid,,13.46,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,Vaya,Medicaid,,36.75,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,Vaya,Medicaid,,3195.07,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,Vaya,Medicaid,,1.31,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,Vaya,Medicaid,,37.53,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Vaya,Medicaid,,41.24,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,Vaya,Medicaid,,41.24,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,Vaya,Medicaid,,6.11,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Vaya,Medicaid,,254.66,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Vaya,Medicaid,,216.10,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Vaya,Medicaid,,145.78,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Vaya,Medicaid,,113.41,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Vaya,Medicaid,,91.14,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Vaya,Medicaid,,96.09,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,Vaya,Medicaid,,254.66,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,Vaya,Medicaid,,216.10,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,Vaya,Medicaid,,145.78,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,Vaya,Medicaid,,113.41,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,Vaya,Medicaid,,91.14,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,Vaya,Medicaid,,96.09,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,Vaya,Medicaid,,5.66,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Vaya,Medicaid,,117.74,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Vaya,Medicaid,,54.02,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,Vaya,Medicaid,,509.11,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Vaya,Medicaid,,143.93,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,Vaya,Medicaid,,143.93,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Vaya,Medicaid,,126.81,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,Vaya,Medicaid,,126.81,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Vaya,Medicaid,,82.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,Vaya,Medicaid,,82.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,Vaya,Medicaid,,487.25,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,Vaya,Medicaid,,117.74,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,Vaya,Medicaid,,54.02,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Vaya,Medicaid,,64.54,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,Vaya,Medicaid,,64.54,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Vaya,Medicaid,,324.76,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,Vaya,Medicaid,,324.76,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Vaya,Medicaid,,258.16,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,Vaya,Medicaid,,258.16,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Vaya,Medicaid,,132.17,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,Vaya,Medicaid,,132.17,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Vaya,Medicaid,,70.11,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,Vaya,Medicaid,,70.11,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Vaya,Medicaid,,56.09,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,Vaya,Medicaid,,56.09,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,Vaya,Medicaid,,44.57,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,Vaya,Medicaid,,187.85,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,Vaya,Medicaid,,93.82,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,Vaya,Medicaid,,1069.56,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,Vaya,Medicaid,,31.71,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,Vaya,Medicaid,,528.28,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,Vaya,Medicaid,,203.73,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,Vaya,Medicaid,,179.84,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,Vaya,Medicaid,,220.68,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,Vaya,Medicaid,,0.44952,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,Vaya,Medicaid,,428.48,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Vaya,Medicaid,,567.87,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Vaya,Medicaid,,250.74,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Vaya,Medicaid,,127.02,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,Vaya,Medicaid,,567.87,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,Vaya,Medicaid,,250.74,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,Vaya,Medicaid,,127.02,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,Vaya,Medicaid,,580.04,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,Vaya,Medicaid,,0.63922,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,Vaya,Medicaid,,2.03,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,Vaya,Medicaid,,39.72,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,Vaya,Medicaid,,13.70,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,Vaya,Medicaid,,25.36,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,Vaya,Medicaid,,49.01,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,Vaya,Medicaid,,56.48,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,Vaya,Medicaid,,32.72,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Vaya,Medicaid,,70.52,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,Vaya,Medicaid,,70.52,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Vaya,Medicaid,,318.79,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,Vaya,Medicaid,,637.98,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,Vaya,Medicaid,,318.79,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,Vaya,Medicaid,,68.13,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,Vaya,Medicaid,,67.90,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,Vaya,Medicaid,,31.58,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,Vaya,Medicaid,,32.75,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Vaya,Medicaid,,88.25,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,Vaya,Medicaid,,88.25,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,Vaya,Medicaid,,2.06,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,Vaya,Medicaid,,0.02474,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,Vaya,Medicaid,,0.05567,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Vaya,Medicaid,,515.09,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,Vaya,Medicaid,,515.09,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Vaya,Medicaid,,417.56,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,Vaya,Medicaid,,417.56,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Vaya,Medicaid,,352.19,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,Vaya,Medicaid,,352.19,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,Vaya,Medicaid,,66.45,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,Vaya,Medicaid,,16.73,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,Vaya,Medicaid,,11.04,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,Vaya,Medicaid,,25.99,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,Vaya,Medicaid,,6.36,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,Vaya,Medicaid,,3.43,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,Vaya,Medicaid,,24.08,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,Vaya,Medicaid,,6.94,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,Vaya,Medicaid,,19.80,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,Vaya,Medicaid,,56.71,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,Vaya,Medicaid,,8.79,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,Vaya,Medicaid,,10.60,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,Vaya,Medicaid,,34.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,Vaya,Medicaid,,26.56,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,Vaya,Medicaid,,31.79,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,Vaya,Medicaid,,30.17,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,Vaya,Medicaid,,5.39,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,Vaya,Medicaid,,5.89,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,Vaya,Medicaid,,14.03,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,Vaya,Medicaid,,29.02,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,Vaya,Medicaid,,0.10516,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,Vaya,Medicaid,,5.41,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,Vaya,Medicaid,,1.22,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,Vaya,Medicaid,,2.17,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,Vaya,Medicaid,,0.02268,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,Vaya,Medicaid,,0.16496,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,Vaya,Medicaid,,1.60,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,Vaya,Medicaid,,0.16290,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,Vaya,Medicaid,,0.09691,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,Vaya,Medicaid,,0.13197,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,Vaya,Medicaid,,343.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Vaya,Medicaid,,0.00412,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,Vaya,Medicaid,,0.01856,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,Vaya,Medicaid,,0.52993,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,Vaya,Medicaid,,5.31,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,Vaya,Medicaid,,16.80,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,Vaya,Medicaid,,0.01443,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,Vaya,Medicaid,,0.87635,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,Vaya,Medicaid,,1.26,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,Vaya,Medicaid,,0.23094,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,Vaya,Medicaid,,0.33198,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,Vaya,Medicaid,,0.52787,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,Vaya,Medicaid,,0.36910,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Vaya,Medicaid,,0.00412,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,Vaya,Medicaid,,4.56,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,Vaya,Medicaid,,226.97,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,Vaya,Medicaid,,15.88,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,Vaya,Medicaid,,27.82,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,Vaya,Medicaid,,34.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,Vaya,Medicaid,,3.56,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,Vaya,Medicaid,,0.02681,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,Vaya,Medicaid,,7.49,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,Vaya,Medicaid,,13.46,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,Vaya,Medicaid,,29.67,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,Vaya,Medicaid,,13.11,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,Vaya,Medicaid,,51.36,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,Vaya,Medicaid,,2.32,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,Vaya,Medicaid,,5.25,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,Vaya,Medicaid,,0.15465,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,Vaya,Medicaid,,0.00825,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,Vaya,Medicaid,,3.12,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,Vaya,Medicaid,,2.75,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,Vaya,Medicaid,,2.45,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,Vaya,Medicaid,,3.65,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,Vaya,Medicaid,,6.88,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,Vaya,Medicaid,,11.33,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,Vaya,Medicaid,,28.69,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,Vaya,Medicaid,,113.14,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,Vaya,Medicaid,,65.21,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,Vaya,Medicaid,,76.55,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,Vaya,Medicaid,,17.10,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,Vaya,Medicaid,,13.38,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,Vaya,Medicaid,,13.38,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,Vaya,Medicaid,,9.79,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,Vaya,Medicaid,,0.24744,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Vaya,Medicaid,,604.11,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Vaya,Medicaid,,4010.97,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,Vaya,Medicaid,,3.41,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,Vaya,Medicaid,,4.08,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,Vaya,Medicaid,,3.77,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,Vaya,Medicaid,,4.12,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,Vaya,Medicaid,,4.40,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,Vaya,Medicaid,,26.49,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,Vaya,Medicaid,,17.34,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,Vaya,Medicaid,,72.31,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,Vaya,Medicaid,,79.50,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,Vaya,Medicaid,,4.00,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,Vaya,Medicaid,,730.77,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,Vaya,Medicaid,,62.74,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,Vaya,Medicaid,,8.96,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,Vaya,Medicaid,,3.35,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,Vaya,Medicaid,,3.34,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,Vaya,Medicaid,,497.83,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,Vaya,Medicaid,,3.72,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,Vaya,Medicaid,,97.23,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Vaya,Medicaid,,3.57,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,Vaya,Medicaid,,3.47,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,Vaya,Medicaid,,3.41,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,Vaya,Medicaid,,1076.45,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,Vaya,Medicaid,,3.47,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,Vaya,Medicaid,,16.48,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,Vaya,Medicaid,,6.94,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,Vaya,Medicaid,,7.19,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,Vaya,Medicaid,,9.69,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,Vaya,Medicaid,,4.09,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,Vaya,Medicaid,,5.20,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,Vaya,Medicaid,,16.56,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,Vaya,Medicaid,,6.68,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,Vaya,Medicaid,,4.91,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,Vaya,Medicaid,,5.92,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,Vaya,Medicaid,,0.46395,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,Vaya,Medicaid,,90.05,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,Vaya,Medicaid,,154.28,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,Vaya,Medicaid,,471.07,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Vaya,Medicaid,,45.16,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Vaya,Medicaid,,45.16,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Vaya,Medicaid,,45.16,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,Vaya,Medicaid,,0.30930,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,Vaya,Medicaid,,10.20,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,Vaya,Medicaid,,11.87,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,Vaya,Medicaid,,117.22,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,Vaya,Medicaid,,4.50,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,Vaya,Medicaid,,5.08,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,Vaya,Medicaid,,1.44,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,Vaya,Medicaid,,3.77,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,Vaya,Medicaid,,0.53612,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,Vaya,Medicaid,,3.72,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,Vaya,Medicaid,,3.79,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,Vaya,Medicaid,,5.52,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,Vaya,Medicaid,,6.37,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,Vaya,Medicaid,,4.91,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,Vaya,Medicaid,,9.80,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,Vaya,Medicaid,,6.05,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Vaya,Medicaid,,6.67,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,Vaya,Medicaid,,565.27,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,Vaya,Medicaid,,3.66,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,Vaya,Medicaid,,3.45,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,Vaya,Medicaid,,3.51,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,Vaya,Medicaid,,4.40,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,Vaya,Medicaid,,8.41,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,Vaya,Medicaid,,379.33,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,Vaya,Medicaid,,3.33,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,Vaya,Medicaid,,3.58,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,Vaya,Medicaid,,3.66,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,Vaya,Medicaid,,6.75,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,Vaya,Medicaid,,50.91,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,Vaya,Medicaid,,0.34023,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Vaya,Medicaid,,4.78,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,Vaya,Medicaid,,4.69,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,Vaya,Medicaid,,4190.45,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,Vaya,Medicaid,,6.60,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,Vaya,Medicaid,,0.29899,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,Vaya,Medicaid,,32.55,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,Vaya,Medicaid,,62.05,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Vaya,Medicaid,,510.35,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,Vaya,Medicaid,,14.50,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,Vaya,Medicaid,,17.49,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Vaya,Medicaid,,7.77,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,Vaya,Medicaid,,9.51,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,Vaya,Medicaid,,159.67,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,Vaya,Medicaid,,3.34,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,Vaya,Medicaid,,10.49,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,Vaya,Medicaid,,14.20,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,Vaya,Medicaid,,13.74,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,Vaya,Medicaid,,14.90,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,Vaya,Medicaid,,8.18,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,Vaya,Medicaid,,5.80,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,Vaya,Medicaid,,12544.61,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,Vaya,Medicaid,,164.56,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,Vaya,Medicaid,,32.65,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,Vaya,Medicaid,,47.66,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,Vaya,Medicaid,,107.28,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,Vaya,Medicaid,,4.04,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,Vaya,Medicaid,,5.57,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,Vaya,Medicaid,,5.87,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,Vaya,Medicaid,,10.29,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,Vaya,Medicaid,,12.62,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,Vaya,Medicaid,,17.29,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,Vaya,Medicaid,,21.95,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,Vaya,Medicaid,,26.61,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,Vaya,Medicaid,,14.61,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,Vaya,Medicaid,,15.69,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,Vaya,Medicaid,,4.37,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,Vaya,Medicaid,,4.08,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,Vaya,Medicaid,,254.74,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,Vaya,Medicaid,,482.72,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,Vaya,Medicaid,,1.75,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,Vaya,Medicaid,,35.26,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Vaya,Medicaid,,8.80,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,Vaya,Medicaid,,3.51,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,Vaya,Medicaid,,4.25,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,Vaya,Medicaid,,7.64,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,Vaya,Medicaid,,7.68,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,Vaya,Medicaid,,14.44,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,Vaya,Medicaid,,25.36,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,Vaya,Medicaid,,630.10,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Vaya,Medicaid,,1203.48,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,Vaya,Medicaid,,277.42,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,Vaya,Medicaid,,4.43,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,Vaya,Medicaid,,13.31,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,Vaya,Medicaid,,7.34,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,Vaya,Medicaid,,6.88,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,Vaya,Medicaid,,7.02,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,Vaya,Medicaid,,6.03,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,Vaya,Medicaid,,6.03,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,Vaya,Medicaid,,499.15,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,Vaya,Medicaid,,1335.97,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,Vaya,Medicaid,,34.64,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,Vaya,Medicaid,,5.68,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,Vaya,Medicaid,,13.13,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,Vaya,Medicaid,,0.30930,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,Vaya,Medicaid,,0.29899,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,Vaya,Medicaid,,5.67,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,Vaya,Medicaid,,6.48,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,Vaya,Medicaid,,32.46,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,Vaya,Medicaid,,4.84,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,Vaya,Medicaid,,21.23,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,Vaya,Medicaid,,120.64,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,Vaya,Medicaid,,37.30,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,Vaya,Medicaid,,53.67,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,Vaya,Medicaid,,42.31,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Vaya,Medicaid,,235.96,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,Vaya,Medicaid,,3.75,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,Vaya,Medicaid,,20.82,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,Vaya,Medicaid,,36.81,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,Vaya,Medicaid,,108.35,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,Vaya,Medicaid,,0.31961,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,Vaya,Medicaid,,20.86,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,Vaya,Medicaid,,54.27,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,Vaya,Medicaid,,54.27,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,Vaya,Medicaid,,181.77,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,Vaya,Medicaid,,12.06,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,Vaya,Medicaid,,184.85,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,Vaya,Medicaid,,293.77,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,Vaya,Medicaid,,439.01,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,Vaya,Medicaid,,729.47,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,Vaya,Medicaid,,1455.65,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,Vaya,Medicaid,,2181.82,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,Vaya,Medicaid,,349.54,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,Vaya,Medicaid,,1700.39,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,Vaya,Medicaid,,6631.40,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Vaya,Medicaid,,1163.02,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Vaya,Medicaid,,2313.04,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Vaya,Medicaid,,65.75,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,Vaya,Medicaid,,65.75,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,Vaya,Medicaid,,1815.97,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,Vaya,Medicaid,,3.36,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,Vaya,Medicaid,,17.18,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,Vaya,Medicaid,,20.90,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,Vaya,Medicaid,,31.74,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,Vaya,Medicaid,,4.81,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,Vaya,Medicaid,,3.86,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,Vaya,Medicaid,,23.90,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,Vaya,Medicaid,,29.27,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,Vaya,Medicaid,,3.57,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,Vaya,Medicaid,,182.43,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,Vaya,Medicaid,,0.28868,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Vaya,Medicaid,,8271.90,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Vaya,Medicaid,,32917.38,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,Vaya,Medicaid,,203.21,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,Vaya,Medicaid,,0.41240,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,Vaya,Medicaid,,0.36085,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,Vaya,Medicaid,,0.35054,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,Vaya,Medicaid,,0.32992,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,Vaya,Medicaid,,20.75,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,Vaya,Medicaid,,39.96,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,Vaya,Medicaid,,2734.35,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,Vaya,Medicaid,,21.86,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,Vaya,Medicaid,,2.84,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,Vaya,Medicaid,,462.99,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,Vaya,Medicaid,,17.74,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,Vaya,Medicaid,,146.38,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,Vaya,Medicaid,,44.09,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,Vaya,Medicaid,,12.50,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,Vaya,Medicaid,,19.74,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,Vaya,Medicaid,,38.03,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,Vaya,Medicaid,,46.33,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,Vaya,Medicaid,,12.42,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,Vaya,Medicaid,,217.95,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,Vaya,Medicaid,,0.29899,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,Vaya,Medicaid,,9.69,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,Vaya,Medicaid,,0.24744,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,Vaya,Medicaid,,0.63922,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,Vaya,Medicaid,,16.53,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,Vaya,Medicaid,,15.95,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,Vaya,Medicaid,,15.73,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,Vaya,Medicaid,,15.95,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Vaya,Medicaid,,20.93,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,Vaya,Medicaid,,21.65,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,Vaya,Medicaid,,97.24,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,Vaya,Medicaid,,3.77,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,Vaya,Medicaid,,58.10,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,Vaya,Medicaid,,3.98,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,Vaya,Medicaid,,11557.21,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,Vaya,Medicaid,,11.34,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,Vaya,Medicaid,,920.60,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,Vaya,Medicaid,,11.34,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,Vaya,Medicaid,,14.56,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,Vaya,Medicaid,,5.56,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,Vaya,Medicaid,,0.30930,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,Vaya,Medicaid,,6.47,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,Vaya,Medicaid,,3.98,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,Vaya,Medicaid,,13.97,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,Vaya,Medicaid,,6.14,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,Vaya,Medicaid,,229.69,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,Vaya,Medicaid,,377.35,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,Vaya,Medicaid,,65.18,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,Vaya,Medicaid,,97.80,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,Vaya,Medicaid,,19.74,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,Vaya,Medicaid,,19.74,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,Vaya,Medicaid,,146.45,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,Vaya,Medicaid,,5.93,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,Vaya,Medicaid,,4.84,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,Vaya,Medicaid,,116.50,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,Vaya,Medicaid,,247.10,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,Vaya,Medicaid,,0.84542,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,Vaya,Medicaid,,117.29,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,Vaya,Medicaid,,23.09,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,Vaya,Medicaid,,34.64,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,Vaya,Medicaid,,3.50,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,Vaya,Medicaid,,3.64,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,Vaya,Medicaid,,42.31,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,Vaya,Medicaid,,125.71,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,Vaya,Medicaid,,32.86,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Vaya,Medicaid,,17.94,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,Vaya,Medicaid,,0.88666,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,Vaya,Medicaid,,4.35,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,Vaya,Medicaid,,3.47,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,Vaya,Medicaid,,5.93,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,Vaya,Medicaid,,5.93,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Vaya,Medicaid,,3.57,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,Vaya,Medicaid,,6.19,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,Vaya,Medicaid,,7.05,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,Vaya,Medicaid,,25.47,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,Vaya,Medicaid,,25.75,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,Vaya,Medicaid,,10.07,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,Vaya,Medicaid,,12.77,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,Vaya,Medicaid,,6.51,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Vaya,Medicaid,,15.99,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,Vaya,Medicaid,,78.36,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,Vaya,Medicaid,,187.70,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,Vaya,Medicaid,,34.59,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,Vaya,Medicaid,,66.03,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Vaya,Medicaid,,18.19,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,Vaya,Medicaid,,124.56,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,Vaya,Medicaid,,5238.42,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,Vaya,Medicaid,,382.42,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,Vaya,Medicaid,,4.33,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,Vaya,Medicaid,,198.33,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,Vaya,Medicaid,,5.14,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Vaya,Medicaid,,17.45,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,Vaya,Medicaid,,7.43,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,Vaya,Medicaid,,3.57,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,Vaya,Medicaid,,340.48,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,Vaya,Medicaid,,6244.81,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,Vaya,Medicaid,,3.61,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,Vaya,Medicaid,,6.53,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,Vaya,Medicaid,,11.00,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,Vaya,Medicaid,,7.85,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,Vaya,Medicaid,,9.92,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,Vaya,Medicaid,,14.86,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,Vaya,Medicaid,,15.96,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,Vaya,Medicaid,,38.28,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,Vaya,Medicaid,,4.23,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,Vaya,Medicaid,,4.61,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,Vaya,Medicaid,,4.60,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,Vaya,Medicaid,,66.10,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,Vaya,Medicaid,,90.32,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Vaya,Medicaid,,3265.93,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,Vaya,Medicaid,,22.16,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,Vaya,Medicaid,,425.49,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,Vaya,Medicaid,,566.23,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Vaya,Medicaid,,5.43,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,Vaya,Medicaid,,40.46,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,Vaya,Medicaid,,3.73,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,Vaya,Medicaid,,0.55674,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,Vaya,Medicaid,,12.37,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,Vaya,Medicaid,,6.64,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,Vaya,Medicaid,,4.60,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,Vaya,Medicaid,,18.05,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,Vaya,Medicaid,,23.75,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,Vaya,Medicaid,,0.26806,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,Vaya,Medicaid,,10.25,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,Vaya,Medicaid,,7.44,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,Vaya,Medicaid,,30.51,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,Vaya,Medicaid,,0.31961,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,Vaya,Medicaid,,0.36085,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,Vaya,Medicaid,,3.37,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,Vaya,Medicaid,,42.69,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,Vaya,Medicaid,,4.67,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,Vaya,Medicaid,,5.07,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,Vaya,Medicaid,,6.62,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,Vaya,Medicaid,,3.57,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,Vaya,Medicaid,,113.64,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,Vaya,Medicaid,,5.53,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,Vaya,Medicaid,,4.94,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,Vaya,Medicaid,,6.07,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,Vaya,Medicaid,,8.89,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,Vaya,Medicaid,,11.02,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,Vaya,Medicaid,,12.55,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,Vaya,Medicaid,,36.81,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,Vaya,Medicaid,,104.77,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,Vaya,Medicaid,,10.95,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,Vaya,Medicaid,,5.09,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Vaya,Medicaid,,6.14,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,Vaya,Medicaid,,12.63,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,Vaya,Medicaid,,5.75,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,Vaya,Medicaid,,35.10,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Vaya,Medicaid,,73.66,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Vaya,Medicaid,,238.38,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,Vaya,Medicaid,,1.77,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,Vaya,Medicaid,,3.41,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,Vaya,Medicaid,,3.36,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,Vaya,Medicaid,,24385.56,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,Vaya,Medicaid,,25.87,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,Vaya,Medicaid,,154.83,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,Vaya,Medicaid,,2.06,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,Vaya,Medicaid,,3.08,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,Vaya,Medicaid,,15.81,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,Vaya,Medicaid,,1.10,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,Vaya,Medicaid,,3.55,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,Vaya,Medicaid,,8.28,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,Vaya,Medicaid,,9.22,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,Vaya,Medicaid,,7.51,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,Vaya,Medicaid,,17.51,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,Vaya,Medicaid,,17.48,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,Vaya,Medicaid,,17.51,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,Vaya,Medicaid,,17.10,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,Vaya,Medicaid,,216.99,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,Vaya,Medicaid,,1111.41,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,Vaya,Medicaid,,749.91,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,Vaya,Medicaid,,6.83,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,Vaya,Medicaid,,3250.74,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,Vaya,Medicaid,,0.59798,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,Vaya,Medicaid,,4.34,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,Vaya,Medicaid,,88.83,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,Vaya,Medicaid,,48.77,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,Vaya,Medicaid,,13.38,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,Vaya,Medicaid,,22.27,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,Vaya,Medicaid,,2.56,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,Vaya,Medicaid,,29.74,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,Vaya,Medicaid,,59.76,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,Vaya,Medicaid,,551.32,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Vaya,Medicaid,,18.04,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,Vaya,Medicaid,,2.01,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,Vaya,Medicaid,,687.97,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,Vaya,Medicaid,,4.88,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,Vaya,Medicaid,,6.37,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Vaya,Medicaid,,70.69,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,Vaya,Medicaid,,168.71,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,Vaya,Medicaid,,65.92,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,Vaya,Medicaid,,203.09,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,Vaya,Medicaid,,5.18,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,Vaya,Medicaid,,280.59,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,Vaya,Medicaid,,18.04,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,Vaya,Medicaid,,44.82,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,Vaya,Medicaid,,7.92,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,Vaya,Medicaid,,8.08,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,Vaya,Medicaid,,1288.30,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,Vaya,Medicaid,,3.88,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,Vaya,Medicaid,,4.29,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,Vaya,Medicaid,,1959.81,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,Vaya,Medicaid,,0.79387,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,Vaya,Medicaid,,11.91,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Vaya,Medicaid,,9.37,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Vaya,Medicaid,,13.08,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,Vaya,Medicaid,,54.02,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,Vaya,Medicaid,,72.69,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,Vaya,Medicaid,,2.24,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,Vaya,Medicaid,,61.57,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,Vaya,Medicaid,,0.34023,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,Vaya,Medicaid,,0.28868,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,Vaya,Medicaid,,0.32992,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,Vaya,Medicaid,,9.55,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,Vaya,Medicaid,,45.09,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,Vaya,Medicaid,,36.99,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,Vaya,Medicaid,,20.58,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,Vaya,Medicaid,,0.26806,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,Vaya,Medicaid,,32.16,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Vaya,Medicaid,,8.32,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,Vaya,Medicaid,,4.54,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,Vaya,Medicaid,,13.35,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,Vaya,Medicaid,,2469.49,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,Vaya,Medicaid,,11.89,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,Vaya,Medicaid,,7.05,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,Vaya,Medicaid,,16.60,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,Vaya,Medicaid,,4.88,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,Vaya,Medicaid,,2004.02,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,Vaya,Medicaid,,51.53,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,Vaya,Medicaid,,0.26806,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,Vaya,Medicaid,,1.52,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,Vaya,Medicaid,,28.42,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,Vaya,Medicaid,,3.81,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,Vaya,Medicaid,,16.65,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,Vaya,Medicaid,,17.73,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,Vaya,Medicaid,,37.12,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,Vaya,Medicaid,,20.03,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,Vaya,Medicaid,,4010.97,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,Vaya,Medicaid,,32.80,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,Vaya,Medicaid,,19.35,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,Vaya,Medicaid,,14.53,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,Vaya,Medicaid,,15.33,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,Vaya,Medicaid,,15.33,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,Vaya,Medicaid,,17.33,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,Vaya,Medicaid,,2.43,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,Vaya,Medicaid,,3.72,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,Vaya,Medicaid,,3.64,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,Vaya,Medicaid,,4.97,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,Vaya,Medicaid,,2.28,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,Vaya,Medicaid,,1690.82,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,Vaya,Medicaid,,4.15,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,Vaya,Medicaid,,3.45,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,Vaya,Medicaid,,12.72,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,Vaya,Medicaid,,77.02,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,Vaya,Medicaid,,39.70,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,Vaya,Medicaid,,14.51,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,Vaya,Medicaid,,13.67,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,Vaya,Medicaid,,3.45,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,Vaya,Medicaid,,3.45,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,Vaya,Medicaid,,4.59,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,Vaya,Medicaid,,6.04,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,Vaya,Medicaid,,3.74,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,Vaya,Medicaid,,3.37,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,Vaya,Medicaid,,23.28,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,Vaya,Medicaid,,27.25,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,Vaya,Medicaid,,0.28868,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,Vaya,Medicaid,,18.59,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,Vaya,Medicaid,,30.65,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,Vaya,Medicaid,,9.19,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,Vaya,Medicaid,,21.51,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,Vaya,Medicaid,,4.18,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,Vaya,Medicaid,,71.35,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,Vaya,Medicaid,,260.62,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,Vaya,Medicaid,,4.75,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,Vaya,Medicaid,,93.37,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,Vaya,Medicaid,,187.19,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,Vaya,Medicaid,,0.36085,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,Vaya,Medicaid,,0.35054,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,Vaya,Medicaid,,1.84,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,Vaya,Medicaid,,3.84,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,Vaya,Medicaid,,49.62,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,Vaya,Medicaid,,3.35,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Vaya,Medicaid,,3.41,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,Vaya,Medicaid,,19.50,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,Vaya,Medicaid,,5.84,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,Vaya,Medicaid,,27.79,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,Vaya,Medicaid,,29.23,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,Vaya,Medicaid,,9.02,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,Vaya,Medicaid,,71.89,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,Vaya,Medicaid,,4.32,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,Vaya,Medicaid,,3.87,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,Vaya,Medicaid,,29.23,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,Vaya,Medicaid,,33.92,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,Vaya,Medicaid,,36.09,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,Vaya,Medicaid,,0.65984,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Vaya,Medicaid,,20.93,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,Vaya,Medicaid,,25.57,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,Vaya,Medicaid,,25.57,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,Vaya,Medicaid,,18.91,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,Vaya,Medicaid,,16.43,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,Vaya,Medicaid,,97.12,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,Vaya,Medicaid,,5.40,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Vaya,Medicaid,,4.78,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,Vaya,Medicaid,,4.85,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,Vaya,Medicaid,,4.64,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,Vaya,Medicaid,,4.66,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,Vaya,Medicaid,,2862.29,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,Vaya,Medicaid,,62.64,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,Vaya,Medicaid,,0.87635,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,Vaya,Medicaid,,11.64,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,Vaya,Medicaid,,11.64,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,Vaya,Medicaid,,838.32,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,Vaya,Medicaid,,23.31,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,Vaya,Medicaid,,24.30,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,Vaya,Medicaid,,3676.42,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,Vaya,Medicaid,,5848.24,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Vaya,Medicaid,,13.48,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,Vaya,Medicaid,,1.27,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,Vaya,Medicaid,,30.40,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,Vaya,Medicaid,,5.17,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,Vaya,Medicaid,,8.56,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,Vaya,Medicaid,,4.89,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,Vaya,Medicaid,,3.96,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,Vaya,Medicaid,,33.30,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,Vaya,Medicaid,,100.36,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,Vaya,Medicaid,,20.19,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,Vaya,Medicaid,,19.43,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,Vaya,Medicaid,,943.57,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,Vaya,Medicaid,,31.55,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,Vaya,Medicaid,,4.96,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,Vaya,Medicaid,,0.98976,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,Vaya,Medicaid,,67.23,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Vaya,Medicaid,,17.44,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,Vaya,Medicaid,,17.44,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,Vaya,Medicaid,,132.62,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,Vaya,Medicaid,,132.62,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,Vaya,Medicaid,,3.55,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,Vaya,Medicaid,,113.40,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Vaya,Medicaid,,5.38,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,Vaya,Medicaid,,4.61,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,Vaya,Medicaid,,0.38147,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,Vaya,Medicaid,,17.34,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,Vaya,Medicaid,,66.88,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,Vaya,Medicaid,,101.76,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,Vaya,Medicaid,,4.22,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,Vaya,Medicaid,,73.64,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,Vaya,Medicaid,,108.81,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,Vaya,Medicaid,,20.61,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,Vaya,Medicaid,,20.61,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,Vaya,Medicaid,,76.02,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,Vaya,Medicaid,,1318.11,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,Vaya,Medicaid,,5.86,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,Vaya,Medicaid,,1418.35,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,Vaya,Medicaid,,6864.89,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Vaya,Medicaid,,4.68,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,Vaya,Medicaid,,11.34,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,Vaya,Medicaid,,0.35054,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Vaya,Medicaid,,18.34,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,Vaya,Medicaid,,8119.05,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,Vaya,Medicaid,,1672.50,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,Vaya,Medicaid,,18.34,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,Vaya,Medicaid,,78.63,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,Vaya,Medicaid,,15.59,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Vaya,Medicaid,,18.10,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,Vaya,Medicaid,,431.64,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,Vaya,Medicaid,,2883.37,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,Vaya,Medicaid,,3.67,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,Vaya,Medicaid,,95.32,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,Vaya,Medicaid,,225.79,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,Vaya,Medicaid,,51.03,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,Vaya,Medicaid,,3.38,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Vaya,Medicaid,,7.99,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,Vaya,Medicaid,,7.99,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,Vaya,Medicaid,,49.73,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,Vaya,Medicaid,,63.49,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,Vaya,Medicaid,,83.88,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Vaya,Medicaid,,5098.25,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,Vaya,Medicaid,,166.89,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,Vaya,Medicaid,,1257.81,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,Vaya,Medicaid,,3059.44,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,Vaya,Medicaid,,3.34,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,Vaya,Medicaid,,3.35,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,Vaya,Medicaid,,150.76,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,Vaya,Medicaid,,8.14,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,Vaya,Medicaid,,9.84,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,Vaya,Medicaid,,11.25,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,Vaya,Medicaid,,16.02,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Vaya,Medicaid,,6024.73,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,Vaya,Medicaid,,5407.60,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,Vaya,Medicaid,,5.16,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,Vaya,Medicaid,,15.30,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,Vaya,Medicaid,,15.30,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,Vaya,Medicaid,,22.54,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,Vaya,Medicaid,,367.04,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Vaya,Medicaid,,11.91,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,Vaya,Medicaid,,11.91,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,Vaya,Medicaid,,4334.37,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,Vaya,Medicaid,,6488.73,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,Vaya,Medicaid,,3309.03,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,Vaya,Medicaid,,372.72,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,Vaya,Medicaid,,772.62,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,Vaya,Medicaid,,1.67,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,Vaya,Medicaid,,19.49,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,Vaya,Medicaid,,100.36,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,Vaya,Medicaid,,807.11,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,Vaya,Medicaid,,17337.91,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,Vaya,Medicaid,,407.99,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,Vaya,Medicaid,,101.70,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,Vaya,Medicaid,,954.58,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,Vaya,Medicaid,,1893.29,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,Vaya,Medicaid,,942.64,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,Vaya,Medicaid,,13.00,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,Vaya,Medicaid,,13.00,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,Vaya,Medicaid,,13.00,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,Vaya,Medicaid,,415.16,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,Vaya,Medicaid,,260.71,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,Vaya,Medicaid,,9.13,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,Vaya,Medicaid,,26.64,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,Vaya,Medicaid,,9.69,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,Vaya,Medicaid,,17.36,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Vaya,Medicaid,,15.67,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,Vaya,Medicaid,,2222.43,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,Vaya,Medicaid,,2759.49,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,Vaya,Medicaid,,9.20,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,Vaya,Medicaid,,9.20,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,Vaya,Medicaid,,11.86,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,Vaya,Medicaid,,3383.50,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Vaya,Medicaid,,119.21,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,Vaya,Medicaid,,20.16,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,Vaya,Medicaid,,30.37,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,Vaya,Medicaid,,12.27,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,Vaya,Medicaid,,2301.14,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,Vaya,Medicaid,,214.29,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,Vaya,Medicaid,,131.03,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,Vaya,Medicaid,,3.39,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,Vaya,Medicaid,,45.07,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,Vaya,Medicaid,,3.95,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,Vaya,Medicaid,,180.90,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,Vaya,Medicaid,,4.04,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,Vaya,Medicaid,,832.51,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,Vaya,Medicaid,,341.64,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,Vaya,Medicaid,,63.85,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,Vaya,Medicaid,,2785.95,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,Vaya,Medicaid,,15.89,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,Vaya,Medicaid,,58.85,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,Vaya,Medicaid,,112.50,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,Vaya,Medicaid,,958.25,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,Vaya,Medicaid,,43.59,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,Vaya,Medicaid,,19.72,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Vaya,Medicaid,,30.55,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Vaya,Medicaid,,10571.50,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,Vaya,Medicaid,,4.54,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,Vaya,Medicaid,,278.40,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,Vaya,Medicaid,,25.26,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,Vaya,Medicaid,,566.47,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,Vaya,Medicaid,,12.65,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,Vaya,Medicaid,,223.21,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,Vaya,Medicaid,,12.64,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,Vaya,Medicaid,,3303.94,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,Vaya,Medicaid,,8.49,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,Vaya,Medicaid,,39.52,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Vaya,Medicaid,,13.66,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,Vaya,Medicaid,,75.74,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,Vaya,Medicaid,,11.86,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,Vaya,Medicaid,,7.06,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,Vaya,Medicaid,,8.23,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,Vaya,Medicaid,,18532.70,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,Vaya,Medicaid,,1956.57,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,Vaya,Medicaid,,17888.89,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,Vaya,Medicaid,,9.24,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,Vaya,Medicaid,,1470.64,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,Vaya,Medicaid,,184.90,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,Vaya,Medicaid,,3953.17,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,Vaya,Medicaid,,991.86,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,Vaya,Medicaid,,6023.51,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,Vaya,Medicaid,,1.37,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,Vaya,Medicaid,,14.79,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,Vaya,Medicaid,,6875.90,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,Vaya,Medicaid,,14.70,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,Vaya,Medicaid,,14.17,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,Vaya,Medicaid,,270.69,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,Vaya,Medicaid,,930.25,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,Vaya,Medicaid,,9.86,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,Vaya,Medicaid,,10018.64,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,Vaya,Medicaid,,21755.17,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,Vaya,Medicaid,,3.60,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,Vaya,Medicaid,,27.14,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,Vaya,Medicaid,,19.65,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,Vaya,Medicaid,,19.65,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Vaya,Medicaid,,18.62,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,Vaya,Medicaid,,3.47,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,Vaya,Medicaid,,5.74,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,Vaya,Medicaid,,3.65,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,Vaya,Medicaid,,41.14,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,Vaya,Medicaid,,205.68,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,Vaya,Medicaid,,13.63,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,Vaya,Medicaid,,137.86,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,Vaya,Medicaid,,0.96914,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,Vaya,Medicaid,,3.79,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,Vaya,Medicaid,,406.68,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,Vaya,Medicaid,,5489.06,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,Vaya,Medicaid,,1214.65,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,Vaya,Medicaid,,3.94,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,Vaya,Medicaid,,7263.31,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,Vaya,Medicaid,,16.51,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,Vaya,Medicaid,,49.89,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,Vaya,Medicaid,,80.31,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Vaya,Medicaid,,5.43,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,Vaya,Medicaid,,12.05,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,Vaya,Medicaid,,24.00,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,Vaya,Medicaid,,34.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,Vaya,Medicaid,,44.69,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,Vaya,Medicaid,,106.79,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,Vaya,Medicaid,,417.25,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,Vaya,Medicaid,,1961.82,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,Vaya,Medicaid,,108.25,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,Vaya,Medicaid,,26.99,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,Vaya,Medicaid,,26.99,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,Vaya,Medicaid,,100.88,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,Vaya,Medicaid,,4395.68,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,Vaya,Medicaid,,208.77,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,Vaya,Medicaid,,332.05,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,Vaya,Medicaid,,71.09,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,Vaya,Medicaid,,3.41,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,Vaya,Medicaid,,11.53,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,Vaya,Medicaid,,1061.11,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,Vaya,Medicaid,,9968.71,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Vaya,Medicaid,,3920.33,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,Vaya,Medicaid,,9.92,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,Vaya,Medicaid,,936.82,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Vaya,Medicaid,,2077.88,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Vaya,Medicaid,,208.77,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,Vaya,Medicaid,,7436.42,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,Vaya,Medicaid,,603.75,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Vaya,Medicaid,,7417.08,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,Vaya,Medicaid,,4298.47,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,Vaya,Medicaid,,41.86,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,Vaya,Medicaid,,59.18,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,Vaya,Medicaid,,86.51,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,Vaya,Medicaid,,367.24,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,Vaya,Medicaid,,16942.47,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,Vaya,Medicaid,,2588.83,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,Vaya,Medicaid,,689.75,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,Vaya,Medicaid,,41.50,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,Vaya,Medicaid,,9.90,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,Vaya,Medicaid,,4.92,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,Vaya,Medicaid,,3.67,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,Vaya,Medicaid,,823.86,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,Vaya,Medicaid,,3892.46,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,Vaya,Medicaid,,3575.14,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,Vaya,Medicaid,,10699.39,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,Vaya,Medicaid,,2137.34,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,Vaya,Medicaid,,1294.78,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,Vaya,Medicaid,,22.09,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,Vaya,Medicaid,,2605.25,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Vaya,Medicaid,,3879.53,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,Vaya,Medicaid,,2857.00,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,Vaya,Medicaid,,2282.81,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,Vaya,Medicaid,,613.24,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,Vaya,Medicaid,,707.05,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,Vaya,Medicaid,,3308.40,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,Vaya,Medicaid,,15618.12,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,Vaya,Medicaid,,3133.37,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Vaya,Medicaid,,29.60,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,Vaya,Medicaid,,29.60,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,Vaya,Medicaid,,5.90,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,Vaya,Medicaid,,1693.17,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,Vaya,Medicaid,,4003.01,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,Vaya,Medicaid,,845.97,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,Vaya,Medicaid,,30.74,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,Vaya,Medicaid,,2382.52,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,Vaya,Medicaid,,22688.80,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,Vaya,Medicaid,,446.01,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,Vaya,Medicaid,,3.51,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,Vaya,Medicaid,,8.82,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,Vaya,Medicaid,,36.34,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,Vaya,Medicaid,,3.69,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,Vaya,Medicaid,,12682.91,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,Vaya,Medicaid,,8473.84,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,Vaya,Medicaid,,13.54,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,Vaya,Medicaid,,1323.15,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,Vaya,Medicaid,,3675.09,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,Vaya,Medicaid,,20755.48,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,Vaya,Medicaid,,5670.04,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,Vaya,Medicaid,,210.27,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,Vaya,Medicaid,,1390.51,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,Vaya,Medicaid,,1155.52,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,Vaya,Medicaid,,1900.48,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,Vaya,Medicaid,,25752.45,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,Vaya,Medicaid,,10971.53,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,Vaya,Medicaid,,4221.12,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,Vaya,Medicaid,,3510.43,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,Vaya,Medicaid,,3.61,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,Vaya,Medicaid,,3.51,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,Vaya,Medicaid,,16.75,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,Vaya,Medicaid,,179.27,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,Vaya,Medicaid,,6771.31,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,Vaya,Medicaid,,22.16,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,Vaya,Medicaid,,85.23,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,Vaya,Medicaid,,3369.35,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,Vaya,Medicaid,,7512.64,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,Vaya,Medicaid,,7.04,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,Vaya,Medicaid,,18.06,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Vaya,Medicaid,,17.06,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,Vaya,Medicaid,,17.06,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,Vaya,Medicaid,,152.47,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,Vaya,Medicaid,,241.99,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,Vaya,Medicaid,,14048.77,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,Vaya,Medicaid,,15.67,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Vaya,Medicaid,,541.54,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Vaya,Medicaid,,234.24,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,Vaya,Medicaid,,234.24,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,Vaya,Medicaid,,541.54,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,Vaya,Medicaid,,21.46,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,Vaya,Medicaid,,9535.56,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,Vaya,Medicaid,,1915.30,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,Vaya,Medicaid,,107.22,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,Vaya,Medicaid,,6210.21,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,Vaya,Medicaid,,623.07,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,Vaya,Medicaid,,17047.94,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,Vaya,Medicaid,,13432.73,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,Vaya,Medicaid,,2467.70,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,Vaya,Medicaid,,4931.91,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,Vaya,Medicaid,,6164.15,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,Vaya,Medicaid,,14054.22,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,Vaya,Medicaid,,194.32,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,Vaya,Medicaid,,525.07,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,Vaya,Medicaid,,525.08,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,Vaya,Medicaid,,12.89,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Vaya,Medicaid,,10538.54,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,Vaya,Medicaid,,842.85,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,Vaya,Medicaid,,304.31,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,Vaya,Medicaid,,42.97,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,Vaya,Medicaid,,52.68,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,Vaya,Medicaid,,6.37,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,Vaya,Medicaid,,21.86,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,Vaya,Medicaid,,14.29,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,Vaya,Medicaid,,13091.33,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,Vaya,Medicaid,,48.33,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,Vaya,Medicaid,,3920.33,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,Vaya,Medicaid,,72.68,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,Vaya,Medicaid,,5512.35,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,Vaya,Medicaid,,3.38,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,Vaya,Medicaid,,2266.78,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,Vaya,Medicaid,,9028.11,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,Vaya,Medicaid,,182.07,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,Vaya,Medicaid,,12628.11,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,Vaya,Medicaid,,1508.35,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,Vaya,Medicaid,,53.06,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,Vaya,Medicaid,,16.75,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,Vaya,Medicaid,,3.52,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,Vaya,Medicaid,,3.45,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,Vaya,Medicaid,,7263.31,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,Vaya,Medicaid,,4494.28,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,Vaya,Medicaid,,0.27837,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,Vaya,Medicaid,,0.26806,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,Vaya,Medicaid,,75.15,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,Vaya,Medicaid,,3.35,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Vaya,Medicaid,,7787.88,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,Vaya,Medicaid,,95.90,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Vaya,Medicaid,,3.35,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,Vaya,Medicaid,,10.12,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,Vaya,Medicaid,,18.38,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,Vaya,Medicaid,,3.34,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,Vaya,Medicaid,,15.14,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,Vaya,Medicaid,,67.59,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,Vaya,Medicaid,,7.93,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,Vaya,Medicaid,,4.84,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,Vaya,Medicaid,,5.62,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,Vaya,Medicaid,,6.64,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,Vaya,Medicaid,,0.60829,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,Vaya,Medicaid,,39.78,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,Vaya,Medicaid,,2.29,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,Vaya,Medicaid,,4.03,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,Vaya,Medicaid,,3.35,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,Vaya,Medicaid,,19.43,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,Vaya,Medicaid,,3.56,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,Vaya,Medicaid,,5.61,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,Vaya,Medicaid,,5.40,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,Vaya,Medicaid,,3.77,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,Vaya,Medicaid,,3.55,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,Vaya,Medicaid,,3.69,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,Vaya,Medicaid,,18.77,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,Vaya,Medicaid,,288.67,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,Vaya,Medicaid,,3.52,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,Vaya,Medicaid,,3.84,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,Vaya,Medicaid,,909.12,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,Vaya,Medicaid,,4318.75,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,Vaya,Medicaid,,14.01,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,Vaya,Medicaid,,1312.05,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,Vaya,Medicaid,,17.30,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,Vaya,Medicaid,,3.86,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,Vaya,Medicaid,,40.79,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,Vaya,Medicaid,,9.51,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Vaya,Medicaid,,9.43,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,Vaya,Medicaid,,3.58,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,Vaya,Medicaid,,4.08,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,Vaya,Medicaid,,862.42,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,Vaya,Medicaid,,16.82,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,Vaya,Medicaid,,3.88,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,Vaya,Medicaid,,26.12,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,Vaya,Medicaid,,97.51,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,Vaya,Medicaid,,1.99,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,Vaya,Medicaid,,4.21,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,Vaya,Medicaid,,229.50,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,Vaya,Medicaid,,4.13,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,Vaya,Medicaid,,5.13,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,Vaya,Medicaid,,36.64,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,Vaya,Medicaid,,2.44,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,Vaya,Medicaid,,17.94,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,Vaya,Medicaid,,16.86,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,Vaya,Medicaid,,21.96,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,Vaya,Medicaid,,22.62,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,Vaya,Medicaid,,134.91,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,Vaya,Medicaid,,14.66,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,Vaya,Medicaid,,14.78,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,Vaya,Medicaid,,16.24,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,Vaya,Medicaid,,14.69,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,Vaya,Medicaid,,15.77,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Vaya,Medicaid,,8.19,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,Vaya,Medicaid,,16.08,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,Vaya,Medicaid,,424.36,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,Vaya,Medicaid,,4.21,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,Vaya,Medicaid,,4.21,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,Vaya,Medicaid,,106.51,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,Vaya,Medicaid,,4.59,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,Vaya,Medicaid,,4.59,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,Vaya,Medicaid,,11.11,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,Vaya,Medicaid,,1.77,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,Vaya,Medicaid,,3.87,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,Vaya,Medicaid,,29.30,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,Vaya,Medicaid,,3.43,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,Vaya,Medicaid,,87.10,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,Vaya,Medicaid,,10.45,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,Vaya,Medicaid,,18.28,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,Vaya,Medicaid,,4.41,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Vaya,Medicaid,,3.61,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,Vaya,Medicaid,,3.62,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,Vaya,Medicaid,,18.75,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,Vaya,Medicaid,,4.38,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,Vaya,Medicaid,,3.61,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,Vaya,Medicaid,,0.39178,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,Vaya,Medicaid,,4.94,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,Vaya,Medicaid,,4.62,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,Vaya,Medicaid,,40.54,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,Vaya,Medicaid,,3.51,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,Vaya,Medicaid,,9.98,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,Vaya,Medicaid,,6.12,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,Vaya,Medicaid,,1.55,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,Vaya,Medicaid,,3.56,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,Vaya,Medicaid,,4.28,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,Vaya,Medicaid,,16.78,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,Vaya,Medicaid,,0.69077,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,Vaya,Medicaid,,2.97,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,Vaya,Medicaid,,3.36,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,Vaya,Medicaid,,3.50,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,Vaya,Medicaid,,4.64,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,Vaya,Medicaid,,0.26806,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,Vaya,Medicaid,,6.72,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,Vaya,Medicaid,,16.47,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,Vaya,Medicaid,,4.72,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Vaya,Medicaid,,3.74,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,Vaya,Medicaid,,3.89,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,Vaya,Medicaid,,4.10,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,Vaya,Medicaid,,33.92,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,Vaya,Medicaid,,3.39,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,Vaya,Medicaid,,3.55,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,Vaya,Medicaid,,17.39,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,Vaya,Medicaid,,6.46,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,Vaya,Medicaid,,1514.82,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,Vaya,Medicaid,,5.79,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,Vaya,Medicaid,,15.84,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,Vaya,Medicaid,,6.54,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,Vaya,Medicaid,,3.51,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,Vaya,Medicaid,,3.47,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,Vaya,Medicaid,,565.26,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Vaya,Medicaid,,18.19,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,Vaya,Medicaid,,8.23,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,Vaya,Medicaid,,5.43,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,Vaya,Medicaid,,20.03,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,Vaya,Medicaid,,20.95,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,Vaya,Medicaid,,30.31,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,Vaya,Medicaid,,5.33,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,Vaya,Medicaid,,243.21,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,Vaya,Medicaid,,464.98,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,Vaya,Medicaid,,1190.81,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Vaya,Medicaid,,1.22,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,Vaya,Medicaid,,457.09,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,Vaya,Medicaid,,3.89,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,Vaya,Medicaid,,47.01,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,Vaya,Medicaid,,3.98,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,Vaya,Medicaid,,4.15,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,Vaya,Medicaid,,54.35,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,Vaya,Medicaid,,4.37,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,Vaya,Medicaid,,4.00,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,Vaya,Medicaid,,4.76,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,Vaya,Medicaid,,4.67,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,Vaya,Medicaid,,4.12,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,Vaya,Medicaid,,5.34,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,Vaya,Medicaid,,20.87,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,Vaya,Medicaid,,125.17,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Vaya,Medicaid,,37.29,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,Vaya,Medicaid,,37.29,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,Vaya,Medicaid,,40.11,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,Vaya,Medicaid,,40.34,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Vaya,Medicaid,,16.08,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,Vaya,Medicaid,,0.76294,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,Vaya,Medicaid,,0.76294,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,Vaya,Medicaid,,0.80418,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,Vaya,Medicaid,,7.35,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,Vaya,Medicaid,,8.95,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,Vaya,Medicaid,,12.37,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,Vaya,Medicaid,,16.93,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,Vaya,Medicaid,,21.59,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,Vaya,Medicaid,,45.52,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,Vaya,Medicaid,,2.76,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,Vaya,Medicaid,,0.29899,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,Vaya,Medicaid,,208.63,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,Vaya,Medicaid,,1.66,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,Vaya,Medicaid,,23.51,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,Vaya,Medicaid,,4.77,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,Vaya,Medicaid,,5.46,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,Vaya,Medicaid,,6.19,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,Vaya,Medicaid,,155.20,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,Vaya,Medicaid,,3.78,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,Vaya,Medicaid,,63.59,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,Vaya,Medicaid,,4.97,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,Vaya,Medicaid,,19.03,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,Vaya,Medicaid,,18.62,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,Vaya,Medicaid,,4.71,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,Vaya,Medicaid,,4.19,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,Vaya,Medicaid,,3.73,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,Vaya,Medicaid,,9.52,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,Vaya,Medicaid,,10.62,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,Vaya,Medicaid,,55.20,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,Vaya,Medicaid,,5.75,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,Vaya,Medicaid,,13.02,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,Vaya,Medicaid,,123.54,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,Vaya,Medicaid,,7.78,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,Vaya,Medicaid,,12.88,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,Vaya,Medicaid,,725.82,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,Vaya,Medicaid,,320.02,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,Vaya,Medicaid,,248.29,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,Vaya,Medicaid,,3.67,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,Vaya,Medicaid,,44.54,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,Vaya,Medicaid,,23.76,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,Vaya,Medicaid,,108.04,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,Vaya,Medicaid,,144.03,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,Vaya,Medicaid,,247.23,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,Vaya,Medicaid,,69.24,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,Vaya,Medicaid,,72.07,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,Vaya,Medicaid,,3.94,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,Vaya,Medicaid,,3.97,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,Vaya,Medicaid,,4.40,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,Vaya,Medicaid,,5.87,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,Vaya,Medicaid,,3.98,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,Vaya,Medicaid,,2653.59,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,Vaya,Medicaid,,10.80,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,Vaya,Medicaid,,73.66,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,Vaya,Medicaid,,13.73,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,Vaya,Medicaid,,3.66,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,Vaya,Medicaid,,0.50519,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,Vaya,Medicaid,,0.91759,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,Vaya,Medicaid,,4.40,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,Vaya,Medicaid,,5.59,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,Vaya,Medicaid,,142.90,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,Vaya,Medicaid,,4.02,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,Vaya,Medicaid,,3.52,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,Vaya,Medicaid,,4.02,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,Vaya,Medicaid,,4.45,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,Vaya,Medicaid,,17.14,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,Vaya,Medicaid,,76.22,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,Vaya,Medicaid,,86.60,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,Vaya,Medicaid,,5.91,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,Vaya,Medicaid,,8.74,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,Vaya,Medicaid,,5.86,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,Vaya,Medicaid,,11.02,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,Vaya,Medicaid,,5.35,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,Vaya,Medicaid,,0.36085,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,Vaya,Medicaid,,24.72,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,Vaya,Medicaid,,1.30,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,Vaya,Medicaid,,19.38,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,Vaya,Medicaid,,17.84,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,Vaya,Medicaid,,3.57,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,Vaya,Medicaid,,95.89,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,Vaya,Medicaid,,65.78,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,Vaya,Medicaid,,174.02,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,Vaya,Medicaid,,4.23,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,Vaya,Medicaid,,3.59,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,Vaya,Medicaid,,54.65,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,Vaya,Medicaid,,177.03,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,Vaya,Medicaid,,4118.43,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,Vaya,Medicaid,,6.97,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,Vaya,Medicaid,,4.40,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,Vaya,Medicaid,,4.40,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,Vaya,Medicaid,,37.77,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,Vaya,Medicaid,,23.98,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,Vaya,Medicaid,,6.17,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,Vaya,Medicaid,,25.85,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,Vaya,Medicaid,,14.74,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,Vaya,Medicaid,,39.20,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,Vaya,Medicaid,,17.43,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,Vaya,Medicaid,,107.49,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,Vaya,Medicaid,,12.31,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,Vaya,Medicaid,,4.54,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,Vaya,Medicaid,,5.90,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,Vaya,Medicaid,,24.96,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,Vaya,Medicaid,,6024.73,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,Vaya,Medicaid,,7.56,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,Vaya,Medicaid,,4.57,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,Vaya,Medicaid,,4.61,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,Vaya,Medicaid,,19.25,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,Vaya,Medicaid,,614.07,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,Vaya,Medicaid,,7.38,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,Vaya,Medicaid,,26.53,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,Vaya,Medicaid,,466.52,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,Vaya,Medicaid,,8.78,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,Vaya,Medicaid,,7.23,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,Vaya,Medicaid,,6.05,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,Vaya,Medicaid,,11.39,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,Vaya,Medicaid,,7.46,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,Vaya,Medicaid,,1078.49,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,Vaya,Medicaid,,2691.26,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,Vaya,Medicaid,,5379.19,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,Vaya,Medicaid,,10755.08,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,Vaya,Medicaid,,37.31,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,Vaya,Medicaid,,82.40,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,Vaya,Medicaid,,5.26,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,Vaya,Medicaid,,10.34,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,Vaya,Medicaid,,30.48,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,Vaya,Medicaid,,65.22,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,Vaya,Medicaid,,3.79,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,Vaya,Medicaid,,3.67,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,Vaya,Medicaid,,9.98,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,Vaya,Medicaid,,10.40,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,Vaya,Medicaid,,3.51,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,Vaya,Medicaid,,3.70,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,Vaya,Medicaid,,971.70,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,Vaya,Medicaid,,3.52,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,Vaya,Medicaid,,11.83,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,Vaya,Medicaid,,27.73,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,Vaya,Medicaid,,7.66,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Vaya,Medicaid,,34.57,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,Vaya,Medicaid,,10.08,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,Vaya,Medicaid,,4.52,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,Vaya,Medicaid,,4.64,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,Vaya,Medicaid,,4.72,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,Vaya,Medicaid,,66.32,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,Vaya,Medicaid,,4.43,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,Vaya,Medicaid,,5.41,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,Vaya,Medicaid,,7.65,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,Vaya,Medicaid,,5.74,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,Vaya,Medicaid,,95.89,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,Vaya,Medicaid,,2.33,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,Vaya,Medicaid,,0.34023,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,Vaya,Medicaid,,213.39,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,Vaya,Medicaid,,5.12,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,Vaya,Medicaid,,5.11,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,Vaya,Medicaid,,51.96,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,Vaya,Medicaid,,6.19,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,Vaya,Medicaid,,6.67,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,Vaya,Medicaid,,3.65,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,Vaya,Medicaid,,3.64,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,Vaya,Medicaid,,3.76,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,Vaya,Medicaid,,4.05,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Vaya,Medicaid,,1511.07,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,Vaya,Medicaid,,3.64,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,Vaya,Medicaid,,3.73,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,Vaya,Medicaid,,4.17,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,Vaya,Medicaid,,3.45,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,Vaya,Medicaid,,18.04,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,Vaya,Medicaid,,1288.46,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,Vaya,Medicaid,,18.05,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,Vaya,Medicaid,,10.08,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,Vaya,Medicaid,,19.98,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,Vaya,Medicaid,,21.73,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,Vaya,Medicaid,,4.38,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,Vaya,Medicaid,,0.30930,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,Vaya,Medicaid,,3.86,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,Vaya,Medicaid,,14.56,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,Vaya,Medicaid,,1.00,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,Vaya,Medicaid,,3.50,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,Vaya,Medicaid,,5.86,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,Vaya,Medicaid,,3.47,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,Vaya,Medicaid,,3.70,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,Vaya,Medicaid,,3.34,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,Vaya,Medicaid,,4.87,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,Vaya,Medicaid,,0.88666,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,Vaya,Medicaid,,5.66,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,Vaya,Medicaid,,0.88666,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,Vaya,Medicaid,,5.34,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,Vaya,Medicaid,,3.54,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,Vaya,Medicaid,,0.36085,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,Vaya,Medicaid,,4.65,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,Vaya,Medicaid,,4.80,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,Vaya,Medicaid,,4.65,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,Vaya,Medicaid,,1.72,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,Vaya,Medicaid,,4.68,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,Vaya,Medicaid,,3.32,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,Vaya,Medicaid,,23.40,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,Vaya,Medicaid,,34.93,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,Vaya,Medicaid,,5.74,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,Vaya,Medicaid,,6.46,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,Vaya,Medicaid,,3724.84,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Vaya,Medicaid,,815.64,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,Vaya,Medicaid,,6.37,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,Vaya,Medicaid,,156.22,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,Vaya,Medicaid,,47.66,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,Vaya,Medicaid,,29.64,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Vaya,Medicaid,,565.11,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,Vaya,Medicaid,,310.92,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,Vaya,Medicaid,,0.72170,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,Vaya,Medicaid,,22.53,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,Vaya,Medicaid,,0.32992,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,Vaya,Medicaid,,3.36,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,Vaya,Medicaid,,5.65,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,Vaya,Medicaid,,4.17,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,Vaya,Medicaid,,8.44,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,Vaya,Medicaid,,286.88,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,Vaya,Medicaid,,12.57,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,Vaya,Medicaid,,7.64,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,Vaya,Medicaid,,4.91,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,Vaya,Medicaid,,77.79,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,Vaya,Medicaid,,99.50,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,Vaya,Medicaid,,68.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,Vaya,Medicaid,,110.39,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,Vaya,Medicaid,,24.25,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,Vaya,Medicaid,,18.62,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,Vaya,Medicaid,,3.31,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,Vaya,Medicaid,,5.17,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,Vaya,Medicaid,,23.94,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,Vaya,Medicaid,,141.49,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,Vaya,Medicaid,,331.40,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,Vaya,Medicaid,,3.60,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,Vaya,Medicaid,,3.85,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,Vaya,Medicaid,,13.76,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,Vaya,Medicaid,,14.38,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,Vaya,Medicaid,,13.92,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Vaya,Medicaid,,16.24,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,Vaya,Medicaid,,14.38,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,Vaya,Medicaid,,13.92,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,Vaya,Medicaid,,30.93,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,Vaya,Medicaid,,15.16,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,Vaya,Medicaid,,14.38,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,Vaya,Medicaid,,13.92,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,Vaya,Medicaid,,13.92,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,Vaya,Medicaid,,13.76,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,Vaya,Medicaid,,14.38,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,Vaya,Medicaid,,16.24,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,Vaya,Medicaid,,13.76,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,Vaya,Medicaid,,3.33,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,Vaya,Medicaid,,211.05,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,Vaya,Medicaid,,4.67,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,Vaya,Medicaid,,1490.27,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,Vaya,Medicaid,,5457.77,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,Vaya,Medicaid,,1152.75,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,Vaya,Medicaid,,5457.77,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,Vaya,Medicaid,,3.90,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,Vaya,Medicaid,,3.96,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,Vaya,Medicaid,,1511.07,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,Vaya,Medicaid,,72.21,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,Vaya,Medicaid,,256.31,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,Vaya,Medicaid,,4.70,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,Vaya,Medicaid,,9.53,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,Vaya,Medicaid,,1449.71,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,Vaya,Medicaid,,68.52,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,Vaya,Medicaid,,63.57,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,Vaya,Medicaid,,138.89,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,Vaya,Medicaid,,8271.90,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,Vaya,Medicaid,,32917.38,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Vaya,Medicaid,,303.38,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,Vaya,Medicaid,,604.11,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,Vaya,Medicaid,,5530.96,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,Vaya,Medicaid,,66.01,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Vaya,Medicaid,,59.81,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Vaya,Medicaid,,64.90,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Vaya,Medicaid,,59.76,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Vaya,Medicaid,,86.87,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,Vaya,Medicaid,,419.62,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,Vaya,Medicaid,,102.07,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,Vaya,Medicaid,,205.50,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,Vaya,Medicaid,,4.72,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,Vaya,Medicaid,,15.99,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,Vaya,Medicaid,,69.57,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,Vaya,Medicaid,,1163.02,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,Vaya,Medicaid,,2313.04,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,Vaya,Medicaid,,21.72,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,Vaya,Medicaid,,9.37,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,Vaya,Medicaid,,13.08,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,Vaya,Medicaid,,3.93,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,Vaya,Medicaid,,5.50,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,Vaya,Medicaid,,70.69,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,Vaya,Medicaid,,15.67,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,Vaya,Medicaid,,60.39,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,Vaya,Medicaid,,4.29,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Vaya,Medicaid,,8.93,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,Vaya,Medicaid,,5.18,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Vaya,Medicaid,,6.02,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,Vaya,Medicaid,,4.02,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,Vaya,Medicaid,,3.97,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,Vaya,Medicaid,,21.31,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Vaya,Medicaid,,16.08,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,Vaya,Medicaid,,14.72,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,Vaya,Medicaid,,15.62,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,Vaya,Medicaid,,14.57,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Vaya,Medicaid,,59.08,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,Vaya,Medicaid,,13.00,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,Vaya,Medicaid,,22.56,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,Vaya,Medicaid,,0.97945,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Vaya,Medicaid,,45.16,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Vaya,Medicaid,,235.96,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,Vaya,Medicaid,,223.97,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,Vaya,Medicaid,,9.18,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,Vaya,Medicaid,,9.59,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,Vaya,Medicaid,,6.51,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,Vaya,Medicaid,,0.57736,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,Vaya,Medicaid,,7541.77,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,Vaya,Medicaid,,65.60,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,Vaya,Medicaid,,45.16,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,Vaya,Medicaid,,13.17,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,Vaya,Medicaid,,23.82,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,Vaya,Medicaid,,5.72,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,Vaya,Medicaid,,2.42,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,Vaya,Medicaid,,2.42,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,Vaya,Medicaid,,2.42,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,Vaya,Medicaid,,2.42,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,Vaya,Medicaid,,15.49,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,Vaya,Medicaid,,22.30,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,Vaya,Medicaid,,31.60,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,Vaya,Medicaid,,4.51,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,Vaya,Medicaid,,4.04,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,Vaya,Medicaid,,11.91,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,Vaya,Medicaid,,42.13,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,Vaya,Medicaid,,3.38,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,Vaya,Medicaid,,10.97,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,Vaya,Medicaid,,3.34,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,Vaya,Medicaid,,4.94,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,Vaya,Medicaid,,2822.24,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,Vaya,Medicaid,,577.15,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,Vaya,Medicaid,,16.42,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,Vaya,Medicaid,,9.97,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,Vaya,Medicaid,,5.81,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,Vaya,Medicaid,,15.71,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,Vaya,Medicaid,,9.43,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,Vaya,Medicaid,,21.53,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Vaya,Medicaid,,50.11,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,Vaya,Medicaid,,13.11,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Vaya,Medicaid,,50.11,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,Vaya,Medicaid,,6.14,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,Vaya,Medicaid,,119.21,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,Vaya,Medicaid,,5.88,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,Vaya,Medicaid,,4.26,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,Vaya,Medicaid,,4.15,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,Vaya,Medicaid,,4.18,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Vaya,Medicaid,,5.43,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,Vaya,Medicaid,,1.46,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,Vaya,Medicaid,,31.70,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,Vaya,Medicaid,,83.52,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,Vaya,Medicaid,,31.96,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,Vaya,Medicaid,,165.68,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,Vaya,Medicaid,,13.65,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,Vaya,Medicaid,,5.16,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,Vaya,Medicaid,,3.92,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,Vaya,Medicaid,,14.43,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,Vaya,Medicaid,,15.42,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,Vaya,Medicaid,,12.45,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,Vaya,Medicaid,,19.01,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,Vaya,Medicaid,,77.53,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,Vaya,Medicaid,,3.92,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,Vaya,Medicaid,,13.27,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,Vaya,Medicaid,,5.58,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,Vaya,Medicaid,,23.66,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,Vaya,Medicaid,,50.11,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,Vaya,Medicaid,,9.79,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,Vaya,Medicaid,,3.59,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Vaya,Medicaid,,5.92,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,Vaya,Medicaid,,3.38,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,Vaya,Medicaid,,3.58,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,Vaya,Medicaid,,19.49,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,Vaya,Medicaid,,7.01,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,Vaya,Medicaid,,4.81,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,Vaya,Medicaid,,44.46,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,Vaya,Medicaid,,69.84,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,Vaya,Medicaid,,172.18,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,Vaya,Medicaid,,13.45,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,Vaya,Medicaid,,16.90,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,Vaya,Medicaid,,45.90,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,Vaya,Medicaid,,18.19,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Vaya,Medicaid,,18.16,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,Vaya,Medicaid,,26.51,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,Vaya,Medicaid,,1.22,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Vaya,Medicaid,,10.54,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,Vaya,Medicaid,,5.86,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Vaya,Medicaid,,7787.88,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,Vaya,Medicaid,,65.78,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,Vaya,Medicaid,,34.72,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,Vaya,Medicaid,,13.31,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,Vaya,Medicaid,,14.99,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,Vaya,Medicaid,,13.38,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,Vaya,Medicaid,,12.45,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,Vaya,Medicaid,,18.14,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,Vaya,Medicaid,,76.73,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,Vaya,Medicaid,,3.97,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,Vaya,Medicaid,,13.90,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,Vaya,Medicaid,,14.10,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,Vaya,Medicaid,,19.92,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,Vaya,Medicaid,,6.33,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,Vaya,Medicaid,,21.97,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,Vaya,Medicaid,,35.43,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,Vaya,Medicaid,,21.43,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,Vaya,Medicaid,,51.63,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,Vaya,Medicaid,,35.25,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,Vaya,Medicaid,,16.63,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,Vaya,Medicaid,,14.51,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,Vaya,Medicaid,,21.43,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,Vaya,Medicaid,,16.89,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,Vaya,Medicaid,,19.92,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,Vaya,Medicaid,,22.52,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,Vaya,Medicaid,,98.73,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,Vaya,Medicaid,,24.30,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,Vaya,Medicaid,,116.92,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,Vaya,Medicaid,,240.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,Vaya,Medicaid,,256.18,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Vaya,Medicaid,,7.53,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,Vaya,Medicaid,,17.24,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,Vaya,Medicaid,,15.33,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,Vaya,Medicaid,,31.61,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,Vaya,Medicaid,,45.05,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,Vaya,Medicaid,,105.66,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,Vaya,Medicaid,,198.32,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,Vaya,Medicaid,,18.62,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,Vaya,Medicaid,,21.27,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,Vaya,Medicaid,,51.09,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,Vaya,Medicaid,,13.77,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,Vaya,Medicaid,,16.11,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,Vaya,Medicaid,,151.59,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,Vaya,Medicaid,,3.62,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,Vaya,Medicaid,,56.75,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,Vaya,Medicaid,,13.08,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,Vaya,Medicaid,,21.67,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,Vaya,Medicaid,,59.76,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,Vaya,Medicaid,,36.37,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,Vaya,Medicaid,,4.99,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,Vaya,Medicaid,,24.86,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,Vaya,Medicaid,,14.72,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,Vaya,Medicaid,,16.16,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,Vaya,Medicaid,,37.24,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,Vaya,Medicaid,,35.43,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,Vaya,Medicaid,,15.59,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,Vaya,Medicaid,,6.02,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,Vaya,Medicaid,,7.17,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,Vaya,Medicaid,,14.72,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,Vaya,Medicaid,,368.07,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,Vaya,Medicaid,,20.53,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,Vaya,Medicaid,,5.19,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,Vaya,Medicaid,,7.19,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,Vaya,Medicaid,,14.79,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,Vaya,Medicaid,,5.72,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Vaya,Medicaid,,13.01,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,Vaya,Medicaid,,35.88,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,Vaya,Medicaid,,18.19,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,Vaya,Medicaid,,4.63,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,Vaya,Medicaid,,4.64,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,Vaya,Medicaid,,5.28,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Vaya,Medicaid,,8.80,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,Vaya,Medicaid,,5.38,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,Vaya,Medicaid,,27.02,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,Vaya,Medicaid,,19.49,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,Vaya,Medicaid,,28.80,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,Vaya,Medicaid,,6.01,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,Vaya,Medicaid,,21.51,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,Vaya,Medicaid,,16.89,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,Vaya,Medicaid,,3.66,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,Vaya,Medicaid,,14.08,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,Vaya,Medicaid,,3.56,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,Vaya,Medicaid,,11.53,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,Vaya,Medicaid,,16.96,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,Vaya,Medicaid,,21.93,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,Vaya,Medicaid,,64.09,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,Vaya,Medicaid,,16.44,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,Vaya,Medicaid,,65.83,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,Vaya,Medicaid,,13.23,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,Vaya,Medicaid,,8.19,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,Vaya,Medicaid,,21.65,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,Vaya,Medicaid,,15.41,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,Vaya,Medicaid,,10.72,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,Vaya,Medicaid,,33.32,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,Vaya,Medicaid,,4.57,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,Vaya,Medicaid,,13.01,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,Vaya,Medicaid,,93.17,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,Vaya,Medicaid,,34.57,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,Vaya,Medicaid,,57.03,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,Vaya,Medicaid,,49.36,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,Vaya,Medicaid,,15.24,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,Vaya,Medicaid,,13.55,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,Vaya,Medicaid,,16.41,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,Vaya,Medicaid,,12.33,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,Vaya,Medicaid,,3.31,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,Vaya,Medicaid,,51.06,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,Vaya,Medicaid,,2077.88,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,Vaya,Medicaid,,18.06,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,Vaya,Medicaid,,31.01,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,Vaya,Medicaid,,31.68,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,Vaya,Medicaid,,75.11,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,Vaya,Medicaid,,3265.93,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,Vaya,Medicaid,,81.37,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Vaya,Medicaid,,115.67,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Vaya,Medicaid,,64.19,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Vaya,Medicaid,,99.82,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Vaya,Medicaid,,93.27,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Vaya,Medicaid,,83.92,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,Vaya,Medicaid,,75.76,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,Vaya,Medicaid,,115.67,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,Vaya,Medicaid,,64.19,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,Vaya,Medicaid,,99.82,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,Vaya,Medicaid,,565.11,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,Vaya,Medicaid,,20.87,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,Vaya,Medicaid,,23.74,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Vaya,Medicaid,,5.18,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Vaya,Medicaid,,6.11,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,Vaya,Medicaid,,18.19,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,Vaya,Medicaid,,40.27,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,Vaya,Medicaid,,30.15,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Vaya,Medicaid,,235.96,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,Vaya,Medicaid,,235.96,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,Vaya,Medicaid,,15.18,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,Vaya,Medicaid,,13.29,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,Vaya,Medicaid,,84.99,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,Vaya,Medicaid,,8.32,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,Vaya,Medicaid,,35.72,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,Vaya,Medicaid,,13.03,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,Vaya,Medicaid,,23.74,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Vaya,Medicaid,,10.08,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Vaya,Medicaid,,5.31,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,Vaya,Medicaid,,6.67,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,Vaya,Medicaid,,326.80,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,Vaya,Medicaid,,7.99,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,Vaya,Medicaid,,98.65,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Vaya,Medicaid,,532.09,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,Vaya,Medicaid,,3.55,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,Vaya,Medicaid,,29.75,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,Vaya,Medicaid,,284.59,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,Vaya,Medicaid,,15.22,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,Vaya,Medicaid,,44.33,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,Vaya,Medicaid,,123.15,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,Vaya,Medicaid,,22.52,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,Vaya,Medicaid,,23.82,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,Vaya,Medicaid,,8.93,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,Vaya,Medicaid,,13.48,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,Vaya,Medicaid,,9.78,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,Vaya,Medicaid,,13.62,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,Vaya,Medicaid,,7.53,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,Vaya,Medicaid,,13.62,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,Vaya,Medicaid,,9.99,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,Vaya,Medicaid,,18.31,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,Vaya,Medicaid,,53.69,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,Vaya,Medicaid,,24.68,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,Vaya,Medicaid,,24.38,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Vaya,Medicaid,,3.31,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Vaya,Medicaid,,1400.72,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,Vaya,Medicaid,,6.38,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,Vaya,Medicaid,,17.17,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,Vaya,Medicaid,,13.42,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,Vaya,Medicaid,,36.78,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,Vaya,Medicaid,,10.43,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,Vaya,Medicaid,,47.78,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,Vaya,Medicaid,,49.02,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,Vaya,Medicaid,,31.01,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,Vaya,Medicaid,,14.07,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,Vaya,Medicaid,,4.56,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,Vaya,Medicaid,,4.70,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,Vaya,Medicaid,,94.64,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,Vaya,Medicaid,,5.37,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,Vaya,Medicaid,,1203.48,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,Vaya,Medicaid,,13.00,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,Vaya,Medicaid,,13.02,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,Vaya,Medicaid,,13.04,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,Vaya,Medicaid,,13.05,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,Vaya,Medicaid,,13.00,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,Vaya,Medicaid,,29.88,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,Vaya,Medicaid,,3.99,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Vaya,Medicaid,,3.31,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,Vaya,Medicaid,,13.65,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,Vaya,Medicaid,,10.32,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,Vaya,Medicaid,,94.06,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,Vaya,Medicaid,,95.29,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,Vaya,Medicaid,,74.45,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,Vaya,Medicaid,,16.45,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Vaya,Medicaid,,18.20,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,Vaya,Medicaid,,15.59,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,Vaya,Medicaid,,16.24,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,Vaya,Medicaid,,3.31,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,Vaya,Medicaid,,4.67,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,Vaya,Medicaid,,5.12,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,Vaya,Medicaid,,32.71,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,Vaya,Medicaid,,18.34,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,Vaya,Medicaid,,25.89,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,Vaya,Medicaid,,17.34,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,Vaya,Medicaid,,73.66,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,Vaya,Medicaid,,238.38,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Vaya,Medicaid,,5.43,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,Vaya,Medicaid,,5.14,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,Vaya,Medicaid,,150.58,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,Vaya,Medicaid,,20.97,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,Vaya,Medicaid,,21.34,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,Vaya,Medicaid,,12.79,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Vaya,Medicaid,,31.19,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,Vaya,Medicaid,,59.08,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,Vaya,Medicaid,,8.04,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,Vaya,Medicaid,,12.68,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,Vaya,Medicaid,,5.44,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,Vaya,Medicaid,,7.53,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,Vaya,Medicaid,,43.30,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,Vaya,Medicaid,,15.59,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,Vaya,Medicaid,,18.10,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,Vaya,Medicaid,,16.97,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,Vaya,Medicaid,,5.18,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,Vaya,Medicaid,,6.11,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,Vaya,Medicaid,,13.81,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,Vaya,Medicaid,,4.78,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,Vaya,Medicaid,,7.09,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,Vaya,Medicaid,,4.26,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,Vaya,Medicaid,,8.80,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,Vaya,Medicaid,,4.94,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,Vaya,Medicaid,,5.40,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,Vaya,Medicaid,,3.64,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,Vaya,Medicaid,,3.37,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,Vaya,Medicaid,,109.55,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,Vaya,Medicaid,,7.01,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,Vaya,Medicaid,,532.09,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Vaya,Medicaid,,5098.25,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Vaya,Medicaid,,5098.25,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Vaya,Medicaid,,5098.25,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Vaya,Medicaid,,5098.25,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,Vaya,Medicaid,,5098.25,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,Vaya,Medicaid,,7787.88,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,Vaya,Medicaid,,83.29,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,Vaya,Medicaid,,22.00,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Vaya,Medicaid,,6.11,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,Vaya,Medicaid,,4.75,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,Vaya,Medicaid,,30.55,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Vaya,Medicaid,,6.18,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,Vaya,Medicaid,,2.56,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,Vaya,Medicaid,,156.09,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,Vaya,Medicaid,,10.08,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,Vaya,Medicaid,,5.31,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,Vaya,Medicaid,,5.38,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,Vaya,Medicaid,,57.38,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,Vaya,Medicaid,,12.04,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,Vaya,Medicaid,,15.99,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,Vaya,Medicaid,,3.47,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Vaya,Medicaid,,111.31,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Vaya,Medicaid,,63.59,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,Vaya,Medicaid,,0.85573,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,Vaya,Medicaid,,0.57736,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,Vaya,Medicaid,,57.07,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,Vaya,Medicaid,,61.54,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,Vaya,Medicaid,,49.21,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,Vaya,Medicaid,,53.74,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,Vaya,Medicaid,,0.46395,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,Vaya,Medicaid,,60.07,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,Vaya,Medicaid,,8.49,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,Vaya,Medicaid,,13.66,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,Vaya,Medicaid,,16.04,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,Vaya,Medicaid,,5.92,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,Vaya,Medicaid,,7.77,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Vaya,Medicaid,,7.67,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,Vaya,Medicaid,,9307.04,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,Vaya,Medicaid,,7417.08,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,Vaya,Medicaid,,10571.50,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,Vaya,Medicaid,,5.66,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,Vaya,Medicaid,,114.65,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,Vaya,Medicaid,,64.90,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,Vaya,Medicaid,,59.76,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,Vaya,Medicaid,,86.87,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,Vaya,Medicaid,,9648.36,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Vaya,Medicaid,,1574.58,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Vaya,Medicaid,,815.64,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Vaya,Medicaid,,1574.58,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Vaya,Medicaid,,815.64,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,Vaya,Medicaid,,1574.58,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,Vaya,Medicaid,,815.64,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,Vaya,Medicaid,,208.77,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Vaya,Medicaid,,3879.53,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Vaya,Medicaid,,3879.53,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,Vaya,Medicaid,,3879.53,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,Vaya,Medicaid,,10538.54,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,Vaya,Medicaid,,510.35,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Vaya,Medicaid,,861.02,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Vaya,Medicaid,,1709.05,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Vaya,Medicaid,,352.21,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,Vaya,Medicaid,,861.02,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,Vaya,Medicaid,,1709.05,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,Vaya,Medicaid,,352.21,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,Vaya,Medicaid,,57.50,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,Vaya,Medicaid,,9.09,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,Vaya,Medicaid,,6.13,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,Vaya,Medicaid,,39556.99,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,Vaya,Medicaid,,26.58,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,Vaya,Medicaid,,14.54,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,Vaya,Medicaid,,15.31,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,Vaya,Medicaid,,303.38,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,Vaya,Medicaid,,14.59,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,Vaya,Medicaid,,4.19,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,Vaya,Medicaid,,4.43,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,Vaya,Medicaid,,3.97,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,Vaya,Medicaid,,138.36,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,Vaya,Medicaid,,29.91,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,Vaya,Medicaid,,151.76,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,Vaya,Medicaid,,54.32,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,Vaya,Medicaid,,11.42,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,Vaya,Medicaid,,11.42,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,Vaya,Medicaid,,1.05,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,Vaya,Medicaid,,2.67,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,Vaya,Medicaid,,16.48,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,Vaya,Medicaid,,12.42,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,Vaya,Medicaid,,95.01,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,Vaya,Medicaid,,16.08,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,Vaya,Medicaid,,3.54,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,Vaya,Medicaid,,12.21,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,Vaya,Medicaid,,7.89,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,Vaya,Medicaid,,89.89,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,Vaya,Medicaid,,3.77,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,Vaya,Medicaid,,21.98,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,Vaya,Medicaid,,120.21,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,Vaya,Medicaid,,64.70,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,Vaya,Medicaid,,10.68,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,Vaya,Medicaid,,4.21,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,Vaya,Medicaid,,3.67,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,Vaya,Medicaid,,3.75,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,Vaya,Medicaid,,3.65,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,Vaya,Medicaid,,4.67,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,Vaya,Medicaid,,7.01,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,Vaya,Medicaid,,6.29,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,Vaya,Medicaid,,6.31,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,Vaya,Medicaid,,7.04,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,Vaya,Medicaid,,7.84,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,Vaya,Medicaid,,23.73,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,Vaya,Medicaid,,10.12,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,Vaya,Medicaid,,3.35,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,Vaya,Medicaid,,3.74,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Vaya,Medicaid,,3.38,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,Vaya,Medicaid,,3.53,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,Vaya,Medicaid,,3.39,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,Vaya,Medicaid,,0.44333,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,Vaya,Medicaid,,4.91,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,Vaya,Medicaid,,24.06,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,Vaya,Medicaid,,48.33,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,Vaya,Medicaid,,9.78,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,Vaya,Medicaid,,0.87635,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,Vaya,Medicaid,,9.97,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,Vaya,Medicaid,,5.43,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,Vaya,Medicaid,,6.44,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,Vaya,Medicaid,,6.11,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,Vaya,Medicaid,,38.28,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,Vaya,Medicaid,,15.91,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,Vaya,Medicaid,,6.17,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,Vaya,Medicaid,,3.53,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,Vaya,Medicaid,,6.11,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,Vaya,Medicaid,,6.18,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,Vaya,Medicaid,,17.99,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,Vaya,Medicaid,,18.36,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,Vaya,Medicaid,,4.83,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,Vaya,Medicaid,,11.04,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,Vaya,Medicaid,,3.37,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,Vaya,Medicaid,,7.67,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,Vaya,Medicaid,,63.30,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,Vaya,Medicaid,,97.53,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,Vaya,Medicaid,,4.66,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,Vaya,Medicaid,,5.97,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,Vaya,Medicaid,,21.81,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,Vaya,Medicaid,,3.96,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,Vaya,Medicaid,,3.93,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,Vaya,Medicaid,,4.24,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,Vaya,Medicaid,,3.39,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,Vaya,Medicaid,,3.64,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,Vaya,Medicaid,,3.85,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,Vaya,Medicaid,,15.30,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,Vaya,Medicaid,,2.78,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Vaya,Medicaid,,3.53,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,Vaya,Medicaid,,3.84,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,Vaya,Medicaid,,3.73,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,Vaya,Medicaid,,5.48,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,Vaya,Medicaid,,6.32,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,Vaya,Medicaid,,5.43,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,Vaya,Medicaid,,4.56,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,Vaya,Medicaid,,5.38,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,Vaya,Medicaid,,4.80,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,Vaya,Medicaid,,6.66,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,Vaya,Medicaid,,18.16,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,Vaya,Medicaid,,34.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,Vaya,Medicaid,,3.52,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,Vaya,Medicaid,,26.47,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,Vaya,Medicaid,,11.07,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,Vaya,Medicaid,,5.30,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,Vaya,Medicaid,,3.53,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,Vaya,Medicaid,,3.79,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,Vaya,Medicaid,,4.79,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,Vaya,Medicaid,,2.17,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,Vaya,Medicaid,,4.32,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,Vaya,Medicaid,,3.70,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,Vaya,Medicaid,,42.16,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,Vaya,Medicaid,,51.04,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,Vaya,Medicaid,,15.24,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,Vaya,Medicaid,,8.80,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,Vaya,Medicaid,,1400.72,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,Vaya,Medicaid,,3.57,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,Vaya,Medicaid,,5.01,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,Vaya,Medicaid,,4.88,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,Vaya,Medicaid,,46.85,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,Vaya,Medicaid,,20.85,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,Vaya,Medicaid,,7.05,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,Vaya,Medicaid,,43.86,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,Vaya,Medicaid,,1.32,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,Vaya,Medicaid,,1.32,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,Vaya,Medicaid,,23.40,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,Vaya,Medicaid,,4.61,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,Vaya,Medicaid,,4.88,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,Vaya,Medicaid,,14.91,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,Vaya,Medicaid,,52.09,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,Vaya,Medicaid,,53.20,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,Vaya,Medicaid,,55.61,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,Vaya,Medicaid,,32.04,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,Vaya,Medicaid,,17.67,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,Vaya,Medicaid,,22.69,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,Vaya,Medicaid,,14.98,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,Vaya,Medicaid,,39.00,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,Vaya,Medicaid,,9.25,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,Vaya,Medicaid,,0.79387,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,Vaya,Medicaid,,0.62891,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,Vaya,Medicaid,,84.65,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,Vaya,Medicaid,,4.55,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,Vaya,Medicaid,,5.04,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,Vaya,Medicaid,,30.67,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,Vaya,Medicaid,,258.99,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,Vaya,Medicaid,,3.50,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,Vaya,Medicaid,,4.39,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,Vaya,Medicaid,,3.60,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,Vaya,Medicaid,,41.76,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,Vaya,Medicaid,,4.58,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,Vaya,Medicaid,,3.59,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,Vaya,Medicaid,,3.62,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,Vaya,Medicaid,,5.04,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,Vaya,Medicaid,,3.65,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,Vaya,Medicaid,,25.01,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,Vaya,Medicaid,,33.30,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,Vaya,Medicaid,,3.43,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,Vaya,Medicaid,,3.59,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,Vaya,Medicaid,,3.52,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,Vaya,Medicaid,,3.80,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,Vaya,Medicaid,,52.93,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,Vaya,Medicaid,,17.83,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,Vaya,Medicaid,,5.20,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,Vaya,Medicaid,,13.50,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,Vaya,Medicaid,,0.28868,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,Vaya,Medicaid,,0.28868,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,Vaya,Medicaid,,0.58767,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,Vaya,Medicaid,,1.58,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,Vaya,Medicaid,,19.35,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,Vaya,Medicaid,,3.55,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,Vaya,Medicaid,,17.24,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,Vaya,Medicaid,,17.24,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,Vaya,Medicaid,,17.24,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,Vaya,Medicaid,,195.34,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,Vaya,Medicaid,,4.58,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,Vaya,Medicaid,,73.53,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,Vaya,Medicaid,,83.44,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,Vaya,Medicaid,,0.24744,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,Vaya,Medicaid,,3.38,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,Vaya,Medicaid,,10.97,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,Vaya,Medicaid,,21.60,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,Vaya,Medicaid,,13.82,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,Vaya,Medicaid,,24.05,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,Vaya,Medicaid,,23.10,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,Vaya,Medicaid,,16.24,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,Vaya,Medicaid,,15.77,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,Vaya,Medicaid,,17.01,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,Vaya,Medicaid,,17.00,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,Vaya,Medicaid,,19.62,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,Vaya,Medicaid,,3.86,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,Vaya,Medicaid,,28.18,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,Vaya,Medicaid,,15.31,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,Vaya,Medicaid,,88.26,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,Vaya,Medicaid,,81.41,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,Vaya,Medicaid,,3.50,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,Vaya,Medicaid,,14.23,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,Vaya,Medicaid,,16.53,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,Vaya,Medicaid,,23.86,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,Vaya,Medicaid,,3.46,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,Vaya,Medicaid,,3.56,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,Vaya,Medicaid,,1092.56,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,Vaya,Medicaid,,55.65,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,Vaya,Medicaid,,147.43,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,Vaya,Medicaid,,17.55,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,Vaya,Medicaid,,9.42,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,Vaya,Medicaid,,10.22,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,Vaya,Medicaid,,0.31961,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,Vaya,Medicaid,,84.08,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,Vaya,Medicaid,,408.12,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,Vaya,Medicaid,,75.84,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,Vaya,Medicaid,,1.42,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,Vaya,Medicaid,,133.21,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,Vaya,Medicaid,,5.47,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,Vaya,Medicaid,,16.45,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,Vaya,Medicaid,,24.51,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,Vaya,Medicaid,,4.60,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,Vaya,Medicaid,,19.55,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,Vaya,Medicaid,,174.94,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,Vaya,Medicaid,,6.64,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,Vaya,Medicaid,,5.76,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,Vaya,Medicaid,,5.92,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,Vaya,Medicaid,,58.97,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,Vaya,Medicaid,,1.29,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,Vaya,Medicaid,,5.17,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,Vaya,Medicaid,,5.17,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,Vaya,Medicaid,,11.02,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,Vaya,Medicaid,,587.69,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,Vaya,Medicaid,,12.79,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,Vaya,Medicaid,,4.70,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,Vaya,Medicaid,,4.08,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,Vaya,Medicaid,,4.88,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,Vaya,Medicaid,,12.89,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,Vaya,Medicaid,,3.40,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,Vaya,Medicaid,,3.41,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,Vaya,Medicaid,,5.16,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,Vaya,Medicaid,,8.37,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,Vaya,Medicaid,,6.18,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,Vaya,Medicaid,,12.08,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,Vaya,Medicaid,,11.43,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,Vaya,Medicaid,,9.38,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,Vaya,Medicaid,,43.19,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,Vaya,Medicaid,,3.53,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,Vaya,Medicaid,,5.35,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,Vaya,Medicaid,,88.92,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,Vaya,Medicaid,,101.78,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,Vaya,Medicaid,,5662.17,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,Vaya,Medicaid,,19.05,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,Vaya,Medicaid,,3.86,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,Vaya,Medicaid,,59.81,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,Vaya,Medicaid,,62.91,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,Vaya,Medicaid,,1871.56,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,Vaya,Medicaid,,5.64,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,Vaya,Medicaid,,24.87,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,Vaya,Medicaid,,21.86,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,Vaya,Medicaid,,22.17,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,Vaya,Medicaid,,22.16,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,Vaya,Medicaid,,11.70,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,Vaya,Medicaid,,27.09,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,Vaya,Medicaid,,20.06,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,Vaya,Medicaid,,91.16,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,Vaya,Medicaid,,0.91759,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,Vaya,Medicaid,,12.68,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,Vaya,Medicaid,,9.32,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,Vaya,Medicaid,,3.38,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,Vaya,Medicaid,,3.56,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,Vaya,Medicaid,,1.08,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,Vaya,Medicaid,,105.48,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,Vaya,Medicaid,,72.81,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,Vaya,Medicaid,,3.69,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,Vaya,Medicaid,,3.62,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,Vaya,Medicaid,,3.63,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,Vaya,Medicaid,,3.64,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,Vaya,Medicaid,,3.78,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,Vaya,Medicaid,,6.89,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,Vaya,Medicaid,,8346.49,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,Vaya,Medicaid,,117.11,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,Vaya,Medicaid,,8.43,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,Vaya,Medicaid,,20.23,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,Vaya,Medicaid,,93.27,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,Vaya,Medicaid,,83.92,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,Vaya,Medicaid,,31.94,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,Vaya,Medicaid,,12.20,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,Vaya,Medicaid,,5540.02,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,Vaya,Medicaid,,14.79,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,Vaya,Medicaid,,164.56,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,Vaya,Medicaid,,1.89,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,Vaya,Medicaid,,0.28868,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,Vaya,Medicaid,,20.43,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,Vaya,Medicaid,,790.33,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,Vaya,Medicaid,,0.67015,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,Vaya,Medicaid,,0.50519,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,Vaya,Medicaid,,223.63,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,Vaya,Medicaid,,8.38,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,Vaya,Medicaid,,111.31,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,Vaya,Medicaid,,63.59,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,Vaya,Medicaid,,90.11,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,Vaya,Medicaid,,90.11,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,Vaya,Medicaid,,162.19,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,Vaya,Medicaid,,8259.89,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,Vaya,Medicaid,,4131.60,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,Vaya,Medicaid,,0.81449,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,Vaya,Medicaid,,0.25775,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,Vaya,Medicaid,,0.41240,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,Vaya,Medicaid,,21.02,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,Vaya,Medicaid,,3.61,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,Vaya,Medicaid,,3.39,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,Vaya,Medicaid,,3.42,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,Vaya,Medicaid,,10.54,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,Vaya,Medicaid,,7.01,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,Vaya,Medicaid,,20.21,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,Vaya,Medicaid,,26.61,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,Vaya,Medicaid,,76.64,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,Vaya,Medicaid,,19.56,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,Vaya,Medicaid,,43.30,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,Vaya,Medicaid,,5.41,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,Vaya,Medicaid,,10.30,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,Vaya,Medicaid,,36.14,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,Vaya,Medicaid,,6.37,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,Vaya,Medicaid,,167.65,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,Vaya,Medicaid,,0.21651,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,Vaya,Medicaid,,4.12,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,Vaya,Medicaid,,109.60,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,Vaya,Medicaid,,16.51,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,Vaya,Medicaid,,7.74,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,Vaya,Medicaid,,3.87,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,Vaya,Medicaid,,31.19,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,Vaya,Medicaid,,56.97,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,Vaya,Medicaid,,9.97,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,Vaya,Medicaid,,54.93,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,Vaya,Medicaid,,0.83511,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,Vaya,Medicaid,,32.97,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,Vaya,Medicaid,,18.20,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,Vaya,Medicaid,,18.20,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,Vaya,Medicaid,,18.20,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,Vaya,Medicaid,,108.61,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,Vaya,Medicaid,,6.03,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,Vaya,Medicaid,,17.45,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,Vaya,Medicaid,,17.45,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,Vaya,Medicaid,,1.08,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,Vaya,Medicaid,,6.13,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,Vaya,Medicaid,,15.48,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,Vaya,Medicaid,,15.56,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,Vaya,Medicaid,,14.73,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,Vaya,Medicaid,,5.98,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,Vaya,Medicaid,,3.61,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,Vaya,Medicaid,,4.32,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,Vaya,Medicaid,,3.36,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,Vaya,Medicaid,,3.33,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,Vaya,Medicaid,,8.05,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,Vaya,Medicaid,,753.87,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,Vaya,Medicaid,,4.08,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,Vaya,Medicaid,,2586.21,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,Vaya,Medicaid,,5169.10,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,Vaya,Medicaid,,426.58,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,Vaya,Medicaid,,567.73,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,Vaya,Medicaid,,635.10,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,Vaya,Medicaid,,0.22682,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,Vaya,Medicaid,,3.72,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,Vaya,Medicaid,,89.34,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,Vaya,Medicaid,,4.47,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,Vaya,Medicaid,,4.58,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,Vaya,Medicaid,,3.52,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,Vaya,Medicaid,,3.61,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,Vaya,Medicaid,,134.65,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,Vaya,Medicaid,,0.23713,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,Vaya,Medicaid,,17.75,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,Vaya,Medicaid,,12.50,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,Vaya,Medicaid,,153.81,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,Vaya,Medicaid,,21.65,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,Vaya,Medicaid,,8.19,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,Vaya,Medicaid,,12.68,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,Vaya,Medicaid,,6.02,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,Vaya,Medicaid,,4.47,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,Vaya,Medicaid,,3.44,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,Vaya,Medicaid,,3.48,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,Vaya,Medicaid,,17.53,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,Vaya,Medicaid,,3.83,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,Vaya,Medicaid,,45.97,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,Vaya,Medicaid,,64.95,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,Vaya,Medicaid,,3.05,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,Vaya,Medicaid,,342.93,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,Vaya,Medicaid,,16.22,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,Vaya,Medicaid,,4.99,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,Vaya,Medicaid,,16.91,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,Vaya,Medicaid,,9.79,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,Vaya,Medicaid,,451.37,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,Vaya,Medicaid,,7.41,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,Vaya,Medicaid,,54.60,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,Vaya,Medicaid,,21.55,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,Vaya,Medicaid,,23.46,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,Vaya,Medicaid,,9.50,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,Vaya,Medicaid,,4.56,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,Vaya,Medicaid,,4.61,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,Vaya,Medicaid,,5.57,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,Vaya,Medicaid,,4.68,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,Vaya,Medicaid,,3.84,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,Vaya,Medicaid,,86.03,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,Vaya,Medicaid,,316.27,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,Vaya,Medicaid,,7.94,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,Vaya,Medicaid,,12.75,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,Vaya,Medicaid,,16.22,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,Vaya,Medicaid,,19.87,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,Vaya,Medicaid,,62.47,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,Vaya,Medicaid,,748.13,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,Vaya,Medicaid,,26.21,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,Vaya,Medicaid,,43.54,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,Vaya,Medicaid,,18.36,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,Vaya,Medicaid,,7.07,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,Vaya,Medicaid,,12.38,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,Vaya,Medicaid,,6.44,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,Vaya,Medicaid,,41.51,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,Vaya,Medicaid,,35.89,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,Vaya,Medicaid,,13.31,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,Vaya,Medicaid,,13.37,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,Vaya,Medicaid,,13.34,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,Vaya,Medicaid,,49.27,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,Vaya,Medicaid,,18.78,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,Vaya,Medicaid,,0.29899,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,Vaya,Medicaid,,136.36,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,Vaya,Medicaid,,79.43,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,Vaya,Medicaid,,373.89,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,Vaya,Medicaid,,17.10,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,Vaya,Medicaid,,0.94852,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,Vaya,Medicaid,,448.40,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,Vaya,Medicaid,,20.93,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Vaya,Medicaid,,20.21,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,Vaya,Medicaid,,19.49,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,Vaya,Medicaid,,5.07,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,Vaya,Medicaid,,6.85,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,Vaya,Medicaid,,10.32,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Vaya,Medicaid,,20.21,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,Vaya,Medicaid,,20.21,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,Vaya,Medicaid,,15.77,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,Vaya,Medicaid,,73.41,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,Vaya,Medicaid,,12.07,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,Vaya,Medicaid,,10.09,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,Vaya,Medicaid,,1046.72,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,Vaya,Medicaid,,14.43,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,Vaya,Medicaid,,4.12,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,Vaya,Medicaid,,3.98,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,Vaya,Medicaid,,132.52,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,Vaya,Medicaid,,52.56,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,Vaya,Medicaid,,3.55,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,Vaya,Medicaid,,19.70,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,Vaya,Medicaid,,5.19,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,Vaya,Medicaid,,34.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,Vaya,Medicaid,,17.59,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,Vaya,Medicaid,,21.21,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,Vaya,Medicaid,,5.25,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,Vaya,Medicaid,,0.28868,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,Vaya,Medicaid,,498.35,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,Vaya,Medicaid,,829.40,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,Vaya,Medicaid,,100.25,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,Vaya,Medicaid,,147.43,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,Vaya,Medicaid,,3.56,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,Vaya,Medicaid,,216.57,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,Vaya,Medicaid,,11.10,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,Vaya,Medicaid,,356.90,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,Vaya,Medicaid,,9.13,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,Vaya,Medicaid,,9.13,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,Vaya,Medicaid,,23.47,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,Vaya,Medicaid,,3.68,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,Vaya,Medicaid,,340.29,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,Vaya,Medicaid,,9364.48,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,Vaya,Medicaid,,32210.99,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,Vaya,Medicaid,,53096.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,Vaya,Medicaid,,2301.14,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,Vaya,Medicaid,,1523.86,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,Vaya,Medicaid,,53.41,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,Vaya,Medicaid,,2.81,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,Vaya,Medicaid,,0.24744,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,Vaya,Medicaid,,1.89,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,Vaya,Medicaid,,8.66,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,Vaya,Medicaid,,0.04124,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,Vaya,Medicaid,,107.02,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,Vaya,Medicaid,,265.38,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,Vaya,Medicaid,,396.94,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,Vaya,Medicaid,,596.12,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,Vaya,Medicaid,,715.31,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,Vaya,Medicaid,,858.20,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,Vaya,Medicaid,,1030.18,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,Vaya,Medicaid,,425.80,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,Vaya,Medicaid,,625.40,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,Vaya,Medicaid,,1137.40,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,Vaya,Medicaid,,32.99,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,Vaya,Medicaid,,130.52,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,Vaya,Medicaid,,35.67,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,,24.13,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,Vaya,Medicaid,,5.36,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,Vaya,Medicaid,,29.49,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,Vaya,Medicaid,,32.58,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,Vaya,Medicaid,,108.05,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,Vaya,Medicaid,,123.10,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,Vaya,Medicaid,,104.75,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,Vaya,Medicaid,,18.97,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,Vaya,Medicaid,,15.05,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,Vaya,Medicaid,,47.43,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,Vaya,Medicaid,,43.51,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Vaya,Medicaid,,1079.04,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,Vaya,Medicaid,,1079.04,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,Vaya,Medicaid,,1027.29,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,Vaya,Medicaid,,368.27,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,Vaya,Medicaid,,619.63,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,Vaya,Medicaid,,314.66,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,Vaya,Medicaid,,64.54,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,Vaya,Medicaid,,225.38,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,Vaya,Medicaid,,70.52,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,Vaya,Medicaid,,254.86,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,Vaya,Medicaid,,187.44,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,Vaya,Medicaid,,62.48,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Vaya,Medicaid,,103.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,Vaya,Medicaid,,193.42,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,Vaya,Medicaid,,54.85,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,Vaya,Medicaid,,42.06,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,Vaya,Medicaid,,225.17,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,Vaya,Medicaid,,195.48,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Vaya,Medicaid,,58.97,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,Vaya,Medicaid,,8.87,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,Vaya,Medicaid,,7.22,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,Vaya,Medicaid,,28.87,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,Vaya,Medicaid,,97.74,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,Vaya,Medicaid,,25.98,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,Vaya,Medicaid,,58.97,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,Vaya,Medicaid,,27.63,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,Vaya,Medicaid,,2.27,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,Vaya,Medicaid,,1027.91,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,Vaya,Medicaid,,4144.62,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,Vaya,Medicaid,,1046.26,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,Vaya,Medicaid,,874.29,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,Vaya,Medicaid,,717.16,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,Vaya,Medicaid,,95.47,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Vaya,Medicaid,,815.31,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,Vaya,Medicaid,,934.09,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,Vaya,Medicaid,,919.86,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Vaya,Medicaid,,728.09,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,Vaya,Medicaid,,1203.18,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Vaya,Medicaid,,854.29,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,Vaya,Medicaid,,854.29,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Vaya,Medicaid,,994.09,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,Vaya,Medicaid,,994.09,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,Vaya,Medicaid,,1209.57,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Vaya,Medicaid,,815.31,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Vaya,Medicaid,,815.31,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,Vaya,Medicaid,,728.09,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,Vaya,Medicaid,,815.31,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,Vaya,Medicaid,,359.82,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,Vaya,Medicaid,,847.48,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,Vaya,Medicaid,,348.68,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,Vaya,Medicaid,,1340.09,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,Vaya,Medicaid,,244.14,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,Vaya,Medicaid,,501.48,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,Vaya,Medicaid,,759.64,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,Vaya,Medicaid,,886.04,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,Vaya,Medicaid,,24.95,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,Vaya,Medicaid,,351.78,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,Vaya,Medicaid,,706.44,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,Vaya,Medicaid,,17.11,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,Vaya,Medicaid,,96.30,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,Vaya,Medicaid,,142.07,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,Vaya,Medicaid,,321.05,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,Vaya,Medicaid,,243.11,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,Vaya,Medicaid,,16.29,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,Vaya,Medicaid,GP,4.33,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,Vaya,Medicaid,,68.66,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,Vaya,Medicaid,,309.71,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,Vaya,Medicaid,,293.22,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,Vaya,Medicaid,,235.07,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,Vaya,Medicaid,,176.92,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,Vaya,Medicaid,,118.77,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,Vaya,Medicaid,,60.62,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,Vaya,Medicaid,,337.76,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,Vaya,Medicaid,,1009.35,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,Vaya,Medicaid,,1338.65,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Vaya,Medicaid,,707.27,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,Vaya,Medicaid,,536.94,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,Vaya,Medicaid,,5393.78,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,Vaya,Medicaid,,5649.67,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,Vaya,Medicaid,,5946.19,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,Vaya,Medicaid,,6201.26,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,Vaya,Medicaid,,6457.36,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,Vaya,Medicaid,,6712.63,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,Vaya,Medicaid,,6926.46,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,Vaya,Medicaid,,7222.98,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,Vaya,Medicaid,,7478.46,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,Vaya,Medicaid,,7733.94,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,Vaya,Medicaid,,7989.63,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,Vaya,Medicaid,,80.01,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,Vaya,Medicaid,,110.11,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,Vaya,Medicaid,,170.94,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,Vaya,Medicaid,,172.38,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,Vaya,Medicaid,,832.02,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,Vaya,Medicaid,,1997.05,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,Vaya,Medicaid,,2145.92,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,Vaya,Medicaid,,2305.11,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,Vaya,Medicaid,,1256.58,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,Vaya,Medicaid,,1623.41,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,Vaya,Medicaid,,1846.52,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,Vaya,Medicaid,,2377.49,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,Vaya,Medicaid,,2440.58,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,Vaya,Medicaid,,2499.97,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,Vaya,Medicaid,,2559.56,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,Vaya,Medicaid,,2618.95,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,Vaya,Medicaid,,1019.87,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,Vaya,Medicaid,,137.74,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,Vaya,Medicaid,,908.52,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,Vaya,Medicaid,,1226.68,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,Vaya,Medicaid,,1679.71,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,Vaya,Medicaid,,2128.81,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,Vaya,Medicaid,,2430.48,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,Vaya,Medicaid,,2752.77,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,Vaya,Medicaid,,3140.22,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,Vaya,Medicaid,,3366.01,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,Vaya,Medicaid,,3699.23,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,Vaya,Medicaid,,3880.48,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,Vaya,Medicaid,,4117.81,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,Vaya,Medicaid,,4270.61,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,Vaya,Medicaid,,4308.96,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,Vaya,Medicaid,,4372.88,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,Vaya,Medicaid,,4500.31,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,Vaya,Medicaid,,4627.95,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,Vaya,Medicaid,,4755.38,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,Vaya,Medicaid,,4883.85,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,Vaya,Medicaid,,5011.07,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,Vaya,Medicaid,,5138.92,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Vaya,Medicaid,,2764.32,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,Vaya,Medicaid,,2342.84,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Vaya,Medicaid,,1452.27,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Vaya,Medicaid,,1452.27,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,Vaya,Medicaid,,1452.27,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,Vaya,Medicaid,,1336.18,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,Vaya,Medicaid,,2764.32,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,Vaya,Medicaid,,1559.28,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,Vaya,Medicaid,,1757.03,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,Vaya,Medicaid,,62.48,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,Vaya,Medicaid,,262.08,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Vaya,Medicaid,,104.75,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,Vaya,Medicaid,,104.75,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,Vaya,Medicaid,,166.61,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,Vaya,Medicaid,,2225.72,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,Vaya,Medicaid,,389.72,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,Vaya,Medicaid,,252.59,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,Vaya,Medicaid,,1479.28,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,Vaya,Medicaid,,61.04,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,Vaya,Medicaid,,155.89,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,Vaya,Medicaid,,0.61860,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Vaya,Medicaid,,340.02,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,Vaya,Medicaid,,438.59,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,Vaya,Medicaid,,537.56,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,Vaya,Medicaid,,636.13,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,Vaya,Medicaid,,734.90,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,Vaya,Medicaid,,833.67,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,Vaya,Medicaid,,932.23,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,Vaya,Medicaid,,136.30,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Vaya,Medicaid,,676.34,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Vaya,Medicaid,,891.20,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Vaya,Medicaid,,266.82,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Vaya,Medicaid,,363.53,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Vaya,Medicaid,,405.39,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Vaya,Medicaid,,448.90,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Vaya,Medicaid,,492.20,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Vaya,Medicaid,,535.30,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Vaya,Medicaid,,578.80,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,Vaya,Medicaid,,340.02,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,Vaya,Medicaid,,197.54,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,Vaya,Medicaid,,492.20,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,Vaya,Medicaid,,266.82,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,Vaya,Medicaid,,363.53,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,Vaya,Medicaid,,405.39,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,Vaya,Medicaid,,448.90,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,Vaya,Medicaid,,535.30,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,Vaya,Medicaid,,578.80,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,Vaya,Medicaid,,676.34,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,Vaya,Medicaid,,891.20,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Vaya,Medicaid,,102.89,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,Vaya,Medicaid,,707.27,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,Vaya,Medicaid,,58.77,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,Vaya,Medicaid,,279.81,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,Vaya,Medicaid,,316.93,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,Vaya,Medicaid,,354.46,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,Vaya,Medicaid,,391.99,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,Vaya,Medicaid,,429.93,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,Vaya,Medicaid,,467.66,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,Vaya,Medicaid,,505.19,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,Vaya,Medicaid,,542.51,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,Vaya,Medicaid,,579.83,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,Vaya,Medicaid,,617.78,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,Vaya,Medicaid,,655.10,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,Vaya,Medicaid,,703.97,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,Vaya,Medicaid,,741.91,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,Vaya,Medicaid,,885.22,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Vaya,Medicaid,,943.16,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,Vaya,Medicaid,,987.08,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,Vaya,Medicaid,,1024.61,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,Vaya,Medicaid,,1061.93,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,Vaya,Medicaid,,900.89,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,Vaya,Medicaid,,955.94,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,Vaya,Medicaid,,850.16,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,Vaya,Medicaid,,538.80,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,Vaya,Medicaid,,582.51,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,Vaya,Medicaid,,512.61,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,Vaya,Medicaid,,689.12,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,Vaya,Medicaid,,69.49,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Vaya,Medicaid,,2078.91,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Vaya,Medicaid,,2078.91,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,Vaya,Medicaid,,2078.91,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,Vaya,Medicaid,,262.90,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,Vaya,Medicaid,,432.20,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,Vaya,Medicaid,,480.24,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,Vaya,Medicaid,,260.64,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,Vaya,Medicaid,,1545.26,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Vaya,Medicaid,,209.50,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,Vaya,Medicaid,,83.30,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,Vaya,Medicaid,,943.16,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,Vaya,Medicaid,,2234.59,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,Vaya,Medicaid,,1087.50,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,Vaya,Medicaid,,63.30,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,Vaya,Medicaid,,8244.70,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,Vaya,Medicaid,,8499.98,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,Vaya,Medicaid,,388.69,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,Vaya,Medicaid,,114.85,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,Vaya,Medicaid,,601.07,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,Vaya,Medicaid,,17.73,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,Vaya,Medicaid,,37.73,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,Vaya,Medicaid,,20.41,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,Vaya,Medicaid,Q0,0.20826,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,Vaya,Medicaid,Q0,0.20826,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Vaya,Medicaid,,123.72,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Vaya,Medicaid,,153.83,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,Vaya,Medicaid,,283.52,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,Vaya,Medicaid,,4035.13,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,Vaya,Medicaid,,1880.54,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Vaya,Medicaid,,1055.74,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,Vaya,Medicaid,,1021.51,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,Vaya,Medicaid,,1533.72,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,Vaya,Medicaid,,1735.79,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Vaya,Medicaid,,1055.74,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,Vaya,Medicaid,,1308.96,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Vaya,Medicaid,,65.57,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Vaya,Medicaid,,21.24,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,Vaya,Medicaid,,43.10,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,Vaya,Medicaid,,29.90,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,Vaya,Medicaid,,65.57,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,Vaya,Medicaid,,25.98,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,Vaya,Medicaid,,31.14,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,Vaya,Medicaid,,37.94,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,Vaya,Medicaid,,60.83,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,Vaya,Medicaid,,73.20,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,Vaya,Medicaid,,216.10,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,Vaya,Medicaid,,21.24,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,Vaya,Medicaid,,87.64,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,Vaya,Medicaid,,123.72,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,Vaya,Medicaid,,221.25,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,Vaya,Medicaid,,195.48,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Vaya,Medicaid,,153.83,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,Vaya,Medicaid,,153.83,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,Vaya,Medicaid,,159.60,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Vaya,Medicaid,,1055.74,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,Vaya,Medicaid,,103.72,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,Vaya,Medicaid,,93.20,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,Vaya,Medicaid,,278.16,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,Vaya,Medicaid,,1055.74,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,Vaya,Medicaid,,306.00,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,Vaya,Medicaid,,284.35,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Vaya,Medicaid,,110.32,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Vaya,Medicaid,,110.32,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,Vaya,Medicaid,,110.32,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Vaya,Medicaid,,1385.66,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Vaya,Medicaid,,190.12,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Vaya,Medicaid,,190.12,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,Vaya,Medicaid,,190.12,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,Vaya,Medicaid,,250.53,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,Vaya,Medicaid,,336.31,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,Vaya,Medicaid,,597.77,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,Vaya,Medicaid,,72.17,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,Vaya,Medicaid,,95.47,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,Vaya,Medicaid,,28.87,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,Vaya,Medicaid,,34.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,Vaya,Medicaid,,72.17,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Vaya,Medicaid,,1086.67,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,Vaya,Medicaid,,211.15,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,Vaya,Medicaid,,131.35,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,Vaya,Medicaid,,8159.33,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,Vaya,Medicaid,,3506.22,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,Vaya,Medicaid,,61.24,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,Vaya,Medicaid,,63.51,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,Vaya,Medicaid,,395.70,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,Vaya,Medicaid,,1495.36,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,Vaya,Medicaid,,357.55,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,Vaya,Medicaid,,679.43,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,Vaya,Medicaid,,8293.36,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,Vaya,Medicaid,,2581.01,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,Vaya,Medicaid,,2292.94,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,Vaya,Medicaid,,3230.12,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,Vaya,Medicaid,,6511.38,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Vaya,Medicaid,,544.16,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,Vaya,Medicaid,,2292.33,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,Vaya,Medicaid,,3307.86,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Vaya,Medicaid,,1953.95,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Vaya,Medicaid,,555.92,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,Vaya,Medicaid,,555.92,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,Vaya,Medicaid,,1725.07,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,Vaya,Medicaid,,0.20826,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,Vaya,Medicaid,,1839.30,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,Vaya,Medicaid,,2325.32,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,Vaya,Medicaid,,1264.21,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,Vaya,Medicaid,,3195.07,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,Vaya,Medicaid,,258.78,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,Vaya,Medicaid,,110.73,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,Vaya,Medicaid,,1385.66,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,Vaya,Medicaid,,1086.67,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,Vaya,Medicaid,,193.83,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,Vaya,Medicaid,,45.36,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,Vaya,Medicaid,,114.44,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,Vaya,Medicaid,,1120.90,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,Vaya,Medicaid,,4092.04,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,Vaya,Medicaid,,5647.82,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Vaya,Medicaid,,57.94,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,Vaya,Medicaid,,57.94,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Vaya,Medicaid,,54.23,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Vaya,Medicaid,,54.23,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,Vaya,Medicaid,,54.23,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,Vaya,Medicaid,,644.38,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,Vaya,Medicaid,,241.67,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,Vaya,Medicaid,,310.74,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,Vaya,Medicaid,,291.77,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,Vaya,Medicaid,,282.49,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,Vaya,Medicaid,,2054.58,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,Vaya,Medicaid,Q1,1306.28,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,Vaya,Medicaid,Q0,782.53,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,Vaya,Medicaid,,37.53,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,Vaya,Medicaid,,87.22,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,Vaya,Medicaid,,113.20,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,Vaya,Medicaid,,77.74,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,Vaya,Medicaid,,120.63,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,Vaya,Medicaid,,77.74,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,Vaya,Medicaid,,77.74,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,Vaya,Medicaid,,18.97,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,Vaya,Medicaid,,59.39,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,Vaya,Medicaid,,90.11,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,Vaya,Medicaid,,54.02,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,Vaya,Medicaid,,48.25,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,Vaya,Medicaid,,134.44,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,Vaya,Medicaid,,6.80,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,Vaya,Medicaid,,391.57,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,,24.13,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,,24.13,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,Vaya,Medicaid,,49.49,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,Vaya,Medicaid,,74.23,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,Vaya,Medicaid,,95.47,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,Vaya,Medicaid,,86.60,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,Vaya,Medicaid,,401.47,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Vaya,Medicaid,,410.34,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,Vaya,Medicaid,,192.18,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,Vaya,Medicaid,,290.12,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,Vaya,Medicaid,,301.05,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,Vaya,Medicaid,,355.49,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,Vaya,Medicaid,,432.61,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,Vaya,Medicaid,,725.62,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,Vaya,Medicaid,,1287.10,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,Vaya,Medicaid,,1387.93,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,Vaya,Medicaid,,130.94,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,Vaya,Medicaid,,175.48,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,Vaya,Medicaid,,1309.78,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Vaya,Medicaid,,1471.24,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Vaya,Medicaid,,1471.24,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Vaya,Medicaid,,350.13,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,Vaya,Medicaid,,570.97,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,Vaya,Medicaid,,151.35,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,Vaya,Medicaid,,226.00,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,Vaya,Medicaid,,96.71,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,Vaya,Medicaid,,199.60,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,Vaya,Medicaid,,141.66,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,Vaya,Medicaid,,318.58,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,Vaya,Medicaid,,220.84,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,Vaya,Medicaid,,383.94,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,Vaya,Medicaid,,92.79,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,Vaya,Medicaid,,248.26,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,Vaya,Medicaid,,1544.85,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,Vaya,Medicaid,,1537.01,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,Vaya,Medicaid,,494.47,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,Vaya,Medicaid,,360.03,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,Vaya,Medicaid,,639.22,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,Vaya,Medicaid,,1736.82,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,Vaya,Medicaid,,87.64,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,Vaya,Medicaid,,116.92,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Vaya,Medicaid,,449.10,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,Vaya,Medicaid,,431.37,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,Vaya,Medicaid,,955.74,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,Vaya,Medicaid,,506.84,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Vaya,Medicaid,,618.39,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,Vaya,Medicaid,,65.16,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,Vaya,Medicaid,,66.19,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,Vaya,Medicaid,,221.87,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,Vaya,Medicaid,,102.28,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,Vaya,Medicaid,,124.34,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,Vaya,Medicaid,,102.28,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,Vaya,Medicaid,,316.93,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,Vaya,Medicaid,,126.81,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,Vaya,Medicaid,,151.35,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,Vaya,Medicaid,,94.23,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,Vaya,Medicaid,,68.25,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,Vaya,Medicaid,,107.84,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,Vaya,Medicaid,,1471.24,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,Vaya,Medicaid,,212.80,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,Vaya,Medicaid,,183.31,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,Vaya,Medicaid,,239.81,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,Vaya,Medicaid,,216.72,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Vaya,Medicaid,,289.92,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,Vaya,Medicaid,76,289.92,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,,384.56,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Vaya,Medicaid,,772.84,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,Vaya,Medicaid,76,772.84,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Vaya,Medicaid,,813.46,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,Vaya,Medicaid,76,813.46,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Vaya,Medicaid,,419.41,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Vaya,Medicaid,,466.22,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,Vaya,Medicaid,,491.37,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,Vaya,Medicaid,,542.10,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,Vaya,Medicaid,,377.96,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Vaya,Medicaid,,540.66,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Vaya,Medicaid,,70.73,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Vaya,Medicaid,,85.16,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Vaya,Medicaid,,85.16,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,Vaya,Medicaid,,60.21,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,Vaya,Medicaid,,586.02,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,Vaya,Medicaid,,5629.05,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,Vaya,Medicaid,,773.87,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Vaya,Medicaid,,889.96,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,Vaya,Medicaid,,889.96,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,Vaya,Medicaid,,133.62,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,Vaya,Medicaid,,145.99,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,Vaya,Medicaid,,252.59,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Vaya,Medicaid,,177.33,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Vaya,Medicaid,,188.47,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,Vaya,Medicaid,,193.42,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,Vaya,Medicaid,,132.17,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,,384.56,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,76,384.56,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,,384.56,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,76,384.56,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,Vaya,Medicaid,,70.73,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Vaya,Medicaid,,134.03,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,Vaya,Medicaid,,74.85,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,,384.56,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,76,384.56,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,Vaya,Medicaid,,93.82,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,Vaya,Medicaid,76,177.33,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,Vaya,Medicaid,76,188.47,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,Vaya,Medicaid,,102.89,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,Vaya,Medicaid,,215.27,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,Vaya,Medicaid,,335.90,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Vaya,Medicaid,,483.13,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,Vaya,Medicaid,,1425.67,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,Vaya,Medicaid,,151.14,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,Vaya,Medicaid,,1251.02,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,Vaya,Medicaid,,464.77,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,Vaya,Medicaid,,584.99,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Vaya,Medicaid,,381.06,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,Vaya,Medicaid,,179.60,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,Vaya,Medicaid,,113.20,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,Vaya,Medicaid,,165.99,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,Vaya,Medicaid,,258.16,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,Vaya,Medicaid,,1683.42,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,Vaya,Medicaid,,496.94,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,Vaya,Medicaid,,83.51,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,Vaya,Medicaid,,115.47,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,Vaya,Medicaid,,342.70,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,Vaya,Medicaid,,396.52,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,Vaya,Medicaid,,262.70,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,Vaya,Medicaid,,65.16,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,Vaya,Medicaid,,134.03,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,Vaya,Medicaid,,449.10,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Vaya,Medicaid,,643.96,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,Vaya,Medicaid,,72.38,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,Vaya,Medicaid,,217.33,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,Vaya,Medicaid,,7.01,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,Vaya,Medicaid,,95.88,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,Vaya,Medicaid,,211.97,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,Vaya,Medicaid,,249.91,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,Vaya,Medicaid,,66.40,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,Vaya,Medicaid,,156.09,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,Vaya,Medicaid,,33.40,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Vaya,Medicaid,,241.25,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,Vaya,Medicaid,,61.65,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,Vaya,Medicaid,,122.69,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Vaya,Medicaid,,23.30,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,Vaya,Medicaid,,62.27,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,Vaya,Medicaid,,22.48,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,Vaya,Medicaid,,41.24,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,Vaya,Medicaid,,33.20,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Vaya,Medicaid,,23.30,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,Vaya,Medicaid,,27.42,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,Vaya,Medicaid,,23.30,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,Vaya,Medicaid,,90.32,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,Vaya,Medicaid,,10.31,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,Vaya,Medicaid,,85.16,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,Vaya,Medicaid,,59.39,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,Vaya,Medicaid,,39.38,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,Vaya,Medicaid,,55.47,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,Vaya,Medicaid,GP,13.82,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,Vaya,Medicaid,GP,15.46,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Vaya,Medicaid,GP,2.47,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,Vaya,Medicaid,GP,24.95,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,GP,10.10,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,Vaya,Medicaid,GP,3.30,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,Vaya,Medicaid,GP,31.55,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Vaya,Medicaid,GP,33.61,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Vaya,Medicaid,GP,26.39,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,GP,22.68,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,GP,12.17,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Vaya,Medicaid,GP,33.82,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Vaya,Medicaid,GP,32.99,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Vaya,Medicaid,GP,29.69,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,GP,34.02,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,Vaya,Medicaid,GP,28.66,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,Vaya,Medicaid,GP,41.65,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,GP,24.13,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,GP,26.60,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,Vaya,Medicaid,GP,31.14,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,Vaya,Medicaid,GP,9.69,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,GP,24.33,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Vaya,Medicaid,GP,17.53,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,GP,26.60,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Vaya,Medicaid,GP,20.41,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,Vaya,Medicaid,GP,37.12,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,Vaya,Medicaid,GP,37.12,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,GP,18.76,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,GP,18.76,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,GP,18.35,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Vaya,Medicaid,GP,26.19,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Vaya,Medicaid,GP,26.81,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Vaya,Medicaid,GP,14.43,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Vaya,Medicaid,GP,6.19,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,Vaya,Medicaid,GP,63.10,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,Vaya,Medicaid,GP,87.22,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,Vaya,Medicaid,GP,89.49,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,Vaya,Medicaid,GP,59.39,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,GO,18.76,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,GO,24.13,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,GO,26.60,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,GO,24.33,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Vaya,Medicaid,GO,14.43,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,GO,26.60,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Vaya,Medicaid,GO,20.41,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,Vaya,Medicaid,GO,2.47,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,Vaya,Medicaid,GO,33.61,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Vaya,Medicaid,GO,26.39,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,GO,12.78,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,Vaya,Medicaid,GO,33.82,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,Vaya,Medicaid,GO,32.99,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,Vaya,Medicaid,GO,29.69,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,GO,34.02,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,GO,10.10,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,Vaya,Medicaid,GO,46.19,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,Vaya,Medicaid,GO,31.34,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,Vaya,Medicaid,GO,26.19,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,Vaya,Medicaid,GO,15.46,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,Vaya,Medicaid,GO,65.57,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,Vaya,Medicaid,GO,83.10,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,Vaya,Medicaid,GO,85.57,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,Vaya,Medicaid,GO,41.65,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,Vaya,Medicaid,GN,73.41,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,Vaya,Medicaid,GN,69.28,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,Vaya,Medicaid,GN,38.56,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,Vaya,Medicaid,GN,55.47,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,Vaya,Medicaid,GN,41.24,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,Vaya,Medicaid,GN,64.95,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,Vaya,Medicaid,GN,26.39,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,Vaya,Medicaid,GN,14.43,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,Vaya,Medicaid,GN,17.53,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,Vaya,Medicaid,GN,20.41,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,Vaya,Medicaid,GN,47.22,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,GN,28.04,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,Vaya,Medicaid,GN,135.06,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,Vaya,Medicaid,GN,53.41,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,Vaya,Medicaid,GN,14.02,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,Vaya,Medicaid,GN,26.81,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,Vaya,Medicaid,GN,14.43,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,Vaya,Medicaid,GN,6.19,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,Vaya,Medicaid,GN,44.13,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,Vaya,Medicaid,GN,47.22,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,Vaya,Medicaid,GN,22.06,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,Vaya,Medicaid,GN,72.79,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,Vaya,Medicaid,GN,113.20,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,Vaya,Medicaid,GN,121.86,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,Vaya,Medicaid,,178.16,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,Vaya,Medicaid,,113.20,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,Vaya,Medicaid,,182.49,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,Vaya,Medicaid,,103.92,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,Vaya,Medicaid,,153.62,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,Vaya,Medicaid,,774.49,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,Vaya,Medicaid,,8.87,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,Vaya,Medicaid,,30.52,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,Vaya,Medicaid,,108.25,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,Vaya,Medicaid,,107.84,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,Vaya,Medicaid,,116.09,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Vaya,Medicaid,,77.74,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,Vaya,Medicaid,,77.74,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,Vaya,Medicaid,,279.81,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,Vaya,Medicaid,,86.19,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,Vaya,Medicaid,,167.43,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,Vaya,Medicaid,,116.92,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,Vaya,Medicaid,,98.15,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,Vaya,Medicaid,,134.44,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,Vaya,Medicaid,,94.44,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,Vaya,Medicaid,,32.17,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,Vaya,Medicaid,,37.12,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,Vaya,Medicaid,,241.25,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,Vaya,Medicaid,,27.01,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,Vaya,Medicaid,,317.96,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,Vaya,Medicaid,,317.96,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,Vaya,Medicaid,,54.44,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,Vaya,Medicaid,,54.44,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,Vaya,Medicaid,,412.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Vaya,Medicaid,,643.96,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,Vaya,Medicaid,,144.34,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,Vaya,Medicaid,,468.49,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,Vaya,Medicaid,,171.35,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,Vaya,Medicaid,,104.13,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,Vaya,Medicaid,,45.78,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,Vaya,Medicaid,,68.66,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,Vaya,Medicaid,,69.70,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,Vaya,Medicaid,,38.15,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Vaya,Medicaid,,1246.07,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,Vaya,Medicaid,,1246.07,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,Vaya,Medicaid,,209.71,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Vaya,Medicaid,,866.04,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,Vaya,Medicaid,,866.04,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,Vaya,Medicaid,,879.65,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,Vaya,Medicaid,,237.95,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,Vaya,Medicaid,,113.82,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,Vaya,Medicaid,,116.50,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,Vaya,Medicaid,,278.37,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,Vaya,Medicaid,,198.57,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,Vaya,Medicaid,,113.41,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,Vaya,Medicaid,,198.57,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,Vaya,Medicaid,,216.72,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,Vaya,Medicaid,,93.41,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,Vaya,Medicaid,,262.08,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,Vaya,Medicaid,,238.99,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,Vaya,Medicaid,,150.11,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,Vaya,Medicaid,,99.18,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,Vaya,Medicaid,,232.18,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,Vaya,Medicaid,,65.16,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,Vaya,Medicaid,,156.30,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,Vaya,Medicaid,,25.57,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,Vaya,Medicaid,,197.54,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,Vaya,Medicaid,,117.74,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,Vaya,Medicaid,,95.68,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,Vaya,Medicaid,,111.14,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,Vaya,Medicaid,,103.72,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,Vaya,Medicaid,,324.15,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,Vaya,Medicaid,,83.51,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,Vaya,Medicaid,,324.15,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,Vaya,Medicaid,,83.51,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,Vaya,Medicaid,,76.91,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,Vaya,Medicaid,,138.98,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,Vaya,Medicaid,,169.50,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,Vaya,Medicaid,,176.30,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,Vaya,Medicaid,,183.11,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,Vaya,Medicaid,,111.14,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,Vaya,Medicaid,,88.46,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,Vaya,Medicaid,,60.83,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,Vaya,Medicaid,,90.11,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,Vaya,Medicaid,,52.17,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,Vaya,Medicaid,,126.61,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,Vaya,Medicaid,,126.61,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,Vaya,Medicaid,,112.79,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,Vaya,Medicaid,,43.71,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,Vaya,Medicaid,,43.71,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,Vaya,Medicaid,,43.71,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,Vaya,Medicaid,,43.71,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,Vaya,Medicaid,,82.48,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,Vaya,Medicaid,,82.48,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,Vaya,Medicaid,,82.48,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,Vaya,Medicaid,,55.06,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,Vaya,Medicaid,,75.47,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,Vaya,Medicaid,,75.47,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,Vaya,Medicaid,,337.14,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,Vaya,Medicaid,,337.14,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,Vaya,Medicaid,,94.23,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,Vaya,Medicaid,,93.82,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,Vaya,Medicaid,,307.44,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,Vaya,Medicaid,,314.66,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,Vaya,Medicaid,,174.86,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,Vaya,Medicaid,,254.24,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,Vaya,Medicaid,,87.22,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,Vaya,Medicaid,,205.58,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,Vaya,Medicaid,,95.47,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,Vaya,Medicaid,,112.17,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,Vaya,Medicaid,,271.15,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,Vaya,Medicaid,,327.45,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Vaya,Medicaid,,402.09,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,Vaya,Medicaid,,570.56,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,Vaya,Medicaid,,626.64,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,Vaya,Medicaid,,795.11,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Vaya,Medicaid,,467.66,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,Vaya,Medicaid,,523.75,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,Vaya,Medicaid,,589.32,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,Vaya,Medicaid,,935.32,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,Vaya,Medicaid,,1047.50,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,Vaya,Medicaid,,1169.15,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,Vaya,Medicaid,,214.86,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,Vaya,Medicaid,,46.40,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,Vaya,Medicaid,,60.21,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,Vaya,Medicaid,,60.62,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,Vaya,Medicaid,,9.90,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,Vaya,Medicaid,,9.90,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,Vaya,Medicaid,,21.86,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,Vaya,Medicaid,,159.81,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,Vaya,Medicaid,,159.81,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,Vaya,Medicaid,,159.81,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,Vaya,Medicaid,,159.81,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,Vaya,Medicaid,,159.81,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,Vaya,Medicaid,,159.81,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,Vaya,Medicaid,GP,13.75,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,Vaya,Medicaid,,98.77,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Vaya,Medicaid,,565.81,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,Vaya,Medicaid,,565.81,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Vaya,Medicaid,,799.02,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Vaya,Medicaid,,223.73,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,Vaya,Medicaid,,223.73,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,Vaya,Medicaid,,508.08,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,Vaya,Medicaid,,214.24,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,Vaya,Medicaid,,214.24,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,Vaya,Medicaid,,657.78,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,Vaya,Medicaid,,88.67,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,Vaya,Medicaid,,98.98,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,Vaya,Medicaid,,110.52,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,Vaya,Medicaid,,94.44,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,Vaya,Medicaid,,24.54,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,,26.60,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,,26.60,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,Vaya,Medicaid,,42.89,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,Vaya,Medicaid,,33.61,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,Vaya,Medicaid,,63.30,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,Vaya,Medicaid,,107.22,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,Vaya,Medicaid,,103.92,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,Vaya,Medicaid,,127.43,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,Vaya,Medicaid,,84.34,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Vaya,Medicaid,,158.77,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,Vaya,Medicaid,,158.77,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,Vaya,Medicaid,,131.56,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,Vaya,Medicaid,,124.34,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,Vaya,Medicaid,,185.99,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,Vaya,Medicaid,,37.53,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,Vaya,Medicaid,,31.34,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,Vaya,Medicaid,,57.74,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,Vaya,Medicaid,,80.01,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Vaya,Medicaid,,156.51,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Vaya,Medicaid,,156.51,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Vaya,Medicaid,,473.23,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,Vaya,Medicaid,,125.16,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Vaya,Medicaid,,384.15,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,Vaya,Medicaid,,384.15,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Vaya,Medicaid,,439.62,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,Vaya,Medicaid,,110.52,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,Vaya,Medicaid,,213.83,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,Vaya,Medicaid,,2578.94,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,Vaya,Medicaid,,313.42,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,Vaya,Medicaid,,398.58,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,Vaya,Medicaid,,171.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,Vaya,Medicaid,,179.19,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,Vaya,Medicaid,,190.74,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,Vaya,Medicaid,,317.14,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Vaya,Medicaid,,395.49,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,Vaya,Medicaid,,2015.40,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Vaya,Medicaid,,136.09,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,Vaya,Medicaid,,136.09,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Vaya,Medicaid,,657.57,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Vaya,Medicaid,,657.57,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Vaya,Medicaid,,315.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,Vaya,Medicaid,,315.07,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,Vaya,Medicaid,,356.11,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Vaya,Medicaid,,441.68,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,Vaya,Medicaid,,441.68,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Vaya,Medicaid,,288.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,Vaya,Medicaid,,288.06,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Vaya,Medicaid,,128.05,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,Vaya,Medicaid,,128.05,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Vaya,Medicaid,,148.46,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,Vaya,Medicaid,,148.46,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,Vaya,Medicaid,,76.91,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Vaya,Medicaid,,461.89,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,Vaya,Medicaid,JW,27.22,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,Vaya,Medicaid,,120.83,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,Vaya,Medicaid,,102.89,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,Vaya,Medicaid,,124.54,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,Vaya,Medicaid,,102.89,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,Vaya,Medicaid,,120.83,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,Vaya,Medicaid,,169.50,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,Vaya,Medicaid,,281.26,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,Vaya,Medicaid,,72.58,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Vaya,Medicaid,,812.63,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Vaya,Medicaid,,812.63,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Vaya,Medicaid,,812.63,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,Vaya,Medicaid,,812.63,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Vaya,Medicaid,,402.09,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,Vaya,Medicaid,,402.09,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Vaya,Medicaid,,639.84,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,Vaya,Medicaid,,639.84,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,Vaya,Medicaid,,355.28,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,Vaya,Medicaid,,439.62,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Vaya,Medicaid,,577.36,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,Vaya,Medicaid,,111.97,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,Vaya,Medicaid,,904.19,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,Vaya,Medicaid,,1000.07,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,Vaya,Medicaid,,1182.35,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,Vaya,Medicaid,,165.78,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,Vaya,Medicaid,,322.70,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,Vaya,Medicaid,,322.70,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,Vaya,Medicaid,,396.11,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,Vaya,Medicaid,,350.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,Vaya,Medicaid,,120.01,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,Vaya,Medicaid,,467.66,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,Vaya,Medicaid,,260.84,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Vaya,Medicaid,,481.06,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Vaya,Medicaid,,481.06,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,Vaya,Medicaid,,422.09,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,Vaya,Medicaid,,275.28,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,Vaya,Medicaid,,174.65,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Vaya,Medicaid,,367.24,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,Vaya,Medicaid,,367.24,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,Vaya,Medicaid,,350.13,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,Vaya,Medicaid,,284.76,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,Vaya,Medicaid,,284.76,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Vaya,Medicaid,,369.92,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Vaya,Medicaid,,369.92,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Vaya,Medicaid,,849.34,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,Vaya,Medicaid,,849.34,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Vaya,Medicaid,,716.54,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,Vaya,Medicaid,,716.54,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Vaya,Medicaid,,105.57,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Vaya,Medicaid,,122.48,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,Vaya,Medicaid,52,226.82,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,Vaya,Medicaid,,156.51,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,Vaya,Medicaid,,146.61,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,Vaya,Medicaid,,301.26,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,Vaya,Medicaid,,26.19,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Vaya,Medicaid,,189.50,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,Vaya,Medicaid,,189.50,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,Vaya,Medicaid,,76.91,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,Vaya,Medicaid,,65.37,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,Vaya,Medicaid,,143.72,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,Vaya,Medicaid,,287.24,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,Vaya,Medicaid,,489.73,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,Vaya,Medicaid,,653.04,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,Vaya,Medicaid,,827.07,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,Vaya,Medicaid,,273.01,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,Vaya,Medicaid,,248.88,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,Vaya,Medicaid,,74.44,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,Vaya,Medicaid,,61.04,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,Vaya,Medicaid,,38.97,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,Vaya,Medicaid,,32.17,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,Vaya,Medicaid,,32.17,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Vaya,Medicaid,,564.16,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,Vaya,Medicaid,,41.45,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,Vaya,Medicaid,,51.34,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,Vaya,Medicaid,,49.49,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,Vaya,Medicaid,,65.37,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,Vaya,Medicaid,,82.27,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,Vaya,Medicaid,,76.50,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,Vaya,Medicaid,,97.94,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Vaya,Medicaid,,37.32,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,Vaya,Medicaid,,46.81,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,Vaya,Medicaid,,55.06,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,Vaya,Medicaid,,51.55,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,Vaya,Medicaid,,83.72,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,Vaya,Medicaid,,89.70,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,Vaya,Medicaid,,90.11,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,Vaya,Medicaid,,81.86,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,Vaya,Medicaid,,37.32,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,Vaya,Medicaid,,52.37,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,Vaya,Medicaid,,80.01,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,Vaya,Medicaid,,100.83,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,Vaya,Medicaid,,13.61,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,Vaya,Medicaid,,21.86,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,Vaya,Medicaid,,36.29,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,Vaya,Medicaid,,53.61,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,Vaya,Medicaid,,70.73,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,Vaya,Medicaid,,47.63,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,Vaya,Medicaid,,65.37,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,Vaya,Medicaid,,97.94,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,Vaya,Medicaid,,118.77,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,Vaya,Medicaid,,28.25,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,Vaya,Medicaid,,23.09,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,Vaya,Medicaid,,9.90,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,Vaya,Medicaid,,26.81,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,Vaya,Medicaid,,5.16,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Vaya,Medicaid,JW,25.36,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Vaya,Medicaid,,25.36,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,JW,19.59,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,Vaya,Medicaid,,29.28,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,Vaya,Medicaid,,56.70,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Vaya,Medicaid,,41.24,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,Vaya,Medicaid,JW,41.24,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Vaya,Medicaid,,93.82,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Vaya,Medicaid,,187.85,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,Vaya,Medicaid,JW,187.85,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,Vaya,Medicaid,JW,93.82,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Vaya,Medicaid,,203.73,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,Vaya,Medicaid,JW,203.73,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,Vaya,Medicaid,JW,56.29,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Vaya,Medicaid,,117.74,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Vaya,Medicaid,,54.02,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Vaya,Medicaid,,567.87,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Vaya,Medicaid,,250.74,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Vaya,Medicaid,,127.02,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,Vaya,Medicaid,JW,567.87,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,Vaya,Medicaid,JW,250.74,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,Vaya,Medicaid,JW,127.02,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Vaya,Medicaid,,580.04,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,Vaya,Medicaid,,25.36,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Vaya,Medicaid,,70.52,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,Vaya,Medicaid,JW,70.52,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Vaya,Medicaid,,318.79,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,Vaya,Medicaid,,637.98,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,Vaya,Medicaid,JW,318.79,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Vaya,Medicaid,,88.25,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,Vaya,Medicaid,JW,88.25,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,Vaya,Medicaid,JW,99.59,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,Vaya,Medicaid,,2.06,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Vaya,Medicaid,,515.09,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,Vaya,Medicaid,JW,515.09,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Vaya,Medicaid,,417.56,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,Vaya,Medicaid,JW,417.56,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Vaya,Medicaid,,352.19,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,Vaya,Medicaid,JW,352.19,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,JW,13.40,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Vaya,Medicaid,,509.11,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Vaya,Medicaid,,143.93,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,Vaya,Medicaid,,143.93,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Vaya,Medicaid,,126.81,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,Vaya,Medicaid,,126.81,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Vaya,Medicaid,,82.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,Vaya,Medicaid,,82.27,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,Vaya,Medicaid,JW,487.25,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,Vaya,Medicaid,JW,117.74,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,Vaya,Medicaid,JW,54.02,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Vaya,Medicaid,,64.54,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,Vaya,Medicaid,JW,64.54,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Vaya,Medicaid,,324.76,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,Vaya,Medicaid,JW,324.76,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Vaya,Medicaid,,258.16,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,Vaya,Medicaid,JW,258.16,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Vaya,Medicaid,,132.17,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,Vaya,Medicaid,JW,132.17,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Vaya,Medicaid,,70.11,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,Vaya,Medicaid,JW,70.11,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Vaya,Medicaid,,56.09,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,Vaya,Medicaid,JW,56.09,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,Vaya,Medicaid,,528.28,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,Vaya,Medicaid,,60.83,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Vaya,Medicaid,,131.35,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Vaya,Medicaid,,131.35,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,Vaya,Medicaid,,131.35,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,Vaya,Medicaid,,131.35,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,Vaya,Medicaid,,55.67,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,Vaya,Medicaid,,874.91,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,Vaya,Medicaid,,37.32,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,Vaya,Medicaid,,50.73,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,Vaya,Medicaid,,531.38,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,Vaya,Medicaid,,43.10,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,Vaya,Medicaid,,62.48,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Vaya,Medicaid,,407.45,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,Vaya,Medicaid,,407.45,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,Vaya,Medicaid,,89.08,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,Vaya,Medicaid,,89.08,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,Vaya,Medicaid,,69.49,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,Vaya,Medicaid,,57.74,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Vaya,Medicaid,,55.47,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,Vaya,Medicaid,,1933.95,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,Vaya,Medicaid,,229.50,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,Vaya,Medicaid,,213.83,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,Vaya,Medicaid,,246.82,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,Vaya,Medicaid,,166.20,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Vaya,Medicaid,,409.31,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,Vaya,Medicaid,,409.31,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Vaya,Medicaid,,2407.59,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,Vaya,Medicaid,,2407.59,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Vaya,Medicaid,,4189.16,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,Vaya,Medicaid,,4189.16,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Vaya,Medicaid,,1781.57,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,Vaya,Medicaid,,1781.57,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Vaya,Medicaid,,3779.85,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,Vaya,Medicaid,,3779.85,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Vaya,Medicaid,,6115.27,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,Vaya,Medicaid,,6115.27,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,Vaya,Medicaid,,55.47,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Vaya,Medicaid,,84.54,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,Vaya,Medicaid,,122.48,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,Vaya,Medicaid,,105.57,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,Vaya,Medicaid,,158.98,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,Vaya,Medicaid,,140.42,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,Vaya,Medicaid,,799.02,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,Vaya,Medicaid,,29.49,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,Vaya,Medicaid,,64.95,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,Vaya,Medicaid,,40.21,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,Vaya,Medicaid,,64.95,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,Vaya,Medicaid,,40.21,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,Vaya,Medicaid,,64.95,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,Vaya,Medicaid,,40.21,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Vaya,Medicaid,,106.19,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,,34.02,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,Vaya,Medicaid,,195.68,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,Vaya,Medicaid,,99.80,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,Vaya,Medicaid,,26.39,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,Vaya,Medicaid,,29.07,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,Vaya,Medicaid,,32.58,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Vaya,Medicaid,,18.97,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,Vaya,Medicaid,,18.97,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,Vaya,Medicaid,,43.71,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,Vaya,Medicaid,,84.54,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Vaya,Medicaid,,106.19,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,Vaya,Medicaid,,30.93,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,Vaya,Medicaid,,17.53,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,Vaya,Medicaid,,27.42,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,Vaya,Medicaid,,106.19,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,Vaya,Medicaid,,8248.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,Vaya,Medicaid,,160.22,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Vaya,Medicaid,,1810.02,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,Vaya,Medicaid,,1810.02,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,Vaya,Medicaid,,1018.83,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,Vaya,Medicaid,,60.21,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,Vaya,Medicaid,,182.28,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Vaya,Medicaid,,42.27,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,Vaya,Medicaid,,42.27,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,Vaya,Medicaid,,200.01,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,Vaya,Medicaid,,253.63,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,Vaya,Medicaid,,66.81,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,Vaya,Medicaid,,1290.61,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Vaya,Medicaid,,643.96,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,Vaya,Medicaid,,100.21,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,Vaya,Medicaid,,4252.67,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,Vaya,Medicaid,,643.96,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,Vaya,Medicaid,,173.62,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,Vaya,Medicaid,,481.68,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,Vaya,Medicaid,,477.77,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,Vaya,Medicaid,,478.80,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,Vaya,Medicaid,,2459.76,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,Vaya,Medicaid,,108.05,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,Vaya,Medicaid,,118.15,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,Vaya,Medicaid,,274.45,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Vaya,Medicaid,,528.08,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Vaya,Medicaid,,528.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Vaya,Medicaid,,390.75,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,Vaya,Medicaid,,390.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Vaya,Medicaid,,712.63,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,Vaya,Medicaid,,712.63,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Vaya,Medicaid,,528.08,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,Vaya,Medicaid,,528.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,Vaya,Medicaid,,1069.56,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Vaya,Medicaid,,254.66,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Vaya,Medicaid,,216.10,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Vaya,Medicaid,,145.78,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Vaya,Medicaid,,113.41,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Vaya,Medicaid,,91.14,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Vaya,Medicaid,,96.09,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,Vaya,Medicaid,JW,254.66,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,Vaya,Medicaid,JW,216.10,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,Vaya,Medicaid,JW,145.78,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,Vaya,Medicaid,JW,113.41,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,Vaya,Medicaid,JW,91.14,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,Vaya,Medicaid,JW,96.09,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,Vaya,Medicaid,,428.48,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,Vaya,Medicaid,,36.91,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,Vaya,Medicaid,,164.34,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,Vaya,Medicaid,,203.73,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,Vaya,Medicaid,,295.28,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,Vaya,Medicaid,,182.69,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,Vaya,Medicaid,,36.91,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,Vaya,Medicaid,,376.93,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,Vaya,Medicaid,,534.88,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,Vaya,Medicaid,,194.86,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,Vaya,Medicaid,,594.47,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,Vaya,Medicaid,,197.13,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,Vaya,Medicaid,,182.69,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,Vaya,Medicaid,,289.09,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,Vaya,Medicaid,,448.28,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,Vaya,Medicaid,,872.64,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,Vaya,Medicaid,,3945.02,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,Vaya,Medicaid,,88.46,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,Vaya,Medicaid,,93.20,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,Vaya,Medicaid,,82.69,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,Vaya,Medicaid,,137.12,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,Vaya,Medicaid,,65.57,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Vaya,Medicaid,,62.89,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,Vaya,Medicaid,,66.81,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,Vaya,Medicaid,,112.38,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,Vaya,Medicaid,,72.58,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,Vaya,Medicaid,,99.18,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,Vaya,Medicaid,,123.93,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,Vaya,Medicaid,,81.24,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,Vaya,Medicaid,,91.14,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,Vaya,Medicaid,,103.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,Vaya,Medicaid,,31.34,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,Vaya,Medicaid,,55.67,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,Vaya,Medicaid,,24.74,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Vaya,Medicaid,,103.31,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,Vaya,Medicaid,,138.36,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,Vaya,Medicaid,,36.91,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,Vaya,Medicaid,,62.27,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,Vaya,Medicaid,,74.64,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,Vaya,Medicaid,,99.59,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,Vaya,Medicaid,,120.42,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,Vaya,Medicaid,,222.49,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,Vaya,Medicaid,,120.63,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,Vaya,Medicaid,,62.89,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,Vaya,Medicaid,,91.14,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,Vaya,Medicaid,,102.28,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,Vaya,Medicaid,,136.09,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,Vaya,Medicaid,,191.56,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,Vaya,Medicaid,,90.11,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,Vaya,Medicaid,,67.43,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,Vaya,Medicaid,,116.30,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,Vaya,Medicaid,,101.45,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,Vaya,Medicaid,,146.40,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,Vaya,Medicaid,,180.43,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,Vaya,Medicaid,,120.01,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,Vaya,Medicaid,,70.31,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,Vaya,Medicaid,,111.55,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,Vaya,Medicaid,,76.09,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,Vaya,Medicaid,,75.88,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,Vaya,Medicaid,,249.71,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,Vaya,Medicaid,,155.06,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,Vaya,Medicaid,,275.48,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,Vaya,Medicaid,,390.13,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Vaya,Medicaid,,429.10,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,Vaya,Medicaid,,87.64,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,Vaya,Medicaid,,78.77,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,Vaya,Medicaid,,94.65,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,Vaya,Medicaid,,95.26,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,Vaya,Medicaid,,262.08,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,Vaya,Medicaid,,107.64,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,Vaya,Medicaid,,90.73,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,Vaya,Medicaid,,83.72,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,Vaya,Medicaid,,91.14,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,Vaya,Medicaid,,100.42,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,Vaya,Medicaid,,78.15,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,Vaya,Medicaid,,61.45,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,Vaya,Medicaid,,77.33,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,Vaya,Medicaid,,71.55,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,Vaya,Medicaid,,134.65,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,Vaya,Medicaid,,88.87,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,Vaya,Medicaid,,81.24,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,Vaya,Medicaid,,56.91,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,Vaya,Medicaid,,173.41,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,Vaya,Medicaid,,88.05,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,Vaya,Medicaid,,76.50,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,Vaya,Medicaid,,99.39,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,Vaya,Medicaid,,65.16,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,Vaya,Medicaid,,78.36,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,Vaya,Medicaid,,72.99,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,Vaya,Medicaid,,44.95,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,Vaya,Medicaid,,91.76,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,Vaya,Medicaid,,95.47,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,Vaya,Medicaid,,78.36,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,Vaya,Medicaid,,109.29,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,Vaya,Medicaid,,95.47,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,Vaya,Medicaid,,82.69,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,Vaya,Medicaid,,66.81,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Vaya,Medicaid,,87.84,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,,102.07,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,,102.07,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,,102.07,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,Vaya,Medicaid,,161.25,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,Vaya,Medicaid,,66.40,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,Vaya,Medicaid,,50.93,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,Vaya,Medicaid,,217.54,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,Vaya,Medicaid,,150.11,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,Vaya,Medicaid,,183.11,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,Vaya,Medicaid,,102.69,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,Vaya,Medicaid,,109.08,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,Vaya,Medicaid,,203.73,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,Vaya,Medicaid,,214.65,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,Vaya,Medicaid,,221.46,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,Vaya,Medicaid,,110.73,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,Vaya,Medicaid,,20.21,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,Vaya,Medicaid,,119.60,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,Vaya,Medicaid,,132.59,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,Vaya,Medicaid,,168.67,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,Vaya,Medicaid,,137.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,Vaya,Medicaid,,167.02,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,Vaya,Medicaid,,430.55,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,Vaya,Medicaid,,957.80,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,Vaya,Medicaid,,737.58,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,Vaya,Medicaid,,38.15,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,Vaya,Medicaid,,282.08,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,Vaya,Medicaid,,287.65,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,Vaya,Medicaid,,834.49,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,Vaya,Medicaid,,1184.83,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,Vaya,Medicaid,,273.42,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,Vaya,Medicaid,,530.35,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,Vaya,Medicaid,,212.59,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,Vaya,Medicaid,,247.85,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,Vaya,Medicaid,,331.57,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,Vaya,Medicaid,,165.78,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,Vaya,Medicaid,,333.22,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,Vaya,Medicaid,,199.40,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,Vaya,Medicaid,,164.75,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,Vaya,Medicaid,,228.06,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,Vaya,Medicaid,,481.06,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,Vaya,Medicaid,,283.73,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,Vaya,Medicaid,,42.06,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,Vaya,Medicaid,,36.09,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,Vaya,Medicaid,,248.26,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,Vaya,Medicaid,,158.98,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,Vaya,Medicaid,,217.95,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,Vaya,Medicaid,,73.82,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,Vaya,Medicaid,,196.51,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,Vaya,Medicaid,,34.85,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,Vaya,Medicaid,,193.00,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,Vaya,Medicaid,,63.10,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,Vaya,Medicaid,,70.31,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,Vaya,Medicaid,,29.49,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,Vaya,Medicaid,,153.41,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,Vaya,Medicaid,,136.50,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,Vaya,Medicaid,,135.47,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,Vaya,Medicaid,,66.60,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,Vaya,Medicaid,,133.21,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,Vaya,Medicaid,,71.35,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,Vaya,Medicaid,,50.11,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,Vaya,Medicaid,,55.26,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,Vaya,Medicaid,,191.15,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,Vaya,Medicaid,,63.10,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,Vaya,Medicaid,,187.85,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,Vaya,Medicaid,,60.00,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,Vaya,Medicaid,,162.49,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,Vaya,Medicaid,,483.13,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,Vaya,Medicaid,,832.84,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,Vaya,Medicaid,,688.30,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,Vaya,Medicaid,,741.91,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,Vaya,Medicaid,,419.62,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Vaya,Medicaid,,930.79,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Vaya,Medicaid,,930.79,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,Vaya,Medicaid,,930.79,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,Vaya,Medicaid,,629.53,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,Vaya,Medicaid,,368.27,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,Vaya,Medicaid,,289.50,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,Vaya,Medicaid,,55.26,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,Vaya,Medicaid,,77.12,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,Vaya,Medicaid,,68.46,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,Vaya,Medicaid,,171.35,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,Vaya,Medicaid,,33.61,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,Vaya,Medicaid,,103.31,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,Vaya,Medicaid,,429.10,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,Vaya,Medicaid,,127.23,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,Vaya,Medicaid,,167.43,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,Vaya,Medicaid,,177.54,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,Vaya,Medicaid,,96.30,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,Vaya,Medicaid,,101.86,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,Vaya,Medicaid,,107.84,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,Vaya,Medicaid,,156.30,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,Vaya,Medicaid,,151.76,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,Vaya,Medicaid,,222.49,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,Vaya,Medicaid,,47.22,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,Vaya,Medicaid,,89.08,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,Vaya,Medicaid,,219.19,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,Vaya,Medicaid,,126.81,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,Vaya,Medicaid,,161.87,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,Vaya,Medicaid,,7732.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,Vaya,Medicaid,,44.75,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,Vaya,Medicaid,,382.09,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,Vaya,Medicaid,,464.57,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,Vaya,Medicaid,,86.60,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,Vaya,Medicaid,,113.41,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,Vaya,Medicaid,,111.35,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,Vaya,Medicaid,,82.69,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,Vaya,Medicaid,,122.90,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,Vaya,Medicaid,,102.48,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,Vaya,Medicaid,,155.06,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,Vaya,Medicaid,,119.80,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,Vaya,Medicaid,,191.35,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,Vaya,Medicaid,,284.97,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,Vaya,Medicaid,,55.67,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,Vaya,Medicaid,,170.94,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,Vaya,Medicaid,,70.73,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,Vaya,Medicaid,,85.16,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,Vaya,Medicaid,,279.81,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Vaya,Medicaid,,139.60,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,Vaya,Medicaid,,141.25,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,Vaya,Medicaid,,227.64,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,Vaya,Medicaid,,120.21,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,Vaya,Medicaid,,601.49,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,Vaya,Medicaid,,308.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,Vaya,Medicaid,,225.38,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,Vaya,Medicaid,,201.25,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,Vaya,Medicaid,,147.85,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Vaya,Medicaid,,384.77,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,Vaya,Medicaid,,209.09,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,Vaya,Medicaid,,428.69,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,Vaya,Medicaid,,330.33,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,Vaya,Medicaid,,472.20,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,Vaya,Medicaid,,330.33,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Vaya,Medicaid,,490.34,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,Vaya,Medicaid,,563.54,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,Vaya,Medicaid,,176.51,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,Vaya,Medicaid,,323.12,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,Vaya,Medicaid,,253.63,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,Vaya,Medicaid,,462.92,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,Vaya,Medicaid,,214.86,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,Vaya,Medicaid,,236.72,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,Vaya,Medicaid,,258.78,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,Vaya,Medicaid,,367.86,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Vaya,Medicaid,,543.54,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,Vaya,Medicaid,,543.54,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,Vaya,Medicaid,,514.88,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,Vaya,Medicaid,,799.23,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,Vaya,Medicaid,,998.83,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,Vaya,Medicaid,,171.35,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,Vaya,Medicaid,,296.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,Vaya,Medicaid,,266.82,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,Vaya,Medicaid,,328.27,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,Vaya,Medicaid,,512.61,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,Vaya,Medicaid,,160.42,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,Vaya,Medicaid,,301.88,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,Vaya,Medicaid,,178.16,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,Vaya,Medicaid,,224.76,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,Vaya,Medicaid,,164.75,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,Vaya,Medicaid,,239.19,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,Vaya,Medicaid,,272.39,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,Vaya,Medicaid,,239.19,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,Vaya,Medicaid,,332.19,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,Vaya,Medicaid,,262.08,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,Vaya,Medicaid,,190.32,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,Vaya,Medicaid,,482.71,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,Vaya,Medicaid,,606.85,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,Vaya,Medicaid,,57.12,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,Vaya,Medicaid,,20.41,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,Vaya,Medicaid,,418.59,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,Vaya,Medicaid,,203.73,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,Vaya,Medicaid,,42.89,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,Vaya,Medicaid,,576.12,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,Vaya,Medicaid,,2576.06,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,Vaya,Medicaid,,338.79,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,Vaya,Medicaid,,107.02,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,Vaya,Medicaid,,419.20,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,Vaya,Medicaid,,96.91,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,Vaya,Medicaid,,2550.90,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,Vaya,Medicaid,,139.60,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,Vaya,Medicaid,,0.20826,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,Vaya,Medicaid,,17.94,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,Vaya,Medicaid,,181.04,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,Vaya,Medicaid,,24.54,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,Vaya,Medicaid,,120.42,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,Vaya,Medicaid,,66.60,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,Vaya,Medicaid,,9.07,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,Vaya,Medicaid,,1088.74,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,Vaya,Medicaid,,1.24,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,Vaya,Medicaid,,133.82,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,Vaya,Medicaid,,25.16,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,Vaya,Medicaid,,8.66,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,Vaya,Medicaid,,16.91,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,Vaya,Medicaid,,52.37,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,Vaya,Medicaid,,1249.16,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,Vaya,Medicaid,,37.73,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,Vaya,Medicaid,,221.66,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,Vaya,Medicaid,,62.89,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,Vaya,Medicaid,,294.45,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,Vaya,Medicaid,,62.89,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Vaya,Medicaid,,415.70,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,Vaya,Medicaid,,415.70,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,Vaya,Medicaid,,276.93,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,Vaya,Medicaid,,100.42,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,Vaya,Medicaid,,89.70,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,Vaya,Medicaid,,461.89,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,Vaya,Medicaid,,330.95,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Vaya,Medicaid,,689.53,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Vaya,Medicaid,,689.53,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,Vaya,Medicaid,,689.53,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,Vaya,Medicaid,,269.92,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,Vaya,Medicaid,,397.76,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,Vaya,Medicaid,,220.43,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,Vaya,Medicaid,,393.43,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,Vaya,Medicaid,,253.63,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,Vaya,Medicaid,,828.51,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,Vaya,Medicaid,,682.52,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Vaya,Medicaid,,854.08,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,Vaya,Medicaid,,854.08,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,Vaya,Medicaid,,837.58,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Vaya,Medicaid,,213.00,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,Vaya,Medicaid,,232.18,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,Vaya,Medicaid,,66.81,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,Vaya,Medicaid,,523.13,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,Vaya,Medicaid,,265.79,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,Vaya,Medicaid,,234.66,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,Vaya,Medicaid,,261.67,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,Vaya,Medicaid,,466.22,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,Vaya,Medicaid,,550.14,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,Vaya,Medicaid,,673.04,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,Vaya,Medicaid,,505.19,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,Vaya,Medicaid,,606.64,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,Vaya,Medicaid,,676.75,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,Vaya,Medicaid,,522.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,Vaya,Medicaid,,638.40,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,Vaya,Medicaid,,722.11,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,Vaya,Medicaid,,532.82,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,Vaya,Medicaid,,635.51,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,Vaya,Medicaid,,724.17,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Vaya,Medicaid,,863.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Vaya,Medicaid,,818.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,Vaya,Medicaid,,480.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Vaya,Medicaid,,603.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,Vaya,Medicaid,,709.33,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,Vaya,Medicaid,,798.82,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,Vaya,Medicaid,,592.21,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,Vaya,Medicaid,,746.03,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,Vaya,Medicaid,,763.76,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,Vaya,Medicaid,,462.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,Vaya,Medicaid,,562.72,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,Vaya,Medicaid,,656.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,Vaya,Medicaid,,540.66,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,Vaya,Medicaid,,657.57,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Vaya,Medicaid,,767.68,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,Vaya,Medicaid,,622.31,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,Vaya,Medicaid,,472.61,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,Vaya,Medicaid,,590.76,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,Vaya,Medicaid,,633.24,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,Vaya,Medicaid,,604.99,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,Vaya,Medicaid,,829.34,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,Vaya,Medicaid,,895.53,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,Vaya,Medicaid,,819.44,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Vaya,Medicaid,,517.77,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,Vaya,Medicaid,,666.23,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,Vaya,Medicaid,,873.26,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,Vaya,Medicaid,,1015.95,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,Vaya,Medicaid,,514.26,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,Vaya,Medicaid,,654.48,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,Vaya,Medicaid,,774.90,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,Vaya,Medicaid,,1517.84,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Vaya,Medicaid,,7106.27,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,Vaya,Medicaid,,1104.20,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,Vaya,Medicaid,,1315.35,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,Vaya,Medicaid,,1528.97,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,Vaya,Medicaid,,269.92,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,Vaya,Medicaid,,836.97,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,Vaya,Medicaid,,818.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Vaya,Medicaid,,863.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,Vaya,Medicaid,,603.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,Vaya,Medicaid,,577.36,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,Vaya,Medicaid,,98.36,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,Vaya,Medicaid,,241.87,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Vaya,Medicaid,,274.66,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,Vaya,Medicaid,,274.66,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,Vaya,Medicaid,,298.99,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Vaya,Medicaid,,363.74,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,Vaya,Medicaid,,363.74,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,Vaya,Medicaid,,391.99,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,Vaya,Medicaid,,97.94,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,Vaya,Medicaid,,69.49,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Vaya,Medicaid,,7106.27,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,Vaya,Medicaid,,7106.27,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,Vaya,Medicaid,,6488.29,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,Vaya,Medicaid,,55.47,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,Vaya,Medicaid,,150.11,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,Vaya,Medicaid,,129.70,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,Vaya,Medicaid,,410.96,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,Vaya,Medicaid,,1052.65,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,Vaya,Medicaid,,111.97,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,Vaya,Medicaid,,286.00,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,Vaya,Medicaid,,181.46,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,Vaya,Medicaid,,11867.02,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Vaya,Medicaid,,1001.51,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Vaya,Medicaid,,1001.51,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,Vaya,Medicaid,,6090.12,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,Vaya,Medicaid,,228.88,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,Vaya,Medicaid,,618.39,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Vaya,Medicaid,,31.96,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,Vaya,Medicaid,,31.96,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,Vaya,Medicaid,,86.81,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Vaya,Medicaid,,602.31,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,Vaya,Medicaid,,129.70,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,Vaya,Medicaid,,94.03,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,Vaya,Medicaid,,47.84,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,Vaya,Medicaid,,41.45,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,Vaya,Medicaid,,99.18,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,Vaya,Medicaid,,228.68,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,Vaya,Medicaid,,94.44,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,Vaya,Medicaid,,58.77,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,Vaya,Medicaid,,288.68,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Vaya,Medicaid,,326.21,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,Vaya,Medicaid,,326.21,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Vaya,Medicaid,,480.45,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,Vaya,Medicaid,,480.45,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,Vaya,Medicaid,,64.13,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,Vaya,Medicaid,,64.13,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Vaya,Medicaid,,165.78,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,Vaya,Medicaid,,165.78,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,Vaya,Medicaid,,148.88,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Vaya,Medicaid,,118.98,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,Vaya,Medicaid,,118.98,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,Vaya,Medicaid,,973.26,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,Vaya,Medicaid,,696.34,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,Vaya,Medicaid,,146.81,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,Vaya,Medicaid,,116.50,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,Vaya,Medicaid,,291.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,Vaya,Medicaid,,157.74,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,Vaya,Medicaid,,266.41,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,Vaya,Medicaid,,119.80,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Vaya,Medicaid,,262.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,Vaya,Medicaid,,262.90,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Vaya,Medicaid,,240.84,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Vaya,Medicaid,,622.52,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,Vaya,Medicaid,,622.52,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,Vaya,Medicaid,,61.86,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,Vaya,Medicaid,,400.65,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,Vaya,Medicaid,,301.88,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,Vaya,Medicaid,,171.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,Vaya,Medicaid,,334.66,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,Vaya,Medicaid,,364.97,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Vaya,Medicaid,,373.02,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Vaya,Medicaid,,373.02,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Vaya,Medicaid,,434.05,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,Vaya,Medicaid,,434.05,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Vaya,Medicaid,,139.60,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,Vaya,Medicaid,,139.60,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Vaya,Medicaid,,107.02,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Vaya,Medicaid,,141.04,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,Vaya,Medicaid,,141.04,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,Vaya,Medicaid,,554.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Vaya,Medicaid,,568.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,Vaya,Medicaid,,568.29,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Vaya,Medicaid,,328.68,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,Vaya,Medicaid,,328.68,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Vaya,Medicaid,,188.88,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,Vaya,Medicaid,,188.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Vaya,Medicaid,,233.01,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,Vaya,Medicaid,,233.01,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Vaya,Medicaid,,237.75,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,Vaya,Medicaid,,237.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,Vaya,Medicaid,,1043.17,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,Vaya,Medicaid,,1015.53,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,Vaya,Medicaid,,163.93,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,Vaya,Medicaid,,149.50,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,Vaya,Medicaid,,168.67,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,Vaya,Medicaid,,153.00,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,Vaya,Medicaid,,463.33,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,Vaya,Medicaid,,153.00,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,Vaya,Medicaid,,767.68,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,Vaya,Medicaid,,182.69,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,Vaya,Medicaid,,141.45,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,Vaya,Medicaid,,40.21,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,Vaya,Medicaid,,109.90,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,Vaya,Medicaid,,114.44,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,Vaya,Medicaid,,121.66,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,Vaya,Medicaid,,120.21,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,Vaya,Medicaid,,137.12,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,Vaya,Medicaid,,858.41,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,Vaya,Medicaid,,438.79,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,Vaya,Medicaid,,276.93,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,Vaya,Medicaid,,301.88,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,Vaya,Medicaid,,143.10,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,Vaya,Medicaid,,121.04,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,Vaya,Medicaid,,124.96,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Vaya,Medicaid,,182.28,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,Vaya,Medicaid,,182.28,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Vaya,Medicaid,,2898.76,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Vaya,Medicaid,,2898.76,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,Vaya,Medicaid,,2898.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,Vaya,Medicaid,,1275.55,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Vaya,Medicaid,,2167.99,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Vaya,Medicaid,,2167.99,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Vaya,Medicaid,,2167.99,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,Vaya,Medicaid,,2167.99,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Vaya,Medicaid,,2361.40,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,Vaya,Medicaid,,2361.40,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,Vaya,Medicaid,,1582.17,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Vaya,Medicaid,,1629.39,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,Vaya,Medicaid,,1629.39,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Vaya,Medicaid,,989.76,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,Vaya,Medicaid,,921.92,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Vaya,Medicaid,,1249.98,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Vaya,Medicaid,,1249.98,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,Vaya,Medicaid,,1249.98,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Vaya,Medicaid,,906.04,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,Vaya,Medicaid,,498.39,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,Vaya,Medicaid,,510.35,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,Vaya,Medicaid,,332.60,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,Vaya,Medicaid,,163.31,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Vaya,Medicaid,,510.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,Vaya,Medicaid,,78.15,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,Vaya,Medicaid,,99.39,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,Vaya,Medicaid,,58.15,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,Vaya,Medicaid,,111.76,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Vaya,Medicaid,,1091.62,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,Vaya,Medicaid,,263.32,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,Vaya,Medicaid,,1545.26,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,Vaya,Medicaid,,81.45,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Vaya,Medicaid,,338.17,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,Vaya,Medicaid,,338.17,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,Vaya,Medicaid,,440.44,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,Vaya,Medicaid,,187.85,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,Vaya,Medicaid,,634.48,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,Vaya,Medicaid,,461.68,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,Vaya,Medicaid,,110.32,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,Vaya,Medicaid,,209.50,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,Vaya,Medicaid,,794.69,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,Vaya,Medicaid,,132.38,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,Vaya,Medicaid,,165.37,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,Vaya,Medicaid,,132.38,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,Vaya,Medicaid,,143.31,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,Vaya,Medicaid,,1091.62,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,Vaya,Medicaid,,490.34,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,Vaya,Medicaid,,515.91,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,Vaya,Medicaid,,510.96,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,Vaya,Medicaid,,131.14,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,Vaya,Medicaid,,239.19,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,Vaya,Medicaid,,36.09,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,Vaya,Medicaid,,1297.20,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,Vaya,Medicaid,,1601.56,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,Vaya,Medicaid,,513.64,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,Vaya,Medicaid,,60.62,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,Vaya,Medicaid,,47.63,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,Vaya,Medicaid,,42.89,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,Vaya,Medicaid,,83.30,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,Vaya,Medicaid,,84.13,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Vaya,Medicaid,,510.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,Vaya,Medicaid,,41.65,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,Vaya,Medicaid,,328.27,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,Vaya,Medicaid,,927.28,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,Vaya,Medicaid,,873.05,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,Vaya,Medicaid,,602.31,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,Vaya,Medicaid,,943.16,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Vaya,Medicaid,,217.54,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,Vaya,Medicaid,,217.54,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,Vaya,Medicaid,,303.32,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Vaya,Medicaid,,59.39,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,Vaya,Medicaid,,59.39,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Vaya,Medicaid,,395.49,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,Vaya,Medicaid,,395.49,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,Vaya,Medicaid,,241.87,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Vaya,Medicaid,,517.77,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,Vaya,Medicaid,,517.77,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Vaya,Medicaid,,419.41,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,Vaya,Medicaid,,419.41,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Vaya,Medicaid,,358.38,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,Vaya,Medicaid,,358.38,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Vaya,Medicaid,,326.41,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,Vaya,Medicaid,,326.41,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Vaya,Medicaid,,339.41,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,Vaya,Medicaid,,339.41,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,Vaya,Medicaid,,352.60,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Vaya,Medicaid,,312.39,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,Vaya,Medicaid,,312.39,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Vaya,Medicaid,,311.16,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,Vaya,Medicaid,,311.16,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Vaya,Medicaid,,685.00,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,Vaya,Medicaid,,685.00,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Vaya,Medicaid,,383.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,Vaya,Medicaid,,383.53,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Vaya,Medicaid,,374.87,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,Vaya,Medicaid,,374.87,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,Vaya,Medicaid,,475.50,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,Vaya,Medicaid,,75.88,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,Vaya,Medicaid,,1001.51,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,Vaya,Medicaid,,45.36,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,Vaya,Medicaid,,585.81,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,Vaya,Medicaid,,616.54,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Vaya,Medicaid,,4152.25,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Vaya,Medicaid,,2207.58,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,Vaya,Medicaid,,107.02,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,Vaya,Medicaid,,240.84,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,Vaya,Medicaid,,221.46,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,Vaya,Medicaid,,142.90,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,Vaya,Medicaid,,160.01,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,Vaya,Medicaid,,1125.44,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Vaya,Medicaid,,765.41,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,Vaya,Medicaid,,973.06,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,Vaya,Medicaid,,797.79,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,Vaya,Medicaid,,1002.96,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,Vaya,Medicaid,,822.33,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,Vaya,Medicaid,,348.07,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,Vaya,Medicaid,,118.15,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,Vaya,Medicaid,,1538.66,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,Vaya,Medicaid,,410.34,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,Vaya,Medicaid,,307.65,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,Vaya,Medicaid,,547.05,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,Vaya,Medicaid,,5931.55,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,Vaya,Medicaid,,863.36,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,Vaya,Medicaid,,2738.13,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,Vaya,Medicaid,,1824.46,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,Vaya,Medicaid,,717.37,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,Vaya,Medicaid,,255.89,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Vaya,Medicaid,,349.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,Vaya,Medicaid,,349.72,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Vaya,Medicaid,,386.83,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,Vaya,Medicaid,,386.83,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Vaya,Medicaid,,357.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,Vaya,Medicaid,,357.14,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,Vaya,Medicaid,,265.79,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,Vaya,Medicaid,,151.14,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,Vaya,Medicaid,,253.42,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,Vaya,Medicaid,,1477.42,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,Vaya,Medicaid,,369.30,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,Vaya,Medicaid,,324.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,Vaya,Medicaid,,382.29,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,Vaya,Medicaid,,215.69,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Vaya,Medicaid,,739.43,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,Vaya,Medicaid,,739.43,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Vaya,Medicaid,,536.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Vaya,Medicaid,,536.53,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Vaya,Medicaid,,536.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,Vaya,Medicaid,,536.53,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,Vaya,Medicaid,,714.48,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,Vaya,Medicaid,,614.48,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,Vaya,Medicaid,,1266.89,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,Vaya,Medicaid,,1473.09,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,Vaya,Medicaid,,1091.00,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,Vaya,Medicaid,,982.96,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,Vaya,Medicaid,,245.79,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,Vaya,Medicaid,,1657.44,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,Vaya,Medicaid,,1710.64,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,Vaya,Medicaid,,2571.31,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,Vaya,Medicaid,,1434.12,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Vaya,Medicaid,,548.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,Vaya,Medicaid,,381.06,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,Vaya,Medicaid,,183.72,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,Vaya,Medicaid,,332.19,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,Vaya,Medicaid,,245.58,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,Vaya,Medicaid,,763.35,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,Vaya,Medicaid,,670.36,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,Vaya,Medicaid,,670.97,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,Vaya,Medicaid,,578.39,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,Vaya,Medicaid,,548.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,Vaya,Medicaid,,983.37,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,Vaya,Medicaid,,1140.70,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,Vaya,Medicaid,,1671.66,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,Vaya,Medicaid,,154.86,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,Vaya,Medicaid,,2242.84,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,Vaya,Medicaid,,1614.75,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,Vaya,Medicaid,,785.00,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,Vaya,Medicaid,,3530.35,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,Vaya,Medicaid,,1510.83,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,Vaya,Medicaid,,185.99,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Vaya,Medicaid,,717.78,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,Vaya,Medicaid,,717.78,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,Vaya,Medicaid,,3554.48,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Vaya,Medicaid,,3336.73,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,Vaya,Medicaid,,3336.73,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Vaya,Medicaid,,1813.53,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,Vaya,Medicaid,,1813.53,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Vaya,Medicaid,,1922.20,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,Vaya,Medicaid,,1922.20,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,Vaya,Medicaid,,2562.65,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,Vaya,Medicaid,,1863.02,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,Vaya,Medicaid,,600.04,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Vaya,Medicaid,,488.28,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,Vaya,Medicaid,,488.28,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,Vaya,Medicaid,,165.78,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,Vaya,Medicaid,,1352.67,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,Vaya,Medicaid,,347.65,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,Vaya,Medicaid,,416.73,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,Vaya,Medicaid,,662.11,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,Vaya,Medicaid,,100.42,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Vaya,Medicaid,,589.53,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Vaya,Medicaid,,589.53,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,Vaya,Medicaid,,44.95,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,Vaya,Medicaid,,44.95,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Vaya,Medicaid,,2050.45,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,Vaya,Medicaid,,2050.45,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,Vaya,Medicaid,,827.69,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,Vaya,Medicaid,,1256.17,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,Vaya,Medicaid,,711.80,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,Vaya,Medicaid,,373.02,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,Vaya,Medicaid,,129.70,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Vaya,Medicaid,,589.53,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,Vaya,Medicaid,,589.53,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,Vaya,Medicaid,,836.76,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,Vaya,Medicaid,,403.95,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Vaya,Medicaid,,80.83,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,Vaya,Medicaid,,94.65,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Vaya,Medicaid,,76.91,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,Vaya,Medicaid,,76.91,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,Vaya,Medicaid,,80.83,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,Vaya,Medicaid,,65.98,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,Vaya,Medicaid,,184.34,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,Vaya,Medicaid,,118.36,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,Vaya,Medicaid,,235.48,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,Vaya,Medicaid,,193.00,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,Vaya,Medicaid,,218.16,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,Vaya,Medicaid,,158.98,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,Vaya,Medicaid,,172.59,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,Vaya,Medicaid,,64.95,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,Vaya,Medicaid,,156.30,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,Vaya,Medicaid,,63.92,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,Vaya,Medicaid,,170.12,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,Vaya,Medicaid,,198.16,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,Vaya,Medicaid,,107.02,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,Vaya,Medicaid,,131.35,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,Vaya,Medicaid,,88.05,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,Vaya,Medicaid,,172.18,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,Vaya,Medicaid,,137.74,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,Vaya,Medicaid,,111.14,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,Vaya,Medicaid,,135.68,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,Vaya,Medicaid,,213.83,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,Vaya,Medicaid,,169.70,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,Vaya,Medicaid,,189.50,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,Vaya,Medicaid,,62.07,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,Vaya,Medicaid,,242.90,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,Vaya,Medicaid,,157.54,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,Vaya,Medicaid,,51.55,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,Vaya,Medicaid,,47.63,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,Vaya,Medicaid,,38.35,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,Vaya,Medicaid,,227.23,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,Vaya,Medicaid,,170.12,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,Vaya,Medicaid,,41.03,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,Vaya,Medicaid,,141.04,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,Vaya,Medicaid,,87.02,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,Vaya,Medicaid,,199.40,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,Vaya,Medicaid,,149.29,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,Vaya,Medicaid,,85.16,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,Vaya,Medicaid,,101.45,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,Vaya,Medicaid,,94.65,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,Vaya,Medicaid,,28.66,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,Vaya,Medicaid,,13.82,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,Vaya,Medicaid,,22.48,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,Vaya,Medicaid,,1316.79,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,Vaya,Medicaid,,959.65,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,Vaya,Medicaid,,862.33,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,Vaya,Medicaid,,1338.44,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Vaya,Medicaid,,1268.13,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,Vaya,Medicaid,,554.27,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Vaya,Medicaid,,1268.13,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,Vaya,Medicaid,,1268.13,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,Vaya,Medicaid,,191.97,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,Vaya,Medicaid,,315.69,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,Vaya,Medicaid,,631.18,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,Vaya,Medicaid,,960.89,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,Vaya,Medicaid,,861.09,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,Vaya,Medicaid,,1247.92,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,Vaya,Medicaid,,1834.36,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,Vaya,Medicaid,,108.67,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Vaya,Medicaid,,185.37,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,Vaya,Medicaid,,117.74,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,Vaya,Medicaid,,208.67,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Vaya,Medicaid,,564.16,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,Vaya,Medicaid,,509.11,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,Vaya,Medicaid,,99.18,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,Vaya,Medicaid,,580.04,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,Vaya,Medicaid,,678.81,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,Vaya,Medicaid,,1045.23,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,Vaya,Medicaid,,1263.39,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,Vaya,Medicaid,,713.25,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,Vaya,Medicaid,,1066.67,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,Vaya,Medicaid,,1111.01,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,Vaya,Medicaid,,743.14,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,Vaya,Medicaid,,776.34,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Vaya,Medicaid,,1063.58,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,Vaya,Medicaid,,715.93,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,Vaya,Medicaid,,840.47,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,Vaya,Medicaid,,968.93,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,Vaya,Medicaid,,764.59,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,Vaya,Medicaid,,802.53,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,Vaya,Medicaid,,1099.46,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,Vaya,Medicaid,,757.78,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,Vaya,Medicaid,,765.41,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,Vaya,Medicaid,,1063.58,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,Vaya,Medicaid,,877.59,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,Vaya,Medicaid,,928.11,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,Vaya,Medicaid,,1079.25,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,Vaya,Medicaid,,601.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,Vaya,Medicaid,,862.95,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,Vaya,Medicaid,,654.07,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,Vaya,Medicaid,,52.17,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Vaya,Medicaid,52,814.90,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,Vaya,Medicaid,52,810.98,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,Vaya,Medicaid,,792.43,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,Vaya,Medicaid,,908.31,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,Vaya,Medicaid,,1071.42,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,Vaya,Medicaid,,829.75,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,Vaya,Medicaid,,852.64,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,Vaya,Medicaid,,725.00,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,Vaya,Medicaid,,881.30,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Vaya,Medicaid,,726.44,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,Vaya,Medicaid,,835.32,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,Vaya,Medicaid,,1052.44,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,Vaya,Medicaid,,1012.85,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,Vaya,Medicaid,,1124.61,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,Vaya,Medicaid,,863.98,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,Vaya,Medicaid,,956.15,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,Vaya,Medicaid,,1151.83,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,Vaya,Medicaid,,715.10,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,Vaya,Medicaid,,756.96,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,Vaya,Medicaid,,1101.11,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,Vaya,Medicaid,,669.12,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,Vaya,Medicaid,,742.11,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,Vaya,Medicaid,,1030.79,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,Vaya,Medicaid,,871.20,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,Vaya,Medicaid,,667.26,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,Vaya,Medicaid,,922.13,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Vaya,Medicaid,,873.88,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Vaya,Medicaid,,873.88,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,Vaya,Medicaid,,873.88,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,Vaya,Medicaid,,728.92,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Vaya,Medicaid,,838.82,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,Vaya,Medicaid,,838.82,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,Vaya,Medicaid,,926.46,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,Vaya,Medicaid,,670.15,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,Vaya,Medicaid,,947.28,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,Vaya,Medicaid,,920.89,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Vaya,Medicaid,,870.78,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,Vaya,Medicaid,,870.78,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Vaya,Medicaid,,936.15,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Vaya,Medicaid,,936.15,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,Vaya,Medicaid,,936.15,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,Vaya,Medicaid,,726.44,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,Vaya,Medicaid,,213.00,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,Vaya,Medicaid,,494.88,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,Vaya,Medicaid,,491.79,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,Vaya,Medicaid,,814.90,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,Vaya,Medicaid,,386.62,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,Vaya,Medicaid,,87.84,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,Vaya,Medicaid,,66.81,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,Vaya,Medicaid,,82.27,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Vaya,Medicaid,,359.82,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,Vaya,Medicaid,,359.82,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,Vaya,Medicaid,,32.58,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Vaya,Medicaid,,377.55,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,Vaya,Medicaid,,377.55,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,Vaya,Medicaid,,186.61,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,Vaya,Medicaid,,111.35,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,Vaya,Medicaid,,97.94,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,Vaya,Medicaid,,97.94,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,Vaya,Medicaid,,267.85,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,Vaya,Medicaid,,213.83,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,Vaya,Medicaid,,174.65,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,Vaya,Medicaid,,127.02,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,Vaya,Medicaid,,123.51,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,Vaya,Medicaid,,60.21,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,Vaya,Medicaid,,88.87,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,Vaya,Medicaid,,65.37,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,Vaya,Medicaid,,59.39,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,Vaya,Medicaid,,140.22,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,Vaya,Medicaid,,57.94,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,Vaya,Medicaid,,120.01,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,Vaya,Medicaid,,120.01,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,Vaya,Medicaid,,296.10,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,Vaya,Medicaid,,155.06,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,Vaya,Medicaid,,384.77,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,Vaya,Medicaid,,896.97,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,Vaya,Medicaid,,51.96,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,Vaya,Medicaid,,36.50,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,Vaya,Medicaid,,76.09,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,Vaya,Medicaid,,37.73,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,Vaya,Medicaid,,88.05,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,Vaya,Medicaid,,67.84,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,Vaya,Medicaid,,56.70,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,Vaya,Medicaid,,82.27,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,Vaya,Medicaid,,130.11,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,Vaya,Medicaid,,106.81,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,Vaya,Medicaid,,180.22,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,Vaya,Medicaid,,115.88,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Vaya,Medicaid,,11.75,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,Vaya,Medicaid,,74.64,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,Vaya,Medicaid,,155.89,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,Vaya,Medicaid,,62.89,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,Vaya,Medicaid,,137.12,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,Vaya,Medicaid,,87.02,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,Vaya,Medicaid,,197.13,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,Vaya,Medicaid,,123.51,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,Vaya,Medicaid,,87.02,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,Vaya,Medicaid,,94.44,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,Vaya,Medicaid,,75.06,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,Vaya,Medicaid,,520.45,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,Vaya,Medicaid,,447.25,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,Vaya,Medicaid,,228.06,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,Vaya,Medicaid,,107.43,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,Vaya,Medicaid,,114.03,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,Vaya,Medicaid,,69.28,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,Vaya,Medicaid,,26.39,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,Vaya,Medicaid,,105.57,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,Vaya,Medicaid,,83.30,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,Vaya,Medicaid,,83.30,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,Vaya,Medicaid,,495.70,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,Vaya,Medicaid,,9.69,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,Vaya,Medicaid,,2.89,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,Vaya,Medicaid,,23.09,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,Vaya,Medicaid,,33.61,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,Vaya,Medicaid,,27.22,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,Vaya,Medicaid,,5.36,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,Vaya,Medicaid,,9.07,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Vaya,Medicaid,,38.97,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,Vaya,Medicaid,,54.64,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Vaya,Medicaid,,52.17,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,Vaya,Medicaid,,38.97,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,Vaya,Medicaid,,81.86,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,Vaya,Medicaid,,31.96,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,Vaya,Medicaid,,110.32,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,Vaya,Medicaid,,14.64,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Vaya,Medicaid,,27.42,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Vaya,Medicaid,,27.42,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,Vaya,Medicaid,,27.42,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,Vaya,Medicaid,,5.98,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,Vaya,Medicaid,,36.50,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,Vaya,Medicaid,,25.57,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,Vaya,Medicaid,,8.04,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Vaya,Medicaid,,29.90,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Vaya,Medicaid,,29.90,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,Vaya,Medicaid,,29.90,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,Vaya,Medicaid,,31.75,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,Vaya,Medicaid,,5.98,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,Vaya,Medicaid,,8.87,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,Vaya,Medicaid,,8.66,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,Vaya,Medicaid,,9.90,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,Vaya,Medicaid,,33.40,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Vaya,Medicaid,,23.71,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Vaya,Medicaid,,23.71,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,Vaya,Medicaid,,23.71,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,Vaya,Medicaid,,8.66,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,Vaya,Medicaid,,12.37,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,Vaya,Medicaid,,8.25,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,Vaya,Medicaid,,8.25,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,Vaya,Medicaid,,34.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,,18.35,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,,18.35,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,Vaya,Medicaid,,13.61,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,Vaya,Medicaid,,10.93,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,Vaya,Medicaid,,53.20,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,Vaya,Medicaid,,13.61,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,Vaya,Medicaid,,50.11,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,Vaya,Medicaid,,37.12,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,Vaya,Medicaid,,30.11,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,Vaya,Medicaid,,16.29,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,Vaya,Medicaid,,8.04,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,Vaya,Medicaid,,61.65,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,Vaya,Medicaid,,1.24,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,Vaya,Medicaid,,41.45,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,Vaya,Medicaid,,119.39,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,Vaya,Medicaid,,32.37,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Vaya,Medicaid,,25.16,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Vaya,Medicaid,,25.16,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Vaya,Medicaid,,25.16,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,Vaya,Medicaid,,25.16,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,Vaya,Medicaid,,8.04,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Vaya,Medicaid,,41.86,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Vaya,Medicaid,,41.86,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Vaya,Medicaid,,41.86,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,Vaya,Medicaid,,41.86,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,Vaya,Medicaid,,6.19,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,Vaya,Medicaid,,14.64,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Vaya,Medicaid,,35.26,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Vaya,Medicaid,,33.40,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,Vaya,Medicaid,,16.08,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,Vaya,Medicaid,,49.08,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,Vaya,Medicaid,,32.17,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,Vaya,Medicaid,,45.57,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,Vaya,Medicaid,,24.74,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,Vaya,Medicaid,,31.34,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Vaya,Medicaid,,9.69,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,Vaya,Medicaid,,9.69,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,Vaya,Medicaid,,40.62,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,Vaya,Medicaid,,27.22,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,Vaya,Medicaid,,8.25,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,Vaya,Medicaid,,7.84,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,Vaya,Medicaid,,8.66,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Vaya,Medicaid,,32.58,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,Vaya,Medicaid,,32.58,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,Vaya,Medicaid,,30.72,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,Vaya,Medicaid,,7.84,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,Vaya,Medicaid,,29.49,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,Vaya,Medicaid,,17.11,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,Vaya,Medicaid,,29.49,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,Vaya,Medicaid,,36.50,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Vaya,Medicaid,,5.36,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Vaya,Medicaid,,5.36,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,Vaya,Medicaid,,5.36,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,Vaya,Medicaid,,0.41240,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,Vaya,Medicaid,,67.84,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,Vaya,Medicaid,,11.34,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,Vaya,Medicaid,,30.11,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,Vaya,Medicaid,,46.81,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Vaya,Medicaid,,44.33,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,Vaya,Medicaid,,44.33,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,Vaya,Medicaid,,9.28,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,Vaya,Medicaid,,10.93,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,Vaya,Medicaid,,10.31,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,Vaya,Medicaid,,13.61,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,Vaya,Medicaid,,9.28,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Vaya,Medicaid,,6.60,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,Vaya,Medicaid,,6.60,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,Vaya,Medicaid,,8.87,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,Vaya,Medicaid,,3.09,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,Vaya,Medicaid,,34.44,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,Vaya,Medicaid,,9.28,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,Vaya,Medicaid,,32.99,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,Vaya,Medicaid,,39.18,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,Vaya,Medicaid,,13.61,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,Vaya,Medicaid,,27.63,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,Vaya,Medicaid,,26.81,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,Vaya,Medicaid,,22.27,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,Vaya,Medicaid,,7.84,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Vaya,Medicaid,,23.71,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,Vaya,Medicaid,,23.71,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,Vaya,Medicaid,,26.81,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,Vaya,Medicaid,,39.80,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,Vaya,Medicaid,,16.29,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,Vaya,Medicaid,,2.47,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Vaya,Medicaid,,76.50,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,Vaya,Medicaid,,76.50,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,Vaya,Medicaid,,46.40,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,Vaya,Medicaid,,6.60,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,Vaya,Medicaid,,28.87,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,Vaya,Medicaid,,23.30,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,Vaya,Medicaid,,20.00,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,Vaya,Medicaid,,28.25,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,Vaya,Medicaid,,24.74,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,Vaya,Medicaid,,1.65,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,Vaya,Medicaid,,4.54,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Vaya,Medicaid,,21.86,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,Vaya,Medicaid,,35.88,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,Vaya,Medicaid,,26.39,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,Vaya,Medicaid,,55.06,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,Vaya,Medicaid,,30.31,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,Vaya,Medicaid,,56.29,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,Vaya,Medicaid,,42.68,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,Vaya,Medicaid,,10.31,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,Vaya,Medicaid,,48.87,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,Vaya,Medicaid,,42.48,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,Vaya,Medicaid,,8.45,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,Vaya,Medicaid,,60.42,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,Vaya,Medicaid,,41.45,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,Vaya,Medicaid,,9.49,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Vaya,Medicaid,,23.30,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,Vaya,Medicaid,,23.30,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,Vaya,Medicaid,,10.31,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,Vaya,Medicaid,,27.84,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,Vaya,Medicaid,,45.98,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,Vaya,Medicaid,,4.33,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,Vaya,Medicaid,,11.75,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,Vaya,Medicaid,,29.90,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,Vaya,Medicaid,,14.02,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,,24.13,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,Vaya,Medicaid,,35.67,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,Vaya,Medicaid,,20.00,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Vaya,Medicaid,,23.92,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,Vaya,Medicaid,,23.92,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,Vaya,Medicaid,,3.09,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,,18.35,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,,18.35,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,Vaya,Medicaid,,7.22,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,Vaya,Medicaid,,9.28,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,Vaya,Medicaid,,14.23,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,Vaya,Medicaid,,95.06,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,Vaya,Medicaid,,25.16,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,Vaya,Medicaid,,40.21,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,Vaya,Medicaid,,17.11,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,Vaya,Medicaid,,2.27,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Vaya,Medicaid,,7.22,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,Vaya,Medicaid,,27.84,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,Vaya,Medicaid,,22.27,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,Vaya,Medicaid,,163.72,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,Vaya,Medicaid,,92.17,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,Vaya,Medicaid,,54.85,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,Vaya,Medicaid,,117.53,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,Vaya,Medicaid,,173.41,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,,34.02,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,Vaya,Medicaid,,61.04,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,Vaya,Medicaid,,74.44,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Vaya,Medicaid,,17.53,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Vaya,Medicaid,,17.53,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,Vaya,Medicaid,,17.53,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,Vaya,Medicaid,,48.04,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,Vaya,Medicaid,,29.90,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,Vaya,Medicaid,,25.36,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,Vaya,Medicaid,,27.63,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,Vaya,Medicaid,,40.42,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,Vaya,Medicaid,,35.67,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,Vaya,Medicaid,,103.31,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,Vaya,Medicaid,,151.97,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,Vaya,Medicaid,,25.98,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,Vaya,Medicaid,,28.66,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,Vaya,Medicaid,,30.93,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,Vaya,Medicaid,,19.18,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,Vaya,Medicaid,,33.40,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Vaya,Medicaid,,89.28,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,Vaya,Medicaid,,89.28,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,Vaya,Medicaid,,66.60,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,Vaya,Medicaid,,56.70,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,Vaya,Medicaid,,60.00,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,Vaya,Medicaid,,54.44,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,Vaya,Medicaid,,126.19,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,Vaya,Medicaid,,33.20,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,Vaya,Medicaid,,48.87,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,Vaya,Medicaid,,41.03,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,Vaya,Medicaid,,20.41,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,Vaya,Medicaid,,67.02,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,Vaya,Medicaid,,55.88,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,Vaya,Medicaid,,66.60,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,Vaya,Medicaid,,51.76,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,Vaya,Medicaid,,37.53,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,Vaya,Medicaid,,38.35,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,Vaya,Medicaid,,38.35,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,Vaya,Medicaid,,50.93,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,Vaya,Medicaid,,9.07,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,Vaya,Medicaid,,30.93,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,Vaya,Medicaid,,40.42,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,Vaya,Medicaid,,96.50,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,Vaya,Medicaid,,58.35,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,Vaya,Medicaid,,7.22,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,Vaya,Medicaid,,14.85,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,Vaya,Medicaid,,23.30,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,Vaya,Medicaid,,73.41,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,Vaya,Medicaid,,30.11,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,Vaya,Medicaid,,41.65,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,Vaya,Medicaid,,29.49,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,,24.13,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,Vaya,Medicaid,,24.13,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Vaya,Medicaid,,16.29,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,Vaya,Medicaid,,21.03,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,Vaya,Medicaid,,17.53,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,Vaya,Medicaid,,20.21,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,Vaya,Medicaid,,46.19,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,Vaya,Medicaid,,8.04,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,Vaya,Medicaid,,3.92,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,Vaya,Medicaid,,9.69,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,Vaya,Medicaid,,3.09,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,Vaya,Medicaid,,8.45,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,Vaya,Medicaid,,38.77,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,Vaya,Medicaid,,25.16,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,Vaya,Medicaid,,26.81,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,Vaya,Medicaid,,14.64,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,Vaya,Medicaid,,32.37,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,Vaya,Medicaid,,5.57,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,Vaya,Medicaid,,10.93,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Vaya,Medicaid,,38.56,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,Vaya,Medicaid,,38.56,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,Vaya,Medicaid,,20.00,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,Vaya,Medicaid,,43.92,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,Vaya,Medicaid,,42.06,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,Vaya,Medicaid,,6.60,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,Vaya,Medicaid,,42.06,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,Vaya,Medicaid,,6.39,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,Vaya,Medicaid,,14.43,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,Vaya,Medicaid,,29.90,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,Vaya,Medicaid,,18.97,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,Vaya,Medicaid,,8.04,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Vaya,Medicaid,,6.19,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Vaya,Medicaid,,6.19,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,Vaya,Medicaid,,5.36,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,,26.60,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,Vaya,Medicaid,,23.92,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,Vaya,Medicaid,,16.29,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,Vaya,Medicaid,,69.90,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,Vaya,Medicaid,,14.02,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,,18.35,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,Vaya,Medicaid,,3.30,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,Vaya,Medicaid,,50.52,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,Vaya,Medicaid,,31.75,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,Vaya,Medicaid,,7.63,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,Vaya,Medicaid,,20.41,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,Vaya,Medicaid,,16.08,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,Vaya,Medicaid,,8.25,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,Vaya,Medicaid,,11.75,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,Vaya,Medicaid,,7.84,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,Vaya,Medicaid,,12.99,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,Vaya,Medicaid,,37.12,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,Vaya,Medicaid,,6.80,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Vaya,Medicaid,,7.84,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,Vaya,Medicaid,,47.01,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,Vaya,Medicaid,,34.85,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,Vaya,Medicaid,,95.06,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,Vaya,Medicaid,,43.92,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,Vaya,Medicaid,,43.92,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,Vaya,Medicaid,,129.70,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,Vaya,Medicaid,,119.80,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,Vaya,Medicaid,,35.88,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,Vaya,Medicaid,,33.20,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,Vaya,Medicaid,,72.17,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,Vaya,Medicaid,,43.71,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Vaya,Medicaid,,33.82,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,Vaya,Medicaid,,33.82,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,Vaya,Medicaid,,56.70,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,Vaya,Medicaid,,52.99,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,Vaya,Medicaid,,158.77,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,Vaya,Medicaid,,17.94,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,Vaya,Medicaid,,17.11,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,Vaya,Medicaid,,9.90,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,Vaya,Medicaid,,23.09,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,Vaya,Medicaid,,119.39,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,Vaya,Medicaid,,57.53,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,Vaya,Medicaid,,11.34,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,Vaya,Medicaid,,31.75,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Vaya,Medicaid,,19.80,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Vaya,Medicaid,,19.80,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,Vaya,Medicaid,,19.80,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,Vaya,Medicaid,,95.47,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,Vaya,Medicaid,,60.62,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,Vaya,Medicaid,,18.15,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,Vaya,Medicaid,,10.52,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,Vaya,Medicaid,,25.98,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,Vaya,Medicaid,,2.47,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,Vaya,Medicaid,,30.93,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,Vaya,Medicaid,,24.74,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,Vaya,Medicaid,,113.00,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,Vaya,Medicaid,,63.72,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,Vaya,Medicaid,,26.19,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,Vaya,Medicaid,,7.42,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,Vaya,Medicaid,,4.54,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,Vaya,Medicaid,,47.43,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,Vaya,Medicaid,,5.98,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,Vaya,Medicaid,,21.86,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,Vaya,Medicaid,,11.96,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,Vaya,Medicaid,,7.22,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,Vaya,Medicaid,,7.22,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,Vaya,Medicaid,,3.92,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,Vaya,Medicaid,,12.58,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,Vaya,Medicaid,,13.20,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,Vaya,Medicaid,,9.49,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,Vaya,Medicaid,,11.55,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,Vaya,Medicaid,,14.64,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,Vaya,Medicaid,,3.09,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,Vaya,Medicaid,,6.19,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,Vaya,Medicaid,,52.17,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,Vaya,Medicaid,,27.63,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,Vaya,Medicaid,,35.26,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,Vaya,Medicaid,,5.36,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,Vaya,Medicaid,,33.40,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,Vaya,Medicaid,,16.29,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,Vaya,Medicaid,,5.98,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Vaya,Medicaid,,85.37,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,Vaya,Medicaid,,0.41240,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,Vaya,Medicaid,,106.81,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,Vaya,Medicaid,,16.70,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,Vaya,Medicaid,,5.98,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,Vaya,Medicaid,,33.20,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Vaya,Medicaid,,404.15,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,Vaya,Medicaid,,29.07,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,,18.35,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,Vaya,Medicaid,,7.01,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,Vaya,Medicaid,,7.84,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Vaya,Medicaid,,14.43,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,Vaya,Medicaid,,14.43,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,Vaya,Medicaid,,3.09,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,Vaya,Medicaid,,7.22,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,Vaya,Medicaid,,15.46,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,Vaya,Medicaid,,10.10,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,Vaya,Medicaid,,109.08,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,Vaya,Medicaid,,158.16,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,Vaya,Medicaid,,27.63,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,Vaya,Medicaid,,372.19,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,Vaya,Medicaid,,259.40,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,Vaya,Medicaid,,60.42,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,Vaya,Medicaid,,23.92,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Vaya,Medicaid,,398.17,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,Vaya,Medicaid,,4.74,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,Vaya,Medicaid,,53.41,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,Vaya,Medicaid,,9.49,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,Vaya,Medicaid,,372.81,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,Vaya,Medicaid,,145.78,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,Vaya,Medicaid,,105.78,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,Vaya,Medicaid,,38.97,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,Vaya,Medicaid,,404.15,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,Vaya,Medicaid,,23.51,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,Vaya,Medicaid,,66.81,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,Vaya,Medicaid,,40.00,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,Vaya,Medicaid,,196.51,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,Vaya,Medicaid,,131.76,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Vaya,Medicaid,,28.87,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,Vaya,Medicaid,QW,28.87,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,Vaya,Medicaid,,9.49,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,Vaya,Medicaid,,57.32,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,Vaya,Medicaid,,327.65,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,Vaya,Medicaid,,244.76,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,Vaya,Medicaid,,57.32,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,Vaya,Medicaid,,125.58,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,Vaya,Medicaid,,98.56,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,Vaya,Medicaid,,42.06,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,Vaya,Medicaid,,87.84,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,Vaya,Medicaid,,10.31,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,Vaya,Medicaid,QW,20.62,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,Vaya,Medicaid,,20.62,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,Vaya,Medicaid,,33.61,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,Vaya,Medicaid,,187.02,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,Vaya,Medicaid,,56.70,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,Vaya,Medicaid,,27.22,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,,34.02,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,Vaya,Medicaid,,18.35,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,Vaya,Medicaid,,8.87,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,Vaya,Medicaid,,57.74,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,Vaya,Medicaid,,16.29,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,Vaya,Medicaid,,40.00,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,Vaya,Medicaid,,14.23,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,Vaya,Medicaid,,13.61,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,Vaya,Medicaid,,72.17,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,Vaya,Medicaid,,27.84,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,Vaya,Medicaid,,43.92,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,Vaya,Medicaid,,45.16,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,Vaya,Medicaid,,27.84,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,Vaya,Medicaid,,27.84,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,Vaya,Medicaid,,56.70,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,Vaya,Medicaid,,9.28,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,Vaya,Medicaid,,9.28,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,Vaya,Medicaid,,15.67,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,Vaya,Medicaid,,8.87,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,Vaya,Medicaid,,17.32,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,Vaya,Medicaid,,20.83,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,Vaya,Medicaid,,30.72,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,Vaya,Medicaid,,273.83,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,Vaya,Medicaid,,11.34,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,Vaya,Medicaid,,22.27,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,Vaya,Medicaid,,24.33,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,Vaya,Medicaid,,13.40,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,Vaya,Medicaid,,11.75,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,Vaya,Medicaid,,55.88,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,Vaya,Medicaid,,34.44,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,Vaya,Medicaid,,55.88,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,Vaya,Medicaid,,65.78,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,Vaya,Medicaid,,106.19,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,Vaya,Medicaid,,108.46,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,Vaya,Medicaid,,43.30,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,Vaya,Medicaid,,5.57,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,Vaya,Medicaid,,22.68,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,Vaya,Medicaid,,38.35,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Vaya,Medicaid,,30.31,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,Vaya,Medicaid,,30.31,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,Vaya,Medicaid,,8.04,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,Vaya,Medicaid,,40.83,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,Vaya,Medicaid,,24.54,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,Vaya,Medicaid,,52.58,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,Vaya,Medicaid,,53.82,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,Vaya,Medicaid,,16.08,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,Vaya,Medicaid,,28.04,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,Vaya,Medicaid,,43.10,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,Vaya,Medicaid,,42.68,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,Vaya,Medicaid,,106.81,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,Vaya,Medicaid,,30.52,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,Vaya,Medicaid,,94.03,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,Vaya,Medicaid,,123.10,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,Vaya,Medicaid,,155.68,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,Vaya,Medicaid,,115.68,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,Vaya,Medicaid,,67.02,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,Vaya,Medicaid,,46.40,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,Vaya,Medicaid,,210.12,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Vaya,Medicaid,,72.99,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,Vaya,Medicaid,,125.58,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,Vaya,Medicaid,,46.19,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,Vaya,Medicaid,,27.22,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,Vaya,Medicaid,,27.84,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,Vaya,Medicaid,,113.00,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,Vaya,Medicaid,,21.03,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,Vaya,Medicaid,,36.09,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,Vaya,Medicaid,,75.68,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,Vaya,Medicaid,,136.09,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,Vaya,Medicaid,,0.00206,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,Vaya,Medicaid,,25.57,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,Vaya,Medicaid,,46.60,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,Vaya,Medicaid,,76.29,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Vaya,Medicaid,,65.78,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,Vaya,Medicaid,,65.78,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,Vaya,Medicaid,,122.28,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,Vaya,Medicaid,,113.00,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,Vaya,Medicaid,,20.00,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,,26.60,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,Vaya,Medicaid,,81.24,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,Vaya,Medicaid,,64.54,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,Vaya,Medicaid,,51.34,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,Vaya,Medicaid,,15.88,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,Vaya,Medicaid,,79.18,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,Vaya,Medicaid,,27.22,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,Vaya,Medicaid,,139.19,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,Vaya,Medicaid,,38.97,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,Vaya,Medicaid,,85.37,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,Vaya,Medicaid,,52.79,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,Vaya,Medicaid,,53.82,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Vaya,Medicaid,,32.37,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,Vaya,Medicaid,,32.37,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,Vaya,Medicaid,,111.14,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,Vaya,Medicaid,,28.66,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,Vaya,Medicaid,,33.82,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,Vaya,Medicaid,,3.71,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,Vaya,Medicaid,,85.37,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,Vaya,Medicaid,,50.93,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,Vaya,Medicaid,,451.78,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,Vaya,Medicaid,,72.79,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Vaya,Medicaid,,39.59,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,Vaya,Medicaid,,145.99,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,Vaya,Medicaid,,106.81,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,Vaya,Medicaid,,72.99,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Vaya,Medicaid,,75.68,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,Vaya,Medicaid,,107.02,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,Vaya,Medicaid,,264.97,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,Vaya,Medicaid,,75.68,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,Vaya,Medicaid,,64.33,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,Vaya,Medicaid,,26.60,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,Vaya,Medicaid,,256.31,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,Vaya,Medicaid,,4.95,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,Vaya,Medicaid,,39.59,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,Vaya,Medicaid,,187.23,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,Vaya,Medicaid,,136.09,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,Vaya,Medicaid,,97.74,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,Vaya,Medicaid,,73.41,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,Vaya,Medicaid,,25.77,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,Vaya,Medicaid,,30.93,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,Vaya,Medicaid,,19.59,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,Vaya,Medicaid,,34.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,Vaya,Medicaid,,16.50,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,Vaya,Medicaid,,32.79,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,Vaya,Medicaid,,327.65,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,Vaya,Medicaid,,164.55,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,Vaya,Medicaid,,67.22,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,Vaya,Medicaid,,13.61,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,Vaya,Medicaid,,8.66,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,Vaya,Medicaid,,21.65,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,Vaya,Medicaid,,51.14,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Vaya,Medicaid,,61.86,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,Vaya,Medicaid,,61.86,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,Vaya,Medicaid,,57.12,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,Vaya,Medicaid,,116.71,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,Vaya,Medicaid,,11.75,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,Vaya,Medicaid,,140.01,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,Vaya,Medicaid,,134.24,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Vaya,Medicaid,,214.65,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,Vaya,Medicaid,,220.63,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,Vaya,Medicaid,,44.33,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,Vaya,Medicaid,,86.40,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,Vaya,Medicaid,,60.62,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,Vaya,Medicaid,,195.68,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,Vaya,Medicaid,,255.69,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,Vaya,Medicaid,,123.72,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,Vaya,Medicaid,,18.76,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,Vaya,Medicaid,,315.07,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,Vaya,Medicaid,,5.77,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,,34.02,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,,34.02,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,Vaya,Medicaid,,34.02,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,Vaya,Medicaid,,12.17,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Vaya,Medicaid,,214.65,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,Vaya,Medicaid,,214.65,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,Vaya,Medicaid,,239.19,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,Vaya,Medicaid,,12.78,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,Vaya,Medicaid,,539.42,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Vaya,Medicaid,,1767.13,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Vaya,Medicaid,,1767.13,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Vaya,Medicaid,,1767.13,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Vaya,Medicaid,,1767.13,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Vaya,Medicaid,,1767.13,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,Vaya,Medicaid,,7315.36,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,Vaya,Medicaid,,1239.67,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Vaya,Medicaid,,510.14,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,Vaya,Medicaid,,510.14,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,Vaya,Medicaid,,1384.63,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,Vaya,Medicaid,,421.27,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,Vaya,Medicaid,,694.48,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,Vaya,Medicaid,,187.44,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,Vaya,Medicaid,,187.44,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Vaya,Medicaid,,408.48,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,Vaya,Medicaid,,408.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Vaya,Medicaid,,859.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,Vaya,Medicaid,,859.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Vaya,Medicaid,,390.96,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,Vaya,Medicaid,,390.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,Vaya,Medicaid,,92.17,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,Vaya,Medicaid,,169.70,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Vaya,Medicaid,,369.92,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,Vaya,Medicaid,,369.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Vaya,Medicaid,,291.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,Vaya,Medicaid,,291.98,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Vaya,Medicaid,,327.03,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,Vaya,Medicaid,,327.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Vaya,Medicaid,,291.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,Vaya,Medicaid,,291.98,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,Vaya,Medicaid,,1591.25,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Vaya,Medicaid,,795.52,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,Vaya,Medicaid,,795.52,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Vaya,Medicaid,,1477.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,Vaya,Medicaid,,1477.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Vaya,Medicaid,,1136.57,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Vaya,Medicaid,,1136.57,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Vaya,Medicaid,,284.14,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,Vaya,Medicaid,,284.14,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Vaya,Medicaid,,1136.57,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,Vaya,Medicaid,,1136.57,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,Vaya,Medicaid,,548.29,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Vaya,Medicaid,,1767.13,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,Vaya,Medicaid,,1767.13,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,Vaya,Medicaid,,163.72,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,Vaya,Medicaid,,5991.55,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Vaya,Medicaid,,906.04,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,Vaya,Medicaid,,906.04,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,Vaya,Medicaid,,90.52,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Vaya,Medicaid,,465.39,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Vaya,Medicaid,,465.39,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Vaya,Medicaid,,465.39,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,Vaya,Medicaid,,465.39,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Vaya,Medicaid,,3449.52,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,Vaya,Medicaid,,3449.52,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Vaya,Medicaid,,5749.27,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,Vaya,Medicaid,,5749.27,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Vaya,Medicaid,,2069.63,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,Vaya,Medicaid,,2069.63,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Vaya,Medicaid,,4771.88,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,Vaya,Medicaid,,4771.88,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Vaya,Medicaid,,1919.10,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,Vaya,Medicaid,,1919.10,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Vaya,Medicaid,,4841.37,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,Vaya,Medicaid,,4841.37,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Vaya,Medicaid,,4361.54,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,Vaya,Medicaid,,4361.54,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Vaya,Medicaid,,5801.02,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,Vaya,Medicaid,,5801.02,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,Vaya,Medicaid,,2542.03,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Vaya,Medicaid,,4804.46,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,Vaya,Medicaid,,4804.46,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Vaya,Medicaid,,4372.26,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,Vaya,Medicaid,,4372.26,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Vaya,Medicaid,,4957.05,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,Vaya,Medicaid,,4957.05,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Vaya,Medicaid,,1957.46,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,Vaya,Medicaid,,1957.46,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Vaya,Medicaid,,4219.68,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,Vaya,Medicaid,,4219.68,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Vaya,Medicaid,,3635.10,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,Vaya,Medicaid,,3635.10,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,Vaya,Medicaid,,4245.25,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Vaya,Medicaid,LM,3340.23,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Vaya,Medicaid,RI,3340.23,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Vaya,Medicaid,RC,3340.23,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Vaya,Medicaid,LD,3340.23,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,Vaya,Medicaid,LC,3340.23,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Vaya,Medicaid,LC,1723.21,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Vaya,Medicaid,RI,1723.21,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Vaya,Medicaid,RC,1723.21,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Vaya,Medicaid,LD,1723.21,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,Vaya,Medicaid,LC,1723.21,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,LM,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,RI,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,RC,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,LD,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,LC,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,LM,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,RI,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,RC,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,LD,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,Vaya,Medicaid,LC,2960.62,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,LM,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,RI,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,RC,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,LD,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,LC,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,LM,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,RI,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,RC,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,LD,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,Vaya,Medicaid,LC,4418.87,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,LM,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,RI,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,RC,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,LD,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,LC,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,RC,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,LD,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,Vaya,Medicaid,LC,4683.83,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LM,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,RI,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,RC,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LD,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LC,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LM,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,RI,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,RC,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LD,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LC,8351.51,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LM,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,RI,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,RC,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LD,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LC,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,RC,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LD,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,Vaya,Medicaid,LC,8351.51,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Vaya,Medicaid,,4772.09,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,Vaya,Medicaid,,4772.09,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Vaya,Medicaid,,4904.88,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,Vaya,Medicaid,,4904.88,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,LM,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,RI,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,RC,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,LD,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,LC,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,LM,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,RI,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,RC,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,LD,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,Vaya,Medicaid,LC,5125.72,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LM,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,RI,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,RC,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LD,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LC,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LM,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,RI,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,RC,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LD,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LC,5346.77,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LM,5346.77,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,RI,5346.77,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,RC,5346.77,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LD,5346.77,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,Vaya,Medicaid,LC,5346.77,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,Vaya,Medicaid,,81.04,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,Vaya,Medicaid,,343.12,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,Vaya,Medicaid,,384.56,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,Vaya,Medicaid,,87.02,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,Vaya,Medicaid,,521.07,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,Vaya,Medicaid,,203.31,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,Vaya,Medicaid,,2386.15,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Vaya,Medicaid,,2207.58,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,Vaya,Medicaid,,2207.58,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,Vaya,Medicaid,,2105.30,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,Vaya,Medicaid,,876.35,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,Vaya,Medicaid,,1519.08,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,Vaya,Medicaid,,2246.14,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,Vaya,Medicaid,,1994.57,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,Vaya,Medicaid,,2129.22,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,Vaya,Medicaid,,936.77,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,Vaya,Medicaid,,2190.67,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,Vaya,Medicaid,,2732.36,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,Vaya,Medicaid,,2461.41,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,Vaya,Medicaid,,2625.75,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,Vaya,Medicaid,,2670.29,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,Vaya,Medicaid,,3273.84,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,Vaya,Medicaid,,1397.62,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,Vaya,Medicaid,,41.86,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,Vaya,Medicaid,,20.00,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,Vaya,Medicaid,,309.92,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,Vaya,Medicaid,,851.19,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,Vaya,Medicaid,,1662.80,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,Vaya,Medicaid,,99.80,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,Vaya,Medicaid,,129.08,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,Vaya,Medicaid,,44.33,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,Vaya,Medicaid,,1581.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,Vaya,Medicaid,,8069.22,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,Vaya,Medicaid,,2532.55,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,Vaya,Medicaid,,520.65,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,Vaya,Medicaid,,582.31,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,Vaya,Medicaid,,261.05,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Vaya,Medicaid,,108.87,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,Vaya,Medicaid,,108.87,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,Vaya,Medicaid,,108.87,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Vaya,Medicaid,,1625.27,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,Vaya,Medicaid,,1625.27,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Vaya,Medicaid,,3088.67,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,Vaya,Medicaid,,3088.67,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,Vaya,Medicaid,,3766.66,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,Vaya,Medicaid,,2735.86,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,Vaya,Medicaid,,3108.88,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,Vaya,Medicaid,,3751.60,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,Vaya,Medicaid,,658.40,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Vaya,Medicaid,,2905.15,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,Vaya,Medicaid,,2905.15,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,Vaya,Medicaid,,2106.33,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,Vaya,Medicaid,,607.05,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Vaya,Medicaid,,598.39,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,Vaya,Medicaid,,598.39,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,Vaya,Medicaid,,4204.83,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,Vaya,Medicaid,,3077.53,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,Vaya,Medicaid,,488.08,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,Vaya,Medicaid,,4904.67,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,Vaya,Medicaid,,5056.23,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,Vaya,Medicaid,,5511.31,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,Vaya,Medicaid,,1754.35,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Vaya,Medicaid,,2350.89,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,Vaya,Medicaid,,2350.89,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,Vaya,Medicaid,,10286.70,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,Vaya,Medicaid,,1185.65,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,Vaya,Medicaid,,787.89,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,Vaya,Medicaid,,11897.33,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,Vaya,Medicaid,,544.16,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,Vaya,Medicaid,,2405.74,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,Vaya,Medicaid,,430.13,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,Vaya,Medicaid,,863.57,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Vaya,Medicaid,,1336.18,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,Vaya,Medicaid,,1336.18,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Vaya,Medicaid,,666.44,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,Vaya,Medicaid,,473.23,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Vaya,Medicaid,,666.44,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,Vaya,Medicaid,,666.44,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,Vaya,Medicaid,,627.47,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,Vaya,Medicaid,,574.68,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,Vaya,Medicaid,,1975.40,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Vaya,Medicaid,,3140.43,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,Vaya,Medicaid,,3140.43,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,Vaya,Medicaid,,334.87,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,Vaya,Medicaid,,1666.92,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,Vaya,Medicaid,,341.88,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,Vaya,Medicaid,,650.77,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,Vaya,Medicaid,,5246.14,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Vaya,Medicaid,,4646.51,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,Vaya,Medicaid,,4646.51,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,Vaya,Medicaid,,623.75,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Vaya,Medicaid,,292.39,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,Vaya,Medicaid,,4152.25,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,Vaya,Medicaid,,4614.96,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,Vaya,Medicaid,,511.79,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,Vaya,Medicaid,,398.17,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Vaya,Medicaid,,1144.00,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,Vaya,Medicaid,,1144.00,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,Vaya,Medicaid,,1314.94,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,Vaya,Medicaid,,530.97,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,Vaya,Medicaid,,2829.27,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,Vaya,Medicaid,,989.76,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Vaya,Medicaid,,292.39,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,Vaya,Medicaid,,438.59,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,Vaya,Medicaid,,584.78,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,Vaya,Medicaid,,1642.38,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,Vaya,Medicaid,,3819.24,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,Vaya,Medicaid,,1901.99,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,Vaya,Medicaid,,1333.50,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,Vaya,Medicaid,,1541.55,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,Vaya,Medicaid,,59.39,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,Vaya,Medicaid,,292.39,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,Vaya,Medicaid,,1643.41,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Vaya,Medicaid,,627.05,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Vaya,Medicaid,,627.05,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Vaya,Medicaid,,627.05,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,Vaya,Medicaid,,627.05,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,Vaya,Medicaid,,2742.67,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Vaya,Medicaid,,5485.33,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,Vaya,Medicaid,,5485.33,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,Vaya,Medicaid,,8831.34,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,Vaya,Medicaid,,7209.16,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,Vaya,Medicaid,,1953.95,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,Vaya,Medicaid,,895.94,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,Vaya,Medicaid,,4413.92,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Vaya,Medicaid,,7060.49,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Vaya,Medicaid,,7060.49,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,Vaya,Medicaid,,7060.49,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,Vaya,Medicaid,,6675.31,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Vaya,Medicaid,,1395.15,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,Vaya,Medicaid,,1395.15,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,Vaya,Medicaid,,22.06,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Vaya,Medicaid,,8071.08,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,Vaya,Medicaid,,8071.08,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,Vaya,Medicaid,,9886.05,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,Vaya,Medicaid,,494.67,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,Vaya,Medicaid,,1339.06,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,Vaya,Medicaid,,2234.59,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Vaya,Medicaid,LD,708.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Vaya,Medicaid,RC,708.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Vaya,Medicaid,RI,708.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Vaya,Medicaid,LM,708.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Vaya,Medicaid,LD,566.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Vaya,Medicaid,RC,566.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Vaya,Medicaid,RI,566.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Vaya,Medicaid,LM,566.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Vaya,Medicaid,LD,485.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Vaya,Medicaid,RC,485.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Vaya,Medicaid,RI,485.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Vaya,Medicaid,LM,485.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,LD,102.07,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,RC,102.07,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,RI,102.07,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,LM,102.07,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,Vaya,Medicaid,LC,708.50,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,Vaya,Medicaid,LC,566.64,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,Vaya,Medicaid,LC,485.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,Vaya,Medicaid,LC,102.07,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,Vaya,Medicaid,,6724.39,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,Vaya,Medicaid,,12730.17,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,Vaya,Medicaid,,2351.30,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,Vaya,Medicaid,,587.88,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,Vaya,Medicaid,,118.56,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,Vaya,Medicaid,,829.13,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,Vaya,Medicaid,,681.28,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,Vaya,Medicaid,,266.00,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,Vaya,Medicaid,,322.29,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,Vaya,Medicaid,,238.57,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Vaya,Medicaid,,459.62,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,Vaya,Medicaid,,459.62,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,Vaya,Medicaid,,185.37,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Vaya,Medicaid,,149.70,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,Vaya,Medicaid,,149.70,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Vaya,Medicaid,,527.46,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,Vaya,Medicaid,,527.46,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,Vaya,Medicaid,,102.28,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,Vaya,Medicaid,,79.39,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,Vaya,Medicaid,,564.16,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,Vaya,Medicaid,,11.34,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,Vaya,Medicaid,,282.08,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,Vaya,Medicaid,,50.11,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,Vaya,Medicaid,,180.43,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,Vaya,Medicaid,,128.26,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,Vaya,Medicaid,,33.40,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,Vaya,Medicaid,,39.80,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,Vaya,Medicaid,,263.11,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,Vaya,Medicaid,,58.77,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,Vaya,Medicaid,,44.95,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,Vaya,Medicaid,,61.24,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,Vaya,Medicaid,,22.48,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,Vaya,Medicaid,,29.07,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,Vaya,Medicaid,,8.87,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,Vaya,Medicaid,,1340.09,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,Vaya,Medicaid,,747.27,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,Vaya,Medicaid,,1646.30,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,Vaya,Medicaid,,537.56,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Vaya,Medicaid,,435.29,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Vaya,Medicaid,,435.29,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,Vaya,Medicaid,,435.29,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,Vaya,Medicaid,,1314.53,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,Vaya,Medicaid,,1740.95,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,Vaya,Medicaid,,1954.16,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,Vaya,Medicaid,,1614.75,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,Vaya,Medicaid,,2092.72,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,Vaya,Medicaid,,2331.71,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Vaya,Medicaid,,98.98,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Vaya,Medicaid,,61.86,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,Vaya,Medicaid,,98.98,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,Vaya,Medicaid,,61.86,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,Vaya,Medicaid,,7.01,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,Vaya,Medicaid,,49.49,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,Vaya,Medicaid,,77.12,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,Vaya,Medicaid,,272.18,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,Vaya,Medicaid,,293.83,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,Vaya,Medicaid,,460.24,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,Vaya,Medicaid,,60.42,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,Vaya,Medicaid,,138.57,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,Vaya,Medicaid,,21.44,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,Vaya,Medicaid,,209.50,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,Vaya,Medicaid,,36.09,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,Vaya,Medicaid,,53.20,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,Vaya,Medicaid,,39.59,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,Vaya,Medicaid,,652.00,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,Vaya,Medicaid,,62.27,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,Vaya,Medicaid,,61.04,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,Vaya,Medicaid,,63.72,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,Vaya,Medicaid,,58.77,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,Vaya,Medicaid,,70.31,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,Vaya,Medicaid,,89.08,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,Vaya,Medicaid,,127.23,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,Vaya,Medicaid,,9.07,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,Vaya,Medicaid,,8.66,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,Vaya,Medicaid,,14.64,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,Vaya,Medicaid,,45.57,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,Vaya,Medicaid,,82.89,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,Vaya,Medicaid,,183.52,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,Vaya,Medicaid,,15.26,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,Vaya,Medicaid,,11.13,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,Vaya,Medicaid,,54.64,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,Vaya,Medicaid,,8.25,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,Vaya,Medicaid,,154.65,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,Vaya,Medicaid,,242.28,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Vaya,Medicaid,,826.86,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,Vaya,Medicaid,,252.39,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,Vaya,Medicaid,,369.92,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,Vaya,Medicaid,,467.87,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,Vaya,Medicaid,,101.45,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,Vaya,Medicaid,,826.86,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,Vaya,Medicaid,,144.34,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,Vaya,Medicaid,,160.84,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,Vaya,Medicaid,,18.56,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,Vaya,Medicaid,,329.51,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,Vaya,Medicaid,,529.73,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,Vaya,Medicaid,,103.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,Vaya,Medicaid,,824.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Vaya,Medicaid,,500.04,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Vaya,Medicaid,,371.16,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,Vaya,Medicaid,,500.04,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,Vaya,Medicaid,,371.16,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Vaya,Medicaid,,243.32,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,Vaya,Medicaid,,243.32,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,Vaya,Medicaid,,217.95,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,Vaya,Medicaid,GP,49.08,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Vaya,Medicaid,,6372.20,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Vaya,Medicaid,,3081.25,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,Vaya,Medicaid,,6372.20,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,Vaya,Medicaid,,3081.25,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,Vaya,Medicaid,,2677.92,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,Vaya,Medicaid,,2736.89,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,Vaya,Medicaid,,2796.07,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,Vaya,Medicaid,,2855.46,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,Vaya,Medicaid,,2914.64,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,Vaya,Medicaid,,2973.61,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,Vaya,Medicaid,,3032.79,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,Vaya,Medicaid,,3091.97,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,Vaya,Medicaid,,102.89,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,Vaya,Medicaid,,50.73,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,Vaya,Medicaid,,41.24,,,,,,,34.82,150.00,percent of total billed charges,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,72424.36,per diem,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,17993.19,per diem,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,17631.53,per diem,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,20121.94,per diem,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,36846.50,per diem,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,30149.18,per diem,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,26174.64,per diem,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,38889.05,per diem,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,20067.60,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,11560.09,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,26526.93,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,32701.43,per diem,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,823.98,,,,,,,823.98,16542.79,per diem,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,526.87,,,,,,,526.87,29019.22,per diem,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Managed Medicaid,,526.87,,,,,,,526.87,21489.89,per diem,
Inj Mdrxyprgestron Actat,PX-J1050,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,0.14000,0.08000,WellCare of North Carolina,Managed Medicaid,,0.02803,,,,,,,0.02803,1.47,percent of total billed charges,
HC Apligraf per Sq Cm,PX-56360001,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC Oasis Wound Matrix per Sq Cm,PX-56360002,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,25.00000,15.00000,WellCare of North Carolina,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC Dermagraft per Sq Cm,PX-56360003,CDM,636,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC Matristem Micromatrix 1 Mg,PX-56360006,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC Discarded Theraskin per Sq Cm,PX-56360009,CDM,250,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC Theraskin per Sq Cm,PX-56360010,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,WellCare of North Carolina,Managed Medicaid,,4.42,,,,,,,4.42,81.55,percent of total billed charges,
"Ondansetron Oral, 1 Mg",PX-Q0162,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
HC Discarded Dermagraft per Sq Cm,PX-56360013,CDM,250,RC,Q4106,HCPCS,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC Graft Jacket per Sq Cm,PX-56360016,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,142.00000,85.20000,WellCare of North Carolina,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC Graft Surgimend 20x30,PX-22780109,CDM,636,RC,C9360,HCPCS,,,facility,outpatient,,,39570.00000,23742.00000,WellCare of North Carolina,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC Matrix Wound Meshed Bilayer,PX-22780114,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,17004.00000,10202.40000,WellCare of North Carolina,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,WellCare of North Carolina,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC Graft Dural Mat Duragen Sut 1x3,PX-22780122,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,1919.00000,1151.40000,WellCare of North Carolina,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC Graft Dural Matrix Duragen Xs,PX-22780123,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,7252.00000,4351.20000,WellCare of North Carolina,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC Graft Matristem Micro Part 100mg,PX-22780124,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,1734.00000,1040.40000,WellCare of North Carolina,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC Graft Matristem Micro Part 200mg,PX-22780125,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,3295.00000,1977.00000,WellCare of North Carolina,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC Graft Matristem Tiss Matx 20x30c,PX-22780126,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,40220.00000,24132.00000,WellCare of North Carolina,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC Graft Matristem Tissue Matrix 8c,PX-22780127,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,12517.00000,7510.20000,WellCare of North Carolina,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC Graft Matristem3l Tissmatrix10x1,PX-22780128,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,11120.00000,6672.00000,WellCare of North Carolina,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC Graft Surgical Hernia Repair 12x15c,PX-22780129,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,15665.00000,9399.00000,WellCare of North Carolina,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC Graft Surgisis Hernia Rep 20x30c,PX-22780130,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,31578.00000,18946.80000,WellCare of North Carolina,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC Grft Dural Matrx Duragen Plus 1x,PX-22780131,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2639.00000,1583.40000,WellCare of North Carolina,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC Grft Matristem Tissue Matrix 6x1,PX-22780132,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,11117.00000,6670.20000,WellCare of North Carolina,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC Grft Matristem Tissue Matrix10x1,PX-22780133,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,16042.00000,9625.20000,WellCare of North Carolina,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC Enduragen Collagen 2cmx 5cmx1mm,PX-22780135,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,2696.00000,1617.60000,WellCare of North Carolina,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC Matristem Tissue Matrix 7cmx10,PX-22780136,CDM,636,RC,C1763,HCPCS,,,facility,outpatient,,,8366.00000,5019.60000,WellCare of North Carolina,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC Gft Arthroflex Human Derm 15x140,PX-22780141,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,8920.00000,5352.00000,WellCare of North Carolina,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC Gft Arthroflex Human Derm 40x70,PX-22780142,CDM,636,RC,C1781,HCPCS,,,facility,outpatient,,,11277.00000,6766.20000,WellCare of North Carolina,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC Discarded Apligraf per Sq Cm,PX-53610169,CDM,250,RC,Q4101,HCPCS,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Managed Medicaid,,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad,PX-56360032,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC Oasis Ultra Tri Layer Matrix 3x7 Cm Pad,PX-56360033,CDM,636,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
Cciiv4 Vaccine Preservative Free 0.5 Ml Im Use,PX-90674,CDM,636,RC,90674,HCPCS,,,facility,outpatient,,,31.28000,18.77000,WellCare of North Carolina,Managed Medicaid,,6.26,,,,,,,6.26,79.56,percent of total billed charges,
Influenza Vacc Iiv4 Split Virus Prsrv Free ID,PX-90630,CDM,636,RC,90630,HCPCS,,,facility,outpatient,,,20.34000,12.20000,WellCare of North Carolina,Managed Medicaid,,4.07,,,,,,,4.07,16.54,percent of total billed charges,
9vhpv Vacc 2/3 Dose Sched Im Use,PX-90651,CDM,636,RC,90651,HCPCS,,,facility,outpatient,,,278.96000,167.38000,WellCare of North Carolina,Managed Medicaid,,55.85,,,,,,,55.85,1004.55,percent of total billed charges,
Iiv4 Presrv Free Vacc Child 6-35 Mo for Im Use,PX-90685,CDM,636,RC,90685,HCPCS,,,facility,outpatient,,,21.64000,12.98000,WellCare of North Carolina,Managed Medicaid,,4.33,,,,,,,4.33,50.50,percent of total billed charges,
Inj testosterone cypionate,PX-J1071,CDM,636,RC,J1071,HCPCS,,,facility,outpatient,,,0.03000,0.02000,WellCare of North Carolina,Managed Medicaid,,0.00601,,,,,,,0.00601,0.08250,percent of total billed charges,
Iiv4 Vacc Presrv Free 6 Mos & Older Im Use,PX-90686,CDM,636,RC,90686,HCPCS,,,facility,outpatient,,,21.42000,12.85000,WellCare of North Carolina,Managed Medicaid,,4.29,,,,,,,4.29,52.16,percent of total billed charges,
Riv3 Vaccine Preservative Free for Im Use,PX-90673,CDM,636,RC,90673,HCPCS,,,facility,outpatient,,,40.61000,24.37000,WellCare of North Carolina,Managed Medicaid,,8.13,,,,,,,8.13,232.85,percent of total billed charges,
Iiv4 Vaccine Child 6-35 Mo for Im Use,PX-90687,CDM,636,RC,90687,HCPCS,,,facility,outpatient,,,20.37000,12.22000,WellCare of North Carolina,Managed Medicaid,,4.08,,,,,,,4.08,24.38,percent of total billed charges,
Iiv4 Vaccine 3 Yrs & Older for Im Use,PX-90688,CDM,636,RC,90688,HCPCS,,,facility,outpatient,,,19.90000,11.94000,WellCare of North Carolina,Managed Medicaid,,3.98,,,,,,,3.98,48.73,percent of total billed charges,
HC Discarded Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360056,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Managed Medicaid,,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC Discarded Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360058,CDM,250,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,54.65,238.43,percent of total billed charges,
Riv4 Vacc Recombinant Dna Prsrv Antibio Free Im,PX-90682,CDM,636,RC,90682,HCPCS,,,facility,outpatient,,,65.26000,39.16000,WellCare of North Carolina,Managed Medicaid,,13.07,,,,,,,13.07,170.51,percent of total billed charges,
Hzv Zoster Vacc Recombinant Adjuvanted Im Njx,PX-90750,CDM,250,RC,90750,HCPCS,,,facility,outpatient,,,178.21000,106.93000,WellCare of North Carolina,Managed Medicaid,,35.68,,,,,,,35.68,569.63,percent of total billed charges,
HC Seri Scaffold 250sqcm 10x25,PX-22780244,CDM,636,RC,Q4100,HCPCS,,,facility,outpatient,,,15495.00000,9297.00000,WellCare of North Carolina,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,WellCare of North Carolina,Managed Medicaid,,1.27,,,,,,,1.27,20.19,percent of total billed charges,
HC Nxstage Therapy Solution,PX-32500002,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,,,182.00000,109.20000,WellCare of North Carolina,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC Talymed per Sq Cm Used,PX-56360030,CDM,636,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC Discarded Talymed per Sq Cm,PX-56360031,CDM,250,RC,Q4127,HCPCS,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Managed Medicaid,,40.04,,,,,,,40.04,162.60,percent of total billed charges,
Cciiv4 Vaccine Antibiotic Free 0.5 Ml Dos Im Use,PX-90756,CDM,636,RC,90756,HCPCS,,,facility,outpatient,,,29.65000,17.79000,WellCare of North Carolina,Managed Medicaid,,5.94,,,,,,,5.94,75.38,percent of total billed charges,
HC Neox 1k 2.0x1.0cm per Sq Cm,PX-66360053,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,WellCare of North Carolina,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC Neox 1k 2.0x2.0cm per Sq Cm,PX-66360054,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,WellCare of North Carolina,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC Neox 1k 3.0x2.0cm per Sq Cm,PX-66360055,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,WellCare of North Carolina,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC Neox 1k 3.0x3.0cm per Sq Cm,PX-66360056,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC Neox 1k 4.0x3.0cm per Sq Cm,PX-66360057,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC Neox 1k 6.0x3.0cm per Sq Cm,PX-66360058,CDM,636,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,WellCare of North Carolina,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC Discarded Neox 1k 2.0x1.0cm per Sq Cm,PX-66360059,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1235.00000,741.00000,WellCare of North Carolina,Managed Medicaid,,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC Discarded Neox 1k 2.0x2.0cm per Sq Cm,PX-66360060,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,1048.00000,628.80000,WellCare of North Carolina,Managed Medicaid,,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC Discarded Neox 1k 3.0x2.0cm per Sq Cm,PX-66360061,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,707.00000,424.20000,WellCare of North Carolina,Managed Medicaid,,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC Discarded Neox 1k 3.0x3.0cm per Sq Cm,PX-66360062,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Managed Medicaid,,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC Discarded Neox 1k 4.0x3.0cm per Sq Cm,PX-66360063,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Managed Medicaid,,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC Discarded Neox 1k 6.0x3.0cm per Sq Cm,PX-66360064,CDM,250,RC,Q4148,HCPCS,,,facility,outpatient,,,466.00000,279.60000,WellCare of North Carolina,Managed Medicaid,,93.29,,,,,,,93.29,378.86,percent of total billed charges,
"Makena, 10 mg",PX-J1726,CDM,636,RC,J1726,HCPCS,,,facility,outpatient,,,27.47000,16.48000,WellCare of North Carolina,Managed Medicaid,,5.50,,,,,,,5.50,79.91,percent of total billed charges,
HC Primatrix 4sqcm 2x2 per Sq Cm,PX-56360091,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC Primatrix 16sqcm 4x4 per Sq Cm,PX-56360093,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,WellCare of North Carolina,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC Nushield Disc 1.6 per Sq Cm,PX-56361004,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,2469.00000,1481.40000,WellCare of North Carolina,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC Nushield 2x3 per Sq Cm,PX-56361006,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,WellCare of North Carolina,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Discarded Nushield 2x3 per Sq Cm,PX-56361007,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,698.00000,418.80000,WellCare of North Carolina,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC Nushield 2x4 per Sq Cm,PX-56361008,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Discarded Nushield 2x4 per Sq Cm,PX-56361009,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC Nushield 3x4 per Sq Cm,PX-56361010,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Discarded Nushield 3x4 per Sq Cm,PX-56361011,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC Nushield 4x6 per Sq Cm,PX-56361014,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Discarded Nushield 4x6 per Sq Cm,PX-56361015,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC Nushield 6x6 per Sq Cm,PX-56361016,CDM,636,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Nushield 6x6 per Sq Cm,PX-56361017,CDM,250,RC,Q4160,HCPCS,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC Discarded Primatrix 18mm Disc,PX-56361018,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,2363.00000,1417.80000,WellCare of North Carolina,Managed Medicaid,,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC Discarded Primatrix 2cmx2cm per Sq Cm,PX-56361019,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Managed Medicaid,,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC Discarded Primatrix 4cmx4cm per Sq Cm,PX-56361020,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,262.00000,157.20000,WellCare of North Carolina,Managed Medicaid,,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC Primatrix 3cmx3cm,PX-56361021,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,WellCare of North Carolina,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC Discarded Primatrix 3cmx3cm per Sq Cm,PX-56361022,CDM,250,RC,Q4110,HCPCS,,,facility,outpatient,,,313.00000,187.80000,WellCare of North Carolina,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC Amnioexcel 15mm Disc,PX-56361023,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,WellCare of North Carolina,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC Discarded Amnioexcel 15mm Disc per Cm,PX-56361024,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1575.00000,945.00000,WellCare of North Carolina,Managed Medicaid,,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361025,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,WellCare of North Carolina,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC Discarded Amnioexcel 1.5x1.5cm per Sq Cm,PX-56361026,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1252.00000,751.20000,WellCare of North Carolina,Managed Medicaid,,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC Amnioexcel 2x3cm per Sq Cm,PX-56361027,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,WellCare of North Carolina,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC Discarded Amnioexcel 2x3cm per Sq Cm,PX-56361028,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,641.00000,384.60000,WellCare of North Carolina,Managed Medicaid,,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361029,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,WellCare of North Carolina,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC Discarded Amnioexcel 3.5x3.5cm per Sq Cm,PX-56361030,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,340.00000,204.00000,WellCare of North Carolina,Managed Medicaid,,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC Amnioexcel 4x4cm per Sq Cm,PX-56361031,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,WellCare of North Carolina,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC Discarded Amnioexcel 4x4cm per Sq Cm,PX-56361032,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,272.00000,163.20000,WellCare of North Carolina,Managed Medicaid,,54.45,,,,,,,54.45,240.06,percent of total billed charges,
Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im,PX-90620,CDM,636,RC,90620,HCPCS,,,facility,outpatient,,,216.17000,129.70000,WellCare of North Carolina,Managed Medicaid,,43.28,,,,,,,43.28,774.28,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x7 Cm Pad per Sq Cm,PX-56360043,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Managed Medicaid,,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC Discarded Oasis Ultra Tri Layer Matrix 3x3.5 Cm Pad per Sq Cm,PX-56360044,CDM,250,RC,Q4124,HCPCS,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Managed Medicaid,,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC Integra Bilayer Matrix Wound Dressing 4sqcm 2x2 per Sq Cm,PX-66360038,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,5187.00000,3112.20000,WellCare of North Carolina,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
Dtap-Ipv-Hib-Hepb Vaccine Intramuscular,PX-90697,CDM,636,RC,90697,HCPCS,,,facility,outpatient,,,153.80000,92.28000,WellCare of North Carolina,Managed Medicaid,,30.79,,,,,,,30.79,509.36,percent of total billed charges,
HC Amnioexcel or Biodexcel 18mm Disk,PX-56361033,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2562.00000,1537.20000,WellCare of North Carolina,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC Puraply Am 4sqcm 2x2 per Sq Cm,PX-56360046,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC Puraply Am 8sqcm 2x4 per Sq Cm,PX-56360047,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC Puraply Am 25sqcm 5x5 per Sq Cm,PX-56360048,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
"Liletta, 52 mg",PX-J7297,CDM,636,RC,J7297,HCPCS,,,facility,outpatient,,,872.14000,523.28000,WellCare of North Carolina,Managed Medicaid,,174.60,,,,,,,174.60,3043.97,percent of total billed charges,
"Mirena, 52 mg",PX-J7298,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,1070.23000,642.14000,WellCare of North Carolina,Managed Medicaid,,214.26,,,,,,,214.26,3968.20,percent of total billed charges,
Gel-syn injection 0.1 mg,PX-J7328,CDM,636,RC,J7328,HCPCS,,,facility,outpatient,,,2.18000,1.31000,WellCare of North Carolina,Managed Medicaid,,0.43644,,,,,,,0.43644,1.77,percent of total billed charges,
HC Integra Bilayer Wound Matrix 20sqcm 4x5 per Sq Cm,PX-66360143,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,2078.00000,1246.80000,WellCare of North Carolina,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC Amnioexcel Plus 17mm Disc,PX-56360132,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,WellCare of North Carolina,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360133,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,WellCare of North Carolina,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360134,CDM,636,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,WellCare of North Carolina,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC Discarded Amnioexcel Plus 17mm Disc,PX-56360135,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,2754.00000,1652.40000,WellCare of North Carolina,Managed Medicaid,,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC Discarded Amnioexcel Plus 2cm X 2 Cm per Sq Cm,PX-56360136,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,1216.00000,729.60000,WellCare of North Carolina,Managed Medicaid,,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC Discarded Amnioexcel Plus 3cm X 3cm per Sq Cm,PX-56360137,CDM,250,RC,Q4137,HCPCS,,,facility,outpatient,,,616.00000,369.60000,WellCare of North Carolina,Managed Medicaid,,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC Puraply Am 1.6cm Disc,PX-56360138,CDM,636,RC,Q4196,HCPCS,,,facility,outpatient,,,2813.00000,1687.80000,WellCare of North Carolina,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,WellCare of North Carolina,Managed Medicaid,,0.62062,,,,,,,0.62062,9.29,percent of total billed charges,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,WellCare of North Carolina,Managed Medicaid,,1.97,,,,,,,1.97,33.47,percent of total billed charges,
Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use,PX-90619,CDM,250,RC,90619,HCPCS,,,facility,outpatient,,,192.61000,115.57000,WellCare of North Carolina,Managed Medicaid,,38.56,,,,,,,38.56,454.56,percent of total billed charges,
Aiiv4 Vacc Inactivated Prsrv Fr 0.5ml Dos Im Use,PX-90694,CDM,636,RC,90694,HCPCS,,,facility,outpatient,,,66.43000,39.86000,WellCare of North Carolina,Managed Medicaid,,13.30,,,,,,,13.30,179.69,percent of total billed charges,
HC Theraskin 7.6cm X 15.2cm per Sq Cm,PX-56360149,CDM,636,RC,Q4121,HCPCS,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
Sarscov2 Vaccine Dil Recon 30 Mcg/0.3 Ml Im Use,PX-91300,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 100 Mcg/0.5 Ml Im Use,PX-91301,CDM,636,RC,91301,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine Chadox1 5x1010 Vp/0.5ml Im Use,PX-91302,CDM,636,RC,91302,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 50 Mcg/0.25 Ml Im Use,PX-91306,CDM,636,RC,91306,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 10mcg/0.2ml Tris-Sucrose Im Use,PX-91307,CDM,636,RC,91307,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Pcv15 Vaccine for Intramuscular Use,PX-90671,CDM,636,RC,90671,HCPCS,,,facility,outpatient,,,237.69000,142.61000,WellCare of North Carolina,Managed Medicaid,,47.59,,,,,,,47.59,728.32,percent of total billed charges,
Pcv20 Vaccine for Intramuscular Use,PX-90677,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,273.90000,164.34000,WellCare of North Carolina,Managed Medicaid,,54.83,,,,,,,54.83,872.64,percent of total billed charges,
Sarscov2 Vacc Saponin-Bsd Adjt 5mcg/0.5ml Im Use,PX-91304,CDM,636,RC,91304,HCPCS,,,facility,outpatient,,,158.70000,95.22000,WellCare of North Carolina,Managed Medicaid,,31.77,,,,,,,31.77,450.52,percent of total billed charges,
HC Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360193,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,WellCare of North Carolina,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC Discarded Allopatch 4 Cm X 4 Cm per Sq Cm,PX-56360200,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,342.00000,205.20000,WellCare of North Carolina,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
Sarscov2 Vaccine 30mcg/0.3ml Tris-Sucrose Im Use,PX-91305,CDM,636,RC,91305,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
Sarscov2 Vaccine 3mcg/0.2ml Tris-Sucrose Im Use,PX-91308,CDM,636,RC,91308,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC Grafix Pl 1.5x2 per Sq Cm,PX-56360225,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,WellCare of North Carolina,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC Grafix Pl 16 Mm Disc,PX-56360226,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,3094.00000,1856.40000,WellCare of North Carolina,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC Discarded Grafix Pl 1.5x2 per Sq Cm,PX-56360229,CDM,250,RC,Q4133,HCPCS,,,facility,outpatient,,,1546.00000,927.60000,WellCare of North Carolina,Managed Medicaid,,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
Rsv Vaccine Pref Subunit Bivalent for Im Use,PX-90678,CDM,636,RC,90678,HCPCS,,,facility,outpatient,,,330.40000,198.24000,WellCare of North Carolina,Managed Medicaid,,66.15,,,,,,,66.15,1002.31,percent of total billed charges,
"Inj, bupivacaine, nos, 0.5mg",PX-J0665,CDM,636,RC,J0665,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.03300,percent of total billed charges,
Rsv Vacc Pref Recombinant Adjuvanted for Im Use,PX-90679,CDM,636,RC,90679,HCPCS,,,facility,outpatient,,,329.28000,197.57000,WellCare of North Carolina,Managed Medicaid,,65.92,,,,,,,65.92,1000.84,percent of total billed charges,
Sarscv2 Vac 30mcg Trs-Suc Im,PX-91320,CDM,636,RC,91320,HCPCS,,,facility,outpatient,,,153.16000,91.90000,WellCare of North Carolina,Managed Medicaid,,30.66,,,,,,,30.66,434.78,percent of total billed charges,
Sarscov2 Vac 50 Mcg/0.5ml Im,PX-91322,CDM,636,RC,91322,HCPCS,,,facility,outpatient,,,158.82000,95.29000,WellCare of North Carolina,Managed Medicaid,,31.80,,,,,,,31.80,450.83,percent of total billed charges,
HC Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360238,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,WellCare of North Carolina,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC Discarded Allopatch 1.5 Cm X 1.5 Cm per Sq Cm,PX-56360239,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,428.00000,256.80000,WellCare of North Carolina,Managed Medicaid,,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360240,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC Discarded Allopatch 2 Cm X 2 Cm per Sq Cm,PX-56360241,CDM,250,RC,Q4128,HCPCS,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC Matristem Micromatrix 1000mg per 1 Mg,PX-56360248,CDM,636,RC,Q4118,HCPCS,,,facility,outpatient,,,10.00000,6.00000,WellCare of North Carolina,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,WellCare of North Carolina,Managed Medicaid,,0.02402,,,,,,,0.02402,0.28320,percent of total billed charges,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,WellCare of North Carolina,Managed Medicaid,,0.05405,,,,,,,0.05405,0.49560,percent of total billed charges,
HC Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360274,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,WellCare of North Carolina,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC Discarded Cygnus Dual 6 Sq Cm 2 X 3 per Sq Cm,PX-56360275,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2498.00000,1498.80000,WellCare of North Carolina,Managed Medicaid,,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360276,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,WellCare of North Carolina,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC Discarded Cygnus Dual 16 Sq Cm 4 X 4 per Sq Cm,PX-56360277,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,2025.00000,1215.00000,WellCare of North Carolina,Managed Medicaid,,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360278,CDM,636,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,WellCare of North Carolina,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC Discarded Cygnus Dual 24 Sq Cm 4 X 6 per Sq Cm,PX-56360279,CDM,250,RC,Q4282,HCPCS,,,facility,outpatient,,,1708.00000,1024.80000,WellCare of North Carolina,Managed Medicaid,,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
"Inj, lidocaine hcl, 1 mg",PX-J2003,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.16500,percent of total billed charges,
PR Pcv21 Vaccine Im,PX-90684,CDM,636,RC,90684,HCPCS,,,facility,outpatient,,,322.28000,193.37000,WellCare of North Carolina,Managed Medicaid,,64.52,,,,,,,64.52,914.46,percent of total billed charges,
HC Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360310,CDM,636,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC Discarded Oasis Wound Matrix 11 Sq Cm 3 X 3.5 per Sq Cm,PX-56360311,CDM,250,RC,Q4102,HCPCS,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,13.01,52.84,percent of total billed charges,
Hepa Vaccine Adult Dose for Intramuscular Use,PX-90632,CDM,636,RC,90632,HCPCS,,,facility,outpatient,,,81.13000,48.68000,WellCare of North Carolina,Managed Medicaid,,16.24,,,,,,,16.24,221.32,percent of total billed charges,
Hepa Vaccine 2 Dose Schedule Ped/Adolesc Im Use,PX-90633,CDM,636,RC,90633,HCPCS,,,facility,outpatient,,,53.52000,32.11000,WellCare of North Carolina,Managed Medicaid,,10.71,,,,,,,10.71,115.22,percent of total billed charges,
Hepa/Hepb Vaccine Adult Im,PX-90636,CDM,636,RC,90636,HCPCS,,,facility,outpatient,,,126.03000,75.62000,WellCare of North Carolina,Managed Medicaid,,25.23,,,,,,,25.23,431.84,percent of total billed charges,
Hib Prp-Omp Vaccine 3 Dose Schedule Im Use,PX-90647,CDM,636,RC,90647,HCPCS,,,facility,outpatient,,,30.86000,18.52000,WellCare of North Carolina,Managed Medicaid,,6.18,,,,,,,6.18,99.48,percent of total billed charges,
Hib Prp-T Vaccine 4 Dose Schedule Im Use,PX-90648,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,16.63000,9.98000,WellCare of North Carolina,Managed Medicaid,,3.33,,,,,,,3.33,42.98,percent of total billed charges,
Dtap-Ipv/Hib Vaccine for Intramuscular Use,PX-90698,CDM,636,RC,90698,HCPCS,,,facility,outpatient,,,116.79000,70.07000,WellCare of North Carolina,Managed Medicaid,,23.38,,,,,,,23.38,367.50,percent of total billed charges,
"Dtap Vaccine, Im",PX-90700,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,33.65000,20.19000,WellCare of North Carolina,Managed Medicaid,,6.74,,,,,,,6.74,97.20,percent of total billed charges,
"Mmr Vaccine, Subq",PX-90707,CDM,636,RC,90707,HCPCS,,,facility,outpatient,,,96.04000,57.62000,WellCare of North Carolina,Managed Medicaid,,19.23,,,,,,,19.23,309.79,percent of total billed charges,
"Mmrv Vaccine, Subq",PX-90710,CDM,636,RC,90710,HCPCS,,,facility,outpatient,,,275.02000,165.01000,WellCare of North Carolina,Managed Medicaid,,55.06,,,,,,,55.06,907.10,percent of total billed charges,
"Poliovirus, Ipv, Subq",PX-90713,CDM,636,RC,90713,HCPCS,,,facility,outpatient,,,42.62000,25.57000,WellCare of North Carolina,Managed Medicaid,,8.53,,,,,,,8.53,145.73,percent of total billed charges,
Tdap Vacc Ind 7 Years/Older Im,PX-90715,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,51.42000,30.85000,WellCare of North Carolina,Managed Medicaid,,10.29,,,,,,,10.29,128.86,percent of total billed charges,
Var Vaccine Live for Subcutaneous Use,PX-90716,CDM,636,RC,90716,HCPCS,,,facility,outpatient,,,166.08000,99.65000,WellCare of North Carolina,Managed Medicaid,,33.25,,,,,,,33.25,597.45,percent of total billed charges,
Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use,PX-90732,CDM,636,RC,90732,HCPCS,,,facility,outpatient,,,128.79000,77.27000,WellCare of North Carolina,Managed Medicaid,,25.78,,,,,,,25.78,372.23,percent of total billed charges,
Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use,PX-90734,CDM,636,RC,90734,HCPCS,,,facility,outpatient,,,154.18000,92.51000,WellCare of North Carolina,Managed Medicaid,,30.87,,,,,,,30.87,544.37,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 3 Dose Im,PX-90740,CDM,636,RC,90740,HCPCS,,,facility,outpatient,,,146.33000,87.80000,WellCare of North Carolina,Managed Medicaid,,29.30,,,,,,,29.30,518.30,percent of total billed charges,
Hepb Vaccine Adolescent 2 Dose Schedule Im,PX-90743,CDM,636,RC,90743,HCPCS,,,facility,outpatient,,,26.14000,15.68000,WellCare of North Carolina,Managed Medicaid,,5.23,,,,,,,5.23,209.59,percent of total billed charges,
Hepb Vaccine Ped/Adolesc 3 Dose Schedule Im,PX-90744,CDM,636,RC,90744,HCPCS,,,facility,outpatient,,,28.56000,17.14000,WellCare of North Carolina,Managed Medicaid,,5.72,,,,,,,5.72,88.33,percent of total billed charges,
Hepb Vaccine Adult 3 Dose Schedule for Im Use,PX-90746,CDM,636,RC,90746,HCPCS,,,facility,outpatient,,,68.05000,40.83000,WellCare of North Carolina,Managed Medicaid,,13.62,,,,,,,13.62,196.28,percent of total billed charges,
Hepb Vaccine Dialysis/Immunsup Pat 4 Dose Im,PX-90747,CDM,636,RC,90747,HCPCS,,,facility,outpatient,,,140.75000,84.45000,WellCare of North Carolina,Managed Medicaid,,28.18,,,,,,,28.18,392.53,percent of total billed charges,
Injection Ceftriaxone Sodium,PX-J0696,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,0.51000,0.31000,WellCare of North Carolina,Managed Medicaid,,0.10210,,,,,,,0.10210,1.30,percent of total billed charges,
Inj Clonidine Hydrochlorid 1,PX-J0735,CDM,636,RC,J0735,HCPCS,,,facility,outpatient,,,26.23000,15.74000,WellCare of North Carolina,Managed Medicaid,,5.25,,,,,,,5.25,48.11,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1030,CDM,636,RC,J1030,HCPCS,,,facility,outpatient,,,5.92000,3.55000,WellCare of North Carolina,Managed Medicaid,,1.19,,,,,,,1.19,4.81,percent of total billed charges,
Inj Methylprdnisolone Actat,PX-J1040,CDM,250,RC,J1040,HCPCS,,,facility,outpatient,,,10.52000,6.31000,WellCare of North Carolina,Managed Medicaid,,2.11,,,,,,,2.11,8.55,percent of total billed charges,
Inj Dexethosone Sodim Phosha,PX-J1100,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,0.11000,0.07000,WellCare of North Carolina,Managed Medicaid,,0.02202,,,,,,,0.02202,0.33000,percent of total billed charges,
Inj Diphenhydramine Hcl,PX-J1200,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,0.80000,0.48000,WellCare of North Carolina,Managed Medicaid,,0.16016,,,,,,,0.16016,2.46,percent of total billed charges,
Inj Haloperidol Decanoate,PX-J1631,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,7.76000,4.66000,WellCare of North Carolina,Managed Medicaid,,1.55,,,,,,,1.55,12.74,percent of total billed charges,
Injection Enoxaparin Sodium,PX-J1650,CDM,636,RC,J1650,HCPCS,,,facility,outpatient,,,0.79000,0.47000,WellCare of North Carolina,Managed Medicaid,,0.15816,,,,,,,0.15816,1.55,percent of total billed charges,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,WellCare of North Carolina,Managed Medicaid,,0.09409,,,,,,,0.09409,0.95700,percent of total billed charges,
Injection Furosemide,PX-J1940,CDM,636,RC,J1940,HCPCS,,,facility,outpatient,,,0.64000,0.38000,WellCare of North Carolina,Managed Medicaid,,0.12813,,,,,,,0.12813,0.52032,percent of total billed charges,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,WellCare of North Carolina,Managed Medicaid,,333.69,,,,,,,333.69,4844.60,percent of total billed charges,
Injection Lido Hcl IV Infusion,PX-J2001,CDM,636,RC,J2001,HCPCS,,,facility,outpatient,,,0.02000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00400,,,,,,,0.00400,0.01626,percent of total billed charges,
Injection Ondansetron Hcl,PX-J2405,CDM,250,RC,J2405,HCPCS,,,facility,outpatient,,,0.09000,0.05000,WellCare of North Carolina,Managed Medicaid,,0.01802,,,,,,,0.01802,1.94,percent of total billed charges,
Injection Promethazine Hcl,PX-J2550,CDM,250,RC,J2550,HCPCS,,,facility,outpatient,,,2.57000,1.54000,WellCare of North Carolina,Managed Medicaid,,0.51451,,,,,,,0.51451,6.96,percent of total billed charges,
Inj Rho D Ig Humn Minidose,PX-J2788,CDM,636,RC,J2788,HCPCS,,,facility,outpatient,,,25.77000,15.46000,WellCare of North Carolina,Managed Medicaid,,5.16,,,,,,,5.16,75.85,percent of total billed charges,
Inj Rho D Ig Humn Full Dose,PX-J2790,CDM,636,RC,J2790,HCPCS,,,facility,outpatient,,,81.46000,48.88000,WellCare of North Carolina,Managed Medicaid,,16.31,,,,,,,16.31,224.38,percent of total billed charges,
Inj Ropivacaine Hydrochlorid,PX-J2795,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,0.07000,0.04000,WellCare of North Carolina,Managed Medicaid,,0.01401,,,,,,,0.01401,0.16500,percent of total billed charges,
Inj Methylprdnisolon Sodim,PX-J2920,CDM,636,RC,J2920,HCPCS,,,facility,outpatient,,,4.25000,2.55000,WellCare of North Carolina,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
Inj Methylprdnisln Sodim,PX-J2930,CDM,636,RC,J2930,HCPCS,,,facility,outpatient,,,6.12000,3.67000,WellCare of North Carolina,Managed Medicaid,,1.23,,,,,,,1.23,4.98,percent of total billed charges,
Inj Triamcinolone Acetonide,PX-J3301,CDM,636,RC,J3301,HCPCS,,,facility,outpatient,,,1.12000,0.67000,WellCare of North Carolina,Managed Medicaid,,0.22422,,,,,,,0.22422,2.34,percent of total billed charges,
Inj Vit B-12 Cynocoblmn,PX-J3420,CDM,636,RC,J3420,HCPCS,,,facility,outpatient,,,1.61000,0.97000,WellCare of North Carolina,Managed Medicaid,,0.32232,,,,,,,0.32232,2.59,percent of total billed charges,
Infus Normal Saline Sol 1000,PX-J7030,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,2.56000,1.54000,WellCare of North Carolina,Managed Medicaid,,0.51251,,,,,,,0.51251,6.20,percent of total billed charges,
Sugar Solution,PX-J7060,CDM,636,RC,J7060,HCPCS,,,facility,outpatient,,,1.79000,1.07000,WellCare of North Carolina,Managed Medicaid,,0.35836,,,,,,,0.35836,5.53,percent of total billed charges,
Ipratropium Bromide Inhal Sol,PX-J7644,CDM,636,RC,J7644,HCPCS,,,facility,outpatient,,,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.06,percent of total billed charges,
Diphenhydramine Hcl 50 Mg Oral,PX-Q0163,CDM,636,RC,Q0163,HCPCS,,,facility,outpatient,,,0.02000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00400,,,,,,,0.00400,3.60,percent of total billed charges,
Iiv3 Vacc Preservative Free Im Use,PX-90656,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,22.10000,13.26000,WellCare of North Carolina,Managed Medicaid,,4.42,,,,,,,4.42,62.32,percent of total billed charges,
Etonogestrel Cntracpt Impl Sys,PX-J7307,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,1100.73000,660.44000,WellCare of North Carolina,Managed Medicaid,,220.37,,,,,,,220.37,3968.20,percent of total billed charges,
Hyalgan supartz visco-3 dose,PX-J7321,CDM,636,RC,J7321,HCPCS,,,facility,outpatient,,,77.03000,46.22000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,15.42,199.80,percent of total billed charges,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,WellCare of North Carolina,Managed Medicaid,,27.01,,,,,,,27.01,319.27,percent of total billed charges,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,WellCare of North Carolina,Managed Medicaid,,33.32,,,,,,,33.32,272.48,percent of total billed charges,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,18.64,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7620,CDM,636,RC,J7620,HCPCS,,,facility,outpatient,,,0.13000,0.08000,WellCare of North Carolina,Managed Medicaid,,0.02603,,,,,,,0.02603,0.54450,percent of total billed charges,
Cciiv3 Vac Abx Fr 0.5 Ml Im,PX-90661,CDM,636,RC,90661,HCPCS,,,facility,outpatient,,,36.34000,21.80000,WellCare of North Carolina,Managed Medicaid,,7.28,,,,,,,7.28,115.07,percent of total billed charges,
Iiv Vaccine Preserv Free Increased Ag Count Im,PX-90662,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,65.26000,39.16000,WellCare of North Carolina,Managed Medicaid,,13.07,,,,,,,13.07,232.85,percent of total billed charges,
Rv1 Vaccine 2 Dose Schedule Live for Oral Use,PX-90681,CDM,636,RC,90681,HCPCS,,,facility,outpatient,,,143.90000,86.34000,WellCare of North Carolina,Managed Medicaid,,28.81,,,,,,,28.81,479.90,percent of total billed charges,
Dtap-Ipv Vaccine Child 4-6 Yrs for Im Use,PX-90696,CDM,636,RC,90696,HCPCS,,,facility,outpatient,,,63.57000,38.14000,WellCare of North Carolina,Managed Medicaid,,12.73,,,,,,,12.73,208.49,percent of total billed charges,
Pcv13 Vaccine for Intramuscular Use,PX-90670,CDM,636,RC,90670,HCPCS,,,facility,outpatient,,,249.07000,149.44000,WellCare of North Carolina,Managed Medicaid,,49.86,,,,,,,49.86,719.50,percent of total billed charges,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,WellCare of North Carolina,Managed Medicaid,,2.25,,,,,,,2.25,25.35,percent of total billed charges,
Azithromycin Oral Cap/Powder,PX-Q0144,CDM,636,RC,Q0144,HCPCS,,,facility,outpatient,,,25.48000,15.29000,WellCare of North Carolina,Managed Medicaid,,5.10,,,,,,,5.10,53.27,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7611,CDM,636,RC,J7611,HCPCS,,,facility,outpatient,,,0.75000,0.45000,WellCare of North Carolina,Managed Medicaid,,0.15015,,,,,,,0.15015,0.55665,percent of total billed charges,
Breathing Inhalation Medicine,PX-J7613,CDM,636,RC,J7613,HCPCS,,,facility,outpatient,,,0.04000,0.02000,WellCare of North Carolina,Managed Medicaid,,0.00801,,,,,,,0.00801,0.21450,percent of total billed charges,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,WellCare of North Carolina,Managed Medicaid,,3.03,,,,,,,3.03,70.82,percent of total billed charges,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,WellCare of North Carolina,Managed Medicaid,,2.67,,,,,,,2.67,42.05,percent of total billed charges,
Flu Vaccine Shot,PX-Q2035,CDM,636,RC,Q2035,HCPCS,,,facility,outpatient,,,11.89000,7.13000,WellCare of North Carolina,Managed Medicaid,,2.38,,,,,,,2.38,71.79,percent of total billed charges,
Flu Vaccination,PX-Q2037,CDM,636,RC,Q2037,HCPCS,,,facility,outpatient,,,17.69000,10.61000,WellCare of North Carolina,Managed Medicaid,,3.54,,,,,,,3.54,41.35,percent of total billed charges,
Td Vaccine Prsrv Free 7 Yrs or Older for Im Use,PX-90714,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,33.35000,20.01000,WellCare of North Carolina,Managed Medicaid,,6.68,,,,,,,6.68,111.68,percent of total billed charges,
Iiv Adjuvanted Vaccine for Intramuscular Use,PX-90653,CDM,636,RC,90653,HCPCS,,,facility,outpatient,,,54.96000,32.98000,WellCare of North Carolina,Managed Medicaid,,11.00,,,,,,,11.00,232.85,percent of total billed charges,
Hepb Vaccine Adult 2/4 Dose Schedule for Im Use,PX-90739,CDM,636,RC,90739,HCPCS,,,facility,outpatient,,,139.15000,83.49000,WellCare of North Carolina,Managed Medicaid,,27.86,,,,,,,27.86,495.21,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,63323010425,NDC,facility,outpatient,25,ML,548.70000,329.22000,WellCare of North Carolina,Managed Medicaid,,109.85,,,,,,,2.22,407.25,percent of total billed charges,
ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION,RX-10000,CDM,636,RC,J9181,HCPCS,68001026525,NDC,facility,outpatient,5,ML,316.25000,189.75000,WellCare of North Carolina,Managed Medicaid,,63.31,,,,,,,2.22,234.72,percent of total billed charges,
ETOPOSIDE 50 MG CAPSULE,RX-10001,CDM,636,RC,J8560,HCPCS,00378326694,NDC,facility,outpatient,1,UN,371.25000,222.75000,WellCare of North Carolina,Managed Medicaid,,74.32,,,,,,,74.32,275.54,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,WellCare of North Carolina,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,63323073809,NDC,facility,outpatient,1,ML,64.90000,38.94000,WellCare of North Carolina,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-10009,CDM,636,RC,J1308,HCPCS,67457045720,NDC,facility,outpatient,1,ML,64.90000,38.94000,WellCare of North Carolina,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION,RX-10010,CDM,250,RC,J3490,HCPCS,68180015001,NDC,facility,outpatient,50,ML,47.50000,28.50000,WellCare of North Carolina,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
FAMOTIDINE 20 MG TABLET,RX-10011,CDM,250,RC,J3490,HCPCS,51079096620,NDC,facility,outpatient,1,UN,1.20000,0.72000,WellCare of North Carolina,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,WellCare of North Carolina,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,WellCare of North Carolina,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
FINASTERIDE 5 MG TABLET,RX-10037,CDM,250,RC,J3490,HCPCS,31722052590,NDC,facility,outpatient,1,UN,16.55000,9.93000,WellCare of North Carolina,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
FLECAINIDE 100 MG TABLET,RX-10041,CDM,250,RC,J3490,HCPCS,00054001121,NDC,facility,outpatient,1,UN,19.80000,11.88000,WellCare of North Carolina,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
FLECAINIDE 50 MG TABLET,RX-10043,CDM,250,RC,J3490,HCPCS,00054001025,NDC,facility,outpatient,1,UN,18.30000,10.98000,WellCare of North Carolina,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
FLUCONAZOLE 100 MG TABLET,RX-10044,CDM,250,RC,J3490,HCPCS,68462010230,NDC,facility,outpatient,1,UN,20.00000,12.00000,WellCare of North Carolina,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
FLUCONAZOLE 200 MG TABLET,RX-10045,CDM,250,RC,J3490,HCPCS,68462010430,NDC,facility,outpatient,1,UN,21.35000,12.81000,WellCare of North Carolina,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK,RX-10049,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,100,ML,128.45000,77.07000,WellCare of North Carolina,Managed Medicaid,,25.72,,,,,,,5.33,95.34,percent of total billed charges,
"EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR",RX-100491,CDM,636,RC,J0165,HCPCS,09999010609,NDC,facility,outpatient,1,ML,84.10000,50.46000,WellCare of North Carolina,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
FLUCYTOSINE 250 MG CAPSULE,RX-10051,CDM,250,RC,J3490,HCPCS,00904683407,NDC,facility,outpatient,1,UN,350.70000,210.42000,WellCare of North Carolina,Managed Medicaid,,70.21,,,,,,,70.21,285.12,percent of total billed charges,
FLUCYTOSINE 500 MG CAPSULE,RX-10052,CDM,250,RC,J3490,HCPCS,42494034001,NDC,facility,outpatient,1,UN,385.55000,231.33000,WellCare of North Carolina,Managed Medicaid,,77.19,,,,,,,77.19,313.45,percent of total billed charges,
FLUDROCORTISONE 0.1 MG TABLET,RX-10054,CDM,250,RC,J3490,HCPCS,68084028811,NDC,facility,outpatient,1,UN,19.40000,11.64000,WellCare of North Carolina,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,WellCare of North Carolina,Managed Medicaid,,709.51,,,,,,,1.82,2630.36,percent of total billed charges,
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION,RX-10059,CDM,636,RC,A9612,HCPCS,00065009265,NDC,facility,outpatient,5,ML,304.25000,182.55000,WellCare of North Carolina,Managed Medicaid,,60.91,,,,,,,0.89680,247.36,percent of total billed charges,
FLUORESCEIN 0.25 %-PROPARACAINE 0.5 % EYE DROPS,RX-10062,CDM,250,RC,J3490,HCPCS,59390020505,NDC,facility,outpatient,5,ML,43.45000,26.07000,WellCare of North Carolina,Managed Medicaid,,8.70,,,,,,,8.70,35.32,percent of total billed charges,
FLUOXETINE 10 MG CAPSULE,RX-10069,CDM,250,RC,J3490,HCPCS,68001039900,NDC,facility,outpatient,1,UN,16.25000,9.75000,WellCare of North Carolina,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
FLUOXETINE 20 MG CAPSULE,RX-10070,CDM,250,RC,J3490,HCPCS,68001040008,NDC,facility,outpatient,1,UN,16.20000,9.72000,WellCare of North Carolina,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,WellCare of North Carolina,Managed Medicaid,,483.34,,,,,,,167.14,1791.89,percent of total billed charges,
FLUVOXAMINE 50 MG TABLET,RX-10085,CDM,250,RC,J3490,HCPCS,51079099220,NDC,facility,outpatient,1,UN,18.05000,10.83000,WellCare of North Carolina,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
ACETAMINOPHEN 325 MG TABLET,RX-101,CDM,250,RC,J3490,HCPCS,00904677361,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION,RX-10101,CDM,636,RC,J1570,HCPCS,63323031510,NDC,facility,outpatient,1,UN,471.55000,282.93000,WellCare of North Carolina,Managed Medicaid,,94.40,,,,,,,93.31,349.98,percent of total billed charges,
GLIPIZIDE 10 MG TABLET,RX-10116,CDM,250,RC,J3490,HCPCS,51079081101,NDC,facility,outpatient,1,UN,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
GLIPIZIDE 5 MG TABLET,RX-10117,CDM,250,RC,J3490,HCPCS,51079081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
GLYBURIDE 2.5 MG TABLET,RX-10126,CDM,250,RC,J3490,HCPCS,00093943301,NDC,facility,outpatient,1,UN,16.85000,10.11000,WellCare of North Carolina,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GLYCOPYRROLATE 1 MG TABLET,RX-10130,CDM,250,RC,J3490,HCPCS,16571074309,NDC,facility,outpatient,1,UN,16.55000,9.93000,WellCare of North Carolina,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,WellCare of North Carolina,Managed Medicaid,,1045.12,,,,,,,711.66,3874.58,percent of total billed charges,
GUANFACINE 1 MG TABLET,RX-10149,CDM,250,RC,J3490,HCPCS,00591044401,NDC,facility,outpatient,1,UN,16.85000,10.11000,WellCare of North Carolina,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION,RX-10163,CDM,636,RC,J1631,HCPCS,63323046901,NDC,facility,outpatient,0.5,ML,79.90000,47.94000,WellCare of North Carolina,Managed Medicaid,,16.00,,,,,,,10.38,59.30,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,63323054013,NDC,facility,outpatient,1,ML,33.65000,20.19000,WellCare of North Carolina,Managed Medicaid,,6.74,,,,,,,0.49560,24.98,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,67457038510,NDC,facility,outpatient,10,ML,34.85000,20.91000,WellCare of North Carolina,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30,ML,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,,9.41,,,,,,,0.49560,34.88,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,25021040210,NDC,facility,outpatient,1,ML,19.85000,11.91000,WellCare of North Carolina,Managed Medicaid,,3.97,,,,,,,0.49560,14.73,percent of total billed charges,
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,636,RC,J1644,HCPCS,00409272330,NDC,facility,outpatient,1,ML,25.20000,15.12000,WellCare of North Carolina,Managed Medicaid,,5.05,,,,,,,0.49560,18.70,percent of total billed charges,
ACETAMINOPHEN 500 MG TABLET,RX-102,CDM,250,RC,J3490,HCPCS,57896022110,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
HYDROCORTISONE 100 MG/60 ML ENEMA,RX-10210,CDM,250,RC,J3490,HCPCS,62559013807,NDC,facility,outpatient,60,ML,80.30000,48.18000,WellCare of North Carolina,Managed Medicaid,,16.08,,,,,,,16.08,65.28,percent of total billed charges,
HYDROMORPHONE 1 MG/ML ORAL LIQUID,RX-10225,CDM,250,RC,J3490,HCPCS,99999000752,NDC,facility,outpatient,4,ML,32.40000,19.44000,WellCare of North Carolina,Managed Medicaid,,6.49,,,,,,,6.49,26.34,percent of total billed charges,
HYDROXYCHLOROQUINE 200 MG TABLET,RX-10235,CDM,250,RC,J3490,HCPCS,68084026911,NDC,facility,outpatient,1,UN,23.80000,14.28000,WellCare of North Carolina,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
HYDROXYUREA 500 MG CAPSULE,RX-10236,CDM,250,RC,J3490,HCPCS,68084028411,NDC,facility,outpatient,1,UN,28.70000,17.22000,WellCare of North Carolina,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION,RX-10246,CDM,250,RC,J3490,HCPCS,68094049459,NDC,facility,outpatient,5,ML,2.25000,1.35000,WellCare of North Carolina,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION,RX-10248,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1,UN,436.70000,262.02000,WellCare of North Carolina,Managed Medicaid,,87.43,,,,,,,59.47,324.12,percent of total billed charges,
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION,RX-10249,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,outpatient,1,UN,748.20000,448.92000,WellCare of North Carolina,Managed Medicaid,,149.79,,,,,,,59.47,555.31,percent of total billed charges,
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION,RX-10267,CDM,250,RC,J3490,HCPCS,63323065903,NDC,facility,outpatient,1,UN,2284.55000,1370.73000,WellCare of North Carolina,Managed Medicaid,,457.37,,,,,,,457.37,1857.34,percent of total billed charges,
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION,RX-10284,CDM,636,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,10,ML,219.00000,131.40000,WellCare of North Carolina,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP,RX-10286,CDM,636,RC,J1815,HCPCS,00002871501,NDC,facility,outpatient,10,ML,219.00000,131.40000,WellCare of North Carolina,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION,RX-10289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,WellCare of North Carolina,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY,RX-103,CDM,250,RC,J3490,HCPCS,45802073230,NDC,facility,outpatient,1,UN,1.50000,0.90000,WellCare of North Carolina,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
IOHEXOL 240 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10321,CDM,254,RC,Q9966,HCPCS,00407141230,NDC,facility,outpatient,50,ML,49.45000,29.67000,WellCare of North Carolina,Managed Medicaid,,9.90,,,,,,,1.06,40.20,percent of total billed charges,
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION,RX-10322,CDM,254,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,50,ML,57.55000,34.53000,WellCare of North Carolina,Managed Medicaid,,11.52,,,,,,,0.35400,46.79,percent of total billed charges,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,WellCare of North Carolina,Managed Medicaid,,113.81,,,,,,,6.49,421.94,percent of total billed charges,
ISRADIPINE 2.5 MG CAPSULE,RX-10362,CDM,250,RC,J3490,HCPCS,16252053901,NDC,facility,outpatient,1,UN,21.80000,13.08000,WellCare of North Carolina,Managed Medicaid,,4.36,,,,,,,4.36,17.72,percent of total billed charges,
ITRACONAZOLE 100 MG CAPSULE,RX-10364,CDM,250,RC,J3490,HCPCS,50268045012,NDC,facility,outpatient,1,UN,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
KETOCONAZOLE 200 MG TABLET,RX-10369,CDM,250,RC,J3490,HCPCS,51672402606,NDC,facility,outpatient,1,UN,24.65000,14.79000,WellCare of North Carolina,Managed Medicaid,,4.93,,,,,,,4.93,20.04,percent of total billed charges,
LABETALOL 100 MG TABLET,RX-10373,CDM,250,RC,J3490,HCPCS,51079092801,NDC,facility,outpatient,1,UN,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
LABETALOL 200 MG TABLET,RX-10374,CDM,250,RC,J3490,HCPCS,51079092901,NDC,facility,outpatient,1,UN,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMMONIUM LACTATE 12 % LOTION,RX-10380,CDM,250,RC,J3490,HCPCS,00904598426,NDC,facility,outpatient,226,GR,7.00000,4.20000,WellCare of North Carolina,Managed Medicaid,,1.40,,,,,,,1.40,5.69,percent of total billed charges,
TAMSULOSIN 0.4 MG CAPSULE,RX-103890,CDM,250,RC,J3490,HCPCS,51079029401,NDC,facility,outpatient,1,UN,18.30000,10.98000,WellCare of North Carolina,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY,RX-104,CDM,250,RC,J3490,HCPCS,51672211600,NDC,facility,outpatient,1,UN,2.60000,1.56000,WellCare of North Carolina,Managed Medicaid,,0.52052,,,,,,,0.52052,2.11,percent of total billed charges,
LEVOTHYROXINE 88 MCG TABLET,RX-10403,CDM,250,RC,J3490,HCPCS,42292003801,NDC,facility,outpatient,1,UN,18.05000,10.83000,WellCare of North Carolina,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
LEVOTHYROXINE 112 MCG TABLET,RX-10404,CDM,250,RC,J3490,HCPCS,42292003901,NDC,facility,outpatient,1,UN,18.40000,11.04000,WellCare of North Carolina,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,63323049227,NDC,facility,outpatient,2,ML,26.75000,16.05000,WellCare of North Carolina,Managed Medicaid,,5.36,,,,,,,0.02360,19.85,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409427902,NDC,facility,outpatient,30,ML,30.90000,18.54000,WellCare of North Carolina,Managed Medicaid,,6.19,,,,,,,0.02360,22.93,percent of total billed charges,
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-104207,CDM,636,RC,J2003,HCPCS,00409471302,NDC,facility,outpatient,5,ML,23.80000,14.28000,WellCare of North Carolina,Managed Medicaid,,4.76,,,,,,,0.02360,17.66,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049697,NDC,facility,outpatient,10,ML,47.55000,28.53000,WellCare of North Carolina,Managed Medicaid,,9.52,,,,,,,0.02360,35.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049527,NDC,facility,outpatient,2,ML,29.35000,17.61000,WellCare of North Carolina,Managed Medicaid,,5.88,,,,,,,0.02360,21.78,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-104208,CDM,636,RC,J2003,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,WellCare of North Carolina,Managed Medicaid,,6.48,,,,,,,0.02360,24.01,percent of total billed charges,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,WellCare of North Carolina,Managed Medicaid,,548.82,,,,,,,3.32,2034.63,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317802,NDC,facility,outpatient,1,ML,17.75000,10.65000,WellCare of North Carolina,Managed Medicaid,,3.55,,,,,,,0.02360,13.17,percent of total billed charges,
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,636,RC,J2004,HCPCS,00409317803,NDC,facility,outpatient,1,ML,16.75000,10.05000,WellCare of North Carolina,Managed Medicaid,,3.35,,,,,,,0.02360,12.43,percent of total billed charges,
BETHANECHOL CHLORIDE 10 MG TABLET,RX-1043,CDM,250,RC,J3490,HCPCS,00832051189,NDC,facility,outpatient,1,UN,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
"LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10430,CDM,636,RC,J2004,HCPCS,63323048357,NDC,facility,outpatient,1,ML,17.00000,10.20000,WellCare of North Carolina,Managed Medicaid,,3.40,,,,,,,0.02360,12.62,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION",RX-10431,CDM,636,RC,J2004,HCPCS,63323048927,NDC,facility,outpatient,1,ML,21.35000,12.81000,WellCare of North Carolina,Managed Medicaid,,4.27,,,,,,,0.02360,15.85,percent of total billed charges,
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,RX-10434,CDM,250,RC,J3490,HCPCS,00168035705,NDC,facility,outpatient,5,GR,40.80000,24.48000,WellCare of North Carolina,Managed Medicaid,,8.17,,,,,,,8.17,33.17,percent of total billed charges,
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-10442,CDM,250,RC,J3490,HCPCS,39822015101,NDC,facility,outpatient,1,ML,1839.60000,1103.76000,WellCare of North Carolina,Managed Medicaid,,368.29,,,,,,,368.29,1495.59,percent of total billed charges,
LIOTHYRONINE 5 MCG TABLET,RX-10443,CDM,250,RC,J3490,HCPCS,42794001802,NDC,facility,outpatient,1,UN,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
LISINOPRIL 10 MG TABLET,RX-10449,CDM,250,RC,J3490,HCPCS,60687032501,NDC,facility,outpatient,1,UN,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LISINOPRIL 5 MG TABLET,RX-10451,CDM,250,RC,J3490,HCPCS,68001033308,NDC,facility,outpatient,1,UN,16.15000,9.69000,WellCare of North Carolina,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
"LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE",RX-10454,CDM,250,RC,J3490,HCPCS,00054002125,NDC,facility,outpatient,1,UN,17.35000,10.41000,WellCare of North Carolina,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
"LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE",RX-10455,CDM,250,RC,J3490,HCPCS,00054002025,NDC,facility,outpatient,1,UN,17.75000,10.65000,WellCare of North Carolina,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
TRANEXAMIC ACID 650 MG TABLET,RX-104576,CDM,250,RC,J3490,HCPCS,00591372030,NDC,facility,outpatient,1,UN,32.75000,19.65000,WellCare of North Carolina,Managed Medicaid,,6.56,,,,,,,6.56,26.63,percent of total billed charges,
RIFAXIMIN 550 MG TABLET,RX-104604,CDM,250,RC,J3490,HCPCS,65649030303,NDC,facility,outpatient,1,UN,246.90000,148.14000,WellCare of North Carolina,Managed Medicaid,,49.43,,,,,,,49.43,200.73,percent of total billed charges,
LORATADINE 10 MG TABLET,RX-10466,CDM,250,RC,J3490,HCPCS,51079024601,NDC,facility,outpatient,1,UN,1.65000,0.99000,WellCare of North Carolina,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,WellCare of North Carolina,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SOLUTION,RX-10467,CDM,636,RC,J2060,HCPCS,76329826101,NDC,facility,outpatient,0.25,ML,22.75000,13.65000,WellCare of North Carolina,Managed Medicaid,,4.55,,,,,,,3.26,16.89,percent of total billed charges,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,WellCare of North Carolina,Managed Medicaid,,4068.51,,,,,,,4068.51,15083.17,percent of total billed charges,
SIROLIMUS 0.5 MG TABLET,RX-104764,CDM,250,RC,J7520,HCPCS,68462068201,NDC,facility,outpatient,1,UN,32.00000,19.20000,WellCare of North Carolina,Managed Medicaid,,6.41,,,,,,,2.05,26.02,percent of total billed charges,
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET,RX-10491,CDM,250,RC,J3490,HCPCS,10006073038,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY,RX-105,CDM,250,RC,J3490,HCPCS,45802073032,NDC,facility,outpatient,1,UN,1.45000,0.87000,WellCare of North Carolina,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GATIFLOXACIN 0.5 % EYE DROPS,RX-105011,CDM,250,RC,J3490,HCPCS,61314067225,NDC,facility,outpatient,2.5,ML,157.85000,94.71000,WellCare of North Carolina,Managed Medicaid,,31.60,,,,,,,31.60,128.33,percent of total billed charges,
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,636,RC,90707,HCPCS,00006468101,NDC,facility,outpatient,1,UN,300.90000,180.54000,WellCare of North Carolina,Managed Medicaid,,60.24,,,,,,,60.24,309.79,percent of total billed charges,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,WellCare of North Carolina,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
MELPHALAN 2 MG TABLET,RX-10523,CDM,636,RC,J8600,HCPCS,52609000105,NDC,facility,outpatient,1,UN,70.30000,42.18000,WellCare of North Carolina,Managed Medicaid,,14.07,,,,,,,14.07,52.18,percent of total billed charges,
MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION,RX-10529,CDM,636,RC,J0670,HCPCS,63323029301,NDC,facility,outpatient,30,ML,84.80000,50.88000,WellCare of North Carolina,Managed Medicaid,,16.98,,,,,,,9.32,62.94,percent of total billed charges,
MERCAPTOPURINE 50 MG TABLET,RX-10531,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,WellCare of North Carolina,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
MESALAMINE 4 GRAM/60 ML ENEMA,RX-10535,CDM,250,RC,J3490,HCPCS,45802009851,NDC,facility,outpatient,60,ML,46.10000,27.66000,WellCare of North Carolina,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
MESNA 100 MG/ML INTRAVENOUS SOLUTION,RX-10537,CDM,636,RC,J9209,HCPCS,10019095301,NDC,facility,outpatient,10,ML,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,3.61,285.75,percent of total billed charges,
GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION,RX-105417,CDM,636,RC,J9201,HCPCS,00409018701,NDC,facility,outpatient,1,UN,774.35000,464.61000,WellCare of North Carolina,Managed Medicaid,,155.02,,,,,,,7.39,574.72,percent of total billed charges,
METFORMIN 500 MG TABLET,RX-10544,CDM,250,RC,J3490,HCPCS,57664039751,NDC,facility,outpatient,1,UN,16.20000,9.72000,WellCare of North Carolina,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,63323046817,NDC,facility,outpatient,10,ML,50.85000,30.51000,WellCare of North Carolina,Managed Medicaid,,10.18,,,,,,,10.18,41.34,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,250,RC,J3490,HCPCS,00409174671,NDC,facility,outpatient,30,ML,68.85000,41.31000,WellCare of North Carolina,Managed Medicaid,,13.78,,,,,,,13.78,55.98,percent of total billed charges,
MEPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION,RX-105637,CDM,636,RC,J0670,HCPCS,63323026037,NDC,facility,outpatient,30,ML,66.65000,39.99000,WellCare of North Carolina,Managed Medicaid,,13.34,,,,,,,9.32,49.47,percent of total billed charges,
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-105638,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,20,ML,72.25000,43.35000,WellCare of North Carolina,Managed Medicaid,,14.46,,,,,,,9.32,53.62,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409156010,NDC,facility,outpatient,10,ML,39.65000,23.79000,WellCare of North Carolina,Managed Medicaid,,7.94,,,,,,,0.02360,29.43,percent of total billed charges,
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-105640,CDM,636,RC,J0665,HCPCS,00409116202,NDC,facility,outpatient,30,ML,28.15000,16.89000,WellCare of North Carolina,Managed Medicaid,,5.64,,,,,,,0.02360,20.89,percent of total billed charges,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,WellCare of North Carolina,Managed Medicaid,,12179.59,,,,,,,220.46,45153.30,percent of total billed charges,
NILOTINIB HCL 150 MG CAPSULE,RX-105679,CDM,250,RC,J3490,HCPCS,00078059251,NDC,facility,outpatient,1,UN,798.05000,478.83000,WellCare of North Carolina,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION,RX-10571,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,1,ML,158.35000,95.01000,WellCare of North Carolina,Managed Medicaid,,31.70,,,,,,,31.70,117.53,percent of total billed charges,
METHYLERGONOVINE 0.2 MG TABLET,RX-10572,CDM,250,RC,J3490,HCPCS,00054063905,NDC,facility,outpatient,1,UN,231.15000,138.69000,WellCare of North Carolina,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,WellCare of North Carolina,Managed Medicaid,,104.15,,,,,,,0.20370,386.13,percent of total billed charges,
METOLAZONE 10 MG TABLET,RX-10586,CDM,250,RC,J3490,HCPCS,00185560001,NDC,facility,outpatient,1,UN,19.60000,11.76000,WellCare of North Carolina,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
METOLAZONE 2.5 MG TABLET,RX-10587,CDM,250,RC,J3490,HCPCS,51079002301,NDC,facility,outpatient,1,UN,27.00000,16.20000,WellCare of North Carolina,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
METOLAZONE 5 MG TABLET,RX-10588,CDM,250,RC,J3490,HCPCS,51079002420,NDC,facility,outpatient,1,UN,28.45000,17.07000,WellCare of North Carolina,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE,RX-105899,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,0.3,ML,49.90000,29.94000,WellCare of North Carolina,Managed Medicaid,,9.99,,,,,,,1.39,37.04,percent of total billed charges,
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE,RX-105900,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,0.4,ML,61.20000,36.72000,WellCare of North Carolina,Managed Medicaid,,12.25,,,,,,,1.39,45.42,percent of total billed charges,
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-105901,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,0.6,ML,83.85000,50.31000,WellCare of North Carolina,Managed Medicaid,,16.79,,,,,,,1.39,62.23,percent of total billed charges,
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105902,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,0.8,ML,106.45000,63.87000,WellCare of North Carolina,Managed Medicaid,,21.31,,,,,,,1.39,79.01,percent of total billed charges,
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE,RX-105903,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,1,ML,129.05000,77.43000,WellCare of North Carolina,Managed Medicaid,,25.84,,,,,,,1.39,95.78,percent of total billed charges,
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE,RX-105904,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,0.8,ML,70.85000,42.51000,WellCare of North Carolina,Managed Medicaid,,14.18,,,,,,,1.39,52.58,percent of total billed charges,
METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL,RX-10592,CDM,250,RC,J3490,HCPCS,45802013970,NDC,facility,outpatient,70,GR,76.10000,45.66000,WellCare of North Carolina,Managed Medicaid,,15.24,,,,,,,15.24,61.87,percent of total billed charges,
MEXILETINE 150 MG CAPSULE,RX-10595,CDM,250,RC,J3490,HCPCS,00093873901,NDC,facility,outpatient,1,UN,21.20000,12.72000,WellCare of North Carolina,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
MEXILETINE 200 MG CAPSULE,RX-10596,CDM,250,RC,J3490,HCPCS,00527410837,NDC,facility,outpatient,1,UN,19.80000,11.88000,WellCare of North Carolina,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,WellCare of North Carolina,Managed Medicaid,,247.33,,,,,,,5.40,916.91,percent of total billed charges,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,WellCare of North Carolina,Managed Medicaid,,468.68,,,,,,,5.40,1737.53,percent of total billed charges,
MICONAZOLE NITRATE 2 % TOPICAL POWDER,RX-10599,CDM,250,RC,J3490,HCPCS,46122044427,NDC,facility,outpatient,71,GR,8.50000,5.10000,WellCare of North Carolina,Managed Medicaid,,1.70,,,,,,,1.70,6.91,percent of total billed charges,
ULIPRISTAL 30 MG TABLET,RX-106079,CDM,250,RC,J3490,HCPCS,73302045601,NDC,facility,outpatient,1,UN,171.00000,102.60000,WellCare of North Carolina,Managed Medicaid,,34.23,,,,,,,34.23,139.02,percent of total billed charges,
MIDAZOLAM 5 MG/ML INJECTION SOLUTION,RX-10608,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,WellCare of North Carolina,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDODRINE 2.5 MG TABLET,RX-10609,CDM,250,RC,J3490,HCPCS,00245021111,NDC,facility,outpatient,1,UN,17.00000,10.20000,WellCare of North Carolina,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MIDODRINE 5 MG TABLET,RX-10610,CDM,250,RC,J3490,HCPCS,51079045301,NDC,facility,outpatient,1,UN,20.60000,12.36000,WellCare of North Carolina,Managed Medicaid,,4.12,,,,,,,4.12,16.75,percent of total billed charges,
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM,RX-106176,CDM,250,RC,J0572,HCPCS,12496120201,NDC,facility,outpatient,1,UN,37.05000,22.23000,WellCare of North Carolina,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM,RX-106177,CDM,250,RC,J0574,HCPCS,43598058230,NDC,facility,outpatient,1,UN,37.25000,22.35000,WellCare of North Carolina,Managed Medicaid,,7.46,,,,,,,7.46,30.28,percent of total billed charges,
"NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT",RX-106249,CDM,250,RC,J3490,HCPCS,61314063136,NDC,facility,outpatient,3.5,GR,70.05000,42.03000,WellCare of North Carolina,Managed Medicaid,,14.02,,,,,,,14.02,56.95,percent of total billed charges,
DIAZEPAM 5 MG/ML INJECTION SYRINGE,RX-106278,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,2,ML,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,,24.62,,,,,,,16.80,91.29,percent of total billed charges,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,WellCare of North Carolina,Managed Medicaid,,611.76,,,,,,,19.74,2267.98,percent of total billed charges,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,WellCare of North Carolina,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,WellCare of North Carolina,Managed Medicaid,,269.35,,,,,,,19.74,998.56,percent of total billed charges,
ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION,RX-106348,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,2,ML,21.50000,12.90000,WellCare of North Carolina,Managed Medicaid,,4.30,,,,,,,0.24750,15.96,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION,RX-106349,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,1,ML,64.55000,38.73000,WellCare of North Carolina,Managed Medicaid,,12.92,,,,,,,0.24750,47.91,percent of total billed charges,
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-106363,CDM,636,RC,J2003,HCPCS,00409427801,NDC,facility,outpatient,50,ML,35.60000,21.36000,WellCare of North Carolina,Managed Medicaid,,7.13,,,,,,,0.02360,26.42,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904501,NDC,facility,outpatient,10,ML,33.35000,20.01000,WellCare of North Carolina,Managed Medicaid,,6.68,,,,,,,6.68,27.11,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-106364,CDM,250,RC,J3490,HCPCS,00409904517,NDC,facility,outpatient,30,ML,34.05000,20.43000,WellCare of North Carolina,Managed Medicaid,,6.82,,,,,,,6.82,27.68,percent of total billed charges,
DABIGATRAN ETEXILATE 75 MG CAPSULE,RX-106490,CDM,250,RC,J3490,HCPCS,00597035556,NDC,facility,outpatient,1,UN,29.25000,17.55000,WellCare of North Carolina,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
DABIGATRAN ETEXILATE 150 MG CAPSULE,RX-106491,CDM,250,RC,J3490,HCPCS,00597036055,NDC,facility,outpatient,1,UN,29.25000,17.55000,WellCare of North Carolina,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,WellCare of North Carolina,Managed Medicaid,,484.62,,,,,,,8.49,1796.64,percent of total billed charges,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,WellCare of North Carolina,Managed Medicaid,,1297.10,,,,,,,86.66,4808.71,percent of total billed charges,
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION,RX-106783,CDM,636,RC,J1453,HCPCS,00143942801,NDC,facility,outpatient,1,UN,168.00000,100.80000,WellCare of North Carolina,Managed Medicaid,,33.63,,,,,,,0.23600,124.69,percent of total billed charges,
NALTREXONE 50 MG TABLET,RX-10685,CDM,250,RC,J3490,HCPCS,68084029121,NDC,facility,outpatient,1,UN,27.55000,16.53000,WellCare of North Carolina,Managed Medicaid,,5.52,,,,,,,5.52,22.40,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",RX-10708,CDM,250,RC,J3490,HCPCS,24208083060,NDC,facility,outpatient,5,ML,63.70000,38.22000,WellCare of North Carolina,Managed Medicaid,,12.75,,,,,,,12.75,51.79,percent of total billed charges,
NICOTINE (POLACRILEX) 2 MG GUM,RX-10717,CDM,250,RC,J3490,HCPCS,00536302906,NDC,facility,outpatient,1,UN,1.50000,0.90000,WellCare of North Carolina,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
NICOTINE (POLACRILEX) 4 MG GUM,RX-10718,CDM,250,RC,J3490,HCPCS,00536303023,NDC,facility,outpatient,1,UN,1.45000,0.87000,WellCare of North Carolina,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
NIMODIPINE 30 MG CAPSULE,RX-10722,CDM,250,RC,J3490,HCPCS,69452020907,NDC,facility,outpatient,1,UN,27.50000,16.50000,WellCare of North Carolina,Managed Medicaid,,5.51,,,,,,,5.51,22.36,percent of total billed charges,
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE,RX-10724,CDM,250,RC,J3490,HCPCS,51079034801,NDC,facility,outpatient,1,UN,31.45000,18.87000,WellCare of North Carolina,Managed Medicaid,,6.30,,,,,,,6.30,25.57,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION,RX-10734,CDM,250,RC,J3490,HCPCS,00409337504,NDC,facility,outpatient,4,ML,157.40000,94.44000,WellCare of North Carolina,Managed Medicaid,,31.51,,,,,,,31.51,127.97,percent of total billed charges,
NORETHINDRONE ACETATE 5 MG TABLET,RX-10747,CDM,250,RC,J3490,HCPCS,00555021110,NDC,facility,outpatient,1,UN,23.45000,14.07000,WellCare of North Carolina,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET,RX-10749,CDM,250,RC,J3490,HCPCS,00378728653,NDC,facility,outpatient,1,UN,102.95000,61.77000,WellCare of North Carolina,Managed Medicaid,,20.61,,,,,,,20.61,83.70,percent of total billed charges,
NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION,RX-10757,CDM,250,RC,J3490,HCPCS,00121067816,NDC,facility,outpatient,473,ML,585.05000,351.03000,WellCare of North Carolina,Managed Medicaid,,117.13,,,,,,,117.13,475.65,percent of total billed charges,
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107660,CDM,250,RC,J3490,HCPCS,00093365621,NDC,facility,outpatient,1,UN,180.90000,108.54000,WellCare of North Carolina,Managed Medicaid,,36.22,,,,,,,36.22,147.07,percent of total billed charges,
BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-107661,CDM,250,RC,J3490,HCPCS,00093365721,NDC,facility,outpatient,1,UN,260.30000,156.18000,WellCare of North Carolina,Managed Medicaid,,52.11,,,,,,,52.11,211.62,percent of total billed charges,
LURASIDONE 40 MG TABLET,RX-107668,CDM,250,RC,J3490,HCPCS,63402030430,NDC,facility,outpatient,1,UN,205.20000,123.12000,WellCare of North Carolina,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
ONDANSETRON HCL 8 MG TABLET,RX-10779,CDM,250,RC,J3490,HCPCS,67877017030,NDC,facility,outpatient,1,UN,18.20000,10.92000,WellCare of North Carolina,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079515,NDC,facility,outpatient,15,ML,100.95000,60.57000,WellCare of North Carolina,Managed Medicaid,,20.21,,,,,,,20.21,82.07,percent of total billed charges,
BALANCED SALT IRRIGATION SOLUTION (BSS PLAIN),RX-10781,CDM,250,RC,J3490,HCPCS,00065079550,NDC,facility,outpatient,500,ML,178.50000,107.10000,WellCare of North Carolina,Managed Medicaid,,35.74,,,,,,,35.74,145.12,percent of total billed charges,
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION,RX-107829,CDM,250,RC,J3490,HCPCS,31722001647,NDC,facility,outpatient,473,ML,525.45000,315.27000,WellCare of North Carolina,Managed Medicaid,,105.20,,,,,,,105.20,427.19,percent of total billed charges,
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,250,RC,J3490,HCPCS,00904640761,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
BISACODYL 10 MG RECTAL SUPPOSITORY,RX-1080,CDM,250,RC,J3490,HCPCS,00574705012,NDC,facility,outpatient,1,UN,1.55000,0.93000,WellCare of North Carolina,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,636,RC,J0131,HCPCS,24201010001,NDC,facility,outpatient,100,ML,101.15000,60.69000,WellCare of North Carolina,Managed Medicaid,,20.25,,,,,,,0.13200,75.07,percent of total billed charges,
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108028,CDM,636,RC,J1652,HCPCS,55111068011,NDC,facility,outpatient,0.6,ML,263.20000,157.92000,WellCare of North Carolina,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-108029,CDM,636,RC,J1652,HCPCS,55111068111,NDC,facility,outpatient,0.8,ML,263.20000,157.92000,WellCare of North Carolina,Managed Medicaid,,52.69,,,,,,,1.70,195.35,percent of total billed charges,
"DALTEPARIN (PORCINE) 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE",RX-108036,CDM,636,RC,J1645,HCPCS,00069022802,NDC,facility,outpatient,0.6,ML,881.50000,528.90000,WellCare of North Carolina,Managed Medicaid,,176.48,,,,,,,39.03,654.25,percent of total billed charges,
TESTOSTERONE 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET,RX-108038,CDM,250,RC,J3490,HCPCS,00591321630,NDC,facility,outpatient,0.025,GR,58.50000,35.10000,WellCare of North Carolina,Managed Medicaid,,11.71,,,,,,,11.71,47.56,percent of total billed charges,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,WellCare of North Carolina,Managed Medicaid,,179.47,,,,,,,2.84,665.35,percent of total billed charges,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,WellCare of North Carolina,Managed Medicaid,,285.22,,,,,,,2.84,1057.41,percent of total billed charges,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,WellCare of North Carolina,Managed Medicaid,,426.24,,,,,,,2.84,1580.18,percent of total billed charges,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,WellCare of North Carolina,Managed Medicaid,,708.25,,,,,,,2.84,2625.68,percent of total billed charges,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,WellCare of North Carolina,Managed Medicaid,,1413.29,,,,,,,2.84,5239.49,percent of total billed charges,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,WellCare of North Carolina,Managed Medicaid,,2118.34,,,,,,,2.84,7853.29,percent of total billed charges,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,WellCare of North Carolina,Managed Medicaid,,339.37,,,,,,,29.11,1258.14,percent of total billed charges,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,WellCare of North Carolina,Managed Medicaid,,1650.91,,,,,,,167.84,6120.40,percent of total billed charges,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,WellCare of North Carolina,Managed Medicaid,,6438.44,,,,,,,167.84,23869.19,percent of total billed charges,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,WellCare of North Carolina,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,WellCare of North Carolina,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,WellCare of North Carolina,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,WellCare of North Carolina,Managed Medicaid,,63.83,,,,,,,63.83,236.65,percent of total billed charges,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,WellCare of North Carolina,Managed Medicaid,,1763.13,,,,,,,6.53,6536.44,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP,RX-10810,CDM,250,RC,J3490,HCPCS,54838051080,NDC,facility,outpatient,2.5,ML,16.30000,9.78000,WellCare of North Carolina,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108119,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,100,ML,83.30000,49.98000,WellCare of North Carolina,Managed Medicaid,,16.68,,,,,,,5.33,61.83,percent of total billed charges,
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-108120,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,150,ML,101.35000,60.81000,WellCare of North Carolina,Managed Medicaid,,20.29,,,,,,,5.33,75.22,percent of total billed charges,
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION,RX-108127,CDM,636,RC,90713,HCPCS,49281086010,NDC,facility,outpatient,0.5,ML,153.95000,92.37000,WellCare of North Carolina,Managed Medicaid,,30.82,,,,,,,30.82,145.73,percent of total billed charges,
OXYCODONE 5 MG/5 ML ORAL SOLUTION,RX-10813,CDM,250,RC,J3490,HCPCS,99999000757,NDC,facility,outpatient,5,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
OXYCODONE 5 MG TABLET,RX-10814,CDM,250,RC,J3490,HCPCS,00406055223,NDC,facility,outpatient,1,UN,23.35000,14.01000,WellCare of North Carolina,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,WellCare of North Carolina,Managed Medicaid,,3.74,,,,,,,3.74,490.35,percent of total billed charges,
ETRAVIRINE 200 MG TABLET,RX-108431,CDM,250,RC,J3490,HCPCS,59676057101,NDC,facility,outpatient,1,UN,115.90000,69.54000,WellCare of North Carolina,Managed Medicaid,,23.20,,,,,,,23.20,94.23,percent of total billed charges,
PAMIDRONATE 30 MG INTRAVENOUS SOLUTION,RX-10845,CDM,636,RC,J2430,HCPCS,59923060110,NDC,facility,outpatient,1,UN,141.95000,85.17000,WellCare of North Carolina,Managed Medicaid,,28.42,,,,,,,22.75,105.36,percent of total billed charges,
PAROXETINE 20 MG TABLET,RX-10855,CDM,250,RC,J3490,HCPCS,68084004511,NDC,facility,outpatient,1,UN,17.30000,10.38000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-108590,CDM,636,RC,J9351,HCPCS,00409030201,NDC,facility,outpatient,4,ML,884.70000,530.82000,WellCare of North Carolina,Managed Medicaid,,177.12,,,,,,,3.65,656.62,percent of total billed charges,
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,250,RC,J3490,HCPCS,77333095125,NDC,facility,outpatient,1,UN,1.40000,0.84000,WellCare of North Carolina,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,WellCare of North Carolina,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,WellCare of North Carolina,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,WellCare of North Carolina,Managed Medicaid,,197.30,,,,,,,29.11,731.44,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003201,NDC,facility,outpatient,30,ML,2.00000,1.20000,WellCare of North Carolina,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003202,NDC,facility,outpatient,30,ML,1.75000,1.05000,WellCare of North Carolina,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003203,NDC,facility,outpatient,30,ML,1.70000,1.02000,WellCare of North Carolina,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION,RX-1090,CDM,250,RC,J3490,HCPCS,37000003204,NDC,facility,outpatient,30,ML,1.60000,0.96000,WellCare of North Carolina,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK,RX-10900,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,50,ML,100.65000,60.39000,WellCare of North Carolina,Managed Medicaid,,20.15,,,,,,,1.86,74.70,percent of total billed charges,
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-109034,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,193.80000,116.28000,WellCare of North Carolina,Managed Medicaid,,38.80,,,,,,,2.90,143.84,percent of total billed charges,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,WellCare of North Carolina,Managed Medicaid,,2654.78,,,,,,,2529.92,9842.05,percent of total billed charges,
PERMETHRIN 5 % TOPICAL CREAM,RX-10917,CDM,250,RC,J3490,HCPCS,45802026937,NDC,facility,outpatient,60,GR,106.00000,63.60000,WellCare of North Carolina,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
PERMETHRIN 1 % TOPICAL LIQUID,RX-10918,CDM,250,RC,J3490,HCPCS,63736012002,NDC,facility,outpatient,59,ML,13.75000,8.25000,WellCare of North Carolina,Managed Medicaid,,2.75,,,,,,,2.75,11.18,percent of total billed charges,
ROFLUMILAST 500 MCG TABLET,RX-109401,CDM,250,RC,J3490,HCPCS,00310009530,NDC,facility,outpatient,1,UN,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,15.42,62.60,percent of total billed charges,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,WellCare of North Carolina,Managed Medicaid,,449.52,,,,,,,419.06,1666.50,percent of total billed charges,
LINAGLIPTIN 5 MG TABLET,RX-109773,CDM,250,RC,J3490,HCPCS,00597014061,NDC,facility,outpatient,1,UN,86.05000,51.63000,WellCare of North Carolina,Managed Medicaid,,17.23,,,,,,,17.23,69.96,percent of total billed charges,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,WellCare of North Carolina,Managed Medicaid,,142.12,,,,,,,2.16,526.89,percent of total billed charges,
RILPIVIRINE HCL 25 MG TABLET,RX-109909,CDM,250,RC,J3490,HCPCS,59676027801,NDC,facility,outpatient,1,UN,213.80000,128.28000,WellCare of North Carolina,Managed Medicaid,,42.80,,,,,,,42.80,173.82,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION,RX-11023,CDM,636,RC,J3430,HCPCS,00409915831,NDC,facility,outpatient,0.2,ML,60.60000,36.36000,WellCare of North Carolina,Managed Medicaid,,12.13,,,,,,,6.44,44.98,percent of total billed charges,
RIVAROXABAN 10 MG TABLET,RX-110250,CDM,250,RC,J3490,HCPCS,50458058001,NDC,facility,outpatient,1,UN,95.75000,57.45000,WellCare of North Carolina,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
"AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110257,CDM,636,RC,J0283,HCPCS,43066015010,NDC,facility,outpatient,100,ML,184.45000,110.67000,WellCare of North Carolina,Managed Medicaid,,36.93,,,,,,,6.16,136.90,percent of total billed charges,
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,outpatient,200,ML,224.70000,134.82000,WellCare of North Carolina,Managed Medicaid,,44.98,,,,,,,6.16,166.77,percent of total billed charges,
"TAPENTADOL ER 50 MG TABLET,EXTENDED RELEASE,12 HR",RX-110262,CDM,250,RC,J3490,HCPCS,24510005860,NDC,facility,outpatient,1,UN,60.25000,36.15000,WellCare of North Carolina,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
FIDAXOMICIN 200 MG TABLET,RX-110360,CDM,250,RC,J3490,HCPCS,52015008001,NDC,facility,outpatient,1,UN,1057.00000,634.20000,WellCare of North Carolina,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET,RX-110366,CDM,250,RC,J3490,HCPCS,50268085711,NDC,facility,outpatient,1,UN,1.45000,0.87000,WellCare of North Carolina,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
TICAGRELOR 90 MG TABLET,RX-110427,CDM,250,RC,J3490,HCPCS,00186077739,NDC,facility,outpatient,1,UN,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE,RX-11050,CDM,250,RC,J3490,HCPCS,51991020311,NDC,facility,outpatient,1,UN,1.20000,0.72000,WellCare of North Carolina,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET,RX-11067,CDM,250,RC,J3490,HCPCS,68084076495,NDC,facility,outpatient,1,UN,3.10000,1.86000,WellCare of North Carolina,Managed Medicaid,,0.62062,,,,,,,0.62062,2.52,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11074,CDM,258,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,100,ML,80.15000,48.09000,WellCare of North Carolina,Managed Medicaid,,16.05,,,,,,,0.25960,60.06,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11076,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,100,ML,77.35000,46.41000,WellCare of North Carolina,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11077,CDM,636,RC,J3480,HCPCS,00338070341,NDC,facility,outpatient,50,ML,76.30000,45.78000,WellCare of North Carolina,Managed Medicaid,,15.28,,,,,,,0.25960,56.63,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK,RX-11079,CDM,636,RC,J3480,HCPCS,00338070348,NDC,facility,outpatient,100,ML,77.35000,46.41000,WellCare of North Carolina,Managed Medicaid,,15.49,,,,,,,0.25960,57.41,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11081,CDM,636,RC,J3480,HCPCS,00338069104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,WellCare of North Carolina,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-11082,CDM,636,RC,J3480,HCPCS,00338069504,NDC,facility,outpatient,1000,ML,105.00000,63.00000,WellCare of North Carolina,Managed Medicaid,,21.02,,,,,,,0.25960,77.93,percent of total billed charges,
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION,RX-110998,CDM,250,RC,J3490,HCPCS,00004082205,NDC,facility,outpatient,60,ML,471.60000,282.96000,WellCare of North Carolina,Managed Medicaid,,94.41,,,,,,,94.41,383.41,percent of total billed charges,
PRAVASTATIN 20 MG TABLET,RX-11111,CDM,250,RC,J3490,HCPCS,00904589261,NDC,facility,outpatient,1,UN,18.30000,10.98000,WellCare of North Carolina,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
PRAZIQUANTEL 600 MG TABLET,RX-11113,CDM,250,RC,J3490,HCPCS,49884023183,NDC,facility,outpatient,1,UN,281.75000,169.05000,WellCare of North Carolina,Managed Medicaid,,56.41,,,,,,,56.41,229.06,percent of total billed charges,
PRIMIDONE 50 MG TABLET,RX-11129,CDM,250,RC,J3490,HCPCS,68084020211,NDC,facility,outpatient,1,UN,19.30000,11.58000,WellCare of North Carolina,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,WellCare of North Carolina,Managed Medicaid,,11220.92,,,,,,,250.88,41599.23,percent of total billed charges,
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY,RX-11143,CDM,250,RC,J3490,HCPCS,45802075830,NDC,facility,outpatient,1,UN,55.00000,33.00000,WellCare of North Carolina,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,WellCare of North Carolina,Managed Medicaid,,893.81,,,,,,,5.03,3313.63,percent of total billed charges,
PROMETHAZINE 25 MG RECTAL SUPPOSITORY,RX-11144,CDM,250,RC,J3490,HCPCS,45802075930,NDC,facility,outpatient,1,UN,55.00000,33.00000,WellCare of North Carolina,Managed Medicaid,,11.01,,,,,,,11.01,44.72,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,100,ML,70.60000,42.36000,WellCare of North Carolina,Managed Medicaid,,14.13,,,,,,,0.21240,52.40,percent of total billed charges,
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION,RX-11150,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,20,ML,26.95000,16.17000,WellCare of North Carolina,Managed Medicaid,,5.40,,,,,,,0.21240,20.00,percent of total billed charges,
PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET,RX-11218,CDM,250,RC,J3490,HCPCS,37000002410,NDC,facility,outpatient,1,UN,1.50000,0.90000,WellCare of North Carolina,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION,RX-11237,CDM,250,RC,J3490,HCPCS,00781304072,NDC,facility,outpatient,0.2,ML,31.40000,18.84000,WellCare of North Carolina,Managed Medicaid,,6.29,,,,,,,6.29,25.53,percent of total billed charges,
PYRIDOSTIGMINE BROMIDE 60 MG TABLET,RX-11239,CDM,250,RC,J3490,HCPCS,00115351101,NDC,facility,outpatient,1,UN,19.30000,11.58000,WellCare of North Carolina,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION,RX-112481,CDM,250,RC,J3490,HCPCS,67850014100,NDC,facility,outpatient,0.1,ML,67.75000,40.65000,WellCare of North Carolina,Managed Medicaid,,13.56,,,,,,,13.56,55.08,percent of total billed charges,
CLOBAZAM 10 MG TABLET,RX-112703,CDM,250,RC,J3490,HCPCS,60687042311,NDC,facility,outpatient,1,UN,29.80000,17.88000,WellCare of North Carolina,Managed Medicaid,,5.97,,,,,,,5.97,24.23,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,WellCare of North Carolina,Managed Medicaid,,223.00,,,,,,,1.42,826.74,percent of total billed charges,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,WellCare of North Carolina,Managed Medicaid,,366.37,,,,,,,1.42,1358.23,percent of total billed charges,
GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112786,CDM,636,RC,J9201,HCPCS,00409018301,NDC,facility,outpatient,5.26,ML,316.10000,189.66000,WellCare of North Carolina,Managed Medicaid,,63.28,,,,,,,7.39,234.61,percent of total billed charges,
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION,RX-112787,CDM,636,RC,J9201,HCPCS,00409018101,NDC,facility,outpatient,26.3,ML,474.30000,284.58000,WellCare of North Carolina,Managed Medicaid,,94.95,,,,,,,7.39,352.03,percent of total billed charges,
RIVAROXABAN 15 MG TABLET,RX-112834,CDM,250,RC,J3490,HCPCS,50458057810,NDC,facility,outpatient,1,UN,95.75000,57.45000,WellCare of North Carolina,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIVAROXABAN 20 MG TABLET,RX-112835,CDM,250,RC,J3490,HCPCS,50458057910,NDC,facility,outpatient,1,UN,95.75000,57.45000,WellCare of North Carolina,Managed Medicaid,,19.17,,,,,,,19.17,77.84,percent of total billed charges,
RIFAMPIN 600 MG INTRAVENOUS SOLUTION,RX-11291,CDM,636,RC,J2804,HCPCS,67457044560,NDC,facility,outpatient,1,UN,710.25000,426.15000,WellCare of North Carolina,Managed Medicaid,,142.19,,,,,,,0.33040,527.15,percent of total billed charges,
RIFAMPIN 150 MG CAPSULE,RX-11292,CDM,250,RC,J3490,HCPCS,60687057511,NDC,facility,outpatient,1,UN,28.75000,17.25000,WellCare of North Carolina,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
RIFAMPIN 300 MG CAPSULE,RX-11293,CDM,250,RC,J3490,HCPCS,60687058611,NDC,facility,outpatient,1,UN,23.45000,14.07000,WellCare of North Carolina,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
RUXOLITINIB 5 MG TABLET,RX-112936,CDM,250,RC,J3490,HCPCS,50881000560,NDC,facility,outpatient,1,UN,565.00000,339.00000,WellCare of North Carolina,Managed Medicaid,,113.11,,,,,,,113.11,459.35,percent of total billed charges,
RUXOLITINIB 10 MG TABLET,RX-112937,CDM,250,RC,J3490,HCPCS,50881001060,NDC,facility,outpatient,1,UN,1198.35000,719.01000,WellCare of North Carolina,Managed Medicaid,,239.91,,,,,,,239.91,974.26,percent of total billed charges,
RINGER'S INTRAVENOUS SOLUTION,RX-11295,CDM,258,RC,J7120,HCPCS,00264778000,NDC,facility,outpatient,1000,ML,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,5.69,69.68,percent of total billed charges,
RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION,RX-113082,CDM,250,RC,J3490,HCPCS,00487590199,NDC,facility,outpatient,1,UN,4.10000,2.46000,WellCare of North Carolina,Managed Medicaid,,0.82082,,,,,,,0.82082,3.33,percent of total billed charges,
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP",RX-113088,CDM,636,RC,90716,HCPCS,00006482700,NDC,facility,outpatient,1,UN,568.80000,341.28000,WellCare of North Carolina,Managed Medicaid,,113.87,,,,,,,113.87,597.45,percent of total billed charges,
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK,RX-113475,CDM,636,RC,J1953,HCPCS,67457025500,NDC,facility,outpatient,100,ML,112.00000,67.20000,WellCare of North Carolina,Managed Medicaid,,22.42,,,,,,,0.09440,83.13,percent of total billed charges,
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-113476,CDM,636,RC,J1953,HCPCS,43598063652,NDC,facility,outpatient,100,ML,168.00000,100.80000,WellCare of North Carolina,Managed Medicaid,,33.63,,,,,,,0.09440,124.69,percent of total billed charges,
SERTRALINE 100 MG TABLET,RX-11350,CDM,250,RC,J3490,HCPCS,59762491003,NDC,facility,outpatient,1,UN,16.95000,10.17000,WellCare of North Carolina,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
SERTRALINE 50 MG TABLET,RX-11351,CDM,250,RC,J3490,HCPCS,00904692561,NDC,facility,outpatient,1,UN,17.65000,10.59000,WellCare of North Carolina,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
LURASIDONE 20 MG TABLET,RX-113587,CDM,250,RC,J3490,HCPCS,63402030230,NDC,facility,outpatient,1,UN,205.20000,123.12000,WellCare of North Carolina,Managed Medicaid,,41.08,,,,,,,41.08,166.83,percent of total billed charges,
SINCALIDE 5 MCG SOLUTION FOR INJECTION,RX-11368,CDM,636,RC,J2805,HCPCS,00270055615,NDC,facility,outpatient,1,UN,609.65000,365.79000,WellCare of North Carolina,Managed Medicaid,,122.05,,,,,,,122.05,452.48,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-113850,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION,RX-114,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,1,UN,159.35000,95.61000,WellCare of North Carolina,Managed Medicaid,,31.90,,,,,,,31.90,118.27,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004727,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,00338004744,NDC,facility,outpatient,1000,ML,87.00000,52.20000,WellCare of North Carolina,Managed Medicaid,,17.42,,,,,,,17.42,70.73,percent of total billed charges,
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION,RX-11403,CDM,250,RC,J3490,HCPCS,99999000820,NDC,facility,outpatient,1000,ML,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
SODIUM CHLORIDE 2 % EYE DROPS,RX-11404,CDM,250,RC,J3490,HCPCS,24208027615,NDC,facility,outpatient,0.05,ML,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WHITE PETROLATUM TOPICAL OINTMENT,RX-11408,CDM,250,RC,J3490,HCPCS,67777000571,NDC,facility,outpatient,425,GR,4.30000,2.58000,WellCare of North Carolina,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
SOTALOL 80 MG TABLET,RX-11421,CDM,250,RC,J3490,HCPCS,68084065411,NDC,facility,outpatient,1,UN,21.10000,12.66000,WellCare of North Carolina,Managed Medicaid,,4.22,,,,,,,4.22,17.15,percent of total billed charges,
SPIRONOLACTONE 100 MG TABLET,RX-11425,CDM,250,RC,J3490,HCPCS,59746021801,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
SPIRONOLACTONE 50 MG TABLET,RX-11426,CDM,250,RC,J3490,HCPCS,59746021701,NDC,facility,outpatient,1,UN,16.85000,10.11000,WellCare of North Carolina,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,58914017014,NDC,facility,outpatient,5,ML,28.75000,17.25000,WellCare of North Carolina,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 100 MG/ML ORAL SUSPENSION,RX-11441,CDM,250,RC,J3490,HCPCS,99999000388,NDC,facility,outpatient,5,ML,28.75000,17.25000,WellCare of North Carolina,Managed Medicaid,,5.76,,,,,,,5.76,23.37,percent of total billed charges,
SUCRALFATE 1 GRAM TABLET,RX-11442,CDM,250,RC,J3490,HCPCS,51079075301,NDC,facility,outpatient,1,UN,17.30000,10.38000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
TEMAZEPAM 7.5 MG CAPSULE,RX-11500,CDM,250,RC,J3490,HCPCS,00406996001,NDC,facility,outpatient,1,UN,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION,RX-11507,CDM,636,RC,J3105,HCPCS,00143974601,NDC,facility,outpatient,1,ML,34.20000,20.52000,WellCare of North Carolina,Managed Medicaid,,6.85,,,,,,,6.85,25.38,percent of total billed charges,
TERCONAZOLE 0.4 % VAGINAL CREAM,RX-11510,CDM,250,RC,J3490,HCPCS,00168034646,NDC,facility,outpatient,45,GR,123.50000,74.10000,WellCare of North Carolina,Managed Medicaid,,24.72,,,,,,,24.72,100.41,percent of total billed charges,
TERCONAZOLE 80 MG VAGINAL SUPPOSITORY,RX-11512,CDM,250,RC,J3490,HCPCS,45802071708,NDC,facility,outpatient,1,UN,124.90000,74.94000,WellCare of North Carolina,Managed Medicaid,,25.00,,,,,,,25.00,101.54,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022610,NDC,facility,outpatient,10,ML,48.85000,29.31000,WellCare of North Carolina,Managed Medicaid,,9.78,,,,,,,9.78,39.72,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022615,NDC,facility,outpatient,15,ML,61.95000,37.17000,WellCare of North Carolina,Managed Medicaid,,12.40,,,,,,,12.40,50.37,percent of total billed charges,
TIMOLOL MALEATE 0.25 % EYE DROPS,RX-11561,CDM,250,RC,J3490,HCPCS,61314022605,NDC,facility,outpatient,5,ML,31.55000,18.93000,WellCare of North Carolina,Managed Medicaid,,6.32,,,,,,,6.32,25.65,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS,RX-11562,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,WellCare of North Carolina,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION,RX-11565,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,outpatient,1,UN,380.00000,228.00000,WellCare of North Carolina,Managed Medicaid,,76.08,,,,,,,5.59,282.04,percent of total billed charges,
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,RX-11566,CDM,250,RC,J3490,HCPCS,00078087601,NDC,facility,outpatient,3.5,GR,910.30000,546.18000,WellCare of North Carolina,Managed Medicaid,,182.24,,,,,,,182.24,740.07,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029525,NDC,facility,outpatient,2.5,ML,167.75000,100.65000,WellCare of North Carolina,Managed Medicaid,,33.58,,,,,,,33.58,136.38,percent of total billed charges,
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,250,RC,J3490,HCPCS,24208029505,NDC,facility,outpatient,5,ML,320.20000,192.12000,WellCare of North Carolina,Managed Medicaid,,64.10,,,,,,,64.10,260.32,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION",RX-11573,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,WellCare of North Carolina,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
TRIFLURIDINE 1 % EYE DROPS,RX-11595,CDM,250,RC,J3490,HCPCS,61314004475,NDC,facility,outpatient,7.5,ML,604.05000,362.43000,WellCare of North Carolina,Managed Medicaid,,120.93,,,,,,,120.93,491.09,percent of total billed charges,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,WellCare of North Carolina,Managed Medicaid,,5085.99,,,,,,,60.36,18855.26,percent of total billed charges,
MITOMYCIN 0.2 MG OPHTHALMIC KIT,RX-116028,CDM,636,RC,J7315,HCPCS,49771000201,NDC,facility,outpatient,1,UN,1854.60000,1112.76000,WellCare of North Carolina,Managed Medicaid,,371.29,,,,,,,371.29,1376.48,percent of total billed charges,
URSODIOL 300 MG CAPSULE,RX-11624,CDM,250,RC,J3490,HCPCS,00527132601,NDC,facility,outpatient,1,UN,21.00000,12.60000,WellCare of North Carolina,Managed Medicaid,,4.20,,,,,,,4.20,17.07,percent of total billed charges,
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION,RX-11627,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,UN,961.85000,577.11000,WellCare of North Carolina,Managed Medicaid,,192.56,,,,,,,0.07080,713.89,percent of total billed charges,
VANCOMYCIN 50 MG/ML ORAL SOLUTION,RX-11630,CDM,250,RC,J3490,HCPCS,65628020605,NDC,facility,outpatient,2.5,ML,24.95000,14.97000,WellCare of North Carolina,Managed Medicaid,,4.99,,,,,,,4.99,20.28,percent of total billed charges,
VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION,RX-11634,CDM,250,RC,J3490,HCPCS,00143923401,NDC,facility,outpatient,1,UN,84.65000,50.79000,WellCare of North Carolina,Managed Medicaid,,16.95,,,,,,,16.95,68.82,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION,RX-116345,CDM,636,RC,J1100,HCPCS,55150030401,NDC,facility,outpatient,1,ML,36.05000,21.63000,WellCare of North Carolina,Managed Medicaid,,7.22,,,,,,,0.21240,26.76,percent of total billed charges,
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,250,RC,J3490,HCPCS,68462029201,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE",RX-11640,CDM,250,RC,J3490,HCPCS,68462029301,NDC,facility,outpatient,1,UN,17.30000,10.38000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"VITAMIN A PALMITATE 15,000 MCG RAE/ML (50,000 UNIT/ML) INTRAMUSCULAR SOLUTION",RX-11641,CDM,250,RC,J3490,HCPCS,70199002611,NDC,facility,outpatient,1,ML,1651.20000,990.72000,WellCare of North Carolina,Managed Medicaid,,330.57,,,,,,,330.57,1342.43,percent of total billed charges,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,WellCare of North Carolina,Managed Medicaid,,6063.10,,,,,,,16.51,22477.68,percent of total billed charges,
WARFARIN 1 MG TABLET,RX-11664,CDM,250,RC,J3490,HCPCS,00832121189,NDC,facility,outpatient,1,UN,17.50000,10.50000,WellCare of North Carolina,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488717,NDC,facility,outpatient,10,ML,31.65000,18.99000,WellCare of North Carolina,Managed Medicaid,,6.34,,,,,,,6.34,25.73,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488725,NDC,facility,outpatient,100,ML,53.35000,32.01000,WellCare of North Carolina,Managed Medicaid,,10.68,,,,,,,10.68,43.37,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488720,NDC,facility,outpatient,20,ML,38.05000,22.83000,WellCare of North Carolina,Managed Medicaid,,7.62,,,,,,,7.62,30.93,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,63833076140,NDC,facility,outpatient,40,ML,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
"WATER FOR INJECTION, STERILE INJECTION SOLUTION",RX-11671,CDM,250,RC,J3490,HCPCS,00409488724,NDC,facility,outpatient,50,ML,48.10000,28.86000,WellCare of North Carolina,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION,RX-116809,CDM,636,RC,J1171,HCPCS,63323085107,NDC,facility,outpatient,5,ML,72.05000,43.23000,WellCare of North Carolina,Managed Medicaid,,14.42,,,,,,,0.21240,53.48,percent of total billed charges,
"MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-116842,CDM,250,RC,J3490,HCPCS,00469260130,NDC,facility,outpatient,1,UN,77.40000,46.44000,WellCare of North Carolina,Managed Medicaid,,15.50,,,,,,,15.50,62.93,percent of total billed charges,
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION,RX-11691,CDM,636,RC,J3485,HCPCS,49702021301,NDC,facility,outpatient,20,ML,185.65000,111.39000,WellCare of North Carolina,Managed Medicaid,,37.17,,,,,,,3.56,137.79,percent of total billed charges,
ZIDOVUDINE 10 MG/ML ORAL SYRUP,RX-11693,CDM,250,RC,J3490,HCPCS,65862004824,NDC,facility,outpatient,10,ML,20.50000,12.30000,WellCare of North Carolina,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
ZOLPIDEM 10 MG TABLET,RX-11700,CDM,250,RC,J3490,HCPCS,51079072501,NDC,facility,outpatient,1,UN,22.35000,13.41000,WellCare of North Carolina,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
ZOLPIDEM 5 MG TABLET,RX-11701,CDM,250,RC,J3490,HCPCS,00904608261,NDC,facility,outpatient,1,UN,22.30000,13.38000,WellCare of North Carolina,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,00703367101,NDC,facility,outpatient,2,ML,320.55000,192.33000,WellCare of North Carolina,Managed Medicaid,,64.17,,,,,,,6.15,237.91,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION,RX-117032,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,40,ML,438.00000,262.80000,WellCare of North Carolina,Managed Medicaid,,87.69,,,,,,,6.15,325.08,percent of total billed charges,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,WellCare of North Carolina,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
RIVASTIGMINE 13.3 MG/24 HOUR TRANSDERMAL PATCH,RX-117356,CDM,250,RC,J3490,HCPCS,00078050361,NDC,facility,outpatient,1,UN,107.45000,64.47000,WellCare of North Carolina,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001101,NDC,facility,outpatient,1,ML,2063.50000,1238.10000,WellCare of North Carolina,Managed Medicaid,,413.11,,,,,,,413.11,1677.63,percent of total billed charges,
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION,RX-119061,CDM,250,RC,J3490,HCPCS,14789001505,NDC,facility,outpatient,5,ML,2746.00000,1647.60000,WellCare of North Carolina,Managed Medicaid,,549.75,,,,,,,549.75,2232.50,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SOLUTION,RX-119074,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,WellCare of North Carolina,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION,RX-119125,CDM,250,RC,J3490,HCPCS,00409409201,NDC,facility,outpatient,10,ML,196.20000,117.72000,WellCare of North Carolina,Managed Medicaid,,39.28,,,,,,,39.28,159.51,percent of total billed charges,
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION,RX-119129,CDM,250,RC,J3490,HCPCS,48433023015,NDC,facility,outpatient,0.25,ML,18.10000,10.86000,WellCare of North Carolina,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
LIDOCAINE 4 % TOPICAL PATCH,RX-119190,CDM,250,RC,J3490,HCPCS,00536120207,NDC,facility,outpatient,1,UN,2.70000,1.62000,WellCare of North Carolina,Managed Medicaid,,0.54054,,,,,,,0.54054,2.20,percent of total billed charges,
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN,RX-11931,CDM,636,RC,90648,HCPCS,49281054758,NDC,facility,outpatient,1,UN,60.00000,36.00000,WellCare of North Carolina,Managed Medicaid,,12.01,,,,,,,12.01,44.53,percent of total billed charges,
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-119318,CDM,636,RC,J0665,HCPCS,00409116018,NDC,facility,outpatient,50,ML,32.20000,19.32000,WellCare of North Carolina,Managed Medicaid,,6.45,,,,,,,0.02360,23.90,percent of total billed charges,
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP,RX-119615,CDM,250,RC,J3490,HCPCS,71399823708,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION,RX-119668,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ML,22.30000,13.38000,WellCare of North Carolina,Managed Medicaid,,4.46,,,,,,,4.46,21.36,percent of total billed charges,
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE),RX-119671,CDM,636,RC,J8540,HCPCS,00054317644,NDC,facility,outpatient,30,ML,87.55000,52.53000,WellCare of North Carolina,Managed Medicaid,,17.53,,,,,,,0.04720,64.98,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION,RX-119756,CDM,250,RC,J3490,HCPCS,63323008950,NDC,facility,outpatient,25,ML,115.20000,69.12000,WellCare of North Carolina,Managed Medicaid,,23.06,,,,,,,23.06,93.66,percent of total billed charges,
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID,RX-119769,CDM,250,RC,J3490,HCPCS,87701088843,NDC,facility,outpatient,10,ML,1.30000,0.78000,WellCare of North Carolina,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,51754501201,NDC,facility,outpatient,10,ML,49.70000,29.82000,WellCare of North Carolina,Managed Medicaid,,9.95,,,,,,,9.95,40.41,percent of total billed charges,
SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION,RX-119826,CDM,250,RC,J3490,HCPCS,00409555511,NDC,facility,outpatient,5,ML,36.10000,21.66000,WellCare of North Carolina,Managed Medicaid,,7.23,,,,,,,7.23,29.35,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-119902,CDM,636,RC,J0618,HCPCS,00517671010,NDC,facility,outpatient,10,ML,147.95000,88.77000,WellCare of North Carolina,Managed Medicaid,,29.62,,,,,,,0.07080,109.81,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,00121043130,NDC,facility,outpatient,5,ML,1.55000,0.93000,WellCare of North Carolina,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION,RX-119913,CDM,250,RC,J3490,HCPCS,57896064916,NDC,facility,outpatient,5,ML,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MECLIZINE 12.5 MG TABLET,RX-12024,CDM,250,RC,J3490,HCPCS,50268052215,NDC,facility,outpatient,1,UN,1.75000,1.05000,WellCare of North Carolina,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
LIDOCAINE HCL 2 % MUCOSAL SOLUTION,RX-120360,CDM,250,RC,J3490,HCPCS,00054350049,NDC,facility,outpatient,1,ML,16.35000,9.81000,WellCare of North Carolina,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY,RX-120439,CDM,250,RC,J3490,HCPCS,00472173803,NDC,facility,outpatient,1,UN,207.05000,124.23000,WellCare of North Carolina,Managed Medicaid,,41.45,,,,,,,41.45,168.33,percent of total billed charges,
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION,RX-120565,CDM,250,RC,J3490,HCPCS,00078050883,NDC,facility,outpatient,5,ML,22.65000,13.59000,WellCare of North Carolina,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET,RX-120778,CDM,250,RC,J3490,HCPCS,00555097102,NDC,facility,outpatient,1,UN,24.60000,14.76000,WellCare of North Carolina,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE,RX-121573,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,1,ML,32.10000,19.26000,WellCare of North Carolina,Managed Medicaid,,6.43,,,,,,,0.21240,23.82,percent of total billed charges,
VENLAFAXINE 25 MG TABLET,RX-12203,CDM,250,RC,J3490,HCPCS,68382001801,NDC,facility,outpatient,1,UN,17.30000,10.38000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION,RX-12211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,2.5,ML,551.10000,330.66000,WellCare of North Carolina,Managed Medicaid,,110.33,,,,,,,110.33,448.04,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115901,NDC,facility,outpatient,10,ML,26.80000,16.08000,WellCare of North Carolina,Managed Medicaid,,5.37,,,,,,,0.02360,19.89,percent of total billed charges,
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION,RX-1222,CDM,636,RC,J0665,HCPCS,00409115909,NDC,facility,outpatient,30,ML,23.95000,14.37000,WellCare of North Carolina,Managed Medicaid,,4.79,,,,,,,0.02360,17.78,percent of total billed charges,
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION,RX-1223,CDM,636,RC,J0665,HCPCS,00409116301,NDC,facility,outpatient,50,ML,29.45000,17.67000,WellCare of North Carolina,Managed Medicaid,,5.90,,,,,,,0.02360,21.86,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047217,NDC,facility,outpatient,10,ML,43.10000,25.86000,WellCare of North Carolina,Managed Medicaid,,8.63,,,,,,,0.02360,31.99,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION,RX-1224,CDM,636,RC,J0665,HCPCS,63323047237,NDC,facility,outpatient,30,ML,53.45000,32.07000,WellCare of North Carolina,Managed Medicaid,,10.70,,,,,,,0.02360,39.67,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE,RX-122633,CDM,250,RC,J3490,HCPCS,00409751716,NDC,facility,outpatient,25,ML,60.85000,36.51000,WellCare of North Carolina,Managed Medicaid,,12.18,,,,,,,12.18,49.47,percent of total billed charges,
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK,RX-122641,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,300,ML,178.50000,107.10000,WellCare of North Carolina,Managed Medicaid,,35.74,,,,,,,8.43,132.48,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SYRINGE,RX-122758,CDM,250,RC,J3490,HCPCS,00409963305,NDC,facility,outpatient,4,ML,508.10000,304.86000,WellCare of North Carolina,Managed Medicaid,,101.72,,,,,,,101.72,413.09,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SYRINGE,RX-122764,CDM,636,RC,J3475,HCPCS,00409175410,NDC,facility,outpatient,2,ML,53.10000,31.86000,WellCare of North Carolina,Managed Medicaid,,10.63,,,,,,,1.13,39.41,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION SYRINGE,RX-122799,CDM,636,RC,J2060,HCPCS,00409198503,NDC,facility,outpatient,0.25,ML,24.70000,14.82000,WellCare of North Carolina,Managed Medicaid,,4.94,,,,,,,3.26,18.33,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION SYRINGE,RX-122812,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,WellCare of North Carolina,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,00517760425,NDC,facility,outpatient,3,ML,61.25000,36.75000,WellCare of North Carolina,Managed Medicaid,,12.26,,,,,,,12.26,49.80,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION,RX-123,CDM,250,RC,J3490,HCPCS,63323069030,NDC,facility,outpatient,3,ML,27.90000,16.74000,WellCare of North Carolina,Managed Medicaid,,5.59,,,,,,,5.59,22.68,percent of total billed charges,
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET,RX-123642,CDM,250,RC,J3490,HCPCS,53329008986,NDC,facility,outpatient,1,UN,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET,RX-123643,CDM,250,RC,J3490,HCPCS,45802006070,NDC,facility,outpatient,1,UN,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION,RX-12370,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,10,ML,170.20000,102.12000,WellCare of North Carolina,Managed Medicaid,,34.07,,,,,,,0.16520,126.32,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,WellCare of North Carolina,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION SOLUTION,RX-123851,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,WellCare of North Carolina,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
WHITE PETROLATUM 41 % TOPICAL OINTMENT,RX-124059,CDM,250,RC,J3490,HCPCS,72140045231,NDC,facility,outpatient,50,GR,8.60000,5.16000,WellCare of North Carolina,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT,RX-124410,CDM,250,RC,J3490,HCPCS,46287050704,NDC,facility,outpatient,114,GR,16.55000,9.93000,WellCare of North Carolina,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
ESTRADIOL 0.5 MG TABLET,RX-12491,CDM,250,RC,J3490,HCPCS,42806008701,NDC,facility,outpatient,1,UN,16.30000,9.78000,WellCare of North Carolina,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,WellCare of North Carolina,Managed Medicaid,,23675.99,,,,,,,23675.99,87773.83,percent of total billed charges,
ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION,RX-125214,CDM,250,RC,J3490,HCPCS,00487990130,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564601,NDC,facility,outpatient,5,ML,125.45000,75.27000,WellCare of North Carolina,Managed Medicaid,,25.12,,,,,,,25.12,101.99,percent of total billed charges,
"MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN",RX-125470,CDM,250,RC,J3490,HCPCS,54643564700,NDC,facility,outpatient,50,ML,750.85000,450.51000,WellCare of North Carolina,Managed Medicaid,,150.32,,,,,,,150.32,610.44,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053404,NDC,facility,outpatient,118,ML,10.00000,6.00000,WellCare of North Carolina,Managed Medicaid,,2.00,,,,,,,2.00,8.13,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,RX-12556,CDM,250,RC,J3490,HCPCS,50580053408,NDC,facility,outpatient,236,ML,14.95000,8.97000,WellCare of North Carolina,Managed Medicaid,,2.99,,,,,,,2.99,12.15,percent of total billed charges,
CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-125580,CDM,636,RC,J0690,HCPCS,09999007202,NDC,facility,outpatient,100,ML,76.65000,45.99000,WellCare of North Carolina,Managed Medicaid,,15.35,,,,,,,1.89,56.89,percent of total billed charges,
OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-125594,CDM,250,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,500,ML,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,3.37,68.29,percent of total billed charges,
SODIUM CHLORIDE-ALOE VERA NASAL GEL,RX-125667,CDM,250,RC,J3490,HCPCS,00225052547,NDC,facility,outpatient,14.1,GR,5.35000,3.21000,WellCare of North Carolina,Managed Medicaid,,1.07,,,,,,,1.07,4.35,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION,RX-12580,CDM,250,RC,J3490,HCPCS,00487980101,NDC,facility,outpatient,2.5,ML,17.20000,10.32000,WellCare of North Carolina,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
CAFFEINE 200 MG TABLET,RX-1259,CDM,250,RC,J3490,HCPCS,10135017516,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE,RX-125994,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,1,ML,40.15000,24.09000,WellCare of North Carolina,Managed Medicaid,,8.04,,,,,,,8.04,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE,RX-125995,CDM,636,RC,J2175,HCPCS,00409117830,NDC,facility,outpatient,1,ML,44.70000,26.82000,WellCare of North Carolina,Managed Medicaid,,8.95,,,,,,,8.95,42.72,percent of total billed charges,
MEPERIDINE (PF) 100 MG/ML INJECTION SYRINGE,RX-125999,CDM,636,RC,J2175,HCPCS,00409118069,NDC,facility,outpatient,0.75,ML,36.40000,21.84000,WellCare of North Carolina,Managed Medicaid,,7.29,,,,,,,7.29,42.72,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055318,NDC,facility,outpatient,100,ML,84.90000,50.94000,WellCare of North Carolina,Managed Medicaid,,17.00,,,,,,,17.00,63.62,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK,RX-126012,CDM,258,RC,J3490,HCPCS,00338055311,NDC,facility,outpatient,50,ML,84.75000,50.85000,WellCare of North Carolina,Managed Medicaid,,16.97,,,,,,,16.97,63.50,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055118,NDC,facility,outpatient,100,ML,84.90000,50.94000,WellCare of North Carolina,Managed Medicaid,,17.00,,,,,,,4.27,63.62,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK,RX-126013,CDM,258,RC,J7060,HCPCS,00338055111,NDC,facility,outpatient,50,ML,82.95000,49.77000,WellCare of North Carolina,Managed Medicaid,,16.61,,,,,,,4.27,62.15,percent of total billed charges,
BCG LIVE 50 MG INTRAVESICAL SUSPENSION,RX-126040,CDM,636,RC,J9030,HCPCS,00052060202,NDC,facility,outpatient,1,UN,1052.35000,631.41000,WellCare of North Carolina,Managed Medicaid,,210.68,,,,,,,7.69,781.05,percent of total billed charges,
PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION,RX-126060,CDM,250,RC,J3490,HCPCS,10122051003,NDC,facility,outpatient,3,ML,5389.95000,3233.97000,WellCare of North Carolina,Managed Medicaid,,1079.07,,,,,,,1079.07,4382.03,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,WellCare of North Carolina,Managed Medicaid,,728.09,,,,,,,64.64,2699.23,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION,RX-126252,CDM,636,RC,J2003,HCPCS,63323020805,NDC,facility,outpatient,5,ML,33.10000,19.86000,WellCare of North Carolina,Managed Medicaid,,6.63,,,,,,,0.02360,24.57,percent of total billed charges,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,WellCare of North Carolina,Managed Medicaid,,3156.15,,,,,,,88.98,11700.78,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-126458,CDM,250,RC,J3490,HCPCS,39892083001,NDC,facility,outpatient,1,UN,2.90000,1.74000,WellCare of North Carolina,Managed Medicaid,,0.58058,,,,,,,0.58058,2.36,percent of total billed charges,
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION,RX-126554,CDM,636,RC,J0166,HCPCS,54288010310,NDC,facility,outpatient,0.1,ML,21.05000,12.63000,WellCare of North Carolina,Managed Medicaid,,4.21,,,,,,,2.50,15.62,percent of total billed charges,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,WellCare of North Carolina,Managed Medicaid,,86.25,,,,,,,86.25,417.81,percent of total billed charges,
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE,RX-126749,CDM,636,RC,90746,HCPCS,58160082143,NDC,facility,outpatient,1,ML,236.50000,141.90000,WellCare of North Carolina,Managed Medicaid,,47.35,,,,,,,47.35,196.28,percent of total billed charges,
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-127439,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,1,ML,64.90000,38.94000,WellCare of North Carolina,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-127496,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,50,ML,108.00000,64.80000,WellCare of North Carolina,Managed Medicaid,,21.62,,,,,,,1.13,80.16,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,RX-127584,CDM,250,RC,J3490,HCPCS,10119002239,NDC,facility,outpatient,3.5,GR,12.40000,7.44000,WellCare of North Carolina,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,RX-127646,CDM,636,RC,90714,HCPCS,49281021588,NDC,facility,outpatient,0.5,ML,144.25000,86.55000,WellCare of North Carolina,Managed Medicaid,,28.88,,,,,,,28.88,111.68,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.7 INTRAVENOUS SOLUTION,RX-127698,CDM,250,RC,J3490,HCPCS,00338113003,NDC,facility,outpatient,500,ML,289.80000,173.88000,WellCare of North Carolina,Managed Medicaid,,58.02,,,,,,,58.02,235.61,percent of total billed charges,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,WellCare of North Carolina,Managed Medicaid,,535.27,,,,,,,535.27,1984.42,percent of total billed charges,
"HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV",RX-127902,CDM,636,RC,J1644,HCPCS,00409762059,NDC,facility,outpatient,1000,ML,87.50000,52.50000,WellCare of North Carolina,Managed Medicaid,,17.52,,,,,,,0.49560,64.94,percent of total billed charges,
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY,RX-127972,CDM,250,RC,J3490,HCPCS,48582000155,NDC,facility,outpatient,44.3,ML,9.75000,5.85000,WellCare of North Carolina,Managed Medicaid,,1.95,,,,,,,1.95,7.93,percent of total billed charges,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,WellCare of North Carolina,Managed Medicaid,,667.95,,,,,,,667.95,2476.28,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,76329301505,NDC,facility,outpatient,5,ML,23.65000,14.19000,WellCare of North Carolina,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR,RX-127978,CDM,250,RC,J3490,HCPCS,25021067376,NDC,facility,outpatient,5,ML,30.90000,18.54000,WellCare of North Carolina,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (2 MG MAX DOSE),RX-127981,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,WellCare of North Carolina,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,WellCare of North Carolina,Managed Medicaid,,163.80,,,,,,,2.76,665.20,percent of total billed charges,
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION,RX-128013,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,5,ML,319.70000,191.82000,WellCare of North Carolina,Managed Medicaid,,64.00,,,,,,,7.13,237.28,percent of total billed charges,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,WellCare of North Carolina,Managed Medicaid,,197.18,,,,,,,137.63,800.72,percent of total billed charges,
PILOCARPINE 5 MG TABLET,RX-12803,CDM,250,RC,J3490,HCPCS,68084092895,NDC,facility,outpatient,1,UN,25.10000,15.06000,WellCare of North Carolina,Managed Medicaid,,5.03,,,,,,,5.03,20.41,percent of total billed charges,
INTERFERON BETA-1B 0.3 MG SUBCUTANEOUS KIT,RX-128084,CDM,636,RC,J1830,HCPCS,,,facility,outpatient,1,UN,1360.75000,816.45000,WellCare of North Carolina,Managed Medicaid,,272.42,,,,,,,272.42,1710.46,percent of total billed charges,
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-128099,CDM,636,RC,J1265,HCPCS,00409910420,NDC,facility,outpatient,10,ML,87.50000,52.50000,WellCare of North Carolina,Managed Medicaid,,17.52,,,,,,,1.80,64.94,percent of total billed charges,
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE,RX-128148,CDM,250,RC,J3490,HCPCS,70092247744,NDC,facility,outpatient,5,ML,217.35000,130.41000,WellCare of North Carolina,Managed Medicaid,,43.51,,,,,,,43.51,176.71,percent of total billed charges,
FENTANYL (PF) 250 MCG/5 ML (50 MCG/ML) INTRAVENOUS SYRINGE,RX-128197,CDM,636,RC,J3010,HCPCS,70092109844,NDC,facility,outpatient,5,ML,38.40000,23.04000,WellCare of North Carolina,Managed Medicaid,,7.69,,,,,,,2.60,28.50,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION,RX-128202,CDM,250,RC,J3490,HCPCS,60687024940,NDC,facility,outpatient,5,ML,39.20000,23.52000,WellCare of North Carolina,Managed Medicaid,,7.85,,,,,,,7.85,31.87,percent of total billed charges,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,WellCare of North Carolina,Managed Medicaid,,1250.81,,,,,,,7.71,4637.12,percent of total billed charges,
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET,RX-128364,CDM,250,RC,J3490,HCPCS,77333086110,NDC,facility,outpatient,1,UN,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
THYROID (PORK) 30 MG TABLET,RX-128492,CDM,250,RC,J3490,HCPCS,42192032901,NDC,facility,outpatient,1,UN,18.80000,11.28000,WellCare of North Carolina,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
THYROID (PORK) 90 MG TABLET,RX-128494,CDM,250,RC,J3490,HCPCS,42192033101,NDC,facility,outpatient,1,UN,20.80000,12.48000,WellCare of North Carolina,Managed Medicaid,,4.16,,,,,,,4.16,16.91,percent of total billed charges,
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION,RX-128540,CDM,250,RC,J7686,HCPCS,66302020603,NDC,facility,outpatient,11.6,ML,9504.40000,5702.64000,WellCare of North Carolina,Managed Medicaid,,1902.78,,,,,,,1878.77,7727.08,percent of total billed charges,
ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION,RX-128670,CDM,250,RC,J3490,HCPCS,00121131411,NDC,facility,outpatient,10.15,ML,3.85000,2.31000,WellCare of North Carolina,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
SODIUM CITRATE 4 % (3 ML) INTRA-CATHETER INJECTION SYRINGE,RX-128755,CDM,250,RC,J3490,HCPCS,70092114843,NDC,facility,outpatient,3,ML,57.75000,34.65000,WellCare of North Carolina,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,WellCare of North Carolina,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,WellCare of North Carolina,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,WellCare of North Carolina,Managed Medicaid,,52.45,,,,,,,0.20370,194.46,percent of total billed charges,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,WellCare of North Carolina,Managed Medicaid,,70.57,,,,,,,0.20370,261.63,percent of total billed charges,
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE,RX-128832,CDM,250,RC,J3490,HCPCS,74300000071,NDC,facility,outpatient,113,GR,10.85000,6.51000,WellCare of North Carolina,Managed Medicaid,,2.17,,,,,,,2.17,8.82,percent of total billed charges,
CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION,RX-12886,CDM,250,RC,J3490,HCPCS,00781602352,NDC,facility,outpatient,50,ML,298.60000,179.16000,WellCare of North Carolina,Managed Medicaid,,59.78,,,,,,,59.78,242.76,percent of total billed charges,
WITCH HAZEL 50 % TOPICAL PADS,RX-128861,CDM,250,RC,J3490,HCPCS,41388000730,NDC,facility,outpatient,1,UN,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,00005434462,NDC,facility,outpatient,15,ML,1.65000,0.99000,WellCare of North Carolina,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.40000,0.84000,WellCare of North Carolina,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID,RX-128932,CDM,250,RC,J3490,HCPCS,99999077751,NDC,facility,outpatient,15,ML,1.60000,0.96000,WellCare of North Carolina,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SYRINGE,RX-128936,CDM,636,RC,J2270,HCPCS,70092112548,NDC,facility,outpatient,30,ML,46.30000,27.78000,WellCare of North Carolina,Managed Medicaid,,9.27,,,,,,,5.14,34.36,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION,RX-128975,CDM,636,RC,J1720,HCPCS,00009001305,NDC,facility,outpatient,1,UN,218.65000,131.19000,WellCare of North Carolina,Managed Medicaid,,43.77,,,,,,,43.77,162.28,percent of total billed charges,
PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET,RX-129072,CDM,250,RC,J3490,HCPCS,69367026701,NDC,facility,outpatient,1,UN,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN DEXTROSE 5 % IV,RX-129095,CDM,250,RC,J3490,HCPCS,00338010820,NDC,facility,outpatient,250,ML,179.40000,107.64000,WellCare of North Carolina,Managed Medicaid,,35.92,,,,,,,35.92,145.85,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE,RX-129103,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,99.80000,59.88000,WellCare of North Carolina,Managed Medicaid,,19.98,,,,,,,2.17,74.07,percent of total billed charges,
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET,RX-129162,CDM,250,RC,J3490,HCPCS,77333093410,NDC,facility,outpatient,1,UN,1.30000,0.78000,WellCare of North Carolina,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION,RX-129312,CDM,636,RC,J3010,HCPCS,99999077768,NDC,facility,outpatient,50,ML,155.95000,93.57000,WellCare of North Carolina,Managed Medicaid,,31.22,,,,,,,2.60,115.75,percent of total billed charges,
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP,RX-129315,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,WellCare of North Carolina,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,636,RC,J7507,HCPCS,68084045011,NDC,facility,outpatient,1,UN,22.00000,13.20000,WellCare of North Carolina,Managed Medicaid,,4.40,,,,,,,0.40120,16.33,percent of total billed charges,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,WellCare of North Carolina,Managed Medicaid,,12.96,,,,,,,12.96,731.33,percent of total billed charges,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,WellCare of North Carolina,Managed Medicaid,,2397.64,,,,,,,47.49,8888.74,percent of total billed charges,
TETRACAINE HCL (PF) 0.5 % EYE DROPS,RX-129423,CDM,250,RC,J3490,HCPCS,00065074114,NDC,facility,outpatient,4,ML,57.65000,34.59000,WellCare of North Carolina,Managed Medicaid,,11.54,,,,,,,11.54,46.87,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SOLUTION",RX-129455,CDM,636,RC,J1644,HCPCS,71839011801,NDC,facility,outpatient,0.5,ML,34.20000,20.52000,WellCare of North Carolina,Managed Medicaid,,6.85,,,,,,,0.49560,25.38,percent of total billed charges,
AMIODARONE 450 MG/250 ML (1.8 MG/ML) IN DEXTROSE 5 % INTRAVENOUS SOLN,RX-129477,CDM,636,RC,J0282,HCPCS,70092100437,NDC,facility,outpatient,250,ML,80.50000,48.30000,WellCare of North Carolina,Managed Medicaid,,16.12,,,,,,,1.01,59.75,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE,RX-129607,CDM,636,RC,J2354,HCPCS,67457024500,NDC,facility,outpatient,0.25,ML,23.65000,14.19000,WellCare of North Carolina,Managed Medicaid,,4.73,,,,,,,1.44,17.55,percent of total billed charges,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,WellCare of North Carolina,Managed Medicaid,,1945.70,,,,,,,171.16,7213.29,percent of total billed charges,
EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION,RX-129810,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,outpatient,1,UN,249.90000,149.94000,WellCare of North Carolina,Managed Medicaid,,50.03,,,,,,,38.23,185.48,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121076616,NDC,facility,outpatient,8,ML,1.30000,0.78000,WellCare of North Carolina,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
"CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION",RX-1299,CDM,250,RC,J3490,HCPCS,00121476605,NDC,facility,outpatient,8,ML,7.35000,4.41000,WellCare of North Carolina,Managed Medicaid,,1.47,,,,,,,1.47,5.98,percent of total billed charges,
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-129978,CDM,636,RC,J2371,HCPCS,99999007900,NDC,facility,outpatient,250,ML,137.85000,82.71000,WellCare of North Carolina,Managed Medicaid,,27.60,,,,,,,0.02360,102.31,percent of total billed charges,
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION,RX-130109,CDM,250,RC,J3490,HCPCS,68094019359,NDC,facility,outpatient,5,ML,18.50000,11.10000,WellCare of North Carolina,Managed Medicaid,,3.70,,,,,,,3.70,15.04,percent of total billed charges,
"CALCIUM 600 MG (AS CALCIUM CARBONATE 1,500 MG) TABLET",RX-1302,CDM,250,RC,J3490,HCPCS,80681000500,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643565002,NDC,facility,outpatient,10,ML,80.75000,48.45000,WellCare of North Carolina,Managed Medicaid,,16.17,,,,,,,16.17,65.65,percent of total billed charges,
"MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION",RX-130235,CDM,250,RC,J3490,HCPCS,54643564901,NDC,facility,outpatient,10,ML,86.00000,51.60000,WellCare of North Carolina,Managed Medicaid,,17.22,,,,,,,17.22,69.92,percent of total billed charges,
ISOFLURANE 99.9 % INHALATION LIQUID,RX-130353,CDM,250,RC,J3490,HCPCS,66794001725,NDC,facility,outpatient,250,ML,180.00000,108.00000,WellCare of North Carolina,Managed Medicaid,,36.04,,,,,,,36.04,146.34,percent of total billed charges,
EPINEPHRINE HCL 8 MG/250 ML (32 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-130441,CDM,250,RC,J3490,HCPCS,99999008255,NDC,facility,outpatient,250,ML,97.15000,58.29000,WellCare of North Carolina,Managed Medicaid,,19.45,,,,,,,19.45,78.98,percent of total billed charges,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,WellCare of North Carolina,Managed Medicaid,,3894.26,,,,,,,73.58,14437.16,percent of total billed charges,
SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) INTRAVENOUS SYRINGE,RX-130528,CDM,250,RC,J3490,HCPCS,00409490024,NDC,facility,outpatient,10,ML,159.05000,95.43000,WellCare of North Carolina,Managed Medicaid,,31.84,,,,,,,31.84,129.31,percent of total billed charges,
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE,RX-1306,CDM,636,RC,J0618,HCPCS,00409492834,NDC,facility,outpatient,10,ML,93.85000,56.31000,WellCare of North Carolina,Managed Medicaid,,18.79,,,,,,,0.07080,69.66,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET,RX-1308,CDM,250,RC,J3490,HCPCS,80681014000,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.8 MG/2 ML (0.4 MG/ML) INTRAVENOUS SYRINGE,RX-130882,CDM,636,RC,J0461,HCPCS,70092117343,NDC,facility,outpatient,0.25,ML,70.45000,42.27000,WellCare of North Carolina,Managed Medicaid,,14.10,,,,,,,0.19800,52.29,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,5,ML,74.35000,44.61000,WellCare of North Carolina,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,outpatient,5,ML,74.35000,44.61000,WellCare of North Carolina,Managed Medicaid,,14.88,,,,,,,0.09440,55.18,percent of total billed charges,
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION,RX-1312,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,5,ML,84.05000,50.43000,WellCare of North Carolina,Managed Medicaid,,16.83,,,,,,,0.09440,62.38,percent of total billed charges,
VALACYCLOVIR 500 MG TABLET,RX-13133,CDM,250,RC,J3490,HCPCS,00378427577,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
CAPSAICIN 0.025 % TOPICAL CREAM,RX-1350,CDM,250,RC,J3490,HCPCS,00536252525,NDC,facility,outpatient,60,GR,11.80000,7.08000,WellCare of North Carolina,Managed Medicaid,,2.36,,,,,,,2.36,9.59,percent of total billed charges,
CARBAMAZEPINE 100 MG CHEWABLE TABLET,RX-1355,CDM,250,RC,J3490,HCPCS,00904385461,NDC,facility,outpatient,1,UN,18.05000,10.83000,WellCare of North Carolina,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CARBAMAZEPINE 200 MG TABLET,RX-1357,CDM,250,RC,J3490,HCPCS,51672400501,NDC,facility,outpatient,1,UN,17.65000,10.59000,WellCare of North Carolina,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
FLUCONAZOLE 150 MG TABLET,RX-13577,CDM,250,RC,J3490,HCPCS,68001025317,NDC,facility,outpatient,1,UN,24.10000,14.46000,WellCare of North Carolina,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
CARBAMIDE PEROXIDE 6.5 % EAR DROPS,RX-1359,CDM,250,RC,J3490,HCPCS,42037010479,NDC,facility,outpatient,15,ML,11.05000,6.63000,WellCare of North Carolina,Managed Medicaid,,2.21,,,,,,,2.21,8.98,percent of total billed charges,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,WellCare of North Carolina,Managed Medicaid,,1641.62,,,,,,,1641.62,6085.97,percent of total billed charges,
COLESTIPOL 1 GRAM TABLET,RX-13884,CDM,250,RC,J3490,HCPCS,00115521116,NDC,facility,outpatient,1,UN,20.15000,12.09000,WellCare of North Carolina,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
LAMOTRIGINE 25 MG TABLET,RX-13981,CDM,250,RC,J3490,HCPCS,68084031801,NDC,facility,outpatient,1,UN,16.75000,10.05000,WellCare of North Carolina,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
LAMOTRIGINE 100 MG TABLET,RX-13982,CDM,250,RC,J3490,HCPCS,00173064255,NDC,facility,outpatient,1,UN,61.70000,37.02000,WellCare of North Carolina,Managed Medicaid,,12.35,,,,,,,12.35,50.16,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION COMBINATION NO.1,RX-14123,CDM,250,RC,J3490,HCPCS,00065080050,NDC,facility,outpatient,500,ML,373.50000,224.10000,WellCare of North Carolina,Managed Medicaid,,74.77,,,,,,,74.77,303.66,percent of total billed charges,
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION,RX-14203,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,outpatient,1,ML,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,5.33,285.75,percent of total billed charges,
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION,RX-14233,CDM,250,RC,J3490,HCPCS,59762503001,NDC,facility,outpatient,35,ML,192.55000,115.53000,WellCare of North Carolina,Managed Medicaid,,38.55,,,,,,,38.55,156.54,percent of total billed charges,
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION,RX-1445,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1,UN,70.35000,42.21000,WellCare of North Carolina,Managed Medicaid,,14.08,,,,,,,1.89,52.21,percent of total billed charges,
CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION,RX-1446,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,1,UN,66.30000,39.78000,WellCare of North Carolina,Managed Medicaid,,13.27,,,,,,,1.89,49.21,percent of total billed charges,
DORZOLAMIDE 2 % EYE DROPS,RX-14471,CDM,250,RC,J3490,HCPCS,61314001910,NDC,facility,outpatient,10,ML,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
TERAZOSIN 1 MG CAPSULE,RX-14550,CDM,250,RC,J3490,HCPCS,59746038306,NDC,facility,outpatient,1,UN,16.75000,10.05000,WellCare of North Carolina,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TERAZOSIN 5 MG CAPSULE,RX-14553,CDM,250,RC,J3490,HCPCS,59746038506,NDC,facility,outpatient,1,UN,16.75000,10.05000,WellCare of North Carolina,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
TRAMADOL 50 MG TABLET,RX-14632,CDM,250,RC,J3490,HCPCS,51079099101,NDC,facility,outpatient,1,UN,22.25000,13.35000,WellCare of North Carolina,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION,RX-1465,CDM,636,RC,J0697,HCPCS,00143997922,NDC,facility,outpatient,1,UN,29.30000,17.58000,WellCare of North Carolina,Managed Medicaid,,5.87,,,,,,,4.37,21.75,percent of total billed charges,
METFORMIN 850 MG TABLET,RX-14719,CDM,250,RC,J3490,HCPCS,60687014311,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
TIZANIDINE 4 MG TABLET,RX-14793,CDM,250,RC,J3490,HCPCS,00904641861,NDC,facility,outpatient,1,UN,18.15000,10.89000,WellCare of North Carolina,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
LOSARTAN 25 MG TABLET,RX-14823,CDM,250,RC,J3490,HCPCS,31722070090,NDC,facility,outpatient,1,UN,16.35000,9.81000,WellCare of North Carolina,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
LOSARTAN 50 MG TABLET,RX-14824,CDM,250,RC,J3490,HCPCS,68084034711,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,250,ML,112.90000,67.74000,WellCare of North Carolina,Managed Medicaid,,22.60,,,,,,,1.80,83.79,percent of total billed charges,
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14846,CDM,636,RC,J1265,HCPCS,00338100902,NDC,facility,outpatient,250,ML,132.15000,79.29000,WellCare of North Carolina,Managed Medicaid,,26.46,,,,,,,1.80,98.08,percent of total billed charges,
DOXYLAMINE SUCCINATE 25 MG TABLET,RX-14847,CDM,250,RC,J3490,HCPCS,41167000609,NDC,facility,outpatient,1,UN,1.40000,0.84000,WellCare of North Carolina,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION,RX-14869,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,250,ML,90.15000,54.09000,WellCare of North Carolina,Managed Medicaid,,18.05,,,,,,,0.02360,66.91,percent of total billed charges,
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION,RX-14953,CDM,250,RC,J3490,HCPCS,00173054700,NDC,facility,outpatient,5,ML,148.65000,89.19000,WellCare of North Carolina,Managed Medicaid,,29.76,,,,,,,29.76,120.85,percent of total billed charges,
"WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION",RX-14979,CDM,250,RC,J3490,HCPCS,00409397701,NDC,facility,outpatient,30,ML,44.55000,26.73000,WellCare of North Carolina,Managed Medicaid,,8.92,,,,,,,8.92,36.22,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,250,RC,J3490,HCPCS,63323046157,NDC,facility,outpatient,50,ML,104.30000,62.58000,WellCare of North Carolina,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION",RX-14984,CDM,250,RC,J3490,HCPCS,00409904601,NDC,facility,outpatient,5,ML,20.25000,12.15000,WellCare of North Carolina,Managed Medicaid,,4.05,,,,,,,4.05,16.46,percent of total billed charges,
MYCOPHENOLATE MOFETIL 250 MG CAPSULE,RX-15113,CDM,636,RC,J7517,HCPCS,51079072101,NDC,facility,outpatient,1,UN,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,0.37760,13.25,percent of total billed charges,
SEVOFLURANE 99.97 % INHALATION LIQUID,RX-15119,CDM,250,RC,J3490,HCPCS,10019065164,NDC,facility,outpatient,250,ML,346.00000,207.60000,WellCare of North Carolina,Managed Medicaid,,69.27,,,,,,,69.27,281.30,percent of total billed charges,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,WellCare of North Carolina,Managed Medicaid,,253.03,,,,,,,61.17,938.07,percent of total billed charges,
SUMATRIPTAN 50 MG TABLET,RX-15328,CDM,250,RC,J3490,HCPCS,63304009811,NDC,facility,outpatient,1,UN,23.05000,13.83000,WellCare of North Carolina,Managed Medicaid,,4.61,,,,,,,4.61,18.74,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,55150019201,NDC,facility,outpatient,20,ML,452.80000,271.68000,WellCare of North Carolina,Managed Medicaid,,90.65,,,,,,,1.25,336.07,percent of total billed charges,
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION,RX-15330,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,outpatient,30,ML,907.80000,544.68000,WellCare of North Carolina,Managed Medicaid,,181.74,,,,,,,1.25,673.77,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,15,ML,1.75000,1.05000,WellCare of North Carolina,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
CHERRY FLAVOR (BULK) ORAL LIQUID,RX-1562,CDM,250,RC,J3490,HCPCS,31722093847,NDC,facility,outpatient,15,ML,1.70000,1.02000,WellCare of North Carolina,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121119030,NDC,facility,outpatient,30,ML,8.90000,5.34000,WellCare of North Carolina,Managed Medicaid,,1.78,,,,,,,1.78,7.24,percent of total billed charges,
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION,RX-15706,CDM,250,RC,J3490,HCPCS,00121059516,NDC,facility,outpatient,473,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
SOTALOL 120 MG TABLET,RX-15723,CDM,250,RC,J3490,HCPCS,60505022301,NDC,facility,outpatient,1,UN,18.60000,11.16000,WellCare of North Carolina,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY,RX-15738,CDM,250,RC,J3490,HCPCS,60505082306,NDC,facility,outpatient,3.7,ML,240.65000,144.39000,WellCare of North Carolina,Managed Medicaid,,48.18,,,,,,,48.18,195.65,percent of total billed charges,
CARVEDILOL 6.25 MG TABLET,RX-15747,CDM,250,RC,J3490,HCPCS,68462016301,NDC,facility,outpatient,1,UN,16.25000,9.75000,WellCare of North Carolina,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
CARVEDILOL 12.5 MG TABLET,RX-15749,CDM,250,RC,J3490,HCPCS,51079093101,NDC,facility,outpatient,1,UN,16.55000,9.93000,WellCare of North Carolina,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION,RX-15797,CDM,250,RC,J3490,HCPCS,00093202694,NDC,facility,outpatient,22.5,ML,94.55000,56.73000,WellCare of North Carolina,Managed Medicaid,,18.93,,,,,,,18.93,76.87,percent of total billed charges,
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION,RX-15852,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,1,ML,28.30000,16.98000,WellCare of North Carolina,Managed Medicaid,,5.67,,,,,,,5.67,29.37,percent of total billed charges,
NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS,RX-15858,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,250,ML,134.75000,80.85000,WellCare of North Carolina,Managed Medicaid,,26.98,,,,,,,3.52,100.01,percent of total billed charges,
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15859,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,250,ML,141.75000,85.05000,WellCare of North Carolina,Managed Medicaid,,28.38,,,,,,,3.52,105.21,percent of total billed charges,
LAMIVUDINE 150 MG TABLET,RX-15880,CDM,250,RC,J3490,HCPCS,49702020318,NDC,facility,outpatient,1,UN,43.75000,26.25000,WellCare of North Carolina,Managed Medicaid,,8.76,,,,,,,8.76,35.57,percent of total billed charges,
LAMIVUDINE 10 MG/ML ORAL SOLUTION,RX-15881,CDM,250,RC,J3490,HCPCS,49702020548,NDC,facility,outpatient,240,ML,348.65000,209.19000,WellCare of North Carolina,Managed Medicaid,,69.80,,,,,,,69.80,283.45,percent of total billed charges,
SODIUM HYPOCHLORITE 0.25 % SOLUTION,RX-15950,CDM,250,RC,J3490,HCPCS,00436093616,NDC,facility,outpatient,473,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,00409120901,NDC,facility,outpatient,1,ML,20.95000,12.57000,WellCare of North Carolina,Managed Medicaid,,4.19,,,,,,,0.02360,15.55,percent of total billed charges,
"LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION",RX-15956,CDM,636,RC,J2004,HCPCS,63323048837,NDC,facility,outpatient,1,ML,18.75000,11.25000,WellCare of North Carolina,Managed Medicaid,,3.75,,,,,,,0.02360,13.92,percent of total billed charges,
DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS,RX-15981,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ML,141.75000,85.05000,WellCare of North Carolina,Managed Medicaid,,28.38,,,,,,,16.71,105.21,percent of total billed charges,
"DOBUTAMINE 1,000 MG/250 ML(4,000 MCG/ML) IN 5 % DEXTROSE IV",RX-15982,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,250,ML,164.50000,98.70000,WellCare of North Carolina,Managed Medicaid,,32.93,,,,,,,16.71,122.09,percent of total billed charges,
METHADONE 10 MG/ML ORAL CONCENTRATE,RX-15996,CDM,250,RC,J3490,HCPCS,00054039268,NDC,facility,outpatient,1000,ML,175.00000,105.00000,WellCare of North Carolina,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
ISOPROPYL ALCOHOL 70 % SOLUTION,RX-16013,CDM,250,RC,J3490,HCPCS,00869081043,NDC,facility,outpatient,473,ML,3.20000,1.92000,WellCare of North Carolina,Managed Medicaid,,0.64064,,,,,,,0.64064,2.60,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS,RX-16014,CDM,636,RC,J3480,HCPCS,00338081104,NDC,facility,outpatient,1000,ML,101.50000,60.90000,WellCare of North Carolina,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
GLUCOSE 4 GRAM CHEWABLE TABLET,RX-16050,CDM,250,RC,J3490,HCPCS,09999197825,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY,RX-16070,CDM,250,RC,J3490,HCPCS,00054004544,NDC,facility,outpatient,30,ML,124.00000,74.40000,WellCare of North Carolina,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY,RX-16071,CDM,250,RC,J3490,HCPCS,00054004641,NDC,facility,outpatient,15,ML,124.00000,74.40000,WellCare of North Carolina,Managed Medicaid,,24.82,,,,,,,24.82,100.81,percent of total billed charges,
MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK,RX-16162,CDM,636,RC,J3475,HCPCS,00409672723,NDC,facility,outpatient,100,ML,91.70000,55.02000,WellCare of North Carolina,Managed Medicaid,,18.36,,,,,,,1.13,68.06,percent of total billed charges,
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION,RX-16168,CDM,250,RC,J3490,HCPCS,63323041605,NDC,facility,outpatient,5,ML,79.70000,47.82000,WellCare of North Carolina,Managed Medicaid,,15.96,,,,,,,15.96,64.80,percent of total billed charges,
CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION,RX-16169,CDM,250,RC,J3490,HCPCS,00781315380,NDC,facility,outpatient,20,ML,471.00000,282.60000,WellCare of North Carolina,Managed Medicaid,,94.29,,,,,,,94.29,382.92,percent of total billed charges,
ANASTROZOLE 1 MG TABLET,RX-16205,CDM,250,RC,J3490,HCPCS,16729003510,NDC,facility,outpatient,1,UN,26.20000,15.72000,WellCare of North Carolina,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
CALCITRIOL 1 MCG/ML ORAL SOLUTION,RX-16218,CDM,250,RC,J3490,HCPCS,00054312041,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,WellCare of North Carolina,Managed Medicaid,,4.64,,,,,,,4.64,18.86,percent of total billed charges,
CHLORDIAZEPOXIDE 10 MG CAPSULE,RX-1622,CDM,250,RC,J3490,HCPCS,51079037501,NDC,facility,outpatient,1,UN,23.50000,14.10000,WellCare of North Carolina,Managed Medicaid,,4.70,,,,,,,4.70,19.11,percent of total billed charges,
CHLORDIAZEPOXIDE 25 MG CAPSULE,RX-1623,CDM,250,RC,J3490,HCPCS,00555015902,NDC,facility,outpatient,1,UN,22.50000,13.50000,WellCare of North Carolina,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
CHLORDIAZEPOXIDE 5 MG CAPSULE,RX-1624,CDM,250,RC,J3490,HCPCS,00555015802,NDC,facility,outpatient,1,UN,22.60000,13.56000,WellCare of North Carolina,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,WellCare of North Carolina,Managed Medicaid,,2779.01,,,,,,,711.66,10302.59,percent of total billed charges,
DARUNAVIR 800 MG TABLET,RX-162827,CDM,250,RC,J3490,HCPCS,59676056630,NDC,facility,outpatient,1,UN,303.80000,182.28000,WellCare of North Carolina,Managed Medicaid,,60.82,,,,,,,60.82,246.99,percent of total billed charges,
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,RX-16299,CDM,250,RC,J3490,HCPCS,87701055284,NDC,facility,outpatient,28.4,GR,4.25000,2.55000,WellCare of North Carolina,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
APIXABAN 2.5 MG TABLET,RX-163024,CDM,250,RC,J3490,HCPCS,00003089331,NDC,facility,outpatient,1,UN,56.45000,33.87000,WellCare of North Carolina,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
APIXABAN 5 MG TABLET,RX-163141,CDM,250,RC,J3490,HCPCS,00003089431,NDC,facility,outpatient,1,UN,56.45000,33.87000,WellCare of North Carolina,Managed Medicaid,,11.30,,,,,,,11.30,45.89,percent of total billed charges,
LEVONORGESTREL 14 MCG/24 HR (UP TO 3 YRS) 13.5 MG INTRAUTERINE DEVICE,RX-163231,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,outpatient,1,UN,4065.55000,2439.33000,WellCare of North Carolina,Managed Medicaid,,813.92,,,,,,,813.92,3304.19,percent of total billed charges,
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION,RX-1634,CDM,636,RC,J2401,HCPCS,00143920901,NDC,facility,outpatient,20,ML,113.05000,67.83000,WellCare of North Carolina,Managed Medicaid,,22.63,,,,,,,0.09440,83.91,percent of total billed charges,
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION,RX-1635,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,20,ML,117.85000,70.71000,WellCare of North Carolina,Managed Medicaid,,23.59,,,,,,,0.09440,87.47,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,WellCare of North Carolina,Managed Medicaid,,3569.45,,,,,,,40.90,13232.98,percent of total billed charges,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,WellCare of North Carolina,Managed Medicaid,,5678.07,,,,,,,40.90,21050.28,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR INJECTION,RX-16371,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,WellCare of North Carolina,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN,RX-163710,CDM,250,RC,J3490,HCPCS,10119000252,NDC,facility,outpatient,118,ML,6.15000,3.69000,WellCare of North Carolina,Managed Medicaid,,1.23,,,,,,,1.23,5.00,percent of total billed charges,
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION,RX-1649,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,1,ML,147.45000,88.47000,WellCare of North Carolina,Managed Medicaid,,29.52,,,,,,,29.52,109.44,percent of total billed charges,
CHLORPROMAZINE 100 MG TABLET,RX-1654,CDM,250,RC,J3490,HCPCS,69238106001,NDC,facility,outpatient,1,UN,25.05000,15.03000,WellCare of North Carolina,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
CHLORPROMAZINE 25 MG TABLET,RX-1656,CDM,250,RC,J3490,HCPCS,51079051901,NDC,facility,outpatient,1,UN,41.50000,24.90000,WellCare of North Carolina,Managed Medicaid,,8.31,,,,,,,8.31,33.74,percent of total billed charges,
CHLORTHALIDONE 25 MG TABLET,RX-1661,CDM,250,RC,J3490,HCPCS,51079005801,NDC,facility,outpatient,1,UN,23.70000,14.22000,WellCare of North Carolina,Managed Medicaid,,4.74,,,,,,,4.74,19.27,percent of total billed charges,
PAROXETINE 10 MG TABLET,RX-16632,CDM,250,RC,J3490,HCPCS,00904567661,NDC,facility,outpatient,1,UN,19.20000,11.52000,WellCare of North Carolina,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
"DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE",RX-168114,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,0.5,ML,161.50000,96.90000,WellCare of North Carolina,Managed Medicaid,,32.33,,,,,,,32.33,128.86,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK,RX-168143,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-168273,CDM,250,RC,J3490,HCPCS,00173085914,NDC,facility,outpatient,1,UN,486.70000,292.02000,WellCare of North Carolina,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
MELATONIN 3 MG TABLET,RX-16830,CDM,250,RC,J3490,HCPCS,31604002741,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION,RX-168440,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ML,97.90000,58.74000,WellCare of North Carolina,Managed Medicaid,,19.60,,,,,,,1.82,72.66,percent of total billed charges,
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION,RX-1685,CDM,250,RC,J3490,HCPCS,00409409301,NDC,facility,outpatient,3.75,ML,94.25000,56.55000,WellCare of North Carolina,Managed Medicaid,,18.87,,,,,,,18.87,76.63,percent of total billed charges,
COPPER 380 SQUARE MM INTRAUTERINE DEVICE,RX-168623,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,outpatient,1,UN,4576.00000,2745.60000,WellCare of North Carolina,Managed Medicaid,,916.12,,,,,,,916.12,3718.93,percent of total billed charges,
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN,RX-168624,CDM,250,RC,J3490,HCPCS,00942064104,NDC,facility,outpatient,3000,ML,153.00000,91.80000,WellCare of North Carolina,Managed Medicaid,,30.63,,,,,,,30.63,124.39,percent of total billed charges,
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION,RX-168748,CDM,250,RC,J3490,HCPCS,00378804321,NDC,facility,outpatient,1,ML,24.05000,14.43000,WellCare of North Carolina,Managed Medicaid,,4.81,,,,,,,4.81,19.55,percent of total billed charges,
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT,RX-168777,CDM,250,RC,J3490,HCPCS,00536128806,NDC,facility,outpatient,57,GR,4.80000,2.88000,WellCare of North Carolina,Managed Medicaid,,0.96096,,,,,,,0.96096,3.90,percent of total billed charges,
DOLUTEGRAVIR 50 MG TABLET,RX-168817,CDM,250,RC,J3490,HCPCS,49702022813,NDC,facility,outpatient,1,UN,326.05000,195.63000,WellCare of North Carolina,Managed Medicaid,,65.28,,,,,,,65.28,265.08,percent of total billed charges,
VORTIOXETINE 5 MG TABLET,RX-169081,CDM,250,RC,J3490,HCPCS,64764072030,NDC,facility,outpatient,1,UN,84.60000,50.76000,WellCare of North Carolina,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
VORTIOXETINE 10 MG TABLET,RX-169082,CDM,250,RC,J3490,HCPCS,64764073030,NDC,facility,outpatient,1,UN,84.60000,50.76000,WellCare of North Carolina,Managed Medicaid,,16.94,,,,,,,16.94,68.78,percent of total billed charges,
RIOCIGUAT 0.5 MG TABLET,RX-169109,CDM,250,RC,J3490,HCPCS,50419025091,NDC,facility,outpatient,1,UN,643.15000,385.89000,WellCare of North Carolina,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
RIOCIGUAT 2 MG TABLET,RX-169112,CDM,250,RC,J3490,HCPCS,50419025391,NDC,facility,outpatient,1,UN,643.15000,385.89000,WellCare of North Carolina,Managed Medicaid,,128.76,,,,,,,128.76,522.88,percent of total billed charges,
"HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR",RX-17010,CDM,250,RC,J3490,HCPCS,16477073801,NDC,facility,outpatient,1,UN,17.20000,10.32000,WellCare of North Carolina,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION,RX-17012,CDM,636,RC,J9040,HCPCS,00409032320,NDC,facility,outpatient,1,UN,549.95000,329.97000,WellCare of North Carolina,Managed Medicaid,,110.10,,,,,,,50.79,408.17,percent of total billed charges,
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION,RX-170902,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,WellCare of North Carolina,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION,RX-170903,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,0.5,ML,22.35000,13.41000,WellCare of North Carolina,Managed Medicaid,,4.47,,,,,,,0.35400,16.59,percent of total billed charges,
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY,RX-171001,CDM,250,RC,J3490,HCPCS,00573288311,NDC,facility,outpatient,1,UN,1.85000,1.11000,WellCare of North Carolina,Managed Medicaid,,0.37037,,,,,,,0.37037,1.50,percent of total billed charges,
PERAMPANEL 2 MG TABLET,RX-171113,CDM,250,RC,J3490,HCPCS,69616027230,NDC,facility,outpatient,1,UN,84.10000,50.46000,WellCare of North Carolina,Managed Medicaid,,16.84,,,,,,,16.84,68.37,percent of total billed charges,
GEMCITABINE 200 MG INTRAVENOUS SOLUTION,RX-17121,CDM,636,RC,J9201,HCPCS,00409018501,NDC,facility,outpatient,1,UN,324.35000,194.61000,WellCare of North Carolina,Managed Medicaid,,64.93,,,,,,,7.39,240.73,percent of total billed charges,
GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION,RX-17122,CDM,636,RC,J9201,HCPCS,25021023550,NDC,facility,outpatient,1,UN,493.50000,296.10000,WellCare of North Carolina,Managed Medicaid,,98.80,,,,,,,7.39,366.28,percent of total billed charges,
DROXIDOPA 100 MG CAPSULE,RX-171862,CDM,250,RC,J3490,HCPCS,63304008690,NDC,facility,outpatient,1,UN,20.45000,12.27000,WellCare of North Carolina,Managed Medicaid,,4.09,,,,,,,4.09,16.63,percent of total billed charges,
DROXIDOPA 200 MG CAPSULE,RX-171863,CDM,250,RC,J3490,HCPCS,67386082119,NDC,facility,outpatient,1,UN,357.15000,214.29000,WellCare of North Carolina,Managed Medicaid,,71.50,,,,,,,71.50,290.36,percent of total billed charges,
DROXIDOPA 300 MG CAPSULE,RX-171864,CDM,250,RC,J3490,HCPCS,67386082219,NDC,facility,outpatient,1,UN,527.70000,316.62000,WellCare of North Carolina,Managed Medicaid,,105.65,,,,,,,105.65,429.02,percent of total billed charges,
EMPAGLIFLOZIN 25 MG TABLET,RX-171941,CDM,250,RC,J3490,HCPCS,00597015330,NDC,facility,outpatient,1,UN,99.95000,59.97000,WellCare of North Carolina,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
EMPAGLIFLOZIN 10 MG TABLET,RX-171943,CDM,250,RC,J3490,HCPCS,00597015230,NDC,facility,outpatient,1,UN,99.95000,59.97000,WellCare of North Carolina,Managed Medicaid,,20.01,,,,,,,20.01,81.26,percent of total billed charges,
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION,RX-172072,CDM,250,RC,J3490,HCPCS,00173086906,NDC,facility,outpatient,1,UN,368.65000,221.19000,WellCare of North Carolina,Managed Medicaid,,73.80,,,,,,,73.80,299.71,percent of total billed charges,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,WellCare of North Carolina,Managed Medicaid,,1279.76,,,,,,,299.42,4744.44,percent of total billed charges,
MORPHINE 2 MG/ML INTRAVENOUS SYRINGE,RX-172210,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,1,ML,28.40000,17.04000,WellCare of North Carolina,Managed Medicaid,,5.69,,,,,,,5.14,21.08,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,WellCare of North Carolina,Managed Medicaid,,1377.08,,,,,,,72.13,5105.22,percent of total billed charges,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,WellCare of North Carolina,Managed Medicaid,,6665.14,,,,,,,72.13,24709.62,percent of total billed charges,
SELEGILINE 5 MG CAPSULE,RX-17280,CDM,250,RC,J3490,HCPCS,60505005501,NDC,facility,outpatient,1,UN,22.70000,13.62000,WellCare of North Carolina,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CYCLOPHOSPHAMIDE 25 MG CAPSULE,RX-173082,CDM,636,RC,J8530,HCPCS,00054038225,NDC,facility,outpatient,1,UN,55.00000,33.00000,WellCare of North Carolina,Managed Medicaid,,11.01,,,,,,,2.60,40.82,percent of total billed charges,
CYCLOPHOSPHAMIDE 50 MG CAPSULE,RX-173083,CDM,636,RC,J8530,HCPCS,00054038325,NDC,facility,outpatient,1,UN,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,2.60,59.38,percent of total billed charges,
"GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR",RX-173085,CDM,250,RC,J3490,HCPCS,63824000815,NDC,facility,outpatient,1,UN,1.70000,1.02000,WellCare of North Carolina,Managed Medicaid,,0.34034,,,,,,,0.34034,1.38,percent of total billed charges,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,WellCare of North Carolina,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,WellCare of North Carolina,Managed Medicaid,,7882.80,,,,,,,20.67,29223.87,percent of total billed charges,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,WellCare of North Carolina,Managed Medicaid,,1623.83,,,,,,,15.14,6020.02,percent of total billed charges,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,WellCare of North Carolina,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
RISPERIDONE 1 MG/ML ORAL SOLUTION,RX-17377,CDM,250,RC,J3490,HCPCS,50458059601,NDC,facility,outpatient,30,ML,381.35000,228.81000,WellCare of North Carolina,Managed Medicaid,,76.35,,,,,,,76.35,310.04,percent of total billed charges,
MEROPENEM 500 MG INTRAVENOUS SOLUTION,RX-17379,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,1,UN,75.60000,45.36000,WellCare of North Carolina,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION,RX-17380,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,WellCare of North Carolina,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,WellCare of North Carolina,Managed Medicaid,,419.08,,,,,,,7.71,1553.65,percent of total billed charges,
DANTROLENE 250 MG INTRAVENOUS SUSPENSION,RX-173869,CDM,250,RC,J3490,HCPCS,42367054032,NDC,facility,outpatient,1,UN,13983.35000,8390.01000,WellCare of North Carolina,Managed Medicaid,,2799.47,,,,,,,2799.47,11368.46,percent of total billed charges,
CLINDAMYCIN HCL 150 MG CAPSULE,RX-1740,CDM,250,RC,J3490,HCPCS,68084024311,NDC,facility,outpatient,1,UN,17.80000,10.68000,WellCare of North Carolina,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-17405,CDM,636,RC,J1815,HCPCS,00024592410,NDC,facility,outpatient,10,ML,462.25000,277.35000,WellCare of North Carolina,Managed Medicaid,,92.54,,,,,,,0.54280,343.08,percent of total billed charges,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,WellCare of North Carolina,Managed Medicaid,,219.22,,,,,,,150.45,812.71,percent of total billed charges,
BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH,RX-174289,CDM,250,RC,J3490,HCPCS,42858035340,NDC,facility,outpatient,1,UN,247.50000,148.50000,WellCare of North Carolina,Managed Medicaid,,49.55,,,,,,,49.55,201.22,percent of total billed charges,
BUSPIRONE 15 MG TABLET,RX-17464,CDM,250,RC,J3490,HCPCS,00093100301,NDC,facility,outpatient,1,UN,16.40000,9.84000,WellCare of North Carolina,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COBICISTAT 150 MG TABLET,RX-174722,CDM,250,RC,J3490,HCPCS,61958140101,NDC,facility,outpatient,1,UN,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,WellCare of North Carolina,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION,RX-174932,CDM,636,RC,J2598,HCPCS,42023019001,NDC,facility,outpatient,0.25,ML,38.75000,23.25000,WellCare of North Carolina,Managed Medicaid,,7.76,,,,,,,2.19,28.76,percent of total billed charges,
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175253,CDM,250,RC,J3490,HCPCS,00173087306,NDC,facility,outpatient,1,UN,241.15000,144.69000,WellCare of North Carolina,Managed Medicaid,,48.28,,,,,,,48.28,196.05,percent of total billed charges,
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175263,CDM,250,RC,J3490,HCPCS,00173087414,NDC,facility,outpatient,1,UN,307.90000,184.74000,WellCare of North Carolina,Managed Medicaid,,61.64,,,,,,,61.64,250.32,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION,RX-175264,CDM,250,RC,J3490,HCPCS,00173087614,NDC,facility,outpatient,1,UN,406.80000,244.08000,WellCare of North Carolina,Managed Medicaid,,81.44,,,,,,,81.44,330.73,percent of total billed charges,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,WellCare of North Carolina,Managed Medicaid,,162.03,,,,,,,8.80,600.70,percent of total billed charges,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,WellCare of North Carolina,Managed Medicaid,,1221.21,,,,,,,31.97,4527.38,percent of total billed charges,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,WellCare of North Carolina,Managed Medicaid,,2970.42,,,,,,,31.97,11012.21,percent of total billed charges,
CLONIDINE HCL 0.1 MG TABLET,RX-1755,CDM,250,RC,J3490,HCPCS,68001023700,NDC,facility,outpatient,1,UN,16.20000,9.72000,WellCare of North Carolina,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLONIDINE HCL 0.2 MG TABLET,RX-1756,CDM,250,RC,J3490,HCPCS,68001023800,NDC,facility,outpatient,1,UN,16.25000,9.75000,WellCare of North Carolina,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
"MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE",RX-175606,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,outpatient,0.5,ML,731.15000,438.69000,WellCare of North Carolina,Managed Medicaid,,146.38,,,,,,,146.38,774.28,percent of total billed charges,
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175608,CDM,250,RC,J3490,HCPCS,59011041020,NDC,facility,outpatient,1,UN,39.50000,23.70000,WellCare of North Carolina,Managed Medicaid,,7.91,,,,,,,7.91,32.11,percent of total billed charges,
"OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175609,CDM,250,RC,J3490,HCPCS,59011041520,NDC,facility,outpatient,1,UN,47.70000,28.62000,WellCare of North Carolina,Managed Medicaid,,9.55,,,,,,,9.55,38.78,percent of total billed charges,
"OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175610,CDM,250,RC,J3490,HCPCS,59011042020,NDC,facility,outpatient,1,UN,54.55000,32.73000,WellCare of North Carolina,Managed Medicaid,,10.92,,,,,,,10.92,44.35,percent of total billed charges,
"OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-175612,CDM,250,RC,J3490,HCPCS,59011044020,NDC,facility,outpatient,1,UN,77.70000,46.62000,WellCare of North Carolina,Managed Medicaid,,15.56,,,,,,,15.56,63.17,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,WellCare of North Carolina,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,WellCare of North Carolina,Managed Medicaid,,5250.24,,,,,,,58.48,19464.19,percent of total billed charges,
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET,RX-1759,CDM,250,RC,J3490,HCPCS,51672404201,NDC,facility,outpatient,1,UN,25.00000,15.00000,WellCare of North Carolina,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
NALOXEGOL 12.5 MG TABLET,RX-176010,CDM,250,RC,J3490,HCPCS,82625880101,NDC,facility,outpatient,1,UN,74.20000,44.52000,WellCare of North Carolina,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
NALOXEGOL 25 MG TABLET,RX-176011,CDM,250,RC,J3490,HCPCS,82625880203,NDC,facility,outpatient,1,UN,74.20000,44.52000,WellCare of North Carolina,Managed Medicaid,,14.85,,,,,,,14.85,60.32,percent of total billed charges,
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV,RX-176034,CDM,250,RC,J3490,HCPCS,00409330101,NDC,facility,outpatient,20,ML,109.30000,65.58000,WellCare of North Carolina,Managed Medicaid,,21.88,,,,,,,21.88,88.86,percent of total billed charges,
SOTALOL 5 MG/ML ORAL SOLUTION,RX-176080,CDM,250,RC,J3490,HCPCS,24338053025,NDC,facility,outpatient,250,ML,1780.00000,1068.00000,WellCare of North Carolina,Managed Medicaid,,356.36,,,,,,,356.36,1447.14,percent of total billed charges,
IVABRADINE 5 MG TABLET,RX-176622,CDM,250,RC,J3490,HCPCS,55513080060,NDC,facility,outpatient,1,UN,57.75000,34.65000,WellCare of North Carolina,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
IVABRADINE 7.5 MG TABLET,RX-176623,CDM,250,RC,J3490,HCPCS,55513081060,NDC,facility,outpatient,1,UN,57.75000,34.65000,WellCare of North Carolina,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,WellCare of North Carolina,Managed Medicaid,,4208.24,,,,,,,197.47,15601.19,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,WellCare of North Carolina,Managed Medicaid,,6299.92,,,,,,,197.47,23355.66,percent of total billed charges,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,WellCare of North Carolina,Managed Medicaid,,3212.74,,,,,,,197.47,11910.57,percent of total billed charges,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,WellCare of North Carolina,Managed Medicaid,,361.87,,,,,,,101.59,1341.56,percent of total billed charges,
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE,RX-176660,CDM,636,RC,J7297,HCPCS,00023585801,NDC,facility,outpatient,1,UN,3746.95000,2248.17000,WellCare of North Carolina,Managed Medicaid,,750.14,,,,,,,750.14,3043.97,percent of total billed charges,
CLOTRIMAZOLE 1 % TOPICAL CREAM,RX-1767,CDM,250,RC,J3490,HCPCS,45802043411,NDC,facility,outpatient,30,GR,8.10000,4.86000,WellCare of North Carolina,Managed Medicaid,,1.62,,,,,,,1.62,6.59,percent of total billed charges,
CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK,RX-176919,CDM,636,RC,J0690,HCPCS,09999199014,NDC,facility,outpatient,100,ML,94.50000,56.70000,WellCare of North Carolina,Managed Medicaid,,18.92,,,,,,,1.89,70.14,percent of total billed charges,
FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER,RX-177070,CDM,250,RC,J3490,HCPCS,00173088214,NDC,facility,outpatient,1,UN,486.70000,292.02000,WellCare of North Carolina,Managed Medicaid,,97.44,,,,,,,97.44,395.69,percent of total billed charges,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,WellCare of North Carolina,Managed Medicaid,,783.62,,,,,,,49.22,2905.12,percent of total billed charges,
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION,RX-177083,CDM,636,RC,J1246,HCPCS,66302001401,NDC,facility,outpatient,5,ML,84083.00000,50449.80000,WellCare of North Carolina,Managed Medicaid,,16833.42,,,,,,,16833.42,68359.48,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,WellCare of North Carolina,Managed Medicaid,,396.12,,,,,,,47.56,1468.52,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,WellCare of North Carolina,Managed Medicaid,,98.74,,,,,,,47.56,366.05,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,WellCare of North Carolina,Managed Medicaid,,926.81,,,,,,,76.44,3435.94,percent of total billed charges,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,WellCare of North Carolina,Managed Medicaid,,1838.20,,,,,,,76.44,6814.73,percent of total billed charges,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,WellCare of North Carolina,Managed Medicaid,,915.21,,,,,,,19.38,3392.97,percent of total billed charges,
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET,RX-177412,CDM,250,RC,J3490,HCPCS,00078065920,NDC,facility,outpatient,1,UN,63.05000,37.83000,WellCare of North Carolina,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET,RX-177413,CDM,250,RC,J3490,HCPCS,00078077720,NDC,facility,outpatient,1,UN,63.05000,37.83000,WellCare of North Carolina,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET,RX-177414,CDM,250,RC,J3490,HCPCS,00078069620,NDC,facility,outpatient,1,UN,63.05000,37.83000,WellCare of North Carolina,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,WellCare of North Carolina,Managed Medicaid,,403.08,,,,,,,0.44620,1494.35,percent of total billed charges,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,WellCare of North Carolina,Managed Medicaid,,253.12,,,,,,,0.44620,938.40,percent of total billed charges,
"TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR",RX-178020,CDM,636,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,UN,44.30000,26.58000,WellCare of North Carolina,Managed Medicaid,,8.87,,,,,,,4.32,32.88,percent of total billed charges,
"TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR",RX-178021,CDM,636,RC,J7503,HCPCS,68992304001,NDC,facility,outpatient,1,UN,129.20000,77.52000,WellCare of North Carolina,Managed Medicaid,,25.87,,,,,,,4.32,95.89,percent of total billed charges,
TICAGRELOR 60 MG TABLET,RX-178095,CDM,250,RC,J3490,HCPCS,00186077660,NDC,facility,outpatient,1,UN,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,,9.41,,,,,,,9.41,38.21,percent of total billed charges,
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER,RX-17837,CDM,250,RC,J3490,HCPCS,00173068224,NDC,facility,outpatient,8,GR,84.20000,50.52000,WellCare of North Carolina,Managed Medicaid,,16.86,,,,,,,16.86,68.45,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,WellCare of North Carolina,Managed Medicaid,,15.22,,,,,,,0.46200,56.41,percent of total billed charges,
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-178436,CDM,636,RC,J2251,HCPCS,00143937901,NDC,facility,outpatient,50,ML,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,0.46200,65.31,percent of total billed charges,
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION,RX-178450,CDM,636,RC,J3590,HCPCS,00597019705,NDC,facility,outpatient,50,ML,10778.05000,6466.83000,WellCare of North Carolina,Managed Medicaid,,2157.77,,,,,,,2157.77,7999.47,percent of total billed charges,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,WellCare of North Carolina,Managed Medicaid,,2679.20,,,,,,,64.02,9932.57,percent of total billed charges,
BUPRENORPHINE HCL 75 MCG BUCCAL FILM,RX-178590,CDM,250,RC,J3490,HCPCS,59385002101,NDC,facility,outpatient,1,UN,44.60000,26.76000,WellCare of North Carolina,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 150 MCG BUCCAL FILM,RX-178591,CDM,250,RC,J3490,HCPCS,59385002201,NDC,facility,outpatient,1,UN,44.60000,26.76000,WellCare of North Carolina,Managed Medicaid,,8.93,,,,,,,8.93,36.26,percent of total billed charges,
BUPRENORPHINE HCL 300 MCG BUCCAL FILM,RX-178592,CDM,250,RC,J3490,HCPCS,59385002301,NDC,facility,outpatient,1,UN,57.50000,34.50000,WellCare of North Carolina,Managed Medicaid,,11.51,,,,,,,11.51,46.75,percent of total billed charges,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,WellCare of North Carolina,Managed Medicaid,,3285.05,,,,,,,30.33,12178.65,percent of total billed charges,
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET,RX-178644,CDM,250,RC,J3490,HCPCS,61958190101,NDC,facility,outpatient,1,UN,578.15000,346.89000,WellCare of North Carolina,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041110,NDC,facility,outpatient,10,ML,97.75000,58.65000,WellCare of North Carolina,Managed Medicaid,,19.57,,,,,,,19.57,79.47,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041115,NDC,facility,outpatient,15,ML,147.30000,88.38000,WellCare of North Carolina,Managed Medicaid,,29.49,,,,,,,29.49,119.75,percent of total billed charges,
BRIMONIDINE 0.2 % EYE DROPS,RX-17881,CDM,250,RC,J3490,HCPCS,24208041105,NDC,facility,outpatient,5,ML,59.50000,35.70000,WellCare of North Carolina,Managed Medicaid,,11.91,,,,,,,11.91,48.37,percent of total billed charges,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,WellCare of North Carolina,Managed Medicaid,,2234.18,,,,,,,13.09,8282.77,percent of total billed charges,
SELEXIPAG 200 MCG TABLET,RX-178923,CDM,250,RC,J3490,HCPCS,66215060206,NDC,facility,outpatient,1,UN,1039.25000,623.55000,WellCare of North Carolina,Managed Medicaid,,208.06,,,,,,,208.06,844.91,percent of total billed charges,
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION,RX-178998,CDM,250,RC,J3490,HCPCS,00006542302,NDC,facility,outpatient,2,ML,635.45000,381.27000,WellCare of North Carolina,Managed Medicaid,,127.22,,,,,,,127.22,516.62,percent of total billed charges,
SELENIUM SULFIDE 2.5 % LOTION,RX-179011,CDM,250,RC,J3490,HCPCS,45802004064,NDC,facility,outpatient,120,ML,16.45000,9.87000,WellCare of North Carolina,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
CARIPRAZINE 1.5 MG CAPSULE,RX-179315,CDM,250,RC,J3490,HCPCS,61874011520,NDC,facility,outpatient,1,UN,218.55000,131.13000,WellCare of North Carolina,Managed Medicaid,,43.75,,,,,,,43.75,177.68,percent of total billed charges,
OLANZAPINE 10 MG TABLET,RX-17937,CDM,250,RC,J3490,HCPCS,68084074011,NDC,facility,outpatient,1,UN,19.15000,11.49000,WellCare of North Carolina,Managed Medicaid,,3.83,,,,,,,3.83,15.57,percent of total billed charges,
INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN,RX-179567,CDM,636,RC,J1815,HCPCS,00002882401,NDC,facility,outpatient,3,ML,877.30000,526.38000,WellCare of North Carolina,Managed Medicaid,,175.64,,,,,,,0.54280,651.13,percent of total billed charges,
ZIDOVUDINE 300 MG TABLET,RX-17961,CDM,250,RC,J3490,HCPCS,65862002460,NDC,facility,outpatient,1,UN,19.60000,11.76000,WellCare of North Carolina,Managed Medicaid,,3.92,,,,,,,3.92,15.93,percent of total billed charges,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,WellCare of North Carolina,Managed Medicaid,,808.29,,,,,,,19.39,2996.56,percent of total billed charges,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,WellCare of North Carolina,Managed Medicaid,,331.70,,,,,,,109.08,1229.71,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,WellCare of North Carolina,Managed Medicaid,,61.99,,,,,,,61.99,229.82,percent of total billed charges,
VENETOCLAX 10 MG (14)-50 MG (7)-100 MG (21) TABLETS IN A DOSE PACK,RX-180043,CDM,250,RC,J3490,HCPCS,00074057928,NDC,facility,outpatient,0.9996,UN,13510.90000,8106.54000,WellCare of North Carolina,Managed Medicaid,,2704.88,,,,,,,2704.88,10984.36,percent of total billed charges,
VENETOCLAX 10 MG TABLET,RX-180044,CDM,250,RC,J3490,HCPCS,00074056111,NDC,facility,outpatient,1,UN,77.05000,46.23000,WellCare of North Carolina,Managed Medicaid,,15.43,,,,,,,15.43,62.64,percent of total billed charges,
VENETOCLAX 50 MG TABLET,RX-180045,CDM,250,RC,J3490,HCPCS,00074056611,NDC,facility,outpatient,1,UN,285.40000,171.24000,WellCare of North Carolina,Managed Medicaid,,57.14,,,,,,,57.14,232.03,percent of total billed charges,
VENETOCLAX 100 MG TABLET,RX-180046,CDM,250,RC,J3490,HCPCS,00074057611,NDC,facility,outpatient,1,UN,545.60000,327.36000,WellCare of North Carolina,Managed Medicaid,,109.23,,,,,,,109.23,443.57,percent of total billed charges,
LEVONORGESTREL 17.5 MCG/24 HOUR (5 YEARS) INTRAUTERINE DEVICE,RX-180172,CDM,636,RC,J7296,HCPCS,50419042408,NDC,facility,outpatient,1,UN,4647.20000,2788.32000,WellCare of North Carolina,Managed Medicaid,,930.37,,,,,,,930.37,3968.20,percent of total billed charges,
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION,RX-180236,CDM,250,RC,J3490,HCPCS,50474097075,NDC,facility,outpatient,5,ML,211.40000,126.84000,WellCare of North Carolina,Managed Medicaid,,42.32,,,,,,,42.32,171.87,percent of total billed charges,
BRIVARACETAM 50 MG TABLET,RX-180240,CDM,250,RC,J3490,HCPCS,50474057009,NDC,facility,outpatient,1,UN,95.65000,57.39000,WellCare of North Carolina,Managed Medicaid,,19.15,,,,,,,19.15,77.76,percent of total billed charges,
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION,RX-180347,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,WellCare of North Carolina,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,WellCare of North Carolina,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION),RX-180455,CDM,250,RC,J3490,HCPCS,13668058130,NDC,facility,outpatient,1,UN,22.00000,13.20000,WellCare of North Carolina,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
GLYCOPYRROLATE 9 MCG-FORMOTEROL 4.8 MCG HFA AEROSOL INHALER,RX-180708,CDM,250,RC,J3490,HCPCS,00310460012,NDC,facility,outpatient,10.7,GR,1350.15000,810.09000,WellCare of North Carolina,Managed Medicaid,,270.30,,,,,,,270.30,1097.67,percent of total billed charges,
"HEPARIN (PORCINE) 4,000 UNIT/1,000 ML (4 UNIT/ML) IN 0.9% NACL IV SOLN",RX-180780,CDM,636,RC,J1644,HCPCS,71285702201,NDC,facility,outpatient,1000,ML,122.50000,73.50000,WellCare of North Carolina,Managed Medicaid,,24.52,,,,,,,0.49560,90.92,percent of total billed charges,
LISINOPRIL 1 MG/ML ORAL SOLUTION,RX-181003,CDM,250,RC,J3490,HCPCS,52652300101,NDC,facility,outpatient,150,ML,2747.20000,1648.32000,WellCare of North Carolina,Managed Medicaid,,549.99,,,,,,,549.99,2233.47,percent of total billed charges,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,WellCare of North Carolina,Managed Medicaid,,12.28,,,,,,,1.78,45.53,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,WellCare of North Carolina,Managed Medicaid,,216.72,,,,,,,6.49,803.43,percent of total billed charges,
ENALAPRIL MALEATE 1 MG/ML ORAL SOLUTION,RX-181494,CDM,250,RC,J3490,HCPCS,52652400101,NDC,facility,outpatient,2.5,ML,61.30000,36.78000,WellCare of North Carolina,Managed Medicaid,,12.27,,,,,,,12.27,49.84,percent of total billed charges,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,WellCare of North Carolina,Managed Medicaid,,3207.80,,,,,,,38.64,11892.27,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,outpatient,10,ML,41.15000,24.69000,WellCare of North Carolina,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,100,ML,191.65000,114.99000,WellCare of North Carolina,Managed Medicaid,,38.37,,,,,,,0.11800,142.24,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,WellCare of North Carolina,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION,RX-18192,CDM,636,RC,J2795,HCPCS,63323028563,NDC,facility,outpatient,200,ML,367.30000,220.38000,WellCare of North Carolina,Managed Medicaid,,73.53,,,,,,,0.11800,272.61,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,15,ML,57.50000,34.50000,WellCare of North Carolina,Managed Medicaid,,11.51,,,,,,,0.11800,42.68,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,15,ML,34.25000,20.55000,WellCare of North Carolina,Managed Medicaid,,6.86,,,,,,,0.11800,25.42,percent of total billed charges,
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION,RX-18195,CDM,636,RC,J2795,HCPCS,43066001901,NDC,facility,outpatient,15,ML,39.90000,23.94000,WellCare of North Carolina,Managed Medicaid,,7.99,,,,,,,0.11800,29.61,percent of total billed charges,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,WellCare of North Carolina,Managed Medicaid,,17993.44,,,,,,,137.35,66706.93,percent of total billed charges,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,WellCare of North Carolina,Managed Medicaid,,1899.64,,,,,,,97.09,7042.51,percent of total billed charges,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,WellCare of North Carolina,Managed Medicaid,,17368.36,,,,,,,57.63,64389.60,percent of total billed charges,
COLCHICINE 0.6 MG TABLET,RX-1821,CDM,250,RC,J3490,HCPCS,64764011907,NDC,facility,outpatient,1,UN,44.80000,26.88000,WellCare of North Carolina,Managed Medicaid,,8.97,,,,,,,8.97,36.42,percent of total billed charges,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,WellCare of North Carolina,Managed Medicaid,,1427.85,,,,,,,72.78,5293.44,percent of total billed charges,
MIDOSTAURIN 25 MG CAPSULE,RX-182328,CDM,250,RC,J3490,HCPCS,00078069899,NDC,facility,outpatient,1,UN,896.70000,538.02000,WellCare of North Carolina,Managed Medicaid,,179.52,,,,,,,179.52,729.02,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,WellCare of North Carolina,Managed Medicaid,,3838.14,,,,,,,82.57,14229.12,percent of total billed charges,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,WellCare of North Carolina,Managed Medicaid,,963.00,,,,,,,82.57,3570.13,percent of total billed charges,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,WellCare of North Carolina,Managed Medicaid,,5848.24,,,,,,,35.59,21681.15,percent of total billed charges,
UREA 15 GRAM ORAL POWDER PACKET,RX-182556,CDM,250,RC,J3490,HCPCS,62530000011,NDC,facility,outpatient,1,UN,6.65000,3.99000,WellCare of North Carolina,Managed Medicaid,,1.33,,,,,,,1.33,5.41,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN,RX-18262,CDM,250,RC,J3490,HCPCS,00517720125,NDC,facility,outpatient,1,ML,71.75000,43.05000,WellCare of North Carolina,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,WellCare of North Carolina,Managed Medicaid,,6675.83,,,,,,,35.59,24749.25,percent of total billed charges,
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS,RX-18266,CDM,250,RC,J3490,HCPCS,00517920325,NDC,facility,outpatient,3,ML,71.30000,42.78000,WellCare of North Carolina,Managed Medicaid,,14.27,,,,,,,14.27,57.97,percent of total billed charges,
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS,RX-18267,CDM,250,RC,J3490,HCPCS,00517620225,NDC,facility,outpatient,2,ML,68.70000,41.22000,WellCare of North Carolina,Managed Medicaid,,13.75,,,,,,,13.75,55.85,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,46287002004,NDC,facility,outpatient,118,ML,1312.75000,787.65000,WellCare of North Carolina,Managed Medicaid,,262.81,,,,,,,262.81,1067.27,percent of total billed charges,
SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION,RX-182808,CDM,250,RC,J3490,HCPCS,00574113316,NDC,facility,outpatient,473,ML,4511.40000,2706.84000,WellCare of North Carolina,Managed Medicaid,,903.18,,,,,,,903.18,3667.77,percent of total billed charges,
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL,RX-182858,CDM,250,RC,J3490,HCPCS,70092161144,NDC,facility,outpatient,3,ML,47.80000,28.68000,WellCare of North Carolina,Managed Medicaid,,9.57,,,,,,,9.57,38.86,percent of total billed charges,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,WellCare of North Carolina,Managed Medicaid,,9727.12,,,,,,,248.41,36061.27,percent of total billed charges,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,WellCare of North Carolina,Managed Medicaid,,21122.14,,,,,,,2617.11,78305.96,percent of total billed charges,
TORSEMIDE 20 MG TABLET,RX-18293,CDM,250,RC,J3490,HCPCS,68084053911,NDC,facility,outpatient,1,UN,17.45000,10.47000,WellCare of North Carolina,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
TORSEMIDE 5 MG TABLET,RX-18295,CDM,250,RC,J3490,HCPCS,31722052901,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
LIDOCAINE 1 %-PHENYLEPHRINE 1.5 % IN STERILE WATER INTRAOCULAR SOLN,RX-182998,CDM,250,RC,J3490,HCPCS,71449009042,NDC,facility,outpatient,1,ML,131.60000,78.96000,WellCare of North Carolina,Managed Medicaid,,26.35,,,,,,,26.35,106.99,percent of total billed charges,
"MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN",RX-183014,CDM,250,RC,J3490,HCPCS,54643900708,NDC,facility,outpatient,5,ML,95.30000,57.18000,WellCare of North Carolina,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
"MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN",RX-183015,CDM,250,RC,J3490,HCPCS,54643900709,NDC,facility,outpatient,5,ML,95.30000,57.18000,WellCare of North Carolina,Managed Medicaid,,19.08,,,,,,,19.08,77.48,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION,RX-18302,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,WellCare of North Carolina,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
GABAPENTIN 400 MG CAPSULE,RX-18307,CDM,250,RC,J3490,HCPCS,00904666761,NDC,facility,outpatient,1,UN,16.85000,10.11000,WellCare of North Carolina,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
GABAPENTIN 300 MG CAPSULE,RX-18308,CDM,250,RC,J3490,HCPCS,00904666661,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
GABAPENTIN 100 MG CAPSULE,RX-18309,CDM,250,RC,J3490,HCPCS,00071080324,NDC,facility,outpatient,1,UN,27.85000,16.71000,WellCare of North Carolina,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
RISPERIDONE 1 MG TABLET,RX-18313,CDM,250,RC,J3490,HCPCS,68084027211,NDC,facility,outpatient,1,UN,17.70000,10.62000,WellCare of North Carolina,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,636,RC,J1250,HCPCS,00409234732,NDC,facility,outpatient,250,ML,199.50000,119.70000,WellCare of North Carolina,Managed Medicaid,,39.94,,,,,,,16.71,148.07,percent of total billed charges,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,WellCare of North Carolina,Managed Medicaid,,199.70,,,,,,,2.11,740.34,percent of total billed charges,
TOCOPHERSOLAN (VITAMIN E TPGS) 75 UNIT/ML ORAL DROPS,RX-183205,CDM,250,RC,J3490,HCPCS,68176000017,NDC,facility,outpatient,60,ML,66.10000,39.66000,WellCare of North Carolina,Managed Medicaid,,13.23,,,,,,,13.23,53.74,percent of total billed charges,
"VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT",RX-183322,CDM,636,RC,90750,HCPCS,58160082311,NDC,facility,outpatient,1,UN,668.55000,401.13000,WellCare of North Carolina,Managed Medicaid,,133.84,,,,,,,133.84,569.63,percent of total billed charges,
ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT,RX-183476,CDM,250,RC,J3490,HCPCS,59781066679,NDC,facility,outpatient,1,UN,4.70000,2.82000,WellCare of North Carolina,Managed Medicaid,,0.94094,,,,,,,0.94094,3.82,percent of total billed charges,
EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE,RX-183577,CDM,636,RC,J0165,HCPCS,70092161746,NDC,facility,outpatient,1,ML,18.40000,11.04000,WellCare of North Carolina,Managed Medicaid,,3.68,,,,,,,1.13,13.66,percent of total billed charges,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,WellCare of North Carolina,Managed Medicaid,,394.84,,,,,,,1.59,1463.80,percent of total billed charges,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,WellCare of North Carolina,Managed Medicaid,,5329.34,,,,,,,159.65,19757.44,percent of total billed charges,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,WellCare of North Carolina,Managed Medicaid,,1179.31,,,,,,,7.91,4372.04,percent of total billed charges,
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,250,RC,J3490,HCPCS,51079039101,NDC,facility,outpatient,1,UN,19.10000,11.46000,WellCare of North Carolina,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,WellCare of North Carolina,Managed Medicaid,,7051.96,,,,,,,31.97,26143.70,percent of total billed charges,
HYDROMORPHONE (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-183963,CDM,636,RC,J1171,HCPCS,70092954635,NDC,facility,outpatient,50,ML,80.05000,48.03000,WellCare of North Carolina,Managed Medicaid,,16.03,,,,,,,0.21240,59.41,percent of total billed charges,
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION,RX-18398,CDM,250,RC,J3490,HCPCS,63323072301,NDC,facility,outpatient,1,UN,241.95000,145.17000,WellCare of North Carolina,Managed Medicaid,,48.44,,,,,,,48.44,196.71,percent of total billed charges,
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION,RX-18400,CDM,250,RC,J3490,HCPCS,00143939201,NDC,facility,outpatient,1,UN,389.50000,233.70000,WellCare of North Carolina,Managed Medicaid,,77.98,,,,,,,77.98,316.66,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SOLUTION,RX-184612,CDM,636,RC,J2272,HCPCS,63323045400,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,WellCare of North Carolina,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,WellCare of North Carolina,Managed Medicaid,,11.70,,,,,,,11.70,50.28,percent of total billed charges,
BARICITINIB 2 MG TABLET,RX-184820,CDM,250,RC,J3490,HCPCS,00002418230,NDC,facility,outpatient,1,UN,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,77.08,313.00,percent of total billed charges,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,WellCare of North Carolina,Managed Medicaid,,23.30,,,,,,,7.61,94.63,percent of total billed charges,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,WellCare of North Carolina,Managed Medicaid,,33.35,,,,,,,7.61,135.45,percent of total billed charges,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,WellCare of North Carolina,Managed Medicaid,,43.39,,,,,,,7.61,176.22,percent of total billed charges,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,WellCare of North Carolina,Managed Medicaid,,103.68,,,,,,,7.61,421.05,percent of total billed charges,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,WellCare of North Carolina,Managed Medicaid,,405.10,,,,,,,7.61,1645.11,percent of total billed charges,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,WellCare of North Carolina,Managed Medicaid,,1904.73,,,,,,,96.16,7061.40,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION,RX-185234,CDM,250,RC,J3490,HCPCS,00338050206,NDC,facility,outpatient,2000,ML,525.00000,315.00000,WellCare of North Carolina,Managed Medicaid,,105.11,,,,,,,105.11,426.82,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET,RX-185235,CDM,250,RC,J3490,HCPCS,00310110539,NDC,facility,outpatient,1,UN,130.90000,78.54000,WellCare of North Carolina,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET,RX-185236,CDM,250,RC,J3490,HCPCS,00310111039,NDC,facility,outpatient,1,UN,130.90000,78.54000,WellCare of North Carolina,Managed Medicaid,,26.21,,,,,,,26.21,106.42,percent of total billed charges,
HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE,RX-185241,CDM,636,RC,90739,HCPCS,43528000305,NDC,facility,outpatient,0.5,ML,489.25000,293.55000,WellCare of North Carolina,Managed Medicaid,,97.95,,,,,,,97.95,495.21,percent of total billed charges,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,WellCare of North Carolina,Managed Medicaid,,4267.77,,,,,,,241.04,15821.89,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,WellCare of North Carolina,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,WellCare of North Carolina,Managed Medicaid,,322.39,,,,,,,0.29100,1195.20,percent of total billed charges,
ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION,RX-185487,CDM,636,RC,J0122,HCPCS,71773005005,NDC,facility,outpatient,1,UN,344.75000,206.85000,WellCare of North Carolina,Managed Medicaid,,69.02,,,,,,,3.14,255.87,percent of total billed charges,
CARVEDILOL 3.125 MG TABLET,RX-18551,CDM,250,RC,J3490,HCPCS,51079077101,NDC,facility,outpatient,1,UN,16.55000,9.93000,WellCare of North Carolina,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
RIVAROXABAN 2.5 MG TABLET,RX-185706,CDM,250,RC,J3490,HCPCS,50458057701,NDC,facility,outpatient,1,UN,55.90000,33.54000,WellCare of North Carolina,Managed Medicaid,,11.19,,,,,,,11.19,45.45,percent of total billed charges,
CANNABIDIOL 100 MG/ML ORAL SOLUTION,RX-185713,CDM,250,RC,J3490,HCPCS,70127010001,NDC,facility,outpatient,100,ML,5146.00000,3087.60000,WellCare of North Carolina,Managed Medicaid,,1030.23,,,,,,,1030.23,4183.70,percent of total billed charges,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,WellCare of North Carolina,Managed Medicaid,,9678.64,,,,,,,28.41,35881.55,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,WellCare of North Carolina,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
LATANOPROST 0.005 % EYE DROPS,RX-18621,CDM,250,RC,J3490,HCPCS,61314054701,NDC,facility,outpatient,2.5,ML,48.10000,28.86000,WellCare of North Carolina,Managed Medicaid,,9.63,,,,,,,9.63,39.11,percent of total billed charges,
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION,RX-186326,CDM,250,RC,J3490,HCPCS,54288010502,NDC,facility,outpatient,5,ML,4543.25000,2725.95000,WellCare of North Carolina,Managed Medicaid,,909.56,,,,,,,909.56,3693.66,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,WellCare of North Carolina,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,WellCare of North Carolina,Managed Medicaid,,202.69,,,,,,,0.29100,751.44,percent of total billed charges,
CAPLACIZUMAB-YHDP 11 MG INJECTION KIT,RX-186479,CDM,636,RC,C9047,HCPCS,58468022501,NDC,facility,outpatient,1,UN,36064.10000,21638.46000,WellCare of North Carolina,Managed Medicaid,,7220.03,,,,,,,1875.80,26766.78,percent of total billed charges,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,WellCare of North Carolina,Managed Medicaid,,586.19,,,,,,,99.04,2173.16,percent of total billed charges,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,WellCare of North Carolina,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,WellCare of North Carolina,Managed Medicaid,,4173.39,,,,,,,59.60,15471.98,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450000,NDC,facility,outpatient,1000,ML,203.00000,121.80000,WellCare of North Carolina,Managed Medicaid,,40.64,,,,,,,40.64,165.04,percent of total billed charges,
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-186824,CDM,250,RC,J3490,HCPCS,00264450005,NDC,facility,outpatient,2000,ML,287.00000,172.20000,WellCare of North Carolina,Managed Medicaid,,57.46,,,,,,,57.46,233.33,percent of total billed charges,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,WellCare of North Carolina,Managed Medicaid,,83.99,,,,,,,6.63,311.39,percent of total billed charges,
SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION,RX-187079,CDM,250,RC,J3490,HCPCS,00517656001,NDC,facility,outpatient,10,ML,1781.00000,1068.60000,WellCare of North Carolina,Managed Medicaid,,356.56,,,,,,,356.56,1447.95,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,WellCare of North Carolina,Managed Medicaid,,16449.48,,,,,,,132.57,60983.05,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,WellCare of North Carolina,Managed Medicaid,,2513.50,,,,,,,27.02,9318.28,percent of total billed charges,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,WellCare of North Carolina,Managed Medicaid,,669.68,,,,,,,27.02,2482.70,percent of total billed charges,
"CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-187224,CDM,636,RC,J0613,HCPCS,44567062101,NDC,facility,outpatient,100,ML,201.25000,120.75000,WellCare of North Carolina,Managed Medicaid,,40.29,,,,,,,0.21240,149.37,percent of total billed charges,
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION,RX-187311,CDM,250,RC,J3490,HCPCS,52652500101,NDC,facility,outpatient,2.5,ML,48.00000,28.80000,WellCare of North Carolina,Managed Medicaid,,9.61,,,,,,,9.61,39.02,percent of total billed charges,
IVABRADINE 5 MG/5 ML ORAL SOLUTION,RX-187432,CDM,250,RC,J3490,HCPCS,55513081301,NDC,facility,outpatient,1.25,ML,23.85000,14.31000,WellCare of North Carolina,Managed Medicaid,,4.77,,,,,,,4.77,19.39,percent of total billed charges,
DONEPEZIL 5 MG TABLET,RX-18786,CDM,250,RC,J3490,HCPCS,59762024503,NDC,facility,outpatient,1,UN,17.80000,10.68000,WellCare of North Carolina,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
DONEPEZIL 10 MG TABLET,RX-18787,CDM,250,RC,J3490,HCPCS,13668010390,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,WellCare of North Carolina,Managed Medicaid,,799.89,,,,,,,28.50,2965.42,percent of total billed charges,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,WellCare of North Carolina,Managed Medicaid,,3779.20,,,,,,,28.50,14010.58,percent of total billed charges,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,WellCare of North Carolina,Managed Medicaid,,3471.11,,,,,,,40.72,12868.41,percent of total billed charges,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,WellCare of North Carolina,Managed Medicaid,,10388.06,,,,,,,40.72,38511.57,percent of total billed charges,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,WellCare of North Carolina,Managed Medicaid,,2075.14,,,,,,,125.60,7693.16,percent of total billed charges,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,WellCare of North Carolina,Managed Medicaid,,1257.11,,,,,,,10.68,4660.46,percent of total billed charges,
"MINERAL OIL, LIGHT STERILE",RX-188260,CDM,250,RC,J3490,HCPCS,63323025410,NDC,facility,outpatient,10,ML,107.15000,64.29000,WellCare of North Carolina,Managed Medicaid,,21.45,,,,,,,21.45,87.11,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,WellCare of North Carolina,Managed Medicaid,,2529.45,,,,,,,35.64,9377.40,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,WellCare of North Carolina,Managed Medicaid,,2773.87,,,,,,,29.08,10283.55,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,WellCare of North Carolina,Managed Medicaid,,2216.38,,,,,,,25.00,8216.78,percent of total billed charges,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,WellCare of North Carolina,Managed Medicaid,,595.39,,,,,,,25.00,2207.30,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,WellCare of North Carolina,Managed Medicaid,,686.48,,,,,,,27.01,2544.97,percent of total billed charges,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,WellCare of North Carolina,Managed Medicaid,,3212.13,,,,,,,27.01,11908.30,percent of total billed charges,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,WellCare of North Carolina,Managed Medicaid,,15163.67,,,,,,,348.41,56216.16,percent of total billed charges,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,WellCare of North Carolina,Managed Medicaid,,3042.20,,,,,,,27.15,11278.32,percent of total billed charges,
CENOBAMATE 50 MG TABLET,RX-188765,CDM,250,RC,J3490,HCPCS,71699005030,NDC,facility,outpatient,1,UN,143.55000,86.13000,WellCare of North Carolina,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
CENOBAMATE 200 MG TABLET,RX-188768,CDM,250,RC,J3490,HCPCS,71699020030,NDC,facility,outpatient,1,UN,143.55000,86.13000,WellCare of North Carolina,Managed Medicaid,,28.74,,,,,,,28.74,116.71,percent of total billed charges,
ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION,RX-18877,CDM,250,RC,J3490,HCPCS,00054006447,NDC,facility,outpatient,2.5,ML,28.60000,17.16000,WellCare of North Carolina,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,WellCare of North Carolina,Managed Medicaid,,1643.90,,,,,,,19.37,6094.43,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,WellCare of North Carolina,Managed Medicaid,,3886.53,,,,,,,79.44,14408.51,percent of total billed charges,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,WellCare of North Carolina,Managed Medicaid,,821.35,,,,,,,79.44,3044.99,percent of total billed charges,
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION,RX-18908,CDM,250,RC,J3490,HCPCS,25021031066,NDC,facility,outpatient,2,ML,149.10000,89.46000,WellCare of North Carolina,Managed Medicaid,,29.85,,,,,,,29.85,121.22,percent of total billed charges,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,WellCare of North Carolina,Managed Medicaid,,2313.19,,,,,,,35.19,8575.68,percent of total billed charges,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,WellCare of North Carolina,Managed Medicaid,,22028.61,,,,,,,308.97,81666.49,percent of total billed charges,
LEVOFLOXACIN 250 MG TABLET,RX-18918,CDM,250,RC,J3490,HCPCS,00904635161,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,WellCare of North Carolina,Managed Medicaid,,433.03,,,,,,,19.80,1605.38,percent of total billed charges,
LEVOFLOXACIN 500 MG TABLET,RX-18919,CDM,250,RC,J3490,HCPCS,00904635261,NDC,facility,outpatient,1,UN,17.00000,10.20000,WellCare of North Carolina,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
TOPIRAMATE 25 MG TABLET,RX-18920,CDM,250,RC,J3490,HCPCS,50458063965,NDC,facility,outpatient,1,UN,42.75000,25.65000,WellCare of North Carolina,Managed Medicaid,,8.56,,,,,,,8.56,34.76,percent of total billed charges,
NIMODIPINE 60 MG/10 ML ORAL SYRINGE (FOR ORAL USE ONLY),RX-189211,CDM,250,RC,J3490,HCPCS,24338026012,NDC,facility,outpatient,5,ML,176.25000,105.75000,WellCare of North Carolina,Managed Medicaid,,35.29,,,,,,,35.29,143.29,percent of total billed charges,
TOPIRAMATE 100 MG TABLET,RX-18922,CDM,250,RC,J3490,HCPCS,68084034411,NDC,facility,outpatient,1,UN,17.90000,10.74000,WellCare of North Carolina,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
DILUENT FOR MITOMYCIN INTRA-PYELOCALYCEAL SOLUTION,RX-189593,CDM,250,RC,J3490,HCPCS,72493010220,NDC,facility,outpatient,20,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,WellCare of North Carolina,Managed Medicaid,,12313.86,,,,,,,60.24,45651.09,percent of total billed charges,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,WellCare of North Carolina,Managed Medicaid,,8227.27,,,,,,,60.24,30500.89,percent of total billed charges,
ATROPINE 1.2 MG/3 ML (0.4 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE,RX-189636,CDM,636,RC,J0461,HCPCS,69374093503,NDC,facility,outpatient,0.25,ML,65.65000,39.39000,WellCare of North Carolina,Managed Medicaid,,13.14,,,,,,,0.19800,48.73,percent of total billed charges,
"MIDAZOLAM (PF) 1 MG/ML IN SODIUM CHLORIDE,ISO-OSM INTRAVENOUS SOLUTION",RX-189662,CDM,636,RC,J2250,HCPCS,51754913101,NDC,facility,outpatient,100,ML,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,0.35400,65.31,percent of total billed charges,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,WellCare of North Carolina,Managed Medicaid,,1284.65,,,,,,,13.88,4762.59,percent of total billed charges,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,WellCare of North Carolina,Managed Medicaid,,3568.15,,,,,,,132.57,13228.19,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,WellCare of North Carolina,Managed Medicaid,,20151.54,,,,,,,218.36,74707.66,percent of total billed charges,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,WellCare of North Carolina,Managed Medicaid,,5505.05,,,,,,,218.36,20408.83,percent of total billed charges,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,WellCare of North Carolina,Managed Medicaid,,204.15,,,,,,,7.61,829.06,percent of total billed charges,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,WellCare of North Carolina,Managed Medicaid,,1350.05,,,,,,,5.30,5005.03,percent of total billed charges,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,WellCare of North Carolina,Managed Medicaid,,1121.90,,,,,,,27.15,4159.21,percent of total billed charges,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,WellCare of North Carolina,Managed Medicaid,,1845.18,,,,,,,1845.18,6840.63,percent of total billed charges,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,WellCare of North Carolina,Managed Medicaid,,25003.11,,,,,,,210.39,92693.84,percent of total billed charges,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,WellCare of North Carolina,Managed Medicaid,,10652.28,,,,,,,236.40,39491.13,percent of total billed charges,
"PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION",RX-191712,CDM,636,RC,J3590,HCPCS,73606001001,NDC,facility,outpatient,20,ML,20471.00000,12282.60000,WellCare of North Carolina,Managed Medicaid,,4098.29,,,,,,,4098.29,15193.58,percent of total billed charges,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,WellCare of North Carolina,Managed Medicaid,,3408.28,,,,,,,21.86,12635.51,percent of total billed charges,
ATORVASTATIN 10 MG TABLET,RX-19176,CDM,250,RC,J3490,HCPCS,68084009711,NDC,facility,outpatient,1,UN,17.50000,10.50000,WellCare of North Carolina,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
ATORVASTATIN 20 MG TABLET,RX-19178,CDM,250,RC,J3490,HCPCS,60505257909,NDC,facility,outpatient,1,UN,17.00000,10.20000,WellCare of North Carolina,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
AZELASTINE 137 MCG (0.1 %) NASAL SPRAY,RX-19179,CDM,250,RC,J3490,HCPCS,60505083305,NDC,facility,outpatient,30,ML,81.25000,48.75000,WellCare of North Carolina,Managed Medicaid,,16.27,,,,,,,16.27,66.06,percent of total billed charges,
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-192119,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,0.5,ML,869.40000,521.64000,WellCare of North Carolina,Managed Medicaid,,174.05,,,,,,,174.05,872.64,percent of total billed charges,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,WellCare of North Carolina,Managed Medicaid,,6574.28,,,,,,,183.10,24372.77,percent of total billed charges,
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-192529,CDM,636,RC,J0613,HCPCS,44567062201,NDC,facility,outpatient,100,ML,107.45000,64.47000,WellCare of North Carolina,Managed Medicaid,,21.51,,,,,,,0.21240,79.75,percent of total billed charges,
AVACOPAN 10 MG CAPSULE,RX-192644,CDM,250,RC,J3490,HCPCS,73556016802,NDC,facility,outpatient,1,UN,413.35000,248.01000,WellCare of North Carolina,Managed Medicaid,,82.75,,,,,,,82.75,336.05,percent of total billed charges,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,WellCare of North Carolina,Managed Medicaid,,3271.31,,,,,,,11.95,12127.70,percent of total billed charges,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,WellCare of North Carolina,Managed Medicaid,,7294.04,,,,,,,82.03,27041.13,percent of total billed charges,
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSPENSION,RX-193199,CDM,250,RC,J3490,HCPCS,52652600101,NDC,facility,outpatient,1,ML,34.15000,20.49000,WellCare of North Carolina,Managed Medicaid,,6.84,,,,,,,6.84,27.76,percent of total billed charges,
VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION,RX-193221,CDM,636,RC,J2598,HCPCS,42023023710,NDC,facility,outpatient,100,ML,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,2.19,202.62,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION,RX-193278,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,1,UN,87.60000,52.56000,WellCare of North Carolina,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,WellCare of North Carolina,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,636,RC,J0735,HCPCS,09999199182,NDC,facility,outpatient,1.5,ML,82.75000,49.65000,WellCare of North Carolina,Managed Medicaid,,16.57,,,,,,,16.57,61.42,percent of total billed charges,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,WellCare of North Carolina,Managed Medicaid,,148.04,,,,,,,0.36860,548.82,percent of total billed charges,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,WellCare of North Carolina,Managed Medicaid,,234.94,,,,,,,0.36860,871.01,percent of total billed charges,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,WellCare of North Carolina,Managed Medicaid,,13639.98,,,,,,,191.90,50567.38,percent of total billed charges,
CORTISONE 25 MG TABLET,RX-1935,CDM,250,RC,J3490,HCPCS,62135017330,NDC,facility,outpatient,1,UN,76.00000,45.60000,WellCare of North Carolina,Managed Medicaid,,15.22,,,,,,,15.22,61.79,percent of total billed charges,
TREPROSTINIL 16 MCG CARTRIDGE WITH INHALER,RX-193923,CDM,250,RC,j3490,HCPCS,66302061601,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,WellCare of North Carolina,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
TREPROSTINIL 32 MCG CARTRIDGE WITH INHALER,RX-193924,CDM,250,RC,J3490,HCPCS,66302063201,NDC,facility,outpatient,4,UN,1136.00000,681.60000,WellCare of North Carolina,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 48 MCG CARTRIDGE WITH INHALER,RX-193925,CDM,250,RC,J3490,HCPCS,66302064801,NDC,facility,outpatient,4,UN,1136.00000,681.60000,WellCare of North Carolina,Managed Medicaid,,227.43,,,,,,,227.43,923.57,percent of total billed charges,
TREPROSTINIL 64 MCG CARTRIDGE WITH INHALER,RX-193926,CDM,250,RC,J3490,HCPCS,66302066401,NDC,facility,outpatient,4,UN,2626.30000,1575.78000,WellCare of North Carolina,Managed Medicaid,,525.79,,,,,,,525.79,2135.18,percent of total billed charges,
WARFARIN 3 MG TABLET,RX-19433,CDM,250,RC,J3490,HCPCS,00832121489,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,636,RC,90700,HCPCS,58160081043,NDC,facility,outpatient,0.5,ML,104.05000,62.43000,WellCare of North Carolina,Managed Medicaid,,20.83,,,,,,,20.83,97.20,percent of total billed charges,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,WellCare of North Carolina,Managed Medicaid,,9258.10,,,,,,,32.57,34322.48,percent of total billed charges,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,WellCare of North Carolina,Managed Medicaid,,1859.57,,,,,,,32.57,6893.96,percent of total billed charges,
"MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION",RX-195043,CDM,636,RC,90734,HCPCS,58160082703,NDC,facility,outpatient,0.5,ML,520.00000,312.00000,WellCare of North Carolina,Managed Medicaid,,104.10,,,,,,,104.10,544.37,percent of total billed charges,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,WellCare of North Carolina,Managed Medicaid,,6029.50,,,,,,,67.41,22353.13,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,WellCare of North Carolina,Managed Medicaid,,604.94,,,,,,,604.94,2242.71,percent of total billed charges,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,WellCare of North Carolina,Managed Medicaid,,16551.88,,,,,,,634.99,61362.65,percent of total billed charges,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,WellCare of North Carolina,Managed Medicaid,,13041.87,,,,,,,29.64,48350.03,percent of total billed charges,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,WellCare of North Carolina,Managed Medicaid,,2395.89,,,,,,,24.29,8882.28,percent of total billed charges,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,WellCare of North Carolina,Managed Medicaid,,4788.40,,,,,,,24.29,17752.01,percent of total billed charges,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,WellCare of North Carolina,Managed Medicaid,,5984.79,,,,,,,24.29,22187.36,percent of total billed charges,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,WellCare of North Carolina,Managed Medicaid,,13645.27,,,,,,,13645.27,176902.85,percent of total billed charges,
"RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION",RX-196766,CDM,636,RC,90678,HCPCS,00069020701,NDC,facility,outpatient,1,UN,942.40000,565.44000,WellCare of North Carolina,Managed Medicaid,,188.67,,,,,,,188.67,1002.31,percent of total billed charges,
NIRSEVIMAB-ALIP 50 MG/0.5 ML INTRAMUSCULAR SYRINGE,RX-196954,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,outpatient,0.5,ML,2546.40000,1527.84000,WellCare of North Carolina,Managed Medicaid,,509.79,,,,,,,509.79,1889.94,percent of total billed charges,
NIRSEVIMAB-ALIP 100 MG/ML INTRAMUSCULAR SYRINGE,RX-196955,CDM,636,RC,90381,HCPCS,49281057415,NDC,facility,outpatient,1,ML,2546.45000,1527.87000,WellCare of North Carolina,Managed Medicaid,,509.80,,,,,,,509.80,1889.98,percent of total billed charges,
CARBACHOL 0.01 % INTRAOCULAR SOLUTION,RX-19704,CDM,250,RC,J3490,HCPCS,00065002315,NDC,facility,outpatient,0.5,ML,62.50000,37.50000,WellCare of North Carolina,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,WellCare of North Carolina,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,WellCare of North Carolina,Managed Medicaid,,818.33,,,,,,,70.44,3033.78,percent of total billed charges,
DIAZOXIDE 50 MG/ML ORAL SUSPENSION,RX-19713,CDM,250,RC,J3490,HCPCS,00575620030,NDC,facility,outpatient,30,ML,1475.80000,885.48000,WellCare of North Carolina,Managed Medicaid,,295.46,,,,,,,295.46,1199.83,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,60505100302,NDC,facility,outpatient,10,ML,208.40000,125.04000,WellCare of North Carolina,Managed Medicaid,,41.72,,,,,,,41.72,169.43,percent of total billed charges,
KETOROLAC 0.5 % EYE DROPS,RX-19733,CDM,250,RC,J3490,HCPCS,61314012605,NDC,facility,outpatient,5,ML,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION,RX-19736,CDM,636,RC,J1050,HCPCS,00009074635,NDC,facility,outpatient,1,ML,255.50000,153.30000,WellCare of North Carolina,Managed Medicaid,,51.15,,,,,,,1.35,189.63,percent of total billed charges,
NORETHINDRONE (CONTRACEPTIVE) 0.35 MG TABLET,RX-19743,CDM,250,RC,J3490,HCPCS,00378729253,NDC,facility,outpatient,1,UN,30.90000,18.54000,WellCare of North Carolina,Managed Medicaid,,6.19,,,,,,,6.19,25.12,percent of total billed charges,
OFLOXACIN 0.3 % EYE DROPS,RX-19746,CDM,250,RC,J3490,HCPCS,64980051501,NDC,facility,outpatient,10,ML,106.00000,63.60000,WellCare of North Carolina,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
POVIDONE-IODINE 5 % EYE SOLUTION,RX-19791,CDM,250,RC,J3490,HCPCS,00065041130,NDC,facility,outpatient,30,ML,69.30000,41.58000,WellCare of North Carolina,Managed Medicaid,,13.87,,,,,,,13.87,56.34,percent of total billed charges,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,WellCare of North Carolina,Managed Medicaid,,12710.40,,,,,,,189.85,47121.16,percent of total billed charges,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,WellCare of North Carolina,Managed Medicaid,,46.93,,,,,,,6.49,173.97,percent of total billed charges,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,WellCare of North Carolina,Managed Medicaid,,3806.25,,,,,,,103.14,14110.89,percent of total billed charges,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,WellCare of North Carolina,Managed Medicaid,,70.56,,,,,,,1.78,261.59,percent of total billed charges,
PEMIVIBART 125 MG/ML INTRAVENOUS SOLUTION (EUA),RX-198468,CDM,636,RC,Q0224,HCPCS,81960003103,NDC,facility,outpatient,36,ML,26733.05000,16039.83000,WellCare of North Carolina,Managed Medicaid,,5351.96,,,,,,,5351.96,20188.85,percent of total billed charges,
SERTRALINE 25 MG TABLET,RX-19882,CDM,250,RC,J3490,HCPCS,65862001130,NDC,facility,outpatient,1,UN,16.40000,9.84000,WellCare of North Carolina,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,WellCare of North Carolina,Managed Medicaid,,2200.82,,,,,,,55.32,8159.08,percent of total billed charges,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,WellCare of North Carolina,Managed Medicaid,,8765.41,,,,,,,55.32,32495.93,percent of total billed charges,
PNEUMOCOCCAL 21-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE,RX-199176,CDM,636,RC,90684,HCPCS,00006434702,NDC,facility,outpatient,0.5,ML,883.00000,529.80000,WellCare of North Carolina,Managed Medicaid,,176.78,,,,,,,176.78,914.46,percent of total billed charges,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,WellCare of North Carolina,Managed Medicaid,,12260.66,,,,,,,73.69,45453.85,percent of total billed charges,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,WellCare of North Carolina,Managed Medicaid,,1464.46,,,,,,,32.43,5429.19,percent of total billed charges,
FLU VACC 2025-26(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE,RX-200137,CDM,636,RC,90653,HCPCS,70461002503,NDC,facility,outpatient,0.5,ML,257.30000,154.38000,WellCare of North Carolina,Managed Medicaid,,51.51,,,,,,,51.51,232.85,percent of total billed charges,
FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE,RX-200146,CDM,636,RC,90656,HCPCS,19515090452,NDC,facility,outpatient,0.5,ML,81.25000,48.75000,WellCare of North Carolina,Managed Medicaid,,16.27,,,,,,,16.27,62.32,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,00143962101,NDC,facility,outpatient,0.1,ML,17.05000,10.23000,WellCare of North Carolina,Managed Medicaid,,3.41,,,,,,,2.36,12.65,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680012130,NDC,facility,outpatient,0.1,ML,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,2.36,12.54,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,636,RC,J3420,HCPCS,69680011310,NDC,facility,outpatient,0.1,ML,16.75000,10.05000,WellCare of North Carolina,Managed Medicaid,,3.35,,,,,,,2.36,12.43,percent of total billed charges,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,WellCare of North Carolina,Managed Medicaid,,7051.96,,,,,,,26.54,26143.70,percent of total billed charges,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,WellCare of North Carolina,Managed Medicaid,,4363.51,,,,,,,50.01,17719.94,percent of total billed charges,
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,250,RC,J3490,HCPCS,50268085511,NDC,facility,outpatient,1,UN,1.35000,0.81000,WellCare of North Carolina,Managed Medicaid,,0.27027,,,,,,,0.27027,1.10,percent of total billed charges,
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET,RX-2012,CDM,250,RC,J3490,HCPCS,77333093725,NDC,facility,outpatient,1,UN,1.30000,0.78000,WellCare of North Carolina,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
CYTARABINE (PF) 100 MG/ML INJECTION,RX-20156,CDM,636,RC,J9100,HCPCS,61703031922,NDC,facility,outpatient,20,ML,364.45000,218.67000,WellCare of North Carolina,Managed Medicaid,,72.96,,,,,,,1.96,270.49,percent of total billed charges,
CYCLOBENZAPRINE 10 MG TABLET,RX-2017,CDM,250,RC,J3490,HCPCS,43547040010,NDC,facility,outpatient,1,UN,16.25000,9.75000,WellCare of North Carolina,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,WellCare of North Carolina,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
COVID VACC 2025-2026 (12 YRS UP) (PFIZER)(PF) 30 MCG/0.3 ML IM SYRINGE,RX-202058,CDM,636,RC,91320,HCPCS,00069252801,NDC,facility,outpatient,0.3,ML,465.10000,279.06000,WellCare of North Carolina,Managed Medicaid,,93.11,,,,,,,93.11,434.78,percent of total billed charges,
CYPROHEPTADINE 4 MG TABLET,RX-2033,CDM,250,RC,J3490,HCPCS,50742019001,NDC,facility,outpatient,1,UN,16.25000,9.75000,WellCare of North Carolina,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
ANAGRELIDE 0.5 MG CAPSULE,RX-20446,CDM,250,RC,J3490,HCPCS,54092006301,NDC,facility,outpatient,1,UN,49.10000,29.46000,WellCare of North Carolina,Managed Medicaid,,9.83,,,,,,,9.83,39.92,percent of total billed charges,
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION,RX-20472,CDM,250,RC,J3490,HCPCS,00143950601,NDC,facility,outpatient,10,ML,89.15000,53.49000,WellCare of North Carolina,Managed Medicaid,,17.85,,,,,,,17.85,72.48,percent of total billed charges,
MELOXICAM 7.5 MG TABLET,RX-20566,CDM,250,RC,J3490,HCPCS,50268052515,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
MELOXICAM 15 MG TABLET,RX-20580,CDM,250,RC,J3490,HCPCS,68382005101,NDC,facility,outpatient,1,UN,16.20000,9.72000,WellCare of North Carolina,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION,RX-20887,CDM,250,RC,J3490,HCPCS,00143963701,NDC,facility,outpatient,5,ML,73.40000,44.04000,WellCare of North Carolina,Managed Medicaid,,14.69,,,,,,,14.69,59.67,percent of total billed charges,
DACARBAZINE 200 MG INTRAVENOUS SOLUTION,RX-2091,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,outpatient,1,UN,327.80000,196.68000,WellCare of North Carolina,Managed Medicaid,,65.63,,,,,,,8.14,243.29,percent of total billed charges,
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,250,RC,J3490,HCPCS,00406839023,NDC,facility,outpatient,1,UN,38.45000,23.07000,WellCare of North Carolina,Managed Medicaid,,7.70,,,,,,,7.70,31.26,percent of total billed charges,
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,250,RC,J3490,HCPCS,42858080101,NDC,facility,outpatient,1,UN,23.45000,14.07000,WellCare of North Carolina,Managed Medicaid,,4.69,,,,,,,4.69,19.06,percent of total billed charges,
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,250,RC,J3490,HCPCS,00406833062,NDC,facility,outpatient,1,UN,27.25000,16.35000,WellCare of North Carolina,Managed Medicaid,,5.46,,,,,,,5.46,22.15,percent of total billed charges,
"MORPHINE ER 60 MG TABLET,EXTENDED RELEASE",RX-20922,CDM,250,RC,J3490,HCPCS,00406838062,NDC,facility,outpatient,1,UN,32.20000,19.32000,WellCare of North Carolina,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
LEVOCARNITINE 330 MG TABLET,RX-20952,CDM,250,RC,J3490,HCPCS,54482014407,NDC,facility,outpatient,1,UN,2.95000,1.77000,WellCare of North Carolina,Managed Medicaid,,0.59059,,,,,,,0.59059,2.40,percent of total billed charges,
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION,RX-20954,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,5,ML,192.90000,115.74000,WellCare of North Carolina,Managed Medicaid,,38.62,,,,,,,38.62,143.17,percent of total billed charges,
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL,RX-21058,CDM,250,RC,J3490,HCPCS,00065806401,NDC,facility,outpatient,10,GR,11.10000,6.66000,WellCare of North Carolina,Managed Medicaid,,2.22,,,,,,,2.22,9.02,percent of total billed charges,
OXCARBAZEPINE 300 MG TABLET,RX-21061,CDM,250,RC,J3490,HCPCS,60687072211,NDC,facility,outpatient,1,UN,19.55000,11.73000,WellCare of North Carolina,Managed Medicaid,,3.91,,,,,,,3.91,15.89,percent of total billed charges,
CITALOPRAM 20 MG TABLET,RX-21062,CDM,250,RC,J3490,HCPCS,00904608561,NDC,facility,outpatient,1,UN,16.25000,9.75000,WellCare of North Carolina,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION,RX-21063,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,outpatient,1,UN,94.25000,56.55000,WellCare of North Carolina,Managed Medicaid,,18.87,,,,,,,4.81,69.95,percent of total billed charges,
SODIUM HYPOCHLORITE 0.5 % SOLUTION,RX-2110,CDM,250,RC,J3490,HCPCS,00436094616,NDC,facility,outpatient,473,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
PRAMIPEXOLE 0.125 MG TABLET,RX-21287,CDM,250,RC,J3490,HCPCS,13668009190,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-21300,CDM,250,RC,J3490,HCPCS,00904544861,NDC,facility,outpatient,1,UN,17.25000,10.35000,WellCare of North Carolina,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DAPSONE 100 MG TABLET,RX-2131,CDM,250,RC,J3490,HCPCS,49938010130,NDC,facility,outpatient,1,UN,27.20000,16.32000,WellCare of North Carolina,Managed Medicaid,,5.45,,,,,,,5.45,22.11,percent of total billed charges,
WARFARIN 4 MG TABLET,RX-21372,CDM,250,RC,J3490,HCPCS,00832121589,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
LETROZOLE 2.5 MG TABLET,RX-21509,CDM,250,RC,J3490,HCPCS,00093762056,NDC,facility,outpatient,1,UN,26.20000,15.72000,WellCare of North Carolina,Managed Medicaid,,5.25,,,,,,,5.25,21.30,percent of total billed charges,
ROPINIROLE 0.25 MG TABLET,RX-21688,CDM,250,RC,J3490,HCPCS,68462025301,NDC,facility,outpatient,1,UN,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
ROPINIROLE 1 MG TABLET,RX-21689,CDM,250,RC,J3490,HCPCS,00904637461,NDC,facility,outpatient,1,UN,18.30000,10.98000,WellCare of North Carolina,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
QUETIAPINE 25 MG TABLET,RX-21823,CDM,250,RC,J3490,HCPCS,00904663861,NDC,facility,outpatient,1,UN,17.20000,10.32000,WellCare of North Carolina,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
QUETIAPINE 100 MG TABLET,RX-21824,CDM,250,RC,J3490,HCPCS,00904664061,NDC,facility,outpatient,1,UN,17.90000,10.74000,WellCare of North Carolina,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION,RX-21880,CDM,636,RC,J0476,HCPCS,70257056211,NDC,facility,outpatient,0.5,ML,91.05000,54.63000,WellCare of North Carolina,Managed Medicaid,,18.23,,,,,,,18.23,182.95,percent of total billed charges,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,WellCare of North Carolina,Managed Medicaid,,280.27,,,,,,,20.84,1039.04,percent of total billed charges,
CLOPIDOGREL 75 MG TABLET,RX-22142,CDM,250,RC,J3490,HCPCS,68084053611,NDC,facility,outpatient,1,UN,17.05000,10.23000,WellCare of North Carolina,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
RALOXIFENE 60 MG TABLET,RX-22143,CDM,250,RC,J3490,HCPCS,43598050530,NDC,facility,outpatient,1,UN,18.60000,11.16000,WellCare of North Carolina,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,WellCare of North Carolina,Managed Medicaid,,882.66,,,,,,,72.96,3272.29,percent of total billed charges,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,WellCare of North Carolina,Managed Medicaid,,4193.08,,,,,,,72.96,15544.97,percent of total billed charges,
DILTIAZEM 100 MG INTRAVENOUS SOLUTION,RX-22156,CDM,250,RC,J3490,HCPCS,00409435003,NDC,facility,outpatient,1,UN,67.95000,40.77000,WellCare of North Carolina,Managed Medicaid,,13.60,,,,,,,13.60,55.24,percent of total billed charges,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,WellCare of North Carolina,Managed Medicaid,,1273.87,,,,,,,6.09,4722.62,percent of total billed charges,
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION,RX-22240,CDM,250,RC,J3490,HCPCS,65162091446,NDC,facility,outpatient,5,ML,83.90000,50.34000,WellCare of North Carolina,Managed Medicaid,,16.80,,,,,,,16.80,68.21,percent of total billed charges,
CEFDINIR 300 MG CAPSULE,RX-22289,CDM,250,RC,J3490,HCPCS,68180071160,NDC,facility,outpatient,1,UN,18.70000,11.22000,WellCare of North Carolina,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,00093413673,NDC,facility,outpatient,100,ML,197.80000,118.68000,WellCare of North Carolina,Managed Medicaid,,39.60,,,,,,,39.60,160.81,percent of total billed charges,
CEFDINIR 125 MG/5 ML ORAL SUSPENSION,RX-22290,CDM,250,RC,J3490,HCPCS,67877054798,NDC,facility,outpatient,60,ML,46.10000,27.66000,WellCare of North Carolina,Managed Medicaid,,9.23,,,,,,,9.23,37.48,percent of total billed charges,
"LACTASE 3,000 UNIT TABLET",RX-22469,CDM,250,RC,J3490,HCPCS,00904522452,NDC,facility,outpatient,1,UN,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,WellCare of North Carolina,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
MONTELUKAST 10 MG TABLET,RX-22509,CDM,250,RC,J3490,HCPCS,00904680861,NDC,facility,outpatient,1,UN,17.35000,10.41000,WellCare of North Carolina,Managed Medicaid,,3.47,,,,,,,3.47,14.11,percent of total billed charges,
MONTELUKAST 5 MG CHEWABLE TABLET,RX-22510,CDM,250,RC,J3490,HCPCS,50268057411,NDC,facility,outpatient,1,UN,19.80000,11.88000,WellCare of North Carolina,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-22532,CDM,636,RC,Q3028,HCPCS,44087004403,NDC,facility,outpatient,0.5,ML,4182.45000,2509.47000,WellCare of North Carolina,Managed Medicaid,,837.33,,,,,,,100.21,3104.21,percent of total billed charges,
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION,RX-22560,CDM,250,RC,J3490,HCPCS,00121085320,NDC,facility,outpatient,20,ML,81.55000,48.93000,WellCare of North Carolina,Managed Medicaid,,16.33,,,,,,,16.33,66.30,percent of total billed charges,
LOSARTAN 100 MG TABLET,RX-22588,CDM,250,RC,J3490,HCPCS,68084034801,NDC,facility,outpatient,1,UN,18.80000,11.28000,WellCare of North Carolina,Managed Medicaid,,3.76,,,,,,,3.76,15.28,percent of total billed charges,
PRAMIPEXOLE 0.5 MG TABLET,RX-22719,CDM,250,RC,J3490,HCPCS,13668009390,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION,RX-22960,CDM,636,RC,J2501,HCPCS,00074165801,NDC,facility,outpatient,1,ML,126.65000,75.99000,WellCare of North Carolina,Managed Medicaid,,25.36,,,,,,,1.83,94.00,percent of total billed charges,
CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION,RX-22988,CDM,250,RC,J3490,HCPCS,50419077301,NDC,facility,outpatient,100,ML,472.90000,283.74000,WellCare of North Carolina,Managed Medicaid,,94.67,,,,,,,94.67,384.47,percent of total billed charges,
CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION,RX-23063,CDM,250,RC,J3490,HCPCS,46122057310,NDC,facility,outpatient,222,ML,9.65000,5.79000,WellCare of North Carolina,Managed Medicaid,,1.93,,,,,,,1.93,7.85,percent of total billed charges,
PROGESTERONE MICRONIZED 100 MG CAPSULE,RX-23122,CDM,250,RC,J3490,HCPCS,43598034901,NDC,facility,outpatient,1,UN,20.40000,12.24000,WellCare of North Carolina,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION,RX-23123,CDM,636,RC,J1327,HCPCS,25021040851,NDC,facility,outpatient,100,ML,1113.00000,667.80000,WellCare of North Carolina,Managed Medicaid,,222.82,,,,,,,24.07,826.07,percent of total billed charges,
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION,RX-2320,CDM,636,RC,J8540,HCPCS,00054317763,NDC,facility,outpatient,500,ML,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,0.04720,47.50,percent of total billed charges,
DEXAMETHASONE 0.5 MG TABLET,RX-2322,CDM,636,RC,J8540,HCPCS,00054817925,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,0.04720,12.39,percent of total billed charges,
DEXAMETHASONE 1.5 MG TABLET,RX-2325,CDM,636,RC,J8540,HCPCS,00054418225,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,0.04720,13.06,percent of total billed charges,
DEXAMETHASONE 2 MG TABLET,RX-2326,CDM,250,RC,J3490,HCPCS,00054418325,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
DEXAMETHASONE 4 MG TABLET,RX-2327,CDM,636,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,1,UN,20.05000,12.03000,WellCare of North Carolina,Managed Medicaid,,4.01,,,,,,,0.04720,14.88,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION,RX-2332,CDM,636,RC,J1100,HCPCS,67457042200,NDC,facility,outpatient,5,ML,24.90000,14.94000,WellCare of North Carolina,Managed Medicaid,,4.98,,,,,,,0.21240,18.48,percent of total billed charges,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS,RX-2335,CDM,250,RC,J3490,HCPCS,24208072002,NDC,facility,outpatient,5,ML,177.70000,106.62000,WellCare of North Carolina,Managed Medicaid,,35.58,,,,,,,35.58,144.47,percent of total billed charges,
LIDOCAINE 4 % TOPICAL CREAM,RX-23461,CDM,250,RC,J3490,HCPCS,00496088205,NDC,facility,outpatient,5,GR,11.85000,7.11000,WellCare of North Carolina,Managed Medicaid,,2.37,,,,,,,2.37,9.63,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002304,NDC,facility,outpatient,1000,ML,87.00000,52.20000,WellCare of North Carolina,Managed Medicaid,,17.42,,,,,,,17.42,65.19,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002302,NDC,facility,outpatient,250,ML,81.75000,49.05000,WellCare of North Carolina,Managed Medicaid,,16.37,,,,,,,16.37,61.26,percent of total billed charges,
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION,RX-2357,CDM,258,RC,J3490,HCPCS,00338002303,NDC,facility,outpatient,500,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION,RX-2359,CDM,258,RC,J3490,HCPCS,00990793519,NDC,facility,outpatient,500,ML,106.50000,63.90000,WellCare of North Carolina,Managed Medicaid,,21.32,,,,,,,21.32,79.80,percent of total billed charges,
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE,RX-2361,CDM,250,RC,J3490,HCPCS,00409177510,NDC,facility,outpatient,10,ML,109.70000,65.82000,WellCare of North Carolina,Managed Medicaid,,21.96,,,,,,,21.96,89.19,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION,RX-23617,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,outpatient,1,UN,654.25000,392.55000,WellCare of North Carolina,Managed Medicaid,,130.98,,,,,,,7.60,485.58,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001748,NDC,facility,outpatient,100,ML,71.10000,42.66000,WellCare of North Carolina,Managed Medicaid,,14.23,,,,,,,14.23,53.28,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,7.34,60.69,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,25,ML,71.70000,43.02000,WellCare of North Carolina,Managed Medicaid,,14.35,,,,,,,14.35,53.72,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00990792202,NDC,facility,outpatient,250,ML,78.75000,47.25000,WellCare of North Carolina,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J3490,HCPCS,00338001741,NDC,facility,outpatient,50,ML,71.25000,42.75000,WellCare of North Carolina,Managed Medicaid,,14.26,,,,,,,14.26,53.39,percent of total billed charges,
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION,RX-2364,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,500,ML,76.50000,45.90000,WellCare of North Carolina,Managed Medicaid,,15.32,,,,,,,4.27,57.32,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION,RX-2365,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,WellCare of North Carolina,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION,RX-2367,CDM,258,RC,J3490,HCPCS,00338071906,NDC,facility,outpatient,500,ML,78.00000,46.80000,WellCare of North Carolina,Managed Medicaid,,15.62,,,,,,,15.62,58.45,percent of total billed charges,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,WellCare of North Carolina,Managed Medicaid,,412.01,,,,,,,30.16,1527.45,percent of total billed charges,
LEFLUNOMIDE 10 MG TABLET,RX-23872,CDM,250,RC,J3490,HCPCS,62332006130,NDC,facility,outpatient,1,UN,20.40000,12.24000,WellCare of North Carolina,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEFLUNOMIDE 20 MG TABLET,RX-23873,CDM,250,RC,J3490,HCPCS,62332006230,NDC,facility,outpatient,1,UN,20.40000,12.24000,WellCare of North Carolina,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION,RX-23968,CDM,636,RC,J7519,HCPCS,00004029830,NDC,facility,outpatient,1,UN,516.55000,309.93000,WellCare of North Carolina,Managed Medicaid,,103.41,,,,,,,0.84960,383.38,percent of total billed charges,
DIAZEPAM 10 MG TABLET,RX-2403,CDM,250,RC,J3490,HCPCS,51079028601,NDC,facility,outpatient,1,UN,22.25000,13.35000,WellCare of North Carolina,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
DIAZEPAM 5 MG TABLET,RX-2405,CDM,250,RC,J3490,HCPCS,51079028501,NDC,facility,outpatient,1,UN,22.25000,13.35000,WellCare of North Carolina,Managed Medicaid,,4.45,,,,,,,4.45,18.09,percent of total billed charges,
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION,RX-24119,CDM,250,RC,J3490,HCPCS,65862005724,NDC,facility,outpatient,20,ML,53.90000,32.34000,WellCare of North Carolina,Managed Medicaid,,10.79,,,,,,,10.79,43.82,percent of total billed charges,
DIBUCAINE 1 % TOPICAL OINTMENT,RX-2412,CDM,250,RC,J3490,HCPCS,00536121195,NDC,facility,outpatient,28,GR,8.60000,5.16000,WellCare of North Carolina,Managed Medicaid,,1.72,,,,,,,1.72,6.99,percent of total billed charges,
DICLOXACILLIN 250 MG CAPSULE,RX-2414,CDM,250,RC,J3490,HCPCS,00093312301,NDC,facility,outpatient,1,UN,18.75000,11.25000,WellCare of North Carolina,Managed Medicaid,,3.75,,,,,,,3.75,15.24,percent of total billed charges,
DICYCLOMINE 10 MG CAPSULE,RX-2418,CDM,250,RC,J3490,HCPCS,51079011820,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION",RX-24188,CDM,250,RC,J3490,HCPCS,00006542402,NDC,facility,outpatient,1,UN,142.10000,85.26000,WellCare of North Carolina,Managed Medicaid,,28.45,,,,,,,28.45,115.53,percent of total billed charges,
DICYCLOMINE 20 MG TABLET,RX-2420,CDM,250,RC,J3490,HCPCS,00591079501,NDC,facility,outpatient,1,UN,16.65000,9.99000,WellCare of North Carolina,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION,RX-24314,CDM,250,RC,J3490,HCPCS,87701088827,NDC,facility,outpatient,15,ML,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,RX-24385,CDM,250,RC,J3490,HCPCS,51672300701,NDC,facility,outpatient,10,ML,422.40000,253.44000,WellCare of North Carolina,Managed Medicaid,,84.56,,,,,,,84.56,343.41,percent of total billed charges,
"METFORMIN 1,000 MG TABLET",RX-24398,CDM,250,RC,J3490,HCPCS,60687016201,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ABACAVIR 300 MG TABLET,RX-24438,CDM,250,RC,J3490,HCPCS,00904687404,NDC,facility,outpatient,1,UN,50.70000,30.42000,WellCare of North Carolina,Managed Medicaid,,10.15,,,,,,,10.15,41.22,percent of total billed charges,
DIGOXIN 125 MCG (0.125 MG) TABLET,RX-2444,CDM,250,RC,J3490,HCPCS,59212024256,NDC,facility,outpatient,1,UN,88.65000,53.19000,WellCare of North Carolina,Managed Medicaid,,17.75,,,,,,,17.75,72.07,percent of total billed charges,
DIGOXIN 250 MCG (0.25 MG) TABLET,RX-2445,CDM,250,RC,J3490,HCPCS,42292000201,NDC,facility,outpatient,1,UN,21.40000,12.84000,WellCare of North Carolina,Managed Medicaid,,4.28,,,,,,,4.28,17.40,percent of total billed charges,
CILOSTAZOL 100 MG TABLET,RX-24474,CDM,250,RC,J3490,HCPCS,60505252201,NDC,facility,outpatient,1,UN,17.50000,10.50000,WellCare of North Carolina,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
CELECOXIB 200 MG CAPSULE,RX-24501,CDM,250,RC,J3490,HCPCS,00025152534,NDC,facility,outpatient,1,UN,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
"ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-24521,CDM,250,RC,J3490,HCPCS,00904644961,NDC,facility,outpatient,1,UN,17.55000,10.53000,WellCare of North Carolina,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET,RX-24559,CDM,250,RC,J3490,HCPCS,00904582360,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
MODAFINIL 200 MG TABLET,RX-24703,CDM,250,RC,J3490,HCPCS,51079056203,NDC,facility,outpatient,1,UN,90.95000,54.57000,WellCare of North Carolina,Managed Medicaid,,18.21,,,,,,,18.21,73.94,percent of total billed charges,
DILTIAZEM 30 MG TABLET,RX-2475,CDM,250,RC,J3490,HCPCS,00093031801,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
DILTIAZEM 60 MG TABLET,RX-2476,CDM,250,RC,J3490,HCPCS,68682000710,NDC,facility,outpatient,1,UN,21.25000,12.75000,WellCare of North Carolina,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DILTIAZEM 90 MG TABLET,RX-2477,CDM,250,RC,J3490,HCPCS,51079074701,NDC,facility,outpatient,1,UN,17.50000,10.50000,WellCare of North Carolina,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR,RX-24844,CDM,250,RC,J3490,HCPCS,63824005634,NDC,facility,outpatient,1,UN,1.90000,1.14000,WellCare of North Carolina,Managed Medicaid,,0.38038,,,,,,,0.38038,1.54,percent of total billed charges,
"TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE",RX-24914,CDM,636,RC,J7507,HCPCS,68084044911,NDC,facility,outpatient,1,UN,23.95000,14.37000,WellCare of North Carolina,Managed Medicaid,,4.79,,,,,,,0.40120,17.78,percent of total billed charges,
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-24915,CDM,250,RC,J3490,HCPCS,76204080011,NDC,facility,outpatient,3,ML,22.40000,13.44000,WellCare of North Carolina,Managed Medicaid,,4.48,,,,,,,4.48,18.21,percent of total billed charges,
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS,RX-24932,CDM,636,RC,J2916,HCPCS,00143957001,NDC,facility,outpatient,5,ML,196.60000,117.96000,WellCare of North Carolina,Managed Medicaid,,39.36,,,,,,,4.77,145.92,percent of total billed charges,
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION,RX-250,CDM,250,RC,J3490,HCPCS,00487950103,NDC,facility,outpatient,3,ML,17.00000,10.20000,WellCare of North Carolina,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION,RX-25005,CDM,636,RC,J7517,HCPCS,00004026129,NDC,facility,outpatient,1.25,ML,48.40000,29.04000,WellCare of North Carolina,Managed Medicaid,,9.69,,,,,,,0.37760,35.92,percent of total billed charges,
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION,RX-2508,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,1,ML,29.70000,17.82000,WellCare of North Carolina,Managed Medicaid,,5.95,,,,,,,1.79,22.04,percent of total billed charges,
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR,RX-2511,CDM,250,RC,J3490,HCPCS,00121048905,NDC,facility,outpatient,5,ML,7.50000,4.50000,WellCare of North Carolina,Managed Medicaid,,1.50,,,,,,,1.50,6.10,percent of total billed charges,
CIPROFLOXACIN 250 MG TABLET,RX-25118,CDM,250,RC,J3490,HCPCS,60687052811,NDC,facility,outpatient,1,UN,17.25000,10.35000,WellCare of North Carolina,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
CIPROFLOXACIN 500 MG TABLET,RX-25119,CDM,250,RC,J3490,HCPCS,51079018201,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
DIPYRIDAMOLE 25 MG TABLET,RX-2528,CDM,250,RC,J3490,HCPCS,64980013301,NDC,facility,outpatient,1,UN,20.75000,12.45000,WellCare of North Carolina,Managed Medicaid,,4.15,,,,,,,4.15,16.87,percent of total billed charges,
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK,RX-25365,CDM,636,RC,J0689,HCPCS,00338350341,NDC,facility,outpatient,50,ML,81.40000,48.84000,WellCare of North Carolina,Managed Medicaid,,16.30,,,,,,,3.07,60.42,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET,RX-25424,CDM,250,RC,J3490,HCPCS,51079030601,NDC,facility,outpatient,1,UN,3.35000,2.01000,WellCare of North Carolina,Managed Medicaid,,0.67067,,,,,,,0.67067,2.72,percent of total billed charges,
KETOTIFEN 0.025 % (0.035 %) EYE DROPS,RX-25471,CDM,250,RC,J3490,HCPCS,24208060110,NDC,facility,outpatient,10,ML,14.40000,8.64000,WellCare of North Carolina,Managed Medicaid,,2.88,,,,,,,2.88,11.71,percent of total billed charges,
"DIVALPROEX 125 MG TABLET,DELAYED RELEASE",RX-2551,CDM,250,RC,J3490,HCPCS,62756079688,NDC,facility,outpatient,1,UN,16.30000,9.78000,WellCare of North Carolina,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
RISPERIDONE 0.25 MG TABLET,RX-25519,CDM,250,RC,J3490,HCPCS,68084027001,NDC,facility,outpatient,1,UN,16.95000,10.17000,WellCare of North Carolina,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"DIVALPROEX 250 MG TABLET,DELAYED RELEASE",RX-2552,CDM,250,RC,J3490,HCPCS,62756079788,NDC,facility,outpatient,1,UN,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PIOGLITAZONE 15 MG TABLET,RX-25528,CDM,250,RC,J3490,HCPCS,51079051301,NDC,facility,outpatient,1,UN,22.50000,13.50000,WellCare of North Carolina,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
DOCUSATE SODIUM 100 MG CAPSULE,RX-2566,CDM,250,RC,J3490,HCPCS,60687012901,NDC,facility,outpatient,1,UN,1.30000,0.78000,WellCare of North Carolina,Managed Medicaid,,0.26026,,,,,,,0.26026,1.06,percent of total billed charges,
IVERMECTIN 3 MG TABLET,RX-25820,CDM,250,RC,J3490,HCPCS,42799080601,NDC,facility,outpatient,1,UN,32.60000,19.56000,WellCare of North Carolina,Managed Medicaid,,6.53,,,,,,,6.53,26.50,percent of total billed charges,
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION,RX-2595,CDM,636,RC,J1265,HCPCS,00409582001,NDC,facility,outpatient,5,ML,79.85000,47.91000,WellCare of North Carolina,Managed Medicaid,,15.99,,,,,,,1.80,59.26,percent of total billed charges,
ZALEPLON 5 MG CAPSULE,RX-25997,CDM,250,RC,J3490,HCPCS,57237023901,NDC,facility,outpatient,1,UN,22.90000,13.74000,WellCare of North Carolina,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
DOXEPIN 10 MG CAPSULE,RX-2608,CDM,250,RC,J3490,HCPCS,51079043601,NDC,facility,outpatient,1,UN,18.15000,10.89000,WellCare of North Carolina,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
DOXEPIN 25 MG CAPSULE,RX-2611,CDM,250,RC,J3490,HCPCS,51079043701,NDC,facility,outpatient,1,UN,18.85000,11.31000,WellCare of North Carolina,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
DOXEPIN 50 MG CAPSULE,RX-2612,CDM,250,RC,J3490,HCPCS,51079043801,NDC,facility,outpatient,1,UN,19.90000,11.94000,WellCare of North Carolina,Managed Medicaid,,3.98,,,,,,,3.98,16.18,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-2622,CDM,636,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,1,UN,164.50000,98.70000,WellCare of North Carolina,Managed Medicaid,,32.93,,,,,,,0.25960,122.09,percent of total billed charges,
"PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE",RX-26224,CDM,250,RC,J3490,HCPCS,00378668877,NDC,facility,outpatient,1,UN,16.45000,9.87000,WellCare of North Carolina,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,250,RC,J3490,HCPCS,00904647461,NDC,facility,outpatient,1,UN,17.20000,10.32000,WellCare of North Carolina,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION,RX-26226,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,1,UN,84.35000,50.61000,WellCare of North Carolina,Managed Medicaid,,16.89,,,,,,,4.55,62.60,percent of total billed charges,
DOXYCYCLINE HYCLATE 100 MG TABLET,RX-2625,CDM,250,RC,J3490,HCPCS,62584069321,NDC,facility,outpatient,1,UN,31.35000,18.81000,WellCare of North Carolina,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,WellCare of North Carolina,Managed Medicaid,,1470.74,,,,,,,41.89,5452.46,percent of total billed charges,
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION,RX-2654,CDM,636,RC,J1790,HCPCS,00517970201,NDC,facility,outpatient,0.5,ML,28.10000,16.86000,WellCare of North Carolina,Managed Medicaid,,5.63,,,,,,,5.63,20.86,percent of total billed charges,
OSELTAMIVIR 75 MG CAPSULE,RX-26546,CDM,250,RC,J3490,HCPCS,00004080085,NDC,facility,outpatient,1,UN,76.80000,46.08000,WellCare of North Carolina,Managed Medicaid,,15.38,,,,,,,15.38,62.44,percent of total billed charges,
EXEMESTANE 25 MG TABLET,RX-26551,CDM,250,RC,J3490,HCPCS,59762285801,NDC,facility,outpatient,1,UN,31.70000,19.02000,WellCare of North Carolina,Managed Medicaid,,6.35,,,,,,,6.35,25.77,percent of total billed charges,
LEVETIRACETAM 250 MG TABLET,RX-26816,CDM,250,RC,J3490,HCPCS,68084085911,NDC,facility,outpatient,1,UN,17.00000,10.20000,WellCare of North Carolina,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
LEVETIRACETAM 500 MG TABLET,RX-26817,CDM,250,RC,J3490,HCPCS,00904712461,NDC,facility,outpatient,1,UN,16.85000,10.11000,WellCare of North Carolina,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION,RX-27047,CDM,250,RC,J3490,HCPCS,10122051001,NDC,facility,outpatient,1.5,ML,2741.30000,1644.78000,WellCare of North Carolina,Managed Medicaid,,548.81,,,,,,,548.81,2228.68,percent of total billed charges,
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION,RX-27103,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,WellCare of North Carolina,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
"CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION",RX-27113,CDM,636,RC,J0735,HCPCS,00517073101,NDC,facility,outpatient,0.3,ML,39.90000,23.94000,WellCare of North Carolina,Managed Medicaid,,7.99,,,,,,,7.99,48.11,percent of total billed charges,
CEVIMELINE 30 MG CAPSULE,RX-27253,CDM,250,RC,J3490,HCPCS,63304047901,NDC,facility,outpatient,1,UN,26.35000,15.81000,WellCare of North Carolina,Managed Medicaid,,5.28,,,,,,,5.28,21.42,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,63323061710,NDC,facility,outpatient,10,ML,97.15000,58.29000,WellCare of North Carolina,Managed Medicaid,,19.45,,,,,,,3.42,72.10,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970910,NDC,facility,outpatient,20,ML,101.60000,60.96000,WellCare of North Carolina,Managed Medicaid,,20.34,,,,,,,3.42,75.41,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION,RX-27327,CDM,636,RC,J2260,HCPCS,00143970801,NDC,facility,outpatient,50,ML,147.00000,88.20000,WellCare of North Carolina,Managed Medicaid,,29.43,,,,,,,3.42,109.10,percent of total billed charges,
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION,RX-27390,CDM,636,RC,J2270,HCPCS,00641612701,NDC,facility,outpatient,0.5,ML,25.85000,15.51000,WellCare of North Carolina,Managed Medicaid,,5.18,,,,,,,5.14,19.19,percent of total billed charges,
MORPHINE (PF) 25 MG/ML INJECTION SOLUTION,RX-27392,CDM,636,RC,J2274,HCPCS,66794016202,NDC,facility,outpatient,20,ML,1179.50000,707.70000,WellCare of North Carolina,Managed Medicaid,,236.14,,,,,,,28.44,875.42,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,WellCare of North Carolina,Managed Medicaid,,451.45,,,,,,,105.22,1673.66,percent of total billed charges,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,WellCare of North Carolina,Managed Medicaid,,1156.15,,,,,,,105.22,4286.20,percent of total billed charges,
DEXTROSE 40 % ORAL GEL,RX-27466,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,WellCare of North Carolina,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
"DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE",RX-27467,CDM,250,RC,J3490,HCPCS,55566280001,NDC,facility,outpatient,1,UN,2216.75000,1330.05000,WellCare of North Carolina,Managed Medicaid,,443.79,,,,,,,443.79,1802.22,percent of total billed charges,
NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27471,CDM,250,RC,J3490,HCPCS,00378910216,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27472,CDM,250,RC,J3490,HCPCS,49730011130,NDC,facility,outpatient,1,UN,18.85000,11.31000,WellCare of North Carolina,Managed Medicaid,,3.77,,,,,,,3.77,15.33,percent of total billed charges,
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27473,CDM,250,RC,J3490,HCPCS,50742051501,NDC,facility,outpatient,1,UN,228.00000,136.80000,WellCare of North Carolina,Managed Medicaid,,45.65,,,,,,,45.65,185.36,percent of total billed charges,
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27474,CDM,250,RC,J3490,HCPCS,00378911216,NDC,facility,outpatient,1,UN,19.30000,11.58000,WellCare of North Carolina,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH,RX-27475,CDM,250,RC,J3490,HCPCS,00378911693,NDC,facility,outpatient,1,UN,20.15000,12.09000,WellCare of North Carolina,Managed Medicaid,,4.03,,,,,,,4.03,16.38,percent of total billed charges,
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-27507,CDM,250,RC,J3490,HCPCS,00591351054,NDC,facility,outpatient,1,UN,263.60000,158.16000,WellCare of North Carolina,Managed Medicaid,,52.77,,,,,,,52.77,214.31,percent of total billed charges,
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-27614,CDM,250,RC,J3490,HCPCS,62332002531,NDC,facility,outpatient,1,UN,21.20000,12.72000,WellCare of North Carolina,Managed Medicaid,,4.24,,,,,,,4.24,17.24,percent of total billed charges,
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,250,RC,J3490,HCPCS,68084031311,NDC,facility,outpatient,1,UN,19.40000,11.64000,WellCare of North Carolina,Managed Medicaid,,3.88,,,,,,,3.88,15.77,percent of total billed charges,
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE 12HR",RX-27633,CDM,250,RC,J3490,HCPCS,54092017312,NDC,facility,outpatient,1,UN,23.10000,13.86000,WellCare of North Carolina,Managed Medicaid,,4.62,,,,,,,4.62,18.78,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR",RX-27634,CDM,250,RC,J3490,HCPCS,00078051005,NDC,facility,outpatient,1,UN,22.65000,13.59000,WellCare of North Carolina,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,250,RC,J3490,HCPCS,65162059606,NDC,facility,outpatient,1,UN,20.00000,12.00000,WellCare of North Carolina,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
"NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR",RX-27659,CDM,250,RC,J3490,HCPCS,68084059811,NDC,facility,outpatient,1,UN,25.90000,15.54000,WellCare of North Carolina,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH,RX-27696,CDM,250,RC,J3490,HCPCS,10019055390,NDC,facility,outpatient,1,UN,101.20000,60.72000,WellCare of North Carolina,Managed Medicaid,,20.26,,,,,,,20.26,82.28,percent of total billed charges,
ONDANSETRON 4 MG DISINTEGRATING TABLET,RX-27697,CDM,250,RC,J3490,HCPCS,62756024064,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY,RX-27770,CDM,250,RC,J3490,HCPCS,24208034205,NDC,facility,outpatient,5,ML,607.05000,364.23000,WellCare of North Carolina,Managed Medicaid,,121.53,,,,,,,121.53,493.53,percent of total billed charges,
ZONISAMIDE 100 MG CAPSULE,RX-27780,CDM,250,RC,J3490,HCPCS,62756026002,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27796,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,2000,ML,180.85000,108.51000,WellCare of North Carolina,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 4-1.5 % DEXTR CA+ 3.5 MEQ/L-LOW MAG 0.5 MEQ/L,RX-27797,CDM,636,RC,A4722,HCPCS,00941042652,NDC,facility,outpatient,2000,ML,180.85000,108.51000,WellCare of North Carolina,Managed Medicaid,,36.21,,,,,,,36.21,134.23,percent of total billed charges,
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L,RX-27800,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,2000,ML,194.50000,116.70000,WellCare of North Carolina,Managed Medicaid,,38.94,,,,,,,38.94,144.36,percent of total billed charges,
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L,RX-27805,CDM,636,RC,A4722,HCPCS,00941042952,NDC,facility,outpatient,2000,ML,195.65000,117.39000,WellCare of North Carolina,Managed Medicaid,,39.17,,,,,,,39.17,145.21,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION,RX-27838,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,WellCare of North Carolina,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
"VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27857,CDM,250,RC,J3490,HCPCS,68084069811,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,250,RC,J3490,HCPCS,59762018103,NDC,facility,outpatient,1,UN,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27860,CDM,250,RC,J3490,HCPCS,00536110688,NDC,facility,outpatient,1,UN,3.70000,2.22000,WellCare of North Carolina,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27862,CDM,250,RC,J3490,HCPCS,43598044771,NDC,facility,outpatient,1,UN,3.70000,2.22000,WellCare of North Carolina,Managed Medicaid,,0.74074,,,,,,,0.74074,3.01,percent of total billed charges,
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH,RX-27863,CDM,250,RC,J3490,HCPCS,60505706300,NDC,facility,outpatient,1,UN,3.90000,2.34000,WellCare of North Carolina,Managed Medicaid,,0.78078,,,,,,,0.78078,3.17,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-27871,CDM,250,RC,J3490,HCPCS,00832022700,NDC,facility,outpatient,1,UN,35.65000,21.39000,WellCare of North Carolina,Managed Medicaid,,7.14,,,,,,,7.14,28.98,percent of total billed charges,
FENTANYL 25 MCG/HR TRANSDERMAL PATCH,RX-27905,CDM,250,RC,J3490,HCPCS,00406902576,NDC,facility,outpatient,1,UN,43.40000,26.04000,WellCare of North Carolina,Managed Medicaid,,8.69,,,,,,,8.69,35.28,percent of total billed charges,
FENTANYL 50 MCG/HR TRANSDERMAL PATCH,RX-27906,CDM,250,RC,J3490,HCPCS,00406905076,NDC,facility,outpatient,1,UN,60.00000,36.00000,WellCare of North Carolina,Managed Medicaid,,12.01,,,,,,,12.01,48.78,percent of total billed charges,
FENTANYL 75 MCG/HR TRANSDERMAL PATCH,RX-27907,CDM,250,RC,J3490,HCPCS,00406907576,NDC,facility,outpatient,1,UN,82.10000,49.26000,WellCare of North Carolina,Managed Medicaid,,16.44,,,,,,,16.44,66.75,percent of total billed charges,
FENTANYL 100 MCG/HR TRANSDERMAL PATCH,RX-27908,CDM,250,RC,J3490,HCPCS,00406900076,NDC,facility,outpatient,1,UN,104.70000,62.82000,WellCare of North Carolina,Managed Medicaid,,20.96,,,,,,,20.96,85.12,percent of total billed charges,
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION,RX-27963,CDM,250,RC,J3490,HCPCS,00338114703,NDC,facility,outpatient,1000,ML,220.75000,132.45000,WellCare of North Carolina,Managed Medicaid,,44.19,,,,,,,44.19,179.47,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS,RX-27990,CDM,250,RC,J3490,HCPCS,58790000115,NDC,facility,outpatient,15,ML,13.40000,8.04000,WellCare of North Carolina,Managed Medicaid,,2.68,,,,,,,2.68,10.89,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE,RX-27991,CDM,250,RC,J3490,HCPCS,00023040350,NDC,facility,outpatient,1,UN,1.45000,0.87000,WellCare of North Carolina,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
GELATIN ABSORBABLE EYE FILM,RX-28028,CDM,250,RC,J3490,HCPCS,00009029703,NDC,facility,outpatient,1,UN,1011.80000,607.08000,WellCare of North Carolina,Managed Medicaid,,202.56,,,,,,,202.56,822.59,percent of total billed charges,
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL,RX-28048,CDM,250,RC,J3490,HCPCS,16864068002,NDC,facility,outpatient,56,GR,8.05000,4.83000,WellCare of North Carolina,Managed Medicaid,,1.61,,,,,,,1.61,6.54,percent of total billed charges,
ELECTROLYTE-A INTRAVENOUS SOLUTION,RX-28113,CDM,250,RC,J3490,HCPCS,00338022104,NDC,facility,outpatient,1000,ML,114.00000,68.40000,WellCare of North Carolina,Managed Medicaid,,22.82,,,,,,,22.82,92.68,percent of total billed charges,
OLANZAPINE 5 MG DISINTEGRATING TABLET,RX-28159,CDM,250,RC,J3490,HCPCS,60505327500,NDC,facility,outpatient,1,UN,23.15000,13.89000,WellCare of North Carolina,Managed Medicaid,,4.63,,,,,,,4.63,18.82,percent of total billed charges,
OLANZAPINE 10 MG DISINTEGRATING TABLET,RX-28160,CDM,250,RC,J3490,HCPCS,60505327600,NDC,facility,outpatient,1,UN,26.50000,15.90000,WellCare of North Carolina,Managed Medicaid,,5.31,,,,,,,5.31,21.54,percent of total billed charges,
LINEZOLID 600 MG TABLET,RX-28224,CDM,250,RC,J3490,HCPCS,67877041933,NDC,facility,outpatient,1,UN,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
LINEZOLID 100 MG/5 ML ORAL SUSPENSION,RX-28225,CDM,250,RC,J3490,HCPCS,00009513601,NDC,facility,outpatient,150,ML,752.65000,451.59000,WellCare of North Carolina,Managed Medicaid,,150.68,,,,,,,150.68,611.90,percent of total billed charges,
RIVASTIGMINE 1.5 MG CAPSULE,RX-28278,CDM,250,RC,J3490,HCPCS,62756014586,NDC,facility,outpatient,1,UN,18.35000,11.01000,WellCare of North Carolina,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION,RX-28282,CDM,636,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,10,ML,308.40000,185.04000,WellCare of North Carolina,Managed Medicaid,,61.74,,,,,,,0.54280,228.89,percent of total billed charges,
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET,RX-28384,CDM,250,RC,J3490,HCPCS,00406012523,NDC,facility,outpatient,1,UN,24.10000,14.46000,WellCare of North Carolina,Managed Medicaid,,4.82,,,,,,,4.82,19.59,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001304,NDC,facility,outpatient,1000,ML,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,18.62,75.61,percent of total billed charges,
"WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-28400,CDM,250,RC,J3490,HCPCS,00338001306,NDC,facility,outpatient,2000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28408,CDM,250,RC,J3490,HCPCS,50419045104,NDC,facility,outpatient,1,UN,92.30000,55.38000,WellCare of North Carolina,Managed Medicaid,,18.48,,,,,,,18.48,75.04,percent of total billed charges,
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH,RX-28409,CDM,250,RC,J3490,HCPCS,00378335216,NDC,facility,outpatient,1,UN,90.30000,54.18000,WellCare of North Carolina,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION,RX-2850,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,0.1,ML,22.85000,13.71000,WellCare of North Carolina,Managed Medicaid,,4.57,,,,,,,1.13,16.96,percent of total billed charges,
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-28643,CDM,250,RC,J3490,HCPCS,62175026037,NDC,facility,outpatient,1,UN,20.30000,12.18000,WellCare of North Carolina,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
ATORVASTATIN 80 MG TABLET,RX-28645,CDM,250,RC,J3490,HCPCS,50268009611,NDC,facility,outpatient,1,UN,18.10000,10.86000,WellCare of North Carolina,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28774,CDM,250,RC,J3490,HCPCS,00093681545,NDC,facility,outpatient,2,ML,46.15000,27.69000,WellCare of North Carolina,Managed Medicaid,,9.24,,,,,,,9.24,37.52,percent of total billed charges,
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-28775,CDM,250,RC,J3490,HCPCS,00093681645,NDC,facility,outpatient,2,ML,51.50000,30.90000,WellCare of North Carolina,Managed Medicaid,,10.31,,,,,,,10.31,41.87,percent of total billed charges,
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP",RX-28810,CDM,250,RC,J3490,HCPCS,24208063562,NDC,facility,outpatient,10,ML,267.70000,160.62000,WellCare of North Carolina,Managed Medicaid,,53.59,,,,,,,53.59,217.64,percent of total billed charges,
CYCLOSPORINE MODIFIED 25 MG CAPSULE,RX-28842,CDM,636,RC,J7515,HCPCS,00078024661,NDC,facility,outpatient,1,UN,27.90000,16.74000,WellCare of North Carolina,Managed Medicaid,,5.59,,,,,,,1.89,20.71,percent of total billed charges,
CYCLOSPORINE MODIFIED 100 MG CAPSULE,RX-28843,CDM,636,RC,J7502,HCPCS,00078024861,NDC,facility,outpatient,1,UN,63.15000,37.89000,WellCare of North Carolina,Managed Medicaid,,12.64,,,,,,,4.81,46.87,percent of total billed charges,
HYDROCORTISONE 1 %-PRAMOXINE 1 % RECTAL FOAM,RX-28849,CDM,250,RC,J3490,HCPCS,00037682210,NDC,facility,outpatient,10,GR,599.15000,359.49000,WellCare of North Carolina,Managed Medicaid,,119.95,,,,,,,119.95,487.11,percent of total billed charges,
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT,RX-2888,CDM,250,RC,J3490,HCPCS,00574402411,NDC,facility,outpatient,1,GR,37.75000,22.65000,WellCare of North Carolina,Managed Medicaid,,7.56,,,,,,,7.56,30.69,percent of total billed charges,
ERYTHROMYCIN 250 MG TABLET,RX-2889,CDM,250,RC,J3490,HCPCS,24338010203,NDC,facility,outpatient,1,UN,62.45000,37.47000,WellCare of North Carolina,Managed Medicaid,,12.50,,,,,,,12.50,50.77,percent of total billed charges,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,WellCare of North Carolina,Managed Medicaid,,704.70,,,,,,,318.49,2612.54,percent of total billed charges,
LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML ORAL SOLUTION,RX-28929,CDM,250,RC,J3490,HCPCS,00074395646,NDC,facility,outpatient,160,ML,1552.00000,931.20000,WellCare of North Carolina,Managed Medicaid,,310.71,,,,,,,310.71,1261.78,percent of total billed charges,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,WellCare of North Carolina,Managed Medicaid,,241.06,,,,,,,0.77600,893.68,percent of total billed charges,
LEVOFLOXACIN 750 MG TABLET,RX-28964,CDM,250,RC,J3490,HCPCS,00904635361,NDC,facility,outpatient,1,UN,17.80000,10.68000,WellCare of North Carolina,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
MIFEPRISTONE 200 MG TABLET,RX-28975,CDM,250,RC,J3490,HCPCS,43393000101,NDC,facility,outpatient,1,UN,216.00000,129.60000,WellCare of North Carolina,Managed Medicaid,,43.24,,,,,,,43.24,175.61,percent of total billed charges,
"METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-28995,CDM,250,RC,J3490,HCPCS,50268055011,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION,RX-2900,CDM,250,RC,J3490,HCPCS,24338013013,NDC,facility,outpatient,5,ML,115.25000,69.15000,WellCare of North Carolina,Managed Medicaid,,23.07,,,,,,,23.07,93.70,percent of total billed charges,
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION,RX-2903,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,1,UN,523.95000,314.37000,WellCare of North Carolina,Managed Medicaid,,104.89,,,,,,,104.89,388.88,percent of total billed charges,
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,636,RC,J0165,HCPCS,49502010101,NDC,facility,outpatient,1,UN,698.50000,419.10000,WellCare of North Carolina,Managed Medicaid,,139.84,,,,,,,1.13,518.43,percent of total billed charges,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,WellCare of North Carolina,Managed Medicaid,,240.04,,,,,,,7.91,889.90,percent of total billed charges,
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION,RX-29132,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,5,ML,335.80000,201.48000,WellCare of North Carolina,Managed Medicaid,,67.23,,,,,,,0.54280,249.23,percent of total billed charges,
GABAPENTIN 250 MG/5 ML ORAL SOLUTION,RX-29169,CDM,250,RC,J3490,HCPCS,65162069890,NDC,facility,outpatient,473,ML,349.50000,209.70000,WellCare of North Carolina,Managed Medicaid,,69.97,,,,,,,69.97,284.14,percent of total billed charges,
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29270,CDM,250,RC,J3490,HCPCS,10370082909,NDC,facility,outpatient,1,UN,19.10000,11.46000,WellCare of North Carolina,Managed Medicaid,,3.82,,,,,,,3.82,15.53,percent of total billed charges,
"DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29272,CDM,250,RC,J3490,HCPCS,60687020601,NDC,facility,outpatient,1,UN,19.25000,11.55000,WellCare of North Carolina,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
"DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-29274,CDM,250,RC,J3490,HCPCS,68682099798,NDC,facility,outpatient,1,UN,21.35000,12.81000,WellCare of North Carolina,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
DOCOSANOL 10 % TOPICAL CREAM,RX-29287,CDM,250,RC,J3490,HCPCS,00135020001,NDC,facility,outpatient,2,GR,28.45000,17.07000,WellCare of North Carolina,Managed Medicaid,,5.70,,,,,,,5.70,23.13,percent of total billed charges,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION,RX-29302,CDM,636,RC,J7510,HCPCS,99999000798,NDC,facility,outpatient,5,ML,19.30000,11.58000,WellCare of North Carolina,Managed Medicaid,,3.86,,,,,,,0.54280,14.32,percent of total billed charges,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,WellCare of North Carolina,Managed Medicaid,,2576.37,,,,,,,1773.86,9551.37,percent of total billed charges,
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION,RX-29335,CDM,636,RC,J1800,HCPCS,00143987201,NDC,facility,outpatient,1,ML,52.40000,31.44000,WellCare of North Carolina,Managed Medicaid,,10.49,,,,,,,10.49,38.89,percent of total billed charges,
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION,RX-29396,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,1,UN,357.25000,214.35000,WellCare of North Carolina,Managed Medicaid,,71.52,,,,,,,0.40120,265.15,percent of total billed charges,
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,RX-29424,CDM,250,RC,J3490,HCPCS,51672404801,NDC,facility,outpatient,15,GR,66.60000,39.96000,WellCare of North Carolina,Managed Medicaid,,13.33,,,,,,,13.33,54.15,percent of total billed charges,
MIRTAZAPINE 15 MG DISINTEGRATING TABLET,RX-29531,CDM,250,RC,J3490,HCPCS,65862002106,NDC,facility,outpatient,1,UN,17.75000,10.65000,WellCare of North Carolina,Managed Medicaid,,3.55,,,,,,,3.55,14.43,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,00904386575,NDC,facility,outpatient,44,ML,2.45000,1.47000,WellCare of North Carolina,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL,RX-29676,CDM,250,RC,J3490,HCPCS,24385032521,NDC,facility,outpatient,88,ML,4.45000,2.67000,WellCare of North Carolina,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
ZIPRASIDONE 20 MG CAPSULE,RX-29778,CDM,250,RC,J3490,HCPCS,68180033107,NDC,facility,outpatient,1,UN,21.35000,12.81000,WellCare of North Carolina,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ZIPRASIDONE 40 MG CAPSULE,RX-29779,CDM,250,RC,J3490,HCPCS,68084010411,NDC,facility,outpatient,1,UN,27.10000,16.26000,WellCare of North Carolina,Managed Medicaid,,5.43,,,,,,,5.43,22.03,percent of total billed charges,
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,250,ML,693.00000,415.80000,WellCare of North Carolina,Managed Medicaid,,138.74,,,,,,,0.51920,514.34,percent of total billed charges,
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,250,RC,J3490,HCPCS,00904632261,NDC,facility,outpatient,1,UN,19.50000,11.70000,WellCare of North Carolina,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
BUSPIRONE 7.5 MG TABLET,RX-29967,CDM,250,RC,J3490,HCPCS,64380078706,NDC,facility,outpatient,1,UN,17.05000,10.23000,WellCare of North Carolina,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
"METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-30070,CDM,250,RC,J3490,HCPCS,51079017001,NDC,facility,outpatient,1,UN,19.50000,11.70000,WellCare of North Carolina,Managed Medicaid,,3.90,,,,,,,3.90,15.85,percent of total billed charges,
"METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR",RX-30071,CDM,250,RC,J3490,HCPCS,60687041301,NDC,facility,outpatient,1,UN,21.60000,12.96000,WellCare of North Carolina,Managed Medicaid,,4.32,,,,,,,4.32,17.56,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,WellCare of North Carolina,Managed Medicaid,,16.64,,,,,,,1.65,61.68,percent of total billed charges,
VALGANCICLOVIR 450 MG TABLET,RX-30148,CDM,250,RC,J3490,HCPCS,00004003822,NDC,facility,outpatient,1,UN,369.65000,221.79000,WellCare of North Carolina,Managed Medicaid,,74.00,,,,,,,74.00,300.53,percent of total billed charges,
CARDIOPLEGIC SOLUTION 16 MEQ/L (POTASSIUM) FOR PERFUSION,RX-30275,CDM,250,RC,J3490,HCPCS,00409796905,NDC,facility,outpatient,1000,ML,420.00000,252.00000,WellCare of North Carolina,Managed Medicaid,,84.08,,,,,,,84.08,341.46,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,1,ML,28.65000,17.19000,WellCare of North Carolina,Managed Medicaid,,5.74,,,,,,,2.60,21.26,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909428,NDC,facility,outpatient,10,ML,42.40000,25.44000,WellCare of North Carolina,Managed Medicaid,,8.49,,,,,,,2.60,31.47,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602701,NDC,facility,outpatient,2,ML,28.40000,17.04000,WellCare of North Carolina,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00409909431,NDC,facility,outpatient,20,ML,53.45000,32.07000,WellCare of North Carolina,Managed Medicaid,,10.70,,,,,,,2.60,39.67,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION,RX-3037,CDM,636,RC,J3010,HCPCS,00641602801,NDC,facility,outpatient,5,ML,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,2.60,23.01,percent of total billed charges,
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION,RX-30479,CDM,250,RC,J3490,HCPCS,65162064978,NDC,facility,outpatient,5,ML,25.95000,15.57000,WellCare of North Carolina,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
GUAR GUM ORAL PACKET,RX-30538,CDM,250,RC,J3490,HCPCS,43900097647,NDC,facility,outpatient,1,UN,1.75000,1.05000,WellCare of North Carolina,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
FERRIC SUBSULFATE (BULK) 20 TO 22 GRAM/100 ML SOLUTION,RX-3059,CDM,250,RC,J3490,HCPCS,38779128405,NDC,facility,outpatient,100,ML,119.90000,71.94000,WellCare of North Carolina,Managed Medicaid,,24.00,,,,,,,24.00,97.48,percent of total billed charges,
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID,RX-3071,CDM,250,RC,J3490,HCPCS,00121053005,NDC,facility,outpatient,5,ML,6.30000,3.78000,WellCare of North Carolina,Managed Medicaid,,1.26,,,,,,,1.26,5.12,percent of total billed charges,
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,RX-3074,CDM,250,RC,J3490,HCPCS,00904759161,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-30807,CDM,636,RC,J3010,HCPCS,61553029301,NDC,facility,outpatient,150,ML,94.00000,56.40000,WellCare of North Carolina,Managed Medicaid,,18.82,,,,,,,2.60,69.77,percent of total billed charges,
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION,RX-30862,CDM,250,RC,J3490,HCPCS,70092110436,NDC,facility,outpatient,100,ML,86.50000,51.90000,WellCare of North Carolina,Managed Medicaid,,17.32,,,,,,,17.32,70.32,percent of total billed charges,
CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE,RX-30961,CDM,250,RC,J3490,HCPCS,00781208102,NDC,facility,outpatient,1,UN,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
ALLOPURINOL 100 MG TABLET,RX-310,CDM,250,RC,J3490,HCPCS,51079020520,NDC,facility,outpatient,1,UN,17.30000,10.38000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,outpatient,16.7,ML,465.05000,279.03000,WellCare of North Carolina,Managed Medicaid,,93.10,,,,,,,0.29700,345.16,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,70860020005,NDC,facility,outpatient,5,ML,319.00000,191.40000,WellCare of North Carolina,Managed Medicaid,,63.86,,,,,,,0.29700,236.76,percent of total billed charges,
"PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS",RX-31025,CDM,636,RC,J9267,HCPCS,63323076350,NDC,facility,outpatient,50,ML,843.95000,506.37000,WellCare of North Carolina,Managed Medicaid,,168.96,,,,,,,0.29700,626.38,percent of total billed charges,
ALLOPURINOL 300 MG TABLET,RX-311,CDM,250,RC,J3490,HCPCS,51079020601,NDC,facility,outpatient,1,UN,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION,RX-31177,CDM,250,RC,J3490,HCPCS,00781613957,NDC,facility,outpatient,5,ML,20.50000,12.30000,WellCare of North Carolina,Managed Medicaid,,4.10,,,,,,,4.10,16.67,percent of total billed charges,
VALSARTAN 80 MG TABLET,RX-31209,CDM,250,RC,J3490,HCPCS,51660014190,NDC,facility,outpatient,1,UN,17.40000,10.44000,WellCare of North Carolina,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
VALSARTAN 160 MG TABLET,RX-31210,CDM,250,RC,J3490,HCPCS,51660014290,NDC,facility,outpatient,1,UN,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION,RX-31270,CDM,254,RC,Q9957,HCPCS,11994001104,NDC,facility,outpatient,2,ML,265.05000,159.03000,WellCare of North Carolina,Managed Medicaid,,53.06,,,,,,,53.06,215.49,percent of total billed charges,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,WellCare of North Carolina,Managed Medicaid,,171.88,,,,,,,91.62,637.22,percent of total billed charges,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,WellCare of North Carolina,Managed Medicaid,,3998.59,,,,,,,3998.59,14823.96,percent of total billed charges,
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,250,RC,J3490,HCPCS,00378715501,NDC,facility,outpatient,1,UN,33.80000,20.28000,WellCare of North Carolina,Managed Medicaid,,6.77,,,,,,,6.77,27.48,percent of total billed charges,
ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31577,CDM,250,RC,J3490,HCPCS,00591346753,NDC,facility,outpatient,3,ML,21.35000,12.81000,WellCare of North Carolina,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION,RX-31578,CDM,250,RC,J3490,HCPCS,00487990425,NDC,facility,outpatient,3,ML,21.35000,12.81000,WellCare of North Carolina,Managed Medicaid,,4.27,,,,,,,4.27,17.36,percent of total billed charges,
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-31684,CDM,250,RC,J3490,HCPCS,61958040101,NDC,facility,outpatient,1,UN,183.15000,109.89000,WellCare of North Carolina,Managed Medicaid,,36.67,,,,,,,36.67,148.90,percent of total billed charges,
FLUOCINOLONE 0.01 % TOPICAL SOLUTION,RX-3186,CDM,250,RC,J3490,HCPCS,00168005960,NDC,facility,outpatient,60,ML,116.30000,69.78000,WellCare of North Carolina,Managed Medicaid,,23.28,,,,,,,23.28,94.55,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET,RX-31864,CDM,250,RC,J3490,HCPCS,00406052323,NDC,facility,outpatient,1,UN,29.90000,17.94000,WellCare of North Carolina,Managed Medicaid,,5.99,,,,,,,5.99,24.31,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL CREAM,RX-3187,CDM,250,RC,J3490,HCPCS,00093026215,NDC,facility,outpatient,15,GR,125.35000,75.21000,WellCare of North Carolina,Managed Medicaid,,25.10,,,,,,,25.10,101.91,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL OINTMENT,RX-3189,CDM,250,RC,J3490,HCPCS,51672126401,NDC,facility,outpatient,15,GR,71.50000,42.90000,WellCare of North Carolina,Managed Medicaid,,14.31,,,,,,,14.31,58.13,percent of total billed charges,
FLUOCINONIDE 0.05 % TOPICAL SOLUTION,RX-3190,CDM,250,RC,J3490,HCPCS,51672127304,NDC,facility,outpatient,60,ML,190.10000,114.06000,WellCare of North Carolina,Managed Medicaid,,38.06,,,,,,,38.06,154.55,percent of total billed charges,
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE,RX-31921,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,1,ML,84.55000,50.73000,WellCare of North Carolina,Managed Medicaid,,16.93,,,,,,,1.39,62.75,percent of total billed charges,
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,250,RC,J3490,HCPCS,11980021105,NDC,facility,outpatient,5,ML,521.30000,312.78000,WellCare of North Carolina,Managed Medicaid,,104.36,,,,,,,104.36,423.82,percent of total billed charges,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,WellCare of North Carolina,Managed Medicaid,,11.95,,,,,,,7.12,44.31,percent of total billed charges,
FLUPHENAZINE 1 MG TABLET,RX-3218,CDM,250,RC,J3490,HCPCS,00527178801,NDC,facility,outpatient,1,UN,22.00000,13.20000,WellCare of North Carolina,Managed Medicaid,,4.40,,,,,,,4.40,17.89,percent of total billed charges,
FLUPHENAZINE 5 MG TABLET,RX-3221,CDM,250,RC,J3490,HCPCS,00527179001,NDC,facility,outpatient,1,UN,28.60000,17.16000,WellCare of North Carolina,Managed Medicaid,,5.73,,,,,,,5.73,23.25,percent of total billed charges,
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE,RX-32215,CDM,636,RC,J1652,HCPCS,55111067811,NDC,facility,outpatient,0.5,ML,121.05000,72.63000,WellCare of North Carolina,Managed Medicaid,,24.23,,,,,,,1.70,89.84,percent of total billed charges,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,WellCare of North Carolina,Managed Medicaid,,5849.42,,,,,,,86.66,21685.53,percent of total billed charges,
FOLIC ACID 5 MG/ML INJECTION SOLUTION,RX-3232,CDM,636,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,0.2,ML,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,0.14160,13.69,percent of total billed charges,
LEVALBUTEROL 0.31 MG/3 ML SOLUTION FOR NEBULIZATION,RX-32329,CDM,250,RC,J3490,HCPCS,43598041225,NDC,facility,outpatient,3,ML,36.65000,21.99000,WellCare of North Carolina,Managed Medicaid,,7.34,,,,,,,7.34,29.80,percent of total billed charges,
FOLIC ACID 1 MG TABLET,RX-3233,CDM,250,RC,J3490,HCPCS,69315012701,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
ALPRAZOLAM 0.25 MG TABLET,RX-324,CDM,250,RC,J3490,HCPCS,00228202710,NDC,facility,outpatient,1,UN,22.15000,13.29000,WellCare of North Carolina,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
ALPRAZOLAM 0.5 MG TABLET,RX-325,CDM,250,RC,J3490,HCPCS,51079078901,NDC,facility,outpatient,1,UN,22.35000,13.41000,WellCare of North Carolina,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION,RX-32589,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,outpatient,5,ML,93.35000,56.01000,WellCare of North Carolina,Managed Medicaid,,18.69,,,,,,,18.69,69.28,percent of total billed charges,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,WellCare of North Carolina,Managed Medicaid,,596.21,,,,,,,6.30,2210.31,percent of total billed charges,
"MORPHINE ER 30 MG CAPSULE,EXTENDED RELEASE 24 HR MULTIPHASE",RX-32709,CDM,250,RC,J3490,HCPCS,00228309011,NDC,facility,outpatient,1,UN,35.80000,21.48000,WellCare of North Carolina,Managed Medicaid,,7.17,,,,,,,7.17,29.11,percent of total billed charges,
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION,RX-32855,CDM,636,RC,J2430,HCPCS,67457044610,NDC,facility,outpatient,1.6666666666666665,ML,128.65000,77.19000,WellCare of North Carolina,Managed Medicaid,,25.76,,,,,,,22.75,95.48,percent of total billed charges,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,WellCare of North Carolina,Managed Medicaid,,452.94,,,,,,,171.16,1679.19,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,10,ML,42.60000,25.56000,WellCare of North Carolina,Managed Medicaid,,8.53,,,,,,,0.04720,31.62,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,2,ML,35.05000,21.03000,WellCare of North Carolina,Managed Medicaid,,7.02,,,,,,,0.04720,26.01,percent of total billed charges,
FUROSEMIDE 10 MG/ML INJECTION SOLUTION,RX-3291,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,4,ML,29.35000,17.61000,WellCare of North Carolina,Managed Medicaid,,5.88,,,,,,,0.04720,21.78,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329450,NDC,facility,outpatient,120,ML,55.25000,33.15000,WellCare of North Carolina,Managed Medicaid,,11.06,,,,,,,11.06,44.92,percent of total billed charges,
FUROSEMIDE 10 MG/ML ORAL SOLUTION,RX-3292,CDM,250,RC,J3490,HCPCS,00054329446,NDC,facility,outpatient,60,ML,36.20000,21.72000,WellCare of North Carolina,Managed Medicaid,,7.25,,,,,,,7.25,29.43,percent of total billed charges,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,WellCare of North Carolina,Managed Medicaid,,1047.11,,,,,,,53.07,3881.93,percent of total billed charges,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,WellCare of North Carolina,Managed Medicaid,,2612.95,,,,,,,53.07,9686.97,percent of total billed charges,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,WellCare of North Carolina,Managed Medicaid,,5222.67,,,,,,,53.07,19361.96,percent of total billed charges,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,WellCare of North Carolina,Managed Medicaid,,10442.13,,,,,,,53.07,38712.04,percent of total billed charges,
FUROSEMIDE 40 MG TABLET,RX-3295,CDM,250,RC,J3490,HCPCS,00054829925,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK,RX-32950,CDM,636,RC,J2260,HCPCS,00338601048,NDC,facility,outpatient,100,ML,180.95000,108.57000,WellCare of North Carolina,Managed Medicaid,,36.23,,,,,,,3.42,134.30,percent of total billed charges,
IMATINIB 100 MG TABLET,RX-32979,CDM,250,RC,J3490,HCPCS,00078040134,NDC,facility,outpatient,1,UN,399.60000,239.76000,WellCare of North Carolina,Managed Medicaid,,80.00,,,,,,,80.00,324.87,percent of total billed charges,
"DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE",RX-33005,CDM,250,RC,J3490,HCPCS,00228306211,NDC,facility,outpatient,1,UN,25.50000,15.30000,WellCare of North Carolina,Managed Medicaid,,5.11,,,,,,,5.11,20.73,percent of total billed charges,
VORICONAZOLE 50 MG TABLET,RX-33008,CDM,250,RC,J3490,HCPCS,51079016403,NDC,facility,outpatient,1,UN,50.15000,30.09000,WellCare of North Carolina,Managed Medicaid,,10.04,,,,,,,10.04,40.77,percent of total billed charges,
VORICONAZOLE 200 MG TABLET,RX-33009,CDM,250,RC,J3490,HCPCS,51079016501,NDC,facility,outpatient,1,UN,147.80000,88.68000,WellCare of North Carolina,Managed Medicaid,,29.59,,,,,,,29.59,120.16,percent of total billed charges,
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION,RX-33010,CDM,636,RC,J3465,HCPCS,00049319028,NDC,facility,outpatient,1,UN,316.30000,189.78000,WellCare of North Carolina,Managed Medicaid,,63.32,,,,,,,1.82,234.76,percent of total billed charges,
MIDODRINE 10 MG TABLET,RX-33083,CDM,250,RC,J3490,HCPCS,00245021311,NDC,facility,outpatient,1,UN,18.40000,11.04000,WellCare of North Carolina,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET,RX-33227,CDM,250,RC,J3490,HCPCS,65862050220,NDC,facility,outpatient,1,UN,17.80000,10.68000,WellCare of North Carolina,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,00143998250,NDC,facility,outpatient,50,ML,48.40000,29.04000,WellCare of North Carolina,Managed Medicaid,,9.69,,,,,,,9.69,39.35,percent of total billed charges,
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION,RX-33230,CDM,250,RC,J3490,HCPCS,65862053475,NDC,facility,outpatient,75,ML,50.45000,30.27000,WellCare of North Carolina,Managed Medicaid,,10.10,,,,,,,10.10,41.02,percent of total billed charges,
ESCITALOPRAM 10 MG TABLET,RX-33512,CDM,250,RC,J3490,HCPCS,68084061711,NDC,facility,outpatient,1,UN,17.00000,10.20000,WellCare of North Carolina,Managed Medicaid,,3.40,,,,,,,3.40,13.82,percent of total billed charges,
VALSARTAN 40 MG TABLET,RX-33541,CDM,250,RC,J3490,HCPCS,51660014030,NDC,facility,outpatient,1,UN,17.95000,10.77000,WellCare of North Carolina,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,WellCare of North Carolina,Managed Medicaid,,943.42,,,,,,,366.19,3497.54,percent of total billed charges,
GEMFIBROZIL 600 MG TABLET,RX-3378,CDM,250,RC,J3490,HCPCS,60687022401,NDC,facility,outpatient,1,UN,17.05000,10.23000,WellCare of North Carolina,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
EZETIMIBE 10 MG TABLET,RX-34153,CDM,250,RC,J3490,HCPCS,60687037321,NDC,facility,outpatient,1,UN,57.35000,34.41000,WellCare of North Carolina,Managed Medicaid,,11.48,,,,,,,11.48,46.63,percent of total billed charges,
GENTAMICIN 0.1 % TOPICAL CREAM,RX-3423,CDM,250,RC,J3490,HCPCS,45802005635,NDC,facility,outpatient,15,GR,134.50000,80.70000,WellCare of North Carolina,Managed Medicaid,,26.93,,,,,,,26.93,109.35,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,2,ML,37.15000,22.29000,WellCare of North Carolina,Managed Medicaid,,7.44,,,,,,,5.22,27.57,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION SOLUTION,RX-3426,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,WellCare of North Carolina,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
ARIPIPRAZOLE 10 MG TABLET,RX-34369,CDM,250,RC,J3490,HCPCS,60687017911,NDC,facility,outpatient,1,UN,48.90000,29.34000,WellCare of North Carolina,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,250,RC,J3490,HCPCS,51079076601,NDC,facility,outpatient,1,UN,21.90000,13.14000,WellCare of North Carolina,Managed Medicaid,,4.38,,,,,,,4.38,17.80,percent of total billed charges,
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34505,CDM,250,RC,J3490,HCPCS,57664012688,NDC,facility,outpatient,1,UN,22.50000,13.50000,WellCare of North Carolina,Managed Medicaid,,4.50,,,,,,,4.50,18.29,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET,RX-34544,CDM,250,RC,J3490,HCPCS,57664017088,NDC,facility,outpatient,1,UN,22.90000,13.74000,WellCare of North Carolina,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE,RX-34550,CDM,636,RC,90723,HCPCS,58160081143,NDC,facility,outpatient,0.5,ML,321.65000,192.99000,WellCare of North Carolina,Managed Medicaid,,64.39,,,,,,,64.39,336.47,percent of total billed charges,
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET,RX-34711,CDM,250,RC,J3490,HCPCS,00228315603,NDC,facility,outpatient,1,UN,21.50000,12.90000,WellCare of North Carolina,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET,RX-34712,CDM,250,RC,J3490,HCPCS,00228315303,NDC,facility,outpatient,1,UN,26.25000,15.75000,WellCare of North Carolina,Managed Medicaid,,5.26,,,,,,,5.26,21.34,percent of total billed charges,
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET,RX-34714,CDM,636,RC,J0574,HCPCS,50268014515,NDC,facility,outpatient,1,UN,37.10000,22.26000,WellCare of North Carolina,Managed Medicaid,,7.43,,,,,,,7.43,27.54,percent of total billed charges,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,WellCare of North Carolina,Managed Medicaid,,5.58,,,,,,,0.44620,20.67,percent of total billed charges,
"NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP",RX-35126,CDM,250,RC,J3490,HCPCS,61314064175,NDC,facility,outpatient,7.5,ML,465.05000,279.03000,WellCare of North Carolina,Managed Medicaid,,93.10,,,,,,,93.10,378.09,percent of total billed charges,
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION,RX-353,CDM,250,RC,J3490,HCPCS,00536009185,NDC,facility,outpatient,473,ML,11.30000,6.78000,WellCare of North Carolina,Managed Medicaid,,2.26,,,,,,,2.26,9.19,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,00121148810,NDC,facility,outpatient,2.5,ML,1.65000,0.99000,WellCare of North Carolina,Managed Medicaid,,0.33033,,,,,,,0.33033,1.34,percent of total billed charges,
GUAIFENESIN 100 MG/5 ML ORAL LIQUID,RX-3542,CDM,250,RC,J3490,HCPCS,71399100506,NDC,facility,outpatient,2.5,ML,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
APREPITANT 125 MG CAPSULE,RX-35489,CDM,636,RC,J8501,HCPCS,68462058576,NDC,facility,outpatient,1,UN,1034.85000,620.91000,WellCare of North Carolina,Managed Medicaid,,207.18,,,,,,,6.44,768.07,percent of total billed charges,
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET,RX-35625,CDM,250,RC,J3490,HCPCS,62332036406,NDC,facility,outpatient,1,UN,24.85000,14.91000,WellCare of North Carolina,Managed Medicaid,,4.97,,,,,,,4.97,20.20,percent of total billed charges,
CLONAZEPAM 0.25 MG DISINTEGRATING TABLET,RX-35626,CDM,250,RC,J3490,HCPCS,49884030702,NDC,facility,outpatient,1,UN,24.80000,14.88000,WellCare of North Carolina,Managed Medicaid,,4.96,,,,,,,4.96,20.16,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION,RX-35640,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,5,ML,252.00000,151.20000,WellCare of North Carolina,Managed Medicaid,,50.45,,,,,,,11.94,187.03,percent of total billed charges,
RISPERIDONE 0.5 MG DISINTEGRATING TABLET,RX-35686,CDM,250,RC,J3490,HCPCS,49884031155,NDC,facility,outpatient,1,UN,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,,6.01,,,,,,,6.01,24.39,percent of total billed charges,
RISPERIDONE 1 MG DISINTEGRATING TABLET,RX-35687,CDM,250,RC,J3490,HCPCS,49884031555,NDC,facility,outpatient,1,UN,32.35000,19.41000,WellCare of North Carolina,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
"METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR",RX-35771,CDM,250,RC,J3490,HCPCS,50268055111,NDC,facility,outpatient,1,UN,17.70000,10.62000,WellCare of North Carolina,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
HALOPERIDOL 1 MG TABLET,RX-3579,CDM,250,RC,J3490,HCPCS,51079073401,NDC,facility,outpatient,1,UN,17.65000,10.59000,WellCare of North Carolina,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HALOPERIDOL 2 MG TABLET,RX-3581,CDM,250,RC,J3490,HCPCS,51079073501,NDC,facility,outpatient,1,UN,18.25000,10.95000,WellCare of North Carolina,Managed Medicaid,,3.65,,,,,,,3.65,14.84,percent of total billed charges,
HALOPERIDOL 5 MG TABLET,RX-3583,CDM,250,RC,J3490,HCPCS,51079073601,NDC,facility,outpatient,1,UN,19.65000,11.79000,WellCare of North Carolina,Managed Medicaid,,3.93,,,,,,,3.93,15.98,percent of total billed charges,
BORTEZOMIB (VELCADE) IV SYRINGE 1 MG/ML,RX-35839,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,WellCare of North Carolina,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION,RX-3584,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.4,ML,17.65000,10.59000,WellCare of North Carolina,Managed Medicaid,,3.53,,,,,,,1.89,13.10,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,00121058105,NDC,facility,outpatient,1,ML,18.10000,10.86000,WellCare of North Carolina,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050115,NDC,facility,outpatient,1,ML,20.20000,12.12000,WellCare of North Carolina,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE,RX-3585,CDM,250,RC,J3490,HCPCS,54838050140,NDC,facility,outpatient,1,ML,16.75000,10.05000,WellCare of North Carolina,Managed Medicaid,,3.35,,,,,,,3.35,13.62,percent of total billed charges,
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,250,RC,J3490,HCPCS,00245531701,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN,RX-36046,CDM,636,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1000,ML,87.50000,52.50000,WellCare of North Carolina,Managed Medicaid,,17.52,,,,,,,0.25960,64.94,percent of total billed charges,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,WellCare of North Carolina,Managed Medicaid,,1250.97,,,,,,,43.26,4637.71,percent of total billed charges,
EMTRICITABINE 200 MG CAPSULE,RX-36252,CDM,250,RC,J3490,HCPCS,61958060101,NDC,facility,outpatient,1,UN,87.55000,52.53000,WellCare of North Carolina,Managed Medicaid,,17.53,,,,,,,17.53,71.18,percent of total billed charges,
AMANTADINE HCL 100 MG CAPSULE,RX-364,CDM,250,RC,J3490,HCPCS,50268006915,NDC,facility,outpatient,1,UN,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
ARIPIPRAZOLE 5 MG TABLET,RX-36438,CDM,250,RC,J3490,HCPCS,60687016811,NDC,facility,outpatient,1,UN,48.90000,29.34000,WellCare of North Carolina,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION,RX-365,CDM,250,RC,J3490,HCPCS,00121064616,NDC,facility,outpatient,473,ML,96.90000,58.14000,WellCare of North Carolina,Managed Medicaid,,19.40,,,,,,,19.40,78.78,percent of total billed charges,
LEVETIRACETAM 100 MG/ML ORAL SOLUTION,RX-36590,CDM,250,RC,J3490,HCPCS,31722057447,NDC,facility,outpatient,473,ML,105.40000,63.24000,WellCare of North Carolina,Managed Medicaid,,21.10,,,,,,,21.10,85.69,percent of total billed charges,
"BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE",RX-36775,CDM,250,RC,J3490,HCPCS,00591333119,NDC,facility,outpatient,1,UN,21.25000,12.75000,WellCare of North Carolina,Managed Medicaid,,4.25,,,,,,,4.25,17.28,percent of total billed charges,
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID,RX-36962,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,10,ML,1.50000,0.90000,WellCare of North Carolina,Managed Medicaid,,0.30030,,,,,,,0.30030,1.22,percent of total billed charges,
MEMANTINE 10 MG TABLET,RX-36966,CDM,250,RC,J3490,HCPCS,60687018411,NDC,facility,outpatient,1,UN,18.70000,11.22000,WellCare of North Carolina,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
HYDRALAZINE 20 MG/ML INJECTION SOLUTION,RX-3697,CDM,636,RC,J0360,HCPCS,67457029100,NDC,facility,outpatient,1,ML,70.60000,42.36000,WellCare of North Carolina,Managed Medicaid,,14.13,,,,,,,13.22,52.40,percent of total billed charges,
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY,RX-36976,CDM,250,RC,J3490,HCPCS,00904630521,NDC,facility,outpatient,177,ML,4.85000,2.91000,WellCare of North Carolina,Managed Medicaid,,0.97097,,,,,,,0.97097,3.94,percent of total billed charges,
HYDRALAZINE 10 MG TABLET,RX-3698,CDM,250,RC,J3490,HCPCS,51079007401,NDC,facility,outpatient,1,UN,16.95000,10.17000,WellCare of North Carolina,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
EPLERENONE 25 MG TABLET,RX-36983,CDM,250,RC,J3490,HCPCS,59762171001,NDC,facility,outpatient,1,UN,28.40000,17.04000,WellCare of North Carolina,Managed Medicaid,,5.69,,,,,,,5.69,23.09,percent of total billed charges,
ZONISAMIDE 25 MG CAPSULE,RX-36987,CDM,250,RC,J3490,HCPCS,68001024200,NDC,facility,outpatient,1,UN,16.85000,10.11000,WellCare of North Carolina,Managed Medicaid,,3.37,,,,,,,3.37,13.70,percent of total billed charges,
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-36989,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,outpatient,1,UN,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,0.07080,358.48,percent of total billed charges,
HYDRALAZINE 25 MG TABLET,RX-3700,CDM,250,RC,J3490,HCPCS,51079007501,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
MEMANTINE 5 MG TABLET,RX-37170,CDM,250,RC,J3490,HCPCS,60687017357,NDC,facility,outpatient,1,UN,17.95000,10.77000,WellCare of North Carolina,Managed Medicaid,,3.59,,,,,,,3.59,14.59,percent of total billed charges,
HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-3720,CDM,250,RC,J3490,HCPCS,00172208360,NDC,facility,outpatient,1,UN,16.20000,9.72000,WellCare of North Carolina,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
HYDROCODONE-HOMATROPINE 5 MG-1.5 MG/5 ML ORAL SOLUTION,RX-3724,CDM,250,RC,J3490,HCPCS,64950034247,NDC,facility,outpatient,5,ML,23.60000,14.16000,WellCare of North Carolina,Managed Medicaid,,4.72,,,,,,,4.72,19.19,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL CREAM,RX-3726,CDM,250,RC,J3490,HCPCS,45802043803,NDC,facility,outpatient,28,GR,4.30000,2.58000,WellCare of North Carolina,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL CREAM,RX-3727,CDM,250,RC,J3490,HCPCS,45802000403,NDC,facility,outpatient,28,GR,27.45000,16.47000,WellCare of North Carolina,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
HYDROCORTISONE 1 % TOPICAL OINTMENT,RX-3731,CDM,250,RC,J3490,HCPCS,45802027603,NDC,facility,outpatient,28,GR,4.30000,2.58000,WellCare of North Carolina,Managed Medicaid,,0.86086,,,,,,,0.86086,3.50,percent of total billed charges,
HYDROCORTISONE 2.5 % TOPICAL OINTMENT,RX-3732,CDM,250,RC,J3490,HCPCS,00168014630,NDC,facility,outpatient,28.35,GR,25.90000,15.54000,WellCare of North Carolina,Managed Medicaid,,5.19,,,,,,,5.19,21.06,percent of total billed charges,
HYDROCORTISONE 10 MG TABLET,RX-3733,CDM,250,RC,J3490,HCPCS,59762007401,NDC,facility,outpatient,1,UN,17.15000,10.29000,WellCare of North Carolina,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY,RX-3738,CDM,250,RC,J3490,HCPCS,00713050306,NDC,facility,outpatient,1,UN,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HYDROGEN PEROXIDE 3 % SOLUTION,RX-3752,CDM,250,RC,J3490,HCPCS,00869087143,NDC,facility,outpatient,473,ML,1.75000,1.05000,WellCare of North Carolina,Managed Medicaid,,0.35035,,,,,,,0.35035,1.42,percent of total billed charges,
"CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE 12HR",RX-37567,CDM,250,RC,J3490,HCPCS,66993040732,NDC,facility,outpatient,1,UN,22.55000,13.53000,WellCare of North Carolina,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION,RX-3758,CDM,636,RC,J1171,HCPCS,00409336511,NDC,facility,outpatient,0.1,ML,23.30000,13.98000,WellCare of North Carolina,Managed Medicaid,,4.66,,,,,,,0.21240,17.29,percent of total billed charges,
HYDROMORPHONE 2 MG TABLET,RX-3760,CDM,250,RC,J3490,HCPCS,42858030125,NDC,facility,outpatient,1,UN,22.55000,13.53000,WellCare of North Carolina,Managed Medicaid,,4.51,,,,,,,4.51,18.33,percent of total billed charges,
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSPENSION,RX-37605,CDM,250,RC,A9270,HCPCS,00121176030,NDC,facility,outpatient,30,ML,8.35000,5.01000,WellCare of North Carolina,Managed Medicaid,,1.67,,,,,,,1.67,6.79,percent of total billed charges,
HYDROMORPHONE 4 MG TABLET,RX-3761,CDM,250,RC,J3490,HCPCS,42858030225,NDC,facility,outpatient,1,UN,22.70000,13.62000,WellCare of North Carolina,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
METOPROLOL TARTRATE 25 MG TABLET,RX-37637,CDM,250,RC,J3490,HCPCS,51079025501,NDC,facility,outpatient,1,UN,16.10000,9.66000,WellCare of North Carolina,Managed Medicaid,,3.22,,,,,,,3.22,13.09,percent of total billed charges,
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,RX-37642,CDM,250,RC,J3490,HCPCS,00009076004,NDC,facility,outpatient,100,ML,113.50000,68.10000,WellCare of North Carolina,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION,RX-3770,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,1,ML,169.40000,101.64000,WellCare of North Carolina,Managed Medicaid,,33.91,,,,,,,33.91,125.73,percent of total billed charges,
HYOSCYAMINE SULFATE 0.125 MG TABLET,RX-3783,CDM,250,RC,J3490,HCPCS,68220011210,NDC,facility,outpatient,1,UN,27.85000,16.71000,WellCare of North Carolina,Managed Medicaid,,5.58,,,,,,,5.58,22.64,percent of total billed charges,
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION,RX-37848,CDM,250,RC,J3490,HCPCS,00121231615,NDC,facility,outpatient,10,ML,31.35000,18.81000,WellCare of North Carolina,Managed Medicaid,,6.28,,,,,,,6.28,25.49,percent of total billed charges,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,WellCare of North Carolina,Managed Medicaid,,3616.45,,,,,,,4.23,13407.25,percent of total billed charges,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
"MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE",RX-38062,CDM,636,RC,J7518,HCPCS,68084090711,NDC,facility,outpatient,1,UN,30.90000,18.54000,WellCare of North Carolina,Managed Medicaid,,6.19,,,,,,,0.80240,22.93,percent of total billed charges,
"RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE",RX-38072,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,outpatient,2,ML,757.60000,454.56000,WellCare of North Carolina,Managed Medicaid,,151.67,,,,,,,11.47,562.29,percent of total billed charges,
CINACALCET 30 MG TABLET,RX-38100,CDM,250,RC,J3490,HCPCS,16729044010,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
CINACALCET 60 MG TABLET,RX-38101,CDM,250,RC,J3490,HCPCS,55513007430,NDC,facility,outpatient,1,UN,231.15000,138.69000,WellCare of North Carolina,Managed Medicaid,,46.28,,,,,,,46.28,187.92,percent of total billed charges,
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION,RX-38263,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,1,UN,143.75000,86.25000,WellCare of North Carolina,Managed Medicaid,,28.78,,,,,,,2.05,106.69,percent of total billed charges,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,WellCare of North Carolina,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,WellCare of North Carolina,Managed Medicaid,,301.87,,,,,,,0.46560,1119.13,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,00536129383,NDC,facility,outpatient,15,ML,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP,RX-38285,CDM,250,RC,J3490,HCPCS,57237031603,NDC,facility,outpatient,15,ML,3.50000,2.10000,WellCare of North Carolina,Managed Medicaid,,0.70070,,,,,,,0.70070,2.85,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION,RX-38303,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,3,ML,109.25000,65.55000,WellCare of North Carolina,Managed Medicaid,,21.87,,,,,,,0.89680,81.09,percent of total billed charges,
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE,RX-38321,CDM,250,RC,J3490,HCPCS,00023455430,NDC,facility,outpatient,1,UN,1.60000,0.96000,WellCare of North Carolina,Managed Medicaid,,0.32032,,,,,,,0.32032,1.30,percent of total billed charges,
IBUPROFEN 200 MG TABLET,RX-3841,CDM,250,RC,J3490,HCPCS,00904791461,NDC,facility,outpatient,1,UN,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
IBUPROFEN 800 MG TABLET,RX-3845,CDM,250,RC,J3490,HCPCS,00904585561,NDC,facility,outpatient,1,UN,16.30000,9.78000,WellCare of North Carolina,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00121472105,NDC,facility,outpatient,2.5,ML,27.40000,16.44000,WellCare of North Carolina,Managed Medicaid,,5.49,,,,,,,5.49,22.28,percent of total billed charges,
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-38488,CDM,250,RC,J3490,HCPCS,00832603212,NDC,facility,outpatient,2.5,ML,20.20000,12.12000,WellCare of North Carolina,Managed Medicaid,,4.04,,,,,,,4.04,16.42,percent of total billed charges,
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION,RX-38703,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,1,ML,40.95000,24.57000,WellCare of North Carolina,Managed Medicaid,,8.20,,,,,,,1.25,30.39,percent of total billed charges,
INDOMETHACIN 25 MG CAPSULE,RX-3897,CDM,250,RC,J3490,HCPCS,68462040601,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
INDOMETHACIN 50 MG RECTAL SUPPOSITORY,RX-3901,CDM,250,RC,J3490,HCPCS,70710185207,NDC,facility,outpatient,1,UN,1391.25000,834.75000,WellCare of North Carolina,Managed Medicaid,,278.53,,,,,,,278.53,1131.09,percent of total billed charges,
RIFAXIMIN 200 MG TABLET,RX-39063,CDM,250,RC,J3490,HCPCS,65649030103,NDC,facility,outpatient,1,UN,60.95000,36.57000,WellCare of North Carolina,Managed Medicaid,,12.20,,,,,,,12.20,49.55,percent of total billed charges,
AMILORIDE 5 MG TABLET,RX-391,CDM,250,RC,J3490,HCPCS,00574029201,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER",RX-39136,CDM,250,RC,J3490,HCPCS,00574200815,NDC,facility,outpatient,15,GR,37.05000,22.23000,WellCare of North Carolina,Managed Medicaid,,7.42,,,,,,,7.42,30.12,percent of total billed charges,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,WellCare of North Carolina,Managed Medicaid,,4.76,,,,,,,1.68,17.66,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,15,ML,377.25000,226.35000,WellCare of North Carolina,Managed Medicaid,,75.53,,,,,,,5.74,279.99,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,45,ML,482.55000,289.53000,WellCare of North Carolina,Managed Medicaid,,96.61,,,,,,,5.74,358.15,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,outpatient,5,ML,334.00000,200.40000,WellCare of North Carolina,Managed Medicaid,,66.87,,,,,,,5.74,247.89,percent of total billed charges,
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION,RX-39265,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,outpatient,60,ML,535.35000,321.21000,WellCare of North Carolina,Managed Medicaid,,107.18,,,,,,,5.74,397.34,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968310,NDC,facility,outpatient,10,ML,117.60000,70.56000,WellCare of North Carolina,Managed Medicaid,,23.54,,,,,,,23.54,95.61,percent of total billed charges,
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION,RX-39744,CDM,250,RC,J3490,HCPCS,00143968401,NDC,facility,outpatient,5,ML,90.30000,54.18000,WellCare of North Carolina,Managed Medicaid,,18.08,,,,,,,18.08,73.41,percent of total billed charges,
NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY,RX-39802,CDM,250,RC,J3490,HCPCS,00386000803,NDC,facility,outpatient,0.01,ML,16.05000,9.63000,WellCare of North Carolina,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,67457047322,NDC,facility,outpatient,2,ML,25.05000,15.03000,WellCare of North Carolina,Managed Medicaid,,5.02,,,,,,,5.02,18.59,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION,RX-39918,CDM,636,RC,J3260,HCPCS,63323030630,NDC,facility,outpatient,30,ML,116.10000,69.66000,WellCare of North Carolina,Managed Medicaid,,23.24,,,,,,,5.59,86.17,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028608,NDC,facility,outpatient,200,ML,686.20000,411.72000,WellCare of North Carolina,Managed Medicaid,,137.38,,,,,,,137.38,557.88,percent of total billed charges,
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION,RX-39970,CDM,250,RC,J3490,HCPCS,50383028616,NDC,facility,outpatient,480,ML,1607.20000,964.32000,WellCare of North Carolina,Managed Medicaid,,321.76,,,,,,,321.76,1306.65,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET,RX-40009,CDM,250,RC,J3490,HCPCS,00378306577,NDC,facility,outpatient,1,UN,17.45000,10.47000,WellCare of North Carolina,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET,RX-40010,CDM,250,RC,J3490,HCPCS,00378306677,NDC,facility,outpatient,1,UN,18.65000,11.19000,WellCare of North Carolina,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
SODIUM CHLORIDE 0.9% IV BOLUS,RX-400291,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,250,ML,66.75000,40.05000,WellCare of North Carolina,Managed Medicaid,,13.36,,,,,,,4.60,50.02,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,250,ML,69.75000,41.85000,WellCare of North Carolina,Managed Medicaid,,13.96,,,,,,,2.97,52.26,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,250,ML,67.50000,40.50000,WellCare of North Carolina,Managed Medicaid,,13.51,,,,,,,2.97,50.58,percent of total billed charges,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,WellCare of North Carolina,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7060,HCPCS,00338001703,NDC,facility,outpatient,250,ML,69.75000,41.85000,WellCare of North Carolina,Managed Medicaid,,13.96,,,,,,,4.27,52.26,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,250,ML,67.50000,40.50000,WellCare of North Carolina,Managed Medicaid,,13.51,,,,,,,7.34,50.58,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,00338001710,NDC,facility,outpatient,250,ML,150.00000,90.00000,WellCare of North Carolina,Managed Medicaid,,30.03,,,,,,,30.03,112.39,percent of total billed charges,
DEXTROSE 5 % IV BOLUS,RX-400293,CDM,258,RC,J3490,HCPCS,65219023801,NDC,facility,outpatient,250,ML,73.50000,44.10000,WellCare of North Carolina,Managed Medicaid,,14.71,,,,,,,14.71,55.07,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,250,ML,69.75000,41.85000,WellCare of North Carolina,Managed Medicaid,,13.96,,,,,,,3.33,52.26,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS,RX-400294,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,250,ML,67.50000,40.50000,WellCare of North Carolina,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS,RX-400295,CDM,258,RC,J7042,HCPCS,00338008504,NDC,facility,outpatient,250,ML,67.50000,40.50000,WellCare of North Carolina,Managed Medicaid,,13.51,,,,,,,3.33,50.58,percent of total billed charges,
LACTATED RINGERS IV BOLUS,RX-400296,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,250,ML,66.75000,40.05000,WellCare of North Carolina,Managed Medicaid,,13.36,,,,,,,5.69,50.02,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS,RX-400297,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,500,ML,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,14.41,53.95,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00264752010,NDC,facility,outpatient,250,ML,69.75000,41.85000,WellCare of North Carolina,Managed Medicaid,,13.96,,,,,,,13.96,52.26,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793002,NDC,facility,outpatient,250,ML,78.75000,47.25000,WellCare of North Carolina,Managed Medicaid,,15.77,,,,,,,15.77,59.01,percent of total billed charges,
DEXTROSE 10 % IV BOLUS,RX-400302,CDM,258,RC,J3490,HCPCS,00990793009,NDC,facility,outpatient,250,ML,66.75000,40.05000,WellCare of North Carolina,Managed Medicaid,,13.36,,,,,,,13.36,50.02,percent of total billed charges,
MAGIC MOUTHWASH ORAL SUSPENSION,RX-400499,CDM,250,RC,J3490,HCPCS,09999197831,NDC,facility,outpatient,5,ML,16.15000,9.69000,WellCare of North Carolina,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
ISONIAZID 50 MG/5 ML ORAL SOLUTION,RX-4025,CDM,250,RC,J3490,HCPCS,46287000901,NDC,facility,outpatient,473,ML,1023.50000,614.10000,WellCare of North Carolina,Managed Medicaid,,204.90,,,,,,,204.90,832.11,percent of total billed charges,
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION,RX-403,CDM,636,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,4,ML,22.65000,13.59000,WellCare of North Carolina,Managed Medicaid,,4.53,,,,,,,4.04,16.81,percent of total billed charges,
SOLIFENACIN 5 MG TABLET,RX-40392,CDM,250,RC,J3490,HCPCS,67877052790,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,WellCare of North Carolina,Managed Medicaid,,1446.91,,,,,,,10.22,5364.10,percent of total billed charges,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,WellCare of North Carolina,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,WellCare of North Carolina,Managed Medicaid,,1119.21,,,,,,,9.84,4149.23,percent of total billed charges,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,WellCare of North Carolina,Managed Medicaid,,5298.96,,,,,,,9.84,19644.81,percent of total billed charges,
ISOSORBIDE DINITRATE 10 MG TABLET,RX-4064,CDM,250,RC,J3490,HCPCS,00904661961,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
ISOSORBIDE DINITRATE 20 MG TABLET,RX-4065,CDM,250,RC,J3490,HCPCS,00904662061,NDC,facility,outpatient,1,UN,18.90000,11.34000,WellCare of North Carolina,Managed Medicaid,,3.78,,,,,,,3.78,15.37,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
ISOSORBIDE DINITRATE 5 MG TABLET,RX-4068,CDM,250,RC,J3490,HCPCS,00781163501,NDC,facility,outpatient,1,UN,19.20000,11.52000,WellCare of North Carolina,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION,RX-407,CDM,636,RC,J0280,HCPCS,00409592101,NDC,facility,outpatient,10,ML,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,21.42,79.42,percent of total billed charges,
BORTEZOMIB (VELCADE) SUBCUTANEOUS SYRINGE 2.5 MG/ML,RX-40800001,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,1,UN,7328.20000,4396.92000,WellCare of North Carolina,Managed Medicaid,,1467.11,,,,,,,4.32,5438.99,percent of total billed charges,
BLEOMYCIN (BLENOXANE) SYRINGE 15 UNITS/ML,RX-40800005,CDM,636,RC,J9040,HCPCS,00000000090,NDC,facility,outpatient,1,ML,350.20000,210.12000,WellCare of North Carolina,Managed Medicaid,,70.11,,,,,,,50.79,259.92,percent of total billed charges,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,WellCare of North Carolina,Managed Medicaid,,248.85,,,,,,,19.74,922.55,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00409330803,NDC,facility,outpatient,2,ML,22.80000,13.68000,WellCare of North Carolina,Managed Medicaid,,4.56,,,,,,,4.56,18.54,percent of total billed charges,
ACETYLCYSTEINE 200 MG/ML (20 %) INHALATION SOLUTION,RX-408000123,CDM,250,RC,J3490,HCPCS,00517760401,NDC,facility,outpatient,2,ML,46.20000,27.72000,WellCare of North Carolina,Managed Medicaid,,9.25,,,,,,,9.25,37.56,percent of total billed charges,
DECITABINE (DACOGEN) SYRINGE 10 MG/ML,RX-40800013,CDM,636,RC,J0894,HCPCS,00000000061,NDC,facility,outpatient,1,ML,7030.60000,4218.36000,WellCare of North Carolina,Managed Medicaid,,1407.53,,,,,,,2.88,5218.11,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018125,NDC,facility,outpatient,26.3,ML,332.30000,199.38000,WellCare of North Carolina,Managed Medicaid,,66.53,,,,,,,7.39,246.63,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,outpatient,5.26,ML,308.30000,184.98000,WellCare of North Carolina,Managed Medicaid,,61.72,,,,,,,7.39,228.82,percent of total billed charges,
GEMCITABINE 38 MG/ML INJECTABLE SOLUTION WRAPPER,RX-40800025,CDM,636,RC,J9201,HCPCS,00409018201,NDC,facility,outpatient,52.6,ML,673.55000,404.13000,WellCare of North Carolina,Managed Medicaid,,134.84,,,,,,,7.39,499.91,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,WellCare of North Carolina,Managed Medicaid,,8031.20,,,,,,,177.98,29774.02,percent of total billed charges,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,WellCare of North Carolina,Managed Medicaid,,31959.55,,,,,,,177.98,118483.40,percent of total billed charges,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,WellCare of North Carolina,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,WellCare of North Carolina,Managed Medicaid,,586.54,,,,,,,60.36,2174.46,percent of total billed charges,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,WellCare of North Carolina,Managed Medicaid,,5370.02,,,,,,,60.36,19908.25,percent of total billed charges,
DOXORUBICIN (ADRIAMYCIN) 25 MG/ML INJECTION,RX-40800034,CDM,636,RC,J9000,HCPCS,00000000103,NDC,facility,outpatient,1,ML,320.15000,192.09000,WellCare of North Carolina,Managed Medicaid,,64.09,,,,,,,7.13,237.62,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER,RX-40800035,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,WellCare of North Carolina,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,WellCare of North Carolina,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,WellCare of North Carolina,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE INJECTION (PF) 25 MG/ML (NON-ONCOLOGY),RX-408000554,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,WellCare of North Carolina,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,outpatient,16,ML,2035.00000,1221.00000,WellCare of North Carolina,Managed Medicaid,,407.41,,,,,,,1.04,1510.38,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,66758005001,NDC,facility,outpatient,2,ML,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,,99.10,,,,,,,1.04,367.39,percent of total billed charges,
DOCETAXEL (TAXOTERE) 10 MG/ML INJECTION WRAPPER,RX-40800074,CDM,636,RC,J9171,HCPCS,43066000601,NDC,facility,outpatient,8,ML,996.60000,597.96000,WellCare of North Carolina,Managed Medicaid,,199.52,,,,,,,1.04,739.68,percent of total billed charges,
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLUTION WRAPPER,RX-4080010655,CDM,250,RC,J3490,HCPCS,99999000756,NDC,facility,outpatient,0.5,ML,22.90000,13.74000,WellCare of North Carolina,Managed Medicaid,,4.58,,,,,,,4.58,18.62,percent of total billed charges,
GANCICLOVIR 2 MG/0.1 ML OPHTHALMIC INJECTION,RX-40800114,CDM,636,RC,J1570,HCPCS,00000000298,NDC,facility,outpatient,0.5,ML,77.55000,46.53000,WellCare of North Carolina,Managed Medicaid,,15.53,,,,,,,15.53,107.86,percent of total billed charges,
GEMCITABINE BLADDER INSTILLATION (38 MG/ML),RX-40800119,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,26.3,ML,337.40000,202.44000,WellCare of North Carolina,Managed Medicaid,,67.55,,,,,,,7.39,250.42,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,WellCare of North Carolina,Managed Medicaid,,1129.18,,,,,,,5.54,4186.19,percent of total billed charges,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,WellCare of North Carolina,Managed Medicaid,,2245.73,,,,,,,5.54,8325.59,percent of total billed charges,
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-40800128175,CDM,250,RC,J3490,HCPCS,99999007901,NDC,facility,outpatient,2,ML,105.35000,63.21000,WellCare of North Carolina,Managed Medicaid,,21.09,,,,,,,21.09,85.65,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,WellCare of North Carolina,Managed Medicaid,,9.10,,,,,,,0.20370,33.73,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,WellCare of North Carolina,Managed Medicaid,,12.70,,,,,,,0.20370,47.09,percent of total billed charges,
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV WRAPPER,RX-40800129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,1,ML,19.05000,11.43000,WellCare of North Carolina,Managed Medicaid,,3.81,,,,,,,0.02360,14.14,percent of total billed charges,
"HEPARIN (PORCINE) 10,000 UNIT/1,000 ML IN 0.9 % SOD. CHLORIDE IV SOLN",RX-40800129599,CDM,636,RC,J1644,HCPCS,09999007726,NDC,facility,outpatient,1000,ML,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,0.49560,62.34,percent of total billed charges,
REMIFENTANIL 100 MCG/2 ML (50 MCG/ML) IN 0.9 % NACL IV SYRINGE,RX-40800129758,CDM,250,RC,J3490,HCPCS,09999197620,NDC,facility,outpatient,0.5,ML,26.65000,15.99000,WellCare of North Carolina,Managed Medicaid,,5.34,,,,,,,5.34,21.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (>2 MG MAX DOSE),RX-40800141,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ML,342.80000,205.68000,WellCare of North Carolina,Managed Medicaid,,68.63,,,,,,,19.40,254.43,percent of total billed charges,
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-4080030851,CDM,636,RC,J2270,HCPCS,70092113036,NDC,facility,outpatient,100,ML,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,5.14,45.27,percent of total billed charges,
MIDAZOLAM 1 MG/ML INFUSION WRAPPER,RX-4080034270,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ML,76.00000,45.60000,WellCare of North Carolina,Managed Medicaid,,15.22,,,,,,,0.35400,56.41,percent of total billed charges,
LEUCOVORIN CALCIUM 500 MG SOL FOR INJ (10 MG/ML),RX-40800500,CDM,636,RC,J0640,HCPCS,00000000685,NDC,facility,outpatient,5,ML,292.85000,175.71000,WellCare of North Carolina,Managed Medicaid,,58.63,,,,,,,7.60,217.35,percent of total billed charges,
CEFAZOLIN 1 GRAM INJ SOLR IM,RX-408007002,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1,UN,20.80000,12.48000,WellCare of North Carolina,Managed Medicaid,,4.16,,,,,,,1.89,15.44,percent of total billed charges,
CEFEPIME 1 GRAM INJ SOLR IM,RX-408007004,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,WellCare of North Carolina,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ SOLR IM,RX-408007009,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,UN,25.10000,15.06000,WellCare of North Carolina,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ SOLR IM,RX-408007010,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,WellCare of North Carolina,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
STUDY CMX-2043/PLACEBO 25MG/ML INTRAVENOUS SOLUTION,RX-4080070108,CDM,256,RC,J3490,HCPCS,99990001073,NDC,facility,outpatient,18,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CEFTRIAXONE 250 MG INJ SOLR IM,RX-408007011,CDM,636,RC,J0696,HCPCS,00409733701,NDC,facility,outpatient,1,UN,19.50000,11.70000,WellCare of North Carolina,Managed Medicaid,,3.90,,,,,,,1.01,14.47,percent of total billed charges,
CEFTRIAXONE 500 MG INJ SOLR IM,RX-408007012,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,1,UN,19.25000,11.55000,WellCare of North Carolina,Managed Medicaid,,3.85,,,,,,,1.01,14.29,percent of total billed charges,
STUDY BI 1321.3 IDARUCIZUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-4080070219,CDM,256,RC,J3490,HCPCS,99990001173,NDC,facility,outpatient,50,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
MISOPROSTOL 25 MCG SPLIT TABLET,RX-4080070386,CDM,250,RC,J3490,HCPCS,09999001308,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
STUDY NICHD PROSPECT PROGESTERONE/PLACEBO 200 MG MICRONIZED CAPSULE,RX-4080070402,CDM,256,RC,J3490,HCPCS,09999001337,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
WARFARIN 1.25 MG SPLIT TABLET,RX-4080070435,CDM,250,RC,J3490,HCPCS,09999001423,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
STUDY NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE,RX-4080070441,CDM,636,RC,J2305,HCPCS,09999001492,NDC,facility,outpatient,250,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,3.86,percent of total billed charges,
STUDY ALLSTAR CAP-1002/PLACEBO ALLOGENEIC CARDIOSPHERE-DERIVED CELLS,RX-4080070442,CDM,256,RC,J3490,HCPCS,09999001491,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
"STUDY HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-4080070443,CDM,636,RC,J1644,HCPCS,09999001493,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.59400,percent of total billed charges,
ACETAMINOPHEN (OFIRMEV) 10 MG/ML INJECTION,RX-408007048,CDM,636,RC,J0131,HCPCS,09999108021,NDC,facility,outpatient,100,ML,103.35000,62.01000,WellCare of North Carolina,Managed Medicaid,,20.69,,,,,,,0.13200,76.71,percent of total billed charges,
STUDY LIMBO-ATX DEXAMETHASONE 4MG/ML,RX-4080070603,CDM,636,RC,J1100,HCPCS,09999001655,NDC,facility,outpatient,12,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN TABLET 81 MG,RX-4080070609,CDM,250,RC,A9270,HCPCS,09999001661,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 ASPIRIN/PLACEBO TABLET 81 MG,RX-4080070610,CDM,250,RC,A9270,HCPCS,,,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY ISSBRIL0345 TICAGRELOR TABLET 90 MG,RX-4080070611,CDM,250,RC,A9270,HCPCS,09999001660,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DU176B-D-U311 EDOXABAN TABLET 30 MG,RX-4080070627,CDM,250,RC,J3490,HCPCS,09999001677,NDC,facility,outpatient,40,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN/PLACEBO TABLET 10 MG,RX-4080070631,CDM,250,RC,A9270,HCPCS,09999001681,NDC,facility,outpatient,30,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RIVAROXDVT3002 RIVAROXABAN PLACEBO TABLET 7.5 MG,RX-4080070632,CDM,250,RC,A9270,HCPCS,09999001682,NDC,facility,outpatient,30,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML OTO,RX-4080070655,CDM,636,RC,J1938,HCPCS,09999001735,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D FUROSEMIDE 10 MG/ML PRN,RX-4080070656,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,100,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,4.60,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004910,NDC,facility,outpatient,25,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,50,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070657,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,2.97,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004948,NDC,facility,outpatient,100,ML,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,2.97,53.95,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1000,ML,78.00000,46.80000,WellCare of North Carolina,Managed Medicaid,,15.62,,,,,,,4.60,58.45,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004910,NDC,facility,outpatient,25,ML,71.40000,42.84000,WellCare of North Carolina,Managed Medicaid,,14.29,,,,,,,2.97,53.50,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,250,ML,75.75000,45.45000,WellCare of North Carolina,Managed Medicaid,,15.17,,,,,,,1.53,56.76,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004941,NDC,facility,outpatient,50,ML,70.65000,42.39000,WellCare of North Carolina,Managed Medicaid,,14.14,,,,,,,2.97,52.94,percent of total billed charges,
STUDY RGS001D SODIUM CHLORIDE 0.9% (NS) BOLUS,RX-4080070658,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,500,ML,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
STUDY GSK 201023 SODIUM CHLORIDE 0.9% (NS) INFUSION,RX-4080070699,CDM,258,RC,J7050,HCPCS,09999001843,NDC,facility,outpatient,48,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.53,percent of total billed charges,
STUDY FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-4080070732,CDM,636,RC,J1308,HCPCS,09999001928,NDC,facility,outpatient,1,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.02360,0.14844,percent of total billed charges,
STUDY DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-4080070734,CDM,636,RC,J1100,HCPCS,09999001929,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IM,RX-408007163,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,WellCare of North Carolina,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
STUDY EPAD ASPIRIN 100 MG,RX-408007355,CDM,250,RC,J3490,HCPCS,00000000500,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY EPINEPHRINE 0.3MG/0.3 ML (1:1,000) IM PEN INJECTOR",RX-408007489,CDM,250,RC,J3490,HCPCS,00000000616,NDC,facility,outpatient,0.3,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY DIPHENHYDRAMINE 50 MG/ML INJECTION,RX-408007497,CDM,636,RC,J1200,HCPCS,00000000624,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,2.46,percent of total billed charges,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.71810,percent of total billed charges,
CEFTAZIDIME 2.25% (22.5 MG/ML) INTRAOCULAR SYRINGE,RX-408007617,CDM,636,RC,J0713,HCPCS,99990000435,NDC,facility,outpatient,0.09999,ML,63.05000,37.83000,WellCare of North Carolina,Managed Medicaid,,12.62,,,,,,,3.71,46.80,percent of total billed charges,
CAFFEINE CITRATE 20 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-4080077411,CDM,250,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,3,ML,109.40000,65.64000,WellCare of North Carolina,Managed Medicaid,,21.90,,,,,,,2.90,88.94,percent of total billed charges,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,720.99,percent of total billed charges,
SMOG ENEMA 480ML,RX-408007850,CDM,250,RC,J3490,HCPCS,99990000832,NDC,facility,outpatient,480,ML,4.75000,2.85000,WellCare of North Carolina,Managed Medicaid,,0.95095,,,,,,,0.95095,3.86,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488710,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
"STUDY WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION",RX-408007977,CDM,636,RC,A4217,HCPCS,00409488724,NDC,facility,outpatient,50,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML CORRECTION SCALE ADULT,RX-408010289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,WellCare of North Carolina,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
DORNASE ALFA 1 MG/ML SOLUTION FOR CHEST TUBE,RX-408012211,CDM,250,RC,J3490,HCPCS,50242010039,NDC,facility,outpatient,5,ML,1086.20000,651.72000,WellCare of North Carolina,Managed Medicaid,,217.46,,,,,,,217.46,883.08,percent of total billed charges,
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLORIDE IV SYRINGE WRAPPER,RX-4080128177,CDM,250,RC,J3490,HCPCS,71449006811,NDC,facility,outpatient,5,ML,44.50000,26.70000,WellCare of North Carolina,Managed Medicaid,,8.91,,,,,,,8.91,36.18,percent of total billed charges,
PHENYLEPHRINE FOR PRIAPISM 100 MCG/ML VIAL/SYRINGE WRAPPER,RX-4080129102,CDM,636,RC,J2371,HCPCS,71449000115,NDC,facility,outpatient,10,ML,46.50000,27.90000,WellCare of North Carolina,Managed Medicaid,,9.31,,,,,,,0.02360,34.51,percent of total billed charges,
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE WRAPPER,RX-4080181794,CDM,636,RC,J1171,HCPCS,00641620601,NDC,facility,outpatient,0.5,ML,31.55000,18.93000,WellCare of North Carolina,Managed Medicaid,,6.32,,,,,,,0.21240,23.42,percent of total billed charges,
PEDIATRIC MULTIVITAMIN-FERROUS SULFATE 11 MG/ML ORAL DROPS WRAPPER,RX-4080189367,CDM,250,RC,J3490,HCPCS,00087040501,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001703,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,09999001704,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PEDIATRIC MULTIVITAMIN ORAL DROPS WRAPPER,RX-4080189607,CDM,250,RC,J3490,HCPCS,00087040203,NDC,facility,outpatient,0.25,ML,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
POLYETHYLENE GLYCOL 3350 ORAL PACKET FOR LARGE DOSE,RX-408025424,CDM,250,RC,J3490,HCPCS,00904693186,NDC,facility,outpatient,1,UN,2.80000,1.68000,WellCare of North Carolina,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,WellCare of North Carolina,Managed Medicaid,,7322.31,,,,,,,200.92,27145.97,percent of total billed charges,
INSULIN LISPRO 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-408102325,CDM,636,RC,J1815,HCPCS,00002751001,NDC,facility,outpatient,10,ML,318.15000,190.89000,WellCare of North Carolina,Managed Medicaid,,63.69,,,,,,,0.54280,236.13,percent of total billed charges,
INSULIN REGULAR 100 UNIT/ML PERCENTAGE MEAL EATEN ADULT,RX-40810289,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,219.00000,131.40000,WellCare of North Carolina,Managed Medicaid,,43.84,,,,,,,0.54280,162.54,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 8 ML PEDIATRIC INFUSION,RX-4081031017,CDM,636,RC,J2002,HCPCS,09999008005,NDC,facility,outpatient,8,ML,63.85000,38.31000,WellCare of North Carolina,Managed Medicaid,,12.78,,,,,,,0.02360,47.39,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML (0.8 %) PEDIATRIC INJECTION,RX-4081031018,CDM,636,RC,J2002,HCPCS,09999008006,NDC,facility,outpatient,500,ML,115.50000,69.30000,WellCare of North Carolina,Managed Medicaid,,23.12,,,,,,,0.02360,85.72,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE 1 ML INFUSION,RX-4081031028,CDM,636,RC,J3010,HCPCS,99999008185,NDC,facility,outpatient,1,ML,27.75000,16.65000,WellCare of North Carolina,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
STUDY DEXTROSE 5% IN WATER (D5W) INTRAVENOUS SYRINGE,RX-4081031104,CDM,250,RC,J3490,HCPCS,99999007971,NDC,facility,outpatient,30,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028100,NDC,facility,outpatient,1,ML,11.75000,7.05000,WellCare of North Carolina,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028103,NDC,facility,outpatient,1,ML,11.75000,7.05000,WellCare of North Carolina,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028105,NDC,facility,outpatient,1,ML,11.75000,7.05000,WellCare of North Carolina,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
GADOBUTROL 1 MMOL/ML INTRAVENOUS WRAPPER,RX-4081031111,CDM,254,RC,A9585,HCPCS,65219028108,NDC,facility,outpatient,1,ML,11.75000,7.05000,WellCare of North Carolina,Managed Medicaid,,2.35,,,,,,,0.63720,9.55,percent of total billed charges,
STUDY COPPER-A PACLITAXEL 60 MG/10 ML,RX-4081031126,CDM,636,RC,J9267,HCPCS,99999007980,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33040,percent of total billed charges,
DEXAMETHASONE 4 MG/ML IV PEDIATRIC,RX-4081031153,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,75.10000,45.06000,WellCare of North Carolina,Managed Medicaid,,15.04,,,,,,,0.21240,55.74,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,99999008079,NDC,facility,outpatient,20,ML,108.15000,64.89000,WellCare of North Carolina,Managed Medicaid,,21.65,,,,,,,21.65,80.27,percent of total billed charges,
PROPRANOLOL 0.05 MG/ML PEDIATRIC DILUTION,RX-4081031175,CDM,636,RC,J1800,HCPCS,,,facility,outpatient,40,ML,153.25000,91.95000,WellCare of North Carolina,Managed Medicaid,,30.68,,,,,,,23.46,113.74,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,2,ML,21.85000,13.11000,WellCare of North Carolina,Managed Medicaid,,4.37,,,,,,,0.24750,16.22,percent of total billed charges,
ONDANSETRON HCL 2 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-4081031194,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,2,ML,19.60000,11.76000,WellCare of North Carolina,Managed Medicaid,,3.92,,,,,,,0.24750,14.55,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE/VIAL WRAPPER,RX-4081031284,CDM,250,RC,J3490,HCPCS,00409490234,NDC,facility,outpatient,25,ML,57.75000,34.65000,WellCare of North Carolina,Managed Medicaid,,11.56,,,,,,,11.56,46.95,percent of total billed charges,
URSODIOL 60 MG/ML ORAL SUSPENSION,RX-4081031359,CDM,250,RC,J3490,HCPCS,09999009051,NDC,facility,outpatient,60,ML,204.30000,122.58000,WellCare of North Carolina,Managed Medicaid,,40.90,,,,,,,40.90,166.10,percent of total billed charges,
STUDY CL7018 RELEIVE-HF ASPIRIN EC 81 MG TABLET,RX-4081031410,CDM,250,RC,A9270,HCPCS,09999009484,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY CL7018 RELIEVE-HF CLOPIDOGREL/PLACEBO 75 MG TABLET,RX-4081031411,CDM,250,RC,J3490,HCPCS,09999009486,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
SPIRONOLACTONE 12.5 MG SPLIT TABLET,RX-4081031433,CDM,250,RC,J3490,HCPCS,09999099510,NDC,facility,outpatient,1,UN,16.40000,9.84000,WellCare of North Carolina,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
COLCHICINE 0.3 MG SPLIT TABLET,RX-4081031475,CDM,250,RC,J3490,HCPCS,09999009851,NDC,facility,outpatient,1,UN,53.20000,31.92000,WellCare of North Carolina,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
METHIMAZOLE 2.5 MG SPLIT TABLET,RX-4081031477,CDM,250,RC,J3490,HCPCS,09999009853,NDC,facility,outpatient,1,UN,16.20000,9.72000,WellCare of North Carolina,Managed Medicaid,,3.24,,,,,,,3.24,13.17,percent of total billed charges,
CLOBAZAM 5 MG SPLIT TABLET,RX-4081031577,CDM,250,RC,J3490,HCPCS,09999010459,NDC,facility,outpatient,1,UN,23.95000,14.37000,WellCare of North Carolina,Managed Medicaid,,4.79,,,,,,,4.79,19.47,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,WellCare of North Carolina,Managed Medicaid,,2740.12,,,,,,,271.45,10158.42,percent of total billed charges,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,WellCare of North Carolina,Managed Medicaid,,560.36,,,,,,,271.45,2077.42,percent of total billed charges,
LABETALOL 5 MG/ML PEDIATRIC SYRINGE,RX-40810372,CDM,636,RC,J1920,HCPCS,09999007203,NDC,facility,outpatient,20,ML,79.65000,47.79000,WellCare of North Carolina,Managed Medicaid,,15.95,,,,,,,0.80240,59.12,percent of total billed charges,
AMPICILLIN SODIUM 2 GRAM INJ SOLR IM,RX-408112,CDM,636,RC,J0290,HCPCS,00781340880,NDC,facility,outpatient,1,UN,48.35000,29.01000,WellCare of North Carolina,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
AMPICILLIN SODIUM 250 MG INJ SOLR IM,RX-408113,CDM,636,RC,J0290,HCPCS,00781340295,NDC,facility,outpatient,1,UN,28.20000,16.92000,WellCare of North Carolina,Managed Medicaid,,5.65,,,,,,,1.30,20.93,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK (ADDVANTAGE),RX-408126012,CDM,258,RC,J3490,HCPCS,00409710167,NDC,facility,outpatient,100,ML,76.20000,45.72000,WellCare of North Carolina,Managed Medicaid,,15.26,,,,,,,15.26,57.10,percent of total billed charges,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,WellCare of North Carolina,Managed Medicaid,,9.16,,,,,,,0.29100,33.96,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INJECTION (COMBINED) WRAPPER,RX-408173,CDM,250,RC,J3490,HCPCS,76329335201,NDC,facility,outpatient,25,ML,104.40000,62.64000,WellCare of North Carolina,Managed Medicaid,,20.90,,,,,,,20.90,84.88,percent of total billed charges,
NXSTAGE RFP 400 (+/- BB) - CONTAINS 2 MEQ/L POTASSIUM,RX-408180,CDM,250,RC,J3490,HCPCS,09999001241,NDC,facility,outpatient,5000,ML,243.00000,145.80000,WellCare of North Carolina,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLUTION FOR IV PUSH,RX-40818303,CDM,636,RC,J2543,HCPCS,00409338511,NDC,facility,outpatient,1,UN,63.60000,38.16000,WellCare of North Carolina,Managed Medicaid,,12.73,,,,,,,2.53,47.20,percent of total billed charges,
NXSTAGE RFP 404 - CONTAINS 4 MEQ/L POTASSIUM,RX-408186,CDM,250,RC,J3490,HCPCS,09999001665,NDC,facility,outpatient,5000,ML,243.00000,145.80000,WellCare of North Carolina,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
HYDROMORPHONE 1 MG/ML INJECTION WRAPPER,RX-408202,CDM,636,RC,J1171,HCPCS,00409128303,NDC,facility,outpatient,1,ML,29.80000,17.88000,WellCare of North Carolina,Managed Medicaid,,5.97,,,,,,,0.21240,22.12,percent of total billed charges,
BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET,RX-408204,CDM,250,RC,J3490,HCPCS,61958250101,NDC,facility,outpatient,1,UN,578.15000,346.89000,WellCare of North Carolina,Managed Medicaid,,115.75,,,,,,,115.75,470.04,percent of total billed charges,
MILRINONE 1 MG/ML INTRAVENOUS SOLUTION (FOR NEBULIZATION),RX-408211968,CDM,636,RC,J2260,HCPCS,00143971010,NDC,facility,outpatient,5,ML,28.50000,17.10000,WellCare of North Carolina,Managed Medicaid,,5.71,,,,,,,3.42,21.15,percent of total billed charges,
NXSTAGE RFP 453 - CONTAINS POTASSIUM 2 MEQ/L (CALCIUM FREE),RX-408320001,CDM,250,RC,J3490,HCPCS,09999008901,NDC,facility,outpatient,5000,ML,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 454 - CONTAINS POTASSIUM 4 MEQ/L (CALCIUM FREE),RX-408320002,CDM,250,RC,J3490,HCPCS,09999008902,NDC,facility,outpatient,5000,ML,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
TOBRAMYCIN 40 MG/ML INJECTION FOR ORAL USE,RX-40839918,CDM,636,RC,J3260,HCPCS,63323030626,NDC,facility,outpatient,2,ML,20.65000,12.39000,WellCare of North Carolina,Managed Medicaid,,4.13,,,,,,,4.13,15.33,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,2,ML,20.15000,12.09000,WellCare of North Carolina,Managed Medicaid,,4.03,,,,,,,1.13,14.96,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323064250,NDC,facility,outpatient,2,ML,20.25000,12.15000,WellCare of North Carolina,Managed Medicaid,,4.05,,,,,,,1.13,15.03,percent of total billed charges,
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAPPER,RX-408400021,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,WellCare of North Carolina,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
"BACITRACIN 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT (+/- ZINC) WRAPPER",RX-4084000855,CDM,250,RC,J3490,HCPCS,69968006003,NDC,facility,outpatient,14.2,GR,7.10000,4.26000,WellCare of North Carolina,Managed Medicaid,,1.42,,,,,,,1.42,5.77,percent of total billed charges,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,100,ML,153.75000,92.25000,WellCare of North Carolina,Managed Medicaid,,30.78,,,,,,,0.21240,114.11,percent of total billed charges,
TACROLIMUS 1 MG/ML ORAL SUSPENSION,RX-40840050,CDM,636,RC,J7507,HCPCS,00000000003,NDC,facility,outpatient,100,ML,405.05000,243.03000,WellCare of North Carolina,Managed Medicaid,,81.09,,,,,,,0.40120,300.63,percent of total billed charges,
ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION,RX-40840080,CDM,250,RC,J3490,HCPCS,00000000006,NDC,facility,outpatient,120,ML,155.00000,93.00000,WellCare of North Carolina,Managed Medicaid,,31.03,,,,,,,31.03,126.02,percent of total billed charges,
HYDRALAZINE 4 MG/ML ORAL SOLN,RX-40840107,CDM,250,RC,J3490,HCPCS,00000000048,NDC,facility,outpatient,100,ML,803.50000,482.10000,WellCare of North Carolina,Managed Medicaid,,160.86,,,,,,,160.86,653.25,percent of total billed charges,
DIGOXIN 25 MCG/ML NEONATAL DILUTION,RX-408401083,CDM,636,RC,J1160,HCPCS,99999000365,NDC,facility,outpatient,4,ML,66.20000,39.72000,WellCare of North Carolina,Managed Medicaid,,13.25,,,,,,,10.89,49.13,percent of total billed charges,
LABETALOL 40 MG/ML ORAL SUSP,RX-40840112,CDM,250,RC,J3490,HCPCS,00000000056,NDC,facility,outpatient,100,ML,25.00000,15.00000,WellCare of North Carolina,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
LAMOTRIGINE 1 MG/ML ORAL SOLN,RX-40840113,CDM,250,RC,J3490,HCPCS,00000000058,NDC,facility,outpatient,100,ML,19.00000,11.40000,WellCare of North Carolina,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LOSARTAN 2.5 MG/ML ORAL SUSP,RX-40840115,CDM,250,RC,J3490,HCPCS,00000000062,NDC,facility,outpatient,100,ML,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
METOPROLOL TARTRATE 10 MG/ML ORAL SOLN,RX-40840121,CDM,250,RC,J3490,HCPCS,09999009797,NDC,facility,outpatient,200,ML,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
METRONIDAZOLE 50 MG/ML ORAL SUSP,RX-40840122,CDM,250,RC,J3490,HCPCS,00000000071,NDC,facility,outpatient,120,ML,74.80000,44.88000,WellCare of North Carolina,Managed Medicaid,,14.97,,,,,,,14.97,60.81,percent of total billed charges,
POTASSIUM PHOSPHATE 3 MMOL/ML ORAL SOLN,RX-40840126,CDM,250,RC,J3490,HCPCS,09999199081,NDC,facility,outpatient,15,ML,60.40000,36.24000,WellCare of North Carolina,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
PROPYLTHIOURACIL 5 MG/ML ORAL SUSP,RX-40840129,CDM,250,RC,J3490,HCPCS,00000000085,NDC,facility,outpatient,100,ML,92.20000,55.32000,WellCare of North Carolina,Managed Medicaid,,18.46,,,,,,,18.46,74.96,percent of total billed charges,
SEVELAMER 50 MG/ML ORAL SOLN,RX-40840135,CDM,250,RC,J3490,HCPCS,09999009806,NDC,facility,outpatient,240,ML,376.00000,225.60000,WellCare of North Carolina,Managed Medicaid,,75.28,,,,,,,75.28,305.69,percent of total billed charges,
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLN,RX-40840141,CDM,250,RC,J3490,HCPCS,99999077787,NDC,facility,outpatient,200,ML,19.00000,11.40000,WellCare of North Carolina,Managed Medicaid,,3.80,,,,,,,3.80,15.45,percent of total billed charges,
LEECH,RX-40840182,CDM,250,RC,J3490,HCPCS,00000000139,NDC,facility,outpatient,1,UN,64.35000,38.61000,WellCare of North Carolina,Managed Medicaid,,12.88,,,,,,,12.88,52.32,percent of total billed charges,
PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION,RX-40840215,CDM,250,RC,J3490,HCPCS,99999000389,NDC,facility,outpatient,20,ML,27.05000,16.23000,WellCare of North Carolina,Managed Medicaid,,5.42,,,,,,,5.42,21.99,percent of total billed charges,
SLEEPY BUTTER,RX-40840222,CDM,250,RC,J3490,HCPCS,00000000096,NDC,facility,outpatient,5,ML,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,19.51,percent of total billed charges,
DEXAMETHASONE 24 MG/ML INJECTION,RX-40840227,CDM,636,RC,J1100,HCPCS,00000000142,NDC,facility,outpatient,1,ML,114.75000,68.85000,WellCare of North Carolina,Managed Medicaid,,22.97,,,,,,,0.21240,85.17,percent of total billed charges,
NXSTAGE/MULTIBIC RFP 401 (+/- BB) - CONTAINS 4 MEQ/L POTASSIUM,RX-40840228,CDM,250,RC,J3490,HCPCS,00000000144,NDC,facility,outpatient,5000,ML,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,54.65,221.95,percent of total billed charges,
NXSTAGE RFP 402 - CONTAINS NO POTASSIUM,RX-40840229,CDM,250,RC,J3490,HCPCS,09999000400,NDC,facility,outpatient,5000,ML,243.00000,145.80000,WellCare of North Carolina,Managed Medicaid,,48.65,,,,,,,48.65,197.56,percent of total billed charges,
DR. IRON'S DIAPER RASH CREAM,RX-40840230,CDM,250,RC,J3490,HCPCS,00000000199,NDC,facility,outpatient,30,GR,47.50000,28.50000,WellCare of North Carolina,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
AZATHIOPRINE 25 MG SPLIT TAB,RX-40840309,CDM,636,RC,J7500,HCPCS,00000000166,NDC,facility,outpatient,1,UN,17.40000,10.44000,WellCare of North Carolina,Managed Medicaid,,3.48,,,,,,,0.14160,12.91,percent of total billed charges,
COSYNTROPIN 2.5 MCG/ML DILUTION INJECTION,RX-40840325,CDM,636,RC,J0834,HCPCS,99999000526,NDC,facility,outpatient,0.4,ML,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,12.81,76.28,percent of total billed charges,
MERCAPTOPURINE 25 MG SPLIT TAB,RX-40840341,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,WellCare of North Carolina,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
WARFARIN 0.5 MG SPLIT TABLET,RX-40840383,CDM,250,RC,J3490,HCPCS,09999500000,NDC,facility,outpatient,1,UN,16.40000,9.84000,WellCare of North Carolina,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
DIPHENHYDRAMINE 50 MG VIAL/SYRINGE WRAPPER,RX-40840408,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,0.25,ML,17.35000,10.41000,WellCare of North Carolina,Managed Medicaid,,3.47,,,,,,,1.79,12.88,percent of total billed charges,
HEPARIN 500 UNITS IN 500 ML NS (FOR VASCULAR SERVICE),RX-40840479,CDM,636,RC,J1644,HCPCS,99999000515,NDC,facility,outpatient,500,ML,94.50000,56.70000,WellCare of North Carolina,Managed Medicaid,,18.92,,,,,,,0.49560,70.14,percent of total billed charges,
LACTULOSE ENEMA 200 G/300 ML,RX-40840593,CDM,250,RC,J3490,HCPCS,45963043965,NDC,facility,outpatient,300,ML,34.00000,20.40000,WellCare of North Carolina,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
ARGININE (L) 5 GRAM POWDER (100 MG/ML) FOR ORAL SOLN,RX-40840595,CDM,250,RC,J3490,HCPCS,00000000276,NDC,facility,outpatient,50,ML,23.35000,14.01000,WellCare of North Carolina,Managed Medicaid,,4.67,,,,,,,4.67,18.98,percent of total billed charges,
NEONATAL AA ISOTONIC 3.6%/HEPARIN 1 UNIT/ML,RX-40840656,CDM,636,RC,J3490,HCPCS,00000000309,NDC,facility,outpatient,50,ML,215.60000,129.36000,WellCare of North Carolina,Managed Medicaid,,43.16,,,,,,,43.16,160.02,percent of total billed charges,
SELENIUM 10 MCG/ML DILUTION,RX-40840701,CDM,250,RC,J3490,HCPCS,00000000318,NDC,facility,outpatient,40,ML,338.70000,203.22000,WellCare of North Carolina,Managed Medicaid,,67.81,,,,,,,67.81,275.36,percent of total billed charges,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,WellCare of North Carolina,Managed Medicaid,,167.17,,,,,,,17.57,619.74,percent of total billed charges,
CEFAZOLIN (ANCEF) 100 MG/ML SYRINGE (PEDIATRIC),RX-40840762,CDM,636,RC,J0690,HCPCS,00143926201,NDC,facility,outpatient,0.5,UN,65.25000,39.15000,WellCare of North Carolina,Managed Medicaid,,13.06,,,,,,,1.89,48.43,percent of total billed charges,
CEFUROXIME (ZINACEF) 90 MG/ML SYRINGE (PEDIATRIC),RX-40840763,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,81.95000,49.17000,WellCare of North Carolina,Managed Medicaid,,16.41,,,,,,,4.37,60.82,percent of total billed charges,
LINEZOLID (ZYVOX) 2 MG/ML IVPB,RX-40840767,CDM,636,RC,J2020,HCPCS,63323071313,NDC,facility,outpatient,300,ML,222.60000,133.56000,WellCare of North Carolina,Managed Medicaid,,44.56,,,,,,,8.43,165.21,percent of total billed charges,
SODIUM BICARBONATE 1 MEQ/ML INJ SOLUTION WRAPPER (MULTI-VIAL SIZE),RX-40840788,CDM,250,RC,J3490,HCPCS,69374091450,NDC,facility,outpatient,25,ML,88.20000,52.92000,WellCare of North Carolina,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
NALOXONE 0.4 MG/ML INJ SOLUTION (COMBINED) WRAPPER,RX-40840789,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,WellCare of North Carolina,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
PHYTONADIONE 1 MG/0.5 ML INJ SOLUTION (MULTI-VIAL SIZE),RX-40840790,CDM,250,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.5,ML,128.55000,77.13000,WellCare of North Carolina,Managed Medicaid,,25.74,,,,,,,6.44,104.51,percent of total billed charges,
DEXTROSE 40 % ORAL GEL (NEONATAL) WRAPPER,RX-408408107,CDM,250,RC,J3490,HCPCS,00574007030,NDC,facility,outpatient,37.5,GR,5.90000,3.54000,WellCare of North Carolina,Managed Medicaid,,1.18,,,,,,,1.18,4.80,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM MBP/ADV WRAPPER,RX-408408144,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,WellCare of North Carolina,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
FENTANYL 50 MCG/ML INTRANASAL SOLUTION,RX-408408181,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,2,ML,28.40000,17.04000,WellCare of North Carolina,Managed Medicaid,,5.69,,,,,,,2.60,21.08,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,WellCare of North Carolina,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLN FOR INJ (10 MG/ML),RX-408408260,CDM,636,RC,J0640,HCPCS,00143955501,NDC,facility,outpatient,1,UN,319.00000,191.40000,WellCare of North Carolina,Managed Medicaid,,63.86,,,,,,,7.60,236.76,percent of total billed charges,
CISATRACURIUM 2 MG/ML PEDIATRIC INFUSION (CSAC),RX-408408264,CDM,250,RC,J3490,HCPCS,09999199166,NDC,facility,outpatient,8,ML,168.40000,101.04000,WellCare of North Carolina,Managed Medicaid,,33.71,,,,,,,33.71,136.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840830,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,8,ML,64.55000,38.73000,WellCare of North Carolina,Managed Medicaid,,12.92,,,,,,,1.80,47.91,percent of total billed charges,
DOPAMINE 1600 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840831,CDM,636,RC,J1265,HCPCS,99999000879,NDC,facility,outpatient,50,ML,72.70000,43.62000,WellCare of North Carolina,Managed Medicaid,,14.55,,,,,,,1.80,53.96,percent of total billed charges,
LIDOCAINE (PF) 8 MG/ML IN DEXTROSE 5% 50 ML PEDIATRIC INFUSION,RX-40840834,CDM,636,RC,J2002,HCPCS,00000000330,NDC,facility,outpatient,50,ML,64.90000,38.94000,WellCare of North Carolina,Managed Medicaid,,12.99,,,,,,,0.02360,48.17,percent of total billed charges,
HEPARIN 100 UNITS/ML IN SODIUM CHLORIDE 0.45% 50 ML PEDIATRIC,RX-40840837,CDM,636,RC,J1644,HCPCS,00000000331,NDC,facility,outpatient,50,ML,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,0.49560,55.66,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,00409729501,NDC,facility,outpatient,15,ML,60.40000,36.24000,WellCare of North Carolina,Managed Medicaid,,12.09,,,,,,,12.09,49.11,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005209,NDC,facility,outpatient,5,ML,87.95000,52.77000,WellCare of North Carolina,Managed Medicaid,,17.61,,,,,,,17.61,71.50,percent of total billed charges,
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION WRAPPER,RX-408408382,CDM,250,RC,J3490,HCPCS,65219005609,NDC,facility,outpatient,50,ML,372.10000,223.26000,WellCare of North Carolina,Managed Medicaid,,74.49,,,,,,,74.49,302.52,percent of total billed charges,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,WellCare of North Carolina,Managed Medicaid,,3.85,,,,,,,0.29100,14.29,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 4 ML,RX-408408414,CDM,250,RC,J3490,HCPCS,09999199122,NDC,facility,outpatient,4,ML,67.40000,40.44000,WellCare of North Carolina,Managed Medicaid,,13.49,,,,,,,13.49,54.80,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40840849,CDM,636,RC,J2260,HCPCS,00000000335,NDC,facility,outpatient,8,ML,68.40000,41.04000,WellCare of North Carolina,Managed Medicaid,,13.69,,,,,,,3.42,50.77,percent of total billed charges,
MILRINONE 200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40840850,CDM,636,RC,J2260,HCPCS,00000000336,NDC,facility,outpatient,50,ML,96.60000,57.96000,WellCare of North Carolina,Managed Medicaid,,19.34,,,,,,,3.42,71.70,percent of total billed charges,
MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION WRAPPER,RX-408408555,CDM,636,RC,J2274,HCPCS,00641602001,NDC,facility,outpatient,1,ML,30.70000,18.42000,WellCare of North Carolina,Managed Medicaid,,6.15,,,,,,,6.15,29.37,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 40ML,RX-40840878,CDM,250,RC,J3490,HCPCS,00000000346,NDC,facility,outpatient,40,ML,106.55000,63.93000,WellCare of North Carolina,Managed Medicaid,,21.33,,,,,,,21.33,86.63,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSON 100ML,RX-40840879,CDM,250,RC,J3490,HCPCS,00000000347,NDC,facility,outpatient,100,ML,171.80000,103.08000,WellCare of North Carolina,Managed Medicaid,,34.39,,,,,,,34.39,139.67,percent of total billed charges,
SODIUM BICARBONATE 1MEQ/ML PEDIATRIC 50ML INFUSION,RX-40840884,CDM,636,RC,J3490,HCPCS,00000000348,NDC,facility,outpatient,50,ML,103.95000,62.37000,WellCare of North Carolina,Managed Medicaid,,20.81,,,,,,,20.81,77.15,percent of total billed charges,
INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION (IV USE),RX-40840889,CDM,636,RC,J1815,HCPCS,00002821501,NDC,facility,outpatient,10,ML,250.40000,150.24000,WellCare of North Carolina,Managed Medicaid,,50.13,,,,,,,0.54280,185.85,percent of total billed charges,
FAMOTIDINE 2 MG/ML PEDIATRIC DILUTION,RX-40840890,CDM,636,RC,J1308,HCPCS,00000000353,NDC,facility,outpatient,10,ML,170.95000,102.57000,WellCare of North Carolina,Managed Medicaid,,34.22,,,,,,,0.02360,126.88,percent of total billed charges,
LEVOFLOXACIN 5 MG/ML IN 5 % DEXTROSE PEDIATRIC,RX-40840895,CDM,636,RC,J1956,HCPCS,99999000670,NDC,facility,outpatient,50,ML,80.65000,48.39000,WellCare of North Carolina,Managed Medicaid,,16.15,,,,,,,5.33,59.86,percent of total billed charges,
METRONIDAZOLE 5 MG/ML IN SODIUM CHLORIDE (ODD DOSE),RX-40840896,CDM,636,RC,J1836,HCPCS,09999197853,NDC,facility,outpatient,100,ML,70.35000,42.21000,WellCare of North Carolina,Managed Medicaid,,14.08,,,,,,,0.07080,52.21,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,09999199080,NDC,facility,outpatient,1,GR,103.95000,62.37000,WellCare of North Carolina,Managed Medicaid,,20.81,,,,,,,19.39,77.15,percent of total billed charges,
CEFOTAXIME 100 MG/ML IV PEDIATRIC,RX-40841007,CDM,636,RC,J0698,HCPCS,,,facility,outpatient,20,ML,81.90000,49.14000,WellCare of North Carolina,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
CEFOXITIN 100 MG/ML SYRINGE PEDIATRIC,RX-40841008,CDM,636,RC,J0694,HCPCS,00143987701,NDC,facility,outpatient,1,UN,96.60000,57.96000,WellCare of North Carolina,Managed Medicaid,,19.34,,,,,,,11.28,71.70,percent of total billed charges,
CEFTAZIDIME 100 MG/ML SYRINGE PEDIATRIC,RX-40841009,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,109.20000,65.52000,WellCare of North Carolina,Managed Medicaid,,21.86,,,,,,,3.71,81.05,percent of total billed charges,
CEFEPIME 40 MG/ML PEDIATRIC DILUTION,RX-40841010,CDM,636,RC,J0692,HCPCS,,,facility,outpatient,500,ML,478.80000,287.28000,WellCare of North Carolina,Managed Medicaid,,95.86,,,,,,,2.88,355.37,percent of total billed charges,
CLINDAMYCIN 18 MG/ML SYRINGE PEDIATRIC,RX-40841015,CDM,636,RC,J0736,HCPCS,00338381424,NDC,facility,outpatient,50,ML,117.85000,70.71000,WellCare of North Carolina,Managed Medicaid,,23.59,,,,,,,4.32,87.47,percent of total billed charges,
MEROPENEM 20 MG/ML PEDIATRIC DILUTION,RX-40841017,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,300,ML,567.00000,340.20000,WellCare of North Carolina,Managed Medicaid,,113.51,,,,,,,0.99120,420.83,percent of total billed charges,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,WellCare of North Carolina,Managed Medicaid,,233.37,,,,,,,144.52,865.18,percent of total billed charges,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,WellCare of North Carolina,Managed Medicaid,,248.73,,,,,,,176.98,922.11,percent of total billed charges,
CEFUROXIME 1.5 GRAM (COMBINED) INJECTION WRAPPER,RX-40841027,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,WellCare of North Carolina,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
POTASSIUM CHLORIDE 0.1 MEQ/ML (PERIPHERAL LINE) IV PEDIATRIC,RX-40841043,CDM,258,RC,J3480,HCPCS,99999000577,NDC,facility,outpatient,100,ML,83.60000,50.16000,WellCare of North Carolina,Managed Medicaid,,16.74,,,,,,,0.25960,62.64,percent of total billed charges,
POTASSIUM CHLORIDE 0.2 MEQ/ML (CENTRAL LINE) IV PEDIATRIC,RX-40841044,CDM,636,RC,J3480,HCPCS,99999000576,NDC,facility,outpatient,100,ML,74.35000,44.61000,WellCare of North Carolina,Managed Medicaid,,14.88,,,,,,,0.25960,55.18,percent of total billed charges,
LEVETIRACETAM 10 MG/ML IV PEDIATRIC,RX-40841053,CDM,636,RC,J1953,HCPCS,09999077195,NDC,facility,outpatient,100,ML,153.30000,91.98000,WellCare of North Carolina,Managed Medicaid,,30.69,,,,,,,0.09440,113.78,percent of total billed charges,
CEFTRIAXONE 40 MG/ML PEDIATRIC DILUTION,RX-40841056,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,250,ML,218.50000,131.10000,WellCare of North Carolina,Managed Medicaid,,43.74,,,,,,,1.01,162.17,percent of total billed charges,
VANCOMYCIN 5 MG/ML PEDIATRIC DILUTION,RX-40841057,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,1000,ML,512.40000,307.44000,WellCare of North Carolina,Managed Medicaid,,102.58,,,,,,,0.07080,380.30,percent of total billed charges,
VANCOMYCIN 10 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841058,CDM,636,RC,J3373,HCPCS,09999199058,NDC,facility,outpatient,1000,ML,961.80000,577.08000,WellCare of North Carolina,Managed Medicaid,,192.55,,,,,,,0.07080,713.85,percent of total billed charges,
PIPERACILLIN-TAZOBACTAM (200 MG OF PIPERACILLIN/ML) PEDIATRIC,RX-40841063,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,1,UN,90.30000,54.18000,WellCare of North Carolina,Managed Medicaid,,18.08,,,,,,,2.53,67.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 50 MG/ML PEDIATRIC,RX-40841070,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,1,UN,103.15000,61.89000,WellCare of North Carolina,Managed Medicaid,,20.65,,,,,,,20.65,76.56,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,WellCare of North Carolina,Managed Medicaid,,49.60,,,,,,,0.20370,183.88,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,99999000366,NDC,facility,outpatient,10,ML,66.80000,40.08000,WellCare of North Carolina,Managed Medicaid,,13.37,,,,,,,13.22,49.58,percent of total billed charges,
HYDRALAZINE 0.5 MG/ML PEDIATRIC DILUTION,RX-40841084,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,40,ML,78.15000,46.89000,WellCare of North Carolina,Managed Medicaid,,15.65,,,,,,,13.22,58.00,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 28 MG/ML (PEDIATRIC),RX-40841089,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,1,UN,735.15000,441.09000,WellCare of North Carolina,Managed Medicaid,,147.18,,,,,,,93.10,545.63,percent of total billed charges,
EPINEPHRINE 0.3MG/0.3ML OPHTH INJECTION,RX-40841117,CDM,636,RC,J0165,HCPCS,99999000450,NDC,facility,outpatient,1,UN,17.55000,10.53000,WellCare of North Carolina,Managed Medicaid,,3.51,,,,,,,1.13,13.03,percent of total billed charges,
FLUOROURACIL 50MG/ML OPHTH SOLUTION,RX-40841118,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,0.1,ML,275.20000,165.12000,WellCare of North Carolina,Managed Medicaid,,55.10,,,,,,,4.69,204.25,percent of total billed charges,
VANCOMYCIN OPHTH 10MG/0.2ML INJECTION,RX-40841120,CDM,636,RC,J3373,HCPCS,99999001064,NDC,facility,outpatient,0.2,ML,63.45000,38.07000,WellCare of North Carolina,Managed Medicaid,,12.70,,,,,,,0.07080,47.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036001,NDC,facility,outpatient,10,ML,105.10000,63.06000,WellCare of North Carolina,Managed Medicaid,,21.04,,,,,,,0.09440,78.01,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036061,NDC,facility,outpatient,100,ML,289.80000,173.88000,WellCare of North Carolina,Managed Medicaid,,58.02,,,,,,,0.09440,215.09,percent of total billed charges,
CALCIUM GLUCONATE (PICU-UNC) 100 MG/ML PEDIATRIC BOLUS,RX-40841127,CDM,636,RC,J0612,HCPCS,63323036003,NDC,facility,outpatient,50,ML,176.40000,105.84000,WellCare of North Carolina,Managed Medicaid,,35.32,,,,,,,0.09440,130.92,percent of total billed charges,
TOLUIDINE BLUE 1 % SOLUTION,RX-40841133,CDM,250,RC,J3490,HCPCS,99999000444,NDC,facility,outpatient,1,ML,24.20000,14.52000,WellCare of North Carolina,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
ENOXAPARIN 20 MG/ML DILUTION PEDIATRIC INJECTION,RX-40841140,CDM,636,RC,J1650,HCPCS,99999000525,NDC,facility,outpatient,5,ML,120.55000,72.33000,WellCare of North Carolina,Managed Medicaid,,24.13,,,,,,,1.39,89.47,percent of total billed charges,
PHENYLEPHRINE 4 MG/50 ML (80 MCG/ML) IN 0.9% SODIUM CHLORIDE,RX-40841151,CDM,636,RC,J2371,HCPCS,99999000517,NDC,facility,outpatient,50,ML,71.40000,42.84000,WellCare of North Carolina,Managed Medicaid,,14.29,,,,,,,0.02360,52.99,percent of total billed charges,
NEONATAL AA 3.75%/HEPARIN 0.5 UNIT/ML/ D10W 200ML,RX-40841190,CDM,250,RC,J3490,HCPCS,99999000557,NDC,facility,outpatient,1,UN,78.35000,47.01000,WellCare of North Carolina,Managed Medicaid,,15.69,,,,,,,15.69,63.70,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) NS PEDIATRIC INFUSION,RX-40841198,CDM,250,RC,J3490,HCPCS,99999000570,NDC,facility,outpatient,50,ML,180.60000,108.36000,WellCare of North Carolina,Managed Medicaid,,36.16,,,,,,,36.16,146.83,percent of total billed charges,
DEXMEDETOMIDINE 4 MCG/ML BOLUS FROM INFUSION (CSAC),RX-40841232,CDM,250,RC,J3490,HCPCS,99999000578,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
ESMOLOL 500 MG/50 ML NS SYRINGE,RX-40841233,CDM,636,RC,J1805,HCPCS,99999000579,NDC,facility,outpatient,50,ML,171.80000,103.08000,WellCare of North Carolina,Managed Medicaid,,34.39,,,,,,,0.51920,127.51,percent of total billed charges,
CISATRACURIUM (NIMBEX) 2 MG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841238,CDM,250,RC,J3490,HCPCS,99999000602,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML PEDIATRIC BOLUS FROM INFUSION (CSAC),RX-40841239,CDM,636,RC,J3010,HCPCS,99999000604,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML BOLUS FROM INFUSION,RX-40841240,CDM,636,RC,J3010,HCPCS,99999000603,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,2.61,percent of total billed charges,
MORPHINE 1 MG/ML BOLUS FROM INFUSION,RX-40841246,CDM,636,RC,Q9974,HCPCS,99999000610,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
PENTOBARBITAL (NEMBUTAL) 50 MG/ML BOLUS FROM INFUSION,RX-40841249,CDM,636,RC,J2515,HCPCS,99999000613,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,173.61,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML PEDIATRIC DILUTION,RX-40841260,CDM,636,RC,J1815,HCPCS,99999000596,NDC,facility,outpatient,50,ML,75.60000,45.36000,WellCare of North Carolina,Managed Medicaid,,15.14,,,,,,,0.54280,56.11,percent of total billed charges,
PYRIMETHAMINE 2 MG/ML ORAL SUSPENSION,RX-40841268,CDM,250,RC,J3490,HCPCS,99999000630,NDC,facility,outpatient,100,ML,29.20000,17.52000,WellCare of North Carolina,Managed Medicaid,,5.85,,,,,,,5.85,23.74,percent of total billed charges,
FUROSEMIDE 10 MG/ML PEDIATRIC SYRINGE,RX-40841269,CDM,636,RC,J1938,HCPCS,09999199013,NDC,facility,outpatient,2,ML,34.75000,20.85000,WellCare of North Carolina,Managed Medicaid,,6.96,,,,,,,0.04720,25.79,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 1 MG/ML PEDIATRIC DILUTION,RX-40841274,CDM,636,RC,J1720,HCPCS,,,facility,outpatient,100,ML,71.40000,42.84000,WellCare of North Carolina,Managed Medicaid,,14.29,,,,,,,14.29,57.72,percent of total billed charges,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,WellCare of North Carolina,Managed Medicaid,,357.36,,,,,,,0.20370,1324.83,percent of total billed charges,
DEXAMETHASONE 0.2 MG/ML PEDIATRIC DILUTION,RX-40841293,CDM,636,RC,J1100,HCPCS,99999000653,NDC,facility,outpatient,10,ML,99.55000,59.73000,WellCare of North Carolina,Managed Medicaid,,19.93,,,,,,,0.21240,73.89,percent of total billed charges,
MORPHINE (PF) 0.5MG/0.5ML INJECTION SOLUTION,RX-40841307,CDM,636,RC,J2274,HCPCS,99999000767,NDC,facility,outpatient,0.5,ML,25.15000,15.09000,WellCare of North Carolina,Managed Medicaid,,5.04,,,,,,,5.04,29.37,percent of total billed charges,
"HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION WRAPPER",RX-40841316,CDM,636,RC,J1644,HCPCS,00409131632,NDC,facility,outpatient,0.5,ML,34.85000,20.91000,WellCare of North Carolina,Managed Medicaid,,6.98,,,,,,,0.49560,25.87,percent of total billed charges,
VECURONIUM (NORCURON) 1 MG/ML PEDIATRIC INFUSION 8 ML,RX-40841351,CDM,250,RC,J3490,HCPCS,99999000681,NDC,facility,outpatient,8,ML,71.75000,43.05000,WellCare of North Carolina,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
FENTANYL (PF) 10 MCG/ML NEONATAL DILUTION INJECTION,RX-40841368,CDM,636,RC,J3010,HCPCS,99999008077,NDC,facility,outpatient,1,ML,27.75000,16.65000,WellCare of North Carolina,Managed Medicaid,,5.56,,,,,,,2.60,20.60,percent of total billed charges,
NITROGLYCERIN 2MG/20ML INTRAVENOUS SYRINGE,RX-40841371,CDM,636,RC,J2305,HCPCS,99999000783,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,WellCare of North Carolina,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
BALANCED SALT IRRIGATION INTRAOCULAR SOLUTION 500ML,RX-40841372,CDM,250,RC,J3490,HCPCS,00065179504,NDC,facility,outpatient,500,ML,174.00000,104.40000,WellCare of North Carolina,Managed Medicaid,,34.83,,,,,,,34.83,141.46,percent of total billed charges,
FERRIC SUBSULFATE TOPICAL PASTE,RX-40841377,CDM,250,RC,J3490,HCPCS,48783011208,NDC,facility,outpatient,8,ML,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,12.81,52.03,percent of total billed charges,
DEXMEDETOMIDINE 200 MCG/2 ML INTRANASAL SOLUTION,RX-40841401,CDM,250,RC,J3490,HCPCS,00409163802,NDC,facility,outpatient,2,ML,88.20000,52.92000,WellCare of North Carolina,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,0.5,ML,22.45000,13.47000,WellCare of North Carolina,Managed Medicaid,,4.49,,,,,,,0.35400,16.66,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841433,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,0.5,ML,22.50000,13.50000,WellCare of North Carolina,Managed Medicaid,,4.50,,,,,,,0.35400,16.70,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606101,NDC,facility,outpatient,1,ML,25.60000,15.36000,WellCare of North Carolina,Managed Medicaid,,5.13,,,,,,,0.35400,19.00,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,WellCare of North Carolina,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INJECTION SOLUTION WRAPPER,RX-40841434,CDM,636,RC,J2250,HCPCS,00409230802,NDC,facility,outpatient,2,ML,26.10000,15.66000,WellCare of North Carolina,Managed Medicaid,,5.23,,,,,,,0.35400,19.37,percent of total billed charges,
ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL WRAPPER,RX-40841476,CDM,636,RC,J3489,HCPCS,25021082667,NDC,facility,outpatient,100,ML,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,11.94,202.62,percent of total billed charges,
MAGNESIUM SULFATE 40 MG/ML (PERIPHERAL) PEDIATRIC IV,RX-40841489,CDM,636,RC,J3475,HCPCS,99999000892,NDC,facility,outpatient,50,ML,131.05000,78.63000,WellCare of North Carolina,Managed Medicaid,,26.24,,,,,,,1.13,97.27,percent of total billed charges,
MAGNESIUM SULFATE 100 MG/ML (CENTRAL) PEDIATRIC DILUTION,RX-40841493,CDM,636,RC,J3475,HCPCS,99999000907,NDC,facility,outpatient,100,ML,94.50000,56.70000,WellCare of North Carolina,Managed Medicaid,,18.92,,,,,,,1.13,70.14,percent of total billed charges,
ROCURONIUM 10 MG/ML INFUSION CSAC,RX-40841516,CDM,250,RC,J3490,HCPCS,09999991015,NDC,facility,outpatient,50,ML,139.65000,83.79000,WellCare of North Carolina,Managed Medicaid,,27.96,,,,,,,27.96,113.54,percent of total billed charges,
DEXAMETHASONE 4 MG/ML (FOR ORAL USE) INJECTION SOLUTION,RX-40841531,CDM,250,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,1,ML,29.15000,17.49000,WellCare of North Carolina,Managed Medicaid,,5.84,,,,,,,0.21240,23.70,percent of total billed charges,
PHYTONADIONE 1 MG/ML ORAL SUSPENSION,RX-40841532,CDM,250,RC,J3490,HCPCS,99999001061,NDC,facility,outpatient,2.5,ML,104.30000,62.58000,WellCare of North Carolina,Managed Medicaid,,20.88,,,,,,,20.88,84.80,percent of total billed charges,
VALACYCLOVIR 50MG/ML ORAL SUSPENSION,RX-40841534,CDM,250,RC,J3490,HCPCS,99999001063,NDC,facility,outpatient,180,ML,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,21.42,86.99,percent of total billed charges,
DOBUTAMINE 50 MG/50 ML (1000MCG/ML) IN DEXTROSE 5% SYRINGE,RX-40841538,CDM,636,RC,J1250,HCPCS,99999001090,NDC,facility,outpatient,50,ML,81.90000,49.14000,WellCare of North Carolina,Managed Medicaid,,16.40,,,,,,,16.40,60.79,percent of total billed charges,
"HEPARIN, PORCINE (PF) 100 UNIT/ML ADDITIVE SYRINGE",RX-40841545,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,3,ML,17.75000,10.65000,WellCare of North Carolina,Managed Medicaid,,3.55,,,,,,,0.04720,13.17,percent of total billed charges,
FUROSEMIDE 2 MG/ML IV SYRINGE (NEONATAL-REX),RX-40841547,CDM,636,RC,J1938,HCPCS,99999001106,NDC,facility,outpatient,10,ML,68.30000,40.98000,WellCare of North Carolina,Managed Medicaid,,13.67,,,,,,,0.04720,50.69,percent of total billed charges,
IPRATROPIUM BROMIDE 0.02 % SOLN FOR CONTINUOUS NEBULIZATION,RX-40841569,CDM,250,RC,J3490,HCPCS,60687039483,NDC,facility,outpatient,2.5,ML,17.25000,10.35000,WellCare of North Carolina,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
SUCCINYLCHOLINE CHLORIDE 20MG/ML SYRINGE/VIAL WRAPPER,RX-40841572,CDM,636,RC,J0330,HCPCS,99999900002,NDC,facility,outpatient,5,ML,55.90000,33.54000,WellCare of North Carolina,Managed Medicaid,,11.19,,,,,,,2.17,41.49,percent of total billed charges,
"HEPARIN (PORCINE) 1,000 UNIT/500 ML IN 0.9% SODIUM CHLORIDE IV (COMBINED)",RX-40841589,CDM,636,RC,J1644,HCPCS,00409762013,NDC,facility,outpatient,500,ML,82.25000,49.35000,WellCare of North Carolina,Managed Medicaid,,16.47,,,,,,,0.49560,61.05,percent of total billed charges,
RIFAXIMIN 20 MG/ML ORAL SUSPENSION,RX-40841610,CDM,250,RC,J3490,HCPCS,99999001180,NDC,facility,outpatient,10,ML,106.35000,63.81000,WellCare of North Carolina,Managed Medicaid,,21.29,,,,,,,21.29,86.46,percent of total billed charges,
AMPICILLIN 30 MG/ML PEDIATRIC DILUTION,RX-40841613,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,333.3,ML,310.80000,186.48000,WellCare of North Carolina,Managed Medicaid,,62.22,,,,,,,1.30,230.68,percent of total billed charges,
ADENOSINE 300 MCG/ML SYRINGE (NEONATAL-REX),RX-40841619,CDM,636,RC,J0153,HCPCS,99999001205,NDC,facility,outpatient,10,ML,79.75000,47.85000,WellCare of North Carolina,Managed Medicaid,,15.97,,,,,,,1.25,59.19,percent of total billed charges,
LACOSAMIDE 10 MG/1 ML INTRAVENOUS SOLUTION (PEDS),RX-40841626,CDM,636,RC,C9254,HCPCS,99999001221,NDC,facility,outpatient,20,ML,319.25000,191.55000,WellCare of North Carolina,Managed Medicaid,,63.91,,,,,,,0.47200,236.95,percent of total billed charges,
SODIUM CHLORIDE 3 % INTRAVENOUS BOLUS SOLUTION,RX-40841628,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,500,ML,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,0.28050,55.66,percent of total billed charges,
INSULIN REGULAR 0.5 UNIT/ML NEONATAL 4 ML INFUSION,RX-40841771,CDM,636,RC,J1815,HCPCS,99999001727,NDC,facility,outpatient,4,ML,64.15000,38.49000,WellCare of North Carolina,Managed Medicaid,,12.84,,,,,,,0.54280,47.61,percent of total billed charges,
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION BUILDER,RX-40841785,CDM,258,RC,J3490,HCPCS,00409664802,NDC,facility,outpatient,50,ML,39.70000,23.82000,WellCare of North Carolina,Managed Medicaid,,7.95,,,,,,,7.95,29.75,percent of total billed charges,
METOCLOPRAMIDE 0.1 MG/ML IV SYRINGE NEONATAL,RX-40841793,CDM,636,RC,J2765,HCPCS,99999001805,NDC,facility,outpatient,100,ML,105.00000,63.00000,WellCare of North Carolina,Managed Medicaid,,21.02,,,,,,,2.57,77.93,percent of total billed charges,
ENALAPRILAT 125 MCG/ML IV SYRINGE NEONATAL,RX-40841794,CDM,250,RC,J3490,HCPCS,99999001808,NDC,facility,outpatient,10,ML,74.75000,44.85000,WellCare of North Carolina,Managed Medicaid,,14.96,,,,,,,14.96,60.77,percent of total billed charges,
MORPHINE 5 MG/ML IN 0.9 % SODIUM CHLORIDE 50 ML PCA,RX-40841797,CDM,636,RC,Q9974,HCPCS,61553064775,NDC,facility,outpatient,50,ML,52.00000,31.20000,WellCare of North Carolina,Managed Medicaid,,10.41,,,,,,,10.41,42.28,percent of total billed charges,
AMPICILLIN-SULBACTAM DILUTION 25 MG AS AMPICILLIN/ML,RX-40841845,CDM,636,RC,J0295,HCPCS,,,facility,outpatient,400,ML,161.60000,96.96000,WellCare of North Carolina,Managed Medicaid,,32.35,,,,,,,3.28,119.94,percent of total billed charges,
MORPHINE 0.4 MG/ML ORAL SOLUTION (NEONATAL),RX-40841891,CDM,250,RC,J3490,HCPCS,09999001507,NDC,facility,outpatient,0.5,ML,22.15000,13.29000,WellCare of North Carolina,Managed Medicaid,,4.43,,,,,,,4.43,18.01,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML BOLUS INJECTION (10 ML SYRINGE),RX-40842218,CDM,636,RC,J2305,HCPCS,99999001706,NDC,facility,outpatient,0.5,ML,63.10000,37.86000,WellCare of North Carolina,Managed Medicaid,,12.63,,,,,,,3.52,46.83,percent of total billed charges,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,WellCare of North Carolina,Managed Medicaid,,90.46,,,,,,,90.46,335.36,percent of total billed charges,
GENTAMICIN 40 MG/ML INJECTION IM USE ONLY,RX-40842287,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,20,ML,167.65000,100.59000,WellCare of North Carolina,Managed Medicaid,,33.56,,,,,,,5.22,124.43,percent of total billed charges,
NICARDIPINE 0.2 MG/ML IN NS 50 ML PEDIATRIC INFUSION,RX-40842331,CDM,636,RC,J2404,HCPCS,99999001937,NDC,facility,outpatient,50,ML,276.60000,165.96000,WellCare of North Carolina,Managed Medicaid,,55.38,,,,,,,0.16520,205.29,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION (PED),RX-40842334,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,239.40000,143.64000,WellCare of North Carolina,Managed Medicaid,,47.93,,,,,,,47.93,194.63,percent of total billed charges,
VECURONIUM 1 MG/ML NEONATAL INJECTION,RX-40842343,CDM,250,RC,J3490,HCPCS,09999842343,NDC,facility,outpatient,10,ML,73.90000,44.34000,WellCare of North Carolina,Managed Medicaid,,14.79,,,,,,,14.79,60.08,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 8 ML PEDIATRIC,RX-40842356,CDM,636,RC,J1265,HCPCS,09999007925,NDC,facility,outpatient,8,ML,65.70000,39.42000,WellCare of North Carolina,Managed Medicaid,,13.15,,,,,,,1.80,48.76,percent of total billed charges,
DOPAMINE 3200 MCG/ML IN DEXTROSE 5% 50 ML PEDIATRIC,RX-40842357,CDM,636,RC,J1265,HCPCS,09999007926,NDC,facility,outpatient,50,ML,79.60000,47.76000,WellCare of North Carolina,Managed Medicaid,,15.94,,,,,,,1.80,59.08,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,200.52,percent of total billed charges,
CHOLESTYRAMINE-MAALOX PLUS-ZINC OXIDE OINTMENT,RX-408426030,CDM,250,RC,J3490,HCPCS,09999010511,NDC,facility,outpatient,60,GR,59.80000,35.88000,WellCare of North Carolina,Managed Medicaid,,11.97,,,,,,,11.97,48.62,percent of total billed charges,
METOPROLOL TARTRATE 6.25 MG SPLIT QUARTER TABLET,RX-408426045,CDM,250,RC,J3490,HCPCS,99999010516,NDC,facility,outpatient,6.25,ME,16.05000,9.63000,WellCare of North Carolina,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
MIDAZOLAM 5 MG/ML INFUSION (MAXIMUM CONCENTRATION),RX-408450043,CDM,636,RC,J2250,HCPCS,99999077796,NDC,facility,outpatient,100,ML,247.60000,148.56000,WellCare of North Carolina,Managed Medicaid,,49.57,,,,,,,0.35400,183.77,percent of total billed charges,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,WellCare of North Carolina,Managed Medicaid,,2017.42,,,,,,,127.44,7479.15,percent of total billed charges,
CEFAZOLIN 2 GRAM SOLUTION FOR IVPB WRAPPER,RX-408450163,CDM,636,RC,J0690,HCPCS,60505623100,NDC,facility,outpatient,1,UN,87.60000,52.56000,WellCare of North Carolina,Managed Medicaid,,17.54,,,,,,,1.89,65.02,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (120MIN ADMIN),RX-408450164,CDM,636,RC,J1450,HCPCS,09999197868,NDC,facility,outpatient,200,ML,150.40000,90.24000,WellCare of North Carolina,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
SODIUM BICARBONATE 150 MEQ/1000 ML IN DEXTROSE 5 % CONT INFUSION PREMIX,RX-408450168,CDM,250,RC,J3490,HCPCS,09999197872,NDC,facility,outpatient,1150,ML,153.65000,92.19000,WellCare of North Carolina,Managed Medicaid,,30.76,,,,,,,30.76,124.92,percent of total billed charges,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,WellCare of North Carolina,Managed Medicaid,,72.92,,,,,,,72.92,270.35,percent of total billed charges,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,215.56,percent of total billed charges,
STUDY CIP0218 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION,RX-408451670,CDM,636,RC,J1100,HCPCS,99999010111,NDC,facility,outpatient,20,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.33000,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 CAMIZESTRANT 75 MG TABLET,RX-408453785,CDM,256,RC,J3490,HCPCS,99999010365,NDC,facility,outpatient,96,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,4844.60,percent of total billed charges,
STUDY NRG-GU010-CIRB DAROLUTAMIDE 300 MG TABLET,RX-408453799,CDM,250,RC,J3490,HCPCS,99999010373,NDC,facility,outpatient,120,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY NRG-GU009 APALUTAMIDE 60 MG TABLET,RX-408453804,CDM,250,RC,J8999,HCPCS,99999010376,NDC,facility,outpatient,120,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,101.12,percent of total billed charges,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,237.76,percent of total billed charges,
STUDY EX6018-4979 ZILTIVEKIMAB C/PLACEBO 15 MG/0.5 ML SUBCUTANEOUS PEN,RX-408453866,CDM,256,RC,J3490,HCPCS,99999011474,NDC,facility,outpatient,0.5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,WellCare of North Carolina,Managed Medicaid,,3170.90,,,,,,,53.98,11755.45,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,outpatient,15,ML,394.60000,236.76000,WellCare of North Carolina,Managed Medicaid,,79.00,,,,,,,5.74,292.87,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,WellCare of North Carolina,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,WellCare of North Carolina,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY AUC),RX-408454014,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,WellCare of North Carolina,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,WellCare of North Carolina,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN (PLATINOL) IVPB 1 MG/ML,RX-408454018,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,WellCare of North Carolina,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,15,ML,367.40000,220.44000,WellCare of North Carolina,Managed Medicaid,,73.55,,,,,,,5.74,272.68,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424801,NDC,facility,outpatient,45,ML,560.95000,336.57000,WellCare of North Carolina,Managed Medicaid,,112.30,,,,,,,5.74,416.34,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,00703424401,NDC,facility,outpatient,5,ML,311.30000,186.78000,WellCare of North Carolina,Managed Medicaid,,62.32,,,,,,,5.74,231.05,percent of total billed charges,
CARBOPLATIN (PARAPLATIN) 10 MG/ML IVPB (BY MG/M2),RX-408454030,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,outpatient,60,ML,484.10000,290.46000,WellCare of North Carolina,Managed Medicaid,,96.92,,,,,,,5.74,359.30,percent of total billed charges,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,WellCare of North Carolina,Managed Medicaid,,548.67,,,,,,,0.46560,2034.07,percent of total billed charges,
"BUPROPION HCL SR 150 MG TABLET,SUSTAINED-RELEASE (COMBINED) WRAPPER",RX-40846025,CDM,250,RC,J3490,HCPCS,68084070895,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LABETALOL 5 MG/ML INTRAVENOUS VIAL/SYRINGE WRAPPER,RX-40846030,CDM,636,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,4,ML,101.20000,60.72000,WellCare of North Carolina,Managed Medicaid,,20.26,,,,,,,0.80240,75.11,percent of total billed charges,
SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL COMBINED WRAPPER,RX-40846040,CDM,250,RC,J3490,HCPCS,46287000660,NDC,facility,outpatient,60,ML,115.15000,69.09000,WellCare of North Carolina,Managed Medicaid,,23.05,,,,,,,23.05,93.62,percent of total billed charges,
CEFTRIAXONE 1 GRAM INJ COMBINED WRAPPER,RX-40846063,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,WellCare of North Carolina,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM INJ COMBINED WRAPPER,RX-40846064,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,WellCare of North Carolina,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION (PED)",RX-40846071,CDM,250,RC,J3490,HCPCS,39822100001,NDC,facility,outpatient,10,ML,88.20000,52.92000,WellCare of North Carolina,Managed Medicaid,,17.66,,,,,,,17.66,71.71,percent of total billed charges,
ACETAZOLAMIDE 100 MG/ML IV PEDIATRIC,RX-40846089,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,1,UN,195.30000,117.18000,WellCare of North Carolina,Managed Medicaid,,39.10,,,,,,,39.10,144.95,percent of total billed charges,
HISTAMINE 1 MG/ML (2.75 MG/ML) PERCUTANEOUS SOLUTION,RX-40846097,CDM,250,RC,J3490,HCPCS,00268024705,NDC,facility,outpatient,0.25,ML,146.20000,87.72000,WellCare of North Carolina,Managed Medicaid,,29.27,,,,,,,29.27,118.86,percent of total billed charges,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Managed Medicaid,,229.10,,,,,,,4.10,849.34,percent of total billed charges,
HYDROMORPHONE 1 MG/ML IN NS INFUSION WRAPPER,RX-408470157,CDM,636,RC,J1171,HCPCS,70092154635,NDC,facility,outpatient,50,ML,73.60000,44.16000,WellCare of North Carolina,Managed Medicaid,,14.73,,,,,,,0.21240,54.63,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML IN D5W 8 ML PEDIATRIC INFUSION,RX-408470177,CDM,636,RC,J2305,HCPCS,99999077734,NDC,facility,outpatient,8,ML,64.45000,38.67000,WellCare of North Carolina,Managed Medicaid,,12.90,,,,,,,3.52,47.83,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,00054356699,NDC,facility,outpatient,118,ML,412.15000,247.29000,WellCare of North Carolina,Managed Medicaid,,82.51,,,,,,,82.51,335.08,percent of total billed charges,
MIDAZOLAM 2 MG/ML ORAL LIQUID WRAPPER,RX-408470197,CDM,250,RC,J3490,HCPCS,68094076459,NDC,facility,outpatient,5,ML,40.35000,24.21000,WellCare of North Carolina,Managed Medicaid,,8.08,,,,,,,8.08,32.80,percent of total billed charges,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,WellCare of North Carolina,Managed Medicaid,,34.68,,,,,,,0.35890,128.59,percent of total billed charges,
NITROGLYCERIN 200 MCG/ML BOLUS INJECTION (VIR/CATH),RX-408470212,CDM,636,RC,J2305,HCPCS,00338104902,NDC,facility,outpatient,0.5,ML,63.20000,37.92000,WellCare of North Carolina,Managed Medicaid,,12.65,,,,,,,3.52,46.91,percent of total billed charges,
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) COMPOUNDED PREMADE BAG,RX-408470216,CDM,250,RC,J1815,HCPCS,99999077759,NDC,facility,outpatient,100,ML,115.15000,69.09000,WellCare of North Carolina,Managed Medicaid,,23.05,,,,,,,0.54280,93.62,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,WellCare of North Carolina,Managed Medicaid,,9.79,,,,,,,9.79,39.76,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,WellCare of North Carolina,Managed Medicaid,,5.16,,,,,,,5.16,20.93,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) ATOMIZED SOLUTION,RX-408470219,CDM,250,RC,J3490,HCPCS,63323049507,NDC,facility,outpatient,5,ML,32.35000,19.41000,WellCare of North Carolina,Managed Medicaid,,6.48,,,,,,,6.48,26.30,percent of total billed charges,
SELENIUM 12 MCG/ML DILUTION,RX-408470228,CDM,250,RC,J3490,HCPCS,09999197618,NDC,facility,outpatient,50,ML,1584.85000,950.91000,WellCare of North Carolina,Managed Medicaid,,317.29,,,,,,,317.29,1288.48,percent of total billed charges,
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE WRAPPER,RX-408470247,CDM,636,RC,J0165,HCPCS,69374092510,NDC,facility,outpatient,10,ML,38.75000,23.25000,WellCare of North Carolina,Managed Medicaid,,7.76,,,,,,,1.13,28.76,percent of total billed charges,
KETAMINE 1000 MG/100 ML (10 MG/ML) INFUSION (STRAIGHT DRUG),RX-408470253,CDM,250,RC,J3490,HCPCS,99999077765,NDC,facility,outpatient,100,ML,478.40000,287.04000,WellCare of North Carolina,Managed Medicaid,,95.78,,,,,,,95.78,388.94,percent of total billed charges,
FENTANYL (PF) 50 MCG/ML INFUSION,RX-408470277,CDM,636,RC,J3010,HCPCS,51754915001,NDC,facility,outpatient,50,ML,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,2.60,65.31,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,WellCare of North Carolina,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IV (PED DILUTION)",RX-408470311,CDM,636,RC,J2540,HCPCS,99999077780,NDC,facility,outpatient,1,ML,17.20000,10.32000,WellCare of North Carolina,Managed Medicaid,,3.44,,,,,,,1.86,12.77,percent of total billed charges,
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION,RX-408470320,CDM,250,RC,J3490,HCPCS,00517930501,NDC,facility,outpatient,1,ML,144.30000,86.58000,WellCare of North Carolina,Managed Medicaid,,28.89,,,,,,,28.89,117.32,percent of total billed charges,
CISATRACURIUM 2 MG/ML CONTINUOUS INFUSION (2 MG/ML VIALS) (CSAC),RX-408470332,CDM,250,RC,J3490,HCPCS,99999077786,NDC,facility,outpatient,100,ML,1380.15000,828.09000,WellCare of North Carolina,Managed Medicaid,,276.31,,,,,,,276.31,1122.06,percent of total billed charges,
"PENICILLIN G POTASSIUM 100,000 UNITS/ML IM DILUTION",RX-408470437,CDM,636,RC,J2540,HCPCS,99999777702,NDC,facility,outpatient,50,ML,73.80000,44.28000,WellCare of North Carolina,Managed Medicaid,,14.77,,,,,,,1.86,54.77,percent of total billed charges,
REMIFENTANIL (50 MCG/ML) IN NS INFUSION (ANESTHESIA),RX-408470469,CDM,250,RC,J3490,HCPCS,99999777703,NDC,facility,outpatient,20,ML,215.00000,129.00000,WellCare of North Carolina,Managed Medicaid,,43.04,,,,,,,43.04,174.79,percent of total billed charges,
SODIUM FERRIC GLUCONATE 250 MG IN 100 ML PREMIX (SSC),RX-408470509,CDM,636,RC,J2916,HCPCS,09999777707,NDC,facility,outpatient,100,ML,597.25000,358.35000,WellCare of North Carolina,Managed Medicaid,,119.57,,,,,,,4.77,443.28,percent of total billed charges,
NAFCILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847151,CDM,636,RC,J2290,HCPCS,44567022110,NDC,facility,outpatient,1,UN,109.20000,65.52000,WellCare of North Carolina,Managed Medicaid,,21.86,,,,,,,0.11800,81.05,percent of total billed charges,
NAFCILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847152,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,1,UN,115.50000,69.30000,WellCare of North Carolina,Managed Medicaid,,23.12,,,,,,,0.11800,85.72,percent of total billed charges,
CEFEPIME 1 GRAM INJ COMBINED WRAPPER,RX-40847153,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,UN,43.30000,25.98000,WellCare of North Carolina,Managed Medicaid,,8.67,,,,,,,2.88,32.14,percent of total billed charges,
CEFEPIME 2 GRAM INJ COMBINED WRAPPER,RX-40847154,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,1,UN,65.35000,39.21000,WellCare of North Carolina,Managed Medicaid,,13.08,,,,,,,2.88,48.50,percent of total billed charges,
AMPICILLIN 1 GRAM INJ COMBINED WRAPPER,RX-40847164,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,UN,47.45000,28.47000,WellCare of North Carolina,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
AMPICILLIN 2 GRAM INJ COMBINED WRAPPER,RX-40847165,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,1,UN,66.05000,39.63000,WellCare of North Carolina,Managed Medicaid,,13.22,,,,,,,1.30,49.02,percent of total billed charges,
CEFTAZIDIME 1 GRAM INJECTION COMBINED WRAPPER,RX-40847169,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,UN,36.50000,21.90000,WellCare of North Carolina,Managed Medicaid,,7.31,,,,,,,3.71,27.09,percent of total billed charges,
CEFTAZIDIME 2 GRAM INJECTION COMBINED WRAPPER,RX-40847170,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,outpatient,1,UN,66.05000,39.63000,WellCare of North Carolina,Managed Medicaid,,13.22,,,,,,,3.71,49.02,percent of total billed charges,
HYDROMORPHONE 10 MG/50 ML (0.2 MG/ML) IN NS PCA SYRINGE (WRAPPER),RX-40847175,CDM,636,RC,J1171,HCPCS,70092111450,NDC,facility,outpatient,50,ML,48.45000,29.07000,WellCare of North Carolina,Managed Medicaid,,9.70,,,,,,,0.21240,35.96,percent of total billed charges,
AMIKACIN 250 MG/ML INJECTION SOLUTION WRAPPER,RX-40847176,CDM,636,RC,J0278,HCPCS,00641616601,NDC,facility,outpatient,4,ML,88.80000,53.28000,WellCare of North Carolina,Managed Medicaid,,17.78,,,,,,,1.49,65.91,percent of total billed charges,
PHENYLEPHRINE 100 MG IN 250 ML NS (400 MCG/ML) (PMB),RX-408480255,CDM,636,RC,J2371,HCPCS,99999002736,NDC,facility,outpatient,250,ML,260.40000,156.24000,WellCare of North Carolina,Managed Medicaid,,52.13,,,,,,,0.02360,193.27,percent of total billed charges,
DEXMEDETOMIDINE 20 MCG/5 ML SYRINGE (OR),RX-40849120,CDM,250,RC,J3490,HCPCS,71449010811,NDC,facility,outpatient,5,ML,119.70000,71.82000,WellCare of North Carolina,Managed Medicaid,,23.96,,,,,,,23.96,97.32,percent of total billed charges,
EPI-SHUGARCAINE COMPOUNDED SYRINGE,RX-40849124,CDM,636,RC,J0165,HCPCS,00000000384,NDC,facility,outpatient,1,ML,118.25000,70.95000,WellCare of North Carolina,Managed Medicaid,,23.67,,,,,,,1.13,87.77,percent of total billed charges,
ASPIRIN ORAL DESENSITIZATION 1 MG/ML BULK SOLUTION,RX-40849130,CDM,250,RC,J3490,HCPCS,99999000701,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,WellCare of North Carolina,Managed Medicaid,,3.21,,,,,,,3.21,13.05,percent of total billed charges,
PENTOBARBITAL 2500MG/50 ML ADULT INFUSION,RX-40849151,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,WellCare of North Carolina,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
BUPIVACAINE 0.125% IN NS EPIDURAL SYRINGE FOR OR,RX-40849164,CDM,636,RC,J0665,HCPCS,99999000713,NDC,facility,outpatient,12,ML,30.95000,18.57000,WellCare of North Carolina,Managed Medicaid,,6.20,,,,,,,0.02360,22.97,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR IV ADMIXTURE USE,RX-40849172,CDM,636,RC,J0895,HCPCS,63323059710,NDC,facility,outpatient,1,UN,83.25000,49.95000,WellCare of North Carolina,Managed Medicaid,,16.67,,,,,,,16.67,61.79,percent of total billed charges,
CUPRIC CHLORIDE 40 MCG/ML INTRAVENOUS DILUTION,RX-40849174,CDM,250,RC,J3490,HCPCS,99999000724,NDC,facility,outpatient,50,ML,65.10000,39.06000,WellCare of North Carolina,Managed Medicaid,,13.03,,,,,,,13.03,52.93,percent of total billed charges,
LEVOCARNITINE 25 MG/ML INTRAVENOUS DILUTION,RX-40849175,CDM,636,RC,J1955,HCPCS,99999000721,NDC,facility,outpatient,40,ML,178.35000,107.01000,WellCare of North Carolina,Managed Medicaid,,35.71,,,,,,,35.71,132.37,percent of total billed charges,
MAGNESIUM SULFATE 2.03 MEQ/ML INJECTION DILUTION,RX-40849176,CDM,636,RC,J3475,HCPCS,99999000723,NDC,facility,outpatient,40,ML,50.60000,30.36000,WellCare of North Carolina,Managed Medicaid,,10.13,,,,,,,1.13,37.56,percent of total billed charges,
ZINC CHLORIDE 0.5 MG/ML INTRAVENOUS DILUTION,RX-40849177,CDM,250,RC,J3490,HCPCS,99999000722,NDC,facility,outpatient,40,ML,231.70000,139.02000,WellCare of North Carolina,Managed Medicaid,,46.39,,,,,,,46.39,188.37,percent of total billed charges,
FLUCONAZOLE 800 MG/400 ML NS IVPB,RX-40849205,CDM,636,RC,J1450,HCPCS,99999000736,NDC,facility,outpatient,400,ML,237.75000,142.65000,WellCare of North Carolina,Managed Medicaid,,47.60,,,,,,,5.33,176.46,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE) IN SODIUM CHLORIDE 0.9% IVPB (60MIN ADMIN),RX-40849208,CDM,636,RC,J1450,HCPCS,09999000738,NDC,facility,outpatient,200,ML,150.40000,90.24000,WellCare of North Carolina,Managed Medicaid,,30.11,,,,,,,5.33,111.63,percent of total billed charges,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
CEFAZOLIN 50 MG/0.5 ML (100 MG/ML) INTRAOCULAR INJECTION,RX-40849256,CDM,636,RC,J0690,HCPCS,99999000746,NDC,facility,outpatient,0.5,ML,68.25000,40.95000,WellCare of North Carolina,Managed Medicaid,,13.66,,,,,,,1.89,50.66,percent of total billed charges,
CEFUROXIME 5 MG/0.5 ML INTRAOCULAR INJECTION,RX-40849271,CDM,636,RC,J0697,HCPCS,99999000748,NDC,facility,outpatient,1,UN,22.10000,13.26000,WellCare of North Carolina,Managed Medicaid,,4.42,,,,,,,4.37,16.40,percent of total billed charges,
VANCOMYCIN 5 MG/0.5 ML INTRACAMERAL INJECTION,RX-40849272,CDM,636,RC,J3373,HCPCS,99999000747,NDC,facility,outpatient,1,UN,22.80000,13.68000,WellCare of North Carolina,Managed Medicaid,,4.56,,,,,,,0.07080,16.92,percent of total billed charges,
IC-GREEN 25 MG/25 ML IN DEXTROSE 5%,RX-40849300,CDM,250,RC,J3490,HCPCS,99999000749,NDC,facility,outpatient,25,ML,458.95000,275.37000,WellCare of North Carolina,Managed Medicaid,,91.88,,,,,,,91.88,373.13,percent of total billed charges,
FENTANYL (SUBLIMAZE) 100 MCG IN NS 50ML (REX OR),RX-40849309,CDM,636,RC,J3010,HCPCS,99999000790,NDC,facility,outpatient,50,ML,26.05000,15.63000,WellCare of North Carolina,Managed Medicaid,,5.22,,,,,,,2.60,19.33,percent of total billed charges,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,WellCare of North Carolina,Managed Medicaid,,1168.46,,,,,,,19.74,4331.81,percent of total billed charges,
NOREPINEPHRINE 1 MCG/ML CATH/EP SOLUTION,RX-40849323,CDM,250,RC,J3490,HCPCS,99999007701,NDC,facility,outpatient,4,ML,63.05000,37.83000,WellCare of North Carolina,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
NICARDIPINE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849333,CDM,636,RC,J2404,HCPCS,99999007702,NDC,facility,outpatient,5,ML,63.15000,37.89000,WellCare of North Carolina,Managed Medicaid,,12.64,,,,,,,0.16520,46.87,percent of total billed charges,
NITROPRUSSIDE 10 MCG/ML INTRAVENOUS SOLUTION,RX-40849336,CDM,250,RC,J3490,HCPCS,99999007703,NDC,facility,outpatient,5,ML,63.25000,37.95000,WellCare of North Carolina,Managed Medicaid,,12.66,,,,,,,12.66,51.42,percent of total billed charges,
NITROGLYCERIN 100 MCG/ML INJECTION FOR VIR/CATH,RX-40849340,CDM,636,RC,J2305,HCPCS,99999007704,NDC,facility,outpatient,0.5,ML,63.30000,37.98000,WellCare of North Carolina,Managed Medicaid,,12.67,,,,,,,3.52,46.98,percent of total billed charges,
DILTIAZEM 100 MCG/ML IN NS,RX-40849341,CDM,250,RC,J3490,HCPCS,99999007705,NDC,facility,outpatient,1,ML,63.05000,37.83000,WellCare of North Carolina,Managed Medicaid,,12.62,,,,,,,12.62,51.26,percent of total billed charges,
BIVALIRUDIN 250 MG/50 ML INFUSION (CATH LAB),RX-40849344,CDM,636,RC,J0583,HCPCS,99999000737,NDC,facility,outpatient,1,UN,144.90000,86.94000,WellCare of North Carolina,Managed Medicaid,,29.01,,,,,,,0.40120,107.54,percent of total billed charges,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,WellCare of North Carolina,Managed Medicaid,,3.87,,,,,,,3.87,262.57,percent of total billed charges,
AMPHOTERICIN B 50 MCG/ML INTRAOCULAR INJECTION,RX-40849378,CDM,636,RC,J0285,HCPCS,99999007721,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,WellCare of North Carolina,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
PHENYLEPHRINE 1 MG/ML IV BOLUS (REX-JHH CATH),RX-40849382,CDM,636,RC,J2371,HCPCS,99999007716,NDC,facility,outpatient,0.08,ML,66.20000,39.72000,WellCare of North Carolina,Managed Medicaid,,13.25,,,,,,,0.02360,49.13,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL (TUBE DECLOG)",RX-40849386,CDM,250,RC,J3490,HCPCS,00032263601,NDC,facility,outpatient,1,UN,50.05000,30.03000,WellCare of North Carolina,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,10,ML,456.15000,273.69000,WellCare of North Carolina,Managed Medicaid,,91.32,,,,,,,1.98,338.55,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029320,NDC,facility,outpatient,10,ML,462.10000,277.26000,WellCare of North Carolina,Managed Medicaid,,92.51,,,,,,,1.98,342.97,percent of total billed charges,
TRIAMCINOLONE (KENALOG) 40 MG IN NS (REX OR OSM),RX-40849403,CDM,636,RC,J3301,HCPCS,00003029328,NDC,facility,outpatient,10,ML,361.05000,216.63000,WellCare of North Carolina,Managed Medicaid,,72.28,,,,,,,1.98,267.97,percent of total billed charges,
GATIFLOXACIN WITH ATROPINE (REX OR OSM),RX-40849406,CDM,250,RC,J3490,HCPCS,99999007731,NDC,facility,outpatient,0.5,ML,79.80000,47.88000,WellCare of North Carolina,Managed Medicaid,,15.98,,,,,,,15.98,64.88,percent of total billed charges,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SYRINGE WRAPPER,RX-40849501,CDM,250,RC,J3490,HCPCS,69374098255,NDC,facility,outpatient,5,ML,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J3490,HCPCS,70512084111,NDC,facility,outpatient,100,ML,75.60000,45.36000,WellCare of North Carolina,Managed Medicaid,,15.14,,,,,,,15.14,56.65,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,250,ML,78.75000,47.25000,WellCare of North Carolina,Managed Medicaid,,15.77,,,,,,,1.53,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION NON-PVC,RX-40849530,CDM,258,RC,J7040,HCPCS,17271070106,NDC,facility,outpatient,500,ML,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,2.97,56.20,percent of total billed charges,
AMPHOTERICIN B 100 MCG/ML INTRAOCULAR INJECTION,RX-40849580,CDM,636,RC,J0285,HCPCS,99999007772,NDC,facility,outpatient,0.1,ML,16.05000,9.63000,WellCare of North Carolina,Managed Medicaid,,3.21,,,,,,,3.21,102.45,percent of total billed charges,
"FENTANYL 12.5 MCG, BUPIVACAINE 0.2% (1.25 ML SYRINGE) CSE",RX-40849737,CDM,250,RC,J3490,HCPCS,99999000084,NDC,facility,outpatient,1.25,ML,22.65000,13.59000,WellCare of North Carolina,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
FENTANYL 50 MCG BUPIVACAINE 0.125% IN SODIUM CHLORIDE 0.9% (15 ML SYRINGE),RX-40849738,CDM,636,RC,J3010,HCPCS,99999007785,NDC,facility,outpatient,5,ML,24.85000,14.91000,WellCare of North Carolina,Managed Medicaid,,4.97,,,,,,,2.60,18.44,percent of total billed charges,
NALOXONE 1 MG/ML INTRANASAL SOLUTION,RX-40849764,CDM,636,RC,J2312,HCPCS,43598075011,NDC,facility,outpatient,2,ML,158.65000,95.19000,WellCare of North Carolina,Managed Medicaid,,31.76,,,,,,,0.18880,117.75,percent of total billed charges,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,WellCare of North Carolina,Managed Medicaid,,17.81,,,,,,,2.08,66.02,percent of total billed charges,
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION INJ ACTOVIAL/VIAL WRAPPER,RX-40849771,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,1,UN,125.55000,75.33000,WellCare of North Carolina,Managed Medicaid,,25.14,,,,,,,25.14,93.18,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ML,84.10000,50.46000,WellCare of North Carolina,Managed Medicaid,,16.84,,,,,,,1.13,62.42,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0166,HCPCS,54288012001,NDC,facility,outpatient,10,ML,357.25000,214.35000,WellCare of North Carolina,Managed Medicaid,,71.52,,,,,,,2.50,265.15,percent of total billed charges,
EPINEPHRINE 1 MG/ML INJECTION WRAPPER,RX-40849802,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,30,ML,1156.05000,693.63000,WellCare of North Carolina,Managed Medicaid,,231.44,,,,,,,1.13,858.02,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION PF WRAPPER,RX-40849811,CDM,636,RC,J2272,HCPCS,63323045200,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,WellCare of North Carolina,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION WRAPPER,RX-40849812,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,0.5,ML,24.95000,14.97000,WellCare of North Carolina,Managed Medicaid,,4.99,,,,,,,4.99,18.52,percent of total billed charges,
RIFAMPIN 600 MG TOPICAL POWDER FOR AAA (REX OPTIME),RX-40849827,CDM,636,RC,J2804,HCPCS,00068059701,NDC,facility,outpatient,1,UN,730.25000,438.15000,WellCare of North Carolina,Managed Medicaid,,146.20,,,,,,,0.33040,541.99,percent of total billed charges,
CHOLESTYRAMINE 20% IN AQUAPHOR OINTMENT,RX-40849835,CDM,250,RC,J3490,HCPCS,99999007798,NDC,facility,outpatient,100,GR,101.70000,61.02000,WellCare of North Carolina,Managed Medicaid,,20.36,,,,,,,20.36,82.68,percent of total billed charges,
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE WRAPPER,RX-40849886,CDM,636,RC,J0690,HCPCS,00000000747,NDC,facility,outpatient,50,ML,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,1.89,47.50,percent of total billed charges,
HEPATITIS B VACC RECMB(PF) 0.5 ML IM WRAPPER,RX-40849890,CDM,636,RC,90744,HCPCS,00006409302,NDC,facility,outpatient,0.5,ML,103.50000,62.10000,WellCare of North Carolina,Managed Medicaid,,20.72,,,,,,,20.72,88.33,percent of total billed charges,
KETAMINE 100 MG/ML INTRANASAL SOLUTION,RX-40849896,CDM,250,RC,J3490,HCPCS,42023011510,NDC,facility,outpatient,5,ML,62.05000,37.23000,WellCare of North Carolina,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
MENTHOL LOZENGES WRAPPER,RX-40849902,CDM,250,RC,J3490,HCPCS,12546062869,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR IV PUSH,RX-40849905,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,WellCare of North Carolina,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR IV PUSH,RX-40849906,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,1,UN,286.50000,171.90000,WellCare of North Carolina,Managed Medicaid,,57.36,,,,,,,5.97,212.64,percent of total billed charges,
CEFEPIME 1 GRAM SOLUTION FOR IV PUSH,RX-40849909,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,UN,39.00000,23.40000,WellCare of North Carolina,Managed Medicaid,,7.81,,,,,,,2.88,28.95,percent of total billed charges,
CEFEPIME 2 GRAM SOLUTION FOR IV PUSH',RX-40849910,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,1,UN,61.50000,36.90000,WellCare of North Carolina,Managed Medicaid,,12.31,,,,,,,2.88,45.65,percent of total billed charges,
CEFUROXIME SODIUM 750 MG SOLUTION FOR IV PUSH,RX-40849916,CDM,636,RC,J0697,HCPCS,00143956801,NDC,facility,outpatient,1,UN,26.40000,15.84000,WellCare of North Carolina,Managed Medicaid,,5.29,,,,,,,4.37,19.59,percent of total billed charges,
CEFUROXIME SODIUM 1.5 GRAM SOLUTION FOR IV PUSH,RX-40849917,CDM,636,RC,J0697,HCPCS,00143956725,NDC,facility,outpatient,1,UN,36.50000,21.90000,WellCare of North Carolina,Managed Medicaid,,7.31,,,,,,,4.37,27.09,percent of total billed charges,
DAPTOMYCIN 500 MG SOLUTION FOR IV PUSH,RX-40849918,CDM,636,RC,J0878,HCPCS,00143937801,NDC,facility,outpatient,1,UN,210.00000,126.00000,WellCare of North Carolina,Managed Medicaid,,42.04,,,,,,,0.07080,155.86,percent of total billed charges,
MEROPENEM 500 MG SOLUTION FOR IV PUSH,RX-40849919,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,1,UN,75.60000,45.36000,WellCare of North Carolina,Managed Medicaid,,15.14,,,,,,,0.99120,56.11,percent of total billed charges,
MEROPENEM 1 GRAM SOLUTION FOR IV PUSH,RX-40849920,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,UN,87.80000,52.68000,WellCare of North Carolina,Managed Medicaid,,17.58,,,,,,,0.99120,65.17,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM MBP/ADV WRAPPER,RX-40849929,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,1,UN,82.30000,49.38000,WellCare of North Carolina,Managed Medicaid,,16.48,,,,,,,3.28,61.08,percent of total billed charges,
CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH,RX-40849952,CDM,636,RC,J0696,HCPCS,00143985701,NDC,facility,outpatient,1,UN,25.10000,15.06000,WellCare of North Carolina,Managed Medicaid,,5.03,,,,,,,1.01,18.63,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH,RX-40849953,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,1,UN,29.65000,17.79000,WellCare of North Carolina,Managed Medicaid,,5.94,,,,,,,1.01,22.01,percent of total billed charges,
"DOBUTAMINE 32 MG/8 ML (4,000 MCG/ML) IN 5 % DEXTROSE (8 ML)",RX-40849972,CDM,636,RC,J1250,HCPCS,99999077709,NDC,facility,outpatient,8,ML,66.95000,40.17000,WellCare of North Carolina,Managed Medicaid,,13.40,,,,,,,13.40,49.69,percent of total billed charges,
"DOBUTAMINE 200 MG/50 ML (4,000 MCG/ML) IN 5 % DEXTROSE (50 ML)",RX-40849973,CDM,636,RC,J1250,HCPCS,99999077710,NDC,facility,outpatient,50,ML,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,16.71,62.34,percent of total billed charges,
LORAZEPAM 2 MG/ML INJECTION WRAPPER,RX-40849994,CDM,636,RC,J2060,HCPCS,00641604401,NDC,facility,outpatient,0.25,ML,23.20000,13.92000,WellCare of North Carolina,Managed Medicaid,,4.64,,,,,,,3.26,17.22,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,99999008261,NDC,facility,outpatient,120,ML,34.40000,20.64000,WellCare of North Carolina,Managed Medicaid,,6.89,,,,,,,6.89,27.97,percent of total billed charges,
HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION,RX-40850049,CDM,250,RC,J3490,HCPCS,09999007903,NDC,facility,outpatient,50,ML,20.65000,12.39000,WellCare of North Carolina,Managed Medicaid,,4.13,,,,,,,4.13,16.79,percent of total billed charges,
MIDAZOLAM 5 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850068,CDM,636,RC,J2250,HCPCS,00641606001,NDC,facility,outpatient,10,ML,42.70000,25.62000,WellCare of North Carolina,Managed Medicaid,,8.55,,,,,,,0.35400,31.69,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605701,NDC,facility,outpatient,2,ML,23.95000,14.37000,WellCare of North Carolina,Managed Medicaid,,4.79,,,,,,,0.35400,17.78,percent of total billed charges,
MIDAZOLAM 1 MG/ML (COMBINED) INTRANASAL SOLUTION WRAPPER,RX-40850071,CDM,636,RC,J2250,HCPCS,00641605901,NDC,facility,outpatient,5,ML,26.20000,15.72000,WellCare of North Carolina,Managed Medicaid,,5.25,,,,,,,0.35400,19.45,percent of total billed charges,
CLONIDINE 20 MCG/ML ORAL SOLN,RX-40850075,CDM,250,RC,J3490,HCPCS,99999008251,NDC,facility,outpatient,5,ML,17.65000,10.59000,WellCare of North Carolina,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
HYDROCORTISONE 2 MG/ML ORAL SUSPENSION,RX-40850084,CDM,250,RC,J3490,HCPCS,99999008257,NDC,facility,outpatient,1.25,ML,16.35000,9.81000,WellCare of North Carolina,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
NAFCILLIN 20 MG/ML PEDIATRIC DILUTION,RX-40850094,CDM,636,RC,J2290,HCPCS,09999199097,NDC,facility,outpatient,500,ML,531.30000,318.78000,WellCare of North Carolina,Managed Medicaid,,106.37,,,,,,,0.11800,394.33,percent of total billed charges,
BETHANECHOL 5 MG/ML ORAL SUSPENSION,RX-40850414,CDM,250,RC,J3490,HCPCS,99999001711,NDC,facility,outpatient,120,ML,34.00000,20.40000,WellCare of North Carolina,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
RIFAMPIN 25 MG/ML ORAL SUSPENSION,RX-40850415,CDM,250,RC,J3490,HCPCS,99999001712,NDC,facility,outpatient,120,ML,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,WellCare of North Carolina,Managed Medicaid,,516.61,,,,,,,6.53,1915.21,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Managed Medicaid,,4949.90,,,,,,,159.32,18350.75,percent of total billed charges,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,WellCare of North Carolina,Managed Medicaid,,7561.26,,,,,,,167.05,28031.82,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-40850887,CDM,636,RC,J3490,HCPCS,09999010484,NDC,facility,outpatient,14,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,212.46,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,175.62,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,176.79,percent of total billed charges,
FLUOROURACIL (ADRUCIL) 50 MG/ML IV SOLUTION WRAPPER (UNC HOMECARE),RX-40851400,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,outpatient,100,ML,403.95000,242.37000,WellCare of North Carolina,Managed Medicaid,,80.87,,,,,,,4.69,299.81,percent of total billed charges,
STUDY J3M-MC-JZQB CARBOPLATIN 10 MG/ML IV SOLUTION,RX-40851417,CDM,636,RC,J9045,HCPCS,09999011531,NDC,facility,outpatient,60,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,5.83,percent of total billed charges,
STUDY J3M-MC-JZQB CISPLATIN 1 MG/ML IV SOLUTION,RX-40851419,CDM,636,RC,J9060,HCPCS,09999011532,NDC,facility,outpatient,100,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,5.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,10.40,percent of total billed charges,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,163.33,percent of total billed charges,
STUDY MK-2870-011 DEXAMETHASONE 0.1 MG/ML ORAL SOLUTION,RX-40851520,CDM,636,RC,J8540,HCPCS,09999011908,NDC,facility,outpatient,500,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14844,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 10 MG/ML IV SOLUTION,RX-40851525,CDM,636,RC,J9171,HCPCS,09999011913,NDC,facility,outpatient,16,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
STUDY RMC-6236-301 DOCETAXEL 20 MG/ML IV SOLUTION,RX-40851526,CDM,636,RC,J9171,HCPCS,09999011914,NDC,facility,outpatient,8,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,1.42,percent of total billed charges,
FLUCONAZOLE 2 MG/ML (ODD DOSE IN BAG) IN SODIUM CHLORIDE 0.9% IVPB,RX-40859208,CDM,636,RC,J1450,HCPCS,09999059208,NDC,facility,outpatient,100,ML,106.70000,64.02000,WellCare of North Carolina,Managed Medicaid,,21.36,,,,,,,5.33,79.19,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION WRAPPER,RX-40860001,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,WellCare of North Carolina,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
HYDROMORPHONE 2 MG/ML INJECTION WRAPPER,RX-40860003,CDM,636,RC,J1171,HCPCS,00409131203,NDC,facility,outpatient,0.1,ML,23.05000,13.83000,WellCare of North Carolina,Managed Medicaid,,4.61,,,,,,,0.21240,17.11,percent of total billed charges,
EPHEDRINE 50 MG/ML INJECTION WRAPPER,RX-40860004,CDM,250,RC,J3490,HCPCS,42023021601,NDC,facility,outpatient,1,ML,148.15000,88.89000,WellCare of North Carolina,Managed Medicaid,,29.66,,,,,,,29.66,120.45,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION WRAPPER,RX-40860007,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,WellCare of North Carolina,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL-LANOLIN TOPICAL CREAM WRAPPER,RX-40860008,CDM,250,RC,J3490,HCPCS,72140000022,NDC,facility,outpatient,113,GR,12.40000,7.44000,WellCare of North Carolina,Managed Medicaid,,2.48,,,,,,,2.48,10.08,percent of total billed charges,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,0.77600,358.48,percent of total billed charges,
COCAINE 4 % SOLUTION WRAPPER,RX-40860011,CDM,636,RC,C9046,HCPCS,64950035904,NDC,facility,outpatient,4,ML,757.00000,454.20000,WellCare of North Carolina,Managed Medicaid,,151.55,,,,,,,4.06,561.85,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428202,NDC,facility,outpatient,10,ML,48.90000,29.34000,WellCare of North Carolina,Managed Medicaid,,9.79,,,,,,,0.02360,36.29,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00409428201,NDC,facility,outpatient,2,ML,25.75000,15.45000,WellCare of North Carolina,Managed Medicaid,,5.16,,,,,,,0.02360,19.11,percent of total billed charges,
LIDOCAINE (PF) 20 MG/ML (2 %) INECTION SOLUTION WRAPPER,RX-40860012,CDM,636,RC,J2003,HCPCS,00143959401,NDC,facility,outpatient,5,ML,26.10000,15.66000,WellCare of North Carolina,Managed Medicaid,,5.23,,,,,,,0.02360,19.37,percent of total billed charges,
"HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR WRAPPER",RX-40860013,CDM,636,RC,90632,HCPCS,58160082643,NDC,facility,outpatient,1,ML,278.25000,166.95000,WellCare of North Carolina,Managed Medicaid,,55.71,,,,,,,55.71,221.32,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET WRAPPER,RX-40860014,CDM,250,RC,J3490,HCPCS,45802006000,NDC,facility,outpatient,1,UN,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022710,NDC,facility,outpatient,10,ML,58.40000,35.04000,WellCare of North Carolina,Managed Medicaid,,11.69,,,,,,,11.69,47.48,percent of total billed charges,
TIMOLOL MALEATE 0.5 % EYE DROPS WRAPPER,RX-40860015,CDM,250,RC,J3490,HCPCS,61314022715,NDC,facility,outpatient,15,ML,77.55000,46.53000,WellCare of North Carolina,Managed Medicaid,,15.53,,,,,,,15.53,63.05,percent of total billed charges,
HALOPERIDOL LACTATE 5 MG/ML INJECTION WRAPPER,RX-40860017,CDM,636,RC,J1630,HCPCS,67457042600,NDC,facility,outpatient,0.2,ML,16.85000,10.11000,WellCare of North Carolina,Managed Medicaid,,3.37,,,,,,,1.89,12.51,percent of total billed charges,
PEG-ELECTROLYTE ORAL SOLUTION WRAPPER,RX-40860018,CDM,250,RC,J3490,HCPCS,52268010001,NDC,facility,outpatient,4000,ML,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,17.62,71.54,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,WellCare of North Carolina,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION WRAPPER",RX-40860021,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,WellCare of North Carolina,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
ACETAMINOPHEN 650 MG/20.3 ML ORAL LIQUID WRAPPER,RX-40860022,CDM,250,RC,J3490,HCPCS,00121197121,NDC,facility,outpatient,20.3,ML,4.15000,2.49000,WellCare of North Carolina,Managed Medicaid,,0.83083,,,,,,,0.83083,3.37,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL LIQUID WRAPPER,RX-40860023,CDM,250,RC,J3490,HCPCS,00121178105,NDC,facility,outpatient,5,ML,2.80000,1.68000,WellCare of North Carolina,Managed Medicaid,,0.56056,,,,,,,0.56056,2.28,percent of total billed charges,
VANCOMYCIN 1250 MG IN 250 ML NS IVPB PREMADE (287.5 ML TOTAL VOLUME),RX-40860221,CDM,636,RC,J3373,HCPCS,99999011054,NDC,facility,outpatient,287.5,ML,276.75000,166.05000,WellCare of North Carolina,Managed Medicaid,,55.41,,,,,,,0.07080,205.40,percent of total billed charges,
VANCOMYCIN 1500 MG IN 500 ML NS IVPB PREMADE (555 ML TOTAL VOLUME),RX-40860222,CDM,636,RC,J3373,HCPCS,99999011055,NDC,facility,outpatient,555,ML,298.45000,179.07000,WellCare of North Carolina,Managed Medicaid,,59.75,,,,,,,0.07080,221.51,percent of total billed charges,
VANCOMYCIN 1750 MG IN 500 ML NS IVPB PREMADE (557.5 ML TOTAL VOLUME),RX-40860223,CDM,636,RC,J3373,HCPCS,99999011056,NDC,facility,outpatient,557.5,ML,238.65000,143.19000,WellCare of North Carolina,Managed Medicaid,,47.78,,,,,,,0.07080,177.13,percent of total billed charges,
VANCOMYCIN 2000 MG IN 500 ML NS IVPB PREMADE (560 ML TOTAL VOLUME),RX-40860224,CDM,636,RC,J3373,HCPCS,99999011057,NDC,facility,outpatient,560,ML,260.60000,156.36000,WellCare of North Carolina,Managed Medicaid,,52.17,,,,,,,0.07080,193.42,percent of total billed charges,
VITAMIN A ORAL SOLUTION 2500 MCG RAE/ML,RX-4087108639,CDM,250,RC,J3490,HCPCS,09999508639,NDC,facility,outpatient,30,ML,2.25000,1.35000,WellCare of North Carolina,Managed Medicaid,,0.45045,,,,,,,0.45045,1.83,percent of total billed charges,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,WellCare of North Carolina,Managed Medicaid,,58.32,,,,,,,1.78,216.20,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
MIDAZOLAM 1 MG/ML INJECTION SOLUTION,RX-40872,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,0.5,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,0.35400,17.07,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028503,NDC,facility,outpatient,10,ML,41.15000,24.69000,WellCare of North Carolina,Managed Medicaid,,8.24,,,,,,,0.11800,30.54,percent of total billed charges,
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLN OSM,RX-408722020,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,outpatient,20,ML,66.25000,39.75000,WellCare of North Carolina,Managed Medicaid,,13.26,,,,,,,0.11800,49.17,percent of total billed charges,
ISRADIPINE 1 MG/ML ORAL SUSPENSION,RX-408729001,CDM,250,RC,J3490,HCPCS,09998728001,NDC,facility,outpatient,50,ML,77.80000,46.68000,WellCare of North Carolina,Managed Medicaid,,15.58,,,,,,,15.58,63.25,percent of total billed charges,
MERCAPTOPURINE 25 MG (ONCOLOGY) SPLIT TAB,RX-408880075,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,28.70000,17.22000,WellCare of North Carolina,Managed Medicaid,,5.75,,,,,,,5.75,23.33,percent of total billed charges,
MERCAPTOPURINE 50 MG (ONCOLOGY) TABLET,RX-408880076,CDM,250,RC,J3490,HCPCS,00054458111,NDC,facility,outpatient,1,UN,37.70000,22.62000,WellCare of North Carolina,Managed Medicaid,,7.55,,,,,,,7.55,30.65,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG (ONCOLOGY) TABLET,RX-408880078,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,WellCare of North Carolina,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,WellCare of North Carolina,Managed Medicaid,,9036.23,,,,,,,229.52,33499.94,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,WellCare of North Carolina,Managed Medicaid,,7201.25,,,,,,,88.60,26697.16,percent of total billed charges,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,WellCare of North Carolina,Managed Medicaid,,10263.89,,,,,,,88.60,38051.26,percent of total billed charges,
IMATINIB 50 MG SPLIT TABLET,RX-408880316,CDM,250,RC,J3490,HCPCS,00000000749,NDC,facility,outpatient,1,UN,27.45000,16.47000,WellCare of North Carolina,Managed Medicaid,,5.50,,,,,,,5.50,22.32,percent of total billed charges,
RUXOLITINIB 2.5 MG SPLIT TABLET,RX-408880318,CDM,250,RC,J3490,HCPCS,00000000751,NDC,facility,outpatient,1,UN,556.00000,333.60000,WellCare of North Carolina,Managed Medicaid,,111.31,,,,,,,111.31,452.03,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367501,NDC,facility,outpatient,10,ML,314.75000,188.85000,WellCare of North Carolina,Managed Medicaid,,63.01,,,,,,,6.15,233.61,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00143951901,NDC,facility,outpatient,2,ML,289.80000,173.88000,WellCare of North Carolina,Managed Medicaid,,58.02,,,,,,,6.15,215.09,percent of total billed charges,
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION FOR INTRATHECAL,RX-408880328,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,40,ML,421.30000,252.78000,WellCare of North Carolina,Managed Medicaid,,84.34,,,,,,,6.15,312.69,percent of total billed charges,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,WellCare of North Carolina,Managed Medicaid,,9367.61,,,,,,,53.90,34728.47,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,WellCare of North Carolina,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,WellCare of North Carolina,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,WellCare of North Carolina,Managed Medicaid,,1528.77,,,,,,,76.02,5667.59,percent of total billed charges,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Managed Medicaid,,791.91,,,,,,,76.02,2935.85,percent of total billed charges,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,6806.87,percent of total billed charges,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,WellCare of North Carolina,Managed Medicaid,,202.69,,,,,,,0.27160,751.44,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Managed Medicaid,,3766.64,,,,,,,35.64,13964.05,percent of total billed charges,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,WellCare of North Carolina,Managed Medicaid,,10231.89,,,,,,,70.44,37932.62,percent of total billed charges,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,WellCare of North Carolina,Managed Medicaid,,495.50,,,,,,,93.02,1836.94,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,WellCare of North Carolina,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,WellCare of North Carolina,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,WellCare of North Carolina,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,WellCare of North Carolina,Managed Medicaid,,835.97,,,,,,,4.29,3099.17,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,WellCare of North Carolina,Managed Medicaid,,1659.32,,,,,,,4.29,6151.58,percent of total billed charges,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,WellCare of North Carolina,Managed Medicaid,,341.96,,,,,,,4.29,1267.75,percent of total billed charges,
FOSPHENYTOIN IV 500 MG PE NS 50 ML INFUSION (TOTAL VOLUME 67 ML),RX-4088900119,CDM,636,RC,Q2009,HCPCS,09999010940,NDC,facility,outpatient,67,ML,278.85000,167.31000,WellCare of North Carolina,Managed Medicaid,,55.83,,,,,,,6.18,206.96,percent of total billed charges,
GENTAMICIN SULFATE (PF) 20 MG/2 ML INJ SOLN WRAPPER,RX-40891712,CDM,636,RC,J1580,HCPCS,63323017302,NDC,facility,outpatient,2,ML,44.10000,26.46000,WellCare of North Carolina,Managed Medicaid,,8.83,,,,,,,5.22,32.73,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,WellCare of North Carolina,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION,RX-40917,CDM,250,RC,J3490,HCPCS,00187001050,NDC,facility,outpatient,50,ML,191837.95000,115102.77000,WellCare of North Carolina,Managed Medicaid,,38405.96,,,,,,,38405.96,155964.25,percent of total billed charges,
SULFASALAZINE 100 MG/ML ORAL SUSP,RX-40940147,CDM,250,RC,J3490,HCPCS,00000000111,NDC,facility,outpatient,100,ML,128.90000,77.34000,WellCare of North Carolina,Managed Medicaid,,25.81,,,,,,,25.81,104.80,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264151032,NDC,facility,outpatient,100,ML,70.50000,42.30000,WellCare of North Carolina,Managed Medicaid,,14.11,,,,,,,14.11,52.83,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1000,ML,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,7.34,56.20,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J3490,HCPCS,00264751020,NDC,facility,outpatient,250,ML,74.25000,44.55000,WellCare of North Carolina,Managed Medicaid,,14.86,,,,,,,14.86,55.64,percent of total billed charges,
DEXTROSE 5% WATER (D5W) NON-PVC,RX-40940266,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,500,ML,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,4.27,56.20,percent of total billed charges,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,WellCare of North Carolina,Managed Medicaid,,294.55,,,,,,,66.15,1092.00,percent of total billed charges,
FENTANYL 12 MCG/HR TRANSDERMAL PATCH,RX-41382,CDM,250,RC,J3490,HCPCS,00378911916,NDC,facility,outpatient,1,UN,70.75000,42.45000,WellCare of North Carolina,Managed Medicaid,,14.16,,,,,,,14.16,57.52,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488802,NDC,facility,outpatient,10,ML,20.30000,12.18000,WellCare of North Carolina,Managed Medicaid,,4.06,,,,,,,4.06,16.50,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488803,NDC,facility,outpatient,10,ML,21.50000,12.90000,WellCare of North Carolina,Managed Medicaid,,4.30,,,,,,,4.30,17.48,percent of total billed charges,
SODIUM CHLORIDE 0.9 % INJECTION SOLUTION,RX-41463,CDM,250,RC,J3490,HCPCS,00409488806,NDC,facility,outpatient,10,ML,19.25000,11.55000,WellCare of North Carolina,Managed Medicaid,,3.85,,,,,,,3.85,15.65,percent of total billed charges,
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION,RX-41673,CDM,636,RC,J9390,HCPCS,25021020405,NDC,facility,outpatient,5,ML,671.00000,402.60000,WellCare of North Carolina,Managed Medicaid,,134.33,,,,,,,5.33,498.02,percent of total billed charges,
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION,RX-41793,CDM,250,RC,J3490,HCPCS,67457016300,NDC,facility,outpatient,0.5,ML,145.05000,87.03000,WellCare of North Carolina,Managed Medicaid,,29.04,,,,,,,29.04,117.93,percent of total billed charges,
LIDOCAINE 5 % TOPICAL OINTMENT,RX-41831,CDM,250,RC,J3490,HCPCS,00168020437,NDC,facility,outpatient,35.44,GR,736.00000,441.60000,WellCare of North Carolina,Managed Medicaid,,147.35,,,,,,,147.35,598.37,percent of total billed charges,
SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET,RX-41832,CDM,250,RC,J3490,HCPCS,00069419068,NDC,facility,outpatient,1,UN,263.45000,158.07000,WellCare of North Carolina,Managed Medicaid,,52.74,,,,,,,52.74,214.18,percent of total billed charges,
PREGABALIN 75 MG CAPSULE,RX-42164,CDM,250,RC,J3490,HCPCS,00071101441,NDC,facility,outpatient,1,UN,55.40000,33.24000,WellCare of North Carolina,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
PREGABALIN 100 MG CAPSULE,RX-42165,CDM,250,RC,J3490,HCPCS,00071101541,NDC,facility,outpatient,1,UN,55.40000,33.24000,WellCare of North Carolina,Managed Medicaid,,11.09,,,,,,,11.09,45.04,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,68094012959,NDC,facility,outpatient,15,ML,5.10000,3.06000,WellCare of North Carolina,Managed Medicaid,,1.02,,,,,,,1.02,4.15,percent of total billed charges,
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID,RX-42219,CDM,250,RC,J3490,HCPCS,50580013408,NDC,facility,outpatient,240,ML,12.95000,7.77000,WellCare of North Carolina,Managed Medicaid,,2.59,,,,,,,2.59,10.53,percent of total billed charges,
KETAMINE 10 MG/ML INJECTION SOLUTION,RX-4236,CDM,250,RC,J3490,HCPCS,55150043801,NDC,facility,outpatient,20,ML,79.90000,47.94000,WellCare of North Carolina,Managed Medicaid,,16.00,,,,,,,16.00,64.96,percent of total billed charges,
KETAMINE 100 MG/ML INJECTION SOLUTION,RX-4237,CDM,250,RC,J3490,HCPCS,00143950901,NDC,facility,outpatient,5,ML,60.25000,36.15000,WellCare of North Carolina,Managed Medicaid,,12.06,,,,,,,12.06,48.98,percent of total billed charges,
CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION,RX-4294,CDM,250,RC,J3490,HCPCS,51754100701,NDC,facility,outpatient,10,ML,460.75000,276.45000,WellCare of North Carolina,Managed Medicaid,,92.24,,,,,,,92.24,374.59,percent of total billed charges,
LACTATED RINGERS INTRAVENOUS SOLUTION,RX-4318,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1000,ML,78.00000,46.80000,WellCare of North Carolina,Managed Medicaid,,15.62,,,,,,,5.69,58.45,percent of total billed charges,
LACTATED RINGERS IRRIGATION SOLUTION,RX-4319,CDM,258,RC,J3490,HCPCS,00264220300,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
AMITRIPTYLINE 10 MG TABLET,RX-432,CDM,250,RC,J3490,HCPCS,00781148601,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMITRIPTYLINE 25 MG TABLET,RX-435,CDM,250,RC,J3490,HCPCS,00781148701,NDC,facility,outpatient,1,UN,17.15000,10.29000,WellCare of North Carolina,Managed Medicaid,,3.43,,,,,,,3.43,13.94,percent of total billed charges,
LANTHANUM 750 MG CHEWABLE TABLET,RX-43547,CDM,250,RC,J3490,HCPCS,66993042385,NDC,facility,outpatient,1,UN,59.20000,35.52000,WellCare of North Carolina,Managed Medicaid,,11.85,,,,,,,11.85,48.13,percent of total billed charges,
"LANTHANUM 1,000 MG CHEWABLE TABLET",RX-43548,CDM,250,RC,J3490,HCPCS,68180082147,NDC,facility,outpatient,1,UN,38.25000,22.95000,WellCare of North Carolina,Managed Medicaid,,7.66,,,,,,,7.66,31.10,percent of total billed charges,
DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION,RX-43556,CDM,250,RC,J3490,HCPCS,00054005746,NDC,facility,outpatient,60,ML,435.95000,261.57000,WellCare of North Carolina,Managed Medicaid,,87.28,,,,,,,87.28,354.43,percent of total billed charges,
AMITRIPTYLINE 50 MG TABLET,RX-436,CDM,250,RC,J3490,HCPCS,51079013301,NDC,facility,outpatient,1,UN,18.30000,10.98000,WellCare of North Carolina,Managed Medicaid,,3.66,,,,,,,3.66,14.88,percent of total billed charges,
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION,RX-43717,CDM,250,RC,J3490,HCPCS,76329630005,NDC,facility,outpatient,4,ML,106.60000,63.96000,WellCare of North Carolina,Managed Medicaid,,21.34,,,,,,,21.34,86.67,percent of total billed charges,
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION,RX-4392,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,outpatient,1,UN,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,7.60,79.42,percent of total billed charges,
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION,RX-4393,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,1,UN,583.00000,349.80000,WellCare of North Carolina,Managed Medicaid,,116.72,,,,,,,7.60,432.70,percent of total billed charges,
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION,RX-4394,CDM,636,RC,J0640,HCPCS,25021081310,NDC,facility,outpatient,1,UN,313.75000,188.25000,WellCare of North Carolina,Managed Medicaid,,62.81,,,,,,,7.60,232.87,percent of total billed charges,
LEUCOVORIN CALCIUM 25 MG TABLET,RX-4397,CDM,250,RC,J3490,HCPCS,00555048527,NDC,facility,outpatient,1,UN,51.80000,31.08000,WellCare of North Carolina,Managed Medicaid,,10.37,,,,,,,10.37,42.11,percent of total billed charges,
LEUCOVORIN CALCIUM 5 MG TABLET,RX-4398,CDM,250,RC,J3490,HCPCS,00054449625,NDC,facility,outpatient,1,UN,20.40000,12.24000,WellCare of North Carolina,Managed Medicaid,,4.08,,,,,,,4.08,16.59,percent of total billed charges,
LEVOTHYROXINE 25 MCG TABLET,RX-4420,CDM,250,RC,J3490,HCPCS,51079044401,NDC,facility,outpatient,1,UN,17.80000,10.68000,WellCare of North Carolina,Managed Medicaid,,3.56,,,,,,,3.56,14.47,percent of total billed charges,
LEVOTHYROXINE 50 MCG TABLET,RX-4421,CDM,250,RC,J3490,HCPCS,51079044001,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 75 MCG TABLET,RX-4422,CDM,250,RC,J3490,HCPCS,51079044101,NDC,facility,outpatient,1,UN,18.20000,10.92000,WellCare of North Carolina,Managed Medicaid,,3.64,,,,,,,3.64,14.80,percent of total billed charges,
LEVOTHYROXINE 100 MCG TABLET,RX-4423,CDM,250,RC,J3490,HCPCS,00378180977,NDC,facility,outpatient,1,UN,17.70000,10.62000,WellCare of North Carolina,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
LEVOTHYROXINE 125 MCG TABLET,RX-4424,CDM,250,RC,J3490,HCPCS,00378181377,NDC,facility,outpatient,1,UN,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,14.63,percent of total billed charges,
LEVOTHYROXINE 150 MCG TABLET,RX-4425,CDM,250,RC,J3490,HCPCS,00074706990,NDC,facility,outpatient,1,UN,22.65000,13.59000,WellCare of North Carolina,Managed Medicaid,,4.53,,,,,,,4.53,18.41,percent of total billed charges,
LEVOTHYROXINE 200 MCG TABLET,RX-4426,CDM,250,RC,J3490,HCPCS,00378181910,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION,RX-4450,CDM,250,RC,J3490,HCPCS,09999011000,NDC,facility,outpatient,7.5,ML,34.00000,20.40000,WellCare of North Carolina,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427601,NDC,facility,outpatient,20,ML,30.50000,18.30000,WellCare of North Carolina,Managed Medicaid,,6.11,,,,,,,0.02360,22.64,percent of total billed charges,
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION,RX-4452,CDM,636,RC,J2003,HCPCS,00409427602,NDC,facility,outpatient,50,ML,30.60000,18.36000,WellCare of North Carolina,Managed Medicaid,,6.13,,,,,,,0.02360,22.71,percent of total billed charges,
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION,RX-4454,CDM,636,RC,J2003,HCPCS,00409427701,NDC,facility,outpatient,20,ML,34.15000,20.49000,WellCare of North Carolina,Managed Medicaid,,6.84,,,,,,,0.02360,25.35,percent of total billed charges,
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION,RX-4455,CDM,636,RC,J2003,HCPCS,00409428301,NDC,facility,outpatient,5,ML,38.00000,22.80000,WellCare of North Carolina,Managed Medicaid,,7.61,,,,,,,0.02360,28.20,percent of total billed charges,
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE,RX-4457,CDM,636,RC,J2003,HCPCS,00409490434,NDC,facility,outpatient,5,ML,115.10000,69.06000,WellCare of North Carolina,Managed Medicaid,,23.04,,,,,,,0.02360,85.43,percent of total billed charges,
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE,RX-4459,CDM,636,RC,J2003,HCPCS,00409132305,NDC,facility,outpatient,5,ML,49.10000,29.46000,WellCare of North Carolina,Managed Medicaid,,9.83,,,,,,,0.02360,36.44,percent of total billed charges,
AMOXICILLIN 250 MG CAPSULE,RX-450,CDM,250,RC,J3490,HCPCS,57237003001,NDC,facility,outpatient,1,UN,16.25000,9.75000,WellCare of North Carolina,Managed Medicaid,,3.25,,,,,,,3.25,13.21,percent of total billed charges,
LIOTHYRONINE 25 MCG TABLET,RX-4504,CDM,250,RC,J3490,HCPCS,60793011601,NDC,facility,outpatient,1,UN,18.15000,10.89000,WellCare of North Carolina,Managed Medicaid,,3.63,,,,,,,3.63,14.76,percent of total billed charges,
AMOXICILLIN 500 MG CAPSULE,RX-451,CDM,250,RC,J3490,HCPCS,65862001701,NDC,facility,outpatient,1,UN,16.40000,9.84000,WellCare of North Carolina,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
LISINOPRIL 20 MG TABLET,RX-4526,CDM,250,RC,J3490,HCPCS,60687033311,NDC,facility,outpatient,1,UN,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LITHIUM CARBONATE 300 MG TABLET,RX-4531,CDM,250,RC,J3490,HCPCS,00054852825,NDC,facility,outpatient,1,UN,17.10000,10.26000,WellCare of North Carolina,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988901,NDC,facility,outpatient,5,ML,16.45000,9.87000,WellCare of North Carolina,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION,RX-454,CDM,250,RC,J3490,HCPCS,00143988915,NDC,facility,outpatient,5,ML,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
LOPERAMIDE 2 MG CAPSULE,RX-4560,CDM,250,RC,J3490,HCPCS,51079069001,NDC,facility,outpatient,1,UN,2.15000,1.29000,WellCare of North Carolina,Managed Medicaid,,0.43043,,,,,,,0.43043,1.75,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,0.5,ML,23.80000,14.28000,WellCare of North Carolina,Managed Medicaid,,4.76,,,,,,,4.76,19.35,percent of total billed charges,
LORAZEPAM 2 MG/ML ORAL CONCENTRATE,RX-4571,CDM,250,RC,J3490,HCPCS,00054353244,NDC,facility,outpatient,30,ML,116.70000,70.02000,WellCare of North Carolina,Managed Medicaid,,23.36,,,,,,,23.36,94.88,percent of total billed charges,
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION,RX-464,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,outpatient,1,UN,234.40000,140.64000,WellCare of North Carolina,Managed Medicaid,,46.93,,,,,,,46.93,173.97,percent of total billed charges,
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,RX-469,CDM,636,RC,J0290,HCPCS,00781940485,NDC,facility,outpatient,1,UN,47.45000,28.47000,WellCare of North Carolina,Managed Medicaid,,9.50,,,,,,,1.30,35.22,percent of total billed charges,
MAGNESIUM CITRATE ORAL SOLUTION,RX-4712,CDM,250,RC,J3490,HCPCS,46122074138,NDC,facility,outpatient,296,ML,4.25000,2.55000,WellCare of North Carolina,Managed Medicaid,,0.85085,,,,,,,0.85085,3.46,percent of total billed charges,
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK,RX-4719,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,100,ML,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,1.13,67.54,percent of total billed charges,
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION,RX-472,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,1,UN,48.35000,29.01000,WellCare of North Carolina,Managed Medicaid,,9.68,,,,,,,1.30,35.89,percent of total billed charges,
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION,RX-4720,CDM,636,RC,J3475,HCPCS,63323006401,NDC,facility,outpatient,2,ML,26.35000,15.81000,WellCare of North Carolina,Managed Medicaid,,5.28,,,,,,,1.13,19.56,percent of total billed charges,
AMPICILLIN 250 MG SOLUTION FOR INJECTION,RX-473,CDM,636,RC,J0290,HCPCS,00781940278,NDC,facility,outpatient,1,UN,31.25000,18.75000,WellCare of North Carolina,Managed Medicaid,,6.26,,,,,,,1.30,23.19,percent of total billed charges,
AMPICILLIN 500 MG SOLUTION FOR INJECTION,RX-474,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,1,UN,29.65000,17.79000,WellCare of North Carolina,Managed Medicaid,,5.94,,,,,,,1.30,22.01,percent of total billed charges,
MANGANESE CHLORIDE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-4744,CDM,250,RC,J3490,HCPCS,00409409101,NDC,facility,outpatient,10,ML,185.65000,111.39000,WellCare of North Carolina,Managed Medicaid,,37.17,,,,,,,37.17,150.93,percent of total billed charges,
MANNITOL 20 % INTRAVENOUS SOLUTION,RX-4749,CDM,258,RC,J2151,HCPCS,00338035703,NDC,facility,outpatient,31.25,ML,77.15000,46.29000,WellCare of North Carolina,Managed Medicaid,,15.45,,,,,,,0.14160,57.81,percent of total billed charges,
MANNITOL 25 % INTRAVENOUS SOLUTION,RX-4750,CDM,258,RC,J2151,HCPCS,00409403116,NDC,facility,outpatient,25,ML,29.90000,17.94000,WellCare of North Carolina,Managed Medicaid,,5.99,,,,,,,0.14160,22.40,percent of total billed charges,
MEDROXYPROGESTERONE 10 MG TABLET,RX-4854,CDM,250,RC,J3490,HCPCS,00555077902,NDC,facility,outpatient,1,UN,17.10000,10.26000,WellCare of North Carolina,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MEDROXYPROGESTERONE 2.5 MG TABLET,RX-4855,CDM,250,RC,J3490,HCPCS,00555087202,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION,RX-4903,CDM,636,RC,J2175,HCPCS,00641605201,NDC,facility,outpatient,1,ML,29.65000,17.79000,WellCare of North Carolina,Managed Medicaid,,5.94,,,,,,,5.94,42.72,percent of total billed charges,
MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION,RX-4904,CDM,636,RC,J2175,HCPCS,00641605301,NDC,facility,outpatient,1,ML,29.95000,17.97000,WellCare of North Carolina,Managed Medicaid,,6.00,,,,,,,6.00,42.72,percent of total billed charges,
MEPIVACAINE 1 % (10 MG/ML) INJECTION SOLUTION,RX-4914,CDM,636,RC,J0670,HCPCS,63323028301,NDC,facility,outpatient,50,ML,87.25000,52.35000,WellCare of North Carolina,Managed Medicaid,,17.47,,,,,,,9.32,64.76,percent of total billed charges,
MEPIVACAINE 2 % INJECTION SOLUTION,RX-4915,CDM,636,RC,J0670,HCPCS,63323029601,NDC,facility,outpatient,50,ML,89.05000,53.43000,WellCare of North Carolina,Managed Medicaid,,17.83,,,,,,,9.32,66.09,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,09999000582,NDC,facility,outpatient,5,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
METHADONE 5 MG/5 ML ORAL SOLUTION,RX-4952,CDM,250,RC,J3490,HCPCS,00054355563,NDC,facility,outpatient,500,ML,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,23.62,95.93,percent of total billed charges,
METHADONE 10 MG TABLET,RX-4953,CDM,250,RC,J3490,HCPCS,00406577162,NDC,facility,outpatient,1,UN,23.40000,14.04000,WellCare of North Carolina,Managed Medicaid,,4.68,,,,,,,4.68,19.02,percent of total billed charges,
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION,RX-4970,CDM,636,RC,J2800,HCPCS,70069010101,NDC,facility,outpatient,5,ML,53.55000,32.13000,WellCare of North Carolina,Managed Medicaid,,10.72,,,,,,,10.72,39.74,percent of total billed charges,
METHOCARBAMOL 500 MG TABLET,RX-4971,CDM,250,RC,J3490,HCPCS,76385012301,NDC,facility,outpatient,1,UN,16.35000,9.81000,WellCare of North Carolina,Managed Medicaid,,3.27,,,,,,,3.27,13.29,percent of total billed charges,
METHOTREXATE SODIUM 2.5 MG TABLET,RX-4973,CDM,636,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,1,UN,37.20000,22.32000,WellCare of North Carolina,Managed Medicaid,,7.45,,,,,,,0.44840,27.61,percent of total billed charges,
METHOTREXATE SODIUM (CONTAINS PRESERVATIVES) 25 MG/ML INJECTION SOLUTION,RX-4974,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,2,ML,307.00000,184.20000,WellCare of North Carolina,Managed Medicaid,,61.46,,,,,,,6.15,227.86,percent of total billed charges,
METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION,RX-4975,CDM,636,RC,J9260,HCPCS,00143936701,NDC,facility,outpatient,1,UN,473.00000,283.80000,WellCare of North Carolina,Managed Medicaid,,94.69,,,,,,,6.15,351.06,percent of total billed charges,
METHYLPHENIDATE 5 MG TABLET,RX-4988,CDM,250,RC,J3490,HCPCS,00406114201,NDC,facility,outpatient,1,UN,22.60000,13.56000,WellCare of North Carolina,Managed Medicaid,,4.52,,,,,,,4.52,18.37,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,WellCare of North Carolina,Managed Medicaid,,5.80,,,,,,,0.11640,21.49,percent of total billed charges,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,WellCare of North Carolina,Managed Medicaid,,21.17,,,,,,,0.11640,78.49,percent of total billed charges,
METOCLOPRAMIDE 10 MG TABLET,RX-5005,CDM,250,RC,J3490,HCPCS,51079088801,NDC,facility,outpatient,1,UN,19.20000,11.52000,WellCare of North Carolina,Managed Medicaid,,3.84,,,,,,,3.84,15.61,percent of total billed charges,
METOCLOPRAMIDE 5 MG TABLET,RX-5006,CDM,250,RC,J3490,HCPCS,51079088620,NDC,facility,outpatient,1,UN,19.05000,11.43000,WellCare of North Carolina,Managed Medicaid,,3.81,,,,,,,3.81,15.49,percent of total billed charges,
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION,RX-5007,CDM,636,RC,J0616,HCPCS,36000003310,NDC,facility,outpatient,5,ML,20.55000,12.33000,WellCare of North Carolina,Managed Medicaid,,4.11,,,,,,,0.28320,15.25,percent of total billed charges,
METOPROLOL TARTRATE 100 MG TABLET,RX-5008,CDM,250,RC,J3490,HCPCS,51079080201,NDC,facility,outpatient,1,UN,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
METOPROLOL TARTRATE 50 MG TABLET,RX-5009,CDM,250,RC,J3490,HCPCS,62584026611,NDC,facility,outpatient,1,UN,16.45000,9.87000,WellCare of North Carolina,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
METRONIDAZOLE 250 MG TABLET,RX-5015,CDM,250,RC,J3490,HCPCS,00904715661,NDC,facility,outpatient,1,UN,17.65000,10.59000,WellCare of North Carolina,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
METRONIDAZOLE 500 MG TABLET,RX-5016,CDM,250,RC,J3490,HCPCS,42292000120,NDC,facility,outpatient,1,UN,18.65000,11.19000,WellCare of North Carolina,Managed Medicaid,,3.73,,,,,,,3.73,15.16,percent of total billed charges,
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK,RX-5018,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,100,ML,74.20000,44.52000,WellCare of North Carolina,Managed Medicaid,,14.85,,,,,,,0.07080,55.07,percent of total billed charges,
MICONAZOLE NITRATE 2 % VAGINAL CREAM,RX-5040,CDM,250,RC,J3490,HCPCS,51672203506,NDC,facility,outpatient,45,GR,13.50000,8.10000,WellCare of North Carolina,Managed Medicaid,,2.70,,,,,,,2.70,10.98,percent of total billed charges,
MINOCYCLINE 50 MG CAPSULE,RX-5111,CDM,250,RC,J3490,HCPCS,00591569401,NDC,facility,outpatient,1,UN,17.10000,10.26000,WellCare of North Carolina,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
MINOXIDIL 10 MG TABLET,RX-5114,CDM,250,RC,J3490,HCPCS,68084020511,NDC,facility,outpatient,1,UN,18.60000,11.16000,WellCare of North Carolina,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
MINOXIDIL 2.5 MG TABLET,RX-5115,CDM,250,RC,J3490,HCPCS,68084020411,NDC,facility,outpatient,1,UN,18.10000,10.86000,WellCare of North Carolina,Managed Medicaid,,3.62,,,,,,,3.62,14.72,percent of total billed charges,
MORPHINE 10 MG/ML INJECTION SOLUTION,RX-5168,CDM,636,RC,J2272,HCPCS,63323045100,NDC,facility,outpatient,0.5,ML,26.60000,15.96000,WellCare of North Carolina,Managed Medicaid,,5.33,,,,,,,5.33,22.13,percent of total billed charges,
MORPHINE 2 MG/ML INJECTION SYRINGE,RX-5170,CDM,636,RC,J2272,HCPCS,76045000401,NDC,facility,outpatient,1,ML,30.65000,18.39000,WellCare of North Carolina,Managed Medicaid,,6.14,,,,,,,6.14,22.75,percent of total billed charges,
MORPHINE 4 MG/ML INJECTION SYRINGE,RX-5172,CDM,636,RC,J2272,HCPCS,76045000510,NDC,facility,outpatient,0.5,ML,26.35000,15.81000,WellCare of North Carolina,Managed Medicaid,,5.28,,,,,,,5.28,22.13,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,09999007802,NDC,facility,outpatient,0.4,ML,22.10000,13.26000,WellCare of North Carolina,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,68094000162,NDC,facility,outpatient,5,ML,26.10000,15.66000,WellCare of North Carolina,Managed Medicaid,,5.23,,,,,,,5.23,21.22,percent of total billed charges,
MORPHINE 10 MG/5 ML ORAL SOLUTION,RX-5176,CDM,250,RC,J3490,HCPCS,00054023763,NDC,facility,outpatient,500,ML,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,18.22,73.98,percent of total billed charges,
MORPHINE 15 MG IMMEDIATE RELEASE TABLET,RX-5178,CDM,250,RC,J3490,HCPCS,00054023525,NDC,facility,outpatient,1,UN,23.30000,13.98000,WellCare of North Carolina,Managed Medicaid,,4.66,,,,,,,4.66,18.94,percent of total billed charges,
MORPHINE 10 MG RECTAL SUPPOSITORY,RX-5180,CDM,250,RC,J3490,HCPCS,00574711212,NDC,facility,outpatient,1,UN,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,7.41,30.08,percent of total billed charges,
NALBUPHINE 10 MG/ML INJECTION SOLUTION,RX-5339,CDM,636,RC,J2300,HCPCS,00409146369,NDC,facility,outpatient,1,ML,32.30000,19.38000,WellCare of North Carolina,Managed Medicaid,,6.47,,,,,,,6.47,23.97,percent of total billed charges,
NALOXONE 0.4 MG/ML INJECTION SOLUTION,RX-5373,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,1,ML,88.05000,52.83000,WellCare of North Carolina,Managed Medicaid,,17.63,,,,,,,0.18880,65.35,percent of total billed charges,
NALOXONE 1 MG/ML INJECTION SYRINGE,RX-5374,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ML,166.15000,99.69000,WellCare of North Carolina,Managed Medicaid,,33.26,,,,,,,0.18880,123.32,percent of total billed charges,
NAPROXEN 250 MG TABLET,RX-5391,CDM,250,RC,J3490,HCPCS,50268059411,NDC,facility,outpatient,1,UN,17.05000,10.23000,WellCare of North Carolina,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
NAPROXEN 500 MG TABLET,RX-5393,CDM,250,RC,J3490,HCPCS,60687049111,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-5599,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,10,ML,128.35000,77.01000,WellCare of North Carolina,Managed Medicaid,,25.70,,,,,,,3.52,95.26,percent of total billed charges,
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET,RX-5604,CDM,250,RC,J3490,HCPCS,59762330403,NDC,facility,outpatient,1,UN,53.70000,32.22000,WellCare of North Carolina,Managed Medicaid,,10.75,,,,,,,10.75,43.66,percent of total billed charges,
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT,RX-5606,CDM,250,RC,J3490,HCPCS,00281032608,NDC,facility,outpatient,1,GR,25.70000,15.42000,WellCare of North Carolina,Managed Medicaid,,5.15,,,,,,,5.15,20.89,percent of total billed charges,
NORTRIPTYLINE 10 MG CAPSULE,RX-5674,CDM,250,RC,J3490,HCPCS,51672400101,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
NORTRIPTYLINE 25 MG CAPSULE,RX-5675,CDM,250,RC,J3490,HCPCS,51672400201,NDC,facility,outpatient,1,UN,17.10000,10.26000,WellCare of North Carolina,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,250,RC,J3490,HCPCS,45802005935,NDC,facility,outpatient,15,GR,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
"NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT",RX-5750,CDM,250,RC,J3490,HCPCS,45802004835,NDC,facility,outpatient,15,GR,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
OXYBUTYNIN CHLORIDE 5 MG TABLET,RX-5938,CDM,250,RC,J3490,HCPCS,00904702761,NDC,facility,outpatient,1,UN,18.40000,11.04000,WellCare of North Carolina,Managed Medicaid,,3.68,,,,,,,3.68,14.96,percent of total billed charges,
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET,RX-5940,CDM,250,RC,J3490,HCPCS,00406051223,NDC,facility,outpatient,1,UN,23.25000,13.95000,WellCare of North Carolina,Managed Medicaid,,4.65,,,,,,,4.65,18.90,percent of total billed charges,
OXYMETAZOLINE 0.05 % NASAL SPRAY,RX-5943,CDM,250,RC,J3490,HCPCS,11523116706,NDC,facility,outpatient,15,ML,10.50000,6.30000,WellCare of North Carolina,Managed Medicaid,,2.10,,,,,,,2.10,8.54,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,0.3,ML,20.95000,12.57000,WellCare of North Carolina,Managed Medicaid,,4.19,,,,,,,3.37,15.55,percent of total billed charges,
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION,RX-5944,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,outpatient,0.3,ML,17.95000,10.77000,WellCare of North Carolina,Managed Medicaid,,3.59,,,,,,,3.37,13.32,percent of total billed charges,
PAPAVERINE 30 MG/ML INJECTION SOLUTION,RX-6030,CDM,636,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,2,ML,204.45000,122.67000,WellCare of North Carolina,Managed Medicaid,,40.93,,,,,,,40.93,151.74,percent of total billed charges,
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION,RX-6085,CDM,636,RC,J2540,HCPCS,00049053028,NDC,facility,outpatient,1,UN,247.55000,148.53000,WellCare of North Carolina,Managed Medicaid,,49.56,,,,,,,1.86,183.73,percent of total billed charges,
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION,RX-6086,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,UN,73.90000,44.34000,WellCare of North Carolina,Managed Medicaid,,14.79,,,,,,,1.86,54.85,percent of total billed charges,
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION,RX-6091,CDM,250,RC,J3490,HCPCS,00093412773,NDC,facility,outpatient,100,ML,42.70000,25.62000,WellCare of North Carolina,Managed Medicaid,,8.55,,,,,,,8.55,34.72,percent of total billed charges,
PENICILLIN V POTASSIUM 500 MG TABLET,RX-6093,CDM,250,RC,J3490,HCPCS,57237004101,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION,RX-6097,CDM,636,RC,J2515,HCPCS,24201001050,NDC,facility,outpatient,50,ML,6793.00000,4075.80000,WellCare of North Carolina,Managed Medicaid,,1359.96,,,,,,,127.13,5041.76,percent of total billed charges,
PERPHENAZINE 2 MG TABLET,RX-6157,CDM,250,RC,J3490,HCPCS,00591410101,NDC,facility,outpatient,1,UN,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
PHENAZOPYRIDINE 100 MG TABLET,RX-6193,CDM,250,RC,J3490,HCPCS,51293081001,NDC,facility,outpatient,1,UN,17.30000,10.38000,WellCare of North Carolina,Managed Medicaid,,3.46,,,,,,,3.46,14.06,percent of total billed charges,
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR,RX-6212,CDM,250,RC,J3490,HCPCS,09999000759,NDC,facility,outpatient,5,ML,24.30000,14.58000,WellCare of North Carolina,Managed Medicaid,,4.86,,,,,,,4.86,19.76,percent of total billed charges,
PHENOBARBITAL 32.4 MG TABLET,RX-6217,CDM,250,RC,J3490,HCPCS,00603516621,NDC,facility,outpatient,1,UN,23.65000,14.19000,WellCare of North Carolina,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION,RX-6221,CDM,636,RC,J2560,HCPCS,00641047721,NDC,facility,outpatient,1,ML,227.20000,136.32000,WellCare of North Carolina,Managed Medicaid,,45.49,,,,,,,45.49,168.63,percent of total billed charges,
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION,RX-6224,CDM,636,RC,J2560,HCPCS,00641047621,NDC,facility,outpatient,1,ML,101.10000,60.66000,WellCare of North Carolina,Managed Medicaid,,20.24,,,,,,,20.24,75.04,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,00641614225,NDC,facility,outpatient,1,ML,34.20000,20.52000,WellCare of North Carolina,Managed Medicaid,,6.85,,,,,,,0.02360,25.38,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,63323075110,NDC,facility,outpatient,10,ML,212.70000,127.62000,WellCare of North Carolina,Managed Medicaid,,42.58,,,,,,,0.02360,157.87,percent of total billed charges,
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION,RX-6242,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,5,ML,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,0.02360,79.42,percent of total billed charges,
PHENYLEPHRINE 0.25 % NASAL SPRAY,RX-6243,CDM,250,RC,J3490,HCPCS,00225080047,NDC,facility,outpatient,15,ML,6.40000,3.84000,WellCare of North Carolina,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 0.5 % NASAL SPRAY,RX-6244,CDM,250,RC,J3490,HCPCS,00225080547,NDC,facility,outpatient,15,ML,6.40000,3.84000,WellCare of North Carolina,Managed Medicaid,,1.28,,,,,,,1.28,5.20,percent of total billed charges,
PHENYLEPHRINE 2.5 % EYE DROPS,RX-6246,CDM,250,RC,J3490,HCPCS,70756062925,NDC,facility,outpatient,2,ML,113.50000,68.10000,WellCare of North Carolina,Managed Medicaid,,22.72,,,,,,,22.72,92.28,percent of total billed charges,
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION,RX-6256,CDM,636,RC,J1165,HCPCS,00641049325,NDC,facility,outpatient,2,ML,22.35000,13.41000,WellCare of North Carolina,Managed Medicaid,,4.47,,,,,,,1.06,16.59,percent of total billed charges,
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE,RX-6257,CDM,250,RC,J3490,HCPCS,00071036940,NDC,facility,outpatient,1,UN,23.65000,14.19000,WellCare of North Carolina,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE,RX-6271,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,0.25,ML,72.30000,43.38000,WellCare of North Carolina,Managed Medicaid,,14.47,,,,,,,6.44,53.66,percent of total billed charges,
PILOCARPINE 1 % EYE DROPS,RX-6279,CDM,250,RC,J3490,HCPCS,61314020315,NDC,facility,outpatient,15,ML,252.60000,151.56000,WellCare of North Carolina,Managed Medicaid,,50.57,,,,,,,50.57,205.36,percent of total billed charges,
PILOCARPINE 2 % EYE DROPS,RX-6280,CDM,250,RC,J3490,HCPCS,61314020415,NDC,facility,outpatient,15,ML,258.00000,154.80000,WellCare of North Carolina,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
PILOCARPINE 4 % EYE DROPS,RX-6282,CDM,250,RC,J3490,HCPCS,61314020615,NDC,facility,outpatient,15,ML,269.70000,161.82000,WellCare of North Carolina,Managed Medicaid,,53.99,,,,,,,53.99,219.27,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,51754200401,NDC,facility,outpatient,100,ML,155.40000,93.24000,WellCare of North Carolina,Managed Medicaid,,31.11,,,,,,,31.11,126.34,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409818301,NDC,facility,outpatient,20,ML,85.70000,51.42000,WellCare of North Carolina,Managed Medicaid,,17.16,,,,,,,17.16,69.67,percent of total billed charges,
POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6420,CDM,250,RC,J3490,HCPCS,00409329461,NDC,facility,outpatient,50,ML,110.05000,66.03000,WellCare of North Carolina,Managed Medicaid,,22.03,,,,,,,22.03,89.47,percent of total billed charges,
POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-6429,CDM,636,RC,J3480,HCPCS,63323096503,NDC,facility,outpatient,10,ML,72.65000,43.59000,WellCare of North Carolina,Managed Medicaid,,14.54,,,,,,,0.25960,53.92,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID,RX-6432,CDM,250,RC,J3490,HCPCS,69238145902,NDC,facility,outpatient,473,ML,189.15000,113.49000,WellCare of North Carolina,Managed Medicaid,,37.87,,,,,,,37.87,153.78,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET,RX-6434,CDM,250,RC,J3490,HCPCS,00603155410,NDC,facility,outpatient,1,UN,44.85000,26.91000,WellCare of North Carolina,Managed Medicaid,,8.98,,,,,,,8.98,36.46,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL OINTMENT,RX-6455,CDM,250,RC,J3490,HCPCS,00536127180,NDC,facility,outpatient,28.4,GR,3.85000,2.31000,WellCare of North Carolina,Managed Medicaid,,0.77077,,,,,,,0.77077,3.13,percent of total billed charges,
POVIDONE-IODINE 10 % TOPICAL SOLUTION,RX-6458,CDM,250,RC,J3490,HCPCS,65517000903,NDC,facility,outpatient,118,ML,3.05000,1.83000,WellCare of North Carolina,Managed Medicaid,,0.61061,,,,,,,0.61061,2.48,percent of total billed charges,
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION,RX-6462,CDM,636,RC,J2730,HCPCS,60977014101,NDC,facility,outpatient,1,UN,410.50000,246.30000,WellCare of North Carolina,Managed Medicaid,,82.18,,,,,,,82.18,304.67,percent of total billed charges,
PRAZOSIN 1 MG CAPSULE,RX-6468,CDM,250,RC,J3490,HCPCS,51079063001,NDC,facility,outpatient,1,UN,22.05000,13.23000,WellCare of North Carolina,Managed Medicaid,,4.41,,,,,,,4.41,17.93,percent of total billed charges,
PRAZOSIN 2 MG CAPSULE,RX-6469,CDM,250,RC,J3490,HCPCS,51079063120,NDC,facility,outpatient,1,UN,24.45000,14.67000,WellCare of North Carolina,Managed Medicaid,,4.89,,,,,,,4.89,19.88,percent of total billed charges,
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,250,RC,J3490,HCPCS,61314063705,NDC,facility,outpatient,5,ML,148.75000,89.25000,WellCare of North Carolina,Managed Medicaid,,29.78,,,,,,,29.78,120.93,percent of total billed charges,
PREDNISONE 5 MG/5 ML ORAL SOLUTION,RX-6492,CDM,636,RC,J7512,HCPCS,00054372263,NDC,facility,outpatient,500,ML,1256.00000,753.60000,WellCare of North Carolina,Managed Medicaid,,251.45,,,,,,,0.02360,932.20,percent of total billed charges,
PREDNISONE 1 MG TABLET,RX-6493,CDM,636,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 10 MG TABLET,RX-6494,CDM,636,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,0.02360,12.54,percent of total billed charges,
PREDNISONE 20 MG TABLET,RX-6496,CDM,636,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,1,UN,16.95000,10.17000,WellCare of North Carolina,Managed Medicaid,,3.39,,,,,,,0.02360,12.58,percent of total billed charges,
PREDNISONE 5 MG TABLET,RX-6497,CDM,636,RC,J7512,HCPCS,00054872425,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,0.02360,12.47,percent of total billed charges,
PRIMAQUINE 15 MG TABLET,RX-6541,CDM,250,RC,J3490,HCPCS,42291051001,NDC,facility,outpatient,1,UN,21.30000,12.78000,WellCare of North Carolina,Managed Medicaid,,4.26,,,,,,,4.26,17.32,percent of total billed charges,
PRIMIDONE 250 MG TABLET,RX-6544,CDM,250,RC,J3490,HCPCS,00591532101,NDC,facility,outpatient,1,UN,17.45000,10.47000,WellCare of North Carolina,Managed Medicaid,,3.49,,,,,,,3.49,14.19,percent of total billed charges,
PROBENECID 500 MG TABLET,RX-6561,CDM,250,RC,J3490,HCPCS,00378015601,NDC,facility,outpatient,1,UN,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,WellCare of North Carolina,Managed Medicaid,,40.54,,,,,,,40.54,695.47,percent of total billed charges,
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION,RX-6580,CDM,636,RC,J0780,HCPCS,23155029431,NDC,facility,outpatient,0.5,ML,22.20000,13.32000,WellCare of North Carolina,Managed Medicaid,,4.44,,,,,,,4.27,16.48,percent of total billed charges,
PROCHLORPERAZINE MALEATE 5 MG TABLET,RX-6583,CDM,250,RC,J3490,HCPCS,59746011306,NDC,facility,outpatient,1,UN,17.40000,10.44000,WellCare of North Carolina,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL,RX-6597,CDM,636,RC,J2675,HCPCS,00143972501,NDC,facility,outpatient,0.1,ML,17.55000,10.53000,WellCare of North Carolina,Managed Medicaid,,3.51,,,,,,,1.65,13.03,percent of total billed charges,
PROMETHAZINE 25 MG/ML INJECTION SOLUTION,RX-6618,CDM,636,RC,J2550,HCPCS,00641092825,NDC,facility,outpatient,1,ML,24.45000,14.67000,WellCare of North Carolina,Managed Medicaid,,4.89,,,,,,,4.89,18.15,percent of total billed charges,
PROMETHAZINE 12.5 MG TABLET,RX-6621,CDM,250,RC,J3490,HCPCS,68001016100,NDC,facility,outpatient,1,UN,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
PROMETHAZINE 25 MG TABLET,RX-6622,CDM,250,RC,J3490,HCPCS,68084015511,NDC,facility,outpatient,1,UN,17.70000,10.62000,WellCare of North Carolina,Managed Medicaid,,3.54,,,,,,,3.54,14.39,percent of total billed charges,
ASCORBIC ACID (VITAMIN C) 500 MG TABLET,RX-664,CDM,250,RC,J3490,HCPCS,00904052360,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PROPARACAINE 0.5 % EYE DROPS,RX-6644,CDM,250,RC,J3490,HCPCS,61314001601,NDC,facility,outpatient,15,ML,121.30000,72.78000,WellCare of North Carolina,Managed Medicaid,,24.28,,,,,,,24.28,98.62,percent of total billed charges,
PROPRANOLOL 20 MG/5 ML (4 MG/ML) ORAL SOLUTION,RX-6654,CDM,250,RC,J3490,HCPCS,00054372763,NDC,facility,outpatient,500,ML,161.50000,96.90000,WellCare of North Carolina,Managed Medicaid,,32.33,,,,,,,32.33,131.30,percent of total billed charges,
PROPRANOLOL 10 MG TABLET,RX-6656,CDM,250,RC,J3490,HCPCS,23155011001,NDC,facility,outpatient,1,UN,16.65000,9.99000,WellCare of North Carolina,Managed Medicaid,,3.33,,,,,,,3.33,13.54,percent of total billed charges,
PROPRANOLOL 20 MG TABLET,RX-6657,CDM,250,RC,J3490,HCPCS,00591555501,NDC,facility,outpatient,1,UN,17.40000,10.44000,WellCare of North Carolina,Managed Medicaid,,3.48,,,,,,,3.48,14.15,percent of total billed charges,
PROPRANOLOL 40 MG TABLET,RX-6658,CDM,250,RC,J3490,HCPCS,00603548421,NDC,facility,outpatient,1,UN,17.05000,10.23000,WellCare of North Carolina,Managed Medicaid,,3.41,,,,,,,3.41,13.86,percent of total billed charges,
PROPRANOLOL 80 MG TABLET,RX-6660,CDM,250,RC,J3490,HCPCS,00591555701,NDC,facility,outpatient,1,UN,18.45000,11.07000,WellCare of North Carolina,Managed Medicaid,,3.69,,,,,,,3.69,15.00,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,25,ML,256.70000,154.02000,WellCare of North Carolina,Managed Medicaid,,51.39,,,,,,,4.11,190.52,percent of total billed charges,
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION,RX-6677,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,5,ML,86.45000,51.87000,WellCare of North Carolina,Managed Medicaid,,17.31,,,,,,,4.11,64.16,percent of total billed charges,
PSEUDOEPHEDRINE 30 MG TABLET,RX-6714,CDM,250,RC,J3490,HCPCS,24385043280,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
PYRAZINAMIDE 500 MG TABLET,RX-6738,CDM,250,RC,J3490,HCPCS,06068713801,NDC,facility,outpatient,1,UN,25.20000,15.12000,WellCare of North Carolina,Managed Medicaid,,5.05,,,,,,,5.05,20.49,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION,RX-6744,CDM,636,RC,J3415,HCPCS,63323018000,NDC,facility,outpatient,0.5,ML,65.45000,39.27000,WellCare of North Carolina,Managed Medicaid,,13.10,,,,,,,13.10,48.58,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 100 MG TABLET,RX-6745,CDM,250,RC,J3490,HCPCS,50268085911,NDC,facility,outpatient,1,UN,1.40000,0.84000,WellCare of North Carolina,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 25 MG TABLET,RX-6746,CDM,250,RC,J3490,HCPCS,00536440601,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
PYRIDOXINE (VITAMIN B6) 50 MG TABLET,RX-6748,CDM,250,RC,J3490,HCPCS,50268085811,NDC,facility,outpatient,1,UN,1.40000,0.84000,WellCare of North Carolina,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
ASPIRIN 81 MG CHEWABLE TABLET,RX-679,CDM,250,RC,J3490,HCPCS,66553000201,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ASPIRIN 325 MG TABLET,RX-681,CDM,250,RC,J3490,HCPCS,66553000101,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"ASPIRIN 325 MG TABLET,DELAYED RELEASE",RX-685,CDM,250,RC,J3490,HCPCS,46122059602,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
ASPIRIN 300 MG RECTAL SUPPOSITORY,RX-693,CDM,250,RC,J3490,HCPCS,00574703412,NDC,facility,outpatient,1,UN,2.85000,1.71000,WellCare of North Carolina,Managed Medicaid,,0.57057,,,,,,,0.57057,2.32,percent of total billed charges,
POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS,RX-70255,CDM,250,RC,J3490,HCPCS,24385000605,NDC,facility,outpatient,15,ML,7.65000,4.59000,WellCare of North Carolina,Managed Medicaid,,1.53,,,,,,,1.53,6.22,percent of total billed charges,
ARIPIPRAZOLE 2 MG TABLET,RX-70306,CDM,250,RC,J3490,HCPCS,59148000613,NDC,facility,outpatient,1,UN,93.85000,56.31000,WellCare of North Carolina,Managed Medicaid,,18.79,,,,,,,18.79,76.30,percent of total billed charges,
SALSALATE 500 MG TABLET,RX-7034,CDM,250,RC,J3490,HCPCS,65162051210,NDC,facility,outpatient,1,UN,17.20000,10.32000,WellCare of North Carolina,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
SALSALATE 750 MG TABLET,RX-7035,CDM,250,RC,J3490,HCPCS,65162051310,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,WellCare of North Carolina,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,WellCare of North Carolina,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,WellCare of North Carolina,Managed Medicaid,,16.74,,,,,,,1.45,62.05,percent of total billed charges,
SUNITINIB MALATE 12.5 MG CAPSULE,RX-70424,CDM,250,RC,J3490,HCPCS,00069055038,NDC,facility,outpatient,1,UN,947.35000,568.41000,WellCare of North Carolina,Managed Medicaid,,189.66,,,,,,,189.66,770.20,percent of total billed charges,
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,250,RC,J3490,HCPCS,00054327099,NDC,facility,outpatient,16,GR,22.20000,13.32000,WellCare of North Carolina,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
METHOHEXITAL 500 MG SOLUTION FOR INJECTION,RX-70545,CDM,250,RC,J3490,HCPCS,42023010501,NDC,facility,outpatient,1,UN,356.60000,213.96000,WellCare of North Carolina,Managed Medicaid,,71.39,,,,,,,71.39,289.92,percent of total billed charges,
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP,RX-70693,CDM,636,RC,J1815,HCPCS,00002751101,NDC,facility,outpatient,10,ML,404.65000,242.79000,WellCare of North Carolina,Managed Medicaid,,81.01,,,,,,,0.54280,300.33,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,51672407008,NDC,facility,outpatient,2.5,ML,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
CETIRIZINE 1 MG/ML ORAL SOLUTION,RX-70838,CDM,250,RC,J3490,HCPCS,00904676520,NDC,facility,outpatient,2.5,ML,1.20000,0.72000,WellCare of North Carolina,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
SELENIUM 200 MCG TABLET,RX-7139,CDM,250,RC,J3490,HCPCS,40093010196,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATENOLOL 25 MG TABLET,RX-717,CDM,250,RC,J3490,HCPCS,51079075901,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
ATENOLOL 50 MG TABLET,RX-718,CDM,250,RC,J3490,HCPCS,51079068401,NDC,facility,outpatient,1,UN,16.40000,9.84000,WellCare of North Carolina,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
SILVER SULFADIAZINE 1 % TOPICAL CREAM,RX-7224,CDM,250,RC,J3490,HCPCS,43598021050,NDC,facility,outpatient,50,GR,53.20000,31.92000,WellCare of North Carolina,Managed Medicaid,,10.65,,,,,,,10.65,43.25,percent of total billed charges,
SIMETHICONE 80 MG CHEWABLE TABLET,RX-7227,CDM,250,RC,J3490,HCPCS,24385011878,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
"SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION",RX-7228,CDM,250,RC,J3490,HCPCS,09999009102,NDC,facility,outpatient,0.3,ML,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,10,ML,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,0.19800,74.22,percent of total billed charges,
ATROPINE 0.1 MG/ML INJECTION SYRINGE,RX-730,CDM,636,RC,J0461,HCPCS,00409491034,NDC,facility,outpatient,5,ML,104.75000,62.85000,WellCare of North Carolina,Managed Medicaid,,20.97,,,,,,,0.19800,77.75,percent of total billed charges,
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION,RX-7301,CDM,250,RC,J3490,HCPCS,00409729973,NDC,facility,outpatient,20,ML,67.00000,40.20000,WellCare of North Carolina,Managed Medicaid,,13.41,,,,,,,13.41,54.47,percent of total billed charges,
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION,RX-7302,CDM,250,RC,J3490,HCPCS,63323003204,NDC,facility,outpatient,100,ML,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,20.02,81.30,percent of total billed charges,
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE,RX-7306,CDM,250,RC,J3490,HCPCS,00409553424,NDC,facility,outpatient,10,ML,116.65000,69.99000,WellCare of North Carolina,Managed Medicaid,,23.35,,,,,,,23.35,94.84,percent of total billed charges,
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE,RX-7309,CDM,250,RC,J3490,HCPCS,00409663724,NDC,facility,outpatient,50,ML,112.05000,67.23000,WellCare of North Carolina,Managed Medicaid,,22.43,,,,,,,22.43,91.10,percent of total billed charges,
SODIUM BICARBONATE 650 MG TABLET,RX-7312,CDM,250,RC,J3490,HCPCS,66553000801,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004304,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,2.97,60.69,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00990798502,NDC,facility,outpatient,250,ML,78.75000,47.25000,WellCare of North Carolina,Managed Medicaid,,15.77,,,,,,,2.97,59.01,percent of total billed charges,
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION,RX-7318,CDM,258,RC,J7040,HCPCS,00338004303,NDC,facility,outpatient,500,ML,76.50000,45.90000,WellCare of North Carolina,Managed Medicaid,,15.32,,,,,,,2.97,57.32,percent of total billed charges,
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION,RX-7321,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,500,ML,82.50000,49.50000,WellCare of North Carolina,Managed Medicaid,,16.52,,,,,,,0.28050,61.23,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,00409114102,NDC,facility,outpatient,30,ML,82.45000,49.47000,WellCare of North Carolina,Managed Medicaid,,16.51,,,,,,,0.28050,61.19,percent of total billed charges,
SODIUM CHLORIDE 23.4% (4 MEQ/ML) INTRAVENOUS SOLUTION,RX-7322,CDM,636,RC,J7131,HCPCS,63323009301,NDC,facility,outpatient,30,ML,95.15000,57.09000,WellCare of North Carolina,Managed Medicaid,,19.05,,,,,,,0.28050,70.62,percent of total billed charges,
SODIUM CHLORIDE 3 % FOR NEBULIZATION,RX-7327,CDM,250,RC,J3490,HCPCS,00487900330,NDC,facility,outpatient,4,ML,18.70000,11.22000,WellCare of North Carolina,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,00409739172,NDC,facility,outpatient,15,ML,136.65000,81.99000,WellCare of North Carolina,Managed Medicaid,,27.36,,,,,,,27.36,111.10,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088401,NDC,facility,outpatient,5,ML,74.25000,44.55000,WellCare of North Carolina,Managed Medicaid,,14.86,,,,,,,14.86,60.37,percent of total billed charges,
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION,RX-7351,CDM,250,RC,J3490,HCPCS,63323088601,NDC,facility,outpatient,50,ML,428.05000,256.83000,WellCare of North Carolina,Managed Medicaid,,85.70,,,,,,,85.70,348.00,percent of total billed charges,
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION,RX-7364,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,50,ML,394.80000,236.88000,WellCare of North Carolina,Managed Medicaid,,79.04,,,,,,,1.94,293.02,percent of total billed charges,
SPIRONOLACTONE 25 MG TABLET,RX-7437,CDM,250,RC,J3490,HCPCS,63739054410,NDC,facility,outpatient,1,UN,16.95000,10.17000,WellCare of North Carolina,Managed Medicaid,,3.39,,,,,,,3.39,13.78,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000346,NDC,facility,outpatient,500,ML,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,14.41,58.54,percent of total billed charges,
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,250,RC,J3490,HCPCS,00338000404,NDC,facility,outpatient,500,ML,69.00000,41.40000,WellCare of North Carolina,Managed Medicaid,,13.81,,,,,,,13.81,56.10,percent of total billed charges,
SULFADIAZINE 500 MG TABLET,RX-7554,CDM,250,RC,J3490,HCPCS,42806075760,NDC,facility,outpatient,1,UN,80.15000,48.09000,WellCare of North Carolina,Managed Medicaid,,16.05,,,,,,,16.05,65.16,percent of total billed charges,
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION,RX-7556,CDM,636,RC,J2865,HCPCS,00703951491,NDC,facility,outpatient,10,ML,115.70000,69.42000,WellCare of North Carolina,Managed Medicaid,,23.16,,,,,,,0.11800,85.87,percent of total billed charges,
SULFASALAZINE 500 MG TABLET,RX-7562,CDM,250,RC,J3490,HCPCS,59762500005,NDC,facility,outpatient,1,UN,16.80000,10.08000,WellCare of North Carolina,Managed Medicaid,,3.36,,,,,,,3.36,13.66,percent of total billed charges,
SULINDAC 150 MG TABLET,RX-7578,CDM,250,RC,J3490,HCPCS,00591566101,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
SULINDAC 200 MG TABLET,RX-7579,CDM,250,RC,J3490,HCPCS,42806001101,NDC,facility,outpatient,1,UN,17.25000,10.35000,WellCare of North Carolina,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,WellCare of North Carolina,Managed Medicaid,,1060.77,,,,,,,2.84,3932.58,percent of total billed charges,
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,636,RC,J3473,HCPCS,18657011701,NDC,facility,outpatient,1,ML,269.90000,161.94000,WellCare of North Carolina,Managed Medicaid,,54.03,,,,,,,0.84960,200.32,percent of total billed charges,
DECITABINE 50 MG INTRAVENOUS SOLUTION,RX-76364,CDM,636,RC,J0893,HCPCS,47335036141,NDC,facility,outpatient,1,UN,715.00000,429.00000,WellCare of North Carolina,Managed Medicaid,,143.14,,,,,,,1.84,530.67,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,WellCare of North Carolina,Managed Medicaid,,17.04,,,,,,,1.56,63.16,percent of total billed charges,
VARENICLINE TARTRATE 0.5 MG TABLET,RX-76444,CDM,250,RC,J3490,HCPCS,60505476505,NDC,facility,outpatient,1,UN,45.70000,27.42000,WellCare of North Carolina,Managed Medicaid,,9.15,,,,,,,9.15,37.15,percent of total billed charges,
VARENICLINE TARTRATE 1 MG TABLET,RX-76445,CDM,250,RC,J3490,HCPCS,00069046956,NDC,facility,outpatient,1,UN,49.55000,29.73000,WellCare of North Carolina,Managed Medicaid,,9.92,,,,,,,9.92,40.28,percent of total billed charges,
LORATADINE 5 MG/5 ML ORAL SOLUTION,RX-76472,CDM,250,RC,J3490,HCPCS,51672207308,NDC,facility,outpatient,5,ML,1.55000,0.93000,WellCare of North Carolina,Managed Medicaid,,0.31031,,,,,,,0.31031,1.26,percent of total billed charges,
ACETYLCHOLINE CHLORIDE 1 % (20 MG/2 ML) INTRAOCULAR KIT,RX-76641,CDM,250,RC,J3490,HCPCS,24208053920,NDC,facility,outpatient,1,UN,407.75000,244.65000,WellCare of North Carolina,Managed Medicaid,,81.63,,,,,,,81.63,331.50,percent of total billed charges,
SODIUM HYPOCHLORITE 0.125 % SOLUTION,RX-76720,CDM,250,RC,J3490,HCPCS,00436067216,NDC,facility,outpatient,473,ML,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,18.70,percent of total billed charges,
IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION,RX-76780,CDM,250,RC,J3490,HCPCS,66993049036,NDC,facility,outpatient,2,ML,1979.25000,1187.55000,WellCare of North Carolina,Managed Medicaid,,396.25,,,,,,,396.25,1609.13,percent of total billed charges,
APREPITANT 40 MG CAPSULE,RX-76843,CDM,636,RC,J8501,HCPCS,00781232151,NDC,facility,outpatient,1,UN,367.80000,220.68000,WellCare of North Carolina,Managed Medicaid,,73.63,,,,,,,6.44,272.98,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,250,RC,J3490,HCPCS,87701040749,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT,RX-76967,CDM,250,RC,J3490,HCPCS,23900000361,NDC,facility,outpatient,50,GR,6.90000,4.14000,WellCare of North Carolina,Managed Medicaid,,1.38,,,,,,,1.38,5.61,percent of total billed charges,
GLYCERIN (CHILD) RECTAL SUPPOSITORY,RX-76974,CDM,250,RC,J3490,HCPCS,46122022263,NDC,facility,outpatient,1,UN,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION,RX-77009,CDM,636,RC,J2274,HCPCS,00641603901,NDC,facility,outpatient,20,ML,646.00000,387.60000,WellCare of North Carolina,Managed Medicaid,,129.33,,,,,,,28.44,479.46,percent of total billed charges,
TAMOXIFEN 10 MG TABLET,RX-7711,CDM,250,RC,J3490,HCPCS,00591247260,NDC,facility,outpatient,1,UN,26.55000,15.93000,WellCare of North Carolina,Managed Medicaid,,5.32,,,,,,,5.32,21.59,percent of total billed charges,
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION,RX-77195,CDM,636,RC,J1953,HCPCS,00143967301,NDC,facility,outpatient,5,ML,79.80000,47.88000,WellCare of North Carolina,Managed Medicaid,,15.98,,,,,,,0.09440,59.23,percent of total billed charges,
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION,RX-77371,CDM,250,RC,J3490,HCPCS,00085132801,NDC,facility,outpatient,2.5,ML,118.85000,71.31000,WellCare of North Carolina,Managed Medicaid,,23.79,,,,,,,23.79,96.63,percent of total billed charges,
TEMAZEPAM 15 MG CAPSULE,RX-7753,CDM,250,RC,J3490,HCPCS,67877014601,NDC,facility,outpatient,1,UN,22.30000,13.38000,WellCare of North Carolina,Managed Medicaid,,4.46,,,,,,,4.46,18.13,percent of total billed charges,
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION,RX-77581,CDM,250,RC,J3490,HCPCS,63402091101,NDC,facility,outpatient,2,ML,94.80000,56.88000,WellCare of North Carolina,Managed Medicaid,,18.98,,,,,,,18.98,77.07,percent of total billed charges,
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION,RX-77685,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,1,UN,848.40000,509.04000,WellCare of North Carolina,Managed Medicaid,,169.85,,,,,,,0.61360,629.68,percent of total billed charges,
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION,RX-77725,CDM,250,RC,J3490,HCPCS,00121157610,NDC,facility,outpatient,10,ML,32.20000,19.32000,WellCare of North Carolina,Managed Medicaid,,6.45,,,,,,,6.45,26.18,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,00009008601,NDC,facility,outpatient,0.25,ML,27.95000,16.77000,WellCare of North Carolina,Managed Medicaid,,5.60,,,,,,,0.07080,20.74,percent of total billed charges,
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL,RX-7784,CDM,636,RC,J1071,HCPCS,70700029022,NDC,facility,outpatient,0.25,ML,28.70000,17.22000,WellCare of North Carolina,Managed Medicaid,,5.75,,,,,,,0.07080,21.30,percent of total billed charges,
TETRACAINE 0.5 % EYE DROPS,RX-7795,CDM,250,RC,J3490,HCPCS,68682092064,NDC,facility,outpatient,15,ML,286.00000,171.60000,WellCare of North Carolina,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
TETRAHYDROZOLINE 0.05 % EYE DROPS,RX-7800,CDM,250,RC,J3490,HCPCS,24385007505,NDC,facility,outpatient,15,ML,6.25000,3.75000,WellCare of North Carolina,Managed Medicaid,,1.25,,,,,,,1.25,5.08,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,27808003301,NDC,facility,outpatient,18.75,ML,25.05000,15.03000,WellCare of North Carolina,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION,RX-7821,CDM,250,RC,J3490,HCPCS,,,facility,outpatient,18.75,ML,25.05000,15.03000,WellCare of North Carolina,Managed Medicaid,,5.02,,,,,,,5.02,20.37,percent of total billed charges,
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,250,RC,J3490,HCPCS,54092047612,NDC,facility,outpatient,1,UN,53.45000,32.07000,WellCare of North Carolina,Managed Medicaid,,10.70,,,,,,,10.70,43.45,percent of total billed charges,
AZACITIDINE (VIDAZA) SYRINGE 25 MG/ML,RX-78420,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,1,UN,2850.10000,1710.06000,WellCare of North Carolina,Managed Medicaid,,570.59,,,,,,,0.57750,2115.34,percent of total billed charges,
ALISKIREN 150 MG TABLET,RX-78653,CDM,250,RC,J3490,HCPCS,70839015030,NDC,facility,outpatient,1,UN,62.05000,37.23000,WellCare of North Carolina,Managed Medicaid,,12.42,,,,,,,12.42,50.45,percent of total billed charges,
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION,RX-7876,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,0.25,ML,22.80000,13.68000,WellCare of North Carolina,Managed Medicaid,,4.56,,,,,,,4.30,16.92,percent of total billed charges,
THIOTHIXENE 1 MG CAPSULE,RX-7902,CDM,250,RC,J3490,HCPCS,70954001410,NDC,facility,outpatient,1,UN,19.80000,11.88000,WellCare of North Carolina,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
THIOTHIXENE 5 MG CAPSULE,RX-7906,CDM,250,RC,J3490,HCPCS,70954001610,NDC,facility,outpatient,1,UN,23.65000,14.19000,WellCare of North Carolina,Managed Medicaid,,4.73,,,,,,,4.73,19.23,percent of total billed charges,
TOBRAMYCIN 0.3 % EYE DROPS,RX-7995,CDM,250,RC,J3490,HCPCS,61314064305,NDC,facility,outpatient,5,ML,62.50000,37.50000,WellCare of North Carolina,Managed Medicaid,,12.51,,,,,,,12.51,50.81,percent of total billed charges,
TRAZODONE 100 MG TABLET,RX-8083,CDM,250,RC,J3490,HCPCS,60505265401,NDC,facility,outpatient,1,UN,16.50000,9.90000,WellCare of North Carolina,Managed Medicaid,,3.30,,,,,,,3.30,13.41,percent of total billed charges,
TRAZODONE 50 MG TABLET,RX-8085,CDM,250,RC,J3490,HCPCS,60687044301,NDC,facility,outpatient,1,UN,16.55000,9.93000,WellCare of North Carolina,Managed Medicaid,,3.31,,,,,,,3.31,13.46,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM,RX-8113,CDM,250,RC,J3490,HCPCS,00168000415,NDC,facility,outpatient,15,GR,25.00000,15.00000,WellCare of North Carolina,Managed Medicaid,,5.00,,,,,,,5.00,20.32,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM,RX-8114,CDM,250,RC,J3490,HCPCS,45802006535,NDC,facility,outpatient,15,GR,40.60000,24.36000,WellCare of North Carolina,Managed Medicaid,,8.13,,,,,,,8.13,33.01,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT,RX-8118,CDM,250,RC,J3490,HCPCS,00168000615,NDC,facility,outpatient,15,GR,29.95000,17.97000,WellCare of North Carolina,Managed Medicaid,,6.00,,,,,,,6.00,24.35,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,1,ML,58.60000,35.16000,WellCare of North Carolina,Managed Medicaid,,11.73,,,,,,,1.98,43.49,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116801,NDC,facility,outpatient,1,ML,55.45000,33.27000,WellCare of North Carolina,Managed Medicaid,,11.10,,,,,,,1.98,41.15,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION,RX-8120,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,outpatient,1,ML,45.50000,27.30000,WellCare of North Carolina,Managed Medicaid,,9.11,,,,,,,1.98,33.77,percent of total billed charges,
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE,RX-8121,CDM,250,RC,J3490,HCPCS,51672126705,NDC,facility,outpatient,5,GR,209.45000,125.67000,WellCare of North Carolina,Managed Medicaid,,41.93,,,,,,,41.93,170.28,percent of total billed charges,
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET,RX-8132,CDM,250,RC,J3490,HCPCS,00591042401,NDC,facility,outpatient,1,UN,17.10000,10.26000,WellCare of North Carolina,Managed Medicaid,,3.42,,,,,,,3.42,13.90,percent of total billed charges,
"DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-81426,CDM,250,RC,J3490,HCPCS,51079076701,NDC,facility,outpatient,1,UN,25.95000,15.57000,WellCare of North Carolina,Managed Medicaid,,5.20,,,,,,,5.20,21.10,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81453,CDM,250,RC,J3490,HCPCS,00186037228,NDC,facility,outpatient,6.9,GR,431.25000,258.75000,WellCare of North Carolina,Managed Medicaid,,86.34,,,,,,,86.34,350.61,percent of total billed charges,
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER,RX-81454,CDM,250,RC,J3490,HCPCS,00186037028,NDC,facility,outpatient,6,GR,493.60000,296.16000,WellCare of North Carolina,Managed Medicaid,,98.82,,,,,,,98.82,401.30,percent of total billed charges,
TRIHEXYPHENIDYL 2 MG TABLET,RX-8166,CDM,250,RC,J3490,HCPCS,00591533501,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,WellCare of North Carolina,Managed Medicaid,,5497.41,,,,,,,43.48,20380.52,percent of total billed charges,
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-82085,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,10,ML,92.40000,55.44000,WellCare of North Carolina,Managed Medicaid,,18.50,,,,,,,0.51920,68.58,percent of total billed charges,
SODIUM CHLORIDE 7 % FOR NEBULIZATION,RX-82134,CDM,250,RC,J3490,HCPCS,00487900730,NDC,facility,outpatient,4,ML,18.70000,11.22000,WellCare of North Carolina,Managed Medicaid,,3.74,,,,,,,3.74,15.20,percent of total billed charges,
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION,RX-82200,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,10,ML,290.05000,174.03000,WellCare of North Carolina,Managed Medicaid,,58.07,,,,,,,4.69,215.28,percent of total billed charges,
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION,RX-82204,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,outpatient,20,ML,305.10000,183.06000,WellCare of North Carolina,Managed Medicaid,,61.08,,,,,,,4.69,226.45,percent of total billed charges,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,WellCare of North Carolina,Managed Medicaid,,1817.11,,,,,,,25.91,6736.54,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,00009087021,NDC,facility,outpatient,2,ML,27.35000,16.41000,WellCare of North Carolina,Managed Medicaid,,5.48,,,,,,,4.32,20.30,percent of total billed charges,
CLINDAMYCIN 150 MG/ML INJECTION SOLUTION,RX-82301,CDM,636,RC,J0736,HCPCS,25021011551,NDC,facility,outpatient,60,ML,120.60000,72.36000,WellCare of North Carolina,Managed Medicaid,,24.14,,,,,,,4.32,89.51,percent of total billed charges,
TROPICAMIDE 1 % EYE DROPS,RX-8250,CDM,250,RC,J3490,HCPCS,24208058564,NDC,facility,outpatient,15,ML,106.00000,63.60000,WellCare of North Carolina,Managed Medicaid,,21.22,,,,,,,21.22,86.18,percent of total billed charges,
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH,RX-82504,CDM,250,RC,J3490,HCPCS,00078050115,NDC,facility,outpatient,1,UN,107.50000,64.50000,WellCare of North Carolina,Managed Medicaid,,21.52,,,,,,,21.52,87.40,percent of total billed charges,
RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH,RX-82505,CDM,250,RC,J3490,HCPCS,00078050261,NDC,facility,outpatient,1,UN,107.45000,64.47000,WellCare of North Carolina,Managed Medicaid,,21.51,,,,,,,21.51,87.36,percent of total billed charges,
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION,RX-8259,CDM,250,RC,J3490,HCPCS,99999000815,NDC,facility,outpatient,0.1,ML,56.75000,34.05000,WellCare of North Carolina,Managed Medicaid,,11.36,,,,,,,11.36,46.14,percent of total billed charges,
"VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION",RX-8442,CDM,636,RC,J3373,HCPCS,00409653311,NDC,facility,outpatient,1,UN,131.40000,78.84000,WellCare of North Carolina,Managed Medicaid,,26.31,,,,,,,0.07080,97.53,percent of total billed charges,
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION,RX-8443,CDM,636,RC,J3373,HCPCS,00409433211,NDC,facility,outpatient,1,UN,97.30000,58.38000,WellCare of North Carolina,Managed Medicaid,,19.48,,,,,,,0.07080,72.22,percent of total billed charges,
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION,RX-8444,CDM,636,RC,J3373,HCPCS,00409650901,NDC,facility,outpatient,1,UN,442.10000,265.26000,WellCare of North Carolina,Managed Medicaid,,88.51,,,,,,,0.07080,328.13,percent of total billed charges,
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT,RX-850,CDM,250,RC,J3490,HCPCS,00713028031,NDC,facility,outpatient,28.4,GR,4.45000,2.67000,WellCare of North Carolina,Managed Medicaid,,0.89089,,,,,,,0.89089,3.62,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,51754020302,NDC,facility,outpatient,2,ML,61.50000,36.90000,WellCare of North Carolina,Managed Medicaid,,12.31,,,,,,,12.31,50.00,percent of total billed charges,
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION,RX-8527,CDM,250,RC,J3490,HCPCS,43066003501,NDC,facility,outpatient,4,ML,45.20000,27.12000,WellCare of North Carolina,Managed Medicaid,,9.05,,,,,,,9.05,36.75,percent of total billed charges,
VERAPAMIL 120 MG TABLET,RX-8528,CDM,250,RC,J3490,HCPCS,23155002701,NDC,facility,outpatient,1,UN,16.40000,9.84000,WellCare of North Carolina,Managed Medicaid,,3.28,,,,,,,3.28,13.33,percent of total billed charges,
VERAPAMIL 80 MG TABLET,RX-8530,CDM,250,RC,J3490,HCPCS,23155002601,NDC,facility,outpatient,1,UN,17.25000,10.35000,WellCare of North Carolina,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,250,RC,J3490,HCPCS,00713026831,NDC,facility,outpatient,28,GR,5.25000,3.15000,WellCare of North Carolina,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8594,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,10,ML,511.55000,306.93000,WellCare of North Carolina,Managed Medicaid,,102.41,,,,,,,12.51,379.67,percent of total billed charges,
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION,RX-8597,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,1,ML,353.10000,211.86000,WellCare of North Carolina,Managed Medicaid,,70.69,,,,,,,19.40,262.07,percent of total billed charges,
BACLOFEN 10 MG TABLET,RX-860,CDM,250,RC,J3490,HCPCS,63739047910,NDC,facility,outpatient,1,UN,17.90000,10.74000,WellCare of North Carolina,Managed Medicaid,,3.58,,,,,,,3.58,14.55,percent of total billed charges,
"VITAMIN A CAPSULE 3,000 MCG RAE (10000 UNITS)",RX-8639,CDM,250,RC,J3490,HCPCS,00904208560,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
WARFARIN 2 MG TABLET,RX-8749,CDM,250,RC,J3490,HCPCS,00832121289,NDC,facility,outpatient,1,UN,17.55000,10.53000,WellCare of North Carolina,Managed Medicaid,,3.51,,,,,,,3.51,14.27,percent of total billed charges,
WARFARIN 2.5 MG TABLET,RX-8750,CDM,250,RC,J3490,HCPCS,00832121389,NDC,facility,outpatient,1,UN,17.60000,10.56000,WellCare of North Carolina,Managed Medicaid,,3.52,,,,,,,3.52,14.31,percent of total billed charges,
WARFARIN 5 MG TABLET,RX-8751,CDM,250,RC,J3490,HCPCS,00832121689,NDC,facility,outpatient,1,UN,17.65000,10.59000,WellCare of North Carolina,Managed Medicaid,,3.53,,,,,,,3.53,14.35,percent of total billed charges,
WARFARIN 7.5 MG TABLET,RX-8752,CDM,250,RC,J3490,HCPCS,00832121801,NDC,facility,outpatient,1,UN,18.35000,11.01000,WellCare of North Carolina,Managed Medicaid,,3.67,,,,,,,3.67,14.92,percent of total billed charges,
"MORPHINE ER 10 MG CAPSULE,EXTENDED RELEASE PELLETS",RX-87824,CDM,250,RC,J3490,HCPCS,00832022500,NDC,facility,outpatient,1,UN,33.40000,20.04000,WellCare of North Carolina,Managed Medicaid,,6.69,,,,,,,6.69,27.15,percent of total billed charges,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,WellCare of North Carolina,Managed Medicaid,,8103.63,,,,,,,28.94,30042.51,percent of total billed charges,
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION,RX-88010,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,10,ML,567.95000,340.77000,WellCare of North Carolina,Managed Medicaid,,113.70,,,,,,,6.18,421.53,percent of total billed charges,
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION,RX-88011,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,2,ML,40.90000,24.54000,WellCare of North Carolina,Managed Medicaid,,8.19,,,,,,,6.18,30.36,percent of total billed charges,
BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION,RX-88223,CDM,250,RC,J3490,HCPCS,00186199004,NDC,facility,outpatient,2,ML,98.10000,58.86000,WellCare of North Carolina,Managed Medicaid,,19.64,,,,,,,19.64,79.76,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574811,NDC,facility,outpatient,100,ML,452.35000,271.41000,WellCare of North Carolina,Managed Medicaid,,90.56,,,,,,,5.31,335.73,percent of total billed charges,
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION,RX-88376,CDM,636,RC,J9060,HCPCS,00703574711,NDC,facility,outpatient,50,ML,407.00000,244.20000,WellCare of North Carolina,Managed Medicaid,,81.48,,,,,,,5.31,302.08,percent of total billed charges,
RALTEGRAVIR 400 MG TABLET,RX-88608,CDM,250,RC,J3490,HCPCS,00006022761,NDC,facility,outpatient,1,UN,154.90000,92.94000,WellCare of North Carolina,Managed Medicaid,,31.01,,,,,,,31.01,125.93,percent of total billed charges,
ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-8865,CDM,250,RC,J3490,HCPCS,00409409001,NDC,facility,outpatient,4,ML,59.15000,35.49000,WellCare of North Carolina,Managed Medicaid,,11.84,,,,,,,11.84,48.09,percent of total billed charges,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,WellCare of North Carolina,Managed Medicaid,,5378.81,,,,,,,135.03,19940.84,percent of total billed charges,
OSELTAMIVIR 30 MG CAPSULE,RX-88704,CDM,250,RC,J3490,HCPCS,00004080285,NDC,facility,outpatient,1,UN,71.75000,43.05000,WellCare of North Carolina,Managed Medicaid,,14.36,,,,,,,14.36,58.33,percent of total billed charges,
NILOTINIB HCL 200 MG CAPSULE,RX-88720,CDM,250,RC,J3490,HCPCS,00078052651,NDC,facility,outpatient,1,UN,798.05000,478.83000,WellCare of North Carolina,Managed Medicaid,,159.77,,,,,,,159.77,648.81,percent of total billed charges,
ZINC OXIDE 20 % TOPICAL OINTMENT,RX-8874,CDM,250,RC,J3490,HCPCS,75834017001,NDC,facility,outpatient,28.4,GR,9.15000,5.49000,WellCare of North Carolina,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE,RX-8880,CDM,250,RC,J3490,HCPCS,77333098325,NDC,facility,outpatient,1,UN,1.40000,0.84000,WellCare of North Carolina,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
CLOPIDOGREL 300 MG TABLET,RX-89346,CDM,250,RC,J3490,HCPCS,55111067106,NDC,facility,outpatient,1,UN,99.10000,59.46000,WellCare of North Carolina,Managed Medicaid,,19.84,,,,,,,19.84,80.57,percent of total billed charges,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,WellCare of North Carolina,Managed Medicaid,,767.34,,,,,,,4.23,2844.74,percent of total billed charges,
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM,RX-89412,CDM,250,RC,J3490,HCPCS,16864090801,NDC,facility,outpatient,113,GR,3.25000,1.95000,WellCare of North Carolina,Managed Medicaid,,0.65065,,,,,,,0.65065,2.64,percent of total billed charges,
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY,RX-8946,CDM,250,RC,J3490,HCPCS,51672211400,NDC,facility,outpatient,1,UN,2.45000,1.47000,WellCare of North Carolina,Managed Medicaid,,0.49049,,,,,,,0.49049,1.99,percent of total billed charges,
ACETIC ACID 0.25 % IRRIGATION SOLUTION,RX-8963,CDM,250,RC,J3490,HCPCS,00338065604,NDC,facility,outpatient,1000,ML,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION,RX-8970,CDM,250,RC,J3490,HCPCS,00472008216,NDC,facility,outpatient,473,ML,1084.55000,650.73000,WellCare of North Carolina,Managed Medicaid,,217.13,,,,,,,217.13,881.74,percent of total billed charges,
LISDEXAMFETAMINE 20 MG CAPSULE,RX-89783,CDM,250,RC,J3490,HCPCS,60505474001,NDC,facility,outpatient,1,UN,40.65000,24.39000,WellCare of North Carolina,Managed Medicaid,,8.14,,,,,,,8.14,33.05,percent of total billed charges,
ALBENDAZOLE 200 MG TABLET,RX-8979,CDM,250,RC,J3490,HCPCS,31722093502,NDC,facility,outpatient,1,UN,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,27.23,110.57,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049302,NDC,facility,outpatient,100,ML,539.80000,323.88000,WellCare of North Carolina,Managed Medicaid,,108.07,,,,,,,108.07,400.64,percent of total billed charges,
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,50,ML,308.40000,185.04000,WellCare of North Carolina,Managed Medicaid,,61.74,,,,,,,61.74,228.89,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,WellCare of North Carolina,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,WellCare of North Carolina,Managed Medicaid,,87.49,,,,,,,51.49,324.34,percent of total billed charges,
STUDY RESEARCH STUDY DRUG FROM OUTSIDE FACILITY,RX-900004,CDM,256,RC,J3490,HCPCS,99999000101,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.14986,percent of total billed charges,
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION,RX-9001,CDM,636,RC,J0270,HCPCS,00009316906,NDC,facility,outpatient,1,ML,786.55000,471.93000,WellCare of North Carolina,Managed Medicaid,,157.47,,,,,,,1.30,583.78,percent of total billed charges,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,WellCare of North Carolina,Managed Medicaid,,8019.54,,,,,,,91.62,29730.79,percent of total billed charges,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,WellCare of North Carolina,Managed Medicaid,,4011.38,,,,,,,91.62,14871.35,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00121176230,NDC,facility,outpatient,15,ML,3.95000,2.37000,WellCare of North Carolina,Managed Medicaid,,0.79079,,,,,,,0.79079,3.21,percent of total billed charges,
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP,RX-9014,CDM,250,RC,J3490,HCPCS,00904572514,NDC,facility,outpatient,15,ML,1.25000,0.75000,WellCare of North Carolina,Managed Medicaid,,0.25025,,,,,,,0.25025,1.02,percent of total billed charges,
"CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET",RX-9020,CDM,250,RC,J3490,HCPCS,16864024014,NDC,facility,outpatient,1,UN,2.00000,1.20000,WellCare of North Carolina,Managed Medicaid,,0.40040,,,,,,,0.40040,1.63,percent of total billed charges,
AMINOCAPROIC ACID 500 MG TABLET,RX-9063,CDM,250,RC,J3490,HCPCS,49411005030,NDC,facility,outpatient,1,UN,101.95000,61.17000,WellCare of North Carolina,Managed Medicaid,,20.41,,,,,,,20.41,82.89,percent of total billed charges,
AMIODARONE 200 MG TABLET,RX-9066,CDM,250,RC,J3490,HCPCS,00245014789,NDC,facility,outpatient,1,UN,17.50000,10.50000,WellCare of North Carolina,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
AMLODIPINE 10 MG TABLET,RX-9069,CDM,250,RC,J3490,HCPCS,00904637161,NDC,facility,outpatient,1,UN,16.45000,9.87000,WellCare of North Carolina,Managed Medicaid,,3.29,,,,,,,3.29,13.37,percent of total billed charges,
AMLODIPINE 2.5 MG TABLET,RX-9070,CDM,250,RC,J3490,HCPCS,00904636961,NDC,facility,outpatient,1,UN,16.60000,9.96000,WellCare of North Carolina,Managed Medicaid,,3.32,,,,,,,3.32,13.50,percent of total billed charges,
AMLODIPINE 5 MG TABLET,RX-9071,CDM,250,RC,J3490,HCPCS,51079045120,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION,RX-9083,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1,UN,51.10000,30.66000,WellCare of North Carolina,Managed Medicaid,,10.23,,,,,,,3.28,37.93,percent of total billed charges,
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION,RX-9084,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,1,UN,34.00000,20.40000,WellCare of North Carolina,Managed Medicaid,,6.81,,,,,,,3.28,25.23,percent of total billed charges,
SODIUM CITRATE 4 GRAM/100 ML (4 %) SOLUTION,RX-90999,CDM,250,RC,J3490,HCPCS,00942950625,NDC,facility,outpatient,250,ML,98.00000,58.80000,WellCare of North Carolina,Managed Medicaid,,19.62,,,,,,,19.62,79.67,percent of total billed charges,
"CEFOXITIN 1 GRAM/50 ML IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS PIGGYBACK",RX-91039,CDM,636,RC,J0694,HCPCS,00264312311,NDC,facility,outpatient,1,UN,129.05000,77.43000,WellCare of North Carolina,Managed Medicaid,,25.84,,,,,,,11.28,95.78,percent of total billed charges,
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION,RX-91054,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,5,ML,371.70000,223.02000,WellCare of North Carolina,Managed Medicaid,,74.41,,,,,,,3.81,275.88,percent of total billed charges,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,WellCare of North Carolina,Managed Medicaid,,18.99,,,,,,,3.98,70.40,percent of total billed charges,
ARGININE HCL (L-ARGININE) 10 % INTRAVENOUS SOLUTION,RX-9123,CDM,250,RC,J3490,HCPCS,00009043601,NDC,facility,outpatient,300,ML,210.00000,126.00000,WellCare of North Carolina,Managed Medicaid,,42.04,,,,,,,42.04,170.73,percent of total billed charges,
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION,RX-91278,CDM,636,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.5,ML,26.25000,15.75000,WellCare of North Carolina,Managed Medicaid,,5.26,,,,,,,1.44,19.48,percent of total billed charges,
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION,RX-91279,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.75,ML,49.95000,29.97000,WellCare of North Carolina,Managed Medicaid,,10.00,,,,,,,1.44,37.07,percent of total billed charges,
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION,RX-91281,CDM,636,RC,J2354,HCPCS,00641617601,NDC,facility,outpatient,1,ML,175.25000,105.15000,WellCare of North Carolina,Managed Medicaid,,35.09,,,,,,,1.44,130.07,percent of total billed charges,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,WellCare of North Carolina,Managed Medicaid,,6.19,,,,,,,0.29100,22.93,percent of total billed charges,
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE,RX-91408,CDM,636,RC,J2785,HCPCS,00409140105,NDC,facility,outpatient,5,ML,813.05000,487.83000,WellCare of North Carolina,Managed Medicaid,,162.77,,,,,,,7.13,603.45,percent of total billed charges,
"ASPIRIN 81 MG TABLET,DELAYED RELEASE",RX-9151,CDM,250,RC,J3490,HCPCS,00536123441,NDC,facility,outpatient,1,UN,1.05000,0.63000,WellCare of North Carolina,Managed Medicaid,,0.21021,,,,,,,0.21021,0.85365,percent of total billed charges,
LUBIPROSTONE 8 MCG CAPSULE,RX-91534,CDM,250,RC,J3490,HCPCS,00254302802,NDC,facility,outpatient,1,UN,20.00000,12.00000,WellCare of North Carolina,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION,RX-91651,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,0.4,ML,531.50000,318.90000,WellCare of North Carolina,Managed Medicaid,,106.41,,,,,,,3.42,394.48,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,00409110502,NDC,facility,outpatient,10,ML,80.05000,48.03000,WellCare of North Carolina,Managed Medicaid,,16.03,,,,,,,16.03,65.08,percent of total billed charges,
ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-9168,CDM,250,RC,J3490,HCPCS,71288070105,NDC,facility,outpatient,5,ML,37.55000,22.53000,WellCare of North Carolina,Managed Medicaid,,7.52,,,,,,,7.52,30.53,percent of total billed charges,
AZATHIOPRINE 50 MG TABLET,RX-9183,CDM,636,RC,J7500,HCPCS,68084022911,NDC,facility,outpatient,1,UN,18.75000,11.25000,WellCare of North Carolina,Managed Medicaid,,3.75,,,,,,,0.14160,13.92,percent of total billed charges,
AZTREONAM 1 GRAM SOLUTION FOR INJECTION,RX-9185,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,UN,151.25000,90.75000,WellCare of North Carolina,Managed Medicaid,,30.28,,,,,,,5.97,112.26,percent of total billed charges,
AZTREONAM 2 GRAM SOLUTION FOR INJECTION,RX-9186,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,1,UN,276.30000,165.78000,WellCare of North Carolina,Managed Medicaid,,55.32,,,,,,,5.97,205.07,percent of total billed charges,
BENZYLPENICILLOYL POLYLYSINE 0.25 ML INTRADERMAL INJECTION SOLUTION,RX-9260,CDM,250,RC,J3490,HCPCS,49471000105,NDC,facility,outpatient,0.01,ML,48.35000,29.01000,WellCare of North Carolina,Managed Medicaid,,9.68,,,,,,,9.68,39.31,percent of total billed charges,
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION,RX-9266,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,5,ML,266.40000,159.84000,WellCare of North Carolina,Managed Medicaid,,53.33,,,,,,,16.43,197.72,percent of total billed charges,
BISACODYL 10 MG/30 ML ENEMA,RX-9281,CDM,250,RC,J3490,HCPCS,00132070336,NDC,facility,outpatient,30,ML,4.05000,2.43000,WellCare of North Carolina,Managed Medicaid,,0.81081,,,,,,,0.81081,3.29,percent of total billed charges,
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET,RX-9285,CDM,250,RC,J3490,HCPCS,46122070165,NDC,facility,outpatient,1,UN,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
DARUNAVIR 600 MG TABLET,RX-92851,CDM,250,RC,J3490,HCPCS,59676056201,NDC,facility,outpatient,1,UN,159.90000,95.94000,WellCare of North Carolina,Managed Medicaid,,32.01,,,,,,,32.01,130.00,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Managed Medicaid,,17.67,,,,,,,2.58,65.50,percent of total billed charges,
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION,RX-9289,CDM,636,RC,J9040,HCPCS,00143924001,NDC,facility,outpatient,1,UN,526.70000,316.02000,WellCare of North Carolina,Managed Medicaid,,105.45,,,,,,,50.79,390.92,percent of total billed charges,
BROMOCRIPTINE 2.5 MG TABLET,RX-9297,CDM,250,RC,J3490,HCPCS,00574010603,NDC,facility,outpatient,1,UN,29.25000,17.55000,WellCare of North Carolina,Managed Medicaid,,5.86,,,,,,,5.86,23.78,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,WellCare of North Carolina,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,WellCare of North Carolina,Managed Medicaid,,16.95,,,,,,,1.62,62.83,percent of total billed charges,
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION,RX-93073,CDM,250,RC,J3490,HCPCS,46122021026,NDC,facility,outpatient,118,ML,5.25000,3.15000,WellCare of North Carolina,Managed Medicaid,,1.05,,,,,,,1.05,4.27,percent of total billed charges,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,WellCare of North Carolina,Managed Medicaid,,5.96,,,,,,,0.35890,22.08,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015318,NDC,facility,outpatient,3,ML,75.05000,45.03000,WellCare of North Carolina,Managed Medicaid,,15.03,,,,,,,1.01,55.70,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,67457015399,NDC,facility,outpatient,3,ML,75.45000,45.27000,WellCare of North Carolina,Managed Medicaid,,15.11,,,,,,,1.01,56.00,percent of total billed charges,
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION,RX-93084,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,3,ML,71.45000,42.87000,WellCare of North Carolina,Managed Medicaid,,14.30,,,,,,,1.01,53.03,percent of total billed charges,
BUMETANIDE 1 MG TABLET,RX-9310,CDM,250,RC,J3490,HCPCS,00185012901,NDC,facility,outpatient,1,UN,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION,RX-9316,CDM,636,RC,J0665,HCPCS,00409361301,NDC,facility,outpatient,2,ML,29.00000,17.40000,WellCare of North Carolina,Managed Medicaid,,5.81,,,,,,,0.02360,21.52,percent of total billed charges,
BUPROPION HCL 100 MG TABLET,RX-9321,CDM,250,RC,J3490,HCPCS,23155019201,NDC,facility,outpatient,1,UN,17.50000,10.50000,WellCare of North Carolina,Managed Medicaid,,3.50,,,,,,,3.50,14.23,percent of total billed charges,
BUPROPION HCL 75 MG TABLET,RX-9322,CDM,250,RC,J3490,HCPCS,51079094301,NDC,facility,outpatient,1,UN,20.95000,12.57000,WellCare of North Carolina,Managed Medicaid,,4.19,,,,,,,4.19,17.03,percent of total billed charges,
BUSPIRONE 10 MG TABLET,RX-9323,CDM,250,RC,J3490,HCPCS,00093005401,NDC,facility,outpatient,1,UN,16.30000,9.78000,WellCare of North Carolina,Managed Medicaid,,3.26,,,,,,,3.26,13.25,percent of total billed charges,
BUSPIRONE 5 MG TABLET,RX-9324,CDM,250,RC,J3490,HCPCS,16729020001,NDC,facility,outpatient,1,UN,16.15000,9.69000,WellCare of North Carolina,Managed Medicaid,,3.23,,,,,,,3.23,13.13,percent of total billed charges,
BUTORPHANOL 1 MG/ML INJECTION SOLUTION,RX-9333,CDM,636,RC,J0595,HCPCS,00409162301,NDC,facility,outpatient,0.5,ML,39.05000,23.43000,WellCare of North Carolina,Managed Medicaid,,7.82,,,,,,,7.82,28.98,percent of total billed charges,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,WellCare of North Carolina,Managed Medicaid,,731.93,,,,,,,470.42,2713.48,percent of total billed charges,
CALCITRIOL 0.25 MCG CAPSULE,RX-9350,CDM,250,RC,J3490,HCPCS,00054000725,NDC,facility,outpatient,1,UN,19.80000,11.88000,WellCare of North Carolina,Managed Medicaid,,3.96,,,,,,,3.96,16.10,percent of total billed charges,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,WellCare of North Carolina,Managed Medicaid,,2510.96,,,,,,,10.68,9308.86,percent of total billed charges,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,WellCare of North Carolina,Managed Medicaid,,5018.69,,,,,,,10.68,18605.77,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,WellCare of North Carolina,Managed Medicaid,,414.16,,,,,,,23.16,1535.43,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,WellCare of North Carolina,Managed Medicaid,,551.21,,,,,,,23.16,2043.50,percent of total billed charges,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,WellCare of North Carolina,Managed Medicaid,,616.62,,,,,,,23.16,2285.98,percent of total billed charges,
CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET,RX-9385,CDM,250,RC,J3490,HCPCS,66553000401,NDC,facility,outpatient,1,UN,1.10000,0.66000,WellCare of North Carolina,Managed Medicaid,,0.22022,,,,,,,0.22022,0.89430,percent of total billed charges,
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN,RX-93931,CDM,250,RC,J3490,HCPCS,00487020101,NDC,facility,outpatient,3,ML,18.05000,10.83000,WellCare of North Carolina,Managed Medicaid,,3.61,,,,,,,3.61,14.67,percent of total billed charges,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,WellCare of North Carolina,Managed Medicaid,,86.74,,,,,,,2.76,352.23,percent of total billed charges,
CAPTOPRIL 12.5 MG TABLET,RX-9401,CDM,250,RC,J3490,HCPCS,60687030411,NDC,facility,outpatient,1,UN,21.70000,13.02000,WellCare of North Carolina,Managed Medicaid,,4.34,,,,,,,4.34,17.64,percent of total billed charges,
CAPTOPRIL 25 MG TABLET,RX-9402,CDM,250,RC,J3490,HCPCS,60687031511,NDC,facility,outpatient,1,UN,22.20000,13.32000,WellCare of North Carolina,Managed Medicaid,,4.44,,,,,,,4.44,18.05,percent of total billed charges,
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET,RX-9406,CDM,636,RC,J3490,HCPCS,62756051788,NDC,facility,outpatient,1,UN,17.05000,10.23000,WellCare of North Carolina,Managed Medicaid,,3.41,,,,,,,3.41,12.65,percent of total billed charges,
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET,RX-9407,CDM,636,RC,J3490,HCPCS,60687066101,NDC,facility,outpatient,1,UN,17.50000,10.50000,WellCare of North Carolina,Managed Medicaid,,3.50,,,,,,,3.50,12.99,percent of total billed charges,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,WellCare of North Carolina,Managed Medicaid,,130.73,,,,,,,49.52,530.89,percent of total billed charges,
"SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET",RX-94158,CDM,250,RC,J3490,HCPCS,00223176001,NDC,facility,outpatient,1,UN,1.15000,0.69000,WellCare of North Carolina,Managed Medicaid,,0.23023,,,,,,,0.23023,0.93495,percent of total billed charges,
LIDOCAINE (PF) 3.5 % EYE GEL,RX-94220,CDM,250,RC,J3490,HCPCS,82584079201,NDC,facility,outpatient,1,ML,86.10000,51.66000,WellCare of North Carolina,Managed Medicaid,,17.24,,,,,,,17.24,70.00,percent of total billed charges,
CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION,RX-9452,CDM,636,RC,J0698,HCPCS,21586001102,NDC,facility,outpatient,1,UN,60.60000,36.36000,WellCare of North Carolina,Managed Medicaid,,12.13,,,,,,,12.13,44.98,percent of total billed charges,
NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN,RX-94576,CDM,636,RC,J2404,HCPCS,00143963301,NDC,facility,outpatient,200,ML,745.95000,447.57000,WellCare of North Carolina,Managed Medicaid,,149.34,,,,,,,0.16520,553.64,percent of total billed charges,
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION,RX-9463,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,1,UN,105.00000,63.00000,WellCare of North Carolina,Managed Medicaid,,21.02,,,,,,,11.28,77.93,percent of total billed charges,
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION,RX-9474,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,UN,39.70000,23.82000,WellCare of North Carolina,Managed Medicaid,,7.95,,,,,,,3.71,29.47,percent of total billed charges,
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION,RX-9476,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,outpatient,1,UN,61.50000,36.90000,WellCare of North Carolina,Managed Medicaid,,12.31,,,,,,,3.71,45.65,percent of total billed charges,
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION,RX-9488,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,1,UN,29.20000,17.52000,WellCare of North Carolina,Managed Medicaid,,5.85,,,,,,,1.01,21.67,percent of total billed charges,
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION,RX-9490,CDM,636,RC,J0696,HCPCS,00143985801,NDC,facility,outpatient,1,UN,21.70000,13.02000,WellCare of North Carolina,Managed Medicaid,,4.34,,,,,,,1.01,16.11,percent of total billed charges,
CEPHALEXIN 250 MG CAPSULE,RX-9499,CDM,250,RC,J3490,HCPCS,68180012101,NDC,facility,outpatient,1,UN,16.70000,10.02000,WellCare of North Carolina,Managed Medicaid,,3.34,,,,,,,3.34,13.58,percent of total billed charges,
CEPHALEXIN 500 MG CAPSULE,RX-9500,CDM,250,RC,J3490,HCPCS,00093314701,NDC,facility,outpatient,1,UN,16.90000,10.14000,WellCare of North Carolina,Managed Medicaid,,3.38,,,,,,,3.38,13.74,percent of total billed charges,
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION,RX-9502,CDM,250,RC,J3490,HCPCS,00093417773,NDC,facility,outpatient,100,ML,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,,17.02,,,,,,,17.02,69.11,percent of total billed charges,
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH,RX-9516,CDM,250,RC,J3490,HCPCS,69339013817,NDC,facility,outpatient,5,ML,18.55000,11.13000,WellCare of North Carolina,Managed Medicaid,,3.71,,,,,,,3.71,15.08,percent of total billed charges,
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION,RX-9525,CDM,250,RC,J3490,HCPCS,65649031112,NDC,facility,outpatient,237,ML,222.95000,133.77000,WellCare of North Carolina,Managed Medicaid,,44.63,,,,,,,44.63,181.26,percent of total billed charges,
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION,RX-9526,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,1,UN,315.00000,189.00000,WellCare of North Carolina,Managed Medicaid,,63.06,,,,,,,63.06,233.79,percent of total billed charges,
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS,RX-95693,CDM,250,RC,J3490,HCPCS,00087074002,NDC,facility,outpatient,50,ML,14.80000,8.88000,WellCare of North Carolina,Managed Medicaid,,2.96,,,,,,,2.96,12.03,percent of total billed charges,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,WellCare of North Carolina,Managed Medicaid,,332.95,,,,,,,6.30,1234.35,percent of total billed charges,
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION,RX-95811,CDM,250,RC,J3490,HCPCS,00409318910,NDC,facility,outpatient,5,ML,78.65000,47.19000,WellCare of North Carolina,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET,RX-9588,CDM,250,RC,J3490,HCPCS,68382052860,NDC,facility,outpatient,1,UN,24.20000,14.52000,WellCare of North Carolina,Managed Medicaid,,4.84,,,,,,,4.84,19.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065610,NDC,facility,outpatient,10,ML,82.00000,49.20000,WellCare of North Carolina,Managed Medicaid,,16.42,,,,,,,16.42,66.67,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065625,NDC,facility,outpatient,2.5,ML,47.50000,28.50000,WellCare of North Carolina,Managed Medicaid,,9.51,,,,,,,9.51,38.62,percent of total billed charges,
CIPROFLOXACIN 0.3 % EYE DROPS,RX-9610,CDM,250,RC,J3490,HCPCS,61314065605,NDC,facility,outpatient,5,ML,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,WellCare of North Carolina,Managed Medicaid,,438.24,,,,,,,10.36,1624.68,percent of total billed charges,
CLARITHROMYCIN 500 MG TABLET,RX-9617,CDM,250,RC,J3490,HCPCS,68084065195,NDC,facility,outpatient,1,UN,35.95000,21.57000,WellCare of North Carolina,Managed Medicaid,,7.20,,,,,,,7.20,29.23,percent of total billed charges,
CLINDAMYCIN 1 % TOPICAL GEL,RX-9623,CDM,250,RC,J3490,HCPCS,00168020230,NDC,facility,outpatient,30,GR,264.80000,158.88000,WellCare of North Carolina,Managed Medicaid,,53.01,,,,,,,53.01,215.28,percent of total billed charges,
CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9626,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,50,ML,104.50000,62.70000,WellCare of North Carolina,Managed Medicaid,,20.92,,,,,,,4.32,77.56,percent of total billed charges,
CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK,RX-9627,CDM,636,RC,J0736,HCPCS,00781329009,NDC,facility,outpatient,50,ML,113.75000,68.25000,WellCare of North Carolina,Managed Medicaid,,22.77,,,,,,,4.32,84.43,percent of total billed charges,
CLOBETASOL 0.05 % TOPICAL CREAM,RX-9630,CDM,250,RC,J3490,HCPCS,51672125801,NDC,facility,outpatient,15,GR,46.05000,27.63000,WellCare of North Carolina,Managed Medicaid,,9.22,,,,,,,9.22,37.44,percent of total billed charges,
CLONAZEPAM 0.5 MG TABLET,RX-9637,CDM,250,RC,J3490,HCPCS,00093083201,NDC,facility,outpatient,1,UN,22.10000,13.26000,WellCare of North Carolina,Managed Medicaid,,4.42,,,,,,,4.42,17.97,percent of total billed charges,
CLONAZEPAM 1 MG TABLET,RX-9638,CDM,250,RC,J3490,HCPCS,51079088220,NDC,facility,outpatient,1,UN,22.35000,13.41000,WellCare of North Carolina,Managed Medicaid,,4.47,,,,,,,4.47,18.17,percent of total billed charges,
CLOTRIMAZOLE 10 MG TROCHE,RX-9644,CDM,250,RC,J3490,HCPCS,00054814622,NDC,facility,outpatient,1,UN,27.00000,16.20000,WellCare of North Carolina,Managed Medicaid,,5.41,,,,,,,5.41,21.95,percent of total billed charges,
CLOZAPINE 100 MG TABLET,RX-9647,CDM,250,RC,J3490,HCPCS,60687041501,NDC,facility,outpatient,1,UN,22.70000,13.62000,WellCare of North Carolina,Managed Medicaid,,4.54,,,,,,,4.54,18.46,percent of total billed charges,
CLOZAPINE 25 MG TABLET,RX-9648,CDM,250,RC,J3490,HCPCS,51079092101,NDC,facility,outpatient,1,UN,18.60000,11.16000,WellCare of North Carolina,Managed Medicaid,,3.72,,,,,,,3.72,15.12,percent of total billed charges,
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION,RX-9686,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,1,UN,417.20000,250.32000,WellCare of North Carolina,Managed Medicaid,,83.52,,,,,,,59.87,309.65,percent of total billed charges,
CROTAMITON 10 % TOPICAL CREAM,RX-9692,CDM,250,RC,J3490,HCPCS,10631009160,NDC,facility,outpatient,60,GR,1533.80000,920.28000,WellCare of North Carolina,Managed Medicaid,,307.07,,,,,,,307.07,1246.98,percent of total billed charges,
ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET,RX-96948,CDM,250,RC,J3490,HCPCS,00078056845,NDC,facility,outpatient,1,UN,38.50000,23.10000,WellCare of North Carolina,Managed Medicaid,,7.71,,,,,,,7.71,31.30,percent of total billed charges,
LACOSAMIDE 50 MG TABLET,RX-96968,CDM,250,RC,J3490,HCPCS,00131247760,NDC,facility,outpatient,1,UN,61.85000,37.11000,WellCare of North Carolina,Managed Medicaid,,12.38,,,,,,,12.38,50.28,percent of total billed charges,
LACOSAMIDE 100 MG TABLET,RX-96969,CDM,250,RC,J3490,HCPCS,00131247835,NDC,facility,outpatient,1,UN,78.65000,47.19000,WellCare of North Carolina,Managed Medicaid,,15.75,,,,,,,15.75,63.94,percent of total billed charges,
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION,RX-96972,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,5,ML,96.35000,57.81000,WellCare of North Carolina,Managed Medicaid,,19.29,,,,,,,0.47200,71.51,percent of total billed charges,
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION,RX-96982,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,outpatient,5,ML,302.95000,181.77000,WellCare of North Carolina,Managed Medicaid,,60.65,,,,,,,1.96,224.85,percent of total billed charges,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,WellCare of North Carolina,Managed Medicaid,,726.37,,,,,,,4.32,2692.85,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035902,NDC,facility,outpatient,2,ML,127.10000,76.26000,WellCare of North Carolina,Managed Medicaid,,25.45,,,,,,,25.45,103.33,percent of total billed charges,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,RX-9701,CDM,250,RC,J3490,HCPCS,00065035905,NDC,facility,outpatient,5,ML,211.15000,126.69000,WellCare of North Carolina,Managed Medicaid,,42.27,,,,,,,42.27,171.66,percent of total billed charges,
CYCLOSPORINE 100 MG CAPSULE,RX-9706,CDM,636,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,1,UN,89.05000,53.43000,WellCare of North Carolina,Managed Medicaid,,17.83,,,,,,,4.81,66.09,percent of total billed charges,
CYCLOSPORINE 25 MG CAPSULE,RX-9707,CDM,636,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,1,UN,34.30000,20.58000,WellCare of North Carolina,Managed Medicaid,,6.87,,,,,,,1.89,25.46,percent of total billed charges,
FEBUXOSTAT 40 MG TABLET,RX-97133,CDM,250,RC,J3490,HCPCS,64764091830,NDC,facility,outpatient,1,UN,60.05000,36.03000,WellCare of North Carolina,Managed Medicaid,,12.02,,,,,,,12.02,48.82,percent of total billed charges,
DANAZOL 100 MG CAPSULE,RX-9714,CDM,250,RC,J3490,HCPCS,00527136801,NDC,facility,outpatient,1,UN,31.25000,18.75000,WellCare of North Carolina,Managed Medicaid,,6.26,,,,,,,6.26,25.41,percent of total billed charges,
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION,RX-9722,CDM,636,RC,J0895,HCPCS,00409233725,NDC,facility,outpatient,1,UN,201.30000,120.78000,WellCare of North Carolina,Managed Medicaid,,40.30,,,,,,,21.26,149.40,percent of total billed charges,
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION,RX-9723,CDM,636,RC,J0895,HCPCS,00078046761,NDC,facility,outpatient,1,UN,174.05000,104.43000,WellCare of North Carolina,Managed Medicaid,,34.84,,,,,,,21.26,129.18,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641601501,NDC,facility,outpatient,1,ML,64.55000,38.73000,WellCare of North Carolina,Managed Medicaid,,12.92,,,,,,,0.07080,47.91,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921701,NDC,facility,outpatient,1,ML,64.85000,38.91000,WellCare of North Carolina,Managed Medicaid,,12.98,,,,,,,0.07080,48.13,percent of total billed charges,
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION,RX-97252,CDM,636,RC,J1163,HCPCS,00641921801,NDC,facility,outpatient,1,ML,64.70000,38.82000,WellCare of North Carolina,Managed Medicaid,,12.95,,,,,,,0.07080,48.02,percent of total billed charges,
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION,RX-97343,CDM,636,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,0.5,ML,238.95000,143.37000,WellCare of North Carolina,Managed Medicaid,,47.84,,,,,,,47.84,445.83,percent of total billed charges,
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION,RX-97371,CDM,636,RC,J3373,HCPCS,00409653101,NDC,facility,outpatient,1,UN,91.10000,54.66000,WellCare of North Carolina,Managed Medicaid,,18.24,,,,,,,0.07080,67.61,percent of total billed charges,
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,250,RC,J3490,HCPCS,50268086611,NDC,facility,outpatient,1,UN,1.45000,0.87000,WellCare of North Carolina,Managed Medicaid,,0.29029,,,,,,,0.29029,1.18,percent of total billed charges,
DESFLURANE 100 % INHALATION LIQUID,RX-9747,CDM,250,RC,J3490,HCPCS,10019064164,NDC,facility,outpatient,240,ML,661.30000,396.78000,WellCare of North Carolina,Managed Medicaid,,132.39,,,,,,,132.39,537.64,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,WellCare of North Carolina,Managed Medicaid,,77.12,,,,,,,3.41,285.90,percent of total billed charges,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,WellCare of North Carolina,Managed Medicaid,,363.01,,,,,,,3.41,1345.79,percent of total billed charges,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,WellCare of North Carolina,Managed Medicaid,,16.61,,,,,,,1.65,61.57,percent of total billed charges,
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP,RX-9774,CDM,250,RC,J3490,HCPCS,00121127610,NDC,facility,outpatient,10,ML,4.60000,2.76000,WellCare of North Carolina,Managed Medicaid,,0.92092,,,,,,,0.92092,3.74,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION,RX-9788,CDM,258,RC,J7121,HCPCS,00338012503,NDC,facility,outpatient,500,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
TOLVAPTAN 30 MG TABLET,RX-97894,CDM,250,RC,J3490,HCPCS,59148002150,NDC,facility,outpatient,1,UN,2174.60000,1304.76000,WellCare of North Carolina,Managed Medicaid,,435.35,,,,,,,435.35,1767.95,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9795,CDM,636,RC,J3480,HCPCS,00338080304,NDC,facility,outpatient,1000,ML,101.50000,60.90000,WellCare of North Carolina,Managed Medicaid,,20.32,,,,,,,0.25960,75.33,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS,RX-9796,CDM,636,RC,J3480,HCPCS,00338080704,NDC,facility,outpatient,1000,ML,98.00000,58.80000,WellCare of North Carolina,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9799,CDM,258,RC,J3480,HCPCS,00338066904,NDC,facility,outpatient,1000,ML,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,0.25960,69.68,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV,RX-9800,CDM,636,RC,J3480,HCPCS,00338066304,NDC,facility,outpatient,1000,ML,94.50000,56.70000,WellCare of North Carolina,Managed Medicaid,,18.92,,,,,,,0.25960,70.14,percent of total billed charges,
POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9801,CDM,636,RC,J3480,HCPCS,00338067104,NDC,facility,outpatient,1000,ML,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,0.25960,62.34,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL",RX-98034,CDM,250,RC,J3490,HCPCS,00032004670,NDC,facility,outpatient,1,UN,24.60000,14.76000,WellCare of North Carolina,Managed Medicaid,,4.92,,,,,,,4.92,20.00,percent of total billed charges,
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,250,RC,J3490,HCPCS,99999000622,NDC,facility,outpatient,1,UN,33.20000,19.92000,WellCare of North Carolina,Managed Medicaid,,6.65,,,,,,,6.65,26.99,percent of total billed charges,
"LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL",RX-98036,CDM,250,RC,J3490,HCPCS,09999000626,NDC,facility,outpatient,1,UN,50.05000,30.03000,WellCare of North Carolina,Managed Medicaid,,10.02,,,,,,,10.02,40.69,percent of total billed charges,
POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9804,CDM,636,RC,J3480,HCPCS,00338067304,NDC,facility,outpatient,1000,ML,98.00000,58.80000,WellCare of North Carolina,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV,RX-9807,CDM,636,RC,J3480,HCPCS,00338067504,NDC,facility,outpatient,1000,ML,98.00000,58.80000,WellCare of North Carolina,Managed Medicaid,,19.62,,,,,,,0.25960,72.74,percent of total billed charges,
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9812,CDM,258,RC,J3490,HCPCS,00338007704,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9814,CDM,258,RC,J3490,HCPCS,00338008504,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1000,ML,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,3.33,60.69,percent of total billed charges,
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION,RX-9815,CDM,258,RC,J7042,HCPCS,00338008903,NDC,facility,outpatient,500,ML,76.50000,45.90000,WellCare of North Carolina,Managed Medicaid,,15.32,,,,,,,3.33,57.32,percent of total billed charges,
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION,RX-98249,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,outpatient,100,ML,356.00000,213.60000,WellCare of North Carolina,Managed Medicaid,,71.27,,,,,,,4.69,264.22,percent of total billed charges,
TAPENTADOL 50 MG TABLET,RX-98253,CDM,250,RC,J3490,HCPCS,24510005010,NDC,facility,outpatient,1,UN,58.55000,35.13000,WellCare of North Carolina,Managed Medicaid,,11.72,,,,,,,11.72,47.60,percent of total billed charges,
TAPENTADOL 75 MG TABLET,RX-98254,CDM,250,RC,J3490,HCPCS,50458083002,NDC,facility,outpatient,1,UN,48.95000,29.37000,WellCare of North Carolina,Managed Medicaid,,9.80,,,,,,,9.80,39.80,percent of total billed charges,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,WellCare of North Carolina,Managed Medicaid,,1016.27,,,,,,,0.31040,3767.59,percent of total billed charges,
DRONEDARONE 400 MG TABLET,RX-98329,CDM,250,RC,J3490,HCPCS,00024414260,NDC,facility,outpatient,1,UN,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,,14.01,,,,,,,14.01,56.91,percent of total billed charges,
PRASUGREL HCL 5 MG TABLET,RX-98372,CDM,250,RC,J3490,HCPCS,00378518593,NDC,facility,outpatient,1,UN,20.00000,12.00000,WellCare of North Carolina,Managed Medicaid,,4.00,,,,,,,4.00,16.26,percent of total billed charges,
PRASUGREL HCL 10 MG TABLET,RX-98373,CDM,250,RC,J3490,HCPCS,60505464303,NDC,facility,outpatient,1,UN,19.30000,11.58000,WellCare of North Carolina,Managed Medicaid,,3.86,,,,,,,3.86,15.69,percent of total billed charges,
DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION,RX-9853,CDM,636,RC,J1160,HCPCS,70515026210,NDC,facility,outpatient,1,ML,642.70000,385.62000,WellCare of North Carolina,Managed Medicaid,,128.67,,,,,,,10.89,477.01,percent of total billed charges,
DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION,RX-9859,CDM,636,RC,J1110,HCPCS,00143927301,NDC,facility,outpatient,0.5,ML,254.90000,152.94000,WellCare of North Carolina,Managed Medicaid,,51.03,,,,,,,51.03,264.28,percent of total billed charges,
BENZONATATE 100 MG CAPSULE,RX-988,CDM,250,RC,J3490,HCPCS,69452014320,NDC,facility,outpatient,1,UN,17.20000,10.32000,WellCare of North Carolina,Managed Medicaid,,3.44,,,,,,,3.44,13.98,percent of total billed charges,
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION,RX-9892,CDM,636,RC,J1250,HCPCS,00409234401,NDC,facility,outpatient,20,ML,95.55000,57.33000,WellCare of North Carolina,Managed Medicaid,,19.13,,,,,,,16.71,70.92,percent of total billed charges,
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION,RX-9902,CDM,250,RC,J3490,HCPCS,68180065701,NDC,facility,outpatient,10,ML,25.15000,15.09000,WellCare of North Carolina,Managed Medicaid,,5.04,,,,,,,5.04,20.45,percent of total billed charges,
ECONAZOLE NITRATE 1 % TOPICAL CREAM,RX-9915,CDM,250,RC,J3490,HCPCS,51672130302,NDC,facility,outpatient,30,GR,166.25000,99.75000,WellCare of North Carolina,Managed Medicaid,,33.28,,,,,,,33.28,135.16,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978701,NDC,facility,outpatient,1,ML,85.30000,51.18000,WellCare of North Carolina,Managed Medicaid,,17.08,,,,,,,17.08,69.35,percent of total billed charges,
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION,RX-9929,CDM,250,RC,J3490,HCPCS,00143978601,NDC,facility,outpatient,2,ML,102.85000,61.71000,WellCare of North Carolina,Managed Medicaid,,20.59,,,,,,,20.59,83.62,percent of total billed charges,
OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL,RX-99405,CDM,250,RC,J3490,HCPCS,09999000370,NDC,facility,outpatient,0.3,ML,25.45000,15.27000,WellCare of North Carolina,Managed Medicaid,,5.10,,,,,,,5.10,20.69,percent of total billed charges,
"ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS",RX-9943,CDM,250,RC,J3490,HCPCS,47781064726,NDC,facility,outpatient,0.25,ML,1.40000,0.84000,WellCare of North Carolina,Managed Medicaid,,0.28028,,,,,,,0.28028,1.14,percent of total billed charges,
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION,RX-99443,CDM,250,RC,J3490,HCPCS,00591257920,NDC,facility,outpatient,88,ML,2416.85000,1450.11000,WellCare of North Carolina,Managed Medicaid,,483.85,,,,,,,483.85,1964.90,percent of total billed charges,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,WellCare of North Carolina,Managed Medicaid,,805.26,,,,,,,8.49,2985.35,percent of total billed charges,
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-99610,CDM,636,RC,J9263,HCPCS,61703036318,NDC,facility,outpatient,10,ML,486.20000,291.72000,WellCare of North Carolina,Managed Medicaid,,97.34,,,,,,,0.18880,360.86,percent of total billed charges,
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION,RX-99612,CDM,636,RC,J9263,HCPCS,67457044220,NDC,facility,outpatient,20,ML,715.00000,429.00000,WellCare of North Carolina,Managed Medicaid,,143.14,,,,,,,0.18880,530.67,percent of total billed charges,
ESTRADIOL 1 MG TABLET,RX-9967,CDM,250,RC,J3490,HCPCS,00555088602,NDC,facility,outpatient,1,UN,17.25000,10.35000,WellCare of North Carolina,Managed Medicaid,,3.45,,,,,,,3.45,14.02,percent of total billed charges,
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM,RX-9969,CDM,250,RC,J3490,HCPCS,00430375414,NDC,facility,outpatient,42.5,GR,1050.30000,630.18000,WellCare of North Carolina,Managed Medicaid,,210.27,,,,,,,210.27,853.89,percent of total billed charges,
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET,RX-99694,CDM,250,RC,J3490,HCPCS,43598047801,NDC,facility,outpatient,1,UN,53.85000,32.31000,WellCare of North Carolina,Managed Medicaid,,10.78,,,,,,,10.78,43.78,percent of total billed charges,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,WellCare of North Carolina,Managed Medicaid,,346.52,,,,,,,346.52,1284.64,percent of total billed charges,
CONJUGATED ESTROGENS 0.3 MG TABLET,RX-9973,CDM,250,RC,J3490,HCPCS,00046110081,NDC,facility,outpatient,1,UN,44.30000,26.58000,WellCare of North Carolina,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
CONJUGATED ESTROGENS 0.625 MG TABLET,RX-9974,CDM,250,RC,J3490,HCPCS,00046110281,NDC,facility,outpatient,1,UN,44.30000,26.58000,WellCare of North Carolina,Managed Medicaid,,8.87,,,,,,,8.87,36.02,percent of total billed charges,
ETHACRYNIC ACID 25 MG TABLET,RX-9980,CDM,250,RC,J3490,HCPCS,25010021515,NDC,facility,outpatient,1,UN,113.80000,68.28000,WellCare of North Carolina,Managed Medicaid,,22.78,,,,,,,22.78,92.52,percent of total billed charges,
ETHAMBUTOL 100 MG TABLET,RX-9982,CDM,250,RC,J3490,HCPCS,68180028001,NDC,facility,outpatient,1,UN,17.85000,10.71000,WellCare of North Carolina,Managed Medicaid,,3.57,,,,,,,3.57,14.51,percent of total billed charges,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,WellCare of North Carolina,Managed Medicaid,,330.39,,,,,,,330.39,1448.89,percent of total billed charges,
GRAFT INTEGRA BILAYER MESHED W,SUP-133921,CDM,636,RC,C9363,HCPCS,,,facility,outpatient,,,45414.56000,27248.74000,WellCare of North Carolina,Managed Medicaid,,9091.99,,,,,,,162.39,33706.69,percent of total billed charges,
MEMBRANE AUTOLOGOUS CULTURED CHONDROCYTES,SUP-148836,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,156212.38000,93727.43000,WellCare of North Carolina,Managed Medicaid,,31273.72,,,,,,,31273.72,215040.47,percent of total billed charges,
MEMBRANE 2 AUTOLOGOUS CULTURED  CHONDROCYTES,SUP-149784,CDM,636,RC,J7330,HCPCS,,,facility,outpatient,,,257500.00000,154500.00000,WellCare of North Carolina,Managed Medicaid,,51551.50,,,,,,,51551.50,215040.47,percent of total billed charges,
SKIN GRAFT SOFT TISS 3X6CM STRAVIX,SUP-239665,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,11159.74000,6695.84000,WellCare of North Carolina,Managed Medicaid,,2234.18,,,,,,,327.43,8282.76,percent of total billed charges,
SKIN GRAFT SOFT TISS 2X4CM STRAVIX,SUP-239666,CDM,636,RC,Q4133,HCPCS,,,facility,outpatient,,,7390.20000,4434.12000,WellCare of North Carolina,Managed Medicaid,,1479.52,,,,,,,327.43,5485.01,percent of total billed charges,
PARENTERAL AMINO ACID 10 % COMBINATION NO.6 INTRAVENOUS SOLUTION,RX-127606,CDM,250,RC,00338064406,NDC,,,facility,outpatient,2000,ML,259.00000,155.40000,WellCare of North Carolina,Managed Medicaid,,51.85,,,,,,,51.85,210.57,percent of total billed charges,
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT,RX-127908,CDM,250,RC,00065050935,NDC,,,facility,outpatient,3.5,GR,13.65000,8.19000,WellCare of North Carolina,Managed Medicaid,,2.73,,,,,,,2.73,11.10,percent of total billed charges,
PEDIATRIC MULTIVITAMIN NO.226-FERROUS SULFATE 18 MG CHEWABLE TABLET,RX-196543,CDM,250,RC,16500059920,NDC,,,facility,outpatient,1,UN,1.20000,0.72000,WellCare of North Carolina,Managed Medicaid,,0.24024,,,,,,,0.24024,0.97560,percent of total billed charges,
XYLITOL-YERBA SANTA MUCOSAL SPRAY WITH PUMP,RX-199275,CDM,250,RC,50930009802,NDC,,,facility,outpatient,59,ML,9.15000,5.49000,WellCare of North Carolina,Managed Medicaid,,1.83,,,,,,,1.83,7.44,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 5,000 UNITS/0.2 ML",RX-4080070621,CDM,636,RC,09999001671,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 7,500 UNITS/0.3 ML",RX-4080070622,CDM,636,RC,09999001672,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 10,000 UNITS/0.4 ML",RX-4080070623,CDM,636,RC,09999001673,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 12,500 UNITS/0.5 ML",RX-4080070624,CDM,636,RC,09999001674,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 15,000 UNITS/0.6 ML",RX-4080070625,CDM,636,RC,,,,,facility,outpatient,35,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
"STUDY DU176B-D-U311 DALTEPARIN INJECTION 18,000 UNITS/0.72 ML",RX-4080070626,CDM,636,RC,09999001676,NDC,,,facility,outpatient,35,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY 20604 BAY 2433334 ASUNDEXIAN/PLACEBO 50 MG TABLET,RX-4081031736,CDM,256,RC,09999011061,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
PAIN CLINIC SYRINGE (COMPOUNDED PRODUCT),RX-40841187,CDM,636,RC,99999000558,NDC,,,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
FORMALIN 1 % IN SWFI 1000 ML,RX-40842262,CDM,636,RC,09999199003,NDC,,,facility,outpatient,1000,ML,42.00000,25.20000,WellCare of North Carolina,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
STUDY NSABP B-61 GIREDESTRANT 30 MG CAPSULE,RX-40846245,CDM,256,RC,09999009887,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 25 MG CAPSULE,RX-40850128,CDM,256,RC,09999011558,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY J3M-MC-JZQB OLOMORASIB (LY3537982)/PLACEBO 50 MG CAPSULE,RX-40850129,CDM,256,RC,09999011559,NDC,,,facility,outpatient,24,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY NSABP-B-59/GBG-96 ATEZOLIZUMAB/PLACEBO 60 MG/ML INTRAVENOUS SOLUTION,RX-40850334,CDM,636,RC,09999008324,NDC,,,facility,outpatient,20,ML,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.16260,percent of total billed charges,
STUDY MK-2870-011 SACITUZUMAB TIRUMOTECAN 20 MG/ML IV SOLUTION,RX-40851516,CDM,256,RC,09999011906,NDC,,,facility,outpatient,200,ME,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 20 MG TABLET,RX-40851523,CDM,256,RC,09999011911,NDC,,,facility,outpatient,30,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
STUDY RMC-6236-301 RMC-6236 100 MG TABLET,RX-40851524,CDM,256,RC,09999011912,NDC,,,facility,outpatient,25,UN,0.20000,0.12000,WellCare of North Carolina,Managed Medicaid,,0.04004,,,,,,,0.04004,0.15000,percent of total billed charges,
HC REX LABOR CARE TIME LESS THAN 2 HRS,11720002,CDM,720,RC,,,,,facility,outpatient,,,519.00000,311.40000,WellCare of North Carolina,Managed Medicaid,,103.90,,,,,,,103.90,954.00,percent of total billed charges,
HC REX LABOR CARE 2-4 HRS,11720003,CDM,720,RC,,,,,facility,outpatient,,,1287.00000,772.20000,WellCare of North Carolina,Managed Medicaid,,257.66,,,,,,,257.66,965.25,percent of total billed charges,
HC REX LABOR CARE 4-8 HRS,11720004,CDM,720,RC,,,,,facility,outpatient,,,1925.00000,1155.00000,WellCare of North Carolina,Managed Medicaid,,385.38,,,,,,,385.38,1443.75,percent of total billed charges,
HC REX LABOR CARE 8-12 HRS,11720005,CDM,720,RC,,,,,facility,outpatient,,,2891.00000,1734.60000,WellCare of North Carolina,Managed Medicaid,,578.78,,,,,,,578.78,2168.25,percent of total billed charges,
HC REX LABOR CARE 12-16 HRS,11720006,CDM,720,RC,,,,,facility,outpatient,,,3469.00000,2081.40000,WellCare of North Carolina,Managed Medicaid,,694.49,,,,,,,615.00,2601.75,percent of total billed charges,
HC REX LABOR CARE 16-20 HRS,11720007,CDM,720,RC,,,,,facility,outpatient,,,4162.00000,2497.20000,WellCare of North Carolina,Managed Medicaid,,833.23,,,,,,,615.00,3121.50,percent of total billed charges,
HC REX LABOR CARE 20-24 HRS,11720008,CDM,720,RC,,,,,facility,outpatient,,,4996.00000,2997.60000,WellCare of North Carolina,Managed Medicaid,,1000.20,,,,,,,615.00,3747.00,percent of total billed charges,
HC REX INTENSIVE CARE LESS THAN 6 HRS,12000005,CDM,720,RC,,,,,facility,outpatient,,,2065.00000,1239.00000,WellCare of North Carolina,Managed Medicaid,,413.41,,,,,,,413.41,1548.75,percent of total billed charges,
HC REX INTENSIVE CARE 6-12 HRS,12000006,CDM,720,RC,,,,,facility,outpatient,,,3033.00000,1819.80000,WellCare of North Carolina,Managed Medicaid,,607.21,,,,,,,607.21,2274.75,percent of total billed charges,
HC REX INTENSIVE CARE 13-24 HRS,12000007,CDM,720,RC,,,,,facility,outpatient,,,5516.00000,3309.60000,WellCare of North Carolina,Managed Medicaid,,1104.30,,,,,,,615.00,4137.00,percent of total billed charges,
HC H.O.L.D BELT,22700047,CDM,270,RC,,,,,facility,outpatient,,,160.00000,96.00000,WellCare of North Carolina,Managed Medicaid,,32.03,,,,,,,32.03,130.08,percent of total billed charges,
HC PICC LINE,22700050,CDM,270,RC,,,,,facility,outpatient,,,633.00000,379.80000,WellCare of North Carolina,Managed Medicaid,,126.73,,,,,,,126.73,514.63,percent of total billed charges,
HC PREEMIE NEST SET,22700051,CDM,270,RC,,,,,facility,outpatient,,,173.00000,103.80000,WellCare of North Carolina,Managed Medicaid,,34.63,,,,,,,34.63,140.65,percent of total billed charges,
HC AEROSOL THERAPY SUPPLY PER DAY,22700091,CDM,270,RC,,,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,,23.42,,,,,,,23.42,95.12,percent of total billed charges,
HC CYTOLOGY BRUSH,22700101,CDM,270,RC,,,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,50.41,percent of total billed charges,
HC DISPOSABLE NEBULIZER SUPPLY,22700103,CDM,270,RC,,,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Managed Medicaid,,5.21,,,,,,,5.21,21.14,percent of total billed charges,
"HC INFANT HOOD,INITIAL",22700117,CDM,270,RC,,,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Managed Medicaid,,28.63,,,,,,,28.63,116.26,percent of total billed charges,
HC PULMONARY OXIMIZER PENDANT,22700127,CDM,270,RC,,,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC SURGICAL ABSORBABLE HEMOSTAT,22700147,CDM,270,RC,,,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC SHEATH INTRODUCER PERCUTANEOUS,22700167,CDM,270,RC,,,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Managed Medicaid,,31.63,,,,,,,31.63,128.45,percent of total billed charges,
HC TRI CLOSE THORACIC TRAY,22700168,CDM,270,RC,,,,,facility,outpatient,,,524.00000,314.40000,WellCare of North Carolina,Managed Medicaid,,104.90,,,,,,,104.90,426.01,percent of total billed charges,
HC VENTRICULAR PACING LEAD,22700169,CDM,270,RC,,,,,facility,outpatient,,,597.00000,358.20000,WellCare of North Carolina,Managed Medicaid,,119.52,,,,,,,119.52,485.36,percent of total billed charges,
HC REX PATIENT TRIAL PRECISION COMPONEN,22700506,CDM,272,RC,,,,,facility,outpatient,,,508.00000,304.80000,WellCare of North Carolina,Managed Medicaid,,101.70,,,,,,,101.70,413.00,percent of total billed charges,
HC REPLACEMENT VENTRICLE DRAIN BAG,22710005,CDM,271,RC,,,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Managed Medicaid,,18.42,,,,,,,18.42,74.80,percent of total billed charges,
HC MAXITHERM LITE HEAD WRAP,22710006,CDM,271,RC,,,,,facility,outpatient,,,73.00000,43.80000,WellCare of North Carolina,Managed Medicaid,,14.61,,,,,,,14.61,59.35,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS 3XL TO 5XL,22710014,CDM,271,RC,,,,,facility,outpatient,,,230.00000,138.00000,WellCare of North Carolina,Managed Medicaid,,46.05,,,,,,,46.05,186.99,percent of total billed charges,
HC RADIATION IMPLANT BRIEFS SM TO 2XL,22710020,CDM,271,RC,,,,,facility,outpatient,,,211.00000,126.60000,WellCare of North Carolina,Managed Medicaid,,42.24,,,,,,,42.24,171.54,percent of total billed charges,
HC ARCTIC SUN GEL LARGE PAD,22720072,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,WellCare of North Carolina,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL MEDIUM PAD,22720073,CDM,272,RC,,,,,facility,outpatient,,,5233.00000,3139.80000,WellCare of North Carolina,Managed Medicaid,,1047.65,,,,,,,1047.65,4254.43,percent of total billed charges,
HC ARCTIC SUN GEL SMALL PAD,22720074,CDM,272,RC,,,,,facility,outpatient,,,4982.00000,2989.20000,WellCare of North Carolina,Managed Medicaid,,997.40,,,,,,,997.40,4050.37,percent of total billed charges,
HC ARCTIC SUN GEL UNIVERSAL SINGLE PAD,22720075,CDM,272,RC,,,,,facility,outpatient,,,1786.00000,1071.60000,WellCare of North Carolina,Managed Medicaid,,357.56,,,,,,,357.56,1452.02,percent of total billed charges,
HC WRIST COCK UP SPLINT,22720146,CDM,272,RC,,,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,11.61,47.15,percent of total billed charges,
HC TRACH SHILEY PERCUT 6 OR 8 FR,22720161,CDM,272,RC,,,,,facility,outpatient,,,3005.00000,1803.00000,WellCare of North Carolina,Managed Medicaid,,601.60,,,,,,,601.60,2443.07,percent of total billed charges,
HC IP IABP CATH,22720193,CDM,272,RC,,,,,facility,outpatient,,,1526.00000,915.60000,WellCare of North Carolina,Managed Medicaid,,305.51,,,,,,,305.51,1240.64,percent of total billed charges,
HC D STAT RADIAL HEMOSTAT BAND,22720194,CDM,272,RC,,,,,facility,outpatient,,,313.00000,187.80000,WellCare of North Carolina,Managed Medicaid,,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC PACER CATHETER,22720197,CDM,272,RC,,,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,65.85,percent of total billed charges,
HC VAT QUICKCLOT,22720205,CDM,272,RC,,,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,12.61,51.22,percent of total billed charges,
HC RICHLI PNEUMOTHORAX CATH,22720206,CDM,272,RC,,,,,facility,outpatient,,,1093.00000,655.80000,WellCare of North Carolina,Managed Medicaid,,218.82,,,,,,,218.82,888.61,percent of total billed charges,
HC VAT ARROW LONG WIRE,22720208,CDM,272,RC,,,,,facility,outpatient,,,342.00000,205.20000,WellCare of North Carolina,Managed Medicaid,,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC VENTRICLEAR EVD CATHETER,22720210,CDM,272,RC,,,,,facility,outpatient,,,1236.00000,741.60000,WellCare of North Carolina,Managed Medicaid,,247.45,,,,,,,247.45,1004.87,percent of total billed charges,
HC NXSTAGE CARTRIDGE,22720213,CDM,272,RC,,,,,facility,outpatient,,,909.00000,545.40000,WellCare of North Carolina,Managed Medicaid,,181.98,,,,,,,181.98,739.02,percent of total billed charges,
HC HERMETIC LRG VENTRICULAR CATH SET,22720214,CDM,272,RC,,,,,facility,outpatient,,,303.00000,181.80000,WellCare of North Carolina,Managed Medicaid,,60.66,,,,,,,60.66,246.34,percent of total billed charges,
HC MAX 5FR TRIPLE FULL,22720217,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,WellCare of North Carolina,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC CRRT SOLUTION BAG SPIKE SUPPLIES,22720219,CDM,272,RC,,,,,facility,outpatient,,,938.00000,562.80000,WellCare of North Carolina,Managed Medicaid,,187.79,,,,,,,187.79,762.59,percent of total billed charges,
HC EXTERNAL VENTRICLE DRAIN,22720220,CDM,272,RC,,,,,facility,outpatient,,,266.00000,159.60000,WellCare of North Carolina,Managed Medicaid,,53.25,,,,,,,53.25,216.26,percent of total billed charges,
HC VAT ARROW 4FR PICC CONVERSION KIT,22720224,CDM,272,RC,,,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Managed Medicaid,,40.84,,,,,,,40.84,165.85,percent of total billed charges,
HC VAT BARD DUAL LUMEN POWER 5FR PICC,22720227,CDM,272,RC,,,,,facility,outpatient,,,1092.00000,655.20000,WellCare of North Carolina,Managed Medicaid,,218.62,,,,,,,218.62,887.80,percent of total billed charges,
HC ACUTE HEMODIALYSIS CATH 15 CM,22720235,CDM,272,RC,,,,,facility,outpatient,,,948.00000,568.80000,WellCare of North Carolina,Managed Medicaid,,189.79,,,,,,,189.79,770.72,percent of total billed charges,
HC IP INTRAOSSEOUS SUPPLY,22720236,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,WellCare of North Carolina,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC ELASTABAND 10CM,22720239,CDM,272,RC,,,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Managed Medicaid,,8.61,,,,,,,8.61,34.96,percent of total billed charges,
HC ELASTABAND 8CM,22720240,CDM,272,RC,,,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Managed Medicaid,,7.01,,,,,,,7.01,28.45,percent of total billed charges,
HC BRONCH ALVEOLAR LAVAGE KIT,22720261,CDM,272,RC,,,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Managed Medicaid,,28.03,,,,,,,28.03,113.82,percent of total billed charges,
HC FILSHIE CLIPS,22720292,CDM,272,RC,,,,,facility,outpatient,,,474.00000,284.40000,WellCare of North Carolina,Managed Medicaid,,94.89,,,,,,,94.89,385.36,percent of total billed charges,
HC FOREARM THUMB SPICA,22720296,CDM,272,RC,,,,,facility,outpatient,,,126.00000,75.60000,WellCare of North Carolina,Managed Medicaid,,25.23,,,,,,,25.23,102.44,percent of total billed charges,
HC INTRAOSSEOUS SUPPLY,22720301,CDM,272,RC,,,,,facility,outpatient,,,286.00000,171.60000,WellCare of North Carolina,Managed Medicaid,,57.26,,,,,,,57.26,232.52,percent of total billed charges,
HC REX PATELLAR TRACKING ORTHOSIS,22720311,CDM,272,RC,,,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Managed Medicaid,,26.83,,,,,,,26.83,108.94,percent of total billed charges,
HC ROSIDOL BANDAGE,22720323,CDM,272,RC,,,,,facility,outpatient,,,11.00000,6.60000,WellCare of North Carolina,Managed Medicaid,,2.20,,,,,,,2.20,8.94,percent of total billed charges,
HC AUGMENT PFC SIGMA POSTERIOR,22780143,CDM,278,RC,,,,,facility,outpatient,,,4985.00000,2991.00000,WellCare of North Carolina,Managed Medicaid,,998.00,,,,,,,633.10,3669.96,percent of total billed charges,
HC CORE AILERON MEDIUM,22780144,CDM,278,RC,,,,,facility,outpatient,,,20100.00000,12060.00000,WellCare of North Carolina,Managed Medicaid,,4024.02,,,,,,,2552.70,14797.62,percent of total billed charges,
HC CONNECTOR SMALL TSRH 3DX,22780146,CDM,278,RC,,,,,facility,outpatient,,,5074.00000,3044.40000,WellCare of North Carolina,Managed Medicaid,,1015.81,,,,,,,644.40,3735.48,percent of total billed charges,
HC INSERT TRIDENT 10 DEG ECCENTRIC,22780147,CDM,278,RC,,,,,facility,outpatient,,,4240.00000,2544.00000,WellCare of North Carolina,Managed Medicaid,,848.85,,,,,,,538.48,3121.49,percent of total billed charges,
HC SLEEVE ADAPTER MORSE C TAPER,22780148,CDM,278,RC,,,,,facility,outpatient,,,3478.00000,2086.80000,WellCare of North Carolina,Managed Medicaid,,696.30,,,,,,,441.71,2560.50,percent of total billed charges,
HC GAS NITRIC OXIDE HOURLY,42720001,CDM,270,RC,,,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Managed Medicaid,,92.69,,,,,,,92.69,376.42,percent of total billed charges,
HC BRONCHOSCOPY CT GUIDED,43600017,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,WellCare of North Carolina,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC TRACHEOBRONCH THRU EST TRACH,43610016,CDM,361,RC,,,,,facility,outpatient,,,4530.00000,2718.00000,WellCare of North Carolina,Managed Medicaid,,906.91,,,,,,,906.91,3134.31,percent of total billed charges,
HC BRONCHOSCOPY DIAGNOSTIC,43610018,CDM,361,RC,,,,,facility,outpatient,,,4461.00000,2676.60000,WellCare of North Carolina,Managed Medicaid,,893.09,,,,,,,893.09,3086.57,percent of total billed charges,
HC BRONCH W BRUSHINGS,43610019,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,WellCare of North Carolina,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W LAVAGE,43610021,CDM,361,RC,,,,,facility,outpatient,,,5835.00000,3501.00000,WellCare of North Carolina,Managed Medicaid,,1168.17,,,,,,,1168.17,4037.24,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,750,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,WellCare of North Carolina,Managed Medicaid,,829.43,,,,,,,829.43,3080.32,percent of total billed charges,
HC BRONCH WITH BRONCH OR ENDOBRONCH BIOPSY,43610023,CDM,361,RC,,,,,facility,outpatient,,,4143.00000,2485.80000,WellCare of North Carolina,Managed Medicaid,,829.43,,,,,,,829.43,2866.54,percent of total billed charges,
HC BRONCH W TB BX SNGLE LOBE,43610025,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,WellCare of North Carolina,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TB NDL ASP BX,43610026,CDM,361,RC,,,,,facility,outpatient,,,4821.00000,2892.60000,WellCare of North Carolina,Managed Medicaid,,965.16,,,,,,,965.16,3335.65,percent of total billed charges,
HC BRONCH W TRACH BRONCH DILATION,43610027,CDM,361,RC,,,,,facility,outpatient,,,5866.00000,3519.60000,WellCare of North Carolina,Managed Medicaid,,1174.37,,,,,,,1174.37,4058.69,percent of total billed charges,
HC BRONCH W TB BX EA ADDL LOBE,43610028,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,WellCare of North Carolina,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W TB NDL ASP BX EAADD,43610029,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,WellCare of North Carolina,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W REMOVAL FOREIGN BODY,43610030,CDM,361,RC,,,,,facility,outpatient,,,3531.00000,2118.60000,WellCare of North Carolina,Managed Medicaid,,706.91,,,,,,,706.91,2443.10,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP INIT,43610031,CDM,361,RC,,,,,facility,outpatient,,,3954.00000,2372.40000,WellCare of North Carolina,Managed Medicaid,,791.59,,,,,,,791.59,2735.77,percent of total billed charges,
HC BRONCH W THERAPEUTIC ASP SUBS,43610032,CDM,361,RC,,,,,facility,outpatient,,,1745.00000,1047.00000,WellCare of North Carolina,Managed Medicaid,,349.35,,,,,,,349.35,1207.37,percent of total billed charges,
HC BRONCH INTRACAV APPL,43610036,CDM,361,RC,,,,,facility,outpatient,,,4110.00000,2466.00000,WellCare of North Carolina,Managed Medicaid,,822.82,,,,,,,822.82,2843.71,percent of total billed charges,
HC REM TUNNELED PLEURAL CATH,43610043,CDM,361,RC,,,,,facility,outpatient,,,1691.00000,1014.60000,WellCare of North Carolina,Managed Medicaid,,338.54,,,,,,,338.54,1170.00,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 3 OR MORE NODES,43610050,CDM,361,RC,,,,,facility,outpatient,,,6499.00000,3899.40000,WellCare of North Carolina,Managed Medicaid,,1301.10,,,,,,,1301.10,4496.66,percent of total billed charges,
HC REGIONAL ANES LESS THAN 4 HRS,43700001,CDM,370,RC,,,,,facility,outpatient,,,1184.00000,710.40000,WellCare of North Carolina,Managed Medicaid,,237.04,,,,,,,237.04,962.59,percent of total billed charges,
HC REGIONAL ANES 4-8 HOURS,43700002,CDM,370,RC,,,,,facility,outpatient,,,2432.00000,1459.20000,WellCare of North Carolina,Managed Medicaid,,486.89,,,,,,,486.89,1977.22,percent of total billed charges,
HC REGIONAL ANES 8-12 HOURS,43700003,CDM,370,RC,,,,,facility,outpatient,,,3684.00000,2210.40000,WellCare of North Carolina,Managed Medicaid,,737.54,,,,,,,737.54,2995.09,percent of total billed charges,
HC REGIONAL ANES GREATER THAN 12 HR,43700004,CDM,370,RC,,,,,facility,outpatient,,,4297.00000,2578.20000,WellCare of North Carolina,Managed Medicaid,,860.26,,,,,,,860.26,3493.46,percent of total billed charges,
HC INCENTIVE SPIROMETRY SUPPLY,44100016,CDM,270,RC,,,,,facility,outpatient,,,121.00000,72.60000,WellCare of North Carolina,Managed Medicaid,,24.22,,,,,,,24.22,98.37,percent of total billed charges,
HC VAGINAL DEL W FORCEPS VACUUM,47200001,CDM,722,RC,,,,,facility,outpatient,,,1706.00000,1023.60000,WellCare of North Carolina,Managed Medicaid,,341.54,,,,,,,341.54,1279.50,percent of total billed charges,
HC VAGINAL DELIVERY FEE,47200002,CDM,720,RC,,,,,facility,outpatient,,,3426.00000,2055.60000,WellCare of North Carolina,Managed Medicaid,,685.89,,,,,,,615.00,2569.50,percent of total billed charges,
HC FETAL MONITORING HOURLY,47200003,CDM,720,RC,,,,,facility,outpatient,,,83.00000,49.80000,WellCare of North Carolina,Managed Medicaid,,16.62,,,,,,,16.62,954.00,percent of total billed charges,
HC HEMATOMA EVACUATION,47200004,CDM,720,RC,,,,,facility,outpatient,,,467.00000,280.20000,WellCare of North Carolina,Managed Medicaid,,93.49,,,,,,,93.49,954.00,percent of total billed charges,
HC UNIT BEDSIDE HEMODIALYSIS,48010004,CDM,801,RC,,,,,facility,outpatient,,,689.00000,413.40000,WellCare of North Carolina,Managed Medicaid,,137.94,,,,,,,119.95,560.16,percent of total billed charges,
HC ADULT CRRT START UP,48010015,CDM,801,RC,,,,,facility,outpatient,,,1557.00000,934.20000,WellCare of North Carolina,Managed Medicaid,,311.71,,,,,,,271.07,1265.84,percent of total billed charges,
HC CRRT ADULT,48010017,CDM,801,RC,,,,,facility,outpatient,,,1179.00000,707.40000,WellCare of North Carolina,Managed Medicaid,,236.04,,,,,,,205.26,958.53,percent of total billed charges,
HC CAPD IP DAILY,48010025,CDM,803,RC,,,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Managed Medicaid,,15.82,,,,,,,13.75,64.23,percent of total billed charges,
HC DIABETIC ED 15 MIN IP,49420004,CDM,942,RC,,,,,facility,outpatient,,,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,15.32,1090.00,percent of total billed charges,
HC PT MAINTENANCE SELF PYMT,49900001,CDM,990,RC,,,,,facility,outpatient,,,21.00000,12.60000,WellCare of North Carolina,Managed Medicaid,GP,4.20,,,,,,,3.66,15.75,percent of total billed charges,
HC US BREAST BIOPSY VABB NC PROG 1,53610171,CDM,361,RC,,,,,facility,outpatient,,,333.00000,199.80000,WellCare of North Carolina,Managed Medicaid,,66.67,,,,,,,66.67,230.40,percent of total billed charges,
HC ED PROCEDURE LEVEL 6,54500002,CDM,450,RC,,,,,facility,outpatient,,,1502.00000,901.20000,WellCare of North Carolina,Managed Medicaid,,300.70,,,,,,,280.12,1126.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 5,54500003,CDM,450,RC,,,,,facility,outpatient,,,1422.00000,853.20000,WellCare of North Carolina,Managed Medicaid,,284.68,,,,,,,265.20,1066.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 4,54500004,CDM,450,RC,,,,,facility,outpatient,,,1140.00000,684.00000,WellCare of North Carolina,Managed Medicaid,,228.23,,,,,,,212.61,855.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 3,54500006,CDM,450,RC,,,,,facility,outpatient,,,858.00000,514.80000,WellCare of North Carolina,Managed Medicaid,,171.77,,,,,,,160.02,643.50,percent of total billed charges,
HC ED PROCEDURE LEVEL 2,54500007,CDM,450,RC,,,,,facility,outpatient,,,576.00000,345.60000,WellCare of North Carolina,Managed Medicaid,,115.32,,,,,,,107.42,432.00,percent of total billed charges,
HC ED PROCEDURE LEVEL 1,54500008,CDM,450,RC,,,,,facility,outpatient,,,294.00000,176.40000,WellCare of North Carolina,Managed Medicaid,,58.86,,,,,,,54.83,220.50,percent of total billed charges,
HC PLEURAL DRAIN PERCT W CATH W O IMAGE,57610197,CDM,361,RC,,,,,facility,outpatient,,,1638.00000,982.80000,WellCare of North Carolina,Managed Medicaid,,327.93,,,,,,,327.93,1133.33,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 1,63600002,CDM,360,RC,,,,,facility,outpatient,,,4895.00000,2937.00000,WellCare of North Carolina,Managed Medicaid,,979.98,,,,,,,979.98,3386.85,percent of total billed charges,
HC CYSTO PROCEDURE TIME LEVEL 2,63600003,CDM,360,RC,,,,,facility,outpatient,,,6492.00000,3895.20000,WellCare of North Carolina,Managed Medicaid,,1299.70,,,,,,,1299.70,4491.81,percent of total billed charges,
HC REX COLONOSCOPY,63600004,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,WellCare of North Carolina,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC CHG EGD REX ONLY,63600005,CDM,750,RC,,,,,facility,outpatient,,,2604.00000,1562.40000,WellCare of North Carolina,Managed Medicaid,,521.32,,,,,,,521.32,1936.07,percent of total billed charges,
HC OR TIME 601-660 MIN,63600006,CDM,360,RC,,,,,facility,outpatient,,,26158.00000,15694.80000,WellCare of North Carolina,Managed Medicaid,,5236.83,,,,,,,5236.83,18098.72,percent of total billed charges,
HC OR TIME 661-720 MIN,63600007,CDM,360,RC,,,,,facility,outpatient,,,27399.00000,16439.40000,WellCare of North Carolina,Managed Medicaid,,5485.28,,,,,,,5485.28,18957.37,percent of total billed charges,
HC OR TIME 721-780 MIN,63600008,CDM,360,RC,,,,,facility,outpatient,,,28837.00000,17302.20000,WellCare of North Carolina,Managed Medicaid,,5773.17,,,,,,,5773.17,19952.32,percent of total billed charges,
HC OR TIME 781-840 MIN,63600009,CDM,360,RC,,,,,facility,outpatient,,,30074.00000,18044.40000,WellCare of North Carolina,Managed Medicaid,,6020.81,,,,,,,6020.81,20808.20,percent of total billed charges,
HC OR TIME 841-900 MIN,63600010,CDM,360,RC,,,,,facility,outpatient,,,31316.00000,18789.60000,WellCare of North Carolina,Managed Medicaid,,6269.46,,,,,,,6269.46,21667.54,percent of total billed charges,
HC OR TIME 901-960 MIN,63600011,CDM,360,RC,,,,,facility,outpatient,,,32554.00000,19532.40000,WellCare of North Carolina,Managed Medicaid,,6517.31,,,,,,,6517.31,22524.11,percent of total billed charges,
HC OR TIME 961-1020 MIN,63600012,CDM,360,RC,,,,,facility,outpatient,,,33591.00000,20154.60000,WellCare of North Carolina,Managed Medicaid,,6724.92,,,,,,,6724.92,23241.61,percent of total billed charges,
HC OR TIME 1021-1080 MIN,63600013,CDM,360,RC,,,,,facility,outpatient,,,35029.00000,21017.40000,WellCare of North Carolina,Managed Medicaid,,7012.81,,,,,,,7012.81,24236.57,percent of total billed charges,
HC OR TIME 1081-1140 MIN,63600014,CDM,360,RC,,,,,facility,outpatient,,,36268.00000,21760.80000,WellCare of North Carolina,Managed Medicaid,,7260.85,,,,,,,7260.85,25093.83,percent of total billed charges,
HC OR TIME 1141-1200 MIN,63600015,CDM,360,RC,,,,,facility,outpatient,,,37507.00000,22504.20000,WellCare of North Carolina,Managed Medicaid,,7508.90,,,,,,,7508.90,25951.09,percent of total billed charges,
HC OR TIME 1201-1260 MIN,63600016,CDM,360,RC,,,,,facility,outpatient,,,38747.00000,23248.20000,WellCare of North Carolina,Managed Medicaid,,7757.15,,,,,,,7757.15,26809.05,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 0 TO 60 MIN,63600017,CDM,360,RC,,,,,facility,outpatient,,,388.00000,232.80000,WellCare of North Carolina,Managed Medicaid,,77.68,,,,,,,77.68,268.46,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 61 TO 120 MIN,63600018,CDM,360,RC,,,,,facility,outpatient,,,534.00000,320.40000,WellCare of North Carolina,Managed Medicaid,,106.91,,,,,,,106.91,369.47,percent of total billed charges,
HC PAIN MANAGEMENT 121 TO 180 MIN,63600019,CDM,360,RC,,,,,facility,outpatient,,,829.00000,497.40000,WellCare of North Carolina,Managed Medicaid,,165.97,,,,,,,165.97,573.59,percent of total billed charges,
HC PAIN MANAGEMENT THERAPY 181 TO 240 MIN,63600020,CDM,360,RC,,,,,facility,outpatient,,,836.00000,501.60000,WellCare of North Carolina,Managed Medicaid,,167.37,,,,,,,167.37,578.43,percent of total billed charges,
HC PROCEDURE TIME 0 TO 30 MINS,63600021,CDM,360,RC,,,,,facility,outpatient,,,4035.00000,2421.00000,WellCare of North Carolina,Managed Medicaid,,807.81,,,,,,,807.81,2791.82,percent of total billed charges,
HC PROCEDURE TIME 121 TO 150 MINS,63600022,CDM,360,RC,,,,,facility,outpatient,,,9685.00000,5811.00000,WellCare of North Carolina,Managed Medicaid,,1938.94,,,,,,,1938.94,6701.05,percent of total billed charges,
HC PROCEDURE TIME 151 TO 180 MINS,63600023,CDM,360,RC,,,,,facility,outpatient,,,10407.00000,6244.20000,WellCare of North Carolina,Managed Medicaid,,2083.48,,,,,,,2083.48,7200.60,percent of total billed charges,
HC PROCEDURE TIME 211 TO 240 MINS,63600024,CDM,360,RC,,,,,facility,outpatient,,,11179.00000,6707.40000,WellCare of North Carolina,Managed Medicaid,,2238.04,,,,,,,2238.04,7734.75,percent of total billed charges,
HC PROCEDURE TIME 31 TO 60 MINS,63600025,CDM,360,RC,,,,,facility,outpatient,,,6094.00000,3656.40000,WellCare of North Carolina,Managed Medicaid,,1220.02,,,,,,,1220.02,4216.44,percent of total billed charges,
HC PROCEDURE TIME 61 TO 90 MINS,63600026,CDM,360,RC,,,,,facility,outpatient,,,7873.00000,4723.80000,WellCare of North Carolina,Managed Medicaid,,1576.17,,,,,,,1576.17,5447.33,percent of total billed charges,
HC PROCEDURE TIME 91 TO 120 MINS,63600027,CDM,360,RC,,,,,facility,outpatient,,,8955.00000,5373.00000,WellCare of North Carolina,Managed Medicaid,,1792.79,,,,,,,1792.79,6195.96,percent of total billed charges,
HC PROCEDURE TIME 241 TO 270 MINS,63600028,CDM,360,RC,,,,,facility,outpatient,,,11530.00000,6918.00000,WellCare of North Carolina,Managed Medicaid,,2308.31,,,,,,,2308.31,7977.61,percent of total billed charges,
HC PROCEDURE TIME 271 TO 300 MINS,63600029,CDM,360,RC,,,,,facility,outpatient,,,11836.00000,7101.60000,WellCare of North Carolina,Managed Medicaid,,2369.57,,,,,,,2369.57,8189.33,percent of total billed charges,
HC PROCEDURE TIME 301 TO 330 MINS,63600030,CDM,360,RC,,,,,facility,outpatient,,,12124.00000,7274.40000,WellCare of North Carolina,Managed Medicaid,,2427.22,,,,,,,2427.22,8388.60,percent of total billed charges,
HC PROCEDURE TIME 331 TO 360 MINS,63600031,CDM,360,RC,,,,,facility,outpatient,,,12413.00000,7447.80000,WellCare of North Carolina,Managed Medicaid,,2485.08,,,,,,,2485.08,8588.55,percent of total billed charges,
HC PROCEDURE TIME 361 TO 390 MINS,63600032,CDM,360,RC,,,,,facility,outpatient,,,12701.00000,7620.60000,WellCare of North Carolina,Managed Medicaid,,2542.74,,,,,,,2542.74,8787.82,percent of total billed charges,
HC MINOR PROCEDURE 0-60,63600033,CDM,360,RC,,,,,facility,outpatient,,,4946.00000,2967.60000,WellCare of North Carolina,Managed Medicaid,,990.19,,,,,,,990.19,3422.14,percent of total billed charges,
HC CELL SAVER MACHINE,63600121,CDM,360,RC,,,,,facility,outpatient,,,668.00000,400.80000,WellCare of North Carolina,Managed Medicaid,,133.73,,,,,,,133.73,462.19,percent of total billed charges,
HC OR TIME 0-30 MIN,63600122,CDM,360,RC,,,,,facility,outpatient,,,4406.00000,2643.60000,WellCare of North Carolina,Managed Medicaid,,882.08,,,,,,,882.08,3048.51,percent of total billed charges,
HC OR TIME 31-60 MIN,63600123,CDM,360,RC,,,,,facility,outpatient,,,5949.00000,3569.40000,WellCare of North Carolina,Managed Medicaid,,1190.99,,,,,,,1190.99,4116.11,percent of total billed charges,
HC OR TIME 61-90 MIN,63600124,CDM,360,RC,,,,,facility,outpatient,,,8146.00000,4887.60000,WellCare of North Carolina,Managed Medicaid,,1630.83,,,,,,,1630.83,5636.22,percent of total billed charges,
HC OR TIME 91-120 MIN,63600125,CDM,360,RC,,,,,facility,outpatient,,,10324.00000,6194.40000,WellCare of North Carolina,Managed Medicaid,,2066.86,,,,,,,2066.86,7143.18,percent of total billed charges,
HC OR TIME 121-150 MIN,63600126,CDM,360,RC,,,,,facility,outpatient,,,11787.00000,7072.20000,WellCare of North Carolina,Managed Medicaid,,2359.76,,,,,,,2359.76,8155.43,percent of total billed charges,
HC OR TIME 151-180 MIN,63600127,CDM,360,RC,,,,,facility,outpatient,,,13350.00000,8010.00000,WellCare of North Carolina,Managed Medicaid,,2672.67,,,,,,,2672.67,9236.86,percent of total billed charges,
HC OR TIME 181-210 MIN,63600128,CDM,360,RC,,,,,facility,outpatient,,,15229.00000,9137.40000,WellCare of North Carolina,Managed Medicaid,,3048.85,,,,,,,3048.85,10536.95,percent of total billed charges,
HC OR TIME 211-240 MIN,63600129,CDM,360,RC,,,,,facility,outpatient,,,16324.00000,9794.40000,WellCare of North Carolina,Managed Medicaid,,3268.06,,,,,,,3268.06,11294.58,percent of total billed charges,
HC OR TIME 241-270 MIN,63600130,CDM,360,RC,,,,,facility,outpatient,,,17940.00000,10764.00000,WellCare of North Carolina,Managed Medicaid,,3591.59,,,,,,,3591.59,12412.69,percent of total billed charges,
HC OR TIME 271-300 MIN,63600131,CDM,360,RC,,,,,facility,outpatient,,,18819.00000,11291.40000,WellCare of North Carolina,Managed Medicaid,,3767.56,,,,,,,3767.56,13020.87,percent of total billed charges,
HC OR TIME 301-330 MIN,63600132,CDM,360,RC,,,,,facility,outpatient,,,19970.00000,11982.00000,WellCare of North Carolina,Managed Medicaid,,3997.99,,,,,,,3997.99,13817.24,percent of total billed charges,
HC OR TIME 331-360 MIN,63600133,CDM,360,RC,,,,,facility,outpatient,,,20711.00000,12426.60000,WellCare of North Carolina,Managed Medicaid,,4146.34,,,,,,,4146.34,14329.94,percent of total billed charges,
HC OR TIME 361-390 MIN,63600134,CDM,360,RC,,,,,facility,outpatient,,,20897.00000,12538.20000,WellCare of North Carolina,Managed Medicaid,,4183.58,,,,,,,4183.58,14458.63,percent of total billed charges,
HC OR TIME 391-420 MIN,63600135,CDM,360,RC,,,,,facility,outpatient,,,21207.00000,12724.20000,WellCare of North Carolina,Managed Medicaid,,4245.64,,,,,,,4245.64,14673.12,percent of total billed charges,
HC OR TIME 421-450 MIN,63600136,CDM,360,RC,,,,,facility,outpatient,,,21825.00000,13095.00000,WellCare of North Carolina,Managed Medicaid,,4369.36,,,,,,,4369.36,15100.72,percent of total billed charges,
HC OR TIME 451-480 MIN,63600137,CDM,360,RC,,,,,facility,outpatient,,,22444.00000,13466.40000,WellCare of North Carolina,Managed Medicaid,,4493.29,,,,,,,4493.29,15529.00,percent of total billed charges,
HC OR TIME 481-510 MIN,63600138,CDM,360,RC,,,,,facility,outpatient,,,23062.00000,13837.20000,WellCare of North Carolina,Managed Medicaid,,4617.01,,,,,,,4617.01,15956.60,percent of total billed charges,
HC OR TIME 511-540 MIN,63600139,CDM,360,RC,,,,,facility,outpatient,,,23685.00000,14211.00000,WellCare of North Carolina,Managed Medicaid,,4741.74,,,,,,,4741.74,16387.65,percent of total billed charges,
HC OR TIME 541-570 MIN,63600140,CDM,360,RC,,,,,facility,outpatient,,,24302.00000,14581.20000,WellCare of North Carolina,Managed Medicaid,,4865.26,,,,,,,4865.26,16814.55,percent of total billed charges,
HC OR TIME 571-600 MIN,63600141,CDM,360,RC,,,,,facility,outpatient,,,24922.00000,14953.20000,WellCare of North Carolina,Managed Medicaid,,4989.38,,,,,,,4989.38,17243.53,percent of total billed charges,
HC CHG SEPTOPLASTY,63600146,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,WellCare of North Carolina,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG ADENOIDECTOMY BIL TONSI,63600148,CDM,360,RC,,,,,facility,outpatient,,,11362.00000,6817.20000,WellCare of North Carolina,Managed Medicaid,,2274.67,,,,,,,2274.67,7861.37,percent of total billed charges,
HC CHG TONSILLECTOMY,63600149,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,WellCare of North Carolina,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG LAP RX EN Y GAS BYPSW E,63600150,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP APPL GASTRIC BAND,63600151,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SNG W APP GASTRIC B,63600152,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG ROUX EN Y GASTR BYP EGD,63600153,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG LAP SLEEVE GASTRECW EG,63600154,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG REVIS GASTRIC BAND PORT,63600155,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC CHG HERNIA INGUIN FEM BILAT,63600156,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,WellCare of North Carolina,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG HERNIA INGUIN FEM REPAIR,63600157,CDM,360,RC,,,,,facility,outpatient,,,7043.00000,4225.80000,WellCare of North Carolina,Managed Medicaid,,1410.01,,,,,,,1410.01,4873.05,percent of total billed charges,
HC CHG MYRINGOTOMY,63600158,CDM,360,RC,,,,,facility,outpatient,,,6480.00000,3888.00000,WellCare of North Carolina,Managed Medicaid,,1297.30,,,,,,,1297.30,4483.51,percent of total billed charges,
HC CHG SEPTOPLASTY ENDO SINUS,63600159,CDM,360,RC,,,,,facility,outpatient,,,13406.00000,8043.60000,WellCare of North Carolina,Managed Medicaid,,2683.88,,,,,,,2683.88,9275.61,percent of total billed charges,
HC CHG MYRINGOTOMY ADENOID,63600160,CDM,360,RC,,,,,facility,outpatient,,,7562.00000,4537.20000,WellCare of North Carolina,Managed Medicaid,,1513.91,,,,,,,1513.91,5232.15,percent of total billed charges,
HC CHG MYRING ADENOID TONSIL,63600161,CDM,360,RC,,,,,facility,outpatient,,,8521.00000,5112.60000,WellCare of North Carolina,Managed Medicaid,,1705.90,,,,,,,1705.90,5895.68,percent of total billed charges,
HC PROF FEE FOR BIVAD PER HOUR,63600169,CDM,360,RC,,,,,facility,outpatient,,,303.00000,181.80000,WellCare of North Carolina,Managed Medicaid,,60.66,,,,,,,60.66,209.65,percent of total billed charges,
HC AUTOTRANSFUSION PROFESSIONAL FEE,63600175,CDM,360,RC,,,,,facility,outpatient,,,1271.00000,762.60000,WellCare of North Carolina,Managed Medicaid,,254.45,,,,,,,254.45,879.40,percent of total billed charges,
HC AUTOTRANSFUSION STANDBY FEE,63600176,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,WellCare of North Carolina,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC AUTOTRANSFUSION CANCELLATION FEE,63600177,CDM,360,RC,,,,,facility,outpatient,,,508.00000,304.80000,WellCare of North Carolina,Managed Medicaid,,101.70,,,,,,,101.70,351.49,percent of total billed charges,
HC EXCHANGE LYSIS CATH,63600178,CDM,360,RC,,,,,facility,outpatient,,,808.00000,484.80000,WellCare of North Carolina,Managed Medicaid,,161.76,,,,,,,161.76,559.06,percent of total billed charges,
HC PROCEDURE TIME 181 TO 210 MINS,63600181,CDM,360,RC,,,,,facility,outpatient,,,10794.00000,6476.40000,WellCare of North Carolina,Managed Medicaid,,2160.96,,,,,,,2160.96,7468.37,percent of total billed charges,
HC FEE LOANER PECTUS,63600234,CDM,360,RC,,,,,facility,outpatient,,,1890.00000,1134.00000,WellCare of North Carolina,Managed Medicaid,,378.38,,,,,,,378.38,1307.69,percent of total billed charges,
HC THORACENTESIS W O IMAGING,63610014,CDM,361,RC,,,,,facility,outpatient,,,1225.00000,735.00000,WellCare of North Carolina,Managed Medicaid,,245.25,,,,,,,245.25,847.58,percent of total billed charges,
HC GREENLIGHT LASER,63610072,CDM,272,RC,,,,,facility,outpatient,,,7174.00000,4304.40000,WellCare of North Carolina,Managed Medicaid,,1436.23,,,,,,,1436.23,5832.46,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CHEMICAL PLEURODESIS,63610090,CDM,361,RC,,,,,facility,outpatient,,,296.00000,177.60000,WellCare of North Carolina,Managed Medicaid,,59.26,,,,,,,59.26,204.80,percent of total billed charges,
HC ANESTHESIA 0-30 MIN,63700001,CDM,370,RC,,,,,facility,outpatient,,,756.00000,453.60000,WellCare of North Carolina,Managed Medicaid,,151.35,,,,,,,151.35,614.63,percent of total billed charges,
HC ANESTHESIA EACH ADDL 1 MIN,63700002,CDM,370,RC,,,,,facility,outpatient,,,3.00000,1.80000,WellCare of North Carolina,Managed Medicaid,,0.60060,,,,,,,0.60060,2.44,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 0-60,67100001,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,WellCare of North Carolina,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 61-90,67100002,CDM,710,RC,,,,,facility,outpatient,,,2127.00000,1276.20000,WellCare of North Carolina,Managed Medicaid,,425.83,,,,,,,425.83,1729.25,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 91-120,67100003,CDM,710,RC,,,,,facility,outpatient,,,2607.00000,1564.20000,WellCare of North Carolina,Managed Medicaid,,521.92,,,,,,,521.92,2119.49,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 121-15,67100004,CDM,710,RC,,,,,facility,outpatient,,,3085.00000,1851.00000,WellCare of North Carolina,Managed Medicaid,,617.62,,,,,,,617.62,2508.11,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 151-18,67100005,CDM,710,RC,,,,,facility,outpatient,,,3564.00000,2138.40000,WellCare of North Carolina,Managed Medicaid,,713.51,,,,,,,713.51,2897.53,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE 181-21,67100006,CDM,710,RC,,,,,facility,outpatient,,,4043.00000,2425.80000,WellCare of North Carolina,Managed Medicaid,,809.41,,,,,,,809.41,3286.96,percent of total billed charges,
HC POST PROCEDURE RECOVERY CARE >210,67100007,CDM,710,RC,,,,,facility,outpatient,,,4521.00000,2712.60000,WellCare of North Carolina,Managed Medicaid,,905.10,,,,,,,905.10,3675.57,percent of total billed charges,
HC POST PROCEDURE CARE NO SEDATION,67100008,CDM,710,RC,,,,,facility,outpatient,,,661.00000,396.60000,WellCare of North Carolina,Managed Medicaid,,132.33,,,,,,,132.33,537.39,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 240-300 MINS,67100018,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,WellCare of North Carolina,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE OVER 300 MIN,67100019,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,WellCare of North Carolina,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 0-30 MINS,67100020,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,WellCare of North Carolina,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 31-60 MINS,67100021,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,WellCare of North Carolina,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 61-90 MINS,67100022,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,WellCare of North Carolina,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 91-120 MINS,67100023,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,WellCare of North Carolina,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 121-150 MINS,67100024,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,WellCare of North Carolina,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 151-180 MINS,67100025,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,WellCare of North Carolina,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC LEVEL 1 RECOVERY DISCHARGE 181-240 MINS,67100026,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,WellCare of North Carolina,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC LEVEL 2 POST RECOVERY CARE 1ST HR,67100027,CDM,710,RC,,,,,facility,outpatient,,,1649.00000,989.40000,WellCare of North Carolina,Managed Medicaid,,330.13,,,,,,,330.13,1340.64,percent of total billed charges,
HC LEVEL 2 POST RECOVERY EACH ADD HR,67100028,CDM,710,RC,,,,,facility,outpatient,,,958.00000,574.80000,WellCare of North Carolina,Managed Medicaid,,191.79,,,,,,,191.79,778.85,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 121 TO 150 MINS,67100050,CDM,710,RC,,,,,facility,outpatient,,,2387.00000,1432.20000,WellCare of North Carolina,Managed Medicaid,,477.88,,,,,,,477.88,1940.63,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 0 TO 30 MINS,67100079,CDM,710,RC,,,,,facility,outpatient,,,1294.00000,776.40000,WellCare of North Carolina,Managed Medicaid,,259.06,,,,,,,259.06,1052.02,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 31 TO 60 MINS,67100080,CDM,710,RC,,,,,facility,outpatient,,,1763.00000,1057.80000,WellCare of North Carolina,Managed Medicaid,,352.95,,,,,,,352.95,1433.32,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 61 TO 90 MINS,67100081,CDM,710,RC,,,,,facility,outpatient,,,1966.00000,1179.60000,WellCare of North Carolina,Managed Medicaid,,393.59,,,,,,,393.59,1598.36,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 91 TO 120 MINS,67100082,CDM,710,RC,,,,,facility,outpatient,,,2177.00000,1306.20000,WellCare of North Carolina,Managed Medicaid,,435.84,,,,,,,435.84,1769.90,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 151 TO 180 MINS,67100085,CDM,710,RC,,,,,facility,outpatient,,,2596.00000,1557.60000,WellCare of North Carolina,Managed Medicaid,,519.72,,,,,,,519.72,2110.55,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 181 TO 240 MINS,67100086,CDM,710,RC,,,,,facility,outpatient,,,2807.00000,1684.20000,WellCare of North Carolina,Managed Medicaid,,561.96,,,,,,,561.96,2282.09,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY 240 TO 300 MINS,67100087,CDM,710,RC,,,,,facility,outpatient,,,3280.00000,1968.00000,WellCare of North Carolina,Managed Medicaid,,656.66,,,,,,,656.66,2666.64,percent of total billed charges,
HC PACU LEVEL 1 RECOVERY OVER 300 MINS,67100088,CDM,710,RC,,,,,facility,outpatient,,,4322.00000,2593.20000,WellCare of North Carolina,Managed Medicaid,,865.26,,,,,,,865.26,3513.79,percent of total billed charges,
HC ADULT BRONCH RECOVERY LEVEL 1,67100109,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,WellCare of North Carolina,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC EGD COLONOSCOPY,67500013,CDM,750,RC,,,,,facility,outpatient,,,3430.00000,2058.00000,WellCare of North Carolina,Managed Medicaid,,686.69,,,,,,,686.69,2550.20,percent of total billed charges,
HC ENDO ADDITIONAL TIME 1-15 MIN,67500014,CDM,750,RC,,,,,facility,outpatient,,,285.00000,171.00000,WellCare of North Carolina,Managed Medicaid,,57.06,,,,,,,57.06,211.90,percent of total billed charges,
HC ENDO PROCEDURE TIME 0-15,67500015,CDM,750,RC,,,,,facility,outpatient,,,1357.00000,814.20000,WellCare of North Carolina,Managed Medicaid,,271.67,,,,,,,271.67,1008.93,percent of total billed charges,
HC ENDO PROCEDURE TIME 16-30,67500016,CDM,750,RC,,,,,facility,outpatient,,,1537.00000,922.20000,WellCare of North Carolina,Managed Medicaid,,307.71,,,,,,,307.71,1142.76,percent of total billed charges,
HC ENDO PROCEDURE TIME 31-45,67500017,CDM,750,RC,,,,,facility,outpatient,,,1719.00000,1031.40000,WellCare of North Carolina,Managed Medicaid,,344.14,,,,,,,344.14,1278.08,percent of total billed charges,
HC ENDO PROCEDURE TIME 46-60,67500018,CDM,750,RC,,,,,facility,outpatient,,,1901.00000,1140.60000,WellCare of North Carolina,Managed Medicaid,,380.58,,,,,,,380.58,1413.39,percent of total billed charges,
HC ENDO PROCEDURE TIME 61-75,67500019,CDM,750,RC,,,,,facility,outpatient,,,2085.00000,1251.00000,WellCare of North Carolina,Managed Medicaid,,417.42,,,,,,,417.42,1550.20,percent of total billed charges,
HC ENDO PROCEDURE TIME 76-90,67500020,CDM,750,RC,,,,,facility,outpatient,,,2268.00000,1360.80000,WellCare of North Carolina,Managed Medicaid,,454.05,,,,,,,454.05,1686.26,percent of total billed charges,
HC ENDO PROCEDURE TIME 91-105,67500021,CDM,750,RC,,,,,facility,outpatient,,,2450.00000,1470.00000,WellCare of North Carolina,Managed Medicaid,,490.49,,,,,,,490.49,1821.58,percent of total billed charges,
HC ENDO PROCEDURE TIME 106-120,67500022,CDM,750,RC,,,,,facility,outpatient,,,2631.00000,1578.60000,WellCare of North Carolina,Managed Medicaid,,526.73,,,,,,,526.73,1956.15,percent of total billed charges,
HC ENDO PROCEDURE TIME 121-135,67500023,CDM,750,RC,,,,,facility,outpatient,,,2812.00000,1687.20000,WellCare of North Carolina,Managed Medicaid,,562.96,,,,,,,562.96,2090.72,percent of total billed charges,
HC ENDO PROCEDURE TIME 136-150,67500024,CDM,750,RC,,,,,facility,outpatient,,,2996.00000,1797.60000,WellCare of North Carolina,Managed Medicaid,,599.80,,,,,,,599.80,2227.53,percent of total billed charges,
HC ENDO PROCEDURE TIME 151-165,67500025,CDM,750,RC,,,,,facility,outpatient,,,3177.00000,1906.20000,WellCare of North Carolina,Managed Medicaid,,636.04,,,,,,,636.04,2362.10,percent of total billed charges,
HC ENDO PROCEDURE TIME 166-180,67500026,CDM,750,RC,,,,,facility,outpatient,,,3414.00000,2048.40000,WellCare of North Carolina,Managed Medicaid,,683.48,,,,,,,683.48,2538.31,percent of total billed charges,
HC ENDO PROCEDURE TIME 181-196,67500027,CDM,750,RC,,,,,facility,outpatient,,,3598.00000,2158.80000,WellCare of North Carolina,Managed Medicaid,,720.32,,,,,,,720.32,2675.11,percent of total billed charges,
HC ENDO PROCEDURE TIME 196-210,67500028,CDM,750,RC,,,,,facility,outpatient,,,4293.00000,2575.80000,WellCare of North Carolina,Managed Medicaid,,859.46,,,,,,,859.46,3191.85,percent of total billed charges,
HC ENDO PROCEDURE TIME 211-225,67500029,CDM,750,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,WellCare of North Carolina,Managed Medicaid,,915.71,,,,,,,915.71,3400.77,percent of total billed charges,
HC ENDO PROCEDURE TIME 226-240,67500030,CDM,750,RC,,,,,facility,outpatient,,,4787.00000,2872.20000,WellCare of North Carolina,Managed Medicaid,,958.36,,,,,,,958.36,3559.13,percent of total billed charges,
HC ENDO PROCEDURE TIME 241-255,67500032,CDM,750,RC,,,,,facility,outpatient,,,4969.00000,2981.40000,WellCare of North Carolina,Managed Medicaid,,994.79,,,,,,,994.79,3694.45,percent of total billed charges,
HC ENDO PROCEDURE TIME 256-270,67500033,CDM,750,RC,,,,,facility,outpatient,,,5150.00000,3090.00000,WellCare of North Carolina,Managed Medicaid,,1031.03,,,,,,,1031.03,3829.03,percent of total billed charges,
HC PROC CHG OPEN APPL GASTRIC BAND,67500062,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP BILIOPANC DIV W EGD,67500063,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC PROC CHG LAP RX EN Y GAS BYPASS,67500064,CDM,360,RC,,,,,facility,outpatient,,,4369.00000,2621.40000,WellCare of North Carolina,Managed Medicaid,,874.67,,,,,,,874.67,3022.91,percent of total billed charges,
HC NAVIGATIONAL BRONCHOSOPY,67500066,CDM,361,RC,,,,,facility,outpatient,,,4636.00000,2781.60000,WellCare of North Carolina,Managed Medicaid,,928.13,,,,,,,928.13,3207.65,percent of total billed charges,
HC HEMORRHOIDECTOMY W 2 OR MORE COLUMNS GROUPS WO IMG GUIDANCE,67500068,CDM,750,RC,,,,,facility,outpatient,,,4123.00000,2473.80000,WellCare of North Carolina,Managed Medicaid,,825.42,,,,,,,825.42,3065.45,percent of total billed charges,
HC INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD INCL ASSESSMENT OF DONOR SPECIMEN,67500070,CDM,750,RC,,,,,facility,outpatient,,,2613.00000,1567.80000,WellCare of North Carolina,Managed Medicaid,,523.12,,,,,,,523.12,1942.77,percent of total billed charges,
HC PROCTOSIGMOIDOSCOPY W BIOPSY,67500073,CDM,750,RC,,,,,facility,outpatient,,,2825.00000,1695.00000,WellCare of North Carolina,Managed Medicaid,,565.57,,,,,,,565.57,2100.39,percent of total billed charges,
HC EGD FLEX SIGMOIDOSCOPY,67500111,CDM,750,RC,,,,,facility,outpatient,,,2486.00000,1491.60000,WellCare of North Carolina,Managed Medicaid,,497.70,,,,,,,497.70,1848.34,percent of total billed charges,
HC POUCH ENTEROSCOPY WITH BIOPSY,67500112,CDM,750,RC,,,,,facility,outpatient,,,3342.00000,2005.20000,WellCare of North Carolina,Managed Medicaid,,669.07,,,,,,,669.07,2484.78,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,,,,,facility,outpatient,,,337.00000,202.20000,WellCare of North Carolina,Managed Medicaid,,67.47,,,,,,,67.47,233.17,percent of total billed charges,
HC ADENOIDECTOMY YOUNGER THAN 12 PRIMARY,73600028,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,WellCare of North Carolina,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC ADENOIDECTOMY OLDER THAN 12 PRIMARY,73600029,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,WellCare of North Carolina,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC CHG ADENOIDEC PED SINUS WAS,73600037,CDM,360,RC,,,,,facility,outpatient,,,10082.00000,6049.20000,WellCare of North Carolina,Managed Medicaid,,2018.42,,,,,,,2018.42,6975.74,percent of total billed charges,
HC PERFUSION PROFESS FEE IABP,73600038,CDM,360,RC,,,,,facility,outpatient,,,1275.00000,765.00000,WellCare of North Carolina,Managed Medicaid,,255.25,,,,,,,255.25,882.17,percent of total billed charges,
HC PERFUSION SERVICE FEE OPCABG BRA,73600039,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,1257.60000,WellCare of North Carolina,Managed Medicaid,,419.62,,,,,,,419.62,1450.22,percent of total billed charges,
HC PERFUSION SERVICE FEE STAND BY,73600040,CDM,360,RC,,,,,facility,outpatient,,,2329.00000,1397.40000,WellCare of North Carolina,Managed Medicaid,,466.27,,,,,,,466.27,1611.44,percent of total billed charges,
HC PERFUSION FEE BRAT CELLSAVER,73600052,CDM,360,RC,,,,,facility,outpatient,,,1264.00000,758.40000,WellCare of North Carolina,Managed Medicaid,,253.05,,,,,,,253.05,874.56,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,361,RC,,,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,96.70,334.19,percent of total billed charges,
HC CATHETER SEG SUBSEG P,73610089,CDM,481,RC,,,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,96.70,9423.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,,,,,facility,outpatient,,,7494.00000,4496.40000,WellCare of North Carolina,Managed Medicaid,,1500.30,,,,,,,1500.30,5185.10,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,,,,,facility,outpatient,,,1016.00000,609.60000,WellCare of North Carolina,Managed Medicaid,,203.40,,,,,,,203.40,702.97,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,,,,,facility,outpatient,,,404.00000,242.40000,WellCare of North Carolina,Managed Medicaid,,80.88,,,,,,,80.88,279.53,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,,,,,facility,outpatient,,,4574.00000,2744.40000,WellCare of North Carolina,Managed Medicaid,,915.71,,,,,,,915.71,3164.75,percent of total billed charges,
HC TRANSCATH PLACE INTRAVAS STENT,73610244,CDM,361,RC,,,,,facility,outpatient,,,10837.00000,6502.20000,WellCare of North Carolina,Managed Medicaid,,2169.57,,,,,,,2169.57,7498.12,percent of total billed charges,
HC BALLOON DILATION OF BILIARY DUCT  INCLDS IMG SI,73610522,CDM,361,RC,,,,,facility,outpatient,,,5274.00000,3164.40000,WellCare of North Carolina,Managed Medicaid,,1055.85,,,,,,,1055.85,3649.08,percent of total billed charges,
HC SCREENING CARDIAC CALCIUM SCORE,79900003,CDM,990,RC,,,,,facility,outpatient,,,307.00000,184.20000,WellCare of North Carolina,Managed Medicaid,,61.46,,,,,,,53.45,230.25,percent of total billed charges,
HC CHEMISTRY REFERENCE,83001641,CDM,301,RC,,,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00750,percent of total billed charges,
HC OR TIME 1261-1320 MIN,93600028,CDM,360,RC,,,,,facility,outpatient,,,39984.00000,23990.40000,WellCare of North Carolina,Managed Medicaid,,8004.80,,,,,,,8004.80,27664.93,percent of total billed charges,
HC OR TIME 1321-1380 MIN,93600029,CDM,360,RC,,,,,facility,outpatient,,,41222.00000,24733.20000,WellCare of North Carolina,Managed Medicaid,,8252.64,,,,,,,8252.64,28521.50,percent of total billed charges,
HC PACEMAKER EP ROOM TIME 0 120MI,93600030,CDM,360,RC,,,,,facility,outpatient,,,1885.00000,1131.00000,WellCare of North Carolina,Managed Medicaid,,377.38,,,,,,,377.38,1304.23,percent of total billed charges,
HC PACEMAKER EP ROOM ADDITIONAL 30 MIN,93600031,CDM,360,RC,,,,,facility,outpatient,,,557.00000,334.20000,WellCare of North Carolina,Managed Medicaid,,111.51,,,,,,,111.51,385.39,percent of total billed charges,
HC PERFUSION SERVICE FEE CABG,93600032,CDM,361,RC,,,,,facility,outpatient,,,2915.00000,1749.00000,WellCare of North Carolina,Managed Medicaid,,583.58,,,,,,,583.58,2016.89,percent of total billed charges,
HC CARDIAC SURVEILLANCE TELEMETRY MONITORING,97300010,CDM,732,RC,,,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,15.42,134.00,percent of total billed charges,
HC REX OBSERVATION CARE PER HOUR,17620005,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,10.56,7281.00,percent of total billed charges,
HC REX INTERMEDIATE OBSERVATION CARE PER HOUR,17620007,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,86.00000,51.60000,WellCare of North Carolina,Managed Medicaid,,17.22,,,,,,,16.21,7281.00,percent of total billed charges,
HC REX INTENSIVE OBSERVATION CARE PER HOUR,17620008,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,183.00000,109.80000,WellCare of North Carolina,Managed Medicaid,,36.64,,,,,,,34.50,7281.00,percent of total billed charges,
HC REX SPECIAL CARE NURSERY OBSERVATION CARE PER HOUR,17620009,CDM,762,RC,G0378,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,18.85,7281.00,percent of total billed charges,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Managed Medicaid,,19.82,,,,,,,18.66,7281.00,percent of total billed charges,
HC ROADSAVER CAROTID ARTERY STENT SYSTEM IDE G140240,22640031,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,1.01000,0.61000,WellCare of North Carolina,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC NANOPARASOL EMBOLIC PROTECTION DEVICE IDE G140240,22640032,CDM,624,RC,C1884,CPT,,,facility,outpatient,,,1.01000,0.61000,WellCare of North Carolina,Managed Medicaid,Q0,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC REX PLEURX PLEURAL CATHETER KIT,22700468,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,WellCare of North Carolina,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC REX OPTI-Q SO2 CCO PA CATHETER HEP,22700469,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,WellCare of North Carolina,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC REX CABLE MULTI-LEAD TRIAL,22700541,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,1375.00000,825.00000,WellCare of North Carolina,Managed Medicaid,,275.27,,,,,,,174.62,1012.27,percent of total billed charges,
HC REX CABLE TRIAL,22700542,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,19569.00000,11741.40000,WellCare of North Carolina,Managed Medicaid,,3917.71,,,,,,,2485.26,14406.70,percent of total billed charges,
HC REX LEAD 16-CONTACT TRIAL 50CM,22700544,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,9120.00000,5472.00000,WellCare of North Carolina,Managed Medicaid,,1825.82,,,,,,,1158.24,6714.14,percent of total billed charges,
HC LEAD RESTORE TRIAL STANDARD,22700545,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,WellCare of North Carolina,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL PERCUT OCTRODE 60CM,22700546,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,4954.00000,2972.40000,WellCare of North Carolina,Managed Medicaid,,991.79,,,,,,,629.16,3647.13,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION TRIAL,22700547,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,7438.00000,4462.80000,WellCare of North Carolina,Managed Medicaid,,1489.09,,,,,,,944.63,5475.86,percent of total billed charges,
HC LEAD 8-CONTACT PRECISION 50CM,22700548,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,8418.00000,5050.80000,WellCare of North Carolina,Managed Medicaid,,1685.28,,,,,,,1069.09,6197.33,percent of total billed charges,
HC LEAD TRIAL SUBCOMPACT 3875-60,22700549,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5120.00000,3072.00000,WellCare of North Carolina,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC LEAD TRIAL 50CM,22700550,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,6348.00000,3808.80000,WellCare of North Carolina,Managed Medicaid,,1270.87,,,,,,,806.20,4673.40,percent of total billed charges,
HC ANESTHESIA CVP CATH MULTILUMEN,22700558,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,WellCare of North Carolina,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC ANESTHESIA CVP CATH S LUMEN,22700559,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,WellCare of North Carolina,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC ANESTHESIA CVP DOUBLE LUMEN,22700560,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,209.00000,125.40000,WellCare of North Carolina,Managed Medicaid,,41.84,,,,,,,26.54,153.87,percent of total billed charges,
HC UNA BOOT WITH CALAMINE,22710016,CDM,271,RC,A6456,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,22.76,percent of total billed charges,
HC PICC CATHETER TRIPLE LUMEN BARD,22720187,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Managed Medicaid,,29.03,,,,,,,18.41,106.75,percent of total billed charges,
HC CVP CATH MULTILUMEN,22720195,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,318.00000,190.80000,WellCare of North Carolina,Managed Medicaid,,63.66,,,,,,,40.39,234.11,percent of total billed charges,
HC 3F POLY SINGLE LUMEN PICC CATH,22720198,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,126.00000,75.60000,WellCare of North Carolina,Managed Medicaid,,25.23,,,,,,,16.00,92.76,percent of total billed charges,
HC 4F POLY SINGLE LUMEN PICC CATH,22720199,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,151.00000,90.60000,WellCare of North Carolina,Managed Medicaid,,30.23,,,,,,,19.18,111.17,percent of total billed charges,
HC 5F POLY SINGLE LUMEN PICC CATH,22720200,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,184.00000,110.40000,WellCare of North Carolina,Managed Medicaid,,36.84,,,,,,,23.37,135.46,percent of total billed charges,
HC 4F POLY DUAL LUMEN PICC CATH,22720201,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,295.00000,177.00000,WellCare of North Carolina,Managed Medicaid,,59.06,,,,,,,37.47,217.18,percent of total billed charges,
HC 5F POLY DUAL LUMEN PICC CATH,22720202,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,355.00000,213.00000,WellCare of North Carolina,Managed Medicaid,,71.07,,,,,,,45.09,261.35,percent of total billed charges,
HC CVP DOUBLE LUMEN,22720211,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1048.00000,628.80000,WellCare of North Carolina,Managed Medicaid,,209.81,,,,,,,133.10,771.54,percent of total billed charges,
HC CVP CATH S LUMEN,22720212,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,103.00000,61.80000,WellCare of North Carolina,Managed Medicaid,,20.62,,,,,,,13.08,75.83,percent of total billed charges,
HC VAT 3FR SINGLE LUMEN BARD PICC,22720215,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,425.00000,255.00000,WellCare of North Carolina,Managed Medicaid,,85.08,,,,,,,53.98,312.88,percent of total billed charges,
HC PLEURX PLEURAL CATHETER,22720221,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,600.00000,360.00000,WellCare of North Carolina,Managed Medicaid,,120.12,,,,,,,76.20,441.72,percent of total billed charges,
HC CATHETER D LUMEN 24CMSCHONXL,22720222,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1073.00000,643.80000,WellCare of North Carolina,Managed Medicaid,,214.81,,,,,,,136.27,789.94,percent of total billed charges,
HC 24CMSCHONXL CATHETER D LUMEN,22720223,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,948.00000,568.80000,WellCare of North Carolina,Managed Medicaid,,189.79,,,,,,,120.40,697.92,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP,22720232,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,WellCare of North Carolina,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC OPTI Q SO2 CCO PA  HEP J TIP,22720233,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,746.00000,447.60000,WellCare of North Carolina,Managed Medicaid,,149.35,,,,,,,94.74,549.21,percent of total billed charges,
HC CHEST TUBE INSERTION,22720234,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,34.67,200.98,percent of total billed charges,
HC ULTRAFILTRATION CATHETER,22720458,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,774.00000,464.40000,WellCare of North Carolina,Managed Medicaid,,154.95,,,,,,,98.30,569.82,percent of total billed charges,
HC Q GUIDE ELECTRODE INSERTION TOOL,22720459,CDM,272,RC,C1762,CPT,,,facility,outpatient,,,5120.00000,3072.00000,WellCare of North Carolina,Managed Medicaid,,1025.02,,,,,,,1025.02,4162.56,percent of total billed charges,
HC SUP ARROW TRIPLE LUMEN CVA CATH,22720468,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,503.00000,301.80000,WellCare of North Carolina,Managed Medicaid,,100.70,,,,,,,63.88,370.31,percent of total billed charges,
HC CATHETER DIAG,22720482,CDM,272,RC,C1887,CPT,,,facility,outpatient,,,452.00000,271.20000,WellCare of North Carolina,Managed Medicaid,,90.49,,,,,,,90.49,367.48,percent of total billed charges,
HC PLEURX CATHETER UNC,22720486,CDM,278,RC,C1729,CPT,,,facility,outpatient,,,1349.00000,809.40000,WellCare of North Carolina,Managed Medicaid,,270.07,,,,,,,171.32,993.13,percent of total billed charges,
HC LEAD RESTORE TRIAL COMPACT,22720495,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5120.00000,3072.00000,WellCare of North Carolina,Managed Medicaid,,1025.02,,,,,,,650.24,3769.34,percent of total billed charges,
HC VAT 5FR TL BARD PROVENA PICC,22721008,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1484.00000,890.40000,WellCare of North Carolina,Managed Medicaid,,297.10,,,,,,,188.47,1092.52,percent of total billed charges,
HC VAT 4FR DL BARD PROVENA PICC,22721009,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1379.00000,827.40000,WellCare of North Carolina,Managed Medicaid,,276.08,,,,,,,175.13,1015.22,percent of total billed charges,
HC VAT POWER PRO 20GA 8CM BARD,22721010,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 20GA 10CM BARD,22721011,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 8CM BARD,22721012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC VAT POWER PRO 18GA 10CM BARD,22721013,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,7.37,42.70,percent of total billed charges,
HC CVW SINGLE PICC CATHETER,22721043,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,WellCare of North Carolina,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP DUAL PICC CATHETER,22721044,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,WellCare of North Carolina,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC CVW IP TRIPLE PICC CATHETER,22721045,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,535.00000,321.00000,WellCare of North Carolina,Managed Medicaid,,107.11,,,,,,,67.94,393.87,percent of total billed charges,
HC NEEDLE LOCALIZATION SUPPLY,22721111,CDM,272,RC,C1819,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,0.00813,percent of total billed charges,
HC CT BOSTON CRYO PROBE NEEDLE EACH,22721114,CDM,272,RC,C2618,CPT,,,facility,outpatient,,,6720.00000,4032.00000,WellCare of North Carolina,Managed Medicaid,,1345.34,,,,,,,1345.34,5463.36,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 15CM,22721156,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,WellCare of North Carolina,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 20CM,22721157,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,WellCare of North Carolina,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC BARD POWER TRIALYSIS DIALYSIS CATH 24CM,22721158,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,922.00000,553.20000,WellCare of North Carolina,Managed Medicaid,,184.58,,,,,,,117.09,678.78,percent of total billed charges,
HC VAT 4FR SL BARD PROVENA PICC,22723012,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1215.00000,729.00000,WellCare of North Carolina,Managed Medicaid,,243.24,,,,,,,154.31,894.48,percent of total billed charges,
HC VAT 5FR TRIPLE 3 CG POWER BARD CATHETER,22723014,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,1631.00000,978.60000,WellCare of North Carolina,Managed Medicaid,,326.53,,,,,,,207.14,1200.74,percent of total billed charges,
HC EXTERNAL PULSE GENERATOR 2 PORT HEADER ABBOTT 3032ANS TRIAL KIT,22723019,CDM,272,RC,C1889,CPT,,,facility,outpatient,,,2899.00000,1739.40000,WellCare of North Carolina,Managed Medicaid,,580.38,,,,,,,580.38,2356.89,percent of total billed charges,
HC WRIST FX VELCRO SPLINT,22740018,CDM,274,RC,L3809,CPT,,,facility,outpatient,,,350.00000,210.00000,WellCare of North Carolina,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC HUMERAL FRACTURE ORTHOTIC,22740156,CDM,274,RC,L3980,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Managed Medicaid,,92.69,,,,,,,58.80,340.86,percent of total billed charges,
HC WALKING BOOT PREFABRICATED,22740157,CDM,274,RC,L4387,CPT,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Managed Medicaid,,28.03,,,,,,,17.78,103.07,percent of total billed charges,
HC KNEE IMMOBILIZER PREFABRICATED,22740158,CDM,274,RC,L1830,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,12.06,69.94,percent of total billed charges,
HC KNEE IMMOBILIZER HINGED PREFABRICATED,22740159,CDM,274,RC,L1812,CPT,,,facility,outpatient,,,166.00000,99.60000,WellCare of North Carolina,Managed Medicaid,,33.23,,,,,,,21.08,122.21,percent of total billed charges,
HC WRIST FX SPLINT PREFABRICATED,22740160,CDM,274,RC,L3984,CPT,,,facility,outpatient,,,350.00000,210.00000,WellCare of North Carolina,Managed Medicaid,,70.07,,,,,,,44.45,257.67,percent of total billed charges,
HC WRIST SPLINT PREFABRICATED,22740161,CDM,274,RC,L3908,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,11.56,66.99,percent of total billed charges,
HC ANKLE STIRRUP PREFABRICATED,22740162,CDM,274,RC,L4350,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,12.83,74.36,percent of total billed charges,
HC LEAD NEUROSTIM TEST KIT,22780088,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5270.00000,3162.00000,WellCare of North Carolina,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC SCHON XL DIALYSIS CATH 14FR 20CM,22780089,CDM,278,RC,C1752,CPT,,,facility,outpatient,,,1024.00000,614.40000,WellCare of North Carolina,Managed Medicaid,,205.00,,,,,,,130.05,753.87,percent of total billed charges,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Managed Medicaid,,127.53,,,,,,,80.90,468.96,percent of total billed charges,
HC GRAFT SURGIMEND 20X30,22780109,CDM,636,RC,C9360,CPT,,,facility,outpatient,,,39570.00000,23742.00000,WellCare of North Carolina,Managed Medicaid,,7921.91,,,,,,,7921.91,29368.85,percent of total billed charges,
HC MATRIX WOUND MESHED BILAYER,22780114,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,17004.00000,10202.40000,WellCare of North Carolina,Managed Medicaid,,3404.20,,,,,,,162.39,12620.37,percent of total billed charges,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,WellCare of North Carolina,Managed Medicaid,,59.46,,,,,,,33.78,218.65,percent of total billed charges,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,WellCare of North Carolina,Managed Medicaid,,61.66,,,,,,,33.78,226.75,percent of total billed charges,
HC GRAFT DURAL MAT DURAGEN SUT 1X3,22780122,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,1919.00000,1151.40000,WellCare of North Carolina,Managed Medicaid,,384.18,,,,,,,384.18,1424.28,percent of total billed charges,
HC GRAFT DURAL MATRIX DURAGEN XS,22780123,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,7252.00000,4351.20000,WellCare of North Carolina,Managed Medicaid,,1451.85,,,,,,,1451.85,5382.43,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 100MG,22780124,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,1734.00000,1040.40000,WellCare of North Carolina,Managed Medicaid,,347.15,,,,,,,347.15,1286.97,percent of total billed charges,
HC GRAFT MATRISTEM MICRO PART 200MG,22780125,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,3295.00000,1977.00000,WellCare of North Carolina,Managed Medicaid,,659.66,,,,,,,659.66,2445.55,percent of total billed charges,
HC GRAFT MATRISTEM TISS MATX 20X30C,22780126,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,40220.00000,24132.00000,WellCare of North Carolina,Managed Medicaid,,8052.04,,,,,,,8052.04,29851.28,percent of total billed charges,
HC GRAFT MATRISTEM TISSUE MATRIX 8C,22780127,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,12517.00000,7510.20000,WellCare of North Carolina,Managed Medicaid,,2505.90,,,,,,,2505.90,9290.12,percent of total billed charges,
HC GRAFT MATRISTEM3L TISSMATRIX10X1,22780128,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,11120.00000,6672.00000,WellCare of North Carolina,Managed Medicaid,,2226.22,,,,,,,2226.22,8253.26,percent of total billed charges,
HC GRAFT SURGICAL HERNIA REPAIR 12X15C,22780129,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,15665.00000,9399.00000,WellCare of North Carolina,Managed Medicaid,,3136.13,,,,,,,3136.13,11626.56,percent of total billed charges,
HC GRAFT SURGISIS HERNIA REP 20X30C,22780130,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,31578.00000,18946.80000,WellCare of North Carolina,Managed Medicaid,,6321.92,,,,,,,6321.92,23437.19,percent of total billed charges,
HC GRFT DURAL MATRX DURAGEN PLUS 1X,22780131,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,2639.00000,1583.40000,WellCare of North Carolina,Managed Medicaid,,528.33,,,,,,,528.33,1958.67,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX 6X1,22780132,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,11117.00000,6670.20000,WellCare of North Carolina,Managed Medicaid,,2225.62,,,,,,,2225.62,8251.04,percent of total billed charges,
HC GRFT MATRISTEM TISSUE MATRIX10X1,22780133,CDM,636,RC,C1762,CPT,,,facility,outpatient,,,16042.00000,9625.20000,WellCare of North Carolina,Managed Medicaid,,3211.61,,,,,,,3211.61,11906.37,percent of total billed charges,
HC ELEV SYST W INTEXEN GFT POST REP,22780134,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,9476.00000,5685.60000,WellCare of North Carolina,Managed Medicaid,,1897.10,,,,,,,1203.45,6976.23,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,WellCare of North Carolina,Managed Medicaid,,539.74,,,,,,,539.74,2000.97,percent of total billed charges,
HC ENDURAGEN COLLAGEN 2CMX 5CMX1MM,22780135,CDM,278,RC,C1763,CPT,,,facility,outpatient,,,2696.00000,1617.60000,WellCare of North Carolina,Managed Medicaid,,539.74,,,,,,,342.39,1984.80,percent of total billed charges,
HC MATRISTEM TISSUE MATRIX 7CMX10,22780136,CDM,636,RC,C1763,CPT,,,facility,outpatient,,,8366.00000,5019.60000,WellCare of North Carolina,Managed Medicaid,,1674.87,,,,,,,1674.87,6209.25,percent of total billed charges,
HC MEDTRONIC ADMIRAL DEB IDE G11020,22780137,CDM,624,RC,C1725,CPT,,,facility,outpatient,,,1.01000,0.61000,WellCare of North Carolina,Managed Medicaid,,0.20220,,,,,,,0.20220,0.75750,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 15X140,22780141,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,8920.00000,5352.00000,WellCare of North Carolina,Managed Medicaid,,1785.78,,,,,,,1785.78,6620.42,percent of total billed charges,
HC GFT ARTHROFLEX HUMAN DERM 40X70,22780142,CDM,636,RC,C1781,CPT,,,facility,outpatient,,,11277.00000,6766.20000,WellCare of North Carolina,Managed Medicaid,,2257.66,,,,,,,2257.66,8369.79,percent of total billed charges,
HC GRAFT GORE PROPATEN TW H470045A,22780243,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6131.00000,3678.60000,WellCare of North Carolina,Managed Medicaid,,1227.43,,,,,,,778.64,4513.64,percent of total billed charges,
HC SERI SCAFFOLD 250SQCM 10X25,22780244,CDM,636,RC,Q4100,CPT,,,facility,outpatient,,,15495.00000,9297.00000,WellCare of North Carolina,Managed Medicaid,,3102.10,,,,,,,3102.10,11500.39,percent of total billed charges,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,WellCare of North Carolina,Managed Medicaid,,251.25,,,,,,,35.64,923.93,percent of total billed charges,
HC TISSUE MARKER,22780425,CDM,278,RC,A4648,CPT,,,facility,outpatient,,,537.00000,322.20000,WellCare of North Carolina,Managed Medicaid,,107.51,,,,,,,68.20,395.34,percent of total billed charges,
HC CATHETER DECOMPRESSION,22780426,CDM,278,RC,C1754,CPT,,,facility,outpatient,,,6720.00000,4032.00000,WellCare of North Carolina,Managed Medicaid,,1345.34,,,,,,,853.44,4947.26,percent of total billed charges,
HC VECTRIS SUBCOMPACT TRIAL LEAD KT,22780427,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,5270.00000,3162.00000,WellCare of North Carolina,Managed Medicaid,,1055.05,,,,,,,669.29,3879.77,percent of total billed charges,
HC NEUROSTIM IMPL LEAD 8CH60CM T SJMG DPP HR NONM GEN3 PR,22780473,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,940.00000,564.00000,WellCare of North Carolina,Managed Medicaid,,188.19,,,,,,,119.38,692.03,percent of total billed charges,
HC NEUROSTIM 3013 MULTI LEAD TRIALCABLE,22780474,CDM,278,RC,C1883,CPT,,,facility,outpatient,,,220.00000,132.00000,WellCare of North Carolina,Managed Medicaid,,44.04,,,,,,,27.94,161.96,percent of total billed charges,
HC NEUROSTIM C65EPG TRIAL NON CE BURST,22780475,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,555.00000,333.00000,WellCare of North Carolina,Managed Medicaid,,111.11,,,,,,,70.48,408.59,percent of total billed charges,
HC INFINION 16 TRIAL LEAD SYSTEM 50 CM,22780477,CDM,278,RC,C1897,CPT,,,facility,outpatient,,,5436.00000,3261.60000,WellCare of North Carolina,Managed Medicaid,,1088.29,,,,,,,690.37,4001.98,percent of total billed charges,
HC ENDURA SINGLE LEAD SYSTEM 92446001,22780494,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,19845.00000,11907.00000,WellCare of North Carolina,Managed Medicaid,,3972.97,,,,,,,2520.32,14609.89,percent of total billed charges,
HC EXTENSA DUAL LEAD SYSTEM 92446002,22780495,CDM,278,RC,L8680,CPT,,,facility,outpatient,,,27390.00000,16434.00000,WellCare of North Carolina,Managed Medicaid,,5483.48,,,,,,,3478.53,20164.52,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 18G 10 CM,22780505,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,WellCare of North Carolina,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC POWERGLIDE PRO MIDLINE CATHETER 20G 10 CM,22780506,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,281.00000,168.60000,WellCare of North Carolina,Managed Medicaid,,56.26,,,,,,,35.69,206.87,percent of total billed charges,
HC ACCUCATH INTRAVASCULAR CATHETER 10G BY 2.25 IN,22780507,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,WellCare of North Carolina,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 20G BY 2.25 IN,22780508,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,WellCare of North Carolina,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC VAT ACCUCATH INTRAVASCULAR CATHETER 18G BY 2.25 IN,22780511,CDM,278,RC,C1751,CPT,,,facility,outpatient,,,263.00000,157.80000,WellCare of North Carolina,Managed Medicaid,,52.65,,,,,,,33.40,193.62,percent of total billed charges,
HC SPACEOAR HYDROGEL,22780527,CDM,278,RC,C1889,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00127,0.00736,percent of total billed charges,
HC TRIAL LEAD NEVRO,22780530,CDM,278,RC,C1778,CPT,,,facility,outpatient,,,3125.00000,1875.00000,WellCare of North Carolina,Managed Medicaid,,625.62,,,,,,,396.88,2300.62,percent of total billed charges,
HC REX IP STORZ DISPOSABLE ENDOSCOPE,22780540,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1172.00000,703.20000,WellCare of North Carolina,Managed Medicaid,,234.63,,,,,,,234.63,952.84,percent of total billed charges,
HC REX IP AMBU REGULAR DISPOSABLE ENDOSCOPE,22780541,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1507.00000,904.20000,WellCare of North Carolina,Managed Medicaid,,301.70,,,,,,,301.70,1225.19,percent of total billed charges,
HC REX IP AMBU LARGE DISPOSABLE ENDOSCOPE,22780542,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1415.00000,849.00000,WellCare of North Carolina,Managed Medicaid,,283.28,,,,,,,283.28,1150.39,percent of total billed charges,
HC REX IP AMBU SLIM DISPOSABLE ENDOSCOPE,22780545,CDM,272,RC,C1748,CPT,,,facility,outpatient,,,1370.00000,822.00000,WellCare of North Carolina,Managed Medicaid,,274.27,,,,,,,274.27,1113.81,percent of total billed charges,
HC SCAFFOLD TRIAL IDE G110127,26240007,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,9964.00000,5978.40000,WellCare of North Carolina,Managed Medicaid,,1994.79,,,,,,,1994.79,7473.00,percent of total billed charges,
HC DURABILITY PAS IDE P110023,26240009,CDM,624,RC,C1876,CPT,,,facility,outpatient,,,6335.00000,3801.00000,WellCare of North Carolina,Managed Medicaid,Q1,1268.27,,,,,,,1268.27,4751.25,percent of total billed charges,
HC COAST IDE G090106,26240010,CDM,624,RC,C1724,CPT,,,facility,outpatient,,,3795.00000,2277.00000,WellCare of North Carolina,Managed Medicaid,Q0,759.76,,,,,,,759.76,2846.25,percent of total billed charges,
HC NXSTAGE THERAPY SOLUTION,32500002,CDM,250,RC,J3490,CPT,,,facility,outpatient,,,182.00000,109.20000,WellCare of North Carolina,Managed Medicaid,,36.44,,,,,,,36.44,147.97,percent of total billed charges,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,WellCare of North Carolina,Managed Medicaid,,84.68,,,,,,,84.68,767.00,percent of total billed charges,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,WellCare of North Carolina,Managed Medicaid,,109.91,,,,,,,95.58,759.00,percent of total billed charges,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,WellCare of North Carolina,Managed Medicaid,,117.12,,,,,,,101.85,759.00,percent of total billed charges,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Managed Medicaid,,75.48,,,,,,,44.39,759.00,percent of total billed charges,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Managed Medicaid,,75.48,,,,,,,65.64,759.00,percent of total billed charges,
HC IV INFUSION CONCURRENT,42600006,CDM,260,RC,96368,CPT,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Managed Medicaid,,18.42,,,,,,,16.02,759.00,percent of total billed charges,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Managed Medicaid,,57.66,,,,,,,50.14,759.00,percent of total billed charges,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,WellCare of North Carolina,Managed Medicaid,,87.49,,,,,,,76.08,759.00,percent of total billed charges,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,WellCare of North Carolina,Managed Medicaid,,52.45,,,,,,,44.39,759.00,percent of total billed charges,
HC IV PUSH SAME DRUG EA ADD,42600010,CDM,260,RC,96376,CPT,,,facility,outpatient,,,234.00000,140.40000,WellCare of North Carolina,Managed Medicaid,,46.85,,,,,,,40.74,759.00,percent of total billed charges,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,WellCare of North Carolina,Managed Medicaid,,130.53,,,,,,,113.51,759.00,percent of total billed charges,
HC ANTERIOR AFO,42740001,CDM,274,RC,L1941,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,13.97,80.98,percent of total billed charges,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,WellCare of North Carolina,Managed Medicaid,,6.61,,,,,,,3.90,24.75,percent of total billed charges,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,WellCare of North Carolina,Managed Medicaid,,380.18,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,,23.42,,,,,,,23.42,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,WellCare of North Carolina,Managed Medicaid,,48.05,,,,,,,48.05,3466.00,percent of total billed charges,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,WellCare of North Carolina,Managed Medicaid,,72.07,,,,,,,72.07,3466.00,percent of total billed charges,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Managed Medicaid,,92.69,,,,,,,92.69,3466.00,percent of total billed charges,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,WellCare of North Carolina,Managed Medicaid,,84.08,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,WellCare of North Carolina,Managed Medicaid,,389.79,,,,,,,319.11,3466.00,percent of total billed charges,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,WellCare of North Carolina,Managed Medicaid,,398.40,,,,,,,319.11,3466.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,WellCare of North Carolina,Managed Medicaid,,186.59,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,WellCare of North Carolina,Managed Medicaid,,281.68,,,,,,,127.74,1067.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,WellCare of North Carolina,Managed Medicaid,,292.29,,,,,,,292.29,1095.00,percent of total billed charges,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,WellCare of North Carolina,Managed Medicaid,,345.14,,,,,,,345.14,1293.00,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,WellCare of North Carolina,Managed Medicaid,,420.02,,,,,,,352.19,1573.50,percent of total billed charges,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,WellCare of North Carolina,Managed Medicaid,,704.50,,,,,,,352.19,2639.25,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,WellCare of North Carolina,Managed Medicaid,,1249.65,,,,,,,688.00,4681.50,percent of total billed charges,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,WellCare of North Carolina,Managed Medicaid,,1347.55,,,,,,,688.00,5048.25,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,WellCare of North Carolina,Managed Medicaid,,127.13,,,,,,,127.13,1067.00,percent of total billed charges,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,WellCare of North Carolina,Managed Medicaid,,170.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,WellCare of North Carolina,Managed Medicaid,,1271.67,,,,,,,688.00,4764.00,percent of total billed charges,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,WellCare of North Carolina,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,WellCare of North Carolina,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,WellCare of North Carolina,Managed Medicaid,,339.94,,,,,,,339.94,1273.50,percent of total billed charges,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,WellCare of North Carolina,Managed Medicaid,,554.35,,,,,,,352.19,2076.75,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,WellCare of North Carolina,Managed Medicaid,,146.95,,,,,,,127.74,1067.00,percent of total billed charges,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,WellCare of North Carolina,Managed Medicaid,,219.42,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,WellCare of North Carolina,Managed Medicaid,,93.89,,,,,,,93.89,1067.00,percent of total billed charges,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,WellCare of North Carolina,Managed Medicaid,,193.79,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,WellCare of North Carolina,Managed Medicaid,,137.54,,,,,,,127.74,1067.00,percent of total billed charges,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,WellCare of North Carolina,Managed Medicaid,,309.31,,,,,,,127.74,1158.75,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,WellCare of North Carolina,Managed Medicaid,,214.41,,,,,,,214.41,1067.00,percent of total billed charges,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,WellCare of North Carolina,Managed Medicaid,,372.77,,,,,,,352.19,1396.50,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,WellCare of North Carolina,Managed Medicaid,,90.09,,,,,,,90.09,1067.00,percent of total billed charges,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,WellCare of North Carolina,Managed Medicaid,,241.04,,,,,,,127.74,1067.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,WellCare of North Carolina,Managed Medicaid,,1499.90,,,,,,,352.19,5619.00,percent of total billed charges,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,WellCare of North Carolina,Managed Medicaid,,1492.29,,,,,,,352.19,5590.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,WellCare of North Carolina,Managed Medicaid,,480.08,,,,,,,127.74,1798.50,percent of total billed charges,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,WellCare of North Carolina,Managed Medicaid,,349.55,,,,,,,127.74,1309.50,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,WellCare of North Carolina,Managed Medicaid,,620.62,,,,,,,620.62,3185.00,percent of total billed charges,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,WellCare of North Carolina,Managed Medicaid,,1686.28,,,,,,,1686.28,6317.25,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,425.00000,255.00000,WellCare of North Carolina,Managed Medicaid,,85.08,,,,,,,85.08,1067.00,percent of total billed charges,
HC PORT FILMS,43300047,CDM,333,RC,77417,CPT,,,facility,outpatient,,,567.00000,340.20000,WellCare of North Carolina,Managed Medicaid,,113.51,,,,,,,113.51,1067.00,percent of total billed charges,
HC SBRT MANAGEMENT,43300052,CDM,333,RC,77435,CPT,,,facility,outpatient,,,2178.00000,1306.80000,WellCare of North Carolina,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,WellCare of North Carolina,Managed Medicaid,,418.82,,,,,,,418.82,1569.00,percent of total billed charges,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,WellCare of North Carolina,Managed Medicaid,,927.93,,,,,,,556.54,3476.25,percent of total billed charges,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,WellCare of North Carolina,Managed Medicaid,,492.09,,,,,,,492.09,1843.50,percent of total billed charges,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,WellCare of North Carolina,Managed Medicaid,,600.40,,,,,,,600.40,2249.25,percent of total billed charges,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,WellCare of North Carolina,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC SUPERVISION HANDLING LOADING,43300065,CDM,333,RC,77790,CPT,,,facility,outpatient,,,321.00000,192.60000,WellCare of North Carolina,Managed Medicaid,,64.26,,,,,,,64.26,1067.00,percent of total billed charges,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,WellCare of North Carolina,Managed Medicaid,,215.42,,,,,,,215.42,3466.00,percent of total billed charges,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,WellCare of North Carolina,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,WellCare of North Carolina,Managed Medicaid,,120.72,,,,,,,120.72,3466.00,percent of total billed charges,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,WellCare of North Carolina,Managed Medicaid,,99.30,,,,,,,68.47,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,WellCare of North Carolina,Managed Medicaid,,307.71,,,,,,,307.71,3466.00,percent of total billed charges,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Managed Medicaid,,123.12,,,,,,,44.39,3466.00,percent of total billed charges,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,WellCare of North Carolina,Managed Medicaid,,146.95,,,,,,,146.95,3466.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,WellCare of North Carolina,Managed Medicaid,,91.49,,,,,,,91.49,767.00,percent of total billed charges,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,WellCare of North Carolina,Managed Medicaid,,66.27,,,,,,,66.27,767.00,percent of total billed charges,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,WellCare of North Carolina,Managed Medicaid,,104.70,,,,,,,104.70,3466.00,percent of total billed charges,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,WellCare of North Carolina,Managed Medicaid,,1428.43,,,,,,,688.00,5351.25,percent of total billed charges,
HC RESPIRATORY MOTION MGMT SIMUL,43300092,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1032.00000,619.20000,WellCare of North Carolina,Managed Medicaid,,206.61,,,,,,,206.61,1067.00,percent of total billed charges,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,WellCare of North Carolina,Managed Medicaid,,177.98,,,,,,,105.35,1067.00,percent of total billed charges,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,WellCare of North Carolina,Managed Medicaid,,232.83,,,,,,,232.83,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,WellCare of North Carolina,Managed Medicaid,,210.41,,,,,,,210.41,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,WellCare of North Carolina,Managed Medicaid,,281.48,,,,,,,253.01,1067.00,percent of total billed charges,
HC RT TRMT COMPLEX 2ND VISIT,43300096,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,WellCare of North Carolina,Managed Medicaid,76,281.48,,,,,,,281.48,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,WellCare of North Carolina,Managed Medicaid,,750.35,,,,,,,556.54,2811.00,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300098,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,WellCare of North Carolina,Managed Medicaid,76,750.35,,,,,,,688.00,2811.00,percent of total billed charges,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,WellCare of North Carolina,Managed Medicaid,,789.79,,,,,,,556.54,2958.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300100,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,WellCare of North Carolina,Managed Medicaid,76,789.79,,,,,,,688.00,2958.75,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,WellCare of North Carolina,Managed Medicaid,,407.21,,,,,,,352.19,1525.50,percent of total billed charges,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,WellCare of North Carolina,Managed Medicaid,,452.65,,,,,,,352.19,1695.75,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,WellCare of North Carolina,Managed Medicaid,,477.08,,,,,,,352.19,1787.25,percent of total billed charges,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,WellCare of North Carolina,Managed Medicaid,,526.33,,,,,,,352.19,1971.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,WellCare of North Carolina,Managed Medicaid,,366.97,,,,,,,352.19,1374.75,percent of total billed charges,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,WellCare of North Carolina,Managed Medicaid,,524.92,,,,,,,352.19,1966.50,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,WellCare of North Carolina,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300107,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,WellCare of North Carolina,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC DAILY INTRAFRACTION LOC AND TRACKG,43300108,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,WellCare of North Carolina,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,WellCare of North Carolina,Managed Medicaid,,58.46,,,,,,,58.46,3466.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,WellCare of North Carolina,Managed Medicaid,,568.97,,,,,,,568.97,26864.00,percent of total billed charges,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,WellCare of North Carolina,Managed Medicaid,,5465.26,,,,,,,5465.26,26864.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,WellCare of North Carolina,Managed Medicaid,,751.35,,,,,,,667.51,2814.75,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,WellCare of North Carolina,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,WellCare of North Carolina,Managed Medicaid,,864.06,,,,,,,667.51,3237.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 6-10 MV/MEV,43300114,CDM,333,RC,G6008,CPT,,,facility,outpatient,,,648.00000,388.80000,WellCare of North Carolina,Managed Medicaid,,129.73,,,,,,,129.73,1067.00,percent of total billed charges,
HC DAILY TX MGMT INTERMED 11-19 MEV,43300115,CDM,333,RC,G6009,CPT,,,facility,outpatient,,,708.00000,424.80000,WellCare of North Carolina,Managed Medicaid,,141.74,,,,,,,141.74,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX LESS THAN OR EQUAL TO MV/MEV,43300116,CDM,333,RC,G6011,CPT,,,facility,outpatient,,,1225.00000,735.00000,WellCare of North Carolina,Managed Medicaid,,245.25,,,,,,,245.25,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX <=5 MV/MEV,43300117,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,WellCare of North Carolina,Managed Medicaid,,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 11-19 MV/MEV,43300118,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,WellCare of North Carolina,Managed Medicaid,,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX GREATER THAN OR EQUAL TO 20 MV/MEV,43300119,CDM,333,RC,G6014,CPT,,,facility,outpatient,,,938.00000,562.80000,WellCare of North Carolina,Managed Medicaid,,187.79,,,,,,,187.79,1067.00,percent of total billed charges,
HC RT TRMT-INTER,43300121,CDM,333,RC,G6005,CPT,,,facility,outpatient,,,641.00000,384.60000,WellCare of North Carolina,Managed Medicaid,,128.33,,,,,,,128.33,1067.00,percent of total billed charges,
HC IMRT SIMPLE,43300122,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT SIMPLE 2ND VISIT,43300123,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX,43300124,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300125,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC STEREOSCOPIC XRAY GUIDANCE,43300126,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,343.00000,205.80000,WellCare of North Carolina,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,WellCare of North Carolina,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC INTRAFRACTION TRACK MOTION,43300128,CDM,333,RC,77387,CPT,,,facility,outpatient,,,363.00000,217.80000,WellCare of North Carolina,Managed Medicaid,,72.67,,,,,,,72.67,1067.00,percent of total billed charges,
HC IMRT COMPLEX,43300129,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC IMRT COMPLEX 2ND VISIT,43300130,CDM,333,RC,G6015,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,76,373.37,,,,,,,373.37,1398.75,percent of total billed charges,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Managed Medicaid,,91.09,,,,,,,91.09,3466.00,percent of total billed charges,
HC DAILY TX MGMT COMPLEX 2ND VISIT,43300133,CDM,333,RC,G6012,CPT,,,facility,outpatient,,,860.00000,516.00000,WellCare of North Carolina,Managed Medicaid,76,172.17,,,,,,,172.17,1067.00,percent of total billed charges,
HC DAILY MGMT COMPLEX 2ND VISIT,43300134,CDM,333,RC,G6013,CPT,,,facility,outpatient,,,914.00000,548.40000,WellCare of North Carolina,Managed Medicaid,76,182.98,,,,,,,182.98,1067.00,percent of total billed charges,
HC JV THERAPEUTIC RAD TREATMENT PLANNING COMPLEX GL,43300135,CDM,333,RC,77263,CPT,,,facility,outpatient,,,499.00000,299.40000,WellCare of North Carolina,Managed Medicaid,,99.90,,,,,,,99.90,1067.00,percent of total billed charges,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,WellCare of North Carolina,Managed Medicaid,,209.01,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,WellCare of North Carolina,Managed Medicaid,,326.13,,,,,,,326.13,1221.75,percent of total billed charges,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,WellCare of North Carolina,Managed Medicaid,,469.07,,,,,,,352.19,1757.25,percent of total billed charges,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,WellCare of North Carolina,Managed Medicaid,,1384.18,,,,,,,688.00,5185.50,percent of total billed charges,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,WellCare of North Carolina,Managed Medicaid,,146.75,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,WellCare of North Carolina,Managed Medicaid,,1214.61,,,,,,,688.00,4550.25,percent of total billed charges,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,WellCare of North Carolina,Managed Medicaid,,451.25,,,,,,,352.19,1690.50,percent of total billed charges,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,WellCare of North Carolina,Managed Medicaid,,567.97,,,,,,,352.19,2127.75,percent of total billed charges,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,WellCare of North Carolina,Managed Medicaid,,369.97,,,,,,,352.19,1386.00,percent of total billed charges,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,WellCare of North Carolina,Managed Medicaid,,174.37,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,WellCare of North Carolina,Managed Medicaid,,109.91,,,,,,,109.91,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,WellCare of North Carolina,Managed Medicaid,,161.16,,,,,,,127.74,1067.00,percent of total billed charges,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,WellCare of North Carolina,Managed Medicaid,,250.65,,,,,,,250.65,1067.00,percent of total billed charges,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,WellCare of North Carolina,Managed Medicaid,,1634.43,,,,,,,352.19,6123.00,percent of total billed charges,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,WellCare of North Carolina,Managed Medicaid,,482.48,,,,,,,482.48,1807.50,percent of total billed charges,
HC JV STEREOSCOPIC XRAY GUIDANCE GL,43300151,CDM,333,RC,G6002,CPT,,,facility,outpatient,,,405.00000,243.00000,WellCare of North Carolina,Managed Medicaid,,81.08,,,,,,,81.08,1067.00,percent of total billed charges,
HC JV RADIATION TX MANAGEMENT X5 GL,43300152,CDM,333,RC,77427,CPT,,,facility,outpatient,,,560.00000,336.00000,WellCare of North Carolina,Managed Medicaid,,112.11,,,,,,,112.11,1067.00,percent of total billed charges,
HC JV RESPIRATORY MOTION MANAGEMENT GL,43300153,CDM,333,RC,77293,CPT,,,facility,outpatient,,,1662.00000,997.20000,WellCare of North Carolina,Managed Medicaid,,332.73,,,,,,,332.73,1246.50,percent of total billed charges,
HC JV SBRT PHYSICIAN MGT GL,43300154,CDM,333,RC,77435,CPT,,,facility,outpatient,,,1923.00000,1153.80000,WellCare of North Carolina,Managed Medicaid,,384.98,,,,,,,384.98,1442.25,percent of total billed charges,
HC JV SRS PHYSICIAN MGT GL,43300155,CDM,333,RC,77432,CPT,,,facility,outpatient,,,1274.00000,764.40000,WellCare of North Carolina,Managed Medicaid,,255.05,,,,,,,255.05,1067.00,percent of total billed charges,
HC JV RADIATION THERAPY MGT W COMPLETE COURSE 1 OR 2 FX,43300156,CDM,333,RC,77431,CPT,,,facility,outpatient,,,316.00000,189.60000,WellCare of North Carolina,Managed Medicaid,,63.26,,,,,,,63.26,1067.00,percent of total billed charges,
HC JV INTRAFRACTION TRACK MOTION,43300157,CDM,333,RC,77387,CPT,,,facility,outpatient,,,650.00000,390.00000,WellCare of North Carolina,Managed Medicaid,,130.13,,,,,,,130.13,1067.00,percent of total billed charges,
HC SRS MANAGEMENT,43300158,CDM,333,RC,77432,CPT,,,facility,outpatient,,,2178.00000,1306.80000,WellCare of North Carolina,Managed Medicaid,,436.04,,,,,,,436.04,1633.50,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Managed Medicaid,,625.22,,,,,,,625.22,4376.00,percent of total billed charges,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,WellCare of North Carolina,Managed Medicaid,,70.27,,,,,,,61.11,767.00,percent of total billed charges,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,WellCare of North Carolina,Managed Medicaid,,211.01,,,,,,,211.01,5754.00,percent of total billed charges,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,WellCare of North Carolina,Managed Medicaid,,6.81,,,,,,,6.41,4311.00,percent of total billed charges,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,WellCare of North Carolina,Managed Medicaid,,93.09,,,,,,,93.09,4311.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,WellCare of North Carolina,Managed Medicaid,,205.81,,,,,,,186.78,4376.00,percent of total billed charges,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,WellCare of North Carolina,Managed Medicaid,,242.64,,,,,,,186.78,4376.00,percent of total billed charges,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,WellCare of North Carolina,Managed Medicaid,,64.46,,,,,,,64.46,5189.94,percent of total billed charges,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,WellCare of North Carolina,Managed Medicaid,,151.55,,,,,,,151.55,4376.00,percent of total billed charges,
HC ARTERIAL CATHETER PLACEMENT BY RESPIRATORY THERAPY,43610048,CDM,361,RC,36620,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Managed Medicaid,,32.43,,,,,,,32.43,4311.00,percent of total billed charges,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,WellCare of North Carolina,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC US GUIDANCE INTRST RADIOELEMENT APPLICATION,44020002,CDM,402,RC,76965,CPT,,,facility,outpatient,,,299.00000,179.40000,WellCare of North Carolina,Managed Medicaid,,59.86,,,,,,,59.86,467.00,percent of total billed charges,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,WellCare of North Carolina,Managed Medicaid,,119.12,,,,,,,103.59,4311.00,percent of total billed charges,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,10.97,440.00,percent of total billed charges,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,4.87,440.00,percent of total billed charges,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,WellCare of North Carolina,Managed Medicaid,,60.46,,,,,,,52.58,440.00,percent of total billed charges,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.00,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,10.10,440.00,percent of total billed charges,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,9.75,440.00,percent of total billed charges,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,WellCare of North Carolina,Managed Medicaid,,21.82,,,,,,,18.98,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Managed Medicaid,,40.04,,,,,,,34.82,440.00,percent of total billed charges,
HC CONTINUOUS MEDICATION NEBULIZER PER HR,44100015,CDM,412,RC,94645,CPT,,,facility,outpatient,,,161.00000,96.60000,WellCare of North Carolina,Managed Medicaid,,32.23,,,,,,,28.03,440.00,percent of total billed charges,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Managed Medicaid,,26.63,,,,,,,23.16,440.00,percent of total billed charges,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Managed Medicaid,,22.62,,,,,,,19.67,440.00,percent of total billed charges,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,WellCare of North Carolina,Managed Medicaid,,87.69,,,,,,,76.26,440.00,percent of total billed charges,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Managed Medicaid,,10.01,,,,,,,8.71,440.00,percent of total billed charges,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,WellCare of North Carolina,Managed Medicaid,,82.68,,,,,,,71.90,440.00,percent of total billed charges,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Managed Medicaid,,57.66,,,,,,,50.14,440.00,percent of total billed charges,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,9.40,440.00,percent of total billed charges,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,6.44,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,WellCare of North Carolina,Managed Medicaid,,38.24,,,,,,,33.25,440.00,percent of total billed charges,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Managed Medicaid,,53.85,,,,,,,35.88,440.00,percent of total billed charges,
HC PT BIOFEEDBACK TRAIN ANY MODALITY,44200001,CDM,420,RC,90901,CPT,,,facility,outpatient,,,67.00000,40.20000,WellCare of North Carolina,Managed Medicaid,GP,13.41,,,,,,,10.44,276.00,percent of total billed charges,
HC PT CANALITH REPOSITIONING PER DAY,44200003,CDM,420,RC,95992,CPT,,,facility,outpatient,,,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,GP,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC PT HOT OR COLD PACK APPLICATION,44200004,CDM,420,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,WellCare of North Carolina,Managed Medicaid,GP,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC PT TRACTION MECHANICAL,44200005,CDM,420,RC,97012,CPT,,,facility,outpatient,,,121.00000,72.60000,WellCare of North Carolina,Managed Medicaid,GP,24.22,,,,,,,18.85,276.00,percent of total billed charges,
HC PT VASOPNEUMATIC DEVICE TX,44200006,CDM,420,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,GP,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC PT ANODYNE INFRARED TREATMENT,44200007,CDM,420,RC,97026,CPT,,,facility,outpatient,,,16.00000,9.60000,WellCare of North Carolina,Managed Medicaid,GP,3.20,,,,,,,2.49,276.00,percent of total billed charges,
HC PT E STIM ATTENDED 15MIN,44200008,CDM,420,RC,97032,CPT,,,facility,outpatient,,,153.00000,91.80000,WellCare of North Carolina,Managed Medicaid,GP,30.63,,,,,,,23.84,276.00,percent of total billed charges,
HC PT THERAPEUTIC EXERCISE 15MIN,44200009,CDM,420,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Managed Medicaid,GP,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC PT NEUROMUSC RE EDUCATION 15MIN,44200010,CDM,420,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Managed Medicaid,GP,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC PT GAIT TRAINING 15MIN,44200011,CDM,420,RC,97116,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,GP,22.02,,,,,,,17.14,276.00,percent of total billed charges,
HC PT MASSAGE 15MIN,44200012,CDM,420,RC,97124,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,GP,11.81,,,,,,,9.19,276.00,percent of total billed charges,
HC PT MANUAL THERAPY TECHNIQUE 15MIN,44200013,CDM,420,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Managed Medicaid,GP,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC PT THERAPEUTIC ACTIVITIES 15MIN,44200014,CDM,420,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,WellCare of North Carolina,Managed Medicaid,GP,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC PT WHEELCHAIR MGMNT 15MIN,44200015,CDM,420,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,WellCare of North Carolina,Managed Medicaid,GP,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC PT PHY PERF TEST MEAS 15MIN,44200018,CDM,420,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,GP,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC PT E STIM UNATTENDED,44200040,CDM,420,RC,G0283,CPT,,,facility,outpatient,,,139.00000,83.40000,WellCare of North Carolina,Managed Medicaid,GP,27.83,,,,,,,21.66,276.00,percent of total billed charges,
HC PT WHIRLPOOL,44200044,CDM,420,RC,97022,CPT,,,facility,outpatient,,,202.00000,121.20000,WellCare of North Carolina,Managed Medicaid,GP,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC PT IONTOPHORESIS 15MIN,44200045,CDM,420,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,GP,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC PT ULTRASOUND 15MIN,44200046,CDM,420,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT AQUATIC TX W THERAPEUTIC EX 15 MIN,44200047,CDM,420,RC,97113,CPT,,,facility,outpatient,,,151.00000,90.60000,WellCare of North Carolina,Managed Medicaid,GP,30.23,,,,,,,23.53,276.00,percent of total billed charges,
HC PT WOUND CARE,44200048,CDM,420,RC,97139,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,GP,9.41,,,,,,,7.32,276.00,percent of total billed charges,
HC PT GROUP THERAPY PROCEDURE,44200049,CDM,420,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,GP,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC PT SENSORY INTEGRATION 15MIN,44200050,CDM,420,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,GP,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC PT SELFCARE HOME MGMT TRAINING 15 MIN,44200051,CDM,420,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,GP,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC PT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44200052,CDM,420,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Managed Medicaid,GP,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND 1ST 20 SQ CM OR LESS,44200064,CDM,420,RC,97597,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT DEBRID OPEN WOUND EA ADDL 20 SQ CM,44200065,CDM,420,RC,97598,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Managed Medicaid,GP,36.04,,,,,,,28.04,4311.00,percent of total billed charges,
HC PT COGNITIVE PERFORMANCE TESTING,44200067,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PARAFFIN BATH,44200068,CDM,420,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,GP,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC PT PROSTHETIC TRAINING UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44200130,CDM,420,RC,97761,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,GP,17.82,,,,,,,13.87,276.00,percent of total billed charges,
HC PT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBSQ ENCOUNTER EACH 15MINS,44200131,CDM,420,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,WellCare of North Carolina,Managed Medicaid,GP,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING 1ST 30 MINS,44200181,CDM,420,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Managed Medicaid,GP,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC PT CAREGIVER TRAINING EACH ADDL 15 MINS,44200182,CDM,420,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,GP,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC PT CAREGIVER GROUP TRAINING,44200183,CDM,420,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,GP,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC PT EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240005,CDM,424,RC,97161,CPT,,,facility,outpatient,,,306.00000,183.60000,WellCare of North Carolina,Managed Medicaid,GP,61.26,,,,,,,47.67,276.00,percent of total billed charges,
HC PT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44240006,CDM,424,RC,97162,CPT,,,facility,outpatient,,,423.00000,253.80000,WellCare of North Carolina,Managed Medicaid,GP,84.68,,,,,,,65.90,276.00,percent of total billed charges,
HC PT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44240007,CDM,424,RC,97163,CPT,,,facility,outpatient,,,434.00000,260.40000,WellCare of North Carolina,Managed Medicaid,GP,86.89,,,,,,,67.62,276.00,percent of total billed charges,
HC PT RE EVALUATION 20 MINS W PATIENT AND OR FAMILY,44240014,CDM,424,RC,97164,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Managed Medicaid,GP,57.66,,,,,,,44.87,276.00,percent of total billed charges,
HC OT PARAFFIN BATH,44300002,CDM,430,RC,97018,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,GO,18.22,,,,,,,14.18,276.00,percent of total billed charges,
HC OT IONTOPHORESIS 15MIN,44300004,CDM,430,RC,97033,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,GO,23.42,,,,,,,18.23,276.00,percent of total billed charges,
HC OT ULTRASOUND 15MIN,44300005,CDM,430,RC,97035,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT GROUP THERAPY PROCEDURE,44300009,CDM,430,RC,97150,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,GO,23.62,,,,,,,18.38,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT 15MIN,44300010,CDM,430,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,GO,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC OT SELFCARE HOME MGMT TRAINING 15 MIN,44300012,CDM,430,RC,97535,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,GO,25.83,,,,,,,20.10,276.00,percent of total billed charges,
HC OT COMMUNITY WORK REINTEGRATION TRAINING 15MIN,44300013,CDM,430,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Managed Medicaid,GO,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC OT HOT OR COLD PACK APPLICATION,44300040,CDM,430,RC,97010,CPT,,,facility,outpatient,,,12.00000,7.20000,WellCare of North Carolina,Managed Medicaid,GO,2.40,,,,,,,1.87,276.00,percent of total billed charges,
HC OT THERAPEUTIC EXERCISE 15MIN,44300041,CDM,430,RC,97110,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Managed Medicaid,GO,32.63,,,,,,,25.40,276.00,percent of total billed charges,
HC OT NEUROMUSC RE EDUCATION 15MIN,44300042,CDM,430,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Managed Medicaid,GO,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC OT MASSAGE 15MIN,44300043,CDM,430,RC,97124,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,GO,12.41,,,,,,,9.66,276.00,percent of total billed charges,
HC OT MANUAL THERAPY TECHNIQ 15MIN,44300044,CDM,430,RC,97140,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Managed Medicaid,GO,32.83,,,,,,,25.55,276.00,percent of total billed charges,
HC OT THERAPEUTIC ACTIVITIES 15MIN,44300045,CDM,430,RC,97530,CPT,,,facility,outpatient,,,160.00000,96.00000,WellCare of North Carolina,Managed Medicaid,GO,32.03,,,,,,,24.93,276.00,percent of total billed charges,
HC OT WHEELCHAIR MGMNT 15MIN,44300046,CDM,430,RC,97542,CPT,,,facility,outpatient,,,144.00000,86.40000,WellCare of North Carolina,Managed Medicaid,GO,28.83,,,,,,,22.44,276.00,percent of total billed charges,
HC OT PHY PERF TEST MEAS 15MIN,44300048,CDM,430,RC,97750,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,GO,33.03,,,,,,,25.71,276.00,percent of total billed charges,
HC OT VASOPNEUMATIC DEVICE TX,44300074,CDM,430,RC,97016,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,GO,9.81,,,,,,,7.63,276.00,percent of total billed charges,
HC OT WORKSITE EVALUATION,44300076,CDM,430,RC,97799,CPT,,,facility,outpatient,,,224.00000,134.40000,WellCare of North Carolina,Managed Medicaid,GO,44.84,,,,,,,34.90,276.00,percent of total billed charges,
HC OT ORTHOTIC MNGMT TRAIN UE LE TRUNK INITIAL ENCOUNTER EACH 15MINS,44300090,CDM,430,RC,97760,CPT,,,facility,outpatient,,,152.00000,91.20000,WellCare of North Carolina,Managed Medicaid,GO,30.43,,,,,,,23.68,276.00,percent of total billed charges,
HC OT ORTH PROSTH MNGMT TRAIN UE LE TRUNK SUBQ ENCOUNTER EACH 15MINS,44300091,CDM,430,RC,97763,CPT,,,facility,outpatient,,,127.00000,76.20000,WellCare of North Carolina,Managed Medicaid,GO,25.43,,,,,,,19.79,276.00,percent of total billed charges,
HC OT COGNITIVE SKILL DEVELOPMENT EACH ADDITIONAL 15 MIN,44300102,CDM,430,RC,97130,CPT,,,facility,outpatient,,,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,GO,15.02,,,,,,,11.69,276.00,percent of total billed charges,
HC OT EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340006,CDM,434,RC,97165,CPT,,,facility,outpatient,,,318.00000,190.80000,WellCare of North Carolina,Managed Medicaid,GO,63.66,,,,,,,49.54,276.00,percent of total billed charges,
HC OT EVALUATION 45 MINS W PATIENT AND OR FAMILY,44340007,CDM,434,RC,97166,CPT,,,facility,outpatient,,,403.00000,241.80000,WellCare of North Carolina,Managed Medicaid,GO,80.68,,,,,,,62.79,276.00,percent of total billed charges,
HC OT EVALUATION 60 MINS W PATIENT AND OR FAMILY,44340008,CDM,434,RC,97167,CPT,,,facility,outpatient,,,415.00000,249.00000,WellCare of North Carolina,Managed Medicaid,GO,83.08,,,,,,,64.66,276.00,percent of total billed charges,
HC OT RE EVALUATION 30 MINS W PATIENT AND OR FAMILY,44340009,CDM,434,RC,97168,CPT,,,facility,outpatient,,,202.00000,121.20000,WellCare of North Carolina,Managed Medicaid,GO,40.44,,,,,,,31.47,276.00,percent of total billed charges,
HC SP TREATMENT S L V,44400001,CDM,440,RC,92507,CPT,,,facility,outpatient,,,356.00000,213.60000,WellCare of North Carolina,Managed Medicaid,GN,71.27,,,,,,,55.46,276.00,percent of total billed charges,
HC SP SWALLOWING THERAPY,44400004,CDM,440,RC,92526,CPT,,,facility,outpatient,,,336.00000,201.60000,WellCare of North Carolina,Managed Medicaid,GN,67.27,,,,,,,52.35,276.00,percent of total billed charges,
HC SP THERAPY SPEECH GENERATING DEV,44400005,CDM,440,RC,92609,CPT,,,facility,outpatient,,,187.00000,112.20000,WellCare of North Carolina,Managed Medicaid,GN,37.44,,,,,,,29.13,276.00,percent of total billed charges,
HC SP APHASIA ASSESSMENT,44400006,CDM,440,RC,96105,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Managed Medicaid,GN,53.85,,,,,,,41.91,276.00,percent of total billed charges,
HC SP BIOFEEDBACK TRAIN ANY MODALITY,44400028,CDM,440,RC,90901,CPT,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Managed Medicaid,GN,40.04,,,,,,,31.16,276.00,percent of total billed charges,
HC SP COGNITIVE PERFORMANCE TESTING,44400029,CDM,440,RC,96125,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Managed Medicaid,GN,63.06,,,,,,,49.08,276.00,percent of total billed charges,
HC SP NEUROMUSC RE EDUCATION 15MIN,44400031,CDM,440,RC,97112,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Managed Medicaid,GN,25.63,,,,,,,19.94,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT 15 MIN,44400035,CDM,440,RC,97129,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP SENSORY INTEGRATION 15 MIN,44400036,CDM,440,RC,97533,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,GN,17.02,,,,,,,13.24,276.00,percent of total billed charges,
HC SP COMMUNITY/WORK REINTEGRATION TRAINING 15MIN,44400037,CDM,440,RC,97537,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Managed Medicaid,GN,19.82,,,,,,,15.42,276.00,percent of total billed charges,
HC EVAL SPEECH FLUENCY,44400048,CDM,444,RC,92521,CPT,,,facility,outpatient,,,229.00000,137.40000,WellCare of North Carolina,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SPEECH SOUND PRODUCTION,44400049,CDM,444,RC,92522,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,GN,27.23,,,,,,,21.19,276.00,percent of total billed charges,
HC EVAL SPEECH SOUND LANG COMP/EXP,44400050,CDM,444,RC,92523,CPT,,,facility,outpatient,,,655.00000,393.00000,WellCare of North Carolina,Managed Medicaid,GN,131.13,,,,,,,102.05,399.55,percent of total billed charges,
HC BEHAVRL QUAL ANALYS VOICE,44400051,CDM,444,RC,92524,CPT,,,facility,outpatient,,,259.00000,155.40000,WellCare of North Carolina,Managed Medicaid,GN,51.85,,,,,,,40.35,276.00,percent of total billed charges,
HC SP COGNITIVE SKILL DEVELOPMENT EACH ADDL 15 MIN,44400062,CDM,440,RC,97130,CPT,,,facility,outpatient,,,68.00000,40.80000,WellCare of North Carolina,Managed Medicaid,GN,13.61,,,,,,,10.59,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING 1ST 30 MINS,44400087,CDM,440,RC,97550,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Managed Medicaid,GN,26.03,,,,,,,20.25,276.00,percent of total billed charges,
HC SP CAREGIVER TRAINING EACH ADDL 15 MINS,44400088,CDM,440,RC,97551,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,GN,14.01,,,,,,,10.91,276.00,percent of total billed charges,
HC SP CAREGIVER GROUP TRAINING,44400089,CDM,440,RC,97552,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,GN,6.01,,,,,,,4.67,276.00,percent of total billed charges,
HC SP EVAL FOR USE FIT VOICE PROSTH,44440002,CDM,444,RC,92597,CPT,,,facility,outpatient,,,214.00000,128.40000,WellCare of North Carolina,Managed Medicaid,GN,42.84,,,,,,,33.34,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP SP GEN DEV,44440003,CDM,444,RC,92607,CPT,,,facility,outpatient,,,229.00000,137.40000,WellCare of North Carolina,Managed Medicaid,GN,45.85,,,,,,,35.68,276.00,percent of total billed charges,
HC SP EVAL FOR PRESCRIP ADD 30 MIN,44440004,CDM,444,RC,92608,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,GN,21.42,,,,,,,16.67,276.00,percent of total billed charges,
HC SP SWALLOWING EVALUATION,44440005,CDM,444,RC,92610,CPT,,,facility,outpatient,,,353.00000,211.80000,WellCare of North Carolina,Managed Medicaid,GN,70.67,,,,,,,55.00,276.00,percent of total billed charges,
HC SP MOTION FLUORO EVAL SWALLOW FUNC,44440006,CDM,444,RC,92611,CPT,,,facility,outpatient,,,549.00000,329.40000,WellCare of North Carolina,Managed Medicaid,GN,109.91,,,,,,,85.53,411.75,percent of total billed charges,
HC SP FLEX ENDO EVAL SWALLOW,44440007,CDM,440,RC,92612,CPT,,,facility,outpatient,,,591.00000,354.60000,WellCare of North Carolina,Managed Medicaid,GN,118.32,,,,,,,92.08,443.25,percent of total billed charges,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,WellCare of North Carolina,Managed Medicaid,,172.97,,,,,,,150.42,648.00,percent of total billed charges,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,WellCare of North Carolina,Managed Medicaid,,109.91,,,,,,,95.58,411.75,percent of total billed charges,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,WellCare of North Carolina,Managed Medicaid,,177.18,,,,,,,154.08,663.75,percent of total billed charges,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,WellCare of North Carolina,Managed Medicaid,,100.90,,,,,,,87.75,557.85,percent of total billed charges,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,WellCare of North Carolina,Managed Medicaid,,149.15,,,,,,,129.70,558.75,percent of total billed charges,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,WellCare of North Carolina,Managed Medicaid,,751.95,,,,,,,243.00,2817.00,percent of total billed charges,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Managed Medicaid,,8.61,,,,,,,7.49,374.00,percent of total billed charges,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,WellCare of North Carolina,Managed Medicaid,,29.63,,,,,,,25.77,374.00,percent of total billed charges,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,WellCare of North Carolina,Managed Medicaid,,105.11,,,,,,,91.40,393.75,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,WellCare of North Carolina,Managed Medicaid,,104.70,,,,,,,91.05,392.25,percent of total billed charges,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,WellCare of North Carolina,Managed Medicaid,,112.71,,,,,,,98.02,422.25,percent of total billed charges,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Managed Medicaid,,75.48,,,,,,,65.64,374.00,percent of total billed charges,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,WellCare of North Carolina,Managed Medicaid,,271.67,,,,,,,236.25,1017.75,percent of total billed charges,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,WellCare of North Carolina,Managed Medicaid,,83.68,,,,,,,72.77,374.00,percent of total billed charges,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,WellCare of North Carolina,Managed Medicaid,,162.56,,,,,,,141.37,609.00,percent of total billed charges,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,18.63,374.00,percent of total billed charges,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,WellCare of North Carolina,Managed Medicaid,,113.51,,,,,,,98.71,425.25,percent of total billed charges,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,WellCare of North Carolina,Managed Medicaid,,95.30,,,,,,,82.87,374.00,percent of total billed charges,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,WellCare of North Carolina,Managed Medicaid,,130.53,,,,,,,113.51,489.00,percent of total billed charges,
HC DLCO CARB MON DIFFUS CAPCTY,44600021,CDM,460,RC,94729,CPT,,,facility,outpatient,,,458.00000,274.80000,WellCare of North Carolina,Managed Medicaid,,91.69,,,,,,,79.74,374.00,percent of total billed charges,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Managed Medicaid,,31.23,,,,,,,27.16,374.00,percent of total billed charges,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Managed Medicaid,,36.04,,,,,,,31.34,327.39,percent of total billed charges,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,WellCare of North Carolina,Managed Medicaid,,234.23,,,,,,,203.70,4311.00,percent of total billed charges,
HC EVOKED OTOACOUSTIC EMISSION COMPREHENSIVE,44700082,CDM,471,RC,92558,CPT,,,facility,outpatient,,,131.00000,78.60000,WellCare of North Carolina,Managed Medicaid,,26.23,,,,,,,22.81,192.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,WellCare of North Carolina,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,WellCare of North Carolina,Managed Medicaid,,308.71,,,,,,,124.00,1156.50,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL SCREEN W STIMULI AUTO ANALYSIS,44710008,CDM,471,RC,92650,CPT,,,facility,outpatient,,,264.00000,158.40000,WellCare of North Carolina,Managed Medicaid,,52.85,,,,,,,45.96,198.00,percent of total billed charges,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,WellCare of North Carolina,Managed Medicaid,,52.85,,,,,,,45.96,327.39,percent of total billed charges,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,WellCare of North Carolina,Managed Medicaid,,400.40,,,,,,,186.78,4376.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Managed Medicaid,,625.22,,,,,,,494.00,4376.00,percent of total billed charges,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,WellCare of North Carolina,Managed Medicaid,,140.14,,,,,,,121.87,735.65,percent of total billed charges,
HC EP EVAL SINGLE OR DUAL CD LEADS INCLUDING DEFIB THRESHOLD EVAL AT TIME OF INITIAL IMPLANT REPLACE,48010032,CDM,480,RC,93640,CPT,,,facility,outpatient,,,2272.00000,1363.20000,WellCare of North Carolina,Managed Medicaid,,454.85,,,,,,,303.99,12247.00,percent of total billed charges,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,WellCare of North Carolina,Managed Medicaid,,166.37,,,,,,,144.68,675.60,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,WellCare of North Carolina,Managed Medicaid,,101.10,,,,,,,87.92,557.85,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN SCORE BY QHCP ADDL 30 MINS,49100076,CDM,918,RC,96137,CPT,,,facility,outpatient,,,222.00000,133.20000,WellCare of North Carolina,Managed Medicaid,,44.44,,,,,,,38.65,528.00,percent of total billed charges,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,WellCare of North Carolina,Managed Medicaid,,66.67,,,,,,,57.98,528.00,percent of total billed charges,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP EA ADDL HOUR,49100079,CDM,918,RC,96133,CPT,,,facility,outpatient,,,338.00000,202.80000,WellCare of North Carolina,Managed Medicaid,,67.67,,,,,,,58.85,528.00,percent of total billed charges,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,WellCare of North Carolina,Managed Medicaid,,37.04,,,,,,,32.21,767.00,percent of total billed charges,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,WellCare of North Carolina,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,WellCare of North Carolina,Managed Medicaid,,1209.81,,,,,,,510.48,4532.25,percent of total billed charges,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,WellCare of North Carolina,Managed Medicaid,,203.60,,,,,,,150.52,1990.00,percent of total billed charges,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,WellCare of North Carolina,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,WellCare of North Carolina,Managed Medicaid,,840.84,,,,,,,840.84,3150.00,percent of total billed charges,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,WellCare of North Carolina,Managed Medicaid,,854.05,,,,,,,854.05,3199.50,percent of total billed charges,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,WellCare of North Carolina,Managed Medicaid,,231.03,,,,,,,175.00,865.50,percent of total billed charges,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,WellCare of North Carolina,Managed Medicaid,,110.51,,,,,,,110.51,954.00,percent of total billed charges,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,WellCare of North Carolina,Managed Medicaid,,113.11,,,,,,,98.37,423.75,percent of total billed charges,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,WellCare of North Carolina,Managed Medicaid,,270.27,,,,,,,175.00,1012.50,percent of total billed charges,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,WellCare of North Carolina,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Managed Medicaid,,110.11,,,,,,,95.75,412.50,percent of total billed charges,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,WellCare of North Carolina,Managed Medicaid,,192.79,,,,,,,192.79,954.00,percent of total billed charges,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,WellCare of North Carolina,Managed Medicaid,,210.41,,,,,,,150.52,788.25,percent of total billed charges,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,WellCare of North Carolina,Managed Medicaid,,90.69,,,,,,,90.69,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,WellCare of North Carolina,Managed Medicaid,,254.45,,,,,,,175.00,953.25,percent of total billed charges,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,WellCare of North Carolina,Managed Medicaid,,232.03,,,,,,,232.03,954.00,percent of total billed charges,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,WellCare of North Carolina,Managed Medicaid,,145.75,,,,,,,102.31,546.00,percent of total billed charges,
HC ELECTROCORTICOGRAPHY IN OR,49200035,CDM,740,RC,95829,CPT,,,facility,outpatient,,,481.00000,288.60000,WellCare of North Carolina,Managed Medicaid,,96.30,,,,,,,96.30,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,WellCare of North Carolina,Managed Medicaid,,225.43,,,,,,,175.00,844.50,percent of total billed charges,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,WellCare of North Carolina,Managed Medicaid,,63.26,,,,,,,63.26,954.00,percent of total billed charges,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,WellCare of North Carolina,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,WellCare of North Carolina,Managed Medicaid,,24.82,,,,,,,24.82,954.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,WellCare of North Carolina,Managed Medicaid,,191.79,,,,,,,102.31,718.50,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Managed Medicaid,,114.31,,,,,,,99.41,428.25,percent of total billed charges,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,WellCare of North Carolina,Managed Medicaid,,92.89,,,,,,,80.78,348.00,percent of total billed charges,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Managed Medicaid,,107.91,,,,,,,93.70,404.25,percent of total billed charges,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,WellCare of North Carolina,Managed Medicaid,,100.70,,,,,,,87.57,377.25,percent of total billed charges,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,WellCare of North Carolina,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,WellCare of North Carolina,Managed Medicaid,,81.08,,,,,,,81.08,1069.64,percent of total billed charges,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,WellCare of North Carolina,Managed Medicaid,,314.71,,,,,,,273.69,1990.00,percent of total billed charges,
HC CORTICAL MAPPING EA ADDL HR,49200061,CDM,740,RC,95962,CPT,,,facility,outpatient,,,405.00000,243.00000,WellCare of North Carolina,Managed Medicaid,,81.08,,,,,,,81.08,954.00,percent of total billed charges,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Managed Medicaid,,74.67,,,,,,,74.67,1990.00,percent of total billed charges,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,WellCare of North Carolina,Managed Medicaid,,134.93,,,,,,,117.34,1831.00,percent of total billed charges,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,WellCare of North Carolina,Managed Medicaid,,164.56,,,,,,,124.01,1831.00,percent of total billed charges,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,WellCare of North Carolina,Managed Medicaid,,171.17,,,,,,,148.86,1831.00,percent of total billed charges,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,WellCare of North Carolina,Managed Medicaid,,177.78,,,,,,,150.52,1831.00,percent of total billed charges,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Managed Medicaid,,107.91,,,,,,,93.84,1831.00,percent of total billed charges,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,WellCare of North Carolina,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,WellCare of North Carolina,Managed Medicaid,,59.06,,,,,,,51.36,1831.00,percent of total billed charges,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,WellCare of North Carolina,Managed Medicaid,,87.49,,,,,,,76.08,1831.00,percent of total billed charges,
HC EMG NEEDLE GUIDANCE CHEMODENRV,49200077,CDM,922,RC,95874,CPT,,,facility,outpatient,,,253.00000,151.80000,WellCare of North Carolina,Managed Medicaid,,50.65,,,,,,,44.05,1831.00,percent of total billed charges,
HC EMG LTD W NCV 4 OR LESS MUSCLES PER EXT,49200078,CDM,922,RC,95885,CPT,,,facility,outpatient,,,614.00000,368.40000,WellCare of North Carolina,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG COMPL W NCV 5 OR MORE MUSCLES PER EXT,49200079,CDM,922,RC,95886,CPT,,,facility,outpatient,,,614.00000,368.40000,WellCare of North Carolina,Managed Medicaid,,122.92,,,,,,,106.90,1831.00,percent of total billed charges,
HC EMG NON EXTREMITY W NCV,49200080,CDM,922,RC,95887,CPT,,,facility,outpatient,,,547.00000,328.20000,WellCare of North Carolina,Managed Medicaid,,109.51,,,,,,,95.23,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Managed Medicaid,,42.44,,,,,,,36.91,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,WellCare of North Carolina,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,WellCare of North Carolina,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,WellCare of North Carolina,Managed Medicaid,,80.08,,,,,,,69.64,1831.00,percent of total billed charges,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,WellCare of North Carolina,Managed Medicaid,,53.45,,,,,,,46.48,1831.00,percent of total billed charges,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,WellCare of North Carolina,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,WellCare of North Carolina,Managed Medicaid,,73.27,,,,,,,63.72,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,WellCare of North Carolina,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,WellCare of North Carolina,Managed Medicaid,,327.33,,,,,,,284.65,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,WellCare of North Carolina,Managed Medicaid,,91.49,,,,,,,79.56,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Managed Medicaid,,91.09,,,,,,,79.22,1831.00,percent of total billed charges,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,WellCare of North Carolina,Managed Medicaid,,298.50,,,,,,,259.58,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,WellCare of North Carolina,Managed Medicaid,,305.51,,,,,,,265.68,1831.00,percent of total billed charges,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,WellCare of North Carolina,Managed Medicaid,,169.77,,,,,,,147.64,1831.00,percent of total billed charges,
HC INTRA OP MONITORING PER 15MINS,49200098,CDM,922,RC,95940,CPT,,,facility,outpatient,,,1233.00000,739.80000,WellCare of North Carolina,Managed Medicaid,,246.85,,,,,,,214.67,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,WellCare of North Carolina,Managed Medicaid,,84.68,,,,,,,73.64,1831.00,percent of total billed charges,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,WellCare of North Carolina,Managed Medicaid,,199.60,,,,,,,199.60,1990.00,percent of total billed charges,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Managed Medicaid,,92.69,,,,,,,92.69,467.00,percent of total billed charges,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,WellCare of North Carolina,Managed Medicaid,,108.91,,,,,,,108.91,954.00,percent of total billed charges,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,WellCare of North Carolina,Managed Medicaid,,263.26,,,,,,,263.26,986.25,percent of total billed charges,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,WellCare of North Carolina,Managed Medicaid,,317.92,,,,,,,299.59,1191.00,percent of total billed charges,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,WellCare of North Carolina,Managed Medicaid,,390.39,,,,,,,299.59,1462.50,percent of total billed charges,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,WellCare of North Carolina,Managed Medicaid,,553.95,,,,,,,510.48,2075.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,WellCare of North Carolina,Managed Medicaid,,608.41,,,,,,,510.48,2279.25,percent of total billed charges,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,WellCare of North Carolina,Managed Medicaid,,771.97,,,,,,,510.48,2892.00,percent of total billed charges,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,WellCare of North Carolina,Managed Medicaid,,454.05,,,,,,,299.59,1701.00,percent of total billed charges,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,WellCare of North Carolina,Managed Medicaid,,508.51,,,,,,,299.59,1905.00,percent of total billed charges,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,WellCare of North Carolina,Managed Medicaid,,572.17,,,,,,,510.48,2143.50,percent of total billed charges,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,WellCare of North Carolina,Managed Medicaid,,908.11,,,,,,,510.48,3402.00,percent of total billed charges,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,WellCare of North Carolina,Managed Medicaid,,1017.02,,,,,,,510.48,3810.00,percent of total billed charges,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,WellCare of North Carolina,Managed Medicaid,,1135.13,,,,,,,615.00,4252.50,percent of total billed charges,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,WellCare of North Carolina,Managed Medicaid,,208.61,,,,,,,208.61,954.00,percent of total billed charges,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,37.64,767.00,percent of total billed charges,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,10.97,1090.00,percent of total billed charges,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,WellCare of North Carolina,Managed Medicaid,,45.05,,,,,,,44.39,4311.00,percent of total billed charges,
HC NUTRITION COUNSELING GROUP BCBS,49420016,CDM,942,RC,S9455,CPT,,,facility,outpatient,,,292.00000,175.20000,WellCare of North Carolina,Managed Medicaid,,58.46,,,,,,,50.84,1090.00,percent of total billed charges,
HC DIETICIAN VISIT BCBS,49420017,CDM,942,RC,S9465,CPT,,,facility,outpatient,,,294.00000,176.40000,WellCare of North Carolina,Managed Medicaid,,58.86,,,,,,,51.19,1090.00,percent of total billed charges,
HC IMMUNIZATION ADMIN 1ST VACCINE THRU 18YRS,49420018,CDM,771,RC,90460,CPT,,,facility,outpatient,,,48.00000,28.80000,WellCare of North Carolina,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ADDL VACCINE THRU 18YRS,49420019,CDM,771,RC,90461,CPT,,,facility,outpatient,,,48.00000,28.80000,WellCare of North Carolina,Managed Medicaid,,9.61,,,,,,,8.36,42.00,percent of total billed charges,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IMMUNIZATION ADMIN EACH ADDITIONAL VACCINE,49420025,CDM,771,RC,90472,CPT,,,facility,outpatient,,,106.00000,63.60000,WellCare of North Carolina,Managed Medicaid,,21.22,,,,,,,18.45,79.50,percent of total billed charges,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,20.54,88.50,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITORING,49420206,CDM,260,RC,M0243,CPT,,,facility,outpatient,,,775.00000,465.00000,WellCare of North Carolina,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN BAMLANIVIMAB AND ETESEVIMAB INCL POST ADMIN MONITORING,49420209,CDM,260,RC,M0245,CPT,,,facility,outpatient,,,775.00000,465.00000,WellCare of North Carolina,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV OR SQ INJ ADMIN CASIRIVIMAB/IMDEVIMAB INCL POST ADMIN MONITOR REPEAT DOSES,49420228,CDM,260,RC,M0240,CPT,,,facility,outpatient,,,775.00000,465.00000,WellCare of North Carolina,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC IV ADMIN SOTROVIMAB INCL POST ADMIN MONITORING,49420232,CDM,260,RC,M0247,CPT,,,facility,outpatient,,,775.00000,465.00000,WellCare of North Carolina,Managed Medicaid,,155.16,,,,,,,134.93,759.00,percent of total billed charges,
HC INJ IM ADMIN EVUSHELD TIXAGEVIMAB CILGAVIMAB INCL POST ADMIN MONITORING,49420233,CDM,771,RC,M0220,CPT,,,facility,outpatient,,,775.00000,465.00000,WellCare of North Carolina,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC IV INJ ADMIN BEBTELOVIMAB INCL POST ADMIN MONITORING,49420237,CDM,771,RC,M0222,CPT,,,facility,outpatient,,,775.00000,465.00000,WellCare of North Carolina,Managed Medicaid,,155.16,,,,,,,26.00,581.25,percent of total billed charges,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,13.06,56.25,percent of total billed charges,
HC PT DRY NEEDLING,49900035,CDM,420,RC,20560,CPT,,,facility,outpatient,,,66.67000,40.00000,WellCare of North Carolina,Managed Medicaid,GP,13.35,,,,,,,10.39,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,WellCare of North Carolina,Managed Medicaid,,95.90,,,,,,,90.29,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,WellCare of North Carolina,Managed Medicaid,,549.35,,,,,,,549.35,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,WellCare of North Carolina,Managed Medicaid,,549.35,,,,,,,517.24,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,WellCare of North Carolina,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,WellCare of North Carolina,Managed Medicaid,,217.22,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,WellCare of North Carolina,Managed Medicaid,,217.22,,,,,,,204.52,4376.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,WellCare of North Carolina,Managed Medicaid,,493.29,,,,,,,464.46,4376.00,percent of total billed charges,
HC DEBRIDEMENT TISSUE SKIN ADD 20SQCM,53610008,CDM,761,RC,11045,CPT,,,facility,outpatient,,,1039.00000,623.40000,WellCare of North Carolina,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT MUSCLE SKIN TISSUE ADD 20SQCM,53610009,CDM,761,RC,11046,CPT,,,facility,outpatient,,,1039.00000,623.40000,WellCare of North Carolina,Managed Medicaid,,208.01,,,,,,,195.85,4311.00,percent of total billed charges,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE ADD 20SQCM,53610010,CDM,761,RC,11047,CPT,,,facility,outpatient,,,3190.00000,1914.00000,WellCare of North Carolina,Managed Medicaid,,638.64,,,,,,,601.32,4311.00,percent of total billed charges,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,WellCare of North Carolina,Managed Medicaid,,86.09,,,,,,,81.06,4311.00,percent of total billed charges,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,WellCare of North Carolina,Managed Medicaid,,96.10,,,,,,,90.48,4311.00,percent of total billed charges,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,WellCare of North Carolina,Managed Medicaid,,107.31,,,,,,,101.04,4311.00,percent of total billed charges,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,WellCare of North Carolina,Managed Medicaid,,91.69,,,,,,,86.33,4311.00,percent of total billed charges,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,WellCare of North Carolina,Managed Medicaid,,23.82,,,,,,,22.43,96.75,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,,25.83,,,,,,,24.32,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,WellCare of North Carolina,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC AVULSION NAIL PLATE EA ADD,53610020,CDM,761,RC,11732,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Managed Medicaid,,32.63,,,,,,,30.73,4311.00,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,WellCare of North Carolina,Managed Medicaid,,61.46,,,,,,,57.87,4311.00,percent of total billed charges,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,WellCare of North Carolina,Managed Medicaid,,104.10,,,,,,,98.02,4311.00,percent of total billed charges,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,WellCare of North Carolina,Managed Medicaid,,100.90,,,,,,,95.00,4311.00,percent of total billed charges,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,WellCare of North Carolina,Managed Medicaid,,123.72,,,,,,,116.49,4311.00,percent of total billed charges,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,WellCare of North Carolina,Managed Medicaid,,81.88,,,,,,,77.10,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,WellCare of North Carolina,Managed Medicaid,,154.15,,,,,,,154.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,WellCare of North Carolina,Managed Medicaid,,154.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,WellCare of North Carolina,Managed Medicaid,,127.73,,,,,,,127.73,4311.00,percent of total billed charges,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,WellCare of North Carolina,Managed Medicaid,,120.72,,,,,,,113.67,490.24,percent of total billed charges,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,WellCare of North Carolina,Managed Medicaid,,180.58,,,,,,,170.03,4311.00,percent of total billed charges,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,WellCare of North Carolina,Managed Medicaid,,36.44,,,,,,,36.44,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,WellCare of North Carolina,Managed Medicaid,,30.43,,,,,,,30.43,4311.00,percent of total billed charges,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,WellCare of North Carolina,Managed Medicaid,,56.06,,,,,,,56.06,4311.00,percent of total billed charges,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,WellCare of North Carolina,Managed Medicaid,,77.68,,,,,,,73.14,315.44,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,WellCare of North Carolina,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,WellCare of North Carolina,Managed Medicaid,,151.95,,,,,,,143.07,4311.00,percent of total billed charges,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,WellCare of North Carolina,Managed Medicaid,,459.46,,,,,,,459.46,4311.00,percent of total billed charges,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,WellCare of North Carolina,Managed Medicaid,,121.52,,,,,,,114.42,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,WellCare of North Carolina,Managed Medicaid,,372.97,,,,,,,372.97,4311.00,percent of total billed charges,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,WellCare of North Carolina,Managed Medicaid,,372.97,,,,,,,351.18,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY LUMB EA LVL,53610082,CDM,360,RC,62290,CPT,,,facility,outpatient,,,2132.00000,1279.20000,WellCare of North Carolina,Managed Medicaid,,426.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,WellCare of North Carolina,Managed Medicaid,,107.31,,,,,,,101.04,4376.00,percent of total billed charges,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Managed Medicaid,,207.61,,,,,,,195.47,843.08,percent of total billed charges,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,WellCare of North Carolina,Managed Medicaid,,2503.90,,,,,,,2357.57,10168.19,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,WellCare of North Carolina,Managed Medicaid,,304.30,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,WellCare of North Carolina,Managed Medicaid,,386.99,,,,,,,364.37,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 2ND LEVEL,53610103,CDM,761,RC,64491,CPT,,,facility,outpatient,,,834.00000,500.40000,WellCare of North Carolina,Managed Medicaid,,166.97,,,,,,,157.21,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT FACET JOINT C T 3RD LEVEL AND MORE,53610104,CDM,761,RC,64492,CPT,,,facility,outpatient,,,869.00000,521.40000,WellCare of North Carolina,Managed Medicaid,,173.97,,,,,,,163.81,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,WellCare of North Carolina,Managed Medicaid,,185.19,,,,,,,174.36,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,WellCare of North Carolina,Managed Medicaid,,307.91,,,,,,,289.91,4311.00,percent of total billed charges,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,WellCare of North Carolina,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,WellCare of North Carolina,Managed Medicaid,,1956.75,,,,,,,1842.40,7946.26,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Managed Medicaid,,132.13,,,,,,,132.13,4311.00,percent of total billed charges,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Managed Medicaid,,132.13,,,,,,,124.41,4311.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,WellCare of North Carolina,Managed Medicaid,,638.44,,,,,,,638.44,5754.00,percent of total billed charges,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,WellCare of North Carolina,Managed Medicaid,,638.44,,,,,,,601.13,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,361,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,WellCare of North Carolina,Managed Medicaid,,305.91,,,,,,,173.00,4311.00,percent of total billed charges,
HC RF DENERV C T ADD W IG,53610114,CDM,761,RC,64634,CPT,,,facility,outpatient,,,1528.00000,916.80000,WellCare of North Carolina,Managed Medicaid,,305.91,,,,,,,288.03,4311.00,percent of total billed charges,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,WellCare of North Carolina,Managed Medicaid,,345.75,,,,,,,325.54,4311.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,WellCare of North Carolina,Managed Medicaid,,428.83,,,,,,,428.83,5152.00,percent of total billed charges,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,WellCare of North Carolina,Managed Medicaid,,428.83,,,,,,,403.77,4376.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,WellCare of North Carolina,Managed Medicaid,,279.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,WellCare of North Carolina,Managed Medicaid,,279.68,,,,,,,263.33,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,WellCare of North Carolina,Managed Medicaid,,124.32,,,,,,,124.32,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,WellCare of North Carolina,Managed Medicaid,,124.32,,,,,,,117.06,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,361,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,WellCare of North Carolina,Managed Medicaid,,144.14,,,,,,,144.14,4311.00,percent of total billed charges,
HC DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610128,CDM,761,RC,97598,CPT,,,facility,outpatient,,,720.00000,432.00000,WellCare of North Carolina,Managed Medicaid,,144.14,,,,,,,135.72,4311.00,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,11.50,208.90,percent of total billed charges,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,WellCare of North Carolina,Managed Medicaid,,448.45,,,,,,,422.24,4376.00,percent of total billed charges,
HC DISCARDED APLIGRAF PER SQ CM,53610169,CDM,250,RC,Q4101,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Managed Medicaid,JW,26.43,,,,,,,26.43,107.32,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,WellCare of North Carolina,Managed Medicaid,,117.32,,,,,,,110.46,4311.00,percent of total billed charges,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,WellCare of North Carolina,Managed Medicaid,,99.90,,,,,,,99.90,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 1 TO 4 MUSCLES,53610175,CDM,361,RC,64643,CPT,,,facility,outpatient,,,604.00000,362.40000,WellCare of North Carolina,Managed Medicaid,,120.92,,,,,,,120.92,4311.00,percent of total billed charges,
HC CHEMODNRVTN ADDITIONAL EXTREMITIES 5 OR MORE MUSCLES,53610176,CDM,761,RC,64645,CPT,,,facility,outpatient,,,499.00000,299.40000,WellCare of North Carolina,Managed Medicaid,,99.90,,,,,,,94.06,4311.00,percent of total billed charges,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,WellCare of North Carolina,Managed Medicaid,,117.32,,,,,,,117.32,4311.00,percent of total billed charges,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,WellCare of North Carolina,Managed Medicaid,,164.56,,,,,,,154.95,4311.00,percent of total billed charges,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,WellCare of North Carolina,Managed Medicaid,,273.07,,,,,,,257.11,4376.00,percent of total billed charges,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,WellCare of North Carolina,Managed Medicaid,,70.47,,,,,,,66.35,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Managed Medicaid,,788.99,,,,,,,666.26,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,WellCare of North Carolina,Managed Medicaid,,390.39,,,,,,,390.39,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,WellCare of North Carolina,Managed Medicaid,,390.39,,,,,,,367.57,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,WellCare of North Carolina,Managed Medicaid,,621.22,,,,,,,621.22,4311.00,percent of total billed charges,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,WellCare of North Carolina,Managed Medicaid,,621.22,,,,,,,584.92,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,WellCare of North Carolina,Managed Medicaid,,344.94,,,,,,,324.79,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,WellCare of North Carolina,Managed Medicaid,,426.83,,,,,,,401.88,4311.00,percent of total billed charges,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,WellCare of North Carolina,Managed Medicaid,,560.56,,,,,,,527.80,4311.00,percent of total billed charges,
HC TAP BLOCK UNILATERAL,53610250,CDM,361,RC,64486,CPT,,,facility,outpatient,,,543.00000,325.80000,WellCare of North Carolina,Managed Medicaid,,108.71,,,,,,,108.71,4376.00,percent of total billed charges,
HC COOLED RF ABLATION CERVICAL EA ADDL LVL,53610267,CDM,361,RC,64634,CPT,,,facility,outpatient,,,4385.00000,2631.00000,WellCare of North Carolina,Managed Medicaid,,877.88,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION LUMB SACRAL EA ADDL LVL,53610269,CDM,361,RC,64636,CPT,,,facility,outpatient,,,4850.00000,2910.00000,WellCare of North Carolina,Managed Medicaid,,970.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,WellCare of North Carolina,Managed Medicaid,,1147.95,,,,,,,856.54,4311.00,percent of total billed charges,
HC TAP BLOCK BILATERAL,53610271,CDM,361,RC,64488,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Managed Medicaid,,160.96,,,,,,,160.96,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT T A L EACH ADDL 100 SQCM OR LESS OR 1% BODY AREA INFANTS CHILDREN,53610277,CDM,761,RC,15111,CPT,,,facility,outpatient,,,1565.00000,939.00000,WellCare of North Carolina,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D EACH ADDL 100 SQCM OR 1% BODY AREA INFANTS CHILDREN,53610278,CDM,761,RC,15116,CPT,,,facility,outpatient,,,1565.00000,939.00000,WellCare of North Carolina,Managed Medicaid,,313.31,,,,,,,295.00,4311.00,percent of total billed charges,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,WellCare of North Carolina,Managed Medicaid,,384.58,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,WellCare of North Carolina,Managed Medicaid,,340.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Managed Medicaid,,116.52,,,,,,,109.71,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,WellCare of North Carolina,Managed Medicaid,,454.05,,,,,,,427.52,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,WellCare of North Carolina,Managed Medicaid,,253.25,,,,,,,238.45,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,WellCare of North Carolina,Managed Medicaid,,467.07,,,,,,,467.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,WellCare of North Carolina,Managed Medicaid,,467.07,,,,,,,439.77,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,WellCare of North Carolina,Managed Medicaid,,409.81,,,,,,,385.86,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,WellCare of North Carolina,Managed Medicaid,,267.27,,,,,,,251.65,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,WellCare of North Carolina,Managed Medicaid,,169.57,,,,,,,159.66,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,WellCare of North Carolina,Managed Medicaid,,356.56,,,,,,,356.56,4121.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,WellCare of North Carolina,Managed Medicaid,,356.56,,,,,,,335.72,1447.95,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,WellCare of North Carolina,Managed Medicaid,,339.94,,,,,,,320.07,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,WellCare of North Carolina,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,WellCare of North Carolina,Managed Medicaid,,276.48,,,,,,,260.32,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,WellCare of North Carolina,Managed Medicaid,,359.16,,,,,,,338.17,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,WellCare of North Carolina,Managed Medicaid,,359.16,,,,,,,359.16,5754.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,WellCare of North Carolina,Managed Medicaid,,824.62,,,,,,,776.43,8442.00,percent of total billed charges,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,WellCare of North Carolina,Managed Medicaid,,824.62,,,,,,,824.62,12408.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,WellCare of North Carolina,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,WellCare of North Carolina,Managed Medicaid,,695.70,,,,,,,695.70,17457.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,WellCare of North Carolina,Managed Medicaid,,102.50,,,,,,,102.50,4311.00,percent of total billed charges,
HC INPT DEBRIDE OPEN WOUND EA ADDL 20 SQ CM,53610315,CDM,361,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,WellCare of North Carolina,Managed Medicaid,,118.92,,,,,,,118.92,4311.00,percent of total billed charges,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,12.21,208.90,percent of total billed charges,
HC NEUROPLASTY MAJOR NERVE LEG ARM,53610318,CDM,361,RC,64708,CPT,,,facility,outpatient,,,1100.00000,660.00000,WellCare of North Carolina,Managed Medicaid,52,220.22,,,,,,,220.22,5754.00,percent of total billed charges,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,WellCare of North Carolina,Managed Medicaid,,151.95,,,,,,,151.95,4311.00,percent of total billed charges,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,WellCare of North Carolina,Managed Medicaid,,142.34,,,,,,,123.79,1912.00,percent of total billed charges,
HC HYBERBARIC O2 THERAPY PRIV INS,54130002,CDM,413,RC,99183,CPT,,,facility,outpatient,,,1461.00000,876.60000,WellCare of North Carolina,Managed Medicaid,,292.49,,,,,,,254.36,1912.00,percent of total billed charges,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,WellCare of North Carolina,Managed Medicaid,,25.43,,,,,,,22.11,767.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,WellCare of North Carolina,Managed Medicaid,,183.98,,,,,,,173.00,5152.00,percent of total billed charges,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,WellCare of North Carolina,Managed Medicaid,,183.98,,,,,,,173.23,4376.00,percent of total billed charges,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Managed Medicaid,,74.67,,,,,,,74.67,4311.00,percent of total billed charges,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,WellCare of North Carolina,Managed Medicaid,,63.46,,,,,,,59.12,365.00,percent of total billed charges,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,WellCare of North Carolina,Managed Medicaid,,139.54,,,,,,,129.99,624.00,percent of total billed charges,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,WellCare of North Carolina,Managed Medicaid,,278.88,,,,,,,259.79,1295.00,percent of total billed charges,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,WellCare of North Carolina,Managed Medicaid,,475.48,,,,,,,409.68,3235.00,percent of total billed charges,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,WellCare of North Carolina,Managed Medicaid,,634.03,,,,,,,589.86,3709.00,percent of total billed charges,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,WellCare of North Carolina,Managed Medicaid,,803.00,,,,,,,748.05,5152.00,percent of total billed charges,
HC ED CRITICAL CARE EACH ADDL 30 MIN,54500017,CDM,450,RC,99292,CPT,,,facility,outpatient,,,1324.00000,794.40000,WellCare of North Carolina,Managed Medicaid,,265.06,,,,,,,246.93,5152.00,percent of total billed charges,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,WellCare of North Carolina,Managed Medicaid,,241.64,,,,,,,161.50,3641.00,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES YOUNGER THAN 5 YEARS OF AGE,54500051,CDM,370,RC,99151,CPT,,,facility,outpatient,,,361.00000,216.60000,WellCare of North Carolina,Managed Medicaid,,72.27,,,,,,,72.27,293.49,percent of total billed charges,
HC MODERATE SEDATION INITIAL 15 MINUTES 5 YEARS OF AGE OR OLDER,54500052,CDM,370,RC,99152,CPT,,,facility,outpatient,,,296.00000,177.60000,WellCare of North Carolina,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC MODERATE SEDATION EACH ADDITIONAL 15 MINUTES,54500053,CDM,370,RC,99153,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Managed Medicaid,,37.84,,,,,,,37.84,153.66,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Managed Medicaid,,31.23,,,,,,,20.87,3641.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,WellCare of North Carolina,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,201.00000,120.60000,WellCare of North Carolina,Managed Medicaid,,40.24,,,,,,,34.99,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 2,55100004,CDM,510,RC,99202,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,32.73,134.00,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,249.00000,149.40000,WellCare of North Carolina,Managed Medicaid,,49.85,,,,,,,43.35,151.89,percent of total billed charges,
HC NEW PATIENT LEVEL 3,55100006,CDM,510,RC,99203,CPT,,,facility,outpatient,,,240.00000,144.00000,WellCare of North Carolina,Managed Medicaid,,48.05,,,,,,,41.78,146.40,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,317.00000,190.20000,WellCare of North Carolina,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC NEW PATIENT LEVEL 4,55100008,CDM,510,RC,99204,CPT,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Managed Medicaid,,79.88,,,,,,,69.47,243.39,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,371.00000,222.60000,WellCare of North Carolina,Managed Medicaid,,74.27,,,,,,,64.59,226.31,percent of total billed charges,
HC NEW PATIENT LEVEL 5,55100010,CDM,510,RC,99205,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,WellCare of North Carolina,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 1,55100012,CDM,510,RC,99211,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,12.54,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,227.00000,136.20000,WellCare of North Carolina,Managed Medicaid,,45.45,,,,,,,39.52,138.47,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 2,55100016,CDM,510,RC,99212,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,17.41,134.00,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,267.00000,160.20000,WellCare of North Carolina,Managed Medicaid,,53.45,,,,,,,46.48,162.87,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 3,55100018,CDM,510,RC,99213,CPT,,,facility,outpatient,,,250.00000,150.00000,WellCare of North Carolina,Managed Medicaid,,50.05,,,,,,,43.52,152.50,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,406.00000,243.60000,WellCare of North Carolina,Managed Medicaid,,81.28,,,,,,,70.68,247.66,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 4,55100020,CDM,510,RC,99214,CPT,,,facility,outpatient,,,435.00000,261.00000,WellCare of North Carolina,Managed Medicaid,,87.09,,,,,,,75.73,265.35,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,437.00000,262.20000,WellCare of North Carolina,Managed Medicaid,,87.49,,,,,,,76.08,266.57,percent of total billed charges,
HC ESTABLISHED PATIENT LEVEL 5,55100023,CDM,510,RC,99215,CPT,,,facility,outpatient,,,397.00000,238.20000,WellCare of North Carolina,Managed Medicaid,,79.48,,,,,,,69.12,242.17,percent of total billed charges,
HC JV NEW PATIENT LEVEL 2 GL,55100087,CDM,510,RC,99202,CPT,,,facility,outpatient,,,181.00000,108.60000,WellCare of North Carolina,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC JV NEW PATIENT LEVEL 3 GL,55100088,CDM,510,RC,99203,CPT,,,facility,outpatient,,,254.00000,152.40000,WellCare of North Carolina,Managed Medicaid,,50.85,,,,,,,44.22,154.94,percent of total billed charges,
HC JV NEW PATIENT LEVEL 4 GL,55100089,CDM,510,RC,99204,CPT,,,facility,outpatient,,,388.00000,232.80000,WellCare of North Carolina,Managed Medicaid,,77.68,,,,,,,67.55,236.68,percent of total billed charges,
HC JV NEW PATIENT LEVEL 5 GL,55100090,CDM,510,RC,99205,CPT,,,facility,outpatient,,,489.00000,293.40000,WellCare of North Carolina,Managed Medicaid,,97.90,,,,,,,85.13,298.29,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 1 GL,55100091,CDM,510,RC,99211,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Managed Medicaid,,13.21,,,,,,,11.49,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 2 GL,55100092,CDM,510,RC,99212,CPT,,,facility,outpatient,,,106.00000,63.60000,WellCare of North Carolina,Managed Medicaid,,21.22,,,,,,,18.45,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 3 GL,55100093,CDM,510,RC,99213,CPT,,,facility,outpatient,,,176.00000,105.60000,WellCare of North Carolina,Managed Medicaid,,35.24,,,,,,,30.64,134.00,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 4 GL,55100094,CDM,510,RC,99214,CPT,,,facility,outpatient,,,260.00000,156.00000,WellCare of North Carolina,Managed Medicaid,,52.05,,,,,,,45.27,158.60,percent of total billed charges,
HC JV ESTABLISHED PATIENT LEVEL 5 GL,55100095,CDM,510,RC,99215,CPT,,,facility,outpatient,,,343.00000,205.80000,WellCare of North Carolina,Managed Medicaid,,68.67,,,,,,,59.72,209.23,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 20 MIN,55100097,CDM,510,RC,99242,CPT,,,facility,outpatient,,,231.00000,138.60000,WellCare of North Carolina,Managed Medicaid,,46.25,,,,,,,40.22,140.91,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 30 MIN,55100098,CDM,510,RC,99243,CPT,,,facility,outpatient,,,317.00000,190.20000,WellCare of North Carolina,Managed Medicaid,,63.46,,,,,,,55.19,193.37,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 40 MIN,55100099,CDM,510,RC,99244,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Managed Medicaid,,95.09,,,,,,,82.70,289.75,percent of total billed charges,
HC JV OFFICE OR OTHER OP CONSULTATION NEW ESTAB PATIENT MEET OR EXCEED 55 MIN,55100100,CDM,510,RC,99245,CPT,,,facility,outpatient,,,576.00000,345.60000,WellCare of North Carolina,Managed Medicaid,,115.32,,,,,,,100.28,351.36,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 5-10 MINS GL,55100101,CDM,510,RC,99441,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,8.53,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 11-20 MINS GL,55100102,CDM,510,RC,99442,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,16.19,134.00,percent of total billed charges,
HC JV PHYS TELEPHONE EVAL 21-30 MINS GL,55100103,CDM,510,RC,99443,CPT,,,facility,outpatient,,,137.00000,82.20000,WellCare of North Carolina,Managed Medicaid,,27.43,,,,,,,23.85,134.00,percent of total billed charges,
HC LACTATION INDIVIDUAL EDUCATION AND TRAINING FACE TO FACE EACH 30 MINS,55100105,CDM,510,RC,98960,CPT,,,facility,outpatient,,,112.00000,67.20000,WellCare of North Carolina,Managed Medicaid,,22.42,,,,,,,19.50,134.00,percent of total billed charges,
HC JV COMPLEX E/M VISIT ADD ON GL,55100108,CDM,510,RC,G2211,CPT,,,facility,outpatient,,,48.00000,28.80000,WellCare of North Carolina,Managed Medicaid,,9.61,,,,,,,8.36,134.00,percent of total billed charges,
HC APLIGRAF PER SQ CM,56360001,CDM,636,RC,Q4101,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Managed Medicaid,,26.03,,,,,,,26.03,96.49,percent of total billed charges,
HC OASIS TISSUE NONHUM PER SQ CM,56360002,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,25.00000,15.00000,WellCare of North Carolina,Managed Medicaid,,5.00,,,,,,,5.00,31.86,percent of total billed charges,
HC DERMAGRAFT PER SQ CM,56360003,CDM,636,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,19.02,138.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1 MG,56360006,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,5.99,40.08,percent of total billed charges,
HC DISCARDED THERASKIN PER SQ CM,56360009,CDM,250,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,JW,24.62,,,,,,,24.62,124.49,percent of total billed charges,
HC THERASKIN PER SQ CM,56360010,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC DISCARDED DERMAGRAFT PER SQ CM,56360013,CDM,250,RC,Q4106,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,JW,19.02,,,,,,,19.02,106.06,percent of total billed charges,
HC GRAFT JACKET PER SQ CM,56360016,CDM,636,RC,Q4107,CPT,,,facility,outpatient,,,142.00000,85.20000,WellCare of North Carolina,Managed Medicaid,,28.43,,,,,,,28.43,371.55,percent of total billed charges,
HC MATRISTEM WOUND MATRIX PER SQ C,56360025,CDM,278,RC,Q4121,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Managed Medicaid,,55.05,,,,,,,34.92,202.46,percent of total billed charges,
HC TALYMED PER SQ CM USED,56360030,CDM,636,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Managed Medicaid,,40.04,,,,,,,40.04,186.47,percent of total billed charges,
HC DISCARDED TALYMED PER SQ CM,56360031,CDM,250,RC,Q4127,CPT,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Managed Medicaid,JW,40.04,,,,,,,40.04,162.60,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD,56360032,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Managed Medicaid,,91.09,,,,,,,5.88,337.70,percent of total billed charges,
HC OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD,56360033,CDM,636,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Managed Medicaid,,182.38,,,,,,,5.88,676.14,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X7 CM PAD PER SQ CM,56360043,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Managed Medicaid,JW,182.38,,,,,,,5.88,740.64,percent of total billed charges,
HC DISCARDED OASIS ULTRA TRI LAYER MATRIX 3X3.5 CM PAD PER SQ CM,56360044,CDM,250,RC,Q4124,CPT,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Managed Medicaid,JW,91.09,,,,,,,5.88,369.92,percent of total billed charges,
HC PURAPLY AM 4SQCM 2X2 PER SQ CM,56360046,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Managed Medicaid,,197.80,,,,,,,197.80,733.29,percent of total billed charges,
HC PURAPLY AM 8SQCM 2X4 PER SQ CM,56360047,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,464.62,percent of total billed charges,
HC PURAPLY AM 25SQCM 5X5 PER SQ CM,56360048,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,54.65,268.27,percent of total billed charges,
HC DISCARDED PURAPLY AM 4SQCM 2X2 PER SQ CM,56360056,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Managed Medicaid,JW,197.80,,,,,,,197.80,803.24,percent of total billed charges,
HC DISCARDED PURAPLY AM 25SQCM 5X5 PER SQ CM,56360058,CDM,250,RC,Q4196,CPT,,,facility,outpatient,,,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,JW,54.65,,,,,,,54.65,238.43,percent of total billed charges,
HC PRIMATRIX 4SQCM 2X2 PER SQ CM,56360091,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Managed Medicaid,,114.31,,,,,,,114.31,423.80,percent of total billed charges,
HC PRIMATRIX 16SQCM 4X4 PER SQ CM,56360093,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,WellCare of North Carolina,Managed Medicaid,,52.45,,,,,,,52.45,194.46,percent of total billed charges,
HC AMNIOEXCEL PLUS 17MM DISC,56360132,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,WellCare of North Carolina,Managed Medicaid,,551.35,,,,,,,240.06,2044.02,percent of total billed charges,
HC AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360133,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,WellCare of North Carolina,Managed Medicaid,,243.44,,,,,,,240.06,902.52,percent of total billed charges,
HC AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360134,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,WellCare of North Carolina,Managed Medicaid,,123.32,,,,,,,123.32,457.20,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 17MM DISC,56360135,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,2754.00000,1652.40000,WellCare of North Carolina,Managed Medicaid,JW,551.35,,,,,,,240.06,2239.00,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 2CM X 2 CM PER SQ CM,56360136,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1216.00000,729.60000,WellCare of North Carolina,Managed Medicaid,JW,243.44,,,,,,,240.06,988.61,percent of total billed charges,
HC DISCARDED AMNIOEXCEL PLUS 3CM X 3CM PER SQ CM,56360137,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,616.00000,369.60000,WellCare of North Carolina,Managed Medicaid,JW,123.32,,,,,,,123.32,500.81,percent of total billed charges,
HC PURAPLY AM 1.6CM DISC,56360138,CDM,636,RC,Q4196,CPT,,,facility,outpatient,,,2813.00000,1687.80000,WellCare of North Carolina,Managed Medicaid,,563.16,,,,,,,238.43,2087.81,percent of total billed charges,
HC THERASKIN 7.6CM X 15.2CM PER SQ CM,56360149,CDM,636,RC,Q4121,CPT,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,,24.62,,,,,,,24.62,132.99,percent of total billed charges,
HC ALLOPATCH 4 CM X 4 CM PER SQ CM,56360193,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,WellCare of North Carolina,Managed Medicaid,,68.47,,,,,,,68.47,253.83,percent of total billed charges,
HC DISCARDED ALLOPATCH 4 CM X 4 CM PER SQ CM,56360200,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,342.00000,205.20000,WellCare of North Carolina,Managed Medicaid,JW,68.47,,,,,,,68.47,278.05,percent of total billed charges,
HC GRAFIX PL 1.5X2 PER SQ CM,56360225,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,WellCare of North Carolina,Managed Medicaid,,309.51,,,,,,,309.51,1147.44,percent of total billed charges,
HC GRAFIX PL 16 MM DISC,56360226,CDM,636,RC,Q4133,CPT,,,facility,outpatient,,,3094.00000,1856.40000,WellCare of North Carolina,Managed Medicaid,,619.42,,,,,,,327.43,2296.37,percent of total billed charges,
HC DISCARDED GRAFIX PL 1.5X2 PER SQ CM,56360229,CDM,250,RC,Q4133,CPT,,,facility,outpatient,,,1546.00000,927.60000,WellCare of North Carolina,Managed Medicaid,JW,309.51,,,,,,,309.51,1256.90,percent of total billed charges,
HC ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360238,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,WellCare of North Carolina,Managed Medicaid,,85.69,,,,,,,70.59,317.66,percent of total billed charges,
HC DISCARDED ALLOPATCH 1.5 CM X 1.5 CM PER SQ CM,56360239,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,428.00000,256.80000,WellCare of North Carolina,Managed Medicaid,JW,85.69,,,,,,,70.59,347.96,percent of total billed charges,
HC ALLOPATCH 2 CM X 2 CM PER SQ CM,56360240,CDM,636,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,70.59,358.48,percent of total billed charges,
HC DISCARDED ALLOPATCH 2 CM X 2 CM PER SQ CM,56360241,CDM,250,RC,Q4128,CPT,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,JW,96.70,,,,,,,70.59,392.68,percent of total billed charges,
HC MATRISTEM MICROMATRIX 1000MG PER 1 MG,56360248,CDM,636,RC,Q4118,CPT,,,facility,outpatient,,,10.00000,6.00000,WellCare of North Carolina,Managed Medicaid,,2.00,,,,,,,2.00,7.42,percent of total billed charges,
HC CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360274,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,WellCare of North Carolina,Managed Medicaid,,500.10,,,,,,,500.10,1854.02,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 6 SQ CM 2 X 3 PER SQ CM,56360275,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2498.00000,1498.80000,WellCare of North Carolina,Managed Medicaid,JW,500.10,,,,,,,500.10,2030.87,percent of total billed charges,
HC CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360276,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,WellCare of North Carolina,Managed Medicaid,,405.40,,,,,,,405.40,1502.95,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 16 SQ CM 4 X 4 PER SQ CM,56360277,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,2025.00000,1215.00000,WellCare of North Carolina,Managed Medicaid,JW,405.40,,,,,,,405.40,1646.33,percent of total billed charges,
HC CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360278,CDM,636,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,WellCare of North Carolina,Managed Medicaid,,341.94,,,,,,,341.94,1267.68,percent of total billed charges,
HC DISCARDED CYGNUS DUAL 24 SQ CM 4 X 6 PER SQ CM,56360279,CDM,250,RC,Q4282,CPT,,,facility,outpatient,,,1708.00000,1024.80000,WellCare of North Carolina,Managed Medicaid,JW,341.94,,,,,,,341.94,1388.60,percent of total billed charges,
HC OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360310,CDM,636,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,13.01,48.24,percent of total billed charges,
HC DISCARDED OASIS WOUND MATRIX 11 SQ CM 3 X 3.5 PER SQ CM,56360311,CDM,250,RC,Q4102,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,JW,13.01,,,,,,,13.01,52.84,percent of total billed charges,
HC NUSHIELD DISC 1.6 PER SQ CM,56361004,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,2469.00000,1481.40000,WellCare of North Carolina,Managed Medicaid,,494.29,,,,,,,494.29,6571.14,percent of total billed charges,
HC NUSHIELD 2X3 PER SQ CM,56361006,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,WellCare of North Carolina,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X3 PER SQ CM,56361007,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,698.00000,418.80000,WellCare of North Carolina,Managed Medicaid,,139.74,,,,,,,139.74,6571.14,percent of total billed charges,
HC NUSHIELD 2X4 PER SQ CM,56361008,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 2X4 PER SQ CM,56361009,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,6571.14,percent of total billed charges,
HC NUSHIELD 3X4 PER SQ CM,56361010,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 3X4 PER SQ CM,56361011,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Managed Medicaid,,123.12,,,,,,,123.12,6571.14,percent of total billed charges,
HC NUSHIELD 4X6 PER SQ CM,56361014,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 4X6 PER SQ CM,56361015,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,6571.14,percent of total billed charges,
HC NUSHIELD 6X6 PER SQ CM,56361016,CDM,636,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED NUSHIELD 6X6 PER SQ CM,56361017,CDM,250,RC,Q4160,CPT,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Managed Medicaid,,79.88,,,,,,,79.88,6571.14,percent of total billed charges,
HC DISCARDED PRIMATRIX 18MM DISC,56361018,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,2363.00000,1417.80000,WellCare of North Carolina,Managed Medicaid,JW,473.07,,,,,,,154.34,1921.12,percent of total billed charges,
HC DISCARDED PRIMATRIX 2CMX2CM PER SQ CM,56361019,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Managed Medicaid,JW,114.31,,,,,,,114.31,464.22,percent of total billed charges,
HC DISCARDED PRIMATRIX 4CMX4CM PER SQ CM,56361020,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,262.00000,157.20000,WellCare of North Carolina,Managed Medicaid,JW,52.45,,,,,,,52.45,213.01,percent of total billed charges,
HC PRIMATRIX 3CMX3CM,56361021,CDM,636,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,WellCare of North Carolina,Managed Medicaid,,62.66,,,,,,,62.66,232.31,percent of total billed charges,
HC DISCARDED PRIMATRIX 3CMX3CM PER SQ CM,56361022,CDM,250,RC,Q4110,CPT,,,facility,outpatient,,,313.00000,187.80000,WellCare of North Carolina,Managed Medicaid,JW,62.66,,,,,,,62.66,254.47,percent of total billed charges,
HC AMNIOEXCEL 15MM DISC,56361023,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,WellCare of North Carolina,Managed Medicaid,,315.31,,,,,,,240.06,1168.96,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 15MM DISC PER CM,56361024,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1575.00000,945.00000,WellCare of North Carolina,Managed Medicaid,JW,315.31,,,,,,,240.06,1280.47,percent of total billed charges,
HC AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361025,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,WellCare of North Carolina,Managed Medicaid,,250.65,,,,,,,240.06,929.23,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 1.5X1.5CM PER SQ CM,56361026,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,1252.00000,751.20000,WellCare of North Carolina,Managed Medicaid,JW,250.65,,,,,,,240.06,1017.88,percent of total billed charges,
HC AMNIOEXCEL 2X3CM PER SQ CM,56361027,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,WellCare of North Carolina,Managed Medicaid,,128.33,,,,,,,128.33,475.75,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 2X3CM PER SQ CM,56361028,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,641.00000,384.60000,WellCare of North Carolina,Managed Medicaid,JW,128.33,,,,,,,128.33,521.13,percent of total billed charges,
HC AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361029,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,WellCare of North Carolina,Managed Medicaid,,68.07,,,,,,,68.07,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 3.5X3.5CM PER SQ CM,56361030,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,340.00000,204.00000,WellCare of North Carolina,Managed Medicaid,JW,68.07,,,,,,,68.07,276.42,percent of total billed charges,
HC AMNIOEXCEL 4X4CM PER SQ CM,56361031,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,WellCare of North Carolina,Managed Medicaid,,54.45,,,,,,,54.45,274.21,percent of total billed charges,
HC DISCARDED AMNIOEXCEL 4X4CM PER SQ CM,56361032,CDM,250,RC,Q4137,CPT,,,facility,outpatient,,,272.00000,163.20000,WellCare of North Carolina,Managed Medicaid,JW,54.45,,,,,,,54.45,240.06,percent of total billed charges,
HC AMNIOEXCEL OR BIODEXCEL 18MM DISK,56361033,CDM,636,RC,Q4137,CPT,,,facility,outpatient,,,2562.00000,1537.20000,WellCare of North Carolina,Managed Medicaid,,512.91,,,,,,,240.06,1901.52,percent of total billed charges,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,WellCare of North Carolina,Managed Medicaid,,59.06,,,,,,,57.15,221.25,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Managed Medicaid,,127.53,,,,,,,37.76,477.75,percent of total billed charges,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,WellCare of North Carolina,Managed Medicaid,,54.05,,,,,,,50.90,4311.00,percent of total billed charges,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,WellCare of North Carolina,Managed Medicaid,,849.45,,,,,,,799.81,4311.00,percent of total billed charges,
HC EDUCATION SESSION,57610040,CDM,510,RC,99211,CPT,,,facility,outpatient,,,181.00000,108.60000,WellCare of North Carolina,Managed Medicaid,,36.24,,,,,,,31.51,134.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,WellCare of North Carolina,Managed Medicaid,,49.25,,,,,,,46.37,4311.00,percent of total billed charges,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,WellCare of North Carolina,Managed Medicaid,,515.92,,,,,,,485.76,4376.00,percent of total billed charges,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,WellCare of North Carolina,Managed Medicaid,,41.84,,,,,,,41.84,142.48,percent of total billed charges,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,WellCare of North Carolina,Managed Medicaid,,60.66,,,,,,,57.12,246.34,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,WellCare of North Carolina,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,WellCare of North Carolina,Managed Medicaid,,395.60,,,,,,,372.48,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,WellCare of North Carolina,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,WellCare of North Carolina,Managed Medicaid,,86.49,,,,,,,81.43,4376.00,percent of total billed charges,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,WellCare of North Carolina,Managed Medicaid,,67.47,,,,,,,63.52,273.98,percent of total billed charges,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,WellCare of North Carolina,Managed Medicaid,,56.06,,,,,,,52.78,227.64,percent of total billed charges,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,WellCare of North Carolina,Managed Medicaid,,1877.68,,,,,,,1877.68,9423.00,percent of total billed charges,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,WellCare of North Carolina,Managed Medicaid,,222.82,,,,,,,222.82,3342.81,percent of total billed charges,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Managed Medicaid,,207.61,,,,,,,195.47,4376.00,percent of total billed charges,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,WellCare of North Carolina,Managed Medicaid,,239.64,,,,,,,225.63,4376.00,percent of total billed charges,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,WellCare of North Carolina,Managed Medicaid,,161.36,,,,,,,151.93,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,WellCare of North Carolina,Managed Medicaid,,397.40,,,,,,,397.40,4311.00,percent of total billed charges,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,WellCare of North Carolina,Managed Medicaid,,397.40,,,,,,,397.40,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,WellCare of North Carolina,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,WellCare of North Carolina,Managed Medicaid,,2337.54,,,,,,,2337.54,13852.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,WellCare of North Carolina,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,WellCare of North Carolina,Managed Medicaid,,4067.26,,,,,,,4067.26,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,WellCare of North Carolina,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,WellCare of North Carolina,Managed Medicaid,,1729.73,,,,,,,1729.73,13852.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,WellCare of North Carolina,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,WellCare of North Carolina,Managed Medicaid,,3669.87,,,,,,,3669.87,24600.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,WellCare of North Carolina,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,WellCare of North Carolina,Managed Medicaid,,5937.33,,,,,,,5937.33,52940.00,percent of total billed charges,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Managed Medicaid,,53.85,,,,,,,50.71,218.70,percent of total billed charges,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,WellCare of North Carolina,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE EA ADD 20 SQCM,57610344,CDM,761,RC,97598,CPT,,,facility,outpatient,,,594.00000,356.40000,WellCare of North Carolina,Managed Medicaid,,118.92,,,,,,,111.97,4311.00,percent of total billed charges,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,WellCare of North Carolina,Managed Medicaid,,102.50,,,,,,,96.51,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE EA ADD 20 SQCM,57610350,CDM,761,RC,11045,CPT,,,facility,outpatient,,,771.00000,462.60000,WellCare of North Carolina,Managed Medicaid,,154.35,,,,,,,145.33,4311.00,percent of total billed charges,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,WellCare of North Carolina,Managed Medicaid,,136.34,,,,,,,128.37,4376.00,percent of total billed charges,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,WellCare of North Carolina,Managed Medicaid,,775.77,,,,,,,730.44,4376.00,percent of total billed charges,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Managed Medicaid,,28.63,,,,,,,26.96,116.26,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC TANGENTIAL BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610463,CDM,761,RC,11103,CPT,,,facility,outpatient,,,195.00000,117.00000,WellCare of North Carolina,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC PUNCH BIOPSY OF SKIN EA SEPARATE ADDL LESION,57610465,CDM,761,RC,11105,CPT,,,facility,outpatient,,,195.00000,117.00000,WellCare of North Carolina,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Managed Medicaid,,63.06,,,,,,,59.38,4311.00,percent of total billed charges,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE EACH SEPARATE ADDL LESION,57610467,CDM,761,RC,11107,CPT,,,facility,outpatient,,,195.00000,117.00000,WellCare of North Carolina,Managed Medicaid,,39.04,,,,,,,36.76,4311.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,,33.03,,,,,,,28.73,767.00,percent of total billed charges,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,WellCare of North Carolina,Managed Medicaid,,189.99,,,,,,,88.31,767.00,percent of total billed charges,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,WellCare of North Carolina,Managed Medicaid,,96.90,,,,,,,84.26,767.00,percent of total billed charges,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Managed Medicaid,,25.63,,,,,,,22.28,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,WellCare of North Carolina,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Managed Medicaid,,31.63,,,,,,,27.51,269.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Managed Medicaid,,18.42,,,,,,,16.02,767.00,percent of total billed charges,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Managed Medicaid,,18.42,,,,,,,16.02,269.00,percent of total billed charges,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Managed Medicaid,,42.44,,,,,,,23.56,269.00,percent of total billed charges,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,WellCare of North Carolina,Managed Medicaid,,82.08,,,,,,,77.28,333.33,percent of total billed charges,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC MNT ASSESSMNT INITL INDV 15MIN,59400007,CDM,942,RC,97802,CPT,,,facility,outpatient,,,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT REASSESSMNT INDV 15MIN,59400008,CDM,942,RC,97803,CPT,,,facility,outpatient,,,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,11.14,1090.00,percent of total billed charges,
HC MNT GROUP EACH 30MIN,59400009,CDM,942,RC,97804,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,4.87,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT INDIV 30MIN,59400010,CDM,942,RC,G0108,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Managed Medicaid,,30.03,,,,,,,26.11,1090.00,percent of total billed charges,
HC DIABETIC SELF MGMT GROUP 30MIN,59400011,CDM,942,RC,G0109,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,,17.02,,,,,,,14.80,1090.00,percent of total billed charges,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Managed Medicaid,,26.63,,,,,,,26.63,767.00,percent of total billed charges,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Managed Medicaid,,103.10,,,,,,,97.08,420.05,percent of total billed charges,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,WellCare of North Carolina,Managed Medicaid,,8008.00,,,,,,,5080.00,29448.00,percent of total billed charges,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,WellCare of North Carolina,Managed Medicaid,,155.56,,,,,,,155.56,12408.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W OPEN FEM ILIAC AXIL A AND V CANNU,63600212,CDM,481,RC,33368,CPT,,,facility,outpatient,,,8778.00000,5266.80000,WellCare of North Carolina,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC TAVR W CARD PULM SUP W PERC FEM A AND V APPROACH,63600213,CDM,481,RC,33367,CPT,,,facility,outpatient,,,8778.00000,5266.80000,WellCare of North Carolina,Managed Medicaid,,1757.36,,,,,,,1757.36,9423.00,percent of total billed charges,
HC EP EVAL OF SICD,63600222,CDM,480,RC,93644,CPT,,,facility,outpatient,,,4941.00000,2964.60000,WellCare of North Carolina,Managed Medicaid,,989.19,,,,,,,661.11,3641.00,percent of total billed charges,
HC ASPIRAT BREAST CYST EA ADD,63610010,CDM,361,RC,19001,CPT,,,facility,outpatient,,,292.00000,175.20000,WellCare of North Carolina,Managed Medicaid,,58.46,,,,,,,58.46,4311.00,percent of total billed charges,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,WellCare of North Carolina,Managed Medicaid,,176.98,,,,,,,176.98,4311.00,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,WellCare of North Carolina,Managed Medicaid,,41.04,,,,,,,38.64,166.66,percent of total billed charges,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,WellCare of North Carolina,Managed Medicaid,,41.04,,,,,,,38.23,153.75,percent of total billed charges,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,WellCare of North Carolina,Managed Medicaid,,194.19,,,,,,,194.19,4311.00,percent of total billed charges,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,WellCare of North Carolina,Managed Medicaid,,246.25,,,,,,,246.25,4376.00,percent of total billed charges,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Managed Medicaid,,64.86,,,,,,,64.86,4311.00,percent of total billed charges,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,WellCare of North Carolina,Managed Medicaid,,1253.05,,,,,,,1253.05,5152.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Managed Medicaid,,625.22,,,,,,,420.60,4376.00,percent of total billed charges,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,WellCare of North Carolina,Managed Medicaid,,97.30,,,,,,,97.30,5754.00,percent of total billed charges,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,WellCare of North Carolina,Managed Medicaid,,4128.92,,,,,,,3318.21,17457.00,percent of total billed charges,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Managed Medicaid,,625.22,,,,,,,588.69,4376.00,percent of total billed charges,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,WellCare of North Carolina,Managed Medicaid,,168.57,,,,,,,168.57,4376.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,WellCare of North Carolina,Managed Medicaid,,467.67,,,,,,,467.67,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,WellCare of North Carolina,Managed Medicaid,,463.86,,,,,,,463.86,17457.00,percent of total billed charges,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,WellCare of North Carolina,Managed Medicaid,,464.86,,,,,,,464.86,6735.00,percent of total billed charges,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,WellCare of North Carolina,Managed Medicaid,,2388.19,,,,,,,2388.19,24600.00,percent of total billed charges,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,WellCare of North Carolina,Managed Medicaid,,104.90,,,,,,,104.90,4311.00,percent of total billed charges,
HC ANESTHESIA US GUIDANCE VASCULAR ACCESS,63610099,CDM,402,RC,76937,CPT,,,facility,outpatient,,,573.00000,343.80000,WellCare of North Carolina,Managed Medicaid,,114.71,,,,,,,114.71,467.00,percent of total billed charges,
HC FNA BIOPSY W OUT GUIDANCE EACH ADDL LESION,63610107,CDM,361,RC,10004,CPT,,,facility,outpatient,,,1331.00000,798.60000,WellCare of North Carolina,Managed Medicaid,,266.47,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,WellCare of North Carolina,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BIOPSY INCL US GUIDANCE EA ADDL LESION,63610109,CDM,361,RC,10006,CPT,,,facility,outpatient,,,2561.00000,1536.60000,WellCare of North Carolina,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,WellCare of North Carolina,Managed Medicaid,,379.38,,,,,,,379.38,4311.00,percent of total billed charges,
HC FNA BX INCL FLUORO GUIDANCE EA ADDL LESION,63610111,CDM,361,RC,10008,CPT,,,facility,outpatient,,,1895.00000,1137.00000,WellCare of North Carolina,Managed Medicaid,,379.38,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,WellCare of North Carolina,Managed Medicaid,,691.89,,,,,,,676.91,4311.00,percent of total billed charges,
HC FNA BX INCL CT GUIDANCE EA ADDL LESION,63610113,CDM,361,RC,10010,CPT,,,facility,outpatient,,,3456.00000,2073.60000,WellCare of North Carolina,Managed Medicaid,,691.89,,,,,,,173.00,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,WellCare of North Carolina,Managed Medicaid,,512.71,,,,,,,512.71,4311.00,percent of total billed charges,
HC FNA BX INCL MR GUIDANCE EA ADDL LESION,63610115,CDM,361,RC,10012,CPT,,,facility,outpatient,,,2561.00000,1536.60000,WellCare of North Carolina,Managed Medicaid,,512.71,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTEGRA BILAYER MATRIX WOUND DRESSING 4SQCM 2X2 PER SQ CM,66360038,CDM,636,RC,Q4104,CPT,,,facility,outpatient,,,5187.00000,3112.20000,WellCare of North Carolina,Managed Medicaid,,1038.44,,,,,,,120.36,3849.79,percent of total billed charges,
HC NEOX 1K 2.0X1.0CM PER SQ CM,66360053,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,WellCare of North Carolina,Managed Medicaid,,247.25,,,,,,,247.25,916.62,percent of total billed charges,
HC NEOX 1K 2.0X2.0CM PER SQ CM,66360054,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,WellCare of North Carolina,Managed Medicaid,,209.81,,,,,,,209.81,777.83,percent of total billed charges,
HC NEOX 1K 3.0X2.0CM PER SQ CM,66360055,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,WellCare of North Carolina,Managed Medicaid,,141.54,,,,,,,141.54,524.74,percent of total billed charges,
HC NEOX 1K 3.0X3.0CM PER SQ CM,66360056,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Managed Medicaid,,110.11,,,,,,,110.11,408.21,percent of total billed charges,
HC NEOX 1K 4.0X3.0CM PER SQ CM,66360057,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Managed Medicaid,,88.49,,,,,,,88.49,343.20,percent of total billed charges,
HC NEOX 1K 6.0X3.0CM PER SQ CM,66360058,CDM,636,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,WellCare of North Carolina,Managed Medicaid,,93.29,,,,,,,93.29,345.87,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X1.0CM PER SQ CM,66360059,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1235.00000,741.00000,WellCare of North Carolina,Managed Medicaid,JW,247.25,,,,,,,247.25,1004.05,percent of total billed charges,
HC DISCARDED NEOX 1K 2.0X2.0CM PER SQ CM,66360060,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,1048.00000,628.80000,WellCare of North Carolina,Managed Medicaid,JW,209.81,,,,,,,209.81,852.02,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X2.0CM PER SQ CM,66360061,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,707.00000,424.20000,WellCare of North Carolina,Managed Medicaid,JW,141.54,,,,,,,141.54,574.79,percent of total billed charges,
HC DISCARDED NEOX 1K 3.0X3.0CM PER SQ CM,66360062,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Managed Medicaid,JW,110.11,,,,,,,110.11,447.15,percent of total billed charges,
HC DISCARDED NEOX 1K 4.0X3.0CM PER SQ CM,66360063,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Managed Medicaid,JW,88.49,,,,,,,88.49,359.35,percent of total billed charges,
HC DISCARDED NEOX 1K 6.0X3.0CM PER SQ CM,66360064,CDM,250,RC,Q4148,CPT,,,facility,outpatient,,,466.00000,279.60000,WellCare of North Carolina,Managed Medicaid,JW,93.29,,,,,,,93.29,378.86,percent of total billed charges,
HC INTEGRA BILAYER WOUND MATRIX 20SQCM 4X5 PER SQ CM,66360143,CDM,636,RC,C9363,CPT,,,facility,outpatient,,,2078.00000,1246.80000,WellCare of North Carolina,Managed Medicaid,,416.02,,,,,,,162.39,1542.29,percent of total billed charges,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,WellCare of North Carolina,Managed Medicaid,,35.84,,,,,,,33.74,145.53,percent of total billed charges,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,35.44,152.84,percent of total billed charges,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,WellCare of North Carolina,Managed Medicaid,,159.56,,,,,,,159.56,4311.00,percent of total billed charges,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Managed Medicaid,,197.80,,,,,,,173.00,832.00,percent of total billed charges,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,WellCare of North Carolina,Managed Medicaid,,286.69,,,,,,,173.00,1064.69,percent of total billed charges,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,WellCare of North Carolina,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,WellCare of North Carolina,Managed Medicaid,,35.84,,,,,,,35.84,832.00,percent of total billed charges,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,WellCare of North Carolina,Managed Medicaid,,365.97,,,,,,,365.97,3142.00,percent of total billed charges,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,WellCare of North Carolina,Managed Medicaid,,519.32,,,,,,,519.32,3142.00,percent of total billed charges,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,WellCare of North Carolina,Managed Medicaid,,189.19,,,,,,,173.00,832.00,percent of total billed charges,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,WellCare of North Carolina,Managed Medicaid,,577.18,,,,,,,577.18,3142.00,percent of total billed charges,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,WellCare of North Carolina,Managed Medicaid,,191.39,,,,,,,173.00,832.00,percent of total billed charges,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,WellCare of North Carolina,Managed Medicaid,,177.38,,,,,,,173.00,832.00,percent of total billed charges,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,WellCare of North Carolina,Managed Medicaid,,280.68,,,,,,,173.00,4311.00,percent of total billed charges,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,WellCare of North Carolina,Managed Medicaid,,435.23,,,,,,,409.80,2452.76,percent of total billed charges,
HC CORNEAL TISSUE,67610006,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,4232.00000,2539.20000,WellCare of North Carolina,Managed Medicaid,,847.25,,,,,,,736.79,3440.62,percent of total billed charges,
HC ENDOTHELIAL CORNEA TISSUE,67610007,CDM,812,RC,V2785,CPT,,,facility,outpatient,,,19132.00000,11479.20000,WellCare of North Carolina,Managed Medicaid,,3830.23,,,,,,,3330.88,15554.32,percent of total billed charges,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,WellCare of North Carolina,Managed Medicaid,,85.89,,,,,,,74.69,1831.00,percent of total billed charges,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,WellCare of North Carolina,Managed Medicaid,,90.49,,,,,,,78.69,1831.00,percent of total billed charges,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,WellCare of North Carolina,Managed Medicaid,,80.28,,,,,,,69.81,1831.00,percent of total billed charges,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,WellCare of North Carolina,Managed Medicaid,,133.13,,,,,,,115.78,1831.00,percent of total billed charges,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,WellCare of North Carolina,Managed Medicaid,,63.66,,,,,,,55.36,1831.00,percent of total billed charges,
HC STANDBY BEFORE MONITORING,69600001,CDM,960,RC,99360,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC F18 SODIUM FLUORIDE DX PSD UP TO 30MCI,72550006,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Managed Medicaid,,64.86,,,,,,,45.52,268.00,percent of total billed charges,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,WellCare of North Carolina,Managed Medicaid,,109.11,,,,,,,61.58,408.75,percent of total billed charges,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,WellCare of North Carolina,Managed Medicaid,,70.47,,,,,,,70.47,268.00,percent of total billed charges,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,WellCare of North Carolina,Managed Medicaid,,96.30,,,,,,,42.96,360.75,percent of total billed charges,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,WellCare of North Carolina,Managed Medicaid,,120.32,,,,,,,67.36,450.75,percent of total billed charges,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,WellCare of North Carolina,Managed Medicaid,,78.88,,,,,,,57.08,295.50,percent of total billed charges,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Managed Medicaid,,88.49,,,,,,,65.78,331.50,percent of total billed charges,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,WellCare of North Carolina,Managed Medicaid,,100.10,,,,,,,67.36,375.00,percent of total billed charges,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,WellCare of North Carolina,Managed Medicaid,,30.43,,,,,,,30.43,268.00,percent of total billed charges,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,WellCare of North Carolina,Managed Medicaid,,54.05,,,,,,,52.60,268.00,percent of total billed charges,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Managed Medicaid,,24.02,,,,,,,24.02,268.00,percent of total billed charges,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,WellCare of North Carolina,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,WellCare of North Carolina,Managed Medicaid,,134.33,,,,,,,60.30,503.25,percent of total billed charges,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,WellCare of North Carolina,Managed Medicaid,,35.84,,,,,,,35.84,268.00,percent of total billed charges,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,WellCare of North Carolina,Managed Medicaid,,60.46,,,,,,,15.34,268.00,percent of total billed charges,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,WellCare of North Carolina,Managed Medicaid,,72.47,,,,,,,43.60,271.50,percent of total billed charges,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Managed Medicaid,,96.70,,,,,,,50.02,362.25,percent of total billed charges,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,WellCare of North Carolina,Managed Medicaid,,116.92,,,,,,,56.44,438.00,percent of total billed charges,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,WellCare of North Carolina,Managed Medicaid,,216.02,,,,,,,57.74,809.25,percent of total billed charges,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,WellCare of North Carolina,Managed Medicaid,,117.12,,,,,,,71.86,438.75,percent of total billed charges,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,46.82,288.75,percent of total billed charges,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Managed Medicaid,,61.06,,,,,,,59.66,268.00,percent of total billed charges,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Managed Medicaid,,88.49,,,,,,,32.04,331.50,percent of total billed charges,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,WellCare of North Carolina,Managed Medicaid,,99.30,,,,,,,55.16,372.00,percent of total billed charges,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Managed Medicaid,,132.13,,,,,,,77.00,495.00,percent of total billed charges,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,WellCare of North Carolina,Managed Medicaid,,185.99,,,,,,,91.78,696.75,percent of total billed charges,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,WellCare of North Carolina,Managed Medicaid,,87.49,,,,,,,44.24,327.75,percent of total billed charges,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,WellCare of North Carolina,Managed Medicaid,,65.47,,,,,,,54.52,268.00,percent of total billed charges,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,WellCare of North Carolina,Managed Medicaid,,112.91,,,,,,,47.46,423.00,percent of total billed charges,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,WellCare of North Carolina,Managed Medicaid,,98.50,,,,,,,55.80,369.00,percent of total billed charges,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,WellCare of North Carolina,Managed Medicaid,,142.14,,,,,,,74.44,532.50,percent of total billed charges,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,WellCare of North Carolina,Managed Medicaid,,175.18,,,,,,,91.12,656.25,percent of total billed charges,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Managed Medicaid,,116.52,,,,,,,57.74,436.50,percent of total billed charges,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,WellCare of North Carolina,Managed Medicaid,,68.27,,,,,,,37.18,268.00,percent of total billed charges,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,WellCare of North Carolina,Managed Medicaid,,108.31,,,,,,,57.74,405.75,percent of total billed charges,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,WellCare of North Carolina,Managed Medicaid,,73.87,,,,,,,54.52,276.75,percent of total billed charges,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,WellCare of North Carolina,Managed Medicaid,,73.67,,,,,,,46.16,276.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,WellCare of North Carolina,Managed Medicaid,,242.44,,,,,,,138.66,908.25,percent of total billed charges,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,WellCare of North Carolina,Managed Medicaid,,150.55,,,,,,,141.22,830.63,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,WellCare of North Carolina,Managed Medicaid,,267.47,,,,,,,135.44,1002.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,WellCare of North Carolina,Managed Medicaid,,378.78,,,,,,,195.18,1419.00,percent of total billed charges,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,WellCare of North Carolina,Managed Medicaid,,416.62,,,,,,,139.30,2053.05,percent of total billed charges,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,WellCare of North Carolina,Managed Medicaid,,85.08,,,,,,,46.16,318.75,percent of total billed charges,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,WellCare of North Carolina,Managed Medicaid,,76.48,,,,,,,28.82,286.50,percent of total billed charges,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,WellCare of North Carolina,Managed Medicaid,,91.89,,,,,,,26.90,344.25,percent of total billed charges,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,WellCare of North Carolina,Managed Medicaid,,92.49,,,,,,,48.74,346.50,percent of total billed charges,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,WellCare of North Carolina,Managed Medicaid,,254.45,,,,,,,204.18,953.25,percent of total billed charges,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,WellCare of North Carolina,Managed Medicaid,,104.50,,,,,,,37.18,391.50,percent of total billed charges,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,WellCare of North Carolina,Managed Medicaid,,88.09,,,,,,,46.16,330.00,percent of total billed charges,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,WellCare of North Carolina,Managed Medicaid,,81.28,,,,,,,40.38,304.50,percent of total billed charges,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Managed Medicaid,,88.49,,,,,,,46.16,331.50,percent of total billed charges,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,WellCare of North Carolina,Managed Medicaid,,97.50,,,,,,,97.50,375.47,percent of total billed charges,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,WellCare of North Carolina,Managed Medicaid,,75.88,,,,,,,41.04,284.25,percent of total billed charges,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,WellCare of North Carolina,Managed Medicaid,,59.66,,,,,,,46.16,268.00,percent of total billed charges,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,WellCare of North Carolina,Managed Medicaid,,75.08,,,,,,,49.38,281.25,percent of total billed charges,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,WellCare of North Carolina,Managed Medicaid,,69.47,,,,,,,62.22,268.00,percent of total billed charges,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,WellCare of North Carolina,Managed Medicaid,,130.73,,,,,,,130.73,489.75,percent of total billed charges,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,WellCare of North Carolina,Managed Medicaid,,86.29,,,,,,,44.24,323.25,percent of total billed charges,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,WellCare of North Carolina,Managed Medicaid,,78.88,,,,,,,53.88,295.50,percent of total billed charges,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,WellCare of North Carolina,Managed Medicaid,,55.26,,,,,,,55.26,268.00,percent of total billed charges,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,WellCare of North Carolina,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,WellCare of North Carolina,Managed Medicaid,,85.49,,,,,,,50.02,320.25,percent of total billed charges,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,WellCare of North Carolina,Managed Medicaid,,74.27,,,,,,,60.94,278.25,percent of total billed charges,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,WellCare of North Carolina,Managed Medicaid,,96.50,,,,,,,68.00,361.50,percent of total billed charges,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,WellCare of North Carolina,Managed Medicaid,,63.26,,,,,,,61.58,268.00,percent of total billed charges,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,WellCare of North Carolina,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,WellCare of North Carolina,Managed Medicaid,,70.87,,,,,,,45.52,268.00,percent of total billed charges,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Managed Medicaid,,43.64,,,,,,,43.64,268.00,percent of total billed charges,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,WellCare of North Carolina,Managed Medicaid,,89.09,,,,,,,46.82,333.75,percent of total billed charges,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Managed Medicaid,,92.69,,,,,,,54.52,347.25,percent of total billed charges,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,WellCare of North Carolina,Managed Medicaid,,76.08,,,,,,,76.08,375.47,percent of total billed charges,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,WellCare of North Carolina,Managed Medicaid,,106.11,,,,,,,39.74,397.50,percent of total billed charges,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Managed Medicaid,,92.69,,,,,,,50.66,347.25,percent of total billed charges,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,WellCare of North Carolina,Managed Medicaid,,80.28,,,,,,,40.38,300.75,percent of total billed charges,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Managed Medicaid,,64.86,,,,,,,43.60,268.00,percent of total billed charges,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,WellCare of North Carolina,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,,99.10,,,,,,,63.20,576.46,percent of total billed charges,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,WellCare of North Carolina,Managed Medicaid,,156.56,,,,,,,138.66,586.50,percent of total billed charges,
HC S AND I REMOVE FOREIGN BODY ESOPHAGUS,72550123,CDM,320,RC,74235,CPT,,,facility,outpatient,,,322.00000,193.20000,WellCare of North Carolina,Managed Medicaid,,64.46,,,,,,,64.46,268.00,percent of total billed charges,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,WellCare of North Carolina,Managed Medicaid,,49.45,,,,,,,49.45,311.44,percent of total billed charges,
HC CHOLANGIOGRAPHY INTRAOPERATIVE,72550136,CDM,320,RC,74300,CPT,,,facility,outpatient,,,1055.00000,633.00000,WellCare of North Carolina,Managed Medicaid,,211.21,,,,,,,211.21,791.25,percent of total billed charges,
HC OR S AND I CHOLANGIO INTRAOPERATIVE T TUBE,72550137,CDM,320,RC,74301,CPT,,,facility,outpatient,,,728.00000,436.80000,WellCare of North Carolina,Managed Medicaid,,145.75,,,,,,,145.75,546.00,percent of total billed charges,
HC PLCMT GASTROINT TUBE W FLUORO,72550144,CDM,320,RC,74340,CPT,,,facility,outpatient,,,888.00000,532.80000,WellCare of North Carolina,Managed Medicaid,,177.78,,,,,,,177.78,666.00,percent of total billed charges,
HC S AND I DILATION OF ESOPHAGUS,72550146,CDM,320,RC,74360,CPT,,,facility,outpatient,,,498.00000,298.80000,WellCare of North Carolina,Managed Medicaid,,99.70,,,,,,,99.70,373.50,percent of total billed charges,
HC DILATION BILIARY STRICTURE W WO STENT S AND I,72550147,CDM,320,RC,74363,CPT,,,facility,outpatient,,,529.00000,317.40000,WellCare of North Carolina,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Managed Medicaid,,197.80,,,,,,,171.27,741.00,percent of total billed charges,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Managed Medicaid,,208.41,,,,,,,171.27,780.75,percent of total billed charges,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,WellCare of North Carolina,Managed Medicaid,,215.01,,,,,,,100.76,805.50,percent of total billed charges,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,WellCare of North Carolina,Managed Medicaid,,107.51,,,,,,,107.51,402.75,percent of total billed charges,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,WellCare of North Carolina,Managed Medicaid,,19.62,,,,,,,19.62,375.47,percent of total billed charges,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,WellCare of North Carolina,Managed Medicaid,,116.12,,,,,,,116.12,435.00,percent of total billed charges,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,WellCare of North Carolina,Managed Medicaid,,128.73,,,,,,,98.30,482.25,percent of total billed charges,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,WellCare of North Carolina,Managed Medicaid,,163.76,,,,,,,163.76,613.50,percent of total billed charges,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,WellCare of North Carolina,Managed Medicaid,,133.33,,,,,,,133.33,2153.70,percent of total billed charges,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,WellCare of North Carolina,Managed Medicaid,,162.16,,,,,,,154.08,607.50,percent of total billed charges,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,WellCare of North Carolina,Managed Medicaid,,418.02,,,,,,,130.88,5683.29,percent of total billed charges,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,WellCare of North Carolina,Managed Medicaid,,929.93,,,,,,,116.82,3483.75,percent of total billed charges,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,WellCare of North Carolina,Managed Medicaid,,716.12,,,,,,,125.18,3309.13,percent of total billed charges,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,WellCare of North Carolina,Managed Medicaid,,37.04,,,,,,,37.04,268.00,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,WellCare of North Carolina,Managed Medicaid,,273.87,,,,,,,117.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,WellCare of North Carolina,Managed Medicaid,,279.28,,,,,,,126.46,1633.21,percent of total billed charges,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,WellCare of North Carolina,Managed Medicaid,,810.21,,,,,,,118.74,3309.13,percent of total billed charges,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,WellCare of North Carolina,Managed Medicaid,,1150.35,,,,,,,129.02,4309.50,percent of total billed charges,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,WellCare of North Carolina,Managed Medicaid,,265.47,,,,,,,130.96,3309.13,percent of total billed charges,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,WellCare of North Carolina,Managed Medicaid,,514.91,,,,,,,150.14,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,WellCare of North Carolina,Managed Medicaid,,206.41,,,,,,,143.80,3309.13,percent of total billed charges,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,WellCare of North Carolina,Managed Medicaid,,240.64,,,,,,,167.48,5683.29,percent of total billed charges,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,WellCare of North Carolina,Managed Medicaid,,321.92,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Managed Medicaid,,160.96,,,,,,,160.96,3309.13,percent of total billed charges,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,WellCare of North Carolina,Managed Medicaid,,323.52,,,,,,,139.94,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,WellCare of North Carolina,Managed Medicaid,,193.59,,,,,,,138.66,3309.13,percent of total billed charges,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,WellCare of North Carolina,Managed Medicaid,,159.96,,,,,,,139.30,3309.13,percent of total billed charges,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,WellCare of North Carolina,Managed Medicaid,,221.42,,,,,,,150.22,5683.29,percent of total billed charges,
HC S AND I TRANSCATHETER EMBOLIZATION,72550186,CDM,320,RC,75894,CPT,,,facility,outpatient,,,2333.00000,1399.80000,WellCare of North Carolina,Managed Medicaid,,467.07,,,,,,,232.00,1749.75,percent of total billed charges,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,WellCare of North Carolina,Managed Medicaid,,275.48,,,,,,,82.40,3309.13,percent of total billed charges,
HC S AND I MECH REMVL PERICATH OBS MAT,72550189,CDM,320,RC,75901,CPT,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Managed Medicaid,,40.84,,,,,,,40.84,268.00,percent of total billed charges,
HC S AND I MECH REMVL INTRALUMINL OBS,72550190,CDM,320,RC,75902,CPT,,,facility,outpatient,,,175.00000,105.00000,WellCare of North Carolina,Managed Medicaid,,35.03,,,,,,,35.03,268.00,percent of total billed charges,
HC S AND I ENDOV REPAIR DTA INV LSA,72550196,CDM,320,RC,75956,CPT,,,facility,outpatient,,,1204.00000,722.40000,WellCare of North Carolina,Managed Medicaid,,241.04,,,,,,,232.00,903.00,percent of total billed charges,
HC S AND I TRANSCATHETER BIOPSY,72550205,CDM,320,RC,75970,CPT,,,facility,outpatient,,,771.00000,462.60000,WellCare of North Carolina,Managed Medicaid,,154.35,,,,,,,154.35,578.25,percent of total billed charges,
HC S AND I CHANGE DRAIN CATH,72550209,CDM,320,RC,75984,CPT,,,facility,outpatient,,,1057.00000,634.20000,WellCare of North Carolina,Managed Medicaid,,211.61,,,,,,,211.61,792.75,percent of total billed charges,
HC S AND I DRAINAGE CATHETER PLACEMENT,72550210,CDM,320,RC,75989,CPT,,,facility,outpatient,,,358.00000,214.80000,WellCare of North Carolina,Managed Medicaid,,71.67,,,,,,,71.67,268.50,percent of total billed charges,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,WellCare of North Carolina,Managed Medicaid,,190.79,,,,,,,53.24,714.75,percent of total billed charges,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,WellCare of North Carolina,Managed Medicaid,,33.83,,,,,,,33.83,268.00,percent of total billed charges,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,WellCare of North Carolina,Managed Medicaid,,187.39,,,,,,,68.64,702.00,percent of total billed charges,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,WellCare of North Carolina,Managed Medicaid,,61.26,,,,,,,48.74,576.46,percent of total billed charges,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,WellCare of North Carolina,Managed Medicaid,,68.27,,,,,,,68.27,268.00,percent of total billed charges,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Managed Medicaid,,28.63,,,,,,,28.63,268.00,percent of total billed charges,
HC FLUORO GUIDE CVA DEV PLACEMENT,72550219,CDM,320,RC,77001,CPT,,,facility,outpatient,,,744.00000,446.40000,WellCare of North Carolina,Managed Medicaid,,148.95,,,,,,,148.95,558.00,percent of total billed charges,
HC FLUORO GUIDANCE NEEDLE PLACEMENT,72550220,CDM,320,RC,77002,CPT,,,facility,outpatient,,,662.00000,397.20000,WellCare of North Carolina,Managed Medicaid,,132.53,,,,,,,132.53,496.50,percent of total billed charges,
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT INE INJ,72550221,CDM,320,RC,77003,CPT,,,facility,outpatient,,,657.00000,394.20000,WellCare of North Carolina,Managed Medicaid,,131.53,,,,,,,131.53,492.75,percent of total billed charges,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,WellCare of North Carolina,Managed Medicaid,,64.66,,,,,,,64.66,268.00,percent of total billed charges,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,WellCare of North Carolina,Managed Medicaid,,129.33,,,,,,,91.12,484.50,percent of total billed charges,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,WellCare of North Carolina,Managed Medicaid,,69.27,,,,,,,32.68,268.00,percent of total billed charges,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,WellCare of North Carolina,Managed Medicaid,,48.65,,,,,,,48.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,WellCare of North Carolina,Managed Medicaid,,53.65,,,,,,,53.65,268.00,percent of total billed charges,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,WellCare of North Carolina,Managed Medicaid,,185.59,,,,,,,102.31,695.25,percent of total billed charges,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,WellCare of North Carolina,Managed Medicaid,,61.26,,,,,,,61.26,268.00,percent of total billed charges,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Managed Medicaid,,182.38,,,,,,,52.60,683.25,percent of total billed charges,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,WellCare of North Carolina,Managed Medicaid,,58.26,,,,,,,40.38,268.00,percent of total billed charges,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,WellCare of North Carolina,Managed Medicaid,,157.76,,,,,,,157.76,5683.29,percent of total billed charges,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,WellCare of North Carolina,Managed Medicaid,,469.07,,,,,,,133.52,3309.13,percent of total billed charges,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,WellCare of North Carolina,Managed Medicaid,,808.61,,,,,,,137.94,3309.13,percent of total billed charges,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,WellCare of North Carolina,Managed Medicaid,,668.27,,,,,,,148.86,5683.29,percent of total billed charges,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,WellCare of North Carolina,Managed Medicaid,,720.32,,,,,,,186.12,3309.13,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,WellCare of North Carolina,Managed Medicaid,,407.41,,,,,,,170.70,5683.29,percent of total billed charges,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,WellCare of North Carolina,Managed Medicaid,,903.70,,,,,,,136.10,3385.50,percent of total billed charges,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,WellCare of North Carolina,Managed Medicaid,,903.70,,,,,,,138.58,3385.50,percent of total billed charges,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,WellCare of North Carolina,Managed Medicaid,,903.70,,,,,,,155.28,3385.50,percent of total billed charges,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,WellCare of North Carolina,Managed Medicaid,,611.21,,,,,,,198.96,3309.13,percent of total billed charges,
HC S AND I ANGIO SELECT EACH ADDITIONAL VESSEL,72550249,CDM,323,RC,75774,CPT,,,facility,outpatient,,,1786.00000,1071.60000,WellCare of North Carolina,Managed Medicaid,,357.56,,,,,,,232.00,1339.50,percent of total billed charges,
HC ANGIO ILIAC ARTERY W CATH,72550252,CDM,481,RC,G0278,CPT,,,facility,outpatient,,,1404.00000,842.40000,WellCare of North Carolina,Managed Medicaid,,281.08,,,,,,,281.08,9423.00,percent of total billed charges,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,WellCare of North Carolina,Managed Medicaid,,53.65,,,,,,,32.68,268.00,percent of total billed charges,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,WellCare of North Carolina,Managed Medicaid,,74.87,,,,,,,44.24,280.50,percent of total billed charges,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,WellCare of North Carolina,Managed Medicaid,,66.47,,,,,,,60.30,268.00,percent of total billed charges,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,WellCare of North Carolina,Managed Medicaid,,166.37,,,,,,,166.37,623.25,percent of total billed charges,
HC TC99M PENTETATE DX PSD UP TO 25 MCI,72550261,CDM,343,RC,A9539,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Managed Medicaid,,32.63,,,,,,,32.63,104.79,percent of total billed charges,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,WellCare of North Carolina,Managed Medicaid,,100.30,,,,,,,51.96,375.75,percent of total billed charges,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,WellCare of North Carolina,Managed Medicaid,,416.62,,,,,,,137.38,2053.05,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,WellCare of North Carolina,Managed Medicaid,,123.52,,,,,,,57.74,462.75,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,WellCare of North Carolina,Managed Medicaid,,162.56,,,,,,,102.31,609.00,percent of total billed charges,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,WellCare of North Carolina,Managed Medicaid,,172.37,,,,,,,102.31,645.75,percent of total billed charges,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,WellCare of North Carolina,Managed Medicaid,,93.49,,,,,,,44.88,350.25,percent of total billed charges,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,WellCare of North Carolina,Managed Medicaid,,98.90,,,,,,,69.30,370.50,percent of total billed charges,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,WellCare of North Carolina,Managed Medicaid,,104.70,,,,,,,87.92,392.25,percent of total billed charges,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,WellCare of North Carolina,Managed Medicaid,,151.75,,,,,,,58.38,568.50,percent of total billed charges,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,WellCare of North Carolina,Managed Medicaid,,147.35,,,,,,,75.72,552.00,percent of total billed charges,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,WellCare of North Carolina,Managed Medicaid,,216.02,,,,,,,89.20,809.25,percent of total billed charges,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,WellCare of North Carolina,Managed Medicaid,,45.85,,,,,,,40.38,268.00,percent of total billed charges,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,WellCare of North Carolina,Managed Medicaid,,86.49,,,,,,,50.66,324.00,percent of total billed charges,
HC RAD EXAM SMALL INTESTINE FOLLOW THROUGH STUDY,72550293,CDM,320,RC,74248,CPT,,,facility,outpatient,,,1063.00000,637.80000,WellCare of North Carolina,Managed Medicaid,,212.81,,,,,,,212.81,797.25,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Managed Medicaid,,123.12,,,,,,,123.12,461.25,percent of total billed charges,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,WellCare of North Carolina,Managed Medicaid,,157.16,,,,,,,154.08,588.75,percent of total billed charges,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,WellCare of North Carolina,Managed Medicaid,,7507.50,,,,,,,4762.50,27607.50,percent of total billed charges,
HC US CYST PUNCTURE,73200001,CDM,402,RC,76942,CPT,,,facility,outpatient,,,217.00000,130.20000,WellCare of North Carolina,Managed Medicaid,,43.44,,,,,,,43.44,467.00,percent of total billed charges,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,WellCare of North Carolina,Managed Medicaid,,370.97,,,,,,,170.70,5683.29,percent of total billed charges,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,WellCare of North Carolina,Managed Medicaid,,451.05,,,,,,,451.05,8213.00,percent of total billed charges,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,WellCare of North Carolina,Managed Medicaid,,84.08,,,,,,,56.44,315.00,percent of total billed charges,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Managed Medicaid,,110.11,,,,,,,49.38,412.50,percent of total billed charges,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,WellCare of North Carolina,Managed Medicaid,,108.11,,,,,,,58.38,405.00,percent of total billed charges,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,WellCare of North Carolina,Managed Medicaid,,80.28,,,,,,,80.28,300.75,percent of total billed charges,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,WellCare of North Carolina,Managed Medicaid,,119.32,,,,,,,119.32,447.00,percent of total billed charges,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,WellCare of North Carolina,Managed Medicaid,,99.50,,,,,,,99.50,372.75,percent of total billed charges,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,WellCare of North Carolina,Managed Medicaid,,150.55,,,,,,,66.72,564.00,percent of total billed charges,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,WellCare of North Carolina,Managed Medicaid,,116.32,,,,,,,116.32,633.86,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,WellCare of North Carolina,Managed Medicaid,,185.79,,,,,,,171.27,696.00,percent of total billed charges,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,WellCare of North Carolina,Managed Medicaid,,276.68,,,,,,,171.27,1036.50,percent of total billed charges,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,WellCare of North Carolina,Managed Medicaid,,54.05,,,,,,,54.05,2905.00,percent of total billed charges,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,WellCare of North Carolina,Managed Medicaid,,165.97,,,,,,,165.97,3466.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,343.00000,205.80000,WellCare of North Carolina,Managed Medicaid,,68.67,,,,,,,68.67,1067.00,percent of total billed charges,
HC CT IGRT,73300002,CDM,333,RC,77387,CPT,,,facility,outpatient,,,413.00000,247.80000,WellCare of North Carolina,Managed Medicaid,,82.68,,,,,,,82.68,1067.00,percent of total billed charges,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,WellCare of North Carolina,Managed Medicaid,,271.67,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,WellCare of North Carolina,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,WellCare of North Carolina,Managed Medicaid,,137.14,,,,,,,137.14,1560.00,percent of total billed charges,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,WellCare of North Carolina,Managed Medicaid,,221.02,,,,,,,221.02,1560.00,percent of total billed charges,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,WellCare of North Carolina,Managed Medicaid,,116.72,,,,,,,116.72,1560.00,percent of total billed charges,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,WellCare of North Carolina,Managed Medicaid,,583.98,,,,,,,257.00,2187.75,percent of total billed charges,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,WellCare of North Carolina,Managed Medicaid,,299.10,,,,,,,257.00,1560.00,percent of total billed charges,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,WellCare of North Carolina,Managed Medicaid,,218.82,,,,,,,218.82,1560.00,percent of total billed charges,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,WellCare of North Carolina,Managed Medicaid,,195.40,,,,,,,195.40,1560.00,percent of total billed charges,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,WellCare of North Carolina,Managed Medicaid,,143.54,,,,,,,143.54,1560.00,percent of total billed charges,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,WellCare of North Carolina,Managed Medicaid,,373.57,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,WellCare of North Carolina,Managed Medicaid,,203.00,,,,,,,203.00,1560.00,percent of total billed charges,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,WellCare of North Carolina,Managed Medicaid,,416.22,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,WellCare of North Carolina,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,WellCare of North Carolina,Managed Medicaid,,458.46,,,,,,,257.00,1717.50,percent of total billed charges,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,WellCare of North Carolina,Managed Medicaid,,320.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,WellCare of North Carolina,Managed Medicaid,,476.08,,,,,,,257.00,1783.50,percent of total billed charges,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,WellCare of North Carolina,Managed Medicaid,,547.15,,,,,,,257.00,2049.75,percent of total billed charges,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,WellCare of North Carolina,Managed Medicaid,,171.37,,,,,,,171.37,1560.00,percent of total billed charges,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,WellCare of North Carolina,Managed Medicaid,,313.71,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,WellCare of North Carolina,Managed Medicaid,,246.25,,,,,,,246.25,1560.00,percent of total billed charges,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,WellCare of North Carolina,Managed Medicaid,,449.45,,,,,,,257.00,1683.75,percent of total billed charges,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,WellCare of North Carolina,Managed Medicaid,,208.61,,,,,,,208.61,1560.00,percent of total billed charges,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,WellCare of North Carolina,Managed Medicaid,,229.83,,,,,,,229.83,1560.00,percent of total billed charges,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,WellCare of North Carolina,Managed Medicaid,,251.25,,,,,,,251.25,1560.00,percent of total billed charges,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,WellCare of North Carolina,Managed Medicaid,,357.16,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,WellCare of North Carolina,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,WellCare of North Carolina,Managed Medicaid,,527.73,,,,,,,257.00,1977.00,percent of total billed charges,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,WellCare of North Carolina,Managed Medicaid,,499.90,,,,,,,257.00,1872.75,percent of total billed charges,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,WellCare of North Carolina,Managed Medicaid,,775.98,,,,,,,257.00,2907.00,percent of total billed charges,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,WellCare of North Carolina,Managed Medicaid,,969.77,,,,,,,257.00,3633.00,percent of total billed charges,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,WellCare of North Carolina,Managed Medicaid,,166.37,,,,,,,166.37,1560.00,percent of total billed charges,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,WellCare of North Carolina,Managed Medicaid,,288.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,WellCare of North Carolina,Managed Medicaid,,259.06,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,WellCare of North Carolina,Managed Medicaid,,318.72,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,WellCare of North Carolina,Managed Medicaid,,497.70,,,,,,,257.00,1864.50,percent of total billed charges,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,WellCare of North Carolina,Managed Medicaid,,155.76,,,,,,,155.76,1560.00,percent of total billed charges,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,WellCare of North Carolina,Managed Medicaid,,293.09,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,WellCare of North Carolina,Managed Medicaid,,172.97,,,,,,,172.97,1560.00,percent of total billed charges,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,WellCare of North Carolina,Managed Medicaid,,218.22,,,,,,,218.22,1560.00,percent of total billed charges,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,WellCare of North Carolina,Managed Medicaid,,159.96,,,,,,,159.96,1560.00,percent of total billed charges,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,WellCare of North Carolina,Managed Medicaid,,264.46,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Managed Medicaid,,232.23,,,,,,,232.23,1560.00,percent of total billed charges,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,WellCare of North Carolina,Managed Medicaid,,322.52,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,WellCare of North Carolina,Managed Medicaid,,254.45,,,,,,,254.45,1560.00,percent of total billed charges,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,WellCare of North Carolina,Managed Medicaid,,184.78,,,,,,,184.78,1560.00,percent of total billed charges,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,WellCare of North Carolina,Managed Medicaid,,468.67,,,,,,,257.00,1755.75,percent of total billed charges,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,WellCare of North Carolina,Managed Medicaid,,589.19,,,,,,,257.00,2207.25,percent of total billed charges,
HC TC99M MACROAGGREGATED ALBUMIN DX PSD UP TO 10MCI,73400077,CDM,343,RC,A9540,CPT,,,facility,outpatient,,,277.00000,166.20000,WellCare of North Carolina,Managed Medicaid,,55.46,,,,,,,55.46,178.08,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,10.21,208.95,percent of total billed charges,
HC TC99M PYROPHOSPHATE DX PSD UP TO 25MCI,73400097,CDM,343,RC,A9538,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Managed Medicaid,,19.82,,,,,,,19.82,154.18,percent of total billed charges,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,WellCare of North Carolina,Managed Medicaid,,406.41,,,,,,,406.41,2131.58,percent of total billed charges,
HC RB82 DX PSD UP TO 60MCI,73400107,CDM,343,RC,A9555,CPT,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Managed Medicaid,,197.80,,,,,,,197.80,1410.77,percent of total billed charges,
HC GA67 CITRATE DX PER MCI,73400108,CDM,343,RC,A9556,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,21.42,325.02,percent of total billed charges,
HC XE133 GAS DX PER 10MCI,73400110,CDM,343,RC,A9558,CPT,,,facility,outpatient,,,208.00000,124.80000,WellCare of North Carolina,Managed Medicaid,,41.64,,,,,,,41.64,807.54,percent of total billed charges,
HC TC99M PENTETATE AEROSOL DX PSD UP TO 75MCI,73400114,CDM,343,RC,A9567,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,37.64,120.87,percent of total billed charges,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,WellCare of North Carolina,Managed Medicaid,,559.36,,,,,,,559.36,9315.86,percent of total billed charges,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,WellCare of North Carolina,Managed Medicaid,,2501.10,,,,,,,2012.57,12296.97,percent of total billed charges,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,WellCare of North Carolina,Managed Medicaid,,328.93,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,WellCare of North Carolina,Managed Medicaid,,103.90,,,,,,,103.90,1560.00,percent of total billed charges,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,WellCare of North Carolina,Managed Medicaid,,407.01,,,,,,,215.63,1560.00,percent of total billed charges,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,WellCare of North Carolina,Managed Medicaid,,94.09,,,,,,,94.09,1560.00,percent of total billed charges,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,WellCare of North Carolina,Managed Medicaid,,2476.67,,,,,,,2476.67,39196.15,percent of total billed charges,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,WellCare of North Carolina,Managed Medicaid,,135.54,,,,,,,135.54,1560.00,percent of total billed charges,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,WellCare of North Carolina,Managed Medicaid,,0.20220,,,,,,,0.20220,163224.30,percent of total billed charges,
HC TC99M SULFUR COLLOID DX PSD UP TO 20MCI,73400153,CDM,343,RC,A9541,CPT,,,facility,outpatient,,,87.00000,52.20000,WellCare of North Carolina,Managed Medicaid,,17.42,,,,,,,17.42,2045.69,percent of total billed charges,
HC F18FDG DX PSD UP TO 45MCI,73400164,CDM,343,RC,A9552,CPT,,,facility,outpatient,,,878.00000,526.80000,WellCare of North Carolina,Managed Medicaid,,175.78,,,,,,,175.78,1136.88,percent of total billed charges,
HC I123 SODIUM IODIDE  DX PER 100MICRO UP TO 999MICRO,73400167,CDM,343,RC,A9516,CPT,,,facility,outpatient,,,119.00000,71.40000,WellCare of North Carolina,Managed Medicaid,,23.82,,,,,,,23.82,318.78,percent of total billed charges,
HC I123 SOD IODIDE DX PER MCI,73400189,CDM,343,RC,A9509,CPT,,,facility,outpatient,,,584.00000,350.40000,WellCare of North Carolina,Managed Medicaid,,116.92,,,,,,,116.92,458.82,percent of total billed charges,
HC I131 SODIUM IODIDE CAPSULE DX PER MCI,73400191,CDM,343,RC,A9528,CPT,,,facility,outpatient,,,323.00000,193.80000,WellCare of North Carolina,Managed Medicaid,,64.66,,,,,,,64.66,257.14,percent of total billed charges,
HC I131 SODIUM IODIDE DX PER MICRO UP TO 100UCI,73400193,CDM,343,RC,A9531,CPT,,,facility,outpatient,,,44.00000,26.40000,WellCare of North Carolina,Managed Medicaid,,8.81,,,,,,,8.43,28.29,percent of total billed charges,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,WellCare of North Carolina,Managed Medicaid,,1057.06,,,,,,,1000.45,10134.22,percent of total billed charges,
HC TC99M PERTECHNETATE DX PER MCI,73400199,CDM,343,RC,A9512,CPT,,,facility,outpatient,,,6.00000,3.60000,WellCare of North Carolina,Managed Medicaid,,1.20,,,,,,,1.20,29.06,percent of total billed charges,
HC TC99M MERTIATIDE DX PSD UP TO 15MCI,73400204,CDM,343,RC,A9562,CPT,,,facility,outpatient,,,649.00000,389.40000,WellCare of North Carolina,Managed Medicaid,,129.93,,,,,,,129.93,2091.51,percent of total billed charges,
HC TL201 THALLOUS CHLORIDE DX PER MCI,73400209,CDM,343,RC,A9505,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Managed Medicaid,,24.42,,,,,,,24.42,132.97,percent of total billed charges,
HC TC99M MEDRONATE DX PSD UP TO 30MCI,73400223,CDM,343,RC,A9503,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Managed Medicaid,,8.41,,,,,,,8.41,161.14,percent of total billed charges,
HC TC99M SESTAMIBI DX PSD,73400225,CDM,343,RC,A9500,CPT,,,facility,outpatient,,,82.00000,49.20000,WellCare of North Carolina,Managed Medicaid,,16.42,,,,,,,16.42,1226.71,percent of total billed charges,
HC TC99M LABELED RBC DX PSD UP TO 30 MCI,73400228,CDM,343,RC,A9560,CPT,,,facility,outpatient,,,254.00000,152.40000,WellCare of North Carolina,Managed Medicaid,,50.85,,,,,,,50.85,287.08,percent of total billed charges,
HC TC99M MEBROFENIN DX PSD UP TO 15MCI,73400230,CDM,343,RC,A9537,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,15.42,308.90,percent of total billed charges,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,WellCare of North Carolina,Managed Medicaid,,1212.81,,,,,,,1212.81,6878.34,percent of total billed charges,
HC TC99M OXIDRONATE DX PSD UP TO 30MCI,73400245,CDM,343,RC,A9561,CPT,,,facility,outpatient,,,183.00000,109.80000,WellCare of North Carolina,Managed Medicaid,,36.64,,,,,,,36.64,137.38,percent of total billed charges,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,WellCare of North Carolina,Managed Medicaid,,215.22,,,,,,,215.22,1560.00,percent of total billed charges,
HC PET PHARM NAF18,73400253,CDM,343,RC,A9580,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Managed Medicaid,,61.06,,,,,,,61.06,722.16,percent of total billed charges,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,WellCare of North Carolina,Managed Medicaid,,285.89,,,,,,,257.00,1560.00,percent of total billed charges,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Managed Medicaid,,61.06,,,,,,,61.06,479.07,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,WellCare of North Carolina,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,WellCare of North Carolina,Managed Medicaid,,403.60,,,,,,,257.00,1560.00,percent of total billed charges,
HC TECHNETIUM TC99M TILMANOCEPT DX UP TO 0.5MCI,73400275,CDM,343,RC,A9520,CPT,,,facility,outpatient,,,1343.00000,805.80000,WellCare of North Carolina,Managed Medicaid,,268.87,,,,,,,268.87,1592.55,percent of total billed charges,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,WellCare of North Carolina,Managed Medicaid,,97.50,,,,,,,97.50,1243.67,percent of total billed charges,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,WellCare of North Carolina,Managed Medicaid,,87.09,,,,,,,87.09,1560.00,percent of total billed charges,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,WellCare of North Carolina,Managed Medicaid,,448.45,,,,,,,257.00,1680.00,percent of total billed charges,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,WellCare of North Carolina,Managed Medicaid,,321.32,,,,,,,257.00,1560.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,WellCare of North Carolina,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,WellCare of North Carolina,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,WellCare of North Carolina,Managed Medicaid,,669.47,,,,,,,257.00,2508.00,percent of total billed charges,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,WellCare of North Carolina,Managed Medicaid,,262.06,,,,,,,262.06,1851.54,percent of total billed charges,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,WellCare of North Carolina,Managed Medicaid,,386.19,,,,,,,386.19,2316.93,percent of total billed charges,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,WellCare of North Carolina,Managed Medicaid,,214.01,,,,,,,214.01,1480.57,percent of total billed charges,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,WellCare of North Carolina,Managed Medicaid,,381.98,,,,,,,369.58,2435.93,percent of total billed charges,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,WellCare of North Carolina,Managed Medicaid,,246.25,,,,,,,246.25,1871.97,percent of total billed charges,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,WellCare of North Carolina,Managed Medicaid,,804.40,,,,,,,84.71,2905.00,percent of total billed charges,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,WellCare of North Carolina,Managed Medicaid,,662.66,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,WellCare of North Carolina,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,WellCare of North Carolina,Managed Medicaid,,829.23,,,,,,,343.59,2942.87,percent of total billed charges,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,WellCare of North Carolina,Managed Medicaid,,813.21,,,,,,,171.27,3501.50,percent of total billed charges,
HC 3D RECON NOT REQ INDEP WORKST,73500009,CDM,350,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,WellCare of North Carolina,Managed Medicaid,,206.81,,,,,,,206.81,2905.00,percent of total billed charges,
HC 3D RECON REQUIRE INDEP WORKST,73500010,CDM,350,RC,76377,CPT,,,facility,outpatient,,,1126.00000,675.60000,WellCare of North Carolina,Managed Medicaid,,225.43,,,,,,,225.43,2905.00,percent of total billed charges,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Managed Medicaid,,64.86,,,,,,,64.86,2905.00,percent of total billed charges,
HC CT GUIDE NEEDLE PLACEMENT,73500012,CDM,350,RC,77012,CPT,,,facility,outpatient,,,2537.00000,1522.20000,WellCare of North Carolina,Managed Medicaid,,507.91,,,,,,,507.91,2905.00,percent of total billed charges,
HC CT GUID PARENCHYMAL TIS ABLATION,73500013,CDM,350,RC,77013,CPT,,,facility,outpatient,,,1289.00000,773.40000,WellCare of North Carolina,Managed Medicaid,,258.06,,,,,,,258.06,2905.00,percent of total billed charges,
HC CT GUIDANCE PLACEMENT RADIATION FIELDS,73500014,CDM,350,RC,77014,CPT,,,facility,outpatient,,,1138.00000,682.80000,WellCare of North Carolina,Managed Medicaid,,227.83,,,,,,,227.83,2905.00,percent of total billed charges,
HC CTA RECONS AORTA SURG PLAN MMS,73500015,CDM,352,RC,G0288,CPT,,,facility,outpatient,,,1269.00000,761.40000,WellCare of North Carolina,Managed Medicaid,,254.05,,,,,,,254.05,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,WellCare of North Carolina,Managed Medicaid,,452.65,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,WellCare of North Carolina,Managed Medicaid,,534.13,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,WellCare of North Carolina,Managed Medicaid,,653.45,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,WellCare of North Carolina,Managed Medicaid,,490.49,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,WellCare of North Carolina,Managed Medicaid,,588.99,,,,,,,171.27,2908.74,percent of total billed charges,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,WellCare of North Carolina,Managed Medicaid,,657.06,,,,,,,171.27,3211.99,percent of total billed charges,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,WellCare of North Carolina,Managed Medicaid,,507.71,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,WellCare of North Carolina,Managed Medicaid,,619.82,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,WellCare of North Carolina,Managed Medicaid,,701.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,WellCare of North Carolina,Managed Medicaid,,517.32,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,WellCare of North Carolina,Managed Medicaid,,617.02,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,WellCare of North Carolina,Managed Medicaid,,703.10,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,WellCare of North Carolina,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,WellCare of North Carolina,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,WellCare of North Carolina,Managed Medicaid,,466.67,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,WellCare of North Carolina,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,WellCare of North Carolina,Managed Medicaid,,688.69,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,WellCare of North Carolina,Managed Medicaid,,775.57,,,,,,,171.27,2942.40,percent of total billed charges,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,WellCare of North Carolina,Managed Medicaid,,574.97,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,WellCare of North Carolina,Managed Medicaid,,724.32,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,WellCare of North Carolina,Managed Medicaid,,741.54,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,WellCare of North Carolina,Managed Medicaid,,448.85,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,WellCare of North Carolina,Managed Medicaid,,546.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,WellCare of North Carolina,Managed Medicaid,,637.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,WellCare of North Carolina,Managed Medicaid,,524.92,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,WellCare of North Carolina,Managed Medicaid,,638.44,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,WellCare of North Carolina,Managed Medicaid,,745.34,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,WellCare of North Carolina,Managed Medicaid,,604.20,,,,,,,171.27,3037.26,percent of total billed charges,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,WellCare of North Carolina,Managed Medicaid,,458.86,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,WellCare of North Carolina,Managed Medicaid,,573.57,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,WellCare of North Carolina,Managed Medicaid,,614.81,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,WellCare of North Carolina,Managed Medicaid,,587.39,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,WellCare of North Carolina,Managed Medicaid,,805.20,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,WellCare of North Carolina,Managed Medicaid,,869.47,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,WellCare of North Carolina,Managed Medicaid,,795.59,,,,,,,171.27,3356.74,percent of total billed charges,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,WellCare of North Carolina,Managed Medicaid,,502.70,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,WellCare of North Carolina,Managed Medicaid,,646.85,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,WellCare of North Carolina,Managed Medicaid,,847.85,,,,,,,171.27,3008.52,percent of total billed charges,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,WellCare of North Carolina,Managed Medicaid,,986.39,,,,,,,171.27,3500.13,percent of total billed charges,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,WellCare of North Carolina,Managed Medicaid,,499.30,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,WellCare of North Carolina,Managed Medicaid,,635.43,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,WellCare of North Carolina,Managed Medicaid,,752.35,,,,,,,171.27,2905.00,percent of total billed charges,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,WellCare of North Carolina,Managed Medicaid,,1473.67,,,,,,,343.59,4490.21,percent of total billed charges,
HC TAVR PERCUTANEOUS FEM ART,73500059,CDM,481,RC,33361,CPT,,,facility,outpatient,,,34463.00000,20677.80000,WellCare of North Carolina,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,WellCare of North Carolina,Managed Medicaid,,1072.07,,,,,,,232.56,3266.55,percent of total billed charges,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,WellCare of North Carolina,Managed Medicaid,,1277.08,,,,,,,343.59,3891.19,percent of total billed charges,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,WellCare of North Carolina,Managed Medicaid,,1484.48,,,,,,,343.59,4523.15,percent of total billed charges,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,WellCare of North Carolina,Managed Medicaid,,262.06,,,,,,,84.71,2905.00,percent of total billed charges,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,WellCare of North Carolina,Managed Medicaid,,812.61,,,,,,,171.27,3052.31,percent of total billed charges,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,WellCare of North Carolina,Managed Medicaid,,794.99,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,WellCare of North Carolina,Managed Medicaid,,838.44,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,WellCare of North Carolina,Managed Medicaid,,585.59,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT CEREBRAL PERFUSION STUDY,73500082,CDM,350,RC,0042T,CPT,,,facility,outpatient,,,2800.00000,1680.00000,WellCare of North Carolina,Managed Medicaid,,560.56,,,,,,,560.56,2905.00,percent of total billed charges,
HC JV CT GUIDANCE PLACEMENT RADIATION FIELDS GL,73500083,CDM,333,RC,77014,CPT,,,facility,outpatient,,,477.00000,286.20000,WellCare of North Carolina,Managed Medicaid,,95.50,,,,,,,95.50,1067.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,WellCare of North Carolina,Managed Medicaid,,234.83,,,,,,,102.31,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,WellCare of North Carolina,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,WellCare of North Carolina,Managed Medicaid,,266.67,,,,,,,171.27,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,WellCare of North Carolina,Managed Medicaid,,290.29,,,,,,,232.56,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,WellCare of North Carolina,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,WellCare of North Carolina,Managed Medicaid,,353.15,,,,,,,343.59,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE ANALYSIS DATA PREP AND TRANSMISSION,73500090,CDM,350,RC,0624T,CPT,,,facility,outpatient,,,1901.00000,1140.60000,WellCare of North Carolina,Managed Medicaid,,380.58,,,,,,,380.58,2905.00,percent of total billed charges,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Managed Medicaid,,95.09,,,,,,,95.09,2905.00,percent of total billed charges,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,WellCare of North Carolina,Managed Medicaid,,67.47,,,,,,,67.47,4376.00,percent of total billed charges,
HC TAVR OPEN FEM ART,73600003,CDM,481,RC,33362,CPT,,,facility,outpatient,,,34463.00000,20677.80000,WellCare of North Carolina,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR OPEN AXILLARY ART,73600004,CDM,481,RC,33363,CPT,,,facility,outpatient,,,34463.00000,20677.80000,WellCare of North Carolina,Managed Medicaid,,6899.49,,,,,,,2025.00,21022.43,percent of total billed charges,
HC TAVR TRANS AORTIC,73600006,CDM,481,RC,33365,CPT,,,facility,outpatient,,,31466.00000,18879.60000,WellCare of North Carolina,Managed Medicaid,,6299.49,,,,,,,2025.00,19194.26,percent of total billed charges,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Managed Medicaid,,53.85,,,,,,,53.85,5152.00,percent of total billed charges,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,WellCare of North Carolina,Managed Medicaid,,145.75,,,,,,,145.75,5152.00,percent of total billed charges,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Managed Medicaid,,125.93,,,,,,,125.93,8045.00,percent of total billed charges,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,WellCare of North Carolina,Managed Medicaid,,399.00,,,,,,,399.00,8045.00,percent of total billed charges,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,WellCare of North Carolina,Managed Medicaid,,1022.02,,,,,,,1022.02,17457.00,percent of total billed charges,
HC PROC EPIDURAL INJ  BLOOD PATCH,73600018,CDM,361,RC,77002,CPT,,,facility,outpatient,,,543.00000,325.80000,WellCare of North Carolina,Managed Medicaid,,108.71,,,,,,,108.71,375.70,percent of total billed charges,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,WellCare of North Carolina,Managed Medicaid,,277.68,,,,,,,277.68,4311.00,percent of total billed charges,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,WellCare of North Carolina,Managed Medicaid,,176.18,,,,,,,176.18,4311.00,percent of total billed charges,
HC TAVR OPEN THORACIC APPROACH,73600025,CDM,481,RC,33365,CPT,,,facility,outpatient,,,57551.00000,34530.60000,WellCare of North Carolina,Managed Medicaid,,11521.71,,,,,,,2025.00,35106.11,percent of total billed charges,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,WellCare of North Carolina,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,WellCare of North Carolina,Managed Medicaid,,972.37,,,,,,,972.37,13852.00,percent of total billed charges,
HC TAVR TAVI W PROSTHETIC VALVE TRANSAPICAL EXPOSURE,73600056,CDM,481,RC,33366,CPT,,,facility,outpatient,,,29535.00000,17721.00000,WellCare of North Carolina,Managed Medicaid,,5912.91,,,,,,,2025.00,18016.35,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,WellCare of North Carolina,Managed Medicaid,,222.22,,,,,,,222.22,4311.00,percent of total billed charges,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,WellCare of North Carolina,Managed Medicaid,,600.40,,,,,,,600.40,5754.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,WellCare of North Carolina,Managed Medicaid,,31.03,,,,,,,31.03,4311.00,percent of total billed charges,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,WellCare of North Carolina,Managed Medicaid,,31.03,,,,,,,29.22,4311.00,percent of total billed charges,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,WellCare of North Carolina,Managed Medicaid,,84.28,,,,,,,84.28,4311.00,percent of total billed charges,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,WellCare of North Carolina,Managed Medicaid,,584.78,,,,,,,584.78,13852.00,percent of total billed charges,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Managed Medicaid,,125.93,,,,,,,125.93,13852.00,percent of total billed charges,
HC INJECTION PERITONEUM CONTRAST AIR,73610010,CDM,361,RC,49400,CPT,,,facility,outpatient,,,456.00000,273.60000,WellCare of North Carolina,Managed Medicaid,,91.29,,,,,,,91.29,4311.00,percent of total billed charges,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,WellCare of North Carolina,Managed Medicaid,,46.45,,,,,,,46.45,4311.00,percent of total billed charges,
HC CONTRAST INJ FOR ASSESSMENT ABSCESS CYST EXIST CATH,73610012,CDM,361,RC,49424,CPT,,,facility,outpatient,,,201.00000,120.60000,WellCare of North Carolina,Managed Medicaid,,40.24,,,,,,,40.24,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,WellCare of North Carolina,Managed Medicaid,,96.30,,,,,,,96.30,4311.00,percent of total billed charges,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,WellCare of North Carolina,Managed Medicaid,,222.02,,,,,,,222.02,4311.00,percent of total billed charges,
HC INJ DISCOGRAPHY CERV/THOR,73610018,CDM,361,RC,62291,CPT,,,facility,outpatient,,,458.00000,274.80000,WellCare of North Carolina,Managed Medicaid,,91.69,,,,,,,91.69,4311.00,percent of total billed charges,
HC PLACE OCCLUSIVE DEVICE,73610019,CDM,361,RC,G0269,CPT,,,facility,outpatient,,,285.00000,171.00000,WellCare of North Carolina,Managed Medicaid,,57.06,,,,,,,57.06,832.00,percent of total billed charges,
HC INJ ONLY FOR MAMM DUCTOGRAM,73610025,CDM,361,RC,19030,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,20.22,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,WellCare of North Carolina,Managed Medicaid,,280.28,,,,,,,280.28,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,WellCare of North Carolina,Managed Medicaid,,316.72,,,,,,,316.72,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,WellCare of North Carolina,Managed Medicaid,,316.72,,,,,,,298.21,4311.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,WellCare of North Carolina,Managed Medicaid,,466.47,,,,,,,466.47,5152.00,percent of total billed charges,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,WellCare of North Carolina,Managed Medicaid,,466.47,,,,,,,439.20,4376.00,percent of total billed charges,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,WellCare of North Carolina,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC INJ SINUS TRACT DIAGNOSTIC,73610037,CDM,361,RC,20501,CPT,,,facility,outpatient,,,311.00000,186.60000,WellCare of North Carolina,Managed Medicaid,,62.26,,,,,,,62.26,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Managed Medicaid,,160.96,,,,,,,160.96,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Managed Medicaid,,160.96,,,,,,,151.55,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,WellCare of North Carolina,Managed Medicaid,,144.54,,,,,,,136.10,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,WellCare of North Carolina,Managed Medicaid,,115.52,,,,,,,115.52,4311.00,percent of total billed charges,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,WellCare of North Carolina,Managed Medicaid,,115.52,,,,,,,108.76,4311.00,percent of total billed charges,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,WellCare of North Carolina,Managed Medicaid,,944.94,,,,,,,944.94,13527.54,percent of total billed charges,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,WellCare of North Carolina,Managed Medicaid,,676.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,WellCare of North Carolina,Managed Medicaid,,142.54,,,,,,,142.54,4311.00,percent of total billed charges,
HC INJ SHOULDER ARTHROGRAPHY,73610054,CDM,361,RC,23350,CPT,,,facility,outpatient,,,565.00000,339.00000,WellCare of North Carolina,Managed Medicaid,,113.11,,,,,,,113.11,4311.00,percent of total billed charges,
HC INJ ELBOW ARTHROGRAPHY,73610055,CDM,361,RC,24220,CPT,,,facility,outpatient,,,1414.00000,848.40000,WellCare of North Carolina,Managed Medicaid,,283.08,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ WRIST ARTHROGRAPHY,73610057,CDM,361,RC,25246,CPT,,,facility,outpatient,,,765.00000,459.00000,WellCare of North Carolina,Managed Medicaid,,153.15,,,,,,,153.15,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY WO ANESTHESIA,73610058,CDM,361,RC,27093,CPT,,,facility,outpatient,,,1292.00000,775.20000,WellCare of North Carolina,Managed Medicaid,,258.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ HIP ARTHROGRAPHY W ANESTHESIA,73610059,CDM,361,RC,27095,CPT,,,facility,outpatient,,,581.00000,348.60000,WellCare of North Carolina,Managed Medicaid,,116.32,,,,,,,116.32,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,361,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,WellCare of North Carolina,Managed Medicaid,,255.25,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ SACROILIAC JOINT INCLUDING IMAGE GUIDANCE,73610060,CDM,761,RC,27096,CPT,,,facility,outpatient,,,1275.00000,765.00000,WellCare of North Carolina,Managed Medicaid,,255.25,,,,,,,240.34,4311.00,percent of total billed charges,
HC INJ ANKLE ARTHROGRAPHY,73610064,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,WellCare of North Carolina,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,WellCare of North Carolina,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,WellCare of North Carolina,Managed Medicaid,,604.40,,,,,,,604.40,5754.00,percent of total billed charges,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Managed Medicaid,,60.06,,,,,,,60.06,4311.00,percent of total billed charges,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,WellCare of North Carolina,Managed Medicaid,,388.99,,,,,,,388.99,17457.00,percent of total billed charges,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,WellCare of North Carolina,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,WellCare of North Carolina,Managed Medicaid,,166.97,,,,,,,166.97,9350.00,percent of total billed charges,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,WellCare of North Carolina,Managed Medicaid,,324.92,,,,,,,324.92,4311.00,percent of total billed charges,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,WellCare of North Carolina,Managed Medicaid,,354.35,,,,,,,354.35,4376.00,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,WellCare of North Carolina,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610086,CDM,481,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,WellCare of North Carolina,Managed Medicaid,,362.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,361,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,WellCare of North Carolina,Managed Medicaid,,421.42,,,,,,,173.00,4311.00,percent of total billed charges,
HC SELECTIVE VENOUS 1ST ORD,73610087,CDM,481,RC,36011,CPT,,,facility,outpatient,,,2105.00000,1263.00000,WellCare of North Carolina,Managed Medicaid,,421.42,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,361,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,WellCare of North Carolina,Managed Medicaid,,135.54,,,,,,,135.54,4311.00,percent of total billed charges,
HC CATHETER SELECTIVE PULM ART RT LT,73610088,CDM,481,RC,36014,CPT,,,facility,outpatient,,,677.00000,406.20000,WellCare of North Carolina,Managed Medicaid,,135.54,,,,,,,135.54,9423.00,percent of total billed charges,
HC INTRO NEEDLE CATH EXT ART,73610091,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,WellCare of North Carolina,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,361,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,WellCare of North Carolina,Managed Medicaid,,136.94,,,,,,,136.94,4376.00,percent of total billed charges,
HC NEEDLE CATH AORTA TRANSLUMBAR,73610094,CDM,481,RC,36160,CPT,,,facility,outpatient,,,684.00000,410.40000,WellCare of North Carolina,Managed Medicaid,,136.94,,,,,,,136.94,9423.00,percent of total billed charges,
HC INTRO CATHETER AORTA,73610095,CDM,481,RC,36200,CPT,,,facility,outpatient,,,2691.00000,1614.60000,WellCare of North Carolina,Managed Medicaid,,538.74,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,361,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,WellCare of North Carolina,Managed Medicaid,,551.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH EXTERNAL CAROTID UNILAT,73610096,CDM,481,RC,36227,CPT,,,facility,outpatient,,,2756.00000,1653.60000,WellCare of North Carolina,Managed Medicaid,,551.75,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,361,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,WellCare of North Carolina,Managed Medicaid,,319.12,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 1ST ORD ART,73610097,CDM,481,RC,36245,CPT,,,facility,outpatient,,,1594.00000,956.40000,WellCare of North Carolina,Managed Medicaid,,319.12,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,361,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,WellCare of North Carolina,Managed Medicaid,,183.38,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 2ND ORD ART,73610098,CDM,481,RC,36246,CPT,,,facility,outpatient,,,916.00000,549.60000,WellCare of North Carolina,Managed Medicaid,,183.38,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,361,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,WellCare of North Carolina,Managed Medicaid,,226.23,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL 3RD ORD ART,73610099,CDM,481,RC,36247,CPT,,,facility,outpatient,,,1130.00000,678.00000,WellCare of North Carolina,Managed Medicaid,,226.23,,,,,,,173.00,9423.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,361,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,WellCare of North Carolina,Managed Medicaid,,230.83,,,,,,,173.00,4376.00,percent of total billed charges,
HC ABD PELVIC OR LE SEL ADDL ORD ART,73610100,CDM,481,RC,36248,CPT,,,facility,outpatient,,,1153.00000,691.80000,WellCare of North Carolina,Managed Medicaid,,230.83,,,,,,,173.00,9423.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,WellCare of North Carolina,Managed Medicaid,,1012.81,,,,,,,1012.81,17457.00,percent of total billed charges,
HC LASER ABLATION INCOMPETENT VEIN EACH ADDITIONAL SAME EXTREMITY,73610106,CDM,761,RC,36479,CPT,,,facility,outpatient,,,4925.00000,2955.00000,WellCare of North Carolina,Managed Medicaid,,985.99,,,,,,,928.36,4311.00,percent of total billed charges,
HC PORTAL VEIN ACCESS,73610107,CDM,361,RC,36481,CPT,,,facility,outpatient,,,795.00000,477.00000,WellCare of North Carolina,Managed Medicaid,,159.16,,,,,,,159.16,4311.00,percent of total billed charges,
HC VENOUS CATH ORGAN BLOOD SAMPLING,73610108,CDM,361,RC,36500,CPT,,,facility,outpatient,,,725.00000,435.00000,WellCare of North Carolina,Managed Medicaid,,145.15,,,,,,,145.15,4311.00,percent of total billed charges,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,WellCare of North Carolina,Managed Medicaid,,163.76,,,,,,,163.76,4311.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,WellCare of North Carolina,Managed Medicaid,,148.55,,,,,,,148.55,13852.00,percent of total billed charges,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,WellCare of North Carolina,Managed Medicaid,,449.85,,,,,,,449.85,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,WellCare of North Carolina,Managed Medicaid,,148.55,,,,,,,148.55,8045.00,percent of total billed charges,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,WellCare of North Carolina,Managed Medicaid,,745.34,,,,,,,745.34,8045.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,WellCare of North Carolina,Managed Medicaid,,177.38,,,,,,,177.38,4311.00,percent of total billed charges,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,WellCare of North Carolina,Managed Medicaid,,137.34,,,,,,,137.34,4311.00,percent of total billed charges,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,WellCare of North Carolina,Managed Medicaid,,39.04,,,,,,,39.04,5152.00,percent of total billed charges,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,WellCare of North Carolina,Managed Medicaid,,106.71,,,,,,,106.71,5152.00,percent of total billed charges,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,WellCare of North Carolina,Managed Medicaid,,111.11,,,,,,,111.11,8045.00,percent of total billed charges,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,WellCare of North Carolina,Managed Medicaid,,118.12,,,,,,,118.12,4311.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,WellCare of North Carolina,Managed Medicaid,,116.72,,,,,,,116.72,8045.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,WellCare of North Carolina,Managed Medicaid,,133.13,,,,,,,133.13,13852.00,percent of total billed charges,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,WellCare of North Carolina,Managed Medicaid,,833.43,,,,,,,833.43,8045.00,percent of total billed charges,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,WellCare of North Carolina,Managed Medicaid,,426.03,,,,,,,426.03,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,WellCare of North Carolina,Managed Medicaid,,268.87,,,,,,,268.87,4311.00,percent of total billed charges,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,WellCare of North Carolina,Managed Medicaid,,293.09,,,,,,,293.09,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,WellCare of North Carolina,Managed Medicaid,,138.94,,,,,,,138.94,8442.00,percent of total billed charges,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,WellCare of North Carolina,Managed Medicaid,,117.52,,,,,,,117.52,4311.00,percent of total billed charges,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,WellCare of North Carolina,Managed Medicaid,,121.32,,,,,,,121.32,4311.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,WellCare of North Carolina,Managed Medicaid,,176.98,,,,,,,173.00,4376.00,percent of total billed charges,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,WellCare of North Carolina,Managed Medicaid,,176.98,,,,,,,166.63,4376.00,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,WellCare of North Carolina,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,WellCare of North Carolina,Managed Medicaid,,2814.41,,,,,,,2814.41,18878.80,percent of total billed charges,
HC PRIMARY PTMT NONCOR 2 AND SUBQ FLUORO,73610136,CDM,481,RC,37185,CPT,,,facility,outpatient,,,14058.00000,8434.80000,WellCare of North Carolina,Managed Medicaid,,2814.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC SECONDARY PTT NONCOR FLUORO GUIDE,73610137,CDM,481,RC,37186,CPT,,,facility,outpatient,,,6186.00000,3711.60000,WellCare of North Carolina,Managed Medicaid,,1238.44,,,,,,,173.00,9423.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Managed Medicaid,,2104.90,,,,,,,2104.90,17457.00,percent of total billed charges,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Managed Medicaid,,2104.90,,,,,,,2104.90,15260.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,WellCare of North Carolina,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,WellCare of North Carolina,Managed Medicaid,,2292.69,,,,,,,2292.69,13852.00,percent of total billed charges,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,WellCare of North Carolina,Managed Medicaid,,1536.13,,,,,,,1536.13,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,WellCare of North Carolina,Managed Medicaid,,1581.98,,,,,,,1581.98,8045.00,percent of total billed charges,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,WellCare of North Carolina,Managed Medicaid,,1581.98,,,,,,,1581.98,9423.00,percent of total billed charges,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,WellCare of North Carolina,Managed Medicaid,,960.96,,,,,,,960.96,9423.00,percent of total billed charges,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,WellCare of North Carolina,Managed Medicaid,,895.09,,,,,,,895.09,13852.00,percent of total billed charges,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,WellCare of North Carolina,Managed Medicaid,,1213.61,,,,,,,1213.61,24600.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,361,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,WellCare of North Carolina,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC STENT PLACEMENT EACH ADDITIONAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610147,CDM,481,RC,37237,CPT,,,facility,outpatient,,,6062.00000,3637.20000,WellCare of North Carolina,Managed Medicaid,,1213.61,,,,,,,1213.61,13852.00,percent of total billed charges,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,WellCare of North Carolina,Managed Medicaid,,879.68,,,,,,,879.68,13852.00,percent of total billed charges,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,WellCare of North Carolina,Managed Medicaid,,483.88,,,,,,,483.88,4376.00,percent of total billed charges,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,WellCare of North Carolina,Managed Medicaid,,495.50,,,,,,,495.50,4311.00,percent of total billed charges,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,WellCare of North Carolina,Managed Medicaid,,322.92,,,,,,,322.92,4311.00,percent of total billed charges,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,WellCare of North Carolina,Managed Medicaid,,158.56,,,,,,,158.56,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION SIALOGRAM,73610160,CDM,361,RC,42550,CPT,,,facility,outpatient,,,379.00000,227.40000,WellCare of North Carolina,Managed Medicaid,,75.88,,,,,,,75.88,4311.00,percent of total billed charges,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,WellCare of North Carolina,Managed Medicaid,,96.50,,,,,,,96.50,4376.00,percent of total billed charges,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,WellCare of North Carolina,Managed Medicaid,,56.46,,,,,,,56.46,4121.00,percent of total billed charges,
HC PERC BIOPSY LIVER W OTHER,73610170,CDM,361,RC,47001,CPT,,,facility,outpatient,,,542.00000,325.20000,WellCare of North Carolina,Managed Medicaid,,108.51,,,,,,,108.51,4311.00,percent of total billed charges,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,WellCare of North Carolina,Managed Medicaid,,1059.86,,,,,,,1059.86,17457.00,percent of total billed charges,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,WellCare of North Carolina,Managed Medicaid,,255.66,,,,,,,255.66,8045.00,percent of total billed charges,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,WellCare of North Carolina,Managed Medicaid,,1500.30,,,,,,,1500.30,17457.00,percent of total billed charges,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,WellCare of North Carolina,Managed Medicaid,,79.08,,,,,,,79.08,4311.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,WellCare of North Carolina,Managed Medicaid,,328.33,,,,,,,328.33,4376.00,percent of total billed charges,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,WellCare of North Carolina,Managed Medicaid,,328.33,,,,,,,309.14,4376.00,percent of total billed charges,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,WellCare of North Carolina,Managed Medicaid,,427.63,,,,,,,427.63,4311.00,percent of total billed charges,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Managed Medicaid,,182.38,,,,,,,171.72,4311.00,percent of total billed charges,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,WellCare of North Carolina,Managed Medicaid,,616.02,,,,,,,616.02,17457.00,percent of total billed charges,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,WellCare of North Carolina,Managed Medicaid,,448.25,,,,,,,448.25,8045.00,percent of total billed charges,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,WellCare of North Carolina,Managed Medicaid,,107.11,,,,,,,107.11,4376.00,percent of total billed charges,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,WellCare of North Carolina,Managed Medicaid,,203.40,,,,,,,203.40,4376.00,percent of total billed charges,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,WellCare of North Carolina,Managed Medicaid,,771.57,,,,,,,771.57,4311.00,percent of total billed charges,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,WellCare of North Carolina,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,WellCare of North Carolina,Managed Medicaid,,160.56,,,,,,,160.56,4311.00,percent of total billed charges,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,WellCare of North Carolina,Managed Medicaid,,128.53,,,,,,,128.53,4311.00,percent of total billed charges,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,WellCare of North Carolina,Managed Medicaid,,139.14,,,,,,,139.14,4311.00,percent of total billed charges,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,WellCare of North Carolina,Managed Medicaid,,1059.86,,,,,,,902.01,4311.00,percent of total billed charges,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,WellCare of North Carolina,Managed Medicaid,,476.08,,,,,,,476.08,4311.00,percent of total billed charges,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,WellCare of North Carolina,Managed Medicaid,,500.90,,,,,,,500.90,5754.00,percent of total billed charges,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,WellCare of North Carolina,Managed Medicaid,,496.10,,,,,,,496.10,5754.00,percent of total billed charges,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,WellCare of North Carolina,Managed Medicaid,,127.33,,,,,,,127.33,5152.00,percent of total billed charges,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Managed Medicaid,,232.23,,,,,,,232.23,4311.00,percent of total billed charges,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,WellCare of North Carolina,Managed Medicaid,,35.03,,,,,,,35.03,4311.00,percent of total billed charges,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,WellCare of North Carolina,Managed Medicaid,,1259.46,,,,,,,1259.46,13852.00,percent of total billed charges,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,WellCare of North Carolina,Managed Medicaid,,1554.95,,,,,,,1554.95,17457.00,percent of total billed charges,
HC INJECTION ILEAL CONDUIT,73610216,CDM,361,RC,50690,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,18.02,4311.00,percent of total billed charges,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,WellCare of North Carolina,Managed Medicaid,,498.70,,,,,,,498.70,5754.00,percent of total billed charges,
HC INJECTION FOR CYSTOGRAPHY OR VOIDING,73610220,CDM,361,RC,51600,CPT,,,facility,outpatient,,,294.00000,176.40000,WellCare of North Carolina,Managed Medicaid,,58.86,,,,,,,58.86,832.00,percent of total billed charges,
HC INJECTION RETROGRADE URETHROCYSTOGRAPHY,73610221,CDM,361,RC,51610,CPT,,,facility,outpatient,,,231.00000,138.60000,WellCare of North Carolina,Managed Medicaid,,46.25,,,,,,,46.25,832.00,percent of total billed charges,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,WellCare of North Carolina,Managed Medicaid,,41.64,,,,,,,39.21,4311.00,percent of total billed charges,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,WellCare of North Carolina,Managed Medicaid,,80.88,,,,,,,80.88,4311.00,percent of total billed charges,
HC INJECTION HYSTEROSALPINOGRAPHY,73610226,CDM,361,RC,58340,CPT,,,facility,outpatient,,,408.00000,244.80000,WellCare of North Carolina,Managed Medicaid,,81.68,,,,,,,81.68,4311.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Managed Medicaid,,495.29,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,WellCare of North Carolina,Managed Medicaid,,40.44,,,,,,,40.44,4311.00,percent of total billed charges,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,WellCare of North Carolina,Managed Medicaid,,318.72,,,,,,,173.00,4311.00,percent of total billed charges,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,WellCare of North Carolina,Managed Medicaid,,900.30,,,,,,,900.30,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION INTRACRANIAL N,73610241,CDM,361,RC,61624,CPT,,,facility,outpatient,,,4234.00000,2540.40000,WellCare of North Carolina,Managed Medicaid,,847.65,,,,,,,847.65,24600.00,percent of total billed charges,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,WellCare of North Carolina,Managed Medicaid,,584.78,,,,,,,584.78,24600.00,percent of total billed charges,
HC BALLOON ANGIO INTRACRANIAL PER,73610243,CDM,361,RC,61630,CPT,,,facility,outpatient,,,4574.00000,2744.40000,WellCare of North Carolina,Managed Medicaid,,915.71,,,,,,,915.71,6649.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,WellCare of North Carolina,Managed Medicaid,,211.21,,,,,,,211.21,4311.00,percent of total billed charges,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,WellCare of North Carolina,Managed Medicaid,,211.21,,,,,,,198.87,4311.00,percent of total billed charges,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,WellCare of North Carolina,Managed Medicaid,,294.49,,,,,,,294.49,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,361,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Managed Medicaid,,57.66,,,,,,,57.66,4311.00,percent of total billed charges,
HC INJECTION SPINAL MYELOGRAM NOT C1 C2,73610250,CDM,761,RC,62284,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Managed Medicaid,,57.66,,,,,,,54.29,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,WellCare of North Carolina,Managed Medicaid,,383.98,,,,,,,383.98,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,WellCare of North Carolina,Managed Medicaid,,383.98,,,,,,,361.54,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T  EACH ADDL LEVEL W IMG GUIDE,73610254,CDM,761,RC,64480,CPT,,,facility,outpatient,,,1173.00000,703.80000,WellCare of North Carolina,Managed Medicaid,,234.83,,,,,,,221.11,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,WellCare of North Carolina,Managed Medicaid,,502.70,,,,,,,502.70,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,WellCare of North Carolina,Managed Medicaid,,502.70,,,,,,,473.32,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,361,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,WellCare of North Carolina,Managed Medicaid,,407.21,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S EACH ADDL LVL W IMAGE GUIDANCE,73610256,CDM,761,RC,64484,CPT,,,facility,outpatient,,,2034.00000,1220.40000,WellCare of North Carolina,Managed Medicaid,,407.21,,,,,,,383.41,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,WellCare of North Carolina,Managed Medicaid,,347.95,,,,,,,347.95,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,WellCare of North Carolina,Managed Medicaid,,347.95,,,,,,,327.61,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,WellCare of North Carolina,Managed Medicaid,,316.92,,,,,,,316.92,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,WellCare of North Carolina,Managed Medicaid,,316.92,,,,,,,298.40,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,361,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,WellCare of North Carolina,Managed Medicaid,,329.53,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 2ND LVL,73610259,CDM,761,RC,64494,CPT,,,facility,outpatient,,,1646.00000,987.60000,WellCare of North Carolina,Managed Medicaid,,329.53,,,,,,,310.27,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT PV FACET L S 3RD EACH ADDL LVL,73610260,CDM,761,RC,64495,CPT,,,facility,outpatient,,,1710.00000,1026.00000,WellCare of North Carolina,Managed Medicaid,,342.34,,,,,,,322.33,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,WellCare of North Carolina,Managed Medicaid,,303.30,,,,,,,303.30,4311.00,percent of total billed charges,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,WellCare of North Carolina,Managed Medicaid,,303.30,,,,,,,285.58,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,WellCare of North Carolina,Managed Medicaid,,302.10,,,,,,,302.10,4311.00,percent of total billed charges,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,WellCare of North Carolina,Managed Medicaid,,302.10,,,,,,,284.45,4311.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,WellCare of North Carolina,Managed Medicaid,,665.06,,,,,,,665.06,9350.00,percent of total billed charges,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,WellCare of North Carolina,Managed Medicaid,,665.06,,,,,,,626.20,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,361,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,WellCare of North Carolina,Managed Medicaid,,372.37,,,,,,,173.00,4311.00,percent of total billed charges,
HC DEST FACET JT NV LS ADD W IG,73610264,CDM,761,RC,64636,CPT,,,facility,outpatient,,,1860.00000,1116.00000,WellCare of North Carolina,Managed Medicaid,,372.37,,,,,,,350.61,4311.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,WellCare of North Carolina,Managed Medicaid,,363.96,,,,,,,363.96,5152.00,percent of total billed charges,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,WellCare of North Carolina,Managed Medicaid,,363.96,,,,,,,342.69,4376.00,percent of total billed charges,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,WellCare of North Carolina,Managed Medicaid,,461.66,,,,,,,173.00,4311.00,percent of total billed charges,
HC INTRAOPERATIVE LYMPH NODE MAPPING,73610268,CDM,361,RC,38900,CPT,,,facility,outpatient,,,368.00000,220.80000,WellCare of North Carolina,Managed Medicaid,,73.67,,,,,,,73.67,4311.00,percent of total billed charges,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,WellCare of North Carolina,Managed Medicaid,,972.37,,,,,,,915.54,6735.00,percent of total billed charges,
HC REMOVE TEMP CV CATH,73610270,CDM,361,RC,99211,CPT,,,facility,outpatient,,,220.00000,132.00000,WellCare of North Carolina,Managed Medicaid,,44.04,,,,,,,44.04,152.22,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,WellCare of North Carolina,Managed Medicaid,,568.77,,,,,,,568.77,12408.00,percent of total billed charges,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,WellCare of North Carolina,Managed Medicaid,,598.60,,,,,,,598.60,17457.00,percent of total billed charges,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,WellCare of North Carolina,Managed Medicaid,,4031.43,,,,,,,4031.43,24600.00,percent of total billed charges,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,WellCare of North Carolina,Managed Medicaid,,2143.34,,,,,,,2143.34,24600.00,percent of total billed charges,
HC ART RETRO BRACHIAL,73610297,CDM,481,RC,36140,CPT,,,facility,outpatient,,,519.00000,311.40000,WellCare of North Carolina,Managed Medicaid,,103.90,,,,,,,103.90,9423.00,percent of total billed charges,
HC INJECTION ANKLE ARTHROGRAM BIL,73610315,CDM,361,RC,27648,CPT,,,facility,outpatient,,,1168.00000,700.80000,WellCare of North Carolina,Managed Medicaid,,233.83,,,,,,,173.00,4311.00,percent of total billed charges,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,WellCare of North Carolina,Managed Medicaid,,215.01,,,,,,,215.01,5152.00,percent of total billed charges,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,WellCare of North Carolina,Managed Medicaid,,138.74,,,,,,,138.74,4311.00,percent of total billed charges,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,WellCare of North Carolina,Managed Medicaid,,155.36,,,,,,,155.36,4311.00,percent of total billed charges,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,WellCare of North Carolina,Managed Medicaid,,1092.69,,,,,,,1092.69,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W STG,73610327,CDM,361,RC,19082,CPT,,,facility,outpatient,,,3712.00000,2227.20000,WellCare of North Carolina,Managed Medicaid,,743.14,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,WellCare of North Carolina,Managed Medicaid,,944.74,,,,,,,944.74,6649.00,percent of total billed charges,
HC BX BRST PLC LOC DEV +LES W USG,73610329,CDM,361,RC,19084,CPT,,,facility,outpatient,,,3869.00000,2321.40000,WellCare of North Carolina,Managed Medicaid,,774.57,,,,,,,173.00,4311.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,WellCare of North Carolina,Managed Medicaid,,973.77,,,,,,,973.77,6735.00,percent of total billed charges,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE EACH ADDITIONAL LESION W MRI GUIDANCE,73610331,CDM,361,RC,19086,CPT,,,facility,outpatient,,,3988.00000,2392.80000,WellCare of North Carolina,Managed Medicaid,,798.40,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,WellCare of North Carolina,Managed Medicaid,,337.94,,,,,,,337.94,4376.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE ADDL LESION W MAMMO GUIDANCE,73610333,CDM,361,RC,19282,CPT,,,facility,outpatient,,,573.00000,343.80000,WellCare of North Carolina,Managed Medicaid,,114.71,,,,,,,114.71,4311.00,percent of total billed charges,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,WellCare of North Carolina,Managed Medicaid,,1493.89,,,,,,,1493.89,13852.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,WellCare of North Carolina,Managed Medicaid,,398.40,,,,,,,398.40,4376.00,percent of total billed charges,
HC PLACEMENT BREAST LOC DEV EACH ADDL LES W USG,73610337,CDM,361,RC,19286,CPT,,,facility,outpatient,,,1492.00000,895.20000,WellCare of North Carolina,Managed Medicaid,,298.70,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,WellCare of North Carolina,Managed Medicaid,,531.13,,,,,,,531.13,6735.00,percent of total billed charges,
HC STENT INTRAVASULAR OPEN EACH ADDITIONAL VEIN,73610444,CDM,481,RC,37239,CPT,,,facility,outpatient,,,28766.00000,17259.60000,WellCare of North Carolina,Managed Medicaid,,5758.95,,,,,,,4311.00,17547.26,percent of total billed charges,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,WellCare of North Carolina,Managed Medicaid,,838.24,,,,,,,838.24,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,WellCare of North Carolina,Managed Medicaid,,2658.46,,,,,,,2658.46,24600.00,percent of total billed charges,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,WellCare of North Carolina,Managed Medicaid,,1771.37,,,,,,,1771.37,24600.00,percent of total billed charges,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,WellCare of North Carolina,Managed Medicaid,,696.50,,,,,,,676.91,4376.00,percent of total billed charges,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,WellCare of North Carolina,Managed Medicaid,,248.45,,,,,,,248.45,8045.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,WellCare of North Carolina,Managed Medicaid,,339.54,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,WellCare of North Carolina,Managed Medicaid,,339.54,,,,,,,284.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,WellCare of North Carolina,Managed Medicaid,,375.58,,,,,,,375.58,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,WellCare of North Carolina,Managed Medicaid,,375.58,,,,,,,353.63,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,WellCare of North Carolina,Managed Medicaid,,346.75,,,,,,,173.00,4311.00,percent of total billed charges,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,WellCare of North Carolina,Managed Medicaid,,346.75,,,,,,,284.00,4311.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,WellCare of North Carolina,Managed Medicaid,,258.06,,,,,,,258.06,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,WellCare of North Carolina,Managed Medicaid,,146.75,,,,,,,146.75,17457.00,percent of total billed charges,
HC PERC VERT 1 VERT BODY EACH ADDITIONAL CT OR LS UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610460,CDM,361,RC,22512,CPT,,,facility,outpatient,,,1229.00000,737.40000,WellCare of North Carolina,Managed Medicaid,,246.05,,,,,,,173.00,17457.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,WellCare of North Carolina,Managed Medicaid,,1434.43,,,,,,,1434.43,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,WellCare of North Carolina,Managed Medicaid,,358.56,,,,,,,358.56,13852.00,percent of total billed charges,
HC PERC VERT AUGMENT EACH ADDITIONAL THOR LUM UNIL OR BIL W IMAGE GUIDANCE,73610463,CDM,361,RC,22515,CPT,,,facility,outpatient,,,1576.00000,945.60000,WellCare of North Carolina,Managed Medicaid,,315.52,,,,,,,173.00,4311.00,percent of total billed charges,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,WellCare of North Carolina,Managed Medicaid,,371.17,,,,,,,371.17,8213.00,percent of total billed charges,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,WellCare of North Carolina,Managed Medicaid,,209.41,,,,,,,209.41,8213.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,361,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,WellCare of North Carolina,Managed Medicaid,,717.92,,,,,,,717.92,6735.00,percent of total billed charges,
HC STENT PLCMNT INTRATHORACIC CAROTID W ANGIO W S AND I,73610467,CDM,481,RC,37218,CPT,,,facility,outpatient,,,3586.00000,2151.60000,WellCare of North Carolina,Managed Medicaid,,717.92,,,,,,,717.92,9423.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,361,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,WellCare of North Carolina,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY INITIAL VESSEL INCL S AND I,73610509,CDM,481,RC,37252,CPT,,,facility,outpatient,,,2602.00000,1561.20000,WellCare of North Carolina,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,361,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,WellCare of North Carolina,Managed Medicaid,,520.92,,,,,,,173.00,4311.00,percent of total billed charges,
HC IVUS NON CORONARY EACH ADDITIONAL VESSEL INCL S AND I,73610510,CDM,481,RC,37253,CPT,,,facility,outpatient,,,2602.00000,1561.20000,WellCare of North Carolina,Managed Medicaid,,520.92,,,,,,,173.00,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,WellCare of North Carolina,Managed Medicaid,,693.69,,,,,,,693.69,8045.00,percent of total billed charges,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,WellCare of North Carolina,Managed Medicaid,,596.60,,,,,,,596.60,17457.00,percent of total billed charges,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,WellCare of North Carolina,Managed Medicaid,,1230.03,,,,,,,1230.03,17457.00,percent of total billed charges,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,WellCare of North Carolina,Managed Medicaid,,1430.23,,,,,,,1430.23,17457.00,percent of total billed charges,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,WellCare of North Carolina,Managed Medicaid,,1059.26,,,,,,,1059.26,17457.00,percent of total billed charges,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,WellCare of North Carolina,Managed Medicaid,,954.35,,,,,,,954.35,17457.00,percent of total billed charges,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,WellCare of North Carolina,Managed Medicaid,,238.64,,,,,,,238.64,4311.00,percent of total billed charges,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,WellCare of North Carolina,Managed Medicaid,,1609.21,,,,,,,1609.21,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,WellCare of North Carolina,Managed Medicaid,,1660.86,,,,,,,1660.86,17457.00,percent of total billed charges,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,WellCare of North Carolina,Managed Medicaid,,2496.49,,,,,,,2496.49,17457.00,percent of total billed charges,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,WellCare of North Carolina,Managed Medicaid,,1392.39,,,,,,,1392.39,17457.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY BILIARY TREE INCL IMAGE S AND I,73610523,CDM,361,RC,47543,CPT,,,facility,outpatient,,,2658.00000,1594.80000,WellCare of North Carolina,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC REMOVAL OF CALCULI DEBRIS FROM BILIARY DUCT AND OR GB INCL DESTRUC WHEN PERFORMED IMAGE S AND I,73610524,CDM,361,RC,47544,CPT,,,facility,outpatient,,,1848.00000,1108.80000,WellCare of North Carolina,Managed Medicaid,,369.97,,,,,,,173.00,4311.00,percent of total billed charges,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,WellCare of North Carolina,Managed Medicaid,,178.38,,,,,,,178.38,12408.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,WellCare of North Carolina,Managed Medicaid,,322.52,,,,,,,322.52,6649.00,percent of total billed charges,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,WellCare of North Carolina,Managed Medicaid,,238.44,,,,,,,238.44,6649.00,percent of total billed charges,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,WellCare of North Carolina,Managed Medicaid,,741.14,,,,,,,741.14,12408.00,percent of total billed charges,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,WellCare of North Carolina,Managed Medicaid,,650.85,,,,,,,650.85,12408.00,percent of total billed charges,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,WellCare of North Carolina,Managed Medicaid,,651.45,,,,,,,651.45,6649.00,percent of total billed charges,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,WellCare of North Carolina,Managed Medicaid,,561.56,,,,,,,561.56,6649.00,percent of total billed charges,
HC ENDOLUMINAL BIOPSY URETER AND OR RENAL PELVIS NON ENDO INCL IMAGE S AND I,73610532,CDM,361,RC,50606,CPT,,,facility,outpatient,,,2658.00000,1594.80000,WellCare of North Carolina,Managed Medicaid,,532.13,,,,,,,173.00,4311.00,percent of total billed charges,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,WellCare of North Carolina,Managed Medicaid,,954.75,,,,,,,954.75,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,WellCare of North Carolina,Managed Medicaid,,1107.51,,,,,,,1107.51,17457.00,percent of total billed charges,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,WellCare of North Carolina,Managed Medicaid,,1623.02,,,,,,,1623.02,17457.00,percent of total billed charges,
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE S AND I,73610536,CDM,361,RC,50706,CPT,,,facility,outpatient,,,751.00000,450.60000,WellCare of North Carolina,Managed Medicaid,,150.35,,,,,,,150.35,4311.00,percent of total billed charges,
HC ARTERIAL TRANSLUM MECH THRMBCTMY AND OR INFUS THRM INTRCRNL INCL ANGIO FLG CATH PLAC PHAR THROB INJ,73610537,CDM,361,RC,61645,CPT,,,facility,outpatient,,,10877.00000,6526.20000,WellCare of North Carolina,Managed Medicaid,,2177.58,,,,,,,2025.00,11124.00,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS INITIAL INCL CATH PLACE IMAGE,73610538,CDM,361,RC,61650,CPT,,,facility,outpatient,,,7831.00000,4698.60000,WellCare of North Carolina,Managed Medicaid,,1567.77,,,,,,,1567.77,5418.27,percent of total billed charges,
HC EV INTRCRNL PRLNGD ADMIN PHARM AGENT NOT THROMBLYSIS EA ADDL INCL CATH PLACE IMAGE,73610539,CDM,361,RC,61651,CPT,,,facility,outpatient,,,3807.00000,2284.20000,WellCare of North Carolina,Managed Medicaid,,762.16,,,,,,,762.16,4681.00,percent of total billed charges,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,WellCare of North Carolina,Managed Medicaid,,3427.62,,,,,,,3427.62,52940.00,percent of total billed charges,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,WellCare of North Carolina,Managed Medicaid,,1466.87,,,,,,,1466.87,13852.00,percent of total billed charges,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,WellCare of North Carolina,Managed Medicaid,,180.58,,,,,,,180.58,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,361,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,WellCare of North Carolina,Managed Medicaid,,696.90,,,,,,,173.00,4311.00,percent of total billed charges,
HC TRANS BALLOON ANGIO CENTRAL DIALYSIS SEGMENT,73610551,CDM,481,RC,36907,CPT,,,facility,outpatient,,,3481.00000,2088.60000,WellCare of North Carolina,Managed Medicaid,,696.90,,,,,,,173.00,9423.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,WellCare of North Carolina,Managed Medicaid,,3451.05,,,,,,,3451.05,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,361,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,WellCare of North Carolina,Managed Medicaid,,3239.64,,,,,,,173.00,11196.33,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS EACH ADDITIONAL ARTERY,73610553,CDM,481,RC,37247,CPT,,,facility,outpatient,,,16182.00000,9709.20000,WellCare of North Carolina,Managed Medicaid,,3239.64,,,,,,,173.00,9871.02,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,WellCare of North Carolina,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,WellCare of North Carolina,Managed Medicaid,,1760.76,,,,,,,1760.76,13852.00,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,361,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,WellCare of North Carolina,Managed Medicaid,,1866.26,,,,,,,173.00,6449.89,percent of total billed charges,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT EACH ADDITIONAL VEIN,73610555,CDM,481,RC,37249,CPT,,,facility,outpatient,,,9322.00000,5593.20000,WellCare of North Carolina,Managed Medicaid,,1866.26,,,,,,,173.00,9423.00,percent of total billed charges,
HC STENT PLACEMENT CENTRAL DIALYSIS SEGMENT,73610559,CDM,481,RC,36908,CPT,,,facility,outpatient,,,12428.00000,7456.80000,WellCare of North Carolina,Managed Medicaid,,2488.09,,,,,,,173.00,9423.00,percent of total billed charges,
HC DIALYSIS CIRCUIT EMBOLIZATION OR OCCLUSION,73610560,CDM,481,RC,36909,CPT,,,facility,outpatient,,,9035.00000,5421.00000,WellCare of North Carolina,Managed Medicaid,,1808.81,,,,,,,173.00,9423.00,percent of total billed charges,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,WellCare of North Carolina,Managed Medicaid,,582.58,,,,,,,582.58,4311.00,percent of total billed charges,
HC PLACEMENT OF PROXIMAL OR DISTAL EXTENSIONS FOR ENDVASC REPAIR OF INFRARENAL ABD OR ILIAC ANEURYSM,73610580,CDM,361,RC,34709,CPT,,,facility,outpatient,,,2368.00000,1420.80000,WellCare of North Carolina,Managed Medicaid,,474.07,,,,,,,474.07,4681.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM INITIAL VESSEL,73610581,CDM,361,RC,34710,CPT,,,facility,outpatient,,,2368.00000,1420.80000,WellCare of North Carolina,Managed Medicaid,,474.07,,,,,,,474.07,8442.00,percent of total billed charges,
HC DELAYED PLACEMENT OF PROX OR DISTAL EXTENSION FOR ENDO REPAIR OF AO OR ILIAC ANEURYSM EACH ADDITIONAL VESSEL,73610582,CDM,361,RC,34711,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Managed Medicaid,,160.96,,,,,,,160.96,4681.00,percent of total billed charges,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,WellCare of North Carolina,Managed Medicaid,,1313.31,,,,,,,990.00,4538.86,percent of total billed charges,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,WellCare of North Carolina,Managed Medicaid,,337.54,,,,,,,317.81,4311.00,percent of total billed charges,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,WellCare of North Carolina,Managed Medicaid,,404.60,,,,,,,404.60,4311.00,percent of total billed charges,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,WellCare of North Carolina,Managed Medicaid,,642.84,,,,,,,594.81,9423.00,percent of total billed charges,
HC INJECTION PROC FOR CONTRAST KNEE ARTHRO OR CONTRAST ENHANCED CT MRI KNEE ARTHRO,73610616,CDM,361,RC,27369,CPT,,,facility,outpatient,,,487.00000,292.20000,WellCare of North Carolina,Managed Medicaid,,97.50,,,,,,,97.50,4311.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Managed Medicaid,,43.64,,,,,,,43.64,4311.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,WellCare of North Carolina,Managed Medicaid,,1990.79,,,,,,,1990.79,17457.00,percent of total billed charges,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,WellCare of North Carolina,Managed Medicaid,,1990.79,,,,,,,1990.79,8045.00,percent of total billed charges,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,WellCare of North Carolina,Managed Medicaid,,803.60,,,,,,,803.60,12408.00,percent of total billed charges,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,WellCare of North Carolina,Managed Medicaid,,1219.62,,,,,,,1219.62,10022.00,percent of total billed charges,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,WellCare of North Carolina,Managed Medicaid,,691.09,,,,,,,594.81,4376.00,percent of total billed charges,
HC VAT PIV VEIN INTRODUCTION NEEDLE OR INTRACATHETER,73610655,CDM,361,RC,36000,CPT,,,facility,outpatient,,,1809.00000,1085.40000,WellCare of North Carolina,Managed Medicaid,,362.16,,,,,,,173.00,1251.65,percent of total billed charges,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Managed Medicaid,,125.93,,,,,,,125.93,4311.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Managed Medicaid,,572.37,,,,,,,572.37,6649.00,percent of total billed charges,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Managed Medicaid,,572.37,,,,,,,572.37,10768.00,percent of total billed charges,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,WellCare of North Carolina,Managed Medicaid,,812.41,,,,,,,651.00,2905.00,percent of total billed charges,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,WellCare of North Carolina,Managed Medicaid,,392.19,,,,,,,392.19,8213.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO WITH CAD UNILATERAL,74010009,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,WellCare of North Carolina,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC DIAGNOSTIC MAMMO W CAD BILATERAL,74010010,CDM,401,RC,77066,CPT,,,facility,outpatient,,,459.00000,275.40000,WellCare of North Carolina,Managed Medicaid,,91.89,,,,,,,91.89,344.25,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL W CAD,74010014,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC SCREENING MAMMO 2 VIEW STUDY EACH BREAST BIL WO CAD,74010015,CDM,403,RC,77067,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Managed Medicaid,,74.67,,,,,,,74.67,279.75,percent of total billed charges,
HC DIAGNOSTIC MAMMO WO CAD UNILATERAL,74010016,CDM,401,RC,77065,CPT,,,facility,outpatient,,,392.00000,235.20000,WellCare of North Carolina,Managed Medicaid,,78.48,,,,,,,78.48,294.00,percent of total billed charges,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,WellCare of North Carolina,Managed Medicaid,,64.06,,,,,,,64.06,467.00,percent of total billed charges,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,WellCare of North Carolina,Managed Medicaid,,178.98,,,,,,,102.31,670.50,percent of total billed charges,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,WellCare of North Carolina,Managed Medicaid,,114.91,,,,,,,59.02,467.00,percent of total billed charges,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,WellCare of North Carolina,Managed Medicaid,,228.63,,,,,,,102.31,856.50,percent of total billed charges,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,WellCare of North Carolina,Managed Medicaid,,187.39,,,,,,,102.31,702.00,percent of total billed charges,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,WellCare of North Carolina,Managed Medicaid,,211.81,,,,,,,102.31,793.50,percent of total billed charges,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,WellCare of North Carolina,Managed Medicaid,,154.35,,,,,,,58.38,578.25,percent of total billed charges,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,WellCare of North Carolina,Managed Medicaid,,167.57,,,,,,,102.31,627.75,percent of total billed charges,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Managed Medicaid,,63.06,,,,,,,63.06,467.00,percent of total billed charges,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,WellCare of North Carolina,Managed Medicaid,,151.75,,,,,,,102.31,568.50,percent of total billed charges,
HC US OB LESS THAN 14 WKS EACH ADDITIONAL GEST,74020015,CDM,402,RC,76802,CPT,,,facility,outpatient,,,310.00000,186.00000,WellCare of North Carolina,Managed Medicaid,,62.06,,,,,,,62.06,467.00,percent of total billed charges,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,WellCare of North Carolina,Managed Medicaid,,165.16,,,,,,,102.31,618.75,percent of total billed charges,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,WellCare of North Carolina,Managed Medicaid,,192.39,,,,,,,160.28,720.75,percent of total billed charges,
HC US OB TRANSABD EACH ADDITIONAL GEST,74020019,CDM,402,RC,76812,CPT,,,facility,outpatient,,,519.00000,311.40000,WellCare of North Carolina,Managed Medicaid,,103.90,,,,,,,103.90,467.00,percent of total billed charges,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Managed Medicaid,,127.53,,,,,,,97.56,477.75,percent of total billed charges,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,WellCare of North Carolina,Managed Medicaid,,85.49,,,,,,,85.49,467.00,percent of total billed charges,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,WellCare of North Carolina,Managed Medicaid,,167.17,,,,,,,102.31,626.25,percent of total billed charges,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,WellCare of North Carolina,Managed Medicaid,,133.73,,,,,,,102.31,501.00,percent of total billed charges,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Managed Medicaid,,107.91,,,,,,,89.84,467.00,percent of total billed charges,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,WellCare of North Carolina,Managed Medicaid,,131.73,,,,,,,131.73,493.50,percent of total billed charges,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Managed Medicaid,,207.61,,,,,,,102.31,777.75,percent of total billed charges,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,WellCare of North Carolina,Managed Medicaid,,164.76,,,,,,,46.82,617.25,percent of total billed charges,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,WellCare of North Carolina,Managed Medicaid,,183.98,,,,,,,102.31,689.25,percent of total billed charges,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,WellCare of North Carolina,Managed Medicaid,,60.26,,,,,,,60.26,467.00,percent of total billed charges,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,WellCare of North Carolina,Managed Medicaid,,235.84,,,,,,,54.52,883.50,percent of total billed charges,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,WellCare of North Carolina,Managed Medicaid,,152.95,,,,,,,63.52,573.00,percent of total billed charges,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,WellCare of North Carolina,Managed Medicaid,,50.05,,,,,,,50.05,467.00,percent of total billed charges,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,WellCare of North Carolina,Managed Medicaid,,46.25,,,,,,,46.25,467.00,percent of total billed charges,
HC US GUIDE FOR ENDOMYOCARDIAL BX,74020037,CDM,402,RC,76932,CPT,,,facility,outpatient,,,186.00000,111.60000,WellCare of North Carolina,Managed Medicaid,,37.24,,,,,,,37.24,467.00,percent of total billed charges,
HC US GUIDANCE VASCULAR ACCESS,74020038,CDM,402,RC,76937,CPT,,,facility,outpatient,,,1102.00000,661.20000,WellCare of North Carolina,Managed Medicaid,,220.62,,,,,,,220.62,826.50,percent of total billed charges,
HC S AND I US GUIDANCE NEEDLE PLACEMENT,74020040,CDM,402,RC,76942,CPT,,,facility,outpatient,,,825.00000,495.00000,WellCare of North Carolina,Managed Medicaid,,165.16,,,,,,,165.16,618.75,percent of total billed charges,
HC US GUIDE AMNIOCENTESIS,74020043,CDM,402,RC,76946,CPT,,,facility,outpatient,,,199.00000,119.40000,WellCare of North Carolina,Managed Medicaid,,39.84,,,,,,,39.84,467.00,percent of total billed charges,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,8.28,467.00,percent of total billed charges,
HC US INTRAOPERATIVE,74020047,CDM,402,RC,76998,CPT,,,facility,outpatient,,,684.00000,410.40000,WellCare of North Carolina,Managed Medicaid,,136.94,,,,,,,136.94,513.00,percent of total billed charges,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,WellCare of North Carolina,Managed Medicaid,,84.48,,,,,,,84.48,467.00,percent of total billed charges,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,WellCare of North Carolina,Managed Medicaid,,193.59,,,,,,,102.31,725.25,percent of total billed charges,
HC ANESTHESIA US GUIDANCE,74020056,CDM,402,RC,76942,CPT,,,facility,outpatient,,,724.00000,434.40000,WellCare of North Carolina,Managed Medicaid,,144.94,,,,,,,144.94,543.00,percent of total billed charges,
HC WAKE RESEARCH US GUIDANCE,74020057,CDM,402,RC,76942,CPT,,,facility,outpatient,,,413.00000,247.80000,WellCare of North Carolina,Managed Medicaid,,82.68,,,,,,,82.68,467.00,percent of total billed charges,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,WellCare of North Carolina,Managed Medicaid,,98.50,,,,,,,84.71,467.00,percent of total billed charges,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,WellCare of North Carolina,Managed Medicaid,,91.89,,,,,,,91.89,467.00,percent of total billed charges,
HC US GUIDANCE FOR VASC ACCESS IV TEAM ONLY,74020078,CDM,402,RC,76937,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,22.02,467.00,percent of total billed charges,
HC MG SCREENING DIGITAL BREAST TOMO BIL,74030011,CDM,403,RC,77063,CPT,,,facility,outpatient,,,139.00000,83.40000,WellCare of North Carolina,Managed Medicaid,,27.83,,,,,,,27.83,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO UNIL,74030012,CDM,401,RC,77061,CPT,,,facility,outpatient,,,67.00000,40.20000,WellCare of North Carolina,Managed Medicaid,,13.41,,,,,,,13.41,246.00,percent of total billed charges,
HC MG DX DIGITAL BREAST TOMO BIL,74030013,CDM,401,RC,77062,CPT,,,facility,outpatient,,,109.00000,65.40000,WellCare of North Carolina,Managed Medicaid,,21.82,,,,,,,21.82,246.00,percent of total billed charges,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,WellCare of North Carolina,Managed Medicaid,,1278.48,,,,,,,1113.08,5598.00,percent of total billed charges,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,WellCare of North Carolina,Managed Medicaid,,931.73,,,,,,,811.19,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,WellCare of North Carolina,Managed Medicaid,,837.24,,,,,,,728.92,5598.00,percent of total billed charges,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,WellCare of North Carolina,Managed Medicaid,,1299.50,,,,,,,1131.38,5598.00,percent of total billed charges,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,WellCare of North Carolina,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,WellCare of North Carolina,Managed Medicaid,,538.14,,,,,,,257.00,2016.00,percent of total billed charges,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,WellCare of North Carolina,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,WellCare of North Carolina,Managed Medicaid,,1231.23,,,,,,,1071.94,5598.00,percent of total billed charges,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,WellCare of North Carolina,Managed Medicaid,,186.39,,,,,,,162.27,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,WellCare of North Carolina,Managed Medicaid,,306.51,,,,,,,266.85,5598.00,percent of total billed charges,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,WellCare of North Carolina,Managed Medicaid,,612.81,,,,,,,533.53,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,WellCare of North Carolina,Managed Medicaid,,932.93,,,,,,,812.24,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,WellCare of North Carolina,Managed Medicaid,,836.04,,,,,,,727.88,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,WellCare of North Carolina,Managed Medicaid,,1211.61,,,,,,,1054.86,5598.00,percent of total billed charges,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,WellCare of North Carolina,Managed Medicaid,,1780.98,,,,,,,1550.57,5598.00,percent of total billed charges,
HC DOPPLER ECHO COLOR FLOW MAPPING,74800001,CDM,483,RC,93325,CPT,,,facility,outpatient,,,527.00000,316.20000,WellCare of North Carolina,Managed Medicaid,,105.51,,,,,,,73.94,968.00,percent of total billed charges,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,WellCare of North Carolina,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Managed Medicaid,,114.31,,,,,,,80.11,968.00,percent of total billed charges,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,WellCare of North Carolina,Managed Medicaid,,202.60,,,,,,,141.98,968.00,percent of total billed charges,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,WellCare of North Carolina,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,WellCare of North Carolina,Managed Medicaid,,494.29,,,,,,,266.00,1851.75,percent of total billed charges,
HC INTERVENTIONAL TEE,74830010,CDM,483,RC,93355,CPT,,,facility,outpatient,,,481.00000,288.60000,WellCare of North Carolina,Managed Medicaid,,96.30,,,,,,,67.48,968.00,percent of total billed charges,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,WellCare of North Carolina,Managed Medicaid,,563.16,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,WellCare of North Carolina,Managed Medicaid,,659.06,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,WellCare of North Carolina,Managed Medicaid,,1014.81,,,,,,,760.10,3601.53,percent of total billed charges,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,WellCare of North Carolina,Managed Medicaid,,1226.63,,,,,,,343.59,4352.85,percent of total billed charges,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,WellCare of North Carolina,Managed Medicaid,,692.49,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,WellCare of North Carolina,Managed Medicaid,,1035.63,,,,,,,343.59,3155.53,percent of total billed charges,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,WellCare of North Carolina,Managed Medicaid,,1078.68,,,,,,,343.59,3286.68,percent of total billed charges,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,WellCare of North Carolina,Managed Medicaid,,721.52,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,WellCare of North Carolina,Managed Medicaid,,753.75,,,,,,,343.59,3127.52,percent of total billed charges,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,WellCare of North Carolina,Managed Medicaid,,1032.63,,,,,,,343.59,3810.99,percent of total billed charges,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,WellCare of North Carolina,Managed Medicaid,,695.09,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,WellCare of North Carolina,Managed Medicaid,,816.02,,,,,,,760.10,2893.96,percent of total billed charges,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,WellCare of North Carolina,Managed Medicaid,,940.74,,,,,,,343.59,3525.98,percent of total billed charges,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,WellCare of North Carolina,Managed Medicaid,,742.34,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,WellCare of North Carolina,Managed Medicaid,,779.18,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,WellCare of North Carolina,Managed Medicaid,,1067.47,,,,,,,343.59,3252.52,percent of total billed charges,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,WellCare of North Carolina,Managed Medicaid,,735.74,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,WellCare of North Carolina,Managed Medicaid,,743.14,,,,,,,743.14,2917.94,percent of total billed charges,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,WellCare of North Carolina,Managed Medicaid,,1032.63,,,,,,,343.59,3522.51,percent of total billed charges,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,WellCare of North Carolina,Managed Medicaid,,852.05,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,WellCare of North Carolina,Managed Medicaid,,901.10,,,,,,,343.59,2876.72,percent of total billed charges,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,WellCare of North Carolina,Managed Medicaid,,1047.85,,,,,,,343.59,3192.74,percent of total billed charges,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,WellCare of North Carolina,Managed Medicaid,,584.38,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,WellCare of North Carolina,Managed Medicaid,,837.84,,,,,,,343.59,2972.99,percent of total billed charges,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,WellCare of North Carolina,Managed Medicaid,,635.03,,,,,,,84.71,2825.00,percent of total billed charges,
HC MRI GUIDANCE NEEDLE PLACEMENT BIOPSY,76100030,CDM,610,RC,77021,CPT,,,facility,outpatient,,,253.00000,151.80000,WellCare of North Carolina,Managed Medicaid,,50.65,,,,,,,50.65,2825.00,percent of total billed charges,
HC MRI BREAST W CONT UNIL,76100032,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,WellCare of North Carolina,Managed Medicaid,52,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W CONT BIL,76100033,CDM,610,RC,77049,CPT,,,facility,outpatient,,,3933.00000,2359.80000,WellCare of North Carolina,Managed Medicaid,52,787.39,,,,,,,787.39,2825.00,percent of total billed charges,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,WellCare of North Carolina,Managed Medicaid,,769.37,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,WellCare of North Carolina,Managed Medicaid,,881.88,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,WellCare of North Carolina,Managed Medicaid,,1040.24,,,,,,,343.59,3169.56,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,WellCare of North Carolina,Managed Medicaid,,805.60,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,WellCare of North Carolina,Managed Medicaid,,827.83,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,WellCare of North Carolina,Managed Medicaid,,703.90,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,WellCare of North Carolina,Managed Medicaid,,855.65,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,WellCare of North Carolina,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,WellCare of North Carolina,Managed Medicaid,,811.01,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,WellCare of North Carolina,Managed Medicaid,,1021.82,,,,,,,343.59,3113.44,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,WellCare of North Carolina,Managed Medicaid,,983.38,,,,,,,343.59,2996.32,percent of total billed charges,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,WellCare of North Carolina,Managed Medicaid,,1091.89,,,,,,,343.59,3326.94,percent of total billed charges,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,WellCare of North Carolina,Managed Medicaid,,838.84,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,WellCare of North Carolina,Managed Medicaid,,928.33,,,,,,,343.59,2828.57,percent of total billed charges,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,WellCare of North Carolina,Managed Medicaid,,1118.32,,,,,,,343.59,3407.46,percent of total billed charges,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,WellCare of North Carolina,Managed Medicaid,,694.29,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,WellCare of North Carolina,Managed Medicaid,,734.93,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,WellCare of North Carolina,Managed Medicaid,,1069.07,,,,,,,343.59,3981.96,percent of total billed charges,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,WellCare of North Carolina,Managed Medicaid,,649.65,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,WellCare of North Carolina,Managed Medicaid,,720.52,,,,,,,343.59,2825.00,percent of total billed charges,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,WellCare of North Carolina,Managed Medicaid,,1000.80,,,,,,,343.59,4009.45,percent of total billed charges,
HC MRA LE W CONT,76100061,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4225.00000,2535.00000,WellCare of North Carolina,Managed Medicaid,,845.85,,,,,,,845.85,3021.02,percent of total billed charges,
HC MRA LE WO CONT,76100062,CDM,616,RC,73725,CPT,,,facility,outpatient,,,3236.00000,1941.60000,WellCare of North Carolina,Managed Medicaid,,647.85,,,,,,,647.85,3021.02,percent of total billed charges,
HC MRA LE WO W CONT,76100063,CDM,616,RC,73725,CPT,,,facility,outpatient,,,4472.00000,2683.20000,WellCare of North Carolina,Managed Medicaid,,895.29,,,,,,,895.29,3021.02,percent of total billed charges,
HC MRA CHEST W CONT,76100064,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,WellCare of North Carolina,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO CONT,76100065,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,WellCare of North Carolina,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA CHEST WO W CONT,76100066,CDM,618,RC,71555,CPT,,,facility,outpatient,,,4238.00000,2542.80000,WellCare of North Carolina,Managed Medicaid,,848.45,,,,,,,848.45,3010.70,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W CONT,76100067,CDM,618,RC,72159,CPT,,,facility,outpatient,,,3535.00000,2121.00000,WellCare of North Carolina,Managed Medicaid,,707.71,,,,,,,707.71,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS WO CONT,76100068,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,WellCare of North Carolina,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA SPINAL CANAL AND CONTENTS W WO CONT,76100069,CDM,618,RC,72159,CPT,,,facility,outpatient,,,4068.00000,2440.80000,WellCare of North Carolina,Managed Medicaid,,814.41,,,,,,,814.41,2825.00,percent of total billed charges,
HC MRA PELVIS W CONT,76100070,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4493.00000,2695.80000,WellCare of North Carolina,Managed Medicaid,,899.50,,,,,,,899.50,3027.91,percent of total billed charges,
HC MRA PELVIS WO CONT,76100071,CDM,618,RC,72198,CPT,,,facility,outpatient,,,3250.00000,1950.00000,WellCare of North Carolina,Managed Medicaid,,650.65,,,,,,,650.65,3027.91,percent of total billed charges,
HC MRA PELVIS WO W CONT,76100072,CDM,618,RC,72198,CPT,,,facility,outpatient,,,4594.00000,2756.40000,WellCare of North Carolina,Managed Medicaid,,919.72,,,,,,,919.72,3027.91,percent of total billed charges,
HC MRA UE W CONT,76100073,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4466.00000,2679.60000,WellCare of North Carolina,Managed Medicaid,,894.09,,,,,,,894.09,2825.00,percent of total billed charges,
HC MRA UE WO CONT,76100074,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,WellCare of North Carolina,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA UE W OR WO CONT,76100075,CDM,618,RC,73225,CPT,,,facility,outpatient,,,4223.00000,2533.80000,WellCare of North Carolina,Managed Medicaid,,845.44,,,,,,,845.44,2825.00,percent of total billed charges,
HC MRA ABD W CONT,76100076,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,WellCare of North Carolina,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO CONT,76100077,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,WellCare of North Carolina,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRA ABD WO W CONT,76100078,CDM,618,RC,74185,CPT,,,facility,outpatient,,,4540.00000,2724.00000,WellCare of North Carolina,Managed Medicaid,,908.91,,,,,,,908.91,3048.50,percent of total billed charges,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,WellCare of North Carolina,Managed Medicaid,,705.30,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI REFORMAT,76100115,CDM,610,RC,76376,CPT,,,facility,outpatient,,,1033.00000,619.80000,WellCare of North Carolina,Managed Medicaid,,206.81,,,,,,,206.81,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,WellCare of North Carolina,Managed Medicaid,,480.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,WellCare of North Carolina,Managed Medicaid,,477.48,,,,,,,232.56,2825.00,percent of total billed charges,
HC MRI BREAST W WO CONT INCLUDE CAD UNILATERAL,76100124,CDM,610,RC,77048,CPT,,,facility,outpatient,,,3952.00000,2371.20000,WellCare of North Carolina,Managed Medicaid,,791.19,,,,,,,791.19,2825.00,percent of total billed charges,
HC MRI BREAST W  WO CONT INCLUDE CAD BILATERAL,76100125,CDM,610,RC,77049,CPT,,,facility,outpatient,,,1875.00000,1125.00000,WellCare of North Carolina,Managed Medicaid,,375.38,,,,,,,375.38,2825.00,percent of total billed charges,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,WellCare of North Carolina,Managed Medicaid,,85.29,,,,,,,41.04,319.50,percent of total billed charges,
HC EKG EVENT INTERPRETATION,77300001,CDM,730,RC,93272,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Managed Medicaid,,64.86,,,,,,,64.86,243.00,percent of total billed charges,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Managed Medicaid,,79.88,,,,,,,57.15,299.25,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,WellCare of North Carolina,Managed Medicaid,,349.35,,,,,,,349.35,4311.00,percent of total billed charges,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,WellCare of North Carolina,Managed Medicaid,,349.35,,,,,,,328.93,4311.00,percent of total billed charges,
HC MYOCARDIAL STRAIN IMG SPCKL TRCK,77610006,CDM,761,RC,93356,CPT,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Managed Medicaid,,31.63,,,,,,,29.78,128.45,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,WellCare of North Carolina,Managed Medicaid,,366.57,,,,,,,366.57,4311.00,percent of total billed charges,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,WellCare of North Carolina,Managed Medicaid,,366.57,,,,,,,345.14,4311.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,WellCare of North Carolina,Managed Medicaid,,181.18,,,,,,,102.31,678.75,percent of total billed charges,
HC TRANSCRANIAL DOPPLER VASOREACTIVITY STUDY,79210002,CDM,921,RC,93890,CPT,,,facility,outpatient,,,540.00000,324.00000,WellCare of North Carolina,Managed Medicaid,,108.11,,,,,,,94.01,405.00,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Managed Medicaid,,95.09,,,,,,,82.70,356.25,percent of total billed charges,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,WellCare of North Carolina,Managed Medicaid,,260.06,,,,,,,150.52,974.25,percent of total billed charges,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Managed Medicaid,,207.61,,,,,,,175.00,777.75,percent of total billed charges,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,WellCare of North Carolina,Managed Medicaid,,169.57,,,,,,,102.31,635.25,percent of total billed charges,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,WellCare of North Carolina,Managed Medicaid,,123.32,,,,,,,102.31,462.00,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,WellCare of North Carolina,Managed Medicaid,,119.92,,,,,,,104.29,449.25,percent of total billed charges,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,WellCare of North Carolina,Managed Medicaid,,58.46,,,,,,,50.84,269.00,percent of total billed charges,
HC CAPILLARY BLOOD COLLECTION,83000001,CDM,300,RC,36416,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,4.01,23.25,percent of total billed charges,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,WellCare of North Carolina,Managed Medicaid,,86.29,,,,,,,10.24,323.25,percent of total billed charges,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,WellCare of North Carolina,Managed Medicaid,,63.46,,,,,,,46.38,237.75,percent of total billed charges,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Managed Medicaid,,57.66,,,,,,,8.42,216.00,percent of total billed charges,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,WellCare of North Carolina,Managed Medicaid,,136.14,,,,,,,46.20,510.00,percent of total billed charges,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,WellCare of North Carolina,Managed Medicaid,,56.26,,,,,,,7.92,210.75,percent of total billed charges,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Managed Medicaid,,116.52,,,,,,,116.52,436.50,percent of total billed charges,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,WellCare of North Carolina,Managed Medicaid,,287.49,,,,,,,287.49,1077.00,percent of total billed charges,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,WellCare of North Carolina,Managed Medicaid,,150.55,,,,,,,150.55,564.00,percent of total billed charges,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,WellCare of North Carolina,Managed Medicaid,,373.57,,,,,,,373.57,2152.96,percent of total billed charges,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,WellCare of North Carolina,Managed Medicaid,,870.87,,,,,,,870.87,3262.50,percent of total billed charges,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,WellCare of North Carolina,Managed Medicaid,,50.45,,,,,,,50.45,189.00,percent of total billed charges,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,WellCare of North Carolina,Managed Medicaid,,35.44,,,,,,,35.44,136.16,percent of total billed charges,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,WellCare of North Carolina,Managed Medicaid,,73.87,,,,,,,55.33,276.75,percent of total billed charges,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,WellCare of North Carolina,Managed Medicaid,,36.64,,,,,,,36.64,137.25,percent of total billed charges,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,WellCare of North Carolina,Managed Medicaid,,85.49,,,,,,,85.49,320.25,percent of total billed charges,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,WellCare of North Carolina,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Managed Medicaid,,55.05,,,,,,,33.95,206.25,percent of total billed charges,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Managed Medicaid,,79.88,,,,,,,63.40,299.25,percent of total billed charges,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,WellCare of North Carolina,Managed Medicaid,,126.33,,,,,,,126.33,473.25,percent of total billed charges,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,WellCare of North Carolina,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,WellCare of North Carolina,Managed Medicaid,,174.97,,,,,,,174.97,655.50,percent of total billed charges,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,WellCare of North Carolina,Managed Medicaid,,112.51,,,,,,,112.51,436.66,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,WellCare of North Carolina,Managed Medicaid,,72.47,,,,,,,72.47,646.78,percent of total billed charges,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,WellCare of North Carolina,Managed Medicaid,,151.35,,,,,,,49.54,567.00,percent of total billed charges,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Managed Medicaid,,61.06,,,,,,,42.34,228.75,percent of total billed charges,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,WellCare of North Carolina,Managed Medicaid,,133.13,,,,,,,133.13,498.75,percent of total billed charges,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,WellCare of North Carolina,Managed Medicaid,,84.48,,,,,,,84.48,434.18,percent of total billed charges,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,WellCare of North Carolina,Managed Medicaid,,191.39,,,,,,,191.39,816.53,percent of total billed charges,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,WellCare of North Carolina,Managed Medicaid,,119.92,,,,,,,119.92,748.92,percent of total billed charges,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,WellCare of North Carolina,Managed Medicaid,,84.48,,,,,,,84.48,316.50,percent of total billed charges,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,WellCare of North Carolina,Managed Medicaid,,91.69,,,,,,,72.10,343.50,percent of total billed charges,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,WellCare of North Carolina,Managed Medicaid,,72.87,,,,,,,72.87,273.00,percent of total billed charges,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,WellCare of North Carolina,Managed Medicaid,,505.30,,,,,,,335.20,1893.00,percent of total billed charges,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,WellCare of North Carolina,Managed Medicaid,,434.23,,,,,,,325.32,1626.75,percent of total billed charges,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,WellCare of North Carolina,Managed Medicaid,,221.42,,,,,,,171.93,829.50,percent of total billed charges,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,WellCare of North Carolina,Managed Medicaid,,104.30,,,,,,,104.30,390.75,percent of total billed charges,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,WellCare of North Carolina,Managed Medicaid,,110.71,,,,,,,110.71,414.75,percent of total billed charges,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,WellCare of North Carolina,Managed Medicaid,,67.27,,,,,,,67.27,457.32,percent of total billed charges,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Managed Medicaid,,25.63,,,,,,,25.63,173.55,percent of total billed charges,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,WellCare of North Carolina,Managed Medicaid,,102.50,,,,,,,102.50,556.86,percent of total billed charges,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,WellCare of North Carolina,Managed Medicaid,,80.88,,,,,,,80.88,358.40,percent of total billed charges,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,WellCare of North Carolina,Managed Medicaid,,80.88,,,,,,,80.88,549.16,percent of total billed charges,
HC PCD DNA ANALYSIS,83000082,CDM,300,RC,81479,CPT,,,facility,outpatient,,,2404.00000,1442.40000,WellCare of North Carolina,Managed Medicaid,,481.28,,,,,,,218.46,1803.00,percent of total billed charges,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,,9.41,,,,,,,9.41,35.77,percent of total billed charges,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,WellCare of North Carolina,Managed Medicaid,,2.80,,,,,,,2.80,10.50,percent of total billed charges,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,WellCare of North Carolina,Managed Medicaid,,22.42,,,,,,,8.48,84.00,percent of total billed charges,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Managed Medicaid,,32.63,,,,,,,9.37,122.25,percent of total billed charges,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Managed Medicaid,,26.43,,,,,,,7.29,99.00,percent of total billed charges,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Managed Medicaid,,5.21,,,,,,,4.18,19.50,percent of total billed charges,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,WellCare of North Carolina,Managed Medicaid,,8.81,,,,,,,4.14,33.00,percent of total billed charges,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,WellCare of North Carolina,Managed Medicaid,,53.05,,,,,,,8.21,198.75,percent of total billed charges,
HC GENERAL HEALTH PANEL,83000134,CDM,301,RC,80050,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,76.44,percent of total billed charges,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,6.80,66.00,percent of total billed charges,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,WellCare of North Carolina,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Managed Medicaid,,37.84,,,,,,,37.84,141.75,percent of total billed charges,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,WellCare of North Carolina,Managed Medicaid,,79.48,,,,,,,60.28,297.75,percent of total billed charges,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,WellCare of North Carolina,Managed Medicaid,,31.03,,,,,,,31.03,118.79,percent of total billed charges,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,18.62,118.79,percent of total billed charges,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,WellCare of North Carolina,Managed Medicaid,,107.11,,,,,,,60.28,401.25,percent of total billed charges,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,14.63,68.25,percent of total billed charges,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,14.63,60.75,percent of total billed charges,
HC BENZODIAZEPINE UR CONFIRMATION,83000171,CDM,301,RC,80347,CPT,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Managed Medicaid,,14.21,,,,,,,14.21,53.25,percent of total billed charges,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,14.13,75.75,percent of total billed charges,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,10.21,38.25,percent of total billed charges,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,13.13,75.75,percent of total billed charges,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Managed Medicaid,,26.63,,,,,,,15.89,99.75,percent of total billed charges,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.41,75.75,percent of total billed charges,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Managed Medicaid,,5.81,,,,,,,5.81,28.26,percent of total billed charges,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,13.35,54.00,percent of total billed charges,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,WellCare of North Carolina,Managed Medicaid,,35.44,,,,,,,13.32,132.75,percent of total billed charges,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,WellCare of North Carolina,Managed Medicaid,,24.82,,,,,,,13.32,93.00,percent of total billed charges,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Managed Medicaid,,7.81,,,,,,,7.81,30.17,percent of total billed charges,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Managed Medicaid,,29.03,,,,,,,15.65,108.75,percent of total billed charges,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,13.13,67.50,percent of total billed charges,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,WellCare of North Carolina,Managed Medicaid,,30.83,,,,,,,30.83,115.50,percent of total billed charges,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Managed Medicaid,,5.81,,,,,,,4.38,21.75,percent of total billed charges,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Managed Medicaid,,8.61,,,,,,,7.92,32.25,percent of total billed charges,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,7.92,75.75,percent of total billed charges,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,4.80,36.75,percent of total billed charges,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Managed Medicaid,,8.41,,,,,,,7.55,31.50,percent of total billed charges,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,5.61,23.25,percent of total billed charges,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,16.75,141.00,percent of total billed charges,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,WellCare of North Carolina,Managed Medicaid,,9.61,,,,,,,9.61,36.00,percent of total billed charges,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Managed Medicaid,,32.43,,,,,,,16.27,121.50,percent of total billed charges,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,14.13,60.75,percent of total billed charges,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Managed Medicaid,,23.02,,,,,,,6.29,86.25,percent of total billed charges,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,15.69,75.00,percent of total billed charges,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Managed Medicaid,,8.41,,,,,,,4.87,31.50,percent of total billed charges,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,4.87,69.75,percent of total billed charges,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,4.87,48.75,percent of total billed charges,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,WellCare of North Carolina,Managed Medicaid,,12.01,,,,,,,4.25,45.00,percent of total billed charges,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Managed Medicaid,,8.01,,,,,,,5.16,30.00,percent of total billed charges,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Managed Medicaid,,8.01,,,,,,,4.10,30.00,percent of total billed charges,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,WellCare of North Carolina,Managed Medicaid,,33.23,,,,,,,28.71,124.50,percent of total billed charges,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,,17.82,,,,,,,5.01,66.75,percent of total billed charges,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Managed Medicaid,,13.21,,,,,,,5.85,49.50,percent of total billed charges,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,WellCare of North Carolina,Managed Medicaid,,10.61,,,,,,,4.73,39.75,percent of total billed charges,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,11.95,48.75,percent of total billed charges,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,WellCare of North Carolina,Managed Medicaid,,51.65,,,,,,,18.39,193.50,percent of total billed charges,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,10.42,47.25,percent of total billed charges,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,13.70,71.25,percent of total billed charges,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,4.46,27.00,percent of total billed charges,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,5.58,27.00,percent of total billed charges,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,18.00,percent of total billed charges,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Managed Medicaid,,13.21,,,,,,,4.22,49.50,percent of total billed charges,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,WellCare of North Carolina,Managed Medicaid,,48.65,,,,,,,28.73,182.25,percent of total billed charges,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,18.02,67.50,percent of total billed charges,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Managed Medicaid,,36.04,,,,,,,18.08,135.00,percent of total billed charges,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,15.81,69.75,percent of total billed charges,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,WellCare of North Carolina,Managed Medicaid,,29.23,,,,,,,13.32,109.50,percent of total billed charges,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,6.31,36.75,percent of total billed charges,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Managed Medicaid,,15.82,,,,,,,11.20,59.25,percent of total billed charges,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Managed Medicaid,,7.81,,,,,,,4.97,29.25,percent of total billed charges,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,5.02,48.75,percent of total billed charges,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,WellCare of North Carolina,Managed Medicaid,,59.86,,,,,,,27.10,224.25,percent of total billed charges,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,WellCare of North Carolina,Managed Medicaid,,1.20,,,,,,,1.20,31.74,percent of total billed charges,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,4.95,69.75,percent of total billed charges,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,WellCare of North Carolina,Managed Medicaid,,40.24,,,,,,,13.22,150.75,percent of total billed charges,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,WellCare of North Carolina,Managed Medicaid,,115.92,,,,,,,62.48,434.25,percent of total billed charges,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Managed Medicaid,,31.43,,,,,,,14.26,117.75,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Managed Medicaid,,24.42,,,,,,,9.02,91.50,percent of total billed charges,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,25.29,141.00,percent of total billed charges,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Managed Medicaid,,40.64,,,,,,,40.64,152.25,percent of total billed charges,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,9.48,38.25,percent of total billed charges,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,,6.01,,,,,,,3.81,22.50,percent of total billed charges,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,3.81,82.50,percent of total billed charges,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Managed Medicaid,,14.21,,,,,,,3.81,53.25,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,WellCare of North Carolina,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,3.80,23.25,percent of total billed charges,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,WellCare of North Carolina,Managed Medicaid,,15.62,,,,,,,6.98,58.50,percent of total billed charges,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,WellCare of North Carolina,Managed Medicaid,,47.65,,,,,,,18.02,178.50,percent of total billed charges,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Managed Medicaid,,31.23,,,,,,,17.96,117.00,percent of total billed charges,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,12.20,69.75,percent of total billed charges,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,WellCare of North Carolina,Managed Medicaid,,44.24,,,,,,,12.48,165.75,percent of total billed charges,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Managed Medicaid,,24.02,,,,,,,17.52,90.00,percent of total billed charges,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,WellCare of North Carolina,Managed Medicaid,,30.43,,,,,,,7.76,114.00,percent of total billed charges,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,,9.41,,,,,,,7.95,35.25,percent of total billed charges,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,WellCare of North Carolina,Managed Medicaid,,39.44,,,,,,,17.38,147.75,percent of total billed charges,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Managed Medicaid,,26.43,,,,,,,23.38,99.00,percent of total billed charges,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,11.18,63.00,percent of total billed charges,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.28,75.75,percent of total billed charges,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,5.86,60.00,percent of total billed charges,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,10.81,41.83,percent of total billed charges,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Managed Medicaid,,8.41,,,,,,,8.41,40.33,percent of total billed charges,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Managed Medicaid,,31.63,,,,,,,6.68,118.50,percent of total billed charges,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,WellCare of North Carolina,Managed Medicaid,,29.83,,,,,,,7.94,111.75,percent of total billed charges,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,10.19,54.00,percent of total billed charges,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,6.50,40.50,percent of total billed charges,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Managed Medicaid,,28.63,,,,,,,16.75,107.25,percent of total billed charges,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,WellCare of North Carolina,Managed Medicaid,,16.62,,,,,,,6.41,62.25,percent of total billed charges,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,6.62,71.25,percent of total billed charges,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Managed Medicaid,,28.63,,,,,,,28.63,107.25,percent of total billed charges,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,WellCare of North Carolina,Managed Medicaid,,35.44,,,,,,,35.44,132.75,percent of total billed charges,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Managed Medicaid,,5.21,,,,,,,3.47,19.50,percent of total billed charges,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,5.02,43.50,percent of total billed charges,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,4.60,38.25,percent of total billed charges,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,5.61,80.25,percent of total billed charges,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,WellCare of North Carolina,Managed Medicaid,,0.40040,,,,,,,0.40040,11.03,percent of total billed charges,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,WellCare of North Carolina,Managed Medicaid,,65.87,,,,,,,65.87,246.75,percent of total billed charges,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,WellCare of North Carolina,Managed Medicaid,,11.01,,,,,,,4.62,41.25,percent of total billed charges,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,4.59,27.00,percent of total billed charges,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,14.15,57.75,percent of total billed charges,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,WellCare of North Carolina,Managed Medicaid,,29.23,,,,,,,20.23,109.50,percent of total billed charges,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,WellCare of North Carolina,Managed Medicaid,,45.45,,,,,,,18.80,170.25,percent of total billed charges,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,WellCare of North Carolina,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,WellCare of North Carolina,Managed Medicaid,,43.04,,,,,,,17.84,161.25,percent of total billed charges,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Managed Medicaid,,9.01,,,,,,,3.56,33.75,percent of total billed charges,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,3.56,45.75,percent of total billed charges,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,WellCare of North Carolina,Managed Medicaid,,10.61,,,,,,,3.88,39.75,percent of total billed charges,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,10.42,75.00,percent of total billed charges,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Managed Medicaid,,10.01,,,,,,,10.01,38.02,percent of total billed charges,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Managed Medicaid,,9.01,,,,,,,4.67,33.75,percent of total billed charges,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Managed Medicaid,,6.41,,,,,,,4.91,24.00,percent of total billed charges,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Managed Medicaid,,8.61,,,,,,,4.71,32.25,percent of total billed charges,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,WellCare of North Carolina,Managed Medicaid,,33.43,,,,,,,25.04,125.25,percent of total billed charges,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Managed Medicaid,,9.01,,,,,,,6.66,33.75,percent of total billed charges,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,WellCare of North Carolina,Managed Medicaid,,32.03,,,,,,,8.75,120.00,percent of total billed charges,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,WellCare of North Carolina,Managed Medicaid,,38.04,,,,,,,16.30,142.50,percent of total billed charges,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,5.02,45.75,percent of total billed charges,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,5.14,54.00,percent of total billed charges,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,12.38,55.50,percent of total billed charges,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Managed Medicaid,,13.21,,,,,,,5.57,49.50,percent of total billed charges,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Managed Medicaid,,26.83,,,,,,,13.75,100.50,percent of total billed charges,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Managed Medicaid,,26.03,,,,,,,16.43,97.50,percent of total billed charges,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,WellCare of North Carolina,Managed Medicaid,,21.62,,,,,,,12.10,81.00,percent of total billed charges,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,3.83,27.00,percent of total billed charges,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Managed Medicaid,,7.61,,,,,,,5.39,28.50,percent of total billed charges,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,4.38,57.75,percent of total billed charges,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Managed Medicaid,,23.02,,,,,,,4.93,86.25,percent of total billed charges,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Managed Medicaid,,26.03,,,,,,,26.03,118.79,percent of total billed charges,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,WellCare of North Carolina,Managed Medicaid,,38.64,,,,,,,38.64,144.75,percent of total billed charges,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Managed Medicaid,,15.82,,,,,,,7.63,59.25,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,WellCare of North Carolina,Managed Medicaid,,2.40,,,,,,,2.40,11.11,percent of total billed charges,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,WellCare of North Carolina,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,WellCare of North Carolina,Managed Medicaid,,74.27,,,,,,,14.60,278.25,percent of total billed charges,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,WellCare of North Carolina,Managed Medicaid,,45.05,,,,,,,17.82,168.75,percent of total billed charges,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Managed Medicaid,,28.03,,,,,,,5.02,105.00,percent of total billed charges,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Managed Medicaid,,22.62,,,,,,,12.56,84.75,percent of total billed charges,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Managed Medicaid,,19.42,,,,,,,19.42,72.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,60.75,percent of total billed charges,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,WellCare of North Carolina,Managed Medicaid,,27.43,,,,,,,11.64,102.75,percent of total billed charges,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Managed Medicaid,,24.02,,,,,,,13.33,90.00,percent of total billed charges,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,WellCare of North Carolina,Managed Medicaid,,1.60,,,,,,,1.60,29.29,percent of total billed charges,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,WellCare of North Carolina,Managed Medicaid,,4.40,,,,,,,4.40,38.23,percent of total billed charges,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,WellCare of North Carolina,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,WellCare of North Carolina,Managed Medicaid,,34.83,,,,,,,11.69,130.50,percent of total billed charges,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Managed Medicaid,,25.63,,,,,,,20.19,96.00,percent of total billed charges,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,WellCare of North Carolina,Managed Medicaid,,53.45,,,,,,,20.19,200.25,percent of total billed charges,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,WellCare of North Carolina,Managed Medicaid,,29.43,,,,,,,5.02,110.25,percent of total billed charges,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,WellCare of North Carolina,Managed Medicaid,,54.65,,,,,,,29.02,204.75,percent of total billed charges,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,WellCare of North Carolina,Managed Medicaid,,41.44,,,,,,,21.67,155.25,percent of total billed charges,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Managed Medicaid,,10.01,,,,,,,10.01,62.57,percent of total billed charges,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,WellCare of North Carolina,Managed Medicaid,,47.45,,,,,,,36.60,177.75,percent of total billed charges,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,25.98,141.00,percent of total billed charges,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,381.82,percent of total billed charges,
HC PNH CD59,83000923,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,WellCare of North Carolina,Managed Medicaid,,41.24,,,,,,,36.60,154.50,percent of total billed charges,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,WellCare of North Carolina,Managed Medicaid,,8.21,,,,,,,8.21,80.42,percent of total billed charges,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,WellCare of North Carolina,Managed Medicaid,,58.66,,,,,,,45.57,219.75,percent of total billed charges,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,WellCare of North Carolina,Managed Medicaid,,40.24,,,,,,,40.24,150.75,percent of total billed charges,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Managed Medicaid,,22.62,,,,,,,11.19,84.75,percent of total billed charges,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Managed Medicaid,,10.01,,,,,,,10.01,37.50,percent of total billed charges,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Managed Medicaid,,27.03,,,,,,,5.50,101.25,percent of total billed charges,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,WellCare of North Carolina,Managed Medicaid,,44.64,,,,,,,44.64,167.25,percent of total billed charges,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,WellCare of North Carolina,Managed Medicaid,,4.20,,,,,,,4.20,25.75,percent of total billed charges,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,4.14,42.00,percent of total billed charges,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Managed Medicaid,,11.41,,,,,,,4.27,42.75,percent of total billed charges,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Managed Medicaid,,29.03,,,,,,,4.27,108.75,percent of total billed charges,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,WellCare of North Carolina,Managed Medicaid,,13.61,,,,,,,13.61,51.00,percent of total billed charges,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,,23.42,,,,,,,13.96,87.75,percent of total billed charges,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,WellCare of North Carolina,Managed Medicaid,,34.63,,,,,,,16.34,129.75,percent of total billed charges,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Managed Medicaid,,19.42,,,,,,,14.83,72.75,percent of total billed charges,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Managed Medicaid,,23.22,,,,,,,17.60,87.00,percent of total billed charges,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,9.87,57.75,percent of total billed charges,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Managed Medicaid,,3.00,,,,,,,3.00,21.69,percent of total billed charges,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,,17.82,,,,,,,16.34,66.75,percent of total billed charges,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Managed Medicaid,,7.01,,,,,,,7.01,26.25,percent of total billed charges,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,WellCare of North Carolina,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,WellCare of North Carolina,Managed Medicaid,,92.29,,,,,,,8.62,345.75,percent of total billed charges,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Managed Medicaid,,24.42,,,,,,,11.42,91.50,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,10.42,54.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,WellCare of North Carolina,Managed Medicaid,,39.04,,,,,,,10.92,146.25,percent of total billed charges,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,WellCare of North Carolina,Managed Medicaid,,16.62,,,,,,,12.02,62.25,percent of total billed charges,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,WellCare of North Carolina,Managed Medicaid,,2.20,,,,,,,2.20,41.26,percent of total billed charges,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,41.26,percent of total billed charges,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Managed Medicaid,,27.03,,,,,,,13.96,101.25,percent of total billed charges,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,WellCare of North Carolina,Managed Medicaid,,21.62,,,,,,,13.98,81.00,percent of total billed charges,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,13.84,57.75,percent of total billed charges,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,WellCare of North Carolina,Managed Medicaid,,158.96,,,,,,,106.21,595.50,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,WellCare of North Carolina,Managed Medicaid,,89.49,,,,,,,62.26,335.25,percent of total billed charges,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,WellCare of North Carolina,Managed Medicaid,,53.25,,,,,,,53.25,199.50,percent of total billed charges,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,WellCare of North Carolina,Managed Medicaid,,114.11,,,,,,,114.11,601.18,percent of total billed charges,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,WellCare of North Carolina,Managed Medicaid,,168.37,,,,,,,168.37,630.75,percent of total billed charges,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,WellCare of North Carolina,Managed Medicaid,,59.26,,,,,,,37.47,222.00,percent of total billed charges,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,WellCare of North Carolina,Managed Medicaid,,72.27,,,,,,,37.47,381.82,percent of total billed charges,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,,17.02,,,,,,,5.23,63.75,percent of total billed charges,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,WellCare of North Carolina,Managed Medicaid,,46.65,,,,,,,5.02,174.75,percent of total billed charges,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Managed Medicaid,,29.03,,,,,,,2.90,108.75,percent of total billed charges,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,2.90,44.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Managed Medicaid,,24.62,,,,,,,6.16,92.25,percent of total billed charges,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Managed Medicaid,,26.83,,,,,,,6.16,100.50,percent of total billed charges,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,WellCare of North Carolina,Managed Medicaid,,39.24,,,,,,,3.72,147.00,percent of total billed charges,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,WellCare of North Carolina,Managed Medicaid,,34.63,,,,,,,22.03,201.52,percent of total billed charges,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,12.21,201.52,percent of total billed charges,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,WellCare of North Carolina,Managed Medicaid,,100.30,,,,,,,37.47,375.75,percent of total billed charges,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,WellCare of North Carolina,Managed Medicaid,,147.55,,,,,,,37.47,552.75,percent of total billed charges,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,WellCare of North Carolina,Managed Medicaid,,25.23,,,,,,,22.03,94.50,percent of total billed charges,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,WellCare of North Carolina,Managed Medicaid,,27.83,,,,,,,13.49,104.25,percent of total billed charges,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,3.69,27.75,percent of total billed charges,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,2.30,36.75,percent of total billed charges,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Managed Medicaid,,30.03,,,,,,,7.54,112.50,percent of total billed charges,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,6.28,88.50,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,3.87,38.25,percent of total billed charges,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Managed Medicaid,,18.62,,,,,,,5.40,69.75,percent of total billed charges,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Managed Medicaid,,32.43,,,,,,,2.46,121.50,percent of total billed charges,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,4.35,57.75,percent of total billed charges,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,WellCare of North Carolina,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,WellCare of North Carolina,Managed Medicaid,,86.69,,,,,,,53.18,858.84,percent of total billed charges,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,WellCare of North Carolina,Managed Medicaid,,64.66,,,,,,,12.59,242.25,percent of total billed charges,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Managed Medicaid,,55.05,,,,,,,17.12,206.25,percent of total billed charges,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,WellCare of North Carolina,Managed Medicaid,,58.26,,,,,,,17.36,218.25,percent of total billed charges,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,WellCare of North Carolina,Managed Medicaid,,52.85,,,,,,,17.36,198.00,percent of total billed charges,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,WellCare of North Carolina,Managed Medicaid,,122.52,,,,,,,11.53,459.00,percent of total billed charges,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,WellCare of North Carolina,Managed Medicaid,,32.23,,,,,,,22.25,120.75,percent of total billed charges,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,WellCare of North Carolina,Managed Medicaid,,47.45,,,,,,,22.25,177.75,percent of total billed charges,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,WellCare of North Carolina,Managed Medicaid,,39.84,,,,,,,29.93,149.25,percent of total billed charges,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Managed Medicaid,,19.82,,,,,,,19.82,74.25,percent of total billed charges,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,WellCare of North Carolina,Managed Medicaid,,65.06,,,,,,,18.47,243.75,percent of total billed charges,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,WellCare of North Carolina,Managed Medicaid,,54.25,,,,,,,17.36,203.25,percent of total billed charges,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,WellCare of North Carolina,Managed Medicaid,,64.66,,,,,,,17.36,242.25,percent of total billed charges,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,WellCare of North Carolina,Managed Medicaid,,50.25,,,,,,,18.77,188.25,percent of total billed charges,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,WellCare of North Carolina,Managed Medicaid,,36.44,,,,,,,8.84,136.50,percent of total billed charges,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,WellCare of North Carolina,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,WellCare of North Carolina,Managed Medicaid,,37.24,,,,,,,18.36,139.50,percent of total billed charges,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,WellCare of North Carolina,Managed Medicaid,,49.45,,,,,,,11.49,185.25,percent of total billed charges,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,13.42,54.00,percent of total billed charges,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,WellCare of North Carolina,Managed Medicaid,,8.81,,,,,,,8.81,33.00,percent of total billed charges,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Managed Medicaid,,30.03,,,,,,,29.93,112.50,percent of total billed charges,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,WellCare of North Carolina,Managed Medicaid,,39.24,,,,,,,14.86,147.00,percent of total billed charges,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,WellCare of North Carolina,Managed Medicaid,,93.69,,,,,,,12.48,351.00,percent of total billed charges,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,WellCare of North Carolina,Managed Medicaid,,56.66,,,,,,,12.48,212.25,percent of total billed charges,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,12.48,55.50,percent of total billed charges,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Managed Medicaid,,7.01,,,,,,,4.15,26.25,percent of total billed charges,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,6.68,42.00,percent of total billed charges,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Managed Medicaid,,14.41,,,,,,,9.87,54.00,percent of total billed charges,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Managed Medicaid,,22.62,,,,,,,9.43,84.75,percent of total billed charges,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,WellCare of North Carolina,Managed Medicaid,,71.27,,,,,,,16.67,267.00,percent of total billed charges,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,9.08,46.50,percent of total billed charges,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,WellCare of North Carolina,Managed Medicaid,,29.23,,,,,,,12.70,109.50,percent of total billed charges,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,12.61,47.25,percent of total billed charges,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,WellCare of North Carolina,Managed Medicaid,,40.44,,,,,,,24.16,151.50,percent of total billed charges,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Managed Medicaid,,28.63,,,,,,,24.16,107.25,percent of total billed charges,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Managed Medicaid,,23.42,,,,,,,17.44,87.75,percent of total billed charges,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,WellCare of North Carolina,Managed Medicaid,,20.42,,,,,,,3.82,76.50,percent of total billed charges,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,9.29,42.00,percent of total billed charges,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Managed Medicaid,,17.02,,,,,,,9.29,63.75,percent of total billed charges,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,WellCare of North Carolina,Managed Medicaid,,19.62,,,,,,,17.44,73.50,percent of total billed charges,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,9.55,42.00,percent of total billed charges,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,WellCare of North Carolina,Managed Medicaid,,44.84,,,,,,,18.08,168.00,percent of total billed charges,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,4.14,60.00,percent of total billed charges,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,5.34,40.50,percent of total billed charges,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Managed Medicaid,,7.81,,,,,,,5.60,29.25,percent of total billed charges,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,WellCare of North Carolina,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,5.83,71.25,percent of total billed charges,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Managed Medicaid,,9.41,,,,,,,6.28,35.25,percent of total billed charges,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Managed Medicaid,,3.00,,,,,,,3.00,13.80,percent of total billed charges,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,WellCare of North Carolina,Managed Medicaid,,8.21,,,,,,,8.21,30.75,percent of total billed charges,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,6.48,45.75,percent of total billed charges,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Managed Medicaid,,37.64,,,,,,,10.01,141.00,percent of total billed charges,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Managed Medicaid,,24.42,,,,,,,10.01,91.50,percent of total billed charges,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Managed Medicaid,,26.03,,,,,,,9.16,97.50,percent of total billed charges,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,9.16,40.50,percent of total billed charges,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Managed Medicaid,,14.21,,,,,,,9.16,53.25,percent of total billed charges,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Managed Medicaid,,31.43,,,,,,,8.36,117.75,percent of total billed charges,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,WellCare of North Carolina,Managed Medicaid,,5.41,,,,,,,5.41,20.25,percent of total billed charges,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,WellCare of North Carolina,Managed Medicaid,,10.61,,,,,,,9.59,39.75,percent of total billed charges,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,WellCare of North Carolina,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,WellCare of North Carolina,Managed Medicaid,,37.44,,,,,,,9.19,140.25,percent of total billed charges,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Managed Medicaid,,19.42,,,,,,,9.19,72.75,percent of total billed charges,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,WellCare of North Carolina,Managed Medicaid,,42.64,,,,,,,7.84,159.75,percent of total billed charges,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Managed Medicaid,,40.84,,,,,,,7.84,153.00,percent of total billed charges,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,7.84,55.50,percent of total billed charges,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,7.84,44.25,percent of total billed charges,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Managed Medicaid,,6.41,,,,,,,6.41,24.00,percent of total billed charges,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Managed Medicaid,,40.84,,,,,,,6.43,153.00,percent of total billed charges,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Managed Medicaid,,6.21,,,,,,,6.21,23.25,percent of total billed charges,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,6.43,75.75,percent of total billed charges,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,,14.01,,,,,,,6.43,52.50,percent of total billed charges,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Managed Medicaid,,29.03,,,,,,,7.83,108.75,percent of total billed charges,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Managed Medicaid,,18.42,,,,,,,7.48,69.00,percent of total billed charges,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.16,102.00,percent of total billed charges,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Managed Medicaid,,7.81,,,,,,,7.81,29.25,percent of total billed charges,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,10.01,75.75,percent of total billed charges,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Managed Medicaid,,5.21,,,,,,,5.21,245.92,percent of total billed charges,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.18,18.00,percent of total billed charges,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,,25.83,,,,,,,4.14,96.75,percent of total billed charges,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,5.70,38.25,percent of total billed charges,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Managed Medicaid,,23.22,,,,,,,8.63,87.00,percent of total billed charges,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Managed Medicaid,,15.82,,,,,,,4.61,59.25,percent of total billed charges,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,7.26,82.50,percent of total billed charges,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,8.39,55.50,percent of total billed charges,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,WellCare of North Carolina,Managed Medicaid,,67.87,,,,,,,8.39,254.25,percent of total billed charges,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,WellCare of North Carolina,Managed Medicaid,,13.61,,,,,,,4.14,51.00,percent of total billed charges,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,4.14,63.00,percent of total billed charges,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,,17.82,,,,,,,4.14,66.75,percent of total billed charges,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,5.23,45.75,percent of total billed charges,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,WellCare of North Carolina,Managed Medicaid,,3.20,,,,,,,3.20,12.00,percent of total billed charges,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,5.23,36.75,percent of total billed charges,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,WellCare of North Carolina,Managed Medicaid,,49.05,,,,,,,5.81,183.75,percent of total billed charges,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,WellCare of North Carolina,Managed Medicaid,,30.83,,,,,,,5.65,115.50,percent of total billed charges,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,5.65,38.25,percent of total billed charges,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Managed Medicaid,,7.41,,,,,,,7.41,27.75,percent of total billed charges,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Managed Medicaid,,19.82,,,,,,,11.62,74.25,percent of total billed charges,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,11.62,60.75,percent of total billed charges,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,WellCare of North Carolina,Managed Medicaid,,15.62,,,,,,,11.62,58.50,percent of total billed charges,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Managed Medicaid,,8.01,,,,,,,8.01,30.00,percent of total billed charges,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Managed Medicaid,,11.41,,,,,,,10.02,42.75,percent of total billed charges,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Managed Medicaid,,12.61,,,,,,,12.61,50.79,percent of total billed charges,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Managed Medicaid,,36.04,,,,,,,11.62,135.00,percent of total billed charges,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,WellCare of North Carolina,Managed Medicaid,,6.61,,,,,,,6.61,25.57,percent of total billed charges,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,WellCare of North Carolina,Managed Medicaid,,45.65,,,,,,,34.04,171.00,percent of total billed charges,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,WellCare of North Carolina,Managed Medicaid,,33.83,,,,,,,33.83,126.75,percent of total billed charges,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,WellCare of North Carolina,Managed Medicaid,,92.29,,,,,,,34.04,345.75,percent of total billed charges,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,WellCare of North Carolina,Managed Medicaid,,42.64,,,,,,,41.55,159.75,percent of total billed charges,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,WellCare of North Carolina,Managed Medicaid,,42.64,,,,,,,34.04,159.75,percent of total billed charges,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Managed Medicaid,,125.93,,,,,,,41.55,471.75,percent of total billed charges,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,WellCare of North Carolina,Managed Medicaid,,116.32,,,,,,,41.55,435.75,percent of total billed charges,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,WellCare of North Carolina,Managed Medicaid,,34.83,,,,,,,34.04,130.50,percent of total billed charges,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,WellCare of North Carolina,Managed Medicaid,,32.23,,,,,,,32.23,120.75,percent of total billed charges,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,WellCare of North Carolina,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Managed Medicaid,,42.44,,,,,,,34.04,159.00,percent of total billed charges,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Managed Medicaid,,32.83,,,,,,,32.83,123.00,percent of total billed charges,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,WellCare of North Carolina,Managed Medicaid,,51.45,,,,,,,51.45,264.62,percent of total billed charges,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,WellCare of North Carolina,Managed Medicaid,,154.15,,,,,,,154.15,852.72,percent of total billed charges,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,WellCare of North Carolina,Managed Medicaid,,17.42,,,,,,,17.42,74.82,percent of total billed charges,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,WellCare of North Carolina,Managed Medicaid,,16.62,,,,,,,16.62,74.82,percent of total billed charges,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,WellCare of North Carolina,Managed Medicaid,,9.61,,,,,,,9.61,74.82,percent of total billed charges,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,16.22,74.82,percent of total billed charges,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,WellCare of North Carolina,Managed Medicaid,,22.42,,,,,,,22.42,84.00,percent of total billed charges,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,WellCare of North Carolina,Managed Medicaid,,115.92,,,,,,,41.55,434.25,percent of total billed charges,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,WellCare of North Carolina,Managed Medicaid,,55.86,,,,,,,55.86,488.14,percent of total billed charges,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,WellCare of North Carolina,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,WellCare of North Carolina,Managed Medicaid,,30.83,,,,,,,16.03,115.50,percent of total billed charges,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,WellCare of North Carolina,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,WellCare of North Carolina,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,WellCare of North Carolina,Managed Medicaid,,19.22,,,,,,,15.59,72.00,percent of total billed charges,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Managed Medicaid,,92.69,,,,,,,92.69,548.82,percent of total billed charges,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,WellCare of North Carolina,Managed Medicaid,,58.86,,,,,,,58.86,548.82,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,WellCare of North Carolina,Managed Medicaid,,17.62,,,,,,,3.07,66.00,percent of total billed charges,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Managed Medicaid,,10.21,,,,,,,3.38,38.25,percent of total billed charges,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,WellCare of North Carolina,Managed Medicaid,,25.23,,,,,,,8.35,94.50,percent of total billed charges,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,WellCare of North Carolina,Managed Medicaid,,2.40,,,,,,,2.40,201.52,percent of total billed charges,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Managed Medicaid,,30.03,,,,,,,5.43,112.50,percent of total billed charges,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,7.11,46.50,percent of total billed charges,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Managed Medicaid,,24.02,,,,,,,5.62,90.00,percent of total billed charges,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,WellCare of North Carolina,Managed Medicaid,,109.71,,,,,,,88.91,411.00,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,WellCare of North Carolina,Managed Medicaid,,61.86,,,,,,,17.51,231.75,percent of total billed charges,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,WellCare of North Carolina,Managed Medicaid,,25.43,,,,,,,23.45,95.25,percent of total billed charges,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Managed Medicaid,,7.21,,,,,,,7.21,27.00,percent of total billed charges,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,WellCare of North Carolina,Managed Medicaid,,4.40,,,,,,,4.40,16.50,percent of total billed charges,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,WellCare of North Carolina,Managed Medicaid,,46.05,,,,,,,12.85,172.50,percent of total billed charges,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,15.42,57.75,percent of total billed charges,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,WellCare of North Carolina,Managed Medicaid,,21.22,,,,,,,17.39,79.50,percent of total billed charges,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Managed Medicaid,,11.61,,,,,,,4.14,43.50,percent of total billed charges,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Managed Medicaid,,7.01,,,,,,,7.01,27.82,percent of total billed charges,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Managed Medicaid,,7.01,,,,,,,7.01,27.47,percent of total billed charges,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,WellCare of North Carolina,Managed Medicaid,,3.80,,,,,,,3.80,14.25,percent of total billed charges,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Managed Medicaid,,12.21,,,,,,,12.21,45.75,percent of total billed charges,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,WellCare of North Carolina,Managed Medicaid,,12.81,,,,,,,7.84,48.00,percent of total billed charges,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Managed Medicaid,,9.21,,,,,,,7.84,34.50,percent of total billed charges,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Managed Medicaid,,11.21,,,,,,,11.21,42.00,percent of total billed charges,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Managed Medicaid,,14.21,,,,,,,8.35,53.25,percent of total billed charges,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Managed Medicaid,,3.00,,,,,,,3.00,28.12,percent of total billed charges,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,6.48,36.75,percent of total billed charges,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Managed Medicaid,,6.01,,,,,,,5.02,22.50,percent of total billed charges,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,WellCare of North Carolina,Managed Medicaid,,50.65,,,,,,,12.99,189.75,percent of total billed charges,
HC ETHANOL FORENSIC UNC,83002115,CDM,301,RC,80320,CPT,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Managed Medicaid,,26.83,,,,,,,26.83,100.50,percent of total billed charges,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,WellCare of North Carolina,Managed Medicaid,,34.23,,,,,,,4.61,128.25,percent of total billed charges,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Managed Medicaid,,5.21,,,,,,,4.61,19.50,percent of total billed charges,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Managed Medicaid,,32.43,,,,,,,12.48,121.50,percent of total billed charges,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Managed Medicaid,,15.82,,,,,,,4.16,59.25,percent of total billed charges,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,21.00,percent of total billed charges,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,10.81,40.50,percent of total billed charges,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,381.82,percent of total billed charges,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,WellCare of North Carolina,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC EFPO OSMOLALITY F,83002170,CDM,301,RC,84999,CPT,,,facility,outpatient,,,2.00000,1.20000,WellCare of North Carolina,Managed Medicaid,,0.40040,,,,,,,0.40040,45.98,percent of total billed charges,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,WellCare of North Carolina,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Managed Medicaid,,16.22,,,,,,,14.17,60.75,percent of total billed charges,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Managed Medicaid,,5.81,,,,,,,5.81,21.75,percent of total billed charges,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,WellCare of North Carolina,Managed Medicaid,,32.23,,,,,,,25.04,120.75,percent of total billed charges,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,WellCare of North Carolina,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,15.44,71.25,percent of total billed charges,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,WellCare of North Carolina,Managed Medicaid,,28.23,,,,,,,5.33,105.75,percent of total billed charges,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,WellCare of North Carolina,Managed Medicaid,,6.81,,,,,,,2.62,25.50,percent of total billed charges,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,8.36,102.00,percent of total billed charges,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Managed Medicaid,,7.61,,,,,,,7.61,28.50,percent of total billed charges,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Managed Medicaid,,14.01,,,,,,,14.01,52.50,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Managed Medicaid,,3.00,,,,,,,3.00,11.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Managed Medicaid,,7.01,,,,,,,3.90,26.25,percent of total billed charges,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,WellCare of North Carolina,Managed Medicaid,,15.02,,,,,,,3.90,56.25,percent of total billed charges,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Managed Medicaid,,9.81,,,,,,,9.81,74.82,percent of total billed charges,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,WellCare of North Carolina,Managed Medicaid,,105.91,,,,,,,105.91,396.75,percent of total billed charges,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,WellCare of North Carolina,Managed Medicaid,,153.55,,,,,,,153.55,575.25,percent of total billed charges,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Managed Medicaid,,26.83,,,,,,,26.83,154.14,percent of total billed charges,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,WellCare of North Carolina,Managed Medicaid,,361.36,,,,,,,361.36,1353.75,percent of total billed charges,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,WellCare of North Carolina,Managed Medicaid,,251.85,,,,,,,251.85,3699.95,percent of total billed charges,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,WellCare of North Carolina,Managed Medicaid,,58.66,,,,,,,58.66,696.24,percent of total billed charges,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Managed Medicaid,,23.22,,,,,,,4.18,4311.00,percent of total billed charges,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,WellCare of North Carolina,Managed Medicaid,,386.59,,,,,,,10.82,1448.25,percent of total billed charges,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,WellCare of North Carolina,Managed Medicaid,,4.60,,,,,,,4.60,17.25,percent of total billed charges,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,WellCare of North Carolina,Managed Medicaid,,51.85,,,,,,,5.34,194.25,percent of total billed charges,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Managed Medicaid,,9.21,,,,,,,9.21,34.68,percent of total billed charges,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,57.08,percent of total billed charges,
HC KIDNEY GENETICS MUTATIION PANEL,83002619,CDM,301,RC,81479,CPT,,,facility,outpatient,,,1808.00000,1084.80000,WellCare of North Carolina,Managed Medicaid,,361.96,,,,,,,218.46,1356.00,percent of total billed charges,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,WellCare of North Carolina,Managed Medicaid,,141.54,,,,,,,141.54,530.25,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,12.41,46.50,percent of total billed charges,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,21.42,80.25,percent of total billed charges,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,WellCare of North Carolina,Managed Medicaid,,102.70,,,,,,,102.70,384.75,percent of total billed charges,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Managed Medicaid,,37.84,,,,,,,34.04,141.75,percent of total billed charges,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,WellCare of North Carolina,Managed Medicaid,,392.39,,,,,,,133.70,1470.00,percent of total billed charges,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,WellCare of North Carolina,Managed Medicaid,,22.82,,,,,,,22.82,324.56,percent of total billed charges,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Managed Medicaid,,64.86,,,,,,,34.04,243.00,percent of total billed charges,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,27.23,102.00,percent of total billed charges,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,WellCare of North Carolina,Managed Medicaid,,38.84,,,,,,,38.84,145.50,percent of total billed charges,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,WellCare of North Carolina,Managed Medicaid,,190.79,,,,,,,117.98,714.75,percent of total billed charges,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,WellCare of North Carolina,Managed Medicaid,,127.93,,,,,,,127.93,479.25,percent of total billed charges,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Managed Medicaid,,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Managed Medicaid,QW,28.03,,,,,,,24.16,105.00,percent of total billed charges,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Managed Medicaid,,9.21,,,,,,,9.21,34.50,percent of total billed charges,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,WellCare of North Carolina,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,WellCare of North Carolina,Managed Medicaid,,318.12,,,,,,,318.12,2152.96,percent of total billed charges,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,WellCare of North Carolina,Managed Medicaid,,237.64,,,,,,,237.64,890.25,percent of total billed charges,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,WellCare of North Carolina,Managed Medicaid,,55.66,,,,,,,55.66,208.50,percent of total billed charges,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,20.19,75.75,percent of total billed charges,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,WellCare of North Carolina,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,WellCare of North Carolina,Managed Medicaid,,95.70,,,,,,,40.51,358.50,percent of total billed charges,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Managed Medicaid,,40.84,,,,,,,40.84,153.00,percent of total billed charges,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,WellCare of North Carolina,Managed Medicaid,,85.29,,,,,,,15.59,319.50,percent of total billed charges,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Managed Medicaid,,10.01,,,,,,,5.06,37.50,percent of total billed charges,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,QW,20.02,,,,,,,20.02,76.37,percent of total billed charges,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Managed Medicaid,,20.02,,,,,,,20.02,75.00,percent of total billed charges,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Managed Medicaid,,32.63,,,,,,,16.75,122.25,percent of total billed charges,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,WellCare of North Carolina,Managed Medicaid,,181.58,,,,,,,181.58,680.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Managed Medicaid,,55.05,,,,,,,55.05,212.24,percent of total billed charges,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Managed Medicaid,,26.43,,,,,,,10.01,99.00,percent of total billed charges,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,,33.03,,,,,,,18.08,123.75,percent of total billed charges,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Managed Medicaid,,17.82,,,,,,,17.82,66.75,percent of total billed charges,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Managed Medicaid,,8.61,,,,,,,8.61,50.10,percent of total billed charges,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,WellCare of North Carolina,Managed Medicaid,,56.06,,,,,,,37.41,210.00,percent of total billed charges,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Managed Medicaid,,15.82,,,,,,,8.39,59.25,percent of total billed charges,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,WellCare of North Carolina,Managed Medicaid,,38.84,,,,,,,38.84,264.62,percent of total billed charges,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,18.22,72.58,percent of total billed charges,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,WellCare of North Carolina,Managed Medicaid,,13.81,,,,,,,13.81,51.75,percent of total billed charges,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Managed Medicaid,,13.21,,,,,,,13.21,49.50,percent of total billed charges,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,WellCare of North Carolina,Managed Medicaid,,70.07,,,,,,,70.07,262.50,percent of total billed charges,
HC 6-MONOACETYLMORPHINE CONFIRMATION RANDOM URINE,83003008,CDM,301,RC,80356,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC BUPRENORPHINE W METABOLITES CONFIRMATION RANDOM URINE,83003009,CDM,301,RC,80348,CPT,,,facility,outpatient,,,213.00000,127.80000,WellCare of North Carolina,Managed Medicaid,,42.64,,,,,,,24.11,159.75,percent of total billed charges,
HC CODEINE AND HYDROCODONE W METABOLITES CONFIRMATION RANDOM URINE,83003010,CDM,301,RC,80361,CPT,,,facility,outpatient,,,219.00000,131.40000,WellCare of North Carolina,Managed Medicaid,,43.84,,,,,,,43.84,164.25,percent of total billed charges,
HC FENTANYL W METABOLITE CONFIRMATION RANDOM URINE,83003011,CDM,301,RC,80354,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC OXYCODONE W METABOLITE CONFIRMATION RANDOM URINE,83003012,CDM,301,RC,80365,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC RAPID RSFLU COVID FLURVID CEPHEID - INACTIVE,83003013,CDM,306,RC,0241U,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Managed Medicaid,,55.05,,,,,,,55.05,206.25,percent of total billed charges,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Managed Medicaid,,9.01,,,,,,,9.01,33.75,percent of total billed charges,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,WellCare of North Carolina,Managed Medicaid,,15.22,,,,,,,15.22,57.00,percent of total billed charges,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,13.01,48.75,percent of total billed charges,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Managed Medicaid,,16.82,,,,,,,16.82,63.00,percent of total billed charges,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Managed Medicaid,,20.22,,,,,,,20.22,75.75,percent of total billed charges,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,WellCare of North Carolina,Managed Medicaid,,29.83,,,,,,,26.57,111.75,percent of total billed charges,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,WellCare of North Carolina,Managed Medicaid,,265.87,,,,,,,124.44,996.00,percent of total billed charges,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,WellCare of North Carolina,Managed Medicaid,,11.01,,,,,,,11.01,41.25,percent of total billed charges,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,WellCare of North Carolina,Managed Medicaid,,21.62,,,,,,,21.62,81.00,percent of total billed charges,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Managed Medicaid,,23.62,,,,,,,23.62,88.50,percent of total billed charges,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,9.42,48.75,percent of total billed charges,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Managed Medicaid,,13.01,,,,,,,11.22,48.75,percent of total billed charges,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Managed Medicaid,,11.41,,,,,,,2.18,42.75,percent of total billed charges,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,WellCare of North Carolina,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,WellCare of North Carolina,Managed Medicaid,,33.43,,,,,,,33.43,125.25,percent of total billed charges,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,WellCare of North Carolina,Managed Medicaid,,54.25,,,,,,,34.04,203.25,percent of total billed charges,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,WellCare of North Carolina,Managed Medicaid,,63.86,,,,,,,63.86,254.34,percent of total billed charges,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Managed Medicaid,,103.10,,,,,,,8.36,356.33,percent of total billed charges,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,WellCare of North Carolina,Managed Medicaid,,105.31,,,,,,,105.31,394.50,percent of total billed charges,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,WellCare of North Carolina,Managed Medicaid,,42.04,,,,,,,42.04,157.50,percent of total billed charges,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,70.99,percent of total billed charges,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,WellCare of North Carolina,Managed Medicaid,,5.41,,,,,,,2.30,20.25,percent of total billed charges,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Managed Medicaid,,22.02,,,,,,,22.02,82.50,percent of total billed charges,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,WellCare of North Carolina,Managed Medicaid,,37.24,,,,,,,24.90,139.50,percent of total billed charges,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,WellCare of North Carolina,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,WellCare of North Carolina,Managed Medicaid,,29.43,,,,,,,29.43,110.25,percent of total billed charges,
HC PATHOLOGIST REVIEW,83100011,CDM,311,RC,88141,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Managed Medicaid,,7.81,,,,,,,7.81,47.45,percent of total billed charges,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,WellCare of North Carolina,Managed Medicaid,,39.64,,,,,,,19.65,148.50,percent of total billed charges,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,WellCare of North Carolina,Managed Medicaid,,23.82,,,,,,,23.56,89.25,percent of total billed charges,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,WellCare of North Carolina,Managed Medicaid,,51.05,,,,,,,36.54,201.52,percent of total billed charges,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,WellCare of North Carolina,Managed Medicaid,,52.25,,,,,,,51.40,195.75,percent of total billed charges,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,WellCare of North Carolina,Managed Medicaid,,15.62,,,,,,,15.62,58.50,percent of total billed charges,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Managed Medicaid,,27.23,,,,,,,25.81,102.00,percent of total billed charges,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,WellCare of North Carolina,Managed Medicaid,,41.84,,,,,,,24.90,381.82,percent of total billed charges,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,WellCare of North Carolina,Managed Medicaid,,41.44,,,,,,,24.90,381.82,percent of total billed charges,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,WellCare of North Carolina,Managed Medicaid,,103.70,,,,,,,103.70,388.50,percent of total billed charges,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,WellCare of North Carolina,Managed Medicaid,,29.63,,,,,,,29.63,248.36,percent of total billed charges,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,WellCare of North Carolina,Managed Medicaid,,91.29,,,,,,,91.29,342.00,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,WellCare of North Carolina,Managed Medicaid,,119.52,,,,,,,119.52,447.75,percent of total billed charges,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,WellCare of North Carolina,Managed Medicaid,,151.15,,,,,,,145.79,566.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,WellCare of North Carolina,Managed Medicaid,,112.31,,,,,,,112.31,420.75,percent of total billed charges,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,WellCare of North Carolina,Managed Medicaid,,65.06,,,,,,,12.68,243.75,percent of total billed charges,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,WellCare of North Carolina,Managed Medicaid,,45.05,,,,,,,45.05,490.72,percent of total billed charges,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,WellCare of North Carolina,Managed Medicaid,,204.00,,,,,,,121.73,764.25,percent of total billed charges,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,WellCare of North Carolina,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,WellCare of North Carolina,Managed Medicaid,,121.92,,,,,,,121.92,456.75,percent of total billed charges,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,WellCare of North Carolina,Managed Medicaid,,44.84,,,,,,,20.78,168.00,percent of total billed charges,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Managed Medicaid,,26.43,,,,,,,26.43,99.00,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Managed Medicaid,,27.03,,,,,,,27.03,101.25,percent of total billed charges,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,WellCare of North Carolina,Managed Medicaid,,109.71,,,,,,,49.65,411.00,percent of total billed charges,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,WellCare of North Carolina,Managed Medicaid,,20.42,,,,,,,20.42,76.50,percent of total billed charges,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,WellCare of North Carolina,Managed Medicaid,,35.03,,,,,,,35.03,146.24,percent of total billed charges,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,WellCare of North Carolina,Managed Medicaid,,73.47,,,,,,,26.10,275.25,percent of total billed charges,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Managed Medicaid,,132.13,,,,,,,15.51,495.00,percent of total billed charges,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Managed Medicaid,,0.00200,,,,,,,0.00200,109.32,percent of total billed charges,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,WellCare of North Carolina,Managed Medicaid,,24.82,,,,,,,20.48,93.00,percent of total billed charges,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,WellCare of North Carolina,Managed Medicaid,,45.25,,,,,,,24.90,169.50,percent of total billed charges,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,WellCare of North Carolina,Managed Medicaid,,74.07,,,,,,,51.40,277.50,percent of total billed charges,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,WellCare of North Carolina,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,WellCare of North Carolina,Managed Medicaid,,63.86,,,,,,,51.40,239.25,percent of total billed charges,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,WellCare of North Carolina,Managed Medicaid,,118.72,,,,,,,80.53,444.75,percent of total billed charges,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,WellCare of North Carolina,Managed Medicaid,,109.71,,,,,,,80.53,858.84,percent of total billed charges,
HC DECALCIFICATION,83100099,CDM,312,RC,88311,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Managed Medicaid,,19.42,,,,,,,12.54,72.75,percent of total billed charges,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC HISTOCHEM STAIN MUSCLE W FS SENDOUT,83100135,CDM,312,RC,88314,CPT,,,facility,outpatient,,,394.00000,236.40000,WellCare of North Carolina,Managed Medicaid,,78.88,,,,,,,24.90,295.50,percent of total billed charges,
HC HISTOCHEM STAIN-MUSCLE W/ FS,83100136,CDM,312,RC,88314,CPT,,,facility,outpatient,,,313.00000,187.80000,WellCare of North Carolina,Managed Medicaid,,62.66,,,,,,,24.90,234.75,percent of total billed charges,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,WellCare of North Carolina,Managed Medicaid,,49.85,,,,,,,49.85,858.84,percent of total billed charges,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Managed Medicaid,,15.42,,,,,,,15.42,70.99,percent of total billed charges,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,WellCare of North Carolina,Managed Medicaid,,76.88,,,,,,,53.18,288.00,percent of total billed charges,
HC FROZEN SECTION EA ADDTL BLOCK,83100164,CDM,312,RC,88332,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Managed Medicaid,,26.43,,,,,,,24.90,99.00,percent of total billed charges,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,WellCare of North Carolina,Managed Medicaid,,135.13,,,,,,,24.90,858.84,percent of total billed charges,
HC TOUCH PREP ADDITIONAL,83100166,CDM,312,RC,88334,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Managed Medicaid,,37.84,,,,,,,23.59,141.75,percent of total billed charges,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,WellCare of North Carolina,Managed Medicaid,,82.88,,,,,,,53.18,381.82,percent of total billed charges,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,WellCare of North Carolina,Managed Medicaid,,51.25,,,,,,,11.69,192.00,percent of total billed charges,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,WellCare of North Carolina,Managed Medicaid,,52.25,,,,,,,52.25,201.52,percent of total billed charges,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Managed Medicaid,,31.43,,,,,,,31.43,201.52,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Managed Medicaid,,107.91,,,,,,,80.53,404.25,percent of total billed charges,
HC UNC P CYTOGEN INTERPRETATION AND REPORT,83100374,CDM,319,RC,88291,CPT,,,facility,outpatient,,,139.00000,83.40000,WellCare of North Carolina,Managed Medicaid,,27.83,,,,,,,27.83,104.25,percent of total billed charges,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Managed Medicaid,,32.83,,,,,,,32.83,189.48,percent of total billed charges,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,WellCare of North Carolina,Managed Medicaid,,3.60,,,,,,,3.60,13.50,percent of total billed charges,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,WellCare of North Carolina,Managed Medicaid,,82.88,,,,,,,53.18,310.50,percent of total billed charges,
HC CELL MARKER EACH ADDITIONAL,83100407,CDM,311,RC,88185,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,18.22,68.25,percent of total billed charges,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,WellCare of North Carolina,Managed Medicaid,,49.45,,,,,,,49.45,269.27,percent of total billed charges,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,WellCare of North Carolina,Managed Medicaid,,438.64,,,,,,,136.51,1643.25,percent of total billed charges,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,WellCare of North Carolina,Managed Medicaid,,70.67,,,,,,,70.67,269.27,percent of total billed charges,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,WellCare of North Carolina,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC 88466 FLOW CYTOMETRY INTERPRETATION 9 TO 15 MAKERS,83100435,CDM,311,RC,88188,CPT,,,facility,outpatient,,,708.00000,424.80000,WellCare of North Carolina,Managed Medicaid,,141.74,,,,,,,53.18,531.00,percent of total billed charges,
HC FLOW MARKER 16 OR MORE,83100436,CDM,311,RC,88189,CPT,,,facility,outpatient,,,518.00000,310.80000,WellCare of North Carolina,Managed Medicaid,,103.70,,,,,,,53.18,388.50,percent of total billed charges,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,WellCare of North Carolina,Managed Medicaid,,70.87,,,,,,,70.87,268.48,percent of total billed charges,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,77.08,381.82,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE EACH ADDITIONAL,83100457,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,WellCare of North Carolina,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IN SITU HYBRIDIZATION EACH SPECIMEN EACH ADDITIONAL,83100655,CDM,312,RC,88364,CPT,,,facility,outpatient,,,519.00000,311.40000,WellCare of North Carolina,Managed Medicaid,,103.90,,,,,,,103.90,389.25,percent of total billed charges,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,WellCare of North Carolina,Managed Medicaid,,257.26,,,,,,,49.65,963.75,percent of total billed charges,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,53.18,288.75,percent of total billed charges,
HC IHC STAIN ADDITIONAL SINGLE ANTIBODY STAIN,83100696,CDM,312,RC,88341,CPT,,,facility,outpatient,,,367.00000,220.20000,WellCare of North Carolina,Managed Medicaid,,73.47,,,,,,,67.67,275.25,percent of total billed charges,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,WellCare of North Carolina,Managed Medicaid,,62.46,,,,,,,24.90,234.00,percent of total billed charges,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Managed Medicaid,,25.83,,,,,,,24.90,135.52,percent of total billed charges,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,WellCare of North Carolina,Managed Medicaid,,248.85,,,,,,,24.90,932.25,percent of total billed charges,
HC PNH CD14,83100718,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD15,83100719,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD24,83100720,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD64,83100721,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD45,83100722,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC PNH CD235A,83100723,CDM,311,RC,88185,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Managed Medicaid,,4.80,,,,,,,4.80,41.10,percent of total billed charges,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,WellCare of North Carolina,Managed Medicaid,,38.44,,,,,,,38.44,144.00,percent of total billed charges,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,WellCare of North Carolina,Managed Medicaid,,181.78,,,,,,,164.86,681.00,percent of total billed charges,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Managed Medicaid,,132.13,,,,,,,132.13,646.00,percent of total billed charges,
HC CMA QPCR FOLLOW UP,83100746,CDM,310,RC,81479,CPT,,,facility,outpatient,,,474.00000,284.40000,WellCare of North Carolina,Managed Medicaid,,94.89,,,,,,,94.89,355.50,percent of total billed charges,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,WellCare of North Carolina,Managed Medicaid,,71.27,,,,,,,70.99,267.00,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,WellCare of North Carolina,Managed Medicaid,,25.02,,,,,,,20.78,93.75,percent of total billed charges,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Managed Medicaid,,30.03,,,,,,,20.78,112.50,percent of total billed charges,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Managed Medicaid,,19.02,,,,,,,19.02,71.25,percent of total billed charges,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,WellCare of North Carolina,Managed Medicaid,,33.23,,,,,,,33.23,124.50,percent of total billed charges,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Managed Medicaid,,16.02,,,,,,,16.02,60.00,percent of total billed charges,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,WellCare of North Carolina,Managed Medicaid,,31.83,,,,,,,31.83,119.25,percent of total billed charges,
HC MPN HOTSPOT PANEL MPL JAK2 CALR,83100796,CDM,310,RC,81479,CPT,,,facility,outpatient,,,1589.00000,953.40000,WellCare of North Carolina,Managed Medicaid,,318.12,,,,,,,218.46,1191.75,percent of total billed charges,
HC TP53 NOTCH1 SF3B1 DNA ANALYSIS,83100797,CDM,310,RC,81479,CPT,,,facility,outpatient,,,798.00000,478.80000,WellCare of North Carolina,Managed Medicaid,,159.76,,,,,,,159.76,598.50,percent of total billed charges,
HC APOL1 GENE TESTING,83100808,CDM,310,RC,81479,CPT,,,facility,outpatient,,,326.00000,195.60000,WellCare of North Carolina,Managed Medicaid,,65.27,,,,,,,65.27,244.50,percent of total billed charges,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Managed Medicaid,,13.21,,,,,,,13.21,201.52,percent of total billed charges,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Managed Medicaid,,8.41,,,,,,,8.41,201.52,percent of total billed charges,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,5.61,381.82,percent of total billed charges,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,WellCare of North Carolina,Managed Medicaid,,21.02,,,,,,,21.02,78.75,percent of total billed charges,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,WellCare of North Carolina,Managed Medicaid,,49.65,,,,,,,37.47,201.52,percent of total billed charges,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Managed Medicaid,,60.06,,,,,,,52.23,2907.00,percent of total billed charges,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,WellCare of North Carolina,Managed Medicaid,,55.46,,,,,,,48.23,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,WellCare of North Carolina,Managed Medicaid,,113.31,,,,,,,98.54,2907.00,percent of total billed charges,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Managed Medicaid,,11.41,,,,,,,9.92,2907.00,percent of total billed charges,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,WellCare of North Carolina,Managed Medicaid,,135.94,,,,,,,118.21,2907.00,percent of total billed charges,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,WellCare of North Carolina,Managed Medicaid,,130.33,,,,,,,113.34,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,WellCare of North Carolina,Managed Medicaid,,214.21,,,,,,,186.29,2907.00,percent of total billed charges,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,WellCare of North Carolina,Managed Medicaid,,43.04,,,,,,,37.43,2907.00,percent of total billed charges,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,WellCare of North Carolina,Managed Medicaid,,83.88,,,,,,,72.95,2907.00,percent of total billed charges,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,WellCare of North Carolina,Managed Medicaid,,58.86,,,,,,,51.19,2907.00,percent of total billed charges,
HC GRANULOCYTES PHERESIS EACH UNIT,83900056,CDM,390,RC,P9050,CPT,,,facility,outpatient,,,949.00000,569.40000,WellCare of North Carolina,Managed Medicaid,,189.99,,,,,,,165.22,2907.00,percent of total billed charges,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,WellCare of North Carolina,Managed Medicaid,,248.25,,,,,,,215.88,2907.00,percent of total billed charges,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,WellCare of North Carolina,Managed Medicaid,,120.12,,,,,,,104.46,2907.00,percent of total billed charges,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Managed Medicaid,,18.22,,,,,,,15.84,2907.00,percent of total billed charges,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,WellCare of North Carolina,Managed Medicaid,,305.91,,,,,,,266.02,2907.00,percent of total billed charges,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Managed Medicaid,,5.61,,,,,,,2.90,21.00,percent of total billed charges,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Managed Medicaid,,33.03,,,,,,,9.48,123.75,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Managed Medicaid,,11.81,,,,,,,5.55,44.25,percent of total billed charges,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Managed Medicaid,,208.41,,,,,,,181.24,2907.00,percent of total billed charges,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Managed Medicaid,,232.23,,,,,,,201.96,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Managed Medicaid,,12.41,,,,,,,10.79,2907.00,percent of total billed charges,
HC THROMBOENDARTERECTOMY COMMON FEMORAL,93600014,CDM,481,RC,35371,CPT,,,facility,outpatient,,,2616.00000,1569.60000,WellCare of North Carolina,Managed Medicaid,,523.72,,,,,,,523.72,9423.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Managed Medicaid,,1715.71,,,,,,,1715.71,13852.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,WellCare of North Carolina,Managed Medicaid,,7102.50,,,,,,,150.52,21640.97,percent of total billed charges,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,WellCare of North Carolina,Managed Medicaid,,1203.60,,,,,,,150.52,9423.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Managed Medicaid,,495.29,,,,,,,495.29,13852.00,percent of total billed charges,
HC INSERT IA BALLOON DEVICE,93610005,CDM,481,RC,33967,CPT,,,facility,outpatient,,,6715.00000,4029.00000,WellCare of North Carolina,Managed Medicaid,,1344.34,,,,,,,1344.34,52940.00,percent of total billed charges,
HC REMOVE IABP,93610006,CDM,481,RC,33968,CPT,,,facility,outpatient,,,2043.00000,1225.80000,WellCare of North Carolina,Managed Medicaid,,409.01,,,,,,,409.01,52940.00,percent of total billed charges,
HC INSERTION OF IMPELLA LT HEART W S AND I,93610007,CDM,481,RC,33990,CPT,,,facility,outpatient,,,3368.00000,2020.80000,WellCare of North Carolina,Managed Medicaid,,674.27,,,,,,,674.27,9423.00,percent of total billed charges,
HC IMPELLA REMOVAL LT HEART ARTERIAL OR ARTERIAL AND VENOUS CANNULA SEPARATE FROM INSERTION,93610008,CDM,481,RC,33992,CPT,,,facility,outpatient,,,909.00000,545.40000,WellCare of North Carolina,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC IMPELLA REPOSITIONING RT OR LT HEART INCLD IMG GUIDANCE SEPARATE FROM INSERTION,93610009,CDM,481,RC,33993,CPT,,,facility,outpatient,,,909.00000,545.40000,WellCare of North Carolina,Managed Medicaid,,181.98,,,,,,,181.98,9423.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,361,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,WellCare of North Carolina,Managed Medicaid,,396.60,,,,,,,173.00,4311.00,percent of total billed charges,
HC INJ EXTREMITY VENOGRAPHY,93610010,CDM,481,RC,36005,CPT,,,facility,outpatient,,,1981.00000,1188.60000,WellCare of North Carolina,Managed Medicaid,,396.60,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,361,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,WellCare of North Carolina,Managed Medicaid,,834.03,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATHETER INTO IVC OR SVC VEIN ATYPICAL,93610011,CDM,481,RC,36010,CPT,,,facility,outpatient,,,4166.00000,2499.60000,WellCare of North Carolina,Managed Medicaid,,834.03,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,361,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,WellCare of North Carolina,Managed Medicaid,,379.58,,,,,,,173.00,4311.00,percent of total billed charges,
HC CATH 2ND OR MORE ORDER VENOUS,93610012,CDM,481,RC,36012,CPT,,,facility,outpatient,,,1896.00000,1137.60000,WellCare of North Carolina,Managed Medicaid,,379.58,,,,,,,173.00,9423.00,percent of total billed charges,
HC CATH RT HRT OR MAIN PULM ART,93610013,CDM,361,RC,36013,CPT,,,facility,outpatient,,,447.00000,268.20000,WellCare of North Carolina,Managed Medicaid,,89.49,,,,,,,89.49,4311.00,percent of total billed charges,
HC INTROD CATH CAROTID OR VERTBRL,93610014,CDM,481,RC,36100,CPT,,,facility,outpatient,,,823.00000,493.80000,WellCare of North Carolina,Managed Medicaid,,164.76,,,,,,,164.76,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,361,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,WellCare of North Carolina,Managed Medicaid,,359.16,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT EACH 1ST ORDER,93610015,CDM,481,RC,36215,CPT,,,facility,outpatient,,,1794.00000,1076.40000,WellCare of North Carolina,Managed Medicaid,,359.16,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,361,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,WellCare of North Carolina,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 2ND ORDER,93610016,CDM,481,RC,36216,CPT,,,facility,outpatient,,,1416.00000,849.60000,WellCare of North Carolina,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,361,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,WellCare of North Carolina,Managed Medicaid,,317.52,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT INITIAL 3RD ORDER,93610017,CDM,481,RC,36217,CPT,,,facility,outpatient,,,1586.00000,951.60000,WellCare of North Carolina,Managed Medicaid,,317.52,,,,,,,173.00,9423.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,361,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,WellCare of North Carolina,Managed Medicaid,,283.48,,,,,,,173.00,4376.00,percent of total billed charges,
HC SELECTIVE CATH PLACEMENT ADDITIONAL 2ND 3RD OR MORE ORDER,93610018,CDM,481,RC,36218,CPT,,,facility,outpatient,,,1416.00000,849.60000,WellCare of North Carolina,Managed Medicaid,,283.48,,,,,,,173.00,9423.00,percent of total billed charges,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,WellCare of North Carolina,Managed Medicaid,,1544.94,,,,,,,1544.94,9423.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,WellCare of North Carolina,Managed Medicaid,,772.37,,,,,,,772.37,8045.00,percent of total billed charges,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,WellCare of North Carolina,Managed Medicaid,,772.37,,,,,,,772.37,9423.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,WellCare of North Carolina,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,WellCare of North Carolina,Managed Medicaid,,1434.63,,,,,,,1434.63,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,WellCare of North Carolina,Managed Medicaid,,275.88,,,,,,,275.88,8045.00,percent of total billed charges,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,WellCare of North Carolina,Managed Medicaid,,275.88,,,,,,,275.88,9423.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Managed Medicaid,,1103.50,,,,,,,1103.50,13852.00,percent of total billed charges,
HC INTRACRAN ART   UNILATERAL,93610025,CDM,481,RC,36228,CPT,,,facility,outpatient,,,2659.00000,1595.40000,WellCare of North Carolina,Managed Medicaid,,532.33,,,,,,,173.00,9423.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Managed Medicaid,,1715.71,,,,,,,1715.71,8045.00,percent of total billed charges,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Managed Medicaid,,1715.71,,,,,,,1715.71,9423.00,percent of total billed charges,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,WellCare of North Carolina,Managed Medicaid,,158.96,,,,,,,158.96,4311.00,percent of total billed charges,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,WellCare of North Carolina,Managed Medicaid,,5817.21,,,,,,,5817.21,24600.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,WellCare of North Carolina,Managed Medicaid,,879.68,,,,,,,879.68,8213.00,percent of total billed charges,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,WellCare of North Carolina,Managed Medicaid,,879.68,,,,,,,879.68,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,17457.00,percent of total billed charges,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Managed Medicaid,,87.89,,,,,,,87.89,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,361,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,WellCare of North Carolina,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID W DISTAL PROTECTION,93610033,CDM,481,RC,37215,CPT,,,facility,outpatient,,,2257.00000,1354.20000,WellCare of North Carolina,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,361,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,WellCare of North Carolina,Managed Medicaid,,451.85,,,,,,,451.85,6735.00,percent of total billed charges,
HC STENT PLACEMENT CAROTID WO DISTAL PROTECTION,93610034,CDM,481,RC,37216,CPT,,,facility,outpatient,,,2257.00000,1354.20000,WellCare of North Carolina,Managed Medicaid,,451.85,,,,,,,451.85,9423.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,WellCare of North Carolina,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,WellCare of North Carolina,Managed Medicaid,,3349.15,,,,,,,3349.15,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,WellCare of North Carolina,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,WellCare of North Carolina,Managed Medicaid,,5581.98,,,,,,,5581.98,24600.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,361,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,WellCare of North Carolina,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ARTERY EACH ADDITIONAL ILIAC VESSEL,93610037,CDM,481,RC,37222,CPT,,,facility,outpatient,,,10037.00000,6022.20000,WellCare of North Carolina,Managed Medicaid,,2009.41,,,,,,,2009.41,13852.00,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,361,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,WellCare of North Carolina,Managed Medicaid,,4633.03,,,,,,,4311.00,16011.95,percent of total billed charges,
HC REVASC PTA ILIAC ART W STENT INITIAL SAME VESSEL,93610038,CDM,481,RC,37223,CPT,,,facility,outpatient,,,23142.00000,13885.20000,WellCare of North Carolina,Managed Medicaid,,4633.03,,,,,,,4311.00,14116.62,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,WellCare of North Carolina,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,WellCare of North Carolina,Managed Medicaid,,1863.26,,,,,,,1863.26,13852.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,WellCare of North Carolina,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,WellCare of North Carolina,Managed Medicaid,,4700.50,,,,,,,4700.50,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,WellCare of North Carolina,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,WellCare of North Carolina,Managed Medicaid,,4234.63,,,,,,,4234.63,24600.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,WellCare of North Carolina,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,WellCare of North Carolina,Managed Medicaid,,5632.23,,,,,,,5632.23,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,WellCare of North Carolina,Managed Medicaid,,2468.07,,,,,,,2468.07,13852.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,WellCare of North Carolina,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,WellCare of North Carolina,Managed Medicaid,,4664.66,,,,,,,4664.66,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,WellCare of North Carolina,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,WellCare of North Carolina,Managed Medicaid,,4245.04,,,,,,,4245.04,24600.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,WellCare of North Carolina,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,WellCare of North Carolina,Managed Medicaid,,4812.81,,,,,,,4812.81,52940.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,361,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,WellCare of North Carolina,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL EACH ADDITIONAL VESSEL UNIL,93610047,CDM,481,RC,37232,CPT,,,facility,outpatient,,,9493.00000,5695.80000,WellCare of North Carolina,Managed Medicaid,,1900.50,,,,,,,1900.50,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,361,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,WellCare of North Carolina,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610048,CDM,481,RC,37233,CPT,,,facility,outpatient,,,20464.00000,12278.40000,WellCare of North Carolina,Managed Medicaid,,4096.89,,,,,,,4096.89,24600.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,361,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,WellCare of North Carolina,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT EACH ADDITIONAL VESSEL UNIL,93610049,CDM,481,RC,37234,CPT,,,facility,outpatient,,,17629.00000,10577.40000,WellCare of North Carolina,Managed Medicaid,,3529.33,,,,,,,3529.33,13852.00,percent of total billed charges,
HC REVASC PTA TIBIAL PERONEAL W STENT AND ATHERECTOMY EACH ADDITIONAL VESSEL UNIL,93610050,CDM,361,RC,37235,CPT,,,facility,outpatient,,,20588.00000,12352.80000,WellCare of North Carolina,Managed Medicaid,,4121.72,,,,,,,4121.72,14244.84,percent of total billed charges,
HC PTCA SINGLE VSL LEFT MAIN,93610053,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,WellCare of North Carolina,Managed Medicaid,LM,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA SINGLE VSL RAMUS,93610054,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,WellCare of North Carolina,Managed Medicaid,RI,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA RCA,93610055,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,WellCare of North Carolina,Managed Medicaid,RC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LAD DIAG,93610056,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,WellCare of North Carolina,Managed Medicaid,LD,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA LCF OM,93610057,CDM,481,RC,92920,CPT,,,facility,outpatient,,,16199.00000,9719.40000,WellCare of North Carolina,Managed Medicaid,LC,3243.04,,,,,,,3243.04,27871.00,percent of total billed charges,
HC PTCA EA ADDL CIRCUMFLEX,93610058,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,WellCare of North Carolina,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RAMUS,93610059,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,WellCare of North Carolina,Managed Medicaid,RI,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EA ADDL RCA,93610060,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,WellCare of North Carolina,Managed Medicaid,RC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LAD DIAG,93610061,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,WellCare of North Carolina,Managed Medicaid,LD,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA EACH ADDITIONAL LCF OM,93610062,CDM,481,RC,92921,CPT,,,facility,outpatient,,,8357.00000,5014.20000,WellCare of North Carolina,Managed Medicaid,LC,1673.07,,,,,,,1673.07,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LEFT MAIN,93610063,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RAMUS,93610064,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY RCA,93610065,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LAD DIAG,93610066,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY LCF OM,93610067,CDM,481,RC,92924,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD LEFT MN,93610068,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,LM,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RAMUS,93610069,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,RI,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EA ADD RCA,93610070,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,RC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LAD DIAG,93610071,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,LD,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC PTCA ATHERECTOMY EACH ADDITIONAL LCF OM,93610072,CDM,481,RC,92925,CPT,,,facility,outpatient,,,14358.00000,8614.80000,WellCare of North Carolina,Managed Medicaid,LC,2874.47,,,,,,,2874.47,27871.00,percent of total billed charges,
HC BM STENT LEFT MAIN W OR WO PTCA,93610073,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RAMUS W OR WO PTCA,93610074,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT RCA W OR WO PTCA,93610075,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LAD DIAG W OR WO PTCA,93610076,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT LCF OM W OR WO PTCA,93610077,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LEFT MAIN W OR WO PTCA,93610078,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,LM,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT RAMUS W OR WO PTCA,93610079,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,RI,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL RCA W OR WO PTCA,93610080,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,RC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT SNGL LAD W OR WO PTCA,93610081,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,LD,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC DES STENT LCF W OR WO PTCA,93610082,CDM,481,RC,92928,CPT,,,facility,outpatient,,,21430.00000,12858.00000,WellCare of North Carolina,Managed Medicaid,LC,4290.29,,,,,,,4290.29,27871.00,percent of total billed charges,
HC BM STENT ADD LEFT MAIN W OR WO PTCA,93610083,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,LM,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADD RAMUS W OR WO PTCA,93610084,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,RI,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDL RCA W OR WO PTCA,93610085,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LAD DIAG W OR WO PTCA,93610086,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ADDITIONAL LCF OM W OR WO PTCA,93610087,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD RCA W OR WO PTCA,93610090,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,RC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LAD W OR WO PTCA,93610091,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,LD,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT EA ADD LCF W OR WO PTCA,93610092,CDM,481,RC,92929,CPT,,,facility,outpatient,,,22715.00000,13629.00000,WellCare of North Carolina,Managed Medicaid,LC,4547.54,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA LEFT MAIN,93610093,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RAMUS,93610094,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA RCA,93610095,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH  W OR WO PTCA LAD,93610096,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO  PTCA LCF,93610097,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LM,93610098,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LM,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RAMUS,93610099,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,RI,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT RCA,93610100,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,RC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT LD,93610101,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LD,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT  LC,93610102,CDM,481,RC,92933,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LC,8108.50,,,,,,,8108.50,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD LEFT MN,93610103,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LM,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENTATH W OR WO PTCA ADD RI,93610104,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,RI,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATH W OR WO PTCA ADD RCA,93610105,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LAD DIAG,93610106,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT ATHERECTOMY W OR WO PTCA ADDITIONAL LCF OM,93610107,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL RCA,93610110,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,RC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LD,93610111,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LD,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC ATHERECTOMY W STENT ADDITIONAL LC,93610112,CDM,481,RC,92934,CPT,,,facility,outpatient,,,40502.00000,24301.20000,WellCare of North Carolina,Managed Medicaid,LC,8108.50,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,WellCare of North Carolina,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,WellCare of North Carolina,Managed Medicaid,,4633.23,,,,,,,4633.23,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATH ADD BYPASS GRAFT,93610115,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,WellCare of North Carolina,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT ADD BYPASS GRAFT,93610116,CDM,481,RC,92938,CPT,,,facility,outpatient,,,23787.00000,14272.20000,WellCare of North Carolina,Managed Medicaid,,4762.16,,,,,,,4311.00,27871.00,percent of total billed charges,
HC BM STENT AMI LEFT MAIN,93610117,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RAMUS GRAFT,93610118,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI RCA GRAFT,93610119,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LAD GRAFT,93610120,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT AMI LCF GRAFT,93610121,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LEFT MAIN,93610122,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,LM,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RAMUS,93610123,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,RI,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI RCA,93610124,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,RC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LAD,93610125,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,LD,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC DES STENT AMI LCF,93610126,CDM,481,RC,92941,CPT,,,facility,outpatient,,,24858.00000,14914.80000,WellCare of North Carolina,Managed Medicaid,LC,4976.57,,,,,,,4976.57,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LEFT MAIN GRAFT,93610127,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RAMUS GRAFT,93610128,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO RCA GRAFT,93610129,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LAD DIAG GRAFT,93610130,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC BM STENT OR PTCA OR ATHERECTOMY CTO LCF OM GRAFT,93610131,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION LM,93610132,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LM,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION RAMUS,93610133,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,RI,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   RCA,93610134,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,RC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LD,93610135,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LD,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION   LC,93610136,CDM,481,RC,92943,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LC,5191.19,,,,,,,5191.19,27871.00,percent of total billed charges,
HC DES STENT CTO ADD LEFT MAIN GRAFT,93610142,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LM,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC DES STENT CTO ADD RAMUS GRAFT,93610143,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,RI,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL RCA,93610144,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,RC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LD,93610145,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LD,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC CTO ANY INTERVENTION ADDITIONAL LC,93610146,CDM,481,RC,92944,CPT,,,facility,outpatient,,,25930.00000,15558.00000,WellCare of North Carolina,Managed Medicaid,LC,5191.19,,,,,,,4311.00,27871.00,percent of total billed charges,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,WellCare of North Carolina,Managed Medicaid,,78.68,,,,,,,78.68,9423.00,percent of total billed charges,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,WellCare of North Carolina,Managed Medicaid,,333.13,,,,,,,222.64,3641.00,percent of total billed charges,
HC INSERT INTER CARDIO ASSIST DEVIC,93610149,CDM,481,RC,92970,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Managed Medicaid,,373.37,,,,,,,373.37,9423.00,percent of total billed charges,
HC PERC TRANSL CORONARY THROMBECTOMY MECHANICAL,93610150,CDM,481,RC,92973,CPT,,,facility,outpatient,,,422.00000,253.20000,WellCare of North Carolina,Managed Medicaid,,84.48,,,,,,,84.48,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY INTRACOR INFUS,93610151,CDM,481,RC,92975,CPT,,,facility,outpatient,,,2527.00000,1516.20000,WellCare of North Carolina,Managed Medicaid,,505.91,,,,,,,505.91,9423.00,percent of total billed charges,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,WellCare of North Carolina,Managed Medicaid,,197.40,,,,,,,173.00,9423.00,percent of total billed charges,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,WellCare of North Carolina,Managed Medicaid,,2316.71,,,,,,,2316.71,27871.00,percent of total billed charges,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,WellCare of North Carolina,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,WellCare of North Carolina,Managed Medicaid,,2143.34,,,,,,,2143.34,27871.00,percent of total billed charges,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,WellCare of North Carolina,Managed Medicaid,,2044.04,,,,,,,2044.04,27871.00,percent of total billed charges,
HC PTA PULM ARTERY EA ADDL VSL,93610160,CDM,481,RC,92998,CPT,,,facility,outpatient,,,4250.00000,2550.00000,WellCare of North Carolina,Managed Medicaid,,850.85,,,,,,,850.85,27871.00,percent of total billed charges,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,WellCare of North Carolina,Managed Medicaid,,1474.87,,,,,,,1474.87,10022.00,percent of total billed charges,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,WellCare of North Carolina,Managed Medicaid,,2180.78,,,,,,,2180.78,12247.00,percent of total billed charges,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,WellCare of North Carolina,Managed Medicaid,,1936.53,,,,,,,1936.53,12247.00,percent of total billed charges,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,WellCare of North Carolina,Managed Medicaid,,2067.27,,,,,,,2067.27,12247.00,percent of total billed charges,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,WellCare of North Carolina,Managed Medicaid,,909.51,,,,,,,909.51,12247.00,percent of total billed charges,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,WellCare of North Carolina,Managed Medicaid,,2126.92,,,,,,,2126.92,12247.00,percent of total billed charges,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,WellCare of North Carolina,Managed Medicaid,,2652.85,,,,,,,2652.85,12247.00,percent of total billed charges,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,WellCare of North Carolina,Managed Medicaid,,2389.79,,,,,,,2389.79,12247.00,percent of total billed charges,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,WellCare of North Carolina,Managed Medicaid,,2549.35,,,,,,,2549.35,12247.00,percent of total billed charges,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,WellCare of North Carolina,Managed Medicaid,,2592.59,,,,,,,2592.59,12247.00,percent of total billed charges,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,WellCare of North Carolina,Managed Medicaid,,3178.58,,,,,,,3094.46,12247.00,percent of total billed charges,
HC LHC BY TRANSSEPTL PUNCTURE,93610172,CDM,481,RC,93462,CPT,,,facility,outpatient,,,6778.00000,4066.80000,WellCare of North Carolina,Managed Medicaid,,1356.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC PHARMACOLOGIC AGENT ADMIN,93610173,CDM,481,RC,93463,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Managed Medicaid,,40.64,,,,,,,40.64,9423.00,percent of total billed charges,
HC EXERCISE CHALLENGE TEST,93610174,CDM,481,RC,93464,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Managed Medicaid,,19.42,,,,,,,19.42,9423.00,percent of total billed charges,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,WellCare of North Carolina,Managed Medicaid,,300.90,,,,,,,300.90,9423.00,percent of total billed charges,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,WellCare of North Carolina,Managed Medicaid,,826.43,,,,,,,826.43,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SELECT COR ANGIOGRAPHY  INCL S AND I,93610182,CDM,481,RC,93563,CPT,,,facility,outpatient,,,8064.00000,4838.40000,WellCare of North Carolina,Managed Medicaid,,1614.41,,,,,,,173.00,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION IMAGING OR NATIVE GRAFTS INCL S AND I,93610183,CDM,481,RC,93564,CPT,,,facility,outpatient,,,484.00000,290.40000,WellCare of North Carolina,Managed Medicaid,,96.90,,,,,,,96.90,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION LT VENTRICULAR OR LT ATRIAL ANGIOGRAPHY INCL S AND I,93610184,CDM,481,RC,93565,CPT,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION RT VENTRICULAR OR RT ATRIAL ANGIOGRAPHY INCL S AND I,93610185,CDM,481,RC,93566,CPT,,,facility,outpatient,,,626.00000,375.60000,WellCare of North Carolina,Managed Medicaid,,125.33,,,,,,,125.33,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION SUPRAVALVULAR AORTOGRAPHY INCL S AND I,93610186,CDM,481,RC,93567,CPT,,,facility,outpatient,,,215.00000,129.00000,WellCare of North Carolina,Managed Medicaid,,43.04,,,,,,,43.04,9423.00,percent of total billed charges,
HC CONGENTIAL INJECTION NONSELECTIVE PULMONARY ATRERIAL ANGIOGRAPHY INCL S AND I,93610187,CDM,481,RC,93568,CPT,,,facility,outpatient,,,7671.00000,4602.60000,WellCare of North Carolina,Managed Medicaid,,1535.73,,,,,,,173.00,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,WellCare of North Carolina,Managed Medicaid,,7834.43,,,,,,,7834.43,39682.00,percent of total billed charges,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,WellCare of North Carolina,Managed Medicaid,,2458.86,,,,,,,1411.00,12247.00,percent of total billed charges,
HC EP EVALUATION HEART ACID GEN,93610192,CDM,480,RC,93641,CPT,,,facility,outpatient,,,2525.00000,1515.00000,WellCare of North Carolina,Managed Medicaid,,505.50,,,,,,,337.85,12247.00,percent of total billed charges,
HC INTRACARDIAC ECHO,93610194,CDM,480,RC,93662,CPT,,,facility,outpatient,,,2824.00000,1694.40000,WellCare of North Carolina,Managed Medicaid,,565.36,,,,,,,377.85,3641.00,percent of total billed charges,
HC PERC TRANSCATH SEPT REDUCTION THERAPY INCLUDE TEMP PACER,93610195,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1266.00000,759.60000,WellCare of North Carolina,Managed Medicaid,,253.45,,,,,,,253.45,9503.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,361,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,WellCare of North Carolina,Managed Medicaid,,105.71,,,,,,,105.71,4681.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I FIRST VESSEL,93610196,CDM,481,RC,0075T,CPT,,,facility,outpatient,,,528.00000,316.80000,WellCare of North Carolina,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC STENT ECV IT CAROTID W S AND I EACH ADDITIONAL VESSEL,93610197,CDM,481,RC,0076T,CPT,,,facility,outpatient,,,528.00000,316.80000,WellCare of North Carolina,Managed Medicaid,,105.71,,,,,,,105.71,9423.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,WellCare of North Carolina,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,WellCare of North Carolina,Managed Medicaid,,1577.98,,,,,,,1577.98,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,WellCare of North Carolina,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,WellCare of North Carolina,Managed Medicaid,,2998.80,,,,,,,2998.80,24600.00,percent of total billed charges,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,WellCare of North Carolina,Managed Medicaid,,3657.05,,,,,,,3657.05,39682.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,WellCare of North Carolina,Managed Medicaid,,2656.25,,,,,,,2656.25,24600.00,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,WellCare of North Carolina,Managed Medicaid,,3018.42,,,,,,,3018.42,24600.00,percent of total billed charges,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,WellCare of North Carolina,Managed Medicaid,,3642.44,,,,,,,3642.44,39682.00,percent of total billed charges,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,WellCare of North Carolina,Managed Medicaid,,639.24,,,,,,,639.24,8045.00,percent of total billed charges,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,WellCare of North Carolina,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,WellCare of North Carolina,Managed Medicaid,,2820.62,,,,,,,2820.62,13852.00,percent of total billed charges,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,WellCare of North Carolina,Managed Medicaid,,2045.04,,,,,,,2045.04,8442.00,percent of total billed charges,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,WellCare of North Carolina,Managed Medicaid,,589.39,,,,,,,589.39,8442.00,percent of total billed charges,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,WellCare of North Carolina,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,WellCare of North Carolina,Managed Medicaid,,580.98,,,,,,,580.98,5152.00,percent of total billed charges,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,WellCare of North Carolina,Managed Medicaid,,4082.48,,,,,,,4082.48,39682.00,percent of total billed charges,
HC LV LEAD INSERT NEW DEVICE OR UPGRADE,93610215,CDM,361,RC,33225,CPT,,,facility,outpatient,,,14925.00000,8955.00000,WellCare of North Carolina,Managed Medicaid,,2987.99,,,,,,,2987.99,39682.00,percent of total billed charges,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,WellCare of North Carolina,Managed Medicaid,,473.87,,,,,,,473.87,8045.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,WellCare of North Carolina,Managed Medicaid,,4761.96,,,,,,,4761.96,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,WellCare of North Carolina,Managed Medicaid,,4909.10,,,,,,,4909.10,24600.00,percent of total billed charges,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,WellCare of North Carolina,Managed Medicaid,,5350.95,,,,,,,5350.95,24600.00,percent of total billed charges,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,WellCare of North Carolina,Managed Medicaid,,1703.30,,,,,,,1703.30,8700.96,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,WellCare of North Carolina,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,WellCare of North Carolina,Managed Medicaid,,2282.48,,,,,,,2282.48,8442.00,percent of total billed charges,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,WellCare of North Carolina,Managed Medicaid,,9987.38,,,,,,,9987.38,82346.00,percent of total billed charges,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,WellCare of North Carolina,Managed Medicaid,,1151.15,,,,,,,1151.15,8442.00,percent of total billed charges,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,WellCare of North Carolina,Managed Medicaid,,764.96,,,,,,,764.96,8442.00,percent of total billed charges,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,WellCare of North Carolina,Managed Medicaid,,11551.14,,,,,,,11551.14,82346.00,percent of total billed charges,
HC EXTERNAL MAZE PROCEDURE,93610230,CDM,361,RC,33266,CPT,,,facility,outpatient,,,2639.00000,1583.40000,WellCare of North Carolina,Managed Medicaid,,528.33,,,,,,,528.33,4681.00,percent of total billed charges,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,WellCare of North Carolina,Managed Medicaid,,2335.73,,,,,,,2199.23,9485.27,percent of total billed charges,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,WellCare of North Carolina,Managed Medicaid,,417.62,,,,,,,417.62,5152.00,percent of total billed charges,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,WellCare of North Carolina,Managed Medicaid,,838.44,,,,,,,594.81,2912.00,percent of total billed charges,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,WellCare of North Carolina,Managed Medicaid,,1297.30,,,,,,,867.02,12247.00,percent of total billed charges,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,WellCare of North Carolina,Managed Medicaid,,1297.30,,,,,,,867.02,7977.75,percent of total billed charges,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,WellCare of North Carolina,Managed Medicaid,,647.05,,,,,,,432.44,3641.00,percent of total billed charges,
HC INTRAVENTRICULAR AND OR INTRA ATRIAL MAPPING,93610237,CDM,480,RC,93609,CPT,,,facility,outpatient,,,2295.00000,1377.00000,WellCare of North Carolina,Managed Medicaid,,459.46,,,,,,,307.07,12247.00,percent of total billed charges,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,WellCare of North Carolina,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,WellCare of North Carolina,Managed Medicaid,,647.05,,,,,,,432.44,7977.75,percent of total billed charges,
HC MAPPING 3D INTRACARDIAC,93610240,CDM,480,RC,93613,CPT,,,facility,outpatient,,,3043.00000,1825.80000,WellCare of North Carolina,Managed Medicaid,,609.21,,,,,,,407.15,3641.00,percent of total billed charges,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,WellCare of North Carolina,Managed Medicaid,,557.96,,,,,,,372.90,12247.00,percent of total billed charges,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,WellCare of North Carolina,Managed Medicaid,,1917.92,,,,,,,1281.80,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L ATRIALCS,93610243,CDM,480,RC,93621,CPT,,,facility,outpatient,,,15230.00000,9138.00000,WellCare of North Carolina,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC COMP EP EVAL ADD ON L VENT,93610244,CDM,480,RC,93622,CPT,,,facility,outpatient,,,15230.00000,9138.00000,WellCare of North Carolina,Managed Medicaid,,3049.05,,,,,,,1411.00,12247.00,percent of total billed charges,
HC STIMULATION AND PACING AFTER IV DRUGS,93610245,CDM,480,RC,93623,CPT,,,facility,outpatient,,,1624.00000,974.40000,WellCare of North Carolina,Managed Medicaid,,325.12,,,,,,,217.29,3641.00,percent of total billed charges,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,WellCare of North Carolina,Managed Medicaid,,1618.42,,,,,,,1081.64,7977.75,percent of total billed charges,
HC EPICARDIAL INTERROGATION,93610247,CDM,480,RC,93631,CPT,,,facility,outpatient,,,1658.00000,994.80000,WellCare of North Carolina,Managed Medicaid,,331.93,,,,,,,221.84,3641.00,percent of total billed charges,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,WellCare of North Carolina,Managed Medicaid,,631.83,,,,,,,422.27,12247.00,percent of total billed charges,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,WellCare of North Carolina,Managed Medicaid,,5093.49,,,,,,,1411.00,16639.07,percent of total billed charges,
HC ABLATION D AND S MECH OF ARRHYTHMIA,93610251,CDM,480,RC,93655,CPT,,,facility,outpatient,,,22534.00000,13520.40000,WellCare of North Carolina,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC ADDITIONAL LINEAR OR FOCAL ABLATION LT OR RT ATRIUM FLW PVI,93610253,CDM,480,RC,93657,CPT,,,facility,outpatient,,,22534.00000,13520.40000,WellCare of North Carolina,Managed Medicaid,,4511.31,,,,,,,1411.00,14737.24,percent of total billed charges,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,WellCare of North Carolina,Managed Medicaid,,605.61,,,,,,,404.75,3641.00,percent of total billed charges,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,WellCare of North Carolina,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC ATHERECTOMY VISCERAL W S AND I EACH VESSEL,93610257,CDM,481,RC,0235T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,WellCare of North Carolina,Managed Medicaid,,4031.43,,,,,,,2025.00,12283.57,percent of total billed charges,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,WellCare of North Carolina,Managed Medicaid,,4480.68,,,,,,,4480.68,24600.00,percent of total billed charges,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,WellCare of North Carolina,Managed Medicaid,,496.90,,,,,,,496.90,82346.00,percent of total billed charges,
HC PERC TRANSCATH SEPTAL ABLATION WITH TEMP PM INSERT,93610271,CDM,481,RC,93583,CPT,,,facility,outpatient,,,1931.00000,1158.60000,WellCare of North Carolina,Managed Medicaid,,386.59,,,,,,,386.59,9503.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,WellCare of North Carolina,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,WellCare of North Carolina,Managed Medicaid,,1110.71,,,,,,,1110.71,82346.00,percent of total billed charges,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,WellCare of North Carolina,Managed Medicaid,,1276.68,,,,,,,1276.68,82346.00,percent of total billed charges,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,WellCare of North Carolina,Managed Medicaid,,515.51,,,,,,,515.51,82346.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE INITIAL,93610283,CDM,481,RC,33418,CPT,,,facility,outpatient,,,13721.00000,8232.60000,WellCare of North Carolina,Managed Medicaid,,2746.94,,,,,,,2025.00,9423.00,percent of total billed charges,
HC MITRAL CLIP PROCEDURE ADDL CLIP,93610284,CDM,481,RC,33419,CPT,,,facility,outpatient,,,4800.00000,2880.00000,WellCare of North Carolina,Managed Medicaid,,960.96,,,,,,,173.00,9423.00,percent of total billed charges,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,WellCare of North Carolina,Managed Medicaid,,283.88,,,,,,,150.52,3641.00,percent of total billed charges,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,WellCare of North Carolina,Managed Medicaid,,425.83,,,,,,,150.52,9423.00,percent of total billed charges,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,WellCare of North Carolina,Managed Medicaid,,567.77,,,,,,,150.52,9423.00,percent of total billed charges,
HC MODIFIED MAZE PROCEDURE,93610304,CDM,481,RC,33265,CPT,,,facility,outpatient,,,7965.00000,4779.00000,WellCare of North Carolina,Managed Medicaid,,1594.59,,,,,,,1594.59,9423.00,percent of total billed charges,
HC BYPASS GRAFT WITH OTHER THAN VEIN AXILLARY FEMORAL,93610305,CDM,481,RC,35621,CPT,,,facility,outpatient,,,18522.00000,11113.20000,WellCare of North Carolina,Managed Medicaid,,3708.10,,,,,,,2025.00,11298.42,percent of total billed charges,
HC BYPASS GRAFT REOPERATION,93610306,CDM,481,RC,35700,CPT,,,facility,outpatient,,,9224.00000,5534.40000,WellCare of North Carolina,Managed Medicaid,,1846.64,,,,,,,1846.64,9423.00,percent of total billed charges,
HC ADD ON CODE REPEAT SURGERY ON ENDARTERECTOMY,93610307,CDM,481,RC,35390,CPT,,,facility,outpatient,,,6467.00000,3880.20000,WellCare of North Carolina,Managed Medicaid,,1294.69,,,,,,,1294.69,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE OF LA APPENDAGE W IMPLANT INCL FLUORO S AND I WATCHMAN,93610309,CDM,481,RC,33340,CPT,,,facility,outpatient,,,7476.00000,4485.60000,WellCare of North Carolina,Managed Medicaid,,1496.70,,,,,,,1496.70,10022.00,percent of total billed charges,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Managed Medicaid,,57.66,,,,,,,57.66,9423.00,percent of total billed charges,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,WellCare of North Carolina,Managed Medicaid,,283.88,,,,,,,150.52,981.11,percent of total billed charges,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,WellCare of North Carolina,Managed Medicaid,,1595.59,,,,,,,1595.59,8045.00,percent of total billed charges,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,WellCare of North Carolina,Managed Medicaid,,608.81,,,,,,,406.89,4376.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE 6 YRS AND OLDER WO CONGENITAL CARDIAC ANOMALY,93610327,CDM,480,RC,33017,CPT,,,facility,outpatient,,,3041.00000,1824.60000,WellCare of North Carolina,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD FLUORO AND OR US GUIDE BIRTH TO 5 YRS OR ANY AGE W CONGENITAL CARDIAC ANOMALY,93610328,CDM,480,RC,33018,CPT,,,facility,outpatient,,,3041.00000,1824.60000,WellCare of North Carolina,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC PERICARDIAL DRAIN W INSERT CATH PERC INCLD CT GUIDANCE,93610329,CDM,480,RC,33019,CPT,,,facility,outpatient,,,3041.00000,1824.60000,WellCare of North Carolina,Managed Medicaid,,608.81,,,,,,,406.89,3641.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,WellCare of North Carolina,Managed Medicaid,,2662.86,,,,,,,2662.86,13852.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,WellCare of North Carolina,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,WellCare of North Carolina,Managed Medicaid,,5325.72,,,,,,,5325.72,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,WellCare of North Carolina,Managed Medicaid,,8574.37,,,,,,,8574.37,26125.69,percent of total billed charges,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,WellCare of North Carolina,Managed Medicaid,,6999.39,,,,,,,594.81,21326.82,percent of total billed charges,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,WellCare of North Carolina,Managed Medicaid,,1897.10,,,,,,,1897.10,82346.00,percent of total billed charges,
HC INSERT PERC VAD RT HEART VENOUS ACCESS ONLY,93610341,CDM,481,RC,33995,CPT,,,facility,outpatient,,,4345.00000,2607.00000,WellCare of North Carolina,Managed Medicaid,,869.87,,,,,,,869.87,9423.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,WellCare of North Carolina,Managed Medicaid,,4285.48,,,,,,,4285.48,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,WellCare of North Carolina,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,WellCare of North Carolina,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,WellCare of North Carolina,Managed Medicaid,,6855.05,,,,,,,6855.05,24600.00,percent of total billed charges,
HC TMVR IMPLANT OR REPLACE PERCUTANEOUS,93610347,CDM,361,RC,0483T,CPT,,,facility,outpatient,,,32373.00000,19423.80000,WellCare of North Carolina,Managed Medicaid,,6481.07,,,,,,,2025.00,22398.88,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,WellCare of North Carolina,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,WellCare of North Carolina,Managed Medicaid,,1354.55,,,,,,,1354.55,12247.00,percent of total billed charges,
HC CARDIAC OUTPUT MEASUREMENT DURING CATH,93610354,CDM,481,RC,93598,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Managed Medicaid,,21.42,,,,,,,21.42,9423.00,percent of total billed charges,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,WellCare of North Carolina,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,WellCare of North Carolina,Managed Medicaid,,7836.23,,,,,,,1411.00,25792.05,percent of total billed charges,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,WellCare of North Carolina,Managed Medicaid,,9598.39,,,,,,,1411.00,31355.38,percent of total billed charges,
HC TTVI PERC INCLD PROSTHETIC VALVE RHC TEMP PACER RA RV ANGIO,93610364,CDM,481,RC,0646T,CPT,,,facility,outpatient,,,2399.00000,1439.40000,WellCare of North Carolina,Managed Medicaid,,480.28,,,,,,,480.28,9423.00,percent of total billed charges,
HC PERC TRANSLUMINAL CORONARY LITHOTRIPSY ADD ON,93610367,CDM,481,RC,92972,CPT,,,facility,outpatient,,,6494.00000,3896.40000,WellCare of North Carolina,Managed Medicaid,,1300.10,,,,,,,1300.10,9423.00,percent of total billed charges,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,WellCare of North Carolina,Managed Medicaid,,2169.57,,,,,,,2169.57,12247.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LD,93610378,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,WellCare of North Carolina,Managed Medicaid,LD,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RC,93610379,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,WellCare of North Carolina,Managed Medicaid,RC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL RI,93610380,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,WellCare of North Carolina,Managed Medicaid,RI,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LM,93610381,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,WellCare of North Carolina,Managed Medicaid,LM,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LD,93610382,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,WellCare of North Carolina,Managed Medicaid,LD,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RC,93610383,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,WellCare of North Carolina,Managed Medicaid,RC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD RI,93610384,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,WellCare of North Carolina,Managed Medicaid,RI,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LM,93610385,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,WellCare of North Carolina,Managed Medicaid,LM,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL LD,93610386,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,WellCare of North Carolina,Managed Medicaid,LD,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  RC,93610387,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,WellCare of North Carolina,Managed Medicaid,RC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL RI,93610388,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,WellCare of North Carolina,Managed Medicaid,RI,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITIAL VESSEL  LM,93610389,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,WellCare of North Carolina,Managed Medicaid,LM,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LD,93610390,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,LD,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RC,93610391,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,RC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL RI,93610392,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,RI,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LM,93610393,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,LM,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL INITIAL LC,93610394,CDM,481,RC,92978,CPT,,,facility,outpatient,,,3436.00000,2061.60000,WellCare of North Carolina,Managed Medicaid,LC,687.89,,,,,,,173.00,9423.00,percent of total billed charges,
HC IVUS OR OCT CORONARY VESSEL EA ADD LC,93610395,CDM,481,RC,92979,CPT,,,facility,outpatient,,,2748.00000,1648.80000,WellCare of North Carolina,Managed Medicaid,LC,550.15,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE INITAL VESSEL LC,93610396,CDM,481,RC,93571,CPT,,,facility,outpatient,,,2356.00000,1413.60000,WellCare of North Carolina,Managed Medicaid,LC,471.67,,,,,,,173.00,9423.00,percent of total billed charges,
HC FRACTIONAL FLOW RESERVE ADD VESSEL LC,93610397,CDM,481,RC,93572,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Managed Medicaid,LC,99.10,,,,,,,99.10,9423.00,percent of total billed charges,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,WellCare of North Carolina,Managed Medicaid,,6528.72,,,,,,,594.81,19892.71,percent of total billed charges,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,WellCare of North Carolina,Managed Medicaid,,12359.75,,,,,,,9423.00,82346.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,WellCare of North Carolina,Managed Medicaid,,2282.88,,,,,,,2282.88,13852.00,percent of total billed charges,
HC PERC TRANSCATH THERAPY RX INTRAC BALLOON DONE ON SEP TARGET LESION INCL MECH DILATION BY NON RX DEL BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610401,CDM,481,RC,0914T,CPT,,,facility,outpatient,,,2851.00000,1710.60000,WellCare of North Carolina,Managed Medicaid,,570.77,,,,,,,173.00,9423.00,percent of total billed charges,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,WellCare of North Carolina,Managed Medicaid,,115.11,,,,,,,41.04,467.00,percent of total billed charges,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,WellCare of North Carolina,Managed Medicaid,,805.00,,,,,,,538.01,20050.47,percent of total billed charges,
HC INTRAPROCEDURAL CORONARY FFR W 3D MAP FOR COR TREE REAL TIME REVIEW AND INTERP POSS STENT INTERV ADD ON,94800013,CDM,480,RC,0523T,CPT,,,facility,outpatient,,,3304.00000,1982.40000,WellCare of North Carolina,Managed Medicaid,,661.46,,,,,,,442.08,3641.00,percent of total billed charges,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,WellCare of North Carolina,Managed Medicaid,,258.26,,,,,,,198.53,967.50,percent of total billed charges,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,WellCare of North Carolina,Managed Medicaid,,312.91,,,,,,,219.29,1172.25,percent of total billed charges,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,WellCare of North Carolina,Managed Medicaid,,231.63,,,,,,,162.33,968.00,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,WellCare of North Carolina,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,WellCare of North Carolina,Managed Medicaid,,446.25,,,,,,,266.00,1671.75,percent of total billed charges,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,WellCare of North Carolina,Managed Medicaid,,179.98,,,,,,,126.13,968.00,percent of total billed charges,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,WellCare of North Carolina,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,WellCare of North Carolina,Managed Medicaid,,145.35,,,,,,,101.86,968.00,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,WellCare of North Carolina,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,WellCare of North Carolina,Managed Medicaid,,512.11,,,,,,,266.00,1918.50,percent of total billed charges,
HC DOPPLER SPECTRAL COMPLETE,94830013,CDM,483,RC,93320,CPT,,,facility,outpatient,,,496.00000,297.60000,WellCare of North Carolina,Managed Medicaid,,99.30,,,,,,,69.59,968.00,percent of total billed charges,
HC DOPPLER SPECTRAL LIMITED,94830014,CDM,483,RC,93321,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Managed Medicaid,,77.08,,,,,,,54.02,968.00,percent of total billed charges,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,WellCare of North Carolina,Managed Medicaid,,547.75,,,,,,,266.00,2052.00,percent of total billed charges,
HC CONTRAST FOR STRESS ECHO NON MED,94830016,CDM,483,RC,93352,CPT,,,facility,outpatient,,,55.00000,33.00000,WellCare of North Carolina,Managed Medicaid,,11.01,,,,,,,7.72,968.00,percent of total billed charges,
HC 3D ECHOCARDIOGRAPHIC IMAGING POST PROCESSING,94830017,CDM,483,RC,93319,CPT,,,facility,outpatient,,,1368.00000,820.80000,WellCare of North Carolina,Managed Medicaid,,273.87,,,,,,,191.93,1026.00,percent of total billed charges,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,WellCare of North Carolina,Managed Medicaid,,48.65,,,,,,,35.88,182.25,percent of total billed charges,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,WellCare of North Carolina,Managed Medicaid,,175.18,,,,,,,87.00,656.25,percent of total billed charges,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,WellCare of North Carolina,Managed Medicaid,,124.52,,,,,,,57.15,466.50,percent of total billed charges,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Managed Medicaid,,32.43,,,,,,,32.43,134.00,percent of total billed charges,
HC PRE POST ANALYSIS AND PROGRAMMING PACEMAKER,99210001,CDM,921,RC,93286,CPT,,,facility,outpatient,,,193.00000,115.80000,WellCare of North Carolina,Managed Medicaid,,38.64,,,,,,,33.60,269.00,percent of total billed charges,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,WellCare of North Carolina,Managed Medicaid,,255.46,,,,,,,175.00,957.00,percent of total billed charges,
HC PERIOPERATIVE REPROGRAMMING ICD,99210003,CDM,921,RC,93287,CPT,,,facility,outpatient,,,285.00000,171.00000,WellCare of North Carolina,Managed Medicaid,,57.06,,,,,,,49.62,269.00,percent of total billed charges,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Managed Medicaid,,43.64,,,,,,,37.95,269.00,percent of total billed charges,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,WellCare of North Carolina,Managed Medicaid,,59.46,,,,,,,51.71,269.00,percent of total billed charges,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,WellCare of North Carolina,Managed Medicaid,,21.82,,,,,,,18.98,269.00,percent of total billed charges,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,WellCare of North Carolina,Managed Medicaid,,28.23,,,,,,,24.55,269.00,percent of total billed charges,
HC EKG INTERPRETATION,99850001,CDM,985,RC,93010,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Managed Medicaid,,8.61,,,,,,,8.61,32.25,percent of total billed charges,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,WellCare of North Carolina,Managed Medicaid,,1301.10,,,,,,,1301.10,17457.00,percent of total billed charges,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,WellCare of North Carolina,Managed Medicaid,,725.52,,,,,,,725.52,8045.00,percent of total billed charges,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,WellCare of North Carolina,Managed Medicaid,,1598.40,,,,,,,1598.40,13852.00,percent of total billed charges,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,WellCare of North Carolina,Managed Medicaid,,521.92,,,,,,,521.92,5152.00,percent of total billed charges,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,WellCare of North Carolina,Managed Medicaid,,422.62,,,,,,,422.62,24600.00,percent of total billed charges,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,WellCare of North Carolina,Managed Medicaid,,422.62,,,,,,,422.62,8045.00,percent of total billed charges,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,WellCare of North Carolina,Managed Medicaid,,422.62,,,,,,,422.62,17457.00,percent of total billed charges,
HC REX LABOR CARE 24-36 HRS,11720009,CDM,720,RC,,,,,facility,outpatient,,,6375.00000,3825.00000,WellCare of North Carolina,Managed Medicaid,,1276.28,,,,,,,615.00,4781.25,percent of total billed charges,
HC REX LABOR CARE 36-48 HRS,11720010,CDM,720,RC,,,,,facility,outpatient,,,8443.00000,5065.80000,WellCare of North Carolina,Managed Medicaid,,1690.29,,,,,,,615.00,6332.25,percent of total billed charges,
HC REX LABOR CARE GREATER THAN 48 HRS,11720011,CDM,720,RC,,,,,facility,outpatient,,,9477.00000,5686.20000,WellCare of North Carolina,Managed Medicaid,,1897.30,,,,,,,615.00,7107.75,percent of total billed charges,
HC REX INTENSIVE CARE 24-36 HRS,12000009,CDM,720,RC,,,,,facility,outpatient,,,7831.00000,4698.60000,WellCare of North Carolina,Managed Medicaid,,1567.77,,,,,,,615.00,5873.25,percent of total billed charges,
HC REX INTENSIVE CARE 36-48 HRS,12000010,CDM,720,RC,,,,,facility,outpatient,,,10149.00000,6089.40000,WellCare of North Carolina,Managed Medicaid,,2031.83,,,,,,,615.00,7611.75,percent of total billed charges,
HC REX INTENSIVE CARE GREATER THAN 48 HRS,12000011,CDM,720,RC,,,,,facility,outpatient,,,11308.00000,6784.80000,WellCare of North Carolina,Managed Medicaid,,2263.86,,,,,,,615.00,8481.00,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATH SYSTEM,22700457,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,WellCare of North Carolina,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 10CM CATHETER,22700458,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATH SYSTEM,22700459,CDM,272,RC,,,,,facility,outpatient,,,480.00000,288.00000,WellCare of North Carolina,Managed Medicaid,,96.10,,,,,,,96.10,390.24,percent of total billed charges,
HC VAT POWERGLIDE 8CM CATHETER,22700460,CDM,272,RC,,,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Managed Medicaid,,60.06,,,,,,,60.06,243.90,percent of total billed charges,
HC REX TRANSFORAMINAL SUPPLIES,22700495,CDM,272,RC,,,,,facility,outpatient,,,34.00000,20.40000,WellCare of North Carolina,Managed Medicaid,,6.81,,,,,,,6.81,27.64,percent of total billed charges,
HC REX CANNULA RF CERVICAL/LUMBAR TIP,22700498,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC REX REFILL SYNCHROMED SUPPLIES,22700503,CDM,272,RC,,,,,facility,outpatient,,,240.00000,144.00000,WellCare of North Carolina,Managed Medicaid,,48.05,,,,,,,48.05,195.12,percent of total billed charges,
HC REX STYLET ENHANCED PRICISION 50CM,22700505,CDM,272,RC,,,,,facility,outpatient,,,374.00000,224.40000,WellCare of North Carolina,Managed Medicaid,,74.87,,,,,,,74.87,304.06,percent of total billed charges,
HC REX CABLE SCRNG SNAP-LID CONN RESTOR,22700507,CDM,272,RC,,,,,facility,outpatient,,,1320.00000,792.00000,WellCare of North Carolina,Managed Medicaid,,264.26,,,,,,,264.26,1073.16,percent of total billed charges,
HC REX SCS ACCESSORY SUPPLY,22700508,CDM,272,RC,,,,,facility,outpatient,,,1425.00000,855.00000,WellCare of North Carolina,Managed Medicaid,,285.29,,,,,,,285.29,1158.53,percent of total billed charges,
HC REX PROBE SIMPLICITY III ELECTRO NEE,22700509,CDM,272,RC,,,,,facility,outpatient,,,2232.00000,1339.20000,WellCare of North Carolina,Managed Medicaid,,446.85,,,,,,,446.85,1814.62,percent of total billed charges,
HC LEAD BLANK,22700540,CDM,278,RC,,,,,facility,outpatient,,,293.00000,175.80000,WellCare of North Carolina,Managed Medicaid,,58.66,,,,,,,37.21,215.71,percent of total billed charges,
HC ANESTHESIA AIRWAY COMBITUBE ESOPHAGEAL,22700554,CDM,272,RC,,,,,facility,outpatient,,,672.00000,403.20000,WellCare of North Carolina,Managed Medicaid,,134.53,,,,,,,134.53,546.34,percent of total billed charges,
HC ANESTHESIA CIRCUIT HEATED HUMIDIFIER,22700555,CDM,272,RC,,,,,facility,outpatient,,,104.00000,62.40000,WellCare of North Carolina,Managed Medicaid,,20.82,,,,,,,20.82,84.55,percent of total billed charges,
HC ANESTHESIA QUICKTRACH,22700556,CDM,272,RC,,,,,facility,outpatient,,,1016.00000,609.60000,WellCare of North Carolina,Managed Medicaid,,203.40,,,,,,,203.40,826.01,percent of total billed charges,
HC NITROUS SUPPLIES,22700579,CDM,270,RC,,,,,facility,outpatient,,,175.00000,105.00000,WellCare of North Carolina,Managed Medicaid,,35.03,,,,,,,35.03,142.28,percent of total billed charges,
HC MRI EEG ELECTRODES,22700749,CDM,270,RC,,,,,facility,outpatient,,,258.00000,154.80000,WellCare of North Carolina,Managed Medicaid,,51.65,,,,,,,51.65,209.75,percent of total billed charges,
HC WOUND VAC DAILY CHARGE,22700886,CDM,270,RC,,,,,facility,outpatient,,,192.00000,115.20000,WellCare of North Carolina,Managed Medicaid,,38.44,,,,,,,38.44,156.10,percent of total billed charges,
HC CERIBELL HEADBAND,22700965,CDM,270,RC,,,,,facility,outpatient,,,3162.00000,1897.20000,WellCare of North Carolina,Managed Medicaid,,633.03,,,,,,,633.03,2570.71,percent of total billed charges,
HC AGILITI VITAL GO TLB THERAPY BED,22700970,CDM,270,RC,,,,,facility,outpatient,,,302.00000,181.20000,WellCare of North Carolina,Managed Medicaid,,60.46,,,,,,,60.46,245.53,percent of total billed charges,
HC AGILITI UMANO W ADAPT STANDARD BARIATRIC THERAPY BED,22700971,CDM,270,RC,,,,,facility,outpatient,,,296.00000,177.60000,WellCare of North Carolina,Managed Medicaid,,59.26,,,,,,,59.26,240.65,percent of total billed charges,
HC AGILITI UMANO BARIATRIC W PERCUSSION THERAPY BED,22700972,CDM,270,RC,,,,,facility,outpatient,,,309.00000,185.40000,WellCare of North Carolina,Managed Medicaid,,61.86,,,,,,,61.86,251.22,percent of total billed charges,
HC KREG EZ WIDER WITH LAL THERAPY BED,22700973,CDM,270,RC,,,,,facility,outpatient,,,285.00000,171.00000,WellCare of North Carolina,Managed Medicaid,,57.06,,,,,,,57.06,231.71,percent of total billed charges,
HC KREG EZ WIDER WITH LAL AND CLRT THERAPY BED,22700974,CDM,270,RC,,,,,facility,outpatient,,,341.00000,204.60000,WellCare of North Carolina,Managed Medicaid,,68.27,,,,,,,68.27,277.23,percent of total billed charges,
HC KREG CATALYST STANDARD THERAPY BED,22700975,CDM,270,RC,,,,,facility,outpatient,,,432.00000,259.20000,WellCare of North Carolina,Managed Medicaid,,86.49,,,,,,,86.49,351.22,percent of total billed charges,
HC KREG CATALYST BARIATRIC THERAPY BED,22700976,CDM,270,RC,,,,,facility,outpatient,,,617.00000,370.20000,WellCare of North Carolina,Managed Medicaid,,123.52,,,,,,,123.52,501.62,percent of total billed charges,
HC OXYHOOD SET UP,22710068,CDM,271,RC,,,,,facility,outpatient,,,44.00000,26.40000,WellCare of North Carolina,Managed Medicaid,,8.81,,,,,,,8.81,35.77,percent of total billed charges,
HC BLOOD FILTER PALL LIPGURD REINFU,22720418,CDM,272,RC,,,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Managed Medicaid,,8.41,,,,,,,8.41,34.15,percent of total billed charges,
HC CONTINUOUS PLEXUS,22720419,CDM,272,RC,,,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Managed Medicaid,,14.21,,,,,,,14.21,57.72,percent of total billed charges,
HC COOK AIRWAY EXCHANGE CATHETER,22720420,CDM,272,RC,,,,,facility,outpatient,,,221.00000,132.60000,WellCare of North Carolina,Managed Medicaid,,44.24,,,,,,,44.24,179.67,percent of total billed charges,
HC DOUBLE LUMEN ENDOBRONCHIAL TUB,22720421,CDM,272,RC,,,,,facility,outpatient,,,402.00000,241.20000,WellCare of North Carolina,Managed Medicaid,,80.48,,,,,,,80.48,326.83,percent of total billed charges,
HC ENDOBRONCHIAL UNIBLOCKER,22720422,CDM,272,RC,,,,,facility,outpatient,,,890.00000,534.00000,WellCare of North Carolina,Managed Medicaid,,178.18,,,,,,,178.18,723.57,percent of total billed charges,
HC LIGHT WAND ILLUMINATING,22720426,CDM,272,RC,,,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Managed Medicaid,,14.81,,,,,,,14.81,60.16,percent of total billed charges,
HC MEDRAD IV TUBING STD CONT PUMP,22720427,CDM,272,RC,,,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Managed Medicaid,,10.81,,,,,,,10.81,43.90,percent of total billed charges,
HC MV SVO2 SWAN GANZ CATHETER,22720428,CDM,272,RC,,,,,facility,outpatient,,,265.00000,159.00000,WellCare of North Carolina,Managed Medicaid,,53.05,,,,,,,53.05,215.44,percent of total billed charges,
HC SET BLOOD Y TYPE HI FLO PUMP,22720431,CDM,272,RC,,,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Managed Medicaid,,8.01,,,,,,,8.01,32.52,percent of total billed charges,
HC TUBE UNIVENT,22720432,CDM,272,RC,,,,,facility,outpatient,,,750.00000,450.00000,WellCare of North Carolina,Managed Medicaid,,150.15,,,,,,,150.15,609.75,percent of total billed charges,
HC REX SCOPE AMBU FLEXIBLE DIFF INTUB,22720433,CDM,272,RC,,,,,facility,outpatient,,,1175.00000,705.00000,WellCare of North Carolina,Managed Medicaid,,235.24,,,,,,,235.24,955.27,percent of total billed charges,
HC RADIOFREQUENCY COOLED SU,22720435,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,WellCare of North Carolina,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC CABLE OR EXTENSION,22720465,CDM,272,RC,,,,,facility,outpatient,,,1224.00000,734.40000,WellCare of North Carolina,Managed Medicaid,,245.04,,,,,,,245.04,995.11,percent of total billed charges,
HC RETR HEARTPT DISP SOFT TISSUE SM,22720466,CDM,272,RC,,,,,facility,outpatient,,,1794.00000,1076.40000,WellCare of North Carolina,Managed Medicaid,,359.16,,,,,,,359.16,1458.52,percent of total billed charges,
HC SP T J LIVER BIOPSY SET,22720469,CDM,272,RC,,,,,facility,outpatient,,,2269.00000,1361.40000,WellCare of North Carolina,Managed Medicaid,,454.25,,,,,,,454.25,1844.70,percent of total billed charges,
HC SPECTRA TRIAL COMP,22720470,CDM,272,RC,,,,,facility,outpatient,,,492.00000,295.20000,WellCare of North Carolina,Managed Medicaid,,98.50,,,,,,,98.50,400.00,percent of total billed charges,
HC GENICULAR KIT ACTIVE TIP,22720473,CDM,272,RC,,,,,facility,outpatient,,,4010.00000,2406.00000,WellCare of North Carolina,Managed Medicaid,,802.80,,,,,,,802.80,3260.13,percent of total billed charges,
HC D STAT FLOWABLE HEMOSTAT,22720476,CDM,272,RC,,,,,facility,outpatient,,,700.00000,420.00000,WellCare of North Carolina,Managed Medicaid,,140.14,,,,,,,140.14,569.10,percent of total billed charges,
HC MAMMOTOME 11 GAUGE VACUUM CANN,22720477,CDM,272,RC,,,,,facility,outpatient,,,780.00000,468.00000,WellCare of North Carolina,Managed Medicaid,,156.16,,,,,,,156.16,634.14,percent of total billed charges,
HC SUPPLIES BREAST NEEDLE,22720481,CDM,272,RC,,,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Managed Medicaid,,18.02,,,,,,,18.02,73.17,percent of total billed charges,
HC DISPOSABLE ENDORECTAL COIL,22720483,CDM,272,RC,,,,,facility,outpatient,,,1598.00000,958.80000,WellCare of North Carolina,Managed Medicaid,,319.92,,,,,,,319.92,1299.17,percent of total billed charges,
HC PROBE SINERGY 17G X 75MM X 4MM ACTIVE TIP,22721005,CDM,272,RC,,,,,facility,outpatient,,,2569.00000,1541.40000,WellCare of North Carolina,Managed Medicaid,,514.31,,,,,,,514.31,2088.60,percent of total billed charges,
HC WIRELESS EXTERNAL NEUROSTIMULATOR,22721030,CDM,272,RC,,,,,facility,outpatient,,,500.00000,300.00000,WellCare of North Carolina,Managed Medicaid,,100.10,,,,,,,100.10,406.50,percent of total billed charges,
HC JADA INTRAUTERINE VACUUM HEMORRHAGE,22721118,CDM,272,RC,,,,,facility,outpatient,,,4000.00000,2400.00000,WellCare of North Carolina,Managed Medicaid,,800.80,,,,,,,800.80,3252.00,percent of total billed charges,
HC ACUMEN CUFF AIQCS AIQCM AIQCL,22721119,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,WellCare of North Carolina,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC ACUMEN CUFF CSCS CSCM CSCL,22721120,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,WellCare of North Carolina,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC FLOTRAC SENSOR AIQS85,22721121,CDM,272,RC,,,,,facility,outpatient,,,2425.00000,1455.00000,WellCare of North Carolina,Managed Medicaid,,485.49,,,,,,,485.49,1971.53,percent of total billed charges,
HC FLOTRAC SENSOR MHD85,22721122,CDM,272,RC,,,,,facility,outpatient,,,1800.00000,1080.00000,WellCare of North Carolina,Managed Medicaid,,360.36,,,,,,,360.36,1463.40,percent of total billed charges,
HC REX IP 10FR IRIS FEEDING TUBE SYSTEM,22721159,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,WellCare of North Carolina,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC REX IP 12FR IRIS FEEDING TUBE SYSTEM,22721160,CDM,272,RC,,,,,facility,outpatient,,,1180.00000,708.00000,WellCare of North Carolina,Managed Medicaid,,236.24,,,,,,,236.24,959.34,percent of total billed charges,
HC BELMONT DISPOSABLE 3 SPIKE RAPID INFUSER,22721161,CDM,272,RC,,,,,facility,outpatient,,,1057.00000,634.20000,WellCare of North Carolina,Managed Medicaid,,211.61,,,,,,,211.61,859.34,percent of total billed charges,
HC PT WORKSITE EVALUATION,44200071,CDM,420,RC,,,,,facility,outpatient,,,238.00000,142.80000,WellCare of North Carolina,Managed Medicaid,GP,47.65,,,,,,,37.08,276.00,percent of total billed charges,
HC OPEN PERC PLACE STENT 1ST,63600226,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,WellCare of North Carolina,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT EACH ADDITIONAL,63600227,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,WellCare of North Carolina,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN SAME,63600228,CDM,360,RC,,,,,facility,outpatient,,,30903.00000,18541.80000,WellCare of North Carolina,Managed Medicaid,,6186.78,,,,,,,6186.78,21381.79,percent of total billed charges,
HC OPEN PERC PLACE STENT VEIN EACH ADDITIONAL,63600238,CDM,360,RC,,,,,facility,outpatient,,,14943.00000,8965.80000,WellCare of North Carolina,Managed Medicaid,,2991.59,,,,,,,2991.59,10339.06,percent of total billed charges,
HC PROCEDURE TIME 391 TO 420 MINS,63600255,CDM,360,RC,,,,,facility,outpatient,,,12987.00000,7792.20000,WellCare of North Carolina,Managed Medicaid,,2600.00,,,,,,,2600.00,8985.71,percent of total billed charges,
HC PROCEDURE TIME 421 TO 450 MINS,63600256,CDM,360,RC,,,,,facility,outpatient,,,13273.00000,7963.80000,WellCare of North Carolina,Managed Medicaid,,2657.25,,,,,,,2657.25,9183.59,percent of total billed charges,
HC PROCEDURE TIME 451 TO 480 MINS,63600257,CDM,360,RC,,,,,facility,outpatient,,,13560.00000,8136.00000,WellCare of North Carolina,Managed Medicaid,,2714.71,,,,,,,2714.71,9382.16,percent of total billed charges,
HC PROCEDURE TIME 481 TO 510 MINS,63600258,CDM,360,RC,,,,,facility,outpatient,,,13848.00000,8308.80000,WellCare of North Carolina,Managed Medicaid,,2772.37,,,,,,,2772.37,9581.43,percent of total billed charges,
HC PROCEDURE TIME 511 TO 540 MINS,63600259,CDM,360,RC,,,,,facility,outpatient,,,14135.00000,8481.00000,WellCare of North Carolina,Managed Medicaid,,2829.83,,,,,,,2829.83,9780.01,percent of total billed charges,
HC PROCEDURE TIME 541 TO 570 MINS,63600260,CDM,360,RC,,,,,facility,outpatient,,,14421.00000,8652.60000,WellCare of North Carolina,Managed Medicaid,,2887.08,,,,,,,2887.08,9977.89,percent of total billed charges,
HC PROCEDURE TIME 571 TO 600 MINS,63600261,CDM,360,RC,,,,,facility,outpatient,,,14708.00000,8824.80000,WellCare of North Carolina,Managed Medicaid,,2944.54,,,,,,,2944.54,10176.47,percent of total billed charges,
HC PROCEDURE TIME 601 TO 630 MINS,63600262,CDM,360,RC,,,,,facility,outpatient,,,14995.00000,8997.00000,WellCare of North Carolina,Managed Medicaid,,3002.00,,,,,,,3002.00,10375.04,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY FIRST HOUR,67100127,CDM,710,RC,,,,,facility,outpatient,,,499.00000,299.40000,WellCare of North Carolina,Managed Medicaid,,99.90,,,,,,,99.90,405.69,percent of total billed charges,
HC UNC VIR BRONCH RECOVERY EACH ADDL HOUR,67100128,CDM,710,RC,,,,,facility,outpatient,,,246.00000,147.60000,WellCare of North Carolina,Managed Medicaid,,49.25,,,,,,,49.25,200.00,percent of total billed charges,
HC FIT FOR DUTY EVALUATION,99900028,CDM,990,RC,,,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Managed Medicaid,,40.04,,,,,,,34.82,150.00,percent of total billed charges,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,215412.76,,,,,,,199000.36,360919.81,fee schedule,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,87653.85,,,,,,,80975.46,145942.25,fee schedule,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,163376.49,,,,,,,150928.76,397739.02,fee schedule,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,106938.50,,,,,,,98790.80,259561.38,fee schedule,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,79836.98,,,,,,,73754.16,132788.93,fee schedule,
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,36412.81,,,,,,,33638.50,59719.92,fee schedule,
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,100040.85,,,,,,,92418.69,166785.63,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,43818.68,,,,,,,40480.12,72181.64,fee schedule,
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,55843.64,,,,,,,22680.42,56375.49,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,42666.79,,,,,,,39415.99,102204.38,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33190.55,,,,,,,30661.75,79003.62,fee schedule,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22978.77,,,,,,,21228.00,54002.05,fee schedule,
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,92905.15,,,,,,,85826.67,154778.53,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,46306.95,,,,,,,42778.80,76368.61,fee schedule,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,42499.92,,,,,,,35745.36,62312.47,fee schedule,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,331436.76,,,,,,,306184.44,556151.28,fee schedule,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,55529.08,,,,,,,48961.75,85351.71,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,61148.55,,,,,,,56489.61,147453.44,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,41439.87,,,,,,,38282.54,99200.52,fee schedule,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25241.25,,,,,,,22718.84,57624.30,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,44780.78,,,,,,,41368.91,107380.09,fee schedule,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,30863.01,,,,,,,28511.54,73305.09,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,35721.67,,,,,,,33000.02,85200.61,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24719.26,,,,,,,22835.89,58263.30,fee schedule,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20231.80,,,,,,,18639.19,47276.62,fee schedule,
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,46908.54,,,,,,,43334.56,112589.53,fee schedule,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27033.77,,,,,,,24974.06,63929.97,fee schedule,
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17723.63,,,,,,,16218.14,41135.85,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,35214.98,,,,,,,32531.94,83960.09,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17232.26,,,,,,,15743.83,39932.81,fee schedule,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13649.49,,,,,,,12285.51,31161.08,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,30547.68,,,,,,,28220.24,72533.05,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19218.43,,,,,,,17661.01,44795.58,fee schedule,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15791.80,,,,,,,14353.41,36406.13,fee schedule,
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,26119.14,,,,,,,24129.11,61690.66,fee schedule,
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13341.04,,,,,,,11987.77,30405.90,fee schedule,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9918.99,,,,,,,8684.59,22027.69,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,30474.96,,,,,,,28153.06,72355.03,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17750.42,,,,,,,16244.00,41201.44,fee schedule,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14145.45,,,,,,,12764.25,32375.37,fee schedule,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14785.32,,,,,,,13156.55,33370.41,fee schedule,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8416.54,,,,,,,7234.33,18349.23,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12608.57,,,,,,,11280.74,28612.58,fee schedule,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8725.76,,,,,,,7532.80,19106.28,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18702.56,,,,,,,17163.06,43532.57,fee schedule,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10838.23,,,,,,,9571.89,24278.25,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14006.15,,,,,,,12629.79,32034.32,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10419.55,,,,,,,9167.77,23253.23,fee schedule,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7961.91,,,,,,,6795.48,17236.13,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22024.35,,,,,,,20346.30,51665.30,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14371.25,,,,,,,12982.19,32928.17,fee schedule,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11666.37,,,,,,,10371.27,26305.81,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16313.80,,,,,,,14857.27,37684.13,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8654.58,,,,,,,7464.10,18932.01,fee schedule,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.19,,,,,,,5056.35,12824.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12163.11,,,,,,,10850.76,27521.97,fee schedule,
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7537.89,,,,,,,6386.19,16197.99,fee schedule,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7035.79,,,,,,,5901.53,14968.71,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13664.02,,,,,,,12299.54,31196.69,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8774.75,,,,,,,7580.09,19226.21,fee schedule,
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6709.73,,,,,,,5586.81,14170.43,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13200.97,,,,,,,11852.57,30062.98,fee schedule,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8811.48,,,,,,,7615.55,19316.16,fee schedule,
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15598.15,,,,,,,14166.49,35932.03,fee schedule,
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7237.86,,,,,,,5532.13,14031.76,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14775.38,,,,,,,13372.28,33917.59,fee schedule,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7776.68,,,,,,,6616.69,16782.65,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18415.54,,,,,,,16886.01,42829.86,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11605.15,,,,,,,10312.17,26155.90,fee schedule,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8237.46,,,,,,,7061.45,17910.74,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18310.69,,,,,,,16784.80,42573.13,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10892.56,,,,,,,9624.35,24411.30,fee schedule,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7922.88,,,,,,,6757.80,17140.56,fee schedule,
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11268.38,,,,,,,9987.10,25331.38,fee schedule,
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9330.42,,,,,,,8116.46,20586.67,fee schedule,
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7222.55,,,,,,,6081.80,15425.94,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14363.60,,,,,,,12974.81,32909.43,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8751.77,,,,,,,7557.92,19170.00,fee schedule,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7016.65,,,,,,,5883.06,14921.87,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27858.86,,,,,,,25736.28,65950.04,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20662.73,,,,,,,19055.13,48331.63,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28566.09,,,,,,,26389.63,67681.52,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18486.74,,,,,,,16954.72,43004.13,fee schedule,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11349.49,,,,,,,10065.41,25530.01,fee schedule,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15745.88,,,,,,,14309.08,36293.70,fee schedule,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7830.26,,,,,,,6668.41,16913.82,fee schedule,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9501.09,,,,,,,8281.21,21004.55,fee schedule,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7322.81,,,,,,,6178.58,15671.43,fee schedule,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18916.86,,,,,,,17369.93,44057.26,fee schedule,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11277.56,,,,,,,9995.96,25353.87,fee schedule,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12669.80,,,,,,,11339.84,28762.49,fee schedule,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14760.82,,,,,,,13358.24,33881.99,fee schedule,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9225.55,,,,,,,8015.24,20329.94,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9825.63,,,,,,,8594.46,21799.08,fee schedule,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6936.29,,,,,,,5805.49,14725.11,fee schedule,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7034.25,,,,,,,5900.06,14964.97,fee schedule,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11048.71,,,,,,,9775.06,24793.57,fee schedule,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6798.52,,,,,,,5672.51,14387.80,fee schedule,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17530.75,,,,,,,15627.10,39636.73,fee schedule,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8692.84,,,,,,,7501.04,19025.71,fee schedule,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12350.62,,,,,,,11031.76,27981.07,fee schedule,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7704.74,,,,,,,6547.25,16606.50,fee schedule,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10379.75,,,,,,,8929.14,22647.96,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33567.88,,,,,,,31010.33,79927.46,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17615.72,,,,,,,16113.97,40871.63,fee schedule,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13140.51,,,,,,,11794.20,29914.94,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29597.83,,,,,,,27342.76,70207.54,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14185.27,,,,,,,12802.67,32472.81,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10124.13,,,,,,,8882.59,22529.90,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17128.17,,,,,,,15643.35,39677.96,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10653.76,,,,,,,9393.84,23826.64,fee schedule,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7022.79,,,,,,,5888.97,14936.86,fee schedule,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6674.53,,,,,,,5552.82,14084.23,fee schedule,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11113.00,,,,,,,9837.12,24950.98,fee schedule,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6539.82,,,,,,,5422.79,13754.43,fee schedule,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9970.26,,,,,,,8734.09,22153.25,fee schedule,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6571.97,,,,,,,5453.82,13833.13,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12888.69,,,,,,,11551.14,29298.43,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7936.65,,,,,,,6771.10,17174.29,fee schedule,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6211.46,,,,,,,5105.85,12950.52,fee schedule,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14062.03,,,,,,,12683.72,32171.12,fee schedule,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7885.36,,,,,,,6721.60,17048.74,fee schedule,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6344.65,,,,,,,5234.40,13276.58,fee schedule,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,35224.95,,,,,,,32541.14,83984.45,fee schedule,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20240.22,,,,,,,18647.31,47297.24,fee schedule,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15572.92,,,,,,,14142.11,35870.19,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29529.70,,,,,,,27279.81,70040.76,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14724.84,,,,,,,13323.52,33793.91,fee schedule,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11380.10,,,,,,,10094.96,25604.97,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23702.83,,,,,,,21896.90,55774.76,fee schedule,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11435.22,,,,,,,10148.16,25739.89,fee schedule,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7083.25,,,,,,,5947.34,15084.90,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12882.57,,,,,,,11545.23,29283.44,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8392.06,,,,,,,7210.69,18289.26,fee schedule,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6700.55,,,,,,,5577.94,14147.94,fee schedule,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14438.60,,,,,,,13047.21,33093.07,fee schedule,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9119.17,,,,,,,7912.55,20069.47,fee schedule,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6691.37,,,,,,,5496.67,13941.82,fee schedule,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12631.53,,,,,,,11302.90,28668.80,fee schedule,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9066.35,,,,,,,7861.57,19940.17,fee schedule,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6941.65,,,,,,,5810.66,14738.22,fee schedule,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12850.44,,,,,,,11514.20,29204.73,fee schedule,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8492.31,,,,,,,7307.47,18534.74,fee schedule,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6411.24,,,,,,,5298.67,13439.61,fee schedule,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10377.45,,,,,,,9127.14,23150.16,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9400.07,,,,,,,8183.69,20757.19,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7374.09,,,,,,,6228.08,15796.98,fee schedule,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5835.67,,,,,,,4743.10,12030.44,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10982.12,,,,,,,9710.79,24630.54,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7090.12,,,,,,,5953.99,15101.76,fee schedule,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5732.34,,,,,,,4643.36,11777.46,fee schedule,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15366.26,,,,,,,13942.63,35364.24,fee schedule,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8186.17,,,,,,,7011.95,17785.18,fee schedule,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6403.58,,,,,,,5291.29,13420.87,fee schedule,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14424.06,,,,,,,13033.17,33057.47,fee schedule,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9335.77,,,,,,,8121.63,20599.78,fee schedule,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6395.17,,,,,,,5283.16,13400.26,fee schedule,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8355.32,,,,,,,7175.23,18199.32,fee schedule,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6049.98,,,,,,,4949.96,12555.13,fee schedule,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7101.62,,,,,,,5965.07,15129.87,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14936.10,,,,,,,13527.43,34311.11,fee schedule,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8124.94,,,,,,,6952.85,17635.27,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,50172.15,,,,,,,46349.51,120579.84,fee schedule,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21960.03,,,,,,,20286.88,51507.89,fee schedule,
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,87554.35,,,,,,,80883.55,212102.99,fee schedule,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,84150.68,,,,,,,77739.20,203769.76,fee schedule,
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,44601.69,,,,,,,41203.47,106941.60,fee schedule,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,77131.34,,,,,,,71254.67,186584.22,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,75798.02,,,,,,,70022.93,183319.89,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,51248.28,,,,,,,47343.65,123214.55,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,59690.48,,,,,,,55142.64,143883.66,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,41738.37,,,,,,,38558.31,99931.34,fee schedule,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,39498.86,,,,,,,36489.42,94448.31,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,38788.59,,,,,,,35833.26,92709.33,fee schedule,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25027.69,,,,,,,23120.82,59018.48,fee schedule,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,65443.13,,,,,,,60456.99,157967.90,fee schedule,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,47324.16,,,,,,,43718.51,113607.06,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,59437.13,,,,,,,54908.59,143263.40,fee schedule,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,42732.61,,,,,,,39476.79,102365.54,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,45839.31,,,,,,,42346.80,109971.70,fee schedule,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,32982.36,,,,,,,30469.42,78493.92,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,38591.88,,,,,,,35651.54,92227.74,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22739.22,,,,,,,21006.71,53415.52,fee schedule,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11517.89,,,,,,,10227.95,25942.27,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25359.12,,,,,,,23426.99,59829.88,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17231.49,,,,,,,15743.09,44147.00,fee schedule,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14756.23,,,,,,,13353.81,33870.74,fee schedule,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,35841.82,,,,,,,33111.02,85494.81,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17626.41,,,,,,,16124.31,40897.87,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12360.57,,,,,,,11041.37,28005.44,fee schedule,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27620.84,,,,,,,25516.39,65367.25,fee schedule,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20788.24,,,,,,,19176.29,48638.95,fee schedule,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14558.76,,,,,,,13163.20,33387.28,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21567.41,,,,,,,19924.18,50546.58,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13917.37,,,,,,,12544.09,31816.95,fee schedule,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9281.42,,,,,,,8069.17,20466.74,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24971.07,,,,,,,23068.51,58879.81,fee schedule,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16398.75,,,,,,,14939.27,37892.13,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25818.35,,,,,,,22172.00,60954.22,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13396.91,,,,,,,12041.70,30542.70,fee schedule,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24322.78,,,,,,,22469.61,57292.62,fee schedule,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,26490.37,,,,,,,24472.05,62599.50,fee schedule,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28615.06,,,,,,,26434.87,67801.45,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,47827.79,,,,,,,44183.77,114840.09,fee schedule,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,37360.36,,,,,,,34513.86,89212.63,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,53564.34,,,,,,,49483.25,128884.97,fee schedule,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33245.65,,,,,,,30712.64,79138.54,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,41305.94,,,,,,,38158.82,98872.59,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28141.31,,,,,,,25997.21,66641.51,fee schedule,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20462.18,,,,,,,18861.56,47840.67,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,32497.87,,,,,,,30021.84,77307.74,fee schedule,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,26116.07,,,,,,,24126.28,61683.17,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,55496.94,,,,,,,51268.60,133616.57,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,46895.53,,,,,,,43322.54,112557.68,fee schedule,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,36271.21,,,,,,,33507.69,86546.07,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,43524.79,,,,,,,40208.61,104305.02,fee schedule,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28524.74,,,,,,,26351.43,67580.33,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13199.44,,,,,,,11851.09,30059.23,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7956.55,,,,,,,6790.31,17223.01,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6456.39,,,,,,,5342.26,13550.17,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16082.64,,,,,,,14634.15,37118.21,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6219.89,,,,,,,5113.97,12971.14,fee schedule,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5505.79,,,,,,,4424.67,11222.79,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17858.34,,,,,,,16348.17,41465.66,fee schedule,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9112.27,,,,,,,7905.90,20052.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21634.77,,,,,,,19986.40,50711.48,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13986.26,,,,,,,12610.58,31985.60,fee schedule,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8037.68,,,,,,,6868.62,17421.65,fee schedule,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10747.91,,,,,,,9484.71,24057.13,fee schedule,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7420.02,,,,,,,6272.41,15909.41,fee schedule,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5253.97,,,,,,,4181.61,10606.27,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12876.45,,,,,,,11539.32,29268.44,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5774.43,,,,,,,4606.42,11683.77,fee schedule,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4405.15,,,,,,,3362.28,8528.12,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13418.34,,,,,,,12062.39,30595.17,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9092.37,,,,,,,7886.69,20003.88,fee schedule,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6430.38,,,,,,,5317.14,13486.46,fee schedule,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10080.51,,,,,,,8840.48,22423.09,fee schedule,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6074.47,,,,,,,4973.60,12615.09,fee schedule,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10029.98,,,,,,,8791.72,22299.41,fee schedule,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6701.31,,,,,,,5578.68,14149.82,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12982.83,,,,,,,11642.01,29528.92,fee schedule,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7911.39,,,,,,,6746.72,17112.45,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6552.83,,,,,,,5435.35,13786.28,fee schedule,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5254.73,,,,,,,4182.35,10608.15,fee schedule,
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6294.12,,,,,,,5185.64,13152.90,fee schedule,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7593.00,,,,,,,6439.38,16332.91,fee schedule,
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6432.66,,,,,,,5319.36,13492.08,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16881.72,,,,,,,15405.46,39074.56,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8294.85,,,,,,,7116.86,18051.28,fee schedule,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6142.58,,,,,,,5039.35,12781.87,fee schedule,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,52099.39,,,,,,,48129.92,125298.32,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19461.06,,,,,,,17895.21,45389.61,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,35080.27,,,,,,,32407.49,83630.28,fee schedule,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19331.71,,,,,,,17770.36,45072.92,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21746.51,,,,,,,20089.63,50985.07,fee schedule,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14415.63,,,,,,,13025.04,33036.86,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,34043.17,,,,,,,31449.41,81091.15,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25039.17,,,,,,,23131.43,59046.59,fee schedule,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25493.84,,,,,,,23551.45,60159.69,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,39094.73,,,,,,,36116.09,93458.89,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19629.42,,,,,,,18057.75,45801.86,fee schedule,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13185.67,,,,,,,11837.79,30025.50,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,36102.84,,,,,,,33352.15,86133.81,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19269.71,,,,,,,17710.51,44921.13,fee schedule,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13802.57,,,,,,,12433.27,31535.86,fee schedule,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28634.21,,,,,,,26452.56,67848.30,fee schedule,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18848.74,,,,,,,17304.17,43890.49,fee schedule,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13458.14,,,,,,,12100.81,30692.61,fee schedule,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28253.06,,,,,,,26100.45,66915.10,fee schedule,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17061.59,,,,,,,15579.08,39514.93,fee schedule,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12670.56,,,,,,,11340.58,28764.37,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20690.27,,,,,,,19081.73,48399.09,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12438.65,,,,,,,11116.72,28196.57,fee schedule,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10000.89,,,,,,,8763.65,22228.20,fee schedule,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18492.09,,,,,,,16959.89,43017.25,fee schedule,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10939.25,,,,,,,9669.41,24525.60,fee schedule,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7585.34,,,,,,,6431.99,16314.17,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19994.53,,,,,,,18410.16,46695.71,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12590.19,,,,,,,11263.01,28567.61,fee schedule,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9860.08,,,,,,,8627.71,21883.40,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23133.38,,,,,,,21370.84,54380.58,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13798.74,,,,,,,12429.57,31526.49,fee schedule,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11216.32,,,,,,,9936.86,25203.96,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,34543.75,,,,,,,31911.85,82316.68,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18720.94,,,,,,,17180.79,43577.54,fee schedule,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11621.20,,,,,,,10327.69,26195.25,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27240.44,,,,,,,25164.98,64435.93,fee schedule,
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19400.60,,,,,,,17836.85,45241.57,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13106.07,,,,,,,11760.96,29830.61,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8577.27,,,,,,,7389.48,18742.75,fee schedule,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6285.71,,,,,,,5177.51,13132.29,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14492.95,,,,,,,13099.66,33226.12,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8736.47,,,,,,,7543.15,19132.52,fee schedule,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6489.29,,,,,,,5374.03,13630.75,fee schedule,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17291.19,,,,,,,15800.72,40077.10,fee schedule,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10179.99,,,,,,,8936.52,22666.69,fee schedule,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7996.35,,,,,,,6828.73,17320.46,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14913.13,,,,,,,13505.26,34254.89,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8428.02,,,,,,,7245.41,18377.34,fee schedule,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5746.87,,,,,,,4657.40,11813.07,fee schedule,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15940.27,,,,,,,14496.73,36769.67,fee schedule,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9214.84,,,,,,,8004.90,20303.71,fee schedule,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7049.57,,,,,,,5914.83,15002.44,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11489.57,,,,,,,10200.61,25872.94,fee schedule,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7464.40,,,,,,,6315.26,16018.10,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13032.60,,,,,,,11690.03,29650.72,fee schedule,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8394.36,,,,,,,7212.90,18294.89,fee schedule,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6136.47,,,,,,,5033.44,12766.88,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12225.09,,,,,,,10910.60,27673.76,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6966.90,,,,,,,5835.04,14800.06,fee schedule,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5085.59,,,,,,,4019.07,10194.02,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10629.27,,,,,,,9370.20,23766.67,fee schedule,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6888.84,,,,,,,5759.68,14608.92,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13162.69,,,,,,,11815.63,29969.28,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8083.60,,,,,,,6912.95,17534.08,fee schedule,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5889.25,,,,,,,4794.81,12161.61,fee schedule,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19252.10,,,,,,,17693.52,44878.03,fee schedule,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12506.75,,,,,,,11182.48,28363.35,fee schedule,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9683.26,,,,,,,8457.04,21450.53,fee schedule,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,31694.22,,,,,,,29279.42,75340.15,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,42792.31,,,,,,,39531.94,102511.70,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23119.60,,,,,,,21358.11,54346.85,fee schedule,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17910.39,,,,,,,16398.40,41593.08,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28212.47,,,,,,,26062.95,66815.78,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17586.64,,,,,,,16085.89,40800.42,fee schedule,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13073.91,,,,,,,11729.93,29751.91,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,26204.87,,,,,,,24208.31,61900.54,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17014.13,,,,,,,15533.27,39398.75,fee schedule,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13631.12,,,,,,,12267.77,31116.11,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28189.53,,,,,,,26041.75,66759.56,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16740.12,,,,,,,15268.78,38727.89,fee schedule,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11356.39,,,,,,,10072.06,25546.88,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19187.05,,,,,,,17630.72,44718.75,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13869.16,,,,,,,12497.54,31698.89,fee schedule,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11375.53,,,,,,,10090.53,25593.73,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,26999.33,,,,,,,24942.24,63845.65,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14220.47,,,,,,,12836.65,32559.01,fee schedule,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11633.46,,,,,,,10339.51,26225.23,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,32708.36,,,,,,,30216.30,77823.07,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17667.76,,,,,,,16164.21,40999.06,fee schedule,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12404.98,,,,,,,11084.22,28114.12,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,85276.57,,,,,,,78779.31,206526.27,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,56172.01,,,,,,,51892.24,135269.35,fee schedule,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,43951.87,,,,,,,40603.15,105350.66,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,69880.07,,,,,,,64555.88,168830.89,fee schedule,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,45062.43,,,,,,,41629.10,108069.69,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15986.21,,,,,,,14541.06,36882.10,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9005.88,,,,,,,7803.21,19792.13,fee schedule,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6375.27,,,,,,,5263.95,13351.54,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14979.72,,,,,,,13569.54,34417.92,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9579.16,,,,,,,8356.57,21195.68,fee schedule,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7452.92,,,,,,,6304.18,15989.99,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.20,,,,,,,12043.92,30548.32,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7360.31,,,,,,,6214.79,15763.25,fee schedule,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5678.00,,,,,,,4590.90,11644.41,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14658.27,,,,,,,13259.24,33630.88,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8310.15,,,,,,,7131.64,18088.76,fee schedule,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6277.29,,,,,,,5169.38,13111.68,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13710.70,,,,,,,12344.61,31311.00,fee schedule,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9298.26,,,,,,,8085.43,20507.96,fee schedule,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7253.93,,,,,,,6112.09,15502.77,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,52061.88,,,,,,,48095.26,125206.50,fee schedule,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33380.36,,,,,,,30837.10,79468.35,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,41713.86,,,,,,,38535.67,99871.37,fee schedule,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25646.90,,,,,,,23692.85,60534.47,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,65240.30,,,,,,,60269.61,157471.31,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,46562.60,,,,,,,43014.97,111742.53,fee schedule,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,32858.36,,,,,,,30354.87,78190.35,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,43194.12,,,,,,,39604.11,100452.28,fee schedule,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21281.15,,,,,,,19652.08,49845.74,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,44545.04,,,,,,,41151.13,106802.93,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24761.35,,,,,,,22874.77,58366.36,fee schedule,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,40763.27,,,,,,,32841.00,97543.99,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27913.97,,,,,,,25787.19,66084.96,fee schedule,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21954.69,,,,,,,20281.95,51494.77,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24137.57,,,,,,,22298.52,56839.13,fee schedule,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15685.42,,,,,,,14490.34,36145.66,fee schedule,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,37880.05,,,,,,,34993.95,90485.01,fee schedule,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23470.91,,,,,,,21682.65,55206.97,fee schedule,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19607.24,,,,,,,18036.32,45747.52,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33779.12,,,,,,,31205.47,80444.65,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18339.78,,,,,,,16812.87,42644.34,fee schedule,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9954.97,,,,,,,8719.32,22115.77,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27362.90,,,,,,,25278.10,64735.75,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19744.25,,,,,,,18168.57,46082.95,fee schedule,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23212.22,,,,,,,21443.67,54573.59,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16952.88,,,,,,,15474.17,39248.84,fee schedule,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13405.34,,,,,,,12049.83,30563.31,fee schedule,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22137.61,,,,,,,20450.94,51942.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25621.65,,,,,,,23669.52,60472.63,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16926.87,,,,,,,15449.05,39185.12,fee schedule,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12909.36,,,,,,,11571.09,29349.02,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14460.79,,,,,,,11256.36,28550.74,fee schedule,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9469.72,,,,,,,8250.92,20927.72,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29023.77,,,,,,,26812.44,68802.11,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20332.84,,,,,,,18736.71,47523.98,fee schedule,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16279.37,,,,,,,14824.02,37599.80,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28672.47,,,,,,,26487.90,67941.99,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14728.68,,,,,,,13327.21,33803.28,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10170.04,,,,,,,8508.76,21581.71,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24012.02,,,,,,,22182.53,56531.82,fee schedule,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16342.87,,,,,,,14885.34,37755.34,fee schedule,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25144.82,,,,,,,23229.03,59305.19,fee schedule,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14301.58,,,,,,,12914.96,32757.65,fee schedule,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11223.21,,,,,,,9943.51,25220.82,fee schedule,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22284.56,,,,,,,20586.69,52302.42,fee schedule,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15228.48,,,,,,,13809.65,35026.94,fee schedule,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14643.73,,,,,,,13245.21,33595.28,fee schedule,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11248.47,,,,,,,8862.64,22479.30,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14747.82,,,,,,,13345.68,33850.13,fee schedule,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12512.90,,,,,,,11188.39,28378.34,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24040.37,,,,,,,22208.72,56601.15,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16837.31,,,,,,,15362.61,38965.88,fee schedule,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13592.09,,,,,,,12230.10,31020.54,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12971.36,,,,,,,11630.93,29500.81,fee schedule,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8746.44,,,,,,,7552.75,19156.88,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25313.97,,,,,,,23385.28,59719.32,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16827.37,,,,,,,15353.00,38941.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12683.56,,,,,,,11353.14,28796.22,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29526.63,,,,,,,27276.98,70033.26,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16231.12,,,,,,,14777.48,37481.75,fee schedule,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12355.99,,,,,,,11036.93,27994.19,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22889.99,,,,,,,21145.99,53784.68,fee schedule,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17130.46,,,,,,,15645.57,39683.58,fee schedule,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12920.83,,,,,,,11582.17,29377.13,fee schedule,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7091.66,,,,,,,5955.47,15105.51,fee schedule,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10734.13,,,,,,,9471.42,24023.40,fee schedule,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7103.15,,,,,,,5966.55,15133.62,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8225.97,,,,,,,7050.37,17882.63,fee schedule,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6434.97,,,,,,,5321.58,13497.70,fee schedule,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15997.69,,,,,,,14552.14,36910.21,fee schedule,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6948.53,,,,,,,5699.84,14457.14,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14442.42,,,,,,,13050.90,33102.44,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8790.05,,,,,,,7594.86,19263.69,fee schedule,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6697.49,,,,,,,5574.98,14140.45,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19916.46,,,,,,,18334.80,46504.58,fee schedule,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9749.85,,,,,,,8521.32,21613.56,fee schedule,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7322.04,,,,,,,6177.85,15669.55,fee schedule,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15700.72,,,,,,,14265.49,36183.14,fee schedule,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10161.62,,,,,,,8918.79,22621.72,fee schedule,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7612.12,,,,,,,6457.85,16379.76,fee schedule,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13750.53,,,,,,,12383.03,31408.44,fee schedule,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8279.54,,,,,,,7102.08,18013.80,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10843.57,,,,,,,9577.06,24291.37,fee schedule,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7275.36,,,,,,,6132.78,15555.24,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11038.75,,,,,,,9765.46,24769.21,fee schedule,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7279.18,,,,,,,6136.47,15564.61,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12302.40,,,,,,,10985.22,27863.02,fee schedule,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7758.30,,,,,,,6598.96,16737.67,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15195.59,,,,,,,13777.88,34946.36,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9540.90,,,,,,,8319.63,21101.99,fee schedule,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7074.82,,,,,,,5939.21,15064.28,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11827.11,,,,,,,10526.42,26699.33,fee schedule,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7775.91,,,,,,,6615.95,16780.77,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12736.38,,,,,,,11404.12,28925.52,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8379.80,,,,,,,7198.87,18259.28,fee schedule,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6656.93,,,,,,,5535.83,14041.13,fee schedule,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23432.65,,,,,,,21647.31,55113.27,fee schedule,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13853.08,,,,,,,12482.03,31659.54,fee schedule,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9695.51,,,,,,,8468.86,21480.52,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,51065.36,,,,,,,47174.67,122766.68,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27491.49,,,,,,,25396.90,65050.56,fee schedule,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14675.87,,,,,,,12069.04,30612.03,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,38434.98,,,,,,,35506.60,91843.59,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21209.97,,,,,,,19583.37,49671.47,fee schedule,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13217.04,,,,,,,11868.08,30102.33,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25708.90,,,,,,,23750.13,60686.25,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14147.76,,,,,,,12766.46,32380.99,fee schedule,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11967.17,,,,,,,10661.62,27042.25,fee schedule,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15667.80,,,,,,,14233.72,36102.56,fee schedule,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14120.20,,,,,,,12739.87,32313.53,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17306.50,,,,,,,15815.49,40114.58,fee schedule,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15686.94,,,,,,,14252.19,36149.40,fee schedule,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15734.39,,,,,,,14298.00,36265.59,fee schedule,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10001.65,,,,,,,8764.38,22230.08,fee schedule,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7556.25,,,,,,,6403.92,16242.97,fee schedule,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17153.42,,,,,,,15667.73,39739.80,fee schedule,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9207.19,,,,,,,7997.51,20284.97,fee schedule,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13681.63,,,,,,,12316.53,31239.79,fee schedule,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9580.68,,,,,,,8358.04,21199.43,fee schedule,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6810.76,,,,,,,5416.88,13739.43,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8894.14,,,,,,,7695.34,19518.54,fee schedule,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5552.46,,,,,,,4469.74,11337.09,fee schedule,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11800.31,,,,,,,10500.56,26633.74,fee schedule,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7587.64,,,,,,,6434.21,16319.80,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12189.12,,,,,,,10875.87,27585.68,fee schedule,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7932.82,,,,,,,6767.41,17164.92,fee schedule,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12503.69,,,,,,,11179.52,28355.85,fee schedule,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7859.34,,,,,,,6696.48,16985.03,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17697.61,,,,,,,16193.02,41072.14,fee schedule,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11631.94,,,,,,,10338.03,26221.48,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27613.94,,,,,,,25510.02,65350.39,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15236.90,,,,,,,13817.78,35047.55,fee schedule,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11777.35,,,,,,,10478.40,26577.52,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23021.63,,,,,,,16490.00,54106.99,fee schedule,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13170.34,,,,,,,11823.02,35030.00,fee schedule,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12466.97,,,,,,,11144.06,35030.00,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28163.50,,,,,,,26017.71,66695.85,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14652.15,,,,,,,13253.33,33615.89,fee schedule,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10503.75,,,,,,,9249.04,23459.35,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24037.29,,,,,,,22205.88,56593.65,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12398.07,,,,,,,11077.57,28097.26,fee schedule,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11088.51,,,,,,,9813.48,24891.01,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29446.28,,,,,,,27202.76,69836.51,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17598.10,,,,,,,16096.97,40828.53,fee schedule,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12092.68,,,,,,,10782.79,27349.57,fee schedule,
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11918.19,,,,,,,10614.34,26922.32,fee schedule,
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7781.28,,,,,,,6621.13,16793.89,fee schedule,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5676.47,,,,,,,4589.43,11640.67,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11144.39,,,,,,,9867.41,25027.81,fee schedule,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6878.11,,,,,,,5749.34,14582.69,fee schedule,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11806.44,,,,,,,10506.47,26648.73,fee schedule,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13520.90,,,,,,,12161.39,30846.27,fee schedule,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8767.08,,,,,,,7572.70,19207.47,fee schedule,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6802.33,,,,,,,5676.20,14397.17,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,36905.73,,,,,,,34093.86,60549.33,fee schedule,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29285.54,,,,,,,27054.26,47727.00,fee schedule,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25640.01,,,,,,,23686.49,41592.73,fee schedule,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,40694.39,,,,,,,37593.86,97375.34,fee schedule,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22347.32,,,,,,,20644.67,52456.08,fee schedule,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17122.05,,,,,,,15637.44,39662.97,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25290.24,,,,,,,23363.36,59661.23,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14928.45,,,,,,,13520.04,34292.37,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12799.14,,,,,,,11464.70,29079.18,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20369.56,,,,,,,18772.17,47613.93,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11037.99,,,,,,,9764.72,24767.34,fee schedule,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8846.69,,,,,,,7649.54,19402.36,fee schedule,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24354.16,,,,,,,22498.61,57369.45,fee schedule,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12557.29,,,,,,,11231.24,28487.03,fee schedule,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8934.71,,,,,,,7734.50,19617.86,fee schedule,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,24811.11,,,,,,,22920.74,58488.17,fee schedule,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14310.76,,,,,,,12923.83,32780.13,fee schedule,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9388.58,,,,,,,8172.61,20729.08,fee schedule,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23271.15,,,,,,,21498.11,54717.88,fee schedule,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12800.68,,,,,,,11466.18,29082.93,fee schedule,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8402.00,,,,,,,7220.29,18313.62,fee schedule,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14660.56,,,,,,,13261.46,33636.50,fee schedule,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9184.23,,,,,,,7975.35,20228.75,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33080.34,,,,,,,30559.94,78733.78,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18821.20,,,,,,,17277.58,43823.03,fee schedule,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13484.93,,,,,,,12126.66,30758.19,fee schedule,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12257.25,,,,,,,10941.63,27752.46,fee schedule,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7625.13,,,,,,,6470.41,16411.62,fee schedule,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5516.50,,,,,,,4435.02,11249.02,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14727.15,,,,,,,13325.74,33799.53,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8941.60,,,,,,,7741.15,19634.72,fee schedule,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6970.73,,,,,,,5838.74,14809.43,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9802.66,,,,,,,8572.30,21742.86,fee schedule,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7117.70,,,,,,,5980.59,15169.22,fee schedule,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11212.51,,,,,,,9933.17,25194.59,fee schedule,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6904.90,,,,,,,5775.20,14648.28,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9676.36,,,,,,,8450.39,21433.67,fee schedule,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6195.39,,,,,,,5090.33,12911.17,fee schedule,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9171.21,,,,,,,7962.79,20196.89,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13584.44,,,,,,,12222.71,31001.80,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8690.56,,,,,,,7498.82,19020.08,fee schedule,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6202.28,,,,,,,5096.98,12928.04,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16231.91,,,,,,,14778.22,37483.62,fee schedule,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12664.44,,,,,,,11334.67,28749.37,fee schedule,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18733.19,,,,,,,17192.61,43607.53,fee schedule,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11646.48,,,,,,,10352.07,26257.09,fee schedule,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16871.00,,,,,,,15395.11,39048.33,fee schedule,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9338.83,,,,,,,8124.58,20607.28,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12428.70,,,,,,,11107.12,28172.21,fee schedule,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9015.07,,,,,,,7812.07,19814.62,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18045.87,,,,,,,16529.17,41924.76,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12180.70,,,,,,,10867.75,27565.07,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15391.50,,,,,,,13967.01,35426.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11201.78,,,,,,,9922.82,25168.35,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14773.07,,,,,,,13370.06,33911.97,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9667.94,,,,,,,8442.27,21413.06,fee schedule,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5940.52,,,,,,,4519.24,11462.65,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9878.43,,,,,,,8645.44,21928.38,fee schedule,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6447.99,,,,,,,5334.14,13529.56,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12271.80,,,,,,,10955.67,27788.06,fee schedule,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7130.69,,,,,,,5993.15,15201.08,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9025.02,,,,,,,7821.68,19838.98,fee schedule,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6065.28,,,,,,,4964.74,12592.61,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17224.61,,,,,,,15736.44,39914.07,fee schedule,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11220.15,,,,,,,9940.55,25213.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28280.60,,,,,,,26125.88,66982.56,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16693.42,,,,,,,15223.71,38613.58,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12161.57,,,,,,,10849.28,27518.22,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28344.13,,,,,,,26052.30,66079.34,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14772.31,,,,,,,13369.32,33910.09,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11837.06,,,,,,,10536.03,26723.69,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14965.18,,,,,,,13555.50,34382.32,fee schedule,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10418.04,,,,,,,9166.29,23249.48,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16605.42,,,,,,,15138.75,38398.08,fee schedule,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9628.15,,,,,,,8403.85,21315.61,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14217.40,,,,,,,12833.69,32551.52,fee schedule,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7501.91,,,,,,,6202.23,15731.39,fee schedule,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11540.09,,,,,,,10249.37,25996.61,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20573.93,,,,,,,18969.43,48114.26,fee schedule,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12217.45,,,,,,,10903.21,27655.02,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15018.00,,,,,,,13606.48,34511.62,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9247.76,,,,,,,8036.67,20384.28,fee schedule,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8273.41,,,,,,,7096.17,17998.81,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11881.44,,,,,,,10578.88,26832.37,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8415.00,,,,,,,7232.85,18345.48,fee schedule,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6000.99,,,,,,,4902.68,12435.20,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8633.14,,,,,,,7443.41,18879.54,fee schedule,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5288.42,,,,,,,4208.20,10673.73,fee schedule,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9123.75,,,,,,,4210.00,9518.00,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13855.37,,,,,,,12484.24,31665.16,fee schedule,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8596.40,,,,,,,7407.95,18789.60,fee schedule,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5932.88,,,,,,,4836.92,12268.42,fee schedule,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7361.08,,,,,,,5268.38,13362.78,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19712.87,,,,,,,5414.00,31619.23,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9035.74,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8252.75,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13546.92,,,,,,,5414.00,21243.91,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9469.72,,,,,,,5414.00,15908.00,fee schedule,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8260.41,,,,,,,5414.00,15908.00,fee schedule,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14715.68,,,,,,,1810.00,33771.43,fee schedule,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,46412.59,,,,,,,1810.00,111375.25,fee schedule,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,31988.89,,,,,,,1810.00,76061.60,fee schedule,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19667.71,,,,,,,1810.00,45895.56,fee schedule,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,32835.41,,,,,,,1810.00,78134.13,fee schedule,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12218.22,,,,,,,375.00,27656.89,fee schedule,
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2451.13,,,,,,,314.00,3744.05,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9853.93,,,,,,,4210.00,9947.78,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8578.80,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8247.39,,,,,,,4210.00,9518.00,fee schedule,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,35585.44,,,,,,,32874.17,84867.06,fee schedule,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22424.63,,,,,,,20716.09,52645.35,fee schedule,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15532.33,,,,,,,14102.95,35770.88,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,31415.61,,,,,,,29022.04,74658.05,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15149.64,,,,,,,13733.55,34833.93,fee schedule,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11300.51,,,,,,,10018.13,25410.08,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9181.93,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6692.90,,,,,,,4210.00,9518.00,fee schedule,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6082.11,,,,,,,4210.00,9518.00,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17820.82,,,,,,,16311.97,41373.84,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10610.90,,,,,,,9352.47,23721.70,fee schedule,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8932.41,,,,,,,7732.28,19612.24,fee schedule,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11670.19,,,,,,,10374.97,26315.18,fee schedule,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7949.65,,,,,,,6783.66,17206.15,fee schedule,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12596.31,,,,,,,11268.92,28582.60,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17199.35,,,,,,,15712.06,39852.23,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8682.89,,,,,,,7491.43,19001.35,fee schedule,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5759.11,,,,,,,4669.22,11843.05,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18384.93,,,,,,,12470.94,31631.43,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9794.24,,,,,,,7788.43,19754.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7503.45,,,,,,,6352.94,16113.67,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,45810.23,,,,,,,42319.93,109900.49,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18055.80,,,,,,,16538.78,41949.13,fee schedule,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10137.14,,,,,,,8895.15,22561.76,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,36013.28,,,,,,,33269.41,85914.57,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18262.46,,,,,,,16738.25,42455.08,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11249.99,,,,,,,9969.37,25286.41,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,36725.08,,,,,,,33926.98,87657.29,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18611.49,,,,,,,17075.15,43309.58,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13962.53,,,,,,,12587.67,31927.51,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25108.06,,,,,,,23195.07,59215.24,fee schedule,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12440.96,,,,,,,11118.94,28202.19,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10125.65,,,,,,,8884.07,22533.65,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6444.91,,,,,,,5331.18,13522.06,fee schedule,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4924.09,,,,,,,3863.19,9798.62,fee schedule,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,42940.80,,,,,,,39669.12,102875.24,fee schedule,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16886.29,,,,,,,15409.89,39085.81,fee schedule,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10255.76,,,,,,,9009.67,22852.21,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,37693.32,,,,,,,34821.45,90027.78,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16898.56,,,,,,,15421.71,39115.79,fee schedule,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11973.30,,,,,,,10667.53,27057.24,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25681.35,,,,,,,23724.68,60618.79,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13408.38,,,,,,,12052.78,30570.80,fee schedule,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8655.36,,,,,,,7464.84,18933.89,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16189.80,,,,,,,14737.58,37380.56,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10239.68,,,,,,,8994.15,22812.86,fee schedule,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.92,,,,,,,6291.62,15958.13,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20764.51,,,,,,,19153.39,48580.86,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10934.67,,,,,,,9664.98,24514.36,fee schedule,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7423.08,,,,,,,6275.37,15916.91,fee schedule,
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21660.01,,,,,,,20009.72,50773.32,fee schedule,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,67200.45,,,,,,,62080.42,162270.37,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,38721.22,,,,,,,35771.03,92544.43,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16215.06,,,,,,,14761.96,37442.40,fee schedule,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12381.24,,,,,,,11061.31,28056.03,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,35736.97,,,,,,,33014.15,85238.09,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17312.62,,,,,,,15821.40,40129.57,fee schedule,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11582.94,,,,,,,10290.75,26101.55,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14880.23,,,,,,,13473.50,34174.31,fee schedule,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8559.68,,,,,,,7372.49,18699.65,fee schedule,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7716.22,,,,,,,6558.33,16634.61,fee schedule,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12389.66,,,,,,,11069.44,28076.64,fee schedule,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7577.68,,,,,,,6424.60,16295.43,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16942.94,,,,,,,15464.56,39224.47,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8813.78,,,,,,,7617.77,19321.78,fee schedule,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6506.90,,,,,,,5391.02,13673.85,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,53823.82,,,,,,,49722.96,129520.22,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15789.50,,,,,,,14351.19,36400.51,fee schedule,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8754.09,,,,,,,7560.14,19175.62,fee schedule,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,30503.29,,,,,,,823.98,72424.36,fee schedule,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8271.10,,,,,,,823.98,17993.19,fee schedule,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8123.40,,,,,,,823.98,17631.53,fee schedule,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9140.60,,,,,,,823.98,20121.94,fee schedule,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15971.67,,,,,,,823.98,36846.50,fee schedule,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13236.18,,,,,,,823.98,30149.18,fee schedule,
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11612.79,,,,,,,823.98,26174.64,fee schedule,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16805.94,,,,,,,823.98,38889.05,fee schedule,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9118.42,,,,,,,823.98,20067.60,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5643.55,,,,,,,823.98,11560.09,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11756.68,,,,,,,823.98,26526.93,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14278.65,,,,,,,823.98,32701.43,fee schedule,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7678.71,,,,,,,823.98,16542.79,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33042.06,,,,,,,30524.57,78640.09,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15575.19,,,,,,,14144.33,35875.82,fee schedule,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9873.84,,,,,,,8641.00,21917.13,fee schedule,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29035.26,,,,,,,26823.05,68830.22,fee schedule,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12275.62,,,,,,,10578.14,26830.50,fee schedule,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,15956.36,,,,,,,13020.61,33025.61,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,30307.32,,,,,,,27998.19,71944.64,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16192.86,,,,,,,14740.54,37388.05,fee schedule,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10969.12,,,,,,,9698.23,24598.69,fee schedule,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13432.90,,,,,,,12076.42,30630.77,fee schedule,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7699.38,,,,,,,6542.07,16593.38,fee schedule,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13792.61,,,,,,,12423.66,31511.50,fee schedule,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6021.67,,,,,,,4922.62,12485.80,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12926.20,,,,,,,11587.34,29390.25,fee schedule,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7482.00,,,,,,,6332.25,16061.20,fee schedule,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14934.57,,,,,,,13525.95,34307.36,fee schedule,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8593.35,,,,,,,7404.99,18782.10,fee schedule,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6190.80,,,,,,,5085.90,12899.93,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14311.54,,,,,,,12924.57,32782.01,fee schedule,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8711.22,,,,,,,7518.77,19070.68,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,164335.51,,,,,,,136162.32,345363.52,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,55820.70,,,,,,,51567.69,134409.23,fee schedule,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25573.43,,,,,,,23624.98,60354.57,fee schedule,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,30727.54,,,,,,,28197.78,71521.14,fee schedule,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,17841.49,,,,,,,16331.91,41424.43,fee schedule,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16688.83,,,,,,,15219.28,38602.34,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,28693.91,,,,,,,26507.70,67994.46,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18808.19,,,,,,,17265.02,43791.17,fee schedule,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,16441.60,,,,,,,14980.65,37997.07,fee schedule,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12774.66,,,,,,,526.87,29019.22,fee schedule,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9699.34,,,,,,,526.87,21489.89,fee schedule,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10637.70,,,,,,,9378.33,23787.29,fee schedule,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7048.81,,,,,,,5914.09,15000.57,fee schedule,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10027.67,,,,,,,8789.50,22293.79,fee schedule,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5726.21,,,,,,,4637.45,11762.47,fee schedule,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5177.42,,,,,,,4107.73,10418.88,fee schedule,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,52440.77,,,,,,,48445.28,126134.08,fee schedule,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,29723.35,,,,,,,27458.71,70514.86,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,59243.50,,,,,,,54729.71,142789.31,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33174.46,,,,,,,30646.88,78964.27,fee schedule,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23455.60,,,,,,,21668.51,55169.49,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21846.01,,,,,,,20181.55,51228.68,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12652.20,,,,,,,11322.85,28719.39,fee schedule,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8120.32,,,,,,,6948.41,17624.03,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,47773.44,,,,,,,44133.55,114707.04,fee schedule,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,21108.17,,,,,,,19485.11,49422.24,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23010.91,,,,,,,21257.70,54080.75,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10833.63,,,,,,,9567.46,24267.01,fee schedule,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7831.04,,,,,,,6608.57,16762.04,fee schedule,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10854.29,,,,,,,9365.03,23753.56,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,36832.24,,,,,,,34025.97,87919.64,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19738.90,,,,,,,18163.40,46069.83,fee schedule,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,14040.60,,,,,,,12663.03,32118.65,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,27162.37,,,,,,,25092.85,64244.79,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13501.77,,,,,,,12142.92,30799.42,fee schedule,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10100.38,,,,,,,8859.69,22471.81,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66984,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,11124.00,24600.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",361,RC,31629,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE",360,RC,66999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2025.00,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",361,RC,31653,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4121.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE",360,RC,67108,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION",360,RC,67040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18119.20,,,,,,,8612.00,18291.76,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION",360,RC,66982,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,12686.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,10016.47,24600.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL)",360,RC,67042,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL,360,RC,65756,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, INCLUDING, WHEN PERFORMED, AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS",360,RC,67113,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5373.49,,,,,,,4964.08,17457.00,fee schedule,
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,17457.00,fee schedule,
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22332.87,,,,,,,4376.00,52940.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
GONIOTOMY,360,RC,65820,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3788.00,5754.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,6274.19,10087.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER)",360,RC,67041,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;",360,RC,67036,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT",360,RC,66180,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5373.49,,,,,,,4964.08,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9965.52,,,,,,,6649.00,13852.00,fee schedule,
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,11124.00,39682.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)",360,RC,19340,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,4376.00,10022.00,fee schedule,
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6834.82,,,,,,,6314.07,13852.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,22332.87,,,,,,,11124.00,24600.00,fee schedule,
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT",360,RC,66174,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7701.19,,,,,,,6636.00,10087.00,fee schedule,
"CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, TRANSSCLERAL",360,RC,66710,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,10087.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,173.00,4311.00,fee schedule,
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6834.82,,,,,,,6314.07,24600.00,fee schedule,
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66991,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,4376.00,10022.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT,360,RC,65426,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,6735.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6199.45,,,,,,,3788.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,4311.00,10022.00,fee schedule,
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ABLATION OF MALIGNANT PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY-FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE",360,RC,55880,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE",360,RC,15771,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 HORIZONTAL MUSCLE",360,RC,67311,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCHANGE OF INTRAOCULAR LENS,360,RC,66986,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,13652.00,fee schedule,
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G",360,RC,58546,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,6636.00,10087.00,fee schedule,
MASTOPEXY,360,RC,19316,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,5219.00,8442.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY",360,RC,64582,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,31736.18,,,,,,,4376.00,52940.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)",360,RC,0266T,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,46864.96,,,,,,,34125.00,52940.00,fee schedule,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)",360,RC,67924,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,24600.00,fee schedule,
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)",360,RC,67917,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,10087.00,24600.00,fee schedule,
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION,360,RC,67412,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
CANTHOPLASTY (RECONSTRUCTION OF CANTHUS),360,RC,67950,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32550,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID",360,RC,67107,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,10087.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY",360,RC,19302,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,6274.19,12408.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64461,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,8442.00,fee schedule,
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION",481,RC,93660,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,173.00,9423.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM",360,RC,14301,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC,360,RC,46275,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,9350.00,fee schedule,
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,173.00,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY",360,RC,47370,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8442.00,24600.00,fee schedule,
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE-EXPLORATION,360,RC,60502,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA),360,RC,65730,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF",360,RC,53445,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
REPAIR OF RECTOCELE (SEPARATE PROCEDURE),360,RC,45560,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,6735.00,24600.00,fee schedule,
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL",360,RC,66985,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,11124.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)",360,RC,67908,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,8612.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3581.50,,,,,,,3308.62,8045.00,fee schedule,
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT",360,RC,21243,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,6636.00,19334.39,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY",360,RC,66852,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,10022.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",360,RC,22514,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
REMOVAL OF INTACT BREAST IMPLANT,360,RC,19328,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
"ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46606,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,6735.00,fee schedule,
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION",360,RC,68816,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,9350.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)",360,RC,43653,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BREAST AUGMENTATION WITH IMPLANT,360,RC,19325,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9965.52,,,,,,,8612.00,17457.00,fee schedule,
"REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE PROCEDURE)",360,RC,66825,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44366,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,12408.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",360,RC,64520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",360,RC,22513,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,11124.00,24600.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY",360,RC,15830,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,6274.19,10022.00,fee schedule,
"FISSURECTOMY, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED",360,RC,46200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BAND LIGATION(S)",360,RC,46221,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,31622,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD",360,RC,28292,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER,360,RC,46505,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH",360,RC,68841,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
RELOCATION OF SKIN POCKET FOR PACEMAKER,360,RC,33222,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,0184T,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6199.45,,,,,,,5219.00,8045.00,fee schedule,
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11626,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,6649.00,fee schedule,
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES)",360,RC,28313,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,10087.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6498.27,,,,,,,5219.00,8442.00,fee schedule,
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,6636.00,10022.00,fee schedule,
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH",360,RC,66183,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38572,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,25548.73,,,,,,,9423.00,39682.00,fee schedule,
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3581.50,,,,,,,3308.62,12408.00,fee schedule,
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, CURETTAGE)",360,RC,65435,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE",360,RC,67808,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION",360,RC,67039,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,17457.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR",360,RC,67121,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,8045.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,2025.00,6649.00,fee schedule,
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION",360,RC,66850,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42415,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN",360,RC,67961,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE",360,RC,64620,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,6274.19,17457.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
RELOCATION OF SKIN POCKET FOR IMPLANTABLE DEFIBRILLATOR,360,RC,33223,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH",360,RC,67903,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"MEDIASTINOSCOPY; INCLUDES BIOPSY(IES) OF MEDIASTINAL MASS (EG, LYMPHOMA), WHEN PERFORMED",360,RC,39401,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",360,RC,46946,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44385,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
TRABECULOTOMY AB EXTERNO,360,RC,65850,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6834.82,,,,,,,4376.00,17457.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,23376.18,,,,,,,6735.00,82346.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)",360,RC,58660,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY),360,RC,64716,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,6735.00,fee schedule,
"REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION",360,RC,54410,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20962.53,,,,,,,6649.00,39682.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,3788.00,8442.00,fee schedule,
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5152.00,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"BLEPHAROPLASTY, UPPER EYELID;",360,RC,15822,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISSURECTOMY",360,RC,46261,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD",360,RC,28298,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE)",360,RC,51045,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,990.00,8442.00,fee schedule,
"RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT",360,RC,21141,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)",360,RC,57530,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA",360,RC,27252,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,990.00,5152.00,fee schedule,
PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION,360,RC,54360,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 2 HORIZONTAL MUSCLES",360,RC,67312,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60210,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45340,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,10087.00,fee schedule,
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)",360,RC,58100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); TIBIA",360,RC,27640,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
SUCTION ASSISTED LIPECTOMY; TRUNK,360,RC,15877,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,360,RC,33264,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57061,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,8442.00,24600.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, 1 OR MORE STAGES",360,RC,66840,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,1494.54,4311.00,fee schedule,
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,10087.00,fee schedule,
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"REMOVAL OF SUTURES OR STAPLES REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION)",360,RC,15851,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18406.40,,,,,,,4376.00,52940.00,fee schedule,
"PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA",360,RC,27745,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
EXCISION OF HYDROCELE; BILATERAL,360,RC,55041,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
"TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION",360,RC,67228,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITH GRAFT,360,RC,66185,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45334,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,9350.00,fee schedule,
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30130,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
REPAIR INCOMPLETE CIRCUMCISION,360,RC,54163,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,57.15,832.00,fee schedule,
"THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE)",360,RC,60520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS",360,RC,63005,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,5219.00,13527.54,fee schedule,
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT,360,RC,65420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE)",360,RC,46080,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,360,RC,33233,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,4376.00,8700.96,fee schedule,
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH",360,RC,45541,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT",360,RC,46750,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE)",360,RC,67875,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,44380,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL",360,RC,64772,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,9503.00,27871.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM",360,RC,12042,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58544,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON",360,RC,27680,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION",360,RC,36820,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE",360,RC,15773,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,17457.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITHOUT IMPLANT",360,RC,28289,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,316.80,,,,,,,173.00,5152.00,fee schedule,
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",361,RC,33285,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, TRACHEA, BRONCHI",361,RC,31899,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,202.19,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE",361,RC,31626,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA",360,RC,54300,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
PLASTIC REPAIR OF CANALICULI,360,RC,68700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR",360,RC,63017,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,57.15,4311.00,fee schedule,
"ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT",360,RC,29848,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,17457.00,fee schedule,
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM",360,RC,45005,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6791.65,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN",360,RC,27415,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR",360,RC,67120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13530.72,,,,,,,4376.00,24600.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28465,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL)",360,RC,30802,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27659,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, TESIO TYPE CATHETER)",360,RC,36565,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"CORRECTION OF EVERTED PUNCTUM, CAUTERY",360,RC,68705,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT,360,RC,67255,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3788.00,6735.00,fee schedule,
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; 1 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE)",360,RC,67314,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION",360,RC,36819,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT",360,RC,28291,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION",360,RC,53447,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,20962.53,,,,,,,4121.00,39682.00,fee schedule,
"CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT)",360,RC,67912,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2025.00,8213.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION",360,RC,37244,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE",360,RC,17999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,4376.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION",360,RC,35011,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,360,RC,33231,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,33389.96,,,,,,,6735.00,82346.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,6735.00,24600.00,fee schedule,
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL MEGACOLON)",360,RC,45100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY",360,RC,60225,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC BALLOON DILATION",750,RC,45386,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14001,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31259,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION",360,RC,68801,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,173.00,832.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND,360,RC,42440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK",360,RC,54150,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
"REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION)",360,RC,30465,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,17457.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED PROCEDURE, PANCREAS",750,RC,48999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,2912.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,51992,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4376.00,fee schedule,
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL,360,RC,45905,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CYSTOURETHROSCOPY WITH TRANSURETHRAL ANTERIOR PROSTATE COMMISSUROTOMY AND DRUG DELIVERY, INCLUDING TRANSRECTAL ULTRASOUND AND FLUOROSCOPY, WHEN PERFORMED",360,RC,0619T,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,3788.00,17457.00,fee schedule,
REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE),360,RC,55060,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST (INCLUDES PLACEMENT OF TRANSMURAL DRAINAGE CATHETER[S]/STENT[S], WHEN PERFORMED, AND ENDOSCOPIC ULTRASOUND, WHEN PERFORMED)",750,RC,43240,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6199.45,,,,,,,3788.00,6258.49,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43202,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,4376.00,fee schedule,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS",360,RC,31288,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,17457.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS",360,RC,14000,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION",360,RC,34111,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",360,RC,10121,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION",360,RC,36818,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; LESS THAN 2 CM",360,RC,21011,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,5152.00,fee schedule,
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,2025.00,12408.00,fee schedule,
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;",360,RC,67880,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE; PHOTOCOAGULATION",360,RC,67145,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,23075,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,23076,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2025.00,5152.00,fee schedule,
EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT,360,RC,65093,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTIDIRECTIONAL INSTABILITY",360,RC,23466,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,12408.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT",360,RC,47564,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12986.98,,,,,,,4311.00,13852.00,fee schedule,
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6834.82,,,,,,,4311.00,13852.00,fee schedule,
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,12408.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH",360,RC,28470,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;,360,RC,60280,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION",360,RC,24546,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8612.00,13852.00,fee schedule,
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; SINGLE HEMORRHOID COLUMN/GROUP, WITHOUT IMAGING GUIDANCE",360,RC,46945,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,173.00,832.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION",360,RC,21195,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
CORONOIDECTOMY (SEPARATE PROCEDURE),360,RC,21070,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE",360,RC,51990,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,4311.00,13527.54,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH OPTICAL ENDOMICROSCOPY",750,RC,43252,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS,360,RC,54162,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, BONE, OPEN; DEEP (EG, HUMERAL SHAFT, ISCHIUM, FEMORAL SHAFT)",360,RC,20245,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
SCROTAL EXPLORATION,360,RC,55110,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52345,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG AND/OR ANKLE",360,RC,27630,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW",360,RC,37722,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH ALLOGRAFT",360,RC,27638,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS",360,RC,58565,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY), BONE (EG, OSTEOMYELITIS); FIBULA",360,RC,27641,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY",360,RC,62350,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,316.80,,,,,,,173.00,4376.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS",361,RC,73610,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,54.52,92.57,fee schedule,
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15273,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION",360,RC,34101,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA,360,RC,32609,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,17457.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,642.16,6649.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,13852.00,fee schedule,
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5754.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS",360,RC,11900,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR",360,RC,51500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5219.00,8442.00,fee schedule,
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,4311.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)",360,RC,29870,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM",360,RC,65400,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE,360,RC,46285,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM,360,RC,65772,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1008.67,,,,,,,931.82,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE",360,RC,66989,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5373.49,,,,,,,4964.08,12686.00,fee schedule,
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45335,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44386,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,10087.00,24600.00,fee schedule,
CORRECTION OF LID RETRACTION,360,RC,67911,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD",360,RC,28111,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
METATARSECTOMY,360,RC,28140,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON",360,RC,28208,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28315,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH",360,RC,28475,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION,360,RC,27781,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION,360,RC,27780,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE",360,RC,29871,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,990.00,4376.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY",360,RC,32606,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,8442.00,13852.00,fee schedule,
RADICAL RESECTION OF TUMOR; TALUS OR CALCANEUS,360,RC,27647,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS,360,RC,38232,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4879.29,,,,,,,4507.53,17457.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING TENOSYNOVECTOMY",360,RC,27626,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,3788.00,8442.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)",360,RC,44186,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4121.00,8045.00,fee schedule,
"DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH",360,RC,45190,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",360,RC,45333,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",360,RC,45350,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR",360,RC,27334,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS",360,RC,46230,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5754.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46262,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,46607,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",360,RC,46615,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION",360,RC,46910,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,12408.00,fee schedule,
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,3788.00,9721.99,fee schedule,
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE",360,RC,53505,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4376.00,8045.00,fee schedule,
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
FRENULOTOMY OF PENIS,360,RC,54164,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
REPAIR OF TRAUMATIC CORPOREAL TEAR(S),360,RC,54437,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,12408.00,fee schedule,
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,990.00,6735.00,fee schedule,
CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH,360,RC,57320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,8045.00,fee schedule,
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57400,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,10087.00,fee schedule,
"CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL",360,RC,57700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY",360,RC,25320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY",360,RC,58674,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"INDUCED ABORTION, BY DILATION AND EVACUATION",360,RC,59841,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,360,RC,61888,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,12986.98,,,,,,,4121.00,13110.66,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE",360,RC,62322,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL",360,RC,63265,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"NEUROPLASTY; DIGITAL, 1 OR BOTH, SAME DIGIT",360,RC,64702,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; SCIATIC NERVE",360,RC,64712,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6669.40,,,,,,,4376.00,10022.00,fee schedule,
"PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED",360,RC,65779,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION",360,RC,65815,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE",360,RC,66250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)",360,RC,66821,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,571.33,,,,,,,527.80,5152.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; CRYOTHERAPY",360,RC,67101,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY",360,RC,67400,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE",360,RC,67973,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
BIOPSY OF CONJUNCTIVA,360,RC,68100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,990.00,6649.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM",360,RC,68115,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,8045.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,4376.00,17457.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH REMOVAL OF FOREIGN BODY",361,RC,31635,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)",360,RC,20650,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"BIOPSY, MUSCLE; SUPERFICIAL",360,RC,20200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
NIPPLE/AREOLA RECONSTRUCTION,360,RC,19350,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD",360,RC,15821,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY",360,RC,15738,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,4311.00,24600.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,6735.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL",360,RC,11750,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11641,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,7300.39,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11602,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,43250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED",750,RC,43278,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,17457.00,fee schedule,
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",360,RC,11011,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45350,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,8213.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45392,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",750,RC,64680,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,5152.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28102,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,10087.00,fee schedule,
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON",360,RC,26483,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27769,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,17457.00,fee schedule,
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,10087.00,fee schedule,
"ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL",360,RC,29820,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,4749.28,12408.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58541,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",750,RC,47563,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,17457.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, UTERUS",360,RC,58578,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE",360,RC,51535,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,12247.00,24600.00,fee schedule,
"ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26841,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION",360,RC,27884,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50385,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,9350.00,fee schedule,
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24575,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,24435,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6649.00,13852.00,fee schedule,
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION",360,RC,62365,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6669.40,,,,,,,4376.00,13852.00,fee schedule,
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8442.00,fee schedule,
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6498.27,,,,,,,5219.00,17457.00,fee schedule,
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC",360,RC,63266,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS",360,RC,24200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4121.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)",360,RC,64449,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,46917,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23930,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT",360,RC,23616,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS,360,RC,23440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
"ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE)",360,RC,46604,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
CHEMODENERVATION OF TRUNK MUSCLE(S); 1-5 MUSCLE(S),360,RC,64646,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; BRACHIAL PLEXUS",360,RC,64713,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP,360,RC,46288,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL",360,RC,27323,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISTULECTOMY, INCLUDING FISSURECTOMY, WHEN PERFORMED",360,RC,46258,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"TENOTOMY, SHOULDER AREA; SINGLE TENDON",360,RC,23405,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES",360,RC,27331,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27339,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA),360,RC,65755,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,12408.00,fee schedule,
PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF AQUEOUS,360,RC,65800,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE",360,RC,65920,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,12408.00,fee schedule,
"REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS)",360,RC,66680,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,6735.00,fee schedule,
"REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN",360,RC,23000,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,5152.00,fee schedule,
"UNLISTED PROCEDURE, COLON",360,RC,45399,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,9350.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,12408.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,8442.00,fee schedule,
"VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION",360,RC,67043,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,4189.53,,,,,,,3870.33,17457.00,fee schedule,
"REPAIR OF RETINAL DETACHMENT, INCLUDING DRAINAGE OF SUBRETINAL FLUID WHEN PERFORMED; PHOTOCOAGULATION",360,RC,67105,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,571.33,,,,,,,527.80,10087.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",360,RC,44799,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROCEDURE)",360,RC,44500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4121.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,44376,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S CAPSULE,360,RC,67515,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF CHALAZION; SINGLE,360,RC,67800,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
INCISIONAL BIOPSY OF EYELID SKIN INCLUDING LID MARGIN,360,RC,67810,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1008.67,,,,,,,931.82,4376.00,fee schedule,
"OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S])",360,RC,27416,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,17457.00,fee schedule,
"REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)",360,RC,67901,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
REPAIR OF ENTROPION; SUTURE,360,RC,67921,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REPAIR OF ENTROPION; EXCISION TARSAL WEDGE,360,RC,67923,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44364,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; DEEP",360,RC,28192,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
BIOPSY OF LACRIMAL GLAND,360,RC,68510,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES",360,RC,68530,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT,360,RC,68750,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL ANESTHESIA",360,RC,68811,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,C5275,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,17457.00,fee schedule,
"LATERAL RETINACULAR RELEASE, OPEN",360,RC,27425,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,12408.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44382,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
EXCISION OF CHEST WALL TUMOR INCLUDING RIB(S),360,RC,21601,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,10087.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS",360,RC,43289,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",361,RC,31267,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,3788.00,7277.94,fee schedule,
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED",360,RC,43284,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT",360,RC,21199,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"OSTEOTOMY, MANDIBLE, SEGMENTAL;",360,RC,21198,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,3788.00,6735.00,fee schedule,
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",360,RC,43226,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43215,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION",360,RC,27530,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM",360,RC,21013,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,5152.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND PRESERVATION OF FACIAL NERVE",360,RC,42420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSECTION",360,RC,42410,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,3788.00,10087.00,fee schedule,
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT REPAIR",360,RC,40810,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
CARTILAGE GRAFT; NASAL SEPTUM,360,RC,20912,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"UNLISTED PROCEDURE, SMALL INTESTINE",750,RC,44799,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES TENDON LENGTHENING",360,RC,27612,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GREATER",360,RC,27616,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE",360,RC,28124,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6649.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"REPAIR, NONUNION OR MALUNION; TARSAL BONES",360,RC,28320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN",360,RC,38129,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE",360,RC,28002,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SPLENECTOMY",360,RC,38120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
EXCISION OF LACTIFEROUS DUCT FISTULA,360,RC,19112,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,6735.00,fee schedule,
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE),360,RC,37780,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,990.00,6735.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA;",360,RC,27635,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED",750,RC,45337,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",360,RC,15839,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,10910.59,24600.00,fee schedule,
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,990.00,4311.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON",360,RC,28010,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)",360,RC,15733,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,17457.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",360,RC,36425,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH",360,RC,28092,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY",360,RC,35226,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,8442.00,fee schedule,
"REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER",360,RC,35207,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8442.00,fee schedule,
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS",360,RC,15220,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,360,RC,33241,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
"HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS",360,RC,15040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14061,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,360,RC,32552,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,2025.00,5152.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS",750,RC,45384,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE",360,RC,31243,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30903,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL",360,RC,30801,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
REPAIR FISTULA; ORONASAL,360,RC,30600,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,2025.00,6735.00,fee schedule,
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,27758,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11470,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,9503.00,27871.00,fee schedule,
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",750,RC,47562,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",750,RC,11420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4376.00,fee schedule,
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
BIOPSY OF PENIS; (SEPARATE PROCEDURE),360,RC,54100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
SCROTOPLASTY; COMPLICATED,360,RC,55180,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53665,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
OPEN TREATMENT OF LUNATE DISLOCATION,360,RC,25695,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ABLATION OF PROSTATE TISSUE, TRANSURETHRAL, USING THERMAL ULTRASOUND, INCLUDING MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION; WITH INSERTION OF TRANSURETHRAL ULTRASOUND TRANSDUCER FOR DELIVERY OF THERMAL ULTRASOUND, INCLUDING SUPRAPUBIC TUBE PLACEMENT AND PLACEMENT OF AN ENDORECTAL COOLING DEVICE, WHEN PERFORMED",360,RC,55882,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13530.72,,,,,,,6735.00,24600.00,fee schedule,
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4121.00,13852.00,fee schedule,
INCISION AND DRAINAGE OF VAGINAL HEMATOMA; OBSTETRICAL/POSTPARTUM,360,RC,57022,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,4376.00,fee schedule,
"EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON",360,RC,26180,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4376.00,10022.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,9350.00,fee schedule,
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,173.00,5152.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER",360,RC,26235,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;",360,RC,57420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX",360,RC,57421,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,906.81,,,,,,,837.72,4311.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11442,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
"TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON",360,RC,26445,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM,360,RC,25445,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10087.00,fee schedule,
"CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL",360,RC,52300,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",360,RC,22511,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)",360,RC,53460,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",750,RC,44365,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE",360,RC,67975,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
"UNLISTED PROCEDURE, EYELIDS",360,RC,67999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,832.00,fee schedule,
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM",360,RC,68110,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT,360,RC,68320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY)",360,RC,68420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,990.00,9350.00,fee schedule,
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS,360,RC,33213,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,6649.00,24600.00,fee schedule,
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),360,RC,33210,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,22100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6735.00,13852.00,fee schedule,
"CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH",360,RC,68761,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM",360,RC,14021,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS",360,RC,14020,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS, PERICARDIAL SAC, MEDIASTINAL OR PLEURAL SPACE, WITHOUT BIOPSY",360,RC,32601,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",360,RC,32554,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION,360,RC,69420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,173.00,6735.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",750,RC,44378,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION, WITH MANIPULATION",360,RC,25680,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,5152.00,fee schedule,
"STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;",360,RC,69660,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,4311.00,17457.00,fee schedule,
"RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE",360,RC,28126,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR",360,RC,69714,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,12378.98,24600.00,fee schedule,
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,681.49,,,,,,,629.57,2912.00,fee schedule,
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,95.59,,,,,,,88.31,96.50,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,191.17,208.90,fee schedule,
"NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97607,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,384.38,420.05,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53449,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,9630.27,,,,,,,4121.00,9721.99,fee schedule,
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
CLOSURE OF URETHROVAGINAL FISTULA;,360,RC,57310,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7701.19,,,,,,,6636.00,10022.00,fee schedule,
"GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY",360,RC,43886,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,360,RC,G0104,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,5152.00,fee schedule,
"CLOSURE OF GASTROSTOMY, SURGICAL",360,RC,43870,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM",360,RC,11446,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING",360,RC,28261,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON",360,RC,26145,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY",360,RC,43772,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,8045.00,fee schedule,
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,6735.00,fee schedule,
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)",360,RC,43770,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,6735.00,13852.00,fee schedule,
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,360,RC,31502,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RIB, PARTIAL",360,RC,21600,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,8045.00,fee schedule,
"QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE)",360,RC,27430,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS",360,RC,27437,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION,360,RC,28430,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL",360,RC,43651,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6636.00,13527.54,fee schedule,
"CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT",360,RC,21485,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,5152.00,fee schedule,
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); FRONTAL SINUS OSTIUM",360,RC,31296,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7209.28,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
PLASTIC REPAIR OF INTROITUS,360,RC,56800,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL PROLAPSE,360,RC,53275,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY",360,RC,31241,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,6735.00,fee schedule,
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY",360,RC,31239,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,8442.00,fee schedule,
"ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, PROXIMAL",360,RC,27477,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,10087.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",360,RC,43266,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6199.45,,,,,,,5219.00,17457.00,fee schedule,
"OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES",360,RC,21365,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,12408.00,fee schedule,
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,202.19,,,,,,,173.00,4376.00,fee schedule,
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3962.16,,,,,,,3660.29,5754.00,fee schedule,
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,43254,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,6735.00,fee schedule,
"CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE",360,RC,52305,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
EXCISION OR FULGURATION; URETHRAL CARUNCLE,360,RC,53265,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1970.84,5754.00,fee schedule,
"DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,57065,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH EXCISION OF TUMOR",361,RC,31640,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY)",361,RC,31641,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,3547.15,8045.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",360,RC,43245,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
REPAIR NASAL SEPTAL PERFORATIONS,360,RC,30630,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,12408.00,fee schedule,
"EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA",360,RC,53260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43202,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM",360,RC,12037,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,5152.00,fee schedule,
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,4311.00,fee schedule,
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE",361,RC,32556,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,4376.00,fee schedule,
"CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY",360,RC,42970,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,173.00,4311.00,fee schedule,
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION,360,RC,28400,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS,360,RC,52700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,5754.00,fee schedule,
"CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21050,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10022.00,fee schedule,
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,530.34,,,,,,,173.00,5152.00,fee schedule,
REMOVAL OF ANKLE IMPLANT,360,RC,27704,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING",360,RC,30469,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,12247.00,fee schedule,
"BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE",360,RC,42804,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,2025.00,4311.00,fee schedule,
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,990.00,5152.00,fee schedule,
"RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR",360,RC,30420,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
"RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP",360,RC,30410,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6160.76,,,,,,,5691.37,10087.00,fee schedule,
EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA),360,RC,42408,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,6735.00,fee schedule,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,832.00,fee schedule,
"RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION)",360,RC,28035,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,8442.00,fee schedule,
"INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON)",360,RC,30220,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,6735.00,fee schedule,
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
"DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S)",360,RC,27602,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
EXCISION OF LINGUAL FRENUM (FRENECTOMY),360,RC,41115,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,1425.11,4311.00,fee schedule,
EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO-THIRDS,360,RC,41112,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,2025.00,5152.00,fee schedule,
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION,360,RC,25505,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,990.00,4311.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE",360,RC,40816,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,4376.00,10022.00,fee schedule,
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH COMPLEX REPAIR",360,RC,40814,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3377.44,,,,,,,3120.11,5754.00,fee schedule,
"LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED)",360,RC,52647,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,17457.00,fee schedule,
"INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT EXPANSION",360,RC,11960,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
INCISION OF LABIAL FRENUM (FRENOTOMY),360,RC,40806,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,530.34,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,17457.00,fee schedule,
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
BIOPSY OF LIP,360,RC,40490,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,173.00,832.00,fee schedule,
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",360,RC,38999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,455.29,,,,,,,173.00,4311.00,fee schedule,
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"EXCISION OF CERVICAL STUMP, VAGINAL APPROACH;",360,RC,57550,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,3788.00,6735.00,fee schedule,
"TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE PROCEDURE)",360,RC,28230,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER",361,RC,36425,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT",360,RC,29906,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)",360,RC,10040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,832.00,fee schedule,
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON",360,RC,28225,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11623,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF FOOT OR TOE; LESS THAN 3 CM",360,RC,28046,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,360,RC,20551,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",750,RC,45172,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,17457.00,fee schedule,
OSTEOTOMY; FIBULA,360,RC,27707,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED,360,RC,20525,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,6735.00,fee schedule,
AXILLARY LYMPHADENECTOMY; SUPERFICIAL,360,RC,38740,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,4376.00,13852.00,fee schedule,
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",360,RC,20225,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11622,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",750,RC,46260,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING, PERITONEAL WASHINGS, PERITONEAL BIOPSY(IES), OMENTECTOMY, AND DIAPHRAGMATIC WASHINGS, INCLUDING DIAPHRAGMATIC AND OTHER SEROSAL BIOPSY(IES), WHEN PERFORMED",360,RC,38573,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11621,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",360,RC,20206,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",361,RC,37238,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6735.00,17457.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11620,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,5152.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",361,RC,38531,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,8045.00,fee schedule,
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,3142.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL, BY LIGATION OTHER THAN RUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS, WITHOUT IMAGING GUIDANCE",750,RC,46946,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"UNLISTED PROCEDURE, BREAST",360,RC,19499,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11601,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27619,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,6735.00,fee schedule,
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,173.00,832.00,fee schedule,
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION SCALENE FAT PAD",360,RC,38520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,26215,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL)",360,RC,57210,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)",360,RC,29867,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,6735.00,13852.00,fee schedule,
CAUTERY OF CERVIX; ELECTRO OR THERMAL,360,RC,57510,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11462,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT",360,RC,19110,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3987.93,,,,,,,3684.09,5754.00,fee schedule,
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX REPAIR",360,RC,11451,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA",360,RC,25574,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27634,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL",360,RC,26230,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,2025.00,12408.00,fee schedule,
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",750,RC,31623,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,6735.00,24600.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",750,RC,31624,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37230,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,8442.00,52940.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
PLASTIC OPERATION OF PENIS FOR INJURY,360,RC,54440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,2025.00,6735.00,fee schedule,
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25295,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN FLAP OR GRAFT",360,RC,15860,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,8442.00,24600.00,fee schedule,
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION)",360,RC,25275,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25270,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM",360,RC,54435,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS",360,RC,54408,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,8612.00,17457.00,fee schedule,
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58543,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,17457.00,fee schedule,
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,2025.00,8442.00,fee schedule,
CARPECTOMY; 1 BONE,360,RC,25210,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA",360,RC,25150,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 1.5 CM",360,RC,26116,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT),360,RC,25135,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8045.00,fee schedule,
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58553,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,8612.00,13852.00,fee schedule,
"ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION",360,RC,54535,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA",360,RC,25119,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; LOCAL ANESTHESIA",360,RC,52265,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,990.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT",360,RC,25112,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,8442.00,fee schedule,
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,5152.00,fee schedule,
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,642.16,4311.00,fee schedule,
"ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,25101,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4376.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,173.00,6735.00,fee schedule,
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR INTRAMUSCULAR)",360,RC,25066,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,4311.00,fee schedule,
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED",360,RC,28193,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,8442.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION",360,RC,27825,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE PROCEDURE); VAGINAL APPROACH",360,RC,58800,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,3058.98,6735.00,fee schedule,
FETAL NON-STRESS TEST,361,RC,59025,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,173.00,832.00,fee schedule,
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR",360,RC,52355,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,8442.00,fee schedule,
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
EXCISION OF LOCAL LESION OF EPIDIDYMIS,360,RC,54830,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,6735.00,fee schedule,
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION)",360,RC,28735,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT)",360,RC,50575,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4890.88,10022.00,fee schedule,
INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID),360,RC,54400,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13530.72,,,,,,,6649.00,24600.00,fee schedule,
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24635,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION",360,RC,55000,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,2912.00,fee schedule,
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",360,RC,60100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
"LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS",360,RC,50541,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,6636.00,10945.84,fee schedule,
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,642.16,6649.00,fee schedule,
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA,360,RC,24605,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,5485.35,13852.00,fee schedule,
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,27652,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",360,RC,27040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,990.00,4311.00,fee schedule,
EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT,360,RC,60281,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,13852.00,fee schedule,
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS",360,RC,24516,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,8213.00,13852.00,fee schedule,
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28295,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF PELVIS AND HIP AREA; 5 CM OR GREATER",360,RC,27059,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER,360,RC,36861,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH",360,RC,26100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,2025.00,5152.00,fee schedule,
IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM,360,RC,54220,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT",360,RC,24371,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,12247.00,24600.00,fee schedule,
AMPUTATION OF PENIS; PARTIAL,360,RC,54120,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8045.00,fee schedule,
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,8213.00,19334.39,fee schedule,
"TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS (THROUGH SEPARATE INCISION[S])",360,RC,27681,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63001,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28666,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL",360,RC,63011,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,10087.00,fee schedule,
REPAIR LUMBAR HERNIA,360,RC,49540,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,4376.00,8045.00,fee schedule,
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,17457.00,fee schedule,
"ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED",360,RC,36475,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,17457.00,fee schedule,
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),360,RC,49423,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,4311.00,fee schedule,
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,17457.00,fee schedule,
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",361,RC,64517,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,5152.00,fee schedule,
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY,360,RC,49402,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,3395.25,8045.00,fee schedule,
"TENOLYSIS, TRICEPS",360,RC,24332,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE",360,RC,63075,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,316.80,,,,,,,173.00,4311.00,fee schedule,
"PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH MANIPULATION",360,RC,28606,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",750,RC,31625,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1795.92,,,,,,,1659.09,5152.00,fee schedule,
"TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON",360,RC,24305,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG",360,RC,36471,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,4311.00,fee schedule,
SCROTOPLASTY; SIMPLE,360,RC,55175,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,10022.00,fee schedule,
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED",360,RC,25525,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",360,RC,48102,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,5613.15,10022.00,fee schedule,
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; RADIAL HEAD",360,RC,24164,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE)",360,RC,24149,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS",360,RC,24147,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA",360,RC,27275,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S),361,RC,64642,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
"DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)",360,RC,46930,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,990.00,9350.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4121.00,fee schedule,
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,4311.00,fee schedule,
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,5152.00,fee schedule,
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR)",360,RC,46761,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE,360,RC,46753,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,23605,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5754.00,fee schedule,
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
"ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT",360,RC,46700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,46614,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,4311.00,fee schedule,
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK",360,RC,23460,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY",360,RC,46610,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,5754.00,fee schedule,
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET",360,RC,15620,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,8442.00,fee schedule,
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,3028.17,8045.00,fee schedule,
"FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL",360,RC,15576,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,6735.00,fee schedule,
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,8442.00,fee schedule,
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,588.93,4311.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED",360,RC,46601,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,173.00,4311.00,fee schedule,
"OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28585,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,3788.00,7510.57,fee schedule,
"ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY)",360,RC,29855,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6872.88,13852.00,fee schedule,
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,124.01,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH",360,RC,55705,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,2025.00,5152.00,fee schedule,
"EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE",360,RC,64774,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1878.73,5754.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,173.00,4311.00,fee schedule,
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP; WITH FISSURECTOMY",360,RC,46257,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,6735.00,fee schedule,
"ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT",360,RC,65105,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8442.00,fee schedule,
"INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT",360,RC,65135,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP",360,RC,65222,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,124.01,832.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE",360,RC,65270,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITHOUT HOSPITALIZATION",360,RC,65272,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15277,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,1759.87,4376.00,fee schedule,
"INCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46083,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS",360,RC,23184,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE",360,RC,65430,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,173.00,832.00,fee schedule,
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA),360,RC,65750,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5373.49,,,,,,,4964.08,12408.00,fee schedule,
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,2912.00,fee schedule,
"EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), KNEE",360,RC,27347,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45900,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION, MULTIPLE LAYERS",360,RC,65780,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
PATELLECTOMY OR HEMIPATELLECTOMY,360,RC,27350,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE",360,RC,65865,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY,360,RC,66170,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,8442.00,fee schedule,
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8045.00,fee schedule,
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,5754.00,fee schedule,
PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE,360,RC,45505,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2856.01,,,,,,,2638.41,8045.00,fee schedule,
REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR; WITHOUT GRAFT,360,RC,66184,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,17457.00,fee schedule,
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT",360,RC,28107,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6649.00,13852.00,fee schedule,
IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION,360,RC,66500,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,173.00,4311.00,fee schedule,
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL",360,RC,35321,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,5200.74,13852.00,fee schedule,
"SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE)",360,RC,66682,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; CARPOMETACARPAL JOINT",360,RC,26070,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,5152.00,fee schedule,
"IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (PER SESSION)",360,RC,66761,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,571.33,,,,,,,527.80,4311.00,fee schedule,
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,6735.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; 5 CM OR GREATER",360,RC,22905,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2753.54,17457.00,fee schedule,
"RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF ABDOMINAL WALL; LESS THAN 5 CM",360,RC,22904,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,2025.00,12408.00,fee schedule,
"DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)",360,RC,26011,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4311.00,fee schedule,
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,1134.38,5152.00,fee schedule,
"TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED",360,RC,55874,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,4311.00,17457.00,fee schedule,
"SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45335,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,45300,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,949.48,,,,,,,877.14,4311.00,fee schedule,
"UNLISTED PROCEDURE, SPINE",360,RC,22899,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL",360,RC,22867,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,19151.99,,,,,,,8612.00,19334.39,fee schedule,
"ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY)",360,RC,67015,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2375.23,,,,,,,2194.26,5754.00,fee schedule,
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,5219.00,8442.00,fee schedule,
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",360,RC,55876,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,1316.38,4311.00,fee schedule,
"CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION",360,RC,28490,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
"ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44382,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,360,RC,33272,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,3501.31,8045.00,fee schedule,
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,360,RC,33244,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,3501.31,8442.00,fee schedule,
REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44340,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
"INCISION AND DRAINAGE, BURSA, FOOT",360,RC,28001,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1558.81,4376.00,fee schedule,
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,8442.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF FOREIGN BODY,360,RC,67413,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,10087.00,fee schedule,
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION,360,RC,67414,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)",360,RC,26432,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1666.72,,,,,,,1539.73,6735.00,fee schedule,
ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION,360,RC,67560,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,8045.00,fee schedule,
"BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID",360,RC,67700,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,311.31,,,,,,,173.00,4311.00,fee schedule,
CANTHOTOMY (SEPARATE PROCEDURE),360,RC,67715,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,5754.00,fee schedule,
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4376.00,fee schedule,
"EXCISION OF CHALAZION; MULTIPLE, SAME LID",360,RC,67801,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1008.67,,,,,,,931.82,4311.00,fee schedule,
REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE),360,RC,44312,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3812.66,,,,,,,3522.17,8045.00,fee schedule,
DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; INITIAL,360,RC,53660,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,4311.00,fee schedule,
"CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE",360,RC,67882,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,6735.00,fee schedule,
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,360,RC,33227,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,6735.00,24600.00,fee schedule,
REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA),360,RC,67902,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3927.24,,,,,,,3628.02,10087.00,fee schedule,
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,44363,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,1825.06,5152.00,fee schedule,
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",360,RC,33216,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,7962.20,13852.00,fee schedule,
REPAIR OF ECTROPION; EXCISION TARSAL WEDGE,360,RC,67916,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,2244.50,8442.00,fee schedule,
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,6636.00,10022.00,fee schedule,
"DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE; INITIAL",360,RC,53600,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,173.00,4311.00,fee schedule,
"URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL",360,RC,53510,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,5294.25,,,,,,,3788.00,5754.00,fee schedule,
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT",360,RC,28022,CPT,,,,,facility,outpatient,,,,,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,3121.59,5754.00,fee schedule,
Prolia 60mg,PX-J0897,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,22.07000,13.24000,WellCare of North Carolina,Medicare Advantage,,30.85,,,,,,,4.42,81.55,fee schedule,
HC NM Pharm S1001 Trial,PX-73400146,CDM,256,RC,A9543,HCPCS,,,facility,outpatient,,,1.01000,0.61000,WellCare of North Carolina,Medicare Advantage,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
Injection Aripiprazole Ext Rel 1mg-J0401,PX-J0401,CDM,636,RC,J0401,HCPCS,,,facility,outpatient,,,6.33000,3.80000,WellCare of North Carolina,Medicare Advantage,,7.64,,,,,,,1.27,20.19,fee schedule,
Aripirazole lauroxil 1 mg,PX-J1944,CDM,636,RC,J1944,HCPCS,,,facility,outpatient,,,3.10000,1.86000,WellCare of North Carolina,Medicare Advantage,,3.52,,,,,,,0.62062,9.29,fee schedule,
Inj. romosozumab-aqqg 1 mg,PX-J3111,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,9.84000,5.90000,WellCare of North Carolina,Medicare Advantage,,12.67,,,,,,,1.97,33.47,fee schedule,
"Injection, methylprednisolone acetate, 1 mg",PX-J1010,CDM,250,RC,J1010,HCPCS,,,facility,outpatient,,,0.12000,0.07000,WellCare of North Carolina,Medicare Advantage,,0.12600,,,,,,,0.02402,0.28320,fee schedule,
"Injection, methylprednisolone sodium succinate, 5 mg",PX-J2919,CDM,250,RC,J2919,HCPCS,,,facility,outpatient,,,0.27000,0.16000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.05405,0.49560,fee schedule,
Inj Ketorolac Tromethamine,PX-J1885,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,0.47000,0.28000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.09409,0.95700,fee schedule,
Injection Leuprolide Actat,PX-J1950,CDM,636,RC,J1950,HCPCS,,,facility,outpatient,,,1666.78000,1000.07000,WellCare of North Carolina,Medicare Advantage,,1816.84,,,,,,,333.69,4844.60,fee schedule,
Hyaluronan/Derivative Euflexxa,PX-J7323,CDM,636,RC,J7323,HCPCS,,,facility,outpatient,,,134.92000,80.95000,WellCare of North Carolina,Medicare Advantage,,118.07,,,,,,,27.01,319.27,fee schedule,
Hyaluronan/Deriv Orthovisc Ia,PX-J7324,CDM,636,RC,J7324,HCPCS,,,facility,outpatient,,,166.43000,99.86000,WellCare of North Carolina,Medicare Advantage,,120.27,,,,,,,33.32,272.48,fee schedule,
"Inj, durolane 1 mg",PX-J7318,CDM,636,RC,J7318,HCPCS,,,facility,outpatient,,,17.28000,10.37000,WellCare of North Carolina,Medicare Advantage,,7.11,,,,,,,3.46,18.64,fee schedule,
Hyaluronan/Derivative Synvisc,PX-J7325,CDM,636,RC,J7325,HCPCS,,,facility,outpatient,,,11.23000,6.74000,WellCare of North Carolina,Medicare Advantage,,8.35,,,,,,,2.25,25.35,fee schedule,
Injection Penicillin,PX-J0561,CDM,250,RC,J0561,HCPCS,,,facility,outpatient,,,15.12000,9.07000,WellCare of North Carolina,Medicare Advantage,,31.51,,,,,,,3.03,70.82,fee schedule,
"Inj, invega sustenna, 1 mg",PX-J2426,CDM,636,RC,J2426,HCPCS,,,facility,outpatient,,,13.35000,8.01000,WellCare of North Carolina,Medicare Advantage,,15.87,,,,,,,2.67,42.05,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,000 (+/-) UNIT INTRAVENOUS SOLUTION",RX-10008,CDM,636,RC,J7194,HCPCS,68516320502,NDC,facility,outpatient,1,UN,82.95000,49.77000,WellCare of North Carolina,Medicare Advantage,,1.78,,,,,,,1.65,61.57,fee schedule,
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION,RX-100265,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,WellCare of North Carolina,Medicare Advantage,,65.34,,,,,,,60.36,2174.46,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT,RX-100272,CDM,636,RC,J0597,HCPCS,63833082502,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,WellCare of North Carolina,Medicare Advantage,,79.65,,,,,,,73.58,14437.16,fee schedule,
BENDAMUSTINE 25 MG INTRAVENOUS POWDER FOR SOLUTION,RX-100581,CDM,636,RC,J9033,HCPCS,63459039008,NDC,facility,outpatient,1,UN,3544.00000,2126.40000,WellCare of North Carolina,Medicare Advantage,,1.97,,,,,,,1.82,2630.36,fee schedule,
IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION,RX-100740,CDM,636,RC,J1742,HCPCS,00009379401,NDC,facility,outpatient,10,ML,2414.30000,1448.58000,WellCare of North Carolina,Medicare Advantage,,180.93,,,,,,,167.14,1791.89,fee schedule,
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT,RX-10137,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,outpatient,1,UN,5220.40000,3132.24000,WellCare of North Carolina,Medicare Advantage,,770.35,,,,,,,711.66,3874.58,fee schedule,
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION,RX-10358,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,0.5,ML,568.50000,341.10000,WellCare of North Carolina,Medicare Advantage,,9.17,,,,,,,6.49,421.94,fee schedule,
CAPSAICIN-SKIN CLEANSER 8 % TOPICAL KIT,RX-104258,CDM,636,RC,J7336,HCPCS,72512092801,NDC,facility,outpatient,1,UN,2741.35000,1644.81000,WellCare of North Carolina,Medicare Advantage,,3.59,,,,,,,3.32,2034.63,fee schedule,
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION",RX-10475,CDM,636,RC,J7504,HCPCS,00009722402,NDC,facility,outpatient,5,ML,20322.25000,12193.35000,WellCare of North Carolina,Medicare Advantage,,5391.84,,,,,,,4068.51,15083.17,fee schedule,
MELPHALAN (ALKERAN) IVPB,RX-10522,CDM,636,RC,J9245,HCPCS,52609300100,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,WellCare of North Carolina,Medicare Advantage,,100.69,,,,,,,93.02,1836.94,fee schedule,
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION,RX-105644,CDM,636,RC,J9043,HCPCS,00024582411,NDC,facility,outpatient,6,ML,60837.10000,36502.26000,WellCare of North Carolina,Medicare Advantage,,238.64,,,,,,,220.46,45153.30,fee schedule,
METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION,RX-10579,CDM,636,RC,J2919,HCPCS,00009085001,NDC,facility,outpatient,1,UN,520.25000,312.15000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,386.13,fee schedule,
INCOBOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-105970,CDM,636,RC,J0588,HCPCS,00259160501,NDC,facility,outpatient,1,UN,1235.40000,741.24000,WellCare of North Carolina,Medicare Advantage,,5.85,,,,,,,5.40,916.91,fee schedule,
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION,RX-105971,CDM,636,RC,J0588,HCPCS,00259161001,NDC,facility,outpatient,1,UN,2341.05000,1404.63000,WellCare of North Carolina,Medicare Advantage,,5.85,,,,,,,5.40,1737.53,fee schedule,
MITOMYCIN 20 MG INTRAVENOUS SOLUTION,RX-10630,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,1,UN,3055.75000,1833.45000,WellCare of North Carolina,Medicare Advantage,,21.37,,,,,,,19.74,2267.98,fee schedule,
MITOMYCIN 40 MG INTRAVENOUS SOLUTION,RX-10631,CDM,636,RC,J9280,HCPCS,16729011638,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,WellCare of North Carolina,Medicare Advantage,,21.37,,,,,,,19.74,4331.81,fee schedule,
MITOMYCIN 5 MG INTRAVENOUS SOLUTION,RX-10632,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,outpatient,1,UN,1345.40000,807.24000,WellCare of North Carolina,Medicare Advantage,,21.37,,,,,,,19.74,998.56,fee schedule,
ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION,RX-106761,CDM,636,RC,J0586,HCPCS,15054053006,NDC,facility,outpatient,1,UN,2420.70000,1452.42000,WellCare of North Carolina,Medicare Advantage,,9.19,,,,,,,8.49,1796.64,fee schedule,
ERIBULIN (HALAVEN) SYRINGE 0.5 MG/ML,RX-106773,CDM,636,RC,J9179,HCPCS,62856038901,NDC,facility,outpatient,2,ML,6479.00000,3887.40000,WellCare of North Carolina,Medicare Advantage,,93.81,,,,,,,86.66,4808.71,fee schedule,
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION,RX-107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE,RX-108041,CDM,636,RC,J0881,HCPCS,55513005701,NDC,facility,outpatient,0.42,ML,896.45000,537.87000,WellCare of North Carolina,Medicare Advantage,,3.08,,,,,,,2.84,665.35,fee schedule,
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108042,CDM,636,RC,J0881,HCPCS,55513002101,NDC,facility,outpatient,0.4,ML,1424.70000,854.82000,WellCare of North Carolina,Medicare Advantage,,3.08,,,,,,,2.84,1057.41,fee schedule,
DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE,RX-108043,CDM,636,RC,J0881,HCPCS,55513002301,NDC,facility,outpatient,0.3,ML,2129.05000,1277.43000,WellCare of North Carolina,Medicare Advantage,,3.08,,,,,,,2.84,1580.18,fee schedule,
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE,RX-108044,CDM,636,RC,J0881,HCPCS,55513002504,NDC,facility,outpatient,0.5,ML,3537.70000,2122.62000,WellCare of North Carolina,Medicare Advantage,,3.08,,,,,,,2.84,2625.68,fee schedule,
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE,RX-108047,CDM,636,RC,J0881,HCPCS,55513002801,NDC,facility,outpatient,0.4,ML,7059.40000,4235.64000,WellCare of North Carolina,Medicare Advantage,,3.08,,,,,,,2.84,5239.49,fee schedule,
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE,RX-108048,CDM,636,RC,J0881,HCPCS,55513011101,NDC,facility,outpatient,0.6,ML,10581.10000,6348.66000,WellCare of North Carolina,Medicare Advantage,,3.08,,,,,,,2.84,7853.29,fee schedule,
"PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE",RX-108049,CDM,636,RC,J0561,HCPCS,60793070102,NDC,facility,outpatient,2,ML,1695.15000,1017.09000,WellCare of North Carolina,Medicare Advantage,,31.51,,,,,,,29.11,1258.14,fee schedule,
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108055,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,5,ML,8246.30000,4947.78000,WellCare of North Carolina,Medicare Advantage,,181.68,,,,,,,167.84,6120.40,fee schedule,
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108057,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,20,ML,32160.05000,19296.03000,WellCare of North Carolina,Medicare Advantage,,181.68,,,,,,,167.84,23869.19,fee schedule,
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108062,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,WellCare of North Carolina,Medicare Advantage,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION,RX-108063,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,WellCare of North Carolina,Medicare Advantage,,6.00,,,,,,,5.54,8325.59,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,WellCare of North Carolina,Medicare Advantage,,76.86,,,,,,,63.83,236.65,fee schedule,
BEVACIZUMAB (AVASTIN) 25 MG/ML,RX-108065,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,outpatient,0.05,ML,318.85000,191.31000,WellCare of North Carolina,Medicare Advantage,,76.86,,,,,,,63.83,236.65,fee schedule,
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE,RX-108096,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,10,ML,8806.85000,5284.11000,WellCare of North Carolina,Medicare Advantage,,7.07,,,,,,,6.53,6536.44,fee schedule,
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION,RX-108155,CDM,636,RC,J0475,HCPCS,70257056001,NDC,facility,outpatient,0.05,ML,18.70000,11.22000,WellCare of North Carolina,Medicare Advantage,,190.28,,,,,,,3.74,490.35,fee schedule,
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108955,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,WellCare of North Carolina,Medicare Advantage,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION,RX-108956,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,WellCare of North Carolina,Medicare Advantage,,192.65,,,,,,,177.98,118483.40,fee schedule,
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,636,RC,J0561,HCPCS,60793070010,NDC,facility,outpatient,1,ML,985.50000,591.30000,WellCare of North Carolina,Medicare Advantage,,31.51,,,,,,,29.11,731.44,fee schedule,
PENTOSTATIN (NIPENT) SYRINGE,RX-10910,CDM,636,RC,J9268,HCPCS,00409080101,NDC,facility,outpatient,1,UN,13260.65000,7956.39000,WellCare of North Carolina,Medicare Advantage,,2738.57,,,,,,,2529.92,9842.05,fee schedule,
PHENTOLAMINE 5 MG INJECTION SOLUTION,RX-10947,CDM,636,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,1,UN,2245.35000,1347.21000,WellCare of North Carolina,Medicare Advantage,,453.62,,,,,,,419.06,1666.50,fee schedule,
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN,RX-109784,CDM,636,RC,J0211,HCPCS,60267081200,NDC,facility,outpatient,60,ML,709.90000,425.94000,WellCare of North Carolina,Medicare Advantage,,2.34,,,,,,,2.16,526.89,fee schedule,
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION,RX-111348,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,outpatient,1,UN,56048.55000,33629.13000,WellCare of North Carolina,Medicare Advantage,,271.57,,,,,,,250.88,41599.23,fee schedule,
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION,RX-111437,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,1,UN,4464.60000,2678.76000,WellCare of North Carolina,Medicare Advantage,,5.45,,,,,,,5.03,3313.63,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250013310,NDC,facility,outpatient,10,ML,1113.90000,668.34000,WellCare of North Carolina,Medicare Advantage,,1.53,,,,,,,1.42,826.74,fee schedule,
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION,RX-112781,CDM,636,RC,J0666,HCPCS,65250026620,NDC,facility,outpatient,20,ML,1830.00000,1098.00000,WellCare of North Carolina,Medicare Advantage,,1.53,,,,,,,1.42,1358.23,fee schedule,
"OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION",RX-116016,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,25404.55000,15242.73000,WellCare of North Carolina,Medicare Advantage,,65.34,,,,,,,60.36,18855.26,fee schedule,
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-116596,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,14,ML,30285.20000,18171.12000,WellCare of North Carolina,Medicare Advantage,,17.87,,,,,,,16.51,22477.68,fee schedule,
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION,RX-117047,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,WellCare of North Carolina,Medicare Advantage,,58.43,,,,,,,53.98,11755.45,fee schedule,
PEGASPARGASE (ONCASPAR) SYRINGE,RX-12519,CDM,636,RC,J9266,HCPCS,72694095401,NDC,facility,outpatient,5,ML,118261.70000,70957.02000,WellCare of North Carolina,Medicare Advantage,,29845.26,,,,,,,23675.99,87773.83,fee schedule,
HEPATITIS B IMMUNE GLOBULIN-MALTOSE (HEPAGAM B) >312 UNIT/ML (5 ML) INJECTION SOLN,RX-126230,CDM,636,RC,J1571,HCPCS,49591005151,NDC,facility,outpatient,5,ML,3636.80000,2182.08000,WellCare of North Carolina,Medicare Advantage,,69.97,,,,,,,64.64,2699.23,fee schedule,
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS PEN KIT,RX-126393,CDM,636,RC,J0139,HCPCS,00074433902,NDC,facility,outpatient,1,UN,15765.00000,9459.00000,WellCare of North Carolina,Medicare Advantage,,96.32,,,,,,,88.98,11700.78,fee schedule,
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE,RX-126644,CDM,636,RC,90371,HCPCS,13533063630,NDC,facility,outpatient,0.5,ML,430.80000,258.48000,WellCare of North Carolina,Medicare Advantage,,140.90,,,,,,,86.25,417.81,fee schedule,
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE,RX-127771,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,1,ML,2673.70000,1604.22000,WellCare of North Carolina,Medicare Advantage,,622.65,,,,,,,535.27,1984.42,fee schedule,
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION,RX-127974,CDM,636,RC,J1212,HCPCS,67457017750,NDC,facility,outpatient,50,ML,3336.40000,2001.84000,WellCare of North Carolina,Medicare Advantage,,786.29,,,,,,,667.95,2476.28,fee schedule,
CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION,RX-128003,CDM,636,RC,J0759,HCPCS,10122061101,NDC,facility,outpatient,100,ML,818.20000,490.92000,WellCare of North Carolina,Medicare Advantage,,2.99,,,,,,,2.76,665.20,fee schedule,
THROMBIN(HUM PLAS)-FIBRIN-APROT-CA 2.5 TO 6.5 UNIT/ML(2ML) TOPICAL SYR,RX-128026,CDM,250,RC,C9250,HCPCS,00338850302,NDC,facility,outpatient,2,ML,984.90000,590.94000,WellCare of North Carolina,Medicare Advantage,,148.98,,,,,,,137.63,800.72,fee schedule,
HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE,RX-128227,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,outpatient,6,ML,6247.80000,3748.68000,WellCare of North Carolina,Medicare Advantage,,8.35,,,,,,,7.71,4637.12,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION,RX-128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION,RX-128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,47.09,fee schedule,
METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION,RX-128783,CDM,636,RC,J2919,HCPCS,00009000302,NDC,facility,outpatient,1,UN,262.00000,157.20000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,194.46,fee schedule,
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION",RX-128784,CDM,636,RC,J2919,HCPCS,00009001820,NDC,facility,outpatient,1,UN,352.50000,211.50000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,261.63,fee schedule,
TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION,RX-12935,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,1,ML,64.75000,38.85000,WellCare of North Carolina,Medicare Advantage,,276.31,,,,,,,12.96,731.33,fee schedule,
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INFUSION SOLN,RX-129384,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,outpatient,200,ML,11976.20000,7185.72000,WellCare of North Carolina,Medicare Advantage,,51.41,,,,,,,47.49,8888.74,fee schedule,
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT,RX-129667,CDM,636,RC,J9217,HCPCS,00074364203,NDC,facility,outpatient,1,UN,9718.80000,5831.28000,WellCare of North Carolina,Medicare Advantage,,185.27,,,,,,,171.16,7213.29,fee schedule,
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION,RX-130504,CDM,636,RC,J0597,HCPCS,63833083501,NDC,facility,outpatient,1,UN,19451.85000,11671.11000,WellCare of North Carolina,Medicare Advantage,,79.65,,,,,,,73.58,14437.16,fee schedule,
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT,RX-13691,CDM,636,RC,J1950,HCPCS,00074364103,NDC,facility,outpatient,1,UN,8199.90000,4919.94000,WellCare of North Carolina,Medicare Advantage,,1816.84,,,,,,,1641.62,6085.97,fee schedule,
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION,RX-15156,CDM,636,RC,J1190,HCPCS,55150043401,NDC,facility,outpatient,1,UN,1263.90000,758.34000,WellCare of North Carolina,Medicare Advantage,,66.21,,,,,,,61.17,938.07,fee schedule,
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT,RX-16254,CDM,636,RC,J9202,HCPCS,70720095130,NDC,facility,outpatient,1,UN,13881.15000,8328.69000,WellCare of North Carolina,Medicare Advantage,,770.35,,,,,,,711.66,10302.59,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION,RX-163525,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,outpatient,1,UN,17829.40000,10697.64000,WellCare of North Carolina,Medicare Advantage,,44.27,,,,,,,40.90,13232.98,fee schedule,
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION,RX-163526,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,outpatient,1,UN,28362.00000,17017.20000,WellCare of North Carolina,Medicare Advantage,,44.27,,,,,,,40.90,21050.28,fee schedule,
ELOSULFASE ALFA 5 MG/5 ML (1 MG/ML) INTRAVENOUS SOLUTION,RX-172122,CDM,636,RC,J1322,HCPCS,68135010001,NDC,facility,outpatient,5,ML,6392.40000,3835.44000,WellCare of North Carolina,Medicare Advantage,,324.11,,,,,,,299.42,4744.44,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002766901,NDC,facility,outpatient,10,ML,6878.50000,4127.10000,WellCare of North Carolina,Medicare Advantage,,78.08,,,,,,,72.13,5105.22,fee schedule,
RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-172456,CDM,636,RC,J9308,HCPCS,00002767801,NDC,facility,outpatient,50,ML,33292.40000,19975.44000,WellCare of North Carolina,Medicare Advantage,,78.08,,,,,,,72.13,24709.62,fee schedule,
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-173179,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,WellCare of North Carolina,Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION,RX-173205,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,1,UN,39374.65000,23624.79000,WellCare of North Carolina,Medicare Advantage,,22.38,,,,,,,20.67,29223.87,fee schedule,
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION,RX-173219,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,1,UN,8111.05000,4866.63000,WellCare of North Carolina,Medicare Advantage,,16.39,,,,,,,15.14,6020.02,fee schedule,
"HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION",RX-173339,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,88.95000,53.37000,WellCare of North Carolina,Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE,RX-17381,CDM,636,RC,J7325,HCPCS,58468009002,NDC,facility,outpatient,2,ML,2093.30000,1255.98000,WellCare of North Carolina,Medicare Advantage,,8.35,,,,,,,7.71,1553.65,fee schedule,
GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE,RX-174283,CDM,636,RC,J1595,HCPCS,68546031730,NDC,facility,outpatient,1,ML,1095.00000,657.00000,WellCare of North Carolina,Medicare Advantage,,175.68,,,,,,,150.45,812.71,fee schedule,
BLINATUMOMAB 35 MCG INTRAVENOUS KIT,RX-175329,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION,RX-175394,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1,UN,809.35000,485.61000,WellCare of North Carolina,Medicare Advantage,,9.52,,,,,,,8.80,600.70,fee schedule,
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION,RX-175414,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,4,ML,6099.95000,3659.97000,WellCare of North Carolina,Medicare Advantage,,34.61,,,,,,,31.97,4527.38,fee schedule,
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION,RX-175415,CDM,636,RC,J9299,HCPCS,00003377412,NDC,facility,outpatient,10,ML,14837.25000,8902.35000,WellCare of North Carolina,Medicare Advantage,,34.61,,,,,,,31.97,11012.21,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR,RX-175704,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,WellCare of North Carolina,Medicare Advantage,,93.81,,,,,,,86.66,21685.53,fee schedule,
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-175735,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,4,ML,26225.00000,15735.00000,WellCare of North Carolina,Medicare Advantage,,63.30,,,,,,,58.48,19464.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176625,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,1,UN,21020.20000,12612.12000,WellCare of North Carolina,Medicare Advantage,,213.76,,,,,,,197.47,15601.19,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176626,CDM,636,RC,J2353,HCPCS,00078082581,NDC,facility,outpatient,1,UN,31468.15000,18880.89000,WellCare of North Carolina,Medicare Advantage,,213.76,,,,,,,197.47,23355.66,fee schedule,
"OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE",RX-176627,CDM,636,RC,J2353,HCPCS,00078081181,NDC,facility,outpatient,1,UN,16047.65000,9628.59000,WellCare of North Carolina,Medicare Advantage,,213.76,,,,,,,197.47,11910.57,fee schedule,
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION,RX-176637,CDM,636,RC,J0714,HCPCS,00456270001,NDC,facility,outpatient,1,UN,1807.55000,1084.53000,WellCare of North Carolina,Medicare Advantage,,109.97,,,,,,,101.59,1341.56,fee schedule,
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-177077,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,outpatient,50,ML,3914.20000,2348.52000,WellCare of North Carolina,Medicare Advantage,,53.28,,,,,,,49.22,2905.12,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033513,NDC,facility,outpatient,10,ML,1978.60000,1187.16000,WellCare of North Carolina,Medicare Advantage,,51.48,,,,,,,47.56,1468.52,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 15 %-18 % RANGE-GLYCINE INTRAMUSCULAR SOLUTION",RX-177307,CDM,636,RC,J1460,HCPCS,13533033504,NDC,facility,outpatient,2,ML,493.20000,295.92000,WellCare of North Carolina,Medicare Advantage,,51.48,,,,,,,47.56,366.05,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 5 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177318,CDM,636,RC,J1566,HCPCS,00944265603,NDC,facility,outpatient,1,UN,4629.40000,2777.64000,WellCare of North Carolina,Medicare Advantage,,82.74,,,,,,,76.44,3435.94,fee schedule,
"IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION",RX-177319,CDM,636,RC,J1566,HCPCS,00944265804,NDC,facility,outpatient,1,UN,9181.80000,5509.08000,WellCare of North Carolina,Medicare Advantage,,82.74,,,,,,,76.44,6814.73,fee schedule,
CANGRELOR 50 MG INTRAVENOUS SOLUTION,RX-177342,CDM,636,RC,C9460,HCPCS,10122062001,NDC,facility,outpatient,1,UN,4571.50000,2742.90000,WellCare of North Carolina,Medicare Advantage,,20.98,,,,,,,19.38,3392.97,fee schedule,
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE,RX-178016,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,outpatient,0.8,ML,2013.40000,1208.04000,WellCare of North Carolina,Medicare Advantage,,0.48300,,,,,,,0.44620,1494.35,fee schedule,
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE,RX-178017,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,outpatient,0.5,ML,1264.35000,758.61000,WellCare of North Carolina,Medicare Advantage,,0.48300,,,,,,,0.44620,938.40,fee schedule,
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS,RX-178467,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,outpatient,10,ML,13382.60000,8029.56000,WellCare of North Carolina,Medicare Advantage,,69.30,,,,,,,64.02,9932.57,fee schedule,
MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION,RX-178637,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,1,UN,16408.85000,9845.31000,WellCare of North Carolina,Medicare Advantage,,32.83,,,,,,,30.33,12178.65,fee schedule,
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION,RX-178868,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,outpatient,4,ML,11159.75000,6695.85000,WellCare of North Carolina,Medicare Advantage,,14.16,,,,,,,13.09,8282.77,fee schedule,
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION,RX-179871,CDM,636,RC,Q5103,HCPCS,00069080901,NDC,facility,outpatient,1,UN,4037.40000,2422.44000,WellCare of North Carolina,Medicare Advantage,,20.99,,,,,,,19.39,2996.56,fee schedule,
SODIUM HYALURONATE 10 MG/ML(MW 2.4-3.6 MILLION)INTRA-ARTICULAR SYRINGE,RX-179881,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,outpatient,2,ML,1656.85000,994.11000,WellCare of North Carolina,Medicare Advantage,,118.07,,,,,,,109.08,1229.71,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET,RX-179980,CDM,636,RC,J0751,HCPCS,61958200201,NDC,facility,outpatient,1,UN,309.65000,185.79000,WellCare of North Carolina,Medicare Advantage,,74.89,,,,,,,61.99,229.82,fee schedule,
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION",RX-180358,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,WellCare of North Carolina,Medicare Advantage,,95.91,,,,,,,88.60,38051.26,fee schedule,
BEVACIZUMAB 2.5 MG/0.1 ML INTRAVITREAL SYRINGE,RX-181150,CDM,636,RC,C9257,HCPCS,09999000534,NDC,facility,outpatient,0.05,ML,61.35000,36.81000,WellCare of North Carolina,Medicare Advantage,,1.92,,,,,,,1.78,45.53,fee schedule,
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION,RX-181156,CDM,636,RC,Q9968,HCPCS,00517037401,NDC,facility,outpatient,10,ML,1082.50000,649.50000,WellCare of North Carolina,Medicare Advantage,,9.17,,,,,,,6.49,803.43,fee schedule,
BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-181503,CDM,636,RC,J0565,HCPCS,00006302501,NDC,facility,outpatient,40,ML,16023.00000,9613.80000,WellCare of North Carolina,Medicare Advantage,,41.82,,,,,,,38.64,11892.27,fee schedule,
CANAKINUMAB (PF) 150 MG/ML SUBCUTANEOUS SOLUTION,RX-182015,CDM,636,RC,J0638,HCPCS,00078073461,NDC,facility,outpatient,1,ML,89877.30000,53926.38000,WellCare of North Carolina,Medicare Advantage,,148.68,,,,,,,137.35,66706.93,fee schedule,
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION,RX-182066,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,outpatient,10,ML,9488.70000,5693.22000,WellCare of North Carolina,Medicare Advantage,,105.09,,,,,,,97.09,7042.51,fee schedule,
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION,RX-182080,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,10,ML,86755.05000,52053.03000,WellCare of North Carolina,Medicare Advantage,,62.38,,,,,,,57.63,64389.60,fee schedule,
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION,RX-182286,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,1,UN,7132.10000,4279.26000,WellCare of North Carolina,Medicare Advantage,,78.78,,,,,,,72.78,5293.44,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,10,ML,19171.55000,11502.93000,WellCare of North Carolina,Medicare Advantage,,89.38,,,,,,,82.57,14229.12,fee schedule,
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-182334,CDM,636,RC,J9173,HCPCS,00310450012,NDC,facility,outpatient,2.4,ML,4810.20000,2886.12000,WellCare of North Carolina,Medicare Advantage,,89.38,,,,,,,82.57,3570.13,fee schedule,
"RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182522,CDM,636,RC,J9311,HCPCS,50242010801,NDC,facility,outpatient,11.7,ML,29212.00000,17527.20000,WellCare of North Carolina,Medicare Advantage,,38.52,,,,,,,35.59,21681.15,fee schedule,
"RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN",RX-182620,CDM,636,RC,J9311,HCPCS,50242010901,NDC,facility,outpatient,13.4,ML,33345.80000,20007.48000,WellCare of North Carolina,Medicare Advantage,,38.52,,,,,,,35.59,24749.25,fee schedule,
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION,RX-182891,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,outpatient,1,UN,48587.00000,29152.20000,WellCare of North Carolina,Medicare Advantage,,268.89,,,,,,,248.41,36061.27,fee schedule,
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-182904,CDM,636,RC,J9229,HCPCS,00008010001,NDC,facility,outpatient,1,UN,105505.20000,63303.12000,WellCare of North Carolina,Medicare Advantage,,2832.95,,,,,,,2617.11,78305.96,fee schedule,
MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION,RX-183201,CDM,636,RC,J2186,HCPCS,70842012001,NDC,facility,outpatient,1,UN,997.50000,598.50000,WellCare of North Carolina,Medicare Advantage,,2.29,,,,,,,2.11,740.34,fee schedule,
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION,RX-183578,CDM,636,RC,J0185,HCPCS,47426020101,NDC,facility,outpatient,18,ML,1972.25000,1183.35000,WellCare of North Carolina,Medicare Advantage,,1.72,,,,,,,1.59,1463.80,fee schedule,
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE,RX-183586,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,1,ML,26620.10000,15972.06000,WellCare of North Carolina,Medicare Advantage,,172.82,,,,,,,159.65,19757.44,fee schedule,
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION,RX-183685,CDM,636,RC,J9017,HCPCS,63459060111,NDC,facility,outpatient,6,ML,5890.65000,3534.39000,WellCare of North Carolina,Medicare Advantage,,8.56,,,,,,,7.91,4372.04,fee schedule,
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION,RX-183891,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,24,ML,35224.60000,21134.76000,WellCare of North Carolina,Medicare Advantage,,34.61,,,,,,,31.97,26143.70,fee schedule,
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION,RX-184619,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,0.5,ML,58.45000,35.07000,WellCare of North Carolina,Medicare Advantage,,19.02,,,,,,,11.70,50.28,fee schedule,
"EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION",RX-184832,CDM,635,RC,Q5106,HCPCS,00069130510,NDC,facility,outpatient,1,ML,116.40000,69.84000,WellCare of North Carolina,Medicare Advantage,,8.24,,,,,,,7.61,94.63,fee schedule,
"EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION",RX-184833,CDM,635,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,1,ML,166.60000,99.96000,WellCare of North Carolina,Medicare Advantage,,8.24,,,,,,,7.61,135.45,fee schedule,
"EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION",RX-184834,CDM,635,RC,Q5106,HCPCS,59353000410,NDC,facility,outpatient,1,ML,216.75000,130.05000,WellCare of North Carolina,Medicare Advantage,,8.24,,,,,,,7.61,176.22,fee schedule,
"EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION",RX-184835,CDM,635,RC,Q5106,HCPCS,00069130801,NDC,facility,outpatient,1,ML,517.90000,310.74000,WellCare of North Carolina,Medicare Advantage,,8.24,,,,,,,7.61,421.05,fee schedule,
"EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION",RX-184836,CDM,635,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,1,ML,2023.50000,1214.10000,WellCare of North Carolina,Medicare Advantage,,8.24,,,,,,,7.61,1645.11,fee schedule,
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-185041,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,0.6,ML,9514.15000,5708.49000,WellCare of North Carolina,Medicare Advantage,,104.09,,,,,,,96.16,7061.40,fee schedule,
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION,RX-185291,CDM,636,RC,J9204,HCPCS,42747076101,NDC,facility,outpatient,5,ML,21317.55000,12790.53000,WellCare of North Carolina,Medicare Advantage,,260.93,,,,,,,241.04,15821.89,fee schedule,
FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-185476,CDM,636,RC,Q5110,HCPCS,00069029101,NDC,facility,outpatient,0.5,ML,1012.45000,607.47000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.29100,751.44,fee schedule,
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-185477,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.8,ML,1610.35000,966.21000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.29100,1195.20,fee schedule,
CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION,RX-185743,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,7,ML,48344.85000,29006.91000,WellCare of North Carolina,Medicare Advantage,,30.75,,,,,,,28.41,35881.55,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-186144,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,WellCare of North Carolina,Medicare Advantage,,111.65,,,,,,,103.14,14110.89,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION",RX-186373,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,WellCare of North Carolina,Medicare Advantage,,137.95,,,,,,,127.44,7479.15,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML INJECTION SOLUTION,RX-186457,CDM,636,RC,Q5110,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.29100,751.44,fee schedule,
DEXAMETHASONE 0.4 MG INTRACANALICULAR INSERT,RX-186611,CDM,636,RC,J1096,HCPCS,70382020488,NDC,facility,outpatient,1,UN,2928.00000,1756.80000,WellCare of North Carolina,Medicare Advantage,,107.20,,,,,,,99.04,2173.16,fee schedule,
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION,RX-186675,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,WellCare of North Carolina,Medicare Advantage,,95.91,,,,,,,88.60,26697.16,fee schedule,
"TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-186766,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,outpatient,5,ML,20846.10000,12507.66000,WellCare of North Carolina,Medicare Advantage,,64.51,,,,,,,59.60,15471.98,fee schedule,
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION,RX-186918,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,5,ML,419.55000,251.73000,WellCare of North Carolina,Medicare Advantage,,7.17,,,,,,,6.63,311.39,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION,RX-187119,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,1,UN,82165.25000,49299.15000,WellCare of North Carolina,Medicare Advantage,,143.50,,,,,,,132.57,60983.05,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020701,NDC,facility,outpatient,16,ML,12554.95000,7532.97000,WellCare of North Carolina,Medicare Advantage,,29.25,,,,,,,27.02,9318.28,fee schedule,
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION,RX-187220,CDM,636,RC,Q5107,HCPCS,55513020601,NDC,facility,outpatient,4,ML,3345.05000,2007.03000,WellCare of North Carolina,Medicare Advantage,,29.25,,,,,,,27.02,2482.70,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,outpatient,10,ML,3995.45000,2397.27000,WellCare of North Carolina,Medicare Advantage,,30.85,,,,,,,28.50,2965.42,fee schedule,
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION,RX-188032,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,outpatient,50,ML,18877.10000,11326.26000,WellCare of North Carolina,Medicare Advantage,,30.85,,,,,,,28.50,14010.58,fee schedule,
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION,RX-188104,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,outpatient,1,UN,17338.20000,10402.92000,WellCare of North Carolina,Medicare Advantage,,44.08,,,,,,,40.72,12868.41,fee schedule,
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION,RX-188105,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,outpatient,1,UN,51888.40000,31133.04000,WellCare of North Carolina,Medicare Advantage,,44.08,,,,,,,40.72,38511.57,fee schedule,
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION,RX-188124,CDM,636,RC,J0791,HCPCS,00078088361,NDC,facility,outpatient,10,ML,10365.35000,6219.21000,WellCare of North Carolina,Medicare Advantage,,135.95,,,,,,,125.60,7693.16,fee schedule,
ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION,RX-188137,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,1,UN,6279.25000,3767.55000,WellCare of North Carolina,Medicare Advantage,,11.56,,,,,,,10.68,4660.46,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION,RX-188339,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,1,UN,12634.60000,7580.76000,WellCare of North Carolina,Medicare Advantage,,38.58,,,,,,,35.64,9377.40,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION,RX-188340,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION,RX-188344,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,outpatient,1,UN,13855.50000,8313.30000,WellCare of North Carolina,Medicare Advantage,,31.48,,,,,,,29.08,10283.55,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069034201,NDC,facility,outpatient,16,ML,11070.85000,6642.51000,WellCare of North Carolina,Medicare Advantage,,27.06,,,,,,,25.00,8216.78,fee schedule,
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION,RX-188418,CDM,636,RC,Q5118,HCPCS,00069031501,NDC,facility,outpatient,4,ML,2974.00000,1784.40000,WellCare of North Carolina,Medicare Advantage,,27.06,,,,,,,25.00,2207.30,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,10,ML,3428.95000,2057.37000,WellCare of North Carolina,Medicare Advantage,,29.24,,,,,,,27.01,2544.97,fee schedule,
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION,RX-188420,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,50,ML,16044.60000,9626.76000,WellCare of North Carolina,Medicare Advantage,,29.24,,,,,,,27.01,11908.30,fee schedule,
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION,RX-188516,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,outpatient,1,UN,75742.60000,45445.56000,WellCare of North Carolina,Medicare Advantage,,377.15,,,,,,,348.41,56216.16,fee schedule,
TRASTUZUMAB-QYYP 420 MG INTRAVENOUS SOLUTION,RX-188595,CDM,636,RC,Q5116,HCPCS,00069030601,NDC,facility,outpatient,1,UN,15195.80000,9117.48000,WellCare of North Carolina,Medicare Advantage,,29.39,,,,,,,27.15,11278.32,fee schedule,
EPTINEZUMAB-JJMR 100 MG/ML INTRAVENOUS SOLUTION,RX-188789,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,1,ML,8211.30000,4926.78000,WellCare of North Carolina,Medicare Advantage,,20.97,,,,,,,19.37,6094.43,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065601,NDC,facility,outpatient,25,ML,19413.25000,11647.95000,WellCare of North Carolina,Medicare Advantage,,86.00,,,,,,,79.44,14408.51,fee schedule,
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION,RX-188809,CDM,636,RC,J9227,HCPCS,00024065401,NDC,facility,outpatient,5,ML,4102.65000,2461.59000,WellCare of North Carolina,Medicare Advantage,,86.00,,,,,,,79.44,3044.99,fee schedule,
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION,RX-189111,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,outpatient,1,UN,11554.40000,6932.64000,WellCare of North Carolina,Medicare Advantage,,38.09,,,,,,,35.19,8575.68,fee schedule,
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT,RX-189115,CDM,636,RC,J9281,HCPCS,72493010140,NDC,facility,outpatient,1,UN,110033.00000,66019.80000,WellCare of North Carolina,Medicare Advantage,,334.46,,,,,,,308.97,81666.49,fee schedule,
INFLIXIMAB-AXXQ 100 MG INTRAVENOUS SOLUTION,RX-189186,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,1,UN,2163.00000,1297.80000,WellCare of North Carolina,Medicare Advantage,,21.43,,,,,,,19.80,1605.38,fee schedule,
"PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN",RX-189618,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,outpatient,15,ML,61507.80000,36904.68000,WellCare of North Carolina,Medicare Advantage,,65.20,,,,,,,60.24,45651.09,fee schedule,
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN,RX-189619,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,10,ML,41095.25000,24657.15000,WellCare of North Carolina,Medicare Advantage,,65.20,,,,,,,60.24,30500.89,fee schedule,
TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION,RX-189818,CDM,636,RC,J9349,HCPCS,73535020801,NDC,facility,outpatient,1,UN,6416.85000,3850.11000,WellCare of North Carolina,Medicare Advantage,,15.03,,,,,,,13.88,4762.59,fee schedule,
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION,RX-190105,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,1,UN,17822.95000,10693.77000,WellCare of North Carolina,Medicare Advantage,,143.50,,,,,,,132.57,13228.19,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,11,ML,100657.05000,60394.23000,WellCare of North Carolina,Medicare Advantage,,236.37,,,,,,,218.36,74707.66,fee schedule,
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION,RX-190261,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,outpatient,3,ML,27497.75000,16498.65000,WellCare of North Carolina,Medicare Advantage,,236.37,,,,,,,218.36,20408.83,fee schedule,
"EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION",RX-190548,CDM,635,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,1,ML,1019.75000,611.85000,WellCare of North Carolina,Medicare Advantage,,8.24,,,,,,,7.61,829.06,fee schedule,
TRILACICLIB 300 MG INTRAVENOUS SOLUTION,RX-190973,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,outpatient,1,UN,6743.50000,4046.10000,WellCare of North Carolina,Medicare Advantage,,5.73,,,,,,,5.30,5005.03,fee schedule,
TRASTUZUMAB-QYYP 150 MG INTRAVENOUS SOLUTION,RX-191110,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,1,UN,5603.90000,3362.34000,WellCare of North Carolina,Medicare Advantage,,29.39,,,,,,,27.15,4159.21,fee schedule,
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION,RX-191365,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,outpatient,1,UN,9216.70000,5530.02000,WellCare of North Carolina,Medicare Advantage,,2222.14,,,,,,,1845.18,6840.63,fee schedule,
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION,RX-191513,CDM,636,RC,J9359,HCPCS,79952011001,NDC,facility,outpatient,1,UN,124890.65000,74934.39000,WellCare of North Carolina,Medicare Advantage,,227.75,,,,,,,210.39,92693.84,fee schedule,
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION,RX-191521,CDM,636,RC,J9272,HCPCS,00173089803,NDC,facility,outpatient,10,ML,53208.20000,31924.92000,WellCare of North Carolina,Medicare Advantage,,255.90,,,,,,,236.40,39491.13,fee schedule,
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION,RX-191720,CDM,636,RC,J9061,HCPCS,57894050101,NDC,facility,outpatient,7,ML,17024.40000,10214.64000,WellCare of North Carolina,Medicare Advantage,,23.67,,,,,,,21.86,12635.51,fee schedule,
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION,RX-192514,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,outpatient,1,UN,32838.55000,19703.13000,WellCare of North Carolina,Medicare Advantage,,198.20,,,,,,,183.10,24372.77,fee schedule,
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE,RX-192861,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,1.5,ML,16340.20000,9804.12000,WellCare of North Carolina,Medicare Advantage,,12.94,,,,,,,11.95,12127.70,fee schedule,
SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION,RX-192891,CDM,636,RC,J9331,HCPCS,80803015350,NDC,facility,outpatient,1,UN,36433.75000,21860.25000,WellCare of North Carolina,Medicare Advantage,,88.80,,,,,,,82.03,27041.13,fee schedule,
FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE,RX-193338,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,outpatient,0.5,ML,739.45000,443.67000,WellCare of North Carolina,Medicare Advantage,,0.39900,,,,,,,0.36860,548.82,fee schedule,
FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE,RX-193339,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,outpatient,0.8,ML,1173.55000,704.13000,WellCare of North Carolina,Medicare Advantage,,0.39900,,,,,,,0.36860,871.01,fee schedule,
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION,RX-193432,CDM,636,RC,J9298,HCPCS,00003712511,NDC,facility,outpatient,20,ML,68131.75000,40879.05000,WellCare of North Carolina,Medicare Advantage,,207.72,,,,,,,191.90,50567.38,fee schedule,
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION,RX-194935,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,outpatient,1.7,ML,46244.25000,27746.55000,WellCare of North Carolina,Medicare Advantage,,35.26,,,,,,,32.57,34322.48,fee schedule,
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION,RX-194936,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,outpatient,3,ML,9288.55000,5573.13000,WellCare of North Carolina,Medicare Advantage,,35.26,,,,,,,32.57,6893.96,fee schedule,
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION,RX-195085,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,outpatient,20,ML,30117.40000,18070.44000,WellCare of North Carolina,Medicare Advantage,,72.96,,,,,,,67.41,22353.13,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,outpatient,1,ML,3021.70000,1813.02000,WellCare of North Carolina,Medicare Advantage,,687.36,,,,,,,604.94,2242.71,fee schedule,
MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION,RX-195327,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,outpatient,30,ML,82676.70000,49606.02000,WellCare of North Carolina,Medicare Advantage,,687.36,,,,,,,634.99,61362.65,fee schedule,
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION,RX-195941,CDM,636,RC,J9345,HCPCS,50881000603,NDC,facility,outpatient,20,ML,65144.20000,39086.52000,WellCare of North Carolina,Medicare Advantage,,32.09,,,,,,,29.64,48350.03,fee schedule,
RISPERIDONE ER 100 MG/0.28 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196225,CDM,636,RC,J2799,HCPCS,51759052010,NDC,facility,outpatient,0.28,ML,11967.50000,7180.50000,WellCare of North Carolina,Medicare Advantage,,26.29,,,,,,,24.29,8882.28,fee schedule,
RISPERIDONE ER 200 MG/0.56 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196227,CDM,636,RC,J2799,HCPCS,51759085010,NDC,facility,outpatient,0.56,ML,23918.10000,14350.86000,WellCare of North Carolina,Medicare Advantage,,26.29,,,,,,,24.29,17752.01,fee schedule,
RISPERIDONE ER 250 MG/0.7 ML SUBCUTANEOUS EXTEND RELEASE SUSP SYRINGE,RX-196228,CDM,636,RC,J2799,HCPCS,51759096010,NDC,facility,outpatient,0.7,ML,29894.05000,17936.43000,WellCare of North Carolina,Medicare Advantage,,26.29,,,,,,,24.29,22187.36,fee schedule,
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML INTRAVESICAL SUSPENSION,RX-196721,CDM,636,RC,J9029,HCPCS,55566105001,NDC,facility,outpatient,1,UN,68158.20000,40894.92000,WellCare of North Carolina,Medicare Advantage,,66509.39,,,,,,,13645.27,176902.85,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION,RX-197053,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,WellCare of North Carolina,Medicare Advantage,,76.25,,,,,,,70.44,37932.62,fee schedule,
TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION,RX-197054,CDM,636,RC,J3055,HCPCS,57894046901,NDC,facility,outpatient,1.5,ML,4087.55000,2452.53000,WellCare of North Carolina,Medicare Advantage,,76.25,,,,,,,70.44,3033.78,fee schedule,
TRAVOPROST 75 MCG INTRACAMERAL IMPLANT,RX-197960,CDM,636,RC,J7355,HCPCS,25357010001,NDC,facility,outpatient,1,UN,63488.50000,38093.10000,WellCare of North Carolina,Medicare Advantage,,205.51,,,,,,,189.85,47121.16,fee schedule,
METHYLENE BLUE (ANTIDOTE) 20 MG/2 ML (10 MG/ML) 1 % IV SYRINGE,RX-198062,CDM,636,RC,Q9968,HCPCS,54288015901,NDC,facility,outpatient,2,ML,234.40000,140.64000,WellCare of North Carolina,Medicare Advantage,,9.17,,,,,,,6.49,173.97,fee schedule,
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR,RX-198112,CDM,636,RC,Q5111,HCPCS,70114013001,NDC,facility,outpatient,0.6,ML,19012.25000,11407.35000,WellCare of North Carolina,Medicare Advantage,,111.65,,,,,,,103.14,14110.89,fee schedule,
BEVACIZUMAB 2.75 MG/0.11 ML INTRAVITREAL SYRINGE,RX-198250,CDM,636,RC,C9257,HCPCS,71449009190,NDC,facility,outpatient,0.11,ML,352.45000,211.47000,WellCare of North Carolina,Medicare Advantage,,1.92,,,,,,,1.78,261.59,fee schedule,
IMETELSTAT 47 MG INTRAVENOUS SOLUTION,RX-199151,CDM,636,RC,J0870,HCPCS,82959011201,NDC,facility,outpatient,1,UN,10993.10000,6595.86000,WellCare of North Carolina,Medicare Advantage,,59.88,,,,,,,55.32,8159.08,fee schedule,
IMETELSTAT 188 MG INTRAVENOUS SOLUTION,RX-199153,CDM,636,RC,J0870,HCPCS,82959011101,NDC,facility,outpatient,1,UN,43783.25000,26269.95000,WellCare of North Carolina,Medicare Advantage,,59.88,,,,,,,55.32,32495.93,fee schedule,
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION,RX-199746,CDM,636,RC,J1628,HCPCS,57894065001,NDC,facility,outpatient,20,ML,61242.05000,36745.23000,WellCare of North Carolina,Medicare Advantage,,79.77,,,,,,,73.69,45453.85,fee schedule,
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION,RX-200024,CDM,636,RC,J1326,HCPCS,00469342510,NDC,facility,outpatient,1,UN,7315.00000,4389.00000,WellCare of North Carolina,Medicare Advantage,,35.10,,,,,,,32.43,5429.19,fee schedule,
"NIVOLUMAB 600 MG-HYALURONIDASE-NVHY 10,000 UNIT/5 ML SUBCUT SOLUTION",RX-200710,CDM,636,RC,J9289,HCPCS,00003612001,NDC,facility,outpatient,5,ML,35224.60000,21134.76000,WellCare of North Carolina,Medicare Advantage,,28.73,,,,,,,26.54,26143.70,fee schedule,
DATOPOTAMAB DERUXTECAN-DLNK 100 MG INTRAVENOUS SOLUTION,RX-200800,CDM,636,RC,J9011,HCPCS,65597080101,NDC,facility,outpatient,1,UN,21795.75000,13077.45000,WellCare of North Carolina,Medicare Advantage,,54.14,,,,,,,50.01,17719.94,fee schedule,
TENECTEPLASE 25 MG INTRAVENOUS SOLUTION FOR STROKE,RX-202035,CDM,636,RC,J3101,HCPCS,50242001403,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,WellCare of North Carolina,Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION,RX-21900,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,1,UN,1399.95000,839.97000,WellCare of North Carolina,Medicare Advantage,,22.55,,,,,,,20.84,1039.04,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,10,ML,4408.90000,2645.34000,WellCare of North Carolina,Medicare Advantage,,78.98,,,,,,,72.96,3272.29,fee schedule,
"RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS",RX-22149,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,50,ML,20944.45000,12566.67000,WellCare of North Carolina,Medicare Advantage,,78.98,,,,,,,72.96,15544.97,fee schedule,
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION,RX-22185,CDM,636,RC,J1451,HCPCS,70710147801,NDC,facility,outpatient,1.5,ML,6363.00000,3817.80000,WellCare of North Carolina,Medicare Advantage,,6.59,,,,,,,6.09,4722.62,fee schedule,
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION,RX-22473,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.29100,33.96,fee schedule,
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION,RX-23796,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,1,UN,2058.00000,1234.80000,WellCare of North Carolina,Medicare Advantage,,32.64,,,,,,,30.16,1527.45,fee schedule,
IMIGLUCERASE 400 UNIT INTRAVENOUS SOLUTION,RX-26431,CDM,636,RC,J1786,HCPCS,58468466301,NDC,facility,outpatient,1,UN,7346.35000,4407.81000,WellCare of North Carolina,Medicare Advantage,,45.35,,,,,,,41.89,5452.46,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335004940,NDC,facility,outpatient,10,ML,2255.00000,1353.00000,WellCare of North Carolina,Medicare Advantage,,113.89,,,,,,,105.22,1673.66,fee schedule,
"DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION",RX-27431,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,outpatient,25,ML,5775.00000,3465.00000,WellCare of North Carolina,Medicare Advantage,,113.89,,,,,,,105.22,4286.20,fee schedule,
DACTINOMYCIN (COSMEGEN) SYRINGE 0.5 MG/ML,RX-28912,CDM,636,RC,J9120,HCPCS,39822210002,NDC,facility,outpatient,1,UN,3520.00000,2112.00000,WellCare of North Carolina,Medicare Advantage,,344.76,,,,,,,318.49,2612.54,fee schedule,
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION,RX-28947,CDM,636,RC,J0883,HCPCS,00409114001,NDC,facility,outpatient,2.5,ML,1204.10000,722.46000,WellCare of North Carolina,Medicare Advantage,,0.84000,,,,,,,0.77600,893.68,fee schedule,
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION,RX-29071,CDM,636,RC,J9017,HCPCS,69918072010,NDC,facility,outpatient,10,ML,1199.00000,719.40000,WellCare of North Carolina,Medicare Advantage,,8.56,,,,,,,7.91,889.90,fee schedule,
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,RX-29313,CDM,636,RC,J0840,HCPCS,50633011012,NDC,facility,outpatient,1,UN,12869.00000,7721.40000,WellCare of North Carolina,Medicare Advantage,,1920.16,,,,,,,1773.86,9551.37,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-3013,CDM,636,RC,J7194,HCPCS,68516321001,NDC,facility,outpatient,1,UN,83.10000,49.86000,WellCare of North Carolina,Medicare Advantage,,1.78,,,,,,,1.65,61.68,fee schedule,
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION,RX-31310,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,1,UN,858.55000,515.13000,WellCare of North Carolina,Medicare Advantage,,99.17,,,,,,,91.62,637.22,fee schedule,
DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION,RX-31432,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,outpatient,1,UN,19973.00000,11983.80000,WellCare of North Carolina,Medicare Advantage,,5426.64,,,,,,,3998.59,14823.96,fee schedule,
FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION,RX-3216,CDM,636,RC,J2679,HCPCS,63323028110,NDC,facility,outpatient,0.5,ML,59.70000,35.82000,WellCare of North Carolina,Medicare Advantage,,7.71,,,,,,,7.12,44.31,fee schedule,
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE,RX-32267,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,0.6,ML,29217.90000,17530.74000,WellCare of North Carolina,Medicare Advantage,,93.81,,,,,,,86.66,21685.53,fee schedule,
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION,RX-32700,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,1,UN,2978.05000,1786.83000,WellCare of North Carolina,Medicare Advantage,,6.83,,,,,,,6.30,2210.31,fee schedule,
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE,RX-32893,CDM,636,RC,J9217,HCPCS,62935075474,NDC,facility,outpatient,1,UN,2262.45000,1357.47000,WellCare of North Carolina,Medicare Advantage,,185.27,,,,,,,171.16,1679.19,fee schedule,
TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION,RX-32931,CDM,636,RC,J3285,HCPCS,00781342080,NDC,facility,outpatient,20,ML,5230.30000,3138.18000,WellCare of North Carolina,Medicare Advantage,,57.45,,,,,,,53.07,3881.93,fee schedule,
TREPROSTINIL SODIUM 2.5 MG/ML INJECTION SOLUTION,RX-32932,CDM,636,RC,J3285,HCPCS,00781342580,NDC,facility,outpatient,20,ML,13051.70000,7831.02000,WellCare of North Carolina,Medicare Advantage,,57.45,,,,,,,53.07,9686.97,fee schedule,
TREPROSTINIL SODIUM 5 MG/ML INJECTION SOLUTION,RX-32933,CDM,636,RC,J3285,HCPCS,00781342780,NDC,facility,outpatient,20,ML,26087.25000,15652.35000,WellCare of North Carolina,Medicare Advantage,,57.45,,,,,,,53.07,19361.96,fee schedule,
TREPROSTINIL SODIUM 10 MG/ML INJECTION SOLUTION,RX-32934,CDM,636,RC,J3285,HCPCS,00781343080,NDC,facility,outpatient,20,ML,52158.50000,31295.10000,WellCare of North Carolina,Medicare Advantage,,57.45,,,,,,,53.07,38712.04,fee schedule,
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION,RX-33591,CDM,636,RC,J2783,HCPCS,00024515010,NDC,facility,outpatient,1,UN,4712.40000,2827.44000,WellCare of North Carolina,Medicare Advantage,,396.40,,,,,,,366.19,3497.54,fee schedule,
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION,RX-3497,CDM,636,RC,J1596,HCPCS,00143968201,NDC,facility,outpatient,1,ML,27.85000,16.71000,WellCare of North Carolina,Medicare Advantage,,0.48300,,,,,,,0.44620,20.67,fee schedule,
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION,RX-36151,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,outpatient,1,UN,6248.60000,3749.16000,WellCare of North Carolina,Medicare Advantage,,46.83,,,,,,,43.26,4637.71,fee schedule,
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-37894,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,1,UN,18064.20000,10838.52000,WellCare of North Carolina,Medicare Advantage,,4.58,,,,,,,4.23,13407.25,fee schedule,
CETUXIMAB 100 MG/50 ML IV,RX-37989,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CYCLOPHOSPHAMIDE (CYTOXAN) 1 GM INJECTION,RX-38270,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,WellCare of North Carolina,Medicare Advantage,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION,RX-38271,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,1,UN,1507.85000,904.71000,WellCare of North Carolina,Medicare Advantage,,0.50400,,,,,,,0.46560,1119.13,fee schedule,
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET,RX-39255,CDM,636,RC,J0750,HCPCS,00904717207,NDC,facility,outpatient,1,UN,23.80000,14.28000,WellCare of North Carolina,Medicare Advantage,,1.82,,,,,,,1.68,17.66,fee schedule,
PACLITAXEL-PROTEIN BOUND (ABRAXANE) IVPB,RX-40475,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,1,UN,7227.30000,4336.38000,WellCare of North Carolina,Medicare Advantage,,11.07,,,,,,,10.22,5364.10,fee schedule,
ZICONOTIDE 25 MCG/ML INTRATHECAL SOLUTION,RX-40573,CDM,636,RC,J2278,HCPCS,70720072310,NDC,facility,outpatient,20,ML,26468.35000,15881.01000,WellCare of North Carolina,Medicare Advantage,,10.65,,,,,,,9.84,19644.81,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072010,NDC,facility,outpatient,1,ML,5590.45000,3354.27000,WellCare of North Carolina,Medicare Advantage,,10.65,,,,,,,9.84,4149.23,fee schedule,
ZICONOTIDE 100 MCG/ML INTRATHECAL SOLUTION,RX-40574,CDM,636,RC,J2278,HCPCS,70720072210,NDC,facility,outpatient,5,ML,26468.35000,15881.01000,WellCare of North Carolina,Medicare Advantage,,10.65,,,,,,,9.84,19644.81,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (ONCOLOGY),RX-40661,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
MITOMYCIN BLADDER INSTILLATION (2 MG/ML; 40 MG VIAL),RX-40800008,CDM,636,RC,J9280,HCPCS,00143913601,NDC,facility,outpatient,1,UN,1243.00000,745.80000,WellCare of North Carolina,Medicare Advantage,,21.37,,,,,,,19.74,922.55,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,10,ML,40115.90000,24069.54000,WellCare of North Carolina,Medicare Advantage,,192.65,,,,,,,177.98,29774.02,fee schedule,
IPILIMUMAB (YERVOY) 5 MG/ML INJECTION WRAPPER,RX-40800030,CDM,636,RC,J9228,HCPCS,00003232822,NDC,facility,outpatient,40,ML,159638.10000,95782.86000,WellCare of North Carolina,Medicare Advantage,,192.65,,,,,,,177.98,118483.40,fee schedule,
FLUDARABINE (FLUDARA) 50 MG INJECTION WRAPPER,RX-40800031,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,WellCare of North Carolina,Medicare Advantage,,71.61,,,,,,,66.15,1092.00,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078066961,NDC,facility,outpatient,5,ML,2929.75000,1757.85000,WellCare of North Carolina,Medicare Advantage,,65.34,,,,,,,60.36,2174.46,fee schedule,
OFATUMUMAB (ARZERRA) 20 MG/ML INJECTION WRAPPER,RX-40800033,CDM,636,RC,J9302,HCPCS,00078069061,NDC,facility,outpatient,50,ML,26823.30000,16093.98000,WellCare of North Carolina,Medicare Advantage,,65.34,,,,,,,60.36,19908.25,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,outpatient,10,ML,5640.25000,3384.15000,WellCare of North Carolina,Medicare Advantage,,6.00,,,,,,,5.54,4186.19,fee schedule,
TOCILIZUMAB (ACTEMRA) 20 MG/ML INJECTION WRAPPER,RX-40800122,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,outpatient,20,ML,11217.45000,6730.47000,WellCare of North Carolina,Medicare Advantage,,6.00,,,,,,,5.54,8325.59,fee schedule,
METHYLPREDNISOLONE SOD SUCC 40 MG/ML SOLUTION FOR INJECTION WRAPPER,RX-40800128781,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,1,UN,45.45000,27.27000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,33.73,fee schedule,
METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLUTION FOR INJECTION WRAPPER,RX-40800128782,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,63.45000,38.07000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,47.09,fee schedule,
STUDY METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2ML SOLUTION FOR INJECTION,RX-408007498,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.04004,0.71810,fee schedule,
STUDY C25003 BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLN,RX-408007842,CDM,636,RC,J9042,HCPCS,99990000829,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,271.57,,,,,,,0.04004,720.99,fee schedule,
CEFTAROLINE FOSAMIL 600 MG/20ML IV WETTED VIAL,RX-4080107671,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION,RX-4080800218,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,1,UN,36575.00000,21945.00000,WellCare of North Carolina,Medicare Advantage,,217.49,,,,,,,200.92,27145.97,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 5 ML VIALS,RX-4081031592,CDM,636,RC,90375,HCPCS,13533031805,NDC,facility,outpatient,5,ML,13686.90000,8212.14000,WellCare of North Carolina,Medicare Advantage,,293.84,,,,,,,271.45,10158.42,fee schedule,
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR - 1 ML VIALS,RX-4081031594,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,1,ML,2799.00000,1679.40000,WellCare of North Carolina,Medicare Advantage,,293.84,,,,,,,271.45,2077.42,fee schedule,
KETOROLAC 30 MG/ML INJECTION WRAPPER,RX-408170,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,1,ML,45.75000,27.45000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.29100,33.96,fee schedule,
IRON DEXTRAN 2.5 MG/ML DILUTION,RX-40840702,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,10,ML,835.00000,501.00000,WellCare of North Carolina,Medicare Advantage,,19.02,,,,,,,17.57,619.74,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION WRAPPER FOR MI,RX-408408256,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,WellCare of North Carolina,Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
KETOROLAC 15 MG/ML INJECTION SOLUTION WRAPPER,RX-408408383,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,1,ML,19.25000,11.55000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.29100,14.29,fee schedule,
GLUCAGON 1 MG SOLUTION FOR INJECTION (COMBINED VIALS) WRAPPER,RX-40841026,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,outpatient,1,UN,1165.70000,699.42000,WellCare of North Carolina,Medicare Advantage,,156.44,,,,,,,144.52,865.18,fee schedule,
GLUCAGON 1 MG/ML IV PEDIATRIC,RX-408410260,CDM,636,RC,J1610,HCPCS,09999007861,NDC,facility,outpatient,1,UN,1242.40000,745.44000,WellCare of North Carolina,Medicare Advantage,,191.57,,,,,,,176.98,922.11,fee schedule,
METHYLPREDNISOLONE SOD SUCC 62.5 MG/ML IV PEDIATRIC,RX-40841071,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,UN,247.75000,148.65000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,183.88,fee schedule,
METHYLPREDNISOLONE SOD SUCC 4 MG/ML PEDIATRIC DILUTION,RX-40841291,CDM,636,RC,J2919,HCPCS,99999000650,NDC,facility,outpatient,250,ML,1785.00000,1071.00000,WellCare of North Carolina,Medicare Advantage,,0.22050,,,,,,,0.20370,1324.83,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 10 MG/ML INTRAVENOUS SOLUTION,RX-40841935,CDM,636,RC,J2329,HCPCS,09999001541,NDC,facility,outpatient,15,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
ALTEPLASE 1 MG/ML INTRATHECAL INJECTION,RX-40842263,CDM,636,RC,J2997,HCPCS,09999226301,NDC,facility,outpatient,1,ML,451.85000,271.11000,WellCare of North Carolina,Medicare Advantage,,99.17,,,,,,,90.46,335.36,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999009450,NDC,facility,outpatient,36,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
STUDY UTX-TGR-304/204 UBLITUXIMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40842448,CDM,636,RC,J2329,HCPCS,09999001967,NDC,facility,outpatient,6,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,74.29,,,,,,,0.04004,200.52,fee schedule,
"FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS BOLUS",RX-408450147,CDM,636,RC,J7169,HCPCS,00310320001,NDC,facility,outpatient,1,UN,10077.00000,6046.20000,WellCare of North Carolina,Medicare Advantage,,137.95,,,,,,,127.44,7479.15,fee schedule,
ALTEPLASE 1 MG/1 ML SOLUTION FOR INJECTION,RX-408451019,CDM,636,RC,J2997,HCPCS,99999001713,NDC,facility,outpatient,1,ML,364.25000,218.55000,WellCare of North Carolina,Medicare Advantage,,99.17,,,,,,,72.92,270.35,fee schedule,
STUDY S1914 ATEZOLIZUMAB 60 MG/ML IV SOLUTION,RX-408451156,CDM,256,RC,J9022,HCPCS,99999009156,NDC,facility,outpatient,20,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,95.91,,,,,,,0.04004,215.56,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 3.75 MG INTRAMUSCULAR INJECTION (1 MONTH),RX-408453792,CDM,636,RC,J1950,HCPCS,99999010366,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY NSABP B-62/CAMBRIA-1 LEUPROLIDE 11.25 MG INTRAMUSCULAR INJECTION (3 MONTH),RX-408453793,CDM,636,RC,J1950,HCPCS,99999010367,NDC,facility,outpatient,1,UN,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,1816.84,,,,,,,0.04004,4844.60,fee schedule,
STUDY GS-US-595-6184 SACITUZUMAB GOVITECAN-HZIY 10 MG/ML INTRAVENOUS SOLUTION,RX-408453812,CDM,636,RC,J9317,HCPCS,99999010381,NDC,facility,outpatient,180,ME,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,38.09,,,,,,,0.04004,101.12,fee schedule,
STUDY S2206 DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION,RX-408453830,CDM,636,RC,J9173,HCPCS,99999010394,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,89.38,,,,,,,0.04004,237.76,fee schedule,
CARFILZOMIB (KYPROLIS) IVPB 2 MG/ML,RX-408454006,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,outpatient,1,UN,15838.65000,9503.19000,WellCare of North Carolina,Medicare Advantage,,58.43,,,,,,,53.98,11755.45,fee schedule,
CYCLOPHOSPHAMIDE (POWDER) (CYTOXAN) 20 MG/ML IVPB,RX-408454040,CDM,636,RC,J9075,HCPCS,00781324494,NDC,facility,outpatient,1,UN,2740.60000,1644.36000,WellCare of North Carolina,Medicare Advantage,,0.50400,,,,,,,0.46560,2034.07,fee schedule,
CEFTAROLINE FOSAMIL 1 MG/ML DESENSITIZATION SOLUTION,RX-408470072,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
CEFTAROLINE FOSAMIL 0.1 MG/ML DESENSITIZATION SOLUTION,RX-408470073,CDM,636,RC,J0712,HCPCS,00456060001,NDC,facility,outpatient,1,UN,1144.35000,686.61000,WellCare of North Carolina,Medicare Advantage,,4.44,,,,,,,4.10,849.34,fee schedule,
BUMETANIDE 20 MG/80 ML (0.25 MG/ML) INFUSION CSAC,RX-408470198,CDM,636,RC,J1939,HCPCS,99999077752,NDC,facility,outpatient,80,ML,173.25000,103.95000,WellCare of North Carolina,Medicare Advantage,,0.38850,,,,,,,0.35890,128.59,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-408470296,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,WellCare of North Carolina,Medicare Advantage,,7.07,,,,,,,6.53,1915.21,fee schedule,
ARGATROBAN CRRT REGIONAL CIRCUIT INFUSION (50 MG/50 ML),RX-40849242,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,WellCare of North Carolina,Medicare Advantage,,0.84000,,,,,,,0.77600,358.48,fee schedule,
MITOMYCIN 40 MG/40 ML (ONE-STEP BLADDER IRRIGATION),RX-40849314,CDM,636,RC,J9280,HCPCS,99999000792,NDC,facility,outpatient,1,UN,5836.45000,3501.87000,WellCare of North Carolina,Medicare Advantage,,21.37,,,,,,,19.74,4331.81,fee schedule,
ALTEPLASE 125 MCG/ML INTRAOCULAR INJECTION,RX-40849375,CDM,636,RC,J2997,HCPCS,99999007719,NDC,facility,outpatient,0.1,ML,19.35000,11.61000,WellCare of North Carolina,Medicare Advantage,,99.17,,,,,,,3.87,262.57,fee schedule,
FACTOR VIIA RECOMB (NOVOSEVEN) INTERMITTENT INFUSION,RX-40849443,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT/20 ML IV KIT,RX-40849770,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,88.95000,53.37000,WellCare of North Carolina,Medicare Advantage,,2.25,,,,,,,2.08,66.02,fee schedule,
STUDY MK7902-010-WIRB PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION,RX-40850523,CDM,636,RC,J9271,HCPCS,09999008984,NDC,facility,outpatient,4,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION (EUA),RX-40850739,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,1,UN,2580.45000,1548.27000,WellCare of North Carolina,Medicare Advantage,,7.07,,,,,,,6.53,1915.21,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 24-HR INFUSION)",RX-40850768,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 24-HR INFUSION)",RX-40850770,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (5 MCG/M2/DAY, 48-HR INFUSION)",RX-40850772,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 48-HR INFUSION)",RX-40850774,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
"BLINATUMOMAB 12.5 MCG/ML IV SOLN (15 MCG/M2/DAY, 7-DAY INFUSION)",RX-40850776,CDM,636,RC,J9039,HCPCS,55513015001,NDC,facility,outpatient,1,UN,24724.80000,14834.88000,WellCare of North Carolina,Medicare Advantage,,172.46,,,,,,,159.32,18350.75,fee schedule,
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION FOR STROKE,RX-408508256,CDM,636,RC,J3101,HCPCS,09999508256,NDC,facility,outpatient,1,UN,37768.55000,22661.13000,WellCare of North Carolina,Medicare Advantage,,180.83,,,,,,,167.05,28031.82,fee schedule,
STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 21 MG/ML INTRAVENOUS SOLUTION,RX-40850889,CDM,636,RC,J9355,HCPCS,09999010485,NDC,facility,outpatient,150,ME,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,78.78,,,,,,,0.04004,212.46,fee schedule,
"STUDY DF-HCC-20-347-ADEPT TRASTUZUMAB 600 MG-HYALURONIDASE 10,000 UNITS/5 ML SUBCUTANEOUS SOLUTION",RX-40850891,CDM,636,RC,J9356,HCPCS,09999010486,NDC,facility,outpatient,5,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,64.51,,,,,,,0.04004,175.62,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 1200 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 30,000 UNITS/15 ML SUBCUTANEOUS SOLUTION",RX-40850892,CDM,636,RC,J9316,HCPCS,09999010487,NDC,facility,outpatient,15,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,65.20,,,,,,,0.04004,176.79,fee schedule,
"STUDY DF-HCC-20-347-ADEPT PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONIDASE 20,000 UNITS/10 ML SUBCUTANEOUS SOLUTION",RX-40850893,CDM,636,RC,J9316,HCPCS,09999010488,NDC,facility,outpatient,10,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,65.20,,,,,,,0.04004,176.79,fee schedule,
STUDY J3M-MC-JZQB PEMETREXED 25 MG/ML IV SOLUTION,RX-40851421,CDM,636,RC,J9305,HCPCS,09999011533,NDC,facility,outpatient,500,ME,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,4.58,,,,,,,0.04004,10.40,fee schedule,
STUDY J3M-MC-JZQB PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851423,CDM,636,RC,J9271,HCPCS,09999011534,NDC,facility,outpatient,4,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
STUDY MK-2870-011 PEMBROLIZUMAB 25 MG/ML IV SOLUTION,RX-40851518,CDM,636,RC,J9271,HCPCS,09999011907,NDC,facility,outpatient,4,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,63.30,,,,,,,0.04004,163.33,fee schedule,
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS WRAPPER,RX-40860010,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ML,483.00000,289.80000,WellCare of North Carolina,Medicare Advantage,,0.84000,,,,,,,0.77600,358.48,fee schedule,
BEVACIZUMAB 2.25 MG/0.09 ML INTRAVITREAL SYRINGE,RX-40871198250,CDM,636,RC,C9257,HCPCS,71449009199,NDC,facility,outpatient,0.09,ML,291.30000,174.78000,WellCare of North Carolina,Medicare Advantage,,1.92,,,,,,,1.78,216.20,fee schedule,
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN,RX-408880146,CDM,636,RC,J9203,HCPCS,00008451001,NDC,facility,outpatient,1,UN,45136.00000,27081.60000,WellCare of North Carolina,Medicare Advantage,,248.45,,,,,,,229.52,33499.94,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,14,ML,35970.30000,21582.18000,WellCare of North Carolina,Medicare Advantage,,95.91,,,,,,,88.60,26697.16,fee schedule,
ATEZOLIZUMAB (TECENTRIQ) 60 MG/ML INJECTION SOLUTION WRAPPER,RX-408880287,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,20,ML,51268.20000,30760.92000,WellCare of North Carolina,Medicare Advantage,,95.91,,,,,,,88.60,38051.26,fee schedule,
"DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN",RX-408880336,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,15,ML,46791.25000,28074.75000,WellCare of North Carolina,Medicare Advantage,,58.35,,,,,,,53.90,34728.47,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,WellCare of North Carolina,Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 2 HOURS,RX-408880458,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,WellCare of North Carolina,Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 3 HOURS,RX-408880459,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,outpatient,100,ML,7636.20000,4581.72000,WellCare of North Carolina,Medicare Advantage,,82.29,,,,,,,76.02,5667.59,fee schedule,
CETUXIMAB IVPB OVER 1 HOUR,RX-408880460,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,outpatient,50,ML,3955.60000,2373.36000,WellCare of North Carolina,Medicare Advantage,,82.29,,,,,,,76.02,2935.85,fee schedule,
ALEMTUZUMAB (CAMPATH) SYRINGE 30 MG/ML (SOLID ORGAN TRANSPLANT),RX-408880480,CDM,636,RC,J0202,HCPCS,58468035703,NDC,facility,outpatient,1,ML,0.20000,0.12000,WellCare of North Carolina,Medicare Advantage,,2551.38,,,,,,,0.04004,6806.87,fee schedule,
FILGRASTIM-AAFI 300 MCG/ML SUBCUTANEOUS SOLUTION (COMPOUNDED SYRINGE),RX-408880530,CDM,636,RC,J1447,HCPCS,00069029301,NDC,facility,outpatient,1,ML,1012.45000,607.47000,WellCare of North Carolina,Medicare Advantage,,0.29400,,,,,,,0.27160,751.44,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 100 MG),RX-408880697,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 75 MG),RX-408880698,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION (MAX DOSE 50 MG),RX-408880699,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,1,UN,18814.40000,11288.64000,WellCare of North Carolina,Medicare Advantage,,38.58,,,,,,,35.64,13964.05,fee schedule,
TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION (FOR 0.8 MG/KG DOSAGE),RX-408880702,CDM,636,RC,J3055,HCPCS,57894047001,NDC,facility,outpatient,1,ML,51108.35000,30665.01000,WellCare of North Carolina,Medicare Advantage,,76.25,,,,,,,70.44,37932.62,fee schedule,
MELPHALAN (ALKERAN) SYRINGE,RX-408880720,CDM,636,RC,J9245,HCPCS,67457019501,NDC,facility,outpatient,1,UN,2475.00000,1485.00000,WellCare of North Carolina,Medicare Advantage,,100.69,,,,,,,93.02,1836.94,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,WellCare of North Carolina,Medicare Advantage,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,WellCare of North Carolina,Medicare Advantage,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (TYENNE) 20 MG/ML INJECTION WRAPPER,RX-408880806,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,WellCare of North Carolina,Medicare Advantage,,4.64,,,,,,,4.29,1267.75,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059210,NDC,facility,outpatient,10,ML,4175.65000,2505.39000,WellCare of North Carolina,Medicare Advantage,,4.64,,,,,,,4.29,3099.17,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059420,NDC,facility,outpatient,20,ML,8288.30000,4972.98000,WellCare of North Carolina,Medicare Advantage,,4.64,,,,,,,4.29,6151.58,fee schedule,
TOCILIZUMAB-AAZG (FOR COVID-19) 20 MG/ML INJECTION (EUA) WRAPPER,RX-408880815,CDM,636,RC,Q5135,HCPCS,65219059004,NDC,facility,outpatient,4,ML,1708.10000,1024.86000,WellCare of North Carolina,Medicare Advantage,,4.64,,,,,,,4.29,1267.75,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION PEDIATRIC SYRINGE,RX-4089308,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,4,ML,29.75000,17.85000,WellCare of North Carolina,Medicare Advantage,,0.38850,,,,,,,0.35890,22.08,fee schedule,
FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION,RX-41294,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,outpatient,2,ML,1471.30000,882.78000,WellCare of North Carolina,Medicare Advantage,,71.61,,,,,,,66.15,1092.00,fee schedule,
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION,RX-4995,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,0.25,ML,28.95000,17.37000,WellCare of North Carolina,Medicare Advantage,,0.12600,,,,,,,0.11640,21.49,fee schedule,
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION,RX-4996,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,1,ML,105.75000,63.45000,WellCare of North Carolina,Medicare Advantage,,0.12600,,,,,,,0.11640,78.49,fee schedule,
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION,RX-6562,CDM,636,RC,J2690,HCPCS,00409190201,NDC,facility,outpatient,1,ML,202.50000,121.50000,WellCare of North Carolina,Medicare Advantage,,309.42,,,,,,,40.54,695.47,fee schedule,
ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION,RX-70404,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,outpatient,1,UN,83.60000,50.16000,WellCare of North Carolina,Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
"ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION",RX-70405,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,outpatient,1,UN,83.60000,50.16000,WellCare of North Carolina,Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
"(VWF DOSING) ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION",RX-70406,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,outpatient,1,UN,83.60000,50.16000,WellCare of North Carolina,Medicare Advantage,,1.56,,,,,,,1.45,62.05,fee schedule,
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE,RX-76334,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,outpatient,0.3,ML,5298.55000,3179.13000,WellCare of North Carolina,Medicare Advantage,,3.08,,,,,,,2.84,3932.58,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,000 (+/-) UNIT IV SOLUTION",RX-76367,CDM,636,RC,J7192,HCPCS,00026478501,NDC,facility,outpatient,1,UN,85.10000,51.06000,WellCare of North Carolina,Medicare Advantage,,1.69,,,,,,,1.56,63.16,fee schedule,
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION,RX-81696,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,30,ML,27459.60000,16475.76000,WellCare of North Carolina,Medicare Advantage,,47.06,,,,,,,43.48,20380.52,fee schedule,
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN,RX-82228,CDM,636,RC,J9330,HCPCS,00008117901,NDC,facility,outpatient,1,UN,9076.45000,5445.87000,WellCare of North Carolina,Medicare Advantage,,28.05,,,,,,,25.91,6736.54,fee schedule,
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE,RX-87861,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,outpatient,0.5,ML,40477.65000,24286.59000,WellCare of North Carolina,Medicare Advantage,,31.33,,,,,,,28.94,30042.51,fee schedule,
IXABEPILONE 45 MG INTRAVENOUS SOLUTION,RX-88653,CDM,636,RC,J9207,HCPCS,70020191101,NDC,facility,outpatient,1,UN,26867.20000,16120.32000,WellCare of North Carolina,Medicare Advantage,,146.17,,,,,,,135.03,19940.84,fee schedule,
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION,RX-89350,CDM,636,RC,J9305,HCPCS,00002764001,NDC,facility,outpatient,1,UN,3832.85000,2299.71000,WellCare of North Carolina,Medicare Advantage,,4.58,,,,,,,4.23,2844.74,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031090,NDC,facility,outpatient,250,ML,437.00000,262.20000,WellCare of North Carolina,Medicare Advantage,,55.73,,,,,,,51.49,324.34,fee schedule,
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,outpatient,250,ML,437.00000,262.20000,WellCare of North Carolina,Medicare Advantage,,55.73,,,,,,,51.49,324.34,fee schedule,
ALTEPLASE 100 MG INTRAVENOUS SOLUTION,RX-9002,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,outpatient,1,UN,40057.65000,24034.59000,WellCare of North Carolina,Medicare Advantage,,99.17,,,,,,,91.62,29730.79,fee schedule,
ALTEPLASE 50 MG INTRAVENOUS SOLUTION,RX-9003,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,outpatient,1,UN,20036.85000,12022.11000,WellCare of North Carolina,Medicare Advantage,,99.17,,,,,,,91.62,14871.35,fee schedule,
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION,RX-9116,CDM,636,RC,J7197,HCPCS,13533060250,NDC,facility,outpatient,1,UN,94.85000,56.91000,WellCare of North Carolina,Medicare Advantage,,4.30,,,,,,,3.98,70.40,fee schedule,
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION,RX-91349,CDM,636,RC,J1885,HCPCS,00409379601,NDC,facility,outpatient,2,ML,30.90000,18.54000,WellCare of North Carolina,Medicare Advantage,,0.31500,,,,,,,0.29100,22.93,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION",RX-92853,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION",RX-92854,CDM,636,RC,J7189,HCPCS,00169720201,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION",RX-92855,CDM,636,RC,J7189,HCPCS,00169721511,NDC,facility,outpatient,1,UN,88.25000,52.95000,WellCare of North Carolina,Medicare Advantage,,2.79,,,,,,,2.58,65.50,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 250 (+/-) UNIT IV SOLN",RX-93025,CDM,636,RC,J7185,HCPCS,58394001201,NDC,facility,outpatient,1,UN,84.65000,50.79000,WellCare of North Carolina,Medicare Advantage,,1.75,,,,,,,1.62,62.83,fee schedule,
"ANTIHEMOPHILIC FACTOR VIII,REC B-DOMAIN DELETED 1,000 (+/-) UNIT IV SOLN",RX-93027,CDM,636,RC,J7185,HCPCS,58394001401,NDC,facility,outpatient,1,UN,84.65000,50.79000,WellCare of North Carolina,Medicare Advantage,,1.75,,,,,,,1.62,62.83,fee schedule,
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION,RX-9308,CDM,636,RC,J1939,HCPCS,00641600801,NDC,facility,outpatient,4,ML,29.75000,17.85000,WellCare of North Carolina,Medicare Advantage,,0.38850,,,,,,,0.35890,22.08,fee schedule,
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION,RX-9347,CDM,636,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,2,ML,3656.00000,2193.60000,WellCare of North Carolina,Medicare Advantage,,509.22,,,,,,,470.42,2713.48,fee schedule,
ROMIPLOSTIM (NPLATE) SYRINGE 500 MCG/ML (250 MCG),RX-93566,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,1,UN,12542.25000,7525.35000,WellCare of North Carolina,Medicare Advantage,,11.56,,,,,,,10.68,9308.86,fee schedule,
ROMIPLOSTIM (NPLATE) INJECTION 500 MCG/ML (500 MCG),RX-93567,CDM,636,RC,J2802,HCPCS,55513022201,NDC,facility,outpatient,1,UN,25068.40000,15041.04000,WellCare of North Carolina,Medicare Advantage,,11.56,,,,,,,10.68,18605.77,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,outpatient,10,ML,2068.75000,1241.25000,WellCare of North Carolina,Medicare Advantage,,25.07,,,,,,,23.16,1535.43,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013212,NDC,facility,outpatient,12.5,ML,2753.30000,1651.98000,WellCare of North Carolina,Medicare Advantage,,25.07,,,,,,,23.16,2043.50,fee schedule,
MITOXANTRONE (NOVANTRONE) INJECTION,RX-93747,CDM,636,RC,J9293,HCPCS,63323013215,NDC,facility,outpatient,15,ML,3080.00000,1848.00000,WellCare of North Carolina,Medicare Advantage,,25.07,,,,,,,23.16,2285.98,fee schedule,
CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION,RX-93936,CDM,636,RC,J0759,HCPCS,10122061001,NDC,facility,outpatient,50,ML,433.25000,259.95000,WellCare of North Carolina,Medicare Advantage,,2.99,,,,,,,2.76,352.23,fee schedule,
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION,RX-9413,CDM,636,RC,J0675,HCPCS,00009085605,NDC,facility,outpatient,1,ML,653.00000,391.80000,WellCare of North Carolina,Medicare Advantage,,53.60,,,,,,,49.52,530.89,fee schedule,
ONABOTULINUMTOXINA 50 UNIT INTRAMUSCULAR SOLUTION,RX-95794,CDM,636,RC,J0585,HCPCS,00023391950,NDC,facility,outpatient,1,UN,1663.10000,997.86000,WellCare of North Carolina,Medicare Advantage,,6.83,,,,,,,6.30,1234.35,fee schedule,
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION,RX-9615,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ML,2189.00000,1313.40000,WellCare of North Carolina,Medicare Advantage,,11.21,,,,,,,10.36,1624.68,fee schedule,
DEGARELIX 120 MG SUBCUTANEOUS SOLUTION,RX-96987,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,outpatient,1,UN,3628.20000,2176.92000,WellCare of North Carolina,Medicare Advantage,,4.67,,,,,,,4.32,2692.85,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,55566220000,NDC,facility,outpatient,1,ML,385.20000,231.12000,WellCare of North Carolina,Medicare Advantage,,3.70,,,,,,,3.41,285.90,fee schedule,
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION,RX-9748,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,10,ML,1813.25000,1087.95000,WellCare of North Carolina,Medicare Advantage,,3.70,,,,,,,3.41,1345.79,fee schedule,
"FACTOR IX COMPLEX NO.4, 3-FACTOR 1,500 (+/-) UNIT INTRAVENOUS SOLUTION",RX-97682,CDM,636,RC,J7194,HCPCS,68516320602,NDC,facility,outpatient,1,UN,82.95000,49.77000,WellCare of North Carolina,Medicare Advantage,,1.78,,,,,,,1.65,61.57,fee schedule,
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION,RX-98312,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,outpatient,17,ML,5076.25000,3045.75000,WellCare of North Carolina,Medicare Advantage,,0.33600,,,,,,,0.31040,3767.59,fee schedule,
ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION,RX-99465,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,outpatient,1,UN,4022.30000,2413.38000,WellCare of North Carolina,Medicare Advantage,,9.19,,,,,,,8.49,2985.35,fee schedule,
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION,RX-9972,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,1,UN,1730.85000,1038.51000,WellCare of North Carolina,Medicare Advantage,,411.66,,,,,,,346.52,1284.64,fee schedule,
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION,RX-9984,CDM,636,RC,J1430,HCPCS,67871479006,NDC,facility,outpatient,1.5,ML,1650.30000,990.18000,WellCare of North Carolina,Medicare Advantage,,534.41,,,,,,,330.39,1448.89,fee schedule,
HC REX OBSERVATION DIRECT ADMISSION,17620010,CDM,762,RC,G0379,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Medicare Advantage,,638.50,,,,,,,18.66,7281.00,fee schedule,
HC BRACHYTX HDR IR-192 NON STRANDED,22780093,CDM,278,RC,C1717,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Medicare Advantage,,356.58,,,,,,,80.90,468.96,fee schedule,
HC BRACHYTX IODINE 125 NON STRANDED,22780119,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,297.00000,178.20000,WellCare of North Carolina,Medicare Advantage,,36.56,,,,,,,33.78,218.65,fee schedule,
HC BRACHYTX PALLADIUM 103 NON STRAN,22780120,CDM,278,RC,C2639,CPT,,,facility,outpatient,,,308.00000,184.80000,WellCare of North Carolina,Medicare Advantage,,36.56,,,,,,,33.78,226.75,fee schedule,
HC BRACHYTHERAPY SEED STRANDED IODINE 125 PER SOURCE,22780400,CDM,278,RC,C2638,CPT,,,facility,outpatient,,,1255.00000,753.00000,WellCare of North Carolina,Medicare Advantage,,38.58,,,,,,,35.64,923.93,fee schedule,
HC THERAPEUTIC PHLEBOTOMY,39400001,CDM,940,RC,99195,CPT,,,facility,outpatient,,,423.00000,253.80000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,84.68,767.00,fee schedule,
HC HYDRATION IV INITIAL 31MIN-1HR,42600001,CDM,260,RC,96360,CPT,,,facility,outpatient,,,549.00000,329.40000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,95.58,759.00,fee schedule,
HC HYDRATION IV EACH ADDTL HR,42600002,CDM,260,RC,96361,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION INITIAL UP TO 1HR,42600003,CDM,260,RC,96365,CPT,,,facility,outpatient,,,585.00000,351.00000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,101.85,759.00,fee schedule,
HC IV INFUSION EACH ADDTL HR,42600004,CDM,260,RC,96366,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC IV INFUSION SEQUENTIAL UP TO 1 HR,42600005,CDM,260,RC,96367,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,65.64,759.00,fee schedule,
HC INJECTION ADMIN INTRA ARTERIAL,42600007,CDM,260,RC,96373,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,50.14,759.00,fee schedule,
HC IV PUSH SINGLE INITIAL,42600008,CDM,260,RC,96374,CPT,,,facility,outpatient,,,437.00000,262.20000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,76.08,759.00,fee schedule,
HC IV PUSH SEQ EA ADD NEW DRUG,42600009,CDM,260,RC,96375,CPT,,,facility,outpatient,,,262.00000,157.20000,WellCare of North Carolina,Medicare Advantage,,48.05,,,,,,,44.39,759.00,fee schedule,
HC PROLONGED IV INFUS REQUIRING PUM,42600011,CDM,260,RC,C8957,CPT,,,facility,outpatient,,,652.00000,391.20000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,113.51,759.00,fee schedule,
HC COLLECTION BLOOD VENIPUNCTURE,43000003,CDM,300,RC,36415,CPT,,,facility,outpatient,,,33.00000,19.80000,WellCare of North Carolina,Medicare Advantage,,9.54,,,,,,,3.90,24.75,fee schedule,
HC REFL MAINT IMPL PUMP INTRATHCL INCL ANALYSIS,43300001,CDM,331,RC,95990,CPT,,,facility,outpatient,,,1899.00000,1139.40000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMO INJ SQ IM NON HORMONAL,43300002,CDM,331,RC,96401,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC CHEMO INJ SQ IM HORMONAL,43300003,CDM,331,RC,96402,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,23.42,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 1-7 LESIONS,43300004,CDM,331,RC,96405,CPT,,,facility,outpatient,,,240.00000,144.00000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,48.05,3466.00,fee schedule,
HC INTRALESIONAL CHEMO 8+ LESIONS,43300005,CDM,331,RC,96406,CPT,,,facility,outpatient,,,360.00000,216.00000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,72.07,3466.00,fee schedule,
HC CHEMO IV PUSH SINGLE INITIAL,43300006,CDM,335,RC,96409,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,92.69,3466.00,fee schedule,
HC CHEMO IV PUSH EACH ADDITIONAL SUBSTANCE DRUG,43300007,CDM,335,RC,96411,CPT,,,facility,outpatient,,,420.00000,252.00000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO PLEURAL W THORACENTESIS,43300008,CDM,331,RC,96440,CPT,,,facility,outpatient,,,1947.00000,1168.20000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC CHEMOTHERAPY PERITONEAL CAVITY PORT OR CATH,43300009,CDM,331,RC,96446,CPT,,,facility,outpatient,,,1990.00000,1194.00000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,319.11,3466.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,932.00000,559.20000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION SIMPLE,43300010,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1407.00000,844.20000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1460.00000,876.00000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,292.29,1095.00,fee schedule,
HC SIMULATION INTERMEDIATE,43300011,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1724.00000,1034.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,345.14,1293.00,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2098.00000,1258.80000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1573.50,fee schedule,
HC SIMULATION COMPLEX,43300012,CDM,333,RC,77290,CPT,,,facility,outpatient,,,3519.00000,2111.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,2639.25,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6242.00000,3745.20000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,4681.50,fee schedule,
HC 3-D SIMULATION AIDED FIELD SETTING,43300013,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6731.00000,4038.60000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,5048.25,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,635.00000,381.00000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.13,1067.00,fee schedule,
HC DOSIMETRY BASIC,43300014,CDM,333,RC,77300,CPT,,,facility,outpatient,,,851.00000,510.60000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6352.00000,3811.20000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,4764.00,fee schedule,
HC IMRT TX PLANNING,43300015,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC IMRT TX PLANNING II,43300016,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1698.00000,1018.80000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,339.94,1273.50,fee schedule,
HC SPECIAL TELETHERAPY PORT PLAN,43300024,CDM,333,RC,77321,CPT,,,facility,outpatient,,,2769.00000,1661.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,2076.75,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,734.00000,440.40000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC SPECIAL DOSIMETRY,43300028,CDM,333,RC,77331,CPT,,,facility,outpatient,,,1096.00000,657.60000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,469.00000,281.40000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,93.89,1067.00,fee schedule,
HC TREATMENT DEVICES SIMPLE,43300029,CDM,333,RC,77332,CPT,,,facility,outpatient,,,968.00000,580.80000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,687.00000,412.20000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC TREATMENT DEVICES INTERMEDIATE,43300030,CDM,333,RC,77333,CPT,,,facility,outpatient,,,1545.00000,927.00000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1158.75,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1071.00000,642.60000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,214.41,1067.00,fee schedule,
HC TREATMENT DEVICES COMPLEX,43300031,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1862.00000,1117.20000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1396.50,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,450.00000,270.00000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,90.09,1067.00,fee schedule,
HC CONTINUING PHYSICS CONSULT,43300032,CDM,333,RC,77336,CPT,,,facility,outpatient,,,1204.00000,722.40000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7492.00000,4495.20000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,5619.00,fee schedule,
HC MLC DESIGN PER IMRT PLAN,43300033,CDM,333,RC,77338,CPT,,,facility,outpatient,,,7454.00000,4472.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,5590.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,2398.00000,1438.80000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1798.50,fee schedule,
HC SPECIAL MEDICAL PHYSIC CONSULT,43300034,CDM,333,RC,77370,CPT,,,facility,outpatient,,,1746.00000,1047.60000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1309.50,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,3100.00000,1860.00000,WellCare of North Carolina,Medicare Advantage,,1828.66,,,,,,,620.62,3185.00,fee schedule,
HC SBRT 1-5 FX,43300035,CDM,333,RC,77373,CPT,,,facility,outpatient,,,8423.00000,5053.80000,WellCare of North Carolina,Medicare Advantage,,1828.66,,,,,,,1686.28,6317.25,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2092.00000,1255.20000,WellCare of North Carolina,Medicare Advantage,,602.44,,,,,,,418.82,1569.00,fee schedule,
HC SPECIAL TX PROCEDURE,43300053,CDM,333,RC,77470,CPT,,,facility,outpatient,,,4635.00000,2781.00000,WellCare of North Carolina,Medicare Advantage,,602.44,,,,,,,556.54,3476.25,fee schedule,
HC INTRACAVITARY RADIOELEMT SIMPLE 1-4,43300055,CDM,333,RC,77761,CPT,,,facility,outpatient,,,2458.00000,1474.80000,WellCare of North Carolina,Medicare Advantage,,602.44,,,,,,,492.09,1843.50,fee schedule,
HC INTERSTITIAL COMPLEX INCL SUPERV HANDLE LOAD,43300060,CDM,333,RC,77778,CPT,,,facility,outpatient,,,2999.00000,1799.40000,WellCare of North Carolina,Medicare Advantage,,722.56,,,,,,,600.40,2249.25,fee schedule,
HC SURFACE APPL RADIOELEMENT LDR,43300064,CDM,333,RC,77789,CPT,,,facility,outpatient,,,316.00000,189.60000,WellCare of North Carolina,Medicare Advantage,,114.04,,,,,,,63.26,1067.00,fee schedule,
HC CHEMO IV INITIAL UP TO 1HR,43300072,CDM,335,RC,96413,CPT,,,facility,outpatient,,,1076.00000,645.60000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,215.42,3466.00,fee schedule,
HC CHEMO IV EACH ADDITIONAL HOUR,43300073,CDM,335,RC,96415,CPT,,,facility,outpatient,,,496.00000,297.60000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS,43300074,CDM,335,RC,96416,CPT,,,facility,outpatient,,,603.00000,361.80000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,120.72,3466.00,fee schedule,
HC CHEMO IV SEQ DIFF DRUG TO 1HR,43300075,CDM,335,RC,96417,CPT,,,facility,outpatient,,,496.00000,297.60000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,68.47,3466.00,fee schedule,
HC CHEMO IA INFUSION 1ST HOUR,43300077,CDM,335,RC,96422,CPT,,,facility,outpatient,,,1537.00000,922.20000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,307.71,3466.00,fee schedule,
HC CHEMO IA INFUSION EACH ADD HR,43300078,CDM,335,RC,96423,CPT,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Medicare Advantage,,48.05,,,,,,,44.39,3466.00,fee schedule,
HC CHEMO IA INFUS PROLONGED 8+ HRS,43300079,CDM,335,RC,96425,CPT,,,facility,outpatient,,,734.00000,440.40000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,146.95,3466.00,fee schedule,
HC REFILLING AND MAINTENANCE OF PORTABLE PUMP,43300085,CDM,940,RC,96521,CPT,,,facility,outpatient,,,457.00000,274.20000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,91.49,767.00,fee schedule,
HC REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR,43300086,CDM,940,RC,96522,CPT,,,facility,outpatient,,,331.00000,198.60000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,66.27,767.00,fee schedule,
HC CHEMO ADMIN INTR ARTERIAL PUSH,43300087,CDM,335,RC,96420,CPT,,,facility,outpatient,,,523.00000,313.80000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,104.70,3466.00,fee schedule,
HC IMRT COMPLEX ISO TX PLANNING,43300090,CDM,333,RC,77301,CPT,,,facility,outpatient,,,7135.00000,4281.00000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,5351.25,fee schedule,
HC RT TRMT SIMPLE,43300093,CDM,333,RC,77402,CPT,,,facility,outpatient,,,889.00000,533.40000,WellCare of North Carolina,Medicare Advantage,,114.04,,,,,,,105.35,1067.00,fee schedule,
HC RT TRMT INTERMEDIATE,43300094,CDM,333,RC,77407,CPT,,,facility,outpatient,,,1163.00000,697.80000,WellCare of North Carolina,Medicare Advantage,,273.87,,,,,,,232.83,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1051.00000,630.60000,WellCare of North Carolina,Medicare Advantage,,273.87,,,,,,,210.41,1067.00,fee schedule,
HC RT TRMT COMPLEX,43300095,CDM,333,RC,77412,CPT,,,facility,outpatient,,,1406.00000,843.60000,WellCare of North Carolina,Medicare Advantage,,273.87,,,,,,,253.01,1067.00,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,1865.00000,1119.00000,WellCare of North Carolina,Medicare Advantage,,602.44,,,,,,,373.37,1398.75,fee schedule,
HC IMRT SIMPLE,43300097,CDM,333,RC,77385,CPT,,,facility,outpatient,,,3748.00000,2248.80000,WellCare of North Carolina,Medicare Advantage,,602.44,,,,,,,556.54,2811.00,fee schedule,
HC IMRT COMPLEX,43300099,CDM,333,RC,77386,CPT,,,facility,outpatient,,,3945.00000,2367.00000,WellCare of North Carolina,Medicare Advantage,,602.44,,,,,,,556.54,2958.75,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2034.00000,1220.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1525.50,fee schedule,
HC ISODOSE PLANNING SIMPLE,43300101,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2261.00000,1356.60000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1695.75,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2383.00000,1429.80000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1787.25,fee schedule,
HC ISODOSE PLANNING COMPLEX,43300102,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2629.00000,1577.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1971.75,fee schedule,
HC BRACHYTHERAPY ISODOSE SIMPLE,43300104,CDM,333,RC,77316,CPT,,,facility,outpatient,,,1833.00000,1099.80000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1374.75,fee schedule,
HC BRACHYTHERAPY ISODOSE COMPLEX,43300106,CDM,333,RC,77318,CPT,,,facility,outpatient,,,2622.00000,1573.20000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1966.50,fee schedule,
HC CHEMO INJ SUBARACH/INTRAVENT VIA SUBQ RESV SGL MULTI,43300109,CDM,331,RC,96542,CPT,,,facility,outpatient,,,292.00000,175.20000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,58.46,3466.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,2842.00000,1705.20000,WellCare of North Carolina,Medicare Advantage,,7961.22,,,,,,,568.97,26864.00,fee schedule,
HC CRANIAL 1 LESION LINAC,43300110,CDM,333,RC,77372,CPT,,,facility,outpatient,,,27299.00000,16379.40000,WellCare of North Carolina,Medicare Advantage,,7961.22,,,,,,,5465.26,26864.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  1 CHANNEL,43300111,CDM,333,RC,77770,CPT,,,facility,outpatient,,,3753.00000,2251.80000,WellCare of North Carolina,Medicare Advantage,,722.56,,,,,,,667.51,2814.75,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL INTRCAV  2-12 CHANNELS,43300112,CDM,333,RC,77771,CPT,,,facility,outpatient,,,4316.00000,2589.60000,WellCare of North Carolina,Medicare Advantage,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC BRACHYTHERAPY RDNCL NTRSTL/INTRCAV  OVER 12 CHANNELS,43300113,CDM,333,RC,77772,CPT,,,facility,outpatient,,,4316.00000,2589.60000,WellCare of North Carolina,Medicare Advantage,,722.56,,,,,,,667.51,3237.00,fee schedule,
HC CHEMO INFUSION PROLONGED 8+ HRS INCLUDING EQUIPMENT,43300132,CDM,335,RC,G0498,CPT,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,91.09,3466.00,fee schedule,
HC JV SIMULATION SIMPLE GL,43300136,CDM,333,RC,77280,CPT,,,facility,outpatient,,,1044.00000,626.40000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV SIMULATION INTERMEDIATE GL,43300137,CDM,333,RC,77285,CPT,,,facility,outpatient,,,1629.00000,977.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,326.13,1221.75,fee schedule,
HC JV SIMULATION COMPLEX GL,43300138,CDM,333,RC,77290,CPT,,,facility,outpatient,,,2343.00000,1405.80000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1757.25,fee schedule,
HC JV 3-D SIMULATION AIDED FIELD SETTING GL,43300139,CDM,333,RC,77295,CPT,,,facility,outpatient,,,6914.00000,4148.40000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,5185.50,fee schedule,
HC JV DOSIMETRY BASIC GL,43300140,CDM,333,RC,77300,CPT,,,facility,outpatient,,,733.00000,439.80000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV IMRT TX PLANNING GL,43300141,CDM,333,RC,77301,CPT,,,facility,outpatient,,,6067.00000,3640.20000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,688.00,4550.25,fee schedule,
HC JV ISODOSE PLANNING SIMPLE GL,43300142,CDM,333,RC,77306,CPT,,,facility,outpatient,,,2254.00000,1352.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1690.50,fee schedule,
HC JV ISODOSE PLANNING COMPLEX GL,43300143,CDM,333,RC,77307,CPT,,,facility,outpatient,,,2837.00000,1702.20000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,2127.75,fee schedule,
HC JV SPECIAL TELETHERAPY PORT PLAN GL,43300144,CDM,333,RC,77321,CPT,,,facility,outpatient,,,1848.00000,1108.80000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,1386.00,fee schedule,
HC JV SPECIAL DOSIMETRY GL,43300145,CDM,333,RC,77331,CPT,,,facility,outpatient,,,871.00000,522.60000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES SIMPLE GL,43300146,CDM,333,RC,77332,CPT,,,facility,outpatient,,,549.00000,329.40000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,109.91,1067.00,fee schedule,
HC JV TREATMENT DEVICES INTERMEDIATE GL,43300147,CDM,333,RC,77333,CPT,,,facility,outpatient,,,805.00000,483.00000,WellCare of North Carolina,Medicare Advantage,,138.27,,,,,,,127.74,1067.00,fee schedule,
HC JV TREATMENT DEVICES COMPLEX GL,43300148,CDM,333,RC,77334,CPT,,,facility,outpatient,,,1252.00000,751.20000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,250.65,1067.00,fee schedule,
HC JV MLC FOR IMRT GL,43300149,CDM,333,RC,77338,CPT,,,facility,outpatient,,,8164.00000,4898.40000,WellCare of North Carolina,Medicare Advantage,,381.23,,,,,,,352.19,6123.00,fee schedule,
HC JV SPECIAL TX PROCEDURE GL,43300150,CDM,333,RC,77470,CPT,,,facility,outpatient,,,2410.00000,1446.00000,WellCare of North Carolina,Medicare Advantage,,602.44,,,,,,,482.48,1807.50,fee schedule,
HC THERAPEUTIC APHERESIS PLASMA EXCHANGE,43610001,CDM,361,RC,36514,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Medicare Advantage,,1707.19,,,,,,,625.22,4376.00,fee schedule,
HC FETAL NON STRESS TEST,43610003,CDM,920,RC,59025,CPT,,,facility,outpatient,,,351.00000,210.60000,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,61.11,767.00,fee schedule,
HC EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TOCOLYSIS,43610009,CDM,361,RC,59412,CPT,,,facility,outpatient,,,1054.00000,632.40000,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,211.01,5754.00,fee schedule,
HC NASOTRACHEAL ASPIRATION,43610012,CDM,761,RC,31720,CPT,,,facility,outpatient,,,34.00000,20.40000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,6.41,4311.00,fee schedule,
HC RT TRACH TUBE EXCHANGE,43610015,CDM,361,RC,31502,CPT,,,facility,outpatient,,,465.00000,279.00000,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,93.09,4311.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1028.00000,616.80000,WellCare of North Carolina,Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC DIRECT LARYNGOSCOPY,43610035,CDM,761,RC,31575,CPT,,,facility,outpatient,,,1212.00000,727.20000,WellCare of North Carolina,Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC INSERT TANDEMS VAG OVOIDS HDR,43610038,CDM,361,RC,57155,CPT,,,facility,outpatient,,,322.00000,193.20000,WellCare of North Carolina,Medicare Advantage,,5140.98,,,,,,,64.46,5189.94,fee schedule,
HC INSERT VAG RAD AFTERLOAD APP BRACHYTHERAPY,43610039,CDM,361,RC,57156,CPT,,,facility,outpatient,,,757.00000,454.20000,WellCare of North Carolina,Medicare Advantage,,316.80,,,,,,,151.55,4376.00,fee schedule,
HC DIALYSIS TRANSFUSION BLD BLD COMPONENTS,43910002,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,WellCare of North Carolina,Medicare Advantage,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC INTUBATION,44100001,CDM,412,RC,31500,CPT,,,facility,outpatient,,,595.00000,357.00000,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,103.59,4311.00,fee schedule,
HC NEBULIZER TREATMENT,44100002,CDM,412,RC,94640,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,10.97,440.00,fee schedule,
HC MDI METRD DOSE INHAL,44100003,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY INITIAL,44100005,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,4.87,440.00,fee schedule,
HC TREATMENT W ACT THERAPY INITIAL,44100006,CDM,410,RC,94667,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,4.87,440.00,fee schedule,
HC CHEST VEST THERAPY INITIAL,44100007,CDM,410,RC,94669,CPT,,,facility,outpatient,,,302.00000,181.20000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,52.58,440.00,fee schedule,
HC CHEST PHYSICAL THERAPY SUBSEQUENT,44100008,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,6.44,440.00,fee schedule,
HC TREATMENT W ACT THERAPY SUBSEQUENT,44100009,CDM,410,RC,94668,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,6.44,440.00,fee schedule,
HC CHEST VEST THERAPY SUBSEQUENT,44100010,CDM,410,RC,94669,CPT,,,facility,outpatient,,,23.00000,13.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,4.00,440.00,fee schedule,
HC THERAPY STRENGTH ENDURANCE IND 1,44100011,CDM,410,RC,G0237,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Medicare Advantage,,25.50,,,,,,,10.10,440.00,fee schedule,
HC RT THERAPY OTHER IND 15 MIN,44100012,CDM,410,RC,G0238,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Medicare Advantage,,25.50,,,,,,,9.75,440.00,fee schedule,
HC THERAPY STRENGTH ENDUR GROUP,44100013,CDM,410,RC,G0239,CPT,,,facility,outpatient,,,109.00000,65.40000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,18.98,440.00,fee schedule,
HC CONTINUOUS MEDICATION NEBULIZER TREATMENT,44100014,CDM,412,RC,94644,CPT,,,facility,outpatient,,,200.00000,120.00000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,34.82,440.00,fee schedule,
HC SPUTUM COLLECTION,44100017,CDM,410,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC SURFACTANT ADMINISTRATION THROUGH ENDOTRACHEAL TUBE,44120015,CDM,412,RC,94610,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,23.16,440.00,fee schedule,
HC AEROSOL TREATMENT,44120017,CDM,412,RC,94640,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,19.67,440.00,fee schedule,
HC IPV TREATMENT INITIAL,44120020,CDM,412,RC,94640,CPT,,,facility,outpatient,,,438.00000,262.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,76.26,440.00,fee schedule,
HC IPV TREATMENT SUBSEQUENT,44120021,CDM,412,RC,94640,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,8.71,440.00,fee schedule,
HC AEROSOL INHAL OF PENTAMINDINE,44120022,CDM,412,RC,94642,CPT,,,facility,outpatient,,,413.00000,247.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,71.90,440.00,fee schedule,
HC BIPAP CPAP,44120024,CDM,412,RC,94660,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,50.14,440.00,fee schedule,
HC PATIENT DEMO EVALUATION OF NEBULIZER INHALER IPPB DEVICE,44120026,CDM,412,RC,94664,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,9.40,440.00,fee schedule,
HC BIPAP CPAP WITH PATIENTS OWN EQUIPMENT,44120031,CDM,412,RC,94660,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Medicare Advantage,,211.82,,,,,,,6.44,440.00,fee schedule,
HC RT INTERROGATION ONLY PACEMAKER,44120032,CDM,410,RC,93288,CPT,,,facility,outpatient,,,191.00000,114.60000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,33.25,440.00,fee schedule,
HC RT INTERROGATION ONLY ICD,44120033,CDM,410,RC,93289,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,35.88,440.00,fee schedule,
HC SPIROMETRY,44600001,CDM,460,RC,94010,CPT,,,facility,outpatient,,,864.00000,518.40000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.42,648.00,fee schedule,
HC SPIROMETRY INFANT,44600002,CDM,460,RC,94011,CPT,,,facility,outpatient,,,549.00000,329.40000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,95.58,411.75,fee schedule,
HC SPIROMETRY PRE POST INFANT,44600003,CDM,460,RC,94012,CPT,,,facility,outpatient,,,885.00000,531.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,154.08,663.75,fee schedule,
HC THORACIC GAS VOL INFANT,44600004,CDM,460,RC,94013,CPT,,,facility,outpatient,,,504.00000,302.40000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,87.75,557.85,fee schedule,
HC SPIROMETRY PRE POST,44600005,CDM,460,RC,94060,CPT,,,facility,outpatient,,,745.00000,447.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,129.70,558.75,fee schedule,
HC BRONCHOSPASM PROVOCATN EVAL,44600006,CDM,460,RC,94070,CPT,,,facility,outpatient,,,3756.00000,2253.60000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,243.00,2817.00,fee schedule,
HC VITAL CAPACITY TOTAL,44600007,CDM,460,RC,94150,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,7.49,374.00,fee schedule,
HC MAXIMUM VOLUNTARY VENTILATION,44600008,CDM,460,RC,94200,CPT,,,facility,outpatient,,,148.00000,88.80000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,25.77,374.00,fee schedule,
HC RESPIRATORY FLOW VOL LOOP,44600009,CDM,460,RC,94375,CPT,,,facility,outpatient,,,525.00000,315.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,91.40,393.75,fee schedule,
HC HIGH ALTITUDE SIMULATION TEST,44600010,CDM,460,RC,94452,CPT,,,facility,outpatient,,,523.00000,313.80000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,91.05,392.25,fee schedule,
HC HIGH ALTITUDE SIMULATION W 02,44600011,CDM,460,RC,94453,CPT,,,facility,outpatient,,,563.00000,337.80000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,98.02,422.25,fee schedule,
HC 6 MIN WALK PULM STRESS TEST,44600012,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,65.64,374.00,fee schedule,
HC 6 MIN PULMONARY STRESS TEST SIMPLE,44600013,CDM,460,RC,94618,CPT,,,facility,outpatient,,,377.00000,226.20000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,65.64,374.00,fee schedule,
HC PULMONARY STRESS TEST COMPLEX,44600014,CDM,460,RC,94621,CPT,,,facility,outpatient,,,1357.00000,814.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,236.25,1017.75,fee schedule,
HC PULMONARY SHUNT STUDY,44600015,CDM,460,RC,94680,CPT,,,facility,outpatient,,,418.00000,250.80000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,72.77,374.00,fee schedule,
HC METABOLIC TESTING CALO,44600016,CDM,460,RC,94681,CPT,,,facility,outpatient,,,812.00000,487.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,141.37,609.00,fee schedule,
HC INDIRECT CALORIMETRY,44600017,CDM,460,RC,94690,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,18.63,374.00,fee schedule,
HC LUNG VOL BODY BOX,44600018,CDM,460,RC,94726,CPT,,,facility,outpatient,,,567.00000,340.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,98.71,425.25,fee schedule,
HC LUNG VOL N2 WASHOUT,44600019,CDM,460,RC,94727,CPT,,,facility,outpatient,,,476.00000,285.60000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,82.87,374.00,fee schedule,
HC AIRWAY RESISTANCE,44600020,CDM,460,RC,94728,CPT,,,facility,outpatient,,,652.00000,391.20000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,113.51,489.00,fee schedule,
HC RT TRANSCUTANEOUS MONITORING,44600027,CDM,460,RC,94799,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,27.16,374.00,fee schedule,
HC OTOACOUSTIC EMISSIONS LIMITED EVAL,44700019,CDM,471,RC,92587,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,31.34,327.39,fee schedule,
HC TRANSFUSION BLD BLD COMPONENTS,44700022,CDM,391,RC,36430,CPT,,,facility,outpatient,,,1170.00000,702.00000,WellCare of North Carolina,Medicare Advantage,,455.29,,,,,,,203.70,4311.00,fee schedule,
HC AUDITORY EVOKED POTENTIAL THRESHOLD ESTIMATION MULTIPLE FREQUENCIES INTERP AND RPT,44710006,CDM,471,RC,92652,CPT,,,facility,outpatient,,,1542.00000,925.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL NEURODIAGNOSTIC INTERP AND RPT,44710007,CDM,471,RC,92653,CPT,,,facility,outpatient,,,1542.00000,925.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,124.00,1156.50,fee schedule,
HC AUDITORY EVOKED POTENTIAL HEARING STATUS DETER BROADBAND STIMULI INTERP AND RPT,44710009,CDM,471,RC,92651,CPT,,,facility,outpatient,,,264.00000,158.40000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,45.96,327.39,fee schedule,
HC JV DIRECT LARYNGOSCOPY,47610002,CDM,761,RC,31575,CPT,,,facility,outpatient,,,2000.00000,1200.00000,WellCare of North Carolina,Medicare Advantage,,202.19,,,,,,,186.78,4376.00,fee schedule,
HC THERAPEUTIC APHERESIS RED BLOOD CELL,48010003,CDM,940,RC,36512,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Medicare Advantage,,1707.19,,,,,,,494.00,4376.00,fee schedule,
HC HEMODIALYSIS PROCEDURE W SINGLE EVAL,48010029,CDM,801,RC,90935,CPT,,,facility,outpatient,,,700.00000,420.00000,WellCare of North Carolina,Medicare Advantage,,728.71,,,,,,,121.87,735.65,fee schedule,
HC DIALYSIS ACUTE PERITONEAL DIALYSIS INPATIENT,48010034,CDM,802,RC,90945,CPT,,,facility,outpatient,,,831.00000,498.60000,WellCare of North Carolina,Medicare Advantage,,443.47,,,,,,,144.68,675.60,fee schedule,
HC NEUROPSYCHOLOGICAL TST EVAL PHYS QHP 1ST HOUR,49100074,CDM,918,RC,96132,CPT,,,facility,outpatient,,,505.00000,303.00000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,87.92,557.85,fee schedule,
HC PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMIN AND SCORE BY QHCP FIRST 30 MINS,49100078,CDM,918,RC,96138,CPT,,,facility,outpatient,,,333.00000,199.80000,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,57.98,528.00,fee schedule,
HC MAX INSP EXP MUSC PRES,49200003,CDM,920,RC,94799,CPT,,,facility,outpatient,,,185.00000,111.00000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,32.21,767.00,fee schedule,
HC SLEEP MULT SLEEP LAT TEST,49200004,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP MAINT OF WAKEFULNESS TEST,49200005,CDM,740,RC,95805,CPT,,,facility,outpatient,,,6043.00000,3625.80000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,4532.25,fee schedule,
HC SLEEP OVERNIGHT SCREEN,49200009,CDM,740,RC,95806,CPT,,,facility,outpatient,,,1017.00000,610.20000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,1990.00,fee schedule,
HC POLYSOM LESS THAN 6 HRS AND 6 YRS OLD OR MORE,49200011,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS,49200013,CDM,740,RC,95810,CPT,,,facility,outpatient,,,4200.00000,2520.00000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,840.84,3150.00,fee schedule,
HC POLYSOM  6 YRS AND OLDER 4 OR MORE PARAMETERS W CPAP,49200019,CDM,740,RC,95811,CPT,,,facility,outpatient,,,4266.00000,2559.60000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,854.05,3199.50,fee schedule,
HC CV DUPLEX COMPL BILAT,49200022,CDM,921,RC,93880,CPT,,,facility,outpatient,,,1154.00000,692.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,175.00,865.50,fee schedule,
HC EEG EXTENDED 41-60 MIN,49200023,CDM,740,RC,95812,CPT,,,facility,outpatient,,,552.00000,331.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,110.51,954.00,fee schedule,
HC CV DUPLEX LTD UNIL,49200024,CDM,921,RC,93882,CPT,,,facility,outpatient,,,565.00000,339.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,98.37,423.75,fee schedule,
HC TRANSCRANIAL DOPP COMPL,49200026,CDM,921,RC,93886,CPT,,,facility,outpatient,,,1350.00000,810.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,175.00,1012.50,fee schedule,
HC EEG AWAKE AND DROWSY,49200027,CDM,740,RC,95816,CPT,,,facility,outpatient,,,963.00000,577.80000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE ARTERY PHYSIOLOGIC LTD BIL 1 TO 2 LEVELS,49200028,CDM,921,RC,93922,CPT,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,95.75,412.50,fee schedule,
HC EEG AWAKE AND ASLEEP,49200029,CDM,740,RC,95819,CPT,,,facility,outpatient,,,963.00000,577.80000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,192.79,954.00,fee schedule,
HC UE OR LE  ARTERY PHYSIOLOGIC COMPL BIL 3 OR MORE LEVELS,49200030,CDM,921,RC,93923,CPT,,,facility,outpatient,,,1051.00000,630.60000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,788.25,fee schedule,
HC EEG SLEEP ONLY,49200031,CDM,740,RC,95822,CPT,,,facility,outpatient,,,453.00000,271.80000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,90.69,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX COMPL BIL,49200032,CDM,921,RC,93925,CPT,,,facility,outpatient,,,1271.00000,762.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,175.00,953.25,fee schedule,
HC EEG CEREBRAL DEATH EVAL,49200033,CDM,740,RC,95824,CPT,,,facility,outpatient,,,1159.00000,695.40000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,232.03,954.00,fee schedule,
HC LE ARTERY OR GRAFT DUPLEX LTD UNIL,49200034,CDM,921,RC,93926,CPT,,,facility,outpatient,,,728.00000,436.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,546.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX COMP BIL,49200036,CDM,921,RC,93930,CPT,,,facility,outpatient,,,1126.00000,675.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,175.00,844.50,fee schedule,
HC TENSILON TEST MYASTHENIA GRAVIS,49200037,CDM,740,RC,95857,CPT,,,facility,outpatient,,,316.00000,189.60000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,63.26,954.00,fee schedule,
HC UE ARTERY OR GRAFT DUPLEX LTD UNIL,49200038,CDM,921,RC,93931,CPT,,,facility,outpatient,,,758.00000,454.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,568.50,fee schedule,
HC BLINK REFLEX,49200039,CDM,740,RC,95933,CPT,,,facility,outpatient,,,124.00000,74.40000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,24.82,954.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX LTD UNIL,49200044,CDM,921,RC,93971,CPT,,,facility,outpatient,,,958.00000,574.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,718.50,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS COMPL BIL,49200046,CDM,921,RC,93978,CPT,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,99.41,428.25,fee schedule,
HC DUPLEX AORTA IVC ILIAC OR GRAFTS LTD UNIL,49200048,CDM,921,RC,93979,CPT,,,facility,outpatient,,,464.00000,278.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,80.78,348.00,fee schedule,
HC PENILE VESSEL DUPLEX LTD OR FOLLOW UP,49200050,CDM,921,RC,93981,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,93.70,404.25,fee schedule,
HC HEMODIALYSIS ACCESS DUPLEX,49200052,CDM,921,RC,93990,CPT,,,facility,outpatient,,,503.00000,301.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,87.57,377.25,fee schedule,
HC POLYSOM  LESS THAN 6 YRS 4 OR MORE PARAMETERS,49200056,CDM,920,RC,95782,CPT,,,facility,outpatient,,,1572.00000,943.20000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC CORTICAL MAPPING INITIAL HR,49200059,CDM,740,RC,95961,CPT,,,facility,outpatient,,,405.00000,243.00000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,81.08,1069.64,fee schedule,
HC POLYSOM LESS THAN 6 YRS 4 OR MORE PARAMETERS CPAP OR BILVL,49200060,CDM,920,RC,95783,CPT,,,facility,outpatient,,,1572.00000,943.20000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,273.69,1990.00,fee schedule,
HC HOME SLEEP TEST,49200063,CDM,740,RC,G0399,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,74.67,1990.00,fee schedule,
HC EMG 1 EXTREMITY,49200065,CDM,922,RC,95860,CPT,,,facility,outpatient,,,674.00000,404.40000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,117.34,1831.00,fee schedule,
HC EMG 2 EXTREMITY,49200066,CDM,922,RC,95861,CPT,,,facility,outpatient,,,822.00000,493.20000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,124.01,1831.00,fee schedule,
HC EMG 3 EXTREMITY,49200067,CDM,922,RC,95863,CPT,,,facility,outpatient,,,855.00000,513.00000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,148.86,1831.00,fee schedule,
HC EMG 4 EXTREMITY,49200068,CDM,922,RC,95864,CPT,,,facility,outpatient,,,888.00000,532.80000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,1831.00,fee schedule,
HC EMG NEEDLE LARYNX UNIL,49200070,CDM,922,RC,95865,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,93.84,1831.00,fee schedule,
HC EMG CRANIAL UNIL,49200072,CDM,922,RC,95867,CPT,,,facility,outpatient,,,429.00000,257.40000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EMG THORACIC PARASPINAL,49200073,CDM,922,RC,95869,CPT,,,facility,outpatient,,,295.00000,177.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,51.36,1831.00,fee schedule,
HC EMG LIMITED 1 EXTREMITY OR NON LIMB MUSCLES,49200074,CDM,922,RC,95870,CPT,,,facility,outpatient,,,437.00000,262.20000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,76.08,1831.00,fee schedule,
HC NERVE CONDUCTION 1-2 STUDIES,49200081,CDM,922,RC,95907,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 3-4 STUDIES,49200082,CDM,922,RC,95908,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 5-6 STUDIES,49200083,CDM,922,RC,95909,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 7-8 STUDIES,49200084,CDM,922,RC,95910,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,36.91,1831.00,fee schedule,
HC NERVE CONDUCTION 9-10 STUDIES,49200085,CDM,922,RC,95911,CPT,,,facility,outpatient,,,400.00000,240.00000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 11-12 STUDIES,49200086,CDM,922,RC,95912,CPT,,,facility,outpatient,,,400.00000,240.00000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC NERVE CONDUCTION 13 OR GREATER THAN STUDIES,49200087,CDM,922,RC,95913,CPT,,,facility,outpatient,,,400.00000,240.00000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,69.64,1831.00,fee schedule,
HC AUTONOMIC CARDIOVAGAL W RR INTERVAL,49200088,CDM,922,RC,95921,CPT,,,facility,outpatient,,,267.00000,160.20000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,46.48,1831.00,fee schedule,
HC AUTONOMIC VASOMOTOR,49200089,CDM,922,RC,95922,CPT,,,facility,outpatient,,,366.00000,219.60000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC AUTONOMIC SUDOMOTOR,49200090,CDM,922,RC,95923,CPT,,,facility,outpatient,,,366.00000,219.60000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,63.72,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE,49200091,CDM,922,RC,95925,CPT,,,facility,outpatient,,,1635.00000,981.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL LE,49200092,CDM,922,RC,95926,CPT,,,facility,outpatient,,,1635.00000,981.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,284.65,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UPPER,49200093,CDM,922,RC,95928,CPT,,,facility,outpatient,,,457.00000,274.20000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,79.56,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL LOWER,49200094,CDM,922,RC,95929,CPT,,,facility,outpatient,,,455.00000,273.00000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,79.22,1831.00,fee schedule,
HC VISUAL EVOKED POTENTIAL,49200095,CDM,922,RC,95930,CPT,,,facility,outpatient,,,1491.00000,894.60000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,259.58,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UE AND LE,49200096,CDM,922,RC,95938,CPT,,,facility,outpatient,,,1526.00000,915.60000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,265.68,1831.00,fee schedule,
HC CENTRAL MOTOR EVOKED POTENTIAL UE AND LE,49200097,CDM,922,RC,95939,CPT,,,facility,outpatient,,,848.00000,508.80000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,147.64,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL UNI,49200108,CDM,922,RC,95925,CPT,,,facility,outpatient,,,423.00000,253.80000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,73.64,1831.00,fee schedule,
HC PAP NAP,49200109,CDM,740,RC,95807,CPT,,,facility,outpatient,,,997.00000,598.20000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,199.60,1990.00,fee schedule,
HC SCREENING AAA ULTRASOUND,49200119,CDM,402,RC,76706,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,92.69,467.00,fee schedule,
HC EEG CONT REC W VID EEG TECH MIN 8 CHANNELS,49200134,CDM,740,RC,95700,CPT,,,facility,outpatient,,,544.00000,326.40000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,108.91,954.00,fee schedule,
HC EEG W O VID 2-12 HR UNMNTR,49200135,CDM,740,RC,95705,CPT,,,facility,outpatient,,,1315.00000,789.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,263.26,986.25,fee schedule,
HC EEG WO VID 2-12HR INTMT MNTR,49200136,CDM,740,RC,95706,CPT,,,facility,outpatient,,,1588.00000,952.80000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,299.59,1191.00,fee schedule,
HC EEG W O VID 2-12HR CONT MNTR,49200137,CDM,740,RC,95707,CPT,,,facility,outpatient,,,1950.00000,1170.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,299.59,1462.50,fee schedule,
HC EEG WO VID EA 12-26HR UNMNTR,49200138,CDM,740,RC,95708,CPT,,,facility,outpatient,,,2767.00000,1660.20000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,2075.25,fee schedule,
HC EEG W O VID EA 12-26HR INTMT,49200139,CDM,740,RC,95709,CPT,,,facility,outpatient,,,3039.00000,1823.40000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,2279.25,fee schedule,
HC EEG W O VID EA 12-26HR CONT,49200140,CDM,740,RC,95710,CPT,,,facility,outpatient,,,3856.00000,2313.60000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,2892.00,fee schedule,
HC VEEG 2-12 HR UNMNTR,49200141,CDM,740,RC,95711,CPT,,,facility,outpatient,,,2268.00000,1360.80000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,299.59,1701.00,fee schedule,
HC VEEG 2-12 HR INTMT MNTR,49200142,CDM,740,RC,95712,CPT,,,facility,outpatient,,,2540.00000,1524.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,299.59,1905.00,fee schedule,
HC VEEG 2-12 HR CONT MNTR,49200143,CDM,740,RC,95713,CPT,,,facility,outpatient,,,2858.00000,1714.80000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,2143.50,fee schedule,
HC VEEG EA 12-26 HR UNMNTR,49200144,CDM,740,RC,95714,CPT,,,facility,outpatient,,,4536.00000,2721.60000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,3402.00,fee schedule,
HC VEEG EA 12-26HR INTMT MNTR,49200145,CDM,740,RC,95715,CPT,,,facility,outpatient,,,5080.00000,3048.00000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,510.48,3810.00,fee schedule,
HC VEEG EA 12-26HR CONT MNTR,49200146,CDM,740,RC,95716,CPT,,,facility,outpatient,,,5670.00000,3402.00000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,615.00,4252.50,fee schedule,
HC EEG EXTENDED 61-119 MINUTES,49200157,CDM,740,RC,95813,CPT,,,facility,outpatient,,,1042.00000,625.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,208.61,954.00,fee schedule,
HC INJECTION ADMIN SQ IM,49400003,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,37.64,767.00,fee schedule,
HC INJECTION SQ IM SELF ADMIN,49400005,CDM,940,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,37.64,767.00,fee schedule,
HC RT SMOKING TOBACCO USE CESSATION COUNSELING>10 MINS,49400014,CDM,942,RC,99407,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Medicare Advantage,,31.03,,,,,,,10.97,1090.00,fee schedule,
HC ON BODY INJECTION APPLICATION,49400015,CDM,940,RC,96377,CPT,,,facility,outpatient,,,225.00000,135.00000,WellCare of North Carolina,Medicare Advantage,,48.05,,,,,,,44.39,4311.00,fee schedule,
HC IMMUNIZATION ADMIN ONE VACCINE,49420020,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC INFLUENZA VAC ADMIN,49420021,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC PNEUMOCOCCAL VAC ADMIN,49420022,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC HEPATITIS B VAC ADMIN,49420023,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC ADM OF FREE VACCINE,49420026,CDM,771,RC,90471,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,20.54,88.50,fee schedule,
HC COVID19 VACCINE ADMINISTRATION,49420261,CDM,771,RC,90480,CPT,,,facility,outpatient,,,75.00000,45.00000,WellCare of North Carolina,Medicare Advantage,,43.24,,,,,,,13.06,56.25,fee schedule,
HC INCISION AND DRAINAGE ABSCESS SIMPLE SINGLE,53610002,CDM,761,RC,10060,CPT,,,facility,outpatient,,,479.00000,287.40000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,90.29,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,361,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,549.35,4311.00,fee schedule,
HC INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID,53610004,CDM,761,RC,10140,CPT,,,facility,outpatient,,,2744.00000,1646.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,517.24,4311.00,fee schedule,
HC INCISION AND DRAINAGE POSTOP WOUND INFECTION COMPLEX,53610005,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,361,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT MUSCLE SKIN TISSUE 1ST 20SQCM,53610006,CDM,761,RC,11043,CPT,,,facility,outpatient,,,1085.00000,651.00000,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,204.52,4376.00,fee schedule,
HC DEBRIDEMENT BONE SKIN TISSUE MUSCLE 1ST 20SQCM,53610007,CDM,761,RC,11044,CPT,,,facility,outpatient,,,2464.00000,1478.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,464.46,4376.00,fee schedule,
HC PARING BENIGN LESION SINGLE,53610011,CDM,761,RC,11055,CPT,,,facility,outpatient,,,430.00000,258.00000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,81.06,4311.00,fee schedule,
HC PARING BENIGN LESION 2-4,53610012,CDM,761,RC,11056,CPT,,,facility,outpatient,,,480.00000,288.00000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,90.48,4311.00,fee schedule,
HC PARING BENIGN LESION GREATER THAN 4,53610013,CDM,761,RC,11057,CPT,,,facility,outpatient,,,536.00000,321.60000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,101.04,4311.00,fee schedule,
HC EXCISION BENIGN LESION T A L 0.6 TO 1 CM,53610015,CDM,761,RC,11401,CPT,,,facility,outpatient,,,458.00000,274.80000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,86.33,4311.00,fee schedule,
HC TRIM NONDYSTROPHIC NAILS,53610016,CDM,761,RC,11719,CPT,,,facility,outpatient,,,119.00000,71.40000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,22.43,96.75,fee schedule,
HC DEBRID NAILS ANY METHOD 1-5,53610017,CDM,761,RC,11720,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC DEBRID NAILS ANY METHOD 6 AND GREATER,53610018,CDM,761,RC,11721,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,24.32,4311.00,fee schedule,
HC AVULSION NAIL PLATE P C S SNGL,53610019,CDM,761,RC,11730,CPT,,,facility,outpatient,,,208.00000,124.80000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,39.21,4311.00,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.5 CM OR LESS,53610023,CDM,761,RC,12001,CPT,,,facility,outpatient,,,307.00000,184.20000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,57.87,4311.00,fee schedule,
HC WOUND CAUTERY CHEMICAL,53610038,CDM,761,RC,17250,CPT,,,facility,outpatient,,,520.00000,312.00000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,98.02,4311.00,fee schedule,
HC ASPIRAT PUNCT BREAST CYST,53610039,CDM,761,RC,19000,CPT,,,facility,outpatient,,,504.00000,302.40000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,95.00,4311.00,fee schedule,
HC INJ CARPAL TUNNEL THERPTC,53610040,CDM,761,RC,20526,CPT,,,facility,outpatient,,,618.00000,370.80000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,116.49,4311.00,fee schedule,
HC INJECTION SINGLE TENDON SHEATH OR LIGAMENT,53610041,CDM,761,RC,20550,CPT,,,facility,outpatient,,,409.00000,245.40000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,77.10,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,361,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,154.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 1 OR 2 MUSCLES,53610043,CDM,761,RC,20552,CPT,,,facility,outpatient,,,770.00000,462.00000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,145.15,4311.00,fee schedule,
HC INJECTION TRIGGER POINT 3 OR MORE MUSCLES,53610044,CDM,361,RC,20553,CPT,,,facility,outpatient,,,638.00000,382.80000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,127.73,4311.00,fee schedule,
HC APPLICATION CAST RIG TOTAL CONT LEG,53610049,CDM,761,RC,29445,CPT,,,facility,outpatient,,,603.00000,361.80000,WellCare of North Carolina,Medicare Advantage,,276.58,,,,,,,113.67,490.24,fee schedule,
HC TRACH TUBE EXCHANGE,53610052,CDM,761,RC,31502,CPT,,,facility,outpatient,,,902.00000,541.20000,WellCare of North Carolina,Medicare Advantage,,241.85,,,,,,,170.03,4311.00,fee schedule,
HC SPIDER VEINS INJ SINGLE OR MULT LIMB OR TRUNK,53610053,CDM,361,RC,36468,CPT,,,facility,outpatient,,,182.00000,109.20000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,36.44,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION SINGLE VEIN,53610054,CDM,361,RC,36470,CPT,,,facility,outpatient,,,152.00000,91.20000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,30.43,4311.00,fee schedule,
HC INJ SCLEROSING SOLUTION MULT VEINS SAME LEG,53610055,CDM,361,RC,36471,CPT,,,facility,outpatient,,,280.00000,168.00000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,56.06,4311.00,fee schedule,
HC COLLECT BLOOD VIA VENOUS CATH,53610056,CDM,761,RC,36592,CPT,,,facility,outpatient,,,388.00000,232.80000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,73.14,315.44,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC DECLOT IMPLNTD VASC ACC DEV,53610057,CDM,761,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,143.07,4311.00,fee schedule,
HC BIOPSY LIVER NEEDLE PERCUTAN,53610058,CDM,361,RC,47000,CPT,,,facility,outpatient,,,2295.00000,1377.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,459.46,4311.00,fee schedule,
HC PUNCTURE OF SHUNT OR PUMP FOR INJECTION,53610077,CDM,761,RC,61070,CPT,,,facility,outpatient,,,607.00000,364.20000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,114.42,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,361,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,372.97,4311.00,fee schedule,
HC INJ EPID BLOOD PATCH,53610081,CDM,761,RC,62273,CPT,,,facility,outpatient,,,1863.00000,1117.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,351.18,4311.00,fee schedule,
HC PUMP ANALYSIS W REPROGRAM,53610088,CDM,761,RC,62368,CPT,,,facility,outpatient,,,536.00000,321.60000,WellCare of North Carolina,Medicare Advantage,,312.33,,,,,,,101.04,4376.00,fee schedule,
HC PUMP REFILL W ANLYS AND PROGRAM,53610089,CDM,761,RC,62369,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Medicare Advantage,,312.33,,,,,,,195.47,843.08,fee schedule,
HC PERC IMPLANT NEURO ELECTRODE,53610090,CDM,761,RC,63650,CPT,,,facility,outpatient,,,12507.00000,7504.20000,WellCare of North Carolina,Medicare Advantage,,6834.82,,,,,,,2357.57,10168.19,fee schedule,
HC INJECTION ANESTHETIC AGENT CERVICAL PLEXUS,53610093,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1520.00000,912.00000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SCIATIC NERVE SINGLE INCL IMG GUIDANCE,53610099,CDM,761,RC,64445,CPT,,,facility,outpatient,,,1933.00000,1159.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,364.37,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION,53610105,CDM,761,RC,64505,CPT,,,facility,outpatient,,,925.00000,555.00000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,174.36,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STELLATE GANGLION,53610106,CDM,761,RC,64510,CPT,,,facility,outpatient,,,1538.00000,922.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,289.91,4311.00,fee schedule,
HC INJECTION ANESTHETC AGENT L T PARAVERTEBRAL,53610107,CDM,761,RC,64520,CPT,,,facility,outpatient,,,1918.00000,1150.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC PERC IMPL NEURO ELCTR PER NRV,53610108,CDM,761,RC,64555,CPT,,,facility,outpatient,,,9774.00000,5864.40000,WellCare of North Carolina,Medicare Advantage,,6834.82,,,,,,,1842.40,7946.26,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,361,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,132.13,4311.00,fee schedule,
HC CHEMODNRVTN NECK MUSCL,53610111,CDM,761,RC,64616,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,124.41,4311.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,361,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,638.44,5754.00,fee schedule,
HC RF DENERV C T SNGL W IG,53610113,CDM,761,RC,64633,CPT,,,facility,outpatient,,,3189.00000,1913.40000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,601.13,4311.00,fee schedule,
HC DESTROY PERIPH NERVE BRANCH,53610115,CDM,761,RC,64640,CPT,,,facility,outpatient,,,1727.00000,1036.20000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,325.54,4311.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,361,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,428.83,5152.00,fee schedule,
HC DESTR SUPER HYPOGASTRIC PLEX,53610118,CDM,761,RC,64681,CPT,,,facility,outpatient,,,2142.00000,1285.20000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,403.77,4376.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,361,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC GANGLION IMPAR BLOCK,53610119,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1397.00000,838.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,263.33,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,361,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,124.32,4311.00,fee schedule,
HC DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610127,CDM,761,RC,97597,CPT,,,facility,outpatient,,,621.00000,372.60000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,117.06,4311.00,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,12.21,208.90,fee schedule,
HC NONSELECTIVE DEBRIDEMENT WOUND,53610151,CDM,761,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,11.50,208.90,fee schedule,
HC CYST ASP UNDER MAMM GUIDANCE BI,53610153,CDM,361,RC,19000,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,74.67,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,53610165,CDM,761,RC,64517,CPT,,,facility,outpatient,,,2240.00000,1344.00000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,422.24,4376.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 1 TO 4 MUSCLES,53610173,CDM,761,RC,64642,CPT,,,facility,outpatient,,,586.00000,351.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,110.46,4311.00,fee schedule,
HC CHEMODNRVTN 1 EXTREMITY 5 OR MORE MUSCLES,53610174,CDM,361,RC,64644,CPT,,,facility,outpatient,,,499.00000,299.40000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,99.90,4311.00,fee schedule,
HC CHEMODNRVTN TRUNK 1 TO 5 MUSCLES,53610177,CDM,361,RC,64646,CPT,,,facility,outpatient,,,586.00000,351.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,117.32,4311.00,fee schedule,
HC CHEMODENERVATION MUSCLE BILATERAL FACIAL TRIGEMINAL CERVICAL ACCESSORY NERVE,53610179,CDM,761,RC,64615,CPT,,,facility,outpatient,,,822.00000,493.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,154.95,4311.00,fee schedule,
HC RF DENERV PUDENDAL NRV,53610190,CDM,761,RC,64630,CPT,,,facility,outpatient,,,1364.00000,818.40000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,257.11,4376.00,fee schedule,
HC EXCISION OF NAIL FOLD TOE,53610225,CDM,761,RC,11765,CPT,,,facility,outpatient,,,352.00000,211.20000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,66.35,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,361,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T WO GUID,53610241,CDM,761,RC,62320,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,361,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT C T  W GUID,53610242,CDM,761,RC,62321,CPT,,,facility,outpatient,,,3941.00000,2364.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,666.26,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,361,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,390.39,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT  L S WO GUIDE,53610243,CDM,761,RC,62322,CPT,,,facility,outpatient,,,1950.00000,1170.00000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,367.57,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,361,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,621.22,4311.00,fee schedule,
HC INJECTION DIAGNOSTIC OR THERAPEUTIC INCL NEEDLE PLACEMENT L S W GUID,53610244,CDM,761,RC,62323,CPT,,,facility,outpatient,,,3103.00000,1861.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,584.92,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW CERV THOR WO IMG GUIDANCE,53610245,CDM,761,RC,62324,CPT,,,facility,outpatient,,,1723.00000,1033.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,324.79,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W O GUID,53610247,CDM,761,RC,62326,CPT,,,facility,outpatient,,,2132.00000,1279.20000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,401.88,4311.00,fee schedule,
HC INJECTION INCL INDWELLING CATHETER PLACEMENT CONTINUOUS FLOW L S W GUID,53610248,CDM,761,RC,62327,CPT,,,facility,outpatient,,,2800.00000,1680.00000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,527.80,4311.00,fee schedule,
HC COOLED RF ABLATION OTHER NERVE,53610270,CDM,361,RC,64640,CPT,,,facility,outpatient,,,5734.00000,3440.40000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,856.54,4311.00,fee schedule,
HC INSERTION OF FIDUCIAL MARKERS,53610286,CDM,761,RC,64999,CPT,,,facility,outpatient,,,1921.00000,1152.60000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRIGEMINAL NERVE EA BRANCH,53610289,CDM,761,RC,64400,CPT,,,facility,outpatient,,,1701.00000,1020.60000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID GREATER OCCIPITAL NERVE,53610290,CDM,761,RC,64405,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,109.71,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID BRACHIAL PLEXUS INCL IMG GUIDANCE,53610291,CDM,761,RC,64415,CPT,,,facility,outpatient,,,2268.00000,1360.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,427.52,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID SUPRASCAPULAR NERVE,53610292,CDM,761,RC,64418,CPT,,,facility,outpatient,,,1265.00000,759.00000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,238.45,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,361,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,467.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE SINGLE LEVEL,53610293,CDM,761,RC,64420,CPT,,,facility,outpatient,,,2333.00000,1399.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,439.77,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID INTERCOSTAL NERVE EACH ADDL LEVEL,53610294,CDM,761,RC,64421,CPT,,,facility,outpatient,,,2047.00000,1228.20000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,385.86,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID ILIOINGUINAL ILIOHYPOGASTRIC NERVES,53610295,CDM,761,RC,64425,CPT,,,facility,outpatient,,,1335.00000,801.00000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,251.65,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID PUDENDAL NERVE,53610296,CDM,761,RC,64430,CPT,,,facility,outpatient,,,847.00000,508.20000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,159.66,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,361,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,356.56,4121.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID FEMORAL NERVE INCL IMG GUIDANCE,53610297,CDM,761,RC,64447,CPT,,,facility,outpatient,,,1781.00000,1068.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,335.72,1447.95,fee schedule,
HC INJECTION ANESTHETIC AGENT ANDOR STEROID OTHER PERIPHERAL NERVE BRANCH,53610299,CDM,761,RC,64450,CPT,,,facility,outpatient,,,1698.00000,1018.80000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,320.07,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID NERVES SI JOINT INCL IMAGING GUIDANCE,53610300,CDM,761,RC,64451,CPT,,,facility,outpatient,,,1381.00000,828.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT STEROID GENICULAR NERVE BRANCHES INCL IMAGING GUIDANCE,53610301,CDM,761,RC,64454,CPT,,,facility,outpatient,,,1381.00000,828.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,260.32,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,761,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,338.17,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT GENICULAR NERVE INCLD IMG GUIDANCE,53610302,CDM,361,RC,64624,CPT,,,facility,outpatient,,,1794.00000,1076.40000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,359.16,5754.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,761,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,776.43,8442.00,fee schedule,
HC RF ABLATION NERVE SI JOINT INCLD CT FLUORO GUIDANCE,53610303,CDM,361,RC,64625,CPT,,,facility,outpatient,,,4119.00000,2471.40000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,824.62,12408.00,fee schedule,
HC INJ NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN,53610309,CDM,361,RC,36465,CPT,,,facility,outpatient,,,3475.00000,2085.00000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INJ NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS,53610310,CDM,361,RC,36466,CPT,,,facility,outpatient,,,3475.00000,2085.00000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,695.70,17457.00,fee schedule,
HC INPT DEBRIDE OPEN WOUND 1ST 20 SQ CM OR LESS,53610314,CDM,361,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,102.50,4311.00,fee schedule,
HC INPT NONSELECTIVE DEBRIDEMENT WOUND,53610316,CDM,361,RC,97602,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,12.21,208.90,fee schedule,
HC VAT DECLOT IMPLNTD VASC ACC DEV,53610323,CDM,361,RC,36593,CPT,,,facility,outpatient,,,759.00000,455.40000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,151.95,4311.00,fee schedule,
HC HYPERBARIC OXYGEN TX FBC 30MIN,54130001,CDM,413,RC,G0277,CPT,,,facility,outpatient,,,711.00000,426.60000,WellCare of North Carolina,Medicare Advantage,,143.61,,,,,,,123.79,1912.00,fee schedule,
HC ARTERIAL PUNCT DRAW BLD FOR DX,54500001,CDM,920,RC,36600,CPT,,,facility,outpatient,,,127.00000,76.20000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,22.11,767.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,361,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.00,5152.00,fee schedule,
HC DEBRIDEMENT SQ TISSUE SKIN 1ST 20SQCM,54500005,CDM,761,RC,11042,CPT,,,facility,outpatient,,,919.00000,551.40000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,173.23,4376.00,fee schedule,
HC NASOPHARYNGOSCOPY,54500010,CDM,361,RC,92511,CPT,,,facility,outpatient,,,373.00000,223.80000,WellCare of North Carolina,Medicare Advantage,,202.19,,,,,,,74.67,4311.00,fee schedule,
HC ED VISIT LEVEL 1,54500011,CDM,450,RC,99281,CPT,,,facility,outpatient,,,317.00000,190.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,59.12,365.00,fee schedule,
HC ED VISIT LEVEL 2,54500012,CDM,450,RC,99282,CPT,,,facility,outpatient,,,697.00000,418.20000,WellCare of North Carolina,Medicare Advantage,,164.92,,,,,,,129.99,624.00,fee schedule,
HC ED VISIT LEVEL 3,54500013,CDM,450,RC,99283,CPT,,,facility,outpatient,,,1393.00000,835.80000,WellCare of North Carolina,Medicare Advantage,,288.36,,,,,,,259.79,1295.00,fee schedule,
HC ED VISIT LEVEL 4,54500014,CDM,450,RC,99284,CPT,,,facility,outpatient,,,2375.00000,1425.00000,WellCare of North Carolina,Medicare Advantage,,443.47,,,,,,,409.68,3235.00,fee schedule,
HC ED VISIT LEVEL 5,54500015,CDM,450,RC,99285,CPT,,,facility,outpatient,,,3167.00000,1900.20000,WellCare of North Carolina,Medicare Advantage,,638.50,,,,,,,589.86,3709.00,fee schedule,
HC ED CRITICAL CARE 1ST 30-74 MIN,54500016,CDM,450,RC,99291,CPT,,,facility,outpatient,,,4011.00000,2406.60000,WellCare of North Carolina,Medicare Advantage,,877.52,,,,,,,748.05,5152.00,fee schedule,
HC CARDIOPULMONARY RESUSCITATION,54500018,CDM,480,RC,92950,CPT,,,facility,outpatient,,,1207.00000,724.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,161.50,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS RPT ONLY,54800001,CDM,480,RC,93786,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC AMBULATORY BP MONITOR RPT AUTOMATED WORN 24 HRS LONGER SCAN ANLY W RPT,54800002,CDM,480,RC,93788,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,20.87,3641.00,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG WO CONT,54830001,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG,57300001,CDM,730,RC,93005,CPT,,,facility,outpatient,,,295.00000,177.00000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,57.15,221.25,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300008,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300009,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 48 HRS LESS THAN 7 DAYS,57300012,CDM,731,RC,93242,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC RT ZP HOOKUP W RECORD GREATER THAN 7 DAYS LESS THAN 15 DAYS,57300013,CDM,731,RC,93246,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,37.76,477.75,fee schedule,
HC INJECTION INTRALESIONAL </= 7 LESION,57610036,CDM,761,RC,11900,CPT,,,facility,outpatient,,,270.00000,162.00000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,50.90,4311.00,fee schedule,
HC EXCISION SINGLE TAG ANUS,57610038,CDM,761,RC,46220,CPT,,,facility,outpatient,,,4243.00000,2545.80000,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,799.81,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE SIMPLE,57610049,CDM,761,RC,10120,CPT,,,facility,outpatient,,,246.00000,147.60000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,46.37,4311.00,fee schedule,
HC INCISE AND REMOVE FOREIGN BODY SUBQ TISSUE COMPLICATED,57610050,CDM,761,RC,10121,CPT,,,facility,outpatient,,,2577.00000,1546.20000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,485.76,4376.00,fee schedule,
HC GALLIUM GA 68 DOTATATE DX 0.1 MCI,57610099,CDM,343,RC,A9587,CPT,,,facility,outpatient,,,209.00000,125.40000,WellCare of North Carolina,Medicare Advantage,,53.64,,,,,,,41.84,142.48,fee schedule,
HC SIMPLE REPAIR SUPERFCL WND RPR SC NK GEN EXT 2.6 CM - 7.5 CM,57610111,CDM,761,RC,12002,CPT,,,facility,outpatient,,,303.00000,181.80000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,57.12,246.34,fee schedule,
HC EPIDERMAL AUTOGRAFT TAL 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610131,CDM,761,RC,15110,CPT,,,facility,outpatient,,,1976.00000,1185.60000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC EPIDERMAL AUTOGRAFT FEET F S E M N E O G H F D 1ST 100 SQCM OR LESS OR 1% BODY AREA INFANT CHILDREN,57610132,CDM,761,RC,15115,CPT,,,facility,outpatient,,,1976.00000,1185.60000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,372.48,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT T A L TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610133,CDM,761,RC,15271,CPT,,,facility,outpatient,,,432.00000,259.20000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION SKIN GRAFT F S E M N E O G H F D TOTAL AREA UP TO 100 SQ CM 1ST 25 SQ CM,57610135,CDM,761,RC,15275,CPT,,,facility,outpatient,,,432.00000,259.20000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,81.43,4376.00,fee schedule,
HC APPLICATION OF SPLINT CALF TO FOOT SHORT LEG,57610188,CDM,761,RC,29515,CPT,,,facility,outpatient,,,337.00000,202.20000,WellCare of North Carolina,Medicare Advantage,,164.32,,,,,,,63.52,273.98,fee schedule,
HC STRAPPING UNNA BOOT,57610190,CDM,761,RC,29580,CPT,,,facility,outpatient,,,280.00000,168.00000,WellCare of North Carolina,Medicare Advantage,,164.32,,,,,,,52.78,227.64,fee schedule,
HC APPLICATION MULTILAYER COMPRESSION SYSTEM BELOW KNEED INCLUDING ANKLE AND FOOT,57610191,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Medicare Advantage,,164.32,,,,,,,50.71,218.70,fee schedule,
HC LIGATION OR BANDING OF ANGIOACCESS AV FISTULA,57610210,CDM,481,RC,37607,CPT,,,facility,outpatient,,,9379.00000,5627.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1877.68,9423.00,fee schedule,
HC DELIVERY OF PLACENTA SEP PROCEDURE,57610256,CDM,720,RC,59414,CPT,,,facility,outpatient,,,1113.00000,667.80000,WellCare of North Carolina,Medicare Advantage,,3311.27,,,,,,,222.82,3342.81,fee schedule,
HC EVAL IMPL PUMP W/PROG/REFILL,57610259,CDM,761,RC,62370,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Medicare Advantage,,312.33,,,,,,,195.47,4376.00,fee schedule,
HC APPLICATION SKIN SUB F S G H F 1ST 25 SQCM LC,57610279,CDM,761,RC,C5275,CPT,,,facility,outpatient,,,1197.00000,718.20000,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,225.63,4376.00,fee schedule,
HC PVB THORACIC SINGLE INJ SITE,57610314,CDM,761,RC,64461,CPT,,,facility,outpatient,,,806.00000,483.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,151.93,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,361,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,397.40,4311.00,fee schedule,
HC DIALYSIS CIRCUIT INCLUDES INTRO NEEDLES CATH IMAGING RAD SUPERVISION AND INTERP,57610328,CDM,481,RC,36901,CPT,,,facility,outpatient,,,1985.00000,1191.00000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,397.40,9423.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,361,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH TRANS ANGIO PERIPHERAL SEGMENT,57610329,CDM,481,RC,36902,CPT,,,facility,outpatient,,,11676.00000,7005.60000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,2337.54,13852.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,361,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC DIALYSIS CIRCUIT WITH PLACEMENT OF STENT PERIPHERAL SEGMENT,57610330,CDM,481,RC,36903,CPT,,,facility,outpatient,,,20316.00000,12189.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4067.26,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,361,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT INCLUDES DIAG ANGIO,57610331,CDM,481,RC,36904,CPT,,,facility,outpatient,,,8640.00000,5184.00000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,1729.73,13852.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,361,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH PTA,57610332,CDM,481,RC,36905,CPT,,,facility,outpatient,,,18331.00000,10998.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,3669.87,24600.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,361,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC MECHANICAL THROMBECTOMY INFUSION DIALYSIS CIRCUIT PERIPHERAL SEGMENT WITH STENT,57610333,CDM,481,RC,36906,CPT,,,facility,outpatient,,,29657.00000,17794.20000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,5937.33,52940.00,fee schedule,
HC INPT APPLICATION MULTILAYER COMPRESSION SYSTEM LOWER LEG,57610341,CDM,761,RC,29581,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Medicare Advantage,,164.32,,,,,,,50.71,218.70,fee schedule,
HC INPT NEG PRESSURE WOUND TX USING DME 50CM OR LESS,57610342,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,77.28,333.33,fee schedule,
HC INPT SELECTIVE DEBRIDE FIRST 20 SQCM OR LESS,57610347,CDM,761,RC,97597,CPT,,,facility,outpatient,,,512.00000,307.20000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,96.51,4311.00,fee schedule,
HC INPT DEBRIDE SQ TISSUE FIRST 20 SQCM OR LESS,57610353,CDM,761,RC,11042,CPT,,,facility,outpatient,,,681.00000,408.60000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,128.37,4376.00,fee schedule,
HC INPT  COMPLEX DRAINAGE WOUND,57610361,CDM,761,RC,10180,CPT,,,facility,outpatient,,,3875.00000,2325.00000,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,730.44,4376.00,fee schedule,
HC EXHALED NITRIC OXIDE MEAS,57610443,CDM,761,RC,95012,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,26.96,116.26,fee schedule,
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,57610462,CDM,761,RC,11102,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,59.38,4311.00,fee schedule,
HC PUNCH BIOPSY OF SKIN SINGLE LESION,57610464,CDM,761,RC,11104,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,59.38,4311.00,fee schedule,
HC INCISIONAL BIOPSY OF SKIN W SIMPLE CLOSURE SINGLE LESION,57610466,CDM,761,RC,11106,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Medicare Advantage,,637.50,,,,,,,59.38,4311.00,fee schedule,
HC INPT NEG PRESS WOUND TX USING DME GREATER THAN 50 CM,57610543,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC ELEC ANALYSIS IMPL NEUROSTIM W O REP,59200003,CDM,920,RC,95970,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,28.73,767.00,fee schedule,
HC ELEC ANALYSIS SIMPLE SPINAL CORD NEUROSTIMULATOR,59200004,CDM,920,RC,95971,CPT,,,facility,outpatient,,,949.00000,569.40000,WellCare of North Carolina,Medicare Advantage,,95.59,,,,,,,88.31,767.00,fee schedule,
HC ELEC ANALYSIS COMPLEX SPINAL CORD NEUROSTIMULATOR,59200005,CDM,920,RC,95972,CPT,,,facility,outpatient,,,484.00000,290.40000,WellCare of North Carolina,Medicare Advantage,,95.59,,,,,,,84.26,767.00,fee schedule,
HC PROGRAM EVAL SNGL LD PACEMAKER,59210001,CDM,921,RC,93279,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,22.28,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD PACEMAKER,59210002,CDM,921,RC,93280,CPT,,,facility,outpatient,,,141.00000,84.60000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,24.55,269.00,fee schedule,
HC PROGRAM EVAL MULT LD PACEMAKER,59210003,CDM,921,RC,93281,CPT,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,27.51,269.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,920,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,16.02,767.00,fee schedule,
HC PROGRAM EVAL DUAL LD ICD,59210005,CDM,921,RC,93283,CPT,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,16.02,269.00,fee schedule,
HC INTERROGATION LOOP RECORDER,59210009,CDM,921,RC,93291,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Medicare Advantage,,25.50,,,,,,,23.56,269.00,fee schedule,
HC NEG PRESS WOUND TX USING DME 50 CM OR LESS,59400002,CDM,761,RC,97605,CPT,,,facility,outpatient,,,410.00000,246.00000,WellCare of North Carolina,Medicare Advantage,,206.93,,,,,,,77.28,333.33,fee schedule,
HC NEG PRESS WOUND TX GREATER THAN 50 CM,59400003,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC SUPERVISED EXERCISE THERAPY PERIPHERAL ARTERIAL DISEASE PER SESSION,59400017,CDM,940,RC,93668,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,26.63,767.00,fee schedule,
HC INPT NEG PRESS WOUND TX NOT USING DME 50 SQ CM OR MORE SNAP TREATMENT,59400019,CDM,761,RC,97606,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,97.08,420.05,fee schedule,
HC NM Y90 BRACHYTHERAPY,63600142,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,40000.00000,24000.00000,WellCare of North Carolina,Medicare Advantage,,18209.54,,,,,,,5080.00,29448.00,fee schedule,
HC SACROPLASTY,63600211,CDM,360,RC,0200T,CPT,,,facility,outpatient,,,777.00000,466.20000,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,155.56,12408.00,fee schedule,
HC BX BREAST NEEDLE NO IMAGE,63610011,CDM,361,RC,19100,CPT,,,facility,outpatient,,,884.00000,530.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,176.98,4311.00,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,761,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,38.64,166.66,fee schedule,
HC COLLECT BLOOD IMPL VENOUS ACCESS DEVICE,63610015,CDM,450,RC,36591,CPT,,,facility,outpatient,,,205.00000,123.00000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,38.23,153.75,fee schedule,
HC BONE MARROW ASPIRATION,63610016,CDM,361,RC,38220,CPT,,,facility,outpatient,,,970.00000,582.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,194.19,4311.00,fee schedule,
HC PARACENTESIS WO IMAGING,63610019,CDM,361,RC,49082,CPT,,,facility,outpatient,,,1230.00000,738.00000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,246.25,4376.00,fee schedule,
HC BLADDER IRRIGATION SIMPLE AND OR INSTILLATION NON CARCINOGEN,63610020,CDM,361,RC,51700,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,64.86,4311.00,fee schedule,
HC BIOPSY PROSTATE SINGLE MULT,63610035,CDM,361,RC,55700,CPT,,,facility,outpatient,,,6259.00000,3755.40000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,1253.05,5152.00,fee schedule,
HC THERAPEUTIC APHERESIS PLATELET,63610048,CDM,761,RC,36513,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Medicare Advantage,,455.29,,,,,,,420.60,4376.00,fee schedule,
HC CIRCUMCISION,63610049,CDM,361,RC,54150,CPT,,,facility,outpatient,,,486.00000,291.60000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,97.30,5754.00,fee schedule,
HC LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE,63610058,CDM,790,RC,50590,CPT,,,facility,outpatient,,,20624.00000,12374.40000,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,3318.21,17457.00,fee schedule,
HC THERAPEUTIC APHERESIS WHITE BLOOD CELL,63610079,CDM,761,RC,36511,CPT,,,facility,outpatient,,,3123.00000,1873.80000,WellCare of North Carolina,Medicare Advantage,,1707.19,,,,,,,588.69,4376.00,fee schedule,
HC DRAIN CATH PLMT OTHER,63610082,CDM,361,RC,10030,CPT,,,facility,outpatient,,,842.00000,505.20000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,168.57,4376.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH VISCERAL,63610083,CDM,361,RC,49405,CPT,,,facility,outpatient,,,2336.00000,1401.60000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,467.67,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH PERI RETRO,63610084,CDM,361,RC,49406,CPT,,,facility,outpatient,,,2317.00000,1390.20000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,463.86,17457.00,fee schedule,
HC IMAGE GUIDED FLUID COLLECTION DRAINAGE BY CATH TRNSVAG REC,63610085,CDM,361,RC,49407,CPT,,,facility,outpatient,,,2322.00000,1393.20000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,464.86,6735.00,fee schedule,
HC EMBO TUMOR ISCHEMIA INFARCT,63610089,CDM,361,RC,37243,CPT,,,facility,outpatient,,,11929.00000,7157.40000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2388.19,24600.00,fee schedule,
HC INSTILLATION VIA CHEST TUBE CATH FIBRINOLYTIC AGENT,63610094,CDM,361,RC,32561,CPT,,,facility,outpatient,,,524.00000,314.40000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,104.90,4311.00,fee schedule,
HC FNA BIOPSY INCL US GUIDANCE 1ST LESION,63610108,CDM,361,RC,10005,CPT,,,facility,outpatient,,,2561.00000,1536.60000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC FNA BX INCL FLUORO GUIDANCE 1ST LESION,63610110,CDM,361,RC,10007,CPT,,,facility,outpatient,,,1895.00000,1137.00000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,379.38,4311.00,fee schedule,
HC FNA BX INCL CT GUIDANCE 1ST LESION,63610112,CDM,361,RC,10009,CPT,,,facility,outpatient,,,3456.00000,2073.60000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4311.00,fee schedule,
HC FNA BX INCL MR GUIDANCE 1ST LESION,63610114,CDM,361,RC,10011,CPT,,,facility,outpatient,,,2561.00000,1536.60000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,512.71,4311.00,fee schedule,
HC IRRIGATION IMPLNTD VEN ACC DEV,66710001,CDM,761,RC,96523,CPT,,,facility,outpatient,,,179.00000,107.40000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,33.74,145.53,fee schedule,
HC PACU INJECTION ADMIN SQ/IM,67100106,CDM,761,RC,96372,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Medicare Advantage,,74.12,,,,,,,35.44,152.84,fee schedule,
HC ESOPHAGEAL MOTILITY MANOMETRY,67500001,CDM,750,RC,91010,CPT,,,facility,outpatient,,,797.00000,478.20000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,159.56,4311.00,fee schedule,
HC ESOPHAGEAL PH STUDY,67500002,CDM,750,RC,91034,CPT,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,173.00,832.00,fee schedule,
HC 48 HR PH MONITORING AND INSERT CAP,67500004,CDM,750,RC,91035,CPT,,,facility,outpatient,,,1432.00000,859.20000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,173.00,1064.69,fee schedule,
HC ESOPHAGEAL FUNCTION TEST W IMPEDANCE ELECTRODE PLACEMENT,67500005,CDM,750,RC,91037,CPT,,,facility,outpatient,,,886.00000,531.60000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC BREATH HYDROGEN TEST,67500007,CDM,750,RC,91065,CPT,,,facility,outpatient,,,179.00000,107.40000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,35.84,832.00,fee schedule,
HC GI TRACK IMAGING CAPSULE STUDY ESOPHAGUS THROUGH ILEUM,67500008,CDM,750,RC,91110,CPT,,,facility,outpatient,,,1828.00000,1096.80000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,365.97,3142.00,fee schedule,
HC ESOPHAGEAL CAPSULE ENDOSCOPY,67500009,CDM,750,RC,91111,CPT,,,facility,outpatient,,,2594.00000,1556.40000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,519.32,3142.00,fee schedule,
HC ANORECTAL MANOMETRY,67500011,CDM,750,RC,91122,CPT,,,facility,outpatient,,,945.00000,567.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC GI PATENCY CAPSULE STUDY,67500012,CDM,750,RC,91112,CPT,,,facility,outpatient,,,2883.00000,1729.80000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,577.18,3142.00,fee schedule,
HC ESOPHAGEAL IMPED MAN W IMPED PH MON,67500058,CDM,750,RC,91037,CPT,,,facility,outpatient,,,956.00000,573.60000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,173.00,832.00,fee schedule,
HC IMPEDANCE PH MONITORING,67500059,CDM,750,RC,91038,CPT,,,facility,outpatient,,,886.00000,531.60000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,173.00,832.00,fee schedule,
HC ESOPHAGEAL MANO W IMPED PH MONITORN,67500060,CDM,750,RC,91010,CPT,,,facility,outpatient,,,1402.00000,841.20000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,173.00,4311.00,fee schedule,
HC EYE EXAM UNDER ANESTH PROCEDURE,67610003,CDM,761,RC,92019,CPT,,,facility,outpatient,,,2174.00000,1304.40000,WellCare of North Carolina,Medicare Advantage,,2429.62,,,,,,,409.80,2452.76,fee schedule,
HC EMG CRANIAL NERVES BIL,69220001,CDM,922,RC,95868,CPT,,,facility,outpatient,,,429.00000,257.40000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,74.69,1831.00,fee schedule,
HC EVOKED POT TRUNK HEAD SSEP UNIL,69220002,CDM,922,RC,95927,CPT,,,facility,outpatient,,,452.00000,271.20000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,78.69,1831.00,fee schedule,
HC NEUROMUSCULAR JUNCTION TEST EA NERVE ANY 1 METHOD,69220003,CDM,922,RC,95937,CPT,,,facility,outpatient,,,401.00000,240.60000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,69.81,1831.00,fee schedule,
HC SOMATOSENSORY EVOKED POTENTIAL TRUNK OR HEAD,69220006,CDM,922,RC,95927,CPT,,,facility,outpatient,,,665.00000,399.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,115.78,1831.00,fee schedule,
HC AUTONOMIC COMBINED,69220008,CDM,922,RC,95924,CPT,,,facility,outpatient,,,318.00000,190.80000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,55.36,1831.00,fee schedule,
HC ORBIT DETECTION FOREIGN BODY,72550015,CDM,320,RC,70030,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,45.52,268.00,fee schedule,
HC MANDIBLE COMP 4 VWS,72550017,CDM,320,RC,70110,CPT,,,facility,outpatient,,,545.00000,327.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,61.58,408.75,fee schedule,
HC MASTOID COMP MIN 3 VWS PER SIDE,72550018,CDM,320,RC,70130,CPT,,,facility,outpatient,,,352.00000,211.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,70.47,268.00,fee schedule,
HC FACIAL BONES LESS THAN 3 VWS,72550020,CDM,320,RC,70140,CPT,,,facility,outpatient,,,481.00000,288.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,42.96,360.75,fee schedule,
HC FACE BONES COMP MIN 3 VWS,72550021,CDM,320,RC,70150,CPT,,,facility,outpatient,,,601.00000,360.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,67.36,450.75,fee schedule,
HC NASAL BONES COMP MIN 3 VWS,72550022,CDM,320,RC,70160,CPT,,,facility,outpatient,,,394.00000,236.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,57.08,295.50,fee schedule,
HC DACRYOCYSTOGRAPHY,72550023,CDM,320,RC,70170,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,65.78,331.50,fee schedule,
HC ORBITS COMP MIN 4 VWS,72550024,CDM,320,RC,70200,CPT,,,facility,outpatient,,,500.00000,300.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,67.36,375.00,fee schedule,
HC SINUSES PARANASAL LESS THAN 3 VWS,72550025,CDM,320,RC,70210,CPT,,,facility,outpatient,,,152.00000,91.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,30.43,268.00,fee schedule,
HC SINUSES PARANASAL COMP MIN 3 VWS,72550026,CDM,320,RC,70220,CPT,,,facility,outpatient,,,270.00000,162.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,52.60,268.00,fee schedule,
HC SELLA TURCICA,72550027,CDM,320,RC,70240,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,24.02,268.00,fee schedule,
HC SKULL LESS THAN 4 VWS,72550028,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,51.96,375.75,fee schedule,
HC SKULL COMP MIN 4 VWS,72550029,CDM,320,RC,70260,CPT,,,facility,outpatient,,,671.00000,402.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,60.30,503.25,fee schedule,
HC TMJ OPEN  AND CLOSED BIL,72550030,CDM,320,RC,70330,CPT,,,facility,outpatient,,,179.00000,107.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,35.84,268.00,fee schedule,
HC PANOREX,72550032,CDM,320,RC,70355,CPT,,,facility,outpatient,,,302.00000,181.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,15.34,268.00,fee schedule,
HC NECK SOFT TISSUE,72550033,CDM,320,RC,70360,CPT,,,facility,outpatient,,,362.00000,217.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,43.60,271.50,fee schedule,
HC RIBS UNIL 2 VWS,72550040,CDM,320,RC,71100,CPT,,,facility,outpatient,,,483.00000,289.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,50.02,362.25,fee schedule,
HC RIBS UNIL W PA CHEST MIN 3 VWS,72550041,CDM,320,RC,71101,CPT,,,facility,outpatient,,,584.00000,350.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,56.44,438.00,fee schedule,
HC RIBS BIL 3 VWS,72550042,CDM,320,RC,71110,CPT,,,facility,outpatient,,,1079.00000,647.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,57.74,809.25,fee schedule,
HC RIBS BIL W PA CHEST MIN 4 VWS,72550043,CDM,320,RC,71111,CPT,,,facility,outpatient,,,585.00000,351.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,71.86,438.75,fee schedule,
HC STERNUM MIN 2 VWS,72550044,CDM,320,RC,71120,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,46.82,288.75,fee schedule,
HC STERNOCLAVICULAR JOINT MIN 3 VWS,72550045,CDM,320,RC,71130,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,59.66,268.00,fee schedule,
HC SPINE SINGLE VIEW,72550047,CDM,320,RC,72020,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,32.04,331.50,fee schedule,
HC SPINE CERVICAL 2 OR 3 VIEWS,72550048,CDM,320,RC,72040,CPT,,,facility,outpatient,,,496.00000,297.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,55.16,372.00,fee schedule,
HC SPINE CERVICAL 4 OR 5 VWS,72550049,CDM,320,RC,72050,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,77.00,495.00,fee schedule,
HC SPINE CERVICAL 6 OR MORE VWS,72550050,CDM,320,RC,72052,CPT,,,facility,outpatient,,,929.00000,557.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,91.78,696.75,fee schedule,
HC SPINE THORACIC 2 VWS,72550052,CDM,320,RC,72070,CPT,,,facility,outpatient,,,437.00000,262.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,44.24,327.75,fee schedule,
HC SPINE THORACIC 3 VWS,72550053,CDM,320,RC,72072,CPT,,,facility,outpatient,,,327.00000,196.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,54.52,268.00,fee schedule,
HC SPINE THORACOLUMBAR 2 VWS,72550055,CDM,320,RC,72080,CPT,,,facility,outpatient,,,564.00000,338.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,47.46,423.00,fee schedule,
HC SPINE LUMBOSACRAL 2 OR 3 VWS,72550057,CDM,320,RC,72100,CPT,,,facility,outpatient,,,492.00000,295.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,55.80,369.00,fee schedule,
HC LUMBAR SPINE MIN 4 VWS,72550058,CDM,320,RC,72110,CPT,,,facility,outpatient,,,710.00000,426.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,74.44,532.50,fee schedule,
HC LUMBAR SPINE COMP BENDING VWS MIN 6,72550059,CDM,320,RC,72114,CPT,,,facility,outpatient,,,875.00000,525.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,91.12,656.25,fee schedule,
HC LUMBAR SPINE BENDING 2 TO 3 VWS,72550060,CDM,320,RC,72120,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,57.74,436.50,fee schedule,
HC PELVIS 1 OR 2 VWS,72550061,CDM,320,RC,72170,CPT,,,facility,outpatient,,,341.00000,204.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,37.18,268.00,fee schedule,
HC PELVIS COMPLETE MIN 3 VWS,72550062,CDM,320,RC,72190,CPT,,,facility,outpatient,,,541.00000,324.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,57.74,405.75,fee schedule,
HC SACROILIAC JNTS 3 OR MORE VWS,72550063,CDM,320,RC,72202,CPT,,,facility,outpatient,,,369.00000,221.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,54.52,276.75,fee schedule,
HC SACRUM AND COCCYX MIN 2 VWS,72550064,CDM,320,RC,72220,CPT,,,facility,outpatient,,,368.00000,220.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,46.16,276.00,fee schedule,
HC MYELOGRAPHY CERVICAL,72550065,CDM,320,RC,72240,CPT,,,facility,outpatient,,,1211.00000,726.60000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,138.66,908.25,fee schedule,
HC MYELOGRAPHY THORACIC,72550066,CDM,320,RC,72255,CPT,,,facility,outpatient,,,752.00000,451.20000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,141.22,830.63,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL,72550067,CDM,320,RC,72265,CPT,,,facility,outpatient,,,1336.00000,801.60000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,135.44,1002.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS,72550068,CDM,320,RC,72270,CPT,,,facility,outpatient,,,1892.00000,1135.20000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,195.18,1419.00,fee schedule,
HC DISCOGRAM LUMBAR,72550073,CDM,320,RC,72295,CPT,,,facility,outpatient,,,2081.00000,1248.60000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,139.30,2053.05,fee schedule,
HC CLAVICLE COMP,72550074,CDM,320,RC,73000,CPT,,,facility,outpatient,,,425.00000,255.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,46.16,318.75,fee schedule,
HC SCAPULA COMP,72550075,CDM,320,RC,73010,CPT,,,facility,outpatient,,,382.00000,229.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,28.82,286.50,fee schedule,
HC SHOULDER 1 VW,72550076,CDM,320,RC,73020,CPT,,,facility,outpatient,,,459.00000,275.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,26.90,344.25,fee schedule,
HC SHOULDER COMP 2 VWS,72550077,CDM,320,RC,73030,CPT,,,facility,outpatient,,,462.00000,277.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,48.74,346.50,fee schedule,
HC SHOULDER ARTHROGRAPHY,72550078,CDM,320,RC,73040,CPT,,,facility,outpatient,,,1271.00000,762.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,204.18,953.25,fee schedule,
HC ACROMIOCLAVICULAR JOINTS BIL W WO WEIGHT,72550079,CDM,320,RC,73050,CPT,,,facility,outpatient,,,522.00000,313.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,37.18,391.50,fee schedule,
HC HUMERUS MIN 2 VWS,72550080,CDM,320,RC,73060,CPT,,,facility,outpatient,,,440.00000,264.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,46.16,330.00,fee schedule,
HC ELBOW 2 VWS,72550081,CDM,320,RC,73070,CPT,,,facility,outpatient,,,406.00000,243.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,40.38,304.50,fee schedule,
HC ELBOW COMP MIN 3 VWS,72550082,CDM,320,RC,73080,CPT,,,facility,outpatient,,,442.00000,265.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,46.16,331.50,fee schedule,
HC ELBOW ARTHROGRAPHY,72550083,CDM,322,RC,73085,CPT,,,facility,outpatient,,,487.00000,292.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,97.50,375.47,fee schedule,
HC FOREARM 2 VWS,72550084,CDM,320,RC,73090,CPT,,,facility,outpatient,,,379.00000,227.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,41.04,284.25,fee schedule,
HC UE INFANT MIN 2 VWS,72550085,CDM,320,RC,73092,CPT,,,facility,outpatient,,,298.00000,178.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,46.16,268.00,fee schedule,
HC WRIST 2 VIEWS,72550086,CDM,320,RC,73100,CPT,,,facility,outpatient,,,375.00000,225.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,49.38,281.25,fee schedule,
HC WRIST COMP MIN 3 VWS,72550087,CDM,320,RC,73110,CPT,,,facility,outpatient,,,347.00000,208.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,62.22,268.00,fee schedule,
HC WRIST ARTHROGRAPHY,72550088,CDM,322,RC,73115,CPT,,,facility,outpatient,,,653.00000,391.80000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,130.73,489.75,fee schedule,
HC HAND 2 VWS,72550089,CDM,320,RC,73120,CPT,,,facility,outpatient,,,431.00000,258.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,44.24,323.25,fee schedule,
HC HAND MIN 3 VWS,72550090,CDM,320,RC,73130,CPT,,,facility,outpatient,,,394.00000,236.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,53.88,295.50,fee schedule,
HC FINGERS MIN 2 VIEWS,72550091,CDM,320,RC,73140,CPT,,,facility,outpatient,,,276.00000,165.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,55.26,268.00,fee schedule,
HC HIP ARTHROGRAPHY,72550095,CDM,322,RC,73525,CPT,,,facility,outpatient,,,841.00000,504.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,168.37,630.75,fee schedule,
HC KNEE 1 OR 2 VWS,72550099,CDM,320,RC,73560,CPT,,,facility,outpatient,,,427.00000,256.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,50.02,320.25,fee schedule,
HC KNEE 3 VWS,72550100,CDM,320,RC,73562,CPT,,,facility,outpatient,,,371.00000,222.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,60.94,278.25,fee schedule,
HC KNEE COMPL 4 OR MORE VWS,72550101,CDM,320,RC,73564,CPT,,,facility,outpatient,,,482.00000,289.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,68.00,361.50,fee schedule,
HC KNEES BOTH STANDING AP,72550102,CDM,320,RC,73565,CPT,,,facility,outpatient,,,316.00000,189.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,61.58,268.00,fee schedule,
HC KNEE ARTHROGRAPHY,72550103,CDM,322,RC,73580,CPT,,,facility,outpatient,,,380.00000,228.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,76.08,375.47,fee schedule,
HC TIBIA AND FIBULA 2 VIEWS,72550104,CDM,320,RC,73590,CPT,,,facility,outpatient,,,354.00000,212.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,45.52,268.00,fee schedule,
HC LE INFANT MIN 2 VWS,72550105,CDM,320,RC,73592,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,43.64,268.00,fee schedule,
HC ANKLE 2 VWS,72550106,CDM,320,RC,73600,CPT,,,facility,outpatient,,,445.00000,267.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,46.82,333.75,fee schedule,
HC ANKLE COMPLETE MIN 3 VWS,72550107,CDM,320,RC,73610,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,54.52,347.25,fee schedule,
HC ANKLE ARTHROGRAPHY,72550108,CDM,320,RC,73615,CPT,,,facility,outpatient,,,380.00000,228.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,76.08,375.47,fee schedule,
HC FOOT 2 VWS,72550109,CDM,320,RC,73620,CPT,,,facility,outpatient,,,530.00000,318.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,39.74,397.50,fee schedule,
HC FOOT COMPLETE MIN 3 VWS,72550110,CDM,320,RC,73630,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,50.66,347.25,fee schedule,
HC CALCANEUS MIN 2 VWS,72550111,CDM,320,RC,73650,CPT,,,facility,outpatient,,,401.00000,240.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,40.38,300.75,fee schedule,
HC TOES MIN 2 VIEWS,72550112,CDM,320,RC,73660,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,43.60,268.00,fee schedule,
HC ABDOMEN 1 VIEW,72550113,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,41.04,319.50,fee schedule,
HC PERITONEOGRAM S AND I,72550117,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM,72550118,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC S AND I PERITONEOGRAM AIR CONTRAST,72550119,CDM,320,RC,74190,CPT,,,facility,outpatient,,,495.00000,297.00000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,63.20,576.46,fee schedule,
HC RAD EXAM ESOPHAGUS,72550121,CDM,320,RC,74220,CPT,,,facility,outpatient,,,782.00000,469.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,138.66,586.50,fee schedule,
HC THERAPEUTIC ENEMA CONT OR AIR,72550135,CDM,320,RC,74283,CPT,,,facility,outpatient,,,247.00000,148.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,49.45,311.44,fee schedule,
HC UROG W WO KUB W WO TOMOGRAPHY,72550148,CDM,320,RC,74400,CPT,,,facility,outpatient,,,988.00000,592.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,741.00,fee schedule,
HC IVP W NEPHROTOMOGRAPHY,72550149,CDM,320,RC,74415,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,780.75,fee schedule,
HC UROGRAPHY RETROG W WO KUB,72550150,CDM,320,RC,74420,CPT,,,facility,outpatient,,,1074.00000,644.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,100.76,805.50,fee schedule,
HC UROGRAPHY ANTEGRADE RADIOLOGICAL S AND I,72550151,CDM,320,RC,74425,CPT,,,facility,outpatient,,,537.00000,322.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,107.51,402.75,fee schedule,
HC CYSTOGRAPHY MIN 3 VWS,72550152,CDM,320,RC,74430,CPT,,,facility,outpatient,,,98.00000,58.80000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,19.62,375.47,fee schedule,
HC OR S AND I VASOGRAPHY,72550153,CDM,320,RC,74440,CPT,,,facility,outpatient,,,580.00000,348.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,116.12,435.00,fee schedule,
HC S AND I URETHROCYSTOGRAPHY RETRO,72550154,CDM,320,RC,74450,CPT,,,facility,outpatient,,,643.00000,385.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,98.30,482.25,fee schedule,
HC URETHROCYSTOGRAPHY VOIDING,72550155,CDM,320,RC,74455,CPT,,,facility,outpatient,,,818.00000,490.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,163.76,613.50,fee schedule,
HC S AND I DILITATION URETERS OR URETHRA,72550159,CDM,320,RC,74485,CPT,,,facility,outpatient,,,666.00000,399.60000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,133.33,2153.70,fee schedule,
HC S AND I HYSTEROSALPINGOGRAM,72550160,CDM,320,RC,74740,CPT,,,facility,outpatient,,,810.00000,486.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,154.08,607.50,fee schedule,
HC S AND I AORTOGRAM THORACIC BY SERIALOGRAPHY,72550162,CDM,320,RC,75605,CPT,,,facility,outpatient,,,2088.00000,1252.80000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,130.88,5683.29,fee schedule,
HC S AND I AORTOGRAM ABDOMINAL BY SERIALOGRAPHY,72550163,CDM,320,RC,75625,CPT,,,facility,outpatient,,,4645.00000,2787.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,116.82,3483.75,fee schedule,
HC S AND I AORTOGRAPHY ABD AND BIL ILIOFEM,72550164,CDM,320,RC,75630,CPT,,,facility,outpatient,,,3577.00000,2146.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,125.18,3309.13,fee schedule,
HC S AND I SHUNTOGRAM,72550169,CDM,320,RC,75809,CPT,,,facility,outpatient,,,185.00000,111.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,37.04,268.00,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY UNIL,72550171,CDM,320,RC,75820,CPT,,,facility,outpatient,,,1368.00000,820.80000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,117.46,1633.21,fee schedule,
HC S AND I VENOGRAPHY EXTREMITY BILAT,72550172,CDM,320,RC,75822,CPT,,,facility,outpatient,,,1395.00000,837.00000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,126.46,1633.21,fee schedule,
HC S AND I VENOGRAM CAVAL INFER SERIAL,72550173,CDM,320,RC,75825,CPT,,,facility,outpatient,,,4047.00000,2428.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,118.74,3309.13,fee schedule,
HC S AND I VENOGRAM CAVAL SUPERIOR SERIAL,72550174,CDM,320,RC,75827,CPT,,,facility,outpatient,,,5746.00000,3447.60000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,129.02,4309.50,fee schedule,
HC S AND I VENOGRAM RENAL UNIL SELECTIVE,72550175,CDM,320,RC,75831,CPT,,,facility,outpatient,,,1326.00000,795.60000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,130.96,3309.13,fee schedule,
HC S AND I RENAL VENOGRAM BIL SELECTIVE,72550176,CDM,320,RC,75833,CPT,,,facility,outpatient,,,2572.00000,1543.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,150.14,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL UNIL SELECTIVE,72550177,CDM,320,RC,75840,CPT,,,facility,outpatient,,,1031.00000,618.60000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,143.80,3309.13,fee schedule,
HC S AND I VENOGRAM ADRENAL BIL SELECTIVE,72550178,CDM,320,RC,75842,CPT,,,facility,outpatient,,,1202.00000,721.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,167.48,5683.29,fee schedule,
HC S AND I VENOGRAM JUG OR VENOUS SINU,72550179,CDM,320,RC,75860,CPT,,,facility,outpatient,,,1608.00000,964.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I VENOGRAM SUPERIOR SAGITTAL SINUS,72550180,CDM,320,RC,75870,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,160.96,3309.13,fee schedule,
HC S AND I TRANSHEPATIC PORTOG WO HEM,72550182,CDM,320,RC,75887,CPT,,,facility,outpatient,,,1616.00000,969.60000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,139.94,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE W HEM,72550183,CDM,320,RC,75889,CPT,,,facility,outpatient,,,967.00000,580.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,138.66,3309.13,fee schedule,
HC S AND I HEPATIC VENOGRAM WEDGE OR FREE WO HEM,72550184,CDM,320,RC,75891,CPT,,,facility,outpatient,,,799.00000,479.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,139.30,3309.13,fee schedule,
HC S AND I VENOUS SAMPLING VIA CATH W  WO ANGI,72550185,CDM,320,RC,75893,CPT,,,facility,outpatient,,,1106.00000,663.60000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,150.22,5683.29,fee schedule,
HC ANGIO FOLLOW UP VIA EXIST CATHETER OTHER THAN THROMBOLYSIS,72550188,CDM,320,RC,75898,CPT,,,facility,outpatient,,,1376.00000,825.60000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,82.40,3309.13,fee schedule,
HC FLUOROSCOPY UP TO 1 HR,72550211,CDM,320,RC,76000,CPT,,,facility,outpatient,,,953.00000,571.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,53.24,714.75,fee schedule,
HC FOREIGN BODY 1 VW CHILD NOSE TO RECTUM,72550213,CDM,320,RC,76010,CPT,,,facility,outpatient,,,169.00000,101.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,33.83,268.00,fee schedule,
HC S AND I FISTULA SINUS STUDY,72550214,CDM,320,RC,76080,CPT,,,facility,outpatient,,,936.00000,561.60000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,68.64,702.00,fee schedule,
HC RAD EXAM SURG SPECIMEN,72550215,CDM,320,RC,76098,CPT,,,facility,outpatient,,,306.00000,183.60000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,48.74,576.46,fee schedule,
HC TOMOGRAPHY SGL PLANE BDY SECT,72550216,CDM,320,RC,76100,CPT,,,facility,outpatient,,,341.00000,204.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,68.27,268.00,fee schedule,
HC UNLISTED FLUOROSCOPIC,72550218,CDM,320,RC,76496,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,28.63,268.00,fee schedule,
HC BREAST DUCTOGRAM SINGLE DUCT,72550224,CDM,320,RC,77053,CPT,,,facility,outpatient,,,323.00000,193.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,64.66,268.00,fee schedule,
HC BREAST DUCTOGRAM MULTIPL DUCTS,72550225,CDM,320,RC,77054,CPT,,,facility,outpatient,,,646.00000,387.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,91.12,484.50,fee schedule,
HC BONE AGE STUDIES,72550227,CDM,320,RC,77072,CPT,,,facility,outpatient,,,346.00000,207.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,32.68,268.00,fee schedule,
HC BONE LENGTH STUDY SCANOGRAM,72550228,CDM,320,RC,77073,CPT,,,facility,outpatient,,,243.00000,145.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,48.65,268.00,fee schedule,
HC OSSEOUS SURVEY LIMITED,72550229,CDM,320,RC,77074,CPT,,,facility,outpatient,,,268.00000,160.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,53.65,268.00,fee schedule,
HC OSSEOUS SURVEY COMPLETE,72550230,CDM,320,RC,77075,CPT,,,facility,outpatient,,,927.00000,556.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,695.25,fee schedule,
HC OSSEOUS SURVEY INFANT,72550231,CDM,320,RC,77076,CPT,,,facility,outpatient,,,306.00000,183.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,61.26,268.00,fee schedule,
HC DEXA AXIAL SKELETON 1 OR MORE SITES,72550233,CDM,320,RC,77080,CPT,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,52.60,683.25,fee schedule,
HC DEXA APPENDICULAR SKELETON,72550234,CDM,320,RC,77081,CPT,,,facility,outpatient,,,291.00000,174.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,40.38,268.00,fee schedule,
HC S AND I ANGIO  SPINAL SELECTIVE,72550238,CDM,323,RC,75705,CPT,,,facility,outpatient,,,788.00000,472.80000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,157.76,5683.29,fee schedule,
HC S AND I ANGIO ART EXTREMITY UNIL,72550239,CDM,323,RC,75710,CPT,,,facility,outpatient,,,2343.00000,1405.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,133.52,3309.13,fee schedule,
HC S AND I ANGIO EXTREMITY BIL,72550240,CDM,323,RC,75716,CPT,,,facility,outpatient,,,4039.00000,2423.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,137.94,3309.13,fee schedule,
HC S AND I ANGIO ART VISCERAL W OR WO FLUSH,72550241,CDM,323,RC,75726,CPT,,,facility,outpatient,,,3338.00000,2002.80000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,148.86,5683.29,fee schedule,
HC S AND I ANGIO ADRENAL GLAND UNILATERAL SELECTIVE,72550242,CDM,323,RC,75731,CPT,,,facility,outpatient,,,3598.00000,2158.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,186.12,3309.13,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE,72550244,CDM,323,RC,75736,CPT,,,facility,outpatient,,,2035.00000,1221.00000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC S AND I ANGIO PULMONARY UNIL SELECTIVE,72550245,CDM,323,RC,75741,CPT,,,facility,outpatient,,,4514.00000,2708.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,136.10,3385.50,fee schedule,
HC S AND I ANGIO PULMONARY BIL SELECTIVE,72550246,CDM,323,RC,75743,CPT,,,facility,outpatient,,,4514.00000,2708.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,138.58,3385.50,fee schedule,
HC S AND I ANGIO PULM NON SELECTIVE CATH VE,72550247,CDM,323,RC,75746,CPT,,,facility,outpatient,,,4514.00000,2708.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,155.28,3385.50,fee schedule,
HC S AND I ANGIO INTERNAL MAMMARY,72550248,CDM,323,RC,75756,CPT,,,facility,outpatient,,,3053.00000,1831.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,198.96,3309.13,fee schedule,
HC CHEST 1 VW FRONTAL,72550253,CDM,324,RC,71045,CPT,,,facility,outpatient,,,268.00000,160.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,32.68,268.00,fee schedule,
HC CHEST 2 VWS FRONT LATERAL,72550254,CDM,324,RC,71046,CPT,,,facility,outpatient,,,374.00000,224.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,44.24,280.50,fee schedule,
HC CHEST 4 OR MORE VWS,72550255,CDM,324,RC,71048,CPT,,,facility,outpatient,,,332.00000,199.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,60.30,268.00,fee schedule,
HC SIALOGRAPHY,72550257,CDM,320,RC,70390,CPT,,,facility,outpatient,,,831.00000,498.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,166.37,623.25,fee schedule,
HC SKULL 2 VWS XRAY,72550275,CDM,320,RC,70250,CPT,,,facility,outpatient,,,501.00000,300.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,51.96,375.75,fee schedule,
HC DISCOGRAPHY CERV THOR INITIAL,72550276,CDM,320,RC,72285,CPT,,,facility,outpatient,,,2081.00000,1248.60000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,137.38,2053.05,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 1 VW,72550278,CDM,320,RC,72081,CPT,,,facility,outpatient,,,617.00000,370.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,57.74,462.75,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 2 OR 3 VWS,72550279,CDM,320,RC,72082,CPT,,,facility,outpatient,,,812.00000,487.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,609.00,fee schedule,
HC SPINE ENTIRE THOR LUMB INCL SKULL CERV AND SACRAL 4 OR 5 VWS,72550280,CDM,320,RC,72083,CPT,,,facility,outpatient,,,861.00000,516.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,645.75,fee schedule,
HC HIP UNIL W PELVIS 1 VW,72550281,CDM,320,RC,73501,CPT,,,facility,outpatient,,,467.00000,280.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,44.88,350.25,fee schedule,
HC HIP UNIL W PELVIS 2 TO 3 VWS,72550282,CDM,320,RC,73502,CPT,,,facility,outpatient,,,494.00000,296.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,69.30,370.50,fee schedule,
HC HIP UNIL W PELVIS MIN 4 VWS,72550283,CDM,320,RC,73503,CPT,,,facility,outpatient,,,523.00000,313.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,87.92,392.25,fee schedule,
HC HIPS BILAT W PELVIS 2 VWS,72550284,CDM,320,RC,73521,CPT,,,facility,outpatient,,,758.00000,454.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,58.38,568.50,fee schedule,
HC HIPS BILAT W PELVIS 3 TO 4 VWS,72550285,CDM,320,RC,73522,CPT,,,facility,outpatient,,,736.00000,441.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,75.72,552.00,fee schedule,
HC HIPS BILAT W PELVIS MIN 5 VWS,72550286,CDM,320,RC,73523,CPT,,,facility,outpatient,,,1079.00000,647.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,89.20,809.25,fee schedule,
HC FEMUR 1 VW,72550287,CDM,320,RC,73551,CPT,,,facility,outpatient,,,229.00000,137.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,40.38,268.00,fee schedule,
HC FEMUR MIN 2 VWS,72550288,CDM,320,RC,73552,CPT,,,facility,outpatient,,,432.00000,259.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,50.66,324.00,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,72550294,CDM,320,RC,74240,CPT,,,facility,outpatient,,,615.00000,369.00000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,123.12,461.25,fee schedule,
HC RAD EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,72550295,CDM,320,RC,74221,CPT,,,facility,outpatient,,,785.00000,471.00000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,154.08,588.75,fee schedule,
HC BRACHYTHERAPY Y90 NS PER SOURCE,72780001,CDM,278,RC,C2616,CPT,,,facility,outpatient,,,37500.00000,22500.00000,WellCare of North Carolina,Medicare Advantage,,18209.54,,,,,,,4762.50,27607.50,fee schedule,
HC S AND I PELVIC SUPRA SELECTIVE ADDL,73200002,CDM,320,RC,75736,CPT,,,facility,outpatient,,,1853.00000,1111.80000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,170.70,5683.29,fee schedule,
HC MYELOGRAPHY LUMBOSACRAL VIA LUMBAR INJ INCL S AND I,73200016,CDM,361,RC,62304,CPT,,,facility,outpatient,,,2253.00000,1351.80000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,451.05,8213.00,fee schedule,
HC CHEST 3 VWS,73200022,CDM,324,RC,71047,CPT,,,facility,outpatient,,,420.00000,252.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,56.44,315.00,fee schedule,
HC ABDOMEN 2 VWS,73200023,CDM,320,RC,74019,CPT,,,facility,outpatient,,,550.00000,330.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,49.38,412.50,fee schedule,
HC ABDOMEN 3 OR MORE VWS,73200024,CDM,320,RC,74021,CPT,,,facility,outpatient,,,540.00000,324.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,58.38,405.00,fee schedule,
HC RAD EXAM SWALLOWING FUNCTION W CINEVIDEO INCLD SCOUT NECK RADGPH AND DELAYED IMG W CONTRAST,73200037,CDM,320,RC,74230,CPT,,,facility,outpatient,,,401.00000,240.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,80.28,300.75,fee schedule,
HC RAD EXAM UGI INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST STUDY INCLD GLUCAGON,73200038,CDM,320,RC,74246,CPT,,,facility,outpatient,,,596.00000,357.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,119.32,447.00,fee schedule,
HC RAD EXAM SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRPH SINGLE CONTRAST STUDY,73200039,CDM,320,RC,74250,CPT,,,facility,outpatient,,,497.00000,298.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,99.50,372.75,fee schedule,
HC RAD EXAM ABDOMEN ACUTE SERIES CMPL INCLD 2 OR MORE ABD VIEW AND SINGLE CHEST,73200040,CDM,320,RC,74022,CPT,,,facility,outpatient,,,752.00000,451.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,66.72,564.00,fee schedule,
HC RAD ONC SM INTESTINE INCLD MULTI SERIAL IMAGES AND SCOUT ABD RADGRP DOUBLE CONTRAST INCLD GLUCAGON,73200041,CDM,320,RC,74251,CPT,,,facility,outpatient,,,581.00000,348.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,116.32,633.86,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE SINGLE CONTRAST STUDY,73200042,CDM,320,RC,74270,CPT,,,facility,outpatient,,,928.00000,556.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,696.00,fee schedule,
HC RAD EXAM COLON INCLD SCOUT ABD RADGRPH AND DELAYED IMAGE DOUBLE CONTRAST INCLD GLUCAGON,73200043,CDM,320,RC,74280,CPT,,,facility,outpatient,,,1382.00000,829.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,1036.50,fee schedule,
HC CT THORAX LOW DOSE LUNG CANCER SCREENING WO CONTRAST,73200045,CDM,350,RC,71271,CPT,,,facility,outpatient,,,270.00000,162.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,54.05,2905.00,fee schedule,
HC CHEMO INTO CNS INTRATHECAL W LP,73300001,CDM,331,RC,96450,CPT,,,facility,outpatient,,,829.00000,497.40000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,165.97,3466.00,fee schedule,
HC BRAIN IMAGING WITH FLOW,73400002,CDM,340,RC,78601,CPT,,,facility,outpatient,,,1357.00000,814.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM THYROID UPTAKE SINGLE MULT,73400003,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM THYROID IMG INCL FLOW,73400004,CDM,341,RC,78013,CPT,,,facility,outpatient,,,685.00000,411.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,137.14,1560.00,fee schedule,
HC NM THYROID FLOW AND UPTAKE,73400005,CDM,341,RC,78014,CPT,,,facility,outpatient,,,1104.00000,662.40000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,221.02,1560.00,fee schedule,
HC NM THYROID CA METS LTD,73400006,CDM,341,RC,78015,CPT,,,facility,outpatient,,,583.00000,349.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,116.72,1560.00,fee schedule,
HC NM I131 TOTAL BODY,73400008,CDM,341,RC,78018,CPT,,,facility,outpatient,,,2917.00000,1750.20000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,2187.75,fee schedule,
HC NM PARATHYROID PLANAR,73400010,CDM,341,RC,78070,CPT,,,facility,outpatient,,,1494.00000,896.40000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC PARATHYROID PLANAR AND SPECT,73400011,CDM,341,RC,78071,CPT,,,facility,outpatient,,,1093.00000,655.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,218.82,1560.00,fee schedule,
HC NM PARATHYROID PLANAR AND SPECT CT,73400012,CDM,341,RC,78072,CPT,,,facility,outpatient,,,976.00000,585.60000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,195.40,1560.00,fee schedule,
HC NM ENDOCRINE PROCEDURE,73400013,CDM,341,RC,78099,CPT,,,facility,outpatient,,,717.00000,430.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,143.54,1560.00,fee schedule,
HC NM BONE MARROW WHOLE BODY,73400015,CDM,341,RC,78104,CPT,,,facility,outpatient,,,1866.00000,1119.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RBC SEQUESTRATION,73400016,CDM,341,RC,78140,CPT,,,facility,outpatient,,,1014.00000,608.40000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,203.00,1560.00,fee schedule,
HC NM LYMPHOSCINTIGRAPHY,73400018,CDM,341,RC,78195,CPT,,,facility,outpatient,,,2079.00000,1247.40000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER STATIC IMAGING,73400019,CDM,341,RC,78201,CPT,,,facility,outpatient,,,1602.00000,961.20000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LIVER SCAN W VASCULAR FLOW,73400020,CDM,341,RC,78202,CPT,,,facility,outpatient,,,2290.00000,1374.00000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,1717.50,fee schedule,
HC LIVER SPLEEN SCAN STATIC,73400022,CDM,341,RC,78215,CPT,,,facility,outpatient,,,1602.00000,961.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM HEPATOBILIARY IMG INCL GB,73400024,CDM,341,RC,78226,CPT,,,facility,outpatient,,,2378.00000,1426.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1783.50,fee schedule,
HC NM HEPATOBILIARY SYS IMAG W PHARM,73400025,CDM,341,RC,78227,CPT,,,facility,outpatient,,,2733.00000,1639.80000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,2049.75,fee schedule,
HC SALIVARY GLAND IMAGING,73400026,CDM,341,RC,78230,CPT,,,facility,outpatient,,,856.00000,513.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,171.37,1560.00,fee schedule,
HC NM ESOPHAGEAL SCAN,73400027,CDM,341,RC,78258,CPT,,,facility,outpatient,,,1567.00000,940.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM GASTR REFL STUDY,73400028,CDM,341,RC,78262,CPT,,,facility,outpatient,,,1230.00000,738.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,246.25,1560.00,fee schedule,
HC NM GASTRIC EMPTYING,73400029,CDM,341,RC,78264,CPT,,,facility,outpatient,,,2245.00000,1347.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1683.75,fee schedule,
HC NM GI BLEEDING,73400030,CDM,341,RC,78278,CPT,,,facility,outpatient,,,1042.00000,625.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,208.61,1560.00,fee schedule,
HC NM ABDOMEN MECKELS,73400031,CDM,341,RC,78290,CPT,,,facility,outpatient,,,1148.00000,688.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,229.83,1560.00,fee schedule,
HC NM PERITONEAL SHUNT PATENCY,73400032,CDM,341,RC,78291,CPT,,,facility,outpatient,,,1255.00000,753.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,251.25,1560.00,fee schedule,
HC NM BONE LTD,73400033,CDM,341,RC,78300,CPT,,,facility,outpatient,,,1784.00000,1070.40000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM BONE MULTI AREAS,73400034,CDM,341,RC,78305,CPT,,,facility,outpatient,,,2636.00000,1581.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE SCAN WHOLE BODY,73400035,CDM,341,RC,78306,CPT,,,facility,outpatient,,,2636.00000,1581.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1977.00,fee schedule,
HC NM BONE 3 PHASE,73400036,CDM,341,RC,78315,CPT,,,facility,outpatient,,,2497.00000,1498.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1872.75,fee schedule,
HC NM SPECT SINGLE REST STRESS,73400038,CDM,341,RC,78451,CPT,,,facility,outpatient,,,3876.00000,2325.60000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,257.00,2907.00,fee schedule,
HC NM SPECT MULTI STRESS REST,73400039,CDM,341,RC,78452,CPT,,,facility,outpatient,,,4844.00000,2906.40000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,257.00,3633.00,fee schedule,
HC MYOCARDIAL INFARCT SCAN,73400040,CDM,341,RC,78466,CPT,,,facility,outpatient,,,831.00000,498.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,166.37,1560.00,fee schedule,
HC NM CARD KINETIC REST,73400041,CDM,341,RC,78472,CPT,,,facility,outpatient,,,1439.00000,863.40000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENTILATION IMAGING,73400045,CDM,341,RC,78579,CPT,,,facility,outpatient,,,1294.00000,776.40000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM LUNG PERFUSION,73400046,CDM,341,RC,78580,CPT,,,facility,outpatient,,,1592.00000,955.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM PULM VENT AND PERF IMAGING,73400047,CDM,341,RC,78582,CPT,,,facility,outpatient,,,2486.00000,1491.60000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,1864.50,fee schedule,
HC NM PERF ONLY QUANTITATIVE,73400048,CDM,341,RC,78597,CPT,,,facility,outpatient,,,778.00000,466.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,155.76,1560.00,fee schedule,
HC NM VQ SCAN QUANTITATIVE,73400049,CDM,341,RC,78598,CPT,,,facility,outpatient,,,1464.00000,878.40000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM CSF SCAN CISTERN,73400053,CDM,341,RC,78630,CPT,,,facility,outpatient,,,864.00000,518.40000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,172.97,1560.00,fee schedule,
HC NM CSF SHUNT EVALUATION,73400054,CDM,341,RC,78645,CPT,,,facility,outpatient,,,1090.00000,654.00000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,218.22,1560.00,fee schedule,
HC NM CSF LEAK DETECT LOCALIZATION,73400055,CDM,341,RC,78650,CPT,,,facility,outpatient,,,799.00000,479.40000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,159.96,1560.00,fee schedule,
HC NM RENAL MORPHOLOGY,73400057,CDM,341,RC,78700,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,232.23,1560.00,fee schedule,
HC NM RENAL W VASCULAR FLOW,73400058,CDM,341,RC,78701,CPT,,,facility,outpatient,,,1321.00000,792.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC NM RENAL VASC AND FUNCTION,73400059,CDM,341,RC,78707,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,232.23,1560.00,fee schedule,
HC NM RENOGRAM W PHARMACOLOGICAL INTERVENTION,73400060,CDM,341,RC,78708,CPT,,,facility,outpatient,,,1611.00000,966.60000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC NM URETERAL REFLUX STUDY,73400064,CDM,341,RC,78740,CPT,,,facility,outpatient,,,1271.00000,762.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,254.45,1560.00,fee schedule,
HC NM TESTICULAR SCAN,73400065,CDM,341,RC,78761,CPT,,,facility,outpatient,,,923.00000,553.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,184.78,1560.00,fee schedule,
HC NM TUMOR LOC WB 1 DAY,73400068,CDM,341,RC,78802,CPT,,,facility,outpatient,,,2341.00000,1404.60000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,257.00,1755.75,fee schedule,
HC NM TUMOR LOC WB 2 OR MORE DAYS,73400070,CDM,341,RC,78804,CPT,,,facility,outpatient,,,2943.00000,1765.80000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,257.00,2207.25,fee schedule,
HC I131 SODIUM IODIDE CAPSULE TX PER MCI,73400089,CDM,344,RC,A9517,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,24.29,,,,,,,10.21,208.95,fee schedule,
HC IN111 PENETETATE DX PER 0.5MCI,73400101,CDM,343,RC,A9548,CPT,,,facility,outpatient,,,2030.00000,1218.00000,WellCare of North Carolina,Medicare Advantage,,751.05,,,,,,,406.41,2131.58,fee schedule,
HC IN111 PENTETRE PENTETREOTIDE DX PSD UP TO 6MCI,73400116,CDM,343,RC,A9572,CPT,,,facility,outpatient,,,2794.00000,1676.40000,WellCare of North Carolina,Medicare Advantage,,2010.34,,,,,,,559.36,9315.86,fee schedule,
HC I123 IOBENGUANE DX PSD UP TO 15MCI,73400122,CDM,343,RC,A9582,CPT,,,facility,outpatient,,,12493.00000,7495.80000,WellCare of North Carolina,Medicare Advantage,,2178.55,,,,,,,2012.57,12296.97,fee schedule,
HC NM RADIOPHARM TX ORAL ADM,73400123,CDM,342,RC,79005,CPT,,,facility,outpatient,,,1643.00000,985.80000,WellCare of North Carolina,Medicare Advantage,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX IV ADM,73400124,CDM,342,RC,79101,CPT,,,facility,outpatient,,,519.00000,311.40000,WellCare of North Carolina,Medicare Advantage,,233.41,,,,,,,103.90,1560.00,fee schedule,
HC NM IV RADPHARM MONOCLONAL ANTI,73400125,CDM,342,RC,79403,CPT,,,facility,outpatient,,,2033.00000,1219.80000,WellCare of North Carolina,Medicare Advantage,,233.41,,,,,,,215.63,1560.00,fee schedule,
HC NM RADIOPHARM TX INTRA ARTERIA,73400127,CDM,342,RC,79445,CPT,,,facility,outpatient,,,470.00000,282.00000,WellCare of North Carolina,Medicare Advantage,,233.41,,,,,,,94.09,1560.00,fee schedule,
HC SM153 LEXIDRONAM TX PTD UP TO 150MCI,73400135,CDM,344,RC,A9604,CPT,,,facility,outpatient,,,12371.00000,7422.60000,WellCare of North Carolina,Medicare Advantage,,4530.66,,,,,,,2476.67,39196.15,fee schedule,
HC NM THYROID UPTAKE MULTIPLE,73400145,CDM,341,RC,78012,CPT,,,facility,outpatient,,,677.00000,406.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,135.54,1560.00,fee schedule,
HC NM PHARM S1001 TRIAL,73400146,CDM,256,RC,A9543,CPT,,,facility,outpatient,,,1.01000,0.61000,WellCare of North Carolina,Medicare Advantage,,59665.78,,,,,,,0.20220,163224.30,fee schedule,
HC IN111 AUTO WBC DX PSD,73400194,CDM,343,RC,A9570,CPT,,,facility,outpatient,,,5280.00000,3168.00000,WellCare of North Carolina,Medicare Advantage,,1082.96,,,,,,,1000.45,10134.22,fee schedule,
HC F18 FLORBETAPIR DX PSD UP TO 10MCI AMYVID INJ,73400231,CDM,343,RC,A9586,CPT,,,facility,outpatient,,,6058.00000,3634.80000,WellCare of North Carolina,Medicare Advantage,,2304.35,,,,,,,1212.81,6878.34,fee schedule,
HC NM RADIONUCLIDE VASCULAR FLOW,73400246,CDM,341,RC,78445,CPT,,,facility,outpatient,,,1075.00000,645.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,215.22,1560.00,fee schedule,
HC NM BONE MARROW MULTIPLE,73400254,CDM,341,RC,78103,CPT,,,facility,outpatient,,,1428.00000,856.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC RADIUM RA223 DICHLORIDE TX PER MICROCURIE,73400255,CDM,344,RC,A9606,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Medicare Advantage,,180.83,,,,,,,61.06,479.07,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL TRANSIT,73400269,CDM,341,RC,78265,CPT,,,facility,outpatient,,,2016.00000,1209.60000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1560.00,fee schedule,
HC GASTRIC EMPTYING W SM BOWEL COLON TRANSIT MULTI DAYS,73400270,CDM,341,RC,78266,CPT,,,facility,outpatient,,,2016.00000,1209.60000,WellCare of North Carolina,Medicare Advantage,,560.57,,,,,,,257.00,1560.00,fee schedule,
HC FLUCICLOVINE F18 DX 1MCI,73400276,CDM,343,RC,A9588,CPT,,,facility,outpatient,,,487.00000,292.20000,WellCare of North Carolina,Medicare Advantage,,281.84,,,,,,,97.50,1243.67,fee schedule,
HC NM TUMOR LOC 1 AREA 1 DAY IMG,73400284,CDM,341,RC,78800,CPT,,,facility,outpatient,,,435.00000,261.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,87.09,1560.00,fee schedule,
HC NM TUMOR LOC 2 OR MORE AREAS 1 OR MORE DAYS OR 1 AREA IMG OVER 2 OR MORE DAYS,73400285,CDM,341,RC,78801,CPT,,,facility,outpatient,,,2240.00000,1344.00000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,1680.00,fee schedule,
HC NM TUMOR LOCAL SPECT 1 AREA 1 DAY IMG,73400286,CDM,341,RC,78803,CPT,,,facility,outpatient,,,1605.00000,963.00000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,257.00,1560.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY,73400287,CDM,341,RC,78830,CPT,,,facility,outpatient,,,3344.00000,2006.40000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400288,CDM,341,RC,78831,CPT,,,facility,outpatient,,,3344.00000,2006.40000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,257.00,2508.00,fee schedule,
HC NM LOCAL TUMOR INFLAMMATORY PROCESS ETC WITH SPECT WITH CT SINGLE DAY OR MULTIPLE AREA 2 OR MORE DAYS,73400289,CDM,341,RC,78832,CPT,,,facility,outpatient,,,3344.00000,2006.40000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,257.00,2508.00,fee schedule,
HC FLUOROESTRADIOL F18 DX 1 MCI,73400292,CDM,343,RC,A9591,CPT,,,facility,outpatient,,,1309.00000,785.40000,WellCare of North Carolina,Medicare Advantage,,523.60,,,,,,,262.06,1851.54,fee schedule,
HC COPPER CU64 DOTATATE DX 1 MCI,73400293,CDM,343,RC,A9592,CPT,,,facility,outpatient,,,1929.00000,1157.40000,WellCare of North Carolina,Medicare Advantage,,624.86,,,,,,,386.19,2316.93,fee schedule,
HC F18 PIFLUFOLASTAT PYLARIFY PER MCI,73400295,CDM,343,RC,A9595,CPT,,,facility,outpatient,,,1069.00000,641.40000,WellCare of North Carolina,Medicare Advantage,,349.06,,,,,,,214.01,1480.57,fee schedule,
HC LOCAMETZ GALLIUM GA 68 PSMA DX PER MCI,73400296,CDM,343,RC,A9800,CPT,,,facility,outpatient,,,1908.00000,1144.80000,WellCare of North Carolina,Medicare Advantage,,400.06,,,,,,,369.58,2435.93,fee schedule,
HC F18 FLOTUFOLASTAT POSLUMA DX 1 MCI,73400300,CDM,343,RC,A9608,CPT,,,facility,outpatient,,,1230.00000,738.00000,WellCare of North Carolina,Medicare Advantage,,704.78,,,,,,,246.25,1871.97,fee schedule,
HC CT HEART WO CONT W COR CAL SCORE,73500004,CDM,350,RC,75571,CPT,,,facility,outpatient,,,4018.00000,2410.80000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CT HEART W CONT 3D PP,73500005,CDM,350,RC,75572,CPT,,,facility,outpatient,,,3310.00000,1986.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CARD STRUCT MORPH W CONG DISEASE,73500006,CDM,350,RC,75573,CPT,,,facility,outpatient,,,4142.00000,2485.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA CARD STRUCT MORPH W CALC,73500007,CDM,350,RC,75574,CPT,,,facility,outpatient,,,4142.00000,2485.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2942.87,fee schedule,
HC CTA ABD AORTA AND BIL ILIEOFM W CONT,73500008,CDM,352,RC,75635,CPT,,,facility,outpatient,,,4062.00000,2437.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,3501.50,fee schedule,
HC CT UNLISTED DIAG INTERVENTNAL,73500011,CDM,350,RC,76497,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,64.86,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO CONT,73500016,CDM,351,RC,70450,CPT,,,facility,outpatient,,,2261.00000,1356.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT HEAD OR BRAIN W CONT,73500017,CDM,351,RC,70460,CPT,,,facility,outpatient,,,2668.00000,1600.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT HEAD OR BRAIN WO FLD W CONT,73500018,CDM,351,RC,70470,CPT,,,facility,outpatient,,,3264.00000,1958.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ORBIT SELLA PF WO CONT,73500019,CDM,351,RC,70480,CPT,,,facility,outpatient,,,2450.00000,1470.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ORBIT SELLA PF W CONT,73500020,CDM,351,RC,70481,CPT,,,facility,outpatient,,,2942.00000,1765.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2908.74,fee schedule,
HC CT ORBIT SELLA PF WO FLD W CONT,73500021,CDM,351,RC,70482,CPT,,,facility,outpatient,,,3282.00000,1969.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,3211.99,fee schedule,
HC CT MAXILLOFACIAL WO CONT,73500022,CDM,351,RC,70486,CPT,,,facility,outpatient,,,2536.00000,1521.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT MAXILLOFACIAL W CONT,73500023,CDM,351,RC,70487,CPT,,,facility,outpatient,,,3096.00000,1857.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT MAXILLOFACIAL WO FLD W CONT,73500024,CDM,351,RC,70488,CPT,,,facility,outpatient,,,3502.00000,2101.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT NECK SOFT TISSUE WO CONT,73500025,CDM,351,RC,70490,CPT,,,facility,outpatient,,,2584.00000,1550.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT SOFT TISSUE NECK W CONT,73500026,CDM,351,RC,70491,CPT,,,facility,outpatient,,,3082.00000,1849.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT SOFT TISSUE NECK WO FLD W CONT,73500027,CDM,351,RC,70492,CPT,,,facility,outpatient,,,3512.00000,2107.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA HEAD W CONT INCL NON CONT,73500028,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA NECK W CONT INCL NON CONT,73500029,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO CONT,73500030,CDM,352,RC,71250,CPT,,,facility,outpatient,,,2331.00000,1398.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC W CONT,73500031,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORAX DIAGNOSTIC WO FLD W CONT,73500032,CDM,352,RC,71270,CPT,,,facility,outpatient,,,3440.00000,2064.00000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA CHEST NONCOR WO W CONT,73500033,CDM,352,RC,71275,CPT,,,facility,outpatient,,,3874.00000,2324.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2942.40,fee schedule,
HC CT CERVICAL WO CONT,73500034,CDM,352,RC,72125,CPT,,,facility,outpatient,,,2872.00000,1723.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT CERVICAL W CONT,73500035,CDM,352,RC,72126,CPT,,,facility,outpatient,,,3618.00000,2170.80000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT CERVICAL WO FLD W CONT,73500036,CDM,352,RC,72127,CPT,,,facility,outpatient,,,3704.00000,2222.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO CONT,73500037,CDM,352,RC,72128,CPT,,,facility,outpatient,,,2242.00000,1345.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT THORACIC W CONT,73500038,CDM,352,RC,72129,CPT,,,facility,outpatient,,,2729.00000,1637.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT THORACIC WO FLD W CONT,73500039,CDM,352,RC,72130,CPT,,,facility,outpatient,,,3184.00000,1910.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LUMBAR WO CONT,73500040,CDM,352,RC,72131,CPT,,,facility,outpatient,,,2622.00000,1573.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LUMBAR W CONT,73500041,CDM,352,RC,72132,CPT,,,facility,outpatient,,,3189.00000,1913.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT LUMBAR WO FLD W CONT,73500042,CDM,352,RC,72133,CPT,,,facility,outpatient,,,3723.00000,2233.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA PELVIS W CONT INCL NON CONT,73500043,CDM,352,RC,72191,CPT,,,facility,outpatient,,,3018.00000,1810.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,3037.26,fee schedule,
HC CT PELVIS WO CONT,73500044,CDM,352,RC,72192,CPT,,,facility,outpatient,,,2292.00000,1375.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT PELVIS W CONT,73500045,CDM,352,RC,72193,CPT,,,facility,outpatient,,,2865.00000,1719.00000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT PELVIS WO FLD W CONT,73500046,CDM,352,RC,72194,CPT,,,facility,outpatient,,,3071.00000,1842.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT UE WO CONT,73500047,CDM,352,RC,73200,CPT,,,facility,outpatient,,,2934.00000,1760.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT UE W CONT,73500048,CDM,352,RC,73201,CPT,,,facility,outpatient,,,4022.00000,2413.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT UE WO FLD W CONT,73500049,CDM,352,RC,73202,CPT,,,facility,outpatient,,,4343.00000,2605.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA UE W CONT W NON CONT,73500050,CDM,352,RC,73206,CPT,,,facility,outpatient,,,3974.00000,2384.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,3356.74,fee schedule,
HC CT LE WO CONT,73500051,CDM,352,RC,73700,CPT,,,facility,outpatient,,,2511.00000,1506.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT LE W CONT,73500052,CDM,352,RC,73701,CPT,,,facility,outpatient,,,3231.00000,1938.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT LE  WO FLD W CONT,73500053,CDM,352,RC,73702,CPT,,,facility,outpatient,,,4235.00000,2541.00000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,3008.52,fee schedule,
HC CTA LE W CONT AND INCL NON CONT,73500054,CDM,352,RC,73706,CPT,,,facility,outpatient,,,4927.00000,2956.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,3500.13,fee schedule,
HC CT ABDOMEN WO CONT,73500055,CDM,352,RC,74150,CPT,,,facility,outpatient,,,2494.00000,1496.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT ABDOMEN W CONT,73500056,CDM,352,RC,74160,CPT,,,facility,outpatient,,,3174.00000,1904.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ABDOMEN WO W CONT,73500057,CDM,352,RC,74170,CPT,,,facility,outpatient,,,3758.00000,2254.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CTA ABD PELVIS W CONT W NON CONT,73500058,CDM,352,RC,74174,CPT,,,facility,outpatient,,,7361.00000,4416.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,4490.21,fee schedule,
HC CT ABD PELVIS WO CONT,73500060,CDM,352,RC,74176,CPT,,,facility,outpatient,,,5355.00000,3213.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,3266.55,fee schedule,
HC CT ABD PELVIS W CONT,73500061,CDM,352,RC,74177,CPT,,,facility,outpatient,,,6379.00000,3827.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3891.19,fee schedule,
HC CT ABD PELVIS WO W CONT,73500062,CDM,352,RC,74178,CPT,,,facility,outpatient,,,7415.00000,4449.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,4523.15,fee schedule,
HC CT LIMITED OR LOCALIZED FOLLOW UP,73500063,CDM,352,RC,76380,CPT,,,facility,outpatient,,,1309.00000,785.40000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,84.71,2905.00,fee schedule,
HC CTA ABDOMEN W CONT W NONCONT,73500068,CDM,352,RC,74175,CPT,,,facility,outpatient,,,4059.00000,2435.40000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,3052.31,fee schedule,
HC CTA NECK W CONT,73500072,CDM,351,RC,70498,CPT,,,facility,outpatient,,,3971.00000,2382.60000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT ANGIO HEAD W CONT,73500073,CDM,351,RC,70496,CPT,,,facility,outpatient,,,4188.00000,2512.80000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT RESEARCH STUDY,73500077,CDM,352,RC,71260,CPT,,,facility,outpatient,,,2925.00000,1755.00000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT,73500084,CDM,350,RC,0633T,CPT,,,facility,outpatient,,,1173.00000,703.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL W CONT,73500085,CDM,350,RC,0634T,CPT,,,facility,outpatient,,,1332.00000,799.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING UNIL WO CONT FLD W CONT,73500086,CDM,350,RC,0635T,CPT,,,facility,outpatient,,,1332.00000,799.20000,WellCare of North Carolina,Medicare Advantage,,185.40,,,,,,,171.27,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT,73500087,CDM,350,RC,0636T,CPT,,,facility,outpatient,,,1450.00000,870.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL W CONT,73500088,CDM,350,RC,0637T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC CT BREAST W 3D RENDERING BIL WO CONT FLD CONT,73500089,CDM,350,RC,0638T,CPT,,,facility,outpatient,,,1764.00000,1058.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2905.00,fee schedule,
HC AUTOMATED QUANTIFICATION CT ANGIO CORONARY ATHEROSCLEROTIC PLAQUE COMPUTERIZED ANALYSIS OF DATA,73500091,CDM,350,RC,0625T,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Medicare Advantage,,989.88,,,,,,,95.09,2905.00,fee schedule,
HC PROC TUBE THORACOSTOMY,73600001,CDM,361,RC,32551,CPT,,,facility,outpatient,,,337.00000,202.20000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,67.47,4376.00,fee schedule,
HC PERC J TUBE PLACEMENT,73600011,CDM,361,RC,44372,CPT,,,facility,outpatient,,,269.00000,161.40000,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,53.85,5152.00,fee schedule,
HC CONVERSION G TUBE TO J TUBE,73600012,CDM,361,RC,44373,CPT,,,facility,outpatient,,,728.00000,436.80000,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,145.75,5152.00,fee schedule,
HC BILIARY BRUSHING VIA PERC CAT,73600014,CDM,361,RC,47552,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Medicare Advantage,,6498.27,,,,,,,125.93,8045.00,fee schedule,
HC INSERT INTRAPERITONEAL TEMP,73600015,CDM,361,RC,49421,CPT,,,facility,outpatient,,,1993.00000,1195.80000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,399.00,8045.00,fee schedule,
HC DISK A DECOMPRESS LUMBAR,73600017,CDM,361,RC,62287,CPT,,,facility,outpatient,,,5105.00000,3063.00000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,1022.02,17457.00,fee schedule,
HC AMNIOCENTESIS DIAG,73600022,CDM,361,RC,59000,CPT,,,facility,outpatient,,,1387.00000,832.20000,WellCare of North Carolina,Medicare Advantage,,906.81,,,,,,,277.68,4311.00,fee schedule,
HC CT SPINE BIOPSY,73600024,CDM,361,RC,62269,CPT,,,facility,outpatient,,,880.00000,528.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,176.18,4311.00,fee schedule,
HC CREATION OF A V FISTULA AUTO GENOUS GRAFT,73600026,CDM,481,RC,36825,CPT,,,facility,outpatient,,,4857.00000,2914.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CREATION OF A V FISTULA GRAFT NONAUTOGENOUS GRAFT,73600027,CDM,481,RC,36830,CPT,,,facility,outpatient,,,4857.00000,2914.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,972.37,13852.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE SUPERFICIAL,73600057,CDM,360,RC,21920,CPT,,,facility,outpatient,,,1110.00000,666.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,222.22,4311.00,fee schedule,
HC CT BIOPSY BACK FLANK SOFT TISSUE DEEP,73600058,CDM,360,RC,21925,CPT,,,facility,outpatient,,,2999.00000,1799.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,600.40,5754.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,361,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,31.03,4311.00,fee schedule,
HC ASPIR HEMATOMA ABCES BUL CYST,73610001,CDM,761,RC,10160,CPT,,,facility,outpatient,,,155.00000,93.00000,WellCare of North Carolina,Medicare Advantage,,416.08,,,,,,,29.22,4311.00,fee schedule,
HC INJ TREATMENT OF PSEUDOANEURYSM EXT,73610002,CDM,361,RC,36002,CPT,,,facility,outpatient,,,421.00000,252.60000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,84.28,4311.00,fee schedule,
HC RF ABLATION LIVER TUMOR PERC,73610004,CDM,361,RC,47382,CPT,,,facility,outpatient,,,2921.00000,1752.60000,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,584.78,13852.00,fee schedule,
HC BILIARY BIOPSY PERC CATH,73610009,CDM,361,RC,47553,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Medicare Advantage,,6498.27,,,,,,,125.93,13852.00,fee schedule,
HC EXCHANGE DRAIN CATH ABS CYS,73610011,CDM,361,RC,49423,CPT,,,facility,outpatient,,,232.00000,139.20000,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,46.45,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE OR CECOSTOMY UNDER FLUORO,73610013,CDM,361,RC,49450,CPT,,,facility,outpatient,,,481.00000,288.60000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,96.30,4311.00,fee schedule,
HC CHANGE URETERAL STENT ILEAL CONDUIT,73610017,CDM,361,RC,50688,CPT,,,facility,outpatient,,,1109.00000,665.40000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,222.02,4311.00,fee schedule,
HC BIOPSY NEEDLE MUSCLE PERC,73610033,CDM,361,RC,20206,CPT,,,facility,outpatient,,,1400.00000,840.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,280.28,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,361,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,316.72,4311.00,fee schedule,
HC BX NDL BONE TROCAR SUPERFICIAL,73610034,CDM,761,RC,20220,CPT,,,facility,outpatient,,,1582.00000,949.20000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,298.21,4311.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,361,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,466.47,5152.00,fee schedule,
HC BX NDL BONE TROCAR DEEP,73610035,CDM,761,RC,20225,CPT,,,facility,outpatient,,,2330.00000,1398.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,439.20,4376.00,fee schedule,
HC INJECTION SINUS TRACT THERAPEUTIC,73610036,CDM,361,RC,20500,CPT,,,facility,outpatient,,,311.00000,186.60000,WellCare of North Carolina,Medicare Advantage,,1542.65,,,,,,,62.26,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,361,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,160.96,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ SMALL JNT OR BURSA WO US GUIDE,73610038,CDM,761,RC,20600,CPT,,,facility,outpatient,,,804.00000,482.40000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,151.55,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIR INJ INTERMEDIATE JNT OR BURSA WO US GUIDE,73610039,CDM,761,RC,20605,CPT,,,facility,outpatient,,,722.00000,433.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,136.10,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,361,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,115.52,4311.00,fee schedule,
HC ARTHROCENTESIS A IR INJ MAJOR JNT OR BURSA W/O US GUIDE,73610040,CDM,761,RC,20610,CPT,,,facility,outpatient,,,577.00000,346.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,108.76,4311.00,fee schedule,
HC RFA ABLAT BONE TUM W CONT,73610041,CDM,361,RC,20982,CPT,,,facility,outpatient,,,4720.00000,2832.00000,WellCare of North Carolina,Medicare Advantage,,13399.92,,,,,,,944.94,13527.54,fee schedule,
HC CRYOABL MUSCULOSKELETAL,73610042,CDM,361,RC,20999,CPT,,,facility,outpatient,,,3377.00000,2026.20000,WellCare of North Carolina,Medicare Advantage,,249.82,,,,,,,173.00,4311.00,fee schedule,
HC BX SOFT TISSUE NECK OR THORAX,73610044,CDM,361,RC,21550,CPT,,,facility,outpatient,,,712.00000,427.20000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,142.54,4311.00,fee schedule,
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,73610068,CDM,361,RC,28820,CPT,,,facility,outpatient,,,3019.00000,1811.40000,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC AMPUTATION TOE INTERPHALANGEAL JOINT,73610069,CDM,361,RC,28825,CPT,,,facility,outpatient,,,3019.00000,1811.40000,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,604.40,5754.00,fee schedule,
HC BIOPSY PLEURA PERC NEEDLE,73610072,CDM,361,RC,32400,CPT,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,60.06,4311.00,fee schedule,
HC INSERT INDWELLING TUNNEL PLEURAL CATH W CUFF,73610074,CDM,361,RC,32550,CPT,,,facility,outpatient,,,1943.00000,1165.80000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,388.99,17457.00,fee schedule,
HC REMOVAL TUNNELED PLEURAL CATH,73610075,CDM,361,RC,32552,CPT,,,facility,outpatient,,,1464.00000,878.40000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,293.09,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE INTRATHORACIC,73610076,CDM,361,RC,32553,CPT,,,facility,outpatient,,,834.00000,500.40000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,166.97,9350.00,fee schedule,
HC THORACENTESIS NLD CATH W IMAGE,73610077,CDM,361,RC,32555,CPT,,,facility,outpatient,,,1623.00000,973.80000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,324.92,4311.00,fee schedule,
HC PLEURAL DRAIN W CATH W IMAGE GUIDANCE,73610078,CDM,361,RC,32557,CPT,,,facility,outpatient,,,1770.00000,1062.00000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,354.35,4376.00,fee schedule,
HC LASER ABLATION INCOMPETENT VEIN 1ST,73610105,CDM,361,RC,36478,CPT,,,facility,outpatient,,,5059.00000,3035.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1012.81,17457.00,fee schedule,
HC INSERT NON TUNNEL CVC UNDER 5YRS,73610109,CDM,361,RC,36555,CPT,,,facility,outpatient,,,818.00000,490.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,163.76,4311.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP UNDER 5YRS,73610110,CDM,361,RC,36557,CPT,,,facility,outpatient,,,742.00000,445.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,148.55,13852.00,fee schedule,
HC INSERT TUNNEL CVC WO SUBQ PORT PUMP 5YRS AND OLDER,73610111,CDM,361,RC,36558,CPT,,,facility,outpatient,,,2247.00000,1348.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,449.85,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT UNDER 5 YRS,73610112,CDM,361,RC,36560,CPT,,,facility,outpatient,,,742.00000,445.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,148.55,8045.00,fee schedule,
HC INSERT TUNNEL CVC W SUBQ PORT 5YRS AND OLDER,73610113,CDM,361,RC,36561,CPT,,,facility,outpatient,,,3723.00000,2233.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,745.34,8045.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE UNDER 5YRS,73610114,CDM,361,RC,36568,CPT,,,facility,outpatient,,,886.00000,531.60000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,177.38,4311.00,fee schedule,
HC PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610115,CDM,361,RC,36569,CPT,,,facility,outpatient,,,686.00000,411.60000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,137.34,4311.00,fee schedule,
HC REPAIR TUNNEL OR  NONTUNNEL CVC WO PORT PUMP,73610118,CDM,361,RC,36575,CPT,,,facility,outpatient,,,195.00000,117.00000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,39.04,5152.00,fee schedule,
HC REPAIR TUNNEL OR NONTUNNEL CVC W PORT PUMP,73610119,CDM,361,RC,36576,CPT,,,facility,outpatient,,,533.00000,319.80000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,106.71,5152.00,fee schedule,
HC REPLACE TUNNEL CATH CVAD W SUBQ PORT PUMP,73610120,CDM,361,RC,36578,CPT,,,facility,outpatient,,,555.00000,333.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,111.11,8045.00,fee schedule,
HC REPLACE COMPLETE NONTUNNEL CVC WO SUBQ PORT PUMP,73610121,CDM,361,RC,36580,CPT,,,facility,outpatient,,,590.00000,354.00000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,118.12,4311.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVC WO SUBQ PORT PUMP,73610122,CDM,361,RC,36581,CPT,,,facility,outpatient,,,583.00000,349.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,116.72,8045.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PUMP,73610123,CDM,361,RC,36583,CPT,,,facility,outpatient,,,665.00000,399.00000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,133.13,13852.00,fee schedule,
HC REPLACE COMPLETE TUNNEL CVAD W SUBQ PORT,73610124,CDM,361,RC,36582,CPT,,,facility,outpatient,,,4163.00000,2497.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,833.43,8045.00,fee schedule,
HC REPLACE COMPLETE PICC WO SUBQ PORT PUMP,73610125,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2128.00000,1276.80000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,426.03,4311.00,fee schedule,
HC REMOVAL TUNNEL CVC WO SUBQ PORT PUMP,73610127,CDM,361,RC,36589,CPT,,,facility,outpatient,,,1343.00000,805.80000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,268.87,4311.00,fee schedule,
HC REMOVAL TUNNEL CVAD W SUBQ PORT PUMP CENTRAL OR PERIPHERAL INSERTION,73610128,CDM,361,RC,36590,CPT,,,facility,outpatient,,,1464.00000,878.40000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,293.09,4311.00,fee schedule,
HC MECHANICAL REMOVAL PERICATH OBSTRUCTIVE MATERIAL,73610129,CDM,361,RC,36595,CPT,,,facility,outpatient,,,694.00000,416.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,138.94,8442.00,fee schedule,
HC MECHANICAL REMOVAL INTRALUMINAL OBSTRUCTIVE MATERIAL,73610130,CDM,361,RC,36596,CPT,,,facility,outpatient,,,587.00000,352.20000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,117.52,4311.00,fee schedule,
HC REPOSITION PREV CVC W FLUORO,73610131,CDM,361,RC,36597,CPT,,,facility,outpatient,,,606.00000,363.60000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,121.32,4311.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,361,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,173.00,4376.00,fee schedule,
HC CONTRAST INJ CVA DEVICE W FLUORO,73610132,CDM,761,RC,36598,CPT,,,facility,outpatient,,,884.00000,530.40000,WellCare of North Carolina,Medicare Advantage,,219.42,,,,,,,166.63,4376.00,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,361,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PRIMARY PTMT NONCOR INITIAL W FLUORO GUIDANCE,73610135,CDM,481,RC,37184,CPT,,,facility,outpatient,,,14058.00000,8434.80000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,2814.41,18878.80,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,361,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INCL INJ AND FLUORO GUIDANCE,73610138,CDM,481,RC,37187,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2104.90,15260.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,361,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,2104.90,17457.00,fee schedule,
HC PTMT INJ AND FLUORO REPEAT TX,73610139,CDM,481,RC,37188,CPT,,,facility,outpatient,,,10514.00000,6308.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,2104.90,15260.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,361,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC INSERT IVC FILTER W S AND I INCLD IMAGE GUIDANCE,73610140,CDM,481,RC,37191,CPT,,,facility,outpatient,,,11452.00000,6871.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,2292.69,13852.00,fee schedule,
HC REPOSITION IVC FILTER W S AND I INCL IMAGE GUIDANCE,73610141,CDM,361,RC,37192,CPT,,,facility,outpatient,,,7673.00000,4603.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1536.13,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,361,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1581.98,8045.00,fee schedule,
HC RETRIEVAL IVC FILTER ENDOVASC APPROACH W S AND I INCLD IMAGE GUIDANCE,73610142,CDM,481,RC,37193,CPT,,,facility,outpatient,,,7902.00000,4741.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1581.98,9423.00,fee schedule,
HC INTRAVASCULAR FOREIGN BODY RETRIEVAL,73610143,CDM,481,RC,37197,CPT,,,facility,outpatient,,,4800.00000,2880.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,960.96,9423.00,fee schedule,
HC TRANSCATHETER BIOPSY VASCULAR,73610144,CDM,361,RC,37200,CPT,,,facility,outpatient,,,4471.00000,2682.60000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,895.09,13852.00,fee schedule,
HC STENT PLACEMENT INITIAL ARTERY OTHER THAN LOWER EXT CAROTIDS VERT,73610146,CDM,481,RC,37236,CPT,,,facility,outpatient,,,6062.00000,3637.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,1213.61,24600.00,fee schedule,
HC TRANSCTH THROMBOTHRPY ART INT,73610149,CDM,481,RC,37211,CPT,,,facility,outpatient,,,4394.00000,2636.40000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,879.68,13852.00,fee schedule,
HC CRYO ABLATION VASCULAR MALFORMATION,73610150,CDM,361,RC,37799,CPT,,,facility,outpatient,,,2417.00000,1450.20000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,483.88,4376.00,fee schedule,
HC BONE MARROW BIOPSY,73610153,CDM,361,RC,38221,CPT,,,facility,outpatient,,,2475.00000,1485.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,495.50,4311.00,fee schedule,
HC BIOPSY LYMPH NODE SUPERFICIAL,73610154,CDM,361,RC,38505,CPT,,,facility,outpatient,,,1613.00000,967.80000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,322.92,4311.00,fee schedule,
HC INJECTION ID SENTINEL NODE,73610156,CDM,361,RC,38792,CPT,,,facility,outpatient,,,792.00000,475.20000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,158.56,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY HEMIC LYMPH,73610157,CDM,361,RC,38999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Medicare Advantage,,455.29,,,,,,,173.00,4311.00,fee schedule,
HC PLACEMENT NG OR OG TUBE INCL FLUORO,73610162,CDM,361,RC,43752,CPT,,,facility,outpatient,,,482.00000,289.20000,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,96.50,4376.00,fee schedule,
HC INTRO LONG GI TUBE,73610165,CDM,361,RC,44500,CPT,,,facility,outpatient,,,282.00000,169.20000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,56.46,4121.00,fee schedule,
HC CRYOABL LIVER 1 OR MORE TUMORS PERCUT,73610172,CDM,361,RC,47383,CPT,,,facility,outpatient,,,5294.00000,3176.40000,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,1059.86,17457.00,fee schedule,
HC PERC CHOLECYSTOSTOMY COMP INCL GUIDANCE,73610173,CDM,361,RC,47490,CPT,,,facility,outpatient,,,1277.00000,766.20000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,255.66,8045.00,fee schedule,
HC PERC BILIARY METALLIC STENT,73610176,CDM,361,RC,47556,CPT,,,facility,outpatient,,,7494.00000,4496.40000,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,1500.30,17457.00,fee schedule,
HC BIOPSY PANCREAS PERCUTANEOUS NEEDLE,73610178,CDM,361,RC,48102,CPT,,,facility,outpatient,,,395.00000,237.00000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,79.08,4311.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,361,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,328.33,4376.00,fee schedule,
HC ABD PARACENTESIS INCL IMAGING,73610183,CDM,761,RC,49083,CPT,,,facility,outpatient,,,1640.00000,984.00000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,309.14,4376.00,fee schedule,
HC BIOPSY ABD OR RETROPERITONEAL PERCUTANEOUS NEEDLE,73610184,CDM,361,RC,49180,CPT,,,facility,outpatient,,,2136.00000,1281.60000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,427.63,4311.00,fee schedule,
HC PLACEMENT INTERSTITIAL DEVICE PERC INTRA ABD PEL RETROPERI,73610185,CDM,761,RC,49411,CPT,,,facility,outpatient,,,911.00000,546.60000,WellCare of North Carolina,Medicare Advantage,,1424.94,,,,,,,171.72,4311.00,fee schedule,
HC INSERT TUNNEL INTRAPERITONEAL CATH INCL IMAGING,73610186,CDM,361,RC,49418,CPT,,,facility,outpatient,,,3077.00000,1846.20000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,616.02,17457.00,fee schedule,
HC REMOVAL TUNNEL INTRAPERITONEAL CATH,73610188,CDM,361,RC,49422,CPT,,,facility,outpatient,,,2239.00000,1343.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,448.25,8045.00,fee schedule,
HC PERC INSERT GASTROSTOMY TUBE INCL FLUORO GUIDANCE,73610190,CDM,361,RC,49440,CPT,,,facility,outpatient,,,535.00000,321.00000,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,107.11,4376.00,fee schedule,
HC PERCUTANEOUS INSERT JEJUN OR DUOD TUBE INCL FLUORO GUIDANCE,73610191,CDM,361,RC,49441,CPT,,,facility,outpatient,,,1016.00000,609.60000,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,203.40,4376.00,fee schedule,
HC CONVERSION G TUBE TO GJ TUBE INCL FLUORO GUIDANCE,73610193,CDM,361,RC,49446,CPT,,,facility,outpatient,,,3854.00000,2312.40000,WellCare of North Carolina,Medicare Advantage,,1975.59,,,,,,,771.57,4311.00,fee schedule,
HC REPLACE D OR J TUBE INCL FLUORO GUIDANCE,73610194,CDM,361,RC,49451,CPT,,,facility,outpatient,,,642.00000,385.20000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC REPLACE G OR J TUBE INCL FLUORO GUIDANCE,73610195,CDM,361,RC,49452,CPT,,,facility,outpatient,,,802.00000,481.20000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,160.56,4311.00,fee schedule,
HC MECHANICAL REMOVAL OBSTRUCTIVE MATERIAL G OR J OR GJ INCL FLUORO GUIDANCE,73610196,CDM,361,RC,49460,CPT,,,facility,outpatient,,,642.00000,385.20000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,128.53,4311.00,fee schedule,
HC INJECTION EXISTING G OR J OR GJ INCL GUIDE,73610197,CDM,361,RC,49465,CPT,,,facility,outpatient,,,695.00000,417.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,139.14,4311.00,fee schedule,
HC CRYOABL ABD PERI OMENTUM,73610199,CDM,361,RC,49999,CPT,,,facility,outpatient,,,5294.00000,3176.40000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,902.01,4311.00,fee schedule,
HC BIOPSY RENAL PERC BY TROCAR OR NEEDLE,73610201,CDM,361,RC,50200,CPT,,,facility,outpatient,,,2378.00000,1426.80000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,476.08,4311.00,fee schedule,
HC REMOVE AND REPLACE INDWELL URETERAL STENT PERCUTANEOUS,73610202,CDM,361,RC,50382,CPT,,,facility,outpatient,,,2502.00000,1501.20000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,500.90,5754.00,fee schedule,
HC REMOVE INDWELL URETERAL STENT PERC,73610203,CDM,361,RC,50384,CPT,,,facility,outpatient,,,2478.00000,1486.80000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,496.10,5754.00,fee schedule,
HC REMOVE REPLACE EXT URETERAL STENT INCL FLUORO GUIDANCE,73610206,CDM,361,RC,50387,CPT,,,facility,outpatient,,,636.00000,381.60000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,127.33,5152.00,fee schedule,
HC REMOVE NEPHROSTOMY TUBE INCL FLUORO GUIDANCE,73610207,CDM,361,RC,50389,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,232.23,4311.00,fee schedule,
HC INJECTION ASPIRATION RENAL PELVIC CYST BY PERCUTANEOUS NEEDLE,73610208,CDM,361,RC,50390,CPT,,,facility,outpatient,,,175.00000,105.00000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,35.03,4311.00,fee schedule,
HC RF ABLATION RENAL TUMOR UNIL PERC,73610213,CDM,361,RC,50592,CPT,,,facility,outpatient,,,6291.00000,3774.60000,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,1259.46,13852.00,fee schedule,
HC CRYOABL RENAL TUMOR UNIL PERC,73610214,CDM,361,RC,50593,CPT,,,facility,outpatient,,,7767.00000,4660.20000,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,1554.95,17457.00,fee schedule,
HC ASPIR BLADDER W SUPRAPUBIC CATH,73610219,CDM,361,RC,51102,CPT,,,facility,outpatient,,,2491.00000,1494.60000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,498.70,5754.00,fee schedule,
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,73610222,CDM,761,RC,51702,CPT,,,facility,outpatient,,,208.00000,124.80000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,39.21,4311.00,fee schedule,
HC CHANGE CYSTOSTOMY TUBE SIMPLE,73610223,CDM,361,RC,51705,CPT,,,facility,outpatient,,,404.00000,242.40000,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,80.88,4311.00,fee schedule,
HC ABLATION SCLEROTHERAPY FEMALE,73610230,CDM,361,RC,58999,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Medicare Advantage,,209.51,,,,,,,173.00,4311.00,fee schedule,
HC BIOPSY NEEDLE THYROID CORE,73610238,CDM,361,RC,60100,CPT,,,facility,outpatient,,,202.00000,121.20000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,40.44,4311.00,fee schedule,
HC C1 C2 PUNCTURE W INJECTION SUBARACH ACE,73610239,CDM,361,RC,61055,CPT,,,facility,outpatient,,,1592.00000,955.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ENDOVASC TEMP BALLOON ARTERIAL OCCLUSION HEAD NECK,73610240,CDM,361,RC,61623,CPT,,,facility,outpatient,,,4497.00000,2698.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,900.30,24600.00,fee schedule,
HC EMBOLIZATION OCCLUSION EXTRACRANIAL INN,73610242,CDM,361,RC,61626,CPT,,,facility,outpatient,,,2921.00000,1752.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,584.78,24600.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,361,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,211.21,4311.00,fee schedule,
HC PERC ASPIRATION INTERVERTEBRAL DISC OR PARAVERTEBRAL TISSUE,73610248,CDM,761,RC,62267,CPT,,,facility,outpatient,,,1055.00000,633.00000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,198.87,4311.00,fee schedule,
HC LUMBAR PUNCTURE DIAGNOSTIC,73610249,CDM,361,RC,62270,CPT,,,facility,outpatient,,,1471.00000,882.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,294.49,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,361,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,383.98,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID TRANSFORAMINAL EPIDURAL C T 1 LEVEL W IMG GUIDE,73610253,CDM,761,RC,64479,CPT,,,facility,outpatient,,,1918.00000,1150.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,361.54,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,361,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,502.70,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT AND OR STEROID L S 1LVL W IMAGE GUIDANCE,73610255,CDM,761,RC,64483,CPT,,,facility,outpatient,,,2511.00000,1506.60000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,473.32,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,361,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,347.95,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET C T SGL LVL,73610257,CDM,761,RC,64490,CPT,,,facility,outpatient,,,1738.00000,1042.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,327.61,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,361,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,316.92,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT PV FACET L S SGL LVL,73610258,CDM,761,RC,64493,CPT,,,facility,outpatient,,,1583.00000,949.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,298.40,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,361,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,303.30,4311.00,fee schedule,
HC INJECTION ANESTHETIC AGENT CELIAC PLEXUS,73610261,CDM,761,RC,64530,CPT,,,facility,outpatient,,,1515.00000,909.00000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,285.58,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,361,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,302.10,4311.00,fee schedule,
HC DESTRUCTION INTERCOSTAL NERVE,73610262,CDM,761,RC,64620,CPT,,,facility,outpatient,,,1509.00000,905.40000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,284.45,4311.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,361,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,665.06,9350.00,fee schedule,
HC DESTRUCTION PV FACET JOINT NERVE LS SGL W IMAGE GUIDANCE,73610263,CDM,761,RC,64635,CPT,,,facility,outpatient,,,3322.00000,1993.20000,WellCare of North Carolina,Medicare Advantage,,2033.68,,,,,,,626.20,4311.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,361,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,363.96,5152.00,fee schedule,
HC DESTRUCTION NEUROLYTIC AGENT CELIAC PLEXUS,73610265,CDM,761,RC,64680,CPT,,,facility,outpatient,,,1818.00000,1090.80000,WellCare of North Carolina,Medicare Advantage,,927.18,,,,,,,342.69,4376.00,fee schedule,
HC ABLATION SCLEROTHERAPY NERVOUS SYSTEM,73610266,CDM,361,RC,64999,CPT,,,facility,outpatient,,,2306.00000,1383.60000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC INCISION AND DRAINAGE PERIRECTAL ABSCESS,73610269,CDM,761,RC,46040,CPT,,,facility,outpatient,,,4857.00000,2914.20000,WellCare of North Carolina,Medicare Advantage,,1227.93,,,,,,,915.54,6735.00,fee schedule,
HC PERC AUGMENT SACRAL INJ UNIL 1 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610273,CDM,361,RC,0200T,CPT,,,facility,outpatient,,,2841.00000,1704.60000,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,568.77,12408.00,fee schedule,
HC PERC AUGMENT SACRAL INJ BIL 2 OR MORE NEEDLES W BIOPSY W IMAGE GUIDANCE,73610274,CDM,361,RC,0201T,CPT,,,facility,outpatient,,,2990.00000,1794.00000,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,598.60,17457.00,fee schedule,
HC ATHERECTOMY BRACHCPHLC BRCH W S AND I,73610278,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,20137.00000,12082.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4031.43,24600.00,fee schedule,
HC CT RENAL BIOPSY,73610290,CDM,361,RC,0237T,CPT,,,facility,outpatient,,,10706.00000,6423.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2143.34,24600.00,fee schedule,
HC NEEDLE LOC BREAST INITIAL,73610316,CDM,361,RC,10035,CPT,,,facility,outpatient,,,1074.00000,644.40000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,215.01,5152.00,fee schedule,
HC PLACEMENT METAL CLIP DURING LYMPH NODE BIOPSY,73610322,CDM,361,RC,38999,CPT,,,facility,outpatient,,,693.00000,415.80000,WellCare of North Carolina,Medicare Advantage,,455.29,,,,,,,138.74,4311.00,fee schedule,
HC US GUIDANCE CYST ASPIRATION BREAST BIL,73610323,CDM,361,RC,19000,CPT,,,facility,outpatient,,,776.00000,465.60000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,155.36,4311.00,fee schedule,
HC BX BRST PLC LOC DEV 1LES W STG,73610326,CDM,361,RC,19081,CPT,,,facility,outpatient,,,5458.00000,3274.80000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,1092.69,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610328,CDM,361,RC,19083,CPT,,,facility,outpatient,,,4719.00000,2831.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,944.74,6649.00,fee schedule,
HC BIOPSY BREAST PLACE LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610330,CDM,361,RC,19085,CPT,,,facility,outpatient,,,4864.00000,2918.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,973.77,6735.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MAMMO GUIDANCE,73610332,CDM,361,RC,19281,CPT,,,facility,outpatient,,,1688.00000,1012.80000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,337.94,4376.00,fee schedule,
HC CRYOABL PULM TUM INCLD GUID,73610334,CDM,361,RC,32994,CPT,,,facility,outpatient,,,7462.00000,4477.20000,WellCare of North Carolina,Medicare Advantage,,10842.57,,,,,,,1493.89,13852.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W US GUIDANCE,73610336,CDM,361,RC,19285,CPT,,,facility,outpatient,,,1990.00000,1194.00000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,398.40,4376.00,fee schedule,
HC PLACE BREAST LOCALIZATION DEVICE 1 LESION W MRI GUIDANCE,73610338,CDM,361,RC,19287,CPT,,,facility,outpatient,,,2653.00000,1591.80000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,531.13,6735.00,fee schedule,
HC VASCULAR EMBOLIZATION OR OCCLUSION VENOUS OTHER THAN HEMMORRHAGE INCLD SI IMG GUIDE ROADMAPPING,73610445,CDM,481,RC,37241,CPT,,,facility,outpatient,,,4187.00000,2512.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,838.24,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL NOT HEMORRHAGE,73610446,CDM,481,RC,37242,CPT,,,facility,outpatient,,,13279.00000,7967.40000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,2658.46,24600.00,fee schedule,
HC EMBOLIZATION ARTERIAL OR VENOUS HEMORRHAGE,73610447,CDM,481,RC,37244,CPT,,,facility,outpatient,,,8848.00000,5308.80000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,1771.37,24600.00,fee schedule,
HC PLC BRST LOC DEV 1LES W STG,73610448,CDM,361,RC,19283,CPT,,,facility,outpatient,,,3479.00000,2087.40000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,676.91,4376.00,fee schedule,
HC REMOVAL OF FOREIGN BODY PERITONEAL CAVITY,73610453,CDM,361,RC,49402,CPT,,,facility,outpatient,,,1241.00000,744.60000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,248.45,8045.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,361,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION SMALL JOINT OR BURSA W US GUIDANCE,73610455,CDM,761,RC,20604,CPT,,,facility,outpatient,,,1696.00000,1017.60000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,361,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,375.58,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION INTERMEDIATE JOINT OR BURSA W US GUIDANCE,73610456,CDM,761,RC,20606,CPT,,,facility,outpatient,,,1876.00000,1125.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,353.63,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,361,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,173.00,4311.00,fee schedule,
HC ARTHROCENTESIS ASPIRATION INJECTION MAJOR JOINT OR BURSA W US GUIDANCE,73610457,CDM,761,RC,20611,CPT,,,facility,outpatient,,,1732.00000,1039.20000,WellCare of North Carolina,Medicare Advantage,,307.42,,,,,,,284.00,4311.00,fee schedule,
HC PERC VERT 1 VERT BODY CERVICOTHORACIC UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610458,CDM,361,RC,22510,CPT,,,facility,outpatient,,,1289.00000,773.40000,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,258.06,17457.00,fee schedule,
HC PERC VERT 1 VERT BODY LUMBOSACRAL UNIL OR BIL W BIOPSY W IMAGE GUIDANCE,73610459,CDM,361,RC,22511,CPT,,,facility,outpatient,,,733.00000,439.80000,WellCare of North Carolina,Medicare Advantage,,3379.04,,,,,,,146.75,17457.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY THORACIC UNIL OR BIL W IMAGE GUIDANCE,73610461,CDM,361,RC,22513,CPT,,,facility,outpatient,,,7165.00000,4299.00000,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,1434.43,13852.00,fee schedule,
HC PERC VERT AUGMENT 1 VERT BODY LUMBAR UNIL OR BIL W IMAGE GUIDANCE,73610462,CDM,361,RC,22514,CPT,,,facility,outpatient,,,1791.00000,1074.60000,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,358.56,13852.00,fee schedule,
HC MYELOGRAPHY CERVICAL VIA LUMBER INJECTION INCL S AND I,73610464,CDM,361,RC,62302,CPT,,,facility,outpatient,,,1854.00000,1112.40000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,371.17,8213.00,fee schedule,
HC MYELOGRAPHY THORACIC VIA LUMBAR INJECTION INCL S AND I,73610465,CDM,361,RC,62303,CPT,,,facility,outpatient,,,1046.00000,627.60000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,209.41,8213.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO EXIST ACCESS INCL IMAGE S AND I,73610511,CDM,361,RC,47531,CPT,,,facility,outpatient,,,3465.00000,2079.00000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,693.69,8045.00,fee schedule,
HC INJECTION PROC FOR CHOLANGIO NEW ACCESS INCL IMAGE S AND I,73610512,CDM,361,RC,47532,CPT,,,facility,outpatient,,,2980.00000,1788.00000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,596.60,17457.00,fee schedule,
HC PLACE EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610513,CDM,361,RC,47533,CPT,,,facility,outpatient,,,6144.00000,3686.40000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,1230.03,17457.00,fee schedule,
HC PLACE INT EXT BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610514,CDM,361,RC,47534,CPT,,,facility,outpatient,,,7144.00000,4286.40000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,1430.23,17457.00,fee schedule,
HC CONVERT EXT BILIARY DRAIN TO INT EXT BIL DRAIN INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610515,CDM,361,RC,47535,CPT,,,facility,outpatient,,,5291.00000,3174.60000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,1059.26,17457.00,fee schedule,
HC EXCHANGE BILIARY DRAIN CATH INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610516,CDM,361,RC,47536,CPT,,,facility,outpatient,,,4767.00000,2860.20000,WellCare of North Carolina,Medicare Advantage,,3675.27,,,,,,,954.35,17457.00,fee schedule,
HC REMOVAL BILIARY DRAIN CATH REQ FLUORO INCL CHOLANG WHEN PERFORMED IMAGE S AND I,73610517,CDM,361,RC,47537,CPT,,,facility,outpatient,,,1192.00000,715.20000,WellCare of North Carolina,Medicare Advantage,,976.41,,,,,,,238.64,4311.00,fee schedule,
HC PLACE STENT BILE DUCT EXIST ACCESS,73610518,CDM,361,RC,47538,CPT,,,facility,outpatient,,,8038.00000,4822.80000,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,1609.21,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS WO PLC SEP BIL DRAIN CATH,73610519,CDM,361,RC,47539,CPT,,,facility,outpatient,,,8296.00000,4977.60000,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,1660.86,17457.00,fee schedule,
HC PLACE STENT BILE DUCT NEW ACCESS W PLC SEP BIL DRAIN CATH I,73610520,CDM,361,RC,47540,CPT,,,facility,outpatient,,,12470.00000,7482.00000,WellCare of North Carolina,Medicare Advantage,,6076.09,,,,,,,2496.49,17457.00,fee schedule,
HC PLACE NEW ACCESS THRU BILIARY TREE INTO SM BOWEL FOR ENDO PROC EG RENDEVOUS,73610521,CDM,361,RC,47541,CPT,,,facility,outpatient,,,6955.00000,4173.00000,WellCare of North Carolina,Medicare Advantage,,6498.27,,,,,,,1392.39,17457.00,fee schedule,
HC SCLERO FLUID COLLECT LYMPHOCELE CYST SEROMA INCL CONT INJ IMAGE S AND I WHEN PERFORMED,73610525,CDM,361,RC,49185,CPT,,,facility,outpatient,,,891.00000,534.60000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,178.38,12408.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM NEW ACCESS INCL IMAGE S AND I,73610526,CDM,361,RC,50430,CPT,,,facility,outpatient,,,1611.00000,966.60000,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,322.52,6649.00,fee schedule,
HC INJECTION PROCEDURE FOR NEPHROSTOGRAM AND OR URETEROGRAM EXIST ACCESS INCL IMAGE S AND I,73610527,CDM,361,RC,50431,CPT,,,facility,outpatient,,,1191.00000,714.60000,WellCare of North Carolina,Medicare Advantage,,695.12,,,,,,,238.44,6649.00,fee schedule,
HC PLACE NEPHROSTOMY CATH INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610528,CDM,361,RC,50432,CPT,,,facility,outpatient,,,3702.00000,2221.20000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,741.14,12408.00,fee schedule,
HC PLACE NEPHROURETERAL CATH NEW ACCESS INCL NEPHRO URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610529,CDM,361,RC,50433,CPT,,,facility,outpatient,,,3251.00000,1950.60000,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,650.85,12408.00,fee schedule,
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH VIA EXISTING NEPH TRACT,73610530,CDM,361,RC,50434,CPT,,,facility,outpatient,,,3254.00000,1952.40000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,651.45,6649.00,fee schedule,
HC EXCHANGE NEPHROSTOMY CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610531,CDM,361,RC,50435,CPT,,,facility,outpatient,,,2805.00000,1683.00000,WellCare of North Carolina,Medicare Advantage,,2133.38,,,,,,,561.56,6649.00,fee schedule,
HC PLACE URETERAL STENT THRU PRE EXIST NEPHROSTOMY TRACT INCL NEPHR URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610533,CDM,361,RC,50693,CPT,,,facility,outpatient,,,4769.00000,2861.40000,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,954.75,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS WO SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE SUPERVISION,73610534,CDM,361,RC,50694,CPT,,,facility,outpatient,,,5532.00000,3319.20000,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,1107.51,17457.00,fee schedule,
HC PLACE URETERAL STENT NEW ACCESS W SEP NEPHRO CATH INCL NEPH URETEROGRAM WHEN PERFORMED IMAGE S AND I,73610535,CDM,361,RC,50695,CPT,,,facility,outpatient,,,8107.00000,4864.20000,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,1623.02,17457.00,fee schedule,
HC TRANSCATH REPAIR MITRAL VALVE PARAVAL LEAK,73610540,CDM,481,RC,93590,CPT,,,facility,outpatient,,,17121.00000,10272.60000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,3427.62,52940.00,fee schedule,
HC THROMBECTOMY ARTERIAL VENOUS NONHEMODIALYSIS GRAFT WO REVISION,73610541,CDM,481,RC,35875,CPT,,,facility,outpatient,,,7327.00000,4396.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1466.87,13852.00,fee schedule,
HC BIOPSY SALIVARY GLAND,73610542,CDM,361,RC,42400,CPT,,,facility,outpatient,,,902.00000,541.20000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,180.58,4311.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT LE PULMONARY CORONARY INTRACRANIAL DIALYSIS INITIAL ARTERY,73610552,CDM,481,RC,37246,CPT,,,facility,outpatient,,,17238.00000,10342.80000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,3451.05,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,361,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC TRANS BALLOON ANGIO EXCEPT DIALYSIS CIRCUIT INITIAL VEIN,73610554,CDM,481,RC,37248,CPT,,,facility,outpatient,,,8795.00000,5277.00000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,1760.76,13852.00,fee schedule,
HC BONE MARROW BIOPSY AND ASPIRATION DIAGNOSTIC,73610568,CDM,361,RC,38222,CPT,,,facility,outpatient,,,2910.00000,1746.00000,WellCare of North Carolina,Medicare Advantage,,2980.64,,,,,,,582.58,4311.00,fee schedule,
HC CVW INS PICC WO SQ PRT PUMP UNDER 5YRS WO IMG GUIDANCE,73610590,CDM,361,RC,36568,CPT,,,facility,outpatient,,,6560.00000,3936.00000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,990.00,4538.86,fee schedule,
HC CVW INS PICC WO SQ PORT PUMP 5YRS AND OLDER WO IMG GUIDANCE,73610591,CDM,761,RC,36569,CPT,,,facility,outpatient,,,1686.00000,1011.60000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,317.81,4311.00,fee schedule,
HC CVW REPL COMP PICC WO SQ PORT PMP,73610592,CDM,361,RC,36584,CPT,,,facility,outpatient,,,2021.00000,1212.60000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,404.60,4311.00,fee schedule,
HC PERIPHERAL FFR,73610615,CDM,481,RC,37799,CPT,,,facility,outpatient,,,3211.00000,1926.60000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,9423.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610617,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610618,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE NOT REQ REV G TRACT,73610619,CDM,361,RC,43762,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC REPLACEMENT OF G TUBE PERC INCL REMOVAL WO IMAGE OR ENDO GUIDANCE W REV OF G TRACT,73610620,CDM,361,RC,43763,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Medicare Advantage,,253.29,,,,,,,43.64,4311.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACEMENT,73610621,CDM,361,RC,50436,CPT,,,facility,outpatient,,,9944.00000,5966.40000,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,1990.79,17457.00,fee schedule,
HC DILATION OF EXISTING TRACT PERC ENDOUROLOGIC PROCEDURE INCL GUIDE AND SI W POSTPROC TUBE PLACE INCL ACCESS TO RSC,73610622,CDM,361,RC,50437,CPT,,,facility,outpatient,,,9944.00000,5966.40000,WellCare of North Carolina,Medicare Advantage,,3591.87,,,,,,,1990.79,8045.00,fee schedule,
HC CORE NEEDLE BIOPSY LUNG MEDIASTINUM PERQ W IMG,73610644,CDM,361,RC,32408,CPT,,,facility,outpatient,,,4014.00000,2408.40000,WellCare of North Carolina,Medicare Advantage,,1687.37,,,,,,,803.60,12408.00,fee schedule,
HC CRYOABL NERVE PLEXUS OR TRUNCAL NERVE INCL GUIDANCE,73610645,CDM,361,RC,0442T,CPT,,,facility,outpatient,,,6092.00000,3655.20000,WellCare of North Carolina,Medicare Advantage,,6669.40,,,,,,,1219.62,10022.00,fee schedule,
HC VENOUS EMBOLIZATION NOT HEMORRHAGE W NEEDLE,73610654,CDM,361,RC,37799,CPT,,,facility,outpatient,,,3452.00000,2071.20000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,4376.00,fee schedule,
HC VAT PICC LINE PLACEMENT WO IMAGING GUIDANCE 5YRS AND OLDER,73610657,CDM,361,RC,36569,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,125.93,4311.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP YOUNGER THAN 5 YEARS OLD,73610659,CDM,361,RC,36572,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,572.37,6649.00,fee schedule,
HC VAT INSERT PICC WO PORT OR PUMP INCL GUIDANCE AND SUPERVISION INTERP 5 YEARS AND OLDER,73610660,CDM,361,RC,36573,CPT,,,facility,outpatient,,,2859.00000,1715.40000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,572.37,10768.00,fee schedule,
HC NONINVASIVE ESTIMATE OF CORONARY FRACTIONAL FLOW RESERVE FROM AUGMENT SOFTWARE ANALYSIS W CT ANGIO INCL INTERPRETATION AND REPORT BY PHY QHP,73610661,CDM,350,RC,75580,CPT,,,facility,outpatient,,,4058.00000,2434.80000,WellCare of North Carolina,Medicare Advantage,,1059.54,,,,,,,651.00,2905.00,fee schedule,
HC MYELOGRAPHY 2 OR MORE REGIONS LT CT LC LTC,73620017,CDM,361,RC,62305,CPT,,,facility,outpatient,,,1959.00000,1175.40000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,392.19,8213.00,fee schedule,
HC US HEAD ECHOENCEPHALOGRAPHY,74020004,CDM,402,RC,76506,CPT,,,facility,outpatient,,,320.00000,192.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,64.06,467.00,fee schedule,
HC US SOFT TISSUES HEAD AND NECK,74020005,CDM,402,RC,76536,CPT,,,facility,outpatient,,,894.00000,536.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,670.50,fee schedule,
HC US CHEST,74020006,CDM,402,RC,76604,CPT,,,facility,outpatient,,,574.00000,344.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,59.02,467.00,fee schedule,
HC US ABDOMINAL COMPLETE,74020008,CDM,402,RC,76700,CPT,,,facility,outpatient,,,1142.00000,685.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,856.50,fee schedule,
HC US ABDOMINAL LIMITED,74020009,CDM,402,RC,76705,CPT,,,facility,outpatient,,,936.00000,561.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,702.00,fee schedule,
HC US RETROPERITONEAL COMPLETE,74020010,CDM,402,RC,76770,CPT,,,facility,outpatient,,,1058.00000,634.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,793.50,fee schedule,
HC US RETROPERITONEAL LIMITED,74020011,CDM,402,RC,76775,CPT,,,facility,outpatient,,,771.00000,462.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,58.38,578.25,fee schedule,
HC US DOPPLER TRANSPLANT RENAL,74020012,CDM,402,RC,76776,CPT,,,facility,outpatient,,,837.00000,502.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,627.75,fee schedule,
HC US SPINAL CANAL AND CONTENTS,74020013,CDM,402,RC,76800,CPT,,,facility,outpatient,,,315.00000,189.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,63.06,467.00,fee schedule,
HC US PREG UTERUS LESS THAN 14 WKS SINGLE OR 1 GEST,74020014,CDM,402,RC,76801,CPT,,,facility,outpatient,,,758.00000,454.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,568.50,fee schedule,
HC US OB GREATER THAN 14 WKS TRANSABD SINGLE OR 1ST GEST,74020016,CDM,402,RC,76805,CPT,,,facility,outpatient,,,825.00000,495.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,618.75,fee schedule,
HC US OB TRANSABD SINGLE OR 1ST GEST,74020018,CDM,402,RC,76811,CPT,,,facility,outpatient,,,961.00000,576.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,160.28,720.75,fee schedule,
HC US PREG UTERUS LIMITED 1 OR MORE,74020022,CDM,402,RC,76815,CPT,,,facility,outpatient,,,637.00000,382.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,97.56,477.75,fee schedule,
HC US PREG UTERUS FOLLOW UP PER FETUS,74020023,CDM,402,RC,76816,CPT,,,facility,outpatient,,,427.00000,256.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,85.49,467.00,fee schedule,
HC US TRANSVAGINAL PREG UTERUS,74020024,CDM,402,RC,76817,CPT,,,facility,outpatient,,,835.00000,501.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,626.25,fee schedule,
HC US BIOPHYSICAL PROFILE W NONSTRESS,74020025,CDM,402,RC,76818,CPT,,,facility,outpatient,,,668.00000,400.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,501.00,fee schedule,
HC US BIOPHYSICAL PROFILE WO NONSTRESS,74020026,CDM,402,RC,76819,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,89.84,467.00,fee schedule,
HC US SIS INCLD COLOR FLOW DPLR,74020027,CDM,402,RC,76831,CPT,,,facility,outpatient,,,658.00000,394.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,131.73,493.50,fee schedule,
HC US PELVIC NONOB COMPLETE,74020028,CDM,402,RC,76856,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,777.75,fee schedule,
HC US PELVIC NONOB LIMITED,74020029,CDM,402,RC,76857,CPT,,,facility,outpatient,,,823.00000,493.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,46.82,617.25,fee schedule,
HC US SCROTUM AND CONTENTS,74020030,CDM,402,RC,76870,CPT,,,facility,outpatient,,,919.00000,551.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,689.25,fee schedule,
HC US TRANSRECTAL,74020031,CDM,402,RC,76872,CPT,,,facility,outpatient,,,301.00000,180.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,60.26,467.00,fee schedule,
HC US EXTREMITY NV W IMAGE COMPLETE,74020032,CDM,402,RC,76881,CPT,,,facility,outpatient,,,1178.00000,706.80000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,54.52,883.50,fee schedule,
HC US EXTREMITY NV W IMAGE LIMITED,74020033,CDM,402,RC,76882,CPT,,,facility,outpatient,,,764.00000,458.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,63.52,573.00,fee schedule,
HC US INFANT HIPS W IMAGING W MANIPULATION,74020034,CDM,402,RC,76885,CPT,,,facility,outpatient,,,250.00000,150.00000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,50.05,467.00,fee schedule,
HC US INFANT HIP LIMITED WO STRESS,74020035,CDM,402,RC,76886,CPT,,,facility,outpatient,,,231.00000,138.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,46.25,467.00,fee schedule,
HC US BONE DENSITY MEASURE,74020046,CDM,402,RC,76977,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,8.28,467.00,fee schedule,
HC US UNLISTED PROCEDURE,74020048,CDM,402,RC,76999,CPT,,,facility,outpatient,,,422.00000,253.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,84.48,467.00,fee schedule,
HC US TRANSVAGINAL NONOB COMPLETE,74020049,CDM,402,RC,76830,CPT,,,facility,outpatient,,,967.00000,580.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,725.25,fee schedule,
HC US BREAST UNILATERAL LIMITED,74020072,CDM,402,RC,76642,CPT,,,facility,outpatient,,,492.00000,295.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,84.71,467.00,fee schedule,
HC US BREAST UNILATERAL COMPLETE,74020073,CDM,402,RC,76641,CPT,,,facility,outpatient,,,459.00000,275.40000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,91.89,467.00,fee schedule,
HC PET CT MYOCARDIAL IMAG MET EVAL,74040001,CDM,404,RC,78459,CPT,,,facility,outpatient,,,6386.00000,3831.60000,WellCare of North Carolina,Medicare Advantage,,1359.57,,,,,,,1113.08,5598.00,fee schedule,
HC PET CT METABOLIC BRAIN,74040004,CDM,404,RC,78608,CPT,,,facility,outpatient,,,4654.00000,2792.40000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,811.19,5598.00,fee schedule,
HC PET CT TUMOR IMAGING LIMITED,74040008,CDM,404,RC,78814,CPT,,,facility,outpatient,,,4182.00000,2509.20000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,728.92,5598.00,fee schedule,
HC PET CT SKULL TO THIGH,74040009,CDM,404,RC,78815,CPT,,,facility,outpatient,,,6491.00000,3894.60000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,1131.38,5598.00,fee schedule,
HC PET CT TUMOR IMAGING WHOLE BODY,74040010,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NM DX UNLISTED PROCEDURE,74040011,CDM,341,RC,78999,CPT,,,facility,outpatient,,,2688.00000,1612.80000,WellCare of North Carolina,Medicare Advantage,,418.48,,,,,,,257.00,2016.00,fee schedule,
HC PET TOTAL BODY BONE SCAN,74040013,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC NOPR NAF 18 TOTAL BODY BONE SCAN,74040015,CDM,404,RC,78816,CPT,,,facility,outpatient,,,6150.00000,3690.00000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,1071.94,5598.00,fee schedule,
HC PET AMYVID BRAIN SCAN,74040016,CDM,404,RC,78608,CPT,,,facility,outpatient,,,931.00000,558.60000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,162.27,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT SINGLE STUDY REST STRESS,74040017,CDM,404,RC,78491,CPT,,,facility,outpatient,,,1531.00000,918.60000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,266.85,5598.00,fee schedule,
HC PET MYOCARDIAL PERFUSION INCLD VENT WALL AND OR EJECT FRACT MULTIPLE STUDY REST STRESS,74040018,CDM,404,RC,78492,CPT,,,facility,outpatient,,,3061.00000,1836.60000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,533.53,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING METABOLIC EVAL WITH CT SINGLE STUDY,74040019,CDM,404,RC,78429,CPT,,,facility,outpatient,,,4660.00000,2796.00000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,812.24,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT SINGLE STUDY AT REST OR STRESS,74040020,CDM,404,RC,78430,CPT,,,facility,outpatient,,,4176.00000,2505.60000,WellCare of North Carolina,Medicare Advantage,,1519.02,,,,,,,727.88,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING PERFUSION EVAL WITH CT MULTIPLE STUDIES AT REST OR STRESS,74040021,CDM,404,RC,78431,CPT,,,facility,outpatient,,,6052.00000,3631.20000,WellCare of North Carolina,Medicare Advantage,,2343.75,,,,,,,1054.86,5598.00,fee schedule,
HC PET MYOCARDIAL IMAGING COMBINED PERFUSION W METABOLIC DUAL RADIOTRACER WITH CT,74040022,CDM,404,RC,78433,CPT,,,facility,outpatient,,,8896.00000,5337.60000,WellCare of North Carolina,Medicare Advantage,,2031.31,,,,,,,1550.57,5598.00,fee schedule,
HC ROUTINE 2D ECHO WM MOD CON,74830001,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,126.13,968.00,fee schedule,
HC INTRAOPERATIVE MONITORING TEE,74830004,CDM,483,RC,93318,CPT,,,facility,outpatient,,,571.00000,342.60000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,80.11,968.00,fee schedule,
HC STRESS 2D ECHO ONLY,74830005,CDM,483,RC,93350,CPT,,,facility,outpatient,,,1012.00000,607.20000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,141.98,968.00,fee schedule,
HC STRESS 2D ECHO CONTRAST,74830006,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC INTRAOPERATVIE MONITOR TEE WITH CONTRAST,74830009,CDM,483,RC,93318,CPT,,,facility,outpatient,,,2469.00000,1481.40000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,1851.75,fee schedule,
HC MRI TMJ,76100001,CDM,610,RC,70336,CPT,,,facility,outpatient,,,2813.00000,1687.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST WO CONT,76100002,CDM,610,RC,71550,CPT,,,facility,outpatient,,,3292.00000,1975.20000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CHEST W CONT,76100003,CDM,610,RC,71551,CPT,,,facility,outpatient,,,5069.00000,3041.40000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,760.10,3601.53,fee schedule,
HC MRI CHEST WO CONT FLD W CONT,76100004,CDM,610,RC,71552,CPT,,,facility,outpatient,,,6127.00000,3676.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,4352.85,fee schedule,
HC MRI PELVIS WO CONT,76100005,CDM,610,RC,72195,CPT,,,facility,outpatient,,,3459.00000,2075.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI PELVIS W CONT,76100006,CDM,610,RC,72196,CPT,,,facility,outpatient,,,5173.00000,3103.80000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3155.53,fee schedule,
HC MRI PELVIS WO FLD W CONT,76100007,CDM,610,RC,72197,CPT,,,facility,outpatient,,,5388.00000,3232.80000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3286.68,fee schedule,
HC MRI UE NOT JOINT WO CONT,76100008,CDM,610,RC,73218,CPT,,,facility,outpatient,,,3604.00000,2162.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE NOT JOINT W CONT,76100009,CDM,610,RC,73219,CPT,,,facility,outpatient,,,3765.00000,2259.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3127.52,fee schedule,
HC MRI UE NOT JOINT WO FLD W CONT,76100010,CDM,610,RC,73220,CPT,,,facility,outpatient,,,5158.00000,3094.80000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3810.99,fee schedule,
HC MRI UE ANY JOINT WO CONT,76100011,CDM,610,RC,73221,CPT,,,facility,outpatient,,,3472.00000,2083.20000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI UE ANY JOINT W CONT,76100012,CDM,610,RC,73222,CPT,,,facility,outpatient,,,4076.00000,2445.60000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,760.10,2893.96,fee schedule,
HC MRI UE ANY JOINT WO FLD W CONT,76100013,CDM,610,RC,73223,CPT,,,facility,outpatient,,,4699.00000,2819.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3525.98,fee schedule,
HC MRI LE NOT JOINT WO CONT,76100014,CDM,610,RC,73718,CPT,,,facility,outpatient,,,3708.00000,2224.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE NOT JOINT W CONT,76100015,CDM,610,RC,73719,CPT,,,facility,outpatient,,,3892.00000,2335.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI LE NOT JOINT WO FLD W CONT,76100016,CDM,610,RC,73720,CPT,,,facility,outpatient,,,5332.00000,3199.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3252.52,fee schedule,
HC MRI LEG JOINT WO CONT,76100017,CDM,610,RC,73721,CPT,,,facility,outpatient,,,3675.00000,2205.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI LE ANY JOINT W CONT,76100018,CDM,610,RC,73722,CPT,,,facility,outpatient,,,3712.00000,2227.20000,WellCare of North Carolina,Medicare Advantage,,822.79,,,,,,,743.14,2917.94,fee schedule,
HC MRI LE ANY JOINT WO FLD W CONT,76100019,CDM,610,RC,73723,CPT,,,facility,outpatient,,,5158.00000,3094.80000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3522.51,fee schedule,
HC MRI ABD WO CONT,76100020,CDM,610,RC,74181,CPT,,,facility,outpatient,,,4256.00000,2553.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ABD W CONT,76100021,CDM,610,RC,74182,CPT,,,facility,outpatient,,,4501.00000,2700.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2876.72,fee schedule,
HC MRI ABD W WO CONT,76100022,CDM,610,RC,74183,CPT,,,facility,outpatient,,,5234.00000,3140.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3192.74,fee schedule,
HC MRI CARDIAC MORPHOLOGY WO CONT,76100023,CDM,610,RC,75557,CPT,,,facility,outpatient,,,2919.00000,1751.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI CARDIAC MORPH WO W CONT,76100025,CDM,610,RC,75561,CPT,,,facility,outpatient,,,4185.00000,2511.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2972.99,fee schedule,
HC MRI SPECTROSCOPY BRAIN,76100028,CDM,610,RC,76390,CPT,,,facility,outpatient,,,3172.00000,1903.20000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,84.71,2825.00,fee schedule,
HC MRI BRAIN WO CONT,76100037,CDM,611,RC,70551,CPT,,,facility,outpatient,,,3843.00000,2305.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BRAIN W CONT,76100038,CDM,611,RC,70552,CPT,,,facility,outpatient,,,4405.00000,2643.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI BRAIN WO FLD W CONT,76100039,CDM,611,RC,70553,CPT,,,facility,outpatient,,,5196.00000,3117.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3169.56,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO CONT,76100041,CDM,612,RC,72141,CPT,,,facility,outpatient,,,4024.00000,2414.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV W CONT,76100042,CDM,612,RC,72142,CPT,,,facility,outpatient,,,4135.00000,2481.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO CONT,76100043,CDM,612,RC,72146,CPT,,,facility,outpatient,,,3516.00000,2109.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR W CONT,76100044,CDM,612,RC,72147,CPT,,,facility,outpatient,,,4274.00000,2564.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO CONT,76100045,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB W CONT,76100046,CDM,612,RC,72149,CPT,,,facility,outpatient,,,4051.00000,2430.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS CERV WO FLD W CONT,76100047,CDM,612,RC,72156,CPT,,,facility,outpatient,,,5104.00000,3062.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3113.44,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS THOR WO FLD W CONT,76100048,CDM,612,RC,72157,CPT,,,facility,outpatient,,,4912.00000,2947.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2996.32,fee schedule,
HC MRI SPINAL CANAL AND CONTENTS LUMB WO FLD W CONT,76100049,CDM,612,RC,72158,CPT,,,facility,outpatient,,,5454.00000,3272.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3326.94,fee schedule,
HC MRI ORBIT FACE NECK WO CONT,76100052,CDM,610,RC,70540,CPT,,,facility,outpatient,,,4190.00000,2514.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI ORBIT FACE NECK W CONT,76100053,CDM,610,RC,70542,CPT,,,facility,outpatient,,,4637.00000,2782.20000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2828.57,fee schedule,
HC MRI ORBIT FACE NECK WO FLD W CONT,76100054,CDM,610,RC,70543,CPT,,,facility,outpatient,,,5586.00000,3351.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3407.46,fee schedule,
HC MRA HEAD WO CONT,76100055,CDM,615,RC,70544,CPT,,,facility,outpatient,,,3468.00000,2080.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA HEAD W CONT,76100056,CDM,615,RC,70545,CPT,,,facility,outpatient,,,3671.00000,2202.60000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA HEAD WO FLD W CONT,76100057,CDM,615,RC,70546,CPT,,,facility,outpatient,,,5340.00000,3204.00000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,3981.96,fee schedule,
HC MRA NECK WO CONT,76100058,CDM,615,RC,70547,CPT,,,facility,outpatient,,,3245.00000,1947.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRA NECK W CONT,76100059,CDM,615,RC,70548,CPT,,,facility,outpatient,,,3599.00000,2159.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,2825.00,fee schedule,
HC MRA NECK WO FLD W CONT,76100060,CDM,615,RC,70549,CPT,,,facility,outpatient,,,4999.00000,2999.40000,WellCare of North Carolina,Medicare Advantage,,371.93,,,,,,,343.59,4009.45,fee schedule,
HC MRI LUMBAR SPINE LIMITED,76100110,CDM,612,RC,72148,CPT,,,facility,outpatient,,,3523.00000,2113.80000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT UNILATERAL,76100122,CDM,610,RC,77046,CPT,,,facility,outpatient,,,2400.00000,1440.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC MRI BREAST WO CONT BILATERAL,76100123,CDM,610,RC,77047,CPT,,,facility,outpatient,,,2385.00000,1431.00000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,232.56,2825.00,fee schedule,
HC SITZ MARKER STUDY ABD 1 VW,76200009,CDM,320,RC,74018,CPT,,,facility,outpatient,,,426.00000,255.60000,WellCare of North Carolina,Medicare Advantage,,91.70,,,,,,,41.04,319.50,fee schedule,
HC SIGNAL AVERAGED EKG,77300002,CDM,730,RC,93278,CPT,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,57.15,299.25,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,361,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,349.35,4311.00,fee schedule,
HC DX LMBR SPINAL PUNCTURE W FLOURO OR CT GUIDANCE,77610005,CDM,761,RC,62328,CPT,,,facility,outpatient,,,1745.00000,1047.00000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,328.93,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,361,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,366.57,4311.00,fee schedule,
HC THERAPEUTIC SPINAL DRAIN CSF USING CATHETER INCLD CT FLUORO GUIDE,77610007,CDM,761,RC,62329,CPT,,,facility,outpatient,,,1831.00000,1098.60000,WellCare of North Carolina,Medicare Advantage,,721.21,,,,,,,345.14,4311.00,fee schedule,
HC TRANSCRANIAL DOPPLER LIMITED,79210001,CDM,921,RC,93888,CPT,,,facility,outpatient,,,905.00000,543.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,678.75,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI WO MIC,79210003,CDM,921,RC,93892,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,82.70,356.25,fee schedule,
HC TRANSCRANIAL DOPPLER EMBOLI W MICRO,79210004,CDM,921,RC,93893,CPT,,,facility,outpatient,,,475.00000,285.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,82.70,356.25,fee schedule,
HC EXERCISE HYPEREMIA BIL,79210005,CDM,921,RC,93924,CPT,,,facility,outpatient,,,1299.00000,779.40000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,974.25,fee schedule,
HC DUPLEX COMPLETE ABD PEL SCRO RETRO,79210006,CDM,921,RC,93975,CPT,,,facility,outpatient,,,1037.00000,622.20000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,175.00,777.75,fee schedule,
HC DUPLEX LIMITED ABD PEL SCRO RETRO,79210007,CDM,921,RC,93976,CPT,,,facility,outpatient,,,847.00000,508.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,635.25,fee schedule,
HC DUPLEX PENILE SCAN COMPLETE,79210008,CDM,921,RC,93980,CPT,,,facility,outpatient,,,616.00000,369.60000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,102.31,462.00,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL BIL,79210011,CDM,921,RC,93985,CPT,,,facility,outpatient,,,599.00000,359.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,104.29,449.25,fee schedule,
HC DUPLEX ART INFLOW VEN OUTFLOW FOR PREOP VESSEL ASSESSMENT HEMODIALYSIS ACCESS COMPL UNI STD,79210012,CDM,921,RC,93986,CPT,,,facility,outpatient,,,292.00000,175.20000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,50.84,269.00,fee schedule,
HC COMPREHENSIVE METABOLIC PANEL,83000002,CDM,301,RC,80053,CPT,,,facility,outpatient,,,431.00000,258.60000,WellCare of North Carolina,Medicare Advantage,,11.09,,,,,,,10.24,323.25,fee schedule,
HC OBSTETRIC PANEL,83000003,CDM,300,RC,80055,CPT,,,facility,outpatient,,,317.00000,190.20000,WellCare of North Carolina,Medicare Advantage,,50.20,,,,,,,46.38,237.75,fee schedule,
HC RENAL PANEL,83000004,CDM,301,RC,80069,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Medicare Advantage,,9.11,,,,,,,8.42,216.00,fee schedule,
HC ACUTE HEPATITIS PANEL,83000005,CDM,301,RC,80074,CPT,,,facility,outpatient,,,680.00000,408.00000,WellCare of North Carolina,Medicare Advantage,,50.01,,,,,,,46.20,510.00,fee schedule,
HC HEPATIC FUNCTION PANEL,83000006,CDM,301,RC,80076,CPT,,,facility,outpatient,,,281.00000,168.60000,WellCare of North Carolina,Medicare Advantage,,8.58,,,,,,,7.92,210.75,fee schedule,
HC BCR ABL MAJOR BREAKPOINT,83000013,CDM,300,RC,81206,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Medicare Advantage,,172.16,,,,,,,116.52,436.50,fee schedule,
HC BCR ABL MINOR BREAKPOINT,83000014,CDM,300,RC,81207,CPT,,,facility,outpatient,,,582.00000,349.20000,WellCare of North Carolina,Medicare Advantage,,152.08,,,,,,,116.52,436.50,fee schedule,
HC CF DNA ANALYSIS,83000018,CDM,300,RC,81220,CPT,,,facility,outpatient,,,1436.00000,861.60000,WellCare of North Carolina,Medicare Advantage,,584.43,,,,,,,287.49,1077.00,fee schedule,
HC CYP2C19 RESPONSE GENOTYPING,83000019,CDM,300,RC,81225,CPT,,,facility,outpatient,,,752.00000,451.20000,WellCare of North Carolina,Medicare Advantage,,305.93,,,,,,,150.55,564.00,fee schedule,
HC MICROARRAY ANALYSIS SNP,83000022,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1866.00000,1119.60000,WellCare of North Carolina,Medicare Advantage,,1218.00,,,,,,,373.57,2152.96,fee schedule,
HC REF MICROARRAY ANALYSIS SNP,83000023,CDM,300,RC,81229,CPT,,,facility,outpatient,,,4350.00000,2610.00000,WellCare of North Carolina,Medicare Advantage,,1218.00,,,,,,,870.87,3262.50,fee schedule,
HC FACTOR 2 GENE ANALYSIS,83000025,CDM,300,RC,81240,CPT,,,facility,outpatient,,,252.00000,151.20000,WellCare of North Carolina,Medicare Advantage,,68.97,,,,,,,50.45,189.00,fee schedule,
HC FACTOR V LEIDEN,83000026,CDM,300,RC,81241,CPT,,,facility,outpatient,,,177.00000,106.20000,WellCare of North Carolina,Medicare Advantage,,77.04,,,,,,,35.44,136.16,fee schedule,
HC FMR 1 GENE ANALYSIS,83000027,CDM,300,RC,81243,CPT,,,facility,outpatient,,,369.00000,221.40000,WellCare of North Carolina,Medicare Advantage,,59.89,,,,,,,55.33,276.75,fee schedule,
HC FMR 1 EXPANDED SIZE METHYLATIO,83000029,CDM,300,RC,81244,CPT,,,facility,outpatient,,,183.00000,109.80000,WellCare of North Carolina,Medicare Advantage,,47.13,,,,,,,36.64,137.25,fee schedule,
HC FLT3 ITD GENE ANALYSIS,83000030,CDM,300,RC,81245,CPT,,,facility,outpatient,,,427.00000,256.20000,WellCare of North Carolina,Medicare Advantage,,173.79,,,,,,,85.49,320.25,fee schedule,
HC CONX 26 SEQUENCE ANALYSIS,83000031,CDM,300,RC,81252,CPT,,,facility,outpatient,,,329.00000,197.40000,WellCare of North Carolina,Medicare Advantage,,106.18,,,,,,,65.87,246.75,fee schedule,
HC CONX 30 FRAGMENT ANALYSIS,83000032,CDM,300,RC,81254,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Medicare Advantage,,36.75,,,,,,,33.95,206.25,fee schedule,
HC HFE GENE ANALYSIS,83000033,CDM,300,RC,81256,CPT,,,facility,outpatient,,,399.00000,239.40000,WellCare of North Carolina,Medicare Advantage,,68.63,,,,,,,63.40,299.25,fee schedule,
HC IGH GENE REARRANGEMENT,83000034,CDM,300,RC,81261,CPT,,,facility,outpatient,,,631.00000,378.60000,WellCare of North Carolina,Medicare Advantage,,207.89,,,,,,,126.33,473.25,fee schedule,
HC IGK GENE REARRANGEMENT,83000035,CDM,300,RC,81264,CPT,,,facility,outpatient,,,518.00000,310.80000,WellCare of North Carolina,Medicare Advantage,,181.37,,,,,,,103.70,388.50,fee schedule,
HC REF MATERNL CELL CONTAMINATION,83000036,CDM,300,RC,81265,CPT,,,facility,outpatient,,,874.00000,524.40000,WellCare of North Carolina,Medicare Advantage,,244.72,,,,,,,174.97,655.50,fee schedule,
HC FINGERPRINT PRETRANS ANALYSIS,83000038,CDM,300,RC,81265,CPT,,,facility,outpatient,,,562.00000,337.20000,WellCare of North Carolina,Medicare Advantage,,244.72,,,,,,,112.51,436.66,fee schedule,
HC UA WITHOUT MICROSCOPIC POCT,83000041,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Medicare Advantage,,2.36,,,,,,,2.18,42.75,fee schedule,
HC MSI ANALYSIS,83000043,CDM,300,RC,81301,CPT,,,facility,outpatient,,,362.00000,217.20000,WellCare of North Carolina,Medicare Advantage,,365.99,,,,,,,72.47,646.78,fee schedule,
HC PWA METHYLATION ANALYSIS,83000046,CDM,300,RC,81331,CPT,,,facility,outpatient,,,756.00000,453.60000,WellCare of North Carolina,Medicare Advantage,,53.62,,,,,,,49.54,567.00,fee schedule,
HC A1AT GENE ANALYSIS,83000047,CDM,300,RC,81332,CPT,,,facility,outpatient,,,305.00000,183.00000,WellCare of North Carolina,Medicare Advantage,,45.83,,,,,,,42.34,228.75,fee schedule,
HC TRG GENE REARRANGEMENT,83000048,CDM,300,RC,81342,CPT,,,facility,outpatient,,,665.00000,399.00000,WellCare of North Carolina,Medicare Advantage,,211.57,,,,,,,133.13,498.75,fee schedule,
HC UGT1A1 GENE ANALYSIS,83000049,CDM,300,RC,81350,CPT,,,facility,outpatient,,,422.00000,253.20000,WellCare of North Carolina,Medicare Advantage,,245.70,,,,,,,84.48,434.18,fee schedule,
HC HLA ABCDRB1/3/4/5DQB1 LORES,83000051,CDM,300,RC,81370,CPT,,,facility,outpatient,,,956.00000,573.60000,WellCare of North Carolina,Medicare Advantage,,422.23,,,,,,,191.39,816.53,fee schedule,
HC HLA ABC LORES TYPING,83000053,CDM,300,RC,81372,CPT,,,facility,outpatient,,,599.00000,359.40000,WellCare of North Carolina,Medicare Advantage,,423.77,,,,,,,119.92,748.92,fee schedule,
HC HLA B LOCUS LORES TYPING,83000055,CDM,300,RC,81373,CPT,,,facility,outpatient,,,422.00000,253.20000,WellCare of North Carolina,Medicare Advantage,,133.80,,,,,,,84.48,316.50,fee schedule,
HC SNGL AGN LORES CLASS I TYPING,83000057,CDM,300,RC,81374,CPT,,,facility,outpatient,,,458.00000,274.80000,WellCare of North Carolina,Medicare Advantage,,78.05,,,,,,,72.10,343.50,fee schedule,
HC SNGL AGN LORES CLASS II TYPING,83000061,CDM,300,RC,81377,CPT,,,facility,outpatient,,,364.00000,218.40000,WellCare of North Carolina,Medicare Advantage,,99.48,,,,,,,72.87,273.00,fee schedule,
HC HLA ABC DRB1 HIRES TYPING,83000062,CDM,300,RC,81378,CPT,,,facility,outpatient,,,2524.00000,1514.40000,WellCare of North Carolina,Medicare Advantage,,362.85,,,,,,,335.20,1893.00,fee schedule,
HC HLA ABC HIRES TYPING,83000063,CDM,300,RC,81379,CPT,,,facility,outpatient,,,2169.00000,1301.40000,WellCare of North Carolina,Medicare Advantage,,352.15,,,,,,,325.32,1626.75,fee schedule,
HC HLA A LOCUS HIRES TYPING,83000064,CDM,300,RC,81380,CPT,,,facility,outpatient,,,1106.00000,663.60000,WellCare of North Carolina,Medicare Advantage,,186.11,,,,,,,171.93,829.50,fee schedule,
HC SNGL AGN HIRES CLASS I TYPING,83000067,CDM,300,RC,81381,CPT,,,facility,outpatient,,,521.00000,312.60000,WellCare of North Carolina,Medicare Advantage,,178.40,,,,,,,104.30,390.75,fee schedule,
HC HLA DQB1 HIRES TYPING,83000069,CDM,300,RC,81382,CPT,,,facility,outpatient,,,553.00000,331.80000,WellCare of North Carolina,Medicare Advantage,,129.86,,,,,,,110.71,414.75,fee schedule,
HC NPM1 QUANT ANALYSIS,83000073,CDM,300,RC,81310,CPT,,,facility,outpatient,,,336.00000,201.60000,WellCare of North Carolina,Medicare Advantage,,258.85,,,,,,,67.27,457.32,fee schedule,
HC MGMT BY PYROSEQUENCING,83000074,CDM,300,RC,81287,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Medicare Advantage,,130.87,,,,,,,25.63,173.55,fee schedule,
HC TKI RESISTANCE,83000077,CDM,300,RC,81170,CPT,,,facility,outpatient,,,512.00000,307.20000,WellCare of North Carolina,Medicare Advantage,,315.00,,,,,,,102.50,556.86,fee schedule,
HC IDH1 BY PYROSEQUENCING,83000078,CDM,300,RC,81120,CPT,,,facility,outpatient,,,404.00000,242.40000,WellCare of North Carolina,Medicare Advantage,,202.91,,,,,,,80.88,358.40,fee schedule,
HC IDH2 BY PYROSEQUENCING,83000079,CDM,300,RC,81121,CPT,,,facility,outpatient,,,404.00000,242.40000,WellCare of North Carolina,Medicare Advantage,,310.58,,,,,,,80.88,549.16,fee schedule,
HC ALPHA FETOPROTEIN TUMOR MARKER,83000084,CDM,301,RC,82105,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Medicare Advantage,,17.61,,,,,,,9.41,35.77,fee schedule,
HC GLUCOSE STICK TEST,83000087,CDM,301,RC,82948,CPT,,,facility,outpatient,,,14.00000,8.40000,WellCare of North Carolina,Medicare Advantage,,5.29,,,,,,,2.80,10.50,fee schedule,
HC TOTAL IRON BINDING CAPACITY,83000089,CDM,301,RC,83550,CPT,,,facility,outpatient,,,112.00000,67.20000,WellCare of North Carolina,Medicare Advantage,,9.18,,,,,,,8.48,84.00,fee schedule,
HC PROSTATIC ACID PHOSPHATASE,83000094,CDM,301,RC,84066,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Medicare Advantage,,10.14,,,,,,,9.37,122.25,fee schedule,
HC BETA HCG QUALITATIVE,83000098,CDM,301,RC,84703,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Medicare Advantage,,7.90,,,,,,,7.29,99.00,fee schedule,
HC RETICULOCYTE COUNT MANUAL,83000100,CDM,305,RC,85044,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Medicare Advantage,,4.53,,,,,,,4.18,19.50,fee schedule,
HC KOH SKIN SCRAPING,83000116,CDM,306,RC,87220,CPT,,,facility,outpatient,,,44.00000,26.40000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,33.00,fee schedule,
HC DRUG SCREEN 7 DRUGS,83000130,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,37.84,141.75,fee schedule,
HC BASIC METABOLIC PANEL,83000133,CDM,301,RC,80048,CPT,,,facility,outpatient,,,265.00000,159.00000,WellCare of North Carolina,Medicare Advantage,,8.88,,,,,,,8.21,198.75,fee schedule,
HC ELECTROLYTES PANEL,83000135,CDM,301,RC,80051,CPT,,,facility,outpatient,,,88.00000,52.80000,WellCare of North Carolina,Medicare Advantage,,7.36,,,,,,,6.80,66.00,fee schedule,
HC LIPID PANEL,83000136,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,WellCare of North Carolina,Medicare Advantage,,14.06,,,,,,,12.99,189.75,fee schedule,
HC DRUG SCREEN QUAL MULT DRUG CL,83000138,CDM,301,RC,80307,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,37.84,141.75,fee schedule,
HC METHADONE URINE SCREENING PRESUMPTIVE,83000151,CDM,301,RC,80307,CPT,,,facility,outpatient,,,397.00000,238.20000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,60.28,297.75,fee schedule,
HC BENZODIAZEPINE URINE SCREENING PRESUMPTIVE,83000155,CDM,301,RC,80307,CPT,,,facility,outpatient,,,155.00000,93.00000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,31.03,118.79,fee schedule,
HC AMPHETAMINE URINE PRESUMPTIVE,83000158,CDM,301,RC,80307,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,18.62,118.79,fee schedule,
HC URINE TOX MULTIPLE DRUG CLASSES PRESUMPTIVE,83000165,CDM,301,RC,80307,CPT,,,facility,outpatient,,,535.00000,321.00000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,60.28,401.25,fee schedule,
HC AMIKACIN PEAK,83000166,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Medicare Advantage,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN TROUGH,83000167,CDM,301,RC,80150,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Medicare Advantage,,15.83,,,,,,,14.63,68.25,fee schedule,
HC AMIKACIN,83000168,CDM,301,RC,80150,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,15.83,,,,,,,14.63,60.75,fee schedule,
HC CARBAMAZEPINE,83000173,CDM,301,RC,80156,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,15.30,,,,,,,14.13,75.75,fee schedule,
HC DIGOXIN TOTAL,83000176,CDM,301,RC,80162,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,13.94,,,,,,,10.21,38.25,fee schedule,
HC VALPROIC ACID TOTAL,83000177,CDM,301,RC,80164,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,14.22,,,,,,,13.13,75.75,fee schedule,
HC GENTAMICIN TROUGH,83000179,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN PEAK,83000180,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC GENTAMICIN RANDOM LEVEL,83000181,CDM,301,RC,80170,CPT,,,facility,outpatient,,,133.00000,79.80000,WellCare of North Carolina,Medicare Advantage,,17.20,,,,,,,15.89,99.75,fee schedule,
HC LIDOCAINE,83000183,CDM,301,RC,80176,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Medicare Advantage,,15.42,,,,,,,12.61,47.25,fee schedule,
HC LITHIUM,83000184,CDM,301,RC,80178,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.94,,,,,,,6.41,75.75,fee schedule,
HC PHENOBARBITAL,83000187,CDM,301,RC,80184,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Medicare Advantage,,16.07,,,,,,,5.81,28.26,fee schedule,
HC DILANTIN PHENYTOIN,83000188,CDM,301,RC,80185,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,13.91,,,,,,,12.41,46.50,fee schedule,
HC FREE DILANTIN PHENYTOIN,83000189,CDM,301,RC,80186,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Medicare Advantage,,14.45,,,,,,,13.35,54.00,fee schedule,
HC SIROLUMUS RAPMUNE,83000191,CDM,301,RC,80195,CPT,,,facility,outpatient,,,177.00000,106.20000,WellCare of North Carolina,Medicare Advantage,,14.42,,,,,,,13.32,132.75,fee schedule,
HC TACROLIMUS,83000193,CDM,301,RC,80197,CPT,,,facility,outpatient,,,124.00000,74.40000,WellCare of North Carolina,Medicare Advantage,,14.42,,,,,,,13.32,93.00,fee schedule,
HC THEOPHYLLINE,83000194,CDM,301,RC,80198,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Medicare Advantage,,14.85,,,,,,,7.81,30.17,fee schedule,
HC TOBRAMYCIN PEAK,83000195,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMCYIN,83000196,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC TOBRAMYCIN RANDOM,83000197,CDM,301,RC,80200,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Medicare Advantage,,16.94,,,,,,,15.65,108.75,fee schedule,
HC VANCOMYCIN PEAK,83000200,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN TROUGH,83000201,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC VANCOMYCIN RANDOM,83000202,CDM,301,RC,80202,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Medicare Advantage,,14.22,,,,,,,13.13,67.50,fee schedule,
HC CORTISOL STIMULATION,83000222,CDM,301,RC,80400,CPT,,,facility,outpatient,,,154.00000,92.40000,WellCare of North Carolina,Medicare Advantage,,34.25,,,,,,,30.83,115.50,fee schedule,
HC ACETONE QUALITATIVE,83000228,CDM,301,RC,82009,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Medicare Advantage,,4.75,,,,,,,4.38,21.75,fee schedule,
HC URINE KETONES,83000229,CDM,301,RC,82010,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Medicare Advantage,,8.58,,,,,,,7.92,32.25,fee schedule,
HC BETA HYDROXYBUTYRATE,83000231,CDM,301,RC,82010,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,8.58,,,,,,,7.92,75.75,fee schedule,
HC ALBUMIN,83000235,CDM,301,RC,82040,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,5.20,,,,,,,4.80,36.75,fee schedule,
HC ALBUMIN OTHER FLUID,83000237,CDM,301,RC,82042,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Medicare Advantage,,8.17,,,,,,,7.55,31.50,fee schedule,
HC URINARY MICRO ALBUMIN RANDOM,83000239,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Medicare Advantage,,6.07,,,,,,,5.61,23.25,fee schedule,
HC MICRO ALBUMIN URINE QUANT,83000240,CDM,301,RC,82043,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Medicare Advantage,,6.07,,,,,,,5.61,23.25,fee schedule,
HC ALCOHOL BY IMMUNOASSAY AND ENZYMATIC METHOD,83000243,CDM,301,RC,82077,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Medicare Advantage,,18.13,,,,,,,16.75,141.00,fee schedule,
HC A1 ANTITRYPSIN,83000248,CDM,301,RC,82103,CPT,,,facility,outpatient,,,48.00000,28.80000,WellCare of North Carolina,Medicare Advantage,,14.11,,,,,,,9.61,36.00,fee schedule,
HC ALPHA FETOPROTEIN MATERNAL,83000251,CDM,301,RC,82105,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Medicare Advantage,,17.61,,,,,,,16.27,121.50,fee schedule,
HC AMMONIA,83000260,CDM,301,RC,82140,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,15.30,,,,,,,14.13,60.75,fee schedule,
HC AMYLASE,83000265,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE BODY FLUID,83000266,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC AMYLASE TIMED URINE,83000267,CDM,301,RC,82150,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Medicare Advantage,,6.80,,,,,,,6.29,86.25,fee schedule,
HC BETA 2 MICROGLOBULIN,83000284,CDM,301,RC,82232,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Medicare Advantage,,16.99,,,,,,,15.69,75.00,fee schedule,
HC BILIRUBIN TOTAL,83000289,CDM,301,RC,82247,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Medicare Advantage,,5.27,,,,,,,4.87,31.50,fee schedule,
HC BILIRUBIN BODY FLUID,83000290,CDM,301,RC,82247,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Medicare Advantage,,5.27,,,,,,,4.87,69.75,fee schedule,
HC BILIRUBIN DIRECT,83000292,CDM,301,RC,82248,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,5.27,,,,,,,4.87,48.75,fee schedule,
HC FECAL OCCULT BLOOD SINGLE DETERM,83000297,CDM,301,RC,82270,CPT,,,facility,outpatient,,,60.00000,36.00000,WellCare of North Carolina,Medicare Advantage,,4.60,,,,,,,4.25,45.00,fee schedule,
HC GASTRIC OCCULT TESTING,83000298,CDM,301,RC,82271,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Medicare Advantage,,5.59,,,,,,,5.16,30.00,fee schedule,
HC FECAL OCCULT BLOOD 1 TO 3 DETERM,83000299,CDM,301,RC,82272,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Medicare Advantage,,4.44,,,,,,,4.10,30.00,fee schedule,
HC VITAMIN D 25 OH,83000302,CDM,301,RC,82306,CPT,,,facility,outpatient,,,166.00000,99.60000,WellCare of North Carolina,Medicare Advantage,,31.08,,,,,,,28.71,124.50,fee schedule,
HC CALCIUM,83000303,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Medicare Advantage,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM RANDOM URINE,83000304,CDM,301,RC,82310,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Medicare Advantage,,5.42,,,,,,,5.01,66.75,fee schedule,
HC CALCIUM URINE 24HR,83000307,CDM,301,RC,82340,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Medicare Advantage,,6.33,,,,,,,5.85,49.50,fee schedule,
HC CARBON DIOXIDE CO 2,83000310,CDM,301,RC,82374,CPT,,,facility,outpatient,,,53.00000,31.80000,WellCare of North Carolina,Medicare Advantage,,5.12,,,,,,,4.73,39.75,fee schedule,
HC CARBOXYHEMOGLOBIN,83000312,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CARBON MONOXIDE SAT,83000313,CDM,301,RC,82375,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,12.94,,,,,,,11.95,48.75,fee schedule,
HC CEA,83000314,CDM,301,RC,82378,CPT,,,facility,outpatient,,,258.00000,154.80000,WellCare of North Carolina,Medicare Advantage,,19.91,,,,,,,18.39,193.50,fee schedule,
HC CERULOPLASMIN,83000319,CDM,301,RC,82390,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Medicare Advantage,,11.28,,,,,,,10.42,47.25,fee schedule,
HC ADP 5 SECRETION,83000320,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,14.83,,,,,,,13.70,71.25,fee schedule,
HC ADP 10 SECRETION,83000321,CDM,301,RC,82397,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,14.83,,,,,,,13.70,71.25,fee schedule,
HC CHLORIDE SERUM,83000330,CDM,301,RC,82435,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,4.83,,,,,,,4.46,27.00,fee schedule,
HC CHLORIDE URINE 24 HR,83000331,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE URINE,83000333,CDM,301,RC,82436,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,6.04,,,,,,,5.58,27.00,fee schedule,
HC CHLORIDE OTHER FLUID,83000335,CDM,301,RC,82438,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Medicare Advantage,,5.25,,,,,,,4.80,18.00,fee schedule,
HC CHOLESTEROL,83000336,CDM,301,RC,82465,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Medicare Advantage,,4.57,,,,,,,4.22,49.50,fee schedule,
HC CAFFEINE BY HPLC,83000343,CDM,301,RC,80155,CPT,,,facility,outpatient,,,243.00000,145.80000,WellCare of North Carolina,Medicare Advantage,,40.50,,,,,,,28.73,182.25,fee schedule,
HC VORICONAZOLE,83000344,CDM,301,RC,80285,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Medicare Advantage,,28.47,,,,,,,18.02,67.50,fee schedule,
HC POSACONAZOLE CHROMATOGRAPHY,83000345,CDM,301,RC,80187,CPT,,,facility,outpatient,,,90.00000,54.00000,WellCare of North Carolina,Medicare Advantage,,28.47,,,,,,,18.02,67.50,fee schedule,
HC FLUCONAZOLE,83000346,CDM,301,RC,80299,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Medicare Advantage,,19.57,,,,,,,18.08,135.00,fee schedule,
HC CORTISOL,83000360,CDM,301,RC,82533,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Medicare Advantage,,17.11,,,,,,,15.81,69.75,fee schedule,
HC EVEROLIMUS,83000375,CDM,301,RC,80169,CPT,,,facility,outpatient,,,146.00000,87.60000,WellCare of North Carolina,Medicare Advantage,,14.42,,,,,,,13.32,109.50,fee schedule,
HC CREATINE KINASE,83000383,CDM,301,RC,82550,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,6.84,,,,,,,6.31,36.75,fee schedule,
HC CREATINE KINASE MB,83000385,CDM,301,RC,82553,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Medicare Advantage,,12.13,,,,,,,11.20,59.25,fee schedule,
HC CREATININE,83000386,CDM,301,RC,82565,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Medicare Advantage,,5.38,,,,,,,4.97,29.25,fee schedule,
HC CREATININE OTHER SOURCE,83000389,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,48.75,fee schedule,
HC CREATININE RANDOM URINE,83000390,CDM,301,RC,82570,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,48.75,fee schedule,
HC ESTRADIOL TOTAL,83000418,CDM,301,RC,82670,CPT,,,facility,outpatient,,,299.00000,179.40000,WellCare of North Carolina,Medicare Advantage,,29.34,,,,,,,27.10,224.25,fee schedule,
HC ETHYLINE GLYCOL,83000421,CDM,301,RC,82693,CPT,,,facility,outpatient,,,6.00000,3.60000,WellCare of North Carolina,Medicare Advantage,,15.64,,,,,,,1.20,31.74,fee schedule,
HC FAT STOOL,83000423,CDM,301,RC,82705,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Medicare Advantage,,5.36,,,,,,,4.95,69.75,fee schedule,
HC FERRITIN,83000427,CDM,301,RC,82728,CPT,,,facility,outpatient,,,201.00000,120.60000,WellCare of North Carolina,Medicare Advantage,,14.31,,,,,,,13.22,150.75,fee schedule,
HC FETAL FIBRONECTIN,83000428,CDM,301,RC,82731,CPT,,,facility,outpatient,,,579.00000,347.40000,WellCare of North Carolina,Medicare Advantage,,67.63,,,,,,,62.48,434.25,fee schedule,
HC ASSAY OF FOLIC ACID SERUM,83000429,CDM,301,RC,82746,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Medicare Advantage,,15.44,,,,,,,14.26,117.75,fee schedule,
HC IMMUNOGLOBULIN G,83000432,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN A,83000434,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN G,83000435,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC IMMUNOGLOBULIN M,83000437,CDM,301,RC,82784,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Medicare Advantage,,9.77,,,,,,,9.02,91.50,fee schedule,
HC VENOUS PH,83000445,CDM,301,RC,82800,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Medicare Advantage,,11.55,,,,,,,7.81,29.25,fee schedule,
HC OR BLOOD GAS PACKAGE,83000447,CDM,301,RC,82803,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Medicare Advantage,,27.37,,,,,,,25.29,141.00,fee schedule,
HC ARTERIAL BLOOD GAS,83000448,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC VENOUS BLOOD GASES,83000449,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC NEONATAL BLOOD GAS,83000450,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC BLOOD GASES,83000451,CDM,301,RC,82805,CPT,,,facility,outpatient,,,203.00000,121.80000,WellCare of North Carolina,Medicare Advantage,,82.71,,,,,,,40.64,152.25,fee schedule,
HC O2 SATURATION MEASURED,83000452,CDM,301,RC,82810,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,10.26,,,,,,,9.48,38.25,fee schedule,
HC GLUCOSE BODY FLUID,83000455,CDM,301,RC,82945,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Medicare Advantage,,4.13,,,,,,,3.81,22.50,fee schedule,
HC CSF GLUCOSE,83000456,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE 24 HR URINE,83000457,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE URINE,83000458,CDM,301,RC,82945,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Medicare Advantage,,4.13,,,,,,,3.81,82.50,fee schedule,
HC GLUCOSE,83000460,CDM,301,RC,82947,CPT,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Medicare Advantage,,4.13,,,,,,,3.81,53.25,fee schedule,
HC 2HR PC SUGAR LAB TEST,83000464,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,WellCare of North Carolina,Medicare Advantage,,4.99,,,,,,,4.61,128.25,fee schedule,
HC GTT 3 SPECIMENS,83000468,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Medicare Advantage,,13.51,,,,,,,12.48,121.50,fee schedule,
HC GLUCOSE ADDITIONAL SPECIMEN GTT,83000470,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Medicare Advantage,,4.12,,,,,,,3.80,23.25,fee schedule,
HC TOLERANCE TEST EACH ADDITIONAL OVER 3 SPECIMENS,83000471,CDM,301,RC,82952,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Medicare Advantage,,4.12,,,,,,,3.80,23.25,fee schedule,
HC GGT,83000473,CDM,301,RC,82977,CPT,,,facility,outpatient,,,78.00000,46.80000,WellCare of North Carolina,Medicare Advantage,,7.56,,,,,,,6.98,58.50,fee schedule,
HC FSH,83000476,CDM,301,RC,83001,CPT,,,facility,outpatient,,,238.00000,142.80000,WellCare of North Carolina,Medicare Advantage,,19.51,,,,,,,18.02,178.50,fee schedule,
HC LH,83000478,CDM,301,RC,83002,CPT,,,facility,outpatient,,,156.00000,93.60000,WellCare of North Carolina,Medicare Advantage,,19.45,,,,,,,17.96,117.00,fee schedule,
HC HAPTOGLOBIN,83000481,CDM,301,RC,83010,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Medicare Advantage,,13.21,,,,,,,12.20,69.75,fee schedule,
HC HEMOGLOBIN ELECTROPHORESIS,83000484,CDM,301,RC,83020,CPT,,,facility,outpatient,,,221.00000,132.60000,WellCare of North Carolina,Medicare Advantage,,13.51,,,,,,,12.48,165.75,fee schedule,
HC HB THAL PROFILE,83000488,CDM,301,RC,83021,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Medicare Advantage,,18.96,,,,,,,17.52,90.00,fee schedule,
HC APT TEST FOR FETAL HGB,83000490,CDM,301,RC,83033,CPT,,,facility,outpatient,,,152.00000,91.20000,WellCare of North Carolina,Medicare Advantage,,8.40,,,,,,,7.76,114.00,fee schedule,
HC HGB A1C POCT,83000491,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,10.20,,,,,,,9.42,48.75,fee schedule,
HC METHEMOGLOBIN,83000492,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Medicare Advantage,,8.61,,,,,,,7.95,35.25,fee schedule,
HC METHEMOGLOBIN SAT,83000493,CDM,301,RC,83050,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Medicare Advantage,,8.61,,,,,,,7.95,35.25,fee schedule,
HC HEMOSIDERIN,83000495,CDM,301,RC,83070,CPT,,,facility,outpatient,,,23.00000,13.80000,WellCare of North Carolina,Medicare Advantage,,4.99,,,,,,,4.60,17.25,fee schedule,
HC HOMOCYSTEINE,83000497,CDM,301,RC,83090,CPT,,,facility,outpatient,,,197.00000,118.20000,WellCare of North Carolina,Medicare Advantage,,18.82,,,,,,,17.38,147.75,fee schedule,
HC ANTI MITOCHONDRIAL AB,83000512,CDM,302,RC,86381,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Medicare Advantage,,26.72,,,,,,,23.38,99.00,fee schedule,
HC ANCA MPO ELISA,83000513,CDM,301,RC,83516,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Medicare Advantage,,12.11,,,,,,,8.01,30.00,fee schedule,
HC ANCA PR3 ELISA,83000514,CDM,301,RC,83516,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Medicare Advantage,,12.11,,,,,,,11.18,63.00,fee schedule,
HC INSULIN,83000576,CDM,301,RC,83525,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Medicare Advantage,,12.00,,,,,,,7.61,28.50,fee schedule,
HC IRON,83000577,CDM,301,RC,83540,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.79,,,,,,,6.28,75.75,fee schedule,
HC LACTIC ACID,83000578,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,12.15,,,,,,,11.22,48.75,fee schedule,
HC LDH,83000579,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Medicare Advantage,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LD SERUM,83000580,CDM,301,RC,83615,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Medicare Advantage,,6.34,,,,,,,5.86,60.00,fee schedule,
HC LACTOFERRIN,83000582,CDM,301,RC,83630,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,20.68,,,,,,,10.81,41.83,fee schedule,
HC LAMELLAR BODY COUNT,83000586,CDM,301,RC,83664,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Medicare Advantage,,20.29,,,,,,,8.41,40.33,fee schedule,
HC LIPASE,83000587,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Medicare Advantage,,7.23,,,,,,,6.68,118.50,fee schedule,
HC LIPASE OTHER FLUID,83000589,CDM,301,RC,83690,CPT,,,facility,outpatient,,,158.00000,94.80000,WellCare of North Carolina,Medicare Advantage,,7.23,,,,,,,6.68,118.50,fee schedule,
HC HDL CHOLESTEROL,83000593,CDM,301,RC,83718,CPT,,,facility,outpatient,,,149.00000,89.40000,WellCare of North Carolina,Medicare Advantage,,8.60,,,,,,,7.94,111.75,fee schedule,
HC LDL DIRECT,83000594,CDM,301,RC,83721,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Medicare Advantage,,11.03,,,,,,,10.19,54.00,fee schedule,
HC MAGNESIUM,83000595,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM 24 HR URINE,83000596,CDM,301,RC,83735,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,7.04,,,,,,,6.50,40.50,fee schedule,
HC MAGNESIUM URINE,83000598,CDM,301,RC,83735,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Medicare Advantage,,7.04,,,,,,,6.21,23.25,fee schedule,
HC MYOGLOBIN URINE,83000618,CDM,301,RC,83874,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Medicare Advantage,,13.57,,,,,,,7.61,28.50,fee schedule,
HC PROBNP,83000619,CDM,301,RC,83880,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Medicare Advantage,,41.22,,,,,,,20.02,75.00,fee schedule,
HC FREE KAPPA LIGHT CHAINS,83000621,CDM,301,RC,83521,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Medicare Advantage,,18.13,,,,,,,16.75,107.25,fee schedule,
HC FREE LAMBDA LIGHT CHAINS,83000622,CDM,301,RC,83521,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,18.13,,,,,,,16.22,60.75,fee schedule,
HC OSMOLALITY SERUM,83000636,CDM,301,RC,83930,CPT,,,facility,outpatient,,,83.00000,49.80000,WellCare of North Carolina,Medicare Advantage,,6.94,,,,,,,6.41,62.25,fee schedule,
HC OSMOLALITY URINE,83000637,CDM,301,RC,83935,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,7.16,,,,,,,6.62,71.25,fee schedule,
HC PARATHYROID HORMONE INTRAOPERATIVE,83000640,CDM,301,RC,83970,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Medicare Advantage,,43.34,,,,,,,28.63,107.25,fee schedule,
HC PTH,83000641,CDM,301,RC,83970,CPT,,,facility,outpatient,,,177.00000,106.20000,WellCare of North Carolina,Medicare Advantage,,43.34,,,,,,,35.44,132.75,fee schedule,
HC PH FLUID,83000642,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FECAL,83000643,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC PH FLUID NOT BLOOD,83000644,CDM,301,RC,83986,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Medicare Advantage,,3.76,,,,,,,3.47,19.50,fee schedule,
HC ALKALINE PHOSPHATASE,83000648,CDM,301,RC,84075,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,43.50,fee schedule,
HC PHOSPHOROUS SERUM,83000653,CDM,301,RC,84100,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,4.98,,,,,,,4.60,38.25,fee schedule,
HC PHOSPHORUS 24 HR URINE,83000657,CDM,301,RC,84105,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Medicare Advantage,,6.07,,,,,,,5.61,80.25,fee schedule,
HC PHOSPHORUS URINE,83000658,CDM,301,RC,84105,CPT,,,facility,outpatient,,,2.00000,1.20000,WellCare of North Carolina,Medicare Advantage,,6.07,,,,,,,0.40040,11.03,fee schedule,
HC AMNISURE,83000661,CDM,301,RC,84112,CPT,,,facility,outpatient,,,329.00000,197.40000,WellCare of North Carolina,Medicare Advantage,,103.02,,,,,,,65.87,246.75,fee schedule,
HC POTASSIUM,83000665,CDM,301,RC,84132,CPT,,,facility,outpatient,,,55.00000,33.00000,WellCare of North Carolina,Medicare Advantage,,5.00,,,,,,,4.62,41.25,fee schedule,
HC POTASSIUM URINE,83000668,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM RANDOM URINE,83000669,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC POTASSIUM OTHER FLUID,83000670,CDM,301,RC,84133,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,4.97,,,,,,,4.59,27.00,fee schedule,
HC PREALBUMIN,83000671,CDM,301,RC,84134,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,15.32,,,,,,,14.15,57.75,fee schedule,
HC PROGESTERONE,83000673,CDM,301,RC,84144,CPT,,,facility,outpatient,,,146.00000,87.60000,WellCare of North Carolina,Medicare Advantage,,21.90,,,,,,,20.23,109.50,fee schedule,
HC PROLACTIN,83000674,CDM,301,RC,84146,CPT,,,facility,outpatient,,,227.00000,136.20000,WellCare of North Carolina,Medicare Advantage,,20.35,,,,,,,18.80,170.25,fee schedule,
HC PSA SCREENING,83000675,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,WellCare of North Carolina,Medicare Advantage,,19.31,,,,,,,17.84,161.25,fee schedule,
HC PSA DIAGNOSTIC,83000676,CDM,301,RC,84153,CPT,,,facility,outpatient,,,215.00000,129.00000,WellCare of North Carolina,Medicare Advantage,,19.31,,,,,,,17.84,161.25,fee schedule,
HC TOTAL PROTEIN,83000678,CDM,301,RC,84155,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Medicare Advantage,,3.85,,,,,,,3.56,33.75,fee schedule,
HC TOTAL PROTEIN URINE,83000680,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN 24 HR URINE,83000681,CDM,301,RC,84156,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,3.85,,,,,,,3.56,45.75,fee schedule,
HC TOTAL PROTEIN OTHER FLUID,83000683,CDM,301,RC,84157,CPT,,,facility,outpatient,,,53.00000,31.80000,WellCare of North Carolina,Medicare Advantage,,4.20,,,,,,,3.88,39.75,fee schedule,
HC SERUM PROTEIN ELECTROPHORESIS,83000685,CDM,301,RC,84165,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Medicare Advantage,,11.28,,,,,,,10.42,75.00,fee schedule,
HC CSF IMMUNOGLOBULIN PROF,83000688,CDM,301,RC,84166,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Medicare Advantage,,18.72,,,,,,,10.01,38.02,fee schedule,
HC PROTEIN ELECTROPHORESIS URINE,83000690,CDM,301,RC,84166,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Medicare Advantage,,18.72,,,,,,,13.21,49.50,fee schedule,
HC SODIUM,83000708,CDM,301,RC,84295,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Medicare Advantage,,5.05,,,,,,,4.67,33.75,fee schedule,
HC SODIUM RANDOM,83000711,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Medicare Advantage,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM 24 HR URINE,83000712,CDM,301,RC,84300,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Medicare Advantage,,5.31,,,,,,,4.91,24.00,fee schedule,
HC SODIUM OTHER SOURCE,83000713,CDM,301,RC,84302,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Medicare Advantage,,5.10,,,,,,,4.71,32.25,fee schedule,
HC FLUID SPECIFIC GRAVITY,83000720,CDM,301,RC,84315,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Medicare Advantage,,3.44,,,,,,,3.00,11.25,fee schedule,
HC TESTOSTERONE TOTAL,83000726,CDM,301,RC,84403,CPT,,,facility,outpatient,,,167.00000,100.20000,WellCare of North Carolina,Medicare Advantage,,27.10,,,,,,,25.04,125.25,fee schedule,
HC T4 RIA TOTAL,83000731,CDM,301,RC,84436,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Medicare Advantage,,7.21,,,,,,,6.66,33.75,fee schedule,
HC FREE T4,83000732,CDM,301,RC,84439,CPT,,,facility,outpatient,,,160.00000,96.00000,WellCare of North Carolina,Medicare Advantage,,9.47,,,,,,,8.75,120.00,fee schedule,
HC TSH,83000734,CDM,301,RC,84443,CPT,,,facility,outpatient,,,190.00000,114.00000,WellCare of North Carolina,Medicare Advantage,,17.64,,,,,,,16.30,142.50,fee schedule,
HC AST,83000738,CDM,301,RC,84450,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,45.75,fee schedule,
HC ALT,83000739,CDM,301,RC,84460,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Medicare Advantage,,5.57,,,,,,,5.14,54.00,fee schedule,
HC TRANSFERRIN,83000740,CDM,301,RC,84466,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Medicare Advantage,,13.40,,,,,,,12.38,55.50,fee schedule,
HC TRIGLYCERIDES,83000741,CDM,301,RC,84478,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Medicare Advantage,,6.03,,,,,,,5.57,49.50,fee schedule,
HC T3 TOTAL,83000743,CDM,301,RC,84480,CPT,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Medicare Advantage,,14.89,,,,,,,13.75,100.50,fee schedule,
HC FREE T3,83000744,CDM,301,RC,84481,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Medicare Advantage,,17.79,,,,,,,16.43,97.50,fee schedule,
HC TROPONIN,83000745,CDM,301,RC,84484,CPT,,,facility,outpatient,,,108.00000,64.80000,WellCare of North Carolina,Medicare Advantage,,13.09,,,,,,,12.10,81.00,fee schedule,
HC BUN,83000746,CDM,301,RC,84520,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,4.15,,,,,,,3.83,27.00,fee schedule,
HC UREA NITROGEN URINE,83000749,CDM,301,RC,84540,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Medicare Advantage,,5.84,,,,,,,5.39,28.50,fee schedule,
HC URIC ACID,83000750,CDM,301,RC,84550,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,4.75,,,,,,,4.38,57.75,fee schedule,
HC URIC ACID URINE,83000751,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Medicare Advantage,,5.33,,,,,,,4.93,86.25,fee schedule,
HC URIC ACID BODY FLUID,83000753,CDM,301,RC,84560,CPT,,,facility,outpatient,,,115.00000,69.00000,WellCare of North Carolina,Medicare Advantage,,5.33,,,,,,,4.93,86.25,fee schedule,
HC ALCOHOL ISOPROPYL PRESUMPTIVE,83000763,CDM,301,RC,80307,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,26.03,118.79,fee schedule,
HC ALCOHOL METHYL PRESUMPTIVE,83000764,CDM,301,RC,80307,CPT,,,facility,outpatient,,,193.00000,115.80000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,38.64,144.75,fee schedule,
HC BETA HCG QUANTITATIVE,83000768,CDM,301,RC,84702,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,15.80,,,,,,,10.81,40.50,fee schedule,
HC PSEUDOCHOLINESTERASE,83000772,CDM,301,RC,82480,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Medicare Advantage,,8.26,,,,,,,7.63,59.25,fee schedule,
HC ALLERGEN SPECIFIC IGE,83000791,CDM,302,RC,86003,CPT,,,facility,outpatient,,,12.00000,7.20000,WellCare of North Carolina,Medicare Advantage,,5.48,,,,,,,2.40,11.11,fee schedule,
HC NEUTROPHIL AB GA,83000792,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,WellCare of North Carolina,Medicare Advantage,,15.80,,,,,,,14.60,278.25,fee schedule,
HC NEUTROPHIL AB GIF,83000793,CDM,302,RC,86021,CPT,,,facility,outpatient,,,371.00000,222.60000,WellCare of North Carolina,Medicare Advantage,,15.80,,,,,,,14.60,278.25,fee schedule,
HC HAT ANTI PF4 ANTIBODY,83000795,CDM,302,RC,86022,CPT,,,facility,outpatient,,,225.00000,135.00000,WellCare of North Carolina,Medicare Advantage,,19.29,,,,,,,17.82,168.75,fee schedule,
HC ANA ANTIBODY TITER,83000800,CDM,302,RC,86039,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Medicare Advantage,,11.72,,,,,,,6.41,24.00,fee schedule,
HC C REACTIVE PROTEIN,83000802,CDM,302,RC,86140,CPT,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,105.00,fee schedule,
HC C REACTIVE PROTEIN HI SENSITIVITY,83000803,CDM,302,RC,86141,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Medicare Advantage,,13.60,,,,,,,12.56,84.75,fee schedule,
HC BETA 2 GLYCOPROTEIN 1 AB,83000805,CDM,302,RC,86146,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Medicare Advantage,,26.72,,,,,,,19.42,72.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGG,83000808,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,26.72,,,,,,,16.22,60.75,fee schedule,
HC ANTIBODY CARDIOLIPIN AB IGM,83000809,CDM,302,RC,86147,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,26.72,,,,,,,16.22,60.75,fee schedule,
HC COMPLEMENT ANTIGEN,83000815,CDM,302,RC,86160,CPT,,,facility,outpatient,,,137.00000,82.20000,WellCare of North Carolina,Medicare Advantage,,12.60,,,,,,,11.64,102.75,fee schedule,
HC ANTI DNA,83000828,CDM,302,RC,86225,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Medicare Advantage,,14.43,,,,,,,13.33,90.00,fee schedule,
HC DS DNA ANTIBODY,83000829,CDM,302,RC,86225,CPT,,,facility,outpatient,,,8.00000,4.80000,WellCare of North Carolina,Medicare Advantage,,14.43,,,,,,,1.60,29.29,fee schedule,
HC ENA SCREEN,83000843,CDM,302,RC,86235,CPT,,,facility,outpatient,,,22.00000,13.20000,WellCare of North Carolina,Medicare Advantage,,18.83,,,,,,,4.40,38.23,fee schedule,
HC ENA ANTIBODY,83000848,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,WellCare of North Carolina,Medicare Advantage,,18.83,,,,,,,17.39,79.50,fee schedule,
HC TITER EACH ANTIBODY,83000857,CDM,302,RC,86256,CPT,,,facility,outpatient,,,174.00000,104.40000,WellCare of North Carolina,Medicare Advantage,,12.65,,,,,,,11.69,130.50,fee schedule,
HC DS DNA AB TITER,83000860,CDM,302,RC,86256,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Medicare Advantage,,12.65,,,,,,,7.41,27.75,fee schedule,
HC CA 19 9,83000873,CDM,302,RC,86301,CPT,,,facility,outpatient,,,128.00000,76.80000,WellCare of North Carolina,Medicare Advantage,,21.85,,,,,,,20.19,96.00,fee schedule,
HC CA 125,83000874,CDM,302,RC,86304,CPT,,,facility,outpatient,,,267.00000,160.20000,WellCare of North Carolina,Medicare Advantage,,21.85,,,,,,,20.19,200.25,fee schedule,
HC MONONUCLEOSIS SCREEN,83000877,CDM,302,RC,86308,CPT,,,facility,outpatient,,,147.00000,88.20000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,110.25,fee schedule,
HC IMMUNOELECTROPHORESIS,83000903,CDM,302,RC,86320,CPT,,,facility,outpatient,,,273.00000,163.80000,WellCare of North Carolina,Medicare Advantage,,31.42,,,,,,,29.02,204.75,fee schedule,
HC IMMUNOFIXATION ELECTROPH SERUM,83000907,CDM,302,RC,86334,CPT,,,facility,outpatient,,,207.00000,124.20000,WellCare of North Carolina,Medicare Advantage,,23.46,,,,,,,21.67,155.25,fee schedule,
HC IMMUNOFIX ELECTROPHOR FLUID,83000910,CDM,302,RC,86335,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Medicare Advantage,,30.82,,,,,,,10.01,62.57,fee schedule,
HC B CELLS TOTAL COUNT,83000916,CDM,302,RC,86355,CPT,,,facility,outpatient,,,237.00000,142.20000,WellCare of North Carolina,Medicare Advantage,,39.62,,,,,,,36.60,177.75,fee schedule,
HC FETAL HEMOGL. BY FLOW CYT.,83000918,CDM,302,RC,86356,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Medicare Advantage,,28.12,,,,,,,25.98,141.00,fee schedule,
HC UNLISTED FLOW ANTIGEN EACH,83000921,CDM,302,RC,86356,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,28.12,,,,,,,23.62,88.50,fee schedule,
HC PNH FLAER,83000922,CDM,311,RC,88184,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,374.62,,,,,,,16.22,381.82,fee schedule,
HC NATURAL KILLER CELLS TOTAL COUNT,83000926,CDM,302,RC,86357,CPT,,,facility,outpatient,,,206.00000,123.60000,WellCare of North Carolina,Medicare Advantage,,39.62,,,,,,,36.60,154.50,fee schedule,
HC TOTAL T CELL CD3,83000927,CDM,302,RC,86359,CPT,,,facility,outpatient,,,41.00000,24.60000,WellCare of North Carolina,Medicare Advantage,,39.62,,,,,,,8.21,80.42,fee schedule,
HC CD4 CD8 W RATIO,83000928,CDM,302,RC,86360,CPT,,,facility,outpatient,,,293.00000,175.80000,WellCare of North Carolina,Medicare Advantage,,49.33,,,,,,,45.57,219.75,fee schedule,
HC CD34 TOTAL COUNT,83000929,CDM,302,RC,86367,CPT,,,facility,outpatient,,,201.00000,120.60000,WellCare of North Carolina,Medicare Advantage,,81.67,,,,,,,40.24,150.75,fee schedule,
HC THYROPEROXIDASE AB,83000931,CDM,302,RC,86376,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Medicare Advantage,,15.28,,,,,,,9.21,34.50,fee schedule,
HC CRYPTOCOCCAL ANTIGEN,83000939,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Medicare Advantage,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTOCOCCAL ANTIGEN CSF,83000940,CDM,302,RC,86403,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Medicare Advantage,,12.12,,,,,,,11.19,84.75,fee schedule,
HC CRYPTO AG TITER,83000941,CDM,302,RC,86406,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Medicare Advantage,,11.17,,,,,,,10.01,37.50,fee schedule,
HC RHEUMATOID FACTOR QUANTITATIVE,83000945,CDM,302,RC,86431,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Medicare Advantage,,5.95,,,,,,,5.50,101.25,fee schedule,
HC QUANTIFERON,83000946,CDM,302,RC,86480,CPT,,,facility,outpatient,,,223.00000,133.80000,WellCare of North Carolina,Medicare Advantage,,65.08,,,,,,,44.64,167.25,fee schedule,
HC SKIN TEST PPD,83000949,CDM,302,RC,86580,CPT,,,facility,outpatient,,,21.00000,12.60000,WellCare of North Carolina,Medicare Advantage,,25.50,,,,,,,4.20,25.75,fee schedule,
HC RPR,83000950,CDM,302,RC,86592,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,42.00,fee schedule,
HC RPR TITER,83000952,CDM,302,RC,86593,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Medicare Advantage,,4.62,,,,,,,4.27,42.75,fee schedule,
HC CSF VDRL TITER,83000953,CDM,302,RC,86593,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Medicare Advantage,,4.62,,,,,,,4.27,108.75,fee schedule,
HC LYME DISEASE ANTIBODIES,83000968,CDM,302,RC,86618,CPT,,,facility,outpatient,,,68.00000,40.80000,WellCare of North Carolina,Medicare Advantage,,17.88,,,,,,,13.61,51.00,fee schedule,
HC CMV IGG SEROLOGY,83000988,CDM,302,RC,86644,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Medicare Advantage,,15.11,,,,,,,13.96,87.75,fee schedule,
HC CMV IGM,83000990,CDM,302,RC,86645,CPT,,,facility,outpatient,,,173.00000,103.80000,WellCare of North Carolina,Medicare Advantage,,17.69,,,,,,,16.34,129.75,fee schedule,
HC EBV NA IGG,83001014,CDM,302,RC,86664,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Medicare Advantage,,16.05,,,,,,,14.83,72.75,fee schedule,
HC EBV VCA IGG,83001015,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Medicare Advantage,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EBV VCA IGM,83001016,CDM,302,RC,86665,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Medicare Advantage,,19.05,,,,,,,17.60,87.00,fee schedule,
HC EHRLICHIA ANTIBODIES,83001017,CDM,302,RC,86666,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,10.69,,,,,,,9.87,57.75,fee schedule,
HC EHRLICHIA IGG TITER,83001020,CDM,302,RC,86666,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Medicare Advantage,,10.69,,,,,,,3.00,21.69,fee schedule,
HC GASTRIC UREASE,83001024,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Medicare Advantage,,17.69,,,,,,,16.34,66.75,fee schedule,
HC H PYLORI IGG ANTIBODIES,83001026,CDM,302,RC,86677,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Medicare Advantage,,17.69,,,,,,,16.34,66.75,fee schedule,
HC HTLV I II ANTIBODY,83001033,CDM,302,RC,86687,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Medicare Advantage,,9.54,,,,,,,7.01,26.25,fee schedule,
HC HSV 1 IGG,83001041,CDM,302,RC,86695,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Medicare Advantage,,13.85,,,,,,,9.01,33.75,fee schedule,
HC HSV 2 IGG,83001042,CDM,302,RC,86696,CPT,,,facility,outpatient,,,69.00000,41.40000,WellCare of North Carolina,Medicare Advantage,,20.32,,,,,,,13.81,51.75,fee schedule,
HC HIV SCREEN,83001047,CDM,302,RC,86701,CPT,,,facility,outpatient,,,461.00000,276.60000,WellCare of North Carolina,Medicare Advantage,,9.33,,,,,,,8.62,345.75,fee schedule,
HC SUPPLEMENTAL HIV 1/2 RAPID TEST,83001050,CDM,302,RC,86703,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Medicare Advantage,,14.40,,,,,,,12.61,47.25,fee schedule,
HC HEPATITIS B CORE ANTIBODY IGM,83001053,CDM,302,RC,86705,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Medicare Advantage,,12.36,,,,,,,11.42,91.50,fee schedule,
HC HEPATITIS B SURFACE ANTIBODY,83001055,CDM,302,RC,86706,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Medicare Advantage,,11.28,,,,,,,10.42,54.00,fee schedule,
HC HEPATITIS A ANTIBODY TOTAL,83001057,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,13.01,,,,,,,7.21,27.00,fee schedule,
HC HEPATITIS A ANTIBODY IGM,83001058,CDM,302,RC,86709,CPT,,,facility,outpatient,,,195.00000,117.00000,WellCare of North Carolina,Medicare Advantage,,11.82,,,,,,,10.92,146.25,fee schedule,
HC TRYPANOSOMA CRUZI AB,83001071,CDM,302,RC,86753,CPT,,,facility,outpatient,,,83.00000,49.80000,WellCare of North Carolina,Medicare Advantage,,13.01,,,,,,,12.02,62.25,fee schedule,
HC RMSF IFA,83001076,CDM,302,RC,86757,CPT,,,facility,outpatient,,,11.00000,6.60000,WellCare of North Carolina,Medicare Advantage,,20.32,,,,,,,2.20,41.26,fee schedule,
HC RMSF IFA TITER,83001077,CDM,302,RC,86757,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,20.32,,,,,,,5.61,41.26,fee schedule,
HC RUBEOLA IGG AB,83001080,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Medicare Advantage,,13.52,,,,,,,7.01,27.47,fee schedule,
HC TOXOPLASMA IGG ANTIBODY,83001082,CDM,302,RC,86777,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Medicare Advantage,,15.11,,,,,,,13.96,101.25,fee schedule,
HC TOXOPLASMA IGM ANTIBODY,83001083,CDM,302,RC,86778,CPT,,,facility,outpatient,,,108.00000,64.80000,WellCare of North Carolina,Medicare Advantage,,15.13,,,,,,,13.98,81.00,fee schedule,
HC SYPHILIS TP PA,83001084,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,13.90,,,,,,,10.81,40.50,fee schedule,
HC VARICELLA ZOSTER AB IGG,83001085,CDM,302,RC,86787,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Medicare Advantage,,13.52,,,,,,,11.21,42.00,fee schedule,
HC HEPATITIS C ANTIBODY,83001096,CDM,302,RC,86803,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,14.98,,,,,,,13.84,57.75,fee schedule,
HC FLOW X MATCH 1ST SAMPLE SERUM,83001100,CDM,302,RC,86825,CPT,,,facility,outpatient,,,794.00000,476.40000,WellCare of North Carolina,Medicare Advantage,,114.96,,,,,,,106.21,595.50,fee schedule,
HC HLA FLOW AB SCR CLASS I AND II,83001102,CDM,302,RC,86828,CPT,,,facility,outpatient,,,447.00000,268.20000,WellCare of North Carolina,Medicare Advantage,,67.40,,,,,,,62.26,335.25,fee schedule,
HC HLA FLOW AB SCR CLASS I,83001104,CDM,302,RC,86829,CPT,,,facility,outpatient,,,266.00000,159.60000,WellCare of North Carolina,Medicare Advantage,,67.40,,,,,,,53.25,199.50,fee schedule,
HC HLA FLOW SINGLE ANTIGEN CL 1,83001106,CDM,302,RC,86832,CPT,,,facility,outpatient,,,570.00000,342.00000,WellCare of North Carolina,Medicare Advantage,,339.94,,,,,,,114.11,601.18,fee schedule,
HC HLA FLOW SNGL ANTGN CL 2,83001107,CDM,302,RC,86833,CPT,,,facility,outpatient,,,841.00000,504.60000,WellCare of North Carolina,Medicare Advantage,,342.09,,,,,,,168.37,630.75,fee schedule,
HC ANTIBODY SCREEN,83001112,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY ELUATE,83001116,CDM,302,RC,86860,CPT,,,facility,outpatient,,,296.00000,177.60000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,37.47,222.00,fee schedule,
HC ANTIBODY IDENTIFICATION,83001119,CDM,302,RC,86870,CPT,,,facility,outpatient,,,361.00000,216.60000,WellCare of North Carolina,Medicare Advantage,,374.62,,,,,,,37.47,381.82,fee schedule,
HC DIRECT COOMBS,83001120,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS IGG,83001122,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC DIRECT COOMBS C3,83001123,CDM,302,RC,86880,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Medicare Advantage,,5.66,,,,,,,5.23,63.75,fee schedule,
HC RULE OUT CELL,83001126,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC ANTIBODY TITER,83001127,CDM,302,RC,86886,CPT,,,facility,outpatient,,,233.00000,139.80000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,174.75,fee schedule,
HC ABO GROUP,83001128,CDM,302,RC,86900,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Medicare Advantage,,3.14,,,,,,,2.90,108.75,fee schedule,
HC BLOOD TYPING RH D,83001130,CDM,302,RC,86901,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,3.14,,,,,,,2.90,44.25,fee schedule,
HC DONOR ANTIGEN SCREEN,83001132,CDM,302,RC,86902,CPT,,,facility,outpatient,,,123.00000,73.80000,WellCare of North Carolina,Medicare Advantage,,6.67,,,,,,,6.16,92.25,fee schedule,
HC DONOR ANTIGEN SCREEN ARC,83001133,CDM,302,RC,86902,CPT,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Medicare Advantage,,6.67,,,,,,,6.16,100.50,fee schedule,
HC PATIENT RBC ANTIGEN SCREEN,83001134,CDM,302,RC,86905,CPT,,,facility,outpatient,,,196.00000,117.60000,WellCare of North Carolina,Medicare Advantage,,4.02,,,,,,,3.72,147.00,fee schedule,
HC CROSSMATCH EACH UNIT IMMEDIATE SPIN,83001135,CDM,302,RC,86920,CPT,,,facility,outpatient,,,173.00000,103.80000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,22.03,201.52,fee schedule,
HC ELECTRONIC CROSSMATCH,83001136,CDM,302,RC,86923,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,12.21,201.52,fee schedule,
HC COLD ABSORPTION,83001141,CDM,302,RC,86978,CPT,,,facility,outpatient,,,501.00000,300.60000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,37.47,375.75,fee schedule,
HC WARM ABSORPTION,83001142,CDM,302,RC,86978,CPT,,,facility,outpatient,,,737.00000,442.20000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,37.47,552.75,fee schedule,
HC CELL SEP PHENOTYPING ID,83001144,CDM,302,RC,86999,CPT,,,facility,outpatient,,,126.00000,75.60000,WellCare of North Carolina,Medicare Advantage,,25.50,,,,,,,22.03,94.50,fee schedule,
HC RSV DIRECT ANTIGEN,83001147,CDM,306,RC,87420,CPT,,,facility,outpatient,,,139.00000,83.40000,WellCare of North Carolina,Medicare Advantage,,14.61,,,,,,,13.49,104.25,fee schedule,
HC BLOOD COUNT SMEAR MICRO EXAM W MANUAL DIFF WBC COUNT,83001148,CDM,305,RC,85007,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Medicare Advantage,,3.99,,,,,,,3.69,27.75,fee schedule,
HC HEMOGLOBIN,83001150,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,2.49,,,,,,,2.30,36.75,fee schedule,
HC HEMOGLOBIN WHOLE BLOOD,83001151,CDM,305,RC,85018,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,2.49,,,,,,,2.30,36.75,fee schedule,
HC CBC W DIFFERENTIAL AUTO,83001153,CDM,305,RC,85025,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Medicare Advantage,,8.16,,,,,,,7.54,112.50,fee schedule,
HC COMPLETE CBC AUTOMATED WO DIFF,83001154,CDM,305,RC,85027,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,6.79,,,,,,,6.28,88.50,fee schedule,
HC RETICULOCYTE COUNT AUTO,83001155,CDM,305,RC,85045,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,4.19,,,,,,,3.87,38.25,fee schedule,
HC RETICULOCYTE COUNT AUTO ADDL PARAMETERS,83001156,CDM,305,RC,85046,CPT,,,facility,outpatient,,,93.00000,55.80000,WellCare of North Carolina,Medicare Advantage,,5.85,,,,,,,5.40,69.75,fee schedule,
HC WHITE BLOOD CELL WBC AUTO,83001158,CDM,305,RC,85048,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Medicare Advantage,,2.67,,,,,,,2.46,121.50,fee schedule,
HC PLATELET AUTOMATED,83001159,CDM,305,RC,85049,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,4.70,,,,,,,4.35,57.75,fee schedule,
HC BONE MARROW TECH ASSIST,83001160,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,WellCare of North Carolina,Medicare Advantage,,850.74,,,,,,,53.18,858.84,fee schedule,
HC BN MARROW ASP PREP,83001161,CDM,305,RC,85097,CPT,,,facility,outpatient,,,433.00000,259.80000,WellCare of North Carolina,Medicare Advantage,,850.74,,,,,,,53.18,858.84,fee schedule,
HC FACTOR II ASSAY,83001164,CDM,305,RC,85210,CPT,,,facility,outpatient,,,323.00000,193.80000,WellCare of North Carolina,Medicare Advantage,,13.63,,,,,,,12.59,242.25,fee schedule,
HC FACTOR V ASSAY,83001165,CDM,305,RC,85220,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Medicare Advantage,,18.53,,,,,,,17.12,206.25,fee schedule,
HC FACTOR VII ASSAY,83001166,CDM,305,RC,85230,CPT,,,facility,outpatient,,,291.00000,174.60000,WellCare of North Carolina,Medicare Advantage,,18.80,,,,,,,17.36,218.25,fee schedule,
HC FACTOR VIII ACTIVITY,83001167,CDM,305,RC,85240,CPT,,,facility,outpatient,,,264.00000,158.40000,WellCare of North Carolina,Medicare Advantage,,18.80,,,,,,,17.36,198.00,fee schedule,
HC CHROMOGENIC FACTOR VIII,83001168,CDM,305,RC,85130,CPT,,,facility,outpatient,,,612.00000,367.20000,WellCare of North Carolina,Medicare Advantage,,12.48,,,,,,,11.53,459.00,fee schedule,
HC VON WILLEBRAND FACTOR ACTIVITY,83001169,CDM,305,RC,85245,CPT,,,facility,outpatient,,,161.00000,96.60000,WellCare of North Carolina,Medicare Advantage,,24.09,,,,,,,22.25,120.75,fee schedule,
HC VWF ACTIVITY RISTOCETIN,83001170,CDM,305,RC,85245,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,24.09,,,,,,,15.42,57.75,fee schedule,
HC VON WILLEBRAND FACTOR ANTIGEN,83001171,CDM,305,RC,85246,CPT,,,facility,outpatient,,,237.00000,142.20000,WellCare of North Carolina,Medicare Advantage,,24.09,,,,,,,22.25,177.75,fee schedule,
HC ADAMST 13 ACTIVITY,83001172,CDM,305,RC,85397,CPT,,,facility,outpatient,,,199.00000,119.40000,WellCare of North Carolina,Medicare Advantage,,32.40,,,,,,,29.93,149.25,fee schedule,
HC VWF MULTIMER,83001173,CDM,305,RC,85247,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Medicare Advantage,,24.09,,,,,,,19.82,74.25,fee schedule,
HC FACTOR IX ASSAY,83001174,CDM,305,RC,85250,CPT,,,facility,outpatient,,,325.00000,195.00000,WellCare of North Carolina,Medicare Advantage,,19.99,,,,,,,18.47,243.75,fee schedule,
HC FACTOR X ASSAY,83001175,CDM,305,RC,85260,CPT,,,facility,outpatient,,,271.00000,162.60000,WellCare of North Carolina,Medicare Advantage,,18.80,,,,,,,17.36,203.25,fee schedule,
HC FACTOR XI ASSAY,83001176,CDM,305,RC,85270,CPT,,,facility,outpatient,,,323.00000,193.80000,WellCare of North Carolina,Medicare Advantage,,18.80,,,,,,,17.36,242.25,fee schedule,
HC FACTOR XII ASSAY,83001177,CDM,305,RC,85280,CPT,,,facility,outpatient,,,251.00000,150.60000,WellCare of North Carolina,Medicare Advantage,,20.32,,,,,,,18.77,188.25,fee schedule,
HC FACTOR XIII ASSAY,83001178,CDM,305,RC,85291,CPT,,,facility,outpatient,,,182.00000,109.20000,WellCare of North Carolina,Medicare Advantage,,9.57,,,,,,,8.84,136.50,fee schedule,
HC FLETCHER FACTOR MIX,83001180,CDM,305,RC,85292,CPT,,,facility,outpatient,,,186.00000,111.60000,WellCare of North Carolina,Medicare Advantage,,19.88,,,,,,,18.36,139.50,fee schedule,
HC FITZGERALD FACTOR MIX,83001181,CDM,305,RC,85293,CPT,,,facility,outpatient,,,186.00000,111.60000,WellCare of North Carolina,Medicare Advantage,,19.88,,,,,,,18.36,139.50,fee schedule,
HC ANTITHROMBIN III ACT ASSAY,83001183,CDM,305,RC,85300,CPT,,,facility,outpatient,,,247.00000,148.20000,WellCare of North Carolina,Medicare Advantage,,12.44,,,,,,,11.49,185.25,fee schedule,
HC PROTEIN C ACTIVITY,83001185,CDM,305,RC,85303,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Medicare Advantage,,14.53,,,,,,,13.42,54.00,fee schedule,
HC PROTEIN S ANTIGEN FREE,83001186,CDM,305,RC,85306,CPT,,,facility,outpatient,,,44.00000,26.40000,WellCare of North Carolina,Medicare Advantage,,16.09,,,,,,,8.81,33.00,fee schedule,
HC PROTEIN S ACTIVITY,83001187,CDM,305,RC,85397,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Medicare Advantage,,32.40,,,,,,,29.93,112.50,fee schedule,
HC ACTIVATED PROTEIN C RESISTANCE,83001188,CDM,305,RC,85307,CPT,,,facility,outpatient,,,196.00000,117.60000,WellCare of North Carolina,Medicare Advantage,,16.09,,,,,,,14.86,147.00,fee schedule,
HC BETHESDA INHIBITOR ASSAY,83001189,CDM,305,RC,85335,CPT,,,facility,outpatient,,,468.00000,280.80000,WellCare of North Carolina,Medicare Advantage,,13.51,,,,,,,12.48,351.00,fee schedule,
HC ADAMST 13 INHIBITOR,83001190,CDM,305,RC,85335,CPT,,,facility,outpatient,,,283.00000,169.80000,WellCare of North Carolina,Medicare Advantage,,13.51,,,,,,,12.48,212.25,fee schedule,
HC FACTOR IX INHIBITOR,83001191,CDM,305,RC,85335,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Medicare Advantage,,13.51,,,,,,,12.48,55.50,fee schedule,
HC ACT,83001193,CDM,305,RC,85347,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Medicare Advantage,,4.49,,,,,,,4.15,26.25,fee schedule,
HC FIBRIN DEGRADATION PRODUCT SCREEN,83001194,CDM,305,RC,85362,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Medicare Advantage,,7.23,,,,,,,6.68,42.00,fee schedule,
HC D DIMER QUANT,83001195,CDM,305,RC,85379,CPT,,,facility,outpatient,,,72.00000,43.20000,WellCare of North Carolina,Medicare Advantage,,10.69,,,,,,,9.87,54.00,fee schedule,
HC FIBRINOGEN,83001198,CDM,305,RC,85384,CPT,,,facility,outpatient,,,113.00000,67.80000,WellCare of North Carolina,Medicare Advantage,,10.21,,,,,,,9.43,84.75,fee schedule,
HC PLASMINOGEN ACTIVITY,83001202,CDM,305,RC,85415,CPT,,,facility,outpatient,,,356.00000,213.60000,WellCare of North Carolina,Medicare Advantage,,18.05,,,,,,,16.67,267.00,fee schedule,
HC FETAL BLEED SCREEN,83001205,CDM,305,RC,85461,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,9.83,,,,,,,9.08,46.50,fee schedule,
HC LMW HEPARIN QUANTITATIVE,83001207,CDM,305,RC,85520,CPT,,,facility,outpatient,,,146.00000,87.60000,WellCare of North Carolina,Medicare Advantage,,13.74,,,,,,,12.70,109.50,fee schedule,
HC HEPARIN QUANT,83001208,CDM,305,RC,85520,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Medicare Advantage,,13.74,,,,,,,12.61,47.25,fee schedule,
HC HEPARIN INDUCED PLAT AGG,83001217,CDM,305,RC,85576,CPT,,,facility,outpatient,,,202.00000,121.20000,WellCare of North Carolina,Medicare Advantage,,26.16,,,,,,,24.16,151.50,fee schedule,
HC PLATELET FUNCTION SCREEN,83001242,CDM,305,RC,85576,CPT,,,facility,outpatient,,,143.00000,85.80000,WellCare of North Carolina,Medicare Advantage,,26.16,,,,,,,24.16,107.25,fee schedule,
HC LUPUS HEX PHOS PTT,83001243,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Medicare Advantage,,18.88,,,,,,,17.44,87.75,fee schedule,
HC HEXAGONAL PHOSPHO NEUTRAL,83001244,CDM,305,RC,85598,CPT,,,facility,outpatient,,,117.00000,70.20000,WellCare of North Carolina,Medicare Advantage,,18.88,,,,,,,17.44,87.75,fee schedule,
HC PROTHROMBIN TIME,83001245,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Medicare Advantage,,4.50,,,,,,,4.16,59.25,fee schedule,
HC PROTHROMBIN TIME MIX,83001246,CDM,305,RC,85611,CPT,,,facility,outpatient,,,102.00000,61.20000,WellCare of North Carolina,Medicare Advantage,,4.14,,,,,,,3.82,76.50,fee schedule,
HC LUPUS ANTICOAG,83001248,CDM,305,RC,85613,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Medicare Advantage,,10.06,,,,,,,9.29,42.00,fee schedule,
HC LUPUS DIL RVV TIME DRVVT,83001249,CDM,305,RC,85613,CPT,,,facility,outpatient,,,85.00000,51.00000,WellCare of North Carolina,Medicare Advantage,,10.06,,,,,,,9.29,63.75,fee schedule,
HC LUPUS DIL RVV TIME CONFIRM,83001250,CDM,305,RC,85597,CPT,,,facility,outpatient,,,98.00000,58.80000,WellCare of North Carolina,Medicare Advantage,,18.88,,,,,,,17.44,73.50,fee schedule,
HC REPTILASE TIME,83001251,CDM,305,RC,85635,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Medicare Advantage,,10.34,,,,,,,9.55,42.00,fee schedule,
HC DABIGATRAN,83001252,CDM,305,RC,80299,CPT,,,facility,outpatient,,,224.00000,134.40000,WellCare of North Carolina,Medicare Advantage,,19.57,,,,,,,18.08,168.00,fee schedule,
HC SED RATE,83001253,CDM,305,RC,85651,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,60.00,fee schedule,
HC SICKLE CELL TEST,83001257,CDM,305,RC,85660,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,5.79,,,,,,,5.34,40.50,fee schedule,
HC THROMBIN CLOTTING TIME,83001258,CDM,305,RC,85670,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Medicare Advantage,,6.06,,,,,,,5.60,29.25,fee schedule,
HC THROMBIN CLOTTNG TIME MIX,83001259,CDM,305,RC,85670,CPT,,,facility,outpatient,,,19.00000,11.40000,WellCare of North Carolina,Medicare Advantage,,6.06,,,,,,,3.80,14.25,fee schedule,
HC APTT,83001261,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,6.31,,,,,,,5.83,71.25,fee schedule,
HC LUPUS APTT,83001262,CDM,305,RC,85730,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,6.31,,,,,,,5.83,71.25,fee schedule,
HC APTT MIX,83001264,CDM,305,RC,85732,CPT,,,facility,outpatient,,,47.00000,28.20000,WellCare of North Carolina,Medicare Advantage,,6.79,,,,,,,6.28,35.25,fee schedule,
HC INCUBATED APTT,83001265,CDM,305,RC,85732,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Medicare Advantage,,6.79,,,,,,,3.00,13.80,fee schedule,
HC VISCOSITY,83001266,CDM,305,RC,85810,CPT,,,facility,outpatient,,,41.00000,24.60000,WellCare of North Carolina,Medicare Advantage,,12.25,,,,,,,8.21,30.75,fee schedule,
HC CONCENTRATION ANY TYPE INFECTIOUS AGENT,83001267,CDM,306,RC,87015,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,7.01,,,,,,,6.48,45.75,fee schedule,
HC CULTURE BLOOD ROUTINE,83001268,CDM,306,RC,87040,CPT,,,facility,outpatient,,,188.00000,112.80000,WellCare of North Carolina,Medicare Advantage,,10.84,,,,,,,10.01,141.00,fee schedule,
HC CULTURE BLOOD ISOLATOR,83001269,CDM,306,RC,87040,CPT,,,facility,outpatient,,,122.00000,73.20000,WellCare of North Carolina,Medicare Advantage,,10.84,,,,,,,10.01,91.50,fee schedule,
HC STOOL CULTURE,83001270,CDM,306,RC,87045,CPT,,,facility,outpatient,,,130.00000,78.00000,WellCare of North Carolina,Medicare Advantage,,9.91,,,,,,,9.16,97.50,fee schedule,
HC YERSINIA SCREEN,83001272,CDM,306,RC,87046,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,9.91,,,,,,,9.16,40.50,fee schedule,
HC CAMPYLOBACTER CULTURE,83001273,CDM,306,RC,87046,CPT,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Medicare Advantage,,9.91,,,,,,,9.16,53.25,fee schedule,
HC AEROBIC CULTURE CSF,83001281,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DEVICE,83001283,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE TISSUE,83001284,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC GENITAL CULTURE,83001286,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE WATER,83001288,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE ROUTINE,83001290,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE DIALYSIS,83001291,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC JOINT FLUID CULTURE,83001293,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE  EYE OPTHT,83001294,CDM,306,RC,87070,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,117.75,fee schedule,
HC AEROBIC CULTURE UPPER RESPIRATORY,83001295,CDM,306,RC,87070,CPT,,,facility,outpatient,,,27.00000,16.20000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,5.41,20.25,fee schedule,
HC AEROBIC CULTURE WOUND,83001296,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE LOWER RESPIRATORY,83001297,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC AEROBIC CULTURE VITREOUS WASHING,83001299,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC CULTURE QUANTITATIVE BRONCHIAL,83001301,CDM,306,RC,87071,CPT,,,facility,outpatient,,,53.00000,31.80000,WellCare of North Carolina,Medicare Advantage,,10.38,,,,,,,9.59,39.75,fee schedule,
HC ANAEROBIC CULTURE,83001304,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,WellCare of North Carolina,Medicare Advantage,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ASCITIC FLUID CULTURE,83001305,CDM,306,RC,87075,CPT,,,facility,outpatient,,,187.00000,112.20000,WellCare of North Carolina,Medicare Advantage,,9.94,,,,,,,9.19,140.25,fee schedule,
HC ANAEROBIC CULTURE FLUID,83001306,CDM,306,RC,87075,CPT,,,facility,outpatient,,,97.00000,58.20000,WellCare of North Carolina,Medicare Advantage,,9.94,,,,,,,9.19,72.75,fee schedule,
HC ORGANISM ID BACTERIAL,83001313,CDM,306,RC,87077,CPT,,,facility,outpatient,,,213.00000,127.80000,WellCare of North Carolina,Medicare Advantage,,8.48,,,,,,,7.84,159.75,fee schedule,
HC MICROBIAL ID MANUAL,83001315,CDM,306,RC,87077,CPT,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Medicare Advantage,,8.48,,,,,,,7.84,153.00,fee schedule,
HC MANUAL ID GRAM STAIN,83001323,CDM,306,RC,87077,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Medicare Advantage,,8.48,,,,,,,7.84,55.50,fee schedule,
HC ORGANISM ID DEFINITIVE,83001332,CDM,306,RC,87077,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,8.48,,,,,,,7.84,44.25,fee schedule,
HC GC CULTURE,83001334,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC VRE CULTURE SCREEN,83001337,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC MRSA SCREENING,83001338,CDM,306,RC,87081,CPT,,,facility,outpatient,,,32.00000,19.20000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.41,24.00,fee schedule,
HC GROUP A STREP SCREEN,83001340,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC GROUP B STREP SCREEN,83001341,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC YEAST SCREEN,83001343,CDM,306,RC,87081,CPT,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,153.00,fee schedule,
HC FUNGAL SCREENING PLATE,83001346,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.21,23.25,fee schedule,
HC AFB SCREENING PLATE,83001348,CDM,306,RC,87081,CPT,,,facility,outpatient,,,31.00000,18.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.21,23.25,fee schedule,
HC CULTURE MRSA OUTPATIENT,83001349,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE LEGIONELLA SP,83001351,CDM,306,RC,87081,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,75.75,fee schedule,
HC CULTURE ACTINOMYCES SP,83001352,CDM,306,RC,87081,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,6.43,52.50,fee schedule,
HC URINE CULTURE,83001355,CDM,306,RC,87086,CPT,,,facility,outpatient,,,145.00000,87.00000,WellCare of North Carolina,Medicare Advantage,,8.47,,,,,,,7.83,108.75,fee schedule,
HC DERMATOLOGY SCREEN,83001359,CDM,306,RC,87101,CPT,,,facility,outpatient,,,92.00000,55.20000,WellCare of North Carolina,Medicare Advantage,,8.10,,,,,,,7.48,69.00,fee schedule,
HC CULTURE FUNGUS,83001360,CDM,306,RC,87102,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,8.83,,,,,,,8.16,102.00,fee schedule,
HC YEAST ID,83001362,CDM,306,RC,87106,CPT,,,facility,outpatient,,,39.00000,23.40000,WellCare of North Carolina,Medicare Advantage,,10.84,,,,,,,7.81,29.25,fee schedule,
HC MOLD ID,83001363,CDM,306,RC,87107,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,10.84,,,,,,,10.01,75.75,fee schedule,
HC STAPHYLOCOCCUS AGGLUTINATION,83001374,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC OXACILLIN RESISTANT TEST,83001375,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC BACTERIAL ID BY SEQUENCING,83001380,CDM,306,RC,87153,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Medicare Advantage,,121.13,,,,,,,5.21,245.92,fee schedule,
HC PARASITE ID WORM,83001383,CDM,306,RC,87169,CPT,,,facility,outpatient,,,24.00000,14.40000,WellCare of North Carolina,Medicare Advantage,,4.53,,,,,,,4.18,18.00,fee schedule,
HC PINWORM EXAMINATION,83001384,CDM,306,RC,87172,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,96.75,fee schedule,
HC TISSUE HOMOGENIZATION,83001385,CDM,306,RC,87176,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,6.17,,,,,,,5.70,38.25,fee schedule,
HC OVA AND PARASITES,83001386,CDM,306,RC,87177,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Medicare Advantage,,9.35,,,,,,,8.63,87.00,fee schedule,
HC E TEST MIC ADDITIONAL STRIP,83001388,CDM,306,RC,87181,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Medicare Advantage,,4.99,,,,,,,4.61,59.25,fee schedule,
HC SUSCEPTIBILITY DISK,83001392,CDM,306,RC,87184,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Medicare Advantage,,7.85,,,,,,,7.26,82.50,fee schedule,
HC BETA LACTAMASE DETECTION,83001394,CDM,306,RC,87185,CPT,,,facility,outpatient,,,18.00000,10.80000,WellCare of North Carolina,Medicare Advantage,,4.99,,,,,,,3.60,13.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM NEG,83001397,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEPTIBILITY GRAM POS,83001399,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC AUTO SUSCEP STREP PNEUMO,83001401,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC YEAST SUSCEPTIBILITY,83001406,CDM,306,RC,87186,CPT,,,facility,outpatient,,,74.00000,44.40000,WellCare of North Carolina,Medicare Advantage,,9.08,,,,,,,8.39,55.50,fee schedule,
HC RG MYCOBACTERIA SUSCEPT,83001408,CDM,306,RC,87186,CPT,,,facility,outpatient,,,339.00000,203.40000,WellCare of North Carolina,Medicare Advantage,,9.08,,,,,,,8.39,254.25,fee schedule,
HC EXAM FOR SEGGS,83001428,CDM,306,RC,87205,CPT,,,facility,outpatient,,,68.00000,40.80000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,51.00,fee schedule,
HC GRAM STAIN,83001429,CDM,306,RC,87205,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,63.00,fee schedule,
HC STAIN BACTERIAL VAGINOSIS YST,83001430,CDM,306,RC,87205,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,66.75,fee schedule,
HC TB AFB SMEAR,83001431,CDM,306,RC,87206,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,5.66,,,,,,,5.23,45.75,fee schedule,
HC FUNGAL EXAM DIRECT,83001432,CDM,306,RC,87206,CPT,,,facility,outpatient,,,16.00000,9.60000,WellCare of North Carolina,Medicare Advantage,,5.66,,,,,,,3.20,12.00,fee schedule,
HC CYCLO IS ACID FAST STAIN,83001433,CDM,306,RC,87206,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,5.66,,,,,,,5.23,36.75,fee schedule,
HC BLOOD SMEAR FOR MALARIA,83001434,CDM,306,RC,87207,CPT,,,facility,outpatient,,,245.00000,147.00000,WellCare of North Carolina,Medicare Advantage,,6.29,,,,,,,5.81,183.75,fee schedule,
HC TRICHROME STAIN,83001436,CDM,306,RC,87209,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Medicare Advantage,,18.88,,,,,,,16.82,63.00,fee schedule,
HC INDIA INK PREP,83001438,CDM,306,RC,87210,CPT,,,facility,outpatient,,,154.00000,92.40000,WellCare of North Carolina,Medicare Advantage,,6.11,,,,,,,5.65,115.50,fee schedule,
HC WET PREP,83001439,CDM,306,RC,87210,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,6.11,,,,,,,5.65,38.25,fee schedule,
HC PARASITE SCRN CRYPTOSPORIDIUM,83001451,CDM,306,RC,87272,CPT,,,facility,outpatient,,,37.00000,22.20000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,7.41,27.75,fee schedule,
HC PNEUMOCYSTIS DFA,83001452,CDM,306,RC,87281,CPT,,,facility,outpatient,,,99.00000,59.40000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,11.62,74.25,fee schedule,
HC GALACTOMANNAN,83001454,CDM,306,RC,87305,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,11.62,60.75,fee schedule,
HC C DIFF TOXINS,83001455,CDM,306,RC,87324,CPT,,,facility,outpatient,,,78.00000,46.80000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,11.62,58.50,fee schedule,
HC CRYPTOSPORIDIUM BY DIRECT ANTIGE,83001456,CDM,306,RC,87328,CPT,,,facility,outpatient,,,40.00000,24.00000,WellCare of North Carolina,Medicare Advantage,,14.51,,,,,,,8.01,30.00,fee schedule,
HC HEPATITIS B SURFACE ANTIGEN,83001459,CDM,306,RC,87340,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Medicare Advantage,,10.85,,,,,,,10.02,42.75,fee schedule,
HC HBV SURFACE AG CONFIRM,83001460,CDM,306,RC,87341,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Medicare Advantage,,10.85,,,,,,,7.61,28.50,fee schedule,
HC HIV ANTIGEN ANTIBODY COMBO,83001464,CDM,306,RC,87389,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,25.28,,,,,,,19.02,71.25,fee schedule,
HC DIAGNOSTIC HIV AG AB COMBO,83001465,CDM,306,RC,87389,CPT,,,facility,outpatient,,,63.00000,37.80000,WellCare of North Carolina,Medicare Advantage,,25.28,,,,,,,12.61,50.79,fee schedule,
HC ROTAVIRUS DIRECT ANTIGEN,83001467,CDM,306,RC,87425,CPT,,,facility,outpatient,,,180.00000,108.00000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,11.62,135.00,fee schedule,
HC LEGIONELLA URINARY ANTIGEN,83001469,CDM,306,RC,87449,CPT,,,facility,outpatient,,,33.00000,19.80000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,6.61,25.57,fee schedule,
HC C DIFFICILE ANTIGEN,83001470,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,7.61,28.50,fee schedule,
HC CHLAMYDIA BY PCR,83001480,CDM,306,RC,87491,CPT,,,facility,outpatient,,,228.00000,136.80000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,171.00,fee schedule,
HC C DIFFICILE BY PCR,83001482,CDM,306,RC,87493,CPT,,,facility,outpatient,,,169.00000,101.40000,WellCare of North Carolina,Medicare Advantage,,39.13,,,,,,,33.83,126.75,fee schedule,
HC CMV PCR QUAL NOT BLOOD,83001483,CDM,306,RC,87496,CPT,,,facility,outpatient,,,461.00000,276.60000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,345.75,fee schedule,
HC CMV VIRAL LOAD QUANTITATIVE,83001486,CDM,306,RC,87497,CPT,,,facility,outpatient,,,213.00000,127.80000,WellCare of North Carolina,Medicare Advantage,,44.98,,,,,,,41.55,159.75,fee schedule,
HC ENTEROVIRUS PCR,83001487,CDM,306,RC,87498,CPT,,,facility,outpatient,,,213.00000,127.80000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,159.75,fee schedule,
HC HBV DNA PCR QUANT,83001491,CDM,306,RC,87517,CPT,,,facility,outpatient,,,629.00000,377.40000,WellCare of North Carolina,Medicare Advantage,,44.98,,,,,,,41.55,471.75,fee schedule,
HC HCV RNA QUANT PCR,83001495,CDM,306,RC,87522,CPT,,,facility,outpatient,,,581.00000,348.60000,WellCare of North Carolina,Medicare Advantage,,44.98,,,,,,,41.55,435.75,fee schedule,
HC HSV 1/2 PCR,83001498,CDM,306,RC,87529,CPT,,,facility,outpatient,,,174.00000,104.40000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,130.50,fee schedule,
HC HHV 6 PCR HERPES VIRUS 6,83001499,CDM,306,RC,87532,CPT,,,facility,outpatient,,,161.00000,96.60000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,32.23,120.75,fee schedule,
HC HIV RNA PCR,83001502,CDM,306,RC,87536,CPT,,,facility,outpatient,,,350.00000,210.00000,WellCare of North Carolina,Medicare Advantage,,89.36,,,,,,,70.07,262.50,fee schedule,
HC GONORRHOEAE BY PCR,83001506,CDM,306,RC,87591,CPT,,,facility,outpatient,,,212.00000,127.20000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,159.00,fee schedule,
HC HPV DNA AMP PROBE HIGH RISK,83001507,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,32.83,123.00,fee schedule,
HC HPV PCR,83001508,CDM,306,RC,87624,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,32.83,123.00,fee schedule,
HC INFLUENZA DNA AMP PROBE,83001509,CDM,306,RC,87502,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Medicare Advantage,,100.59,,,,,,,55.05,206.25,fee schedule,
HC RSV FLU COMBO PCR,83001510,CDM,306,RC,87631,CPT,,,facility,outpatient,,,257.00000,154.20000,WellCare of North Carolina,Medicare Advantage,,149.76,,,,,,,51.45,264.62,fee schedule,
HC RESPIRATORY PATHOGEN PANEL,83001511,CDM,306,RC,87633,CPT,,,facility,outpatient,,,770.00000,462.00000,WellCare of North Carolina,Medicare Advantage,,437.62,,,,,,,154.15,852.72,fee schedule,
HC VZV PCR,83001518,CDM,306,RC,87798,CPT,,,facility,outpatient,,,87.00000,52.20000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,17.42,74.82,fee schedule,
HC PARVOVIRUS PCR,83001519,CDM,306,RC,87798,CPT,,,facility,outpatient,,,83.00000,49.80000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,16.62,74.82,fee schedule,
HC ADENOVIRUS PCR,83001520,CDM,306,RC,87798,CPT,,,facility,outpatient,,,48.00000,28.80000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,9.61,74.82,fee schedule,
HC TOXOPLASMA PCR,83001523,CDM,306,RC,87798,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,16.22,74.82,fee schedule,
HC TRICHOMONAS PCR,83001528,CDM,306,RC,87661,CPT,,,facility,outpatient,,,112.00000,67.20000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,22.42,84.00,fee schedule,
HC BK VIRAL LOAD QUANTITATIVE,83001530,CDM,306,RC,87799,CPT,,,facility,outpatient,,,579.00000,347.40000,WellCare of North Carolina,Medicare Advantage,,44.98,,,,,,,41.55,434.25,fee schedule,
HC GI PCR PANEL 6 TO 11 TARGETS,83001534,CDM,306,RC,87506,CPT,,,facility,outpatient,,,279.00000,167.40000,WellCare of North Carolina,Medicare Advantage,,276.14,,,,,,,55.86,488.14,fee schedule,
HC TRICHOMONAS DETECTION,83001535,CDM,306,RC,87808,CPT,,,facility,outpatient,,,55.00000,33.00000,WellCare of North Carolina,Medicare Advantage,,16.05,,,,,,,11.01,41.25,fee schedule,
HC GROUP A STREP RAPID,83001536,CDM,306,RC,87880,CPT,,,facility,outpatient,,,154.00000,92.40000,WellCare of North Carolina,Medicare Advantage,,17.36,,,,,,,16.03,115.50,fee schedule,
HC CAMPYLOBACTER ANTIGEN DETECTION,83001539,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,WellCare of North Carolina,Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST1,83001540,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,WellCare of North Carolina,Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC SHIGA TOXIN E COLI EIA ST2,83001541,CDM,306,RC,87899,CPT,,,facility,outpatient,,,96.00000,57.60000,WellCare of North Carolina,Medicare Advantage,,16.87,,,,,,,15.59,72.00,fee schedule,
HC HIV GENOTYPING,83001543,CDM,306,RC,87901,CPT,,,facility,outpatient,,,463.00000,277.80000,WellCare of North Carolina,Medicare Advantage,,270.32,,,,,,,92.69,548.82,fee schedule,
HC HCV GENOTYPING,83001545,CDM,306,RC,87902,CPT,,,facility,outpatient,,,294.00000,176.40000,WellCare of North Carolina,Medicare Advantage,,270.32,,,,,,,58.86,548.82,fee schedule,
HC URINALYSIS W MICROSCOPIC POCT,83001550,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,WellCare of North Carolina,Medicare Advantage,,3.33,,,,,,,3.07,66.00,fee schedule,
HC URINALYSIS W MICROSCOPIC,83001551,CDM,307,RC,81001,CPT,,,facility,outpatient,,,88.00000,52.80000,WellCare of North Carolina,Medicare Advantage,,3.33,,,,,,,3.07,66.00,fee schedule,
HC KETONE COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001552,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC UA OR COMPONENT WO MICROSCOPIC MANUAL DIPSTICK,83001553,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC SPECIFIC GRAVITY,83001557,CDM,307,RC,81002,CPT,,,facility,outpatient,,,51.00000,30.60000,WellCare of North Carolina,Medicare Advantage,,3.65,,,,,,,3.38,38.25,fee schedule,
HC BCGP STREPTOCOCCUS PNEUMONIAE,83001560,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS PYOGENES,83001561,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC URINE PREGNANCY QUALITATIVE,83001563,CDM,307,RC,81025,CPT,,,facility,outpatient,,,126.00000,75.60000,WellCare of North Carolina,Medicare Advantage,,9.04,,,,,,,8.35,94.50,fee schedule,
HC COMPAT TESTING ANTIGLOBULIN TECH,83001566,CDM,302,RC,86922,CPT,,,facility,outpatient,,,12.00000,7.20000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,2.40,201.52,fee schedule,
HC FLUID CELL COUNT W/DIFF,83001574,CDM,309,RC,89051,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Medicare Advantage,,5.88,,,,,,,5.43,112.50,fee schedule,
HC CRYSTAL IDENTIFICATION TISSUE OR BODY FLUID,83001578,CDM,309,RC,89060,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,7.70,,,,,,,7.11,46.50,fee schedule,
HC SMEAR FOR EOSINS,83001579,CDM,309,RC,89190,CPT,,,facility,outpatient,,,120.00000,72.00000,WellCare of North Carolina,Medicare Advantage,,6.08,,,,,,,5.62,90.00,fee schedule,
HC JAK2 GENE ANALYSIS,83001583,CDM,310,RC,81270,CPT,,,facility,outpatient,,,548.00000,328.80000,WellCare of North Carolina,Medicare Advantage,,96.24,,,,,,,88.91,411.00,fee schedule,
HC BCGP ENTEROCOCCUS FAECALIS,83001586,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP ENTEROCOCCUS FAECIUM,83001587,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS AGALACTIAE,83001588,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STREPTOCOCCUS ANGINOSIS,83001589,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC CYCLOSPORINE LC MS,83001612,CDM,301,RC,80158,CPT,,,facility,outpatient,,,309.00000,185.40000,WellCare of North Carolina,Medicare Advantage,,18.95,,,,,,,17.51,231.75,fee schedule,
HC ESTRIOL,83001629,CDM,301,RC,82677,CPT,,,facility,outpatient,,,127.00000,76.20000,WellCare of North Carolina,Medicare Advantage,,25.39,,,,,,,23.45,95.25,fee schedule,
HC ANTI HAV IGG,83001652,CDM,302,RC,86708,CPT,,,facility,outpatient,,,36.00000,21.60000,WellCare of North Carolina,Medicare Advantage,,13.01,,,,,,,7.21,27.00,fee schedule,
HC EOSINOPHIL ID HANSEL STAIN,83001670,CDM,309,RC,89050,CPT,,,facility,outpatient,,,22.00000,13.20000,WellCare of North Carolina,Medicare Advantage,,4.96,,,,,,,4.40,16.50,fee schedule,
HC KEPPRA LEVETRIRACETAM,83001682,CDM,301,RC,80177,CPT,,,facility,outpatient,,,230.00000,138.00000,WellCare of North Carolina,Medicare Advantage,,13.91,,,,,,,12.85,172.50,fee schedule,
HC IGE REGION II ALLERGEN PROFILE,83001711,CDM,301,RC,82785,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,17.28,,,,,,,15.42,57.75,fee schedule,
HC TTG AB,83001732,CDM,301,RC,86364,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Medicare Advantage,,12.11,,,,,,,5.81,21.75,fee schedule,
HC HOUSE DUST PANEL,83001822,CDM,302,RC,86003,CPT,,,facility,outpatient,,,18.00000,10.80000,WellCare of North Carolina,Medicare Advantage,,5.48,,,,,,,3.60,13.50,fee schedule,
HC AB EXTRAC NUCLEAR A,83001841,CDM,302,RC,86235,CPT,,,facility,outpatient,,,106.00000,63.60000,WellCare of North Carolina,Medicare Advantage,,18.83,,,,,,,17.39,79.50,fee schedule,
HC CSF VDRL,83001867,CDM,302,RC,86592,CPT,,,facility,outpatient,,,58.00000,34.80000,WellCare of North Carolina,Medicare Advantage,,4.48,,,,,,,4.14,43.50,fee schedule,
HC MUMPS ANTIBODIES IGG,83001881,CDM,302,RC,86735,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Medicare Advantage,,13.70,,,,,,,7.01,27.82,fee schedule,
HC 8763 RUBEOLA IGM AB,83001888,CDM,302,RC,86765,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Medicare Advantage,,13.52,,,,,,,7.01,27.47,fee schedule,
HC SALMONELLA SHIGELLA AGGLUTINATIO,83001907,CDM,306,RC,87147,CPT,,,facility,outpatient,,,19.00000,11.40000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,3.80,14.25,fee schedule,
HC 81806 H PYLORI AG FECES,83001929,CDM,306,RC,87338,CPT,,,facility,outpatient,,,61.00000,36.60000,WellCare of North Carolina,Medicare Advantage,,15.10,,,,,,,12.21,45.75,fee schedule,
HC BCGP STREPTOCOCCUS SP,83001960,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP VAN A RESISTANCE,83001961,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN A,83001979,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN B,83001980,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN C,83001981,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN D,83001982,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN E,83001983,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC EYE CULTURE,83001995,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC ANAEROBE ID BY MS,83002065,CDM,306,RC,87076,CPT,,,facility,outpatient,,,64.00000,38.40000,WellCare of North Carolina,Medicare Advantage,,8.48,,,,,,,7.84,48.00,fee schedule,
HC AEROBE ID BY MS,83002066,CDM,306,RC,87077,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Medicare Advantage,,8.48,,,,,,,7.84,34.50,fee schedule,
HC PARASITE SCREEN GIARDIA,83002072,CDM,306,RC,87269,CPT,,,facility,outpatient,,,56.00000,33.60000,WellCare of North Carolina,Medicare Advantage,,14.29,,,,,,,11.21,42.00,fee schedule,
HC SEMEN ANALYSIS POST VASECTOMY,83002082,CDM,309,RC,89310,CPT,,,facility,outpatient,,,71.00000,42.60000,WellCare of North Carolina,Medicare Advantage,,9.04,,,,,,,8.35,53.25,fee schedule,
HC BCGP VAN B RESISTANCE,83002085,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC 83267 CALIFORNIA VIRUS IGG AND IGM,83002087,CDM,302,RC,86651,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Medicare Advantage,,13.85,,,,,,,3.00,28.12,fee schedule,
HC TB CONCENTRATION,83002095,CDM,306,RC,87015,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,7.01,,,,,,,6.48,36.75,fee schedule,
HC STREPTOCOCCUS AGGLUTINATION,83002097,CDM,306,RC,87147,CPT,,,facility,outpatient,,,30.00000,18.00000,WellCare of North Carolina,Medicare Advantage,,5.44,,,,,,,5.02,22.50,fee schedule,
HC 8409 LIPID PANEL,83002099,CDM,301,RC,80061,CPT,,,facility,outpatient,,,253.00000,151.80000,WellCare of North Carolina,Medicare Advantage,,14.06,,,,,,,12.99,189.75,fee schedule,
HC 2HR PC SUGAR LAB TEST,83002129,CDM,301,RC,82950,CPT,,,facility,outpatient,,,171.00000,102.60000,WellCare of North Carolina,Medicare Advantage,,4.99,,,,,,,4.61,128.25,fee schedule,
HC SULLIVAN OB GLUCOSE SCREEN,83002131,CDM,301,RC,82950,CPT,,,facility,outpatient,,,26.00000,15.60000,WellCare of North Carolina,Medicare Advantage,,4.99,,,,,,,4.61,19.50,fee schedule,
HC 2HR GLUCOSE TOLERANCE LAB TEST,83002133,CDM,301,RC,82951,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Medicare Advantage,,13.51,,,,,,,12.48,121.50,fee schedule,
HC FINGERSTICK PT,83002140,CDM,305,RC,85610,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Medicare Advantage,,4.50,,,,,,,4.16,59.25,fee schedule,
HC 80406 RHEUMATOID FACTOR,83002143,CDM,302,RC,86430,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,6.45,,,,,,,5.61,21.00,fee schedule,
HC SYPHILIS AB IGG AND IGM,83002153,CDM,302,RC,86780,CPT,,,facility,outpatient,,,54.00000,32.40000,WellCare of North Carolina,Medicare Advantage,,13.90,,,,,,,10.81,40.50,fee schedule,
HC CRE CULTURE SCREEN,83002155,CDM,306,RC,87081,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Medicare Advantage,,6.96,,,,,,,5.81,21.75,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83002163,CDM,312,RC,88346,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,0.00200,381.82,fee schedule,
HC CUTANEOUS IMMUNO BIOPSY INITIAL,83002164,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,53.18,381.82,fee schedule,
HC HLA DPB1 HIRES TYPING,83002184,CDM,300,RC,81382,CPT,,,facility,outpatient,,,518.00000,310.80000,WellCare of North Carolina,Medicare Advantage,,129.86,,,,,,,103.70,388.50,fee schedule,
HC MYCOBACTERIA ID BY MS,83002185,CDM,306,RC,87118,CPT,,,facility,outpatient,,,81.00000,48.60000,WellCare of North Carolina,Medicare Advantage,,15.34,,,,,,,14.17,60.75,fee schedule,
HC GONADOTROPIN,83002222,CDM,301,RC,84702,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,15.80,,,,,,,12.41,46.50,fee schedule,
HC PLASMA HEMOGLOBIN,83002225,CDM,301,RC,83051,CPT,,,facility,outpatient,,,29.00000,17.40000,WellCare of North Carolina,Medicare Advantage,,7.68,,,,,,,5.81,21.75,fee schedule,
HC HLA B57 SINGLE BY FLOW CYTOMETRY,83002240,CDM,302,RC,86812,CPT,,,facility,outpatient,,,161.00000,96.60000,WellCare of North Carolina,Medicare Advantage,,27.10,,,,,,,25.04,120.75,fee schedule,
HC MYELOID MUTATION PANEL,83002242,CDM,300,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,WellCare of North Carolina,Medicare Advantage,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC CEPHEID NOROVIRUS GI,83002244,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,9.81,74.82,fee schedule,
HC FECAL IMMUNOCHEMICAL TEST,83002286,CDM,301,RC,82274,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,16.72,,,,,,,15.44,71.25,fee schedule,
HC PKU,83002306,CDM,301,RC,84030,CPT,,,facility,outpatient,,,141.00000,84.60000,WellCare of North Carolina,Medicare Advantage,,5.78,,,,,,,5.33,105.75,fee schedule,
HC PROCALCITONIN,83002307,CDM,301,RC,84145,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Medicare Advantage,,28.58,,,,,,,17.82,66.75,fee schedule,
HC SED RATE AUTOMATED,83002372,CDM,305,RC,85652,CPT,,,facility,outpatient,,,34.00000,20.40000,WellCare of North Carolina,Medicare Advantage,,2.83,,,,,,,2.62,25.50,fee schedule,
HC PLEURAL FLUID CULTURE,83002375,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC EAR CULTURE,83002377,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC NASOPHARYNGEAL CULTURE,83002380,CDM,306,RC,87070,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,102.00,fee schedule,
HC STREP PNEUMO URINE ANTIGEN,83002390,CDM,306,RC,87449,CPT,,,facility,outpatient,,,38.00000,22.80000,WellCare of North Carolina,Medicare Advantage,,12.58,,,,,,,7.61,28.50,fee schedule,
HC INFLUENZA A ANTIGEN,83002397,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Medicare Advantage,,17.38,,,,,,,14.01,52.50,fee schedule,
HC INFLUENZA B ANTIGEN,83002399,CDM,306,RC,87804,CPT,,,facility,outpatient,,,70.00000,42.00000,WellCare of North Carolina,Medicare Advantage,,17.38,,,,,,,14.01,52.50,fee schedule,
HC SPECIAL COLLECTION LEVEL 1,83002423,CDM,300,RC,36415,CPT,,,facility,outpatient,,,15.00000,9.00000,WellCare of North Carolina,Medicare Advantage,,9.54,,,,,,,3.00,11.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 2,83002424,CDM,300,RC,36415,CPT,,,facility,outpatient,,,35.00000,21.00000,WellCare of North Carolina,Medicare Advantage,,9.54,,,,,,,3.90,26.25,fee schedule,
HC SPECIAL COLLECTION LEVEL 3,83002425,CDM,300,RC,36415,CPT,,,facility,outpatient,,,75.00000,45.00000,WellCare of North Carolina,Medicare Advantage,,9.54,,,,,,,3.90,56.25,fee schedule,
HC CEPHEID NOROVIRUS GII,83002426,CDM,306,RC,87798,CPT,,,facility,outpatient,,,49.00000,29.40000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,9.81,74.82,fee schedule,
HC CALR GENE ANALYSIS,83002427,CDM,300,RC,81219,CPT,,,facility,outpatient,,,529.00000,317.40000,WellCare of North Carolina,Medicare Advantage,,127.71,,,,,,,105.91,396.75,fee schedule,
HC MPL GENE ANALYSIS,83002428,CDM,300,RC,81339,CPT,,,facility,outpatient,,,767.00000,460.20000,WellCare of North Carolina,Medicare Advantage,,194.46,,,,,,,153.55,575.25,fee schedule,
HC FLT3 TKD GENE ANALYSIS,83002429,CDM,300,RC,81246,CPT,,,facility,outpatient,,,134.00000,80.40000,WellCare of North Carolina,Medicare Advantage,,87.15,,,,,,,26.83,154.14,fee schedule,
HC TP53 GENE ANALYSIS,83002430,CDM,300,RC,81351,CPT,,,facility,outpatient,,,1805.00000,1083.00000,WellCare of North Carolina,Medicare Advantage,,673.94,,,,,,,361.36,1353.75,fee schedule,
HC BRCA 1 AND 2 MUTATION TESTING,83002432,CDM,310,RC,81162,CPT,,,facility,outpatient,,,1258.00000,754.80000,WellCare of North Carolina,Medicare Advantage,,1916.12,,,,,,,251.85,3699.95,fee schedule,
HC BRCA 2 KNOWN FAMILIAL MUTATION TESTING,83002434,CDM,310,RC,81217,CPT,,,facility,outpatient,,,293.00000,175.80000,WellCare of North Carolina,Medicare Advantage,,394.01,,,,,,,58.66,696.24,fee schedule,
HC CATHETERIZATION FOR COLLECTION OF SPECIMEN SINGLE PATIENT ALL POS,83002462,CDM,300,RC,P9612,CPT,,,facility,outpatient,,,116.00000,69.60000,WellCare of North Carolina,Medicare Advantage,,9.54,,,,,,,4.18,4311.00,fee schedule,
HC PYRIMIDINE 5' NUCLEOTIDASE,83002478,CDM,301,RC,83915,CPT,,,facility,outpatient,,,1931.00000,1158.60000,WellCare of North Carolina,Medicare Advantage,,11.71,,,,,,,10.82,1448.25,fee schedule,
HC AUTOMATED DIFFERENTIAL WBC COUNT,83002559,CDM,301,RC,85004,CPT,,,facility,outpatient,,,23.00000,13.80000,WellCare of North Carolina,Medicare Advantage,,6.79,,,,,,,4.60,17.25,fee schedule,
HC HEMOGLOBIN S ARC,83002579,CDM,305,RC,85660,CPT,,,facility,outpatient,,,259.00000,155.40000,WellCare of North Carolina,Medicare Advantage,,5.79,,,,,,,5.34,194.25,fee schedule,
HC CYSTATIN C,83002580,CDM,301,RC,82610,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Medicare Advantage,,19.45,,,,,,,9.21,34.68,fee schedule,
HC CD3 BAL,83002603,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD4 BAL,83002604,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD8 BAL,83002605,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD19 BAL,83002606,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC CD16 AND 56 BAL,83002607,CDM,302,RC,86356,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,28.12,,,,,,,5.61,57.08,fee schedule,
HC TERT PROMOTER MUTATION ASSAY,83002620,CDM,301,RC,81345,CPT,,,facility,outpatient,,,707.00000,424.20000,WellCare of North Carolina,Medicare Advantage,,194.46,,,,,,,141.54,530.25,fee schedule,
HC BCGP STAPHYLOCOCCUS AUREUS,83002622,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS EPIDERMIDIS,83002623,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS LUGDUNENSIS,83002624,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP STAPHYLOCOCCUS SPP,83002625,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC BCGP MECA RESISTANCE,83002626,CDM,306,RC,87149,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,21.05,,,,,,,12.41,46.50,fee schedule,
HC GROUP B STREP WITH LIM BROTH BY NUCLEIC ACID PROBE,83002633,CDM,306,RC,87150,CPT,,,facility,outpatient,,,107.00000,64.20000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,21.42,80.25,fee schedule,
HC SMA CARRIER SCREEN,83002640,CDM,301,RC,81329,CPT,,,facility,outpatient,,,513.00000,307.80000,WellCare of North Carolina,Medicare Advantage,,143.85,,,,,,,102.70,384.75,fee schedule,
HC MRSA DNA AMP PROBE,83002642,CDM,306,RC,87641,CPT,,,facility,outpatient,,,189.00000,113.40000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,141.75,fee schedule,
HC NEOTYPE NGS HEMATOLYMPHOID NEOPLASM 5 TO 50 GENES,83002651,CDM,309,RC,81450,CPT,,,facility,outpatient,,,1960.00000,1176.00000,WellCare of North Carolina,Medicare Advantage,,797.51,,,,,,,133.70,1470.00,fee schedule,
HC BLOOD CULTURE IDENTIFICATION PANEL,83002656,CDM,306,RC,87154,CPT,,,facility,outpatient,,,114.00000,68.40000,WellCare of North Carolina,Medicare Advantage,,228.96,,,,,,,22.82,324.56,fee schedule,
HC EBV PCR QUALITATIVE NOT BLOOD,83002658,CDM,306,RC,87798,CPT,,,facility,outpatient,,,324.00000,194.40000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,243.00,fee schedule,
HC STREP GROUP A AMPLIFIED PROBE TECHNIQUE,83002688,CDM,306,RC,87651,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,27.23,102.00,fee schedule,
HC CEPHEID RSV PCR,83002689,CDM,306,RC,87634,CPT,,,facility,outpatient,,,194.00000,116.40000,WellCare of North Carolina,Medicare Advantage,,73.71,,,,,,,38.84,145.50,fee schedule,
HC CALR GENE MUTATION EXON 9 REFLEX,83002694,CDM,300,RC,81219,CPT,,,facility,outpatient,,,953.00000,571.80000,WellCare of North Carolina,Medicare Advantage,,127.71,,,,,,,117.98,714.75,fee schedule,
HC MPLR MPL EXON MUTATON DETECTION,83002695,CDM,300,RC,81403,CPT,,,facility,outpatient,,,639.00000,383.40000,WellCare of North Carolina,Medicare Advantage,,194.46,,,,,,,127.93,479.25,fee schedule,
HC PLATELETS RESPONSE P2Y12,83002696,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Medicare Advantage,,26.16,,,,,,,24.16,105.00,fee schedule,
HC PLATELETS RESPONSE ASPIRIN,83002697,CDM,305,RC,85576,CPT,,,facility,outpatient,,,140.00000,84.00000,WellCare of North Carolina,Medicare Advantage,QW,26.16,,,,,,,24.16,105.00,fee schedule,
HC H PYLORI AG STOOL IN HOUSE,83002720,CDM,306,RC,87338,CPT,,,facility,outpatient,,,46.00000,27.60000,WellCare of North Carolina,Medicare Advantage,,15.10,,,,,,,9.21,34.50,fee schedule,
HC SUBSTANCE ABUSE PANEL 8 DRUGS,83002767,CDM,301,RC,80307,CPT,,,facility,outpatient,,,278.00000,166.80000,WellCare of North Carolina,Medicare Advantage,,65.25,,,,,,,55.66,208.50,fee schedule,
HC MICROARRAY POC,83002795,CDM,300,RC,81229,CPT,,,facility,outpatient,,,1589.00000,953.40000,WellCare of North Carolina,Medicare Advantage,,1218.00,,,,,,,318.12,2152.96,fee schedule,
HC MENINGITIS MOLECULAR IDENTIFICATION PANEL,83002797,CDM,306,RC,87483,CPT,,,facility,outpatient,,,1187.00000,712.20000,WellCare of North Carolina,Medicare Advantage,,437.62,,,,,,,237.64,890.25,fee schedule,
HC JAK2 V617F QUANT MUTATION ANALYSIS,83002812,CDM,310,RC,81270,CPT,,,facility,outpatient,,,278.00000,166.80000,WellCare of North Carolina,Medicare Advantage,,96.24,,,,,,,55.66,208.50,fee schedule,
HC CA 27.29 IN HOUSE,83002820,CDM,302,RC,86300,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,21.85,,,,,,,20.19,75.75,fee schedule,
HC CHIMERISM FOR MATERNAL CELL CONTAMINATION OF FETAL CELLS,83002858,CDM,300,RC,81265,CPT,,,facility,outpatient,,,609.00000,365.40000,WellCare of North Carolina,Medicare Advantage,,244.72,,,,,,,121.92,456.75,fee schedule,
HC HHV6 QUANTITATIVE PCR,83002859,CDM,300,RC,87533,CPT,,,facility,outpatient,,,478.00000,286.80000,WellCare of North Carolina,Medicare Advantage,,43.85,,,,,,,40.51,358.50,fee schedule,
HC ADENOVIRUS QUANT PCR,83002860,CDM,300,RC,87799,CPT,,,facility,outpatient,,,204.00000,122.40000,WellCare of North Carolina,Medicare Advantage,,44.98,,,,,,,40.84,153.00,fee schedule,
HC IMMUNOASSAY MALARIA SCREEN,83002864,CDM,306,RC,87899,CPT,,,facility,outpatient,,,426.00000,255.60000,WellCare of North Carolina,Medicare Advantage,,16.87,,,,,,,15.59,319.50,fee schedule,
HC ALLERGEN SPECIFIC IGE ALPHA GAL,83002865,CDM,302,RC,86003,CPT,,,facility,outpatient,,,50.00000,30.00000,WellCare of North Carolina,Medicare Advantage,,5.48,,,,,,,5.06,37.50,fee schedule,
HC NEUROPATHY AB BY WESTERN BLOT,83002872,CDM,301,RC,84182,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Medicare Advantage,,30.67,,,,,,,22.02,82.50,fee schedule,
HC COVID19 PCR,83002899,CDM,306,RC,87635,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Medicare Advantage,QW,53.88,,,,,,,20.02,76.37,fee schedule,
HC COVID IGG ANTIBODY,83002901,CDM,302,RC,86769,CPT,,,facility,outpatient,,,100.00000,60.00000,WellCare of North Carolina,Medicare Advantage,,44.24,,,,,,,20.02,75.00,fee schedule,
HC IL 6,83002913,CDM,301,RC,83529,CPT,,,facility,outpatient,,,163.00000,97.80000,WellCare of North Carolina,Medicare Advantage,,18.13,,,,,,,16.75,122.25,fee schedule,
HC BIOFIRE RESPIRATORY PANEL 2.1 RP2.1 TEST,83002918,CDM,306,RC,0202U,CPT,,,facility,outpatient,,,907.00000,544.20000,WellCare of North Carolina,Medicare Advantage,,437.62,,,,,,,181.58,680.25,fee schedule,
HC RAPID RSFLU COVID FLURVID,83002939,CDM,306,RC,87637,CPT,,,facility,outpatient,,,275.00000,165.00000,WellCare of North Carolina,Medicare Advantage,,149.76,,,,,,,55.05,212.24,fee schedule,
HC MOLD ID BY MS,83002957,CDM,306,RC,87107,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Medicare Advantage,,10.84,,,,,,,10.01,99.00,fee schedule,
HC ACETAMINOPHEN THERAPEUTIC DRUG ASSAY,83002959,CDM,301,RC,80143,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Medicare Advantage,,19.57,,,,,,,18.08,123.75,fee schedule,
HC SALICYLATE THERAPEUTIC DRUG ASSAY,83002961,CDM,301,RC,80179,CPT,,,facility,outpatient,,,89.00000,53.40000,WellCare of North Carolina,Medicare Advantage,,19.57,,,,,,,17.82,66.75,fee schedule,
HC ITRACONAZOLE THERAPEUTIC DRUG ASSAY,83002963,CDM,301,RC,80189,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Medicare Advantage,,28.47,,,,,,,8.61,50.10,fee schedule,
HC METHOTREXATE THERAPEUTIC DRUG ASSAY,83002965,CDM,301,RC,80204,CPT,,,facility,outpatient,,,280.00000,168.00000,WellCare of North Carolina,Medicare Advantage,,40.50,,,,,,,37.41,210.00,fee schedule,
HC GRAM NEGATIVE SUSCEPTIBILITY,83002971,CDM,306,RC,87186,CPT,,,facility,outpatient,,,79.00000,47.40000,WellCare of North Carolina,Medicare Advantage,,9.08,,,,,,,8.39,59.25,fee schedule,
HC VAGINITIS MOLECULAR PANEL,83002973,CDM,306,RC,81513,CPT,,,facility,outpatient,,,194.00000,116.40000,WellCare of North Carolina,Medicare Advantage,,149.76,,,,,,,38.84,264.62,fee schedule,
HC BNP,83002991,CDM,301,RC,83880,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Medicare Advantage,,41.22,,,,,,,18.22,72.58,fee schedule,
HC SEX HORMONE BINDING GLOBULIN,83002992,CDM,301,RC,84270,CPT,,,facility,outpatient,,,69.00000,41.40000,WellCare of North Carolina,Medicare Advantage,,22.82,,,,,,,13.81,51.75,fee schedule,
HC C PEPTIDE,83002993,CDM,301,RC,84681,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Medicare Advantage,,21.85,,,,,,,13.21,49.50,fee schedule,
HC SMA SPINAL MUSCULAR ATROPHY DNA,83002994,CDM,301,RC,81329,CPT,,,facility,outpatient,,,350.00000,210.00000,WellCare of North Carolina,Medicare Advantage,,143.85,,,,,,,70.07,262.50,fee schedule,
HC COMPLEMENT ANTIGEN PANEL,83003038,CDM,302,RC,86160,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Medicare Advantage,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT FUNCTIONAL ACTIVITY PANEL,83003039,CDM,302,RC,86161,CPT,,,facility,outpatient,,,45.00000,27.00000,WellCare of North Carolina,Medicare Advantage,,12.60,,,,,,,9.01,33.75,fee schedule,
HC COMPLEMENT TOTAL PANEL,83003040,CDM,302,RC,86162,CPT,,,facility,outpatient,,,76.00000,45.60000,WellCare of North Carolina,Medicare Advantage,,21.34,,,,,,,15.22,57.00,fee schedule,
HC FH/FB AUTOANTIBODY PANEL,83003041,CDM,301,RC,83516,CPT,,,facility,outpatient,,,43.00000,25.80000,WellCare of North Carolina,Medicare Advantage,,12.11,,,,,,,8.61,32.25,fee schedule,
HC SOLUBLE C5B-9 PANEL,83003042,CDM,301,RC,83520,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,18.13,,,,,,,13.01,48.75,fee schedule,
HC FLUID PHASE ACTIVITY ASSAY IFE PANEL,83003043,CDM,302,RC,86334,CPT,,,facility,outpatient,,,84.00000,50.40000,WellCare of North Carolina,Medicare Advantage,,23.46,,,,,,,16.82,63.00,fee schedule,
HC IMMUNFIX E-PHORSIS BETA-2 TRANSFERRIN,83003046,CDM,302,RC,86335,CPT,,,facility,outpatient,,,101.00000,60.60000,WellCare of North Carolina,Medicare Advantage,,30.82,,,,,,,20.22,75.75,fee schedule,
HC OLIGOCLONAL BANDS,83003047,CDM,301,RC,83916,CPT,,,facility,outpatient,,,149.00000,89.40000,WellCare of North Carolina,Medicare Advantage,,28.76,,,,,,,26.57,111.75,fee schedule,
HC GI MOLECULAR ID PANEL,83003052,CDM,306,RC,87505,CPT,,,facility,outpatient,,,1328.00000,796.80000,WellCare of North Carolina,Medicare Advantage,,134.70,,,,,,,124.44,996.00,fee schedule,
HC ANTI GBM,83003063,CDM,301,RC,83516,CPT,,,facility,outpatient,,,55.00000,33.00000,WellCare of North Carolina,Medicare Advantage,,12.11,,,,,,,11.01,41.25,fee schedule,
HC MONKEYPOX PCR,83003067,CDM,306,RC,87593,CPT,,,facility,outpatient,,,108.00000,64.80000,WellCare of North Carolina,Medicare Advantage,,53.88,,,,,,,21.62,81.00,fee schedule,
HC LEGIONELLA PNEUMOPHILA PCR,83003072,CDM,306,RC,87541,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,23.62,88.50,fee schedule,
HC LEGIONELLA SPECIES PCR,83003073,CDM,306,RC,87798,CPT,,,facility,outpatient,,,118.00000,70.80000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,23.62,88.50,fee schedule,
HC HGB A1C,83003075,CDM,301,RC,83036,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,10.20,,,,,,,9.42,48.75,fee schedule,
HC LACTATE VENOUS POCT,83003076,CDM,301,RC,83605,CPT,,,facility,outpatient,,,65.00000,39.00000,WellCare of North Carolina,Medicare Advantage,,12.15,,,,,,,11.22,48.75,fee schedule,
HC UA WITHOUT MICROSCOPIC,83003077,CDM,307,RC,81003,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Medicare Advantage,,2.36,,,,,,,2.18,42.75,fee schedule,
HC PNEUMOCYSTIS PCR,83003081,CDM,306,RC,87798,CPT,,,facility,outpatient,,,271.00000,162.60000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,203.25,fee schedule,
HC MYCOPLASMA GENITALIUM PCR,83003118,CDM,306,RC,87563,CPT,,,facility,outpatient,,,167.00000,100.20000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,33.43,125.25,fee schedule,
HC EHRLICHIA PCR,83003120,CDM,306,RC,87484,CPT,,,facility,outpatient,,,271.00000,162.60000,WellCare of North Carolina,Medicare Advantage,,36.84,,,,,,,34.04,203.25,fee schedule,
HC APOE GENOTYPING ASSAY,83003160,CDM,300,RC,81401,CPT,,,facility,outpatient,,,319.00000,191.40000,WellCare of North Carolina,Medicare Advantage,,143.85,,,,,,,63.86,254.34,fee schedule,
HC BONE MARROW CULTURE,83003188,CDM,361,RC,87070,CPT,,,facility,outpatient,,,515.00000,309.00000,WellCare of North Carolina,Medicare Advantage,,9.05,,,,,,,8.36,356.33,fee schedule,
HC CEPHEID MOLECULAR VAGINITIS PANEL,83003195,CDM,306,RC,81515,CPT,,,facility,outpatient,,,526.00000,315.60000,WellCare of North Carolina,Medicare Advantage,,276.14,,,,,,,105.31,394.50,fee schedule,
HC HPV DNA PROBE WITH EXTENDED GENOTYPE,83003197,CDM,306,RC,87626,CPT,,,facility,outpatient,,,210.00000,126.00000,WellCare of North Carolina,Medicare Advantage,,73.71,,,,,,,42.04,157.50,fee schedule,
HC SURG PATH MISCELLANEOUS,83100004,CDM,310,RC,88399,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,0.00200,70.99,fee schedule,
HC HEMATOCRIT,83100006,CDM,305,RC,85014,CPT,,,facility,outpatient,,,27.00000,16.20000,WellCare of North Carolina,Medicare Advantage,,2.49,,,,,,,2.30,20.25,fee schedule,
HC NON GYN SMEAR SPECIMEN,83100007,CDM,311,RC,88104,CPT,,,facility,outpatient,,,110.00000,66.00000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,22.02,82.50,fee schedule,
HC NONGYN CONCENTRATION SPECIMEN,83100008,CDM,311,RC,88108,CPT,,,facility,outpatient,,,186.00000,111.60000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,24.90,139.50,fee schedule,
HC CYSTOSPIN INTERP NON GYN,83100009,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,29.43,110.25,fee schedule,
HC NON GYN PREP W CELL ENHANCE,83100010,CDM,311,RC,88112,CPT,,,facility,outpatient,,,147.00000,88.20000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,29.43,110.25,fee schedule,
HC THINPREP PAP SMEAR CYTOLOGY,83100012,CDM,311,RC,88142,CPT,,,facility,outpatient,,,198.00000,118.80000,WellCare of North Carolina,Medicare Advantage,,21.27,,,,,,,19.65,148.50,fee schedule,
HC SMEAR CYTOLOGY,83100016,CDM,311,RC,88160,CPT,,,facility,outpatient,,,119.00000,71.40000,WellCare of North Carolina,Medicare Advantage,,25.50,,,,,,,23.56,89.25,fee schedule,
HC FNA W IMMED EVAL FIRST PASS,83100020,CDM,311,RC,88172,CPT,,,facility,outpatient,,,255.00000,153.00000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,36.54,201.52,fee schedule,
HC FNA W PATHOLOGIST INTERPRETATION,83100021,CDM,311,RC,88173,CPT,,,facility,outpatient,,,261.00000,156.60000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,51.40,195.75,fee schedule,
HC LIQUID BASE PREP W MANUAL AND AUTO SCREEN,83100022,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,27.94,,,,,,,25.81,102.00,fee schedule,
HC PAP TP IMAGED SCREEN,83100023,CDM,311,RC,88175,CPT,,,facility,outpatient,,,78.00000,46.80000,WellCare of North Carolina,Medicare Advantage,,27.94,,,,,,,15.62,58.50,fee schedule,
HC PAP TP IMAGED MED DX,83100024,CDM,311,RC,88175,CPT,,,facility,outpatient,,,136.00000,81.60000,WellCare of North Carolina,Medicare Advantage,,27.94,,,,,,,25.81,102.00,fee schedule,
HC FLOW MARKER 1ST,83100026,CDM,311,RC,88184,CPT,,,facility,outpatient,,,209.00000,125.40000,WellCare of North Carolina,Medicare Advantage,,374.62,,,,,,,24.90,381.82,fee schedule,
HC CELL MARKER 1ST MARKER,83100030,CDM,311,RC,88184,CPT,,,facility,outpatient,,,207.00000,124.20000,WellCare of North Carolina,Medicare Advantage,,374.62,,,,,,,24.90,381.82,fee schedule,
HC TISSUE CULTURE NON NEOPLASTIC DISORDERS,83100047,CDM,311,RC,88230,CPT,,,facility,outpatient,,,518.00000,310.80000,WellCare of North Carolina,Medicare Advantage,,122.31,,,,,,,103.70,388.50,fee schedule,
HC TISSUE CULTURE BLOOD SETUP ONLY,83100048,CDM,311,RC,88230,CPT,,,facility,outpatient,,,148.00000,88.80000,WellCare of North Carolina,Medicare Advantage,,122.31,,,,,,,29.63,248.36,fee schedule,
HC SOLID TISSUE OR SKIN CULTURE,83100050,CDM,311,RC,88233,CPT,,,facility,outpatient,,,456.00000,273.60000,WellCare of North Carolina,Medicare Advantage,,147.77,,,,,,,91.29,342.00,fee schedule,
HC TISSUE CULTURE AMNIO CVS,83100051,CDM,311,RC,88235,CPT,,,facility,outpatient,,,597.00000,358.20000,WellCare of North Carolina,Medicare Advantage,,157.81,,,,,,,119.52,447.75,fee schedule,
HC TISSUE CULTURE AMNIO CVS W SENDOUT,83100052,CDM,311,RC,88235,CPT,,,facility,outpatient,,,755.00000,453.00000,WellCare of North Carolina,Medicare Advantage,,157.81,,,,,,,145.79,566.25,fee schedule,
HC TISSUE CULTURE BONE MARROW,83100053,CDM,311,RC,88237,CPT,,,facility,outpatient,,,561.00000,336.60000,WellCare of North Carolina,Medicare Advantage,,150.94,,,,,,,112.31,420.75,fee schedule,
HC FREEZING AND STORAGE CELLS,83100055,CDM,311,RC,88240,CPT,,,facility,outpatient,,,325.00000,195.00000,WellCare of North Carolina,Medicare Advantage,,13.72,,,,,,,12.68,243.75,fee schedule,
HC CHROMOSOME ANALYSIS 5 CELL 1 KARYOTYPE,83100059,CDM,311,RC,88261,CPT,,,facility,outpatient,,,225.00000,135.00000,WellCare of North Carolina,Medicare Advantage,,277.56,,,,,,,45.05,490.72,fee schedule,
HC KARYOTYPING W BANDING,83100060,CDM,311,RC,88262,CPT,,,facility,outpatient,,,1019.00000,611.40000,WellCare of North Carolina,Medicare Advantage,,131.76,,,,,,,121.73,764.25,fee schedule,
HC CHROMOSOME ANALYSIS 20 TO 25 CELLS,83100061,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,WellCare of North Carolina,Medicare Advantage,,151.84,,,,,,,70.87,268.48,fee schedule,
HC KARYOTYPE W BANDING AMNIO CVS,83100062,CDM,311,RC,88267,CPT,,,facility,outpatient,,,609.00000,365.40000,WellCare of North Carolina,Medicare Advantage,,198.00,,,,,,,121.92,456.75,fee schedule,
HC MOLECULAR CYTOGEN DNA PROBE,83100064,CDM,311,RC,88271,CPT,,,facility,outpatient,,,224.00000,134.40000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,20.78,168.00,fee schedule,
HC REF MOL CYTOG DNA PROBE,83100065,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC CHROMOSOMAL IN SITU HYBRIDIZATION 10 TO 30 CELLS,83100068,CDM,311,RC,88273,CPT,,,facility,outpatient,,,132.00000,79.20000,WellCare of North Carolina,Medicare Advantage,,36.55,,,,,,,26.43,99.00,fee schedule,
HC INTERPHASE IN SITU HYBRID 25 TO 99 CELLS,83100069,CDM,311,RC,88274,CPT,,,facility,outpatient,,,135.00000,81.00000,WellCare of North Carolina,Medicare Advantage,,44.50,,,,,,,27.03,101.25,fee schedule,
HC INTERPHASE IN SITU HYBRID 100 TO 300 CELLS,83100070,CDM,311,RC,88275,CPT,,,facility,outpatient,,,548.00000,328.80000,WellCare of North Carolina,Medicare Advantage,,53.75,,,,,,,49.65,411.00,fee schedule,
HC ADDITIONAL KARYOTYPE,83100071,CDM,311,RC,88280,CPT,,,facility,outpatient,,,102.00000,61.20000,WellCare of North Carolina,Medicare Advantage,,35.14,,,,,,,20.42,76.50,fee schedule,
HC ADDITIONAL SPEC BAND TECH,83100072,CDM,311,RC,88283,CPT,,,facility,outpatient,,,175.00000,105.00000,WellCare of North Carolina,Medicare Advantage,,72.03,,,,,,,35.03,146.24,fee schedule,
HC ADDITIONAL CELLS COUNTED,83100073,CDM,311,RC,88285,CPT,,,facility,outpatient,,,367.00000,220.20000,WellCare of North Carolina,Medicare Advantage,,28.26,,,,,,,26.10,275.25,fee schedule,
HC MISC CYTOGENETICS PROCEDURE,83100074,CDM,311,RC,88299,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,15.51,495.00,fee schedule,
HC OUTSIDE CONSULTATION ON REFERRED SLIDES,83100075,CDM,312,RC,88321,CPT,,,facility,outpatient,,,0.01000,0.01000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,0.00200,109.32,fee schedule,
HC LEVEL I SURG PATH GROSS ONLY,83100077,CDM,312,RC,88300,CPT,,,facility,outpatient,,,124.00000,74.40000,WellCare of North Carolina,Medicare Advantage,,25.50,,,,,,,20.48,93.00,fee schedule,
HC LEVEL II SURG PATH GROSS AND MICRO,83100078,CDM,312,RC,88302,CPT,,,facility,outpatient,,,226.00000,135.60000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,24.90,169.50,fee schedule,
HC LEVEL III SURG PATH GROSS AND MICRO,83100079,CDM,312,RC,88304,CPT,,,facility,outpatient,,,370.00000,222.00000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,51.40,277.50,fee schedule,
HC BONE MARROW CLOT EXAM,83100090,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL IV SURG PATH GROSS AND MICRO,83100094,CDM,312,RC,88305,CPT,,,facility,outpatient,,,319.00000,191.40000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,51.40,239.25,fee schedule,
HC LEVEL V SURG PATH OR CYTO GROSS AND MICRO,83100096,CDM,312,RC,88307,CPT,,,facility,outpatient,,,593.00000,355.80000,WellCare of North Carolina,Medicare Advantage,,374.62,,,,,,,80.53,444.75,fee schedule,
HC LEVEL VI SURG PATH GROSS AND MICRO,83100098,CDM,312,RC,88309,CPT,,,facility,outpatient,,,548.00000,328.80000,WellCare of North Carolina,Medicare Advantage,,850.74,,,,,,,80.53,858.84,fee schedule,
HC SPECIAL STAINS GRP 2 IRON STAIN BM,83100110,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,24.90,135.52,fee schedule,
HC SPECIAL STAINS GRP 3 PEROXIDASE STAIN,83100149,CDM,312,RC,88319,CPT,,,facility,outpatient,,,249.00000,149.40000,WellCare of North Carolina,Medicare Advantage,,850.74,,,,,,,49.85,858.84,fee schedule,
HC CONSULT REPORT W SLIDE PREP,83100162,CDM,312,RC,88323,CPT,,,facility,outpatient,,,77.00000,46.20000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,15.42,70.99,fee schedule,
HC FROZEN SECTION FIRST BLOCK,83100163,CDM,312,RC,88331,CPT,,,facility,outpatient,,,384.00000,230.40000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,53.18,288.00,fee schedule,
HC INTRAOPERATIVE TOUCH PREP,83100165,CDM,312,RC,88333,CPT,,,facility,outpatient,,,675.00000,405.00000,WellCare of North Carolina,Medicare Advantage,,850.74,,,,,,,24.90,858.84,fee schedule,
HC IMMUNO FLUORESCENCE CONSULT INITIAL,83100343,CDM,312,RC,88346,CPT,,,facility,outpatient,,,414.00000,248.40000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,53.18,381.82,fee schedule,
HC ANCA IFA,83100357,CDM,302,RC,86036,CPT,,,facility,outpatient,,,256.00000,153.60000,WellCare of North Carolina,Medicare Advantage,,12.65,,,,,,,11.69,192.00,fee schedule,
HC HER2NEU MORPHOMETRIC SPECIMEN,83100363,CDM,312,RC,88360,CPT,,,facility,outpatient,,,261.00000,156.60000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,52.25,201.52,fee schedule,
HC ESTROGEN RECEPTOR MORPHOMETRIC SPECIMEN,83100364,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,31.43,201.52,fee schedule,
HC PROGESTERONE RECEPTOR MORPHOME SPECIMEN,83100365,CDM,312,RC,88360,CPT,,,facility,outpatient,,,157.00000,94.20000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,31.43,201.52,fee schedule,
HC IN SITU HYBRIDIZATION EACH SPECIMEN,83100368,CDM,312,RC,88365,CPT,,,facility,outpatient,,,539.00000,323.40000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,80.53,404.25,fee schedule,
HC HBA1 HBA2 GENE ANALYSIS FOR COMMON DELETIONS OR VARIANTS,83100377,CDM,310,RC,81257,CPT,,,facility,outpatient,,,164.00000,98.40000,WellCare of North Carolina,Medicare Advantage,,107.37,,,,,,,32.83,189.48,fee schedule,
HC BILICHEK,83100380,CDM,310,RC,88720,CPT,,,facility,outpatient,,,18.00000,10.80000,WellCare of North Carolina,Medicare Advantage,,5.27,,,,,,,3.60,13.50,fee schedule,
HC TUMOR IMMUNOHISTOCHEMISTRY QUANT,83100406,CDM,312,RC,88360,CPT,,,facility,outpatient,,,414.00000,248.40000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,53.18,310.50,fee schedule,
HC 8537 TISSUE CULTURE FOR CHROM,83100408,CDM,311,RC,88237,CPT,,,facility,outpatient,,,247.00000,148.20000,WellCare of North Carolina,Medicare Advantage,,150.94,,,,,,,49.45,269.27,fee schedule,
HC TISSUE CULTURE SKIN SETUP ONLY,83100409,CDM,311,RC,88233,CPT,,,facility,outpatient,,,2191.00000,1314.60000,WellCare of North Carolina,Medicare Advantage,,147.77,,,,,,,136.51,1643.25,fee schedule,
HC TISSUE CULTURE BONE MARROW SETUP ONLY,83100411,CDM,311,RC,88237,CPT,,,facility,outpatient,,,353.00000,211.80000,WellCare of North Carolina,Medicare Advantage,,150.94,,,,,,,70.67,269.27,fee schedule,
HC REF INTERPHS ISH ANLYZ 100 TO 300 CELLS,83100419,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,WellCare of North Carolina,Medicare Advantage,,53.75,,,,,,,38.44,144.00,fee schedule,
HC 8506 CHROMOSOMES HEMO BONE M,83100437,CDM,311,RC,88264,CPT,,,facility,outpatient,,,354.00000,212.40000,WellCare of North Carolina,Medicare Advantage,,151.84,,,,,,,70.87,268.48,fee schedule,
HC PIN4 COCKTAIL SPECIMEN,83100443,CDM,312,RC,88344,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Medicare Advantage,,374.62,,,,,,,77.08,381.82,fee schedule,
HC TISSUE IMMUNOPEROXIDASE,83100460,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,53.18,288.75,fee schedule,
HC TRB GENE ARRANGE AMPLIFY,83100662,CDM,311,RC,88275,CPT,,,facility,outpatient,,,1285.00000,771.00000,WellCare of North Carolina,Medicare Advantage,,53.75,,,,,,,49.65,963.75,fee schedule,
HC REF MULTIPLE MYELOMA MOL CYTOG DNA PROBE,83100693,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC IHC STAIN INITIAL SINGLE ANTIBODY STAIN,83100695,CDM,312,RC,88342,CPT,,,facility,outpatient,,,385.00000,231.00000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,53.18,288.75,fee schedule,
HC SPECIAL STAINS GRP 1,83100697,CDM,312,RC,88312,CPT,,,facility,outpatient,,,312.00000,187.20000,WellCare of North Carolina,Medicare Advantage,,55.64,,,,,,,24.90,234.00,fee schedule,
HC SPECIAL STAINS GRP 2,83100698,CDM,312,RC,88313,CPT,,,facility,outpatient,,,129.00000,77.40000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,24.90,135.52,fee schedule,
HC FLOW CYTOMETRY MARKER FISH CYTOGENETICS,83100710,CDM,311,RC,88184,CPT,,,facility,outpatient,,,1243.00000,745.80000,WellCare of North Carolina,Medicare Advantage,,374.62,,,,,,,24.90,932.25,fee schedule,
HC REF AML ALL INTERPHS ISH ANLYZ 100 TO 300 CELLS EACH,83100724,CDM,311,RC,88275,CPT,,,facility,outpatient,,,192.00000,115.20000,WellCare of North Carolina,Medicare Advantage,,53.75,,,,,,,38.44,144.00,fee schedule,
HC REF AML ALL MOLE CYTOG DNA PROBE,83100725,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC NEOTYPE AUTO TC MULTIPLEX PROBE,83100744,CDM,311,RC,88374,CPT,,,facility,outpatient,,,908.00000,544.80000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,164.86,681.00,fee schedule,
HC NEOTYPE LUNG FISH MANUAL,83100745,CDM,311,RC,88377,CPT,,,facility,outpatient,,,660.00000,396.00000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,132.13,646.00,fee schedule,
HC CONSULT REPORT W REFERRED MATERIAL,83100768,CDM,312,RC,88325,CPT,,,facility,outpatient,,,356.00000,213.60000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,70.99,267.00,fee schedule,
HC MOL CYTOGENETICS DNA PROBE,83100777,CDM,311,RC,88271,CPT,,,facility,outpatient,,,125.00000,75.00000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,20.78,93.75,fee schedule,
HC MOL CYTOGEN DNA PROBE ADDITIONAL,83100778,CDM,311,RC,88271,CPT,,,facility,outpatient,,,150.00000,90.00000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,20.78,112.50,fee schedule,
HC MOL CYTOGENETICS DNA PROBE FISH,83100784,CDM,311,RC,88271,CPT,,,facility,outpatient,,,95.00000,57.00000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,19.02,71.25,fee schedule,
HC INTERPHASE ISH ANALYZE 100 TO 300 CELLS FISH,83100785,CDM,311,RC,88275,CPT,,,facility,outpatient,,,166.00000,99.60000,WellCare of North Carolina,Medicare Advantage,,53.75,,,,,,,33.23,124.50,fee schedule,
HC REF MDM2 CYTOGENETICS DNA PROBE,83100787,CDM,311,RC,88271,CPT,,,facility,outpatient,,,80.00000,48.00000,WellCare of North Carolina,Medicare Advantage,,22.49,,,,,,,16.02,60.00,fee schedule,
HC REF FISH ANALYSIS 25 TO 99 CELLS,83100788,CDM,311,RC,88274,CPT,,,facility,outpatient,,,159.00000,95.40000,WellCare of North Carolina,Medicare Advantage,,44.50,,,,,,,31.83,119.25,fee schedule,
HC TRANSACTION REACTION INVESTIGATION,83900002,CDM,300,RC,86078,CPT,,,facility,outpatient,,,66.00000,39.60000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,13.21,201.52,fee schedule,
HC THAWING FROZEN PLASMA EACH UNIT,83900004,CDM,300,RC,86927,CPT,,,facility,outpatient,,,42.00000,25.20000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,8.41,201.52,fee schedule,
HC THAWING FROZEN POOLED CRYO,83900007,CDM,300,RC,86931,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,5.61,381.82,fee schedule,
HC BLOOD PRODUCT IRRADIATION EACH UNIT,83900009,CDM,300,RC,86945,CPT,,,facility,outpatient,,,105.00000,63.00000,WellCare of North Carolina,Medicare Advantage,,40.88,,,,,,,21.02,78.75,fee schedule,
HC POOLING BLOOD PRODUCTS,83900010,CDM,300,RC,86965,CPT,,,facility,outpatient,,,248.00000,148.80000,WellCare of North Carolina,Medicare Advantage,,178.46,,,,,,,37.47,201.52,fee schedule,
HC CRYOPRECIPITATE,83900020,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RED CELLS ER LEUKOCYTE REDUCED,83900022,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Medicare Advantage,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RED CELLS LEUKOCYTE REDUCED,83900023,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,300.00000,180.00000,WellCare of North Carolina,Medicare Advantage,,189.54,,,,,,,52.23,2907.00,fee schedule,
HC RBC ALIQUOT,83900024,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,277.00000,166.20000,WellCare of North Carolina,Medicare Advantage,,189.54,,,,,,,48.23,2907.00,fee schedule,
HC RBC LEUKO REDUCED,83900026,CDM,390,RC,P9016,CPT,,,facility,outpatient,,,566.00000,339.60000,WellCare of North Carolina,Medicare Advantage,,189.54,,,,,,,98.54,2907.00,fee schedule,
HC PHERESIS FFP,83900028,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Medicare Advantage,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FFP ALIQUOT,83900029,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Medicare Advantage,,87.78,,,,,,,15.84,2907.00,fee schedule,
HC FRESH FROZEN PLASMA,83900030,CDM,390,RC,P9017,CPT,,,facility,outpatient,,,57.00000,34.20000,WellCare of North Carolina,Medicare Advantage,,87.78,,,,,,,9.92,2907.00,fee schedule,
HC RBC AUTOLOGOUS,83900033,CDM,390,RC,P9021,CPT,,,facility,outpatient,,,679.00000,407.40000,WellCare of North Carolina,Medicare Advantage,,150.30,,,,,,,118.21,2907.00,fee schedule,
HC WASHED RED BLOOD CELLS EACH UNIT,83900034,CDM,390,RC,P9022,CPT,,,facility,outpatient,,,651.00000,390.60000,WellCare of North Carolina,Medicare Advantage,,413.31,,,,,,,113.34,2907.00,fee schedule,
HC PLATELET PHERESIS LEUKOCYTE REDUCED EACH UNIT,83900039,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLATELET PHERESIS LR ONE FOURTH IRRADIATED,83900050,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1070.00000,642.00000,WellCare of North Carolina,Medicare Advantage,,703.66,,,,,,,186.29,2907.00,fee schedule,
HC DEGLYCERLIZED RED CELLS,83900053,CDM,390,RC,P9039,CPT,,,facility,outpatient,,,215.00000,129.00000,WellCare of North Carolina,Medicare Advantage,,680.83,,,,,,,37.43,2907.00,fee schedule,
HC RBC LEUKO REDUCED IRRADIATED,83900054,CDM,390,RC,P9040,CPT,,,facility,outpatient,,,419.00000,251.40000,WellCare of North Carolina,Medicare Advantage,,266.40,,,,,,,72.95,2907.00,fee schedule,
HC CRYO POOR PLASMA,83900055,CDM,390,RC,P9044,CPT,,,facility,outpatient,,,294.00000,176.40000,WellCare of North Carolina,Medicare Advantage,,153.41,,,,,,,51.19,2907.00,fee schedule,
HC PLATELET APHERESIS HLA MATCH,83900057,CDM,390,RC,P9052,CPT,,,facility,outpatient,,,1240.00000,744.00000,WellCare of North Carolina,Medicare Advantage,,809.71,,,,,,,215.88,2907.00,fee schedule,
HC RBC LEUKOREDUCED WASHED,83900060,CDM,390,RC,P9054,CPT,,,facility,outpatient,,,600.00000,360.00000,WellCare of North Carolina,Medicare Advantage,,252.48,,,,,,,104.46,2907.00,fee schedule,
HC PLASMA,83900062,CDM,390,RC,P9059,CPT,,,facility,outpatient,,,91.00000,54.60000,WellCare of North Carolina,Medicare Advantage,,74.04,,,,,,,15.84,2907.00,fee schedule,
HC PATHOGEN REDUCED PAS APHERESIS PLTS,83900087,CDM,390,RC,P9073,CPT,,,facility,outpatient,,,1528.00000,916.80000,WellCare of North Carolina,Medicare Advantage,,611.61,,,,,,,266.02,2907.00,fee schedule,
HC ABO GROUP EXP,83999901,CDM,302,RC,86900,CPT,,,facility,outpatient,,,28.00000,16.80000,WellCare of North Carolina,Medicare Advantage,,3.14,,,,,,,2.90,21.00,fee schedule,
HC ANTIBODY SCREEN W COLD ADSORPTION EXP,83999902,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W ELUATE EXP,83999903,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC ANTIBODY SCREEN W WARM ADSORPTION EXP,83999904,CDM,302,RC,86850,CPT,,,facility,outpatient,,,165.00000,99.00000,WellCare of North Carolina,Medicare Advantage,,10.26,,,,,,,9.48,123.75,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 2 EXP,83999905,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 3 EXP,83999906,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 4 EXP,83999907,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 5 EXP,83999908,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 6 EXP,83999909,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC SELECTED CELL ANTIBODY SCREEN 7 EXP,83999910,CDM,302,RC,86885,CPT,,,facility,outpatient,,,59.00000,35.40000,WellCare of North Carolina,Medicare Advantage,,6.01,,,,,,,5.55,44.25,fee schedule,
HC PLT PHERESIS LEUKO RED WASH EXP,83999915,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKO REDUCED EXP,83999916,CDM,390,RC,P9035,CPT,,,facility,outpatient,,,1041.00000,624.60000,WellCare of North Carolina,Medicare Advantage,,507.29,,,,,,,181.24,2907.00,fee schedule,
HC PLT PHERESIS LEUKOREDUCD IRRAD EXP,83999917,CDM,390,RC,P9037,CPT,,,facility,outpatient,,,1160.00000,696.00000,WellCare of North Carolina,Medicare Advantage,,703.66,,,,,,,201.96,2907.00,fee schedule,
HC CRYOPRECIPITATE A,83999918,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE B,83999919,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE C,83999920,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE D,83999921,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC CRYOPRECIPITATE 5 EXP,83999922,CDM,390,RC,P9012,CPT,,,facility,outpatient,,,62.00000,37.20000,WellCare of North Carolina,Medicare Advantage,,66.20,,,,,,,10.79,2907.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,361,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 1ST ORDER INCL S AND I,93600017,CDM,481,RC,36252,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC RENAL ANGIO UNIL SEL 2ND OR MORE ORDER INCL S AND I,93600018,CDM,361,RC,36253,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1715.71,13852.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,361,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO BIL SEL 2ND OR MORE ORDER INCL S AND I,93600019,CDM,481,RC,36254,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC TMVR,93600034,CDM,481,RC,93799,CPT,,,facility,outpatient,,,35477.00000,21286.20000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,21640.97,fee schedule,
HC PVL CLOSURES,93600035,CDM,481,RC,93799,CPT,,,facility,outpatient,,,6012.00000,3607.20000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,481,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC TEMPORARY PACEMAKER INSERTION,93610004,CDM,361,RC,33210,CPT,,,facility,outpatient,,,2474.00000,1484.40000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,495.29,13852.00,fee schedule,
HC THORACIC ARTERY NON SEL CATH PLACEMENT W ANGIOGRAPHY INCL CAROTID VERT CEREB ARCH,93610019,CDM,481,RC,36221,CPT,,,facility,outpatient,,,7717.00000,4630.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1544.94,9423.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,361,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,772.37,8045.00,fee schedule,
HC COMMON CAROTID EXTRACRANIAL UNILAT,93610020,CDM,481,RC,36222,CPT,,,facility,outpatient,,,3858.00000,2314.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,772.37,9423.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,361,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC COMMON CAROTID INTRACRANIAL UNILAT,93610021,CDM,481,RC,36223,CPT,,,facility,outpatient,,,7166.00000,4299.60000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1434.63,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,361,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC INTERNAL CAROTID ART UNILAT,93610022,CDM,481,RC,36224,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,361,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,275.88,8045.00,fee schedule,
HC SUBCLAVIAN OR INNOMINATE ARTERY SEL CATH PLACEMENT UNILATERAL W ANGIOGRAPHY,93610023,CDM,481,RC,36225,CPT,,,facility,outpatient,,,1378.00000,826.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,275.88,9423.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,361,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC VERTEBRAL ART UNILATERAL,93610024,CDM,481,RC,36226,CPT,,,facility,outpatient,,,5512.00000,3307.20000,WellCare of North Carolina,Medicare Advantage,,5629.67,,,,,,,1103.50,13852.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,361,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1715.71,8045.00,fee schedule,
HC RENAL ANGIO UNIL SEL 1ST ORDER INCL S AND I,93610026,CDM,481,RC,36251,CPT,,,facility,outpatient,,,8570.00000,5142.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1715.71,9423.00,fee schedule,
HC INSERT NON TUNNELED CVC 5YRS OR OLDER,93610027,CDM,361,RC,36556,CPT,,,facility,outpatient,,,794.00000,476.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,158.96,4311.00,fee schedule,
HC STENT INTRAVASCULAR INITIAL VESSEL OPEN,93610029,CDM,481,RC,37238,CPT,,,facility,outpatient,,,29057.00000,17434.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,5817.21,24600.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,361,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,879.68,8213.00,fee schedule,
HC TRANSCATH THERAPY VENOUS LYSIS,93610030,CDM,481,RC,37212,CPT,,,facility,outpatient,,,4394.00000,2636.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,879.68,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,361,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS,93610031,CDM,481,RC,37213,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,361,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,87.89,17457.00,fee schedule,
HC TRANSCATH THERAPY FOLLOW UP LYSIS INCL CATH REMOVAL,93610032,CDM,481,RC,37214,CPT,,,facility,outpatient,,,439.00000,263.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,87.89,9423.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,361,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY INITIAL VESSEL UNIL,93610035,CDM,481,RC,37220,CPT,,,facility,outpatient,,,16729.00000,10037.40000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,3349.15,13852.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,361,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA ILIAC ARTERY W STENT INITIAL VESSEL UNIL,93610036,CDM,481,RC,37221,CPT,,,facility,outpatient,,,27882.00000,16729.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,5581.98,24600.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,361,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP UNIL,93610039,CDM,481,RC,37224,CPT,,,facility,outpatient,,,9307.00000,5584.20000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,1863.26,13852.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,361,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W ATHERECTOMY UNIL,93610040,CDM,481,RC,37225,CPT,,,facility,outpatient,,,23479.00000,14087.40000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4700.50,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,361,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT SAME VESSEL UNIL,93610041,CDM,481,RC,37226,CPT,,,facility,outpatient,,,21152.00000,12691.20000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4234.63,24600.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,361,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA FEM POP W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610042,CDM,481,RC,37227,CPT,,,facility,outpatient,,,28133.00000,16879.80000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,5632.23,52940.00,fee schedule,
HC REVASC PTA TIBIAL PERONEAL INITIAL VESSEL UNIL,93610043,CDM,481,RC,37228,CPT,,,facility,outpatient,,,12328.00000,7396.80000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2468.07,13852.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,361,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W ATHERECTOMY SAME VESSEL UNIL,93610044,CDM,481,RC,37229,CPT,,,facility,outpatient,,,23300.00000,13980.00000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4664.66,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,361,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT SAME VESSEL UNIL,93610045,CDM,481,RC,37230,CPT,,,facility,outpatient,,,21204.00000,12722.40000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4245.04,24600.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,361,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC REVASC PTA TIBAL PERONEAL W STENT AND ATHERECTOMY SAME VESSEL UNIL,93610046,CDM,481,RC,37231,CPT,,,facility,outpatient,,,24040.00000,14424.00000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,4812.81,52940.00,fee schedule,
HC BM STENT OR PTCA OR ATH BYPASS GRAFT,93610113,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC DES STENT BYPASS GRAFT,93610114,CDM,481,RC,92937,CPT,,,facility,outpatient,,,23143.00000,13885.80000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4633.23,27871.00,fee schedule,
HC TEMP TRANSCUTANEOUS PACING,93610147,CDM,481,RC,92953,CPT,,,facility,outpatient,,,393.00000,235.80000,WellCare of North Carolina,Medicare Advantage,,681.49,,,,,,,78.68,9423.00,fee schedule,
HC CARDIOVERSION EXTERNAL,93610148,CDM,480,RC,92960,CPT,,,facility,outpatient,,,1664.00000,998.40000,WellCare of North Carolina,Medicare Advantage,,681.49,,,,,,,222.64,3641.00,fee schedule,
HC THROMBOLYSIS BY IV INFUSION,93610152,CDM,481,RC,92977,CPT,,,facility,outpatient,,,986.00000,591.60000,WellCare of North Carolina,Medicare Advantage,,345.43,,,,,,,173.00,9423.00,fee schedule,
HC BALLON VALVULOPLASTY AORTIC,93610155,CDM,481,RC,92986,CPT,,,facility,outpatient,,,11572.00000,6943.20000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,2316.71,27871.00,fee schedule,
HC BALLOON VALVULOPLASTY MITRAL,93610156,CDM,481,RC,92987,CPT,,,facility,outpatient,,,10706.00000,6423.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC BALLON VALVULOPLASTY PULMONARY,93610157,CDM,481,RC,92990,CPT,,,facility,outpatient,,,10706.00000,6423.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2143.34,27871.00,fee schedule,
HC PTA PULM ARTERY SINGLE VSL,93610159,CDM,481,RC,92997,CPT,,,facility,outpatient,,,10210.00000,6126.00000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2044.04,27871.00,fee schedule,
HC RHC W O2 SAT AND CARD OUTPUT,93610161,CDM,481,RC,93451,CPT,,,facility,outpatient,,,7367.00000,4420.20000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,1474.87,10022.00,fee schedule,
HC LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610162,CDM,481,RC,93452,CPT,,,facility,outpatient,,,10893.00000,6535.80000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,2180.78,12247.00,fee schedule,
HC RHC AND LHC W LT VENTRICULOGRAPHY INJ INCL S AND I,93610163,CDM,481,RC,93453,CPT,,,facility,outpatient,,,9673.00000,5803.80000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,1936.53,12247.00,fee schedule,
HC CATHETER COR ANGIOGRAPHY W INJ INCL S AND I,93610164,CDM,481,RC,93454,CPT,,,facility,outpatient,,,10326.00000,6195.60000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,2067.27,12247.00,fee schedule,
HC CATHETER PLACE W COR INJ AND GRAFTS AND NO LV,93610165,CDM,481,RC,93455,CPT,,,facility,outpatient,,,4543.00000,2725.80000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,909.51,12247.00,fee schedule,
HC RHC CORS ONLY,93610166,CDM,481,RC,93456,CPT,,,facility,outpatient,,,10624.00000,6374.40000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,2126.92,12247.00,fee schedule,
HC RHC CORS IMA SVG,93610167,CDM,481,RC,93457,CPT,,,facility,outpatient,,,13251.00000,7950.60000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,2652.85,12247.00,fee schedule,
HC LHC CORS,93610168,CDM,481,RC,93458,CPT,,,facility,outpatient,,,11937.00000,7162.20000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,2389.79,12247.00,fee schedule,
HC LHC CORS IMA SVG,93610169,CDM,481,RC,93459,CPT,,,facility,outpatient,,,12734.00000,7640.40000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,2549.35,12247.00,fee schedule,
HC RLHC CORS,93610170,CDM,481,RC,93460,CPT,,,facility,outpatient,,,12950.00000,7770.00000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,2592.59,12247.00,fee schedule,
HC RLHC CORS BYPASS W OR WO LV GAM,93610171,CDM,481,RC,93461,CPT,,,facility,outpatient,,,15877.00000,9526.20000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,3094.46,12247.00,fee schedule,
HC SWAN GANZ PLACEMENT ONLY,93610175,CDM,481,RC,93503,CPT,,,facility,outpatient,,,1503.00000,901.80000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,300.90,9423.00,fee schedule,
HC ENDOMYOCARDIAL BIOPSY,93610176,CDM,481,RC,93505,CPT,,,facility,outpatient,,,4128.00000,2476.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,826.43,9423.00,fee schedule,
HC PERC TRANSCATH CLOSURE CONGENITAL SEPTAL DEFECT ASD OR PFO W IMPLANT,93610190,CDM,481,RC,93580,CPT,,,facility,outpatient,,,39133.00000,23479.80000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,7834.43,39682.00,fee schedule,
HC COMP EP EVAL INITIAL RA RV HIS,93610191,CDM,480,RC,93620,CPT,,,facility,outpatient,,,12282.00000,7369.20000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,1411.00,12247.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,361,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC REVASC ATHERECTOMY ILIAC ARTERY INCLD S AND I EACH VESSEL,93610198,CDM,481,RC,0238T,CPT,,,facility,outpatient,,,7882.00000,4729.20000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,1577.98,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL LEAD,93610201,CDM,361,RC,33206,CPT,,,facility,outpatient,,,14979.00000,8987.40000,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMARKER W VENTRICULAR LEAD,93610202,CDM,361,RC,33207,CPT,,,facility,outpatient,,,14979.00000,8987.40000,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,2998.80,24600.00,fee schedule,
HC INSERT REPLACE PERMANENT PACEMAKER W ATRIAL AND VENTRICULAR LEAD,93610203,CDM,361,RC,33208,CPT,,,facility,outpatient,,,18267.00000,10960.20000,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,3657.05,39682.00,fee schedule,
HC INSERT PM GEN ONLY EXIST SNGL LEAD,93610204,CDM,361,RC,33212,CPT,,,facility,outpatient,,,13268.00000,7960.80000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,2656.25,24600.00,fee schedule,
HC INSERT PM GEN ONLY EXIST DUAL LEAD,93610205,CDM,361,RC,33213,CPT,,,facility,outpatient,,,15077.00000,9046.20000,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,3018.42,24600.00,fee schedule,
HC UPGRADE SINGLE PPM TO DUAL PPM,93610206,CDM,361,RC,33214,CPT,,,facility,outpatient,,,18194.00000,10916.40000,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,3642.44,39682.00,fee schedule,
HC REPOSITIONING RT ATRIAL OR RT VENTRICAL LEAD PERMANENT PACEMAKER ICD,93610207,CDM,361,RC,33215,CPT,,,facility,outpatient,,,3193.00000,1915.80000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,639.24,8045.00,fee schedule,
HC INSERT SINGLE CHAMBER LEAD PERMANENT PACEMAKER ICD,93610208,CDM,361,RC,33216,CPT,,,facility,outpatient,,,14089.00000,8453.40000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC INSERT 2 LEADS FOR PMKR/ICD,93610209,CDM,361,RC,33217,CPT,,,facility,outpatient,,,14089.00000,8453.40000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,2820.62,13852.00,fee schedule,
HC REPAIR LEAD SINGLE CHAMBER PACEMAKER ICD,93610210,CDM,361,RC,33218,CPT,,,facility,outpatient,,,10215.00000,6129.00000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,2045.04,8442.00,fee schedule,
HC REPAIR LEADS DUAL PACEMAKER DEFIB,93610211,CDM,361,RC,33220,CPT,,,facility,outpatient,,,2944.00000,1766.40000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,589.39,8442.00,fee schedule,
HC RELOCATION POCKET PACEMAKER,93610212,CDM,361,RC,33222,CPT,,,facility,outpatient,,,2902.00000,1741.20000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC RELOCATE POCKET FOR DEFIB,93610213,CDM,361,RC,33223,CPT,,,facility,outpatient,,,2902.00000,1741.20000,WellCare of North Carolina,Medicare Advantage,,1905.02,,,,,,,580.98,5152.00,fee schedule,
HC ADD LV LEAD TO EXISTING DEVICE,93610214,CDM,361,RC,33224,CPT,,,facility,outpatient,,,20392.00000,12235.20000,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,4082.48,39682.00,fee schedule,
HC REPOSITION OF LV LEAD,93610216,CDM,361,RC,33226,CPT,,,facility,outpatient,,,2367.00000,1420.20000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,473.87,8045.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER SINGLE SYSTEM,93610217,CDM,361,RC,33227,CPT,,,facility,outpatient,,,23786.00000,14271.60000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,4761.96,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER DUAL SYSTEM,93610218,CDM,361,RC,33228,CPT,,,facility,outpatient,,,24521.00000,14712.60000,WellCare of North Carolina,Medicare Advantage,,10898.93,,,,,,,4909.10,24600.00,fee schedule,
HC REMOVE AND REPLACE PACEMAKER BIV SYSTEM,93610219,CDM,361,RC,33229,CPT,,,facility,outpatient,,,26728.00000,16036.80000,WellCare of North Carolina,Medicare Advantage,,19861.32,,,,,,,5350.95,24600.00,fee schedule,
HC REMOVE OLD PACEMKR GENERATOR,93610220,CDM,361,RC,33233,CPT,,,facility,outpatient,,,8508.00000,5104.80000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,1703.30,8700.96,fee schedule,
HC REMOVAL PACEMAKER LEADS SINGLE CHAMBER,93610221,CDM,361,RC,33234,CPT,,,facility,outpatient,,,11401.00000,6840.60000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC REMOVAL PACEMAKER LEADS DUAL CHAMBER,93610222,CDM,361,RC,33235,CPT,,,facility,outpatient,,,11401.00000,6840.60000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,2282.48,8442.00,fee schedule,
HC INSERT ICD GENERATOR W EXIST SINGLE LEAD,93610223,CDM,361,RC,33240,CPT,,,facility,outpatient,,,49887.00000,29932.20000,WellCare of North Carolina,Medicare Advantage,,23376.18,,,,,,,9987.38,82346.00,fee schedule,
HC REMOVE OLD ICD GENERATOR ONLY,93610224,CDM,361,RC,33241,CPT,,,facility,outpatient,,,5750.00000,3450.00000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,1151.15,8442.00,fee schedule,
HC REMOVE LEADS DUAL CHAMBER ICD,93610225,CDM,361,RC,33244,CPT,,,facility,outpatient,,,3821.00000,2292.60000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,764.96,8442.00,fee schedule,
HC INSERT OR REPLACE ICD SYSTEM,93610226,CDM,361,RC,33249,CPT,,,facility,outpatient,,,57698.00000,34618.80000,WellCare of North Carolina,Medicare Advantage,,33389.96,,,,,,,11551.14,82346.00,fee schedule,
HC INSERT LOOP RECORDER,93610231,CDM,761,RC,33285,CPT,,,facility,outpatient,,,11667.00000,7000.20000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,2199.23,9485.27,fee schedule,
HC REMOVE LOOP RECORDER,93610232,CDM,361,RC,33286,CPT,,,facility,outpatient,,,2086.00000,1251.60000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,417.62,5152.00,fee schedule,
HC TIGHTEN LEAD SCREWS ONLY,93610233,CDM,361,RC,33999,CPT,,,facility,outpatient,,,4188.00000,2512.80000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,2912.00,fee schedule,
HC BUNDLE OF HIS RECORDING,93610234,CDM,480,RC,93600,CPT,,,facility,outpatient,,,6480.00000,3888.00000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,867.02,12247.00,fee schedule,
HC INTRA ATRIAL RECORDING,93610235,CDM,480,RC,93602,CPT,,,facility,outpatient,,,6480.00000,3888.00000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,867.02,7977.75,fee schedule,
HC RIGHT VENTRICULAR RECORDING,93610236,CDM,480,RC,93603,CPT,,,facility,outpatient,,,3232.00000,1939.20000,WellCare of North Carolina,Medicare Advantage,,1264.28,,,,,,,432.44,3641.00,fee schedule,
HC INTRA ATRIAL PACING,93610238,CDM,480,RC,93610,CPT,,,facility,outpatient,,,3232.00000,1939.20000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INTRAVENTRICULAR PACING,93610239,CDM,480,RC,93612,CPT,,,facility,outpatient,,,3232.00000,1939.20000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,432.44,7977.75,fee schedule,
HC INDUCE ARRHYTHMIA ELECT PACING,93610241,CDM,480,RC,93618,CPT,,,facility,outpatient,,,2787.00000,1672.20000,WellCare of North Carolina,Medicare Advantage,,1264.28,,,,,,,372.90,12247.00,fee schedule,
HC COMPREHENSIVE EP STUDY WO INDUCTION OF ARRHYTHMIA,93610242,CDM,480,RC,93619,CPT,,,facility,outpatient,,,9580.00000,5748.00000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,1281.80,12247.00,fee schedule,
HC EP FOLLOW UP STUDY,93610246,CDM,480,RC,93624,CPT,,,facility,outpatient,,,8084.00000,4850.40000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,1081.64,7977.75,fee schedule,
HC EP EVAL ICD POSTOP FOLLWUP DFT,93610248,CDM,480,RC,93642,CPT,,,facility,outpatient,,,3156.00000,1893.60000,WellCare of North Carolina,Medicare Advantage,,1264.28,,,,,,,422.27,12247.00,fee schedule,
HC ABLATION OF AV NODE,93610249,CDM,480,RC,93650,CPT,,,facility,outpatient,,,25442.00000,15265.20000,WellCare of North Carolina,Medicare Advantage,,7902.49,,,,,,,1411.00,16639.07,fee schedule,
HC TILT TABLE EVALUATION,93610254,CDM,480,RC,93660,CPT,,,facility,outpatient,,,3025.00000,1815.00000,WellCare of North Carolina,Medicare Advantage,,552.58,,,,,,,404.75,3641.00,fee schedule,
HC REMOVE INTER CARDIO ASSIST DEVIC,93610255,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC INSERT PM GEN ONLY EXIST MULTI,93610261,CDM,361,RC,33221,CPT,,,facility,outpatient,,,22381.00000,13428.60000,WellCare of North Carolina,Medicare Advantage,,19861.32,,,,,,,4480.68,24600.00,fee schedule,
HC INSERT REPLACE SUBQ IMPLT DEFIB SYST W SUBQ ELECTRODE,93610264,CDM,361,RC,33270,CPT,,,facility,outpatient,,,2482.00000,1489.20000,WellCare of North Carolina,Medicare Advantage,,33389.96,,,,,,,496.90,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN SINGLE LEAD SYSTEM,93610279,CDM,361,RC,33262,CPT,,,facility,outpatient,,,5548.00000,3328.80000,WellCare of North Carolina,Medicare Advantage,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN DUAL LEAD SYSTEM,93610280,CDM,361,RC,33263,CPT,,,facility,outpatient,,,5548.00000,3328.80000,WellCare of North Carolina,Medicare Advantage,,23376.18,,,,,,,1110.71,82346.00,fee schedule,
HC REMOVE AND REPLACE IMPLT DEFIB PLS GEN MULT LEAD SYSTEM,93610281,CDM,361,RC,33264,CPT,,,facility,outpatient,,,6377.00000,3826.20000,WellCare of North Carolina,Medicare Advantage,,33389.96,,,,,,,1276.68,82346.00,fee schedule,
HC RHC W IMPL OF WIRELESS PULM ART PRESSURE SENSOR W ANGIO,93610282,CDM,481,RC,33289,CPT,,,facility,outpatient,,,2575.00000,1545.00000,WellCare of North Carolina,Medicare Advantage,,29606.17,,,,,,,515.51,82346.00,fee schedule,
HC DRUG CHALLENGE TEST,93610285,CDM,480,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,3641.00,fee schedule,
HC FFR ONLY NO HEART CATH STAND ALONE PROC,93610300,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2127.00000,1276.20000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC IVUS ONLY ON HEART CATH STAND ALONE PROC,93610301,CDM,481,RC,93799,CPT,,,facility,outpatient,,,2836.00000,1701.60000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,9423.00,fee schedule,
HC PROVOCATION TEST FOR CORONARY VASOSPASM,93610314,CDM,481,RC,93024,CPT,,,facility,outpatient,,,288.00000,172.80000,WellCare of North Carolina,Medicare Advantage,,415.57,,,,,,,57.66,9423.00,fee schedule,
HC PACEMAKER ICD POCKET REVISION,93610319,CDM,361,RC,93799,CPT,,,facility,outpatient,,,1418.00000,850.80000,WellCare of North Carolina,Medicare Advantage,,162.94,,,,,,,150.52,981.11,fee schedule,
HC EXCISION OF INFECTED GRAFT EXTREMITY,93610322,CDM,361,RC,35903,CPT,,,facility,outpatient,,,7970.00000,4782.00000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,1595.59,8045.00,fee schedule,
HC PERICARDIOCENTESIS INCLD IMG GUIDANCE,93610326,CDM,480,RC,33016,CPT,,,facility,outpatient,,,3041.00000,1824.60000,WellCare of North Carolina,Medicare Advantage,,1617.80,,,,,,,406.89,4376.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610331,CDM,481,RC,C9764,CPT,,,facility,outpatient,,,13301.00000,7980.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,2662.86,13852.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY LE ARTERY OTHER THAN TIBIAL PERONEAL W STENT INCL ANGIOPLASTY SAME VESSEL,93610332,CDM,481,RC,C9765,CPT,,,facility,outpatient,,,26602.00000,15961.20000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610333,CDM,481,RC,C9766,CPT,,,facility,outpatient,,,26602.00000,15961.20000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,5325.72,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY LE ARTERY OTHER THAN TIBIAL PERONEAL INCL ANGIOPLASTY SAME VSL,93610334,CDM,481,RC,C9767,CPT,,,facility,outpatient,,,42829.00000,25697.40000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,8574.37,26125.69,fee schedule,
HC TAVR TRANSCAROTID,93610335,CDM,481,RC,33999,CPT,,,facility,outpatient,,,34962.00000,20977.20000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,21326.82,fee schedule,
HC INSERT OR REPLACE PERM CARDIAC CCM SYSTEM,93610336,CDM,361,RC,0408T,CPT,,,facility,outpatient,,,9476.00000,5685.60000,WellCare of North Carolina,Medicare Advantage,,33389.96,,,,,,,1897.10,82346.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610343,CDM,481,RC,C9772,CPT,,,facility,outpatient,,,21406.00000,12843.60000,WellCare of North Carolina,Medicare Advantage,,11810.43,,,,,,,4285.48,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY TIBIAL PERONEAL ART W/STENT INCL ANGIOPLASTY SAME VSL,93610344,CDM,481,RC,C9773,CPT,,,facility,outpatient,,,34241.00000,20544.60000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610345,CDM,481,RC,C9774,CPT,,,facility,outpatient,,,34241.00000,20544.60000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC INTRAVASCULAR LITHOTRIPSY STENT ATHERECTOMY TIBIAL PERONEAL ART INCL ANGIOPLASTY SAME VSL,93610346,CDM,481,RC,C9775,CPT,,,facility,outpatient,,,34241.00000,20544.60000,WellCare of North Carolina,Medicare Advantage,,18700.70,,,,,,,6855.05,24600.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT NORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610350,CDM,481,RC,93593,CPT,,,facility,outpatient,,,6766.00000,4059.60000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC RT HEART CATH FOR CONGENITAL DEFECT ABNORMAL NATIVE CONNECTIONS INCL GUIDANCE,93610351,CDM,481,RC,93594,CPT,,,facility,outpatient,,,6766.00000,4059.60000,WellCare of North Carolina,Medicare Advantage,,3349.67,,,,,,,1354.55,12247.00,fee schedule,
HC ABLATION SVT INCL RA RV LA PACING 3DMAP HIS BUNDLE,93610355,CDM,480,RC,93653,CPT,,,facility,outpatient,,,39142.00000,23485.20000,WellCare of North Carolina,Medicare Advantage,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION VT INCL RV LA LV PACING 3DMAP HIS BUNDLE,93610356,CDM,480,RC,93654,CPT,,,facility,outpatient,,,39142.00000,23485.20000,WellCare of North Carolina,Medicare Advantage,,25548.73,,,,,,,1411.00,25792.05,fee schedule,
HC ABLATION AFIB PULM VEIN INCL 3DMAP ICE LA RA RV PACING HIS BUNDLE,93610357,CDM,480,RC,93656,CPT,,,facility,outpatient,,,47944.00000,28766.40000,WellCare of North Carolina,Medicare Advantage,,25548.73,,,,,,,1411.00,31355.38,fee schedule,
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION BILATERAL INCL FLUORO W S AND I,93610375,CDM,481,RC,0339T,CPT,,,facility,outpatient,,,10837.00000,6502.20000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,2169.57,12247.00,fee schedule,
HC PERC TRANSCATH CLOSURE IATROGENIC SEPTAL DEFECT ASD OR PFO W IMPLANT,93610398,CDM,481,RC,33999,CPT,,,facility,outpatient,,,32611.00000,19566.60000,WellCare of North Carolina,Medicare Advantage,,643.87,,,,,,,594.81,19892.71,fee schedule,
HC INSERT OR REPLACE IMPL DEFIB SYSTEM W SUBSTERNAL ELECTRODES,93610399,CDM,481,RC,0571T,CPT,,,facility,outpatient,,,61737.00000,37042.20000,WellCare of North Carolina,Medicare Advantage,,33389.96,,,,,,,9423.00,82346.00,fee schedule,
HC PERC TRANSCATH THERAPY RX INTRACORONARY BALLOON INCL MECH DILATION BY NON RX DELIVERY BALLOON ANGIO IMG USING IVUS OR OCT INCL SINGLE MAJOR CORONARY ARTERY OR BRANCH,93610400,CDM,481,RC,0913T,CPT,,,facility,outpatient,,,11403.00000,6841.80000,WellCare of North Carolina,Medicare Advantage,,5937.75,,,,,,,2282.88,13852.00,fee schedule,
HC DOPPLER FETAL UMBILICAL ARTERY,94020001,CDM,402,RC,76820,CPT,,,facility,outpatient,,,575.00000,345.00000,WellCare of North Carolina,Medicare Advantage,,110.74,,,,,,,41.04,467.00,fee schedule,
HC TRANSCATH INSERT REPLACE OF PERM LEADLESS PACEMKR RT VENT INCL IMG GUIDANCE AND DEVICE EVAL,94800003,CDM,480,RC,33274,CPT,,,facility,outpatient,,,4021.00000,2412.60000,WellCare of North Carolina,Medicare Advantage,,19861.32,,,,,,,538.01,20050.47,fee schedule,
HC CARDIAC STRESS TEST TRACING,94820001,CDM,482,RC,93017,CPT,,,facility,outpatient,,,1290.00000,774.00000,WellCare of North Carolina,Medicare Advantage,,324.30,,,,,,,198.53,967.50,fee schedule,
HC COMPLETE CONGENITAL ECHO,94830001,CDM,483,RC,93303,CPT,,,facility,outpatient,,,1563.00000,937.80000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,219.29,1172.25,fee schedule,
HC LIMITED CONGENITAL ECHO,94830002,CDM,483,RC,93304,CPT,,,facility,outpatient,,,1157.00000,694.20000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,162.33,968.00,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW W CONT,94830003,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE W DOPPLER AND COLOR FLW WO CONT,94830004,CDM,483,RC,93306,CPT,,,facility,outpatient,,,2229.00000,1337.40000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,1671.75,fee schedule,
HC ECHO COMPLETE WO DOPPLER WO CONT,94830006,CDM,483,RC,93307,CPT,,,facility,outpatient,,,899.00000,539.40000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,126.13,968.00,fee schedule,
HC ECHO LIMITED W CONT,94830007,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,101.86,968.00,fee schedule,
HC ECHO LIMITED WO CONT,94830008,CDM,483,RC,93308,CPT,,,facility,outpatient,,,726.00000,435.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,101.86,968.00,fee schedule,
HC TEE W 2D IMAGE AND PROBE WO CONT,94830010,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC TEE W 2D IMAGE AND PROBE W CONT,94830011,CDM,483,RC,93312,CPT,,,facility,outpatient,,,2558.00000,1534.80000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,1918.50,fee schedule,
HC STRESS ECHO W CONTINUOUS EKG W CONTRAST,94830015,CDM,483,RC,93351,CPT,,,facility,outpatient,,,2736.00000,1641.60000,WellCare of North Carolina,Medicare Advantage,,571.02,,,,,,,266.00,2052.00,fee schedule,
HC EKG EVENT RECORDING HOOKUP UP TO 30 DAYS,97300003,CDM,730,RC,93270,CPT,,,facility,outpatient,,,243.00000,145.80000,WellCare of North Carolina,Medicare Advantage,,38.84,,,,,,,35.88,182.25,fee schedule,
HC HOLTER HOOKUP UP TO 48HRS,97300004,CDM,731,RC,93225,CPT,,,facility,outpatient,,,875.00000,525.00000,WellCare of North Carolina,Medicare Advantage,,134.24,,,,,,,87.00,656.25,fee schedule,
HC HOLTER SCANNING ANALYSIS W REPORT UP TO 48HRS,97300005,CDM,731,RC,93226,CPT,,,facility,outpatient,,,622.00000,373.20000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,57.15,466.50,fee schedule,
HC EKG EVENT TRANSMISSION AND ANALYSIS UP TO 30 DAYS,97300006,CDM,731,RC,93271,CPT,,,facility,outpatient,,,162.00000,97.20000,WellCare of North Carolina,Medicare Advantage,,95.59,,,,,,,32.43,134.00,fee schedule,
HC VENOUS EXTREMITY DUPLEX COMPLETE BIL,99210002,CDM,921,RC,93970,CPT,,,facility,outpatient,,,1276.00000,765.60000,WellCare of North Carolina,Medicare Advantage,,251.74,,,,,,,175.00,957.00,fee schedule,
HC CARDIAC THERAPY WO CONT ECG,99430001,CDM,943,RC,93797,CPT,,,facility,outpatient,,,218.00000,130.80000,WellCare of North Carolina,Medicare Advantage,,131.12,,,,,,,37.95,269.00,fee schedule,
HC CARDIAC THERAPY W CONT ECG,99430005,CDM,943,RC,93798,CPT,,,facility,outpatient,,,297.00000,178.20000,WellCare of North Carolina,Medicare Advantage,,131.12,,,,,,,51.71,269.00,fee schedule,
HC PULMONARY REHAB WO CONTINUOUS OXIMETRY MONITORING PER SESSION,99480002,CDM,948,RC,94625,CPT,,,facility,outpatient,,,109.00000,65.40000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,18.98,269.00,fee schedule,
HC PULMONARY REHAB W CONTINUOUS OXIMETRY MONITORING PER SESSION,99480003,CDM,948,RC,94626,CPT,,,facility,outpatient,,,141.00000,84.60000,WellCare of North Carolina,Medicare Advantage,,61.87,,,,,,,24.55,269.00,fee schedule,
HC BRONCHOSCOPY W EBUS SAMPLE 1-2 NODES,43610049,CDM,361,RC,31652,HCPCS,,,facility,outpatient,,,6499.00000,3899.40000,WellCare of North Carolina,Medicare Advantage,,3839.70,,,,,,,1301.10,17457.00,fee schedule,
HC PERIPHERAL INSERTED CVAD W SUBQ PORT 5 YRS AND OLDER,73610451,CDM,361,RC,36571,HCPCS,,,facility,outpatient,,,3624.00000,2174.40000,WellCare of North Carolina,Medicare Advantage,,3277.91,,,,,,,725.52,8045.00,fee schedule,
HC CRYOABL BONE TUMOR PERCUT W IMAGE GUIDE,73610466,CDM,361,RC,20983,HCPCS,,,facility,outpatient,,,7984.00000,4790.40000,WellCare of North Carolina,Medicare Advantage,,7439.71,,,,,,,1598.40,13852.00,fee schedule,
HC PLACE SOFT TISSUE MARKER 1ST LESION,73610507,CDM,361,RC,10035,HCPCS,,,facility,outpatient,,,2607.00000,1564.20000,WellCare of North Carolina,Medicare Advantage,,732.74,,,,,,,521.92,5152.00,fee schedule,
HC INSERT SUBQ DEFIB ELECTRODE,93610265,CDM,361,RC,33271,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,WellCare of North Carolina,Medicare Advantage,,8618.87,,,,,,,422.62,24600.00,fee schedule,
HC REMOVAL SUBQ DEFIB ELECTRODE,93610269,CDM,361,RC,33272,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,422.62,8045.00,fee schedule,
HC REPOS SUBQ IMPLT DEFIB ELECTRODE AND PLS GEN,93610270,CDM,361,RC,33273,HCPCS,,,facility,outpatient,,,2111.00000,1266.60000,WellCare of North Carolina,Medicare Advantage,,3790.08,,,,,,,422.62,17457.00,fee schedule,
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,Aetna,Commercial,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Aetna,Commercial,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,Aetna,Commercial,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,Aetna,Commercial,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,Aetna,Commercial,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Aetna,Commercial,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Aetna,Commercial,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Aetna,Medicare Advantage,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Select/HMO/PPO,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended
Reduced Services,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Select/HMO/PPO,52,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Select/HMO/PPO,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Value Individual,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended
Reduced Services,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Value Individual,52,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Value Individual,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Value Group,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended
Reduced Services,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Value Group,52,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,BCBS NC,Blue Value Group,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,BCBS NC,Medicare Advantage,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Services,,,,,,,,,facility,outpatient,,,,,Cigna,Commercial,50,,,,,,,,,,,"100% payment adjustment for the item or service to which the modifier is appended for the first procedure, 50% for the second procedure. 200% payment adjustment for bilateral radiology items or services to which the modifier is appended"
Discontinued OP Hospital/ASC Procedure Prior to Administration of Anesthesia,,,,,,,,,facility,outpatient,,,,,Cigna,Commercial,73,,,,,,,,,,,50% payment adjustment for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Healthspring (Cigna Medicare Advantage),Medicare Advantage,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,Humana,Medicare HMO,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Humana,Medicare HMO,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,Humana,Medicare HMO,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,Humana,Medicare HMO,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,Humana,Medicare HMO,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Humana,Medicare HMO,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Humana,Medicare HMO,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,Humana,Medicare PPO,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Humana,Medicare PPO,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,Humana,Medicare PPO,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,Humana,Medicare PPO,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,Humana,Medicare PPO,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Humana,Medicare PPO,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Humana,Medicare PPO,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Services,,,,,,,,,facility,outpatient,,,,,United Healthcare,Commercial,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended for codes with Bilateral Procedure Indicator of 1. 200% payment adjustment for the item or service to which the modifier is appended for codes with Bilateral Procedure Indicator of 3.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,United Healthcare,Commercial,73,,,,,,,,,,,50% payment adjustment for the item or service to which the modifier is appended
Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (NEMA) XR-29-2013 standard,,,,,,,,,facility,outpatient,,,,,United Healthcare,Commercial,CT,,,,,,,,,,,85% payment adjustment for the item or service to which the modifier is appended
X-ray was performed using film,,,,,,,,,facility,outpatient,,,,,United Healthcare,Commercial,FX,,,,,,,,,,,90% payment adjustment for the item or service to which the modifier is appended
X-ray was taken using computed radiography technology/cassette-based imaging,,,,,,,,,facility,outpatient,,,,,United Healthcare,Commercial,FY,,,,,,,,,,,90% payment adjustment for the item or service to which the modifier is appended
Bilateral Services,,,,,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended for codes with Bilateral Procedure Indicator of 1. 200% payment adjustment for the item or service to which the modifier is appended for codes with Bilateral Procedure Indicator of 3.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,73,,,,,,,,,,,50% payment adjustment for the item or service to which the modifier is appended
Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (NEMA) XR-29-2013 standard,,,,,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,CT,,,,,,,,,,,85% payment adjustment for the item or service to which the modifier is appended
X-ray was performed using film,,,,,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,FX,,,,,,,,,,,90% payment adjustment for the item or service to which the modifier is appended
X-ray was taken using computed radiography technology/cassette-based imaging,,,,,,,,,facility,outpatient,,,,,United Healthcare,Individual Exchange,FY,,,,,,,,,,,90% payment adjustment for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Optum,VACCN Behavioral Health,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Procedures,,,,,,,,,facility,outpatient,,,,,Optum,VACCN,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended. Multiple surgery guidelines apply.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Optum,VACCN,73,,,,,,,,,,,50% of the amount for the item or service to which the modifier is appended
CT services furnished with equipment that don't meet NEMA standard,,,,,,,,,facility,outpatient,,,,,Optum,VACCN,CT,,,,,,,,,,,85% of the amount for the item or service to which the modifier is appended
X-ray taken using film,,,,,,,,,facility,outpatient,,,,,Optum,VACCN,FX,,,,,,,,,,,80% of the amount for the item or service to which the modifier is appended
Computed radiography x-ray,,,,,,,,,facility,outpatient,,,,,Optum,VACCN,FY,,,,,,,,,,,90% of the amount for the item or service to which the modifier is appended
Excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Optum,VACCN,PO,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Non-excepted off-campus service,,,,,,,,,facility,outpatient,,,,,Optum,VACCN,PN,,,,,,,,,,,40% of the amount for the item or service to which the modifier is appended
Bilateral Services,,,,,,,,,facility,outpatient,,,,,Optum,Transplant,50,,,,,,,,,,,150% payment adjustment for the item or service to which the modifier is appended for codes with Bilateral Procedure Indicator of 1. 200% payment adjustment for the item or service to which the modifier is appended for codes with Bilateral Procedure Indicator of 3.
Discontinued Procedure,,,,,,,,,facility,outpatient,,,,,Optum,Transplant,73,,,,,,,,,,,50% payment adjustment for the item or service to which the modifier is appended
Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (NEMA) XR-29-2013 standard,,,,,,,,,facility,outpatient,,,,,Optum,Transplant,CT,,,,,,,,,,,85% payment adjustment for the item or service to which the modifier is appended
X-ray was performed using film,,,,,,,,,facility,outpatient,,,,,Optum,Transplant,FX,,,,,,,,,,,90% payment adjustment for the item or service to which the modifier is appended
X-ray was taken using computed radiography technology/cassette-based imaging,,,,,,,,,facility,outpatient,,,,,Optum,Transplant,FY,,,,,,,,,,,90% payment adjustment for the item or service to which the modifier is appended